Angiogenesis in Inflammatory Bowel Disease

Angiogenesis is an important component of pathogenesis of inflammatory bowel disease (IBD). Chronic inflammation and angiogenesis are two closely related processes. Chronic intestinal inflammation is dependent on angiogenesis and this angiogenesis is modulated by immune system in IBD. Angiogenesis is a very complex process which includes multiple cell types, growth factors, cytokines, adhesion molecules, and signal transduction. Lymphangiogenesis is a new research area in the pathogenesis of IBD. While angiogenesis supports inflammation via leukocyte migration, carrying oxygen and nutrients, on the other hand, it has a major role in wound healing. Angiogenic molecules look like perfect targets for the treatment of IBD, but they have risk for serious side effects because of their nature.

Role of Bismuth in the Eradication of Helicobacter pylori

Bismuth salts exert their activity within the upper gastrointestinal tract through action of luminal bismuth. Bismuth exerts direct bactericidal effect on Helicobacter pylori by different ways: forms complexes in the bacterial wall and periplasmic space, inhibits different enzymes, ATP synthesis, and adherence of the bacteria to the gastric mucosa. Bismuth also helps ulcer healing by acting as a barrier to the aggressive factors and increasing mucosal protective factors such as prostaglandin, epidermal growth factor, and bicarbonate secretion. To date, no resistance to bismuth has been reported. Also synergism between bismuth salts and antibiotics was present. It was shown that metronidazole and clarithromycin resistant H. pylori strains become susceptible if they are administered together with bismuth. Bismuth-containing quadruple therapy was recommended both by the Second Asia-Pacific Consensus Guidelines and by the Maastricht IV/Florence Consensus Report as an alternative first choice regimen to standard triple therapy, in areas with low clarithromycin resistance, and it is recommended as the first-line therapeutic option in areas with a high prevalence of clarithromycin resistance. Greater than 90% eradication success can be obtained by bismuth-containing quadruple therapy. Choosing bismuth as an indispensable part of first-line therapy is logical as both metronidazole and clarithromycin resistances can be overcome by adding bismuth to the regimen.

Etiopathogenesis, Prevention, and Treatment of Thromboembolism in Inflammatory Bowel Disease

The close relationship between inflammation and thrombosis affects the progression and severity of inflammatory bowel disease (IBD). The prevalence of venous thromboembolism (VTE) varies between 1% and 7% among patients with IBD. The VTE risk in patients with IBD is at least 3 times higher than that in the normal general population. The absolute risk is very high during hospitalization, active disease, and surgery. The IBD-related VTE occurs at younger ages and recurs more frequently. The development of thrombosis in IBD is due to the interaction of many hereditary and acquired risk factors. Each patient diagnosed with IBD should be evaluated for a personal and family history of thrombosis and for prothrombotic drug use. Although procoagulant factors are increased during the natural course of inflammation, natural anticoagulants and fibrinolytic activity are decreased. Although IBD is accepted as a prothrombotic condition, there is no treatment that can remove this risk from daily practice. Patient training is required to control important factors, such as long-term immobilization and smoking. Oral contraceptives and hormone replacement therapy should be avoided. Inducing permanent disease remission must be the key approach for the prevention of thrombosis. Low-molecular-weight heparin (LMWH) is the basis of prophylactic treatment, which reduces the thrombosis risk by 50%. Prophylaxis with LMWH should be administered to all patients with IBD hospitalized due to disease attack or surgery. Long-term or even life-long anticoagulation therapy should be planned if there is insufficient disease control, recurrent VTE attacks, positive thrombophilia tests, or thrombosis in vital veins.

Endoplasmic reticulum stress in biological processing and disease

The ability of translated cellular proteins to perform their functions requires their proper folding after synthesis. The endoplasmic reticulum (ER) is responsible for coordinating protein folding and maturation. Infections, genetic mutations, environmental factors and many other conditions can lead to challenges to the ER known as ER stress. Altering ER homeostasis results in accumulation of misfolded or unfolded proteins. To eliminate this problem, a response is initiated by the cell called the unfolded protein response (UPR), which involves multiple signaling pathways. Prolonged ER stress or a dysregulated UPR can lead to premature apoptosis and an exaggerated inflammatory response. Following these discoveries, ER stress was shown to be related to several chronic diseases, such as diabetes mellitus, neurodegenerative disorders, fatty liver disease and inflammatory bowel disease that have not yet been clearly demonstrated pathophysiologically. Here, we review the field and present up-to-date information on the relationship between biological processing, ER stress, UPR, and several chronic diseases.

The Relationship of Serum Hemojuvelin and Hepcidin Levels with Iron Overload in Nonalcoholic Fatty Liver Disease

BACKGROUND AND AIMS

Mild iron overload is frequently reported in patients with nonalcoholic fatty liver disease (NAFLD). Hepcidin is the master iron-regulatory peptide and hemojuvelin (HJV) is the key regulator of iron-dependent secretion of hepcidin. The aims of this study were to evaluate serum HJV and hepcidin levels in patients with biopsy-proven NAFLD with and without hepatic iron overload, and to identify potential associations of HJV and hepcidin with the clinical characteristics of the patients enrolled.

METHODS

Serum levels of HJV and hepcidin were measured in 66 NAFLD patients with (n=12) and without (n=54) iron overload, and controls (n=35) by enzyme-linked immunosorbent assay. Hemojuvelin and hepcidin levels were assessed in relation to clinical characteristics and liver histologic evaluation of the participants.

RESULTS

Significantly lower serum HJV (281.1 [239.2-353.6] vs. 584.8 [440.3-661] ng/ml, p<0.001) and similar serum hepcidin levels (60.5+/-31.1 vs. 55.8+/-11.9 ng/ml, p=0.285) were found in NAFLD patients when compared to controls. İron-overloaded NAFLD patients had significantly lower HJV (249.9 [187.6-296.3] vs. 292.9 [243-435] ng/ml, p=0.032) and significantly higher hepcidin (78.4+/-35.5 vs. 56.5+/-28.9ng/ml, p=0.027) levels than NAFLD patients without iron overload. Fibrosis stage was significantly higher in iron overloaded NAFLD group (p<0.001). Ferritin levels correlated significantly both with HOMA-IR (r=0.368, p=0.002) and fibrosis stage (r=0.571, p<0.001).

CONCLUSIONS

Our findings suggest that HJV levels are low in NAFLD and even lower in iron overloaded NAFLD, while hepcidin levels are higher in NAFLD with iron overload. The gradually decreased HJV and increased hepcidin concentrations in our patients most likely reflect the physiological response to iron accumulation in the liver.

Plasma Pentraxin 3 Differentiates Nonalcoholic Steatohepatitis (NASH) from Non-NASH

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) includes a variety of histopathological findings ranging from simple steatosis to nonalcoholic steatohepatitis (NASH) which can only be differentiated by liver biopsy. There is yet no unique biomarker found to discriminate NASH from simple steatosis.We aimed to investigate the relationship of plasma pentraxin 3 (PTX3) and its main stimulant tumor necrosis factor alpha (TNF-α) with the degree of liver damage in NAFLD.

METHODS

Plasma PTX3 and TNF-α levels were measured in 70 patients with histologically verified NAFLD (56 with NASH, 14 with non-NASH) and 12 controls.

RESULTS

PTX3 and TNF-α levels were found significantly higher in the NAFLD group than in the control group (4.1 ± 2.3 vs. 1.3 ± 0.8 ng/mL, P < 0.001, and 7.6 ± 4.1 vs. 3.3 ± 1.3 pg/mL, P < 0.001 respectively) and in biopsy proven NASH subgroup than non-NASH subgroup (4.6 ± 2.2 vs. 2.2 ± 1.7 ng/mL, P = 0.001, and 8.3 ± 4.3 vs. 4.6 ± 1.6 pg/mL, P = 0.001 respectively). To discriminate NASH from non-NASH PTX3 had 91.1% sensitivity and 71.4% specificity at the cutoff value of 2.45 ng/mL. Plasma PTX3 levels showed correlation with NAFLD activity score, fibrosis stage and steatosis grade (r = 0.659, P < 0.001; r = 0.354, P < 0.01; and r = 0.455, P < 0.001, respectively).

CONCLUSION

This study demonstrated markedly higher PTX3 levels in NAFLD patients compared with controls, and in biopsy proven NASH patients compared with non-NASH ones. Thus, in this cohort we showed that plasma PTX3 may be a promising biomarker for the presence of NASH.

Extracellular Vesicle Release Promotes Viral Replication during Persistent HCV Infection

Hepatitis C virus (HCV) infection promotes autophagic degradation of viral replicative intermediates for sustaining replication and spread. The excessive activation of autophagy can induce cell death and terminate infection without proper regulation. A prior publication from this laboratory showed that an adaptive cellular response to HCV microbial stress inhibits autophagy through beclin 1 degradation. The mechanisms of how secretory and degradative autophagy are regulated during persistent HCV infection is unknown. This study was performed to understand the mechanisms of viral persistence in the absence of degradative autophagy, which is essential for virus survival. Using HCV infection of a CD63-green fluorescence protein (CD63-GFP), labeled stable transfected Huh-7.5 cell, we found that autophagy induction at the early stage of HCV infection increased the degradation of CD63-GFP that favored virus replication. However, the late-stage of persistent HCV infection showed impaired autophagic degradation, leading to the accumulation of CD63-GFP. We found that impaired autophagic degradation promoted the release of extracellular vesicles and exosomes. The impact of blocking the release of extracellular vesicles (EVs) on virus survival was investigated in persistently infected cells and sub-genomic replicon cells. Our study illustrates that blocking EV and exosome release severely suppresses virus replication without effecting host cell viability. Furthermore, we found that blocking EV release triggers interferon lambda 1 secretion. These findings suggest that the release of EVs is an innate immune escape mechanism that promotes persistent HCV infection. We propose that inhibition of extracellular vesicle release can be explored as a potential antiviral strategy for the treatment of HCV and other emerging RNA viruses.

Serum ST2 in inflammatory bowel disease: a potential biomarker for disease activity

ST2, a specific ligand of interleukin 33, was described as a biomarker protein of inflammatory processes and overexpression of ST2 in ulcerative colitis (UC) was shown previously. We aimed to investigate the potential relationship of serum ST2 levels with the clinical, endoscopic and histopathological activity scores in UC and Crohn's disease (CD). Serum ST2 levels were determined in 143 patients with inflammatory bowel disease (IBD) (83 UC and 60 CD), in 50 healthy controls (HC), and in 32 patients with irritable bowel syndrome (IBS). Serum ST2 levels were elevated in IBD (56.8 (41.9-87.2) pg/mL) compared to HC and IBS (30.7 (20.2-54.3), p<0.001 and 39.9 (25.9-68.7) pg/mL, p=0.002, respectively). No significant difference was found between UC (54.2 (41.3-93.0) pg/mL) and CD (63.8 (42.7-88.4) pg/mL) and between IBS and HC. Serum ST2 levels were significantly increased in active UC compared to inactive UC (72.5 (44.1-99.5) vs 40.0 (34.7-51.6) pg/mL, p<0.001) and in active CD in comparison with inactive CD (63.8 (42.7-88.4) vs 48.4 (29.6-56.9) pg/mL, p=0.036). Patients with CD showing fistulizing behavior had significantly higher ST2 levels compared to patients with inflammatory and stricturing CD (p<0.001). Clinical activity scores of patients with UC and CD were correlated with serum ST2 levels (r=0.692, p<0.001 and r=0.242, p=0.043, respectively). Serum ST2 levels showed stepwise increases with the increasing histopathological scores of patients with UC and CD (p<0.001 for both). The present study highlights significant associations between ST2 and IBD presence and activity and demonstrates elevated serum ST2 levels in patients with active CD as a novel finding.

Pathogenesis and Mechanisms of SARS-CoV-2 Infection in the Intestine, Liver, and Pancreas

The novel coronavirus, SARS-CoV-2, rapidly spread worldwide, causing an ongoing global pandemic. While the respiratory system is the most common site of infection, a significant number of reported cases indicate gastrointestinal (GI) involvement. GI symptoms include anorexia, abdominal pain, nausea, vomiting, and diarrhea. Although the mechanisms of GI pathogenesis are still being examined, viral components isolated from stool samples of infected patients suggest a potential fecal-oral transmission route. In addition, viral RNA has been detected in blood samples of infected patients, making hematologic dissemination of the virus a proposed route for GI involvement. Angiotensin-converting enzyme 2 (ACE2) receptors serve as the cellular entry mechanism for the virus, and these receptors are particularly abundant throughout the GI tract, making the intestine, liver, and pancreas potential extrapulmonary sites for infection and reservoirs sites for developing mutations and new variants that contribute to the uncontrolled spread of the disease and resistance to treatments. This transmission mechanism and the dysregulation of the immune system play a significant role in the profound inflammatory and coagulative cascades that contribute to the increased severity and risk of death in several COVID-19 patients. This article reviews various potential mechanisms of gastrointestinal, liver, and pancreatic injury.

Effect of Entecavir and Tenofovir Treatment on Noninvasive Fibrosis Scores: Which One Is Better?

Liver biopsy is the best method for detecting fibrosis grade of the liver in chronic hepatitis B. However, the invasiveness of liver biopsy complicates its routine use in follow-up of treatment. We planned to determine the usage of fibrosis predicting noninvasive scores in the follow-up of the treatment of patients with chronic hepatitis B treated with entecavir or tenofovir. Two hundred twenty-eight patients with hepatitis B with liver biopsy were included in the study. Fibrosis grade was determined by Ishak score. The laboratory data at months 0, 12, and 24 during treatment were collected and noninvasive fibrosis scores (aspartate aminotransferase to alanine aminotransferase ratio [AAR], aspartate aminotransferase to platelet ratio index [APRI], fibrosis index based on the 4 factors [FIB-4] and red cell distribution width to platelet ratio [RPR]) were calculated. Statistically significant increase in all scores and decrease in platelet count were observed as the fibrosis level increased. For differentiation of patients with fibrosis ≥grade 2, the highest sensitivity and specificity rates were shown by APRI score (sensitivity 67%, specificity 69%, and cutoff ≥0.5). FIB-4 was the most successful score for differentiation of patients with fibrosis ≥grade 3 (sensitivity 83%, specificity 74%, and cutoff ≥1.45). A significant decrease in all noninvasive fibrosis scores was observed at months 12 and 24 during treatment with both entecavir and tenofovir (P < 0.001). Among these, only the improvement in APRI score was found better in entecavir group with statistical significance (P < 0.05). APRI score was effective in demonstrating early-stage fibrosis. FIB-4, RPR, and platelet count were better in demonstrating advanced fibrosis. Although noninvasive scores cannot replace liver biopsy for diagnosis, they can be used for monitoring the response to treatment.

How does a biopsy of endoscopically normal terminal ileum contribute to the diagnosis? Which patients should undergo biopsy?

BACKGROUND

Terminal ileum endoscopy and biopsy are the diagnostic tools of diseases attacking the ileum. However, abnormal histological findings can be found in endoscopically normal terminal ileum.

OBJECTIVE

This study was performed to evaluate the histopathological results of biopsies from endoscopically normal terminal ileum in order to determine pre-procedure clinical and laboratory factors predicting abnormal histopathological results, if any.

METHODS

A total of 297 patients who underwent colonoscopy and terminal ileum biopsy and had normal terminal ileum or a few aphthous ulcers in the terminal ileum together with completely normal colon mucosa were included in the study. The patients were grouped into two arms as normal cases and cases with aphthous ulcers. Histopathological and pre-procedural laboratory results of patients were analyzed according to their indications.

RESULTS

The terminal ileum was endoscopically normal in 200 patients, and 97 patients had aphthous ulcers. Chronic ileitis rate was present in 5.5% of those with endoscopically normal terminal ileum and in 39.2% of the patients with aphthous ulcers. In both groups, the highest rate of chronic ileitis was detected in the patients with known inflammatory bowel disease (IBD) (15.4 and 50%, respectively), anemia (9.5 and 43.5%, respectively), and in the patients having chronic diarrhea together with abdominal pain (7.7 and 44.8%, respectively). We found that the sensitivity of mean platelet volume for predicting chronic ileitis was 87% and the specificity was 45% at a cut-off value lower than 9.35 fl.

CONCLUSION

In anemia indication or chronic diarrhea together with abdominal pain, the frequency of aphthous ulcers detected by ileoscopy and the frequency of chronic ileitis detected histopathologically despite a normal-appearing ileum were elevated.

Liver and pancreas: 'Castor and Pollux' regarding the relationship between hepatic steatosis and pancreas exocrine insufficiency

BACKGROUND

Pancreatic exocrine insufficiency (PEI) is found in 30-50% of diabetes mellitus (DM). Insulin resistance is triggering factor in both DM and nonalcoholic fatty liver disease (NAFLD). Therefore, we aimed to investigate frequency of PEI in NAFLD, and relationship of fecal pancreatic elastase (PE) levels with liver histology and pancreatic fat.

METHODS

Ninety-seven biopsy proven NAFLD patients and 50 controls were enrolled. Pancreas exocrine functions were measured by PE. Magnetic resonance imaging-estimated proton density fat fraction (MRI-PDFF) was used to quantify fat.

RESULTS

NAFLD patients had significantly lower PE levels than controls (297 [204-517] vs. 500 [298-678] μg/g, p < 0.01). PEI (PE < 200 μg/g) ratio of NAFLD patients (22.7%, n = 22) was higher than PEI ratio of controls (6%, n = 3) (p = 0.011). Among diabetic (n = 35) NAFLD patients, 9 (25.7%) exhibited PEI, compared to 13 (21%) of non-diabetics. There was no significant difference in patients with and without DM in terms of PEI (p = 0.592). Among NASH (n = 68) patients 16 (23.5%) exhibited PEI, compared to (20.7%) of non-NASH (p = 0.76). Multiple analysis revealed NAFLD as a predictor of PEI independent of age, sex and DM (OR = 4.892, p = 0,021). Mean pancreas MRI-PDFF was significantly higher in diabetics (13.7% ± 3.6% vs. 8.7% ± 5.1%, p = 0.001). There was no significant pancreas MRI-PDFF difference between NASH and non-NASH (P = 0.95). Mean pancreas MRI-PDFF was significantly higher in patients with PEI (13.7% ± 3.4% vs. 8.9% ± 5.2%, P < 0.01).

CONCLUSION

This is the first study demonstrating the high frequency of PEI in NAFLD independent of DM. Moreover, increasing pancreatic steatosis appears to be associated with higher frequency of PEI in NAFLD.

Increased prevalence of colorectal polyp in acromegaly patients: a case-control study

An increase in the prevalence of colorectal polyps and cancer is reported in patients with acromegaly. This trial is designed to determine whether there is an increase in the prevalence of colorectal polyps/cancer in Turkish acromegaly patients. Sixty-six patients, who were under follow-up with the diagnosis of acromegaly and underwent total colonoscopic examination, were enrolled in the study. Sixty-five age- and gender-matched patients with nonspecific complaints were selected as control. The mean age of acromegalic patients was 51.5 ± 12.8 years of whom 27 (40.9%) were females. In 20 (30.3%) of the patients with acromegaly a total of 65 colorectal polyps were detected. Forty-seven (72.3%) of the polyps were detected at the rectosigmoid region. In 8 (12.3%) of the 65 control patients a total of 17 polyps were found. There was a statistically significant difference between the groups (P = 0.018). At the logistic regression analysis we found that the risk for colon polyps increased 3.2-fold in the presence of acromegaly, irrespective of age and gender (OR: 3.191, 95% CI: 1.25-8.13). In conclusion, patients who were followed up with the diagnosis of acromegaly should be taken to the colonoscopic surveillance program and all polyps detected should be excised in order to protect them from colorectal cancer.

What is the Importance of Body Composition in Obesity-related Depression?

OBJECTIVE

It is known that depression is common in obese individuals. Besides the effects of obesity, pathogenic effects of increase in visceral and abdominal fat mass on depression are also being investigated. Our study aimed to show the relationship between visceral fat percentage detected with practical methods and the presence and severity of depression.

MATERIALS AND METHODS

Our study included 104 obese patients and 50 healthy controls. In all individuals, the severity of depression was assessed using the Beck Depression Inventory (BDI). Anthropometric measurements, visceral fat percentage, and body fat percentage were measured using the bioelectric impedance method.

RESULTS

The mean age was 51.5±12.3 years, and 65 participants (62.5%) were women. BDI scores were statistically higher in the obese group than in the control group (23.1±10.9 and 12.1±9.4, p<0.001). In the obese group, 63.5% of patients were depressed, and in the control group, this was 24%. Women were more depressed in the obese group, but there was no significant difference between men and women in the control group. Body fat percentage was the highest correlating parameter with depression severity. Positive correlation was found between depression severity and body mass index, waist circumference, hip circumference, and visceral fat percentage. In the logistic regression analysis, obesity was found as an independent risk factor for depression (OR: 4.84, 2.1-10.7, p<0.001).

CONCLUSION

According to the results of our study, obesity is a significant and independent risk factor for depression. Obesity type and body composition are important factors that determine the severity of depression.

The effect of sarcopenia and serum myokines on prognosis and survival in cirrhotic patients: a multicenter cross-sectional study

OBJECTIVE

Sarcopenia is one of the most significant contributors to morbidity in patients with chronic liver disease. Serum myokines are potential biomarkers for detecting early sarcopenia. We aimed to investigate the relationship between serum myokines and cirrhosis-related mortality in the early stages of the disease.

METHODS

In total, 262 patients and 50 healthy controls were enrolled in this study, which was designed as a multicenter cross-sectional study. At the beginning of the study, sarcopenia was defined by computed tomography scans using the third lumbar vertebra skeletal muscle index. Serum myostatin, irisin, and follistatin levels, nutritional status of the patients, and muscle strength as measured by the handgrip test were recorded. Cirrhosis-related mortality and overall survival were evaluated in the fourth year of the study as the second checkpoint of cross-sectional analysis.

RESULTS

A total of 145 (55.3%) patients were diagnosed with sarcopenia. Multivariate analysis revealed that low BMI, high levels of myostatin, and decreased irisin levels were independent predictors of sarcopenia. While serum irisin level was the most predictive parameter in terms of 4th-year cirrhosis-related mortality in the CHILD A group, serum myostatin levels were found more indicative in the CHILD BC group regardless of sarcopenia status ( P < 0.001).

CONCLUSION

Serum myostatin levels predict sarcopenia in all stages of cirrhosis. Serum irisin levels can also be used as a potential biomarker to predict both treatable sarcopenia and cirrhosis-related mortality in CHILD A patients.

Changes in Liver Tissue Trace Element Concentrations During Hepatitis B Viral Infection Treatment

Approximately 350-400 million people in the world have Hbs Ag (hepatitis B virus surface antigen) positivity. In the international guidelines, the permanent suppression of replication in chronic hepatitis B virus (HBV) infection therapy is reported as the primary therapeutic goal. Trace elements play a key role in liver diseases. The aim of our study is to determine some trace element concentrations in the liver during HBV treatment periods. The measurement of 11 trace elements (manganese, lead, nickel, chromium, cadmium, iron, copper, zinc, silver, cobalt, and aluminum) was carried out by the method of inductively coupled plasma mass spectrometry in liver biopsy materials (before starting treatment and at the sixth month of the treatment period). There was an increase in zinc and copper concentrations in liver materials at the sixth month of treatment compared to the pre-treatment values (the median zinc value was 48.05 μg/g before treatment and 74.9 μg/g at 6 months after initial treatment, p = 0.035; median copper was 2.82 μg/g before treatment and 5.31 μg/g after 6 months, p = 0.002). General estimations indicated that zinc (p = 0.002), iron (p = 0.0244), copper (p = 0.0003), and aluminum (p = 0.0239) values may be effective in HAI (histological activity index) changes. Only iron levels could be at a very low level effective on the changes caused by fibrosis (p = 0.0002). Liver tissue zinc and copper levels increased in parallel with the improvement of inflammation in antiviral-treated HBV patients. In addition, the levels of zinc and copper in the liver tissue can be useful markers for liver tissue damage detection.

Additional Inhibition of Wnt/β-Catenin Signaling by Metformin in DAA Treatments as a Novel Therapeutic Strategy for HCV-Infected Patients

Chronic hepatitis C virus (HCV) infection causes hepatocellular carcinoma (HCC). Although HCV clearance has been improved by the advent of direct-acting antiviral agents (DAA), retrospective studies have shown that the risk of subsequent HCC, while considerably decreased compared with active HCV infection, persists after DAA regimens. However, either the mechanisms of how chronic HCV infection causes HCC or the factors responsible for HCC development after viral eradication in patients with DAA treatments remain elusive. We reported an in vitro model of chronic HCV infection and determined Wnt/β-catenin signaling activation due to the inhibition of GSK-3β activity via serine 9 phosphorylation (p-ser9-GSK-3β) leading to stable non-phosphorylated β-catenin. Immunohistochemical staining demonstrated the upregulation of both β-catenin and p-Ser9-GSK-3β in HCV-induced HCC tissues. Chronic HCV infection increased proliferation and colony-forming ability, but knockdown of β-catenin decreased proliferation and increased apoptosis. Unexpectedly, Wnt/β-catenin signaling remained activated in chronic HCV-infected cells after HCV eradication by DAA, but metformin reversed it through PKA/GSK-3β-mediated β-catenin degradation, inhibited colony-forming ability and proliferation, and increased apoptosis, suggesting that DAA therapy in combination with metformin may be a novel therapy to treat HCV-associated HCC where metformin suppresses Wnt/β-catenin signaling for HCV-infected patients.

Prognostic Nutritional Index and CRP, age, platelet count, albumin level score in predicting mortality and intensive care unit admission for COVID-19

Aim: In our study, we investigated the efficiency of the prognostic nutritional index (PNI) score and the CRP, age, platelet count, albumin level (CAPA) score predicting mortality and intensive care unit (ICU) admission in COVID-19 disease. Materials & methods: PNI and CAPA score of patients confirmed with COVID-19 calculated by using the complete blood count and biochemical parameters at admission to the hospital, in predicting the COVID-19-associated mortality and ICU admission were analyzed. Results: PNI and CAPA scores in predicting mortality were detected as AUC: 0.67 (p < 0.001), AUC: 0.71 (p < 0.001), respectively. For predicting ICU admission AUC was 0.66 (p < 0.001), AUC was 0.77 (p < 0.001), respectively. Conclusion: PNI and CAPA scores are effective scores in COVID-19, with CAPA score being better in predicting mortality and ICU admission.

Value of Cystatin C-Based e-GFR Measurements to Predict Long-Term Tenofovir Nephrotoxicity in Patients With Hepatitis B

BACKGROUND

Cystatin C is a genuine marker for detecting minor reductions in estimated glomerular filtration rate (e-GFR).

STUDY QUESTION

We aimed to investigate the efficiency of cystatin C levels in predicting nephrotoxicity due to antiviral therapy in patients with chronic hepatitis B virus infection.

STUDY DESIGN

Seventy-six naive hepatitis B virus patients and 44 controls were enrolled in this prospective cohort study.

MEASURES AND OUTCOMES

Serum cystatin C, phosphate and creatinine levels, and urinary albumin/creatinine ratios of all patients were measured at baseline, 3rd, 12th, and 24th months. Nephrotoxicity was determined according to the amount of change in creatinine level at the fourth year of treatment compared with baseline ([INCREMENT]Cr0-4).

RESULTS

Mean age was 36.1 ± 9.2 years and 40 (52.2%) of patients were women. There was no significant difference between baseline values of tenofovir disoproxil fumarate and entecavir groups. Although the creatinine level at the fourth year of treatment was statistically nonsignificant compared with baseline in the entecavir group, it was significantly higher in the fourth year of tenofovir treatment compared with baseline (0.95 ± 0.27 mg/dL vs. 0.76 ± 0.16 mg/dL, P = 0.002). While the increase in [INCREMENT]Cr0-4 was ≥0.2 mg/dL in 43.2% of patients in the tenofovir group, this rate was 18.8% in the entecavir group. Diagnostic accuracy in identifying decreased renal function as area under the curve (AUC) was high for baseline serum cystatin C level; furthermore, the highest AUC was calculated for cystatin C plus creatinine-based e-GFR equation (AUC: 0.81, P < 0.001).

CONCLUSIONS

Long-term tenofovir disoproxil fumarate nephrotoxicity can be predicted by serum cystatin C plus creatinine-based e-GFR measured before treatment.

Chemerin: a new biomarker to predict postendoscopic retrograde cholangiopancreatography pancreatitis

INTRODUCTION

Individuals with increased visceral adiposity are considered to be more sensitive and more prone to severe acute pancreatitis because of the inflammatory microenvironment they have. We hypothesized that insulin resistance, adipokines, and proinflammatory cytokines that markedly affect the course of pancreatitis can contribute toward development of postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP) and aimed to investigate the association between PEP risk and preprocedural serum vaspin, chemerin, tumor necrosis factor α, interleukin-6 (IL-6) levels, and homeostasis model assessment of insulin resistance.

PATIENTS AND METHODS

Eighty-two patients with a diagnosis of choledocholithiasis and 30 controls were enrolled. Preprocedural chemerin, vaspin, IL-6, and well-known PEP risk factors were compared between PEP and non-PEP groups.

RESULTS

The mean age of the patients was 56.3±14.4 years; 52 patients were women. Adipocytokine levels, BMIs, and waist circumferences of the patient group were found to be higher than those of the controls. Total cannulation success and the mean procedure time were 82.9% and 28.7±8.8 min, respectively. PEP developed in 12 (14.6%) patients. Chemerin levels in the PEP group were higher than those in the non-PEP group (580.2±172.5 vs. 392.2±168.2 ng/ml, P<0.01). Insulin resistance was higher in the PEP group than the non-PEP group (P=0.001), but there was no significant difference between PEP and non-PEP groups in terms of preprocedural vaspin, tumor necrosis factor α, IL-6, and C-reactive protein levels. According to logistic regression analysis, increased chemerin levels, homeostasis model assessment of insulin resistance 2.5 or greater, and pancreatic duct cannulation were found to be independent risk factors for PEP [odds ratio (OR)=1.006, P=0.006; OR=4.57, P=0.05; OR=6.54, P=0.02].

CONCLUSION

Elevated serum chemerin levels and insulin resistance are independent risk factors of PEP development.

Targeting ER stress/PKA/GSK-3β/β-catenin pathway as a potential novel strategy for hepatitis C virus-infected patients

BACKGROUND

Chronic hepatitis C virus (HCV) infection causes hepatocellular carcinoma (HCC). The HCC risk, while decreased compared with active HCV infection, persists in HCV-cured patients by direct-acting antiviral agents (DAA). We previously demonstrated that Wnt/β-catenin signaling remained activated after DAA-mediated HCV eradication. Developing therapeutic strategies to both eradicate HCV and reverse Wnt/β-catenin signaling is needed.

METHODS

Cell-based HCV long term infection was established. Chronically HCV infected cells were treated with DAA, protein kinase A (PKA) inhibitor H89 and endoplasmic reticulum (ER) stress inhibitor tauroursodeoxycholic acid (TUDCA). Western blotting analysis and fluorescence microscopy were performed to determine HCV levels and component levels involved in ER stress/PKA/glycogen synthase kinase-3β (GSK-3β)/β-catenin pathway. Meanwhile, the effects of H89 and TUDCA were determined on HCV infection.

RESULTS

Both chronic HCV infection and replicon-induced Wnt/β-catenin signaling remained activated after HCV and replicon eradication by DAA. HCV infection activated PKA activity and PKA/GSK-3β-mediated Wnt/β-catenin signaling. Inhibition of PKA with H89 both repressed HCV and replicon replication and reversed PKA/GSK-3β-mediated Wnt/β-catenin signaling in both chronic HCV infection and replicon. Both chronic HCV infection and replicon induced ER stress. Inhibition of ER stress with TUDCA both repressed HCV and replicon replication and reversed ER stress/PKA/GSK-3β-dependent Wnt/β-catenin signaling. Inhibition of either PKA or ER stress both inhibited extracellular HCV infection.

CONCLUSION

Targeting ER stress/PKA/GSK-3β-dependent Wnt/β-catenin signaling with PKA inhibitor could be a novel therapeutic strategy for HCV-infected patients to overcomes the issue of remaining activated Wnt/β-catenin signaling by DAA treatment. Video Abstract.

Infliximab- and azathioprine-related severe neutropenia and thrombocytopenia in a case with Crohn's disease

A 25-year-old female patient with Crohn's disease had been using azathioprine and metronidazole for an extended period because of recurrent perianal and rectovaginal fistulae. Infliximab was added to the treatment regimen following postoperative recurrence of a rectovaginal fistula. Upon the development of severe neutropenia and thrombocytopenia after the third dose of infliximab, azathioprine and infliximab were stopped. Neutropenia work-up did not reveal any other cause. Neutropenia was ameliorated with use of granulocyte colony-stimulating factor. Treatment was restarted with infliximab alone upon leakage from the rectovaginal fistula with no hematologic toxicity. This case was considered as a serious adverse effect of infliximab and azathioprine combination therapy.

Insulin Resistance as a Novel Risk Factor for Post-ERCP Pancreatitis: A Pilot Study

BACKGROUND AND AIMS

The relationship between insulin resistance and post-ERCP pancreatitis (PEP) is not known. We aimed to determine the relation between pre-ERCP insulin resistance and risk of PEP, and to evaluate the relationship of insulin resistance with well-established risk factors for PEP.

METHODS

Consecutive patients who underwent ERCP with the diagnosis of choledocolithiasis between January and December 2013 were enrolled in this prospective study. Pre-procedural insulin resistance state and other risk factors were evaluated according to PEP development.

RESULTS

Pancreatitis developed in 16 (11.3 %) of 141 ERCP procedure. Homeostasis model assessment of insulin resistance (HOMA-IR) levels was found statistically significantly higher in patients who developed PEP than the ones who did not (3.37 ± 0.8 vs. 2.38 ± 1.4, p < 0.001). Common bile duct (CBD) diameter of the patients developing PEP was found significantly lower than the non-PEP group (10.1 ± 4 vs. 13.4 ± 4.5 mm, p = 0.01). Mean procedure time was 33.5 min in PEP group and 27.9 min in non-PEP group (p = 0.006). HOMA-IR (OR 2.39), procedure time (OR 1.15), and CBD diameter (OR 0.82) were independent predictors of PEP development.

CONCLUSIONS

The presence of insulin resistance is an important risk factor for PEP, and these data can be used as a considerable clue to predict the risk of PEP before ERCP and to decrease related morbidity.