Urge fecal incontinence: are intramural rectal injections of botulinum toxin a long-term treatment option?

BACKGROUND AND AIMS

Unsuccessful first-line conservative treatments for managing fecal incontinence (FI) lead to considering predominantly invasive options, posing challenges in terms of cost and patient acceptance of benefit/risk ratio. Recent data from a prospective randomized study have highlighted intramural rectal botulinum toxin (BoNT/A) injection as a promising minimally invasive alternative for urge FI, demonstrating efficacy at 3 months but lacking long-term evidence. This study aimed to evaluate the sustained efficacy and injection frequency of intramural rectal BoNT/A injection in the treatment of urge FI.

METHODS

This retrospective monocentric study enrolled all patients who underwent intramural rectal BoNT/A injection for urge FI after failed conservative therapy or sacral neuromodulation (SNM). Injections were administered during sigmoidoscopy, delivering 200 U of BoNT/A at 10 circumferentially distributed sites. Treatment effectiveness was assessed using the Cleveland clinic incontinence score (CCS) and a visual analog scale (VAS) to measure the severity of discomfort related to episodes of fecal urgency, with reinjection performed upon symptom recurrence.

RESULTS

In total, 41 patients (34 females) were included, with a median follow-up of 24.9 (range 3.2-70.3) months. Overall, 11 patients had previously failed sacral nerve stimulation. Significant reductions were observed in the CCS (median 11 versus 7, p = 0.001) and VAS symptoms (median 4, range 0-5 versus median 2, range 0-5, p = 0.001). In total, 22 patients (53%) experienced a reduction in the CCS by over 50%. The median interval between intramural rectal BoNT/A injections was 9.8 months (range 5.3-47.9 months).

CONCLUSIONS

This study provides the first evidence of the sustained efficacy of intramural rectal BoNT/A injection for urge FI. Further investigations are warranted to refine patient selection and reinjection criteria, evaluate socioeconomic impacts, and compare rectal BoNT/A injection with other therapeutic modalities.

Colon capsule endoscopy polyp detection rate vs colonoscopy polyp detection rate: Systematic review and meta-analysis

BACKGROUND

Colon capsule endoscopy (CCE) is a modern, non-invasive method for large bowel visualization, offering a less invasive alternative to traditional colonoscopy (TC). While TC remains the gold standard for comprehensive large bowel assessment, including the detection and treatment of various conditions, the effectiveness of CCE in detecting polyps is less established.

AIM

To systematically review and compare the polyp detection rates (PDR) of CCE and TC.

METHODS

A systematic literature search was conducted using four scientific databases: CINAHL, MEDLINE via EBSCO, Cochrane Library, and MEDLINE/PubMed. A standardized search command was utilized to ensure consistency. Full papers were retrieved if they compared PDR between CCE and TC and involved patients over 18 years old. A meta-analysis was then conducted using the meta package in R software.

RESULTS

Initially, 339 articles were identified, with 128 duplicates and 15 non-English articles excluded, leaving 196 for screening. After further exclusions, 9 articles were included in the review. The meta-analysis revealed minimal differences in PDR between CCE and TC. The pooled PDR for TC was 0.61 (95%CI: 0.48–0.72), and for CCE, it was 0.61 (95%CI: 0.48–0.73). The overall comparison of the pooled PDR of both methods was 0.96 (95%CI: 0.90–1.02), indicating that CCE is non-inferior to TC.

CONCLUSION

CCE has emerged as a modern and safe diagnostic alternative to TC for polyp detection, demonstrating non-inferiority when compared to the conventional method.

Severe hypophosphataemia and hypocalcaemia following intravenous ferric derisomaltose and denosumab administration

Serum calcium and phosphorus levels are tightly regulated by the calciotropic hormone parathyroid hormone, fibroblast growth factor 23 and 1,25(OH)2 vitamin D. Commonly prescribed therapies for iron-deficiency anaemia (IDA) such as ferric carboxymaltose and ferric derisomaltose (FDM) have been shown to disrupt phosphorus homeostasis, resulting in hypophosphataemia. Similarly, denosumab use can result in hypocalcaemia due to the inhibition of osteoclastic maturation, activity and survival. Here, we report the development of severe hypophosphataemia and hypocalcaemia in a patient with osteoporosis and IDA following treatment with denosumab and FDM. The patient remained asymptomatic; however, supplementation with calcium, phosphorus and calcitriol replacement was required prior to eventual normalisation of serum levels. Often concomitantly prescribed, little guidance exists regarding electrolyte disturbances following the administration of FDM and denosumab. While hypophosphataemia and hypocalcaemia are relatively uncommon when prescribed individually, synergistic effects likely exist that warrant regular monitoring and occasional supplementation.

Revealing therapeutic targets and drugs from Chinese medicine for ulcerative colitis using bioinformatics

Pathogenesis and therapeutic drugs for ulcerative colitis (UC) have plagued researchers worldwide. In this study, therapeutic targets, and drugs from Chinese medicines for UC were screened using bioinformatics. We downloaded five datasets from the GEO database and three machine learning algorithms were used for screening diagnostic biomarkers of UC. Combined with the differential genes for UC, gene sets related to bile acid metabolism, short-chain fatty acids, apoptosis, pyroptosis, G-protein-coupled receptors, mitochondria, and autophagy were collected to screen the core targets, and analyze the association of therapeutic genes (diagnostic biomarkers and core targets) with immune cells. In addition, screening ingredients of Chinese medicines based on UC therapeutic targets was performed. Molecular docking, molecular dynamics simulation, and literature validation were also performed. The screening yielded 37 key therapeutic targets, including 5 diagnostic biomarkers (CCL11, CXCL1, PDZK1IP1, TIMP1, and UGT2A3) and 32 core targets based on hot gene sets. Immune cell infiltration was strongly associated with therapeutic targets in UC, especially neutrophils, macrophages, mast cells, and dendritic cells. Furthermore, a total of 33 compounds with high safety had been recognized as having potential to mitigate UC by reverse prediction from Chinese medicines, and molecular docking, molecular dynamics simulation, and literature reports preliminarily validated the screening results. Although further experimental validation is needed, this work provides some potential therapeutic targets and drugs from Chinese medicines against UC.

Pancreatic pseudocyst after acute pancreatitis in children

Acute pancreatitis in children is a rare condition; however, the incidence of this acute condition has been increasing over the past few decades. In most cases, acute pancreatitis does not cause severe complications in children, but in some cases, it can be complicated by fluid accumulation, fistulas and vascular pathologies, but the most common complication remains the formation of pseudocysts. This article describes the clinical case of a 11-year-old girl from Lithuania, which effectively illustrates a rare condition in children-acute pancreatitis and its developed complication-the formation of a pancreatic pseudocyst. The article discusses the frequency of acute pancreatitis and its complication, pancreatic pseudocyst in children, and the clinical expression of the disease and methods of diagnostics and treatment.

The role of inflammasomes in hepatocellular carcinoma: Mechanisms and therapeutic insights

Hepatocellular carcinoma is among the most frequent forms of primary liver cancer and develops within a context of chronic inflammation, frequently associated with a multitude of risk factors, including viral infections, metabolic dysfunction-associated fatty liver disease, metabolic dysfunction-associated steatohepatitis and liver fibrosis. The tumor microenvironment is crucial for the progression of HCC, as immune cells, tumor-associated fibroblasts and hepatic stellate cells interact to promote chronic inflammation and tumor spread. Inflammasomes, the multiprotein complexes that launch the innate immune response, emerge as important mediators in the pathogenesis of HCC. Among others, the inflammasome Nucleotide-binding oligomerization domain, Leucine rich Repeat (NLR) and Pyrin (NLRP) 3 (NLRP3), and absent in melanoma 2 (AIM2), exhibit a dual role in HCC background. It has been reported that they can exert oncosuppressive functions by triggering the inflammatory death of cancer cells. Vice versa, chronic activation contributes to the development of a pro-tumorigenic environment, thus supporting tumor growth. In addition, other inflammasomes such as Nucleotide-binding oligomerization domain, Leucine rich Repeat (NLR) and Pyrin (NLRP) 6 and 12 (NLRP6 and NLRP12, respectively) regulate HCC onset and progression, although more experimental evidence is required. This review focuses on the molecular mechanisms underpinning the inflammasome's contribution to the onset, progression and spread of HCC. Moreover, we will explore the potential therapeutic approaches currently under investigation, which aim to improve the efficacy and reduce the side effects of the treatments currently available. Targeting inflammasomes may be a promising therapeutic strategy for the treatment of HCC, offering new opportunities to improve patient prognosis.

Rapid automated production of tubular 3D intestine-on-a-chip with diverse cell types using coaxial bioprinting

Despite considerable animal sacrifices and investments, drug development often falters in clinical trials due to species differences. To address this issue, specific in vitro models, such as organ-on-a-chip technology using human cells in microfluidic devices, are recognized as promising alternatives. Among the various organs, the human small intestine plays a pivotal role in drug development, particularly in the assessment of digestion and nutrient absorption. However, current intestine-on-a-chip devices struggle to accurately replicate the complex 3D tubular structures of the human small intestine, particularly when it comes to integrating a variety of cell types effectively. This limitation is primarily due to conventional fabrication methods, such as soft lithography and replica molding. In this research, we introduce a novel coaxial bioprinting method to construct 3D tubular structures that closely emulate the organization and functionality of the small intestine with multiple cell types. To ensure stable production of these small intestine-like tubular structures, we analyzed the rheological properties of bioinks to select the most suitable materials for coaxial bioprinting technology. Additionally, we conducted biological assessments to validate the gene expression patterns and functional attributes of the 3D intestine-on-a-chip. Our 3D intestine-on-a-chip, which faithfully replicates intestinal functions and organization, demonstrates clear superiority in both structure and biological function compared to the conventional 2D model. This innovative approach holds significant promise for a wide range of future applications.

Soothing the Itch: The Role of Medicinal Plants in Alleviating Pruritus in Palliative Care

Chronic pruritus, or persistent itching, is a debilitating condition that severely impacts quality of life, especially in palliative care settings. Traditional treatments often fail to provide adequate relief or are associated with significant side effects, prompting interest in alternative therapies. This review investigates the antipruritic potential of eight medicinal plants: chamomile (Matricaria chamomilla), aloe vera (Aloe barbadensis), calendula (Calendula officinalis), curcumin (Curcuma longa), lavender (Lavandula angustifolia), licorice (Glycyrrhiza glabra), peppermint (Mentha piperita), and evening primrose (Oenothera biennis). These plants are analyzed for their traditional applications, active bioactive compounds, mechanisms of action, clinical evidence, usage, dosage, and safety profiles. Comprehensive searches were conducted in databases including PubMed, Web of Science, Scopus, and b-on, focusing on in vitro, animal, and clinical studies using keywords like "plant", "extract", and "pruritus". Studies were included regardless of publication date and limited to English-language articles. Findings indicate that active compounds such as polysaccharides in aloe vera, curcuminoids in turmeric, and menthol in peppermint exhibit significant anti-inflammatory, antioxidant, and immune-modulating properties. Chamomile and calendula alleviate itching through anti-inflammatory and skin-soothing effects, while lavender and licorice offer antimicrobial benefits alongside antipruritic relief. Evening primrose, rich in gamma-linolenic acid, is effective in atopic dermatitis-related itching. Despite promising preclinical and clinical results, challenges remain in standardizing dosages and formulations. The review highlights the necessity of further clinical trials to ensure efficacy and safety, advocating for integrating these botanical therapies into complementary palliative care practices. Such approaches emphasize holistic treatment, addressing chronic pruritus's physical and emotional burden, thereby enhancing patient well-being.

Evaluation of the potential use of protoporphyrins as biomarkers of anemic disease in human urine from inflammatory bowel disease patients

Protoporphyrins are organic compounds with cyclic structure that are synthesised by a wide variety of organisms. In humans, these compounds are detected in blood and urine, with significantly higher levels in blood. Their potential as biomarkers of anemia and other diseases is currently being investigated, as their levels change according to the biochemical processes associated with the disease. The most widely used biomarker of anemia is serum ferritin, but it is unreliable in patients with inflammatory bowel disease (IBD) because its levels can be altered by acute inflammation and/or infections. There is therefore a need to look for new markers to help diagnose anemia in IBD patients. This work develops and validates a method for the determination of three protoporphyrins in human urine: protoporphyrin IX (PPIX), protoporphyrin IX complex with Zn (ZnPPIX) and protoporphyrin IX complex with Fe (II) (FePPIX), the latter also known as heme. The aim is to evaluate their potential as biomarkers of anemic disease in patients diagnosed with IBD. The proposed analytical method is based on high performance liquid chromatography (HPLC) with dual detection based on photodiode array (PDA) and fluorescence (FD). Quantification of the analytes at very low concentrations is possible due to the efficient preconcentration provided by dispersive liquid-liquid microextraction (DLLME) and the sensitivity of the detection systems. The method was validated by evaluating linearity (25-1000 ng mL-1), matrix effect, sensitivity (limits of quantification were between 5 and 11 ng mL-1), selectivity, accuracy, carry-over, dilution integrity, stability and precision (< 12.1 %). Finally, statistical analyses applied to the sample quantification results showed these three markers, together with five clinical markers, were significantly different between anemic and non-anemic IBD patients.

Bidirectional associations among gallstone disease, non-alcoholic fatty liver disease, kidney stone disease

BACKGROUND

A body of evidence has suggested bidirectional relationships among gallstone disease (GSD), non-alcoholic fatty liver disease (NAFLD), and kidney stone disease (KSD). However, the results are inconsistent, and studies on this topic in China are relatively few. Our goal is to explore the bidirectional associations among these three diseases through a multicenter study, systematic review, and meta-analysis.

AIM

To explore the bidirectional associations among these three diseases through a multicenter study, systematic review, and meta-analysis. The results may help to investigate the etiology of these diseases and shed light on the individualized prevention of these three diseases.

METHODS

Subjects who participated in physical examinations in Beijing, Tianjin, Chongqing in China were recruited. Multivariable logistic regression was employed to explore the bidirectional relationships among GSD, KSD, and NAFLD. Systematic review and meta-analysis were initiated to confirm the epidemiologic evidence from previous observational studies. Furthermore, trial sequential analysis (TSA) was conducted to evaluate whether the evidence was sufficient and conclusive.

RESULTS

Significant bidirectional associations were detected among the three diseases, independent of potential confounding factors. The pooled results of the systematic review and meta-analysis also corroborated the aforementioned results. The combined evidence from the multicenter study and meta-analysis was significant [pooled odds ratio (OR) = 1.42, 95%CI: 1.16-1.75, KSD → GSD; pooled OR = 1.48, 95%CI: 1.31-1.67, GSD → KSD; pooled OR = 1.31, 95%CI: 1.17-1.47, GSD → NAFLD; pooled OR = 1.37, 95%CI: 1.26-1.50, NAFLD → GSD; pooled OR = 1.28, 95%CI: 1.08-1.51, NAFLD → KSD; pooled OR = 1.21, 95%CI: 1.16-1.25, KSD → NAFLD]. TSA indicated that the evidence was sufficient and conclusive.

CONCLUSION

The present study presents relatively sufficient evidence for the positive bidirectional associations among GSD, KSD, and NAFLD. The results may provide clues for investigating the etiology of these three diseases and offer a guideline for identifying high-risk patients.

Helicobacter pylori outer membrane vesicles and infected cell exosomes: new players in host immune modulation and pathogenesis

Outer membrane vesicles (OMVs) and exosomes are essential mediators of host-pathogen interactions. Elucidating their mechanisms of action offers valuable insights into diagnosing and treating infectious diseases and cancers. However, the specific interactions of Helicobacter pylori (H. pylori) with host cells via OMVs and exosomes in modulating host immune responses have not been thoroughly investigated. This review explores how these vesicles elicit inflammatory and immunosuppressive responses in the host environment, facilitate pathogen invasion of host cells, and enable evasion of host defenses, thereby contributing to the progression of gastric diseases and extra-gastric diseases disseminated through the bloodstream. Furthermore, the review discusses the challenges and future directions for investigating OMVs and exosomes, underscoring their potential as therapeutic targets in H. pylori-associated diseases.

Trends for Admission, Mortality and Emergency Surgery in Upper Gastrointestinal Bleeding: A Study of Eight Years of Admissions in a Tertiary Care Hospital

Introduction

Most studies have shown a declining incidence of upper gastrointestinal bleeding (UGIB) in recent years. Data regarding mortality were controversial; in non-variceal bleeding, the increasing age of the population, increased use of anti-thrombotic and anticoagulant therapy in patients with cardiovascular diseases, and the use of non-steroidal anti-inflammatory drugs are counterbalanced by the progress in endoscopic therapy with stable mortality.

Material and Method

We performed a retrospective, cross-sectional study that included patients admitted with UGIB in Clinical Emergency Hospital Craiova during 2013-2020.

Results

3571 patients with UGIB were selected; a trend toward increased admission for UGIB from 2013 to 2019 was noted, with a significant decrease in 2020. Non-variceal bleeding remains the most frequent form, with a slight increase in variceal bleeding, of Mallory-Weiss syndrome and angiodysplasia, and a 3-fold decrease for unknown etiology bleeding (with no endoscopy performed) during the 2017-2020 period as compared to 2013-2016. There was a trend toward decreased mortality, with lower mortality in 2017-2020 (12.83%) compared to 2013-2016 (17.41%). The mortality for variceal bleeding and peptic ulcer bleeding has declined, but mortality for non-variceal bleeding has slightly increased during 2013-2020. Mortality has decreased in admissions during regular hours/after hours and weekdays/weekends, but the difference (off-hours and weekend effects) had increased. The percentage of endoscopies performed in the first 24 hours after admission and the rate of therapeutic endoscopy increased during 2017-2020; the median time between admission and endoscopy was 17.0 hours during 2017-2020 and 59.1 hours during 2013-2016. The proportion of patients who needed emergency surgery for uncontrolled bleeding has significantly declined since 2013-2015, with an average value of 1% in the last 5 years of the study.

Conclusion

Increased admissions for UGIB, with lower mortality, especially for peptic ulcer bleeding and variceal bleeding were noted; higher percentages of therapeutic endoscopies and endoscopies performed during the first 24 hours after admission were also recorded.

Diagnostic accuracy of Fatty Liver Index (FLI) for detecting Metabolic Associated Fatty Liver Disease (MAFLD) in adults attending a tertiary care hospital, a cross-sectional study

BACKGROUND

Metabolic-associated fatty liver disease (MAFLD) is a major public health problem worldwide. This study aimed to determine the prevalence of MAFLD and evaluate the diagnostic accuracy of the Fatty Liver Index (FLI) compared to ultrasonography for detecting fatty liver in adults attending a tertiary care hospital in Gujarat, India.

METHODS

This cross-sectional study included 500 adults visiting the outpatient department between January 2023 and December 2023. MAFLD was diagnosed on ultrasound. FLI was calculated using body mass index, waist circumference, triglycerides, and gamma-glutamyl transpeptidase levels. FLI ≥ 60 indicated fatty liver. Logistic regression analysis identified factors associated with fatty liver.

RESULTS

MAFLD prevalence was 32.2% on ultrasound. High FLI (≥ 60) was present in 26.2%. Male sex, higher BMI, waist circumference, night shift work, diabetes, and triglycerides were independent predictors of fatty liver. FLI showed excellent diagnostic accuracy with a sensitivity of 96%, specificity of 92.5%, and AUC of 0.92 for detecting fatty liver on ultrasound.

CONCLUSION

MAFLD prevalence among adults was high in this hospital-based sample. FLI can serve as an accurate non-invasive tool for identifying individuals with a high probability of MAFLD. These findings emphasize the need for larger population-based studies and the implementation of regular MAFLD screening programs in high-risk groups.

Non-Invasive Methods of Diagnosis and Management of Patients with Ulcerative Colitis

The global incidence and age-standardized prevalence rate of ulcerative colitis (UC) is increasing worldwide. It is a debilitating and lifelong inflammatory disease affecting both pediatric and adult patients. Thus, it is important to focus on modern treat-to-target approach, based on a tight control of the disease with close monitoring through interval assessments and modification of the treatment. Endoscopy remains the key method for UC assessment, but recent guidelines focus on implementation of non-invasive methods for UC diagnosis and management such as biomarkers (C-reactive protein, fecal calprotectin, and fecal lactofferin) and imaging methods (intestinal ultrasound). We summarize the diagnostic performance of non-invasive tests and present current evidence-based non-invasive strategy recommendations for UC monitoring.

The Dynamic Role of Curcumin in Mitigating Human Illnesses: Recent Advances in Therapeutic Applications

Herbal medicine, particularly in developing regions, remains highly popular due to its cost-effectiveness, accessibility, and minimal risk of adverse effects. Curcuma longa L., commonly known as turmeric, exemplifies such herbal remedies with its extensive history of culinary and medicinal applications across Asia for thousands of years. Traditionally utilized as a dye, flavoring, and in cultural rituals, turmeric has also been employed to treat a spectrum of medical conditions, including inflammatory, bacterial, and fungal infections, jaundice, tumors, and ulcers. Building on this longstanding use, contemporary biochemical and clinical research has identified curcumin-the primary active compound in turmeric-as possessing significant therapeutic potential. This review hypothesizes that curcumin's antioxidant properties are pivotal in preventing and treating chronic inflammatory diseases, which are often precursors to more severe conditions, such as cancer, and neurological disorders, like Parkinson's and Alzheimer's disease. Additionally, while curcumin demonstrates a favorable safety profile, its anticoagulant effects warrant cautious application. This article synthesizes recent studies to elucidate the molecular mechanisms underlying curcumin's actions and evaluates its therapeutic efficacy in various human illnesses, including cancer, inflammatory bowel disease, osteoarthritis, atherosclerosis, peptic ulcers, COVID-19, psoriasis, vitiligo, and depression. By integrating diverse research findings, this review aims to provide a comprehensive perspective on curcumin's role in modern medicine and its potential as a multifaceted therapeutic agent.

Fructooligosaccharides for Relieving Functional Constipation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Fructooligosaccharides (FOS) are prebiotics with great potential to improve constipation. This study set out to investigate the usefulness of consuming FOS as a dietary supplement on bowel movement frequency, stool consistency, abundance of Bifidobacteria, gastrointestinal transit time, and gastrointestinal symptoms through a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched the Cochrane Library, PubMed, EMBASE, and Web of Science databases up to 2 March 2024. Randomized controlled trials reporting the use of FOS as a supplement by participants were included. Bias risk was assessed using the Cochrane Risk of Bias assessment tool. Results were synthesized using a random-effects model or fixed-effects model, combining outcomes using odds ratios (OR), weighted mean differences (MD), or standardized mean differences (SMD) with 95% confidence intervals (CI). The meta-analysis encompassed 17 randomized controlled trials, involving a total of 713 study participants. Overall, the intake of FOS significantly increased bowel movement frequency (95% CI: 0.80, 1.50, p < 0.00001) and positively affected stool consistency, softening the stool (SMD: 0.36, 95% CI: 0.12, 0.60, p = 0.76). It also reduced the effort and pain during defecation (SMD: -0.60, 95% CI: -0.85, -0.34, p = 0.12). At the same time, mild bloating was noted as an adverse event associated with FOS ingestion (OR: 10.36, 95% CI: 3.32, 33.23, p = 0.24). No reports of serious adverse events were documented. Overall, FOS may enhance bowel movement frequency, stool consistency, and overall constipation symptoms, suggesting cautious optimism regarding their use as a dietary treatment alternative. Nevertheless, further robust and definitive randomized controlled trials are required to more accurately determine the most effective dosage and duration of use. Additional research and evidence are necessary before the efficacy of FOS as a therapeutic method for treating functional constipation can be firmly established.

Occupational and environmental factors cause the seasonal variation of peptic ulcers by Superposition Mechanism

The seasonal variation of peptic ulcers, a rhythmic phenomenon with diverse patterns and controversies, has remained an unresolved mystery for more than 90 years. A recent study identified that environmental factors cause peptic ulcers by inducing psychological stress. Based on this etiology, a synthetic review found that seasonal changes profoundly affect multiple occupational and environmental factors, each of which plays a causal role in peptic ulcers if they are studied individually. An integration of the monthly incidences caused by three occupational and environmental factors simulated the fluctuation curves in three representative seasonal patterns. The similarity between the simulated and original curves suggests that multiple occupational and environmental factors cause the seasonal variation by Superposition Mechanism, and regional differences in occupational and environmental factors account for the diverse patterns and controversies. Significantly, a full understanding of the seasonal variation of peptic ulcers validated a new concept, Superposition Mechanism, which may represent an indispensable methodological complement to modern life science and medicine.

5-Aminosalicylic Acid Distribution into the Intestinal Membrane Along the Gastrointestinal Tract After Oral Administration in Rats

BACKGROUND

5-Aminosalicylic acid (5-ASA), the first-line therapy for ulcerative colitis, is a poorly soluble zwitterionic drug. Unformulated 5-ASA is thought to be extensively absorbed in the small intestine.

METHODS

The pH-dependent solubility of 5-ASA in vitro and the intestinal membrane distribution of 5-ASA and its N-acetyl metabolite (AC-5-ASA) after the oral administration of 5-ASA were examined in fed rats. 5-ASA was administered as a suspension in water, 0.1 M HCl, or 0.1 M NaOH to untreated rats or as a solution in 5% NaHCO3 to lansoprazole-pretreated rats.

RESULTS

5-ASA solubility in vitro was higher at pH < 2 and pH > 7. In rats, the 5-ASA and AC-5-ASA were detected mostly in the small intestine at 3 h and in the colonic region at 8 h after administration. The dosing vehicle (suspension or solution) and lansoprazole pretreatment did not significantly affect the pH of the luminal fluid in rats or the 5-ASA distribution in membranes.

CONCLUSIONS

The 5-ASA distribution in membranes in the proximal intestine was found to be restricted by the intrinsic regional luminal pH, low solubility, and saturable membrane permeability. Unabsorbed 5-ASA in the proximal intestine was delivered to the distal intestine. The higher the oral dose of 5-ASA, the more 5-ASA may be delivered to the distal intestine due to the restricted absorption in the small intestine.

Zinc supplementation for acute and persistent watery diarrhoea in children: A systematic review and meta-analysis

Background

Zinc is a micronutrient that plays a role in immune system strengthening and regulation of intestinal epithelial cells, and can reduce the duration and severity of diarrhoea. We conducted a systematic review of randomised controlled trials (RCTs) to assess the effectiveness of zinc compared to no zinc for the management of acute and persistent diarrhoea in children.

Methods

We searched PubMed, the Cochrane Library, Scopus, CINAHL, ClinicalTrials.gov, and World Health Organization (WHO) International Clinical Trials Registry Platform from inception until 31 July 2023 for studies published from year 2000 onwards that assessed the use of zinc in the management of acute and persistent diarrhoea in children aged less than 10 years. We conducted the meta-analysis in Cochrane's RevMan software, determined risk of bias in individual studies using the Risk of Bias 2 (RoB 2) tool, and assessed the quality of evidence through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. This review was commissioned by the WHO for revision of their guidelines for childhood diarrhoea management.

Results

We included 38 RCTs in this systematic review. Our findings suggest that, in children with acute diarrhoea, zinc supplementation resulted in a greater proportion of children who recovered from diarrhoea at last follow-up (risk ratio (RR) = 1.07; 95% confidence interval (CI) = 1.03, 1.1; moderate certainty of evidence) and a reduction in the duration of diarrhoea (mean difference (MD) = -13.27 hours; 95% CI = -17.66, -8.89; moderate certainty of evidence) when compared to placebo. A significant number of children in the zinc group compared to placebo experienced vomiting (RR = 1.46; 95% CI = 1.22, 1.76; moderate certainty of evidence), however, there were few vomiting episodes in low-dose zinc group compared to high-dose (RR = 0.80; 95% CI = 0.72, 0.89; moderate certainty of evidence). In children with persistent diarrhoea, zinc supplementation led to a greater proportion of children who recovered from diarrhoea (RR = 1.75; 95% CI = 1.34, 2.30; low certainty of evidence). The low certainty of evidence ratings were mostly due to high heterogeneity among the studies.

Conclusions

Zinc should continue to be recommended in children under the age of 10 years with acute or persistent diarrhoea, but moderate certainty of evidence concludes that the dose of zinc should be reduced. However, further multi-country randomised clinical trials are required with a direct comparison to assess the appropriate dosage, duration and adverse effects.

Registration

PROSPERO: CRD42023439028.

Midostaurin-Associated acute pancreatitis

INTRODUCTION

The multikinase inhibitor midostaurin is the first targeted drug for the treatment of AML FLT3. It reduces mortality by 23% more than standard chemotherapy group. Although it has many gastrointestinal side effects, there is no data in the literature regarding its association with acute pancreatitis. We wanted to present an acute pancreatitis case that developed after midostaurin treatment in our clinic.

CASE REPORT

A patient with AML FLT3 who developed abdominal pain, elevated amylase-lipase enzymes and increased volume around the pancreas on abdominal imaging after the addition of midostaurin to chemotherapy was hospitalized with a prediagnosis of acute pancreatitis.

MANAGEMENT & OUTCOME

Oral feeding was stopped, intravenous hydration was provided and anti-symptomatic treatment was given. The patient was discharged on the 4th day of hospitalization after the acute pancreatitis clinic resolved.

DISCUSSION

Drug induced acute pancreatitis is a rare clinical condition which is difficult to diagnose. It has a good prognosis and low mortality rate. The mechanisms of drug-induced pancreatitis include immunological reactions, direct toxic effect, accumulation of toxic metabolites, overstimulation of pancreatic acinar cells, ischemia, intravascular thrombosis and increased viscosity of pancreatic secretion. Although there are many gastrointestinal side effects of midostaurin, there are no clear data in the literature regarding the relationship with acute pancreatitis.

Non-Alcoholic Fatty Liver Disease, Awareness of a Diagnostic Challenge—A Clinician’s Perspective

Non-alcoholic fatty liver disease (NAFLD) is the main cause of chronic liver disease globally. NAFLD is a complex pathology, considered to be the hepatic expression of metabolic syndrome (MetS). It is supposed to become the main indication for liver transplantation in the coming years and is estimated to affect 57.5–74.0% of obese people, 22.5% of children and 52.8% of obese children, with 50% of individuals with type 2 diabetes being diagnosed with NAFLD. Recent research has proved that an increase in adipose tissue insulin resistance index is an important marker of liver injury in patients with NAFLD. Despite being the main underlying cause of incidental liver damage and a growing worldwide health problem, NAFLD is mostly under-appreciated. Currently, NAFLD is considered a multifactorial disease, with various factors contributing to its pathogenesis, associated with insulin resistance and diabetes mellitus, but also with cardiovascular, kidney and endocrine disorders (polycystic ovary syndrome, hypothyroidism, growth hormone deficiency). Hepatitis B and hepatitis C, sleep apnea, inflammatory bowel diseases, cystic fibrosis, viral infections, autoimmune liver diseases and malnutrition are some other conditions in which NAFLD can be found. The aim of this review is to emphasize that, from the clinician’s perspective, NAFLD is an actual and valuable key diagnosis factor for multiple conditions; thus, efforts need to be made in order to increase recognition of the disease and its consequences. Although there is no global consensus, physicians should consider screening people who are at risk of NAFLD. A large dissemination of current concepts on NAFLD and an extensive collaboration between physicians, such as gastroenterologists, internists, cardiologists, diabetologists, nutritionists and endocrinologists, is equally needed to ensure we have the knowledge and resources to address this public health challenge.

Antimicrobial resistance in plant endophytes associated with poultry-manure application revealed by selective culture and whole genome sequencing

Poultry manure is widely used as organic fertilizer in agriculture during the cultivation of crops, but the persistent high-level use of antibiotics in poultry production has raised concerns about the selection for reservoirs of antimicrobial resistance genes (ARGs). Previous studies have shown that the addition of poultry manure can increase the abundance of genes associated with resistance to tetracyclines, aminoglycosides, fluoroquinolones, sulfonamides, bacitracin, chloramphenicol, and macrolide-lincosamide-streptogramin in soil and plants. Understanding the microbial populations that harbor these ARGs is important to identify microorganisms that could enter the human food chain. Here, we test the hypothesis that environmental exposure to poultry manure increases the occurrence of antimicrobial resistance (AMR) in plant endophytes using selective culture, phenotypic Antibiotic Susceptibility Testing (AST), phylogenetic analysis, and whole genome sequencing (WGS). Endophytes from poultry manure treated Sorghum bicolor (L.) Moench plant root and stem samples showed increased phenotypic and genotypic resistance against multiple antibiotics compared to untreated controls. Comparison of AMR phenotype-to-genotype relationships highlighted the detection of multi-drug resistant (MDR) plant endophytes, demonstrating the value of genomic surveillance for emerging drug-resistant pathogens. The increased occurrence of ARGs in poultry manure-exposed endophytes highlights the need for responsible antibiotic use in poultry and animal farming to reduce contamination of ecological niches and transgression into endophytic plant microbiome compartments. It also emphasizes the requirement for proper manure management practices and vigilance in monitoring and surveillance efforts to tackle the growing problem of antibiotic resistance and preserve the efficacy of antibiotics for human and veterinary medicine.

Short-sighted evolution of virulence for invasive gut microbes: From hypothesis to tests

Why microbes harm their hosts is a fundamental question in evolutionary biology with broad relevance to our understanding of infectious diseases. Several hypotheses have been proposed to explain this "evolution of virulence." In this perspective, we reexamine one of these hypotheses in the specific context of the human gut microbiome, namely short-sighted evolution. According to the short-sighted evolution hypothesis, virulence is a product of niche expansion within a colonized host, whereby variants of commensal microbes establish populations in tissues and sites where the infection causes morbidity or mortality. This evolution is short-sighted in that the evolved variants that infect those tissues and sites are not transmitted to other hosts. The specific hypothesis that we propose is that some bacteria responsible for invasive infections and disease are the products of the short-sighted evolution of commensal bacteria residing in the gut microbiota. We present observations in support of this hypothesis and discuss the challenges inherent in assessing its general application to infections and diseases associated with specific members of the gut microbiota. We then describe how this hypothesis can be tested using genomic data and animal model experiments and outline how such studies will serve to provide fundamental information about both the evolution and genetic basis of virulence, and the bacteria of intensively studied yet poorly understood habitats including the gut microbiomes of humans and other mammals.

Lipopolysaccharide-regulated RNF31/NRF2 axis in colonic epithelial cells mediates homeostasis of the intestinal barrier in ulcerative colitis

BACKGROUND

Although previous studies have shown that the Ring Finger Protein 31 (RNF31) gene confers susceptibility to inflammatory disease and colorectal cancer, the exact function of this protein in ulcerative colitis (UC) has not been determined.

METHODS

A mouse dextran sulfate sodium (DSS)-induced experimental colitis model was used to study RNF31 and NRF2 in colitis. RNF31 silencing or overexpression in vitro was applied to address the role of RNF31 in colonic mucosal barrier damage. Immunohistochemistry and silico analysis was performed to investigate the expression of RNF31 via taking advantage of UC tissue samples and Gene Expression Omnibus (GEO) data, respectively. The cycloheximide (CHX)-chase experiment and Co-Immunoprecipitation (Co-IP) assays were conducted to explore the association of RNF31 protein with NRF2 and P62.

RESULTS

RNF31 is highly expressed in UC patients, in inflamed murine colon induced DSS and Lipopolysaccharide (LPS)-treated epithelial cells, while the express of NRF2 was Tabdecreased. RNF31-knockdown mice in the DSS-induced colitis model had a less severe phenotype, which was associated with a more integrated barrier of colon epithelial cells. While depletion of NRF2 in colitis model exacerbated intestinal inflammation. Mechanistically, RNF31 promoted the degradation of NRF2 by regulating its ubiquitination. Upon stimulation by RNF31, NRF2 is K63 ubiquitinated, which is associated with the C871 residue of RNF31. Moreover, downregulated NRF2 mediates inflammation by promoting the secretion of IL1β and IL18, leading to damage of the intestinal barrier. Upon LPS stimulation, the interaction of the PUB domain of RNF31 with the UBA domain of P62 increased, resulting in decreased degradation of the RNF31 protein via autophagy.

CONCLUSION

Overall, depletion of RNF31 effectively relieves DSS-induced colitis in mice by inhibiting NRF2 degradation, suggesting that RNF31 may be a potential therapy for human ulcerative colitis.

Emergency surgery influences oncological outcome in small intestinal neuroendocrine tumors

BACKGROUND AND AIMS

Patients with small intestinal neuroendocrine tumors (siNETs) frequently present emergently due to bowel ischemia or bowel obstruction. The influence of emergency surgery on the prognosis of siNET remains controversial. The aim of this study was to investigate the association between type of presentation (emergency/elective) and oncological outcome.

METHODS

Clinicopathological data of patients who underwent bowel resection and were treated due to siNET at the Charité - Universitätsmedizin Berlin, Germany were analyzed retrospectively.

RESULTS

A total of 165 patients underwent bowel resection for siNET. Of these, 22.4% (n = 37) were emergency and 77.6% (n = 128) were elective procedures. A preoperative known diagnosis was less common in patients with emergency surgery (48.6% vs 85.2%; p < 0.001) and complete resections of all tumor manifestations were performed less often (32.4% vs 50.8%; p = 0.049), while more completion operations had to be performed (24.3% vs 11.1%; p = 0.049). Overall survival (OS) and progression-free survival (PFS) of emergently operated patients were reduced (5-year OS: 85.2% vs 89.5% (p = 0.023); 5-year PFS: 26.7% versus 52.5% (p = 0.018)). In addition, emergency surgery was negatively associated with OS after multivariable regression analysis.

CONCLUSION

Emergency surgery in siNET patients is associated with adverse oncological outcomes including shorter OS and PFS. Prevention of emergency conditions should be emphasized in advanced disease.

Development and validation of the MRI-based deep learning classifier for distinguishing perianal fistulizing Crohn's disease from cryptoglandular fistula: a multicenter cohort study

BACKGROUND

A singular reliable modality for early distinguishing perianal fistulizing Crohn's disease (PFCD) from cryptoglandular fistula (CGF) is currently lacking. We aimed to develop and validate an MRI-based deep learning classifier to effectively discriminate between them.

METHODS

The present study retrospectively enrolled 1054 patients with PFCD or CGF from three Chinese tertiary referral hospitals between January 1, 2015, and December 31, 2021. The patients were divided into four cohorts: training cohort (n = 800), validation cohort (n = 100), internal test cohort (n = 100) and external test cohort (n = 54). Two deep convolutional neural networks (DCNN), namely MobileNetV2 and ResNet50, were respectively trained using the transfer learning strategy on a dataset consisting of 44871 MR images. The performance of the DCNN models was compared to that of radiologists using various metrics, including receiver operating characteristic curve (ROC) analysis, accuracy, sensitivity, and specificity. Delong testing was employed for comparing the area under curves (AUCs). Univariate and multivariate analyses were conducted to explore potential factors associated with classifier performance.

FINDINGS

A total of 532 PFCD and 522 CGF patients were included. Both pre-trained DCNN classifiers achieved encouraging performances in the internal test cohort (MobileNetV2 AUC: 0.962, 95% CI 0.903-0.990; ResNet50 AUC: 0.963, 95% CI 0.905-0.990), as well as external test cohort (MobileNetV2 AUC: 0.885, 95% CI 0.769-0.956; ResNet50 AUC: 0.874, 95% CI 0.756-0.949). They had greater AUCs than the radiologists (all p ≤ 0.001), while had comparable AUCs to each other (p = 0.83 and p = 0.60 in the two test cohorts). None of the potential characteristics had a significant impact on the performance of pre-trained MobileNetV2 classifier in etiologic diagnosis. Previous fistula surgery influenced the performance of the pre-trained ResNet50 classifier in the internal test cohort (OR 0.157, 95% CI 0.025-0.997, p = 0.05).

INTERPRETATION

The developed DCNN classifiers exhibited superior robustness in distinguishing PFCD from CGF compared to artificial visual assessment, showing their potential for assisting in early detection of PFCD. Our findings highlight the promising generalized performance of MobileNetV2 over ResNet50, rendering it suitable for deployment on mobile terminals.

FUNDING

National Natural Science Foundation of China.

Localized Administration of Mesenchymal Stem Cell-Derived Exosomes for the Treatment of Refractory Perianal Fistula in Patients With Crohn's Disease: A Phase II Clinical Trial

BACKGROUND

Crohn's disease perianal fistulas are often resistant to standard anti-tumor necrosis factor-α therapies. Mesenchymal stem cell-derived exosomes are extracellular vesicles with highly potent anti-inflammatory effects, and the previous phase of this study demonstrated their safety in the treatment of refractory perianal fistulas.

OBJECTIVE

To evaluate the efficacy of mesenchymal stem cell-derived exosomes for the treatment of refractory perianal fistulas.

DESIGN

Nonrandomized, nonblinded single-center phase II clinical trial.

SETTINGS

Tertiary university hospital.

PATIENTS

Twenty-three patients were enrolled, 20 of whom completed the study. Refractory perianal fistula was defined as resistance to at least 1 course of treatment with anti-tumor necrosis factor-α therapy.

INTERVENTIONS

After clinical assessment and MRI, the patients received general anesthesia, and 5 mL of exosome solution was injected directly into the fistula tracts. The injections were repeated 3 times at 2-month intervals, and patients were followed monthly for 6 months after the last injection. Tissue samples from the tracts were obtained before each injection and subjected to immunohistopathological assessment. MRI data were obtained before and 6 months after the last injection.

MAIN OUTCOME MEASURES

The primary outcome of this study was fistula tract closure on clinical examination and MRI. The secondary outcome was an improvement in the discharge from the tracts.

RESULTS

Fistula tracts were fully closed in 12 patients (60%). Four patients showed clinical improvement, with some tracts remaining open, and 4 patients were completely resistant to treatment. A total of 43 fistula tracts were treated during the trial, 30 of which (69.7%) showed complete closure. Histopathological analysis revealed substantial reductions in local inflammation and signs of enhanced tissue regeneration. Immunohistochemical analysis of CD68, CD20, and CD31 reaffirmed these results.

CONCLUSIONS

Mesenchymal stem cell-derived exosomes are safe and effective for treating refractory perianal fistulas in patients with Crohn's disease. See Video Abstract .

ADMINISTRACIN LOCALIZADA DE EXOSOMAS DERIVADOS DE CLULAS MADRE MESENQUIMALES PARA EL TRATAMIENTO DE LA FSTULA PERIANAL REFRACTARIA EN PACIENTES CON ENFERMEDAD DE CROHN ENSAYO CLNICO DE FASE II

ANTECEDENTES:Las fístulas perianales de la enfermedad de Crohn a menudo son resistentes a las terapias anti-TNF-α estándares. Los exosomas derivados de células madre mesenquimales (MSC) son vesículas extracelulares que tienen efectos antiinflamatorios muy potentes, y la fase anterior de este estudio demostró su seguridad en el tratamiento de fístulas perianales refractarias.OBJETIVO:Evaluar la eficacia de los exosomas derivados de MSC para el tratamiento de fístulas perianales refractarias.DISEÑO:Ensayo clínico de fase II, no aleatorizado y no ciego, unicéntrico.LUGARES:Hospital universitario terciario.PACIENTES:Se inscribieron veintitrés pacientes, 20 de los cuales completaron el estudio. La fístula perianal refractaria se definió como la resistencia a al menos un ciclo de tratamiento con terapia anti-TNF-α.INTERVENCIONES:Después de la evaluación clínica y la resonancia magnética, los pacientes fueron sometidos a anestesia general y se inyectaron 5 ml de solución de exosoma directamente en los trayectos de la fístula. Las inyecciones se repitieron tres veces a intervalos de 2 meses y los pacientes fueron seguidos mensualmente durante 6 meses después de la última inyección. Se obtuvieron muestras de tejido de los tractos antes de cada inyección y se sometieron a evaluación inmunohistopatológica. Los datos de imágenes de resonancia magnética se obtuvieron antes y seis meses después de la última inyección.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario de este estudio fue el cierre del trayecto de la fístula en el examen clínico y la imagen de resonancia magnética. El resultado secundario fue una mejora en la descarga de los tractos.RESULTADOS:Los trayectos de la fístula se cerraron completamente en 12 (60%) de los pacientes. Cuatro pacientes mostraron mejoría clínica, algunos tractos permanecieron abiertos y cuatro pacientes fueron completamente resistentes al tratamiento. Durante el ensayo se trataron un total de 43 trayectos fistulosos, 30 (69,7%) de los cuales mostraron un cierre completo. El análisis histopatológico reveló reducciones sustanciales en la inflamación local y signos de una mayor regeneración tisular. El análisis inmunohistoquímico del grupo de diferenciación 68, 20 y 31 reafirmó estos resultados.CONCLUSIONES:Los exosomas derivados de MSC son seguros y eficaces para el tratamiento de fístulas perianales refractarias en pacientes con enfermedad de Crohn. (Traducción-Dr. Aurian Garcia Gonzalez ).

Nonepithelial Gene Expression Correlates With Symptom Severity in Adults With Eosinophilic Esophagitis

BACKGROUND

The mechanistic basis of the variable symptomatology seen in eosinophilic esophagitis (EoE) remains poorly understood.

OBJECTIVE

We examined the correlation of a validated, patient-reported outcome metric with a broad spectrum of esophageal transcripts to uncover potential symptom pathogenesis.

METHODS

We extracted data from 146 adults with EoE through the Consortium of Eosinophilic Gastrointestinal Disease Researchers. Patients were subgrouped by esophageal dilation history. We compared a validated patient-reported outcome metric, the EoE Activity Index (EEsAI), with a set of transcripts expressed in the esophagus of patients with EoE, the EoE Diagnostic Panel (EDP). We used single-cell RNA sequencing data to identify the cellular source of EEsAI-related EDP genes and further analyzed patients with mild and severe symptoms.

RESULTS

The EEsAI correlated with the EDP total score, especially in patients without recent esophageal dilation (r = -0.31; P = .003). We identified 14 EDP genes that correlated with EEsAI scores (r ≥ 0.3; P < .05). Of these, 11 were expressed in nonepithelial cells and three in epithelial cells. During histologic remission, only four of 11 nonepithelial genes (36%) versus all three epithelial genes (100%) had decreased expression to less than 50% of that in active EoE. Fibroblasts expressed five of 11 nonepithelial EEsAI-associated EDP genes (45%). A subset of nonepithelial genes (eight of 11; 73%), but not EoE-representative genes (none of four; 0%; CCL26, CAPN14, DSG1, and SPINK7), was upregulated in patients with EoE with the highest versus lowest symptom burden.

CONCLUSION

The correlation of symptoms and nonepithelial esophageal gene expression substantiates that nonepithelial cells (eg, fibroblasts) likely contribute to symptom severity.

Effect of Neurostimulation on Chronic Pancreatic Pain: A Systematic Review

BACKGROUND

Chronic pancreatic pain is one of the most severe causes of visceral pain, and treatment response is often limited. Neurostimulation techniques have been investigated for chronic pain syndromes once there are pathophysiological reasons to believe that these methods activate descending pain inhibitory systems. Considering this, we designed this systematic literature review to investigate the evidence on neuromodulation techniques as a treatment for chronic pancreatic pain.

MATERIALS AND METHODS

We performed a literature search using the databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase until April 2024. The included studies used neurostimulation techniques in participants with chronic pancreatic pain and reported pain-related outcomes, with a focus on pain scales and opioid intake. Two reviewers screened and extracted data, and a third reviewer resolved discrepancies. We assessed the risk of bias using the Jadad scale. The authors then grouped the findings by the target of the neurostimulation, cortex, spinal cord, or peripheral nerves; described the findings qualitatively in the results section, including qualitative data reported by the articles; and calculated effect sizes of pain-related outcomes.

RESULTS

A total of 22 studies were included (7 randomized clinical trials [RCTs], 14 case series, and 1 survey), including a total of 257 clinical trial participants. The two outcomes most commonly reported were pain, measured by the visual analogue scale (VAS), numeric rating scale (NRS), and pressure pain threshold scores, and opioid intake. Two RCTs investigated repetitive transcranial magnetic stimulation (rTMS), showing a reduction of 36% (±16) (d = 2.25; 95% CI, 0.66-3.83) and 27.2% (±24.5%) (d = 2.594; 95% CI, 1.303-3.885) in VAS pain scale. In another clinical trial, transcranial direct-current stimulation (tDCS) and transcranial pulsed current stimulation were not observed to effect a significant reduction in VAS pain (χ2 = 5.87; p = 0.12). However, a complete remission was reported in one tDCS case. Spinal cord stimulation (SCS) and dorsal root ganglion stimulation were performed in a survey and 11 case series, showing major pain decrease and diminished opioid use in 90% of participants after successful implantation; most studies had follow-up periods of months to years. Two noninvasive vagal nerve stimulation (VNS) RCTs showed no significant pain reduction in pain thresholds or VAS (d = 0.916; 95% CI, -0.005 to 1.838; and d = 0.17; -0.86 to 1.20; p = 0.72; respectively). Splanchnic nerve stimulation in one case report showed complete pain reduction accompanied by discontinuation of oral morphine and fentanyl lozenges and a 95% decrease in fentanyl patch use. Two RCTs investigated transcutaneous electrical nerve stimulation (TENS). One found a significant pain reduction effect with the NRS (d = 1.481; 95% CI, 1.82-1.143), and decreased opioid use, while the other RCT did not show significant benefit. Additionally, one case report with TENS showed pain improvement that was not quantitatively measured.

DISCUSSION

The neuromodulation techniques of rTMS and SCS showed the most consistent potential as a treatment method for chronic pancreatic pain. However, the studies have notable limitations, and SCS has had no clinical trials. For VNS, we have two RCTs that showed a non-statistically significant improvement; we believe that both studies had a lack of power issue and suggest a gap in the literature for new RCTs exploring this modality. Additionally, tDCS and TENS showed mixed results. Another important insight was that opioid intake decrease is a common trend among most studies included and that adverse effects were rarely reported. To further elucidate the potential of these neurostimulation techniques, we suggest the development of new clinical trials with larger samples and adequate sham controls.

Bacterial cellulose is a desirable biological macromolecule that can prevent obesity via modulating lipid metabolism and gut microbiota

Obesity has attracted great concern because of its undesirable effects on our life quality. Bacterial cellulose (BC) is a biological macromolecule that can improve gut homeostasis and lipid metabolism. However, its potential role in preventing obesity and associated mechanisms is still poorly understood. Herein, a supplement of BC was used to fully evaluate how it prevents obesity based on physio-biochemical and gut microbial analyses. Results showed that BC consumption helped decrease body and liver weight, and fat accumulation in kidney and epididymis. Correspondingly, glucose concentrations, total triglycerides, total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol were reversed to the control levels. Consuming BC also improved liver fat metabolism and intestinal function, and alleviated ileum and epididymis inflammation. High-throughput sequencing suggested that a high-fat diet significantly decreased gut microbiota diversity, which could be reversed by consuming BC. A decreased Firmicutes and Proteobacteria and an increased Bacteroidetes following BC consumption were observed. The OTU-based analysis identified that Lachnospiraceae, Desulfovibrio, Lachnoclostridium, Blautia, Anaerotruncus, Bacteroides, Faecalibaculum, Bacteroidales S24-7 group, Prevotellaceae UCG-001 group, and Alloprevotella might be involved in obesity development or prevention. Our data suggest that BC is a good insoluble dietary fiber to prevent obesity via regulating lipid metabolism and gut microbiota.

Immunologic derangement caused by intestinal dysbiosis and stress is the intrinsic basis of reactive arthritis

Reactive arthritis (ReA) is defined as arthritis resulting from infections in other body parts, such as the gastrointestinal and urogenital tracts. The primary clinical manifestations involve acute-onset and self-limiting asymmetric large joint inflammation in the lower limbs. Although bacterial or chlamydia infections have long been recognized as playing a pivotal role in its pathogenesis, recent studies suggest that antibiotic treatment may perpetuate rather than eradicate chlamydia within the host, indicating an involvement of other mechanisms in Reactive arthritis. Reactive arthritis is currently believed to be associated with infection, genetic marker (HLA-B27), and immunologic derangement. As an autoimmune disease, increasing attention has been given to understanding the role of the immune system in Reactive arthritis. This review focuses on elucidating how the immune system mediates reactive arthritis and explores the roles of intestinal dysbiosis-induced immune disorders and stress-related factors in autoimmune diseases, providing novel insights into understanding reactive arthritis.

Hemangioendothelioma as a rare cause of lower gastrointestinal bleeding - a case report

INTRODUCTION AND IMPORTANCE

Gastrointestinal bleeding is a serious health threat, especially when it originates from the small intestine, often termed small bowel bleeding (SBB). Hemangioendothelioma, a rare vascular tumor, can be a significant yet uncommon cause of gastrointestinal bleeding. This case report highlights hemangioendothelioma's diagnostic challenges and clinical significance in SBB.

CASE PRESENTATION

A 16-year-old female experienced six months of intermittent massive rectorrhagia and melena, along with nausea, vomiting, loss of appetite, and abdominal pain. Initial endoscopic investigations, including colonoscopy and enteroscopy, did not identify the bleeding source. Imaging studies, including a CT scan and Meckel's scintigraphy, were also inconclusive. Persistent bleeding and a significant drop in hemoglobin levels led to exploratory laparotomy with intraoperative enteroscopy, which revealed a nodular lesion in the small intestine. Histopathological examination confirmed the lesion as hemangioendothelioma. Surgical resection of the lesion stopped the bleeding, and the patient recovered without complications, remaining asymptomatic during follow-ups at one and six months post-surgery.

CLINICAL DISCUSSION

Hemangioendothelioma is a rare, locally aggressive vascular tumor that can present with abdominal pain, bowel obstruction, anemia, and gastrointestinal bleeding. Due to its rarity and location, it often goes undetected in conventional endoscopy. The definitive diagnosis is made through histopathological examination, which shows characteristic endothelial cells and vascular structures. Surgical excision is the primary treatment, although there is a risk of recurrence and metastasis.

CONCLUSION

This case underscores hemangioendothelioma's diagnostic challenges and clinical relevance in obscure gastrointestinal bleeding. Intraoperative enteroscopy plays a crucial role in the diagnosis and management. Clinicians should consider hemangioendothelioma in similar cases to ensure appropriate treatment and management.

Gastrointestinal pathophysiology in long COVID: Exploring roles of microbiota dysbiosis and serotonin dysregulation in post-infectious bowel symptoms

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) triggered an unprecedented public health crisis known as the coronavirus disease 2019 (COVID-19) pandemic. Gastrointestinal (GI) symptoms develop in patients during acute infection and persist after recovery from airway distress in a chronic form of the disease (long COVID). A high incidence of irritable bowel syndrome (IBS) manifested by severe abdominal pain and defecation pattern changes is reported in COVID patients. Although COVID is primarily considered a respiratory disease, fecal shedding of SARS-CoV-2 antigens positively correlates with bowel symptoms. Active viral infection in the GI tract was identified by human intestinal organoid studies showing SARS-CoV-2 replication in gut epithelial cells. In this review, we highlight the key findings in post-COVID bowel symptoms and explore possible mechanisms underlying the pathophysiology of the illness. These mechanisms include mucosal inflammation, gut barrier dysfunction, and microbiota dysbiosis during viral infection. Viral shedding through the GI route may be the primary factor causing the alteration of the microbiome ecosystem, particularly the virome. Recent evidence in experimental models suggested that microbiome dysbiosis could be further aggravated by epithelial barrier damage and immune activation. Moreover, altered microbiota composition has been associated with dysregulated serotonin pathways, resulting in intestinal nerve hypersensitivity. These mechanisms may explain the development of post-infectious IBS-like symptoms in long COVID. Understanding how coronavirus infection affects gut pathophysiology, including microbiome changes, would benefit the therapeutic advancement for managing post-infectious bowel symptoms.

NLRP3 activation maintains intestinal epithelial barrier and reduces liver injury in alcoholic liver disease mice

BACKGROUND

Alcoholic liver disease (ALD) patients with bacterial infections usually exhibit high mortality rates. Infections frequently involve bacteria such as Vibrio vulnificus and Enterococcus faecalis. Nevertheless, the mechanisms predisposing ALD patients to bacterial infections and the role of the NLRP3 inflammasome in the intestinal epithelial barrier in ALD remain unclear.

METHODS

We established ALD mice models of WT, Nlrp3-/- and Gsdmd-/- through chronic alcohol consumption feeding and acute alcohol induction. We compared alterations in gut microbiota, ileitis, and adhesion protein expression, to analyze the role and potential mechanism of NLRP3 in the early onset of ALD. Concurrently, we examined the changes in inflammation and liver damage in the ileum of ALD and healthy mice following foodborne infection with V. vulnificus.

RESULTS

Compared with the control group, the expression levels of ZO-1, Claudin-1 and E-cadherin were reduced in the ileum of ALD mice, while those of NLRP3, caspase-1(p20), GSDMD-N and IL-1β were elevated. Nlrp3-/- and Gsdmd-/- ALD mice showed an increased gut bacterial load, decreased ileal expression of E-cadherin, more severe ileitis, pronounced liver damage, steatosis and higher plasma levels of FITC-dextran, D-LA and ZO-1 compared with WT mice. Notably, Nlrp3-/- ALD mice exhibited a higher presence of Deferribacterota and Enterobacteriaceae. Furthermore, ALD mice infected with V. vulnificus infection exhibited no further activation of NLRP3 in the ileum, leading to increased intestinal permeability and bloodstream infections.

CONCLUSIONS

This study indicated that NLRP3 activation in the ileum of ALD mice stabilizes the inflammation-related gut microbiota, preserves the intestinal epithelial barrier, and diminishes inflammation and liver injury. Furthermore, the compromised immune defence in ALD mice may contribute to their heightened susceptibility to bacterial pathogens.

KEY POINTS

Activation of the NLRP3-GSDMD pathway in the ileum of Alcoholic liver disease (ALD) mice. NLRP3 activation maintains homeostasis of gut microbiota and intestinal epithelial barrier in ALD mice. ALD mice infected with V. vulnificus infection exhibited no further activation of NLRP3 in the ileum, leading to increased intestinal permeability and bloodstream infections.

A 52-Year-Old Man with Abdominal Pain and Jaundice

AbstractMorning Report is a time-honored tradition where physicians-in-training present cases to their colleagues and clinical experts to collaboratively examine an interesting patient presentation. The Morning Report section seeks to carry on this tradition by presenting a patient's chief concern and story, inviting the reader to develop a differential diagnosis and discover the diagnosis alongside the authors of the case. This report examines the story of a 52-year-old man who presented to the emergency department with subacute abdominal pain and jaundice. Fever, worsening liver function tests, and multi-organ failure developed. Using questions, physical examination, and testing, an illness script for the presentation emerges; the differential is refined until a final diagnosis is made.

Extended Monitoring for Transition to Oral Corticosteroids in Acute Severe Ulcerative Colitis May Be Unnecessarily Prolonging Length of Stay

BACKGROUND

There is no guideline regarding whether patients treated with intravenous corticosteroids for acute severe ulcerative colitis (ASUC) should be monitored in the hospital after transitioning to oral steroids. Our study aimed to: (1) compare rates of oral steroid transition failure and 30-day readmission between ASUC hospitalizations with extended inpatient monitoring compared to accelerated inpatient monitoring, and (2) identify predictors of oral steroid transition failure.

METHODS

A retrospective cohort study of ulcerative colitis (UC) related admissions at UCSF from 2014 to 2022 was conducted comparing rates of steroid transition failures in extended inpatient monitoring (≥ 24 h on oral steroids prior to discharge) to accelerated inpatient monitoring (< 24 h on oral steroids). Steroid transition failure was defined as worsening colitis activity with the need to return to IV steroids or undergo colectomy. Data analysis incorporated demographics, disease features, and treatment history.

RESULTS

Transition failures from intravenous to oral corticosteroids occurred in 8% of all UC-related admissions. There was a significant difference in transition failure observed between the extended and accelerated monitoring groups, 13 vs 3% (p = 0.03), respectively, with 83.3% of total transition failures occurring within the extended monitoring group. The 30-day readmission rate was 6% in each group (p = 0.93). No significant predictors of transition failures were identified.

CONCLUSION

Transition failures from IV to oral steroids are uncommon in ASUC hospitalizations. Transition failures were more likely to occur with extended monitoring, suggesting potential predictors and/or patient selection bias within this group. Further studies are needed to investigate the parameters driving clinician decision-making regarding oral steroid transitioning.

Semaglutide 2.4 mg in Participants With Metabolic Dysfunction-Associated Steatohepatitis: Baseline Characteristics and Design of the Phase 3 ESSENCE Trial

BACKGROUND

Semaglutide, a glucagon-like peptide-1 receptor agonist, has demonstrated potential beneficial effects in metabolic dysfunction-associated steatohepatitis (MASH).

AIMS

To describe the trial design and baseline characteristics of the 'Effect of Semaglutide in Subjects with Non-cirrhotic Non-alcoholic Steatohepatitis' (ESSENCE) trial (NCT04822181).

METHODS

ESSENCE is a two-part, phase 3, randomised, multicentre trial evaluating the effect of subcutaneous semaglutide 2.4 mg in participants with biopsy-proven MASH and fibrosis stage 2 or 3. The primary objective of Part 1 is to demonstrate that semaglutide improves liver histology compared with placebo. The two primary endpoints are: resolution of steatohepatitis and no worsening of liver fibrosis, and improvement in liver fibrosis and no worsening of steatohepatitis. The Part 2 objective is based on clinical outcomes. The current work reports baseline characteristics of the first 800 randomised participants which includes demographics, laboratory parameters, liver histology, non-invasive tests and presence of metabolic dysfunction-associated steatotic liver disease (MASLD) cardiometabolic criteria.

RESULTS

Of 800 participants, 250 (31.3%) had fibrosis stage 2 and 550 (68.8%) had fibrosis stage 3. In the overall population, mean (standard deviation [SD]) age was 56 (11.6) years, 57.1% were female, mean (SD) body mass index was 34.6 (7.2) kg/m2, 55.5% had type 2 diabetes and > 99% had at least one MASLD cardiometabolic criterion according to the published definition.

CONCLUSION

The ESSENCE baseline population includes participants with clinically significant fibrosis stages 2 and 3. Although MASLD cardiometabolic criteria were not a requirement for study enrolment, almost all participants (> 99%) had at least one MASLD cardiometabolic criterion.

TRIAL REGISTRATION

NCT04822181.

Exploring the relationship between Faecalibacterium duncaniae and Escherichia coli in inflammatory bowel disease (IBD): Insights and implications

Inflammatory bowel disease (IBD) is a group of disorders characterized by an inflammation of the gastrointestinal tract (GIT) and represents a major social and economic burden. Despite ongoing research into the etiology and pathophysiology of this multifactorial disease, treatment options remain limited. From this perspective, the gut microbiota has emerged as a potential player in the pathogenesis of IBD, and animal and human studies support this hypothesis. Indeed, the human gut is one of the most complex ecological communities (composed of 1013-1014 microorganisms) that plays a critical role in human health by influencing normal physiology and disease susceptibility through its collective metabolic activities and host interactions. In addition, live probiotic bacteria present in some food products (which transit through the GIT) have been shown to interact with the host immune system and confer several health benefits. The aim of this review is to provide an overview of the link between Faecalibacterium duncaniae and Escherichia coli and IBD, highlighting the main areas of research in this field. An ecological perspective on the gut microbiota may offer new insights for the development of clinical therapies targeting this bacterial community to improve human health.

Effects of the interaction between body mass index and dietary patterns on severe NAFLD incidence: A prospective cohort study

BACKGROUND

It remains unclear whether the associations between dietary patterns and non-alcoholic fatty liver disease (NAFLD) vary by body mass index (BMI). We aimed to explore the association between dietary patterns and severe NAFLD incidence, and further investigate the interaction of BMI with dietary patterns.

METHODS

In a prospective cohort study using UK Biobank data, we included White participants with baseline food frequency questionnaire (FFQ) information. Principal component analysis (PCA) with varimax rotation was performed to identify major dietary patterns. The primary outcome was severe NAFLD, defined as hospitalization due to NAFLD or non-alcoholic steatohepatitis (NASH). We employed cause-specific Cox regression for competing risks to assess the association and calculated the relative excess risk due to interaction (RERI) to estimate the interaction of BMI.

RESULTS

This study included 307,130 participants with a median follow-up of 12.68 years. 3104 cases of severe NAFLD were identified. PCA analysis revealed two primary dietary patterns: a prudent diet (RC1) and a meat-based diet (RC2). Multivariate analysis showed a standard deviation (SD) increase in RC1 was associated with lower severe NAFLD risk (HR 0.91 [95 % CI 0.88 to 0.94]), while a SD increase in RC2 was associated with higher risk (1.10 [1.05 to 1.14]). Significant interactions were observed between baseline BMI ≥25 kg/m2 and dietary patterns (RC1: RERI: -0.22 [95 % CI -0.43 to -0.003]; RC2: 0.29 [0.03 to 0.56]).

CONCLUSIONS

Targeted dietary modifications are vital for specific populations at risk of severe NAFLD, considering the significant interaction observed between BMI and dietary patterns.

A Complex, Convexity, Anterior Superior Sagittal Sinus Dural Arteriovenous Fistula Secondary to Venous Sinus Thrombosis

We report the management of a convexity dural arteriovenous fistula (dAVF) in an uncommon anterior superior sagittal sinus (SSS) location. This was a high-risk Cognard IIa+b dAVF, which is notoriously complex to treat. Endoscopic management alone for complex SSS dAVFs is challenging due to the often bilateral arterial supply to the fistula, as demonstrated in this case. Hence, proceeding straight to surgery is a viable option, skipping the need for interventional radiological (IR) coiling. This is the first reported case of a fistula secondary to venous sinus thrombosis in a coeliac patient. Our patient initially underwent endoscopic treatment, which failed due to arterial supply from other arteries continuing to supply the fistula. The patient then underwent a midline craniotomy where the feeding arteries were ligated, followed by division of the anterior third of the SSS, allowing further division and ligation of arterial feeders. It is essential to be aware of the prothrombotic state of coeliacs and the risk of thrombosis and fistula formation. This allows physicians to recognize the signs of raised intracranial pressure, facilitating early intervention.

Assessment of Non-alcoholic Fatty Liver Disease and Level of Risk of Fibrosis in Diabetic and Non-diabetic Individuals

Background and aim Non-alcoholic fatty liver disease (NAFLD), now known as metabolic dysfunction-associated steatotic liver disease (MASLD), is more common in people with type-2 diabetes mellitus (T2DM) than in people without diabetes mellitus (non-DM). This disease can lead to cirrhosis or hepatic cancer. There is limited data on NAFLD prevalence and the level of risk of fibrosis in Bangladeshi individuals. This study aimed to assess NAFLD prevalence and compare the proportion of NAFLD and the level of risk of fibrosis between T2DM and non-DM Bangladeshi individuals. Methods A cross-sectional analytical study was conducted for six months in 2024 in the outpatient section of the Department of Medicine at Holy Family Red Crescent Medical College, Dhaka, Bangladesh. Among the patients seeking outpatient care, a total of 179 male and non-pregnant female participants aged 18 years and older were selected using a purposive sampling technique. Individuals with a history of alcohol use, diagnosed cases of chronic liver diseases, prior use of hepatotoxic drugs, and primary biliary cholangitis were excluded from the study. Detailed demographic characteristics, comorbidities, family history of diabetes and liver disease, physical measurements, and biochemical tests were done. Ultrasonography (USG) of the hepatobiliary system was employed to ascertain the existence of NAFLD. The presence or absence of T2DM was evaluated through prior medical documents, corroborated by laboratory analyses of random blood glucose (RBS) and glycosylated hemoglobin (HbA1c) levels. The Fibrosis-4 (FIB-4) index score was utilized to evaluate the risk of liver fibrosis. Results The mean age of the participants was 49.11±12.25 years and 107 (59.8%) of participants were female. Almost two-thirds of the participants were suffering from T2DM. About 17 (9.5%) of the study participants were suffering from NAFLD, which was much higher among T2DM (15 (12.5%)) than non-DM individuals (two (3.3%)). T2DM and family history of liver disease were found to significantly increase the risk of suffering from NAFLD by 5.247 times (95% CI: 1.081-25.468) and 4.202 times (95% CI: 1.249-14.135), respectively. About one (6.7%) of T2DM individuals with NAFLD were at high risk for fibrosis. Conclusion Almost one in 10 people had NAFLD, and it was way more common among those with T2DM, who also exhibit a higher risk of hepatic fibrosis. Moreover, T2DM and a family history of liver disease can independently increase the risk of NAFLD.

Natural products: Harnessing the power of gut microbiota for neurological health

BACKGROUND

Neurological diseases are the primary cause of disability and death and impose substantial financial burdens. However, existing treatments only relieve symptoms and may cause many adverse effects. Natural products are a promising source of neurological therapeutic agents due to their excellent neuroprotective effect and safety. The gut microbiota has an essential impact on maintaining brain homeostasis via the gut-brain axis. Multiple investigations show that natural products offer neuroprotective effects by regulating gut microbiota-driven signaling networks.

OBJECTIVES

This review aims to provide a systematic review of how natural products promote neurological health by harnessing the power of gut microbiota.

METHODS

The pre-January 1, 2024 literature was gathered from several databases, including Scopus, PubMed, Google Scholar, and Web of Science, utilizing appropriate keywords. The gathered publications underwent a review process and were classified based on their study content, specifically focusing on the impact of natural products on gut microbiota and neurological health.

RESULTS

Here, we review how natural products promote neurological health by regulating the gut microbiota-brain axis. Specifically, we focus on the following areas. (1) Altering microorganism community structure, including increasing α-diversity and altering β-diversity. (2) Regulating the population of certain bacteria, including enriching beneficial microorganisms Akkermansia and Bifidobacterium, and inhibiting potentially hazardous microorganisms Bilophila, Klebsiella, and Helicobacter. (3) Regulating microbial neuroactive metabolites levels, including short-chain fatty acids, tryptophan and its derivatives, trimethylamine N-oxide, dopa/dopamine, γ-aminobutyric acid, and lipopolysaccharide. Furthermore, we review how natural products promote neurological health by regulating intestinal barrier homeostasis.

CONCLUSION

Natural products promote neurological health by harnessing the power of gut microbiota. This review will contribute to understanding how natural products promote neurological health by orchestrating the gut microbiota-brain axis.

Comparison of Population Attributable Fractions of Cancer Incidence and Mortality Linked to Excess Body Weight in Korea from 2015 to 2030

BACKGRUOUND

The increasing rate of excess body weight (EBW) in the global population has led to growing health concerns, including cancer-related EBW. We aimed to estimate the population attributable fraction (PAF) of cancer incidence and deaths linked to EBW in Korean individuals from 2015 to 2030 and to compare its value with various body mass index cutoffs.

METHODS

Levin's formula was used to calculate the PAF; the prevalence rates were computed using the Korean National Health and Nutrition Examination Survey data, while the relative risks of specific cancers related to EBW were estimated based on the results of Korean cohort studies. To account for the 15-year latency period when estimating the PAF in 2020, the prevalence rates from 2015 and attributable cases or deaths from 2020 were used.

RESULTS

The PAF attributed to EBW was similar for both cancer incidence and deaths using either the World Health Organization (WHO) Asian-Pacific region standard or a modified Asian standard, with the WHO standard yielding the lowest values. In the Korean population, the PAFs of EBW for cancer incidence were 2.96% in men and 3.61% in women, while those for cancer deaths were 0.67% in men and 3.06% in women in 2020. Additionally, PAFs showed a gradual increase in both sexes until 2030.

CONCLUSION

The EBW continues to have a significant impact on cancer incidence and deaths in Korea. Effective prevention strategies targeting the reduction of this modifiable risk factor can substantially decrease the cancer burden.

Complex Cardiovascular Management in an 80-Year-Old Female With Gastrointestinal Bleeds and Klatskin Tumor: A Case of ST-Elevation Myocardial Infarction (MI) Management Complicated by Severe Anemia and Post-MI Ventricular Septal Defect Development

Managing acute coronary syndrome (ACS) in patients with a recent history of gastrointestinal bleeding presents a unique and challenging clinical dilemma, necessitating a careful balance between minimizing ischemic risk and avoiding potentially life-threatening rebleeding. Standard treatment for ACS typically involves dual antiplatelet therapy (DAPT) to prevent recurrent thrombotic events. However, in patients with recent gastrointestinal hemorrhage or significant anemia, these therapies may substantially increase the risk of life-threatening bleeding, complicating the decision-making process and often leading to conservative management strategies. In this case, we describe the presentation and management of an 80-year-old female with a history of Klatskin tumor resection, duodenal ulcer, and recurrent gastrointestinal bleeding who was admitted with symptoms suggestive of ACS. An electrocardiogram (EKG) revealed ST elevation in anterolateral leads, raising concerns for an acute myocardial infarction (MI). However, given her critically low hemoglobin (5.7 g/dL) and recent history of gastrointestinal hemorrhage, the decision was made to forgo aggressive interventions such as percutaneous coronary intervention (PCI) and DAPT. A conservative approach, including aspirin monotherapy and supportive care, was prioritized due to the high risk of rebleeding. Despite initial stabilization with transfusions, the patient later developed hemodynamic instability and was found to have a large ventricular septal defect (VSD) on echocardiography, ultimately leading to her demise. This case underscores the complexities of managing ACS in patients with severe anemia and recent gastrointestinal bleeding, where standard ACS protocols may be contraindicated. It highlights the importance of individualized, multidisciplinary treatment strategies and shared decision-making with patients and families to optimize care while aligning with the patient's overall health goals. In high-risk cases like this, a conservative approach may be warranted, even when it conflicts with traditional aggressive treatment pathways. The lessons learned from this case reinforce the need for flexibility and critical thinking in navigating the delicate balance between preventing ischemic complications and avoiding catastrophic bleeding in vulnerable patients.

Risk factors for acute kidney injury in patients with severe acute pancreatitis: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to identify the risk factors for acute kidney injury (AKI) in patients with severe acute pancreatitis (SAP).

METHODS

A comprehensive literature search was conducted using the PubMed, Embase and Cochrane Library databases for case-control studies comparing the clinical characteristics of patients with SAP with and without AKI. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS). Pooled odds ratios (ORs) with 95 % confidence intervals (CIs) were calculated using fixed- or random-effects models, based on heterogeneity.

RESULTS

Five studies involving 795 patients with SAP were included, of whom 173 (21.8 %) developed AKI. All studies were of high quality according to the NOS. Among the 17 potential risk factors that were analysed, a history of alcohol consumption (OR = 2.36, 95% CI = 0.54-10.43, p < 0.001), elevated serum amylase (OR = 4.50, 95% CI = 1.77-11.43, p = 0.002) and Acute Physiology and Chronic Health Evaluation II (APACHE II) score (OR = 1.57, 95% CI = 0.49-2.64, p = 0.004) were significantly associated with an increased risk of AKI. However, hypertension (OR = 1.14, 95% CI = 0.60-2.16, p = 0.69) and diabetes (OR = 1.88, 95% CI = 0.51-6.95, p = 0.34) were not significantly associated with AKI risk. Based on funnel plots, no obvious publication bias was detected.

CONCLUSIONS

A history of alcohol consumption, elevated serum amylase and APACHE II score are significant risk factors for AKI in patients with SAP. For early intervention, clinical physicians should be vigilant about the risk of AKI in patients with SAP with these factors. More high-quality studies are needed to validate these findings and explore other potential risk factors.

Recognizing the biological barriers and pathophysiological characteristics of the gastrointestinal tract for the design and application of nanotherapeutics

The gastrointestinal tract (GIT) is an important and complex system by which humans to digest food and absorb nutrients. The GIT is vulnerable to diseases, which may led to discomfort or even death in humans. Therapeutics for GIT disease treatment face multiple biological barriers, which significantly decrease the efficacy of therapeutics. Recognizing the biological barriers and pathophysiological characteristics of GIT may be helpful to design innovative therapeutics. Nanotherapeutics, which have special targeting and controlled therapeutic release profiles, have been widely used for the treatment of GIT diseases. Herein, we provide a comprehensive review of the biological barrier and pathophysiological characteristics of GIT, which may aid in the design of promising nanotherapeutics for GIT disease treatment. Furthermore, several typical diseases of the upper and lower digestive tracts, such as Helicobacter pylori infection and inflammatory bowel disease, were selected to investigate the application of nanotherapeutics for GIT disease treatment.