A search was performed for the literature on cinnabar and realgar in PubMed, the Chinese Pharmacopeia, Google, and other sources. The search included studies using single herbs, traditional formulations, or novel dosage forms.  Cinnabar and cinnabar formulas exhibit good efficacy for sedation, sleep improvement, anxiety alleviation, and brain protection. However, previous studies on neurotransmitters have reached different conclusions, and detailed pharmacological mechanisms are lacking. Realgar and its formulas exert promising antitumor activity through regulation of cell cycle arrest, intrinsic and extrinsic apoptosis, induction of differentiation, autophagy, metabolic reprogramming, matrix metalloproteinase-9 (MMP-9) signaling, and reactive oxygen species (ROS) generation. In addition, realgar can be used to treat a variety of refractory diseases by regulating immunity and exerting antibacterial, antiviral, and other effects. However, the existing pharmacological research on the use of realgar for epidemic prevention is insufficient, and animal experiments and research at the cellular level are lacking. Inappropriate applications of cinnabar and realgar can cause toxicity, including neurotoxicity, liver toxicity, kidney toxicity, and genotoxicity. The toxicological mechanism is complex, and molecular-level research is limited. For clinical applications, theory and clinical experience must be combined to guide scientific and rational drug use and to achieve reduced toxicity and increased efficacy through the use of modern preparation methods or combined drugs. Notably, when cinnabar and realgar are used to treat targeted diseases, these agents have a bidirectional effect of “treatment” and “toxicity” on the central nervous system in pathological and normal states. The pharmacological and toxicological mechanisms need to be elucidated in greater detail in the future. Overall, systematic research is needed to provide a basis for better promotion of the rational use of cinnabar and realgar in the clinic.  Mineral medicines are multicomponent, multiactivity, and multitargeted substances. The pharmacology and mechanisms of the toxicity and action of realgar and cinnabar are extremely complex. A number of Chinese medicinal preparations of realgar and cinnabar have demonstrated unique efficacy in the treatment of refractory diseases. Mineral medicines include raw minerals , processed products of raw mineral materials , and animal bones or fossils of animal bones  and are characteristic of traditional medicines used in China.Throughout history, mineral medicines have played an important role in traditional Chinese medicine (TCM). TCM has a long application history with the accumulation of rich clinical experiences and is still widely used today. The earliest record of the roles of mineral medicines is documented in The Classic of Mountains and Seas, which states that taking mineral medicines can “make people healthy and live longer.” In addition, the modern 2020 edition of the Pharmacopoeia of the People's Republic of China (2020ChP)  affirms Cinnabar is described by the 2020ChP  as folloRealgar is described by the 2020ChP  as a sulIn recent years, the occurrence of phytotoxicity incidents caused by the improper use of mineral drugs has increased the concern regarding their toxicity. Cinnabar and realgar have become popular discussion topics because their main components (Mercury and arsenic) are known toxic metals/metalloids. Some have even questioned the necessity of heavy metal minerals, such as cinnabar and realgar, in medicinal formulas.Several studies have found that different forms of Mercury can be absorbed through the gastrointestinal tract, respiratory tract, and skin and that excess levels of Mercury and its compounds have acute or chronic toxic effects on the human body –23. Arseα-HgS) differs from environmental Mercury  based on its bioavailability, intestinal transport levels, distribution, metabolism, elimination, and toxicity [4S4) differs from sodium arsenate (As5+) and sodium arsenite (As3+) in structure, disposition, efficacy, and toxicity [When discussing Mercury toxicity and arsenic toxicity, it is necessary to distinguish the chemical forms. In traditional Chinese medicine, Mercury and arsenic are used orally in sulfide forms . The chetoxicity , 32. Simtoxicity .Thousands of years of clinical practice have suggested the effectiveness of cinnabar and realgar. However, the exact pharmacodynamic and toxic mechanisms of these minerals and how to optimize their clinical applications remain unclear; an in-depth research with modern research techniques is needed. A literature search of the use of Chinese materia medica in the treatment of diseases reveals that cinnabar and realgar are seldom used alone. These agents are commonly used in multiherb/metal mixtures. Therefore, we recommend that analyzing the mechanisms of clinically effective formulations at the molecular, cellular, and organismal levels represents a potentially effective method for assessing the value of traditional medicines.In this article, we briefly summarize the main pharmacological and toxicological characteristics and usage specifications of the mineral medicines cinnabar, realgar, and their commonly used preparations, aiming to provide a theoretical basis for the rational and safe clinical use of cinnabar and realgar.For thousands of years, cinnabar has been used to treat different diseases . AccordiHowever, the use of cinnabar in clinical practice has been controversial because it contains the heavy metal Mercury. Epidemiological investigations and animal experiments have shown that excessive intake of cinnabar can exert toxic effects on the kidneys, liver, and nervous system. Therefore, the pharmacology and toxicology of cinnabar and traditional medicines containing cinnabar have attracted attention.Cinnabar has long been used in combination with other Chinese materia medica as a sedative for more than 2000 years . Wang etOxidative stress plays a key role in neuronal death and underlies neurodegenerative diseases. Thus, antioxidants can play important roles in treating several neurodegenerative diseases . ReactivOne study confirmed that cinnabar can reduce the disappearance of antioxidant enzymes and the overproduction of ROS through regulation of the 5-HT metabolism pathway under hypoxic conditions at the cellular level and in zebrafish in vivo, ultimately alleviating hypoxia-induced oxidative stress and significantly improving the survival of neuronal cells under high-ROS conditions . This fiIn the endoplasmic reticulum (ER) stress response, protein kinase RNA-like ER kinase (PERK) induces the activation of C/EBP homologous protein (CHOP). Activated CHOP then induces apoptosis via the apoptosis receptor BCL2 family proteins and the death receptor caspase family proteins of the downstream mitochondria-dependent pathway . Low cinγ-aminobutyric acid in the brain [Given its good curative effect, cinnabar has been widely used as a sedative ingredient in TCM prescriptions. However, the mechanisms of cinnabar and its various formulations have been the subject of few studies. Some pharmacological studies on the use of cinnabar and its formulations for the treatment of insomnia have been reported in the Chinese literature but are not available in PubMed. One study found that the formula ASAS, which includes cinnabar as the main therapeutic ingredient, exhibits good sedative and antianxiety effects. A study on ASAS in rats with conditioned fear showed that this pill can antagonize conditioned fear; the antagonistic effect is mainly reflected in the fading stage of fear memory and may be involved in regulating the content of monoamine neurotransmitters and the expression of c-Fos protein in the basolateral amygdala. This mechanism increases the efficiency of fear extinction and improves sleep in rats . The meche brain .Cinnabar is a natural medicinal substance containing metallic Mercury . RegardiCinnabar toxicity may occur because high dose or long-term use of Chinese compound preparations containing cinnabar leads to the accumulation of Mercury in the kidneys, resulting in kidney damage, such as kidney inflammation and mild fibrosis . Cinnaba2 [Although long-term use of cinnabar can cause a series of toxic side effects, scholars have found that cinnabar is indeed much less toxic than other mercury-containing compounds, such as HgCl2 , 32 and 2 , 31.This reduced toxicity may be related to the downregulation of oligopeptide transporter 1 mRNA and protein expression by cinnabar , which aThe toxic effects of cinnabar have varied greatly in different experiments. In addition to disparities in the administered dose, different methods of cinnabar processing may also have contributed to the different toxicities. Ancient traditional Chinese medicine practitioners stressed that the washing  method during cinnabar processing was extremely sensible, as it avoided high temperatures and reduced the levels of soluble toxic elements. However, different researchers have used different medicinal materials in their toxicological studies on cinnabar, and only a few studies have emphasized the use of washing methods, which may be another important reason explaining the inconsistently experimental results. Given that the detoxification methods of cinnabar and realgar are similar, the final statement is unified.Realgar contains >90% arsenic sulfide (As₂S₂) and is widely used externally and internally in many traditional medicine recipes in China. The 2020ChP  containsRecent studies have found that realgar exhibits significant anticancer activity. The possible antitumor mechanism may be closely related to the regulation of cell cycle arrest, intrinsic and extrinsic apoptosis, induction of differentiation, autophagy, metabolic reprogramming, matrix metalloproteinase-9 (MMP-9) signaling, and ROS generation , 10.However, 90% of realgar is As₂S₂, which exhibits toxic effects characteristic of heavy metals; thus, the clinical application of realgar is controversial. Epidemiological investigations and animal experiments have shown that long-term arsenic exposure can lead to language, cognitive, behavioral, and hearing and motor impairments, as well as mental retardation and neurological deficits in severe cases. Even when arsenic exposure ceases, central nervous system function does not quickly return to normal . Therefo(1) Antitumor Mechanism. Induction of tumor cell apoptosis is the main mechanism of action of realgar in the treatment of tumors, and these effects can be achieved through a variety of ways. Studies have demonstrated a link between oxidative stress and tumor cell apoptosis [poptosis . To imprpoptosis . Similarpoptosis . The respoptosis .Cell cycle-regulated gene mutations play important roles in tumorigenesis. Cell cycle arrest provides cells with additional time to repair damage, thereby reducing the occurrence of mutations and tumor development. In a molecular study on the use of As₂S₂ in the treatment of APL, As₂S₂ was found to induce the accumulation of NB4-R1 cells in S and G(2)/M phases . This efα fusion protein, making it ineffective; (2) enhancement of the level of cellular ubiquitin by realgar; (3) promotion of pML/RARα fusion protein ubiquitination; (4) formation of a covalent enzyme system; and (5) entry into the protease system for degradation into short peptides and loss of activity [Induction of differentiation is a common strategy in tumor therapy. Realgar induces multilineage differentiation in the human promyelocytic leukemia cell line HL-60, thereby exerting anticancer effects. Myeloid differentiation of HL-60 cells is induced via the p38 mitogen-activated protein kinase-related signaling pathway , and montem; and  entry inAutophagy is an important cell biological process induced by multiple forms of cellular stress, including nutrient or growth factor deprivation, hypoxia, and ROS . Excessiα expression via the PI3K/Akt/mTOR pathway [Under hypoxic conditions, hypoxia-inducible factor (HIF-1) promotes the metabolic reprogramming of tumor cells and induces acidification of the tumor extracellular environment, which helps tumor cells obtain energy and survive . However pathway .MMP-9 is one of the most complex matrix metalloproteinases. In tumor cells, MMP-9 contributes to the remodeling of extracellular matrix proteins, providing a microenvironment for tumorigenesis. MMP-9 degrades basal type IV collagen near tumor cells and then invades other normal tissues, thereby inducing cancer invasion and metastasis . HoweverStudies have shown that As₂S₂ inhibits the proliferation of colon cancer cells by regulating the nuclear factor of activated T cells (NFAT) pathway , 67. ItsThese results suggest that realgar preparations have broad-spectrum scavenging effects in tumor cells. In cells and tissues, regulation is a complex process involving multiple signaling pathways, and the pathways in which realgar is involved require further study.(2) Immunoregulatory and Antibacterial Mechanisms. Severe systemic lupus erythematosus (SSLE) refers to a manifestation of systemic lupus erythematosus (SLE) involving important organs. Patients with SSLE often experience multiple complications simultaneously, treatment difficulties, and worse prognoses [rognoses . Studiesrognoses .2+ concentrations, reducing surface molecule activation, stimulating surface factor expression, and restraining its activation to reduce the production of antibodies, reduce MRL/lpr mouse autoimmune injury, and slow down the SLE course [Caenorhabditis elegans, realgar can alleviate the infection of wild-type N2, glp-4 mutant, and daf-2 mutant nematode strains by inducing both immune and protective responses and significantly increasing antibacterial effector levels, which leads to pathogen elimination [Realgar promotes apoptosis of B cells from MRL/lpr mice by increasing CaE course . In addimination , 73.(3) Prevention and Treatment of Epidemics. Epidemic diseases are highly contagious and dangerous. Historically, realgar has played an important role in the prevention and treatment of epidemics in China in past dynasties. However, pharmacological research on realgar use for epidemic prevention and treatment is scarce. According to a recent literature search, realgar was the drug most frequently used by physicians for epidemic prevention in past dynasties [ynasties . Wearingynasties .External use through various methods  can block the transmission of the epidemic pathogen. Realgar can also be taken internally in the form of pills, medicinal liquors, etc. and can be combined with cinnabar for epidemic prevention. Ruan  and othe(4) Antiviral Mechanism. In an experiment using acyclovir as a positive control, nanorealgar showed good anti-herpes simplex virus type II activity when administered in 3 modes  [ivation) . The antivation) . The pha(1) Antitumor Mechanisms. Since the 1970s, researchers in the field of blood diseases in China have successively applied realgar-Indigo naturalis formula (RIF) as the active ingredient in the clinical treatment of APL, achieving definite curative effects. RIF, a typical representative of realgar anticancer preparations, has now been approved for marketing in China.α oncoprotein, (3) relief of transcriptional suppression, and (4) G1/G0 arrest of APL cells with effects on key regulators of cell cycle progression. The main component realgar cooperates with other components in RIF to increase the absorption rate by inducing upregulation of the transmembrane protein aquaglyceroporin 9. Further studies have shown that RIF can significantly inhibit the growth of APL NB4 cells [A molecular-level study indicated that realgar is the principal component of the formula, whereas tanshinone IIA and indirubin serve as adjuvant ingredients . ClinicaB4 cells  and the B4 cells .Clinical studies have shown that the Chinese medicine Qinghuang Powder (QHP) , the main component of which is realgar, is effective and safe for the treatment of patients with MDS and that reasonable adjustment of the daily dose of realgar can improve the efficacy without increasing the clinical toxicity , 9. In vDifferent DNA methylation subtypes may be present in MDS-metachromatic leukodystrophy (MLD) patients. A clinical study found that Chinese herbal medicine containing realgar has good effects in the treatment of MDS-MLD patients with the hypomethylation subtype . The theThese findings suggest that traditional Chinese medicine products containing realgar represent potential drugs with multiple activities. The active ingredients of realgar can be combined with some antitumor drugs to synergistically enhance the inhibition of tumor cells and reverse antitumor drug resistance , thus en(2) Antiviral and Anti-Inflammatory Mechanisms. Modern physicians have also applied realgar to various conditions. Professor Liangchun, a master of traditional Chinese medicine, used the traditional Chinese medicine formula Duo-Tan-Ding-Jing-San created with realgar to treat viral infectious diseases such as Japanese encephalitis, pneumonia, and meningitis and achieved good clinical results [ results .кB signaling pathway [The realgar-containing Chinese medicine formula Liu Shen Wan (LSW) can significantly inhibit the influenza virus at different stages of viral replication in vitro. The antiviral effect is attributable to downregulation of the expression of inflammatory cytokines induced by the influenza virus via regulation of the activity of the TLR4/NF- pathway . Further pathway .Studies have shown that the disturbance of the intestinal flora and the severity of intestinal inflammation in realgar-treated mice are related to the realgar dose . TherefoOne study performed untargeted lipidomics and other analyses on realgar-exposed mice to identify markers of the toxicity of realgar exposure to the nervous system . The stuMetabolomics studies have revealed that oral administration of realgar disrupts endogenous metabolites and related metabolic pathways in mice . Follow-Cytochrome P450 enzymes are extremely important enzyme transport systems in the body. The main function of these enzymes is to metabolize exogenous substances (such as drugs) and endogenous substances. However, some studies have shown that higher doses of realgar can inhibit the enzymatic activity of cytochrome P450 enzymes, which may be related to the accumulation of arsenic from realgar . RealgarAlthough the toxicity of realgar nanoparticles is lower than that of realgar, studies have shown that realgar nanoparticles can induce free fatty acid and triglyceride accumulation, resulting in hepatotoxicity, and the metabolic markers of nanoparticle-treated subjects are different from those of traditional realgar-treated subjects .Long-term or high-dose consumption of realgar can lead to the accumulation of heavy metals in the body, causing damage to the liver, blood, and nervous system. However, some clinical studies have found that higher concentrations of As₂S₂ in peripheral blood can enhance the clinical efficacy of realgar in the treatment of MDS-MLD patients . TherefoCompared with single mineral medicines, traditional Chinese medicine formulas containing multiple mineral medicines are more widely used in clinical practice. The mechanisms of action of mineral medicines or mineral-containing medicines in the treatment of diseases are complex but are related to the multicomponent, multitarget, and multichannel treatment characteristics of the medicines; these features also represent the characteristics and advantages of TCM for the treatment of diseases in general. Cinnabar and realgar are often used together in traditional Chinese medicine compounds.An-Gong-Niu-Huang Wan (AGNH) is a famous traditional Chinese medicine used to treat cerebral emergencies, such as traumatic brain injury, hemorrhage, brain infection, ischemia, and stroke, with a history of use of more than 3,000 years . Modern Based on skepticism about mineral medicines, some scholars have tried to remove cinnabar and realgar from AGNH. Interestingly, removing realgar and/or cinnabar from AGNH abolishes the neuroprotective effects . In one Wu Jutong, a warm-disease scientist of the Qing Dynasty, called Angong Niuhuang Pill the first of the “three classic antipyretic preparations” and believed that it had good heat-clearing, detoxifying, and sedating effects. Modern research suggests that cinnabar and realgar in the Angong Niuhuang Pill may play the main roles in “clearing heat and detoxifying” by helping inhibit the excessive release of inflammatory mediators . This foSome scholars  have conAGNH and HFD are still widely used clinically in their traditional and new forms. These agents can be used alone or in combination with other drugs for synergistic treatment.Some meta-analyses of clinical studies on AGNH have revealed that AGNH has been widely used for acute cerebral infarction and intracerebral hemorrhage , traumatWith the introduction of modern biopharmaceutical technologies, innovations in the dosage forms of traditional Chinese medicine, such as capsules or liquid forms, have been reported. Based on these innovations, the pharmacological effects of the medicines are relatively clear, and these formulations have achieved outstanding curative effects that have been widely recognized in the medical field in recent years.Traditional Chinese medicine injections are unique dosage forms in mainland China  that areIn a previous study, QKL (or combined treatment) had a better effect on most outcome indicators compared with control, but the occurrence of adverse reactions cannot be ignored . The curXingnaojing injection (XNJ) is the only Chinese herbal injection approved for emergency treatment of stroke in China . In the The above findings clearly show that the application of new technologies and new processes in development and production processes has enabled innovations and improvements of TCM preparations. This new technology has not only driven the development of traditional Chinese medicine, but also (and more importantly) promoted the internationalization of traditional Chinese medicine. In the Chinese Pharmacopeia (2020) , 24 reciChinese materia medica containing cinnabar and realgar are generally relatively nontoxic at therapeutic doses under the pharmacopeia guidelines . ImportaIn TCM, cinnabar and realgar are subjected to grinding and washing  at least 3-4 times, which is crucial for the safe use of cinnabar and realgar in medicine.Ancient physicians emphasized several important purposes of concocting mineral medicines using the grinding and washing method: to remove impurities, to reduce soluble elements as much as possible, to control the temperature to avoid the formation of new toxic and harmful substances, and to make the drug powder extremely fine and improve its bioavailability. Modern research illustrates that, as a TCM processing method, water grinding reduces toxicity , 137.The 1995 edition of the Chinese Pharmacopoeia reduced the daily dose of cinnabar from 0.3 to 1.5 g to 0.1∼0.5 g, and this standard is still used today  is conceIn TCM, minerals are not applied alone but mixed with herbs and/or animal products. Chemical reactions may occur due to the mixing of agents, and it is assumed that the various components promote each other to achieve the desired therapeutic effect and reduce toxicity . StudiesMetabolomics studies have confirmed that the other herbs present in AGNH alleviate inflammatory cell infiltration and damage in the liver and kidneys as well as the serum metabolic profile disruptions induced by cinnabar and realgar insults , 142. ThThe above review demonstrates that, despite great progress in research on the pharmacological and toxicological mechanisms of cinnabar and realgar, limited pharmacological studies have assessed cinnabar's sedative and soothing effects and realgar's anti-inflammatory, antioxidant, and epidemic-preventing effects. Notably, the compositions of metal mineral medicines are complex, as these medicines contain a variety of compounds. However, research on the physiological effects of the other components is relatively limited. In addition, because the body itself contains various trace elements, it is difficult for the current analytical technologies to achieve accurate detection in vivo, which is the key hindrance to in-depth research on the absorption and metabolism of metal-based mineral drugs. Researching pharmacology, toxicology, and mechanisms of action is an important method to study medicinal properties. However, most of the research conducted to date has focused on the overall efficacy and toxicity of cinnabar, realgar, or their formulations. Many researchers are observing and testing some macro-indicators, but research to clarify the mechanisms of action at the molecular-level remains lacking. There is no sufficient scientific basis for rational clinical drug use, and there is an urgent need to conduct more in-depth research on the molecular mechanisms of the pharmacological and toxic effects of cinnabar and realgar.To date, research on the toxicity of mineral drugs has mostly adopted modern toxicology methods to analyze the toxicity to normal organisms. However, due to neglect of the toxicity-reducing compatibility theory of traditional Chinese medicine, the toxicity of mineral medicines has been exaggerated.To improve efficacy and reduce adverse effects, TCM often combines mineral medicines with herbs, animal products, and/or other minerals in products called formulas. Increasing evidence demonstrates that treatment regimens for various illnesses contain multiple drugs with distinct but related mechanisms. These drugs can often amplify the therapeutic efficacy of the other drugs, enabling multitargeted synergistic therapy and leading to maximal therapeutic efficacy with minimal adverse effects. However, the essential compounds have not been identified in most formulas, and the precise mechanisms of the formulas remain to be addressed using molecular approaches. When the specific mechanisms of action and toxicity mechanisms of two-drug formulas are unclear, the use of each single drug may not completely explain the pharmacodynamic and toxicity mechanisms of the two drugs together. Each drug may need to be combined with other compatible drugs to completely explain the possible mechanisms of action, and pharmacodynamic research may need to be conducted to achieve attenuation and antiviral effects.For clinical applications, it is necessary to combine theory and clinical experience to guide scientific and rational drug use and achieve the purposes of reducing toxicity and increasing efficacy through the use of modern preparation methods or drug combinations. Processing has a significant effect on the content of toxic impurities in mineral medicines. The processing parameters of the washing method should be further standardized, and the amount of water added and the numbers of repeated grinding operations should be clarified to obtain decoctions of uniform quality. The development of nanopreparations, microbial leaching preparations, new crystal preparations, and compound preparations represents the current focus of research on mineral pharmaceutical preparations. How to effectively improve drug solubility, bioavailability, and targeting, adjust sustained release and controlled release, and reduce the occurrence of adverse reactions is the key issue to be considered with these new processing methods.The next steps are to explore the effective traditional formulas through the combination of minerals and other drugs, to elucidate the mechanisms of these formulas, to upgrade the formulas into modern dosage forms, and to describe the traditional theories of traditional Chinese medicine, such as synergistic treatments and toxin counteraction with toxin therapy, in the modern language of molecular biology. The complementary combination of systems biology and theoretical research on TCM will greatly promote the pace of traditional Chinese medicine internationalization.


To explore the mechanism of glioma from MYB family genes from the perspective of the circRNA-miRNA-mRNA regulatory network.  First, the MYB family genes were analyzed by multiple bioinformatics analyses to identify one gene most associated with glioma. Then, the prognostic value and clinical characteristics of the gene were evaluated by bioinformatics analysis and experiments in glioma cells. Next, the target miRNA and circRNA were predicted and verified by dual-luciferase reporter assays. Besides, the functions of target circRNA in glioma were investigated by CCK-8 and Transwell assays. At last, the relation between the screened MYB gene, miRNA, and circRNA in glioma was identified by rescue experiments.  After expression and Cox and survival analysis of six MYB family genes, MYBL2 was identified as the gene most associated with glioma. Then, we found that MYBL2 expression in primary gliomas was higher than those in other histologies, and it had variable expression according to clinical features. Furthermore, MYBL2 knockdown in glioma cells impairs cell growth, invasion, and migration in functional studies. Then, miR-30e-5p and circFAT1(e2) were identified as targets of MYBL2 by bioinformatics prediction and experimental verification. Finally, the relationship between circFAT1(e2), MYBL2, and miR-30e-5p was elucidated by rescue experiments.  circFAT1(e2) could promote glioma development by regulating MYBL2 and miR-30e-5p, and MYBL2 has diagnostic and prognostic values in glioma. Due to malignant alterations in glial cells in the brain and spinal cord, glioma is the most frequent primary brain tumor . The yeaSo far, 30 oncogenes homologous to retrovirus oncogenes have been identified in vertebrate cells, and more than 20 of them have been mapped in the human genome. For the convenience of research, oncogenes are temporarily divided into five families according to their structure, gene products, and function similarity, the MYB gene family included. In this family, its members contain MYBL1, MYBL2, MYBBP1A, MYPOP, MYSM1, and others, and presently, they have been focused on the aspect of cancer development. For example, Bayley and colleagues outline the importance of enhanced MYBL2 expression in the development and pathophysiology of BC, as well as potential therapeutic targets for this multifunctional protein to avoid disease recurrence . The relThe circRNA-miRNA-mRNA regulatory network is the main mechanism that can influence cancer-related gene expression . The maiPrevious studies have shown that circFAT1(e2) is a novel circRNA derived from exon 2 of the FAT1 gene. In PTC, circFAT1(e2) exerts oncogenic effects by promoting cell invasion and metastasis and is a potential new target for PTC therapy. It is found in gastric cancer that overexpression of circFAT1(e2) inhibits the proliferation, migration, and invasion of gastric cancer cells and is associated with the overall survival of gastric cancer patients. Moreover, miR-30e-5p is a novel cancer-associated miRNA that plays a key role in the progression of different cancers such as nonsmall cell lung cancer, colorectal cancer, and bladder cancer. However, there are few reports on the functional roles of circFAT1(e2) and miR-30e-5p in glioma.In the present study, we plan to make research on the relations between MYB family genes and glioma from the aspect of the circRNA-miRNA-mRNA regulatory network. Thus, we perform bioinformatics analysis on MYB family genes and glioma to determine the hub gene related to glioma and predict its target miRNA and circRNA. Finally, these findings will unveil the potential mechanism of glioma.https://portal.gdc.com) [P value, hazard ratio (HR), and confidence interval (CI) were computed using a univariate Cox regression analysis on the 6 genes. Then, to investigate the relationship between their expressions and prognosis, a progression-free survival (PFS) study was carried out (331 glioma patients vs. 331 controls). The worse the prognosis, the higher the expression, which indicates that the gene promotes tumor formation and is otherwise protective. Finally, we selected one gene most related to glioma for the next analysis.The corresponding data of MYBL2 family genes and glioma were obtained from The Cancer Genome Atlas (TCGA) database (gdc.com) . Batch eThe effect of MYBL2 expression on the survival of primary (202 highly expressed groups vs. 202 lowly expressed groups) and recurrent gliomas (127 highly expressed groups vs. 126 lowly expressed groups) was detected. Then, univariate and multivariate analyses were then performed on MYBL2 and several clinical features , and the results were displayed by forest plots. The “rms” program was used to create a nomogram and calibration curve based on the aforementioned data to forecast the 1-year, 3-year, and 5-year survival conditions. The nomogram presented a graphical representation of these characteristics, and the points associated with each risk factor could be used to compute the prognosis risk of an individual patient.Next, we evaluated the MYBL2 expressions in O (oligodendroglioma), A (astrocytoma), rO (recurrence of oligodendroglioma), rA (recurrence of astrocytoma), AO (anaplastic oligodendro), AA (anaplastic astrocytoma), rAO (recurrence of anaplastic oligodendro), rAA (recurrence of anaplastic astrocytoma), GBM, rGBM (recurrence of glioblastoma) groups, and patients with different clinical features, including grade , IDH mutation status (mutant and wildtype), 1p/19q codeletion status (codel and noncodel), age status (<42 and ≥42), and gender . All the data were acquired from the TCGA database.2. circFAT1(e2) overexpression was achieved using the pcDNA3.1 (+) plasmid. Two siRNAs (si-circ1 and si-circ2) targeting the splice junction site of circFAT1(e2) were ordered from Gene-Pharma . MYBL2 was knocked down by si-MYBL2 and overexpressed by over-MYBL2 . Overexpression and knockdown of miR-30e-5p were accomplished using miR-30e-5p mimics and inhibitors . Lipofectamine 2000  was used to transfect the cells as directed.The American Type Culture Collection (ATCC) provided U373 and SW1783 (glioma cells), which were kept in RPMI-1640 media  with 10% FBS  in a 37°C incubator with 5% COΔΔCt– technique .Total RNA was extracted using Trizol  according to the manufacturer's instructions and quantified using spectrophotometry . The reverse transcription was then completed using a reverse transcription kit . Real-time PCR was performed using the TaKara Premix Ex Taq™ II (USA). An iQ multicolor real-time PCR detection system was used to perform RT-qPCR experiments . Quantification was done using the 24 cells per well were seeded in a 37°C incubator with 5% CO2. CCK-8 kit  was used to measure cell proliferation 24 hours, 48 hours, 72 hours, and 96 hours after transfection. The absorption wavelength at 450 nm was detected by the reader.In a 96-well plate, 1 × 10μm well, BD Biosciences) was utilized to determine cell migration [2 for 1 hour. To summarize, a medium containing 10% FBS was introduced to the bottom chamber. And medium free of FBS was put into the upper chamber under a 37°C incubator for 24 hours. The nonmigrated or noninvaded cells were then wiped clean using a cotton swab, while the migrated or invaded cells were washed in PBS before being fixed in 95 percent paraffin and stained with DAPI. Cells were stochastically photographed and counted under a 200× optical microscope of an individual sample.After 24 hours of transfection, cells were collected and resuspended in media without serum. Transwell chamber in 24 well plates  circFAT1(e2), which included miR-30e-5p-specific binding sites, and the mutant fragment, which contained mutant (Mut) miR-30e-5p binding sites, were created. The Lipofectamine 3000 reagents were used for transfection, and the luciferase activity assay was carried out 24 hours later according to the manufacturer's procedure .P < 0.05.GraphPad Prism 19.0 was used to conduct the analysis. ANOVA was used to analyze differences between two or more groups. The possible associations between gene levels and other clinicopathological characteristics were calculated using Fisher's exact test. Kaplan-Meier curves with log-rank test and Cox regression analysis were used to analyze the patients' overall survival. Statistical significance was determined at P < 0.05), while that of MYSM1 was not significant (P > 0.05). So, we chose the first five genes for subsequent PFS analysis. The results showed that their higher expressions were usually accompanied by worse survival status  and WT-MYBL2 in the dual-luciferase reporter assay Figures . The expin vitro assays to determine the genes with clinical value in glioma.Although surgery and drug treatment of glioma have made much progress recently, the prognostic status of patients with malignant glioma is deadly poor, mainly due to the rapid proliferation and poor differentiation of glioma, and the presence of drug-resistant cells that are not sensitive to available treatments in gliomas . TherefoP < 0.05), while MYSM1 was not (P > 0.05). Therefore, MYB, MYBL2, MYBL1, MYBBP1A, and MYPOP were analyzed by PFS curves, in which their higher expression indicated a worse prognosis, especially MYBL2. Considering all the results, MYBL2 was chosen for the study.In this study, we firstly selected 6 genes, MYB, MYBL1, MYBBP1A, MYPOP, MYSM1, and MYBL2, from the MYB family for the bioinformatic analysis. We found that all 6 genes were upregulated in GBM and LGG groups. MYB, MYBL2, and MYBL1 had the highest levels in the GBM group, whereas MYBBP1A, MYPOP, and MYSM1 had the highest expression levels in the LGG group. In the Cox regression analysis, the statistics of MYB, MYBL2, MYBL1, MYBBP1A, and MYPOP were significant  were first discovered in 1979 , and theBased on the analysis of public databases, we found that miR-30e-5p was a downstream target of MYBL2, and circFAT1(e2) was a downstream target of miR-30e-5p. Recent studies have shown that miR-30e-5p is dysregulated in several human cancers. For example, the study by Zhang et al. shows that miR-30e-5p may inhibit the growth and invasion of bladder cancer cells by targeting MTDH . The stuMoreover, there are certain limitations of this study that must also be considered. First, these studies were mostly nonrandomized with a small sample size and had issues related to the risk of bias. Second, the results of this study are rarely validated experimentally; thus, the results of this study should be regarded as preliminary results only. Furthermore, the direct correlation between miRNA and mRNA was not assessed on samples from the same patients. In the future, more studies are needed to further investigate the associations described in this analysis.Our findings reveal that MYBL2 is increased in gliomas and that overexpression of MYBL2 is associated with poorer survival and prognosis, implying that MYBL2 might be used as an independent glioma prognostic biomarker. Furthermore, circFAT1(e2) exerts an oncogenic role in glioma cells. Mechanistically, circFAT1(e2) can reduce miR-30e-5p, leading to the elevation of MYBL2, thus promoting tumor cell progression. These findings reveal the potential mechanism between circFAT1(e2) and glioma, providing promising diagnostic biomarkers and therapeutic targets in glioma treatment. Although the above results are considered preliminary, they are encouraging.


Medial patellofemoral ligament (MPFL) reconstruction is an important surgical therapy for recurrent patellar dislocation. However, few studies have focused on exercise therapy after MPFL reconstruction. Therefore, the first purpose was to compare the active and traditional postoperative exercise therapies on the recovery of knee joint function and reduction of muscle atrophy after MPFL reconstruction, and the second purpose was to compare the active and traditional postoperative exercise therapies on the patellar stability after MPFL reconstruction.The cases of 31 patients with recurrent patellar dislocation treated with patella double semi-tunnel anatomical MPFL reconstruction from February 2016 and February 2019 were retrospectively reviewed. The clinical outcomes, including the patellar tilt angle (PTA), lateral patellofemoral angle (LPFA), thigh circumference reduction, Kujala score, and Lysholm score, were compared between two groups  preoperatively, 3 months postoperatively, 6 months postoperatively, 12 months postoperatively, and 24 months postoperatively.P < 0.01), 6 months postoperatively , 12 months postoperatively , and 24 months postoperatively . Similarly, there was a higher Lysholm score in the active exercise group compared with traditional exercise group 3 months postoperatively , 6 months postoperatively , 12 months postoperatively , and 24 months postoperatively . Significantly lower thigh circumference reduction was reported in the active exercise group compared with that in the traditional exercise group 3 months postoperatively  and 6 months postoperatively . No statistical difference was observed between the two groups in terms of PTA (P > 0.05) or LPFA postoperatively (P > 0.05).The Kujala score was significantly higher in the active exercise group than traditional exercise group 3 months postoperatively (80.06 vs. 74.80, Our results suggested that active exercise therapy might benefit the early recovery of knee joint function and reduction of muscle atrophy in patients with recurrent patellar dislocation after MPFL reconstruction. Patellar dislocation is a common knee injury, accounting for 2% to 3% of all knee injuries worldwide , 2. RecuAn appropriate exercise therapy after MPFL reconstruction is as important as the surgical process in the treatment of recurrent patellar dislocation given its vital effect on the recovery of the knee joint function; however, there is no consensus on the postoperative exercise therapy recommend . SeveralTherefore, this study was retrospectively performed on patients with recurrent patellar dislocation treated with MPFL reconstruction. The first purpose of this study was to compare the active and traditional postoperative exercise therapies on the recovery of knee joint function and reduction of muscle atrophy after MPFL reconstruction, and the second purpose was to compare the active and traditional postoperative exercise therapies on the patellar stability after MPFL reconstruction.This study was approved by the ethics committee of our hospital, and informed consent was obtained from each patient included in the research. The cases of patients with recurrent patellar dislocation who had undergone patella double semi-tunnel anatomical MPFL reconstruction between February 2016 and February 2019 were retrospectively reviewed.Q angle >20° (The inclusion criteria were as follows: (1) patellar dislocation occurred at least two times; (2) patellar instability following the initial dislocation persisted for more than three months; (3) magnetic resonance imaging indicated the injury, and even rupture, of the MPFL; (4) grade 1 or 2 focal articular cartilage defects according to the Outerbridge standard ; (5) patgle >20° ; (6) patgle >20° , and (8)gle >20° .The details of the surgical technique were described in our previous studies , 23. TheAll the patients were divided into the active exercise group and the traditional exercise group on the basis of the training schedule of the knee flexion. In the active exercise group, patients were required to start the knee flexion exercise 5 days postoperatively with the assistance of an adjustable brace  . The degWith respect to weight training, all patients began to gradually bear the body weight with the assistance of a brace 2 weeks postoperatively, and they would be permitted to bear full body weight at 4 weeks postoperatively. For strength training, ankle pump exercises were used to promote blood circulation and prevent thrombosis after surgery. The straight leg raise exercises started at the third day postoperatively, and the half-squat exercises started at 6 weeks postoperatively, and both of them stopped at 12 weeks postoperatively. Moreover, all the patients started the patella-shifting exercise by shifting the patella medially at 3 days postoperatively until the knee joint reached its full range of motion (ROM) at 8 weeks postoperatively to reduce the tension of the reconstructed MPFL and promote the healing of soft tissues.All patients could walk normally without the support of a brace at 8 weeks postoperatively. Patients could perform short-distance accelerated running and long-distance slow running at 12 weeks postoperatively. They could do normal physical exercise, such as running and rotational motion of the knee, at 26 weeks postoperatively.The ROM of the knee was measured using a universal goniometer. Thigh circumference was measured 5 cm above the patella superior border by using a medical ruler . Thigh ct-test or Mann-Whitney U test was used for the continuous variables, and the Fisher exact test was used for the categorical variables to determine the difference between the two groups. The paired sample t-test or Wilcoxon signed rank test was used to detect changes during the treatment for continuous variables for the same one patient. Normally distributed data were represented by mean ± standard deviation (SD), and non-normally distributed data were represented by a median with a range. A statistical difference was indicated by P < 0.05. All the analyses were performed using SPSS 20.0 .The independent sample n = 2), lost to the follow-up (n = 2), and insufficient data (n = 1). Finally, 31 patients were included in this study.A total of 36 patients underwent MPFL reconstruction for recurrent patellar dislocation in our hospital from February 2016 and February 2019. Among them, 5 patients were excluded from this study because of the following reasons: bilateral patellar dislocation (2. The median follow-up time was 30 months (range: 25–48 months). The active exercise group comprised 16 patients, while the conventional exercise group consisted of 15 patients. No significant difference was observed between two groups in terms of gender (P = 1.00), age (P = 0.90), surgical side (P = 0.72), BMI (P = 0.58), interval between the first dislocation and the surgery (P = 0.35), or follow-up time (P = 0.07). All patients completed the exercise plan, and there was no complication relevant to the exercise therapy during the regular follow-up, including recurrent dislocation and patellar instability.The demographic data of all the patients are provided in P > 0.05). Kujala score, Lysholm score, PTA, and LPFA improved considerably postoperatively compared with preoperatively (P < 0.05). Patients in the active exercise group had significantly higher Kujala score compared with those in the traditional exercise group 3 months postoperatively , 6 months postoperatively , 12 months postoperatively , and 24 months postoperatively . Similarly, patients in the active exercise group had significantly higher Lysholm score compared with those in the traditional exercise group 3 months postoperatively , 6 months postoperatively , 12 months postoperatively , and 24 months postoperatively . Moreover, the thigh circumference reduction in the active exercise group was significantly lower than that in the traditional exercise group 3 months postoperatively  and 6 months postoperatively , but the significant difference disappeared 12 months postoperatively (P = 0.32) and 24 months postoperatively (P = 0.20). However, no evident difference was observed between two groups in terms of PTA (P > 0.05) or LPFA (P > 0.05) postoperatively.The details of clinical outcomes are provided in Although different rehabilitation plans for improving the knee function after MPFL reconstruction have been proposed , 30, fewIn the current study, we used the traditional tunnel bioabsorbable interference screw to fix the femoral end of the ligament . SimilarPostoperative rehabilitation exercise plays a crucial role in the recovery of the knee joint function after MPFL reconstruction, however, no consensus exists regarding the exercise schedule , 17. On In recent years, an increasing number of studies have shown that early postoperative exercise helped patients return to their activity level before the injury by alleviating pain, reducing fluid accumulation, strengthening the quadriceps muscle and neuromuscular control, promoting healing, and preventing capsule contracture . Ronga eSeveral limitations should be considered when interpreting our results. First, the retrospective design might lead to selection bias, which reduced the accuracy of our results. Second, the sample size in the current study was relatively small, probably decreasing the stringency of the results. Third, follow-up time was relatively short for the assessment of PTA and LPFA, and a longer follow-up period is necessary to confirm our results. Forth, the factor of leg dominance was not considered when calculating the thigh circumference. Notably, we are conducting a prospective study that focuses on this topic with a larger sample size and a longer follow-up period. We believe our future results can eliminate the aforementioned limitations.Compared with traditional exercise, active exercise after MPFL reconstruction was beneficial for the early recovery of knee joint function and reduction of muscle atrophy in patients with recurrent patellar dislocation without harmful effects on the patellar stability.


The use of biologic therapies continues to become more prevalent in the treatment of inflammatory bowel disease, particularly for more severe disease. Although generally safe and effective, specific biologic classes such as tumor necrosis factor inhibitor (anti-TNF) medications are known to increase the risk of certain cancers. Glioblastoma multiforme (GBM) is an aggressive brain tumor which tends to arise sporadically but may be associated with anti-TNF therapies. Here, we present a case of a 69-year-old male with Crohn’s disease who developed GBM while on adalimumab therapy. This case report highlights the potential rare association between GBM and anti-TNF therapy and further discusses the difficulty of managing active Crohn’s disease with concomitant GBM, specifically the difficulty encountered in managing a disease flare. Biologics have rapidly gained favor in controlling inflammatory bowel disease (IBD), particularly moderate to severe Crohn’s disease (CD) due to their efficacy and favorable side effect profile when compared to corticosteroids and immunomodulators. In less than a decade, a large proportion of CD patients have received biologic therapy with a reported increase from 21.8% in 2007 to 43.8% in 2015 [Commonly prescribed tumor necrosis factor inhibitors (anti-TNF) currently available for the treatment of CD in the United States include infliximab (Remicade®), adalimumab (Humira®), and certolizumab (Cimzia®) -5. AlthoCurrently, the only known environmental factor linked to primary brain cancer is ionizing radiation . RecentlOur case pertains to a 69-year-old male with fibrostenotic ileal CD first diagnosed in 1995, status post ileocecectomy for small bowel obstruction (SBO) in 1997, and current therapy with weekly 40mg adalimumab since 2014. His other medical problems include cervicalgia which required surgery in the past, and a history of skin cancer . Outside of a handful of minor flares, his symptoms have been well controlled with adalimumab. In September 2020, he presented with symptoms of worsening right-sided hemiparesis and aphasia. Imaging obtained at the time revealed a left parietal mass which was confirmed as a GBM on MRI  were normal alongside a negative infectious workup and he had no nocturnal bowel movements, which he had during his previous flares. A short course of corticosteroids was given alongside of a psyllium fiber supplement. Due to complete symptomatic resolution within two weeks of initiating the aforementioned therapy, endoscopic evaluation was not completed and corticosteroids were discontinued. Fiber supplement was continued and it is thought his flare symptoms were due to concomitant irritable bowel syndrome with predominant diarrhea (IBS-D). He is currently not on any maintenance therapy for his CD, with symptoms still in remission.Anti-TNF therapies, such as adalimumab, are growing in use due to their effectiveness in treating CD. It is well reported in the literature that TNF is essential in the regulation of the immune system including deterring tumorigenesis. In vivo studies have shown inhibition of glioma cell growth with cellular transfection with the TNF-a gene suggesting TNF may play an essential role in reducing glioma progression ,10-13. TDespite a plethora of pharmacologic therapies available to include anti-TNF therapies, there are a substantial number of patients who show poor clinical response and never fully reach remission of their IBD symptoms . TherefoFortunately for our patient, his symptoms were found to be related to overlying IBS-D. His treatment options would have been limited in the case of an active CD flare. Corticosteroids are a temporary option that generally work within days to achieve a clinical response but their use should be limited due to numerous side effects. Other treatment options include immunomodulatory therapy such as methotrexate and 6-MP which can take weeks to take effect. Newer biologic therapies that do not work by the anti-TNF mechanism such as vedolizumab and ustekinumab are a consideration, but carry a theoretical risk of malignancy as well. Specifically, long-term data on the development of brain tumors is lacking with these agents and the frequency is not yet known. Lastly, these medications would also take weeks to take effect which limits their utility in an acute flare.If uncontrolled CD flare symptoms were to develop, it can result in complications and symptoms that may result in early termination of chemotherapy. GBM has a poor prognosis with a 2%, two-year survival rate for patients ≥ 65 years old [Our case highlights the rare development of GBM in an individual on anti-TNF therapy, which presents with both challenges in management and portends a poor overall prognosis; a potential association patients should be educated on. With their growing use in the IBD population, more patients on these therapies will be encountered by clinicians in all specialties. Clinicians should become very familiar with these therapies and maintain a high index of suspicion for their potential association with rare malignancies.


Mutation of plant homeodomain finger protein 6 (PHF6) occurs in approximately 3% of acute myeloid leukaemia (AML) cases. Although it was reported to be associated with poor prognosis, it was not confirmed by other groups. Recently, propensity score matching has provided an effective way to minimise bias by creating two groups that are well balanced with respect to baseline characteristics, providing more convincing results, which has an advantage, especially for rare subtype studies. To provide further evidence on the role of PHF6 mutation, we performed a retrospective propensity score‐matched cohort study to assess the therapeutic responses and survival outcomes of AML patients with PHF6 mutation compared with those without PHF6 mutation after balancing age, sex and risk categories.A total of 22 patients with PHF6 mutation from 801 consecutive newly diagnosed AML cases in our center were identified, and 43 patients with the PHF6 wild‐type genotype were successfully matched at a 1:2 ratio.AML harbouring PHF6 mutation was associated with a lower complete remission (CR) rate  and shorter median overall survival (OS)  and event‐free survival (EFS)  compared with PHF6 wild‐type patients. Further multivariate analysis supported that PHF6 mutation was an independent risk factor for overall survival in AML . In addition, allogeneic haematopoietic stem cell transplantation  seemed to ameliorate the poor prognosis of AML with PHF6 mutation in this study.Our data revealed that PHF6 mutation was associated with a lower chemotherapy response and shorter survival, suggesting that PHF6 mutation is a predictor of poor prognosis in AML. PHF6 mutation compared with those without PHF6 mutation after balancing age, sex and risk categories. Our data revealed that PHF6 mutation was associated with a lower chemotherapy response and shorter survival, suggesting that PHF6 mutation is a predictor of poor prognosis in AML.We performed a retrospective propensity score‐matched cohort study to assess the therapeutic responses and survival outcomes of AML patients with  Hence, identifying mutations that carry prognostic and therapeutic impacts (including PHF6) is a member of the plant homeodomain‐like finger family whose germline mutation was known to cause Börjeson‐Forssman‐Lehmann syndrome (BFLS).PHF6 somatic mutations have been recently identified in many haematologic malignancies, including approximately 20% of T‐ALL (T‐cell acute lymphoblastic leukaemia) and 3% of AML cases.PHF6 was suggested to be a tumour suppressor gene, and its loss synergizes with leukaemic lesions to promote the onset of T‐ALL.Plant homeodomain finger protein 6  and 442 AML patients without PHF6 mutation (PHF6wtAML) were included for matching.A total of 801 patients with AML admitted between April 1, 2016 and April 1, 2021 were screened from the database of Zhujiang Hospital of Southern Medical University. All cases were definitely diagnosed as AML, and mixed phenotype acute leukaemia was excluded according to the 2016 revision to the WHO classification of myeloid neoplasms and acute leukaemia.This retrospective, matched‐cohort study was approved by the Ethics Committees of Zhujiang Hospital of Southern Medical University.2.22/d or daunorubicin 45–60 mg/m2/d, d1–3; cytarabine 100–200 mg/m2/d, d1–7) were given as the initial induction therapy. For unfit de novo patients, low‐dose cytarabine‐based regimens  were given as the initial induction therapy. In addition, few patients only received hypomethylating agents as their induction regimen. Novel‐targeted drugs, such as ivosidenib, enasidenib, gilteritinib and venetoclax, were not applied because they were not available during the treatment period in this study. For patients assigned to poor prognosis groups according to risk categories, allo‐HSCT was conducted in their first remission if they had suitable donors. For patients assigned to the favourable group, four to six cycles of intermediate‐dose cytarabine  followed by autologous haematopoietic stem cell transplantation were given as consolidation. For patients assigned to intermediate prognosis groups, whether to perform allo‐HSCT after receiving complete remission (CR) depends on the physician's decision and the specific condition of the patients.For fit de novo patients, standard‐dose cytarabine‐based regimens , event‐free survival (EFS) and relapse‐free survival (RFS) were determined per the modified International Working Group criteria for AML.t test and Mann–Whitney U test were used to analyse differences in the distribution of variables between different groups. The balance of matching was assessed through standardised mean differences. Univariate conditional logistic regression and odds ratios (ORs) were used to evaluate treatment effects after matching. The Kaplan–Meier method with the log‐rank test was used to compare time‐to‐event variables. Multivariate Cox regression was applied to evaluate the association between patient characteristics and survival with hazard ratios (HRs). Statistical tests were two‐sided, and p < 0.05 was considered significant. IBM SPSS Statistics 25 (IBM), R v4.0.5 (R Development Core Team) and the R package MatchIt were used for statistical analyses.The chi‐square test, 33.1PHF6mutAML patients was 46.27 (20–69) and 59% (n = 13) were male. The risk categories included favourable , intermediate  and poor . What caught our attention was that more than half of the patients with PHF6 mutation were assigned to the poor prognosis group, and only 38% of patients without PHF6 mutation were assigned to the poor group. Thus, we constructed a propensity score‐matched analysis stratified by risk category as well as key baseline demographic characteristics (age at diagnosis and sex). All matched covariates had standardised mean differences <0.1 , KRAS mutation  and +11 , and no differences were found in the odds of having other prognosis‐related gene mutations and important chromosomal aberrations. In addition, we found no statistically significant differences in the choices of induction therapy or whether allo‐HSCT was performed.The clinical and laboratory characteristics of 22 PHF6 in lineage plasticity, we further described the immunophenotypic characteristics of leukaemic blasts in PHF6mutAML to explore whether these leukaemic blasts were accompanied by the expression of other lineage markers. In leukaemic blasts from PHF6mutAML, the most common myeloid differentiation antigens were CD33 , CD117 , CD13 , MPO , CD64  and CD15 . Nonlineage‐specific differentiation antigens included HLA‐DR , CD34 , CD38 , CD123  and TdT . Additionally, aberrant expression of lymphoid antigens, including CD56 , CD7 , CD22 , CD19  and cCD79a , was observed in some AML cases. cCD3, which is a powerful T‐lineage marker, was not detected in all cases.Given the role of 3.3PHF6 mutation. The CR rate was significantly lower in the PHF6mutAML cohort than in the PHF6wtAML cohort . However, the rate of minimal residual disease (MRD) by flow cytometry in those patients who achieved CR was similar between the two groups  (Table p = 0.316) showed no significant difference between PHF6mutAML and PHF6wtAML patients.First, the chemotherapy response was evaluated in patients with and without PHF6mutAML patients had a significantly shorter median OS than PHF6wtAML patients  . Similarly, the median EFS   between PHF6mutAML and PHF6wtAML patients.Second, we performed survival analysis. ) Figure , and the) Figure  was shorPHF6mutAML patients, which may be partly due to drug resistance. To date, the mechanism of PHF6 mutation‐mediated resistance in AML remains unknown; thus, further clinical and basic studies are urgently needed. Fortunately, allo‐HSCT may improve the prognosis of such patients. PHF6mutAML patients who received allo‐HSCT had a prolonged median OS compared to those only treated with chemotherapy , with no difference in EFS   and EFS , suggesting that allo‐HSCT may at least partly overcome the poor prognosis related to PHF6 mutation  Figure . Addition Figure .IDH2 mutation and KRAS mutation with PHF6 mutation, we also performed further survival analyses. The co‐mutation genotype did not show any difference in survival  with respect to IDH2 mutation. Additionally, survival outcomes for PHF6mut/KRASmutAML seemed worse than those without KRAS mutation . Aside from IDH2 mutation and KRAS mutation, we also added analyses of the effects of other concomitant mutations on survival in PHF6mutAML patients. These results showed that no other additional mutations were associated with clinical outcomes.Considering the co‐mutation tendency of 3.4For all 65 AML patients, the median OS was 27.0 months. To identify all factors that influenced survival, univariate and multivariate analyses were subsequently performed on all patients in our study.p = 0.012), −7/7q‐ (p = 0.019), PHF6 mutation (p < 0.001) and KRAS mutation (p < 0.001) were associated with reduced overall survival. Allo‐HSCT was associated with improved overall survival (p = 0.004). Characteristics significant in the univariate models at level 0.10 were included in the multivariate model. Multivariate analysis revealed that survival was adversely impacted by secondary AML , +8 , −7/7q‐  and PHF6 mutation . In contrast, treatment with allo‐HSCT  was a prognostic marker for improved OS.Univariate analysis revealed that +8 (3.5PHF6mutAML patients and 14 PHF6wtAML patients) who were assigned to the moderate prognosis group according to the ELN 2017 risk categories. Similar to the results of matched‐cohort analysis, we also found that PHF6mutAML patients had a significantly shorter median OS  and median EFS  than PHF6wtAML patients in intermediate‐risk AML   , ) Figure . However) Figure .4PHF6 encodes a chromatin remodelling protein that is involved in a variety of biological processes including lineage plasticity within haematopoietic malignancies.PHF6 played an important role in regulating chromatin accessibility to lineage‐specific transcription factors and that loss of Phf6 could result in disruption of lineage differentiation. Moreover, loss of Phf6 in leukaemia lymphoblasts activates a leukaemia stem cell transcriptional program and drives enhanced T‐ALL leukaemia‐initiating cell activity.PHF6mutAML has aberrant expression of lymphoid antigens, we have further described the immunophenotypic characteristics of leukaemic blasts. The results suggested that most of the leukaemic blasts in PHF6mutAML still showed a typical myeloid blast immunophenotype, and some aberrant expression of lymphoid antigens, including 41% expressed CD56, 37% expressed CD7 and 11% expressed CD19. We reported a lineage differentiation profile similar to previous studies which reported that CD56 (26%–41%) and CD7 (21–42%) were the most commonly expressed lymphoid markers in AML, whereas the incidence of positivity for the B‐cell‐associated markers (approximately 10% for CD19) was low.PHF6 is important for leukaemogenesis. Recent findings from Phf6 conditional knockout mouse models showed that the loss of Phf6 synergizes with leukaemic lesions, such as aberrant expression of TLX3, activating mutations in NOTCH1 or JAK3 activation to promote the onset of T‐ALL, demonstrating a tumour‐suppressive function for PHF6 in T‐ALL.PHF6 in AML has seldom been studied, and the clinical features and prognostic implications of PHF6 mutation in AML remain unclear. Thus, the clinical significance and biological function of PHF6 in AML have yet to be clarified. Our propensity score‐matched cohort study which identified 22 patients with PHF6 mutation from 801 AML patients contains the largest cases of PHF6 mutation in AML reported to date. Importantly, our survival analyses showed that PHF6 mutation was associated with inferior median EFS  and median OS  compared with PHF6 wild‐type patients. In addition, the results of univariate analysis and the subsequent multivariate analysis consistently supported that PHF6 mutation was associated with an adverse outcome. Similar results were obtained when the analysis was restricted to intermediate‐risk AML patients. These results were consistent with a previous study by Patel et al., which reported that PHF6 mutation was associated with adverse prognosis via univariate analysis.PHF6mut AML vs. 16.0 months in PHF6wtAML; p = 0.03) among AML patients habouring RUNX1 mutation.In addition, PHF6mutAML patients. In addition, allo‐HSCT in the first CR resulted in similar survival to that of patients with wild‐type PHF6. Thus, our study may provide some information for strategy decision making. Although patients in the intermediate prognosis group can either receive chemotherapy or allo‐HSCT for consolidation according to AML guidelines, our data suggested that PHF6 may be related to poor prognosis and that it may be better to perform allo‐HSCT for PHF6mutAML patients assigned to the intermediate prognosis group. Even for PHF6mutAML patients in the favourable prognosis group, more close monitoring of MRD during consolidation and after the end of therapy may be necessary.It is known that allo‐HSCT could be an effective therapeutic in intermediate and high‐risk AML. We also found that receipt of allo‐HSCT was correlated with improved median OS compared with those who did not receive allo‐HSCT in PHF6mutAML , although there were no significant differences in RFS or remission duration, which was partly due to the relatively small sample size. Besides, 63% of PHF6mutAML patients experienced relapse. As a matter of fact, in our AML cases, we used intermediate‐dose cytarabine (IDAC) for consolidation therapy. It was reported that high‐dose cytarabine (HiDAC) may lower relapse risk compared with IDAC for consolidation in favourable‐risk AML.PHF6mutAML, whether HiDAC can reduce relapse or improve survival in PHF6mutAML patients needs to be clarified in the further studies.Our data showed a trend for a shorter RFS in PHF6mutAML cohort than in the PHF6wtAML cohort . The data were consistent with Gaidzik et al.'s study in which the data of 246 AML patients with RUNX1 mutation were analysed. Among patients with different additional mutations, the chemotherapy response was lowest for patients with a genotype of RUNX1mut/PHF6mut .PHF6 mutation showed more chemotherapy resistance.What is more, our study reported a lower CR rate in the PHF6 mutation mediated drug resistance in T‐ALL. Depletion of PHF6 decreased the drug sensitivity of T‐ALL to prednisolone by repressing p21 expression, and cotreatment with a p21 inhibitor increased the sensitivity of T‐ALL cells to prednisolone.PHF6‐mediated drug resistance in AML remains unexplored. Our team found that significantly elevated levels of pre‐rRNA were observed in clinical AML patients with PHF6 mutation and loss of PHF6 may promote rDNA transcription to mediate chemotherapy resistance by regulating histone epigenetic modification of rDNA loci (data not shown). We believe that further detailed mechanistic studies may help to identify novel therapeutic targets for PHF6 mutant AML patients.It was reported that Finally, although propensity score matching could provide an effective way to minimise bias, our study still has some limitations due to its retrospective and single‐centre nature. Moreover, the number of enrolled cases was relatively small. These findings need to be validated in large, homogeneously treated, multicentre cohorts of patients with AML in the future.PHF6 mutant and wild‐type AML patients in our AML cohort from a series of 801 cases and identified 22 PHF6mutAML cases and 43 matched PHF6wtAML cases. Our data demonstrated that patients with AML harbouring PHF6 mutation had a lower CR rate to induction chemotherapy and shorter overall survival. Furthermore, PHF6mutAML and PHF6wtAML patients who received allo‐HSCT showed comparable OS. Our study suggests that PHF6 mutation may be related to poor prognosis, and the detection of PHF6 mutation in AML would tend to support the selection of more active treatments.In summary, we performed a propensity score matching study for Kexiu Huang and Rui Huang contributed to the study design, Kexiu Huang, Lei Wang, Yaling Zheng and Chunyan Yue were involved in the collection and assembly of clinical data. Kexiu Huang and Xuedan Xu performed data analysis and wrote the manuscript. Hongbo Chen, Rui Huang and Yuhua Li supervised the study.This work was supported by the National Natural Science Foundation of China  and Natural Science Foundation of Guangdong Province, China (grant number: 2020A1515011465).The authors declare no conflicts of interest.The study was approved by the Ethics Committees of Zhujiang Hospital of Southern Medical University.Figure S1Click here for additional data file.


Inflammatory responses are involved in ischemic injuries and cardiac repair after acute myocardial infarction (AMI). Dectin-2 is a C-type lectin receptor that induces cytokine production and promotes local inflammatory responses. α (TNF-α), interferon-gamma (IFN)-γ, interleukin (IL) 4, and IL-5 levels in the serum were determined using ELISAs.  Sixty C57BL/6 mice were randomly assigned to a sham-surgery group, AMI group, or AMI + etanercept group, with 20 mice in each group. Programmed electrical stimulation (PES) was used to anesthetized mice to induce ventricular tachycardia. Real-time polymerase chain reaction (PCR) and western blot analysis were adopted to determine the expression and distribution of dectin-2 in heart tissues. The tumor necrosis factor-α was increased in the myocardium in AMI, and the susceptibility to ventricular arrhythmia (VA) was increased. The induction rate of VA was significantly decreased by etanercept. Compared with those in the sham-surgery group, the AMI group showed significantly higher serum TNF-α and IFN-γ levels and lower IL-4 and IL-5levels.  The expression of dectin-2 and TNF-α immune reaction through the Th1 differentiation, which may increase vulnerability to VA in AMI. Dectin-2 intensifies the activation of the TNF- Acute myocardial infarction (AMI) is a condition of acute ischemic necrosis of the myocardium. Modern medicine suggests that patients with AMI usually exist with a certain degree of the pathological basis for coronary artery disease. At the onset of AMI, patients exhibit a dramatic reduction or interruption of coronary blood supply, which leads to a severe and persistent acute ischemia of the myocardium and eventually myocardial necrosis , 2. Epidγ (IFN-γ) level , may also explicate the beginning of re-entrant VT in these mice [2+-dependent processes via cAMP- or calmodulin-dependent kinases may influence the occurrence of arrhythmia [TNF-actility . These rncreased . These aese mice . Alternarhythmia .2+ treatment, the main reason for APD prolongation is a decreased expression of several K+ channels, leading to arrhythmia in TNF mice, which was similar to previous research results. The results showed that the attenuation of transient outward K+ current in TNF mice was similar to that reported by Ito in heart failure patients and similar to that in a rat heart failure model and spontaneous arrhythmia [+ current observed in TNF mouse ventricular myocytes seems to contribute partially to the increase in APD that was previously measured with optical localization. Transgenic mice overexpressing the mutant Kv2.x a-subunit had prolonged APD and spontaneous arrhythmia due to a lack of IK and slow2 [In addition to abnormal Carhythmia . The decnd slow2 .2+ plasma channels and the generation of K+ channel action potentials, which may lead to VA.The changes in the electrical properties of these marker cells indicate that the overexpression of TNF cells leads to the remodeling of Caγ, TNF-α, granulocyte-macrophage colony-stimulating factor, and IL-17A), which activate neutrophils, monocytes, macrophages, and dendritic cells to remove fungi [Candida albicans and Aspergillus fumigatus [γ production after Streptococcus pneumoniae infection [α and IFN-γ was increased, whereas the levels of IL-4 and IL-5 were decreased in the AMI group. The expression of TNF-α, IFN-γ, and transcription factors is responsible for Th1 differentiation, and the expression of IL-4, IL-5, and transcription factors is responsible for Th2 differentiation. Interleukin 1β (IL-1β) promotes the inflammatory response and exacerbates the disease. TNF-α is critical in the inflammatory response and is an important mediator of inflammation [α and IFN-γ expression to promote the local inflammatory response by modulating Th1 differentiation in a mouse AMI model. IL-1, IL-1β, and TNF-1 levels are locally increased, and thus the inhibition of the production of such inflammatory vesicles might be effective in preventing and attenuating the myocardial inflammatory response and protecting myocardial tissue in mice with acute myocardial infarction [As a C-type lectin receptor, dectin-2 is expressed in various myeloid cells and promotes the local inflammatory response. Dectin-2 triggers the production of many kinds of cytokines and chemokines, with proinflammatory Th1, Th17, and Th2 cytokines included . CD4+ T ve fungi . Dectin-ve fungi . Dectin-umigatus . Dectin-nfection . Dectin-nfection . It alsonfection . Dectin-ammation . This stfarction .α pathway in mediating inflammatory markers to affect disease prognosis.Despite ongoing studies on acute myocardial infarction , 41, theα in the myocardium and serum is increased and susceptibility to VA is increased in AMI mice. However, the expression of TNF-α in the myocardium and serum is decreased, and the incidence of VA after PES is lower in AMI + etanercept mice than that in AMI mice. The AMI mice showed increased serum levels of TNF-α and IFN-γ and decreased levels of IL-4 and IL-5. It is possible that dectin-2 increases activation of the TNF-α-mediated immune reaction by modulating Th1 differentiation, which may increase vulnerability to VA in the hearts of AMI mice.The expression of dectin-2 is increased in the myocardial tissue of AMI mice. Compared with the sham-surgery mice, the expression of TNF-


Historically, only patients with a left ventricular ejection fraction (LVEF) of less than or equal to 40% were considered to have heart failure (HF). However, it was later found that patients could have elevated cardiac filling pressures and the stigmata of HF signs and symptoms with normal LVEF. This subset of patients has undergone multiple taxonomical variations and is now termed heart failure with preserved ejection fraction (HFpEF) with the lower limit of LVEF assigned as roughly ≥40%–50% in clinical trials and ≥50% in HF guidelines. Patients with LVEF 41%–49% did not clearly fit these designations but bear resemblance to both heart failure with reduced ejection fraction (HFrEF) and HFpEF. This cohort was initially assigned the term HFpEF (borderline), which has also undergone several modifications and is currently termed heart failure with mildly reduced ejection fraction (HFmrEF). Earlier landmark HF trials were heavily focused on patients with HFrEF. Only in the last 2 decades has there been an increasing focus on HFpEF with emergence of key drug therapies including sodium‐glucose cotransport‐2 inhibitors that have shown to improve outcomes across the whole LVEF spectrum. There is yet to be a focused clinical trial to determine therapeutic modalities for HFmrEF; most of the evidence has been extrapolated from subgroup analysis mostly from HFpEF trials. In this review, we provide an overview of the historical basis of HFpEF and HFmrEF and discuss key therapeutic advances in their management. The LVEF cutoffs for heart failure with reduced ejection fraction (HFrEF) have not changed much since randomized controlled trials first started using LVEF as a parameter for HF diagnosis and trial enrollment, the first of which was the Veterans Administration Cooperative Study (V‐HeFT‐I) in 1986.Clinical trials for HFpEF have used varying cutoffs for enrollment; most have denoted a cutoff of >40%–50%,2The prevalence of different HF phenotypes follows a bimodal distribution in the general population. The majority of patients fall in the HFrEF and HFpEF subgroups with a relatively smaller percentage in the HFmrEF subgroup.3HFmrEF has mixed characteristics to both HFrEF and HFpEF, although it does bear more similarities with HFrEF. In observational studies performed in the US, HFmrEF was found to have similar age distribution, body mass index, and prevalence of hypertension and atrial fibrillation to HFpEF; however, distribution of sex and prevalence of ischemic heart disease resembled that of HFrEF.N‐terminal pro‐B type natriuretic peptide (NT‐proBNP) and serum norepinephrine, markers of neurohormonal activation and sympathetic activity, in HFmrEF were found to be similar to HFpEF with significantly higher levels observed in HFrEF.Treatment response to neurohormonal antagonism in HFmrEF (as discussed below) also suggests a similarity in pathophysiology to HFrEF. However, the circulating levels of 4HFpEF remains a considerably difficult diagnosis to manage owing to its multifaceted etiology, ranging from cardiovascular risk factors like hypertension, diabetes mellitus, and chronic kidney disease to infiltrative disorders like amyloidosis and sarcoidosis primarily causing diastolic dysfunction. Until recently, there had been a dearth of major clinical trials of pharmacological therapies for HFpEF. Management strategies focused only on targeted optimization of treatment of culprit risk factors for example, drug therapy for blood pressure control and as‐needed use of diuretics for HF exacerbation episodes to ensure optimization of patient's volume status. Although there have been several successful clinical trials for HFpEF in the past 20 years which has led to a paradigm shift in its treatment, there is no current therapy that significantly improves mortality. In contrast, there have been no dedicated clinical trials for HFmrEF thus far given its relatively recent emergence as a clinically meaningful entity. Most of the evidence for beneficial pharmacological therapy has been derived from subgroup analysis cohorts with LVEF 41%–49% from existing HFrEF and HFpEF trials4.1The CHARM preserved trial4.2A patient‐level meta‐analysis4.3>40% for a primary composite endpoint of HF hospitalizations and cardiovascular mortality.The treatment of preserved cardiac function with aldosterone antagonist4.4In the prospective comparison of angiotensin receptor–neprilysin inhibitor (ARNI) with ARB on the management of heart failure with preserved ejection fraction (PARAMOUNT)4.5More recently, the empagliflozin outcome trial in patients with chronic heart failure with preserved ejection fraction (EMPEROR‐Preserved)5Data for the efficacy of device therapy in HF patients with higher LVEF is limited. Device therapies are usually aimed at supplementing cardiac contractility during systole  and aborting fatal arrhythmias (implantable cardioverter‐defibrillator). HFmrEF does have a component of systolic dysfunction and can potentially benefit from device therapies. A posthoc analysis from the predictors of response to cardiac resynchronization therapy trial6Figure 7HFpEF has garnered greater recognition over the past 2 decades and has prompted several dedicated randomized controlled trials. HFmrEF is still of growing interest as it exhibits overlapping features of both HFrEF and HFpEF of varying degrees in different populations. Although there have been multiple drug therapies that have shown to ameliorate adverse clinical outcomes in HFpEF, most of the observed benefit seems to be concentrated in patients with LVEF at the lower end of the spectrum of preserved EF and in patients with mildly reduced EF. There is growing evidence of the efficacy of neurohormonal antagonism in HFmrEF that may suggest that it is an extension of the HFrEF spectrum which has long been excluded from HFrEF trials. It would be of interest to speculate whether HFmrEF will be treated as a separate entity with its own dedicated trials or finally be merged with LVEF ≤40% group in HFrEF in future trials.Javed Butler is a consultant to Abbott, Adrenomed, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol‐Myers Squib, CVRx, G3 Pharmaceutical, Innolife, Janssen, LivaNova, Luitpold, Medtronic, Merck, Novartis, Novo Nordisk, Relypsa, Roche, and Vifor. Khawaja M. Talha declares no conflict of interest.