Over-the-scope clip as a rescue treatment for massive bleeding due to Dieulafoy lesion at the colorectal anastomosis: A case report

RATIONALE

The bleeding of Dieulafoy lesion predominantly involves the proximal stomach and leads to severe gastrointestinal bleeding. However, these lesions have also been reported in the whole gastrointestinal tract. Bleeding of Dieulafoy lesions at the anastomosis was seldomly reported and was very easy to be ignored clinically.

PATIENT CONCERNS

We describe a 72-year-old woman with a past history of surgery for rectal carcinoma hospitalized with chief complaint of massive rectal bleeding. No gross bleeding lesion was found during the first emergency colonoscopy. Despite multiple blood transfusions, her hemoglobin rapidly dropped to 5.8 g/dL.

DIAGNOSIS

She was diagnosed with Dieulafoy lesion at the colorectal anastomosis during the second emergency colonoscopy.

INTERVENTIONS

Primary hemostasis was achieved by endoscopic hemostatic clipping. However, she experienced another large volume hematochezia 3 days later, and then received another endoscopic hemostatic clipping. She was improved and discharged. However, this patient underwent hematochezia again 1 month later. Bleeding was arrested successfully after the over-the-scope clip (OTSC) was placed during the fourth emergency colonoscopy.

OUTCOMES

This patient underwent 4 endoscopic examinations and treatments during 2 hospitalizations. The lesion was overlooked during the first emergency colonoscopy. The second and third endoscopes revealed Dieulafoy lesion at the colorectal anastomosis and performed endoscopic hemostatic clippings, but delayed rebleeding occurred. The bleeding was stopped after the fourth emergency colonoscopy using OTSC. There was no further rebleeding during hospitalization and after 2-year of follow-up.

LESSONS

As far as we know, there is no reported case of lower gastrointestinal bleeding caused by Dieulafoy lesion at the colorectal anastomosis, OTSC is a safe and effective rescue treatment for Dieulafoy lesions.

TH17 cell: a double-edged sword in the development of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic nonspecific inflammatory disease of the gastrointestinal tract, and its pathogenesis has not been fully understood. Extensive dysregulation of the intestinal mucosal immune system is critical in the development and progression of IBD. T helper (Th) 17 cells have the characteristics of plasticity. They can transdifferentiate into subpopulations with different functions in response to different factors in the surrounding environment, thus taking on different roles in regulating the intestinal immune responses. In this review, we will focus on the plasticity of Th17 cells as well as the function of Th17 cells and their related cytokines in IBD. We will summarize their pathogenic and protective roles in IBD under different conditions, respectively, hoping to further deepen the understanding of the pathological mechanisms underlying IBD and provide insights for future treatment.

L-lysine supplementation attenuates experimental autoimmune hepatitis in a chronic murine model

The incidence of autoimmune hepatitis (AIH) has increased significantly worldwide. The present study aims to explore the protective effect of L-lysine supplementation against AIH and to investigate its potential underlying mechanisms. A chronic experimental AIH mouse model was established by repeated tail vein injection of human cytochrome P450 2D6 (CYP2D6) plasmid. Starting from day 14 of the modeling, mice in the CYP2D6-AIH +L-lysine group were given 200 µl of purified water containing 10 mg/kg L-lysine by gavage until day27, once a day, and mice in the healthy control group and model group were given an equal volume of purified water by gavage. Our results showed that L-lysine supplementation partially reversed the liver injury mediated by CYP2D6 overexpression. These effects were consistent with the restraining impacts of L-lysine supplementation on decreasing pro-inflammatory cytokines expression level and CD4+ and CD8+ T lymphocytes infiltration, as well as curbing hepatic oxidative stress. Furthermore, L-lysine supplement relieved liver fibrosis in the context of AIH. In conclusion, L-lysine supplementation attenuates CYP2D6-induced immune liver injury in mice, which may serve as a novel nutrition support approach for AIH.

Development and validation of a three-dimensional deep learning-based system for assessing bowel preparation on colonoscopy video

Background

The performance of existing image-based training models in evaluating bowel preparation on colonoscopy videos was relatively low, and only a few models used external data to prove their generalization. Therefore, this study attempted to develop a more precise and stable AI system for assessing bowel preparation of colonoscopy video.

Methods

We proposed a system named ViENDO to assess the bowel preparation quality, including two CNNs. First, Information-Net was used to identify and filter out colonoscopy video frames unsuitable for Boston bowel preparation scale (BBPS) scoring. Second, BBPS-Net was trained and tested with 5,566 suitable short video clips through three-dimensional (3D) convolutional neural network (CNN) technology to detect BBPS-based insufficient bowel preparation. Then, ViENDO was applied to complete withdrawal colonoscopy videos from multiple centers to predict BBPS segment scores in clinical settings. We also conducted a human-machine contest to compare its performance with endoscopists.

Results

In video clips, BBPS-Net for determining inadequate bowel preparation generated an area under the curve of up to 0.98 and accuracy of 95.2%. When applied to full-length withdrawal colonoscopy videos, ViENDO assessed bowel cleanliness with an accuracy of 93.8% in the internal test set and 91.7% in the external dataset. The human-machine contest demonstrated that the accuracy of ViENDO was slightly superior compared to most endoscopists, though no statistical significance was found.

Conclusion

The 3D-CNN-based AI model showed good performance in evaluating full-length bowel preparation on colonoscopy video. It has the potential as a substitute for endoscopists to provide BBPS-based assessments during daily clinical practice.

Role of macrophage-to-myofibroblast transition in chronic liver injury and liver fibrosis

BACKGROUND

Chronic liver injury contributes to liver fibrosis, which is characterized by the excessive deposition of extracellular matrix (ECM) components. ECM is mainly composed of myofibroblasts. Recently, macrophage-to-myofibroblasts transition (MMT), has been identified as a novel origin for myofibroblasts. However, the potential functions of MMT in chronic liver injury and liver fibrosis remain unknown.

METHODS

To clarify the transformation of fibrotic cells in hepatic fibrosis, liver specimens were collected from people at different stages in the progression of hepatic fibrosis and stained with immunofluorescence. Models of hepatic fibrosis such as the CCL4 model, HFD-induced NAFLD model, MCD-induced NAFLD model and ethanol-induced AFLD model were demonstrated and were stained with immunofluorescence.

RESULTS

Here, we uncovered macrophages underwent MMT in clinical liver fibrosis tissue samples and multiple animal models of chronic liver injury. MMT cells were found in specimens from patients with liver fibrosis on the basis of co-expression of macrophage (CD68) and myofibroblast (a-SMA) markers. Moreover, macrophages could transform into myofibroblasts in CCL4-induced liver fibrosis model, high-fat diet (HFD) and methionine-choline-deficient diet (MCD)-induced nonalcoholic fatty liver diseases (NAFLD) model, and ethanol-induced alcoholic fatty liver diseases (AFLD) model. In addition, we highlighted that MMT cells mainly had a predominant M2 phenotype in both human and experimental chronic liver injury.

CONCLUSIONS

Taken together, MMT acts a crucial role in chronic liver injury and liver fibrosis.

The proportion of regulatory T cells in peripheral blood of patients with autoimmune hepatitis: A systematic review and meta-analysis

BACKGROUND

Many researches have reported the impairment of regulatory T cells (Tregs) in autoimmune hepatitis (AIH), whilst the change of Tregs in peripheral blood remains controversial. We performed this systematic review and meta-analysis to clarify the numerical change of circulating Tregs in AIH patients compared with healthy individuals.

METHODS

Relevant studies were identified from Medline, PubMed, Embase, Web of Science, the Cochrane Library, China National Knowledge Infrastructure, and WanFang Data. Twenty-nine studies involving 968 AIH patients and 583 healthy controls were included. Subgroup analysis stratified by Treg definition or ethnicity was performed, and analysis of active-phase AIH was conducted.

RESULTS

The proportions of Tregs among CD4 T cells and PBMCs were generally decreased in AIH patients compared with healthy controls. Subgroup analysis showed that circulating Tregs identified by CD4+CD25+/high, CD4+CD25+Foxp3+, CD4+CD25+/highCD127-/low, and Tregs in Asian population were decreased among CD4 T cells in AIH patients. No significant change of CD4+CD25+/highFoxp3+CD127-/low Tregs and Tregs in Caucasian population among CD4 T cells were found in AIH patients, whereas the number of studies was limited in these subgroups. Moreover, analysis of the active-phase AIH patients showed that Treg proportions were decreased generally, whereas no significant differences in Tregs/CD4 T cells were observed when markers CD4+CD25+Foxp3+, CD4+CD25+/highFoxp3+CD127-/low were used or in Caucasian population.

CONCLUSIONS

The proportions of Tregs among CD4 T cells and PBMCs were decreased in AIH patients compared with healthy controls generally, whereas Treg definition markers, ethnicity, and disease activity had influence on the results. Further large-scale and rigorous study is warranted.

Sophoricoside attenuates autoimmune‑mediated liver injury through the regulation of oxidative stress and the NF‑κB signaling pathway

The prevalence of autoimmune hepatitis (AIH) is increasing, yet specific pharmacotherapies remain to be explored. The present study aimed to investigate the effects of sophoricoside (SOP), a bioactive component of medical herbs, on AIH and to elucidate the underlying mechanisms. Bioinformatic approaches were used to predict the potential targets and underlying regulatory mechanisms of SOP on AIH. The effects of SOP on AIH were evaluated by determining the expression levels of inflammatory cytokines, histological liver injury and hepatic fibrosis in an improved chronic cytochrome P450 2D6 (CYP2D6)‑AIH mouse model and in a model of concanavalin‑A (ConA)‑induced acute immune‑mediated liver injury. The antioxidant activity of SOP was detected in in vivo and in vitro experiments. The selected signal targeted by SOP in AIH was further confirmed using western blot analysis and immunofluorescence staining. The results of bioinformatic analysis revealed that the targets of SOP in AIH were related to oxidative stress and the NF‑κB gene set. The NF‑κB transcription factor family is a key player that controls both innate and adaptive immunity. The activation of the NF‑κB signaling pathway is often associated with autoimmune disorders. In the animal experiments, SOP attenuated CYP2D6/ConA‑induced AIH, as evidenced by a significant reduction in the levels of hepatic enzymes in serum, inflammatory cytokine expression and histological lesions in the liver. The oxidative response in AIH was also significantly inhibited by SOP, as evidenced by a decrease in the levels of hepatic malondialdehyde, and elevations in the total antioxidant capacity and glutathione peroxidase levels. The results of the in vivo and in vitro experiments revealed that SOP significantly reduced the enhanced expression and nuclear translocation of phosphorylated p65 NF‑κB in the livers of mice with AIH and in lipopolysaccharide‑stimulated AML12 cells. On the whole, the present study demonstrates the protective role of SOP in AIH, which may be mediated by limiting the oxidative response and the activation of the NF‑κB signaling pathway in hepatocytes.

Combined immunotherapy for hepatocellular carcinoma: How to maximize immune checkpoint blockade synergic anti-tumor effect

Hepatocellular carcinoma (HCC) is the most prevalent form of liver cancer and has an increasing incidence worldwide. The management of HCC still has many restrictions, despite the fact that there are now numerous treatment options, including liver transplantation/resection, locoregional treatments (LRT), and systemic medication. As a turning point in the history of cancer treatment, the discovery of the immune checkpoints and the development of their inhibitors provide new hope for HCC patients. However, limited objective response rate and insignificant overall survival improvement are still urgent problems to be solved for immune checkpoint inhibitors (ICIs). Combination therapies are considered a solution for improving the effectiveness and response rate of ICIs, and several forms of combination treatments are currently being actively researched. In this review, we summarize the mainstream combination strategies, explain their theoretical basis, introduce several important and ongoing clinical trials, and suggest some potential future paths in this area at the conclusion of the review. AVAILABILITY OF DATA AND MATERIALS: Not applicable.

Comprehensive Analysis of Sideroflexin 4 in Hepatocellular Carcinoma by Bioinformatics and Experiments

Background: Sideroflexins (SFXNs) are a family of highly conserved mitochondrial transporters which regulate iron homeostasis and mitochondrial respiratory chain. However, the roles and mechanisms of SFXNs in HCC remain unknown. Methods: SFXNs expression and prognostic value in HCC was comprehensively analyzed. Proteins interacting with SFXN4 were analyzed in STRING database. The co-expression genes of SFXN4 were analyzed in cBioPortal database, and function of SFXN4 co-expression genes were annotated. The putative transcription factors and miRNA targeting SFXN4 were analyzed in NetworkAnalyst. The correlation between SFXN4 expression and immune infiltration was analyzed by ssGSEA. Cancer pathway activity and drug sensitivity related to SFXN4 were explored in GSCALite. The roles of SFXN4 in proliferation, migration and invasion of HCC were assessed in vitro and in vivo. Results: SFXN4 was consistently elevated in HCC, positively correlated with clinicopathological characteristics and predicted poor outcome. Functional enrichment showed SFXN4 was mainly related to oxidative phosphorylation, reactive oxygen species and metabolic pathways. SFXN4 expression was regulated by multiple transcription factors and miRNAs, and SFXN4 expression in HCC was associated with several cancer pathways and drug sensitivity. SFXN4 expression correlated with immune infiltration in HCC. In vitro, knockdown of SFXN4 inhibited HCC proliferation, migration and invasion, and decreased the expression of cyclin D1 and MMP2. In vivo, knockdown of SFXN4 inhibited the growth of tumor xenografts in mice. Conclusion: SFXN4 was upregulated in HCC, predicted poor prognosis, and may facilitate HCC development and progression via various mechanisms. For HCC, SFXN4 may provide both prognostic information and therapeutic potential.

CB-HRNet: A Class-Balanced High-Resolution Network for the evaluation of endoscopic activity in patients with ulcerative colitis

Endoscopic evaluation is the key to the management of ulcerative colitis (UC). However, there is interobserver variability in interpreting endoscopic images among gastroenterologists. Furthermore, it is time-consuming. Convolutional neural networks (CNNs) can help overcome these obstacles and has yielded preliminary positive results. We aimed to develop a new CNN-based algorithm to improve the performance for evaluation tasks of endoscopic images in patients with UC. A total of 12,163 endoscopic images from 308 patients with UC were collected from January 2014 to December 2021. The training set and test set images were randomly divided into 37,515 and 3191 after excluding possible interference and data augmentation. Mayo Endoscopic Subscores (MES) were predicted by different CNN-based models with different loss functions. Their performances were evaluated by several metrics. After comparing the results of different CNN-based models with different loss functions, High-Resolution Network with Class-Balanced Loss achieved the best performances in all MES classification subtasks. It was especially great at determining endoscopic remission in UC, which achieved a high accuracy of 95.07% and good performances in other evaluation metrics with sensitivity 92.87%, specificity 95.41%, kappa coefficient 0.8836, positive predictive value 93.44%, negative predictive value 95.00% and area value under the receiver operating characteristic curve 0.9834, respectively. In conclusion, we proposed a new CNN-based algorithm, Class-Balanced High-Resolution Network (CB-HRNet), to evaluate endoscopic activity of UC with excellent performance. Besides, we made an open-source dataset and it can be a new benchmark in the task of MES classification.

The impact of probiotics on gut microbiota in the eradication of Helicobacter pylori infection: a systematic review

OBJECTIVE

The effect of probiotics supplementation on the gut microbiota in Helicobacter pylori (H. pylori) eradication therapy is controversial. Therefore, this review aimed to illustrate changes in the gut microbiota after standard eradication therapy with probiotics supplements.

MATERIALS AND METHODS

A computerized literature search in PubMed, Cochrane Library, Web of Science, and Embase database was performed up to February 1st, 2022, with English language restriction. The extracted outcomes were analyzed, including gut microbiota, adverse effects, and eradication rate.

RESULTS

13 studies reported data on 777 participants who were finally eligible for this systematic review. All of them are randomized controlled trials investigating the effect of H. pylori eradication with probiotics supplementation therapy on gut microbiota. Probiotics supplementation seems to play a positive role in restoring the gut microbiota during H. pylori eradication therapy. However, the changes in the gut microbiota are still controversial. The included studies had significant heterogeneity in the study population, diagnostic methods of H. pylori infection, and detection techniques of the gut microbiota and probiotics species.

CONCLUSIONS

The results provided a basis for the rational selection of probiotics in the H. pylori eradication process. Probiotic supplementation might keep the balance of gut microbiota and reduce the gastrointestinal adverse effects of antibiotics, but whether it could improve the eradication rate or not is a debatable point. Therefore, more research is needed to provide evidence.

MTAP-ANRIL gene fusion promotes melanoma epithelial-mesenchymal transition-like process by activating the JNK and p38 signaling pathways

Gene fusions caused by cytogenetic aberrations play important roles in the initiation and progression of cancers. The recurrent MTAP-ANRIL fusion gene was reported to have a frequency of greater than 7% in melanoma in our previous study. However, its functions remain unclear. Truncated MTAP proteins resulting from point mutations in the last three exons of MTAP can physically interact with the wild-type MTAP protein, a tumor suppressor in several human cancers. Similarly, MTAP-ANRIL, which is translated into a truncated MTAP protein, would influence wild-type MTAP to act as an oncogene. Here, we found that MTAP-ANRIL gene fusion downregulated the expression of wild-type MTAP and promoted epithelial-mesenchymal transition-like process through the activation of JNK and p38 MAPKs in vitro and in vivo. Our results suggest that MTAP-ANRIL is a potential molecular prognostic biomarker and therapeutic target for melanoma.

Capillary leak syndrome presenting as refractory ascites in a patient with lymphoma: A rare case report

Capillary leak syndrome (CLS) is a serious disorder characterized by hypotension and refractory systemic oedema. CLS with marked ascites rather than systemic oedema is rare and prone to misdiagnosis and delayed treatment. We report here a case of marked ascites in an elderly male patient with hepatitis B virus reactivation. Following investigations to exclude common diseases that may have accounted for diffuse oedema and hypercoagulable state, anti-cirrhosis therapy failed and severe refractory shock developed 48 hours after admission. The patient developed mild pleural effusions followed by swelling of the face, neck, and extremities. A high cytokine concentration gradient was detected between serum and ascites. Peritoneal biopsy showed lymphoma cells. The final diagnosis was lymphoma recurrence complicated with CLS. Our case suggests that cytokine detection in serum and ascitic fluid may be helpful in the differential diagnosis of CLS. In similar cases, decisive intervention, such as, hemodiafiltration, should be implemented to lessen the likelihood of serious complications.

Genetic deletion of phosphodiesterase 4D in the liver improves kidney damage in high-fat fed mice: liver-kidney crosstalk

A growing body of epidemiological evidence suggests that nonalcoholic fatty liver disease (NAFLD) is an independent risk factor for chronic kidney disease (CKD), but the regulatory mechanism linking NAFLD and CKD remains unclear. Our previous studies have shown that overexpression of PDE4D in mouse liver is sufficient for NAFLD, but little is known about its role in kidney injury. Here, liver-specific PDE4D conditional knockout (LKO) mice, adeno-associated virus 8 (AAV8)-mediated gene transfer of PDE4D and the PDE4 inhibitor roflumilast were used to assess the involvement of hepatic PDE4D in NAFLD-associated renal injury. We found that mice fed a high-fat diet (HFD) for 16 weeks developed hepatic steatosis and kidney injury, with an associated increase in hepatic PDE4D but no changes in renal PDE4D. Furthermore, liver-specific knockout of PDE4D or pharmacological inhibition of PDE4 with roflumilast ameliorated hepatic steatosis and kidney injury in HFD-fed diabetic mice. Correspondingly, overexpression of hepatic PDE4D resulted in significant renal damage. Mechanistically, highly expressed PDE4D in fatty liver promoted the production and secretion of TGF-β1 into blood, which triggered kidney injury by activating SMADs and subsequent collagen deposition. Our findings revealed PDE4D might act as a critical mediator between NAFLD and associated kidney injury and indicated PDE4 inhibitor roflumilast as a potential therapeutic strategy for NAFLD-associated CKD.

Autotaxin (ATX) inhibits autophagy leading to exaggerated disruption of intestinal epithelial barrier in colitis

Inflammatory bowel disease (IBD) is an immune-mediated disease. Autotaxin (ATX) is associated with increased inflammatory molecules, however, its effect on IBD is not well understood. Autophagy plays an important role in IBD, whether ATX and autophagy act in concert in IBD remains unknown. This study is to explore the possible mechanisms of ATX affecting autophagy leading to the disruption of intestinal epithelial barrier, thereby exacerbating colitis. The expression of ATX was upregulated in UC patients and dextran sulfate sodium (DSS)-induced colitis mice. Here, we described that providing an ATX inhibitor during DSS colitis increased autophagy and ameliorated colonic inflammation. Conversely, intrarectal administration with recombinant (r)ATX increased colitis and decreased autophagy. This pro-colitic effect was attenuated in mice treated with rapamycin, resulting in increased autophagy activity and mild colitis. Moreover, the inhibitory effect of rATX on autophagy was confirmed in vitro and was reversed by the addition of rapamycin. The damaging effects of ATX on epithelial barrier function were reversed by ATX inhibitor or rapamycin treatment. In sum, our results show that ATX can inhibit autophagy through the mTOR pathway, resulting in exaggerated damage to the intestinal epithelial barrier during colitis. These findings suggest that ATX may be a key pro-colitic factor, and represent a potential therapeutic target for treating IBD in the future.

Therapeutic Effect of Costunolide in Autoimmune Hepatitis: Network Pharmacology and Experimental Validation

Novel treatments for autoimmune hepatitis (AIH) are highly demanded due to the limitations of existing therapeutic agents. Costunolide is a promising candidate due to its anti-inflammatory and hepatoprotective function, but its effect in AIH remains obscure. In this study, we integrated network pharmacology and experimental validation to reveal the effect and mechanism of costunolide in AIH. A total of 73 common targets of costunolide and AIH were obtained from databases. Pathway enrichment analysis indicated that PI3K-AKT pathway was the core pathway of costunolide in AIH. Protein–protein interaction network analysis and molecular docking revealed that SRC and IGF1R might play critical roles. In two murine AIH models, costunolide significantly attenuated liver injury, inflammation, and fibrosis reflected by the liver gross appearance, serum transaminases, necrosis area, spleen index, immune cell infiltration, and collagen deposition. Western blot and immunohistochemistry confirmed that phosphorylated AKT, SRC, and IGF1R were upregulated in AIH models, and costunolide administration could inhibit the phosphorylation of these proteins. In summary, costunolide significantly ameliorates murine AIH. The therapeutic effect might work by suppressing the activation of PI3K-AKT pathway and inhibiting the phosphorylation of SRC and IGF1R. Our research reveals the potent therapeutic effect of costunolide in AIH and the potential role of SRC and IGF1R in AIH for the first time, which may further contribute to the novel drug development for AIH and other autoimmune diseases.

Hepatocytes: A key role in liver inflammation

Hepatocytes, the major parenchymal cells in the liver, are responsible for a variety of cellular functions including carbohydrate, lipid and protein metabolism, detoxification and immune cell activation to maintain liver homeotasis. Recent studies show hepatocytes play a pivotal role in liver inflammation. After receiving liver insults and inflammatory signals, hepatocytes may undergo organelle damage, and further respond by releasing mediators and expressing molecules that can act in the microenvironment as well as initiate a robust inflammatory response. In this review, we summarize how the hepatic organelle damage link to liver inflammation and introduce numerous hepatocyte-derived pro-inflammatory factors in response to chronic liver injury.

Prepackaged formula low-residue diet vs. self-prepared low-residue diet before colonoscopy: A multicenter randomized controlled trial

Background and aims

Compared with self-prepared LRD, a prepackaged low-residue diet (LRD) can improve patient compliance, but whether it can further improve the quality of bowel preparation is uncertain. The study aimed to compare the application of the prepackaged formula LRD with self-prepared LRD in bowel preparation for colonoscopy.

Methods

A multicenter randomized controlled trial was conducted in 15 centers. The eligible subjects were randomly assigned to one of two groups: the formula LRD group and the self-prepared LRD group. On the day before the colonoscopy, subjects in the self-prepared LRD group were instructed to consume a restricted LRD prepared by themselves, while subjects in the formula LRD group were given six bags of prepackaged formula LRD and instructed to consume them according to their individual need. The primary outcome was an adequate bowel preparation rate. Secondary outcomes mainly included Boston Bowel Preparation Scale (BBPS) scores, dietary restriction compliance rate, tolerance, satisfaction, adenoma detection rate (ADR), and adverse reactions. The trial was registered at ClinicalTrials.gov under the identifier NCT03943758.

Results

A total of 550 subjects were recruited. Compared with the self-prepared LRD group, the formula LRD group showed a higher adequate bowel preparation rate (94.5 vs. 80.4%; P < 0.01), BBPS scores (7.87 ± 1.13 vs. 6.75 ± 1.47; P < 0.01), dietary compliance rate (92.4 vs. 78.9%; P < 0.01), tolerance (P < 0.01 in degree of hunger, intensity of physical strength, and negative influence on daily activities), satisfaction (8.56 ± 1.61 vs. 7.20 ± 2.02; P < 0.01), and ADR (25.6 vs. 16.0%; P < 0.01). There was no significant difference in adverse reactions.

Conclusion

Compared with self-prepared LRD, the formula LRD showed similar safety and higher bowel preparation quality, compliance, and tolerance in bowel preparation. More formula LRDs could be designed according to different dietary habits and ethnic populations, and further researches are warranted to confirm their effect.

Clinical trial registration

https://register.clinicaltrials.gov, identifier: NCT03943758.

Relationship between endoscopic gastric abnormalities and colorectal polyps: a cross-sectional study based on 33439 Chinese patients

Background: No study on the relationship between common abnormalities of the upper digestive tract and colorectal polyps (CPs) has been conducted. Methods: 33439 patients were enrolled in this cross-sectional study, of which 7700 had available Helicobacter pylori (H.pylori) information. All participants underwent colonoscopy and esophagogastroduodenoscopy (EGD) simultaneously or within six months at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2015 to November 2021. The study assessed whether the risk of CPs was affected by the following gastroesophageal diseases: atrophic gastritis (AG), gastric polyps, Barrett's esophagus and reflux esophagitis, bile reflux, gastric ulcer, gastric mucosal erosion, superficial gastritis, and gastric H.pylori infection. The crude and adjusted odds ratios (ORs) of H.pylori on the occurrence of CPs were computed by logistic regression. Additionally, we also evaluated whether AG had an impact on the relationship between H.pylori infection and CPs. Results: A total of 10600 cases (31.7%) were diagnosed as CPs. Multivariate logistic analysis showed that age, male (OR, 1.80; 95% confidence interval [CI], 1.61 to 2.02), gastric polyps (OR, 1.61; 95% CI, 1.05 to 2.46 for hyperplastic polyps; OR, 1.45; 95% CI, 1.09 to 1.94 for fundic gland polyps), H.pylori infection (OR, 1.21; 95% CI, 1.07 to 1.37) and atrophic gastritis (OR, 1.38; 95% CI, 1.21 to 1.56) were independent risk factors for colorectal polyps. Moreover, the combined effect of H.pylori infection and AG was slightly greater than the sum of their individual effects on the risk of CPs, but there was no additive interaction between them. Conclusions: Gastric conditions including gastric polyps, H.pylori infection, and AG increased the risk of CPs. However, Barrett's esophagus and reflux esophagitis, bile reflux, erosive gastritis, gastric ulcer, and superficial gastritis might not have relationship with CPs occurrence.

Severe lower gastrointestinal bleeding caused by rectal Dieulafoy's lesion: Case reports and literature review

RATIONALE

Dieulafoy's lesion are relatively rare and can cause severe gastrointestinal bleeding. A Dieulafoy's lesion is defined as an artery that erodes the overlying epithelium without the presence of an ulcer. Bleeding in Dieulafoy's lesion predominantly involves the proximal stomach and upper gastrointestinal tract and is rarely observed in the lower gastrointestinal tract.

PATIENT CONCERNS

Case 1 was a 58-year-old woman complaining of sudden headache and vomiting who was diagnosed with subarachnoid hemorrhage. She underwent transcatheter embolization for intracranial aneurysm treatment but had an acute profuse hematochezia on the 11th day of admission. Case 2 was a 63-year-old man admitted to the respiratory intensive care unit because of fever with altered consciousness level for a week. He was diagnosed with advanced lung cancer that had metastasized to multiple organs one month prior. On the third day of admission, he had an attack of profuse hematochezia, and quickly developed shock and apathy.

DIAGNOSIS

Both patients were diagnosed with actively bleeding rectal Dieulafoy's lesion by bedside emergency colonoscopy.

INTERVENTIONS

Endoscopic hemostatic clipping was performed in 2 patients.

OUTCOMES

Hemostasis was successfully achieved in these 2 patients, and there was no recurrence of symptoms during follow-up.

CONCLUSIONS

We propose that hemostatic clipping is one of the options in the treatment of rectal Dieulafoy's lesions.

Improving the quality of bowel preparation by smartphone education platform prior to colonoscopy: a randomized trail

OBJECTIVE

Adequate bowel preparation is an essential factor in colonoscopy. Enhanced education on the procedure of bowel preparation is very necessary for patients before colonoscopy. We analysed the influence of a novel education platform on bowel preparation quality before colonoscopy.

PATIENTS AND METHODS

The study enrolled outpatients who underwent colonoscopy in the digestive endoscopy centre of Wuhan Tongji Hospital. They were divided into the control group and the intervention group according to different educational ways. The control group patients were provided with the regular colonoscopy preparation leaflet. The intervention group patients were asked to add the education platform. The primary outcome was the rate of adequate bowel preparation. The study was registered at Chinese ClinicalTrials.gov (ChiCTR2100053547, 24/11/2021).

RESULTS

A total of 378 patients who underwent colonoscopy were enrolled, including 189 patients in the control group and 189 patients in the intervention group. The Boston bowel preparation score (BBPS) was significantly higher in the intervention group than that in the control group (p < .05). The adequate rate of bowel preparation in the intervention group was significantly improved than that in the control group (p = .000). Compared with the control group, the polyp detection rate (PDR) was significantly higher in the intervention group (p = .006), especially in the left colonic (p = .006). Among constipation patients, the adequate rate of bowel preparation (p = .000) and the PDR (p = .004) were significantly improved than that in the control group.

CONCLUSIONS

The smartphone education platform may effectively improve bowel preparation quality, PDR, and patients' compliance.Key messagesThe quality of bowel preparation mainly relies on the patients' compliance with the bowel preparation instructions.The study reveals that the superiority of the smartphone education platform by Mini Program in improving bowel preparation and colorectal polyp detection rate.The smartphone education platform may provide a more effective, convenient, and labour-saving way to provide further improvements to patients prior to colonoscopy.

Total arterial revascularization is associated with long-term survival benefit in coronary artery bypass grafting: systematic review with meta-analysis

Importance

Total arterial revascularization (TAR), the complete avoidance of saphenous vein grafting (SVG) in coronary artery bypass grafting (CABG), is advocated based on the superior conduit durability and resistance against atherosclerosis. However, the low adoption rate of TAR indicates a high level of controversy.

Objective

To compare long-term survival between TAR and conventional CABG involving SVG.

Data sources

A comprehensive literature search was conducted through digital databases including MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from the inception to May 2021.

Study selection

The inclusion criteria were randomized clinical trials, or propensity-score balanced or multivariable-adjusted observational studies with a sample size of at least 100 patients in each arm, isolated CABG, comparing TAR (SVG=0) vs. non-TAR (SVG≥1), and inclusion of all-cause mortality.

Data extraction and synthesis

Two reviewers performed independent extraction following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Pooled hazard ratios (HR) and 95% confidence intervals (CI) were estimated with random-effect and fixed-effect models using generic inverse variance weighting. Individual patient time-to-event data were reconstructed to create an overall Kaplan-Meier survival function for matched studies. Sensitivity analyses were performed according to the risk of bias, matching status, and source of HR.

Main outcomes and measures

The primary endpoint was all-cause mortality.

Results

A total of 23 studies (100,314 patients), all with a retrospective observational design, were identified. The weighted mean follow-up time was 8.8 years post-operatively. Total arterial revascularization was associated with greater freedom from all-cause mortality than non-TAR (HR, 0.77, 95% CI, 0.71 to 0.84, p&lt;0.001). There was evidence of low heterogeneity (I2=45%) across studies. Low publication bias was observed. Leave-one-out influence analysis and sensitivity analyses produced consistent results. Cochrane Collaboration signaling domains showed no critical risk of bias.

Conclusions and relevance

This meta-analysis found superior late survival associated with total arterial revascularization. Further randomized clinical trials are needed.

Funding Acknowledgement

Type of funding sources: None.

[Long-term outcomes of 328 patients with of autism spectrum disorder after fecal microbiota transplantation]

Objective: To evaluate the efficacy and safety of fecal microbiota transplantation (FMT) in the treatment of autism spectrum disorder (ASD). Methods: A longitudinal study was conducted. Clinical data from ASD patients with gastrointestinal symptoms and who underwent FMT in the Tenth People's Hospital affiliated to Tongji University or Jinling Hospital between May 2012 to May 2021 were retrospectively collected. Scores derived from the autism behavior checklist (ABC), the childhood autism rating scale (CARS), the Bristol stool form scale (BSFS), and the gastrointestinal symptom rating scale (GSRS) were analyzed at baseline and at the 1st, 3rd, 6th, 12th, 24th, 36th, 48th and 60th month after FMT. Records of any adverse reactions were collected. Generalized estimating equations were used for analysis of data on time points before and after FMT. Results: A total of 328 patients met the inclusion criteria for this study. Their mean age was 6.1±3.4 years old. The cohort included 271 boys and 57 girls. The percentage of patients remaining in the study for post-treatment follow-up at the 1st, 3rd, 12th, 24th, 36th, 48th and 60th month were as follows: 303 (92.4%), 284 (86.7%), 213 (64.9%), 190 (57.9%), 143 (43.6%), 79 (24.1%), 46 (14.0%), 31 (9.5%). After FMT, the average ABC score was significantly improved in the first 36 months and remained improved at the 48th month. However, the average score was not significantly different from baseline by the 60th month (1st-36th month, P<0.001; 48th month, P=0.008; 60th month, P=0.108). The average CARS score improved significantly during the first 48 months and remained improved at the 60th month (1st-48th month, P<0.001; 60th month, P=0.010). The average BSFS score was also significantly improved in the first 36 months (with an accompanying stool morphology that resembled type 4). This improvement was maintained at the 48th month. However, the average score was similar to baseline at the 60th month (1st-36th month, P<0.001; 48th month, P=0.008; 60th month, P=0.109). The average GSRS score was significantly improved during the first 24 months, but not afterwards (1st-24th month, P<0.001; 36th month, P=0.209; 48th month, P=0.996; 60th month, P=0.668). The adverse events recorded during treatment included abdominal distension in 21 cases (6.4%), nausea in 14 cases (4.3%), vomiting in 9 cases (2.7%), abdominal pain in 15 cases (4.6%), diarrhea in 18 cases (5.5%), fever in 13 cases (4.0%), and excitement in 24 cases (7.3%). All adverse reactions were mild to moderate and improved immediately after suspension of FMT or on treatment of symptoms. No serious adverse reactions occurred. Conclusion: FMT has satisfactory long-term efficacy and safety for the treatment of ASD with gastrointestinal symptoms.

Cell adhesion molecule BVES functions as a suppressor of tumor cells extrusion in hepatocellular carcinoma metastasis

Background

Tumor cells detachment from primary lesions is an early event for hepatocellular carcinoma (HCC) metastasis, in which cell adhesion molecules play an important role. The role of mechanical crowding has attracted increasing attention. Previous studies have found that overcrowding can induce live cells extrusion to maintain epithelial cell homeostasis, and normally, live extruded cells eventually die through a process termed anoikis, suggesting the potential of tumor cells resistant to anoikis might initiate metastasis from primary tumors by cell extrusion. We have demonstrated transmembrane adhesion molecule blood vessel epicardial substance (BVES) suppression as an early event in HCC metastasis. However, whether its suppression is involved in HCC cell extrusion, especially in HCC metastasis, remains unknown. This study aims to investigate the role of BVES in tumor cells extrusion in HCC metastasis, as well as the underlying mechanisms.

Methods

Cells extrusion was observed by silicone chamber, petri dish inversion, and three-dimensional cell culture model. Polymerase chain reaction, western blotting, immunohistochemistry, immunofluorescence, co-immunoprecipitation, and RhoA activity assays were used to explore the underlying mechanisms of cell extrusion regulated by BVES. An orthotopic xenograft model was established to investigate the effects of BVES and cell extrusion in HCC metastasis in vivo.

Results

Tumor cell extrusion was observed in HCC cells and tissues. BVES expression was decreased both in HCC and extruded tumor cells. BVES overexpression led to the decrease in HCC cells extrusion in vitro and in vivo. Moreover, our data showed that BVES co-localized with ZO-1 and GEFT, regulating ZO-1 expression and localization, and GEFT distribution, thus modulating RhoA activity.

Conclusion

The present study revealed that BVES downregulation in HCC enhanced tumor cells extrusion, thus promoting HCC metastasis, which contributed to a more comprehensive understanding of tumor metastasis, and provided clues for developing novel HCC therapy strategies.

Clinical outcomes of endoscopic treatment for gastric gastrointestinal stromal tumors: a single-center study of 240 cases in China

BACKGROUND AND AIMS

Endoscopic resection (ER) gradually becomes an important treatment method for gastrointestinal stromal tumors (GISTs). The aim of this study is to evaluate the efficacy and safety of ER of gastric GISTs.

METHODS

This retrospective study included 240 patients with gastric GISTs who underwent ER at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2010 to December 2019. The clinicopathologic, endoscopic and follow-up data of the patients were collected and analyzed.

RESULTS

The mean maximum tumor diameter was 1.67 ± 1.00 cm (range 0.2-6.5 cm), of which 156 cases (65.00%) were small gastric GISTs (tumor diameter < 2 cm). A total of 43 patients (17.92%) had perioperative bleeding, including 40 cases (16.67%) of minor bleeding and three cases (1.25%) of major bleeding. Perioperative perforation occurred in 101 patients (42.08%), of which 51 patients (21.25%) were active perforation and 50 patients (20.83%) were passive perforation. The en bloc resection rate was 97.08% (233/240), and seven cases (2.92%) had piecemeal resection. There were three cases (1.92%) of small gastric GISTs at intermediate risk and one case (0.64%) at high risk. A total of 193 patients were followed up, and no tumor residual, recurrence or metastasis occurred within a median follow-up time of 30 months (range 1-127 months).

CONCLUSIONS

Endoscopic treatment for gastric GISTs is safe and effective. Piecemeal resection does not seem to be related to the patient's prognosis. Endoscopic resection can be performed if patients are willing to remove small gastric GISTs.

Pharmacological inhibition of eIF2alpha phosphorylation by integrated stress response inhibitor (ISRIB) ameliorates vascular calcification in rats

Vascular calcification (VC) is an independent risk factor for cardiovascular events and all-cause mortality with the absence of current treatment. This study aimed to investigate whether eIF2alpha phosphorylation inhibition could ameliorate VC. VC in rats was induced by administration of vitamin D3 (3×10(5) IU/kg, intramuscularly) plus nicotine (25 mg/kg, intragastrically). ISRIB (0.25 mg/kg·week), an inhibitor of eIF2alpha phosphorylation, ameliorated the elevation of calcium deposition and ALP activity in calcified rat aortas, accompanied by amelioration of increased SBP, PP, and PWV. The decreased protein levels of calponin and SM22alpha, and the increased levels of RUNX2 and BMP2 in calcified aorta were all rescued by ISRIB, while the increased levels of the GRP78, GRP94, and C/EBP homologous proteins in rats with VC were also attenuated. Moreover, ISRIB could prevent the elevation of eIF2alpha phosphorylation and ATF4, and partially inhibit PERK phosphorylation in the calcified aorta. These results suggested that an eIF2alpha phosphorylation inhibitor could ameliorate VC pathogenesis by blocking eIF2alpha/ATF4 signaling, which may provide a new target for VC prevention and treatment.

Development of a Convolutional Neural Network-Based Colonoscopy Image Assessment Model for Differentiating Crohn’s Disease and Ulcerative Colitis

Objective

Evaluation of the endoscopic features of Crohn’s disease (CD) and ulcerative colitis (UC) is the key diagnostic approach in distinguishing these two diseases. However, making diagnostic differentiation of endoscopic images requires precise interpretation by experienced clinicians, which remains a challenge to date. Therefore, this study aimed to establish a convolutional neural network (CNN)-based model to facilitate the diagnostic classification among CD, UC, and healthy controls based on colonoscopy images.

Methods

A total of 15,330 eligible colonoscopy images from 217 CD patients, 279 UC patients, and 100 healthy subjects recorded in the endoscopic database of Tongji Hospital were retrospectively collected. After selecting the ResNeXt-101 network, it was trained to classify endoscopic images either as CD, UC, or normal. We assessed its performance by comparing the per-image and per-patient parameters of the classification task with that of the six clinicians of different seniority.

Results

In per-image analysis, ResNeXt-101 achieved an overall accuracy of 92.04% for the three-category classification task, which was higher than that of the six clinicians (90.67, 78.33, 86.08, 73.66, 58.30, and 86.21%, respectively). ResNeXt-101 also showed higher differential diagnosis accuracy compared with the best performing clinician (CD 92.39 vs. 91.70%; UC 93.35 vs. 92.39%; normal 98.35 vs. 97.26%). In per-patient analysis, the overall accuracy of the CNN model was 90.91%, compared with 93.94, 78.79, 83.33, 59.09, 56.06, and 90.91% of the clinicians, respectively.

Conclusion

The ResNeXt-101 model, established in our study, performed superior to most clinicians in classifying the colonoscopy images as CD, UC, or healthy subjects, suggesting its potential applications in clinical settings.

Celastrol Alleviates Autoimmune Hepatitis Through the PI3K/AKT Signaling Pathway Based on Network Pharmacology and Experiments

Objective: This work aims to explore the potential targets and underlying therapeutic mechanisms of celastrol in autoimmune hepatitis (AIH) through network pharmacology and experiments on Laboratory Animals.

Methods: A drug-target interaction network was constructed to predict the possible targets of celastrol and their potential relationship with the drug; docking studies were also performed for validation. This study used both acute and chronic rodent models of autoimmune hepatitis. Gross appearance of liver and spleen were obtained from murine models, hematoxylin-eosin staining and Sirius red staining were performed to examine hepatic inflammation and fibrosis respectively. By combining molecular docking and enrichment analysis results, the most prominent signaling pathway was selected and further confirmed by Western blot in AIH models administered with celastrol.

Results: In total, 82 common targets of celastrol and AIH were obtained from databases, identified by network pharmacology, and adequately enriched. Among them, PIK3R1, SRC, MAPK1, AKT1, and HRAS were selected as the top 5 closely related targets to celastrol. They all performed effectively in molecular docking, with AKT1 and PIK3R1 exhibiting more-prominent binding energy. Subsequently, celastrol administration significantly ameliorated hepatitis and liver fibrosis by reducing AKT1 and PI3K phosphorylation in both acute liver injury and chronic models of autoimmune hepatitis.

Conclusion: In summary, celastrol significantly attenuates autoimmune hepatitis by suppressing the PI3K/AKT signaling pathway, confirmed by validated animal models. These findings may help identify the mechanism involved in the anti-inflammatory action of celastrol in autoimmune hepatitis and provide ideas for future comprehensive studies.

NSAID-Associated Small Intestinal Injury: An Overview From Animal Model Development to Pathogenesis, Treatment, and Prevention

With the wide application of non-steroidal anti-inflammatory drugs (NSAIDs), their gastrointestinal side effects are an urgent health burden. There are currently sound preventive measures for upper gastrointestinal injury, however, there is a lack of effective defense against lower gastrointestinal damage. According to a large number of previous animal experiments, a variety of NSAIDs have been demonstrated to induce small intestinal mucosal injury in vivo. This article reviews the descriptive data on the administration dose, administration method, mucosal injury site, and morphological characteristics of inflammatory sites of various NSAIDs. The cells, cytokines, receptors and ligands, pathways, enzyme inhibition, bacteria, enterohepatic circulation, oxidative stress, and other potential pathogenic factors involved in NSAID-associated enteropathy are also reviewed. We point out the limitations of drug modeling at this stage and are also pleased to discover the application prospects of chemically modified NSAIDs, dietary therapy, and many natural products against intestinal mucosal injury.

Protein arginine methyltransferase 3 promotes glycolysis and hepatocellular carcinoma growth by enhancing arginine methylation of lactate dehydrogenase A

BACKGROUND

Protein arginine methylation has emerged a pivotal role in cancer progression. However, the role of protein arginine methyltransferase 3 (PRMT3) in hepatocellular carcinoma (HCC) remains unknown.

METHODS

The expression pattern of PRMT3 in HCC was analysed using quantitative real-time-polymerase chain reaction (qRT-PCR), Western blotting and immunohistochemistry assays. Loss- and gain-of-function experiments were carried out to determine the oncogenic role of PRMT3 in HCC. Glucose consumption and lactate production assays, seahorse bioscience, mass spectrometry, co-immunoprecipitation, metabonomic analysis and site-specific mutation experiments were used to explore the underlying molecular mechanisms. Furthermore, a xenograft mouse model was established to investigate the effects of PRMT3 and its inhibitor, SGC707, treatment on tumour growth in vivo.

RESULTS

The expression of PRMT3 was significantly upregulated in HCC, with high expression of which correlated with poor prognosis. PRMT3 knockdown led to the decrease in proliferation, glycolysis of HCC cells and tumour growth, whilst its overexpression showed opposite results. The catalytic activity of PRMT3 was important in mediating these biological processes. Mechanistically, our data showed that PRMT3 interacted with and mediated asymmetric dimethylarginine (ADMA) modification of lactate dehydrogenase A (LDHA) at arginine 112 (R112). Compared with LDHA-wild-type (LDHA-WT) cells, LDHA-R112K-mutant-expressing HCC cells exhibited a decrease in lactate dehydrogenase (LDH) activity, HCC cell glycolysis and proliferation. Furthermore, the administration of SGC707, a selective inhibitor of PRMT3, disrupted the PRMT3-mediated LDHA methylation and abolished PRMT3-induced HCC glycolysis and tumour growth.

CONCLUSIONS

Our results suggested a novel oncogenic role of PRMT3 in HCC, and it could be a promising therapeutic target for HCC by linking post-translational modification and cancer metabolism.

Hypertriglyceridemia may contribute to stroke and pancreatitis: A case report and review of the literature

Hypertriglyceridemia (HTG) is one of the most common clinical dyslipidemia. Nevertheless, stroke and acute pancreatitis co-occurrence due to hypertriglyceridemia are extremely rare. We present a case of hypertriglyceridemia-associated stroke and pancreatitis in a 39-year-old woman. The patient's laboratory tests reported high triglyceride concentrations beyond the instrument's detection range, and radiological examination showed typical signs of cerebral infarction and acute pancreatitis. The patient received combined blood purification therapy, intravenous thrombolysis with urokinase, and conservative treatment of pancreatitis. We discuss the clinical features, pathogenesis, diagnosis, and treatment of hypertriglyceridemic stroke and pancreatitis combined with the relevant literature. We reviewed the mechanisms by which triglycerides contribute to atherosclerosis and acute pancreatitis. We point out the superiority of combined blood purification therapy and caution physicians about the effects of prescribed drugs on blood lipids.

Epstein-Barr Virus is Associated with Gastric Cancer Precursor: Atrophic Gastritis

Background: About 10% of gastric cancer (GC) has been described to be Epstein-Barr virus (EBV) positive. Previous researches have described the association between EBV and GC. However, the association of EBV with atrophic gastritis (AG) is underrecognized. Our study aimed to investigate the relationship between EBV and AG and assess the influence of EBV on gastric function. Methods: A total of 468 pathologically-confirmed chronic gastritis patients underwent circulating EBV DNA test, include 271 non-atrophic gastritis (NAG) and 197 AG patients. Results: In this study, H. pylori infection rate was 33.3%, EBV infection rate was 40%, and co-infection rate was 15%. The EBV DNA-positive was significantly associated with AG (P=0.031, OR= 1.509, 95% CI 1.037-2.194), especially in H. pylori-negative subjects (P=0.044, OR=1.619, 95% CI 1.012-2.589). EBV DNA-positive patients had a lower pepsinogen I (PG I) / pepsinogen II (PG II) ratio (PGR) than EBV DNA-negative patients (P=0.0026), especially in the AG subgroup (P=0.0062). There was no significant association between EBV and H. pylori co-infection with increased risk of AG (P>0.05). Conclusion: EBV infection significantly increased the risk of AG, especially in H. pylori-negative patients. The circulating EBV DNA had a potential in predicting the risk of atrophic gastritis.

Overexpression of BACH1 mediated by IGF2 facilitates hepatocellular carcinoma growth and metastasis via IGF1R and PTK2

Background: Accumulating studies manifest that BTB and CNC homology 1 (BACH1) facilitates multiple malignancies progression and metastasis, and targeting the BACH1 pathway enhances antitumor efficacy. Nevertheless, the exact mechanism of BACH1 promoting growth and metastasis and its therapeutic significance in hepatocellular carcinoma (HCC) remain unclear.

Methods: The expression of BACH1 in human HCC specimens and HCC cell lines was analyzed by quantitative RT-PCR (RT-qPCR), western blot, and immunohistochemistry (IHC). The invasiveness and metastasis of HCC cells in vitro and in vivo were evaluated using transwell assays and orthotopic xenograft models. The luciferase reporter assays and chromatin immunoprecipitation (ChIP) assays were performed to explore the transcriptional regulation of insulin-like growth factor 1 receptor (IGF1R) and protein tyrosine kinase 2 (PTK2) by BACH1.

Results: BACH1 was prominently upregulated in human HCC samples and elevated BACH1 expression was associated with poor overall survival (OS) and high recurrence rates of HCC patients. BACH1 facilitated growth and metastasis of HCC by upregulating cell motility-related genes IGF1R and PTK2. Notably, insulin-like growth factor 2 (IGF2), the ligand of IGF1R, in turn upregulated BACH1 expression through the IGF1R-ERK1/2-ETS1 cascades, thus forming a positive feedback loop to provoke HCC growth and metastasis. Moreover, combining IGF1R inhibitor linsitinib with PTK2 inhibitor defactinib prominently suppressed BACH1-mediated HCC growth and metastasis.

Conclusions: These results demonstrated the tumorigenic and pro-metastatic role of BACH1 in HCC, which could be a promising biomarker for predicting poor prognosis and selecting patients who could benefit from combination therapy of IGF1R-targeted and PTK2-directed.

Regulatory T-cell and neutrophil extracellular trap interaction contributes to carcinogenesis in non-alcoholic steatohepatitis

BACKGROUND & AIMS

Regulatory T-cells (Tregs) impair cancer immunosurveillance by creating an immunosuppressive environment that fosters tumor cell survival. Our previous findings demonstrated that neutrophil extracellular traps (NETs), which are involved both in innate and adaptive immunity, are abundant in livers affected by non-alcoholic steatohepatitis (NASH). However, how NETs interact with Tregs in the development of NASH-associated hepatocellular carcinoma (NASH-HCC) is not known.

METHODS

A choline-deficient, high-fat diet+diethylnitrosamine mouse model and the stelic animal model were utilized for NASH-HCC and a western diet mouse model was used for NASH development. Treg depletion was achieved using FoxP3-DTR mice. RNA sequencing was used to explore the mechanism by which NETs could regulate Treg differentiation. Bioenergetic analyses of naïve CD4⁺ T-cells were assessed by Seahorse.

RESULTS

Although the absolute number of CD4⁺ T-cells is lower in NASH livers, the Treg subpopulation is selectively increased. Depleting Tregs dramatically inhibits HCC initiation and progression in NASH. There is a positive correlation between increased NET and hepatic Treg levels. RNA sequencing data reveals that NETs impact gene expression profiles in naïve CD4⁺ T-cells, with the most differentially expressed genes being those involved in mitochondrial oxidative phosphorylation. By facilitating mitochondrial respiration, NETs can promote Treg differentiation. Metabolic reprogramming of naïve CD4⁺ T-cells by NETs requires toll-like receptor 4. Blockade of NETs in vivo using Pad4^-/- mice or DNase I treatment reduces the activity of Tregs.

CONCLUSIONS

Tregs can suppress immunosurveillance in the premalignant stages of NASH. NETs facilitate the crosstalk between innate and adaptive immunity in NASH by promoting Treg activity through metabolic reprogramming. Therapies targeting NETs and Treg interactions could offer a potential strategy for preventing HCC in patients with NASH.

LAY SUMMARY

Regulatory T-cells (Tregs) can promote tumor development by suppressing cancer immunosurveillance, but their role in carcinogenesis during non-alcoholic steatohepatitis (NASH) progression is unknown. Herein, we discovered that selectively increased intrahepatic Tregs can promote an immunosuppressive environment in NASH livers. Neutrophil extracellular traps (NETs) link innate and adaptive immunity by promoting Treg differentiation via metabolic reprogramming of naïve CD4⁺ T-cells. This mechanism could be targeted to prevent liver cancer in patients with NASH.

IL-1β-Induced Elevation of Solute Carrier Family 7 Member 11 Promotes Hepatocellular Carcinoma Metastasis Through Up-regulating Programmed Death Ligand 1 and Colony-Stimulating Factor 1

BACKGROUND AND AIMS

Because of a paucity of effective treatment options, metastasis is still a major cause for HCC-associated mortality. The molecular mechanism of inflammation-induced HCC metastasis is open for study. Here, we characterized the function of solute carrier family 7 member 11 (SLC7A11) in inflammation-related HCC metastasis and probed therapy strategies for this subpopulation of patients.

APPROACH AND RESULTS

Elevated expression of SLC7A11 was positively correlated with poor tumor differentiation, and higher tumor-nodule-metastasis stage, and indicated poor prognosis in human HCC. SLC7A11 increased HIF1α expression through reducing α-ketoglutarate (αKG) level by exporting glutamate. SLC7A11 up-regulated programmed death ligand 1 (PD-L1) and colony-stimulating factor 1 (CSF1) expression through αKG-HIF1α cascade. SLC7A11 overexpression in HCC cells promoted intratumoral tumor-associated macrophage (TAM) and myeloid-derived suppressor cell (MDSC) infiltration through the CSF1/colony-stimulating factor 1 receptor (CSF1R) axis, whereas knockdown of CSF1 attenuated SLC7A11-mediated intratumoral TAM and MDSC infiltration and HCC metastasis. Depletion of either TAMs or MDSCs decreased SLC7A11-mediated HCC metastasis. Furthermore, the combination of CSF1R inhibitor BZL945 and anti-PD-L1 antibody blocked SLC7A11-induced HCC metastasis. In addition, IL-1β up-regulated SLC7A11 expression through the interleukin-1 receptor type 1 (IL-1R1)/extracellular signal-regulated kinase/specificity protein 1 pathway. SLC7A11 knockdown impaired IL-1β-promoted HCC metastasis. Anakinra, an IL-1R1 antagonist, reversed IL-1β-promoted HCC metastasis. In human HCC tissues, SLC7A11 expression was positively associated with HIF1α, PD-L1, and CSF1 expression and intratumoral TAM and MDSC infiltration.

CONCLUSIONS

IL-1β-induced SLC7A11 overexpression up-regulated PD-L1 and CSF1 through the αKG/HIF1α axis, which promoted TAM and MDSC infiltration. Interruption of this oncogenic loop may provide a promising therapy strategy for the inhibition of SLC7A11-mediated HCC metastasis.

Novel AVPR2 mutations and clinical characteristics in 28 Chinese families with congenital nephrogenic diabetes insipidus

AIMS

To investigate genotype and phenotype of congenital nephrogenic diabetes insipidus caused by AVPR2 mutations, which is rare and limitedly studied in Chinese population.

METHODS

88 subjects from 28 families with NDI in a department (Beijing, PUMCH) were screened for AVPR2 mutations. Medical records were retrospectively reviewed and characterized. Genotype and phenotype analysis was performed.

RESULTS

23 AVPR2 mutations were identified, including six novel mutations (p.Y117D, p.W208R, p.L313R, p.S127del, p.V162Sfs*30 and p.G251Pfs*96). The onset-age ranged from 1 week to 3 years. Common presentations were polydipsia and polyuria (100%) and intermittent fever (57%). 21% and 14% of patients had short stature and mental impairment. Urine SG and osmolality were decreased, while serum osmolality and sodium were high. Urological ultrasonography results showed hydronephrosis of the kidney (52%), dilation of the ureter (48%), and thickened bladder wall or increased residual urine (32%), led to intermittent urethral catheterization (7%), cystostomy (11%) and binary nephrostomy (4%). Urological defects were developed in older patients. Genotype and phenotype analysis revealed patients with non-missense mutations had higher levels of serum sodium than missense mutations.

CONCLUSION

In the first and largest case series of NDI caused by AVPR2 mutations in Chinese population, we established genetic profile and characterized clinical data, reporting six novel mutations. Further, we found genotype was associated with phenotype. This knowledge broadens genotype and phenotype spectrum of rare congenital NDI caused by AVPR2 mutations, and provides basis for studying molecular biology of AVPR2.

TCF4 enhances hepatic metastasis of colorectal cancer by regulating tumor-associated macrophage via CCL2/CCR2 signaling

Colorectal cancer (CRC) liver metastasis is a significant clinical problem for which better therapies are urgently needed. Tumor-associated macrophage, a major cell population in the tumor microenvironment, is a known contributor to primary cancer progression and cancer metastasis. Here, we found TAM recruitment and M2 polarization were increased in the hepatic metastatic lesion compared with the primary site of human CRC tissues. Moreover, Pearson correlation analysis showed that TAM recruitment and polarization were closely correlated with the elevated TCF4 expression in the metastatic site. To investigate the role of TCF4 in CRC liver metastasis, we generated a syngeneic mouse model using MC38 cells splenic injection. Results from in vivo experiments and mouse models revealed that TCF4 deficiency in MC38 cells does not affect their proliferation and invasion; however, it reduces TAM infiltration and M2 polarization in the metastasis site. Further studies indicated that these effects are mediated by the TCF4 regulated CCL2 and CCR2 expression. TCF4 or CCL2 silencing in the tumor cells prevent CRC liver metastasis in the mouse model. Altogether, these findings suggest that the TCF4-CCL2-CCR2 axis plays an essential role in CRC liver metastasis by enhancing TAMs recruitment and M2 polarization.

Manganese promoted wheat straw decomposition by regulating microbial communities and enzyme activities

AIMS

This study investigated the dose-effect of manganese (Mn) addition on wheat straw (WS) decomposition, and explored the potential mechanisms of Mn involved in the acceleration of WS decomposition in regards to the soil microbial communities and enzyme activities.

METHODS AND RESULTS

A 180-day incubation experiment was performed to examine the decomposition of WS under four Mn levels, that is, 0, 0.25, 1 and 2 mg g^-1 . The effects of microbial communities and enzyme activities were evaluated using control (0 mg g^-1 ) and Mn (0.25 mg g^-1 ) treatments. Our results revealed that Mn (0.25 mg g^-1 ) addition significantly increased WS decomposition, and enhanced the release of carbon and nitrogen. Optimal Mn addition (0.25 mg g^-1 ) also caused significant increases in the activity of neutral xylanase (NEX), laccase (Lac), manganese peroxidase (MnP) and lignin peroxidase (LiP) within the incubation period. Mn (0.25 mg g^-1 ) addition also enriched some operational taxonomic units (OTUs) that, in turn, had the potential ability to decompose crop straw, such as secreting lignocellulolytic enzymes.

CONCLUSIONS

Mn (0.25 mg g^-1 ) could promote WS decomposition through enrichment of the microbial species involved in biomass decomposition, which enhanced the lignocellulose-degrading enzyme activity.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study provides evidence for Mn to promote WS biodegradation after Mn application, opening new windows to improve the utilization efficiency of crop residues.

Protein arginine methyltransferases and hepatocellular carcinoma: A review

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Protein arginine methylation is essential in multiple biological processes.

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The family of PRMTs is a novel regulator of liver diseases.

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Deregulation of PRMTs is correlated with HCC prognosis and clinical features.

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PRMTs play a vital role in HCC malignancy, immune responses and metabolism.

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PRMTs may represent druggable targets as novel strategies for HCC therapy.

Hepatocellular carcinoma (HCC) is one of the most frequently diagnosed cancers with a high mortality rate worldwide. The complexity of HCC initiation and progression poses a great challenge to the diagnosis and treatment. An increasing number of studies have focused on the emerging roles of protein arginine methylation in cancers, including tumor growth, invasion, metastasis, metabolism, immune responses, chemotherapy sensitivity, etc. The family of protein arginine methyltransferases (PRMTs) is the most important proteins that mediate arginine methylation. The deregulation of PRMTs’ expression and functions in cancers have been gradually unveiled, and many PRMTs inhibitors are in preclinical and clinical investigations now. This review focuses predominantly on the aberrant expression of PRMTs, underlying mechanisms, as well as their potential applications in HCC, and provide novel insights into HCC therapy.

The roles of nausea and vomiting in COVID-19: did we miss something?

The Coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an international public health emergency. Although respiratory symptoms predominate the clinical manifestations of COVID-19, gastrointestinal symptoms have been observed in a subset of patients. Notably, some patients have nausea/vomiting as the first clinical manifestation of COVID-19, which is often overlooked by people. It is now clear that not only the lungs, the gastrointestinal tract could also be attacked by SARS-CoV-2. Its host receptor angiotensin-converting enzyme 2 (ACE2), which acts as a gateway to infection, has been found to be highly expressed in the gastrointestinal epithelium and may lead to the development of nausea/vomiting. Raise awareness of these symptoms and take timely intervention would help people combat the pandemic. This review discussed epidemiology, mechanisms, management, and prevention of COVID-19 related nausea and vomiting.

Inverse Association Between Helicobacter pylori Infection and Unexplained Isolated Terminal Ileitis: A Retrospective Study

Background

Isolated terminal ileitis (ITI) is a phenomenon often observed during colonoscopy, but in most cases, the specific etiology of ITI is unclear. Helicobacter pylori (H. pylori) infection has been reported to be associated with a wide variety of diseases, especially gastrointestinal diseases. Here, we conducted a retrospective study to explore a potential correlation between H. pylori infection and unexplained ITI (UITI).

Materials and Methods

The retrospective study was conducted at Sino-French New City Branch of Tongji Hospital, Wuhan, China, from April 2017 to October 2020. All subjects underwent total colonoscopy, with the endoscope being inserted more than 10cm into the terminal ileum. Subjects also received a ¹³C-urea breath test (¹³C-UBT). Data on the age, gender, endoscopic manifestations, and main clinical symptoms of subjects were collected. The presence of H. pylori infection was defined as a positive ¹³C-UBT result. Logistic regression models were used to analyze the potential correlation between H. pylori infection and UITI.

Results

There were 247 subjects (25.1%) in the H. pylori (+) group and 739 subjects (74.9%) in the H. pylori (-) group. The prevalence of UITI in the H. pylori (+) group was significantly lower than that in the H. pylori (-) group (OR = 0.518; 95% CI 0.281-0.956; P = 0.035), and there was no difference in other clinical features between groups. Stratification analysis results showed that there was an inverse association between H. pylori infection and UITI in subjects with age <60 (P = 0.046).

Conclusion

These data showed that H. pylori infection was negatively correlated with UITI. Additional studies are needed to validate these findings in a larger cohort as well as to explore the underlying mechanisms.

HRC promotes anoikis resistance and metastasis by suppressing endoplasmic reticulum stress in hepatocellular carcinoma

Histidine-rich calcium binding protein (HRC) is markedly overexpressed in hepatocellular carcinoma (HCC) and is significantly correlated with metastasis. Anoikis resistance and endoplasmic reticulum (ER) stress may have a critical effect on survival before metastasis. However, the potential functions of HRC in anoikis resistance in HCC remain unknown. Here, we uncovered the clinical value of HRC and its functional significance on anoikis in HCC. The positive expression of HRC was observably correlated with tumor size, tumor encapsulation, and tumor-node-metastasis (TNM) stage. The expression of HRC increased in HCC cells cultured in suspension. HRC enhanced the anoikis resistance of HCC, and promoted the HCC metastasis in vivo. Mechanistically, the anoikis resistance was probably dependent on endoplasmic reticulum stress. Modulating HRC level changed the ERS to affect anoikis resistance by acting protein kinase RNA-like ER kinase (PERK)-eIF2a-ATF4-CHOP signaling axis. In conclusion, we define HRC as a novel candidate oncogene involved in anoikis resistance and HCC metastasis, and provide a new potential therapeutic target for HCC.

SLC7A2 deficiency promotes hepatocellular carcinoma progression by enhancing recruitment of myeloid-derived suppressors cells

The main reason for poor prognosis in hepatocellular carcinoma (HCC) patients is high metastasis and recurrence. Cancer progression depends on a tumor-supportive microenvironment. Therefore, illustrating the mechanisms of tumor immunity in underlying HCC metastasis is essential. Here, we report a novel role of solute carrier family 7 member 2 (SLC7A2), a member of the solute carrier family, in HCC metastasis. The reduction of SLC7A2 was an independent and significant risk factor for the survival of HCC patients. Upregulation of SLC7A2 decreased HCC invasion and metastasis, whereas downregulation of SLC7A2 promoted HCC invasion and metastasis. We further found that deficient SLC7A2 medicated the upregulation of CXCL1 through PI3K/Akt/NF-kκB pathway to recruit myeloid-derived suppressor cells (MDSCs), exerting tumor immunosuppressive effect. Moreover, we found that G9a-mediated di-methylation of H3K9 (H3K9me2) silenced the expression of SLC7A2 to suppress HCC metastasis and immune escape. In conclusion, G9a-mediated silencing of SLC7A2 exerts unexpected functions in cancer metastasis by fostering a tumor-supportive microenvironment through CXCL1 secretion and MDSCs recruitment. Thus, SLC7A2 may provide new mechanistic insight into the cancer-promoting property of MDSCs.

EZH2-mediated inhibition of KLF14 expression promotes HSCs activation and liver fibrosis by downregulating PPARγ

OBJECTIVES

Induction of deactivation and apoptosis of hepatic stellate cells (HSCs) are principal therapeutic strategies for liver fibrosis. Krüppel-like factor 14 (KLF14) regulates various biological processes, however, roles, mechanisms and implications of KLF14 in liver fibrosis are unknown.

MATERIALS AND METHODS

KLF14 expression was detected in human, rat and mouse fibrotic models, and its effects on HSCs were assessed. Chromatin immunoprecipitation assays were utilized to investigate the binding of KLF14 to peroxisome proliferator-activated receptor γ (PPARγ) promoter, and the binding of enhancer of zeste homolog 2 (EZH2) to KLF14 promoter. In vivo, KLF14-overexpressing adenovirus was injected via tail vein to thioacetamide (TAA)-treated rats to investigate the role of KLF14 in liver fibrosis progression. EZH2 inhibitor EPZ-6438 was utilized to treat TAA-induced rat liver fibrosis.

RESULTS

KLF14 expression was remarkably decreased in human, rat and mouse fibrotic liver tissues. Overexpression of KLF14 increased LD accumulation, inhibited HSCs activation, proliferation, migration and induced G2/M arrest and apoptosis. Mechanistically, KLF14 transactivated PPARγ promoter activity. Inhibition of PPARγ blocked the suppressive role of KLF14 overexpression in HSCs. Downregulation of KLF14 in activated HSCs was mediated by EZH2-regulated histone H3 lysine 27 trimethylation. Adenovirus-mediated KLF14 overexpression ameliorated TAA-induced rat liver fibrosis in PPARγ-dependent manner. Furthermore, EPZ-6438 dramatically alleviated TAA-induced rat liver fibrosis. Importantly, KLF14 expression was decreased in human with liver fibrosis, which was significantly correlated with EZH2 upregulation and PPARγ downregulation.

CONCLUSIONS

KLF14 exerts a critical anti-fibrotic role in liver fibrosis, and targeting the EZH2/KLF14/PPARγ axis might be a novel therapeutic strategy for liver fibrosis.

miR-20a/TCF4 axis-mediated inhibition of hepatocytes proliferation impairs liver regeneration in mice PHx model by regulating CDC2 and CDC6

MicroRNAs have emerged as essential regulators in the biological process of liver regeneration by modulating the post‐transcriptional expression of the target genes. In the present study, we found miR‐20a expression is decreased remarkably in three rodent liver regeneration models using miRNA PCR array and Venn diagram analysis. Inhibition of miR‐20a expression enhanced hepatocytes proliferation in vivo and in vitro. In contrast, overexpression of miR‐20a reduces hepatocytes proliferation and subsequently impaired liver regeneration in the mouse PHx model. Moreover, we have identified TCF4 as a target gene of miR‐20a using the PCR Array and luciferase assay. Next, mice with TCF4 deficiency were used to establish the PHx model and subjected to the examination of liver regeneration capacity. We found TCF4‐deficient mice exhibited impaired liver regeneration compared with control. Given that TCF4 acts as a transcription factor, we sort to elucidate the downstream genes involved in liver regeneration. Promoter analysis and Chip assay confirmed that TCF4 enhances CDC2 and CDC6 expression through binding to the promoter region and leads to the proliferation and cell cycle progression in hepatocytes. In conclusion, this study provides evidence that the miR20a‐TCF4‐CDC2/6 axis plays an essential role during liver regeneration.

Clinical Features of Patients Infected With Coronavirus Disease 2019 With Elevated Liver Biochemistries: A Multicenter, Retrospective Study

BACKGROUND AND AIMS

In December 2019, an outbreak of coronavirus disease 2019 (COVID-19) emerged in Wuhan, China. Although it has been reported that some patients with COVID-19 showed elevated liver biochemistries, there are few studies regarding the clinical features and prognosis of these patients.

APPROACH AND RESULTS

In this multicenter, retrospective study, we collected data on laboratory-confirmed patients with COVID-19 from three hospitals in Wuhan, China, who died or were discharged between February 1, 2020, and February 20, 2020. Data on demographics, comorbidities, clinical symptoms, laboratory examinations on admission, complications, treatment, and outcome were collected. A total of 482 patients were enrolled in this study. Of those, 142 (29.5%) patients showed abnormal liver biochemistries on admission, and patients with elevated alanine aminotransferase, aspartate aminotransferase (AST), and total bilirubin (TBIL) accounted for 67.6%, 69.0%, and 16.2%, respectively. Those with abnormal liver biochemistries showed higher percentages of severe cases and comorbidities and were more likely to have dyspnea, chest distress or pain, and increased hemoglobin (Hb) on admission. Higher rates of complications and mortality and worse recovery when discharged were observed in patients with abnormal AST or TBIL. Multivariable regression analysis showed that chest distress or pain (odds ratio [OR], 1.765; P = 0.018), dyspnea (OR, 2.495; P = 0.001), elevated C-reactive protein level (OR, 1.007; P = 0.008), elevated white blood count (OR, 1.139; P = 0.013), and elevated Hb concentration (OR, 1.024; P = 0.001) were independent factors associated with elevated liver biochemistries in patients with COVID-19.

CONCLUSIONS

Elevated liver biochemistries were common in patients with COVID-19. Patients with hypoxia or severe inflammation are more likely to experience increased liver biochemistries on admission. Those with abnormal AST or TBIL on admission are more likely to suffer from severe complications and death.

Homeobox B5 promotes metastasis and poor prognosis in Hepatocellular Carcinoma, via FGFR4 and CXCL1 upregulation

Background: Since metastasis remains the main reason for HCC-associated death, a better understanding of molecular mechanism underlying HCC metastasis is urgently needed. Here, we elucidated the role of Homeobox B5 (HOXB5), a member of the HOX transcriptional factor family, in promoting HCC metastasis.

Method: The expression of HOXB5 and its functional targets fibroblast growth factor receptor 4 (FGFR4) and C-X-C motif chemokine ligand 1 (CXCL1) were detected by immunohistochemistry. Luciferase reporter and chromatin immunoprecipitation assays were performed to measure the transcriptional regulation of target genes by HOXB5. The effects of FGFR4 and CXCL1 on HOXB5-mediated metastasis were analyzed by an orthotopic metastasis model.

Results: Elevated expression of HOXB5 had a positive correlation with poor tumour differentiation, higher TNM stage, and indicated unfavorable prognosis. Overexpression of HOXB5 promoted HCC metastasis through transactivating FGFR4 and CXCL1 expression, whereas knockdown of FGFR4 and CXCL1 decreased HOXB5-enhanced HCC metastasis. Moreover, HOXB5 overexpression in HCC cells promoted myeloid derived suppressor cells (MDSCs) infiltration through CXCL1/CXCR2 axis. Either depletion of MDSCs by anti-Gr1 or blocking CXCL1-CXCR2 axis by CXCR2 inhibitor impaired HOXB5-mediated HCC metastasis. In addition, fibroblast growth factor 19 (FGF19) contributed to the HOXB5 upregulation through PI3K/AKT/HIF1α pathway. Overexpression of FGF15 (an analog of FGF19 in mouse) promoted HCC metastasis, whereas knockdown of HOXB5 significantly inhibited FGF15-enhanced HCC metastasis in immunocompetent mice. HOXB5 expression was positively associated with CXCL1 expression and intratumoral MDSCs accumulation in human HCC tissues. Patients who co-expressed HOXB5/CXCL1 or HOXB5/CD11b exhibited the worst prognosis. Furthermore, the combination of FGFR4 inhibitor BLU-554 and CXCR2 inhibitor SB265610 dramatically decreased HOXB5-mediated HCC metastasis.

Conclusion: HOXB5 was a potential prognostic biomarker in HCC patients and targeting this loop may provide a promising treatment strategy for the inhibition of HOXB5-mediated HCC metastasis.