Role of transient elastography in the diagnosis and prognosis of Fontan-associated liver disease

BACKGROUND

Fontan-associated liver disease (FALD) often occurs in patients with single-ventricle physiology following Fontan surgery, and ranges from liver congestion to cirrhosis. The assessment of the severity of FALD using noninvasive methods is challenging. However, transient elastography (TE) may be useful for the noninvasive evaluation of FALD and prediction of clinical outcomes.

AIM

To evaluate the role of TE in the diagnosis of FALD and its association with clinically relevant events.

METHODS

This retrospective single-center study (Hospital Universitario La Paz, Madrid), including 91 post-Fontan patients aged > 18 years old. Laboratory and ultrasound findings, and liver stiffness measurements (LSM) by TE (FibroScan^®) were assessed. FALD was defined using ultrasound criteria (hepatomegaly, liver surface nodularity, parenchymal heterogeneity, hyperechoic lesions, splenomegaly, collaterals) and advanced FALD was defined according to the European Association for the Study of the Liver-European Reference Network statement (esophageal varices, portosystemic shunts, ascites, splenomegaly). Clinically relevant events included heart or heart-liver transplantation indication, hepatocellular carcinoma, and all-cause mortality.

RESULTS

Patient characteristics were: 60.4% male; Mean age, 33.3 ± 8.2 years; Mean elapsed time since surgery, 24.3 ± 7.7 years; 89% with FALD; 73% with advanced FALD. LSM by TE was associated with FALD [odds ratio (OR) = 1.34; 95% confidence interval (95%CI): 1.10-1.64; P = 0.003] and advanced FALD (OR = 1.10; 95%CI: 1.01-1.19; P = 0.023). Areas under the curve (AUC) were 0.905 and 0.764 for FALD and advanced FALD, respectively. FALD cut-off values comprised: Optimal, 20 kPa (sensitivity: 92.3%; specificity: 80.0%); Rule-out, 15 kPa (sensitivity: 96.9%); Rule-in, 25 kPa (specificity: 100%). A FALD algorithm was proposed based on LSM by TE and elapsed time since surgery (AUC: 0.877; sensitivity, 95.4%; specificity, 80.0%; positive predictive value, 96.9%; negative predictive value, 72.7%). LSM by TE was associated with clinically relevant events (OR = 1.07; 95%CI: 1.01-1.13; P = 0.021) and all-cause mortality (OR = 1.23; 95%CI: 1.02-1.47; P = 0.026).

CONCLUSION

In adult patients post-Fontan surgery, TE is a useful noninvasive method for FALD diagnosis. The association between LSM by TE and clinically relevant events suggests a role in prognosis.

Radiomics and clinicoradiological factors as a promising approach for predicting microvascular invasion in hepatitis B-related hepatocellular carcinoma

Microvascular invasion (MVI) is a critical factor in hepatocellular carcinoma (HCC) prognosis, particularly in hepatitis B virus (HBV)-related cases. This editorial examines a recent study by Xu et al who developed models to predict MVI and high-risk (M2) status in HBV-related HCC using contrast-enhanced computed tomography (CECT) radiomics and clinicoradiological factors. The study analyzed 270 patients, creating models that achieved an area under the curve values of 0.841 and 0.768 for MVI prediction, and 0.865 and 0.798 for M2 status prediction in training and validation datasets, respectively. These results are comparable to previous radiomics-based approaches, which reinforces the potential of this method in MVI prediction. The strengths of the study include its focus on HBV-related HCC and the use of widely accessible CECT imaging. However, limitations, such as retrospective design and manual segmentation, highlight areas for improvement. The editorial discusses the implications of the study including the need for standardized radiomics approaches and the potential impact on personalized treatment strategies. It also suggests future research directions, such as exploring mechanistic links between radiomics features and MVI, as well as integrating additional biomarkers or imaging modalities. Overall, this study contributes significantly to HCC management, paving the way for more accurate, personalized treatment approaches in the era of precision oncology.

Attenuation imaging: Diagnostic differences in hepatic steatosis for chronic hepatitis B vs metabolic dysfunction-associated steatotic liver disease patients

BACKGROUND

Hepatic steatosis, characterized by fat accumulation in hepatocytes, can result from metabolic dysfunction-associated steatotic liver disease (MASLD), infections, alcoholism, chemotherapy, and toxins. MASLD is diagnosed via imaging or biopsy with metabolic criteria and may progress to metabolic dysfunction–associated steatohepatitis, potentially leading to fibrosis, cirrhosis, or cancer. The coexistence of hepatic steatosis with chronic hepatitis B (CHB) is mainly related to metabolic factors and increases mortality and cancer risks. As a noninvasive method, attenuation imaging (ATI) shows promise in quantifying liver fat, demonstrating strong correlation with liver biopsy.

AIM

To investigate the disparity of ATI for assessing biopsy-based hepatic steatosis in CHB patients and MASLD patients.

METHODS

The study enrolled 249 patients who underwent both ATI and liver biopsy, including 78 with CHB and 171 with MASLD. Hepatic steatosis was classified into grades S0 to S3 according to the proportion of fat cells present. Liver fibrosis was staged from 0 to 4 according to the meta-analysis of histological data in viral hepatitis scoring system. The diagnostic performance of attenuation coefficient (AC) values across different groups was compared for each grade of steatosis. Factors associated with the AC values were determined through linear regression analysis. A multivariate logistic regression model was established to predict ≥ S2 within the MASLD group.

RESULTS

In both the CHB and the MASLD groups, AC values increased significantly with higher steatosis grade (P < 0.001). In the CHB group, the areas under the curve (AUCs) of AC for predicting steatosis grades ≥ S1, ≥ S2 and S3 were 0.918, 0.960 and 0.987, respectively. In contrast, the MASLD group showed AUCs of 0.836, 0.774, and 0.688 for the same steatosis grades. The diagnostic performance of AC for detecting ≥ S2 and S3 indicated significant differences between the two groups (both P < 0.001). Multivariate linear regression analysis identified body mass index, triglycerides, and steatosis grade as significant factors for AC. When the steatosis grade is ≥ S2, it can progress to more serious liver conditions. A clinical model integrating blood biochemical parameters and AC was developed in the MASLD group to enhance the prediction of ≥ S2, achieving an AUC of 0.848.

CONCLUSION

The AC could effectively discriminate the degree of steatosis in both the CHB and MASLD groups. In the MASLD group, when combined with blood biochemical parameters, AC exhibited better predictive ability for moderate to severe steatosis.

Development and validation of a predictive model for the pathological upgrading of gastric low-grade intraepithelial neoplasia

BACKGROUND

The discrepancy between endoscopic biopsy pathology and the overall pathology of gastric low-grade intraepithelial neoplasia (LGIN) presents challenges in developing diagnostic and treatment protocols.

AIM

To develop a risk prediction model for the pathological upgrading of gastric LGIN to aid clinical diagnosis and treatment.

METHODS

We retrospectively analyzed data from patients newly diagnosed with gastric LGIN who underwent complete endoscopic resection within 6 months at the First Medical Center of Chinese People’s Liberation Army General Hospital between January 2008 and December 2023. A risk prediction model for the pathological progression of gastric LGIN was constructed and evaluated for accuracy and clinical applicability.

RESULTS

A total of 171 patients were included in this study: 93 patients with high-grade intraepithelial neoplasia or early gastric cancer and 78 with LGIN. The logistic stepwise regression model demonstrated a sensitivity and specificity of 0.868 and 0.800, respectively, while the least absolute shrinkage and selection operator (LASSO) regression model showed sensitivity and specificity values of 0.842 and 0.840, respectively. The area under the curve (AUC) for the logistic model was 0.896, slightly lower than the AUC of 0.904 for the LASSO model. Internal validation with 30% of the data yielded AUC scores of 0.908 for the logistic model and 0.905 for the LASSO model. The LASSO model provided greater utility in clinical decision-making.

CONCLUSION

A risk prediction model for the pathological upgrading of gastric LGIN based on white-light and magnifying endoscopic features can accurately and effectively guide clinical diagnosis and treatment.

Inhibition of the SERPINB5/HSP90AA1 axis restrains the proliferation and invasion of rectal cancer

BACKGROUND

The upregulation of serpin family B member 5 (SERPINB5) has been linked to the progression of rectal cancer. However, the specific roles and underlying mechanisms of SERPINB5 in rectal cancer are not fully understood.

AIM

To investigate the roles and mechanisms of SERPINB5 in rectal cancer.

METHODS

SERPINB5 protein level in rectal cancer tissues and cell lines was measured through western blot analysis. SW480 cells were transfected with pcDNA-SERPINB5 or short-hairpin RNA targeting SERPINB5 (sh-SERPINB5). Cell proliferation, invasion, and apoptosis were then evaluated. The interaction between SERPINB5 and heat shock protein 90 alpha class A member 1 (HSP90AA1) was confirmed through a co-immunoprecipitation assay. Subsequently, pcDNA-HSP90AA1 or sh-HSP90AA1 was transfected into SW480 cells, and cell progression was then detected. Moreover, rescue experiments were used to investigate the effect of the SERPINB5/HSP90AA1 axis on rectal cancer progression. Additionally, sh-SERPINB5-transfected SW480 cells were implanted into nude mice, and xenograft tumor growth was then evaluated.

RESULTS

SERPINB5 was prominently upregulated in rectal cancer tissues and cells. SERPINB5 overexpression increased SW480 cell proliferation and invasion while reducing apoptosis. In contrast, SERPINB5 knockdown had the opposite effects. Moreover, SERPINB5 could interact with HSP90AA1 and promote HSP90AA1 expression in SW480 cells. HSP90AA1 overexpression facilitated SW480 cell proliferation and invasion and restrained apoptosis. By contrast, HSP90AA1 knockdown suppressed cell progression. The upregulation of HSP90AA1 reversed the SERPINB5 silencing-mediated inhibition of SW480 cell progression. Additionally, SERPINB5 knockdown retarded the growth of rectal cancer tumors in vivo.

CONCLUSION

SERPINB5 knockdown inhibited rectal cancer cell proliferation and invasion and retarded xenograft tumor growth by inhibiting HSP90AA1 expression.

Apatinib regulates the glycolysis of vascular endothelial cells through PI3K/AKT/PFKFB3 pathway in hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a prevalent and aggressive malignancy in the Chinese population; the severe vascularization by the tumor makes it difficult to cure. The high incidence and poor survival rates of this disease indicate the search for new therapeutic alternatives. Apatinib became a drug of choice because it inhibits tyrosine kinase activity, mainly through an effect on vascular endothelial growth factor receptor-2, thereby preventing tumor angiogenesis. This mechanism of action makes apatinib effective in the treatment of HCC.

AIM

To investigate the effect of apatinib on the glycolysis of vascular endothelial cells (VECs).

METHODS

This present study has investigated the effects of HCC cells on VECs, paying particular attention to changes in the glycolytic activity of VECs. The co-culture system established in the present study examined key cellular functions such as extracellular acidification rate and oxygen consumption rate. It also discusses participation of apatinib in the above processes. Core to the findings is the phosphatidylinositol 3-kinase (PI3K)/AKT/6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 3 (PFKFB3) signaling pathway, emphasizing the function of phosphorylated AKT and its interaction with PFKFB3, an essential regulator of glycolysis. In the investigation, molecular mechanisms by which such a pathway could influence the above VECs functions of proliferation, migration, and tube formation were underlined through coimmunoprecipitation analysis. Besides, supplementary in vivo experiments on nude mice provided additional biological relevance to the obtained results.

RESULTS

The glycolytic metabolism in VECs co-cultured with HCC cells is highly active, and the increased glycolysis in these endothelial cells accelerates the malignant transformation of HCC cells. Apatinib has been shown to inhibit this glycolytic activity in the VECs. It also hinders the development, multiplication, and movement of these cells while encouraging their programmed cell death. Moreover, biological analysis revealed that apatinib mainly influences VECs by regulating the PI3K/AKT signaling pathway. Subsequent research indicated that apatinib blocks the PI3K/AKT/PFKEB3 pathway, which in turn reduces glycolysis in these cells.

CONCLUSION

Apatinib influences the glycolytic pathway in the VECs of HCC a through the PI3K/AKT/PFKFB3 signaling pathway.

Roles of autophagy and long non-coding RNAs in gastric cancer

Gastric cancer (GC) is one of the most aggressive malignancies worldwide and is characterized by its poor prognosis and resistance to conventional therapies. Autophagy and long non-coding RNAs (lncRNAs) play critical yet complex roles in GC, functioning as both tumor suppressors and promoters depending on the disease stage and context. Autophagy influences cellular homeostasis and metabolism, whereas lncRNAs regulate gene expression through epigenetic modifications, RNA sponging, and protein interactions. Notably, the interplay between lncRNAs and autophagy modulates tumor progression, metastasis, chemoresistance, and the tumor microenvironment. This study explored the intricate relationship between lncRNAs and autophagy in GC, highlighting their roles in pathogenesis and treatment resistance. By addressing current knowledge gaps and proposing innovative therapeutic strategies, we have emphasized the potential of targeting this dynamic interplay for improved diagnostic and therapeutic outcomes.

NAD+/SIRT1 pathway regulates glycolysis to promote oxaliplatin resistance in colorectal cancer

BACKGROUND

Glycolysis provides growth advantages and leads to drug resistance in colorectal cancer (CRC) cells. SIRT1, an NAD+-dependent deacetylase, regulates various cellular processes, and its upregulation results in antitumor effects. This study investigated the role of SIRT1 in metabolic reprogramming and oxaliplatin resistance in CRC cells.

AIM

To investigate the role of SIRT1 in metabolic reprogramming and overcoming oxaliplatin resistance in CRC cells.

METHODS

We performed transcriptome sequencing of human CRC parental cells and oxaliplatin-resistant cells to identify differentially expressed genes. Key regulators were identified via the LINCS database. NAD+ levels were measured by flow cytometry, and the effects of SIRT1 on oxaliplatin sensitivity were assessed by MTS assays, colony formation assays, and xenograft models. Glycolytic function was measured using Western blot and Seahorse assays.

RESULTS

Salermide, a SIRT1 inhibitor, was identified as a candidate compound that enhances oxaliplatin resistance. In oxaliplatin-resistant cells, SIRT1 was downregulated, whereas γH2AX and PARP were upregulated. PARP activation led to NAD+ depletion and SIRT1 inhibition, which were reversed by PARP inhibitor treatment. The increase in SIRT1 expression overcame oxaliplatin resistance, and while SIRT1 inhibition increased glycolysis, the increase in SIRT1 inhibited glycolysis in resistant CRC cells, which was characterized by reduced expression of the glycolytic enzymes PKM2 and LDHA, as well as a decreased extracellular acidification rate. The PKM2 inhibitor shikonin inhibited glycolysis and reversed oxaliplatin resistance induced by SIRT1 inhibition.

CONCLUSION

SIRT1 expression is reduced in oxaliplatin-resistant CRC cells due to PARP activation, which in turn increases glycolysis. Restoring SIRT1 expression reverses oxaliplatin resistance in CRC cells, offering a promising therapeutic strategy to overcome drug resistance.

Intestinal flora was associated with occurrence risk of chronic non-communicable diseases

BACKGROUND

The intestinal flora (IF) has been linked to risks of non-communicable diseases, especially various cancers, stroke, and Alzheimer’s disease. However, many uncertainties of these associations during different stages of growth, development, and aging still exist. Therefore, further in-depth explorations are warranted.

AIM

To explore the associations of the human IF with disease risks during different stages of growth, development, and aging to achieve more accurate and convincing conclusions.

METHODS

Cohort, cross-sectional, case-control, and Mendelian randomization studies published in the PubMed and Web of Science databases until December 31, 2023 were systematically reviewed to clarify the associations of the IF at the genus level with the risks of various non-communicable diseases, which were grouped in accordance with the 10^th revision of the International Classification of Diseases.

RESULTS

In total, 57 studies were included to quantitatively examine the influence of the IF on the risks of 30 non-communicable diseases during different stages of growth, development, and aging. Population studies and Mendelian randomization studies confirmed positive associations of the abundances of Bifidobacterium and Ruminococcus with multiple sclerosis.

CONCLUSION

These findings contribute to a deeper understanding of the roles of the IF and provide novel evidence for effective strategies for the prevention and treatment of non-communicable diseases. In the future, it will be necessary to explore a greater variety of research techniques to uncover the specific mechanisms by which gut microbiota trigger diseases and conduct in-depth studies on the temporal relationship between microbiota alterations and diseases, so as to clarify the causal relationship more accurately.

Preoperative prediction of textbook outcome in intrahepatic cholangiocarcinoma by interpretable machine learning: A multicenter cohort study

BACKGROUND

To investigate the preoperative factors influencing textbook outcomes (TO) in Intrahepatic cholangiocarcinoma (ICC) patients and evaluate the feasibility of an interpretable machine learning model for preoperative prediction of TO, we developed a machine learning model for preoperative prediction of TO and used the SHapley Additive exPlanations (SHAP) technique to illustrate the prediction process.

AIM

To analyze the factors influencing textbook outcomes before surgery and to establish interpretable machine learning models for preoperative prediction.

METHODS

A total of 376 patients diagnosed with ICC were retrospectively collected from four major medical institutions in China, covering the period from 2011 to 2017. Logistic regression analysis was conducted to identify preoperative variables associated with achieving TO. Based on these variables, an EXtreme Gradient Boosting (XGBoost) machine learning prediction model was constructed using the XGBoost package. The SHAP (package: Shapviz) algorithm was employed to visualize each variable's contribution to the model's predictions. Kaplan-Meier survival analysis was performed to compare the prognostic differences between the TO-achieving and non-TO-achieving groups.

RESULTS

Among 376 patients, 287 were included in the training group and 89 in the validation group. Logistic regression identified the following preoperative variables influencing TO: Child-Pugh classification, Eastern Cooperative Oncology Group (ECOG) score, hepatitis B, and tumor size. The XGBoost prediction model demonstrated high accuracy in internal validation (AUC = 0.8825) and external validation (AUC = 0.8346). Survival analysis revealed that the disease-free survival rates for patients achieving TO at 1, 2, and 3 years were 64.2%, 56.8%, and 43.4%, respectively.

CONCLUSION

Child-Pugh classification, ECOG score, hepatitis B, and tumor size are preoperative predictors of TO. In both the training group and the validation group, the machine learning model had certain effectiveness in predicting TO before surgery. The SHAP algorithm provided intuitive visualization of the machine learning prediction process, enhancing its interpretability.

Cholangiocarcinoma: The era of liquid biopsy

Cholangiocarcinoma (CCA) is a highly aggressive and heterogeneous malignancy arising from the epithelial cells of the biliary tract. The limitations of the current methods in the diagnosis of CCA highlight the urgent need for new, accurate tools for early cancer detection, better prognostication and patient monitoring. Liquid biopsy (LB) is a modern and non-invasive technique comprising a diverse group of methodologies aiming to detect tumour biomarkers from body fluids. These biomarkers include circulating tumour cells, cell-free DNA, circulating tumour DNA, RNA and extracellular vesicles. The aim of this review is to explore the current and potential future applications of LB in CCA management, with a focus on diagnosis, prognostication and monitoring. We examine both its significant potential and the inevitable limitations associated with this technology. We conclude that LB holds considerable promise, but further research is necessary to fully integrate it into precision oncology for CCA.

Impact of poorly controlled type II diabetes mellitus on chemoresistance in colorectal cancer

Type 2 diabetes mellitus (T2DM) significantly elevates the risk of colorectal cancer (CRC) and complicates its treatment by promoting chemoresistance. Poor glycemic control has been linked to exacerbated CRC progression and diminished chemotherapy efficacy, impacting patient outcomes through various mechanisms such as oxidative stress, activation of metabolic pathways, and altered protein modifications that hinder apoptosis and enhance tumor survival. Clinical evidence shows that T2DM patients experience higher rates of chemoresistance and reduced disease-free survival and overall survival compared to non-diabetic patients. Specifically, those with poor glycemic control exhibit increased chemoresistance and poorer survival metrics. Antidiabetic treatments, including metformin, acarbose, and gliclazide, show promise in improving chemotherapy response and glycemic management, potentially enhancing patient outcomes. Addressing this challenge requires a comprehensive, multidisciplinary approach involving oncologists, endocrinologists, and surgeons to optimize patient care. Integrated strategies that prioritize glycemic control are essential for reducing chemoresistance and improving survival in CRC patients with T2DM.

Improving radiomics-based models for esophagogastric variceal bleeding risk prediction in cirrhotic patients

A recent study by Peng et al developed a predictive model for first-instance secondary esophageal variceal bleeding in cirrhotic patients by integrating clinical and multi-organ radiomic features. The combined radiomic-clinical model demonstrated strong predictive capabilities, achieving an area under the curve of 0.951 in the training cohort and 0.930 in the validation cohort. The results highlight the potential of noninvasive prediction models in assessing esophageal variceal bleeding risk, aiding in timely clinical decision-making. Additionally, manual delineation of regions of interest raises the risk of observer bias despite efforts to minimize it. The study adjusted for clinical covariates, while some potential confounders, such as socioeconomic status, alcohol use, and liver function scores, were not included. Additionally, an imbalance in cohort sizes between the training and validation groups may reduce the statistical power of validation. Expanding the validation cohort and incorporating multi-center external validation would improve generalizability. Future studies should focus on incorporating long-term patient outcomes, exploring additional imaging modalities, and integrating automated segmentation techniques to refine the predictive model.

Trichostatin A augments cell migration and epithelial-mesenchymal transition in esophageal squamous cell carcinoma through BRD4/c-Myc endoplasmic reticulum-stress pathway

BACKGROUND

The causes of death in patients with advanced esophageal cancer are multifactorial, with tumor metastasis being one of the important factors. Histone acetylation promotes the migration of esophageal squamous cell carcinoma (ESCC) cells, while the histone deacetylase inhibitor (HDACi) shows complex effects on tumor functions.

AIM

To comprehensively elucidate the impact and molecular mechanisms of trichostatin A (TSA), an HDACi, on cell migration in ESCC through bromodomain-containing protein (BRD4)/cellular myelocytomatosis oncogene (c-Myc)/endoplasmic reticulum (ER)-stress.

METHODS

The effects of TSA on ESCC cell lines Eca109 and EC9706 migration were evaluated using Transwell assays, with small interfering transfection and pathway-specific inhibitors to elucidate underlying mechanisms. The mRNA levels involved were examined by quantitative real-time polymerase chain reaction. Protein levels of acetylated histones H3 (acH3) and acetylated histones H4, BRD4, c-Myc, as well as markers of ER stress and epithelial-mesenchymal transition (EMT), were analyzed using western blot. Additionally, this method was also used to examine acH3 levels in esophageal cancer tissues and adjacent tissues. Patient outcomes were subsequently tracked to identify prognostic indicators using Log-Rank tests and Cox multivariate analysis.

RESULTS

TSA promoted the migration of ESCC cells by stimulating the EMT process. TSA-mediated histone acetylation facilitated the recruitment of BRD4, a bromodomain-containing protein, triggering the expression of c-Myc. This cascade induced ER stress and enhanced EMT in ESCC cells. To further elucidate the underlying mechanism, we employed various interventions including the ER stress inhibitor 4-phenylbutyric acid, knockdown of c-Myc and BRD4 expression, and utilization of the BRD4 inhibitor carboxylic acid as well as the inhibitor of TSA 1. Mechanistically, these studies revealed that TSA-mediated histone acetylation facilitated the recruitment of BRD4, which in turn triggered the expression of c-Myc. This sequential activation induced ER stress and subsequently enhanced EMT, thereby promoting the migration of ESCC cells. Additionally, we examined histone acetylation levels in specimens from 43 patients with ESCC, including both tumor tissues and paired adjacent tissues. Statistical analysis unveiled a negative correlation between the level of histone acetylation and the long-term prognosis of patients with ESCC.

CONCLUSION

TSA promoted ESCC cell migration through the BRD4/c-Myc/ER stress pathway. Moreover, elevated histone acetylation in ESCC tissues correlated with poor ESCC prognosis. These findings enhance our understanding of ESCC migration and HDACi therapy.

Validity of the efficacy of the spray flushing cleaning method in flexible endoscope reprocessing

The advancement in endoscopic technology and techniques has increased its use in the diagnosis and treatment of gastrointestinal diseases. Reprocessing of reusable endoscopes remains a challenge. Inadequate reprocessing leads to bacterial contamination of the endoscope, a significant cause of endoscope-related infections. To thoroughly address the complexities of cleaning a flexible endoscope, various cleaning methods have been devised and tested across different studies. This letter evaluates one such method, spray flushing for flexible gastroscopes, developed and tested in a randomized controlled trial by Du et al. Based on the post-processing test results for this method, Du et al conclude that there is improved cleaning efficacy and reduced damage compared to manual brush cleaning. The validity and reliability of the results could be further enhanced by carefully considering the study design and a few underlying concepts that contribute to the reprocessing quality of different types of endoscopes.

NMDAR2B/PKA/CREB signaling pathway contributes to esophageal neuropathic pain in gastroesophageal reflux disease

BACKGROUND

Esophageal hypersensitivity is an important cause of refractory gastroesophageal reflux disease, in which patients do not respond to standard acid-suppressive therapy and suffer from continuous noncardiac chest pain and regurgitation. The N-methyl-D-aspartate receptor (NMDAR) may play a crucial role in the development of visceral hypersensitivity in functional gastrointestinal disorders. However, the specific mechanisms of visceral hypersensitivity in upper digestive tract diseases remain poorly understood.

AIM

To investigate the role of the NMDAR2B/protein kinase A (PKA)/cAMP-response element binding protein (CREB) signaling pathway in the development of esophageal neuropathic pain associated with gastroesophageal reflux disease (GERD).

METHODS

Thirty-six 6-week-old specific pathogen free rats were randomly assigned to six groups: the control, model, model + NMDAR agonist, model + NMDAR antagonist, model + PKA antagonist, and model + NMDAR antagonist + PKA agonist groups, with six rats in each group. The model was induced via an intraperitoneal injection of ovalbumin for sensitization along with local esophageal stimulation. Immunohistochemistry and Western blotting were utilized to assess the expression levels of NMDAR2B signaling pathway-related proteins in the cingulate gyrus, dorsal thalamus, spinal dorsal horn, and peripheral esophageal tissues. RT-PCR was used to measure the corresponding mRNA expression, and ELISA was used to determine the serum brain-derived neurotrophic factor (BDNF) concentration. Behavioral scoring was performed during balloon distention and acid perfusion of the lower esophagus.

RESULTS

Compared with the control group, the model group presented significantly increased expression levels of the NMDAR2B, PKA, CREB, BDNF, substance P, and calcitonin gene-related peptide proteins and mRNAs in the cingulate gyrus, dorsal thalamus, spinal dorsal horn, and lower esophagus (P < 0.05). Compared with the model group, the model + NMDAR agonist group exhibited even higher expression levels of these proteins and mRNAs (P < 0.05), whereas the model + NMDAR antagonist and model + PKA antagonist groups presented lower expression levels (P < 0.05). The model + NMDAR antagonist + PKA agonist group presented higher expression levels than did the model + NMDAR antagonist group (P < 0.05). The changes in the serum BDNF concentration and behavioral score during balloon distention and acid perfusion were consistent with these changes in expression.

CONCLUSION

The NMDAR2B signaling pathway plays a critical role in the development of neuropathic pain in GERD through the PKA/CREB/BDNF pathway.

Phospholipase D2: A biomarker for stratifying disease severity in acute pancreatitis?

In this editorial, we critically evaluate the recent article by Niu et al, which explores the potential of phospholipase D2 (PLD2) as a biomarker for stratifying disease severity in acute pancreatitis (AP). AP is a clinically heterogeneous inflammatory condition that requires reliable biomarkers for early and accurate classification of disease severity. PLD2, an essential regulator of neutrophil migration and inflammatory responses, has emerged as a promising candidate. Although current biomarkers such as C-reactive protein and procalcitonin provide general indications of inflammation, they lack specificity regarding the molecular mechanisms underlying AP progression. Recent studies, including the research conducted by Niu et al, suggest an inverse correlation between PLD2 expression and AP severity, offering both diagnostic insights and mechanistic understanding. This editorial critically evaluates the role of PLD2 as a biomarker in the broader context of AP research. Evidence indicates that decreased levels of PLD2 are associated with increased neutrophil chemotaxis and cytokine release, contributing to pancreatic and systemic inflammation. However, several challenges remain, including the need for large-scale validation and functional studies to establish causation, and standardization of measurement protocols. Additionally, further investigation into the temporal dynamics of PLD2 expression and its variability across diverse populations is warranted. Looking ahead, PLD2 holds the potential to revolutionize AP management by integrating molecular diagnostics with precision medicine. The utilization of large-scale multi-omics approaches and advancements in diagnostic platforms could position PLD2 as a fundamental biomarker for early diagnosis, prognosis, and potentially therapeutic targeting. While promising, it is crucial to conduct critical evaluations and rigorous validations of PLD2’s role to ensure its efficacy in improving patient outcomes.

Construction and validation of machine learning-based predictive model for colorectal polyp recurrence one year after endoscopic mucosal resection

BACKGROUND

Colorectal polyps are precancerous diseases of colorectal cancer. Early detection and resection of colorectal polyps can effectively reduce the mortality of colorectal cancer. Endoscopic mucosal resection (EMR) is a common polypectomy procedure in clinical practice, but it has a high postoperative recurrence rate. Currently, there is no predictive model for the recurrence of colorectal polyps after EMR.

AIM

To construct and validate a machine learning (ML) model for predicting the risk of colorectal polyp recurrence one year after EMR.

METHODS

This study retrospectively collected data from 1694 patients at three medical centers in Xuzhou. Additionally, a total of 166 patients were collected to form a prospective validation set. Feature variable screening was conducted using univariate and multivariate logistic regression analyses, and five ML algorithms were used to construct the predictive models. The optimal models were evaluated based on different performance metrics. Decision curve analysis (DCA) and SHapley Additive exPlanation (SHAP) analysis were performed to assess clinical applicability and predictor importance.

RESULTS

Multivariate logistic regression analysis identified 8 independent risk factors for colorectal polyp recurrence one year after EMR (P < 0.05). Among the models, eXtreme Gradient Boosting (XGBoost) demonstrated the highest area under the curve (AUC) in the training set, internal validation set, and prospective validation set, with AUCs of 0.909 (95%CI: 0.89-0.92), 0.921 (95%CI: 0.90-0.94), and 0.963 (95%CI: 0.94-0.99), respectively. DCA indicated favorable clinical utility for the XGBoost model. SHAP analysis identified smoking history, family history, and age as the top three most important predictors in the model.

CONCLUSION

The XGBoost model has the best predictive performance and can assist clinicians in providing individualized colonoscopy follow-up recommendations.

Overcoming antibiotic-resistant Helicobacter pylori infection: Current challenges and emerging approaches

Recent studies have shown a noticeable increase in global Helicobacter pylori (H. pylori) resistance, with clarithromycin resistance surpassing 15% in various areas. However, inadequate epidemiological monitoring, especially in developing countries, and the absence of uniform testing methods lead to discrepancies between regions and a possible underestimation of resistance levels. The complexity of treating H. pylori is driven by its highly dynamic genome, which is prone to frequent mutations contributing to phenotypical resistance. The usual course of action in empirical treatment involves using a combination of various drugs simultaneously, leading to significant resistance selection pressure and potential side effects. The emergence of H. pylori strains resistant to multiple drugs is closely tied to failures in first-line treatment, highlighting the need to prevent further resistance by using optimal initial empirical therapy or regimens guided by antibiotic susceptibility testing, requiring a collection of mixed samples and multiple isolates for accurate assessment. The emergence of new treatments like potassium-competitive acid blockers offers a hopeful approach to decrease antimicrobial usage while still ensuring effectiveness in comparison to traditional therapies with proton pump inhibitors. Additionally, the use of probiotics is under investigation to identify specific strains and formulations that may mitigate therapy-associated adverse effects.

Endoscopic full-thickness resection: A definitive solution for local complete resection of small rectal neuroendocrine neoplasms

BACKGROUND

Recently, several endoscopic techniques have been used to improve the R0 resection rate of rectal neuroendocrine neoplasms (R-NENs). However, none of these methods can achieve 100% complete resection (CR), particularly in the vertical direction. Endoscopic full-thickness resection (EFTR) has proven to be an effective method for the treatment of submucosal tumors but is seldom utilized in the eradication of R-NENs.

AIM

To review cases of R-NENs removed using EFTR and to evaluate the safety and efficacy of this technique.

METHODS

This retrospective cohort study enrolled 160 patients with pathologically confirmed R-NENs, including 132 who underwent endoscopic submucosal dissection (ESD) and 28 who underwent EFTR. Lesions were categorized as < 1 cm, 1-2 cm, and > 2 cm in size. CR rate, en bloc resection rate, operation time, and complications were evaluated. Subgroup analyses and follow-up were also performed.

RESULTS

EFTR achieved 100% CR rates for lesions < 1 cm and 1-2 cm, compared with 67.0% and 50.0%, respectively, in the ESD group. En bloc resection and successful removal of the R-NENs were achieved in all patients. Meanwhile, EFTR showed performance comparable to ESD in terms of operation time, hospitalization cost, and postoperative adverse events, except for a one-day longer hospital stay. We also analyzed the invasion depth of R-NENs based on full-thickness specimens. The data showed that 80% of lesions (< 1 cm) and 85.7% of lesions (1-2 cm) had invaded the SM3 level or deeper at the time of resection. For ESD specimens, 46.6% (< 1 cm) and 89.3% (1-2 cm) of lesions had infiltrated more than 2000 μm beneath the muscularis mucosae.

CONCLUSION

EFTR has shown superior performance in the resection of small R-NENs compared with that of ESD.

Two treatment methods for hepatocellular carcinoma: Lenvatinib or bevacizumab combined with sintilimab and interventional therapy

In their study, Han et al compared the efficacy of bevacizumab plus sindilizumab plus interventional therapy with that of lenvatinib plus sindilizumab plus interventional therapy for patients with intermediate and advanced hepatocellular carcinoma. The triple therapy, which integrates interventional therapy, targeted therapy, and immunotherapy, has emerged as a promising research focus in the treatment of liver cancer. Consequently, it is of utmost significance to select an appropriate combination of interventional therapy, targeted therapy, and immunotherapy for patients suffering from intermediate and advanced liver cancer.

Lactococcus garvieae aggravates cholestatic liver disease by increasing intestinal permeability and enhancing bile acid reabsorption

BACKGROUND

Although an association between gut microbiota and cholestatic liver disease (CLD) has been reported, the precise functional roles of these microbes in CLD pathogenesis remain largely unknown.

AIM

To explore the function of gut microbes in CLD pathogenesis and the effects of gut microbiota on intestinal barrier and bile acid (BA) metabolism in CLD.

METHODS

Male C57BL/6J mice were fed a 0.05% 3,5-diethoxycarbonyl-1,4-dihydrocollidine diet for 2 weeks to induce CLD. The sterile liver tissues of mice were then meticulously harvested, and bacteria in homogenates were identified through culture methods. Furthermore, 16S ribosomal DNA sequencing was employed to analyze sterile liver samples collected from eight patients with primary biliary cholangitis (PBC) and three control individuals with hepatic cysts. The functional roles of the identified bacteria in CLD pathogenesis were assessed through microbiota transfer experiments, involving the evaluation of changes in intestinal permeability and BA dynamics.

RESULTS

Ligilactobacillus murinus (L. murinus) and Lactococcus garvieae (L. garvieae) were isolated from the bacterial culture of livers from CLD mice. L. murinus was prevalently detected in PBC patients and controls, whereas L. garvieae was detected only in patients with PBC but not in controls. Mice inoculated with L. garvieae exhibited increased susceptibility to experimental CLD, with both in vitro and in vivo indicating that L. garvieae disrupted the intestinal barrier function by down-regulating the expression of occludin and zonula occludens-1. Moreover, L. garvieae administration significantly upregulated the expression of the apical sodium-dependent BA transporter in the terminal ileum and increased serum BA levels.

CONCLUSION

L. garvieae contributes to excessive BA-induced hepatobiliary injury and liver fibrosis by increasing intestinal permeability and enhancing BA reabsorption.

Current considerations for the management of liver echinococcosis

Echinococcosis or hydatid disease is induced mainly by Echinococcus granulosus and occasionally by Echinococcus multilocularis (alveolaris) and affects the liver predominantly. Hepatic alveolar echinococcosis is similar to carcinoma in appearance, and without treatment, it can lead to death. Diagnosis is based on current imaging modalities. Surgical management is the cornerstone of treatment. Complete removal of the cyst (total pericystectomy or hepatectomy) ensures a permanent cure and should be the first-choice treatment for cystic disease. Cyst evacuation, partial cystectomy, and drainage or omentoplasty, may be alternative choices in difficult cases. Albendazole, mebendazole and praziquantel are options for treating small cysts and preventing recurrence after surgery. Despite the efforts, alveolar echinococcus is not usually amenable to surgical management, except in the early stage, which is less common, and management by albendazole is indicated. However, there are few recent reports of major operations (ex-vivo hepatectomy, autotransplantation and vascular reconstruction) in advanced stages.

Catching cancer signals in the blood: Innovative pathways for early esophageal cancer diagnosis

In recent years, significant progress has been made in the application of DNA methylation for the early detection of esophageal cancer (EC). As an epigenetic modification, DNA methylation allows for noninvasive screening by detecting the methylation status of circulating tumor DNA. Studies have shown that the methylation of genes such as SHOX2, SEPTIN9, EPO, and RNF180 significantly improves diagnostic sensitivity and specificity. Currently, SEPTIN9 has been approved by the Food and Drug Administration for colorectal cancer screening, while SHOX2 and EPO show promising results in EC, and RNF180 has potential in gastrointestinal tumors. This editorial reviews the study by Liu et al, which demonstrated the potential of combining the methylation of these four genes for early EC screening. In addition to their roles in early diagnosis, DNA methylation markers are gaining attention because of their roles in predicting recurrence and in postoperative follow-up. By monitoring changes in methylation levels, these markers can provide valuable insights into treatment efficacy and long-term management. As research progresses, liquid biopsy technology is expected to become an essential tool in the precision diagnosis and treatment of EC, benefiting patients significantly.

Artificial intelligence in gastroenterology: Ethical and diagnostic challenges in clinical practice

This article discusses the manuscript recently published in the World Journal of Gastroenterology, which explores the application of deep learning models in decision-making processes via wireless capsule endoscopy. Integrating artificial intelligence (AI) into gastrointestinal disease diagnosis represents a transformative step toward precision medicine, enhancing real-time accuracy in detecting multi-category lesions at earlier stages, including small bowel lesions and precancerous polyps, ultimately improving patient outcomes. However, the use of AI in clinical settings raises ethical considerations that extend beyond technological potential. Issues of patient privacy, data security, and potential diagnostic biases require careful attention. AI models must prioritize diverse and representative datasets to mitigate inequities and ensure diagnostic accuracy across populations. Furthermore, balancing AI with clinical expertise is crucial, positioning AI as a supportive tool rather than a replacement for physician judgment. Addressing these ethical challenges will support the responsible deployment of AI, through equitable contribution to patient-centered care.