Journal of Crohn's and Colitis

Inflammatory bowel disease (IBD) burden is rising globally, yet only subsets of patients benefit from available therapies, underscoring the need for more precise molecular and cellular stratification. In the PREDICT study, we enrolled treatment-naive pediatric patients with IBD, alongside disorders of gut-brain interaction (DGBI) controls and healthy donors, and profiled their intestinal and blood-derived T cells using single-cell RNA sequencing (scRNA-seq). Across 107 participants, we identify a unique population of cytotoxic CD4+ T cells (CD4 CTL) enriched in the inflamed gut of patients with Crohn's disease (CD) and ulcerative colitis. CD4 CTLs are clonally expanded and express cytotoxic effector molecules and IFNG, consistent with antigen-driven activation. Cell-cell interaction analyses implicate macrophage-derived IL-27 as the top candidate for CD4 CTL differentiation, and IL-27 blockade in a mouse model limits CD4 CTL formation. Notably, elevated CD4 CTL frequencies in gut and peripheral blood at diagnosis are associated with subsequent poor outcome of anti-TNF therapy in pediatric CD. Findings in our identification cohort are validated in an independent cohort and through reanalysis of published datasets. Importantly, we designed a simple flow cytometry panel to isolate blood CD4+ CXCR6+ CD27- T cells, which displayed a CD4 CTL transcriptional phenotype. Together, our results link CD4 CTLs to anti-TNF nonresponse and support their potential as an early, blood-accessible biomarker for treatment stratification in pediatric CD.

Background and Aims: The molecular pathogenesis of Inflammatory Bowel Disease (IBD) remains unclear. We aimed to establish a high-resolution immune landscape of treatment-naive IBD to identify central drivers of disease onset and early pathogenic signalling. Methods: We generated a single-cell atlas using intestinal biopsies from a large adult inception cohort of 137 individuals, including treatment-naive Crohn's disease (CD), ulcerative colitis (UC), and symptomatic non-IBD controls. We integrated scRNA-seq (1 million cells) with co-varying neighbourhood analysis (CNA) and unbiased tensor decomposition of cell-cell communication (CCC) networks. Findings were validated in vitro macrophage stimulation model and using serum from patients. Results: The inception cohort exhibited significantly more homogenous compartmental diversity compared to benchmark reference studies (p < 0.001). Inflammation in both CD and UC was characterized by a marked expansion of inflammatory monocytes. Unbiased CCC analysis identified a dominant disease-specific signalling module centred on the Galectin family (LGALS1 and LGALS9). Galectin-9 expression was specifically enriched in inflammatory monocytes, which exhibited distinct. transcriptional programs linked to antigen presentation and microbial sensing. In vitro, Galectin-9 acted as a potent stimulus, driving macrophages toward a pro-inflammatory phenotype. Clinically, serum Galectin-9 levels were significantly elevated in IBD patients and correlated with systemic inflammatory markers and treatment response. Conclusions: Our data identify a galectin-monocyte signalling axis as a unifying inflammatory hallmark of early IBD. Galectin-9 serves as both a functional driver of mucosal inflammation and a dynamic biomarker, offering new opportunities for therapeutic targeting and disease monitoring from diagnosis. Keywords: Inflammatory Bowel Disease; Crohn's Disease; Ulcerative Colitis; Single-cell RNA sequencing; Galectin-9; Inflammatory monocytes.

Malnutrition is common in Crohns disease (CD), and its assessment requires multiple tools. Comprehensive evaluation of nutritional status in a population with CD, predominantly characterized by metabolic phenotype, was inadequately reported. This study evaluated the nutritional status of CD patients using anthropometric, clinical, and biochemical measures and compared patients with active disease with those in remission. This cross-sectional study included 127 adults with CD: 63 with active disease and 64 in remission. Disease activity was classified using the Crohns Disease Activity Index, the Simple Endoscopic Score for Crohns Disease, and magnetic resonance enterography. Nutritional assessment included body mass index (BMI), mid-upper arm circumference, calf circumference, triceps skinfold thickness, mid-arm muscle circumference, Mini Nutritional Assessment-Short Form (MNA-SF), and biochemical markers including hemoglobin, serum iron, folate, vitamin B12, albumin, and zinc. Malnutrition was defined using the Global Leadership Initiative on Malnutrition criteria. Overall, 47.2% of participants were malnourished. Malnutrition was significantly more frequent in active disease than in remission (81.0% vs. 14.1%, P<0.001). Patients with active CD had lower anthropometric indices, MNA-SF score, hemoglobin, serum iron, albumin, and zinc (all P<0.001), whereas folate and vitamin B12 did not differ significantly. BMI showed positive correlations with other anthropometric measures and MNA-SF score (r=0.854-0.914, all P<0.001), whereas correlations with biochemical parameters were weaker and disappeared after subgroup stratification. Overall, the findings indicate that malnutrition is highly prevalent in CD, particularly during active disease. Anthropometric measures and MNA-SF were strongly concordant, whereas biochemical markers were less consistent, supporting a multidimensional nutritional assessment approach in CD.

Inflammatory bowel disease (IBD) arises from dysregulated crosstalk between innate immune, adaptive immune, and stromal compartments, yet the compartment-specific mechanisms driving tissue injury and tumorigenesis remain incompletely defined. To address this gap, we used conditional knockout and overexpression mouse models together with human IBD biopsy analysis to dissect the compartment-specific roles of lamin A/C in intestinal inflammation and colitis-associated tumorigenesis. Pan-hematopoietic lamin A/C deletion attenuated acute dextran sulfate sodium (DSS)-induced colitis. Myeloid-specific lamin A/C deletion ameliorated chronic colitis and was associated with altered dendritic cell (DC) programs, enhanced regulatory T cell (Treg) responses, and reduced effector T cell activation. Adoptive transfer of lamin A/C-deficient bone marrow-derived DCs recapitulated this reduced-damage phenotype in DSS colitis, while proteomic profiling revealed reduced antigen-processing and inflammatory programs together with enhanced metabolic and mucosal defense pathways. T cell-specific lamin A/C deletion reduced the Th1/Treg ratio and limited tumor development by suppressing chronic inflammation, whereas T cell-specific lamin A/C overexpression promoted severe Th1-skewed pathology, sustained intestinal inflammation, and increased colitis-associated tumor burden. Stromal fibroblast-specific lamin A/C deletion generated a tissue-protective niche characterized by enhanced epithelial barrier gene expression, regulatory cytokine production, and remodeling of the local immune milieu. Human IBD biopsies revealed compartment-specific lamin A/C alterations consistent with the murine findings. In lamina propria CD3+; T cells, lamin A/C levels were blunted in IBD and associated with local histological severity rather than IBD diagnosis, whereas epithelial lamin A/C showed a steeper crypt-axis spatial gradient in a Crohn's disease-specific pattern. Together, these findings identify lamin A/C as a cell-type- and context-dependent regulator of intestinal inflammation and tumorigenesis.

Antibiotics (ABXs) represent the current standard of care for treating Clostridioides difficile infection (CDI). Paradoxically, ABX-induced dysbiosis is the primary risk factor for CDI, as disruption of the colonic microbial ecosystem creates an opportunity for C. difficile colonization. Given that ABXs can also alter immune responses, we investigated whether ABXs prime the colonic immune milieu for CDI susceptibility. Here, we implicate ABXs in driving CDI severity through the emergence of pathogenic CCR5-reliant immune populations in the mouse colon. High-throughput immune cell profiling revealed that ABXs shift the colonic immune compartment toward a CCR5-associated type I immunity signature, marked by an expansion of CCR5+ ILC1s and CCR5+ Th1 cells. A partial genetic deletion of CCR5 reversed CDI severity, alleviating colonic inflammation and improving survival. Pharmacological inhibition of the CCL3/4/5-CCR5 circuit also recapitulated these favorable disease outcomes, which we attribute to reduced colonic CCR5+ ILC1, CCR5+ Th1, and CCR5+ CD8 T cell populations during CDI. Together, our findings extend beyond dysbiosis as the canonical CDI risk factor and establish ABX-induced immune imbalance as an underappreciated determinant of CDI susceptibility.

Background: Exact cause of primary dysmenorrhoea is unknown but recent evidence uncovers a potential link between gut dysbiosis and benign gynaecological disorder via disruption of estrobolome. Methods: A randomized controlled trial to investigate the effects of multi-strain oral probiotics on primary dysmenorrhoea has been conducted. This is a secondary analysis comparing the stool microbiome in women with primary dysmenorrhoea and those without (control), and the effects of treatment with probiotics versus placebo. Results: Although microbial richness and evenness were comparable between groups (alpha diversity, p > 0.05), gut microbial community composition differed significantly (Bray Curtis PERMANOVA, p = 0.015), characterised by reduced Bifidobacterium adolescentis and Blautia and enrichment of Faecalibacterium in dysmenorrhoea, alongside condition-specific core taxa. Post-intervention analysis revealed significant shifts in microbial community structure between pre- and post-treatment groups (PERMANOVA, F = 2.11, p = 0.005), with probiotic supplementation inducing more consistent and directed microbiome changes than placebo, without altering alpha diversity (p > 0.05). Functional prediction showed no significant difference in overall beta glucuronidase pathway abundance (p > 0.05); however, dysmenorrhoea was associated with higher abundance of beta glucuronidase producing taxa (MaAsLin2, q < 0.05) that were differentially modulated by probiotic treatment. Conclusion: This discovery provides evidence on the microbial disruption in primary dysmenorrhoea as well as the benefit of probiotics to modulate the intestinal microbiota to improve the condition.

Microsatellite-stable/microsatellite instability-low colorectal cancer (MSS/MSI-L CRC) is generally resistant to immune checkpoint blockade, but the biological states underlying this resistance are heterogeneous. We integrated TCGA COAD/READ patient transcriptomic profiles, MSIsensor-based MSS/MSI-L classification, curated immune and stromal module scoring, focused differential expression and DepMap CRISPR dependency data to prioritize candidate vulnerabilities in immune-cold MSS CRC. Among 494 MSS/MSI-L tumours, 218 were classified as MSS intermediate, 102 as MSS immune-cold, 91 as MSS hot/inflamed and 83 as MSS barrier-high. MSS immune-cold tumours showed lower cytotoxic, IFN{gamma}-chemokine and antigen-presentation programmes than MSS hot/inflamed tumours, including reduced NKG7, CD8A, CXCL9, CXCL10 and LAG3 expression. MSS barrier-high tumours showed enrichment of stromal and extracellular-matrix programmes, including COL1A1, COL1A2 and COL3A1. Integration with DepMap CRISPR gene-effect data from 1208 cancer models, including 63 colorectal cancer models, separated tumour-cell-intrinsic dependencies from patient-derived microenvironmental signatures. Candidate target classes included ERBB2, VEGFA, PIK3CB, ATR/WEE1/CHEK1, HDAC1/HDAC3/BRD4 and BCL2L1/MCL1, while collagen genes were interpreted as stromal-barrier markers rather than tumour-cell dependencies. ERBB2 expression was higher in MSS immune-cold than MSS hot/inflamed tumours and further elevated in MSS barrier-high tumours, supporting ERBB2 as a candidate subset-associated signal that requires orthogonal HER2 validation. These findings support a stratified therapeutic framework for immune-cold, barrier-high and intermediate MSS CRC.

The gut microbiota has emerged as an important modifier of colorectal cancer (CRC), yet how tumor genotype influences host-microbiota interactions and whether microbial signals are required throughout tumor progression remain unclear. Here, we combined genetically engineered mouse models, microbial multi-omics and a germ-free-compatible orthotopic transplantation system to define the functional contribution of the microbiota across distinct stages of CRC evolution. Across multiple CRC genotypes, we identified tumor-associated microbial ecosystem states characterized by distinct taxonomic, functional and metabolic configurations. To directly test their contribution to tumor progression, we established the first orthotopic CRC transplantation platform compatible with long-term experimentation in germ-free mice, enabling side-by-side comparison of genetically identical tumors in the presence or absence of microbiota. Using organoids spanning low-grade adenoma, high-grade adenoma and adenocarcinoma states, we found that the dependence on the presence of microbiota progressively decreases during malignant evolution. Whereas adenoma-derived organoids exhibited profound dependence on microbial exposure and failed or were markedly impaired in establishing tumors under germ-free conditions, adenocarcinoma organoids engrafted and metastasized in both germ-free and specific pathogen-free (SPF) hosts. Unexpectedly, comprehensive histological, immunological and transcriptomic analyses revealed highly similar tumor ecosystem states in advanced tumors arising under both microbial conditions, arguing against broad immune or epithelial defects as primary explanation for the observed phenotype. Together, our findings demonstrate that distinct oncogenic drivers establish specific microbial ecosystem states and reveal a stage-dependent role of the microbiota during colorectal tumorigenesis. Whereas microbial signals are critical during early stages of tumor progression and may promote malignant transformation, advanced tumors progressively acquire microbiota-independent growth programs and increasingly impose genotype-specific ecological signatures on the surrounding microbial ecosystem. More broadly, we establish a versatile framework for the causal dissection of tumor-microbiota interactions in cancer.

Aims: Serrated lesions contribute substantially to colorectal cancer (CRC), while routine management of small distal hyperplastic polyps (HPs) assumes low risk. Surveillance guidelines nevertheless incorporate uncertainty at the HP/SSL interface and recommend shortened intervals for large serrated lesions. We tested whether fibroblast activation protein-alpha; (FAPalpha) expression by stromal fibroblasts within expert-reviewed HPs stratifies risk of subsequent neoplasia. Methods and results: In a single centre historical cohort, FAPalpha; immunohistochemistry (Abcam ab53066, 1:200) was performed on FFPE colon tissues from 64 patients (normal colon n=10; HP n=39; low grade TA n=6; high-grade TA n=4; adenocarcinoma n=5). FAPalpha positive stromal fibroblasts were quantified in 20 randomly selected fields at magnification 1000 by two blinded readers (ICC 0.93). Among 39 patients with expert reviewed index HPs and colonoscopic follow up, the endpoint was metachronous adenoma occurring in the same general colonic area as the index HP, with proximal defined as ascending colon and distal as descending colon. Follow-up colonoscopies were scheduled every 2 years for up to 10 years. ROC analysis identified an optimal threshold of [&ge;]9 FAPalpha positive fibroblasts (AUC 0.8658; sensitivity 81.25%, specificity 87.93%). FAPalpha high status (44% of HPs) was associated with shortened neoplasm free survival (log-rank p=0.0012): five-year neoplasm free survival 41% versus 91% for FAPalpha; no/low. In multivariable Cox modelling, FAPalpha high status remained independently associated with metachronous adenoma (HR 4.5, 95% CI 1.2-16.8, p=0.022). Conclusion: FAPalpha+ fibroblasts in expert-reviewed colorectal HPs identify a high-risk subgroup for metachronous adenoma, supporting stromal activation markers as a feasible pathology-anchored stratification tool.

Common variants detected by the genome-wide association studies (GWAS) create a wealth of knowledge on genetic component of individual traits and diseases. Elucidating the molecular mechanism behind the vast majority of these variants that are found to be non-coding remains a largely unsolved task, especially when distal and pleiotropic interactions between regulatory elements where these variants occur and gene promoters are taken into account. Focusing on four diseases with immune-mediated mechanisms namely ulcerative colitis, Crohn's disease, primary sclerosing cholangitis and ankylosing spondylitis, we demonstrate the utility of the targPred tool, providing prediction of genes targeted by the regulatory variants. We demonstrate that taking into account evolutionary and comparative genomic data, previously unobserved mechanistic trends (the platelet, vascular and sterol clusters) can be detected in terms of implicated genes targeted by the regulatory elements containing common variants, shared between all four diseases, as well as specific trends for subsets of diseases, e.g. two IBD phenotypes. We also elucidate a clinically-relevant target COG6 shared between IBD and PSC, as well as a whole range of other target genes missed by the conventional SNP-to-gene assignments methods.

Cytotoxic chemotherapy remains a cornerstone of cancer treatment but is frequently limited by gastrointestinal toxicity associated with epithelial barrier disruption. Although chemotherapy profoundly perturbs the gut microbiota, it remains unclear whether these microbial alterations actively contribute to intestinal injury or merely reflect collateral tissue damage. Here, we dissect the respective contributions of direct drug toxicity and chemotherapy-induced dysbiosis to gut pathology using cytarabine (Ara-C), a chemotherapeutic agent associated with severe intestinal complications. We show that both Ara-C and post-Ara-C microbiota independently compromise intestinal barrier integrity. However, these effects arise through distinct host transcriptional programs: Whereas Ara-C directly induces interferon-associated inflammatory responses, post-Ara-C microbiota preferentially activate mucosal barrier defense pathways. Together, these findings identify chemotherapy-induced dysbiosis as an active driver of mucosal injury and provide a mechanistic rationale for microbiome-targeted strategies to mitigate treatment-associated toxicity.

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.

Psoriatic disease (PsD) is associated with metabolic dysfunction-associated steatotic liver disease (MASLD), but the hepatic effects of biologic therapies are unclear. We evaluated paired liver MRI and multi-modal immunoprofiling in PsD patients initiating new systemic therapy. COLIPSO is a prospective cohort of adults with moderate-to-severe psoriasis or psoriatic arthritis (PsA) starting a new conventional synthetic or biologic disease-modifying antirheumatic drug (DMARD). Liver MRI was performed at baseline and ~6 months. A subset of participants with PsA underwent peripheral blood flow cytometry and single-cell RNA sequencing (scRNAseq). Primary outcomes were within-subject change in quantitative MRI measures of liver disease activity and fat content (iron-corrected T1 [cT1] and proton density fat fraction [PDFF]). Bayesian models were used. Thirty-five participants (mean age 50 +/- 13 years; 61% male) were followed for ~29 weeks. Baseline disease activity was moderate (mean DAPSA 29) and 40% had MASLD. IL 17 inhibitors (IL-17i) improved PDFF (-1.58 +/- 1.61%) and cT1(-43.6 +/- 52.7ms), whereas TNFi showed little change. Compared with csDMARD, IL 17i improved PDFF (probability of direction [pd] 89%) and cT1 (pd 93%), which was not seen with TNFi. Flow cytometry (n=17) linked baseline gamma delta T-cell and ThGM-CSF T-cell abundance with cT1 and PDFF. scRNAseq highlighted baseline transcriptomic signatures in MAIT cells associated with cT1 and PDFF. Naive T-cell RNA signatures at baseline were associated with MRI improvements. In PsD, only IL-17i were associated with improved liver disease in addition to improving clinical PsD outcomes. T-cell subtypes bridging innate and adaptive immunity were associated with liver disease features.

Microbial dysbiosis is a hallmark of inflammatory bowel diseases (IBD); however, its drivers and impact on disease pathophysiology are poorly understood. Applying neural network-based feature attribution to metabolomics and metagenomics datasets from >5000 individuals, we identified epimerized host derived bile acids (BAs) produced by microbial hydroxysteroid dehydrogenases (HSDHs) as a novel hallmark of IBD-associated dysbiosis. Epimerized BAs reduce FXR activity in intestinal epithelial cells and dampen their production of FGF19, a negative feedback regulator of host-derived bile acid (HBA) production in the liver. Increased HBA levels drive colonic epithelial remodeling by impacting goblet cell maturation and select for HSDH-carrying bacteria that transform bactericidal HBA into less toxic, epimerized forms. Confirming the translational relevance of these findings, we demonstrated that high HBA levels limit fecal microbiota transplant engraftment and show that BA sequestering drugs support microbiome recovery in patients with high HBA levels. Together, we discover that elevated HBAs deplete BA-sensitive commensals and favor the growth of HSDH-encoding pathobionts that disrupt host BA feedback signaling, establishing a causal link between changes in microbial ecology and IBD pathophysiology.

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.

In idiopathic pulmonary fibrosis (IPF), the lung is remodeled through coordinated epithelial, stromal, and immune-associated programs, but individual transcriptomic cohorts are often too small to separate shared disease signals from demographic and study-level variation. To increase statistical power while preserving study-aware interpretation, we integrated raw bulk lung RNA sequencing (RNA-seq) data from five well-annotated studies and analyzed 223 samples in a common framework that modeled sex, age, library layout and repeated sampling. IPF showed a broad and reproducible expression shift, with 2,443 genes meeting the differential-expression threshold of false discovery rate (FDR) <0.05 and absolute log_2 fold change at least 1. The dominant program combined extracellular matrix remodeling, stromal and epithelial activation, complement and B-cell-related pathways, cilium-associated processes, and relative depletion of oxidative phosphorylation and proteasome pathways. Sex-stratified analyses recovered a shared fibrotic core with smaller sex-skewed components, whereas age-related disease effects were weaker and centered on immune activation. A leave-one-study-out elastic-net analysis using fixed disease-gene panels classified IPF across held-out studies, supporting cross-study portability of the core signature. This integrated reanalysis strengthens evidence for a stable matrix-immune IPF program and reinforces the view that core disease-associated transcriptional programs are reproducible across heterogeneous cohorts.

Laboratory-raised specific pathogen-free (SPF) mice have been indispensable for fundamental immunology research, yet their reliability in predicting human clinical outcomes has been questionable. A major factor contributing to this disconnect is the sanitized housing environment, which deprives laboratory mice of physiological microbial exposure critical for immune maturation. Various approaches have been developed to introduce microbes to SPF mice, aiming to mimic human-like microbial experiences and engender adult human-like immune traits. However, some of these methods, specifically the pet store mice cohousing approach suffer from significant variability in pathogen exposure driven by the uncontrolled nature of microbial exchange and is associated with heightened mortality. Here we present an alternative gavage-fomite (GaF) method that exposes mice to a similarly diverse array of pathogens and commensal as the pet store cohousing method while limiting mortality. GaF-treated mice exhibited consistent gut microbial composition, robust immune maturation characterized by mucosal T-cell distribution, elevated serum inflammatory cytokines, and a splenic immune transcriptional signature closely aligned with that of adult humans. Furthermore, these mice demonstrated enhanced protection against a virulent bacterial challenge. The simplicity, and effectiveness of the GaF method for generating mice with natural microbiota, may support broader use of these models in basic and translational immunological research across institutions.

The gut microbiota plays a fundamental role in human health, nutrition, immune development, and disease, driving widespread adoption of 16S rRNA gene sequencing for microbial community characterization. Short-read V3-V4 sequencing remains the dominant approach for large-scale microbiome studies; however, interrogation of only a small fraction of the 16S gene limits phylogenetic resolution and frequently restricts biological interpretation at the species level. Although full-length (V1-V9) 16S sequencing has emerged as a promising alternative, comprehensive evaluation of highly multiplexed full-length workflows in complex human gut microbiomes remains limited. Here, we establish and evaluate a full-length 16S framework for species-resolved human gut microbiome profiling. The workflow was assessed using defined microbial communities, technical replicates, and healthy human fecal microbiomes. Full-length sequencing generated highly concordant taxonomic profiles across independent technical workflows and enabled reproducible recovery of complex microbial communities at both genus and species levels. Application to human fecal microbiomes revealed substantial inter-individual heterogeneity together with extensive ASV-level microdiversity, highlighting the ability of full-length sequencing to resolve fine-scale phylogenetic variation within dominant gut-associated taxa. To quantify the analytical gain afforded by full-length sequencing, V3-V4 datasets were computationally reconstructed directly from identical full-length reads, eliminating methodological and biological confounders. While alpha diversity metrics and overall community structure remained highly concordant between approaches, full-length sequencing markedly improved taxonomic resolution, increasing species-level assignment from approximately 20% to 98% and resolving substantial intra-genus diversity within clinically and ecologically relevant genera including Bifidobacterium, Prevotella, Blautia, Enterococcus, and Klebsiella. Collectively, these findings position full-length 16S sequencing as an enabling technology for the next generation of microbiome studies, where species-level resolution can be integrated with large-scale cohort, longitudinal, and population-health investigations.

Endometrial cancer (EC) is the most common gynaecological malignancy in high income countries, and is increasing in incidence. While molecular stratification has improved its management, precision care is hampered by incomplete characterization of the EC genome. We address this by analysis of whole genome sequencing (WGS) of 665 ECs generated by the UK Genomics England 100,000 Genome Project (100kGP). 5% of cases were associated with germline pathogenic variants in cancer genes, including BRCA1 which we confirmed predisposes to EC. We identified 107 putative coding driver genes, 35% of which had no prior established role in EC. Novel structural variants included gains of MYCN and loss of its negative regulator NEDD4.1 which were significantly mutually exclusive in copy number (CN) high tumours. Immunogenomic analysis confirmed selection for driver alterations of low immunogenicity based on patient HLA haplotype, and pervasive immune escape through multiple mechanisms. Unsupervised clustering of mutational signatures and genomic alterations identified known and novel molecular subgroups, including a CN-high subset with mutational signatures of homologous recombination deficiency (HRD) and favourable outcome. Independent prognostic value of single nucleotide variant (SNV) burden, CN burden and multiple coding drivers, along with the identification of targetable molecular alterations in over one-third of cases, underscores the promise of WGS for precision medicine in EC.

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