Gastroenterology

Background Proton pump inhibitors (PPIs) have been proposed as a risk factor for initial and recurrent Clostridioides difficile infection (CDI) based on observational data. Whether desprescribing PPIs reduces the odds of incident CDI is unknown. Methods This was a secondary analysis of the cluster randomized MedSafer clinical trial dataset, in which hospitalized older adults taking five or more medications were randomized to usual care (a medication review) or electronic deprescribing decision support prior to hospital discharge. For this substudy, all patients were included regardless of trial assignment and were categorized according to their PPI use at hospitalization and discharge. The 30-day occurrence of CDI was compared as a function of PPI use using a Bayesian mixed-effect logistic regression adjusted for prespecified confounders. Results 4990 patients were included in the analysis, including 405 (8.1%) patients who were deprescribed their home PPI and 325 (6.5%) new PPI users. 30-day CDI occurred in 32 (0.6%) patients. PPI deprescription was associated with a 99.1% probability of increased odds of CDI (adjusted odds ratio[aOR]=3.66, 95%Credible interval[95%CrI]=1.25-10.11). New PPI use, however, was not associated with a probable increase in CDI (aOR=1.14, 95%CrI=0.20-4.67). Conclusion Unexpectedly, PPI deprescription was associated with a higher odds of CDI. This challenges the practice of deprescribing unnecessary PPIs in hospitalized patients for CDI prevention. However, it is possible this finding is artefactual due to confounding by indication. Further mechanistic and confirmatory studies are needed.

Chemotherapy resistance is a major challenge in pancreatic ductal adenocarcinoma (PDAC). While high Inositol Polyphosphate-4-Phosphatase Type II (INPP4B) expression correlates with poor outcomes, its function in chemotherapy response is unclear. We show that INPP4B promotes gemcitabine resistance by enhancing lysosomal exocytosis. Across PDAC models, high INPP4B linked to reduced gemcitabine sensitivity, while knockdown restored it. INPP4B also conferred cross-resistance to agents including irinotecan, oxaliplatin, paclitaxel, and daunorubicin. Mechanistically, INPP4B increased cell-surface LAMP1, enhanced extracellular gemcitabine release, and mitigated DNA damage. Pharmacological targeting of lysosomes with chloroquine (CQ), Bafilomycin A (BafA), or specific PIKfyve or TRPML1 inhibitors blocked exocytosis and reversed resistance in vitro. Moreover, chloroquine co-treatment restored gemcitabine sensitivity in INPP4B-overexpressing xenografts. These results establish INPP4B-driven lysosomal exocytosis as a key mechanism of gemcitabine resistance, highlighting a therapeutic target for PDAC resensitization.

Human pluripotent stem cell-derived intestinal organoids hold great promise for disease modeling, drug screening, and regenerative medicine. However, conventional intestinal organoids are predominantly epithelial, small in scale, and lack the multicellular complexity required to recapitulate the pathophysiology of intestinal disorders such as inflammatory bowel disease (IBD) and colorectal cancer (CRC). Here, we report the development of Centimeter-Scale, purely 3D self-organized human intestinal organoids (IOs) from induced pluripotent stem cells (iPSCs) that encompass multiple tissue lineages, including epithelium, mesenchyme, smooth muscle, neurons, immune cells, and vasculature. These organoids achieve functional maturation by day 100+, exhibiting rhythmic peristaltic-like contractions, and by day 147 they display histological structures including lumens, crypt-like architecture, goblet cells, and smooth muscle. Importantly, for the first time, the neuro-muscle lineages arise spontaneously and autonomously in a purely 3D culture system, without any external stimulation (e.g., electrical, chemical, or mechanical), and mature to form functional neuromuscular junctions, driving macroscopically visible peristaltic-like contractions that mimic intestinal motility entirely through in vitro culture, without any xenotransplantation. Single-cell RNA sequencing at day 115 identified 12 cell subtypes across four major lineages, recapitulating the cellular diversity of the developing human intestine. Using this platform, we established an LPS/IFN-{gamma}-induced IBD model that recapitulated key pathological features, including epithelial disruption, immune cell infiltration, and IL-6 elevation. Transcriptomic analysis confirmed activation of the NF-{kappa}B and JAK2-STAT3 pathways, multi-modal cell death, and immune recruitment machinery, all consistent with clinical IBD pathology. Furthermore, we developed intestinal cancer models at 7 and 21 days showing abnormal hyperplasia, and a probiotic co-culture system demonstrating anti-inflammatory efficacy. Together, these results establish Centimeter-Scale intestinal organoids as a physiologically relevant, multicellular platform for modeling intestinal diseases and evaluating therapeutic interventions.

Summary Background Metronidazole (MET) resistance in Helicobacter pylori (H. pylori) exceeds 50-60% globally, yet MET-containing bismuth quadruple therapy (BQT) achieves &gt90% eradication in MET-resistant infections. We hypothesise this discordance stems from a structural limitation of two-fold dilution: a pharmacometric grey zone between the 128 and 256 &microg/mL breakpoints where treatable isolates are systematically misclassified as high-level resistance. Methods In a real-world cohort of 4610 treatment-na&iumlve children (2019-2024), checkerboard assays determined the bismuth-MET synergy factor (SF). Population PK/PD modelling simulated gastric MET exposure (AUC<sub&gt0-24</sub&gt/MIC &ge 70) at 1 g, 1&middot5 g and 2 g daily doses, incorporated bismuth SF, and estimated MIC coverage against the European Committee on Antimicrobial Susceptibility Testing (EUCAST) population distribution. Findings were validated against published adult trials. Findings 56&middot4% (485/860) of isolates were MET-resistant (MIC &gt 8 &microg/mL). At [&le;] 1 g/day MET, BQT offered no advantage over triple therapy for resistant infections. At 1&middot5 g/day, the synergy threshold was surpassed, achieving &gt90% eradication in MET-resistant infections, with efficacy independent of baseline susceptibility status. PK/PD modelling showed 1&middot5 g/day MET plus bismuth (median SF = 8) extended coverage to ~180 &microg/mL. To align modelled coverage with the &gt90% eradication rate, the dominant subpopulation of nominally high-resistant isolates must have a geometric mean MIC well below 256 &microg/mL (centred near 150 &microg/mL), consistent with a mixture of two log-normal subpopulations and confirming systematic upward misclassification by two-fold dilution in the grey zone. Interpretation This grey zone is a structural blind spot of two-fold dilution, not random measurement error. The &plusmn1-dilution reproducibility limit renders the interval inherently unresolvable. We propose a three-tier strategy: omit routine MET susceptibility testing for treatment-na&iumlve patients on optimised BQT; reserve categorical testing for BQT failures; and explore genomic/metabolomic biomarkers beyond MIC paradigms in this enriched population. Funding None. Keywords: Helicobacter pylori; Metronidazole resistance; Bismuth quadruple therapy; Antimicrobial susceptibility testing; Pharmacokinetic/pharmacodynamic modelling; Pharmacometric grey zone

Background and AimsPerianal fistulizing Crohns disease (PFCD) is a challenging complication with poorly understood pathogenesis and limited treatment options, largely due to the lack of clinically relevant animal models. Interferon-gamma (IFN-{gamma}) signaling is hyperactivated in human PFCD. We aimed to establish mouse models recapitulating human PFCD and to evaluate IFN-{gamma} as a new therapeutic target. MethodsPerianal fistulas were established in three mouse models with concurrent Crohns disease-like intestinal inflammation: wild-type (WT) mice with 2,4,6-trinitrobenzenesulfonic acid (TNBS)-induced proctocolitis, Il10-/-mice, and TNF{Delta}69AU/+ mice. A modified MAGNIFI-CD index was developed for longitudinal fistula assessment in mice. Transcriptomic analysis and flow cytometry were conducted on mouse fistula tissue. Re-analysis of single-cell and spatial transcriptomics of human PFCD tissues was performed. Therapeutic benefits of anti-TNF-, upadacitinib, and IFN-{gamma} pathway antagonists were evaluated in the PFCD models. ResultsAll three PFCD models sustained chronic perianal fistula tracts for at least 5 weeks after wire removal. All three models closely recapitulate the pathological and molecular features of PFCD in patients, as confirmed by clinical examination, MRI, histopathology, immunostaining, flow cytometry, and transcriptomics. IFN-{gamma} signaling emerged as a central and conserved pathway across all three mouse models and human PFCD. Targeting of the IFN-{gamma} pathway promptly improved fistula healing with mitigation of IFN-{gamma} signaling, inflammation, and epithelial-to-mesenchymal transition (EMT). Moreover, combining IFN-{gamma} and TNF- blockade demonstrated augmented therapeutic efficacy compared to anti-TNF- monotherapy. ConclusionsThese PFCD mouse models and imaging tools provide first reliable and clinically relevant platforms for mechanistic studies and therapeutic evaluation. IFN-{gamma} signaling represents a potential therapeutic target warranting clinical investigation.

In clinical trials for ulcerative colitis (UC), pathologists assess disease severity through standardized histological indices, including the Geboes Score, Robarts Histopathology Index (RHI), and Nancy Histologic Index (NHI). Despite strong associations with clinical outcomes, histologic scoring suffers from inter- and intra-reader variability, and consensus criteria for histologic remission remain uncertain. Through a consortium approach, we developed an artificial intelligence-based measurement (AIM) tool for scoring histology in UC mucosal biopsies (AIM-HI UC). This model, trained on a large dataset of UC biopsies (N=10,230), utilizes additive multiple instance learning models leveraging PLUTO, a pathology foundation model, that predict each of the Geboes subgrades, from which the Geboes grade-level score, RHI, and NHI can be calculated. Evaluation of this model on a standalone verification set including clinical trial specimens established algorithm non-inferiority and/or superiority relative to standard qualified pathologists through comparison of algorithm-consensus and pathologist-consensus agreement metrics (non-inferior if difference >-0.1, superior if difference >0, inclusive of confidence intervals). AIM-HI UC was determined to be non-inferior to pathologists (N=3) for the prediction of all seven Geboes subgrades, grade-level Geboes, RHI, NHI, histologic improvement (GS<3.1), 2A histologic remission (GS<2A.0), and 2B histologic remission (GS<2B.0). AIM-HI UC was superior to pathologists for several Geboes subgrades (GS 0, GS 1, GS 2B, and GS 5), as well as grade-level Geboes, RHI, and positive percent agreement of 2A histologic remission. The model was shown to be greater than 99% repeatable for all histologic scoring metrics examined. Model-derived scores were shown to strongly correlate with canonical histologic features of inflammation, including the proportion of total epithelium that is inflamed (Spearman r=0.83; p<0.01), the proportion of neutrophils localized within crypt epithelium (Spearman r=0.83, p<0.01), and the amount of mucosal area classified as erosion or ulceration (Spearman r=0.80, p<0.01). Overall, these results suggest that AIM-HI UC has the potential to improve consistency of UC histology interpretation, providing a path toward standardization of UC histology scoring in clinical trials.

Mucosal healing (MH) is the primary therapeutic endpoint in ulcerative colitis (UC), yet frequent relapses suggest it does not reflect complete tissue recovery. To define the basis of this vulnerability, we generated a multimodal atlas of UC integrating single-cell and bulk transcriptomics, Visium HD spatial profiling, and multiplexed imaging across 89 patients. We show that MH represents a distinct biological state marked by persistent stromal remodeling along three axes: emergence of inflammatory fibroblasts, sustained loss of OGN niche-supporting fibroblasts, and expansion of pericytes with matrix-remodeling features and reduced vascular association. Spatial analyses revealed persistent reorganization of mucosal tissue domains despite apparent clinical remission. Across independent cohorts, baseline inflammatory fibroblast and pericyte signatures robustly predicted non-response to anti-TNF therapy. These findings suggest that patients in MH remain in a biologically altered state linked to relapse risk and identify stromal reprogramming as a determinant of disease persistence and therapeutic response in UC.

Background: Pediatric chronic pancreatitis (CP) carries an elevated lifetime risk of pancreatic ductal adenocarcinoma (PDAC), yet the cellular and molecular mechanisms driving disease progression and early neoplastic transformation remain undefined. Methods: We performed single-nucleus RNA sequencing (snRNA-seq) on pancreatic tissue from 15 pediatric CP individuals and 6 healthy controls (HC). Findings were integrated with peripheral blood flow cytometry immunophenotyping of 8 CP and 7 HC individuals and validated by histopathological assessment. Findings: We identified 15 distinct cell populations and profound cellular remodeling in CP, including a 46% reduction in acinar cells and emergence of inflammatory fibroblasts as the dominant stromal population. Acinar-to-ductal metaplasia (ADM) and pancreatic intraepithelial neoplasia (PanIN) populations bearing early PDAC-associated transcriptional signatures were detected in most CP samples. Cell-cell interaction analysis revealed that 68% of CP-specific ligand-receptor interactions converged on ADM and PanIN populations via ECM-integrin and inflammatory pathways. Peripheral blood flow cytometry demonstrated concordant systemic immune activation, including elevated monocyte CCR2 and CD80, increased CD69 on T cells, and upregulated ROR{gamma}t in regulatory T cells. Interpretation: This atlas defines the cellular landscape and intercellular signaling networks underlying pediatric CP, identifying inflammatory fibroblasts and early neoplastic cell states as central features. These findings provide a molecular foundation for understanding cancer risk in pediatric CP and provide a resource to prioritize studies into potential therapeutic targets and biomarkers. Funding: This work was supported by the Network for Pancreatic Organ donors with Diabetes (nPOD) and The Leona M. & Harry B. Helmsley Charitable Trust.

Small bowel gastrointestinal stromal tumors (GISTs) are more aggressive than gastric GISTs, yet the biologic basis for this difference remains poorly understood. We hypothesized that differential expression of immune checkpoints contributes to this site-specific behavior. Bulk RNA sequencing of 42 primary GISTs (36 gastric, 6 small bowel) revealed marked upregulation of VTCN1, which encodes the inhibitory checkpoint B7-H4, in small bowel tumors (log2FC = 7.95, adjusted P < 0.001). In contrast, expression of the therapeutically targeted checkpoints PD-L1, PD-1, and CTLA-4 was comparable between sites. Concordantly, B7-H4 enrichment was accompanied by an immunosuppressive tumor microenvironment, characterized by reduced antigen-presenting cells, fewer effector-memory CD8+ T cells, lower granzyme B expression, and suppression of interferon and inflammatory signaling pathways. Notably, the differences in B7-H4 expression were independent of imatinib-treatment status. These findings were corroborated in an external cohort of 77 untreated GISTs, in which VTCN1 was similarly enriched in small bowel tumors. Independent immunohistochemical analysis of a tissue microarray comprising 68 untreated primary GISTs confirmed the pattern, showing median B7-H4 positivity of 78.6% in duodenal, 20.5% in jejunal/ileal, and 0% in gastric tumors, with staining localized to tumor cells rather than stroma. Collectively, these data identify B7-H4 as a site-specific feature of small bowel GISTs and a potential therapeutic target for tumors that have not responded to conventional checkpoint blockade.

BackgroundBiliary atresia (BA) is a severe neonatal liver disease characterized by progressive fibrosis and bile duct obliteration. ObjectiveAlthough immune dysregulation is implicated in the pathogenesis of BA, the specific mechanisms driving bile duct injury remain incompletely understood. This study aimed to characterize tertiary lymphoid structures (TLSs) within extrahepatic biliary remnants (EBRs), identify their cellular mediators, and evaluate the therapeutic potential of targeting IL-21 receptor signaling. DesignWe performed integrated bulk RNA sequencing, single-cell RNA sequencing, spatial transcriptomics, multiplex immunohistochemistry, and flow cytometry on clinical samples from BA patients and non-BA cholestatic controls. TLS maturation was assessed by CD23 immunohistochemistry in EBRs from 148 BA patients and correlated with clinical parameters. Anti-IL-21R antibody treatment was evaluated in a rhesus rotavirus-induced BA mouse model, with treatment initiated on day 4 post-infection. ResultsTLSs were identified in BA EBRs with significantly higher prevalence than in matched liver tissues. Mature TLSs containing CD23 germinal centers were associated with elevated serum matrix metalloproteinase-7, more advanced hepatic fibrosis, and localized autoantibody deposition on injured bile ducts. Single-cell profiling revealed expanded CD4+ T peripheral helper (Tph) cells expressing IL-21 and CXCL13 within TLS-containing EBRs. Tph cells were enriched in peripheral blood of BA patients compared to non-BA cholestatic controls (P = 0.0025), and serum IL-21 was significantly elevated (P < 0.0001). Post-infection IL-21R blockade in the mouse model reduced jaundice incidence, improved weight gain, prevented extrahepatic biliary obstruction, and significantly improved long-term survival. ConclusionTLSs in BA extrahepatic biliary remnants harbor expanded Tph cells associated with IL-21-mediated B cell activation and bile duct injury. IL-21R blockade ameliorated disease in a murine BA model, identifying the IL-21/IL-21R axis as a potential therapeutic target warranting further investigation. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSImmune dysregulation contributes to biliary atresia (BA), with documented lymphocyte infiltration and defective B cell tolerance. However, the cellular mechanisms linking local immune activation to bile duct injury are unclear, and the roles of organized lymphoid structures and specific CD4 T cell subsets in orchestrating local humoral responses have not been characterized. What this study addsThis study demonstrates that mature tertiary lymphoid structures in extrahepatic biliary remnants are associated with disease severity markers and localized bile duct injury in BA. We identify T peripheral helper cells as an expanded IL-21-producing CD4 T cell population within these structures, and show that post-infection IL-21 receptor blockade prevents biliary obstruction and improves survival in a murine BA model. How this study might affect research, practice or policyThese findings identify the IL-21/IL-21R signaling axis as a candidate therapeutic target in BA warranting further preclinical and translational investigation. TLS maturation status in biliary remnants and serum autoantibody levels may serve as potential biomarkers of disease severity, meriting prospective evaluation in clinical cohorts.

The progression from reflux esophagitis (RE) to Barretts esophagus (BE) and esophageal adenocarcinoma (EAC) is a major route of inflammation-associated esophageal tumorigenesis, but the cellular transitions involved remain incompletely understood. We performed single-cell transcriptomic profiling of RE, BE, and EAC tissues and integrated public EAC datasets, yielding 51,283 cells across the RE-BE-EAC continuum. The analysis identified stage-associated epithelial and microenvironmental differences. Pseudotime analysis placed Basal epithelial cells along two differentiation branches, one toward mature epithelial states and the other through proliferative and gastric-type metaplastic states toward copy number alteration-bearing malignant epithelial cells. MMP7 increased along this malignant branch, was enriched in cancer-associated epithelial cells. Its knockdown reduced the proliferation and migration of OE19 and OE33 cells, supporting an association with proliferative and migratory phenotypes. In parallel, the microenvironment shifted toward immune suppression and stromal remodeling, with increased T-cell exhaustion, macrophage polarization toward tumor-associated states, and enrichment of CAF-like myofibroblasts. Ligand-receptor analysis further suggested an epithelial-centered communication network involving MDK-SDC2/LRP1/NCL interactions between malignant epithelial cells and fibroblast, T-cell, and myeloid compartments. These results identify MMP7-associated epithelial states and candidate MDK-related communication pathways for further longitudinal and functional validation.

Background and aimsPerianal fistulizing Crohns disease (pCD) affects 20% of patients with Crohns disease (CD) and severely impacts quality of life. Current therapies fail to provide sustained relief, and the molecular underpinnings of pCD remain poorly understood. This study aimed to elucidate the molecular landscape of perianal fistulas through multiomic profiling. MethodsPaired fistula-tract and adjacent rectal mucosal biopsies were collected from 63 patients (48 with pCD, 15 with cryptoglandular fistula [CPTGL]). Longitudinal sampling generated 101 unique molecular profiles, comprising of both RNA sequencing (RNA-seq) and 16S rRNA sequencing from both tissue sites, followed by integrative multiomics and gene network analyses. ResultsUnsupervised clustering revealed three patient clusters primarily defined by host gene expression, with minimal contribution from microbial profiles. Fistulae in clusters 1 and 2 showed strong immune activation and epithelial-mesenchymal transition (EMT). In contrast, cluster 3 fistulae displayed keratinization and metabolic reprogramming resembling psoriatic skin, together with reduced JAK-STAT signalling. Cluster 3 was enriched for patients classified as TOpClass:2a, who are more suitable for surgical repair (p = 0.02). Conversely, cluster 2, characterized by rectal keratinization and EMT in both fistula and rectum, showed the highest MRI inflammatory-mass score (p = 0.02) and a greater risk of subsequent ileostomy (Kaplan-Meier; p = 0.008). An independent RNAseq dataset validated the keratinization signature in a subset of pCD fistulae. ConclusionIntegrated multiomic analysis identified distinct molecular subtypes of pCD with surgical and therapeutic relevance. These findings refine the molecular understanding of pCD and support a precision medicine approach. What You Need to Know?O_ST_ABSBACKGROUND AND CONTEXTC_ST_ABSO_LIPerianal fistulas affect 1 in 5 Crohns disease patients and have a severe negative impact on the quality of life of the patients. C_LIO_LIMost advanced IBD therapies are not efficacious for perianal Crohns disease. C_LIO_LISurgical repair is not suitable for all patients. C_LI NEW FINDINGSO_LIThis study is the first to delineate molecularly defined patient subtypes in perianal fistulizing Crohns disease. It further characterizes a psoriasis-like keratinization program in a subset of fistulas. Finally, it identifies molecular features and histological indicators that may explain-and potentially help predict-favorable surgical outcomes in selected patients C_LI LIMITATIONSO_LIFunctional and mechanistic studies will be required to further dissect the drivers and dynamics of the epithelial remodeling identified. C_LI CLINICAL RESEARCH RELEVANCEO_LIRaises the possibility of refining of existing clinical stratification using molecular markers for improved therapeutic management and outcome. C_LI BASIC RESEARCH RELEVANCEO_LIProposes keratinization as an opposing molecular process to EMT within the perianal fistula tract. C_LIO_LIIdentifies robust gene signatures associated with EMT and keratinization in the fistula for further experimental and clinical studies. C_LI

Stomach infection with the bacterium Helicobacter pylori (Hp) can cause chronic gastric inflammation, metaplasia (transdifferentiation of mature cell types), dysplasia (abnormal cells), and finally cancer. Obesity can also increase gastric cancer risk. However, host-Hp interactions during obesity are poorly understood. Here we investigated the impact of diet-induced obesity in two mouse models of Hp-associated disease. To model chronic gastric inflammation, we used C57BL/6 mice, and to model more severe disease, we used transgenic mice in which tamoxifen induces gastric expression of a constitutively active Kras allele, leading to metaplasia. We fed mice a high-fat diet (60% kilocalories from fat) to induce obesity, or a matched control diet (10% kilocalories from fat), then infected them with Hp or mock-infected them. In mock-infected C57BL/6 mice, high-fat diet had a minimal impact on gastric pathology and gene expression. In Hp-infected C57BL/6 mice, high-fat diet increased inflammation at the junction between the glandular stomach and non-glandular forestomach, a squamous epithelium similar to the human esophagus, and increased gastric expression of the cancer-associated genes Cldn7 and Reg3g. In KRAS+ mice with or without Hp infection, the impact of diet-induced obesity was more apparent, with increased metaplasia and dysplasia (abnormal cells). As well, high-fat diet caused an expansion of metaplastic pit cells, a lineage we previously found to be associated with Hp-driven inflammation. Thus, in these mouse models, diet-induced obesity does not directly drive gastric immunopathology, but enhances the development of pre-cancerous changes under susceptible conditions. IMPORTANCEMost gastric cancers are caused by stomach infection with the bacterium Helicobacter pylori. However, most infected individuals never develop cancer. Therefore, additional risk factors must tip the balance toward gastric cancer development. Obesity, or excessive body fat accumulation that poses a risk to health, is associated with gastric cancer development. However, specific mechanisms for obesity-driven gastric cancer risk are not well defined. Here we tested the hypothesis that obesity would exacerbate Helicobacter pylori-associated disease phenotypes using two clinically relevant mouse models. In wild-type mice, obesity induced by a very high-fat diet had a minimal impact on the stomach in the absence of infection, but increased the expression of some cancer-associated genes during infection. However, in mice with genetically driven pre-cancer, diet-induced obesity exacerbated the disease pathology, especially in infected mice. Therefore, obesitys impact on gastric cancer risk may be more evident in the later stages of the disease.

Objective Vedolizumab (VDZ) is effective in ulcerative colitis (UC), but its onset of action may be relatively slow during induction therapy. VSL#3TM, a high-potency multi-strain probiotic, may provide synergistic effects through microbiota modulation and immune regulation. This preliminary real-world study aimed to evaluate the efficacy and safety of VSL#3TM combined with VDZ in patients with UC. Methods Clinical data were retrospectively collected from patients with active UC who received VSL#3TM combined with VDZ for at least 12 weeks at the Second Affiliated Hospital of Zhejiang University School of Medicine in China between January 2023 and December 2024. The primary endpoints were clinical response rates at weeks 6 and 12. Secondary endpoints included clinical remission, changes in inflammatory bowel disease questionnaire (IBDQ) scores, safety assessment. Results Using PRO2 criteria, clinical response rates were 82.4% (14/17) at 6 weeks and 100.0% (17/17) at week 12, with clinical remission in 58.8% (10/17) at week 12. By Full Mayo Score, clinical response and remission at week 12 were 68.8% (11/16) and 50.0% (8/16), respectively. These response rates appeared numerically higher than those reported in published historical VDZ monotherapy studies, although direct comparisons are limited by the single-arm design. Mean IBDQ score improved from 157.3 at baseline to 174.5 at week 12 (p<0.001). The combination was well-tolerated with no serious adverse events. Fatigue, borborygmus, and arthralgia were reported in 1/17 (5.9%), 2/17 (11.8%), and 1/17 (5.9%) patients, respectively. Notably, all 3 patients with baseline history of Clostridioides difficile (CDI) positivity tested negative for both toxin and antigen at 12 weeks; one toxin-positive patient had received anti-CDI antibiotic therapy. Conclusions This preliminary real-world study suggests that VSL#3TM may enhance early clinical outcomes in patients receiving VDZ for active UC. The observed benefits may be related to complementary effects on the gut microbiota and intestinal immune responses, although these mechanisms were not directly assessed. Further larger prospective randomized controlled trials are warranted to confirm these findings.

Gastric cancer is the fifth leading cause of cancer-related mortality in humans globally and remains a clinical challenge with limited treatment options and poor survival. Dogs develop spontaneous gastric cancer that parallels the clinical presentation and histology of human disease, supporting their value as a comparative oncology model. Here we present a comprehensive transcriptomic characterization of canine gastric cancer through single-nucleus RNA-sequencing, bulk RNA-sequencing, and Visium HD 3' spatial transcriptomics of treatment-naive tumor and normal stomach tissues from Belgian Tervuren and Belgian Sheepdogs. Across 107,085 nuclei, we identified 44 distinct cell populations, including tumor-enriched states as well as profound depletion of the normal parietal and chief cell gastric lineages. Cell-cell communication analysis revealed enhanced epithelial-fibroblast crosstalk driving epithelial-mesenchymal transition. Bulk RNA-sequencing further identified enrichment of signaling pathways implicated in H. pylori associated human gastric carcinogenesis, including Hippo, PI3K-Akt, and Wnt. Notably, we observed cell-type-specific altered expression of KLHL29, PDZRN3, and PLAU, which are among our previously identified canine gastric cancer susceptibility genes, linking germline risk to specific tumor cellular contexts. These data establish the first transcriptomic atlas of canine gastric cancer and demonstrate substantial molecular homology between canine and human disease.

Pancreatic ductal adenocarcinoma (PDAC) is currently the third leading cause of cancer-related deaths in the United States. Intraductal papillary mucinous neoplasms (IPMNs) are neoplastic lesions of ductal origin that seed 10-25% of PDAC. There are currently no markers that distinguish between IPMN that will remain benign and those that will progress to cancer. A heterogenous population of secretory cells, including chemosensory tuft cells and hormone-expressing enteroendocrine cells (EECs), form during metaplasia and neoplastic progression in the pancreas, but the relevance of these populations as it relates to IPMN progression is not well characterized. Here, we performed spatial transcriptomics as well as multiplex immunostaining and spatial statistics on surgically resected IPMN from 60 patients to characterize these populations in all subtypes (gastric foveolar, intestinal, pancreatobiliary) and grades (low-grade, high-grade, invasive). We found that POU2F3+ tuft-like cells, CHGA+ EECs, and a subset of pancreatic endocrine cells ([a] and {gamma} cells) were present in all types of IPMN. Further, serotonin-expressing enterochromaffin cells made up the bulk of EECs in low-grade disease. Enterochromaffin, tuft-like, and glucagon-expressing alpha cells were not evenly distributed and instead were significantly enriched in a spatial manner, which is overlooked using conventional whole tissue quantification approaches. Tuft-like cell clusters were enriched with monocytes and resident memory T cells and anti-correlated to activated fibroblasts (myCAFs, iCAFs). Overall, these secretory cell clusters may reflect clonal expansion resulting in formation of distinct stromal niches with unknown consequences for disease progression.

Autoimmune hepatitis (AIH) is a chronic progressive liver disease that despite suggestive serum autoantibodies or plasma cell enrichment, remains functionally a diagnosis of exclusion. Whether the broader cellular composition of the liver might enable improved specificity of diagnosis has not been systematically tested. We prospectively recruited patients undergoing a clinically-indicated liver biopsy for suspected AIH and performed single-nucleus RNA sequencing (snRNA-seq) on biopsy tissue to map the cellular landscape of AIH and its diagnostic mimics. Unsupervised clustering on cell-type abundances alone largely separated AIH from non-AIH samples. Among individual populations, a subset of CD8 T-cells marked by high TOX and PD1 expression was the most discriminating feature: its enrichment perfectly distinguished AIH by both snRNA-seq and in situ density (AUC = 1.00), outperforming plasma cell abundance (AUC = 0.83). CD8TOX T-cell enrichment may therefore be the histologic lesion that marks the diagnosis of AIH.

Peritoneal carcinomatosis is a major cause of death in gastric cancer, yet effective therapies remain limited. Tumor-derived soluble factors are increasingly recognized as key regulators of the peritumoral microenvironment. Here, we nominate osteopontin (SPP1) as a tumor-derived mediator that orchestrates macrophage-driven immunoregulation in gastric peritoneal carcinomatosis. Using integrated analyses of human clinical datasets and murine models, we demonstrate that tumor-secreted SPP1 promotes macrophage recruitment and induces tolerogenic IL-10 production. Clinically, SPP1 correlated with inferior overall survival and progression-free survival in gastric cancer. In syngeneic murine models of gastric peritoneal carcinomatosis, intracavitary pharmacologic inhibition of SPP1 restricted peritoneal dissemination, impaired macrophage infiltration and suppressed IL-10 production. Consistent with these findings, macrophage depletion phenocopied antitumor effects of SPP1 inhibition, resulting in decreased metastatic burden. Collectively, these findings define a mechanism of tumor-macrophage crosstalk that promotes peritoneal dissemination and provide a rationale for therapeutic targeting of SPP1 in gastric peritoneal carcinomatosis.

Leptin receptor (LEPR) signaling has been implicated in multiple malignancies; however, its role in gastric tumors remains poorly defined. We previously demonstrated that mice with gastrointestinal epithelial cell-specific deletion of suppressor of cytokine signaling 3 (SOCS3 cKO), a negative feedback regulator of LEPR signaling, develop gastric tumors due to aberrant leptin production and LEPR activation. Here, we demonstrate that concurrent deletion of both Socs3 and Lepr (double knockout; DKO) under the same promoter substantially suppresses gastric tumorigenesis and markedly prolonged survival. Whereas SOCS3 cKO mice exhibited early stromal activation, increased TGF-{beta}1 production, accumulation of cancer-associated fibroblasts (CAFs) and collagen deposition, these tumor-promoting alterations were substantially attenuated in DKO mice. Additionally, DKO mice showed reduced inflammatory cytokine and chemokine signaling, decreased the accumulation of Gr-1+CD11b+ myeloid-derived suppressor cells, and reduced LEPR and TGF-{beta} signaling. Analysis of The Cancer Genome Atlas stomach adenocarcinoma cohort revealed high LEPR expression in the chromosomal instability and genomically stable subtypes, correlating with poor prognosis. Moreover, LEPR expression was mutually exclusive with CLDN18 and ERBB2, two major therapeutic biomarkers, and positively correlated with a CAF-related transcriptional signature. Our findings identify LEPR signaling in epithelial cells as a key driver of gastric tumorigenesis through promotion of stromal activation and tumor microenvironment development. They further highlight LEPR as a promising therapeutic target for patients with gastric cancer who are unlikely to benefit from current ERBB2/HER2- or CLDN18-directed therapies.

We have previously demonstrated a critical role of c-Maf SUMOylation in the regulation of autoimmune diabetogenesis, but its physiological relevance to and potential clinical impact on gut inflammation need further elucidation. Here, integrating a 14-year population-based time-trend cohort study of 139,204 type 1 diabetes patients with experiments in non-obese diabetic mice, we illustrated that autoimmune diabetes confers resistance to colitis mediated by an impaired c-Maf SUMOylation-driven IL-21-IgA axis. Utilizing T cell-specific c-Maf SUMOylation site-mutated mice, we further demonstrated that SUMOylation-defective c-Maf enhances IL-21 expression in CD4+ T cells to promote fecal IgA production and colitis resistance via microbiota remodeling, specifically through Lactobacillus johnsonii enrichment and activating lithocholic acid (LCA)-mediated AMPK anti-inflammatory pathway. Pharmacological HDAC2 inhibition by BRD6688 promotes c-Maf-mediated IL-21 and suppresses colitis in PBMC-humanized mice. Altogether, we revealed how SUMOylation reciprocally modulates the inflammatory process between autoimmune diabetes and colitis in a T cell-restricted and single transcription factor-based manner.