Apomixis is an asexual mode of reproduction through seeds where progeny are clones of the mother plants. Naturally apomictic modes of reproduction are found in hundreds of plant genera distributed across more than 30 plant families, but are absent in major crop plants. Apomixis has the potential to be a breakthrough technology by allowing the propagation through seed of any genotype, including F1 hybrids. Here, we have summarized the recent progress toward synthetic apomixis, where combining targeted modifications of both the meiosis and fertilization processes leads to the production of clonal seeds at high frequencies. Despite some remaining challenges, the technology has approached a level of maturity that allows its consideration for application in the field. In the last century, significant improvements in yield and other desirable crop traits were seen following the widespread adoption of hybrid crops, the product of F1 crosses between two high performing, divergent lines  alternates with the gametophytic haploid phase (n). Meiosis, occurring in both male and female organs, constitutes the transition from the sporophytic to the gametophytic phase. It produces haploid spores that divide mitotically to generate the male (pollen grain) and female (embryo sac). The gametophytic structures are composed of only a few cells and rely on the sporophyte for nourishment and development. In females, only one of the four spores survives and undergoes three mitotic divisions to form an eight-nuclei embryo sac. In the mature embryo sac, three cells are toward one side , the egg cell and two synergid cells, while three antipodal cells lie at the opposite side , while in between lies a double haploid (diploid) central cell that is produced by the fusion of two haploid cells  has been documented in about 400 species , but for endosperm (see above), the central cell must be pollinated and fertilized, a process called pseudogamy  recombination in prophase of meiosis I, (ii) co-segregation of sister chromatids at meiosis I, and (iii) a second round of division. Abolishing each of these differences with appropriate mutations can turn meiosis into mitosis as a strategy termed MiMe  Recombination in meiosis is initiated with the formation of DNA double-strand breaks (DSB), and a series of proteins catalyzing this step are conserved from yeast to humans and plants. The SPO11 (DNA topoisomerase) complex is a tetramer composed of two copies of TOPOVIB and one copy each of SPO11-1 and SPO11-2 . An additional gene, DFO, is essential for formation of DSB in Arabidopsis, but its homologs have not been functionally analyzed in other plant species  orients toward opposite poles, and as a result, sister chromatids move to the opposite poles. The opposite orientation of the sister kinetochores is called bipolar orientation. In contrast to mitosis, in meiosis each homologous chromosome consists of two sister chromatids that co-orient toward the same pole, a scenario known as monopolar orientation. The monopolar orientation at meiosis persists even in the absence of COs  ids Fig. . Mutatioids Fig.  and thusids Fig. . Similarids Fig. . Some me(iii) Two rounds of division The two consecutive rounds of division during meiosis constitute a third key difference from mitosis. In spo11 rec8, the first division mimics a mitotic division (see above), but the second division still occurs, leading to meiotic catastrophe. A solution to this problem was presented by the identification of the Arabidopsis mutant osd1 (omission of second division1) /Cyclin CYCA1;2 was found that also skips meiosis II and results in diploid gametes similarly to tdm1 knockout causes an aberrant third meiotic division after normal meiosis I and II , although it plays an opposite role to TAM1 or OSD1; Atps1  and Jason, produce diploid gametes due to the fusion of meiotic II spindles  Combining the three turns meiosis into mitosis MiMe, a highly efficient apomeiosis, was created in Arabidopsis by combining one mutant for each function: (i) spo11 to prevent recombination, (ii) rec8 to prevent monopolar orientation, and (iii) osd1 to skip meiosis II  mutant forms diploid female gametes, but only about 5% of them are clonal , was found to segregate with the occurrence of apospory in the grass species Pennisetum and was shown to generate diploid offspring in sexual pearl millet tetraploids  domain-containing gene preferentially expressed in developing embryos and able to induce somatic embryo structures when ectopically expressed ; genetic segregation experiments from the last two decades in dandelion and its close Asteraceae relative hawkweed (Hieracium) implicate distinct loci in controlling different aspects of apomixis. In dandelion, a locus controlling diplospory (DIP) and a separate parthenogenesis (PAR) locus were identified . Genetic mapping by three independent research groups of maize Stock 6, a widely used mutant crucial in haploid induction, implicated a frame-shift mutation in the phospholipase ZmMTL as causal for triggering haploid induction  to direct editing. Several reports have demonstrated success in delivering RNPs into protoplasts, embryos, or zygotes of crop species to confer entirely DNA-free genome editing  (He et al. Following its acceptance by regulators, questions still remain as to how exactly engineered apomixis can fit into modern breeding schemes. Apomicts derived from dominant mutations have been suggested to act as pollen donors for crossing to sexual elite varieties (van Dijk et al.


Peroxisome proliferator-activated receptors (PPARs) are essential nuclear hormone receptors regulating metabolic processes, and they participate in the initiation and progression processes of tumors. Gastrointestinal (GI) cancer is a prevalent malignancy worldwide that originates from the tissues of the gastrointestinal tract and is characterized by severe symptoms and poor prognosis. Numerous published studies have investigated the critical role of PPARs in esophageal, gastric, and colorectal cancers. Here, we summarize and review the current literature to understand the role of PPARs in the pathogenesis of GI cancers and to provide a systematic reference for the subsequent investigation and development of efficient therapies targeting PPARs and their pathways. Gastrointestinal (GI) cancer is a common malignancy worldwide that originates from the gastrointestinal tract and has the characteristics of severe symptoms and poor prognosis . The GI β-oxidation of fatty acids, resulting in fat degradation (Peroxisome proliferator-activated receptors (PPARs) are nuclear hormone receptors activated by fatty acids to regulate the metabolic processes, with three separate isotypes known as PPARα, PPARγ, and PPARβ/δ . Althougradation . PPARγ iradation . PPARδ, radation .The metabolic processes regulated by PPARs are very important to the function of various organs, and the disturbance of PPARs and related pathways could lead to tumorigenesis, especially in the parts of the gastrointestinal system where nutrition is absorbed. In recent years, many researchers have focused on investigating the role of PPARs in GI cancers and on developing efficient targeted therapeutics . In 2012Esophageal cancer (EC) is a prevalent malignant tumor occurring in the mucosal epithelium of the esophagus and includes two main kinds: squamous cell carcinoma (ESCC) and adenocarcinoma . The canADCYAP1R1, in the PPAR signaling pathway, as potentially involved in the prognosis of esophageal cancer  is a severe malignancy and the fifth most common cancer, with about a million new patients suffering this disease every year. It is commonly diagnosed in the late stage, with rapid progression; therefore, the mortality rate remains high despite huge progress in diagnostic equipment and therapies, and it remains the third deadliest cancer in the world . During versus subcutaneous adipose tissue, compared to ones with lower ratios. Furthermore, adipocytes co-cultured with cancer cells could accelerate their proliferation by downregulating the expression of PPARs , β-carotene could prevent cancer cell invasion by inhibiting the expression of MMP-10 mediated by mitogen-activated protein kinase (MAPK), which is due to increased expression of PPARγ-mediated catalase and reduced levels of ROS  is a common malignant tumor of the digestive tract and accounts for the second highest mortality among cancers . Global Systematic analysis of PPARs by bioinformatics has identified the critical roles of PPARs in the progression and prognosis of CRC. Md Misbah et al. investigated the mechanisms of drug resistance and identified biomarkers of CRC in colon cancer cell lines, revealing PPAR signaling to be one of the pathways enriched by different expression genes . In addivia regulating miR-145 (+ CRC cells, for which immunogenicity can be enhanced by the pharmacological application of PPARγ agonists (PPAR signaling pathways play critical roles in colorectal cancer progression. The FABP4 and PPARγ axis has been demonstrated to be a novel target for CRC, while PPARδ has been identified as a tumor suppressor in CRC cells . More st miR-145  and thatagonists . Teresa agonists .Apart from the pathogenic role of PPARs, numerous therapies aiming at PPAR signaling pathways have emerged recently. A team systematically analyzed different genes from different colorectal cancer cell lines and identified PPAR as an important indicator affecting radiotherapy sensitivity . AlessanGenetic regulation, environmental influence, and dietary habits comprehensively contribute to the pathogenesis of cancers. In gastrointestinal cancers, the key role of dietary habits is becoming increasingly important, not only by affecting the local environment of the gastrointestinal tract but also by influencing the entire nutrition metabolism of the body. PPARs are regarded as a kind of central regulatory factor in metabolism and energy conversion, and they regulate diverse aspects of cancer initiation, progression, and prognosis. Overall, PPARs could play protective roles in the homeostasis and function of the gastrointestinal tract, and agonists used to activate PPARs could theoretically inhibit the progression of GI cancers. Some studies have discovered that PPARs could function as promoters of cancers, possibly due to the difference between cancer cells and the tumor stages. Although numerous studies have focused on the roles and mechanisms of PPARs, more studies are still needed to broaden the signaling network and provide more targets for the precise therapy.


Bone remodeling requires a delicate balance between bone-forming osteoblasts and bone-resorbing osteoclasts. However, in pathological conditions, bone remodeling is often deregulated and the uncoupling of osteoclast and osteoblast functions may alter the extent of bone loss. Although in chronic lymphocytic leukemia (CLL), patients’ macroscopic skeletal involvement appears to be rarer than in other lymphoproliferative diseases, recent studies highlighted that the active crosstalk between leukemic B cells and bone tissue components may lead to the alteration of bone homeostasis already at early stages of the disease, becoming further evident in the advanced stages. Since the pathogenesis of bone involvement in CLL is not completely understood, this manuscript provides an overview of the clinical and biological data related to bone erosion in this disease.Chronic lymphocytic leukemia (CLL) is the most frequent leukemia in Western countries. Although characterized by the progressive expansion and accumulation of leukemic B cells in peripheral blood, CLL cells develop in protective niches mainly located within lymph nodes and bone marrow. Multiple interactions between CLL and microenvironmental cells may favor the expansion of a B cell clone, further driving immune cells toward an immunosuppressive phenotype. Here, we summarize the current understanding of bone tissue alterations in CLL patients, further addressing and suggesting how the multiple interactions between CLL cells and osteoblasts/osteoclasts can be involved in these processes. Recent findings proposing the disruption of the endosteal niche by the expansion of a leukemic B cell clone appear to be a novel field of research to be deeply investigated and potentially relevant to provide new therapeutic approaches. Chronic lymphocytic leukemia (CLL) is the most frequent leukemia in Western countries, mainly occurring in the elderly and showing heterogeneous outcomes. Although characterized by the progressive expansion and accumulation of leukemic B cells in peripheral blood, CLL cells develop in protective niches mainly located within lymph nodes and bone marrow. The close interactions between malignant B cells and the surrounding tissue microenvironment play a critical role in leukemic cells’ survival and growth, as well as in drug resistance. Microenvironmental cells favoring the expansion of the B cell clone include T cells, monocytes/macrophages, nurse-like cells, endothelial cells and mesenchymal stromal cells ,2,3. Bon2+ oscillation. After the initial induction of NFATc1 by NF-kB, c-Fos/AP-1 and NFATc2, RANK signaling cooperates with immunoglobulin-like receptor/immunoreceptor tyrosine-based activation motif (ITAM) signals, such as TREM2/DAP12 and OSCAR/FCRγ, leading to the robust amplification of NFATc1 and its translocation to the nucleus . InHere, we would like to further highlight that adipocytes also could take part in bone derangement, since the number of bone marrow adipocytes (BMAs) increases with age and CLL is a disease of the elderly. Increased BM adiposity may inevitably result in impaired osteoblastic bone formation due to competitive lineage allocation between the adipogenesis and osteogenesis of BMSCs. Indeed, bone marrow adipocytes specifically secrete chordin-like1 (Chrdl1) and gremlin1 (Grem1), which significantly suppress bone formation . MoreoveTherapeutic regimens in CLL have undergone tremendous changes in recent years. The BCR signaling pathway is involved in the pathogenesis of CLL, and drugs that inhibit Bruton’s tyrosine kinase (BTK) and phosphoinositide 3′-kinase (PI3K) are the standard of care when treating CLL. The inhibitor of BTK, namely, Ibrutinib, blocks B-cell receptor signaling, driving CLL cells into apoptosis and disrupting cell migration or adherence to the protective microenvironment. Moreover, the evidence that BTK is also expressed on many hematopoietic cells suggests that the huge success of the BTK inhibitors in CLL also appears to be related to its pleiotropic activity on cells of the tumor microenvironment ,82,83. IBruton Tyrosine Kinase (BTK) integrates RANK/RANKL and ITAM pathways along osteoclast formation and activity . ShinohaAmong the second generation of BTK inhibitors that were more recently deeply explored for CLL treatment, Acalabrutinib and the dual BTK/TEC inhibitor Tirabrutinib also appear capable of inhibiting osteoclasts generation ,95. YeonCollectively, the above-discussed observations demonstrate that bone tissue actively interacts with the CLL clones throughout all the disease stages. Support for the survival and expansion of leukemic B cells may take place and exert the most relevant biological effects in the initial phases of the pathology. Once the crosstalks between resident and leukemic cells in the microenvironmental niche have been established, more consistent alterations of the bone homeostatic mechanisms can be observed. This hypothesis could explain why the surmised clinical bone alterations are more evident in late-stage patients. In this respect, further studies corroborated by CT and/or MR imaging of CLL patients could be of help in predicting the stage and course of the disease. Moreover, an apparent good novelty is the body of data that suggests that the BTK and PI3K inhibitors, which are currently in use to treat the disease, are also effective on the tumor microenvironment, additionally limiting the disease-associated bone lesions.


Defects in mitophagy can lead to a buildup of ROS and cell death. Numerous studies have attempted to characterize the relationship between mitochondrial dysfunction and calcium dysregulation in neurodegenerative diseases such as Alzheimer’s Disease, Parkinson’s Disease, Huntington’s Disease, Amyotrophic lateral sclerosis, spinocerebellar ataxia, and aging. Interventional strategies to reduce mitochondrial damage and accumulation could serve as a therapeutic target, but further research is needed to unravel this potential. This review offers an overview of calcium signaling related to mitochondria in various neuronal cells. It critically examines recent findings, exploring the potential roles that mitochondrial dysfunction might play in multiple neurodegenerative diseases and aging. Furthermore, the review identifies existing gaps in knowledge to guide the direction of future research.Efficient cellular communication is essential for the brain to regulate diverse functions like muscle contractions, memory formation and recall, decision-making, and task execution. This communication is facilitated by rapid signaling through electrical and chemical messengers, including voltage-gated ion channels and neurotransmitters. These messengers elicit broad responses by propagating action potentials and mediating synaptic transmission. Calcium influx and efflux are essential for releasing neurotransmitters and regulating synaptic transmission. Mitochondria, which are involved in oxidative phosphorylation, and the energy generation process, also interact with the endoplasmic reticulum to store and regulate cytoplasmic calcium levels. The number, morphology, and distribution of mitochondria in different cell types vary based on energy demands. Mitochondrial damage can cause excess reactive oxygen species (ROS) generation. Mitophagy is a selective process that targets and degrades damaged mitochondria  ATP and ROS production are linked during oxidative phosphorylation through the electron transport chain (ETC) complexes I and III and increases with high inner mitochondrial membrane potential and high NADH/NAD+ ratios (2−), result from electron leak from the ETC and partial reduction of molecular oxygen, which can damage the cell and are typically resolved through anti-oxidative enzymes. Mitochondria interact with the endoplasmic reticulum, considered the primary calcium storage site, at specific locations called mitochondria-associated membranes (MAMs). To facilitate this interaction, protein tethers keep the membranes at the optimal distance to coordinate shared functions, including phospholipid synthesis, exchange and calcium signaling , a non-selective channel that spans both inner and outer mitochondrial membranes. The problematic channel has been implicated as a mechanism of cell death and has since become a target of interest. Several different types of calcium channels are found in the plasma, ER, and mitochondria membranes that respond to various signals. The two types of calcium channels primarily utilized by the mitochondria for [Ca2+] homeostasis are mitochondria calcium uniporters (MCU) and Na+/Ca2+ exchangers (NCX) (Voltage-dependent anion channel (VDAC), also known as mitochondrial porin, controls the passage of metabolites and ions between mitochondria and the rest of the cell and thus mediates metabolic and energetic functions as well as cell survival and death signaling . Both thrs (NCX) .Neurons, being high-energy-demanding cells, naturally possess a greater number of mitochondria. Consequently, they are more susceptible to dysfunctions related to mitochondrial activities. For example, diseases with mutations in the mitochondrial genome alter overall mitochondrial function and often present symptoms in the nervous system  . A compr1.1.2+], Mitochondrial Calcium Uniporters (MCUs), located in the Inner Mitochondrial Membrane (IMM), uptake calcium. This calcium is transported into the mitochondrial matrix by ion channels for storage. The MCU has a wide range of capacity; hence, there must be a high enough concentration before significant transport can occur. This could indicate a safety mechanism to prevent overload of [Ca2+]in the cytosol; however, beyond a certain concentration threshold, the elevation of mitochondrial [Ca2+] might be damaging to the mitochondria. The molecular composition of the uniporter has recently been parsed out to reveal a protein complex containing a pore-forming component and several regulatory units (MICU1 & MICU2), the expression of which may vary slightly based on tissue type. Reports have shown that an MCU enhancer, MICU3, is highly expressed in the brain and dimerizes with MICU1 through disulfide bond formation  is a low affinity, high-capacity sodium-calcium exchanger and transmembrane protein critical in regulating calcium ions [Ca2+] concentration within cells. To mediate mitochondrial [Ca2+] efflux, the NCX found in the IMM employs the electrochemical gradient of Na+ to exchange three Na+ ions for one [Ca2+] ion. The general efflux rate is slower than MCU’s influx rate, indicating a significant role for NCX in mitochondrial [Ca2+] homeostasis. These exchangers are also reversible and can indirectly interact with calpain-induced degradation, pH, and protein kinases C and A. The Na2.Numerous neurodegenerative diseases have been investigated, considering mitochondrial dysfunction and calcium dysregulation. In this review, the focus is on the critical findings in Alzheimer’s Disease (AD), followed by a brief discourse about similar findings in Parkinson’s Disease (PD), Huntington’s Disease (HD), and spinocerebellar ataxia (SCA) research.2+] homeostasis can precede amyloid plaques and neurofibrillary tangles  and neurofibrillary tangles resulting from hyperphosphorylation of Tau, a microtubule-associated protein. The exact mechanisms remain unclear partly due to recent findings that disruption of [Ca tangles . There h opening .2+] alteration and oxidative imbalance; the differences lie in the component(s) of maintenance of mitochondrial bioenergetics and function that is impaired , a heterogeneous group of progressive neurodegenerative diseases of the cerebellum, has long had implications for dysregulated calcium homeostasis . Some tyThe preceding examples of neurodegeneration mechanisms demonstrate how impairments in different components relating to mitochondrial bioenergetics and calcium homeostasis (stemming from either disease or aging) can present similar damage-inducing malfunctions that cascade into neurodegeneration. During aging, over time and in the absence of disease, cells progressively become senescent – i.e., they either lose optimal function and/or have damaged or impacted cellular processes but have not yet begun to die. Many individual alterations can make up cellular senescence or aging, but some that occur are directly related to the mitochondria and calcium signaling. One alteration found is the downregulation of the mitochondrial calcium uptake family member 3 (MICU3) in skeletal muscle of aged mice, which was associated with increased oxidated stress and apoptosis and the reconstitution of MICU3 enhanced antioxidants, decreased apoptosis, and prevented mitochondrial ROS accumulation .2+] sites and regions of high ATP demand to provide buffering capacity and supply energy. Until recently, astrocyte processes were thought to be too small to accommodate mitochondria because of the small size of the astrocyte, but newer studies indicated otherwise  and the Central Nervous System (CNS), given their differences in axonal regeneration capacity . Fecher Lastly, calcium and mitochondria dysregulation have been implicated in various optic neuropathies . In anim3.2+) uptake: transient potential melastatin 2 (TRPM2). This channel is also capable of [Ca2+] uptake and has gained prominence in AD studies. However, there is a notable prevalence of reviews over empirical findings  but has detrimental effects on the brain compared to other tissues  for inhibition in addition to increasing NCX expression . It is w4.2+] homeostasis, which makes it an ideal therapeutic target. The data reviewed here highlight the potential for developing treatments for neurodegeneration in animal models. The main trigger of dysfunction in the mitochondria from disruption of calcium homeostasis remains to be determined. This could involve mitochondrial calcium uniporter , the sodium-calcium exchanger, the TRPM2 cation channel, and specific mechanisms of TRPM2 alteration and NCX downregulation. Increasing NCX expression and using a TRPM2-specific blocker  may be promising approaches for in vivo experiments aimed at developing new therapies. More studies need to be done to support these findings and elucidate the side effects of novel candidate drugs.With aging, most cells in the body become more susceptible to mutations, mitochondrial damage, and associated diseases. By virtue of their high metabolic rate and oxygen consumption, neurons are particularly susceptible to mitochondrial injury and degeneration. Not surprisingly, one of the most prominent and devastating effects of age is the degeneration of neurons and subsequent loss of memory and motor function. There are numerous ways to analyze mechanisms contributing to neurodegeneration in various neurodegenerative diseases. One active area of investigation is the involvement of mitochondria in regulating calcium, ROS, zinc, and sodium. Regardless of the inciting cause of degeneration in aging, AD, PD, and HD, it has become clear that a common denominator leading to cell death is the dysregulation of mitochondrial [CaGJ was responsible for the concept and writing of the current work. DS and RK contributed to the manuscript by providing guidance, expertise, as well as by correcting and editing the text and refining the scientific content. All authors contributed to the article and approved the submitted version.


It is almost a century since nisin was discovered in fermented milk cultures, coincidentally in the same year that penicillin was first described. Over the last 100 years this small, highly modified pentacyclic peptide has not only found success in the food industry as a preservative but has also served as the paradigm for our understanding of the genetic organization, expression, and regulation of genes involved in lantibiotic biosynthesis—one of the few cases of extensive post-translation modification in prokaryotes. Recent developments in understanding the complex biosynthesis of nisin have shed light on the cellular location of the modification and transport machinery and the co-ordinated series of spatio-temporal events required to produce active nisin and provide resistance and immunity. The continued unearthing of new natural variants from within human and animal gastrointestinal tracts has sparked interest in the potential application of nisin to influence the microbiome, given the growing recognition of the role the gastrointestinal microbiota plays in health and disease. Moreover, interdisciplinary approaches have taken advantage of biotechnological advancements to bioengineer nisin to produce novel variants and expand nisin functionality for applications in the biomedical field. This review will discuss the latest progress in these aspects of nisin research. The highly post-translationally modified peptide nisin has been studied over the course of the last 100 years, and although it has been employed successfully as a food preservative, its potent activity against multidrug resistant microbes, long safety record, lack of any significant resistance development, and amenability to bioengineering approaches to improve its antimicrobial and physicochemical properties has meant that the focus on nisin-related research is shifting from food preservation towards therapeutic use for the treatment of bacterial infections. Streptococcus) were inhibitory to starter cheese cultures. Almost 20 years following its discovery, this inhibitory peptide was named nisin, or ‘group N Streptococcus Inhibitory Substance’, the suffix ‘-in’ implying antibacterial properties  composed of a sensor histidine kinase NisK, and response regulator NisR   consisting of a 23-amino acid N-terminal leader peptide and a 34-amino acid C-terminal core peptide Fig. . The leaisF Fig. . Thus, nisF Fig. . A multiisF Fig. . For exain vivo and the highly co-ordinated series of spatio-temporal events that unfold to produce and export active nisin  targets dimeric NisB to the pole of the cell. NisC is recruited to form a NisBC complex that interacts with nisin precursor and both enzymes act in succession to perform the dehydration and cyclization reactions and create each lanthionine ring in turn. NisT is drafted to the cell poles from the cytoplasmic membrane only when the modifications are complete and all five rings are in place. The fully modified pre-NisA is then released from NisBC and transferred to NisT. Following export of the fully modified prepeptide, the complex dissociates and NisT again becomes evenly distributed around the cell. It is thought that this polar-localized synthesis and secretion of nisin prevents access of the peptide to its target lipid II, given that peptidoglycan synthesis would be significantly lower at the old pole, thereby limiting the possibility of any self-killing action  and methicillin resistant Staphylococcus aureus (MRSA)  transporter system from Bacillus subtilis  harbours the cprABCK-R  operon that provides protection from several lantibiotics including nisin, mutacin 1140 and subtilin  system imparts resistance to multiple antimicrobials including nisin , and GraRS) linked to ABC transporters (VraDE and BraDE) that confer nisin resistance  is present  is up to 100-fold less active and exhibits a considerably reduced ability to form pores  suggests that NsrFP may also act by shielding lipid II cycle intermediates from the antimicrobial compound , staphylococci , and in Enterococcus faecium  harboured an nsr gene  and the purified peptide displayed antibacterial activity towards several drug-resistant bacteria, including MRSA, VRE, and penicillin-resistant Streptococcus pneumoniae   Fig. . The firK33 Fig. . SeveralStaphylococcus capitis APC 2923 produces a nisin variant with nine residues differing from those in nisin A, as well as having an extra residue at the C-terminus, making it a 35-residue peptide  and the nisin immunity gene nisI are absent  compared to its nisin U counterpart, prompting the authors to speculate that the I15A and additional asparagine residue could be responsible  represent a novel hinge sequence compared to the other closely related nisin U, nisin U2, and nisin P variants  cluster, the nisin E structural gene (nmdA) is situated upstream of the regulatory and immunity modules in contrast to the downstream location of nsuA  is Streptococcus salivarius DPC6487, which was sourced from a neonatal faecal sample and produces nisin G. Although S. salivarius strains have been shown to produce another lantibiotic, salivaricin D  development. The desire for intestinal-derived bacteriocin producing strains that can kill specific target organisms without causing collateral damage to host bacterial populations makes S. salivarius DPC 6487 a potential candidate for probiotic development  Fig. . The impA systematic saturation mutagenesis approach at the N-terminal isoleucine (Ile1) and analysis of the resulting 20-generated analogues revealed that although the core peptide was completely modified, impacts on production, leader peptide cleavage, and antimicrobial activity varied drastically and correlated with the nature of the amino acid substituted in each case   that led to a dramatic loss of activity   and glycine (Gly10). Mutational analysis has underpinned its importance in both antimicrobial and induction activity  Fig.  and desi10) Fig. , emphasiThe residue Lys12 is located between rings B and C and a site-saturation approach at this location led to the identification of a small number of bioengineered derivatives with improved activity  generated a suite of peptides whereby a preference for small, chiral amino acids was linked to increased bioactivity   or extending the hinge region (20NMKIV24 and 20NIVMK24). These hinge variants were impacted in their ability to form pores when compared to wild type nisin A, in particular the truncated Δ21MK22 peptide, and when assessed against strains expressing the nisin immunity (NisI and NisFEG) and nisin resistance determinants (SaNSR and SaNsrFP), the variant 20NMKIV24 displayed increased activity, possibly as a result of reduced substrate recognition . NMR studies have revealed Ser29 within this region as an important flexible region for the orientation of nisin within the membrane pore  as well as L. lactis strains harbouring the nisin immunity cluster (NisIFEG) and the NSR. Notably, peptides consisting of combinatorial modules of gallidermin and nisin joined by a synthetic hinge were most active against the majority of pathogenic strains tested as well as being able to bypass the nisin immunity system L. lactisThe targeting of lipid II, crucial for bacterial cell wall synthesis and readily accessible on the outer surface of the cell membrane, is an effective and ancient antimicrobial strategy  using click chemistry. The addition of membrane active lipids to the nisin AB ring fragment yielded semisynthetic analogues with enhanced stability , displayed 64-fold higher potency against E. faecium compared to the single lipid II binding component of nisin1-22, highlighting the potential of a single molecule with two lipid II binding motifs to enhance antimicrobial activity  linked to the C-terminal lipid II binding regions of the two-component lantibiotics lacticin 3147 or haloduracin  and a varied C-terminal tail. An additional library of 3000 variants was generated via saturation mutagenesis targeting positions 4, 12, 15, 24, and 29 of nisin Z and expressed in the CFPS system. Subsequent screening identified a further two variants with improved activity against Gram-negative bacteria compared to parental nisin Z  system using C. difficile, a Clostridium genome mining approach was employed that screened over 600 publicly available genomes. A total of 10 putative lanthipeptide genes were identified in Clostridium beijerinckii, Clostridium ihumii, and C. perfringens and expressed in L. lactis using the nisBCT synthetase . The authors note that the specificity and activity observed for the hybrid peptide makes it an interesting potential candidate in the treatment of C. difficile infections, avoiding side effects and protecting the normal gut microbiota . The standard treatment for CDI is use of the antibiotics fidaxomicin, metronidazole, or vancomycin, although none of these antibiotics are fully effective  proved to be an effective inhibitor of C. difficile, achieving over a 100-fold reduction in cell numbers when used at 76 µmol/l  in a simulated human colon system  was also noted, the initial balance was restored 24 hours after nisin addition. In the same study, a L. lactis nisin producer, which was shown to persist and proliferate in the model colon, was ineffective against C. difficile, most likely due to the inability of the strain to generate a sufficient quantity of peptide in these conditions to inhibit the pathogen  was found to inhibit VRE by production of the nisin variant, nisin BPSCSK. Moreover, this variant exhibited reduced activity against intestinal commensal bacteria including Bifidobacterium longum and Pediococcus acidilactici  envelope is suitable for delivery of nisin to the colon , a response that suggests adaption to their environment in the gut. Moreover, the reduced activity of nisin BPSCSK against some beneficial commensal bacteria suggests these residues are excellent targets for bioengineering not only to maintain protection from disintegration in the gastrointestinal tract but also to enhance activity towards specific pathogenic organisms whilst having minimum impact on the commensal microbiota resident in the gastrointestinal tract.Interestingly, nisin A contains three trypsin sensitive residues; K12, N20, and K22 while N20, M21, and H31 are chymotrypsin sensitive residues  is a thrilling new prospect for nisin and lantibiotic research. This, and advances in widening the substrate specificity of existing modification enzymes will undoubtedly lead to new structures with enhanced functional characteristics  and with them a portfolio of potential therapeutic applications.The discovery and characterization of new natural variants from different environments, including the gastrointestinal tract of humans and animals, is welcome and likely to accelerate with the advent of cheaper and faster genome sequencing technologies and finely tuned genome mining tools. Indeed, the current rate of discovery emphasizes the broad distribution of nisin-related BGCs across bacterial species, implying a strong role in Gram-positive bacterial competition within a variety of microbiomes. Furthermore, the mounting evidence of the beneficial role of the gut microbiome in human and animal health will ensure that greater efforts will focus on the ability of nisin and bioengineered nisin derivatives to eliminate specific pathogens and pathobionts in a predictable and beneficial manner that could steer antimicrobial regimens towards more personalized and precise medical methodologies and prevent indiscriminate microbiome damage.We can expect that resistance development will follow any introduction of bacteriocins as new therapeutic tools. Although bioengineering programmes have already identified novel nisin variants or peptide hybrids able to overcome some resistance mechanisms, sensible stewardship, as well as limiting and tailoring applications will ensure the therapeutic success of nisin and minimize future resistance development. Despite almost a century of nisin-related research, no significant investment on the part of Pharma companies is evident in relation to the development of nisin as a drug suitable for human use. However, the fact that nisin has reached a point where it is under consideration for use as a veterinary pharmaceutical in the treatment of bovine mastitis may provide the impetus for increased investment for human clinical applications. The successful clinical development of nisin will require creative improvements in its bioavailability, stability, solubility under physiological conditions, and other parameters including pharmacokinetics and pharmacodynamics. Many knowledge gaps are still evident. Future studies will aim to provide a more complete picture of nisin biosynthesis and the membrane-associated multimeric complex, including the interactions between the transporter and protease components that may aid in the expression of a broader range of substrates. Furthermore, a better understanding of the nisin immunity mechanisms and their as yet unconfirmed co-operative nature in providing full immunity will be required in efforts to increase nisin production, as will a more in-depth analysis of the cell wall precursor target and membrane interactions with nisin to rationalize the membrane disruptive aggregation behaviour recently described.in vivo antibiotic use will finally be realized at the beginning of the second century of nisin research.Given the immense strides and technological improvements in nisin- and bacteriocin-related research in recent years, we have already passed a significant threshold, and it is anticipated that the tremendous potential for the development and application of tailor-made and highly specific nisin derivatives for


Perinatal depression affects >400,000 mother-child dyads in the United States every year and is associated with numerous adverse maternal and child developmental outcomes. Previous research implicates the dysregulation of oxytocin and the hypothalamic-pituitary-adrenal (HPA) axis functioning in mothers and children as potential mechanisms mediating or moderating the transmission of risk associated with maternal depression.The Mood, Mother and Child study will examine the psychobiological sources of risk and resilience within mother-child dyads affected by maternal depression. This manuscript describes (1) the study rationale and aims, (2) the research design and procedures and how they were altered in response to the COVID-19 pandemic, and (3) the data analysis plan to test the study hypotheses.This is a prospective longitudinal study with an embedded randomized controlled trial that examines (1) correlations among postpartum depression and anxiety symptoms, maternal and child oxytocin and HPA axis functioning, and child developmental outcomes and (2) the causal relationship between exogenous oxytocin and HPA reactivity. This study is funded by the National Institute of Child Health and Human Development with institutional review board approval.Recruitment and data collection have commenced, and the expected results will be available in 2024. Analyses are presented for testing the proposed hypotheses.The unique combination of a prospective longitudinal research design with an embedded randomized controlled trial will allow the Mood, Mother and Child study to apply a developmental lens to the study of maternal depression and anxiety symptoms from birth to middle childhood and the psychobiological mechanisms promoting risk and resiliency for both mother and child outcomes. This will be the first study that simultaneously evaluates (1) the role of oxytocin using multiple methodologies, (2) the causal relationships between exogenous oxytocin and HPA axis functioning among mothers with differing levels of depression and anxiety symptoms, and (3) the multiple mediating and moderating roles of parenting behaviors and maternal and child psychobiological characteristics. The goals of these aims are to provide insights into the psychobiological effects of oxytocin in women and inform future clinical trials to treat perinatal mood disorders.ClinicalTrials.gov NCT03593473; https://classic.clinicaltrials.gov/ct2/show/NCT03593473DERR1-10.2196/51132 Perinatal depression (PND) is a common, morbid condition affecting >400,000 mother-child dyads in the United States each year . In addiBoth the severity and chronicity of maternal depression are associated with child developmental outcomes ,15, and A subset of systems contributing to the biopsychosocial process underlying experiences of PND may include oxytocin and its effects on HPA functioning. Research suggests that PND is associated with dysregulation of the HPA axis  and thatThere is mixed evidence from candidate gene studies of oxytocin-related genetic variants functioning as moderators of the associations between adverse developmental exposures and subsequent child outcomes. For example, oxytocin receptor (OXTR) rs53576 G allele carriers who had experienced childhood maltreatment reported more depressive symptomatology compared with AA homozygotes, suggesting that the G allele confers increased vulnerability to stressors . MeanwhiIn addition to the genetic-based moderation of exposure to PDAS and parenting behavior, there is evidence suggesting that epigenetic alterations in children’s oxytocin-related gene systems may mediate the associations between these exposures and child outcomes. Exposure to maternal depression is associated with differences in glucocorticoid receptor (NR3C1) methylation, which are thought to mediate associations between early-life adversity and subsequent psychopathology -45. FurtThe MMC study will address 3 specific aims. The first aim is to examine the role of oxytocin in the prediction of PDAS and other biopsychosocial maternal outcomes —and specifically to examine the causal relationships between exogenous oxytocin and HPA reactivity. The following three hypotheses will be addressed as part of aim 1: (1) more severe PDAS will be associated with oxytocin and HPA axis dysregulation in correlational analyses, and causal relationships between oxytocin activity and HPA axis reactivity will be evidenced through a placebo-blinded trial of intranasal oxytocin effects on serum cortisol levels in response to a social challenge (hypothesis 1a); (2) genetic variation in maternal oxytocin-associated pathways will predict PDAS severity (hypothesis 1b); and (3) genetic variation will moderate associations among depression and anxiety symptoms, maternal oxytocin and HPA axis physiology, and parenting behaviors (hypothesis 1c).The second aim is to examine the associations between PDAS and child biopsychosocial outcomes . The following four hypotheses will be addressed as part of aim 2: (1) more severe PDAS will predict more adverse child biopsychosocial outcomes during early elementary school years (hypothesis 2a); (2) high stress reactivity and maladaptive parenting behaviors will mediate associations between more severe PDAS experienced during the first year post partum and adverse child biopsychosocial outcomes in years 5 to 7 (hypothesis 2b); (3) the direct and indirect effects of PDAS on externalizing behaviors at ages 5 to 7 years will be stronger for boys, the direct and indirect effects of PDAS on internalizing behaviors at ages 5 to 7 years will be stronger for girls, and the direct and indirect effects of PDAS on early elementary cognitive outcomes will be comparable across boys and girls (hypothesis 2c); and (4) the effects of PDAS on early childhood outcomes will persist even after accounting for concurrent maternal depression and anxiety symptoms (hypothesis 2d).The third aim is to examine the associations from the previous aim as moderated by child oxytocin-related genotype and mediated by child oxytocin-related epigenetic changes over time. The following five hypotheses will be addressed as part of aim 3: (1) child genetic variation in oxytocin-associated pathways will moderate the associations between PDAS and child biopsychosocial outcomes (hypothesis 3a); (2) child genetic variation in oxytocin-associated pathways will moderate the associations between maternal parenting behaviors and child biopsychosocial outcomes (hypothesis 3b); (3) child sex will moderate relationships among child oxytocin genetic variation, PDAS, parenting behaviors, and child biopsychosocial outcomes (hypothesis 3c); (4) child epigenetic changes underlying oxytocin functioning between the ages of 2 months and 5 years will mediate the associations between PDAS exposure and parenting behaviors and child biopsychosocial outcomes (hypothesis 3d); and (5) the associations between PDAS or parenting behaviors and child epigenetic changes will be stronger for girls than for boys (hypothesis 3e [exploratory hypothesis]).The MMC study recruits mother-child dyads who previously participated in the Mood, Mother and Infant (MMI) study . AlthougData collection began on February 7, 2019, and was scheduled to continue until the spring of 2022. However, data collection was interrupted by the COVID-19 pandemic. On March 14, 2020, data collection was halted entirely and did not resume until August 25, 2020, at which point an adapted protocol was implemented for the safety of participant families and research staff. On April 21, 2021, the original protocol was largely reinstated and will be implemented until the completion of the project . Descriptions of the data collection protocols for the pre– and post–COVID-19 periods and the protocol during the COVID-19 period are provided in the following sections.Participants for the MMC study are recruited from the MMI sample (N=222). Following the mother’s arrival and informed consent procedures, each participant provides a urine sample used immediately for pregnancy testing, and only nonpregnant participants proceed with the oxytocin randomized controlled trial (RCT) visit. Research staff apply MindWare cardiovascular sensors (MindWare Technologies LTD) to monitor HRV and the cardiac pre-ejection period (PEP), a SunTech Tango monitor  assesses blood pressure and heart rate, and an antecubital intravenous catheter is placed for interval blood sampling. Next, the mother is left to adapt to the testing chamber for a 10-minute habituation period ,52. FollDuring the months affected by the COVID-19 pandemic, the MMC study visit 1 protocol was amended as follows. First, participants completed informed consent protocols over the phone using DocuSign . The research staff reviewed a COVID-19 information sheet and symptom screening before arriving at the study visit. Participants were also screened for symptoms upon arrival. Second, the SCID-NP was conducted via phone call instead of in person. Finally, research staff and participants further enhanced safety protocols by requiring masking for all, limiting contact by leaving the testing chamber when possible, keeping the door open for increased air circulation, and remaining a minimum of 6 feet away as much as possible. The TSST committee members were seated >6 feet away from the participant and from each other. These protocol amendments will be implemented for the remainder of the study.Following the mother’s arrival and informed consent procedures, MindWare cardiovascular sensors were placed on the mother and child, 6 cheek cell swabs were collected from the child, and the child’s height and weight were recorded. After a 5-minute habituation period to the testing chamber, the mothers were taken into a neighboring room, and the children remained in the assessment room with the research staff. The children were then assessed for EF ability using the EF Touch assessment . This lasted for approximately 30 to 45 minutes . Finally, child IQ was assessed using the 6 subscales of the Wechsler Preschool and Primary Scale of Intelligence that comprise the full-scale IQ (FSIQ) measure . While tOnce the mothers and children were done with their separate tasks, a maternal antecubital intravenous was placed for interval blood sampling. The dyad was then reunited for an additional 5-minute baseline rest period. After this period, the mother and child participated in a set of 3 parent-child interaction tasks designed to assess parent and child behaviors within a dynamic interaction context . Three 5During the months affected by the COVID-19 pandemic, the MMC study visit 2 protocol was amended as follows. First, we suspended maternal blood sampling, mother and child MindWare data and hair sample collection, and child cheek cell collection to reduce contact between staff and participants. Second, upon arrival (after completion of wellness screening), mothers and children were directed into a cleaned, unoccupied room without research staff where they could remove their masks to complete the parent-child interaction tasks (cameras were operated remotely for recording). These safety accommodations were important as it was necessary to observe these interactions without masks to code mother and child facial affect. Once the parent-child interaction tasks were complete, mothers and children resumed mask wearing. Suspended protocols were gradually reintroduced as COVID-19 restrictions were reduced. On April 21, 2021, cheek cell collection resumed. On August 23, 2021, MindWare data collection for the children and the baseline rest period were reintroduced. On June 26, 2022, hair samples were reintroduced and moved to the beginning of the protocol. Maternal blood collection and MindWare data collection were not implemented for the remainder of the study. Owing to this, the second baseline rest period was never reintroduced, either. The research staff reviewed a COVID-19 information sheet and symptom screening before arriving at the study visit. Participants were also screened for symptoms upon arrival. Research staff and participants increased safety protocols, including required masking for all, limiting contact by leaving the chamber when possible, keeping the door open for increased air circulation, and remaining a minimum of 6 feet away as much as possible. These protocols will be implemented for the remainder of the study.MMC study measures are presented in the following sequence. First, measures pertinent to the RCT examining oxytocin and HPA axis functioning are presented. Next, measures pertinent to testing the hypotheses in aims 1, 2, and 3 are presented in order of appearance in the passive longitudinal design . This beMothers in the experimental condition are administered 24 international units of nasal oxytocin, and mothers in the placebo condition are administered an equivalent volume of an inert nasal spray. After a rest period, mothers are trained and observed to self-administer 6 separate nasal spray inhalations at approximately 30- to 60-second intervals, alternating between the right and left nostril.Maternal blood samples from the first laboratory visit  will be assayed for adrenocorticotropic hormone in ethylenediaminetetraacetic acid–treated plasma and serum cortisol using commercially available radioimmunoassay reagents from MP Biomedicals.Oxytocin in ethylenediaminetetraacetic acid–treated plasma, with aprotinin added to prevent peptide degradation, will be determined through enzyme immunoassay with extraction (Enzo Life Sciences), as previously described . InterprDNA extracted from maternal blood collected during the MMI study will be used for genotyping. Genome-wide single nucleotide polymorphism (SNP) arrays will be used to identify genetic variations in individual genes (in addition to clusters of genes) whose products interact in pathways that have been implicated in maternal depression, stress reactivity, and parenting behaviors (such as oxytocin). To estimate genetic ancestry in our diverse population, we will apply both structure and Eigensoft SmartPCA to linkage equilibrium-pruned array data.Depression and anxiety symptoms are measured at multiple times , includiMobile Impedance Cardiographs (MindWare Technologies LTD) are used to measure cardiac rate, interbeat interval, and PEP in mothers and children. MindWare HRV software will be used to derive respiration and calculate high-frequency HRV and respiratory sinus arrhythmia from the interbeat interval series as indexes of parasympathetic activity. Respiratory rate will be used in all HRV analyses. MindWare Impedance Cardiography Analysis software will calculate cardiac time intervals, stroke volume, and cardiac output. PEP will index sympathetic activation.Hair cortisol will be assayed from 20 to 25 strands of hair  collectenot at all characteristic to 5 as highly characteristic). On the basis of previous empirical findings and theoretical models of parenting dimensions, we anticipate that these scales will load onto 2 broad dimensions of maternal parenting behavior—overall sensitivity  and negative-controlling behaviors (negative regard and intrusiveness). The ultimate creation of parenting dimensions will be guided by factor analyses comparable with those in previous studies by WRM-K  and maternal HPA functioning to PDAS [b path]). We will use bootstrapped SEs to conduct significance tests for the indirect effects.First, we will use a general linear model to test the hypothesis that participants who are randomized to receive nasal oxytocin experience lower HPA reactivity during the TSST to evaluate this proposed causal pathway (hypothesis 1a). Next, we will also evaluate whether observed oxytocin functioning or genetic variation in oxytocin-associated pathways correlates with PDAS and will then use structural equation modeling (SEM) to assess whether mothers’ HPA functioning mediates the association between oxytocin variation and PDAS (hypotheses 1a and 1b). The SEM framework will enable us to model uncertainty in the growth parameters or latent class membership while simultaneously estimating the 2 mediation pathways . We will also test whether maternal genetic variation moderates the associations between PDAS and maternal HPA functioning, oxytocin functioning, and parenting behaviors (hypothesis 1c). Significant moderation effects will be probed following procedures outlined by Preacher et al  to obtaiOur next step of analysis will be to evaluate the extent to which PDAS predicts more adverse child biopsychosocial outcomes during early elementary years (hypothesis 2a), whether high stress reactivity or maladaptive parenting behaviors mediate this association (hypothesis 2b), whether the direct effects of PDAS on child outcomes remain significant after accounting for concurrent maternal depression and anxiety severity (hypothesis 2b), and whether sex moderates the associations between PDAS and child outcomes such that the effects of PDAS on child externalizing are stronger for male individuals and the effects of PDAS on child internalizing are stronger for female individuals. We will continue within an SEM framework for aim 2 analyses as this approach allows for the simultaneous modeling of mediation, moderation, and a variety of response distributions.In addition to demographic control variables, we will include child temperament (assessed in infancy and concurrently at the age of 5 y) to control for genetic confounds between mothers and children as well as passive gene-environment correlations within the family system.For aim 3, we will conduct SEM analyses in two ways: (1) including estimated risk scores and (2) stratified by child OXT and OXTR genotypes to determine if child genotype moderates the associations between PDAS and developmental outcomes (hypothesis 3a) and between maternal sensitivity and developmental outcomes (hypothesis 3b). Next, we will test whether the pathways tested in aims 1 and 2 vary by child sex by introducing 2-way interactions between PDAS and child sex and parental sensitivity and child sex and probing significant effects. We will test whether the methylation status of oxytocin-related genetic regions mediates associations among PDAS exposure, sensitivity, attachment quality, and developmental outcomes (hypothesis 3d). Finally, we will conduct exploratory analyses using multigroup models to examine whether the effects of PDAS and maternal sensitivity on epigenetic changes in child oxytocin functioning are stronger for girls than for boys (hypothesis 3e). We will use bootstrapped SEs to conduct significance tests for the indirect effects. Moderation effects will be probed following the procedures outlined by Preacher et al .The proposed study design incorporates extensive repeated assessments. Growth models and SEMs are estimated using full information maximum likelihood, which permits the assumption that missing data are missing at random conditional on observed measures. We will rely on this assumption when data are missing exclusively on endogenous variables. We will use multiple imputation for all analyses involving missing covariates to avoid listwise deletion of cases with missing exogenous variables.r≥0.26, a mean difference of Cohen d≥0.5, and an odds ratio of ≥2.02. Thus, broadly, we expect to have the power to detect moderate, clinically meaningful effects; however, we will have limited power to detect smaller effect sizes that tend to occur in mediation and moderation analyses.As described previously, attrition and suspension of data collection because of COVID-19 resulted in a lower enrollment in the MMC study than we had hoped; however, we anticipate enrolling 110 dyads from the original sample. With this sample size and a type-I error rate of Cronbach α=.05, we will have 80% power to detect a correlation of This project received ethics approval from the University of North Carolina at Chapel Hill institutional review board (21-0421).The trial was registered with ClinicalTrials.gov on July 20, 2018 (NCT03593473). The study began in September 2018 and continues through August 2024. Recruitment and data collection have commenced; as of June 1, 2023, a total of 102 participants have been enrolled. Study results should be available in 2024.Previous research has documented associations between PND and offspring developmental outcomes in middle childhood ,86 and e


Wireless vital sign sensors are increasingly being used to monitor patients on surgical wards. Although early warning scores (EWSs) are the current standard for the identification of patient deterioration in a ward setting, their usefulness for continuous monitoring is unknown.This study aimed to explore the usability and predictive value of high-rate EWSs obtained from continuous vital sign recordings for early identification of postoperative complications and compares the performance of a sensor-based EWS alarm system with manual intermittent EWS measurements and threshold alarms applied to individual vital sign recordings .Continuous vital sign measurements  collected with wireless sensors in patients on surgical wards were used for retrospective simulation of EWSs (sensor EWSs) for different time windows (1-240 min), adopting criteria similar to EWSs based on manual vital signs measurements (nurse EWSs). Hourly sensor EWS measurements were compared between patients with  and without  postoperative complications. In addition, alarms were simulated for the sensor EWSs using a range of alarm thresholds (1-9) and compared with alarms based on nurse EWSs and single-parameter alarms. Alarm performance was evaluated using the sensitivity to predict complications within 24 hours, daily alarm rate, and false discovery rate (FDR).P<.004) compared with the control group . The alarm sensitivity of the hourly sensor EWSs was the highest (80%-67%) for thresholds of 3 to 5, which was associated with alarm rates of 2 (FDR=85%) to 1.2 (FDR=83%) alarms per patient per day respectively. The sensitivity of sensor EWS–based alarms was higher than that of nurse EWS–based alarms (maximum=40%) but lower than that of single-parameter alarms (87%) for all thresholds. In contrast, the  alarm rates of sensor EWS–based alarms were higher than that of nurse EWS–based alarms  but lower than that of single-parameter alarms  for most thresholds. Alarm rates for sensor EWSs increased for shorter time windows, reaching 70 alarms per patient per day when calculated every minute.The hourly sensor EWSs of the event group  was significantly higher (EWSs obtained using wireless vital sign sensors may contribute to the early recognition of postoperative complications in a ward setting, with higher alarm sensitivity compared with manual EWS measurements. Although hourly sensor EWSs provide fewer alarms compared with single-parameter alarms, high false alarm rates can be expected when calculated over shorter time spans. Further studies are recommended to optimize care escalation criteria for continuous monitoring of vital signs in a ward setting and to evaluate the effects on patient outcomes. Surgical patients are at risk of developing postoperative complications, which may progress to life-threatening illnesses and seriously affect patient outcomes if not promptly detected and correctly treated . Most poIn hospital wards, patient monitoring typically consists of routine vital sign checks performed by nurses every 6 to 8 hours, complemented by subjective evaluation of the patient status during nursing activities ,8. In adIn recent years, wireless sensors that enable mobile vital sign monitoring have been introduced. These sensors facilitate automated, less obtrusive, and continuous patient monitoring in a ward setting ,13. AlthCurrently, wireless monitoring is often implemented in combination with traditional alarm strategies, where an alert is sent automatically as soon as the measurement of one of the vital signs exceeds a preset upper or lower threshold ,17. AlthAccordingly, it may be of interest to use EWSs instead of single-parameter alarms to detect potential abnormalities in continuously monitored patients on surgical wards, as supported by recently developed remote monitoring systems . HoweverThe study had an observational retrospective design.This study was approved by The Medical Research Ethics Committee Twente .All included participants provided written informed consent to participate in the study and to use their data for research purposes.The study included patients (aged ≥18 years) undergoing elective esophageal or gastric resection  and older patients (aged ≥70 years) undergoing acute surgery for a hip fracture , as these groups are known to have relatively high rates of complications during ward stay. Patients were recruited preoperatively or after postoperative admission to the surgical ward (GI unit or center of geriatric traumatology). Patients were excluded if they had implanted electronic medical devices, had known allergies to materials used in wearable sensors, had suspected delirium or cognitive impairment, or were unable to decide upon study participation. Recruitment was performed during office hours only, and patients who were expected to leave the hospital within 24 hours after possible recruitment were not eligible for study participation.2) was measured with the 3150 WristOx finger pulse oximeter . All the measurements were sent to a bedside patient gateway using an encrypted Bluetooth connection. Sensor recordings were started after the patient was admitted to the surgical ward and informed consent was obtained and continued until hospital discharge (or premature patient dropout). During the recording period, the researchers checked and maintained the technical functionality of the sensor recordings at least once a day on weekdays. Medical professionals and patients were blinded to the sensor measurements to prevent bias, but nurses were instructed to temporarily detach the sensors for showering, diagnostic imaging, or surgical interventions or reinterventions.The patients received standard ward care including routine nursing observations. Nurses were instructed to perform manual measurements of vital signs and calculate a corresponding Modified Early Warning Score (MEWS)  at leastTo explore the added value of routine collection of subjective information from nurses and patients, nurses were instructed to fill in a paper checklist during every nurse shift to register the possible presence and reasons for nurse worry using an adapted version of the Dutch Early Nurse Worry Indicator Score, as specified in Data Preprocessing section). Patients with eligible complications were enrolled in the event group, whereas patients with an uncomplicated postoperative trajectory served as the control group. Patients with only ineligible complications were excluded from further analyses. To evaluate the risk of selection bias, the baseline characteristics were compared between the included and excluded patient groups.An event was defined as a postoperative complication that was diagnosed according to local standards and that was treated during ward stay or within 7 days after hospital discharge. Events were identified retrospectively from patient records and reviewed by a surgeon (EAK or HJH) to ensure correct interpretation. As there is no way to ascertain exactly when a complication started, we recorded the start of targeted treatment as the onset time of the complication. Similarly, the end time of the complication was defined as the timing of the last therapeutic action, for example, the last medication gift. If no information regarding the last therapeutic action was available or if therapy was continued after hospital discharge (or premature patient dropout) or in case of palliative treatment, it was assumed that the complication lasted until the end of the sensor recording period. Complications classified as Clavien-Dindo class  of II orSensor and nurse measurements were used to simulate corresponding EWSs. In addition, alarms were respectively simulated using the EWSs based on sensor vital signs measurements (sensor EWSs), EWSs based on manual vital signs measurements (nurse EWSs), and single vital sign recordings, with the aim of evaluating and comparing the effects of using these measurements as response triggers or active alarms. 2 <70% or >100%), most likely caused by artifacts. As no standard monitoring frequency has currently been established for monitoring patients on surgical wards, sensor measurements were analyzed repeatedly for different time windows. Accordingly, the minute-sampled vital sign recordings were resampled by averaging the signal values in successive windows of 5, 10, 20, 30, 60, 120, and 240 minutes. For each vital parameter, windows wherein data were missing for >50% of the time were disregarded.Data preprocessing and analysis were performed using MATLAB . Sensor recordings were preprocessed by removing implausible extreme values  and based on all available nurse EWS measurements . An alarm was defined as an occurrence where the EWS increased to a higher level compared with a previous measurement, thereby exceeding a preset threshold (“EWS threshold”). When the measurements exceeded the EWS threshold from the beginning of the measurement period, the first sample was considered as the first alarm. EWS alarms were simulated repeatedly for EWS thresholds of 1 to 9, aiming to evaluate the alarms for a wide range of thresholds. However, as MEWS cutoff values of 3 and 5 were used in this study’s hospital as response triggers, these thresholds were selected as EWS threshold in the primary analysis. For the sensor EWSs, the primary investigation was based on 1-hour time windows, but alarms were also simulated for all other time windows (1-240 min).2 ≤91%, and AT ≤34.9 °C or ≥38.5 °C. Single-parameter alarms were simulated for 1-hour time windows, and situations where multiple single-parameter alarms were present in the same window were counted as 1 alarm.In addition to the alarms based on EWSs, sensor measurements were used to simulate single-parameter alarms, similar to traditional physiological alarm systems. A single-parameter alarm was simulated when the vital sign measurement exceeded the predefined normal range. Upper and lower thresholds were defined by the outer limits of the EWS criteria, that is, HR ≤40 or ≥130 bpm, RR ≤8 or ≥30 brpm, SpOAll the simulated alarms were classified based on the timing of the alarms, as illustrated in The availability of sensor measurements, that is, data completeness, was calculated as the percentage of the total recording time where vital sign measurements were available after preprocessing in the total study population. The availability of nurse measurements was verified by the number of measurements available per 24 hours. The agreement between nurse and sensor measurements was explored for each vital parameter using Bland-Altman analysis for repeated measures  by compaU test. In addition, a sensitivity analysis was performed to verify the impact of patient exclusion on group differences by separately evaluating group differences after adding excluded patients to the control group.All the measurements  were compared between the event and control groups to explore their relationships with the development of complications. For all available hourly sensor EWS and nurse EWS measurements obtained during the sensor recording period, the average EWSs and the percentage of measurements where the EWSs were ≥3 (intermediate to high risk) and ≥5 (high risk) was investigated for each group. For the sensor EWSs, the number of EWS points assigned to the hourly sensor measurement windows was evaluated to investigate the contribution of the different vital parameters to the sensor EWSs. Furthermore, the percentage of hourly sensor measurements, that is, single-parameter recordings, that exceeded the upper or lower thresholds defined for the single-parameter alarms were assessed. Finally, the prevalence of worry expressed by nurses and the prevalence of (very) poor current status and (severely) impaired status indicated by patients during the study period were evaluated to explore the potential diagnostic value of this subjective information. All group differences were statistically compared using the Mann-Whitney The performance of the sensor EWS–based, nurse EWS–based, and single-parameter alarms was investigated using 2 sensitivity rates: the total alarm rate (TAR) and the false discovery rate (FDR) . The senA total of 60 patients were included in the study, of whom 33 (55%) were patients undergoing elective esophageal or gastric resection and 27 (45%) were older patients with a hip fracture. The baseline characteristics of the participants are presented in During the measurement period or the 7-day follow-up period, a total of 40 complications were observed in 28 patients. Of all observed complications (n=40), 25 (63%) events were excluded , resulting in the exclusion of 14 patients from the analysis. Out of 40 events, 15 (38%) were included in the analysis . The included events were present in a group of 14 patients , who were selected as the event group. The control group consisted of 32 patients  in whom no events were observed. We found no statistical differences in the baseline characteristics between the event and control groups or between the included and excluded patient groups.2 values were missing more frequently, with a median availability of 46% (IQR 40%-60%). The median number of vital sign observations registered by nurses was 3 (IQR 2-4) per day. On average, HR was available in 96%, RR in 48%, SpO2 in 92%, systolic blood pressure in 95%, and tympanic temperature in 93% of nurse observations.Sensor recordings in the total study population had a median duration of 120 (IQR 93-163) hours. After preprocessing, the median data availability of HR and RR was 84% (IQR 74%-94%) of the measurement time and that of AT was 97% (IQR 84%-100%). SpO2 (mean absolute difference 2.1%) and temperature measurements (mean difference 0.9 °C) recorded by the sensor were lower than the nurse measurements, where the largest deviations were observed in the lower ranges. For all parameters, the limits of agreement were relatively wide compared with the observed range of values.Bland-Altman plots for all available nurse and sensor data pairs are presented in 2 received 2 or 3 points in at least half of the available measurements for both the event and control groups, thereby contributing most to the sensor EWSs.P=.004) than those of the patients with uncomplicated postoperative trajectories. In addition, the sensor EWSs in the event group reached scores of ≥5 more often compared with the control group (P<.001). For nurse EWSs, the number of measurements, as well as the average nurse EWSs and the percentage of observations where sensor EWSs of ≥3 or ≥5, were significantly higher for the event group . Furthermore, nurses expressed worry more often for the patients in the event group (P=.02). Indicators for nurse worry that were reported in both groups are specified in P=.35 and P=.37). However, patients in the event group seemed to report a (very) poor and a (much) impaired status more often, although these patients filled in the daily diary less frequently. According to the sensitivity analysis, adding the excluded patient group to the control group did not change any of the results, as all P values remained within the same levels of significance .P=.006) and from the median value of 2.8 (IQR 2.4-3.2) of the average sensor EWSs observed across the total measurement period in the control group (P=.04).In the 24 hours before the onset of the included events, the average sensor EWSs had a median value of 3.4 (IQR 2.5-4.0), which was significantly different from the median value of 2.0 (IQR 1.1-2.7) of the average nurse EWSs in this period  was classified as FP alarms. In contrast, high HR and high AT alarms were associated with lower alarm rates and lower FDR (≤30%). No single-parameter alarms were observed for low HR or low RR.This study investigated the potential usability of high-rate EWSs obtained from wireless vital sign data for early identification of complications in patients on surgical wards and explored the performance of a sensor EWS–based alarm system in comparison with single-parameter alarms and manual EWS measurements by nurses for various alarm settings. The EWSs based on hourly sensor recordings were significantly higher in patients with complications than in patients with an uncomplicated postoperative trajectory. Furthermore, the sensitivity to predict adverse events within 24 hours was higher for sensor EWS–based alarms compared with nurse EWS–based alarms. Therefore, EWSs obtained from sensor measurements might contribute to early awareness or confirmation of patient deterioration in current ward routines. However, high EWSs were often recurrent in patients with and without events and could therefore lead to high false alarm rates when used as real-time alarm systems. Although hourly EWS measurements resulted in fewer alarms compared with single-parameter alarms, the number of false EWS alarms increased when using shorter time windows and varied between alarm thresholds, highlighting the importance of careful selection of alarm settings.2 abnormalities were often observed, which is in line with the high prevalence of hypoxemic (micro) events found in similar observational studies [Traditionally, vital signs are used to monitor patients after surgery, as vital signs change 4 to 24 hours before adverse events . The add studies ,29.Compared with hourly sensor EWS–based alarms, we found higher sensitivity rates for single-parameter alarms, although the differences were small for some EWS thresholds. This observation is in line with a study by Rothman et al  who repoAnother possible explanation for the low specificity is that sensor-based respiration rates were typically much higher than nurse-based measurements. Whether this reflects the inaccuracy of nurse-based RR measurements  or RR ovThe use of automatic alarm systems in monitoring routines can contribute to the early awareness and active responses of care professionals to potential deterioration . HoweverAlarm rates based on the hourly sensor EWSs were lower than those based on the hourly single-parameter alarms, which underlines the benefits of a multiple-parameter approach to improving specificity. However, it should be noted that the EWS alarm rates increased rapidly when using shorter time windows. Therefore, it might be appropriate to restrict automatic alarm generation based on EWSs to intervals of 1 hour or even longer in a ward setting and additionally present historical data trends for a more detailed evaluation of patient deterioration during nurse rounds. The use of summary measures for continuously measured vital signs is supported by van Goor et al , who rep2, where we found a relatively high rate of missing data related to detachment of the finger probe by patients, loss of Bluetooth connection, and short battery life, as also reported in another study using the same device [2 values from locations on the body that are less prone to (movement) artifacts and sensor dislodgment. Furthermore, adequate methods for correcting missing data periods in postanalysis and real-time alarm systems are desired.The use of wireless sensors provides new opportunities for monitoring vital signs in ward settings. By enabling continuous recording, wireless monitoring supports the comprehensive investigation of data abnormalities and trends, reducing the likelihood that signs of deterioration are missed due to intermittent or incomplete nurse measurements ,27. In ae device . Technol2 as also observed in other studies [Second, wearable sensor measurements are prone to artifacts caused by motion and poor skin contact, and clinical validation studies have shown variable accuracy of remote systems -40. Thes studies . However studies . In addiFinally, when seeking continuous risk prediction methods or fully automatic EWS assessments, it should be considered that currently available wireless monitoring systems are restricted to measuring only a selection of vital parameters. For example, the level of consciousness is implemented in standard EWS or patient monitoring routines  but cannSubjective evaluation of patient status is an essential element of patient monitoring and clinical decision-making ,37. The In addition to nurse worry, well-being indicators reported by patients or by their relatives provide important signs of deterioration , and theThis exploratory study included 2 surgical populations with a relatively high risk of developing postoperative complications and, therefore, may benefit from improved monitoring. The heterogeneity of our study population and the variety of included events allowed the exploration of the predictive value of continuous EWSs for different algorithm settings. However, the total number of included patients and events eligible for analysis were limited, and it should be noted that clinical deterioration may present differently across other settings. Therefore, validation of this study’s results in larger cohorts and other specific or general populations is needed once remote monitoring systems are mature and implemented more widely. Similarly, verification of the performance of high-rate EWSs for monitoring systems using other sensors or different parameter sets is desired. Finally, prospective studies assessing the clinical effects of using high-rate EWSs are needed.The criteria used for the simulation of the sensor EWSs were based on clinical standards to allow comparison with current practice; therefore, the optimization of alarm criteria was limited to exploring different cutoff thresholds and sample frequencies. Furthermore, the EWSs were obtained using average vital sign values, whereas the use of other summary measures can result in different EWSs . BecauseAlthough many studies have focused on the prediction of life-threatening events such as cardiac arrest, this study focused on all minor and major complications that required additional care in a ward setting. Patients with Clavien-Dindo class I complications that, by definition, did not require pharmacological or surgical treatment were excluded from the analysis. The sensitivity analysis indicated that the inclusion of these patients in the control group did not affect the results, indicating that the predictive value of vital signs or EWSs is limited for these events. Following the concept that early warning systems should alert only when action is required, this study used the onset of therapeutic actions as a surrogate marker of complication onset. However, the timing of therapeutic onset depends highly on the diagnostic definitions and is prone to delays in diagnostic or therapeutic activities. Furthermore, delays in clinical reporting hamper accurate retrospective determination of therapy onset. Therefore, prospective clinical trials are needed to investigate the effects of using a high-rate sensor-based EWSs as a diagnostic tool or alarm system on time to treatment and the corresponding patient outcomes.Hourly EWSs obtained using wireless vital sign sensors resulted in higher sensitivity for predicting postoperative complications compared with the currently used 8-hour, nurse-based EWSs. Therefore, sensor EWSs may contribute to the improved detection of clinical deterioration in patients on surgical wards. In addition, using the EWS as an active alarm trigger results in fewer alarms compared with single-parameter alarms in sensor measurements. However, false alarm rates can increase rapidly when calculating EWSs in short time spans, risking alarm fatigue and overdetection. To prevent alarm overload in a ward setting, we suggest restricting EWS-based alarm generation to windows of at least 1 hour or longer. In addition, investigation of alternative care escalation criteria for wireless monitoring is warranted because automatic vital sign recordings differ from nurse measurements and are currently only available for a selected set of vital parameters. Finally, it is recommended to embed a structured collection of subjective nurse and patient information into monitoring routines, as this might provide complementary signs of deterioration. Future clinical studies are needed to evaluate the clinical effects of using the EWSs and the corresponding alarm system for continuous monitoring of patients on wards.