Introduction

The treatments for liver fibrosis are still in need so far. As the crucial initiators, activated hepatic stellate cells (aHSCs) undergo a series of epigenetic changes. The study intends to explore transcription factors (TFs) that facilitate HSCs activation and provide novel therapeutic targets for liver fibrosis.

Aims & Methods

Three distinct HSCs activation models were established in present study. Firstly, in vitro activation involved isolating primary HSCs from normal Sprague-Dawley rats and culturing them for two days (n=5) and seven days (n=5), namely natural activation model. Secondly, in vivo activation entailed isolating primary HSCs from bile duct ligated rats (n=4) and normal controls (n=4), followed by culturing until the next day. Lastly, transforming growth factor-β (TGF-β, 2.5ng/ml) (n=10) or control buffer (n=10) were added to the human HSCs cell line LX2 and cultured for 24 hours. Subsequently, assay for transposase-accessible chromatin using sequencing (ATAC-seq) was conducted on the abovementioned cells, along with motif enrichment and footprint analysis. Pathway enrichment analysis was performed on differentially accessible genes (DAGs). RNA sequencing (RNA-seq) was employed to analyze gene expression profiles of primary HSCs in the natural activation model (n=4). The integration of ATAC-seq and RNA-seq further identified potential key TFs. RT-qPCR and differential expression analysis of public datasets was utilized to confirm the dysregulation of TFs in primary HSCs, fibrotic liver and fibrotic model of induced pluripotent stem cells. Finally, enrichment at enhancers and promoters of these genes was validated by H3K27Ac and H3K4me3 chromatin immunoprecipitation followed by sequencing (ChIP-seq) of human HSCs.

Results

For ATAC-seq, primary HSCs exhibited higher chromatin accessibility after activation compared with the controls. After peak annotation, the up-regulated peaks were mainly located in the promoter region in all comparison groups, uncovering the dynamic transcriptional regulation during HSC activation. In the motif enrichment analysis, 150 aHSCs related TFs and 54 quiescent HSCs (qHSCs) related TFs were identified in the in vitro activation model. The three models shared 12 aHSCs related TFs, namely Runx-aml, Runx1, Runx2, Runx, Ets:Runx, Atf2, Atf4, Atf7, c-Jun-Cre, Creb5, Smad3 and CArG; and 19 qHSCs related TFs, including Foxf1, Foxo3, Foxk1, Foxp1, Hoxa1, Hoxa2, Stat3, Hnf4a, Hnf6, Elk1, Elk4, Cux1, Crx, Duxbl, Vdr, Tr4, Ebf2, Gata2, Gata6. Footprint analysis validated the alteration of accessibility in Atf2, Atf4, Atf7, Creb5, Hnf6 and Gata2. Actin filament organization, Ras protein signal transduction and intrinsic apoptotic signal pathways were enriched in DAGs. Integration of ATAC-seq and RNA-seq showed that gene expression was significantly correlated with chromatin accessibility, among which Runx2, Creb5, and Smad3 were significantly upregulated in aHSCs at transcription level. The dysregulation of these three genes was verified in primary HSCs, fibrotic liver and fibrotic model of human induced pluripotent stem cells. Finally, enrichment at active enhancers and promoters of these TFs was validated by H3K27Ac and H3K4me3 ChIP-seq of human HSCs, revealing the crucial role of genes in the transcription.

Conclusion

We generated chromatin accessibility profiles of different HSCs activation models, highlighting the significance of Runx2, Creb5, and Smad3 as key TFs mediating HSCs activation. These findings proposed these TFs as promising targets for future liver fibrosis treatment.

Disclosure

The author declare no competing interests and financial relationships with commercial interests.

Introduction

Currently, there is no approved medication for the treatment of Metabolic Associated Fatty Liver Disease (MASLD). However, numerous clinical trials have examined the effect of antihyperglycemic agents on MASLD in type 2 diabetic (T2D) patients, given the close association between T2D and this hepatopathy, both of which are closely linked to insulin resistance. Our aim is to evaluate and compare the therapeutic effects of different hypoglycemic agents in patients with MASLD and T2D.

Aims & Methods

This is a prospective cross-sectional study involving 200 T2D patients over a 6-month period. The presence of hepatic steatosis was confirmed by abdominal ultrasound and/or a Fatty Liver Index (FLI) score greater than 60 in 122 patients. Hepatic fibrosis was assessed using FibroScan in all patients with MASLD. Two comparative studies were conducted to identify the therapeutic effects of hypoglycemic medications on hepatic steatosis and significant fibrosis, defined by a LSM value ≥ 8 kPa.

Results

Patients were predominantly female (73.2%) with a median age of 59.76 ± 10 years. The duration of T2D, although longer in cases of steatosis, was not statistically significant. Glycemic control, assessed by fasting blood glucose and HbA1c levels, was less optimal in patients with MASLD, with an average HbA1c level of 8.98%, compared to patients without hepatic steatosis, who had an average HbA1c level of 8.74% (p=0.002). A similar trend was observed with fasting blood glucose levels (81.96% vs 73.07%), but it did not reach statistical significance.

Degenerative complications, regardless of their type, were comparable between the two groups.

The prescription of biguanides was associated with a reduced risk of hepatic steatosis (p=0.05), while insulin use was frequently observed in patients with steatosis, with a statistically significant correlation for long-acting human insulin and rapid-acting analogs (33.61% vs 19.23% in the absence of steatosis, p=0.02) and (4.92% vs 0% in the absence of steatosis, p=0.05) respectively. No other therapeutic modality, including different classes of oral antidiabetic agents, was correlated with the risk of steatosis.

The prescription of sulfonylureas and rapid-acting insulin analogs was associated with a higher risk of significant hepatic fibrosis, with p-values of 0.05 and 0.008 respectively. In contrast, the use of long-acting human insulin was less frequent in patients with significant fibrosis, with a statistical correlation of 0.03. No other treatment modality, including various types of oral antidiabetic agents, was associated with the risk of fibrosis.

Conclusion

The use of biguanides appears to reduce the risk of hepatic steatosis, while insulin therapy, particularly rapid-acting analogs, is associated with an increased risk of hepatic steatosis and fibrosis. These observations emphasize the importance of an individualized therapeutic approach to optimize the management of MASLD in type 2 diabetic patients. Further studies are needed to validate these associations

References

Tang W, Xu Q, Hong T, Tong G, Feng W, Shen S, et al. Comparative efficacy of anti‐diabetic agents on nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus: a systematic review and meta‐analysis of randomized and non‐randomized studies. Diabetes Metabolism Res. févr 2016;32(2):200‑16.

Yan J, Yao B, Kuang H, Yang X, Huang Q, Hong T, et al. Liraglutide, Sitagliptin, and Insulin Glargine Added to Metformin: The Effect on Body Weight and Intrahepatic Lipid in Patients With Type 2 Diabetes Mellitus and Nonalcoholic Fatty Liver Disease. Hepatology. juin 2019;69(6):2414‑26.

Introduction

The consumption of sugar-sweetened beverages is correlated with the development of obesity and type 2 diabetes mellitus which have become major health problems in our century. Consequently, the World Health Organization has proposed sugar reduction as a preventive and therapeutic strategy [1]. The use of artificial low-caloric sweeteners (e.g., sucralose) as sugar alternatives remains controversial due to the mismatch between their sweet taste (rewarding oral effect) and energy content (lack of post-oral satiating effects). Erythritol, a non-caloric bulk sweetener, might be a promising alternative due to its similar sweetness to sucrose and its ability to release gastrointestinal (GI) satiation hormones without affecting glucose or insulin concentrations.
Acquired preference for sweet-flavored beverages could be based on oral (flavor-flavor learning FFL, e.g., sweet taste) and post-oral associations (flavor-nutrient learning FNL, e.g., calories, hormones) [2]. In human studies, evidence is weak whether liking of a novel flavor increases most when it’s paired with sucrose (FFL + FNL_{calories+hormones}) than with an artificial sweetener (only FFL). Furthermore, the rewarding properties of erythritol remain to be determined.

Aims & Methods

The aim of this study was to assess the effect of the non-caloric sweetener erythritol (FFL + FNL_hormones) on the reward responses (liking and wanting), GI hormone release and glycemic control compared to sucrose and sucralose.
In this randomized, double-blind crossover study, 20 participants (10 women, 10 men; mean ± SD; age: 25.8 ± 7.5 years, BMI: 22.3 ± 1.8 kg/m²) rated explicit liking and wanting of three novel and neutral flavored beverages before and after three conditioning visits where the beverages were paired with either erythritol, sucrose or sucralose. Doses of erythritol and sucralose were individually matched to the perceived sweetness of a 10% sucrose solution. After conditioning, participants had to perform a computerized forced choice task to measure implicit wanting. Blood samples were collected to analyze GI hormones (glucagon-like peptide 1 GLP-1, cholecystokinin CCK) and glycemic control (glucose, insulin).

Results

All 20 participants completed the test visits. The results show that: i) explicit liking increased significantly after the conditioning (all p < 0.01) with no differences between the sweeteners (all p_Tukey > 0.4); ii) explicit wanting increased significantly after the conditioning (p = 0.07 for erythritol, p < 0.01 for sucrose and sucralose) with no differences between the sweeteners (all p_Tukey > 0.8); iii) implicit wanting did not differ between the sweeteners (all p_Tukey > 0.5); iv) conditioning with the sweeteners had no effect on GI satiation hormone release and glycemic control.

Conclusion

Erythritol led to similar ratings in explicit liking and wanting compared with sucrose and sucralose. Conditioning with all three sweeteners increased the reward responses. Since erythritol appears to be as rewarding as sucrose and sucralose, this sweetener can be seen as potential sugar alternative. These effects may not to be associated with FNL.

References

1. World Health Organization (WHO). Guideline: Sugars intake for adults and children. 2015.
2. Yeomans, M., et al., Differential hedonic, sensory and behavioral changes associated with flavor-nutrient and flavor-flavor learning. Physiology & behavior, 2008. 93: p. 798-806.

Introduction

Balanced propofol sedation administered by adequately trained non-anesthesiologist personnel has gained popularity in GI endoscopy because of its shorter procedure and recovery time, high patient satisfaction, and low rate of adverse events (AEs), even if it's still considered controversial. We reported data from a retrospective audit of Endoscopist directed nurse administered sedation (ED-NAAS) over a 2-year period in an Italian referral hospital.

Aims & Methods

Consecutive endoscopic procedures performed between October 2020 and October 2022 were considered. Under the guidance of the endoscopist, the nurse administered 1 to 2mg of midazolam, followed by a progressive top-up dosages of 10-20mg bolus of propofol to achieve moderate to deep sedation. Fentanyl was administred based on the patient's weight if indicated. Endoscopists and nurses were all certified in our hospital with a continuous and scheduled training from 2006. The patients' characteristics, dosage of administered drugs, AEs during and after the examination, were all investigated. The following AEs were deemed minor but significant: bradycardia (≤50 beats/min ≥10 seconds), hypoxia (SaO2 ≤ 90% ≥10 seconds) and hypotension (systolic BP ≤100 mmHg with a drop ≥ 20 mmHg). Major consequences included death, a persistently low state of awareness, permanent harm, the need for an emergency anaesthetist evaluation, the need for hospitalization or endotracheal intubation. To increase the sensitivity of AEs detection, reports were reviewed in these cases: (1)AEs declared in the report, (2)search by string "desaturation" "hypotension" "bradycardia" "apnoea” “hypoxia" in the report, (3)oxygen saturation level, systolic BP and heart rate ≤50 bpm annotated during the intra-procedural monitoring compared to parameters measured before sedation, (4)patients administered flumazenil, naloxone, etilephrine, atropine.

Results

A total of 19407 examinations (7803 EGDS, 10439 colonoscopies, 77 PEG, 697 EUS and 365 ERCP) and 14415 patients were enrolled. 29.4% of patients were classified as ASA I, 66.5% as ASA II and 5.1% as ASA III. Balanced sedation with propofol was administered in 86% of EGDS, 94% of colonoscopies, 92% of EUS, 94% of ERCP and in 72% of PEG. Hypotension was recorded in 1293 (6%) examination, which required fluid infusion in 330 cases (26%) and in 8 cases etilephrine to restore blood pressure. Bradycardia was recorded in 176 (0.9%) patients, which required atropine in 134 (72.8%) cases. 11 patients (0.06 %) had a minor respiratory adverse event. The mean age of patients of hypotension, bradycardia and respiratory adverse event was respectively 61.1±15 years, 64.3±15.3 and 55.6±16.2. ASA III patients were respectively 4.1%, 2.8% and 27.2% in the three groups of AEs. The mean SD/median (25^th-75^th percentil) dosage of medications were respectively 2.0±0.7mg, 2.0±0.7mg, 1.8±0.3mg of midazolam, 71.0±34.5mcg, 68.0±31.0mcg and 62.5±9.5mcg of fentanyl, 94.0±74.3mg, 77.0±61.7mg and 120 (70-190)mg of propofol. BMI and Mallampati score of II were respectively 23.0±4.5 and 72.8% in patients with respiratory AEs. 1 patient (0.001%) had a major AE, needing oro-tracheal intubation. He was 63 years old with unknown diagnosis of amyotrophic lateral sclerosis, with normal BMI, Mallampati score I, sedated with 2mg of midazolam + 80mg of propofol. Limits of the study include recall bias (missed cases of AEs not caused by sedation but because of examination itself, e.g., bradycardia or laryngospasm).

Conclusion

Balanced propofol ED-NAAS is safe in low-risk patients. Major adverse events occurred in 0.001% procedures.

Introduction

Colorectal endoscopic submucosal dissection (ESD) is spreading worldwide, with increasing demand for training. Standardized skills assessment has yet to be defined to guarantee the quality and safety of the results obtained by trainees during their learning curve. ESGE recommends that the first ESD procedures should be supervised by an ESD-proficient endoscopist. The impact of a trainee's active participation on these initial supervised ESD results should be addressed.

Aims & Methods

Between 01/2017 and 01/2024, all consecutive colorectal ESD procedures were prospectively registered by 3 participating ESD training centers, and data were analyzed retrospectively. Trainee participation was tracked. A trainee was defined as having performed less than 50 ESD’s on humans, alone or under supervision. We compared the main procedural outcomes with respect to the presence or absence of a trainee involved in the colorectal ESD procedure. Multivariate analysis and propensity score matching (PSM) were performed.

Results

2462 consecutive colorectal ESD were included, of which 543 procedures (22%) involved the active participation of a trainee (15 trainers/15 trainees). Rectal lesions were more often treated with participation of a trainee (56% vs 31%, p<0.001 with-trainee vs trainer-alone respectively). There was no significant difference in en-bloc, R0 and curative resection rates whether a trainee participated or not (95.8%, 85.9% and 84.9% vs 95.1%, 88.2% and 84.7%, with-trainee vs trainer-alone respectively). Participation of a trainee resulted in a significant decrease in dissection speed (29.4 mm²/min vs 43.9 mm²/min, p<0.001 with-trainee vs trainer-alone respectively). Rates of perforation, delayed bleeding and surgery for complications were 8.6%, 5.9% and 0.9% vs 9%, 4.5% and 0.7% for with-trainee vs trainer-alone respectively, without significant differences. After PSM, the presence of a trainee significantly decreased the dissection speed (29.4 mm²/min vs 42.7 mm²/min, p<0.001 with-trainee vs trainer-alone respectively), increased the perforation rate (8.7% vs 5%, p=0.023 with-trainee vs trainer-alone respectively), but did not influence the curative resection rate (84.9% vs 88.8%, p=0.078 with-trainee vs trainer-alone respectively).

Conclusion

Active participation of a trainee during colorectal ESD did not affect the curative resection rate. However slower dissection speed and higher perforation rates, without increasing the need for surgery, were observed.

Disclosure

Nothing to disclose