Exosomes are microvesicles that can be secreted by various cells and carry a variety of contents; thus, they play multiple biological functions. For instance, the tumor-derived exosomes (TEXs) have been proven to have the effect of immunostimulatory in addition to immunosuppression, making TEXs attractive in clinical immunotherapy and targeted therapy for cancer patients. In addition, TEXs as biomarkers have important clinical diagnostic and prognostic value. Recently, TEXs have been recognized to play important roles in the abscopal effect (AbE), a newly discovered mechanism by which the distant tumors are effectively targeted and repressed during immunotherapy and radiotherapy. Therefore, TEXs has demonstrated great clinical potential in the diagnosis, prognosis and treatment of cancer patients in the future. This review summarizes and discusses the role of TEXs in clinical therapy and their role in AbE in recent studies. The abscopal effect (AbE) refers to the regression of a distant tumor away from the primary tumor due to the therapeutic effect of immunotherapy or radiotherapy. The concept of the AbE was first reported by Mole RH in 1953, who described the AbE as the regression of other tumor foci that were outside the initial localized radiation treatment field . Upon thRadiotherapy is one of the most common cancer therapies nowadays, and it is used in the curative and palliative treatment of various cancer for local-regional control . More reExosomes are subgroup of extracellular vesicles, which are released by all types of cells including tumor cells. The molecules carried by exosomes play an important role in intercellular communication. Studies have been focused on the biological and physiological functions of exosomes: immune activation, cancer therapies and being biomarkers. The exosomes have immunological activities including modulating antigen presentation, immune activation, immune suppression, immune surveillance and intercellular communication, which all affect immune-regulating mechanisms. Emerging evidence has shown that tumor-derived exosomes (TEXs) carry both immunostimulatory and immunosuppressing functions, which depend on what molecules are inside the exosomes and the state of the immune cells in the tumor microenvironment . StudiesIntercellular communication plays an important role in proliferation and metastasis of cancer cells, and this process could be triggered by growth factors, cytokines, tumor-associated antigens and some other molecules . TEXs caRecent studies have also demonstrated that TEXs separated from tumor cells could serve as tumor biomarkers because of the TEXs transferring and containing various tumor-related materials, including nucleic acids, glycoconjugates and lipids, which partially reflect the molecular and genetic content of the parent cancer cell. According to this, exosomes are being recognized as very helpful biomarkers for the prognosis, diagnosis and therapeutic response of cancer .Exosomes are a kind of extracellular vesicles that are formed inside the cells and secreted from the cells through exocytosis. Exosomes differ from microvesicles larger than 100 nm in diameter, with an average diameter of 30–100 nm. The biogenesis of exosomes starts from the invagination of the plasma membrane to form endosomes controlled by the endosomal system. Then, during the process with the participation of Golgi bodies, exosomes are formed from endosomes in the early phase to multivesicular bodies in the late phase, and the membrane of multivesicular bodies could form a lumen where intraluminal vesicles are contained. Then the multivesicular bodies could be degraded by lysosomes or fused with plasma membrane, and the intraluminal vesicles could be released outside the cell through exocytosis to form exosomes.The process above is regulated by Rab GTPases and the endosomal-sorting complex required for transport (ESCRT) system. The Rab GTPases in this study included Rab14, Rab22, Rab27 and Rab37, which were responsible for the formation of intraluminal vesicles, the fusion of the multivesicular bodies with the plasma membrane and the degradation of the multivesicular bodies by lysosomes. The ESCRT included ESCRT-0, ESCRT-I, ESCRT-II and ESCRT-III. ESCRT-0 was responsible for assembling molecules and internalizing the ubiquitinated proteins. ESCRT-1 and ESCRT-II were responsible for the invagination process and promoting the deubiquitination of those ubiquitinated proteins. ESCRT-III was responsible for the separation and disassembling of intraluminal vesicles .The exosomes only can be observed under the electron microscopy. Although there are many kinds of exosomes which are composed of different molecules that they transfer, the morphology of the exosomes is similar. Morphologically, the exosomes in our study were round in shape, with a phospholipid bilayer membrane and aqueous core containing proteins and nucleic acids. The molecules contained in exosomes were dependent on their parental cells, their pathophysiological conditions and environmental stimulations. Generally, as shown in TEXs contain some extra immune suppression-associated molecules, such as tumor-associated antigens, FasL, PD-L1, ALIX, TRAIL, IL-10, TGF-β and prostaglandin E2 (PGE2) , which aThe main functions of TEXs are determined by the role they play in the tumor microenvironment. Therefore, because of the abilities of intercellular communication and immune regulation, TEXs play a major role in cancer progression by the bioactive molecules interacting with the recipient cells and changing their functions. Research has demonstrated that TEXs are the carriers of oncogenetic signals and oncogenes to promote the process of neoplastic transformation. In general, TEXs were proven to be related to tumor progression, angiogenesis, drug resistance and immune regulation. Specifically, TEXs promote tumor progression through the upregulation of the tumor cell proliferation and tumor growth, the enhancement of tumor invasion and tumor metastasis, the suppression of anti-tumor immune responses and the promotion of the horizontal transfer of oncogenic mutations . EpidermResearch has shown that most of the tumor-derived exosomes are isolated from the supernatants of cultured tumor cells . VariousThe density-gradient separation is another conventional method with a better purity and recovery rate for isolating exosomes. This separation method is based on the isopycnic point mechanism . AlthougImmunoaffinity-based isolation is a method that depends on specific proteins on the membrane of exosomes. Antibody-conjugated beads are used in this method to recognize the specific antigens on the exosomes membrane and then capture the TEXs. This technique has more advantages: the reduction of cell-debris and protein aggregates in co-purification, better isolation of exosomes subgroups based on the specific antigens on the exosomes membranes, increased recovery rate and the ability to process multiple samples simultaneously ,19.There have also been other techniques used for isolation of exosomes, such as using the force of inertia in microfluidic channels to separate the exosomes from the other substances  and the miRNAs have been recognized as biomarkers in the diagnosis and prognosis of cancers. Studies in hepatocellular carcinoma showed that exosomal miRNA from serum-like miR-103 and miR-638 were potential biomarkers. Elevated miR-103 in hepatocellular carcinoma cells indicated metastasis, while decreased miR-638 was associated with late-stage cancer and the recurrence of cancer ,23. In clncRNAs were regarded as potential biomarkers in clinical applications, as was reported recently, and they also play a crucial role in the tumor microenvironment. In hepatocellular carcinoma, lnc-sox2ot , lnc-h19circRNAs recently emerged as a potential biomarker for diagnosis due to their stable structure, conserved consequence and extensive expression . In addiDNA is increasingly being used for the diagnosis and prognosis of cancer after being proved that it indeed existed in exosomes, though it is not as efficient as miRNA. Because of the short half-life and high sensitivity, stability and mutation rate, DNA has great potential in clinical applications for real-time tumor monitoring . In diffNevertheless, the applications of exosome-dependent biomarkers still face many challenges. Despite the extensive use of exosomes in diagnosis and prognosis of cancer, the lack of standard methods for isolating exosome populations and the lack of heterogeneity in TEXs are still problems that exist . When itAccording to the previous studies, most functions of exosomes are for immune suppression. However, recent studies have suggested that TEXs carry stimulatory molecules, in addition to the inhibitory molecules. These TEXs can deliver the stimulatory signals to distant immune cells and promote immunity, leading to eradication of established tumors. TEXs can indirectly deliver tumor antigens to dendritic cells, and then activate cytotoxic activities of CD8+ T cells and CD4+ T helper cells, resulting in suppressing tumor growth and resistance to malignant tumor development . The tumAll cells in the tumor microenvironment produce exosomes, and TEXs could reprogram the microenvironment to promote immune activities by directly or indirectly inducing the immunostimulatory signals . ActuallIn addition to the immunotherapy, radiotherapy is another common method used for curative or palliative cancer therapy. A phenomenon called the “abscopal effect (AbE)” was first found by Golden and colleagues in clinical trials, and refers to the tumor regression that occurs in fields without irradiation distant from the local tumor area . BecauseOn the other hand, radiotherapy combined with immunotherapy and the mechanism of the AbE had the potential of enhancing the therapeutic effect. For example, in a study by Poggi et al., a TEX-related mouse model named TRAMP-C2 (mouse tumor cell line) was proposed. The TRAMP-C2 cells lacking exosomal PD-L1 were not only unable to grow, but the contralateral tumor growth was significantly reduced when the cells were injected into the other side of the mouse, suggesting that the lack of PD-L1 in tumor cells could induce the AbE. This study indicated that PD-L1 on TEXs can be used as a target for anti-tumor therapy . StudiesBy participating the promotion of angiogenesis, stromal rebuilding, activating the signaling pathway through growth factor/receptor transfer, drug resistance and intercellular genetic exchange, TEXs could be regarded as the central mediator in the tumor microenvironment .Recent studies indicated that being biomarkers was the most important biological function of TEXs . A biomaIn pancreatic cancer patients, glypican-1 (GPC-1), a membrane-anchored proteoglycan, and GPC-1+ exosomes were found with a higher level in serum than in healthy people, and they had great sensitivity and specificity in the diagnosis of early pancreatic cancer . In addiIn prostate cancer, PCA3 and TMPRSS2:ERG are two proteins used as biomarkers for diagnosis, which exist in urinary exosomes . EGFR alIn colorectal cancer, recent studies found that proteins in serum-purified exosomes (SPE) were important biomarkers for tumor metastasis. For instance, hepatocyte growth factor-regulated tyrosine kinase substrate (HGS) was a biomarker for poor prognosis . BesidesThough exosomal proteomics methods are of great importance in tumor diagnosis and prognosis, there are still difficulties in the quality requirements of exosomes because of the low level of exosomal-specific proteins in serum . MoreoveSince TEXs play a role in tumor progression, drug resistance and metastasis, a therapeutic method was developed to block the circulation of TEXs in blood for the treatment of cancer patients. This method is called adaptive dialysis-like affinity platform technology (ADAPT™). When the blood from a cancer patient is transferred through this system, the plasma specimen factor interacts with immobilized affinity agents through porous fibers to target molecules that can be selectively absorbed, while other blood cells and contents can go through the system . Though TEXs can be used for targeting specific tissues and drug delivery. For example, Doxorubicin carried by TEXs can be delivered to the target cancer tissue, like that of colorectal or breast cancers, which has shown a higher efficacy in repressing tumor progression and metastasis . BecauseAs shown in In summary, the TEXs originated from tumor cells possess the ability to suppress anti-tumor immune responses and promote tumor progression and metastasis. TEXs suppress anti-tumor immune responses because of the inhibition of immune effector cells and the interference of cancer therapy, directly or indirectly induced by immunosuppressive ligands carried by TEXs . In addiOn the other hand, TEXs may also contribute to the AbE, an emerging mechanism of anti-tumor immunity . TEX-med


Significant temporary alleviation in neuropathic pain intensity was also observed in the meta-analysis of repetitive TENS . Subgroup analysis showed no effect of the timing of the application of TENS . Leave-one-out sensitivity analyses suggested that no single study had an outsized effect on the pooled estimates, which may partly prove the robustness of these findings. Other stratified analyses were prevented by the insufficient number of included studies. Overall, current data suggest that TENS might be a promising therapy to ameliorate neuropathic pain. However, the high risk of bias in the included studies suggests that cautions must be considered when interpreting these findings and it is not reasonable to directly generalize the results obtained from animal studies to clinical practice. Future studies should pay more attention to improving the quality of study design and reporting, thereby facilitating the understanding of mechanisms underlying TENS treatment, reducing more potentially unsuccessful clinical trials, and optimizing the efficacy of TENS for people with neuropathic pain.Transcutaneous electrical nerve stimulation (TENS) is a non-invasive therapeutic intervention that is typically used for many years to treat chronic pain in patients who are refractory to pain medications. However, evidence of the efficacy of TENS treatment for neuropathic pain is lacking in humans. To further understand the efficacy of TENS under various intervention conditions and illuminate the current circumstance and future research directions, we systematically reviewed animal studies investigating the efficacy of TENS in relieving pain in neuropathic pain rodent models. We searched the Cochrane Library, EMBASE, MEDLINE (via PubMed), and Web of Science and identified 11 studies. Two meta-analyses were performed. The first meta-analysis showed that a single TENS treatment was capable of temporarily ameliorating neuropathic pain when compared to control groups with a significant effect (standardized mean difference: 1.54; 95% CI: 0.65, 2.42;  Neuropathic pain, which is caused by an injury or disease of the somatosensory system, is characterized by spontaneous pain, hyperalgesia, and allodynia and can be classified as peripheral or central neuropathic pain according to the site of injury or disease . It is evia two or more skin electrodes to stimulate underlying nerves for pain control and has an advantage of allowing patients to control their pain autonomously , and Web of Science. Search terms included pain, transcutaneous electrical nerve stimulation, muridae, and keywords that were confirmed following multiple pre-searches  Animal studies using rodent models of neuropathic pain induced by one of the following methods: chronic constriction injury (CCI), spared never injury (SNI), spinal cord injury (SCI), spinal nerve ligation (SNL), nerve crush injury (NCI), viral infection for postherpetic neuralgia, plexus ablation, chemotherapeutics, streptozotocin administration, or central lesions ; (2) Rodex vivo and in vitro preparations; (2) studies in which pulsed electrical stimulation was delivered percutaneously such as electroacupuncture (EA) and percutaneous electrical nerve stimulation (PENS) or in which rodents received vagus/trigeminus nerve stimulation or acupuncture points stimulation, including, but not limited to transcutaneous electrical acupoint stimulation (TEAS); (3) TENS was utilized in conjunction with another intervention; (4) studies not including an independent control group that did not receive active TENS; (5) Conference abstract, editorial, review, and non-English publications.Exclusive criteria were as follows: (1) studies using rodent models of inflammation pain, non-inflammation pain, or cancer pain, and those utilizing non-rodent models, humans, or via email. Discrepancies were resolved through discussion, or by consulting a third investigator.According to the above criteria, two reviewers independently read the titles and abstracts of the retrieved records and eliminated apparently irrelevant studies. Subsequently, the full text of the remaining studies was retrieved, and two investigators independently assessed the studies for final inclusions. In case of ambiguity, we contacted the authors to provide additional information TENS and control data about paw withdrawal thresholds expressed as an absolute value or a percentage after TENS treatment at identical time points were extracted. When quantitative data were not explicitly reported in text and supplementary materials, we extracted the data from figures using Engauge Digitizer . The priTwo investigators independently evaluated the risk of bias of included studies utilizing the SYRCLE’s risk of bias tool for animal studies . High-biI2 to evaluate the heterogeneity. Where comparable data were available from at least three studies, we planned subgroup analysis in the following domains: frequency, the timing of intervention, intensity, electrode placement, species, method of modeling, the timing of outcome measurement, and anesthesia used during intervention procedures. We evaluated the robustness of the results using leave-one-out sensitivity analyses. For studies that could not be included in the meta-analysis, we performed a descriptive summary. The publication bias would be analyzed using a funnel plot in case of at least 10 studies were included in a certain subgroup; otherwise, we would not analyze the publication bias.All meta-analyses and graphical displays were conducted using RevMan 5.3 . A random-effects model was used due to the exploratory nature of animal studies and the anticipated heterogeneity. If methods of outcome measurement or forms of data expression were different among the included studies, we calculated a standardized mean difference (SMD) to summarize effects from studies in this meta-analysis; otherwise, a mean difference (MD) was used. To ensure that the results had the same directional value, we multiplied one kind of outcome by −1 if the change direction to reflect the relief degree of neuropathic pain was different. To prevent double-counting sample sizes of control animals, we split the animal number of the control group in case of studies using a single control group and multiple experimental groups. We used As shown in According to the SYRCLE’s risk of bias tool for animal studies, the overall quality of existing literature was low due to the unclear risk of bias that existed in most of the studies . In termThree studies  assessedp = 0.0007; I2 = 58%; Meta-analysis showed that a single session of TENS has a positive short-term effect in alleviating neuropathic pain relative to comparators : the pooled SMD was 0.63 . And the results persisted in the leave-one-out sensitivity analyses, which may in part prove the robustness of this meta-analysis. This meta-analysis provides a proof of concept for the application of TENS in pain caused by nerve injury. However, the high risk of bias in the included studies shows that care must be taken when interpreting these findings, and the small number of studies leaves many unsolvable knowledge gaps. Finally, evidence from the review does not support the generalization of the findings of the present meta-analysis to female animals and the long-term nociceptive effect of TENS remains unclear.The disadvantages of clinical trials are that independent variables and confounders , includivia δ-opioid receptor class, while low-frequency may work through μ-opioid receptor class and therefore its effects may be limited in people using opioids, as opioids act through the μ-opioid receptor  remaining unknown. There is an urgent need to investigate the effect of TENS on central neuropathic pain in future studies.Sex is also a key factor for pain as both rodent and human studies reported sex differences in the physiologic and anatomical properties related to pain, including the expression and binding of mu-opioid receptor, morphine metabolism, the activation of the immune system, and the descending antinociceptive circuit . HoweverSome limitations inevitably exist in the present meta-analysis. A study limitation is that there might have been several significant heterogeneities in the included studies, such as frequency, duration, and timing of TENS treatment and pain model. For meta-analytic aims, we had to merge these confounding factors in a meta-analysis and, although stratified the studies in terms of the timing of the application of TENS, other factors were analyzed simultaneously due to the insufficient number of included studies. Therefore, a random-effects model that considers this anticipated heterogeneity was utilized in the present meta-analysis. However, to avoid drawing wrong conclusions and thereby gain the most accurate, reliable, and reasonable findings, stratified analyses exploring the influence of the heterogeneity were conducted only if there were three or more comparable studies in a certain index. Another limitation is that the sample sizes of included studies are relatively low, which might restrict the statistical power . HoweverDespite these limitations, the present meta-analysis has some strengths. To obtain the most specific results, we included the largest number and most relevant animal studies published hitherto according to the rigorous criteria for inclusion and exclusion, which may be one of the strengths of the present meta-analysis. In addition, to obtain the most reasonable results and thereby help the future animal research design, we utilized the SYRCLE’s risk of bias tool for animal studies to evaluate the quality of current studies. Besides, meta-analyses of animal studies can explore the influence of the heterogeneity , an impoFuture studies should therefore improve the quality of reporting, such as adequately describing the process of randomization, concealment, and binding and providing the sample size calculation of animals, to increase our confidence in estimating the efficacy of TENS. In addition, there is a need for a high quality of study design in future studies. The intensity of TENS should be titrated during the TENS procedures to produce a prespecified stimulation. In terms of outcome measurement, we would strongly recommend all related outcomes be accurately reported at baseline and all measurement times. This would greatly help the future evaluation of effect, including immediately, short-term, and long-term. Valid evaluations of the function should also be a critical reportable outcome in future studies. Safety data and adverse events should also be routinely monitored and reported as secondary outcomes, to explore how an increased stimulation dose of TENS can be reached. Anesthesia-free TENS is needed to develop to simulate the awake state that is maintained in clinical practice. Besides, female animals and central neuropathic pain models used in TENS studies would significantly help us learn more knowledge about the efficacy of TENS in these domains. Lastly, particular attention to study-level moderators and publication bias may augment the ability of research using animal models of neuropathic pain to optimize the efficacy of TENS for neuropathic pain and to know more about the mechanism underlying TENS treatment.The importance of this meta-analysis lies in the demonstration that, for TENS, both a single session and multiple sessions of applications lead to temporarily ameliorating the pain intensity in animal models of neuropathic pain, of which, repetitive TENS treatments are capable of alleviating neuropathic pain in both acute and relatively chronic phases. However, the direct extrapolation of the animal data to clinical practice is tenuous due to methodological limitations. Particular focus on the quality of TENS study design and reporting may increase the possibility of animal studies to predict the analgesic effect of TENS in humans, thus avoiding more potentially unsuccessful clinical trials, learning more about its therapeutic mechanism, and helping more people with neuropathic pain.The original contributions presented in the study are included in the article/JH and YQ conceived and designed the study. JH, CY, and TW developed the search strategy. JH, ZZ, and YQ screened abstracts and full text reports. JH, YC, and YQ extracted outcomes. JH and KZ interpretation of the data. JH and CY wrote the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Atherosclerosis is a complex pathology that involves both metabolic dysfunction and chronic inflammatory process. During the last decade, a considerable progress was achieved in describing the pathophysiological features of atherosclerosis and developing approaches that target the abnormal lipid metabolism and chronic inflammation. However, early events in the arterial wall that initiate the disease development still remain obscure. Finding effective therapeutic targets in these early processes would allow developing methods for disease prevention and, possibly, atherosclerotic plaque regression. Currently, these early events are being actively studied by several research groups. One of the processes that are being investigated is the development of mitochondrial dysfunction, which was demonstrated to be present in the affected areas of the arterial wall. Detection and characterization of mitochondrial dysfunction associated with several chronic human disorders was made possible by the improved methods of studying mitochondrial biology and detecting mitochondrial DNA (mtDNA) mutations. It was found to be involved in several key atherogenic processes, such as oxidative stress, chronic inflammation, and intracellular lipid accumulation. Mitochondrial dysfunction can occur in all types of cells involved in the pathogenesis of atherosclerosis: monocytes and macrophages, smooth muscle cells, lymphocytes, and the endothelial cells. However, therapies that would specifically target the mitochondria to correct mitochondrial dysfunction and neutralize the defective organelles are still remain to be developed and characterized. The aim of this review is to outline the prospects for mitochondrial therapy for atherosclerosis. We discuss mechanisms of mitochondria-mediated atherogenic processes, known mitochondria-targeting therapy strategies, and novel mitochondria-targeting drugs in the context of atherosclerosis. Despite the tremendous efforts invested in the research of atherosclerosis and associated cardiovascular diseases and considerable progress in its diagnostics and management, the search for antiatherosclerosis therapies is far from finished. The available therapies are mostly focused on reducing known atherosclerosis risk factors, such as hyperlipidemia, alleviating the consequences of the disease and slowing down its progression . MoreoveAmong the events taking place at the early stages of the disease are inflammatory activation of both circulating immune and resident arterial wall cells, endothelial dysfunction, alteration of blood lipid profile, and oxidative stress. Strikingly, all these disturbances appear to be closely related to mitochondrial dysfunction, which may turn out to be the key link in the pathogenesis of atherosclerosis and a target for therapeutic agents . MitochoAccumulating evidence confirms the involvement of mitochondria in many pathological conditions, including cancers, cardiovascular pathologies, and neurodegenerative diseases. In this regard, mitochondriatargeting therapy has become a promising area of research . Human dCurrently, it is believed that 2 processes play a decisive role in the pathogenesis of atherosclerosis: chronic inflammation and impaired lipoprotein metabolism. Atherosclerosis can be characterized as a chronic inflammatory condition, the main initiating factors of which are modified lipids that stimulate the innate and adaptive immune response . Atherosldlr knock-out mice produced more reactive oxygen species (ROS), were more sensitive to apoptosis, had lower antioxidant defense and were more susceptible to mitochondrial permeability transition (MRT) opening. The latter was associated with swelling of defective mitochondria and the outer membrane rupture, accompanied by the release of signaling molecules and apoptogenic factors  . It was  factors .It is currently well-recognized that mitochondria play a prominent role in the regulation of the inflammatory response: they control the expression of pro-inflammatory genes and the assembly of inflammasomes. Mitochondrial dysfunction also entails metabolic malfunction, which ultimately induces chronic inflammation . In addiOxidative stress is one of the earliest and most significant signs of atherogenesis, which greatly contributes to inflammation and atherogenic lipid modification. Early atherosclerosis is characterized by a loss of balance between the oxidative and antioxidant systems of the cell. During the progression of the disease, the activity of antioxidant systems decreases mainly due to peroxynitrite-mediated inactivation of MnSOD2 and proteasome-mediated degradation of other enzymes . IncreasThe loss of redox balance on the inner mitochondrial membrane can lead to a malfunction of the steroidogenesis process contributing to atherosclerosis development. Accumulation of ROS on the inner mitochondrial membrane can disrupt the mitochondrial cholesterol transporter, steroidogenic acute regulatory protein (StAR), which inhibits the delivery of cholesterol (necessary for steroid synthesis) from the outer to the inner mitochondrial membrane .Normal mitochondrial function is critical for cell survival and is determined by the balance between the processes of mitophagy (autophagic degradation of mitochondria) and mitochondrial biogenesis (fission and fusion). The process of mitophagy helps eliminating defective mitochondria, which prevents their accumulation and associated malfunction of the cell and subsequent apoptosis . MitophaThe increased generation of ROS during mitochondrial dysfunction causes damage to mitochondrial DNA (mtDNA), which is more prone to mutagenesis than nuclear DNA due to a difference in DNA packaging and repair systems. Accumulation of certain mtDNA mutations further contributes to mitochondrial dysfunction and atherosclerotic lesion progression, and is also involved in plaque destabilization processes. Mutations in mtDNA can lead to a decrease in the synthesis of respiratory complexes and weaken mitochondrial respiration in smooth muscle monocytes and macrophages . The effMitochondria play a prominent role in cells with high energy consumption, such as many cell types of the cardiovascular system. In vascular endothelial cells, mitochondria act as important regulators of apoptosis and nitric oxide (NO) production. They can affect cell signaling and cellular response to stress, to which this cell type is rather sensitive . EndotheDysfunctional mitochondria were observed in smooth muscle cells isolated from human atherosclerotic plaques. Such cells were characterized by the presence of mtDNA mutations, reduced mitochondrial mass and defects of ATP synthase . ImpaireIn macrophages, mitochondrial oxidative stress associated with atherosclerosis contributes to activation of inflammation through the NF-κB mediated pathway . This prThus, mitochondria have a central position in the pathogenesis of atherosclerosis, mediating the most important aspects of the disease development. This fact allows positioning them as a promising potential therapeutic target.Existing mitochondrial therapies target both primary and secondary mitochondrial dysfunction. Primary mitochondrial dysfunction is caused by inherited defects of genes encoded by mtDNA or of nuclear genes encoding mitochondrial proteins . PrimaryThere are several strategies for the development of mitochondria-targeting therapies. One of them is creation of molecules that selectively accumulate in the mitochondria. Mitochondrial antioxidants are able to alleviate the oxidative stress by selectively eliminating free radicals at the organelle level, where these agents accumulate. Another approach is designing molecules that aim at specific targets in the mitochondria. Gene therapy for correction of defective nuclear or mitochondrial genes is being currently developed. Cell therapy allows changing the number of copies of defective mtDNA and restoring the pool of functional genes. A new area of research is the use of proteasomes to eliminate and process defective mitochondrial components .Studies of mtDNA variants associated with atherosclerosis have demonstrated that some of them correlate with the disease severity and onset timing. The ratio of normal to mutant mtDNA (the heteroplasmy level) appears to be a decisive feature and a potential marker of atherosclerosis-associated mitochondrial dysfunction. The threshold level of heteroplasmy  for several mtDNA variants can be considered as a marker of predisposition to atherosclerosis, and potentially be used for early diagnosis. Moreover, the severity of mitochondrial genome abnormalities can be reduced by increasing the ratio of wild-type mtDNA to mutant mtDNA. This possibility is currently being tested in preclinical studies .in vitro gene editing, was applied to altering mtDNA sequence  of peptide nucleic acids. A promising approach is the use of lipid-based nanocarriers. Penetration through the outer and inner membranes of the mitochondria by these particles is ensured by the presence of hydrophobic and positively charged ligands that facilitate the process of endosomal transport. Lipid carriers are currently regarded as low toxic and highly selective transport systems .Escherichia coli , which accelerates the rate of degeneration of retinal ganglion cells. Replenishment of the amount of OPA1 protein was achieved by transduction of an adeno-associated virus carrying wild-type human OPA1 cDNA under the control of the cytomegalovirus promoter .A promising approach to alleviate mitochondrial dysfunction is removing defective organelles through the ubiquitin-proteasome system. It was shown that cardiovascular pathologies (including atherosclerosis), neurodegenerative processes, and malignant transformation are all associated with a decrease in the activity of ubiquitin proteasome system (UPS) and the accumulation of dysfunctional mitochondria. It is possible that proteasome inhibitors and proteasome rejuvenation pathways will prove efficient for restoration of this pathway through removal of harmful damaged organelles .Another promising therapeutic strategy is activation of factors such as adenosine monophosphate kinase (AMPK) agonists, nitric oxide/cyclic guanosine monophosphate (NO/cGMP) stimulators, since mitochondrial biogenesis stimulation is known to be potentially cardioprotective . The carIn addition, activation of AMPK signaling pathways is capable of leveling mitochondrial fragmentation in the endothelial cells by inhibiting dynamin-related protein 1 (Drp1). Known pharmacological activators of these processes are metformin and resveratrol. Their protective action is mediated by inhibition of the inflammasome ER stress/NLRP3 due to a decrease in mitochondrial division .In addition to metformin, there are other compounds that activate the AMPK pathway and can be considered as potential therapeutic agents for heart failure, among them 5-aminoimidazole-4-carboxamide-1-β-D-ribofuranosyl 5—monophosphate (AICAR), thiazolidinediones and statins , thiazolidinediones, and statins .in vivo. A common lipophilic cation used for that purpose is triphenylphosphonium (TPP). This method allows delivering drugs that have naturally low affinity to the mitochondria because of their physical-chemical properties. Moreover, it reduces the off-target effects outside of the mitochondria therefore potentially reducing side effects. This strategy allows using small amounts of the active substance, which can be toxic, while its target concentration still remains at its maximum. At present, this approach is specific for organs with a high mitochondrial content  are lipophilic compounds that maintain a positive charge and have hydrophobic residues, which are the necessary features for successful penetration through the mitochondrial membrane. MPPs have already been shown to be effective in conjugation with a chemotherapeutic drug cisplatin . The pepCompounds based on guanidine, which can be small molecules or peptides, were shown to be capable of forming a bidentate hydrogen bond with cell surface phosphates, carboxylates and/or sulfates, allowing them to penetrate into cells and accumulate in the mitochondria. Due to the ability of guanidine-based compounds to stably bind to negatively charged proteins, these components can be successfully used for transporting proteins across the cell and mitochondrial membranes .In addition, various nanocarriers, such as liposomes, micelles, and nanoparticles can be used for targeted substance delivery. The use of such delivery methods does not require chemical changes of the active substance, which is delivered in its native form. Nanocarriers are used to deliver low molecular weight substances: peptides, proteins, and small size nucleic acids. The advantage of nanocarrier therapy is the gradual release of the active substance, which reduces the side effects .Non-pharmacological treatment of mitochondrial disorders includes gene therapy, ketogenic diet, and exercise. These methods are aimed to reducing cellular and mitochondrial oxidative stress, increasing the activity of the antioxidant systems, and stabilizing the mitochondrial membrane potential . SeveralAn interesting non-pharmacological therapeutic approach that has been tested for treatment of mitochondrial dysfunction is phototherapy (PT). The mechanism of PT is based on the selective action of photoreactive agents on the mitochondria and other subcellular compartments. This exposure leads to the absorption of light, which promotes the conversion of oxygen to ROS. Because of the key role of the mitochondria in the apoptosis initiation and ROS generation processes, such approach appears to be especially promising. Currently, the effectiveness of PT is being investigated for cancer treatment. PT was shown to induce hyperthermia and oxidative stress in cancer cells, which led to their death .The prominent role of mitochondrial oxidative stress in the development of atherosclerosis is currently well-recognized, and the potential protective capabilities of antioxidants are being actively studied. However, general antioxidant drugs failed to show any efficacy for atherosclerosis treatment. That may be due to the lack of redox status assessment before the treatment, as well as to the fact that the therapy effects were not selective for the mitochondria, which are the main source of the excessive ROS generation. Moreover, excessive antioxidant therapy may interfere with physiological functions of ROS that play an important signaling function in cells and tissues . EmerginHuman enzymes paraoxonase-2 (PON2) and PON3, located on the inner mitochondrial membrane, can also be an interesting candidate for antioxidant therapy of atherosclerosis. They are able to reduce mtROS-mediated apoptosis, which underlies their anti-atherogenic properties. The anti-atherosclerotic effect is based on peroxidation of cardiolipin and the release of cytochrome C, mediated by blocking the production of superoxide. Studies in a mouse model showed that PON2/3 was able to inhibit the production of superoxide due to its binding to ubisemiquinone . It is k2O2-induced oxidative stress by modulating the ROS-mediated P38 MAPK/NF-kB pathway. Luteolin alleviates mitochondrial dysfunction by suppressing the intracellular calcium increase and changing mitochondrial membrane potential. Moreover, it also regulates apoptosis by affecting p53 phosphorylation, decreasing the ratio of Bcl-2/Bax in the mitochondrial membrane, and cytochrome C release from the mitochondria, which leads to caspase 3 activation. The antioxidant properties of luteolin can help improving the endothelial function, thus making it a worthy candidate for atherosclerosis treatment  peptides are aromatic cationic peptides that have antioxidant properties and have been tested for alleviation of mitochondrial dysfunction. These agents have already been studied in the context of mitochondrial diseases. These small molecules can easily penetrate the cell and are not subjected to vesicular endocytosis. The main effect of SS peptides is the ability to prevent cell death and regulate lipid peroxidation. Peptide antioxidants appear to be promising therapeutic agents for treatment of diseases associated with oxidative stress due to their solubility, high efficiency, and low active concentrations compared to other drugs. They are easily synthesized, do not undergo peptidase degradation, have a relatively long half-life, and act on the inner mitochondrial membrane .Another potentially useful antioxidant agent is melatonin, which was also shown to have cardioprotective properties. The mechanism of its antioxidant defense is mediated by the ability to stimulate mitophagy in macrophages, reducing the amount of ROS .Regulation of mitochondrial biogenesis can be considered as a therapeutic approach to reducing the endothelial dysfunction and vascular inflammation. Resveratrol was shown to mitigate vascular inflammation and induce mitochondrial biogenesis in a mouse model of type 2 diabetes and in aged mice. Further studies were performed in human coronary arterial endothelial cells (HCAECs). Due to the dependence of the amount of generated ROS on mitochondrial biogenesis, resveratrol also reduced mitochondrial oxidative stress .apoe knock-out murine atherosclerosis model, such therapy led to a decrease of the lesions volume in the aortic sinus as compared with the control, although the amount of cholesterol in lipids remained unchanged . NLRP3 induces the inflammatory processes by releasing IL-1β and caspase-1, which are involved in atherogenesis, and are known plaque-destabilizing factors. Mitochondria are involved in the initiation of NLRP3 assembly as the main ROS generators and sources of damaged mtDNA. It was shown that blocking mtROS formation inhibited the assembly of NLRP3 inflammasomes . In addiSalidroside is a phenylpropanoid glycoside that shows antiatherogenic activity in mice deficient for the LDL receptor. The effect of salidroside is mediated by an improvement of the endothelial function due to the activation of endothelial NO synthase (eNOS) by enhancing the phosphorylation of eNOS-Ser1177 and reducing the phosphorylation of eNOS-Thr495. Salidroside also exhibits anti-inflammatory effects due to the involvement of the AMPK/PI3K/Akt/eNOS pathway, leading to a decrease of cellular ATP, increase of the ratio of AMP-ATP balance in the cell, and reduction of the mitochondrial membrane potential .The anti-atherogenic effect of anti-inflammatory cytokines, for instance, IL-35 and IL-10, is conveyed by their ability to block acute activation of the endothelial cells. IL-35 and IL-10 are able to suppress the production of mtROS, which contributes to activation of the innate and acute immune responses. These observations position IL-35 and IL-10 and agents enhancing their signaling as potential therapeutic agents .Nanotherapy and the use of nanoparticles (NP) is one of the emerging therapeutic approaches. In 2013, Marrache et al.  developein vivo and in vitro angiogenesis, apoptosis and endothelial cell necrosis, accompanied by oxidative stress. These observations indicate that SiNP can potentially be used for the development of anti-atherosclerosis treatments, although more studies are needed to better characterize their effects (The prospects for the therapeutic use of synthetic amorphous silica nanoparticles (SiNP) are currently widely studied. Initially, SiNP were developed for the delivery of genes and drugs for cancer therapy. However, it was found that the absorption of SiNP could lead to endothelial dysfunction, with disruption of endothelial cell homeostasis,  effects .Among the nuclear genes, it was possible to identify promising targets that could potentially be used to slow down the disease progression, including genes encoding for IL-1β, PCSK9, ApoE, LDR, and a number of lncRNAs and micro RNAs (miRNAs). Identification of target genes in the mitochondrial genome was less successful. Studies of mtDNA from atherosclerotic patients demonstrated that mtDNA damage and certain mtDNA mutations were associated with atherosclerosis. However, studying the mechanisms of these associations is challenging due to the difficulties in creating suitable animal models and lack of effective pathways for transfecting mammalian mitochondria. Mitochondrial genome editing techniques, such as mitochondrial zinc-finger nucleases (ZFNs), MitoTALEN, can potentially be used for mtDNA correction both throughout the body and in individual tissues or cell types .Recent studies have demonstrated the role of miRNAs in the pathogenesis of atherosclerosis. MiRNAs are small regulatory non-coding RNA molecules. However, they are able to control the expression of more than 60% of protein-coding genes, and they themselves are controlled by processes such as DNA and histone methylation. These processes are known to be affected upon atherosclerosis development . Small iThanks to the improvement of genetic manipulation techniques, it became possible to consider the use of siRNAs as a therapeutic approach to atherosclerosis treatment. There are various ways to modulate the expression of siRNAs. The use of antisense nucleotides and/or siRNAs (ASOs or siRNAs) to regulate gene expression and improve cell function is currently under investigation. MiRNA inhibitors  that can inhibit miRNA function in mouse, primate and human cell models of diseases are currently being studied as possible pharmacological agents for regulating gene function. It is possible to inhibit siRNAs using specific blockers for target sites or using miRNA sponges that reduce the number of target sites available for binding .Direct therapies targeting the atherosclerotic plaques may be a promising and selective approach to the disease treatment. Especially dangerous are so-called unstable atherosclerotic plaques that are characterized by a thinned fibrous cap prone to rupture. This event leads to the release of highly thrombogenic material of the plaque necrotic core causing severe and life-threatening complications. Therefore, improving the plaque stability is an important task in managing atherosclerosis. The use of statins, antiplatelet, and antihypertensive drugs help reducing the risk of serious complications by alleviating the endothelial dysfunction and inflammation and reducing thrombogenicity. More specific approach is using immunomodulatory drugs, such as therapeutic antibodies against interferon-γ or recombinant IL-13. In addition, administration of peptides apolipoprotein B100, heat shock protein 60, or oxidized LDL may have a potential for stabilizing atherosclerotic plaques. However, the utility of these approaches for clinical practice could not be demonstrated with certainty .One of the known factors of atherosclerotic plaque destabilization is apoptosis of vascular smooth muscle cells exposed to LDL. It was shown that active mitophagy helped avoiding this process. Stimulating mitophagy through known signaling mechanisms may therefore prove to be an interesting approach for atherosclerosis treatment relevant to plaque management. A study in human vascular smooth muscle cells demonstrated that mitophagy was activated in this cell type in response to oxLDL exposure. Silencing of key proteins regulating mitophagy, PINK1 and Parkin, impaired mitophagy flux, resulting in increased apoptosis of cells . A recenGynostemma pentaphyllum, which has a cardioprotective effect. Gypenoside can contribute to plaque stabilization through regulating the mitochondria of the endothelial cells and preventing their apoptosis. A recent study demonstrated that this compound regulated the expression of proteins involved in the PI3K/Akt/Bad apoptotic pathway, enhancing the expression of PI3K and p-Akt and suppressing the expression of p-Bad, cytochrome C, cleaved caspase 3, cleaved caspase 9, and PARP. In addition, gypenoside appeared to be an effective regulator of mitochondrial functionality, suppressing the expression of DRP1 and MFN2 proteins, which are involved in mitochondrial fusion and division, as shown on a mouse model. Possible beneficial effects of gypenoside for treatment of atherosclerosis are being currently studied  with MitoQ to study its effect on the skeletal muscle mitochondria in patients with peripheral artery disease. The studied parameters included the level of oxidative stress. The double-blind study was conducted in patients aged 50 - 85 years, and the publication of results is expected in the near future .A promising therapeutic strategy is the activation of factors such as adenosine monophosphate kinase (AMPK) agonists, nitric oxide/cyclic guanosine monophosphate (NO/cGMP) stimulators, since stimulation of mitochondrial biogenesis was shown to be cardioprotective .Metformin is an FDA approved diabetes medication. In 2013, clinical trial (NCT01901224) of this drug in patients with peripheral artery disease was started, however, due to the cessation of financing, it was prematurely stopped .Alteration of the blood lipid profile is a well-characterized feature and a risk factor of atherosclerosis. Hypercholesterolemia is associated with increased levels of ROS. In 2016, a study was conducted in patients with hypercholesterolemia to determine the therapeutic potential of simvastatin and ezetimibe in terms of improving the mitochondrial function. These drugs belong to the group of statins with antioxidant properties. Both drugs have shown their effectiveness: simvastatin as a lipophilic compound had a more pronounced effect, while ezetimibe a less pronounced. However, the combined use of both drugs showed the highest functionality. The positive effect of the drugs on the lipid profile, endothelial function, and mitochondrial function was explained by their inhibiting effects on ROS generation. Furthermore, the demonstrated effects included the reduction of plasma 8-Epi prostaglandin F2 alpha (8-epiPGF2a), oxidized LDL and lipoprotein-associated phospholipase A2, increase of the levels of SOD and CAT, and decrease of ICAM-1 in circulating monocytes .apoe knock-out mouse model of wire carotid artery damage. Modulation of mitochondrial morphology and metabolism by means of Drp1 inhibition could be used to prevent atherosclerosis, reducing the activation and migration of monocytes. The study is currently at the recruiting stage  was aimed to study pharmacological inhibition of the mitochondrial fission protein, Drp1, which was shown to reduce the volume of atherosclerotic plaque and accumulation of macrophages in the plaque on ng stage .An important role in the pathogenesis of cardiovascular diseases is played by the NO level. A decrease in its bioavailability, which can occur during oxidative stress, weakens endothelium-dependent dilation. It is possible to improve these functions using tetrahydrobiopterin (BH4), which is an important cofactor that regulates the functioning of eNOS. Studies in mice have shown that the pharmacological supplement BH4 increases NO bioavailability, alleviating inflammation and endothelial and vascular dysfunction. The level of BH4 can be controlled through increasing its production or decreasing its oxidative degradation . A recenValsartan-Entresto belongs to Ang II type 1 receptor blockers (ARBs). It was shown to have anti-atherosclerotic effects in patients with myocardial infarction, as well as in mouse models of atherosclerosis. The therapeutic effect of valsartan can be explained by its ability to modulate the activity of CD4+ T-lymphocytes, which has positive effects for stabilizing atherosclerotic plaques and regulating blood pressure . In 2015in vitro and in animal models, reducing mitochondrial dysfunction. The drug passed 2 phases of clinical trials that have demonstrated its safety, and characterized its pharmacokinetics (NecroX (C25H31N3O3S · 2CH4O3S) is a mitochondrial antioxidant that has been shown to be effective against atherosclerosis kinetics .Astaxanthin is a membrane-penetrating, organic antioxidant of carotenoid nature. The antioxidant and mitochondria-protective effects of astaxanthin are demonstrated in cardiovascular disease models. Astaxanthin was shown to be safe both in healthy people and in patients, demonstrating anti-inflammatory effects and a decrease in lipid peroxidation. The drug passed the IV phase of clinical trials, improving lipid profiles of patients with coronary heart disease, treatment of patients with hyperlipidemia reduced the level of triacylglycerol .In 2017, a clinical trial (NCT01755858) was conducted to study elamipretide, a mitochondria-oriented peptide that improves mitochondrial function when bound to the cardiolipin membrane. The study evaluated the effect of elamipretide along with percutaneous transluminal renal angioplasty on renal function in patients with atherosclerotic renal artery stenosis. It showed a reduction in the negative effects of ischemic damage after surgery .Accumulating evidence supports the hypothesis of the involvement of mitochondrial dysfunction in the pathogenesis of atherosclerosis. Impairment of the mitochondrial function leads to oxidative stress, inflammation, and metabolism changes, therefore contributing to different aspects of the pathology. Although mitochondria have been identified as attractive therapeutic targets in several human diseases, the development of mitochondria-targeting therapies is currently at the early stages. One of the challenges for developing mitochondrial drugs is targeted delivery to the organelles across the plasmatic and mitochondrial membranes. Several delivery methods have been developed, including lipid carriers and nanoparticles. These agents are currently being tested for therapeutic purposes. Antioxidant therapy for atherosclerosis has been extensively studied. It is likely that use of the antioxidants should be more specific and fine-tuned depending on the patient's redox status to improve efficacy and reduce off-target effect of interference with ROS signaling functions. Antioxidant therapy can be substantially improved by targeting the antioxidants to the affected mitochondria therefore alleviating the mitochondrial oxidative stress in a specific manner. Gene therapy targeting the mitochondria is a promising approach for treatment of atherosclerosis. A number of mtDNA mutations associated with atherosclerosis has been identified already, but more studies are needed to explore the possibility of using mitochondrial gene therapy for treatment of atherosclerosis.AO, AVS, and W-KW: conceptualization. AO: resources. TS and EI: writing—original draft preparation and visualization. EI: writing—review and editing. AVS and AO: supervision. AVS and AO: project administration. AO: funding acquisition. All authors have read and agreed to the published version of the manuscript.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.


Variations in the visceral vasculature are often encountered, but rarely cause clinical symptoms. We report a 12-year-old girl with portal hypertension caused by congenital variations in visceral vessels. The clinical manifestations included gastrointestinal hemorrhage and ascites. The common hepatic artery and splenic artery stem shared the same trunk from the aorta, and the common hepatic artery was directly connected with the main portal vein to form an arteriovenous fistula. In addition, the left hepatic artery and the left gastric artery shared a common trunk termed the “hepatic-gastric trunk” which originated from the anterior wall of the aorta, while the right hepatic artery originated from the superior mesenteric artery and supplied the right liver. The patient was treated with interventional embolization and remained in good condition throughout the follow-up and at the time of publication. Congenital variation of the visceral vessels, especially those concerning the celiac trunk and hepatic artery, is well-documented in the medical literature –3. HowevThis study was approved by the Ethics Committee of Guangdong Women and Children Hospital. The patient's mother provided written informed consent prior to the treatment procedures.A 12-year-old girl was admitted with hematemesis and melena. She had no history of chronic liver disease or inherited diseases. The physical examination revealed a heart rate of 99 bpm, blood pressure 89/55 mmHg, and the skin mucosa was pale. Laboratory data showed that hemoglobin was 67 g/L, stool occult blood test (+); and electrolyte, kidney and coagulation function, serum amylase, and liver function tests were normal. The abdomen was flat and soft, with varicose abdominal wall, and without tenderness or rebound pain.Color Doppler ultrasound revealed a common trunk of the common hepatic artery and splenic artery originating from the anterior wall of the aorta, and the common hepatic artery was directly merged into the portal vein . There wComputed tomography angiography confirmed the ultrasound findings, and other variant arteries were found . SpecifiThe patient was treated with fasting, hemostasis and stomach protection, blood transfusion, and portal pressure reduction with beta-blockers. After pre-operative preparation, the patient was treated with interventional embolization under digital subtraction angiography (DSA). The occluder was placed at the arterial end of the common hepatic artery-portal vein fistula . The patVariations of the visceral vessels have important implications in cases of liver transplantation, laparoscopic surgery, abdominal radiation intervention, and abdominal trauma. In classical visceral vascular anatomy , the celiac trunk originates from the anterior wall of the aorta at the level of the first lumbar vertebra, and its branches are the common hepatic artery, the left gastric artery, and the splenic artery , 3, 6. HIn 1904, Tandler  providedSome scholars have classified these variations –11. AmonThe variations of the abdominal trunk branches reported in the present case were not described in either of the Adachi or Michels classifications. However, the variation found by Demirtas et al.  in the aIn our case, the common hepatic artery has no branch to supply the liver, but forms an arteriovenous fistula with the portal vein, and its function is only to supply arterial blood to the fistula. The arterial supply of the liver is directly provided by the abnormal origin of the left and right hepatic arteries. The left hepatic artery and the left gastric artery originate from the anterior wall of the abdominal aorta; the right hepatic artery originates from the superior mesenteric artery.The normal pattern of the common hepatic artery is to form the gastroduodenal and proper hepatic artery, which then divides distally into the right and left hepatic branches. The branching variations of the hepatic artery are also described in detail in the literature and anatomical monographs –15. AmonIn fact, most of the variations have little surgical significance . BecauseHistologically, HAPFs can be classified as follows: type 1, small and peripheral; type 2, large and central; and type 3, intractable and congenital. Type 3 mostly occurs in the liver, and malabsorption and dysplasia are common manifestations in infancy. Older children may have severe portal hypertension, such as esophageal varices that cause upper gastrointestinal bleeding . The preThe portal vein system has large volume and small resistance, which will lead to portal hypertension if the portal vein flow or vascular resistance increases. The common hepatic artery, originated from the abdominal aorta, causes a large amount of arterial blood flow to the portal vein, and then shunts to the systemic circulation through the left branch of the portal vein. Under normal circumstances, the portal vein provides 75% of the liver input blood volume and 50% of the oxygen supply. Damage of the arterial blood supply can lead to ischemia.In our present case, the congenital arteriovenous fistula damaged the arterial blood supply of the liver. Fortunately, the left and right liver arteries supplied the liver. At the same time, the portosystemic shunt made the patient resistant to portal hypertension before she was 12 years old, and there was no abnormal liver function and hepatic encephalopathy during this period.Identifying a visceral vascular variation has important diagnostic and therapeutic significance, because vascular distortion directly affects the procedural strategies of abdominal surgery. This is especially relevant when variation of the hepatic artery is involved. Abnormal arterial anatomy increases the surgical complexity and potential risks of arterial supply injury, which can lead to ischemia, biliary fistula, hemorrhage, and liver abscess. Therefore, clear recognition of these arterial variations, both pre-operatively and intraoperatively, improves the probability of successful operation and limits the harmful results of complicated hepatobiliary surgery.Because of its convenience, economy, reliability, and non-invasiveness, ultrasonography is often the first choice for imaging examination, and it provides much detailed information about vascular anatomy and hemodynamics. Computed tomography is helpful to describe shunt and identify the types of anatomical malformations. DSA can directly display the anatomical structure of blood vessels; compared with traditional open surgery, DSA can better identify multiple shunts and block the fistula at the same time. Multi-imaging examinations can provide accurate pre-operative evaluation for hepatobiliary surgery and interventional radiotherapy, help to design the best surgical plan, avoid potential catastrophic complications, and improve the success rate of donor transplantation.via multiple imaging examinations, to avoid intraoperative vascular injury and post-operative complications.The present study reports an extremely rare and complicated case of portal hypertension caused by a congenital variation in the visceral vasculature. Possible anatomical variations of visceral vessels should be considered in surgical and radiological evaluations. Variations must be identified pre-operatively The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study was approved by the Ethics Committee of Guangdong Women and Children Hospital and written informed consent was obtained from the patient's mother. The patients/participants provided their written informed consent to participate in this study.YW and YP designed and performed most of the investigation, data analysis, and wrote the manuscript. ZY and CY provided data curation. NS and ML contributed to interpretation of the data and analyses. All the authors read and approved the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Despite evidence from case series, the comorbidity of eating disorders (ED) with psychosis is a challenging field to which little attention has been paid. There is no consistent sequence in the co-occurrence of the two conditions-eating disorders sometimes precede, and sometimes follow the onset of psychosis. In this case report, we present a 25-year-old female patient suffering from recurrent episodes of binge eating and inappropriate compensatory purging behaviours with psychotic components to discuss the co-occurrence of these conditions in the light of the literature.Our patient suffered from sleep disturbances, homicidal thoughts, self-induced vomiting worsened in one year. Psychiatric examination revealed psychotic symptoms such as blunted affect, persecutory delusions, and delusions of appeal and justification. In our inpatient psychiatry clinic, she was treated with olanzapine 20 milligrams(mg) and quetiapine 500 mg per day.Psychotic episodes occur in 10–15% of eating disorder patients. The prevalence of primary psychotic diseases like schizophrenia and schizoaffective disorders in eating disorder patients appears to be comparable to that in the general population. An ED can be the early sign of an impending psychosis, or psychotic symptoms can signal the beginning of an ED. The advent of the psychosis, and sometimes the treatment of the psychosis can cure the eating disorder, but it can sometimes aggravate it. The case presented illustrates the difficulties in managing a patient with a comorbid eating disorder and psychosis. To ensure a rigorous assessment of both psychotic and eating disorder symptoms, the focus should be on the pattern of appearance or emergence of symptoms, their phenomenology, clinical and family background of the patient, and clinical status on follow-up.The comorbidity between eating disorders and psychosis is infrequent and raises several conceptual and methodological questions. Epidemiological and family studies show that there is no more significant association between psychosis and ED, although these results are somehow limited by the lack of rigorous data regarding ED.


In photosynthetic plant cells, chloroplasts act as factories of metabolic intermediates that support plant growth. Chloroplast performance is highly influenced by environmental cues. Thus, these organelles have the additional function of sensing ever changing environmental conditions, thereby playing a key role in harmonizing the growth and development of different organs and in plant acclimation to the environment. Moreover, chloroplasts constitute an excellent source of metabolic intermediates that are remobilized to sink tissues during senescence so that chloroplast dismantling is a tightly regulated process that plays a key role in plant development. Stressful environmental conditions enhance the generation of reactive oxygen species (ROS) by chloroplasts, which may lead to oxidative stress causing damage to the organelle. These environmental conditions trigger mechanisms that allow the rapid dismantling of damaged chloroplasts, which is crucial to avoid deleterious effects of toxic by-products of the degradative process. In this review, we discuss the effect of redox homeostasis and ROS generation in the process of chloroplast dismantling. Furthermore, we summarize the structural and biochemical events, both intra- and extraplastid, that characterize the process of chloroplast dismantling in senescence and in response to environmental stresses. Chloroplast dismantling is a complex process involving intra- and extraplastid events essential for remobilizing metabolic intermediates in senescence, and for eliminating damaged plastids caused by stressful environmental conditions. Photosynthesis, the process that allows the conversion of sunlight into chemical energy, is essential for life on Earth. Light-driven photochemical reactions constitute the primary source of the organic material and oxygen that support the biological activity of heterotrophic organisms; for example, it is estimated that photosynthetic reactions produce 10 times more than the global consumption of primary organic material by humans . In planMost of the photosynthetic activity of plants is performed in leaves. Leaf development could be divided into two global phases: expansion, which is started by an initial stage of cell proliferation followed by a post-mitotic cell expansion stage that generates the mature leaf, and senescence, which extends from maturity to death. Both phases are characterized by sink-to-source transitions, so that leaf senescence allows the recycling of the components accumulated during growth and maturation into exportable nutrients to support the requirements of newly developing organs  as relevant upstream signals in the regulation of chloroplast dismantling. Moreover, we summarize the multiple features of chloroplast dismantling and their relationship with leaf senescence and response to stress. Finally, we describe the macromolecular rearrangements, targets of degradation and intra- and extraplastid breakdown pathways occurring during chloroplast dismantling.The photosynthetic electron transport chain operates in the presence of oxygen; thus, chloroplasts inevitably generate ROS as a by-product of photosynthesis. To avoid the detrimental effects of high levels of ROS, chloroplasts are equipped with antioxidant systems . Leaf sef- or x-type Trxs, show high mortality at the seedling stage and bleaching of cotyledons, which are characterized by chloroplasts with the structural features of gerontoplasts  of the organelle, which are summarized in b to chlorophyll a catalysed by chlorophyll b reductase  -induced senescence, 13-lipoxygenase, which is localized at the plastid envelope, catalyses the dioxygenation of unsaturated membrane fatty acids, thereby facilitating the formation of disruptions in the envelope that provoke release of stromal components . Thus, gPhotosynthesis-related transitory starch is mainly degraded at night inside the chloroplast by amylases, but extraplastidic events have also been described. Large starch granules (1–2 µm length) are broken down into small granules (<1 µm length) before being delivered in selective cargo vesicles, the SSGL bodies  chlorophyll b reductase in thylakoid membranes (reviewed by a oxygenase and red chlorophyll catabolite reductase (b reductase (Chloroplast dismantling is a complex process that requires the coordination of intra- and extraplastid events. The process of chlorophyll breakdown, which is started inside chloroplasts in senescent leaves, is completed by the release of non-fluorescent chlorophyll catabolites that are finally degraded in vacuoles . The pheConcerning intraplastid protein degradation, more than 20 chloroplast protein-degrading enzymes have been identified using a combination of biochemical, genetic, and proteomic approaches. Though it is considered that these enzymes are mainly involved in functions of housekeeping, protein quality control and maintenance of homeostasis . The proin vivo assays, and has been questioned (In barley senescing leaves a C1A-type cysteine protease, HvPAP14, associated to thylakoid membranes is activated by cleavage of the inhibitory pro-peptide at low pH at the luminal side of thylakoids. Once active, HvPAP14 has been shown to participate in the degradation of the oxygen-evolving complex protein PsbO and the LHCII proteins Lhcb1 and Lhcb5 . Mature The degradation of stromal proteins occurs by a mixture of intra- and extraplastid events. For example, the degradation of Rubisco, Rubisco activase, and GS is initiated inside the chloroplast . As ment+ pyrophosphatase, that develop during leaf senescence (Despite the intraplastid selective cleavage events, the bulk of chloroplast degradation occurs outside the organelle . At leasnescence , a. SAVsnescence , b is opnescence .The third pathway is chlorophagy of which two types can be distinguished: whole organelle and piecemeal chlorophagy. Whole organelle chlorophagy is observed in leaves undergoing senescence induced by dark , c1, RCBAt early stages of plant development, chloroplast biogenesis is encompassed by cotyledon greening and the development of true leaves. Then, the function of chloroplasts as factories of sugars, amino acids, lipids, and other metabolic intermediates is essential to support plant growth and development, hence making possible the autotrophic lifestyle of plants. Moreover, chloroplasts have the important activity of sensing external environmental conditions that allows the harmonization of the growth of the different plant organs. Nevertheless, stressful environmental conditions may imbalance ROS production and scavenging, which generates oxidative stress and potentially may cause damage to the organelle. These conditions trigger mechanisms of chloroplast degradation, which have the function of avoiding the deleterious effects of damaged chloroplasts on cell viability. In addition, leaf senescence is a complex genetic programme that allows the remobilization and recycling of leaf components to support the growth of sink tissues, and chloroplasts constitute an important source of carbon and nitrogen in this recycling process. Therefore, chloroplast dismantling is an essential process of plant development and adaptation to stressful environmental conditions. Chloroplast dismantling is a rather complex process that involves both intra- and extraplastid events, which may be highly interconnected and tightly regulated. In this review, we have described the most significant morphological and biochemical features that characterize chloroplast dismantling in senescing leaves and in response to environmental stress such as excess light or UV/B radiation. The chloroplast-to-gerontoplast transition is characterized by morphological changes and deep structural rearrangements of the membrane network and pigment–protein supercomplexes. The sequence of events and the enzymes participating in the degradation of chloroplast components are well known and have been described in conjunction with the extraplastidial pathways operating in the process. Finally, structural analyses showing chloroplast instability in Arabidopsis mutants impaired in the redox regulatory network suggest the participation of chloroplast redox homeostasis in the degradation of the organelle. The molecular basis of redox regulation of chloroplast dismantling is still poorly known and deserves more attention in the future.


Dentists’ perceptions about the stressfulness of clinical practice are well-documented, but literature on perceived stress and psychological distress experienced during the COVID-19 pandemic is scarce. This study aims to explore the emotions and attitudes, and the socio-demographic, dental, and COVID-related factors that are associated with the emergence of perceived stress and psychological distress that have been experienced by dentists during the COVID-19 pandemic. General demographic and dental-related data, and specific questions measuring the potential factors regarding dental professionals’ concerns and opinions about their professional circumstances during the pandemic, were electronically collected from 182 dental practitioners. Exploratory and confirmatory factor analyses were used to assess whether dentists’ emotions and attitudes during the pandemic measure the same construct: psychological distress, while linear regression models were built on the exploration of the effects of COVID-related factors on perceived stress and psychological distress. Facets of impulsiveness, lack of interest in social connections, emotional disengagement, mood swings, and acknowledgment of emotional exhaustion due to the pandemic, were measurements of the same construct and manifested in a singular factor: psychological distress. Two aspects, the fear of aerosol propagation and insecurities of financial status, increased the likelihood of the emergence of heightened levels of perceived stress and distress, while years spent in dental practice and age seemed to be protective factors against perceived stress and distress. At the end of 2019, in the Wuhan province of China, the spread of a new virus of the family Coronaviridae was detected. By March 2020, the rapid, global spread of SARS-CoV-2 (COVID-19) caused the World Health Organization (WHO) to categorize the pandemic as a public health emergency ,4, goverIn general, dentists are known to function under stressful conditions ,6, hencePerceived stress represents the feelings or thoughts that an individual has about the level of stress they are under at a given point in time or over a given time period , while pDentists are habitually at high risk of contagion and transmission of infection because of direct and indirect contact with blood, saliva and other biologic fluids in the oral cavity and airways , as wellAlterations to the dental facility are essential to remove PM dispersion. High levels of PM are shown to occur with the use of natural ventilation, as dental treatment rooms are typically of an open design. High-volume evacuation filters (HVE) and high-efficiency particulate-absorbing filtration (HEPA) are effective at removing PM; however, HVE requires the presence of auxiliary personnel and HEPA filters require constant maintenance to ensure that the unit does not become a source of pathogens ,21. The As an occupational hazard, the risk of exposure to sources of infection, such as the human immune deficiency virus (HIV), tuberculosis (TB), and the hepatitis B virus (HBV), invariably heighten anxiety and work stressors . ElevatePsychological variables, such as poor social support and a lack of self-efficacy, were reported as significant risk and contributory factors for the emergence of perceived stress and psychological distress in healthcare workers . Based oThe literature on dentists and perceived stress primarily addresses those in training ,32,33. FLicensed dentists who are members of the Hungarian Dental Association were invited to answer an electronic test battery, to gather information about dentists’ attitudes, emotions, and information about their opinions regarding their practice after severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2) lockdown. A total of 208 dentist replied. A total of 26 participants were excluded from final analysis; thus, 182 participants’ data were evaluated. The study was conducted in accordance with the Declaration of Helsinki, and it was approved by the Human Investigation Review Board, University of Szeged . Informed consent from each participant was also acquired online prior to participation in the survey.The first section of the survey is composed of questions regarding demographic information: age, gender, residence, years of being a dental practitioner, place of practice, marital status, number of children, and financial status. In the second section, dentists filled out the Perceived Stress Scale, which is a self-assessment questionnaire including 14 questions to be rated on a 5-point Likert scale that reflected on stressful experiences in the past months . The HunAdditionally, four specific questions were formed to measure potential factors regarding dental professionals’ concerns and opinions about the likelihood of infection and their professional futures in relation to COVID-19 and its potential consequences see . Questio2), absolute, and incremental fit indices  and a parsimonious fit index (AIC). Since the χ2 value is sensitive to sample size, i.e., in case of larger samples, it is likely that reasonable models also result in statistically significant χ2 and p values [To explore whether the questions posed to dentists, regarding their emotions and attitude during the pandemic, measure the same construct . An exploratory factor analysis (EFA) with principal component analysis was used to test the structure of the presupposed Distress Factor; varimax rotation was selected to determine the factors under which each item loads. To identify the number of factors to be retained in the final model, the Kaiser method of factor retention, the evaluation of eigenvalues above 1, and a screen test were utilized. Item factor loadings were also evaluated, where a cutoff of 0.40 was applied for item inclusion. The goodness of fit of the components of the Distress Factor was tested with confirmatory factor analysis. The models were estimated through covariance matrices with the use of maximum likelihood estimation. Model fitness was evaluated by the following fit indices: chi-square  with an average of almost 26 years spent working in a dental practice. The first 12 items were explored to see whether they measure the same a priori construct: psychological distress connected to the pandemic. Thus, to test whether these measured constructs fit the hypothesized measurement model, both an exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA) were used.–Meyer–Olkin Measure of Sampling Adequacy (KMO = 0.909) and, the Bartlett’s test of sphericity (χ2(66) = 834.092, p ≤ 0.001) suggested that these items are connected but show enough variability to proceed with the principal component analysis. The Kaiser method of factor retention identified two factors with eigenvalues above 1, and a scree test for factor retention suggested a one-factor model; thus, the final model included one factor [The sample size of the present study was sufficient for the analyses, since 182 participants filled out the 12-item survey, which fulfils the recommended 10:1, participant:item ratio . Evaluate factor  .p ≤ 0.001). It was found that the following significantly predicted the level of perceived stress: financial status, number of years in practice, and the feeling that not even strict compliance with professional rules can fully resolve the issues caused by aerosol propagation.Two stepwise linear regression models were built on exploring the effects of COVID-related factors on perceived stress and the result of the factor analyses: psychological distress. The first linear regression was carried out to evaluate whether the following predicted perceived stress: age, gender, residence, place of practice, marital status, number of children, financial status compared to national average, whether they felt that the COVID-19 pandemic will have long-lasting consequences on the financial situation of their practice, whether they felt that phone or online consultations would remain an integral part of their practice even after the COVID-19 pandemic would be under control, whether they felt that not even the strict compliance with professional rules can fully resolve the issues caused by aerosol propagation, and whether they felt that their personal professional development is facilitated by online education until the pandemic is significantly under control. The results of the regression model indicated that the final model explained 22.9% of the variance and was significant (F (1162) = 15.149, p = 0.007. It was found that the following significantly predicted the level of psychological distress: age, financial status, and the feeling that not even the strict compliance with professional rules can fully resolve the issues caused by aerosol propagation  = 7.496, tion see .The aim of this study was to reveal the background and potential risk factors of the level of perceived stress and psychological distress associated with the impact of COVID-19 among dentists. This work investigated the role of socio-demographic variables  to ascertain which factors contribute to the appearance of elevated levels of perceived stress and psychological distress in connection with the COVID-19 lockdown.Factor analysis was used to ascertain whether questions regarding dentists’ emotions and attitude during the pandemic measured the same construct: psychological distress. The present work points out that the psychological distress manifested in one factor, consisting of features of impulsiveness, lack of interest in social connections, emotional disengagement, mood swings, and acknowledgment of emotional exhaustion because of the pandemic. There are ample studies showing that dentists are prone to significant psychological distress due to the intense mental health stressors of clinical practice ,46. TherThe results indicated that aerosol propagation during dental procedures significantly promoted psychological symptoms, such as the elevated level of perceived stress and distress among dentists. In line with this, an in vitro study showed that the SARS-CoV-2 virus remained viable in aerosols for a minimum of 3 h with median estimates of half-life between 1.1 to 1.2 h . MoreoveAt the time of the present study, there were a lack of data about the SARS-CoV-2 virus transmission vectors in the dental office. Infection control measures were in a state of flux : shortfaIt has been reported in the literature that acute COVID-19 infection could contribute to adverse outcomes concerning oral health due to impairment of the immune system. As shown by Dziedic and Wojtyczka, this could lead to xerostomia, opportunistic fungal infections, dysgeusia, unspecific oral ulcerations, recurrent oral herpes simplex (HSV-1), and ulcerative gingivitis due to the increase in susceptibility of the oral mucosa . To dateThe study found that uncertainty regarding income disruption was a significant contributing factor to perceived stress and psychological distress. Financial stress and anxiety are contributory factors to cognitive dysfunction, which could amplify levels of perceived stress . While dIn countries throughout the world, diminished production and lost income due to government-mandated stoppage of elective treatment caused high levels of distress, due to the costs to restructure a practice physical facility, the need to replace PPE after each patient, and stringent infection controls that reduced the number of available appointment times . The panRegarding age and years spent in clinical practice, results of this work conformed to the previous literature , since tDental professionals with more work experience were less likely to report fear of changes in the work environment, fear of being infected and infecting others . Less woThis study has several limitations. The data were self-reported during the early months of the pandemic. As the dynamic nature of the pandemic was associated with repeated modifications of infection controls, it is important to consider the knowledge level of participants in this study within the time frame of response to the questionnaire. Another limitation is that the present study did not incorporate gender disaggregation, for which further studies with increased sample sizes would be necessary to underscore the robustness of the identified distress factor by gender disaggregated analysis. Additionally, further research will be necessary to determine the perceived stress and distress associated with the long-term impact of the financial, psychological, and professional outcomes of the pandemic, especially as the pandemic continues unabated. It is reasonable to assume that this could be of concern to dentists both currently and after the control of the spread and contagion of the pandemic. ,70.This study provided an understanding of two aspects of stress, perceived stress and psychological distress, among dentists during the COVID-19 pandemic. Psychological distress was operationalized by features reflecting on impulsiveness, lack of interest in social connection, emotional disengagement, mood swings, and acknowledgment of emotional exhaustion. Two major risk factors were identified in both aspects of stress: the fear of aerosol propagation and concerns about financial status. Fear of aerosol propagation and insecurities of financial status both increased the likelihood of the emergence of heightened levels of perceived stress and distress. Years spent in dental practice and age seemed to be protective factors against perceived stress and distress. Since dental professionals are proven to be highly prone to distress and perceived stress, measures should be taken that ascertain the factors that are likely to elevate the level of these psychological symptoms.The increasing frequency of global pandemics since the turn of the century warrants aggressive iterations of PPE equipment and modified treatment protocols to minimize aerosol propagation. It is advisable for the dentistry profession to provide mental health support systems for clinicians to mitigate the effects of perceived stress and psychological distress in the long term.