Updated evidence on epidemiology, diagnosis, and treatment for colonic diverticular bleeding

Since 2020, multiple large-scale studies (CODE BLUE-J) in Japan have accelerated the accumulation of evidence on colonic diverticular bleeding (CDB). This review summarizes the latest findings regarding CDB epidemiology and endoscopic hemostasis. Recent data show that CDB has become the most common cause of lower gastrointestinal bleeding in Japan, driven by an aging population and the increased use of antithrombotic medications. Although 70%-90% of patients achieve spontaneous hemostasis, rebleeding occurs in up to 35% of cases within 1 year. Despite an overall mortality rate of < 1%, patients with CDB can present with hypovolemic shock and may require urgent intervention. There are no effective pharmacological treatments for controlling CDB. Therefore, endoscopic therapy plays a crucial role in its management. Based on available evidence, both clipping and endoscopic band ligation are considered effective initial treatments. Recent studies indicate that direct clipping reduces early rebleeding compared with indirect clipping, while endoscopic band ligation achieves lower rebleeding rates (13%-15%) than clipping. The choice between direct clipping and endoscopic band ligation depends on the diverticulum location and the presence of active bleeding. Newer techniques, such as over-the-scope clip and self-assembling peptide application, have shown potential, but require further study. The detection of the bleeding source remains challenging because accurate identification is essential for successful hemostasis. Additional research is needed to refine the endoscopic diagnostic and therapeutic techniques, prevent rebleeding, and improve patient outcomes.

Chronic pancreatitis

Chronic pancreatitis is a progressive fibroinflammatory disease primarily caused by a complex interplay of environmental and genetic risk factors. It might result in pancreatic exocrine and endocrine insufficiency, chronic pain, reduced quality of life, and increased mortality. The diagnosis is based on the presence of typical symptoms and multiple morphological manifestations of the pancreas, including pancreatic duct stones and strictures, parenchymal calcifications, and pseudocysts. Management of chronic pancreatitis consists of prevention and treatment of complications, requiring a multidisciplinary approach focusing on lifestyle modifications, exocrine insufficiency, nutritional status, bone health, endocrine insufficiency, pain management, and psychological care. To optimise clinical outcomes, screening for complications and evaluation of treatment efficacy are indicated in all patients with chronic pancreatitis.

Peptides rapidly transport antibiotic across the intact tympanic membrane to treat a middle ear infection

The tympanic membrane (TM) forms an impenetrable barrier to medical therapies for middle ear (ME) diseases like otitis media. By screening a phage-displayed peptide library, we have previously discovered rare peptides that mediate the active transport of cargo across the intact membrane of animals and humans. Since the M13 filamentous bacteriophage on which the peptides are expressed are large (nearly 1 µm in length), this offers the possibility of noninvasively delivering drugs, large drug packages, or gene therapy to the ME. To evaluate this possibility, EDC chemistry was employed to covalently attach amoxicillin, or neomycin molecules to phage bearing a trans-TM peptide, as a model for large drug packages. Eight hours after application of antibiotic-phage to the TM of infected rats, ME bacterial titers were substantially reduced compared to untreated animals. As a control, antibiotic was linked to wild-type phage, not bearing any peptide, and application to the TM did not affect ME bacteria. The results support the ability of rare peptides to actively deliver pharmacologically relevant amounts of drugs through the intact TM and into the ME. Moreover, since bacteriophage engineered to express peptides are viral vectors, the trans-TM peptides could also transport other viral vectors into the ME.

Unveiling the potential bacteriophage therapy: a systematic review

INTRODUCTION

Antimicrobial resistance renders conventional therapy, demanding the need for alternative therapeutic techniques. A potential strategy for treating infections caused by multi-drug-resistant bacteria is using bacteriophages, viruses that only multiply and infect specific bacteria. This review aims to evaluate the findings of clinical studies on phage therapy for bacterial illnesses.

METHODS

A comprehensive search method was utilized to identify 11 appropriate trials, which were then assessed for safety, efficacy, and treatment outcomes. The Joann-Briggs-Institute checklist and PRISMA criteria were used to evaluate these studies thoroughly. The results were summarized by extracting and analyzing data on trial design, treatment outcomes, safety profiles, and therapeutic effectiveness.

RESULTS

Phage treatment had a strong safety profile, with few side effects recorded across many routes, including oral, intravenous, and topical. Clinical studies demonstrated its effectiveness in lowering bacterial loads, resolving infections, and destroying biofilms. However, diversity in trial designs hampered the generalizability of the findings.

CONCLUSION

This study emphasizes the promise of phage therapy as a safe and efficient treatment for bacterial-illnesses. Despite its potential, there are still significant gaps in clinical application, long-term efficacy assessment, and trial standardization. Addressing these issues is critical to developing phage therapy as an effective alternative treatment for multidrug-resistant-illnesses.

Radiofrequency hyperthermia enhances the antitumor efficacy of oncolytic peptide LTX-315 in liver cancer cells by activating of cGAS-STING pathway

PURPOSE

This study evaluated whether radiofrequency hyperthermia (RFH) could enhance the effects of LTX-315, an oncolytic peptide, for hepatic cancer.

METHODS

In vitro experiments using rat hepatocellular carcinoma (HCC) cells and in vivo experiments with HCC rat models were conducted. Treatments included (1) phosphate buffered saline, (2) RFH at 42 °C for 30 min, (3) LTX-315 alone, and (4) a combination of RFH with LTX-315. Cell viability and apoptosis were measured using MTS assay, flow cytometry, and fluorescence microscopy. Tumor growth was monitored for two weeks using ultrasound and optical imaging. The western blotting, enzyme-linked immunoassay, real-time polymerase chain reaction, were performed to detect the activation of cGAS-STING pathway. The immunohistochemistry, enzyme-linked immunoassay, real-time polymerase chain reaction, and flow cytometry analysis were performed to evaluate changes of immune cells in tumors, and changes of cytokines in plasma and tumors after the treatment.

RESULTS

The combination treatment (RFH + LTX-315) resulted in the highest level of apoptosis and the lowest cell viability, along with the smallest tumor volume and strongest reduction in bioluminescence signal compared to other groups (p < 0.001). LTX-315 activated the cGAS-STING pathway, with RFH further enhancing this activation. After combination therapy, significant increases in CD8+ T cells, CD8+/IFN-γ+ T cells, CD8+/TNF-α+ T cells, and natural killer cells, along with a decrease in Tregs, were observed in tumors (p < 0.001).

CONCLUSION

RFH significantly enhanced the effects of LTX-315 on orthotopic HCC by activating the cGAS-STING pathway.

Gut microbiota in hepatocellular carcinoma immunotherapy: immune microenvironment remodeling and gut microbiota modification

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality, with limited treatment options at advanced stages. The gut microbiota, a diverse community of microorganisms residing in the gastrointestinal tract, plays a pivotal role in regulating immune responses through the gut-liver axis. Emerging evidence underscores its impact on HCC progression and the efficacy of immunotherapy. This review explores the intricate interactions between gut microbiota and the immune system in HCC, with a focus on key immune cells and pathways involved in tumor immunity. Additionally, it highlights strategies for modulating the gut microbiota - such as fecal microbiota transplantation, dietary interventions, and probiotics - as potential approaches to enhancing immunotherapy outcomes. A deeper understanding of these mechanisms could pave the way for novel therapeutic strategies aimed at improving patient prognosis.

Outcomes of Liver Transplantation in Patients With Congenital Heart Disease and Biliary Atresia. A Multicenter Analysis

INTRODUCTION

Congenital heart disease (CHD) frequently coexists with noncardiac malformations. Among which, biliary atresia (BA) occurs in approximately 5%-15% of patients Despite this, outcomes of liver transplantation (LT) in patients with CHD and BA remain unknown.

METHODS

A retrospective review of the Pediatric Health Information System (PHIS) database from January 1, 2004 to October 30, 2023. All patients who underwent LT and had a diagnosis of BA were included. Multiorgan transplants were excluded. International Classification of Diseases 9th and 10th editions were utilized to identify patients with a diagnosis consistent with CHD.

RESULTS

A total of 1677 patients were identified with 983 (59%) female, 811 (5%) white non-Hispanic, and a median age at transplant of 11.6 (interquartile range [IQR]: 7.7-26.6) months. A CHD diagnosis was present in 83 (5%). Overall, the majority of transplants were performed in the CHD population in the modern era (2016-2023) (42/83.51%). CHD had a longer median preoperative length of stay (LOS) compared to non-CHD (1 [1.0-15.0] vs. 1 [0-6.0], p = 0.031). No increased risk of in-hospital mortality was evident (OR: 1.61, 95% CI: 0.37-6.95, p = 0.519). On multivariable analysis, CHD was associated with a 29% (95% CI: 11.04-50.34) increase in LOS (p < 0.001), 25% (95% CI: 6.98-46.47, p = 0.005) increase in postoperative LOS, and was not associated with increased risk for 30-day readmission (OR: 1.14; CI: 0.53-2.45, p = 0.736). Over a median follow-up of 3.5 years (IQR: 0.86-7.78) years, no difference in retransplantation rate was evident.

CONCLUSIONS

LT in patients with CHD and BA is safe. Although patients with CHD display heightened utilization of in-hospital resources, no discernible variance in long-term outcomes was observed. However, additional research is imperative to comprehensively elucidate the influence of CHD on management decisions and outcomes throughout the liver transplant process.

A systematic review on the role of gut microbiome in inflammatory bowel disease: Spotlight on virome and plant metabolites

Inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn's disease, arise from various factors such as dietary, genetic, immunological, and microbiological influences. The gut microbiota plays a crucial role in the development and treatment of IBD, though the exact mechanisms remain uncertain. Current research has yet to definitively establish the beneficial effects of the microbiome on IBD. Bacteria and viruses (both prokaryotic and eukaryotic) are key components of the microbiome uniquely related to IBD. Numerous studies suggest that dysbiosis of the microbiota, including bacteria, viruses, and bacteriophages, contributes to IBD pathogenesis. Conversely, some research indicates that bacteria and bacteriophages may positively impact IBD outcomes. Additionally, plant metabolites play a crucial role in alleviating IBD due to their anti-inflammatory and microbiome-modulating properties. This systematic review discusses the role of the microbiome in IBD pathogenesis and evaluates the potential connection between plant metabolites and the microbiome in the context of IBD pathophysiology.

The role of miRNAs in pathogenesis, diagnosis, and therapy of Helicobacter pylori infection, gastric cancer-causing bacteria: Special highlights on nanotechnology-based therapy

Helicobacter pylori (H. pylori) infection and consequent inflammation in the stomach are widely recognized as major contributors to gastric cancer (GC) development. Recent investigations have placed considerable emphasis on uncovering the controlling influence of small RNA molecules known as microRNAs (miRNAs) in H. pylori-related diseases, particularly gastric cancer. This review aims to offer a comprehensive understanding of the intricate roles fulfilled by miRNAs in conditions associated with H. pylori infection. Exploring miRNA biogenesis pathways reveals their intimate connection with H. pylori infection, shedding light on the underlying molecular mechanisms driving disease progression and identifying potential intervention targets. An examination of epidemiological data surrounding H. pylori infection, including prevalence, risk factors, and transmission routes, underscores the imperative for preventive measures and targeted interventions. Incorporating insights from miRNA-related research into these strategies holds promise for enhancing their efficacy in controlling H. pylori spread. The symptoms, underlying mechanisms, and virulent characteristics of the bacteria highlight the intricate relationship between H. pylori and host cells, influencing the course of diseases. Within this complex web, miRNAs play pivotal roles, regulating various facets of H. pylori's development. MicroRNAs intricately involved in directing the immune response against H. pylori infection serve as key players in molding host defense mechanisms and impacting the bacterium's evasion tactics. Utilizing this knowledge holds the potential to drive forward groundbreaking therapeutic strategies. The diagnostic and prognostic capabilities of miRNAs in H. pylori infection highlight their effectiveness as non-invasive indicators for identifying diseases and evaluating risk. Integration of miRNA signatures into diagnostic algorithms holds promise for enhancing early detection and management of H. pylori-related diseases. MiRNA-based therapeutics offer a promising avenue for combatting H. pylori-induced gastric cancer, targeting specific molecular pathways implicated in tumorigenesis. H. pylori infection induces dysregulation of several miRNAs that contribute to antibiotic resistance, inflammation, and gastric cancer progression, including downregulation of tumor-suppressive miR-7 and miR-153 and upregulation of oncogenic miR-671-5p and miR-155-5p, which promote carcinogenesis and inflammation. Additionally, H. pylori manipulates host immune responses by upregulating miRNAs such as let-7f-5p, let-7i-5p, miR-146b-5p, and miR-185-5p that suppress HLA class II expression and antigen presentation, facilitating immune evasion and chronic gastritis that predispose to gastric cancer. Future research endeavors should focus on refining these therapeutic modalities and identifying novel targets to optimize clinical outcomes. By elucidating the multifaceted roles of miRNAs in H. pylori infection, this review provides invaluable insights into disease pathogenesis, diagnostics, and therapeutics, and the role of some nanoparticles in combating the H. pylori infection. Continued research efforts are imperative for translating these insights into clinical practice and addressing the global burden of H. pylori-related diseases.

The Esophageal Mucosa: Clues to Underlying Pathology

Esophageal mucosal abnormalities, when accurately recognized, can provide clues to underlying pathology. In this article, we discuss strategies to enhance the detection and assessment of benign esophageal diseases during upper endoscopy by esophagogastroduodenoscopy (EGD). We provide a summary of skills required to perform high-quality EGD procedures from a technical standpoint, as well as a comprehensive description of the endoscopic appearance of the esophagus in health and in benign, organic diseases including eosinophilic esophagitis (EoE), lymphocytic esophagitis and EoE variants, erosive reflux disease, medication-induced esophageal injuries, infectious esophagitis, and other acute and chronic esophageal injuries. Endoscopic classification systems are also described.

Preferences on the Use of Prokinetic Agents in Adult Intensive Care Unit Patients-An International Survey

INTRODUCTION

Feeding intolerance complicates enteral nutrition in intensive care unit (ICU) patients but is poorly defined. Prokinetic agents are administered to facilitate the uptake of enteral nutrition, but preferences for their use among clinicians in ICUs are unknown.

METHODS

We conducted an international electronic survey targeting ICU doctors. The survey included 76 questions that focused on symptoms considered when assessing feeding intolerance, preferences for using prokinetic agents, and willingness to participate in a future randomised trial on prokinetic agents.

RESULTS

We received 830 responses from 17 countries, with an overall response rate of 29%. Most respondents were specialists working in mixed ICUs. Feeding intolerance was assessed by 90% of respondents in their clinical work, though only 36% considered it well defined. Gastric residual volume and vomiting were symptoms most frequently used for defining feeding intolerance. Metoclopramide was the preferred prokinetic agent (54% of respondents), followed by erythromycin (42%). Four out of five considered using combination therapy, primarily a combination of metoclopramide and erythromycin (89%). Concerns about side effects were reported for all agents, with extrapyramidal symptoms and QT prolongation being the most common across agents. The majority (91%) of respondents supported a future randomised trial comparing prokinetic agents to placebo.

CONCLUSION

This international survey found practice variations in the symptoms reportedly used to assess feeding intolerance. Metoclopramide was the preferred prokinetic agent, followed by erythromycin. Most respondents supported a future randomised trial.

Harnessing advances in mechanisms, detection, and strategies to combat antimicrobial resistance

Antimicrobial resistance (AMR) is a growing global health crisis, threatening the effectiveness of antibiotics and other antimicrobial agents, leading to increased morbidity, mortality, and economic burdens. This review article provides a comprehensive analysis of AMR, beginning with a timeline of antibiotics discovery and the year of first observed resistance. Main mechanisms of AMR in bacteria, fungi, viruses, and parasites are summarized, and the main mechanisms of bacteria are given in detail. Additionally, we discussed in detail methods for detecting AMR, including phenotypic, genotypic, and advanced methods, which are crucial for identifying and monitoring AMR. In addressing AMR mitigation, we explore innovative interventions such as CRISPR-Cas systems, nanotechnology, antibody therapy, artificial intelligence (AI), and the One Health approach. Moreover, we discussed both finished and ongoing clinical trials for AMR. This review emphasizes the urgent need for global action and highlights promising technologies that could shape the future of AMR surveillance and treatment. By integrating interdisciplinary research and emerging clinical insights, this study aims to guide individuals toward impactful solutions in the battle against AMR.

Recurrent acute pancreatitis as an initial presentation of primary hyperparathyroidism in juvenile patient

Acute pancreatitis recurrence should always alert clinicians to primary hyperparathyroidism, especially in younger patients and those with a hereditary condition. When parathyroid abnormalities are adequately recognized and addressed, more recurrent attacks of acute pancreatitis are unlikely to occur.

Recurrent acute pancreatitis and primary hyperparathyroidism in patients presenting to the emergency department: Diagnostic challenges

We read the article by Karim MM et al discusses the presentation of primary hyperparathyroidism as recurrent acute pancreatitis, a rare clinical condition in pediatric patients presenting to the emergency department. As emergency medicine clinicians, we frequently encounter diverse and complex cases, and such rare conditions pose significant challenges in the diagnostic process. This article will discuss the management and diagnostic approach of such cases encountered in the emergency department.

Acid reflux medication use among adults with depressive symptoms

Emotional stress, including depression, may contribute to increased gastroesophageal reflux disease symptoms. In this paper, we aim to evaluate the associations between depressive symptoms, depressive symptom severity, and symptom clusters with acid reflux medication use, considering the potential interaction effect of sex. Data from the 2007-2018 National Health and Nutrition Examination Survey were used. Participants aged 18 years or older were included if they responded to the depressive symptoms and prescription medication questionnaires. This study included 31,444 participants, of whom 2871 had depressive symptoms. Participants with depressive symptoms had significantly higher odds of using antacids (aOR = 1.735; p < 0.001), histamine-2 receptor antagonists (H2RAs) (aOR = 1.653; p < 0.001), and proton pump inhibitors (PPIs) (aOR = 1.723; p < 0.001). A positive association was also found between depressive symptom severity and the use of antacids (aOR = 1.054; p < 0.001), H2RAs (aOR = 1.048; p < 0.001), and PPIs (aOR = 1.053; p < 0.001). Moreover, increases in cognitive-affective and somatic scores were associated with higher odds of using antacids (aOR = 1.080 for cognitive, 1.102 for somatic; p < 0.001), H2RAs (aOR = 1.078 for cognitive, 1.083 for somatic; p < 0.001), and PPIs (aOR = 1.075 for cognitive, 1.105 for somatic; p < 0.001). No significant sex interaction effects were observed. Adjusted models demonstrated no significant associations between depressive symptoms and the duration of medication use. This study provides evidence of an association between depressive symptoms and acid reflux medication use, highlighting the need to screen for related symptoms in patients with depressive symptoms.

L-Arginine and immune modulation: A pharmacological perspective on inflammation and autoimmune disorders

L- Arginine (2-Amino-5-guanidinovaleric acid, L-Arg) is a semi-essential amino acid that is mainly produced within the urea cycle. It acts as a key precursor in the synthesis of proteins, urea, creatine, prolamines (including putrescine, spermine, and spermidine), proline, and nitric oxide (NO). WhenL-Arg is metabolized, it produces NO, glutamate, and prolamines, which all play important regulatory roles in various physiological functions. In addition to its metabolic roles,L-Arg significantly influences immune responses, especially in the context of inflammation and autoimmune diseases. It affects the activity of immune cells by modulating T-cell function, the polarization of macrophages, and the release of cytokines. Importantly,L-Arg plays a dual role in immune regulation, functioning as both an immunostimulatory and immunosuppressive agent depending on the specific cellular and biochemical environments. This review examines the immunopharmacological mechanisms of L-Arg, emphasizing its involvement in inflammatory responses and its potential therapeutic uses in autoimmune conditions like rheumatoid arthritis, multiple sclerosis, and inflammatory bowel disease. By influencing the pathways of nitric oxide synthase (NOS) and arginase (ARG), L-Arg helps maintain immune balance and contributes to the pathophysiology of diseases. Gaining a better understanding of the pharmacological effects of L-Arg on immune regulation could yield new perspectives on targeted treatments for immune-related diseases. Exploring its impact on immune signaling and metabolic pathways may result in novel therapeutic approaches for chronic inflammatory and autoimmune disorders.

Evaluation of protective effect of the hydroalcoholic extract of aerial parts of Amaranthus spinosus on acetic acid induced colitis in mice via modulating inflammatory markers and oxidative stress

BACKGROUND

Ethnopharmacological practices have long utilized A. spinosus L., a plant known for its anti-inflammatory and antioxidant properties, in traditional medicine. Despite its widespread use, scientific validation of its therapeutic effects, particularly in gastrointestinal disorders like colitis, remains limited.

AIM

This study aimed to assess the protective effect of the hydroalcoholic extract of aerial parts of A. spinosus on acetic acid-induced colitis in mice via modulating inflammatory markers and oxidative stress.

MATERIALS AND METHODS

The study involved phytochemical estimation, quantitative estimation of phytoconstituents along with HPTLC of hydroalcoholic extract of A. spinosus L. Colitis was induced by colonic administration of 150 μl (5 %) acetic acid once, intra-rectally on the 8th day. A. spinosus L. was administered orally at 25 mg/kg, 50 mg/kg, and 100 mg/kg. Mice were euthanized on the 11th day; the colon was examined macroscopically and histopathologically. Malondialdehyde (MDA) biochemical analysis was used to investigate colon lipid peroxidation. ELISA was used to quantify the levels of inflammatory markers. Additionally, an immunohistochemistry investigation evaluated the level of caspase-3 and COX-2.

RESULTS

At doses of 50 and 100 mg/kg, hydroalcoholic extract of A. spinosus L. markedly attenuated histological deterioration and lowered disease activity index. In addition, A. spinosus L. lowered concentrations of MPO, IL-6, TNF-α, and MDA (p < 0.05). A. spinosus L. treatment resulted in decreased COX-2 and caspase-3 expression, as determined by immunohistochemistry.

CONCLUSION

A. spinosus L. hydroalcoholic extract provides prevention against colitis induced by acetic acid. Reduced oxidative stress, apoptosis, and inflammation could be accountable for this effect.

Protective effects of flavonoids against silver nanoparticles-induced toxicity

Silver nanoparticles (AgNP) are becoming increasingly prevalent in daily life due to their unique properties, which have expanded their application across multiple sectors. This widespread use has led to a marked rise in human exposure to AgNP, raising concerns about their safety and potential health impacts. Studies have demonstrated that AgNP can induce harmful effects, including oxidative stress and pro-inflammatory responses, underscoring the need to identify protective agents to mitigate health risks. Flavonoids, known for their anti-inflammatory and antioxidant properties, hold significant  promise as effective agents in mitigating the toxic effects of AgNP. This review examines the current literature on the protective effects of flavonoids against AgNP toxicity. It highlights the underlying mechanisms by which flavonoids exert protective actions, with a focus on relevant pathways and molecular interactions. The results of in vitro and in vivo studies demonstrated that flavonoids exert protective effects against AgNP-induced damages through their antioxidant and anti-inflammatory activity. This analysis underscores the flavonoids potential as a promising strategy to reduce the negative impacts of AgNP, supporting safer and more sustainable applications of nanotechnology across diverse fields.

Post-pyloric feeding improves the nutritional status of severe tetanus patients and reduces the incidence of feeding intolerance

BACKGROUND

Patients with severe tetanus exhibit clinical features such as trismus, tetanic spasms, and rigidity, primarily affecting muscle groups including masseter muscles, erector spinae muscles, abdominal muscles, and limb muscles. The main objective of this study is to investigate whether post-pyloric feeding can improve the nutritional level of patients and reduce the incidence of feeding intolerance during the treatment of severe tetanus.

METHODS

A convenience sampling method was used to select 122 patients with tetanus who met the inclusion criteria from January 2020 to November 2023, and divided into groups that received Nasogastric feeding (NGF, n = 36) and Nasointestinal feeding (NIF, n = 36). Basic information was collected, nutritional biochemical indicators and frequency of intolerance were analyzed.

RESULTS

By day 7 and 14, the NIF group exhibited significantly higher levels of Albumin (ALB), Total Protein (TP), Prealbumin (PA) and Retinol Binding Protein (RBP) compared to the NGF group. At the same time, the incidence of nutritional intolerance in the NIF group was significantly lower compared to the NGF group.

CONCLUSION

Post-pyloric feeding can improve the nutritional level of patients with severe tetanus and reduce the frequency of feeding intolerance (diarrhea, abdominal distension and vomiting).

Polypoid Kaposi Sarcoma Involving the Lower Gastrointestinal Tract: Clinicopathologic Study of 15 Cases

CONTEXT.—

Gastrointestinal manifestations of Kaposi sarcoma are rare but may cause morbidity. Lower gastrointestinal involvement is particularly rare, and lesions may resemble conventional bowel polyps.

OBJECTIVE.—

To study 15 patients who presented with lower gastrointestinal tract Kaposi sarcoma with polypoid architecture.

DESIGN.—

The surgical pathology files of the departments of pathology at multiple institutions were searched for cases of Kaposi sarcoma forming polyps in the lower gastrointestinal tract (jejunum, colon, rectum); 15 cases with such features were identified. Clinicopathologic information was extracted from the medical record and documented by reviewing individual hematoxylin-eosin-stained slides.

RESULTS.—

The patients were 13 men and 2 women aged 26-80 years (median = 44 years). Gastrointestinal tract involvement was multifocal in 11 cases and unifocal in 4. The tumors involved the rectum, rectosigmoid junction, cecum, ascending colon, transverse colon, and descending colon and presented as polypoid lesions measuring 0.2-2.1 cm. Six patients had upper gastrointestinal tract involvement in addition to lower gastrointestinal lesions. Histologically, the tumors were characterized in 6 cases by a dense spindle cell proliferation in the lamina propria; however, the remaining cases showed only a subtle fascicular spindle cell proliferation in the lamina propria that did not form an expansile mass.

CONCLUSIONS.—

Biopsies of gastrointestinal polyps showing absence of the common features of hyperplastic or adenomatous polyps, particularly in immunocompromised patients, should be carefully examined for the presence of a stromal spindle cell proliferation. Use of immunohistochemical stains, particularly human herpesvirus-8, can help in establishing the correct diagnosis.

Surgical management of achalasia

Achalasia is a chronic esophageal motility disorder comprised of ineffective esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter. This disease had historically been managed through medical means as well as endoscopic dilations. However, surgical interventions are now considered standard of care, including minimally invasive Heller myotomy, which was popularized in 1990s, followed by per oral endoscopic myotomy in the 2010s. Both surgical approaches provide acceptable resolution of dysphagia symptoms. Classification of the achalasia as well as other patient-level factors may drive the clinical decision-making between the two approaches, as well as surgical training and surgeon preference.

Epidemiological characteristics of Helicobacter pylori infection and antibiotic resistance in urban areas of Guangdong Province, China: a multi-center, cross-sectional surveillance

PURPOSE

Helicobacter pylori (H. pylori) infection is widespread globally and can cause serious gastrointestinal complications, including gastric cancer. This study assesses the prevalence and antibiotic resistance of H. pylori in Guangdong, one of China's most developed provinces.

METHODS

A multi-center, cross-sectional study was conducted across six cities in Guangdong provinces, that is, Guangzhou, Shenzhen, Heyuan, Foshan, Yunfu, and Zhaoqing. Non-invasive gastric fluid samples were collected via the string test, and H. pylori infection and antibiotic resistance were detected using quantitative PCR. Risk factors for infection were analyzed.

RESULTS

Of 1,764 participants, 444 (25.17%) tested positive for H. pylori, with the highest infection rate in Foshan (29.81%). Antibiotic resistance testing of these 444 infected individuals revealed that, except for levofloxacin resistance in Yunfu (14.29%), clarithromycin resistance in Yunfu and resistance to other antibiotics in all cities exceeded the 15% threshold. Infection rates were significantly higher in males (OR 1.29, 95% CI 1.03-1.60, p = 0.03) and obese individuals (OR 2.04, 95% CI 1.04-3.91, p = 0.03), with obesity identified as an independent risk factor.

CONCLUSION

This study provides a comprehensive update on the prevalence, antibiotic resistance, and risk factors of H. pylori infection in Guangdong, offering valuable insights for public health strategies aimed at improving diagnosis and treatment.

Safety and effectiveness of endoscopic ultrasound-guided gallbladder drainage in patients with cirrhosis: an international multicenter experience

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) for symptomatic gallbladder disease has been shown to be safe and effective in patients with high surgical risk, but data are lacking for patients with cirrhosis. We investigated the safety and effectiveness of EUS-GBD in patients with and without cirrhosis.This retrospective review included patients who underwent EUS-GBD at four (three US and one Spanish) international tertiary care centers. Outcomes, including technical success, clinical success, and procedure-related adverse events, were compared between patients with and without cirrhosis.170 patients (47 with cirrhosis, 123 without cirrhosis) were included. There was no difference in age, sex, race, comorbidities, antiplatelet use, hemoglobin, or international normalized ratio between the two groups (P > 0.05 for all). The most common etiology of cirrhosis was alcohol (42.6%) with mean Model of End-stage Liver Disease-Sodium (MELD-Na) score of 16.2 (SD 8.8). Acute cholecystitis was more common in patients with cirrhosis (74.5% vs. 56.9%; P = 0.02). Technical (cirrhosis 97.9% vs. no cirrhosis 95.1%; P = 0.67) and clinical (93.6% vs. 94.9%; P = 0.71) success rates were similar in the two groups. Adverse events were infrequent and similar between groups, the most common being stent maldeployment (cirrhosis 4.3% vs. no cirrhosis 5.7%; P = 0.99). Survival rates were similar at the end of follow-up.EUS-GBD was safe and effective in patients with cirrhosis, with outcomes similar to patients without cirrhosis when performed by experienced echoendoscopists. Patients with cirrhosis and symptomatic gallbladder disease can be considered for EUS-GBD.

A Systematic Review and Meta-Analysis of The Efficacy of Endoscopic Ultrasound Guided Celiac Plexus Blocks for Chronic Pancreatitis Pain

Chronic pancreatitis is a globally prevalent progressive disease, with pain affecting up to 90% of patients, significantly impairing quality of life and leading to high rates of disability, hospitalizations, and opioid dependence. Pain management is crucial in treating chronic pancreatitis, with endoscopic ultrasound-guided celiac plexus block (EUS-CPB) recognized as an interventional option. This systematic review and meta-analysis, following PRISMA guidelines, synthesized data from 12 studies (5 randomized control trials and 7 observational) on the efficacy of EUS-CPB in managing chronic pancreatitis pain. The overall analysis revealed a significant pain relief proportion of 0.64 (n=612) with moderate heterogeneity. Subgroup analyses revealed a proportion of 0.72 in RCTs and 0.59 in observational studies. Common complications included diarrhea and exacerbation of abdominal pain, with no reported mortality. Despite variations in efficacy due to study heterogeneity and patient differences, the findings suggest EUS-CPB as a safe and effective option, with effects lasting weeks to months. Recent studies have demonstrated the applicability of EUS-CPB across ethnically diverse and pediatric populations. However, limitations including small sample sizes and study variability highlight the need for personalized treatment approaches. Future larger randomized sham-controlled trials are recommended to better assess the duration of pain relief and impact on opioid use.

The Role of Botulinum Toxin A Neuromodulator in the Management of Synkinesis in Facial Palsy

Facial palsy describes the denervation of the facial nerve leading to difficulty in facial animation and expression. Facial synkinesis is the result of complex pathological nerve regeneration following damage to the facial nerve axons. Synkinesis in facial palsy can be managed using facial neuromuscular rehabilitation, botulinum toxin neuromodulators, and surgical treatment options. Botulinum toxin A can be used as an adjunct to other treatment options to manage synkinesis. This article will explore the role of botulinum toxin A in the management of synkinesis in facial palsy including the clinical assessment, injection location (muscles targeted), dosages, treatment interval, and long-term results. It will also include surgical management options.

The role of the three major intestinal barriers in ulcerative colitis in the elderly

With the unprecedented pace of global population aging, there has been a parallel epidemiological shift marked by increasing incidence rates of ulcerative colitis (UC) in geriatric populations, imposing a substantial disease burden on healthcare systems globally. The etiopathogenesis of UC in the elderly remains poorly delineated, while current therapeutic strategies require further optimization to accommodate the unique pathophysiological characteristics of elderly patients. This review systematically elucidates the three barrier dysfunction - encompassing the gut microbiota ecosystem, mucosal epithelial integrity, and immunoregulatory network - that collectively drives UC pathogenesis during biological senescence. We emphasize the therapeutic potential of barrier-targeted interventions, particularly highlighting emerging modalities including fecal microbiota transplantation, intestinal organoid regeneration techniques, mesenchymal stem cell-mediated immunomodulation, and precision-engineered Chimeric Antigen Receptor T-cell therapies. Through this multidimensional analysis, we propose a paradigm-shifting approach to UC management in the elderly, advocating for the development of tailored and evidence-based therapeutic interventions that address the complex interplay between age-related biological changes and intestinal barrier homeostasis in elderly patients.

Hypocalcemia After Thyroidectomy in Patients Taking Proton Pump Inhibitors

Objective

Calcium homeostasis is regulated by the effects of parathyroid hormone (PTH) and vitamin D on the bones, GI tract, and kidneys. Post-thyroidectomy hypoparathyroidism and resultant hypocalcemia are common complications associated with prolonged hospitalization and higher costs. The long-term use of proton pump inhibitors has been associated with metabolic disturbances, including hypocalcemia. The purpose of this study is to determine the rate of hypocalcemia following thyroidectomy in patients taking proton pump inhibitors.

Materials and Methods

Patients treated with total thyroidectomy between 2012 and 2022 were identified via the TriNetX Research Network. The rate of transient (0-6 months following thyroidectomy) and permanent (6-12 months following thyroidectomy) postoperative hypocalcemia was compared between patients with and without a prescription for proton pump inhibitors.

Results

Of 33,309 patients, 21.3% (n = 7081) took proton pump inhibitors before surgery. 50.9% and 10.76% of thyroidectomy patients taking proton pump inhibitors had hypocalcemia compared to 48.3% and 7.22% of patients without proton pump inhibitors at 0-1 and 6-12 months, respectively. Patients prescribed proton pump inhibitors had a significantly increased risk of experiencing hypocalcemia at 0-1, 1-6, and 6-12 months. Patients taking proton pump inhibitors were also at increased risk of visiting the emergency department at 1 and 6 months following surgery.

Conclusions

Patients taking proton pump inhibitors may be more likely to experience short-term and permanent hypocalcemia after thyroid surgery. The current study is the largest to date, indicating an increased risk of hypocalcemia after thyroidectomy in patients taking proton pump inhibitors.

Level of Evidence

3.

Futility of plasmapheresis, insulin in normoglycaemic individuals, or heparin in the treatment of hypertriglyceridaemia-induced acute pancreatitis

There is a well-established link between the severity of hypertriglyceridaemia and acute pancreatitis and long-term triglyceride-lowering therapies known to prevent episodes of acute pancreatitis. Therefore, it has been assumed, without firm evidence, that rapid lowering of plasma triglycerides would be an effective strategy for reducing the clinical severity of acute pancreatitis and improving health outcomes. Therapies, such as intravenous heparin, intravenous insulin in normoglycaemic individuals (with glucose to prevent hypoglycaemia), and plasmapheresis, continue to be widely used as therapeutic interventions to rapidly reduce serum triglyceride concentration. These therapies are all associated with a risk of adverse reactions, require increased resources, and increase health-care costs. Randomised controlled clinical trials of these therapies have generally shown more rapid reductions in plasma triglycerides than conventional supportive care with the patient made nil by mouth. However, these three therapies alone or in combination, have failed to show effectiveness in improving substantial health benefit outcome measures. While we recognise the theoretical basis for rapidly reducing plasma triglycerides in hypertriglyceridaemia-induced pancreatitis-based on our review of studies using heparin, insulin, plasmapheresis, or a combination of these-these strategies overall do not reduce complications associated with acute pancreatitis or the rapidity of disease resolution. Therefore, we do not advocate the use of triglyceride-lowering therapies at this time, pending more convincing evidence.

Mechanistic insights into the protective potential of ambrisentan against L-arginine induced acute pancreatitis and multiorgan damage (role of NRF2/HO-1 and TXNIP/NLRP3 pathways)

Acute pancreatitis (AP) is an abrupt inflammation of the pancreatic tissue. The severity of AP varies from mild and self-limiting to severe, potentially fatal, and can affect several organ systems. The most severe type of AP causes multiple organ damage (MOD) due to systemic inflammation. In this study, ambrisentan (AMB), an endothelin A receptor antagonist (ETA), was investigated for its potential to ameliorate L-arginine (L-Arg) induced AP and MOD in rats. AP was induced using L-Arg (100 mg/100 g). Two doses of AMB were tested and compared to N-acetylcystiene (NAC) effect. AMB restored the normal structure of the pancreatic, hepatic, pulmonary, and renal tissues. In addition, it normalized the levels of pancreatic enzymes, lactate dehydrogenase (LDH), serum liver enzymes, and kidney biomarkers. Furthermore, AMB corrected the imbalance in the levels of oxidants/antioxidants caused by L-Arg. In contrast, AMB (5 mg/kg) significantly upregulated the protein levels of adenosine monophosphate protein kinase (AMPK), nuclear factor erythroid 2-related factor 2 (NRF2), heme oxidase-1(HO-1) and thioredoxin reductase 1 (TXNRD1) by approximately 69.59 %, 85.14 %, 688 % and 96 % respectively, compared with those in rats treated with L-Arg. Furthermore, AMB (5 mg/kg) significantly lowered the thioredoxin-interacting protein (TXNIP), nod-like Receptor Protein 3 (NLRP3), glycogen synthase kinase-3β (GSK-3β), inducible nitric oxide synthase (iNOS), tumor necrosis factor-α (TNF-α), CD68, autophagic markers (P62 and LC3) and apoptotic marker caspase 3 by around 62.43 %, 73.56 %, 62.5 %,70 %, 80.3 %, 93 %, 96.7 %, 95 %, 39.6 % respectively, compared to the group treated with L-Arg. AMB effectively improved the AP and MOD produced by L-Arg through its anti-inflammatory and antioxidant properties. NRF2/HO-1 and TXNIP/NLRP3 pathways play major roles in these protective effects.

What's with the Lump in the Throat? Globus, Dysphagia, and the Role of the Upper Esophageal Sphincter in Laryngopharyngeal Reflux Disease

Globus is a feeling of a lump or fullness in the throat. It can be a symptom of reflux or a distinct functional disorder. Dysphagia is the sensation that food is hindered in passing from the mouth to the stomach. There are connections between gastroesophageal reflux disease (GERD) and dysphagia. Laryngopharyngeal reflux disease (LPR) is likely a subset of GERD patients with specific alterations in upper esophageal sphincter (UES) reflexes that reduce esophageal refluxate clearance and increase the likelihood that refluxate will penetrate the UES barrier. In return, augmentation of the UES barrier can reduce LPR.

Targeting breast cancer: the promise of phage-based nanomedicines

BACKGROUND

Breast cancer is a leading cause of cancer-related mortality among women worldwide, characterized by its aggressive nature, propensity for metastasis, and resistance to standard treatment modalities. Traditional therapies, including surgery, chemotherapy, and radiation, often encounter significant limitations such as systemic toxicity and lack of specificity.

OBJECTIVE

This review aims to evaluate the recent advancements in phage-based nanomedicines as a novel approach for targeted breast cancer therapy, focusing on their mechanisms of action, therapeutic benefits, and the challenges faced in clinical implementation.

METHODS

A comprehensive literature review was conducted, analyzing studies that investigate the application of bacteriophages in cancer therapy, particularly in breast cancer. The review highlights the integration of nanotechnology with phage therapy, examining the potential for enhanced targeting and reduced side effects.

RESULTS

Phage-based nanomedicines have shown promise in selectively targeting breast cancer cells while sparing healthy tissues, thereby improving therapeutic efficacy and safety profiles. The unique properties of bacteriophages, including their ability to be engineered for specific targeting and their natural ability to induce immune responses, present significant advantages over conventional treatments.

CONCLUSION

The integration of phage therapy with nanotechnology represents a promising frontier in the fight against breast cancer. This review underscores the need for continued research to address existing challenges and to explore the full potential of phage-based nanomedicines in improving patient outcomes in breast cancer treatment.

Antimicrobial resistance: Linking molecular mechanisms to public health impact

BACKGROUND

Antimicrobial resistance (AMR) develops into a worldwide health emergency through genetic and biochemical adaptations which enable microorganisms to resist antimicrobial treatment. β-lactamases (blaNDM, blaKPC) and efflux pumps (MexAB-OprM) working with mobile genetic elements facilitate fast proliferation of multidrug-resistant (MDR) and exttreme drug-resistant (XDR) phenotypes thus creating major concerns for healthcare systems and community health as well as the agricultural sector.

OBJECTIVES

The review dissimilarly unifies molecular resistance pathways with public health implications through the study of epidemiological data and monitoring approaches and innovative therapeutic solutions. Previous studies separating their attention between molecular genetics and clinical outcomes have been combined into our approach which delivers an all-encompassing analysis of AMR.

KEY INSIGHTS

The report investigates the resistance mechanisms which feature enzymatic degradation and efflux pump overexpression together with target modification and horizontal gene transfer because these factors represent important contributors to present-day AMR developments. This review investigates AMR effects on hospital and community environments where it affects pathogens including MRSA, carbapenem-resistant Klebsiella pneumoniae, and drug-resistant Pseudomonas aeruginosa. This document explores modern AMR management methods that comprise WHO GLASS molecular surveillance systems and three innovative strategies such as CRISPR-modified genome editing and bacteriophage treatments along with antimicrobial peptides and artificial intelligence diagnostic tools.

CONCLUSION

The resolution of AMR needs complete scientific and global operational methods alongside state-of-the-art therapeutic approaches. Worldwide management of drug-resistant infection burden requires both enhanced infection prevention procedures with next-generation antimicrobial strategies to reduce cases effectively.

Factors Associated With Delayed Endoscopic Retrograde Cholangiopancreatography Among Patients With Acute Cholangitis

BACKGROUND AND GOALS

Delayed ERCP is associated with increased morbidity and mortality from acute cholangitis (AC). We aimed to identify the factors associated with delayed receipt of early or urgent ERCP among patients with AC.

STUDY

For this retrospective cohort study, we analyzed data from the 2016 to 2020 iterations of the Nationwide Inpatient Sample. We stratified the study population as severe versus nonsevere AC and timing of ERCP as urgent (within 24 h of admission), early (between 24 and 48 h of admission), and late (after 48 h of admission). Using multivariable logistic regression, we examined for the factors associated with delay in urgent or early ERCP overall and delay in urgent ERCP among patients with severe AC.

RESULTS

Of the 12,613 participants included in this study, 3032 (24.0%) had severe AC. Blacks [aOR 1.53; 95% CI (1.27, 1.85)], Asians/Pacific Islanders [aOR 1.22; 95% CI (1.02, 1.46)], those with a history of bariatric surgery [aOR 2.10; 95% CI (1.40, 3.17)] and those with one [aOR 1.33; 95% CI (1.13, 1.58)] or more comorbidities were more likely to have a delay in receiving ERCP within 48 hours of admission when compared with non-Hispanic Whites and those with no comorbidities respectively. Racial disparities were not observed among patients with severe AC.

CONCLUSION

Black/AA and API's presenting with AC are more likely to have a delay in the receipt of ERCP within 48 hours of admission. Assessing the impact of medical comorbidities on procedural risk is important when deciding timing of ERCP.

Impact of hyperbilirubinemia on rat cardiomyocyte injury

BACKGROUND

To investigate bilirubin-induced injury in rat myocardial cells at varying concentrations.

METHODS

The study utilized the rat cardiomyocyte cell line H9C2 and primary rat cardiomyocytes. Bilirubin-rich and control sera were prepared, and cells were cultured for 48 h with or without vitamin C. Cell viability was assessed using the CCK-8 assay, while superoxide dismutase (SOD), glutathione peroxidase (GPx), Na+/K+-ATPase, creatine kinase-MB (CK-MB), and cardiac troponin I (cTn-I) levels were measured using their respective assay kits.

RESULTS

Bilirubin treatment markedly reduced the viability of H9C2 cells and primary rat cardiomyocytes compared to the control group. Additionally, it elevated the levels of cardiac injury markers, including cTn-I and CK-MB in the culture supernatant. Conversely, bilirubin exposure led to a decline in the release of GPx, Na+/K+-ATPase, and SOD in the medium. Vitamin C supplementation demonstrated partial attenuation of bilirubin-induced effects: including enhanced viability of primary rat cardiomyocytes, partially restored GPx, Na+/K+-ATPase, and SOD levels, and reduced concentrations of CK-MB and cTn-I in bilirubin-treated cells.

CONCLUSIONS

Hyperbilirubinemia induces concentration-dependent cardiotoxicity in rat models, while vitamin C supplementation partially mitigates bilirubin-induced myocardial damage.

TRIAL REGISTRATION

Not applicable.

Restoration of intestinal barrier function by fexuprazan, a potassium-competitive acid blocker, in Caco-2 cells and its higher gastrointestinal distribution in rats

This study aimed to investigate the efficacy of fexuprazan in restoring intestinal barrier function in comparison with other potassium-competitive acid blockers (P-CABs) and esomeprazole. The effect of fexuprazan on trans-epithelial electrical resistance (TEER) value, mRNA and protein expression of tight junction genes, and cell morphology was investigated using a dextran sulfate sodium (DSS)-induced ulcerative colitis Caco-2 cell model. Treatment with fexuprazan, esomeprazole, tegoprazan, and vonoprazan significantly increased TEER values in a 3 % DSS-induced ulcerative colitis Caco-2 cells in a concentration-dependent manner. The TEER value-concentration profile showed sigmoidal shape curves and yielded half maximal effective concentration of 0.983 - 1.17 μg/mL for P-CABs and 3.27 μg/mL for esomeprazole. Among these drugs, fexuprazan showed the highest activity in the restoring intestinal barrier function. Fexuprazan also increased the expression of tight junction genes including zonula occludens-1, claudin 1, occludin, and mucin 1, and also thickened the epithelial cell membrane after treatment with 20 μg/mL fexuprazan. Fexuprazan showed a particularly high distribution in the liver and gastrointestinal tract in rats following oral administration of 2 mg/kg fexuprazan, which appears to be a positive characteristic of fexuprazan's effect on ulcerative colitis and gastric acid-related diseases although in vivo therapeutic efficacy of fexuprazan for ulcerative colitis requires further validation in both animal and human. In conclusion, fexuprazan can potentially restore intestinal barrier function by increasing the expression of tight junction genes and by strengthening the cell membrane integrity in DSS-induced colitis model.

Efficacy of polyphenols in adjuvant treating ulcerative colitis: A meta-analysis of randomized controlled trials

BACKGROUND

The effectiveness and safety of polyphenols in treating ulcerative colitis remain controversial. This study aimed to evaluate the efficacy and safety of polyphenols in the treatment of ulcerative colitis.

METHODS

This study followed the preferred reporting items for systematic reviews and meta-analyses 2020 guidelines. A systematic search was conducted across PubMed, Embase, Web of Science, and Cochrane databases to identify relevant articles. The random-effects model was employed to calculate the odds ratio (OR) and corresponding 95% confidence intervals (CIs).

RESULTS

A total of 13 trials involving 742 participants were included in the meta-analysis. The clinical remission rates were higher in the polyphenol group compared to the control group, as demonstrated by both the intention-to-treat (ITT) (OR: 4.71; 95% CI: 2.02-10.99; P = .000) and per-protocol (PP) analysis (OR: 7.14; 95% CI: 3.11-16.39; P = .000). Similarly, the clinical response rate was higher in the polyphenol group compared to the control group, according to the ITT (OR: 5.40; 95% CI: 2.60-11.24; P = .000) and PP analysis (OR: 9.14; 95% CI: 4.25-19.64; P = .000). Moreover, the total endoscopic remission rate was superior in the polyphenol group, as indicated by the ITT (OR: 3.16; 95% CI: 1.20-8.37; P = .020) and PP analysis (OR: 4.92; 95% CI: 2.03-11.93; P = .000). No significant differences were observed regarding side effects between the 2 groups, according to the ITT (OR: 0.99; 95% CI: 0.56-1.76; P = .973) and PP analysis (OR: 0.99; 95% CI: 0.54-1.80; P = .971).

CONCLUSION

Polyphenols demonstrated effectiveness in inducing clinical remission, clinical response, and endoscopic remission in patients with ulcerative colitis. Furthermore, there was no evidence of a higher incidence of adverse effects associated with their use.

Alleviation of LPS-induced oxidative stress and inflammation by lesbicoumestan (7) via the increase of Nrf2 expression in mouse Kupffer cells

Lesbicoumestans are a class of bioactive compounds isolated from the roots of Lespedeza bicolor (L. bicolor). These compounds have been reported to exhibit anticancer and antiproliferative activities. In this study, our primary focus was to examine the antioxidant capabilities of lesbicoumestan (7) (LC-7), a newly isolated coumestan from roots of L. bicolor, using lipopolysaccharide (LPS)-stimulated immortalized mouse Kupffer cells (ImKCs) as the experimental model. The investigation revealed that LC-7 played a pivotal role in inhibiting the production of reactive oxygen species (ROS). Additionally, LC-7 effectively restored the imbalanced glutathione(GSH)/glutathione disulfide ratio and enhanced the activity of glutathione peroxidase (GPx) following cellular exposure to LPS. Moreover, our investigation revealed that LC-7 exhibited the capacity to enhance the expression of heme oxygenase-1 (HO-1), leading to inhibition of nitric oxide (NO) and proinflammatory cytokines production induced by LPS. Notably, LC-7 did not significantly impact the nuclear factor kappa B cells (NF-κB) and mitogen-activated protein kinase (MAPK) pathways. Intriguingly, LC-7 modulated the nuclear factor erythroid 2-related factor 2 (Nrf2) signaling pathway by direct interaction with Kelch-like-ECH-associated protein 1 (Keap1). These findings suggest that LC-7 possesses antioxidant and anti-inflammatory properties in LPS-stimulated ImKCs by upregulating Nrf2 expression.

Olive Oil Solution of Volatile Oil from Citri Reticulatae Pericarpium Viride Alleviates Slow-Transit Constipation via Regulating SCF/c-Kit Signaling Pathway and Intestinal Flora

Objective

The aroma of the aromatic class of traditional Chinese medicines can promote gastrointestinal peristalsis. This study aimed to explore the mechanisms by which volatile oil from Citri Reticulatae Pericarpium Viride (VOCRPV) alleviates slow-transit constipation (STC).

Methods

The main active ingredients in VOCRPV were determined by High-Performance Liquid Chromatography (HPLC). Due to poor stability, an olive oil solution was prepared to enhance the volatile oil's stability. A mouse model of STC was induced using loperamide hydrochloride. The mice's body weight was monitored weekly. The number of fecal pellets, fecal water content, and small intestinal propulsion rate were detected. The colon tissues were analyzed using HE staining. The serum content of gastrointestinal hormones was measured using the corresponding ELISA kit. The protein expressions of stem cell factor (SCF) and c-Kit in colon tissues were detected by Western blot and immunohistochemistry methods. The 16S rRNA gene sequencing was used to detect the intestinal flora.

Results

The contents of p-isopropyl toluene, γ-Terpinene, and d-Limonene were determined by HPLC. VOCRPV and its olive oil solution significantly enhanced body weight, increased the number of fecal pellets, improved fecal water content, and boosted small intestinal propulsion rate in mice with loperamide-induced STC, while also repairing colon mucosa damage. They also increased gastrin (Gas) and motilin (MTL) levels in treated mice, upregulated the expression of SCF and c-Kit proteins, and restored intestinal flora balance in STC mice.

Conclusion

VOCRPV could effectively alleviate STC, and olive oil enhances its therapeutic effect. VOCRPV alleviates STC by elevating Gas and MTL levels, activating the SCF/c-Kit signaling pathway, and modulating intestinal flora.

Better diagnostic accuracy for GERD observed with the new MNBI cutoff: an observational study in Vietnam

BACKGROUND

Mean nocturnal baseline impedance (MNBI) is a novel metric for multichannel ambulatory impedance and pH (MI-pH) monitoring used to diagnose gastroesophageal reflux disease (GERD); however, its thresholds vary among different geographic areas and measuring systems. This study analyzed MI-pH data from Vietnamese patients to assess the diagnostic utility of novel MNBI thresholds in identifying GERD.

METHODS

This retrospective study included 133 patients suspected of having GERD who underwent upper gastrointestinal endoscopy, esophageal high-resolution manometry (HRM) and 24-hour MI-pH monitoring (Laborie). The subjects were divided into 3 groups based on the acid exposure time (AET) index (abnormal, inconclusive and normal AET). The mean MNBI and the prevalence of abnormal MNBI values were compared within groups, and the diagnostic accuracy of this index for diagnosing GERD was evaluated via receiver operating characteristic (ROC) curves and their area under the curve (AUC).

RESULTS

MNBI was significantly lower in patients with abnormal AET. The prevalence of MNBI < 2292 Ohms and MNBI < 1500 Ohms were greater in patients with abnormal AET (91.2% and 79.4%, respectively). The percentage of MNBI > 2500 Ohms was 44.4% in patients with normal AET but only 2.9% in patients with abnormal AET. MNBI had the highest AUC in discriminating abnormal AET (0.90, p < 0.001) in comparison with other metrics on MI-pH monitoring. The new cutoff value of 1500 Ohms had lower sensitivity but higher specificity than the previous threshold of 2292 Ohms. A multivariable regression analysis revealed that an MNBI < 1500 Ohms and total number of reflux events > 80/day were significantly associated with abnormal AET (> 6%).

CONCLUSIONS

Among Vietnamese patients with suspected GERD, the new MNBI cutoff of > 1500 Ohms had high sensitivity and specificity in diagnosing GERD, while the cutoff of 2500 Ohms could rule out this disease.

BoostDILI: Extreme Gradient Boost-Powered Drug-Induced Liver Injury Prediction and Structural Alerts Generation

Over the past 60 years, drug-induced liver injury (DILI) has played a key role in the withdrawal of marketed drugs due to safety concerns. Early prediction of DILI is crucial for developing safer pharmaceuticals, yet current in vitro and in vivo testing methods are complex and cumbersome. In this study, we developed an extreme gradient boosting (XGB)-powered machine learning (ML) model for DILI prediction. Comparing various DILI prediction models is challenging because they rely on different public data sets. We comprehensively evaluated the proposed BoostDILI model to address two crucial questions: 1. Can insights derived from public data sets help in DILI prediction for Food and Drug Administration (FDA) approved drugs? 2. Can we generate structural alerts to improve the model's explainability? To address the first question, we developed a DILI prediction model using four publicly available data sets. This effort led to the creation of the BoostDILI model, which achieved a 5-fold CV accuracy of 0.70. A sequential feature selection method was employed to identify relevant descriptors. This model integrates feature-level representations derived from RDKit (12 features) and Mordred (23 features) features. Bayesian statistics was applied to identify high-performance substructures iteratively, and a structural alerts model was developed to address the second question. The developed model was further validated with two FDA-approved drug data sets, DILIst and DILIRank. The BoostDILI model offers a trustable solution for evaluating the DILI risk in preclinical research. The structural alerts help in identifying the substructures that may be responsible for DILI. The data set and the source code are available at https://github.com/Naga270588/BoostDILI.

Microbes with higher metabolic independence are enriched in human gut microbiomes under stress

A wide variety of human diseases are associated with loss of microbial diversity in the human gut, inspiring a great interest in the diagnostic or therapeutic potential of the microbiota. However, the ecological forces that drive diversity reduction in disease states remain unclear, rendering it difficult to ascertain the role of the microbiota in disease emergence or severity. One hypothesis to explain this phenomenon is that microbial diversity is diminished as disease states select for microbial populations that are more fit to survive environmental stress caused by inflammation or other host factors. Here, we tested this hypothesis on a large scale, by developing a software framework to quantify the enrichment of microbial metabolisms in complex metagenomes as a function of microbial diversity. We applied this framework to over 400 gut metagenomes from individuals who are healthy or diagnosed with inflammatory bowel disease (IBD). We found that high metabolic independence (HMI) is a distinguishing characteristic of microbial communities associated with individuals diagnosed with IBD. A classifier we trained using the normalized copy numbers of 33 HMI-associated metabolic modules not only distinguished states of health vs IBD, but also tracked the recovery of the gut microbiome following antibiotic treatment, suggesting that HMI is a hallmark of microbial communities in stressed gut environments.

In vitro activity of cefiderocol against Gram-negative aerobic bacilli in planktonic and biofilm form-alone and in combination with bacteriophages

Multi-drug resistant Gram-negative pathogens are increasingly difficult-to-treat perpetrators of infections. New, innovative, and more multifaceted therapies for the treatment of multi-drug resistant strains are thus urgent to hinder further drug resistance and mitigate deadly, untreatable infections. Our study aimed to investigate the efficacy of cefiderocol against Gram-negative aerobic bacteria alone and in combination with phages. The minimum inhibitory concentration (MIC) of cefiderocol was determined using the microdilution broth method, while the minimum biofilm bactericidal concentration was assessed using isothermal microcalorimetry. The combined effect of cefiderocol and phages was evaluated using colony-forming unit counts. Results demonstrated a notable antibacterial effect of cefiderocol, with 83.4% of tested strains exhibiting susceptibility. When combined with phages, the MIC of cefiderocol was reduced by 2-64-fold, indicating a synergistic interaction between the two agents. Furthermore, the combination therapy showed enhanced efficacy against biofilm compared to monotherapy with either cefiderocol or phages alone, leading to complete biofilm elimination in certain cases. This study highlights the potential of combining cefiderocol with phages as a strategy to combat multi-drug resistant Gram-negative bacterial infections. The observed synergy suggests that this combination therapy could improve treatment outcomes and help address the challenges of antibiotic resistance and biofilm-associated infections.

Colon capsule endoscopy is an effective filter test for colonic polyp surveillance

BACKGROUND

Surveillance colonoscopies are predominantly normal, identifying patients for potential polypectomy is advantageous.

AIM

To assess colon capsule endoscopy (CCE) and/or faecal immunochemical test (FIT) as filters in surveillance.

METHODS

Patients aged ≥ 18 due for polyp surveillance were invited for CCE and FIT. Identifying polyps or colorectal cancer resulted in a positive CCE. Significant lesions (≥ 3 polyps or ≥ 6 mm polyps), incomplete studies and positive FITs (≥ 225 ng/mL) were referred for endoscopy. CCE and endoscopy results, FIT accuracy and patient preference were assessed.

RESULTS

From a total of 126 CCEs [mean age 64 (31-80), 67 (53.2%) males), 70.6% (89/126) were excreted, 86.5% (109/126) had adequate image quality. CCE positivity was 70.6% (89/126), 42.9% (54/126) having significant polyps with 63.5% (80/126) referred for endoscopy (19 sigmoidoscopies, 61 colonoscopies). CCE reduced endoscopy need by 36.5% (46/126) and 51.6% (65/126) were spared a colonoscopy. CCE positive predictive value was 88.2% (45/51). Significant extracolonic findings were reported in 3.2% (4/126). Patients with positive CCEs were older > 65 [odds ratio (OR) = 2.5, 95% confidence interval (CI): 1.1517-5.5787, P = 0.0159], with personal history of polyps (OR = 2.3, 95%CI: 0.9734-5.4066, P = 0.045), with high/intermediate polyp surveillance risk (OR = 5.4, 95%CI: 1.1979-24.3824, P = 0.0156). Overall, 5/114 (4.4%) FITs were positive (range: 0-1394 ng/mL, mean: 54 ng/mL). Sensitivity (9.6%) and negative predictive values (20.3%) were inadequate. Receiver operating curve analysis gave a sensitivity and specificity of 26.9% and 91.7%, for FIT of 43 ng/mL. Patients preferred CCE 63.3% (76/120), with less impact on daily activities (21.7% vs 93.2%) and time off work (average days 0.9 vs 1.2, P = 0.0201).

CONCLUSION

CCE appears effective in low-risk polyp surveillance. FIT does not appear to be of benefit in surveillance.

Crohn's Disease Patients Referred for Home Parenteral Nutrition-A Comprehensive Analysis of 18 Years' Experience at a National Reference Centre

Background: Within 10 years of diagnosis, about 50% of patients with Crohn's disease (CD) require surgery. Repeated small bowel resections can lead to the development of short bowel syndrome (SBS). It is estimated that 65-75% of CD patients are malnourished. This retrospective observational study was conducted in a Polish reference centre for home parenteral nutrition (HPN). The aim of the study was to investigate the nutritional status and characteristics of patients with CD referred to HPN and to analyse the course of their HPN treatment. Methods: The study group consisted of all adult patients (N = 46) with CD who qualified for HPN between November 2004 and April 2022. Results: The most common indication for HPN was SBS (n = 27; 58.70%), followed by ineffective gastrointestinal nutrition causing progressive malnutrition (N = 9; 19.57%), fistulas (N = 6; 13.04%), and short bowel syndrome and fistulas (N = 4; 8.70%). According to the results of Subjective Global Assessment (SGA), 47.83% (N = 22) of patients were diagnosed with severe malnutrition, followed by 15 patients (32.61%) with moderate malnutrition. Global Leadership Initiative on Malnutrition (GLIM) criteria showed that 71.73% (n = 33) of patients were malnourished on admission to the HPN centre. All patients received parenteral formulas based on individually tailored prescriptions. The results showed that patients with a stoma received statistically significantly higher PN volumes (p = 0.027) and higher amounts of amino acids (p = 0.046) and fat emulsion (p = 0.046). Septic complications were twice as common as mechanical or metabolic complications, although 43.47% of patients had no complications. At the time of data analysis, 19 patients (41.30%) had been successfully weaned from HPN, of whom 12 (26%) achieved nutritional autonomy after 136-1419 days (mean: 560 ± 380.9). Conclusions: Malnutrition is a major problem in CD patients, especially those with SBS. Early nutritional intervention and consideration of artificial nutrition in this study group (HPN) are necessary to prevent the long-term consequences of severe malnutrition. To our knowledge, this was the first study to report on Crohn's patients referred to long-term HPN. Further studies are needed to assess the impact of HPN on functional, laboratory, and anthropometric outcomes with a view to optimising treatment outcomes.

Whole genome sequencing of the novel polyvalent bacteriophage Malk1: A powerful biocontrol agent for water pollution

In this study, a novel Malk1 phage, was isolated and characterized for its ability to target a broad range of multidrug-resistant (MDR) bacterial strains. Malk1, classified within the Siphoviridae family, showed lytic activity with a capsid diameter of 84 nm and a tail length of 205 nm. It demonstrated a short latent period of 18 min and a burst size of 102 virions per infected cell. The phage exhibited strong thermal stability up to 60 °C and maintained activity across a pH range of 6.0-10.0. However, exposure to hand soap and 70 % ethanol reduced its titers by over 94 % and 97 %, respectively. Malk1 lysed 92 % of the tested bacterial strains and had a genome of 44.3 kb, encoding 75 open reading frames (ORFs), with no genes for toxins, antibiotic resistance, or CRISPR elements, making it a virulent phage. A novel design utilizing immobilized polyvalent Malk1 phage on plastic sheets demonstrated superior efficacy in reducing multi-drug resistant (MDR) bacterial strains. The removal efficiencies for C.freundii (78-91 %), E.coli (74-85 %), S.enterica (60-76 %), and S.flexneri (63-72 %) were significantly higher compared to purified phage, which achieved removal efficiencies of 63-69 %, 58-66 %, 52-63 %, and 55-68 %, respectively, after 6 to 8 h. Furthermore, the immobilized phage treatment led to a 94.1 % improvement in the removal of physicochemical pollutants in wastewater, significantly surpassing the 65.3 % removal achieved with purified phage. The treatment process led to significant improvements in water quality, achieving an average removal efficiency of 71.1 % for electrical conductivity, 67.52 % for turbidity, 73.67 % for total dissolved solids (TDS), 88.02 % for biochemical oxygen demand (BOD), and 81.88 % for ammonia (NH₃). Additionally, the average dissolved oxygen (DO) levels increased by 79.17 % compared to untreated wastewater. These findings highlight the promising potential of Malk1 phage, particularly in its immobilized form, for pathogen control and enhancing water quality. ORIGINALITY-SIGNIFICANCE STATEMENT: We introduce the newly isolated polyvalent Malk1 phage, which has been thoroughly genome characterized and annotated. Immobilized Malk1 phage has proven effective in controlling drainage water pollution and addressing global concerns for irrigation water quality. Our experiments successfully reduced several multi-drug-resistant (MDR) bacterial strains in highly polluted drainage water, leading to significant improvements in water quality in a short time and at an affordable cost, facilitated by our innovative laboratory design.

Clinical pathways for secondary care and the effects on professional practice, patient outcomes, length of stay and hospital costs

BACKGROUND

Clinical pathways (CPWs) are structured multidisciplinary care plans. They aim to translate evidence into practice and optimize clinical outcomes. This is the first update of the previous systematic review.

OBJECTIVES

To investigate the effect of CPWs on patient outcomes, length of stay, costs and charges, adherence to recommended practice, and to measure the impact of different approaches to implementation of CPWs.

SEARCH METHODS

For this update, CENTRAL, MEDLINE, and Embase were searched on 25 July 2024. Two trial registries were searched on 26 July 2024, along with reference checking, citation searching and contacting authors to identify additional studies.

SELECTION CRITERIA

We considered two groups of participants: health professionals involved in CPW utilization, including (but not limited to) physicians, nurses, physiotherapists, pharmacists, occupational therapists and social workers; and patients managed using a CPW. We included randomized trials, non-randomized trials, controlled before-after (CBA) studies, and interrupted time-series (ITS) studies comparing (1) stand-alone clinical pathways with usual care, and (2) clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two authors independently screened all titles, abstracts and full-text manuscripts to assess eligibility and the methodological quality of included studies using the Cochrane Effective Practice and Organization of Care 'Risk of Bias' tool. Certainty of evidence was assessed by two authors independently. Interventions were scored as 'high', 'moderate' or 'low' for the evidence-based implementation process.

MAIN RESULTS

The update provided 31 additional studies for a total of 58 included studies (24,841 patients and 2027 healthcare professionals). Forty-one (71%) were randomized trials, four (7%) non-randomized trials, four (7%) CBA studies and nine (16%) ITS studies. Forty-nine studies compared stand-alone CPWs to usual care and nine compared multifaceted interventions including a CPW to usual care. Collectively, the risk of bias was high due to potential contamination by healthcare professionals, lack of blinding of patients and personnel, lack of allocation concealment and selective reporting in ITS studies. Stand-alone clinical pathway interventions It is uncertain whether stand-alone CPWs reduce inhospital mortality (13% v 16%: OR 0.79, 95% CI 0.53 to 1.20; P = 0.27; I² = 65%; 7 randomized trials; n = 4603; low-certainty evidence due to serious imprecision and inconsistency) or mortality (up to 6 months) (4% v 3%: OR 1.37, 95% CI 0.72 to 2.60; P = 0.34; I² = 20%; 3 randomized trials, n = 805; low-certainty evidence due to serious risk of bias and imprecision). Stand-alone CPWs likely reduce inhospital complications (10% v 17%: OR 0.57, 95% CI 0.41 to 0.80; P = 0.001; I² = 52%; 11 randomized trials, n = 3668; moderate-certainty evidence due to serious risk of bias). It is very uncertain whether stand-alone CPWs reduce hospital readmissions (up to 6 months) (9% v 13%: OR 0.67, 95% CI 0.44 to 1.03; P = 0.07; I² = 11%; 9 randomized trials, n = 1578; very low-certainty evidence due to serious risk of bias and very serious imprecision). Stand-alone CPWs likely reduce the length of hospital stay compared to usual care (MD -1.12 days, 95% CI -1.60 to -0.65; P < 0.00001; I² = 64%; 21 studies; n = 5201; moderate-certainty evidence due to serious inconsistency). Costs and charges were generally lower in CPWs as indicated by negative MDs in nine studies (10 studies, n = 2113, data not pooled; very low-certainty evidence due to serious indirectness and very serious inconsistency). Stand-alone CPWs may slightly increase adherence to recommended practice compared with usual care (3 randomized studies, n = 573; data not pooled; low-certainty evidence due to serious risk of bias and serious inconsistency). Multifaceted clinical pathway interventions It is uncertain whether multifaceted CPWs reduce inhospital mortality (2 randomized studies, n = 6304, data not pooled; low-certainty evidence due to very serious inconsistency). Multifaceted CPWs may make little or no difference to mortality (up to 6 months) (9% v 8%: OR 1.05, 95% CI 0.88 to 1.25; P = 0.61; I² = 0%; 3 randomized studies; n = 6531; low-certainty evidence due to serious imprecision and serious risk of bias). It is uncertain whether multifaceted CPWs reduce inhospital complications (9% v 23%: OR 0.32, 95% CI 0.12 to 0.87; 1 study, n = 140; low-certainty evidence due to very serious imprecision). It is uncertain whether multifaceted CPWs reduce hospital readmission (up to 6 months) (2 randomized studies, n =1569, data not pooled; low-certainty evidence due to very serious inconsistency), or length of stay (4 randomized studies, n = 1936, data not pooled; low-certainty evidence due to very serious inconsistency), or hospital costs and charges (4 randomized studies, n = 2015, data not pooled; very low-certainty evidence due to very serious imprecision and serious indirectness in outcome measures). It is uncertain whether multifaceted CPWs increase adherence to recommended practice (2 randomized studies, n = 6304, data not pooled, low-certainty evidence due to very serious inconsistency). Key study characteristics The highest proportion of included studies were from the USA (36%), followed by Australia (10%), China (10%), Japan (5%), the UK (5%), Canada (5%), Italy (5%), and Germany (5%). More than half of the included studies tested CPW in general acute wards (53%), followed by emergency departments (17%), intensive care (14%), and extended-stay facilities (10%). The most common clinical conditions were asthma (16%), stroke (10%), mechanical ventilation (9%) and myocardial infarction (7%).

AUTHORS' CONCLUSIONS

Stand-alone CPWs are likely to reduce inhospital complications and length of hospital stay and may slightly increase adherence to recommended practice. There was little conclusive evidence for multifaceted CPWs due to mixed results from a limited number of included studies. It is uncertain whether stand-alone CPWs or CPWs, as part of a multifaceted approach, reduce inhospital mortality, mortality (up to 6 months), hospital readmission (up to 6 months) or costs and charges.

Macrophage immunometabolism dysregulation and inflammatory disorders

Macrophages are innate immune cells which are involved in triggering inflammation. Growing evidence shows that, macrophages respond to intracellular and extracellular cues which makes them adopt either anti-inflammatory or pro-inflammatory functions and phenotypes. Immunometabolism has been identified as one of the prominent factors which contributes massively towards the cessation and the development of inflammation as an immune response to infections and autoimmune diseases. However, when inflammation is poorly regulated, it leads to dire consequences. This illustrates that, understanding the role of immunometabolism in the regulation of inflammation, is paramount. In view of this, the review investigated the role of metabolic pathways such as: glycolysis, tricarboxylic acid cycle, pentose phosphate pathway, fatty acid oxidation, amino acid metabolism in macrophage reprogramming. The role of the intermediates and enzymes associated with these metabolic pathways in the regulation of, macrophage reprogramming and polarisation or activation was also reviewed. It was unveiled that, manipulating metabolic intermediates and enzymes could impact cellular immunometabolism. This eventually influences macrophage reprogramming and thus influences the generation of either a pro-inflammatory or anti-inflammatory response.

Anti-regurgitation infant formulas and antacid medication: match or mismatch?

A perceived need for treatment has led to the development and widespread marketing of various anti-regurgitation (AR) infant formulas, promoted as effective solutions for managing regurgitation symptoms. For practice, limited comparative data exists on the specific thickening agents, or the relative thicknesses of AR formulas. An added concern is that some infants on AR formulas simultaneously receive pharmacological treatments for reflux, such as antacids or gastric acid inhibitors, and no information about compatibility is available. One reference formula (Nutrilon® Profutura 1, Nutricia) and four formulas labelled as 'anti-regurgitation' with different nutritional compositions were used to evaluate the effect of pH and time on viscosity. The viscosity of marketed AR formulas was tested with a rotational rheometer. All four AR formulas demonstrated higher viscosity compared to the reference formula, with notable differences based on the thickening strategy used by the manufacturer. Pre-thickened CBG-based AR formulas generally showed higher viscosity than pre-thickened starch-based formulas. Adding a casein-dominant protein fraction increased viscosity in acidic environments; however, this effect gradually diminished over time, likely due to protein hydrolysis. Moderate (pH 4) compared to strong acidic conditions (pH 1) had only minimal impact on viscosity, indicating compatibility with gastric acid inhibitors across all AR formulas.

CONCLUSION

Our findings suggest that CBG-based AR formulas should be allowed to stand for at least 30 min after preparation to achieve the intended viscosity. Additionally, AR formulas thickened with CBG generally exhibit higher viscosity than pre-thickened starch-based formulas. Notably, casein-based thickening occurs even when gastric acid suppressants are used, and combining casein with acid suppression may even slow down the rate of viscosity reduction over time.

WHAT IS KNOWN

• Commercially available infant formula sometimes uses thickening agents to reduce regurgitation, but their effectiveness may vary depending on composition and gastric conditions. • Some thickening agents require an acidic environment to activate, which may be compromised by concurrent use of gastric acid suppressants.

WHAT IS NEW

• This study demonstrates that CBG-based AR formulas generally maintain higher viscosity than starch-based formulas, even with acid suppression. • Viscosity in some formulas changes over time, indicating that preparation timing affects therapeutic consistency.

The Use of Ossein-Hydroxyapatite Complex in Conjunction with the Ilizarov Method in the Treatment of Tibial Nonunion

Background: Patients with nonunion experience pain, mobility problems, and physical activity limitations; require long-term, costly treatment; and cannot resume work. Some authors recommend the use of pharmaceutical agents as an adjunct therapy in fracture and nonunion treatment. The aim of this study was to assess the effects of ossein-hydroxyapatite complex used as an adjunct therapy in nonunion treatment with the Ilizarov external fixator. Methods: In this retrospective study, we assessed 31 patients (nine women, 22 men) at a mean age of 47 years (29-68 years), who were receiving osteogenon, with aseptic tibial shaft nonunion treated with the Ilizarov external fixator in the period 2019-2023, designated as Group 1. The control group comprised 29 patients (five women, 24 men), at a mean age of 48 years, with aseptic tibial shaft nonunion treated with the Ilizarov external fixator, who did not receive osteogenon during treatment, designated as Group 2. We assessed the following parameters-duration of Ilizarov fixation, achieved bone union, time to resuming normal physical activity, maintained bone union, time to complete pain relief, the number of patients reporting complete pain relief, the number of patients who were fitted with a cast or splint following Ilizarov fixator removal, and the rate of complications. Results: The median time to Ilizarov fixator removal was 275 days in Group 1 and 218 days in Group 2. In Group 1, bone union was observed in 100% of patients, in Group 2, 93% of patients achieved bone union. This difference was statistically significant, p = 0.041. Maintained bone union was observed in 85.7% of patients from the osteogenon group and in 79.3% of patients from the control group, and the difference was not statistically significant. There were no differences between groups in the median time to resuming normal physical activity, the median time to achieving pain relief, the rate of complications, and the rate of pain relief. Conclusions: The use of ossein-hydroxyapatite complex has a beneficial effect on fracture nonunion treatment with the Ilizarov method. The use of osteogenon helps increase the proportion of patients with fracture nonunion who achieve bone union following treatment with the Ilizarov method. Osteogenon does not significantly affect complication rates, time to fixator removal, time to achieving pain relief, time to resuming normal physical activity, maintained bone union rates, or the proportion of patients who achieve pain relief.

Lactate Facilitates Pancreatic Repair Following Acute Pancreatitis by Promoting Reparative Macrophage Polarization

BACKGROUND & AIMS

During acute pancreatitis (AP), glycolysis is enhanced. The upregulation of glycolysis increases the level of metabolite lactate. Lactate has been shown to facilitate tissue repair across various pathologic conditions. However, its role in the recovery following AP remains unclear. This study aims to explore the role of lactate in the regenerative processes following AP and to elucidate its underlying molecular mechanisms.

METHODS

The caerulein-induced recovery AP model was established using wild-type and 6-Phosphofructo-2-Kinase/Fructose-2,6-Biphosphatase 3 (Pfkfb3) heterozygous mice. Pancreatic repair was evaluated histologically, whereas lactate levels and inflammatory markers were measured serologically. Macrophages were isolated from pancreatic tissue using fluorescence-activated cell sorting for mRNA sequencing to identify phenotypes. In ex vivo, macrophages were indirectly co-cultured with inflammatory acinar, and the effect of lactate on macrophage phenotype were investigated through immunoprecipitation, fluorescence analysis, and Western blotting.

RESULTS

We first found that exogenous lactate administration promoted pancreatic repair, whereas Pfkfb3 deficiency lowered lactate levels and ultimately delayed pancreatic repair. Mechanistically, lactate altered macrophage phenotype during recovery after AP, by reducing the proportion of pro-inflammatory macrophages and increasing the percentage of reparative macrophages. In the indirectly co-cultured macrophage, lactate increased lactylation levels and enhanced repair gene expression. Treatment with AZD3965, a chemical inhibitor of lactate transportation, blocked the effects on lactylation and gene expression. Besides, lactate repressed the JAK2-STAT1 pathway via GPR132 receptor, thereby suppressing the expression of pro-inflammatory genes.

CONCLUSIONS

Lactate facilitates pancreatic repair by promoting reparative macrophage polarization, achieved through promoting lactylation and inhibiting JAK2-STAT1 signaling. This phenotypic shift alleviates inflammation and facilitates tissue recovery, highlighting a potential therapeutic approach for AP.