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Hyodo T, Hara S, Goto S, Fujii H, Nishi S, Horinouchi T, Nozu K, Yoshikawa N, Yoshimoto A, Itoh T. Immunohistological analysis reveals IgG1-dominant immunophenotype of tubulointerstitial nephritis unassociated with IgG4-related diseases. Int Urol Nephrol 2024; 56:2363-2369. [PMID: 38381285 PMCID: PMC11189997 DOI: 10.1007/s11255-024-03966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/29/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE Tubulointerstitial nephritis (TIN) has various etiologies, including IgG4-related disease (IgG4-RD), autoimmune diseases, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), and others. IgG4-positive plasma cell infiltration can occasionally be found in TIN unrelated to IgG4-RD. Therefore, there may be problems with usage of IgG4 immunostaining to differentiate between TIN with and TIN without IgG4-RD. This study aimed to compare the proportion of plasma cells that are positive for each IgG subclass and to clarify the predominant IgG subclass trends and clinical characteristics associated with IgG4-RD and non-IgG4-related interstitial nephritis. METHODS The study enrolled 44 cases of TIN: 6 of IgG4-RD, 8 of autoimmune disease, 9 of AAV, and 21 of unknown disease group. In addition to clinical characteristics, IgG subclass composition of interstitial plasma cells was evaluated among 4 groups by immunohistochemistry. RESULTS IgG1 was the predominant IgG subclass in TIN unrelated to IgG4-RD. In the IgG4-RD group, the IgG subclass rate was high in both IgG1 and IgG4. The rate of average IgG4-positive cells was significantly lower in the autoimmune disease group and unknown disease group compared with the IgG4-RD group. CONCLUSION The present study revealed IgG1-dominant immune profiles of TIN unrelated to IgG4-RD. Further investigation is required to elucidate the clinicopathological differences between IgG1-dominant and IgG4-dominant groups in IgG4-RD.
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Affiliation(s)
- Toshiki Hyodo
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Shigeo Hara
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
- Department of Diagnostic Pathology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shunsuke Goto
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hideki Fujii
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Akihiro Yoshimoto
- Department of Nephrology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tomoo Itoh
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
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Vujasinovic M, Said K, Villard C, Carlsson J, Poli C, Maisonneuve P, Löhr JM. The Role of Immunoglobulin G4 in Outcomes of Primary Sclerosing Cholangitis. J Clin Med 2023; 13:79. [PMID: 38202086 PMCID: PMC10779552 DOI: 10.3390/jcm13010079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Primary sclerosing cholangitis (PSC) is a chronic, cholestatic liver disease that is characterized by an inflammatory and fibrotic process affecting bile ducts which eventually develops into liver cirrhosis and liver failure. The aim of this study was to investigate serum IgG subclass distribution in patients with PSC and its possible association with PSC outcomes. PATIENTS AND METHODS We performed a retrospective analysis of 181 patients who had been diagnosed with PSC between January 1970 and December 2015 and followed at our outpatient clinic. Their demographic, immunological, and clinical characteristics were recorded and analyzed. RESULTS This study included 181 patients with PSC (120 males, 61 females). There was no association between IgGs and the development of autoimmune hepatitis, cirrhosis, cholangiocarcinoma, liver transplantation, inflammatory bowel disease, and colectomy. Patients with elevated IgG4 had statistically significant higher rates of cholangitis (p = 0.02) and endoscopic retrograde cholangiopancreatography (ERCP) (p = 0.009). High IgG4 values were observed in nine patients who underwent ERCP. In these nine patients, on average, IgG4 was evaluated 5 years after ERCP (min 3 days, max 11 years). Subanalysis considering only IgG4 values evaluated before ERCP showed no significant difference but remains significant if we consider IgG4 values after ERCP. CONCLUSION Elevated IgG4 in our study showed a possible association with higher rates of cholangitis and ERCP among patients with primary sclerosing cholangitis. It seems that IgGs may be a useful tool for the prediction of outcomes in patients with PSC. A prospective study is necessary, especially to study the trends of IgGs values during disease as well as the role of possible seroconversion.
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Affiliation(s)
- Miroslav Vujasinovic
- Department for Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden; (K.S.); (J.-M.L.)
- Department of Medicine Huddinge, Karolinska Institute, 141 86 Stockholm, Sweden; (C.V.); (C.P.)
| | - Karouk Said
- Department for Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden; (K.S.); (J.-M.L.)
| | - Christina Villard
- Department of Medicine Huddinge, Karolinska Institute, 141 86 Stockholm, Sweden; (C.V.); (C.P.)
- Department of Transplantation Surgery, Karolinska Institute, 141 86 Stockholm, Sweden
| | | | - Christopher Poli
- Department of Medicine Huddinge, Karolinska Institute, 141 86 Stockholm, Sweden; (C.V.); (C.P.)
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - J.-Matthias Löhr
- Department for Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden; (K.S.); (J.-M.L.)
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, 171 77 Stockholm, Sweden
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Kersten R, Trampert DC, Herta T, Hubers LM, Maillette de Buy Wenniger LJ, Verheij J, van de Graaf SFJ, Beuers U. IgG4-related cholangitis - a mimicker of fibrosing and malignant cholangiopathies. J Hepatol 2023; 79:1502-1523. [PMID: 37598939 DOI: 10.1016/j.jhep.2023.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/24/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
IgG4-related cholangitis (IRC) is the major hepatobiliary manifestation of IgG4-related disease (IgG4-RD), a systemic fibroinflammatory disorder. The pathogenesis of IgG4-RD and IRC is currently viewed as multifactorial, as there is evidence of a genetic predisposition while environmental factors, such as blue-collar work, are major risk factors. Various autoantigens have been described in IgG4-RD, including annexin A11 and laminin 511-E8, proteins which may exert a partially protective function in cholangiocytes by enhancing secretion and barrier function, respectively. For the other recently described autoantigens, galectin-3 and prohibitin 1, a distinct role in cholangiocytes appears less apparent. In relation to these autoantigens, oligoclonal expansions of IgG4+ plasmablasts are present in patients with IRC and disappear upon successful treatment. More recently, specific T-cell subtypes including regulatory T cells, follicular T helper 2 cells, peripheral T helper cells and cytotoxic CD8+ and CD4+ SLAMF7+ T cells have been implicated in the pathogenesis of IgG4-RD. The clinical presentation of IRC often mimics other biliary diseases such as primary sclerosing cholangitis or cholangiocarcinoma, which may lead to inappropriate medical and potentially invalidating surgical interventions. As specific biomarkers are lacking, diagnosis is made according to the HISORt criteria comprising histopathology, imaging, serology, other organ manifestations and response to therapy. Treatment of IRC aims to prevent or alleviate organ damage and to improve symptoms and consists of (i) remission induction, (ii) remission maintenance and (iii) long-term management. Glucocorticosteroids are highly effective for remission induction, after which immunomodulators can be introduced for maintenance of remission as glucocorticosteroid-sparing alternatives. Increased insight into the pathogenesis of IRC will lead to improved diagnosis and novel therapeutic strategies in the future.
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Affiliation(s)
- Remco Kersten
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - David C Trampert
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Toni Herta
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Lowiek M Hubers
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Joanne Verheij
- Department of Pathology, Amsterdam University Medical Centers, the Netherlands
| | - Stan F J van de Graaf
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Ulrich Beuers
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, AGEM, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
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The Clinical Utility of Soluble Serum Biomarkers in Autoimmune Pancreatitis: A Systematic Review. Biomedicines 2022; 10:biomedicines10071511. [PMID: 35884816 PMCID: PMC9312496 DOI: 10.3390/biomedicines10071511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022] Open
Abstract
Autoimmune pancreatitis (AIP) is a rare etiological type of chronic pancreatitis. The clinical and radiological presentation of AIP often resembles that of pancreatic cancer. Identifying non-invasive markers for their early distinction is of utmost importance to avoid unnecessary surgery or a delay in steroid therapy. Thus, this systematic review was conducted to revisit all current evidence on the clinical utility of different serum biomarkers in diagnosing AIP, distinguishing AIP from pancreatic cancer, and predicting disease course, steroid therapy response, and relapse. A systematic review was performed for articles published up to August 2021 by searching electronic databases such as MEDLINE, Web of Science, and EMBASE. Among 5123 identified records, 92 studies were included in the qualitative synthesis. Apart from immunoglobulin (Ig) G4, which was by far the most studied biomarker, we identified autoantibodies against the following: lactoferrin, carboanhydrase II, plasminogen-binding protein, amylase-α2A, cationic (PRSS1) and anionic (PRSS2) trypsinogens, pancreatic secretory trypsin inhibitor (PSTI/SPINK1), and type IV collagen. The identified novel autoantigens were laminin 511, annexin A11, HSP-10, and prohibitin. Other biomarkers included cytokines, decreased complement levels, circulating immune complexes, N-glycan profile changes, aberrant miRNAs expression, decreased IgA and IgM levels, increased IgE levels and/or peripheral eosinophil count, and changes in apolipoprotein isoforms levels. To our knowledge, this is the first systematic review that addresses biomarkers in AIP. Evolving research has recognized numerous biomarkers that could help elucidate the pathophysiological mechanisms of AIP, bringing us closer to AIP diagnosis and its preoperative distinction from pancreatic cancer.
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Lekhraj R, Lalezari S, Aguilan JT, Qin J, Sidoli S, Mowrey W, Gollamudi S, Lalezari P. Altered abundances of human immunoglobulin M and immunoglobulin G subclasses in Alzheimer's disease frontal cortex. Sci Rep 2022; 12:6934. [PMID: 35484384 PMCID: PMC9050688 DOI: 10.1038/s41598-022-10793-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 04/13/2022] [Indexed: 11/16/2022] Open
Abstract
The immune system has been described to play a role in the development of Alzheimer’s disease (AD), but the distribution of immunoglobulins and their subclasses in brain tissue has not been explored. In this study, examination of pathologically diagnosed frontal cortex gray matter revealed significantly higher levels of IgM and IgG in late-stage AD (Braak and Braak stages V and VI) compared to age-matched controls. While levels of IgG2 and IgG4 constant region fragments were higher in late-stage AD, concentration of native–state IgG4 with free Fc regions was increased in AD III and VI. RNA analysis did not support parenchymal B-cell production of IgG4 in AD III and V, indicating possible peripheral or meningeal B-cell involvement. Changes in the profile of IgM, IgG and IgG subclasses in AD frontal cortex may provide insight into understanding disease pathogenesis and progression.
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Affiliation(s)
- Rukmani Lekhraj
- Neurological Surgery Research Laboratory, Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Shirin Lalezari
- Neurological Surgery Research Laboratory, Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jennifer T Aguilan
- Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jiyue Qin
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Simone Sidoli
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Wenzhu Mowrey
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Seema Gollamudi
- Neurological Surgery Research Laboratory, Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Parviz Lalezari
- Neurological Surgery Research Laboratory, Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.
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Bućan I, Škunca Herman J, Jerončić Tomić I, Gornik O, Vatavuk Z, Bućan K, Lauc G, Polašek O. N-Glycosylation Patterns across the Age-Related Macular Degeneration Spectrum. Molecules 2022; 27:molecules27061774. [PMID: 35335137 PMCID: PMC8949900 DOI: 10.3390/molecules27061774] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 02/01/2023] Open
Abstract
The pathogenesis of age-related macular degeneration (AMD) remains elusive, despite numerous research studies. Therefore, we aimed to investigate the changes of plasma and IgG-specific N-glycosylation across the disease severity spectrum. We examined 2835 subjects from the 10.001 Dalmatians project, originating from the isolated Croatian islands of Vis and Korčula. All subjects were classified into four groups, namely (i) bilateral AMD, (ii) unilateral AMD, (iii) early-onset drusen, and (iv) controls. We analysed plasma and IgG N-glycans measured by HPLC and their association with retinal fundus photographs. There were 106 (3.7%) detected cases of AMD; 66 of them were bilateral. In addition, 45 (0.9%) subjects were recorded as having early-onset retinal drusen. We detected several interesting differences across the analysed groups, suggesting that N-glycans can be used as a biomarker for AMD. Multivariate analysis suggested a significant decrease in the immunomodulatory bi-antennary glycan structures in unilateral AMD (adjusted odds ratio 0.43 (95% confidence interval 0.22–0.79)). We also detected a substantial increase in the pro-inflammatory tetra-antennary plasma glycans in bilateral AMD (7.90 (2.94–20.95)). Notably, some of these associations were not identified in the aggregated analysis, where all three disease stages were collapsed into a single category, suggesting the need for better-refined phenotypes and the use of disease severity stages in the analysis of more complex diseases. Age-related macular degeneration progression is characterised by the complex interplay of various mechanisms, some of which can be detected by measuring plasma and IgG N-glycans. As opposed to a simple case-control study, more advanced and refined study designs are needed to understand the pathogenesis of complex diseases.
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Affiliation(s)
- Ivona Bućan
- Clinical Hospital Centre Split, 21000 Split, Croatia; (I.B.); (K.B.)
| | - Jelena Škunca Herman
- Clinical Hospital Centre Sisters of Mercy, 10000 Zagreb, Croatia; (J.Š.H.); (Z.V.)
| | - Iris Jerončić Tomić
- Department of Public Health, University of Split School of Medicine, 21000 Split, Croatia;
| | - Olga Gornik
- Department of Ophthalmology, University of Split School of Medicine, 21000 Split, Croatia;
- Genos Ltd., 10000 Zagreb, Croatia;
| | - Zoran Vatavuk
- Clinical Hospital Centre Sisters of Mercy, 10000 Zagreb, Croatia; (J.Š.H.); (Z.V.)
| | - Kajo Bućan
- Clinical Hospital Centre Split, 21000 Split, Croatia; (I.B.); (K.B.)
- Department of Ophthalmology, University of Split School of Medicine, 21000 Split, Croatia;
| | - Gordan Lauc
- Genos Ltd., 10000 Zagreb, Croatia;
- Faculty of Pharmacy and Biochemistry, University of Zagreb, 10000 Zagreb, Croatia
| | - Ozren Polašek
- Department of Public Health, University of Split School of Medicine, 21000 Split, Croatia;
- Algebra LAB, Algebra University College, Ilica 242, 10000 Zagreb, Croatia
- Correspondence: ; Tel.: +385-91-5163443
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Abstract
IgG4-related conditions affecting the digestive tract are part of a multi-organ fibro-inflammatory disorder termed IgG4-related disease (IgG4-RD), with autoimmune pancreatitis and IgG4-related cholangitis being the most prominent manifestations. Gastrointestinal symptoms include jaundice, weight loss, abdominal pain, biliary strictures, and pancreatic and hepatic masses that mimic malignant diseases. IgG4-RD manifestations occur less frequently elsewhere in the digestive tract, namely in the oesophagus, retroperitoneum or intestine. Evidence-based European guidelines frame the current state-of-the-art in the diagnosis and management of IgG4-related digestive tract disease. Diagnosis is based on histology (if available), imaging, serology, other organ involvement and response to therapy (HISORt criteria). Few biomarkers beyond serum IgG4 concentrations are reliable. The first-line therapy (glucocorticoids) is swiftly effective but disease flares are common at low doses or after tapering. Second-line therapy might consist of other immunosuppressive drugs such as thiopurines or rituximab. Further trials, for example, of anti-CD19 drugs, are ongoing. Although an association between IgG4-RD and the development of malignancies has been postulated, the true nature of this relationship remains uncertain at this time.
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Nikolic S, Ghorbani P, Pozzi Mucelli R, Ghazi S, Baldaque-Silva F, Del Chiaro M, Sparrelid E, Verbeke CS, Löhr JM, Vujasinovic M. Surgery in Autoimmune Pancreatitis. Dig Surg 2022; 39:32-41. [PMID: 34915509 PMCID: PMC8985041 DOI: 10.1159/000521490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/28/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Autoimmune pancreatitis (AIP) is a disease that may mimic malignant pancreatic lesions both in terms of symptomatology and imaging appearance. The aim of the present study is to analyze experiences of surgery in patients with AIP in one of the largest European cohorts. PATIENTS AND METHODS We performed a single-center retrospective study of patients diagnosed with AIP at the Department of Abdominal Diseases at Karolinska University Hospital in Stockholm, Sweden, between January 2001 and October 2020. RESULTS There were 159 patients diagnosed with AIP, and among them, 35 (22.0%) patients had surgery: 20 (57.1%) males and 15 (42.9%) females; median age at surgery was 59 years (range 37-81). Median follow-up period after surgery was 50 months (range 1-235). AIP type 1 was diagnosed in 28 (80%) patients and AIP type 2 in 7 (20%) patients. Malignant and premalignant lesions were diagnosed in 8 (22.9%) patients for whom AIP was not the primary differential diagnosis, but in all cases, it was described as a simultaneous finding and recorded in retrospective analysis in histological reports of surgical specimens. CONCLUSIONS Diagnosis of AIP is not always straightforward, and in some cases, it is not easy to differentiate it from the malignancy. Surgery is generally not indicated for AIP but might be considered in patients when suspicion of malignant/premalignant lesions cannot be excluded after complete diagnostic workup.
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Affiliation(s)
- Sara Nikolic
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden,Department of Gastroenterology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Poya Ghorbani
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Raffaella Pozzi Mucelli
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden,Department of Abdominal Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Sam Ghazi
- Department of Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - Francisco Baldaque-Silva
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Del Chiaro
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden,Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ernesto Sparrelid
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline S. Verbeke
- Department of Pathology, Karolinska University Hospital, Stockholm, Sweden,Department of Pathology, Oslo University Hospital, Oslo, and University of Oslo, Oslo, Norway
| | - J.-Matthias Löhr
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Miroslav Vujasinovic
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden,*Miroslav Vujasinovic,
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Affiliation(s)
- Livia Archibugi
- PancreatoBiliary Endoscopy and Endosonography DivisionPancreas Translational and Clinical Research CenterSan Raffaele Scientific Institute IRCCSVita‐Salute San Raffaele UniversityMilanItaly
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