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Zhu L, Bao Y, Liu Z, Liu J, Li Z, Sun X, Zhou A, Wu H. Gualou-Xiebai herb pair ameliorate atherosclerosis in HFD-induced ApoE -/- mice and inhibit the ox-LDL-induced injury of HUVECs by regulating the Nrf2-mediated ferroptosis. JOURNAL OF ETHNOPHARMACOLOGY 2024; 326:117892. [PMID: 38350505 DOI: 10.1016/j.jep.2024.117892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/30/2024] [Accepted: 02/06/2024] [Indexed: 02/15/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Atherosclerosis (AS) is a chronic vascular ailment characterized by inflammatory and lipid deposition in the arterial wall caused by endothelial injury. Ferroptosis is a novel type of cell death, and endothelial ferroptosis is a significant contributor to the progression of AS. Gualou-Xiebai (GLXB) is a renowned Chinese herb pair that serves a crucial function in treating AS. However, whether the underlying mechanism of GLXB plays a role in anti-atherosclerotic effects by inhibiting ferroptosis in endothelial cells has not been determined. AIM OF THE STUDY To explore the influence of GLXB on endothelial ferroptosis and determine its underlying mechanism of action in AS. MATERIALS AND METHODS In ApoE-/- mice, ultrasound was performed in mice fed a high-fat diet (HFD) for 12 weeks to assess the success of AS establishment. Then, ApoE-/- mice were treated with GLXB and Simvastatin (positive control) for 4 weeks. The effects of GLXB on AS pathology were assessed through aorta imaging and hematoxylin-eosin (HE) staining. To confirm the presence of ferroptosis, mitochondrial damage was observed using transmission electron microscope (TEM), along with analysis of free iron and lipid peroxidation levels. In vitro: ox-LDL-induced human vascular endothelial cells (HUVECs) injury and treated with GLXB, the ferroptosis inducer Erastin and an Nrf2 inhibitor ML385. Cell viability was evaluated using the CCK-8 assay in all groups. Flow cytometry was employed to detect lipid peroxidation and intracellular ferrous iron levels. Immunofluorescence staining microscopy verified Nrf2 nuclear translocation. Protein expression were measured by Western blot analysis. RESULTS GLXB improved atherosclerotic aortic lesions and vascular plaques. GLXB inhibited endothelial injury in the aorta by decreasing the levels of inflammatory factors and adhesion factors, and by decreasing the shedding of endothelial cells. GLXB suppressed ferroptosis in ApoE-/- mice by attenuating mitochondrial damage in ECs, increasing the levels of glutathione (GSH) and superoxide dismutase (SOD) in aortic tissues and down-regulating the levels of levels of lipid peroxide (LPO) and malondialdehyde (MDA). Interestingly, Erastin was used to demonstrate in vitro that GLXB inhibition of ferroptosis attenuated ox-LDL-induced injuring effects on HUVECs that were reversed by Erastin. Mechanistically, GLXB activates the Nrf2 signaling pathway to inhibit ferroptosis by increasing downstream anti-ferroptosis target proteins and promoting the interaction between Nrf2 and SLC7A11. More convincingly, ML385 (Nrf2 inhibitor) reversed the anti-ferroptosis effect of GLXB. CONCLUSION GLXB inhibits ferroptosis-mediated endothelial cell injury via activating the Nrf2 signaling pathway and further alleviates AS pathological damage.
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Affiliation(s)
- Li Zhu
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, 230012, China; The Experimental Research Center, Anhui University of Chinese Medicine, Hefei, 230038, China
| | - Youli Bao
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, 230012, China; The Experimental Research Center, Anhui University of Chinese Medicine, Hefei, 230038, China
| | - Zijian Liu
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, 230012, China; The Experimental Research Center, Anhui University of Chinese Medicine, Hefei, 230038, China
| | - Jiahui Liu
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, 230012, China; The Experimental Research Center, Anhui University of Chinese Medicine, Hefei, 230038, China
| | - Zhenglong Li
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, 230012, China; The Experimental Research Center, Anhui University of Chinese Medicine, Hefei, 230038, China
| | - Xin Sun
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, 230012, China; The Experimental Research Center, Anhui University of Chinese Medicine, Hefei, 230038, China
| | - An Zhou
- The Experimental Research Center, Anhui University of Chinese Medicine, Hefei, 230038, China; Anhui Province Key Laboratory of Research & Development of Chinese Medicine, Hefei, 230012, China.
| | - Hongfei Wu
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, 230012, China; The Experimental Research Center, Anhui University of Chinese Medicine, Hefei, 230038, China; Anhui Province Key Laboratory of Research & Development of Chinese Medicine, Hefei, 230012, China.
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Liu H, Nie H, Shi Y, Lai W, Bian L, Tian L, Li K, Xi Z, Lin B. Oil mistparticulate matter exposure induces hyperlipidemia-related inflammation via microbiota/ SCFAs/GPR43 axis inhibition and TLR4/NF-κB activation. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2024; 344:123331. [PMID: 38199482 DOI: 10.1016/j.envpol.2024.123331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/22/2023] [Accepted: 01/07/2024] [Indexed: 01/12/2024]
Abstract
Metabolites produced by the human gut microbiota play an important role in fighting and intervening in inflammatory diseases. It remains unknown whether immune homeostasis is influenced by increasing concentrations of air pollutants such as oil mist particulate matters (OMPM). Herein, we report that OMPM exposure induces a hyperlipidemia-related phenotype through microbiota dysregulation-mediated downregulation of the anti-inflammatory short-chain fatty acid (SCFA)-GPR43 axis and activation of the inflammatory pathway. A rat model showed that exposure to OMPM promoted visceral and serum lipid accumulation and inflammatory cytokine upregulation. Furthermore, our research indicated a reduction in both the "healthy" microbiome and the production of SCFAs in the intestinal contents following exposure to OMPM. The SCFA receptor GPR43 was downregulated in both the ileum and white adipose tissues (WATs). The OMPM treatment mechanism was as follows: the gut barrier was compromised, leading to increased levels of lipopolysaccharide (LPS). This increase activated the Toll-like receptor 4 Nuclear Factor-κB (TLR4-NF-κB) signaling pathway in WATs, consequently fueling hyperlipidemia-related inflammation through a positive-feedback circuit. Our findings thus imply that OMPM pollution leads to hyperlipemia-related inflammation through impairing the microbiota-SCFAs-GPR43 pathway and activating the LSP-induced TLR4-NF-κB cascade; our findings also suggest that OMPM pollution is a potential threat to humanmicrobiota dysregulation and the occurrence of inflammatory diseases.
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Affiliation(s)
- Huanliang Liu
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China; Tianjin Key Laboratory of Risk Assessment and Control Technology for Environment & Food Safety, Tianjin, 300050, China.
| | - Huipeng Nie
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China; Tianjin Key Laboratory of Risk Assessment and Control Technology for Environment & Food Safety, Tianjin, 300050, China
| | - Yue Shi
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China; Tianjin Key Laboratory of Risk Assessment and Control Technology for Environment & Food Safety, Tianjin, 300050, China
| | - Wenqing Lai
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China; Tianjin Key Laboratory of Risk Assessment and Control Technology for Environment & Food Safety, Tianjin, 300050, China
| | - Liping Bian
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China; Tianjin Key Laboratory of Risk Assessment and Control Technology for Environment & Food Safety, Tianjin, 300050, China
| | - Lei Tian
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China; Tianjin Key Laboratory of Risk Assessment and Control Technology for Environment & Food Safety, Tianjin, 300050, China
| | - Kang Li
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China; Tianjin Key Laboratory of Risk Assessment and Control Technology for Environment & Food Safety, Tianjin, 300050, China
| | - Zhuge Xi
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China; Tianjin Key Laboratory of Risk Assessment and Control Technology for Environment & Food Safety, Tianjin, 300050, China
| | - Bencheng Lin
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China; Tianjin Key Laboratory of Risk Assessment and Control Technology for Environment & Food Safety, Tianjin, 300050, China.
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Zhou LJ, Lin WZ, Meng XQ, Zhu H, Liu T, Du LJ, Bai XB, Chen BY, Liu Y, Xu Y, Xie Y, Shu R, Chen FM, Zhu YQ, Duan SZ. Periodontitis exacerbates atherosclerosis through Fusobacterium nucleatum-promoted hepatic glycolysis and lipogenesis. Cardiovasc Res 2023; 119:1706-1717. [PMID: 36943793 DOI: 10.1093/cvr/cvad045] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 12/06/2022] [Accepted: 01/20/2023] [Indexed: 03/23/2023] Open
Abstract
AIMS Positive associations between periodontitis (PD) and atherosclerosis have been established, but the causality and mechanisms are not clear. We aimed to explore the causal roles of PD in atherosclerosis and dissect the underlying mechanisms. METHODS AND RESULTS A mouse model of PD was established by ligation of molars in combination with application of subgingival plaques collected from PD patients and then combined with atherosclerosis model induced by treating atheroprone mice with a high-cholesterol diet (HCD). PD significantly aggravated atherosclerosis in HCD-fed atheroprone mice, including increased en face plaque areas in whole aortas and lesion size at aortic roots. PD also increased circulating levels of triglycerides and cholesterol, hepatic levels of cholesterol, and hepatic expression of rate-limiting enzymes for lipogenesis. Using 16S ribosomal RNA (rRNA) gene sequencing, Fusobacterium nucleatum was identified as the most enriched PD-associated pathobiont that is present in both the oral cavity and livers. Co-culture experiments demonstrated that F. nucleatum directly stimulated lipid biosynthesis in primary mouse hepatocytes. Moreover, oral inoculation of F. nucleatum markedly elevated plasma levels of triglycerides and cholesterol and promoted atherogenesis in HCD-fed ApoE-/- mice. Results of RNA-seq and Seahorse assay indicated that F. nucleatum activated glycolysis, inhibition of which by 2-deoxyglucose in turn suppressed F. nucleatum-induced lipogenesis in hepatocytes. Finally, interrogation of the molecular mechanisms revealed that F. nucleatum-induced glycolysis and lipogenesis by activating PI3K/Akt/mTOR signalling pathway in hepatocytes. CONCLUSIONS PD exacerbates atherosclerosis and impairs lipid metabolism in mice, which may be mediated by F. nucleatum-promoted glycolysis and lipogenesis through PI3K/Akt/mTOR signalling in hepatocytes. Treatment of PD and specific targeting of F. nucleatum are promising strategies to improve therapeutic effectiveness of hyperlipidaemia and atherosclerosis.
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Affiliation(s)
- Lu-Jun Zhou
- Department of General Dentistry, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
- Laboratory of Oral Microbiota and Systemic Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Pudong New District, Shanghai 200125, China
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
| | - Wen-Zhen Lin
- Department of General Dentistry, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
- Laboratory of Oral Microbiota and Systemic Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Pudong New District, Shanghai 200125, China
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
| | - Xiao-Qian Meng
- Laboratory of Oral Microbiota and Systemic Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Pudong New District, Shanghai 200125, China
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
| | - Hong Zhu
- Laboratory of Oral Microbiota and Systemic Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Pudong New District, Shanghai 200125, China
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
| | - Ting Liu
- Laboratory of Oral Microbiota and Systemic Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Pudong New District, Shanghai 200125, China
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
| | - Lin-Juan Du
- Laboratory of Oral Microbiota and Systemic Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Pudong New District, Shanghai 200125, China
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
| | - Xue-Bing Bai
- Department of General Dentistry, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
- Laboratory of Oral Microbiota and Systemic Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Pudong New District, Shanghai 200125, China
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
| | - Bo-Yan Chen
- Laboratory of Oral Microbiota and Systemic Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Pudong New District, Shanghai 200125, China
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
| | - Yan Liu
- Laboratory of Oral Microbiota and Systemic Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Pudong New District, Shanghai 200125, China
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
| | - Yuanzhi Xu
- Department of Stomatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Yufeng Xie
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
- Department of Periodontology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Rong Shu
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
- Department of Periodontology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Fa-Ming Chen
- State Key Laboratory of Military Stomatology and National Clinical Research Center for Oral Diseases, Department of Periodontology, School of Stomatology, Fourth Military Medical University, Xi'an 710032, China
| | - Ya-Qin Zhu
- Department of General Dentistry, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
| | - Sheng-Zhong Duan
- Laboratory of Oral Microbiota and Systemic Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, 115 Jinzun Road, Pudong New District, Shanghai 200125, China
- National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Huangpu District, Shanghai 200011, China
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Gusev E, Sarapultsev A. Atherosclerosis and Inflammation: Insights from the Theory of General Pathological Processes. Int J Mol Sci 2023; 24:ijms24097910. [PMID: 37175617 PMCID: PMC10178362 DOI: 10.3390/ijms24097910] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
Recent advances have greatly improved our understanding of the molecular mechanisms behind atherosclerosis pathogenesis. However, there is still a need to systematize this data from a general pathology perspective, particularly with regard to atherogenesis patterns in the context of both canonical and non-classical inflammation types. In this review, we analyze various typical phenomena and outcomes of cellular pro-inflammatory stress in atherosclerosis, as well as the role of endothelial dysfunction in local and systemic manifestations of low-grade inflammation. We also present the features of immune mechanisms in the development of productive inflammation in stable and unstable plaques, along with their similarities and differences compared to canonical inflammation. There are numerous factors that act as inducers of the inflammatory process in atherosclerosis, including vascular endothelium aging, metabolic dysfunctions, autoimmune, and in some cases, infectious damage factors. Life-critical complications of atherosclerosis, such as cardiogenic shock and severe strokes, are associated with the development of acute systemic hyperinflammation. Additionally, critical atherosclerotic ischemia of the lower extremities induces paracoagulation and the development of chronic systemic inflammation. Conversely, sepsis, other critical conditions, and severe systemic chronic diseases contribute to atherogenesis. In summary, atherosclerosis can be characterized as an independent form of inflammation, sharing similarities but also having fundamental differences from low-grade inflammation and various variants of canonical inflammation (classic vasculitis).
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Affiliation(s)
- Evgenii Gusev
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Science, 620049 Ekaterinburg, Russia
| | - Alexey Sarapultsev
- Institute of Immunology and Physiology, Ural Branch of the Russian Academy of Science, 620049 Ekaterinburg, Russia
- Russian-Chinese Education and Research Center of System Pathology, South Ural State University, 454080 Chelyabinsk, Russia
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Huang JG, Tang X, Wang JJ, Liu J, Chen P, Sun Y. A circular RNA, circUSP36, accelerates endothelial cell dysfunction in atherosclerosis by adsorbing miR-637 to enhance WNT4 expression. Bioengineered 2021; 12:6759-6770. [PMID: 34519627 PMCID: PMC8806706 DOI: 10.1080/21655979.2021.1964891] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Atherosclerosis is a fatal disorder that is fundamental to various cardiovascular diseases and severely threatens people’s health worldwide. Several studies have demonstrated the role of circular RNAs (circRNAs) in the pathogenesis of atherosclerosis. circUSP36 acts as a key modulator in the progression of atherosclerosis, but the molecular mechanism underlying this role is as yet unclear. This study aimed to elucidate the mechanism by which circUSP36 exerts its function in an in vitro cell model of endothelial cell dysfunction, which is one of pathological features of atherosclerosis. The circRNA traits of circUSP36 were confirmed, and we observed high expression of circUSP36 in endothelial cells exposed to oxidized low-density lipoprotein (ox-LDL). Functional assays revealed that overexpression of circUSP36 suppressed proliferation and migration of ox-LDL-treated endothelial cells. In terms of its mechanism, circUSP36 adsorbed miR-637 by acting as an miRNA sponge. Moreover, enhanced expression of miR-637 abated the impact of circUSP36 on ox-LDL-treated endothelial cell dysregulation. Subsequently, the targeting relationship between miR-637 and WNT4 was predicted using bioinformatics tools and was confirmed via luciferase reporter and RNA pull-down assays. Notably, depletion of WNT4 rescued circUSP36-mediated inhibition of endothelial cell proliferation and migration. In conclusion, circUSP36 regulated WNT4 to aggravate endothelial cell injury caused by ox-LDL by competitively binding to miR-637; this finding indicates circUSP36 to be a promising biomarker for the diagnosis and therapy of atherosclerosis.
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Affiliation(s)
- Jian-Guo Huang
- Department of Vascular Surgery, Linyi Central Hospital, Linyi, Shandong Province, China
| | - Xia Tang
- Department of Vascular Surgery, Linyi Central Hospital, Linyi, Shandong Province, China
| | - Jiang-Jie Wang
- Department of Vascular Surgery, Linyi Central Hospital, Linyi, Shandong Province, China
| | - Jia Liu
- Department of Vascular Surgery, Linyi Central Hospital, Linyi, Shandong Province, China
| | - Ping Chen
- Department of Vascular Surgery, Linyi Central Hospital, Linyi, Shandong Province, China
| | - Yan Sun
- Department of Mental Health, Yishui People's Hospital, Linyi, Shandong Province, China
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