Introduction

During severe acute pancreatitis (SAP), large amounts of reactive oxygen species (ROS) are produced in the abdominal cavity, which can directly damage abdominal organs and be absorbed into the blood, causing systemic inflammatory response syndrome and multiple organ dysfunction. Molecular hydrogen (H₂) can target to eliminate harmful ROS such as hydroxyl radical ^[1]. When severe inflammatory damage occurs in the pancreas, microthrombosis are widely produced, and the antioxidant effect is difficult to be fully exerted if H₂ is administered through circulation.

Aims & Methods

We have developed hydrogen-loaded nanoparticles (nano hydrogen) to bring H₂ into direct contact with the pancreas by intraperitoneal administration, providing a new strategy for the anti-inflammatory treatment of SAP. In this study, we investigated the pathophysiological mechanisms by which nano hydrogen ameliorates SAP.
In vivo, SAP was established by retrograde injection of sodium taurocholate through the rat pancreatic duct. Nano hydrogen (37.5 mg/kg) was injected intraperitoneally in the SAP + nano hydrogen group. The survival rate was calculated. Pathological scoring was performed. Neutrophil and macrophage infiltration, ultrastructural changes of acinar cells and vascular endothelial cells, and microthrombosis of pancreatic tissue were detected. In vitro, intracellular ROS of AR42J cells were measured using hydroxyphenyl fluorescein solution. Human umbilical vein endothelial cells (HUVECs) were stimulated with TNF-α, and nano hydrogen was used for intervention. RNA-seq was performed on rat pancreatic tissue and HUVEC samples. The expression of VCAM-1, ICAM-1 and NF-κB p65 in HUVECs was compared. β-galactosidase staining and markers of cellular senescence such as phosphorylated γ-H₂A.X, p53, p21, and p16 were detected. The opening of the mitochondrial permeability transition pore (MPTP) and mitochondrial membrane potential of HUVECs were assessed.

Results

After intraperitoneal administration of nano hydrogen into SAP rats, the survival rate increased by 66%, and the pathological score of pancreas dramatically decreased (p < 0.01). The neutrophil infiltration was significantly reduced (p < 0.01), and the ultrastructure of acinar cells and vascular endothelial cells was significantly improved. The pancreatic tissue of SAP rats had a large number of microthrombi, which were significantly reduced by nano hydrogen. Pancreatic vascular endothelial cells in SAP rats expressed p21.
Nano hydrogen significantly downregulated the dominant transcriptional events in SAP pancreas, such as leukocyte chemotaxis and migration and oxidative stress, and also significantly reduced the production of ROS in the acinar cells and the expression of VCAM-1, ICAM-1 and phosphorylated p65 after TNF-α stimulation of HUVECs (p < 0.01). RNA-seq analysis of HUVECs indicated that TNF-α induced cellular senescence, confirmed by positive β-galactosidase staining and significantly increased expression of phosphorylated γ-H₂A.X, total p53, phosphorylated p53, p21 (p < 0.05) and p16 (p < 0.01). MPTP opened and mitochondrial membrane potential disappeared in TNF-α-stimulated HUVECs. Nano hydrogen significantly attenuated the abovementioned manifestation.

Conclusion

Nano hydrogen can effectively eliminate ROS brought to the pancreas by neutrophil infiltration and etc., and improve vascular endothelial cell function, thus significantly improving pathological damage such as pancreatic necrosis, which has important translational value for clinical treatment.

References

1. Ohsawa I, Ishikawa M, Takahashi K, et al. Hydrogen acts as a therapeutic antioxidant by selectively reducing cytotoxic oxygen radicals. Nat Med, 2007, 13(6): 688-694.

Introduction

The ongoing phase 3 ESSENCE trial (NCT04822181) reported positive results for histological and non-invasive test (NIT) endpoints in an interim analysis of the first 800 randomised participants with biopsy-defined metabolic dysfunction-associated steatohepatitis (MASH) and F2/F3 fibrosis receiving once-weekly subcutaneous semaglutide 2.4 mg vs placebo. Participants receiving semaglutide achieved a mean weight loss of 10.5% vs 2.0% with placebo. In this post hoc analysis, we assessed the weight dependency of the effects of semaglutide 2.4 mg on study endpoints (NITs and histology) after 72 weeks of treatment, using weight loss-independent and weight loss-dependent pathways as covariates.

Aims & Methods

NITs and biopsies were assessed at baseline and week 72. MASH-related NIT responder endpoints were change in alanine aminotransferase (ALT; ≥17-unit reduction) and FibroScan-aspartate aminotransferase (FAST) score (≥0.22 reduction). Fibrosis-related NIT responder endpoints were change in vibration-controlled transient elastography (VCTE) liver stiffness measurement (30% reduction) and Enhanced Liver Fibrosis (ELF) score (≥0.5-unit reduction). Histological endpoints included resolution of MASH and improvement in fibrosis. All endpoints were assessed using logistic regression at week 72 with treatment as exposure, percentage weight loss from baseline to week 72 as mediator, and baseline type 2 diabetes status, fibrosis stage and body weight as covariates. The total and weight loss-independent and weight loss-dependent effect sizes were calculated as odds ratios (ORs), and missing data were omitted. All data are based on the full analysis set from the on-treatment observation period.

Results

For MASH-related endpoints, the total effect (OR [95% confidence interval (CI)]) for ALT, FAST score and resolution of MASH without worsening of fibrosis was 4.7 (3.3, 6.6), 6.9 (4.3, 10.9) and 3.9 (2.8, 5.5), respectively. ORs (95% CI) for the weight loss-independent effect were 3.0 (2.0, 4.6), 2.8 (1.7, 4.7) and 2.0 (1.4, 3.0), respectively; for the weight loss-dependent effect, ORs (95% CI) were 1.5 (1.2, 2.0), 2.5 (1.8, 3.4) and 1.9 (1.6, 2.4), respectively. Overall, 71.9%, 53.3% and 51.9% of the total effect for ALT, FAST score and resolution of MASH, respectively, were not mediated by weight loss. For the fibrosis-related endpoints, the total effect (OR [95% CI]) for VCTE, ELF score and improvement in fibrosis without worsening of MASH were 3.0 (2.0, 4.4), 4.5 (3.1, 6.4) and 2.1 (1.5, 3.1), respectively. ORs (95% CI) for the weight loss-independent effect were 1.7 (1.1, 2.7), 2.4 (1.6, 3.7) and 1.5 (1.0, 2.4), respectively; for the weight loss-dependent effect, ORs (95% CI) were 1.7 (1.4, 2.2), 1.9 (1.5, 2.3) and 1.4 (1.1, 1.8), respectively. This shows that 48.9%, 58.5% and 55.5% of the total effect for VCTE, ELF score and fibrosis improvement, respectively, were not mediated by weight loss.

Conclusion

Semaglutide 2.4 mg improved MASH-related histological and NIT endpoints and fibrosis-related NIT endpoints through equal contributions of weight loss-independent and weight loss-dependent metabolic mechanisms, with effects beyond weight loss.

Disclosure

Philip N. Newsome reports grants from Novo Nordisk, and has received consulting fees from Boehringer Ingelheim, Madrigal and Novo Nordisk. PNN also reports honoraria as a speaker from AiCME, Echosens and Novo Nordisk; support for attending meetings for Novo Nordisk; and participation on an advisory board for Boehringer Ingelheim, GSK, Madrigal, Novo Nordisk and Sagimet.
Elisabetta Bugianesi served as a consultant or advisory board member for Boehringer Ingelheim, Gilead, Intercept, Merck, Novo Nordisk, Pfizer and ProSciento, and as a speaker for Gilead, Intercept, Merck, Novo Nordisk and Pfizer. EB has also received a research grant from Gilead for fatty liver research.
Vlad Ratziu received consulting fees from Boehringer Ingelheim, GSK, Madrigal, Novo Nordisk, ProSciento and Sagimet, and research grants (to institution) from MSD.
Mary E. Rinella consults for 89bio, Akero, Boehringer Ingelheim, CytoDyn, GSK, HistoIndex, Intercept, Madrigal, NGM Bio, Novo Nordisk, Sagimet and Sonic Incytes. MER has received fees for consulting or participation in advisory boards for Boehringer Ingelheim, Echosens, Eli Lilly and Novo Nordisk. MER also reports honoraria as a speaker for CME events sponsored by Boehringer Ingelheim, Madrigal and Novo Nordisk.
Michael Roden received lecture fees or served on advisory boards for AstraZeneca, Echosens, Eli Lilly, Madrigal, Merck-MSD, Novo Nordisk and Target RWE, and performed investigator-initiated research with support from Boehringer Ingelheim, Novo Nordisk and Nutricia/Danone to the German Diabetes Center.
Arun J. Sanyal consults for and advises AstraZeneca and Avant Santé. AJS also consults for and has received grants from Akero, BMS, Eli Lilly, Intercept, Madrigal and Novo Nordisk. AJS consults for and owns stock in Rivus, and consults for 89bio, AGED Diagnostics, Albireo, Alnylam, Altimmune, Boehringer Ingelheim, Echosens, Genentech, Gilead, GSK, HistoIndex, Mallinckrodt, Merck, NGM Bio, Novartis, PathAI, Pfizer, Poxel, Regeneron Pharmaceuticals, Inc., Salix, Siemens, Surrozen, Takeda, Terns and Zydus. AJS owns stock in Durect, Exalenz, Genfit, Indalo, Inversago and Tiziana, and has received royalties from Elsevier and Wolters Kluwer.
Adel Belloum, Niels Krarup, Anna Cali, Mohamed Tawfik and Thea Vestergaard are employees and stockholders of Novo Nordisk A/S.
Jörn M. Schattenberg declares consultant honoraria from 89bio, Alentis, Alexion, Altimmune, AstraZeneca, Bionorica, Boehringer Ingelheim, Gilead Sciences, GSK, Inventiva Pharma, Ipsen, Eli Lilly, Madrigal Pharmaceuticals, MSD, Northsea Therapeutics, Novartis, Novo Nordisk, Pfizer, Roche, Sanofi and Siemens Healthineers; speaker honoraria from AbbVie, Academic Medical Education, Boehringer Ingelheim, Echosens, Forum für Medizinische Fortbildung, Gilead Sciences, Madrigal Pharmaceuticals, MedicalTribune, MedPublico GmbH, MedScape and Novo Nordisk; and stockholder options in AGED Diagnostics and Hepta Bio.
Matthew J. Armstrong reports investigator fees from Novo Nordisk.
Anja Geerts reports no conflicts of interest.
Jacob George is supported by the Robert W. Storr Bequest to the Sydney Medical Foundation, University of Sydney; a National Health and Medical Research Council of Australia Program Grant (APP1053206), Project, Ideas and Investigator grants (APP2001692, APP1107178, APP1108422, APP1196492) and a Cancer Institute, NSW grant (2021/ATRG2028). He serves on advisory boards for AbbVie, AstraZeneca, Boehringer Ingelheim, Novo Nordisk and Roche.
Chun-Jen Liu reports no conflicts of interest.
Ewa Janczewska was involved in clinical trials and lectures with Novo Nordisk, was involved in clinical trials with Inventiva Pharma, MSD, Galectin, Dr Falk and Sanofi and reports travel grants from Novo Nordisk and Eli Lilly.
Håvard Midgard is involved in lectures with Novo Nordisk, AbbVie and Gilead, and reports ad boards for Boeringer Ingelheim, AbbVie and Gilead.
Igor Bakulin reports involvement in clinical trials for Novo Nordisk and Eli Lilly and lectures for AbbVie and Johnson & Johnson.

Introduction

Endoscopic ultrasound (EUS) is the gold standard for evaluating pancreatic lesions, allowing for real-time imaging and biopsy sampling. Nevertheless, the differentiation between solid pancreatic lesions — such as pancreatic ductal adenocarcinoma (PDAC) and pancreatic neuroendocrine tumors (PNETs) — as well as cystic lesions is often troublesome. Specifically, identifying intraductal papillary mucinous neoplasms (IPMNs) with varying degrees of dysplasia is crucial for guiding clinical management. However, the diagnostic accuracy of current methods remains suboptimal. This multicenter study aimed to develop and validate convolutional neural networks (CNNs) to characterize solid and cystic pancreatic lesions and stratify IPMNs into high-grade dysplasia/carcinoma (HGD/C) and low-grade dysplasia (LGD).

Aims & Methods

This multicenter study included EUS images from 12 centers in Spain, Brazil, the United Kingdom and the United States of America. Solid lesion differentiation (PDAC vs. PNET) was achieved using a CNN trained on 49034 images from 95 patients (n=69 for PDAC and n=26 for PNET), with diagnoses confirmed via EUS-guided fine-needle biopsy or surgical specimen analysis. A second CNN was trained on 79395 images from 82 patients (n=64 for mucinous cystic lesions and n=18 for non-mucinous cystic lesions). Finally, a third model used the subset of IPMNs (n=51046 frames, 30 patients) to distinguish between HGD/C (n=5 patients) and LGD (n=25 patients). Histological confirmation was used as the gold standard. Performance metrics included sensitivity, specificity, accuracy, and area under the precision-recall curve (AUC-PR). To comprehensively determine the model's performance, we evaluated multiple thresholds for the confidence score and the IoU, between 0.45 and 0.55 with a step of 0.02 ([0.45, 0.47, 0.50, 0.52, 0.55]). The datasets were split into training (70%), validation (20%), and testing (10%) subsets.

Results

For solid lesions, the model differentiated PDAC from PNETs with an accuracy of 91.8%, with sensitivities of 96.2% and 97.8%, respectively. The AUC-PR was 0.982 for PDAC and 0.977 for PNET. Regarding cystic lesions the model detected mucinous cystic lesions with a sensitivity of 97.5%, an overall accuracy of 89.7% and an AUC-PR of 0.977. When the subset of IPMNs was specifically analyzed, the model distinguished IPMNs with HGD/C from those with LGD with a sensitivity of 97.5%, specificity of 94.3%, and an overall accuracy of 89.8%. The AUC was 0.988.

Conclusion

This is the first multicenter, transatlantic AI study aiming to provide a holistic approach to both solid and cystic pancreatic lesions, focusing on those with a significantly higher malignant potential. Our models achieved high accuracy in identifying and differentiating these conditions. Furthermore, to our knowledge this is the first integrative model to include the ability to stratify IPMNs into LGD and HGD/C, which has significant clinical implications, potentially reducing unnecessary surgeries and ensuring timely intervention for high-risk patients. The inclusion of data from diverse regions reduces demographic bias and enhances model generalizability. Real-time implementation of these solutions could significantly improve decision-making in EUS and optimize patient outcomes.