The entrenchment of NLRP3 inflammasomes in autoimmune disease-related inflammation

Autoinflammation and autoimmunity are almost "opposite" phenomena characterized by chronic activation of the immune system, 'innate' in the first and 'adaptive' in the second, leading to inflammation of several tissues with specific protean effectors of tissue damage. The mechanism of involvement of multiprotein complexes called 'inflammasomes' within autoimmune pictures, differently from autoinflammatory conditions, is yet undeciphered. In this review we provide a comprehensive overview on NLRP3 inflammasome contribution into the pathogenesis of some autoimmune diseases. In response to autoantibodies against nucleic acids or tissue-specific antigens the NLRP3 inflammasome is activated within dendritic cells and macrophages of patients with systemic lupus erythematosus. Crucial is NLRP3 inflammasome to amplify tissue inflammation with interleukin-1 overexpression and matrix metalloproteinase production at the joint level in rheumatoid arthritis. A deregulated NLRP3 inflammasome activation occurs in the serous acini of salivary and lacrimal glands prone to Sjogren's syndrome, but also in the inflammatory process involving endothelial cells, leucocyte recruitment, and platelet plugging of vasculitides. Furthermore, organ-specific autoimmune diseases such as thyroiditis and hepatitis may display hyperactive NLRP3 inflammasomes at the level of resident immune cells within thyroid or liver, respectively. Therefore, it is not unexpected that preclinical studies have shown how specific inflammasome inhibitors may significantly overthrow the severity of different autoimmune diseases and slow down their trend towards an ominous progression. Specific markers of inflammasome activation could also reveal subclinical inflammatory components escaping conventional diagnostic approaches or improve monitoring of autoimmune diseases and personalizing their treatment.

Clinical Value of Circulating Angiopoietin-like Protein 8/Betatrophin Levels in Patients with Acute Pancreatitis

Background and Objectives: Acute pancreatitis (AP) is an inflammatory disorder of the pancreas, with severe cases linked to a higher mortality rate. The prognosis of AP is influenced by factors such as necrosis, secondary infections, and organ failure. Tissue damage in AP is driven by the activation of leukocytes and the release of inflammatory mediators. Angiopoietin-like protein 8 (ANGPTL8), also known as betatrophin, is a recently discovered protein that regulates lipid metabolism. This study aimed to investigate the relationship between ANGPTL8 levels and disease severity in AP patients, and to explore the potential of ANGPTL8 as a biomarker. Materials and Methods: This prospective study included 50 patients diagnosed with AP who were admitted to the Department of Internal Medicine at Dr. Cemil Taşcıoğlu City Hospital between September 2021 and February 2022. Additionally, 39 healthy volunteers who underwent a check-up at the same hospital served as the control group. The Glasgow-Imrie (GI) score was used to assess the severity of pancreatitis. Results: ANGPTL8 levels were found to be significantly lower in the AP group compared to the control group, with a statistically significant correlation between ANGPTL8 levels and the severity of AP (p < 0.05). The cut-off level of ANGPTL8 based on the GI score was determined to be 70.9 ng/L. The GI score for ANGPTL8 was 0.749 (95% CI: 0.606-0.861) (p < 0.001). The overall cut-off value for ANGPTL8 was 179.2 ng/L, with an overall classification rate of 0.936 (95% CI: 0.864-0.977) (p < 0.001). Conclusions: This study demonstrates that ANGPTL8 levels vary between patients with and without AP, with lower levels observed in AP patients. Our research is the first to identify decreased ANGPTL8 levels as an independent predictor of AP severity. ANGPTL8 may play a crucial role in regulating inflammation or metabolic dysfunction in AP. However, further studies are needed to confirm these findings in larger populations and investigate ANGPTL8's mechanistic role in AP. Longitudinal studies could help determine whether ANGPTL8 levels act as a biomarker for disease progression or treatment response, potentially paving the way for targeted therapies to improve outcomes for AP patients.

Vitamin D and Its Role in Rheumatic Diseases

Vitamin D is a fat-soluble molecule with pleiotropic effects, acting as a steroid hormone on three main organs: the intestine, bone, and kidney. Among its best-known functions at the skeletal level are regulating bone metabolism and mineralization. In 1983, the presence of vitamin D receptors on the surface of immune cells was described, which led to the discovery of new functions on immunological and inflammatory processes. Currently, we know that vitamin D modulates the adaptative immune system by suppressing cells that produce inflammatory cytokines by downregulation, acting as an important regulator of immunity and the inflammatory response. In this article, we will review the synthesis, metabolic pathways, and the role of vitamin D in rheumatic autoimmune diseases.

Hepatic Encephalopathy and MELD-Na Predict Treatment Benefit in Autoimmune Hepatitis-related Decompensated Cirrhosis

BACKGROUND & AIMS

Management of patients with autoimmune hepatitis (AIH)-related decompensated cirrhosis is challenging because of the risk of treatment-related complications and lack of clinical recommendations. We investigated the predictive factors for treatment benefit in AIH-related decompensated cirrhosis at diagnosis and developed an algorithm to guide treatment decisions in clinical practice.

METHODS

This retrospective, international, multicenter study included 232 patients with histologically confirmed AIH-related decompensated cirrhosis at diagnosis. The sub-hazard ratio (SHR) of mortality was determined by competing risk analysis, considering liver transplantation (LT) as competing event. A decision tree analysis was used to develop a treatment algorithm.

RESULTS

At diagnosis, 89% of patients had ascites, and 41% had overt hepatic encephalopathy (OHE). Treated patients (n = 214; 92%) had higher aminotransferases, bilirubin, and modified hepatic activity index. The SHR of mortality was lower in treated patients (0.438; 95% confidence interval [CI], 0.196-0.981; P = .045). Patients without OHE grade 3/4 and Model for End-Stage Liver Disease-Sodium (MELD-Na) ≤28 at diagnosis were more likely to benefit from treatment. In these patients, a decline in MELD-Na ≥11 after 4 weeks of treatment had a 100% negative predictive value for death/LT. Forty-nine percent of treated patients recompensated during follow-up. Twenty percent of patients had to discontinue treatment, 65% during the first 4 weeks, and only 4% due to infectious complications. OHE ≥grade 2 and MELD-Na at diagnosis predicted the need for treatment discontinuation.

CONCLUSIONS

Immunosuppression is beneficial in patients with AIH-related decompensated cirrhosis and active disease. OHE and MELD-Na at diagnosis, along with a decline in MELD-Na at 4 weeks of treatment, are the most important determinants of outcome and can guide treatment decisions.

Prevalence and impact of endocrinopathies on growth in pediatric down syndrome patients: A retrospective analysis

OBJECTIVES

To assess the prevalence of endocrinopathies and their impact on growth among pediatric patients with Down syndrome (DS) in the Eastern Region of Saudi Arabia.

METHODS

This study utilized a retrospective cross-sectional design and was conducted at the Qatif Central Hospital between January 2015 and December 2022. Data from 358 pediatric patients with DS (aged 0-14 years), including clinical, anthropometric, and laboratory findings, were analyzed. The prevalence rates of endocrinopathies, their association with comorbidities, and their impact on growth metrics were evaluated using statistical methods.

RESULTS

Hypothyroidism was the most prevalent endocrinopathy (18.9%), followed by vitamin D deficiency (15.4%). Significant associations were observed between hypothyroidism and obesity (p=0.009), as well as vitamin D deficiency (p<0.001). Growth impairment was common, with notable deviations in height and weight Z-scores among patients with hypothyroidism, vitamin D deficiency, and obstructive sleep apnea (p<0.05).

CONCLUSION

Endocrinopathies are common among children with DS and substantially affect growth and health outcomes. Early screening and multidisciplinary management strategies are essential to improve patient care.

The liver as a central "hub" of the immune system: pathophysiological implications

The purpose of this review is to describe the immune function of the liver, guiding the reader from the homeostatic tolerogenic status to the aberrant activation demonstrated in chronic liver disease. An extensive description of the pathways behind the inflammatory modulation of the healthy liver will be provided focusing on the complex immune cell network residing within the liver. The limit of tolerance will be presented in the context of organ transplantation, seizing the limits of homeostatic mechanisms that fail in accepting the graft, progressing eventually toward rejection. The triggers and mechanisms behind chronic activation in metabolic liver conditions and viral hepatitis will be discussed. The last part of the review will be dedicated to one of the greatest paradoxes for a tolerogenic organ, developing autoimmunity. Through the description of the three most common autoimmune liver diseases, the autoimmune reaction against hepatocytes and biliary epithelial cells will be dissected.

Associations of the serum 25-hydroxyvitamin D with mortality among patients in osteopenia or osteoporosis

PURPOSE

The correlation between serum 25-hydroxy vitamin D [(25(OH)D] and mortality in patients with osteopenia or osteoporosis remains unclear. Therefore, this study examined the relationship between serum 25(OH)D and mortality in patients with osteopenia or osteoporosis.

METHODS AND RESULTS

This prospective cohort study included patients with osteopenia or osteoporosis from the National Health and Nutrition Examination Survey from 2001 to 2018. Multivariate Cox regression models examined the correlation between serum 25(OH)D and all-cause mortality, cardiovascular mortality (CVD), and cancer mortality. The cohort included 9282 adult participants with a median follow-up period of 97.01 months, including 1394 all-cause deaths, 413 CVD-related deaths, and 322 cancer deaths. In fully adjusted models, higher serum 25(OH)D levels (≥75.0 nmol/L) were associated with a lower risk of all-cause mortality (hazard ratio 0.54, 95 % confidence interval 0.41 to 0.73) and cardiovascular death (0.47, 0.29 to 0.76), using participants with low 25(OH)D levels (<25 nmol/L) as the reference. In addition, we found an L-shaped non-linear dose-response relationship between serum 25(OH)D and all-cause and cardiovascular mortality, with inflection points of 38.8 nmol/L and 53.6 nmol/L, respectively.

CONCLUSION

Higher serum 25(OH)D concentrations are strongly associated with a diminished risk of all-cause and CVD mortality in patients with osteopenia or osteoporosis. This association has a threshold effect. More in-depth intervention studies are needed to clarify underlying mechanisms.

1α,25(OH)2D3 Regulates the TGF-β1/Samd Signaling Pathway Inhibition of Hepatic Stellate Cell Activation

To investigate the effect of 1α,25(OH)2D3 on hepatic stellate cells and the mechanism of the TGF-β1/Smad signaling pathway.LX2 cells were treated with TGF-β1 and different concentrations of 1α,25(OH)2D3. Cell proliferation was assessed using the CCK8 assay to determine the optimal concentration of 1α,25(OH)2D3 activity. The cell cycle and apoptotic rates were evaluated using flow cytometry. The expressions of Samd2, Samd3, Samd4, and Samd7 was assessed by western blotting, whereas the expression of MMP1, MMP13, and TIMP-1 was detected by qPCR.Compared with the control group, the 1α,25(OH)2D3 group had a higher apoptotic rate of LX2 cells, the cell cycle was blocked from the G1 stage to the S stage, the expressions of Samd2, Samd7, MMP1, and MMP13 increased, while the expressions of Samd3, Samd4, and TIMP-1 decreased.1α,25(OH)2D3 inhibits hepatic stellate cell activation and exerts anti-hepatic fibrosis effects by downregulating the expression of Samd3, Samd4, TIMP-1 and upregulating the expression of Samd2, Samd4, MMP1, and MMP13.

Transcriptomic profile induced by calcitriol in CaSki human cervical cancer cell line

The vitamin D endocrine system, primarily mediated by its main metabolite calcitriol and the vitamin D receptor (VDR), plays a critical role in numerous human physiological processes, ranging from calcium metabolism to the prevention of various tumors, including cervical cancer. In this study, we comprehensively investigated the genomic regulatory effects of calcitriol in a cervical cancer model. We examined the transcriptional changes induced by calcitriol in CaSki cells, a cervical cell line harboring multiple copies of HPV16, the primary causal agent of cervical cancer. Our microarray findings, revealed that calcitriol regulated over 1000 protein-coding genes, exhibiting a predominantly repressive effect on the CaSki cell transcriptome by suppressing twice as many genes as it induced. Calcitriol decreased EPHA2 and RARA expression while inducing KLK6 and CYP4F3 expression in CaSki cells, as validated by qPCR and Western blot. Functional analysis demonstrated that calcitriol effectively inhibited key processes involved in cancer progression, including cell proliferation and migration. This was further supported by the significant downregulation of MMP7 and MMP13 mRNA levels. Our microarray results also showed that, in addition to its effects on protein-coding genes, calcitriol significantly regulates non-coding RNAs, altering the expression of approximately 400 non-coding RNAs, including 111 microRNA precursors and 29 mature microRNAs, of which 17 were upregulated and 12 downregulated. Notably, among these calcitriol-regulated microRNAs are some involved in cervical cancer biology, such as miR-6129, miR-382, miR-655, miR-211, miR-590, miR-130a, miR-301a, and miR-1252. Collectively, these findings suggest that calcitriol exhibits a significant antitumor effect in this advanced cervical cancer model by blocking critical processes for tumor progression, underscoring the importance of maintaining adequate vitamin D nutritional status.

The Schematic Assessment of Vitamin D Deficiency in Relation to Autoimmune Disorders and Its Implications in Internal Medicine

The immune system greatly depends on vitamin D for modulating its function, despite the fact that deficiency of this nutrient is now well recognized as a factor that contributes to the development of several autoimmune disorders. This study observed the occurrence of vitamin D deficiency among autoimmune disease patients and investigated its implications in internal medicine. Two medical research investigators searched through several electronic databases such as PubMed, Scopus, Web of Science, and Google Scholar for studies ranging from 2018 to 2025. The research examined the findings of published studies that measured serum vitamin D levels of autoimmune disorder patients in conjunction with how this measurement affected disease activity, severity, and therapy results. A review process executed a predefined research eligibility framework and incorporated both observational and interventional study types for selection. The extraction of study data was done autonomously by two reviewers. Two tools were used to evaluate the methodological quality of the selected studies: the Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool. The strength of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. The research analysis included a total of eight studies that fulfilled the eligibility requirements. Most studies identified vitamin D deficiency as common among patients who suffered from rheumatoid arthritis, systemic lupus erythematosus, and multiple sclerosis. The literature showed increased severity of disease in patients with insufficient vitamin D levels. Some researchers also observed symptom improvement following vitamin D supplementation. Overall, the reviewed evidence suggested that vitamin D may be a potentially modifiable element in the management of autoimmune diseases. While research demonstrates a connection between vitamin D deficiency and autoimmune disease evolution, additional clinical testing must confirm the usefulness of vitamin D therapy in internal medicine.

Development and validation of pFIB scores for exclusion of significant liver fibrosis in pediatric MASLD

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent pediatric liver disease, yet accurate risk scores for referral of children/adolescents with suspected clinically significant liver fibrosis are currently lacking.

APPROACH AND RESULTS

Clinical and biochemical variables were collected in a prospective cohort of 327 children and adolescents with severe obesity, in whom liver fibrosis was evaluated by transient elastography. Logistic regression was performed to establish continuous (pFIB-c) and simplified (pFIB-6) diagnostic scores that accurately exclude significant (≥F2) fibrosis. Performance for each was compared to established noninvve fibrosis scores. These scores were validated in elastography (n=504) and multiple biopsy-proven MASLD (n=261) cohorts. Patient sex, ethnicity, weight z-score, homeostatic model assessment of insulin resistance index, ALT, and presence of hypertension were included in the scores. The pFIB-c and pFIB-6 exhibited good discriminatory capacity (c-statistic of 0.839 and 0.826), outperforming existing indices. Negative predictive values were >90% for both scores in the derivation and elastography validation cohorts. Performance in the histological cohorts varied (AUROCs for the pFIB-c between 0.710 and 0.770), as the scores were less accurate when applied to populations in tertiary referral centers characterized by a high prevalence of significant fibrosis and high ALT levels.

CONCLUSIONS

Analyzing several cohorts totaling approximately 1100 children and adolescents, we developed novel risk scores incorporating readily available clinical variables. In accordance with the aim of excluding pediatric MASLD-associated fibrosis, the scores performed better in nonselected cohorts of children and adolescents living with obesity than in patients referred to tertiary liver units.

Response to azathioprine treatment in autoimmune hepatitis is dependent on glutathione transferase genotypes

BACKGROUND

Azathioprine (AZA) is part of the standard treatment for autoimmune hepatitis (AIH). The first step in the complex bioconversion of AZA to active metabolites is mediated by glutathione transferases (GSTs).

AIMS

Elucidate the association between GSTM1 and GSTT1 copy number variation (CNV), genetic variation in GSTA2, GSTP1, and inosine-triphosphate-pyrophosphatase, and the response to AZA in AIH.

METHODS

Genotyping was performed in AIH patients (n = 131) on AZA, and in a Swedish background population (n = 283). Thiopurine metabolites in blood erythrocytes were determined by high performance liquid chromatography.

RESULTS

GSTM1 and GSTT1 CNV were associated with treatment response to AZA. Gene deletion of GSTM1-but not of GSTT1-was associated with the liver transaminase levels. None of the studied genetic variants were associated with the thiopurine metabolite concentrations, suggesting non-enzymatic mechanisms of GSTM1 and GSTT1 in the context of AZA efficacy in AIH. The prevalence of GSTM1 and GSTT1 CNV genotypes was similar in AIH and in the background population.

CONCLUSION

This study shows the effects of GSTM1 and GSTT1 CNV on AZA efficacy in AIH, not previously described. It also elaborates on the impact of the definition of treatment response, on the importance of the various GSTs studied. Furthermore, the GSTM1 and GSTT1 CNV frequencies previously reported in European populations were confirmed.

Natural history and long-term management of autoimmune hepatitis

INTRODUCTION

Autoimmune hepatitis (AIH) is a relatively infrequent and complex liver disease characterized by acute or chronic inflammation, interface hepatitis in histology examination, elevation of immunoglobulin G (IgG), production of autoantibodies, and is often responsive to immunosuppression. The incidence of AIH has been increasing worldwide, affecting people of all ages and sexes. AIH represents a diagnostic challenge because of its heterogeneous presentation and the lack of pathognomonic findings. Even when treated, AIH can remain a progressive disease. In this review, we present recent data on the natural history of AIH and the developing evidence on the management of patients with AIH.

AREAS COVERED

This review outlines the clinical presentation, risk factors linked to poorer clinical outcomes, the diagnostic algorithm, and the current management strategies for individuals living with AIH.

EXPERT OPINION

AIH remains a clinical challenge, and new tools for better diagnosis and stratification of risk are needed. In addition, better treatments are needed as a complete response is achieved in less than 60% of cases, and intolerance to first-line treatment is frequent. The use of biological treatment in AIH seems to improve the response rate and minimize the risk of side effects of current medication in this increasingly prevalent disease.

Investigation of an outbreak of novel hepatitis of unknown aetiology in children and adolescents, Ireland, 2021 to 2023

An outbreak of severe acute hepatitis of unknown aetiology in children (HUAC) was reported by the United Kingdom (UK) in spring 2022. Within days, a corresponding increase was identified in Ireland. A multi-agency incident management team (IMT), led by the Health Protection Surveillance Centre (HPSC), established a national case definition, trawling questionnaire, testing protocol and communications plan. Between 1 October 2021 and 12 May 2023, 44 probable and three possible cases of HUAC were identified in Ireland with a median age of 3 years. Adeno-associated virus 2 (AAV2), detected in 18 of 31 probable cases, and SARS-CoV-2 antibodies in 22 of 37 of probable cases were the most common infectious agents, followed by human herpes virus 7 (18/33) and adenovirus (20/44). Immunological findings included the human leukocyte antigen (HLA) class II HLA-DRB1*04:01 allele in 17 of 32 cases. Autoantibodies were found in 15 of 40 patients. Our findings corroborate those of the UK, which suggested a link between HUAC and AAV2 and another virus, in children predisposed due to presence of a particular HLA class II type. Close collaboration with the UK, the European Centre for Disease Prevention and Control (ECDC) and World Health Organization (WHO) was invaluable in the investigation.

Advancements in autoimmune hepatitis epidemiology, treatment and complication - a 15-year retrospective study

INTRODUCTION AND OBJECTIVES

Autoimmune hepatitis (AIH) is a rare, heterogeneous liver disease marked by autoantibodies, hypergammaglobulinemia, and distinct histological features. Predominantly affecting women, its incidence and prevalence show significant regional variability globally. Therefore, our aim is to examine the trends of AIH and to assess its demographics, management, and disease progression using an extensive population-based database.

MATERIALS AND METHODS

This retrospective, population-based study analyzed data from 2.7 million adults in Clalit Health Services, focusing on autoimmune hepatitis (AIH) diagnoses between 2009 and 2023. Data reordered included demographics, clinical details, and treatment regimens. Key outcomes tracked were the development of cirrhosis and its complications.

RESULTS

This study included 992 AIH patients with a median age of 51.5 years, 80.4 % female, and a median follow-up of 6.1 years. Obesity was present in 23.2 %, and 10.9 % had thyroid disease. At diagnosis, 22.9 % had cirrhosis, and an additional 137 patients developed cirrhosis during follow-up, leading to a total prevalence of 36.5 %. Among cirrhotic patients, 29.9 % experienced decompensation, 25.3 % developed ascites, 9.3 % had variceal bleeding, and 10.4 % developed hepatic encephalopathy. Hepatocellular carcinoma (HCC) occurred in 5.24 % of cirrhotic patients, with an incidence rate of 6.32 cases per 1000 patient-years. Overall, 11.2 % of cirrhotic patients underwent liver transplantation. The proportion of AIH patients diagnosed with cirrhosis at the time of diagnosis significantly decreased over the study period (p = 0.0028).

CONCLUSIONS

This study demonstrates a decreasing trend in AIH patients diagnosed with cirrhosis, suggesting earlier detection and improved management, alongside a lower documented incidence of HCC.

Correlation Between Vitamin D Deficiency (25(OH)D3) and the Severity of Purulent Oropharyngeal Infections

Background: Vitamin D plays a crucial role in immune system function, and its deficiency has been associated with an increased risk of infections. This study investigates the relationship between vitamin D deficiency and the severity of purulent oropharyngeal infections, considering the need for surgical interventions and the duration of hospitalization. Materials and Methods: This retrospective study included patients diagnosed with peritonsillar phlegmons, laterocervical abscesses, and peritonsillar abscesses. Patients were categorized based on their vitamin D levels: deficiency (<30 ng/mL) and optimal levels (≥30 ng/mL). The clinical parameters, length of hospitalization, and type of treatment were analyzed. Statistical analyses included Student's t-test, the chi-square test, and ANOVA to assess differences between groups. Results: Patients with vitamin D (25(OH)D3) deficiency had a significantly longer hospital stay (8.50 days vs. 3.24 days, p = 0.001) and required more frequent surgical interventions (55.6% vs. 27.8%, p = 0.002) compared to those with optimal vitamin D levels. A trend toward more complex treatment regimens was also observed, although this relationship was not statistically significant (p > 0.05). Conclusions: These findings suggest that vitamin D (25(OH)D3) deficiency may contribute to a more severe course of oropharyngeal infections, increasing the need for invasive treatments and prolonging hospitalization. This highlights the importance of monitoring vitamin D (25(OH)D3) levels and the potential benefits of supplementation in preventing and managing severe upper respiratory tract infections.

British Society of Gastroenterology guidelines for diagnosis and management of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease which, if untreated, often leads to cirrhosis, liver failure and death. The last British Society of Gastroenterology (BSG) guideline for the management of AIH was published in 2011. Since then, our understanding of AIH has advanced in many areas. This update to the previous guideline was commissioned by the BSG and developed by a multidisciplinary group. The aim of this guideline is to review and summarise the current evidence, in order to inform and guide diagnosis and management of patients with AIH and its variant syndromes. The main focus is on AIH in adults, but the guidelines should also be relevant to older children and adolescents.

Oxidative stress and pediatric diabetic cardiovascular complications: emerging research and clinical applications

The prevalence and incidence of diabetes in pediatrics have dramatically increased over the last three decades. Comparatively, pediatric diabetes has faster pancreatic β-cells decline and early progression to complications compared with adult diabetes. Therefore, diabetic complications are a major concern in children and adolescents with diabetes. Diabetes has detrimental effects on the macro- and microvascular systems, resulting in cardiovascular diseases, leading causes of morbidity and mortality in youth with diabetes. Oxidative stress plays a critical role in developing cardiovascular complications in the context of pediatric diabetes. In pediatric patients with diabetes, several factors can contribute to the development of excess reactive oxygen species and oxidative stress, including nutritional deficiencies, puberty, environmental exposures, and metabolic disorders such as obesity and high blood pressure. The present study aims to raise awareness of diabetic cardiovascular complications in children and adolescents with diabetes and the role of oxidative stress and their molecular mechanisms in the pathogenesis of cardiovascular complications. In addition, some novel therapeutic strategies for the treatment and prevention of diabetic cardiovascular complications in the pediatric populations are highlighted. In summary, children and adolescents with diabetes no matter type 1 diabetes (T1D) or type 1 diabetes (T2D), have many features similar to those in adults with same kinds of diabetes, but also have many their own features distinct from adults. By developing targeted therapies and preventive measures, healthcare providers can better address the rising incidence of diabetes-related complications in children and adolescents.

Identification of Novel Mosaic Variants in Focal Epilepsy-Associated Patients' Brain Lesions

Focal cortical dysplasia type III (FCDIII) is a rare and complex condition associated with drug-resistant epilepsy and often characterized by cortical lamination abnormalities, along with a variety of neoplasms and vascular abnormalities.

OBJECTIVES

This study aimed to elucidate the genetic architecture underlying FCDIII through the use of whole-exome sequencing (WES) of brain and peripheral blood samples from 19 patients who had been diagnosed with FCDIII.

METHODS

Variants were identified through a series of machine-learning-based detection and functional prediction methods and were not previously associated with FCDIII. Mosaic fraction scores of these variants validated the variants' pathogenicity, and in silico and gene ontology enrichment analyses demonstrated that these variants had severe destabilizing effects on protein structure.

RESULTS

We reported ten novel pathogenic somatic missense and loss of function variants across eight genes, including CNTNAP2, ACY1, SERAC1, and BRAF. Genetic alterations were linked to clinical manifestations, such as encephalopathies and intellectual disabilities, thereby emphasizing their role as molecular drivers of FCDIII.

CONCLUSIONS

We demonstrated that next-generation sequencing-based mosaic variant-calling pipelines are useful for the genetic diagnosis of FCDIII, opening up avenues for targeted therapies, yet further research is required to validate these findings and examine their therapeutic implications.

What is the optimal first-line treatment of autoimmune hepatitis? A systematic review with meta-analysis of randomised trials and comparative cohort studies

OBJECTIVES

Uncertainty remains about many aspects of first-line treatment of autoimmune hepatitis (AIH).

DESIGN

Systemic review with meta-analysis (MA).

DATA SOURCES

Bespoke AIH Endnote Library, updated to 30 June 2024.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) and comparative cohort studies including adult patients with AIH, reporting death/transplantation, biochemical response (BR) and/or adverse effects (AEs).

DATA EXTRACTION AND SYNTHESIS

Data pooled in MA as relative risk (RR) under random effects. Risk of bias (ROB) assessed using Cochrane ROB-2 and ROBINS-1 tools.

RESULTS

From seven RCTs (five with low and two with some ROB) and 18 cohort studies (12 moderate ROB, six high for death/transplant), we found lower death/transplantation rates in (a) patients receiving pred+/-aza (vs no pred): overall (RR 0.38 (95% CI 0.20 to 0.74)), in patients without symptoms (0.38 (0.19-0.75)), without cirrhosis (0.30 (0.14-0.65)), and with decompensated cirrhosis (RR 0.38 (0.23-0.61)), and (b) patients receiving pred+aza (vs pred alone) (0.38 (0.22-0.65)). Patients receiving higher (vs lower) initial pred doses had similar BR rates (RR 1.07 (0.92-1.24)) and mortality (0.71 (0.25-2.05)) but more AEs (1.73 (1.17-2.55)). Patients receiving bud (vs pred) had similar BR rates (RR 0.99 (0.71-1.39)), with fewer cosmetic AEs (0.46 (0.34-0.62)). Patients receiving mycophenolate mofetil (MMF) (vs aza) had similar BR rates (RR 1.32 (0.73-2.38)) and fewer AEs requiring drug cessation (0.20 (0.09-0.43)).

CONCLUSIONS

Mortality is lower in pred-treated (vs untreated) patients, overall and in several subgroups, and in those receiving pred+aza (vs pred). Higher initial pred doses confer no clear benefit and cause more AEs. Bud (vs pred) achieves similar BR rates, with fewer cosmetic AEs. MMF (vs aza) achieves similar BR rates, with fewer serious AEs.

Comparative Evaluation of Simplified and Modified Histologic Criteria in the Diagnosis of Chronic Autoimmune Hepatitis

Background

The present study aimed at comparing simplified and modified histologic criteria alone and along with other indicators in the diagnosis of chronic autoimmune hepatitis (AIH).

Materials and Methods

In this cross-sectional study, 48 cases were selected from slides and paraffin blocks of patients suspected of chronic AIH according to clinical and laboratory data, including serology and autoantibody findings and viral hepatitis test results. Then, scores equal to 1 (compatible hepatitis), 2 (typical hepatitis), ≤6 (probable hepatitis), and ≥7 (definite hepatitis) were calculated based on the simplified histologic criteria, modified histologic criteria, and these two criteria, along with other indicators including antinuclear antibodies (Ab), smooth muscle Ab or liver-kidney microsomal Ab or soluble liver antigen (Ag) and serum immunoglobulin G (IgG) and absence of viral hepatitis.

Results

The results of this study revealed that based on the simplified histologic criteria, 43.8% and 56.3% of these cases were assigned a score of 1 and 2 points, respectively. However, calculating the total score using the simplified criteria along with other indicators showed that 60.4% and 39.6% of cases were assigned a score ≤6 and ≥7 points, respectively. Moreover, the modified histologic criteria indicated that 25% and 75% of cases were assigned a score of 1 and 2 points, respectively.

Conclusion

According to the findings of the present study, the modified histologic criteria compared to the simplified histologic criteria identified a higher percentage of patients assigned a score of 2 points. Moreover, modified histologic criteria, along with other indicators, were more accurate in detecting definite AIH (score ≥7 points).

Vitamin D3 and its active form calcitriol suppress erythroleukemia through upregulation of CHAC1 and downregulation of NOTCH1

Vitamin D3 (VD3) and its active form calcitriol (Ca) exhibit anti-neoplastic activity against several types of cancer, although the underlying mechanism is not fully understood. Herein, we tested the effects of VD3 and Ca on erythro-leukemogenesis and investigated the underlying mechanism. VD3 and Ca treatment strongly inhibited cancer progression in a mouse model of erythroleukemia induced by the Friend virus. In tissue culture, VD3 and Ca inhibited proliferation of leukemic cell lines. Growth inhibition was associated with induction of G1 phase cell cycle arrest and apoptosis. Transcription of the VD3 receptor, VDR, is strongly induced by Ca, but not VDR. However, leukemia growth suppression by both VD3 and Ca is shown to be independent of VDR. In leukemic cells, both VD3 and Ca induced genes associated with metabolic pathways. Both VD3 and Ca induce the cytosolic glutathione degradase CHAC1 through activation of the ER stress response pathway ATF3/ATF4/CHOP genes. Higher expression of CHAC1 also suppressed the oncogene NOTCH1. Accordingly, knockdown of CHAC1 antagonized the inhibitory effect of VD3 and Ca on leukemic growth leading to higher NOTCH1 expression. Conversely, overexpression of CHAC1 suppressed leukemia cell growth and inhibited the expression of NOTCH1. Additionally, glutathione antagonized leukemia cell suppression induced by VD3 and Ca, demonstrating that this vitamin inhibits the proliferation of leukemic cells via CHAC1. Taken together, our results demonstrated that VD3 and Ca can prolong the survival of leukemia mice and inhibit the proliferation of erythroleukemia cell HEL through CHAC1 or CHAC1-mediated NOTCH1 inhibition.

Causal relationship between serum 25-hydroxyvitamin D and coronary heart disease: A bi-directional two-sample Mendelian randomization study

BACKGROUND AND AIM

Coronary heart disease (CHD) is the leading cause of severe cardiovascular events, such as acute myocardial infarction. This study investigates the interaction between serum 25-hydroxyvitamin D (25(OH)D) levels and CHD. However, most current studies are observational, which may introduce bias into the results.

METHODS AND RESULTS

We conducted a two-way, two-sample Mendelian randomization study. The CHD sample was drawn from the 2021 population in the FinnGen database (cases: 21,012; controls: 197,780), while the serum 25(OH)D sample was obtained from the 2020 European population in the GWAS Catalog database (417,580 cases). Based on the inverse variance weighted (IVW) results, we found that the risk of CHD decreased with increasing serum 25(OH)D concentrations (P < 0.05), and that higher CHD risk was associated with lower serum 25(OH)D concentrations (P = 0.04).

CONCLUSIONS

Our study found that increased serum 25(OH)D concentration may serve as a protective factor against CHD. Additionally, we found that CHD can be a risk factor that affects serum 25(OH)D concentrations in humans.

Neonatal and Syndromic Forms of Diabetes

PURPOSE OF REVIEW

Neonatal and syndromic diabetes are rare but important conditions. These conditions often result in severe insulin deficiency or insulin resistance. In this review, we aim to discuss the clinical characteristics and genetics of neonatal and syndromic forms of diabetes.

RECENT FINDINGS

Beyond the development of diabetes mellitus, many other organ systems are affected. Understanding the pathophysiology of these conditions have improved our collective understanding of the genetics and developmental biology related to glucose metabolism and beyond. This review will provide new information for researchers and provide a helpful resource for clinicians when evaluating a patient for neonatal and syndromic forms of diabetes.

Genetic Alterations in Atypical Cerebral Palsy Identified Through Chromosomal Microarray and Exome Sequencing

This study investigated the genetic causes of atypical cerebral palsy (CP) through chromosomal microarray (CMA) and exome sequencing (ES) in a cohort of 10 Korean patients to identify variants and expand the spectrum of mutations associated with atypical cerebral palsy. Whole ES and/or genome sequencing (GS) after routine karyotyping and CMA was performed to identify causative variants and expand the spectrum of mutations associated with atypical CP. In cases of atypical CP, scoliosis and/or kyphosis, ranging from mild to severe, were present in all patients. Epilepsy was a comorbidity in seven patients (70%), and intellectual disability (ID) was observed in varying degrees. This study identified three copy number variations (CNVs), including 15q11.2 microdeletion (n = 1), 17p11.2 duplication (n = 1), and 12p13.33p11.23 duplication/18p11.32 microdeletion (n = 1), and six likely pathogenic variants (LPVs) or pathogenic variants (PVs) detected in the SLC2A1, PLAA, CDC42BPB, CACNA1D, ALG12, and SACS genes (n = 6). These findings emphasize the significance of incorporating genetic testing into the diagnostic process for atypical CP to improve our understanding of its molecular basis and inform personalized treatment strategies. To further advance this research, future studies should focus on exploring genotype-phenotype correlations, assessing the functional impact of identified variants, and increasing the sample size to validate the observed patterns.

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

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

The development of thyroid autoimmunity is potentially associated with the deficiency of vitamin D3 rather than vitamin D2 in euthyroid men

OBJECTIVE

Vitamin D(VitD) deficiency has been found prevalent among patients with thyroid autoimmunity (TAI). This study aimed to investigate whether low VitD2 or VitD3 potentially contributed to the development of TAI in euthyroid male patients, which had not been reported before.

METHODS

A total of 2882 euthyroid male petroleum workers were recruited from those participants in the healthcare program at the second affiliated hospital of Dalian Medical University in 2021, whose serum VitD levels, thyroid functions, and autoantibody titers were all examined at the same time. Among them, 2587 (89.8%) individuals received the second health follow-up in 2022. Serum VitD including 25(OH)D2 (VitD2) and 25(OH)D3 (VitD3) levels were detected by liquid chromatography-tandem mass spectrometry. Thyroid functions and autoantibody titers were quantified using chemiluminescent immunoassays.

RESULTS

The serum levels of VitD and VitD3 were pronouncedly lower in the male euthyroid subjects with TAI (n = 195) than those non-TAI men (n = 2687, P < 0.05), whereas serum VitD2 was not significantly different based on the data from the initial investigation in 2021. The prevalence of subjects with TAI among the total male euthyroid subjects with TAI population was markedly increased with the decreasing levels of serum VitD and VitD3, respectively (P for trend < 0.05), but not significantly changed with that of serum VitD2. The binary logistic regression analysis revealed that either the deficiency of VitD (serum VitD < 20 ng/mL, VDD) or low VitD3 level was an independent risk factor for the development of TAI, which had been further demonstrated by the follow-up observation in 2022. Among the non-TAI men in 2021, 6.52% (n = 157) individuals became TAI patients after a one-year follow-up, and their serum VitD and VitD3 levels both exhibited significantly more reduction as compared with those of the remained non-TAI ones in 2022. More of those with VDD developed TAI than the non-VDD ones did in 2022 (8.5% vs. 5.6%, P<0.05). Additionally, the change in serum VitD over the two years was more strongly correlated with serum VitD3 (rs = 0.971, P < 0.001) when compared with that of VitD2 (rs = 0.085, P < 0.001) in the whole euthyroid male population.

CONCLUSION

Based on the cross-sectional and prospective investigations, our findings further indicate that VDD may be an independent risk factor for TAI development. Moreover, the latter is potentially associated with the deficiency of VitD3 rather than VitD2 in the euthyroid male population although the related mechanisms await in-depth exploration. Our findings also suggest that VitD3 supplementation might provide more potential benefits than VitD2 among VDD men in terms of preventing TAI development.

STUDY REGISTRATION

the Dalian Health Management Cohort (DHMC) ChiCTR2300073363.

Pathogenicity analysis of ATP7B in pediatric patients with Wilson's disease and functional verification of alternative splice variants

BACKGROUND

Wilson's disease (WD) is an autosomal recessive inherited disease caused by ATP7B gene mutations. Some mutations in ATP7B are presumed to be pathogenic by altering pre-mRNA splicing, while most have not been functionally verified. This study aimed to perform functional studies to verify the pathogenicity of variants that may affect pre-mRNA splicing.

METHODS

We recruited 42 pediatric patients who were clinically diagnosed with WD (Leipzig score ≥ 4) and underwent ATP7B gene sequencing. We leveraged in silico analysis and prioritized seven splice genic variants in ATP7B. Minigene assays were used to evaluate the effects of the selected variants on transcript splicing. Total RNA was extracted from peripheral blood mononuclear cells (PBMCs), and Reverse Transcription-Polymerase Chain Reaction (RT-PCR) was performed on samples from several patients to verify the splicing alterations.

RESULTS

This study screened 42 distinct mutations for their potential effects on splicing based on in silico analysis and functional verification. Five intronic variants (c.1286-1delG, c.1543 + 1G > T, c.1708-1G > C, c.1870-8A > G, and c.2121 + 3A > T) and one missense variant (c.2120A > G) were proved to alter the splicing of ATP7B transcription by minigene assays. The transcript assays demonstrated splicing changes in vivo in patient PBMCs for c.3993 T > G. The altered transcription products resulting from c.2570_2572del were confirmed by sequencing.

CONCLUSIONS

This study adds experimental evidence to genetic diagnosis based on assessing the genetic defects of 42 pediatric WD patients and provides new insights into the pathogenicity of the splicing variants.

Adherence to the Mediterranean Diet in Paediatric Patients with Inflammatory Bowel Disease and Functional Abdominal Pain Disorders-Comparative Study

Background/Objectives: There is a limited body of evidence regarding dietary intake in children with inflammatory bowel disease despite increasing research about the nutritional implications in the disease pathogenesis. Functional abdominal pain disorders (FAPDs) are also chronic disorders marked by chronic abdominal pain, currently described with the ROME IV criteria. This study was aimed to investigate the adherence to healthy eating habits in an inflammatory bowel disease pediatric population when compared to a matched population with functional abdominal pain gastrointestinal disorders. Methods: We performed a single centre study focused on dietary patterns in children with IBD and FAPDs between January 2021 and April 2024. Data collected included general information, disease phenotype, and the KIDMED index regarding healthy eating. Results: The final analysis was based on full data from the KIDMED index available for 122 (57 vs. 65) participants. Overall, the average KIDMED score did not vary significantly between the study population, meaning 6.89 ± 2.33 for the IBD group and 7.11 ± 2.67 for FAPDs group, p = 0.34. In the same KIDMED index group, mean values were higher for FAPDs patients, but results differ statistically significant only for "medium" adherence to healthy diet, showing that larger proportion of IBD patients were previously exposed to non-healthy diets: 8.99 vs. 11.1, p = 0.45, 5.02 vs. 6.92, p = 0.05, 2.89 vs. 2.56, p = 0.43, for group 1, 2, and 3, respectively. Conclusions: This study showed in our cohort that overall adherence to a healthy pattern diet is poor prior to diagnosis of different gastrointestinal pathologies in children.

On the Knowledge and Prescription of Probiotics by Pediatric Providers: A Cross-Sectional Study

OBJECTIVE

The therapeutic or prophylactic efficacy and safety of probiotics are not well established. The objective of this study was to assess the knowledge and practice of probiotic use in children among pediatric providers.

METHODS

This was a cross-sectional study of pediatric providers. A survey was sent to the members of the American Academy of Pediatrics, New York Chapter 1.

RESULTS

We received 168 responses. Participants were mostly females (70%) and with MD or equivalent education (93%). About 50% of responders did not select the correct definition of probiotics and confused probiotics with prebiotics and synbiotics. About 97% of practitioners were asked about the merits of probiotics by families, and 60% of respondents had prescribed probiotics in their clinical practice. The most common indication for prescription was for treatment of antibiotic-associated diarrhea. When asked about their recommendation for a family who had already started probiotics, 66% of the providers recommended continuing the probiotics. There was a significant association between the frequency of probiotics prescription and the type of practice (p < 0.05). However, this association disappeared after adjusting for age, gender, education, and years of practice. The more experienced the practitioner, the lower the odds were of prescribing probiotics (p < 0.05).

CONCLUSIONS

There was inadequate knowledge about probiotics among general pediatric providers. Of the pediatricians asked about probiotics, most recommended continuing them if a family was using probiotics for a specific condition. Studies with a larger nationally representative sample are required for future research.

Cyberbullying Perpetration and Socio-Behavioral Correlates in Italian and Spanish Preadolescents: A Cross-National Study and Serial Mediation Analysis

The spread of information and communication technologies (ICTs) has brought advantages and disadvantages, particularly impacting youth, who use the Internet and social media applications daily. In preadolescents' social development, problematic social media use (PSMU) and cyberbullying (CB) are potential risk factors across several countries. PSMU is defined as the lack of regulation of social media platforms that is associated with negative outcomes in everyday life, while CB refers to using digital technology to harass, threaten, or embarrass another person. Among preadolescents, CB perpetration is frequently associated with cybervictimization (CV) experiences. The underlying mechanisms that drive this relationship have received limited attention. The aim of the cross-national comparative study, rooted in the general aggression model, is to investigate the direct and indirect effects between cyberbullying perpetration and cybervictimization, testing a model involving PSMU and moral disengagement (MD) as serial mediators in this association. A total of 895 Italian and Spanish preadolescents (Mage = 11.23, SDage = 1.064) completed a self-report survey during school hours. Descriptive statistics were computed, and a serial mediation model was run. The results show that CV is positively associated with CB, and that PSMU and MD positively serially mediate the CV-CB link. This study's insights suggest the need for tailored educational interventions targeting European youth, to promote more positive online social interactions and a safer digital environment.

Metabolic dysfunction-associated steatotic liver disease in children

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease, is the most common cause of chronic liver disease in children. MASLD encompasses a spectrum of liver disease and can be severe, with 10% of affected children presenting with advanced fibrosis. While biopsy remains the most accurate method for diagnosing and staging the disease, MRI proton density fat fraction and magnetic resonance elastography are the most reliable non-invasive measures for assessing steatosis and fibrosis, respectively. MASLD is associated with multiple comorbidities including type 2 diabetes, hypertension, dyslipidaemia, decreased bone mineral density, obstructive sleep apnoea, anxiety and depression. Currently, there are no pharmacological treatments available for children, highlighting the urgent need for paediatric clinical trials. A diet low in free sugars is promising for reducing steatosis and decreasing alanine aminotransferase, a surrogate marker for hepatic inflammation. Emerging data indicate that steatosis can be present in children under 6 years of age, which was previously considered rare. The intricate interplay of genetics may inform future therapeutics and prognostication, with the PNPLA3 gene showing the most evidence for association with the risk and severity of steatotic liver disease and steatohepatitis. MASLD is a complex disease affecting one in ten children and is associated with increased early mortality risk. More dedicated studies are needed in children to advance our understanding of this disease and find effective treatments.

Allyl methyl disulfide attenuates liver injury induced by concanavalin A by suppressing M1 polarization of macrophages and NLRP3 inflammasome activation

The rising prevalence of autoimmune hepatitis (AIH) and its intricate pathogenesis has escalated it to a global health issue. This study centered on investigating the effects of allyl methyl disulfide (AMDS) against concanavalin A (ConA)-induced AIH in mice and elucidate the possible mechanisms. Histopathology and blood biochemistry were performed to assess the protective effects of AMDS on ConA-challenged liver injury in C57BL/6 male mice. Then, Immunohistochemistry, Immunofluorescence, RT-qPCR, ELISA and Western blot assays were performed to test changes in the M1 polarization of macrophage and NLRP3 inflammasome activation. Additionally, J774A.1 and AML12 cells were co-cultured to further investigate protective mechanism of AMDS against AIH. We found that AMDS pretreatment significantly alleviated the elevation of the levels of liver injury marker enzymes, and liver pathological changes triggered by ConA. Additionally, AMDS antagonized liver neutrophil infiltration, liver macrophage M1 polarization, and the increase in serum IL-6 and TNF-α levels induced by ConA. Furthermore, the changes in protein and mRNA levels of crucial molecules in the NF-κB and NLRP3 inflammasome pathways after ConA challenge were restored by AMDS. Additionally, AMDS significantly ameliorated the ConA-induced morphological alterations, the release of IL-6 and TNF-α, and the activation of NLRP3 inflammasome pathway in J774A.1 macrophages. Lastly, in a conditioned co-culture system of AML12 and J774A.1 cells, administration of AMDS at a concentration of 25 μM prominently inhibited the mRNA levels of Tnf and Nos2 in AML12 cells. Collectively, AMDS ameliorates ConA-induced AIH by alleviating hepatic neutrophil infiltration, inhibiting M1-type macrophage polarization, and antagonizing NLRP3 inflammasome activation.

Evaluation of the effects of pre-exposure treatment with hydroxychloroquine on the risk of COVID-19 infection and on the efficacy of anti-COVID-19 vaccination during lupus or Gougerot-Sjögren's disease: Prepcov multicentre trial

OBJECTIVES

Some patients with SLE or Gougerot-Sjögren's disease (GSD) receive long-term treatment with hydroxychloroquine (HCQ), sometimes combined with immunosuppressive therapy (IS). This study sought to assess whether long-term HCQ therapy that had been initiated long before the COVID-19 pandemic had a protective or adverse effect on COVID-19 risk, severity of infection or immunity protection.

METHODS

This prospective multicentre study included 547 patients with SLE, GSD, autoimmune hepatitis, primary biliary cholangitis or cured viral hepatitis C divided into four groups according to HCQ (+/-) and IS (+/-) intake prior to the pandemic: HCQ+IS+ (n=112), HCQ+IS- (n=121), HCQ-IS+ (n=115) and HCQ-IS- (n=199). When COVID-19 vaccination was possible, patients were vaccinated as recommended. Vaccination efficacy was prospectively assessed on the basis of the postvaccination antibody titre.

RESULTS

Compared with HCQ+IS+ patients, HCQ-IS+ patients had a decreased risk of COVID-19 infection (p<0.001). Compared with HCQ+IS+ patients, HCQ-IS- patients had a decreased risk of contracting COVID-19 (p<0.001). Patients in the HCQ-IS+ or HCQ-IS- group had a lower risk of symptomatic or severe infection than HCQ+IS+ patients did (p=0.001 and p<0.001, respectively). Only patients who had two or more exposures (to vaccine and/or infection) had an increased likelihood of COVID-19 immunity after the last dose (p<0.001).

CONCLUSIONS

HCQ treatment that was initiated before the pandemic did not protect against COVID-19 infection. Moreover, non-exposure to HCQ treatment (combined or not with IS) was associated with decreased risk of COVID-19 infection and of developing a symptomatic or severe infection. HCQ and IS do not influence the vaccine response. Only two or more doses of vaccine result in a good vaccine response.

TRIAL REGISTRATION NUMBER

NCT04481633.

Probiotics and Fever Duration in Children With Upper Respiratory Tract Infections: A Randomized Clinical Trial

Importance

Upper respiratory tract infections (URTIs) are prevalent in children, prompting frequent health care consultations, especially among those with fever. Probiotics show potential as an adjuvant treatment for URTIs, but evidence in children is limited.

Objective

To evaluate the efficacy of a probiotic mixture containing Bifidobacterium breve M-16V, Bifidobacterium lactis HN019, and Lactobacillus rhamnosus HN001 in shortening fever duration among children with URTIs.

Design, Setting, and Participants

This randomized clinical trial was conducted between November 19, 2021, and June 20, 2023, at the pediatric emergency department of the Ca' Granda Ospedale Maggiore Policlinico in Milan, Italy. Patients between 28 days and 4 years of age with a fever (≥38.5 °C) and URTI were eligible. Exclusion criteria included recent probiotic use, chronic autoimmune diseases, immunosuppressive treatment, and requirement for hospitalization. Randomization was computer generated and assigned participants to either the intervention (probiotics) or control (placebo) group. Participants, parents or caregivers, and investigators were masked to the group assignments. The primary analysis followed the intention-to-treat approach.

Interventions

The probiotic group received daily single dose of 0.5 mL probiotic mixture containing Bifidobacterium breve M-16V, Bifidobacterium lactis HN019, and Lactobacillus rhamnosus HN001 for 14 days. The placebo group received daily single dose of 0.5 mL placebo for 14 days.

Main Outcomes and Measures

The primary outcome was fever duration, defined as the number of days between the first and the last days with fever.

Results

Of the 128 patients enrolled (69 males [54%]; mean [SD] age 2.5 [1.3] years), 65 (51%) were randomly assigned to receive placebo and 63 (49%) to receive probiotics. The median (IQR) fever duration was shorter in the probiotic group than the placebo group (median [IQR], 3 [2-4] days vs 5 [4-6] days; adjusted risk ratio, 0.64; 95% CI, 0.51-0.80). Few mild adverse events were reported and did not significantly differ between the probiotic and placebo groups, including constipation (6 [16%] and 6 [12%]; P = .80) and abdominal pain (3 [8%] and 2 [4%]; P = .65).

Conclusions and Relevance

In this randomized clinical trial, administering a probiotic mixture reduced fever duration by 2 days compared with placebo, with no meaningful safety concerns. The probiotic mixture under investigation could be an effective adjuvant for shortening fever duration in children with URTIs.

Trial Registration

ClinicalTrials.gov Identifier: NCT06052540.

Clinical Course of Autoimmune Hepatitis in Hispanic and African American Patients: A Retrospective Study at a South Bronx Hospital

Background Autoimmune hepatitis (AIH) is a chronic inflammatory condition that can progress to liver cirrhosis. Genetics, immune system dysfunctions, and environmental factors influence the global prevalence of AIH. AIH exhibits variable clinical outcomes across ethnic groups, with Hispanic patients having a higher prevalence of cirrhosis, whereas African American patients are noted to have higher hospitalization and mortality rates. Aim The purpose of our study is to assess the clinical course of autoimmune hepatitis, specifically in Hispanic and African American patients. Methodology We performed a retrospective chart review of patients diagnosed with AIH and managed by the Gastroenterology Service from July 2006 to June 2023. The study population comprised individuals who were either Hispanic or African American and aged 18 years or older. Patients who were hospitalized and did not continue with outpatient follow-up were excluded from the analysis. Results Out of the 30 patients in our study, 27 (90%) were female and 3 (10%) were male. About 21 (70%) of the patients were Hispanic, while 9 (30%) were African American. The mean age at the time of AIH diagnosis was 45 years. Liver cirrhosis was confirmed with liver biopsy in 21 (70%) of the patients, and by imaging or clinical findings alone in an additional 3 (10%). Concomitant autoimmune diseases were present in 7 (23%) of the patients. Approximately 11 (36%) of the patients required hospitalization due to decompensated liver cirrhosis. About 19 (63%) were initially referred to the gastroenterology service due to abnormal liver function tests and were asymptomatic at the time of the first visit. About 6 (20%) of the patients presented with abdominal pain as their initial symptom. One patient had nausea and vomiting, two presented with jaundice, and one presented with altered mental status. Notably, none of the patients died during the study period. Conclusion Our study indicates that AIH is more prevalent among female and Hispanic patients as compared to male and African American patients. A significant proportion of our patients developed cirrhosis. Further studies are necessary to improve outcomes of autoimmune hepatitis in African American and Hispanic populations.

Calcitriol Treated Mesenchymal Stem Cells Modulated Immune Response in Collagen-Induced Rheumatoid Arthritis in BALB/c Mice

BACKGROUND AND AIM

Rheumatoid arthritis (RA) is a chronic inflammatory disease that primarily involves synovial joints. During the past decade, disease-modifying antirheumatic drugs and biologic agents have been introduced for the treatment of RA. However, they have limitations, including incomplete treatment response, adverse effects requiring drug withdrawal, fall off in efficacy over time, high cost of biologic agents, and refractory cases. Consequently, there is a need to establish safe and effective advanced therapeutic modalities for RA to overcome the shortcomings of current treatments.

METHODS

MSCs after isolation were exposed to 200 nM calcitriol. Rheumatoid arthritis was induced in BALB/c mice using collagen and Freund's complete adjuvant. One week after immunization, the mice were divided into 3 groups including without treatment, groups treated with untreated and treated MSCs. One week after the last injection, mice sacrificed and samples were taken and the desired evaluations were done.

RESULTS

Our results revealed that the respiratory burst capacity, neutrophil phagocytosis, and nitric oxide production in the population of splenocytes were higher in the positive control group compared to the treatment groups. Also, the level of production of IL-4, IL-10 and TGF-β cytokines and INF-γ and IL-17 cytokines showed a significant increase and decrease, respectively, compared to the positive control group.

CONCLUSION

Treatment of MSCs with calcitriol leads to an improvement in regulatory function and inhibitory effects on inflammatory mediators of innate immune cells, particularly splenocytes, in a rheumatoid arthritis model compared to untreated mesenchymal stem cells.

Children-specific environmental protection strategies are needed in China

China, home to over 250 million children, has witnessed remarkable economic development in recent decades, successfully addressing many issues related to basic hygiene and sanitation in children, thereby altering the childhood disease spectrum. However, the emergence of environment-related disorders among children has become a significant concern. Despite the rapid accumulation of scientific knowledge on the adverse effects of environmental pollution on child health, the availability of children-specific protective strategies and actions remains alarmingly low. This commentary synthesizes the information and viewpoints presented and discussed by experts at the International Forum on Children's Environmental Health in China. It summarizes the strategies and actions proposed to reduce adverse environmental exposure and protect children's short- and long-term health and a call for more children-centered evidence-action transformation. The following four specific actions were proposed: (1) strengthen health education in parents, caregivers, and children, and personal protection for children; (2) monitor child exposure and environment-related health status; (3) set up child-specific interventions and regulations; and (4) conduct more research on environment exposures and child health.

[Protection network for child/adolescent victims of violence: a scoping review]

The scope of the study is to analyze how the protection network for children and adolescent victims of violence is organized to guarantee their rights in the Brazilin context. A scoping review was carried out through the portals of the Virtual Health Library (VHL) and CAPES journals in all indexed databases. The question was how is the protection network structured to guarantee the rights of child/adolescent victims of violence? From the 67 publications, two thematic units were identified: organizational and operational axes of the network. Intersectoral and multidisciplinary actions based on decentralized public policies have repercussions on regional characteristics, and the identification of overlooked groups contributes to the construction of a strengthened, agile and effective network in the development of protection and intervention mechanisms to guarantee the fundamental rights of this population. The lack of coordination between policy formulation and professional practice is reflected in the protection network, which often revictimizes children and adolescents. Ethical and moral values are identified as factors that have an impact on decision-making, thereby broadening the disparities.

Performance of Relative Exchangeable Copper for the Diagnosis of Wilson Disease in Acute Liver Failure

Acute liver failure (ALF) can be one of the manifestations of Wilson disease (WD), and due to its severity, prompt diagnosis is essential. A ratio > 15% of the exchangeable copper to total serum copper, known as relative exchangeable copper (REC), has been shown to have a 100% sensitivity and specificity for the diagnosis of WD but this has not yet been studied in an ALF setting. Patients diagnosed with ALF from 1 November 2011 to 31 December 2023, with available REC determination during the acute event, were included. Thirty-three patients were included (11 with WD and 22 without WD). The median age [IQR] at ALF was 12.9 [8.9-20.2] years, range: 0.6-71.0 years. Serum ceruloplasmin (Cp) < 0.20 g/L and 24 h urinary copper excretion > 1.6 μmol/L had both a sensitivity (Se) and specificity (Sp) for the diagnosis of WD of 100% and 72.7%, respectively. A ROC analysis of REC determined that the best cut-off point was 14.4% (AUC 1, p < 0.01). All the WD patients had REC values > 14.4%, yielding a sensitivity and specificity of 100. Relative exchangeable copper has 100% sensitivity and specificity for diagnosing Wilson disease in acute liver failure. Relative exchangeable copper has excellent performance in diagnosing Wilson disease in acute liver failure.

Maternal and fetal outcomes of autoimmune hepatitis in pregnancy: A United States hospitalized patient study

BACKGROUND

Autoimmune hepatitis (AIH) is a chronic inflammatory disease primarily affecting the liver, with a higher prevalence among women of reproductive age. The latest nationwide statistics regarding its impact on maternal and fetal outcomes during pregnancy are lacking.

AIMS

To analyze the real impact of AIH on maternal and fetal outcomes in hospitalized delivery patients, and provide theoretical guidance for comprehensive clinical management.

METHODS

A retrospective analysis was conducted using data from the 2016-2020 National Inpatient Sample database in the United States. Multivariate logistic regression analysis was used to assess the influence of AIH on maternal and fetal outcomes during pregnancy.

RESULTS

A total of 17,825,445 hospitalized delivery patients were included, among which 1,185 had AIH. After adjusting for potential confounding factors, compared to hospitalized delivery patients without AIH, the AIH group exhibited significantly higher rates of adverse maternal and fetal outcomes, including hypertension complications of pregnancy (AOR 1.68, 95 % CI 1.09-2.58), preterm birth (AOR 2.89, 95 % CI 1.91-4.38), fetal growth restriction (AOR 2.21, 95 % CI 1.34-3.64), and fetal death (AOR 4.13, 95 % CI 1.33-12.83). AIH showed no association with cesarean section or large fetus. In the group of delivery in patients with AIH, patients who develop hypertensive disorders have a higher probability of concomitant diabetes mellitus (OR 6.85, 95 % CI 2.19-21.45), hypertension (OR 4.64, 95 % CI 1.68-12.82), and obesity (OR 3.06, 95 % CI 1.26-7.42). Additionally, AIH patients incurred higher total costs and longer hospital stays during the delivery hospitalization.

CONCLUSION

Patients with AIH face an increased risk of hypertensive disorders of pregnancy, preterm birth, fetal growth restriction, and fetal death during delivery. It is crucial to enhance awareness of these potential occurrence risks.

Optimizing the tapering scheme of corticosteroid treatment for acute onset of autoimmune hepatitis

BACKGROUND

Uncertainties persist regarding the optimal management of acute onset of autoimmune hepatitis, including the use of corticosteroids. This study aimed to compare the effectiveness and safety of rapid versus slow corticosteroid tapering in acute onset of AIH.

METHODS

A multicenter study involving patients with acute AIH was conducted. We defined acute AIH as an acute presentation (<30 days) with AIH and exhibiting no evidence of pre-existing liver diseases. Initially, corticosteroid treatment and overall outcomes were reported. Subsequently, the role of corticosteroid tapering rate in modifying outcomes across subgroups was investigated. For patients with an initial corticosteroid dose of 20 mg/day or higher, we further classified patients into rapid tapering group (duration until dose of prednisone <20 mg/day <3 weeks) and slow tapering group (duration until dose of prednisone <20 mg/day ≥3 weeks). Adverse events were defined as any of the following events, progression (e.g., acute icteric AIH progression to AS-AIH or AIH-ALF, AS-AIH progression to AIH-ALF, non-cirrhotic progression to cirrhosis, compensated cirrhosis progression to decompensation), LT, and liver-related death.

RESULTS

This retrospective cohort study enrolled 237 patients, with 109 presenting acute icteric AIH, 97 with acute-severe AIH (AS-AIH), and 31 with AIH-acute liver failure (ALF). Among patients with acute icteric AIH, slow tapering significantly improved adverse outcome-free survival compared to rapid tapering (99 % vs. 71 %, P < 0.0001). Similarly, in AS-AIH patients, slow tapering resulted in notably higher adverse outcome-free survival rates compared to rapid tapering (92 % vs. 54 %, P < 0.001). Slow tapering independently predicted fewer adverse events (OR 0.144; 95 % CI 0.037-0.562; P = 0.005). However, in AIH-acute liver failure (ALF) patients, tapering rate did not significantly affect adverse outcome-free survival (38 % vs. 50 %, P = 0.590). Overall, there were no significant differences in osteoporosis or infection occurrence between tapering groups in the entire acute AIH cohort.

CONCLUSION

A slow corticosteroid tapering reduced adverse outcomes in acute exacerbation of AIH patients, particularly in acute icteric AIH and AS-AIH.

ICAT mediates the inhibition of stemness and tumorigenesis in acute myeloid leukemia cells induced by 1,25-(OH)2D3

Background

The role of 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3) in cancer prevention and treatment is an emerging topic of interest. However, its effects on the stemness of acute myeloid leukemia (AML) cells are poorly understood.

Methods

The proliferation and differentiation of AML cells (HL60 and NB4) were investigated by the CCK-8 assay, immunocytochemical staining, and flow cytometry. The abilities of HL60 and NB4 cells to form spheres were examined by the cell sphere formation assay. In addition, the levels of stemness-associated markers (SOX2, Nanog, OCT4, and c-Myc) in HL60 and NB4 cells were measured by western blotting and quantitative real-time polymerase chain reaction. Moreover, we obtained β-catenin-interacting protein 1 (ICAT)-knockout and ICAT-overexpressing HL-60 cells using gene editing and lentiviral infection techniques and investigated the role of ICAT in modulating the stemness-inhibiting effects of 1,25-(OH)2D3 using the aforementioned experimental methods. Finally, we validated our findings in vivo using NOD/SCID mice.

Results

1,25-(OH)2D3 inhibited the proliferation and stemness of AML cells (HL60 and NB4) and induced their differentiation into monocytes. Additionally, the knockdown of ICAT in HL60 cells attenuated the inhibitory effects of 1,25-(OH)2D3 on proliferation and stemness and suppressed the expression of stemness markers. Conversely, overexpression of ICAT enhanced the aforementioned inhibitory effects of 1,25-(OH)2D3. Consistently, in NOD/SCID mice, 1,25-(OH)2D3 suppressed tumor formation by HL-60 cells, and the effects of ICAT knockdown or overexpression on 1,25-(OH)2D3 aligned with the in vitro findings.

Conclusion

1,25-(OH)2D3 inhibits AML cell stemness, possibly through modulation of the ICAT-mediated Wnt/β-catenin signaling pathway.

The Role of Physical Examination and Clinical Scores in Distinguishing Streptococcal Colonization from Pharyngitis in Pediatric Patients: Insights from a Common Clinical Scenario

The accurate differentiation between asymptomatic carriage with group A streptococcus (GAS) and active streptococcal pharyngitis is a complex task with important clinical and public health implications. This work aims to highlight the key strategies necessary for optimizing the diagnostic and therapeutic management of pediatric pharyngitis. Clinical scores are essential tools for improving diagnostic accuracy. When combined with laboratory tests such as throat cultures and rapid antigen detection tests, these systems enable effective risk stratification of patients, supporting more precise treatment decisions. In addition to diagnostic strategies, the article underscores the importance of patient-centered communication, particularly with the families of pediatric patients. Clear, empathetic discussions about the condition, diagnostic rationale, and treatment plan help foster trust, enhance adherence to medical recommendations, and reduce anxiety related to potential complications. A critical outcome of these combined strategies is the reduction of unnecessary antibiotic use, which plays a pivotal role in preventing both overdiagnosis and overprescription. This, in turn, mitigates the growing threat of antimicrobial resistance, one of the most significant global health challenges. By integrating clinical expertise, standardized protocols, and effective communication, healthcare providers can promote judicious and effective management of streptococcal pharyngitis or asymptomatic carriage, contributing to improved individual and population health outcomes.

Vitamin D: Beyond Traditional Roles-Insights into Its Biochemical Pathways and Physiological Impacts

Background: It is true that vitamin D did not earn its title as the "sunshine vitamin" for nothing. In recent years, however, there has been a shift in the perception surrounding vitamin D to a type of hormone that boasts countless bioactivities and health advantages. Historically, vitamin D has been known to take care of skeletal integrity and the calcium-phosphorus balance in the body, but new scientific research displays a much larger spectrum of actions handled by this vitamin. Materials and Methods: A systematic literature search was performed using the following electronic databases: PubMed, Scopus, Web of Science, Embase, and Cochrane Library. Results: Many emerging new ideas, especially concerning alternative hormonal pathways and vitamin D analogs, are uniformly challenging the classic "one hormone-one receptor" hypothesis. To add more context to this, the vitamin D receptor (VDR) was previously assumed to be the only means through which the biologically active steroid 1,25-dihydroxyvitamin D3 could impact the body. Two other molecules apart from the active hormonal form of 1,25(OH)2D3 have gained interest in recent years, and these have reinvigorated research on D3 metabolism. These metabolites can interact with several other nuclear receptors (like related orphan receptor alpha-RORα, related orphan receptor gamma-RORγ, and aryl hydrocarbon receptor-AhR) and trigger various biological responses. Conclusions: This paper thus makes a case for placing vitamin D at the forefront of new holistic and dermatological health research by investigating the potential synergies between the canonical and noncanonical vitamin D pathways. This means that there are now plentiful new opportunities for manipulating and understanding the full spectrum of vitamin D actions, far beyond those related to minerals.

Drug-Induced Liver Injury-Pharmacological Spectrum Among Children

Drug-induced liver injury (DILI) is one of the main causes of acute liver failure in children. Its incidence is probably underestimated, as specific diagnostic tools are currently lacking. Over 1000 known drugs cause DILI, and the list is expanding. The aim of this review is to describe DILI pathogenesis and emphasize the drugs accountable for child DILI in order to aid its recognition. Intrinsic DILI is well described in terms of mechanism, incriminated drugs, and toxic dose. Conversely, idiosyncratic DILI (iDILI) is unpredictable, occurring as a result of a particular response to drug administration, and its occurrence cannot be foreseen in clinical studies. Half of pediatric iDILI cases are linked to antibiotics, mostly amoxicillin-clavulanate, in the immune-allergic group, while autoimmune DILI is the hallmark of minocycline and nitrofurantoin. Secondly, antiepileptics are responsible for 20% of pediatric iDILI cases, children being more prone to iDILI caused by these agents than adults. A similar tendency was observed in anti-tuberculosis drugs, higher incidences being reported in children below three years old. Current data show growing cases of iDILI related to antineoplastic agents, atomoxetine, and albendazole, so that it is advisable for clinicians to maintain a high index of suspicion regarding iDILI.

EASL-ERN Clinical Practice Guidelines on Wilson's disease

Wilson's disease is an autosomal recessive disorder of copper metabolism which affects the liver, brain and other organs. Diagnosis is based on: clinical features; biochemical tests, including plasma ceruloplasmin concentration, 24-h urinary copper excretion, copper content in the liver; and molecular analysis. Leipzig score and additionally relative exchangeable copper determination are recommended for diagnosis. Pharmacological therapy comprises chelating agents (penicillamine, trientine) and zinc salts, while only chelators are recommended for significant liver disease. Monitoring is based on clinical symptoms, liver tests and copper metabolism (urinary copper excretion, exchangeable copper) to detect poor compliance and over/under-treatment. Acute liver failure is challenging as making a diagnosis is difficult and pharmacological therapy may not be sufficient to save life. Liver transplantation has a well-defined role in Wilsonian acute hepatic failure but may also be considered in neurological disease.