Augmented reality (AR) technology has generated enormous industry investment and buzz, with the food and beverage sector quickly embracing this technology in an effort to enhance the customer experience. However, academic research has only just begun to empirically explore how and why this technology might influence consumer judgements and behaviors in such contexts. Across two field studies involving consequential behavior and two controlled laboratory studies, we find that AR’s unique ability to visually superimpose objects onto a real-time environment increases consumers’ ability to mentally simulate consuming a pictured food, which in turn increases their desire and purchase likelihood of the food item. Further, we find the increased mental simulation produced by AR is itself preceded and driven by an increased sense of personal relevance of the food items.The online version contains supplementary material available at 10.1007/s11747-022-00919-x. Augmented Reality (AR), technology that superimposes digital content onto real-time physical environments  can meaningfully alter the ways consumers behave in today’s marketplace.To build a conceptual framework for how AR technology might systematically influence consumer responses to depicted foods, we first describe the technology itself and recent explorations into how it might influence consumer behavior, before integrating relevant literature on mental simulation to build our theoretical framework.Augmented reality (AR) technology transforms a user’s visual experience of the physical world in real-time, by allowing the user to, “see the real world, with virtual objects superimposed upon or composited with the real world,” Azuma, . While pAlthough sometimes used interchangeably , it should be noted that AR is both theoretically and practically distinct from Virtual Reality (VR). VR is a technology which entirely immerses the user in an artificial, virtually simulated world Schmitt, . One waySome scholarly work in marketing has begun to explore the psychological implications of AR-enabled visualizations. In Table themselves (as opposed to superimposing content into the user’s environment/space). Thus, AR presentation in such contexts necessarily introduces the confound of simultaneously providing a visual portrayal of the user themself , we hold such aspects constant, instead empirically isolating and focusing on AR’s fundamental ability to superimpose digital objects onto a consumer’s real-time environment. In other words, we explore whether and how such superimposition of visual content can, in and of itself, influence consumers’ evaluations and purchase likelihood.mental simulation, particularly by a consumer’s tendency to imagine consuming a designated food  increase desirability; and (b) improve purchase likelihood, relative to depicting the food item in a non-superimposed format.H2 The positive effects of AR presentation on food desirability and purchase likelihood will be driven by increased mental simulation.Given that AR has a unique ability to visually superimpose digital objects on top of one’s real-time visual environment, together with the knowledge that visual contextual cues often serve as critical antecedents of mental simulation  in extant literature . This study was a field experiment, run with the cooperation of a restaurant in a large international city. Specifically, we created an AR version of the restaurant’s existing dessert menu, which allowed us to assess whether diners who viewed the menu in an AR format were more or less likely to purchase a dessert as compared to diners who viewed the menu in a non-superimposed  format.Age = 37.95, SD = 13.04) participated in exchange for a £5 discount on their restaurant bill. The experiment used a two-level (presentation format: control versus AR) between-subjects design. We ran this experiment in collaboration with a brasserie-style restaurant in a large international city . The two presentation formats are illustrated in Appendix The experiment was run on two consecutive weekday evenings during the dinner shift (6 pm – 10:30 pm). After restaurant diners completed the main course of their meal, an experimenter blind to the hypothesis and posing as a waiter approached their table with a tablet and informed them that the restaurant had created a “digital dessert menu” and was offering diners a discount off their bill for simply looking at the menu and providing feedback (without any obligation to order anything if they did not wish to).Each table was randomly assigned to view the dessert menu in either the control or AR format on an alternating basis . While viewing the menu, participants completed a paper survey in which they assessed the desirability of each dessert on a 7-point scale (1 = “very undesirable” to 7 = “very desirable”). After placing their dessert orders (if any) with the experimenter, participants were asked their age, gender, and familiarity with augmented reality technology  = 6.21, p = 0.01). Controlling for the number of people at each table and the average money spent per person strengthened this effect  = 9.50, p < 0.01).p’s > 0.15). While not germane to our investigation, it is worth noting that the number of people at the table did exert a significant and negative main effect on participants’ likelihood to order dessert ,p > 0.98).A binary logistic regression found that participants were significantly more likely to order a dessert if they viewed options in the AR menu (41.2%) versus the control menu  = 7.58, p < 0.01, ηp2 = 0.07). Receipts from the week following our data collection suggest that the typical likelihood of a restaurant diner ordering dessert at this restaurant (ordered from a print-based menu) on a weekday evening is 7%. The increased likelihood of dessert purchase in our study (in both presentation format conditions) is likely due in part to the fact that diners were given a discount off their bill for looking at the menu. Importantly however, this cannot explain the difference we find across the control and AR conditions.As a robustness check, we also calculated the average amount of money each diner spent on dessert (including participants who did not spend any money on dessert). ANOVA results demonstrated that those in the AR menu condition spent significantly more on dessert than those in the control condition  = 0.03, p = 0.87). Importantly, neither the main effect of AR familiarity nor the interaction between presentation format and AR familiarity were significant predictors of purchase likelihood (both p’s > 0.26). In other words, diners with both high and low levels of familiarity with AR technology responded the same way to the presentation format, suggesting that it is unlikely that the AR effect observed here can be explained by the novelty of the technology.7While the menus in both conditions were digitally presented on tablets, one could still reasonably argue that the AR menu format was more novel than the control menu format. Accordingly, to examine whether novelty might explain the positive effect of AR presentation on purchase likelihood, we adopted a procedure from previous literature  = 26.34, p < 0.001, ηp2 = 0.21) in the predicted direction; i.e., the average desirability of the desserts was higher in the AR menu condition than in the control menu condition. Additionally, there was no interaction between presentation format and the within-subject dessert type factor  = 0.06, p = 0.81). As was the case with the purchase likelihood dependent variable, controlling for the number of people at each table and the average money spent per person strengthened the AR effect  = 30.17, p < 0.001, ηp2 = 0.24).p’s > 0.25).Given that diners rated the desirability of all desserts on the menu, we ran a repeated-measures ANOVA with dessert type as a within-subjects variable and presentation format as a between-subjects factor. Results demonstrated a significant effect of presentation format on dessert desirability (p’s > 0.70) or dessert desirability (both p’s > 0.30), and our results continue to hold while controlling for these variables (p < 0.001 for the effect of presentation format on both dessert purchase and desirability).We also examined whether participants’ age or gender might act as significant covariates in the analyses above. Neither variable was significant in predicting the influence on dessert purchase  can increase both desirability and purchase likelihood, supporting H1. Further, we rule out the potential effect of novelty, and demonstrate the effect holds regardless of a viewer’s age or gender. Importantly, the control condition in this study was a non-superimposed two-dimensional image, as this represents an externally-valid depiction commonly used in restaurants. However, to better isolate the role of superimposition specifically, we employed a more conservative control condition in our remaining studies .Study 2 served several purposes. First, we sought to replicate the AR effect on desirability, this time using a more conservative control condition allowing us to isolate the effect of superimposition from visual dimensionality, and to accordingly eliminate any confounds stemming from additional information acquisition in the AR condition. Specifically, we held dimensionality constant , and we solely manipulated superimposition by varying whether or not the item appeared in the user’s real-time environment. Second, we wanted to begin exploring the underlying process , to provide a preliminary test of H2. Finally, we took the opportunity to measure participants’ post-consumption enjoyment of food items, allowing us to examine how AR presentation prior to consumption might ultimately influence this important post-consumption response. To maintain a high degree of external validity, we worked with a university catering team to run this field experiment in the café of a business school that was frequented by students and staff.One hundred and thirty participants (composed of business school students and staff) participated in this study in exchange for a free dessert. We used a two-level (presentation format: control versus AR) between-subjects design. For this study, we worked closely with the university catering team that wanted to showcase three new dessert items developed by their chef for the café  and responded to a one-item measure of mental simulation . Accordingly, we did not exclude any participants and simply include participant batch as a covariate in our remaining analysis. ANCOVA results demonstrated a significant effect of presentation format on dessert desirability  = 8.40, p < 0.01, ηp2 = 0.06) in the same direction as Study 1 (thus adding support for H1): desirability was higher for the chosen dessert when it was viewed in the AR (versus control) menu format. The effect of presentation format did not differ according to which dessert was chosen (p = 0.26).After 109 participants had completed the study, the kitchen ran out of one of the dessert options (chocolate brownie). Accordingly, the final batch of participants (N = 21) were only given two dessert options to choose from. Results did not demonstrate any difference between the two batches of participants on any of our dependent variables  = 5.19, p = 0.02, ηp2 = 0.04). To assess whether mental simulation could explain the increased desirability induced by the AR (versus control) presentation, we ran a mediation analysis  format  = 4.02, p = 0.05, ηp2 = 0.03), in that participants who had viewed the dessert in the AR menu pre-consumption reported greater post-consumption enjoyment than those in the control menu condition. While we did not have formal a priori predictions about the effect of AR presentation on post-consumption enjoyment, these results are consistent with previous work showing that savoring an upcoming experience increases enjoyment of that experience both in real-time as it is happening , and when it is remembered later on  can increase a food’s desirability. Importantly, this study allowed us to isolate superimposition  as the fundamental AR characteristic behind this effect. In addition, we provide preliminary evidence that mental simulation is the underlying process explaining the positive effect of AR on desirability, supporting H2. Finally, we demonstrate that AR presentation does not only influence pre-consumption variables , but can also exert an influence on post-consumption variables .Notably, our finding that increased mental simulation improves desirability , has already been well-established in extant literature. However, this research is the first to empirically demonstrate that the real-time superimposition afforded by AR can increase mental simulation (the first path in our model). Accordingly, to better understand this relationship between AR presentation and mental simulation, we wished to examine what preceding mediators might explain the link between AR presentation and mental simulation to begin with.Thus, in our next study, in addition to more definitively and robustly testing the effect of AR on desirability and purchase likelihood as well as the proposed mediating role of mental simulation, we test a number of additional processes that could possibly explain the link between AR and mental simulation or that could serve as alternative processes explanations more generally.Results from the previous field experiments established the effect of AR presentation on desirability and purchase likelihood and provided initial evidence of the key role mental simulation plays in this process. Study 3 served several additional purposes. First, while Studies 1 and 2 focused on indulgent desserts, this study allowed us to extend our examination to a non-indulgent food category  in extant literature  participated in this experiment in exchange for monetary compensation. The study employed a 2 cell (presentation format: control versus AR) between-subjects design. Presentation format was manipulated as in Study 2 : the control condition featured the 3D food item over a static blank background, while the AR condition superimposed the 3D food item onto the viewer’s real-time environment), except this time the target stimuli was a lamb shawarma . Then, all participants were given a tablet to view the lamb shawarma in either the control or AR presentation format, according to their randomly assigned condition. Importantly, due to social distancing requirements, participants were sat far enough apart as to not be able to interact or engage with one another.This study was conducted during the COVID-19 pandemic in a university that was allowing students to attend classes in person with appropriate protection measures and social distancing in place. To comply with local COVID-19 government regulations, we modified a lecture theater to serve as a laboratory (see Web Appendix α = 0.89) and purchase likelihood . Our proposed mediators were personal relevance  and mental simulation . In addition, we measured potential alternative process explanations including: presence , attention to background , perceptual fluency , psychological ownership , spatial and temporal distance , and realism . Finally, participants indicated their mood , familiarity with AR Technology (as measured in Study 1), gender and age.Participants responded to survey questions on their mobile phones while continuing to view the lamb shawarma on the tablet (should they wish to). To take advantage of the laboratory setting, participants were asked to respond to a battery of measures  = 4.52, p = 0.04, ηp2 = 0.04) and purchase likelihood  = 8.82, p < 0.01, ηp2 = 0.08). These results add support for H1, in that participants who viewed the lamb shawarma in the AR condition rated both the desirability of the dish and their purchase likelihood of the dish as significantly higher than those who viewed the same lamb shawarma in the control (non-superimposed) condition.Consistent with our previous findings, ANOVA results revealed significant main effects of presentation format on the desirability of the lamb shawarma (Mp < 0.001), we conducted a factor analysis which demonstrated that all items loaded onto the same factor . Accordingly, we combined all 4 items into one aggregate product evaluation scale (α = 0.90) to streamline the reporting of the mediation analyses  = 6.39, p = 0.01, ηp2 = 0.06).As desirability and purchase likelihood are arguably related constructs  = 12.07, p = 0.001, ηp2 = 0.10), where participants in the AR (vs. control) condition perceived the lamb shawarma to be more personally relevant to them. Similarly, ANOVA results revealed a significant positive effect of AR format on the degree to which participants engaged in mental simulation  = 5.11, p = 0.03, ηp2 = 0.05), replicating the initial finding in the previous study.To begin testing our proposed processes explaining the positive effect of AR presentation on product evaluations, we ran an ANOVA with presentation format as the predictor and both mental simulation and personal relevance as dependent variables. ANOVA results revealed a significant positive effect of presentation format on personal relevance ; F = 7.91, p = 0.006, ηp2 = 0.07), suggesting that participants in the AR condition perceived the lamb shawarma to be more present in their peripersonal space than those in the control condition. In addition, results revealed marginally significant effects of presentation format on attention to the background  = 3.03, p = 0.09, ηp2 = 0.03) and overall enjoyment of the experience  = 3.52, p = 0.06, ηp2 = 0.03), in that participants in the AR condition reported paying more attention to the background and reported enjoying the experience more than those in the control condition. However, ANOVA results revealed no significant effects of presentation format on the remaining process measures, including fluency, psychological ownership, spatial and temporal distance, mood, or realism.ANOVA results revealed that of the nine potential alternative process explanations, presentation format exerted a significant positive effect on only one of the variables—presence  = 0.217, p = 0.64, ηp2 = 0.00). Importantly, neither the main effect of AR familiarity nor the interaction between presentation format and AR familiarity were significant predictors of product evaluation (both p’s > 0.59). This reinforces the findings in Study 1, suggesting that it is unlikely the positive attitudinal responses to foods presented in AR can be explained by the novelty of this technology.11As in Study 1, to examine whether novelty might explain the positive effect of AR presentation on product evaluation, we test whether participants’ attitudinal response to presentation format differed according to their familiarity with AR technology. Once again, AR familiarity did not differ across the two presentation conditions  leads consumers to deem it as more personally relevant, which facilitates their mental simulation of consuming it, and accordingly improves their evaluation of the food. While our results also demonstrate significant or marginally significant positive effects of AR presentation on other potential mechanisms , they are unable to explain the effect of AR presentation on product evaluation.Results from the previous three studies collectively established the positive effect of AR presentation on product evaluations, while supporting the sequential role of personal relevance and mental simulation as the underlying process explaining the observed effect. Aside from replicating the findings of Studies 1, 2 and 3, Study 4 served three additional purposes. First, the previous three studies utilized a mobile tablet  to view both presentation formats . However, given that consumer ownership and usage of mobile phones is significantly higher than that of tablets Enge, , we wishFinally, our previous studies  treated mental simulation as a unidimensional construct. However, as theorized earlier, we expect the mental simulation facilitated through AR presentation should likely be driven by a process-oriented mindset rather than an outcome-oriented one, as the superimposition facilitated by AR provides users with the opportunity to imagine “engaging” with, or consuming, the food item. Notably, the mental simulation scale we used in the previous studies was comprised of items describing the consumption process  as opposed to a focus on any outcome per se. However, to more rigorously assess the process-oriented versus outcome-oriented distinction, we include additional items from previous literature to distinctively and separately measure both process-oriented and outcome-oriented simulation.Age = 29.87, SD = 7.00) from a university setting participated in this experiment in exchange for monetary compensation. This study employed a 2 (presentation format: control vs. AR) × 2 (food item: undesirable vs. desirable) between-subjects design. Presentation format was manipulated as in Study 2 and 3 : the control condition featured the 3D food item over a static blank background, while the AR condition superimposed the 3D food item onto the viewer’s real-time environment. To manipulate food-item desirability, participants either viewed fermented trout .Once participants arrived at the lab, they scanned a QR code with their personal mobile phone to access a survey that included the consent form and survey questions. Participants were told that the purpose of this study was to view and evaluate a food item. Next, participants were provided with a Samsung S21 smartphone, and were randomly assigned to view either the undesirable food item , or the desirable food item , in either the control or AR format. Prior to viewing the randomly assigned item, but after being told what food item they would be viewing, participants were asked to indicate their previous experience with the assigned food (“I have eaten fermented trout/parmesan fries beforeα = 0.96). In an attempt to measure and replicate the sequential mediation observed in Study 3, participants responded to the same personal relevance (r = 0.72), and mental simulation (α = 0.91) measures that were employed in Study 3. To further investigate the type of mental simulation participants might engage in, they were also asked to respond to a 2-item index measuring process-oriented simulation , and a 2-item index measuring outcome-oriented simulation . Participants indicated the realism of the stimuli (α = 0.85), their overall mood (r = 0.74), and their familiarity with AR Technology, all measured as in Study 3. Finally, they indicated their gender and age (see Web Appendix Participants responded to survey questions on their mobile phones while continuing to view the food item on the mobile phone provided (should they wish to). Our dependent variable of interest in this study was product evaluation  = 4.39; p = 0.04, ηp2 = 0.03) and food item  = 98.21; p < 0.001, ηp2 = 0.37) on overall product evaluation. As was the case in our previous studies, product evaluation was higher in the AR condition (MAR = 4.14) compared to product evaluation in the control condition (MControl = 3.67). As to be expected, product evaluation was also higher in the Desirable  condition (MDesirable = 5.00), compared to product evaluation in the Undesirable  condition (MUndesirable = 2.81). The interactive effect was not significant  = 0.50, p = 0.48), suggesting that AR presentation boosted desirability ratings for both products in a similar manner. An illustration of means is presented in Fig. Upon entering the lab, one participant mentioned they were familiar with the research as one of the researchers was their instructors. We accordingly excluded this participant from analysis, in addition to one participant whose evaluation of the undesirable food item was more than two standard deviations above the mean  = 8.93; p < 0.01, ηp2 = 0.05) on personal relevance, suggesting that participants in the AR condition (MAR = 4.32) perceived the food items to be more personally relevant to them, compared to participants in the control condition (MControl = 3.58). Similarly, ANOVA results revealed a significant main effect of food item  = 41.31; p < 0.001, ηp2 = 0.20) on personal relevance, again suggesting that participants who viewed the desirable food item (MDesirable = 4.75) perceived it to be more personally relevant than those who viewed the undesirable food item (MUndesirable = 3.15). The interactive effect between presentation format and food item was not significant  = 1.35; p = 0.25, ηp2 = 0.01).2 × 2 ANOVA results for personal relevance follow the same pattern observed on product evaluation, indicating a significant main effect of presentation format  = 4.24; p = 0.04, ηp2 = 0.03) on our 6-item measure of mental simulation, suggesting that participants in the AR condition (MAR = 4.78) reported significantly higher mental simulation of consuming the food item compared to participants in the control condition (MControl = 4.33). Similarly, ANOVA results revealed a significant main effect of food item  = 14.97; p < 0.001, ηp2 = 0.08) on mental simulation, suggesting that participants who viewed the desirable food item (MDesirable = 4.98) reported significantly higher mental simulation of consuming the depicted food compared to those who viewed the undesirable food item (MUndesirable – 4.13). Once again, the interactive effect was not significant  = 1.61, p = 0.21, ηp2 = 0.01). We next ran a sequential mediation analysis to test H3 and replicate the mediation observed in Study 3 to explore whether the effect of presentation format on product evaluation could be explained through an increase in personal relevance, followed by an increase in mental simulation. Specifically, we conducted a sequential mediation analysis . Sequential mediation analysis results using this aggregated scale mirror the results reported above  might explain the observed results, we first conducted a factor analysis with the 6 general mental simulation items, the 2 process-oriented simulation items, and the 2 outcome-oriented simulation items  leads the consumer to simulate, mentally, the process of interacting with and consuming the depicted food item (compared to imaging the outcome resulting from eating the food item), ultimately improving their evaluation of the food.Importantly, this study allowed us to explore whether the positive effect of AR presentation works only for desirable food items (as tested in the previous 3 studies), or if AR presentation could also improve evaluations of undesirable food items. Consistent with previous literature . While we did not explicitly manipulate and compare device form  in this study, the positive effect of AR presentation, and the replication of the sequential process from the previous study, add to the robustness of our investigation extend the generalizability and relevance of our investigation.Industry voices have both heralded AR technology for its potential, and criticized it for being over-hyped . However, given our delineation of the underlying process, we can make some logically informed inferences about the generalizability of our findings apply beyond the food domain. Namely, since our research demonstrates mental simulation is one of the critical mechanisms through which AR exerts its effects on consumer responses, positive consumer responses should theoretically manifest in other contexts where mental simulation is considered advantageous. Given that previous research suggests mental simulation is most beneficial for highly sensorial/hedonic (as opposed to utilitarian) product attributes  already offer patrons digital menus via handheld tablets  and online grocery shopping have both been on the rise Kats . AR techIn addition, the camera-enabled nature of mobile devices means these implications can also extend to mobile marketing efforts. Brand managers can use AR tools embedded within Snapchat, Instagram, or TikTok filters to present foods in consumers real-time environments and can even enable transactions through those channels  projects visual content into the user’s current space. As outlined earlier, other AR applications utilize the device’s front-facing camera  to superimpose visual content  onto the users themselves , the effect is likely driven by multiple processes , and these variables may become more or less relevant in alternative contexts that future researchers may wish to explore.Shifting further afield, it is compelling to consider how future research might move beyond products altogether and explore how AR presentation influences consumer responses to the real-time superimposition of other human beings. For example, Google recently created AR “stickers” of the Grammy nominated rapper Childish Gambino, giving users the ability to see a visual depiction of the artist performing in their current environment Holt, . It is iWhile mobile AR is here now (enabled on the billions of Android and Apple smartphones worldwide), the imminent fusion of AR technology into wearable devices  will make it an even more permeating phenomenon. One tech executive described this future by saying, “The world is about to be painted with data,” Fink, . In suchSupplementary file1 (DOCX 938 KB)Below is the link to the electronic supplementary material.


Bell’s palsy is an idiopathic facial nerve dysfunction causing temporary paralysis of muscles of facial expression. This study aimed to determine the incidence rate, common risk factors, and preferred treatment by the Saudi patients with Bell’s palsy.This cross-sectional study was carried out in the Qurayyat region of Saudi Arabia. The retrospective medical records were searched from 2015–2020 of patients diagnosed with Bell’s palsy at Qurayyat General Hospital and King Fahad hospital. A 28-item questionnaire was developed by a team of experts and pre-tested among patients with Bell’s palsy before being sent to the eligible participants. The data were analyzed using summary statistics, Chi-square test, Fisher exact test and Likelihood ratio test.n = 147, 86.0%) accounted for the majority of cases. The most affected age group among participants with Bell’s palsy was 21–30 years . There were 153 (89.5%) cases who reported Bell’s palsy for the first time. The majority of the participants experienced right-sided facial paralysis . Likelihood ratio test revealed significant relationship between exposure to cold air and common cold with age groups  = 14.92, p = 0.021), χ2 = 16.35, pp = 0.012 respectively. The post hoc analyses revealed that participants in the age group of 20–31-years were mostly affected due to exposure to cold air and common cold than the other age groups. The main therapeutic approach preferred was physiotherapy , followed by corticosteroids and antivirals medications , acupressure , traditional Saudi herb medicine , cauterization by hot iron rod , supplementary therapy , facial cosmetic surgery  and no treatment . The most preferred combined therapy was physiotherapy (87.6%) with corticosteroid and antiviral drugs (35.9%), and acupressure (17.6%).We identified 279 cases of Bell’s palsy from the medical records of the hospitals from the years 2015 to 2020, accounting for 46.5 cases per year and an incidence rate of 25.7 per 100,000 per year. Out of 279 patients with Bell’s palsy, only 171 returned the questionnaire accounting for a response rate of 61.2%. Out of 171 patients with Bell’s palsy, females (The rate of Bell’s palsy was approximately 25.7 per 100,000 per year in the Qurayyat region of Saudi Arabia. Exposure to cold air and common cold were the significant risk factors associated with Bell’s palsy. Females were predominantly affected by Bell’s palsy in the Qurayyat region of Saudi Arabia. Bell’s palsy most commonly occurred in the age group 21–30 years. The most favored treatment was physiotherapy following Bell’s palsy. Bell’s palsy is a common lower motor nerve paralysis of the facial nerve of unknown origin . The patThe annual incidence rate (1992–1996) was reportedly 20.2 per 100,000 population, according to the UK General Practice Research database . ResearcThe cause of Bell’s palsy is idiopathic; however many possible causes have been recognized, such as reactivation of the herpes simplex virus, human immunodeficiency virus, and hepatitis C virus . AdditioThe standard recommended treatment of Bell’s palsy is oral corticosteroids, with limited evidence concerning the additive benefit of antiviral drugs for 10–12 days . In addiThere is limited literature on the contribution of risk factors and the treatments preferred by the Saudi population following a diagnosis of Bell’s palsy. Therefore, the aim of this study is to determine the incidence rate, possible risk factors, and preferred treatment options for Bell’s palsy in the Saudi population.The study was a retrospective cross-sectional hospital-based study. The study was carried out in the department of physiotherapy at the Qurayyat General Hospital and King Fahad Hospital. Ethical approval was obtained from the ethical committee of the hospitals in December 2020 prior to the commencement of the study (QGH-EC-16-2020).The files and medical records of patients diagnosed with Bell’s palsy in Qurayyat General Hospital and King Fahad Hospital were reviewed. A total of 279 patients from the years 2015 through 2020, inclusively, were identified and contacted by email and telephone for participation. If the patient was a minor, the parents were contacted for consent . The subhttp://www.raosoft.com/samplesize.html). Out of 279 eligible participants, 171 participants with Bell’s palsy responded to the questionnaire, representing a 61.2% response rate.The target population was Bell’s palsy patients in the Qurayyat region of Saudi Arabia. The sample size from reviewing medical records was 279. To achieve a 95% confidence interval with a 5% margin of error and 50% response distribution, the current study required 162 Bell’s palsy patients to represent the population  and four academic university staff  with an average experience of more than 10 years. A preliminary set of questions was submitted by the authors of this study to the expert committee. The preliminary set of questions was emailed to every member of the expert committee before meeting. The expert committee conducted two meetings before finalizing a set of 28 questions . Out of To evaluate the questionnaire for clarity, it was pre-tested among 10 Bell’s palsy patients visiting Qurayyat General Hospital. Any question identified as unclear by patients was rephrased by the expert committee until all expert members approved the changes.The final version of the questionnaire was piloted among 30 patients with Bell’s palsy visiting Qurayyat General Hospital and King Fahad Hospital.The retrospective medical records of two major hospitals  were searched for patients diagnosed with Bell’s palsy. Contact was made with eligible patients by SMS, telephone, and email. An advertisement to participate was circulated in hospitals and community centers, such as shopping centers, in the form of pamphlets. All eligible participants were invited to participate in the study. Those who consented were asked to fill out an online questionnaire consisting of 28 questions. Non-respondents were contacted again after an interval of two weeks up to a maximum of four times until all communications were stopped.® for Windows®V.20). The demographic data were analyzed through frequency distribution, and the relation between various risk factors was analyzed by a chi-square test, Fishers exact test, and likelihood-ratio test. The total population of the Qurayyat region of Saudi Arabia in the year 2020 was 180,430, according to the Ministry of Health (MOH), Saudi Arabia (n = 279) by cases with the total population  at the region per 100,000 per year.The information and data from the study were entered into an electronic database . The highest number of patients with Bell’s palsy was among the group aged 21–30 years , and the lowest was among those aged 1–10 years . Most were reporting Bell’s palsy for the first time , and 10.5% (n = 18) were reporting recurrent Bell’s palsy. A total of 21 (12.3%) participants had been vaccinated with COVID-19 before experiencing Bell’s palsy  reported being exposed to cold air before experiencing Bell’s palsy. A likelihood-ratio test was performed to examine the relation between age group and exposure to cold air before experiencing Bell’s palsy and was found to be significant, χ2 = 14.92, p = 0.011. The post hoc analysis with Bonferroni correction and adjusted p-value of 0.007 was found to be significant at the p < 0.05 level and revealed that those aged 21–30 years were significantly affected. Sixty-five (38%) participants reported that their parents were cousins, and 20 (11.7%) reported having a familial genetic disorder. There was no significant relationship between consanguinity with gender, onset, and recurrence of Bell’s palsy; however, consanguinity showed a significant relationship with side affected and age group χ2 = 12.090, p = 0.002; χ2 = 13.025, p = 0.023 respectively.A significant number of participants , followed by corticosteroids and antiviral drugs , acupressure , traditional Saudi herb medicine , cauterization by hot iron rod , supplementary therapy , facial cosmetic surgery , and no treatment   .n = 28, 16.4%), diabetes , genetic diseases , high blood pressure , neurological disorder , head injury , balance problems  stroke , or heart disease   .This study aimed to determine the incidence rate, risk factors, and preferred treatment among participants with Bell’s palsy residing in the Qurayyat region of Saudi Arabia. According to this study, females were predominantly affected, and a significant number of participants opted for physiotherapy and corticosteroid and antiviral drug therapy.The average incidence rate of Bell’s palsy was found to be 25.7 cases per 100,000 per year in the Qurayyat region of Saudi Arabia. The most affected age group comprised those aged 21–30 years, with females being 6.12 times more likely to be affected than males. Physiotherapy and standard drug therapy  were preferred over the other modes of treatment. A study conducted in the Arar region of Saudi Arabia found 26.3% of cases of Bell’s palsy with females (61%) more affected than males  and thatMost (75%) of the participants with Bell’s palsy experienced sudden facial muscle paralysis, with the majority having experienced first-time facial paralysis and 10.5% reporting recurrent facial paralysis. A study conducted in the Asir region of Saudi Arabia Bell’s reported a 5.35 per 100,000 population per year incidence rate of Bell’s palsy, with most patients reporting sudden onset Bell’s palsy in winter . In contIn our study, we found that 12.3% of participants reported Bell’s palsy after the COVID-19 vaccination. Research on the association of Bell’s palsy with the COVID-19 vaccination is scarce, with few case reports having been presented. Some studies have reported a significant association between COVID-19 vaccination and the incidence rate of Bell’s palsy ; howeverPre-existing conditions, such as diabetes, middle ear infection, head injury, high blood pressure, head and neck surgery, stroke, genetic disease, neurological disorders, or respiratory disease were reported by a small number of participants with Bell’s palsy. A case-control study conducted in Italy among 381 cases reported no significant difference due to the presence of hypertension or diabetes. However, the likelihood of Bell’s palsy increased linearly every year by 2% with age .(n = 420) found only 49.6% favored steroid treatment, while 54.7% favored traditional medicine (n = 654) reported that only 39% favored corticosteroid therapy (Research has recommended allopathic drug therapy following Bell’s palsy . The usemedicine . A study therapy . Traditi therapy .This study was a regional study with a relatively small number of participants. Recall bias might have existed because the study required that the participants recall past events. The Qurayyat region of Saudi Arabia is smaller than the other 13 major provinces of Saudi Arabia. Therefore, the results cannot be generalized to the whole nation. The actual number of patients with Bell’s palsy in the Qurayyat region of Saudi Arabia could not be determined because some patients might not visit a hospital or choose traditional medicine. This limitation was reduced in our study through regular public advertisements using pamphlets and announcements in public places.The public can be educated about the best treatments available for Bell’s palsy to avoid relying only on traditional medicine. Because Bell’s palsy is more common in the winter, hospitals and clinics must stock up on medications and increase the number of physicians to ensure positive patient outcomes. The education program should target young adults, as the incidence was found to be high among those aged 21–30 years. To increase drug compliance among at-risk groups, educational programs must emphasize the potential benefits and adverse effects of corticosteroids and antiviral drugs. Due to cultural inhibitions, poor participation from females living in the Qurayyat region is to be expected. A special education program dedicated only to females living in the Qurayyat region may be beneficial.The incidence rate of Bell’s palsy was approximately 25.7 per 100,000 per year in the Qurayyat region of Saudi Arabia. Exposure to cold air and influenza were significant risk factors associated with Bell’s palsy. Females were predominantly affected by Bell’s palsy in the Qurayyat region of Saudi Arabia. Bell’s palsy was most common among those aged 21–30 years. The most favored treatment was physiotherapy following Bell’s palsy. The population in the Qurayyat region of Saudi Arabia needs to be educated about the potential benefits of combination therapy, rather than relying on complementary or traditional medicine alone, for improved patient outcomes.10.7717/peerj.14076/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.14076/supp-2Supplemental Information 2Click here for additional data file.


Enzalutamide, an AR inhibitor, or AR knockdown was comparable to GLUT12 suppression. This study identified the role of the AR/GLUT12 pathway in the development of poor responses to everolimus. Interference with AR/GLUT12 pathway may serve as a promising approach to promoting the translational application of everolimus in GC therapy.Everolimus was designed as a mammalian target of rapamycin (mTOR) inhibitor. It has been proven as a targeted drug for gastric cancer (GC) therapy. However, long-term treatment with everolimus may cause severe side effects for recipients. Decreasing the dosage and attenuating the associated risks are feasible to promote clinical translation of everolimus. This study aimed to identify the underlying mechanisms of responses to everolimus and develop novel regimens for GC treatment. Our findings proved that there was a significant dose-dependent relationship of everolimus-induced GC cell apoptosis and glycolysis inhibition. Then, we found that a member of glucose transporter (GLUT12) family, GLUT12, was actively upregulated to counteract the anticancer effects of everolimus. GLUT12 might be overexpressed in GC. High expression of GLUT12 might be correlated with tumor progression and short survival time of GC patients. Bioinformatic analysis suggested that GLUT12 might be involved in regulating cancer development and metabolism. The experiments proved that GLUT12 significantly promoted GC growth, glycolysis and impaired the anticancer effects of everolimus. Androgen receptor (AR) is a classical oncogenic factor in many types of cancer. Everolimus elevated GLUT12 expression in an AR-dependent manner. Inhibition of AR activity abrogated the promotive effects on GLUT12 expression. Both  Gastric cancer (GC) is estimated to be one of the most threatening tumors worldwide. According to the latest epidemiological report, GC ranks the fifth for incidence and the fourth for cancer-associated mortality Everolimus is an orally bioavailable mammalian target of rapamycin (mTOR) inhibitor. Due to its potent effects on immunity suppression, everolimus has been applied for recipients of organ transplantation. mTOR is frequently abnormally expressed and mTOR signaling activation has been identified in cancer. Accumulating evidence has shown that mTOR is associated with malignant transformation, such as proliferation, invasion and stemness  in vitro and tumor growth in vivo of this study. GLUT12 attenuated GC responses to everolimus under androgen receptor (AR)-dependent pathways. Inhibition of AR/GLUT12 axis plus everolimus treatment may become a promising therapeutic regimen for GC.Glucose transporter (GLUT) family is responsible for the first step of glucose uptake. Aberrant expression of GLUTs indicates poor prognosis and is required for cancer development. GLUT1, GLUT3 and GLUT4 have received the most attention P<0.05). The alterations of these selected genes may be mechanistically associated with GLUT12 functions. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were then performed to enrich the biological functions of these genes. The enriched categories could suggest the regulatory role of GLUT12. The software R package operated by an online tool (https://www.xiantao.love) was employed to analyze the data and draw plots.The RNA-seq data of GC tissues in The Cancer Genome Atlas (TCGA) database were downloaded. The genes that were significantly correlated with GLUT12 expression were selected using Spearman analysis  and cultivated in our laboratory. SGC-7901 cells labeled with luciferase (luc-SGC-7901) were specifically generated before this research. Cells were grown in Dulbecco's modified Eagle's medium  supplemented with 10% fetal bovine serum  and 1% penicillin‑streptomycin (Gibco). The cultivation environment referred to the stationary atmosphere of 5% COOverexpression plasmids, small interfering RNAs (siRNAs) and short hairpin RNAs (shRNAs) were designed and synthesized by JTS Scientific . The sequences of siRNAs and shRNAs are displayed in -ΔΔCt method was employed to calculate the relative expression of targeted genes. The primers are listed in Total RNA in cells and tissues was extracted with TRIzol Reagent . Reverse transcription was conducted using the ExScript RT-PCR kit  according to the protocol. Then, cDNA was amplified and marked with green fluorescence using SYBR Premix Ex Taq II (TaKaRa). Determination of β-actin expression was used for data calibration. The 2Treated cells were harvested and washed with phosphate buffered saline (PBS) for three times. To obtain the protein samples, cells were suspended in chemical lysis buffer  for 10 min to achieve cell lysis. The mixture underwent high-speed centrifugation and the supernatant was harvested. Protein concentration was determined using BCA Protein Assay Kit (Thermo Fisher Scientific). Total protein was separated by sodium dodecyl sulfate polyacrylamide gel electrophoresis and transferred onto polyvinylidene fluoride membranes . After the exposure to blocking buffer for 1 h, the membranes were then incubated with primary antibodies at 4 ℃ overnight and anti-human antibodies at 25 ℃ for 1 h. ECL Western Blotting Substrate (Solarbio) was used to image the blots.To detect protein expression in clinical specimens, the tissues were washed three times with cold PBS to remove blood and impurities. Then, 4% paraformaldehyde was used to fix the proteins in tissues. IHC examination and score evaluation were performed as described in a previous study 3 treated cells were seeded in 96-well plates. The medium was replaced by 100 μL DMEM. 10 μL of CCK-8 solution  was prepared and gently added into the wells at the indicated times. The plates were placed in the incubator protected from light for 1 h. The absorbance at 450 nm was detected using a microplate reader .To investigate cell proliferation, 3 × 103 cells were seeded in 6-well plates. They were grown in the incubator for 14 days. The medium was changed every 3 days. Cells were fixed with 4% paraformaldehyde for 10 min and stained with 0.1% crystal violet for 15 min. The colonies with over 50 cells were regarded as the positive count.Treated cells were suspended in complete DMEM and a total of 1 × 104 treated cells were seeded in 96-well plates. Cells were labeled with EdU and stained with probes using a Cell Proliferation EdU Image Kit . Then the nuclei were stained with 4',6-diamidino-2-phenylindole  to mark all cells in wells. The fluorescent pictures were imaged and recorded under a fluorescence microscope .An EdU assay was also conducted to determine cell proliferation in this study. The 2 × 10To detect the apoptosis induced by everolimus, cells were stained with apoptotic biomarkers using FITC Annexin V Apoptosis Detection Kit 1 . The data interpretation was conducted based on the intensity of Annexin V and propidium iodide (PI). Briefly, Annexin V- and PI-negative cells were markers of living cells. Cells labeled with Annexin V were at early apoptosis. Both positive Annexin V and PI served as hallmarks of late apoptosis.Lactate acid, pyruvic acid, ATP production and glucose uptake can reflect glycolytic capability. Therefore, Lactate Colorimetric Assay Kit II, Pyruvate Colorimetric/Fluorometric Assay Kit, ATP Colorimetric/Fluorometric Assay Kit and Glucose Uptake Colorimetric Assay Kit  were used. The prepared samples were transferred into 96-well plates, and the absorbances at the indicated wave lengths were measured by the microplate reader.4 cells were seeded in a Seahorse XFe 96 Cell Culture Microplate . A Seahorse XF Glycolysis Stress Test Kit  was used to measure the ECAR. Glucose, oligomycin and 2-DG were sequentially added to the wells. For OCR, a Seahorse XF Cell Mito Stress Test Kit (Agilent) was employed, and cells were treated with oligomycin, FCCP and antimycin A/rotenone. Signals were read and recorded by a Seahorse XFe96 Analyzer (Agilent) at the indicated times.A total of 1 × 106 luc-SGC-7901 cells were injected subcutaneously into the mouse right flank subcutaneously. After 7 days, mice were treated with everolimus. The lengths and widths were measured using the vernier caliper at intervals of 7 days. Volume = length × width2/2. After 30 days, 100 μL of 15 mg/mL D-luciferin (Solarbio) was intraperitoneally injected into mice. Tumor load was detected using the In-Vivo Imaging System . Mice were sacrificed by CO2 asphyxia. To investigate the side effects of the therapeutic regimens, we chose weight as the indicator. Nude mice without GC transplantation received the same interventions. Mouse weights were measured by an electronic scale at the indicated time. The animal experiments were approved by Animal Center of Chinese PLA General Hospital. Animal experiments conformed to the Animal Research: Reporting of In Vivo Experiments (ARRIVE) guidelines.Four-week-old male nude mice  were fed under the specific pathogen-free conditions. To generate cell-derived xenografts, mice were randomly divided into groups. A total of 5 × 10t test and one-way ANOVA. P < 0.05 was regarded as the significant difference. The experiments were performed in triplicates and repeated at least three times.SPSS 25.0 was used to conduct statistical analysis. Prism 8.0 was employed to draw diagrams in figures. Survival analysis was performed with the support of the online bioinformatic tool Kaplan-Meier Plotter in vivo in the dose-dependent manner  datasets (GSE62254 and GSE15459) was analyzed. In the GSE62254 dataset, the overall survival (OS) of patients in the low-expression group was mildly better than the OS of patients in the high-expression group without significance (Hazard Ratio (HR) = 1.25, 95% confidence interval (CI) 0.84-1.85, P < 0.05) were screened out. The specimens were divided into low and high groups based on the median value of GLUT12 expression. The heatmap displayed top 40 genes of them , cellular component (CC) and molecular function (MF). Most of the top 10 categories in BP analysis were associated with cell membrane structures Figure C. The CCRegarding the close relationships between GLUT12 and cancer proliferation, we established SGC-7901 and HGC-27 cells that stably overexpressed GLUT12, which was validated by WB analysis Figure A. CCK-8,To further reaffirm the results of enrichment analysis based on TCGA database, we chose the top 3 genes positively correlated with GLUT12 expression, including Yes-associated protein 1 (YAP1), TEA domain family member 1 (TEAD1) and NKD Inhibitor Of WNT Signaling Pathway 1 (NKD-1), and top 3 genes negatively correlated with GLUT12 expression, including N-Acetylneuraminate Synthase (NANS), Small Nuclear Ribonucleoprotein U11/U12 Subunit 25 (SNRNP25) and Cytochrome C Oxidase Subunit 7C (COX7C), for expression determination using qRT-PCR. GLUT12 overexpression significantly upregulated expression of YAP1, TEAD1 and NKD1 and downregulated expression of NANS, SNRNP25 and COX7C both in SGC-7901 and HGC-27 cells. For the results of knockdown of GLUT12, the expression of YAP1, TEAD1 and NKD1 was decreased and the levels of NANS and SNRNP25 expression were elevated. However, COX7C expression was mildly upregulated in cells with stable knockdown of GLUT12 A-F. The GLUT12 is a member of the GLUT family and regulates glucose uptake, and GLUT12 may be associated with GC glycolysis based on the bioinformatic data. Thus, glycolytic experiments were used to detect glycolysis after GLUT12 overexpression. Upregulation of GLUT12 expression promoted lactate acid, pyruvic acid, ATP production and rates of glucose uptake Figure A-D. The Mark et al reported that GLUT12 was regulated by the AR pathway Regarding the close associations between AR and GLUT12, it was speculated that AR might also serve as an oncogenic factor. To validate this assumption, we generated SGC-7901 and HGC-27 cell lines with stable overexpression of AR A. UpreguSince the important role of the AR/GLUT12 axis in the impairment of responses to everolimus, GLUT12 or AR suppression was assumed to possibly enhance the efficacies of everolimus. Apoptosis assays demonstrated that cell apoptosis was elevated in cells with GLUT12 or AR knockdown or enzalutamide treatment compared to the single everolimus treatment Figure A. Next, in-vitro glycolytic experiments. Both GLUT12 and AR inhibition suppressed lactate acid production in tumors (Figure Xenografts were generated to validate the effectiveness of this regimen. Single treatment with everolimus moderately inhibited tumor growth. GLUT12 knockdown augmented the inhibitory effects of everolimus. Blocking AR functions also exhibited significant efficacies of tumor growth suppression Figure B-D. The s Figure E. Moreovs Figure F. Collecs Figure G.mTOR is a serine/threonine kinase that obtains inputs from nutrients, growth factors and environmental cues. mTOR regulates multiple physiological and pathological processes, including metabolism, biosynthesis, development, aging, inflammation and immunity To the best of our knowledge, this is the first study to report the role of GLUT12 in GC progression. Only a few studies have focused on the biological functions of GLUT12 since its first identification in 2002 SLC2A12. This evidence hinted us that GLUT12 might be also regulated by AR in GC. The data demonstrated that everolimus-induced GLUT12 overexpression was abrogated by knockdown of AR. AR is emerging as a potential target of cancer therapy. Most studies have focused on its functions in prostate cancer, breast cancer and hepatocellular carcinoma due to the specific distribution in these organs. Recently, AR has been proven to be a prognostic biomarker and therapeutic target of GC. Combinational evaluation of EGFR and AR expression could predict prognosis of GC patients Mark et al reported that AR directly regulated GLUT12 expression by directly binding to an intronic region of The mechanisms underlying cancer self-rescue under the conditions of drug treatment become a hot research topic. Cancer cells can mobilize their potential and activate underlying mechanisms to adapt to harsh environments and ameliorate the anticancer effects of drugs. For instance, breast cancer has been reported to upregulate Rac1 expression to resist against chemotherapeutic-induced DNA damage in-vitro and in-vivo experiments verified our assumption. AR/GLUT12 axis inhibition plus enzalutamide treatment also significantly attenuated glycolysis compared to administration of everolimus alone. The insignificant weight loss preliminarily proved the safety of the regimens. These results jointly suggest that AR/GLUT12 axis can participate in the maintenance of low responses to everolimus. Notably, the effects of enzalutamide treatment were comparable to GLUT12 or AR knockdown in suppressing GC growth, which provide a feasible approach to clinical GC therapy due to the lack of GLUT12 inhibitors currently.Regarding the important role of the AR/GLUT12 pathway in GC, we speculated that inhibition of AR or GLUT12 could enhance the efficacies of everolimus. Both We have to admit that our research has some limitations. First, we found that everolimus induced activation of the AR/GLUT12 axis. The specific mechanisms by which AR regulates GLUT12 expression need further exploration. Second, few studies have focused on the enhancement of responses to everolimus. In addition to GLUT12, there may be more effective targets. More studies, especially high-throughput screening, should be conducted to identify mechanistic networks of targeted therapy responses. Third, the optimal usage and effectiveness for clinical application need more investigation. Fourth, mTOR signaling pathway can affect various cellular phenotypes, not limited to glycolysis. The other underlying mechanisms of everolimus should be deeply investigated.In summary, our findings identified high expression of GLUT12 in GC. GLUT12 expression in tissues was associated with cancer progression and poor survival time of GC patients. GLUT12 overexpression could promote GC proliferation. Importantly, GC cells actively upregulated GLUT12 to relieve anticancer effects of everolimus through facilitating AR pathway. Inhibition of the AR/GLUT12 pathway enhanced the anticancer effects of everolimus. This novel strategy may serve as an effective and safe approach to GC treatment.Supplementary figures and tables.Click here for additional data file.


The results of this study indicate that a relationship between IVDD and AR expression exists. Thus, the SNS and its neurotransmitters might play a role in IVDD pathogenesis. The knowledge of differential AR expression in different etiologies could contribute to the development of new therapeutic approaches for IVDD.Despite advanced knowledge of the cellular and biomechanical processes of intervertebral disc degeneration (IVDD), the trigger and underlying mechanisms remain unclear. Since the sympathetic nervous system (SNS) has been shown to exhibit catabolic effects in osteoarthritis pathogenesis, it is attractive to speculate that it also influences IVDD. Therefore, we explored the adrenoceptor (AR) expression profile in human IVDs and correlated it with clinical parameters of patients. IVD samples were collected from n = 43 patients undergoing lumbar spinal fusion surgery. AR gene expression was analyzed by semi-quantitative polymerase chain reaction. Clinical parameters as well as radiological Pfirrmann and Modic classification were collected and correlated with AR expression levels. In total human IVD homogenates α1A-, α1B-, α2A-, α2B-, α2C-, β1- and β2-AR genes were expressed. Expression of α1A- (r = 0.439), α2A- (r = 0.346) and β2-AR (r = 0.409) showed a positive and significant correlation with Pfirrmann grade. α1A-AR expression was significantly decreased in IVD tissue of patients with adjacent segment disease ( Low back pain (LBP) can lead to severe physical and mental impairment in patients’ quality of life. More than 600 million people worldwide suffer from LBP and globally about 70–85% experience LBP at some time in their lives . DespiteIn this context, analyzing crucial components of the sympathetic nervous system (SNS) could provide a better insight into the pathophysiology of IVDD. Previous studies elucidated that all joint tissue expresses adrenergic receptors (AR) and that the SNS in fact is involved in bone and cartilage metabolism and remodeling ,16. BesiThe aim of the present study was to correlate the expression level of the detected ARs in IVDs with clinical parameters of the patients such as radiological degree of degeneration, preoperative pain level and medication. An increased knowledge of the relationship between those clinical parameters and the AR expression and AR-dependent signaling pathways in IVD tissue could contribute to the development of novel therapeutic strategies for IVDD treatment.2. According to the Numeric Pain Rating Scale (NPRS) patients had a mean preoperative pain of 6.81 (SD:1.53). Altogether, seven patients (16.3%) had a cranial or caudal ASD after previous spinal fusion surgery. The largest proportion of the IVD samples was collected from the segment L4/5 (34.9%). No significant difference in α1A-, α2A- and β2-AR expression was found between the respective segments. Patient characteristics (n = 43) were examined retrospectively. The mean age of the patients was 69.23 (SD:7.66) years and the mean Body Mass Index (BMI) was 30.77 (SD:5.67) kg/mp = 0.009; R = 0.3997), α2A-  and β2-  AR expression were found when analyzing IVDs with intact endplates  in comparison with structurally degenerated endplates . The median of differences in relative α1A-AR expression between both groups was −0.35 (CI: −0.71 to −0.07), in relative α2A-AR expression between both groups was −0.18 (CI:−0.40 to −0.01) and in relative β2-AR expression between both groups was −0.3300 (CI:−0.56 to 0.00).Patients were divided into two groups [no structural degeneration of the endplates (Modic 0-I) vs. structural degeneration of the endplates (Modic II-III)] to investigate whether structural alterations of the endplates correlate with the relative AR expression of the respective IVD. Results are shown in p = 0.005; R = 0.4274), α2A-AR  and β2-AR  expression was found when analyzing IVDs with low degeneration  in comparison with highly degenerated discs . The median of differences in relative α1A-AR expression between both groups was 0.32 (CI: 0.09 to −0.74), in relative α2A-AR expression between both groups was 0.22 (CI: 0.03 to −0.51) and in relative β2-AR expression between both groups was 0.43 (CI: 0.13 to −0.71). Furthermore, relative α1A-AR  and β2-AR  expression was significantly increased comparing Pfirrmann grade IV with Pfirrmann grade III. The expression of α1A- , α2A-  and β2-AR  showed a positive and significant correlation with the Pfirrmann grade of IVDD.The Pfirrmann classification was used to grade IVDD preoperatively. We compared the degree of IVDD with the AR expression in the tissue of 42 IVDs. All examined discs had at least a Pfirrmann grade II. p = 0.009; R = 0.3946). The median of differences in relative α1A-AR expression between both groups was −0.39 (CI: −0.62 to −0.09). There was no significant difference in the α2A-AR expression  and β2-AR expression  between both groups  and β2-AR expression  in disc tissue of patients who received β-blockers preoperatively were significantly reduced   and α2A-AR expression  between both patient cohorts. In addition, there was no significant difference in the AR expression between patients with and without nicotine abuse (The α1A-AR expression in disc tissue of patients with severe pain (NPRS ≥ 7.5) was significantly reduced (h groups a. Furthe reduced b. The me 0.3176) d. The mene abuse c.No correlation between BMI and AR gene expression was found . In addip = 0.041; R = 0.3111). The median of differences in relative α1A-AR expression between both groups was −0.35 (CI: −0.71 to 0.01). In contrast, no statistical difference in α2A-AR  and β2-AR  expression was found when analyzing IVDs from ASD in comparison with discs from primary surgery . α1A-AR expression was significantly decreased in IVD tissue from ASD  joint tissues ,26 and LAn increased severity of IVDD is associated with an increase in sclerosis of the subchondral bone as well as in microscopic and macroscopic endplate damage and is highly related to LBP ,32,33. CA significant increase in α1A-, α2A- and β2-AR expression was found in highly degenerated human IVDs reflected by the above described medians of differences and CIs. The increase in AR expression might be clinically relevant with respect to sympathetic neurotransmitter-mediated catabolic processes or genesis of pain . One expInterestingly, α1A-AR expression was significantly decreased in IVD tissue of patients with ASD after spinal fusion surgery. The interruption of sympathetic innervation of the adjacent segment IVD due to previous surgery could be an explanation for the decreased α1A-AR expression. This might cause a disturbance of cellular responses to mechanical stress and consequently aggravate degeneration. According to this hypothesis, less invasive surgery that affects the adjacent segments as little as possible could prevent the occurrence of ASD due to the reduced soft tissue damage.In line with this assumption, α1A-AR expression was significantly reduced in IVD tissue of patients with a high preoperative pain level (NPRS ≥ 7.5) with a negative estimation of the location shift. Lumbar IVDs are thought to be an important source of LBP ,40. It iFurthermore, standard medication and nicotine abuse of patients was documented and correlated to AR expression levels to investigate whether AR-modulating agents could be used as therapeutic drugs in patients having IVDD. β-blockers are mainly used for treatment of cardiovascular diseases. They can act as agonists or competitive antagonists via different intracellular signaling pathways at the same time ,52. Two In summary, SNS-modulating drugs might have an impact on AR expression in IVD tissue. Although the exact relationship needs to be further investigated, detailed knowledge about SNS-modulating drugs that further aggravate IVDD would improve patient outcomes. In this context, the dose-dependent effects at the cellular level as well as the cellular mechanisms are of particular interest to estimate the use of AR-modulating drugs as therapeutic options. Possible adverse effects of systematically applied AR antagonists and agonists have to be taken into account as well. To reduce the risks of adverse effects, local application of AR modulating drugs should be an additional task of future research.2) of our patient cohort. Under the assumption that a high BMI is associated with an increased load on the IVD, this might have an influence on the AR gene expression. Nevertheless, we found no correlation between BMI and AR gene expression in our patient cohort  were available, it was not possible to compare healthy with degenerated stages. Nevertheless, a similar comparison was performed by Kupka et al. in a murine model and an enhanced and locally expanded AR expression in highly degenerated IVDs of mice was found . In addit cohort . Howevert cohort . This stIn conclusion, the results of this study indicate that a relationship between IVDD and AR expression exists. Thus, the SNS and its neurotransmitters might play a role in IVDD pathogenesis. A dysregulation of AR expression might lead to a disturbance of homeostasis in the IVD and thus aggravate intra- and extracellular processes of degeneration. In future studies, the functional response of isolated IVDs to sympathetic neurotransmitters needs to be investigated. The results will contribute to a better understanding of cellular processes of IVDD and novel therapeutic approaches.Lumbar IVD samples were collected during disc preparation for an interbody cage from 43 patients undergoing spinal fusion surgery. The samples were anonymized and stored at −80 °C until analysis. Patient characteristics as well as the preoperative radiological classifications of IVDD were obtained retrospectively.® RNA/Protein, Macherey and Nagel, Düren, North Rhine-Westphalia, Germany). Reverse transcription of mRNA was performed with Quantabio qScript cDNA Synthesis Kit  and 5 ng of cDNA per optimized primer was used for PCR . Validated primer sets obtained from Thermo Fisher Scientific  were used to amplify human ARs  and tyrosine hydroxylase was measured by semi-quantitative reverse transcriptase polymerase chain reaction (RT-PCR). The intraoperatively obtained IVD tissue was minced with a scalpel and further processed according to manufacturer’s instructions  has approved the study under the number 19/525 and confirmed that no informed consent is required due to the retrospective design. All experiments were performed in accordance with relevant guidelines and regulations. The data were anonymized before use.p ≤ 0.05.The Shapiro-Wilk test was used to test normal distribution of the analyzed parameters. Nonparametric independent variables were compared with Mann–Whitney tests. Effect size (R) was calculated according to Rosenthal . The Hod


Angiogenesis and remodeling (AR) is necessary for the growth and metastasis of cancers. Although AR related genes involved in this process are reported, the correlation between AR and clinical outcome, immune cell infiltration, and immunotherapy is still unknown in diverse cancers. This study aimed to investigate the role of AR in the tumor immune microenvironment (TIME) in pan-cancer, and explore its values in prognostic prediction and therapeutic responses.via integrating multiple computational methods. And we also utilized IMvigor210 and GSE78220 data to explore the prediction value of the AR score on the immunotherapy response.Firstly, AR genes (including angiogenesis genes and blood vessel remodeling genes) are collected from MsigDB database. The differential expression, and prognostic value of AR genes were studied in 33 tumor types based on TCGA and GTEx data. The AR score of each sample was calculated using the “ssGSEA” function of R package “GSVA” in pan-cancer. The correlation of the AR score with TIME index, such as the amount of stromal and immune components and the immune cell infiltration, was evaluated Significant differences in AR gene expression between tumors and adjacent normal tissues were found in most cancer types. The AR score varied depending on the types of tumors, and high score was related to worse survival in various tumors, such as pancreatic and stomach adenocarcinoma and so on. Moreover, the AR score was further explored to be positively correlated with proportions and pathways of immune and stromal in TIME. And the AR score was positively correlated with immunosuppressive cells, including TAMs and iTregs, while negatively with CD8+ T cells. Further analysis revealed that patients with high AR had worse therapy efficacy and survival status in bladder cancer and melanomas.Our systematic analysis revealed that AR is closely associated TIME, and prognosis, and clinical characteristics in multiple cancers. Targeting AR genes may activate immune microenvironment and increase the efficacy of immunotherapy. Angiogenesis and remodeling (AR), which is considered to be one of the hallmarks of cancer, is required for tumor growth and metastasis –3. A lotImmune tolerance is another normal physiologic mechanism that is hijacked by tumors. Nowadays, immune checkpoint inhibitors (ICIs) have made an indelible mark in the field of cancer treatment in the modern era, demonstrating a long-lasting clinical activity against many cancers . But theNowadays, an increasing number of clinical trials have begun to test the efficacy of ICIs/anti-angiogenesis combination to reverse the immune suppression-driven by AR . But thehttp://www.gsea-msigdb.org/gsea/msigdb/index.jsp), using the following keywords of “HALLMARK_ANGIOGENESIS” and “GOBP_BLOOD_VESSEL_REMODELING”.Hallmark gene sets of AR were searched on the Molecular Signatures Database (MSigDB)  and GTEx  were downloaded from the UCSC Xena (https://xenabrowser.net/datapages/) database. The RNA-seq data in transcripts per million read (TPM) format were analyzed and compared after log2 conversion. The immune cell infiltration data of TCGA were obtained from three different sources, including a supplementary information of a published work (http://bioinfo.life.hust.edu.cn/ImmuCellAI#!/) and TIMER2 database (http://timer.cistrome.org/). The microsatellite instability (MSI) data was obtained from the study by Bonneville (https://www.ncbi.nlm.nih.gov/gds/?term=GSE78220) and R package “IMvigor210CoreBiologies” .Gene set variation analysis (GSVA) and gene set enrichment analysis (GSEA) were performed using R package “GSVA” and “clusterprofiler” to explore the associated functions of AR genes. The HALLMARK pathways in GSVA were downloaded from the MsigDB database (The ssGSEA function of R (version 4.1.1) package “GSVA” was used to calculate AR score of each patient in TCGA cohort. R package “survminer” and “survival” were used to perform the Univariate Cox regression (uniCox) and Kaplan-Meier analyses to explore the relationship of AR score with the survival of patients, including overall survival (OS), disease specific survival (DSS), disease free interval (DFI) and progression free interval (PFI).The association between the AR score and TME related factors were analyzed. The R package “ESTIMATE” was used to calculate the stromal, immune, tumor purity, and ESTIMATE score of each patient in the TCGA cohort. The TME-related pathways were obtained and pathway scores were calculated according to the study by Zeng et al. . We furthttps://www.r-project.org/, version:4.1.1). Pearson correlation coefficients were used in correlation analysis. Area under the curves (AUC) of receiver operating characteristic (ROC) was used to assess the predictive accuracy of the AR score. ROC analysis was performed using R package “pROC”, and the AUC values were calculated using auc function. P < 0.05 (two-tailed) was considered statistically significant.Differences between various groups were compared using Student’s t-test using “ggplot2” or “ggpubr” in R software  and Cholangiocarcinoma (CHOL).The outline of our research is shown in We performed ssGSEA to calculate the AR score across 33 tumor types in the TCGA cohort. A pan-cancer comparison revealed great differences in the AR score among the different types of tumors. The AR score was highest in PAAD and lowest in Acute Myeloid Leukemia (LAML) Figure 2The results of uniCox analysis indicated that : For theWe further performed multivariant cox regression analysis in LGG and STAD, in which a high AR score was significantly correlated with poor prognosis according to four outcomes Figure 3To analyze the potential pathways associated with AR, we performed a GSVA and GSEA of the AR score. The association between the AR score and GSVA scores in pan-cancer was shown in Given the importance of TIME in the development of various types of cancers and the correlation between the AR score and immune-related pathways detected previously by GSEA, in a pan-cancer analysis, we also explored the association between the AR score and the estimated proportion of immune and stromal in TIME . TherefoWe further obtained and calculated TME-related pathways according to the published paper . The anaMoreover, to relate the AR score to immune cells in TIME, we firstly used CIBERSORT algorithm based on a published work . As showNext, considering the results that the AR score was related to immunosuppressive cells and genes, we determined whether AR had a non-ignorable impact on the efficacy of immunotherapy. It was reported that tumor patients with low tumor mutation burden (TMB) or MSI may be resistant to immune checkpoint inhibitors (ICIs) treatment –25. HencSince the AR score was negatively correlated with TMB and MSI values in most tumor types, it might represent an important new biomarker for ICIs treatment. To link the AR score with the efficiency of immunotherapy, we evaluated the AR score in different response groups based on IMvigor210 bladder cancer cohort. The result showed that the AR score of patients in stable disease/progressive disease (SD/PD) group was significantly higher than that in complete response/partial response (CR/PR) group , National High Level Hospital Clinical Research  (2022CX11), National High Level Hospital Clinical Research Funding  (no. 2022CR36), and National Natural Science Foundation of China (grant No. 81973320 and No. 81903714).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


H-1,2,3-triazol-4-yl)ethan-1-ones and benzaldehydes in ethanol under basic conditions gave the corresponding chalcones. Reactions of the chalcones combined with thiosemicarbazide in dry ethanol containing sodium hydroxide afforded the corresponding pyrazolin-N-thioamides. Reactions of the synthesized pyrazolin-N-thioamides and several ketones  gave the corresponding novel 2--4,5-dihydro-1H-pyrazol-1-yl)thiazoles in high yields (77–90%). Additionally, 2--4-thiazoles were obtained in high yields (84–87%) from reactions with N-pyrazoline-thioamides and 4-bromoacetyl-1,2,3-triazoles under basic conditions. The structures of six of the newly synthesized heterocycles were confirmed by X-ray crystallography.Reactions of 1-(5-methyl)-1 Heterocycles containing nitrogen and sulfur have received great attention due to their pharmacological and industrial applications ,2. PyrazN-isocyanoiminotriphenylphosphorane in the presence of silver carbonate ,4b [6 [7 , 11 [38,6 [7 [11 , and 12  [11 [12  were pre1a or 1b (12 mmol) and 2a or 2b (12 mmol) in EtOH (50 mL) was added slowly to a solution of NaOH  in water (10 mL). The mixture was stirred at 25 °C for 4 h and the solid obtained was filtrated, washed with cold water, dried, and recrystallized from EtOH to give pure 3a or 3b.A mixture of 1H NMR (ppm): 2.59 , 3.79 , 7.00 , 7.61–7.63 , 7.71 , 7.79 , 7.86 . 13C NMR (ppm): 10.4 (Me), 55.9 (OMe), 115.1 (C3/C5 of Ar), 120.9 (CH), 126.0 (C2/C6 of Ph), 127.6 (C1 of Ar), 130.2 (C2/C6 of Ar), 130.6 (C4 of Ph), 131.1 (C3/C5 of Ph), 135.6 (C5 of triazolyl), 139.01 (C1 of Ph), 143.5 (C4 of triazolyl), 143.7 (CH), 162.0 (C4 of Ar), 183.8 (C=O). Anal. Calcd. for C19H17N3O2 (319.13): C, 71.46; H, 5.37; N, 13.16. Found: C, 71.53, H, 5.66, N, 13.23%.Yield: 89%, mp 144–145 °C. 3b agreed with those reported.Yield: 90%, mp 170–172 °C (lit. 168–170 ). The sp3a or 3b (10 mmol) and NaOH  in EtOH (50 mL), thiosemicarbazide  was added. The mixture was refluxed for 6 h and the solid obtained on cooling was filtered, washed with EtOH, and dried to give 4a or 4b.To a suspension of chalcone 1H NMR (ppm) 2.96 , 3.16 , 3.95 , 3.98 , 5.86 , 6.85 , 7.06 , 7.57–7.59 , 8.03 . 13C NMR (ppm): 10.7 (Me), 40.5 (C4 of pyrazolinyl), 55.6 (OMe), 61.8 (C5 of pyrazolinyl), 114.4 (C3/C5 of Ar), 125.9 (C2/C6 of Ph), 127.2 (C2/C6 of Ar), 130.3 (C3/C5 of Ph), 130.5 (C4 of Ph), 135.1 (C1 of Ar), 135.3 (C1 of Ph), 135.9 (C5 of triazolyl), 137.5 (C4 of triazolyl), 150.8 (C3 of pyrazolinyl), 158.8 (C4 of Ar), 176.5 (C=S). Anal. Calcd. for C20H20N6OS (392.14): C, 61.21; H, 5.14; N, 21.41. Found: C, 61.47, H, 5.42, N, 21.66%.Yield: 82%, mp 183–185 °C. 4b agreed with those reported.Yield: 87%, mp 230–232 °C (lit. 229–231 [4a or 4b (2 mmol) in EtOH (15 mL) and Et3N , 6  or 7  was added. The mixture was heated under reflux for 2 h and the solid obtained on cooling was collected by suction filtration, washed with EtOH, and recrystallized from DMF to give the corresponding heterocycle 8, 9, or 10, respectively.To a suspension of 1H NMR : 1.33 , 2.38 , 2.63 , 3.37 , 3.42 , 3.73 , 4.21 , 5.70 , 6.92 , 7.22 , 7.65–7.68 . 13C NMR (ppm): 10.6 (Me), 14.8 (Me), 18.0 (Me), 45.2 (C4 of pyrazolinyl), 55.5 (OMe), 60.4 (C5 of pyrazolinyl), 62.1 (MeCH2), 110.8 (C3/C5 of Ar), 114.6 (C5 of thiazolyl), 125.7 (C2/C6 of Ph), 127.7 (C2/C6 of Ar), 130.2 (C3/C5 of Ph), 130.5 (C4 of Ph), 133.4 (C3 of pyrazolinyl), 134.8 (C1 of Ar), 135.8 (C1 of Ph), 137.2 (C5 of triazolyl), 150.5 (C4 of triazolyl), 159.2 (C4 of thiazolyl), 159.7 (C4 of Ar), 162.3 (C=O), 165.3 (C2 of thiazolyl). Anal. Calcd. for C26H26N6O3S (502.17): C, 62.13; H, 5.21; N, 16.72. Found: C, 62.29, H, 5.33, N, 16.85%.Yield: 77%, mp 145–146 °C. 1H NMR (ppm): 2.59 , 3.43 , 4.18 , 5.68 , 6.88 , 7.18–7.22 , 7.26 , 7.30 , 7.46–7.53 , 7.61 , 7.71–7.73 . 13C NMR (ppm): 10.5 (Me), 45.0 (C4 of pyrazolinyl), 63.0 (C5 of pyrazolinyl), 103.1 (C3 of benzofuranyl), 107.4 (C5 of thiazolyl), 114.5 (C7 of benzofuranyl), 116.0 , 117.3 , 121.9 (C4 of benzofuranyl), 123.8 (C5 of benzofuranyl), 125.2 (C6 of benzofuranyl), 128.3 , 128.9 (C4a of benzofuranyl), 129.4 , 132.3 (C5 of triazolyl), 134.7 (C4 of triazolyl), 137.5 (C1 of Ar), 138.0 (C1 of Ar), 142.6 (C4 of thiazolyl), 148.7 (C2 of benzofuranyl), 152.4 (C7a of benzofuranyl), 154.6 (C3 of pyrazolinyl), 161.6 , 163.4 , 165.7 (C2 of thiazolyl). Anal. Calcd. for C29H20F2N6OS (538.13): C, 64.67; H, 3.74; N, 15.60. Found: C, 64.77, H, 3.89, N, 15.88%.Yield: 90%, mp 215–216 °C. 1H NMR (ppm): 2.44 , 2.58 , 3.40 , 4.20 , 5.83 , 7.18 , 7.24 , 7.33 , 7.48 , 7.67–7.71 . 13C NMR (ppm): 10.6 (Me), 16.5 (Me), 45.2 (C4 of pyrazolinyl), 61.8 (C5 of pyrazolinyl), 116.3 , 117.2 , 117.4 , 124.0 , 128.3 , 128.4 , 132.2 (C3 of pyrazolinyl), 135.5 (C5 of thiazolyl), 137.1 (C5 of triazolyl), 137.5 (C4 of thiazolyl), 140.9 (C1 of Ar), 149.5 (C1 of Ar), 151.6 (C1 of Ar), 158.7 (C4 of triazolyl), 161.3 , 162.6 , 163.8 (C2 of thiazolyl), 164.5 . Anal. calcd. for C28H21F3N8S (558.15): C, 60.21; H, 3.79; N, 20.06. Found: C, 60.38, H, 3.91, N, 20.21%.Yield: 86%, mp 222–223 °C. 11a or 11b (2 mmol) in EtOH (15 mL) and Et3N (0.2 mL), appropriate bromoketones 12a–12c (2 mmol) were added. The mixture was heated under reflux for 2 h and the solid obtained on cooling was collected by filtration, washed with EtOH, and recrystallized from DMF to give the corresponding compound 13–15.To a suspension of compound 1H NMR (ppm): 2.18 , 3.28 , 3.99 , 5.59 , 7.13 , 7.25 , 7.38 , 7.50–7.58 , 7.76 . 13C NMR (ppm): 9.7 (Me), 43.8 (C4 of pyrazolinyl), 64.8 (C5 of pyrazolinyl), 105.8 (C5 of thiazolyl), 115.9 , 125.8 (C2/C6 of Ph), 128.7 (C2/C6 of Ar), 129.1 , 129.4 (C3/C5 of Ph), 130.0 (C3/C5 of Ar), 130.1 (C4 of Ph), 130.3 (C5 of triazolyl), 131.1 (C3 of pyrazolinyl), 135.1 (C1 of Ar), 136.4 (C4 of Ar), 138.5 (C1 of Ph), 140.2 (C4 of triazolyl), 143.9 1 (C4 of thiazolyl), 152.5 (C1 of Ar), 161.9 , 165.5 (C2 of thiazolyl). Anal. Calcd. for C27H20ClFN6S (514.11): C, 62.97; H, 3.91; N, 16.32. Found: C, 63.11, H, 4.08, N, 16.49%.Yield: 85%, mp 237–238 °C. 1H NMR (ppm): 2.15 , 2.37 , 3.28 , 3.98 , 5.58 , 7.12 , 7.24 , 7.35–7.41 , 7.50 , 7.75 . 13C NMR (ppm): 9.7 (Me), 21.3 (Me), 43.8 (C4 of pyrazolinyl), 64.8 (C5 of pyrazolinyl), 105.7 (C5 of thiazolyl), 115.9 , 125.6 (C2/C6 of Ar), 128.6 (C2/C6 of Ar), 129.1 , 129.4 (C3/C5 of Ar), 130.4 (C5 of triazolyl), 130.5 (C3/C5 of Ar), 131.1 (C4 of triazolyl), 133.9 (C3 of pyrazolinyl), 134.0 (C1 of Ar), 135.1 (C4 of Ar), 139.8 (C1 of Ar), 140.1 (C4 of thiazolyl), 144.0 (C4 of Ar), 152.5 (C1 of Ar), 162.0 , 165.4 (C2 of thiazolyl). Anal. Calcd. for C28H22ClFN6S (528.13): C, 63.57; H, 4.19; N, 15.89. Found: C, 63.70, H, 4.14, N, 15.99.Yield: 84%, mp 252–253 °C. 1H NMR (ppm): 2.28 , 3.24 , 3.77 , 3.98 , 5.54 , 7.00 , 7.13 , 7.25 , 7.37 , 7.69 , 7.89 , 7.39 . 13C NMR (ppm): 9.9 (Me), 44.2 (C4 of pyrazolinyl), 55.9 (OMe), 64.5 (C5 of pyrazolinyl), 105.9 (C5 of thiazolyl), 114.8 (C3/C5 of Ar), 115.9 , 123.9 (C3/C5 of Ar), 125.5 (C2/C6 of Ar), 126.4 (C2/C6 of Ar), 127.6 (C3 of pyrazolinyl), 128.7 (C2/C6 of Ar), 129.0 , 131.4 (C5 of triazolyl), 138.7 (C4 of thiazolyl), 140.8 (C1 of Ar), 141.2 (C4 of triazolyl), 143.4 (C1 of Ar), 147.9 (C4 of Ar), 153.5 (C1 of Ar), 160.1.2 , 165.8 (C2 of thiazolyl). Anal. Calcd. for C28H22FN7O3S (555.15): C, 60.53; H, 3.99; N, 17.65. Found: C, 60.69, H, 3.89, N, 17.81%.Yield: 87%, mp 287–288 °C. Single-crystal X-ray diffraction data were collected at room temperature on an Agilent SuperNova Dual Atlas diffractometer with mirror-monochromated Cu or Mo radiation. SHELXS  and SHELH-pyrazol-1-yl)thiazoles and 2--4-thiazoles were synthesized in high yields using facile methods and their chemical structures were established using spectral data and the single crystal X-ray diffraction.Novel 2--4,5-dihydro-1


A range of extended reality technology integration, including immersive virtual reality (IVR), augmented reality (AR), as well as mixed reality, has lately acquired favour in orthopaedics. The utilization of extended reality machinery in knee arthroplasty is examined in this review study. Virtual reality (VR) and AR are usually exercised together in orthopaedic surgical training as alluring training outside of the operation theatre is acknowledged as a good surgical training tool. The use of this technology, its consequences for orthopaedic surgeons and their patients, and its moral and practical issues are also covered. Head-mounted displays (HMDs) are a potential addition directed toward improving surgical precision along with instruction. Although the hardware is cutting-edge, substantial effort needs to be done to develop software that enables seamless, trustworthy integration into clinical practice and training. Remote virtual rehabilitation has drawn increasing attention in recent years, and its significance has increased in light of the recent outbreak of the COVID-19 epidemic. Numerous medical sectors have shown the benefits of telerehabilitation, gamification, VR, and AR. Given the rising demand for orthopaedic therapy and its rising costs, this is a requirement. A remote surgeon can impart knowledge without being present, by virtually placing his or her hands in the visual field of a local surgeon using AR technology. With the use of this innovation, orthopaedic surgery seems to have been able to participate in the telemedicine revolution. This technology may also have an impact on how surgeons collaborate and train for orthopaedic residencies in the future. Volatility in the HMD market will probably stall improvements in surgical education. One of the four most common chronic musculoskeletal disorders, according to the World Health Organization, is osteoarthritis . PatientIn orthopaedic surgery, the usage of AR has been described as early as 2007. Ortega et al. evaluated the effects and possible advantages of utilising a HUD during spine surgery. According to further research, advantages may include an increase in the surgeon's focus on the surgical field, a decrease in potentially dangerous radiation exposure, and a reduction in surgical field barriers, additionally through services such as rehabilitation that are provided outside of hospitals ,6. ThereThe precision of component location in hip and knee arthroplasty has been proven to be improved using AR-based navigation technology . The goaKnee arthroplastyArthroplasties are surgical procedures where a joint is replaced with unnaturally made materials. A total arthroplasty entails replacing all the affected joint surfaces, whereas a partial replacement merely replaces some or all the affected surfaces. The most often replaced joints are knee joints. Symptomatic osteoarthritis and fracture of the neck part of the femur are the two most representative reasons for knee replacement surgery. Patients who need their first hip or knee replacement owing to osteoarthritis are typically between 60 and 70 years old. The most common reasons for joint replacements, which cause joint surface degradation via the wearing of the cartilage coating, include degenerative diseases such as osteoarthritis, traumas, and other modifications in the osteoblasts and connective tissue components. In some circumstances, they can cause a decline in quality of life with a lifelong impairment, persistent pain, and limited mobility of the afflicted joint. For the patient to continue their full range of daily routines and prevent subsequent problems, restoration with an artificial material becomes crucial if these symptoms do not go away.OsteoarthritisKnee arthroplasty is often performed in the case of osteoarthritis. Risk factors include age and sex, hereditary, biomechanics, and proinflammatory components. Body weight, osteoporosis, cardiovascular disease, and metabolic disorders are some variables that might negatively affect cartilage metabolism. Local consequences may result from trauma, circulatory problems, inherited abnormalities, and excessive stress on just one side of the joint . An imbaIndications of knee arthroplastyModern research confirming favorable outcomes with UKA in younger patients, obese people, patients with patellofemoral dysfunction, and those who are very active has substantially enlarged the original stringent inclusion criteria of Kozinn and Scott .In all pAR, VR, and simulation in orthopaedic education: a historical overviewSurgical Education and Practice in Knee Replacement SurgeryThe degree to which a simulation qualitatively matches the model or fidelity can vary widely. Despite the likelihood, as relatively high simulations may benefit students more, studies have demonstrated the benefits of utilizing minimal simulators in surgical training. For instance, it has been discovered that Fundamentals of Laparoscopic Surgery (FLS)  transfers skills to the operating room more effectively than a comparable high-fidelity general surgery simulator . In orthPreoperative StrategyProper component placement is crucial for maximizing implant life in knee arthroplasty. In the past, surgeons would often strive for a mechanical center that would be less than 3° from neutral to eliminate premature failure, notably on the tibial side . While pAR-Based Intraoperative NavigationIn TKA, computer navigation has increased alignment precision, and some authors have hypothesized that this may eventually increase implant survival rates ,22. The There are many benefits of AR-based navigation over existing navigation systems, despite the requirement for preoperative CT imaging, which adds to the patient's radiation exposure and demands time for scan acquisition. Because AR navigation tools are more compact and more straightforward than traditional computer-assisted systems, they might not require the significant capital expenditures and ongoing maintenance costs that come with them. The small and portable type of enrollment and monitoring equipment will also significantly reduce the footprint in the operating room as ambulatory TKA becomes more popular as a way to lower facility costs, making this innovation quite logistically feasible for ambulatory surgery centers (ASC) .IVR for training in surgeryMany orthopedic simulators and task instructors have been developed and studied since the first VR knee arthroscopy simulators were released in the 1990s . With thSurgical Simulation in IVR for a TKRThroughout the knee replacement procedure, a complex combination of technical (saw control and soft tissue managing), integrated , intellectual , and technical (integrated) skills are needed. The accuracy of implants and surgical problems have been linked to reduced volume and incompetent doctors ,28. OrthDrawbacks of IVRThe visual quality, level of presence, cyber-sickness, haptic realism, device-related concerns (including battery life and wireless technologies), and cost considerations are only a few of the drawbacks of immersive visual reality systems. Computing power and software optimization are required to produce complex audio-visuals as well as second-by-second haptic output of IVR systems. As a result, there are differences in the IVR systems that are currently accessible with regard to experience quality, immersion and presence, and learning potential ,32. The Future of AR and VRThe intraoperative usage of HMDs and their function in clinical treatment have not yet been thoroughly proven, despite the popularity of AR for surgical navigation. If larger clinical studies show benefits over present practice, HMDs may shortly be used to exhibit critical data, photos, and even fluoroscopy imaging in the surgeon's visual field. More sophisticated tracking software needs to be developed to maximise the usefulness of these devices within the operating theatre. The solitary solution is electromagnetic surveillance, which does not require a line of vision, although the techniques are frequently limited by interference from metallic instruments ,35.Both surgical care and surgical education are increasingly relying on VR and AR. Although several studies have exemplified that VR enhances skills even outside the surgery room, it is difficult to determine how effectively these abilities transition to the clinical context. AR techniques for orthopaedic instruction and skills have shown significant promise in terms of enhancing planning before operating, offering intraoperative assistance, along with increasing the precision of surgical procedures. Moreover, these instruments are projected to become more prevalent both in training and clinical services as the equipment's ability to replicate the operative setting improves. Currently, AR is mostly employed for simulated and intraoperative navigation. Most crucially, IVR technology has shown that it has the power to completely transform contemporary surgical education and cost-effectively increase surgical performance, eventually improving patient outcomes. Future uses of IVR may also involve the potential for remote mentorship to address the global access gap to high-quality surgical training. As vital as it is for knee surgeons to deliver affordable treatment, it is also important to continue defining how new technology improves patient outcomes and determine whether or not all patients may benefit from it. As a result, as a profession, we must continue to do and publish high-quality research that identifies which innovations are real advancements and which are simply new ways of performing an operation.