Effects of artificial intelligence assistance on endoscopist performance: Comparison of diagnostic performance in superficial esophageal squamous cell carcinoma detection using video-based models

Objectives

Superficial esophageal squamous cell carcinoma (ESCC) detection is crucial. Although narrow-band imaging improves detection, its effectiveness is diminished by inexperienced endoscopists. The effects of artificial intelligence (AI) assistance on ESCC detection by endoscopists remain unclear. Therefore, this study aimed to develop and validate an AI model for ESCC detection using endoscopic video analysis and evaluate diagnostic improvements.

Methods

Endoscopic videos with and without ESCC lesions were collected from May 2020 to January 2022. The AI model trained on annotated videos and 18 endoscopists (eight experts, 10 non-experts) evaluated their diagnostic performance. After 4 weeks, the endoscopists re-evaluated the test data with AI assistance. Sensitivity, specificity, and accuracy were compared between endoscopists with and without AI assistance.

Results

Training data comprised 280 cases (140 with and 140 without lesions), and test data, 115 cases (52 with and 63 without lesions). In the test data, the median lesion size was 14.5 mm (range: 1-100 mm), with pathological depths ranging from high-grade intraepithelial to submucosal neoplasia. The model's sensitivity, specificity, and accuracy were 76.0%, 79.4%, and 77.2%, respectively. With AI assistance, endoscopist sensitivity (57.4% vs. 66.5%) and accuracy (68.6% vs. 75.9%) improved significantly, while specificity increased slightly (87.0% vs. 91.6%). Experts demonstrated substantial improvements in sensitivity (59.1% vs. 70.0%) and accuracy (72.1% vs. 79.3%). Non-expert accuracy increased significantly (65.8% vs. 73.3%), with slight improvements in sensitivity (56.1% vs. 63.7%) and specificity (81.9% vs. 89.2%).

Conclusions

AI assistance enhances ESCC detection and improves endoscopists' diagnostic performance, regardless of experience.

Novel digital droplet inverse PCR assay shows that natural clearance of hepatitis B infection is associated with fewer viral integrations

Hepatitis B virus (HBV) DNA integration into the host cell genome is reportedly a major cause of liver cancer, and a source of hepatitis B surface antigen (HBsAg). High HBsAg levels can alter immune responses which therefore contributes to the progression of HBV-related disease. However, to what extent integration leads to the persistent circulating HBsAg is unclear. Here, we aimed to determine if the extent of HBV DNA integration is associated with the persistence of circulating HBsAg in people exposed to HBV. We established a digital droplet quantitative inverse PCR (dd-qinvPCR) method to quantify integrated HBV DNA in patients who had been exposed to HBV (anti-HBc positive and HBeAg-negative). Total DNA extracts from both liver resections (n = 32; 14 HBsAg-negative and 18 HBsAg-positive) and fine-needle aspirates (FNA, n = 10; 2 HBsAg-negative and 8 HBsAg-positive) were analysed. Using defined in vitro samples for assay establishment, we showed that dd-qinvPCR could detect integrations within an input of <80 cells. The frequency of integrated HBV DNA in those who had undergone HBsAg loss (n = 14, mean ± SD of 1.514 × 10-3 ± 1.839 × 10-3 integrations per cell) was on average 9-fold lower than those with active HBV infection (n = 18, 1.16 × 10-2 ± 1.76 × 10-2 integrations per cell; p = 0.0179). In conclusion, we have developed and validated a highly precise, sensitive and quantitative PCR-based method for the quantification of HBV integrations in clinical samples. Natural clearance of HBV is associated with fewer viral integrations. Future studies are needed to determine if dynamics of integrated HBV DNA can inform the development of curative therapies.

Innate immune recognition in hepatitis B virus infection

Hepatitis B virus (HBV) remains a major global public health challenge, with approximately 254 million individuals chronically infected worldwide. The interaction between HBV and the innate immune system has garnered significant attention within the scientific community, with numerous studies exploring this relationship over the past several decades. While some research suggests that HBV infection activates the host's innate immune response, other studies indicate that HBV suppresses innate immune signaling pathways. These conflicting findings underscore the complexity of the HBV-innate immunity interaction, which remains inadequately understood. This review aims to clarify this interplay by examining it from three perspectives: (a) studies showing HBV activation of innate immunity; (b) evidence suggesting HBV suppression of innate immunity; and (c) findings that support HBV's role as a stealth virus. By synthesizing these perspectives, we aim to deepen the understanding of virus-host interactions that are crucial to HBV persistence and immune evasion, with potential implications for developing new therapeutic strategies for chronic HBV infection.

Patient and physician preferences for treatment of hepatitis C virus infection in Japan: a discrete choice experiment

AIMS

This study was performed to evaluate patients' and physicians' preferences regarding hepatitis C virus (HCV) treatment in Japan, particularly focusing on direct-acting antivirals. Understanding these preferences is important for maintaining adherence to treatment necessary for achieving HCV elimination.

METHODS

A discrete choice experiment was conducted to identify patients' and physicians' preferences for HCV treatment in Japan. Eligible participants completed a preference survey via an online questionnaire. Eight attributes and their respective levels - pertaining to dosing regimen/schedule, safety, and out-of-pocket costs - were identified. The primary and secondary endpoints were the relative attribute importance (RAI) and utility value of attribute levels, which were compared between patients and physicians to highlight differences.

RESULTS

Both patients (n = 95) and physicians (n = 118) showed the greatest concern for total out-of-pocket treatment costs, followed by safety risks. While patients and physicians generally shared similar treatment preferences, patients placed a higher RAI on total out-of-pocket costs than did physicians (50.4% vs. 39.4%). Conversely, patients assigned lower RAI values to the risks of nasopharyngitis and pruritus (15.2% vs. 17.9% and 11.7% vs. 16.2%, respectively). The RAI for the number of tablets taken daily was higher than that for treatment duration among patients (11.6% vs. 0.2%), but nearly equal among physicians.

LIMITATIONS

The study had potential non-response bias, physicians not being actual care providers for surveyed patients, a small sample size, reliance on predefined DCE attributes, and limited participant diversity from online panels.

CONCLUSIONS

This study highlights the importance of patient-centered care in HCV treatment and the need to raise awareness of the public subsidy for hepatitis, and to ensure an effective access scheme for the patients. Simplifying regimens like once-daily pills and minimal monitoring may enhance treatment convenience. Improved patient-physician communication supports optimized strategies, aiding Japan's goal of HCV elimination by 2030.

Real-world Prevalence of Hepatitis B Reactivation in Patients With Resolved Hepatitis B Receiving Rituximab and Non-rituximab-based Immunosuppressive Therapy Without Chemoprophylaxis

Background

Hepatitis B virus reactivation (HBVr) can occur in patients with resolved hepatitis B virus (HBV) infection receiving immunosuppressive therapy. The class of immunosuppression influences HBV reactivation (HBVr) risk, with B-cell depleting agents such as Rituximab conferring a higher risk. The presence of hepatitis B surface antibodies (HBsAb) may be protective against HBVr.

Objective

To compare the rates of HBVr amongst individuals with resolved HBV infection receiving rituximab and non-rituximab immunosuppressive therapy, without chemoprophylaxis. Our secondary objective was to explore the role of HBsAb in risk stratification for HBVr.

Methods

We retrospectively collected the data of patients with resolved HBV infection receiving immunosuppressants between 2014 and 2022. HBVr rates amongst patients receiving rituximab and non-rituximab therapy were compared. Logistic regression analysis was performed to identify risk factors for HBVr.

Results

148 patients with resolved HBV infection did not receive chemoprophylaxis. Of the 20 (13.5%) patients who developed HBVr, none developed HBV flare. 42 of the 148 (28.3%) patients received rituximab-based therapy. Patients who received rituximab had a higher risk of HBVr, 12(28.6%) vs 8(7.5%), P = 0.001. This was confirmed on multivariable analysis (OR 4.19 [C.I. 1.47-11.9], P = 0.007). HBsAb titres of above 100 mIU/ml were protective against HBVr (OR 0.04 [CI 0.001-0.84], P = 0.039) in the rituximab exposed cohort, but not in the non-rituximab exposed cohort.

Conclusion

The risk of HBVr was higher in patients receiving rituximab; however, no patient developed HBV flare. In patients with resolved HBV infection, the presence of HBsAb titres above 100 mIU/ml may confer additional protection against HBVr and can be used as part of risk stratification for HBVr. In such patients, close surveillance with on-demand therapy instead of chemoprophylaxis may be considered.

The Warburg effect: The hacked mitochondrial-nuclear communication in cancer

Mitochondrial-nuclear communication is vital for maintaining cellular homeostasis. This communication begins with mitochondria sensing environmental cues and transmitting signals to the nucleus through the retrograde cascade, involving metabolic signals such as substrates for epigenetic modifications, ATP and AMP levels, calcium flux, etc. These signals inform the nucleus about the cell's metabolic state, remodel epigenome and regulate gene expression, and modulate mitochondrial function and dynamics through the anterograde feedback cascade to control cell fate and physiology. Disruption of this communication can lead to cellular dysfunction and disease progression, particularly in cancer. The Warburg effect is the metabolic hallmark of cancer, characterized by disruption of mitochondrial respiration and increased lactate generation from glycolysis. This metabolic reprogramming rewires retrograde signaling, leading to epigenetic changes and dedifferentiation, further reprogramming mitochondrial function and promoting carcinogenesis. Understanding these processes and their link to tumorigenesis is crucial for uncovering tumorigenesis mechanisms. Therapeutic strategies targeting these disrupted pathways, including metabolic and epigenetic components, provide promising avenues for cancer treatment.

No Differences in Risk of Cirrhosis or Hepatocellular Carcinoma Among Treatment Naïve Chronic Hepatitis B Patients by Baseline Hepatitis B Viral Load: A Propensity Score Weighted Analysis

BACKGROUND AND OBJECTIVES

Previous studies among Korean adults with treatment-naïve chronic hepatitis B (CHB) observed paradoxical relationships between baseline hepatitis B virus (HBV) DNA and risk of hepatocellular carcinoma (HCC). However, these observations have not been validated in Western cohorts. We aim to evaluate the longitudinal risk of cirrhosis or HCC among a national cohort of treatment-naïve patients with noncirrhotic chronic HBV.

METHODS

Using a national cohort of U.S. Veterans with CHB (with baseline HBV DNA ≥2000 IU/mL) from 1/1/2020 to 3/31/2024, we evaluated the long-term risk of cirrhosis or HCC stratified by baseline high HBV DNA (>6.00 log10 IU/mL) or moderate HBV DNA (2000-6.00 log10 IU/mL). We applied propensity score weighting methods to adjust for baseline differences between the two groups.

RESULTS

A total of 1198 noncirrhotic treatment-naïve CHB patients with HBV DNA ≥2000 IU/mL were identified (90.7% were men, 41.7% African American, 29.6% non-Hispanic white, 18.2% Asian, mean age was 54.7 years, 27.9% were HBeAg positive). After propensity score weighting was applied, no significant differences in the incidence of cirrhosis or HCC were observed between CHB patients with moderate vs. high baseline HBV DNA (cirrhosis: 1.02 (95% CI: 0.83-1.25) vs. 1.19 per 100 person-years (95% CI: 0.94-1.51); HR 0.93, 95% CI: 0.68-1.28, P = 0.66; HCC: 0.34 (95% CI: 0.24-0.48) vs. 0.29 per 100 person-years (95% CI: 0.18-0.46); HR 1.02, 95% CI: 1.83, P = 0.95).

CONCLUSIONS

Among a national cohort of Western, predominantly non-Asian patients with treatment-naïve CHB, no significant differences in risk of cirrhosis or HCC were observed by baseline HBV DNA. These data suggest that some epidemiological trends and associations observed in Asian CHB populations may not necessarily be generalizable to non-Asian cohorts with different modes of transmission, risk factors, and virus-specific characteristics.

Effects of Probiotics on Liver Diseases: Current In Vitro and In Vivo Studies

Various types of liver or hepatic diseases cause the death of about 2 million people worldwide every year, of which 1 million die from the complications of cirrhosis and another million from hepatocellular carcinoma and viral hepatitis. Currently, the second most common solid organ transplant is the liver, and the current rate represents less than 10% of global transplant requests. Hence, finding new approaches to treat and prevent liver diseases is essential. In liver diseases, the interaction between the liver, gut, and immune system is crucial, and probiotics positively affect the human microbiota. Probiotics are a non-toxic and biosafe alternative to synthetic chemical compounds. Health promotion by lowering cholesterol levels, stimulating host immunity, the natural gut microbiota, and other functions are some of the activities of probiotics, and their metabolites, including bacteriocins, can exert antimicrobial effects against a broad range of pathogenic bacteria. The present review discusses the available data on the results of preclinical and clinical studies on the effects of probiotic administration on different types of liver diseases.

Arginine tagged liposomal carrier for the delivery of celastrol for ferroptosis-induced hepatocellular carcinoma therapy

Hepatocellular carcinoma (HCC) is a predominant malignant liver tumor that cannot be efficiently treated because of poor response, toxicity, and drug resistance. Ferroptosis is an iron-dependent way of cell death associated with abnormal intracellular lipid metabolism. Celastrol (Cel) has the ability to inhibit the progression of HCC by regulating multiple signaling pathways and induce ferroptosis. However, Cel exists the limitations of low water solubility, low oral bioavailability, and high organ toxicity. Cel was encapsulated in polyethylene glycol-based liposomes modified with L-arginine (Cel@Lip-Arg). Cel@Lip-Arg has a uniform size distribution (∼100 nm), high drug loading (80 %), and excellent ability to target liver cancer cells. In vitro experiments demonstrated that Cel@Lip-Arg considerably suppressed the activity of HuH7 (hepatoma) cells but had a negligible effect on L02 (normal) cells. Cel@Lip-Arg induced ferroptosis in hepatoma cells by promoting transferrin receptor expression, inhibiting system xc- and glutathione peroxidase 4, and favoring intracellular peroxide accumulation. In vivo experiments revealed that Cel@Lip-Arg plays a therapeutic role by inducing ferroptosis. Compared to Cel, Cel@Lip-Arg had a higher anti-hepatoma activity and effectively reduced the toxicity of Cel in mice. Cel@Lip-Arg-induced ferroptosis was concluded to be an attractive strategy for the precise treatment of HCC.

CCL19/MIP-3β as a key mediator in the production of anti-GPIIb/IIIa antibody-producing B cells in patients with chronic hepatitis C

The roles of specific cytokines and chemokines in modulating the production of anti-GPIIb/IIIa antibody-producing B cells remain poorly understood. We aimed to assess key mediators that influence the number of anti-glycoprotein (GP) IIb/IIIa antibody-producing B cells in patients with hepatitis C virus (HCV). This study used a subset of a previously reported cohort in Japan. We first evaluated the number of anti-GPIIb/IIIa antibody-producing B cells using an enzyme-linked immunospot assay in samples from 22 patients who received direct-acting antivirals (DAA)-based therapy and achieved a sustained virological response (SVR). To identify the key mediators, we then analyzed levels of cytokines, chemokines, and inflammation markers in serum samples obtained from the same cohort using Bio-Plex Multiplex Immunoassays. The analysis revealed a significant correlation between the frequency of anti-GPIIb/IIIa antibody-producing B cells and CCL19/macrophage inflammatory protein-3 beta (MIP-3β) (r = 0.590, p = 0.006). After DAA treatment for HCV, both the frequency of these B cells and the levels of CCL19/MIP-3β significantly decreased. Furthermore, the frequency of anti-GPIIb/IIIa antibody-producing B cells and levels of CCL19/MIP-3β were significantly higher in the thrombocytopenia group compared to the non-thrombocytopenia group (p = 0.001 and p = 0.029, respectively). These results suggest that CCL19/MIP-3β may be a key mediator in the production of anti-GPIIb/IIIa antibody-producing B cells in patients with HCV.

An 11-year retrospective study on hepatitis C in Saudi Arabia: Seroconversion, recovery rates, and viral genotype distribution

Hepatitis C virus (HCV) infection remains a global health concern. This study analyzed 95,864 plasma samples from Saudi patients between 2011 and 2022 to examine HCV seroconversion, viral load, and genotype distribution. Serological screening was performed using the ARCHITECT anti-HCV assay, and HCV RNA levels were quantified with real-time RT-PCR. Of the 970 HCV-positive cases, 47.9 % experienced spontaneous recovery, while 52.1 % had persistent infection. The annual seropositivity rate declined significantly from 2.05 % in 2011 to 0.34 % in 2022. Genotyping of 107 persistently infected samples showed genotypes 4 (49.5 %) and 1a (17.8 %) as the most common, with other genotypes appearing less frequently. Additionally, 13 (12.1 %) samples had untypable genotypes. This study highlights the decrease in HCV infection rates, the high rate of spontaneous recovery, and the predominance of genotypes 4 and 1a. Ongoing surveillance and genotyping, including untypable cases, are essential for effective HCV management in Saudi Arabia.

Antiviral potential of the arctigenin derivative COA in reducing viral adhesion to the epithelial cell surface against IHNV infection

Infectious hematopoietic necrosis virus (IHNV) is a major aquaculture threat, highlighting the need for effective antiviral agents. This study evaluates the arctigenin derivative COA for its antiviral potential against IHNV. COA demonstrated no cytotoxicity to EPC cells at concentrations up to 10 μM and inhibited over 90 % of IHNV gene expression in vitro. It preserved normal nuclear morphology in infected cells, reduced viral titers, and completely blocked IHNV infection at 10 μM. Time-gradient assays identified COA's antiviral action during early infection, specifically inhibiting viral adsorption (82 %) and internalization (92 %). Using DiO-labeled IHNV particles, we visualized COA preventing viral entry into EPC cells, marking a novel finding for arctigenin derivatives. COA remained stable in water for over four days, enhancing its suitability for aquaculture applications. In vivo, COA improved survival rates of IHNV-infected rainbow trout by 46 % (injection) and 22 % (immersion) while significantly reducing IHNV gene expression and viral titers in spleen and kidney. It also upregulated interferon genes, activating antiviral responses and effectively reducing horizontal transmission of IHNV. These results highlight COA's potential as an antiviral agent, providing insights for developing targeted therapies against rhabdoviruses in aquaculture.

Microbial Approaches to Treat and Prevent Hepatic Encephalopathy

This review articulates the significance of the gut-liver-brain axis in understanding hepatic encephalopathy (HE), emphasizing the role of gut microbiota in influencing liver and brain health. Key treatments like lactulose, rifaximin, probiotics, and fecal microbiota transplantation are examined for their ability to modulate the gut microbiome, thereby mitigating HE symptoms through reduced neurotoxin production and enhanced gut barrier integrity. The synopsis highlights both established and emerging microbial therapies, presenting them as crucial to the management and future strategies of HE. This comprehensive overview explores current therapeutic approaches alongside promising future interventions, suggesting that personalized microbiome-focused treatments may revolutionize HE management.

The epigenetic basis of hepatocellular carcinoma - mechanisms and potential directions for biomarkers and therapeutics

Hepatocellular carcinoma (HCC) is the sixth leading cancer worldwide and has complex pathogenesis due to its heterogeneity, along with poor prognoses. Diagnosis is often late as current screening methods have limited sensitivity for early HCC. Moreover, current treatment regimens for intermediate-to-advanced HCC have high resistance rates, no robust predictive biomarkers, and limited survival benefits. A deeper understanding of the molecular biology of HCC may enhance tumor characterization and targeting of key carcinogenic signatures. The epigenetic landscape of HCC includes complex hallmarks of 1) global DNA hypomethylation of oncogenes and hypermethylation of tumor suppressors; 2) histone modifications, altering chromatin accessibility to upregulate oncogene expression, and/or suppress tumor suppressor gene expression; 3) genome-wide rearrangement of chromatin loops facilitating distal enhancer-promoter oncogenic interactions; and 4) RNA regulation via translational repression by microRNAs (miRNAs) and RNA modifications. Additionally, it is useful to consider etiology-specific epigenetic aberrancies, especially in viral hepatitis and metabolic dysfunction-associated steatotic liver disease (MASLD), which are the main risk factors of HCC. This article comprehensively explores the epigenetic signatures in HCC, highlighting their potential as biomarkers and therapeutic targets. Additionally, we examine how etiology-specific epigenetic patterns and the integration of epigenetic therapies with immunotherapy could advance personalized HCC treatment strategies.

Cell-intrinsic regulation of HBV RNAs by the nonsense-mediated mRNA decay pathway controls viral replication

Hepatitis B virus (HBV) is a causative agent for chronic liver hepatitis, which confers risk for liver cirrhosis and hepatocellular carcinoma. Among key viral transcripts, HBV pregenome RNA (pgRNA) is indispensable for viral replication, and therefore, quality control of pgRNA is critical for the HBV life cycle. Here, we revealed degradation of HBV RNAs by the nonsense-mediated mRNA decay (NMD) pathway, a host surveillance system of RNA quality. Degradation kinetics of the HBV RNAs indicated that pgRNA, 2.4 knt RNA, and 2.1 knt RNA were targets of the NMD pathway and also interacted robustly with phosphorylated UPF1 but not X RNA. Northern blotting showed that decay of the viral NMD candidates was also delayed in NMD-deficient cells. In contrast, NMD depletion promoted the formation of capsids containing genomic DNA and exhibiting antigen production. Our data strongly suggest that the NMD pathway inspects HBV transcripts to regulate HBV replication as an intrinsic antiviral defense.

Hepatitis B core-related antigen as a predictive biomarker for recurrence in primary hepatocellular carcinoma: A meta-analysis

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignancies, with high recurrence rates after treatment. Identifying reliable biomarkers for predicting recurrence is essential for improving patient outcomes. Hepatitis B core-related antigen (HBcrAg) has shown potential as a predictive marker for HCC recurrence.

AIM

To evaluate the association between HBcrAg levels and the risk of HCC recurrence.

METHODS

A systematic review was conducted following PRISMA guidelines. PubMed, EMBASE, Web of Science, and the Cochrane Library were searched without restrictions on date or language. Observational studies reporting hazard ratios (HRs) for HBcrAg as a predictor of HCC recurrence were included. Data extraction and quality assessment were performed independently by two reviewers. Statistical analyses used a random-effects model to account for heterogeneity (I² ≥ 50%), and sensitivity analysis was performed to ensure the robustness of the results.

RESULTS

A total of 1339 articles were initially identified, and 17 studies were included in the final meta-analysis after screening. The pooled analysis showed a significant association between elevated HBcrAg levels and HCC recurrence (HR = 4.42, 95% confidence interval: 3.43-5.41) with substantial heterogeneity (I² = 92.6%). Subgroup analysis revealed higher pooled HRs in studies with ≥ 500 participants (HR = 4.18) and HBcrAg cut-offs ≥ 4.0 LogU/mL (HR = 5.29). Studies with ≥ 10 years of follow-up showed a lower HR (2.89) compared to those with < 10 years (3.27). Patients treated with nucleos(t)ide analogs had a pooled HR of 1.98, while those without nucleos(t)ide analog had a higher HR of 3.87. Sensitivity analysis confirmed the robustness of the results, with no significant publication bias detected.

CONCLUSION

This meta-analysis provides strong evidence that elevated HBcrAg levels are associated with an increased risk of HCC recurrence. HBcrAg may serve as a valuable biomarker for predicting recurrence, aiding personalized management and surveillance strategies for HCC patients.

Performance of the AASLD, EASL, and APASL Clinical Practice Guidelines in"grey zone"stages of Chinese patients with chronic hepatitis B

BACKGROUND/OBJECTIVE

Chronic hepatitis B (CHB) patients who do not meet any immunostaging criteria are categorized as the "grey zone" (GZ). However, there are discrepancies in the definition of the GZ in different areas.

AIM

To investigate the prevalence and clinical characteristics of Chinese GZ patients and to validate the application value of three international guidelines.

METHODS

Data from 807 naïve CHB patients with liver biopsies from seven Chinese centres were retrospectively collected. GZ patients were defined and compared across four guidelines: the Chinese guidelines, the American Association for the Study of Liver Diseases (AASLD) guidelines, the European Association for the Study of the Liver (EASL) guidelines, and the Asian Pacific Association for the Study of the Liver (APASL) guidelines.

RESULTS

When the Chinese guidelines were used, 38.79% of patients were categorized into the GZ, 78.91% of whom were indicated for antiviral therapy. The EASL guidelines yielded a greater proportion of GZ patients (50.56%) than did the APSAL (36.68%) and AASLD guidelines (33.21%). The APASL guidelines yielded a lower proportion of GZ patients who were indicated for antiviral therapy (42.57%) than did the AASLD (47.76%) and EASL guidelines (60.54%). According to the AASLD, EASL, APASL and Chinese guidelines, if liver biopsy was not performed, 13.06%, 31.86%, 0% and 64.54% of GZ patients were indicated for antiviral therapy, respectively.

CONCLUSIONS

GZ patients account for a significant proportion of CHB patients, with approximately half of them requiring antiviral therapy.

CLINICAL TRIAL REGISTRATION

NCT06041022.

Identification and characteristics of mutations promoting occult HBV infection by ultrasensitive HBsAg assay

The significance of occult hepatitis B virus (HBV) infection (OBI) has been increasingly recognized while the underlying mechanisms remain incompletely understood. This study aimed to identify high-frequency OBI-related mutations in HBV surface antigen (HBsAg)-negative samples tested by the ultrasensitive Lumipulse G HBsAg-Quant assay. OBI samples were collected from 32 blood establishments across 14 provinces in China. Lumipulse G HBsAg-Quant assay was performed for the re-testing and reclassification of OBI. Mutations in genotypes B (GTB) and C (GTC) were analyzed to identify high-frequency single and combined mutations. Additionally, the efficacy of commercial reagents commonly employed in clinical diagnostics for detecting mutant HBsAg was evaluated. Western Blot was used for the confirmation of extracellular HBsAg as well as the detection of intracellular HBsAg. Hydrophilicity analysis and transmembrane distribution prediction of HBsAg were utilized for further validation. Single mutations at 17 sites and 9 combined mutations in GTB indicated a significantly elevated mutation frequency. In GTC, there were single mutations at 16 sites and 9 combined mutations. Several commercial reagents commonly demonstrated limited capacity toward mutant HBsAg with T123A/P, K141C, and P142R/I/K/L (GTB) and S114A/P (GTC). The findings indicated that mutations including T123A/C/K/S, S132G/Y, P142L/R/S/T, T143M, D144G, G145A, K160R+V168A, I4T+V168A, M103I+K122R, and M103I+Q181R (GTB), along with Q101H, M103I, R160K+C221Y (GTC), were associated with reduced levels of HBsAg both extracellularly and intracellularly. Additionally, K160R (GTB) and E2G (GTC) were associated with intracellular aggregation. This study elucidates the mutations associated with decreased extracellular HBsAg with ultrasensitive HBsAg assay, providing insight for further investigation into the mechanisms of OBI.

IMPORTANCE

The sensitivity of HBsAg detection reagents directly impacts the identification of occult hepatitis B virus (HBV) infection (OBI). This study aims to identify high-frequency OBI-related mutations in HBV surface antigen (HBsAg)-negative samples evaluated using a Fujirebio-Lumipulse ultrasensitive HBsAg assay and to investigate the implications of these mutations on the antigenicity of HBsAg, the detection capacities of various HBsAg assays, and the effects on intracellular and extracellular levels of HBsAg. Generally, our study offers a new perspective on OBI-related mutations by ultrasensitive HBsAg assay and lays the groundwork for further research on the OBI mechanism and the enhancement of HBsAg detection reagents.

Display selection of peptide ligands for helical aromatic foldamers

Helical aromatic oligoamide foldamers with a cluster of five biogenic side chains at their surface were designed and synthesized. Display selection of thioether macrocyclic peptides against these targets generated low micromolar binders that are highly selective for the side-chain arrangement.

Deep Learning-accelerated MRI in Body and Chest

Deep learning reconstruction (DLR) provides an elegant solution for MR acceleration while preserving image quality. This advancement is crucial for body imaging, which is frequently marred by the increased likelihood of motion-related artifacts. Multiple vendor-specific models focusing on T2, T1, and diffusion-weighted imaging have been developed for the abdomen, pelvis, and chest, with the liver and prostate being the most well-studied organ systems. Variational networks with supervised DL models, including data consistency layers and regularizers, are the most common DLR methods. The common theme for all single-center studies on this subject has been noninferior or superior image quality metrics and lesion conspicuity to conventional sequences despite significant acquisition time reduction. DLR also provides a potential for denoising, artifact reduction, increased resolution, and increased signal-noise ratio (SNR) and contrast-to-noise ratio (CNR) that can be balanced with acceleration benefits depending on the imaged organ system. Some specific challenges faced by DLR include slightly reduced lesion detection, cardiac motion-related signal loss, regional SNR variations, and variabilities in ADC measurements as reported in different organ systems. Continued investigations with large-scale multicenter prospective clinical validation of DLR to document generalizability and demonstrate noninferior diagnostic accuracy with histopathologic correlation are the need of the hour. The creation of vendor-neutral solutions, open data sharing, and diversifying training data sets are also critical to strengthening model robustness.

The safety, tolerability, pharmacokinetics, and pharmacodynamics of nebulized pegylated interferon α-2b in healthy adults: a randomized phase 1 trial

BACKGROUND

Interferons (IFNs) are proteins that combat viruses and regulate the immune system. Studies have demonstrated that aerosol inhalation of IFNα is both effective and safe for treating respiratory infections. However, IFNα has a short half-life and is rapidly cleared by lung defenses. Polyethylene glycol (PEG) ylation is a common strategy to extend the duration of drug action. PegIFNα-2b is a long-acting interferon formed by the covalent binding of 40 kDa Y-shaped branched PEG with recombinant human IFNα-2b. This study aimed to assess the safety, tolerability, pharmacokinetic, and pharmacodynamic characteristics of nebulized PegIFNα-2b in healthy adult subjects, providing guidance for further clinical investigations.

METHODS

This study employed a randomized, controlled clinical trial design with a total of 18 healthy adult subjects enrolled. Participants were randomly assigned in a 1:1:1 ratio to three groups. Treatment group 1 and group 2 received 90 µg and 180 µg of nebulized PegIFNα-2b, respectively, while the control group was administered a combination of 180 µg PegIFNα-2b and 15 mg inhalable Ambroxol Hydrochloride solution, all in a single dose. Safety, tolerability, and blood drug concentration were assessed, along with blood neopterin levels for pharmacokinetic and pharmacodynamic evaluation.

RESULTS

The incidence of adverse events (AEs) was 38.9% (7/18) with no significant difference among the groups (P > 0.05). AEs included anemia (N = 5) and leukopenia (N = 2), predominantly of grade 1 severity (6/7), with no severe events. Blood PegIFNα-2b concentrations were below detection limits in most subjects, except one in treatment group 2. Neopterin levels were generally low in treatment group 1 and the control group, with slightly higher observed in most subjects of treatment group 2, but differences were not significant (P > 0.05).

CONCLUSIONS

Nebulized PegIFNα-2b at doses of 90 µg and 180 µg showed acceptable safety and tolerability. Minimal systemic absorption was observed following inhalation. Further studies are needed to explore its potential, especially in patients with lower respiratory tract infections.

CLINICAL TRIAL REGISTRATION

ChiCTR2300074909, retrospectively registered in https://www.chictr.org.cn/ at 20 August 2023.

Predictive factors and clinical outcomes in decompensated non-cirrhotic chronic hepatitis B patients treated with entecavir or tenofovir disoproxil fumarate

BACKGROUND & AIMS

Little is known about the short-term and long-term outcomes of non-cirrhotic chronic hepatitis B (CHB) patients who experience hepatic decompensation. Therefore, this study aimed to investigate the clinical outcomes of decompensated non-cirrhotic CHB patients.

METHODS

We conducted a retrospective study and enrolled a total of 304 decompensated non-cirrhotic CHB patients. Cox regression model was used to analyze factors associated with all-cause mortality. Additionally, the incidence of HBsAg seroclearance and its associated factors were estimated by the competing risk analysis.

RESULTS

The median follow-up time was 4.36 years (IQR 1.04-7.16). Out of the total enrolled patients, 63 (20.72 %) patients either died or underwent liver transplantation, and 14 patients achieved HBsAg seroclearance. Risk factors associated with 1-month, 3-month, and long-term all-cause mortality were the presence of ascites and hepatic encephalopathy, baseline HBV DNA levels, and MELD scores. The cumulative incidence of HBsAg seroclearance was 1.78 %, 3.72 %, 4.25 %, 5.68 %, 5.68 %, 8.28 %, and 8.28 % at the 1-year, 2-year, 3-year, 4-year, 5-year, 6-year, and 7-year follow-up, respectively. Independent predictors for HBsAg seroclearance were baseline alanine aminotransferase (ALT)≧ 25 times upper limit of normal (subdistribution hazard ratio [sHR] = 5.97; 95 %CI, 1.82-19.63; p = 0.0032) and HBV DNA <5 log10 IU/ml (sHR = 4.43; 95 %CI, 1.55-12.63; p = 0.0054).

CONCLUSIONS

The presence of ascites and hepatic encephalopathy, baseline HBV DNA levels, and MELD scores were associated with short-term and long-term all-cause mortality. Additionally, lower HBV DNA levels and higher ALT levels at baseline were independently predictive of sequential HBsAg seroclearance.

Viral oncogenesis in cancer: from mechanisms to therapeutics

The year 2024 marks the 60th anniversary of the discovery of the Epstein-Barr virus (EBV), the first virus confirmed to cause human cancer. Viral infections significantly contribute to the global cancer burden, with seven known Group 1 oncogenic viruses, including hepatitis B virus (HBV), human papillomavirus (HPV), EBV, Kaposi sarcoma-associated herpesvirus (KSHV), hepatitis C virus (HCV), human T-cell leukemia virus type 1 (HTLV-1), and human immunodeficiency virus (HIV). These oncogenic viruses induce cellular transformation and cancer development by altering various biological processes within host cells, particularly under immunosuppression or co-carcinogenic exposures. These viruses are primarily associated with hepatocellular carcinoma, gastric cancer, cervical cancer, nasopharyngeal carcinoma, Kaposi sarcoma, lymphoma, and adult T-cell leukemia/lymphoma. Understanding the mechanisms of viral oncogenesis is crucial for identifying and characterizing the early biological processes of virus-related cancers, providing new targets and strategies for treatment or prevention. This review first outlines the global epidemiology of virus-related tumors, milestone events in research, and the process by which oncogenic viruses infect target cells. It then focuses on the molecular mechanisms by which these viruses induce tumors directly or indirectly, including the regulation of oncogenes or tumor suppressor genes, induction of genomic instability, disruption of regular life cycle of cells, immune suppression, chronic inflammation, and inducing angiogenesis. Finally, current therapeutic strategies for virus-related tumors and recent advances in preclinical and clinical research are discussed.

Multicenter Comparative Study of 6- and 10-mm Fully Covered Self-Expandable Metal Stents for Malignant Distal Biliary Obstruction During Neoadjuvant Chemotherapy for Resectable and Borderline Resectable Pancreatic Cancer

BACKGROUND

The use of 10-mm fully covered self-expandable metal stents for preoperative bile duct drainage in patients with pancreatic cancer is increasing. However, these can cause complications (cholecystitis and pancreatitis) that may affect surgical outcomes. Smaller-diameter self-expandable metal stents may reduce these risks; however, the optimal stent size is unclear.

METHODS

Patients with pancreatic cancer who underwent neoadjuvant chemotherapy and placement of either 6 or 10-mm fully covered self-expandable metal stents for malignant distal biliary obstruction were included. The primary outcome was the 90-day incidence of recurrent biliary obstruction. Secondary outcomes were non-recurrent biliary obstruction and adverse events.

RESULTS

Fifty-three patients were enrolled (27 and 26 patients received 6-mm and 10-mm self-expandable metal stents, respectively). The 90-day incidence of recurrent biliary obstruction of the 6-mm group was significantly higher than that of the 10-mm group (30.8% vs. 3.8%; p = 0.02). Stent migration occurred more frequently in the 6-mm group (26.9% vs. 0%; p = 0.01). Although non-recurrent biliary obstruction adverse events were less common in the 6-mm group, the difference was not statistically significant (11.1% vs. 23.0%; p = 0.29).

CONCLUSIONS

The 10-mm self-expandable metal stents were more suitable for the preoperative management of pancreatic cancer.

Association between antiretroviral therapy and dental caries in children and adolescents with HIV: a systematic review and meta-analysis

OBJECTIVE

To evaluate the evidence regarding the association between antiretroviral therapy and dental caries in children and adolescents with HIV.

METHODS

Searches were conducted in five international databases (PubMed, Scopus, EMBASE, CENTRAL, and LILACS) from the inception of records up to October 2024, including studies that examine the impact of antiretroviral therapy on caries in individuals under 18 years of age. The risk of bias was assessed using the Newcastle-Ottawa Scale. Quantitative synthesis was performed using the inverse variance method or Mantel-Haenszel method, depending on the type of outcome analyzed. Measures of association included odds ratios and mean differences, employing a random-effects model with a 95% confidence interval.

RESULTS

A total of 585 studies were identified, of which 17 were selected for qualitative review and 15 were included in the meta-analysis. The meta-analysis revealed a significantly higher risk of dental caries in children and adolescents with HIV undergoing antiretroviral therapy compared to those without the virus (odds ratio of 2.11; 95% CI: 1.41-3.17). Subgroup analysis showed a stronger association in case-control studies and for the DMFT index. The certainty of the evidence according to GRADE was rated as very low.

CONCLUSION

Despite limited certainty, the results suggest that HIV under antiretroviral therapy is associated with a higher risk of dental caries. It is prudent to interpret these results with caution, considering the methodological limitations of the studies. However, given the possible relevance of this association for public health, it is recommended to consider specific dental care protocols for children and adolescents with HIV, as well as the need for preventive strategies integrated into HIV management.

Ex vivo culture models to study viral infections of the liver

Ex vivo liver culture models, particularly three-dimensional (3D) models, are vital for studying viral infections of the liver, as they replicate the complex microenvironment more accurately than traditional two-dimensional cultures. These models are essential for understanding viral pathogenesis, replication, and host responses, which are crucial for developing antiviral therapies. Here, we review various ex vivo liver culture models, including primary human hepatocytes (PHHs), liver-on-a-chip, organoids, and precision-cut liver slices. Each model has unique advantages and limitations. For instance, PHHs maintain physiological characteristics but have a limited lifespan, while liver-on-a-chip systems enable dynamic studies but require advanced engineering. Despite challenges in translating findings to human disease, these 3D models hold promise for advancing liver disease research and drug development. Future research should focus on expanding the scope of these models to include a wider range of viruses and improving their physiological relevance to better mimic in vivo conditions.

EASL Clinical Practice Guidelines on the management of hepatitis B virus infection

The updated EASL Clinical Practice Guidelines on the management of hepatitis B virus (HBV) infection provide comprehensive, evidence-based recommendations for its management. Spanning ten thematic sections, the guidelines address diagnostics, treatment goals, treatment indications, therapeutic options, hepatocellular carcinoma surveillance, management of special populations, HBV reactivation prophylaxis, post-transplant care, HBV prevention strategies, and finally address open questions and future research directions. Chronic HBV remains a global health challenge, with over 250 million individuals affected and significant mortality due to cirrhosis and hepatocellular carcinoma. These guidelines emphasise the importance of early diagnosis, risk stratification based on viral and host factors, and tailored antiviral therapy. Attention is given to simplified algorithms, vaccination, and screening to support global HBV elimination targets. The guidelines also discuss emerging biomarkers and evolving definitions of functional and partial cure. Developed through literature review, expert consensus, and a Delphi process, the guidelines aim to equip healthcare providers across disciplines with practical tools to optimise HBV care and outcomes worldwide.

Association between resolved hepatitis B virus infection and depression in American adults : a cross-sectional study

Hepatitis B virus (HBV) infection is a global health concern, and it can potentially affect mental health like depression. Resolved HBV infection, often perceived as a milder form of HBV infection, are often overlooked, and the association between it and depression remains unclear. This study aims to investigate the association between resolved HBV infection and depression. A cross-sectional analysis was conducted using the National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2018, including 20,655 adult Americans. Resolved HBV infection was defined as HBV surface antigen (HBsAg) negative and HBV core antibody (HBcAb) positive. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) score. Propensity score matching (PSM) was performed to balance baseline characteristics. Algorithms such as inverse probability of treatment weighting (IPTW) were also applied. Among the participants, 1,551 (7.5%) were reported to have resolved HBV infection. Depression was reported by 1,796 participants (8.7%), with a higher prevalence among those with resolved HBV infection (10.6%) compared to those without HBV infection(8.5%). PSM and IPTW revealed a significantly positive association between resolved HBV infection and depression (PSM: OR = 1.40, 95%CI 1.09-1.79, p = 0.008; IPTW: OR = 1.48, 95%CI 1.26-1.74, p < 0.001). Subgroup and sensitivity analyses supported the robustness of the findings. The results suggest a complex relationship between resolved chronic viral infections and mental health. Based on this finding, it is advisable to conduct psychological monitoring and offer support to individuals who have achieved a functional cure for HBV. Further prospective studies are still needed to reveal the potential mechanism.

Serum miR-30c serves as potential biomarkers for the diagnosis and prognosis of gastric cancer

Gastric cancer (GC)，the fourth leading cause of cancer-related deaths globally and thus early detection, is considered critical for diagnosis and treatment of this disease. It is well known that measurement of microRNA (miRNA) may serve as diagnostic and prognostic biomarker for GC. The aim of this study was to determine whether miR-30c was present in patients with gastric cancer and to correlate relative expression with patient survival. A total of 162 GC patients and 150 healthy controls were recruited. miR-30c levels were quantified in serum using quantitative real-time PCR(QRT-PCR). The sensitivity and specificity of circulating miR-30c was compared to carbohydrate antigen (CA) CA72-4, CA19-9, and carcinoembryonic antigen (CEA), 3 known markers associated with GC. QRT-PCR demonstrated downregulation of gene expression of miR-30c in GC patients. Downregulation of miR-30c gene expression was significantly correlated with stage of cancer, lymphatic metastasis, and distal metastasis. The sensitivity to detect GC of miR-30c, CA72-4, CA19-9, and CEA in serum of GC was 80%, 43%, 21%, and 42%, respectively, while specificity was 89%, 57%, 30%, and 78% respectively. Kaplan-Meier survival analysis showed that the presence of low gene expression of miR-30c was effective in predicting poor prognosis in GC patients. Our data suggest that circulating serum miR-30c concentrations may serve as a reliable biomarker for GC occurrence. (212words).

Plasma proteomic analysis reveals altered protein abundances in HIV/HBV co-infection individuals with HCC and with liver cirrhosis

To develop a risk prediction model for hepatocellular carcinoma (HCC) by screening differentially expressed proteins (DEPs) in HIV/HBV coinfected patients with HCC and liver cirrhosis using proteomic techniques. DEPs were identified in plasma from HIV/HBV co-infected patients with HCC and liver cirrhosis using quantitative liquid chromatography-mass spectrometry (LC-MS). Mapping discovered proteins to the Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and Disease Ontology (DO) databases yielded annotation information for DEPs. Differential plasma apolipoprotein A-1(APOA1) and transthyretin (TTR) expression levels were validated in 88 HIV/HBV co-infected individuals with HCC and liver cirrhosis. In total, 150 DEPs were discovered. The GO entries were primarily enriched for cutaneous immunological response mediated by circulating immunoglobulin and complement activation, as well as lipoprotein particle. The KEGG pathway enrichment was dominated by complement and coagulation cascades. Six of the 15 items enriched in the DO entries were related to lipid metabolism. APOA1, TTR, Prothrombin (F2), Antithrombin-III (SERPINC1), Alpha-2-HS-glycoprotein (AHSG), Alpha-2-macroglobulin (A2M) and Haptoglobin-related protein (HPR) were finally identified as hub proteins. Finally, a visual logistic model using immunoglobulin heavy variable 3-13 (IGHV3-13) and A2M to predict HCC were constructed. Significant variations in plasma APOA1 and TTR levels were found in HIV/HBV co-infected patients with HCC and liver cirrhosis. The screened hub proteins from DEPs can be employed as possible markers for early HCC detection. The developed HCC prediction model can be used to assess the risk of HCC in HIV/HBV co-infected cirrhotic individuals.

Risk factors and clinical outcomes in patients with HCV eradication by direct-acting antivirals: a systematic review and meta-analysis

BACKGROUND

In hepatitis C patients with sustained virologic response (SVR) achieved after direct-acting antivirals (DAAs), the incidence of adverse clinical outcomes can be reduced but not completely eliminated. This meta-analysis aims at estimating the incidence of clinical outcomes in hepatitis C patients after achieving SVR with DAAs.

METHODS

Literature search was carried out in PubMed, Cochrane Library database, Web of Science, and Embase. The primary endpoint was the incidence of hepatocellular carcinoma (HCC) occurrence, HCC recurrence, decompensated cirrhosis, and liver-related mortality, following DAA-induced elimination of hepatitis C virus (HCV). Subgroup analyses were performed according to age, gender, comorbidities, region, fibrosis stage, presence of decompensation, duration of follow-up, start point of follow-up, and HCC treatment modality. Furthermore, meta-regression was performed to explore sources of high heterogeneity.

RESULTS

Finally, 132 articles were included in our study. The pooled HCC occurrence rate was 1.50/100 person-years (95% CI, 1.35-1.65), HCC recurrence rate was 17.00/100 person-years (95% CI, 13.83-20.42), decompensation rate was 0.30/100 person-years (95% CI, 0.16-0.48), and liver-related mortality was 0.32/100 person-years (95% CI, 0.14-0.56). Meta-regression showed that duration of follow-up and fibrosis grade were important contributors to HCC occurrence. Age, start point of follow-up, and duration of follow-up were important contributors to HCC recurrence rate.

CONCLUSION

Patients with DAA-induced HCV elimination remain at risk for adverse outcomes, particularly those with cirrhosis and HCC history. The exposure to adverse outcomes tended to decrease over time, and the frequency and intensity of follow-up might be reduced in the future, which will require new scoring models to identify these individuals.

An elevated percentage of CD4⁺CD25⁺CD127low regulatory T cells in peripheral blood indicates a poorer prognosis in hepatocellular carcinoma after curative hepatectomy

BACKGROUND

Previous studies suggest the percentage of CD4⁺CD25⁺CD127low regulatory T cells (Tregs) in peripheral blood of patients with hepatocellular carcinoma (HCC) was significantly higher than that in healthy, which may be a significant predictor of HCC clinical outcome, and we examined the utility of Tregs in predicting prognosis in HCC after curative hepatectomy.

METHODS

77 diagnosed HCC patients from August 2018 to March 2023 were selected as research objects, we retrospectively analyzed whether the preoperative percentage of CD4⁺CD25⁺CD127low Tregs in peripheral blood predicts prognosis after curative hepatectomy in HCC patients. The percentage of CD4⁺CD25⁺CD127low Tregs was detected by flow cytometry.

RESULTS

The percentage of CD4⁺CD25⁺CD127low Tregs was significantly elevated in patients who developed recurrence and death (p < 0.050). X-tile software was used to calculate optimal cut-off value of Treg percentage (5.85%), and patients were divided into two groups with high and low Treg percentage. Patients with higher preoperative Treg percentage had a significantly poorer prognosis (p < 0.050). Cox regression demonstrated the percentage of CD4⁺CD25⁺CD127low Tregs was an independent indicator for poor prognosis after hepatectomy. The Recurrence-free survival (RFS) (the log-rank test, p < 0.001) and Overall survival (OS) (the log-rank test, p = 0.008) in patients with higher Treg percentage were significantly lower than that in patients with lower Treg percentage. The results were confirmed by the subgroup analysis.

CONCLUSION

The percentage of CD4⁺CD25⁺ CD127low Tregs in peripheral blood is associated with poor prognosis in HCC patients. It can be suggested as a potential prognostic indicator for HCC patients after hepatectomy and complement existing risk stratification tools. Measuring the percentage of CD4⁺CD25⁺ CD127low Tregs may contribute to the formulation of treatment strategies and the improvement of the prognosis for HCC patients.

Association between gut microbiota in HIV-infected patients and immune reconstitution following antiretroviral therapy (ART)

BACKGROUND

This study aims to examine the potential link between incomplete immune reconstitution following ART treatment and gut microbiota dysbiosis.

METHODS

We collected clinical data and fecal samples from 50 HIV patients undergoing ART and 30 untreated patients. Based on the observed immune function reconstruction, we further categorized the ART(+) group into a responder group (n = 30) and a non-responder group (n = 20). The gut microbiota composition differences were assessed using Alpha diversity and Beta diversity analysis, while differential genera were identified through linear discriminant analysis effect size (LEfSe). Subsequently, functional disparities in the gut microbiota were investigated using PICRUSt2 and metagenomeSeq software.

RESULTS

The results of Alpha diversity and Beta diversity revealed significant differences in the composition of gut microbiota among the three groups. Differential genus analysis identified Morganella as an exclusive genus present only in the Non-responder group, exhibiting a significantly higher relative abundance. Correlation analysis demonstrated a positive association between Morganella and LDL levels. The CAZY analysis revealed that glycosyltransferase 25 (GT25) was significantly expressed in the Non-responder group, whereas it was either undetectable or exhibited extremely low expression levels in both the Responder group and the ART(-) group. Importantly, the correlation analysis indicated a positive association between Morganella and GT25 secretion.

CONCLUSIONS

The ecological imbalance of Morganella might be associated with incomplete immune reconstitution following ART, potentially mediated by GT25 secretions. Consequently, Morganella could serve as a promising biomarker for predicting incomplete immune reconstitution in AIDS patients undergoing ART.

A multiscale model of the action of a capsid assembly modulator for the treatment of chronic hepatitis B

Chronic hepatitis B virus (HBV) infection is strongly associated with increased risk of liver cancer and cirrhosis. While existing treatments effectively inhibit the HBV life cycle, viral rebound frequently occurs following treatment interruption. Consequently, functional cure rates of chronic HBV infection remain low and there is increased interest in a novel treatment modality, capsid assembly modulators (CAMs). Here, we develop a multiscale mathematical model of CAM treatment in chronic HBV infection. By fitting the model to participant data from a phase I trial of the first-generation CAM vebicorvir, we estimate the drug's dose-dependent effectiveness and identify the physiological mechanisms that drive the observed biphasic decline in HBV DNA and RNA, and mechanistic differences between HBeAg-positive and negative infection. Finally, we demonstrate analytically and numerically that the relative change of HBV RNA more accurately reflects the antiviral effectiveness of a CAM than the relative change in HBV DNA.

Direct-acting antivirals lower mortality and recurrence in HCV-related hepatocellular carcinoma post liver resection: A multicenter international study

BACKGROUND

The impact of treatment on hepatitis C virus with direct-acting antivirals on 90-day postoperative outcomes, overall survival, and recurrence-free survival in patients after liver resection for hepatocellular carcinoma is unknown.

METHODS

We conducted a multicenter retrospective study. Adults who underwent liver resection for hepatitis C virus-related hepatocellular carcinoma between January 2000 and December 2018 were included from 7 international institutions. Groups included direct-acting antiviral treated, non-direct-acting antiviral treated, and untreated hepatitis C virus infection. We used a multivariable model to evaluate the association between receipt of preoperative direct-acting antivirals and 90-day postoperative major complications (Clavien-Dindo class ≥III).

RESULTS

We identified 738 patients, including 206 (28%) direct-acting antiviral treated, 241 (33%) non-direct-acting antiviral treated, and 291 (39%) untreated patients. The sustained virologic response rate was 92% in the direct-acting antiviral and 71% in the non-direct-acting antiviral treatment groups. The median follow-up was 7.6 years (95% confidence interval 6.1, 8.6) after surgery for the entire cohort. Patients who received direct-acting antiviral therapy had better 5-year overall and recurrence-free survival than those without antiviral therapy (adjusted hazard ratio [95% confidence interval]: 0.26 [0.19, 0.35] and 0.52 [0.43, 0.64], respectively). Patients who received direct-acting antiviral therapy had better 5-year overall and recurrence-free survival than those who received non-direct-acting antiviral therapy (adjusted hazard ratio [95% confidence interval]: 0.49 [0.36, 0.66] and 0.78 [0.63, 0.96], respectively). There was no significant association between preoperative direct-acting antiviral therapy and 90-day postoperative major complications (adjusted odds ratio 0.34, 95% confidence interval 0.08, 1.01).

CONCLUSION

Direct-acting antiviral therapy is associated with improved 5-year overall and recurrence-free survival, without significantly increased risk of 90-day postoperative complications, in patients undergoing liver resection for hepatitis C virus-related hepatocellular carcinoma.

Serum hepatitis B virus RNA in low-level viremia of chronic hepatitis B: clinical features and association with virological response

BACKGROUND

The role of hepatitis B virus (HBV) RNA in the management of patients with chronic hepatitis B (CHB) experienced with low-level viremia (LLV) remains poorly defined. This study was designed to evaluate the prognostic utility of serum HBV RNA as a biomarker for predicting treatment outcomes in this population.

METHODS

A retrospective cohort analysis was conducted on 117 pediatric patients with LLV (mean age: 13.14 years; 34% female) treated with continuous entecavir (ConT) or modified regimens (switching to or combining with tenofovir disoproxil fumarate) for ≥ 120 weeks. Virological response was defined as HBV DNA < 10 IU/mL at week 120.

RESULTS

No significant baseline differences existed between ConT and modified regimen groups. Compared to ConT, modified regimens achieved greater reductions in serum HBV DNA, HBV RNA, and quantitative HBsAg, with higher cumulative undetectable rates at week 120 (HBV DNA: ≥ 80.0%; HBV RNA: ≥ 54.8%; P < 0.05). Notably, qHBsAg levels remained elevated in most patients, with only 3 individuals achieving undetectable levels (< 0.05 IU/mL). Multivariate analysis identified higher HBV RNA levels at week 48 as an independent risk factor for non-virological response (adjusted odds ratio: 5.86; 95% confidence interval: 1.40-24.62; P = 0.016). Although HBV RNA alone was less predictive than HBV DNA (area under the receiver operating characteristic curve [AUC]: 0.76 vs. 0.80; P = 0.459), combining both markers improved prediction accuracy (AUC: 0.82; P < 0.05 vs. single markers).

CONCLUSIONS

In children with LLV, serum HBV RNA level is an independent risk factor for non-virological response and may serve as a complementary biomarker to HBV DNA for guiding antiviral therapy adjustments.

Prognostic Significance and Immune Environment Analysis Using PANoptosis Molecular Clustering in Gastric Cancer

BACKGROUND Stomach adenocarcinoma (STAD) is a common malignant tumor, known for its poor prognosis and challenges in early detection. PANoptosis, a recently discovered form of cell death, is characterized by the integrated activation of pyroptosis, apoptosis, and/or necroptosis pathways. The connection between PANoptosis and the initiation, progression, and prognosis of gastric cancer remains inadequately investigated. MATERIAL AND METHODS Previous research has identified 19 PANoptosis-related genes (PRGs). Using these genes, we performed an in-depth analysis of gastric cancer to identify differentially expressed genes related to prognosis (PRDEGs). These differentially expressed genes were subsequently identified. We analyzed the risk scores, prognoses, and immune landscapes of the patients. Confirmed PRGs and gene clusters have been linked to cancer initiation and progression, patient survival, and immunity. Risk scores were computed, and patients were categorized into 2 groups on the basis of prognostic characteristics linked to 8 specific genes. To increase the accuracy of predicting patient survival, we developed a nomogram that integrates the risk score with various clinical characteristics. RESULTS The analysis revealed that gastric cancer patients classified into high-risk subgroups experienced reduced survival times and a diminished response to immunotherapy. We also found that risk scores demonstrated correlations with immune cell infiltration, tumor microenvironment characteristics (TME), and cancer stem cell (CSC) levels. The differential expression of GPA33 and APOD between gastric tumor and normal tissues was validated by RT-qPCR and immunohistochemical data from the Human Protein Atlas (HPA). In conclusion, our research indicates that genes linked to PANoptosis may serve as key indicators for evaluating the prognosis and survival rates of patients with gastric cancer. CONCLUSIONS This research has the potential to improve the early detection of gastric cancer and contribute to the development of more effective therapeutic approaches.

Deep Learning Reconstruction for Enhanced Resolution and Image Quality in Breath-Hold MRCP: A Preliminary Study

OBJECTIVE

This preliminary study aims to assess the image quality of enhanced-resolution deep learning reconstruction (ER-DLR) in magnetic resonance cholangiopancreatography (MRCP) and compare it with non-ER-DLR MRCP images.

METHODS

Our retrospective study incorporated 34 patients diagnosed with biliary and pancreatic disorders. We obtained MRCP images using a single breath-hold MRCP on a 3T MRI system. We reconstructed MRCP images with ER-DLR (matrix = 768 × 960) and without ER-DLR (matrix = 256 × 320). Quantitative evaluation involved measuring the signal-to-noise ratio (SNR), contrast, contrast-to-noise ratio (CNR) between the common bile duct and periductal tissues, and slope. Two radiologists independently scored image noise, contrast, artifacts, sharpness, and overall image quality for the 2 image types using a 4-point scale. Results are expressed as median and interquartile range (IQR), and we compared quantitative and qualitative scores employing the Wilcoxon test.

RESULTS

In quantitative analyses, ER-DLR significantly improved SNR (21.08 [IQR: 14.85, 31.5] vs 15.07 [IQR: 9.57, 25.23], P  < 0.001), CNR (19.29 [IQR: 13.87, 24.98] vs 11.23 [IQR: 8.98, 15.74], P  < 0.001), contrast (0.96 [IQR: 0.94, 0.97] vs 0.9 [IQR: 0.87, 0.92], P  < 0.001), and slope of MRCP (0.62 [IQR: 0.56, 0.66] vs 0.49 [IQR: 0.45, 0.53], P  < 0.001). The qualitative evaluation demonstrated significant improvements in the perceived noise ( P  < 0.001), contrast ( P  = 0.013), sharpness ( P  < 0.001), and overall image quality ( P  < 0.001).

CONCLUSIONS

ER-DLR markedly increased the resolution, SNR, and CNR of breath-hold-MRCP compared to cases without ER-DLR.

The 2024 updated WHO guidelines for the prevention and management of chronic hepatitis B: Main changes and potential implications for the next major liver society clinical practice guidelines

Progress towards global elimination of hepatitis B virus (HBV) has been slow and most countries are far from reaching the elimination targets set out by the World Health Organization (WHO). The burden of chronic hepatitis B is mainly borne by resource-limited countries where only a minority of people living with HBV are diagnosed and treated, and international guidelines are hardly applicable in real-life. In March 2024, the WHO released its revised guidelines for the prevention and management of chronic hepatitis B. Simplification of care and expansion of treatment criteria represent the core of this revision. Whether and how these updated WHO guidelines will influence the next hepatitis B recommendations from the international liver societies (EASL, AASLD and APASL) remain uncertain. Yet, the European, American and Asian regions encompass multiple low, middle and intermediate-income countries with high HBV endemicity and vulnerable populations that should benefit from simplified clinical algorithms. Here, from an analysis of the WHO guideline development process and its new recommendations, we aimed to identify the anticipated areas of agreement and controversies with the next liver society hepatitis B guidelines, which will have to balance clinical risks and benefits for patients.

Incidences of Virological and Clinical Relapses After Cessation of Tenofovir Alafenamide, Tenofovir Disoproxil Fumarate, or Entecavir in Patients With HBeAg-Negative Chronic Hepatitis B

BACKGROUND AND AIM

The relapse pattern following the discontinuation of tenofovir alafenamide (TAF) in patients with chronic hepatitis B (CHB) remains unclear. This study aimed to compare the 2-year incidences of virological and clinical relapses among patients who discontinued TAF versus those who discontinued tenofovir disoproxil fumarate (TDF) or entecavir (ETV).

METHODS

This multicenter retrospective study enrolled noncirrhotic hepatitis B e antigen (HBeAg)-negative CHB patients who discontinued TAF, TDF, or ETV with undetectable HBV DNA at treatment cessation. For patients who switched from ETV or TDF to TAF, a minimum TAF exposure duration of 12 months was required for inclusion in the off-TAF group. Inverse probability of treatment weighting was employed to adjust for baseline differences.

RESULTS

A total of 162 patients (off-TAF: 37, off-TDF: 87, off-ETV: 38) were included in the primary analysis. The 2-year cumulative incidence of virological relapse was significantly higher in the off-TAF group (85.0%) compared to the off-TDF group (69.5%, p = 0.024) and the off-ETV group (51.5%, p = 0.010). Similarly, the 2-year cumulative incidence of clinical relapse was significantly higher in the off-TAF group (62.4%) compared to the off-TDF group (39.0%, p = 0.026) and the off-ETV group (22.5%, p = 0.024). Consistent results were observed in patients meeting the 2012 APASL stopping criteria.

CONCLUSIONS

HBeAg-negative patients who discontinue TAF face a higher risk of both virological and clinical relapses compared to those discontinuing TDF or ETV. These findings underscore the need for more intense monitoring in CHB patients after TAF cessation.

Clinical validation of preoperative serum markers for liver fibrosis in living donor liver transplantation recipients

PURPOSE

To validate the reliability of fibrosis markers as predictors of graft survival in living donor liver transplantation (LDLT) recipients.

METHODS

We reviewed data retrospectively, from 163 patients who underwent adult LDLT with preoperative measurements of type IV collagen (CIV), Mac-2 binding protein glycosylation isomer (M2BPGi), and hyaluronic acid (HA). Patients were divided into high and low groups for each biomarker, based on optimal cutoff values, and graft loss within 6 months was evaluated in each group.

RESULTS

The high CIV level group showed significantly lower 6-month graft survival rates and significantly higher rates of postoperative sepsis and sepsis from pneumonia. However, the groups with high and low M2BPGi levels and those with high and low HA levels did not show significant differences in 6-month graft survival rates or rates of postoperative sepsis. Multivariate analysis revealed that a CIV level ≥ 590 was a significant predictor of graft loss within 6 months, postoperative sepsis, and sepsis from pneumonia.

CONCLUSION

Unlike other fibrosis markers, preoperative CIV levels can predict graft survival, postoperative sepsis, and sepsis from pneumonia after LDLT.

Comparison of hepatitis B virus genotype B and C patients in Japan in terms of family history and maternal age at birth

AIM

Hepatitis B virus of genotypes B (HBV/B) and C (HBV/C) prevails in Japan and patients with HBV/B have been known to be older than those with HBV/C, but the reason has remained unknown. We aimed to clarify the reason by focusing on the family history of HBV infection.

METHODS

In a total of 508 patients with chronic HBV infection, HBV genotype, patient age, and age of the mother at birth were compared.

RESULTS

Patient age was significantly older in HBV/B than in HBV/C, and the patient percentage with a family history of HBV infection was lower in HBV/B. When comparing maternal age at birth between the two genotypes, there was no significant difference in the overall patient population, but the proportion of older birth group (≥26 years old) was significantly lower in HBV/B (38.7% vs. 59.3%, p = 0.048) in patients with a family history of HBV infection in both mothers and siblings whose HBV were considered to be transmitted vertically. There was a negative correlation between maternal age at birth and patient age in this group, reflecting the fact that the age of childbearing is increasing recently in Japan. Because patients with HBV/B experience hepatitis B e antigen seroconversion at an earlier age, it was considered that HBV/B has become harder to transmit vertically in recent decades.

CONCLUSION

The recent decrease in vertical transmission of HBV/B associated with an older childbearing age in Japan might be one of the reasons for the finding that HBV/B patients were older than HBV/C patients.

Feasibility of modified double-layered suturing for a large mucosal defect after duodenal endoscopic submucosal dissection (origami method)

A modified double-layered suturing procedure (origami method; OGM) can achieve robust closure, even for large mucosal defects, by folding the muscle layer using through-the-scope clips. This study aimed to evaluate the feasibility of OGM in duodenal endoscopic submucosal dissection (ESD).This retrospective, observational study was conducted at a tertiary care hospital. We reviewed cases of OGM attempted after duodenal ESD between June 2022 and April 2023. We excluded lesions located in the duodenal bulb or involving the major papilla. We measured the clinical characteristics and outcomes.OGM was attempted in 28 cases after duodenal ESD. The median mucosal defect size was 38 mm (range 26-110). Complete closure was achieved in 27 cases (96%), including the largest lesion. The median closure time was 16 minutes. There were no perforations caused by clips. Delayed perforation and bleeding were not observed. Among 28 cases, 21 underwent follow-up endoscopy 3-5 days after ESD, and the muscle layer remained folded in all cases.OGM achieved a high rate of complete closure even after duodenal ESD. Closure with OGM was robust enough to maintain the folded muscle layer for at least 3 days postoperatively.

FAM136A depletion induces mitochondrial stress and reduces mitochondrial membrane potential and ATP production

FAM136A deficiency has been associated with Ménière's disease. However, the underlying mechanism of action of this protein remains unclear. We hypothesized that FAM136A functions in maintaining mitochondria, even in HepG2 cells. To better characterize FAM136A function, we analyzed the cellular response caused by its depletion. FAM136A depletion induced reactive oxygen species (ROS) and reduced both mitochondrial membrane potential and ATP production. However, cleaved caspase-9 levels did not increase significantly. We next investigated why the depletion of FAM136A reduced the mitochondrial membrane potential and ATP production but did not lead to apoptosis. Depletion of FAM136A induced the mitochondrial unfolded protein response (UPRmt) and the expression levels of gluconeogenic phosphoenolpyruvate carboxykinases (PCK1 and PCK2) and ketogenic 3-hydroxy-3-methylglutaryl-CoA synthases (HMGCS1 and HMGCS2) were upregulated. Furthermore, depletion of FAM136A reduced accumulation of holocytochrome c synthase (HCCS), a FAM136A interacting enzyme that combines heme to apocytochrome c to produce holocytochrome c. Notably, the amount of heme in cytochrome c did not change significantly with FAM136A depletion, although the amount of total cytochrome c protein increased significantly. This observation suggests that greater amounts of cytochrome c remain unbound to heme in FAM136A-depleted cells.

Hepatitis B and D virus entry

Hepatitis B virus (HBV) entry is the initial step of viral infection, leading to the formation of covalently closed circular DNA, which is a molecular reservoir of viral persistence and a key obstacle for HBV cure. The restricted entry of HBV into specific cell types determines the nature of HBV, which has a narrow host range in tissues and species. Hepatitis D virus (HDV) shares viral surface antigens with HBV and thus follows a similar entry mechanism at its early stages. In late 2012, sodium taurocholate cotransporting polypeptide was discovered as an HBV and HDV entry receptor. Since then, the mechanisms of HBV and HDV entry have been extensively analysed. These analyses have expanded our understanding of HBV and HDV host tropism and have provided new strategies for the development of antiviral agents. Notably, the structures of sodium taurocholate cotransporting polypeptide and its interaction with the 2-48 amino acid region of viral preS1 have been recently solved. These findings will stimulate further entry studies. In this Review, we summarize current understanding of HBV and HDV entry and future perspectives.

Hepatitis B Surface Antigen Seroclearance Rate After Stopping Nucleos(t)ide Analogues in Chronic Hepatitis B-A Systematic Review and Meta-Analysis

AIM

To identify factors influencing HBsAg seroclearance rates after stopping nucleos(t)ide analogue (NA) therapy in patients with chronic hepatitis B (CHB).

METHODS

We conducted a comprehensive literature search in databases from inception to July 2024. Subgroup analyses and meta-regression were performed to determine factors associated with HBsAg seroclearance, including ethnicity, HBV genotype, NA therapy duration, end-of-treatment (EOT) qHBsAg levels, HBeAg status, cirrhosis status, and follow-up duration.

RESULTS

The meta-analysis included 62 studies (n = 9867) with a pooled HBsAg seroclearance rate of 10% (95%CI: 8%-12%, I2 = 92%) after NA cessation. HBeAg-negative patients showed significantly higher rates than HBeAg-positive patients (11% vs. 5%, p = 0.030). Subgroup analysis revealed higher seroclearance with follow-up of >5 years (18%, p = 0.004), showing significantly higher rates were observed in studies with longer follow-up periods. Caucasians showed a higher rate (12%) than Asians (9%, p = 0.067). Studies adhering to AASLD, EASL, or APASL stopping rules showed no significant differences in rates. Patients with EOT qHBsAg ≤2.0 log IU/mL had higher rates (23%) than those with >2.0 log IU/mL (11%). Re-treated patients had lower seroclearance (6%) compared to those not re-treated (17%, p = 0.178). Meta-regression identified ethnicity, HBeAg status, and follow-up duration as significant contributors to heterogeneity. Egger's test showed no evidence of publication bias (p = 0.1928).

CONCLUSION

Our meta-analysis highlights the role of ethnicity, EOT qHBsAg levels, HBeAg-status, and follow-up duration in determining HBsAg seroclearance rates. These findings stress the need for personalized NA discontinuation strategies and further research on HBV genotypes and biomarkers to improve treatment outcomes and predict seroclearance more accurately.

Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025

At a population level, the European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter and Microbiota Study Group (EHMSG), and the European Society of Pathology (ESP) suggest endoscopic screening for gastric cancer (and precancerous conditions) in high-risk regions (age-standardized rate [ASR] > 20 per 100 000 person-years) every 2 to 3 years or, if cost-effectiveness has been proven, in intermediate risk regions (ASR 10-20 per 100 000 person-years) every 5 years, but not in low-risk regions (ASR < 10).ESGE/EHMSG/ESP recommend that irrespective of country of origin, individual gastric risk assessment and stratification of precancerous conditions is recommended for first-time gastroscopy. ESGE/EHMSG/ESP suggest that gastric cancer screening or surveillance in asymptomatic individuals over 80 should be discontinued or not started, and that patients' comorbidities should be considered when treatment of superficial lesions is planned.ESGE/EHMSG/ESP recommend that a high quality endoscopy including the use of virtual chromoendoscopy (VCE), after proper training, is performed for screening, diagnosis, and staging of precancerous conditions (atrophy and intestinal metaplasia) and lesions (dysplasia or cancer), as well as after endoscopic therapy. VCE should be used to guide the sampling site for biopsies in the case of suspected neoplastic lesions as well as to guide biopsies for diagnosis and staging of gastric precancerous conditions, with random biopsies to be taken in the absence of endoscopically suspected changes. When there is a suspected early gastric neoplastic lesion, it should be properly described (location, size, Paris classification, vascular and mucosal pattern), photodocumented, and two targeted biopsies taken.ESGE/EHMSG/ESP do not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection unless there are signs of deep submucosal invasion or if the lesion is not considered suitable for endoscopic resection.ESGE/EHMSG/ESP recommend endoscopic submucosal dissection (ESD) for differentiated gastric lesions clinically staged as dysplastic (low grade and high grade) or as intramucosal carcinoma (of any size if not ulcerated or ≤ 30 mm if ulcerated), with EMR being an alternative for Paris 0-IIa lesions of size ≤ 10 mm with low likelihood of malignancy.ESGE/EHMSG/ESP suggest that a decision about ESD can be considered for malignant lesions clinically staged as having minimal submucosal invasion if differentiated and ≤ 30 mm; or for malignant lesions clinically staged as intramucosal, undifferentiated and ≤ 20 mm; and in both cases with no ulcerative findings.ESGE/EHMSG/ESP recommends patient management based on the following histological risk after endoscopic resection: Curative/very low-risk resection (lymph node metastasis [LNM] risk < 0.5 %-1 %): en bloc R0 resection; dysplastic/pT1a, differentiated lesion, no lymphovascular invasion, independent of size if no ulceration and ≤ 30 mm if ulcerated. No further staging procedure or treatment is recommended.Curative/low-risk resection (LNM risk < 3 %): en bloc R0 resection; lesion with no lymphovascular invasion and: a) pT1b, invasion ≤ 500 µm, differentiated, size ≤ 30 mm; or b) pT1a, undifferentiated, size ≤ 20 mm and no ulceration. Staging should be completed, and further treatment is generally not necessary, but a multidisciplinary discussion is required. Local-risk resection (very low risk of LNM but increased risk of local persistence/recurrence): Piecemeal resection or tumor-positive horizontal margin of a lesion otherwise meeting curative/very low-risk criteria (or meeting low-risk criteria provided that there is no submucosal invasive tumor at the resection margin in the case of piecemeal resection or tumor-positive horizontal margin for pT1b lesions [invasion ≤ 500 µm; well-differentiated; size ≤ 30 mm, and VM0]). Endoscopic surveillance/re-treatment is recommended rather than other additional treatment. High-risk resection (noncurative): Any lesion with any of the following: (a) a positive vertical margin (if carcinoma) or lymphovascular invasion or deep submucosal invasion (> 500 µm from the muscularis mucosae); (b) poorly differentiated lesions if ulceration or size > 20 mm; (c) pT1b differentiated lesions with submucosal invasion ≤ 500 µm with size > 30 mm; or (d) intramucosal ulcerative lesion with size > 30 mm. Complete staging and strong consideration for additional treatments (surgery) in multidisciplinary discussion.ESGE/EHMSG/ESP suggest the use of validated endoscopic classifications of atrophy (e. g. Kimura-Takemoto) or intestinal metaplasia (e. g. endoscopic grading of gastric intestinal metaplasia [EGGIM]) to endoscopically stage precancerous conditions and stratify the risk for gastric cancer.ESGE/EHMSG/ESP recommend that biopsies should be taken from at least two topographic sites (2 biopsies from the antrum/incisura and 2 from the corpus, guided by VCE) in two separate, clearly labeled vials. Additional biopsy from the incisura is optional.ESGE/EHMSG/ESP recommend that patients with extensive endoscopic changes (Kimura C3 + or EGGIM 5 +) or advanced histological stages of atrophic gastritis (severe atrophic changes or intestinal metaplasia, or changes in both antrum and corpus, operative link on gastritis assessment/operative link on gastric intestinal metaplasia [OLGA/OLGIM] III/IV) should be followed up with high quality endoscopy every 3 years, irrespective of the individual's country of origin.ESGE/EHMSG/ESP recommend that no surveillance is proposed for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history, incomplete intestinal metaplasia, persistent H. pylori infection). This group constitutes most individuals found in clinical practice.ESGE/EHMSG/ESP recommend H. pylori eradication for patients with precancerous conditions and after endoscopic or surgical therapy.ESGE/EHMSG/ESP recommend that patients should be advised to stop smoking and low-dose daily aspirin use may be considered for the prevention of gastric cancer in selected individuals with high risk for cardiovascular events.