Introduction

Genes involved in multiple pancreatic diseases suggest shared disease mechanisms. Recently, we demonstrated that ONECUT1 controls a transcriptional and epigenetic machinery regulating endocrine development involved in a spectrum of diabetes, encompassing monogenic (recessive and dominant) as well as multifactorial inheritance^1,2. Interestingly, ONECUT1 mutations causing monogenic recessive syndromic diabetes were not only characterized by endocrine dysfunction but also intrauterine growth retardation, pancreas hypoplasia including exocrine insufficiency and gallbladder agenesis/hypoplasia in line with studies of mouse knockout (KO) models². The latter rodent models also indicate a ONECUT1 role in maintaining pancreatic epithelial homeostasis and pancreatic cancer progression³. However, detailed knowledge of transcriptional regulation in human pancreas is rather limited.

Aims & Methods

To further unravel the role of ONECUT1 in human pancreatic exocrine development and tissue maintenance, we implemented a human embryonic stem cell (hESC) derived pancreatic duct-like organoid (PDLO) model⁴. Wildtype (WT) and ONECUT1 KO cell lines were differentiated to pancreatic progenitor cells (PP) and further matured to PDLOs in 3D matrigel culture accompanied by staged ATAC- and RNA-sequencing as well as functional analysis.

Results

Our data indicate that ONECUT1 is not only vital for pancreatic endocrine development, but rather seems to be a key player in establishing all three lineages that contribute to the human pancreas. Loss of the gene leads to altered exocrine development with changed morphology and functionality resulting in big, cyst-like ducts, which was caused by higher proliferation and reduced apoptosis compared to WT PDLOs. Additionally, polarity was impaired in KO PDLOs, resulting in a redistribution of CFTR channels on both the luminal and basal side of the cells. A lineage bias towards ductal cells was observed when PPs were transplanted onto the porcine urinary bladder (PUB)⁵, resulting in a reduced number of acinar cells and endocrine cells. This is further supported by early expression of maturation marker cytokeratin 7 in PDLO cultures. Moreover, GSEA analysis of RNA-sequencing data highlights a disturbed developmental program in line with results from immunofluorescence staining. Finally, oncogenic activation in KO PDLOs promotes the EMT program supporting its additional role in tissue homeostasis.

Conclusion

In summary, ONECUT1 seems to play a vital role in pancreatic organogenesis and homeostasis. Our in vitro approach directing human ONECUT1-depleted hESCs toward pancreatic ducts recapitulates aspects of patient phenotypes and therefore, provides a valuable methodology to characterize pancreatic diseases.

References

1. Heller, S., et al. Transcriptional changes and the role of ONECUT1 in hPSC pancreatic differentiation. Commun Biol 4, 1298 (2021).
2. Philippi, A., et al. Mutations and variants of ONECUT1 in diabetes. Nature Medicine 27, 1928-1940 (2021).
3. Zhang, H., et al. Multiple, temporal-specific roles for HNF6 in pancreatic endocrine and ductal differentiation. Mechanisms of development 126, 958-973 (2009).
4. Breunig, M., et al. Modeling plasticity and dysplasia of pancreatic ductal organoids derived from human pluripotent stem cells. Cell Stem Cell 28, 1105-1124. e1119 (2021).
5. Melzer, M.K., et al. Organoids at the PUB: the porcine urinary bladder serves as a pancreatic niche for advanced cancer modeling. Advanced Healthcare Materials 11, 2102345 (2022).

Introduction

Celiac disease (CD) is an autoimmune disorder triggered by gluten ingestion in genetically predisposed individuals, leading to chronic intestinal inflammation. It affects about 1% of the global population and is often undiagnosed in childhood due to the absence of symptoms, with around 65% of cases in Italy going unnoticed. Early screening is a key tool for timely diagnosis and preventing long-term complications. In this perspective, the D1Ce Screen pilot study follows Italian Republic Law 130/2023, which mandates screening for pre-symptomatic CD and type 1 diabetes (T1D) in the general paediatric population through autoantibody measurements in capillary blood. Paediatric screening is a key tool for early detection and the prevention of long-term complications, associated with late or missed diagnosis. Individuals who tested positive for CD and T1D -specific autoantibodies will undergo further clinical evaluation at the regional specialized center to confirm the diagnosis

Aims & Methods

Primary objective of D1Ce Screen study is to assess, feasibility, acceptability and sustainability of a nationwide screening program, for the evaluation of undiagnosed CD cases and presymptomatic T1D. To assess operational aspects D1Ce Screen evaluates the involvement of primary care pediatricians (PCPs), blood sample collection accuracy and acceptability for families measuring anxiety, depression and quality of life through 3 validated questionnaires.
This is an observational multicenter study to screen 5,363 children in four Italian regions (Lombardy, Marche, Campania, Sardinia), distributed into three classes of age (2-2.9, 6-6.9, and 10-10.9 years), corresponding to peaks of seroconversion for these diseases. For eligibility, the inclusion criterion is age. T1D is the exclusion criterion. Voluntary PCPs were responsible for recruitment of participants, administration of informed consents and questionnaires, execution of blood drawing by finger prick, capillary blood collection and sample shipment. Specific T1D and CD autoantibodies are measured by ELISA in capillary samples. In addition, HLA DQ2 and DQ8 HLA typing is performed on dried blood spot (DBS).

Results

PCPs initially accepting to participate were 565, with 428 (75,7%) completing the study. Enrolled children were 5534, with 91,1% within the target age. The gender distribution was 49.4% females, 50.6% males. Samples suitable for analysis (adequacy for at least one assay) were 89% of the total collected. Most of DBS samples were suitable for HLA typing. The target of families undergoing questionnaire evaluation of 2% has been exceeded.

Conclusion

The D1Ce Screen pilot study provides evidence supporting the feasibility of a nationwide screening initiative. The active collaboration of PCPs, the high level of participation from families, and the efficient implementation of capillary blood sampling procedures were key contributors to its success. These findings confirm the potential for scalability of a paediatric screening program for T1D and CD within the framework of the Italian National Health Service. Early detection and timely initiation of a gluten-free diet in children diagnosed with CD are essential to preventing long-term complications and improving health outcomes.

References

Bosi E, Catassi C. Screening type 1 diabetes and celiac disease by law. Lancet Diabetes Endocrinol. 2024 Jan;12(1):12-14. doi: 10.1016/S2213-8587(23)00354-6

Introduction

Barrett’s oesophagus endoscopic surveillance pathways exist to aid detection of early progression at the dysplastic phase. Performance in accordance with guidelines can be mixed, and rates of missed dysplasia are high(1). Barrett’s surveillance endoscopy is a complex skill and requires a broad outlook when considering behaviour change interventions. Behavioural theory can be used to target aspects which influence behaviour which are most likely to affect change when used in implementation studies and has been used in prior studies of colonic polyp detection(2).

Aims & Methods

In this study we aimed to explore using qualitative methodology and behavioural theory, factors which influence endoscopists behaviours to identify barriers and facilitators to the adherence of Barrett’s surveillance endoscopy guidelines which could be utilised in future implementation research to improve practice.
Semi-structured interviews were performed over video conferencing software between August 2021 and July 2022 with purposively sampled clinicians who perform endoscopic Barrett’s surveillance from across the UK who work in a range of hospital types. Framework qualitative analysis was used to identify modifiable factors in line with the Theoretical Domains Framework (TDF) and Capability, Opportunity Motivation - Behaviour (COM-B) model of behaviour change(3,4).

Results

Thematic saturation was achieved at 22 interviews consisting of 3 consultant surgeons, 9 consultant gastroenterologists, 6 clinical (nurse) endoscopists, 2 trainee gastroenterologists and 2 trainee surgeons. Themes were mapped into key themes of intrapersonal, interpersonal and organisational factors.
Key intrapersonal factors included the endoscopists' knowledge of and recall of Barrett's surveillance guidelines, their technical skills required to perform quality Barrett's surveillance, the influence of a competing workload and their motivation to perform Barrett’s surveillance well.
Interpersonal factors included having a motivated endoscopy team who are skilled in assisting endoscopic surveillance and who understand the importance of surveillance, endoscopists' training both pre-certification and post certification and facilitating continued professional development for those in later career years.
Organisational factors included departments allowing adequate scheduling of procedure to allow time for lesion detection, the completing burden of other procedures and waiting lists and availability of equipment e.g. acetic acid.
From these themes, 21 barriers and facilitators were identified and mapped to behavioural interventions for use in future intervention studies - some examples are outlined in Table 1.

Table 1: Outlining examples of barriers and facilitators to performing quality Barrett's surveillance mapped to the Theoretical domains framework(TDF).

Conclusion

The findings of this study provide potential targets for intervention studies which may improve Barrett’s surveillance practice through facilitating behaviour change. Intra and interpersonal factors such as training and education are vital, but the real challenge may be the organisational shift from high turnover to a quality-centred approach for Barrett’s endoscopy. As a complex care intervention, clinician behaviour is one aspect in a multifaceted care pathway which can be improved.

References

1) van Putten M, Johnston BT, Murray LJ, et al. ‘Missed’ oesophageal adenocarcinoma and high-grade dysplasia in Barrett’s oesophagus patients: A large population-based study. United Eur Gastroenterol J. Published online 2018. doi:10.1177/2050640617737466
2) Atkins L, Hunkeler EM, Jensen CD, et al. Factors influencing variation in physician adenoma detection rates: A theory-based approach for performance improvement. Gastrointest Endosc. Published online 2016. doi:10.1016/j.gie.2015.08.075
3) Michie S. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14(1):26-33. doi:10.1136/qshc.2004.011155
4) Michie S, Atkins L, West R. The Behaviour Change Wheel: A Guide to Designing interventions$Susan Michie; Lou Atkins; Robert West. Silverback Publishing; 2014

Disclosure

Funding for this study was obtained from Medtronic Ltd ref number ERP-2019-11987. Medtronic Ltd had no input to the study design or undertaking of the study itself.