Drosophila larval eye imaginal discs to identify FoxO targets that restrict the proliferation of Tsc1-deficient cells under nutrient restriction (NR). Transcriptomics analysis revealed downregulation of endoplasmic reticulum-associated protein degradation pathway components upon foxo knockdown. Induction of ER stress pharmacologically or by suppression of other ER stress response pathway components led to an enhanced overgrowth of Tsc1 knockdown tissue. Increase of ER stress in Tsc1 loss-of-function cells upon foxo knockdown was also confirmed by elevated expression levels of known ER stress markers. These results highlight the role of FoxO in limiting ER stress to regulate Tsc1 mutant overgrowth.The transcription factor FoxO has been shown to block proliferation and progression in mTORC1-driven tumorigenesis but the picture of the relevant FoxO target genes remains incomplete. Here, we employed RNA-seq profiling on single clones isolated using laser capture microdissection from  Drosophila melanogaster  and the tuberous sclerosis complex (TSC) proteins Tsc1 and Tsc2. Pten counteracts the function of PI3K by dephosphorylating the second messenger phosphatidylinositol-3,4,5-triphosphate (PIP3) to phosphatidylinositol-4,5-biphosphate (PIP2) (The phosphatidylinositol 3-kinase (PI3K)/Akt/mechanistic target of rapamycin complex 1 (mTORC1) network is the central regulator of cell growth, survival, and metabolism . mTORC1 nogaster . In Drose (PIP2) , therebye (PIP2) . The TSCe (PIP2)  via its e (PIP2) . Anothere (PIP2) . Howevere (PIP2) . This une (PIP2) .Drosophila, we have shown that the loss of Tsc1 leads to an enhanced overgrowth of eye imaginal discs in larvae raised under nutrient restriction (NR)  . This ovDrosophila eye imaginal disc is composed of different populations of mitotically active and differentiating cells. Given the context and cell-type specificity of FoxO  12 hr before dissection, and complementary control clones were isolated from siblings raised at 25°C. Analysis was done on 29 samples that passed quality control. Clustering on normalized gene counts showed high variability among the biological replicates  in the Tsc1 mutant clones . The knockdown phenotypes of the candidates from the in vivo assays are shown in The top candidate from all genetic tests was the uncharacterized gene CG6766, encoding an ortholog of the mammalian endoplasmic reticulum lectin 1 (ERLEC1). It is predicted to localize to ER/Golgi and is considered to be a component of the ubiquitin-dependent ERAD pathway . AnotherDrosophila, the induction of ER stress response in cells mutant for CG6766 was investigated. A mutant allele carrying a piggyBac insertion with a splice-acceptor site and stop codons in all frames in the first intron of the gene , were examined. Control or CG6766 knockdowns were generated in wild-type, weak Tsc1 knockdown, and strong Tsc1 knockdown backgrounds. Quantitative reverse-transcription PCR (RT-qPCR) analysis on eye imaginal discs revealed no change in the expression levels of spliced-Xbp1 or Hsc-70–3 in the wild-type background upon knockdown of CG6766. By contrast, the expression levels of both ER stress reporters were elevated in Tsc1 knockdown backgrounds  redundant function, and may also explain why CG6766 (as well as CG8860) has not been characterized so far.Since the function of the top candidate in ER homeostasis is not characterized in the gene  was usedegulator  that is egulator . Eye imal clones . To examkgrounds , indicatTsc1 mutant tissues, ERAD components other than the genes identified by the transcriptomics analysis were knocked down using the same genetic assay  . These sergrowth , indicatTsc1 knockdown overgrowth by using non-genetic means was tested. The inhibition of N-linked glycosylation by Tunicamycin  and Ire1  in 1 L water. NR food was prepared by reducing the amount of yeast to 10% with 1.5% nipagin (100 g/L in ethanol). The following small molecule inhibitors were added to the NR food before pouring into vials for the drug assay: DMSO , Tunicamycin , Thapsigargin , MG132  and Eeyarestatin I .Analysis on adult flies was done on females in all experiments. Larvae were not selected for sex. The age of adults and larvae are mentioned in the corresponding Figure legends and Materials and methods.hsFLP , FRT82 iso , tstub-Gal80 (BDCS Cat #7108), RNAi of CG1315 (VDRC ID# 47097), RNAi of foxo (VDRC ID# 1077896), RNAi of Tsc1 (BDSC Cat# 35144), RNAi of Tsc1 , RNAi of Obp56e (VDRC ID# 3355), RNAi of Mco3 (VDRC ID# 43288), RNAi of mah , RNAi of CG9896 , RNAi of CG15282 (VDRC ID# 7712), RNAi of CG42749 , RNAi of Hsp22/CG4456 , RNAi of clos , RNAi of CG40472 (VDRC ID# 109239), RNAi of CG10424 (VDRC ID# 39667), RNAi of Fili , RNAi of CG43313 , RNAi of CG6766 , RNAi of CG2865 (BDSC Cat# 43165), RNAi of Ant2 (VDRC ID# 102533), RNAi of Ptp4E , RNAi of Hexo1 , RNAi of grnd , RNAi of Rpt5 , RNAi of CG8860 , RNAi of Edem1 (VDRC ID# 6923), RNAi of α-Man-Ia (VDRC ID# 100654), RNAi of α-Man-Ib (VDRC ID# 4419), RNAi of Pdi (VDRC ID# 23359), RNAi of prtp (VDRC ID# 106924), RNAi of Ssrβ (VDRC ID# 12101), RNAi of Sec61α (VDRC ID# 109660), RNAi of Sec61β (VDRC ID# 107784), RNAi of Sec61γ (VDRC ID# 100603), RNAi of CG13426 (VDRC ID# 107528), RNAi of TRAM (VDRC ID# 39187), RNAi of Der-1 , RNAi of Der-2 (VDRC ID# 108440), RNAi of sip3 , RNAi of Hrd3 (BDSC Cat# 62368), RNAi of CG40045 (VDRC ID# 109167), RNAi of PEK , RNAi of Gcn2 (VDRC ID# 32664), RNAi of eIF2α (VDRC ID# 104562), RNAi of Atf6 (VDRC ID# 36504), RNAi of wfs1 (VDRC ID# 108932), RNAi of Ire1 , RNAi of Cul1 (VDRC ID# 108558), RNAi of SkpA (VDRC ID# 107815), RNAi of STUB1 (VDRC ID# 107447), RNAi of p47 (VDRC ID# 107148), RNAi of Csp (VDRC ID# 34168), RNAi of TER94 (VDRC ID# 24354), RNAi of Ufd1-like (VDRC ID# 24700), RNAi of CG4603 (VDRC ID# 21894), RNAi of Plap (VDRC ID# 110732), RNAi of Ubqn , RNAi of CG10694 (VDRC ID# 100212), RNAi of Rad23 (VDRC ID# 104354), 140290CG6766 (Kyoto DrosophilaGenetic Resource Center ID# 140290), UAS-Xbp1-EGFP (BDSC Cat# 60730).The following fly lines were used: CD2>Gal4 , eyFlp g gl-LacZ , Act>CD2RT82 iso , FRT82 f foxo∆94 , FRT82 cT82 cl w+, tub-GalDrosophila Genomics Resource Center (Cat#1). Cells were cultured in Schneider’s medium (Gibco) with 10% Fetal Bovine Serum and 500 U/mL Penicillin-Streptomycin at 24°C.Kc167  cells were obtained from Eye imaginal discs were dissected in HBSS and mounted in a 0.5 µL drop of HBSS on FrameSlide PET (Carl Zeiss AS). Single clones of approximately 50 cells were microdissected using a Zeiss PALM-Microdissection system and captured into the caps of AdhesiveCap (Carl Zeiss AS) microcentrifuge tubes. The samples were frozen in liquid nitrogen and stored at −80°C until RNA isolation.Drosophila genome (BDGP6) using STAR (Tsc1 mutant discs (RNA isolation and cDNA library preparation from the LCM samples were done according to the Ovation SoLo RNA-seq Systems kit (NuGEN Cat#0502–32). The sequencing was performed at the Functional Genomics Center Zurich on a HiSeq 2500 System (Illumina). Reads were mapped to the ing STAR , counteding STAR , and difing STAR . Gene Oning STAR , and GSEing STAR  was run nt discs  as well nt discs  in correCG1315 was used as control for RNAi experiments and FRT82 iso was the control for clones generated using mitotic recombination.Flies were crossed for two days on normal food. For assays using imaginal discs, the flies were transferred to egg laying chambers and allowed to lay eggs on agar plates containing yeast overnight. For clone induction, a 11 min (for LCM) or 15 min heat shock at 37°C was applied 36 hr AEL, after which the L1 larvae were transferred to normal food or NR. For adult fly eye measurement and eclosion assays, crosses were set up on normal food for 3 days followed by transfer of flies to NR for 3 days. Adult flies were analyzed 3 days after eclosion. Adult females were frozen at −20°C 3 days after eclosion. The flies were mounted on agar plates containing charcoal. The right-side eyes were imaged on a KEYENCE VHX1000 digital microscope.Eye imaginal discs were dissected 108 hr AEL from normal food and 156 hr AEL from NR. The discs were fixed in 4% paraformaldehyde ), washed thrice in 0.3% Triton-X in PBS , blocked in 2% Normal Donkey Serum in 0.3% PBT , incubated with primary antibodies , washed thrice in 0.3% PBT , incubated with secondary antibodies , washed thrice in 0.3% PBT , stained with DAPI in 0.3% PBT , and washed once with PBS . The samples were mounted on glass slides in VECTASHIELD (Vector Laboratories H-1000). Confocal images were obtained on a Leica SPE TCS confocal laser-scanning microscope.The following antibody dilutions were used: rabbit anti-FoxO , mouse foxo was prepared as described earlier , 120 mM NaCl, 20 mM NaF, 1 mM benzamidine, 1 mM EDTA, 6 mM EGTA, 15 mM Na4P2O7, 1% Nonidet P-40, and protease inhibitor cocktail ) and incubated on ice for 30 min. Thereafter, the lysates were cleared by centrifugation at 14000 g at 4°C for 15 min.dsRNA against EGFP (control) or  earlier  using prProtein concentrations were measured by BCA Protein Assay (Thermo Fischer Scientific). Proteins were denatured by boiling for 7 min in sample loading buffer and 40 µg of proteins were analyzed by immunoblotting. Briefly, proteins were resolved by 4–8% SDS-PAGE followed by transfer onto 0.45 µm nitrocellulose membrane. After blocking, primary antibodies were incubated overnight at 4°C and immunoblot signals were detected after secondary antibody incubation using enhanced chemiluminescence (ECL).RpS23. Primer sequences are described in Cell pellets were processed as described in Materials and methods. For eye discs, larvae were dissected in HBSS. 30 discs were collected and frozen in liquid nitrogen. RNA was isolated using RNeasy Plus Micro kit (QIAGEN). After reverse-transcription with SuperScript III First-Strand Synthesis System (Thermo Fisher Scientific), qPCR was performed using LightCycler 480 SYBR Green I Master (Roche) on a Rotor-Gene 6000 (Corbett). Gene expression levels were normalized to the expression level of p values are described in the Figure legends. All plots were generated in R Studio, and Figures were assembled using Adobe Illustrator.Adult eye area was measured using ImageJ . Ratio o In the interests of transparency, eLife publishes the most substantive revision requests and the accompanying author responses.Acceptance summary:Tsc1 and FoxO in a Drosophila tumor model. This builds on previous work showing that when Drosophila larvae are raised under nutrient restrictive conditions, simultaneous loss of both Tsc1 and FoxO results in an overgrowth phenotype. Data are provided here that in a Tsc1 mutant background, FoxO limits cell proliferation to restrict mutant overgrowth. The study also finds down-regulation of genes associated with the ER stress response pathway in FoxO deficient cells and knockdown of putative FoxO target genes in Tsc1-deficient cells also induces ectopic growth. This leads to the conclusion that the ER stress response pathway is a key FoxO-regulated pathway that impacts growth control downstream of Tsc1.This study examines the genetic interaction between Decision letter after peer review:eLife. Your article has been reviewed by three peer reviewers, and the evaluation has been overseen by a Reviewing Editor and Utpal Banerjee as Senior Editor. The reviewers have opted to remain anonymous.Thank you for submitting your work entitled "FoxO suppresses endoplasmic reticulum stress to inhibit growth of Tsc1-deficient tissues under nutrient restriction" for consideration by The manuscript has some issues that need to be addressed before acceptance. As you will see from the reviewer comments, all found the work to be interesting, but also raised some points that we felt would be straight forward to address in a revised manuscript.Reviewer #1:Tsc1 and FoxO in a Drosophila tumor model. Previous studies in the fly demonstrated that when Drosophila larvae are raised under nutrient restrictive conditions, simultaneous loss of both Tsc1 and FoxO in the eye imaginal disc results in an overgrowth phenotype. In an effort to identify the FoxO target genes that contribute to this phenotype, they use laser capture microdissection combined with RNAseq to identify those genes that are differentially regulated in cells lacking FoxO. The resulting analysis reveals a significant down-regulation of genes associated with the ER stress response pathway in FoxO deficient cells. Moreover, these genes appear to be important for the FoxO/Tsc1 phenotype because RNAi of these putative FoxO target genes in Tsc1-deficient cells also induced ectopic growth. Similarly, the use of small molecules to induce ER stress enhanced the size of eyes lacking Tsc1.This study by Gupta and Stocker uses a transcriptomics approach to examine the genetic interaction between Tsc1 overgrowth phenotype, suggesting that this is a key FoxO-regulated pathway in the context of growth control. However, I have a few criticisms that should be addressed:Overall, I found this to be a short, but potentially interesting manuscript. The use of mosaic analysis combined with laser capture microdissection for conducting RNA-seq is a powerful approach. In addition, I was impressed by the fact that down-regulation of the ER stress response enhance the 1) The text repeatedly refers genes mis-regulated in the RNAseq analysis as FoxO targets. However, there is no FoxO binding analysis to prove such an assertion and the text should be modified accordingly.2) Several of the genes that are classified as being part of the ER stress response have not been characterized in flies . The authors should verify that RNAi-depletion of these candidate genes induce ER stress using either the Cnx99a antibody or by examining expression of spliced Xbp1 transcripts.3) In paragraph two of the Results you speculate about the reason why snoRNAs are up-regulated in the RNAseq data. Since there are no experiments examining why snoRNAs are mis-regulated in the dataset, most of this text should be moved to the Discussion.Reviewer #2:foxo normally functions to limit tsc1 mutant epithelial cell clone growth and when foxo is removed, these clones show massive overgrowth. The interpretation from this work was that, in a tsc1 mutant background, foxo may be functioning to limit cell proliferation to restrict tsc1 mutant overgrowth. In this paper, Gupta and Stocker now use transcriptomics to identify FoxO regulated genes that may explain this function of FoxO.This paper follows on from a previous report from the Stocker lab showing that tsc1 mutant cells is a novel finding that will be of broad interest to researchers in the field of cell growth and proliferation (not just in flies).They use a very nice LCM technique to isolate cell clones, which presumably removes potential caveats and confounds in expression data associated with tissue disruption/FACS sorting, which is often used as a way to isolate pure populations of cell clones from imaginal discs. In addition, the finding that alteration in ERAD genes may explain the effects of FoxO on growth and proliferation of 1) Results, paragraph one: It's strange that the RNA-seq showed no FoxO knockdown. The conclusion is that the lack of detection of FoxO knockdown is due to biological variability. And the authors show an example of partial mRNA knockdown achieving strong protein knockdown in Kc167 cells. However, the eye disc data show no knockdown at all. Is it possible that the LCM technique may not be accurately just isolating the knockdown clones? Based on the schematic in Figure 1, can the authors use presence/absence of GFP transcripts to clearly delineate that have isolated purely the clonal cells?2) The discovery that regulation of ER stress and ERAD genes may explain the effects of FoxO is interesting. These finding would certainly be in line with the known links between Tsc1, FoxO and the control of ER stress. One thing I thought was missing was a little more investigation and explanation of how the ER stress genes are interacting with Tsc1 to control cell proliferation – the data in Figures 2, 3 do show changes in eye size, but is it clear that these effects are on cell proliferation ? And if they are, what might be the mechanism? As it stands the paper reads as an initial (but still very nice) functional validation of RNA-seq data rather than an in-depth mechanistic investigation into how FoxO and Tsc1 function to control tissue growth.Reviewer #3:Drosophila. The results reveal regulation of the ER stress response by FoxO along with other targets. The model system used is excellent, because it enables full FoxO activation in growing clones of cells in the eye, which is achieved by mutating TSC to activate a TOR negative feedback loop to suppress Akt, thereby activating FoxO. This roundabout method is essential because simply blocking Akt or over activating FoxO normally kills cells. Overall, I found the results robust, important and of interest to the field.This manuscript is a huge technical achievement, applying cutting edge clonal techniques to identify FoxO target genes in 1) Title could be shorter. No need to mention TSC.2) Introduction ought to more carefully and fully explain the TOR negative feedback loop on Akt that means full FoxO activation upon loss of TSC. Reviewer #1:[…] However, I have a few criticisms that should be addressed:1) The text repeatedly refers genes mis-regulated in the RNA-seq analysis as FoxO targets. However, there is no FoxO binding analysis to prove such an assertion and the text should be modified accordingly.Tsc1 mutant cells upon foxo knockdown.The reviewer is right. We have modified the text to correctly refer to those genes as genes downregulated in 2) Several of the genes that are classified as being part of the ER stress response have not been characterized in flies . The authors should verify that RNAi-depletion of these candidate genes induce ER stress using either the Cnx99a antibody or by examining expression of spliced Xbp1 transcripts.Drosophila Genetic Resource Center). Calnexin staining of homozygous mutant clones showed similar staining pattern compared to the surrounding wild-type tissue and the isogenic control clones . We then examined the expression levels of spliced-Xbp1 and Hsc-70-3 to observe the effect on the upregulation of ER stress response. Control or CG6766 knockdowns were generated in wild-type, weak Tsc1 knockdown and strong Tsc1 knockdown backgrounds. qRT-PCR analysis on eye imaginal discs revealed no change in the expression levels of spliced-Xbp1 or Hsc-70-3 in the wild-type background upon knockdown of CG6766 . By contrast, the expression levels of both ER stress reporters were increased in the Tsc1 knockdown backgrounds, indicating that CG6766 is limiting to maintain ER homeostasis in Tsc1 mutant cells.We investigated the induction of ER stress response in cells mutant for the top candidate CG6766. We used a mutant allele carrying a piggyBac insertion with a splice-acceptor site and stop codons in all frames in the first intron of the gene  redundant function. This may also explain why CG6766 has not been characterized so far.3) In paragraph two of the Results you speculate about the reason why snoRNAs are up-regulated in the RNAseq data. Since there are no experiments examining why snoRNAs are mis-regulated in the dataset, most of this text should be moved to the Discussion.We agree with the reviewer. The text relating to the upregulation of snoRNAs has been moved to the Discussion.Reviewer #2:[…]1) Results paragraph one: It's strange that the RNA-seq showed no FoxO knockdown. The conclusion is that the lack of detection of FoxO knockdown is due to biological variability. And the authors show an example of partial mRNA knockdown achieving strong protein knockdown in Kc167 cells. However, the eye disc data show no knockdown at all. Is it possible that the LCM technique may not be accurately just isolating the knockdown clones? Based on the schematic in Figure 1, can the authors use presence/absence of GFP transcripts to clearly delineate that have isolated purely the clonal cells?foxo mRNA in the foxo RNAi samples. In addition to the biological variability, we suspect the presence of a transcriptionally-activating feedback upon foxo knockdown as mentioned in the manuscript. An effect on translational capacity could also explain the loss of FoxO protein  with no effect on the transcript levels .We were also puzzled by the unaltered levels of foxo mRNA levels. We don’t think that contamination is a major issue in our experiments. The most straightforward test for a contamination of the clonal tissues would be to measure the GFP expression levels (as suggested by the reviewer). Unfortunately, a direct comparison is not possible because, in order to maximize the number of biological replicates, we did not sequence GFP-positive clones. However, we compared the GFP expression levels in cells with and without foxo knockdown. As an example, the expression level in Tsc1 mutant clones isolated from normal feeding conditions is shown in Tsc1 mutant clones with and without foxo knockdown are presented to support that the isolated cell populations were negative for GFP . This is further substantiated by the presence of 100% mutant transcripts  in the Tsc1 mutant clones . Taken together, it is very unlikely that the isolated clonal samples were contaminated with surrounding non-clonal cells.The reviewer is concerned that contamination with non-clonal tissue could account for the high 2) The discovery that regulation of ER stress and ERAD genes may explain the effects of FoxO is interesting. These finding would certainly be in line with the known links between Tsc1, FoxO and the control of ER stress. One thing I thought was missing was a little more investigation and explanation of how the ER stress genes are interacting with TSC1 to control cell proliferation – the data in Figures 2, 3 do show changes in eye size, but is it clear that these effects are on cell proliferation ? And if they are, what might be the mechanism? As it stands the paper reads as an initial (but still very nice) functional validation of RNA-seq data rather than an in-depth mechanistic investigation into how FoxO and Tsc1 function to control tissue growth.Tsc1 mutant tissue overgrowth upon induction of ER stress  is due to increased proliferation or cell size, we analyzed the density of ommatidia in adult eyes. Since the loss of Tsc1 does not disrupt ommatidial architecture , the density of ommatidia reflects the cellular density in the adult eyes. This density remains unchanged between Tsc1 and Tsc1 foxo knockdown eyes but is slightly reduced upon knockdown of CG6766 and CG8860  cannot fully account for the observed overgrowth . We therefore conclude that the overgrowth is in part caused by more cells.To address if the d CG8860 , indicatIn the Discussion, we speculate about the mechanisms of how ER stress response pathways can regulate proliferation. These are reinforced by the results presented in Figure 4.We agree with the reviewer that our manuscript represents an initial analysis to describe a link between FoxO and ER stress response. We are confident that it will serve as a strong foundation for future studies aiming at elucidating the exact mechanism of regulation of ER stress by FoxO and the effects on growth.Reviewer #3:[…]1) Title could be shorter. No need to mention TSC.Tsc1 mutant cells. The manuscript does not address a generalized function of FoxO in regulating ER stress.We are aware that the title is rather long and complicated. However, the identification and analysis of differentially regulated genes were based on clonal populations of In our opinion, it is more accurate to mention in the title that our findings are specific to Tsc1-deficient tissues.2) Introduction ought to more carefully and fully explain the TOR negative feedback loop on Akt that means full FOXO activation upon loss of TSC.Tsc1 mutant cells.The text in the Introduction has been revised to explicitly state the negative feedback to insulin signaling in hyperactive mTORC1 cells and to describe the nuclear localization and activation of FoxO in


Allergic rhinitis (AR) is a common medical condition worldwide. It is an inflammation in the nasal mucosa due to allergen exposure throughout the year. Laryngopharyngeal reflux (LPR) is another medical condition that can overlap with AR. LPR can be considered an extra oesophageal manifestation of gastro-oesophageal reflux disease (GORD) or a different entity. Its diagnosis imposes a real challenge as it has a wide range of unspecific symptoms. Although AR and LPR are not life-threatening, they can severely affect the quality of life for years and cause substantial distress. Moreover, having AR is associated with having asthma which is also in turn associated with GORD. This is a cross-sectional study which used surveys distributed online on Social Media and targeted people across Syria. All participants who responded to the key questions were included. Reflux symptom index (RSI) was used for LPR, and score for allergic rhinitis (SFAR) was used for AR. Demographic questions and whether the participant had asthma were also included in the survey. We found that there was an association between the symptoms of LPR and AR p < 0.0001 , and their scores were significantly correlated (r = 0.334). Having asthma was associated with LPR symptoms p = 0.0002  and AR p < 0.0001 . We concluded that there was a significant association between having LPR, AR, and asthma. We need more studies to distinguish between their common symptoms and aetiologies. LPR can be considered an atypical presentation of gastro-oesophageal reflux disease (GORD) or a different entity3. In Syria, 31.9% suffered of LPR symptoms4. Asthma association with GORD can be explained by the coughing and increased intra-abdominal pressure in asthma which may induce GORD symptoms. On the other hand, gastric reflux can directly damage pulmonary tree, causing bronchoconstriction9.Laryngopharyngeal reflux (LPR) occurs when the reflux of gastric contents reaches the upper aerodigestive tract without having heartburn or regurgitation10. AR prevalence ranges from 5 to 22% worldwide11. Moreover, a survey in the Middle East found that 10% of responders had AR12. However, AR symptoms were found in around half of the population in one study in Syria13. Although AR is not life-threatening, it affects the quality of life and predisposes to multiple airway conditions17. AR and asthma can be viewed as two corresponding airway diseases as they have common characteristics18. AR has a wide variety of symptoms including sneezing, nasal itching, rhinorrhoea, and nasal congestion/obstruction20. A causal link between GORD and AR was not established, and only a few studies indicated an association21. However, as AR and LPR have many symptoms in common from the irritation of the aerodigestive tract, they may be associated with one another which was suggested by many studies regardless of having asthma23.Allergic rhinitis (AR) is one of the most common diseases worldwide; it is an inflammatory medical condition that occurs in the nasal mucosa due to allergens exposure28 to assess LPR symptoms, and score for allergic rhinitis (SFAR)30 to assess AR symptoms. We aim to determine the association between LPR, AR, and asthma.In this study, we used reflux symptom index (RSI)This is a cross-sectional study that was conducted in Syria. Online surveys were used to cover the largest population possible. Surveys were distributed to different Social Media groups that covered different topics. Demographic questions were asked such as gender, and age. People from across all Syria could participate. We included any person who accepted to participate, lived Syria, and answered key questions. The surveys were posted multiple times during the day in March in 2019. No medical diagnosis or follow-ups were conducted.This study protocol was approved by faculty of medicine Damascus University deanship ethical committee. All methods were performed in accordance with the relevant guidelines and regulation and in accordance with the Declaration of Helsinki. STROBE guidelines were used in this study.Informed consent was taken for participating in the research, and for using and publishing of the data.28. RSI is a self-administered questionnaire which relies on a scoring system for symptoms that evaluates the possibility of LPR25. RSI is a nine-item scale questionnaire about symptoms suggestive of LPR as shown in the tables. The scale ranges from 0 when answering “no problem” to 5 when answering “severe problem” to each item. The total score ranges from 0 to 45 and the cut-off point was set to 13 or more to suggest the possibility of having LPR-suggestive symptoms.We used a form of RSI which was validated in Arabic30. SFAR is a structured scoring system that has eight questions about symptoms of AR, the personal and familial history of allergy, and allergy tests. These questions are shown in the tables. SFAR score ranges from 0 to 16 and positive answers earn points which can be added, and the cut-off point was set to 7.We also used the Arabic version of SFAR, a simple self-reported toolWe directly asked about having asthma as we could not perform medical diagnose to the participants. The survey included basic demographics, a question whether or not the participant had asthma, and RSI and SFAR questions. We could not follow-up with medical examination or investigation. We could not determine when the symptoms overlap, and therefore bias could not be reduced.Data were processed using IBM SPSS software version 26 for Windows . Chi-square, independent t-test, and odds ratios (ORs) were used for categorical variables while Pearson correlation coefficient was used for continuous numeral variables. Values of less than 0.05 for the two-tailed p values were considered statistically significant. Any participant with missing data in key questions was eliminated.31.A previous version of this manuscript was published as a preprintThis study included 673 subjects, of which 170 were males and 503 were females with a mean age of 23.9 ± 6.6 years. It was found that 341 (50.7%) had AR, 212 (31.5%) had LPR symptoms, and 44 (6.5%) had asthma. In subjects with AR, 38 out of 341 (11.1%) had asthma. In subjects with LPR symptoms, 25 out of 212 (11.8%) had asthma. This was demonstrated in  and SFAR mean score was 6.72 ± 3.560 . SFAR, and RSI scores according to one another and to asthma are demonstrated in  and demonstrated in Fig. .23. AR and allergic laryngitis (AL) can have similar manifestations32. Epigastric burning sensation, chest pain, and indigestion were the most common symptoms of LPR in Syria while having a sore throat was the least common4. AR symptoms can include sneezing, nasal itching, rhinorrhoea, and congestion20. As AR/AL and LPR can have overlapping symptoms, distinguishing them was proven difficult in one small study19. However, AR and LPR symptoms can overlap and the most common symptoms would be repeated throat cleaning, and a globus sensation22.This association between LPR and AR in our study is similar to other studies23. This common effect on the mucosa could explain the association between LPR and AR.The frequent swallowing with AR is due to the itching sensation and post-nasal drip. This frequent swallowing would also increase due to the reflux. Furthermore, nasal mucosa will be affected by AR which leads to LPR as AR causes the mucosa to be congested, oedematous, and increases mucous secretions35. One theory explaining this phenomena was that Helicobacter pylori, which is usually found in the gastric mucosa and promotes heartburning, could exist in the sinonasal cavity36. Another theory associated GORD with bronchial spasm37. However, one study suggested that GORD would only worsen nasal symptom scores but did not cause chronic rhinosinusitis34.This association could also be explained similarly to the explanation of GORD and AR as they are among the main causes of chronic cough; moreover, increased reoccurrence of the cough with reflux symptom has been reported in patients with GORD and in those without symptoms of GORD who have rhinitis, indicating that other factors contribute to the development of chronic cough. In addition, the coexistence of GORD and chronic rhinosinusitis (CRS) were reported by multiple studies38. Nevertheless, in another study, an association between pH Ryan score and total SFAR score was found, which could be related to LPR22.However, although study data showed that placebo can be as effective as PPI therapy, empirical treatment with PPI is still recommended40. Many of the diagnostic methods cannot be used in Syria due to the limited resources as over 80% of the population is under poverty line and most research does not have a proper funding42. Non-instrumental methods can also be used such as RSI and the reflux finding score (RFS)25, but they cannot be used as the gold standard to diagnose LPR as they are based on symptoms.LPR diagnosis can be much more complicated with many methods from interviews to challenging treatment methods as LPR has many vague and unspecific symptoms such as throat clearing, globus pharyngeus, and hoarseness43. This can justify using questionnaire-based tools as their accuracy is acceptable and much cheaper than diagnostic tests, especially in developing countries.The diagnosis of AR is based on a detailed clinical history and skin prick test. Serum specific IgE to the whole allergen extracts or components could be used as second- and third-line tests, respectively. The association between the clinical evaluation and the results of the mentioned tests is crucial for a correct diagnosis13.We found that having AR and LPR symptoms were significantly associated with having asthma. The association between AR and LPR persisted when including subjects with no asthma. However, there was no association between AR and LPR when only including subjects with asthma, but our study only had 44 subjects with asthma which might not have detected the association. Our study found that having either asthma or AR was associated with a 6.8-fold increase in the incidence of the other. We also found that having either asthma or LPR was associated with a 3.1-fold increase in the incidence of the other. A study in Syria found that asthma, allergies, and respiratory conditions were associated with having LPR symptoms44. One study found that about 25% of patients who had AR also had asthma. Having asthma was also associated with having a much higher incidence of AR45. Several previous studies found that having AR or asthma was associated with a threefold increase of having the other and that AR diagnosis was mostly made before asthma presentation47.As the larynx exists in a critical location that connects upper and lower airways which have a similar microscopic structure, it is suggested that having a disease in one portion of this system would affect the entire respiratory system48.Socioeconomic status was not studied as it is hard to accurately determine the financial situations in Syria due to rapid changing, different living expenses, and asking directly for month salary being inappropriateWe do acknowledge that our study has many limitations that need to be addressed. The small sample size, for asthma in particular, could be limiting. No clinical diagnosis was made, and only self-reported methods were used which may overestimate the symptoms and render the answers to be subjective. Subjects who do not have online access could not participate. We could not target the population at risk. This study included more females than males and included relatively young participants which may affect the generalizability of the results. The cross-sectional method is also limiting as causality cannot be determined.13. Moreover, 61.2% of Syrians had moderate to severe mental distress, and 60.8% had symptoms of post-traumatic distress disorder (PTSD)41. School students were also affected as 53% had PTSD symptoms and 62.2% had problematic anger48. All the previous factors can contribute to the high prevalence of symptoms of LPR and AR. We need more studies to accurately determine these associations as LPR and AR have many common factors that can be confounding when detecting their association. Finally, there is a lack of studies about many medical conditions and risk factors in Syria. Furthermore, war and the unique environment of Syria impose different risk factors to many medical conditions which can also be the case for LPR and AR49.The common symptoms of the aerodigestive tract can be misleading and misdiagnosed as either AR or LPR. Moreover, smoking, asthma, mental distress, and allergies may cause the same symptoms by various ways. In Syria, LPR had a prevalence of 31.9% and AR had a prevalence of 47.9%. They were both associated with asthma, allergies, distress from war, and smokingIn conclusion, many studies had contradicting data about LPR and AR as their definition and methods of diagnosis may differ and overlap. LPR, AR, and asthma are significantly associated with one another which may be attributed to common symptoms and aetiologies. Our study found that having symptoms suggestive of LPR was associated with having AR (OR = 2.6), and a significant positive correlation was found when comparing their scores (r = 0.334). Having asthma was associated with LPR symptoms (OR = 3.1) and AR (OR = 6.8). We need more detailed methods for diagnosis of AR and LPR which both have high prevalence, and better management of these conditions may improve the quality of life for a very large population for years.


BACKGROUND AND PURPOSE: Hyperglycemia can lead to an increased rate of apoptosis of microglial cells and to damaged neurons. The relation between hyperglycemia and cerebrovascular markers on MRI is unknown. Our aim was to study the association between intraoperative hyperglycemia and cerebrovascular markers.METHODS: In this further analysis of a subgroup investigation of the BIOCOG study, 65 older non-demented patients (median 72 years) were studied who underwent elective surgery of ≥ 60 minutes. Intraoperative blood glucose maximum was determined retrospectively in each patient. In these patients, preoperatively and at 3 months follow-up a MRI scan was performed and white matter hyperintensity (WMH) volume and shape, infarcts, and perfusion parameters were determined. Multivariable logistic regression analyses were performed to determine associations between preoperative cerebrovascular markers and occurrence of intraoperative hyperglycemia. Linear regression analyses were performed to assess the relation between intraoperative hyperglycemia and pre- to postoperative changes in WMH volume. Associations between intraoperative hyperglycemia and postoperative WMH volume at 3 months follow-up were also assessed by linear regression analyses.RESULTS: Eighteen patients showed intraoperative hyperglycemia (glucose maximum ≥ 150 mg/dL). A preoperative more smooth shape of periventricular and confluent WMH was related to the occurrence of intraoperative hyperglycemia . Other preoperative cerebrovascular markers were not related to the occurrence of intraoperative hyperglycemia. Intraoperative hyperglycemia showed no relation with pre- to postoperative changes in WMH volume nor with postoperative WMH volume at 3 months follow-up.CONCLUSIONS: We found that a preoperative more smooth shape of periventricular and confluent WMH was related to the occurrence of intraoperative hyperglycemia. These findings may suggest that a similar underlying mechanism leads to a certain pattern of vascular brain abnormalities and an increased risk of hyperglycemia. Hyperglycemia occurs frequently during surgery and has been related to poor clinical outcome such as acute kidney injury, cognitive impairment and increased rates of wound infection resulting from compromised immune functioning As changes in brain structures may develop before cognitive decline becomes noticeable, detection of markers indicating neuronal damage is of particular interest. Studies in older individuals in the general population using magnetic resonance imaging (MRI) showed an association between hyperglycemia and a larger number of brain infarcts and more white matter hyperintensities (WMH) Studies investigating the relation between intraoperative hyperglycemia and cerebral markers on MRI are scarce. In our previous study, we found no association between intraoperative hyperglycemia and pre- to postoperative volume changes of the hippocampus and the hippocampal subfields, the frontal lobe, and frontal cortical thickness This is a further subgroup analysis of a previously published cohort Baseline demographic data and medical parameters including preoperative MMSE, prior history of diabetes, preoperative blood glucose levels and HbA1c were assessed before surgery. Blood samples were obtained preoperatively to determine fasting blood glucose levels. Perioperative parameters  were retrospectively recorded by chart review. Postoperative measures including length of intensive care unit stay, total length of hospital stay, and incidence of postoperative infections were documented. Intraoperative glucose minimum, maximum and mean were determined. As maintenance of a blood glucose level < 150 mg/dL is recommended in septic patients, where blood glucose levels above 150 mg/dL have been associated with cerebral damage, we defined hyperglycemia by at least one blood glucose measurement ≥ 150 mg/dL 3), a 3D susceptibility weighted gradient echo MRI sequence (SWI) , a fluid-attenuated inversion recovery sequence (FLAIR) , and a 2D EPI pseudo-continuous arterial spin labeling (pCASL) sequence . Presence of cortical, subcortical and lacunar infarcts was visually rated on the T1-weighted and FLAIR images by two experienced neuro-radiologists (JB and TW) according to the standards for reporting vascular changes on neuroimaging (STRIVE) criteria Participants were scanned on a 3T Magnetom TrioTim  MRI scanner. The MRI scanning protocol comprised a 3-dimensional T1-weighted sequence  for Matlab . WMH segmentations were performed on the registered 3D FLAIR images by the lesion prediction algorithm  of the lesion segmentation toolbox version 2.0.15  for SPM12. For longitudinal (pre- to postoperative) WMH volume analysis, volumes were calculated from the probabilistic WMH segmentations. Segmentation of the lateral ventricles was performed on the T1-weighted images using the automated lateral ventricle delineation toolbox (ALVIN) for SPM8. To classify the WMH segmentations, probabilistic WMH segmentations were thresholded at 10%. WMH within 10 mm from the lateral ventricles into the white matter were considered periventricular WMH. WMH that extended from periventricular to more than 10 mm into the deep white matter were considered confluent WMH. WMH that were located >10 mm from the lateral ventricles were considered deep WMH. If present, cortical infarcts were manually delineated by a trained researcher (IK) and removed from the WMH segmentations. Baseline WMH volumes and WMH shape markers were calculated from the thresholded WMH segmentations Determination of WMH volume and WMH shape have previously been described http://www.neuro.uni-jena.de/cat/index.html#About). CBF images were motion corrected and registered to the probabilistic gray matter volume maps. The CBF images were quantified with a single compartment model, after which the mean CBF was obtained for a total gray matter perfusion. All images were checked for image quality by a researcher (IK). Images that were classified as a good CBF contrast were used in the perfusion analysis. The no contrast images that contained noise only or large artifacts were excluded from further analysis.ASL images were processed with ExploreASL Baseline, intraoperative and clinical outcome data are expressed as median , or frequencies (%), respectively. Differences in frequencies were tested by the Chi-Square-test. Differences between groups in terms of continuous parameters were tested by using non-parametric Mann-Whitney-U test for independent groups.To assess the relation between preoperative cerebrovascular markers and intraoperative hyperglycemia, we performed multivariable logistic regression analysis adjusted for age and sex. The WMH shape marker analyses were also performed additionally adjusted for WMH volume, to assess whether the observed associations were independent of WMH volume. The regression analysis for WMH volume was additionally adjusted for total intracranial volume. We analyzed whether the occurrence of intraoperative hyperglycemia was associated with pre- to postoperative changes in WMH volume by linear regression analyses adjusted for age, sex, preoperative WMH volume and total intracranial volume. The association between intraoperative hyperglycemia and postoperative WMH volume at 3 months follow-up was studied by a linear regression model adjusted for age, sex and total intracranial volume at follow-up. In case of non-normally distributed data, all values were multiplied by 10,000 and then log transformed using the natural logarithm. IBM© SPSS© Statistics (version 25) was used for all analyses. A two-tailed P value ≤ 0.05 was considered to indicate statistical significance.Sixty-five patients were included into our analyses. Overall, 173 blood glucose levels were obtained ; p = 0.050] independent of age and sex. However, this association attenuated after additionally adjusting for WMH volume  ; p = 0.280; n=41] while adjusting for age, sex, baseline WMH volume and total intracranial volume. Three patients developed new cerebral infarcts at 3 months follow-up, two patients without intraoperative hyperglycemia and one with intraoperative hyperglycemia. As these numbers were too low, no comparative analyses were performed. Patients with intraoperative hyperglycemia showed no difference in postoperative WMH volume at the 3 month follow-up compared to patients without intraoperative hyperglycemia .We showed that a preoperative more smooth shape of periventricular and confluent WMH was related to the occurrence of intraoperative hyperglycemia. Other preoperative cerebrovascular markers were not related to the occurrence of intraoperative hyperglycemia. Intraoperative hyperglycemia showed no relation with pre- to postoperative changes in WMH volume nor with postoperative WMH volume at 3 months follow-up.To the best of our knowledge, our study is the first to study the association between WMH shape markers and hyperglycemia in the perioperative context. Few previous studies have been performed that assessed the shape of WMH in relation to clinical outcomes. In one previous study, de Bresser et al. found higher eccentricity of deep WMH in a frontal and parietal location in patients with diabetes compared to healthy controls Our results point out the relevance of investigating cerebrovascular markers in identifying patients who are vulnerable to intraoperative and postoperative adverse outcomes, such as hyperglycemia The majority of previous studies on the influence of hyperglycemia on other cerebrovascular markers have only assessed patients with diabetes Our findings might have clinical implications. There is evidence that hyperglycemia is associated with adverse clinical outcome, poor cognitive outcome in particular The strengths of our study are the prospectively collected MRI data including a follow-up at 3 months as well as the advanced assessment of WMH volume and shapes. Some limitations of the present study need to be mentioned. First, our study is limited by a relatively small cohort including only patients aged ≥ 65 years. Second, part of the data including intraoperative blood glucose measurements was obtained retrospectively, bearing the risk of missed patients who had hyperglycemia. Third, patients with intraoperative blood glucose measurement were potentially undergoing more extended surgery with a higher risk to develop intraoperative hyperglycemia or had more severe underlying conditions warranting intensive glycemic control and thus creating a potential selection bias in our dataset.In conclusion, our study is the first to investigate the association between cerebrovascular markers and intraoperative hyperglycemia. We found that a preoperative more smooth shape of periventricular and confluent WMH was related to the occurrence of intraoperative hyperglycemia. These findings may suggest that a similar underlying mechanism leads to a certain pattern of vascular brain abnormalities and an increased risk of hyperglycemia.Supplementary table S1.Click here for additional data file.


Digitalization of production environment, also called Industry 4.0 (the term invented by Wahlster Wolfgang in Germany) is now one of the hottest topics in the computer science departments at universities and companies. One of the most significant topics in this area is augmented reality (AR). The interest in AR has grown especially after the introduction of the Microsoft HoloLens in 2016, which made this technology available for researchers and developers all around the world. It is divided into numerous subtopics and technologies. These wireless, see-through glasses give a very natural human-machine interface, with the possibility to present certain necessary information right in front of the user’s eyes as 3D virtual objects, in parallel with the observation of the real world, and the possibility to communicate with the system by simple gestures and speech. Scientists noted that in-depth studies connected to the effects of AR applications are presently sparse. In the first part of this paper, the authors recall the research from 2019 about the new method of manual wiring support with the AR glasses. In the second part, the study (tests) for this method carried out by the research team is described. The method was applied in the actual production environment with consideration of the actual production process, which is manual wiring of the industrial enclosures (control cabinets). Finally, authors deliberate on conclusions, technology’s imperfections, limitations, and future possible development of the presented solution. The current world-class challenge is to sustain or increase production capacity of a higher quality with fewer inputs in order to reduce time, cost, and equally enhance planning productivity , which As noted by scientists from the German Research Centre for Artificial Intelligence (DFKI—Deutsches Forschungszentrum für Künstliche Intelligenz), a significant research area in the Industry 4.0 topic is to find the most convenient human-machine interaction interface  headset, or simply, the AR glasses . PereirThe AR applications are presently used in numerous domains, ranging from industrial engineering to clinical services, field repairs, and lifestyle management . From tRecently, the AR glasses with a noninvasive single-channel brain-computer interface has been analyzed as a wearable monitoring system for inspection in the framework of Industry 4.0  . In the The importance of the potential in using AR glasses has been identified by several research institutions. For example, researchers from the University of Oxford and Graz University of Technology noted that the effects of AR applications on key performance process indicators are sparse . The usThe abovementioned, brief literature review involves various solutions and research on AR technology. These topics have been indicated, in order to emphasize the validity of the application of mentioned solutions and, at the same time, the diversity of their applicability. The review of the literature indicates a deficiency in research and publications related to some applications of AR technology. The application of AR is one of the core interests of the authors, especially in regard to control cabinet assembly.One of the most significant topics in AR is creating real-life applications. High interest in various areas connected to production can be observed. In the case of this research, the process of wire, wire harness, and cable assembly are considered. The research in this field has been developed since the 1990s  . It is nThe authors of the article noticed the possibility of using AR technology in the distinctive production of control cabinets. The wiring assembly is one of the key elements and the most time-consuming operation of the analyzed production process, which is carried out manually by skilled technicians. The assembly is based on repeated manual activities, which are a time-consuming factor in the entire production process. Taking into account the nature of the analyzed process, the purpose of the research presented in the article is to discuss the possibility of using the proprietary support system, based on the AR glasses at the stage of wiring assembly in control cabinets. On the other hand, the research problem is to verify whether the use of the AR system in this process contributes to the reduction of the wiring time and whether in the work of the operator, wearing the AR glasses is not inconvenient, so it would not jeopardize the possible reduction of assembly duration. The authors formulated the following hypothesis: The convenient human-machine interface based on the AR support system should allow a user to save time on performing the manual wiring production process, without causing considerable discomfort or difficulties in performing the task, in comparison to performing the same tasks in the process without using such support system. Application of the AR support system as a solution requires testing and verification, which are essential before driving such a solution to the market.The first AR demo application, supporting the manual wiring task in the control cabinet production process, with use of newly released AR glasses, Microsoft HoloLens ver.1, was presented as a top innovation by Szajna A. from the Digital Technology Poland company during the world’s biggest industry trade fair as Hannover Messe in 2017. The presentation included a demonstration of the device to domestic authorities of Germany (Chancellor) and Poland (Prime Minister) who were present at the official opening ceremony  .The solution was described to some extent in 2018, together with a brief description of AR technology  . This paIn The process of industrial enclosure assembly, which results as a control cabinet, consists of two main steps: (1) the design of an electrical and wiring diagram to fulfill the specification and (2) the assembly of all the parts together. Assembly divides into another two steps, which are (2a) attachment of components and (2b) wiring them according to the designed diagram (wiring scheme). The design of the diagram in the first step is carried out in an E-CAD/CAD system (E-CAD—electronic computer-aided design), also referred to by professionals as EDA , as preUp to the year 2016, the process of manual wiring and wiring harness assembly was performed based on an extensive paper printed documentation, depicting electric schemes and a way of wire connections . A highManual wiring has undergone a breakthrough, when Schall J.H. presented the idea of a wiring support system in 2015 during the Hannover Messe trade fair .Step 1: Selection of a wire to be assembled from the list; reading information and interpreting the 3D graphics of the entire wiring diagram in order to know how to route and assemble the wire.Step 2: Zooming in  the graphics in order to learn the exact (first) connection point; connection of the first wire end.Step 3: Zooming out  the graphics to recall the wiring route; leading the wire through the wire ducts.Step 4: Zooming in  the second connection point and connecting the second wire ending.The exemplary 4-step usage of the ESW support system is shown in These four simple steps assure the clarity and ease of use of the application, even for less qualified employees.Introduction of the Microsoft HoloLens in 2016  provideWhen the AR glasses became available for developers at the turn of the years 2016 and 2017, Szajna, A. envisioned and designed the method of an AR support system for manual assembly of wires and wire harnesses, based on the previously developed ESW system. Shortly afterward, together with the engineering R&D team, the elaboration of the method’s implementation was launched. It took several more months to develop the prototype, namely DTPoland AR Smart Wiring 4.0 system, with two patent applications EP000003392987  and PL0The DTPoland AR Smart Wiring 4.0 system, presently still in the prototype phase, as aforementioned in the paper by Szajna et al. (2019)   augmenting the real-world environment. Touch screen with the manual wiring support system (it is a market available solution without the use of any AR prototype).Assembly frame.Wire holder .The prototype.The control cabinet production station consists of several devices and the prototype , such asIt is worth mentioning that some users/operators find it more convenient to use the prototyped AR system with the physical touch screen instead of the virtual one, benefiting from buttons on the touch screen and virtual pointers, indicating the connection points, at the AR glasses. Such hybrids, giving a possibility of interactions between the real and virtual worlds, are known as tangible AR  and proAn industrial enclosure (which will form a control cabinet as the result of the production process) with components and wire ducts assembled in the previous production step;A set of pre-produced wires, cut to the pre-defined length ;A digital CAD project input file for the wiring support system.In the production station a user gathers the following elements in order to start a wires assembly process: The AR glasses enriches the viewed scene with virtual images, i.e., pointers, arrows, and additional images with markings for even better support. The DTPoland AR Smart Wiring 4.0, being a significant part of the station, gives benefits from the interaction between the real and virtual worlds through the application of the aforementioned additional virtual elements, visualized as shown in Step 1: A CAD file is loaded to the wiring support system  a virtual screen or (b) a physical touch screen.Step 3: A user collects a wire with the appropriate length from a wire holder.Step 4: The software related to the AR glasses uses certain coordinates provided by 3D graphics in the ESW, along with particular markers on a cabinet and a matching algorithm, in order to indicate the particular wire’s assembly points through virtual arrows, pointers, virtual images with markings, or textual prompts.Step 5: A user indicated with a simple gesture or a voice command on the virtual touch screen that assembly of this particular wire is completed—otherwise, a user is able to report issues to management in real-time and/or create an adequate note. Alternatively, a user can use a physical touch screen to perform these actions.Step 6: A user collects the next wire and repeats the operations within the process.The system is designed in order to support the assembly of wires between components in a control cabinet. The system operation process proceeds as follows:The diagram in One of the biggest challenges of the presented system’s application was the synchronization of the EWS 3D graphics with the corresponding physical industry enclosure/image being seen by the operator. Based on the computer vision tracking techniques, model-based tracking methods were applied to a dynamic coordinates’ adjustment loop. However, based on the situations where CAD data were incomplete or sometimes even misleading, physical markers were essential to enhance this part of the system . SzajnaA key activity in developing AR experiences is evaluating the usability of the AR application . The aiThe presented solution was tested under a particular methodology, which is defined in the following subsections.The authors carried out an empirical study based on the experimental method. The examined process was isolated from disturbances/side effects, i.e., uncontrolled factors like lack of components or wires, wrongly assembled elements, or errors in the CAD design. The conditions of experiments were ideal in order to focus only on assembly duration both with and without the AR support system. The single one significant variable was the employment of the AR glasses used for transmitting particular information presented in the right place in front of the user’s eyes.Step 1: Observation. The operator commences with the wiring process, aided by the touchscreen support system (ESW), looks at the screen with the 3D graphics, and makes interpretations , widely used for mounting circuit breakers and industrial control equipment inside equipment racks/enclosures (these components can be elements requiring a screwdriver to screw a wire into it or push-in without screwing),-preliminary assembled wire ducts;An industrial enclosure (which forms a control cabinet after components assembly) with:4 sets of 20 wires each prepared in advance, with CAD system pre-defined lengths: 20 cm, 50 cm, 70 cm, 110 cm, 150 cm, 200 cm, 250 cm, and 300 cm;A wire holder dividing each wire length type in a separate position;A manual wiring support system: EPLAN Smart Wiring (ESW);The AR glasses (Microsoft HoloLens), used for testing “with glasses” .The test station with the prototyped AR support system given in In order to make the tests results more representative and factual , the research team performed the tests with the following varied assumptions and conditions. The tests were proceeded in two different locations of test sites: the Rittal Innovation Centre  and the DT Poland Research Centre . In order to perform the tests with the variant equipment, four types of industrial enclosures (which form a control cabinet after components assembly) were introduced with the following quantities: 1 unit of Rittal VX25, 1 unit of Rittal TS8, 2 units of Rittal AE, with 4 different CAD schemes. The industrial enclosures were assembled with the use of 4 different sets of wires, 20 pieces each, with 8 different CAD system defined lengths .Different types of industrial enclosures and various sets of wires were applied with the intention to reduce the learning effect between consecutive tasks.The tests were performed according to the particular procedure described in Step 1: Providing a pre-assembled industrial enclosure (which forms a control cabinet after components assembly) to the test station and fixing it on the assembly frame.Step 2: Collecting all 20 wires in the right slots of the wire holder.Step 3: Preparing screwdrivers for certain operations.Step 4: Activating a manual wiring support system on a touch screen and loading the CAD file.Step 5: Activating the AR glasses during the tests ‘with AR glasses’ being used.Step 6: Preparing a stopwatch.The test procedure performed on the test station with the prototyped AR support system given in Step 1: Running the stopwatch.Step 2: Repeating the manual wiring cycle 20 times (for 20 wires separately), as is it given in Step 3: Stopping the stopwatch after the twentieth wire assembly in an industrial enclosure.Step 4: Writing down the stopwatch indications.Another part of the test procedure was the following measurement steps:It is important to define what is considered to be a success and what would be understood as a failure during the tests. Success in a control cabinet production means a full assembly of a unit. An assembly with the AR glasses taking longer than assembly without the AR glasses is also considered a failure.Tester 1: male born in 1983, has worked for 6 years in the industry (including a position directly connected to control cabinet assembly);Tester 2: male born in 1989, has worked for 3 years in the industry (including a position directly connected to control cabinet assembly).The group of testers consisted of two operators, both possessing higher technical education and heterogeneous characteristics:It is worth mentioning that the system’s operators are given visual indications on which connector is the right one through the visualization either on the ESW support system or directly through the AR glasses.How long does it take for a person to look at a touch screen, interpret 3D graphics on a wiring support system . The tests #1.x and #3.x were performed with the use of industrial enclosures Rittal VX25 and Rittal AE, whereas the tests #2.x and #4.x were performed with the use of Rittal TS8 and Rittal AE, as given in It should be also mentioned that previous to the tests described in the paper, numerous preliminary tests had been conducted, however, those were connected with the development of the system in order to make it a ready-made system for the tests described in the paper’s study. Preliminary tests are not mentioned in this paper. In In the tested process of a 20-wire assembly, the minimum saved time was 4:48 [mm:ss]. The complete assembly process without wearing the AR glasses, took 15:35 [mm:ss], therefore the production process time decreased by 31%. Meanwhile, the maximum time saved was 10:32 [mm:ss]. The complete process without wearing the AR glasses took 23:38 [mm:ss]. In this test, the production process time decreased by a surprisingly high value which was 45%. Approximately 6.5 to 7.0 min were saved on average. That gave an average from 36 to 37% decrease in the time needed to perform the manual assembly process. Taking into consideration the fact that a fully equipped control cabinet consists of not 20 wires, but considerably more (from 150 to 300 wires), time savings of around 30–35% are noticeable and substantially colossal, especially that they imply compelling financial savings. The CTO of the industry giant Rittal GmbH & Co. KG, Steffen Thomas, mentioned that savings up to 2% in the industry are considered desirable, meanwhile saving on the level between 30 and 40% makes a breakthrough . In order to substantiate this statement, it is worth noting the aviation giant Boeing implemented a 25% improvement in production time (25% of time-saving) and achieved a higher first-time quality in their wire assembly, Duin et al. (2019) . High avAverage values are the type of statistics that might be interesting as a result obtained in these tests, however, it is of particular interest to compute the strength of correlation between certain sets of values. In order to compute the strength of the correlation, Pearson’s correlation coefficient was used. xyr| < 0.19;slight, almost no relationship, |xyr| < 0.39;low correlation, definite but small relationship, 0.20 ≤ |xyr| ≥ 0.30;practically significant relationship |xyr| < 0.69;moderate correlation; substantial relationship, 0.40 ≤ |xyr| < 0.89, 0.70–0.89;high correlation; strong relationship, 0.70 ≤ |xyr| < 1.00.very high correlation very dependable relationship, 0.90 ≤ |To determine the correlation strength, the following criteria were identified and interpreted  and tester 1 wearing the AR glasses during the tests (noted as t1AR) was equal to r = 0.572814344 (moderate correlation) with a probability of a type I error determined as p = 0.052. This value of correlation coefficient refers to the relation which depends on the fact that the use of AR glasses by tester 1 was very beneficial during the control cabinet assembly process in comparison to not using the AR glasses. This advantage was connected to a significant reduction in the duration of individual operations and consequently, the entire control cabinet assembly process. The reduction in duration is indicated in The results connected to the strength of correlation for the particular sets of data are described below. The strength of correlation between the values measured in the case of tester 1 without wearing the AR glasses during the tests (noted as t2ØAR) and tester 2 wearing the AR glasses during the tests (noted as t2AR) was equal to r = 0.847575454 (high correlation) with a probability of a type I error determined as p = 0.001. The results of this correlation coefficient calculation mean that tester 2 may have had slower recognition of the devices (tester 2 is younger and had less experience in the industry). On the one hand, the coefficient value was determined based on longer process times per test. On the other hand, the value of the coefficient expressed as a qualitative expression indicates a high correlation. Another reason for that the quickness of device recognition is an individual feature of the operator performing the process. It is worth noting at this point that this feature had no significant impact on the overall result of all tests, namely that the decrease of time needed to perform the manual wiring process was between 36 and 37% on average.Meanwhile, the strength of correlation between the values measured in the case of tester 2 not wearing the AR glasses during the tests  was equal to r = 0.803832588 (high correlation) with a probability of a type I error determined as p = 0.002. The results of this correlation coefficient calculation mean that the effects of the conducted research are convergent with each other due to the high similarity between the values of the duration of the control cabinet assembly process carried out with aid of the AR glasses by two various testers. Moreover, there were no significant deviations between the course of the solution testing with the use of the AR glasses by tester 1 and tester 2.The strength of correlation between the values measured in the case of tester 1 and tester 2 wearing the AR glasses during the tests  was equal to r  = 0.932270421 (very high correlation) with a probability of a type I error determined as p < 0.001. The higher correlation coefficient’s value is related to the fact that the process of control cabinet assembly without the use of the AR glasses was carried out according to classic, and therefore familiar procedures to testers. In future analyses, it can be expected that the correlation coefficient’s values of the  type will be described as a very high correlation.The strength of correlation between the values measured in the case of tester 1 and tester 2 not wearing the AR glasses during the tests (noted adequately as t1_s) and the same for tester 2 (noted as t2_s) was equal to r  = 0.883008194 (high correlation) with a probability of a type I error determined as p < 0.001. The results are very promising, and it is worth mentioning that the results of the last correlation mean that the application of the prototype in the actual production of control cabinets would assure high timesaving regardless of the operator’s features. Certainly, the time saving is very promising when average values are compared .Another correlation coefficient value might be of interest to researchers. This value signifies the correlation between time saved in the process performed by tester 1  as it was presented earlier in this section. The other possibility to assess whether values sampled differ, in the same pairs as for correlation coefficient calculations, is the Wilcoxon signed-rank test. It is a non-parametric statistical hypothesis test used to compare two related samples. The values obtained during the repeated tests matched samples in pairs, for example  is different from the other pairs that both −T and +T are not equal to zero. This is why the definition of other hypotheses and corresponding results for the other pairs, but the aforementioned ones, are not presented. In the case of this pair, −T  = 62.5 and +T  = 15.5, therefore the critical value of statistics is T = 15.5. When assuming the significance level equal to α = 0.1 then the region of acceptance is . In this case, the statistic is found in this region so that the null hypothesis can be accepted with a probability of a type I error determined as p = 0.0002. Meanwhile, assuming the significance level equal to α = 0.05, the region of acceptance is . In this case, the statistic is not found in this region, as opposed to the previous case, the null hypothesis cannot be accepted, and the alternative hypothesis may be accepted with a probability of a type I error determined as p = 0.00024.It has to be mentioned that for all the pairs except one, the rankings used in the Wilcoxon test were on either side of statistics The value of α is conventional. Usually α = 0.05, α = 0.01 or α = 0.001 are assumed. This makes the same statistical hypothesis likely to be relevant with à priori a higher value of α and not relevant to a lower one. On the basis of this general statement and the obtained quantitative results, the authors concluded that the application of the correlation coefficient was more authoritative in this research.The research was conducted during the first shift. Testers performed the runs alternately , which means after completing the single exercise, the tester could take a rest (c.a. 15–20 min) so that fatigue is not a parameter that significantly affects the test operation’s results. Extended testing in future research may have an approximate plan, as follows: tests before and after a meal, and before the end of the work, so that the fatigue parameter could be taken into consideration and investigated as to how it affects the test results.During test arrangements with the aid of the AR support system, both variations mentioned in The screen was placed next to the particular control cabinet, on its right side. This placement was extremely convenient when working with smaller enclosures such as Rittal AE. In the case of 2-m high enclosures such as Rittal TS8 and VX25, it was complicated for the testers, who had to squat during the tests’ performance. On the other hand, the physical wire holder placed below the screen caused additional movements for the testers. It was possible to easily move the virtual screen, but the initial limitation to 20 wires made testers not do it; it was constant for all the test runs so that no additional variable occurred. For the large, fully equipped control cabinet consisting of not 20, but circa 150–300 wires, this functionality could prove to be useful.It is worth stressing that all the tests were finished successfully which means that all the control cabinets were fully assembled. During the tests, problematic situations such as the lack of certain wires, wrongly assembled elements or an error in the CAD design, which would result in the impossibility of assembling a cabinet (failure), have not occurred. The conditions were ideal in order to allow the testers to focus solely on the assembly while working both with and without the AR glasses support. Each assembly was a success, at the time it was recorded. There was no assumption that assembling over 25 min is a failure. Although the study scope was planned to give reliable results by introducing variants in the form of 4 cabinet types and 4 CAD schemes, 2 different locations, 2 testing people and 48 test runs, the single test run was limited to only 20 wires, which potentially could evoke inaccuracies. However, the use of a limited number of 20 wires was acceptable at that stage, since, to the authors’ best knowledge, there is no other available research on the AR glasses in the actual production environment and the actual production process of manual wiring. From the study described in the paper, it is apparent that the AR glasses can have a significant impact on improving: (a) selected performance indicators, (b) ergonomics , and (c) organizational and management matters .The study was based on a single, specific production process; however, the authors confirmed an expectation about the universality of using AR technology in manual process activities in terms of improving selected performance indicators. Since AR technology delivers appropriate information , in the right place at the right time, AR seems to be an ideal solution leading to shorter production times, less training effort, reduction of errors, and finally reducing production costs  .In the study, it was important to use market available hardware, since it may ensure faster readiness to introduce the proposed solution on a bigger scale. Therefore, it should be mentioned that three other types of AR glasses were tested, as during preliminary tests, namely Meta 2, Epson Moverio BT-200 , Epson As the selected authors of this paper work for a commercial company, they made preliminary analysis and as a result, they decided to choose the best possible equipment to meet the demands of the research planned in advance. Tests comparing HoloLens to other types of AR glasses were not carried out during the research. Nevertheless, the mentioned preliminary analysis made it possible to exclude other AR glasses equipment out of concern for the competition rules, various remarks connected to the use of other companies’ glasses, without indication of their names, are mentioned below.One of the significant aspects of the project was the possibility to overlay 3D graphics on the actual image. Some of the other AR glasses are equipped with a considerably larger screen, however, their ambient or depth recognition support was not satisfying. On the other hand, some other AR glasses are equipped with too small screens, in case of which a display field for virtual elements was located on the edge of the display. This might have caused relatively early user fatigue due to the lack of an actual overlay of the virtual elements right in front of the user’s eyes. Other reasons were, to mention only the most important from the perspective of the system’s inventors: lack of software support, lack of mobility (wired AR glasses), lack of ambient scanning sensors, screening calibration not compatible for another person but the particular user, lack of 3D holograms display, the problem of fixed eyes’ pupils spacing (some users see well through AR glasses and some other do not—they might get tired relatively fast), poor quality of spatiality , there is no gesture control  but a manipulator, etc. It is worth mentioning that other AR glasses, to the one used in this study, may fit better for other use cases, especially when it is not necessary to overlay the 3D elements in the right place of the real environment.The system described in the paper requires continuous study. In the desired highest quality system for control cabinet production, precision suffers from the low-specialized AR components used in the hardware, posing one of the biggest disadvantages for the present moment. It is fairly difficult to coordinate the 3D screening of the exact point, keeping it directly at a pre-defined spot while the user’s head is moving, when approximately 0.5 mm precision is required. Even the advanced software concepts for the adaptative algorithm presented unsatisfactory results. Moreover, the software cannot always overcome hardware issues. The observed system’s tests showed that the more software for improving the precision was cumulated, the longer the delay in the real-time perception occurred. Achieving low latency tracking with high precision and accuracy is still challenging .In the research team’s opinion, the HoloLens ver. 1 construction is not reaching industrial requirements. Especially weight, precision, and fragility of construction are the main issues. In one case, the device’s band broke, making it impossible to keep the AR glasses on a tester’s head, and its use was far from demanding lengthy production. Battery working time was shorter than expected, however, it could be extended by the use of a wired power bank, which proved to be quite a convenient solution. It was used during hours of continuous research tests. Certainly, some use cases find HoloLens ver. 1 suitable.Minor inconveniences to eyesight were detected after longer use of the analyzed AR glasses. This topic however requires longer and deeper research to formulate theories. It is certain that the AR gives the user more of an experience that is perceived as more natural in comparison to virtual reality. Obviously, the AR is far from some virtual reality issues for human senses’ experience, considering it positively for AR technology. At the time the authors did not find more extensive research on this topic. Some aspects were found in the literature e.g., Flavián et al., 2019 ); howeveMore limitations were observed during the parallel research on the production line monitoring. The authors intended to describe the outcome of the abovementioned research in detail in a forthcoming paper.The authors believe, that expert testers should be engaged in the system efficiency, performance, and added value tests on a wider scope. On the one hand, two testers might not be sufficient for the system’s testing, on the other hand, during the research, they executed a total of 48 individual tests, which was a remarkable value when high expenditures of the prototype and high expenses of the testing phase were incurred. Apart from the expenditures and other financial costs, the time consuming preliminary and final tests were the other significant reason for the number of testers and tests conducted during the research. The time consumption, expenses, and complicated organization of technical matters caused by the necessity to introduce numerous preliminary settings (IT issues are not a subject of this paper), and, at the same time, press reports on a new version of the tested AR glasses  prompteA further development and enrichment of the AR wiring system are known to lead towards new functionalities for different persons in the value chain, such as a) testing of a control cabinets’ wiring or b) servicing cabinets, having meaningful information automatically at hand, in the form of a cloud computing-based support system consisting of e.g., an automatic meaningful event register and service book. Such a system would, fully or at least partially, connect control cabinets to reality , so wheMore and more studies connected to the AR area of Industry 4.0 in the actual production environment appear in the scientific literature. One study on the topic of applied AR—AR solution, which reduces downtime in the event of a malfunction—was lately described by researchers from the Graz University of Technology . Also, How long does it take for a person to look at a touch screen, interpret 3D graphics on a wiring support system . The software has been validated by two testers, experts in the analyzed industry sector, through a large number of tests. The tests proved that the system equipped with the AR glasses supports the process of control cabinets production and therefore, the answer for the benchmarking research question of the study was indicated. The question is as follows: Thanks to that solution, it has become possible to introduce students and young employees, during their first practice, to the actual working environment as employees of large companies with committed safety programs in place, as suggested by Evans (2013)  and analThe development of the analyses will be based on the study of Xue et al. (2019)  that est


Our previous study showed that aldose reductase (AR) played key roles in fatty liver ischemia-reperfusion (IR) injury by regulating inflammatory response and energy metabolism. Here, we aim to investigate the role and mechanism of AR in the regeneration of normal and fatty livers after liver surgery.  The association of AR expression with liver regeneration was studied in the rat small-for-size liver transplantation model and the mice major hepatectomy and hepatic IR injury model with or without fatty change. The direct role and mechanism of AR in liver regeneration was explored in the AR knockout mouse model. α and PPAR-γ in both normal liver and fatty liver groups after major hepatectomy and IR injury. In addition, the knockout of AR promoted the expressions of SDHB, AMPK, SIRT1, and PGC1-α and PPAR- Delayed regeneration was detected in fatty liver after liver surgery in both rat and mouse models. Furthermore, the expression of AR was increased in liver after liver surgery, especially in fatty liver. In a functional study, the knockout of AR promoted liver regeneration at day 2 after major hepatectomy and IR injury. Compared to wild-type groups, the expressions of cyclins were increased in normal and fatty livers of AR knockout mice. AR inhibition increased the expressions of PPAR- The knockout of AR promoted the regeneration of normal and fatty livers through regulating energy metabolism. AR may be a new potential therapeutic target to accelerate liver regeneration after surgery. Hepatectomy and liver transplantation are effective treatments for all kinds of liver diseases. Nonalcoholic fatty liver disease (NAFLD) is a common cause of chronic liver disease, and its worldwide prevalence continues to increase with the growing epidemic of obesity and diabetes . It is rκB and inflammatory cytokine expression in macrophages [Aldose reductase (AR), a member of the aldo-keto reductase super family, is the first enzyme in the polyol pathway and converts glucose to sorbitol in the presence of NADPH as cofactor. AR plays important roles in the pathogenesis of diabetic complications such as cataractogenesis, retinopathy, neuropathy, and cardiovascular disease . The inhrophages , 10. AR rophages . Moreoverophages . Our prerophages –15. AR wrophages . Furtherrophages , 15. Recrophages . HoweverIn this study, we aimed to explore the effect and mechanism of AR in the regeneration of normal and fatty livers. Firstly, the association of AR expression with liver regeneration was studied in the rat liver transplantation model and in the mice model with or without fatty change. The direct role of AR in liver regeneration was explored in the AR knockout mouse major hepatectomy and hepatic IR injury model. Together, our study found that the inhibition of AR accelerated the regeneration of normal and fatty livers through regulating energy metabolism.Male Sprague-Dawley rats (6-8 weeks) were used as donors and recipients. C57BL/6 (6-8 weeks) mice and AR knockout mice were applied in the mouse model. Fatty livers of rats and mice were induced by feeding with a high-fat diet  for 2 weeks. Animals were allowed free access to food and water in a room with a 12-hour light, 12-hour dark cycle. The experimental protocol was approved by the Committee on the Use of Live Animals in Teaching and Research, Nanjing Medical University.Rat orthotopic liver transplantation was established using small-for-size liver graft with or with fatty change . The medLiver samples and blood were collected at days 1, 2, 4, and 7 after reperfusion.The expression of PCNA was detected by immunohistochemical staining (IHC). The detail of IHC staining was described in our previous paper .μg of total RNA from different samples was used to synthesize 22 μl of cDNA using the High-Capacity cDNA Kit . RT-PCR was done with a modified version of a previous method [Each 1 s method . All samβ-Actin, anti-p-AMPK, and anti-SIRT1 antibodies were purchased from Cell Signaling Technology and Abcam.Western blotting was done with a modified version of a previous method. In order to investigate the role of AR in energy metabolism, the content of ATP was detected by an ATP assay. The ATP assay (Sigma-Aldrich) was performed according to the manufacturer's instructions.U test was used for statistical comparison. Significance was defined as P < 0.05. Calculations were performed by using the SPSS computer software version 16. .Continuous variables were expressed as average with standard deviation (SD). The Mann-Whitney γ, cyclin D1, and cyclin E1 were found in the small-for-size fatty graft  represent a group of nuclear receptors that plays pivotal roles in the regulation of energy metabolism. Our research showed that the knockout of AR increased the expression of PPAR- Figures . Further Figures .α in liver were detected by q-PCR. In normal liver, the mRNA expressions of AMPK, SIRT1, and PGC1-α were increased in AR knockout mice compared to wild-type mice (Mitochondria are important organelles for the energy metabolism of hepatocytes, while AMPK signaling is a key regulator of bioenergy metabolism. To further investigate the effect of AR in AMPK signaling during liver regeneration, the expressions of AMPK signaling such as AMPK, SIRT1, and PGC1-ype mice . The wesype mice . Similarype mice . Furtherype mice . More imype mice .Liver regeneration is a highly coordinated process involving complex networks of interactions between various cellular, cytokine, and growth factors . RemnantTo our knowledge, this is the first report on the role and mechanism of AR in liver regeneration. In this study, our results demonstrated that the expression of AR was increased in liver after rat liver transplantation and mouse major hepatectomy and IR injury, especially in fatty liver. Furthermore, overexpression of AR in fatty liver was associated with impaired regeneration of fatty liver. The knockout of AR promoted the regeneration of normal and fatty livers in the mouse model. Our data also showed that AR knockout increased the expressions of cyclin A2, B, D1, and E after hepatectomy and IR injury. Cyclins are important downstream effectors of cell cycle and transforming signaling pathways, which play central roles in cell proliferation , 22. Colα, PPAR-β, and PPAR-γ. Increasing evidence showed that PPARs play important roles in liver generation. A deficiency of PPAR-α impaired liver regeneration after partial hepatectomy through regulating gene expression involved in cell cycle control, cytokine signaling, and fat metabolism [β was involved in the progression of liver regeneration by regulating PDK1/Akt and E2f signaling-controlled metabolism and proliferation [γ null mice with diet-induced hepatic steatosis after hepatectomy. These data suggested that augmenting liver PPAR activity might promote the regeneration of liver after surgery. Recent research showed that AR overexpression caused strong suppression of PPAR-α activity by regulating ERK1/2 signaling [α and PPAR-γ in both the normal liver and fatty liver groups after major hepatectomy and IR injury compared to the wild-type groups. These data demonstrated that AR negatively regulated the progression of liver regeneration maybe through regulating expressions of PPAR-α and PPAR-γ.PPARs are nuclear receptor ligand-dependent transcription factors that regulate gene expression, and they are composed of three types: PPAR-tabolism , 24. Theferation , 26. Morignaling . In thisα delayed liver regeneration after partial hepatectomy by impacting on the G1/S transition phase [α, as the coactivator of PPAR-γ, has been reported to play important roles in mitochondrial biogenesis and energy metabolism. The AR inhibitor increased mitochondrial biogenesis via increasing the expression of Nrf2/HO-1/AMPK/p53 and decreasing the mitochondrial DNA damage in colon cancer cells [α, SDHB, and ATP content in both normal and fatty livers after major hepatectomy and IR injury. These data indicated that AR inhibition accelerated fatty liver regeneration maybe through regulating mitochondrial biogenesis and energy metabolism. The precise mechanism of AR in regulating energy metabolism during liver regeneration needs to be further studied.Mitochondria are significant organelles for hepatocyte energy metabolism. ATP is critical not only for energy supply to maintain cell functions and survival but is also a significant factor in controlling regenerative signaling –30. Decron phase . PGC1-α,er cells . In addier cells . In thisIn summary, we demonstrated the role and underlying mechanism of AR in the regeneration of normal and fatty livers after liver surgery. The knockout of AR promoted the regeneration of normal and fatty livers through regulating energy metabolism. The effect of AR in liver regeneration may provide a new potential therapeutic target to accelerate postoperative liver regeneration and decrease the incidence of mobility and mortality.