Effectiveness of Tofacitinib in Ulcerative Proctitis Compared to Left Sided Colitis and Pancolitis

BACKGROUND

Ulcerative proctitis (UP), though associated with high symptom burden and poor quality of life, is excluded from most of the randomized controlled trials in UC, including the OCTAVE trials. We aimed to analyse the effectiveness of tofacitinib in UP, and compare it to that in left sided colitis (LSC) and pancolitis (PC).

METHODS

This was a prospective cohort study. Patients with either steroid-dependent or refractory ulcerative colitis, who received tofacitinib, were divided into three groups based on the disease extent [UP, LSC and PC]. The primary outcome was comparison of proportion of patients in clinical remission in the three groups, at weeks 8, 16 and 48. Safety outcomes were reported using incidence rate per patient year of exposure.

RESULTS

Clinical remission was achieved in 47%(15/32), 24%(23/94), and 43%(23/54) of patients at week 8, 56%(18/32), 37%(35/94), and 56%(30/54) of patients at week 16, and 59%(19/32), 38%(36/94), and 24%(13/54) of patients at week 48 in groups UP, LSC and PC, respectively. Corticosteroid-free clinical remission rates were significantly higher in patients in groups UP at week 48. Five (15%) patients with UP were primary non-responders to tofacitinib at week 16, while three (9%) patients had secondary loss of response at week 48. The probability of sustained clinical response was highest in patients with UP. Patients with UP had the lowest incidence of adverse effects.

CONCLUSION

The effectiveness of tofacitinib in inducing and maintaining clinical remission is greater in patients with UP compared to LSC and PC.

Ammonia is associated with liver-related complications and predicts mortality in acute-on-chronic liver failure patients

The relationship between ammonia and liver-related complications (LRCs) in acute-on-chronic liver failure (ACLF) patients is not clearly established. This study aimed to evaluate the association between ammonia levels and LRCs in patients with ACLF. The study also evaluated the ability of ammonia in predicting mortality and progression of LRCs. The study prospectively recruited ACLF patients based on the APASL definition from the ACLF Research Consortium (AARC) from 2009 to 2019. LRCs were a composite endpoint of bacterial infection, overt hepatic encephalopathy (HE), and ascites. A total of 3871 cases were screened. Of these, 701 ACLF patients were enrolled. Patients with LRCs had significantly higher ammonia levels than those without. Ammonia was significantly higher in patients with overt HE and ascites, but not in those with bacterial infection. Multivariate analysis found that ammonia was associated with LRCs. Additionally, baseline arterial ammonia was an independent predictor of 30-day mortality, but it was not associated with the development of new LRCs within 30 days. In summary, baseline arterial ammonia levels are associated with 30-day mortality and LRCs, mainly overt HE and ascites in ACLF patients.

Reduced expression of Ankyrin-G and E-cadherin in duodenal mucosal biopsy of subjects with celiac disease

Confirmatory diagnosis of celiac disease (CD) include histopathology of duodenal biopsy and tissue trans-glutaminase-IgA. Identification of tissue-specific histological markers is warranted to improve the diagnosis. A genetic study in CD identified the association of ankyrin-G that connects E-cadherin with β2-spectrin in epithelial cells of the duodenal tissue. We attempted to investigate the differential expression of ankyrin-G, E-cadherin and β2-spectrin in duodenal biopsy of CD subjects compared to non-CD controls. Duodenal tissue was collected from 83 study participants, of which 50 were CD, and 33 were non-CD controls. Whole RNA was isolated from 32 CD and 23 non-CD controls from available tissues, and differential mRNA expression was measured using real-time PCR. Tissue sections from 18 CD cases and 10 non-CD controls were immunostained using monoclonal antibodies. Tissue immunohistochemistry were evaluated for differential expression and pattern of expression. RT-PCR revealed significantly reduced expression of ankyrin-G (fold change=0.63; p=0.03) and E-cadherin (fold change=0.50; p=0.02) among CD subjects compared to non-CD controls. Tissue immunohistochemistry confirmed the reduced expression of ankyrin-G and E-cadherin in CD. Differential expression is grossly limited within the outer columnar epithelial cell layer. Expression fold change of E-cadherin was seen to partially correlate with the serum tTG level (r=0.4; p=0.04). In CD, reduced expression of two key cytoskeletal proteins (ankyrin-G and E-cadherin) in duodenum mucosa was observed, which indicates its implication in disease biology and could be tested as a tissue-specific biomarker for CD. Functional studies may unravel the specific contribution of these proteins in CD pathophysiology.

Burden of Anxiety, Depression and Perceived Stress in Patients with Inflammatory Bowel Disease: A Cohort Study from North India

BACKGROUND

Patients with Inflammatory bowel disease (IBD) are susceptible to psychiatric co-morbidities. We aimed to ascertain the burden of anxiety, depression, and perceived stress in patients with IBD from north India.

METHODS

Consenting adult patients with an established diagnosis of IBD were enrolled. The enrolled patients filled the Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS) questionnaires. The patient and disease characteristics were analyzed to determine the correlations and predictors of psychiatric comorbidities.

RESULTS

A total of 318 patients (255 UC, 63 CD; mean age 40.13 ± 12.06 years, 168 [52.8%] males; mean partial Mayo score 2.10 ± 2.35; and mean HBI 2.77 ± 2.13) were enrolled. The prevalence of anxiety, depression and moderate to high perceived stress was 14%, 12%, and 41%, respectively. Females had higher mean perceived stress, anxiety and depression scores compared to males. The partial Mayo score (PMS) correlated poorly with anxiety (ρ = 0.083, p = 0.187), depression (ρ = 0.123, p = 0.49) and perceived stress (ρ = 0.169; p = 0.007). The Harvey Bradshaw index (HBI) correlated fairly with anxiety (ρ = 0.336, p = 0.007) and poorly with depression (ρ = 0.287, p = 0.022) and perceived stress (ρ = 0.20; p = 0.117). Younger age (OR 0.93, 95% CI 0.90-0.97; p = 0.001) and hand-grip strength (OR 4.63, 95% CI 1.88-11.42; p = 0.001) predicted anxiety in patients with UC while rural area of residence (OR 4.75, 95% CI 1.03-21.98; p = 0.046) and HBI (OR 1.60, 95% CI 1.12-2.29; p = 0.009) were significant predictors of anxiety in patients with CD.

CONCLUSION

Psychiatric comorbidities are common in patients with IBD, with higher prevalence in females. Young adults with UC and sarcopenia; and individuals with active CD living in rural areas are at an increased risk of anxiety.

Tofacitinib Versus Oral Prednisolone for Induction of Remission in Moderately Active Ulcerative Colitis [ORCHID]: A Prospective, Open-Label, Randomized, Pilot Study

BACKGROUND

Oral corticosteroids are first-line agents to induce remission in moderately active ulcerative colitis [UC], but are associated with adverse effects. We compared the efficacy and safety of tofacitinib and prednisolone for induction of remission in moderately active UC.

METHODS

This was a single-centre, prospective, open-label, randomized, active-controlled pilot study. Eligible patients [aged ≥18 years] had moderately active UC. Participants were randomly assigned to receive either prednisolone [40 mg daily, tapered by 5 mg every week] or tofacitinib [10 mg twice daily] for 8 weeks. The primary endpoint was composite remission [defined as total Mayo clinic score ≤2, with endoscopic sub-score of 0 and faecal calprotectin <100 µg/g] at 8 weeks.

RESULTS

Seventy-eight patients were randomly assigned to either of the treatment groups. At week 8, the proportion of patients achieving composite remission in the tofacitinib [7/43, 16.28%] and prednisolone groups [3/35, 8.57%] were not significantly different (odds ratio [OR] 2.07, 95% confidence interval [CI] 0.49-8.70; p = 0.31). The time to achieve symptomatic remission [normal stool frequency with absence of rectal bleeding] was similar (10 days, interquartile range [IQR 7-18.75] and 10 days [IQR 5-12.5] for tofacitinib and prednisolone, respectively; p = 0.25) in the two groups. One patient each in the tofacitinib and prednisolone group discontinued treatment due to development of pulmonary tuberculosis and pustular acne, respectively. One patient receiving tofacitinib developed herpes zoster, but did not require cessation of therapy. No serious adverse events or major adverse cardiovascular events were observed.

CONCLUSION

In patients with moderately active UC, there was no difference in the efficacy and safety of tofacitinib and oral prednisolone for induction of remission at 8 weeks.

TRAIL REGISTRATION

Clinical Trials Registry of India [CTRI/2021/10/037641].

Current perspectives on fecal microbiota transplantation in inflammatory bowel disease

Fecal microbiota transplantation (FMT) has emerged as a promising therapeutic modality within the domain of inflammatory bowel disease (IBD). While FMT has secured approval and demonstrated efficacy in addressing recurrent and refractory Clostridioides difficile infection, its application in IBD remains an area of active exploration and research. The current status of FMT in IBD reflects a nuanced landscape, with ongoing investigations delving into its effectiveness, safety and optimal implementation. Early-stage clinical trials and observational studies have provided insights into the potential of FMT to modulate the dysbiotic gut microbiota associated with IBD, aiming to mitigate inflammation and promote mucosal healing. However, considerable complexities persist, including variations in donor selection, treatment protocols and outcome assessments. Challenges in standardizing FMT protocols for IBD treatment are compounded by the dynamic nature of the gut microbiome and the heterogeneity of IBD itself. Despite these challenges, enthusiasm for FMT in IBD emanates from its capacity to address gut microbial dysbiosis, signifying a paradigm shift towards more comprehensive approaches in IBD management. As ongoing research progresses, an enhanced understanding of FMT's role in IBD therapy is anticipated. This article synthesizes the current status of FMT in IBD, elucidating the attendant challenges and aspiring towards the refinement of its application for improved patient outcomes.

Trends of inflammatory bowel disease from the Global Burden of Disease Study (1990-2019)

BACKGROUND

The global burden of inflammatory bowel disease (IBD) is reportedly increasing. Methodologies and datasets are routinely updated, allowing for more accurate estimates to guide healthcare policy.

METHODS

The Global Burden of Diseases, Injuries and Risk Factors Study (GBD) dataset was accessed and the trends in IBD at the global and regional levels from 1990 to 2019 were estimated for incidence, prevalence, deaths, years of life lost (YLL), years lived with disability (YLD) and disability-adjusted life-years (DALYs) per 100,000 population. The three decadal trends of the disease measures were calculated.

RESULTS

In 2019, there were 4.9 million (95% Uncertainty Interval [UI] 4.3-5.5) cases of IBD globally. The age-standardized prevalence and incidence rates decreased from 73.23 (95% UI 63.8-83.6) and 6.1 (95% UI 5.3-6.9) in 1990 to 59.2 (95% UI 52.7-66.4) and 4.9 (95% UI 4.4-5.6) in 2019, respectively. Like prior estimates, the highest age-standardized prevalence and incidence rates occurred in North America, but the lowest rates were reported in Oceania (209.5 [195.4-224.4] and 24.5 [22.6-26.7] and 3.87 [3.1-4.7] and 0.5 [0.5-0.7], respectively) and not the Caribbean, as previously reported. High socio-demographic index (SDI) locations had the highest age-standardized prevalence rate, though the rates declined in 2019 compared to 1990. The age-standardized prevalence and incidence rates increased in middle, low middle and low SDI quintiles over the three decades. The age-standardized rates for deaths, DALYs, YLD and YLL decreased globally from 1990 to 2019. Between 1990 and 2019 the total number of patients with IBD in India doubled from 0.13 million (95% UI 0.10-0.16) to 0.27 million (95% UI 0.21-0.33) with age-standardized incidence rate increasing from 2.23 (95% UI 1.85-2.73) to 2.34 (95% UI 1.95-2.86).

CONCLUSION

This analysis of the GBD 2019 database demonstrates that the overall global burden of IBD is lower than previously estimated, but an increasing disease burden is observed in the middle and low-SDI locations.

A duodenal mucosa transcriptome study identified reduced expression of a novel gene CDH18 in celiac disease

BACKGROUND

Celiac disease (CD) a complex immune disease that affects duodenal mucosa. Identification of tissue specific biomarkers is expected to improve the existing biopsy based CD diagnosis.

AIMS

To investigate the differentially expressed genes (DEGs) in duodenal mucosa tissue to identify clinically relevant gene expression pattern in CD.

METHODS

Whole RNA extracted from the duodenal biopsies of three CD patients and four non-CD controls were sequenced. Significant DEGs were identified. Prioritized DEGs were validated using qRT-PCR in an independent group (CD=23; Control=26). Enriched pathways were analyzed, protein-protein interaction networks were evaluated.

RESULTS

923 DEGs comprising of 135 up-regulated, and 788 down-regulated genes, with p-value≤0.05; log2FC>2 or <-2 were identified. A novel down-regulated gene CDH18 (p = 0.03; log2FC=-0.74) was identified. Previously known CXCL9 was replicated. CDH18, a trans-membrane protein was found to interact with other CDH proteins, α/β catenins, and other membrane transporters such as SLC and ABCB. Pathways and protein networks contributing in channel activity (p = 2.15E-12), membrane transporters (p = 2.15E-12), and cellular adhesion (p = 8.05E-6) were identified.

CONCLUSIONS

CDH18, a novel DEG identified in the present study is a pivotal gene involved in maintaining epithelial membrane organization and integrity. The functional significance of lower expression of CDH18 in pathogenesis of CD warranted to be investigated. CDH18 expression could be tested for its effectiveness in diagnostic, prognostic and therapeutic purposes.

Tofacitinib use in ulcerative colitis: An expert consensus for day-to-day clinical practice

Rising number of inflammatory bowel disease (IBD) cases in developing countries necessitate clear guidance for clinicians for the appropriate use of advanced therapies. An expert consensus document was generated to guide the usage of tofacitinib, a Janus kinase inhibitor, in ulcerative colitis. Tofacitinib is a useful agent for the induction and maintenance of remission in ulcerative colitis. It can be used in the setting of biological failure or even steroid-dependent and thiopurine refractory disease. Typically, the induction dose is 10 mg BD orally. Usually, clinical response is evident within eight weeks of therapy. In those with clinical response, the dose can be reduced from 10 mg BD to 5 mg BD. Tofacitinib should be avoided or used cautiously in the elderly, patients with cardiovascular co-morbidity, uncontrolled cardiac risk factors, previous thrombotic episodes and those at high risk for venous thrombosis or previous malignancy. Baseline evaluation should include testing for and management of hepatitis B infection and latent tuberculosis. Where feasible, it is prudent to ensure complete adult vaccination, including Herpes zoster, before starting tofacitinib. The use of tofacitinib may be associated with an increased risk of infections such as herpes zoster and tuberculosis reactivation. Maternal exposure to tofacitinib should be avoided during pre-conception, pregnancy, and lactation. There is emerging evidence of tofacitinib in acute severe colitis, although the exact positioning (first-line with steroids or second-line) is uncertain.

Tofacitinib in acute severe ulcerative colitis (TACOS): A randomized controlled trial: Tofacitinib in ASUC

BACKGROUND

Intravenous corticosteroids are the mainstay of treatment of patients hospitalized with acute severe ulcerative colitis (ASUC). However, 30%-40% of the patients are refractory to corticosteroids. We investigated whether addition of tofacitinib to corticosteroids improved the treatment responsiveness in patients with ASUC.

METHODS

This single center, double blind, placebo controlled trial randomized adult patients with ASUC (defined by Truelove Witts severity criteria) to receive either tofacitinib (10 mg thrice daily) or a matching placebo for 7 days while continuing intravenous corticosteroids (hydrocortisone 100 mg q6h). The primary end point was response to treatment (decline in Lichtiger index by >3 points, and an absolute score <10 for 2 consecutive days without the need for rescue therapy) by day 7. The key secondary outcome was the cumulative probability of requiring initiation of infliximab or undergoing colectomy within 90 days following randomization. All analyses were done in the intention-to-treat population.

RESULTS

A total of 104 patients were randomly assigned to a treatment group (53 to tofacitinib and 51 to placebo). At day 7, response to treatment was achieved in 44/53 (83.01%) patients receiving tofacitinib versus 30/51 (58.82%) patients receiving placebo (OR 3.42, 95% CI 1.37-8.48, p=0.007). The need for rescue therapy by day 7 was lower in the tofacitinib arm (OR 0.27, 95% CI 0.09-0.78, p=0.01). The cumulative probability of need for rescue therapy at day 90 was 0.13 in patients who received tofacitinib vs 0.38 in patients receiving placebo (Log Rank p=0.003). The majority of the treatment related adverse effects were mild. One patient, receiving tofacitinib, developed dural venous sinus thrombosis.

CONCLUSION

In patients with ASUC, combination of tofacitinib and corticosteroids improved treatment responsiveness and decreased the need for rescue therapy. Trial registration number: ISRCTN42182437.

Cardiovascular implications of inflammatory bowel disease: An updated review

Emerging data highlights the heightened risk of atherosclerotic cardiovascular diseases (ASCVD) in patients with chronic inflammatory disorders, particularly those afflicted with inflammatory bowel disease (IBD). This review delves into the epidemiological connections between IBD and ASCVD, elucidating potential underlying mechanisms. Furthermore, it discusses the impact of current IBD treatments on cardiovascular risk. Additionally, the cardiovascular adverse effects of novel small molecule drugs used in moderate-to-severe IBD are investigated, drawing parallels with observations in patients with rheumatoid arthritis. This article aims to comprehensively evaluate the existing evidence supporting these associations. To achieve this, we conducted a meticulous search of PubMed, spanning from inception to August 2023, using a carefully selected set of keywords. The search encompassed topics related to IBD, such as Crohn's disease and ulcerative colitis, as well as ASCVD, including coronary artery disease, cardiovascular disease, atrial fibrillation, heart failure, conduction abnormalities, heart blocks, and premature coronary artery disease. This review encompasses various types of literature, including retrospective and prospective cohort studies, clinical trials, meta-analyses, and relevant guidelines, with the objective of providing a comprehensive overview of this critical intersection of inflammatory bowel disease and cardiovascular health.

Multi-scale time-resolved electron diffraction: A case study in moiré materials

Ultrafast-optical-pump - structural-probe measurements, including ultrafast electron and x-ray scattering, provide direct experimental access to the fundamental timescales of atomic motion, and are thus foundational techniques for studying matter out of equilibrium. High-performance detectors are needed in scattering experiments to obtain maximum scientific value from every probe particle. We deploy a hybrid pixel array direct electron detector to perform ultrafast electron diffraction experiments on a WSe2/MoSe2 2D heterobilayer, resolving the weak features of diffuse scattering and moiré superlattice structure without saturating the zero order peak. Enabled by the detector's high frame rate, we show that a chopping technique provides diffraction difference images with signal-to-noise at the shot noise limit. Finally, we demonstrate that a fast detector frame rate coupled with a high repetition rate probe can provide continuous time resolution from femtoseconds to seconds, enabling us to perform a scanning ultrafast electron diffraction experiment that maps thermal transport in WSe2/MoSe2 and resolves distinct diffusion mechanisms in space and time.

Navigating Barriers and Challenges to Achieving Critical Career Milestones Among Faculty Mentees

For faculty members, job satisfaction, compensation, and career advancement hinge on achieving 'critical' career milestones (e.g., external funding, tenure). Faculty face unique barriers to achieving career milestones (Bagley et al., 2018), and therefore must employ tailored strategies to overcome challenges. The current project extends research on barriers to career milestones (Soller et al., 2022) to examine strategies faculty employ to overcome barriers in the pursuit of critical career milestones. Thirty-seven faculty members participated across eight US academic institutions, including 22 under-represented minorities in science (URM-S; women or racial/ ethnic minorities). Respondents identified critical career milestones they achieved or will pursue within the next 24 months and then discussed strategies used and suggestions for achieving milestones during semi-structured qualitative interviews. The research team conducted a thematic, qualitative, descriptive analysis of qualitative data using NVivo software in a systematic, interactive, team-based process. Four key strategies emerged for navigating barriers in the pursuit of critical career milestones: 1) Careful engagement of mentors and allies; 2) Collaborate and network; 3) Set boundaries and prioritize; and 4) Reflect on values and use personal strengths. Administrators should aim to remove structural barriers, particularly those that reduce equity (Davis et al., 2022). Identifying strategies that faculty employ to overcome challenges can enhance mentoring by helping mentors understand how mentees overcome unique challenges, particularly those that are not easily addressed through structural interventions.

Why Faculty Leaders Leave a School of Medicine?

Faculty attrition at academic health centers (AHCs) is significant at about 11% nationally, with one in five physicians intending to leave, and replacement costs averaging $500,000 per physician. Attrition among AHC faculty leaders is inadequately studied. This study compares reasons to leave between exiting faculty leaders and faculty non-leaders at the University of New Mexico School of Medicine (UNM SOM). The SOM deans interview all exiting faculty using a structured exit survey. 329 faculty non-leaders and 58 faculty leaders left UNM SOM between July 2017 and June 2022. Distributions of each variable were analyzed for statistically significant differences between the two groups using Fisher's 2-sided exact test. Text comments by leaders were analyzed qualitatively for content using a team-based, iterative process. As compared to non-leaders, exiting faculty leaders were more likely to be professors (51.7% vs 16.7%, p<0.001), and hold tenure (32.8% vs. 12.2%, p=0.001). Faculty leaders were more likely than non-leaders to cite high-level leadership as a reason to leave (41.4% vs. 24.3% p=0.01) and better leadership as a critical issue in development and retention (51.7% vs. 36.8% p=0.04). Qualitative analyses of textual leader comments showed a similar distribution of themes as the quantitative variables when examining open text related to the survey questions related to reasons to leave and the most critical issues. In addition, when asked what would need to change for them to return, qualitative data showed open-ended responses by exiting faculty leaders were twice as frequent to include leadership comments than those by non-leaders (34.2% vs. 16.2%). Exiting faculty leaders disproportionately cite high-level leadership as a reason to leave. The mediatory factors for this association are not known. Investigations to determine the causes for the study findings, and data-driven intervention strategies to retain faculty leaders at SOMs are needed.

Faculty Retention at a School of Medicine, 2010-2022

Faculty retention at academic health centers is a concern with about one-fifth of physicians reporting intentions to leave. We studied factors affecting faculty at risk for attrition, defined as women, racial/ethnic underrepresented minorities (URM), and clinical faculty. Identification of factors predicting retention of at-risk faculty may help mentors and minority-serving institutions devise novel targeted retention strategies. Our study site was a minority-serving institution in a majority-minority state in the US Southwest where at-risk faculty constitute the majority group. Faculty characteristics and departure dates were extracted from an institutional database maintained by the University of New Mexico (UNM) School of Medicine (SOM) for 2,427 participants employed from July 2009 through June 2022. Annual attrition rates and relative risk (RR) of attrition were estimated by discrete-time hazard rate models assuming a Poisson distribution. The overall annual attrition rate was 11.5%, which projects to 50% attrition in 6.0 years. Time to 50% attrition was 4.6 years for assistant professors, 8.9 years for associate professors 7.2 years for full professors. Faculty with a PhD degree had lower attrition (7.2%, RR=0.69, 95% CI 0.60, 0.79) compared to faculty with an MD degree (10.5%) in adjusted analyses. Clinician educators had a higher attrition rate (8.9%) compared to tenure track (6.4%, RRtenure track=0.72, 95% CI 0.61, 0.85). Black faculty had a higher risk of attrition compared to White faculty (RR=1.56, 95% CI 1.09, 2.25), and non-Hispanic White faculty had a lower risk of attrition (RR=0.83, 95% CI 0.71, 0.98). Annual attrition rates increased over the study period with most of the increase before about 2016. We did not detect significant differences in attrition due to sex or URM status.

Gender Differences in Self-reported Faculty Developmental Networks

Scholars have long recognized gender variation in social relationship dynamics. However, how gender shapes developmental networking relationships for career advancement, particularly among university faculty members, is understudied. This area of research is important since women comprise an increasing proportion of faculty and yet report receiving less mentoring and lower career satisfaction, productivity, and advancement than their male counterparts. This cross-sectional study assessed gender differences in self-reported dimensions of faculty participants' developmental networks by collecting information on relationships with developers, who are people who have taken concerted action and offered professional and personal guidance to help participants advance in their careers over the past year. The investigators used egocentric network data from an electronically administered Mentoring Network Questionnaire collected from 159 faculty involved in a mentoring intervention during the pandemic. Faculty were from multiple Southwest and Mountain West institutions. Statistical analyses were performed using the Chi-squared test, Wilcoxon rank-sum test, and unadjusted multilevel regression. Female faculty chose developers of lower gender diversity than male faculty (p=0.01). Compared to male faculty, female faculty reported receiving more psychosocial support from individual developers (p=0.03). Female faculty members' developers were more often characterized as friends and less often described as sponsors and allies than male faculty, based on relative levels of career and psychosocial support that individual developers provided (p<0.001). No gender differences were found in other network characteristics. Female faculty build developmental networks that have different factors compared to male faculty. Greater levels of psychosocial support and fewer allies and sponsors for female faculty may have long-term implications for differential career advancement for women vs. men in academic careers. Strategies to enhance networking should address gender differences and include a structured framework for assessing network gaps.

Inter-Rater Reliability of the Mentor Behavioral Interaction Rubric

An objective assessment of a mentor's behavioral skills is needed to assess the effectiveness of mentor training interventions in academic settings. The Mentor Behavioral Interaction (MBI) Rubric is a newly developed, content-valid, observational measure of a mentor's behavioral skill during single-episode interactions with a mentee. The purpose of this study was to assess the inter-rater reliability (IRR) of the MBI Rubric when used to assess video-recorded mentor-mentee interactions. Three of a pool of four faculty raters with expertise in mentor training synchronously rated 26 videos of mentor-mentee interactions using structured guidelines. The MBI Rubric includes six items (Part 1), each with ratings on a 3- or 4-point scale, and ten yes/no items (Part 2) that characterize the content of the interaction. After initial individual ratings were completed, the three raters met, reviewed disagreements, and reached decisions about final item scores by either consensus or majority vote. Mean total Part 1 scores ranged between 1.42-2.69. IRRs ranged from good (Part 1 IRR=0.67) to excellent (Part 2 IRR=0.83). No training effects were observed, with no decrease (i.e., showing less variability) in inter-rater standard deviations over time. Rater effects in initial individual scoring were observed, with a significant difference between one vs. the other three raters on Part 1 individual scores, with no effects for Part 2 scores. Raters tended to score lower on initial individual scores than the final score for both Part 1 and 2. The MBI Rubric is the first observational measure to assess single episodes of video-recorded mentor-mentee interactions and has demonstrated content validity, and now inter-rater reliability. It may be used in parallel with other instruments to measure the efficacy of mentor training. Limitations include possible ceiling effects, and resource-intensive administration in terms of rater expertise and time. Future work will assess the responsiveness of the Rubric to change in mentor skill and construct validity.

Curriculum-based Faculty Training in Networking: Knowledge and Self-efficacy Outcomes

Although the advantages of developmental networks are well-known, most faculty do not know how to participate in such networks actively. Additionally, institutions face challenges in teaching faculty the best practices of networking. This deficiency constitutes a critical gap in the literature, which may slow career advancement for faculty, particularly from underrepresented groups. The study's purpose was to examine the effectiveness of a curriculum-based faculty training in developmental networks, utilizing the Extension for Community Health Outcomes (ECHO) platform. In this pre-post study, 33 faculty members participated in the intervention utilizing eight modules involving four competencies. Each module followed a standard format, including a short didactic, two facilitated case study discussions based on real-life scenarios, and self-reading of selected literature. Outcomes included (i) change in knowledge scores obtained from two questions per module and (ii) self-efficacy scores measured on a scale of 0-100. Paired student's t-test and mixed model regression analyses were used. A significant increase in knowledge score was documented using mixed model regression for 4 of the eight modules (mean change score 0.4-0.8, p≤0.03 for all analyses). The proportion of faculty participants reporting correct knowledge items for all modules increased from 49.8% (pre) to 64.3% (post), which was statistically significant (p<0.001). Significant increases in paired self-efficacy scores were reported for each of the eight modules (mean change score 17-37, p<0.05 for all analyses). This study highlights the importance of curriculum-based training in networking. Participants showed a significant increase in pre-post networking self-efficacy and knowledge scores. Our ECHO-based curriculum, facilitator training, and manual enable easy implementation in other institutions, ensuring scalability and adaptability. Our analysis provides the evidence basis for examining the impact of a developmental network intervention in enhancing individual career networks.

Inequity Analysis in Faculty Recognition Awards at a School of Medicine

As part of developmental networks, sponsors help provide recognition and visibility opportunities to their faculty protégés. Recognition awards given to the School of Medicine (SOM) faculty are an important mechanism for acknowledging what is valued in academic medicine. Beyond their impact on individual careers, awards help define the culture and climate of an organization. The literature suggests inequities in recognition awards for women and racial/ethnic underrepresented minority faculty. The study's purpose was to examine the characteristics of the awardees relative to the SOM faculty in a minority-serving institution in a minority-majority state. In this observational cross-sectional study, 47 SOM faculty were recognized between 2000-2023 as Regents' Lecturers (9), Regents' Professors (20), Community Engagement Awardees (5), and Gold-headed Cane Awardees (13). SOM sought nominations which a search committee competitively reviewed. Award recipients were characterized by their department, rank, academic track, degree, country of origin, sex, and race/ethnicity, and were compared to all SOM faculty. Male faculty were more likely than women faculty to receive an award (p=0.04). Faculty with tenure, Ph.D. degree, or Professor rank were more likely to receive an award than their counterparts (p<0.001, all analyses). Faculty in basic and diagnostic specialties were more likely to receive an award than medical or surgical specialties (p<0.001). Although rates of awards for racial/ethnic URM faculty were about half that of non-URM faculty, this difference did not reach statistical significance (p=0.14). In addition to demonstrating sex-related inequity in awards, recognized faculty are traditionally associated with the scholarship of discovery compared to other models of scholarship or clinical activity. Sponsors should promote women, physicians, and clinician educators for recognition awards to advance their academic careers. SOM leaders need to examine award criteria and processes to ensure recognition of the diversity of talents and achievements that are critical to the future of academic medicine.

Mentoring Network Questionnaire Support Scales Reliable and Valid with University Faculty

The Developmental Network Questionnaire (DNQ) is used in business to self-assess relationships with developers, or people who support one's career. The Mentoring Network Questionnaire (MNQ) is an online modification of the DNQ and includes two scales that rate developer's contributions to career or psychosocial help. The psychometrics of these scales for different populations are unreported. This study analyzed the construct validity and reliability of the two scales measuring support provided by developers of university faculty. Mentors and mentees (G=156) from multiple Southwestern and Mountain West universities rated 741 developers on the MNQ's five-item career- and psychosocial-support scales. Participants responded on a seven-point scale ranging from "never, not at all" to "to the maximum extent possible." Multilevel confirmatory factor analysis (MCFA) using Mplus and the multi-level reliability coefficient omega assessed construct validity and internal consistency reliability, respectively. Results supported the validity of two latent constructs of career- and psychosocial support, each measured by the established five-item scale: Comparative fit index (CFI)=.93, Tucker-Lewis Index (TLI)=.91, root mean square error of approximation (RMSEA)=.06, standardized root mean square residual (SRMR): W=.09, B=.10. The measurement model was improved when the "removes barriers" item was removed from the career-support scale (CFI=.96, TLI=.95, RMSEA=.05, SRMR: W=.06 B=.09. Factor loadings at both the within- and between-levels were strong and statistically significant. Reliability omegas ranged from .85 to .92. Career and psychosocial support provided to university faculty by developers in their networks may be validly and reliably measured at both the within- and between-levels by a modified four-item career support scale and the original five-item psychosocial support scale from the DNQ and the modified MNQ. Limitations include reduced statistical power due to small sample size and lack of testing at the university level. Future work will assess the responsiveness of these scales to measuring change over time in the amount of support provided.

Analysis of Clinical Trial Screen Failures in Inflammatory Bowel Diseases (IBD): Real World Results from the International Organization for the study of IBD

BACKGROUND

Recruitment for randomized controlled trials (RCTs) in IBD have substantially dropped over time. This study aimed to assess reasons why IBD patients are not included in sponsored multicenter phase IIb-III RCTs.

METHODS

All IOIBD members (n=58) were invited to participate. We divided barriers to participation as follow: 1) reasons patients with active IBD were not deemed appropriate for a RCT; 2) reasons qualified patients did not wish to participate; 3) reasons for screen failure (SF) in patients agreeing to participate. We assess those in a 4-week prospective study including, consecutively, all patients with symptomatic disease for whom a treatment change was required. In addition, we performed a 6-month retrospective study to further evaluate reasons for SF.

RESULTS

A total of 106 patients (60 male (56.6%), 63 Crohn's disease [CD] (59.4%)), from 10 centers across the world, were included in the prospective study. A RCT has not been proposed to 65 of them (mainly due to eligibility criteria). Of the 41 patients to whom a RCT was offered, 8 refused (mainly due to reluctance to receive placebo) and 28 agreed to participate. Among these 28 patients, 5 failed their screening and 23 were finally included in a RCT. A total of 107 patients (61 male (57%), 67 CD (62.6%)), from 13 centers worldwide, were included in our retrospective study of SFs. The main reason was insufficient disease activity.

CONCLUSION

This first multicenter study analyzing reasons for non-enrollment in IBD RCTs shown that we lose patients at each step. Eligibility criteria, the risk of placebo assignment and insufficient disease activity were part of the main barriers.

Inflammatory Bowel Disease and X (Formerly Twitter) Influencers: Who Are They and What Do They Say?

Background and objective More than half of the population suffering from inflammatory bowel disease (IBD) use the internet as a primary source of information on their condition. X (formerly Twitter) has been increasingly used to disseminate healthcare-related information. In this study, we aimed to identify top influencers on the topic of IBD on X and correlate the relevance of their social media engagements with their professional expertise or academic productivity. Methods X (formerly Twitter) influence scores for the search topic IBD were obtained using Cronycle API, a proprietary software employing multiple algorithms to rank influencers. Data regarding gender, profession, location, and research productivity represented as h-index was collected. Results We collected information on the top 100 IBD influencers on X. The majority of influencers were gastroenterologists, followed by IBD advocates. Of note, 62% of the IBD influencers were from the US followed by the UK and Canada. A positive correlation was observed between the X topic score and the h-index of the influencer (r=+0.488, p<0.001) Conclusions The strong correlation observed between the X topic score and h-index suggests that social media is a viable platform for gaining information regarding IBD. Further research aimed at counteracting misleading information by providing facts and data in a succinct manner about IBD on social media is required to improve disease awareness.

Low prevalence of primary sclerosing cholangitis in patients with inflammatory bowel disease in India

BACKGROUND/AIMS

Primary sclerosing cholangitis (PSC) represents the most common hepatobiliary extraintestinal manifestation of inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD). Limited data exist on PSC in patients with IBD from India. We aimed to assess the prevalence and disease spectrum of PSC in Indian patients with IBD.

METHODS

Database of IBD patients at 5 tertiary care IBD centers in India were analyzed retrospectively. Data were extracted and the prevalence of PSC-IBD was calculated.

RESULTS

Forty-eight patients out of 12,216 patients with IBD (9,231 UC, 2,939 CD, and 46 IBD unclassified) were identified to have PSC, resulting in a prevalence of 0.39%. The UC to CD ratio was 7:1. Male sex and pancolitis (UC) or colonic CD were more commonly associated with PSC-IBD. The diagnosis of IBD preceded the diagnosis of PSC in most of the patients. Majority of the patients were symptomatic for liver disease at diagnosis. Eight patients (16.66%) developed cirrhosis, 5 patients (10.41%), all UC, developed malignancies (3 colorectal cancer [6.25%] and 2 cholangiocarcinoma [4.16%]), and 3 patients died (2 decompensated liver disease [4.16%] and 1 cholangiocarcinoma [2.08%]) on follow-up. None of the patients mandated surgical therapy for IBD.

CONCLUSIONS

Concomitant PSC in patients with IBD is uncommon in India and is associated with lower rates of development of malignancies.

Clinical and magnetic resonance imaging spectrum of complex perianal fistulizing Crohn's disease: A cohort study from northern India

BACKGROUND

Fistulizing perianal Crohn's disease (CD) is a debilitating condition associated with significant morbidity and reduction in the quality of life. Magnetic resonance imaging (MRI) of the pelvis is the preferred imaging modality for the comprehensive assessment of the perianal fistula. There is a paucity of data from India on the MRI spectrum of complex perianal fistula in CD.

METHODS

A single-centre cross-sectional analysis of patients with fistulizing perianal CD, who underwent pelvic MRI between January 2020 and December 2021, was performed. The clinical (age, sex, disease duration, disease location and behavior, disease activity [Perianal Disease Activity Index, PDAI] and treatment received) and radiological (number and location of fistulae, extensions, number and location of internal and external openings, fistula activity, presence or absence of perianal abscess and associated proctitis) characteristics of complex perianal fistula (defined according to the American Gastroenterological Association classification) were recorded.

RESULTS

Of total 175 patients with CD who attended the gastroenterology clinic during the study period, 27 (15.42%) (mean age 42±15.5 years, 62.96% females and median disease duration four years) had complex perianal fistula and were included in the analysis. The mean PDAI was 5.48±2.53. The median Van Assche Index was 17 (interquartile range [IQR] 13-19). A majority (96.29%) of the fistulae were trans-sphincteric and four (14.81%) fistulae extended into the supralevator space. All fistulae were active on MRI. Concomitant perianal abscess and proctitis were seen in 59.26% (n=16) and 62.96% (n=17) of patients, respectively. Combination therapy with biologics and antibiotics/immune-suppressants were the most commonly prescribed medical therapy. Six (22.22%) patients underwent combined medical and surgical (non-cutting seton, fistulectomy, fecal diversion) treatment.

CONCLUSION

The cumulative risk of the development of fistulizing perianal CD in a northern Indian cohort was similar to the western populations. Complex perianal fistulae were predominantly trans-sphincteric and commoner in females. MRI evaluation is pivotal for the delineation of fistula anatomy, assessment of disease extent and activity and the evaluation of concomitant perianal abscess and other complications.

Colonic Lipoma: A Rare Cause of Intussusception

The most common and challenging chief complaint in the emergency department is abdominal pain. Intussusception, although rare in adults, is an important etiology to consider. The diagnosis is often delayed because of the nonspecific symptoms, especially in adults. This case highlights a rare case of intussusception in a middle-aged male with a colonic lipoma as a leading point. Endo-loop was applied to the colonic lipoma, leading to the resolution of intussusception. Therefore, this can be an effective alternative to surgery in select cases.

Management of Perianal Fistulizing Crohn's Disease

Perianal fistulizing Crohn's disease (CD) represents a severe phenotype of CD that is associated with significant morbidity and reduction in quality of life. Perianal fistulizing CD is caused by a complex interplay of genetic predisposition, immune dysregulation, gut dysbiosis, and various unknown physiological and mechanical factors. A multidisciplinary approach is hence required for optimal management . A detailed anatomical description and classification of perianal fistula, including comprehensive clinical, endoscopic, and radiological diagnostic workup, is an important prerequisite to treatment. For simple perianal fistulas, use of antibiotics and immunomodulators, with or without fistulotomy, are appropriate measures. The medical management of complex perianal fistula, on the other hand, requires adequate control of infection before initiation of therapy with immunomodulators. In active complex perianal fistula, anti-tumor necrosis factors remain the most accepted therapy, with concomitant use of antibiotics or immunomodulators enhancing the efficacy. For patients refractory to anti-tumor necrosis factors, treatment with anti-integrins, anti-interleukins, and small molecules is being evaluated. Mesenchymal stem cells, hyperbaric oxygen therapy, and exclusive enteral nutrition have also been investigated as adjunct therapies. Despite the expansion of the medical armamentarium, a large proportion of the patients require surgical interventions. In this review, we provide an up-to-date overview of the pathophysiology, clinical presentation, diagnosis, and medical management of perianal fistulizing CD. A brief overview of the surgical management of perianal fistulizing CD is also provided.

Lenvatinib-Induced Tumor Lysis Syndrome in Advanced Hepatocellular Carcinoma

This case report describes a 48-year-old man with hepatocellular carcinoma who developed tumor lysis syndrome (TLS) after 7 days of starting lenvatinib therapy. The patient was hospitalized and received appropriate interventions, including aggressive hydration, allopurinol, rasburicase, and electrolyte management. The patient's condition improved, and he was eventually discharged from the hospital. This case highlights the potential risk of TLS in patients with hepatocellular carcinoma receiving lenvatinib therapy, even after a short duration, and emphasizes the importance of early recognition and management of TLS to prevent serious complications.

Identifying the early predictors of non-response to steroids in patients with flare of autoimmune hepatitis causing acute-on-chronic liver failure

BACKGROUND AND AIMS

Early identification of non-response to steroids is critical in patients with autoimmune hepatitis (AIH) causing acute-on-chronic liver failure (ACLF). We assessed if this non-response can be accurately identified within first few days of treatment.

METHODS

Patients with AIH-ACLF without baseline infection/hepatic encephalopathy were identified from APASL ACLF research consortium (AARC) database. Diagnosis of AIH-ACLF was based mainly on histology. Those treated with steroids were assessed for non-response (defined as death or liver transplant at 90 days for present study). Laboratory parameters, AARC, and model for end-stage liver disease (MELD) scores were assessed at baseline and day 3 to identify early non-response. Utility of dynamic SURFASA score [- 6.80 + 1.92*(D0-INR) + 1.94*(∆%3-INR) + 1.64*(∆%3-bilirubin)] was also evaluated. The performance of early predictors was compared with changes in MELD score at 2 weeks.

RESULTS

Fifty-five out of one hundred and sixty-five patients (age-38.2 ± 15.0 years, 67.2% females) with AIH-ACLF [median MELD 24 (IQR: 22-27); median AARC score 7 (6-9)] given oral prednisolone 40 (20-40) mg per day were analyzed. The 90 day transplant-free survival in this cohort was 45.7% with worse outcomes in those with incident infections (56% vs 28.0%, p = 0.03). The AUROC of pre-therapy AARC score [0.842 (95% CI 0.754-0.93)], MELD [0.837 (95% CI 0.733-0.94)] score and SURFASA score [0.795 (95% CI 0.678-0.911)] were as accurate as ∆MELD at 2 weeks [0.770 (95% CI 0.687-0.845), p = 0.526] and better than ∆MELD at 3 days [0.541 (95% CI 0.395, 0.687), p < 0.001] to predict non-response. Combination of AARC score > 6, MELD score > 24 with SURFASA score ≥ - 1.2, could identify non-responders at day 3 (concomitant- 75% vs either - 42%, p < 0.001).

CONCLUSION

Baseline AARC score, MELD score, and the dynamic SURFASA score on day 3 can accurately identify early non-response to steroids in AIH-ACLF.

Infectious complications in patients with inflammatory bowel disease in Asia: the results of a multinational web-based survey in the 8th Asian Organization for Crohn's and Colitis meeting

BACKGROUND/AIMS

Infectious complications are major concerns when treating patients with inflammatory bowel disease (IBD). This study evaluated clinical differences across countries/regions in the management of infectious diseases in patients with IBD.

METHODS

A multinational online questionnaire survey was administered to participants at the 8th meeting of the Asian Organization for Crohn's and Colitis. The questionnaire included questions regarding surveillance, diagnosis, management, and prevention of infection in patients with IBD.

RESULTS

A total of 384 physicians responded to the questionnaire. The majority of Korean (n=70, 63.6%) and Chinese (n=51, 51.5%) physicians preferred vancomycin to metronidazole in the treatment of Clostridium difficile infection, whereas more than half of the Japanese physicians (n=62, 66.7%) preferred metronidazole. Physicians in Korea (n=88, 80.0%) and China (n=46, 46.5%) preferred a 3-month course of isoniazid and rifampin to treat latent tuberculosis infection, whereas most physicians in Japan (n=71, 76.3%) favored a 9-month course of isoniazid. Most Korean physicians (n=89, 80.9%) recommended hepatitis B virus (HBV) vaccination in patients lacking HBV surface antigen, whereas more than half of Japanese physicians (n=53, 57.0%) did not consider vaccination.

CONCLUSIONS

Differences in the diagnosis, prevention, and management of infections in patients with IBD across countries/regions reflect different prevalence rates of infectious diseases. This survey may broaden understanding of the real-world clinical settings across Asian countries/regions and provide information for establishing practical guidelines to manage patients with IBD.

Fibrolamellar hepatocellular carcinoma presenting as cholestatic jaundice: An unusual presentation of a rare disease

Fibrolamellar hepatocellular carcinoma is a rare primary hepatic tumor that usually occurs in youth. The common presenting features are vague abdominal pain, nausea, vomiting and weight loss. We present a case report of a young male who presented with cholestatic jaundice and on evaluation was diagnosed to have fibrolamellar hepatocellular carcinoma. He underwent successful surgical resection of the tumor. In young individuals presenting with unexplained cholestasis, fibrolamellar hepatocellular carcinoma should be considered.

Celiac disease-associated loci show considerable genetic overlap with neuropsychiatric diseases but with limited transethnic applicability

Clinical and public health research has revealed the co-occurrence of several neuropsychiatric diseases among patients with celiac disease (CD). The significant presence of CD-specific autoantibodies in patients with neuropsychiatric diseases and vice versa are often reported. To explain the genetic basis of such frequent disease co-occurrence and investigate the underlying common pathways/processes, we performed an extensive cross-disease association study followed by supporting in silico functional validation of the leads. Genomewide association study (GWAS) data for CD and eight commonly co-occurring neuropsychiatric diseases from Caucasian populations were analysed, and the shared loci were determined.We performed Immunochip-based fine mapping of these overlapping association signals in an independent European CD data and tested their cross-ethnic transferability using CD association data from the genetically distinct north Indian population. This study identified 12 shared loci between the two diseases with genomewide significance (P = 5e-8). Of these five loci, namely NFIA, KIA1109, NOTCH4-TSBP1-PBX2, HLA-DQA1 and CSK replicated in an independent Dutch cohort representing European ancestry. Three of these loci, namely NFIA, NOTCH4-TSBP1-PBX2 and HLA-DQA1 that are common between CD, anxiety, migraine and schizophrenia respectively withstood locus transferability test in north Indians. Tissue-specific eQTL analysis of SNPs from transferable loci revealed expression QTL effects in brain tissue besides the small intestine and whole blood. Pathway analysis and evidence of epigenetic regulation highlighted the potential contribution of these SNPs to disease pathology. The replicable and transferable association of genetic variants from MHC locus and their functional implications suggest the process of antigen presentation and adaptive/innate immune response regulated by non-HLA genes in the locus may dominate the shared pathogenesis of CD and neuropsychiatric diseases. Functional validation of the shared candidate genes is warranted to unravel the molecular mechanism for the co-occurrence of CD and specific neuropsychiatric diseases.

Evaluation of Nutritional Characteristics Reveals Similar Prevalence of Malnutrition in Patients with Ulcerative Colitis and Crohn's Disease

BACKGROUND

Inflammatory bowel disease (IBD) is associated with an increased risk of malnutrition and sarcopenia.

AIMS

To evaluate the nutritional status of patients with IBD and determine the threshold values of different parameters of nutritional assessment to identify malnutrition.

METHODS

This was a single-centre cross-sectional analysis of adult patients with IBD [ulcerative colitis (UC) and Crohn's disease (CD)] who underwent anthropometry [body mass index (BMI), mid upper arm circumference (MUAC) and triceps-fold thickness (TSF)], body composition analysis and assessment for sarcopenia [hand-grip strength and skeletal muscle index (SMI) at L3 vertebral level)]. Age- and gender-matched healthy adults served as controls. Malnutrition was defined according to the European Society of Clinical Nutrition and Metabolism (ESPEN) criteria.

RESULTS

A total of 406 patients [336 (82.76%) UC and 70 (17.24%) CD; mean age 40.56 ± 13.67 years; 215 (52.95%) males] with IBD and 100 healthy controls (mean age 38.69 ± 10.90 years; 56 (56%) males) were enrolled. The mean BMI, MUAC, TSF thickness, fat and lean mass, hand-grip strength, and SMI at L3 vertebral level were lower in patients with IBD compared to controls. The prevalence of malnutrition was similar in UC and CD [24.40% (n = 82) and 28.57% (n = 20), respectively (p = 0.46)]. Thresholds for fat mass in females (15.8 kg) and visceral fat index in males (0.26) were both sensitive and specific to detect malnutrition. The cutoff values of MUAC and TSF thickness to identify malnutrition were 23.25 cm and 25.25 cm, and 16.50 mm and 8.50 mm, in females and males, respectively.

CONCLUSION

Malnutrition and sarcopenia were common in patients with IBD, with the prevalence being similar in patients with both UC and CD.

APASL-ACLF Research Consortium-Artificial Intelligence (AARC-AI) model precisely predicts outcomes in acute-on-chronic liver failure patients

BACKGROUND AND AIMS

We hypothesized that artificial intelligence (AI) models are more precise than standard models for predicting outcomes in acute-on-chronic liver failure (ACLF).

METHODS

We recruited ACLF patients between 2009 and 2020 from APASL-ACLF Research Consortium (AARC). Their clinical data, investigations and organ involvement were serially noted for 90-days and utilized for AI modelling. Data were split randomly into train and validation sets. Multiple AI models, MELD and AARC-Model, were created/optimized on train set. Outcome prediction abilities were evaluated on validation sets through area under the curve (AUC), accuracy, sensitivity, specificity and class precision.

RESULTS

Among 2481 ACLF patients, 1501 in train set and 980 in validation set, the extreme gradient boost-cross-validated model (XGB-CV) demonstrated the highest AUC in train (0.999), validation (0.907) and overall sets (0.976) for predicting 30-day outcomes. The AUC and accuracy of the XGB-CV model (%Δ) were 7.0% and 6.9% higher than the standard day-7 AARC model (p < .001) and 12.8% and 10.6% higher than the day 7 MELD for 30-day predictions in validation set (p < .001). The XGB model had the highest AUC for 7- and 90-day predictions as well (p < .001). Day-7 creatinine, international normalized ratio (INR), circulatory failure, leucocyte count and day-4 sepsis were top features determining the 30-day outcomes. A simple decision tree incorporating creatinine, INR and circulatory failure was able to classify patients into high (~90%), intermediate (~60%) and low risk (~20%) of mortality. A web-based AARC-AI model was developed and validated twice with optimal performance for 30-day predictions.

CONCLUSIONS

The performance of the AARC-AI model exceeds the standard models for outcome predictions in ACLF. An AI-based decision tree can reliably undertake severity-based stratification of patients for timely interventions.

AARC score determines outcomes in patients with alcohol-associated hepatitis: a multinational study

BACKGROUND AND AIM

Acute-on-chronic liver failure (ACLF) is a severe form of alcoholic hepatitis (SAH). We aimed to study the natural course, response to corticosteroids (CS), and the role of the Asian Pacific Association for the Study of Liver (APASL) research consortium (AARC) score in determining clinical outcomes in AH patients.

METHODS

Prospectively collected data from the AARC database were analyzed.

RESULTS

Of the 1249 AH patients, (aged 43.8 ± 10.6 years, 96.9% male, AARC score 9.2 ± 1.9), 38.8% died on a 90 day follow-up. Of these, 150 (12.0%) had mild-moderate AH (MAH), 65 (5.2%) had SAH and 1034 (82.8%) had ACLF. Two hundred and eleven (16.9%) patients received CS, of which 101 (47.87%) were steroid responders by day 7 of Lille's model, which was associated with improved survival [Hazard ratio (HR) 0.15, 95% CI 0.12-0.19]. AARC-ACLF grade 3 [OR 0.28, 0.14-0.55] was an independent predictor of steroid non-response and mortality [HR 3.29, 2.63-4.11]. Complications increased with degree of liver failure [AARC grade III vs. II vs I], bacterial infections [48.6% vs. 37% vs. 34.7%; p < 0.001); extrahepatic organ failure [66.9% vs. 41.8% vs. 35.4%; p < 0.001] respectively. The AARC score better discriminated 90-day mortality. Harrell's C-index was 0.72 compared to other scores.

CONCLUSION

Nearly 4 of 5 patients with AH present with ACLF. Such patients have a higher risk of infections, organ failures, lower response to CS, and higher mortality. Patients with AH and ACLF with AARC grade 3 should be considered for an early liver transplant.

Organizations' Mentoring Culture is Associated With Mentoring Climate and Involvement

Organizational culture is the shared, often unspoken, basic values, beliefs, and assumptions. Underlying culture influences organizational climate, the observable policies, practices, and procedures that faculty experience. Yet little is known about mentoring culture and climate in higher education. The purpose of this study was to a) conduct a psychometric evaluation of the 4-item Organizational Culture Mentoring Values (OCuM-V) scale and b) determine if organizational culture, operationalized as values related to mentoring, is associated with organizational mentoring climate (OMC) and involvement with mentoring. 298 [55 under-represented minority (URM)] faculty from University of New Mexico and Arizona State University completed a cross-sectional survey, including the OCuM-V scale and the 15-item OMC Availability (OMCA) scale. Items for both scales were rated No (1), Don't know (0), or Yes (1). Faculty reported if they were being mentored or providing mentoring. Exploratory factor analysis (EFA) and Cronbach's alpha were used for scale evaluation. Spearman correlation and logistic regression were used to assess OCuM-V association with climate and mentoring involvement, respectively. Overall, 24% of faculty were being mentored (27% for URM), and 43% were mentoring (38% for URM). OCuM-V items loaded on a single factor in EFA (Cronbach's alpha=0.84 for all; 0.88 for URM). OCuM-V was positively correlated with OMCA (including institutional expectations, mentor-mentee relationships, and resources subscales) for both all and URM faculty (r>0.4 p<.001 for all). Greater OCuM-V was associated with an increased odds of being mentored (OR=1.75±1.19-2.61) and providing mentoring (OR=1.83±1.30-2.58). Mentoring culture is associated with mentoring climate. Faculty who perceive stronger OCuM-V report a stronger OMC (available structure, programs/activities, policies/guidelines) and are being mentored or providing mentoring more often. Limitations include a small sample size for the URM group and cross-sectional data collection. Organizational leaders should explicitly promote values related to mentoring to strengthen both mentoring culture and climate at their institutions.

The Pandemic Effect on Faculty Attrition at a School of Medicine

Mentors at Academic Health Centers (AHC) are challenged by mentee attrition, with one in five physicians reporting an intent to leave in 2020. AHCs struggle with physician replacement costs, which are exorbitant. Data-driven efforts to mitigate attrition during the pandemic require an understanding of reasons to leave. This study compares characteristics of exiting faculty at the University of New Mexico School of Medicine (UNM SOM) two years before to two years after April 1, 2020. Demographic and reason to leave variables from exit interviews of 168 faculty that left UNM SOM between April 2018-to-March 2020 and 151 faculty that left between April 2020-to-March 2022 were compared. Exiting faculty were stratified into those resigning vs. retiring. Distributions of each variable were analyzed for statistically significant differences using a chi-square or Fisher's 2-sided exact test. The pandemic was associated with an approximately three-fold higher proportion of retirement contributing to total attrition than before (25.8% vs. 8.9%; p<0.001). Among those who resigned, the pandemic was associated with a higher proportion of physicians than before (84.3% vs. 72.8%; p=0.03). Hispanic faculty may be more likely to resign during the pandemic than before (p=0.06). Those who resigned during the pandemic may be significantly less likely to cite "inadequate adherence to FTE" or a "challenging work environment" (p= 0.048 and 0.053 respectively) but more likely to cite personal family matters (p=0.06) as reasons to leave than before the pandemic. The increased proportion of retirees during the pandemic presents challenges for AHCs by exacerbating the current shortage of mentors while providing leadership opportunities for those retained. Mentors need to be aware of the top reasons for faculty leaving (which have not materially changed during the pandemic): challenging work environment, personal/family matters, inadequate work-life balance, greater career opportunities, and inadequate salary.

A Qualitative Review of Comments by Faculty Who Cite Work-Life Balance as a Reason to Leave

Despite growing evidence for the need for work-life balance (WLB) for faculty at academic health centers, mentors frequently do not know how to advise their mentees on this topic. WLB impacts job satisfaction and intent to stay, and physicians are particularly at risk. In this study, we explored exit survey comments of faculty of the University of New Mexico School of Medicine citing work-life balance as a reason to leave (WLB-ARTL). Between July 2017 and December 2020, 59 faculty provided open-ended survey responses related to reasons for leaving, what they liked and disliked about being faculty, mentorship, and more. Using a qualitative descriptive design, we analyzed open-ended responses using a systematic, iterative, thematic approach via NVIVO software. We classified themes using Shanafelt's drivers of engagement and burnout: workload/job demands; efficiency/ resources; meaning in work; culture/values; control/flexibility; social support/community at work; and work-life integration. While there were numerous quotes across all themes, we chose to summarize emergent codes with the most faculty representation and those that can most easily be addressed through mentorship: career development, culture and people, and hours and schedule (related to themes of meaning in work, culture and values, community at work, work-life integration, and control and flexibility). To improve faculty retention, institutional leaders should focus on developing mentors' career coaching and mentoring skills. Additional focus should be placed on training mentors to discuss and address WLB among their faculty mentees.

Barriers and Challenges for Career Milestones Among Faculty Mentees

'Critical' career milestones for faculty (e.g., tenure, securing grant funding) relate to career advancement, job satisfaction, service/leadership, scholarship/research, clinical or teaching activities, professionalism, compensation, and work-life balance. However, barriers and challenges to these milestones encountered by junior faculty have been inadequately studied, particularly those affecting underrepresented minorities in science (URM-S). Additionally, little is known about how barriers and challenges to career milestones have changed during the COVID-19 pandemic for URM-S and non-URM faculty mentees in science. In this study, we conducted semi-structured interviews with 31 faculty mentees from four academic institutions (located in New Mexico, Arizona, Idaho, and Hawaii), including 22 URM-S (women or racial/ethnic). Respondents were given examples of 'critical' career milestones and were asked to identify and discuss barriers and challenges that they have encountered or expect to encounter while working toward achieving these milestones. We performed thematic descriptive analysis using NVivo software in an iterative, team-based process. Our preliminary analysis identified five key themes that illustrate barriers and challenges encountered: Job and career development, Discrimination and a lack of workplace diversity; Lack of interpersonal relationships and inadequate social support at the workplace; Personal and family matters; and Unique COVID-19-related issues. COVID-19 barriers and challenges were related to online curriculum creation and administration, interpersonal relationship development, inadequate training/service/conference opportunities, and disruptions in childcare and schooling. Although COVID-19 helped create new barriers and challenges for junior faculty mentees, traditional barriers and challenges for 'critical' career milestones continue to be reported among our respondents. URM-S respondents also identified discrimination and diversity-related barriers and challenges. Subsequent interviews will focus on 12-month and 24-month follow-ups and provide additional insight into the unique challenges and barriers to 'critical' career milestones that URM and non-URM faculty in science have encountered during the unique historical context of the COVID-19 pandemic.

Development and Content Validity Testing of the Mentor Behavioral Interaction Rubric

Many mentor training interventions in higher education focus on improving interactions between mentors and mentees. Existing measures of interactions are based on reported perceptions of the mentor or mentee. However, there are currently no objective assessments of the mentor's behavioral skill. The purpose of this study was to develop a Mentor Behavioral Interaction (MBI) Rubric as a measure of a mentor's behavioral skill during single-episode interactions with a mentee. Subsequently, the content validity was assessed. The six items (Part 1), evaluated by five mentoring experts as quantifiable behaviors in any mentor-mentee interaction, were based on the Mentoring Competency Assessment (Fleming et al., 2013). The experts developed scoring criteria (highest, middle, and lowest performance) for each item, and created another eleven items (Part 2) to characterize the content (yes/no) of the interaction. Seven content experts rated the items and scoring criteria using a scale ranging from very (4) to not relevant (1) (Lynn, 1986). Five of the six Part 1 items and scoring criteria, and nine of the eleven Part 2 items had item content validity indices (I-CVI) ≥ 0.86. The Part 1 "motivates" item and scoring, and the Part 2 "personal/professional preferences" item were revised based on expert recommendations. One Part 2 item was deleted. Average scale content validity indices (S-CVI/Ave) were ≥ 0.90. The MBI Rubric is the first measure developed to assess single episodes of videoed mentor-mentee interactions. The Rubric may be used with other measures to assess the effectiveness of mentor training. Limitations include: evaluation of the mentor's behavior without accounting for the mentee's behavior; inability to infer cognitive processes; and focus on the quality of one interaction, rather than the effectiveness of the relationship over time. Future work will assess inter-rater reliability, sensitivity to change, and construct validity for the Rubric.