Exosomes are nanosized vesicles (30–140 nm) of endocytic origin that play important roles in regenerative medicine. They are derived from cell membranes during endocytic internalization and stabilize in biological fluids such as blood and synovia. Temporomandibular joint osteoarthritis (TMJ OA) is a degenerative disease, which, in addition to chronic pain, is characterized by progressive cartilage breakdown, condylar bone remodeling, and synovitis. However, traditional clinical treatments have limited symptom- and structure-modifying effects to restore damaged cartilage and other TMJ tissues. This is due to the limited self-healing capacity of condylar cartilage. Recently, stem-cell-derived exosomes have been studied as an alternative therapeutic approach to tissue repair and regeneration. It is known that trophic regulation of mesenchymal stem cells (MSCs) has anti-inflammatory and immunomodulatory effects under pathological conditions, and research on MSC-derived exosomes is rapidly accumulating. MSC-derived exosomes mimic the major therapeutic effects of MSCs. They affect the activity of immune effector cells and possess multilineage differentiation potential, including chondrogenic and osteogenic differentiation. Furthermore, exosomes are capable of regenerating cartilage or osseous compartments and restoring injured tissues and can treat dysfunction and pain caused by TMJ OA. In this review, we looked at the uniqueness of TMJ, the pathogenesis of TMJ OA, and the potential role of MSC-derived exosomes for TMJ cartilage and bone regeneration. The temporomandibular joint (TMJ) is a unique joint that connects the mandibular condyle with the articular surface of the temporal bone, accompanied by hinge and gliding activity. It is one of the most frequently used and most complex joints in the human body . OsteoarApproximately 15% of the global population suffers from OA . The preBecause of the limited self-healing ability of articular cartilage, TMJ OA is one of the most difficult joint diseases, and currently there is no consensus treatment for complete remission. The treatment of OA is aimed at pain relief and improvement of affected joint function. The therapeutic strategy of TMJ OA aims to prevent gradual destruction of cartilage and subchondral bone, induce bone remodeling, relieve joint pain, and restore TMJ functions . GeneralMesenchymal stem cells (MSCs) have great potential for cell therapy for articular cartilage repair, which can be affected by MSC-derived exosomes. The efficacy of autologous or allogenic MSCs in cartilage repair has been demonstrated in animal studies ,13, and In this review, we discuss the characteristics and properties of MSCs, the current understanding of MSC exosomes, and advances in our knowledge of their emerging role in treating TMJ OA. Given the limited understanding of its pathogenesis and the low healing potential of avascular cartilage, no effective therapy is available for restoring TMJ structures with progressive OA. Here, we present novel perspectives for the development and implementation of MSC exosomes as a cell-free regenerative medicinal approach for cartilage repair and regeneration of TMJ. For this purpose, four of the authors of this review conducted a literature search. For a period of 32 years prior to January 2020, we searched the literature via PubMed and Google scholar search engines, and we selected the top 99 articles that matched the theme.The TMJ is a complex articulation composed of mandibular condyle and articular surfaces of the temporal bone. Both the temporal articular surface and mandibular condyle are covered by dense articular fibrocartilage. The temporal articular fossa is composed of the mandibular fossa and articular tubercle  19]. Al. Al19]. TMJ is one of the most unique human joints in terms of composition and development. The TMJ in humans consists of two joints in one bone. The two joints, respectively, connect the head and the mandible. One joint may influence the function of the other. In other synovial joints of the body, the joint surface is covered by a layer of hyaline cartilage . HoweverIn the developmental stages of the TMJ, MSCs split within themselves to divide into even smaller cells, eventually attaining full size. Then, these MSCs migrate into the interior condyle and then into the cartilage, where cell differentiation occurs, and then the differentiated cells become immature chondrocytes . The groTMJ OA, a degenerative TMJ disease, occurs due to an imbalance in the synthesis and degradation of the condylar matrix. Degenerative changes in the TMJ are mediated by chondrocytes and fibrocartilage cells in the fibrocartilage of TMJ. This results in a gradual loss of extracellular matrix (ECM) components of subchondral bone and/or articular cartilage . The artInflammation of the synovial membrane, termed synovitis, and subchondral sclerosis can also be caused by structural and mechanical changes in the OA cartilage, making OA more debilitating . In thisTMJ OA is classified as a localized low inflammatory arthritis condition, in contrast to rheumatoid arthritis, which is a systemic high inflammatory condition . ResearcExcessive mechanical stress beyond normal adaptive capacity is considered to be a major factor causing cartilage breakdown in the TMJ . UnilateCartilage cell death caused by apoptosis or necrosis is considered to be a central feature of degenerative changes in cartilages affected by osteoarthritis. Experimentally, apoptosis of chondrocytes was associated with the onset of early stages of cartilage degradation in rat models of iodoacetate induced TMJ OA, and degradation of cartilage and an increase in cytokines released from apoptotic cartilage were observed .There is also accumulating evidence that chondrocytes play a major role in the destruction of subchondral bone. The upregulation of catabolic enzymes in cartilage matrix, such as matrix metalloproteinases (MMPs), disintegrins, and MMPs with thrombospondin motifs (ADAMTS), is a result of the pathologic changes of TMJ OA . In addiTMJ OA is more prevalent in females than males and occurs mainly after puberty, especially during the reproductive periods , suggestcho (chondrodysplasia) mice [cho mice show evidence of osteoarthritic changes in proteoglycan staining, which are observed in the surface articular layers of the mandibular condylar cartilage. Another TMJ OA mouse model is obtained by disruptions in the production of ECM proteoglycans, such as biglycan and fibromodulin [Another possible mechanism by which TMJ OA may arise is from alterations in the ECM; this might be due to genetic disturbances that directly alter the composition of the ECM in the TMJ, or indirectly due to changes in composition and/or turnover of the ECM caused by other genetic factors. Several genes are associated with the painful TMJ disorder as discovered by a genome-wide association study (GWAS) . In a reia) mice . In addiomodulin . In the early stages of TMJ OA, upregulation of genes involved in osteoclast activity and/or an increase in RANKL/OPG ratio in subchondral bone contributes to an increase in subchondral bone turnover in biglycan/fibromodulin-deficient mice . OsteoblThese animal models point out interesting possibilities for the genetic cause of degenerative TMJ disease. However, there is currently no clear evidence of the effect of these genetic factors on human TMJ OA. Of course, there is a strong possibility that future research will find an association between TMJ OA and genetic defects that undermine the robustness of sECM. This may also provide information to identify individuals predisposed to developing TMJ OA.The etiology of TMJ disorders is multi-factorial and complex, and the pathophysiology of TMJ OA is still poorly understood. Etiologic factors may include macrotrauma, parafunctional habit, bruxism, malocclusion, estrogen influence, genetic variations, and even psychological problems . One or Such treatments can be used in various combinations and are applied to eliminate the potential cause of TMJ OA and to treat the symptoms. Examples of noninvasive treatments are occlusal stabilization splints, medications, and physical therapy. The use of occlusal stabilization splints has been used since the 18th century, and they are still commonly used . NoninvaMinimally invasive therapies are as widely used as medication, targeting masticatory muscles or the TMJ itself. Botulinum toxin (Botox) has little side effects and has been injected into the masticatory muscle, including the masseter, temporal, and lateral pterygoid muscles . MinimalIn general, invasive treatments are only performed for patients suffering severely from osteoporosis, neoplastic, and developmental disorders in the TMJ . InvasivExosomes are a type of nanosized extracellular vesicles (EV) with a diameter of 30 to 140 nm. After the fusion of multi-vesicular bodies (MVB) with cell membranes, it is secreted into the extracellular space in most cell types . ExosomeThe major role of exosomes is considered to be as a vehicle for intercellular communications and to transfer cargo contents to recipient cells. Exosomes are essential for cell-to-cell communication and function to induce biological responses in recipient cells by delivering proteins, lipids, and nucleic acids (mRNA and miRNA) from the parent cell . ExosomeUntil recently, MSCs , including MSCs derived from adipose and bone marrow tissues, have been used as representatives of cell-based therapies. Mechanisms regarding the therapeutic potential of MSCs are based on (1) transfer of exosomes, with a relatively narrow range of sizes (diameter of 30 - 140 nm) or microvesicles with a broad size distribution (150–1000 nm), and (2) the action of paracrine factors, including peptides, proteins, and hormones, have been proposed . Increasing experimental/clinical evidence indicates that MSC-derived exosomes (MSC exosomes) might become the new cell-free therapy agents with attractive advantages over MSCs, such as no risk of tumor formation and low immunogenicity, and they also play a crucial role in enhancing angiogenesis, which is fundamental for tissue repair . The carThe mechanism by which MSCs facilitate tissue repair is through the release of bioactive factors, such as exosomes in which MSCs are trophic, immunomodulatory, and/or regenerating at the site of injury or disease . RecentlMSC exosomes are expected to promote the regeneration of damaged TMJ, with a complex structure . MSC exoMSC exosome, the vehicle responsible for intercellular communication, is well suited for delivering timely MSC responses in an effective manner to restore homeostasis of the microenvironment. The bi-lipid membrane structure of MSC exosomes plays an important role in endocytosis or membrane fusion within cells and is important because it provides multifunctionality for interacting with various cell types through extracellular membrane receptor–ligand interactions. Moreover, MSC exosomes are rich in proteins and enzymes, which can regulate and restore homeostasis of ECM . Most importantly, the cargo of MSC exosomes is rich in enzymes and proteins, and these factors have a unique ability to restore homeostasis. Enzyme-mediated activity is a catalytic reaction. The activity of the enzyme is increased in proportion to the impairment of the homeostatic equilibrium between the enzyme substrate and the product. When homeostasis is impaired during injury and disease, enzyme-based exosomes are activated. Activated exosomes restore homeostasis and promote tissue function, as well as contribute to tissue repair and regenerations. When homeostasis is restored and tissue damage is healed, exosome enzyme activity is also reduced. Thus, exosome-based therapeutics are very sensitive to the disease precipitating microenvironment, which is also a limitation . In addiMSC exosomes have advantages over exosomes from other cell types. This is due to the low immunological response, high clinical safety, ease of extraction from a wide range of tissues, and high potential for therapeutic extensibility. The set of evolutionarily conserved cargoes in exosomes contains many housekeeping enzymes involved in the regulation of bio homeostasis, energy conservation, cell number maintenance, and immune function . We woulMitochondrial damage and dysfunction is related to the pathogenesis of OA. Chondrocytes in the area where OA occurred have a decrease in mitochondrial biological production and a decrease in mitochondrial electron transport chain (ETC) protein ,81,82. EThis loss of energy is associated with a series of processes observed in damaged cells in the OA state. Specifically, it causes increased oxidative stress, inflammation of cytokine-induced chondrocytes, disturbed matrix biosynthesis of chondrocytes, increased reactivity of growth factors, increased chondrocyte death, and catabolism and calcification of the cartilage matrix layer ,81. In sDamaged cartilage is generally aggravated by inflammatory reactions, which in turn leads to cell death, matrix degradation, structural changes in OA, and loss of function . Cells iThe proper number of cells is important for maintaining tissue structure and restoring impaired function. The reduced number of cells should be increased to a range that can maintain steady-state levels of homeostasis. To enable matrix tissue formation and deposition at the defective cartilage site, mesenchymal cell proliferation is essential after initiating the cartilage repair response . In injuThis CD73 action is a characteristic of MSC exosomes. MSC exosomes activate the phosphorylation of survival kinases ERK and AKT in the presence of AMP via the theophylline-sensitive adenosine receptor . Thus, CThe immune system is essential for the survival of all organisms. It is primarily responsible for defending the body from harmful pathogens and the external environment. In recent years, there are studies that show that the immune system has an important effect on tissue repair. Rapid upregulation of proinflammatory cytokines, including IL-1, IL-6, IL-8, and MMPs, at damaged cartilage sites plays a role in the degradation of the matrix layer and joint damage . These pM1 macrophage polarization in OA synovial tissue inhibits chondrogenic differentiation of MSCs via IL-6 in vitro. On the other hand, M2 macrophage polarization has recently been reported to produce anti-inflammatory IL-10, thereby inhibiting harmful inflammation ,91. TherThe immunomodulatory activity of MSC exosomes requires multifactor synergy, rather than the action of a single factor. Co-operation and synergy of secreted factors, such as IL-6, interferon (IFN)-γ, TGF-β1, prostaglandin E2 (PGE2), hepatocyte growth factor (HGF), and hemeoxygenase-1 is required . MSC exoIn addition, MSC exosomes have been reported to modulate various inflammatory responses due to myocardial injury, hypoxic pulmonary hypertension, diabetic skin wounds, and retinal damage . For exaThe high prevalence of TMJ OA is the reason we should be alert, and when the symptoms of TMJ OA are severe, clinicians should consider ways to achieve TMJ regeneration. Recently, the development of regenerative medicine in the field of orthopedics can provide the answer to the problem of TMJ regeneration. However, owing to the uniqueness and complexity of the TMJ, anatomical, structural, and functional regeneration is not easy and is very challenging to tackle. The ligaments form a tight link between the mandibular condyle with fibrocartilaginous properties and the dense fibrous disk, which usually starts and progresses when the rigidity of this relationship is compromised. The difficulty in engineering/technical regeneration of the TMJ is not in obtaining pure hyaline cartilage from the basal bone but in obtaining long-term fibrocartilage that has been separated from the basal bone without fibrous or bony adhesion or ossification. In tissue engineering approaches to treat cartilage lesions and OA in animal and human studies, therapies for use with scaffolds have been intensively investigated ,96. The In a recent study, in an immunocompetent rat model of TMJ OA, MSC exosomes were observed to play an important role in the regulation of inflammatory responses, healing of condylar cartilage and subchondral bone, and pain behavior . In addiAnother method is to use chondrocyte cultures. Adenosine activation of AKT, ERK, and AMPK signals is obtained by adding exosome-mediated joint repair, which may increase some chondrocyte activity. Adenosine activation of AKT, ERK, and AMPK signaling can be combined with exosome-mediated repair, which increases chondrocyte activity. MSC exosomes have the ability to enhance s-GAG synthesis, which is impeded by IL-1β, and also inhibit IL-1β-induced nitric oxide and MMP13 production. The effects of these MSC exosomes can be partially inhibited by AKT, ERK, and AMPK phosphorylation and activation of adenosine receptors. Together, our investigations so far have shown that MSC exosomes work through several cellular processes that restore the matrix layer and overall homeostasis. Previous studies demonstrate the potential of exosome-based therapies available as a cell-free approach to treat TMJ pain and degeneration. Exosomes could induce intercellular communication of recipient and parent cells through their cargo at the site of TMJ OA ,67. ThisCurrently, MSC exosomes are widely accepted as major therapeutic agents derived from MSC secretions. MSC exosomes are considered sufficient to promote many of the reported therapeutic effects of MSCs. Research on the benefits of MSC exosome therapy for degenerative diseases, such as systemic OA and TMJ OA, is ongoing. Damaged articular cartilage is at the center of the pathogenesis of OA. OA symptoms can be alleviated by repairing and regenerating with MSC exosomes. Whether naturally occurring or engineered, MSC exosomes can provide therapeutic benefits. Treatment with MSC exosomes produced several positive results. However, most of the studies that yielded these results were conducted using animal models, not human models. While OA is classified as a chronic disease, there are limitations to conducting experiments in animal models with acute injuries. TMJ OA is also characterized by low levels of chronic inflammatory conditions and is a multifactorial chronic degenerative disease. To demonstrate the potential benefits of MSC exosomes towards TMJ OA, further research is needed on the pathogenesis of this degenerative disease, the potential of various MSC sources, appropriate therapeutic concentrations of MSC exosomes, and accompanying treatment regimens. Studies using rat models provide an easy-to-access safe paradigm for traditional cell-based MSC therapies. However, to conduct clinical trials in humans, MSC exosomes in large animal models should be used to repair and regenerate cartilage lesions to validate the safety and efficacy of cell-free exosome therapy. The application of MSC exosomes to treat TMJ OA can be rationalized by scientific evidence, but the ultimate goal of clinical application should be validated in the appropriate animal and human model. Subsequently, rigorous evaluation in properly controlled clinical trials is required. In conclusion, the challenge remains, but the use of exosomes in the treatment of TMJ OA has great potential with regards to their mechanism of action and therapeutic efficacy. These small vesicles can have a significant impact on the future of TMJ OA treatment.


Tumors of the cerebellum are the most common brain tumors in children. Modern treatment and aggressive surgery have improved the overall survival. Consequently, growing numbers of survivors are at high risk for developing adverse and long-term neurological deficits including deficits of cognition, behavior, speech, and language. Post-operative cerebellar mutism syndrome (pCMS) is a well-known and frequently occurring complication of cerebellar tumor surgery in children. In the acute stage, children with pCMS may show deterioration of cerebellar motor function as well as pyramidal and cranial neuropathies. Most debilitating is the mutism or the severe reduction of speech and a range of neurobehavioral symptoms that may occur. In the long term, children that recover from pCMS continue to have more motor, behavioral, and cognitive problems than children who did not develop pCMS after cerebellar tumor surgery. The severity of these long-term sequelae seems to be related to the length of the mute phase.The impact of pCMS on patients and families cannot be overstated. This contribution aims to discuss the present knowledge on the natural course, recovery, and rehabilitation of children with pCMS. We suggest future priorities in developing rehabilitation programs in order to improve the long-term quality of life and participation of children after cerebellar tumor surgery and after pCMS in particular. Postoperative pediatric CMS is characterized by delayed onset of mutism/ reduced speech and emotional lability after cerebellar or 4th ventricle tumor surgery in children. Additional common features include hypotonia and oropharyngeal dysfunction/ dysphagia. It may frequently be accompanied by the cerebellar motor syndrome, cerebellar cognitive affective syndrome and brainstem dysfunction including long tract signs and cranial neuropathies. The mutism is always transient. But recovery from CMS may be prolonged. Speech and language may not return to normal; and other deficits of cognitive, affective and motor function often persist.Transient and total cerebellar-induced speechlessness is a complication of cerebellar tumor surgery. Although it has occasionally been reported in adults , 35, it Long-term follow-up studies show that the children who recover from pCMS continue to have motor, behavioral, and cognitive problems, the severity of which seems to be related to the severity of the cerebellar motor syndrome and the length of the mute phase , 52, 67.Mutism is regarded as the hallmark symptom of pCMS, but speechlessness is not always the core symptom of pCMS as patients occasionally present with verbal adynamia or very inhibited verbal output , 11. TheImmediately after the alleviation of the mutism, the presence of dysarthria appears to be the rule. In a study of 27 children with a posterior fossa tumor by Mei and Morgan, the incidence of mutism, dysarthria, and dysphagia post-surgery was reported to affect approximately one in three cases . In a crEarly optimistic claims that dysarthria in pCMS recovers quickly and completely  were temA number of key prognostic factors have been identified for the development of pCMS. Di Rocco and colleagues  showed tThere is no established treatment for the speech and language disorder of pCMS to date. Attempts have been made to reverse mutism in its acute stage by medication intervention. Corticosteroids, fluoxetine, thyrotropin-releasing hormone, bromocriptine, midazolam, and zolpidem have all been used with inconsistent results . At presEstablish a pre-operative baseline of speech and language function, including identification of existing risk factors/predictors.Identify the nature of speech and language disorders occurring in the post-operative period, including presenting signs and symptoms, and speech and language characteristics.Determine the nature of speech and language rehabilitation required, such as timing of intervention, speech and language rehabilitation, and referral.Follow-up during the recovery process, defining intermediate assessment intervals, including recommendations for surveillance across developmental time points, long-term recovery, and communication with the patient and family.Identify risks of late effects on speech and language, where children tend to grow into their deficits, and the impact on quality of life.Routine clinical management should be central to the rehabilitation of children with pCMS, with a systematic integrated approach to the management, assessment and treatment of speech and language disorders, and follow-up and early intervention. It is therefore recommended that rehabilitation of speech and language in children with pCMS involves multi-phase implementation of evidence-based guidelines and recommendations that identify and highlight risk factors, specific deficits, and knowledge about progression over time , 13, 38.In the acute phase of pCMS, children initially are extremely irritable and suffer from mood lability. They usually are either severely apathetic or indifferent to their surroundings and can show inconsolable crying and whining behavior. More rarely, these children exhibit disinhibition with forced laughter. Compulsive pre-sleep behavior, cortical blindness, and impaired voluntary eye opening (eyelid apraxia) may also be present. The most severe behavioral disturbances almost always slowly diminish before the end of the mute phase and the return of speech , 11.There have been a number of studies reporting on the longer-term neurocognitive outcomes of children with brain tumors with pCMS. The literature is clear that children diagnosed and treated for tumors involving the cerebellum demonstrate a range of neurocognitive and neuroemotional deficits in the years following treatment , 67. TheBeyond the impact on neurocognitive, affective, and behavioral functioning in children with cerebellar tumors more globally, children with pCMS have been described to demonstrate even greater morbidity in these domains as early as 1 year after diagnosis , 42, 66.Children who present with pCMS are at substantial risk for greater long-term cognitive and psychosocial morbidity, making them an important group for which interventions and rehabilitation beyond those focusing exclusively on motor and speech functions should be prioritized in the scientific community. The primary areas of rehabilitation therapy that these children receive target the motoric and speech/language deficits that are observed in the acute period around pCMS via physical, occupational, and speech/language therapies. It may be that cognitive interventions are not implemented in the acute phases of pCMS because the cognitive issues (beyond the obvious disruption in ability to communicate) do not become evident until later. However, there may in fact be opportunities to alter the eventual emergence of these sequelae if we intervene earlier. There have been three primary areas of research targeting neurocognitive impairment in pediatric cancer patients , and while these studies have not specifically targeted children with pCMS, a review of this literature may be prudent to the future development of cognitive rehabilitation research for these children in particular.Stimulant medications have been the most researched pharmacologic approach to addressing cognitive deficits in pediatric cancer survivors to date. Two randomized clinical trials of stimulant medication in pediatric cancer survivors (predominantly brain tumor) have reported positive results. Improvements in performance-based attention as well as improved focus based on parent and/or teacher reports were found , 61. In Neurotransmitter modulators targeting memory processes have also been evaluated. Castellino and colleagues published a single-arm, open-label trial of donepezil in a small sample of pediatric brain tumor survivors . FollowiResearch on cognitive remediation programs fall into two distinct categories: (1) face-to-face therapeutic sessions targeting specific functions such as executive function, attention, memory, and academic achievement, and (2) computer-based intervention programs that are implemented within the home setting. The most comprehensive cognitive remediation research program to date was a phase 3 clinical trial of a multi-dimensional program of interventions targeting (a) hierarchically graded massed practice, (b) strategy acquisition, and (c) cognitive-behavioral therapy. The results indicated significant improvements in academic achievement, attention, and improved implementation of metacognitive skills . This tyA number or recent studies have examined the feasibility, acceptability, and efficacy of computer-based, in-home cognitive intervention programs in pediatric cancer survivors. Two published studies specifically using CogMed, a computerized intervention program targeting working memory, have shown good feasibility, acceptance, and compliance (85–88%) in pediatric cancer populations including brain tumor patients , 22. In Two studies have been published to date and others are in progress evaluating the effect of exercise programs in pediatric brain tumor survivors , 50, 60.Each of these primary areas of neurorehabilitation research have yet to be applied specifically to the population of children with pCMS. However, these intervention approaches may hold promise for addressing the specific neurocognitive sequelae in children with pCMS specifically given that they have been found to suffer more intense long-term consequences than pediatric brain tumor survivors without pCMS.Children who present with pCMS can demonstrate a range of motor disturbances including hypotonia, hemi- or tetraplegia, ataxia, and cranial nerve palsies. The most common motor difficulties seen are known as the cerebellar motor syndrome which incorporates ataxia and postural/gait deficits . Ataxia Ataxia is often present in children pre-operatively . AtaxiaTherapy management remains the mainstay of treatment for motor problems for children with pCMS. Physical rehabilitation is typically delivered as part of a multidisciplinary approach to optimize care, while providing a tailored program with individualized goal setting involving the child’s family . The preAside from emerging evidence for its benefit on cognitive outcomes , 60, theSabel et al. report that home-based video gaming can improve balance in children after brain tumor treatment . Ada et Post-operative pCMS is a prevalent and deleterious complication of cerebellar tumor surgery that affects children far more often than adults , 35. It The profound, persistent, and widespread impact of pCMS highlights the importance of ongoing rehabilitation and effective and early intervention , 52, 67.In patients with pCMS, presenting signs and symptoms and later speech and language characteristics should be analyzed in order to determine the nature of speech and language rehabilitation required, such as timing of intervention, speech and language rehabilitation, and referral. Focused neuropsychological assessments of specific areas of functioning can be beneficial in the more acute phases . The selection of assessment tools used in these early focused assessments requires critical evaluation of tools that are adequately sensitive and consider issues of practice effects and psychometrics. The primary targets of these early focused assessments should include the evaluation of communication, attention, executive functions, visuomotor skills, and psychological functioning. More comprehensive neuropsychological evaluation becomes of greater benefit in the long-term follow-up of patients with pCMS (beginning at 12 months after treatment has been completed). In addition to the cognitive domains evaluated in the focused assessments, comprehensive long-term monitoring should also include the evaluation of memory functions, reasoning skills, processing speed, and adaptive functions.Medication has not been consistently utilized to alleviate symptoms in acute pCMS or in the more chronic stages in which pCMS symptoms are consistent with CCAS. Future research is necessary to determine how effective this approach may be and for what symptoms. Potential targets for future research in this area may build on the preliminary data that has been presented on the use of such medications.During recovery, assessment intervals should be defined, including recommendations for surveillance across developmental time points, long-term recovery, and communication with the patient and family. In addition, the risks of very late effects of pCMS in terms of growing into deficit during further development should be identified and timely addressed. Cognitive rehabilitation after pCMS should be tailored to the individual needs of the child, and evaluations are important in developing such individualized rehabilitation or interventions. Where children are left with significant residual impairment, the incorporation of compensatory technology to aid communication is recommended . InterveAlternative procedures such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation—especially in combination with cognitive interventions—may be promising techniques to stimulate neurorecovery and plasticity in adults . TMS hasGiven the paucity of controlled data on the therapeutic options, there is a need for systematic prospective trials evaluating the effects of different neurosurgical approaches, pharmacological interventions, neurorehabilitation, and other alternative strategies for preventing and addressing the sequelae in children with pCMS. Achieving a balance between optimal survival and minimal long-term sequelae will ultimately result in an improved quality of life and functional outcomes of children after brain tumor treatment and more specifically after pCMS.


Greener processes have emerged as serious and competitive routes to produce various nanomaterials. These ecofriendly methodologies rely on the use of bioresources to both promote crystal growth and, very often, ensure the size and shape control and the colloidal stability of the as-fabricated nanomaterials, while concomitantly avoiding the use of chemicals and the generation of harmful by-products.Nature provides materials scientists with valuable and renewable resources to typically carry out the synthesis of the desired nanomaterials at room or very mild temperatures, atmospheric pressure and aqueous solvents, therefore fulfilling the principles of Green Chemistry. So far, researchers have devised innovative methodologies to expand and advance the biosynthesis of unique nanomaterials by exploiting these bioresources. From a fundamental point-of-view, several research teams have shed light on the underlying synthesis mechanisms.Biogenic Nanomaterials: Versatility and Applications, covers several aspects of nanomaterial biosynthesis and their applications. For instance, Xiang et al. [Phytophthora capsici, a plant pathogen. These CTAB-functionalized cellulose nanocrystals proved to be an efficient and ecofriendly alternative to the use of chemical pesticides. On the other hand, Ghramh et al. [Euphorbia peplus plants to promote the reduction of cationic gold into its metallic counterpart yielding the formation of gold nanoparticles (Au NPs) that exhibited several biological activities, such as the stimulatory effect on HeLa cell lines and an inhibitory effect on the HepG2 cancer cell line, in addition to larvicidal, bactericidal and fungicidal activity, among others.The present Special Issue of Molecules, titled g et al.  extracteh et al.  relied oOchrobactrum sp. MPV1, studied the impact of selenate concentration and culturing conditions on the features of the as-produced Se NPs and proposed a hypothetical mechanism that could explain their outcomes. Bacteria and their extracts have been intensively exploited by the community of material scientists. In their paper, Piacenza et al.  describe3O4 nanocrystals via the smart combination of a first Fe3O4 binding peptide, with a second one consisting of a targeting ovarian cancer cell sequence and ginger extract. This yielded the production of a homogenous population of superparamagnetic Fe3O4 NPs of ~7 nm in size that are stable in both water and human serum. Moreover, these NPs exhibited great promise as contrasts agents in magnetic resonance imaging (MRI).Magnetotactic Bacteria (MTB), a very diverse group of prokaryotes from metabolic and phylogenetic points-of-views, biomineralize magnetic nanoparticles via an intracellular process, giving rise to magnetosomes. The applications of these magnetic crystals, such in drug delivery, cell separation, hyperthermia treatment of cancer or as contrast agent in magnetic resonance imaging, are discussed in the review by Vargas et al. . InspireUsing plant viruses, which are themselves nanoscale, as templates and delivering agents in nanotechnology is another novel way to exploit natural resources. Prominent findings in this field are summed up in the review by Zhang et al. . Indeed,Chlamydomonas reinhardtii on the features of the biosynthesized silver nanoparticles mediated by this photosynthetic microorganism in terms of shape, size, colloidal stability, synthesis kinetics and conversion yield [C. reinhardtii [In their trilogy, Rahman et al. compared the impact of the presence and absence of the cell wall in the green, unicellular microalga on yield . Their son yield . Their lnhardtii .In summary, the readership will discover, in the present Special Issue, prominent and diverse facets of bionanotechnology and nanobiotechnology spanning from the synthesis of inorganic nanomaterials using natural bioresources, to the advantages of natural nanostructures, including their bioapplications.


Despite releases of governmental guidelines for promoting physical fitness among the youth in China, the performance of college students in fitness tests has been declining over the past three decades. Obesity and physical inactivity have been proposed as two main causes. However, their relative importance for improving physical fitness remains unclear. To address this knowledge gap, we collected longitudinal data spanning four consecutive years on the physical fitness test for students from Nanjing University, China. Physical education classes of two hours per week were mandatory for the first two years. Using mixed effects models, we quantify the within-subject effects of weight, muscular endurance, sex, and mandatory physical education courses, among other variables, on physical fitness total score. We found that, in spite of the dominance of normal weight among the students, losing weight was positively associated with the total score, with significant sex differences in the associations. Compulsory exercise provided by physical education classes per week had strong positive impacts on the total score, comparable to losing weight of roughly 15–17 kg for males and 5–10 kg for females. Half sex difference in the total score was explained by male students’ poor performance in the muscular endurance represented by pull-ups. Our results suggest that college students in China should engage in physical activity of higher levels to improve their physical fitness, with a heightened awareness of extra fat under normal weight and insufficient muscular endurance. Rapid economic growth and urbanization since China’s reform and opening-up in the late 1970s have induced great changes in many aspects of the society. Despite improved nutrient supply and quality, the health-related physical fitness, usually assessed in combination of body composition, cardiorespiratory endurance, flexibility, and muscular strength and endurance, of contemporary Chinese students at the age of 7 to 22 has considerably declined compared to that in the 1980s, imposing worrying challenges to national public health . Since 2The contrasting responses of physical fitness between the two age groups of Chinese students beg the question of whether top-down interventions that aim to promote physical activity and thus improve physical fitness would be less effective for students in the transition from adolescence to adulthood. Indeed, the majority of adolescents older than 15 years have been reported to fall short of the recommended one hour per day of moderate to vigorous physical activity , with fuLargely because college students have greater autonomy in their daily lives than during secondary education, they are more subject to weight gain and developing unhealthy behaviors such as physical inactivity and poor diet ,11. ImpoPhysical education has long been considered as a feasible top-down channel to deliver recommended physical activity and improve fitness among the youth . AlthougGiven that the relative importance of weight management and physical education remains unclear, evidence-based interventions and guidelines are urgently needed for both short-term fitness improvement and long-term fitness maintenance among the population of college students. Here, using longitudinal data on college students’ physical fitness covering the entire study span from 2015 to 2019 in Nanjing University, China, we aim to examine the dynamics of their performance in multiple physical fitness tests and the weighted total fitness score, investigate the associations among these tests and the total score, and further quantify the effect sizes of weight and mandatory physical education courses on the total score. Our findings can quantitatively inform future institutional and national guidelines for improving the physical fitness of young adults. The subjects in this study were the undergraduate students from Nanjing University enrolled in the year of 2015. The Department of Physical Education, Nanjing University, annually conducted a series of health-related tests to assess the physical fitness of each subject, with written informed consent obtained from the mentors on behalf of the subjects prior to data collection. The subjects took the tests every year from 2015 to 2018. Following the terminology  for healThe study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Institutional Review Board of Nanjing University (DPHAE (2014) No. 4).According to the criteria published by the Ministry of Education of the People’s Republic of China for assessing the physical fitness of Chinese students , the oriIn addition to data derived from these physical fitness tests, other information related to the subjects were provided. There were 3202 subjects in total involved in the tests four years in a row, who were from 31 provincial-level administrative divisions across China and affiliated to 28 departments and schools: 1039 of them were from the Jiangsu province, with 2006 from the other 30 divisions and 157 not recorded for their origin. Although a few subjects transferred once from their original department on enrollment to another department in the first or second year, no extra combinations of subject and department other than the original combinations on enrollment were recorded in the dataset. Throughout the four years, 11,346 entries of data were generated, with 5989 from males and 5357 from females. Physical education courses mandatory for completing a bachelor’s degree were offered by the university in the first two years of the four-year education program. The courses, scheduled for two hours per week in each semester, were on general physical education for the first semester in the first year and one specific sport for each of the following three semesters. Students may take specific sports among basketball, volleyball, soccer, badminton, table tennis, tennis, shuttlecock kicking, Chinese martial arts, tae kwon do, gymnastics, yoga, orienteering, swimming, Ultimate Frisbee, and track and field. Optional physical education courses were offered in the third and fourth years. As the total score we computed in this study is a linear combination of each score on BMI, vital capacity, sit-and-reach, standing long jump, 50 m dash, and male-specific pull-ups or female-specific sit-ups, accounting for all of them in regression modeling will result in perfect collinearity. Instead, we first used a scatterplot matrix to explore the correlations among the total score and the single tests. The single tests that were both correlated with the total score and other single tests were used as explanatory variables for modeling, without suffering from perfect collinearity and missing variable bias . As the To account for the potential effects of local socioeconomic status before university enrollment on the fitness test scores, the gross domestic product (GDP) per capita in 2015, of the hometown of each subject, was retrieved at the prefectural city level from the 2016 statistical yearbooks for the 31 provinces . Admissiceteris paribus effects  is the purpose [Before enrollment into the university, the students were nurtured in localities where they took NCEE. Apart from individual genetic factors, their physical health and fitness prior to enrollment were to varying degrees related to family and societal factors, such as family socioeconomic status, after-school program participation, local neighborhood, physical education in school, and recreational and sports facilities . However purpose . To avoi purpose .Our unbalanced longitudinal data spanning four years was structured in three levels. Each test record per year at level one was nested within the 3202 subjects at level two, which were nested within the 28 departments and the 31 provinces at level three, with the departments and provinces as partially crossed factors [To quantify the effects of weight and mandatory physical education courses on physical fitness, the fixed effects of the mixed-effects models included the physical test variables as selected above, a dummy variable denoting the presence or absence of physical education courses in the first or latter two years, a dummy variable representing the male or female sex, as well as interaction terms between the sex variable and the other fixed-effects variables. The random effects of the fixed-effects models consisted of student IDs as the lowest level nested within the two cross-classified province and school levels, as well as errors for each observation. The structure of the mixed-effects models was as follows:Total score (of 80 points) ~ Weight + Other correlated physical fitness tests + Exposure to Physical education classes + Sex + Interaction terms with sex + Nested subject-level and crossed department- and provincial level random effects + Independent and identically distributed errors.As we are interested in the explanatory role of weight and physical education classes in physical fitness scores rather than predicting the score from these variables, the Bayesian Information Criterion (BIC) was used for model comparison .lme4 package [All statistical analyses were in R (version 3.4.4)  with the package .α = 0.05) higher than those in the other three years, sharing the same pattern with the single test of standing long jump  for each sex, with 50 m dash and standing long jump presenting large  [In terms of the linear correlation with the total score, all single tests were significant (ue >0.5)  coefficiAs shown in Our four-year longitudinal data showed that female students enrolled at Nanjing University in the year of 2015 performed consistently better than males in terms of the total score of annual physical fitness tests, in line with our quantitative analysis where the female sex represented more than 10 score points in comparison to the male sex. Several studies on the physical fitness of Chinese students have reported similar findings. For example, female freshmen from another top university in China have outperformed male freshmen in almost every single score of physical fitness tests for five years in a row . ChineseBetween-subject heterogeneity of physical fitness resulted mainly from individual background and behavior. Both parental and personal factors have been reported to be significantly associated with the motivation of Chinese students for physical activity and exercise ,38, thus2 and fat percentage greater than 20%) were associated with poorer physical fitness, partially due to less skeletal muscle mass [Within-subject changes in the weight, height, and vital capacity played different roles in affecting the total score of physical fitness. Specifically, weight had an overall consistent negative within-subject effect, with strong province-dependency (−0.1542 vs. −0.0951) for females. BMI values greater than 23.9 and 27.9 were defined as overweight and obesity respectively, for both sexes , resulticle mass , suggestBoth height and vital capacity had positive within-subject effects on physical fitness scores. Given the magnitude of differences in median weight, height, and vital capacity between the first and latter two years , their nCompared with weight, height, and vital capacity, mandatory physical education classes had a much stronger positive impact on physical fitness total scores, especially for the male sex . SpecifiOur rigorous regression analysis of rich longitudinal data on the fitness of students from Nanjing University provides quantitative evidence that mandatory physical education classes are more effective than simple weight control in terms of physical fitness improvement. To arrest the lasting fitness decline among Chinese college students over the past three decades, placing physical education into a much less marginalized position in comparison to conventional core academic subjects should be under serious consideration of government agencies and higher education institutions in China. In fact, the Ministry of Education of China announced in 2019 that college students who fail physical fitness tests shall not meet the standard for graduation . In 2020One limitation of our study is that, due to data quality issues in the middle-distance running test, we were unable to comprehensively assess the role of muscular endurance in physical fitness of college students. The contribution of aerobic exercise within- and outside-curriculum remains to be further explored. Besides, the small within-subject effects of weight in our study can only be interpreted as low effectiveness of simple weight control. As demonstrated by other studies, scientific and effective weight management involving complex strategies for college students is a cost-effective opportunity to form healthy lifestyle patterns among adults ,14.Our study found that the physical fitness of male students from Nanjing University was lagging behind that of females, with sex-specific negative effects of weight and positive effects of height and vital capacity. This lag can be partially explained by the poor performance of male students in the muscular endurance represented by pull-ups. Dynamics of weight, height, and vital capacity during the span of four years canceled out on average their respective impacts on physical fitness scores. Physical education classes of two hours per week can significantly improve the physical fitness of both sexes, comparable to losing more than 15 kg for males or more than 5 kg for females. Our study supports that interventions consisting of mandatory physical activity and effective aerobic exercise should be considered as the priority for keeping Chinese college students in fitness.


Human-induced biodiversity loss has been accelerating since the industrial revolution. The climate change impacts will severely alter the biodiversity and biogeographical patterns at all scales, leading to biotic homogenization. Due to underfunding, a climate smart, conservation-prioritization scheme is needed to optimize species protection. Spatial phylogenetics enable the identification of endemism centers and provide valuable insights regarding the eco-evolutionary and conservation value, as well as the biogeographical origin of a given area. Many studies exist regarding the conservation prioritization of mainland areas, yet none has assessed how climate change might alter the biodiversity and biogeographical patterns of an island biodiversity hotspot. Thus, we conducted a phylogenetically informed, conservation prioritization study dealing with the effects of climate change on Crete’s plant diversity and biogeographical patterns. Using several macroecological analyses, we identified the current and future endemism centers and assessed the impact of climate change on the biogeographical patterns in Crete. The highlands of Cretan mountains have served as both diversity cradles and museums, due to their stable climate and high topographical heterogeneity, providing important ecosystem services. Historical processes seem to have driven diversification and endemic species distribution in Crete. Due to the changing climate and the subsequent biotic homogenization, Crete’s unique bioregionalization, which strongly reminiscent the spatial configuration of the Pliocene/Pleistocene Cretan paleo-islands, will drastically change. The emergence of the ‘Anthropocene’ era calls for the prioritization of biodiversity-rich areas, serving as mixed-endemism centers, with high overlaps among protected areas and climatic refugia. Biodiversity loss due to human actions has been accelerating since the industrial revolution , with cuTo face this phenomenon, the Convention on Biological Diversity established the Aichi Targets, with targets 11 and 12 calling for the establishment of a bare minimum regarding the percentage of terrestrial land under protection and the prevention of known threatened species, respectively . NeverthAs plant diversity is not evenly distributed across the globe , with feA critical step towards effective conservation—apart from identifying areas with high (taxonomic and/or phylogenetic) biodiversity and irreplaceability—is the extinction risk assessment of all the (endemic) species occurring in a given area . This coOur general goal is to investigate how climate change will alter endemism, biogeographical and biodiversity patterns in Crete and assess the conservation implications of those alterations. More specifically, we aim to: (i) identify centers of endemism and the factors leading to their creation, as well as how they will be affected by climate change, (ii) assess the impact of climate change on the biogeographical patterns of Crete and (iii) investigate how climate change induced alterations in species richness, ecological generalism and phylogenetic diversity may affect community composition of Cretan endemic plants. In the end, we will provide a cost-effective, climate-smart and phylogenetically informed conservation strategy framework that could be applied at a regional scale.2, thus being one of the largest Mediterranean islands. Crete hosts 2240 native plant species )in Crete ,152, espIn the future, conservationists should address the impact of biotic homogenization on ecosystem services , since iIn Greece, the identification of endemism centers and biodiversity hotspots will aid the mapping and assessment of ecosystems and their services implementation by providing invaluable information, since locating biodiversity hotspots and refugia is a key prerequisite in the national set of mapping and assessment of ecosystems and their services indicators, in order to map and assess biodiversity-related ecosystem services .This is the first phylogenetically informed, conservation prioritization study taking into consideration the potential impacts of climate change that has ever been conducted in Greece, one of the most species-rich countries of Europe and the Mediterranean Basin. We used Crete, a Mediterranean island regional biodiversity hotspot, as a case study. Even though several climatic refugia exist on Crete and a large part of the island is under efficient protection, urgent measures are needed to halt the biotic homogenization that is under way and preserve the distinct evolutionary heritage present on the high-altitude areas of the study area. Underfunding, taken together with an elevated climate change driven extinction risk, require the application of the cost-effective conservation prioritization scheme that we have developed herein, which could act as a valuable tool to support awareness-raising and decision-making in Greece and at the EU level, in the framework of the EU biodiversity Strategy and the EU Green Deal.


Unfortunately, these observed phenomena are difficult to reflect the reaction under real working conditions and some important short-lived intermediate products cannot be captured, leading to an incomplete understanding of the working mechanism. In-situ techniques can observe the changes of active materials in operando during the charge/discharge processes, providing the concrete process of solid electrolyte formation, ions intercalation mechanism, structural evolutions, etc. Herein, this review aims to provide an overview on the characters of carbon materials in alkali ion batteries and the role of in-situ techniques in developing carbon materials.Lithium-ion batteries (LIBs), used for energy supply and storage equipment, have been widely applied in consumer electronics, electric vehicles, and energy storage systems. However, the urgent demand for high energy density batteries and the shortage of lithium resources is driving scientists to develop high-performance materials and find alternatives. Low-volume expansion carbon material is the ideal choice of anode material. However, the low specific capacity has gradually become the shortcoming for the development of LIBs and thus developing new carbon material with high specific capacity is urgently needed. In addition, developing alternatives of LIBs, such as sodium ion batteries and potassium-ion batteries, also puts forward demands for new types of carbon materials. As is well-known, the design of high-performance electrodes requires a deep understanding on the working mechanism and the structural evolution of active materials. On this issue,  This battery is further commercialized by SONY in 1991   SEI film formation, (2) structural evolution during ion insertion/extraction and (3) performance degradation. In early days, in-situ techniques in the understanding the working mechanism. In detail, carbon materials as well as their reaction mechanism in alkali metal ions batteries are elaborately expounded, followed with a presentation about the in-situ techniques on the investigation of SEI formation, ion insertion/extraction mechanism, degradation mechanism, etc. Subsequently, a summary on the current progress toward in-situ techniques is presented as well as the key issues concerning the challenges and perspectives prospect, which give constructive suggestions on the research focus and direction for developing better carbon anode materials.This review aims to highlight the recent developments and discoveries on carbon materials for alkali ion batteries and provide an overview on employing For anode materials in ion batteries, carbon-based materials, silicon-based materials, tin-based materials, and metal oxides have been developed. And after several years of development, carbon materials have become the most successful anode materials. There are usually three types of orbital hybridization for C atoms in carbon materials, e.g., sp, sp2, and sp3. Generally, carbon materials based on sp or sp3 hybrid orbitals, e.g., polyacetylene, hydrocarbons, are difficult materials with which to form a regular structure allowing the insertion/extraction of guest ion, thus they are rarely used as anode materials for ion batteries. The carbon material with sp2 hybridization takes a planar sheet of carbon atoms in a honeycomb structure as a basic unit, and is formed by a stack of these basic units in an ordered or disordered manner , which makes graphite an anode that can be matched with a variety of positive electrode materials to form a battery with high voltage. Similar to lithium, potassium ions also undergo reversible intercalation/extraction reactions in graphite, resulting in a reversible specific capacity of 273 mAhg−1 , it was found that the local binding of a Na ion to a single layer of graphene was quite unstable by ≈0.5 eV (Ei) compared with those for other alkali metals (AMs). This Ei was in accordance with the formation energy (Ef) reported for AM-GICs , graphite is considered to be difficult to apply as an anode for sodium ions batteries (SIBs). The reason leading to this issue is attributed to the fact that the insertion mechanisms of different alkali ions into graphite are different, so the electrochemical behavior of graphite electrodes in LIBs, SIBs, and PIBs varies a lot. Unfortunately, the fundamental origin of the difference is still not clear due to the complexity of the system and the difficulty of quantifying ion intercalation , high rigidity (Young's modulus of the order of 1 TPa), low density and high tensile strength (60 GPa) , making them a competitive lithium storage material  have been approved to be an additive or substitute in LIBs anode owing to the chemical stability, large surface area, robust mechanical properties, and high electrical conductivity  film has been synthesized by Pan et al., and a high capacity of 390 mAh g−1 and retention of 97% after 200 cycles at a rate of 4C were delivered in LIBs   and mesopore volume of the HCMSC, which facilitated fast mass transport. An ultra-thick mesoporous carbon with a thickness up to 850 μm and an areal mass of 55 mg cm−2 was firstly demonstrated by Shen and his co-workers. This mesoporous carbon showed a high specific capacity of 270 mA h g−1 and a high areal capacity of 13.6 mA h cm−2 in sodium ion half cells, which were significantly higher than those of the state-of-the-art sodium batteries  with hierarchical nanoarchitecture, and this anode material exhibited a ultra-high Li storage capacity of 1,000 mAh g2/C composite with ultra small SnO2 particles (~2.0 nm) homogeneously confined in the micro/mesoporous pores of porous carbon to accommodate the volume changes upon lithiation/delithiation. The as-prepared composite delivered a high initial reversible charge capacity of 916 mAh g−1 and an reversible capacity retention of 79% after a long cycling life   during the pyrolysis process, and then convert to amorphous carbon through the crosslinking and partial aromatic ordering process. In the past few years, biomass materials have developed rapidly. A large amount of biomass materials, such as carbohydrates, lignin, chitin, cellulose, proteins, etc., have been prepared as carbon materials and used as electrode materials for energy storage devices. Carbon nanoparticles were prepared by Gaddam et al. through a flame deposition method with coconut oil as carbon sources, and delivered capacities of 277 and 741 mA h g−1 in sodium and lithium ion batteries, respectively , and achieving the controllable preparation of materials are of great significance for the development of biomass carbon materials.In addition to the above carbon materials, some new types of carbon materials with special structure are synthesized and applied as anode for ion batteries. Xing et al. synthesized polynanocrystalline graphite via chemical vapor deposition on a nanoporous graphenic carbon as an epitaxial template. This new carbon shows a structure of essentially hollow to a certain extent with randomly arranged nanosized graphite building blocks, which is different to most low-dimensional nanocrystalline carbon materials. This novel structure with disorder at nanometric scales but strict order at atomic scales enables substantially superior long-term cycling life and capacity retention for K-ion storage than that of graphite  formation/decomposition as well as the reduction/oxidation of anode material, and (iii) insertion/extraction reaction mechanism that involves the insertion/extraction of Li into/from the lattice of the carbon material   Li-alloy reaction mechanism, (ii) conversion reaction mechanism that involves the Li oxides  while the capacity in the plateau region derived from the insertion/extraction of Li+/Na+. In 2012, Cao et al. investigated the sodium and lithium storage mechanisms in hollow carbon nanowires (HCNWs) and demonstrated that the electrochemical behaviors of HCNWs in SIBs and LIBs are distinctly different , a protective layer on the surface of carbon anode, is formed by electrolyte decomposition during the first charge/discharge process. For LIBs, many performances, e.g., the irreversible charge loss, rate capability, cycling performance, graphite anode spalling and the battery safety, are related to the quality of SEI. Generally, the electrolyte of LIBs is thermodynamically unstable at a relatively low or high potential. Thus, there is a reduction process of solvents and salts on the surface of carbon materials, resulting in a deposition of organic/inorganic decomposition to form an SEI membrane. The potential for SEI formation is not a fixed value, generally ranging from 0.5 to 2 V  which displays as a dense layer near carbin and organic components  which displays as a porous organic or polymer layer  is highly active and could react with lithium to rapidly produce precipitate on the surface of graphite anode , leading to cracks and splits in graphite particles, and thus causing a decrease in orientation  the operando evolution of dynamic structure changes under real working condition; (2) focus on the same location to ensure a good comparability among obtained results; (3) collect signals quickly to capture intermediate product information; (4) simple operation.On the other hand, the “in-situ techniques used to investigate carbon materials are summarized, including scanning probe microscopy (SPM), Raman spectra, Fourier transform infrared spectroscopy (FTIR), X-ray/neutron diffraction (XRD/ND), small-angle X-ray/neutron scattering, transmission electron microscope (TEM), and nuclear magnetic resonance spectroscopy (NMR).In this part, the SPM is an analytical technique for characterizing the real-space morphology of electrodes on the nanometer scale with minimal destruction. One of the most important advantages of SPM is that it can be conducted in a liquid environment to obtain operando information about the SEI film. The edge plane of graphite, which is fault-like, is the main research objective of SPM.+ into graphite; (3) electrolyte reduction on the surface of graphite; (4) enrichment of inorganic phases. The SEI film is initially triggered by electrochemical reaction at the defects and edge plane of graphite at 1.5 V due to the reduction of trace amount of HF to produce LiF particles. The inorganic particles are deposited in a ring-shaped and non-uniform form  which determines the change of the distance between graphite layers, STM can precisely speculate the growth mechanism of SEI film. It is found that SEI film growth mainly includes four stages: (1) HF reduction; (2) intercalation of solvated Lir higher   during the electrochemical process. The absorption strength of oxygen-containing groups is significantly weaker than that of pristine materials after the initial cycle, demonstrating that the capacity of rGO in the first cycle is mostly irreversible. The signal for the C=O group in the EC is clearly identified in the SEI film, proving that the EC molecule plays a great role in the SEI formation.FTIR, sensitive to polar groups, e.g., OHin-situ characterization method for LIBs  are the most important techniques to study material structure. The orientation and intensity of the diffraction in the spatial distribution are closely related to the crystal structure. However, since the principle of XRD is that the X-ray interacts with electrons, the obtained scattering intensity in XRD patterns is proportional to the atomic number of elements, and a low sensitivity to light elements such as Li and C is delivered. Fortunately, scattering intensity of ND originated from the interaction between neutrons and nuclei is non-linearly related to nuclei, therefore ND is particularly suitable for probing the atomic arrangements of lithium and carbon during lithium intercalation. Hence, XRD is applied to provide information on the reversibility of the Liin-situ XRD and ND, the structural evolution and lithium intercalation behavior can be well-characterized.Ion-intercalated graphite would induce a series of phase transitions as well as the volume change. The former has guiding significance for developing new electrode materials while the latter provides valuable information for practical applications (capacity decay and safety issue). Graphite is composed of multiple layers of graphene, and the intercalation mechanism at the beginning of ion intercalation, during which ions would be uniformly intercalated into each layer or into specific layers, is a remaining debate. Fortunately, combining xC6 and presented the single-phase and coexisting-phase region by in-situ XRD  is a technique to study the internal mesoscale structure of materials by elastic neutron scattering. Due to its high sensitivity to light elements, the lithium inercalation/deintercalation process can be visually observed during charging/discharging. During lithium intercalation, the relationship between lithium intercalation and voltage can be deduced due to the different neutron absorption intensity of lithium and graphite  close to the original beam, which is called small-angle neutron scattering (SAXS) . Since tin-situly characterize the porous carbons in lithium-ion batteries, such as the entry of electrolytes, chemical reactions in the pores and the changes of pores. Csencsits et al. investigated the lithium storage during the charging/discharging process through continuous SAXS and no evident structure change was observed, suggesting that the electrolyte does not enter the porous material and would not react with the inside material 2. As the charge/discharge cycle progresses, the content of the inorganic phase, such as Li2O, LiOH, LiF, etc. gradually increases. It is also observed that the intercalation of lithium occurred at a lower potential which was the dominant scattering process  characterizations, in combination with density functional theory simulations are carried out to correlate the real-time electrochemical K+ intercalation/deintercalation process with structure/component evolution. The experimental results, together with theoretical calculations, reveal that the reversible K ion intercalation into graphite follows a staging transition (Liu J. et al., Different from a single technique, multiple techniques can provide more information to better reflect the internal structural changes. To promote better fundamental understanding of KSo far, carbon-based materials are the most ideal and widely used anode materials for alkali ion batteries. With the increasing requirements on the performance of commercial batteries, such as energy density, operating temperature range and rapid charging/discharging, developing new carbon-based anode materials is one of the most concerned issues. Figuring out the ion diffusion behavior of the battery under real working conditions, and understanding the working mechanism of the active materials and the changes of the interface are of great significance for the designing new materials and improving battery performance. However, the mechanism of different carbon materials, the structural changes of the same material at different working conditions, the formation/transformation of chemical compounds are extremely complicated, and it is difficult to characterize them with conventional methods .in-situ technologies, changes of components and material structure in the battery can be characterized operandoly while the electrochemical reaction is proceeding. However, it is difficult to deduce the working mechanism based on the data obtained by a single characterization technique. In terms of the mechanism characterization of alkali metal ion batteries, SPM and TEM are suitable for observing the growth of SEI film on the surface of carbon materials, Raman spectroscopy can observe the changes of carbon materials during the formation of SEI film, FTIR, and NMR are used to determine the chemical composition of the SEI film, XRD and ND are applied to study intercalation/deintercalation behaviors of alkali ions into/from carbon materials, SAXS and SANS mainly observe the structural changes of microporous or mesoporous materials which are of great benefit to help understand the ions intercalation and the SEI formation, and XRD, TEM, and SANS are often used in the study of material failure. By combining the observation of these characterization techniques, a true working mechanism of alkali metal ion batteries would be better understood and deduced.With in-situ techniques has been summarized. The ion intercalation mechanism, SEI formation and degradation of carbon materials in anode have been explored using in-situ techniques including SPM, optical spectroscopy, XRD, SAXS/SANS, TEM, and NMR. Nonetheless, except for graphite, other types of materials are just partially studied. Hence, more details of the different carbon materials need to be investigated in order to provide guidance for future material development. It is noted that there are many studies on graphite anodes and their mechanism is relatively clear. However, the mechanism for new carbon-based materials is still controversial. Research on these new carbon materials can provide guidance for the development of new carbon-based anode materials.In conclusion, the recent research on the understanding the working behavior of carbon materials in alkali ion batteries through As the anode material for the ion batteries, the specific capacity of graphite is limited by the ion intercalation mechanism. To increase the specific capacity of carbon-based materials, it is necessary to introduce a different capacity contribution mechanism. However, the new mechanisms, such as defect adsorption and ions deposition, lead to lower initial Colombic efficiency and thus difficulty in practical application in commercial batteries. Therefore, improving the initial Colombic efficiency and stability of carbon materials is the basis for designing new materials. As is well-known, the adsorption of ions in the defect sites and the deposition in the pores can greatly increase the specific capacity of the carbon based anode materials. However, there are still a large number of phenomena that need to be determined clearly, such as the influence of different kinds of defects, contribution of pore size and distribution to capacity, as well as the exact reaction process. Addressing these issues is essential for the design of practically applicable high specific capacity anode materials.in-situ techniques. However, most of these in-situ techniques suffer from poor penetration and small characterization depth, as a result, in situ devices with complex structures need to be specially designed. Therefore, the development of non-destructive in situ techniques to directly monitor the structural changes in commercial batteries is still urgently needed. In addition, a single in situ characterization only evaluates specific signals which makes it difficult to fully reflect the behaviors inside the battery. To fully understand the behavior of materials under working conditions, multiple in situ techniques are required. Therefore, evaluation of the internal behaviors via multi-techniques under the same working conditions is the focus of future.Analysis and understanding of chemical reactions, degradation mechanisms and thermal failure mechanisms ion batteries play particularly important roles for the development of confidence electrode materials. The material structural transformation during the charge/discharge process, the redox process, the transformation of SEI formation, and other side reactions that occur in the battery can be monitored by In situ techniques exhibit unparalleled advantages in mechanism research and characterization of reaction behavior. With the application of more in situ techniques and the maturity of technology, more details about the real working behaviors in alkali metal ion batteries will be observed. And these new findings will enhance the understanding of alkali metal ion batteries and promote the development of new electrode materials.RD and YalH collected the articles and wrote the first manuscript. GL and QL organized references and revised the manuscript. TW organized the figures. YanH and YL modified the format and revised the manuscript. HH revised the manuscript, approved the final version, and supervised the whole work. All authors contributed to revise the manuscript, approved the final version, and agreed to be accountable for all aspects of this work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Non-alcoholic fatty liver disease (NAFLD), which is emerging as a major public health issue worldwide, is characterized by a wide spectrum of liver disorders, ranging from simple fat accumulation in hepatocytes, also known as steatosis, to non-alcoholic steatohepatitis (NASH) and cirrhosis. At present, the pharmacological treatment of NAFLD is still debated and dietary strategies for the prevention and the treatment of this condition are strongly considered. Polyphenols are a group of plant-derived compounds whose anti-inflammatory and antioxidant properties are associated with a low prevalence of metabolic diseases, including obesity, hypertension, and insulin resistance. Since inflammation and oxidative stress are the main risk factors involved in the pathogenesis of NAFLD, recent studies suggest that the consumption of polyphenol-rich diets is involved in the prevention and treatment of NAFLD. However, few clinical trials are available on human subjects with NAFLD. Here, we reviewed the emerging existing evidence on the potential use of polyphenols to treat NAFLD. After introducing the physiopathology of NAFLD, we focused on the most investigated phenolic compounds in the setting of NAFLD and described their potential benefits, starting from basic science studies to animal models and human trials. Non-Alcoholic Fatty Liver Disease (NAFLD) is a clinical condition primarily characterized by fat accumulation in liver parenchyma (>5% of hepatocytes). Its clinical burden is encompassed in its pathological spectrum, which ranges from simple fatty liver (Simple Fatty Liver—SFL) to steatohepatitis (Non-Alcoholic Steatohepatitis—NASH), ending with hepatic cirrhosis and hepatocarcinoma, through a progressive fibrosis of the organ . These aThe international threshold observed by international guidelines to distinguish the alcohol-induced fatty liver disease from NAFLD is represented by two drinks, corresponding to 20 g of alcohol intake per day .NAFLD is the most common chronic liver disease worldwide and its prevalence is constantly rising in the global population, concurring with that of diabetes and obesity. Twenty-five percent of adults are affected by NAFLD and its prevalence doubles in diabetic or obese subjects ,6. An inPolyphenols are a diversified class of vegetable-derived compounds sharing the chemical property of being hydrosoluble . They arThus, throughout the years, several authors aimed to evaluate the effect of polyphenols on metabolic pathologies, such as insulin resistance and NAFLD. This review aims to explore the promising role of polyphenols in treating NAFLD, according to the most recent updates. After introducing the physiopathology of NAFLD, we focused on the most studied phenolic compounds and described their potential clinical benefits in the setting of NAFLD, through the examination of basic science studies, animal experimental models, and studies on human subjects.Pathophysiological mechanisms underlying NAFLD are classically explained by the two hits hypothesis, in which two harmful events in the sequence occur and compromise the function and structure of the liver parenchyma—the accumulation of fatty acids in the liver , which represents the first one, and the progressive onset of oxidative stress and hepatocyte damage subsequently ,12. ThisLiver steatosis is the biochemical result of an imbalance between fatty acid uptake and synthesis in the hepatocytes, and their discharge from the cell through beta-oxidation and secretion by Very Low-Density Lipoproteins (VLDLs). In greater detail, the metabolic steps that lead to the accumulation of triglycerides in the hepatocytes are fatty acid uptake, de novolipidogenesis, fat oxidation, and VLDL export into the blood ,20. SeveIt is important to underline that the diagnosis of NAFLD, to be sensitive and accurate, needs a liver biopsy and histological staining, as histopathology allows clinicians and researchers to score NAFLD activity. This tool is limited in clinical practice by its invasive nature . Hence, Polyphenols represent an immense family of organic compounds widely present in natural products. The term polyphenol derives from the presence in the chemical structures of phenolic groups that are established in more or less complex structures. Due to their great variety, polyphenols are classified into flavonoids and non-flavonoids . Among tThymbra spicata polyphenol extracts to assay their antisteatotic and antioxidant properties in vitro [Studies based on cell cultures represent a well-established tool to directly assess the molecular mechanisms of action of polyphenols in the prevention or treatment of steatosis. Primary cultures of human hepatocytes are the optimal model to perform in vitro research for discovering NAFLD-related mechanisms, but poor liver sample availability is a limitation of this technique . The humin vitro . Resultsin vitro . More rein vitro . Differein vitro . On thisin vitro ,35.All polyphenols or polyphenol-rich extracts reported some efficacy in reducing triglycerides accumulation in the liver, but each tested compound could show a peculiar molecular target. The mechanisms of action ranged from lipidogenesis regulation to modulation of insulin-resistance, oxidative stress modification, and inflammation control .Inflammation and the subsequent change in the inflammasome pathway, with the derangement of cytokines profile, is the focal point for the transition from the simple accumulation of lipids in the liver to NASH. As several pre-clinical studies reported that NAFLD is characterized by histological and biochemical inflammation, polyphenols can ameliorate the inflammatory response and reduce fat accumulation in hepatocytes . PreferrNrf2 was previously recognized as a key regulator of cellular oxidative status balance, with a protective role, and its mRNA is reduced during High Fat-High Fructose (HFHFr)-induced NAFLD . The benBergamot is a citrus fruit that grows typically in the Calabria region of Southern Italy and its polyphenol extract, the Bergamot Polyphenol Fraction (BPF), was studied on NAFLD induced by a high-calorie diet in male Wistar rats. The results showed that BPF significantly boosted lipid droplet clearance from the liver and reduced the plasma TAGs. Moreover, BPF improved insulin-sensitivity and modulated hepatic inflammation by reducing the pro-inflammatory cytokine IL-6 and increasing the anti-inflammatory cytokine IL-10 levels .Resveratrol is a polyphenolic compound thatwas proven to be effective in ameliorating liver pathologies . In a moGreen Tea Polyphenols (GTP) are known for the beneficial effects on metabolic syndrome, of which NAFLD is a common hepatic manifestation. In rats, GTP significantly reduced transaminases and fasting glucose blood levels, insulin resistance, and hepatic lipid content. Furthermore, GTP reduced inflammation by decreasing levels of IL-6 and TNF-α and the histopathological hallmarks of liver injury, while increasing the concentration of the antioxidant enzyme superoxide dismutase. The proposed mechanism could be the modulation of AMPK activity, as GTP increased AMPK phosphorylation . Chinese raw bowl tea, which is rich in polyphenols, showed benefits in decreasing body weight and liver weight, in HFD-induced NAFLD mice. Moreover, the tea decreased inflammatory cytokines and reactive oxygen species production in the liver, ameliorating the status of liver impairment . Raw bowClinical trials conducted on human subjects suffer from the practical limitation of obtaining liver biopsies to replicate the assessments conducted in studies, using animal models. Hence, surrogate tools for the evaluation of NAFLD are used in this setting, such as surrogate scores, ultrasonography, or magnetic resonance spectroscopy ,49. SeveCurcumin was administered in patients with ultrasonographic evidence of NAFLD, 1000 mg × day for 8 weeks, showing a significant reduction in body mass index (BMI), a significant reduction in liver fat content and a reduction in HbA1c and blood glucose levels in curcumin, compared tothe placebo group. A decrease in liver volume and improvement of portal flux in the curcumin group was also shown. Of note, curcumin was safe and well tolerated by subjects ,52. The biochemical and physiological effects of resveratrol and its benefit on NAFLD was evaluated by a 12-weeks, double-blind, RCT, at a dosage of 75 mg in two oral daily doses. Hepatic fat content was assayed by magnetic resonance spectroscopy. Liver fat content in the resveratrol supplementation group was significantly reduced as compared tothe placebo group, suggesting that resveratrol could prevent the liver fat increase. Resveratrol resulted wassafe and well tolerated during the trial . AnotherIt is recognized that cardiovascular complications are the major cause of mortality in NAFLD, therefore, the effects of resveratrol on the atherogenic risk factors in NAFLD patients were investigated . AlthougSilybum marianum, whose beneficial effects as an antioxidant was reported in patients with NAFLD [Silymarin is a complex mixture of 6 major flavonolignans and other minor polyphenolic compounds derived from the milk thistle plant th NAFLD . In patith NAFLD . Our groth NAFLD .The interest in polyphenols as nutraceutical supplementation in NAFLD is increasing, as any of these compounds might offer healthy properties for the liver. Considering that NAFLD is an upcoming challenge for scholars and health systems worldwide, it is plausible to consider polyphenols as a potential new therapeutic approach to treat hepatic fat accumulation and its sequelae. This approach is supported by several in vitro studies, animal models, and few clinical trials. Additionally, pre-clinical and clinical settings showedmany effects of polyphenols, likethe increase of fatty acid oxidation and the modulation of insulin resistance, oxidative stress, and inflammation, which represent the main pathogenetic steps of the onset and progression from SFL to NASH. However, data from clinical studies are still limited and often conflicting. Further investigations are needed, especiallythrough randomized clinical trials, for validating the intriguing role of polyphenols in the treatment of NAFLD.


Today pre-eclampsia (PE) is considered as a disease of various theories; still all of them agree that endothelial dysfunction is the leading pathogenic factor. Endothelial dysfunction is a sequence of permanent immune activation, resulting in the change of both the phenotype and the functions of an endothelial cell and of the extracellular layer associated with the cell membrane—endothelial glycocalyx (eGC). Numerous studies demonstrate that eGC mediates and regulates the key functions of endothelial cells including regulation of vascular tone and thromboresistance; and these functions are disrupted during PE. Taking into account that eGC and its components undergo alterations under pathological conditions leading to endothelial activation, it is supposed that eGC plays a certain role in pathogenesis of PE. Envisaging the eGC damage as a key factor of PE, might be a new approach to prevention, treatment, and rehabilitation of patients with PE. This approach could include the development of drugs protecting eGC and promoting regeneration of this structure. Since the issue of PE is far from being solved, any effort in this direction might be valuable. Pre-eclampsia (PE) is one of the most serious complications in pregnancy, which takes the third place in the list of causes of maternal mortality, and is the major cause of the neonatal morbidity and mortality . PE is cDevelopment of placental ischemia is characterized by an increase of apoptosis in the placental structures and entry of necrotic debris and microparticles of trophoblastic origin into the maternal blood. These changes initiate the launch of systemic inflammatory response (SIR): activation of immune cells and the complement system, synthesis of proinflammatory cytokines, and, consequently, development of endothelial dysfunction ,6,7.Endothelial dysfunction is thought to play a major role in pathogenesis of PE, since endothelium is a unique monolayer of the cells located in the vessels of the main target organs ); pathologic changes in these organs determine the maternal and fetal outcomes . EndothePro-inflammatory impact on endothelium will inevitably affect the molecular structure of endothelial glycocalyx (eGC) , which iRecent studies indicate that homeostatic functions of endothelium are ensured by the intactness of the eGC; its composition and structure significantly differ under the physiological and pathophysiological conditions ,16,17. TAbnormal changes of eGC can be linked to main clinical symptoms of PE: progressive endotheliosis, hypertension, tissue edema, disseminated intravascular coagulation (DIC) syndrome, impaired permeability of glomerular and hematoencephalic barriers see . HoweverAdditionally, increased blood levels of HA and sdc1 were found in a case–control clinical trial in patients with chronic kidney diseases . Damage If we assume that eGC is the main morphological substrate of PE, one may question, whether this glycopathology is primary  and manifests itself during pregnancy by PE development, or eGC damage is a result of ischemia in the placental tissue, leading, after a “point of no return”, to uncontrollable endothelial dysfunction. At present, there is no direct answer to these questions, since testing for glycopathology is not used in clinical practice. There are no studies comparing the glyco-gene panel in patients whose pregnancy completed successfully or was complicated by one of great obstetrical syndromes, e.g., PE. Anyway, the need of pathogenetic therapy or correction of the pathological condition caused by destabilization of eGC is obvious.Most likely, early PE, which is associated with placentation disorder, would not benefit from therapy, aimed at the protection and regeneration of eGC, since organic dysmorphogenesis can hardly be overcome. Under permanent exposure to a pathogenetic factor, development of SIR and endothelial dysfunction would inevitably lead to premature birth. Late PE associated with the mother’s underlying condition is more likely to respond to eGC targeted therapy, because patients already receive specific treatment of the pre-existing disease. However, such therapy might be appropriate in both forms of PE, for restoration of endothelial function and prevention of the related long-term morbidity, since PE is known to be a risk factor for subsequent cardiovascular disease . AbilityCurrently, the list of drugs and biologically active molecules that were used in vitro in cell and animal models for protection and regeneration of eGC, is quite impressive. However, clinical studies of pathogenetic target therapy are lacking. There is evidence of a stimulating effect of a number of drugs on restoration of eGC after damage in various pathological conditions . In part-/- gene, in contrast to wild-type mice, FFP did not show any protective effect. It is believed that the effects of FFP are caused by certain components: albumin and adiponectin. Removal of albumin from the bathing media in vitro induced collapse or shedding of glycocalyx. Probably, electrostatic interaction between arginine residues on albumin and negatively charged GAGs in the glycocalyx, can stabilize the glycocalyx structure. Albumin is one of the primary carriers of the phospholipid sphingosine-1-phosphate (S1P). The S1P-dependent protective effect of plasma on human umbilical vein endothelial cells (HUVECs) was demonstrated in the models of trauma and hemorrhagic shock [In mice with knockout of the Sdc-1ic shock . It was ic shock . Howeveric shock . There iic shock  and placic shock . Similaric shock ,96. It wic shock , and extic shock . Though A promising approach from the standpoint of etiotropic therapy aimed to protect eGC, is the use of anticoagulant drugs: heparin (unfractionated heparin (UFH), low-molecular-weight heparin (LMWH)) and heparinoids (sulodexide) . HeparinThe majority of clinical data available on pharmacological stabilization of glycocalyx has been obtained in studies that used sulodexide, a pharmacological agent composed of a mixture of two GAGs (80% of fast-moving heparin fraction and 20% of dermatan sulfate) ,107. SulThere are few studies of the use of sulodexide in pregnancy. Normalization of the total capacity of coagulation and fibrinolytic systems in women with autoimmune hyperthyroidism was noted , as wellMetformin might be a promising drug for protection and regeneration of eGC. Experimental studies have shown metformin-induced recovery of endothelial glycocalyx length and density and the resulting attenuation of adhesive interactions between the endothelium and cancer cells, which might be caused by metformin impact on the nanomechanical and adhesive properties of endothelial and cancer cells in chronic hyperglycemia . PreviouAccording to a number of studies metformin has a potential to prevent or treat PE. A systematic review and meta-analysis by Kalafat E et al. (2018) provides evidence that there is a high probability that metformin use is associated with a reduced incidence of hypertensive disorders of pregnancy (HDP) especially in women with gestational diabetes and obesity, when compared with other treatments or placebo . AnotherThe administration of glucocorticoids (hydrocortisone and methylprednisolone) has been shown to protect eGC by prevention of the endothelial perturbation and glycocalyx shedding ,87. HydrGlucocorticoids may be used during pregnancy if the benefits outweigh the potential risk to the fetus, since these drugs easily cross placenta; therefore, it is necessary to control the symptoms of all medical conditions during pregnancy. Assessment of the glucocorticoids efficacy and safety did not find enough evidence to confirm an increased risk of pregnancy complications . At the The protective effect for eGC was demonstrated for a number of drugs and biologically active molecules in experimental studies; for some, efficacy in PE was shown. In particular, in hyperglycemia N-acetylcysteine decreased the release of HA into the bloodstream after induced hyperglycemia in healthy volunteers . In an eA potential ability to protect or restore the eGC was noted in several chemical substances: protein C, antithrombin, exogenous eGC substituents (HA and chondroitin sulfate), pentosan polysulfate, wheat germ agglutinin, rhamnan sulfate, micro RNAs, anti-TNFα agents, and synthetic antimicrobial peptides ,99,104. Aspirin  is well known to be effective for prevention of PE, and is recommended by professional societies for this purpose ,125,126.Since one of the main factors of PE pathogenesis associated with endothelial dysfunction is decreased endothelial nitric oxide synthase/nitric oxide (eNOS/NO) activity, the effect of ASA on NO production is worth consideration. ASA, even in low dose, has shown beneficial effects mediated through NO formation, especially, through increase in haem oxygenase 1 (HO-1) and decrease in ADMA, expression in chronic stable coronary disease . TherefoIt looks like only one study evaluating the indirect effect of ASA on eCG, has been reported so far: the effects of platelet microparticles (PMPs) on aortic vascular endothelial injury were investigated in vitro and in vivo in experimental diabetes models. It was found that in diabetic rat model and in HUVECs, PMPs inhibited endothelial nitric oxide levels to about 50% and caused approximately twofold increase in reactive oxygen species production. Additionally, PMPs significantly decreased the eGC area and expression levels of glypican-1, and increased endothelial permeability; these effects were alleviated in the ASA treatment. It can be assumed that activated PMPs in diabetes contribute to early endothelial injury primarily due to the activation of the mTORC1 pathway, and ASA inhibits his process . Impact It should be noted that therapeutic strategies aimed to protect eGC are poorly understood and studied. Possible mechanisms of the glycocalyx protection by some drugs represented in Therefore, the development of organic and systemic dysfunction in moderate PE, and multiorganic/polysystemic  failure in severe PE, cannot be explained, in our opinion, without considering the damage to the eGC, which is most likely the main morphological substrate of PE. There is a number of major issues to be clarified: is SIR and its severity the key factor in the development of eGC damage and related complications? Or does the development of systemic inflammation superimpose the existing glycopathology, associated with inability of adequate eGC regeneration? Do the existing indirect methods really reflect the destructive processes in eGC in vivo? Since there are other mechanisms of endogenous NO synthesis stimulation, is disruption of shear-induced NO production due to damage and destruction of eCG a critical factor of hypertention development in PE? Is pathogenetic therapy aimed at eGC protection and restoration possible, and which drugs could be recommended for this? Further study of eGC in PE may provide a new insight in the pathogenesis of the disease and help address these questions.