Prevalence of fatty liver disease and the economy in China: A systematic review

AIM: To investigate the relationship between the economy and the adult prevalence of fatty liver disease(FLD) in China's Mainland. METHODS: Literature searches on the Pub Med and Chinese National Knowledge Infrastructure databases were performed to identify eligible studies published before July 2014. Records were limited to crosssectional surveys or baseline surveys of longitudinal studies that reported the adult prevalence of FLD and recruited subjects from the general population or community. The gross domestic product(GDP) per capita was chosen to assess the economic status. Multiple linear regression and Loess regression were chosen to fit the data and calculate the 95%CIs. Fitting and overfitting of the models were considered in choosing the appropriate models. RESULTS: There were 27 population-based surveys from 26 articles included in this study. The pooled mean prevalence of FLD in China was 16.73%(95%CI: 13.92%-19.53%). The prevalence of FLD was correlated with the GDP per capita and survey years in the country(adjusted R2 = 0.8736, P GDP per capita = 0.00426, P years = 0.0000394), as well as in coastal areas(R2 = 0.9196, P GDP per capita = 0.00241, P years = 0.00281). Furthermore, males [19.28%(95%CI: 15.68%-22.88%)] presented a higher prevalence than females [14.1%(95%CI: 11.42%-16.61%), P = 0.0071], especially in coastal areas [21.82(95%CI: 17.94%-25.71%) vs 17.01%(95%CI: 14.30%-19.89%), P = 0.0157]. Finally, the prevalence was predicted to reach 20.21% in 2020, increasing at a rate of 0.594% per year. CONCLUSION: This study reveals a correlation between the economy and the prevalence of FLD in China's Mainland.

Effects of probiotics on nonalcoholic fatty liver disease:A meta-analysis

AIM:To investigate the relationship between the gutliver axis and nonalcoholic fatty liver disease(NAFLD),we performed a meta-analysis to evaluate the effects of probiotic therapy in NAFLD.METHODS:We searched PubMed,Medline,Embase,Web of Science,the Cochrane Library and Chinese Biomedicine Database for all relevant randomized controlled trials on probiotics in patients with NAFLD/nonalcoholic steatohepatitis(NASH).A statistical analysis was performed using RevMan 5.0 software.RESULTS:Four randomized trials involving 134 NAFLD/NASH patients were included.The results showed that probiotic therapy signifcantly decreased alanine aminotransferase(ALT),aspartate transaminase(AST),total-cholesterol(T-chol),high density lipoprotein(HDL),tumor necrosis factor(TNF)-αand homeostasis model assessment of insulin resistance(HOMAIR)[ALT:weighted mean difference(WMD)-23.71,95%CI:-33.46--13.95,P<0.00001;AST:WMD-19.77,95%CI:-32.55--7.00,P=0.002;T-chol:WMD-0.28,95%CI:-0.55--0.01,P=0.04;HDL:WMD-0.09,95%CI:-0.16-0.01,P=0.03;TNF-α:WMD-0.32,95%CI:-0.48--0.17,P<0.0001;HOMA-IR:WMD-0.46,95%CI:-0.73--0.19,P=0.0008].However,the use of probiotics was not associated with changes in body mass index(BMI),glucose(GLU)and low density lipoprotein(LDL)(BMI:WMD 0.05,95%CI:-0.18-0.29,P=0.64;GLU:WMD 0.05,95%CI:-0.25-0.35,P=0.76;LDL:WMD-0.38,95%CI:-0.78-0.02,P=0.06).CONCLUSION:Probiotic therapies can reduce liver aminotransferases,total-cholesterol,TNF-αand improve insulin resistance in NAFLD patients.Modulation of the gut microbiota represents a new treatment for NAFLD.

Risk factors for alcohol-related liver injury in the island population of China: A population-based case-control study

AIM:To investigate the association of alcohol dose, duration of drinking and obesity with abnormal alcohol-related liver injury indicators, the prevalence of alcohol-related liver injury in the island population of China.METHODS:Randomized multistage stratified cluster sampling from the island population of China was used in the population-based case-control study. Then interview, physical examination, laboratory assessments and ultrasonography were done. RESULTS:Daily alcohol intake ≥ 20 g, duration of drinking ≥ 5 years and obesity were closely related to alcohol-related liver injury (P < 0.05). The odds-ratio (OR) (95% CI) was 1.965 (1.122-3.442), 3.412 (1.789-6.507) and 1.887 (1.261-2.824), respectively. The prevalence rate of alcohol-related liver injury in ≥ 20 g daily alcohol intake group and < 20 g daily alcohol intake group was 37.14% and 12.06%, respectively. The prevalence rate of alcohol-related liver injury in ≥ 5 years drinking group and < 5 years drinking group was 34.44% and 8.53%, respectively. No significant dose-response relation was found between daily alcohol intake and abnormal alcohol-related liver injury indicators as well as between duration of drinking and abnormal alcohol-related liver injury indicators. There was no significant difference in the prevalence of alcohol-related liver injury between beer drinking group and yellow rice wine drinking group, hard liquor drinking group, multiple drinking group.CONCLUSION:The risk threshold of daily alcohol intake is 20 g and duration of drinking inducing alcohol-related liver injury 5 years in the island population of China. Liver injury induced by obesity should be concerned.

Role of endoplasmic reticulum stress in the pathogenesis of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease(NAFLD)has emerged as a common public health problem in recent decades.However,the underlying mechanisms leading to the development of NAFLD are not fully understood.The endoplasmic reticulum(ER)stress response has recently been proposed to play a crucial role in both the development of steatosis and progression to nonalcoholic steatohepatitis.ER stress is activated to regulate protein synthesis and restore homeostatic equilibrium when the cell is stressed due to the accumulation of unfolded or misfolded proteins.However,delayed or insufficient responses to ER stress may turn physiological mechanisms into pathological consequences,including fat accumulation,insulin resistance,inflammation,and apoptosis,all of which play important roles in the pathogenesis of NAFLD.Therefore,understanding the role of ER stress in the pathogenesis of NAFLD has become a topic of intense investigation.This review highlights the recent findings linking ER stress signaling pathways to the pathogenesis of NAFLD.

Allyl isothiocyanate ameliorates lipid accumulation and inflammation in nonalcoholic fatty liver disease via the Sirt1/AMPK and NF-κB signaling pathways

BACKGROUND Allyl isothiocyanate(AITC),a classic anti-inflammatory and antitumorigenic agent,was recently identified as a potential treatment for obesity and insulin resistance.However,little is known about its direct impact on the liver.AIM To investigate the effect and underlying mechanism of AITC in nonalcoholic fatty liver disease(commonly referred to as NAFLD).METHODS To establish a mouse and cellular model of NAFLD,C57BL/6 mice were fed a high fat diet(HFD)for 8 wk,and AML-12 cells were treated with 200μM palmitate acid for 24 h.For AITC treatment,mice were administered AITC(100 mg/kg/d)orally and AML-12 cells were treated with AITC(20μmol/L).RESULTS AITC significantly ameliorated HFD-induced weight gain,hepatic lipid accumulation and inflammation in vivo.Furthermore,serum alanine aminotransferase and aspartate aminotransferase levels were markedly reduced in AITC-treated mice.Mechanistically,AITC significantly downregulated the protein levels of sterol regulatory elementbinding protein 1(SREBP1)and its lipogenesis target genes and upregulated the levels of proteins involved in fatty acidβ-oxidation,as well as the upstream mediators Sirtuin 1(Sirt1)and AMPactivated protein kinaseα(AMPKα),in the livers of HFD-fed mice.AITC also attenuated the nuclear factor kappa B(NF-κB)signaling pathway.Consistently,AITC relieved palmitate acid-induced lipid accumulation and inflammation in AML-12 cells in vitro through the Sirt1/AMPK and NF-κB signaling pathways.Importantly,further studies showed that the curative effect of AITC on lipid accumulation was abolished by siRNA-mediated knockdown of either Sirt1 or AMPKαin AML-12 cells.CONCLUSION AITC significantly ameliorates hepatic steatosis and inflammation by activating the Sirt1/AMPK pathway and inhibiting the NF-κB pathway.Therefore,AITC is a potential therapeutic agent for NAFLD.

LB100 ameliorates nonalcoholic fatty liver disease via the AMPK/Sirt1 pathway

BACKGROUND It is well known that nonalcoholic fatty liver disease(NAFLD)is associated with insulin resistance(IR).LB100,a serine/threonine protein phosphatase 2A(PP2A)inhibitor,is closely related to IR.However,there is little data regarding its direct influence on NAFLD.AIM To elucidate the effect and underlying mechanism of LB100 in NAFLD.METHODS After 10 wk of high fat diet(HFD)feeding,male C57BL/6 mice were injected intraperitoneally with vehicle or LB100 for an additional 6 wk(three times a week).The L02 cell line was treated with LB100 and free fatty acids(FFAs)for 24 h.Hematoxylin and eosin and oil red O staining were performed for histological examination.Western blot analysis was used to detect the protein expression of Sirtuin 1(Sirt1),total and phosphorylated AMP-activated protein kinaseα(AMPKα),and the proteins involved in lipogenesis and fatty acid oxidation.The mRNA levels were determined by qPCR.Pharmacological inhibition of AMPK was performed to further examine the exact mechanism of LB100 in NAFLD.RESULTS LB100 significantly ameliorated HFD-induced obesity,hepatic lipid accumulation and hepatic injury in mice.In addition,LB100 significantly downregulated the protein levels of acetyl-CoA carboxylase,sterol regulatory element-binding protein 1 and its lipogenesis target genes,including stearoyl-CoA desaturase-1 and fatty acid synthase,and upregulated the levels of proteins involved in fatty acidβ-oxidation,such as peroxisome proliferator-activated receptorα(PPARα),peroxisome proliferator-activated receptor gamma coactivator-1α(PGC-1α),carnitine palmitoyltransferase 1α,acyl-CoA oxidase 1 and uncoupling protein 2,as well as the upstream mediators Sirt1 and AMPKαin the livers of HFD-fed mice.In vitro,LB100 alleviated FFA-induced lipid accumulation in L02 cells through the AMPK/Sirt1 signaling pathway.Further studies showed that the curative effect of LB100 on lipid accumulation was abolished by inhibiting AMPKαin L02 cells.CONCLUSION PP2A inhibition by LB100 significantly ameliorates hepatic steatosis by regulating hepatic lipogenesis and fatty acid oxidation via the AMPK/Sirt1 pathway.LB100 may be a potential therapeutic agent for NAFLD.

Is Helicobacter pylori infection associated with glycemic control in diabetics?

AIM:To investigate whether Helicobacter pylori(H.pylori) infection is associated with glycemic control and whether hyperglycemia is modified by eradication therapy.METHODS:The databases of Pub Med,Cochrane Library,Chinese Bio Medicine Web Base and Chinese Science and Technology Journals were searched from inception to June 2014.Studies examining the association between H.pylori infection and glycemic control and/or the effect of eradication treatment on glycemic control in diabetic humans were eligible for inclusion.Meta-analyses were conducted using the Review Manager software version 5.2.The outcome measures are presented as weighed mean differences(WMDs) with 95% confidence intervals(CIs).Statistical heterogeneity was assessed by the Cochran Q test and the I2 statistic.RESULTS:A total of 21 relevant publications were identified.A meta-analysis of 11 studies with 513 patients with diabetes mellitus(DM) showed significantly lower glycosylated hemoglobin(Hb A1c) levels in the H.pylori-negative than H.pylori-positive DM participants(WMD = 0.43,95%CI:0.07-0.79;P = 0.02).In children and adolescents with type 1 DM(T1DM),there was a positive association between H.pylori infection and Hb A1 c level(WMD = 0.35,95%CI:0.05-0.64;P = 0.02),but there was no difference in those with type 2 DM(T2DM,WMD = 0.51,95%CI:-0.63-1.65;P = 0.38).A meta-analysis of six studies with 325 T2 DM participants showed a significant difference in the fasting plasma glucose levels between H.pylori-positive and H.pylori-negative participants(WMD = 1.20,95%CI:0.17-2.23;P = 0.02).Eradication of H.pylori did not improve glycemic control in the T2 DM participants in a threemonth follow-up period(Hb A1 c decrease:WMD =-0.03,95%CI =-0.14-0.08;P = 0.57;fasting plasma glucose decrease:WMD =-0.06,95%CI:-0.36-0.23;P = 0.68).Glycemic control was significantly better in T1 DM participants who were not reinfected than in those who were reinfected(Hb A1c:WMD = 0.72,95%CI:0.32-1.13:P = 0.00).CONCLUSION:H.pylori infection is associated with poorer glycemic control in T1 DM patients,but eradication may not improve glycemic control in DM in a short-term follow-up period.

Helicobacter pylori infection is associated with gallstones: Epidemiological survey in China

AIM: To elucidate the prevalence and risk factors for gallstones, primarily focusing on Helicobacter pylori(H. pylori) infection. METHODS: A total of 10016 Chinese subjects, who had undergone physical examination, fasting 13 C urea breath test and abdominal ultrasonography, had sufficient blood test data, and had finished a questionnaire, were included in this cross-sectional study. Participants(n = 1122) who had previous eradication of H. pylori were studied separately. RESULTS: Gallstones were discovered in 9.10% of men and 8.58% of women, with no significant sex difference. Multivariate analyses displayed that age, aspartate aminotransferase, total cholesterol, H. pylori infection, hepatitis C virus(HCV) infection, and fattyliver had a significant association with gallstones(P < 0.05). Successive multiple logistic regression analysis including index of odds ratio(OR) and standardized coefficient(β) indicated that older age(OR/β = 1.056/0.055), H. pylori infection(OR/β = 1.454/0.109), HCV infection(OR/β = 1.871/0.123), and fatty liver(OR/β = 1.947/0.189) had a significant positive association with gallstones. After age stratification, H. pylori infection and fatty liver still had a significant positive association with gallstones in any age-specific groups, whereas HCV infection had a significant positive association in patients aged > 40 years. The prevalence of gallstones among H. pylori-positive, H. pylori-eradicated, and H. pylori-negative subjects was 9.47%, 9.02%, and 8.46%, respectively. The matched analysis showed that gallstones among H. pylori eradicated subjects was significantly lower compared with H. pylori-positive subjects(P < 0.05).CONCLUSION: H. pylori infection and fatty liver have a significant positive association with gallstones. H. pylori eradication may lead to prevention of gallstones.

Association of caveolin-3 and cholecystokinin A receptor with cholesterol gallstone disease in mice

AIM: To investigate the role of caveolin-3 (CAV3) and cholecystokinin A receptor (CCKAR) in cholesterol gallstone disease (CGD).

Effects of pentoxifylline on nonalcoholic fatty liver disease: A meta-analysis

AIM: To evaluate the effects of pentoxifylline therapy in patients with nonalcoholic fatty liver disease (NAFLD).

Screening for pancreatic cancer in familial high-risk individuals: A systematic review

AIM:To analyze the benefits and harms of pancreatic cancer screening in familial high-risk individuals(HRIs).METHODS:Studies were identified by searching PubMed,EBSCO,ClinicalTrials.gov and the Cochrane database from database inception to June 2014.We also obtained papers from the reference lists of pertinent studies and systematic reviews.Englishlanguage trials and observational studies were searched.The key words used as search terms were "screening" and "surveillance".Cost-effectiveness,diagnostic rate,survival rate,mortality and adverse events were the outcomes of interest.Age,sex,lifestyle and other confounding factors were also considered.However,anticipating only a few of these studies,we also included observational studies with or without control groups.We also included studies concerning the anxiety associated with pancreatic cancer risk and other psychological changes in familial HRIs.We extracted details on study design,objectives,population characteristics,inclusion criteria,year of enrollment,method of screening,adjusted and unadjusted mortality,cost-effectiveness and adverse events from the included studies.Studies were assessed using the Reporting of Observational studies in Epidemiology(STROBE) checklist.RESULTS:Sixteen studies on pancreatic cancer screening were included.Five studies included control groups,nine were observational studies without control groups,and the other two studies investigated the worry associated with pancreatic cancer risk.We found that pancreatic cancer screening resulted in a high curative resection rate(60%vs 25%,P = 0.011),longer median survival time(14.5 mo vs 4 mo,P < 0.001),and higher 3-year survival rate(20%vs 15.0%,P =0.624).We also found that familial HRIs had a higher diagnostic rate of pancreatic tumors than controls(34%vs 7.2%,P< 0.001).In patients who underwent regular physical examinations,more stage I pancreatic cancers were observed(19%vs 2.6%,P= 0.001).In addition,endoscopic ultrasonography,which was the main means of detection,diagnosed 64.3%of pancreatic cancers.In comparison,endoscopic retrograde cannulation of the pancreas,magnetic resonance imaging,and computed tomography diagnosed 28.6%,42.9%,and21.4%,respectively.For mass lesions,instant surgery was recommended because of the beneficial effects of post-operative chemotherapy.However,in patients with intraductal papillary mucinous neoplasms,we did not find a significant difference in outcome between surgery and follow-up without treatment.Moreover,pancreatic cancer screening in familial HRIs had a greater perceived risk of pancreatic cancer(P< 0.0001),higher levels of anxiety regarding pancreatic cancer(P< 0.0001),and increased economic burden.CONCLUSION:Pancreatic cancer screening in familial HRIs is associated with a higher detection rate and longer survival,although screening may influence psychological function and increase the economic burden.

Clinical guidelines of non-alcoholic fatty liver disease: A systematic review

AIM To perform a systematic review to grade guidelines and present recommendations for clinical management of non-alcoholic fatty liver disease(NAFLD).METHODS A database search was conducted on Pub Med for guidelines published before May 2016, supplemented by reviewing relevant websites. The Appraisal of Guidelines for Research and Evaluation(ARGEE) instrument Ⅱ was a tool designed to appraise the methodological rigor and transparency in which a clinical guideline is developed and it is used internationally. it was used to appraise the quality of guidelines in this study. The inclusion criteria include: clinical NAFLD guidelines for adults, published in English, and released by governmental agencies or key organizations.RESULTS Eleven guidelines were included in this study. Since 2007, guidelines have been released in Asia(3 in China, 1 in South Korea, and 1 in Japan), Europe(1 in italy),America(1 in United States and 1 in Chile) and three international agencies [European associations joint, Asia-Pacific Working Party and World Gastroenterology Organization(WGO)]. Using the ARGEE Ⅱ instrument, we found US 2012 and Europe 2016 had the highest scores, especially in the areas of rigor of development and applicability. Additionally, italy 2010 and Korea 2013 also presented comprehensive content, rigorous procedures and good applicability. And WGO 2014 offered various algorithms for clinical practice. Lastly, a practical algorithm for the clinical management was developed, based on the recommended guidelines.CONCLUSION This is the first systematic review of NAFLD guidelines. it may yield insights for physicians and policy-makers in the development and application of guidelines.

Construction of a convolutional neural network classifier developed by computed tomography images for pancreatic cancer diagnosis

BACKGROUND Efforts should be made to develop a deep-learning diagnosis system to distinguish pancreatic cancer from benign tissue due to the high morbidity of pancreatic cancer.AIM To identify pancreatic cancer in computed tomography(CT)images automatically by constructing a convolutional neural network(CNN)classifier.METHODS A CNN model was constructed using a dataset of 3494 CT images obtained from 222 patients with pathologically confirmed pancreatic cancer and 3751 CT images from 190 patients with normal pancreas from June 2017 to June 2018.We established three datasets from these images according to the image phases,evaluated the approach in terms of binary classification(i.e.,cancer or not)and ternary classification(i.e.,no cancer,cancer at tail/body,cancer at head/neck of the pancreas)using 10-fold cross validation,and measured the effectiveness of the RESULTS The overall diagnostic accuracy of the trained binary classifier was 95.47%,95.76%,95.15%on the plain scan,arterial phase,and venous phase,respectively.The sensitivity was 91.58%,94.08%,92.28%on three phases,with no significant differences(χ2=0.914,P=0.633).Considering that the plain phase had same sensitivity,easier access,and lower radiation compared with arterial phase and venous phase,it is more sufficient for the binary classifier.Its accuracy on plain scans was 95.47%,sensitivity was 91.58%,and specificity was 98.27%.The CNN and board-certified gastroenterologists achieved higher accuracies than trainees on plain scan diagnosis(χ2=21.534,P<0.001;χ2=9.524,P<0.05;respectively).However,the difference between CNN and gastroenterologists was not significant(χ2=0.759,P=0.384).In the trained ternary classifier,the overall diagnostic accuracy of the ternary classifier CNN was 82.06%,79.06%,and 78.80%on plain phase,arterial phase,and venous phase,respectively.The sensitivity scores for detecting cancers in the tail were 52.51%,41.10%and,36.03%,while sensitivity for cancers in the head was 46.21%,85.24%and 72.87%on three phases,respectively.Difference in sensitivity for cancers in the head among the three phases was significant(χ2=16.651,P<0.001),with arterial phase having the highest sensitivity.CONCLUSION We proposed a deep learning-based pancreatic cancer classifier trained on medium-sized datasets of CT images.It was suitable for screening purposes in pancreatic cancer detection.

Upregulation of caveolin-1 and SR-B1 in mice with non-alcoholic fatty liver disease

BACKGROUND:Non-alcoholic fatty liver disease(NAFLD)is one of the most frequent causes of liver diseases,with markedly increased prevalence.However,its mechanisms are not clear.The present study was undertaken to illustrate the role of caveolin-1(cav1)and the scavenger receptor class B type 1(SR-B1)in NAFLD.METHODS:Adult male C57BL/6 mice were fed with a normal diet or high fat and cholesterol(HFC)diet for 14 weeks.The mice were sacrificed to collect plasma and harvest the liver;their plasma lipid concentration was measured.Hepatic cav1and SR-B1 mRNA and protein expression were determined by real-time quantitative polymerase chain reaction(qPCR)and Western blotting,respectively.In order to study cav1 and SR-B1distribution and change in hepatocytes,immunohistochemical analysis was performed.RESULTS:HFC diet increased plasma lipids,induced NAFLD and increased the liver/body weight ratio.Compared to the control mice(n=6),the mRNA and protein levels of cav1 and SR-B1 in liver tissue of the NAFLD mice(n=12)increased significantly(cav1 mRNA:1.536±0.226 vs 0.980±0.272,P【0.05;protein:0.643±0.240 vs 0.100±0.130,P【0.01;SR-B1 mRNA:1.377±0.125 vs 0.956±0.151,P【0.01;protein:2.156±0.507vs 0.211±0.211,P【0.01).Furthermore,both cav1 and SR-B1immunoreactivity increased and their distribution was also changed,mainly in the plasma membrane of hepatocytes,cytoplasm and membrane of lipid droplets and around.CONCLUSION:NAFLD is associated with increased concentration of plasma lipids and upregulation of hepatic cav1 and SR-B1 gene and protein expressions,which indicate that cav1 and SR-B1 might play crucial roles in the pathogenesis of NAFLD.

Association between serum alpha-fetoprotein levels and fatty liver disease: A cross-sectional study

AIM: To investigate the association between serum alpha-fetoprotein (AFP) levels and fatty liver disease (FLD) in a Chinese population.

Increased intestinal permeability in pathogenesis and progress of nonalcoholic steatohepatitis in rats

AIM： To investigate whether increased intestinal permeability contributes to the pathogenesis and progress of nonalcoholic steatohepatitis by observing its dynamic change in rat models. METHODS： Rat models of nonalcoholic steatohepatitis were established by giving a fat-rich diet. The rats were sacrificed at wk 8, 12 and 16 during the study. Rats fed with normal diet were taken as control. Plasma D-lactate, plasma diarnine oxidase, serum lipids and liver transarninases were measured in blood of the femoral artery. Hepatic steatosis and inflammation were assessed by haematoxylin-eosin staining. RESULTS： A rat model of nonalcoholic steatohepatitis was established successfully. Plasma D-lactate level in model group at wk 8, 12 and 16 and diarnine oxidase level in model group at wk 12, 16 increased significantly compared with those in control group. There were notable differences of D-lactate and diarnine oxidase level in model group between wk 8 and 12 as well as between wk 12 and 16. Serum lipids, liver transaminases and liver injury also increased with disease development CONCLUSION： Increased intestinal permeability caused by intestinal bacterial overgrowth and endotoxin-induced intestinal destruction exists in rats with nonalcoholic steatohepatitis, which may partially explain the pathogenesis and progress of this disease.

Endoscopic mucosal resection-precutting vs conventional endoscopic mucosal resection for sessile colorectal polyps sized 10-20 mm

BACKGROUND The optimal method to remove sessile colorectal lesions sized 10-20 mm remains uncertain.Piecemeal and incomplete resection are major limitations in current practice,such as endoscopic mucosal resection(EMR)and cold or hot snare polypectomy.Recently,EMR with circumferential precutting(EMR-P)has emerged as an effective technique,but the quality of current evidence in comparative studies of conventional EMR(CEMR)and EMR-P is limited.AIM To investigate whether EMR-P is superior to CEMR in removing sessile colorectal polyps.METHODS This multicenter randomized controlled trial involved seven medical institutions in China.Patients with colorectal polyps sized 10-20 mm were enrolled and randomly assigned to undergo EMR-P or CEMR.EMR-P was performed following submucosal injection,and a circumferential mucosa incision(precutting)was conducted using a snare tip.Primary outcomes included a comparison of the rates of en bloc and R0 resection,defined as one-piece resection and one-piece resection with histologically assessed clear margins,respectively.RESULTS A total of 110 patients in the EMR-P group and 110 patients in the CEMR group were finally evaluated.In the per-protocol analysis,the proportion of en bloc resections was 94.3%[95%confidence interval(CI):88.2%-97.4%]in the EMR-P group and 86%(95%CI:78.2%-91.3%)in the CEMR group(P=0.041),while subgroup analysis showed that for lesions>15 mm,EMR-P also resulted in a higher en bloc resection rate(92.0%vs 58.8%P=0.029).The proportion of R0 resections was 81.1%(95%CI:72.6%-87.4%)in the EMR-P group and 76.6%(95%CI:68.8%-84.4%)in the CEMR group(P=0.521).The EMR-P group showed a longer median procedure time(6.4 vs 3.0 min;P<0.001).No significant difference was found in the proportion of patients with adverse events(EMR-P:9.1%;CEMR:6.4%;P=0.449).CONCLUSION In this study,EMR-P served as an alternative to CEMR for removing nonpedunculated colorectal polyps sized 10-20 mm,particularly polyps>15 mm in diameter,with higher R0 and en bloc resection rates and without increasing adverse events.However,EMR-P required a relatively longer procedure time than CEMR.Considering its potential benefits for en bloc and R0 resection,EMR-P may be a promising technique in colorectal polyp resection.

Metabolic dysfunction is associated with steatosis but no other histologic features in nonalcoholic fatty liver disease

BACKGROUND Recently,nonalcoholic fatty liver disease(NAFLD)has been renamed metabolicassociated fatty liver disease(MAFLD).Based on the definition for MAFLD,a group of non-obese and metabolically healthy individuals with fatty liver are excluded from the newly proposed nomenclature.AIM To analyze the histologic features in the MAFLD and non-MAFLD subgroups of NAFLD.METHODS Eighty-three patients with biopsy-proven NAFLD were separated into MAFLD and non-MAFLD groups.The diagnosis of MAFLD was established as hepatic steatosis along with obesity/diabetes or evidence of metabolic dysfunction.The histologic features were compared according to different metabolic disorders and liver enzyme levels.RESULTS MAFLD individuals had a higher NAFLD activity score(P=0.002)and higher severity of hepatic steatosis(42.6%Grade 1,42.6%Grade 2,and 14.8%Grade 3 in MAFLD;81.8%Grade 1,13.6%Grade 2,and 4.5%Grade 3 in non-MAFLD;P=0.007)than the non-MAFLD group.Lobular and portal inflammation,hepatic ballooning,fibrosis grade,and the presence of nonalcoholic steatohepatitis(NASH)and significant fibrosis were comparable between the two groups.The higher the liver enzyme levels,the more severe the grades of hepatic steatosis(75.0%Grade 1 and 25.0%Grade 2 in normal liver function;56.6%Grade 1,39.6%Grade 2,and 3.8%Grade 3 in increased liver enzyme levels;27.8%Grade 1,27.8%Grade 2,and 44.4%Grade 3 in liver injury;P<0.001).Patients with liver injury(alanine aminotransferase>3×upper limit of normal)presented a higher severity of hepatocellular ballooning(P=0.021).Moreover,the grade of steatosis correlated significantly with hepatocellular ballooning degree(r=0.338,P=0.002)and the presence of NASH(r=0.466,P<0.001).CONCLUSION Metabolic dysfunction is associated with hepatic steatosis but no other histologic features in NAFLD.Further research is needed to assess the dynamic histologic characteristics in NAFLD based on the presence or absence of metabolic disorders.

A novel model for predicting fatty liver disease by means of an artificial neural network

Background:The artificial neural network(ANN)emerged recently as a potent diagnostic tool,especially for complicated systemic diseases.This study aimed to establish a diagnostic model for the recognition of fatty liver disease(FLD)by virtue of the ANN.Methods:A total of 7,396 pairs of gender-and age-matched subjects who underwent health check-ups at the First Affiliated Hospital,College of Medicine,Zhejiang University(Hangzhou,China)were enrolled to establish the ANN model.Indices available in health check-up reports were utilized as potential input variables.The performance of our model was evaluated through a receiver-operating characteristic(ROC)curve analysis.Other outcome measures included diagnostic accuracy,sensitivity,specificity,Cohen’s k coefficient,Brier score,and Hosmer-Lemeshow test.The Fatty Liver Index(FLI)and the Hepatic Steatosis Index(HSI),retrained using our training-group data with its original designated input variables,were used as comparisons in the capability of FLD diagnosis.Results:Eight variables(age,gender,body mass index,alanine aminotransferase,aspartate aminotransferase,uric acid,total triglyceride,and fasting plasma glucose)were eventually adopted as input nodes of the ANN model.By applying a cut-off point of 0.51,the area under ROC curves of our ANN model in predicting FLD in the testing group was 0.908[95%confidence interval(CI),0.901-0.915]—significantly higher(P<0.05)than that of the FLI model(0.881,95%CI,0.872-0.891)and that of the HSI model(0.885;95%CI,0.877-0.893).Our ANN model exhibited higher diagnostic accuracy,better concordance with ultrasonography results,and superior capability of calibration than the FLI model and the HSI model.Conclusions:Our ANN system showed good capability in the diagnosis of FLD.It is anticipated that our ANN model will be of both clinical and epidemiological use in the future.