Evidence is accumulating that the earliest stages of the DNA damage response can direct cells toward senescence instead of other cell fates. In particular, tightly regulated signaling through Mitogen-Activated Protein Kinases (MAPKs) in early senescence can lead to a sustained pro-survival program and suppress a pro-apoptotic program. Importantly, an epithelial-to-mesenchymal Transition (EMT)-like program appears essential for preventing apoptosis and favoring senescence following DNA damage. In this review, we discuss how MAPKs might influence EMT features to promote a senescent phenotype that increases cell survival at the detriment of tissue function. Senescence is a cellular response to different types of sublethal damage characterized by indefinite cell cycle arrest and the secretion of bioactive molecules . This seTherefore, careful regulation of the levels of senescence and SASP is necessary for maintaining organ homeostasis in response to tissue damage. Mostly through the SASP, senescent cells also help coordinate the response of nearby and distant damaged cells and even trigger secondary senescence . HoweverBesides circulating factors, senescent cells also produce extracellular matrix (ECM) structural proteins . AlthougThe harmful effect of senescent cells in the aforementioned age-related pathologies has stimulated an escalation of efforts to find therapeutic strategies that reduce senescent cells . SeveralFollowing damage, cells discern at the molecular level whether to undergo rapid mending (for repairable damage), apoptotic death (for catastrophic damage), or sustained senescence  . These pSenescence is implemented in at least two distinct phases in fibroblasts . During The factors responsible for favoring a program of senescence over apoptosis following damage are not sufficiently known . We receIn this regard, the impact of MAPKs on the EMT in other systems could shed light on their impact on EMT in senescence. The EMT program is crucial for processes of tissue remodeling in embryonic development and wound healing , both liIn turn, the molecules secreted by senescent cells may themselves reinforce the EMT program in an autocrine or paracrine manner, thus also promoting survival over apoptosis in response to injury. As mentioned above, many of the proteins secreted by senescent cells promote EMT in multiple paradigms , and senThe MAPK superfamily of proteins comprises a large number of signaling kinases with three central pathways: ERKs (mainly ERK1/2 and ERK5), p38s, and JNKs ; JNK andvia ECM receptors and ECM ligands , but the specific MAPKs inhibited vary depending on the cell type, the stimulus, and the phosphatases expressed . For exaThe SMAD-dependent TGF-β and BMP pathways are also influenced by p53. TGF-β and p53 induce p21 expression , and mayin vivo (Finally, p53 opposes EMT by inhibiting SLUG in vivo  and TWISin vivo . DespiteAlthough it has not been studied in depth in tissues and organs, cultured senescent cells produce ligands that promote EMT, such as TGF-β and ECM matrix proteins . Moreovein vivo could further favor senescence over apoptosis of damaged cells; this process would enable tissue repair, but it would also promote fibrosis when senescent cells accumulate in excess.The connection between EMT and fibrosis is well established , and theA strong connection is emerging between cellular senescence and EMT, two processes associated with fibrosis . It is lIn conclusion, a fuller characterization of pro-fibrotic ECM deposition, cell senescence, and the role of ECM proteins supporting both processes is warranted. This knowledge will accelerate the identification of therapeutic strategies to intervene in fibrosis, tissue repair, aging, and age-associated disease.


Although not completely devoid of risk, pregnancy can be managed in virtually all patients affected by even the most complex forms of congenital heart disease. It is not however advisable in patients with any form of pulmonary arterial hypertension. Pregnancy is even manageable in patients with univentricular heart converted to Fontan circulation. A personalised risk stratification should be performed, and patients affected by advanced NYHA functional class appropriately warned of the potential risks. In this setting, metabolomics might represent a novel tool for use in conducting personalised risk stratification. All pregnancies, particularly those at higher risk, should be managed in a tertiary care centre capable of providing the necessary assistance to both the mother and infant. With a few rare exceptions, vaginal delivery is to be preferred over caesarean section due to the lower degree of maternal and foetal complications. The desire for motherhood, at times extreme in women with congenital heart disease, may often be accomplished, thus providing a ray of hope in the lives of these patients. A significantly higher number of cases of congenital heart disease (CHD) is observed in the adult population  when compared to the number of live paediatric subjects affected by the same condition. Indeed, early diagnosis and progresses made in the field of interventional and surgical treatment have enabled more than 90% of CHD patients to reach adulthood . A largeThe aim of this narrative review is to assess the risk and the management of pregnancy in moderate or great complexity ACHD patients.The prevalence of CHD worldwide is approximately 9/1000 neonates, with some geographical variations . A slighTo investigate why pregnancy is so poorly tolerated in this population, a series of physiological changes that occur during pregnancy should be taken into account ,7.As early as the sixth week of gestation, the primordial heart starts to beat. Likewise, the increase in blood volume manifested throughout pregnancy is first detected in the early weeks of pregnancy and increases rapidly up until the fourth/fifth month of gestation, subsequently progressing at a slower rate ,7.Concomitantly, systemic vascular resistance decreases by approximately 30% compared to baseline, due to both the effect of pregnancy hormones and subsequent development of the placenta. This in turn determines reduced vascular tone with consequent decrease in systemic blood pressure (BP) ,7.This vasodilation is compensated for by an approx. 30–50% increased cardiac output (CO) compared to baseline. This increased output is the result of an increase in both stroke volume and heart rate, with the latter occurring largely during the third trimester. These hemodynamic changes place an additional burden on the heart with increased end-systolic and end-diastolic ventricular volumes. At the end of pregnancy, labour and delivery are both seen as critical events due to the presence of an additional rise in cardiac output and increased oxygen demand. Uterine contractions each produce an approx. 500 cc increase in circulating blood volume. During delivery, a sudden increase in systemic vascular resistance elicited by placental expulsion determines an increment in ventricular filling pressure. Baseline conditions are normally restored within 2–6 weeks of vaginal delivery, or longer in the case of caesarean section. The heart then continues to be subjected to a higher burden following delivery as, paradoxically, although uterine compression on the inferior vena cava lessens, an increased systemic venous return to the heart is manifested .Pregnancy is intrinsically associated with a state of hypercoagulability, a factor to not underestimate in the presence of a series of conditions  .It is evident therefore that the cardiovascular system of a patient affected by depressed cardiac function, increased pulmonary pressure or single ventricle circulation will be faced with a series of major challenges as pregnancy commences.Nevertheless, as a general rule, vaginal delivery is the preferred option, with elective caesarean section limited to women affected by ventricular dysfunction and advanced NYHA functional status . This isMajor cardiac complications during pregnancy include onset of arrhythmias, in particular ventricular arrhythmia, heart failure, fainting episodes, chest pain and thromboembolic events   Figure .Patients with Fontan circulation and cyanotic heart disease have been found to be at higher risk of spontaneous or elective miscarriage .A mortality rate of up to 4% has been reported for infants born to mothers affected by congenital heart disease ,12.The ROPAC registry is the main source of information for issues relating to pregnancy and heart disease. Published for the first time in 2007, the registry is kept continuously updated with data deriving from numerous hospitals worldwide (the majority of which European), and currently includes data from approx. 6000 pregnant women affected mainly by congenital (57%) and valvular heart disease (29%) .The ROPAC registry highlighted the highest mortality rate in patients with pulmonary hypertension . Heart failure was diagnosed in 11% of the population, whilst arrhythmias were present in 2% of cases. The main risk factors for onset of maternal complications during pregnancy comprised pre-existing heart failure, NYHA functional class > II, systemic ejection fraction < 40%, mWHO functional class 4 and use of anticoagulants .Accordingly, risk stratification represents an important tool aimed at limiting potential maternal and foetal complications.The risk of onset of pregnancy-related cardiac complications may be predicted using a series of scoring systems such as CARPREG (CARdiac disease in PREGnancy) and ZAHARA. To date, however, higher-risk populations  have been under-represented in both systems; therefore, the currently recommended and most widely used scoring system is the World Health Organisation (mWHO) risk scale ,14, whicPatients are thus classified as: very low risk (class I), low to moderate risk (class II), high risk (class III), in which pregnancy is not advised, and lastly, extremely high risk (class IV), in which pregnancy is contraindicated .The first group (mWHO I) comprises minor corrected heart defects , mild pulmonary stenosis, minor valve defects and isolated atrial and ventricular extra-systoles.The second group (mWHO II) includes patients with minor uncorrected defects (ASD e VSD) and corrected tetralogy of Fallot, the majority of supraventricular and ventricular arrhythmias and Turner’s syndrome without aortic dilation.The intermediate group (mWHO II–III) comprises patients with mild ventricular dysfunction (EF > 45%), hypertrophic cardiomyopathy, mild mitral valve stenosis, moderate aortic stenosis, Marfan syndrome without aortic dilatation, aorta < 45 mm , repaired coarctation and repaired atrioventricular canal.2; patients with tetralogy of Fallot and aortic diameter < 50 mm.The third group (mWHO III) is made up of patients affected by moderate ventricular dysfunction, EF 30–45%, previous peripartum cardiomyopathy with no residual impairment of systolic function, patients with a mechanical valve, patients with Fontan circulation, systemic right ventricle with conserved or slightly reduced systolic function, cyanotic heart disease (unrepaired), moderate stenosis of the mitral valve, severe asymptomatic aortic stenosis, moderate aortic dilatation 40–45 mm in patients with Marfan syndrome, aortic dilatation 45–50 mm in patients with bicuspid aortic valve, patients with Turner’s syndrome and ASI (aortic size index) of 20–25 mm/m2; patients with tetralogy of Fallot and ascending aorta diameter > 50 mm, severe aortic coarctation, patients with complex Fontan circulation [The last group (mWHO IV) includes patients with any form of pulmonary arterial hypertension, severe systemic ventricular dysfunction , previous peripartum cardiomyopathy with residual ventricular dysfunction, severe stenosis of the mitral valve, severe symptomatic aortic stenosis, patients with moderate or severe systemic right ventricle dysfunction, Marfan syndrome with aortic dilatation > 45 mm, aortic dilatation > 50 mm in the context of aortic disease associated with bicuspid aortic valve, patients with Turner’s syndrome and ASI > 25 mm/mculation .Maternal mortality risk increases gradually between the first and last group patient groups, with a frequency of maternal cardiac events ranging from 2.5 to 5% amongst patients in the first group to 40–100% in patients from the 4th group .Pre-conception counselling should be provided to all women intending to initiate pregnancy, in particular patients affected by complex congenital heart disease. Counselling should be administered by either a cardiologist with expertise in the field of congenital adult heart disease or a gynaecologist with expertise in the specific field (multidisciplinary team) .Pregnant women with NYHA functional class I may not need to be managed in a tertiary care hospital, whilst patients with NYHA functional class II or higher should always receive care in this type of setting. Delivery should take place in a hospital setting equipped to provide adequate support to both mothers and infants .A pathophysiological classification of CHD  with relBelow, the authors evaluate pregnancy management in the presence of a series of major highly or moderately complex heart diseases.Tetralogy of Fallot (TOF) is a common cyanotic congenital heart disease accounting for approx. 5–6% of all congenital heart diseases. The American Heart Association classifies TOF as a moderately complex heart disease ,18.In the presence of TOF, gestational risks are associated with potential surgical repair, presence of residual defects and patient’s overall clinical status. Healthcare staff involved in patient care should be fully trained to recognise the different scenarios that may be presented. In the absence of significant residual defects or post-repair complications and presence of normal ventricular function pregnancy is considered low risk .Patients subjected to transannular patch repair tend to develop severe pulmonary insufficiency. Consequently, the right ventricle adapts to this continual volume overload by dilating (Frank-Starling law). Significantly dilated and malfunctioning right ventricles do not tolerate pregnancy well, and whilst pulmonary valve failure per se is not a serious problem, it does however add an additional volumetric burden beyond the physiological increase present in pregnancy. Prior to programming a pregnancy, pulmonary insufficiency should be corrected, preferably by means of percutaneous biological valve implantation, where possible, or alternatively, surgery. Although the indication for correction is clear in symptomatic patients, in asymptomatic patients, the case should be discussed regularly taking into account other parameters as illustrated in the European Society of Cardiology guidelines on congenital heart disease in adulthood . The preResidual stenosis is even worse tolerated than pulmonary insufficiency, whilst mild stenosis is generally well tolerated; it should however be taken into account that the condition will tend to worsen during pregnancy due to the higher volume of circulating blood .Complications of maternal heart disease have been described in 7–10% of cases, largely represented by supraventricular arrhythmias, symptomatic right heart failure, pulmonary embolism and progressive right ventricle enlargement .Frequency of check-ups should be based on the patient’s clinical and echocardiographic status.Patients receiving treatment with ace inhibitors should suspend treatment due to the risk of teratogenic effects on the foetus, whilst diuretics (furosemide) may continue to be used .Obstetric complications may arise in up to 30% of cases . VaginalEbstein anomaly, a moderately complex congenital heart disorder, accounts for less than 1% of all congenital heart diseases . Due to The main problems related to Ebstein anomaly include tricuspid valve insufficiency, heart failure, onset of arrhythmias and cyanosis which are variably manifested due to persistent presence of atrial septal defect or patent foramen ovale with consequent right-left shunt of desaturated blood. Patients displaying saturation levels of <85% and/or heart failure should be advised not to embark on pregnancy (Class IIa Level C) .Patients with valvular insufficiency and/or mild ventricular dysfunction should tolerate pregnancy well. Conversely, patients with significant pre-existing right or left cardiac dysfunction will tolerate pregnancy poorly due to inability of the heart to meet the required increase in cardiac output. Patients with severe symptomatic valvular insufficiency should undergo surgical correction prior to initiating pregnancy .The onset of prevalently supraventricular arrhythmias (including accessory pathway tachycardias such as Wolff–Parkinson–White syndrome) represents the most frequent complication linked to this condition and may result in less positive outcomes . To thisElectrical cardioversion is recommended in hemodynamically unstable patients, whilst those who are hemodynamically stable may be treated by means of vagal manoeuvres or use of adenosine. In patients with broad complex tachycardia, accessory pathway tachycardia cannot be excluded, thus indicating use of flecainide as a substitute for AV nodal blocking drugs .Major risk factors for the foetus are represented by maternal heart failure and degree of cyanosis, resulting in potential premature birth and small for gestational age infants. One study observed lower birth weight in infants delivered to mothers with cyanotic Ebstein anomaly compared to those born to non-cyanotic mothers (2.5 Kg vs. 3.1 Kg) . A perinFrequency of follow-up during pregnancy is guided by the clinical conditions of the mother. Women who are cyanotic women or present with ventricular dysfunction should be seen every one or two months. Vaginal delivery is recommended .Patients affected by systemic right ventricle were born with a transposition of the great arteries which was either congenitally corrected (cc-TGA) or underwent correction by means of palliative surgery. The latter is the case of a dextro-transposition of the great arteries (d-TGA) corrected by means of atrial switch using the Mustard or Senning procedure  . AlthougPatients with cc-TGA manifest complications associated with dysfunction of the right atrioventricular valve, dysfunction of the systemic right ventricle and electrical conduction disorders leading to complete AV block in 30% of cases .Conversely, the most frequently observed complications in d-TGV patients following atrial switch include arrhythmias , progressive subaortic left ventricular dysfunction, tricuspid valve insufficiency and intra-atrial baffle obstruction or leaks .Accordingly, following a Mustard/Senning procedure, patients with cc-TGA or d-TGA are advised to actively prevent pregnancy, particularly in the presence of an NYHA functional class III–IV, moderate-severe ventricular dysfunction with EF < 40% or severe tricuspid insufficiency (Class IIa Level c) . LikewisLiterature data relating to post-atrial switch patients are lacking and frequently contrasting. A study published several years ago compared a group of female patients who had undergone palliative atrial switch and later initiated a pregnancy with others who had never been pregnant. Mean duration of follow-up was 100 months. Worsening of systemic tricuspid valve regurgitation was observed amongst the group of pregnant women (52%), whilst no such findings were reported in patients from the other group. However, no significant differences were found with regard to worsening of systolic function, onset of arrhythmias or thromboembolic events. Infants were characterised by lower birth weight and intrauterine growth delay. In more than one third of women, tricuspid insufficiency did not decrease over the post-partum follow-up period . ConversThe onset of arrhythmias is generally treated with beta-blockers; however, particular caution should be exercised in patients with cc-TGA in view of the tendency to develop bradycardia caused by sinus node dysfunction during atrial switch or atrioventricular block .There is a paucity of data in literature focused on pregnancy in women with cc-TGA, the majority of which based on small retrospective samples. A study conducted by Kowalik et al. of 20 pregnant women with cc-TGA demonstrated that full-term pregnancy can be achieved. The most common cardiovascular complications observed were supraventricular arrhythmias. Long-term follow-up revealed no significant effect of pregnancy on systemic left ventricular function . PresencMoreover, in pregnant cc-TGA patients, progressive systemic tricuspid valve regurgitation is more severe than that observed following atrial switch in d-TGV .All studies highlighted how patients with systemic right ventricle, either congenital or manifested consequent to palliative surgery, tended to give birth to low birth weight infants . These pPulmonary hypertension (PH) is a disorder manifested secondary to numerous pathological conditions, including congenital heart disease. PH is defined as an increase in mean pulmonary pressure > 20 mmHg, increased pulmonary vascular resistance ≥ 3 Woods units and a wedge pressure ≤ 15 mmHg ,39.An additional sub-classification is present in the context of pulmonary hypertension manifested as a consequence of congenital defects .The first group is comprised of patients with Eisenmenger syndrome. Specifically, this includes all intracardiac and extracardiac defects initially manifested as systemic pulmonary shunt and progressing over time to determine severe elevation of pulmonary vascular resistance, thus resulting in systemic-pulmonary or bidirectional shunt.The second group includes patients affected by arterial pulmonary hypertension associated with prevalently systemic-pulmonary shunt, irrespective of correctability. These defects are of moderate-large entity; vascular resistance is only slightly or moderately increased, although systemic-pulmonary shunt is ongoing and cyanosis is present only on exertion.The third group is comprised of patients with marked increase in pulmonary vascular resistance in the presence of minor defects (VSD < 1 cm and ASD < 2 cm), or defects detected incidentally which alone would not determine an increase in pulmonary vascular resistance. Closure of these defects is contraindicated.Lastly, the fourth group includes patients prone to developing pulmonary arterial hypertension either immediately following correction of congenital heart defects or months or even years after correction .In view of the significantly higher risk of maternal mortality both during and after pregnancy in women with pulmonary arterial hypertension, pregnancy is strongly contraindicated (Class III Level B) . The leaNeonatal outcome is likewise poor. Foetal and/or neonatal mortality is in the range of approx. 7%, with premature birth occurring in approximately 86% of cases, and failure to thrive in 24% .Taking into account the pulmonary barrage manifested in patients with pulmonary arterial hypertension, it is clearly evident that this condition fails to adapt to the increased blood volume typically observed in pregnancy. Pulmonary circulation is unable to cope with the increased output that impinges on the right ventricle, thus resulting in heart failure. Moreover, these patients already present with an underlying prothrombotic status which is inevitably exacerbated during pregnancy; therefore, patients with Eisenmenger syndrome are characterised by an increased risk of paradoxical embolism. The efficacy of standard pharmacological treatment for PDE during pregnancy remains to be clarified. Advanced pharmacological treatment should be established as early as possible to prevent onset of cardiopulmonary failure. Animal studies have demonstrated the teratogenicity of endothelin receptor antagonists ; therefore, other classes of drugs such as phosphodiesterase inhibitors (sildenafil) and/or prostacyclin analogues should be used on a personalised basis. Nifedipine appears however to be safe for use in the treatment of reactive pulmonary arterial hypertension ,42.Once the patient has been warned that pregnancy is strongly contraindicated, if she still wishes to face the challenge involved, she should be immediately referred to a tertiary care centre for frequent clinical check-ups (even weekly) and taught how to recognise the early clinical signs and symptoms of heart failure .Delivery will be performed by scheduled caesarean section between 32 and 34 weeks gestation ,44. As sThis condition is classified as a highly complex heart disease  and is aThis type of circulation is characterised by a higher incidence of arrhythmias, increased risk of thrombosis and high systemic venous pressure. Furthermore, these patients are increasingly prone to developing long-term complications such as protein-losing enteropathy, plastic bronchitis, and systolic and diastolic dysfunction of the single ventricle . As mentThere is a relatively low risk (approximately 6%) of the foetus being born with congenital heart disease, although this percentage is higher than that observed in the general population. It is crucial therefore that the mother is given the opportunity to undergo a complete foetal echocardiogram during pregnancy .The increased blood volume typically observed during pregnancy represents a major challenge for a univentricular heart, particularly when dysfunctional or accompanied by insufficiency of the sole atrioventricular valve . To dateIndeed, in view of the increased risk of thromboembolism, if not already established, all patients should be prescribed anticoagulant treatment (class IIa) ,24.Monthly check-ups should be scheduled both throughout pregnancy and following delivery. Vaginal delivery is preferred due to the lower risk of associated infection, lower blood loss and lower risk of thromboembolism. Women affected by severe heart failure should however be delivered by caesarean section to minimise the effects of continual Valsalva manoeuvres that may be required during vaginal delivery .In women with mechanical valves, pregnancy is linked with a very high -risk of maternal, obstetric, and offspring complications (mWHO class III). In the ROPAC registry, the chances of an event-free pregnancy with a live birth were just 58% for women with a mechanical valve .Regarding maternal risk, the chance of mechanical valve thrombosis is significantly during pregnancy. It decreases with adequate dosing of anticoagulant therapy, varies on the basis of type and position of the mechanical valve, and on the basis of additional patient-related risk factors . CurrentAs regards obstetric and offspring risk, all anticoagulant therapies carry an increased risk of miscarriage and bleeding . In the Oral vitamin k antagonists are the most efficient anticoagulant therapy against these complications in ACHD pregnant ladies. However, they can trigger foetal complications. In fact, since warfarin has a low molecular weight, it crosses the placenta and harms the foetus. It is the so-called foetal warfarin syndrome or warfarin embriopathy, a well-recognised complication of first trimester warfarin use in pregnancy. The disease is characterised by nasal hypoplasia and skeletal abnormalities, including short limbs and digits, and stippled epiphyses. Even when taken in the second or third trimester, warfarin can cause optic nerve atrophy, developmental delay, and microcephaly. ESC guidelines suggest administering warfarin just in the second and third trimester . MaternaWith oral vitamin k antagonists therapy, haemorragic risk during vaginal delivery is not increased. On the contrary, it is augmented in case of caesarian section . WarfariMany cardiac medicines appear safe for use amid and after pregnancy. However, evidence is lacking for some of them. Many of them carry risk of adverse events. Shared decision making, considering risks and benefits of drugs, is crucial to help women weigh up potential risks to themselves and their unborn babies.Regarding beta blockers, they are commonly used by pregnant women. However, foetal bradycardia, hypotension, and hypoglycaemia are often reported along with low birth weight .Concerning antiarrhythmic agents, amiodarone might be used in special circumstances, although it is linked with a risk of hypothyroidism, goitre, bradycardia, foetal growth restriction, and prematurity at birth . The eviDiuretics such as furosemide, bumetanide, and hydrochlorothiazide can cause oligohydroamnios and electrolyte imbalance in the foetus.As regards anticoagulants, warfarin carries a risk of foetal abnormalities if used in the first trimester of pregnancy. It can cause intracranial foetal bleeding in the second trimester. Low-molecular-weight heparin can seldom trigger osteoporosis and markedly less throbocytopenia than unfractionated heparin .The drugs which are contraindicated in pregnancy are angiotensin converting enzyme inhibitors and angiotensin receptor blockers  and spironolactone  .The risk of CHD recurring in the offspring of women affected by congenital heart defects however is not trivial. As a general rule, foetal echocardiography is routinely used to check the developing heart to rule out this risk, although the presence of CHD may at times be missed at ultrasound scan. In this setting, metabolomics might represent a novel technique for use in detecting CHD in utero with a higher sensitivity and specificity than foetal echocardiography. As an example, several studies have succeeded in identifying different metabolic fingerprints when analysing maternal fluids  during the first, second, and third trimester of pregnancy. The findings obtained indicated an apparent link with risk of developing CHD in the offspring ,59,60,61Although not completely devoid of risk, pregnancy can be managed in virtually all patients affected by even the most complex forms of congenital heart disease. It is not however advisable in patients with any form of pulmonary arterial hypertension. Pregnancy is even manageable in patients with Fontan circulation. A personalised risk stratification should be performed, and patients affected by advanced NYHA functional class appropriately warned of the potential risks.All pregnancies, particularly those at higher risk, should be managed in a tertiary care centre capable of providing the necessary assistance to both the mother and infant.With a few rare exceptions, vaginal delivery is to be preferred over caesarean section due to the lower degree of maternal and foetal complications .The desire for motherhood, at times extreme in women with congenital heart disease, may often be accomplished, thus providing a ray of hope in the lives of these patients.


Understanding human mobility patterns is vital for the coordinated development of cities in urban agglomerations. Existing mobility models can capture single-scale travel behavior within or between cities, but the unified modeling of multi-scale human mobility in urban agglomerations is still analytically and computationally intractable. In this study, by simulating people’s mental representations of physical space, we decompose and model the human travel choice process as a cascaded multi-class classification problem. Our multi-scale unified model, built upon cascaded deep neural networks, can predict human mobility in world-class urban agglomerations with thousands of regions. By incorporating individual memory features and population attractiveness features extracted by a graph generative adversarial network, our model can simultaneously predict multi-scale individual and population mobility patterns within urban agglomerations. Our model serves as an exemplar framework for reproducing universal-scale laws of human mobility across various spatial scales, providing vital decision support for urban settings of urban agglomerations. •We propose a multi-scale unified model of human mobility in urban agglomerations•A cascaded deep neural network is used to simulate human travel choice processes•A generative adversarial network is used to extract population attractiveness features•The model can predict multi-scale travel patterns for individuals and populations As urban areas develop, neighboring cities gradually converge to form highly integrated urban spatial forms through a process known as urban agglomeration. Within urban agglomerations, travel occurs at different spatial scales, for example, within local neighborhoods, within cities, or between cities. This makes understanding human mobility in urban agglomerations inherently complex. While various models have been developed in the past to describe human mobility, they generally cannot model and predict the complex multi-scale travel that occurs within urban agglomerations. Methods that can better model mobility in complex urban agglomerations could have significant practical implications for topics such as urban resource management, disease control, and transportation hub optimization. One major weakness of current human mobility models is their inability to accurately measure and quantify large-scale human movements between regions in urban agglomerations. By simulating people’s mental representations of physical space, a novel multi-scale unified model based on cascaded deep neural networks is proposed for human mobility prediction within urban agglomerations. The model simulates people’s hierarchical travel selection behavior and can reproduce the universal-scale laws of individuals and populations in urban agglomerations with thousands of regions. Such inter- or intra-city movements and interactions promote economic circulation and cultural exchange between cities in urban agglomerations.,,,,,Human mobility within urban agglomerations encompasses a wide range of spatial scales, such as intracity, intercity, and interstate. The dynamics of travel behavior are implicitly confined by geographical boundaries, administrative divisions, and transportation facilities,,,From a methodological perspective, existing studiesTo address these issues, we propose a multi-scale unified model (MSUM) to achieve a unified human mobility prediction at multiple spatial scales in urban agglomerations. To characterize the human hierarchical travel choice process, MSUM embeds a cascaded multi-class classifier based on deep convolutional neural networkssoftmaxMSUM is inspired by the classical NL modelIn MSUM, individual travel choice at multiple spatial scales within urban agglomerations is regarded as the process of hierarchically selecting the correct class with the greatest utility from candidate locations A. That iGGAN see C. The gecounty as the primary spatial scale in the urban agglomeration, and further divide the corresponding counties into 7,731, 15,156, and 10,114 non-overlapping square regions according to their area to represent the secondary spatial scale . The mobility data for the Boswash and Great Lakes urban agglomerations are user check-in data from the website Weeplaces,,GGAN is proposed to accurately and robustly predict the single-scale  human trip distribution in urban agglomerations, and it can provide more reliable population attractiveness features for MSUM compared with benchmark models  shows the average performance evaluation results of the inter-community travel flow predictions for all counties. Similar to the county scale, the overall prediction performance of GGAN is better than that of the other two baseline models. The distribution of CPC values for each model at the community scale is shown in To investigate the model’s prediction performance in different active regions, we divide the counties in each urban agglomeration into 10 groups based on county travel volume and rank them in descending order. We then calculate the prediction performance of the trip distribution at the community scale for each group  mobility patterns of different active regions compared with state-of-the-art population mobility models, and it provides a reliable characterization of location attractiveness. For the mobility prediction at multiple spatial scales, taking the Great Lakes urban agglomeration as an example, the human activity space increases from 273 to 15,156 regions. This increase of spatial scale leads to sparsity of data and uncertainty of human activities, amplifying the difficulty of accurate mobility prediction. By simulating the human behavior selection mechanism  to construct a cascaded multi-class classification framework, and leveraging the powerful feature extraction capability of deep neural networks, our MSUM can implicitly reduce the solution space of travel choice layer by layer, thereby accurately capturing various scaling laws in accordance with empirical data, such as the radius of gyration distribution, trip distance distribution, and trip number distribution between two locations.As the main form of settlement in modern human society, understanding the multi-scale mobility patterns of individuals and populations within urban agglomerations can support decision-making for various urban settings. In particular, our model can precisely describe travel behavior at the individual level, unlocking unprecedented possibilities for refined realistic simulation, epidemic prevention and control prediction, regional development, urban planning, transportation planning, etc. For example, the quantitative evaluation results demonstrate that our model can predict travel flow between large-scale regions  more accurately than state-of-the-art individual mobility models. Regarding infrastructure construction, urban decision-makers can identify underdeveloped areas within the urban agglomeration based on the frequency of travel visits between regions and make direct investments to promote balanced growth and development. Simultaneously, the multi-scale mobility prediction results help identify popular tourist destinations and routes for tourism-driven cities. By understanding where individuals spend the most time, tourism managers can focus on improving infrastructure and providing better services, such as providing more passenger corridors or strengthening measures in regions with frequent travel to avoid congestion caused by a large number of trips. Regarding transportation planning, trip distribution prediction results at different spatial scales can assist managers in building intelligent transportation systems. The prediction results of short-distance trips can help optimize the design and operation of public transportation lines within urban agglomerations, ensure that public transportation services are close to citizens' actual needs, and improve public transportation system efficiency and convenience. With long-distance trip distribution prediction results, managers can formulate and optimize transportation networks based on travel needs and recommend multi-modal travel services,Our study has some limitations that should be addressed in future research. MSUM extends the classical NL model by constructing a cascaded deep CNN framework to simulate and express the mechanism of human hierarchical travel choices. The interpretability of deep neural networks remains a key challenge in advancing the understanding of probabilistic relationships between input features  and corresponding travel choices. The abstract feature information extracted by GGAN and deep CNN can be analyzed by future studies using game theory, agnostic,chenxiqun@zju.edu.cn).Further information and requests for resources and reagents should be directed to and will be fulfilled by the lead contact, Xiqun (Michael) Chen . To represent the finer scale regions , we used the Python library scikit-mobilityRegional boundary data for the Boswash, Great Lakes, and England urban agglomerations were provided by the American Regional Planning AssociationAll experimental analyses were based on two check-in datasets collected from publicly available location-based social networks. The first dataset was collected by Gowalla(1)Individual memory and population attractiveness features are concatenated as feature inputs of MSUM for feature extraction. Specifically, to consider an individual’s current location dynamically, we divide the individual memory features into global ((2)The concatenation vectors are input into CNN (see (3)The model output is a vector representing the classification results at the corresponding scale. The vector length equals the total number of classes under the corresponding scale; the smaller the scale, the larger the vector length. To associate the selection results of different scales, the classification probability output of the upper CNN is multiplied by that of the lower CNN to achieve the constraint of hierarchical selection. For example, when an individual has a low probability of selecting a county, s/he is less likely to select a community within that county. Moreover, the classification error of the lower-layer CNN propagates to the upper layer, affecting and participating in updating the network parameters of the upper-layer CNN.The specific implementation process of MSUM includes the following three steps B.(1)Indi(1)Assuming that the total number of movement steps of individual (2)The location after (3)The individual’s historical memory feature vector is updated. Repeat step (2) to complete the individual trace simulation with Given the trained MSUM, we can simulate individual travel traces using the following three steps.For GGAN, we construct a test set by setting a random missing rate of 20% to mask the travel volumes between some locations as missing data. For the non-missing 80% of the data, we generate sufficient training samples by repeatedly performing random masking of 10% of the travel volume information. GGAN is trained for 1,000 epochs using the Adam optimizer


There have been increasing reports of cardiovascular complications of androgen deprivation therapy (ADT) leading to worse outcomes among patients with prostate cancer. While this may result from the direct effects of androgen suppression in the cardiovascular systems, there are ADT-type-specific distinct cardiovascular complications suggestive of mechanisms beyond androgen-mediated. Thus, it is critical to understand the biological and clinical impact of ADT on the cardiovascular system.Gonadotropin-releasing hormone (GnRH) agonists cause increased cardiovascular events compared to GnRH antagonists. Androgen receptor antagonists are linked to an increased risk of long QT syndrome, torsades de pointes, and sudden cardiac death. Androgen synthesis inhibitors are associated with increased rates of hypertension, atrial tachyarrhythmia, and, in rare incidences, heart failure.ADT increases the risk of cardiovascular disease. The risk among ADT drugs differs and must be evaluated to develop a medically optimal plan for prostate cancer patients. ADT is used to lower androgen levels to castration levels through surgical or pharmacologic therapies and has emerged as one of the leading therapies for prostate cancer. While cancer-related survival has significantly improved following the use of ADT, there have been increasing reports of cardiovascular (CV) complications associated with ADT . Recent Androgens are male sex hormones involved in the development and maintenance of reproductive tissues Fig. A 3]. In. In3]. IAndrogen signaling involves an androgen receptor (AR) and its ligand, androgen. AR is encoded on an X chromosome  and is rThe role of androgens in the CV system has been actively studied throughout the past few decades. Historically, testosterone, the main form of androgens, was believed to increase the risk for cardiovascular disease (CVD) ; men werVascular impact: Testosterone plays key roles in various physiological processes, many of which are potentially linked to reduced CV risk and cardioprotection. It has been well documented that endothelial progenitor cells (EPCs) are crucial in promoting endothelial healing and maintaining vascular integrity ) than in other ADT  [AR inhibitors  and CYP17 inhibitors  are newer-generation androgen deprivation therapies used for metastatic castration-resistant prostate cancer (mCRPC). As discussed in the earlier section, these drugs target the androgen receptor or its activation, and both have been shown to be clinically effective, particularly in high-risk prostate cancer patients . While eprorelin , due in prorelin , 30. Mea 0.0001) . In anot 0.0001) . Other R 0.0001) .Though the utilization of surgical castration has declined over time , multiplhttps://www.heart.org/en/healthy-living/healthy-lifestyle/lifes-essential-8). While there are no specific CVD monitoring guidelines for patients on ADT, the care team should have a lower threshold for monitoring and treating the patients on ADT for possible CVD given the heightened risk of CV events compared to the general population. Otherwise, the treatment for adverse cardiovascular events such as MI or HF should follow standard guidelines. Finally, patient involvement in treatment decisions as well as patient education regarding potential adverse CV effects during the course of ADT would be important in the overall care given the often long-term nature of ADT.The first step when caring for prostate cancer patients being considered for ADT is to be aware of the potential cardiovascular complications of ADT as described above and to comprehensively assess patients’ baseline cardiovascular health, especially regarding their preexisting CVD and/or risk factors. Before initiating an ADT, if patients have prior history of CVD or multiple CV risk factors, the care team may consider referral to cardiology or cardio-oncology for further assessment and CV optimization, as well as for multidisciplinary discussion regarding the risks and benefits of different types of ADT. Second, during the course of ADT, it is recommended that the care team focuses on CVD prevention by managing CV risk factors; for instance, patients should be encouraged to follow American Heart Association (AHA)’s 8 life’s essential key measures for improving and maintaining cardiovascular health, which include to (1) eat better, (2) be more active, (3) quit tobacco, (4) get healthy sleep, (5) manage weight, (6) control cholesterol, (7) manage blood sugar, and (8) manage blood pressure (The use of ADT has been instrumental in reducing mortality rates in PCa patients. The mechanism of action for various types of ADT ties into a negative feedback loop regulated by the endocrine system, which is tightly coordinated by various essential modulators designed to either downregulate or overstimulate hormone production, which has been effective in slowing cancer growth. However, the adverse cardiovascular implication associated with long-term ADT use is profound and needs to be addressed to ensure that risk is at a minimum. The potential cardioprotective role of androgens regarding heart health has only partially been elucidated, and more research needs to be conducted to evaluate how/why ADTs lead to CVD. For instance, future studies could potentially perform gene expression and bioinformatic analysis to gain an in-depth understanding of the plethora of genes that are upregulated or downregulated in the cardiovascular system modulated by the different types of ADT. This will allow healthcare professionals to better understand how each drug affects individual patients differently, thus creating a platform for personalized medicine. This customized approach will ultimately serve as the future of cancer therapy and the management of CV complications.


Legumes are extremely valuable because of their high protein content and several other nutritional components. The major challenge lies in maintaining the quantity and quality of protein and other nutritional compounds in view of climate change conditions. The global need for plant-based proteins has increased the demand for seeds with a high protein content that includes essential amino acids. Genome-wide association studies (GWAS) have evolved as a standard approach in agricultural genetics for examining such intricate characters. Recent development in machine learning methods shows promising applications for dimensionality reduction, which is a major challenge in GWAS. With the advancement in biotechnology, sequencing, and bioinformatics tools, estimation of linkage disequilibrium (LD) based associations between a genome-wide collection of single-nucleotide polymorphisms (SNPs) and desired phenotypic traits has become accessible. The markers from GWAS could be utilized for genomic selection (GS) to predict superior lines by calculating genomic estimated breeding values (GEBVs). For prediction accuracy, an assortment of statistical models could be utilized, such as ridge regression best linear unbiased prediction (rrBLUP), genomic best linear unbiased predictor (gBLUP), Bayesian, and random forest (RF). Both naturally diverse germplasm panels and family-based breeding populations can be used for association mapping based on the nature of the breeding system (inbred or outbred) in the plant species. MAGIC, MCILs, RIAILs, NAM, and ROAM are being used for association mapping in several crops. Several modifications of NAM, such as doubled haploid NAM (DH-NAM), backcross NAM (BC-NAM), and advanced backcross NAM (AB-NAM), have also been used in crops like rice, wheat, maize, barley mustard, etc. for reliable marker-trait associations (MTAs), phenotyping accuracy is equally important as genotyping. Highthroughput genotyping, phenomics, and computational techniques have advanced during the past few years, making it possible to explore such enormous datasets. Each population has unique virtues and flaws at the genomics and phenomics levels, which will be covered in more detail in this review study. The current investigation includes utilizing elite breeding lines as association mapping population, optimizing the choice of GWAS selection, population size, and hurdles in phenotyping, and statistical methods which will analyze competitive traits in legume breeding. The term legume originated from the Latin word “legumen”, which denotes “seeds harvested in pods”. During the Neolithic Revolution, which marked the beginning of human farming methods, farmers were accompanied by legumes that belong to the family Fabaceae. It is acknowledged that inadequate protein-energy intake and micronutrient deficits are two of the primary causes of undernutrition. Legumes play a minor but significant role in our food system. They are the superior economical dietary solutions due to their rich protein content (17%–30%) and relevant nutritional richness compared to expensive food sources containing animal-based protein and dairy products that may be difficult to obtain in situations where there is food insecurity .2O) and carbon dioxide (CO2). In addition, they can help to reduce the utilization of fossil-based energy inputs in the chain of agriculture and food production by infusing high-quality organic matter, facilitating nutrient circulation, and promoting water retention in the soil  is an effective technique for determining the genes underlying a particular trait. To accomplish this, it is ideal to assess the genomic regions where genotypic and phenotypic variations are correlated with each other. In comparison to standard biparental populations, GWAS offers greater mapping precision for detecting interactions among molecular markers and desirable characteristics in a variety of crops . It has Furthermore, improvements can be applied in fields like omic-wide association studies, which utilize GWAS techniques to analyze relationships among desirable morphological traits and other kinds of omics data that include transcriptomic or metabolomic. GWAS requires structuring the population of diverse panels to estimate genetic distinction and minimize the detection of spurious connections . BreederAssociation mapping (AM), an alternative to QTL mapping, is dependent on linkage disequilibrium (LD) and uses collections of genotypes with known or unknown ancestry that have a significant degree of genetic variation due to hundreds of recombination cycles. The ultimate goal of association studies is to find a strong correlation between a genome-wide DNA marker and an interesting attribute that can be highly useful in marker-assisted selection for crop development. GWAS and candidate gene (CG)–based analysis are two important approaches to AM.The creation of a mapping population that will be tested for the marker–trait relationship is a prerequisite for the GWAS. Both broad-based natural populations and narrow-based breeding populations can be utilized as the mapping population for GWAS Figure 1Any naturally occurring panmictic population with a significant history of recombination events can undergo AM. Utilizing hundreds of recombination events makes it simple to do an LD analysis of the target characteristic. These populations, however, are not appropriate for QTL mapping. When a germplasm accession collection represents the natural population, it may be a core collection or a sample that is more resilient to environmental changes. The population is excellent for assessing the QTLs for rare alleles that can help develop elite breeding lines or highly heritable domestic features. QTLs for some agronomically key characteristics have been uncovered in germplasms of several crops using GWAS, such as in 135 pea accessions , 366 sesThe cultivars and lines created by a deliberate breeding program are known as elite inbred lines. These lines are unbreakable and can be maintained by numerous researchers in various places to identify QTLs using an AM panel. For instance, two AM panels of maize having 306 dent corn and 292 European flint corn inbred lines were individually assessed using single-nucleotide polymorphism (SNP) markers in the cold and control growth chamber conditions to identify genes related to cold tolerance . For GWASalix sp.) identified several major QTLs along with QTL hotspots (Recombinant inbred lines (RILs) and Near Isogenic Lines (NILs) are the most used biparental population, usually used for linkage mapping or Quantitative Trait Locus (QTL) or QTL mapping. Whereas the power of QTL identification is higher in linkage mapping as compared to AM, the resolution has a reverse relationship with both mapping schemes. The concept of joint linkage AM (JLAM) was introduced to fully exploit the capabilities of both mapping methods. JLAM uses either a biparental population set or one or more multiparental AM panels, or two sets of genotypes consisting of germplasm and biparental mapping populations, which are genotyped utilizing the same set of markers . Hence, hotspots . Severalhotspots , pleiotrhotspots , and thehotspots . Recent hotspots .The multiparent populations include several founder parents, which reflect wider genetic diversity. Hence, in AM studies, the use of multiparent mapping populations helps limit the demerit of recombination frequency in biparental populations. Multiparent mapping populations provides tools to control population structure and balance allele frequencies. The historical and artificial recombinational events of the multiparent mapping populations such as NAM and MAGIC populations and their derivatives increase the efficiency of QTL identification in AM. Because of the controlled crosses, NAM population has higher power because of maximized population structure and minimal familial relatedness and accumulated frequency of rare alleles. The population facilitates cost-effective GWAS and allows the perpetual sharing of the NAM panel with global researchers.2F4:6 lines, which were derived from 25 wild barley accessions by backcrossing to the cultivar Rasmusson , eight-way cross, and single/double round robin. NAM population was first developed in maize using RILs developed from a diverse set of parents. Twenty-five diverse families in maize were used to develop 5,000 RILs that were evaluated for southern leaf blight disease resistance , and theasmusson . Using 3asmusson .Vigna unguiculata) , highly homozygous lines will be developed to establish the MAGIC population. To develop MAGIC populations for wheat and rice that can be deployed for QTL mapping, indica and japonica lines have been adopted. Seven cycles of SSD selfing resulted in 305 F8 lines in cowpea (iculata) . In the iculata) .The molecular markers are being progressively used to expedite breeding efforts in the post-genome sequencing era. Modern plant breeding is shifting from classical breeding to molecular breeding, where various genotyping technologies are being used for the discovery of molecular markers. In the last decade, a huge number of molecular markers were used for structural analysis of large germplasm populations to understand the diversity and use in GWAS. The whole-genome sequencing for most of leguminous crops has already been completed. Chromosome-level genomes are completed for most of the leguminous crops . In the Molecular markers have become crucial components in molecular breeding over the past 2 years . MoleculHowever, continuous improvement of next-generation sequencing (NGS) technologies in recent years has made it cost-effective and accessible for any crop, including legumes . ReferenAmplification of DNA segments with PCR leads to the development of multiple genotyping methods. If the primers in a PCR reaction include the variation of interest, then it is called as allele-specific PCR. Allele-specific markers are generally used during foreground selection during marker assisted selection. PCR-Restriction Fragment Length Polymorphism (RFLP) is another method of PCR-based genotyping , where tAlthough the SSRs are a potent marker system because of high reproducibility, co-dominance, and polymorphism, it is time, therefore, to generate the thousands of genome-wide SNP markers, restriction-sites associated with DNA sequencing (RADSeq) for large populations to study population genetics and genetic dissection of complex traits . HoweverQTL-hotspot” was discovered with 743 SNP loci  was screened using 554 DArT markers. Cicer species, including 94 genotypes. Aldemir and coworkers (2017) used an advanced version of DArT technology, i.e., DArt sequencing (DArTseq), for the identification of QTL for iron content in lentil seeds. DArTseq is also a hybridization-based technology but combines with NGS and provides a much simpler form of sequencing than DArT , PacBio (10–25Kb), and NanoPore (read size of 500 bp to 2.3 Mb). Large LD blocks  in plants, specially self-pollinating. Large LD blocks include several CGs. Therefore, with dense genotyping, we can have SNP variants in each of the CGs in the block and individual CGs can be identified using GWAS carried out on WGRS genotyping data. A gene for salinity tolerance  soybean . Recentl soybean .In the era of different omics like genomics, transcriptomics, and proteomics with the help of NGS technologies, genotyping of large germplasm at multiple locations has become feasible for plant scientists. Thus, phenotyping these large germplasms/populations with higher accuracy have become difficult. Thus, high-throughput genotyping technologies have shifted the bottleneck of plant science from genotyping to phenotyping . Thus, iGWAS has continuously expanded in the last few decades due to advancements in sequencing technologies and the collective effort of the research community. In addition, HTP technologies have allowed us to measure many plant traits that are now frequently analyzed through GWAS tools. Recent years have seen GWAS methods solving issues of computation complexity or enhancing statistical power. It is utilized to detect new associations with traits of interest and to replicate loci detected by other different approaches. A diverse set of researchers is involved in rare-variant detection, statistical model optimization, synthetic associations, and using GWAS findings to better our knowledge of disease etiology. These methods can detect genetic variants associated with biochemical or agronomic and molecular phenotypes. In the future, this will enhance the utility of GWAS methods and their implications for plant science.In the GWAS, linear or logistic regression models are used to test for associations. The linear model is used for continuous traits such as plant height, whereas logistic regression models are used for binary traits indicating that the disease is present or absent. In addition, some covariates are included to account for confounding effects from demographic factors. However, naïve approaches often suffer from inflated false-positive rates that might be induced due to genetic relatedness among study participants . In GWASThe MLM frameworks used in GWAS have drastically decreased the false-positive rates in comparison with conventional naïve approaches. Among these, the fast GWA tool is an ultra-efficient tool for MLM-based GWAS analysis of biobank-scale data . MLM appRecent years have seen tremendous growth in the machine learning methods targeted for GWAS. The approaches used by these methods include classification, regression, ensemble-based learning, and neural networks.Logistic regression coupled with the least absolute shrinkage and selection operator (LASSO) regularization approach is a famous method for GWAS. The penalized logistic regression method was used for the classification of patients with Crohn’s disease using genotyping data at the genome-wide level. The LASSO and ridge regression are among the most frequently utilized penalized regression algorithms . RecentlSupport vector machine (SVM)–based classification methods such as COMBI have been developed for unknown phenotype prediction for a given unseen genotype . In thisThese methods comprise an ensemble of decision trees. For example, random forest is an example of the ensemble learning algorithm. A bootstrapped subsample of the initial training dataset is used to create each decision tree in this instance. Some authors used gradient-boosting and random forest approaches to identify potent SNPs . Nguyen Transcriptome-wide association study (TWAS) methods perform association analysis for gene expression variations and quantitative traits. TWAS is an approach based on genes with the ability to expand GWAS for a better understanding of functional relationships in complex traits. These methods are alternatives to variant-based association methods representing a subgroup of multi-marker association or locus-based methods. The locus-based methods have been so popular due to the larger apprehension and acceptability of the polygenic framework of the complex traits. In principle, locus-based approaches rely on multiple genetic variants to estimate the contribution of a gene or loci. TWAS uses GWAS results and transcriptome-level information to perform association testing at the gene level . The abiPheWAS methods perform unique associations in addition to utilizing known genotype–phenotype associations acquired through GWAS. These established relationships might serve as “positive controls” for additional high-throughput analysis. PheWAS methods suffer from high false-positive rates due to thousands of genotype–phenotype associations being tested in such studies . In addiGS has been utilized as a practical genomic approach for upgrading complex traits in various crops . In segrZhang and coworkers (2016) showed a GWAS-assisted GS with 309 soybean lines and 31,405 SNPs for seed weight using the rrBLUP approach. They showed GS prediction accuracies of 0.75–0.87, outperforming marker-assisted selection with prediction accuracies of 0.62–0.75. In alfalfa, In chickpeas, In common bean, cooking time (CKT), seed weight, and water absorption capacity were evaluated using 922 lines consisting of four populations  panel . Six modIn peanut or groundnut, 281 Kersting’s groundnut lines were used for GWAS-assisted GSs for several traits, including seed traits, 100 seed weight, leaf length, days to 50% flowering, and days to maturity using 493 SNPs and rrBLUP model . They reRecently, genomic resources have been made available in some minor legume crops . In peasSeveral GS methods were used for predicting GEBVs in legume crops Figure 2Since the last decade, GWAS has been successfully used in major legume crops to dissect or identify the genetic bases for various agronomic traits , qualityRevolutionization and rapid development in genomic techniques in the recent past have accelerated molecular studies not only in model crops but also in other crops like legumes . SequencLegumes are an essential component of human nutrition and play a vital role in sustainable agriculture due to their protein-rich content, soil quality improvement, and reduced environmental impact. With the increasing global population and changing climatic conditions, there is a pressing need to develop high-yielding, disease-resistant legume cultivars that can meet the nutritional needs of the growing population. Improvement in the nutritional and production quality of legume crops with the use of conventional breeding methods is not at the required rate. Whole-genome sequencing is available only for a few major crops. As per the availability, low (RFLP) to high-throughput (SNP) markers have been used in various crops for AM, QTL mapping, or GWAS. NGS has become feasible in the model and even in non-model crops with improved efficiency and affordable sequencing methods. GWAS has been used in major legume crops to identify the genomic region linked with desired characteristics of the plant. It is yet to be exploited in minor legumes with sufficient germplasm/population. The availability of reference genomes and rapid development in genomic techniques has made it feasible for researchers to identify the alleles/QTL association with the desired trait in any germplasm. The use of suitable models, methods, and bioinformatic tools determines the accuracy of GWAS. The development of model tools for legume crops can trigger GWAS in major and minor legume crops. Authentication or precision of identified marker–trait association is required for their utilization in plant breeding programs or MAS/BAC programs. Using NGS and other high-throughput techniques for sequencing will make it possible to develop a genomic-assisted crop improvement program in legumes. Rapid development can be gained concerning agronomic traits, biotic/abiotic stress tolerance, and after-use quality improvement. Legume yield potential is meager compared to other major crops; this yield plateau can be broken in legumes for climate change problems using GWAS with multi-location phenotyping. The integration of these new and improved technologies with traditional breeding methods will help to accelerate the development of new legume cultivars with improved yield and nutritional qualities.PS, PK conceptualized the review study and edited the manuscript. PY contributed to advanced methods and tools for GWAS. SS put forth experimental populations for association mapping studies in various crops. GK was associated with GWAS-assisted genomic selection. SSG and MP contributed to new high throughput-genotyping technologies in plants. VS and TT assisted in collecting data for applications of GWAS in plant breeding and drafting the manuscript. All authors contributed to the article and approved the submitted version.


Metabolomics is the analytical study of metabolites in biological matrices using high-throughput profiling. Traditionally, the metabolome has been studied to identify various biomarkers for the diagnosis and pathophysiology of disease. Over the last decade, metabolomic research has grown to include the identification of prognostic markers, the development of novel treatment strategies, and the prediction of disease severity. In this review, we summarized the available evidence on the use of metabolome profiling in neurocritical care populations. Specifically, we focused on aneurysmal subarachnoid hemorrhage, traumatic brain injury, and intracranial hemorrhage to identify the gaps in the current literature and to provide direction for future studies. A primary literature search of the Medline and EMBASE databases was conducted. Upon removing duplicate studies, abstract screening and full-text screening were performed. We screened 648 studies and extracted data from 17 studies. Based on the current evidence, the utility of metabolomic profiling has been limited due to inconsistencies amongst studies and a lack of reproducible data. Studies identified various biomarkers for diagnosis, prognosis, and treatment modification. However, studies evaluated and identified different metabolites, resulting in an inability to compare the study results. Future research towards addressing the gaps in the current literature, including reproducing data on the use of specific metabolite panels, is needed. Metabolomics, the study of metabolites in biological matrices, is a crucial tool for identifying biomarkers and developing individualized treatment plans . It alsoA literature search of databases of available evidence pertaining to metabolome profiling in life-threatening neurological conditions in humans was conducted. Databases searched included Medline and EMBASE from inception to 7 June 2022. Keywords utilized were [ AND (“metabolomics” OR “metabolome”)]. After the removal of duplicates, the remaining studies underwent title and abstract screening. Studies on neurological conditions outside of the interest of this review and studies analyzing metabolome profiling outside of the acute phase were excluded. Nonhuman and non-English studies that could not be easily translated into English, as well as review articles, summary resources, commentaries, or editorials, were excluded.As depicted in Metabolome profiling has been evaluated for a variety of applications in neurocritical conditions. Emerging data support the potential utility of metabolomic analysis in diagnosis and differential diagnosis, prognosis and functional outcome prediction, identification of underlying pathophysiological pathways, and many other clinical implications.aSAH is a serious medical condition resulting from bleeding in the subarachnoid space secondary to a ruptured intracranial aneurysm. aSAH can have a significant burden on patients, families, and society. The mortality rate for aSAH is high, with up to 50% of patients dying within the first few weeks after onset. Among those who survive, many may experience long-term disabilities, such as cognitive impairment and motor deficits. Despite advancements in research, the pathophysiology of aSAH remains uncertain and clinical outcomes remain poor ,4,5. A tA prospective case–control study by Dunne et al., 2004 reported that elevated lactate and glutamine concentrations as well as decreased glucose concentration were associated with Hunt and Hess (H&H) grade, Glasgow Coma scale (GCS), measures of disease severity, and with the cognitive outcome score (COS), a measure of patient outcomes . ElevatiTwo studies investigated the potential association between metabolites and modified Rankin Scale (mRS) at discharge and at 90 days, a common functional outcome scale in stroke studies. They analyzed samples collected on days 0–5, 6–10, and 11–14 post-bleeding utilizing LC/MS . AdditioIn the retrospective cohort study by Sjöberg et al., 2015, venous blood samples were analyzed using GC/MS . The stuProspective cohort studies by Li et al., 2019 and Lu et al., 2018 analyzed CSF samples using GC/TOF-MS ,8. Li etIn conclusion, with emerging evidence, metabolomics profiling can be utilized to predict long-term outcomes and cognitive impairment in aSAH patients. However, caution should be exercised when interpreting current data due to inter-variability in metabolites identified and analyzed in these studies. Further studies should be conducted to replicate the results of current studies and address the limitations of study designs as identified.TBI is a major cause of death and disability in young adults worldwide . By 2031Two prospective studies correlated the metabolomic profiles with brain imaging findings following TBI. Thomas et al., 2020 performed untargeted metabolomic analysis utilizing GC-TOFMS . Serum sAs opposed to untargeted analysis, Fiandaca et al., 2018 performed a targeted six-metabolite panel analysis utilizing tandem MS/MS to objectively classify college athletes sustaining moderate TBI from non-injured teammates within 6 h of trauma . The sixTwo studies conducted metabolomic analysis in cerebral microdialysates. Cerebral microdialysis is an emerging technique used to measure the chemical composition of the extracellular fluid in the brain. In neurocritical care, cerebral microdialysis is used to monitor the metabolic and biochemical changes that occur in the brain after brain injury. By analyzing the chemical composition of the extracellular fluid, clinicians can assess the extent of brain damage, monitor the effectiveness of treatments, and detect complications such as cerebral edema or ischemia. Orešič et al., 2016 sampled serum and cerebral microdialysates from patients with mild, moderate and severe TBI, and performed untargeted metabolic analysis . The samUtilizing urine samples for metabolomic analysis is more feasible and readily available compared to cerebral microdialysis and CSF sampling. Bykowski et al., 2021 utilized 1H-NMR to analyze urine samples from patients with TBI drawn at 7 days and 6 months post-injury . HomovanGlenn et al., 2013 employed 1H-NMR to conduct targeted metabolomic analysis on CSF samples from 44 individuals with severe TBI as well as 13 control subjects, with the objective of establishing a metabolomic fingerprint for TBI . Ten metAnother prospective case–control study conducted by Thomas et al., 2022 in 716 TBI patients and 229 controls further analyzed serum metabolome to classify disease severity and predict prognosis . The autMetabolomic profiles were explored as indicators for management optimization in TBI patients in four studies. Dash et al., 2016 conducted targeted analysis of methionine and its metabolites using LC/MS or GC/MS . Plasma In conclusion, most metabolomic studies in TBI focused on classifying the prognostic markers and disease severity of TBI. There is an emerging interest in analyzing the diagnostic potential of metabolites. However, future studies should focus on validating the results of the metabolites studied with a larger patient population to account for the inherent variability in patient characteristics. Future studies should also aim to conduct multivariate statistical analysis to establish confidence in the correlational analysis between metabolites and disease severity. Lastly, multiple studies have established the correlation between methionine and disease severity of TBI. Further studies focusing on nutritional interventions and impact on prognosis should be considered. ICH is a result of spontaneous rupture of small cerebral arteries due to hypertensive arteriopathy or cerebral amyloid angiopathy ,54. ICH Metabolomic profiling has multiple applications in neurocritical care. For instance, multiple studies identified the correlation between metabolite concentration and functional outcomes for aSAH. However, the study results have not been reproduced in different populations using different analysis techniques to ensure a true correlation. Similarly, metabolomic profiling has its applicability in the classification of TBI severity, diagnostics and functional outcomes. The studies included in this review analyzed different metabolites and metabolic pathways. This review is limited in its ability to provide concrete evidence on the clinical implications of a specific metabolite due to a lack of reproducible data. Furthermore, metabolomics is an emerging field of medicine and thereby, the studies available are limited in multiple ways. Some common limitations of the studies include smaller sample size, narrow inclusion criteria, a lack of validation of methods of analysis, insufficient clinical information available for comparison, and difficulty in obtaining patient samples such as CSF and cerebral microdialysates that represent the metabolome closer to the site of injury. Despite the limitations, this review identifies gaps in the literature and provides direction for future studies. We recognize the need for metabolomic research in personalized medicine to improve diagnostic tests, determine underlying pathophysiology, predict prognostic outcomes, and optimize treatment targets. Future studies should focus on reproducing these study outcomes and utilizing multiple statistical models to avoid biased results. The utilization of multi-omic approaches and animal studies in concert with metbolomic studies will provide valuable insights on the understanding of disease mechanisms, identifying potential biomarkers, and discovering novel therapeutic targets.


Structurally reconfigurable RNA structures enable dynamic transitions of the functional states in response to diverse molecular stimuli, which are fundamental in genetic and epigenetic regulations. Inspired by nature, rationally designed RNA structures with responsively reconfigurable motifs have been developed to serve as switchable components for building engineered nanomachines, which hold promise in synthetic biological applications. In this review, we summarize recent progress in the design, synthesis, and integration of engineered reconfigurable RNA structures for nanomachines. We highlight recent examples of their targeted applications such as biocomputing and smart theranostics. We also discuss their advantages, challenges as well as possible solutions. We further provide an outlook of their potential in future synthetic biology. They often cooperate with metal cofactors and perform specific phosphodiester bond cleavage and formation at the translational level  technology, a variety of artificially selected RNA aptamers and ribozymes have emerged, which can bind the molecules of interest, or show certain catalytic activities when incorporated with given molecules . Like their protein counterparts, these RNA aptamers can be fused to other RNA molecules of interest, thus are suitable for RNA imaging and detection in live cells. These fluorescence aptamers can be further integrated with other structurally reconfigurable aptamers, enabling switchable fluorescence in response to the molecules of interest  have attracted much interest. These RNA aptamers light up when binding to corresponding fluorophores  of mRNAs , allowing switches of translation initiation or transcription termination   have been constructed to disrupt the formation of an intrinsic transcription terminator placed upstream of a gene in et al. et al. A variety of riboswitches have been found involved in regulating post-transcriptional processing  that can bind and reconfigure the regulatory sites  of other mRNAs, leading to post-transcriptional/translational regulations of the latter  or repressed (by the off-antiswitch) in the presence of the ligands, which demonstrates the capability of these riboregulators for bi-directional modulation.For example, Bayer witches"    RNA motifs can interact with K-turn binding protein L7Ae and conduct structural reconfigurations, which can be utilized to build RNP nanomachines that can transform in response to L7Ae -CRISPR associated protein (Cas) system can be regarded as a natural ribonucleoprotein machine for adaptive immunity in microorganisms  responsive to small molecules, Tang et al. designed an inactive sgRNA precursor (pre-sgRNA)  repressors    and therapeutic RNAs such as small interfering RNAs (siRNAs) and anti-miRNAs, enabling cancer-targeted therapeutics   may help construct more complicated RNA systems with optimized performances. However, the efficiency of traditional evolution techniques is poor. It often takes years to find a new RNA structure with the desired functionality. Therefore, there is a need to develop high-throughput yet high-speed selection strategies for evolving input-output responses and dynamic functions.The combination with artificial evolution strategies (Taken together, we envision that in near future, the development of cutting-edge technologies in diverse fields would largely enrich the catalog of designer RNA structures, which enable novel nanomachines with functions that are robust, scalable, and applicable to a wide range of living organisms.Kai Jiao, Yaya Hao, Fei Wang, Lihua Wang, Chunhai Fan and Jiang Li declare that they have no conflict of interest.


Stroke is a debilitating neurovascular injury that those effects hundreds of thousands of Americans each year. Despite the high prevalence, disease morbidity and mortality, options for stroke intervention and rehabilitation are still limited. Stem cells have shown promise in stroke treatment due to their ability to self-renew and differentiate into different cell types. The primary sources of stem cells used today are bone marrow and fetal brain tissue, with mesenchymal stem cells, bone marrow stem cells and neural stem cells being particularly well-studied. By secreting therapeutic and neurogenic substances they are hypothesized to help foster recovery at the site of injury. Delivery mechanisms for stem cell therapy include intracerebral, intra-arterial, intraperitoneal, intravenous, intraventricular and intranasal routes with radiographic imaging now being used to monitor the progress of stem cell therapies. Stem cell implants have been found to be safe but optimal treatment strategies are still being established with several promising studies underway. Future efforts should continue to focus on improving efficacy, exploring alternative stem cell sources, enhancing migration capability and survival and educating stroke patients on the benefits and risks of stem cell therapy. More than 795,000 strokes occur in the United States every year, with nearly 1 in 4 happening in those with a prior history of stroke ,3. Due tThe many varying etiologies of stroke correspond to different treatments which depend largely on the type and timing of the infarctive event. There are two different subtypes of stroke: ischemic and hemorrhagic. Ischemic strokes result from an occlusion of the blood supply whereas hemorrhagic stroke is defined by bleeding from a vessel . IschemiResearch into stem cells is still very much in its infancy. Less than 30 years ago the first primate embryonic stem cell line was derived from rhesus monkeys and it was only in 1998 that the first human embryonic stem cells were derived by Thomson, et al., ,14. SincStem cells are cells that uniquely have the ability to self-renew and create functional tissues. More specifically, they can differentiate into nearly any cell type present in the human body, which is what drew scientific interest to their therapeutic potential in the first place. There are several major categories of stem cells: (1) Totipotent, (2) Pluripotent and (3) Multipotent . TotipotSeveral mechanisms for the action of stem cells have been proposed over the years. Initially, it was thought that grafted cells could replace dead sections of the brain and become integrated in their place. This hypothesis has given way to the modern theory of the bystander effect, wherein implanted cells secrete therapeutic and neurogenic substances that ameliorate injury and foster regeneration ,21. EverPrimarily due to its well-established safety in the literature, the bone marrow is the primary source of stem cells in use today ,24. Bonein-vivo models [Several initial studies determined the various neuroprotective and neuroregenerative effects of these cells in preclinical and later clinical settings –28. Baseo models ,35. HoweThe future of stem cell therapies is multifaceted. Naturally, clinical trials with different lineages of cells are underway, but beyond this classic approach, it has been proposed recently to use derivatives of stem cells such as vesicles, mitochondria, exosomes and micro-RNAs to foster regeneration in the ischemic area . These cUnsurprisingly, several different approaches for stem cell delivery exist in the laboratory setting and many have been translated to clinical settings. Different administration routes have included intracerebral, intra-arterial, intraperitoneal, intravenous, intraventricular and intranasal . Stem ceExtracellular Vesicles (EVs) or exosomes are extracellular membrane-bound vesicles that transmit cargo without direct cellular contact as a form of intercellular communication –46. EVs Much of the current stroke therapy literature turns to EVs as personalized targeted delivery vehicles especially in the application of stroke where multipotent mesenchymal stromal cells have shown therapeutic effects ,52. An iAnother obstacle has been the differentiation of neural stem cells into astrocytes rather than neurons. The use of superparamagnetic iron oxide nanoparticles and small interfering RNA/antisense oligonucleotides against Pnky lncRNA in combination with neural stem cells has shown promise in guiding differentiation into neurons as Pnky lncRNA inhibits neuronal differentiation . When thThe safety of stem cell implants in stroke patients has been well established in several phase 1 and 2 clinical trials ,33,61–82While no trial has found significant safety concerns, efficacy has been harder to establish. Multiple single arm studies have shown significant improvements from baseline in a number of measures of stroke burden, including modified Rankin Scale (mRS), Barthel Index (BI), National Institute of Health Stroke Scale (NIHSS), European Stroke Scale (ESS), Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT) and lesion size ,73,74,79clinicaltrials.gov, trial number: NCT02448641). Other RCTs using intravenous mesenchymal cells in the acute/subacute setting have had mixed results with improvement in some measures of stroke burden but not others and inconsistency between studies in which measures show improvement [Improvement relative to placebos, however, have not been consistent in randomized controlled trials –78,80–82rovement ,75,76,78rovement ,65,71,81A recent meta-analysis of randomized trials with scores on the mRS, NIHSS and BI at 6, 12 and 24 months found significant differences in NIHSS at 6 months and mRS at 12 months that favored treatment . AlthougGiven the large number of parameters that can vary in this space , the number of possible best use cases is vast. Different methods may be better suited in the acute versus the chronic setting and stacking the optimal treatment in each setting may have significant synergistic effects. The established safety of the treatment, along with the exciting possibilities warrants further study and a number of ongoing trials are doing just that The promise of stem cell therapies has mandated the study of how cells are trafficked and utilized in the body. In the preclinical setting, much of this information has come from dissection and analysis of frozen specimens. Imaging as a noninvasive method of monitoring therapeutic efficacy has been explored more recently. Classically there are two different approaches to tracking stem cells: direct and indirect labeling with markers such as super paramagnetic iron oxides, perfluoropolyether and perfluorocarbon which can be picked up by MRI or Positron Emission Tomography (PET) scanning . SeveralNeuron-derived EVs regulate the Blood-Brain Barrier (BBB) in both physiological and pathological states . Becausein-vivo migrating along the corpus callosum to reach these ischemic areas from distances as far as the opposite hemisphere [Radiographic assessment is important for localizing neurological defects and understanding the sequelae of stroke. In acute settings of suspected stroke, Computed Tomography (CT) can be utilized due to fast imaging speed, wide availability and production of good contrast between a bright clot and surrounding lower attenuating cortical tissue and Cerebrospinal Fluid (CSF) –96. MRI misphere . Porcinemisphere . MRI resmisphere . The curAs discussed in the previous section, initial data regarding clinical Phase I/II trials of the utilization of mesenchymal stem cells in chronic stroke shows promise. In two of these studies, MRI results showed no progression or new ischemic lesions in the brain between the delivery of NSCs and prior to discharge ,101. IntIn the present study, we critically appraised and critiqued the wealth of emerging cell therapy research for stroke recovery. Though much has been achieved, several areas for focused inquiry and effort have been identified. The most pressing is to establish the efficacy of Stem Cell Therapy (SCT) as a therapeutic tool, as discussed earlier. However, additional areas for exploration include developing alternative stem cell sources and wider patient education on SCT.Intracerebral transplantation of BMSC and MSC implants has demonstrated early promise in promoting the neurogenesis process post-stroke, but both remain steadily inefficacious relative to NSC implants ,102. CurMoreover, patient attitudes and understanding surrounding SCT also represent a much-desired focus area. The available literature suggests that stroke patients are stratified in their attitudes towards SCT, which may conceivably limit their willingness to participate in clinical trials or, perhaps worse yet, motivate participation without consideration of the associated risks –110. AkiIn-vitro and in-vivo studies have already demonstrated promise in the use of MSC, BMSC and NSC with greater studies on the horizon. Through the use of exosomes and nanoparticles, intravenous and intrathecal delivery of stem cells may soon provide therapeutic benefit to those suffering from cognitive and neurological impairments following a stroke.Stroke remains a debilitating and costly sector of the healthcare system with limited options for intervention and rehabilitation. Due to their unique ability of selective differentiation, stem cells provide a great opportunity to bridge the gap in treatment for these patients.


The goal of this comprehensive review was to synthesize the recent literature on the efficacy of perioperative interventions targeting physical activity to improve pain and functional outcomes in spine surgery patients. Overall, research in this area does not yet permit definitive conclusions. Some evidence suggests that post-surgical interventions may yield more robust long-term outcomes than preoperative interventions, including large effect sizes for disability reduction, although there are no studies directly comparing these surgical approaches. Integrated treatment approaches that include psychosocial intervention components may supplement exercise programs by addressing fear avoidance behaviors that interfere with engagement in activity, thereby maximizing the short- and long-term benefits of exercise. Efforts should be made to test brief, efficient programs that maximize accessibility for surgical patients. Future work in this area should include both subjective and objective indices of physical activity as well as investigating both acute postoperative outcomes and long-term outcomes. Rates of spinal surgery are rapidly increasing ,2. AlthoOne potential behavioral target to enhance surgical outcomes is physical activity. Physical activity, such as walking, is, importantly, associated with recovery of function and less pain-related disability after spinal surgery ,14,15,16Given the documented benefits of physical activity for spine surgery patients, along with patients’ potential fear of movement, interventions aimed at promoting physical activity may be particularly beneficial and could be incorporated into perioperative treatment see . To our Higher levels of preoperative physical activity and fitness are associated with faster recovery and shorter hospital stays following spinal surgery ,23. HoweExercise-based prehabilitation aims to enhance patients’ physiological fitness in preparation for a surgical procedure to minimize physical deterioration and promote faster recovery . StudiesOther studies using a more targeted approach offer stronger support for prehabilitation for spine surgery patients. A recent pilot study , for exaOverall, the current evidence for exercise-based prehabilitation for spine surgery patients is limited. However, the more robust findings for other major joint surgeries such as total knee replacement suggest that additional work in this area is likely warranted  ,31. The Recognizing the importance of cognitive-behavioral factors in promoting physical activity and pain management, researchers have begun to test preoperative integrated approaches for spine surgery patients, including psychological intervention. Broadly, psychological interventions, such as cognitive behavioral therapy (CBT) and motivational interviewing (MI), have long been used to help individuals improve their physical activity ,33,34. TRegular activity post-surgery may facilitate mobility and restore back strength. The extent to which patients engage in postoperative physical activity, including but not limited to prescribed physical therapy, and the types of exercises they engage in can vary considerably. On average, patients have been shown to walk for less than an hour a day over the week after lumbar surgery . During Postoperative exercise programs may include walking, stretching, and strengthening movements  and haveSeveral recent studies focusing on the early initiation of rehabilitation after spinal surgery have yielded mixed long-term results. For instance, Kernc and colleagues  found thOverall, there is significant evidence supporting the short-term benefits of postoperative exercise programs among patients undergoing spinal surgery, with large effect sizes on measures of patient-reported disability up to 3 months post-surgery. Evidence for longer-term benefits is less definitive, but very early postoperative physiotherapy  in particular, appears to be safe and may confer potentially long-term benefits.Integrated approaches such as multidisciplinary rehabilitation have also been tested with patients post-spine surgery. Many postoperative integrated approaches combine exercise with psychologically oriented content, such as CBT or psychoeducation. There appears to be great variability in the types of integrated interventions tested in this population in terms of duration, structure, and setting. Greenwood and colleagues  evaluateOverall, postoperative integrated approaches are shown to improve self-reported disability and fear avoidance behavior for spine surgery patients compared to usual post-surgical care; however, the effects of such programs on pain severity and psychological symptoms are less consistent . A recenand long-term outcomes .The goal of this comprehensive review was to synthesize the recent literature on the efficacy of pre- and post-operative interventions targeting physical activity to improve pain and functional outcomes in spine surgery patients. While methodologies and conclusions show substantial variability across studies, recent systematic reviews report moderate effect sizes for pain reduction and large effect sizes for improvement in disability when evaluating the benefits of activity- and exercise-based interventions delivered postoperatively for patients undergoing spine surgery. Overall, the variation in findings across studies may be partly attributable to differences in how physical activity and post-surgical pain outcomes are operationalized and measured, including self-report measures  and objective measures . Associations between subjective self-report measures of activity and objective indices of activity are often quite modest in studies of patients with pain . AdditioRigorous randomized trials are needed to test the existing and novel approaches aimed at promoting physical activity and pain outcomes in spine surgery patients. Current research indicates that post-surgical interventions may yield more robust long-term outcomes than preoperative interventions, although there are no studies directly comparing pre- vs. post-surgical approaches and this could be a focus of future trials. Alternatively, pre- and post-surgical programs could be studied as complementary interventions, facilitating physical activity and functioning throughout the perioperative period. Integrated approaches that include psychosocial intervention components may supplement exercise programs by addressing fear avoidance behaviors that interfere with engagement in activity, thereby maximizing short- and long-term benefits of exercise. Notably, efforts should be made to test brief and efficient programs that maximize accessibility for surgical patients. Some of the current programs are rather time-intensive, totaling nearly 40 h of intervention post-surgery. Such programs may not be feasible to implement across medical systems and surgical populations. Trials comparing the effects of different types of exercise  and timing of intervention  on short- and long-term post-surgical outcomes can inform the development of more efficient and effective protocols. Different types of exercise may differentially benefit patients depending on their background characteristics and the type of surgery, and this should be investigated. The use of a targeted population and approach, such as high-risk deconditioned patients and/or community-based training specific to a patient’s context, may also enhance acceptability, efficiency, and effectiveness.Given the added value of postoperative psychological intervention on long-term disability and fear avoidance behavior, future studies should continue exploring ways to efficiently integrate such intervention into perioperative protocols. More recently, some physical therapy protocols  have begun incorporating elements of cognitive behavioral therapy, including addressing unhelpful cognitive patterns such as catastrophizing—reductions which may mediate some of the benefits of these treatments . HoweverFinally, it is recommended that future studies test interventions focusing on other relevant behavioral and cognitive targets in addition to physical activity  to effectively enhance recovery and long-term outcomes after spine surgery. For example, recent studies have suggested that reductions in catastrophizing and fear of movement mediate the beneficial effects of CBT on improving pain and function after a variety of surgeries, including knee surgery  and spin