Sensory ataxia is a dysfunction of dynamic balance due to impairment of sensory input into the control of movement. The sequelae of stroke, such as hemiplegia, somatosensory impairment, and impaired balance may cause significant disability and may affect patients’ quality of life. In addition to rehabilitation programs, acupuncture therapy has been applied to stroke patients and is recommended as a complementary therapy in stroke rehabilitation.A 70-year-old male had a sudden onset of conscious loss. The brain computed tomography showed intracerebral hemorrhage with subdural hemorrhage and subarachnoid hemorrhage.Intracerebral hemorrhagic stroke was diagnosed.Yongquan (KI1), Tongtien (BL7) and Houxi (SI3).He received craniotomy with hematoma evacuation immediately and waked up 3 weeks with bilateral hemiparesis (right side weaker than left), impaired position sensation and tactile perception in the right lower limb. He then began to receive rehabilitation therapy and had significant improvement in muscle strength and static balance, but no improvement in tactile perception of position sense in the right lower limbs and reached plateau. Then he received acupuncture therapies to Yongquan (KI1).The patient's walking ability recovered after receiving rehabilitation programs for 3 years, but the impairment in proprioception and dynamic balance persisted. The perception and dynamic balance had significantly improved after patient received acupuncture therapy, especially the acupuncture point of The clinical effect of acupuncture in combination with conventional rehabilitation therapy for neurological impairment recovery, improving activity of daily living performance and improving post-stroke imbalance was explored. We hope that this report can facilitate further well controlled quantitative objective studies on a big size of samples. Sensory ataxia is distinguished from cerebellar ataxia by the presence of near-normal coordination when the movement is visually observed. However, marked worsening of coordination when the eyes are closed (a positive Romberg's sign). Sensory ataxia can be a manifestation of sensory large fiber peripheral neuropathies and conditions causing dysfunction of the dorsal columns of the spinal cord due to a variety of disorders: infectious, auto-immune, metabolic, toxic, vascular and hereditary diseases.Qi” circulated in the whole body regularly every day. Each channel contains many acupuncture points where more “Qi” accumulated and being more sensitive. Acupuncture treatment on different acupuncture points may cure different various diseases, depending on the selection of different acupuncture points. In this case study, we applied two rules:Acupuncture (AcP) is one valuable therapeutic intervention of the Traditional Chinese medicine. According to the theory of acupuncture, there are 14 channels of energy distributed in the whole human body. Inside these 14 channels, there is “(1)the acupuncture points near the lesion, and(2)the distant acupuncture points belonging the same channel passing through the lesion or the channels related to the group containing the lesion. A patient  with sensory ataxia due to subdural hemorrhage with sensory deficit at right sole area was selected for this case study. After therapeutic acupuncture, several subjective and objective evaluation were assessed.The lesion according to theory of acupuncture is defined as the site where symptoms and signs are present.2A 70 year-old male physiatrist (CZH) had a sudden onset of conscious loss on 2014-12-21. He was initially brought to a teaching hospital where computed tomography showed evidence of intra-cerebral hemorrhage with subdural hemorrhage and subarachnoid hemorrhage . Size 36 acupuncture needles with 1 inch in length were inserted into the acupuncture points in sequence. Bilateral Yongquan (KI1) (in the kidney channel) were selected for near acupuncture point, and bilateral Tongtien (BL7) (in the bladder channel) and bilateral Houxi (SI3)  for distant acupuncture point. After each needling, electric stimulation with frequency of 2 Hz were applied for 30 minutes for each point. After only 1 treatment of acupuncture, he had significant improvement in perception, and dynamic balance.On 2017-12-30, he received acupuncture therapy to The case study was conducted after the first acupuncture therapy since the patient found the dramatic therapeutic effectiveness of acupuncture. The findings of evaluation before acupuncture was estimated by the patient depending on his memory. After therapeutic acupuncture, the following items were assessed:(1)Subjective feeling of dynamic stability  (Sd);(2)Subjective feeling of motor function  (Sm);(3)Subjective feeling of sensory function  (Ss);(4)Objective evaluation of walking speed (Ws);(5)Objective evaluation of walking tolerance (Wt);(6)Objective evaluation of static stability, 2 LE standing time with eye closed (2LE);(7)Objective evaluation of static stability, that is, the duration of 1-leg standing time with eye open (1LE). The scales of assessment are listed in Table The results of assessment of functional improvement are listed in Table The most remarkable findings include the subjective walking  and objective assessment of 1 leg standing balance . It appears that the subjective feelings of both motor improvement and to that of sensory improvement were both remarkable immediately after AcP treatment. But they were not sustained, but declined. Walking speed remained unchanged throughout the whole studying period. Walking tolerance improved after each AcP treatment, even in the last treatment. Regarding the objective balance, only little improvement in the 2 leg supported balance, but remarkable improvement in the 1 leg standing balance and became stable after 3 treatments of AcP.3Yongquan (KI1) to the patient. Yongquan (KI1) can treat conscious disturbance, cognitive function impairment, sole unable to touch the ground. Quantitative and accurate measurements are crucial to evaluate the treatment outcomes. The most important findings in this case study include the remarkable improvement in the subjective assessment of dynamic balance  and the objective assessment in 1 leg standing, an important indicator of static balance. Both improvement had continuous improvement even after cessation of acupuncture.All the assessments in this case study were improved except for walking speed. It appeared that these improvements were related to the effectiveness of acupuncture. The patient was considered to reach a “plateau” of rehabilitation, until the physician applied the acupuncture to the point of Yongquan (KI1) acupuncture treatment, including walking speed, walking tolerance and the standing stability with 1 leg and 2 legs support. The overall results indicate the positive effect of acupuncture treatment with Yongquan (KI1) except the walking speed. The walking speed remains a steady performance. According to the patient, the subjective feelings of walking balance  was remarkable, unfortunately we did not design a quantitative and objective measurement of dynamic balance. The subjective feelings of motor and sensory improvement are both also remarkable and immediate increased after acupuncture. Though the effects declined gradually as time goes by, but compare with the baseline data on 2017-12-29, the improvement of subjective feelings of motor and sensory is still marked.In addition to subjective sensations of motor and sensory improvement, we also use several objective tests to evaluate the improvements after Yongquan (KI1), especially 1 leg standing balance. Though the patient can stand with 2 legs without assistance at initial assessment, he cannot resist to the pushing. After treatment, the patient feels subjectively that there is only little improvement in the 2 legs supported balance, but able to resist pushing force is noticed. As for the 1 leg standing balance, the patient can barely stand with 1 leg (0 sec) when first evaluate on 2017-12-29. After treatment, the duration of standing with 1 leg support can lasting for 0.75 sec. It's worth noting that, the improvement of dynamic balance can be sustained after treatment without declined. Lower limbs somatosensory impairment has negative effects on walking tolerance and dynamic balance, etc. Whereas those factors: walking tolerance and dynamic balance play important roles of ambulation and are correlated with the activity of daily living (ADL) performance. Thus, when the patient's foot sensory input regained after acupuncture therapy with Yongquan (KI1), the functional performance also improved.Another important finding is the improvements in the walking tolerance. According to the above data, the patient could only walk without assistance for 10 minutes initially, but the walking time gained gradually with treatment. After complete the whole acupuncture treatment course, the patient can tolerate 60 minutes walking without assistance. Regarding to the dynamic balance, standing with 2 legs and 1 leg supported are chosen to evaluate the treatment results. The improvements of dynamic balance are observed after acupuncture with –10 Though patients may regain the ability to walk after undergoing rehabilitation, but still have higher risk to accidental falls due to impaired balance.,11 Balance deficits may also affect ADL functions such as transfers, ambulation, bath room activity, and so on. Balance can be influenced by many factors including motor function, sensory function, vestibular function, visual function, etc.–13 However, patients with sensory impairment seems tend to have worse functional recovery. In this case, the patient's walking ability recovered after receiving rehabilitation programs for 3 years, but the impairment in proprioception and dynamic balance persisted. The perception and dynamic balance had significantly improved after patient received acupuncture therapy, especially the acupuncture point of Yongquan (KI1).The sequelae of stroke, such as hemiplegia, somatosensory impairment, and impaired balance may cause significant disability and may affect patients’ quality of life.–17 However, some authors believed that, somatosensory impairments are common in chronic stroke patients and which may influence the functional performance.,17 In chronic stroke patients, rehabilitation is often terminated when additional improvement has been reached “plateau” which may occur 6 months later after stroke.–19 However, the exact recovery course of somatosensory impairments is still not well documented, also, there are still no strong evidences can proof that the therapeutics of rehabilitation can effectively improve the somatosensory deficits.,20Previous reports about the prevalence of somatosensory deficits in chronic stoke patents varied in a wide range which probably related to the inadequate precise standard measurements of somatosensory deficits.,21–24 The clinical effect of acupuncture in combination with conventional rehabilitation therapy for neurological impairment recovery, post-stroke shoulder pain, aphasia, improving ADL performance and improving post-stroke imbalance was explored.,21–26 Some researchers reported evidences of increase cerebral blood flow in sensorimotor area and activation of somatosensory cortex in stroke patients after acupuncture therapy, by using studies with images, single photon emission computed tomography (SPECT) perfusion and functional MRI to illustrate. Those studies demonstrated the therapeutic effect of acupuncture in stroke rehabilitation.,14,27,28In addition to rehabilitation programs, acupuncture therapy has been applied to stroke patients and is recommended as a complementary therapy in stroke rehabilitation.Qi to the site that is lacking Qi, enhance the restoration of deficits. Previous studies have indicated that acupuncture therapy is effective in improving balance function.,13,28,29 In some cases, the effectiveness can occur immediately after acupuncture. It also can affects the sensory perceptions. The selection of acupuncture points usually depends on the physicians’ personal experience in clinical practice, or the presenting symptoms of each individual patient. Acupuncture points, Baihui (GV20), Yanglingquan (GB34) and Zusanli (ST36) are often chosen for treating the impairment of balance or coordination in stroke patients.,21,28,30 As for Yongquan (KI1), related studies are few, but in ancient Chinese medicine theory, Yongquan (KI1) can treat conscious disturbance, cognitive function impairment, sole unable to touch the ground. In a recent study conducted by Zhang's colleagues, they found that acupuncture at the Yongquan acupoints may induced stronger neuronal activity and increase synaptic activity in some areas of the brain. Long-term acupuncture may affect the quantity and function of synapses in brain area, leading the neural reorganization.According to the theory of acupuncture in Traditional Chinese Medicine, acupuncture can direct 4Yongquan (KI1). From the pilot case study, more well-designed investigations may be performed in the future. Furthermore, precise quantitative and objective measurements to evaluate treatment outcomes should be designed in the future studies.This is just a single case study, and hopefully this study can facilitate more studies in this aspect. From this case, we have observed the effects and benefits of treating chronic stroke patient with Methodology: Chang-Zern Hong.Supervision: Li-Wei Chou.Writing – original draft: Kuan-Yu Lu, Ka-Fai Yuen, Jia-Yuan Luo.Writing – review & editing: Chang-Zern Hong, Li-Wei Chou.


Initiation and propagation of cracks in composite materials can severely affect their global mechanical properties. Due to the lower strength of the interlaminar bonding compared to fibers and the matrix, delamination between plies is known to be one of the most common failure modes in these materials. It is therefore deemed necessary to gain more insight into this type of failure to guide the design of composite structures towards ensuring their robustness and reliability during service. In this work, delamination of interlaminar bonding in composite end-notched flexure (ENF) samples was modeled using a newly developed stochastic 3D extended finite element method (XFEM). The proposed numerical scheme, which also incorporates the cohesive zone model, was used to characterize the mode II delamination results obtained from ENF testing on polyphenylene sulfide (PPS)/glass unidirectional (UD) composites. The nonrepeatable material responses, often seen during fracture testing of UD composites, were well captured with the current numerical model, demonstrating its capacity to predict the stochastic fracture properties of composites under mode II loading conditions. Nowadays, fiber reinforced polymer (FRP) composites are widely used in various engineering applications, including aeronautical, marine, and automotive industries. These materials have high strength-to-weight ratios as well as good corrosion resistance and can be engineered based on the required strength or performance objectives of a given application. Although FRP composite structures have proven to provide numerous advantages, initiation and propagation of cracks in these materials can drastically affect their mechanical properties. The most common failure modes in these composites are classified as fiber breakage, fiber pull-out, matrix cracking, and interlaminar delamination. Among these, interlaminar delamination is perhaps the most common type and may occur because of weak bonding between composite layers. This failure mechanism can significantly reduce the structural stiffness of FRP structures and weaken their tensile or shear capacity under service loads .To improve the mechanical performance of FRP composites in the presence of process-induced or loading-induced cracks, extensive studies on their fracture properties have been performed, both experimentally and numerically ,3,4,5. GNumerical models of crack initiation and propagation during ENF testing of composites have also been developed in the past  composite structures by considering both material and geometric nonlinearities along with stochastic fracture properties. An Abaqus user element subroutine was developed and linked to MATLAB to model under ENF testing (mode II fracture). Here, we adopted the extended finite element method (XFEM) and enhanced it with contact and cohesive zone modeling capabilities along with stochastic fracture properties to improve the simulation of crack propagation in the composite laminates. The cohesive zone model constituted a bilinear traction–separation law at the crack front, which enabled modelling of the fiber bridging mechanism in the process zone ahead of the crack tip during loading. Stochastic distributions of the fracture properties were captured within the bilinear traction–separation law. The numerical results were compared with a set of tests performed on polyphenylene sulfide (PPS)/glass UD composites.PPS/glass UD composite samples comprising 14 plies and with nominal dimensions of 250 mm length, 25 mm width, and 3 mm thickness were prepared for ENF testing. To introduce an edge crack with a nominal size of 43 mm in each sample, a polyimide Teflon sheet was placed between the middle layers of the stacked laminates before placing them in the oven for curing.Cured specimens with preinserted delamination were put into a three-point bending test fixture and made to undergo mid-span deflection at a rate of 2 mm/min on the grips. At the onset of delamination extension, the force on the loading cell was recorded while the crack was permitted to propagate .During ENF testing, crack propagation occurs due to excessive shear deformation, thus exhibiting mode II failure with an abrupt nature. Such behavior makes it difficult to control the external load to achieve a target crack extension. Due to this limitation, only the first step of crack propagation during ENF testing was considered in the present study following ASTM D7905/D7905M .The results from ENF testing on five FRP samples are depicted in GIIC, b was calorted in , where tThe variation in the test results demonstrates that the material fracture properties change from one sample to another due to uneven distribution of fibers, pressure, heating, and cooling during manufacturing as well as human error. Such behavior of UD laminated composites embraces the necessity of considering the randomness of properties in simulation studies of these materials.In many cases during the early stages of product development, the structure’s dimensions and the test setup configurations make full-scale experimental evaluation cumbersome, increasing the demand for numerical analyses instead. A variety of numerical modeling techniques have been proposed in the past decades, and they can be categorized into mesh-free methods, such as smoothed particle hydrodynamics (SPH) , elementVarious modifications to FEM have been proposed to account for crack nucleation and propagation. In cohesive zone models ,23, it iFEM can also be enhanced and used in modeling discontinuities by enriching its polynomial approximate functions, the so-called shape functions, with the partition of unity method (PUM) proposed by Melenk and Babuška . This hyBased on the XFEM modeling framework, we have previously developed a user-defined element in the finite element (FE) software Abaqus to simulate delamination in UD composites under mode I loading . Here, ii, and Assume a discontinuity (a crack) within an arbitrary finite element mesh . The disntinuity :(2)u(X)=In order to choose the enrichment function, i.e., e node X  and en iDuring ENF testing, samples undergo large deformation and may experience plasticity . We therH is the Heaviside function) [X,Y,Z) and  refer to material and spatial coordinates, respectively. The contact constitutive matrix in Equation (4) is defined as follows [For nonlinear problems, implementation of a finite element method results in a set of nonlinear algebraic equations,  follows :(4)KT=KMunction) :(7)B¯uen follows :(9)DSep=The remaining terms in the constitutive matrix, analysis .As reported in previous studies ,7, depenTo model the cohesive behavior ahead of the crack tip, a cohesive transformation matrix  can be substituted into Equation (12) and used in the tangential stiffness formulation to introduce process zone properties within enriched elements:Finally, in order to evaluate the internal forces, one can simply employ Equation (20) as follows:3 N/mm3 to 107 N/mm3 was considered in trial simulations. It was observed that applying penalty stiffness lower than 104 N/mm3 would result in extensive softening and a significant reduction in the peak load. Such behavior results from lower rigidity in the hardening region of the traction–separation law for the given material. On the other hand, excessive hardening was observed in simulations with 6 N/mm3, for which the deflection of the specimen reduced unrealistically and prevented the physical crack opening behavior from being modeled. A value of 105 N/mm3 for penalty stiffness was eventually selected and used for subsequent simulations.Similar to conventional application of cohesive zone models, a predefined crack path was utilized to model the cracking behavior. With regard to the parameters in the traction–separation law,  samples  considerBased on the experimental results given in Rand2), corresponding to individual enriched elements in each stage of damage evolution, was taken from a uniform distribution with a range of 0 to 1. The randomly selected values were then converted to a Weibull two-parameter distribution between 0 and 1 via the following formula:A random number within the range of experimentally measured mode II fracture toughness values (ive zone :(21)GIICIICGave)( for each specific crack length. For IICGstd). Khokhar et al.  introduction see . This apThe above formulations were integrated into an Abaqus user-defined element subroutine, which is accessible in , coupledThe results for continuous delamination are given in In the present work, a framework is presented to numerically simulate the mode II fracture behavior of FRP composite materials. For this purpose, extending the capability of modeling delamination and contact interfaces in large deformation problems, a user-element subroutine was developed in Abaqus by incorporating nonlinear XFEM element properties with the cohesive zone model and contact formulation. In addition, the stochastic fracture properties of the composite samples were incorporated into the code to capture the randomness in properties evidenced in nonrepeatable ENF testing results of composite materials. The efficacy of the model was demonstrated by predicting the stochastic fracture behavior of PPS/glass UD laminates, which was in good agreement with the experimental data.


Chronic stimulation of the BCR in ABC DLBCL may also result from engagement of the BCR by self-antigens in the tumor microenvironment. These preclinical observations suggest a role for the targeted inhibitors of the BCR pathway in the treatment of DLBCL.1Diffuse large B cell lymphoma (DLBCL) is an aggressive non-Hodgkin lymphoma that is molecularly and clinically heterogeneous. Gene expression studies have revealed how DLBCL can be divided into germinal center and activated B cell (ABC) subtypes. The ABC subtype is associated with constitutive activation of the NF-κB pathway, commonly as a consequence of genetic activation of the B cell receptor (BCR) pathway.2 It predominantly affects older patients and is associated with poor response to conventional therapy.3 The majority of PCDLBCL-LTs exhibit an ABC DLBCL gene expression profile and are strongly enriched for genetic activation of the BCR pathway, suggesting a pathogenesis shared with nodal ABC DLBCL.5DLBCL is most commonly present as malignant infiltration of lymph nodes. However, extranodal disease is seen in one third of cases. Some forms of DLBCL have an apparent tissue–specific restriction that allows them to be defined as specific disease subtypes. These special site forms of DLBCL include primary CNS lymphoma, primary testicular lymphoma, and primary cutaneous DLBCL (PCDLBCL). For reasons that remain mysterious, PCDLBCL most commonly involves the lower leg and PCDLBCL-leg type (PCDLBCL-LT) is recognized as a specific entity in the WHO classification of lymphoma.BTK or PLCG2, has been well-studied.7 By contrast, the role of BCR inhibition in DLBCL remains less clear and little is known about the genetics of acquired resistance.Drugs that target the BCR pathway include inhibitors of the downstream kinases BTK, SYK, and P110delta. Inhibitors of BTK have led to dramatic responses in patients with chronic lymphocytic leukemia (CLL) and mantle cell lymphoma. The use of BTK inhibitors is now incorporated into standard therapy for these conditions, and the genetic basis of acquired resistance in CLL, dominated by acquired mutation of A 75-year-old male presented with rapidly enlarging cutaneous nodules. These initially involved the feet and legs, but subsequently emerged on the arms and abdomen. A computed tomography scan showed no lymph node enlargement. Biopsy revealed sheets of large lymphoid cells expressing PAX5, CD20, BCL2, MUM1, and weak BCL6. CD10 staining was negative. The proliferation fraction was 90%. A diagnosis of PCDLBCL was made. Because of comorbidity, he was initially treated with rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone with partial response. At relapse two years later, he was retreated with rituximab and gemcitabine, and subsequently oral etoposide with minimal response to either therapy. He was referred to our tertiary lymphoma service for further management. Clinical examination revealed cutaneous nodules up to 25 mm in diameter affecting the feet, legs, arms, and abdomen. A repeat biopsy showed features identical to his original diagnostic biopsy .BCL2, MALT1, and TCF4), amplification of Chr13q31 (including miR17-92), and homozygous deletions of GNA13 and RB1 . We did not identify mutation of MYD88 or CD79B . We manually examined the loci of PLCG2 and BTK, mutations that are commonly acquired in BTKi-resistant CLL, and confirmed both genes to be wild type at all timepoints. Alteration of TP53 was not detected. The majority of altered genes lacked any known association with BCR signaling. CDKN2A loss is common in ABC DLBCL; however, we considered it unlikely that single copy loss could mediate resistance to BCR inhibition. In contrast, CARD11 is a critical scaffold protein that, together with BCL10 and MALT1, functions downstream of SYK and BTK in the BCR pathway to activate canonical NF-κB signaling.1 Activating mutation in the coiled-coil domain of CARD11 was previously proposed as a mechanism of resistance to BCR inhibition in mantle cell lymphoma8 and primary resistance in DLBCL.9 The acquired K215T mutation in our patient is located in the coiled-coil domain and has been previously shown to activate NF-κB.10 We confirmed the near-clonal presence of the CARD11 K215T mutation at relapse  but zero mutant reads at this position in either of the two pretreatment biopsies  in CLL.12 This suggests that the BCR signal in CLL and DLBCL may be qualitatively different and therefore that genetic mechanisms of resistance to BCR inhibition may also differ. However, establishing the genetic basis of resistance to BCR inhibition in DLBCL presents specific challenges that contrast with the situation in CLL. First, patients with DLBCL receiving BCR inhibitors are typically treated simultaneously with multiagent immunochemotherapy regimens, making it hard to establish which mutations provide resistance to which agent, or indeed if sensitivity to the BCR inhibitor ever existed in the first place. Second, relapsing DLBCL frequently presents as a rapidly progressive disease that may preclude the opportunity for a repeat biopsy in patients who are often treated palliatively. These factors make analysis of rare exceptional responders especially important for DLBCL. The genetics of our case recapitulate the biology of ABC DLBCL, and importantly, we observed clear initial sensitivity to therapy targeted exclusively to the BCR pathway. Combined with the biopsy-accessible cutaneous location of disease, this provided a rare opportunity to study genetic mechanisms of resistance to BCR inhibition in ABC DLBCL.The limited information about acquired resistance to BCR inhibition in DLBCL suggests potential differences compared with that of CLL. The latter is predominantly associated with mutation of CARD11 mutation  in a patient who relapsed following an initial response to a BTK inhibitor.13 However, the concurrent finding of NFKBIE mutation and IgH-IRF8 translocation reported in that study might also have contributed to resistance, leaving the role of the CARD11 mutation uncertain. Our findings of acquired activating CARD11 mutation, the absence of any likely alternative genetic explanation, and the demonstrated ability of the K215T mutation to affect BTKi resistance in vitro strongly suggest that CARD11 mutation is the dominant driver of BCR independence in our case.Indeed, we have found only one other case describing the genetic basis of acquired resistance to BCR inhibition in DLBCL. This also involved a case of PCDLBCL-LT and also reported acquisition of CARD11 mutation as a driver of acquired resistance to BCR inhibition in DLBCL. We speculate that such cases might be targeted successfully in the future by inhibition of downstream targets such as MALT1 or NF-κB.15As we move toward the introduction of precision medicine in DLBCL and the real-time monitoring of clonal evolution, it will become increasingly important to understand genetic mechanisms of drug resistance. Our study uses the unique features of this case of cutaneous DLBCL to highlight the importance of


For dairy production systems, nitrogen is an expensive nutrient and potentially harmful waste product. With three quarters of fed nitrogen ending up in the manure, significant research efforts have focused on understanding and mitigating lactating dairy cows’ nitrogen losses. Recent changes proposed to the Nutrient Requirement System for Dairy Cattle in the US include variable efficiencies of absorbed essential AA for milk protein production. This first separation from a purely substrate-based system, standing on the old limiting AA theory, recognizes the ability of the cow to alter the metabolism of AA. In this review we summarize a compelling amount of evidence suggesting that AA requirements for milk protein synthesis are based on a demand-driven system. Milk protein synthesis is governed at mammary level by a set of transduction pathways, including the mechanistic target of rapamycin complex 1 (mTORC1), the integrated stress response (ISR), and the unfolded protein response (UPR). In tight coordination, these pathways not only control the rate of milk protein synthesis, setting the demand for AA, but also manipulate cellular AA transport and even blood flow to the mammary glands, securing the supply of those needed nutrients. These transduction pathways, specifically mTORC1, sense specific AA, as well as other physiological signals, including insulin, the canonical indicator of energy status. Insulin plays a key role on mTORC1 signaling, controlling its activation, once AA have determined mTORC1 localization to the lysosomal membrane. Based on this molecular model, AA and insulin signals need to be tightly coordinated to maximize milk protein synthesis rate. The evidence in lactating dairy cows supports this model, in which insulin and glucogenic energy potentiate the effect of AA on milk protein synthesis. Incorporating the effect of specific signaling AA and the differential role of energy sources on utilization of absorbed AA for milk protein synthesis seems like the evident following step in nutrient requirement systems to further improve N efficiency in lactating dairy cow rations. Since some humans evolved to digest lactose into adulthood around 7000 years ago , the nutDespite the impressive ability of the cow to convert low quality dry matter into milk, dietary N is converted to milk proteins with a disappointing efficiency of 25% to 27% on average . DijkstrNutrient requirement systems for several livestock species including lactating dairy cows predict production responses based on the genetic potential of the animal and the substrate  supplied by the diet. In lactating dairy cows, milk protein yield is predicted based on an empirical factorial approach driven by the energy supplied as net energy for lactation, the pool of digestible AA (referred to as metabolizable protein (MP) in North American systems), and the relative content of the most limiting AA in this digestible AA pool . This apModern nutrient requirement systems have started to shift towards using diminishing efficiencies –13, meanNutritional control of milk protein output falls on the regulation of mRNA translation. One cellular pathway that has been established as integral for the regulation of milk protein translation is centered around the mechanistic target of rapamycin complex 1 (mTORC1). This kinase complex is composed of the serine/threonine protein kinase mTOR and its binding partners: mammalian lethal with SEC13 protein 8 (mLST8), required for complex assembly; regulatory associated protein of mTOR (Raptor), a substrate-binding protein; Dishevelled, Egl-10 and Pleckstrin domain domain-containing mTOR interacting protein (DEPTOR), a regulatory protein; and 40-kDa proline-rich Akt substrate (PRAS40) . Active S-adenosylmethionine (SAM), by the SAM sensor upstream of mTORC1 (SAMTOR) [in vitro to in vivo systems.Amino acids stimulate the Ragulator complex to recruit mTORC1 to the lysosomal membrane , where t(SAMTOR) . Other e(SAMTOR) . Similar(SAMTOR) . A recen(SAMTOR) , 27. Thein vivo, insulin or abomasal infusion of starch has been shown to potentiate the effect of AA on milk protein production [This model of activation of mTORC1 indicates that AA only play a role in recruiting mTORC1 to the lysosomal membrane, where mTORC1 is then activated by Rheb . Rheb looduction , 34.in vitro [in vivo in lactating mice [in vivo has not been demonstrated. Some studies in cows even posit contradictory activation of mTORC1 activity and milk protein production, with diminished Lys supply increasing S6K1 phosphorylation even as protein yield is decreased [Activity of the mTORC1 pathway is correlated with milk proteins expression in vitro  and in ving mice , and miling mice . Howeverecreased . Data coecreased . Rapamycin vivo responses in lactating dairy cows, indicates that without insulin signaling, AA alone are unable to fully activate mTORC1. Therefore, evolutionarily selected nutritional signals are essential for determining the mammary demand of AA for milk protein synthesis through mTORC1.Overall, mTORC1 is clearly involved in milk protein synthesis. Certain AA, notably Met and Leu, are responsible for mTORC1 docking at the lysosomal membrane, where it can then orchestrate a cellular anabolic response. The evidence in non-mammary cell types, supported by Unlike mTORC1 that responds to nutritional signals promoting mRNA translation, the integrated stress response (ISR) pathway senses cellular stressors and represses translation of new proteins. The ISR revolves around the eukaryotic translation initiation factor 2 (eIF2), a G-protein and mRNA translation initiation factor responsible for delivering the first, Met-loaded tRNA to the small ribosomal subunit to initiate a new cycle of translation initiation . The Α sThe two eIF2α kinases most clearly related to AA metabolism are GCN2 and PERK, the latter as part of the unfolded protein response (UPR), discussed below. Meanwhile, GCN2 senses AA deficiencies through binding to uncharged tRNA, previously reviewed . There iIn the studies described above, the effect of essential AA on eIF2α phosphorylation would logically be mediated by GCN2, as AA availability was altered. Interestingly, essential AA supplementation also increased the expression of eIF2Bε, one of the subunits of the exchange factor that activates eIF2 , 43, potAs the site of translation for milk proteins and of the synthesis of milk fat globules, the endoplasmic reticulum (ER) is an important structure for milk synthesis. Generally, when the ER experiences stress resulting in an overload of unfolded proteins, a proteostatic system termed the unfolded protein response (UPR) is deployed to either return the cell to homeostasis or induce apoptosis, depending on whether or not the ER stress can be overcome . The UPRin vitro and in several lactating species. Administration of FIL to mammary epithelial cells results in changes to the endoplasmic reticulum morphologically consistent with ER stress and the UPR [In the lactating mammary gland, the UPR has a variety of functions, not all of which are yet understood. Similar to other secretory cell types, in mammary epithelial cells the UPR is required for terminal differentiation into the secretory phenotype . As with the UPR , 57.The interconnectedness between mTORC1, ISR, and UPR pathways highlights the complexity of milk protein synthesis regulation. Although mTORC1 is an anabolic cellular hub, while ISR and UPR are more associated with catabolic responses, environmental insults and stimuli induce a coordinated response of the three pathways to maintain proteostasis. However, if unlike mTORC1, the ISR and UPR in the mammary glands can only respond to dietary protein or total essential AA rather than individual ones, their exploitation as mechanisms to increase N efficiency in lactating dairy cows may be limited.Until now, we briefly described mechanisms that sense environmental and physiological signals that control the rate of milk proteins translation, which set the demand for AA. A successful demand-driven system must not only set the rate of protein synthesis, it also needs to secure the AA supply for that set demand. Mammary extraction of AA from blood is determined at tissue level by: 1) the supply of AA in blood, further determined by the concentration of AA in blood and the flow rate to the glands; 2) the number of secretory cells that extract those AA and produce milk proteins; 3) and by the ability of existing secretory cells to remove those AA from blood and secure them into milk proteins.Blood AA concentrations are determined by the rate of appearance of individual AA into the circulation, which is in turn the result of AA absorption from the lumen of the intestine minus retention by the splanchnic tissues. However, arterial blood supplies about 80% of the AA removed by splanchnic tissues , such thIn the short term, mammary blood flow is positively regulated by nitric oxide through a feedback signal from adenosine, which indicates a decrease in cellular energy, and is negatively regulated by glucose . On the Nitric oxide production in mammary epithelial cells is also regulated by prolactin through a calcium mediated mechanism . In addiThe molecular mechanisms and overall effect of AA in mammary blood flow are far less clear than for insulin. In the short-term, AA infusion linearly increased mammary blood flow . HoweverConversely, supplementation with the mTORC1 signaling AA Leu and Ile increased mammary blood flow, which was partially responsible for an increase in total AA uptake and milk protein yield . TherefoUptake of AA by the mammary glands can change for either of two reasons: because the supply in blood changes, or because the mammary glands actively alter their affinity for a given AA, either increasing the glands capacity or altering enzyme activity. A classic example of a change in mammary affinity for individual AA is observed in the study by Bequette and collaborators in goats, referenced above. In addition to increasing mammary blood flow, restricting His resulted in a 43-fold increase in mammary affinity for that AA, concomitant with a decrease in the affinity for other AA . A purelA more feasible strategy to increase digestive AA efficiency without compromising the yield of milk proteins would be to supplement rather than remove nutritional factors that increase mammary affinity and extraction efficiency of AA. An example of that approach is the study by Yoder and collaborators . In thatThe plasticity of the mammary glands to alter their own blood flow and affinity for AA suggests that the mechanisms sensing AA supplies not only set the rate of protein synthesis but also adequately alter AA uptake to meet that demand. While the evidence is strong in regard to mTORC1 regulation of milk protein synthesis, it is less clear how an established demand of AA for milk protein synthesis induces higher rates of AA uptake by the mammary glands. A nonlinear relationship with arterial AA concentrations suggest that AA removal is not simply based on concentration gradients between the extra- and intracellular spaces . In linein vitro effects of Met on mammary epithelial cell expression of AA transporters have only been studied at supraphysiological concentrations (300–600 μmol/L), leaving uncertainty as to the effect of Met in vivo. In fact, the evidence in vivo does not support the idea that Met alone can stimulate uptake of other AA by the mammary glands. In one study, infusion of Met did not affect extraction of AA by the mammary glands of early lactation dairy cows, while it decreased mammary uptake for most essential AA in mid lactation [Methionine, one of the most limiting AA in modern dairy cow diets, stimulates the expression of several AA transporter systems, also regulated by mTORC1. In bovine mammary epithelial cells, Met increased protein expression of LAT1 through an mTORC1-dependent mechanism –83. Impoactation . Meanwhiactation .Unlike Met, jugular infusion of Leu, a stronger activator of mTORC1, increased mRNA and protein expression of the cationic AA transporter CAT1 in porcine jejunal epithelial cells , which iThe translation repressor eIF2α also stimulates the expression of several AA transport systems, including LAT1, CAT1, SNAT2, ASCT2, and anionic system xCT –98, possInsulin has a remarkable number and variety of functions in lactating animals beyond its canonical role in regulating glucose homeostasis, from initial lactogenesis  to promoSLC7A5 that encodes for LAT1 protein, and increased Lys uptake [+-independent anionic transporter CAT1 [The mechanisms of insulin and insulinemic energy regulation of mammary AA affinity remains unclear. Most important AA transporters on the observed effect of insulin would be system L that transports branched chain AA and CAT1 that transport the cationic AA Arg and Lys. In human trophoblasts, glucose and insulin stimulated system L activity in an mTORC1 dependent fashion . Similars uptake . In mammter CAT1 .The lactogenic hormone prolactin has also been shown to stimulate amino acid transporter expression and activity. In bovine mammary epithelial cells, prolactin increased LAT1 expression . In mammAs the canonical indicator of systemic energy status, it is unsurprising that insulin has an important role in regulating the energy-intensive activity of producing milk. Insulin secretion and activity are unique in ruminating animals due to their digestive anatomy and physiology, but the molecular mechanisms for insulin signaling intracellularly are conserved across species. Insulin has been shown to increase mammary AA uptake and sequestration into milk proteins both by increasing blood flow (and therefore AA supply) to the mammary glands and by increasing mammary AA affinity. Aggregating knowledge from different species and cell types directs towards a coordinated effect of insulin on AA uptake and milk protein synthesis mediated by mTORC1, while the effect of insulin on blood flow could be mTORC1 independent.Estimates indicate that splanchnic tissues sequester half of the essential AA absorbed from the small intestine . HoweverAs opposed to the unequivocal ability of the mammary glands to alter AA use in response to different nutrients and endocrine signals, particularly insulinemic energy, the response of the splanchnic tissues to similar insults is far less conclusive. Hanigan and collaborators previously proposed fractional (i.e. fixed) extraction efficiencies of AA by both the PDV and the liver , 112. A Cantalapiedra-Hijar and collaborators assessed how dietary energy from starch vs fiber impacts hepatic extraction of AA at 12% and 16.5% crude protein (CP) diets in lactating Jersey cows . In lineUnlike the mammary glands and the PDV, the liver has been shown to extract AA proportionally to its supply, of which 80% is from recirculating arterial blood. Although less research exists on the splanchnic tissues than on the mammary gland in this regard, the evidence points toward insulin and insulinemic energy behaving oppositely on hepatic extraction of AA compared to the mammary glands. Most likely, this is not because of different signaling mechanisms between the two organs, but rather because of their metabolically opposite directives, with the liver acting catabolically (AA to urea) and the mammary glands anabolically (AA to protein). In this way, both tissues work in tandem under the same set of systemic signals to meet metabolic needs while maintaining systemic homeostasis.In this review we have discussed physiological and molecular mechanisms that pertain to metabolism of AA during lactation. The prime directive of the lactating mammary glands is to make milk, and to accomplish this goal the glands must be able to sense and respond to nutrient and fuel supply. Although all the genetically encoded AA are required for the synthesis of milk proteins, an evolutionarily selected group of essential AA plays a unique signaling role, communicating substrate availability. Beyond the AA themselves, other metabolic signals also control the synthetic process. Among them, here we present insulin not only as the canonical signal of systemic energy status, but also as key regulator of AA metabolism, controlling AA supply, mammary uptake, and utilization in protein synthesis. Transduction pathways like mTORC1, ISR, and UPR integrate this complex matrix of signals into a set rate of translation that, to yield given amount of protein, will generate a demand for AA. The evidence in mammary epithelial cells as well as other cell types suggest that the same transduction pathways that set the rate of protein synthesis also manipulate AA transport systems to guarantee the supply of substrate, maintaining cellular proteostasis.in vitro, appears to be important in explaining the differential responses to types of energy on AA use, both in non-bovine models and in lactating cows themselves. The splanchnic tissues, significant in part because of their anatomical position between nutrients incoming from the gastrointestinal tract, may be an underexplored system for manipulation of mammary AA availability and utilization. Hepatic functions like ureagenesis, the process by which the liver converts excess N into urea for disposal as urine and a significant route for N loss in dairy cattle, may offer opportunities for improving N efficiency and post-hepatic AA availability through dietary manipulation of insulin signaling.Previous lack of evidence regarding this coordination at cellular level resulted in nutrient requirement systems purely based on substrate supply. Including variable efficiencies for individual AA, as proposed by Lapierre and collaborators , shifts We foresee the integration of substrate and signaling effects of nutrients and other environmental insults  as the major challenge for the next generation of nutrient requirement systems for lactating dairy cows. Hopefully, once this challenge is overcome, future lactating dairy cow diets will be formulated with less excess of the nutrients harvested in milk, and will be strategically supplemented with the signaling nutrients that maximize productive efficiency. In this way, both feed inputs and waste outputs can be minimized.Generation of molecularly informed models like that for casein synthesis in mammary epithelial cells proposed by Castro and collaborators  is likel


Surgery for malignant liver tumors has evolved greatly in the recent past, with the amount of functioning liver parenchyma remaining after resection—referred to as the future liver remnant (FLR)—now being the major determinant of resectability. Hence, the quest for methods to enhance the FLR in patients at risk for postoperative liver failure overcoming the known limitations of portal vein embolization (PVE) or portal vein ligation (PVL) has gained interest. Optimizing the PVE technique using a combination of polyvinyl alcohol particles and venous plugs or coils, the combination of transarterial embolization and portal venous embolization, liver venous deprivation (LVD) combining portal and hepatic vein embolization, as well as the ALPPS  procedure have all been studied in this context, with mixed results and arguments in favor of and against all of these methods.90Yttrium-labeled glass microspheres infused via the portal vein (Y90 PVE) in an experimental study using 22 Sprague–Dawley rats. Animals were assigned to one of five cohorts receiving very high, high, medium, and low-dose Y90 PVE or no treatment, respectively. Seventeen rats survived until necropsy at 12 weeks following Y90 PVE. Of the surviving 13 rats in the treated group, nine demonstrated successful Y90 delivery to the target lobe at 90Y PET/CT. MR volumetry demonstrated dose-dependent atrophy of the target lobe, with periportal fibrosis and dose-dependent decrease in hepatocyte proliferation seen at HE staining and Ki67 immunofluorescence histology.In this issue of CVIR, Gordon et al.  describeY90 microspheres are used for transarterial radioembolization (TARE) in a variety of liver tumors, the greatest amount of evidence obtained from studies in hepatocellular carcinoma (HCC) and metastatic colorectal cancer (mCRC). Besides its effects on tumor tissue, induction of parenchymal hypertrophy in non-treated areas following TARE has been studied by several groups following an initial case report published in 2009 .The study by Gordon et al. adds another small piece of information to this complex picture, even though, for the moment, this study does not provide information on whether the observed atrophy in the treated lobe is associated with meaningful hypertrophy in untreated liver areas, nor is it clear whether the results obtained in rats are transferable to humans, as their different vascular anatomy may have an impact on hypertrophy development , 5. Ulti


Fibrosis is a chronic and progressive disorder characterized by excessive deposition of extracellular matrix, which leads to scarring and loss of function of the affected organ or tissue. Indeed, the fibrotic process affects a variety of organs and tissues, with specific molecular background. However, two common hallmarks are shared: the crucial role of the transforming growth factor-beta (TGF-β) and the involvement of the inflammation process, that is essential for initiating the fibrotic degeneration. TGF-β in particular but also other cytokines regulate the most common molecular mechanism at the basis of fibrosis, the Epithelial-to-Mesenchymal Transition (EMT). EMT has been extensively studied, but not yet fully explored as a possible therapeutic target for fibrosis. A deeper understanding of the crosstalk between fibrosis and EMT may represent an opportunity for the development of a broadly effective anti-fibrotic therapy. Here we report the evidences of the relationship between EMT and multi-organ fibrosis, and the possible therapeutic approaches that may be developed by exploiting this relationship. Fibrosis is characterized by an uncontrolled and excessive deposition of extracellular matrix (ECM) components. The increased ECM deposition then evolves to scar tissue formation and to a loss-of-function of the affected organ  . The celEpithelial-to-Mesenchymal Transition may be classified into three ‘types.’ This classification takes into account the context in which the epithelial-to-mesenchymal transition occurs . Type 1 In wound repair myofibroblasts are located within the granulation tissue and exhibit a cytoplasmic microfilamentous system, which contains actin and myosin, as well as associated proteins of the smooth muscle, in particular alpha-smooth muscle actin (α-SMA), a differentiation marker of these cells. They are derived from fibroblast differentiation induced by growth factors, such as Transforming Growth Factor beta (TGF-β) or Platelet-Derived Growth Factor (PDGF), secreted by the epithelial cells in the wounded or inflamed area . EMT, inEMT has been found to be associated with fibrosis in kidney, liver, lung, intestine and other organs . The firIn vitro and in vivo studies have shown that the major morphological changes of the endothelial cells are indeed triggered by the action of these three cytokines. It has also been observed that in presence of an inflammatory stress, EndoMT may contribute to the increase of fibrogenesis.An EMT-related mechanism of cell transformation that is also involved with fibrosis is called EndoMT  . SimilarHere, we review the basis of the pathophysiological mechanisms of EMT, their regulation, and the roles played by EMT in fibrotic disorders that may allow the development of new therapeutic strategies.Transforming growth factor-beta is the main growth factor involved in fibrosis  Figure . TGF-β iThe role of TGF-β signaling in EMT is well established: adding TGF-β to epithelial cell cultures results in a decreased expression of epithelial markers and an enhanced expression of mesenchymal markers: the typical signature of EMT. Induction of both Smad2 and Smad3 is associated with increased EMT, and KO of Smad3 prevents EMT induction in response to TGF-β stimulation, demonstrating the critical role played by the Smads in the TGF-β-induced EMT .In addition to the ‘canonical’ signaling pathway, TGF-β can also signal through “non canonical”, non-Smad, pathways , that maAnother non-Smad signaling pathway involves the TGF-β activated kinase TAK1 (Transforming growth factor beta-Activated Kinase (1). TAK1 is a serine/threonine kinase that is rapidly activated by TGF-β but it can also be activated by environmental stress. This kinase can transduce signals to several downstream molecules . In partThe link between EMT and TGF-β activity has also been demonstrated in mice models overexpressing the Bone Morphogenetic Protein 7 (BMP7), an antagonist of the TGF-β1 signaling pathway. BMP7 reversed the loss of E-cadherin induced by TGF-β via the canonical Smad pathway, and exogenous systemic administration of BMP7 managed to revert EMT inducing the repair of the damaged epithelia. These observations were later confirmed in human studies .in vitro study has shown that TORC2 (mTOR complex 2) activity is also rapidly induced by TGF-β (via AKT phosphorylation), and activation of TORC2 is required for TGF-β-induced EMT , a key player also in cellular metabolism. Adiponectin, through AMPK activation, is capable of inhibiting the canonical TGF-β signaling. AMPK is also able to inhibit the mTOR signaling (which acts as an EMT activator), The peroxisome proliferator activated receptors (PPARs) are key cellular mediators of fibrosis . They arin vitro studies have proven the cross-talk between Hh signaling and the canonical TGF-β pathway (Members of the Hedgehog (Hh) family of proteins play a critical physiological role during embryo development; but the altered expression of several components of the Hh signaling pathway has been reported during experimental fibrogenesis . Further pathway . TGF-β s pathway . These p pathway . In addi pathway . On thesin vitro and in vivo by decreasing the cellular levels of Smad2 and 3, thus the active YAP/TAZ complex cooperates with TGF-β to induce fibrosis in a Smad2/3-dependent manner , are small non-coding RNAs around 20-25 nucleotides in length. miRNAs act as regulators of gene expression by inhibiting mRNA transcription via binding with its 3′ untranslated region (UTR). This binding is through an imperfect pairing thus a single miRNA can bind and can inactivate various mRNAs. MiRNAs have gathered the attention of many researchers in the last decade because they are virtually involved in all biological processes and may also play a role in various pathologies. Some of these miRNAs have a direct effect on EMT by either enhancing or inhibiting the process. Depending on the affected organ, there are miRNAs with a pro-EMT role and miRNAs with an anti-EMT role. Among the latter, miR-26a has a protective effect against EMT in the lung through a direct inhibition of TGF-β expression . Other mTaken together, these observations suggest the use of miRNAs as a therapeutic tool against the EMT-driven fibrosis. However, this approach might be complicated by the evidence, at least in the intestine, that microRNA mediated posttranscriptional regulation of gene expression also regulates autophagy .Macroautophagy  is an intracellular process that is essential for the clearance of unused long-lived proteins, damaged cytoplasmic proteins and organelles and through this mechanism the cytoplasmic components are degraded and recycled. In autophagy the target structures are engulfed in autophagosomes that then fuse with the lysosomes, forming the autophagolysosomes that degrade their content through the lysosomal hydrolases. Autophagy is regulated by a complex signaling network and its malfunctioning leads to several diseases including fibrosis. In particular autophagy alterations may result in a more severe fibrotic phenotype. Autophagy has also an EMT inducing effect on cancer cells  and it eLiver fibrosis generally occurs as a consequence of a deregulated wound healing, following liver damage . HepaticTo date, there are no available data about the direct involvement of macrophages in EMT activation in the liver. However, according to several studies performed on tumors, macrophages are able to activate EMT, mainly via TGF-β induction , thus itIn vitro, when IL-1β is inhibited by the human monoclonal antibody Canakinumab, the EMT markers  result minimized. Thus, Canakinumab, by blocking IL-1β, has the potential to protect from hepatic fibrosis and likely from fibrosis of other organs , is a complication of distinct chronic pathologies or long-term exposure to damaging agents affecting the respiratory tract, Several possible strategies to counteract pulmonary fibrosis may be proposed for both PF and IPF. Regarding PF, a recent study has reported that inhibition of autophagy in alveolar epithelial cells promotes EMT and can contribute to fibrosis via an aberrant epithelial cells–fibroblasts crosstalk . In contIn IPF, the mTOR pathway also enhances EMT in a TGF-β dependent manner . To suppin vitro and in vivo has underlined a connection between EMT and hypoxia in lungs , has been discovered in lungs after their exposure to silica. Polyguanylic acid (PolyG) is a synthetic polynucleotide capable to inhibit MARCO and is capable to induce a decrease of the level of some EMT related proteins and transcription factors, such as vimentin and α-SMA in lung tissues. Thus, through the reduction of the EMT, PolyG may represent a feasible therapeutic option for the treatment of pulmonary fibrosis caused silicosis . In addiin lungs , thus thRecent discoveries have also shown that in chronic asthma inflammation there is an increased production of TGF-β1 that consequently mediates the EMT progression. Thus, inflammation of the airways could be considered a possible target in IPF treatment. In this regard, it has been shown that the administration of the Bacillus Calmette-Guerin (BCG) alleviates airway inflammation and remodeling through its ability to counteract the TGF-β1-induced EMT Regarding IPF, two agents (pirfenidone and nintedanib) have been approved by the Food and Drug Administration (United States) . NintedaDiscorea. Rats treated with diosgenin in bleomycin-induced IPF showed reduced EMT and TGF-β expression, together with reduced expression of pro-inflammatory mediators  . This acFurthermore, a study on a murine model of pulmonary fibrosis has recently been conducted to evaluate the safety and efficacy of an original PPARγ modulator called GED-0507-34-Levo (GED-0507), in halting or even reversing pulmonary fibrosis induced by bleomycin. Preventive and curative administration of GED-0507 improved both loss of body weight and extension of lung fibrotic lesions. When given in preventive mode GED-0507 was also able to abrogate mortality and the histological score of fibrosis  Figure .in vivo study has underlined a possible role for the Wnt pathway  as a consequence of the persistent inflammatory stimuli typical of both ulcerative colitis (UC) and Crohn’s disease (CD), with the latter showing a wider fibrotic reaction . An impo pathway . I, and  pathway .Furthermore, in intestinal fibrosis, PPAR-γ activation, i.e., by synthetic ligands, has been shown to restore the epithelial phenotype and the stability of the E-cadherin/β-catenin complex, by acting on Smad and non-Smad mediated EMT, suggesting that this mechanism may be exploited to reverse EMT . PPAR-γ There are also molecules from natural sources that could be effective against intestinal fibrosis. One of them is curcumin, the main curcuminoid of turmeric (Curcuma longa), which activates PPAR-γ by promoting its nuclear translocation and expression . MoreoveAnother possibility to counteract the development of intestinal fibrosis consists in the use of microvesicles containing miR-200b. These microvescicles have been used to transduce intestinal epithelial cells and colon tissues and, in both cases, miR-200b has been shown to be effective in preventing EMT and in alleviating fibrosis, by reducing the expression of EMT-related proteins such as ZEB1 and ZEB2, namely the targets of miR-200b . FurtherRecently, in order to better understand the mechanisms favoring the progression of EMT and fibrosis of the bowel, a study has also investigated the involvement of the Zinc Finger Protein 281 (ZNF281), another EMT-inducing transcription factor. This molecule is involved in various diseases, such as cancer stemness, but it also plays an important role in fibrosis. In fact, in ZNF281 knock out-mice, the level of EMT inducers  is decreased, suggesting that silencing of ZFN281 may represent a possible option for bowel fibrosis therapy .Furthermore, in intestinal fibrosis deserves attention the possible pathological role of the microbiome. In fact, studies performed in mice have shown that the microbiome may be responsible for the perpetuation of intestinal fibrosis, while in mice deprived of intestinal microbes, the inflammation and the resulting fibrosis is attenuated. This has been attributed to the microbial metabolic products, which are able to pass the gut barrier and to stimulate the canonical TGF-β pathway and so the EMT . HoweverFibrosis is at the basis of several diseases affecting different districts and cell types of the eye,. In all these cases, the fibrotic reaction leads to a loss of function of the eye and ultimately to blindness. Two common features of these fibrotic diseases are the dysregulation of the eye normal wound healing, that leads to myofibroblasts proliferation, and the enhanced canonical TGF-β signaling . The canThe key role played by EMT in ocular fibrosis is underlined by the observation that while in other organs the myofibroblasts could derive from both EMT and fibroblast to myofibroblast transformation, in the eyes, especially in crystalline lens, myofibroblasts originate only from EMT. Upon direct TGF-β stimuli, normal cells of the eye such as keratocytes, lens epithelial cells, trabecular meshwork cells, or retinal pigment epithelial cells, undergo EMT, acquire myofibroblast phenotype and enhance ECM deposition . FurtherFor therapeutic purposes, the most studied approach in ocular fibrosis consists in targeting EMT via TGF-β signaling inhibition. In this regard, pirfenidone containing nanoparticles have been shown to be effective by decreasing collagen synthesis and preventing myofibroblast formation . Howeverin vivo rabbit model of GFS, has also been evaluated the potential antifibrotic effect of rosiglitazone (RSG), a PPARγ-selective agonist, on subconjunctival fibrosis. It has been shown that RSG treatment prevents subconjunctival fibrosis after GFS through the inhibition of profibrotic gene expression by a mechanism that promotes autophagy in local fibroblasts. Thus, the use of RSG may represent a novel antifibrotic approach with the potential to improve the success rate of GFS , and the reversal of extraocular muscle fibrosis if treated with sirolimus (rapamycin). This drug has been shown to exert its anti-fibrotic activity by acting on myofibroblasts, the primary ECM-secreting cells during wound healing and fibrosis . Furthere of GFS  , is a complex and heterogeneous autoimmune disease that includes the development of fibrosis. In SSc the fibrotic process affects the skin and other organs at once and the TGF-β and Wnt/β-catenin signaling pathways play a crucial role in this process. These pathways are regulated at the post-translational level by modification of ubiquitination and mutations of ubiquitination enzyme genes have been found in scleroderma patients . FurtherThe correlation between scleroderma and cutaneous EMT is supported also by other evidences. The transition process induced by TGF-β in primary keratinocytes is enhanced by TNF-α. Both of them are important EMT mediators and are overexpressed in scleroderma and in combination they contribute to the activation of the Smad-mediated signaling pathway, that consequently could be inhibited to reverse the EMT process . MoreoveIn addition, the EMT has been proposed as a source of myofibroblast also in SSc  and EMT-Another option that may be considered for the treatment of SSc is by interfering with the ubiquitination of the main components of the TGF-β and Wnt/β-catenin pathways. In fact, both pathways are regulated by ubiquitination and recently it has been reported that ubiquitination is dysregulated in patients with SSc. Thus, the understanding of the mechanisms underlying the ubiquitination alteration in this disease, may constitute the basis for developing a new treatment  Figure .Adipose tissue fibrosis is frequently associated with obesity: the adipose tissue expands by hyperplasia and hypertrophy and the combination of these two processes leads to an inadequate tissue oxygen supply and the subsequent development of hypoxia. In this condition HIF-1α is activated and induces adipose tissue fibrosis. In addition, the insufficient oxygen content induces the macrophages of the adipose tissue to release TGF-β, PDGF, cytokines and chemokines, that attract inflammatory cells and fibroblasts, laying the foundations of the inflammatory process. In these conditions, there is also a depletion of PPAR-γ levels in fat cells, causing the inhibition of pre-adipocyte differentiation. Thus, triglycerides surplus is not stocked in lipid droplets of fat cells but its storage occurs ectopically. The consequent stress condition, associated with hypoxia, induces migration of immune cells and stimulates inflammation, thus initiating and exacerbating adipose tissue fibrosis, through the increased production of collagen. Among the immune cells, macrophages and mast cells play a key role in adipose tissue fibrosis. In fact, obesity is a condition in which the number of resident macrophages, especially the pro-inflammatory M1 type, results to be augmented in fat tissue . On the A recent study has shown that the alkaloid berberine, a natural compound found in several plants, by inducing AMPK activity and by inhibiting TGF-β1/Smad3 signaling, attenuated infiltration and polarization of adipose tissue macrophages, attenuated collagen deposition and alleviated adipose tissue fibrosis . Other nIn cardiac or myocardial fibrosis, a substantial accumulation of extracellular matrix proteins occurs in the cardiac interstitium . The matrix remodeling and fibrotic response can follow myocardial infarction, during which acute death of cardiomyocytes results in an intense inflammatory reaction that contributes to the replacement of the injured tissue with scar tissue (replacement fibrosis) . When thMast cells, in particular, contribute to cardiac fibrosis by releasing the content of their granules, including the enzymes tryptase and chymase, pro-inflammatory cytokines and mitogens that act as fibrogenic mediators. All of these factors contribute to fibroblast proliferation and to collagen deposition. We refer you to a review for a detailed discussion on the role of mast cells in the pathophysiology of cardiac fibrosis .in vitro study . Thus, an inhibitor of this microRNA could be effective to reduce the cardiac fibroblast to myofibroblast transformation in cardiac fibrosis . The miRIn addition, some natural compounds have also been evaluated for their effectiveness in improving cardiac fibrosis. Perindropil and modified citrus pectin (MCP) are correlated to the inhibition of myocardial fibrosis by acting on the myocardial Galectin-3  gene . In factThe uncontrolled fibrosis is a complex disease that can be mediated by a large number of mechanisms with molecular basis significantly different in different organs and tissues. This poses a serious obstacle to the development of a broadly effective anti-fibrotic therapy. In fact, currently, a unique treatment effective for all of the fibrotic disease is not yet available. However, in this review we have reported that a common feature shared, more or less strictly, among the fibrotic diseases is the EMT process. On the basis of this feature, we believe that targeting of the molecular mechanisms underlining EMT may provide new possibilities for the development of a broadly effective anti-fibrotic therapy .JD, IR, and VF were responsible for assembling and drafting of the manuscript. All the other authors contributed to the drafting of the manuscript. VF edited and provided guidance for the assembling of 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. The reviewer GL declared a shared affiliation with one of the authors, VF, to the handling editor at the time of review.


The alteration of the climate in a specific region affects the life of indigenous animals and humans. The climate changes influence living beings both directly and indirectly. The immune system of animals dramatically suffers the climate instability, making animals more susceptible to infectious and not infectious diseases. Different species of livestock animals respond with similar mechanisms to global warming, but some of them are more susceptible depending on their age, metabolism, and genetic conditions. The selection and study of autochthonous species and breeds, more easily adapted to specific environmental conditions could be an interesting strategy to face livestock rearing in the future.Climate change involves different dramatic phenomena including desertification and wildfires, severe storms such as hurricanes and blizzards, increased sea levels resulting in flooding coastal cities and rise of atmospheric CO IndePoultry subjected to heat stress showed a reduction of the volume and weight of lymphoid organs, low levels of circulating, and intestinal Ig and reduced phagocytosis –26. The In dairy cows the activation of HPA and SAM axes induce the release of glucocorticoids and catecholamines and the following reduction of cytokine levels, particularly IL-4, IL-5, IL-6, IL-12, IFN-γ, and TNF-α . High leAnother response common in vertebrates after heat stress is the production of HSPs. In poultry the attempt to maintain a correct body temperature induces the production of reactive oxygen species (ROS) and a consequent oxidative stress in the animal. The oxidative stress stimulates the liver of chicken to produce increased levels of HSPs to protect the tissues against the free radicals , 32. In Data on the effect of global warming on the immune system of livestock sometimes are in contrast and this could be due to genetic differences of different breeds under study. For example, in poultry it has been described that different breeds of broilers and hens respond differently to heat stress , 39. In Human activities can have a huge impact on climate changes, influencing directly, and/or indirectly not only terrestrial environments but also aquatic ones. In aquatic environments those changes can be chemical , physical , or biological . These modifications of the environment affect the animals, in particular their immune system, impairing their capability of protection against pathogens –49.Motile organisms, like fish, can be tolerant to some environmental changes or can escape from those alterations moving from one place to another, but aquacultured fish raised in sea cages, are not able to relocate in order to avoid ecological alterations. Those changes can be considered stressors, and in natural environments, those do not normally occur alone but in combination –51.Water temperature can deeply affect fish immune system. Acute and chronic changes in temperature have also different impacts on animals, being short term episodes compensated by processes such as heat shock protein response, while chronic temperature variations are less likely to be solved by such responses –55.Perca fluviatilis) acclimated at lower temperatures, while, opsonin was more effective at higher temperatures  is the increase of the antibody levels. This has been reported in several studies with different fish species , 62–73, Catla catla) Toll Like Receptors (TLRs) and NOD-like receptors are modulated both by cold or warm water. TLR2, TLR4 and NOD2 expression increases with higher water temperatures, while TLR5 and NOD1 expression increases at both high and low temperatures  granulocyte respiratory burst activity and lymphocyte proliferation were inhibited when maintained for short period at high water temperatures and enhanced at low water temperatures. When the animals were exposed to a ‘heat wave' of 28°C for 2 weeks, long lasting immune disorders occurred resulting in the impairment of the immune system and the following spread of infectious diseases among those fish populations (In three-spined sticklebacks (ulations .Gadus morhua), cold water (up to 16°C) caused an increase of b2-M, MHCI, and IgM mRNA expression; on the contrary warmer raising water induced a downregulation of the same genes, being only IL-1β upregulated at high water temperatures  low temperatures induce IL-1β, IL-8, and TNF-α upregulation  exposed to different water temperatures and pH levels showed signs of inflammatory responses with increased expression of complement component C3 and fibrinogen β chain precursor at high CO2 concentrations (reduced pH), without the influence of the temperature, suggesting that these changes are directly a consequence of the decrease of pH  the combination of low pH and high temperature of the water triggers the downregulation of Interferon-induced guanylate-binding protein 1 (GBP1) gene in liver, an antiviral and antimicrobic factor  Hsp70 and IgM expression was correlated to both temperature and salinity, temperature being the dominant factor (Oreochromis niloticus), a freshwater fish that prefers brackish waters, demonstrated that slowly increasing salinity in the environment did not have any significant impact on monocyte and lymphocyte number and phagocytotic process, yet a continuous decrease in water salinity was correlated with an increment in leukocyte number and phagocytosis (Oreochromis mossambicus), the increased salinity water caused a gain in lysozyme activity in plasma and head kidney homogenate , a commonly aquacultured species with a wide range of salinity tolerance, demonstrated that hyper-saline water highly increases IgM production, while a decrease on water salinity do not (Syngnathus typhle) kept in high salinity conditions and infected with Vibrio spp. presented significantly higher phagocytosis values compared to controls. When the fishes remained for a longer period in high salinity environment increased energy was required for osmoregulation leading to both lymphocyte and monocyte proliferation reduction, suggesting that during longer high salinity periods animals can be immunocompromised (A study on gilthead sea bream (y do not . In anotpromised .Gadus morhua), and the expression of HSP70 was significantly higher in hypoxic conditions and at low temperatures (in vitro stimulated with poly I:C (TLR ligand) showed a significant increase of IFN-α mRNA levels in non-hypoxic conditions compared to normoxic conditions. This difference suggests that chronic hypoxia can modulate the innate immune response, altering the susceptibility of those animals to infections   . Given tissions) .JF, VH, GC, DV, and FR discussed the organization of the manuscript, drafted the manuscript and commented on 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.


Diabetes mellitus comprises a group of carbohydrate metabolism disorders that share a common main feature of chronic hyperglycemia that results from defects of insulin secretion, insulin action, or both. Insulin is an important anabolic hormone, and its deficiency leads to various metabolic abnormalities in proteins, lipids, and carbohydrates. Atherosclerosis develops as a result of a multistep process ultimately leading to cardiovascular disease associated with high morbidity and mortality. Alteration of lipid metabolism is a risk factor and characteristic feature of atherosclerosis. Possible links between the two chronic disorders depending on altered metabolic pathways have been investigated in numerous studies. It was shown that both types of diabetes mellitus can actually induce atherosclerosis development or further accelerate its progression. Elevated glucose level, dyslipidemia, and other metabolic alterations that accompany the disease development are tightly involved in the pathogenesis of atherosclerosis at almost every step of the atherogenic process. Chronic inflammation is currently considered as one of the key factors in atherosclerosis development and is present starting from the earliest stages of the pathology initiation. It may also be regarded as one of the possible links between atherosclerosis and diabetes mellitus. However, the data available so far do not allow for developing effective anti-inflammatory therapeutic strategies that would stop atherosclerotic lesion progression or induce lesion reduction. In this review, we summarize the main aspects of diabetes mellitus that possibly affect the atherogenic process and its relationship with chronic inflammation. We also discuss the established pathophysiological features that link atherosclerosis and diabetes mellitus, such as oxidative stress, altered protein kinase signaling, and the role of certain miRNA and epigenetic modifications. Atherosclerosis is a widespread chronic inflammatory disorder of the arterial wall that often leads to disability and even death. At its final stages, atherosclerosis manifests itself as a lesion of the intimal layer of the arterial wall and accumulation of plaques. Subsequent erosion or rupture of atherosclerotic plaques triggers thrombotic events that can potentially be fatal. Decades of intensive research made it clear that atherosclerosis has complex pathogenesis, the main components of which are lipid accumulation and chronic inflammation in the arterial wall . AtherosThe chain of pathological events that leads to atherosclerosis development is believed to be initiated by local endothelial dysfunction, which may be caused by blood flow turbulence near the sites of artery bends or bifurcations. The blood vessel endothelium responds to the mechanical stress with activation that subsequently leads to the recruitment of circulating immune cells. Circulating monocytes adhere to the injured area of the arterial wall and penetrate inside, differentiating into macrophages that actively participate in lipid uptake through phagocytosis and give rise to foam cells that are abundantly present in atherosclerotic plaques .Detailed study of atherosclerotic lesion development is complicated by the fact that the process may differ considerably in humans and available model animals ,7. HowevAtherosclerotic plaques can reduce the lumen of the blood vessel, leading to ischemia and metabolic changes in the alimented tissues . Even moDiabetes mellitus is a group of disorders of carbohydrate metabolism, whose main feature is chronic hyperglycemia that results from defects of insulin secretion, insulin action, or a combination of those. Metabolic abnormalities observed in diabetes can be caused by the low level of insulin production and/or insulin resistance of the target tissues. The disease affects primarily skeletal muscles and adipose tissue, but also liver, at the level of insulin receptors, the signal transduction system, and/or effector enzymes or genes . SymptomType 1 diabetes (T1D) is caused by the autoimmune destruction of insulin-producing pancreatic β-cells . The claPatients with T1D develop pancreatic lesions that can lead to acute pancreatitis with leukocyte accumulation . The disIncreasing prevalence of type 2 diabetes mellitus (T2D), which now affects more than 370 million people, is a result of the worldwide increased incidence of obesity. Diabetes is diagnosed from fasting and two-hour glucose levels following a standardized oral glucose load. Prediabetes is often determined as the distinction between impaired fasting glucose and/or impaired glucose tolerance . HoweverDiabetes mellitus and atherosclerosis appear to be connected through several pathological pathways. Increased risk and accelerated development of atherosclerosis have been shown in studies on diabetic patients. For instance, several studies have reported the early development of atherosclerosis in adolescents and children with T1D ,27. AmonOne of the most studied links between diabetes and atherosclerosis is the level of small dense LDL (sdLDL), which is a known risk factor of atherosclerosis. Although LDL is currently recognized as the main source of intracellular lipid accumulation in the plaque, native LDL particles do not cause prominent lipid accumulation in cultured cells; hence, they do not possess atherogenicity. It is atherogenic modification of LDL, which alters the physical–chemical characteristics of LDL particles, that triggers massive lipid accumulation . A cascaAfter penetration into the subendothelial space at the atherosclerotic lesion site, modified LDL particles reside there for a longer time due to interaction with proteoglycans and therefore have increased chances of being internalized by the lesion cells. Moreover, modified LDL has a lower affinity to LDL receptor (LDLR) and is therefore internalized mainly through unspecific phagocytosis, which leads to intracellular cholesterol accumulation rather than normal degradation of lipoprotein particles. These processes result in the formation of foam cells with the cytoplasm filled with accumulated lipid droplets .Studies conducted in a murine model of diabetes clearly demonstrated the significance of LDL modification for the increase of the subendothelial retention time of lipoprotein particles. The authors extracted the LDL fraction from the blood of T1D patients and healthy controls, injected it into diabetic mice, and measured its retention in the atherosclerosis-prone areas of the arterial wall. It turned out that retention of LDL obtained from T1D patients was more than fourfold higher than that of LDL obtained from control subjects .A cross-sectional study revealed altered lipoprotein levels in young adolescents with T1D and T2D. Increased concentrations of apolipoprotein B, sdLDL, and LDL-cholesterol were not highly prevalent in young subjects with T1D but had increased prevalence in subjects with T2D . ImportaEpidemiological studies indirectly demonstrated the effect of T1D- and T2D-associated metabolic changes on atherosclerosis development. For instance, the Diabetes Control and Complications Trial in patients with T1D and the United Kingdom Prospective Diabetes Study in patients with T2D demonstrated that patients on the conventional treatment who did not achieve adequate blood glucose control were at higher risk of vascular complications than those receiving intensive treatment to ensure strict glucose control ,35.Diabetes-associated dyslipidemia received much attention during recent years and became the subject of numerous review papers ,37. AlteThe risk of diabetic cardiovascular complications after exposure to high glucose levels for a certain period of time is called “metabolic memory” or “legacy effect”. One of the possible mechanisms of this effect is the formation of advanced glycation end-products (AGE), which occurs when the blood glucose level is high. These compounds are not easily metabolized, accumulating in patients with a long history of inadequate blood glucose control. Such accumulation may accelerate the progression of vascular disease in diabetic patients. Numerous studies have established the link between inadequately controlled blood glucose level and microvascular complications of diabetes, such as renal and retinal symptoms. However, the relationship between elevated blood glucose and atherosclerosis of large arteries appears to be less straightforward. Direct pro-atherogenic effects of glucose levels on the cell types typically present in atherosclerotic lesions could not be demonstrated . It remaAnother possibility is that elevated glucose acts primarily through extracellular mechanisms, for example, by inducing glycation and glycoxidation of proteins, resulting in AGE formation. AGE accumulate in diabetic patients when the blood glucose level is elevated and appear to play an important role in atherosclerosis development. These molecules influence endothelium activation and surface expression of adhesion molecules, thereby promoting the adhesion and entrance of monocytes/macrophages into the subendothelial space during the initial stages of plaque formation. Moreover, these molecules enhance cytokine release by macrophages, thereby maintaining a pro-inflammatory context within the developing plaque. Another mechanism is glycation of LDL particles, which can be regarded as one of the atherogenic modifications of LDL. It was also shown that AGE may inhibit reverse cholesterol transport by reducing the expression of ATP-binding membrane cassette transporters A1 and G1 (ABCA1 and ABCG1) on monocytes, to enhance vasoconstriction by increasing endothelin-1 levels, and to reduce vasodilation by decreasing nitric oxide levels. Finally, AGE participate in the modification of extracellular matrix molecules, which also promotes atherosclerotic lesion development ,41. Modi-/-apoE) mice with chemically induced diabetes, RAGE deficiency was shown to alleviate atherosclerotic lesion development [In mouse models of atherosclerosis, such as apolipoprotein E-deficient  [+/Akita:-/-apoE mice were used to demonstrate the beneficial effect of leptin on atherosclerotic plaque progression [Further insights on possible links between hyperglycemia and atherosclerosis came from animal studies. Studies of hyperglycemia’s effect on vascular lesions in the mic mice . A new m/- mice) . These agression .Excessive glycation may also play a role at later stages of atherosclerosis development. As demonstrated in a recent study, glycation of erythrocytes in T2D patients may promote their internalization by the endothelial cells via phagocytosis, which impairs endothelial function. This process is likely to contribute to unstable plaque development with subsequent thrombosis in patients with T2D and atherosclerosis .The level of AGE may also be used for diagnostic purposes to assess the risk of atherosclerosis development and vascular complications in diabetic patients. In a recent study, measurement of skin AGE levels through autofluorescence (AF) in Japanese T1D patients and their gender- and age-matched healthy controls demonstrated the increased AF in diabetes that appeared to be an independent risk factor for carotid atherosclerosis .-/-apoE mice deficient for one of the main regulators of antioxidant enzymes, glutathione peroxidase 1 (Gpx1). Upon diabetes induction with streptozotocin, animals that were also deficient for Gpx1 had accelerated atherogenesis, with increased plaque size, macrophage infiltration, and increased expression of inflammatory markers, while restoration of Gpx1 reduced atherogenesis [Diabetes is known to be associated with both increased ROS production and reduced activity of antioxidant systems . Studiesogenesis . Overallogenesis .-/-apoE mice have shown that chemical or genetic inhibition of PKCβ led to reduced formation of atherosclerotic lesions [-/-apoE and in -/-apoE and -/-PKCβ double knock-out mice with chemically induced diabetes showed that increased PKCβ activation was linked to accelerated atherosclerosis development through the induction of CD11c and pro-inflammatory activation of macrophages. Correspondingly, inhibition of PKCβ reduced the size of atherosclerotic lesions [Protein kinase C (PKC) is one of the key protein kinases mediating the cellular signaling pathway, which responds to cytokines, growth factors, and other messenger molecules . Increas lesions . Another lesions . These f-/-apoE mice that also lacked neutrophil elastase and proteinase-3 necessary for NETosis had reduced atherosclerotic lesion formation compared with single knock-out animals [Chronic inflammation is a known feature that is common to both atherosclerosis and diabetes mellitus. Atherosclerosis is currently regarded as a chronic inflammatory condition. In patients with T2D, increased activity of inflammasomes and elevated levels of nucleotide-binding oligomerization domain-like receptor 3 (NLRP3) were demonstrated, together with increased levels of pro-inflammatory cytokines interleukin (IL)-1β and IL-18 . One of  animals .Naturally, an active search for anti-inflammatory drugs that could reduce the risk of atherosclerotic cardiovascular disease in diabetic patients was conducted during recent years . Among tNon-coding RNAs were shown to be implicated in numerous human disorders and are currently regarded as possible biomarkers and disease modifiers. Advances in genetic methods allowed non-coding RNAs to be studied in more detail and revealed their associations with pathogenic processes. MicroRNA (miRNA) are short RNA fragments that can inhibit the expression of certain genes at the mRNA level. These RNA fragments can be produced by multiple cell types and tissues and can be found circulating in the blood either free or confined in membrane microvesicles. Accumulating evidence highlights miRNAs as important possible biomarkers. However, the complexity of the miRNA landscape associated with human diseases, including diabetes, is so high that it is probably more promising to study miRNA signatures (combinations of multiple miRNA) rather than single miRNA types .In humans, more than 2500 miRNAs have been identified, and several of them were shown to play a role in diabetes mellitus pathogenesis. In particular, multiple miRNAs were found to be involved in the development of microvascular complications of diabetes . Among t-/-apoE mice in comparison to controls, highlighting its important role in the regulation of atherosclerosis-associated processes [Another important miRNA, miR-378a, was shown to play an important role in the regulation of metabolism, including energy and glucose homeostasis . A very rocesses .-/-apoE diabetic mice, as well as in monocytes from T2D patients. Overexpression of this RNA promoted inflammatory gene expression and phagocytosis by macrophages and led to chromatin epigenetic changes, further promoting the inflammatory response [Another non-coding RNA that likely plays a role in diabetes-associated atherosclerosis is long non-coding RNA Dnm3os (dynamin 3 opposite strand). This RNA was shown to be increased in macrophages from diabetic mice, including response . More stBoth persistent and temporal hyperglycemic exposure were shown to influence several significant cellular signaling pathways, including PKC activation and oxidative stress, described above, and transforming growth factor (TGF)-β-SMAD-MAPK signaling ,74. MoreHyperglycemia is associated with the range of chromatin modifications that affect the genetic signature of vascular endothelial cells. For example, a genome-wide sequencing study of aortic endothelial cells exposed to a high level of glucose revealed histone H3K9/K14 hyperacetylation patterns that were inversely associated with DNA methylation in CpG clusters. This finding correlates with the activation of transcription of pathways linked to atherogenic effects and vascular diseases. The study demonstrated that hyperglycemia can induce epigenetic changes in the vascular endothelium that are relevant for atherosclerosis development, thereby providing another link between diabetes and atherosclerosis pathogenesis .RELA gene encoding the NF-κB-p65 subunit persisted for 5–6 days after the cells were returned to a normoglycemic state [Transient hyperglycemia also triggers mono-methylation of H3 histones at lysine 4 (H3K4m1) and other histone lysine modifications. H3K4m1 was shown to be written by the Set7 lysine methyltransferase. The observed changes at the promoter of the ic state ,79. Thusic state . Among tic state . The enhMCP-1, MMP10, ICAM, HMOX1, and SLC7A11 [The concluding result of these hyperglycemia-induced changes is the transcriptional activation of genes that are related to endothelial dysfunction . Acetyla SLC7A11 .HMOX1 was shown to be beyond the methylation of histones but linked to hyperglycemia [Further research identified the role of Set7/9, which possibly coactivates NF-κB transcriptional activity in monocytes in response to inflammation through the activation of the H3K4me promotor, and the analogous effect was observed in endothelial cells in response to hyperglycemia ,81. Moreglycemia . It was glycemia .All the aforementioned findings suggest numerous links between hyperglycemia, epigenetic changes, and cardiovascular risk that cannot be ignored. However, there are still many blind spots in the understanding of the underlying molecular mechanisms and their connections.Both types of diabetes mellitus have been shown to be independent risk factors for accelerated atherosclerosis development. It is now clear that the pathogenesis of diabetes mellitus and atherosclerosis are closely linked, but the mechanisms and molecular interactions of this linkage are still under discussion. Among the known pathological mechanisms connecting diabetes and atherosclerosis are dyslipidemia, hyperglycemia with AGE production, increased oxidative stress, and inflammation. Despite the continuing search for novel therapeutic approaches, few medications have shown strong beneficial effects with regard to reducing the risk of atherosclerosis development in the specific population of diabetic patients. Adequate glycemic control and reduction of known risk factors remain the most frequently used strategies for protecting such patients. More studies are needed to reveal the exact signaling mechanisms of diabetes-associated macrovascular damage and to identify specific therapeutic targets.