Development and validation of a nomogram for predicting overall survival in cirrhotic patients with acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is a common and severe complication in patients with cirrhosis, and is associated with poor prognosis. Therefore, identifying cirrhotic patients with AKI who are at high risk of mortality is very important and may be helpful for providing timely medical interventions to improve the prognosis of these patients. However, studies focused on investigating the risk factors for the mortality of cirrhotic patients with AKI were scarce.

AIM

To identify risk factors for mortality and establish a nomogram for predicting the prognosis of these patients.

METHODS

Two hundred fifty consecutive patients with cirrhosis and AKI were recruited and randomly divided into training cohort (n = 173) and validation cohort (n = 77). In the training cohort, potential risk factors for death were identified by performing a Cox regression analysis, and a nomogram was established. The predictive performance of the nomogram was internally and externally validated by calculating the area under the receiver operating characteristic curve (AUROC), constructing a calibration curve and performing decision curve analysis.

RESULTS

The serum sodium level, international normalized ratio, peak serum creatinine level > 1.5 mg/dL, the presence of hepatic encephalopathy and diabetes were potential risk factors for mortality of cirrhotic patients with AKI in the training dataset. A prognostic nomogram incorporating these variables was established for predicting the overall survival of these patients. Compared with Child-Turcotte-Pugh, the model for end-stage liver disease (MELD) and the MELD-Na scores, the nomogram in predicting 90- and 180-d mortality exhibited better discriminatory power with AUROCs of 0.792 and 0.801 for the training dataset and 0.817 and 0.862 for the validation dataset, respectively. With a nomogram score of 98, patients were divided into low- and high-risk groups, and high-risk patients had a higher mortality rate.

CONCLUSION

A prognostic nomogram displayed good performance for predicting the overall survival of cirrhotic patients with AKI, and will assist clinicians in evaluating the prognosis of these patients.

[Analysis of the necessity of anticoagulation therapy and influencing factors of stent occlusion after transjugular intrahepatic portosystemic shunt]

Objective: To explore the necessity of anticoagulation therapy and influencing factors of stent occlusion after transjugular intrahepatic portosystemic shunt. Methods: The basic information, laboratory test results, preoperative portal venous pressure, postoperative anticoagulation time, postoperative stent stenosis or occlusion, followed-up and other data of all patients who underwent TIPS surgery in Shandong Provincial Hospital from 2010 to 2019 were retrospectively analyzed. Data were analyzed using t-test, χ² test, and multivariate analysis (logistic regression and Cox-regression-analysis). Results: A total of 280 cases were finally included in the study, of which 110 (39.3%) had stent stenosis or occlusion, and 170 (60.7%) had stent patency. New or worsening ascites were identified in 194 cases during the follow-up period, including 14 (31.1%) cases in the stent stenosis or occlusion group and 19 (12.8%) cases in the stent patency group. Univariate analysis showed that presence or absence of platelet (P=0.037) and total bilirubin (P=0.038) were correlated with stent stenosis or occlusion. Postoperative continuous anticoagulation was correlated with stent blockage (P=0.029) in patients with partial portal vein thrombosis. Postoperative continuous anticoagulation and stent occlusions were not significantly correlated in patients with preoperative portal cavernoma and preoperative portal vein patency (P=0.848; P=0.744). Multivariate analysis results showed that whether long-term anticoagulation (P=0.017), all-cause rebleeding (P<0.001), postoperative significant hepatic encephalopathy (P<0.012), and postoperative new or worsening ascites (P<0.001) was significantly associated with stent occlusion (P<0.05), while platelets (P=0.134), total bilirubin (P=0.229), international normalized ratio (P=0.436), and portal vein pressure (P=0.230) were not significantly associated with stent occlusion after surgery. Conclusion: In patients with partial portal vein thrombosis before surgery, continuous anticoagulation for 30 days post-TIPS therapy can effectively prevent stent stenosis or occlusion; while in patients with portal vein patency, portal cavernoma and complete portal vein blockage before surgery, postoperative anticoagulation has no significant effect on stent stenosis or occlusion.

[Voxel-based morphometry (VBM) MRI analysis of gray matter in patients with occupational noise-induced hearing loss]

Objective: To investigate the changes of brain gray matter volume in patients with occupational noise-induced hearing loss by voxel based morphometry (VBM) . Methods: 16 age-and education-matched healthy controls and 42 patients with occupational noise induced hearing loss, including 27 in mild group and 15 in severe group, received MRI 3D-FSPGR sequence T1WI sagittal scan, and then underwent VBM of brain gray matter volume data analysis. Results: The brain gray matter volume of the left occipitotemporal lateral gyrus, the anterior cingulate gyrus, the bilateral angular gyrus, the precuneus and the near midline area of cerebellum differed between experimental group and control group (P<0.01) . Conclusion: The volume of gray matter in specific brain areas of patients with occupational noise-induced hearing loss was changed, and the effect of noise on brain structure was revealed from the perspective of imaging.

Duodenal variceal bleeding secondary to idiopathic portal hypertension treated with transjugular intra-hepatic porto-systemic shunt plus embolization: A case report

BACKGROUND

Duodenal varices are a lesser-known complication with non-cirrhotic portal hypertension. We report a circuitous route from missed diagnosis of duodenal varices to correction. An extremely rare case of duodenal variceal bleeding secondary to idiopathic portal hypertension (IPH) is expounded in this study, which was controlled by transjugular intra-hepatic porto-systemic shunt (TIPS) plus embolization.

CASE SUMMARY

A 46-year-old woman with anemia for two years was frequently admitted to the local hospital. Upon examination, anemia was attributed to gastrointestinal tract bleeding, which resulted from duodenal variceal bleeding detected by repeated esophagogastroduodenoscopy. At the end of a complete workup, IPH leading to duodenal varices was diagnosed. Portal venography revealed that the remarked duodenal varices originated from the proximal superior mesenteric vein. TIPS plus embolization with coils and Histoacryl was performed to obliterate the rupture of duodenal varices. The anemia resolved, and the duodenal varices completely vanished by 2 mo after the initial operation.

CONCLUSION

TIPS plus embolization may be more appropriate to treat the bleeding of large duodenal varices.

[Normal values for solid state high resolution anorectal manometry in healthy adult volunteers]

Objective: To explore the normal values for two-dimension solid state high resolution anorectal manometry (HRAM) in healthy adult volunteers. Methods: The healthy adult volunteers were recruited by advertisement and underwent solid state HRAM in the left lateral position. Anorectal pressures and rectal sensation were recorded and analyzed. Results: (1) A total of 126 Chinese healthy adult volunteers (male: 50 cases (39.7%); age: (37.5±14.2) years old ) were recruited in this study. (2) Mean anal resting pressure (MERP) was (71.8±17.3) mmHg (1 mmHg=0.133 kPa). Maximum anal resting pressure (MARP) was (79.3±17.8) mmHg, Maximum anal squeeze pressure (MSP) was (178.7±52.8) mmHg. Anal high pressure zone (HPZ) length was (3.4±0.6) cm. During simulated evacuation, residual anal pressure (RAP) was (63.8±20.5) mmHg, and anal relaxation rate (ARR) was (37.0±11.5)%. Rectal threshold volume for first sensation (FST), desire to defecate (DDT), urgency to defecate (UDT) and maximum discomfort (MDT) was (47.4±10.0) ml, (84.5±18.2) ml, (125.8±28.5) ml, and (175.5±36.1) ml, respectively. (3) Compared with female subjects, male subjects had higher MSP[(211.0±50.7) mmHg vs (157.5±42.5) mmHg], RAP[(71.6±18.1) mmHg vs (58.8±20.5) mmHg]and rectal MDT[(187.0±36.4) mmHg vs (168.0±34.1)mmHg], but lower ARR[(32.1±8.0)% vs (40.2±12.3)%], all P<0.01. (4) MERP, MARP, MSP and rectal MDT were higher in young group (≤40 years old), all P<0.05. Conclusions: These observations provide normal values for two-dimension solid state HRAM, which have significant difference between genders and different age groups.

IL-25 protects against high-fat diet-induced hepatic steatosis in mice by inducing IL-25 and M2a macrophage production

Interleukin (IL)-25 is a cytokine that has previously been shown to have a protective role against nonalcoholic fatty liver disease (NAFLD), which is associated with the induction of M2 macrophage differentiation. However, the direct relationships between IL-25 expression regulation, M2 induction and NAFLD remain unknown. In this study, we demonstrate that IL-25 promotes hepatic macrophage differentiation into M2a macrophages both in vivo and in vitro via the IL-13/STAT6 pathway. M2 macrophages that were differentiated in vitro were able to ameliorate high-fat diet HFD-induced hepatic steatosis. Furthermore, we found that IL-25 treatment, both in vitro and in vivo, promotes direct binding of STAT6 to the IL-25 gene promoter region. This binding of STAT6 in response to IL-25 treatment also resulted in the increase of IL-25 expression in hepatocytes. Together, these findings identify IL-25 as a protective factor against HFD-induced hepatic steatosis by inducing an increase of IL-25 expression in hepatocytes and through promotion of M2a macrophage production.

Progress in endoscopic treatment of gastric varices in patients with liver cirrhosis

Cirrhosis is defined as diffuse or prolonged hepatic damage caused by one or more etiologies. When liver cirrhosis progresses to decompensation stage, hepatic dysfunction and portal hypertension are the main manifestations. Main symptoms of portal hypertension include collateral circulation, splenomegaly, and ascites. Gastric varices (GV) is one of the most common manifestations of collateral circulation. Gastric variceal bleeding (GVB) is one of the most common complications of cirrhosis, with a high mortality rate. In recent years, there are many studies on GV, but the choice of endoscopic treatments for different types of GV is still controversial. Compared with esophageal variceal bleeding, GVB is associated with large volume of bleeding, high risk, and high mortality. Therefore, selecting an appropriate endoscopic treatment can effectively reduce mortality and improve the prognosis. This article reviews the type of GV and endoscopic treatment of different types of GV.

Natural history of covert hepatic encephalopathy: An observational study of 366 cirrhotic patients

AIM

To explore the natural history of covert hepatic encephalopathy (CHE) in absence of medication intervention.

METHODS

Consecutive outpatient cirrhotic patients in a Chinese tertiary care hospital were enrolled and evaluated for CHE diagnosis. They were followed up for a mean of 11.2 ± 1.3 mo. Time to the first cirrhosis-related complications requiring hospitalization, including overt HE (OHE), resolution of CHE and death/transplantation, were compared between CHE and no-CHE patients. Predictors for complication(s) and death/transplantation were also analyzed.

RESULTS

A total of 366 patients (age: 47.2 ± 8.6 years, male: 73.0%) were enrolled. CHE was identified in 131 patients (35.8%). CHE patients had higher rates of death and incidence of complications requiring hospitalization, including OHE, compared to unimpaired patients. Moreover, 17.6% of CHE patients developed OHE, 42.0% suffered persistent CHE, and 19.8% of CHE spontaneously resolved. In CHE patients, serum albumin < 30 g/L (HR = 5.22, P = 0.03) was the sole predictor for developing OHE, and blood creatinine > 133 μmol/L (HR = 4.75, P = 0.036) predicted mortality. Child-Pugh B/C (HR = 0.084, P < 0.001) and OHE history (HR = 0.15, P = 0.014) were predictors of spontaneous resolution of CHE.

CONCLUSION

CHE exacerbates, persists or resolves without medication intervention in clinically stable cirrhosis. Triage of patients based on these predictors will allow for more cost-effect management of CHE.

Ursolic acid suppresses TGF-β1-induced quiescent HSC activation and transformation by inhibiting NADPH oxidase expression and Hedgehog signaling

Activation of quiescent hepatic stellate cells (q-HSCs) and their transformation to myofibroblasts (MFBs) is a key event in liver fibrosis. Hedgehog (Hh) signaling stimulates q-HSCs to differentiate into MFBs, and NADPH oxidase (NOX) may be involved in regulating Hh signaling. The author's preliminary study demonstrated that ursolic acid (UA) selectively induces apoptosis in activated HSCs and inhibits their proliferation in vitro via negative regulation of NOX activity and expression. However, the effect of UA on q-HSCs remains to be elucidated. The present study aimed to investigate the effect of UA on q-HSC activation and HSC transformation and to observe alterations in the NOX and Hh signaling pathways during q-HSC activation. q-HSC were isolated from adult male Sprague-Dawley rats. Following culture for 3 days, the cells were treated with or without transforming growth factor-β1 (TGF-β1; 5 µg/l); intervention groups were pretreated with UA (40 µM) or diphenyleneiodonium chloride (DPI; 10 µM) for 30 min prior to addition of TGF-β1. mRNA and protein expression of NOX and Hh signaling components and markers of q-HSC activation were examined by western blotting and reverse transcription-polymerase chain reaction. TGF-β1 induced activation of q-HSCs, with increased expression of α-smooth muscle actin (α-SMA) and type I collagen. In addition, expression of NOX subunits (gp91^phox, p67^phox, p22^phox, and Rac1) and Hh signaling components, including sonic Hh, sterol-4-alpha-methyl oxidase, and Gli family zinc finger 2, were upregulated in activated HSCs. Pretreatment of q-HSCs with UA or DPI prior to TGF-β1 significantly downregulated expression of NOX subunits and Hh signaling components and additionally inhibited expression of α-SMA and type I collagen, thereby preventing transformation to MFBs. UA inhibited TGF-β1-induced activation of q-HSCs and their transformation by inhibiting expression of NOX subunits and the downstream Hh pathway.

Utility of endoscopic ultrasound in the diagnosis and management of esophagogastric varices

Endoscopic ultrasound (EUS) has significantly improved our understanding of the complex vascular structural changes in patients with portal hypertension. At present, EUS is a useful diagnostic tool for the evaluation of esophagogastric varices (EGVs) and guidance of endoscopic therapy. Several studies have employed this new technique for the diagnosis and management of esophageal and gastric varices, respectively. In the present review, we have summarized the current status of EUS for the diagnosis and management of EGVs and clarified the clinical feasibility of this procedure. New indications for EUS can be developed in the future after adequate validation.

Value of endoscopic intestinal stent placement in treatment of colorectal cancer complicated with intestinal obstruction

AIM: To evaluate the safety, efficacy and value of endoscopic intestinal stent placement in the treatment of colorectal cancer complicated with acute intestinal obstruction.

METHODS: A total of 263 patients with colorectal cancer complicated with intestinal obstruction treated at our hospital from January 2010 to December 2014 were included. Stenting treatment was performed under endoscopy and (or) X-ray. The rate of success, the incidence of postoperative complications, the rate of symptom remission, the rate of surgical excision and other indicators were evaluated.

RESULTS: Stent implantation was successful in 258 (98.1%) cases. The rates of adverse events were: perforation, 1.1% (3 cases); hemorrhage, 3.8% (10 cases); fever, 4.6% (12 cases), and others such as stent dislocation and migration, 3.0% (8 cases). The rates of symptom remission were: abdominal pain, 97.3% (256 cases); abdominal distension, 97.3% (258 cases); and anal dysfunction, 98.1% (258 cases). The rates of surgical resection were: 60 cases for palliative treatment, 198 cases for surgical resection 5-13 d after stent implantation after intestinal preparation, and 143 cases for removal of the tumor by one-stage operation.

CONCLUSION: The symptoms of intestinal obstruction can be relieved by endoscopic intestinal stenting. Emergency endoscopic stenting can be used as a bridge treatment before operation, and it can turn emergency operation to elective surgery, turn two-stage operation to one-stage operation, reduce the difficulty and risk of operation for clinicians, reduce the incidence of postoperative complications, relieve pain, and improve survival quality.

Helicobacter pylori Infection Synergistic with IL-1β Gene Polymorphisms Potentially Contributes to the Carcinogenesis of Gastric Cancer

Helicobacter pylori (H. pylori) infection is the most common chronic bacterial infection in the world and the etiological agent for most gastric cancer (GC). Interleukin-1β (IL-1β) is a potent proinflammatory cytokine, and its deregulation is closely associated with the tumorigenesis of several cancers. Recent studies have revealed that the IL-1β-31 and -511T alleles are closely associated with gastric carcinogenesis due to their roles in the induction of gastric precancerous lesions and hypochlorhydria. Furthermore, H. pylori infection has a synergistic effect on the development of GC with IL-1β gene polymorphisms, and the highest prevalence of severe gastric abnormalities are found in patients with both host and bacterial high-risk genotypes (cagA(+)/vacAs1(+)/IL-1β-511T). Therefore, these recent advances demonstrate that H. pylori synergistic with IL-1β gene polymorphisms contribute to the gastric carcinogenesis by their involvement in precancerous gastric lesions and low gastric acid secretion.

IL-25 or IL-17E Protects against High-Fat Diet-Induced Hepatic Steatosis in Mice Dependent upon IL-13 Activation of STAT6

IL-25 or IL-17E is a member of IL-17 cytokine family and has immune-modulating activities. The role of IL-25 in maintaining lipid metabolic homeostasis remains unknown. We investigated the effects of exogenous IL-25 or deficiency of IL-25 on hepatic lipid accumulation. IL-25 expression was examined in paraffin-embedded tissue sections of liver from patients or in the livers from mice. Mouse model of steatosis was induced by feeding a high-fat diet (HFD). Extent of steatosis as well as expression of cytokines, key enzymes for lipid metabolic pathways, markers for Kupffer cells/macrophages, and lipid droplet (LD) proteins, were analyzed. Our results show that hepatic steatosis in mice was accompanied by increased LD proteins, but decreased IL-25 in the liver. Decreased hepatic IL-25 was also observed in patients with fatty liver. Administration of IL-25 to HFD-fed wild-type mice led to a significant improvement in hepatic steatosis. This effect was associated with increased expression of IL-13, development of alternatively activated Kupffer cells/macrophages, and decreased expression of LD proteins in the liver. In contrast, administration of IL-25 to HFD-fed mice deficient in STAT6 or IL-13 had no effects. In addition, stimulation of primary hepatocytes with IL-13, but not IL-25, resulted in downregulation of LD proteins. Finally, mice deficient in IL-25 had exacerbated hepatic lipid accumulation when fed the HFD. These data demonstrate that dysregulated IL-25 expression contributes to lipid accumulation, whereas exogenous IL-25 protects against hepatic steatosis through IL-13 activation of STAT6. IL-25 and IL-13 are potential therapeutic agents for hepatic steatosis and associated pathologies.

Type 2 immunity-dependent reduction of segmented filamentous bacteria in mice infected with the helminthic parasite Nippostrongylus brasiliensis

BACKGROUND

Dynamic interactions between the host and gastrointestinal microbiota play an important role for local and systemic immune homeostasis. Helminthic parasites modulate the host immune response, resulting in protection against autoimmune disease but also increased susceptibility to pathogen infection. The underlying mechanisms remain largely unknown.

RESULTS

We showed that the type 2 immune response to enteric Nippostrongylus brasiliensis infection in mice was associated with altered intestinal mucin and AMP expression and shifts in microbiota composition. Most strikingly, infection reduced concentrations of intestinal segmented filamentous bacteria (SFB), known inducers of T helper 17 cells, and IL-17-associated gene expression. Infected mice deficient in IL-13 or STAT6 did not reduce SFB or IL-17, and exogenous IL-25 replicated the effects of parasite infection in wild type mice.

CONCLUSIONS

Our data show that parasite infection acts through host type 2 immunity to reduce intestinal SFB and expression of IL-17, providing an example of a microbiota-dependent immune modulation by parasites.

Clinical and endoscopic features of gastrointestinal ulcer with fungal infection: Analysis of 240 cases

AIM: To investigate the clinical and endoscopic features of gastrointestinal ulcer with fungal infection.

METHODS: A total of 240 consecutive patients with gastrointestinal ulcer concomitant with fungal infection were included, and the recorded demographic, clinical and endoscopic data were analyzed.

RESULTS: In total, 5938 patients with malignant gastrointestinal ulcer and 53574 patients with benign gastrointestinal ulcer were screened, and 240 (0.4%) patients with gastrointestinal ulcer concomitant with fungal infection were included. The prevalence of fungal infection in patients with malignant gastrointestinal ulcer was 1.4%, significantly higher than that in patients with benign gastrointestinal ulcer (0.3%) (P = 0.000). The rates of emaciation, anaemia, nausea and emesis were significantly higher in patients with malignant gastrointestinal ulcer and fungal infection than in those with benign gastrointestinal ulcer and fungal infection (80.7% vs 41.4%, P = 0.000; 37.3% vs 15.9%, P = 0.000; 33.7% vs 21.6%, P = 0.045). The rates of ulcer with a diameter ≥ 3 cm, ulceration location in the gastric antrum and duodenum, and pyloric obstruction were significantly higher in patients with malignant gastrointestinal ulcer and fungal infection than in those with benign gastrointestinal ulcer and fungal infection (94.0% vs 42.0%, P = 0.000; 43.4% vs 21.0%, P = 0.000; 6.0% vs 1.3%, P = 0.05; 20.5% vs 7.6%, P = 0.006).

CONCLUSION: The prevalence of gastrointestinal ulcer with fungal infection is 0.4%, which more frequently occurs in male patients and in the gastric antrum and duodenum. Emaciation, anaemia, nausea, emesis, pyloric obstruction, and ulcer diameter ≥ 3 cm are clinical features of malignant gastrointestinal ulcer and fungal infection.

Genetic deletion of IL-25 (IL-17E) confers resistance to dextran sulfate sodium-induced colitis in mice

BACKGROUND

IL-25 is emerging as a key regulator of inflammation in the intestinal mucosa because of its ability to promote type 2 while suppressing Th1 and Th17 responses. Several previous studies reported inconsistent results on the role of exogenous IL-25 in development of colonic inflammation and none were performed in animals with a genetic deletion of IL-25. We investigated the contribution of endogenous IL-25 to DSS-induced colitis using mice deficient in IL-25.

RESULTS

Mice were exposed to DSS in drinking water ad libitum either for seven days (acute) or for three cycles of seven days with DSS followed by 14 days without DSS (chronic) to induce colitis, respectively. The loss of body weight, appearance of diarrhea and bloody stools, and shortening of colon length were significantly less pronounced in IL-25(-/-) mice compared to WT mice after exposure to acute DSS. Histological examination showed that DSS-treated IL-25(-/-) mice had only mild inflammation in the colon, while severe inflammation developed in DSS-treated WT mice. A significant up-regulation of IL-33 was observed in acute DSS-treated WT but not in the IL-25(-/-) mice. There was significantly lower expression of pro-inflammatory cytokines in the colon of acute DSS-treated IL-25(-/-) compared to WT mice. IL-25(-/-) mice were also partially protected from chronic DSS challenge especially during the first 2 cycles of DSS exposure. In contrast to IL-25(-/-) mice, IL-13(-/-) mice were more susceptible to DSS-induced colitis. Finally, stimulation of T84 colonic epithelial cells with IL-25 up-regulated the expression of IL-33 and several pro-inflammatory cytokines.

CONCLUSIONS

These data indicate that endogenous IL-25 acts as a pro-inflammatory factor in DSS-induced colitis, which is unlikely to be mediated by IL-13 but possibly the induction of IL-33 and other pro-inflammatory mediators from colonic epithelial cells. The present study suggests that IL-25 may contribute to the pathogenesis of inflammatory bowel disease in at least a subgroup of patients.

Gastric ulcer patients are more susceptible to developing gastric cancer compared with concomitant gastric and duodenal ulcer patients

Intestinal metaplasia (IM) and dysplasia are precancerous lesions of gastric cancer (GC); however, the prevalence of IM and dysplasia in patients exhibiting single gastric ulcer (GU) and concomitant gastric and duodenal ulcer (CGDU) varies. In the present study consecutive patients who had undergone esophagogastroduodenal endoscopy were retrospectively screened, and those presenting with GU or CGDU were further evaluated for IM and dysplasia. Patients diagnosed with GC or lymphoma and patients with a history of anti-Helicobacter pylori, non-steroidal anti-inflammatory medicine (NSAIM), H₂-receptor antagonist or proton pump inhibitor therapy, were excluded from the present study. Of the 204,073 consecutively screened cases, 8,855 (4.3%) and 2,397 (1.2%) were diagnosed with GU and CGDU, respectively. A total of 1,722 GU and 233 CGDU patients were excluded; thus, 7,133 and 2,164 cases of GU and CGDU, respectively (n=9,297), were included in the present study. IM and dysplasia were observed in 1,348 (14.5%) and 210 (2.3%) patients, respectively. IM was more frequently identified in GU patients compared with CGDU patients (16.4 vs. 8.3%; odds ratio [OR], 2.158; 95% confidence interval [CI], 1.830–2.545; χ²=86.932; P<0.001); furthermore, GU patients exhibited significantly more frequent IM compared with CGDU patients at the gastric antrum (14.2 vs. 5.5%; OR, 2.818; 95% CI, 2.199–3.610; χ²=72.299; P<0.001), gastric incisura (24.0 vs. 14.1%; OR, 1.922; 95% CI, 1.502–2.432; χ²=30.402; P<0.001) and gastric corpus (12.6 vs. 3.3%; OR, 4.259; 95% CI, 1.030–17.609; χ²=4.736; P=0.026). Dysplasia was significantly more frequently identified in GU patients compared with CGDU patients (2.7 vs. 0.7%; OR, 4.027; 95% CI, 2.376–6.823; χ²=31.315; P<0.001), with GU patients exhibiting significantly more severe dysplasia at the gastric antrum (2.4 vs. 0.7%; OR, 3.339; 95% CI, 1.735–6.425; χ²=14.652; P<0.001) and the gastric incisura (2.9 vs. 0.7%; OR, 4.255; 95% CI, 1.694–10.689; χ²=11.229; P<0.001). Additionally, mild IM was more frequently identified in GU patients compared with CGDU patients (15.2 vs. 7.1%; OR, 2.353; 95% CI, 1.972–2.807; χ²=94.798; P<0.001) and dysplasia of a mild (1.7 vs. 0.6%; OR, 2.807; 95% CI, 1.580–4.987; χ²=13.519; P<0.001) or moderate/severe grade (1.1 vs. 0.09%; OR, 11.642; 95% CI, 2.857–47.439; χ²=18.896; P<0.001) was more frequent in GU patients compared with CGDU patients. IM and dysplasia were more frequently observed in GU compared with CGDU patients in the present study, which may be associated with an increased probability of developing GC.

Expression profile of circulating microRNAs in patients with irritable bowel syndrome

AIM: To investigate the differential expression of circulating microRNAs (miRNAs) between diarrhea-predominant irritable bowel syndrome (D-IBS)/constipation-predominant irritable bowel syndrome (C-IBS) and normal controls to profile abnormally expressed circulating miRNAs in IBS patients.

METHODS: Patients were diagnosed with D-IBS or C-IBS based on the Rome III criteria. MiRNA microarray was performed to detect mixed serum samples of either three patients with D-IBS, three patients with C-IBS, or three normal controls. After miRNA profiling, clustering analysis was conducted.

RESULTS: Compared to normal controls, there were two miRNAs down-regulated and two miRNAs up-regulated in the D-IBS group, and four miRNAs down-regulated and 59 miRNAs up-regulated in the C-IBS group. There was only one miRNA that was expressed differentially in D-IBS patients and 60 miRNAs in C-IBS patients. MiR-23b* was down-regulated and HCMV-miR-US5-2 and hsv2-miR-H11 up-regulated in both types of IBS. Compared to D-IBS patients, one miRNA was down-regulated and 26 miRNAs up-regulated in C-IBS patients.

CONCLUSION: Abnormal expression profile of circulating miRNAs in IBS patients may provide new biomarkers for diagnosis of this disease.

Predictors of acid suppression success in patients with chronic laryngitis

BACKGROUND

Up to 50% of the patients suspected of reflux laryngitis syndrome failed to respond to acid suppression therapy. However, predictors of acid suppression success have not been determined.

METHODS

Consecutive patients with chronic laryngitis were enrolled prospectively. All the patients underwent laryngoscopy, esophagogastroduodenoscopy and 24-h multichannel intraluminal impedance and pH (MII-pH) monitoring before receiving rabeprazole 10 mg b.i.d. for 3 months. Patient was considered as a responder to acid suppression if the chief laryngeal complaint score during the last week since last interview had decreased by at least 50% after the start of therapy compared with baseline. Cox regression analysis was used to determine the independent predictors of acid suppression success.

KEY RESULTS

Of 92 patients (age 42.4 ± 14.3 years, 50 women), 42 (45.7%) responded to acid suppression after 3 months. Gastroesophageal reflux disease was defined in 22 patients, of whom 19 patients had pathological distal esophageal acid exposure and 5 were defined as erosive esophagitis. The time to response showed a significant hazard ratio for patients with increased distal esophageal acid exposure time (β: 0.93; HR: 2.55; 95% CI: 1.24-5.24; P = 0.011) and increased laryngopharyngeal bolus exposure time (BET; β: 0.96; HR: 2.61; 95% CI: 1.36-5.00; P = 0.004). The latter had the best Youden Index (0.34) and accuracy (68.5%).

CONCLUSIONS & INFERENCES

The success of acid suppression on chronic laryngitis could be predicted using reflux parameters detected by MII-pH, among which increased laryngopharyngeal BET is the best.

Advances in drug therapy for gastroesophageal reflux disease

The incidence of gastroesophageal reflux disease (GERD) is increasing drastically in China. GERD could probably cause reflux esophagitis, chronic cough, asthma, Barrett's esophagus and adenocarcinoma, and frequently affects health-related quality of life. The use of proton pump inhibitors (PPIs) provides effective symptomatic relief in most patients; however, some patients appear refractory to the treatment with PPIs. The long term use of PPIs might also cause adverse effects, such as interstitial nephritis, fracture and small intestinal bacterial overgrowth. Many new drugs for GERD have emerged recently. This article reviews the advances in drug therapy for GERD.

Prevalence and symptom pattern of pathologic esophageal acid reflux in patients with functional dyspepsia based on the Rome III criteria

OBJECTIVES

To determine the prevalence and symptom pattern of pathologic esophageal acid reflux (PEAR) in patients with functional dyspepsia (FD) using the Rome III criteria, and to explore the value of a proton pump inhibitor (PPI) test in distinguishing the patients with and those without PEAR among FD patients.

METHODS

Consecutive FD patients who fulfilled the Rome III criteria without predominant typical reflux symptoms (i.e., heartburn or regurgitation) were enrolled. All patients underwent upper endoscopy and an ambulatory 24-h pH monitoring. PEAR was defined as the percentage total time for which a pH value <4 was >4.2% in the distal esophagus. Then, patients were treated with rabeprazole 10 mg twice daily for 28 days. The symptom scores were measured by the frequency score multiplied by the severity scores of the predominant symptom before and at the end of the treatment, and the "PPI test" was defined as positive if the overall scores of the predominant dyspeptic symptom in the fourth week decreased by >50% compared with those of the baseline.

RESULTS

One hundred eighty-six FD patients were enrolled, with predominant symptoms of epigastric pain (n=68), epigastric burning (n=47), bothersome postprandial fullness (n=54), and early satiation (n=17). The prevalence of PEAR was 31.7%, with the highest percentage (48.9%) in patients with epigastric burning as their predominant symptom. The prevalence of PEAR in patients with postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) were 36.6% (26/71) and 28.7% (33/115), respectively. Overall, 63.4% were positive for the "PPI test"; the rates were 51.5, 85.0, 66.7, and 41.1% in patients with epigastric pain, epigastric burning, bothersome postprandial fullness, and early satiation as their predominant symptoms, respectively (χ(2)=17.59, P=0.001). The positive rates were 65.5 and 60.6% in patients with PDS and EPS, respectively (χ(2)=0.41, P=0.522). The sensitivity and specificity of the "PPI test" in distinguishing FD patients with PEAR was 83.1 and 45.7%, respectively.

CONCLUSIONS

PEAR is present in almost one third of FD patients; the prevalence is ∼50% in those with epigastric burning. The "PPI test" has a limited value in distinguishing the FD patients with and those without PEAR.

Combined transplantation of neural stem cells and olfactory ensheathing cells for the repair of spinal cord injuries

Spinal cord repair is a problem that has long puzzled neuroscientists. The failure of the spinal cord to regenerate and undergo reconstruction after spinal cord injury (SCI) can be attributed to secondary axonal demyelination and neuronal death followed by cyst formation and infarction as well as to the nature of the injury environment, which promotes glial scar formation. Cellular replacement and axon guidance are both necessary for SCI repair. Multipotent neural stem cells (NSCs) have the potential to differentiate into both neuronal and glial cells and are, therefore, likely candidates for cell replacement therapy following SCI. However, NSC transplantation alone is not sufficient for spinal cord repair because the majority of the NSCs engrafted into the spinal cord have been shown to differentiate with a phenotype which is restricted to glial lineages, further promoting glial scaring. Olfactory ensheathing cells (OECs) are a unique type of glial cell that occur both peripherally and centrally along the olfactory nerve. The ability of olfactory neurons to grow axons in the mature central nervous system (CNS) milieu has been attributed to the presence of OECs. It has been shown that transplanted OECs are capable of migrating into and through astrocytic scars and thereby facilitating axonal regrowth through an injury barrier. Given the complementary properties of NSCs and OECs, we predict that the co-transplantation of NSCs and OECs into an injured spinal cord would have a synergistic effect, promoting neural regeneration and functional reconstruction. The lost neurocytes would be replaced by NSCs, while the OECs would build "bridges" crossing the glial scaring that conduct axon elongation and promote myelinization simultaneously. Furthermore, the two types of cells could first be seeded into a bioactive scaffold and then the cell seeded construct could be implanted into the defect site. We believe that this type of treatment would lead to improved neural regeneration and functional reconstruction after SCI.

Selective Induction of Necrotic Cell Death in Cancer Cells by β-Lapachone through Activation of DNA Damage Response Pathway

Most efforts thus far have been devoted to develop apoptosis inducers for cancer treatment. However, apoptotic pathway deficiencies are a hallmark of cancer cells. We propose that one way to bypass defective apoptotic pathways in cancer cells is to induce necrotic cell death. Here we show that selective induction of necrotic cell death can be achieved by activation of the DNA damage response pathways. While beta-lapachone induces apoptosis through E2F1 checkpoint pathways, necrotic cell death can be selectively induced by beta-lapachone in a variety of cancer cells. We found that beta-lapachone, unlike DNA damaging chemotherapeutic agents, transiently activates PARP1, a main regulator of the DNA damage response pathway, both in vitro and in vivo. This occurs within minutes of exposure to beta-lapachone, resulting in selective necrotic cell death. Inhibition of PAR blocked beta-lapachone-induced necrosis. Furthermore, necrotic cell death induced by beta-lapachone was significantly reduced in PARP1 knockout cell lines. Our data suggest that selective necrotic cell death can be induced through activation of DNA damage response pathways, supporting the idea of selective necrotic cell death as a therapeutic strategy to eliminate cancer cells.

Dual-enzyme fiber-optic biosensor for glutamate based on reduced nicotinamide adenine dinucleotide luminescence

Response characteristics are presented for a dual-enzyme fiber-optic biosensor for glutamate. An enzyme layer composed of glutamate dehydrogenase (GDH) and glutamate-pyruvate transaminase (GPT) is used to produce reduced nicotinamide adenine dinucleotide (NADH) at the tip of a fiber-optic probe. NADH luminescence is monitored through this probe and the measured fluorescence intensity is related to the concentration of glutamate. GDH catalyzes the formation of NADH, and GPT drives the GDH reaction by removing a reaction product and regenerating glutamate. Optimal response is obtained in a pH 7.4 Tris-HCl buffer maintained at 25 degrees C in the presence of 4 mM NAD+ and 10 mM L-alanine. The temperature profile reveals a strong negative temperature effect which is attributed to the temperature dependency of NADH luminescence. Under optimal conditions, the sensor sensitivity is 0.127 nA/microM over the 1-10 microM concentration range, the detection limit is 0.13 microM, and response times range from 4 to 8 min. The sensor response is stable for 12 days when stored at 4 degrees C. Selectivity for glutamate is excellent over most of the common amino acids as well as ascorbic acid, uric acid, taurine, and GABA. Only slight responses were observed for glutamine and lysine. The effect of ammonia on the glutamate response was found to be minimal at total ammonia nitrogen concentrations as high as 200 microM.

Tryptophan fluorescence quenching by alkaline earth metal cations in deionized bacteriorhodopsin

Tryptophan quenching by the addition of alkaline earth metal cations to deionized bacteriorhodopsin suspensions was determined. The results show that the addition of cation primarily quenches fluorescence from surface tryptophan residues. The quenched intensity exhibits a 1/R dependence, where R is the ionic radius of the corresponding metal ion. This observation results from a stronger energy transfer coupling between the tryptophan and the retinal. The membrane curvature may be involved as a result of cations motion and correlated conformational changes.

Leu-enkephalin induced by IL-2 administration mediates analgesic effect of IL-2

Interleukin-2 (IL-2) was found to have an analgesic effect in both central and peripheral nervous systems. This effect is related to opioid receptors and mediated mainly by IL-2 directly binding to opioid receptors. Using radioimmunoassay, the content of Leu-enkephalin (LEK) in some nuclei were measured at intervals after the injection of IL-2 into the lateral ventricle of rats. Levels of LEK increased in both paraventricular hypothalamic nucleus (PVN) and locus ceruleus (LOC) after IL-2 administration, suggesting that the analgesic effect of IL-2 is also related to the change of LEK in PVN and LOC induced by IL-2 administration.

[Opioid receptor mediated modulation of intrahippocampal enkephalin induced cellular immune function]

In the present work, the effect of intrahippocampal microinjection of opioid receptor antagonist naloxone on the enhancement of cellular immune responses induced by enkephalin was studied in rat. The results showed that (1) the proliferation activity of splenic lymphocytes stimulated by Con A and natural killer (NK) cell activity were decreased with microinjection of 1 microl lipopolysaccharide (LPS,50 ng/microl) into bilateral hippocampus; (2) the decrease of cellular immune responses induced by LPS could be inhibited by a preceding intrahippocampal injection of 1 microl met-enkephalin (10 microg/1 microl); (3) the enhancement of cellular immune responses induced by met-enkephalin could be blocked by an opioid receptor antagonist naloxon (10 microg/microl); and (4) cellular immune responses were also inhibited when naloxon was injected intrahippocampally alone. The above results suggest that the enhancement of cellular immune responses induced by enkephalin was mediated by opioid receptors in hippocampus.

[Effect of intrahippocampal microinjection of enkephalin on cellular immune function and brain IL-1 alpha gene expression in rat]

The effect of intrahippocampal microinjection of enkephalin on cellular immune function and hippocampal IL-1 alpha gene expression was studied in rats. The results showed that: (1) The proliferation activity of splenic lymphocytes stimulated by Con A was significantly increased with microinjection of Leu-enkephalin 1 microliter (18 mmol/L) or Met-enkephalin 1 microliter (18 mmol/L) into bilateral hippocampus, but was inhibited by Lipopolysaccharide 1 microliter (50 ng/microliter). The proliferative response of splenic lymphocytes to Leu-enkephalin still persisted after bilateral adrenalectomy. Low doses of Leu- or Met-enkephalin (10(-10), 10(-11) mol/L) were also capable of causing proliferative activity of the Con A- stimulated cultured splenic lymphocytes in vitro. (2) Using RT-PCR technique, IL-1 alpha gene expression was detected in hippocampus 90 min after bilateral intrahippocampal injection of LPS. The LPS-induced IL-1 alpha gene expression in hippocampus could no longer be detected 30 min after microinjection of Met- or Leu-enkephalin into hippocampus. The above results suggested that intrahippocampal enkephalin might play an important role in neuro-immunomodulation by enhancing the inhibition of IL-1 alpha gene expression in hippocampal formation.

[Possible mechanism of the analgesic effect of interleukin-2 in central nervous system]

The monoclonal antibody against IL-2R (Tac) could not block the analgesic effect of IL-2, and IL-2 mutant that could not bind to beta subunit of IL-2 receptor still had capability of increasing the pain threshold of rats. All these facts suggest that the analgesic effect of IL-2 in CNS is not mediated through the IL-2 receptor, and that the immune and analgesic effects of IL-2 are mediated through different receptor mechanisms. It is suggested that there are common antigenic determinants and similar structure between IL-2 and endogenous opioid peptides (EOP). This implies that the analgesic effect of IL-2 might be mediated by interaction between IL-2 and opioid receptors in CNS. Using radioimmunoassay the contents of EOP of different nuclei were measured at different times after injecting IL-2 into the lateral ventricle of rats. The results suggested that the analgesic effect of IL-2 may be related to beta-EP and LEK in arcuate hypothalamic nucleus, paraventricular hypothalamic nucleus and locus ceruleus.

[Improvement of memory function of fornix-fimbria transected rats by transplantation of the superior cervical ganglion into hippocampus]

Memory impairments of passive avoidance response were observed in 38 Wistar rats with bilateral fornix-fimbria transection. After fornix-fimbria lesions the degree of performance decreased from 65.3% to 13.6% (P < 0.01). Autotransplantation of superior cervical ganglion (SCG) into bilateral dorsal hippocampi improved memory function to a considerable extent. In the end of the behavioral experiments, implanted rats were sacrificed for histofluorescence study of grafts and measurement of norepinephrine (NA) content in the hippocampus. These experiments showed that the hippocampal NA content in implanted rats was considerably higher than that in untransplanted fornix-fimbria transected rats and consequently suggested that improvement of memory function was to some extent due to supplement of monoamine transmitter by the transplanted SCG.

[Effects of morphine on sensitivities of alpha-adrenoceptors in toad spinal ganglion neurons]

Intracellular recordings were performed on 35 neurons from 35 isolated toad spinal ganglia (SG) and the extracellular free calcium ion activities were measured in another 26 isolated toad SG by Ca(2+)-selective microelectrodes. The effects of morphine on the sensitivities of alpha-adrenoceptors were observed. It was found that depolarization of membrane potential induced by norepinephrine (NE 10-100 mumol.L-1) or alpha 1-adrenoceptor agonist phenylephrine (100 mumol.L-1) was depressed by morphine (27 mumol.L-1). Superfusing SG with opioid receptor antagonist naloxone (100 mumol.L-1) blocked the depressing effect of morphine on NE-induced depolarization. The depressing effect of morphine on NE-induced depolarization was not affected by superfusing SG with alpha 2-adrenoceptor antagonist yohimbine (5 mumol.L-1). NE (100 mumol.L-1) reduced the extracellular free calcium ion activity while morphine (27 mumol.L-1) increased the extracellular free calcium ion activity in SG. It is concluded that morphine down-regulates the sensitivity of alpha 1-adrenoceptor in toad SG neuron mediated by opioid receptor and the variation in Ca2+ activity may be involved in this effect.

[Effect of LH-FSH releasing hormone on the sensitivity of cholinergic and adrenergic receptors in toad spinal ganglion neurons]

Intracellular recordings were performed on 81 neurons from 53 isolated toad spinal ganglia (SG). The effects of LH-FSH releasing hormone on the sensitivities of muscarinic receptors and alpha-adrenoceptors located on the soma of SG neurons were observed. Perfusing SG with atropine 10 mumol.L-1 in Ringer's solution depressed the amplitude of depolarization response induced by acetylcholine (ACh, 10-100 mumol.L-1). The depolarization and hyperpolarization induced by norepinephrine (NE, 10-100 mumol.L-1) were blocked by alpha 1-adrenoceptor antagonist prazosin and alpha 2-adrenoceptor antagonist yohimbine respectively. These results indicated that ACh-induced depolarization was mediated by muscarinic receptors while NE-induced depolarization and hyperpolarization were mediated by alpha 1- and alpha 2-adrenoceptors respectively. On the other hand, perfusing SG with LH-FSH releasing hormone 10 mumol.L-1 in Ringer's solution increased the depolarization response caused by ACh or NE, but attenuated NE-caused hyperpolarization response. The above results suggest that LH-FSH releasing hormone may modulate the sensitivities of muscarinic receptors and alpha-adrenoceptors on the soma membrane of toad SG neurons.

[Ionic mechanism of noradrenaline-induced membrane potential changes of neurones in toad dorsal root ganglion]

The membrane conductance and reversal potential were determined for neurones in toad dorsal root ganglion (DRG) with intracellular recording technique during depolarization or hyperpolarization induced by noradrenaline (NA). The effects of blocking agents for potassium or calcium channels on NA-induced membrane potential responses were examined. In 15 neurones, the NA-induced depolarization was accompanied by a 32.6% decrease of membrane conductance; in other 4 neurones, the depolarization was accompanied by an initial increase and subsequent decrease in membrane conductance. The NA hyperpolarization was associated with an increase of membrane conductance by 16.2% (n = 8). The mean reversal potential of NA-induced depolarization was -88.5 +/- 0.9 mV (means +/- SE, n = 4). The NA-induced hyperpolarization was nullified at -89 to -92 mV of membrane potentials (n = 3). Tetraethylammonium superfusion enhanced NA depolarization amplitude by 73.7 +/- 11.9% (means +/- SE, n = 7) and depressed NA hyperpolarization amplitude by 40.5% (n = 4). Intracellular injection of CsCl increased phenylephrine-induced depolarization by 34.5% (n = 4). MnCl2 superfusion decreased the amplitudes of NA-induced depolarization by 50.5 +/- 9.9% (means +/- SE, n = 10), and of NA-induced hyperpolarization by 89.5 +/- 4.9% (means +/- SE, n = 7) respectively. The results suggest that the depolarization or hyperpolarization induced by NA might be mediated by the alteration in activation of K+ or Ca2+ channels.

Left-handed double helical DNA: variations in the backbone conformation

Four different crystals of d(CpGpCpGpCpG) have been solved by x-ray diffraction analysis and all form similar left-handed double helical Z-DNA molecules in the crystal lattice. Two different conformations are observed for the phosphates in the GpC sequences, as the phosphates are found either facing the helical groove or rotated away from it. The latter conformation is often found when hydrated magnesium ions are complexed to a phosphate oxygen atom. These different conformations may be used when right-handed B-DNA joins left-handed Z-DNA. Atomic coordinates and torsion angles are presented for both types of Z-DNA.