Introduction

Although we previously demonstrated that AAV8-hSPINK1 safely exhibited significant alleviation of chronic pancreatitis (CP) progression¹, the limited pancreas specificity of AAV8 leads to off-target expression of the transgenes. Additionally, the CMV promoter, as a ubiquitous promoter, lacks tissue preference, hindering its usage in AAV-mediated gene therapy for pancreatic diseases.

Aims & Methods

We aimed to construct a novel pancreas acini-specific promoter to restrict the ectopic expression of transgenes and further enhancing the precision of gene therapy for pancreatic diseases. By integrating human scRNA-seq database, the TiGER database, and our mouse RNA-seq data from Part II, we identified highly conserved genes that are richly expressed in pancreatic acini across species. Sequences surrounding the transcriptional start site (TSS, designated as +1) were selected as candidate compacted pancreas-specific promoters. We first validated transcriptional activity of the candidate promoters using dual-luciferase reporter assay. Subsequently, we packaged compacted promoters into AAV to drive ZsGreen gene expression and injected into mice. Pancreas and liver were collected and immunofluorescence, qRT-PCR, and Western blot were performed to characterised the efficiency and tissue selectivity of the candidate promoters. Finally, the synergistic effects of combining short enhancer fragments from human or rat amylase genes with the candidate promoters were assessed to enhance transcriptional activity.

Results

We selected the promoter sequences originated from hPRSS1 (408 bp), rCela1(-500/+8) (508 bp), rCela1(-205/+8) (213 bp), hSPINK1 (120 bp) as candidates. In vitro dual luciferase activity assays results indicated that the relative luciferase activities of hPRSS1 promoter and rCela1(-500/+8) promoter were 2.77±1.64 and 3.91±0.93, respectively (compared with CMV [100]), which were significantly higher than that of the empty vector group (0.199±0.20) (all P < 0.001). However, the rCela1(-205/+8) and hSPINK1 promoters exhibited no significant promoter activity. Compared to the CMV promoter, the ZsGreen expression levels driven by the hPRSS1 and rCela1(-500/+8) promoter were lower, whereas the pancreas-to-liver ZsGreen mRNA ratio demonstrated that both compacted promoters had pronounced pancreatic transduction preference, which elevated pancreatic-specific expression by 77.81- and 63.02-fold, respectively (all P < 0.001). We finally introduction of human amylase AMY2A (34 bp) and rat Amy2a3 (40 bp) enhancer into hPRSS1 and rCela1(-500/+8) promoters. The Amy2(rat)-hPRSS1 promoter markedly increased the pancreatic transduction efficiency by 8-fold, and was selected as the optimal compacted enhancer-promoter sequence.

Conclusion

The compact pancreatic acini-specific enhancer-promoter, Amy2(rat)-hPRSS1, dramatically improved the pancreas gene transfer efficiency in vivo and eliminating liver tropism, serving a promising tool for pancreas-specific gene therapy targeting exocrine pancreatic diseases, including acute pancreatitis, chronic pancreatitis, and precancerous lesions of pancreatic cancer.

References

1. Wang YC, Mao XT, Sun C, et al. Pancreas-directed AAV8-hSPINK1 gene therapy safely and effectively protects against pancreatitis in mice. Gut 2024;73:1142-1155.

Disclosure

All authors declare no conflicts of interest.

Introduction

Alcohol is a common cause of acute pancreatitis, and ongoing consumption increases the risk of recurrent episodes. There are no international guidelines to direct behavioural or pharmacological interventions to reduce recurrence of alcohol-associated acute pancreatitis (AAP). Studies exploring the role of addiction medicine in patients with AAP are limited.

Aims & Methods

This study describes the uptake and role of the Addiction Medicine Unit (AMU), a specialist consultative service, in patients admitted with AAP. We conducted a retrospective cohort study including all inpatients diagnosed with AAP at a large multisite tertiary health service in Melbourne, Australia between May 2022 to May 2024. Patient demographics, diagnosis of alcohol use disorder (AUD) and pharmacological and non-pharmacological interventions provided by the AMU were obtained from the patient’s medical records.

Results

A total of 231 patients with 314 admissions with AAP were identified. Most were males (77.9%) with a median age of 44 years (IQR 21), with median bedside index of severity in acute pancreatitis (BISAP) score of 1 (IQR 1). Of the patients, 35 (11.1%) had necrotising pancreatitis, 30 (9.6%) required admission to the intensive care unit (ICU), and 1 patient died from AAP. The prevalence of AUD was 82.3%. Referral to the AMU occurred in 56.7% of admissions, predominantly among those with AUD (87.6%). Patients referred to the AMU had a higher median number of standard drinks per week (70 standards, range 6-385 standards) compared to those who were not referred (49 standards, range 1-301 standards) (p=0.024). The AMU recommended outpatient services alone in 40.4%, both pharmacological and outpatient interventions in 37.6%, and medications alone in 21.9%. Outpatient services included either a service for community-based assessment and counselling (86.4%), residential rehabilitation programs and/or detox services (5.8%), follow up in the AMU outpatient clinic (3.9%) or a combination of these outpatient services (3.9%). There were 137 (43.6%) admissions in which patients were commenced on medications for AUD. Topiramate (42.6%), and naltrexone (42.6%) were the most prescribed pharmacological agents by the AMU, followed by baclofen (9.8%), acamprosate (4.1%) and disulfiram (0.8%). Over the 2-year period, 54 (23.4%) were readmitted with AAP. Most patients were not readmitted within 30 days of discharge (73.2%) however there were 33 (10.5%) patients readmitted for pancreatitis or pancreatitis-related complications including pain or infection, and 18 (5.7%) readmitted to hospital for non-pancreatitis related reasons. Patients who were older (median 49 years) were more likely to be readmitted with AAP compared to those who were younger (median age 43 years) across the study period (p=0.05). There were six patients re-admitted with AAP with their index admission deemed related to an alcoholic binge without suspected underlying AUD. Of these six patients, only two were referred and reviewed by the AMU, with the other four patients not referred.

Conclusion

Our study highlights the critical role of the AMU in managing AAP, particularly given the high prevalence of concurrent AUD in this population. Despite this, significant gaps remain in screening for AUD and initiating referrals, resulting in only half of AAP patients being referred. Considering the substantial morbidity and healthcare cost associated with alcohol, efforts to improve referral practices during index admissions may be key to reduce readmissions for AAP and improve patient outcomes.

Introduction

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is widely recognized as the preferred diagnostic method for pancreatic lesions, achieving diagnostic accuracy rates between 78% and 95%. Rapid on-site evaluation (ROSE) improves adequacy rates but remains unavailable in many centers. In this context, we evaluated a simplified method, Visual On-Site Evaluation (VOSE), based on macroscopic evaluation of the biopsy sample, to predict histo-cytological adequacy without needing ROSE.
Primary aim: assess the accuracy of VOSE in predicting sample adequacy.
Secondary aims: evaluate the diagnostic yield of FNB and the potential reduction in unnecessary needle passes.

Aims & Methods

This prospective single-center study enrolled patients undergoing EUS-FNB for pancreatic lesions between January 2020 and February 2024.
VOSE parameters included the presence of a macroscopic visible core (MVC), number of specimens, and specimen length. Associations between VOSE findings and final histo-cytological adequacy were analyzed using Fisher’s exact test and Student’s t-test. A p-value < 0.05 was considered statistically significant. Study conducted at a university hospital center.

Results

Fifty-nine patients (57.6% male; mean age 67.9 ± 9.8 years) were included, contributing to a total of 59 pancreatic lesions. Across 218 passes performed, the overall sample adequacy rate was 91.5%.
Adequacy was significantly higher when using 22-G needles compared to 25-G needles (95.7% vs. 86.2%, p = 0.018). VOSE criteria (presence of MVC, multiple fragments, and long specimen) demonstrated a sensitivity of 52.3%, a specificity of 61.1%, and a positive predictive value (PPV) of 93.1% for predicting sample adequacy. Applying VOSE led to a 45% reduction in unnecessary additional passes.

Conclusion

EUS-FNB provides excellent diagnostic adequacy for pancreatic lesions, particularly with 22-G needles. The use of VOSE, a simple and reproducible macroscopic evaluation method, can reliably predict histo-cytological adequacy and substantially reduce the number of passes, offering a practical alternative in centers without ROSE availability.

References

1. El Chafic AH, Loren DE, Siddiqui AA. EUS-guided fine-needle biopsy of pancreatic masses: new tools, new techniques. Endosc Ultrasound. 2023;12(1):3-10.
2. Crinò SF, Larghi A, Bernardoni L, et al. EUS-guided fine-needle biopsy with or without ROSE for pancreatic masses: A multicenter randomized trial. Gastrointest Endosc. 2023;98(2):225-234.e3.
3. Bang JY, Hebert-Magee S, Navaneethan U, Hasan MK, Hawes R, Varadarajulu S. EUS-guided fine-needle biopsy of pancreatic masses: a meta-analysis comparing FNA and FNB. Gastrointest Endosc. 2022;95(5):893-905.e2.

Introduction

Pancreatic cancer is one of the most aggressive malignancies, with a poor five-year survival rate. Therefore, optimizing diagnostic strategies is a critical priority. Endoscopic ultrasound (EUS) plays a key role in characterizing focal pancreatic masses (FPM). The development of ancillary EUS techniques including contrast-enhanced EUS (CH-EUS), strain ratio elastography (SRE) and Detective Flow Imaging (DFI) has enhanced the assessment of vascularization and tissue stiffness, potentially improving the differentiation between benign and malignant lesions. Emerging evidence suggests that these parameters may provide valuable insights into the malignant potential of FPM [1,2,3]. This study evaluates whether the combined use of CH-EUS, SRE, and DFI improves diagnostic accuracy in predicting pancreatic ductal adenocarcinoma (PDAC).

Aims & Methods

Single-center, retrospective study including consecutive patients who underwent biliopancreatic EUS for FPM between October 2023 and April 2025 at the Digestive Diseases Unit of Sant’Andrea University Hospital, Rome. During EUS evaluation, CH-EUS, SRE, and DFI were performed to characterize lesions. The final diagnosis was confirmed by histopathology (EUS fine-needle biopsy) and/or radiological workup (Computed Tomography, Magnetic Resonance Imaging, Positron Emission Tomography), with a follow-up of at least 6 months. For CH-EUS, lesions were categorized as hypoenhanced, isoenhanced or hyperenhanced compared to surrounding parenchyma in the early arterial phase after injection of 8 mL of sulphur hexafluoride microbubbles, a second-generation ultrasound contrast agent. Hypoenhanced lesions were considered predictive of PDAC [4]. SRE was assessed using the ultrasound system’s embedded software, comparing a region of interest (ROI) in the FPM with the intestinal wall. A strain ratio>10 was considered predictive of PDAC [5,6]. DFI was employed to evaluate the microvascularization, classifying lesions as hypovascular or hypervascular, with hypovascularity considered predictive of PDAC [7,8].

Results

Overall, 59 patients were included, 27 (45.8%) females, with a median age of 69 years (27–88). About lesions 37 (62.7%) were in the head, 14 (23.7%) in the body, and 8 (13.6%) in the tail, with a median diameter of 25 mm (8–63 mm). Among these, 41 (69.5%) were PDAC, 3 (5.1%) were inflammatory lesions, 2 (3.4%) were metastasis and 13 (22%) were neuroendocrine tumors (G1-G2). CH-EUS was performed in 34 cases (57.6%), SRE in 29 (49.2%), and DFI in 37 (62.7%). All three modalities were applied in 20 (33.9%) cases and combinations of DFI with another technique were used in 13 (22.1%).
The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) for PDAC of each modality, alone and in combination, are summarized in Table 1.

Conclusion

Multimodal approaches by using ancillary EUS techniques (CH-EUS, SRE and DFI), particularly combinations including DFI, showed a high specificity and PPV in predicting malignant FPM. Therefore, a multimodal EUS approach may improve post-test probability for PDAC.

References

[1] Costache MI et al. Clinical impact of strain histogram EUS elastography and contrast-enhanced EUS for the differential diagnosis of focal pancreatic masses: A prospective multicentric study. Endosc Ultrasound. 2020 Mar-Apr; doi: 10.4103/eus.eus_69_19.
[2] Miwa H et al. Differential Diagnosis of Solid Pancreatic Lesions Using Detective Flow Imaging Endoscopic Ultrasonography. Diagnostics (Basel). 2024 doi: 10.3390/diagnostics14090882.
[3] Iglesias-Garcia J et al. Differential diagnosis of solid pancreatic masses: contrast-enhanced harmonic (CEH-EUS), quantitative-elastography (QE-EUS), or both? United European Gastroenterol J. 2017 doi: 10.1177/2050640616640635. Epub 2016 Jun 23.
[4] Gincul R et al. Contrast-harmonic endoscopic ultrasound for the diagnosis of pancreatic adenocarcinoma: a prospective multicenter trial. Endoscopy. 2014 doi: 10.1055/s-0034-1364969.
[5] Iglesias-Garcia J, et al. Endoscopic ultrasound elastography. Endosc Ultrasound. 2012 doi: 10.7178/eus.01.003.
[6] Carrara S et al. EUS elastography (strain ratio) and fractal-based quantitative analysis for the diagnosis of solid pancreatic lesions. Gastrointest Endosc. 2018 doi: 10.1016/j.gie.2017.12.031.
[7] Mulqui MV et al. Detective flow imaging versus contrast-enhanced EUS in solid pancreatic lesions. Endosc Ultrasound. 2024 doi: 10.1097/eus.0000000000000076. Epub 2024 Aug 23.
[8] Yamashita Y et al. A Novel Endoscopic Ultrasonography Imaging Technique for Depicting Microcirculation in Pancreatobiliary Lesions without the Need for Contrast-Enhancement: A Prospective Exploratory Study. Diagnostics (Basel). 2021 doi: 10.3390/diagnostics11112018.

Introduction

Acute pancreatitis (AP) is a major cause of digestive-related hospitalizations. Systemic inflammatory response syndrome (SIRS) is present in 20–60% of cases and is associated with severe AP, multiorgan failure (MOF), or in-hospital mortality. This study aims to assess the clinical impact of transient and persistent SIRS on mortality and MOF, compared with the BISAP score.

Aims & Methods

A retrospective study was conducted on a prospective cohort of patients admitted with AP to a tertiary hospital between March 2017 and June 2019. Blood tests were recorded at admission and at 48 hours. Severity was defined using the 2012 Atlanta classification. MOF was defined as dysfunction of two or more organ systems lasting over 48 hours. Transient SIRS was present only at admission, while persistent SIRS lasted >48h. Univariate analysis and ROC curves were conducted using SPSS. Fagan nomograms estimated post-test probabilities of mortality and MOF using pre-test prevalence from the cohort.

Results

A total of 467 patients were included; 84 (18.41%) had SIRS at admission, of whom 32 (37.52%) had persistent SIRS. ROC analysis showed similar AUCs for persistent SIRS and BISAP ≥2, while transient SIRS had poor predictive value. Fagan nomograms showed persistent SIRS had the highest positive and negative likelihood ratios, and greater post-test probability for mortality and MOF, compared to BISAP ≥2 and transient SIRS.

Conclusion

Persistent SIRS was associated with higher risk of mortality and MOF, while transient SIRS had limited prognostic value. Persistent SIRS and BISAP ≥2 had comparable ROC performance, but Fagan nomograms demonstrated the superior clinical predictive utility of persistent SIRS. It showed post-test probabilities up to 40%, compared to 12–13% for BISAP ≥2. These results highlight the importance of monitoring SIRS persistence in AP for better risk stratification and early intervention.

References

1. Crockett SD, Wani S, Gardner TB, Falck-Ytter Y, Barkun AN; American Gastroenterological Association Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. Gastroenterology. 2018;154(4):1096–1101. doi:10.1053/j.gastro.2018.01.032.
2. Singh VK, Wu BU, Bollen TL, Repas K, Maurer R, Mortele KJ, et al. Early systemic inflammatory response syndrome is associated with severe acute pancreatitis. Clin Gastroenterol Hepatol. 2009;7(11):1247–1251. doi:10.1016/j.cgh.2009.08.012.

Introduction

Pancreatic fluid collections (PFCs) are significant local complications that can arise from acute pancreatitis, and its management often involves drainage, although the benefits of metal stents over plastic stents remain uncertain. This meta-analysis compared the efficacy and safety of metal stents versus plastic stents for endoscopic ultrasound (EUS)-guided drainage of PFCs.

Aims & Methods

We searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs) comparing metal with plastic stents for drainage of PFCs. The odds ratio (OR) was used for binary outcomes and the mean difference (MD) for continuous outcomes with their respective 95% confidence interval (CI).

Results

This study included eight RCTs and over 500 patients. Procedure duration was shorter in the metal stent arm compared with the plastic stent arm (MD -10.63; 95%CI -16.12 to -5.15, p<0.001). However, there was no statistically significant difference between metal and plastic stents in clinical success (p=0.78), technical success (p=0.65), overall mortality (p=0.48), recurrence (p=0.23), number of interventions (p=0.85), need of necrosectomy (p=0.35), need of surgery (p=0.35), length of hospitalization (p=0.86), exocrine insufficiency (p=0.54), endocrine insufficiency (p=0.77), and AEs (p=0.36).

Conclusion

Metal stents for EUS-guided drainage of PFCs are associated with a shorter procedure duration. Besides that, it did not improve other clinically relevant outcomes in comparison with plastic stents.