The acute phase protein Pentraxin 3 (PTX3) plays a non-redundant role as a soluble pattern recognition receptor for selected pathogens and it represents a rapid biomarker for primary local activation of innate immunity and inflammation. Recent evidence indicates that PTX3 exerts an important role in modulating the cardiovascular system in humans and experimental models. In particular, there are conflicting points concerning the effects of PTX3 in cardiovascular diseases (CVD) since several observations indicate a cardiovascular protective effect of PTX3 while others speculate that the increased plasma levels of PTX3 in subjects with CVD correlate with disease severity and with poor prognosis in elderly patients.In the present review, we discuss the multifaceted effects of PTX3 on the cardiovascular system focusing on its involvement in atherosclerosis, endothelial function, hypertension, myocardial infarction and angiogenesis. This may help to explain how the specific modulation of PTX3 such as the use of different dosing, time, and target organs could help to contain different vascular diseases. These opposite actions of PTX3 will be emphasized concerning the modulation of cardiovascular system where potential therapeutic implications of PTX3 in humans are discussed. PTX3 belongs to a superfamily of phylogenically conserved multimeric proteins, which includes short and long pentraxins , 2. All In contrast, PTX3 belongs to long pentraxins and, as mentioned above, it possesses multifaceted properties extending beyond the fields of immunity and inflammation to CVD , 8.Interestingly, its multiple roles can be considered as site-specific since its production occurs in a variety of cell types, including endothelial cells, fibroblasts, hepatocytes, and monocytes. Moreover, during an acute phase response induced by LPS, PTX3 is expressed in a variety of organs, most prominently in the heart and skeletal muscle, unlike SAP, which is produced only in the liver . Thus, tThe present review focuses on findings in humans and it discusses the molecular mechanisms encompassing experimental models and human beings.Cardiovascular diseases (CVD) represent the major cause of death in the developed world . In addiThus, PTX3 represents a specific and sensitive marker connecting inflammation with CVD since it is expressed and released by most cell compartments involved in the onset and progression of CVD.PTX3 is involved in a variety of molecular mechanisms leading to vascular damage and its elevated plasma levels represent a significant predictor of frailty in elderly hypertensive patients . In factHere, we highlight the bad or good associations between PTX3 and CVD in humans. In addition, in experimental models we reported the mechanisms by which this inflammatory protein may exert itson the cardiovascular actions.Although cholesterol accumulation intimal layer is the major pathological feature of atherogenesis, growing evidence suggests that the inflammatory state represents the major detrimental factor for the progression of atherosclerosis both in young and in elderly subjects. In fact, the earliest stage of atherosclerotic damage is characterized by infiltration of macrophages and T-lymphocytes, which are progressively activated during the course of the damage , 18. BasIn fact, human sclerotic mammary arteries possess high levels of PTX3, which is mainly localized within endothelial cells and macrophages , 20. In Recently, epidemiological and clinical data candidate PTX3 as a valid biomarker for atherosclerosis , 22. In Although the presence of PTX3 in human atherosclerotic damage is well defined, its causal role in the onset and progression of atherosclerosis, remains unclear. Here, data obtained in experimental models are reviewed aimed at suggesting the mechanistic role of PTX3 in atherogenesis.In particular, it has been reported that PTX3, by interacting with P-selectin, a cell-adhesion molecule involved in the tethering and rolling of leukocytes and platelets on activated endothelial cells, attenuates leukocytes recruitment at the site of inflammation . These dIn contrast, PTX3 was also reported to induce deleterious effects in the pathogenesis of atherothrombosis . On thisActually, the role of PTX3 in the atherosclerosis is not well-understood. It will be interesting to examine the role of the protein in complement activation during atherogenesis to define the specific role of PTX3 in the atherosclerosis. Overall, PTX3 seems to exert detrimental effects on atherosclerotic process since it promotes plagues formation and leads to an amplification of vascular inflammation such as to be candidate it as a new possible biomarker for plaque vulnerability. However, only in those conditions in which it is able to reduce macrophages infiltration and the expression of adhesion molecules it exerts beneficial effects.Endothelial dysfunction is a typical trait of several cardiovascular disorders including arterial hypertension. The impairment of the nitric oxide pathway and the enhanced smooth muscle vasoconstriction represent the main mechanisms leading to endothelial dysfunction in hypertension , 36.A growing body of evidence attributes to local and systemic inflammation a key role in the development of endothelial dysfunction, thus suggesting a key role for acute phase proteins , 38.On this regard, high plasma levels of the inflammatory molecule PTX3 were associated with endothelial dysfunction in different human diseases. Patients with chronic kidney diseases and with preeclampsia, a multisystemic disorder associated with hypertension –41, showIn addition, elevated plasma level of PTX3 have been found in patients with high systolic and diastolic blood pressure levels , 43 and 1 pathway, thus producing morphological alterations of endothelial cells and disruption of nitric oxide signalling. These effects were associated with an increase in blood pressure in vivo. It is worth to be mentioned that PTX3, and its mediators of vascular damage are present at higher levels within plasma of hypertensive patients compared with normotensive subjects [The evidence described so far in humans suggests a potential role of PTX3 in regulating vascular homeostasis. In experimental models, the absence of PTX3 is accompanied by massive suppression of tissue inflammation, cell injury and it determines decreased lethality after reperfusion of an ischemic superior mesenteric artery in mice, thus demonstrating that PTX3 is relevant in conditioning tissue damage . In a resubjects . Based oMyocardial infarction (MI) continues to be a significant cause of mortality and morbidity worldwide . Over thIn older adults it was reported an association between PTX3 plasma levels, CVD and all causes of death, independently from CVD risk factors . In partRecently, PTX3 was suggested to be a prognostic marker also in patients with coronary artery diseases after drug stent implantation, and in patients with angina pectoris –57, in wptx3 deficient mice. After cardiac ischemia- reperfusion injury, ptx3 deficient mice develop increased myocardial damage, characterized by no-reflow area, increased neutrophil infiltration apoptotic cells and decreased number of capillaries. In addition, in the myocardium of these mice the C3 complement component increased focally being related with the area of damaged myocardium. The evidence that in PTX3-KO mice the administration of exogenous PTX3 reduces complement C3 deposition rescuing the phenotype, highlights the cardio-protective effect of PTX3, through the modulation of the complement cascade [These studies in humans, do not allow to establish the specific action of PTX3 in the myocardium. Thus, to better characterize the cardiac action of PTX3, here we report data obtained in transgenic  cascade .The discovery of PTX3 in the myocardial tissue and the characterization of its role lead to propose PTX3 as an early indicator of myocyte irreversible injury in ischemic cardiomyopathy. In addition, considering the local production and the rapid change in plasma concentration, PTX3 could be considered a novel potential biomarker of myocardial infarction.Additional activities of PTX3 other than those related to innate immunity and inflammation have been described, such as extracellular matrix deposition (ECM), tissue remodeling, and angiogenesis. Several studies demonstrate that PTX3 is required for the secretion of extracellular matrix. This is critical for a number of functions such as maturation of the oophorus follicle, which explains why in PTX3-deficient mice sterility is observed. This condition seems to be related to a defective PTX3-dependent incorporation of the glycosaminoglycan hyaluronic acid into the matrix of the cumulus oophorus . A similInterestingly, PTX3 regulates angiogenesis via FGF2, thus interfering with a variety of conditions, including ontogenesis, growth, inflammation, tissue repair, atherosclerosis, and tumors . The PTXRecently, some studies have investigated on the role of the PTX3 on the modulation of retinal vasculature . In partEpigenetic modulation of PTX3 gene in cardiovascular diseases is increasingly emerging. A candidate modulator of PTX3 is TNFα. In fact, TNFα controls the expression of PTX3 by human adipose tissue, being potentially implicated in the development of atherosclerosis , and admAnother very recent study demonstrated that PTX3 gene is over expressed in the presence of Nogo-B, a member of the reticulon 4 protein family, which is critical in vessel regeneration , 74. In The multiple effects played by PTX3 are now of growing interest. Here we try to explain the mechanistic interactions of PTX3 in cardiovascular diseases discussing recent evidence coming from both cardiovascular and systemic studies showing the fine tuning of time, space, and organ context, which determine the final outcome of PTX3 effects including either detrimental or beneficial effects Fig. . SeveralNevertheless, considering that the ptx3-deficient mice have greater myocardial lesions following the coronary artery ligation/reperfusion damage due to activation of C1q , the PTX


Pneumocystis jiroveci pneumonia (PCP) is an important opportunistic infection among immunosuppressed patients, especially in those infected with human immunodeficiency virus (HIV). The clinical presentation of PCP in immunosuppressed patients have been well-reported in the literature. However, the clinical importance of PCP manifesting in the setting of an immunorestitution disease (IRD), defined as an acute symptomatic or paradoxical deterioration of a (presumably) preexisting infection, which is temporally related to the recovery of the immune system and is due to immunopathological damage associated with the reversal of immunosuppressive processes, has received relatively little attention until recently.10 copies/ml to 3.1 log10 copies/ml) was observed in HIV-positive patients who developed PCP. A similar upsurge in peripheral lymphocyte count was observed in our patients preceding the development of PCP, as well as in other non-HIV immunosuppressed patients reported in the literature.We aim to better define this unique clinical syndrome by reporting two cases of PCP manifesting acutely with respiratory failure during reversal of immunosuppression in non-HIV infected patients, and reviewed the relevant literature. We searched our databases for PCP cases manifesting in the context of IRD according to our predefined case definition, and reviewed the case notes retrospectively. A comprehensive search was performed using the Medline database of the National Library of Medicine for similar cases reported previously in the English literature in October 2003. A total of 28 non-HIV (excluding our present case) and 13 HIV-positive patients with PCP manifesting as immunorestitution disease (IRD) have been reported previously in the literature. During immunorestitution, a consistent rise in the median CD4 lymphocyte count (28/μL to 125/μL), with a concomitant fall in the median HIV viral load (5.5 logPCP manifesting as IRD may be more common than is generally appreciated. Serial monitoring of total lymphocyte or CD4 count could serve as a useful adjunct to facilitate the early diagnosis and pre-emptive treatment of this condition in a wide range of immunosuppressed hosts, especially in the presence of new pulmonary symptoms and/or radiographic abnormalities compatible with the diagnosis. Pneumocystis jiroveci (Pj) (previously known as Pneumocystis carinii f. sp. hominis) was first identified as a pathogen in premature infants suffering from interstitial plasma cell pneumonia in European countries during and after World War II, occasionally occurring in epidemics .-31.28-31PCP manifesting as a form of IRD is not a rare phenomenon. As shown in our previous study, it happens in 7 out of 10 (70%) of HIV-negative immunosuppressed hosts infected with Pj . HoweverRapid reduction of immunosuppressive therapy such as steroids has been implicated as a predisposing factor for the development of PCP in HIV-negative patients ,17,23,24Among HIV positive patients, PCP manifesting acutely during the initiation anti-retroviral therapy is a well-recognized phenomenon. The underlying immunopathological nature of this condition, which is reminiscent to IRD occurring in non-HIV infected patients, has been confirmed by histological examination of the lungs and transbronchial biopsy specimens, which demonstrated mixed inflammatory infiltrates including macrophages, neutrophils, lymphocytes, and plasma cells. Almost all infiltrating lymphocytes found in the tissues were of the T cell lineage, shown by immunophenotyping to be predominantly CD4 and CD8 cells . In anotIn our own experience, as well as from the review of published literature, it appears that a surge of absolute lymphocyte count, especially the CD4 lymphocyte count in HIV-positive patients, could potentially act as a surrogate marker for immunopathological damage during IRD in both HIV-negative and HIV-positive patients. In our recent publication , 7 out oFrom the result of this review, it appears that HIV-positive patients with PCP are at risk of clinical deterioration due to IRD if HAART therapy is started within 1 to 2 weeks after the initiation of treatment for PCP  declare that they have no competing interests.RAL and DSH were involved in the clinical evaluation and treatment of patients. BST and IFH helped with literature searching and review. AKW and VCC drafted and refined the manuscript. KYY conceived the study, participated in its design and coordination, and supervised the preparation of the manuscript. All authors have read and approved the final draft of the manuscript before submission.The pre-publication history for this paper can be accessed here:


Zierath and Hawley discuss how different fiber types affect muscle metabolism and what the signals are that regulate muscle phenotype Skeletal muscle demonstrates a remarkable plasticity, adapting to a variety of external stimuli , includiIn most mammals, skeletal muscle comprises about 55% of individual body mass and plays vital roles in locomotion, heat production during periods of cold stress, and overall metabolism . Thus, ka, and the more anaerobic (glycolytic) fiber is termed FTb. Under aerobic conditions (sufficient oxygen supply to the working muscles), energy is produced without the production of lactate. Under anaerobic conditions (insufficient oxygen supply to the working muscles), energy is produced via the glycolytic pathway, which results in lactate accumulation and in turn limits anaerobic exercise. Thus, muscle fibers can be classified in terms of contractile and metabolic properties , is typically around 55%, with FTa fibers being twice as common as FTb fibers  of 14 elite male long distance runners, 18 good (but not world-class) male long distance runners, and 19 untrained men. The elite group included Olympic medal winners (p < 0.05). The values found for several of the elite runners were the highest observed in human muscle (> 92% ST). Moreover, the ST fibers from the elite runners were 29% larger than FT fibers (p < 0.05), and both ST and FT fibers were larger in the good runners than in the untrained men. Because of the marked hypertrophy (bulk increase) of the ST fibers in the elite runners, the cross-sectional area composed of these fibers was greater than either the good runners or the untrained subjects . When the data from the elite and good runners was combined, a positive correlation between the proportion of ST fibers and the best 6-mile performance time was noted .In this regard, the results of  winners  and Amer2 uptake . Indeed, while an athlete's muscle fiber type is an important morphological component and is related to several contractile and metabolic properties  are more likely to determine the upper limits of endurance capacity  had 50% versus 98% ST muscle fibers. Subsequent work  revealedties see , other pcapacity .The close coupling between muscle fiber type and associated morphological, metabolic, and functional properties is not confined to athletic ability. Insulin sensitivity also correlates with the proportion of ST oxidative fibers . Specifi2+/calmodulin-activated phosphatase implicated in nerve activity-dependent fiber-type specification in skeletal muscle, directly controls the phosphorylation state of the transcription factor NFAT, allowing for its translocation to the nucleus and leading to the activation of slow-type muscle proteins in cooperation with myocyte enhancer factor 2 (MEF2) proteins and other regulatory proteins (2+/calmodulin kinase activity is also upregulated by slow motor neuron activity, possibly because it amplifies the slow-type calcineurin-generated responses by promoting MEF2 transactivator functions and enhancing oxidative capacity through stimulation of mitochondrial biogenesis (Skeletal muscle fiber-type phenotype is regulated by several independent signaling pathways . These iproteins . Calciumogenesis .PLoS Biology (PGC1-α, a transcriptional coactivator of nuclear receptors important to the regulation of a number of mitochondrial genes involved in oxidative metabolism, directly interacts with MEF2 to synergistically activate selective ST muscle genes and also serves as a target for calcineurin signaling . New dat Biology  reveals PLoS Biology (The transition from aerobic to anaerobic metabolism during intense work requires that several systems are rapidly activated to ensure a constant supply of ATP for the working muscles. These include a switch from fat-based to carbohydrate-based fuels, a redistribution of blood flow from nonworking to exercising muscles, and the removal of several of the byproducts of anaerobic metabolism, such as carbon dioxide and lactic acid. Some of these responses are governed by transcriptional control of the FT glycolytic phenotype. For example, skeletal muscle reprogramming from a ST glycolytic phenotype to a FT glycolytic phenotype involves the Six1/Eya1 complex, composed of members of the Six protein family . Moreove Biology , a key rWith the 2004 Olympics still fresh on our minds, many will ask: Who has the right stuff to go the distance? Athletes like Olympic champion Frank Shorter are clearly exceptional and represent an extreme in human skeletal muscle phenotype. Realistically, few of us can ever hope to run a marathon in world-class time. However, there may be cause for some optimism for the average mortal, since endurance exercise training in healthy humans leads to fiber-type specific increases in the abundance of PGC-1 and PPAR-α protein in skeletal muscle . Moreove


Cardiovascular diseases are the leading causes of global mortality. Growing evidence suggests that unresolved inflammation contributes to the chronicity, progression and morbidity of many cardiovascular diseases, thus emphasizing the urgent need to illuminate the mechanisms controlling inflammation and its resolution, for the sake of new effective therapeutic options. Macrophage mediators in resolving inflammation (Maresins) are a family of specialized pro-resolving lipid mediators (SPMs) derived from the ω-3 fatty acid docosahexaenoic acid (DHA). Studies have indicated that Maresins play critical role in initiating the pro-resolving functions of phagocytes, decreasing the magnitude of the overall inflammatory response, and thereby protecting against inflammation-related disorders. In this review, we summarize the detailed actions and the therapeutic potential of Maresins, with a particular emphasis on Maresin-1 (MaR1), in cardiovascular diseases. We hope this review will lead to new avenues to Maresins-based therapies for inflammation-associated cardiovascular diseases. Cardiovascular diseases  are the leading causes of death and disability in the world. It is known that inflammation is an important feature of many cardiovascular disorders, whereas acute inflammation upon tissue injury would activate adaptive immunity, repair damaged tissue, and eventually restore homeostasis. However, while acute and self-limited inflammatory reaction is protective, the persistent and uncontrolled inflammation amplifies tissue damage and drives the development of various undesirable results. Hence, understanding the mechanisms that control the resolution of inflammation may provide insight into preventing and treating inflammation-associated cardiovascular diseases , 2.In recent years, researchers have demonstrated that the resolution of inflammation is not a passive return to homeostasis, but rather an active process governed by endogenous chemical mediators namely specialized pro-resolving mediators (SPMs) . SPMs arMaresins are a series of polyhydroxy and polyunsaturated conjugated double bond molecules synthesized from DHA through a series of enzymatic conversion of ω-3 essential fatty acids. At present, the Maresins family mainly includes Maresin-1 (MaR1), Maresin-2 (MaR2), Maresin conjugate in tissue regeneration (MCTRs), and Maresin-like lipid mediators (MaR-Ls). They are named differently according to the position and conformation of hydroxyl and double bond. As reflected in their nomenclature “Macrophage mediators in resolving inflammation,” macrophages are the source of Maresins in their original identification, while neutrophils, platelets and other cell types have afterwards been reported to be able to produce Maresins as well.Briefly, after a series of complex desaturation and elongation reactions, ω-3 fatty acids  is transformed to their higher unsaturated derivatives, EPA and DHA . DHA is Extensive studies have illustrated that pro-resolving activities of SPMs occur through activation of one or more G protein-coupled receptors (GPCRs) , 17. SimAtherosclerosis is a multifocal chronic inflammatory disease of medium sized and large arteries which is the primary cause of fatal cardiovascular diseases . Analysiin vitro experiments showed that MaR1 and RvD2 didn't influence the expression of collagen production as well as inflammation genes in smooth muscle cells, while when smooth muscle cells were co-cultured of TNF-activated macrophages, MaR1 and RvD2 increased the mRNA levels of collagen production related genes. These data are consistent with the concept that MaR1 and RvD2 generally act on macrophages, modulating macrophage polarization toward a pro-resolving phenotype, thus suppressing local inflammatory phenotype. This in turn acts on the adjacent smooth muscle cells and stimulates collagen production and stabilizes atherosclerotic plaque  and increase of the pro-inflammatory leukotriene B4 (LTB4) through the development of early and advanced stages of atherosclerosis in mice , 26. By c plaque . Noteworc plaque , clarifyin vitro experiments demonstrated that MaR1 can also ameliorate LPS-induced pro-inflammatory response, endoplasmic reticulum stress, and cell apoptosis in cultured human umbilical vein endothelial cells  is related to the degradation of the atheromatous aorta elastic media. It is commonly believed that inflammation is associated with AAA development and contributes to elastin breakdown, smooth muscle cell (SMC) phenotypic switching, and extracellular matrix degradation , 35. Mosmodeling .Inflammation is also important pathology in neointimal formation and restenosis after angioplasty. In a mouse model of carotid ligation arterial injury, MaR1 significant reduced early proliferation of VSMCs in the arterial wall and inhibited vascular remodeling through reducing neutrophil and monocyte/macrophage recruitment, as well as increasing M2 polarization in the arteries . Upon thInflammation is critical to the onset and progression of cardiac remodeling and heart failure. While acute inflammatory response usually coincides with active resolving phase, SPMs may act as a guide for resolution of inflammation in the injured myocardium following acute myocardial infarction. Halade et al. illustrated that the abundance of MaR1 and other members of SPMs was significantly enhanced in the infarcted left ventricle within 24 h after myocardial infarction in mice. Moreover, they proved that the splenic macrophages recruited to the infarcted left ventricle represent the major source of these SPMs, highlighting the importance of macrophage-derived SPMs, including MaR1, in retarding heart failure . In addiSepsis is an inflammatory lethal syndrome and about half of patients with sepsis develop cardiac dysfunction. By detecting the peripheral blood lipid mediator profiles in sepsis patients, Dalli et al. recently reported that patients with sepsis had differentially expressed SPMs, this was correlated with survival and clinical outcomes . SimilarInflammation has been demonstrated as a major component of hypertension and hypertension related organ damage, including peripheral vascular resistance and heart dysfunction. Although the direct relationship between MaR1 and hypertension has not been experimentally tested, by comparing the serum levels of lipoxin and Resolvins in hypertension and normotension patients, Yücel et al. found that the lipoxin A4 (LXA4), RvD1 and Resolvin E1 (RvE1) levels were negatively correlated with systolic blood pressure and total cholesterol levels, implying that reduced SPMs may serve as indicators of the development of hypertension . Indeed,Mounting evidence indicates that patients with metabolic disorders, including obesity, diabetes mellitus, and non-alcoholic fatty liver disease (NAFLD), are at increased risk of cardiovascular events and have a higher cardiovascular morbidity and mortality , 49. MetNon-alcoholic steatohepatitis (NASH) is a potential progressive liver diseases as a subtype of NAFLD . ChronicMaR2 is identified in Maresins metabolome in macrophages via conversion by human 12-LOX followed by sEH, displayed potent anti-inflammatory and pro-resolving actions . In the Inflammation resolution is an active process which can lead to tissue regeneration. MCTRs were identified as evolutionarily conserved chemical signals that are peptide-lipid conjugated mediators in the Maresins biosynthesis and functionally communicate during resolution of inflammation to activate tissue regeneration , 60. WitA large number of studies have shown that inflammation and its resolution are central to most clinically relevant cardiovascular diseases. Although targeting inflammation has been shown to effectively reduce mortality, it has confirmed that anti-inflammatory therapies also enhance the risk of impairing host defense. Thus, boosting inflammation resolution without being overtly immunosuppressive via supplementation of pro-resolving mediators has become new strategy for the treatment of cardiovascular diseases. Maresins are a new family of bioactive lipid mediators synthesized from an ω-3 polyunsaturated fatty acid DHA and have displayed strong anti-inflammatory and pro-resolving abilities and broad beneficial actions in many inflammatory diseases , 63. In ML prepared the manuscript draft. HH carefully checked the manuscript and the references. LC strictly commented and amended the paper. All authors contributed to the final version of this review.This work was supported by the National Natural Science Foundation of China (Grant No. 32071157).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.


The health burden of heart failure with preserved ejection fraction is increasingly recognized. Despite improvements in diagnostic algorithms and established knowledge on the clinical trajectory, effective treatment options for heart failure with preserved ejection fraction remain limited, mainly because of the high mechanistic heterogeneity. Diagnostic scores, big data, and phenomapping categorization are proposed as key steps needed for progress. In the meantime, advancements in imaging techniques combined to high-fidelity pressure signaling analysis have uncovered right ventricular dysfunction as a mediator of heart failure with preserved ejection fraction progression and as major independent determinant of poor outcome. This review summarizes the current understanding of the pathophysiology of right ventricular dysfunction in heart failure with preserved ejection fraction covering the different right heart phenotypes and offering perspectives on new treatments targeting the right ventricle in its function and geometry. The phenogroup with RH disease included older subjects with the highest rate of comorbidities and had the worst hospitalization/mortality evolution. Similarly, in a recent machine learning analysis,8 the older phenogroup showed a poorer RV function and a higher burden of risk factors, such as atrial fibrillation (AF) and hypertension. In most conditions triggering HFpEF, RH disease develops as a consequence of enhanced left atrial pressure and pulmonary hypertension (PH).12 Of note, in 10% to 15% of cases of normal LV ejection fraction (EF), RH disease may be the consequence of infiltrative myocardial disease, such as amyloidosis,13 a condition requiring appropriate diagnosis and specific clarification as a final step in the diagnostic algorithm, according to the European Society of Cardiology Consensus Statement on HFpEF diagnosis.1 Mortality remains elevated irrespective of the etiology and the pre- or postcapillary nature of PH.14 Furthermore, given that in HFpEF the left heart dysfunction is typically associated with comorbid conditions, a specific contributory role of inflammation and oxidative stress in the adverse RH chamber remodeling and dysfunction may not be ruled out15 but rather represents an intriguing pathogenetic hypothesis to be tested in large numbers and multiple RH disease phenotypes.16 Hemodynamic injury and proinflammatory mediators combine with a multitude of gene expression and pathways involved in RV chamber response to injury.18 In a recent analyses of the PROMIS-HFpEF study exploring the protein biomarker that may support the HFpEF comorbidity-inflammation paradigm by a high throughput technology, Sanders-van Wijk et al19 found that systemic inflammation was associated with tricuspid regurgitation and worse RH function. The contribution of multiple pathways and the variable standard of measurements and cutoff for defining the RH disease well explain the heterogeneity observed in prevalence and clinical course itself.11 In the subgroup of patients investigated by echocardiography in the PARAGON-HF trial, the rate of RH disease was 30%.20 In the large HFpEF cohort of Olmsted County,9 RH disease occurred in 35% of cases, as assessed by tricuspid annular plane systolic excursion (TAPSE) measurements, and in 21% of cases by semiquantitative visual score analysis, suggesting a quite weak concordance between the two methods. A similar degree of failure, however, was found if both reduced TAPSE and low motion analysis coincided. RH disease patients were more likely to have AF and to receive higher doses of diuretics. An improved consensus on the diagnostic criteria of RH disease in HFpEF appears to be desirable.RH disease in HFpEF is highly prevalent6 AF and use of diuretics were consistently associated with the worst RH disease phenotypes. The recurrent link between RH disease development and AF has been confirmed in a number of investigations23 with some controversy as to whether AF being the cause or the consequence.24In a study phenotyping RH by assessing RV to Pc coupling by the TAPSE/PASP  ratio,23 recently addressed the time course of functional changes over a median follow-up of 4.0 years. They found a 10% decline in RV fractional area change and 21% increase in RV end-diastolic area. RH disease developed at a rate higher and faster than corresponding changes in the LV and was associated with coronary disease, greater body weight, higher PA and LV filling pressures, RV dilation, and, again, higher rate of AF. Interestingly, RV diastolic dysfunction and increased stiffness occurred before the development of systolic dysfunction, and subjects who developed incident RH disease exhibited a ≈2-fold increased risk of death. Along with these changes, reports document some myocardial fibrosis at the RV insertion points25 and even RV diffuse fibrosis as peculiar features in HFpEF.26 Interestingly, the myocardial fibrosis at the RV insertion point has been found to correlate with wedge, mean pulmonary, and right atrial pressures.25Although RH disease has been mostly studied in cross-sectional analyses, Obokata et al27 As such, the RV is sensitive to brisk increases in pulmonary arterial pressure (PAP), such as in massive pulmonary embolism or experimental PA banding, and may result in acute dilatation and rapidly fatal cardiogenic shock.28 However, if given time, the RV adapts to increased afterload by increased contractility thus preserving the Pc coupling and flow output response to metabolic demand. This has been established in experimental and clinical studies in which high-fidelity manometer-tipped catheters were used to derive RV end-systolic elastance (Ees) or end-systolic pressure (ESP) divided by end-systolic volume as gold standard measure of contractility and arterial elastance (Ea) or ESP divided by stroke volume as a validated lumped parameter of afterload.29 The Ees/Ea ratio measurement of RV-PA coupling is normally around 1.5. It is preserved during exercise in healthy subjects and is either preserved or decreased at rest but decreases during exercise in severely increased PAP such as in pulmonary arterial hypertension (PAH).30 The Ees/Ea ratio has some reserve, as it has to be decreased by some 50%, from 1.5 to around 0.8 until there is an increase in RV volumes. The Ees/Ea decreases to these critical values in pulmonary vascular disease with severe increases in PAP, such as PAH30 or chronic thromboembolic PH,31 but may already reach uncoupling values in the presence of mild to moderately increased PAP, as has been demonstrated in experimental HF.32The RV is a thin-walled volume generator functionally coupled to a low impedance Pc Figure .27 As su27 There is shared information content between the Ees/Ea ratio and EF, as the Ees/Ea ratio can indeed be simplified for a common term of ESP as stroke volume/end-systolic volume, which in turn is equal to EF/(1−EF).33 An Ees/Ea ratio of 0.8 corresponds to an EF of 35% to 40%.Dilatation of the RV signals a shift from homeometric (systolic function) adaptation (Anrep law) to heterometric adaptation (Starling law) to chronic loading conditions.27 As reported in the Figure Practically, RV dysfunction can be defined by a decreased Ees/Ea or EF but preserved end-diastolic volume and end-systolic volume and its transition from adaptive hypertrophy to failure by decreased Ees/Ea or EF and augmented end-diastolic volume and end-systolic volume above normal values.34 It is conceivable to suspect that the same would be true for HFpEF but this relevant aspect has not been yet systematically detailed in the evolving stages of PH due to HFpEF.35The pressure-volume loop also offers a diastolic elastance curve as a gold standard measure of diastolic function. The diastolic elastance curve has a curvilinearity that increases with increased end-diastolic volume and can be described by an equation that contains a diastolic stiffness coefficient, β. The diastolic stiffness of the RV correlates with disease severity in PAH.36 as a consequence of an increase in the pulsatile loading, which typically occurs in the presence of atrial myopathy and increased V wave, especially when associated with AF37 and atrial functional mitral regurgitation.38 The progressive impairment in LA dynamics becomes a central player in the pulmonary congestion cascade and a limiting step in the lung fluid clearance process favoring perivascular inflammatory reaction.39Increased LV filling pressures in HF, as assessed by pulmonary artery wedge pressure (PAWP) measurements, are initially transmitted upstream in a close to 1/1 relationship to mean PAP (mPAP) with unchanged pulmonary vascular resistance (PVR). Even with relatively normal PVR at rest, patients with HFpEF display a compromised pulmonary arterial compliance (PAC)27 Stiffening of the pulmonary vessels, starting from the venous system, further increases this gradient.All together, these mechanisms promote the time- and pressure-related pulmonary vascular remodeling and increase the gradient between PAWP and mPAP.40 RV afterload is determined by a dynamic interplay between PVR, PAC, and wave reflection.41 Although specific evidence in HFpEF patients is lacking, a number of studies have shown that wave reflection affects PA pressure curves by late systolic peaking of pressure and PA flow curves by late or midsystolic deceleration of flow.42 However, these morphological aspects do not necessarily impact on RV afterloading as the product of PVR and PAC or so-called time constant of the Pc (RC time) remains constant or nearly constant, allowing for an essentially unchanged oscillatory to steady flow work (Wosc/Wst) ratio of 25% in all PH conditions.43 Extreme reported variations of the RC time still do not prevent valid estimation of RV afterload by a total hydraulic load calculation (Wtot) as 1.2 to 1.4× Wst.44One could think of quantifying RV afterload by a PVR calculation, assuming Ea or ESP/stroke volume to be equal to PVR divided by heart rate and mPAP a satisfactory estimation of RV ESP. However, this approach is misleading because of variable underestimation of ESP by mPAP.45 However, whether a decreased PAC because of increased PAWP or altered left atrial structure and function may be sufficient to increase Wosc/Wst in HF patients remains to be established.This being said, the constant value of the product of PVR by PAC implies a hyperbolic relationship so that the relative contribution of PAC to afterload is greater in case of increased PAWP with normal or only mildly elevated mPAP. This may at least, in part, explain greater predictive capability of outcome of PAC versus PVR in HF patients and especially in HFpEF.46 The volume load of the tricuspid regurgitation can itself lead to further increase in RV dilatation and associated preload-induced increase in afterload as defined by RV wall tension. Moderate-to-severe tricuspid regurgitation is quite common in stage B and C HFpEF, and47 geometric changes in tricuspid valve and associated tricuspid insufficiency hold a considerable impact on survival.49RV distension is associated with functional tricuspid regurgitation from stretching of the tricuspid valve annulus. Tricuspid valve annulus dilates along the anterior and posterior aspects because of the relatively fixed portion of the medial aspects of the annulus. With this distension, there is a change in the shape of the valve with flattening and modifications of the normal papillary muscle to leaflet and valve relationship.50 The pericardium primarily contributes to the RV to LV interaction exerting a constraining effect.51 Ventricular interdependence is diastolic, which alters LV diastolic function by competition for space between the LV and the dilated RV within a nondistensible pericardium,51 but also systolic, which to some extent preserves RV contractility by the entrainment effect of preserved LV systolic function.22 In the end, negative diastolic interdependence may prevail, resulting in a low-cardiac-output state by decreasing LV distensibility and preload. Although these step-by-step variations in RV geometry and function have been well described in early HFrEF stages, there is now clear characterization in HFpEF.52 Specifically, in HFpEF, the role of an unfavorable diastolic ventricular interaction has been elegantly unmasked even in the early stages during exercise53  to the developed force (PASP).69 Interestingly, in PH-HFpEF, a TAPSE/PASP ratio of 0.36 discriminated pre- from postcapillary PH in patients with HF,70 and, based on these observations, TAPSE/PASP ratio has been used for screening different phenotypes of RV-Pc uncoupling in a parallel assessment of clinical characteristics, pulmonary and systemic hemodynamics, and outcome in HFpEF according to tertile group definition  mm/mm Hg and decreases slightly with aging.n Figure . Progres22 The analysis of this relationship showed a downward shift in the PH-HFpEF with AF compared with HFpEF free of AF unmasking some further degree of RV function mismatch due to a partially load-independent fashion. Other simplified surrogate approaches including RV EF (CMR), /PASP are clinically relevant,71 and more comprehensive and precise indicators such as the tissue Doppler S′ and the RV free wall strain appear promising. Nonetheless, TAPSE/PASP has been the first approach proposed and to date the only noninvasive echocardiography-derived indicator tested against invasive gold standard measures of Ees/area6 and Ees/Ea.66 Figure Echocardiography-derived approaches similar to the TAPSE/PASP ratio have been developed such as, for example, relating RV fractional area changes (%) to mPAP.72 At present, there are no data yet on the effects of fluid loading on RV-Pc coupling in HF. In healthy subjects, exercise is associated with a preserved RV Ees/Ea30 but a decreased TAPSE/PASP, which is accentuated with aging. Exercise decreases RV Ees/Ea in PAH, and, most recently, the same has been shown in HF. In that study, Ees/Ea was recalculated from RV pressure waveforms and was typically most decreased in patients with increased PVR. More data are needed to evaluate the clinical relevance of RV-Pc coupling measurements in fluid loading or exercise stress conditions in HFpEF.In most recent years, there has been a progressive need to recognize and explore the Pc and the RV as an integrated functional unit also during exercise and fluid loading especially in subjects with preserved LV EF and presenting with uncertain diagnosis of true HFpEF. A fluid challenge may be considered as a valid though less strenuous mean than exercise, to test RV function mainly through an increased systemic venous return.39 Specifically, therapeutic strategies should be aimed at contrasting the multifold pathways involved in lung capillary stress failure and remodeling,73 potentially targeting those that may embrace some combinatory biological effects on the pulmonary endothelium with a reverse remodeling of RV myocyte hypertrophy and extracellular matrix proliferation.74Since the RH is quite sensitive to an increase in afterload due to the elevated left atrial pressure, the first goal of therapy should be to reduce LV filling pressure with the double aims of (1) modulating the abnormal pulsatile loading on the RH and (2) avoiding fluid swelling from pulmonary capillaries to the interstitium with consequent increase in transmural arteriolar pressure and loss of PAC.75Effective decongestion is a must, and methods to obtain a long-lasting effect remain an important challenge with recent evidence pointing on devices to monitor intracardiac and pulmonary pressures.58 performed a prospective invasive hemodynamic and echocardiographic study uniquely examining resting RV and pulmonary vascular function along with RV-Pc coupling responses to acute β-adrenergic stimulation with dobutamine in patients with HFpEF at earlier stages versus controls. RV systolic and diastolic function were impaired in HFpEF subjects compared with controls using both invasive and noninvasive indices. Dynamic RV-Pc coupling analysis, assessed by either invasively determined dP/dt versus mPAP or semi-invasively by the echocardiography of tricuspid annulus tissue Doppler velocity s′ versus mPAP, suggested that RV systolic function was blunted during β-adrenergic stimulation in HFpEF and consequent pulmonary vasodilation compared with controls. These findings indicate that an altered pulmonary arterial tone is a major component of the syndrome, even at early stages when any increase in PAP is simply related to the backward passive effect of increased left atrial pressure. This evidence challenges the appropriate timing for interventions and the rationale of eventually using vasodilator agents.Andersen et alIntriguingly, the lack of an inotropic positive response during β-adrenergic stimulation could prospect and reinforce the hypothesis that as for the LV, the failing RV would present with β-adrenergic receptor desensitization. However, no specific data in HFpEF patients are available.76 historical studies performed with pulmonary vasodilators in HFpEF group 2 PH have not been encouraging and mostly negative.78 Nonetheless, study hypotheses, design, inclusion criteria, and phenotyping of populations have been quite incomplete, likely contributing to some delay in the search of effective compounds for RH dysfunction due to LV disease. Specifically, the most crucial questions that have been addressed only in part in the past are: which HFpEF phenotype may be more responsive to pulmonary vasodilators; how much to obtain RH unloading as compared with the biological effects; what pathways to target for expecting some reverse remodeling.Although efforts to effectively treat RV-Pc uncoupling in HFpEF are increasing,5 inhibition on both pulmonary hemodynamics and RV function were tested enrolling patients by a prespecified phenotyping process, that is, documented significant LV hypertrophy; RV-LV interaction ratio of RH  to left heart (PAWP) filling pressures >1; high PVR, increased elastance and documented pulmonary capillary damage .61 Sildenafil was effective on pulmonary hemodynamics, yielding to a significant RV-Pc recoupling and gas diffusion restoration. These findings have been recently confirmed by Belyavskiy et al79 in similar patients of combined pre- and postcapillary PH-HFpEF showing an improvement in RH hemodynamics and exercise performance.In a study of HFpEF with precapillary PH, the effects of PDE5 inhibition has not been documented for isolated postcapillary PH-HFpEF,80 and the RELAX trial exclusively based on estimated PASP led to neutral results as well.81The PASSION trial is underway and will test the effects of tadalafil on hard end points in a larger group of similarly phenotyped patients. The same potential for benefits of PDE5 inhibitors in PH-HFpEF (Table) and conceivably explains differences across studies.Overall, the evidence available to date points to the concept that a thorough RH phenotyping is preliminary to any further reasoning in the potential use of PDE82 In humans, findings with albuterol in HFpEF have shown an improvement in exercise pulmonary vascular reserve without worsening left heart congestion.83 Interestingly, some of the benefits observed with albuterol were driven by a reduction in LV transmural pressure suggesting an RV unloading effect due to perivascular and peribronchial fluid reabsorption and an RV unloading effect.Recently, treatment with β3AR (beta-3 adrenergic receptor) agonists has been found to improve pulmonary hemodynamics, RV remodeling, and pulmonary vascular proliferation in a translational porcine model of postcapillary chronic PH.84Similar findings have been described during acute administration of inhaled sodium nitrite showing a reduction in biventricular filling pressures and PAPs at rest and during exercise in HFpEF.85An ongoing study of combined pre- and postcapillary PH-HFpEF patients, the SPHERE HF, will test the effects of a β3AR, mirabegron, on RH performance using advanced imaging techniques  and several markers of subclinical myocardial disease  to address even subtle changes in RV function.86Promising results have been observed with the TRPV4  channel, which regulates fluid transit across the alveolar capillary interface and represents a novel target to reduce lung interstitial and perivascular water, independent of pulmonary capillary hypertension, definitively impacting the RV.87 but there is some concern on the temporal-related occurrence of RV dysfunction as suggested by experimental models.88An interesting nonpharmacological approach to the treatment of HFpEF is the interatrial communication device whose indications to implantation require no PH at rest and normal RV function. Whether this approach may delay or prevent development of RV dysfunction is a matter of interesting investigations,HFpEF is a complex disease at high and increasing prevalence with no effective therapeutic options. Among the pathophysiologic abnormalities that contribute to the heterogeneity of HFpEF syndrome, recent epidemiological and clinical studies have progressively focused on the RH, pointing out its basic role as a mediator of the progression of the disease, exhibiting a high prediction value for clinical worsening, and representing a main target of newly developed therapeutic opportunities. Several clinical RH phenotypes at rest and during physical challenge have been described, and the pathophysiology behind the different evolving stages is a matter of intriguing investigation. The main reason for the development of RH dysfunction is the augmented load imposed by the increased left atrial pressure associated with LV diastolic dysfunction and atrial myopathy, yielding to an increased pulsatile loading. The development of pulmonary vascular disease and wall remodeling further exacerbates the RH impedance through an increase in resistive load.The gold standard for measuring RH systolic function and its coupling with Pc are cardiac and vascular elastances measured by pressure-volume loops, but a number of echocardiography-derived parameters are alternatively used in daily practice for acquiring either functional and morphological information. Although these measures reflect, only in part, the complex hemodynamic adaptations of the RH, the functional assessment is now comprehensively approached through advanced imaging along with simplified method of RV-PC coupling. These indicators demonstrate a remarkable prognostic value starting from the earlier stages of the disease. Based on this evidence, most of the future research should focus on how the study of RH phenotypes could implement our knowledge on HFpEF.Upcoming research in the field should aim at a better understanding of the mechanisms involved in the RV geometric and functional progression starting from specific attention on the time-dependent changes in LA dynamics and deepest knowledge on the pathways involved in the lung vessel injury and remodeling processes.This study was supported by Monzino Fundation, Milano, Italy.None.


Cardiovascular diseases (CVDs) are a group of complex and multifactorial disorders and their pathogenesis is still not completely understood. It is recognized that inflammation, especially the chronic inflammation is a common pathogenesis of many CVDs, such as atherosclerosis, myocardial infarction and stroke. Continuous inflammation causes a series of pathological changes of hearts and blood vessels. Clinical trials and basic studies have shown that inflammatory inhibition by pharmacological and other interventions can markedly reduce the degree of pathological changes of hearts or blood vessels, and decrease the morbidity and mortality of CVD events. Thus, the advance of therapies direct or indirect modulating chronic inflammation is an important approach for the prevention and treatment of CVDs.Pharmacological interventions are the primary therapeutic approaches for CVDs. In the past few decades, plenty of drugs for different targets including anti-inflammatory agents have been developed and used to prevent and treat different CVDs in the clinic. In the past few years, the flood of new drugs including chemical-based drugs and natural herbal products have provided more choices to the treatment of CVDs. Recently, biotherapies and molecular targeted therapies utilizing cell-based products such as stem cells, exosomes, immune cells, cytokines, peptides and monoclonal antibodies have also been used to treat CVDs, and some of them specifically target to inflammation. The purpose of this Research Topic was to provide interested readers with new advances on prevention and treatment of CVDs, especially on the new therapies targeting chronic inflammation.The Research Topic themed “Chronic inflammation and pharmacological interventions in cardiovascular diseases” presents a series of articles that highlight the latest studies and strategies that overcome current obstacles in treating chronic inflammation and pharmacological interventions in cardiovascular diseases. This issue collates 30 selected peer-reviewed articles  covering molecular mechanisms of therapeutic targets, drug intervention targets, and novel diagnostic approaches to cardiovascular diseases .β (TGF-β) signaling pathway is involved in the development of aortic aneurysms (AAs), the specific action of TGF-β signaling in AAs remains controversial  is one of the serious complications of diabetes, and increasing evidence supports that myocardial inflammation is a key player in the development of DCM . PyroptoLi et al.) and Uramine on heart diseases . For example, the traditional Chinese medicine is effective to treat heart failure by targeting heat shock proteins , as well as to treat atherosclerosis and other cardiovascular diseases by promoting blood circulation together with aspirin . Some researchers have further explored the signaling pathways of its action. Zhang et al. reported that lithospermic acid (LA) protected against myocardial ischemia-reperfusion (MI/R)-induced cardiac injury by promoting eNOS and Nrf2/HO-1 signaling via phosphorylation of AMPKα. Zhou et al. elucidated the molecular mechanism of action of a Chinese traditional medicine Farrerol (FA) in ischemia-reperfusion (I/R) injury. Their findings showed that FA indirectly protected cardiomyocytes by targeting macrophages, without relying on Nrf2-dependent or autophagy-dependent pathways, but indirectly protected cardiomyocytes through the inhibition of the interaction of NEK7 and NLRP3, thereby abolishing the assembly and activation of NLRP3 inflammasome, resulting in an effective inhibition to alleviate MI/R injury. Liu et al. investigated the effects and mechanisms of Honokiol (HL) in a rabbit atrial fibrillation (AF) model and found that the activation of Sirt3-dependent pathway participated in atrial metabolic remodeling during AF, which could be inhibited by HL via regulating the Sirtuin-3 (Sirt3) dependent pathway. Sirt3 is widely recognized to be critically involved in diverse cardiovascular diseases including cardiac and vasculature remodeling  ameliorated ventricular remodeling and heart failure (HF) to some extent in rats by modulating the gut microbiota and NLRP3 inflammasome. Based on network pharmacology and experimental pharmacological analysis, Jing et al. identified that Astragaloside IV, a main active compound from Astragalus membranaceus, could be a promising agent to improve l-NAME-induced hypertensive heart disease partly via modulation of eNOS and oxidative stress. In addition, Zhang et al. found that water-soluble tomato extract fruitflow could inhibit platelet activation, which is beneficial to people who are at risk for platelet hyperactivity-associated thrombosis.Pharmacological interventions are the main treatment for cardiovascular diseases, and a variety of drugs have been developed for the prevention and treatment of different cardiovascular diseases. Chinese medicine has its unique advantages since it treats patients holistically as well as individually based on the personalised interventions . In thismodeling . Lu et aYang et al. demonstrated that Oxytocin (OT) ameliorated cardiac hypertrophy by inhibiting PI3K/Akt pathway via lncRNA GAS5/miR-375-3p/KLF4 axis. Based on in Silico analysis, Chang et al. highlighted the importance of the multitarget therapeutic peptide KCF18 which could alleviate inflammation by blocking the interactions of TNF-α, IL-6, and IL-1β with their cognate receptors, thus reducing the translocation of NF-κB and decreasing the inflammatory gene expressions. By lowering the release of cytokines in plasma and directly affecting vascular cells, KCF18 was shown to significantly attenuate vascular inflammation. The property of KCF18 to prevent inflammation may hold a promise as a new treatment strategy for sepsis and other inflammatory vascular diseases.Recently, molecular targeted therapies have been broadly applied to treat CVDs, which include protein and peptide drugs, nucleic acid drugs, and gene editing technologies . Apart fIschemic stroke is a common serious disease caused by arteriosclerosis . AccuratThe pathogenesis of cardiovascular diseases is complex and interlinked, involving central mechanisms such as cardiomyocyte hypertrophy and death as well as systemic mechanisms such as chronic inflammation. Over last decades, significant evidence from both pre-clinical and clinical studies strongly indicates that targeting inflammation either locally or globally is an effective means for the prevention and treatment of cardiovascular diseases. Here, it is exciting to witness the latest advance, the beautiful works published in this issue elucidate some novel molecular mechanisms, identify some promising peptides, cytokines and natural products, and therefore provide the new insight into the pathogenic role of chronic inflammation in cardiovascular diseases. It is expected that this will continue to be a hot research area, the more detailed dissection of mechanisms and evaluation of the therapeutic potential by targeting inflammation undoubtedly has great translational significance for the treatment of cardiovascular diseases.


Disheveled-associated antagonist of β-catenin (DACT), which ubiquitously expressed in human tissue, is critical for regulating cell proliferation and several developmental processes in different cellular contexts. In addition, DACT is essential for some other cellular processes, such as cell apoptosis, migration and differentiation. Given the importance of DACT in these cellular processes, many scientists are gradually interested in studying the role of DACT in tumorigenesis and cancer progression. This review article focuses on the latest research regarding the essential functions and potential DACT mechanisms in the occurrence and progression of tumors. Our study indicates that DACT may act as a tumor biomarker for cancer diagnosis and prognosis, as well as a promising therapeutic target in cancers. It is well known that cancer remains the leading cause of human death, which results from accumulated genetic and epigenetic alterations of various cancer-related genes, including tumor suppressor genes (TSGs) and oncogenes DACT family members (DACTs) were initially isolated from yeast-two hybrid screens with the Dishevelled (Dvl) PDZ domain as bait DACTs are intracellular proteins that can bind to many molecules in the cytoplasm and nucleus DACTs play a critical role in the regulation of cellular function and vertebrate development. As reported previously, DACTs expression has been associated with the development of most organs and tissues, including the teeth, eye, heart, brain, and kidney Among three members in the DACT family, DACT1 is the best investigated in various types of cancer. Wang et al. reported that DACT1 was down-expressed in primary gastric cancers In addition, researchers reported that the expression of DACT1 was significantly down-regulated in non-small cell lung cancer tissues (NSCLC) compared with that in normal lung tissues Previous studies have reported that DACT2 expression was significantly depressed in primary breast cancer samples compared with adjacent normal breast tissues Compared with DACT1 and 2, DACT3 has been less well characterized, and its function in tumorigenic signaling and development remains unclear. Recent research revealed that DACT3 expression was reduced in NSCLC tissue, which was correlated with lymph node metastasis and poor prognosis of NSCLC Together, all these studies demonstrated that the association between DACTs expression and outcome in most types of cancers strengthened the importance of the role of DACTs in tumor progression and validated their potential value as a robust prognostic biomarker. The expressions of DACTs in cancers are shown in Table Both transcriptional and posttranscriptional regulation play crucial roles in DACTs expression in cancers. MicroRNAs (miRNAs) are small non-coding RNAs that have been identified to play pivotal roles in various biological contexts by mediating the regulation of target gene expression at the posttranscriptional level Transcriptional level regulation is another primary method involved in DACTs expression regulation. Esposito et al. demonstrated that DACT1 was transcriptionally regulated by TGF-β to modulate Wnt signaling Genetic and epigenetic variation work in concert to influence human health and disease Silencing of DACT family members can also be occurred by methylation of CpG islands in the promoter region, which plays an important role in tumorigenesis and development of tumors. For example, Yang et al. reported that the DACT1 gene was inactivated by hyper-methylation in the promoter region in nasopharyngeal carcinoma with 5-aza-deoxycytidine treatment, which can be reactivated by demethylation According to previous reports, DNA methylation played a crucial role in the silencing of DACT2. Guo et al. found that DACT2 was frequently methylated in human ESCC, which may be one of the main mechanisms for DACT2 inactivation DACT3 expression is also frequently reduced in cancers. However, promoter methylation may not be the primary mechanism that mediates DACT3 silencing. According to the research, histone modification may be the main regulated mechanism for the inactivation of DACT3 in colon cancer Uncontrolled proliferation is characteristic of cancer cells and represents one of the hallmarks of neoplastic growth DACT2 has also been reported to be frequently down-expressed in multiple human cancers, which suppressed the proliferation of cancer cells. Restoration of DACT2 expression cloud suppresses human breast cancer cells growth through inducing G1/S checkpoint arrest As a member of the DACT family, DACT3 is also involved in tumor growth. DACT3 transfection inhibited c-Myb expression of NSCLC cells, as well as c-Myc expression and β-catenin nuclear translocation to inhibit cell proliferation Interestingly, DACTs exerted different roles in the regulation of colorectal cancer cell progression. It was found that DACT1 increased the nuclear and cytoplasmic fractions of β-catenin via phosphorylated GSK-3β at Ser9 to promote cell proliferation in colon cancer Resistance to apoptosis is a remarkable hallmark of malignancies. Apoptosis is a programmed cell death, which is critical for removing unessential cells like tumor cells. Specific mechanisms of apoptosis in anti-carcinogenic action include activating poly (ADP-ribose) polymerase (PARP), subsequently fragments of effector caspases, and the Bcl-2 (B-cell lymphoma 2) family of proteins Moreover, DACT1 downregulated anti-apoptotic genes Bcl2 and Bcl-XL, which contributed to the prevention of mitochondrial apoptosis, leading to activation of the downstream apoptotic protease cascade Regarding the signaling pathways implicated in the regulation of cell apoptosis, DACTs have been proved to promote cell apoptosis through blocking Wnt/β-catenin Cell migration and invasion are central to morphogenesis and to multiple aspects of tumor metastasis Mechanically, DACTs exert its migration- and invasion-inhibitory effects through Wnt/β-catenin Autophagy is a regulated self-eating process that eliminates the cellular materials, such as aggregated cytoplasmic proteins or aged and damaged organelles through lysosomal degradation In this review, we have sought here to synthesize the advances in the DACTs and their roles in various cancers and highlighted the function and mechanisms of DACTs in cancer cell proliferation, apoptosis, migration, and invasion, and autophagy, which may contribute to forming an elementary framework for understanding the complex biologic changes induced by the DACT family, and help us to develop more targeted implementation strategies. Until now, research on inhibiting or promoting cancer progression by regulating DACTs has remained in the experimental stage. We hope continuing elucidation of cancer pathogenesis, including precise molecular mechanism, to make most utility of the DACT family members.In clinical practice, DACTs expression is associated with clinicopathological parameters and survival of tumor patients. On this basis, DACT could act as a diagnostic and prognostic biomarker for cancer patients. Nevertheless, confirming the prognostic and diagnostic value of DACTs in cohort studies with well-designed and larger-size needs to be conducted. Further exploring the role of DACTs in more cancer and whether DACTs can serve as a drug target may have important research value. We hope that our review will attract the attention of the scientific research community and clinical practitioners and encourage them to carry out treatments targeting DACTs as soon as possible.


The availability of disease modifying therapies for spinal muscular atrophy (SMA) have created an urgent need to identify clinically meaningful biomarkers that provide insight into disease progression and therapeutic response. microRNAs (miRNA) have been shown to be involved in the pathogenesis of SMA and have the potential to provide insight within the field of SMA. miRNA-sequencing was utilized to identify differential miRNA expression in the cerebrospinal fluid (CSF) in six children with SMA treated with nusinersen in this exploratory study. Fourteen differentially expressed miRNAs were significantly altered in CSF from baseline to follow-up during treatment with nusinersen. The greatest magnitude of change was noted in miR-7-5p, miR-15a-5p, miR-15b-3p/5p, miR-126-5p, miR-128-2-5p and miR-130a-3p which encompassed a spectrum of functions predominantly in neurogenesis, neuronal differentiation and growth. The dominant signaling pathways identified in this study were the mammalian target of rapamycin and the mitogen-activated protein kinase signaling pathways. This study identified multiple miRNAs that were involved in the complex interplay between neurodevelopment and neurodegeneration. SMN1) gene cause SMA [SMN2) gene contains a single nucleotide change that produces alternative splicing with only low levels of functional SMN protein being formed [SMN2 can vary from 0 to 8 copies per genome and is the main modifier of SMA severity [Spinal muscular atrophy (SMA) is characterized by the degeneration of motor neurons in the anterior horn of the spinal cord and disruption of motor axon development in ventral roots due to the deficiency of the survival motor neuron protein (SMN) . Homozygause SMA . The parg formed . SMN2 caseverity .While SMN protein is ubiquitously expressed in the cytoplasm and nucleus of all cells , the selTM) is an antisense oligonucleotide (ASO) that modifies the splicing of SMN2 pre-mRNA to promote expression of functional SMN protein [Therapeutic approaches for SMA focus on increasing the production of SMN protein. Nusinsersen  are essential for the development, differentiation, acquisition and maintenance of axonal growth, cytoskeletal structure, synapse formation and overall activity . miRNAs Increasingly, CSF diagnostics focusing predominantly on the proteome and metabolome are being developed to ascertain disease onset, progress and response to therapy in SMA . HoweverThe primary aim of this exploratory study was to ascertain the feasibility of utilizing a low-input CSF transcriptomic profiling approach for the first time in childhood onset SMA. The secondary aim was to use an untargeted methodology and bioinformatic filtering approach to identify miRNAs modulated by nusinersen treatment, define their associated target genes and signaling pathways. SMN1 deletions. We included children who were either diagnosed through newborn screening or after developing clinical signs and symptoms of SMA from birth to 1 year of age. Children who received sequential or combinatorial therapy with other disease modifying agents were excluded from this study. Parents of participants signed informed consents for the use of CSF and clinical data for research purposes. The study was approved by the Sydney Children’s Hospital Network Human Research Ethics Committee (HREC/18/SCHN/373). This was a single-center prospective longitudinal study. This study included infants with SMA between December 2019 and January 2021 at the Sydney Children’s Hospital, Randwick, New South Wales for whom a CSF specimen was collected during the course of nusinersen treatment, administered as standard clinical care. The first specimen collected from the individual was deemed as baseline and compared to a follow-up sample, collected during the later course of nusinersen treatment. As this was a real-world study, there was variability in the timing and number of CSF collections between individuals. All children had genetically confirmed homozygous exon 7 g for 10 min at 4 °C and the supernatant were aliquoted to 1 mL Eppendorf tubes and stored at −80 °C till further analyzed  was utilized to carry out RNA extraction. To prepare the cell lysate, 200 µL of CSF was transferred to an RNase-free microcentrifuge tube. Then, 600 µL of lysis solution containing was added to the CSF and vortexed for 10 s. Next, 800 μL of 96–100% ethanol was added to the lysate and was added to every 800 μL of the lysate and combined by vortexing for 10 s. To facilitate binding of the lysate to the column, the lysate with the ethanol was centrifuged for 1 min after which the flowthrough was discarded. The column was washed with 800 μL of 96–100% ethanol for a total of three times before the column was spun for two minutes to thoroughly dry the resin. RNA elution was carried out by adding 30–50 μL of elution solution to the column. The column was centrifuged for 2 min at 2000 revolutions per minute (rpm), followed by 1 min at 14,000 rpm. A repeat elution was carried out to increase the recovery of the RNA. The purified RNA sample was stored at −80 °C till further analysis. The quantity and quality of the isolated RNA were assessed by the Agilent 2100 Bioanalyzer™  and by spectrophotometer using 260/280 nm and 260/230 nm ratios. CSF RNA concentrations and RNA integrity number were replicated to previously published literature, demonstrating the quality of the miRNA identified in our study. QIAseq miRNA library kit was used to prepare miRNA sequencing libraries (manufacturer: Qiagen). The QIAseq kit facilitates both enhanced differential expression analysis using integrated Unique Molecular Indices (UMIs) and novel discovery of miRNA from CSF. We analyzed miRNA expression from isolated RNA  by utilizing a low input RNA sequencing methodology . https://geneglobe.qiagen.com/us/analyze (accessed on 27 September 2021)). Raw data were aligned to the human reference genome (GRCh38) using GeneGlobe. miRNA UMI counts generated using the GeneGlobe tool were used to perform further downstream analysis. Differential expression analysis was performed comparing follow-up phase to the baseline phase using the R package edgeR [p-value < 0.05 and a FC >= |2|. The significantly differential miRNAs underwent a systematic literature review and were further filtered for those miRNAs predominantly involved within motor neuron specific physiological and pathophysiological processes, as based on a comprehensive and systematic review of the literature. This filtering approach has been widely used in prior studies to focus transcriptomic profiling for miRNAs that are relevant to specific disease processes [Processing of the raw fastq files and miRNA quantification was carried out using QIAGEN’s web-based analysis tool GeneGlobe  . The topSMN2 genotypes (2 and 3 copies) and disease stages (pre-symptomatic and symptomatic SMA) where symptomatic children were those who had signs and symptoms of SMA disease. Infants were followed for a median of 6 (range 1.6–11.7) months post dosing with nusinersen. All children attained motor function with nusinersen therapy , disease duration,  therapy .We obtained RNA samples of patients through the course of their nusinersen therapy and performed miRNA-sequencing to explore which miRNAs are changing throughout therapy. Differential expression analysis comparing follow-up phase to the baseline treatment phase identified 101 miRNAs in the CSF, of which 66 miRNAs were significantly altered. A systematic literature review on the 66 miRNAs identified 15 of these miRNAs that were the most relevant to motor neuron development and pathophysiology . It is iFourteen of the 15 differentially expressed miRNAs were deemed to fulfil ‘the strong evidence criteria’ from miRTarbase and from at least one other miRNA-target interaction databases (TargetScan and/or miRDB) ,18,19. TPathway analysis using KEGG (see methods) showed that the putative target genes of the selected miRNAs were associated with discrete and overlapping regulatory and signaling pathways D. The siThis exploratory study has for the first time in a paediatric SMA cohort demonstrated that a low-input untargeted transcriptomic profiling methodology is feasible in CSF and can identify alterations in miRNA expression through the course of nusinersen therapy. The techniques used in this study overcome the inherent barriers associated with miRNA analysis in CSF, which is a predominantly acellular biospecimen that reveals a low yield of miRNA. Furthermore, in a therapeutic domain where intrathecal modalities are being continually optimized, identifying a potential biomarker that is specific to the CNS holds potential clinical benefit. As the pathogenesis of SMA occurs early in life, with significant denervation occurring in the first three months (16), the miRNA profile of infants with SMA concurrent with developmental progress is particularly vital to ascertain. Furthermore, as the clinical paradigm shifts to timely diagnosis through newborn screening, facilitating access to prompt intervention, the modulation of miRNA, early in disease modification is warranted. Thus, this study uniquely focused on a cohort of children, diagnostically confirmed and treated with nusinersen early in their disease course. Despite our cohort being heterogenous in biogenetic characteristics, an overall downregulation noted in all the identified miRNAs could be secondary to treatment efficacy and/or the changing transcriptomic profile associated with developmental stage. Further longitudinal studies with age matched controls would be essential to delineate these aspects. From the current literature, several possible roles of these dysregulated miRNAs in preclinical studies and other motor neurone diseases have been reported. However, the present study is the first to translate this preclinical work and identify patterns of miRNA regulation in vivo, and longitudinally with treatment. From a wide spectrum of possible molecular, biological and cellular pathways, 15 candidate miRNAs identified from this treated cohort were associated with processes of neuronal survival, autophagy/apoptois, neuronal differentiation, and cell signaling. This study identified miR-7 and miR-183, known mediators of autophagy and apoptotic processes, contributing to cell fate decision. miR-7, mainly expressed in neurons, reduces neurotoxicity induced apoptosis caused by protein aggregates in neurodegenerative conditions such as Parkinson’s disease, by inhibiting the expression of pro-apoptotic proteins . This miThe balance between cell death and survival is replicated by elucidating the functions of miR-183. This miRNA inhibits axonal growth in motor neurones whilst mediating a protective effect by down regulation of p53, a ubiquitously expressed nuclear protein that controls cell division and cell death . In SMN Neuronal survival and neurite growth are important processes within the development and maturation of the peripheral nervous system. Dysregulation of these normative processes have been noted in peripheral neuropathies such as Charcot-Marie-Tooth type 2 . Heat shNeuroinflammation in SMA has been recently proposed as another pathogenic process, leading to the ultimate pathway of neuronal degeneration, and is also well established in other neurodegenerative disorders . This prDuring late neurogenesis and in the early postnatal development, different types of glial cells are generated from neuronal precursor cells. Recent studies support a role for miRNAs in the development of these glial lineages. For example, it has been shown that miR-338 is specifically enriched in oligodendrocyte precursors and plays a functional role in oligodendrocyte differentiation [Whilst our prior understanding of SMA centered on the survival of the alpha motor neurone and secondary effects on muscle morphology and function, molecular technologies have generated new knowledge attesting to the roles of miRNAs in non-motor neurone tissues in SMA pathogenesis. Particularly, SMN has a key role in myogenesis and mitochondrial biogenesis, with histopathologic features of SMA consistent with aberration of these normative processes . InteresmiRNAs, particularly miR-196 as found in the present study, are involved in the precise regulation of Hox genes in a spatial and temporal manner during development . Hox genWhilst individual miRNAs have been identified through this study, the complexity and variety of their roles in disease mechanisms and disease modifying processes involves interrogation of the signaling pathways that they mediate. SMN2 expression [The MAPK pathway has been identified in this study as a dominant process in treated SMA, with miR-15a-5p and miR-338-3p amongst the miRNAs facilitating its translation. MAPK is a fundamental stress-activated signal transduction process that regulates differentiation, proliferation, cell death, survival, and transformation. The pathway is activated by a wide range of stimuli, including oxidative stress. Many studies have shown that signaling is overactive in amyotrophic lateral sclerosis patients. Inhibiting MAPK signaling protects neurons from degeneration . Similarpression . CumulatAnother dominant signaling pathway highlighted by our study was the mTOR pathway, proposed in this study to be mediated by miR-183 and miR-378. Upstream components of this pathway are mediated by phosphatidylinositol 3 kinase . Studies have reported reduced mTOR activity and impaired protein synthesis . Whilst Due to the limits of cohort size, we were unable to address the clinical and genetic confounders of miRNA expression in treated SMA. However, this study was specifically conducted to ascertain a selection of target miRNAs that could be validated in a wider cohort of children with a spectrum of disease durations, phenotype and genotype in future studies. This will enable us to understand the individualistic roles whilst unravelling the complexities of miRNA functions as highlighted in the current study. Furthermore, and unique to a paediatric onset disease, miRNAs profiles within a physiological developmental window should be interrogated in future studies with incorporation of age matched controls. This will enable delineation of whether the changes seen in this study are wholly due to therapeutic response, residual disease mechanisms, developmental processes, or combinations of these factors. This exploratory study has shown for the first time that miRNAs can be effectively identified in CSF of treated children with SMA. Due to the versatile roles of miRNA in regulating cell survival, differentiation and development as identified in this study, it is proposed that alterations in miRNA can give a holistic view of disease mechanisms alongside processes contributing to disease modification with treatment, enabling the next frontier of biomarker development in SMA.