Intensive glucose control in critically ill adults: a protocol for a systematic review and individual patient data meta-analysis / Controle intensivo da glicose em adultos em estado grave: um protocolo de revisão sistemática e metanálise de dados individuais de pacientes

ABSTRACT Objective: The optimal target for blood glucose concentration in critically ill patients is unclear. We will perform a systematic review and meta-analysis with aggregated and individual patient data from randomized controlled trials, comparing intensive glucose control with liberal glucose control in critically ill adults. Data sources: MEDLINE®, Embase, the Cochrane Central Register of Clinical Trials, and clinical trials registries (World Health Organization, clinical trials.gov). The authors of eligible trials will be invited to provide individual patient data. Published trial-level data from eligible trials that are not at high risk of bias will be included in an aggregated data meta-analysis if individual patient data are not available. Methods: Inclusion criteria: randomized controlled trials that recruited adult patients, targeting a blood glucose of ≤ 120mg/dL (≤ 6.6mmol/L) compared to a higher blood glucose concentration target using intravenous insulin in both groups. Excluded studies: those with an upper limit blood glucose target in the intervention group of > 120mg/dL (> 6.6mmol/L), or where intensive glucose control was only performed in the intraoperative period, and those where loss to follow-up exceeded 10% by hospital discharge. Primary endpoint: In-hospital mortality during index hospital admission. Secondary endpoints: mortality and survival at other timepoints, duration of invasive mechanical ventilation, vasoactive agents, and renal replacement therapy. A random effect Bayesian meta-analysis and hierarchical Bayesian models for individual patient data will be used. Discussion: This systematic review with aggregate and individual patient data will address the clinical question, 'what is the best blood glucose target for critically ill patients overall?' Protocol version 0.4 - 06/26/2023 PROSPERO registration: CRD42021278869

RESUMO Objetivo: Não está claro qual é a meta ideal de concentração de glicose no sangue em pacientes em estado grave. Realizaremos uma revisão sistemática e uma metanálise com dados agregados e de pacientes individuais de estudos controlados e randomizados, comparando o controle intensivo da glicose com o controle liberal da glicose em adultos em estado grave. Fontes de dados: MEDLINE®, Embase, Cochrane Central Register of Clinical Trials e registros de ensaios clínicos (Organização Mundial da Saúde, clinical trials.gov). Os autores dos estudos qualificados serão convidados a fornecer dados individuais de pacientes. Os dados publicados em nível de ensaio qualificado que não apresentem alto risco de viés serão incluídos em uma metanálise de dados agregados se os dados individuais de pacientes não estiverem disponíveis. Métodos: Critérios de inclusão: ensaios clínicos controlados e randomizados que recrutaram pacientes adultos, com meta de glicemia ≤ 120mg/dL (≤ 6,6mmol/L) comparada a uma meta de concentração de glicemia mais alta com insulina intravenosa em ambos os grupos. Estudos excluídos: aqueles com meta de glicemia no limite superior no grupo de intervenção > 120mg/dL (> 6,6mmol/L), ou em que o controle intensivo de glicose foi realizado apenas no período intraoperatório, e aqueles em que a perda de seguimento excedeu 10% até a alta hospitalar. Desfecho primário: Mortalidade intra-hospitalar durante a admissão hospitalar. Desfechos secundários: Mortalidade e sobrevida em outros momentos, duração da ventilação mecânica invasiva, agentes vasoativos e terapia de substituição renal. Utilizaremos metanálise bayesiana de efeito randômico e modelos bayesianos hierárquicos para dados individuais de pacientes. Discussão: Essa revisão sistemática com dados agregados e de pacientes individuais abordará a questão clínica: Qual é a melhor meta de glicose no sangue de pacientes graves em geral? Protocolo versão 0.4 - 26/06/2023 Registro PROSPERO: CRD42021278869

The course and prognostic value of tumor stiffness detected by ultrasound elastography for transarterial chemoembolization of hepatocellular carcinoma.

Background: Transarterial chemoembolization (TACE) is recommended as the first-line treatment in intermediate-stage patients with hepatocellular carcinoma (HCC) or as a palliative treatment modality in advanced patients. However, tumor control usually requires multiple TACE interventions due to the presence of residual and recurrent lesions. Elastography can provide information about tumor stiffness (TS) to predict tumor residual or recurrence. In this study, we aimed to analyze the effects of TACE on HCC stiffness using ultrasound elastography (US-E). We investigated whether quantifying TS using US-E could predict the recurrence of HCC. Methods: This retrospective cohort study included 116 patients undergoing TACE to treat HCC. US-E was performed to measure the tumor's elastic modulus within 3 days before TACE, in the 2 days after the intervention, and at the 1-month follow-up. The known prognostic factors of HCC were also analyzed. Results: The average TS before TACE was 40.1±14.36 kPa, and the average TS 1 month after TACE was 19.3±9.80 kPa. The mean progression-free survival (PFS) was 39.129 months, and the 1-, 3-, and 5-year PFS rates were 81.0%, 56.9%, and 37.9%, respectively. The mean overall survival (OS) was 48.552 months, and the 1-, 3-, and 5-year OS rates of patients with malignant hepatic tumors were 95.7%, 75.0%, and 49.1%, respectively. Tumor number, tumor location, TS before TACE, and TS 1 month after TACE were significant predictive factors for OS (P=0.02, P=0.03, P<0.001, and P<0.001, respectively). Rank correlation analysis and linear regression revealed that a higher TS before or 1 month after TACE was negatively associated with PFS. The reduction ratio in TS before and 1 month after therapy was positively associated with PFS. The optimal cutoff TS value was set at 46 and 24.5 kPa before and 1 month after TACE according to the optimal Youden index. Kaplan-Meier survival analyses demonstrated that the 2 groups had significant differences in OS and PFS and that a higher TS was positively correlated with OS and PFS. Conclusions: Our results verify that US-E provides additional information to characterize the tumoral stiffness of HCC. These findings indicate that US-E is a valuable tool for evaluating the tumor response after TACE therapy in patients. TS can also be an independent prognostic factor. Patients with a high TS had a higher risk of recurrence and a worse survival time.

Intensive glucose control in critically ill adults: a protocol for a systematic review and individual patient data meta-analysis.

OBJECTIVE: The optimal target for blood glucose concentration in critically ill patients is unclear. We will perform a systematic review and meta-analysis with aggregated and individual patient data from randomized controlled trials, comparing intensive glucose control with liberal glucose control in critically ill adults. DATA SOURCES: MEDLINE®, Embase, the Cochrane Central Register of Clinical Trials, and clinical trials registries (World Health Organization, clinical trials.gov). The authors of eligible trials will be invited to provide individual patient data. Published trial-level data from eligible trials that are not at high risk of bias will be included in an aggregated data meta-analysis if individual patient data are not available. METHODS: Inclusion criteria: randomized controlled trials that recruited adult patients, targeting a blood glucose of ≤ 120mg/dL (≤ 6.6mmol/L) compared to a higher blood glucose concentration target using intravenous insulin in both groups. Excluded studies: those with an upper limit blood glucose target in the intervention group of > 120mg/dL (> 6.6mmol/L), or where intensive glucose control was only performed in the intraoperative period, and those where loss to follow-up exceeded 10% by hospital discharge. PRIMARY ENDPOINT: In-hospital mortality during index hospital admission. Secondary endpoints: mortality and survival at other timepoints, duration of invasive mechanical ventilation, vasoactive agents, and renal replacement therapy. A random effect Bayesian meta-analysis and hierarchical Bayesian models for individual patient data will be used. DISCUSSION: This systematic review with aggregate and individual patient data will address the clinical question, 'what is the best blood glucose target for critically ill patients overall?'Protocol version 0.4 - 06/26/2023PROSPERO registration:CRD42021278869.

Upregulation of miR-137 Expression Suppresses Tumor Growth and Progression via Interacting with DNMT3a Through Inhibiting the PTEN/Akt Signaling in HCC.

BACKGROUND: Downregulation of miR-137 regulates tumor growth in hepatocellular carcinoma (HCC). Yet, the underlying molecular mechanisms stay unclear. MATERIALS AND METHODS: miR-137 and DNA methyltransferase 3a (DNMT3a) expression levels were detected by Western blot, immunohistochemistry and qRT-PCR assays. Luciferase reporter and Western blot assays were also carried out to explore the correlation of miR-137 and DNMT3a. Flow cytometry assay, MTT analysis, transwell and wound healing assay were used to evaluate cell apoptosis, proliferation, as well as invasive and migratory abilities. Western blot was used to examine the caspase-3, cleaved caspase-3, PCNA, MMP-2, and MMP-7 protein levels, as well as PTEN/Akt signaling alternations. Methylation-specific PCR was applied to detect the PTEN promoter methylation status. Xenograft tumor assay, Western blot and immunohistochemistry analyses were taken to confirm the miR-137 regulation in vivo. RESULTS: Downregulation of miR-137, upregulation of DNMT3a, as well as an inverse correlation between them were observed in HCC clinical samples and cells. Moreover, miR-137 targeted directly and inhibited DNMT3a in HCC cells, which further retarded cell proliferative, migratory and invasive capabilities, while promoted apoptotic ones. Additionally, miR-137 overexpression inactivated the PTEN/Akt pathway in HCC cell by decreasing DNMT3a expression. Furthermore, miR-137 overexpression inhibited tumor growth in vivo in HCC via interacting with DNMT3a through inhibiting the PTEN/Akt cascades. CONCLUSION: Our findings suggested that miR-137 inhibited HCC tumor growth and progression via interacting with DNMT3a and suppressing the PTEN/Akt signaling in vitro and in vivo.

The positive feedback between ACSL4 expression and O-GlcNAcylation contributes to the growth and survival of hepatocellular carcinoma.

Acyl-CoA ligase 4 (ACSL4) has been reported to be overexpressed in hepatocellular carcinoma (HCC) and to enhance cell proliferation. However, the molecular mechanisms underlying the role of ACSL4 in HCC progression remain largely unclear. Here, we aimed to investigate whether and how O-GlcNAcylation and ACSL4 regulate each other and HCC progression. The clinical significance of ACSL4, O-GlcNAc and GLUT1 in HCC was determined by Pearson chi-squared test and Kaplan-Meier analysis. CCK-8, flow cytometry and in vivo tumour formation assays were performed to detect cell proliferation, apoptosis and tumorigenesis. IP technology was used to evaluate the relationship between ACSL4 and O-GlcNAc. ACSL4, GLUT1 and O-GlcNAc levels were elevated in HCC tissues and predicted poor prognosis in HCC patients. ACSL4 overexpression significantly promoted cell proliferation and tumorigenesis and inhibited cell apoptosis, whereas these effects were all obviously impaired when mTOR signalling was repressed or GLUT1 was downregulated. ACSL4 could be O-GlcNAcylated, and silencing of ACSL4 abolished the effects of O-GlcNAcylation on cell growth promotion and apoptosis inhibition. Collectively, this study demonstrates that ACSL4 contributes to the growth and survival of HCC by enhancing GLUT1-mediated O-GlcNAcylation. In turn, O-GlcNAcylation promotes HCC growth partially by increasing ACSL4 expression.

Genetic variant in DICER gene is associated with prognosis of hepatocellular carcinoma in a Chinese cohort.

AIM: MicroRNAs (miRNAs) function as gene regulators and play crucial roles in the pathogenesis and prognosis of hepatocellular carcinoma (HCC). Genetic variants in miRNA processing genes may affect miRNA expression and contribute to HCC risk and survival. We hypothesized that single nucleotide polymorphisms (SNPs) in miRNA processing genes may be associated with HCC susceptibility and prognosis. The study aims to verify whether this hypothesis is right or not. METHODS: We first genotyped the selected three SNPs in miRNA processing genes (RAN rs3803012 A>G, HIWI rs10773771 T>C, and DICER rs1057035 T>C) in 312 HCC patients and 320 cancer-free controls using the TaqMan assay, and evaluated the associations of the three SNPs with HCC risk. We also investigated the effect of the three SNPs on the overall survival of 312 HCC patients. RESULTS: There were no significant associations between the three SNPs (RAN rs3803012 A>G, HIWI rs10773771 T>C, and DICER rs1057035 T>C) and HCC risk. However, HCC patients carrying DICER rs1057035 CT + CC genotypes had significantly longer median survival time (log-rank, P = 0.018) and decreased death risk (adjusted hazard ratio = 0.68; 95% confidence interval, 0.49-0.95; P = 0.022) than patients with rs1057035 TT genotypes. The DICER rs1057035 genotype was an independent protective factor for HCC survival (CT + CC vs. TT: hazard ratio = 0.72; 95% confidence interval, 0.55-0.96; P = 0.031). CONCLUSION: This study provides evidence that DICER rs1057035 T>C polymorphism may be a prognostic biomarker for HCC patients.

Intensive Versus Conventional Glycemic Control in Patients with Diabetes During Enteral Nutrition After Gastrectomy.

BACKGROUND: This study compared intensive and conventional glycemic management strategies in diabetic patients receiving enteral nutrition after gastrectomy. METHODS: Diabetic patients (n = 212) who underwent gastrectomy between September 2006 and March 2014 were randomized to intensive glycemic (IG) management with continuous insulin infusion (target glucose 4.4-6.1 mmol/l (80-110 mg/dl)) or conventional glycemic (CG) management with intermittent bolus insulin (target glucose <11.1 mmol/l (<200 mg/dl)). Outcomes included blood glucose concentrations, insulin administration, and postoperative morbidity and mortality. RESULTS: Blood glucose levels were lower (5.4 ± 1.2 vs. 9.5 ± 1.8 mmol/l, P < 0.001) and mean insulin dose was higher (55 ± 15 vs.32 ± 16 units/day, P < 0.001) in the IG than in the CG group. Rates of severe hypoglycemia (7.5 vs. 0.9%, P = 0.035) and achievement of target blood glucose (86.3 vs. 72.6%, P = 0.023) were higher, while severe hyperglycemia rate was lower (1.9 vs. 11.3%, P = 0.010), in the IG group. Surgical site infection rate was lower in the IG group (4.7 vs. 13.2%, P < 0.030). Rates of other infective complications, bleeding, delayed gastric emptying, obstruction, hepatic dysfunction, renal dysfunction, and circulatory insufficiency were similar in the two groups. CONCLUSIONS: Intensive glycemic control in diabetic patients receiving enteral nutrition after gastrectomy was associated with a lower surgical site infection rate but a higher hypoglycemia rate.

MicroRNA-542-3p suppresses cell growth of gastric cancer cells via targeting oncogene astrocyte-elevated gene-1.

MicroRNAs (miRNAs) have been suggested to play critical roles in tumorigenesis as well as in the development of therapies for the treatment of cancers. However, the tumor-associated miRNAs in gastric cancers remain poorly understood. Here, we report on miR-542-3p in gastric cancers, which has been widely studied in other cancers as a tumor suppressor. Real-time quantitative PCR analysis demonstrated that miR-542-3p was significantly down-regulated in gastric cancer tissues (p < 0.0001) and cell lines (p < 0.001). Overexpression of miR-542-3p significantly inhibited cell growth of gastric cancer cells both in vitro (p < 0.01) and in vivo (p < 0.01). Notably, overexpression of miR-542-3p apparently reduced the protein expression of astrocyte-elevated gene-1 (AEG-1) (p < 0.01). The dual-luciferase reporter assay validated that miR-542-3p directly bound the 3'-untranslated region (UTR) of AEG-1, which could be abolished by mutation of the predicted miR-542-3p binding site. Furthermore, overexpression of miR-542-3p markedly inhibited the activation of oncogenic signaling pathways including the Akt, ß-catenin and nuclear factor-κB pathways. Additionally, overexpression of AEG-1 without the 3'-UTR partially reversed the cell growth arrest induced by miR-542-3p overexpression in gastric cancer cells (p < 0.05). Taken together, these data suggest that miR-542-3p might function as a tumor suppressor in gastric cancer, potentially by targeting the oncogene AEG-1, implying a potential role for miR-542-3p in the development of therapeutic methods for gastric cancer.

The unfolded protein response potentiates epithelial-to-mesenchymal transition (EMT) of gastric cancer cells under severe hypoxic conditions.

The hypoxic condition occurs in most types of solid tumors and has been shown to be associated with the metastatic ability of gastric cancer. A previous study has demonstrated that hypoxia might stimulate epithelial-to-mesenchymal transition (EMT) of gastric cancer cells. Nevertheless, the mechanism has not yet been completely understood. In the current study, the human gastric cancer cell lines HGC27 and MGC803 were presented to normoxic (21 % O2), hypoxic (1 % O2) or severe hypoxic (0.1 % O2) conditions for 24 h. We found that hypoxia exposure induced EMT of gastric cancer cells, which was promoted by severe hypoxia condition. Meanwhile, expressions of PERK, ATF4 and ATF6 proteins were elevated in cells under conditions of severe hypoxia but not by normoxia or hypoxia. Knockdown of PERK, ATF4 or ATF6 impeded EMT of gastric cancer cells induced by severe hypoxia. Furthermore, severe hypoxia exposure extremely boosted the expression of TGF-ß, which was blocked by the knockdown of PERK, ATF4 or ATF6 expression. Additionally, we found that TGF-ß release caused by hypoxia is facilitated by elevated UPR proteins and led to the activation of Smad2/3 and PI3K/Akt signaling. Our data suggest that UPR potentiates the EMT of gastric cancer cells under conditions of severe hypoxia.