Precision Medicine in Pancreatic Disease-Knowledge Gaps and Research Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop

Circulating immune signatures across clinical stages of chronic pancreatitis: a pilot study

OBJECTIVE

This pilot study seeks to identify serum immune signatures across clinical stages of patients with chronic pancreatitis (CP).

METHODS

We performed a cross-sectional analysis of prospectively collected serum samples from the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translation StuDies-study. CP subjects were categorised into three clinical stages based on the presence/absence of metabolic complications: (1) CP with no diabetes and exocrine pancreatic dysfunction (EPD), (2) CP with either diabetes or EPD, and (3) CP with diabetes and EPD. Blinded samples were analysed using an 80-plex Luminex assay of cytokines/chemokines/adhesion molecules. Group and pairwise comparisons were performed to characterise immune signatures across CP subgroups.

RESULTS

A total of 135 CP subjects (evenly distributed between clinical stages) and 50 controls were studied. Interleukin-6 (IL-6), interleukin-8 (IL-8), and soluble intercellular adhesion molecule 1 (sICAM-1) were significantly elevated in CP subjects compared to controls. The levels of IL-6 and IL-8 increased with advancing disease stages, with the highest levels observed in CP with diabetes and EPD (clinical stage 3). Furthermore, hepatocyte growth factor and macrophage-derived chemokine were significantly increased in clinical stage 3 compared to controls.

CONCLUSION

Our study reveals a progressive elevation in pro-inflammatory cytokines and chemokines with advancing clinical stages of CP. These findings indicate potential targets for the development of disease-modifying interventions.

Development and Evaluation of a Self-care Application Based on Herbal Medicine for Skin and Hair Diseases

Background

Self-care applications are effective in the control and treatment of disease symptoms. Today, the mobile phone is used as one of the tools that can help us in this regard. The present study attempts to develop and evaluate a functional self-care mobile-phone application for patients with skin and hair problems using treatment protocols of herbal medicine.

Materials and Methods

This study is a descriptive-applied type. At first, a questionnaire was prepared for data need assessment and also to determine the data items and required capabilities of the application. Based on the results, an application was designed using the Java programing language in the Android software environment. In the next step, the application was installed on the mobile phones of several specialists and patients, and the necessary corrections were made. Then, the final version of the application was evaluated.

Results

The most critical data elements of the mobile application for skin and hair patients included the application's functionality, temperament survey, and clinical information. After considering users' feedback, the screen functionality, the application's information and idiom, and overall functionality of the application were evaluated and approved by the users.

Conclusion

By and large, the developed application could help the patients to receive the best and high-priority treatment protocols based on their own temperament.

Identification of Novel Ligands for Targeted Antifibrotic Therapy of Chronic Pancreatitis

PURPOSE

Chronic pancreatitis (CP) is an inflammatory disorder of the pancreas that leads to impaired pancreatic function. The limited therapeutic options and the lack of molecular targeting ligands or non-serum-based biomarkers hinder the development of target-specific drugs. Thus, there is a need for an unbiased, comprehensive discovery and evaluation of pancreatitis-specific ligands.

METHODS

This study utilized a computational-guided in vivo phage display approach to select peptide ligands selective for cellular components in the caerulein-induced mouse model of CP. The identified peptides were conjugated to pegylated DOPC liposomes via the reverse-phase evaporation method, and the in vivo specificity and pharmacokinetics were determined. As proof of concept, CP-targeted liposomes were used to deliver an antifibrotic small molecular drug, apigenin. Antifibrotic effects determined by pancreatic histology, fibronectin expression, and collagen deposition were evaluated.

RESULTS

We have identified five peptides specific for chronic pancreatitis and demonstrated selectivity to activated pancreatic stellate cells, acinar cells, macrophages, and extracellular matrix, respectively. MDLSLKP-conjugated liposomes demonstrated an increased particle accumulation by 1.3-fold in the inflamed pancreas compared to the control liposomes. We also observed that targeted delivery of apigenin resulted in improved acini preservation, a 37.2% and 33.1% respective reduction in collagen and fibronectin expression compared to mice receiving the free drug, and reduced oxidative stress in the liver.

CONCLUSION

In summary, we have developed a systematic approach to profile peptide ligands selective for cellular components of complex disease models and demonstrated the biomedical applications of the identified peptides to improve tissue remodeling in the inflamed pancreas.

Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review

Despite considerable research efforts, pancreatic cancer is associated with a dire prognosis and a 5-year survival rate of only 10%. Early symptoms of the disease are mostly nonspecific. The premise of improved survival through early detection is that more individuals will benefit from potentially curative treatment. Artificial intelligence (AI) methodology has emerged as a successful tool for risk stratification and identification in general health care. In response to the maturity of AI, Kenner Family Research Fund conducted the 2020 AI and Early Detection of Pancreatic Cancer Virtual Summit (www.pdac-virtualsummit.org) in conjunction with the American Pancreatic Association, with a focus on the potential of AI to advance early detection efforts in this disease. This comprehensive presummit article was prepared based on information provided by each of the interdisciplinary participants on one of the 5 following topics: Progress, Problems, and Prospects for Early Detection; AI and Machine Learning; AI and Pancreatic Cancer-Current Efforts; Collaborative Opportunities; and Moving Forward-Reflections from Government, Industry, and Advocacy. The outcome from the robust Summit conversations, to be presented in a future white paper, indicate that significant progress must be the result of strategic collaboration among investigators and institutions from multidisciplinary backgrounds, supported by committed funders.

Biomarkers of Chronic Pancreatitis: A systematic literature review

BACKGROUND

Chronic pancreatitis (CP) does not have diagnostic or prognostic biomarkers. CP is the end stage of a progressive inflammatory syndrome that is diagnosed at late stages by morphologic features. To diagnose earlier stages of the disease, a new mechanistic definition was established based on identifying underlying pathogenic processes and biomarker evidence of disease activity and stage. Although multiple risk factors are known, the corresponding biomarkers needed to make a highly accurate diagnosis of earlier disease stages have not been established. The goal of this study is to systematically analyze the literature to identify the most likely candidates for development into biomarkers of CP.

METHODS

We conducted a systematic review of candidate analytes from easily accessible biological fluids and identified 67 studies that compared CP to nonpancreatic-disease controls. We then ranked candidate biomarkers for sensitivity and specificity by area under the receiver operator curves (AUROCs).

RESULTS

Five biomarkers had a large effect size (an AUROC > 0.96), whereas 30 biomarkers had a moderate effect size (an AUROC between 0.96 and 0.83) for distinguishing CP cases from controls or other diseases. However, the studies reviewed had marked variability in design, enrollment criteria, and biospecimen sample handling and collection.

CONCLUSIONS

Several biomarkers have the potential for evaluation in prospective cohort studies and should be correlated with risk factors, clinical features, imaging studies and outcomes. The Consortium for the Study of Chronic Pancreatitis, Diabetes and Pancreas Cancer provides recommendations for avoiding design biases and heterogeneity in sample collection and handling in future studies.

Constant-severe pain in chronic pancreatitis is associated with genetic loci for major depression in the NAPS2 cohort

BACKGROUND

Pain is the most debilitating symptom of recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) and often requires chronic opioids or total pancreatectomy with islet autotransplantation to manage. Pain is a complex experience that can be exacerbated by depression and vice versa. Our aim was to test the hypothesis that depression-associated genes are associated with a constant-severe pain experience in RAP/CP patients.

STUDY

A retrospective study was done using North American Pancreatitis Study II (NAPS2) genotyped RAP and CP patients with completed case report forms (n = 1,357). Subjects were divided based on pattern of pain and pain severity as constant-severe pain (n = 787) versus not constant-severe pain (n = 570) to conduct a nested genome-wide association study. The association between reported antidepressant medication use and depression gene loci was tested.

RESULTS

Constant-severe pain was reported in 58% (n = 787) of pancreatitis patients. No differences in sex or alcohol consumption were found based on pain severity. Antidepressant use was reported in 28% (n = 223), and they had lower SF-12 mental quality of life (MCS, p < 2.2 × 10^- 16). Fifteen loci associated with constant-severe pain (p < 0.00001) were found to be in or near depression-associated genes including ROBO2, CTNND2, SGCZ, CNTN5 and BAIAP2. Three of these genes respond to antidepressant use (SGCZ, ROBO2, and CTNND2).

CONCLUSION

Depression is a major co-factor in the pain experience. This genetic predisposition to depression may have utility in counseling patients and in instituting early antidepressant therapy for pain management of pancreatitis patients. Prospective randomized trials are warranted.

CLINICAL TRIALS REGISTRATION

Clinicaltriasl.gov.# NCT01545167.

Evaluation and Management of Suspected Early Chronic Pancreatitis (ECP)

PURPOSE OF REVIEW

Chronic pancreatitis in the advanced stages leads to significant health care utilization because of the associated complications. Early-stage diagnosis could prevent the development of these complications by appropriate management. In this article, we reviewed the recent evidence pertaining to the diagnosis and management of early chronic pancreatitis (ECP).

RECENT FINDINGS

The working group for the International Consensus Guidelines for Chronic Pancreatitis has published consensus-based statements to streamline the diagnosis of ECP. There is no international consensus on the definition and diagnosis of ECP. The Revised Japanese Diagnostic Criteria for ECP based on clinical features and endoscopic ultrasound findings have been proposed. Large prospective cohort studies are needed to develop and validate internationally acceptable diagnostic criteria. ECP is recognized as a distinct stage in the development and progression of CP. Consensus-based definitions and diagnostic criteria need to be developed.

Barriers and Research Priorities for Implementing Precision Medicine

Effective management of complex pancreatic diseases demands precision medicine. While this new approach is technically feasible, many barriers to implementation impede realization of its promised benefits. Barriers exist in the acquisition and utilization of high quality, accurate, specific and quantitative information from both the clinical records and basic sciences. Barriers exist in integrating various domains of knowledge. Barriers exist in translating new insights from the bench to the bedside. Logistical barriers prevent seamless connection and interpretation of the necessary data elements. Barriers also exist with acceptance and application of precision medicine by major institutions and payers. Overcome these barriers will require high-level planning, clarity of vision into short and long term steps, and the commitment of innovative leaders, representing all stakeholders, to work together to reach a common goal.