Anaphylactic rhinitis (AR) is one of the most common allergic disorders globally. Heat-sensitive moxibustion (HSM) is an effective method for AR without the occurrence of drug damage. This study aims to systematically investigate the effectiveness and safety of HSM for patients with AR.Seven relevant electronic databases from inception until January 2020 including PubMed, Embase, Cochrane Library, the China National Knowledge Infrastructure Database, Wanfang Database, Chinese Biomedical Literature Database, and Chinese Scientific Journal Database will be searched. All relevant randomized clinical trials published in English and Chinese about HSM for AR regardless of blinding or publication types can be included. The Cochrane Central Register of Controlled Trials and other potential articles in the reference list of included studies will also be searched. We recommend total nasal symptom score as primary outcomes. Secondary outcomes includes rhinoconjunctivitis quality of life questionnaire, IgE, visual analogue scale, laboratory examination, and side effects. Study selection, data extraction, and quality assessment will be performed independently by 2 reviewers. Assessment of risk of bias and data synthesis will be conducted by RevMan 5.3 software.Ethical approval is not required for no personal data involved. The results of this SR will be disseminated through peer-reviewed publications according to the Preferred Reporting Items for Systematic reviews and Meta Analysis Protocols guidelines.The results will be published in a peer-reviewed journal.The findings will provide further evidence for the management of AR.CRD42019140723. Clinically, nasal obstruction, frequent sneezing, runny nose, itchy and watery eyes are the main manifestations, accompanying with smell sense losing. and 15.79% in China. Ten years ago, 40% world's population were affected,9 and the prevalence of AR in Europe were 23% to 30%. A survey conducted in 2005 has reported that almost 800 million people suffered from the disease in the rural areas of China. Nowadays, the prevalence of AR rises annually across many countries.People of all ages may get AR, whereas approximately 80% of individuals diagnosed with allergic rhinitis develop symptoms before the age of 20 years. Thirteen percent of US children were diagnosed as having AR There is no doubt that extra expenses will increase the financial burden on the family. In the meantime, AR will increase the risk of other diseases such as headaches, upper airway cough syndrome, hypomnesis, chronic rhinosinusitis, and asthma. It is worth noting that AR is an independent risk factor for the development of asthma. According to a survey conducted in the United States, 78% of asthma patients have AR.The economic survey has showed that they spent more money on medication costs and health care in a family with AR patients. The therapeutic principle of AR involves a comprehensive approach including environmental control, pharmacotherapy, immunotherapy, and patient education.According to the occurrence frequency, AR can be divided into intermittent (<4 days for 1 week or <4 weeks for a year) and persistent (>4 days for 1 week and >4 weeks for a year).,14 and intranasal corticosteroid spray as the first-line therapy for AR works through blocking multiple inflammatory pathways to alleviate the painful sufferings and nasal symptoms; however, recurrence of the disease makes medication less effective over time. Intranasal anticholinergics are recommended as second-line therapy for AR by inhibiting both watery secretion of nasal glands and vasodilatation of airway blood vessels. Based on the theory of traditional Chinese medicine, some Chinese herbal formulae such as Yu-ping-feng San, Xiao Qing Long decoction, Bu Zhong Yi Qi decoction, Shenling Baizhu decoction, and so on, were proved effective and safe in improving the nasal symptoms of perennial and persistent AR through adjusting cyclic nucleotide levels in the body, inhibiting IgE and mast cell degranulation, and restoring blood flow in nasal mucosa.–20Antihistamines1.2 can effectively improve the symptoms of AR patients in practice. HSM refers to practitioners administer moxibustion on heat-sensitive acupuncture points, which are extremely sensitive to the heat stimulation of burning moxa.HSM therapy, as one of suspended moxibustion therapies, The latest American Clinical Practice Guideline for AR published in 2015 recommends that acupuncture be offered as an option for patients with interest in nonpharmacologic approaches to management of AR.,25The therapy has dual-directional regulation effects on human's immune system to balance our inner environment and function, which could improve the blood indices with an increased volume of blood flow and regulate the immunologic function of the human body which brings out therapeutic effects for AR.,27 There is 1 systematic review about the effectiveness of HSM for AR published in Chinese. The previous review included 7 RCTs; it does not refer to other outcomes such as adverse events, recurrence rate, quality of life, and so on. It also did not provide study protocols in advance. Due to the limitations of previous study, the results may uncertain. Therefore, we take stricter search strategy and objective outcome evaluation to conduct this systematic review, to provide reliable evidence about the effectiveness and safety of HSM for AR.Systematic review or meta analysis has been recognized as the basis of evaluating clinical efficacy and formulating clinical guidelines.22.1https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=140723. The protocol follows the Cochrane Handbook for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P) statement guidelines. We will describe the changes in our full review if needed.This systematic review protocol has been registered on PROSPERO as CRD42019140723. which was available from: 2.22.2.1All relevant randomized clinical trials (RCTs) published in English and Chinese about HSM for AR regardless of blinding or publication types can be included.2.2.2Study participants in different age ranges with all types of AR can be included, regardless of sex, race, occupation, education, nationality, etiology, severity.2.2.3HSM as a single intervention or major part of a combination therapy with other active intervention  will be included.2.2.4The comparative interventions could be sham moxibustion, placebo, no treatment, or other active treatments. The following treatment comparisons will be selected.1.Heat-sensitive moxibustion (HSM) versus no treatment.2.HSM versus placebo or sham acupuncture.3.HSM versus other active therapies.4.HSM + active therapy versus the same active therapy.2.2.52.2.5.1 and as the primary outcome and evaluate the sore according to the degree of 4 nasal symptoms: sneezing, rhinorrhea, nasal itching and nasal obstruction. We will also compare the score change before and after treatment, at least a treatment cycle.We recommend the total nasal symptom score2.2.5.2The secondary outcomes of this review mainly include the following aspects:1.Rhinoconjunctivitis quality of life questionnaire.2.Allergen detection: IgE.3.Side effects and adverse events.4.VAS: Patients grade their symptoms by putting a vertical line on a 1- to 10-cm line representing severity score from 0 “no symptoms” to 10 “highest level of symptoms."5.Laboratory examination: IgA, IgM, IgG, C3, C4.2.3The exclusion criteria of this review mainly include the following aspects:1.Patients with asthma, nasosinusitis, vasomotor rhinitis, infectious rhinitis, hormonal rhinitis were excluded.2.Repeated publications and no test data required by this program are available.3.Full text cannot be obtained through various approaches.2.42.4.1Seven relevant electronic databases from inception until January 2020 including PubMed, Embase, Cochrane Library, the China National Knowledge Infrastructure Database, Wanfang Database, Chinese Biomedical Literature Database nd Chinese Scientific Journal Database will be searched. The language within in Chinese and English. The following search terms will be used: thermal moxibustion, heat-sensitive acupoint, HSM, allergic rhinitis, AR, nasal allergy, perennial allergic rhinitis, seasonal allergic rhinitis, hay fever, pollinosis. The search strategy for PubMed is shown in Table 2.4.2To make sure comprehensiveness of the study, we will search the Cochrane Central Register of Controlled Trials and other potential articles in the reference list of included studies.2.5 flowchart  separately discard some articles that are not eligible by looking through the titles and abstracts. Then they download the full texts of all possibly relevant studies for further check to make the final decision. If articles contain insufficient information to make a decision about eligibility, JY will try to contact authors of the original reports to obtain further details. During the procedure, disagreements will be resolved by discussion or consensus with the third reviewer (FYJ). The procedures of study selection will be performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta Analysisart Fig. .2.6Two reviewers (XHZ and LLX) will independently extract the following information: author, publish year, participants, intervention (s), comparison (s), outcome (s), and some relevant characteristics from the full-text. If the reported data are not sufficient, JY will try to contact the authors for further information to supplement the missing data. Any disagreements will be resolved by discussion or consensus with the third reviewer (KL).2.72.7.1 Researcher evaluates 7 items  of the methodological characteristics in high, low, unclear. Meanwhile, the Consolidated Standards of Reporting Trials  and Standards for Reporting Interventions in Clinical Trials of Moxibustion checklist will be also conducted. During the process, disagreement will be solved by communication or consulting for a third reviewer (JX) until the result comes to an agreement.Two reviewers (TY and XW) will independently assess the methodological quality of included studies on the basis of the bias risk assessment tool of the Cochrane Collaborative Network System Evaluator’ Manual for Systematic Reviews of Interventions.2.7.2In our study, we will use RevMan 5.3 software to conduct statistical analyses. The dichotomous data will be analyzed by risk ratio with 95% confidence intervals (CIs), and the continuous data will be analyzed by mean difference (MD) or standard MD with 95% CIs. When meta-analysis is not possible, we will perform narrative analysis.2.7.3We will only select the first-phase data of crossover trials to avoid carryover effects. When it comes to multiple intervention groups, we will combine all relevant experimental groups and control intervention groups into a single respectively group to prevent a unit of analysis issue.2.7.4When the data provided are insufficient, we will attempt to contact the original authors to obtain the missing information. If the missing data are not available, the analysis will rely on available data.2.7.5I2 test calculate by RevMan5.3.5 software to assess the heterogeneity of included studies.,37 According to the heterogeneity levels of the included studies, the random-effects model (I2 ≥50%) or fixed-effects model (I2 < 50%) will be properly selected. If the I2 test is >75%, we should find possible reasons from clinical and methodological aspects by conducting subgroup or sensitivity analysis.We choose 2.7.6If necessary, subgroup analysis will be conducted according to the age, sex, type of AR, treatment frequency, length of follow-up.2.7.7I2 test is >75%) in our study, we will perform sensitivity analyses from sample size, methodological quality, and characteristic of research. Then we will obtain a stable consolidated result of our study.If there is high heterogeneity  from 5 aspects .The quality of evidence will be evaluated by the Grading of Recommendations Assessment, Development, and Evaluation system.2.7.10Ethical approval is not required for no personal data involved. The results of this SR will be disseminated through peer-reviewed publications according to the PRISMA-P guidelines.3 Many people suffer from the negative influence of AR, so patients may resort medicine to relive the uncomfortable symptoms. However, the most common adverse events of intranasal formulations usage including nasal burning, poor taste, sedation, more frequent dosing and increased cost relative to oral formulations. Doctors should pay more attention to side effects with the initiation of intranasal antihistamines.AR is one of the most common allergic disorders globally and it affects 10% to 40% of the world's population.In Traditional Chinese Medicine, AR belongs to the category of “Bi Qiu," the cause of AR was considered from deficiency, excess, cold or heat, involving the “Zang-Fu," organs of the lungs, spleen, and kidneys at the basis of traditional Chinese medicine theory. There are many methods to help patients improve their uncomfortable symptoms. Unlike common suspended moxibustion at fixed acupuncture points, this therapy believed that the responsive site (s) may dynamically change with disease progression raises. Therefore, this technique emphasizes the presence or absence of heat sensitization responses from patients on the treatment. It is reported that the occurrence of heat sensitization appears 10% in healthy people and 70% in sick people. These responses gradually disappear with disease recovery.,43 In large clinical practices, researchers have summarized several types of heat sensitization responses as follows: heat penetration, heat expansion, heat transmission, and nonthermal sensations . Those heat sensitization responses may appear alone or in combination.HSM, as one of effective therapy for AR, is derived from some ancient Chinese medical literatures such as the Yellow Emperor's Internal Classics more than 2500 years ago.HSM can increase blood volume, speed the blood flow, and regulate the immunologic function of the patients with AR. Nowadays, increasing number of original articles and clinical trials have reported the effectiveness and safety of HSM for patients with AR. There are some limitations in the previous studies, without providing study protocols and absence of reporting about adverse events, quality of life and so on. Therefore, we conduct this systematic review to assess the effectiveness and safety of HSM for patients with AR. We hope our study could help establish a better approach for the treatment of AR and provide reliable evidence.Conceptualization: Jun Xiong, Jun Yang , Ting Yuan.Data curation: Jun Yang, Ting Yuan, Xue Wang.Formal analysis: Yunfeng Jiang, Xiaohong Zhou, Lingling Xu.Investigation: Jun Xiong, Jun Yang.Methodology: Jun Xiong, Ting Yuan, Xue Wang.Software: Yunfeng Jiang, Xiaohong Zhou, Lingling Xu.Supervision: Jun Xiong, Kai Liao.Writing – original draft: Jun Xiong, Jun Yang, Ting Yuan, Xue Wang.Writing – review & editing: Yunfeng Jiang, Xiaohong Zhou, Kai Liao, Lingling Xu.Jun Yang orcid: 0000-0002-2804-2267.


However, it is unknown whether npr1-1 and npr1-3 are null mutants. Moreover, the NPR1 transcript levels are induced two- to threefold upon pathogen infection or salicylic acid (SA) treatment, but the biological relevance of the induction is unclear. Here, we used molecular and biochemical approaches including quantitative PCR, immunoblot analysis, site-directed mutagenesis, and CRISPR/Cas9-mediated gene editing to address these questions. We show that npr1-3 is a potential null mutant, whereas npr1-1 is not. We also demonstrated that a truncated npr1 protein longer than the hypothesized npr1-3 protein is not active in SA signaling. Furthermore, we revealed that TGACG-binding (TGA) factors are required for NPR1 induction, but the reverse TGA box in the 5’UTR of NPR1 is dispensable for the induction. Finally, we show that full induction of NPR1 is required for basal immunity, but not for SAR, whereas sufficient basal transcription is essential for full-scale establishment of SAR. Our results indicate that induced transcript accumulation may be differentially required for different functions of a specific gene. Moreover, as npr1-1 is not a null mutant, we recommend that future research should use npr1-3 and potential null T-DNA insertion mutants for dissecting NPR1’s function in various physiopathological processes.Non-expressor of pathogenesis-related (PR) genes1 (NPR1) is a key transcription coactivator of plant basal immunity and systemic acquired resistance (SAR). Two mutant alleles,  PR genes through interaction with transcription factors such as the TGACG-binding (TGA) family of bZIP transcription factors (Plant systemic acquired resistance (SAR) is a long-lasting immune response against a broad-spectrum of pathogens . Establi factors .npr1 mutants  in the third ankyrin-repeat to a tyrosine, whereas npr1-3 introduced a stop codon (residue 400)  signaling, and chemical-mediated defense priming have been well defined using  mutants . A largeh groups , among wdue 400) . Interes mutants , they ex mutants . These dNPR1 transcripts accumulate constitutively at a low basal level throughout the plant, and the accumulation level can be induced two- to threefold upon pathogen infection or SA treatment  sequences within a 28-bp region from position 103 to 129 upstream of the translation start site  in the 5’UTR of NPR1 is dispensable for the induction. Finally, our results show that full induction of NPR1 is required for basal immunity, but not for SAR, whereas sufficient basal transcription is essential for full-scale establishment of SAR, indicating differential quantitative requirements for NPR1 in these immune responses.Here, we show that nduction , and revArabidopsis thaliana (L.) Heynh. Columbia (Col-0) and Landsberg erecta (Ler) ecotypes, and the mutant alleles used were npr1-1, npr1-2, npr1-3  and cold-treated at 4°C for three days. Plants were germinated and grown at ~23°C under a 16 h light/8 h dark regime.The wild types used were the , npr1-3 , SALK_20 npr1-L, . The traeviously . Both trPsm ES4326 was performed by pressure-infiltration with a 1 ml needleless syringe as described previously (Psm ES4326 (OD600 = 0.002). Two days later, the upper uninfected systemic leaves were either collected for gene expression analysis or challenge-inoculated with Psm ES4326 (OD600 = 0.001) for resistance test. Eight leaves were collected 3 days after challenge inoculation to examine the pathogen growth.Inoculation of plants with eviously . After iNPR1 was performed in the previously reported NPR1pro:Myc-NPR1 construct . The coding region of NPR1 cDNA was then amplified, digested with BamHI and SacI, and ligated into BamHI/SacI-digested pBI101-ELP3 promoter plasmid. All primers or oligos used in this study were listed in mNPR1pro:Myc-NPR1 lines, three independent CRISPR mutants, and three independent ELP3pro:NPR1 lines were characterized in this studySite-directed mutagenesis of the TGA box in the 5’UTR of onstruct  using a onstruct . For theβ-aminobutyric acid (BABA) treatments were performed as previously described by SA and NPR1 mRNA was detected with primers qF and qR1, NPR1 pre-mRNA was detected with qF and qR2, and Myc-NPR1 mRNA was detected with the forward primer recognizing a sequence in the Myc tag DNA and the reverse primer a sequence in the first exon of the NPR1 DNA  in Microsoft Excel of Microsoft Office 2004 for Macintosh and the one-way ANOVA in Prism 7 .Statistical analyses were performed with the data analysis tools (Student’s npr1-L)  , SALK_20ectively Table S2antibody . As showidue 400 . AlthougPR1 gene expression, basal resistance, SAR, and crosstalk between SA and JA. As shown in npr1-3 and SALK_204100, indicating that the truncated npr1 protein accumulated in SAIL_708_F09 is not functional in the tested SA responses.The truncated npr1 protein accumulated in SAIL_708_F09 is 67 amino acids longer than the predicted npr1-3 protein. To test whether this truncated protein is functional in SA signaling, we tested its function in tolerance to SA toxicity, SA-induced NPR1 gene induction is compromised in npr1 mutants  site, TGG, immediately downstream of the reverse TGA box  in the 5’UTR is not required for NPR1 gene induction.To confirm the result obtained with the NPR1 transcript accumulation, we treated Col-0 and SALK_203386 with SA and monitored NPR1 transcript levels. As shown in NPR1 pre-mRNA and mature mRNA levels was significantly reduced in the SALK_203386 plants. Similarly, SA-induced NPR1 protein accumulation was also dramatically inhibited in SALK_203386  DC3000 was compromised in npr1-1, but not in npr1-3. Consistently, npr1-1 was shown to be more susceptible than npr1-3 to the fungal pathogens Vericillium longisporum and Piriformospora indica (PLANT DEFENSIN1.2 (PDF1.2) expression was much less affected in npr1-3 than in npr1-1. The differences between npr1-1 and npr1-3 have been attributed to a speculated npr1-3 protein  or GT_5_89558 (Ler background), for evaluating NPR1’s function in various physiopathological processes.The a indica . Further protein . Our res protein . RegardlNPR1 gene induction  leaves three days after inoculation of the lower leaves, but the time point might be too late for detecting NPR1 induction in the systemic leaves . QZ was supported by a scholarship from the Chinese Scholarship Council.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.


Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors, characterized by excessive release of catecholamines (CAs), and manifested as the classic triad of headaches, palpitations, profuse sweating, and a variety of other signs and symptoms. The diagnosis of PPGL requires both evidence of excessive release of CAs and anatomical localization of CA-secreting tumor. Surgery is the mainstay of treatment for all patients with PPGL unless contraindicated. However, without proper preparation, the release of excessive CAs, especially during surgery, can result in lethal cardiovascular complications. Herein, we briefly reviewed the pathogenesis of this disease, discussed the current approaches and evidence available for preoperative management, summarizing the results of the latest studies which compared the efficacies of preoperative management with or without α adrenergic-receptor antagonists, aiming to facilitate better understanding of the preoperative management of PPGL for the physicians. Since the two tumor types have similar histologic characteristics, they can only be differentiated by anatomical location . Sympathetic paragangliomas (CAs-producing) derive from paravertebral ganglia of thorax, abdomen, and pelvis, while parasympathetic paragangliomas (rarely produce CAs) arise from vagal and glossopharyngeal nerves at the base of skull and in the neck. Pheochromocytoma and paraganglioma are together referred to as PPGL. Approximately 80%–85% of PPGL are pheochromocytomas, while about 15%–20% are paragangliomas . Besidestic PPGL . Surgerytic PPGL .The naturally occurring CAs consist of E, NE, and DA, and they are not only important neurotransmitters in the central and peripheral nervous systems, but also play key roles as circulating neurohormones . In PPGLPPGL is characterized by hypertension and low blood volume, resulting from excessive concentration of CAs in the plasma. With insufficient preoperative antihypertensive management or untreated hypovolemia, the hemodynamic instability during surgical treatment of PPGL may be lethal. Therefore, preoperative management, which includes hypertension control and expansion of blood volume, is extremely important , 13. TheAt present, there is no consensus for when preoperative management should be started to ensure adequate preparation for surgery. In most circumstances, α-AR antagonists are usually initiated 1–2 weeks preoperatively to normalize blood pressure, heart rate and to replete contracted blood volume. In patients with CA-induced cardiomyopathy or other organ damage, α-AR antagonists should be start much earlier . There iTwo types of α-AR antagonists are widely used clinically, non-selective and selective α-AR antagonists. Phenoxybenzamine is a non-selective, non-competitive α-AR antagonist, which binds irreversibly with both α1 and α2-AR. Phenoxybenzamine is long-acting and its effects persist long after it has been discontinued, since the effect diminishes only after α-AR resynthesis , 16. TheSelective α-AR antagonists, including prazosin, terazosin, and doxazosin, competitively inhibit only α1-AR, and they are short-acting drugs used for patients with PPGL as well. The initial dose of prazosin is 0.5–1 mg, 2–3 times a day, and the dose can be gradually increased to 6–15 mg per day. Terazosin is usually given in doses of 2–10 mg per day. For both prazosin and terazosin, the doses of higher than 20mg per day may not bring extra benefit. Doxazosin, with a half-life much longer than the other selective α-AR antagonists, can be dosed once daily, and is the most commonly used selective α-AR antagonist in recent years. The starting dose of doxazosin is usually 1 mg per day, and the most commonly used doses are 2–8 mg per day. The maximum recommended dose is 16 mg per day , 18.Evidence from RCTs or systematic reviews comparing the effectiveness of non-selective and selective α-AR antagonists for patients of PPGL is unavailable . HoweverMany retrospective studies have reported the use α-AR antagonists as the first-choice to prevent perioperative complications of PPGL, including intraoperative hypertension, tachycardia, and hemodynamic instability –28. NortThe use of β-AR antagonists is determined by the extent of CA-induced tachycardia or reflex tachycardia after the initiation of phenoxybenzamine. It is noteworthy that β-AR antagonists should never be treated alone or before adequate α-AR blockade. Since for patients with PPGL, loss of β-AR-mediated vasodilatation with unopposed CA-induced vasoconstriction can cause dramatic increase in blood pressure, or even hypertensive crisis , 12. ProCCBs are the most commonly used drugs, in combination with α-AR antagonists, to further improve blood pressure control in patients with PPGL . Some stIt is proved that excessive CAs release results in perioperative cardiovascular instability in the patients with PPGL, so the administration of drugs which inhibit the CA biosynthesis may be beneficial for the treatment of PPGL . MetyrosThe excessive CAs release and resultant hypertension can lead to significant changes in the cardiovascular system, such as vasoconstriction of the coronary arteries, increased arterial stiffness, arrythmias, and cardiomyopathy . MoreoveRestoration of blood volume decreases the risk of protracted hypotension or shock as a result of sudden vasodilation during surgery. However, the management with α-AR antagonists alone will lead to blood volume restoration in only approximately 60% patients with PPGL . TherefoThe administration of drugs that provoke the release of CAs produced by the tumor or interfere with CAs metabolism should be avoided for patients with PPGL. E and NE release can be provoked by steroids, histamine, glucagon, vasopressin, and angiotensin II. Drugs that are used for obesity management, such as phentermine, phendimetrazine, and phenylethylamine, are sympathomimetic amines with a direct action on adrenoceptors. NE reuptake inhibitors, such as tricyclic antidepressants and amitriptyline, cocaine, and those that interfere with NE metabolism, all result in high circulating NE levels, and should be avoided by PPGL patients . MoreoveIt was reported that patients with clinically silent (normotensive) but biologically active PPGL had relatively lower levels of CAs than those with hypertensive PPGL, since the expression of multiple genes which were involved in key processes of CA synthesis was decreased in these tumors , 52. StuFor biochemically silent PPGL, which do not secret CAs, hemodynamic instability resulting from the tumors should not occur theoretically. However, malignant hypertension during surgery has been reported by several cases in patients with biochemically silent PPGL not receiving preoperative management –55. MechPPGL may cause potentially lethal hypertensive crisis due to the effects of the excessive released CAs. Hypertensive crisis is an acute, life-threatening situation associated with severe increase in blood pressure, requiring special attention. It is defined as a systolic blood pressure higher than 180 mmHg or a diastolic blood pressure higher than 120 mmHg, with or without acute target organ damage . HyperteIn summary, preoperative management of PPGL, which includes hypertension control and improvement of blood volume, is crucial. The most common approach is to block the function of excessive plasma CAs, and α-AR antagonists are the first choice. Hypertension may be slightly better controlled by non-selective α-AR antagonist, phenoxybenzamine, for some patients, at the cost of higher risk of postoperative hypotension and other side effects. While selective α-AR antagonist, doxazosin, is proved to have much less adverse effects, but is more likely to be used in combination with additional antihypertensive drugs. With the improvement of diagnostic tools for identification and localization of the lesions, modern minimally invasive surgical techniques, and highly effective, short-acting drugs without severe side effects, the necessity of the preoperative management of α-AR antagonists with potential significant adverse effects should be questioned. The use of β-AR antagonists is determined by the extent of CA-induced tachycardia or reflex tachycardia after the prescription of phenoxybenzamine. It is noteworthy that β-AR antagonists should never be treated alone or before adequate α-AR blockade. CCBs are the most often used drugs in combination with α-AR antagonists, to further improve blood pressure control in patients with PPGL. Some studies considered this kind of drugs as the primary choice of preoperative management of PPGL, especially for normotensive patients or those with very mild hypertension, and for patients with severe side effects when using α-AR antagonists. CA synthesis inhibitor, metyrosine, is used combined with α-AR antagonists to patients with serious symptoms which cannot be well controlled by other medications, such as those with biochemically active tumors or extensive metastatic tumors. It is essential to make cardiovascular evaluation for every patient with PPGL and it is recommended that treatment of PPGL should also include a high-sodium diet and fluid intake to restore blood volume preoperatively and prevent perioperative hypotension. However, PPGL is a rare disease, so large RCTs or meta-analyses are not available at present. Therefore, more convincing evidence is needed to determine the most proper preoperative management strategies.FF, LD, QH, and ML conducted a review of the literature and wrote the review. FF and ML contributed to conception and design of the review, and ML finalized the review. All authors contributed to the article and approved the submitted version.This study was support by the National Key R&D Program of China (2019YFA0802502) and Natural Science Foundation of China (81830025 and 81620108004). We acknowledge support from Tianjin Municipal Science and Technology Commission (17ZXMFSY00150 and 18JCYBJC93900).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.


Lipotoxicity is a major contributor to type 2 diabetes mainly promoting mitochondrial dysfunction. Lipotoxic stress is mediated by elevated levels of free fatty acids through various mechanisms and pathways. Impaired peroxisome proliferator-activated receptor (PPAR) signaling, enhanced oxidative stress levels, and uncoupling of the respiratory chain result in ATP deficiency, while β-cell viability can be severely impaired by lipotoxic modulation of PI3K/Akt and mitogen-activated protein kinase (MAPK)/extracellular-signal-regulated kinase (ERK) pathways. However, fatty acids are physiologically required for an unimpaired β-cell function. Thus, preparation, concentration, and treatment duration determine whether the outcome is beneficial or detrimental when fatty acids are employed in experimental setups. Further, ageing is a crucial contributor to β-cell decay. Cellular senescence is connected to loss of function in β-cells and can further be promoted by lipotoxicity. The potential benefit of nutrients has been broadly investigated, and particularly polyphenols were shown to be protective against both lipotoxicity and cellular senescence, maintaining the physiology of β-cells. Positive effects on blood glucose regulation, mitigation of oxidative stress by radical scavenging properties or regulation of antioxidative enzymes, and modulation of apoptotic factors were reported. This review summarizes the significance of lipotoxicity and cellular senescence for mitochondrial dysfunction in the pancreatic β-cell and outlines potential beneficial effects of plant-based nutrients by the example of polyphenols. The onset and progression of diabetes mellitus (DM) is crucially determined by the deterioration of the glucose-stimulated insulin secretion (GSIS) of pancreatic β-cells. In 2019, there were more than 460 million patients with DM worldwide with a steadily rising prevalence 9.3%) over the last few decades [% over thThe progression of type 2 diabetes mellitus (T2DM) is accompanied by elevated free fatty acids (FFAs) ,6,7 as wBeside elevation of FFA blood and tissue levels, and associated disorders of lipid metabolism, cellular senescence  is the sThere are available data which point towards beneficial effects of plant-based nutrients . Their bThe aim of this review is to (I) summarize the knowledge of basic research on lipotoxicity directed against β-cells, in particular their mitochondria, with special regard to methodology, (II) elucidate the connection with cellular senescence, and (III) outline potential beneficial effects of dietary measures employing polyphenols as an example. The literature search based for this review was executed on 7th of September and 31st of December 2020 on PubMed. The search term (lipotox * OR “free fatty acid *”) AND (mitochondria * OR polyphenol * OR flavonoid * OR ageing) AND “beta cell *” yielded a total of 149 primary articles. The publication dates ranged from February 1977 to September 2020. After screening literature, 22 articles were excluded. Exclusion criteria were no suitable topic (11 exclusions), not written in English (five exclusions), reviews with no primary data (five exclusions) and no available full-texts (one exclusion), leaving 127 articles. Three reviews with primary data have been included. A flow chart of the literature search is given in Since lipotoxicity cannot merely be defined by exceeding a specified concentration of FFA, the respective experimental setup must be considered closely when assessing experimental outcomes. The employed amount of FFA is one of the key factors for activating lipotoxic pathways. However, only few authors state the rationale for the chosen concentrations. A point of reference could be the serum FFA level of healthy and diabetic subjects and animals.n = 104), there are available data for the following concentration ranges: 10–99 µM (n = 12), 100–499 µM (n = 53), 500 µM (n = 49), 501–2000 µM (n = 18) (n = 82) as well as multiple concentrations (n = 22) have been employed.Spectroscopic analysis of blood samples revealed that the total FFA concentration in diabetic human serum is ranging from 3.5 to 15 mM, also giving concentrations of specific FFA like oleic acid (OA) with 0.74–3.9 mM and palmitic acid (PA) with 1.0–3.8 mM ,36,37,38(n = 18) . Single Insulin secretion and ATP levels were frequently examined. Treatment with 400 or 500 µM FFA led to a 6–90% decrease in ATP ,44,45. An = 52), followed by the combination of PA + OA (n = 20), the combination of PA + OA + any additional FFA (n = 8), the combination of PA + any additional FFA (n = 6), treatment with single OA (n = 6), or with any single FFA (n = 4). Concentration range of combined FFA culture was 100–2000 µM (PA + OA), 200–1000 µM (PA + OA + any FFA) and 10–500 µM (PA + any FFA). The group of FFA used occasionally includes myristic, stearic, palmitoleic, linoleic, linolenic, methylpalmitic, docosahexaenoic, and arachidonic acid , NaOH or NaCl (n = 12), dimethyl sulfoxide (n = 4), and methanol (n = 3), while most articles did not specify how the FFA solutions have been prepared (n = 54) (n = 53). The utilized BSA content in the respective cell culture media varied markedly, ranging between 0.05–5% for comparable FFA concentrations [Furthermore, the preparation of FFA solutions can have a major impact on the outcome depending on the applied assays. For dissolving FFA, the reviewed articles used ethanol (n = 54) . The use . The ustrations ,56. The trations . Commonltrations , whereastrations .n = 199) were obtained from rodent cell culture  and animal models (The vast amount of the reviewed data (l models . If compn = 12) was reported. There was no direct treatment of animals with isolated FFA (n = 18).In animal experiments a high fat diet ranging from 20–60% fat content (n = 73) included 23 studies using wild types  and 11 using specific mutations of metabolism , Wistar rats (n = 11), Sprague Dawley rats (n = 9), db/db (n = 4), ob/ob, CD1 mice, Zucker diabetic fatty rats (each n = 3) and ICR, NMRI, KK-Ay, Atg7f/f, HcB19 and nu/nu mice (each n = 1)  . In 17 aFFA are well known to mediate toxic effects and impair the function of β-cells enhancing blood glucose levels and increasing the cellular abundance of glucose molecules. Since T2DM patients are exposed to elevated FFA blood levels, they are considered at special risk to suffer from lipotoxic effects including damaged β-cells.Both reduced insulin levels and action promote lipolysis, but the specific cause why FFA are elevated remain mostly unclear . The abuFFA are able to mediate lipotoxicity at different stages of their metabolism covering the range from uptake  to degraFFA uptake into the cell is mediated by fatty acid transporter, also known as cluster of differentiation (CD) 36 . It is k2 [Cytosolic FFA must be activated to acyl-CoA by coenzyme A for further reactions. Acyl-CoA can be transported into the mitochondria by carnitine palmitoyltransferase (CPT) 1, also known as carnitine acyltransferase I . CPT1, t2 . GlycolyAn important biochemical feature of lipotoxicity is the impaired activity of glycolytic and TCA cycle-related enzymes with the associated ability for anaplerotic reactions. The impaired enzymes, among others the citrate synthase , cause aFFA decrease glutamine levels , an aminInterestingly, Lee et al. reported that pyruvate carboxylase inhibition, both by phenylacetic acid (PAA) as well as by high glucose/PA treatment, mitigates AMP-activated protein kinase (AMPK), promoting apoptosis in insulinoma (INS-1) cells. By contrast, AMPK activation was protective against lipotoxic cytotoxicity. PAA and PA treatment promoted CCAAT/enhancer binding protein homologous protein (CHOP)  and phosIn diabetic mouse models it was observed that T2DM correlates with a decreased activity of the pyruvate dehydrogenase complex . This enThe impaired formation of iron-sulfur (Fe/S) clusters ,95 was rIn cells with adequate oxygen supply complexes I-IV use reduction equivalents generated by acetyl-CoA to build up a proton gradient in the respiratory chain to generate ATP at complex V (ATP synthase). The electron transfer caused by complex I, complex II, and complex III will generate ROS in a reaction with oxygen , complexAnother way of generating ROS out of FFA is the β-oxidation in peroxisomes. Again, it is difficult to define at which specific concentrations ROS become harmful for cell physiology. It is important to note that the imbalance between ROS production and detoxification is the detrimental key factor for oxidative stress. As β-cells have reduced amounts of antioxidative enzymes, it seems likely that the threshold of an overwhelmed antioxidative defense is lower compared to other types of cells. There are some data indicating that FFAs mediate an increasing level of toxicity depending on their carbon chain length. Especially long chain fatty acids are suspected to be preferably metabolized in peroxisomes due to specific FFA importers in mitochondria and peroxisomes while less toxic short chain and middle chain FFAs are degraded in the mitochondria . Thus, a2 and form a double binding in the carbon chain of fatty acids. The acyl-CoA dehydrogenase will perform the same reaction in mitochondria [2 in mitochondria by acyl-CoA dehydrogenase can be further used for ATP production, in peroxisomes the electrons will interact with oxygen to form hydrogen peroxide (H2O2). Loading with FFA leads to an increased formation of H2O2 in peroxisomes as compared to mitochondria [2O2 is membrane permeable [In human plasma, the five most abundant FFAs, namely OA, PA, stearic, linoleic, and palmitoleic acid, do have a minimum carbon chain length of 16 carbon units and belong to the group of long chain fatty acids. These represent more than 90% of the total amount of FFA in human plasma . The reachondria . While tchondria . H2O2 isermeable  and can ermeable ,122. Othermeable .2O2 concentrations further activate calcium-independent phospholipase A2 γ (iPLA₂γ) and fuel UCP2 uncoupling [As an adaptive response to increased oxidative stress, β-cells are able to induce the expression of uncoupling protein (UCP) 2. UCP2 is a proton channel localized at the inner mitochondria membrane dissipating proton gradients . There acoupling . iPLA₂γ coupling . Exendincoupling ,132 as wcoupling . The regcoupling . FFA arecoupling . All of coupling ,138,139.coupling .The promotor region of UCP2 contains a sterol regulatory element (SRE). Binding by sterol regulatory element binding protein (SREBP)-1c can increase UCP2 expression ,142. ThiIt was shown that the uncoupling of the proton gradient is dependent on the structure of FFA, and saturated FFA promote uncoupling and exert cytotoxic effects . The uncThe mitochondrial membrane potential (MMP) is dependent on a sufficiently high proton gradient within the mitochondria. FFA are well known to decrease the MMP by an UCP2-induced lowered proton gradient . The redGlucose can decrease the action of PPARα leading to limited fatty acid metabolization . This soPPARγ regulates the gene expression responsible for autophagy  and apopAcyl-CoA is able to degrade the proton gradient of the respiratory chain through the formation of mitochondrial permeability transition pore  disturbide novo formation of ceramides and upregulates sphingosine kinase 2 (SK2), a key enzyme of ceramide synthesis. Ceramides have impact on various pathways including proliferation, differentiation, growth arrest, and apoptosis [Palmitoyl-CoA, the activated form of PA, is substrate for the poptosis ,175. Thepoptosis  and phospoptosis  as well poptosis . IRS-1, poptosis , is intepoptosis , inhibitpoptosis . They inpoptosis ,178,179 poptosis ,181,182.poptosis , which ipoptosis . It has poptosis ,183, e.gpoptosis , but exppoptosis ,185.Additionally, SK2 was reported to increase apoptosis through Bcl-2, while SK2 inhibition prevented lipotoxic cell death . The regThe initiation and execution of the mitochondrial apoptosis pathway is complex and highly regulated. Briefly, the membrane of damaged cells starts to permeabilize, which is enhanced by Bax or p53-upregulated modulator of apoptosis and suppressed by Bcl-2 . The perThe number of articles reporting beneficial effects of FFA to β-cells and insulin secretion is remarkably low. Most intriguingly, they share the same underlying pathways as detrimental effects. Although this seems to pose a contradiction at first, a more detailed look into the respective methodologies can give possible explanations.FFA concentrations employed in studies delivering evidence for a beneficial impact were notably lower ,171,192.Another decisive aspect in lipotoxicity is the homeostasis between FFA and fat storage mobilization. The available data indicate that stored neutral TG do not act lipotoxic in contrast to FFA . Therefon = 15).Since there are multiple mechanisms by which lipotoxicity can impair β-cell function, this section will review which of the underlying pathways are especially related to accelerated ageing and senescence of β-cells and the pancreas. Cellular senescence is defined by a cell cycle arrest triggered by damaged DNA, exerting an anti-tumorigenic purpose . It can n = 5, in animal experiments: n = 5). Most interestingly, the beneficial effects of polyphenols are targeting pathways affected by lipotoxicity. They counteract the dysregulation of the MAPK and Pi3K pathway [A healthy lifestyle involving sufficient exercise and a balanced diet is a pivotal part of the treatment of T2DM. Plant-based nutrients as mainly recommended in the so-called Mediterranean diet contain numerous phytochemicals mediating wholesome effects. In particular, the major group of polyphenols was reported to wield protective properties, e.g., ameliorating glucotoxicity ,206, oxi pathway ,213,214, pathway . They st pathway . Moreove pathway  in a for pathway ,216,217. pathway . Further pathway , and ame pathway ,212,218. pathway ,23 and l pathway .According to these data, plant-based nutrients rich in polyphenols might be promising agents to counteract lipotoxic damage to β-cell mitochondria in diabetes and account for the beneficial effects of the Mediterranean diet. Yet, their clinical and therapeutical benefit has not been studied in clinical trials, and some authors even claim that toxic effects might arise from dosages required to achieve therapeutic levels in humans . A summaMitochondrial function is a key parameter crucially determining energy supply and cell survival. By those factors, it plays a central role in β-cell decay and development of T2DM. FFAs are well known to impair the glucose metabolism by mediating negative effects on mitochondria generally known as lipotoxicity. As lipotoxicity is multifactorial, most of the reviewed studies described lipotoxic effects mediated by increased oxidative stress, uncoupling of energy production by UCP2, deterioration of lipid homeostasis by PPAR and SREBP-1c signaling, extra-mitochondrial signaling through accumulation of acyl-CoA, and eventually enhanced apoptosis. While lipotoxicity can accelerate senescence of β-cells, there is evidence for a sustained mitochondrial metabolism and reversed effects of lipotoxicity by polyphenols as apparent in plant-based nutrients. However, the data are extremely limited and covering a wide range of different plants and ingredients, preventing a distinct verdict on their significance for T2DM and lipotoxicity. When studying the effects of FFAs, parameters like structure, concentration, treatment duration, and preparation should be considered carefully since they have massive impact on the outcome of the experimental setup. Especially the employed concentration substantially determines if FFAs will have an adverse or beneficial effect on β-cells. Judging cautiously from literature it can be generally assumed that in vitro FFAs mediate physiological effects in the lower micromolar range , whereasThe different results of FFAs and polyphenol treatment as well as the multifactorial presentation of lipotoxicity leaves several questions unanswered. Therefore, further studies with clearly defined experimental setups would benefit this promising field of research and further elucidate the execution of lipotoxicity and respective protective mechanisms for the pancreatic β-cell.


It is unclear when to begin rehabilitation after coronary artery bypass grafting (CABG) in the intensive care unit (ICU). Using the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2018, we identified adult patients who underwent a CABG and who were admitted to the ICU for ≥3 consecutive days from the date of their CABG. Patients who started any rehabilitation program prescribed by physicians or therapists within 3 days of CABG were defined as the early rehabilitation group, and the remaining patients were defined as the usual care group. We identified 30,568 eligible patients, with 13,150 (43%) patients in the early rehabilitation group. An inverse probability of treatment weighting analyses showed that the Barthel Index score at discharge in the early rehabilitation group was significantly higher than that in the usual care group . The early rehabilitation group had significantly lower in-hospital mortality, total hospitalization costs, length of ICU stay, and hospital stay vs. the usual care group. Our results suggested that early rehabilitation by physicians or therapists beginning within 3 days of CABG was safe, as suggested by the low mortality and improved physical function in patients who underwent CABG. Patients admitted to intensive care units (ICUs) can experience physical disabilities, cognitive impairments, or psychological difficulties, which are related to post-intensive care syndrome (PICS). PICS occurs within 24 h of ICU admission and progresses ,2,3, andCoronary artery bypass grafting (CABG) is used for multivessel diseases that are difficult to revascularize using a percutaneous coronary intervention. Following CABG, patients are more likely to have physical impairments and PICS because of their low cardiac function, the risk of ischemia, and the surgical invasiveness . TherefoThis was an observational study using an administrative database, where the study conformed to the REporting of studies Conducted using Observational Routinely-collected Data (RECORD) statement reporting guidelines . This stWe used the Japanese Diagnosis Procedure Combination inpatient database, which contains administrative claims data and discharge abstracts from more than 1200 acute care hospitals and covers approximately 90% of all tertiary emergency hospitals in Japan . The datUsing the Japanese Diagnosis Procedure Combination inpatient database from 1 July 2010 to 31 March 2018, we identified patients who underwent CABG and who were admitted to the ICU for more than 3 consecutive days from the date of CABG. We excluded patients aged <18 years and those who received cardiopulmonary resuscitation within 3 days of their CABG.Patients beginning any rehabilitation program prescribed by physicians, physical therapists, or occupational therapists within 3 days of their CABG were defined as the early rehabilitation group. The remaining patients were defined as the usual care group. In the usual care group, nurses provided rehabilitation as needed, without a formal rehabilitation program. In Japan, rehabilitation by physicians, physical therapists, or occupational therapists is reimbursed by the universal healthcare insurance system, and one rehabilitation unit is considered to be 20 min .The primary outcome was patients’ physical function at discharge, as measured via the Barthel Index score using continuous scales . PatientThe covariates were age, sex, smoking history, body mass index at admission, Barthel Index score at admission, Japan Coma Scale score at admission , calendaSome patients had missing data for body mass index, smoking history, Barthel Index at admission, or Barthel Index at discharge. Therefore, we performed multiple imputation to address missing values that were assumed to be missing at random . We creaWe used the inverse probability of treatment weighting (IPTW) to compare outcomes of the early rehabilitation group with those of the usual care group ,34. We aWe calculated the absolute standardized differences of each covariate in the unweighted and weighted cohorts to confirm the balance of the distribution of the covariates between the early rehabilitation and usual care groups. When the absolute standardized differences between the two groups were less than 10%, we considered the imbalance in the distribution of the covariates to be negligible .We used a weighted generalized linear model to compare the outcomes, with cluster-robust standard errors and individual treating hospitals as clusters. We calculated the differences and their 95% confidence intervals for outcomes using the identity link function.We performed two sensitivity analyses to confirm the robustness of our results. First, we performed a complete case analysis that excluded patients with any variable with missing values. Second, we performed propensity-score-adjusted analyses in which we employed a multivariable regression model using primary or secondary outcomes as the dependent variable with early rehabilitation within 3 days of CABG and the estimated propensity scores in the main analyses as the independent variables.p-values as two-sided and p < 0.05 as statistically significant. All analyses were performed using STATA/MP 16.0 software (StataCorp).Continuous variables were presented as a mean and standard deviation (SD), while categorical variables were presented as a number and percentage. We considered all reported After applying the inclusion and exclusion criteria, 30,568 patients were included in this study . Of thesThe patients’ characteristics and the numbers of patients with missing values for each variable are presented in The present study using nationwide real-world data showed that early rehabilitation beginning within 3 days of CABG prescribed by physicians or therapists was significantly associated with improved ADLs at discharge after the CABG. Furthermore, early rehabilitation was significantly associated with lower in-hospital mortality, total hospitalization costs, length of ICU stay, and hospital stay.Similar to previous studies, our results suggested that early cardiac rehabilitation within 3 days of CABG effectively maintained ADLs in patients after their CABG ,18,19. POur results indicated that cardiac rehabilitation in the early stage in phase 1 after a CABG was safe. Similarly, recent studies showed that early ICU rehabilitation was considered safe without increasing the complications of coronary ischemia or heart failure when the rehabilitation was administered with appropriate timing and discontinuation criteria ,39,40. PEarly cardiac rehabilitation was associated with a lower length of ICU stay, hospital stay, and total hospitalization costs in our study. Guidelines for cardiac diseases recommend starting cardiac rehabilitation during phase 1; however, very early rehabilitation in phase 1, such as beginning on day 2 or 3 after CABG, is not recommended because of limited evidence . The reaThere are several limitations to the present study. First, because we used a real-world Japanese database, the decision whether to start rehabilitation was made by individual clinicians according to their own criteria. The decision to start rehabilitation itself may be an indicator of severity, and the reasons for making this decision were not standardized, which led to confounding by indication. We attempted to control for this confounding by indication using propensity score analyses. However, we were unable to control for possible unmeasured variables, such as vital signs or cardiac function. Second, because the database contained information collected only during hospitalization, we were unable to analyze long-term outcomes after discharge. We were also unable to assess the detailed effects and safety of factors that may have contributed to improved mortality, such as cardiopulmonary function, cardiopulmonary symptoms, stenoses in coronary arteries, the inflammatory response, or autonomic function. Third, we could not evaluate the exercise intensity of the rehabilitation.This study using a national inpatient database suggested that early rehabilitation beginning within 3 days of CABG was safe, as evidenced by the low mortality and improved physical function at discharge in patients who underwent CABG.


AUXIN RESPONSE FACTOR (ARF) and the LATERAL ORGAN BOUNDARIES-DOMAIN (LOB) gene families, and genes associated with auxin transport and homeostasis, the quiescent center (QC) maintenance, and the root apical meristem (RAM) initiation. Several genes involved in cell wall modulation are also known to be involved in the regulation of adventitious rooting. Furthermore, the molecular processes that play roles in the ethylene, cytokinin, and jasmonic acid signaling pathways and their crosstalk modulate the generation of ARs. The crosstalk and interaction among many molecular processes generates complex networks that regulate AR generation.The formation of adventitious roots (ARs) is an ecologically and economically important developmental process in plants. The evolution of AR systems is an important way for plants to cope with various environmental stresses. This review focuses on identified genes that have known to regulate the induction and initiation of ARs and offers an analysis of this process at the molecular level. The critical genes involved in adventitious rooting are the auxin signaling-responsive genes, including the  Root systems are crucial for plant anchor and for the absorption of water and nutrients from the soil. Plant root system consists of primary, lateral, and adventitious roots (ARs) . AlthougArabidopsis thaliana  maintenance have been demonstrated to modulate AR formation . TranscrAuxin has been well known to act as a central regulator controlling adventitious rooting in plants. Increasing evidences have shown that auxin signaling-related genes are the most important molecular bases for the initiation of AR in plants. Three kinds of auxin signaling genes are involved in the AR process, i.e., auxin synthesis- and homeostasis-related genes, auxin transport-related genes, and auxin-responsive genes.YUCCA encodes flavin monooxygenase that is involved in tryptophan-dependent indole-3-acetic acid (IAA) biosynthesis  family genes , WEAK ETHYLENE INSENSITIVE7/ANTHRANILATE SYNTHASE beta 1 (WEI7/ASB1), and TRYPTOPHAN SYNTHASE BETA 1 (TSB1) encode α- and β-subunits of anthranilate synthase, which is a rate-limiting enzyme of Trp-dependent IAA biosynthesis; disruption of their expression reduces auxin biosynthesis and results in a reduction in AR number in Arabidopsis (SUPERROOT1 (SUR1) encodes a C-S lyase that converts S-alkyl-thiohydroximate into thiohydroximate, which is the first step of indole glucosinolate biosynthesis. SUR2 encodes cytochrome P450-dependent monooxygenase CYP83B1, which blocks the synthesis of indole glucosinolates. The expression of these two genes increases endogenous IAA levels and thereby promoting adventitious rooting (ARGONAUTE1 (AGO1) encodes a miRNA-binding protein that regulates post-transcriptional gene silencing  encodes a putative mitochondrial pyruvate dehydrogenase E1α subunit that is involved in IAA metabolism and homeostasis. In Arabidopsis, this enzyme catalyzes the conversion of indole-3-pyruvate to IAA-CoA  encodes 2-oxoacid-dependent dioxygenase, which can oxidize IAA leading to the reduction of AR initiation  and ARFs in controlling AR formation. ARF6 and ARF7 directly bind to the promoter of SAUR15 to promote its expression. SAUR15 promote AR formation via enhancing auxin accumulation and inhibiting the activity of PP2C-D type 2C protein phosphatase, which activates the activity of membrane H+-ATPases leading to apoplastic acidification, thereby facilitating cell expansion and AR emergence , eight PIN family members, and 29 ABCB members, which provide roust functional redundancy in regulating auxin transport and homeostasis (Polar auxin transport (PAT) results in the differential distribution of auxin in certain tissues, which directly triggers the initiation of ARs . Studies rooting . Three meostasis .PIN1 expression is essential for AR formation in cotyledon cuttings of Mangifera indica  and PLT2    and a larimordia , 2011.AUX1 and LIKE-AUX1-3 (LAX3) in Arabidopsis  (CROWN ROOTLESS1 (CRL1), which encodes a member of AS2/LOB protein family (ROOTLESS CONCERNING CROWN AND SEMINAL ROOTS (RTCS)  regulate the initiation and maintenance of root primordia. The auxin-responsive RTCS inhibits AUXIN BINDING PROTEIN1 (ABP1), while activates calmodulin resulting in the activation of downstream calcium-dependent signaling  TFs have been shown to modulate AR formation  through 1 (ARL1)  and CROWn family , the maiS (RTCS) , the Med MtLOB29 , and thend LBD29 . ARL1 annd LBD29 . RTCS anignaling . Memberscultures . In Arabelopment . Moreoveromoters .The initiation of RAM and maintenance of QC are key processes for AR induction. Two steps are required for cell fate transition to RAM formation. Firstly, regeneration-competent cells dedifferentiate to become root founder cells. Secondly, the root founder cells transform into root primordium cells and initiate mitosis to form RAM . The mosSHORTROOT (SHR) and SCARECROW (SCR) genes encode closely related TFs belonging to the GRAS  gene family, and their products play a role in establishing and maintaining the RAM (Arabidopsis (SCARECROW-LIKE (SCL) family genes, such as PrSCL1 from Pinus radiata and CsSCL1 from Castanea sativa  family of AP2/ERPB2 domain TFs genes, including PLETHORA1 (PLT1), PLT2, AINTEGUMENTA (ANT), AINTEGUMENTA-Like (AIL), and BABY BOOM (BBM1), are expressed in all dividing tissues and are required for AR primordium formation  family TF genes characterizes the early derivatives of AR founder cells in Arabidopsis    , a WRKY   , and a bnd CUC2)  are invond CUC2) .ROOT INITIATION DEFECTIVE2 (RID2) encodes a nuclear methyltransferase-like protein that likely contributes to the nucleolar activity of pre-rRNA processing via methylation, thereby promoting cell proliferation and consequently maintaining cell proliferation competence during dedifferentiation (ROOT PRIMORDIUM DEFECTIVE1 (RPD1), ROOT GROWTH DEFECTIVE1 (RGD1), RGD2, and RGD3 play roles in the maintenance of active cell proliferation in AR primordia (ROOT CLAVATA1-HOMOLOGUE1 (RCH1) and RCH2 encode the leucine-rich repeat receptor-like kinases, which are detected to specifically express in RAM cells (MICOTUBULE ORGANIZATION1 (MOR1) encodes a microtubule-associated protein, which is involved in auxin-responsive root meristem initiation (ROOT MERISTEMLESS1 (RML1) mediates meristem initiation and the maintenance of cell division during AR formation in Arabidopsis and Medicago   .EXT during rooting in Vitis vinifera stem cuttings . The elevated CEP activity promotes the degradation of EXT. Thus, NAC1-CEP pathway promotes the emergence of AR tips via antagonizing EXT-mediated wound healing during AR emergence , a cell wall protein family gene, is specifically activated during AR initiation in tobacco cuttings (ROOT HAIR DEFECTIVE3 (RHD3), a large GTP-binding protein-coding gene, is mediated in cell wall biosynthesis and actin organization, both of which are essential for cell expansion during AR formation in Arabidopsis and Populus  is involved in this pathway (ETHYLENE-INSENSITIVE2 (EIN2)-EIN3-like (EIL1) transcriptional cascade resulting in the inhibition of WEI2 (ASA1) and WEI7 (ASB) and YUCCA6 and consequently, reduces IAA level and AR formation , which encodes a negative regulator of vascularization, and PLEIOTROPIC DRUG RESISTANCE TRANSPORTER9 (PDR9), which encodes an auxin efflux pump, further affecting the vascular tissue formation during adventitious rooting. Thus PDR9 acts as a mediator of crosstalk between cytokinin and auxin signaling  , a stress-related hormone, inhibits adventitious rooting and works downstream of the IAA pathway  through 1 (COI1)  and prom1 (COI1) . GH3.3, 1 (COI1) . A studypocotyls . Auxin abidopsis . Furtherto oxIAA .Nicotiana tabacum , another form of JA, is shown to promote adventitious rooting from thin cell layers of  tabacum . MeJA inbidopsis . MeJA mabidopsis . For exabidopsis , 2018, fbidopsis  and furtbidopsis , Druege bidopsis .GA20ox1-OE plays an important role in GA homeostasis (GA-INSENSITIVE DWARF1 (GID1) is a GA receptor gene  gene PtHDT902 from Populus trichocarpa. Overexpressing PtHDT902 in Arabidopsis and poplar enhanced the expression of GA biosynthetic genes and inhibited AR formation in poplar (The GA biosynthetic gene eostasis . GA-INSEtor gene . Both hyransport . A recenn poplar , suggestIn recent years, there have been significant advances in our understanding of the contributions of hormone signaling and gene networks to the regulation of the formation of ARs. An increasing number of genes involved in adventitious rooting and their interactions have been characterized and identified. The diversity of AR types and the complexity of the gene regulation networks pose a challenge to researchers. However, the molecular networks and mechanisms underlying the development of ARs need to be further clarified. At the transcriptional level, it is necessary to ascertain the key genes and gene expression profiles that regulate the different AR types and different stages of AR development. At the post-transcriptional level, the key proteins and protein profiles, as well as their regulation mechanisms during AR formation need to be explored. Another interesting issue is about the inherent differences between the easy-to-root and difficult-to-root plants at the molecular level. Such knowledge should ultimately lead to a better understanding the mechanisms underlying plant cell differentiation and AR development. In practice, we need to exploit the potential of ARs for improving the crop tolerances to various environmental stresses. Rapidly expanding knowledge of plant genomes and proteomes and new technologies will most likely shed more light on these questions in the future.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Entropies were significantly larger in successful shocks and in survivors, and when compared to the available methods, FuzzyEn presented the best prediction results, marginally outperforming SampEn. The sensitivity and specificity of FuzzyEn were 83.3% and 76.7% when predicting defibrillation success, and 83.7% and 73.5% for patient survival. Sensitivities and specificities were two points above those of the best available methods, and the prediction accuracy was kept even for VF intervals as short as 2s. These results suggest that FuzzyEn and SampEn may be promising tools for optimizing the defibrillation time and predicting patient survival in OHCA patients presenting VF.Optimal defibrillation timing guided by ventricular fibrillation (VF) waveform analysis would contribute to improved survival of out-of-hospital cardiac arrest (OHCA) patients by minimizing myocardial damage caused by futile defibrillation shocks and minimizing interruptions to cardiopulmonary resuscitation. Recently, fuzzy entropy (FuzzyEn) tailored to jointly measure VF amplitude and regularity has been shown to be an efficient defibrillation success predictor. In this study, 734 shocks from 296 OHCA patients (50 survivors) were analyzed, and the embedding dimension ( Out-of-hospital cardiac arrest (OHCA) is a major health problem. Yearly estimates of OHCA cases treated by Emergency Medical Systems (EMS) are over 250,000  in EuropDuring VF, the myocardium rapidly deteriorates, and early therapy is, therefore, critical. In the absence of electrical therapy, cardiopulmonary resuscitation (CPR), consisting of ventilations and chest compressions, is key to partially maintaining oxygenated blood flow to the vital organs ,6. In faOver the years, many ECG-based VF waveform analysis features have been introduced as shock outcome predictors ,14,16,17Quantitative measures of the VF waveform entropy have been recently proposed as shock outcome predictors, including the wavelet entropy , spectraThis is the first study to evaluate the prediction of OHCA survival using VF waveform analysis based on SampEn and FuzzyEn. Furthermore, our results show that SampEn and FuzzyEn outperform the rest of the predictors proposed to date, and that entropies should be parametrized differently depending on the criterion used for shock success. In addition, we show that SampEn and FuzzyEn are reliable shock outcome predictors with time series as short as 2 s, even when predicting the survival of the patient. Finally, we conduct an analysis on the evolution of entropy in long VF intervals without CPR therapy (20–30 s) using the pre-shock periods before defibrillation, and show that the deterioration in the characteristics of VF is not as large as predicted in previous studies ,45.The paper is organized as follows. Data were collected from OHCA cases treated by the Basic Life Support (BLS) ambulances of the Basque Autonomous Community (Spain) in the period between October 2013 and December 2017. The Basque emergency medical system (EMS) is organized as a two-tier EMS system with a dense network of non-medicalized BLS ambulances, supported by fewer advanced life support ambulances (ALS) located closer to the most densely populated areas. BLS ambulance personnel provide CPR therapy and defibrillation using automated external defibrillators (AED). The system serves a population of 2.2 million, with a yearly incidence of EMS-treated OHCA of 39.1 cases per 100,000 inhabitants . ElectroIn the study period, over 3600 EMS treated OHCA cases were entered into the cardiac arrest registry. In 67 of those, a BLS ambulance was the first resource on scene, and in 1560 cases, AED files were available and revised. Cases in which defibrillation shocks were delivered and in which uninterrupted ECG and thoracic impedance signals were available were included in the final dataset which included 296 cases. As shown in he shock . There wShock outcome predictors were computed using the VF waveform prior to the shock, leaving a 1 s guard interval for the calculation, as shown in https://github.com/BChicote/shockOutcome. The time domain features included the amplitude range (AR) [For this study, twenty five VF waveform shock outcome predictors were implemented, covering the published methods in the field. Details on the calculations can be found on the original references, and the MATLAB code with our implementation is available in the following online resource: nge (AR) , peak-tonge (AR) , mean amnge (AR) , signal nge (AR) , two defnge (AR)  and RMS2nge (AR) , mean annge (AR) , and a snge (AR) . The spenge (AR) , centroinge (AR) , centroinge (AR) . The VF nge (AR) , the scange (AR) , the lognge (AR) , two coenge (AR)  and the nge (AR) , in addinge (AR)  and specnge (AR) .In a previous contribution, we showed that the measures of entropy chosen to quantify VF waveform regularity are good shock outcome predictors—in particular, SampEn and FuzzyEn . These mm, where N is the number of samples in the interval. This yielded vectors of the form To compute SampEn, the samples of the signal in the analysis interval, r) for the matches in the following way:m match with tolerance r is then:Vector matches were counted using the Heaviside function, The process iwa repeated for vectors of length Then, SampEn was estimated asFuzzyEn is similar to SampEn, but before evaluating vector match counts, the baseline is subtracted from the Equation  were(7)posed in . So, them and r, The probabilities of vectors of lengths quations  and (5),r) is not normalized to the standard deviation of the signal [In the context of shock outcome prediction, the VF amplitude contains relevant information on the metabolic condition of the myocardium . Conseque signal . In mostications . That isShock outcome prediction is a binary decision problem, in which the positive class is shock success. Therefore, a features . In this defined . The ideAccording to the resuscitation guidelines , CPR shoIn addition, it is well known that long interruptions in CPR therapy are detrimental for the survival of the patient ,45. In pm and r [r) increased. As expected, the entropies decreased as the matching tolerance increased for all values of m. Furthermore, entropies for unsuccessful shocks (for both success criteria) were smaller than for successful shocks, which shows that more regular VF is less amenable to defibrillation. This finding is in line with previous studies [An accurate estimation of a time series regularity using SampEn and FuzzyEn involves the proper selection of m and r . Figure  studies ,39, althWhen compared to the rest of the predictors available in the literature, the ROC curve analysis again revealed that FuzzyEn and SampEn are the best predictors, as shown in Shortening the analysis interval may be critical in some shock outcome prediction scenarios, for instance, if the analysis of the VF waveform is performed in the ventilation pauses during CPR . Such siDependence on the window length was also analyzed for AMSA, and the results are shown in n = 92 pauses, 50 patients) and non-survivors 21.9 (18.0–27.6) s  , Longer pre-shock pauses have been associated with lower probability of shock success  and loweause see  showed aThe linear regression analysis for the trends in https://github.com/BChicote/shockOutcome), for researchers to test our results and conduct future experiments using other datasets.Having optimal timing for defibrillation delivery would contribute to an improved survival rate of OHCA patients by avoiding or minimizing interruptions in chest compression therapy and potential myocardial damage caused by futile and repetitive shocks ,25. DefiVF with larger amplitudes are more responsive to defibrillation, and are associated with the so called electrical (<4 min) and circulatory 4–10 min) phases of VF . The amp min phasThe consumption of oxygen and energy in the myocardium is higher during VF because the ventricles activate and contract at a higher frequencies . Increasm and r shows that the prediction of defibrillation success and patient survival is very stable , an effect that was more noticeable as the segment length decreased.The characterization of SampEn and FuzzyEn in terms of  AUC see  in the pr produced, in some cases, very few matches and an ill-valued SampEn. This explains the drop of almost five points in AUC (bottom right figure). Again, FuzzyEn was shown to be robust even in these challenging scenarios, and should be used instead of SampEn for the prediction of defibrillation success and patient survival. This comes at an increase in computational cost associated with the evaluation of the fuzzy membership function and the inapplicability of some recently developed efficient implementations of SampEn [Predicting defibrillation success with very short signal intervals may be critical, particularly if these methods are used during ongoing CPR. Although some studies based on AMSA and related predictors show that intervals as short as 0.8–1 s are sufficient for the prediction of shock success ,38, in pf SampEn . AlthougFinally, our data allowed us to evaluate the evolution of VF waveform in long periods without CPR, using entropies as surrogate measures. This was possible because the pre-shock pauses in our data were long (median duration >20 s), although typical of AED use . We did Cardiac arrest remains difficult to predict. There is evidence suggesting that heart rate variability, as a non-invasive measure of cardiac autonomic dysfunction, could be used to predict cardiac arrest using indexes derived from the temporal, spectral, and non-linear analyses of interbeat series ,79. If rOur study had some limitations. First, data came from a single type of device, the LP1000 AED. Although the ECG acquisition bandwidth and ECG amplitude resolution may differ between devices, the data available for the study was acquired using values similar to those in most commercial devices . Our res


The purpose of this study was to develop and evaluate a novel elbow arthroscopy system with superimposed bone and nerve visualization using preoperative computed tomography (CT) and magnetic resonance imaging (MRI) data. We obtained bone and nerve segmentation data by CT and MRI, respectively, of the elbow of a healthy human volunteer and cadaveric Japanese monkey. A life size 3-dimensional (3D) model of human organs and frame was constructed using a stereo-lithographic 3D printer. Elbow arthroscopy was performed using the elbow of a cadaveric Japanese monkey. The augmented reality (AR) range of error during rotation of arthroscopy was examined at 20 mm scope–object distances. We successfully performed AR arthroscopy using the life-size 3D elbow model and the elbow of the cadaveric Japanese monkey by making anteromedial and posterior portals. The target registration error was 1.63 ± 0.49 mm (range 1–2.7 mm) with respect to the rotation angle of the lens cylinder from 40° to − 40°. We attained reasonable accuracy and demonstrated the operation of the designed system. Given the multiple applications of AR-enhanced arthroscopic visualization, it has the potential to be a next-generation technology for arthroscopy. This technique will contribute to the reduction of serious complications associated with elbow arthroscopy. The small working space and near adjacency of neurovascular and arthroscopic portals make elbow arthroscopy a technically demanding procedure. Successful elbow arthroscopy requires extensive knowledge of the spatial correlations among the neurovasculature, entry portals, and joint structures.Available evidence supports the use of elbow arthroscopy to manage multiple conditions including rheumatoid arthritis, osteoarthritis, tennis elbow, and osteochondritis dissents. A major drawback of elbow arthroscopy is the risk of intraoperative complications, including serious neurovascular injuries2. However, this valuable set of information is ineffectively utilized in elbow arthroscopy at arguably the most decisive point: during the procedure3. The ability to access such data that is optimized for use and seamlessly integrated into the surgical navigation system has remained elusive. We propose that the safety of standard elbow arthroscopy can be improved by incorporating augmented reality (AR). AR can allow the delivery of selective complex and highly useful information through computer graphics (CG) superimposed onto real-time video.Recent advancements in sophisticated image processing technology have made precise preoperative simulations a possibility, and they are becoming increasingly common in clinical practice5. AR is an important technology because it enables the demonstration of the positional relationship between implants and targeted tissues to help complex interventions. However, AR-assisted arthroscopy has only few reports including knee and wrist arthroscopy7. Neurovascular injury is less significant with knee and wrist arthroscopy, because important neurovascular structures do not run near the portal or in the surgical field. Therefore, previous AR arthroscopy reports of the knee and wrist provided only superimposed bone and joint 3D data. On the other hand, all nerves around the elbow are at risk of injury during arthroscopy. Development of a novel technology using AR for elbow arthroscopy is needed with superimposed bone and nerve visualizations based on computed tomography (CT) and magnetic resonance imaging (MRI) data.AR-assisted surgery is expanding rapidly in the field of sports, trauma, oncology, spine, and arthroplastyThe purpose of this study was to develop and evaluate a novel elbow arthroscopy system that uses AR technology to superimpose nerve data on an arthroscopy monitor. We hypothesize that the accuracy of the resulting AR enhancement to standard arthroscopy would be acceptable.8. Segmentation and refinement were performed using VoTracer software 9. All segmented lesion data were exported as standard triangulated language (STL) data.Skin, bone, and nerve segmentation data of the elbow of a healthy human volunteer was obtained by CT and MRI. Inter-modal voxel registration was performed using ANT software with a SyN non-linear registration algorithm and affin registrationWe added support frame STL data to correctly coordinate bones and nerves upon 3D printing and printed a life-size 3D model of organs and frame using a stereo-lithographic 3D printer  Fig. .Figure 1We used a tracking system  for surgical device tracking. MicronTracker3 is an optical pose tracking system with a unique ability to track unlimited number of tools simultaneously.Each tracking marker used in the system was composed of black and white regions, and the system computed target locations at the intersection of four high-contrast regions. Each of the four black and white boundary lines independently served to pinpoint the location of targets called ‘Xpoints’.Unlike bright spot markers, Xpoints have information on location and orientation. This additional discriminating characteristic reduces erroneous mismatches between targets on the left and right images. It also reduces marker misidentification, as matching the characteristics of the observed targets against templates leads to identification. As misleading bright reflection spots are more common in an operating environment compared with Xpoints, the use of Xpoints reduces the risk of misidentification.The markers were identified with reference to a marker template database and allowed to distinguish between multiple different instruments. Furthermore, the database can be updated during run-time, allowing new marker templates to be added by presenting them to the camera and assigning names to them. We placed different markers onto each 3D model baseplate and used the arthroscopy camera for tracking. To stabilize markers on the arthroscopy camera, we made custom stainless-steel guides that could attach markers on the arthroscope with a 30° angled lens Fig. a.Figure While performing elbow arthroscopy on the generated 3D model, an AR-calculated CG image was superimposed onto the arthroscopic video view by our AR system.Arthroscopy image data was captured on the computer through a digital video capture card connected to the arthroscopy camera system.ij from The data of the 3D model base plate and the arthroscopy camera body loci were provided by MicronTracker3, which was able to trace target information using a customized software developed using the MicronTracker software developers’ kit. All the following transformation matrices TThe system summary is as follows Fig. b.ArthrosM and ƩA. The transformation matrix from the MicronTracker3 sensor ) and ƩA: ) was determined by stereo-triangulating the optical marker 3.c must consider this angle.Our custom-made software installed on the computer calculated each 3D organ model and arthroscopy light fiber rod position and direction. The position of the virtual camera was placed on the The coordination system of the 3D model of organs and the arthroscopy camera were defined as ƩM to Ʃc is as follows:Calculation to transform Ʃ4.The rendered image 3 was superimposed on the image 1 and displayed on the monitor.Each 3D organ model data was rendered according to this transformation. A homogenous transformation can be constructed to register the virtual arthroscopy view to the real arthroscopy view. This calculation was performed with the assistance of OpenCV software .10. Reverse distortion correlation was performed using a lens distortion matrix. The matrix was pre-calculated using the calibration pattern of the arthroscopy camera  of a Japanese monkey cadaver was used for this experiment. The X-ray CT data of the cadaveric elbow were used with modeled frame data that could be precisely attached to the humerus and ulna on the posture at 90° elbow flexion and 90° forearm pronation. The frame was printed on a 3D printer  using acrylonitrile butadiene styrene plastic. The frame was then fixed to the cadaver elbow with epoxy resin to ensure that it could not be easily moved Fig. a.Figure X-ray CT and MRI of the elbow and frame were performed, and these datasets were used to obtain the bone and nerve data using methods similar to those used in experiment 1. We obtained bone segmentation from the CT data and nerve segmentation from the MRI data of a cadaveric Japanese monkey elbow. Segmentation and refinement were performed using VoTracer software . All segmented lesion data were exported as STL data Fig. b.The tracking system setup was similar to experiment 1 except that we added an anti-pollution barrier to the system. A washable stainless-steel base plate was constructed to stabilize the elbow frame and placed at different markers on the baseplate and the arthroscopy camera head. The relative position between the baseplate and elbow frame was static. The 3D model base plate and arthroscopy camera body loci data were provided by MicronTracker3. The rendered images were superimposed on the real-time view and displayed on the AR monitor.Elbow arthroscopy was performed on the monkey elbow through anteromedial and posterior portals. While operating on the cadaver elbow, the AR calculated C image was superimposed onto the arthroscopic video by the same method as described in experiment 1. Registration of the CG data positioning was adjusted manually using the shapes of the capitellum and radial head obtained from an arthroscopic view.The AR range of error was examined to evaluate the accuracy of the system. The surgeon usually uses an arthroscope with a 30° angled lens for elbow arthroscopy and obtains the field of view by rotating the lens. We investigated the extent of target registration errors during the rotation of the lens. By installing a marker on the lens cylinder in addition to the marker installed on the camera head of the elbow arthroscope, the coordinate transformation matrix from the marker installed on the camera head to the marker on the lens cylinder of the arthroscope estimates the rotation angle around the axis. By estimating the direction of the elbow arthroscope from the estimated rotation angle, a 3D model that follows the rotation of the lens cylinder is superimposed.Markers were installed on the camera head and lens cylinder. The working distance was set to 20 mm to superimpose the 3D model using an elbow arthroscope whose various parameters were estimated by camera calibration Fig. a.Figure A circular model with a diameter of 2 mm was used as the 3D model, and a checkerboard was used as the object. It was designed such that the center of the circle of the circular model and the intersection of the checkerboard overlap if there is no error in the superimposed position Fig. b.The target registration error was obtained from the superimposed display to evaluate the position accuracy. The angle of the lens cylinder was changed by 10° within the measurable range (− 40° < θ < 40°) of MicronTracker3 Fig. c.The study protocol was approved by the Ethics Committee of Nagoya University Hospital (2020-0013). Informed consent was obtained from all participants in this study. All methods in this study were performed in accordance with relevant guidelines and regulations.We successfully performed AR arthroscopy for the full-size 3D elbow model. The CG data was superimposed onto the elbow arthroscopy video in real-time. We performed a registration to co-visualize the image of the patient’s elbow structures and the CG made by preoperative images. After manual modification of the position, scale, and orientation, the accuracy of the superimposed CG data was deemed acceptable on the AR monitor.AR arthroscopy of the cadaveric Japanese monkey elbow was performed Fig. a. The huThe target registration error was 1.63 ± 0.49 mm (range 1–2.7 mm) at a 20 mm scope-object distance, with respect to the rotation angle of the lens cylinder from 40° to − 40°  of pre-operative CT and MRI data. Segmentation and refinement of bone and nerve data can be performed using this software. A limitation associated with all VCAD software programs is the need for manual work in creating CG of the target tissue. Fine anatomical knowledge of the elbow, especially of the nerve route, is required to complete segmentation and refinement of the tissues. The technology for extracting and superimposing information on large skeletons in the hip and shoulder joints has already been established, and clinical application has advanced11. We employed a video-based display with two monitors for real and AR-enhanced views. This system was a natural fit for arthroscopy, as the surgeon could simultaneously confirm the real and AR-enhanced view. In this system, the surgeon can select to watch the real view or AR-enhanced view depending on the situation. However, in another AR study, fewer gaze shifts reduced task completion time and errors16. In the near future, it is necessary to develop a system that suppresses the gaze shifts of surgeons using fewer monitors with higher precision AR using real-time data.There are several methods of display for AR. See-through glasses and 3D projection mapping are possible AR displays. See-through glasses have a drawback in that it is difficult to obtain an accurate AR view superimposed on the real view. See-through glasses need to track the pupil positions in real-time for registration. 3D projection mapping is another way to display the AR view. In order to obtain an AR view on the patient’s skin, the video projector has to be set over the patient in the operating room. As both deep and superficial structures are displayed on the skin surface, a significant error of perception is noted when more than two surgeons see the AR display18. The accuracy of the tracking device is very important in the clinic as it is directly linked to safety. We used an optical tracking device, MicronTracker3. It was able to trace each target information in real-time using a customized software developers’ kit. The accuracy of this tracking system was deemed acceptable, and the position error was 1.63 ± 0.49 mm (range 1 to 2.7 mm) at a 20 mm scope-object distance, while rotation of the arthroscopy was 40° to − 40°. The error when the rotation angle of the lens cylinder is 0° represents the cumulative error other than the rotation angle estimation error, such as the parameter estimation that occurs during camera calibration and the estimation of positional orientation by MicronTracker3. Whether this accuracy is sufficient for clinical application needs to be confirmed in future clinical studies after further ensuring safety.A variety of tracking systems are available for clinical settings, such as infrared camera-based tracking, the tag video tracking, and electromagnetic tracking23. Recently, multiple types of virtual reality-based training simulators for arthroscopy have been reported22. Among these simulators, high-fidelity virtual reality simulation was reported to be superior to the low-fidelity model to acquire arthroscopic skills23. An AR-enhanced arthroscopic system with superimposed tasks can be a high-fidelity training tool for surgical education. This system can also provide a third-person view using the stereo camera on the optical tracking device, MicronTracker3. The third-person view and record of tracking makers provide a trainee feedback regarding the handling of scope and other instruments during surgery.Arthroscopy simulator training improves the performance of students and residents during knee and shoulder surgery25. In addition, an algorithm for intraoperative data is required.AR-enhanced navigation for arthroscopy may become the next generation arthroscopy system. However, this study has some limitations. First, we used preoperative imaging techniques, such as CT and MRI, but not real-time information of the target tissue. The size and location of the lesion at the time of surgery may differ from the preoperative data. Second, the elbow flexion angle was fixed in our experiments; however, surgeons in a clinical setting typically move the elbow during arthroscopy. Superimposed CG data, therefore, needs to change according to the elbow angle. AR with real-time data of the target tissue is required to solve these problems. Intraoperative CT, MRI, or ultrasonography may be employed to obtain intraoperative data of the target tissue. Actually, nerves around the elbow can be clearly visualized using ultrasonographyThe technological integration of AR with arthroscopy was successful. We attained satisfactory accuracy and demonstrated the working of such a system. Upon resolution of some limitations, AR-enhanced arthroscopic visualization has the potential to become the next-generation arthroscopy. Elbow arthroscopy requires significant training for surgeons, and even skilled surgeons have reported complications during surgery. We believe that AR-enhanced arthroscopy will reduce the risk of serious complications associated with elbow arthroscopy.