Hepatitis Monthly
Volume:23 Issue: 1, Dec 2023

Chronic hepatitis E virus (HEV) infection may progress to end-stage liver disease in immunosuppressed individuals. Ribavirin therapy is efficient in most chronic HEV patients, but 10% remain without a sustained virological response (SVR).

We aimed to study whether zinc supplementation could represent a therapeutic approach in these patients.

Antiviral properties of zinc salts were studied in vitro (subgenomic-replicon system), in vivo (rabbit model), and retrospectively in patients with chronic hepatitis E who did not achieve SVR under ribavirin monotherapy.

Zinc inhibited HEV genotype 3 replication in vitro. In a model of acute HEV infection in immunocompetent rabbits, zinc + ribavirin did not improve viral clearance compared to ribavirin monotherapy. In chronically HEV-infected patients not responding to ribavirin (n = 12), viral clearance was observed in 4/12 (33%) patients receiving additional zinc supplementation.

Oral zinc, an inexpensive, harmless dietary supplement, could potentially represent a rescue treatment option for a few patients with chronic hepatitis E without SVR under ribavirin monotherapy. Further studies are needed to elucidate the role of zinc in HEV.

Hepatocellular carcinoma (HCC) is the most common type of liver cancer worldwide. The current remedies for cancer, including chemotherapy and radiation therapy, might damage patients’ organs, sometimes causing death. Etoposide (ETO), as a widely used chemo-drug, possesses the same problems. For years, combinational therapy has been considered a potential adjustor for common treatments, alleviating their side effects. Quercetin (Que), a phytochemical drug, has been used due to its potential against cancer.

This study explored whether synergy occurs between Que and ETO on the apoptosis of HepG2 HCC cells or not.

The impacts of the drugs on cell growth were assessed through the MTT assay. The apoptotic death rates of treated cells were examined through Annexin/PI double staining and caspase-9 and caspase-3 activities. The relative expression of B-cell lymphoma 2 (Bcl-2) Associated X-protein (Bax), and Bcl-2 genes and proteins were analyzed using quantitative reverse transcription polymerase chain reaction and western blot analysis. Additionally, the levels of p53 protein were determined.

Both Que and ETO reduced the cell viability and increased apoptotic rates, caspases activities, Bax gene and protein expression, and the p53 protein levels of HepG2 cells. The combination of Que and ETO showed apparent synergy in terms of cell growth and cell apoptosis. Que significantly enhanced the effects of ETO on caspase activities, Bax and Bcl-2 genes’ expression, and p53 protein levels.

The obtained results demonstrated that Que showed synergy when co-treated with ETO on HepG2 cells. Therefore, it is concluded that further studies on the aforementioned combination could lead to a potential anticancer compound against HCC.

Abdominal pain is a frequent adverse event in patients with hepatocellular carcinoma (HCC) after transarterial chemoembolisation (TACE). However, there remains uncertainty regarding the determinants of post-TACE pain.

We aimed to create and verify a prediction model for postoperative pain in patients with HCC after TACE treatment.

This prospective study included all patients with HCC undergoing TACE in our hospital. According to the time of treatment, the dataset was divided into two cohorts (development and validation) in a 3: 2 ratio. After TACE, the participants used a visual analog scale to quantify their pain level at rest over a 24-hour period. The age, gender, tumor location, tumor size and number, medication administration route, and presence of portal vein tumor thrombosis (PVTT) were recorded in all patients.

In total, 137 (mean age: 60.3 ± 10.1 years; 78.1% male) and 91 (mean age: 61.1 ± 10.5 years; 73.6% male) patients were included in the development and validation cohorts, respectively. Furthermore, 46.0% and 39.6% of the patients experienced acute moderate to severe pain after TACE in the development and validation cohorts, respectively. The tumor location, the drug delivery method, and the presence of PVTT were independently associated with post-TACE pain, all of which were combined to develop a prediction model based on a logistic equation. The discrimination of this risk score was satisfactory in both the development (area under the curve (AUC): 0.693, 95% confidence interval (CI): 0.609 to 0.769, P < 0.001) and validation (AUC: 0.652, 95% CI: 0.544 to 0.748, P = 0.002) cohorts. There was no significant difference between the two cohorts (difference: 0.042, 95% CI: -0.081 to 0.164, P = 0.506). The risk score had good specificity for predicting post-TACE pain in both the development (83.8% (95% CI: 73.4% to 91.3%)) and validation (76.4% (95% CI: 63.0% to 86.8%)) cohorts.

The presence of PVTT, the tumor location, and the drug administration method were risk factors for post-TACE discomfort. A prediction model based on these risk factors was useful for identifying patients who were vulnerable to post-TACE pain. However, further studies are required to validate these findings and optimize the model’s performance.

Non-alcoholic fatty liver disease (NAFLD) is progressing considerably worldwide. Identifying the risk factors of NAFLD is a critical step in preventing its progression.

In November 2022, two independent researchers studied seven databases, including PubMed, ISI/WoS, ProQuest, Scopus, SID, Magiran, and Google Scholar, and reference list of relevant articles, searching studies that assessed NAFLD risk factors in the Iranian adult population. Heterogeneity between studies was assessed by Cochran’s test and its composition using I2 statistics. A random-effects model was used when heterogeneity was observed; otherwise, a fixed-effects model was applied. Egger’s regression test and Trim-and-Fill analysis were used to assess publication bias. Comprehensive Meta-analysis software (version 3) was used for the analyses of the present study.

The results of this study showed significant associations between NAFLD with age [n = 15, odds ratio (OR) = 2.12, 95% CI: 1.79 - 2.51], body mass index (n = 46, OR = 5.00, 95% CI: 3.34 - 7.49), waist circumference (n = 20, OR = 6.37, 95% CI: 3.25 - 12.48), waist-to-hip ratio (n = 17, OR = 4.72, 95% CI: 3.93 - 5.66), total cholesterol (n = 39, OR = 1.80, 95% CI: 1.52 - 2.13), high-density lipoprotein (n = 37, OR = 0.53, 95% CI: 0.44 - 0.65), low-density lipoprotein (n = 31, OR = 1.68, 95% CI: 1.38 - 2.05), triglyceride (n = 31, OR = 3.21, 95% CI: 2.67 - 3.87), alanine aminotransferase (n = 26, OR = 4.06, 95% CI: 2.94 - 5.62), aspartate aminotransferase (n = 27, OR = 2.16, 95% CI: 1.50 - 3.12), hypertension (n = 13, OR = 2.53, 95% CI: 2.32 - 2.77), systolic blood pressure (n = 13, OR = 1.83, 95% CI: 1.53 - 2.18), diastolic blood pressure (n = 14, OR = 1.80, 95% CI: 1.48 - 2.20), fasting blood sugar (n = 31,OR = 2.91, 95% CI: 2.11- 4.01), homeostatic model assessment for insulin resistance (n = 5, OR = 1.92, 95% CI: 1.48 - 2.59), diabetes mellitus (n = 15, OR = 3.04, 95% CI: 2.46 - 3.75), metabolic syndrome (n = 10, OR = 3.56, 95% CI: 2.79 - 4.55), and physical activity (n = 11, OR = 0.32, 95% CI: 0.24 - 0.43) (P < 0.05).

In conclusion, several factors are significantly associated with NAFLD. However, anthropometric indices had the strongest relationship with NAFLD in the Iranian adult population.

In patients with Hepatocarcinoma (HCC), the association between the rapid decline of kidney function and clinical outcomes is still unknown, although kidney-liver crosstalk is comprehensively studied.

We aimed to investigate the prevalence and determinants of the rapid decline of kidney function and its potential prognostic role and influence on mortality in HCC patients treated by percutaneous injection therapy (PEIT).

This prospective cohort included 114 HCC, with 64.9% males and a mean age of 65.17 years. The rapid decline of kidney function was defined according to kidney disease improving global outcome (KDIGO). The cancer of the liver Italian program (CLIP) score was calculated to predict survival. Multivariable logistic regression analysis for rapid estimated glomerular filtration rate (eGFR) decline was performed after evaluating individual covariates. Multivariable Cox regression models for rapid eGFR decline and mortality were analyzed.

During a median follow-up of 31 months, 43.85% of patients presented a rapid decline in eGFR. The baseline eGFR was significantly higher in the group with the rapid decline of kidney function: 86.08 ± 19.17 mL/min/1.73m2 vs. 75.53 ± 25.7 mL/min/1.73 m2 (P = 0.001). The CLIP score (hazard ratio [HR] = 2.55, 95% confidence interval [CI]: 1.70 - 3.84, P < 0.001) was independently associated with rapid eGFR decline. In Cox regression, rapid eGFR decline was independently associated with mortality (HR = 3.49, 95%CI: 1.28 - 9.56, P = 0.015).

Nearly half of the HCC patients presented a rapid eGFR decline. The HCC severity evaluated by the CLIP score was an independent predictor of the rapid decline of kidney function. The rapid decline in eGFR was associated with a higher mortality risk in HCC patients, independent of other known risk factors.

Entecavir (ETV) has been widely used in the clinical treatment of the Hepatitis B Virus (HBV). However, whether ETV is helpful in the recovery of T cell immune function remains unclear.

We aimed to assess the effects of ETV on serum HBV-DNA, interferon-γ (IFN-γ), and pregenomic RNA (pgRNA) in patients with infection.

The clinical data of 300 HBV patients admitted from January 2017 to January 2019 were retrospectively analyzed, of whom 193 cases administered with ETV were assigned to an observation group, and the remaining 107 untreated cases (who refused treatment) were assigned to a blank control group. Their liver function [aspartate aminotransferase (AST) and alanine aminotransferase (ALT)], serum HBV markers [hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg)], IFN-γ, HBV-DNA, HBV pgRNA, negative conversion rates of HBeAg and HBV-DNA, and adverse reactions were compared.

The levels of HBsAg, IFN-γ, HBV-DNA, and HBV pgRNA were lower in the observation group than in the blank control group 12, 24, and 48 weeks after treatment (P < 0.05). The HBeAg and HBV-DNA negative conversion rates of the observation group were higher than those of the blank control group 12, 24, and 48 weeks after treatment (P < 0.05).

Antiviral therapy with ETV can inhibit the replication of HBV-DNA, increase the HBV-DNA negative conversion rate, enhance immune function, and reduce the expression of HBV pgRNA in HBV patients.

Cholestasis is described as a disease in which bile flow from the liver is reduced or stopped, and due to its oxidative effects, irreversible consequences may occur.

Due to the remarkable antioxidant properties of Oliveria decumbens (OD) and the contribution of oxidants to the progression of bile duct ligation (BDL)-induced cholestasis, this research aimed to examine how the OD ethanolic extract affected liver damage and oxidant-antioxidant balance markers in BDL-induced cholestasis.

Forty male Wistar rats weighing 200 - 250 g were used. Cholestasis was induced using the BDL approach. The rats were categorized into four groups: Group 1, sham-control (SC); group 2, cholestatic; group 3, SC + OD; and group 4, cholestatic + OD. A dose of OD ethanolic extract was administered orally (500 mg/kg/day) to rats for seven days. Seven days following surgery, the rats’ blood samples were collected; after sacrifice, a part of the liver tissue was isolated. A histopathological examination was performed, while the rest was stored at -70°C in liquid nitrogen. Heparin-containing tubes were used to gather blood samples. In plasma and hepatic tissue, biochemical tests, histopathological evaluations, and oxidative stress markers staining levels were performed.

Our findings showed that OD could effectively reduce liver injury by reducing the activity of liver function enzymes (AST and ALP). At the same time, it did not affect total bilirubin and protein. Bile duct ligation-induced hepatic markers of protein oxidation (PCO) and reactive nitrogen species (NO) were significantly decreased by OD, and it also promoted liver antioxidant capacity by enhancing superoxide dismutase (SOD) activities. Moreover, OD treatment prevented liver bile duct proliferative changes in histopathologic analysis.

Our study confirmed that OD exerts substantial hepatoprotective activities against BDL-induced cholestasis by improving liver damage markers and regulating oxidative stress. It may be a beneficial therapeutic agent for managing cholestasis. Bioassay-guided isolation and identification of bioactive OD secondary metabolites can further direct the discovery of potential natural-based drug candidates.

Previous investigations have demonstrated that hepatitis B virus (HBV) infection leads to elevated serum bile acid levels, which is considered to cause liver damage. Thus, we suppose that bile acids may be of considerable significance in inducing immune tolerance.

In this investigation, we explored the functions of the farnesoid X receptor (FXR), a nuclear receptor activated by bile acids, in modulating hepatitis B e antigen (HBeAg) production and toll-like receptor (TLR) expression in vitro and in vivo.

The results showed that FXR activation promoted secreted and intracellular HBeAg expression in HepG2 and HEK293T cells. However, FXR antagonist Z-guggulsterone (Z-g) decreased the bile acid-mediated HBeAg production. Meanwhile, TLR2 expression significantly reduced in HepG2 cells transfected with pAAV/HBV1.2 plasmid comprising whole HBV genome and treated with bile acids, but not with mutant pAAV/HBV1.2 plasmid with defected HBeAg product. In the hydrodynamic injection HBV mouse model, the level of serum HBeAg was decreased, but intrahepatic TLR2 expression was elevated in FXR-/- mice.

In conclusion, FXR activation inhibits TLR2-mediated innate immunity by upregulating HBeAg production. Our data indicate that a mild elevation of serum bile acids may cause immune tolerance and lead to virus persistence in HBV-infected patients.

 Immune checkpoint inhibitor (ICI)-related hepatitis has been increasing in the past decade.

 This study aimed to investigate the effectiveness of plasma exchange (PE) and a double-plasma molecular absorption system (DPMAS) for ICI-related hepatitis.

 A retrospective analysis was conducted on patients with ICI-related hepatitis treated at the Third Affiliated Hospital of Sun Yat-Sen University (China). The collected data included biochemical indices, treatments, the use of an artificial liver support system (ALSS), and outcomes.

 From June 2021 to January 2023, 16 patients were treated and included in the analysis. Eight patients in group A received general support. The other 8 patients in group B received general support, plus 3 rounds of ALSS every 2 - 4 days (4 patients were treated with PE and the others with DPMAS + PE). There was no significant difference in age and treatment days between the two groups. Before treatment, there was no significant difference in direct bilirubin (DBIL), glutamine transpeptidase (GGT), alkaline phosphatase (ALP), aspartate transaminase, alanine transaminase (ALT), procalcitonin, the international normalized ratio (INR), model for end-stage liver disease scores, albumin, globulin, and hemocyte count between groups A and B (in all cases, P > 0.05). However, the total bilirubin (TBIL) of group B was significantly higher than that of group A (P = 0.029). After treatment, TBIL and DBIL were significantly decreased in group B (both P < 0.05), and group B had a significantly lower GGT (P = 0.028) and higher INR (P = 0.004) than group A. The ALP level of group B was also lower, but the difference was not significant (P = 0.068). No allergic reaction or severe adverse effect was observed.

 Both PE and DPMAS + PE can effectively improve ICI-related hepatitis within the short term and are more effective for patients with hyperbilirubinemia. Liver function should be monitored continuously during treatment.

 Most patients with extrahepatic metastases (EHM) from hepatocellular carcinoma (HCC) die from developing the primary tumor within the liver, not from EHM. Although surgery for primary tumors is not recommended in guidelines, some studies suggest that surgical treatment might prolong patient survival.

 This study aimed to develop and validate an easy-to-use nomogram for preoperative assessment by physicians of patients with advanced extrahepatic metastatic hepatocellular carcinoma (HCC-EHM), factors associated with surgical treatment, and probability of benefit.

 By searching the SEER database of HCC patients with EHM by propensity score matching (PSM), 912 patients were finally included in the study. The patients in the surgery group were randomly assigned to the training and validation groups (7:3), and a nomogram was constructed to predict whether patients in the surgery group could benefit from receiving surgical treatment at the primary site and to validate the accuracy of the model and the overall survival of the surgery patients at 1, 3, and 5 years.

 Several factors related to the grade, T staging, NM staging, tumor size, primary site surgery, alpha-fetoprotein (AFP), chemotherapy, and fibrosis score were finally included (P < 0.05). The area under the receiver operating characteristic curve (AUROC/area under the curve (AUC)) was 0.738 and 0.769 for the training and validation groups, respectively. The 1-, 3-, and 5-year survival rates were 0.725, 0.720, and 0.716, respectively.

 Based on the results, a nomogram can individually predict patients suitable for surgery and provide a reference for clinical decision-making.

 The leading cause of mutations in the hepatitis B virus (HBV) genome is the high rate of nucleotide misincorporation during reverse transcription. Most mutations were found within the “a” determinant of the S gene’s major hydrophilic region (MHR). They resulted in escape mutants due to amino acid changes in the MHR. However, mutations outside the MHR can also trigger escape mutants.

 This study focused on further molecular studies on the MHR of genotype D of HBV DNA isolated from patients with chronic HBV infection, together with the coexistence of hepatitis B surface antigen (HBsAg) and hepatitis B surface antibodies (anti-HBs) in their serum samples.

 In this study, serum samples from 83 patients with chronic HBV infection were analyzed by serological and immunological tests for the concurrence of HBsAg and anti-HBs. In addition, the mutation in the HBV DNA was assessed by nucleotide sequencing of S genes within, upstream, and downstream of the MHR.

 Among 83 patients with chronic HBV infection, the coexistence of HBsAg and anti-HBs were detected in 11 (13.25%) individuals. Mutations in eight amino acids of seven samples analyzed for nucleotide sequencing were observed at 27 different sites in three locations, namely upstream, within, and downstream of the MHR. The mutations affected the structure of the epitope and the appearance of an escape mutant.

 The results indicated that mutations downstream and upstream of the MHR play a role in the coexistence of HBsAg and anti-HBs in patients with chronic HBV infection.

 Intrahepatic covalently closed circular DNA (cccDNA) plays a critical role in the life cycle of the hepatitis B virus (HBV). Growing evidence suggests that microRNAs (miRNAs) may regulate cccDNA expression and contribute to the natural history of chronic hepatitis B (CHB).

 This study aimed to investigate potential miRNA-mRNA regulatory axes of intrahepatic cccDNA in CHB-GZ patients and to identify new therapeutic targets.

 Thirteen CHB-GZ patients were included and divided into two groups based on cccDNA levels: Reference group (n = 7) with cccDNA < 1 copy/cell and control group (n = 6) with cccDNA ≥ 1 copy/cell. Transcriptome-wide miRNA and mRNA expression profiles in liver tissue were determined. Differentially expressed miRNAs (DE-miRNAs) and mRNAs (DE-mRNAs) were defined by |logFC| > log1.5 and P < 0.05. Enrichment analyses of gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were performed. Candidate miRNA-mRNA interaction pairs were acquired from miRTarBase, and a miRNA-mRNA network was constructed using Cytoscape based on the Spearman correlation coefficient (r).

 We identified 19 DE-miRNAs and 340 DE-mRNAs. The most enriched GO terms were related to biological processes that regulate the virus life cycle, viral process, and viral genome replication. KEGG pathway enrichment analysis suggested that these predicted targets were associated with hepatitis B. Finally, we found a high correlation between miR-4295 and ZNF224, which suggests that they may form a potential regulatory axis of intrahepatic cccDNA in CHB-GZ patients.

 Our study suggests that miR-4295 and ZNF224 may be the potential regulatory axis of intrahepatic cccDNA in patients with CHB-GZ.

 Chronic immunity to hepatitis A (HA) is largely influenced by environmental factors, such as socioeconomic indicators, public health conditions, and access to safe water. In the past two decades, Iran has witnessed improvements in socioeconomic status, increased urbanization, enhanced health education, improved access to safe drinking water sources, and better public health conditions. However, these changes have not been uniform across all regions of Iran, and varying epidemiological situations are expected.

 This study aimed to delineate the pattern of HA chronic immunity across different regions of Iran using geographical information system (GIS) mapping.

 The study included a total of 3255 individuals who tested positive for anti-hepatitis A virus (anti-HAV) immunoglobulin G (IgG). This study analyzed factors such as place of residence, marital status, age, and gender to explore possible relationships. Univariate and multivariable analyses were conducted to identify independently associated factors for HA. A locally weighted scatterplot smoothing (LOWESS) multivariate model was developed using a backward stepwise approach. Geographical variations in the prevalence of HA chronic immunity in the general population of Iran were assessed to understand spatial effects and risk factors. A Bayesian spatial model was employed to identify the spatial pattern of HA chronic immunity prevalence, using OpenBUGS version 3.2.3.

 The prevalence of HAV immunity was higher in regions with mild semi-dry climates (aPR = 2.37, 95% confidence interval [CI] = 2.30 - 3.33, P< 0.001), medium semi-dry climates (aPR = 1.37, 95% CI = 1.14 - 1.63, P< 0.001), dry climates (aPR = 1.13, 95% CI = 0.9 - 1.4), and ultra-dry climates (aPR = 1.79, 95% CI = 1.05 - 2.98, P = 0.033), compared to semi-humid climates. Other variables did not exhibit a significant relationship with HA chronic immunity. The GIS analysis map revealed that immunity to HA was generally lower in the capital cities of Iran’s provinces. However, most central regions of Iran exhibit medium endemicity; nevertheless, higher immunity to HA was observed in border areas and coastal regions, particularly in the northern part of the country.

 Different regions of Iran display distinct patterns of HAV endemicity, influenced by the country’s climatic diversity.

 With the improvement in living standards and the change in eating habits, the prevalence of nonalcoholic fatty liver disease (NAFLD) has gradually increased, and it has become one of the most common chronic liver diseases worldwide.

 In this study, we used vitamin D3 to interfere with the hyperlipidemia-induced NAFLD cell model to explore the mechanism of vitamin D in improving the lipotoxicity of liver cells by regulating the epigenetic characteristics of genes and to provide new clues for the treatment of late-stage NAFLD.

 GSE200765, a data chip for vitamin D3 intervention in liver cell lipotoxicity, was screened from the GEO database. They were divided into the control group (untreated), model group (oleic OA/PA), and vitamin D3 intervention group (OA/PA+SV-VD3 group). Differential expression genes between the control group and model group, model group, and vitamin D3 intervention group were screened by the GEO2R tool. Differentially expressed genes construct a target PPI network map through the STRING database and analyze the KEGG pathway of differentially expressed genes in the DAVID database. The t-test or Unpaired t-test with Welch's correction was used to analyze the expression trend of pathway genes.

 Compared with the control group, 218 genes were up-regulated, and 255 genes were down-regulated in the model group, of which 26 genes were enriched in the complex and coagulation cascades and cell cycle pathways. After oleic OA/PA was added to HepaRG cells, the complex and coordination cascades pathway was relatively weak, and the cell cycle pathway was relatively strong. Compared with the model group, 554 genes were up-regulated, and 704 genes were down-regulated in the vitamin D3 intervention group, of which 23 genes were enriched in the apoptosis pathway. The apoptosis pathway was relatively weakened after vitamin D3 intervened in oleic OA/PA-treated HepaRG cells. The trend analysis of gene expression in the pathway showed that gene expression disorder in the complex and coagulation cascades, cell cycle, and apoptosis pathways were reversed after vitamin D3 intervention.

 Through bioinformatics, key pathway genes of vitamin D intervention on hepatocyte lipotoxicity were discovered, which were related to the complex and coordination cascades, cell cycles, and apoptosis pathways. The inhibition of vitamin D on lipotoxicity of human hepatocytes and the possible reversal mechanism was found, which provided ideas for the later treatment of NAFLD and hepatocyte damage.

 Glecaprevir/pibrentasvir (G/P) is a pangenotypic direct-acting antiviral (DAA) drug with a high resistance barrier. It has been used in patients with chronic hepatitis C in Turkey since March 2019. This drug's efficacy and safety data in Turkey are very limited, and there are not enough studies on real-life data.

 In this study, we aim to present real-life data, efficacy, and safety for our patients.

 In this retrospective, observational, single-center study, 116 patients who were started on G/P (100mg/40mg) oral therapy at the infectious diseases clinic between March 2019 and December 2021 due to HCV were included. Of the 116 patients included in the study, 92 were analyzed. Demographic data of the patients, previous treatment experience, drug use, viral load (HCV RNA levels at the 4th week of treatment and 12th week after treatment), and viral genotype data were obtained retrospectively from the automation system. Statistical analysis IBM SPSS version 21.0 statistical package program was used.

 Seventy-one (77.2%) of the patients were male, and 21 (22.8%) were female, with a mean age of 47.4 (18 - 89). Genotype distribution of patients 8.7% (n = 8) type 1a, 31.5% (n = 29) type 1b, 26.1% (n = 24) type 2, 22.9% (n = 21) type 3, 10.9% (n = 10) were type 4, 8.7% (n = 8) of the patients were treatment-experienced. In our study, there were no patients with cirrhosis. SVR-12 could not be obtained from a patient infected with only genotype 1a. In addition, this patient was co-infected with Hepatitis B. No side effects were observed in any of the patients that required treatment discontinuation. The SVR-12 rate was 98.6% with patients per protocol analysis (PP), but the SVR-12 rate was 77.2% with intention to treat analysis (ITT).

 In conclusion, this study suggested that G/P therapy in Turkey is used in real life with very high efficacy and tolerability. In addition, a significant change was observed in the genotype distribution previously reported in Turkey in the patient group we treated.

 Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disorders worldwide. Regarding the shortage of evidence on NAFLD in type 1 diabetes mellitus (T1DM) and the importance of a thorough assessment of complications due to childhood diseases, this study aimed to assess the need for the early detection of NAFLD in children with T1DM.

 This cross-sectional study was conducted on 234 children with T1DM referred to 17 Shahrivar Hospital, Rasht, Iran. This study also assessed demographic characteristics, medical history, physical examination, laboratory tests, and hepatic ultrasound. The Mann-Whitney U and chi-square tests were used to compare the children with and without NAFLD. Additionally, univariate and multivariate logistic regressions were used to determine the predictors of NAFLD.

 This study was conducted on 235 children with T1DM with a median age of 11.0 years (interquartile range (IQR): 8.0 - 14.0) and diabetes duration of 2.0 years (IQR: 1.0 - 4.0). The prevalence of NAFLD was estimated to be 10.2%. The children with NAFLD were significantly older (P = 0.016) and had a larger waist circumference (WC) z-score (P = 0.008) than those without NAFLD. Multiple logistic regression analyses showed that the odds of NAFLD increased with rising age (odds ratio (OR) = 1.29, 95% confidence interval (CI): 1.09 - 1.52) and WC z-score (OR = 2.39, 95% CI: 1.49 - 3.84). The cut-off point for the WC z-score was -0.025 (sensitivity = 58.3%, specificity = 72.0%).

 The NAFLD frequency in T1DM is relatively low (10.2%) and mainly consists of grade I fatty liver. The NAFLD screening should be further noticed in T1DM children with increasing age and WC as the predictors of NAFLD.

 Hepatic encephalopathy is a severe neuropsychiatric complication of decompensated cirrhosis associated with high short-term mortality.

 This study aimed to evaluate the predictive value of non-invasive scoring systems and develop a prognostic nomogram to identify the risk of 3-month mortality in patients with hepatic encephalopathy.

 Retrospective data from 251 patients with decompensated cirrhosis and hepatic encephalopathy were collected. Clinical data and non-invasive scoring systems were compared between survivors and non-survivors using univariate and multivariate logistic regression analyses. A prognostic model was developed and validated using bootstrap resampling procedures.

 Among the 251 patients, 40 (15.9%) died within three months. The non-survivor group had a higher incidence of complications and higher non-invasive scores (all P < 0.01). Multivariate analysis revealed that hepatorenal syndrome, spontaneous bacterial peritonitis, upper gastrointestinal bleeding, and Fibrosis-4 index were independent risk factors. A new model incorporating the Fibrosis-4 index and complications was developed, and discrimination was assessed using a bootstrap-corrected C statistic of 0.831. The area under the receiver operating characteristic curve of the new model (0.840, 95% confidence interval: 0.789 - 0.883) was significantly higher than that of the non-invasive scoring systems (all P < 0.05). The calibration plot and Hosmer-Lemeshow test (P = 0.771) showed good calibration accuracy. Kaplan-Meier survival analysis showed that the cumulative survival rate in the high-risk group was significantly lower (P < 0.01).

 The prognostic nomogram consisting of the Fibrosis-4 index and complications can effectively predict the risk of 3-month mortality in patients with hepatic encephalopathy.

 Inflammatory cytokines are related to the occurrence and development of hepatocellular carcinoma (HCC).

 Interleukin 6 (IL-6) is associated with the occurrence and prognosis of HCC, while Dicer inhibits HCC; accordingly, we checked whether Dicer regulates HCC by modulating the IL-6 pathway.

 The HCC cells of SMMC-7721 transfected with Dicer overexpression (pCMV-Dicer) and control (pCMV-NC) lentivirus were divided into 3 groups: The SMMC-7721, pCMV-NC, and pCMV-Dicer groups. The assays of cell proliferation, migration, and invasion were performed using cell counting, wound scratch, and transwell chamber assay. The IL-6 level was measured by flow cytometry bead-based immunoassays. All statistical analyses were analyzed using SPSS version 21 by the student t test and 1-way analysis of variance (ANOVA).

 Dicer inhibited the secretion of IL-6 from HCC cells, as well as the growth of HCC related to proliferation, migration, and invasion. IL-6 incubation with pCMV-NC cells increased proliferation (from 24 hours to 72 hours; P < 0.05), migration (P = 0.008), and invasion (P = 0.85). In addition, IL-6 could reverse the inhibitory effect of Dicer on HCC cells related to proliferation (P < 0.01) and migration (P = 0.006) when incubated with pCMV-Dicer cells, whereas an IL-6 blocker of tocilizumab could enhance the Dicer-induced inhibition related to proliferation (P < 0.05), migration (P = 0.007), and invasion (P = 0.001) when incubated with pCMV-Dicer cells. Furthermore, Dicer could increase the inhibition efficiency of apatinib on HCC treatment by their cooperation in IL-6 downregulation.

 Dicer could inhibit HCC by the IL-6 pathway, which would be a potential target for HCC treatment. The Dicer inducer might be an enhancer of apatinib for HCC treatment.

 Cirrhosis is one of the most critical health problems with a great economic burden on the health system.

 This study evaluated cirrhosis predictors in patients with hepatitis C virus (HCV).

 A total of 608 patients with HCV were included in the present study within 2011 and 2017 and divided into two groups based on the presence and absence of cirrhosis. Demographic and laboratory data (e.g., blood group, aspartate transaminase (AST), alanine transaminase (ALT), prothrombin time (PT), platelet count, anti-HCV antibodies, and virus level count) were collected by referring to patients’ files and compared between the two groups. Predictive factors were determined using the regression model.

 In this study, 85 patients (13.9%) had liver cirrhosis. Univariate analysis showed that hepatic enzymes AST, ALT, platelet count, PT, partial thromboplastin time, international normalized ratio, and HCV ribonucleic acid levels in cirrhosis patients were significantly higher than in non-cirrhosis patients (P < 0.05). Adjusted logistic regression analysis showed age < 45 years (adjusted odds ratio (ORAdj): 1.11, P = 0.028), male gender (ORAdj: 2.08, P = 0.023), co-infection with hepatitis B virus (HBV) infection (ORAdj: 2.58, P = 0.001), and alcohol consumption (ORAdj: 1.87, P = 0.001) were predictive factors for cirrhosis in patients with HCV

 This study showed that in patients with hepatitis C, age > 45 years, male gender, alcohol consumption, and co-infection with HBV significantly increased the risk of liver cirrhosis.

 This study aimed to investigate the combined effects of resveratrol (RES) and saroglitazar (SARO) on a high-fat diet (HFD)-induced non-alcoholic fatty liver disease (NAFLD) in a rat model.

 In this animal study, rats were treated with RES, SARO, or a combination of both. Male rats were fed with an HFD to induce nonalcoholic steatohepatitis (NASH) and then divided into 4 groups: RES treatment, SARO treatment, combined RES and SARO treatment, and no treatment. Various parameters were measured, including body and liver weight, liver enzymes, gene expression of inflammatory markers and reactive oxygen species (ROS), protein expression levels of transforming growth factor-beta (TGF-β) and p-Smad3, and liver histology.

 The combination of RES and SARO significantly reduced blood and hepatic lipids, attenuated weight gain, and decreased inflammatory cytokine production in a NAFLD study. The combination diminished hepatic lipid accumulation, oxidative stress, and TGF-β1 expression, suggesting antifibrotic effects. Histological evaluations showed antisteatotic and antifibrotic outcomes of the combined treatment. Improved glycemic index, blood lipids, and reduced NASH indicators (i.e., aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) were observed after 6 weeks. The treatment also decreased ROS and NOX family expression, lessening oxidative stress. The inhibition of the TGF-β-Smad3 pathway in HFD-induced rats resulted in reduced NASH (P < 0.05).

 The results indicated that the group receiving the combination of RES and SARO showed a more efficient reduction in fibrosis and steatosis in the NASH model induced by an HFD than the groups receiving RES or SARO alone.

 Liver cancer is one of the most common types of cancer, in which early detection plays a significant role in preventing progression and reducing mortality. Ultrasound is one of the methods of liver examination recommended by guidelines due to its performance in detecting focal liver lesions. These small lesions may be missed in the early stages or diagnosed only when the prognosis is poor.

 This study aimed to implement the best classification model for two liver stages by extracting optimal feature subsets to be used in computer-aided diagnosis systems (CAD).

 The model classifies the liver into two stages using B-mode ultrasound images of the liver. It involves extracting statistical texture features utilizing discrete wavelet transform (DWT) and gray level co-occurrence matrix (GLCM). This study applied two feature selection

 t-test and sequential forward floating selection (SFFS). The subset of selected features was presented to the k-nearest neighbor classifier for incorporation into a CAD system.

 The accuracy, sensitivity, and specificity of the k-NN classifier were 98.75%, 98.82%, and 99.1%, respectively.

 Image analysis approaches were successfully performed to extract and select useful features. Therefore, this model is recommended for classifying two liver stages, normal and HCC.

 With the popularity of WeChat, Internet-based nursing approaches are gradually being applied to disease care, as they can better meet nursing requirements.

 To explore the impact of the WeChat health management platform on the self-care ability and quality of life of patients with liver cancer undergoing interventional therapy

 A total of 82 patients with liver cancer who underwent interventional therapy were selected from January 2020 to January 2021 and randomly divided into the observation (n = 41) and control (n = 41) groups. The control group received routine nursing measures, while the observation group received the new nursing mode based on the WeChat health management platform. The WeChat health management platform can help patients develop health education plans, remind them of follow-up appointments, promote knowledge about nursing measures for liver cancer interventional therapies, provide feedback on medication use to doctors, and strengthen doctor–patient communication. The self-care ability and quality of life of the two groups of patients were compared before and after the intervention.

 After the intervention, the Hamilton Anxiety Scale (HAMA) and Hamilton Rating Scale for Depression (HAMD) scores were lower in the patients of the observation group than those in the control group, indicating an improvement in the adverse moods and quality of life of patients in the observation group. Also, the psychological, physical, and social functions and overall health scores of patients in the observation group were higher than those in the control group (all P-values < 0.05).

 The WeChat health management platform could improve the self-care ability of liver cancer patients undergoing interventional therapy and their mood and quality of life, which is worthy of clinical reference.

 The present study was conducted to assess the pattern of HBV Core/Pre-Core mutations and HBV genotype in Iraqi patients with chronic hepatitis B virus (HBV) infection.

 In the current cross-sectional study in an Iraqi province, we evaluated 134 patients diagnosed with HBV hepatitis. We used PCR and, subsequently, Sanger sequencing to assess HBV Core/Pre-Core mutations. Sanger sequencing reads were further used for phylogenetic analysis and multiple sequence alignment. A phylogenetic tree was generated according to the neighbor-joining method.

 The current study revealed that 58 (45%) of the patients were male, and 72 (55%) of them were female. The mean age of the patients was 36 ± 12.7 years, and the mean duration of infection was 5.2 ± 4.8 years. The results revealed 21 nucleic acid alterations in the samples analyzed. The generated phylogenetic tree divided samples into two genotypes. Pre-core/Core mutations were significantly associated with the treatment received (P = 0.0.001) but not with laboratory parameters. Most samples were matched with the genotype D clade, while only four samples were positioned adjacent to the genotype E clade. Direct nucleic acid translation disclosed five nucleic acid variants (73T>G, 347T>G, 364A>G, 365T>C, and 366A>G) on the core protein.

 This study has detected 21 nucleotide variants and 5 amino acid alterations within the coding sequences of the C gene. This study revealed that genotype D represents the primary genotype for the identified viral infections. The current study highlights the importance of these mutations evaluation for future, more comprehensive studies.

 Several studies have indicated the role of quantitative hepatitis B surface antigen (HBsAg) evaluation in managing and prognosis of hepatitis B virus (HBV) infection. Thus, quantitative evaluation of HBsAg using cost-effective assays can be an important approach to managing HBV patients.

 This study aimed to set up and apply an in-house quantitative enzyme-linked immunosorbent assay (ELISA) to evaluate HBsAg in research and diagnosis.

 New Zealand white rabbits were immunized with HBsAg. Sera were collected 28 days after immunization, and polyclonal HBsAb (antibody to hepatitis B surface antigen) were purified and evaluated. Then, the in-house quantitative ELISA was optimized. Finally, the functional characteristics of the assay were evaluated using 200 plasma samples compared to commercial ELISA and quantitative TaqMan real-time PCR.

 The assay has a limit of detection (LOD) of 0.5 ng/mL with a specificity and sensitivity of 94% and 97%, respectively. The assay's highest coefficient of variation (CV) values for intra- and inter-assays were 7.23% and 8.59%, respectively. The correlation of the developed assay with commercial ELISA was 0.987 (P-value = 0.024). The correlations of the developed assay and commercial ELISA with quantitative TaqMan real-time PCR were 0.739 and 0.658, respectively (P-value = 0.017).

 The developed assay has a suitable sensitivity and specificity. It is also reproducible and well-correlated with commercial assays. Most importantly, it is cost-effective and, thus, can be used for detecting and quantifying HBsAg in research and diagnosis.

 This study aimed to systematically evaluate the correlation between cognitive function and brain imaging findings in patients with hepatic encephalopathy (HE).

 We searched PubMed, China National Knowledge Infrastructure, and Wanfang databases to obtain literature on cognitive function and the diagnosis of HE via brain imaging from the establishment of the databases to March 20, 2023. Two researchers independently screened the literature, extracted data, and evaluated the risk of bias in the included studies. RevMan v. 5.3 software was used in the meta-analysis.

 A total of 14 articles were included. The meta-analysis showed that digit symbol test (DST) scores and psychometric HE scores (PHES) were positively correlated with the imaging findings of the frontal lobe in patients with HE, with correlation coefficients of 0.49 (Z = 0.53; 95% confidence interval [CI]: 0.23 ~ 0.83) and 0.52 (Fisher’s Z: 0.58; 95% CI: 0.41 ~ 0.76), respectively. The number connection test-A reaction times were negatively correlated with the signal in the globus pallidus, with a correlation coefficient of -0.23 (Z = - 0.23; 95% CI: - 0.43~ - 0.03); DST scores were positively correlated with the signal in the globus pallidus, with a correlation coefficient of 0.45 (Z = 0.49; 95% CI: 0.29 ~ 0.69); and PHES were positively correlated with the mean peak of grey matter, with a correlation coefficient of 0.52 (Z = 0.57; 95% CI: 0.46 ~ 0.73).

 Imaging findings are related to the cognitive function of patients with HE. Therefore, they can be used to evaluate the cognitive function of these patients and promptly intervene in and prevent the progression of the disease.

 The evaluation of different cell proliferation and apoptosis indicators in cirrhotic tissues caused by different injuries may help recognize the etiology of cirrhosis and the risk of progression to hepatocellular carcinoma.

 This study aimed to measure p53 gene expression and AMPK and pAMPK protein expressions, as well as AgNOR features in cirrhotic tissues associated with five different etiologies in comparison with simple hepatic steatosis and controls.

 In this case-control study, AMPK and PAMPK protein expressions, p53 gene expression, and AgNOR features were investigated in 68 cirrhotic liver tissues obtained from patients with NASH (n = 15), HBV/HCV (n = 14), AIH (n = 15), PSC (n = 15), and alcohol toxicity (n = 9) and compared with tissues from individuals with simple steatosis (n = 15) and control subjects (n = 15). Protein and gene expressions were determined using western blotting and quantitative real-time polymerase chain reaction, respectively. Silver nitrate staining was used to assess AgNOR features.

 Significantly higher levels of AMPK and pAMPK were detected in all cirrhotic tissues compared to controls (P < 0.05). Also, a significantly and simultaneously higher p53 gene expression (P < 0.01) and AgNOR features, including total AgNOR length (TAL) (P < 0.001), total AgNOR number (TAN) (P < 0.01), and total AgNOR area (TAA) (P < 0.01), was detected in the hepatic cirrhotic tissues obtained from patients with PSC, NASH, and AIH. There was a significant positive correlation between p53 gene expression and AgNOR features in cirrhotic tissues (P < 0.01).

 Increased AMPK and pAMPK protein levels may be a general response to cirrhosis. Cirrhotic patients diagnosed with AIH, PSC, and NASH have a higher risk of progressing to hepatocellular carcinoma than those diagnosed with viral and alcoholic cirrhosis.

 Activated hepatic stellate cells (HSC) through the TGF-β signaling pathway are likely to exacerbate liver fibrosis, which is a later stage of NASH, a condition in which, in addition to HSC activation, the overexpression of extracellular matrix (ECM) proteins, specifically collagen-I α and α-SMA, is expected. MicroRNA-126a, a modulator of HSC activation, influences the phosphorylation of Smad2/3.

 This study aimed to investigate the impact of exosomes on miRNAs implicated in the progression of liver fibrosis by focusing on the role of miR-126a in the HSC-T6 cell line.

 In the present study, we investigated the effects of exosomes derived from LPS-stimulated mesenchymal stem cells (MSCs) on the expression of miR-126a and the phosphorylation of Smad3c in the HSC-T6 cell line. First, HSC-T6 cells were cultured in DMEM supplemented with 10% FBS. Next, we isolated exosomes derived from MSCs using the ExoCib kit. Finally, we examined the gene expression levels of collagen-Iα, α-SMA, and miR-126a using real-time PCR.

 The results showed that treatment with TGFβ1 increased the phosphorylation of p-Smad3c (P < 0.0001), as well as the expression of α-SMA and Collagen-Iα. Conversely, miR-126a expression was down-regulated after treatment with TGFβ1 (P < 0.01). However, exposure to LPS-treated MSC-derived exosomes resulted in a significant decrease in the levels of p-Smad3c phosphorylation (P < 0.001) and the gene expression of α-SMA and Collagen-Iα, accompanied by the up-regulation of miR-126a (P < 0.05).

 Based on our observations, MSCs-derived exosomes were able to reduce the expression of the genes associated with hepatic fibrosis, such as collagen-Iα and α-SMA. Furthermore, exosomes inhibited Smad3c phosphorylation by increasing miR-126a expression, ultimately hindering the progression of liver fibrosis. Therefore, exosomes should be recognized as a valuable and beneficial therapeutic tool for liver fibrosis.

 The clinical efficacy of Lenvatinib (a multi‐kinase inhibitor) and Nivolumab (an immune checkpoint inhibitor) have been shown in the management of hepatocellular carcinoma (HCC). However, real-life experience data of HCC patients receiving the Nivolumab and Lenvatinib combination are scarce, especially those who experienced the first-line or even multi-line treatment.

 Recurrent HCC patients (n = 28) treated with Nivolumab plus Lenvatinib as salvage therapy in Hunan Provincial People's Hospital from December 2016 to March 31, 2020, were analyzed. All patients were treated with Nivolumab (3 mg/kg), and Lenvatinib (8 mg/day), and administered every three weeks. Demographics, clinical statistics, and start and end dates of combination therapy were collected and recorded. In addition, progression-free survival (PFS) and OS were calculated from the start of Nivolumab plus Lenvatinib. Treatment outcomes were scored based on the Common Toxicity Criteria for Adverse Events (CTCAE), version 4.0. SPSS17.0 software and GraphPad Prism were used for statistical analyses.

 All the patients had portal vein tumor thrombus (PVTT) who were in Child-Pugh grade A and Barcelona Clinic Liver Cancer (BCLC) stage C. 11 patients (39.3%) were treated with sorafenib only, and 17 patients (60.7%) were treated with at least two lines of multi-target treatment. The disease control rate (CR+PR+SD) was 23/28 (82.1%), with the median overall survival (OS) and median progression-free survival (PFS) of 8.7 months and 5.7 months, respectively. Hyperbilirubinemia was the most common adverse event encountered with these combinations. However, no grade 3 or 4 toxicity was found in all HCC patients.

 The combination salvage therapy of Nivolumab and Lenvatinib was found effective in HCC patients, and most importantly, the side effects were controllable, and no grade 3 - 4 side effects were observed.

 The aspartate aminotransferase to platelet ratio index (APRI) is a non-invasive method used to investigate liver fibrosis in patients with hepatitis C virus (HCV).

 This study aimed to determine the APRI before and after the treatment of HCV patients with sofosbuvir/daclatasvir (Sovodak) in the city of Rafsanjan, southeast Iran.

 This study was conducted on 45 patients with HCV from March 2021 to March 2022 in Rafsanjan. Demographic information, including age, gender, a history of human immunodeficiency virus (HIV) infection, and intravenous (IV) drug injection, was collected. Polymerase chain reaction (PCR) was performed after treatment with Sovodak to calculate sustained virological response (SVR). Also, the APRI was calculated before and after treatment.

 Among 45 HCV patients (97.8% = male, 2.2% = female, age range = 26 to 59 years), the administration of Sovodak to all patients resulted in an efficacy of 100% in the assessment of SRV in 12 weeks (SVR12). Also, the APRI level decreased significantly after treatment with Sovodak (0.35 vs. 0.68, P-value: 0.000), even in HCV patients with a history of HIV (0.77 vs. 1.47, P-value: 0.028) or HCV patients with a history of injecting drugs in the last 12 months (0.38 vs. 0.66, P-value: 0.000).

 The present study indicated that the APRI level in HCV patients decreased significantly after treatment with Sovodak, regardless of having a history of HIV infection or a history of drug injection. Therefore, Sovodak in HCV patients can reduce the odds of liver fibrosis and subsequent hepatocellular carcinoma (HCC) by reducing the APRI level.

 Tenofovir alafenamide (TAF) has been effective against naïve patients with chronic hepatitis B (CHB) in phase 3 clinical trials. However, its real-world data are still limited.

 This study aimed to investigate the effectiveness and safety of TAF in real-life situations in treatment-naïve (TN) and treatment-experienced (TE) CHB patients in China.

 This retrospective study enrolled TAF-treated patients between January 2019 and October 2020 at the outpatient clinic of West China Hospital. The primary endpoint was the rates of virologic response (VR), and the secondary endpoints were the proportion of normal alanine aminotransferase (ALT) and quantitative hepatitis B surface antigen (qHBsAg) levels. Safety endpoints comprised serum lipid profiles, changes in estimated glomerular filtration rate (eGFR), and serum creatinine (Scr).

 A total of 161 TAF-treated patients were enrolled, including 49 TN patients and 112 TE patients. In the TN group, the VR rate at week 96 was 91.7% (22/24), and the proportion of normal ALT at week 96 was 95.8% (23/24). In the TE group, the VR rate at week 96 was 97.2% (69/71), and the proportion of normal ALT at week 96 was 90.1% (64/71). Serum qHBsAg levels decreased from 2930 to 1292 IU/mL in the TN group and 1158 to 533IU/mL in the TE group during 96 weeks of treatment (P = 0.05). For patients in the TN and TE groups, when compared to baseline measurements, serum creatinine increased (+7.91 vs. +6.62 mL/min/1.73m2, P = 0.52) while eGFR decreased (-11.46 vs. -10.90 µmol/L, P = 0.82) at week 96. Simultaneously, triglycerides (TG) (+ 0.39 vs. + 0.31 mmol/L, P = 0.32), total cholesterol (TC) (+0.65 vs. +0.52 mmol/L, P = 0.02), and low-density lipoprotein cholesterol (LDL-C) (+0.25 vs. +0.25 mmol/L, P = 0.60) increased over time.

 TAF was highly effective in TN and TE CHB patients. However, there are potential risks in eGFR decrease and a continuous increase in lipidemia with the prolongation of medication time.

Context:

 There is a link between proton pump inhibitors (PPIs) use and the occurrence of spontaneous bacterial peritonitis (SBP) in cirrhotic patients in some studies; however, in other studies, such a link does not exist.

 The aim of the current systematic review and meta-analysis was to evaluate the association between PPI and the occurrence of SBP or hepatic encephalopathy (HE) in cirrhotic patients.

Data Sources: 

A systematic search of sources was conducted in order to evaluate for any relationship between PPI and the risk of SBP in patients with liver diseases. Medline, Scopus, Ovid, ProQuest, Google Scholar, and Web of Science were searched to find any evidence in this regard from 1980 to November of 2021.

Study Selection:

 The articles were evaluated by two independent reviewers according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses). After deleting the duplicates, first, the titles of the studies were evaluated, and then the full texts were evaluated. Any disagreement between the two researchers was solved by discussion or a third reviewer.

Data Extraction: 

Appropriate Critical Appraisal Checklists of Joanna Briggs Institute (JBI) were used for the quality assessment of eligible studies. Statistical analysis was performed by CMA software (version 2.0), and a P-value of less than 0.05 was considered a significant level.

 In the systematic search of sources, 3705 articles were identified. Finally, 33 studies were included in this meta-analysis study. A total of 6370 PPI users and 8037 patients in the control group experienced at least one of the complications of liver cirrhosis, including SBP or HE. According to meta-analysis, the risk of SBP or HE in the intervention group was 1.95 times higher than in the control group (RR = 1.95; 95% confidence interval [CI]: 1.53 - 2.48, P < 0.001).

 The use of PPIs is associated with a higher risk of SBP and HE in cirrhotic patients. However, the quality of included studies in the current systematic review and meta-analysis was moderate, and high-quality studies with a larger sample size are required.

Non-alcoholic fatty liver disease (NAFLD) is a serious public health issue. Even though various natural and synthetic therapies are in the advanced stages of development, there is no authorized therapy for NAFLD. The use of anti-oxidant and anti-inflammatory compounds is one of these natural treatments. Portulaca oleracea aerial parts' extracts have shown various pharmacological properties, including antioxidant, anti-inflammatory, and liver protection due to alkaloid compounds, flavonoids, terpenoids, sterols, omega-3 unsaturated fatty acids, and many vitamins and minerals.

We intend to examine the effectiveness of Portulaca oleracea extract in improving the symptoms caused by NAFLD.

A randomized, double-blinded, controlled, parallel clinical trial is designed to study the effects of P. oleracea supplementation on the clinical and paraclinical findings in patients with NAFLD. An intervention group will get 700 mg of P. oleracea supplementation for eight weeks, while a control group will receive a placebo. Throughout the intervention, the clinical and nutritional status will be assessed three times. At the 0, 30, and 60th days of the intervention, anthropometric evaluation, blood pressure, and gastrointestinal problems will be monitored. Transient elastography will be done at the start and end of the research to assess the liver state. In addition, an International Physical Activity Questionnaire (IPAQ) and a 3-day food record will be collected, as well as biochemical variables, such as CBC-diff (complete blood count with differential count), lipid profiles, FBS, Fasting Blood Sugar; serum insulin, hepatic-related parameters, namely enzymes [ALP (alkaline phosphatase), AST (aspartate aminotransferase), ALT (alanine aminotransferase), GGT (gamma-glutamyl transferase)], total and direct bilirubin, and inflammatory [hs-CRP (C-reactive protein), ESR (erythrocyte sedimentation rate) and IL-6 (interleukin-6)] and oxidative stress markers [SOD (super oxide dismutase), GSH-Px (glutathione peroxidase) and MDA (malondialdehyde)].

This is the first randomized clinical trial (RCT) protocol specifically created for patients with NAFLD to evaluate the impact of P. oleracea supplementation. We intend to demonstrate that the suggested procedure is a novel and effective approach to decreasing NAFLD's laboratory and clinical symptoms. We also expect that supplementation with 700 mg of P. oleracea for 60 days will improve liver steatosis and clinical and nutritional status and reduce NAFLD patients' inflammation and oxidative stress.

 Modern marketing strategies, accompanied by tools such as social media, mobile platforms, and applications, play a significant role in discovering the healthcare sector's needs and desires of target audiences. Additionally, the emergence of influential individuals, known as influencers, in domains such as marketing, public health promotion, physical and mental well-being, sexual health, beauty, and lifestyle is expanding daily. The inspiration and motivation generated by such influencers tend to offer an attractive opportunity for effective communication with the audience.

 This study aims to extract and identify indicators and factors of influencer marketing in the health domain.

 This study employed a mixed-methods approach, combining qualitative and quantitative analyses. Literature in the field was reviewed, coded, and subjected to analysis. Subsequently, influencer marketing indicators were extracted and screened. Based on the identified factors, a questionnaire consisting of 26 questions was developed and distributed as a survey among a study population of 1126 individuals related to medical and non-medical sciences. The extracted factors were then examined through exploratory factor analysis and confirmatory factor analysis. A structural factor model was developed, and the fit of the model and the number of factors were assessed.

 A total of 26 influencer indicators were identified and categorized into 5 factors: Active and skill-related features, infrastructure actions, consequential features, inherent and intrinsic features, and behavioral characteristics in the health domain. The identified factors were validated through exploratory factor analysis (EFA) and confirmed through confirmatory factor analysis. In addition, the fit model was approved.

 The study revealed that establishing international and local influencers within the health domain, incorporating influencer indicators and features alongside an analysis of environmental conditions, plays a pivotal role in shaping the healthcare system and fostering public health promotion across countries.