Introduction

High-risk human papillomavirus (hr-HPV) has been associated with a subset of Barrett’s dysplasia (BD) and oesophageal adenocarcinoma (OAC).^1,2,3,4 The L1 major capsid protein has been closely linked to disease regression and is a prognostic factor in HPV driven cancers of the cervix and anus.​^5,6​​​​ The progression of cervical intraepithelial neoplasia to invasive cancer is accompanied by a loss of viral L1 capsid protein expression.

Aims & Methods

Thus, in a retrospective, cross-sectional study, we investigated L1 protein expression in HPV-positive patients representing the oesophageal squamous (controls) [Group1]-Barrett’s metaplasia [Group 2]-low-grade dysplasia [Group 3]-high-grade dysplasia [Group 4]-adenocarcinoma [Group 5] sequence. L1 protein immuno-histochemical staining was correlated with p16 overexpression and E6/E7 mRNA in-situ hybridization. The association between the 5 patient groupings and L1 expression was analysed using the Chi-square test. Multivariable logistic regression was undertaken to investigate the above association with adjustment of potential confounders (age, gender, BMI, ever smoked and excess alcohol). Adjusted odds ratio (95% CI) was calculated.​​​​​

Results

^​​​​​​Of 116 HPV DNA-positive patients [(age range: 19-90, mean (SD), 63.2 (13.5)], 88 males and 28 females), 73 (62.9%) were genotype 16, 37 (31.9%) genotype 18 and 6 (5.2%) were genotype 6. L1 nuclear staining was observed in 64 individuals. L1 expression was detected in 84.9% (28/33) of controls; 94.1% (16/17) of BO patients; 50% (7/14) of LGD subjects; 38.1% (8/21) of HGD individuals and 16.1% (5/31) of OAC patients; [adjusted P < 0.0001]. Conversely, p16 was present in 9.1% (3/33) of controls, 17.7% of BO (3/17), 57.1% (8/14) in LGD individuals, 61.9% (13/21) of HGD patients and 64.5% (20/31) of OAC subjects [p<0.0001]. Corresponding figures for E6/E7 mRNA positivity was 6.1% (2/33), 23.5% (4/17), 28.6% (4/14), 38.1% (8/21) and 45.2% (14/31) respectively [p=0.008]. Expression of HPV-L1 and p16 or L1 and E6/E7 mRNA was largely mutually exclusive.

Conclusion

HPV L1 capsid expression is incrementally lost with increasing oesophageal disease severity as in viral driven anal and cervical lesions. Utility of L1 alone or in combination with p16/E6/E7 mRNA in stratifying HPV-positive oesophageal lesions for treatment should be further explored.

References

1. Rajendra S, Wang B, Snow ET, et al. Transcriptionally active human papillomavirus is strongly associated with Barrett’s dysplasia and esophageal adenocarcinoma. Am J Gastroenterol 2013;108:1082–1093.
2. Rajendra S, Yang T, Xuan W, et al. Active human papillomavirus involvement in Barrett's dysplasia and oesophageal adenocarcinoma is characterized by wild-type p53 and aberrations of the retinoblastoma protein pathway. Int J Cancer. 2017;141(10):2037-2049.
3. Li X, Gao C, Yang Y, et al. Systematic review with meta-analysis: the association between human papillomavirus infection and oesophageal cancer. Aliment Pharmacol Ther. 2014;39(3):270-281.
4. Rajendra, S., W. Xuan, N. Merrett, et al. Survival Rates for Patients With Barrett High-grade Dysplasia and Esophageal Adenocarcinoma With or Without Human Papillomavirus Infection. JAMA Netw Open. 2018; 1: e181054.
5. Choi YS, Kang WD, Kim SM, et al. Human papillomavirus L1 capsid protein and human papillomavirus type 16 as prognostic markers in cervical intraepithelial neoplasia 1. Int J Gynecol Cancer 2010;20(2):288-293.
6. Hernandez J, Elahi A, Siegel E, Coppola D, Riggs B, Shibata D. HPV L1 capsid protein detection and progression of anal squamous neoplasia Am J Clin Pathol 2011; 135: 436-41.

Disclosure

None

Introduction

Globally, there is no standardized approach to sedation during endoscopic procedures, leading to variability in practices both regionally and across institutions. Sedation plays a crucial role in alleviating patient discomfort and ensuring the safety of endoscopic examinations and treatments. However, it occasionally leads to paradoxical reaction, which can adversely affect the outcomes of these procedures. As of 2023, in Japan, choice of sedatives and frequency of their use, and the incidence and management of paradoxical reaction during upper gastrointestinal endoscopy remain unclear.

Aims & Methods

This study is aimed to delineate the frequency and types of sedatives used in upper gastrointestinal endoscopy across different medical facilities in Japan and to investigate the extent of anesthesiologist involvement and the incidence and handling of paradoxical reactions. An anonymous online survey was distributed from November 28 to December 13, 2023, through mailing lists reaching about 2,500 gastroenterologists and endoscopists.

Results

The survey received responses from 635 participants including 418 hospital-based endoscopists, 118 clinic-based endoscopists, and screening 29 facility-based endoscopists. Sedation performed by anesthesiologists was found to be rare, with only 3.5% of examinations and 7.1% of treatments being managed by anesthesiologists once a week or more. 87% of respondents reported not using anesthesiologistsmanaged sedation at all for examinations, and 61% reported the same for treatments. Regarding the frequency of sedation use during examinations, 9.8% of respondents reported using sedation in over 95% of cases, and 53% reported using it in more than half of the cases. 6.6%, reported not using sedation at all. In treatments, 86% of respondents used sedation in over 95% of cases, and 96% used it in more than half of their cases.

Midazolam was the most common sedative for examinations (n=593), chosen in over 80% of cases by 54% of respondents, while only 9.9% never selected it. Meperidine was frequently used by 10% of respondents in similar proportions. Other sedatives like flunitrazepam, diazepam, and propofol were selected by 5.0%, 3.5%, and 2.5% of respondents, respectively.

For treatments (n=401), midazolam was again the most frequently chosen, selected in over 80% of cases by 72% of respondents. Other commonly used sedatives were meperidine and pentazocine, selected in over 80% of cases by 29% of respondents, with propofol and dexmedetomidine each chosen by 12%.

64% of endoscopists who use sedative drugs experienced difficult cases to continue procedures due to paradoxical reactions, with a median incidence of 5% of cases and median of two cases are required to discontinue procedures. Midazolam was the most common cause, reported by 91% of respondents, followed by flunitrazepam (13%), diazepam (8.8%), and propofol (8.3%). The typical response involved physically restraining the patient with multiple staff members' assistance. Eighteen percent of respondents did not use antagonist drugs for examinations, and 22% for treatments.

Conclusion

In Japan, over half of upper gastrointestinal procedures used sedation, with 53% in diagnostics and 96% in treatments predominantly using midazolam. Additionally, 64% of physicians experience difficulties with paradoxical reactions during procedures under sedation by themselves.. These reactions are recognized as significant challenges that must be addressed in the management of sedation for upper gastrointestinal endoscopy.

Clinical Case Summary

Introduction: Ulcerative colitis (UC) is a chronic inflammatory disease characterized by remitting and relapsing patterns, necessitating multifaceted therapeutic interventions, among which mesalazine, or 5-aminosalicylic acid (5-ASA), is prominently utilized. Despite its typically favorable tolerability profile, mesalazine may occasionally precipitate severe adverse events, such as myocarditis.
Case presentation: A 46-year-old male recently diagnosed with UC presented with a moderate UC flare-up and was initiated on 5-ASA therapy upon admission.
Within a span of two days following initiation of oral therapy, he developed acute chest pain, palpitations, dyspnea, and desaturation, necessitating intensive care due to cardiogenic shock.
Paraclinical assessments revealed elevated troponin levels, along with electrocardiographic and echocardiographic abnormalities, including left ventricular dysfunction and reduced ejection fraction.
Discontinuation of mesalazine resulted in symptom improvement and reduction of cardiac markers. Subsequent evaluations demonstrated a recovery in cardiac function, establishing a causal relationship between myocarditis and the administration of 5-ASA. Consequently, a therapeutic switch to mercaptopurine was instituted.
Conclusion: This case underscores the infrequent yet significant hazard of mesalazine-triggered myocarditis, emphasizing the critical necessity for vigilant patient monitoring during this therapy and prompt consideration of alternative therapeutic options in the presence of severe cardiac complications.

Introduction

Inflammatory Bowel Diseases (IBD) are chronic inflammatory disorders characterized by alterations of acute relapses and remission. The past decades have brought substantial advances in the pharmacological management of IBD by a wide range of medicines. However, the sustained efficacy of the currently available anti-inflammatory therapies is still far from optimal. Therefore, the development of novel therapies represents a major unmet clinical need in this field. Recently, the enrichment of the coagulation pathway genes and among these, Plasminogen activator inhibitor 1 (PAI-1) was described in IBD, whereas PAI-1 emerged as a link between the epithelium and inflammation. Moreover, the genetic deletion of PAI-1 prevented the severity of experimental colitis in mice.

Aims & Methods

Based on these, we aimed to develop and test novel PAI-1 inhibitors for the treatment of IBD.
The novel, amino acid-based PAI-1 inhibitor, LDN-071 was synthesized by the A³SMO^® platform. The inhibitory potential and cytotoxicity effects of the peptide were determined by in vitro assays. Acute and chronic colitis was induced in mice with DSS and 10 mg/bwkg LDN-071 was administered per os. The changes of body weight, spleen weight, and colon length were measured. Haematoxylin eosin (HE) and Periodic acid-Schiff (PAS) staining were performed for histology. ELISA and qRT-PCR measurements were applied to analyze the cytokine expressions. Hydroxyproline assay was used to quantify the mucosal collagen deposition. In vivo, the toxicity of LDN-071 was determined in mice. Human colon organoid and fibroblast (FB) cell cultures were generated from IBD patients and the effects of LDN-071 were observed.

Results

LDN-071 significantly inhibited PAI-1 in vitro without decreasing the cell viability in a concentration range of 1µM-1mM. In the acute mice model, the administration of 10 mg/bwkg LDN-071 in the DSS-treated mice prevented the body weight loss, the development of bloody diarrhea, the decrease of colon length, and the increase of the spleen weight, which were displayed by the DSS+vehicle-treated animals. The histological analysis of the colon revealed that DSS treatment induced severe transmural inflammation, ulceration, loss of crypt structures, and goblet cell depletion. Importantly, all these parameters were significantly ameliorated by the administration of 10 mg/bwkg LDN-071 in the acute and chronic models as well. Additionally, mucosal gene and protein expressions of TNF-α, IL-1β, and IL-6 were significantly decreased by PAI-1 inhibition in the acute phase. Besides, the LDN-071 treatment significantly reduced the inflammation, epithelial erosion, and fibrosis caused by chronic administration of DSS. However, the collagen deposition was significantly lower in the PAI-1-inhibited DSS mice. Importantly, no signs of toxicity were observed in mice exposed to 100 mg/bwkg LDN-071 for 7 days. In our in vitro models, the PAI-1 inhibition reduced the protein level and gene expression of pro-inflammatory cytokines in human colon organoid of IBD patient. Moreover, the gene expression of fibrosis-related genes significantly decreased after the LDN-071 treatment in IBD patients-derived human FB cell culture.

Conclusion

Our results showed that LDN-071, a novel amino acid-based inhibitor of PAI-1, significantly ameliorated the severity of acute and chronic colitis in mice. However, the LDN-071 reduced the expression of inflammation- and fibrosis-related genes and proteins in vitro human models. We propose that the inhibition of PAI-1 could be a potential novel therapeutic strategy in IBD.

Disclosure

LDN-071 PAI-1 inhibitor is owned by Ladon Therapeutics Ltd.

Clinical Case Summary

A 13-year-old boy presented with abdominal distention, recurrent hypoglycemia, and self-resolving jaundice. Clinical examination revealed growth retardation and hepatosplenomegaly. Blood work revealed anemia, thrombocytopenia, elevated aspartate and alanine transaminase levels, and raised plasma cholesterol and triglycerides. Ultrasound showed an enlarged liver with surface irregularity, splenomegaly, and a dilated portal vein. Etiological work-up for cirrhosis was positive for hepatitis B (HBV) surface antigen (HbsAg) and antibodies for HBV core and envelope antigens (anti Hbc, antiHbe) but an undetectable HBV DNA level. HBV was considered to be an unlikely cause of cirrhosis due to the young age of the patient, hence further metabolic and genetic work-up was done. Tests for Wilson’s and autoimmune liver disease were negative. Liver biopsy revealed a distorted lobular architecture with nodules, thin septae, and portal fibrosis. Hepatocytes showed marked swelling and pyknotic nuclei, and negative HbsAg immunostaining. Molecular analysis revealed a novel mutation in the exon 3 of the PHKG2 gene (c.98G>T, p.Gly33Val). The patient was diagnosed with cirrhosis due to GSD IXc with inactive chronic hepatitis B. His symptoms resolved with an optimized diet of corn starch, high-protein and vitamin supplementation. The importance of liver transplantation was also discussed with the family.

Introduction

Gastric cancer is the 5^th most common cancer globally(1). Europe's Beating Cancer Plan recognises the urgent need for a gastric cancer screening strategy(2). One promising approach, outlined in the Maastricht VI/Florence consensus report, suggests integrating screening modalities for gastric cancer, such as gastroscopy with colorectal cancer screening (3). This method holds the potential for cost-saving benefits through combined screening efforts (4).

Aims & Methods

We aimed to determine the prevalence of preneoplastic and neoplastic lesions in a high-risk age group, in those who underwent gastroscopy at the time of colonoscopy. Our secondary aims were to determine a)the quality of endoscopy performed and b) the endoscopic burden for pathology that required follow-up.
This was a single-centre review and audit of key performance indicators in a colorectal cancer screening centre. The age group targeted was 50-74, i.e. the target group for colon cancer screening in Europe. We included those undergoing colonoscopy for polyp surveillance or as part of the national colon cancer screening programme. Participants with red flag symptoms (iron deficiency anaemia, weight loss, dysphagia), family history of gastric cancer, established diagnosis of Barrett’s, intestinal metaplasia, dysplasia or who had a gastroscopy in the last 3 years were excluded. The sample size required for a 95% confidence interval with a presumed positivity rate of 5-7% was 101. Descriptive statistics, correlations and associations were examined using Stata software.

Results

101 patients were included; the median age was 59;38% were male. Indications for gastroscopy included abdominal pain (45%), chronic reflux (37%), chronic dyspepsia (7%) and other (9%). All patients had a technically complete gastroscopy (D2 intubation rate 100%, retroflexion 100%), the median procedure length was 7 minutes(range 4-21). 93% of patients had a macroscopic finding at the time of gastroscopy. Findings included gastritis(chronic superficial, chemical)(60%), hiatus hernia (50%), oesophagitis (28%), duodenitis (24%), gastric body polyps (10%), Barrett’s mucosa (8%), benign gastric or duodenal ulceration(9%), Schatzki ring (4%), erosions (4%), intestinal metaplasia (IM)(1%), oesophageal candidiasis (1%) and varices (1%). 59% had biopsies taken from two topographical sites as per MAPS guidelines. On biopsy, Helicobacter pylori infection was found in 15% (15/101), 7% had intestinal metaplasia(IM); no atrophy, dysplasia or cancer was detected. In those with IM who had MAPS biopsies (5/7), all were focal IM. In those with suspected Barrett’s (n=8), 88% had biopsies taken in accordance with the Seattle protocol and the Prague classification was used in 50% of cases. Additional pathology encountered included histological evidence of antral gastritis (56%), body gastritis (53%), reflux oesophagitis (21%), Barrett’s without dysplasia (4%), duodenitis (3%), and eosinophilic oesophagitis (1%). There was no statistical difference in age (p<0.82) or gender (p<0.32)in those with preneoplastic changes on gastroscopy.

Conclusion

11% of individuals within the target age bracket exhibited a pre-neoplastic condition on gastroscopy and/or histology (i.e. gastric intestinal metaplasia, gastric atrophy or Barrett's oesophagus), a further 15% were diagnosed and treated for Helicobacter pylori infection, the leading cause of gastric cancer. Among these cases, 4-7% necessitated subsequent surveillance gastroscopy. Our findings support the role of dual endoscopic screening with quality gastroscopy as a potential strategy for gastric cancer screening.

References

1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-49. doi: 10.3322/caac.21660. Epub 2021 Feb 4.
2. Commission E. Europe's Beating Cancer Plan - Communication from the commission to the European Parliament and the Council. 2021.
3. Malfertheiner P, Megraud F, Rokkas T, Gisbert JP, Liou JM, Schulz C, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022.
4. Libanio D, Antonelli G, Marijnissen F, Spaander MC, Hassan C, Dinis-Ribeiro M, Areia M. Combined gastric and colorectal cancer endoscopic screening may be cost-effective in Europe with the implementation of artificial intelligence: an economic evaluation. Eur J Gastroenterol Hepatol. 2024;36(2):155-61. doi: 10.1097/MEG.0000000000002680. Epub 2023 Nov 15.

Introduction

Arsenic, a potent environmental toxin, has been widely reported to cause significant health problems, including liver damage and disturbances in the metabolic processes. One of the lesser-understood facets of arsenic toxicity is its impact on gut microbiota, the community of microorganisms living in the intestinal tract, which plays a crucial role in host metabolism and overall health. Previous studies have indicated that arsenic exposure can alter the composition of gut microbiota, potentially affecting the host’s metabolism of arsenic and exacerbating its toxic effects. Despite ongoing research, the mechanisms underlying the interaction between arsenic exposure, gut microbiota changes, and arsenic metabolism remain inadequately defined.

Aims & Methods

The primary objective of this study was to elucidate the dynamics of gut microbiota changes under varying levels of arsenic exposure and to understand how these changes affect arsenic metabolism and subsequent liver toxicity. We used C57BL/6 mice as a model system, exposing them to 0, 5, or 10 ppm sodium arsenite (NaAsO2) in their drinking water over a period of six months. We conducted a comprehensive analysis of the gut microbiota, focusing on folic acid (FA)/vitamin B12 (VB12)- and butyrate-synthesizing communities. Additionally, molecular interactions between arsenic and methionine synthase (MTR), an enzyme crucial for FA/VB12 utilization, were assessed using 3D molecular simulations and biochemical assays. The intervention model involved supplementation of FA and VB12 to evaluate their protective effects against arsenic-induced disturbances.

Results

Exposure to NaAsO2 significantly altered gut microbiota, with a notable increase in the abundance of FA/VB12- and butyrate-synthesizing microbiota. This shift was hypothesized to compensate for the disrupted utilization of these nutrients due to arsenic exposure. In higher arsenic exposure levels, however, the microbiota changes were inconsistent, suggesting a potential threshold beyond which the compensatory mechanism may be overwhelmed. Biochemical assays confirmed that arsenic binds to MTR, disrupting its function and further impacting FA/VB12 metabolism. The interaction was substantiated by SEC-UV-DAD and fluorescence-labeled arsenic studies, which demonstrated that arsenic directly interacts with MTR in both non-cellular and cellular systems. Our intervention model using FA and VB12 supplementation showed that it was possible to mitigate the disturbances in gut microbiota, restore MTR levels, enhance arsenic metabolism, and reduce liver injury.

Conclusion

This study provides significant insights into the interaction between arsenic exposure and gut microbiota. We demonstrated that changes in gut microbiota are not merely a consequence of arsenic exposure but are intricately linked to the metabolic processes affected by arsenic, particularly through the disruption of MTR function. The supplementation of FA and VB12 proved effective in blocking these disturbances, suggesting potential therapeutic strategies to combat arsenic toxicity. The findings emphasize the importance of considering gut microbiota in the management and treatment of arseniasis and underscore the complex interplay between environmental toxins, gut microbiota, and host metabolism. Future studies should focus on further delineating the specific pathways and mechanisms by which microbiota influence arsenic metabolism and exploring the potential for microbiota-targeted therapies in arsenic-related diseases.