Unveiling the efficacy of paroxetine and gabapentin in ulcerative colitis patients in remission with co-existing IBS-like symptoms: a single-blinded randomized clinical trial

Introduction

This clinical trial is designed to explore the efficacy of paroxetine and gabapentin in alleviating functional gastrointestinal symptoms, anxiety, depression, and quality of life in patients with ulcerative colitis during the remission stage.

Methods

The study enrolled 97 patients with ulcerative colitis in remission who had reported functional gastrointestinal symptoms. Patients were measured in terms of quality of life, anxiety, depression, and IBS severity. One group received paroxetine at a dosage of 20 mg/day, and the other group received gabapentin at a dosage of 100 mg/day in the first month and 300 mg/day in the second and third months. The patients were followed up for 3 months.

Results

Anxiety (p < 0.001), depression (p = 0.012), and severity score levels (p = 0.045) among patients in the paroxetine group were significantly lower compared to the gabapentin group following the intervention. Paired evaluation in each treatment group revealed a significant reduction in the paroxetine group, while changes in the gabapentin group were not significant. Quality-of-life scores among patients in the paroxetine group were significantly higher compared to the gabapentin group following the intervention (p < 0.001).

Conclusion

The rate of improvement in gastrointestinal functional symptoms, anxiety, depression, and quality of life is significantly superior with paroxetine compared to gabapentin.

Clinical trial registration

https://irct.behdasht.gov.ir/trial/69397, identifier RCT20220417054557N1.

Assessment of Bacteriophage Pharmacokinetic Parameters After Intra-Articular Delivery in a Rat Prosthetic Joint Infection Model

Prosthetic joint infections (PJIs) are a serious complication of orthopedic surgery. Bacteriophage (phage) therapy shows promise as an adjunctive treatment but requires further study, particularly in its pharmacokinetics. Consequently, we performed a pharmacokinetic assessment of phage therapy for PJIs using a Staphylococcus epidermidis Kirschner wire-based prosthesis rat model. We used 52 male Sprague-Dawley rats in four groups: negative controls (no phage, sterile implant), PJI controls (bacteria, no phage), sterile phage (phages given, sterile implant), and PJI (bacteria, phages given). The PJI groups were inoculated with ~106 CFU of S. epidermidis. The groups receiving phage were intra-articularly injected with ~108 PFU of vB_SepM_Alex five days post-implantation. The rats were euthanized between 30 min and 48 h post-injection. The measured phage concentrations between the PJI rats and the sterile controls in periarticular tissues were not significantly different. In a noncompartmental pharmacokinetic analysis, the estimated phage half-lives were under 6 h (combined: 3.73 [IQR, 1.45, 10.07]). The maximum phage concentrations were reached within 2 h after administration (combined: 0.75 [0.50, 1.75]). The estimated phage mean residence time was approximately three hours (combined: 3.04 [1.44, 4.19]). Our study provides a preliminary set of pharmacokinetic parameters that can inform future phage dosing studies and animal models of phage therapy for PJIs.

The Impact of Cytomegalovirus Infection on Ulcerative Colitis Relapse: A Multicenter Retrospective Cohort Study

Purpose

Cytomegalovirus (CMV) infection exacerbates intestinal inflammation in ulcerative colitis (UC) patients, yet the effect of CMV infection on UC relapse has not been fully elucidated. This study aimed to investigate the impact of CMV infection on UC relapse and identify associated risk factors.

Patients and Methods

This multicenter retrospective cohort study included UC patients who visited research centers from January 2016 to December 2020. Univariate and multivariate Cox regression analyses were conducted to explore risk factors for UC relapse. Propensity score matching was used to balance the differences in the clinical characteristics between the groups.

Results

A total of 298 UC patients participated in this study, including 19 with CMV colitis, 37 with CMV viremia, and 242 CMV-negative patients. The 2-year cumulative recurrence rate was higher in patients with CMV colitis than that in CMV-negative patients (84.21% vs 51.65%, p = 0.01). Univariate and multivariate Cox regression analyses confirmed that fecal calprotectin ≥ 250 µg/g, Montreal classification E3, CMV colitis, duration > 48 months, and serum albumin < 30 g/L were independent risk factors for UC relapse at 2 years, whereas the use of biologics for induction of remission was identified as an independent protective factor.

Conclusion

Our study suggests that the risk of relapse increases among UC patients with CMV colitis over two years. Risk factors for UC relapse at 2 years include fecal calprotectin ≥ 250 μg/g, Montreal classification E3, CMV colitis, UC duration > 48 months, and albumin < 30 g/L, whereas the use of biologics during induction is a protective factor.

Adjunct Therapies to Standard Care for IBS and IBD Patients: Digestive Symptoms Improvement and Quality of Life Optimization

Background: The prevalence of both inflammatory bowel diseases (IBD) and Irritable Bowel Syndrome (IBS) is increasing, with persistent digestive symptoms, an altered quality of life, and higher rates of anxiety, chronic fatigue, and sleep trouble than the general population. Methods: This scoping review will analyze the latest clinical practice recommendations and clinical studies on non-pharmaceutical interventions such as diet adaptations, physical activity, cognitive behavioral therapies, and medical nutrition therapies such as probiotics, soluble fibers, chitin-glucan, and micronutrients for digestive symptoms relief, quality of life improvement and nutritional deficiencies correction in IBS and IBD patients. The objective is to help healthcare practitioners and dietitians to build personalized care program for IBD and IBS patients. Results: Mediterranean diet, physical activity, cognitive behavioral therapies and medical nutrition therapies such as selected probiotics, soluble fibers, chitin glucan, peppermint oil and micronutrients are effective as adjunct therapies. Conclusions: These adjunct therapies may help to reduce persistent digestive symptoms, correct nutritional deficiencies and improve quality of life of IBS and IBD patients.

Designing a simple and efficient phage biocontainment system using the amber suppressor initiator tRNA

Multidrug-resistant infections are becoming increasingly prevalent worldwide. One of the fastest-emerging alternative and adjuvant therapies being proposed is phage therapy. Naturally isolated phages are used in the vast majority of phage therapy treatments today. Engineered phages are being developed to enhance the effectiveness of phage therapy, but concerns over their potential escape remain a salient issue. To address this problem, we designed a biocontained phage system based on conditional replication using amber stop codon suppression. This system can be easily installed on any natural phage with a known genome sequence. To test the system, we individually mutated the start codons of three essential capsid genes in phage φX174 to the amber stop codon (UAG). These phages were able to efficiently infect host cells expressing the amber initiator tRNA, which suppresses the amber stop codon and initiates translation at TAG stop codons. The amber phage mutants were also able to successfully infect host cells and reduce their population on solid agar and liquid culture but could not produce infectious particles in the absence of the amber initiator tRNA or complementing capsid gene. We did not detect any growth-inhibiting effects on E. coli strains known to lack a receptor for φX174 and we showed that engineered phages have a limited propensity for reversion. The approach outlined here may be useful to control engineered phage replication in both the lab and clinic.

Corticosteroids in critically ill patients with community-acquired pneumonia: A systematic review and Bayesian meta-analysis

Introduction

This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of adjunct systemic corticosteroid therapy in patients admitted to the intensive care unit (ICU) with bacterial community-acquired pneumonia (CAP).

Method

We searched MEDLINE, Embase and the Cochrane Library to identify randomised controlled trials (RCTs) published from the databases' inception to February 2024. All RCTs evaluating the effect of systemic corticosteroids on mortality, compared to standard of care among adult bacterial CAP patients admitted to ICU were included. Bayesian meta-analysis was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Independent authors reviewed each study for eligibility, extracted data and assessed risk of bias in duplicate, with discrepancies referred to senior reviewers.

Results

A total of 6 RCTs comprising 1585 patients were included for analysis. In ICU patients with severe CAP who were treated with corticosteroids, there was no significant reduction in hospital mortality (risk ratio [RR] 0.70, 95% confidence interval [CI] 0.39-1.14, certainty of evidence: ⊕⊕⊝⊝ low) or all-cause mortality (RR 0.68, 95% CI 0.34-1.22, ⊕⊕⊝⊝ low) compared with placebo. The use of corticosteroids showed a significant reduction in mechanical ventilation post-intervention (RR 0.58, 95% CI 0.37-0.86, ⊕⊕⊕⊕ high) compared with placebo. In a subgroup analysis of patients treated with hydrocortisone, hospital mortality was significantly reduced (RR 0.45, 95% CI 0.20-0.88, ⊕⊕⊝⊝ low) compared with placebo. There was no significant increase in gastrointestinal bleeding, secondary infections or hyperglycaemia in patients treated with corticosteroids.

Conclusion

Corticosteroids significantly reduced mechanical ventilation requirements, and hydrocor-tisone significantly reduced hospital mortality. Further work is required to determine whether other corticosteroids reduce mortality among ICU patients with CAP.

Epigenetic modulation of NLRP6 inflammasome sensor as a therapeutic modality to reduce necroptosis-driven gastrointestinal mucosal dysfunction in HIV/SIV infection

The epigenetic mechanisms driving persistent gastrointestinal mucosal dysfunction in HIV/SIV infection is an understudied topic. Using reduced-representation bisulfite sequencing, we identified HIV/SIV infection in combination anti-retroviral therapy (cART)-naive rhesus macaques (RMs) to induce marked hypomethylation throughout promoter-associated CpG islands (paCGIs) in genes related to inflammatory response ( NLRP6, cGAS ), cellular adhesion and proliferation in colonic epithelial cells (CEs). Moreover, low-dose delta-9-tetrahydrocannabinol (THC) administration reduced NLRP6 protein expression in CE by hypermethylating the NLRP6 paCGI and blocked polyI:C induced NLRP6 upregulation in vitro. In cART suppressed SIV-infected RMs, NLRP6 protein upregulation associated with significantly increased expression of necroptosis-driving proteins; phosphorylated-RIPK3(Ser199), phosphorylated-MLKL(Thr357/Ser358), and HMGB1. Most strikingly, supplementing cART with THC effectively reduced NLRP6 and necroptosis-driving protein expression to pre-infection levels. These findings for the first time demonstrate that NLRP6 upregulation and ensuing activation of necroptosis promote HIV/SIV-induced gastrointestinal mucosal dysfunction and that epigenetic modulation using phytocannabinoids represents a feasible therapeutic modality for alleviating HIV/SIV-induced gastrointestinal inflammation and associated comorbidities.

Acidic polymers reversibly deactivate phages due to pH changes

Bacteriophages are promising as therapeutics and biotechnological tools, but they also present a problem for routine and commercial bacterial cultures, where contamination must be avoided. Poly(carboxylic acids) have been reported to inhibit phages' ability to infect their bacterial hosts and hence offer an exciting route to discover additives to prevent infection. Their mechanism and limitations have not been explored. Here, we report the role of pH in inactivating phages to determine if the polymers are unique or simply acidic. It is shown that lower pH (=3) triggered by either acidic polymers or similar changes in pH using HCl lead to inhibition. There is no inhibitory activity at higher pHs (in growth media). This was shown across a panel of phages and different molecular weights of commercial and controlled-radical polymerization-derived poly(acrylic acid)s. It is shown that poly(acrylic acid) leads to reversible deactivation of phage, but when the pH is adjusted using HCl alone the phage is irreversibly deactivated. Further experiments using metal binders ruled out ion depletion as the mode of action. These results show that polymeric phage inhibitors may work by unique mechanisms of action and that pH alone cannot explain the observed effects whilst also placing constraints on the practical utility of poly(acrylic acid).

The Use of Osteogenon as an Adjunctive Treatment in Lower Leg Fractures

Background: The goal of the orthopedic treatment of fractures is to achieve bone union as rapidly as possible in the largest possible number of patients and to minimize the number of complications. The purpose of this study was to assess if the use of Osteogenon would have a positive effect on radiological and clinical parameters in patients with lower leg bone fractures treated with the Ilizarov method. Methods: We evaluated 26 patients who had their lower leg bone fractures treated with the Ilizarov method and received Osteogenon at our clinic in the years 2021-2023. The control group comprised 25 patients with lower leg bone fractures treated with the Ilizarov method who did not receive Osteogenon. We assessed the following parameters: time to achieving bone union, bone union rate, time to resuming normal physical activity, time to achieving pain relief, the number of patients reporting pain relief, and the rate of complications. Results: The median time to achieve bone union after lower leg bone fracture treated with the Ilizarov method was shorter in the Osteogenon group (108.5 days) compared to the control group (134 days), p < 0.001. Bone union was achieved in all the patients in the Osteogenon group and in 96% of the patients in the control group; the difference was not statistically significant. The median time to resuming normal physical activity was shorter in the Osteogenon group (22.5 weeks) compared to the control group (27 weeks), p < 0.001. The median time to achieving pain relief was shorter in the Osteogenon group (21 weeks) compared to the control group (30 weeks), p < 0.001. The proportion of patients who reported pain relief was 88.46% in the group receiving Osteogenon and 76% in the control group; this difference was not statistically significant. The number of complications was lower in the Osteogenon group (8 patients; 30.77%) compared to the control group (15 patients; 60%), p = 0.035. Conclusions: The use of Osteogenon has a beneficial impact on the treatment of lower leg bone fractures with the Ilizarov method. Osteogenon shortens the time to achieve bone union. Moreover, the use of the ossein-hydroxyapatite complex helps reduce the number of complications and shortens the time to achieve pain relief and to resume normal activities.

Lactobacillus helveticus HY7801 Improves Premenstrual Syndrome Symptoms by Regulating Sex Hormones and Inflammatory Cytokines in a Mouse Model of Metoclopramide-Induced Hyperprolactinemia

BACKGROUND/OBJECTIVES

Premenstrual syndrome (PMS), a clinical condition that manifests in the form of various physical and psychological symptoms, occurs periodically during the luteal phase of the menstrual cycle and reduces quality of life.

METHODS

Here, we conducted in vitro and in vivo experiments to investigate the effects of Lactobacillus helveticus HY7801 (HY7801) on PMS symptoms.

RESULTS

Data from the in vitro experiments showed that HY7801 inhibits prolactin secretion by estradiol-induced GH3 cells, as well as the secretion of pro-inflammatory cytokines by LPS-induced Raw 264.7 cells. Additionally, the oral administration of HY7801 (109 colony-forming units/kg/day) to mice with metoclopramide-induced hyperprolactinemia reduced uterine tissue mass and endometrial thickness, both of which were increased excessively in the presence of prolactin. HY7801 also regulated the serum levels of follicle-stimulating hormone and prostaglandin E1/E2, as well as recovering the progesterone/estradiol ratio. HY7801 also downregulated the serum levels of prolactin and pro-inflammatory cytokines such as interleukin (Il)-6, tumor necrosis factor-alpha (Tnf), and IL-1β. Finally, HY7801 reduced the expression of genes encoding inflammatory cytokines (i.e., Tnf and Il-6), cyclooxygenase-2 (Cox-2), and inducible nitric oxide synthase (iNOS) in mice with hyperprolactinemia.

CONCLUSION

In summary, HY7801 may be a functional bacterium that alleviates PMS symptoms by modulating hormones and inflammatory markers.

IEPA, a novel radiation countermeasure, alleviates acute radiation syndrome in rodents

Repurposing therapeutic agents with existing clinical data is a common strategy for developing radiation countermeasures. IEPA (imidazolyl ethanamide pentandioic acid) is an orally bioavailable small molecule pseudopeptide with myeloprotective properties, a good clinical safety profile, and stable chemical characteristics facilitating stockpiling. Here, we evaluated IEPA's radiomitigative efficacy in the hematopoietic subsyndrome of acute radiation syndrome (H-ARS) using total-body irradiation (TBI) models in C57BL/6J mice and WAG/RijCmcr rats, applying various posology schemes and introducing syringe feeding of the IEPA formulation in the pudding. Additionally, we assessed IEPA in the delayed effects of acute radiation exposure (DEARE) model after partial-body irradiation (PBI) in WAG/RijCmcr rats. Endpoints included survival, body weight, hematology, and pulmonary parameters, depending on the model. Results from mouse and rat TBI models demonstrated survival improvements with repeated IEPA dosing at 10 mg/kg, with the largest benefits observed in the bi-daily (BID) treatment over the 30-day ARS phase in female rats. Survival across PBI-DEARE subsyndromes was comparable between IEPA and vehicle groups, though IEPA improved pulmonary parameters in female rats during the lung-DEARE phase. Sex-related differences in response to irradiation and IEPA were noted, with females showing a survival advantage. IEPA treatment is compatible with Neulasta® (Pegfilgrastim; PEG-G-CSF); adequately powered studies are needed to confirm the trend toward improved survival over standard care alone. IEPA is a promising development candidate as a medical countermeasure against the effects of acute radiation syndrome. Further confirmatory studies in small and large animal models should validate the robustness and translatability of preliminary rodent data on IEPA's radiomitigative efficacy.

Myosteatosis Evaluated Based on Intramuscular Adipose Tissue Content Is a Risk Factor for Postoperative Complications in Crohn's Disease

BACKGROUND

Crohn's disease causes acute and chronic inflammation that often make the preoperative evaluation of surgical risks difficult. Myosteatosis is used for the evaluation of muscle quality to assess sarcopenia. However, data on the relationship between myosteatosis and surgical outcomes in patients with Crohn's disease are lacking.

METHODS

Among patients with Crohn's disease who underwent surgery between 2007 and 2022, we investigated the impact of myosteatosis on postoperative complications using intramuscular adipose tissue content (IMAC). Our study included data from 97 patients who underwent analysis for cutoff values and factors associated with IMAC and 72 who underwent analysis for risk factors of postoperative complications.

RESULTS

Body mass index (BMI; P < .001) and visceral adipose tissue/height index (P < .001) were significantly correlated with IMAC. High BMI (P < .001) and a history of abdominal surgery for Crohn's disease (P = .012) were identified as factors affected with high IMAC. Multivariate analysis revealed high IMAC and external fistulas as independent risk factors for postoperative complications (odds ratio [OR], 5.010; 95% CI, 1.300-19.30; P = .019 and OR, 7.850; 95% CI, 1.640-37.50; P = .010, respectively), especially infectious complications.

CONCLUSIONS

This study established IMAC as a valuable marker for sarcopenic obesity and predicting postoperative complications in patients with Crohn's disease. Furthermore, evaluating myosteatosis using IMAC will facilitate the decision of the optimal timing of surgery, prediction of complications, and treatment of sarcopenia in patients with Crohn's disease.

Low Rates of Diagnosis and Treatment of Iron Deficiency Anemia After an Acute Severe Gastrointestinal Hemorrhage

Background

Few studies report about management of iron deficiency anemia after a severe, acute gastrointestinal bleed. Most include good risk patients with upper gastrointestinal bleeds and report only laboratory improvements but not clinical outcomes.

Aims

To assess management of iron deficiency anemia and clinical outcomes of patients after a severe, acute gastrointestinal bleed from either upper or lower sources in an unselected group of patients.

Methods

Retrospective analysis of adult patients hospitalized with severe gastrointestinal bleeding in two referral centers. They had endoscopic diagnoses of lesions including non-variceal upper, variceal, and lower sites (diverticulosis or other colon sources). Analyses were of rates of iron studies ordered and iron treatments up to 4 months post discharge. Composite clinical outcomes were also assessed and analyzed.

Results

For 337 patients studied, iron studies were ordered in only 50%. When tested, iron deficiency was diagnosed in 75% of anemias. Intravenous iron or oral iron was prescribed in only 7.1% and 26.7% of patients respectively. By 4 months, 94% of patients treated with intravenous iron and 80% treated with oral iron achieved ≥ 2 g/dL increase in hemoglobin level. Patients with high rates of severe comorbidities and severe anemia had poorer clinical outcomes than others with severe anemia and less comorbidity.

Conclusions

Despite significant anemia after a severe gastrointestinal bleed from common diagnoses, iron studies were not routinely ordered. Iron deficiency anemia was infrequently recognized or treated with iron therapies. Patients with severe co-morbidities and anemia after an acute gastrointestinal bleed had poor clinical outcomes.

Meeting report of the seventh annual Tri-Service Microbiome Consortium Symposium

The Tri-Service Microbiome Consortium (TSMC) was founded to enhance collaboration, coordination, and communication of microbiome research among DoD organizations and to facilitate resource, material and information sharing among consortium members, which includes collaborators in academia and industry. The 2023 annual symposium was a hybrid meeting held in Washington DC on 26-27 September 2023 concurrent with the virtual attendance, with oral and poster presentations and discussions centered on microbiome-related topics within five broad thematic areas: 1) Environmental Microbiome Characterization; 2) Microbiome Analysis; 3) Human Microbiome Characterization; 4) Microbiome Engineering; and 5) In Vitro and In Vivo Microbiome Models. Collectively, the symposium provided an update on the scope of current DoD and DoD-affiliated microbiome research efforts and fostered collaborative opportunities. This report summarizes the presentations and outcomes of the 7th annual TSMC symposium.

Normalization of Cystic Fibrosis Immune System Reverses Intestinal Neutrophilic Inflammation and Significantly Improves the Survival of Cystic Fibrosis Mice

BACKGROUND & AIMS

Cystic fibrosis (CF) is an autosomal recessive genetic disorder, affecting multiple organ systems. CF intestinal disease develops early, manifesting as intestinal bacterial overgrowth/dysbiosis, neutrophilic inflammation, and obstruction. As unresolvable infection and inflammation reflect host immune deficiency, we sought to determine if the CF-affected immune system plays any significant role in CF intestinal disease pathogenesis.

METHODS

CF and sibling wild-type (WT) mice underwent reciprocal bone marrow transplantation. After immune reconstitution, their mortality, intestinal transit, fecal inflammatory markers, and mucosal immune cell composition were assessed. Moreover, reciprocal neutrophil transfusion was conducted to determine if neutrophil function affects intestinal movement. Furthermore, expression of induced nitric oxide synthase (iNOS) and production of nitric oxide (NO) in CF and WT neutrophils were compared. Lastly, specific iNOS inhibitor 1400W was tested to prevent CF intestinal obstruction.

RESULTS

Immune restoration in CF mice reversed the intestinal neutrophilic inflammation, improved the intestinal dysmotility, and rescued the mice from mortality. Transfusion of WT neutrophils into CF mice ameliorated the retarded bowel movement. CF neutrophils expressed significantly more iNOS and produced significantly more NO. Pharmaceutical blocking of iNOS significantly improved intestinal transit and survival of CF mice.

CONCLUSIONS

CF immune defect plays a critical role in CF intestinal disease development. Activation of iNOS in inflammatory cells produces excessive NO, slows the bowel movement, and facilitates intestinal paralysis and obstruction in CF. Thus, normalization of the CF immune system may offer a novel therapy to treat CF intestinal disease.

Biological Characterization and Evaluation of the Therapeutic Value of Vibrio Phages 4141 and MJW Isolated from Clinical and Sewage Water Samples of Kolkata

The growing prevalence of antimicrobial resistance (AMR) necessitates the development of new treatment methods to combat diseases like cholera. Lytic bacteriophages are viruses that specifically target and lyse bacteria upon infection, making them a possible treatment option for multi-drug-resistant pathogens. The current study investigated the potential role of bacteriophages isolated from clinical stool and sewage water samples in treating multi-drug-resistant Vibrio cholerae infection, finding that over 95% of the strains were susceptible. Whole-genome sequencing (WGS) analysis revealed that both Vibrio phage 4141 (4141) and Vibrio phage MJW (MJW) contain double-stranded DNA genomes consisting of 38,498 bp (43% GC) and 49,880 bp (42.5% GC) with 46 and 64 open reading frames (ORFs), respectively. Transmission electron microscope (TEM) and WGS analysis of Vibrio phage 4141 and Vibrio phage MJW validated that they are classified under the family Autographiviridae and Zobellviridae, respectively. Furthermore, both the phages showed highly significant biofilm degradation properties. The characterization of the phages and their strict host range, high spectrum of lytic ability, high efficiency of biofilm degradation, and close genetic similarity to the therapeutic phages indicates that these phages may be useful for therapeutic purposes for treating MDR V. cholerae infection in the future.

Changes in clinical features and seasonal variations of Crohn's disease at diagnosis: a 10-year observational study in China

Background and aims

The clinical aspects of Crohn's disease (CD) at diagnosis determine its therapy and management. The onset of CD follows a seasonal pattern. We aimed to analyze changes in the clinical features and seasonal variations of newly CD patients over the last decade.

Methods

CD patients were divided into cohort 1 (2012-2016) and cohort 2 (2017-2021). The clinical characteristics were collected and the trends according to the year and season of diagnosis were analyzed.

Results

A total of 2038 patients were included. Cohort 1 had a considerably greater proportion of diarrhea, fever, hematochezia, weight loss and extraintestinal manifestations. The levels of platelet and C-reactive protein were higher in cohort 2 patients, but the opposite was true for albumin levels (p<0.05). The rate of increased eosinophils, increased gangliocyte and abundant lymphoplasmacytic infiltrate significantly decreased over the years. Patients with granulomas were diagnosed with CD at an earlier age (p = 0.006). Cohort 1 patients used more conventional drugs, while cohort 2 patients apply more biologics (p<0.05). The diagnosis occurred more frequently in summer and less frequently in winter. Patients diagnosed in winter had notably higher BMI, lower frequency of perianal disease and lowest incidence of asthenia and weight loss.

Conclusion

The clinical phenotype, laboratory and pathological characteristics of CD has changed over time in China. The diagnosis of CD tends to have a seasonal trend with the highest incidence in summer. CD patients diagnosed in winter appear to have a milder form of the disease.

Treat-to-Target in Inflammatory Bowel Disease: An Updated Survey of Treatment Strategies among Portuguese Gastroenterologists

Background: In 2018, the authors surveyed the clinical practices among Portuguese gastroenterologists (PGEs) regarding treatment targets in Crohn’s disease (CD) and ulcerative colitis (UC). Since then, new evidence has emerged supporting additional targets, such as transmural remission and histological remission. This study provides an updated assessment of treatment practices among PGE with special emphasis on these new targets. Methods: Using the Portuguese Inflammatory bowel disease Study Group (GEDII) physician database, we invited PGE to participate in an anonymous online survey. Results: Fifty-six physicians agreed to participate in the study. Deep remission, steroid-free clinical remission, endoscopic remission, and biomarker remission were ranked among the most important treatment targets in CD (89%, 80%, 89%, and 84%, respectively) and UC (82%, 84%, 79%, and 84%, respectively). In CD, transmural remission was considered a target by 70% of participants, with 48% agreeing to intensify treatment to achieve it. In UC, histological remission was aimed by only 45% of PGE with most (88%) being unwilling to intensify treatment to achieve this goal. Physicians were more likely to seek endoscopic remission in CD and UC in younger and healthier patients, compared to older patients with comorbidities. Conclusion: PGEs are increasingly pursuing tougher treatment targets such as transmural remission in CD and, to a lesser extent, histological remission in UC. Physicians are more willing to escalate treatment to achieve endoscopic remission in younger patients.

Acute pancreatitis following asparaginase treatment in pediatric acute lymphoblastic leukemia with a heterozygous SPINK1 c.194 + 2T>C intronic variant: a case report

Background

Asparaginase is a critical component of chemotherapy for pediatric acute lymphoblastic leukemia (ALL), but its use is often complicated by asparaginase-associated pancreatitis (AAP). Genetic predispositions, such as variants in the SPINK1 gene, have been linked to an increased risk of pancreatitis. However, the role of genetic factors in relation to asparaginase treatment remains incompletely understood, partly because mutations in pancreatitis-causing genes are rarely found in pediatric ALL.

Case description

A four-year and three-month-old Chinese girl was admitted to our hospital due to fever for half a day, with no history of significant prior medical history. Initial blood tests revealed hematological abnormalities, including leukopenia, anemia, and thrombocytosis. Bone marrow aspiration identified 81.5% blast cells with B-lymphocyte morphology and immunophenotype, leading to a diagnosis of B-cell acute lymphoblastic leukemia (B-ALL). The patient began treatment under the CCCG-ALL-2015 protocol, which included PEG-asparaginase (PEG-asp). On day 10 of induction, she developed AAP, which was primarily characterized by severe epigastric pain and elevated serum amylase. Despite effective symptom management with analgesics and anti-inflammatory therapy, AAP recurred following administration of L-asparaginase (L-asp). Genetic analysis revealed a heterozygous SPINK1 c.194 + 2T>C variant (rs148954387), a well-known pathogenic variant associated with increased susceptibility to pancreatitis. Sanger sequencing confirmed that the SPINK1 variant was inherited from her asymptomatic mother. The patient's AAP was managed conservatively, and an asparaginase-free regimen ultimately achieved complete remission without recurrence of pancreatitis.

Conclusions

The identification of the SPINK1 c.194 + 2T>C variant, which is recognized as pathogenic, provides valuable information for understanding the heightened risk of AAP in our pediatric ALL patient. Our case underscores the potential role of genetic predisposition in the development of AAP and highlights the importance of considering genetic screening prior to asparaginase therapy in pediatric ALL patients to identify those at increased risk.

Assessment of resistance to colicinogenic synthetic phage antimicrobial system

This work presents a multi-hurdle approach that addresses antimicrobial resistance by minimizing the selective pressure of antimicrobials using a novel colicinogenic-phage system. We have created two synthetic T7 phages (T7-E1 and T7-M) by inserting the gene of colicin E1 (Cea) or colicin M (Cma) into the genome of the T7 phage, thereby adding an additional colicin-based hurdle to the T7 lytic cycle. The colicin-phages' efficacy in suppressing the outgrowth of a T7-resistant sub-population within a mixed culture of Escherichia coli was demonstrated using a challenge matrix design under planktonic and structured conditions. When T7-resistant cells were present at 1% of the total planktonic population, T7-E1 delayed the outgrowth. At 0.1% resistance, T7-M delayed resistant outgrowth, whereas T7-E1 suppressed the resistant sub-population. When T7-E1 and T7-M were combined into a triple-hurdle treatment, the T7-E1/T7-M cocktail completely suppressed a mixed planktonic population of 50% resistance cell concentrations. In structured environments, the colicin-phage treatments formed clear and confluent plaque-like zones of clearing in the mixed populations of 50% resistant cells with a lawn density of 1 × 106 CFU/mL. Reducing the lawn density to 1 × 105 CFU/mL diminished the multi-hurdle treatments' effectiveness, as demonstrated by localized zones of clearing within turbid bacterial lawns, highlighting the relationship between bacterial lawn density and phage effectiveness in structured environments. Fluctuation assays revealed persistence as the predominant mechanism for overcoming the treatments by T7-sensitive E. coli. Results indicate that T7-M treatment significantly reduces persister formation compared to WT-T7, while T7-E1 unexpectedly increases persister formation significantly. This suggests a complex relationship between antimicrobial stress and persister formation.

IMPORTANCE

Antimicrobial resistance (AMR) poses a significant challenge in treating bacterial infections. To address this, we present a multi-hurdle approach that combines the power of different antimicrobials to target resistance. We have weaponized the natural predator of Escherichia coli, the T7-phage, by engineering it to produce toxins called colicins, resulting in a colicin-phage antimicrobial. This multi-hurdled approach aims to decrease resistance risk because survival requires different tactics to overcome the phage and colicin activity, thus adding a hurdle in a bacterium's pathway to resistance. In cases of pre-existing resistance, the colicin effectively controlled the sub-population resistant to the phage. When investigating the emergence of resistance, we discovered that antimicrobial persistence was the predominant survival strategy. These findings reveal an essential slice of the AMR pie by emphasizing bacterial survival tactics that are not based on resistance genes. By expanding our AMR lens to include persistence, we can more effectively address treatment failure.

The impact of lactose intolerance diagnosis: costs, timing, and quality-of-life

Lactose intolerance (LI) is a very common condition but, despite many efforts of the Italian National Health Service to reduce diagnostic delay of chronic disorders and provide prompt treatments, its early diagnosis remains an unmet need. In addition, the COVID-19 pandemic has exacerbated this problem, due to the conversion of many public health services to COVID centers. This study aims to analyze the diagnostic journey of patients suffering from LI, taking into account the duration of the process, associated costs, and impact on quality of life. Anonymous surveys were designed and distributed to patients with LI as well as physicians involved in LI management. The data were analyzed to determine the time required for a reliable LI diagnosis and average costs. Diagnostic delay of LI proved to be longer than 2 years, its impact on quality of life proved to be moderate to high in most of participants, especially in their psychosocial domain, and average costs proved to be high. Further investigations are needed to determine the economic burden of maintaining an asymptomatic status in patients with LI.

Melatonin regulates endoplasmic reticulum stress in diverse pathophysiological contexts: A comprehensive mechanistic review

The endoplasmic reticulum (ER) is crucial for protein quality control, and disruptions in its function can lead to various diseases. ER stress triggers an adaptive response called the unfolded protein response (UPR), which can either restore cellular homeostasis or induce cell death. Melatonin, a safe and multifunctional compound, shows promise in controlling ER stress and could be a valuable therapeutic agent for managing the UPR. By regulating ER and mitochondrial functions, melatonin helps maintain cellular homeostasis via reduction of oxidative stress, inflammation, and apoptosis. Melatonin can directly or indirectly interfere with ER-associated sensors and downstream targets of the UPR, impacting cell death, autophagy, inflammation, molecular repair, among others. Crucially, this review explores the mechanistic role of melatonin on ER stress in various diseases including liver damage, neurodegeneration, reproductive disorders, pulmonary disease, cardiomyopathy, insulin resistance, renal dysfunction, and cancer. Interestingly, while it alleviates the burden of ER stress in most pathological contexts, it can paradoxically stimulate ER stress in cancer cells, highlighting its intricate involvement in cellular homeostasis. With numerous successful studies using in vivo and in vitro models, the continuation of clinical trials is imperative to fully explore melatonin's therapeutic potential in these conditions.

Therapeutic Phage Candidates for Targeting Prevalent Sequence Types of Carbapenem-Resistant Escherichia coli

Carbapenem-resistant Escherichia coli (CREC) is a global threat to public health; therefore, alternative treatment options are urgently needed. Bacteriophages have emerged as promising candidates for combating CREC infections. This study aimed to investigate the genetic basis of phage sensitivity in CREC by evaluating carbapenem resistance among multidrug-resistant (MDR) E. coli isolated in Daegu, South Korea and analyzing their sequence types (STs) with phage susceptibility spectra. Among the 60 MDR E. coli isolates, 80.4% were identified as CREC, with 77.0% demonstrating resistance to imipenem and 66.6% to meropenem. Moreover, 70 lytic E. coli bacteriophages were isolated from hospital sewage water and evaluated against those 60 E. coli isolates. The phages exhibited lytic activity of 33%-60%, with average titers ranging from 5.6 × 1012 to 2.4 × 1013 PFU/mL (Plaque-Forming Unit). Furthermore, multilocus sequence typing (MLST) analysis of the bacterial isolates revealed 14 distinct STs, mostly belonging to ST131, ST410, and ST648. Notably, the phage susceptibility spectra of ST73, ST13003, ST648, ST2311, ST167, ST405, ST607, ST7962, and ST131 were significantly different. Thus, the isolated phages can effectively lyse CREC isolates, particularly those with clinically dominant STs. Conversely, ST410 exhibited a 14.2%-87.14% susceptibility spectrum, whereas ST1139, ST1487, ST10, and ST206 did not lyse, suggesting the presence of more resistant STs. Future studies are warranted to identify the reasons behind this resistance and address it. Ultimately, this study will aid in developing focused treatments to address these pressing global health issues.

Phage therapy: A primer for orthopaedic trauma surgeons

Phage therapy (PT) continues to attract interest in the fight against fracture-related infection (FRI), particularly for recurring infections that have not been resolved using conventional therapeutic approaches. The journey PT has taken from early clinical application in the pre-antibiotic era to its recent reintroduction to western clinical practice has been accelerated by the increased prevalence of multi-drug resistant (MDR) pathogens in the clinic. This review will present PT's potential as a precise, adaptable, and effective treatment modality, with a focus on patient and phage selection, as well as the various administration protocols currently applied to patients. The challenges for PT, for example the most optimal application technique and dosing, are also discussed and underscore the importance of personalized approaches and the urgent need for more robust clinical evidence. Future perspectives, including phage engineering and innovative delivery systems will be discussed, as they may broaden the applicability of PT to a point where it may become a standard rather than an option of last resort for orthopedic infection management.

Soy lysolecithin prevents hypertension and cognitive impairment induced in mice by high salt intake by inhibiting intestinal inflammation

High salt (HS) intake induces hypertension and cognitive impairment. Preventive strategies include against dietary supplements. Soybean lecithin is a widely used phospholipid supplement. Lysolecithin is important in cell signaling, digestion, and absorption. This study aimed to investigate the effects of lysophosphatidylcholine containing >70% of the total phospholipids (LPC70), on hypertension and cognitive impairment induced in mice by HS intake. Mice were provided with HS solution (2% NaCl in drinking water) with or without LPC70 for 12 weeks. Blood pressure, cognitive function, and inflammatory response of intestine were determined. Hypertension and impaired object recognition memory induced by HS intake were implicated with increased inducible nitric oxide synthase in the small intestine and tau hyperphosphorylation in the prefrontal cortex. LPC70 treatment prevented cognitive impairment by suppressing inducible nitric oxide synthase and tau hyperphosphorylation. LPC70 may be valuable as a functional food component in preventing HS-induced cognitive impairment.

Predicting Severity of Acute Pancreatitis-Evaluation of Neutrophil-to-Lymphocyte Count Ratio as Emerging Biomarker: A Retrospective Analytical Study

Introduction Acute pancreatitis (AP) is a pancreatic inflammatory disease that can range in severity from mild, self-limiting forms to severe cases with high mortality rates. AP has various etiologies, including lifestyle factors like alcohol consumption and obesity, and its rapid progression makes early and accurate prediction of severity critical for effective management and improved patient outcomes. The traditional AP severity assessment tools, such as Ranson's criteria and APACHE II, require extensive data and time, making them less feasible in emergency settings. In response, simpler biomarkers that can quickly predict AP severity upon patient presentation are needed to enable early risk stratification and targeted interventions. The study aims to address this research gap by evaluating the neutrophil-to-lymphocyte ratio (NLR) as a potential biomarker for predicting AP severity, as well as assessing its correlation with the CT Severity Index, a widely used measure of AP severity. Methods The study used a retrospective analytical design, conducted at the R L Jalappa Hospital & Research Centre in Karnataka, India. The researchers included 118 patients diagnosed with acute pancreatitis (AP) according to the Revised Atlanta Classification. The dataset collected from the participants' medical records included variables such as age, gender, history of alcohol and tobacco use, duration of abdominal pain, ICU stay, CT Severity Index scores, and the neutrophil-to-lymphocyte ratio (NLR). Statistical analysis was performed using SPSS software version 21.0 (IBM Corp., Armonk, NY, USA). A p-value of less than 0.05 was considered statistically significant. This comprehensive methodological approach aimed to provide precise insights into the role of NLR in predicting AP severity while accounting for variability in patient data. Results The study included 118 patients, with 85 classified as having mild to moderate pancreatitis and 33 with severe pancreatitis. There were no significant differences between the two groups in terms of demographic factors such as gender, BMI, alcohol use, smoking, and comorbidities. The study also examined the relationship between the neutrophil-to-lymphocyte ratio (NLR) and the CT Severity Index, a measure of pancreatitis severity. The results showed a strong positive correlation between NLR and the CT Severity Index (r = 0.860, p < 0.001). This indicates that higher NLR values are associated with more severe pancreatitis, as measured by the CT Severity Index. These relationships suggest that NLR reflects the inflammatory response in acute pancreatitis, with higher levels of inflammatory markers associated with elevated NLR values. Conclusion This study aimed to evaluate the neutrophil-to-lymphocyte ratio (NLR) as a biomarker for predicting the severity of acute pancreatitis (AP). We conducted a retrospective analysis of 118 AP patients, categorizing them into mild-to-moderate and severe groups. NLR was significantly higher in the severe AP group compared to the mild-to-moderate group, suggesting its potential as an early predictor of AP severity. The study also examined the correlation between NLR and the CT Severity Index, a widely used measure of AP severity, further supporting the utility of NLR as a rapid and accessible tool for risk stratification in AP management.

Persistent Risk of Pulmonary Embolism in Acute Pancreatitis Despite Prophylactic Anticoagulation

Acute pancreatitis, a sudden inflammatory condition, can lead to a hypercoagulable state resulting in complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE). This case report discusses a unique presentation of a massive PE in a patient with acute pancreatitis despite being on appropriate prophylactic anticoagulation. A 27-year-old man presented with acute abdominal pain, nausea, and vomiting. He was diagnosed with diabetic ketoacidosis (DKA) and acute pancreatitis and admitted to the ICU. He was treated with prophylactic enoxaparin. On day 16, he experienced acute respiratory decompensation, and CT angiography revealed bilateral PEs, including a right main pulmonary artery saddle embolus. The patient underwent emergent thrombectomy with the immediate resolution of symptoms. He was transitioned to therapeutic heparin and later discharged on apixaban. A two-month follow-up showed no recurrence of PE. This case underscores the critical need to consider PE in patients with inflammatory conditions, even when on prophylactic anticoagulation. The hypercoagulable state induced by pancreatitis can overcome standard anticoagulation measures, leading to severe complications. Current guidelines may not adequately address the anticoagulation needs in such inflammatory states. Therefore, weight-based dosing of anticoagulants should be considered for patients with significant inflammation. This report highlights the necessity for vigilance in monitoring for PE in similar clinical scenarios to improve patient outcomes and inform future guidelines.

Microbes as medicine

Over the last two decades, advancements in sequencing technologies have significantly deepened our understanding of the human microbiome's complexity, leading to increased concerns about the detrimental effects of antibiotics on these intricate microbial ecosystems. Concurrently, the rise in antimicrobial resistance has intensified the focus on how beneficial microbes can be harnessed to treat diseases and improve health and offer potentially promising alternatives to traditional antibiotic treatments. Here, we provide a comprehensive overview of both established and emerging microbe-centric therapies, from probiotics to advanced microbial ecosystem therapeutics, examine the sophisticated ways in which microbes are used medicinally, and consider their impacts on microbiome homeostasis and health outcomes through a microbial ecology lens. In addition, we explore the concept of rewilding the human microbiome by reintroducing "missing microbes" from nonindustrialized societies and personalizing microbiome modulation to fit individual microbial profiles-highlighting several promising directions for future research. Ultimately, the advancements in sequencing technologies combined with innovative microbial therapies and personalized approaches herald a new era in medicine poised to address antibiotic resistance and improve health outcomes through targeted microbiome management.

Fu brick tea polysaccharides: A state-of-the-art mini-review on extraction, purification, characteristics, bioactivities and applications

Fu brick tea (FBT), a post-fermented dark tea, is highly esteemed for its abundant nutritional and medicinal values. Fu brick polysaccharides (FBTPs) are acidic heteropolysaccharides primarily composed of galactose and galacturonic acid, which are crucial components of FBT. FBTPs exhibit multiple bioactivities, including immunomodulatory, antioxidant, anti-inflammatory, regulatory effects on intestinal microbiota, anti-obesity, among others. Owing to their significant marketing potential and promising development prospects, FBTPs have attracted considerable attention from researchers worldwide. However, the specific mechanisms and underlying structure-function relationships of FBTPs are not well understood. Consequently, this review aims to provide comprehensive and cutting-edge information on the extraction, purification, structural characteristics, and biological activities of FBTPs, with an emphasis on exploring how their structural characteristics influence biological activities and therapeutic potential. We found that different materials and extraction techniques could result in differences in the structure-activity relationship of FBTPs. Furthermore, monosaccharide composition and molecular weight could also significantly impact the bioactivities of FBTPs, such as lipid-lowering effects and immunomodulatory activity. This review would further facilitate the applications of FBTPs as therapeutic agents and functional foods, thereby laying a solid foundation for their further development and utilization.

[Analysis of vocal fold movement and voice onset behavior in patients with laryngopharyngeal reflux based on high speed laryngeal high-speed videoendoscopy]

Objective:Patients with Laryngopharyngeal Reflux（LPR） have chronic inflammation of the laryngeal mucosa leading to a high response state in the larynx, which may make the vocal fold movement too fast. This paper discusses the characteristics of vocal fold movement and voice onset by analyzing laryngeal high-speed videoendoscopy in patients with LPR. Methods:Forty patients with LPR were enrolled as LPR group. The diagnostic criteria of LPR included positive reflux symptom index（RSI） and reflux syndrome score（RFS） to identify suspected LPR, objective oropharyngeal DX pH monitoring was carried out, and positive Ryan index indicated reflux. According to age and sex matching, 40 healthy volunteers were selected as the normal group. Laryngeal high-speed videoendoscopy, and the vocal fold motion and vibration parameters, including vocal fold adduction time, vocal fold abduction time, vocal fold vibration onset mode（vocal onset time and mode） and the opening quotient of vocal fold vibration cycle. Statistical analysis was performed using SPSS 25.0. Results:The time of vocal fold adduction in LPR group（mean 225.81ms） was less than that in normal group（mean 277.01 ms）, and the difference was statistically significant（P<0.05）. There was no significant difference in adduction time between LPR group and normal group（P>0.05）. The vocal onset time in LPR group was significantly longer than that in normal group（P<0.05）. High speed video endoscope showed that there were 17 patients with hard onset in LPR group and 8 patients with hard onset in normal group, the difference was statistically significant（P<0.05）. There was no significant difference in the open quotient of vocal fold vibration between LPR group and normal group（P>0.05）. The vocal fold abduction time in LPR group（mean 372.92 ms） was less than that in normal group（mean 426.98ms）, but the difference was not statistically significant（P>0.05）. The time difference of bilateral abduction of vocal fold in LPR group was significantly higher than that in normal group（P<0.05）. Conclusion:The larynx of LPR patients is in a high response state, the vocal fold moves faster, and it is more likely to have a hard vocal onset. These may result in voice dysfunction.

Disease-specific alterations in central fear network engagement during acquisition and extinction of conditioned interoceptive fear in inflammatory bowel disease

Interoceptive fear, which is shaped by associative threat learning and memory processes, plays a central role in abnormal interoception and psychiatric comorbidity in conditions of the gut-brain axis. Although animal and human studies support that acute inflammation induces brain alterations in the central fear network, mechanistic knowledge in patients with chronic inflammatory conditions remains sparse. We implemented a translational fear conditioning paradigm to elucidate central fear network reactivity in patients with quiescent inflammatory bowel disease (IBD), compared to patients with irritable bowel syndrome (IBS) and healthy controls (HC). Using functional magnetic resonance imaging, conditioned differential neural responses within regions of the fear network were analyzed during acquisition and extinction learning. In contrast to HC and IBS, IBD patients demonstrated distinctly altered engagement of key regions of the central fear network, including amygdala and hippocampus, during differential interoceptive fear learning, with more pronounced responses to conditioned safety relative to pain-predictive cues. Aberrant hippocampal responses correlated with chronic stress exclusively in IBD. During extinction, differential engagement was observed in IBD compared to IBS patients within amygdala, ventral anterior insula, and thalamus. No group differences were found in changes of cue valence as a behavioral measure of fear acquisition and extinction. Together, the disease-specific alterations in neural responses during interoceptive fear conditioning in quiescent IBD suggest persisting effects of recurring intestinal inflammation on central fear network reactivity. Given the crucial role of interoceptive fear in abnormal interoception, these findings point towards inflammation-related brain alterations as one trajectory to bodily symptom chronicity and psychiatric comorbidity. Patients with inflammatory conditions of the gut-brain axis may benefit from tailored treatment approaches targeting maladaptive interoceptive fear.

The incidence and risk factors of gastrointestinal dysfunction during enteral nutrition in mechanically ventilated critically ill patients

AIM

To assess the occurrence and risk factors of gastrointestinal (GI) dysfunction during enteral nutrition (EN) in critically ill patients supported with mechanical ventilation.

DESIGN

Prospective observational study.

METHODS

Totally 252 patients admitted at a mixed medical-surgical ICU were enrolled. GI symptoms and the potential risk variables were recorded during the first 14 days of EN.

RESULTS

The incidence of GI dysfunction was 65.5%, and the incidence of diarrhoea, constipation, abdominal distension, and upper GI intolerance was 28.2%, 18.3%, 6.7% and 12.3%, respectively. The median onset days of constipation, diarrhoea, abdominal distension and UDI was 3, 5, 5 and 6 days, respectively. Multivariable Cox regression analysis showed a significant relationship between GI dysfunction and age (HR = 2.321, 95% CI: 1.024-5.264, p = 0.004), APACHE-II score at ICU admission (HR = 7.523, 95% CI: 4.734-12.592, p = 0.018), serum albumin level (HR = 0.594, 95% CI: 0.218-0.889, p = 0.041), multidrug-resistant bacteria-positive culture (HR = 6.924, 95% CI: 4.612-10.276, p<0.001), negative fluid balance (HR = 0.725, 95% CI: 0.473-0.926, p = 0.037), use of vasopressor drugs (HR = 1.642, 95% CI: 1.297-3.178, p<0.001), EN way (HR = 6.312, 95% CI: 5.143-11.836, p<0.001), infusion rate (HR = 1.947, 95% CI: 1.135-3.339, p<0.001), and intra-abdominal hypertension (HR = 3.864, 95% CI: 2.360-5.839, p<0.001).

CONCLUSION

Critically ill patients supported with mechanical ventilation are at a high risk of GI dysfunction. Interventions such as the use of laxatives or prokinetic agents, control of EN infusion rate, and maintaining a normal state of hydration, might be beneficial for the prevention of GI dysfunction in critically ill patients.

PATIENT OR PUBLIC CONTRIBUTION

No.

Adherent-invasive Escherichia coli LF82 disrupts the tight junctions of Caco-2 monolayers

BACKGROUND AND STUDY AIMS

Adherent invasive Escherichia coli (AIEC) are enriched in IBD (inflammatory bowel disease) patients, but the role and mechanism of AIEC in the intestinal epithelial barrier is poorly defined. We evaluated the role of the AIEC strain E. coli LF82 in vitro and investigated the role of Th17 in this process.

MATERIAL AND METHODS

After coincubation with AIEC, the epithelial barrier integrity was monitored by epithelial resistance measurements. The permeability of the barrier was evaluated by TEER (trans-epithelial electrical resistance) and mucosal-to-serosal flux rate. The presence of interepithelial tight junction proteins ZO-1 and Claudin-1 were determined by immunofluorescence and western blot analysis. Cytokines in the cell culture supernatant were assayed by enzyme-linked immunosorbent assay (ELISA).

RESULTS

AIEC infection decreased TEER and increased the mucosal-to-serosal flux rate of Lucifer yellow in the intestinal barrier model in a time- and dose-dependent manner. AIEC infection decreased the expression and changed the distribution of ZO-1 and claudin-1. It also induced the secretion of cytokines such as TNF-α and IL-17.

CONCLUSION

AIEC strain E. coli LF82 increased the permeability and disrupted the tight junctions of the intestinal epithelial barrier, revealing that AIEC plays an aggravative role in the inflammatory response.

Surgical Versus Conservative Management of Delayed Presentation of Acute Biliary Disease: A Systematic Literature Review

Biliary sepsis, characterized by contamination and infection of the biliary tract, poses a serious medical issue with detrimental effects on the patients. While cholecystectomy is the usual treatment for symptomatic gallstones, the most desirable management approach for biliary sepsis remains debated, prompting a scientific evaluation of the long-term effects of cholecystectomy. To compare the long-term outcomes of biliary sepsis in patients undergoing cholecystectomy versus conservative management (CM), this study will systematically review the existing literature to clarify differences in recurrence rates, complication rates, and overall survival. PubMed and the Cochrane Library were searched thoroughly for the literature review. Studies were included if they reported the effects of surgical and conservative interventions on predefined patient outcomes. A critical appraisal of the studies included was performed using CASP criteria. Fourteen studies were included, comprising prospective cohort studies and randomized controlled trials, with sample sizes varying from 52 to 234 patients. Endoscopic sphincterotomy (ES), early versus delayed laparoscopic cholecystectomy (D-LC), combined endoscopic-laparoscopic techniques, and percutaneous cholecystostomy followed by early laparoscopic cholecystectomy (E-LC) were the analyzed interventions. The primary conclusions showed that, in comparison to D-LC, E-LC significantly reduced hospital stays (p < 0.05), since the times were 58 and 167 hours for E-LC and D-LC, respectively. Additionally, E-LC resulted in fewer recurrent biliary events (4.3 compared to 36.2% of D-LC) and lower overall costs. ES demonstrated efficacy in mitigating the requirement for emergency cholecystectomy in patients at high risk, as evidenced by its 94% success rate in endoscopic stone removal. Without increasing postoperative complications, combined endoscopic-laparoscopic techniques showed high success rates for stone removal (95.6% common bile duct clearance rate). This systematic review highlights the favorable long-term effects of cholecystectomy in managing biliary sepsis. It emphasizes the importance of individualized treatment processes and considers conservative control for patients with high surgical risk and significant comorbidities. It also highlights the need for advancement in CM and provides insights that can help clinical decision-making to optimize outcomes in affected patients.

Cilostazol protects against gastric ulcers by regulating PPAR-γ, HO-1, PECAM-1, pErk-1, NF-κB, Bcl-2, and cleaved caspase-3 protein expression

Millions of individuals worldwide, across all age groups, suffer from the widespread health issue of gastric ulcers. In many experiments, cilostazol (Cls), a phosphodiesterase-3 inhibitor, was recently shown to have anti-ulcer activity. Notably, Cls increases the expression and transcriptional activity of PPAR-γ in vitro and in vivo. This study aimed to evaluate the protective effect of Cls against ethanol-induced gastric ulcers and clarify the possible underlying mechanisms with an emphasis on the role of PPAR-γ. Male albino rats were treated with ethanol to induce gastric ulcers, or they were pretreated with Cls, omeprazole (Omp), GW9662, or Cls + GW9662 for 14 consecutive days before receiving ethanol. Cls protects against ethanol-induced gastric ulcers. Cls treatment significantly reduced ethanol-induced upregulation of the pro-inflammatory markers (IL-1β, IL-6, TNF-α, and NF-κB), MDA (a marker of lipid peroxidation), and caspase-3 and cleaved caspase-3 (apoptotic markers). On the other hand, Cls treatment counteracted ethanol-induced downregulation of PPAR-γ, pErk-1, HO-1 and GSH (antioxidant markers), PECAM-1 and NO (healing markers), and Bcl-2 (antiapoptotic marker). However, when combined with GW9662, a potent antagonist of PPAR-γ, Cls loses its effects. In conclusion, these results suggest that PPAR-γ and pErk-1 are essential for Cls's protective effects against ethanol-induced gastric ulcers.

Comparative Efficacy of Endoscopic Versus Open Surgical Techniques in the Management of Gastric Outlet Obstruction: A Systematic Review

Gastric outlet obstruction (GOO) is a clinical condition that can arise from both benign and malignant causes, requiring effective management strategies to ensure optimal patient outcomes. Traditionally, open surgical techniques like gastrojejunostomy (GJ) have been the standard treatment, but recent advances in minimally invasive procedures, such as endoscopic ultrasound-guided gastroenterostomy (EUS-GE), offer alternative approaches with potentially reduced morbidity. This systematic review compared the efficacy, safety, and clinical outcomes of endoscopic versus open surgical techniques in managing GOO. A comprehensive search of major electronic databases, including PubMed, MEDLINE, Embase, the Cochrane Library, and Scopus, identified relevant studies published from January 2014 to September 2024. The analysis included randomized controlled trials, clinical trials, and meta-analyses involving a total of 8,540 patients. Results indicated that EUS-GE showed high technical and clinical success rates (91-94% and 88-89.9%, respectively) and lower complication rates (6.8-13.1%) compared to open surgical approaches, which were associated with higher perioperative risks but demonstrated better long-term outcomes in specific scenarios, such as malignant GOO. The findings suggest that while endoscopic techniques are preferable for patients with high surgical risk, open surgery may still be necessary in complex cases. Further research, including randomized controlled trials and long-term studies, is recommended to refine these strategies and improve clinical decision-making. This review underscores the importance of tailored treatment approaches in optimizing the management of GOO, balancing efficacy, safety, and patient-centered outcomes.

A game of resistance: War between bacteria and phages and how phage cocktails can be the solution

While phages hold promise as an antibiotic alternative, they encounter significant challenges in combating bacterial infections, primarily due to the emergence of phage-resistant bacteria. Bacterial defence mechanisms like superinfection exclusion, CRISPR, and restriction-modification systems can hinder phage effectiveness. Innovative strategies, such as combining different phages into cocktails, have been explored to address these challenges. This review delves into these defence mechanisms and their impact at each stage of the infection cycle, their challenges, and the strategies phages have developed to counteract them. Additionally, we examine the role of phage cocktails in the evolving landscape of antibacterial treatments and discuss recent studies that highlight the effectiveness of diverse phage cocktails in targeting essential bacterial receptors and combating resistant strains.

Metabolic dysfunction-associated steatotic liver disease and extrahepatic gastrointestinal cancers

Metabolic dysfunction-associated steatotic liver disease (MASLD) poses a significant and ever-increasing health and economic burden worldwide. Substantial epidemiological evidence shows that MASLD is a multisystem disease that is associated not only with liver-related complications but is also associated with an increased risk of developing cardiometabolic comorbidities and extrahepatic cancers (principally gastrointestinal [GI] cancers). GI cancers account for a quarter of the global cancer incidence and a third of cancer-related deaths. In this narrative review, we provide an overview of the literature on (a) the epidemiological data on the risk of non-liver GI cancers in MASLD, (b) the putative mechanisms by which MASLD (and factors linked with MASLD) may increase this risk, and (c) the possible pharmacotherapies beneficially affecting both MASLD and extrahepatic GI cancer risk. There are multiple potential pathophysiological mechanisms by which MASLD may increase extrahepatic GI cancer risk. Although further studies are needed, the current evidence supports a possible extrahepatic carcinogenic role for MASLD, regardless of obesity and diabetes status, thus highlighting the potential role of tailoring cancer screening for individuals with MASLD. Although there are conflicting data in the literature, aspirin, statins and metformin appear to exert some chemo-preventive effects against GI cancer.

Practical approach to acute pancreatitis: from diagnosis to the management of complications

The purpose of this review is to provide a practical guide for the clinical care of patients with acute pancreatitis (AP) from the management of the early phases of disease to the treatment of local complications. AP is one of the most frequent causes of gastroenterological admission in emergency departments. It is characterized by a dynamic and unpredictable course and in its most severe forms, is associated with organ dysfunction and/or local complications, requiring intensive care with significant morbidity and mortality. Initial therapy includes adequate fluid resuscitation, nutrition, analgesia, and when necessary critical care support. In recent years, the development of minimally invasive tailored treatments for local complications, such as endoscopic drainage, has improved patients' acceptance and outcomes. Despite this, the management of AP remains a challenge for clinicians. The present review was conducted by the authors, who formulated specific questions addressing the most critical and current aspects of the clinical course of AP with the aim of providing key messages.

The effect of concurrent clopidogrel and omeprazole administration on clopidogrel metabolism and platelet function in healthy cats

BACKGROUND

Some studies in humans show that the concurrent use of clopidogrel and omeprazole decreases plasma clopidogrel active metabolite (CAM) concentrations and clopidogrel antiplatelet effects. Whether this drug interaction occurs in cats is unknown.

HYPOTHESIS

We hypothesized that administration of clopidogrel with omeprazole would decrease plasma CAM concentrations and decrease clopidogrel antiplatelet effects in healthy cats.

ANIMALS

Ten domestic cats.

METHODS

In this 2-sequence, 2-period, 2-treatment randomized crossover study, healthy cats were randomly assigned to receive clopidogrel only (18.75 mg PO q24h) or clopidogrel with omeprazole (1 mg/kg PO q12h) for 10 days, followed by a 2-week washout period, and then the opposite treatment for another 10 days. Blood was collected by jugular venipuncture on days 0, 5, and 10. Plasma CAM concentrations were measured using high-performance liquid chromatography-tandem mass spectrometry. Platelet function was evaluated using Plateletworks, Multiplate Analyzer, and Platelet Function Analyzer-100 (PFA-100).

RESULTS

Multiplate Analyzer and PFA-100 detected no difference in platelet function between days or treatment groups. Plateletworks detected a significant difference (P < .001) in platelet function from day 0 to 5 and day 0 to 10 in both treatment groups but no difference between treatment groups. Plasma CAM concentrations were significantly lower on day 10 (P < .02) in cats receiving both medications versus clopidogrel only.

CONCLUSIONS AND CLINICAL IMPORTANCE

Concurrent omeprazole and clopidogrel administration was associated with altered pharmacokinetics on day 10, but no difference in pharmacodynamics between the 2 treatment groups. The short-term use of clopidogrel and omeprazole does not seem to alter platelet function significantly.

Blastocystis hominis; Friend or Foe

Blastocystis hominis (B. hominis) remains the most common parasite identified through stool examination. A clinician will undoubtedly encounter the presence of this parasite numerous times in their career. Thus, it is vital to know if this organism is a 'friend or foe', or in other words, whether it is a commensal or a pathogen. This will help clinicians decide whether to treat or not. This literature review discusses the best available evidence of the association of B. hominis and two diseases- irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Particularly, focus has been paid to the effect of antimicrobial therapy in improving disease activity/symptoms and concluding on the pathogenicity of B. hominis based on in vitro, observational studies, and randomized controlled trials. Most importantly, the review presents a concise set of recommendations for when and how to treat B. hominis in a patient presenting gastrointestinal ailments.

The Saudi Gastroenterology Association consensus on the clinical care pathway for the diagnosis and treatment of GERD

ABSTRACT

Gastroesophageal reflux disease (GERD) is one of the most common problems encountered in outpatient general medicine and gastroenterology clinics. GERD may present with classic esophageal symptoms, extraesophageal symptoms, or mixed symptoms. The diagnosis and treatment of GERD are challenging due to the variety of symptoms and multifactorial pathophysiology. Since there is no consensus on the diagnosis and treatment of GERD in Saudi Arabia, the Saudi Gastroenterology Association established an expert group to formulate a consensus on the clinical care pathway for the diagnosis and treatment of GERD to update health-care providers in Saudi Arabia. The expert group reviewed the literature including recently published international guidelines, clinical trials, and expert opinion and conducted virtual and in-person meetings. A total of 22 statements on the definition, diagnosis, and treatment of GERD were formulated, and three algorithms for the clinical care of GERD were developed with a detailed description for each step. The expert group endorsed the new definition of GERD, the practical principles of interpretation of the diagnostic GERD evaluation, and the practical guidance for GERD treatment including medical, surgical, and endoscopic therapy. The expert group recommends further studies to investigate local data on the diagnosis and treatment of GERD.

Efficacy and Safety of Vonoprazan in Dual/Triple/Quadruple Regimens Both in First-Line and Rescue Therapy for Helicobacter pylori Eradication: A Systematic Review With Meta-Analysis

BACKGROUND

The efficacy of Helicobacter pylori (H. pylori) eradication therapies encompassing one or more antibiotics and a proton pump inhibitor (PPI) has lately decreased. Vonoprazan (VPZ), a potassium-competitive acid blocker, provides higher gastric acid suppression than PPIs. We performed a meta-analysis evaluating the efficacy and safety of VPZ in H. pylori eradication therapies.

METHODS

Studies were searched in PubMed, Embase, and the Cochrane Library up to June 2023. Efficacy was evaluated by intention-to-treat analysis. Data were combined by meta-analyzing risk differences (RD). Heterogeneity was evaluated by subgrouping.

RESULTS

Seventy-seven studies (24 randomized clinical trials) evaluated 44,162 patients (22,297 receiving VPZ and 21,865 PPIs). Overall VPZ efficacy was 88% (95% CI = 87%-90%): 86%, 88%, and 94% for dual/triple/quadruple-VPZ-containing therapies. VPZ efficacy was 87% (86%-89%) in first-line and 90% (87%-93%) in rescue therapy. VPZ performed better than PPIs in treatment-naïve patients (87% vs. 70%; RD = 0.13, 95% CI = 0.11-0.15) and when using triple regimens. No significant differences were observed in rescue and quadruple therapies. In patients with clarithromycin-resistant infection, VPZ-based therapies demonstrated an 81% efficacy (76%-85%), surpassing PPIs (76% vs. 40%; RD = 0.33, 95% CI = 0.24-0.43). For clarithromycin-susceptible strains, VPZ efficacy was 92% (89%-95%), similar to PPIs. VPZ adverse events rate was 19% (16%-21%), comparable to PPI-based regimens (18% vs. 13%, respectively; RD = 0.00, 95% CI = -0.01 to 0.02, p = 0.57).

CONCLUSIONS

The efficacy of VPZ-based regimens was over 85% in all treatment combinations. In treatment-naïve and clarithromycin-resistant patients, VPZ performed better than PPIs. In rescue therapy, in clarithromycin-susceptible patients or when quadruple regimens were prescribed, this advantage was not confirmed. Tolerability was similar in both regimens.

Principles, Methods, and Real-Time Applications of Bacteriophage-Based Pathogen Detection

Bacterial pathogens in water, food, and the environment are spreading diseases around the world. According to a World Health Organization (WHO) report, waterborne pathogens pose the most significant global health risks to living organisms, including humans and animals. Conventional bacterial detection approaches such as colony counting, microscopic analysis, biochemical analysis, and molecular analysis are expensive, time-consuming, less sensitive, and require a pre-enrichment step. However, the bacteriophage-based detection of pathogenic bacteria is a robust approach that utilizes bacteriophages, which are viruses that specifically target and infect bacteria, for rapid and accurate detection of targets. This review shed light on cutting-edge technologies about the novel structure of phages and the immobilization process on the surface of electrodes to detect targeted bacterial cells. Similarly, the purpose of this study was to provide a comprehensive assessment of bacteriophage-based biosensors utilized for pathogen detection, as well as their trends, outcomes, and problems. This review article summaries current phage-based pathogen detection strategies for the development of low-cost lab-on-chip (LOC) and point-of-care (POC) devices using electrochemical and optical methods such as surface-enhanced Raman spectroscopy (SERS).

Efficacy and safety of tegoprazan (LXI-15028) vs. esomeprazole in patients with erosive esophagitis: A multicenter, randomized, double-blind, non-inferiority phase Ⅲ trial

BACKGROUND

An evidence gap still exists regarding the efficacy and safety of tegoprazan in Chinese patients with erosive esophagitis (EE) in China. This study aimed to verify the efficacy and safety of tegoprazan vs. esomeprazole in patients with EE in China.

METHODS

This study was a multicenter, randomized, double-blind, parallel, active-controlled, non-inferiority phase III trial of patients with EE randomized 1:1 to tegoprazan 50 mg/day vs. esomeprazole 40 mg/day. This study was conducted in 32 sites between October 24, 2018 and October 18, 2019. The primary endpoint was the cumulative endoscopic healing rate at week 8. The secondary endpoint included endoscopic healing rate at week 4, changes in the reflux disease questionnaire (RDQ) and gastroesophageal reflux disease health-related quality of life (GERD-HRQL) scores, and symptom improvement.

RESULTS

A total of 261 patients were randomized: 132 to the tegoprazan group and 129 to the esomeprazole group. The cumulative endoscopic healing rate at 8 weeks in the tegoprazan group was non-inferior to that of the esomeprazole group (91.1% vs. 92.8%, difference: -1.7, 95% confidence interval [CI]: -8.5, 5.0, P = 0.008). There were no statistically significant differences in the changes in RDQ (total, severity, and frequency) and GERD-HRQL scores between the two groups (all P >0.05). The percentages of days without symptoms, including daytime and nighttime symptoms based on patients' diaries, were similar between the two groups (all P >0.05). In the tegoprazan and esomeprazole groups, 71.5% (93/130) and 61.7% (79/128) of the participants reported adverse events (AEs), 2.3% and 0 experienced serious AEs, while 70.0% and 60.2% had treatment-emergent AEs, respectively.

CONCLUSION

Tegoprazan 50 mg/day demonstrated non-inferior efficacy in healing EE, symptom improvement, and quality of life, and it has similar tolerability compared with esomeprazole 40 mg/day.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03615677.

Navigating Reproductive Care in Patients With Inflammatory Bowel Disease: A Comprehensive Review

Inflammatory bowel disease [IBD] is often diagnosed in patients during their reproductive years. It is crucial that both healthcare providers and patients are adequately informed to avoid misguided decisions regarding family planning. One of the most important aspects during conception and pregnancy is to maintain disease remission, as disease activity is associated with adverse pregnancy outcomes. Apart from methotrexate, most conventional drugs used in IBD are considered low risk during conception and pregnancy. For newer agents, evidence is still limited. If needed, surgery must not be postponed and should ideally be performed in specialized centres. In most patients, delivery should be vaginal except for patients with complex perianal disease, with an ileoanal pouch anastomosis, or if there is an obstetric contraindication. In children exposed to biological treatments during pregnancy, the risk of infections appears to be low, and psychomotor development is probably not affected. Regarding immunizations, the standard vaccination schedule for inactivated vaccines should be followed for children exposed to biologics in utero. In the case of live vaccines, such as rotavirus, decisions should be individualized and take into consideration the risk-benefit ratio, particularly in developing countries. In this review, we provide a comprehensive and updated overview of aspects related to fertility, pregnancy, breastfeeding, and the impact on the care of children born to mothers with IBD. Both the available evidence and areas of uncertainty are discussed, with the goal of assisting healthcare professionals caring for IBD patients during this important stage of their lives.

Optimization of alginate/carboxymethyl chitosan microbeads for the sustained release of celecoxib and attenuation of intestinal inflammation in vitro

Multiple anti-inflammatory medications have helped treat inflammatory bowel disease (IBD). However, oral administration has minimal absorption and systemic side effects. This study aims to investigate the potential of encapsulating anti-inflammatory drug celecoxib (Cele) within microbeads for the treatment of IBD. Microbeads were formed by cross-linking carboxymethyl chitosan (CMCs) with sodium alginate (Alg) through the ionic gelation method and optimized through response surface methodology. Additionally, the study revealed a mucoadhesivity value of 59.32 ± 0.74 % for the optimized microbead system. The drug release study demonstrated the sustained release of Cele CMCs/Alg microbeads upto 24 h compared to quick release of the free drug. The results of the cell viability assay indicated that the Cele-Alg/CMCs microbeads exhibited a non-toxic nature within the concentration range of 100-250 μM. A significant decrease in nitric oxide (NO) generation (61.14 ± 3.67 %) was seen in HCT-116 cells stimulated with lipopolysaccharide (LPS) upon treatment with Cele-250μM/CMCs/Alg microbeads. The results of the reactive oxygen species and wound healing assay suggest that Cele-250μM/CMCs/Alg microbeads had improved anti-inflammatory characteristics comparable to those of free drug treatment. The western blot analysis demonstrated that the microbeads composed of CMCs/Alg-Cele possess the capacity to inhibit the expression of COX-2 in vitro supressing inflammation.

Lactiplantibacillus plantarum NMGL2 exopolysaccharide ameliorates DSS-induced IBD in mice mainly by regulation of intestinal tight junction and NF-κB p65 protein expression

Treatment of inflammatory bowel disease (IBD), a common chronic intestinal disease, by exopolysaccharides (EPSs) produced by lactic acid bacteria has raised increasing concerns. Here, the EPS produced by Lactiplantibacillus plantarum NMGL2 was evaluated for its ameliorating effect on dextran sodium sulfate (DSS)-induced IBD in mice. Administration of the EPS was shown to decrease the body weight loss and the values of disease activity index (DAI) and alleviate the colon damage as evidenced by an improvement in colonic length shortening, a reduction in colonic coefficient, and a reduction in colonic mucosal architecture and inflammatory infiltration. Cytokine assay of the blood and colon tissue samples showed that the EPS could decrease the levels of pro-inflammatory TNF-α and IL-1β, and increase anti-inflammatory IL-10. Oxidative stress assay of the colon tissue showed that the nitric oxide (NO) and malondialdehyde (MDA) levels decreased significantly (p < 0.05), while superoxide dismutase (SOD) and glutathione (GSH) levels increased significantly (p < 0.05) after the EPS intervention. These results were further confirmed by the significantly (p < 0.05) down-regulated levels of NF-κB p65, p-IKKβ, and p-IκBα, and significantly (p < 0.05) enhanced expression of ZO-1 and occludin, as evaluated by Western-blot analysis of these proteins expressed in colonic tissue. The EPS produced by L. plantarum NMGL2 alleviated IBD by suppressing the NF-κB signaling pathway, suggesting its potential as a functional food agent in the prevention of IBD.

Potential role of predictive models in assessment of liver inflammation in patients with hepatocellular carcinoma: a two-center cohort study

BACKGROUND

Hepatic inflammation in patients with hepatocellular carcinoma (HCC) remains unclear. This study aimed to construct a clinically expedient predictive model to grade hepatic inflammation in HCC patients.

METHODS

This is a two-center retrospective cohort study of HCC patients comprising Derivation cohort and External Validation cohort of 1201 and 505 patients, respectively. Variables of liver inflammation identified through uni- and multi-variate logistic regression analyses were incorporated into predictive nomograms and applied to Derivation cohort, subject to internal and external validation.

RESULTS

Liver fibrosis severity score, portal hypertension severity, and model for end-stage liver disease-sodium independently predicted hepatic inflammation grade. Performance for distinguishing G1 and non-G1 (≥ G2) patients was good with C-index of 0.810 and 0.817 in Derivation and External Validation cohort, respectively. The nomogram performed poorly to predict grade G2, G3 and G2 + G3, but performed well to predict G4.

CONCLUSIONS

Our nomogram exhibited good performance for scaling hepatic inflammation (G1 and G4) in HCC, and could be employed as adjunctive diagnostic tools to guide HCC management strategy.