Introduction

Health disparities in the burden of chronic liver disease (CLD) exist across socioeconomic, geographic, and ethnic lines.¹ However, the extent and nature of disparities in European patients with CLD has been minimally explored.

Aims & Methods

This study aims to evaluate socioeconomic and geographic disparities in CLD mortality across Europe between 2013 and 2018. We analysed 6 years of standardized death rates for CLD in NUTS 2 regions within current European Union (EU) member states. NUTS 2 regions are subnational areas containing between 800,000 and 3,000,000 inhabitants, used for standardizing cross-border comparisons.² We linked Eurostat datasets of ‘Gross Domestic Product (GDP) Purchasing Power Standards (PPS) per inhabitant’ and ‘Causes of death’. Standardized death rates were weighted against the European Standard Population, and CLD mortality was defined using the codes K70, K73, and K74 from the International Classification of Diseases, 10th Revision. We chose a start date of 2013 as it coincided with Croatia’s accession into the EU and the first reporting of CLD mortality in several regions. We chose an end date of 2018 due to significant missing data in subsequent years. Regions were divided into quintiles from most to least disadvantaged based on GDP PPS per inhabitant, and summary statistics were calculated for each quintile. Concentration indices and curves were generated in Stata, using GDP PPS per inhabitant to rank regions by socioeconomic status. Finally, choropleth maps were generated to visually compare CLD mortality across NUTS 2 regions. We adhered to REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement guidelines.³

Results

Of the 242 NUTS 2 regions in current EU member states, GDP data was complete for all regions, but CLD mortality data was unavailable in 3 Croatian regions in all years and 1 French region in 2013. 238 (98.4%) regions were therefore analysed in 2013, and 239 (98.8%) were analysed in all other years. In 2013, median GDP PPS per inhabitant was $23,550 (IQR: $17,600 to $30,000), and median standardized death rate across all regions was 12.94 per 100,000 (IQR: 8.46 to 17.64). The rate in the most disadvantaged quintile was 1.38 times higher than this, at 17.9, and 1.43 times higher than the rate in the least disadvantaged quintile (12.52). Concentration indices and curves indicated that the burden of CLD mortality was concentrated in regions with lower GDP PPS per inhabitant. Indices ranged from -0.11 to -0.13, with p<0.001 in all years indicating significant inequality. Choropleth maps showed higher death rates in Eastern and Central Europe. The top 6 regions by CLD mortality were all located in Romania. The highest in all years was the Sud-Est region, where the rate ranged from 59 to 64 deaths per 100,000.

Conclusion

We identified socioeconomic disparities in the distribution of CLD mortality and found a high burden of disease in Eastern European nations. The concentration of mortality in the poorest quintile, with a death rate 1.38 times higher than the overall population, is similar to findings in Australia, where the poorest quintile’s death rate is 1.42 times higher than the population at large.⁴ Limitations included a retrospective design and a lack of granular data on sub-classifications of CLD and potential confounders such as rural status. Ultimately, our findings identify potential targets for health promotion and contribute to an understanding of how disadvantage contributes to health disparities in CLD.

References

1. Kardashian A, Serper M, Terrault N, Nephew LD. Health disparities in chronic liver disease. Hepatology. 2023; 77(4):1382-1403. doi: 10.1002/hep.32743.
2. Frédéric Gouardères. Common classification of territorial units for statistics (NUTS). European Parliament. Updated March, 2024. Accessed April 12, 2024. https://www.europarl.europa.eu/factsheets/en/sheet/99/common-classification-of-territorial-units-for-statistics-nuts-
3. Benchimol EI, Smeeth L, Guttmann A, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015; 12(10):e1001885. doi: 10.1371/journal.pmed.1001885
4. Australian Institute of Health and Welfare. (2011). Mortality Over Regions and Time (MORT) books: Socioeconomic Group 2017-2021. Australian Government. Retrieved February 28, 2024. https://www.aihw.gov.au/reports/life-expectancy-deaths/mort-books/contents/mort-books

Disclosure

The authors have no relevant personal or financial interests to declare.

Introduction

Acute pancreatitis (AP) often has unpredictable and complicated clinical course. Numerous biochemical predictors may aid in the risk stratification of AP (including interleukin 6 (IL-6)), but none of them are accurate. YKL-40 is glycoprotein playing mayor role in inflammation and angiogenesis, with reported average serum concentrations of ≥ 190 ng/mL in inflammatory diseases. It has been shown that IL-6 stimulates the production of YKL-40 and, in reverse, YKL-40 (at least in some tissues) induces the production of IL-6.

Aims & Methods

The aim of our study is to assess whether combined concentrations of both YKL-40 and IL-6 could be more informative in risk stratification of developing more severe form of AP than concentrations of either biomarker alone.
We included 150 consecutive consenting adults with AP admitted to Sestre milosrdnice UHC, Zagreb (June 2020-June 2023). Patients with any acute/chronic diseases known to be associated with dysregulated expression of YKL-40 were excluded. Alongside routine laboratory studies (including C-reactive protein (CRP)), 7 mLs of blood were withdrawn for determining YKL-40 and IL-6 concentrations on admission and 48h after. Severity of disease was defined using revised Atlanta classification. Blood samples for YKL-40 and IL-6 quantification in 30 consenting non-AP adults consistent with previously mentioned exclusion criteria were withdrawn. They were matched 1:1 by age and sex to randomly selected 10 patients from each of AP severity categories. Analysis were performed using enzyme-linked immunosorbent assays. AP patients were classified into 2 categories for each biomarker (based on YKL-40 and IL-6 concentrations on admission and 48h after): 1. for YKL-40: low (<190 ng/mL) and high (≥190 ng/mL); 2. for IL-6: low (<42 pg/mL) and high (≥42 pg/mL). Cumulative multimodal logit models were fitted to ordinal outcome “AP severity” – using raw data, and data after entropy balancing undertaken to balance the two categories of YKL-40 and IL-6 concentrations on age, sex, time between symptom onset and admission, and CRP concentrations.

Results

The results showed lower YKL-40 (<50 ng/mL) and IL-6 (<20 pg/mL) concentrations in 30 non-AP adults compared to AP patients. At both time points (on admission and 48h after), odds of more severe AP were clearly higher with YKL-40 and IL-6 concentrations above vs. below the cut-off values (190 ng/mL and 42 pg/mL, respectively), and were particulary higher in patients with both cytokines above the cut-off vs. patients with both cytokines below the cut-off. The same relationship was maintained with adjustments for age, body mass index, days elapsed since symptom onset and admission, and for CRP concentrations – however, the strength of association was lower. This is in line with the fact that high CRP concentration predicts more strongly severe AP forms when taken 48h after compared to admission. This phenomenon was apparent also when the interaction term was included in the model: at CRP concentrations 45 mg/L, neither YKL-40, or IL-6 or their combination above the cut-off values were associated with the outcome; at CRP concentrations 90 mg/L, odds were higher, and were particularly high for a combination of high YKL-40 and high IL-6. The same was observed at CRP concentrations 180 mg/L.

Conclusion

Overall, data suggest that combined YKL-40 and IL-6 concentrations in acute AP, taken either on admission or 48h after, predict more strongly moderate and/or severe (vs. mild) AP than either cytokine alone, and do so 'on-top' of the CRP concentrations.

References

1. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG et al. Classification of acute pancreatitis - 2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102–111.
2. van den Berg FF, de Bruijn AC, van Santvoort HC, Issa Y, Boermeester MA. Early laboratory biomarkers for severity in acute pancreatitis; A systematic review and meta-analysis. Pancreatology. 2020;20(7):1302-1311.
3. Tizaoui K, Yang JW, Lee KH, Kim JH, Kim M, Yoon S et al. The role of YKL-40 in the pathogenesis of autoimmune diseases: a comprehensive review. Int J Biol Sci. 2022;18(9):3731-3746. doi: 10.7150/ijbs.67587.
4. Blazevic N, Rogic D, Pelajic S, Miler M, Glavcic G, Ratkajec V et al. YKL-40 as a biomarker in various inflammatory diseases: A review. Biochem Med. 2023;34(1):010502.

Introduction

Esophageal squamous cell carcinoma (ESCC) is the most common histological type of esophageal cancer in eastern Asia and Africa. Diagnosis at early stage is crucial to reduce the mortality of ESCC. Currently, esophagogastroduodenoscopy (EGD) is the golden standard for screening ESCC, however, the patient compliance rate has been low due to the invasiveness and high cost of EGD. Thus, there is an unmet need for the development of diagnostic modality that enables non-invasive early detection of ESCC.

Aims & Methods

The purpose of this study is to construct a urinary exosomal miRNA panel as a least invasive test that can detect ESCC with high accuracy and validate its performance in a prospective cohort enriched with early ESCC. We prospectively collected urine samples from 161 ESCC patients and 180 healthy controls (HC) at five institutions from September 2019 to March 2023. Exosomes were extracted from urine specimens by polymer precipitation method, and exosomal miRNAs were subjected for comprehensive expression analysis by small RNA seq. Of the 341 total samples, 309 samples (90.6%) that passed the QC check were selected for subsequent data-analysis. In the training cohort (100 samples of ESCC and 98 samples of HC), we measured the expression of 328 miRNAs to identify candidate biomarker miRNAs. A miRNA diagnostic panel was constructed using machine learning analysis, and diagnostic performance was evaluated using a 5-fold cross-validation method. In the validation cohort (50 samples of ESCC and 61 samples of HC), the diagnostic performance of the urinary miRNA diagnostic panel was verified with blind to clinical information.

Results

In the RNAseq analysis of the training cohort (ESCC; mean age 68.2 years, 77.9% male; HC; mean age 58.1 years, 76.3% male), 33 out of 328 miRNAs were differentially expressed between ESCC and HC. Out of the 33 dysregulated miRNAs, 21 were upregulated and 12 were down-regulated. A multi-miRNA biomarker panel composed of miRNAs that were individually significant and non-significant between ESCC and HC had a diagnostic performance of AUC 0.89 (95% CI 0.84 to 0.94) by 5-fold cross-validation. In the validation cohort (ESCC; mean age 63.0 years, 78.0% male, median size 32mm, Stage I/II/III/IV 54/10/26/10%, HC; mean age 51.0 years, 52.5% male), The diagnostic performance of the miRNA diagnostic panel was AUC 0.85(95% CI 0.80 to 0.90), with a sensitivity of 84%, specificity of 73.8%, and accuracy of 78.4% at a pre-defined cutoff value. There was no confounding of diagnostic performance by age, gender, BMI, history of alcohol consumption or smoking. The sensitivity by clinical stage of ESCC was 88.9/80.0/77.8/80% for Stage I/II/III/IV.

Conclusion

We developed and validated a urinary exosomal miRNA diagnostic panel, which may be a new non-invasive diagnostic method that contributes to the early detection of ESCC.

Disclosure

Tomonori Yano received research funding from Craif Inc.

Introduction

Colorectal cancer, with an estimated two million new cases each year worldwide, poses a significant socioeconomic burden on modern society. It is the second leading cause of cancer-related deaths, accounting for nearly one million premature deaths annually.

Aims & Methods

The role of Signal Transducer and Activator of Transcription 2 (STAT2) in this context is not yet understood, and no therapies targeting this transcription factor are currently being pursued. We explored the function of STAT2 in colorectal cancer by employing experimental mouse models, as well as conducting functional assays with three-dimensional tumoroids in the context of anticancer therapy.

Results

In vivo studies showed that Stat2KO mice were more resistant to developing tumors in both inflammation-driven and inflammation-independent models of experimental colorectal cancer. This unexpected outcome could not be reconciled with the known role of STAT2 in inducing cell death downstream of type I interferon signaling. We consequently performed ex vivo experiments with tumoroids derived from Stat2KO mice carrying the multiple intestinal neoplasia (Min) mutant allele of the adenomatous polyposis coli (Apc) gene. These tumoroids exhibited slower growth, were generally smaller in size, and showed a higher degree of differentiation compared to those derived from ApcMin/+ wildtype mice. Remarkably, when treated with anti-tumor agents that induce cell death through various mechanisms, tumoroids derived from ApcMin/+ Stat2KO mice were found to be highly sensitive. Additional functional studies indicated that the underlying mechanism might involve a STAT2-dependent disruption of innate immune DNA sensing.

Conclusion

Our results establish STAT2 as a promoter of colorectal cancer and a contributor to resistance against anti-tumor therapy. These findings suggest that targeting STAT2-dependent signaling could be a promising therapeutic strategy for patients with colorectal cancer.

Introduction

Irritable bowel syndrome (IBS) is a highly prevalent and challenging condition with limited therapeutic options. Chitin-glucan (CG) is a novel dietary prebiotic considered as a safe food ingredient by EFSA. To provide an alternative approach to the management of IBS patients, we evaluated in preclinical studies the roles of CG on visceral analgesia, intestinal inflammation and barrier function and performed an open-label trial in IBS patients.

Aims & Methods

Analgesic effect of CG used at a human equivalent dose (HED) of 1.5-3 g/d was evaluated in rats and compared to negative-tap water and positive-phloroglucinol control groups. Mice with DSS-induced colitis were used to analyze the anti-inflammatory properties of CG. Molecular mechanisms underlying analgesic, anti-inflammatory, and intestinal barrier-strengthening functions of CG were evaluated in human intestinal HT-29 epithelial cells. CG molecular modeling was developed to study its interactions with microbial cell walls.
A multicenter open-label trial was conducted in 120 patients with IBS (Rome IV criteria) treated with CG 1.5 g/d and simethicone 0.75 mg/d for 4 weeks. The primary endpoint was the responder rate, defined as the number of patients whose abdominal pain score decreased by ≥30% from baseline at week (W) 4. The analysis was performed using the per-protocol set. Cardinal symptoms, impact of global symptoms on daily life, change in stool consistency, and improvement in defecatory disorders were evaluated.

Results

CG in animals was well tolerated. CG at 3g/d HED significantly decreased visceral perception by 14% after 2 weeks (p<0.01) and reduced inflammation by 50% promoting mucosal regeneration in DSS-induced colitis mice. CG at 1.5g/d HED reduced visceral pain perception by 20% after 5 weeks of treatment (p<0.01). At 3g/d HED, this analgesic effect was superior to phloroglucinol with a faster onset of action and a 50% inhibition of pain perception (p<0.0001). The molecular mechanisms contributing to these analgesic and anti-inflammatory effects of CG involved a significant induction of µ-opioid receptor (MOR), cannabinoid-2 (CB2) receptor, IL-10 and a significant decrease of pro-inflammatory cytokines IL-1b and IL-8 mRNA. CG also significantly up-regulated barrier-related genes like muc5AC, claudin-2 and ZO-2. CG molecular modelling revealed a new property of the molecule as a chelator of gram–negative lipopolysaccharide (LPS), gram–positive lipoteichoic acid (LTA) and phospholipomannan (PLM) in fungi.
Overall, 100 IBS patients were evaluated. At week 4, 67% were abdominal pain responders (score: 5.8 ± 2.4 vs. 2.9 ± 2.0, p<0.0001). Similar improvements were observed for bloating (8.0 ± 1.7 vs. 4.7 ± 2.9, p<0.0001; 60% responders), abdominal distension (7.2 ± 2.1 vs. 4.4 ± 3.1, p<0.0001; 53% responders), and impact of global symptoms on daily life (7.1 ± 2.0 vs. 4.6 ± 2.9, p<0.0001; 54% responders). Stool consistency improved in most patients (90% and 57% for patients with liquid and hard stools, respectively). Overall, 42% of patients with defecatory disorders reported very much/considerable improvements by 2 weeks. No severe adverse event occurred, and tolerability was rated “good” or “very good” by 93%.

Conclusion

CG decreased visceral perception and intestinal inflammation. It also impacted master genes regulation and direct binding of microbial products. CG-simethicone was well tolerated and improved IBS symptoms in an uncontrolled trial. A placebo-controlled trial with longer follow-up is now ongoing to confirm the benefits of CG in IBS patients.

Disclosure

Prof Pierre Desreumaux is President of the Scientific Board of BiOkuris SA
Prof Edouard Louis is member of the Scientific Board of BiOkuris SA

Introduction

Parkinson's disease (PD) is a neurodegenerative disorder characterized by both motor and non-motor symptoms, such as gastrointestinal symptoms. Emerging evidence suggests that gut permeability and inflammation play a role in PD pathophysiology via the gut-brain axis. According to Braak’s theory, the pathological degeneration associated with PD may originate from the gut and subsequently develop in the brain through the vagus nerve.

Aims & Methods

The aims were to assess the relationship between gut permeability and neuroinflammation in a cohort of patients with PD and REM behavior disorder (RBD), a condition that often precedes the onset of PD. The study prospectively included 28 PD patients and 18 RBD patients both complaining of GI symptoms. No serious organic diseases or therapies potentially affecting GI motility were reported. Relevant demographic and clinical data were collected for all patients. There was the inclusion of 14 healthy controls (HCs). A serum ELISA assay of tumor necrosis factor (TNF), caspase-1, and lipopolysaccharide-binding protein (LBP) was performed in all participants to investigate systemic inflammatory status and gut permeability, respectively. In a total of 10 PD patients, 4 RBD patients and 9 HCs, multiple colic biopsies were obtained to assay tissue expression of inflammation markers by both western blot (WB) (i.e. caspase-1 and procaspase-1) and immunofluorescence (IF) (i.e. ASC and CD68). Data were expressed as mean ± SD, and ANOVA and Dunnett's tests were used to compare the three groups.

Results

All three groups were comparable in age and sex. Serum assays showed significantly increased LBP, in patients with PD (35.0 ± 0.25; p = 0.002) and RBD (32.2 ± 1.1; p = 0.009) compared with HCs. TNF (0.1 ± 0.02; p = 0.03) and caspase-1 (16.9 ± 9.4; p = 0.04) were significantly raised only in the PD group in comparison with HCs (Table 1). WB analysis showed significant differences in the expression of procaspase-1 (157.3 ± 17.8; p = 0.02) and caspase-1 (168.3 ± 23.3; p = 0.03) only in PD patients compared with HCs. IF showed a qualitative increase in both CD68+ macrophage infiltration and ASC expression in PD and RBD groups compared with HCs.

	PD	RBD	HCs	P-value
LBP (ng/ml)	35.0 ± 0.25	32.2 ± 1.1	23.1 ± 2.1	0.009 (RBD vs HCs) 0.002 (PD vs HCs)
Caspasi-1 (ng/ml)	16.9 ± 9.4	11.4 ± 2.1	9.9 ± 2.7	0.04 (PD vs HCs)
TNF (pg/ml)	0.1 ± 0.02	0.05 ± 0.02	0.04 ± 0.02	0.03 (PD vs HCs)

Conclusion

Our results show a bowel activation of NLRP3 inflammasome in PD, as demonstrated both by the levels of procaspase-1 and caspase-1 on WB analysis and by the increase of CD68+ macrophages and ASC in the lamina propria of colonic mucosa. Only a qualitative increase in NLRP3 activation at IF could be observed in RBD patients. However, findings from colonic biopsies, if related to elevated serum levels of TNF and caspase-1 in PD patients, and LBP in PD and RBD patients, suggest that bowel inflammation, sustained by increased gut permeability, may represent an early stage in the develop of RBD and PD.

Introduction

The detection of cancer within large non-pedunculated colorectal polyps (LNPCPs) is suboptimal in non-expert settings. Identification of 6 macroscopic (Blink) features (6BF) of deep submucosal invasive cancer (SMI) has shown significant improvement in the sensitivity of cancer detection by inexperienced endoscopists at the expense of decreased specificity. This study investigates the impact of endoscopic resection scars, which can resemble deep SMI, on the accuracy of non-expert endoscopists using the 6BF evaluation system known as Blink Impression.

Aims & Methods

An online survey was disseminated containing 20 overview images of LNPCPs (1 image/polyp). Images (randomized) were shown before, and after a 2-minute educational video (the intervention) introducing the 6BF - fold deformation, extra redness, depression, chicken skin mucosa, ulceration and spontaneous bleeding. Before and after the intervention participant Blink Impression was elicited (cancer/no cancer) and only after, the presence of the 6BF. Responses were analysed relative to histopathology (no vs superficial vs deep SMI) and expert opinion on the presence of the 6BF and endoscopic resection scars.

Results

7/20 LNPCPs contained cancer (3 superficial, 4 deep SMI), 3 contained scars. 191 participants from 21 countries completed 3,755 observations. 129/191 (67.5%) participants were inexperienced. Expert-identified scarred LNPCPs contained median 1.0 (IQR 2.0) BF vs 1.0 (IQR 2.0) for no cancer, 2.0 (IQR 2.0) for superficial SMI and 3.0 (IQR 2.0) for deep SMI (all P<.001). Presence of ≥2 BF therefore reliably identifies cancer within LNPCPs but not scars. Fold deformation was the only BF identified more commonly amongst scarred LNPCPs (44.6%) vs no cancer (22.5%, P<.001) and vs superficial SMI (33.0%, P<.001), but similar to deep SMI (44.6%, P=1.000). Depression, chicken skin mucosa and spontaneous bleeding were less commonly identified in scarred polyps (12.3%, 7.6% and 1.8%) than both no cancer (33.1%, 14.4% and 8.6%, all P<.001), superficially invasive (68.6%, 14.3% and 5.8%, all P<.001) or deeply invasive polyps (45.9%, 19.6% and 40.5%, all P<.001). Extra redness and ulceration were identified with similar frequency to no cancer in scars (26.4% vs 26.8%, P=0.891 and 10.2% vs 9%, P=0.441 respectively), but less commonly than superficial (64.2%, P<.001 and 15.7%, P<.001) or deep SMI (60.2%, P<.001 and 24.7%, P<.001) (Table 1).

Conclusion

The presence of ≥2BF reliably discriminates LNPCPs with cancer from non-cancer even in the presence of scarred lesions amongst non-expert endoscopists. Scarred LNPCPs exhibit fold deformation at a similar rate to LNPCPs with deep SMI but other BF are not present.

References

Debels LK, Smeets S, Poortmans PJ, Argenziano ME, Desomer L, Anderson J, Valori R, David J Tate. Identification of 6 key features of colorectal polyps increases the sensitivity of cancer detection and ability to discriminate deep submucosal invasion The basis of the Blink (first) impression? United European Gastroenterology Journal 2023; Vol.11