In the NCI-60 cell line screening, compound 4b showed promising cytostatic activity against multiple cell lines. Notably, it elicited a GI value of 86.28% against the NSCL cancer cell line HOP-92 at a 10 μM dose. Compounds 4a and 4h at 10 μM showed promising GI values of 40.87% and 46.14% against HCT-116 colorectal carcinoma and SK-BR-3 breast cancer cell lines, respectively. ADME-Tox prediction of compounds 4a, 4b, and 4h revealed their acceptable drug-likeness properties. In addition, compounds 4a, 4b, and 4h showed a high probability of targeting kinase receptors via Molinspiration and Swiss TargetPrediction.A new series of 3,4,5-trimethoxyphenyl thiazole pyrimidines has been synthesized and biologically evaluated for its in vitro anticancer activity. Compounds  Cancer is a malignant tumor caused by abnormal growth of malfunctioning tissues that may result from many factors, such as gene mutations or other environmental factors. There is still a massive need to develop new chemotherapeutic agents that target malignant tumors by various mechanisms and help inhibit the abnormal metastatic growth of malignant tumors ,2.I) is a key pharmacophoric structure to bind tubulin, and it inhibits malignant cell division and growth +: 288.2901, found: 289.0075.To a stirred solution of 1-ethan-1-one  in anhydrous Et3 was added to make the reaction mixture basic with a pH value of 8 or 9. Then, using a separation funnel, the aqueous layer was extracted with dichloromethane (3 × 50 mL), and the organic layers were combined, washed with water and brine, and then dried by Na2SO4 filtration. After the evaporation of dichloromethane, the residue was stirred for 20 min with petroleum ether and filtered to purify the mixture. Flash column chromatography (FCC) was performed using 25–50% ethyl acetate in hexane to afford the title compound as a pure white solid; 1.14 g (98% yield); 1H NMR : δ 7.08 , 6.65 , 5.41 , 3.93 , 3.89 ; 13C NMR : δ 167.11 (Ar-C), 153.33 (Ar-C), 151.19 (Ar-C), 137.97 (Ar-C), 130.51 (Ar-C), 103.34 (Ar-C), 102.38 (Ar-C), 60.94, (4-O-CH3), 56.18 ; HRMS (ESI-TOF) m/z calcd. for C12H15N2O3S [M+H]+: 267.0815, found: 267.0803.A solution of thiourea  in ethanol (5 mL) was added to a stirred solution of compound 1  in ethanol (10 mL). The reaction mixture was stirred under a reflux system at 78 °C for 45 min. After the reaction was completed, saturated aqueous NaHCO2  in anhydrous THF (4 mL), 4,6-dichloro-2-methylpyrimidine  was added. Then, the reaction mixture was cooled down to 0 °C, and sodium hydride  was added, which was divided several times. The reaction mixture was stirred at room temperature for 16 h. After the reaction was finished, THF was evaporated, and the residue was purified by FCC using 20–50% ethyl acetate in hexane to afford the title compound as a white solid; 105.7 mg (72% yield); 1H NMR : δ 12.03 , 7.64 , 7.21 , 6.92 , 3.86 , 3.70 , 2.55 ; 13C NMR : δ 167.78 (Ar-C), 158.63 (Ar-C), 158.38 (Ar-C), 158.25 (Ar-C), 153.54 (Ar-C), 149.33 (Ar-C), 137.73 (Ar-C), 130.49 (Ar-C), 108.62 (Ar-C), 103.43 (Ar-C), 103.33 (Ar-C), 60.52 (4-O-CH3), 56.32 , 25.61 (Ar-CH3); HRMS (ESI-TOF) m/z calcd. for C17H18ClN4O3S [M+H]+: 393.0801, found: 393.0788.To a stirred suspension of compound 3  in anhydrous dimethyl sulfoxide (3 mL) and DIPEA . The reaction mixture was stirred at 110 °C for 2 h. After cooling to room temperature, water was added to quench the reaction. Using a separation funnel, the aqueous layer was extracted with ethyl acetate (4 × 50 mL), and the organic layers were combined, washed with water and brine, and then dried by Na2SO4 filtration. The solvent was evaporated under vacuum, and the resulting residue was purified by FCC using the proper eluent.A solution of secondary amines (0.510 mmol) in anhydrous dimethyl sulfoxide (1 mL) was added to a stirred solution of compound 1H NMR : δ 11.61 , 7.12 , 7.11 , 5.28 , 3.85 , 3.81 , 3.20 , 2.48 , 2.40 , 2.31 , 1.09 ; 13C NMR : δ 165.94 (Ar-C), 162.56 (Ar-C), 161.85 (Ar-C), 157.01 (Ar-C), 153.47 (Ar-C), 148.41 (Ar-C), 138.08 (Ar-C), 129.85 (Ar-C), 106.74 (Ar-C), 103.21 (Ar-C), 83.04 (Ar-C), 61.00 (4- O-CH3), 56.04 , 52.30 (2 CH2-piperazine), 52.19 (2 CH2-piperazine), 43.57 (Ar-CH3), 25.70 (2CH-CH3), 11.90 (CH2-3CH); HRMS (ESI-TOF) m/z calcd. for C23H31N6O3S [M+H]+: 471.2178, found: 471.2198.FCC eluent . White solid; 93.0 mg (82% yield); mp: 208–209 °C; 1H NMR : δ 11.54 , 7.17 , 7.08 , 5.28 , 3.86 , 3.82 , 3.66 , 3.19 , 2.71 , 2.55 , 2.50 , 2.39 ; 13C NMR : δ 166.02 (Ar-C), 162.63 (Ar-C), 161.77 (Ar-C), 157.01 (Ar-C), 153.48 (Ar-C), 148.41 (Ar-C), 138.01 (Ar-C), 129.86 (Ar-C), 106.82 (Ar-C), 103.12 (Ar-C), 83.07 (Ar-C), 60.97 (4-O-CH3), 59.39 (-CH2-2CH-OH), 57.80 (-2CH-CH2-OH), 56.02 , 52.29(2 CH2-piperazine), 43.66 (2 CH2-piperazine), 25.68 (Ar-CH3); HRMS (ESI-TOF) m/z calcd. for C23H31N6O4S [M+H]+: 487.2127, found: 487.2122.FCC eluent . White solid; 31.8 mg (30% yield); mp: 113–115 °C; 1H NMR : δ 11.32 , 7.21 , 7.10 , 6.94–6.87 , 5.37 , 3.87 , 3.86 , 3.81 , 3.38 , 2.98 , 2.54 ; 13C NMR : δ 166.12 (Ar-C), 162.66 (Ar-C), 161.65 (Ar-C), 157.06 (Ar-C), 154.18 (Ar-C), 153.56 (Ar-C), 148.54 (Ar-C), 145.53 (Ar-C), 138.17 (Ar-C), 129.92 (Ar-C), 118.67 (Ar-C), 114.51 (Ar-C), 106.77 (Ar-C), 103.22 (Ar-C), 83.03 (Ar-C), 60.99 (4-O-CH3), 56.09 (4-O-CH3), 55.58 , 50.48 (2 CH2-piperazine), 43.81 (2 CH2-piperazine), 25.71 (Ar-CH3); HRMS (ESI-TOF) m/z calcd. for C28H33N6O4S [M+H]+: 549.2284, found: 549.2293.FCC eluent . White solid; 31.8 mg (30% yield); mp: 216–217 °C; 1H NMR : δ 11.31 , 7.49 , 7.20 , 7.12–7.07 , 7.04–7.00 , 6.18 , 3.85 , 3.70 , 3.68 , 3.18 , 2.43 ; 13C NMR : δ 165.64 (Ar-C), 162.83 (Ar-C), 159.67 (Ar-C), 158.15 (Ar-C), 155.55 (Ar-C), 153.51 (Ar-C), 148.95 (Ar-C), 148.21 (Ar-C), 137.58 (Ar-C), 130.88 (Ar-C), 118.07  (Ar-C), 115.81  (Ar-C), 107.44 (Ar-C), 103.39 (Ar-C), 82.72 (Ar-C), 60.54 (4-O-CH3), 56.34 , 49.30 (2 CH2-piperazine), 43.91 (2 CH2-piperazine), 26.08 (Ar-CH3); HRMS (ESI-TOF) m/z calcd. for C27H30FN6O3S [M+H]+: 537.2084, found: 537.2102.FCC eluent . White solid; 107.3 mg (79%); mp: 84–86 °C; v/v). White solid; 73.5 mg (52% yield); mp: 125–130 °C; 1H NMR : δ 11.94 , 7.22 , 7.13–6.73 , 5.88 , 3.94–3.92 , 3.88 , 3.86 , 2.67 ; 13C NMR : δ 167.73 (Ar-C), 160.42 (Ar-C), 159.34 (Ar-C), 157.17 (Ar-C), 153.79 (Ar-C), 149.65 (Ar-C), 145.29 (Ar-C), 138.60 (Ar-C), 132.03 (Ar-C), 129.98 (Ar-C), 118.62 (Ar-C), 113.60 (Ar-C), 108.05 (Ar-C), 103.99 (Ar-C), 103.08 (Ar-C), 61.02 (4-O-CH3), 56.23 , 42.31 (2 CH2-piperazine), 40.82 (2 CH2-piperazine), 25.44 (Ar-CH3); HRMS (ESI-TOF) m/z calcd. for C27H30ClN6O3S [M+H]+: 553.1788, found: 553.1786.FCC eluent : δ 11.07 , 7.24–7.08 , 6.97 , 3.88 , 3.85 , 3.47 , 2.98 , 2.54 ; 13C NMR : δ 167.68 (Ar-C), 162.96 (Ar-C), 160.70 (Ar-C), 157.86 (Ar-C), 153.53 (Ar-C), 151.20 (Ar-C), 150.92 (Ar-C), 139.65 (Ar-C), 134.20 (Ar-C), 130.02 (Ar-C), 127.58 (Ar-C), 125.07 (Ar-C), 124.97 (Ar-C), 118.71 (Ar-C), 106.79 (Ar-C), 103.17 (Ar-C), 83.23 (Ar-C), 60.99 (4-O-CH3), 56.07 , 50.95 (2 CH2-piperazine), 43.97 (2 CH2-piperazine), 25.70 (Ar-CH3); HRMS (ESI-TOF) m/z calcd. for C27H29Cl2N6O3S [M+H]+: 587.1399, found: 587.1414.FCC eluent . White solid; 80.3 mg (53% yield); mp: 202–205 °C; 1H NMR : δ 11.70 , 7.16 , 7.08 , 5.23 , 3.87 , 3.81 , 3.59 , 3.13 , 2.51 ; 13C NMR : δ 165.99 (Ar-C), 162.83 (Ar-C), 161.86 (Ar-C), 156.99 (Ar-C), 153.53 (Ar-C), 148.43 (Ar-C), 138.07 (Ar-C), 129.85 (Ar-C), 106.91 (Ar-C), 103.15 (Ar-C), 83.04 (Ar-C), 66.35 (2 CH2-morpholine), 60.96 (4-O-CH3), 56.02 , 43.95 (2 CH2-morpholine), 25.64 (Ar-CH3); HRMS (ESI-TOF) m/z calcd. for C21H26N5O4S [M+H]+: 444.1706, found: 444.1711.The title compound was produced as a pure white solid; 85.9 mg (76% yield); mp: 110–112 °C; 1H NMR : δ 11.64 , 7.12 , 7.03 , 5.35 , 5.02 , 3.80 , 3.77 , 2.57–2.40 , 2.28; 13C NMR : δ 166.05 (Ar-C), 162.56 (Ar-C), 161.55 (Ar-C), 156.89 (Ar-C), 153.42 (Ar-C), 148.65 (Ar-C), 137.98 (Ar-C), 129.98 (Ar-C), 106.74 (Ar-C), 103.24 (Ar-C), 81.71 (Ar-C), 60.89 (4-O-CH3), 55.95 , 55.85 (N-CH2-CH2-N), 54.85 (N-CH2-CH2-N), 52.39 (N-CH3), 45.81 (2 CH2-piperazine), 37.40 (2 CH2-piperazine), 25.34 (Ar-CH3); HRMS (ESI-TOF) m/z calcd. for C24H34N7O3S [M+H]+: 500.2444, found: 500.2452.FCC eluent . White solid; 77.6 mg (68% yield); mp: 213–219 °C; 1H NMR : δ 11.39 , 7.10 , 7.01 , 5.44 , 5.12 , 3.81 , 3.79 , 3.65 , 2.68 , 2.46 , 2.42–2.37 ; 13C NMR : δ 166.12 (Ar-C), 162.62 (Ar-C), 161.52 (Ar-C), 156.89 (Ar-C), 153.46 (Ar-C), 148.75 (Ar-C), 138.05 (Ar-C), 129.99 (Ar-C), 106.76 (Ar-C), 103.33 (Ar-C), 81.83 (Ar-C), 66.83 (2 CH2-morpholine), 60.92 (4-O-CH3), 56.44 (N-CH2-CH2-N), 56.01 , 53.14 (N-CH2-CH2-N), 37.20 (2 CH2-morpholine), 25.26 (Ar-CH3); HRMS (ESI-TOF) m/z calcd. for C23H31N6O4S [M+H]+: 487.2127, found: 487.2135.FCC eluent . White solid; 73.5 mg (59% yield); mp: 200–202 °C; 1H NMR : δ 10.14 , 7.31 , 7.24 , 6.31 , 6.11 , 5.64 , 3.89 , 3.76–3.74 , 3.48 , 2.43 ; 13C NMR : δ 166.06 (Ar-C), 162.84 (Ar-C), 161.31 (Ar-C), 156.68 (Ar-C), 153.48 (Ar-C), 148.82 (Ar-C), 138.00 (Ar-C), 130.32 (Ar-C), 106.96 (Ar-C), 103.59 (Ar-C), 82.60 (Ar-C), 61.01 (4-O-CH3), 56.14 , 53.45 (2CH-OH), 43.89 (2CH-NH), 25.16 (Ar-CH3); HRMS (ESI-TOF) m/z calcd. for C19H24N5O4S [M+H]+: 418.1549, found: 418.1559.FCC eluent (100% ethyl acetate). Pale yellow solid; 97.8 mg (92% yield); mp: 85–90 °C; 1H NMR : δ 11.01 , 7.13 , 7.03 , 5.50 , 5.18 , 3.84 , 3.83 , 2.83 , 2.57–2.41 , 2.37 , 2.30 , 1.60 ; 13C NMR : δ 166.26 (Ar-C), 163.03 (Ar-C), 161.18 (Ar-C), 156.88 (Ar-C), 153.43 (Ar-C), 148.80 (Ar-C), 138.03 (Ar-C), 130.12 (Ar-C), 106.63 (Ar-C), 103.31 (Ar-C), 81.55 (Ar-C), 60.92 (4-O-CH3), 56.31 (N-CH3), 56.04 , 55.05 (-CH2-2CH-NH), 53.07 (-CH2-2CH-N-), 45.92 (2 CH2-piperazine), 40.29 (2 CH2-piperazine), 25.52 (Ar-CH3), 25.41 (-CH2-2-CHCH2-); HRMS (ESI-TOF) m/z calcd. for C25H36N7O3S [M+H]+: 514.2600, found: 514.2597.FCC eluent . Pale yellow solid; 38.4 mg (74% yield); mp: 89–91 °C; 1H NMR : δ 11.41 , 7.12 , 7.04 , 5.63 , 5.12 , 3.81 , 3.79 , 3.65 , 2.76 , 2.46 , 2.36–2.28 , 1.54 ; 13C NMR : δ 166.18 (Ar-C), 162.99 (Ar-C), 161.44 (Ar-C), 156.90 (Ar-C), 153.42 (Ar-C), 148.65 (Ar-C), 138.00 (Ar-C), 130.02 (Ar-C), 106.67 (Ar-C), 103.28 (Ar-C), 81.56 (Ar-C), 66.90 (2 CH2-morpholine), 60.90 (4-O-CH3), 56.01 , 53.64 (-CH2-2CH-NH), 40.90 (-CH2-2CH-N-), 40.16 (2 CH2-morpholine), 25.40(Ar-CH3), 25.11 (CH2-2-CHCH2); HRMS (ESI-TOF) m/z calcd. for C24H33N6O4S [M+H]+: 501.2284, found: 501.2295.FCC eluent (10% methanol in dichloromethane). White solid; 88.9 mg (68% yield); mp: 170–177 °C; 1H NMR : δ 11.29 , 7.14 , 7.04 , 5.51 , 5.14 , 3.84 , 3.82 , 2.76 , 2.48 , 2.27 , 2.18 , 1.56 ; 13C NMR : δ 166.16 (Ar-C), 163.04 (Ar-C), 161.37 (Ar-C), 156.91 (Ar-C), 153.44 (Ar-C), 148.74 (Ar-C), 138.00 (Ar-C), 130.10 (Ar-C), 106.64 (Ar-C), 103.29 (Ar-C), 81.54 (Ar-C), 60.92 (4-O-CH3), 57.59 (-CH2-2CH-NH), 56.01 , 45.42 (2 N-CH3), 40.23 (-CH2-2CH-N-), 26.35 (Ar-CH3), 25.40 (CH2-2-CHCH2); HRMS (ESI-TOF) m/z calcd. for C22H31N6O3S [M+H]+: 459.2178, found: 459.2193.FCC eluent . White solid; 66.6 mg (82% yield); mp: 86–88 °C; 1H NMR : δ 11.08 , 7.13 , 7.03 , 5.13 , 4.98 , 3.85 , 3.84 , 3.60 , 3.11 , 2.48 , 1.64 ; 13C NMR : δ 166.20 (Ar-C), 163.06 (Ar-C), 161.32 (Ar-C), 156.65 (Ar-C), 153.44 (Ar-C), 148.85 (Ar-C), 138.08 (Ar-C), 130.28 (Ar-C), 106.85 (Ar-C), 103.60 (Ar-C), 82.52 (Ar-C), 60.96 (4-O-CH3), 59.20 (-CH2-2CH-NH), 56.14 , 38.11 (-CH2-2CH-N-), 32.13 (Ar-CH3), 25.26 (CH2-2-CHCH2); HRMS (ESI-TOF) m/z calcd. for C20H26N5O4S [M+H]+: 432.1706, found: 432.1707.FCC eluent (100% ethyl acetate). Pale yellow solid; 38.2 mg (70% yield); mp: 97–99 °C; 4b, 4c, 4k, and 4n over a panel of six human leukemia cell lines was conducted using the Sulforhodamine B (SRB) assay (The anticancer screening of compounds B) assay  at the N4a–4n following the reported procedures [Four human cancer cell lines, MCF-7 and SK-BR-3 (breast cancer cell lines), HCT-116 , K562 (leukemia cell lines), and the normal cell line L132 were used in the in vitro MTT assay. MTT evaluation was performed to examine the antiproliferative activity of compounds N-(6-chloro-2-methylpyrimidin-4-yl)-4-thiazol-2-amine (3), was prepared as shown in 1)  was synthesized via bromination of 3,4,5-trimethoxy acetophenone. Then, compound 1 was refluxed with thiourea for 45 min to yield compound 2 . Next, the key intermediate 3 was achieved by reacting compound 2 with 4,6-dichloro-2-methylpyrimidine using sodium hydride as a base with a 72% yield.The key intermediate, 3 was accomplished through a nucleophilic substitution reaction with substituted amines using N,N-diisopropylethylamine (DIPEA) as a base in DMSO at 110 °C to afford 4a–4n  value of 32.20%  manifested more than 70% GI over all tested cancer cell lines, and 27 cases were above 90% GI at 100 μM. Focusing on the concentration of 10 μM, the ethyl piperazine compounds 4a and 4h showed the best GI% of 40.87 and 46.14 against HCT-116 and SK-BR-3 cell lines, respectively. These GI% values are comparable to sorafenib . Both 4a and 4h compounds possess a piperazine ring in their terminal chain with slight flexibility. Considering the activity at 100 μM and 10 μM doses, it is found that compounds 4c–4f with a substituted phenyl moiety at the terminal N of piperazine have a relatively low percentage of GI (<60% at 100 μM and <40% at 10 μM). In addition, it was noted that the variation in substituents on the phenyl ring in compounds 4c–4f did not impact the anticancer activity. These cellular findings may indicate that the compounds derived from this series should have some flexibility in their terminal configuration to exert a considerable anticancer effect. The morpholine derivative 4g showed an antiproliferative pattern similar to that observed with phenylpiperazines 4c–4f. Moreover, the ethylamines 4h-4i manifested comparable activity with their corresponding propylamines 4k, 4l, and 4n, which reveals that both ethyl and propyl spacers are tolerable.The results reveal that all designed compounds had comparable cytotoxic activity against the four human cancer cell lines at 100 μM. Among the tested compounds, nine compounds  to acquire certain insights about their potential molecular targets. Molinspiration concentrates on certain classes of drugs and calculates the specific activity scores for these classes. These bioactivity scores may be a proper measure to predict the target with the highest probability for the most potent synthesized compounds [The most potent compounds, ompounds .4a, 4b, and 4h revealed their high structural similarity with kinase inhibitors class with scores varying from 0.30 to 0.38 and to a lesser extent G-protein coupled receptor (GPCR) ligands with scores ranging from 0.08 to 0.10. These suggest that compounds 4a, 4b, and 4h may exert their anticancer activity by inhibiting certain oncogenic kinases or targeting GPCR.A Molinspiration bioactivity score greater than zero indicates a high probability of being active against this target. The obtained Molinspiration data  for the 4a, 4b, and 4h. The target prediction was limited to Homo sapiens targets to identify the targets belonging to human sources only.The Swiss TargetPrediction server was used to perform ligand-based target prediction of the precise targets of compounds . It was 4a, 4b, and 4h were insulin-like growth factor I receptor (IGF1R) and serine/threonine-protein kinase 4 (PLK4) and cyclin-dependent kinase 4 (CDK4).The acquired data, shown in 4a, 4b, and 4h were tested to decide whether or not they obey the Lipinski rule of five, utilizing Swiss ADME predictor [Lipinski’s rule of five determines the oral bioavailability and drug-likeness of the designed small bioactive molecules . The mosredictor , as illu4a, 4b, and 4h, shown in The pharmacokinetics ADMET properties for the most potent compounds were calculated via SwissADME and PreADMET predictors ,39. The However, to develop an anticancer agent with better antiproliferative activity and fewer side effects than the existing chemotype, it is necessary to further investigate other structural derivatives based on this scaffold; further design for structural optimization of the TMP-thiazole series is currently underway and will be reported in due course.4a, 4b, and 4h showed the best growth inhibitory effects over certain cancer cell lines. Among the NCI-selected compounds, 4b showed the highest GI values of 86.28% and 73.52% against the NSCL cancer cell line HOP-92 and the CNS cancer cell SF-295, respectively. Regarding the MTT-tested compounds, both 4a and 4h stood out as the most active members in this series with GI values of 40.87% and 46.14% at 10 μM against HCT-116 colorectal carcinoma and SK-BR-3 breast cancer cell lines, respectively. In addition, Molinspiration and Swiss target predictors showed that the potential molecular targets for compounds 4a, 4b, and 4h are protein kinases. The calculated drug-likeness and ADMET data for compounds 4a, 4b, and 4h underscored their good predicted oral bioavailability and a low probability of carcinogenicity or drug–drug interactions. Further optimization of the presented compounds, especially 4b, is currently considered to generate potent anticancer chemotypes that may overcome the drawbacks of the existing anticancer chemotherapeutics.Among the synthesized pyrimidine-based Trimethoxyphenyl-thiazoles, compounds


Introduction: Chronic conditions such as stroke, Parkinson’s disease, spinal cord injury, multiple sclerosis, vestibular disorders, chronic pain, arthritis, diabetes, chronic obstructive pulmonary disease (COPD), and heart disease are leading causes of disability among middle-aged and older adults. While evidence-based treatment can optimize clinical outcomes, few people with chronic conditions engage in the recommended levels of exercise for clinical improvement and successful management of their condition. Rehabilitation technologies that can augment therapeutic care—i.e., exoskeletons, virtual/augmented reality, and remote monitoring—offer the opportunity to bring evidence-based rehabilitation into homes. Successful integration of rehabilitation techniques at home could help recovery and access and foster long term self-management. However, widespread uptake of technology in rehabilitation is still limited, leaving many technologies developed but not adopted. Methods: In this narrative review, clinical need, efficacy, and obstacles and suggestions for implementation are discussed. The use of three technologies is reviewed in the management of the most prevalent chronic diseases that utilize rehabilitation services, including common neurological, musculoskeletal, metabolic, pulmonary, and cardiac conditions. The technologies are (i) exoskeletons, (ii) virtual and augmented reality, and (iii) remote monitoring. Results: Effectiveness evidence backing the use of technology in rehabilitation is growing but remains limited by high heterogeneity, lack of long-term outcomes, and lack of adoption outcomes. Conclusion: While rehabilitation technologies bring opportunities to bridge the gap between clinics and homes, there are many challenges with adoption. Hybrid effectiveness and implementation trials are a possible path to successful technology development and adoption. Chronic neurological, musculoskeletal, and cardiopulmonary conditions, as well as diabetes, are among the leading causes of disability among middle-aged and older adults globally . PhysicaTechnology could help bridge the gap between intensive treatment in a clinic and at home. Rehabilitation technologies such as robotic exoskeletons, virtual and augmented reality systems, and remote monitoring systems have seen unprecedented growth and advancements in rehabilitation research over the past decade. Robotic exoskeletons are mechanical devices that can augment the functioning of the human body by supplementing existing movement, fully replacing non-existent movement , or imprThese technologies hold great promise to improve patient care by supporting the performance of evidence-based therapeutic activities and have the potential to be utilized in a patient’s home. However, the adoption of these technologies to augment therapeutic approaches has challenges. Historically, the adoption of evidence into clinical practice is fraught with obstacles with an average of 17 years between clinical trials and adoption into routine practice, and with only half of efficacy research adopted . From a In this narrative review, we focus on three rehabilitation technology domains that have been extensively researched over the past two decades: (i) robotic exoskeletons, (ii) virtual and augmented reality systems, and (iii) remote monitoring with wearable sensors. We review the three main components of technology uptake in rehabilitation practice: first, we will establish the clinical need within the populations of interest for rehabilitation technology applied in the home and community settings; second, we will review the technology and current evidence of its efficacy; and lastly, we will discuss obstacles, implementation needs, and suggestions for future research.For this narrative review, we aimed to identify the highest level of evidence in evaluating the efficacy of clinical outcomes. Aligned with the goals for narrative reviews, we conducted a broad search in Pubmed and Cochrane systematic reviews. To capture the state of the literature on the efficacy of these rapidly growing technologies, we limited studies to publications between 2018 and 2023. Systematic and meta-analytical reviews were initially identified, with randomized controlled trials (RCTs) included when systematic reviews were limited. The articles identified in the literature search were reviewed to meet the inclusion and exclusion criteria and appropriateness for our study aims. The reference lists of the included articles were searched for additional studies. The included articles were qualitatively synthesized. Inclusion criteria were publications (i) available in the English language, (ii) pertaining to technologies that met the definitions of exoskeletons, VR, AR, or mHealth applications with remote monitoring intervention, and (iii) including an adult population (aged 18 or older). Additionally, the technologies needed to be evaluated in the context of physical rehabilitation or movement outcomes for neurological conditions , multiple sclerosis (MS), vestibular disorders, spinal cord injury (SCI)), musculoskeletal conditions , heart disease, pulmonary disease, and diabetes.Exclusion criteria were non-English articles, technology development or pilot tests, editorials and observational studies, and pediatric populations.Search terms: exoskeleton (Exo* OR exoskeleton OR Robotic), virtual reality/augmented reality , remote monitoring: (remote monitor* OR wearable sens*), rehabilitation We examine the use of augmented technology in five populations of interest: (i) chronic neurological, (ii) chronic musculoskeletal, (iii) diabetes, (iv) chronic obstructive pulmonary disease, and (v) chronic cardiovascular disease. These five populations comprise the leading disabling conditions that utilize rehabilitation services . Of the Neurological conditions are the leading cause of disability-adjusted life years globally, and this is expected to increase as the population grows and ages . People Approximately 1.3 billion people worldwide suffer from musculoskeletal conditions, with the highest prevalence of low back pain, osteoarthritis, and neck pain . ChronicDiabetes occurs when the pancreas does not produce enough insulin or does not process insulin properly. Diabetes is estimated to affect approximately 415 million people worldwide, with a prediction to grow to over 600 million in the next 10 years . Poorly Over 500 million people worldwide are estimated to have a chronic respiratory condition, with chronic obstructive pulmonary disease (COPD) as the leading cause of disability within these conditions . COPD isCardiovascular disease is the leading cause of disease burden in the world and is estimated to be present in over 500 million people globally . CardiacRobotic exoskeletons augment the movement system by providing supplemental forces and mechanics to body segments via an external, powered, motorized orthosis to move limbs ,38. ThesNewer research embeds muscle sensors and stimulators into systems for more efficient movement control . These hAmong people with stroke, two meta-analyses  show small to moderate effects of exoskeleton training on walking and balance compared to conventional training ,43.In PD, two systematic reviews of the use exoskeletons for postural control and gait show improved balance and gait parameters; however, the meta-analytical outcomes were not reported ,45. The Among people with SCI, Dijkers et al.  publisheEvidence for the use of exoskeletons for chronic musculoskeletal applications is limited. In one study of 24 adults in a home setting, an ankle-, knee-, and hip-powered exoskeleton did not immediately improve physical performance; however, over time, with additional use at home, stair time and knee pain significantly improved . SimilarVR and AR technologies are advancing rapidly and are increasingly directed at healthcare use. VR is a technology that simulates a 3D virtual world and allows users to interact with the virtual world in a manner similar to reality . AR techThere are four basic elements of VR: the virtual environment, virtual presence, sensory feedback, and interactivity. It is a powerful modality that may drive neuroplasticity by providing a high number of repetitions, permitting quick and small alterations in task difficulty, and keeping participants motivated and engaged during training sessions . There hn = 3) [n = 1) [n = 1) [n = 1) [n = 1) [There were 16 systematic reviews examining the effects of VR, AR, or mixed reality, with the majority examining VR or mixed reality approaches in rehabilitation ,67,68,69n = 3) ,59,60, s [n = 1) , stroke  [n = 1) , stroke  [n = 1) , and PD  [n = 1)   showed a small beneficial effect on function, gait, and balance [In people with vestibular dysfunction, VR interventions compared to conventional treatments improved dizziness inventories ,59,60. T balance . A study balance . Another balance . For peoThere were five studies comprising people with chronic musculoskeletal conditions: four were of pain populations ,63,64,65Equally, one randomized control trial examined the effects of VR on diabetes management . The resFor pulmonary conditions, one study examined VR outcomes among patients. Among people with COPD participating in a randomized control trial, the use of VR with cardiopulmonary rehabilitation improved strength, functional mobility, and walking endurance .There were three systematic reviews that examined the use of VR and exergaming among people with heart disease ,67,68, aRemote monitoring, a form of telehealth that allows monitoring of patient performance outside of the clinic to capture movement and health trends in a real-life context, is typically conducted using smartphone applications and/or embedded sensors . The most common wearable sensors are motion sensors  or biopotential sensors  . SensorsOverall, 13 studies examined the results of remote monitoring on rehabilitation. The type of intervention and dosing were widely variable. Approaches to intervention included both remote monitoring to augment telehabilitation services and promoting improved self-monitoring for behavior changes. The frequency of monitoring ranged from continuous to only during treatment sessions, with feedback from a healthcare professional ranging from real-time to 1x/month. The duration of monitoring ranged from 11 days to 18 months. There are few studies on the impact of remote monitoring interventions for the chronic neurological population on rehabilitation outcomes. There were two systematic reviews on the use of remote monitoring intervention in the neurological population ,76 and oThe efficacy of remote monitoring for chronic musculoskeletal conditions is limited. See . For ChrThe use of remote monitoring in diabetes care is examined in one systematic review with a meta-analysis . The sysIn COPD, remote monitoring has been mostly used in the context of facilitating pulmonary rehabilitation programs in the home. Evidence on its use is mixed. There were three RCTs identified. . Remote For heart disease, three systematic reviews and one RCT were identified . EvidencOverall, current evidence of the effectiveness of remote monitoring is limited in the neurologic, musculoskeletal, and diabetes populations; however, there is evidence that remote monitoring combined with therapeutic programming is comparable to traditional rehabilitation in cardiac rehabilitation and has significant benefits over usual care. However, the long-term outcomes need to be seen to better understand the impacts on long-term self-management, adherence, and implementation factors such as cost comparisons and uptake.Research is lacking on user experiences. Less than 10% of remote monitoring research explicitly examines patient experience and less than 2% measures clinician experience . StudiesAcross the board, the evidence of effectiveness in these technologies is lacking. A big challenge in technology is the lack of consistent reporting on the specific technological components, intervention dosing, and intervention components. Additionally, there is heterogeneity between studies in the outcome measures chosen and the specific subgroups of the patient population being tested . This combined with the wide variety of competitive types of different technology makes comparisons of technology studies difficult.The majority of research on these technologies heavily focuses on the development phase, with emphasis on reliability, validity, and intial testing. Follow-up research is mostly focused on the use of the technology in clinic settings with scarce research performed to determine the efficacy of these technologies specifically in the home and community. Remote monitoring for pulmonary and cardiac rehabilitation is an exception to this and rehabilitation services in the home have more readily been researched here. Furthermore, little is known about the technologies’ long-term efficacy for sustained behavior change at home and in the community, including the promotion of activity and participation in social roles.Service outcomes include areas such as the efficiency, timeliness, reimbursement, safety, and equity of the intervention. Of these service outcomes, safety in terms of adverse events was the only outcome assessed among studies in our efficacy review. Consideration of safety in a home setting is paramount for technology use in the home. Use of technology in both home and community settings means there is less supervision, and an individual is using technology in uncontrolled environments compared to a controlled clinic setting. Research is needed to ascertain the safety of these devices at therapeutic intensities in a home setting. Ethical and legislative concerns are also salient as the ability to track everyday movements at home calls for enhanced measures to ensure data privacy, security, and accountability for any adverse outcomes.Other service outcomes are necessary to evaluate how technology can fit into current healthcare systems. Early evidence on most of these technologies demonstrates that there is a comparable effect on the standard of care. If the clinical outcomes are comparable, then researchers must start to consider what interventions are preferable based on clinician/patient needs (see above) and what will work best, most efficiently, and most equitably for sustained healthcare delivery.Implementation outcomes are rarely assessed in technological research. This would include outcomes such as cost, the acceptability of an intervention to practictioners and clinicians, how feasibile adoption of the intervention is, and more. None of the reviewed studies commented on specific implementation strategies for adopting the technology into practice after the study period had ended. Cost is a major barrier to implementation for all technologies. However, while cost is commented on in most of the reviewed articles, only two of the included studies had cost comparison outcomes ,90. The The path to the implementation of rehabilitation technologies into practice is complex. While changes in clinical practice behavior are slow and effortful, changes in technological advancement are rapid. Technologies may be obsolete if it takes decades to adopt them into practice. Implementation science, defined as the “scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice” , could bOnce technology is developed and ready for efficacy testing, its efficacy can be evaluated while examining the alternative outcomes of its implementation and its readiness for adoption. Effectiveness–implementation hybrid study designs allow for aims that examine the efficacy of the technological innovation while examining the implementation outcomes in a real-world application context . Rather The suggested path of technological development to adoption is depicted in Lastly, implementation science supports an iterative approach to adopting any new evidence into practice. This includes revisiting after outcomes are evaluated to find new ways to improve and advance the technology to better suit the setting and clinician/patient needs.The purpose of our narrative review was to discuss the clinical need, current evidence, obstacles, and implementation strategies for future research on three promising technologies that could be used to augment physical functioning in the home setting. All the main disease groups reviewed have needs for long-term self-management and are at risk of functional decline. The technologies reviewed hold promise to sustain long-term adherence to evidence-based rehabilitation treatments in a home setting; however, effective evidence is still limited.Our review showed substantial literature pertaining to exoskeletons and VR among chronic neurological and musculoskeletal conditions, with limited applications of these technologies to other patient populations. Broadly, the use of exoskeletons in the neurological population has promise for improving gait, balance, and endurance, and VR improves dizziness among adults with vestibular disorders and may improve balance and mobility among people with strokes; however, the findings are mixed. Interestingly, Dijkers et al.  conducteAll technologies have formidable obstacles to adoption. The main challenges highlighted from our review were a lack of focus on clinician and patient needs, including usability, satisfaction, and preferences; limited effectiveness research across populations due to significant heterogeneity in outcomes, reporting, dosing, and technological components, and lack of reporting; a lack of health system outcomes, including equity, efficiency, timeliness, and reimbursement; and a lack of implementation outcomes, including acceptability, appropriateness, cost, fidelity, penetration, and sustainability. We recommend the use of hybrid effectiveness and implementation studies to assess the outcomes in all these domains to increase the uptake of technology in practice. Consistent with our findings, a systematic review by Mattison et al.  on the eTo our knowledge, this is the first review to combine a broad overview of the major technologies being utilized across the most prevalent chronic diseases worldwide. It is also one of the first to make meaningful suggestions and guidance on the implementation of rapidly changing technologies with hybrid effectiveness and implementation models. The World Health Organization (WHO) has outlined the primary goals for Rehabilitation 2030 , which iOur narrative review approach did not comprise the same level of rigor that is expected for systematic reviews, and as such, there are likely missed articles. Our approach was to undertake a broad descriptive review of technologies that have the potential to augment rehabilitation in a home setting in order to understand the nature of the field. A more in-depth critical review is warranted in several areas of this narrative review. Another limitation is that the scope of this review did not include all chronic disease populations. This was because we aimed to target the disease populations impacted by movement dysfunction the most and present most prevalently in rehabilitation clinics. Future research should evaluate other populations as well.Overall, the future of using rehabilitation technology to foster and track movement at home is promising; however, a lot of work remains. There are many applications across patient populations, and improving technology implementation has significant potential to bridge the gap between the home and the clinic and to foster long-term change. However, the current path of technology development and testing may be insufficient to integrate technology into practice. The focus must be shifted in technology research to include community partnerships early in development and utilize research methodology that integrates implementation, service, and equity factors. The notion of using rehabilitation technologies to bring rehabilitation approaches into the home is exciting, but will we sink or swim in this rapidly evolving field?


Androgen receptor (AR) expression is absent in 40–90% of estrogen receptor (ER)-negative breast cancers. The prognostic value of AR in ER-negative patients and therapeutic targets for patients absent in AR remains poorly explored.We used an RNA-based multigene classifier to identify AR-low and AR-high ER-negative participants in the Carolina Breast Cancer Study  and The Cancer Genome Atlas . We compared AR-defined subgroups by demographics, tumor characteristics, and established molecular signatures .AR-low tumors were more prevalent among Black (relative frequency difference (RFD) = +7%, 95% CI = 1% to 14%) and younger  participants in CBCS and were associated with HER2-negativity , higher grade , and higher risk of recurrence scores , with similar results in TCGA. The AR-low subgroup was strongly associated with HRD in CBCS  and TCGA . In CBCS, AR-low tumors had high adaptive immune marker expression.Multigene, RNA-based low AR expression is associated with aggressive disease characteristics as well as DNA repair defects and immune phenotypes, suggesting plausible precision therapies for AR-low, ER-negative patients. Androgen receptor (AR), which is expressed in approximately 30–60% of estrogen receptor (ER)-/progesterone receptor(PR)-/human epidermal growth factor receptor 2(HER2) + breast cancers and 10–53% of triple negative breast cancers , has emeSome of the technical discrepancies in protein-based AR-staining could be overcome with RNA-based measures of AR-dependent expression. Several groups have reported that non-luminal androgen receptor TNBC molecular subtypes that express AR at low levels demonstrate AR-dependence for tumor cell growth or viability–21. HoweThe Carolina Breast Cancer Study  is a population-based study of breast cancer that oversampled Black and younger women. Using gene expression data for 1202 CBCS participants, we trained a pathway-based classifier to identify AR-low patients and to examine the relationship between AR status and tumor aggressiveness among ER-negative participants. Results in CBCS were validated in TCGA.The Carolina Breast Cancer Study (CBCS) is a population-based study , 23 of whttps://gdc.cancer.gov/).The Cancer Genome Atlas (TCGA) is a large, publicly available data source containing extensive genomic data on over 30 cancer types. Study details are described elsewhere. For ourCharacterization of Androgen Receptor (AR) ExpressionOf the 4806 CBCS participants, 967 were excluded because they had no or too few available slides of FFPE cores for analysis, and 192 were excluded because they failed RNA extraction. Of these 3647 eligible samples, 2734 were selected for sequencing based on adequate coverage of additional sociological and pathological data by the CBCS bioinformaticist. Samples were split into 9 custom codesets, each containing a different mixture of genes from relevant biologic panels; some samples as well as some genes were included on multiple panels. In total, 1649 samples were included on a panel that profiled AR, 1202 (72%) of which passed quality control. Thus, AR RNA expression  was profiled in 1202 CBCS samples (472 ER-negatives), using a custom NanoString protocol optimized for formalin-fixed paraffin-embedded (FFPE) samples–27. To aTo identify features of AR-low tumors, we calculated relative frequency differences (RFDs) and 95% confidence intervals by fitting a generalized linear model with binomial distribution and identity link where AR status was the outcome and the variable of interest was the predictor. Because triple negative status may confound associations between AR and clinical presentation, we also computed models adjusted for triple negative status.To understand overlap between AR-phenotype and deficiencies in immune and DNA repair processes, we analyzed CBCS samples that had RNA expression data on both AR and immune or AR and DNA repair classes. However, because a relatively small number of samples profiled for AR also included information on RNA expression of DNA repair genes , we developed a predictor of AR phenotype to identify additional samples with low AR expression. To do this, we split the 472 ER-negative samples with measured AR expression into five groups (“folds”) using stratified random sampling, therefore ensuring consistent distribution of AR-high and AR-low samples within each fold. In each of five iterations of testing, we retained four of the folds for training  and omitted the last for validation , then repeatedly fit Classification to Nearest Centroid (ClaNC) models that used between two and 150 genes  to distinguish AR-low and AR-high tumors in the training set. For each of these 75 models, we estimated sensitivity, specificity, and the Youden’s index (sensitivity + specificity − 1) in the training and test sets. We selected the final number of genes to use in the classifier by finding the maximum Youden’s index, averaged across the five folds, among the training sets. From this final model, we predicted the AR status of all ER-negative samples, using predictions to calculate a final sensitivity and specificity. Finally, we applied the AR classifier to all ER-negative CBCS samples assayed for selected genes (N = 669) and proceeded to compare AR phenotypes to other molecular indicators, described below.Using custom panels of 50 immune-related and 51 DNA repair-related genes, we classified samples with respect to three immune classes  and two DNA repair classes (recombination/Fanconi anemia (HR/FA), and non-HR/FA) according to published methods.). As abWe used TCGA to validate associations between AR status and molecular tumor characteristics. After applying our ClaNC classifier of AR to ER-negative samples from TCGA, we used the composite Homologous Recombination Deficiency (HRD) Scoring method from Knijenburg et al to assesWe detected associations between single-gene AR RNA expression classes (high vs. low) and aggressive clinical features. RNA levels of AR were strongly correlated with AR protein as measured by RPPA  tumors with AR-low phenotypes. Again, AR-low tumors were more likely to be younger, Black, HER2-negative, grade III, stages II-IV, and have high ROR-PT scores (Supplementary Table 1) as also observed in the TCGA cohort (Supplementary Table 2). ER/AR-low tumors also showed strong evidence of aggressive molecular phenotypes, with 47.0% having enrichment for adaptive immune tumor subtypes, and 85.6% showing enrichment for homologous recombination-related genes  with AR-low phenotypes. AR-low tumors showed higher frequency of homologous recombination deficiency (HRD), with 81 (39.3%) having HRD scores above the clinical cutoff of 42 as compared to 11 (5.3%) of AR-high tumors. We did not find strong evidence of an association between AR and immune expression phenotypes in TCGA , although the TCGA lacks evidence of the immune quiet phenotype due to different selection factors for inclusion in TCGA (cite Hamilton). However, AR-low tumors again had higher proportions of expression-based HRD phenotypes than AR-high tumors .Unique disease features that distinguish ER-negative breast cancer patients by AR status for successful therapeutic targeting remains poorly understood as a result of limitations and inconsistencies with protein-based AR assessment approaches. Using CBCS expression data, we designed and validated a multigene classifier that distinguishes AR-low versus AR-high ER-negative breast cancers. AR-low status in ER-negative breast cancer was significantly associated with younger age at diagnosis, Black race, HER2-negativity, high-grade, and higher ROR; these associations remained significant after adjusting for TNBC status. These findings suggest that in ER-negative breast cancers, low AR expression is associated with aggressive disease. AR-low/ER-negative tumors occur more frequently in Black (versus white) women; consequently AR-low/ER-negative breast cancer may be important for understanding racial disparities in survival. Considering other biological phenotypes, AR-low cancers in the CBCS cohort exhibited adaptive immunity enrichment and both CBCS and TCGA data sets displayed significantly greater homologous recombination repair deficiency among AR-low cancers.et al. reported that women, under the age of 35 years, were diagnosed with AR-negative/ER-negative breast cancer more frequently than women over the age of 35 [Our findings are consistent with what has been previously reported for demographic factors. Park ectively). Severalectively), 32–34. ectively).et al. reported that AR-positivity is associated with longer relapse-free survival among HER2-negative patients[The prognostic role of low AR expression in TNBC remains controversial. Our findings provide evidence that AR-negative TNBC is associated with aggressive disease features such as advanced stage and high histological grade, 10, 11. patients. Wang an patients. Hence, Another distinction observed herein between AR-negative and AR-positive TNBC was with respect to immune profiles. Consistent with our findings, Davis and colleagues previously reported that AR-negative tumors are upregulated in T cell marker (CD4 and CD8), immune checkpoint , and immune cell signaling pathway marker  RNA expression compared to AR-positive tumors in TNBC. These fPrevious studies have not evaluated associations between AR and specific DNA repair pathways. We observed a higher prevalence of homologous recombination deficiency in AR-low (versus AR-positive) ER-negative-breast cancer. This finding is consistent with previous studies showing increased genomic instability in AR-negative (versus AR-positive) TNBC. It has been discovered that AR-negative TNBCs have 1) increased epidermal growth factor receptor, cyclin-dependent kinase 6, Ki-67, and topoisomerase 2a but 2) downregulated PTEN and HER4–53. It wA limitation of this study was the small number of ER-negative breast cancers, particularly TNBC. We also did not evaluate protein-level AR localization compared to our multigene classifier. However previous studies show that AR RNA-based signatures expression correlate with AR protein expression, 56. How


Augmented reality (AR) involves the overlay of computer-generated images onto the user’s real-world visual field to modify or enhance the user’s visual experience. With respect to neurosurgery, AR integrates preoperative and intraoperative imaging data to create an enriched surgical experience that has been shown to improve surgical planning, refine neuronavigation, and reduce operation time. In addition, AR has the potential to serve as a valuable training tool for neurosurgeons in a way that minimizes patient risk while facilitating comprehensive training opportunities. The increased use of AR in neurosurgery over the past decade has led to innovative research endeavors aiming to develop novel, more efficient AR systems while also improving and refining present ones. In this review, we provide a concise overview of AR, detail current and emerging uses of AR in neurosurgery and neurosurgical training, discuss the limitations of AR, and provide future research directions. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 386 articles were initially identified. Two independent reviewers (GH and AC) assessed article eligibility for inclusion, and 31 articles are included in this review. The literature search included original (retrospective and prospective) articles and case reports published in English between 2013 and 2023. AR assistance has shown promise within neuro-oncology, spinal neurosurgery, neurovascular surgery, skull-base surgery, and pediatric neurosurgery. Intraoperative use of AR was found to primarily assist with surgical planning and neuronavigation. Similarly, AR assistance for neurosurgical training focused primarily on surgical planning and neuronavigation. However, studies included in this review utilize small sample sizes and remain largely in the preliminary phase. Thus, future research must be conducted to further refine AR systems before widespread intraoperative and educational use. AR technology involves the superimposition of computer-generated images onto the user’s real-world visual field to modify or enhance the user’s visual experience. In medicine, AR has been utilized in various surgical subspecialties, including ophthalmology, general surgery, orthopedic surgery, urology, and oral and maxillofacial surgery for its ability to integrate computer-generated images with intraoperative visualization of the surgical field . The fieIt should be emphasized how the innate properties of AR facilitate enhanced neurosurgical training. In both cranial and spinal neurosurgery, AR systems are largely designed to project 3D images of cerebral or spinal anatomy onto realistic patient models to aid in neuronavigation and surgical planning. These superimposed images are either injected into the operative microscope or worn as a head-mounted display, allowing for easy and efficient use that does not impact on surgical technique or obstruct the view of the surgical field. As such, AR systems provide the opportunity for refined neuronavigation, assistance with identification of microscopic anatomic structures, improved surgical planning, and reduced operation times. These elements of AR effectively provide neurosurgeons with training materials that can improve surgical planning and surgical technique while simultaneously minimizing patient risk.It is important to note that many forms of AR utilized for intraoperative assistance and training remain largely in the emerging or preliminary phases, highlighting the need for continued research efforts before widespread clinical use. Nonetheless, AR has the potential to significantly improve and revolutionize the field of neurosurgery. Herein we discuss the current uses of AR in cranial and spinal neurosurgery, emerging pre-clinical studies, and future research indications.AR is a computer-based technology allowing users to overlay visual information in their field of view by combining real and virtual objects in the real environment, running in real-time, and connecting real and virtual objects . All thrUp to this point, AR platforms have been used in a variety of different industries, including the entertainment , automotWhile AR systems generate a virtual landscape, they are able to provide haptic feedback to trainees, allowing them to develop their skills . AR addiGiven the increasing prevalence of AR use within various surgical subspecialties, there exists a need to highlight recent applications of AR for intraoperative assistance during cranial and spinal neurosurgery. Furthermore, the potential for AR to be used as a teaching tool demonstrates an additional need to summarize recent advances in AR systems specifically for neurosurgery training programs. This systematic review aims to summarize recent applications of AR systems for intraoperative assistance in both cranial and spinal neurosurgery, as well as recent applications of AR assistance for neurosurgical training.A systematic literature search was performed in June 2023 using PubMed and following the guidelines of PRISMA. Customized queries included the following keywords with AND/OR operators entered into the search engine: AR, augmented reality, neurosurgery, cranial neurosurgery, spinal neurosurgery, and neurosurgical training. The search was limited to full-text original retrospective or prospective studies, or case reports published in English after the year 2013. The search was limited to studies published between 2013 and 2023 in attempts to provide the most up-to-date information, which we defined as studies published within the past 10 years. Article screening and inclusion eligibility was conducted independently by two different reviewers (GH and AC). Studies that evaluated the safety and efficacy of AR systems used for intraoperative assistance during cranial or spinal neurosurgery were included. Similarly, studies that evaluated the feasibility and efficacy of AR integration into education with respect to neurosurgical training were included. A total of 386 articles were initially identified based on our search strategy. After removing obviously irrelevant articles based on title alone, a total of 83 abstracts that fit the inclusion criteria were retrieved and screened. After screening abstracts and removing duplicate articles, 31 total articles published between 2013 and 2023 were identified and included in this review. Original (retrospective and prospective) research articles as well as case reports published in English were included in this systematic review .AR is primarily used in cranial neurosurgery to improve technical skills and assist in surgical planning , though Presently, AR is most commonly used in neurosurgery for neurovascular pathologies , followeIn addition to cerebrovascular surgery, AR has a variety of applications within the subfield of neuro-oncology. The clinical management of many cerebral malignancies typically involves surgical resection, where surgeons aim to maximize the total amount of tumor resected in a way that improves overall patient survival while also preserving neurologic functioning. AR has the ability to improve this process by aiding in neuronavigation, ultimately resulting in more complete tumor resections . To imprIn addition to offering assistance during surgery, AR has emerged as a valuable tool for neurosurgical training. This is because AR provides surgeons with training materials that minimize patient risk. For example, ventricular puncture is a common procedure performed in neurosurgical practice that involves creating an opening in the skull to provide ventricular access to treat ventricular pathologies. AR designed to project 3D images of cerebral anatomy over a 3D-printed patient model was able to improve surgical trajectory accuracy (n = 48 neurosurgeons), demonstrating that AR can be a safe alternative for neurosurgical training . ExternaAR has additionally been used as a valuable tool for training surgeons how to locate, navigate, and treat malignant lesions. A study by Montemurro et al.  investigAR in spine surgery is currently used for spinal fusions, vertebroplasty, kyphoplasty, neuro-oncology, and spinal deformity correction ,34. One Spinal deformity correction surgeries are complex procedures that require intensive preoperative planning and highly precise and accurate surgical technique. AR assistance for spinal osteotomy was first reported by Kosterhon et al. . In thisAR can be used to assist with surgical resection of malignant lesions present in the spine. Identification of malignant lesions within the spinal column is accomplished via surgical biopsy, and clinical management often involves surgical resection. As with cranial neurosurgery, surgical resection of malignant lesions within the spine must be conducted in a careful manner to ensure vital structures within the spinal column are not disturbed, as this could result in significant neurologic deficits. AR has the ability to enhance spinal tumor resection procedures by aiding neurosurgeons in tumor-outline visualization through the projection of preoperative CT and MRI images onto a heads-up display within the operating microscope . En blocAR has the ability to facilitate and enhance spine surgery training while also offering assistance in the operating room. As aforementioned, pedicle screw placement is commonly used to stabilize the spine during surgery and promote functional recovery post-operatively. Pedicle screw placement can be utilized in spinal fusion operations, where bones in the spine are permanently fused together to correct abnormal spine morphology, repair broken bones, or stabilize the spine to prevent movement. Following pedicle screw placement, rods are used to connect the pedicle screws, effectively preventing additional movement while simultaneously supporting the fusion of the target vertebrae . Rod manSimilarly to percutaneous vertebroplasty, percutaneous kyphoplasty involves the insertion and inflation of a balloon into the surgical space, and is designed to create a cavity before injection of bone cement . Both arAs demonstrated in our review of the recent literature, AR is rapidly evolving for use in neurosurgical procedures and neurosurgical training. However, despite technological advances in AR software and supporting hardware modalities, few randomized control trials have been conducted to evaluate patient outcomes in large cohorts, including outcomes related to postoperative complications and cost-effectiveness . A largeThere currently exist two available registered clinical trials investigating the use of AR in neurosurgery . One triSimilarly, many reports included in this review detailing the applications of AR for neurosurgical training remain largely in the early stages of development. More specifically, many forms of AR designed to assist with neurosurgical instruction and training currently reported in the literature focus on teaching scenarios in small sample sizes. AR systems designed to aid in surgical instruction in a highly realistic manner and with the ability to account for individual patient differences take a significant amount of time to develop and refine. The studies detailed in this systematic review ultimately suggest that the use of AR in neurosurgical training remains largely in the developmental stages. Once its use been refined, it would be valuable to conduct studies that evaluate the feasibility and efficacy of AR for assistance with neurosurgical training in a large group of neurosurgeons, each with varying skillsets and years of experience. In this way, it would be possible to better understand how AR can be utilized to train a diverse group of trainees to further refine AR-based training modalities.It is well established throughout the literature that AR has the potential to significantly improve neurosurgical practice through enhanced neuronavigation, improved surgical planning, and reduced operation times. The efficiency and enhanced operative experience that AR assistance offers neurosurgeons ultimately manifests in improved patient outcomes and cost-effective options for surgeons . In addiIt is important to note that the optimal utilization of AR exploits its ability to enhance surgical and training experiences, rather than relying exclusively on it for training, surgical planning, and neuronavigation. This is because despite the apparent benefits of AR-assisted neurosurgery, there are several limitations and challenges preventing translation to clinical practice. Furthermore, most of the studies currently reported in the literature utilize small sample sizes, which may not be fully representative of all patients receiving AR-assisted neurosurgery. For example, ensuring high accuracy and precision in the registration of virtual objects onto the patient’s cerebral anatomy is crucial. Introduction of AR into the operating room has the potential to distort surgical accuracy and precision due to impairments in surgeon depth-perception, visual and tactile asynchrony between the AR and the surgeon, tissue deformation, and technical inaccuracy in AR tracking systems. It is possible for structures in the brain to slightly shift once the skull is open, which can result in surgical errors if not accounted for. Future research directions should look at how AR can predict and account for these errors to further refine surgical practice. In addition, the hardware required for intraoperative AR use, including tracking devices and head-mounted displays, must be designed in a way that is ergonomic and capable of delivering high-quality information in real time. Hardware demands have the potential to serve as a barrier to clinical use, and future studies should be conducted to determine the optimal materials and setup needed to support AR use during surgery. AR systems often utilize a diverse mix of preoperative and real-time intraoperative imaging data. As such, it is possible for errors to arise when integrating different data forms, which may impose on surgical planning and neuronavigation. Similarly, seamless integration of AR into the surgical workflow is essential to ensuring surgical efficiency and optimal surgeon focus. Introduction of novel AR technology into the operating room has the potential to create technological barriers during surgery, which increase surgery time, distract the surgeons, and may negatively impact patient outcomes. To combat these challenges, neurosurgeons and the entire care-providing team must undergo significant training that covers learning new techniques, adapting to the augmented environment, and understanding the limitations of AR to become fully proficient with AR technology. Thus, it is important that future studies continue to focus on refining AR systems to make them more user-friendly to avoid complications during surgery, and on developing education efforts.The overall cost of AR technology can additionally serve as a barrier to clinical implementation, especially in smaller hospitals or clinics that may not benefit from significant research grants or large private donors. Adequate funding is necessary to maintain AR systems, including repairs, software development, hardware maintenance, and training. AR systems are constantly evolving, and significant monetary input is necessary to keep up with software and hardware advances. The use of AR in the intraoperative environment requires the presence of additional staff, such as engineers or software developers, to attend to technological issues that may arise during surgery. Without the presence of these staff members, surgical times can be delayed, AR systems can experience significant damage, and patient safety can be compromised. It should not be surprising to note that the cost of AR systems ultimately impacts their availability. The use of AR in neurosurgery remains largely in the preclinical phases, highlighting the need for continued research efforts before widespread clinical adoption. Many institutions currently utilizing AR in neurosurgery are conducting laboratory-based experiments and human clinical trials. Thus, institutions must possess sufficient funding to support these research efforts to ultimately refine AR systems before clinical implementation. Furthermore, if institutions lack the necessary funding to support the use of AR during surgery, it is possible that the AR software or hardware could become faulty, resulting in a significant financial loss. More importantly, the use of damaged AR systems or AR systems that are not properly maintained can pose a significant risk to patient safety. Accordingly, if institutions cannot afford to properly maintain AR systems and keep up with the advances in technology, they cannot utilize such systems during surgery without creating a significant risk of financial loss, equipment damage, patient morbidity, and patient mortality; this limits the overall viability of AR systems. This is a challenge that must be addressed as AR continues to develop and evolve to ensure all patients have access to the highest-quality neurosurgical care.Additional limitations preventing implementation of AR in neurosurgical training exist. For example, a major limitation of AR in neurosurgery is its inability to provide a fully realistic experience for trainees. This is of utmost importance, because although AR can be used to enhance neurosurgical training, neurosurgeons ultimately practice medicine on real patients. Accordingly, AR simulations for training must be designed in a way that creates a realistic visual and tactile experience to maximize surgical education. Similarly, it can be difficult to develop assessment tools and objective metrics that provide trainees with meaningful feedback. Future studies should investigate how to develop more realistic AR simulations for neurosurgical trainees to ensure surgical proficiency. Integration of AR training into the existing neurosurgical curriculum additionally poses a significant challenge. Careful planning and coordination with training programs and educational institutions is necessary to incorporate AR modules into training without disrupting or reducing the quality of pre-existing training modules. Furthermore, developing and providing access to high-quality AR training platforms specifically tailored for neurosurgery can be a challenge, especially for smaller or newer training programs that may lack substantial financial resources. Thus, it is imperative to address these challenges to ensure affordable and accessible AR training platforms to trainees. Finally, neurosurgical training programs must account for and accommodate the diverse range of skill levels and needs of training neurosurgeons. It can be difficult for AR to adapt to individual needs, which means that future research must be conducted to personalize and further refine the neurosurgical training process.In sum, AR has the potential to revolutionize neurosurgical training and practice. At this point in time, physician oversight is still necessary during neurosurgical training to ensure trainees are receiving the highest-quality training to provide the highest-quality care. More studies need to be conducted to further validate and verify the accuracy and reliability of current AR systems as well as to facilitate expansion to additional neurosurgical procedures.


Prostate cancer (PCa) constitutes a significant cause of mortality, with over 37,000 new deaths each year. It is also the most commonly diagnosed cancer in older men, with more than 288,000 new cases expected in the United States in 2023 . The andJillson et al.  conducteERG, ETV1, ETV4, and FLI1 [ERG with the androgen-regulated gene, TMPRSS2 [ERG can directly or indirectly regulate AR expression. The meta-analysis highlights the inverse relationship between AR and ERG, with the AR-normalized score in the ERG-TMPRSS2 fusion being near to or below the normal level. The authors also highlight the inconclusive effect of ERG fusion-positive PCa in response to AR-targeted therapy, as one study shows that fusion increases survival rates after ADT. In contrast, another study suggests that fusion might elicit a response to high-dose androgen therapy.The authors have begun by first investigating the most common individual genetic variations across three cohorts from the TCGA, the MSKCC, and BROAD. After that, they used the available RNA expression data to show the correlation between AR expression levels and individual variations. Those individual variations include ETS transcription factors such as and FLI1 , as well TMPRSS2 . It servMAP3K7 loss, its role in PCa progression, and how MAP3K7 loss affects AR activity. This study uncovered that the simultaneous loss of MAP3K7 and CHD1 resulted in the upregulation of AR activity. Moreover, MAP3K7 loss renders PCa cells more susceptible to DNA damage and cell cycle inhibitors by disturbing the homologous recombination process. Another frequent genetic variation is CHD1 loss, which increases AR activity and the resistance to AR-targeted therapy. This resistance is typically seen in AR antagonists and enzalutamide, but not in the androgen synthesis inhibitor, abiraterone. This suggests that a patient with CDH1 loss may benefit from androgen withdrawal treatment. These findings align with the results of a meta-analysis that shows that CHD1 is associated with higher AR scores, but not higher mRNA levels.In addition, this review delves into discussing SPOP. The authors revealed that a mutation in SPOP can lead to an increased expression of its targeted substrate. As AR and their cofactors are among those substrates, a mutation in SPOP can result in an increased AR expression level, as well as its cofactors in primary PCa. This positive correlation between mutant SPOP and AR suggests that patients with a mutation in SPOP might benefit from ADT, as well as having an enhanced sensitivity to HDAC3 inhibitors and BET inhibitors.The authors further discussed the interplay between AR and mutation in AKT as well as PIK3CA and PTEN deletion [AKT facilitates phosphorylates and marks AR for degradation, while AR stabilizes the phosphatases that suppress AKT, which is consistent with meta-analysis results. Therefore, targeting both AR and PI3K is recommended instead of solely targeting one or the other, which might lead to resistance. Additionally, the authors explored the delicate relationship between AR and TP53, emphasizing the pivotal role of TP53 in ensuring the functioning of AR. Their analysis has confirmed that a lack of TP53 may result in reduced AR activity, and may potentially impact efficacy in response to chemotherapy.Importantly, the authors delve into discussing the inverse relationship between AR and the PI3K pathway and its downstream, such as mutated or amplified deletion . AKT facRB1 and CDKN1B on AR activity and expression. Their findings suggest that RB1 loss results in an increase in AR activity, despite mixed results from meta-analyses that report overall average AR scores. Although CDKN1B has not been extensively explored in PCa, the authors uncovered evidence that CDKN1B loss is linked to average or above-average AR scores, and observed that CDKN1B deletion often occurs alongside other deletions in MAP3K7 and CHD1. In addition, they further discussed the role of FOXA1 in regulating AR. They demonstrated that FOXA1 mutation can either increase or decrease AR activity and expression. Nevertheless, the meta-analysis results show a slightly above-average AR activity.Moreover, the authors explored the impact of the cell cycle regulators PARP1, ATM, and BRCA1/2. However, increased DNA damage resulted in increased AR expression and activity, and vice versa. PARP1 and ATM deletion are associated with above-average AR activity; in contrast, the association between BRCA1/2 mutations and AR varies between cohorts. Hence, it is warranted to dual-inhibit AR and the DNA damage pathway to prevent resistance. MYC is a well-known oncogene that plays a crucial role in the development of cancer [MYC is found to be over-amplified in PCa and can drive the progression of PCa independently, even in the absence of AR. Consistently, the authors revealed the average AR expression and AR activity levels, implying that AR and MYC are independent. Consequently, MYC amplification can mitigate the effectiveness of AR-targeted therapy.Furthermore, the authors discussed the correlation between AR and DNA repair genes, such as f cancer . MYC is ERG/PTEN/TP53, MAP3K7/CHD1/SPOP, BRCA1/TP53, BRCA2/RB1, and ATM/PARP1, and examined the impact on the AR score and expression level. The first of these subtypes is MAP3K7/CHD1/SPOP, in which MAP3K7 and CHD1 co-deletion is common in primary PCa and is associated with an increased AR score, enzalutamide resistance, and increased AR splice variants. In addition, patients with lower expression exhibit an aggressive subtype and are associated with relapse after radical prostatectomy. In contrast, the co-occurring SPOP mutation with CHD1 and MAP3K7 deletion is associated with increased AR activity as well as sensitivity to baritone and DNA-damaging or -repairing agents. Next, the authors discussed the joint co-occurring ERG fusion with almost all other mutations, which indicates an early significant event in the development of primary PCa that confers a favorable trait for the progression of the disease. One subtype involves ERG fusion with PTEN and TP53. Although ERG and PTEN can individually have a negative effect on AR, the co-occurrence of ERG fusion and PTEN loss restores AR expression and enhances the resistance to the dual inhibition of PI3K and AR. Although PTEN loss in combination with a TP53 mutation is usually linked to promoting resistance to anti-androgen therapy due to the reduced AR expression and lineage plasticity, the co-occurring ERG fusion has the opposite effect by restoring AR expression and rendering PCa more sensitive to anti-androgen treatment.While individual genetic variation plays a significant role in the progression of PCa, it alone cannot fully explain the complexity of the disease or identify the distinct subtypes that determine a patient’s response to AR-targeted therapy. To address this, the authors have categorized PCa into five different subtypes based on the co-occurrence of at least two individual genetic variations, including PARP1 and ATM. Despite the individual deletion of PARP1 and ATM being associated with increased AR activity and expression, respectively, their co-deletion is associated with both increased AR activity and expression. Moreover, alterations in BRCA1 and BRCA2 are mutually exclusive, and commonly occur with various genetic variations, with BRCA1 tending to occur with TP53 deletion, resulting in decreased AR activity. In contrast, BRCA2 occurs with RB1 loss, resulting in average AR activity and AR expression levels, as well as enhanced resistance to ADT, mediated mainly by the epithelial–mesenchymal transition.Moreover, the authors have examined the effect of another subtype, including the significant co-loss of In this review, the authors investigate the effect of individual genomic variation, the joint effect of common, concomitantly occurring variations on AR activity and expression, and their role in primary PCa progression and responses to various treatment options. They further stratify primary PCa into five distinct subtypes. The authors revealed that individual as well as co-occurring alterations impact AR activity by either increasing activity and promoting survival, decreasing activity and facilitating lineage plasticity, or inducing genomic instability, which can lead to disease progression and affect responses to different treatments. This review presents a new viewpoint regarding the influence of genetic variation on a patient’s response to AR therapy. By pinpointing genetic variations that are significantly linked, it may be feasible to stratify patients and decide whether they will respond to AR treatment or require an alternative therapeutic regimen according to their genetic makeup. This personalized approach has the potential to result in more efficient therapies based on a patient’s genetic makeup.


Drosophila were constructed by building Mhc-GAL4/FOXO-UAS-overexpression and Mhc-GAL4/FOXO-UAS-RNAi system. The skeletal muscle and heart function, the balance of oxidation and antioxidant, and mitochondrial homeostasis were measured. The results showed that exercise reversed the age-related decline in climbing ability and downregulation of muscle FOXO expression induced by HSI. Muscle-specific FOXO-RNAi (FOXO-RNAi) and -overexpression (FOXO-OE) promoted or slowed the age-related decline in climbing ability, heart function, and skeletal muscle and heart structure damage, which was accompanied by the inhibition or activation of FOXO/PGC-1α/SDH and FOXO/SOD pathway activity, and oxidative stress (ROS) increased or decreased in both skeletal muscle and heart. The protective effect of exercise on the skeletal muscle and heart was blocked by FOXO-RNAi in aged HSI flies. FOXO-OE prolonged its lifespan, but it did not resist the HSI-induced lifespan shortening. Exercise did not improve HSI-induced lifespan shortening in FOXO-RNAi flies. Therefore, current results confirmed that the muscle FOXO gene played a vital role in exercise against age-related defects of the skeletal muscle and heart induced by HSI because it determined the activity of muscle FOXO/SOD and FOXO/PGC-1α/SDH pathways. The muscle FOXO gene also played an important role in exercise against HSI-induced mortality in aging flies.FOXO has long been associated with aging, exercise, and tissue homeostasis, but it remains unclear what the role is of the muscle FOXO gene in E against high-salt intake(HSI)-induced age-related defects of the skeletal muscle, heart, and mortality. In this research, overexpression and RNAi of the FOXO gene in the skeletal and heart muscle of  In both humans and animals, the health of the skeletal and cardiac muscles is critical to the quality of life of older individuals. There is no doubt that premature aging of the skeletal muscle leads to an increased risk of skeletal muscle disease . Age-relAging in the skeletal muscle and heart is accompanied by changes in many physiological factors, such as oxidative and antioxidant balance, mitochondrial homeostasis, and myofibrillar structure. FOXO regulates the aging by regulating these factors and shuttling from the cytoplasm to nucleus –13. E caDrosophila were constructed by building Mhc-GAL4/FOXO-UAS- overexpression and Mhc-GAL4/FOXO-UAS-RNAi system. Then, the skeletal muscle function and heart function , the balance of oxidation and antioxidant (SOD and ROS level), mitochondrial homeostasis , and myofibrils state (myofibrillary structure and Mhc level) were tested to further confirm whether FOXO in the skeletal muscle was involved in regulating E against ARD of the skeletal muscle and heart induced by HSI in Drosophila.Extensive overexpression of body FOXO in flies can prevent HSI-induced ARD of the skeletal muscle and mortality , 20, but1118 flies , the FOXO-UAS-overexpression (FOXO-UAS-OE) flies , and the MHC-gal4  flies were obtained from the Bloomington Stock Center. The FOXO-UAS-RNAi flies  was obtained from the Vienna Drosophila Resource Center.The wNormal food contained 1.6% soybean powder, 2.0% yeast, 6.7% corn meal, 0.7% agar, 4.8% sucrose, 4.8% maltose, and 0.3% propionic acid. Add 2% sodium chloride to normal food to make a high-salt food .When constructing the exercise device, the advantage of the flies’ natural negative geotaxis behavior was taken to induce upward walking . When flAll exercise groups, flies started exercise from when they were 2 days old and underwent a 5-week-long exercise program. All high-salt-intake flies started feeding high-salt food from when they were 2 days old and underwent a 5-week-long high-salt diet program.The test vials for monitoring flies’ climbing speed and climbing failure were the same as the vials for exercise training. The test vials were left 8 cm in length for the flies to climb. There is a light box behind the vials once flies were shaken to the bottom of the vials, a timed digital camera snapped a picture after 3 s. The height of the fly climbs was clearly shown on the photographs. Seven pictures of each group were taken and averaged to arrive at a fixed height for each vial, and each vial contained about 20–23 flies.A cohort of flies was observed during continuous stimulation by the exercise device. Flies were placed in the exercise device. Twenty flies were put into each vail. They were made to climb until fatigued. Fatigue was recognized as the failure that responded to a negative geotaxis stimulus with climbing behavior. The specific measurement protocol is referred to the study of Tinkerhess et al. .Flies were anesthetized with FlyNap for 2–3 min. The head, ventral thorax, and ventral abdominal cuticle were removed by special glass needles in order to expose the heart and abdomen. Dissections were done in the oxygenated artificial hemolymph . To get Dead flies were recorded daily. The lifespan was estimated for each fly as the number of days alive from eclosion to the day of death. The mean and median lifespan and survival curves were used to characterize the lifespan. The sample sizes were 200 to 210 flies per group .4 (30 min), and stained in 2% uranyl acetate (1 h). The samples were dehydrated in an ethanol series  and embedded in epoxy. Ultrathin Sects. (50 nm) were cut and viewed on a Tecnai G2 Spirit Bio-TWIN electron microscope [According to the electron microscopic analysis, the skeletal muscle and myocardium were dissected in ice-cold fixative . After 10 h of fixation at 4 °C, the samples were washed with 0.1 M PIPES, post-fixed in 1% OsOcroscope .The FOXO level, PGC-1α level, SDH level, SOD activity level, and ROS level were measured by ELISA assay . Twenty flies’ muscles and 80 hearts were homogenized in PBS (pH 7.2–7.4). The samples were rapidly frozen in liquid nitrogen and then maintained at 2–8 °C after melting. Homogenize the samples with grinders, and centrifugation was conducted for 20 min at 2000–3000 rpm. Then, we removed the supernatant. Assay: take the blank well as zero, and read absorbance at 450 nm within 15 min of adding Stop Solution.About 20 flies’ muscles and 80 hearts were homogenized in Trizol. 10 μg of the total RNA was purified by organic solvent extraction from the Trizol . The purified RNA was treated with DNase I , and it was used to produce oligo dT-primed cDNAs , which were then used as templates for quantitative real-time PCR. The rp49 gene was used as an internal reference for normalizing the quantity of total RNAs. The real-time PCR was performed with SYBR green using an ABI7300 Real-time PCR Instrument (Applied Biosystems), with 3 biological replicates. Expression of the various genes was determined by the comparative CT method . Primer sequences of FOXO were as follows: F: 5′-AACAACAGCAGCATCAGCAG-3′; R: 5′-CTGAACC CGAGCATTCAGAT-3′. Primer sequences of PGC-1α were as follows: F: 5′-TGTTGCTGCTACTGCTGCTT-3′; R: 5′-GCCTC TGCATCACCTACACA-3′. Primer sequences of Mhc were as follows: F: 5′-TGCGTTGCCATCAATCCT-3′; R: 5′-GTAGGCAC CGTCAGAGATGG-3′. Primer sequences of Rp49 were as follows: F: 5 -CTAAGCTG TCGCACAAATGG-3′; R: 5′-AACTT CTTGAATCC GGTGGG-3′.P values for lifespan curves and climbing endurance curves were calculated by the log-rank test. Analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 16.0 for Windows , with a statistical significance set at P < 0.05. Data are represented as means ± SEM.Independent-sample tests were used to assess differences between the 1-week-old flies and the 7-week-old flies. The 1-way analysis of variance (ANOVA) with least significant difference (LSD) tests was used to identify differences among these groups. 1118 flies. The system overexpression of FOXO in flies can prevent HSI-induced premature aging of the skeletal muscle. The increased FOXO/SOD pathway activity plays an important role in mediating E resistance to HSI-induced impairment of climbing capacity, heart defects, and longevity in aging Drosophila [Our previous studies have been confirmed that HSI caused premature aging in wosophila , 20. How1118 wild flies. The results showed that at the age of 5 and 7 weeks, HSI significantly decreased the time to fatigue (TTF) and climbing index (CI) of w1118 flies (P < 0.05 or P < 0.01)    , but E significantly upregulated the relative FOXO expression of the skeletal muscle in HSI flies (P < 0.01)            Fig. C, D and 05) Fig. F. At the01) Fig. E. At the01) Fig. A, D and 05) Fig. F. Aging 01) Fig. E and F. 05) Fig. A, B, but05) Fig. C, D. Agi01) Fig. E, F.Fig.P < 0.05 or P < 0.01)    Fig. A to I. M01) Fig. J. Finall01) Fig. A to I. M01) Fig. J. In add05) Fig. A to I. M05) Fig. J.Fig. 3TP < 0.05 or P < 0.01)   , heart period (HP), diastolic diameter (DM), fractional shortening (FS), FOXO expression level, PGC-1α expression level, SDH protein level, and SOD activity level (01) Fig. A to K. M01) Fig. L. In ord01) Fig. A to K. M01) Fig. L. To con05) Fig. A to K. M05) Fig. L.Fig. 4TThese results confirmed that the improvement of E in HSI-induced ARD of the skeletal muscle and heart can be blocked by FOXO-RNAi through inhibiting their FOXO/SOD and FOXO/PGC-1α/SDH pathways.To further confirm the role of the muscle FOXO gene in E against ARD induced by HSI, FOXO-OE flies were subjected to E and HSI interventions.P < 0.05)                 Fig. A to I. M01) Fig. J. Beside05) Fig. A to I. M05) Fig. J. What i01) Fig. A to I. M01) Fig. J. Furthe01) Fig. A to I. M01) Fig. J.Fig. 6TP < 0.05 or P < 0.01)     Fig. A to K. I01) Fig. L. In old05) Fig. A to K. M05) Fig. L. In old01) Fig. A to K. M01) Fig. L. In old01) Fig. A to K. M01) Fig. L.Fig. 7TThese results confirmed that the improvement of E in HSI-induced ARD of the skeletal muscle and heart can be further enhanced by FOXO-OE through further activating their FOXO/SOD and FOXO/PGC-1α/SDH pathways.P < 0.01). The lifespan of FOXO-RNAi + HSI flies was significantly shorter than that of FOXO-RNAi flies (P < 0.001). The lifespan of FOXO-RNAi + HSI flies significantly increased after exercise training (P > 0.05) . The lifespan of FOXO-OE + HSI flies was significantly shorter than that of FOXO-OE flies (P < 0.001). The lifespan of FOXO-OE + HSI + E flies was significantly longer than that of FOXO-OE + HSI flies (P < 0.05)  Fig. A. Moreov05) Fig. B.Fig. 8TThese results suggested that FOXO-OE prolonged the lifespan of flies, but it did not resist the HSI-induced lifespan shortening. E combined with overexpression of FOXO in muscle improved the longevity in HSI flies. FOXO-RNAi decreased the lifespan of flies, and it further decreased longevity when combined with HSI. E improved HSI-induced lifespan shortening in FOXO-RNAi flies. Therefore, the muscle FOXO gene played an important role in E against HSI-induced lifespan shortening.the FOXO gene seems to delay the aging process. For example, alpha-ketoglutarate can extend lifespan in flies remarkably by upregulating mRNA expression of FOXO, Sirt1, and AMPKα [Drosophila [In flies, overexpression of nd AMPKα . Korean osophila . Moreoveosophila . Moreoveosophila . Phosphoosophila . Next, oosophila . Furtherosophila . Motor nosophila . TherefoIn this study, we found the muscle FOXO gene played a key role in regulating the aging of the skeletal muscle, and some of these findings were similar to those of other researchers. Besides, the muscle FOXO gene also played a key role in HSI-induced ARD of the skeletal muscle and heart, and it also played a key role in E against ARD of the skeletal muscle and heart. More importantly, we also found that the muscle FOXO gene played a key role in E against HSI-induced ARD of the skeletal muscle and heart. Their mechanism is related to the regulation of the FOXO activity on muscle FOXO/PGC-1α/DSH and FOXO/SOD pathways.Drosophila homolog PGC-1α is sufficient to increase mitochondrial activity. PGC-1α mutants show mitochondrial respiration defects when complex II of the electron transport chain is stimulated. PGC-1α mediates mitochondrial activity, cell growth, and transcription of target genes in response to insulin signalling [In flies, PGC-1α plays an important role in regulating the function of the skeletal muscle and cardiac muscle since PGC-1α is required for the expression of multiple genes encoding mitochondrial proteins. For instance, it has been reported that the reduction of PGC-1α expression levels in flies acutely compromises negative geotaxis ability and reduces exercise-induced improvement in both negative geotaxis and time to exhaustion. Conversely, muscle/heart-specific PGC-1α overexpression improves negative geotaxis and cardiac performance in unexercised flies . Besidesgnalling . Moreovegnalling . Finallygnalling . Aging dgnalling . Increasgnalling .FOXO is involved in the regulation of oxidation and antioxidant balance, which is closely related to aging in flies. For example, the activation of c-Jun N-terminal kinase (JNK) signaling in neurons increases stress resistance and extends life span in part through FOXO-mediated transcription in Drosophila. JNK/FOXO signaling extends life span via the amelioration of oxidative damage and the mitochondrial dysfunction in neurons , 41. BesIn wild-type flies, exercise training delays muscle aging while HSI promotes muscle aging. For instance, about 2.0 and 2.5 h of exercise per day displayed a reduced incidence of fibrillation events. Only doing physical exercise continuously for a 2.5-h period increased fractional shortening and total sleep time in Drosophila . Both noFinally, these results suggested that the muscle FOXO expression played an important role in the resistance of exercise training to HSI-induced lifespan shortening. Overexpression of the muscle FOXO gene prolonged the life of flies, but it did not resist the HSI-induced lifespan shortening. Exercise training combined with overexpression of FOXO improved the longevity in HSI flies. Muscle FOXO RNAi decreased the lifespan of flies, and it further decreased longevity when combined with HSI. Exercise training improved HSI-induced shortening of lifespan in muscle FOXO RNAi flies. The skeletal muscle and heart are very important organs for mammals or fruit flies, and their pathological changes are important factors leading to the death of elderly individuals. Increasing or decreasing the skeletal muscle and heart function can reduce or increase mortality in elderly individuals , 46, 47.Current results confirmed that the muscle FOXO gene played a vital role in E against ARD of the skeletal muscle and heart induced by HIS because it determined the activity of muscle FOXO/SOD and FOXO/PGC-1α/SDH pathways Fig. . The mus