Background and aims: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is critical for diagnosing solid lesions. The wet-suction technique, which pre-fills the needle lumen with saline, has been proposed to improve specimen quality compared with conventional dry suction. This study aimed to evaluate the efficacy of wet suction versus dry suction in EUS-TA. Objectives: This study aimed to evaluate the efficacy of wet suction versus dry suction in EUS-TA. Design: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) following PRISMA 2020 guidelines. Methods: Electronic searches of PubMed, Embase, Cochrane CENTRAL, and additional databases were performed through January 2025. Primary outcomes were blood contamination, cellularity, and integrity scores; secondary outcomes were diagnostic accuracy and specimen adequacy. Effect sizes were calculated using Hedges’ g or risk ratios (RRs) with 95% confidence intervals (CIs). Results: Seven RCTs (784 patients; 1566 specimens) were included. Wet suction significantly reduced blood contamination (Hedges’ g = 0.289, 95% CI: 0.178–0.401, p < 0.0001) and improved cellularity (Hedges’ g = 0.420, 95% CI: 0.241–0.599, p < 0.0001) with low heterogeneity. Integrity score showed no significant difference ( p = 0.054). Overall diagnostic accuracy was similar between techniques (RR = 1.025, p = 0.548), but subgroup analysis revealed higher accuracy for wet suction in EUS-fine needle aspiration (FNA; RR = 1.162, p = 0.001). Specimen adequacy did not differ significantly ( p = 0.074). Conclusion: Wet suction improves sample quality by reducing blood contamination and increasing cellularity, with potential diagnostic benefit in FNA procedures. Effects on integrity and adequacy remain inconclusive. Larger, standardized trials are warranted to confirm these findings.

Background/Objectives: It is recommended that patients with cirrhosis receive endoscopic screening for esophageal varices because of portal hypertension. However, patients with primary biliary cholangitis (PBC) do not routinely undergo endoscopic examinations. Nevertheless, although bile acids may increase the incidence rate of colon polyps by inducing colonic epithelium cell damage, only a few studies have discussed colonic findings in PBC patients, which are believed to be related to cholestasis. The issues regarding PBC patients’ endoscopic characteristics are still unclear. Methods: This retrospective study was conducted at the Tri-Service General Hospital, Taiwan, and comprised data from patients aged >20 years diagnosed with primary biliary cholangitis between January 2000 and December 2018 after approval from the institutional review board. In these PBC patients, endoscopic findings were recorded, including esophagogastroduodenoscopy (EGD) and colonoscopy. Conclusions: In the PBC group, only 28 patients received EGD examinations. Among the 28 PBC patients who underwent EGD, 13 (46.4%) had EV, and there were no varices in the control group (p < 0.05). Patients with PBC also presented a higher incidence rate of colon polyps (50% vs. 14%; p < 0.001). The findings regarding the higher risks of esophageal varices and colon polyps support the rationale for endoscopic examination in PBC patients.

Endoscopic sleeve gastroplasty (ESG) and intragastric balloon (IGB) are established endoscopic bariatric therapies (EBTs) for obesity, but their comparative efficacy and safety remain uncertain. We conducted a systematic review and meta-analysis of comparative studies evaluating ESG versus IGB. The primary outcome was percentage of total body weight loss (%TBWL), assessed at the longest available follow-up and stratified timepoints (1, 3, 6, and 12 months). To explore temporal trends, we performed a meta-regression using follow-up duration as a continuous moderator. Secondary outcomes included a meta-regression based on baseline BMI differences and a pooled analysis of adverse events. Six comparative studies (n = 5330) were included. ESG was associated with significantly greater %TBWL than IGB (mean difference: 2.541; 95% CI 0.754 to 4.327; p = 0.005), with increasing benefit over time. Meta-regression confirmed a significant positive association between follow-up duration and treatment effect (p = 0.0006). A separate meta-regression revealed greater efficacy of ESG in patients with higher baseline BMI (p = 0.0001). Overall adverse event rates were comparable between the two groups (p = 0.20) ; however, IGB showed observed trends toward higher device intolerance and early removal rates in individual cohorts. Our findings suggest that ESG may offer a therapeutic advantage over IGB regarding weight loss efficacy, a trend that appears more pronounced in cohorts with higher obesity severity and across extended follow-up periods. ESG offers a comparable safety profile to IGB and may represent a more durable endoscopic bariatric option with potential advantages in procedural tolerability. Long-term trials are needed to validate its metabolic and clinical advantages beyond 12 months.

Background/Objectives: Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) has become the standard for diagnosing solid pancreatic masses (SPMs). However, in the absence of rapid on-site cytopathologic evaluation (ROSE), the optimal number of needle passes remains uncertain. This study aimed to evaluate the diagnostic performance of EUS-FNB using a gross-eyed evaluation with the fanning technique in patients with pancreatic malignancy. Methods: This retrospective single-center study included 140 patients with confirmed pancreatic malignancy who underwent EUS-FNB with at least three needle passes between January 2022 and December 2025. Gross-eyed visual inspection for whitish core tissue was used to assess the specimen adequacy. The primary outcome was the diagnostic rate of malignancy. The secondary outcomes included the tissue adequacy and yield rate of malignancy. Results: The diagnostic rate of malignancy improved with additional passes, 72.1% for one pass, 82.9% for two, and 90.7% for three. However, the gain beyond two passes was marginal. The tissue adequacy was high across all passes (≥94.3%), with most samples deemed adequate within two passes. The yield rate of malignancy similarly improved from 82.1% (one pass) to 91.4% (three passes). No adverse events were reported. Gross-eyed evaluation was feasible in all cases and guided effective sampling. Conclusions: EUS-FNB with two puncture numbers and the fanning technique achieves high diagnostic performance for pancreatic malignancy without the need for ROSE and MOSE. Two passes appear sufficient in most cases, supporting a simplified and safe approach that minimizes unnecessary needle passes.

Background and Objectives: In Taiwan, hepatitis B virus (HBV) or hepatitis C virus (HCV) infections are the most common causes of hepatocellular carcinoma (HCC). However, an increasing number of non-HBV and non-HCV (NBNC) patients developing HCC has been noted in recent years. The pathogenic connection between NBNC status and HCC development remains largely elusive. This study aims to explore the differences in clinical manifestations and pathological findings among HCC patients with HBV, HCV, and NBNC etiologies. Methods: This retrospective study analyzed 521 HCC patients with complete hepatic viral profiles at a single medical center in Taiwan between 2016 and 2020. Differentially expressed gene (DEG) analysis, xCell stromal cell estimation, and Gene Set Enrichment Analysis (GSEA) were employed to explore the distinct oncogenic mechanisms between the viral and NBNC groups. Results: The final cohort included 38 NBNC-HCC patients. Clinically, the NBNC-HCC patients exhibited a significantly lower FIB-4 index than the HCV-HCC patients (3.191 vs. 6.077, p = 0.0019). Furthermore, fewer NBNC-HCC patients presented with imaging-defined cirrhosis compared to HBV-HCC patients (44.4% vs. 68.1%, p = 0.0057), and a lower proportion had high Ishak scores (5-6) compared to HCV-HCC patients (31.3% vs. 75.6%, p = 0.0025). DEG analysis revealed differential expression in oncogenes (OIT3, AKR1B10) and liver fibrosis-related genes (COLEC10, CXCL14, and LINC01093). Subsequent GSEA and stromal cell analyses highlighted significant differential enrichment in hepatic stellate cells and vascular endothelial cells. Conclusions: NBNC-HCC patients present with significantly lower rates of cirrhosis and fibrosis compared to their viral counterparts. The distinct gene expression profiles and cell-type enrichment features observed between the viral and NBNC groups indicate a divergent, etiology-specific pathogenesis driving NBNC-HCC.

BACKGROUND & AIMS:Bile acids are carcinogens causing mutations leading to colorectal cancer (CRC). Higher total bile acid concentrations in the serum of patients with primary biliary cholangitis (PBC), compared to healthy controls, have been reported in previous studies. However, the association between PBC and the risk for CRC remains controversial. We investigated the association between PBC and the development of colonic polyps leading to CRC overall in this study. METHODS:The study enrolled 1,936,512 individuals from the Longitudinal Health Insurance Database spanning 2000 to 2017 for cohort analysis. Individuals assigned to ICD-9-CM and ICD-10-CM codes representing PBC were incorporated. A 1:4 control cohort was randomly selected. After adjusting for CRC risk factors using Cox regression analysis, we calculated the hazard ratios for developing colon polyps and CRC in PBC patients compared to the general population. RESULTS:Within the study cohort, consisting of 2024 individuals meeting the inclusion criteria, 199 patients developed colon polyps or CRC. In contrast, among the 8096 individuals in the comparison cohort, 650 cases of colon polyps or CRC were observed during the 17-year-follow-up period. According to Cox regression analysis, the adjusted hazard ratio indicated that the risk was 1.678 times higher in the PBC group compared to the comparison group. CONCLUSION:This population-based retrospective cohort study identified a 1.68-fold increased risk of colon polyps and CRC in patients with PBC, suggesting a potential association with colonic neoplasia. Further research is warranted to evaluate the role of endoscopic surveillance in patients with PBC.

Upper gastrointestinal angiodysplasia (UGIA) is a unique mucosal vascular lesion that causes acute or recurrent gastrointestinal bleeding. Despite the increasing incidence of UGIA, the risk factors for bleeding in this condition remain unclear. We investigated the predictors of active and recurrent bleeding among patients with UGIA. We conducted a retrospective cohort study of 104,086 patients who underwent esophagogastroduodenoscopy (EGD) at the Tri-Service General Hospital in Taiwan between October 2011 and September 2021. UGIA was diagnosed in 112 patients, and the data from these patients were comprehensively analyzed. EGD documented UGIA in 112 patients, which corresponded with an overall diagnostic yield of 1.1%. Active bleeding was documented in 28 (25%) patients. Patients in the active bleeding group were older than the patients in the asymptomatic group (71.6 ± 11.7-years vs 61.3 ± 18.5-years). Most of the UGIA lesions were singular and measured 2 to 5 mm. Nearly 1-quarter of the patients (24.1%) underwent endoscopic hemostasis, and rebleeding occurred in 6 (21.4%) patients during the follow-up period. Multivariate analysis identified diabetes mellitus (DM), chronic kidney disease (CKD), and lesions in the duodenum as significant risk factors for active bleeding (P = .019; P = .006; P = .004). Our cohort study provided real-world data on the clinical and endoscopic features of UGIA. DM, CKD, and lesions in the duodenum were independent predictors of active bleeding.

Objectives: : Protein disulfide isomerase (PDI) family members are specific endoplasmic reticulum proteins associated with inflammation, obesity, and cancer. In HIV infection, the role of PDI family A, member 4 (PDIA4), is unclear. This study aimed to clarify the association between plasma PDIA4 levels and inflammation in people living with HIV (PLWH).Methods: : In this study, 287 PLWH and 74 healthy participants were enrolled. The plasma PDIA4 values, demographic data, laboratory data, and other inflammatory markers were recorded. The association between PDIA4 level and inflammatory extent was analyzed using logistic regression and Spearman rankorder correlations. Other results were analyzed using Student's t -test or chi-square test. Results: : In PLWH, the PDIA4 levels were positively associated with the inflammatory markers, interleukin 6 (r = 0.209, p = 0.001), and tumor necrosis factor- & alpha; (r = 0.162, p = 0.01) levels, but not with high-sensitivity C-reactive protein levels. Moreover, the plasma PDIA4 level of PLWH decreased after antiviral treatment (p = 0.0 0 01).Conclusion: : Plasma PDIA4 levels are closely associated with inflammation in PLWH and have a positive correlation with the viral load during anti-viral therapy.& COPY; 2022 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )

Background: Hepatocellular carcinoma accounts for approximately 90% of primary liver cancers and hepatitis virus was believed to have the potential for altering the pathogenesis of arteriosclerosis. However, the influence of the hepatitis virus on coronary artery disease or cerebral vascular disease remains unclear. This study used the Taiwan National Health Insurance Research Database to clarify the virus-associated risk of coronary artery disease and cerebral vascular disease in patients with hepatocellular carcinoma (HCC). Methods: A total of 188,039 HCC individuals, age 20 years or older, were enrolled from the Longitudinal Health Insurance Database between 2000 and 2017 for cohort analysis. A total of 109,348 with hepatitis B virus (HBV) infection, 37,506 with hepatitis C virus (HCV) infection, 34,110 without HBV or HCV, and 7075 with both HBV and HCV were recorded. Statistically, propensity score matched by sex, age, and index year at a ratio of 15:5:5:1 and a sensitivity test using multivariable Cox regression were used. Results: The risk of coronary artery disease in the HCV-related HCC group was 1.516-fold (95% CI: 1.328–2.034, p < 0.001) higher than in the HBV-related HCC group, followed by the HBV/HCV-related HCC group and the non-B/C HCC group; the cerebral vascular disease risk in the HCV-related HCC group was 1.467-fold higher than in the HBV-related HCC group (95% CI: 1.335 to 1.786, p < 0.001), followed by the HBV/HCV-related HCC group and the non-B/C HCC group. Conclusion: Hepatitis C virus infection was found to have a higher risk of developing coronary artery disease or cerebral vascular disease in patients with hepatocellular carcinoma. For patients with hepatocellular carcinoma, our findings warrant the importance in preventing artherosclerotic disease in the setting of hepatitis C virus infection.

OBJECTIVE:To highlight the clinical characteristics of primary biliary cholangitis on the basis of gender in terms of the extent of liver injury and extra-liver autoimmune expressions.METHODS:The retrospective study was conducted at the Tri-Service General Hospital, Taiwan, and comprised data of patients aged >20 years diagnosed with primary biliary cholangitis between January 2000 and December 2018. Patients in the control group were randomly selected from the health examination centre. Liver injury manifestations and susceptibilities were analysed along gender lines. The gene expression microarray data from the National Centre for Biotechnology Information Gene Expression Omnibus database was also used to explore the relationship between autoimmune-induced inflammation and androgen response expression. Statistical analysis was done using Graph-Pad Prism 7.0.RESULTS:Of the 75 cases, 63(84%) were females with a mean age of 64.6±1.78 years, and 12(16%%) were males with a mean age of 46.6±5.6 years. Of the 66 controls, 55(83.3%) were females with a mean age of 51.67 years, and 11(16.6%) were males with a mean age of 45.9 years. There were no significant differences in terms of liver profiles related to gender in the control group (p>0.05). Among the cases, male patients showed fewer extrahepatic autoimmune disorders and more severe liver injuries before or after ursodeoxycholic acid treatment (p<0.05). There was a positive correlation between androgen receptor response and the extent of systemic inflammation (p<0.05). Conclusion: The association between androgen receptor responses and inflammation was linked to gender-related hepatic injuries, which may explain why liver inflammation in male patients is generally more severe compared to the female patients.Conclusion:The association between androgen receptor responses and inflammation was linked to gender-related hepatic injuries, which may explain why liver inflammation in male patients is generally more severe compared to the female patients.

The treatment of hepatitis C virus (HCV) infection has promising evolution after the development of direct-acting antiviral therapy.1 Nevertheless, little was known about therapeutic efficacy and safety for chronic HCV infection in tube-feeding-dependent patients with swallowing disorders in the real world. Here, we present a case with successful treatment of HCV infection with crushed elbasvir/grazoprevir administered via a nasogastric tube in a standard 12-week treatment. A 58-year-old female nursing home resident was referred to our hepatology clinic for evaluation of abnormal liver function tests. She became bedridden and dependent on nasogastric tube feeding at the age of 44 after an episode of multiple cerebral infractions followed by hypoxic encephalopathy. Chronic HCV infection was screened out and eradication therapy was suggested. Before initiation of the treatment, a complete blood count revealed a white blood cell 5280/μl, a hemoglobin level of 12.9 g/dl, and a platelet count of 208,000/μl. The values for creatinine, bilirubin, and albumin were within normal range except the level of aspartate aminotransferase measured as 127 U/L (normal: <40) and the level of alanine aminotransferase as 90 U/L (normal: <41). Resolved hepatitis B virus infection was found based on positive hepatitis B core antibody, positive surface antibody and negative surface antigen. HCV-polymerase chain reaction verified the presence of viral RNA genotype 1b and a viral load 189,000 U/ml. Abdominal sonography showed mild fatty infiltration of the liver parenchyma without evidence of ascites or cirrhosis. The patient was administrated on a 12-week regimen of crushed elbasvir 50 mg/grazoprevir 100 mg combination starting with a single dose daily through a nasogastric tube. The viral load of HCV was <15 U/ml at week 4 and not detected at the end of treatment. She achieved sustained virologic response at 12 weeks post-treatment (SVR12) with improved liver function without serious adverse effects. The elderly population currently represents a larger proportion of HCV patients and historically, older patients with HCV are considered difficult to treat because of comorbid medical conditions, including the difficulty in swallowing whole tablets or receiving a tube feeding for nutrition and medication secondary to neurological or oncological disorders.2 As the result, such patients may either skip or delay taking medications or employ alternative methods of administration, for example, crushing or splitting the tablets and taking them with liquids or jellies.3 The results from a phase 1 study showed that crushing the tablets resulted in higher primary pharmacokinetic parameters area under curve (AUC) (12–16%) for both elbasvir and grazoprevir, compared with the whole film-coated tablets. Furthermore, crushing lead to a higher maximum concentration (Cmax) of grazoprevir (42%), but had minimal impact on the Cmax of elbasvir. There was no any serious adverse effects in these 11 healthy adult volunteers.4 Yap et al. described a successful treatment of a patient receiving a 16-week course of elbasvir/grazoprevir through a percutaneous endoscopic gastrostomy tube.5 In this report, we presented a clinical case of a noncirrhotic patient with HCV genotype 1b infection treated with crushed elbasvir/grazoprevir administered via a nasogastric tube in a standard treatment course for 12 weeks. The SVR12 was achieved without any adverse events. These findings agree with data in the literature showing the safety and efficacy of crushed elbasvir/grazoprevir therapy without extension of treatment period. The authors declare no conflict of interest.

Background Xanthelasma palpebrarum (XP) is a sign of hyperlipidemia and is closely linked to atherosclerosis. Since fatty liver shares similar risk factors with atherosclerosis, we hypothesized that patients with XP are also at risk of non-alcoholic fatty liver disease (NAFLD). Methods In this retrospective cohort study, 37 patients with XP were compared with sex- and age-matched controls undergoing general health examination. Moreover, demographic information and lipid profiles were compared. The risk of NAFLD was evaluated using the hepatic steatosis and ZJU indices. In addition, we analyzed publicly available RNA sequencing data from the GSE48452 and GSE61260 datasets in the Gene Expression Omnibus database. Findings Patients with XP had higher scores of hepatic steatosis index (37 ± 1.13 vs 32 ± 0.82, p=0.0006) and ZJU index (38.77 ± 1.0 vs 33.88 ± 0.74, p=0.0002). In addition, they had higher levels of lipid parameters, including total cholesterol, low-density lipoprotein (LDL), and fasting glucose. Among patients with fatty liver, individuals presenting with XP showed higher serum levels of total cholesterol (216 ± 10.4 vs 188.9 ± 7.6, p=0.04), fasting glucose (117.1 ± 6.4 vs 98.3 ± 2.4, p=0.002), and low-density lipoprotein (145.1 ± 8.7 vs 115.6 ± 6.4, p=0.009) than those without XP. In gene expression analysis, individuals presenting with non-alcoholic steatohepatitis showed higher Z scores of xanthelasma than those without non-alcoholic steatohepatitis. Conclusion Our results suggest that individuals with XP have a higher risk of progression to NAFLD and develop a more severe dyslipidemia.

Background: Determine factors influencing the continuance intention of the Quit & Win smartphone app based on the technology acceptance model (TAM). Methods: This cross-sectional study was conducted on volunteer military personnel who smoke. Participants were asked to download a smoking cessation app and use it for 15-20 minutes before completing a questionnaire. Items in the questionnaire included those on demographic information, perceived usefulness, perceived ease of use, and continuance intention. The structural equation modeling (SEM) was applied to evaluate the TAM. Results: A total of 90 participants were included in this study. The model accounted for 0.81 of the variance in participants' intention to continue using the app. The results revealed that perceived usefulness affected continuance intention, self-efficacy affected perceived ease of use, and perceived ease of use affected perceived usefulness. Conclusions: This study applied the TAM to determine the factors influencing the continuance intention to use a smoking cessation app and revealed that perceived usefulness is the most crucial factor affecting continuance intention. Therefore, future designers of smoking cessation apps shall improve perceived usefulness to increase the continuance intention of users.

Background Vitamin D contributes to bone health and extra-skeletal effects. The mechanisms underlying vitamin D metabolism have not been extensively evaluated. The relationships between vitamin D and inflammatory cytokines are debated. Our objective was to investigate whether supplemental interferons are associated with longitudinal change of vitamin D status in humans. Methods A total of 48 patients with 24 or 48 weeks of pegylated interferon-α plus ribavirin therapy were examined for serum 25-hydroxyvitamin D (25[OH]D) level before treatment, at the end of treatment, and 24 weeks after treatment. In addition, we analyzed publicly available RNA sequencing data from accession GSE42697 and GSE7123 in the Gene Expression Omnibus. Findings The overall sustained virologic response (SVR) rate was 62.5%. There was no statistically significant association between baseline 25(OH)D concentrations and liver fibrosis. In patients with SVR, serum 25(OH)D increased markedly at end-of-treatment and decreased markedly by the end of the 24-week follow-up period. In the non-SVR group, this treatment-dependent change was lost. In gene expression analysis, the vitamin D biosynthesis process was activated in subjects with SVR, but not in patients without SVR. Furthermore, vitamin D receptor (VDR) signaling in peripheral blood mononuclear cells (PBMCs) was triggered in marked responders but not in poor responders. Conclusion In the aggregate, these data suggest that interferons have a regulatory influence on vitamin D status that can contribute to VDR signaling in PBMCs.

Background/purpose: To evaluate the efficacy and accuracy of bleeder localization in a pre-enteroscopic bleeding scan in patients with obscure gastrointestinal bleeding (OGIB). Methods: From January 2009 to December 2014, 98 patients with OGIB undergoing single-balloon enteroscopy (SBE) were enrolled. These patients were classified based on their history of a previous bleeding scan; 56 patients had undergone a previous bleeding scan, whereas 42 had not. The clinical characteristics, endoscopic findings, and rebleeding rate were compared between these two groups. The ability of the bleeding scan to localize the bleeding site was analyzed. Results: The mean age of patients was 56 +/- 22 years; final diagnostic yield, 65.3%; and the most common etiology of OGIB, angiodysplasia (29.6%). There was no significant difference in demographic characteristics, OGIB etiologies, and final diagnostic yields (67.9% vs. 61.2%, bleeding scan vs. control group) between groups. In the bleeding scan group, the rate of positive detection was approximately 80.4%. However, only 26.7% patients with a positive bleeding scan showed correct localization of bleeding. Moreover, the bleeding scan delayed SBE (8.9 days vs. 3.0 days, p < 0.001). During the 24 months of follow-up, 15 patients (15.3%) exhibited rebleeding and needed to be hospitalized, but there was no significant difference between the groups. Conclusion: In our study, bleeding scans in patients with OGIB revealed poor localization of the bleeder and delay in performing SBE. Thus, a bleeding scan prior to SBE showed a limited role for patients with OGIB.