Antiarrhythmic drug use in atrial fibrillation among different European countries - as determined by a physician survey

Background

There is limited knowledge of physicians' antiarrhythmic drug (AAD) treatment practices for patients with atrial fibrillation and adherence to guidelines in European countries.

Methods

An online survey (n = 321) of cardiologists, cardiac electrophysiologists and interventional electrophysiologists was conducted in Germany (DE; n = 83), Italy (IT; n = 95), Sweden (SE; n = 60) and the United Kingdom (UK; n = 83) including 96 questions on treatment practices.

Results

ESC guidelines were the most important non-patient factor influencing treatment practice (55-72 %). However, while amiodarone was frequently (88-93 %) used in heart failure with reduced left ventricular ejection fraction, it was also a typical treatment choice for minimal/no-structural heart disease (SHD) (28 %), particularly in UK. Other deviations from guidelines were the use of class 1C drugs in coronary artery disease (CAD) and other SHD, and use of sotalol in left ventricular hypertrophy and renal impairment. In-hospital initiation of sotalol was low, with the exception of SE. Sotalol (16-41 %) and dronedarone use (10-54 %) in CAD varied among countries. For frequent, symptomatic paroxysmal AF, ablation was generally favoured, but AADs were preferred by 53 % in SE. In asymptomatic or subclinical AF, AADs were used by 41 % (range: 22-60 %), ablation by 11 % (range 2-18 %). In contrast to guidelines that prioritize safety, anticipated efficacy was more important (51 %) than safety (31 %) when selecting AADs.

Conclusions

Despite recognizing the importance of guidelines, deviations in AAD use were common with the potential to compromise patient safety. These findings indicate the need for more educational support for optimal AAD selection in AF management.

Cell and gene therapeutic approaches in non-alcoholic fatty liver disease

Non-Alcoholic Fatty Liver Disease (NAFLD) refers to a range of conditions marked by the buildup of triglycerides in liver cells, accompanied by inflammation, which contributes to liver damage, clinical symptoms, and histopathological alterations. Multiple molecular pathways contribute to NAFLD pathogenesis, including immune dysregulation, endoplasmic reticulum stress, and tissue injury. Both the innate and adaptive immune systems play crucial roles in disease progression, with intricate crosstalk between liver and immune cells driving NAFLD development. Among emerging therapeutic strategies, cell and gene-based therapies have shown promise. This study reviews the pathophysiological mechanisms of NAFLD and explores the therapeutic potential of cell-based interventions, highlighting their immunomodulatory effects, inhibition of hepatic stellate cells, promotion of hepatocyte regeneration, and potential for hepatocyte differentiation. Additionally, we examine gene delivery vectors designed to target NAFLD, focusing on their role in engineering hepatocytes through gene addition or editing to enhance therapeutic efficacy.

Education of healthcare professionals to improve guideline adherence in atrial fibrillation: the STEEER-AF cluster-randomized clinical trial

Guideline-adherent care is associated with better patient outcomes, but whether this can be achieved by professional education is unclear. Here we conducted a cluster-randomized controlled trial across 70 centers in six countries to understand if a program for the education of healthcare professionals could improve patient-level adherence to clinical practice guidelines on atrial fibrillation (AF). Each center recruited patients with AF seen in routine practice (total N = 1,732), after which the centers were randomized, accounting for baseline guideline adherence to class I and III recommendations from the European Society of Cardiology on stroke prevention and rhythm control. Healthcare professionals in the intervention centers received a 16-week structured educational program with an average of 9 h of online engagement, whereas those at control centers received no additional education beyond standard practice. For the co-primary stroke prevention outcome, guideline adherence was 63.4% and 58.6% at baseline and 67.5% and 60.9% at 6-9-months follow-up for the intervention and control groups, respectively (adjusted risk ratio 1.10; 95% confidence interval (CI) 0.97 to 1.24; P = 0.13). For the co-primary rhythm control outcome, guideline adherence was 21.4% and 20.4% at baseline and 33.9% and 22.9% at follow-up for the intervention and control groups, respectively (adjusted risk ratio 1.51; 95% CI 1.04 to 2.18; P = 0.03). The secondary outcome of patient-reported integrated AF management showed a 5.1% improvement in the intervention group compared with the control group (95% CI 1.4% to 8.9%; P = 0.01). Thus, while the education of healthcare professionals improved substantial gaps in implementation for rhythm control, it had no significant effect on stroke prevention. ClinicalTrials.gov registration: NCT04396418 .

Correlates of polypharmacy and prescription changes in internal medicine: a prospective five-year study

BACKGROUND

Data regarding polypharmacy in the internal medicine setting remain limited. We aimed to assess the prevalence of polypharmacy, examine its associations with clinical and socioeconomic factors, and evaluate its impact on mortality.

METHODS

This was part of the San MAtteo Complexity (SMAC) study (2017-2025), conducted in an internal medicine service of an academic medical center. Patients were consecutively and prospectively enrolled. Polypharmacy prevalence was assessed at admission and discharge. Sociodemographic data, Cumulative Illness Rating Scale (CIRS), Edmonton Frail Scale, comorbidity, multimorbidity, Short Blessed Test, and Barthel Index were collected. Associations with polypharmacy were analyzed using logistic regression, and early and late mortality were tracked using Kaplan-Meier analysis.

RESULTS

Among 1419 patients (median age 80 years, IQR 69-86; F:M ratio 1.14:1), polypharmacy was observed in 71.5% at admission and 82.6% at discharge. Patients with polypharmacy were significantly older, frailer, and had lower socioeconomic status. Independent predictors included age ≥65 years (OR 4.14, 95% CI 1.60-10.69), CIRS >3 (OR 2.67, 95% CI 1.98-3.58), frailty (OR 3.85, 95% CI 0.68-1.50), comorbidity (OR 8.2, 95% CI 2.19-30.7), multimorbidity (OR 20.91, 95% CI 5.65-77.44), and cardiovascular disorders (OR 1.84, 95% CI 1.33-2.55). In-hospital and 4-month mortality were significantly higher among patients who were deprescribed (i.e., discharged with ≤5 fewer medications). Five-year mortality was significantly higher in patients with polypharmacy (HR 2.83, 95% CI 2.07-3.86; p<0.001), regardless of prescription changes.

CONCLUSIONS

Polypharmacy is highly prevalent in internal medicine, and both deprescribing and polypharmacy are associated with increased mortality at different timepoints, underscoring the need for targeted medication optimization strategies.

A comprehensive review and in silico analysis of the role of survivin (BIRC5) in hepatocellular carcinoma hallmarks: A step toward precision

Hepatocellular carcinoma (HCC) is a complex malignancy driven by the dysregulation of multiple cellular pathways. Survivin, a key member of the inhibitor of apoptosis (IAP) family, plays a central role in HCC tumorigenesis and progression. Despite significant research, a comprehensive understanding of the contributions of survivin to the hallmarks of cancer, its molecular network, and its potential as a therapeutic target remains incomplete. In this review, we integrated bioinformatics analysis with an extensive literature review to provide deeper insights into the role of survivin in HCC. Using bioinformatics tools such as the Human Protein Atlas, GEPIA, STRING, TIMER, and Metascape, we analyzed survivin expression and its functional associations and identified the top 20 coexpressed genes in HCC. These include TK1, SPC25, SGO2, PTTG1, PRR11, PLK1, NCAPH, KPNA2, KIF2C, KIF11, HJURP, GTSE1, FOXM1, CEP55, CENPA, CDCA3, CDC45, CCNB2, CCNB1 and CTD-2510F5.4. Our findings also revealed significant protein-protein interactions among these genes, which were enriched in pathways associated with the FOXM1 oncogenic signaling cascade, and biological processes such as cell cycle regulation, mitotic checkpoints, and diseases such as liver neoplasms. We also discussed the involvement of survivin in key oncogenic pathways, including the PI3K/AKT, WNT/β-catenin, Hippo, and JAK/STAT3 pathways, and its role in modulating cell cycle checkpoints, apoptosis, and autophagy. Furthermore, we explored its interactions with the tumor microenvironment, particularly its impact on immune modulation through myeloid-derived suppressor cells (MDSCs), tumor-associated macrophages, and natural killer cell function in HCC. Additionally, we highlighted its involvement in alkylglycerone phosphate synthase (AGPS)-mediated lipid reprogramming and identified important gaps in the survivin network that warrant further investigation. This review also examined the role of survivin in cancer stemness, inflammation, and virally mediated hepatocarcinogenesis. We evaluated its potential as a diagnostic, prognostic, predictive, and pharmacodynamic biomarker in HCC, emphasizing its relevance in precision medicine. Finally, we summarized emerging survivin-targeted therapeutics and ongoing clinical trials, underscoring the need for novel strategies to effectively target survivin in HCC.

Lipidomics reveals different therapeutic potential for natural and synthetic vitamin D formulations in hepatocyte lipotoxicity

Natural sources of vitamin D (VD), have been proposed to represent an alternative to synthetic vitamin D in nutritional interventions, also holding therapeutic potential in non-alcoholic fatty liver disease (NAFLD). In this study lipidomics was used to comparatively investigate the molecular mechanisms behind the therapeutic effects of a natural VD formulation consisting of a Shitake mushroom extracts (NVD) and a synthetic cholecalciferol formulation (SVD) in HepaRG human hepatocytes exposed to free fatty acid (FFA)-induced lipotoxicity. The results demonstrate that the two VD formulations prevent lipotoxicity with similar efficacy, but different lipidomic fingerprints. Differentially expressed lipids in NVD' in vitro therapeutic effect indicated a reduced synthesis of cellular triglycerides; combined with a marked reshaping of glycerophospholipid metabolism and characteristic changes of the chain length and number of double bonds in the phosphatidylcholine pool that were absent in SVD treatment. Bioinformatics interpretation of lipidomics data associated NVD therapeutic properties to an enhanced insulin function and glycerophospholipid metabolism, whereas SVD was primarily associated with the inflammatory signaling and death pathways of the liver cell. These differences between the two VD formulations were further highlighted matching lipidomics data with gene microarray (transcriptomics) data available from previous studies on this experimental model; the resulting multiomics data identified lipid metabolism nodes specific for the multimolecular mechanisms of the two formulations which may deserve further pre-clinical investigation in the treatment of hepatocyte lipotoxicity.

Scutellariae Radix and Coptidis Rhizoma improve NAFLD via regulation of SIRT6/ACSL5 pathway and SCD1

ETHNOPHARMACOLOGICAL RELEVANCE

The herbal pair Scutellariae Radix-Coptidis Rhizoma (SR-CR) has been widely used in Traditional Chinese Medicine (TCM) for treating metabolic disorders, including nonalcoholic fatty liver disease (NAFLD) -related conditions. Its traditional use highlights its potential in addressing the multifaceted pathogenesis of NAFLD, though the underlying mechanisms remain unclear.

AIM OF THE STUDY

To evaluate the therapeutic efficacy of the SR-CR herbal pair in alleviating NAFLD and to elucidate its mechanisms of action, with a specific focus on lipid metabolism pathways.

MATERIALS AND METHODS

The therapeutic effects of SR-CR were assessed using a high-fat diet (HFD)-induced NAFLD rat model and HepG2 cell model. Multi-omics analyses were employed to identify molecular targets and pathways, while affinity ultrafiltration-mass spectrometry characterized bioactive constituents. Findings were validated in vivo and in vitro via Western blot and immunofluorescence. Protein-constituent interactions were further characterized by surface plasmon resonance and molecular docking.

RESULTS

SR-CR significantly alleviated NAFLD symptoms in HFD-fed rats by reducing hepatic lipid accumulation, inflammation, and hepatocyte ballooning while normalizing biochemical indicators. Mechanistic studies revealed that SR-CR regulates the SIRT6/ACSL5 pathway and SCD1, both critical to lipid metabolism. Scutellariae Radix (SR) and its major constituent, baicalin, enhanced ACSL5 activity via SIRT6-mediated deacetylation, promoting fatty acid oxidation and intracellular lipid utilization. Coptidis Rhizoma (CR) and its primary component, berberine, inhibited SCD1, thereby reducing de novo lipogenesis. These complementary effects synergistically enhanced energy expenditure and reduced lipid synthesis.

CONCLUSION

The SR-CR herbal pair effectively alleviates HFD-induced NAFLD by synergistically modulating lipid metabolism, enhancing energy expenditure, and reducing de novo lipogenesis through the regulation of the SIRT6/ACSL5 pathway and SCD1. These findings provide molecular evidence for the traditional use of SR-CR in treating metabolic disorders and highlight its potential as a plant-based therapeutic for NAFLD.

Lesson from COVID-19-Adapting Respiratory Rehabilitation Through Early Multidisciplinary Care: An Opinion Paper from Retrospective Data

The COVID-19 pandemic significantly challenged healthcare systems worldwide, highlighting the critical role of early and multidisciplinary rehabilitation interventions. There remains uncertainty about whether these rehabilitation principles developed in response to COVID-19 can be effectively generalized to chronic respiratory diseases. This opinion paper evaluates retrospective data from early stages of the COVID-19 pandemic to propose a comprehensive early multidisciplinary rehabilitation model, potentially applicable across various chronic respiratory conditions. We retrospectively analyzed data from 62 COVID-19 patients hospitalized at the University Hospital of Messina, Italy, between March and June 2020. The patients underwent structured multidisciplinary rehabilitation sessions initiated upon achieving clinical stability. Functional improvements were assessed weekly using the Barthel Index (BI). Significant correlations were observed between initial BI scores and functional improvements at discharge (p < 0.001) and between functional gains and the number of rehabilitation sessions administered (p = 0.025). Early physiatric evaluation significantly enhanced functional recovery (p = 0.036). Early structured multidisciplinary rehabilitation during acute hospitalization demonstrated clear benefits in COVID-19 patients, indicating potential for broad applicability in chronic respiratory disease management. Systematic implementation could improve clinical outcomes, reduce healthcare resource utilization, and enhance patients' quality of life.

Impact of Viral Infections on the Hemostatic System

The coronavirus disease 2019 (COVID-19) pandemic has brought renewed attention to the significant but often overlooked impact of viral infections on the hemostatic system. This review explores the pathophysiological mechanisms underlying the interaction between viruses and hemostasis, directly through viral components or immune-mediated processes. Viruses are recognized as pathogen-associated molecular patterns (PAMPs) by pattern recognition receptors (PRRs) on innate immune cells such as neutrophils, monocytes, and platelets. This recognition triggers immune responses, including the production of type I interferons (IFN-α and IFN-β) and proinflammatory cytokines like interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α), which recruit immune cells and induce pyroptotic cell death. Inflammatory cytokines contribute to endothelial dysfunction and coagulation activation, interacting with platelets, neutrophils, neutrophil extracellular traps (NETs), and the kallikrein-kinin system. Hyperactivation of the cytokine system, known as the "cytokine storm," correlates with disease severity. Common features of viral infections include platelet activation and endotheliitis, leading to thrombocytopenia and microvascular thrombosis. Interestingly, similar pathogenic mechanisms in COVID-19 and viral hemorrhagic fevers (VHFs) result in contrasting clinical manifestations. While COVID-19 predominantly induces a thrombotic response characterized by endothelial damage, platelet hyperactivity, and complement activation, VHFs typically lead to hemorrhagic complications due to thrombocytopenia, consumptive coagulopathy, and vascular injury. These differences are influenced by the timing and location of coagulation activation, as well as the dynamics of immune responses. In COVID-19, coagulation initially occurs in the lungs, followed by systemic thrombotic phases, whereas VHFs rapidly progress to consumptive coagulopathy with hemorrhage, compounded by immune suppression.

Prognostic risk profiling in COPD using Global Initiative for Chronic Obstructive Lung Disease 2023 ABE and comorbidity assessment: evidence from a register-based COPD cohort

Background

While the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 ABE classification system guides initial chronic obstructive pulmonary disease (COPD) treatment, patient heterogeneity and comorbidities complicate management. We investigated how the GOLD 2023 ABE classification and aligned comorbidity profiles affect patient outcomes in real-world Asian populations with COPD.

Methods

We conducted a register-based cohort study of 38 928 patients from multiple institutions across Taiwan (from April 2017 to December 2021). We classified patients by GOLD 2023 ABE categories. Data included demographics, Charlson comorbidity index (CCI)-defined comorbidities, treatment, symptoms, questionnaires, spirometry, and outcomes.

Results

Among COPD patients, 89.2% were males, and the median age was 71 years. Groups A comprised 30.2%, group B 46.4%, and group E 23.5% of patients. Among these, 28.3% of group A patients used inhaled corticosteroid-containing inhalers. Group E had the highest rates of GOLD 4 airway obstruction (11.8%), CCI score ≥4 (15.6%), and five-year mortality rate (22.6%). Group E demonstrated the highest risk of all-cause mortality (hazard ratio (HR) = 1.727; 95% confidence interval (CI) = 1.605-1.858) and moderate-to-severe exacerbation (HR = 2.127; 95% CI = 1.942-2.330) vs. group A. Key comorbidities, acute myocardial infarction (HR = 1.257; 95% CI = 1.057-1.430), congestive heart failure (HR = 1.836; 95% CI = 1.707-1.909), and pulmonary disease (HR = 1.071; 95% CI = 1.011-1.129), were associated with higher mortality. Acute myocardial infarction (HR = 1.251; 95% CI = 1.031-1.444), congestive heart failure (HR = 1.193; 95% CI = 1.089-1.285), and pulmonary disease (HR = 1.491; 95% CI = 1.405-1.550) were also associated with higher exacerbations, with patterns varying across GOLD groups.

Conclusions

In this large registry-based cohort, group E patients demonstrated the highest mortality and exacerbation risks. Cardiovascular and pulmonary comorbidities increased adverse outcome risks across all GOLD categories. Systematic comorbidity screening should be integrated into routine COPD care. Findings support personalised treatment approaches based on GOLD classification and comorbidity profiles.

Dehydroepiandrosterone (DHEA)-induced autophagy protects against lipotoxicity in hepatic cells

Dehydroepiandrosterone (DHEA), a precursor of sex hormones, has been implicated in the pathogenesis of non-alcoholic steatohepatitis (NASH) or metabolic dysfunction-associated steatohepatitis (MASH), with studies suggesting a strong correlation between DHEA levels and disease severity. In this study, we demonstrated that DHEA alleviated lipotoxicity-induced hepatic damage by promoting autophagy. Our findings demonstrate that DHEA-induced autophagy is mediated by estrogen receptor alpha (ER-α) and androgen receptor (AR) activation and protects hepatic cells against palmitate-induced apoptosis, steatosis, and inflammasome activation. DHEA treatment in a murine NASH model induced significant autophagy in the liver, further supporting the hepatoprotective role of DHEA. Collectively, our results identified DHEA as a pro-autophagic hormone with therapeutic potential for the treatment of lipotoxicity in NASH.

LEADS - a comprehensive human liver-on-a-chip for non-alcoholic steatohepatitis (NASH) drug testing

Metabolic dysfunction associated steatohepatitis (MASH), also known as non-alcoholic steatohepatitis (NASH), is a progressive form of steatotic liver disease (SLD). It is an emerging healthcare threat due its high prevalence, accelerated and non-linear progression, and final culmination as decompensated liver failure and/or hepatocellular carcinoma (HCC). The pathogenesis of NASH is complex with strong ethnic influences and genetic predispositions, underscoring the need for preclinical models that utilize patient-derived cells to enhance our understanding of the disease. Current models face three major limitations: (i) reliance on primary cells with limited reproducibility, high cost, short culture duration and ethical considerations, (ii) failure to recapitulate all key features of NASH, and (iii) inadequate drug testing data and/or data did not correlate with clinical responses. Therefore, there is a pressing need for robust and relevant preclinical models that faithfully recapitulate human NASH, allow generation of patient-specific models and provide quantitative responses for mechanistic studies and drug testing. We have developed a functional liver tissue-on-a-chip by co-culturing human adult liver stem cell (haLSC)-derived hepatobiliary organoids, induced pluripotent stem cell (iPSC)-derived Kupffer cells (iKCs) and iPSC-derived hepatic stellate cells (iHSCs). We simulated the metabolic microenvironment of hyper nutrition and leaky gut by treating the cells with a concoction of free fatty acids (FFAs), fructose, gut-derived lipopolysaccharides (LPS) and a gut-derived metabolite, phenyl acetic acid (PAA). Through optimization of co-culture media and induction regimens, we were able to stably induce steatosis, hepatocellular ballooning, inflammation, and activation of iHSC and fibrosis-all key hallmarks of NASH. Our LEADS (liver-on-a-chip for NASH drug testing) model also recapitulated the pathological types of steatosis and allowed for quantification of the key features via microscopic evaluation and secretome profiling to score for disease severity. Notably, treatment with saroglitazar, pioglitazone, cenicriviroc (CVC), obeticholic acid (OCA) and resmetirom produced responses similar to those observed in clinical trials. Taken together, our LEADS model is the first model developed using patient-derived hepatic stem cells which recapitulated all key features used for comprehensive drug testing, with results matching to clinical responses.

A simple surrogate approach for the quantitation of C4 (7α-hydroxy-4-cholesten-3-one) in human serum via LC-MS/MS and its application in a clinical study

We present a validated LC-MS/MS assay for the quantitation of 7α-hydroxy-4-cholesten-3-one (C4), a key intermediate in the bile acid synthesis pathway from cholesterol, in human serum. A surrogate matrix approach was employed to overcome the challenges posed by the endogenous C4 levels in the biological matrix. Human serum samples were spiked with stable isotope labeled internal standard (SIL-IS), processed using supported liquid extraction (SLE), and analyzed by LC-MS/MS. Parallelism was successfully demonstrated between human serum (authentic matrix) and 5 % bovine serum albumin in phosphate buffered saline containing 0.1 % tween 20 (5 % BSA in PBST) (surrogate matrix). The assay's linear analytical range was established from 0.200 to 200 ng/mL. This validated LC-MS/MS method exhibited excellent accuracy and precision. The overall accuracy was between 97.9 % and 101 % with %CV less than 4.0 % for C4 in human serum. C4 was found to be stable in human serum for up to 24.7 h at room temperature, up to 34 days when stored at -25 °C or - 80 °C, and after five freeze/thaw cycles. The assay has been successfully applied to human serum samples to support a clinical study.

The present and future of geriatric internal medicine: a bibliometric analysis

With the gradual progress of global aging, geriatric medicine is becoming increasingly popular, and within geriatric medicine, internal medicine holds a very important position. Understanding the situation in the field of geriatric internal medicine helps researchers gain a comprehensive understanding of this area. In this study, we analyzed and visualized relevant literature from the Web of Science Core Collection database using bibliometric methods, collecting a total of 831 articles, with a time span from 1978 to August 2024. We analyzed the overview of the field, the degree of aging and the volume of publications by country, the core journals in the field, the collaboration relationships among institutions and authors, as well as the hotspots and their changes, and discussed the results. This study provides a broad perspective for professionals in the field of geriatric internal medicine and discusses the future research development in the field.

A polygenetic rat model of divergent aerobic capacity reveals a liver-brain interaction impacting Alzheimer's disease-like phenotypes

The interaction between liver and brain health is an emerging complex relationship implicated in Alzheimer's disease (AD). Divergence in aerobic capacity influences liver and brain health independently; however, whether these factors converge to influence AD risk is mechanistically unknown. Bile acid metabolism has been implicated as a link between liver and brain health and is modulated by aerobic capacity. Here, we examined rats selectively bred for high vs. low intrinsic aerobic capacity [high and low-capacity runner (HCR or LCR)] on indices of hepatic metabolism and brain health following a chronic low-fat, high-fat, or high-fat diet with bile acid sequestrant from 6 to 12 months of age. Pre- and post-diet measures included learning, memory, and brain volume metabolite levels. We additionally quantified brain and liver Aβ and proteins associated with Aβ production and clearance, as well as liver and brain mitochondrial energetics and liver bile acid species. We found that not only did aerobic capacity and diet influence mitochondrial function, but also it modified Aβ levels across the liver and brain. Additionally, aerobic capacity and diet altered bile acid profiles and brain hippocampal metabolite levels. The addition of bile acid sequestrant lowered brain Aβ levels in a sexually dimorphic manner. Aerobic capacity but not diet altered cognitive outcomes. Our results indicate that aerobic capacity and diet-induced liver health alterations modulate brain health with respect to metabolism and AD-like pathologies, whereas a stimulation of faecal bile acid loss could have positive effects on lowering brain Aβ. KEY POINTS: Aerobic capacity and diet-induced alterations to liver function alter liver bile acid species and faecal energy loss. Aerobic capacity and diet alter both brain and liver Aβ homeostasis. Aerobic capacity modulates brain and hippocampal volume in addition to brain metabolism. Aerobic capacity influences learning in middle-aged rats.

J-shaped association between apolipoprotein B and CV outcomes in statin-treated patients with chronic coronary syndrome

INTRODUCTION AND OBJECTIVES

The association between apolipoprotein B (apoB) and residual cardiovascular (CV) risk in patients with chronic coronary syndrome (CCS) remains unclear. We aimed to investigate the association between apoB levels and CV outcomes in statin-treated CCS patients.

METHODS

We enrolled 8641 statin-treated CCS patients at Fuwai Hospital. The patients were divided into 5 groups based on to apoB quintiles (Q1 to Q5). The primary endpoint was 3-year CV events, including CV death, nonfatal myocardial infarction, and nonfatal stroke.

RESULTS

During a median follow-up of 3.17 years, there were 232 (2.7%) CV events. After multivariable adjustment, a restricted cubic spline illustrated a J-shaped relationship between apoB levels and 3-year CV events, with the risk remaining flat until apoB levels exceeded 0.73g/L, after which the risk increased (nonlinear P <.05). Kaplan-Meier curves showed the lowest CV event rate in the Q3 group (0.68-0.78g/L). Compared with the Q3 group, multivariable Cox regression models revealed that both low (Q1, ≤0.57g/L) and high (Q5, >0.93g/L) apoB levels were associated with an increased risk of major adverse cardiac events (all P <.05). Notably, patients with low apoB levels (Q1) had the highest risk of CV death (HR, 2.44; 95%CI, 1.17-5.08).

CONCLUSIONS

Our analysis indicates that both low and high levels of apoB are associated with elevated CV risk, with the risk being particularly pronounced at higher levels (> 0.73g/L).

Functional disability after clinically significant extracranial bleeding: a secondary analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) Trial

BACKGROUND

Clinically significant extracranial bleeding, defined as bleeding at any site other than the brain or spinal cord requiring either a hospital admission >24 hours, red blood cell transfusion, surgery for hemostasis, or resulting in death, is a common side effect of antithrombotic agents. Compared to intracranial bleeding, the impact of clinically significant extracranial bleeding on long-term outcomes, including functional independence, has been poorly studied.

OBJECTIVES

To determine if clinically significant extracranial bleeding impacts the development of functional disability in healthy older adults.

METHODS

We performed a secondary analysis of the Aspirin in Reducing Events in the Elderly trial. The primary outcome of this study was incident dependence in the Katz Activities of Daily Living (ADLs), defined as being unable to perform or requiring assistance with any ADLs or being admitted to a long-term care facility.

RESULTS

A total of 18 982 participants were included in the analysis, of which 547 (2.9%) developed clinically significant extracranial bleeding during study follow-up. In adjusted analyses, clinically significant extracranial bleeding was significantly associated with the development of incident ADL dependence (hazard ratio [HR], 2.46; 95% CI, 1.97-3.07). This finding was similar for gastrointestinal (HR, 2.29; 95% CI, 1.72-2.08) and nongastrointestinal extracranial bleeds (HR, 2.68; 95% CI, 1.96-3.69). The association with increased risk of incident ADL dependence remained significant in secondary analysis of groups randomized to either aspirin (HR, 2.15; 95% CI, 1.57-2.94) or placebo (HR, 2.84; 95% CI, 2.09-3.86).

CONCLUSION

Clinically significant extracranial bleeding was associated with the development of incident ADL dependence in otherwise healthy older adults.

Oleic acid promotes lipid accumulation in bovine adipocytes: the role of peroxisome proliferator-activated receptor alpha (PPARα) signaling

Excessive lipid mobilization due to negative energy balance in periparturient dairy cows increases their risk for diseases and decreases their productivity, highlighting the importance of enhancing energy availability during the immediate postpartum to limit negative energy balance. Oleic acid (OA) supplementation increases the energy density of the diet and holds promise in addressing metabolic challenges. In periparturient cows, OA limits lipolysis and improves adipose tissue (AT) insulin sensitivity. However, the mechanisms behind these effects are still unknown. Our objective was to characterize the effects of OA, alone and in combination with palmitic acid (PA), on lipogenic function and identify a mechanism of action in bovine adipocytes. We hypothesized that OA enhances lipid accumulation in bovine adipocytes via peroxisome proliferator-activated receptor alpha (PPARα)-dependent activation of lipogenic pathways. Pre-adipocytes were isolated from AT of Holstein dairy cows and induced to differentiate into adipocytes. Mature adipocytes were cultured with standard differentiation media (CON) supplemented with PA or OA (100, 200, and 300 µM), and mixtures of PA-OA (60-40, 50-50, and 40-60 ratios at 300 µM) for 4 or 7 d. To evaluate the effect of PPARα signaling, adipocytes were treated with or without a PPARα-specific antagonist (GW6471; 10 µM) for 7 d after induction. Compared with CON, fatty acid treatments had no effect on preadipocyte differentiation (P = 0.65). The treatments 300PA, 200OA, 300OA, 60-40, 50-50, and 40-60 increased lipid accumulation compared with CON (P < 0.0001). At d 4, 300PA and 300OA increased PPARα protein expression compared with CON (P = 0.04). PPARα inhibition decreased triglyceride levels in OA and 60-40 (P < 0.05) but not in PA (P = 0.26). Our results show a direct effect of OA supplementation on bovine adipocyte metabolism, resulting in lipid accumulation, mainly through PPARα signaling, which in turn activates lipogenic networks. Hence, providing mechanistic evidence for the use of OA, along with PA, in dairy cow diets during the periparturient period to enhance lipid accumulation and limit lipolysis. Improving energy balance will ultimately minimize health disorders and improve the production of early postpartum cows.

Adiponectin alleviates inflammatory response in metabolic dysfunction-associated steatohepatitis by inhibiting NLRP3 inflammasome-mediated hepatocyte pyroptosis

BACKGROUND

Activation of NLRP3 (NOD-, LRR- and pyrin domain-containing protein 3) inflammasomes induced by pyroptosis is crucial in metabolic dysfunction-associated steatohepatitis (MASH) progression. Adiponectin possesses an anti-inflammatory role in various liver diseases. This study aimed to evaluate the effects of adiponectin on MASH.

METHODS

Adiponectin-mediated anti-inflammatory mechanisms, effects on pyroptosis-related proteins, and activation of NLRP3 inflammasomes were investigated using methionine-choline-deficient (MCD)-induced MASH murine model and in vitro models. The degree of MASH inflammation in liver tissue of C57BL/6J mice was assessed using histopathology. Enzyme-linked immunosorbent assay was performed to measure levels of inflammatory factors [interleukin-18 (IL-18), IL-1β, and tumor necrosis factor-α (TNF-α)] in mice serum and culture medium. Western blot and quantitative polymerase chain reaction were performed to analyze the expression of pyroptosis-related genes and proteins in liver tissues of mouse model and in vitro models. Macrophage recruitment in vitro was evaluated using co-culture of upper and lower chambers.

RESULTS

MASH developed in MCD diet mice [metabolic dysfunction-associated steatotic liver disease (MASLD) activity score = 6] but not in methionine-choline-sufficient (MCS) diet mice (MASLD activity score = 3). Compared to MCS-fed mice, MCD-fed mice showed increased serum levels of aspartate aminotransferase, IL-18, IL-1β, and TNF-α and higher MASLD activity score (P < 0.001). Adiponectin inhibited these increases (P < 0.05) and suppressed mRNA and protein levels of NLRP3, gasdermin-D (GSDMD), and GSDMD-N in liver tissues (P < 0.05). In vitro, lipopolysaccharide (LPS)/palmitic acid (PA) increased the levels of IL-18, IL-1β, and TNF-α, mRNA expressions of CASP1 and GSDMD, and production of CASP1, NLRP3, GSDMD, and GSDMD-N (P < 0.01). Adiponectin reduced the levels of these inflammatory factors and downregulated the mRNA expression and protein generation of pyroptosis-related markers (P < 0.05). HepG2 cells pretreated with LPS/PA recruited more J774A.1 cells (P < 0.001) and increased inflammatory factor secretion by J774A.1 cells (P < 0.001). Adiponectin inhibited this recruitment and reduced inflammatory factor secretion (P < 0.001).

CONCLUSIONS

Adiponectin inhibits hepatocyte pyroptosis by reducing the production and activation of NLRP3 inflammasomes, CASP1, and GSDMD, thus improving the inflammatory response in MASH and possibly delaying or reversing MASLD progression.

Influence of triglycerides on the link between gamma-glutamyl transferase to high-density lipoprotein cholesterol ratio and nonalcoholic fatty liver disease in nonobese Chinese adults: A secondary cohort study

Nonalcoholic fatty liver disease (NAFLD) represents a chronic hepatic disorder marked by excessive lipid deposition within liver tissues. Previous studies have identified the gamma-glutamyl transferase to high-density lipoprotein cholesterol (GGT/HDL-c) ratio as a potential marker associated with NAFLD risk. However, the influence of triglyceride (TG) levels on this association has not been fully elucidated. This study was designed to assess whether TG modulates the relationship between GGT/HDL-c and the incidence of NAFLD, and to explore the possible interaction between TG and GGT/HDL-c in relation to NAFLD risk. This investigation was a secondary analysis based on data from a cohort study, encompassing 11,692 nonobese Chinese adults. Participants were stratified into 2 groups according to their triglyceride levels: hypertriglyceridemia (TG ≥ 1.7 mmol/L) and non-hypertriglyceridemia (TG < 1.7 mmol/L). Additionally, the GGT/HDL-c ratio was divided into quartiles for detailed analysis. The association between GGT/HDL-c, TG, and the occurrence of NAFLD was evaluated using Cox proportional hazards regression models. Furthermore, the potential modifying effect of TG on the GGT/HDL-c-NAFLD relationship was examined by categorizing participants into 8 subgroups based on TG status and quartiles of GGT/HDL-c ratio. During a mean follow-up duration of 29.24 months, 1926 individuals (16.47%) were newly diagnosed with NAFLD. Both elevated GGT/HDL-c ratios and higher TG concentrations were significantly correlated with an increased risk of developing NAFLD. TG levels influenced the strength of the association between GGT/HDL-c and NAFLD. Specifically, the association was stronger among individuals without hypertriglyceridemia (HR = 1.019, 95% CI = 1.015-1.023, P < .0001), and comparatively weaker in the hypertriglyceridemia group (HR = 1.012, 95% CI = 1.008-1.016, P < .0001). Moreover, a significant interaction effect was observed between TG and GGT/HDL-c, with the greatest risk identified in participants exhibiting both elevated GGT/HDL-c ratios and high TG levels (HR = 6.662, 95% CI = 5.237-8.474, P < .0001). Triglyceride levels appear to modify the relationship between GGT/HDL-c and NAFLD risk, with a notable interaction effect between these 2 factors. Among nonobese Chinese adults, simultaneous management aimed at reducing both GGT/HDL-c ratios and TG concentrations may contribute to lowering the risk of NAFLD onset.

Unresolved alterations in bile acid composition and dyslipidemia in maternal and cord blood after UDCA treatment for intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is characterized by elevated plasma bile acid levels. ICP is linked to adverse metabolic outcomes, including a reported increased risk of gestational diabetes. The standard therapeutic approach for managing ICP is treatment with ursodeoxycholic acid (UDCA) and induction of labor before 40 wk of gestation. To investigate bile acid and metabolic parameters after UDCA treatment, we enrolled 12 ICP patients with singleton pregnancies-half with and half without gestational diabetes-and 7 controls. Our study reveals that after UDCA treatment, notwithstanding a reduction in total bile acid and alanine aminotransferase levels, imbalances persist in the cholic acid (CA) to chenodeoxycholic acid (CDCA) ratio in maternal and cord blood plasma. This indicates a continued dysregulation of bile acid metabolism despite therapeutic intervention. Maternal plasma lipid analysis showed a distinct maternal dyslipidemia pattern among patients with ICP, marked by elevated cholesterol levels on VLDL particles and heightened triglyceride concentrations on LDL particles, persisting even after UDCA treatment. Cord plasma lipid profiles in patients with ICP exhibited elevated triglyceride and free fatty acid levels alongside a tendency toward increased β-hydroxybutyrate. The changes in lipid metabolism in both maternal and cord blood correlated with the high CA/CDCA ratio but not total bile acid levels or gestational diabetes status. Understanding the imbalances in maternal and cord bile acid and lipid profiles that persist after standard UDCA therapy provides insights for improving management strategies and mitigating the long-term consequences of ICP.NEW & NOTEWORTHY This study uncovers that despite ursodeoxycholic acid treatment, intrahepatic cholestasis of pregnancy (ICP) is associated with increases in the ratio of cholic acid to chenodeoxycholic acid in both maternal and cord blood, suggesting ongoing dysregulation of bile acid metabolism. The high cholic to chenodeoxycholic acid ratio is correlated with maternal dyslipidemia and high cord blood lipids. These findings may inform more targeted approaches to managing ICP.

Hormone replacement therapy for steatotic liver management after surgical menopause

Although steatotic liver onset after natural menopause has been reported, evidence on the clinical course and treatment options for steatotic liver after surgical menopause is scarce. A 34-year-old woman with a history of severe obesity presented to our department with liver dysfunction following total hysterectomy and bilateral oophorectomy. Her serum estradiol level was notably low at 22 pg/mL, and a liver biopsy revealed significant fatty degeneration, lobular inflammation, hepatocyte ballooning, and stage F1 fibrosis. These findings supported a diagnosis of steatotic liver disease following surgical menopause. Subsequent initiation of hormone replacement therapy (HRT) with estrogen led to rapid improvements in liver function and steatotic liver symptoms. Steatotic liver disease should be considered in cases of liver impairment in postoperative menopausal patients, for which HRT represents a promising treatment option.

Accuracy of Non-Invasive Imaging Techniques for the Diagnosis of MASH in Patients With MASLD: A Systematic Review

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a growing public health problem. The secondary stage in MASLD is steatohepatitis (MASH), the co-existence of steatosis and inflammation, a leading cause of progression to fibrosis and mortality. MASH resolution alone improves survival. Currently, MASH diagnosis is via liver biopsy. This study sought to evaluate the accuracy of imaging-based tests for MASH diagnosis, which offer a non-invasive method of diagnosis.

METHODS

Eight academic literature databases were searched and references of previous systematic reviews and included papers were checked for additional papers. Liver biopsy was used for reference standard.

RESULTS

We report on 69 imaging-based studies. There were 31 studies on MRI, 27 on ultrasound, five on CT, 13 on transient elastography, eight on controlled attenuation parameter (CAP) and two on scintigraphy. The pathological definition of MASH was inconsistent, making it difficult to compare studies. 55/69 studies (79.71%) were deemed high-risk of bias as they had no preset thresholds and no validation. The two largest groups of imaging papers were on MRI and ultrasound. AUROCs were up to 0.93 for MRE, 0.90 for MRI, 1.0 for magnetic resonance spectroscopy (MRS) and 0.94 for ultrasound-based studies.

CONCLUSIONS

Our study found that the most promising imaging tools are MRI techniques or ultrasound-based scores and confirmed there is potential to utilise these for MASH diagnosis. However, many publications are single studies without independent prospective validation. Without this, there is no clear imaging tool or score currently available that is reliably tested to diagnose MASH.

Melatonin Repairs the Lipidome of Human Hepatocytes Exposed to Cd and Free Fatty Acid-Induced Lipotoxicity

Hepatocyte lipotoxicity is central to the aetiology of nonalcoholic fatty liver disease (NAFLD), a leading cause of liver failure and transplantation worldwide. Long-lasting toxic pollutants have increasingly been considered as environmental risk factors of NAFLD. These include cadmium (Cd), a metal that synergizes with other cellular toxicants and metabolic stimuli to induce fat build-up and lipotoxicity. Recent studies demonstrated that melatonin (MLT) holds great potential as repairing agent in this form of hepatocyte lipotoxicity. In this study, the molecular hints of this MLT effect were investigated by lipidomics analysis in undifferentiated HepaRG cells, a human pre-hepatocyte cell line, exposed to Cd toxicity either alone or combined with prototypical free fatty acids (FFA), namely the saturated species palmitic acid and the monounsaturated oleic acid (OA and PA, respectively), to simulate the cellular lipotoxicity conditions of fatty liver disease. Cd exposure synergized with FFAs to induce cellular steatosis, and PA produced higher levels of lipotoxicity compared to OA by leading to increased levels of H2O2 production and apoptotic death. These effects were associated with changes of the cellular lipidome, which approximate those of NAFLD liver, with differentially expressed lipids in different classes that included triacylglycerols (TG), di- and mono-acylglycerols, phospholipids (PL), sphingolipids, acylcarnitines and FA; characteristic differences were observed in all these classes comparing the combinations of Cd exposure with PA or OA treatments. MLT significantly reduced the effects of either individual or combinatorial treatments of Cd and FFAs on lipotoxicity hallmarks, also repairing most of the alterations of the cellular lipidome, including those of the chain length and number of double bonds of acyl residues esterified to TG and PL classes. These findings and their bioinformatics interpretation suggest a role for the earliest acyl elongase and desaturase steps of FA metabolism in this repairing effect of MLT; biochemistry studies validated such interpretation identifying a specific role for SCD1 activity. This lipidomics study shed light on the cytoprotective mechanism of MLT in Cd and FFA-induced hepatocyte lipotoxicity, highlighting a repairing effect of this molecule on the cellular lipidome, which may hold therapeutic potential in fatty liver diseases.

Evaluation of glycemic status and subclinical atherosclerosis in familial hypercholesterolemia subjects with or without LDL receptor mutation

BACKGROUND

Familial hypercholesterolemia (FH) is a genetic condition characterized by elevated LDL-C and increased cardiovascular risk. Beyond LDL-C levels, the impact of genotype on glucose homeostasis has not been well evaluated. We aimed to evaluate the impact of genotype on glycemic status and on atherosclerotic injury in FH subjects.

METHODS

We conducted a cross-sectional study on 322 FH subjects not on lipid-lowering therapy and without history of cardiovascular disease. Biochemical and genetic analyses as well as vascular profile assessment were obtained from all subjects. The study population was divided into two groups according to genotype: LDL receptor (LDLR) group and non-LDLR (NLDLR) group.

RESULTS

The LDLR group exhibited a higher prevalence of low glycemic status (LGS) than the NLDLR group (44.1% vs. 26%, p < 0.01), whereas a high glycemic status (HGS) was more prevalent in the NLDLR group compared with LDLR group (74% vs. 55.9%, p < 0.01). The NLDLR group exhibited a higher prevalence of peripheral atherosclerotic plaques than the LDLR group (93.4% vs. 73%, p < 0.05), while coronary artery calcification (CAC) presence was more prevalent in the LDLR group compared with the NLDLR group (74.7% vs. 48%, p < 0.01). In a secondary analysis the study population was stratified into three groups based on LDLR genotype: NLDLR, LDLR defective, LDLR null groups. The prevalence of LGS progressively increased from the NLDLR to the LDLR null group, while HGS showed an inverse trend (p for trend < 0.05). Peripheral atherosclerotic plaque prevalence decreased from the NLDLR to the LDLR null group (p for trend < 0.05), while CAC prevalence increased progressively in the three groups (p for trend < 0.01). Logistic regression analysis showed that FH groups with an LDLR mutation were inversely associated with HGS (p for both < 0.01) and the LDLR null group exhibited the strongest association.

CONCLUSIONS

FH subjects with NLDLR mutations exhibited a worse glycemic profile, while null LDLR mutations showed the strongest inverse association with HGS. The integrations of genetic, lipid and glucose data could be useful to better identify the metabolic profile and the atherosclerosis distribution in FH subjects.

RESEARCH INSIGHTS

WHAT IS CURRENTLY KNOWN ABOUT THIS TOPIC?: Familial hypercholesterolemia (FH) is characterized by elevated LDL-C levels. LDLR null mutations protected pancreatic β-cells from cholesterol accumulation. NGS has improved FH diagnosis by analysis of all genes implicated in the lipid disorder. WHAT IS THE KEY RESEARCH QUESTION?: What is the impact of FH genotype (monogenic with or without LDLR mutation/polygenic) on glycemic status? WHAT IS NEW?: FH population was characterized by a heterogeneous glycemic profile according to LDLR mutation. LDL-C and plasma glucose could modulate the distribution of subclinical atherosclerosis. HOW MIGHT THIS STUDYINFLUENCE CLINICAL PRACTICE?: Genetic, lipid, glucose data could better identify the metabolic and atherosclerotic profiles in FH.

Association of the overlap of cognitive impairment and depression with 6-month mortality in hospitalized older adults: results from the Re.Po.SI register

BACKGROUND

When admitted to hospital for unplanned medical needs, the complexity of multiple conditions, including cognitive and mental health, might put older people at greater risk, affecting their survival. This study aimed to investigate the prevalence of cognitive impairment versus cognitive impairment with depression and their association with six-month mortality in older people after an unplanned hospital admission in Italy.

METHODS

In Re.Po.SI. a multi-centre study performed in Italy, standardized web-based case report forms were used to collect data on socio-demographic factors, clinical parameters, diagnoses, treatment history and at discharge, clinical events during hospitalization, and outcome data was collected. A comprehensive geriatric assessment was conducted using Cumulative Illness Rating Scale (CIRS), Geriatric Depression Scale (GDS-4), Barthel Index, and Short Blessed Test (SBT). To explore the interrelationship between depression and cognitive impairment, a variable categorized the study population into four mutually exclusive groups. This variable assessed the association between its categories and six-month mortality in a Cox multivariate analysis.

RESULTS

One thousand nine hundred fifty six participants were included, with a median age of 80 years (IQR: 73-85). Those who died within six months were likely to be older (82 vs. 79 years), male (56.2% vs. 47.2%), had moderately reduced ability to perform daily activities (82.0 vs. 93.0), exhibited greater illness severity (CIRS-IS: 1.8 vs. 1.6), had more chronically prescribed medications (6.0 vs. 5.0), and had a worse SBT score (10.0 vs. 7.0). When stratified based on cognitive impairment and depression, one-third had neither condition (33.2%), 21.9% had depression, 20.7% had a cognitive impairment, and 24.3% had both conditions. Six-month mortality was higher among people with cognitive impairment only (33.2%) followed by those with both conditions (28.8%), and depression only (22.7%). The unadjusted semi-parametric survival analysis revealed that the hazard ratio (HR) for people with cognitive impairment only was 2.08, for those with both conditions HR was 1.75, and for people with depression only HR was 1.30.

CONCLUSION

While depression alone may contribute to mortality risk, cognitive impairment appears to play a more substantial role in increasing the risk of dying within 6 month from an acute hospitalization. Further research is needed to confirm these finding.

Role of genetic variants and DNA methylation of lipid metabolism-related genes in metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD), is one of the most common chronic liver diseases, which encompasses a spectrum of diseases, from metabolic dysfunction-associated steatotic liver (MASL) to metabolic dysfunction-associated steatohepatitis (MASH), and may ultimately progress to MASH-related cirrhosis and hepatocellular carcinoma (HCC). MASLD is a complex disease that is influenced by genetic and environmental factors. Dysregulation of hepatic lipid metabolism plays a crucial role in the development and progression of MASLD. Therefore, the focus of this review is to discuss the links between the genetic variants and DNA methylation of lipid metabolism-related genes and MASLD pathogenesis. We first summarize the interplay between MASLD and the disturbance of hepatic lipid metabolism. Next, we focus on reviewing the role of hepatic lipid related gene loci in the onset and progression of MASLD. We summarize the existing literature around the single nucleotide polymorphisms (SNPs) associated with MASLD identified by genome-wide association studies (GWAS) and candidate gene analyses. Moreover, based on recent evidence from human and animal studies, we further discussed the regulatory function and associated mechanisms of changes in DNA methylation levels in the occurrence and progression of MASLD, with a particular emphasis on its regulatory role of lipid metabolism-related genes in MASLD and MASH. Furthermore, we review the alterations of hepatic DNA and blood DNA methylation levels associated with lipid metabolism-related genes in MASLD and MASH patients. Finally, we introduce potential value of the genetic variants and DNA methylation profiles of lipid metabolism-related genes in developing novel prognostic biomarkers and therapeutic targets for MASLD, intending to provide references for the future studies of MASLD.

Modifications in hemoglobin levels associated with age in an outpatient population from northern italy

A reduction in hemoglobin levels is common in older subjects. The objective of this study was to investigate the association between changes in blood counts and age in a large outpatient population of adult subjects, in order to verify to what extent such changes may be considered physiological.We examined blood count results in the province of Modena (Italy) from January 2010 to August 2022. Data were analyzed with the platform Anaconda 3, Python 3.7. Appropriate hemoglobin data were extracted from 4,676,003 samples. Hemoglobin levels in subjects over 75 years were largely below lower limits for both sexes (49.3% of 509,834 exams and 35.4% of 704,343 exams for males and females, respectively). The trend was similar in relation to single values per person per year. To exclude patients with some major systemic diseases, we limited our observation to subjects with normal values of serum glucose, creatinine, and alanine transaminase (ALT). In this set of 822,166 analyses, a clinically relevant proportion of older males (nearly 30%) still had hemoglobin values below normal. Such trend was apparent in older age strata. Our findings suggest caution in the interpretation of blood counts in older patients. We therefore advocate a tailored approach in this population.

Prevalence of Delayed Discharge Among Patients Admitted to the Internal Medicine Wards: A Cross-Sectional Study

Background/Objectives: Hospital bed shortage is a widespread issue affecting healthcare systems globally, often exacerbated by bed-blocking, a phenomenon where patients remain hospitalized longer than medically necessary due to discharge delays. The aim of this study was to evaluate the prevalence of patients with bed-blocker status admitted to the internal medicine wards. Methods: This cross-sectional study was conducted at an academic tertiary-level hospital in Milan (Italy) from 1 January to 31 December 2023. All adult patients identified as ready for discharge by the bed management service, but whose actual discharge was delayed by more than 24 h, were included. Clinical data were retrieved from electronic medical and nursing records. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Results: Out of 2480 admissions to the internal medicine wards, 147 patients (5.9%) experienced delayed discharge. The median hospital length of stay was 22 days (IQR: 15.0-33.0); the median duration of appropriate stay was 6 days (IQR: 2.0-13.0), and the median length of delayed stay was 14 days (IQR: 7.0-21.0). Waiting for transfer to lower-intensity care facilities was the primary cause of delayed discharge. Complications during delayed stays included delirium (31.3%) and hospital-acquired infections (35.4%), particularly urinary tract infections (17.7%). Logistic regression identified older age (≥75 years), extended hospital length of stay, emergency admissions, and discharge to long-term care as independent predictors of bed-blocker status. Conclusions: This study highlights delayed discharges as a significant issue in internal medicine wards, driven by advanced age, caregiver absence, and high dependency in activities of daily living.

Updated recommendations for the management of metabolic dysfunction-associated steatotic liver disease (MASLD) by the Latin American working group

Metabolic dysfunction-associated steatotic liver disease (MASLD) is one of the leading causes of chronic liver disease globally. Based on the 2023 definition, MASLD is characterized by the presence of metabolic dysfunction and limited alcohol consumption (<140 grams/week for women, <210 grams/week for men). Given the significant burden of MASLD in Latin America, this guidance was developed by the Latin American Association for the Study of the Liver (ALEH) Working Group to address key aspects of its clinical assessment and therapeutic strategies. In Latin America, ultrasonography is recommended as the initial screening tool for hepatic steatosis due to its accessibility, while Fibrosis-4 (FIB-4) is preferred for fibrosis risk stratification, with further evaluation using more specific techniques (i.e., vibration-controlled transient elastography or Enhanced Liver Fibrosis [ELF] test). A Mediterranean diet is advised for all MASLD patients, with a target of 7-10% weight loss for those with excess weight. Complete alcohol abstinence is recommended for patients with significant fibrosis, and smoking cessation is encouraged regardless of fibrosis stage. Pharmacological options should be tailored based on the presence of steatohepatitis, liver fibrosis, excess weight, and diabetes, including resmetirom, incretin-based therapies, pioglitazone, and sodium-glucose cotransporter-2 inhibitors. Bariatric surgery may be considered for MASLD patients with obesity unresponsive to lifestyle and medical interventions. Hepatocellular carcinoma screening is advised for all cirrhotic patients, with consideration given to those with advanced fibrosis based on individual risk. Finally, routine cardiovascular risk assessment and proper diabetes prevention and management remain crucial for all patients with MASLD.

The Microbiota and Evolution of Obesity

Obesity is a major global concern and is generally attributed to a combination of genetic and environmental factors. Several hypotheses have been proposed to explain the evolutionary origins of obesity epidemic, including thrifty and drifty genotypes, and changes in thermogenesis. Here, we put forward the hypothesis of metaflammation, which proposes that due to intense selection pressures exerted by environmental pathogens, specific genes that help develop a robust defense mechanism against infectious diseases have had evolutionary advantages and that this may contribute to obesity in modern times due to connections between the immune and energy storage systems. Indeed, incorporating the genetic variations of gut microbiota into the complex genetic framework of obesity makes it more polygenic than previously believed. Thus, uncovering the evolutionary origins of obesity requires a multifaceted approach that considers the complexity of human history, the unique genetic makeup of different populations, and the influence of gut microbiome on host genetics.

Gut Microbiota Modulation Through Mediterranean Diet Foods: Implications for Human Health

The Mediterranean diet (MD) is widely recognized for its health benefits, particularly in modulating gut microbiota composition and reducing the risk of metabolic, cardiovascular, and neurodegenerative diseases. Characterized by a high intake of plant-based foods, monounsaturated fats, and polyphenols, primarily from extra virgin olive oil, the MD fosters the growth of beneficial gut bacteria such as Bifidobacterium, Faecalibacterium prausnitzii, and Roseburia, which produce short-chain fatty acids that enhance gut barrier integrity, reduce inflammation, and improve metabolic homeostasis. Clinical and preclinical studies have proved that the MD is associated with increased microbial diversity, reduced pro-inflammatory bacteria, and improved markers of insulin sensitivity, lipid metabolism, and cognitive function. Additionally, the MD positively influences the gut microbiota in various conditions, including obesity, cardiovascular disease, and neurodegeneration, potentially mitigating systemic inflammation and enhancing neuroprotective mechanisms. Emerging evidence suggests that MD variants, such as the Green-MD, and their integration with probiotics can further optimize gut microbiota composition and metabolic parameters. While the beneficial impact of the MD on the gut microbiota and overall health is well supported, further long-term clinical trials are needed to better understand individual variability and improve dietary interventions tailored to different populations.

Edoxaban treatment in routine clinical practice is highly concordant with the 2020 European Society of Cardiology atrial fibrillation guidelines: results from the noninterventional Global ETNA-AF programme

Aims

The 2020 European Society of Cardiology (ESC)-atrial fibrillation (AF) guidelines recommend a risk-based approach to oral anticoagulation (OAC) therapy in patients with AF; however, it is unknown if current practice aligns with these recommendations. This study assessed the associated effectiveness and safety of edoxaban in patients with AF according to the 2020 ESC-AF guidelines and the approved label in routine clinical care.

Methods and results

The Global ETNA-AF programme is a large prospective, noninterventional programme evaluating safety and effectiveness of edoxaban. Baseline characteristics and 2-year clinical event data were analysed in subgroups, defined by ESC-AF guidelines indication of OAC therapy according to CHA2DS2-VASc score [no OAC to be considered, OAC should be considered (2 for females/1 for males), and OAC recommended (≥3 for females/≥2 for males)] and modified HAS-BLED score [(≥3 (bleeding risk high) vs. <3 (bleeding risk low)]. Of 19 960 patients included, 16 912 (84.7%) were categorized as OAC recommended and 2501 (12.5%) as OAC should be considered; 547 (2.7%) were in the no OAC to be considered group. In the OAC recommended group, 12 006 (71.0%) had high bleeding risk. Clinical event rates were <5%/year across all risk groups, even in the OAC recommended and high bleeding risk groups. In the OAC recommended and high bleeding risk groups, patients had low ischaemic stroke and bleeding event rates, regardless of receiving the 30 or 60 mg dose.

Conclusion

This study demonstrated that edoxaban use in patients with AF largely aligns with 2020 ESC-AF guidelines, while maintaining low clinical event rates.

Registration

Europe (NCT02944019), Japan (UMIN000017011), and Korea/Taiwan (NCT02951039).

Palmitic Acid Induced a Dedifferentiation Profile at the Transcriptome Level: A Collagen Synthesis but no Triglyceride Accumulation in Hepatocyte-Like Cells Derived From Human-Induced Pluripotent Stem Cells Cultivated Inside Organ on a Chip

Nonalcoholic fatty liver disease (NAFLD) is one of the main causes of critical liver diseases leading to steatosis, steatohepatitis, fibrosis, and ultimately to liver cirrhosis and hepatic carcinoma. In this study, the effect of palmitic acid (PA), one of the most abundant dietary fatty acids, was investigated using an organ-on-a-chip (OoC) technology on hepatocyte-like cells derived from human-induced pluripotent stem cells (hiPSCs). After 1 week of hepatic maturation, followed by 1 week of exposure, the transcriptomic analysis showed lower liver transcription factor activity. It also revealed that 318 genes were differentially expressed between the control and 0.5-mM PA conditions. The 0.5-mM PA conditions were characterized by the downregulation of hepatic markers (liver transcription factors, phase I and phase II metabolism genes) of lipidic genes (metabolism and transport). In parallel, the 0.5-mM PA treatment upregulated several extracellular matrix genes (such as collagen genes). The physiopathological staining demonstrated no lipid accumulation in our model and confirmed the secretion of collagen in the 0.5-mM PA conditions. However, the production of albumin, the metabolic biotransformation by the cytochrome P450 enzymes, and the biliary acid concentrations were not altered by the PA treatments. Overall, our data illustrated the response to PA characterized by an early stage of dedifferentiation observed at the transcriptomic levels associated with a modification of the collagenic profile but without lipid accumulation. We believe that our model provides new insight of the onset of palmitic lipotoxicity in the early stage of NAFLD.

Association of antinuclear antibody positivity with liver disease severity in pediatric metabolic dysfunction-associated steatotic liver disease

Background

Although antinuclear antibody (ANA) is frequently observed in patients with metabolic dysfunction-associated steatotic liver disease (MASLD), its clinical significance in children remains unclear and controversial. In this study, we investigated the prevalence of ANA positivity and the factors associated with it in pediatric MASLD patients without concurrent autoimmune hepatitis.

Methods

We retrospectively reviewed the medical records of patients aged 4-18 years diagnosed with MASLD and tested for ANA from January 2015 to December 2020 at 10 hospitals in Korea. All statistical analyses were carried out using SPSS 26.0 and P-values <0.05 were considered statistically significant.

Results

Out of the 439 patients included, ANAs were present in 89 (20.3%); 51 (57.3%) patients had ANA titer <1:80; 22 (24.7%), <1:160; 10 (11.2%), <1:320; and 6 (6.7%), <1:640. Compared to ANA-negative patients, aspartate aminotransferase (AST, P = 0.003) and alanine aminotransferase (ALT, P = 0.007) levels were significantly higher in ANA-positive patients. The ALT to Platelet Ratio Index (APRI) score was also associated with the ANA-positive patients (P = 0.005). To predict ANA positivity using APRI, the area under receiver operating characteristic (AUROC) curve was 0.597 (p = 0.004), and the APRI cutoff value of >0.893 could predict ANA, with sensitivity and specificity of 42.7% and 72.9%, respectively.

Conclusions

ANA positivity in pediatric MASLD is associated with greater liver enzyme elevation and increased risk of fibrosis, highlighting the need for careful monitoring in ANA-positive patients.

Outcomes and Disease Management in Patients With Atrial Fibrillation ≥80 Years: Data From a Consecutive 11-Year Real-World Registry

BACKGROUND

As the population ages, atrial fibrillation (AF) prevalence increases, but data on optimal oral anticoagulation (OAC) in patients ≥80 years remain limited. This study tested whether direct OACs offer comparable benefits to vitamin K antagonists in patients ≥80 years with AF presenting to the emergency department.

METHODS

This single-center retrospective all-comer study used data from the Heidelberg Registry of Atrial Fibrillation, including patients with AF presenting to the emergency department of the University Hospital of Heidelberg from June 2009 until March 2020. Data were analyzed by age for outcomes and risk factors for predefined end points.

RESULTS

Patients ≥80 years comprised 32.2% of AF cases. Hazard ratios (HRs) for the primary end point (all-cause mortality, stroke, or myocardial infarction) and secondary end point (including major bleeding) were 3.09 (95% CI, 2.73-3.21) and 2.96 (95% CI, 2.73-3.21) for patients ≥80 years, compared with younger patients. Anticoagulation rates were slightly lower in patients ≥80 years (67.9% versus 70.5%, P=0.0070). OAC use, particularly the use of direct OACs, increased over time. Patients ≥80 years without OACs had higher HRs for primary (3.48 [95% CI, 3.07-3.94]) and secondary end points (3.23 [95% CI, 2.86-3.64]) compared with those with OACs. Vitamin K antagonist use was linked to higher HR for stroke or major bleeding events (HR, 1.25 [95% CI, 1.05-1.50]), rising to 1.64 (95% CI, 1.34-2.01) after excluding reduced direct OAC doses.

CONCLUSIONS

Our data highlight patients ≥80 years as an important and vulnerable subpopulation of patients with AF, where evidence for optimal OAC therapy remains conflicting.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05995561.

Intrahepatic Cholestasis of Pregnancy: A Single-Centre Whole-Exome Sequencing Study in a Maltese Cohort

Intrahepatic cholestasis of pregnancy (ICP) has a multifactorial pathophysiology involving genetic, endocrine, and environmental factors. It is associated with maternal distress and adverse foetal outcomes. The monogenic aetiology of ICP remains unexplored in the Maltese population. We apply whole exome sequencing in 20 unrelated index cases to assess the molecular spectrum of variants in genes linked to bile acid transport. We shortlisted five unique heterozygous variants. Three ABCB4 variants, including a novel likely pathogenic stop-gain variant were detected. Three genealogically unrelated cases carried an ABCB4 p.Asn510Ser variant, suggestive of a founder through shared haplotype analysis. This study provides preliminary insight into the monogenic aetiology of ICP from an unstudied population. It expands the spectrum of genetic variants associated with ICP and provides evidence for a founder effect in the Maltese population.

Ovarian Aging: The Silent Catalyst of Age-Related Disorders in Female Body

Age-related diseases have emerged as a global concern as the population ages. Consequently, understanding the underlying causes of aging and exploring potential anti-aging interventions is imperative. In females, the ovaries serve as the principal organs responsible for ovulation and the production of female hormones. The aging ovaries are related to infertility, menopause, and associated menopausal syndromes, with menopause representing the culmination of ovarian aging. Current evidence indicates that ovarian aging may contribute to dysfunction across multiple organ systems, including, but not limited to, cognitive impairment, osteoporosis, and cardiovascular disease. Nevertheless, due to the widespread distribution of sex hormone receptors throughout the body, ovarian aging affects not only these specific organs but also influences a broader spectrum of age-related diseases in women. Despite this, the impact of ovarian aging on overall age-related diseases has been largely neglected. This review provides a thorough summary of the impact of ovarian aging on age-related diseases, encompassing the nervous, circulatory, locomotor, urinary, digestive, respiratory, and endocrine systems. Additionally, we have outlined prospective therapeutic approaches for addressing both ovarian aging and age-related diseases, with the aim of mitigating their impacts and preserving women's fertility, physical health, and psychological well-being.

Clinicians' experience with infographic summaries from the BMJ Rapid Recommendations: a qualitative user-testing study among residents and interns at a large teaching hospital in Switzerland

OBJECTIVE

Clinicians need trustworthy clinical practice guidelines to succeed with evidence-based diagnosis and treatment at the bedside. The BMJ Rapid Recommendations explore innovative ways to enhance dissemination and uptake, including multilayered interactive infographics linked to a digitally structured authoring and publication platform (the MAGICapp). We aimed to assess user experiences of physicians in training in various specialties when they interact with these infographics.

DESIGN

We conducted a qualitative user-testing study to assess user experience of a convenience sample of physicians in training. User testing was carried out through guided think-aloud sessions. We assessed six facets of user experience using a revised version of Morville's framework: usefulness, understandability, usability, credibility, desirability and identification.

SETTING

Setting include Geneva's University Hospital, a large teaching hospital in Switzerland.

PARTICIPANTS

Participants include a convenience sample of residents and interns without restriction regarding medical field or division of care.

RESULTS

Most users reported a positive experience. The infographics were understandable and useful to rapidly grasp the key elements of the recommendation, its rationale and supporting evidence, in a credible way. Some users felt intimidated by numbers or the amount of information, although they perceived there could be a learning curve while using generic formats. Plain language summaries helped complement the visuals but could be further highlighted. Despite their generally positive experience, several users had limited understanding of key GRADE (Grading of Recommendations Assessment, Development and Evaluation) domains of the quality of evidence and remained uncertain by the implication of weak or conditional recommendations.

CONCLUSION

Our study allowed to identify several aspects of guideline formats that improve their understandability and usefulness. Guideline organisations can use our findings to adapt their presentation format to enhance their dissemination and uptake in clinical practice. Avenues for research include the interplay between infographics and the digital authoring platform, multiple comparisons and living guidelines.

End-of-life symptoms and polypharmacy in lung and other cancer patients receiving palliative care in Turkey

INTRODUCTION

Patients diagnosed with cancer are often prescribed a wide range of medicines. In this study, it was aimed at examining the end-of-life symptoms and polypharmacy status of patients hospitalized in the palliative care unit with the diagnosis of lung cancer and other cancers.

METHODS

The data for the retrospective-descriptive study were obtained from hospital records and an automation system. The sample of the study included the data of all patients (n = 201) who were hospitalized in the palliative care unit between 2016-2021 in Turkey.

RESULTS

The most common symptoms of end-of-life patients were dyspnea (85.1%) and pain (67.7%). The mean number of medications used by the patients on the day of death was 10.89 ± 3.16, it was 12.50 ± 3.11 on the third day before death, 13.24 ± 3.07 on the 6th day before death, 13.50 ± 3.03 on the 9th day before death. There was a statistically significant difference between the mean number of medications used by the patients according to the presence of dyspnea on the day of death (t = 1.997; p = .047) and pain on the day of death (t = 3.781; p = .001). There was a statistically significant difference between the mean number of medications used by the patients according to the presence of pain on the sixth day before death (t = 2.613; p = .010) and the ninth day before death (t = 2.940; p = .004).

CONCLUSION

The number of medications used by the patients decreased from the 9th day before death to the day of death and their polypharmacy status continued.

Hepatic Steatosis Aggravates Vascular Calcification via Extracellular Vesicle-Mediated Osteochondrogenic Switch of Vascular Smooth Muscle Cells

The global incidence of metabolic dysfunction-associated fatty liver disease (MAFLD) has risen sharply. This condition is strongly associated with the risk of cardiovascular disease (CVD), but how MAFLD affects the development and progression of CVD, particularly concerning vascular calcification, remains unclear. Herein, extracellular vesicles (EVs) are identified from steatotic hepatocytes as a trigger that accelerated the progression of both vascular intimal and medial calcification. Steatotic hepatocytes are found to release more EVs, which are able to reach the vascular tissue, be taken up by vascular smooth muscle cells (VSMCs), and promote their osteogenic differentiation. Within these toxic vesicles, a protein cargo is identified called lectin galactoside-binding soluble 3 binding protein (Lgals3bp) that acted as a potent inducer of osteochondrogenic transformation in VSMCs. Both the inhibition of EV release and the liver-specific knockdown of Lgals3bp profoundly attenuated vascular calcification. This work partially explains the reason for the high incidence of vascular calcification in MAFLD and unveils a novel mechanism that may be used to prevent or treat cardiovascular complications in patients with MAFLD.

Kelp nanocellulose combined with fucoxanthin achieves lipid-lowering function by reducing oxidative stress with activation of Nrf2/HO-1/NQO1 pathway

This study innovatively utilized kelp-derived nanocellulose and sodium caseinate (SC) to prepare fucoxanthin (Fx)-loaded nanoparticles, exploring their efficacy in reducing oxidative stress and inhibiting lipid accumulation. 2, 2, 6, 6-Tetramethylpiperidine-1-oxyl (TEMPO)-mediated oxidation produced well-dispersed, kelp-derived nanocellulose. When these celluloses were mixed with SC at varying mass ratios, the composite nanoparticles showed excellent stability. Specifically, at a TEMPO-oxidized kelp nanocellulose (TKNC) to SC mass ratio of 1:3, the encapsulation efficiency for Fx reached 82.2 %, with a retention of 56.12 % after 14 days of storage. In vitro, the nanoparticles demonstrated good biocompatibility and were efficiently absorbed by cells, significantly enhancing Fx bioavailability. This enhanced delivery efficiency alleviates oxidative stress by activating the Nrf2/HO-1/NQO1 signaling pathways and effectively inhibits lipid droplet formation induced by excessive free fatty acids (FFAs). Moreover, distribution studies in mice revealed effective accumulation of nanoparticles in the intestines and liver, indicating their potential for targeted drug delivery. These findings provide strong experimental support for the use of TKNC and SC as biocompatible materials in nanoparticles for drug delivery and treatment applications.

Evaluations of metabolic and innate immunity profiles in subjects with familial hypercholesterolemia with or without subclinical atherosclerosis

BACKGROUND

Familial hypercholesterolemia (FH) is a genetic condition characterized by high low-density lipoprotein cholesterol (LDL-C). The presence of risk modifiers could promote the atherosclerotic injury beyond LDL-C. Our aim was to evaluate metabolic and innate immunity profiles in FH subjects with or without subclinical atherosclerosis.

METHODS

In this cross-sectional observational study, we evaluated 211 genetically confirmed FH subjects on LDL-C target and without cardiovascular diseases. Biochemical analyses, LDL-C burden (LCB) calculation and vascular profile evaluation were obtained from all subjects. Study population was divided into two groups according to subclinical atherosclerosis: the subclinical atherosclerosis (SA) group and non-subclinical atherosclerosis (NSA) group.

RESULTS

SA group had higher LDL-C at diagnosis (288.35 ± 24.52 vs 267.92 ± 23.86, p < 0.05) and LCB (13,465.84 ± 3617.46 vs 10,872.63 ± 3594.7, p < 0.001) than NSA group. SA group had higher white blood cell count (WBCC, 6.9 ± 1.66 vs 6.1 ± 1.16), neutrophil count (NC, 4.2 ± 1.3 vs 3.6 ± 1.11), monocyte count (MC, 0.8 ± 0.2 vs 0.4 ± 0.1), triglyceride to high-density lipoprotein ratio (TG/HDL, 1.73 ± 0.72 vs 1.45 ± 0.69), triglyceride-glucose index (TyG, 8.29 ± 0.35 vs 8.01 ± 0.33) than NSA group (p value for all < 0.01). Multivariate logistic regression analysis showed that LCB (p < 0.01), WBCC (p < 0.01), NC (p < 0.05), MC (p < 0.05) were associated with subclinical atherosclerosis. Simple linear regression analyses showed that LCB was associated with WBCC, NC, MC (p value for all < 0.01).

CONCLUSION

An increased LCB and an impaired innate immunity profile were found in FH subjects with subclinical atherosclerosis and they were independently associated with atherosclerotic injury. LCB could modulate the innate immunity profile.

Quo vadis autoimmune hepatitis? - Summary of the 5th international autoimmune hepatitis group research workshop 2024

Autoimmune hepatitis (AIH) is a rare chronic liver disease with an increasing incidence in many countries. Chronic autoimmune responses against the liver can cause hepatic and extrahepatic symptoms, decreased quality of life and reduced liver transplant-free survival if inadequately treated. Although standard treatment with corticosteroids and thiopurines improves the life expectancy of patients with AIH, remission rates and tolerability are generally overestimated and the development of alternative first-line and salvage therapies has been disappointingly slow compared to in rheumatological diseases or inflammatory bowel disease. Other gaps include the lack of disease-specific diagnostic markers for AIH. Similarly, the new entity of drug-induced autoimmune-like hepatitis underscores the need to re-evaluate previous diagnostic criteria. The International AIH Group (IAIHG) has initiated a series of research workshops over the last decade to promote the identification of research gaps and subsequently improve the pace of scientific progress by stimulating collaboration between expert centres. This review reports on the results of the 5th Research Workshop, held in Hannover, Germany in June 2024, and summarises the progress made since the 4th Workshop in 2022. Patient representatives from the European Reference Network (ERN) Rare Liver Youth Panel participated in the workshop. The specific objectives of this year's 5th Workshop were: (1) To further improve diagnostics. (2) Initiate clinical trials including knowledge transfer on drugs from extrahepatic immune-mediated diseases, including B cell-depleting CAR T cells. (3) Utilisation of multi-omics approaches to improve the understanding of disease pathogenesis. (4) Application of machine learning-based approaches established in oncology or transplantation medicine to improve diagnosis and outcome prediction in AIH.

Thyroid hormone action and liver disease, a complex interplay

Thyroid hormone action is involved in virtually all physiological processes. It is well known that the liver and thyroid are intimately linked, with thyroid hormone playing important roles in de novo lipogenesis, beta-oxidation (fatty acid oxidation), cholesterol metabolism, and carbohydrate metabolism. Clinical and mechanistic research studies have shown that thyroid hormone can be involved in chronic liver diseases, including alcohol-associated or NAFLD and HCC. Thyroid hormone action and synthetic thyroid hormone analogs can exert beneficial actions in terms of lowering lipids, preventing chronic liver disease and as liver anticancer agents. More recently, preclinical and clinical studies have indicated that some analogs of thyroid hormone could also play a role in the treatment of liver disease. These synthetic molecules, thyromimetics, can modulate lipid metabolism, particularly in NAFLD/NASH. In this review, we first summarize the thyroid hormone signaling axis in the context of liver biology, then we describe the changes in thyroid hormone signaling in liver disease and how liver diseases affect the thyroid hormone homeostasis, and finally we discuss the use of thyroid hormone-analog for the treatment of liver disease.

The Effect of Flavonoids and Topiramate on Glucose Carbon Metabolism in a HepG2 Steatosis Cell Culture Model: A Stable Isotope Study

Background: Insufficient treatment options are available for metabolic dysfunction-associated steatotic liver disease (MASLD). Flavonoids and topiramate have been studied for weight loss but need investigation into their effects on liver metabolism. This study's aim was to examine the effects of flavonoids or topiramate on glucose metabolic carbon flux in a cell culture model of steatosis. Methods: Steatosis was induced in HepG2 cells through exposure to oleic acid (OA, 0.5 mml/L) conjugated to bovine serum albumin (2:1). Additionally, 50% U13C-glucose was supplied in the medium as a stable isotope tracer. Cells were treated with DMSO, 10 μM of naringenin, morin, silibinin, or topiramate (44 μM) for 72 h. A non-steatotic, untreated HepG2 cell control was included. Cell extracts were analyzed by gas chromatography/mass spectrometry and mass isotopomer distribution analysis for glycogen synthesis, de novo fatty acid synthesis, tricarboxylic acid (TCA) cycle activity, and ribose synthesis. Groups were compared by ANOVA with Tukey's pair-wise testing. Results: Compared to untreated HepG2 controls, OA-exposed steatotic cells exhibited increased lipid accumulation by ORO staining (1.6-fold), enhanced palmitate de novo synthesis, reduced pyruvate carboxylase/pyruvate dehydrogenase (PC/PDH) ratio, and reduced ribose synthesis. Treatment with topiramate or silibinin ameliorated the lipid accumulation (1.3-fold) and mitigated enhancement of de novo synthesis. Morin-treated cells exhibited enhanced de novo synthesis but suppressed ribose synthesis. Conclusions: Potential mechanisms of reduced lipid accumulation by topiramate and silibinin may include suppression of palmitate de novo synthesis and a relative decrease in carbon flux through the PDH pathway. Further studies are needed on potential utility in MASLD based on their specific metabolic effects.