Visual scanning of the driving environment is a key component in driving. In conditional automation, the vehicle is usually steered by automation, but drivers may be required to take control of the vehicle in certain circumstances. In these takeover situations (TO), visual exploration of the environment is critical for resuming manual control. This study aimed to compare visual explorations over time during TO preparation and actual TO between experienced and non-experienced drivers. Twenty-five participants completed three simulated drives, each comprising three TO maneuvers. Visual strategies were measured by the percentage of gaze time allocated to areas of interest (AOIs) and further characterised through visual exploration sequences (scanpaths) during TO preparation and actual TO. The results indicated that experienced drivers gazed more at the road area in which the vehicle would be located at the time of effective TO than non-experienced drivers. Similarly, immediately after resuming manual control, experienced drivers gazed more at areas where potential hazards may be present than non-experienced drivers. Three main scanpath classes were identified during TO preparation: anticipation of trajectory control, anticipation of speed control, and environment exploration. During subsequent manual driving, two scanpath classes emerged: speed control and trajectory control. These findings are discussed in terms of differences in visual strategies between non-experienced and experienced drivers, shaped by situational context. Functionally classifying visual exploration sequences provides insight into TO processes and offers a promising link to drivers’ situation awareness and performance.

Vehicle automation progressively shifts the driver’s role from active operator to passive supervisor, requiring behavioural adaptation. Although a timely issue, little is known about the influence of previous manual driving experience and the duration of automation use on those adaptations. Gaze behaviour during a car-following task were investigated under four automation conditions: Non-Automated (NA), Automated Steering (AS), Highly Automated Driving (HAD), and Fully Automated driving (FA). The sequences of visual explorations across the different areas of interest of the driving scene (i.e., scan paths) were analysed over seven weeks of automation use and for both unlicenced and experienced drivers. The findings reveal that automation alters the distribution of scan paths compared to manual driving. Specifically, automation promotes scenery and supervision scan paths at the expense of driving-control ones, which are crucial for monitoring the road and vehicle speed control. This shift became noticeable once the driver completely disengaged from the physical control of the vehicle, this function being supported by automation. Additionally, driving experience significantly influences gaze behaviour for each automation solution. Novice drivers focus more on speed-monitoring scan paths, whereas experienced drivers display more balanced scan paths. No significant changes in scan paths were observed over time, suggesting that gaze strategies are highly context-dependent. Altogether, this study provides a better understanding of the effects of automation on the dynamics of drivers’ gaze behaviour.

PRACTITIONER SUMMARY:This study reveals that individuals' affinity for smart tools is linked to specific brain structures. These findings support the theory of Human-Technology Symbiosis and highlight how technology use is associated with brain anatomy, with implications for technology design and user training.

The ability to navigate spatially in the physical world is a fundamental cognitive skill. This study examines the anatomical correlates of map-assisted wayfinding in an unfamiliar virtual environment using structural magnetic resonance magining (MRI). Thirty-three participants were required to reach up to seven different locations represented on a navigational map in a simulated environment, while their gazing behavior was recorded, and, in close temporal proximity, the anatomical MRI of their brain was acquired. Significant predictors of wayfinding performance were the volumes of the right hippocampus, left retrosplenial cortex, and posterior cingulate cortex-left inferior frontal gyrus, right superior frontal gyrus, and right cerebellar lobule VIIB. Detailed analyses revealed a dissociation between two clusters of gray matter density in the right hippocampus. Compared with the poorest wayfinders, the best wayfinders exhibited more gray matter density in a cluster located in the right posterior hippocampus but less gray matter density in a cluster located in the anterior section of the hippocampus. In addition, top performers spent more time gazing at the map, highlighting the benefit of using external aids during navigation tasks. Altogether, these results underscore how structural adaptations are associated with spatial navigation performance.

The end-stage of amyotrophic lateral sclerosis (ALS) is commonly regarded as a complete Locked-In Syndrome (cLIS). Shifting the perspective from cLIS (assumed consciousness) to Cognitive Motor Dissociation (potentially demonstrable consciousness), we aimed to assess the preservation of covert awareness (internally preserved but externally inaccessible) using a multimodal battery. We evaluate two end-stage ALS patients using neurophysiological testing, passive and active auditory oddball paradigms, an auditory Brain-Computer Interface (BCI), functional activation-task imaging, long-term EEG, brain morphology, and resting-state metabolism to characterize underlying brain function. Patient 1 initially follows simple commands but fails twice at BCI control. At follow-up, command following is no longer observed and his oddball cognitive responses disappear. Patient 2, at a single evaluation, is unable to follow commands or control the BCI. Both patients exhibit altered wakefulness, brain atrophy, and a global cortico–subcortical hypometabolism pattern consistent with a disorder of consciousness, regarded as an extreme manifestation of ALS-associated fronto-temporal dementia. Although it is not possible to firmly prove the absence of awareness, each independent measure concurred with suggesting that a “degenerative disorder of consciousness” rather than a cLIS may constitute the final stage of ALS. This condition appears pathophysiologically distinct from typical tetraplegia and anarthria, in which behavioural communication and BCI use persist to enhance quality of life. Identifying the neuroimaging signatures of this condition represents a substantial milestone in understanding end-stage ALS. Large-scale longitudinal investigations are warranted to determine the prevalence of this profile among patients whose communication appears impossible. Some patients with amyotrophic lateral sclerosis become progressively paralyzed to the extent that they can no longer communicate. This raises a critical question: does consciousness remain despite a complete loss of interaction? To address this issue, we analysed brain activity in two patients at the late stage of this disease. Our findings indicate that no reliable signs of awareness could be detected, even when employing advanced methods to assess brain function, including approaches designed to enable communication without movement. Two hypotheses may account for this outcome: either prolonged paralysis progressively leads to the disappearance of consciousness, or the degeneration of brain function itself directly underlies its loss. However, our conclusions ultimately depend on the reliability of consciousness assessment tools, even when used in combination. Gobert et al. investigate whether consciousness persists in end-stage Amyotrophic Lateral Sclerosis, traditionally assumed as being fully aware but unable to communicate. Multimodal assessments, including Brain-Computer Interface, suggest some individuals may show degenerative disorder of consciousness rather than a complete Locked-In Syndrome.

The end-stage of amyotrophic lateral sclerosis [ALS] is presumed to be a complete Locked-In Syndrome [cLIS], assuming an internally preserved consciousness that would not be accessible anymore from the outside. However, whether consciousness persists at this stage of ALS remains to be demonstrated. Shifting the perspective from cLIS (presupposed consciousness) to Cognitive Motor Dissociation (to-be-demonstrated consciousness), we attempted to demonstrate consciousness and communication with two cLIS-ALS patients using a multimodal awareness assessment battery. It involved complete neurophysiological assessments, passive and active auditory oddball paradigm (Subject-Own-Name/P300), an auditory-based Brain-Computer-Interface [BCI] and activation-task imaging using functional MRI or [15O]H2O PET. Wakefulness (long-term EEG), brain morphology (CT or MRI scans) and resting brain metabolism ([18F]fluoro-deoxy-glucose PET) were used to describe the underlying cLIS brain function. While Patient 1 could initially follow simple commands, he failed twice to control the BCI. At follow-up, he showed no more evidence of command following and his oddball (Own Name - P300) cognitive responses has disappeared. At his unique evaluation, Patient 2 was neither able to follow simple commands nor to control the BCI. Both patients had altered wakefulness, brain atrophy, and a global cortico-sub-cortical hypometabolism pattern compatible with a disorder of consciousness, regarded as an extreme form of an ALS-associated fronto-temporal dementia. While it is not possible to firmly demonstrate the absence of awareness, each independent measure concurred with suggesting that a degenerative disorder of consciousness rather than a cLIS might be the final stage of ALS. In future cass, this dramatic cognitive decline should be anticipated before communication disappears to enable precise advance directives regarding end-of-life issues in case complete, and neurophysiologically confirmed, unresponsiveness occurs. Altogether, the neuroimaging features distinguishing the mechanisms in this rare condition is a significant milestone to understand end-stage ALS. The present clinical study calls for further exploration of this terminal stage to determine the prevalence of this profile in whom communication seems hopeless. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement AO was funded by the Fondation pour la Recherche Medicale (FRM, ING20121226307). PS, JM, EM were funded by one grant from the Fondation pour la Recherche Medicale (FRM, FDM201906008524). JM, EM and PS were funded by ANR-17-CE40-0005, MindMadeClear & ANR-20-CE17-0023, ANR HiFi. PS was funded by Perce-Neige Fondation. The teams of the Lyon Neurocience Research Center are funded by the Labex cortex. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: IRB of Hospices Civils de LYON CSE-HCL - IRB 00013204; Pr Cyrille Confavreux gave ethical approval for this work (approval N. 24-310). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript.

Lane Departure Warning Systems (LDWS) are automation that warn drivers in case of immediate lane departure. While LDWS are associated with increased road safety, little is known about the neural aspects of the cooperation between an LDWS and the driver behind the wheel. The present study addresses this issue by combining fMRI and driving simulation for experienced and novice drivers. The results reveal brain areas activated immediately after warning: it involves areas linked to the alertness network (midbrain, thalamus, anterior cingulate cortex), to motor actions and planning (motor and premotor cortexes; BA4/6 -cerebellum) and to attentional redirection (superior frontal cortex; BA10). There were no differences between experienced and novice drivers in this network of cerebral areas. However, prior driving experience mediates the number of lane departures. The results allow for refining a model of cooperation proposed earlier in the literature, by adding a cerebral dimension.

Background The locked-in syndrome (LIS), due to a lesion in the pons, impedes communication. This situation can also be met after some severe brain injury or in advanced Amyotrophic Lateral Sclerosis (ALS). In the most severe condition, the persons cannot communicate at all because of a complete oculomotor paralysis (Complete LIS or CLIS). This even prevents the detection of consciousness. Some studies suggest that auditory brain–computer interface (BCI) could restore a communication through a « yes–no» code. Methods We developed an auditory EEG-based interface which makes use of voluntary modulations of attention, to restore a yes–no communication code in non-responding persons. This binary BCI uses repeated speech sounds (alternating “yes” on the right ear and “no” on the left ear) corresponding to either frequent (short) or rare (long) stimuli. Users are instructed to pay attention to the relevant stimuli only. We tested this BCI with 18 healthy subjects, and 7 people with severe motor disability (3 “classical” persons with locked-in syndrome and 4 persons with ALS). Results We report online BCI performance and offline event-related potential analysis. On average in healthy subjects, online BCI accuracy reached 86% based on 50 questions. Only one out of 18 subjects could not perform above chance level. Ten subjects had an accuracy above 90%. However, most patients could not produce online performance above chance level, except for two people with ALS who obtained 100% accuracy. We report individual event-related potentials and their modulation by attention. In addition to the classical P3b, we observed a signature of sustained attention on responses to frequent sounds, but in healthy subjects and patients with good BCI control only. Conclusions Auditory BCI can be very well controlled by healthy subjects, but it is not a guarantee that it can be readily used by the target population of persons in LIS or CLIS. A conclusion that is supported by a few previous findings in BCI and should now trigger research to assess the reasons of such a gap in order to propose new and efficient solutions. Clinical trial registrations : No. NCT02567201 (2015) and NCT03233282 (2013).

Brain-computer interfaces (BCI) are presented as a solution for people with global paralysis, also known as locked-in syndrome (LIS). The targeted population includes the most severe patients, with no residual eye movements, who cannot use any communication device (Complete LIS). However, BCI reliability is low precisely in these cases, technical pitfalls being considered responsible so far. Here, we propose to consider also that global paralysis could have an impact on cognitive functions that are crucial for being able to control a BCI. We review a bundle of arguments about the role of motor structures in cognition. Especially, we uncover that these patients without oculomotor activity often have injuries in more 'cognitive' structures such as the frontal eye field or the midbrain, exposing them to cognitive deficits further than canonical LIS population. We develop a hypothesis about the putative role of the motor system in (covert) attention, a capacity which is a prerequisite for most BCI paradigms and which should therefore be both better assessed in patients and considered.

Most recent research highlights how a specific form of causal understanding, namely technical reasoning, may support the increasing complexity of tools and techniques developed by humans over generations, i.e., the cumulative technological culture (CTC). Thus, investigating the neurocognitive foundations of technical reasoning is essential to comprehend the emergence of CTC in our lineage. Whereas functional neuroimaging evidence started to highlight the critical role of the area PF of the left inferior parietal cortex (IPC) in technical reasoning, no studies explored the links between the structural characteristics of such a brain region and technical reasoning skills. Therefore, in this study, we assessed participants' technical-reasoning performance by using two ad-hoc psycho-technical tests; then, we extracted from participants' 3 T T1-weighted magnetic-resonance brain images the cortical thickness (i.e., a volume-related measure which is associated with cognitive performance as reflecting the size, density, and arrangement of cells in a brain region) of all the IPC regions for both hemispheres. We found that the cortical thickness of the left area PF predicts participants' technical-reasoning performance. Crucially, we reported no correlations between technical reasoning and the other IPC regions, possibly suggesting the specificity of the left area PF in generating technical knowledge. We discuss these findings from an evolutionary perspective, by speculating about how the evolution of parietal lobes may have supported the emergence of technical reasoning in our lineage.

Background: Innovation in healthcare cannot be conceived without an interdisciplinary approach. Hackathons are an innovative approach to promote team working and demonstrated an interest in higher education through inquiry-based learning. An interdisciplinary team of students and young professionals organized the first hybrid presential and online neurorehabilitation hackathon, within the joined 2020 WCNR-SOFMER congress, adapting to the COVID-19 pandemic. Methods: Interdisciplinary teams worked during two days on concrete issues met by people with a disability and their caregivers, accompanied by multi-skilled mentors to create tangible solutions. An independent jury selected the winning project. Results: HRL met the expectations of 96% of the 31 participants. They reported better knowledge and ability about teamwork, ethics, and patient-centered approaches. Conclusions: HRL allowed the creation of a strong interdisciplinary and international network which will be valuable to foster innovation. It demonstrated its value in the junior and students’ training for teamwork, communication, creativity in innovation, and ethics in health.

A major objective of Brain-Computer interfaces (BCI) is to restore communication and control in patients with severe motor impairments, like people with Locked-in syndrome. These patients are left only with limited eye and eyelid movements. However, they do not benefit from efficient BCI solutions, yet. Different signals can be used as commands for non-invasive BCI: mu and beta rhythm desynchronization, evoked potentials and slow cortical potentials. Whatever the signal, clinical studies show a dramatic loss of performance in severely impaired patients compared to healthy subjects. Interestingly, the control principle is always the same, namely the replacement of an impossible (overt) movement by a (covert) attentional command. Drawing from the premotor theory of attention, from neuroimaging findings about the functional anatomy of spatial attention, from clinical observations and from recent computational accounts of attention for both action and perception, we explore the hypothesis that these patients undergo negative plasticity that extends their impairment from overt to covert attentional processes.

MD-PhD programs allow students to undergo research training and to be granted a PhD during medical education. In France, before years 2000, the scientific training of MD-PhD students was traditionally initiated during, or even after residency. Integrated MD-PhD programs have been launched in France in 2003 by Inserm, the public scientific and technological institute dedicated to biomedical research and human health. Irrespective of the MD-PhD training pathway followed, students enrolled in these programs face several difficulties. Those mainly result from an insufficient integration of scientific and medical trainings. The aims of this work are to describe the structure of the french MD-PhD programs, identify the main difficulties faced by MD-PhD students in France, and make proposals which could facilitate the training and further strengthen the MD-PhD workforce in France.

Spinal cord injury leads to severe locomotor deficits or even complete leg paralysis. Here we introduce targeted spinal cord stimulation neurotechnologies that enabled voluntary control of walking in individuals who had sustained a spinal cord injury more than four years ago and presented with permanent motor deficits or complete paralysis despite extensive rehabilitation. Using an implanted pulse generator with real-time triggering capabilities, we delivered trains of spatially selective stimulation to the lumbosacral spinal cord with timing that coincided with the intended movement. Within one week, this spatiotemporal stimulation had re-established adaptive control of paralysed muscles during overground walking. Locomotor performance improved during rehabilitation. After a few months, participants regained voluntary control over previously paralysed muscles without stimulation and could walk or cycle in ecological settings during spatiotemporal stimulation. These results establish a technological framework for improving neurological recovery and supporting the activities of daily living after spinal cord injury.

Over the past decade, we have developed spatiotemporal neuromodulation therapies of spinal circuits and gravity-assist training procedures in pre-clinical model of spinal cord injury (SCI) which allowed to restore supraspinal control of locomotion in rats with a SCI leading to complete and permanent paralysis. So far, human studies on epidural electrical stimulation (EES) were mainly limited to continuous neuromodulation, which has demonstrated several limitations to promote the recovery of functional movements such as walking. In this study, we aimed to assess the feasibility and the efficacy of a neuroprosthetic rehabilitation program that combines spatiotemporal EES and gravity-assist training to enhance the recovery of voluntary motor control and functional autonomy. Individuals with a chronic incomplete SCI were surgically implanted with a spinal cord electrostimulation system with 16 independent electrodes positioned over the lumbar spinal cord. The stimulator was equipped with real-time triggering capacities based on movement feedback. They then underwent 20 weeks of rehabilitation, four sessions per week, with a gravity-assist that provided a tailored, multidirectional assistance of trunk movements during gait training. Multifaceted evaluations of clinical scores, gait analysis, sensorimotor functions, urodynamics, electrophysiology, and imaging were performed before and throughout the rehabilitation program. A total of 4 chronic SCI patients have been included to date, with deficits ranging from AIS-B to AIS-D. The participants who completed the study have demonstrated various types of improvements in term of muscle force, gait autonomy and quality as well as daily-life-related activities. These positive results have been observed both immediately when the EES therapy was applied and were reinforced after the long-term training. Electrophysiological and neuro-imaging analysis contributed to explaining the mechanisms underlying the long-term improvements. Preliminary data provides encouraging results on the ability of this therapeutic intervention to improve the recovery of motor functions and other important bodily functions after a chronic SCI.

Les doubles cursus médecine-sciences (DC/MS) permettent l’acquisition d’une formation à la recherche et d’un doctorat de sciences au cours des études médicales. En France, avant les années 2000, la formation à la recherche était réalisée durant, voire après, le troisième cycle des études médicales (internat). Des DC/MS intégrés, dits « précoces », ont été développés depuis 2003 à l’initiative du cursus national de l’École de l’Inserm Liliane Bettencourt, suivie par la création de DC/MS par diverses universités. Quel que soit le mode de réalisation du double cursus, les étudiants engagés dans ces voies d’excellence se heurtent à des difficultés qui résultent essentiellement du manque d’articulation entre les formations médicale et scientifique. Les objectifs de ce texte sont de présenter les filières DC/MS de France, de recenser les principales difficultés rencontrées par les étudiants, ainsi que de formaliser un ensemble de propositions d’aménagements pour faciliter et consolider la formation des médecins/chercheurs.