INTRODUCTION:Clinical algorithms are integral to decision-making in gastroenterology, yet the inclusion of sex as a variable remains underexamined. We applied the Fairness Assessment in Representing Sex (FAIRS) framework to evaluate the medical, ethical, and equity implications of sex-based variables in adult gastroenterology algorithms. METHODS:Of 184 algorithms reviewed, 11 met inclusion criteria by explicitly incorporating sex or gender. The FAIRS framework was applied to these algorithms. RESULTS:Using FAIRS, 10 algorithms demonstrated appropriate and clinically justified inclusion of sex, typically reflecting biologically meaningful differences that improved prognostic accuracy without exacerbating disparities. Notably, Model for End-Stage Liver Disease 3.0 exemplified how sex inclusion can mitigate inequity in liver transplant allocation. By contrast, the Obesity Surgery Mortality Risk Score failed FAIRS criteria because evidence suggests sex-based risk differences are confounded by comorbidities and access to care. DISCUSSION:Our findings highlight that sex inclusion in algorithms must be explicitly justified, continuously reevaluated, and contextualized to avoid perpetuating bias.

INTRODUCTION:Biologic persistence, defined as the total uninterrupted time on a biologic agent, is associated with improved outcomes in inflammatory bowel disease (IBD). However, social determinants of health (SDOH), such as socioeconomic status, may influence a patient's ability to access these medications. We aimed to better understand the relationship between socioeconomic status and biologic persistence in patients with IBD and to determine whether patients with poor biologic persistence had higher health care utilization. METHODS:We identified patients with IBD seen at the University of Michigan during 2015-2022. Using the Centers for Disease Control Social Vulnerability Index (SVI), we examined the relationship between socioeconomic status and biologic persistence, defined as an active biologic prescription for 365 days or longer, while controlling a priori for IBD type, age, sex, race, comorbidities, IBD severity, and insurance type. Secondarily, we examined the relationship between biologic persistence and unplanned health care utilization. RESULTS:In this cohort of 3067 patients with IBD who were prescribed biologics, 20% (n = 620) did not achieve biologic persistence. Low socioeconomic status (odds ratio [OR] 0.56; P = .003) was associated with a lower likelihood of achieving biologic persistence. Biologic persistence was associated with lower risk of IBD-related hospitalization (incidence rate ratio [IRR], 0.48; P < .001), readmission (IRR, 0.52; P < .001), and surgery (IRR, 0.33; P < .001). CONCLUSIONS:Low socioeconomic status was associated with lower likelihood of biologic persistence and patients who lacked biologic persistence had greater IBD-related unplanned health care utilization.

Aberrant immune activation within the gut mucosa and gut dysbiosis have been implicated in the pathogenesis of Crohn’s disease (CD). However, the specific immune responses triggered by dysbiotic microbiota, as well as the bacteria responsible for this activation, remain incompletely understood. Here, using the human microbiota-associated (HMA) mouse system, we demonstrated that colonization with dysbiotic gut microbiota from CD patients specifically induces the accumulation of mononuclear phagocytes, which may drive an interleukin-1 (IL-1)-driven inflammatory signature. Moreover, we identified pathobiont strains with a potent IL-1β-inducing capacity, termed ‘IL-1β-inducing pathobionts’ (IBIP). Isolated IBIP strains exhibit genetic and functional similarities to adherent-invasive Escherichia coli but harbor unique virulence-associated genes. Colonization with the IBIP E. coli strain exacerbated experimental colitis in an IL-1 signal-dependent manner. Notably, the colonization of IBIP E. coli can be detected by measuring the levels of specific immunoglobulin A (IgA) in their stool samples. Moreover, the level of IBIP-reactive IgA in stool may serve as a predictive biomarker for treatment response to anti-TNF therapies in treatment-naïve pediatric CD patients. Altogether, IBIP colonization could help identify CD patients with inflammatory dysbiosis who are likely to be refractory to anti-TNF therapies. ### Competing Interest Statement The authors have declared no competing interest.

INTRODUCTION:Evidence-based recommendations for sexual practices regarding anoreceptive intercourse (ARI) do not exist in patients with inflammatory bowel diseases undergoing restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). This study surveys providers on perspectives and attitudes related to sexual practices after IPAA. METHODS:We developed a 23-item survey and distributed it to providers caring for patients with inflammatory bowel diseases. RESULTS:95% of providers believe that it is important to discuss sexual orientation or practices before IPAA, but only 27% routinely discuss this. 50% did not feel comfortable and 74% did not feel confident discussing ARI recommendations with patients who underwent or will undergo IPAA. DISCUSSION:Future interventions should aim to standardize recommendations regarding feasibility and time line to safe ARI after IPAA.

Sexual health counseling (SHC) is a critical aspect of inflammatory bowel disease (IBD) care. Less is known about sexual health counseling in patients who identify as members of a sexual or gender minority (SGM) group. This study aims to characterize patient-reported sexual health counseling in SGM vs. non-SGM patients with IBD. We conducted an anonymous, cross-sectional survey of patients over 18 years old with IBD, currently receiving care at a large, tertiary care IBD center. Data collection included demographics, IBD history, and patient recall of SHC. Patients who self-identified as SGM were compared to non-SGM patients, with subgroup analyses by sex assigned at birth. Means were compared using t tests and percentages compared using chi-square analysis. A total of 162 patients (41 SGM and 121 non-SGM) completed the survey. Both groups reported IBD impacted their sexual practices (ranging from 44

Background Sexual and gender minority (SGM) individuals often experience more discrimination and worse health than non-SGM people. Less is known about SGM individuals with inflammatory bowel disease (IBD). We studied IBD outcomes, discrimination, illness-related stigma, and SGM status in a cross-sectional survey. Methods In total, 1586 IBD Partners e-cohort participants self-reported sexual orientation, gender identity, and prior IBD treatment. They completed the Short Crohn’s Disease Activity Index or Simple Clinical Colitis Activity Index, the Everyday Discrimination Scale, and the Paradox of Self Stigma (PASS-24) scale. We performed regression analyses controlling for age, race, disease duration, and IBD type. Results SGM people were 7.8% (n = 124) of the cohort. SGM participants were younger than non-SGM participants (median age 40 vs. 54 years, P < .001). Among SGM individuals, 67% (n = 74) were in remission based on disease activity scores. Among non-SGM individuals, 74% (n = 936) were in remission (P = .097). Similar proportions of SGM and non-SGM persons reported prior IBD-related hospitalization (40% vs. 37%, P = .426; adjusted odds ratio [aOR] 0.95, 95% confidence interval [CI], 0.62-1.45) and IBD-related surgery (52% vs. 54%, P = .707, aOR 1.25, 95% CI, 0.81-1.94). SGM respondents reported more discrimination (71% vs. 47%, P < .001), and 43% of SGM individuals reported healthcare-related discrimination versus 21% of non-SGM individuals (P < .001). SGM persons also endorsed more internalized stigma (median PASS-24 scores 53 vs. 47, P = .026). Conclusions SGM individuals with IBD are more likely to experience discrimination, including in healthcare, and illness-related stigma. These may significantly impact the quality of life and should be considered in the care of SGM people with IBD.

Alterations in the gut microbiota, known as gut dysbiosis, are associated with inflammatory bowel disease (IBD). There is a need for model systems that can recapitulate the IBD gut microbiome to better understand the mechanistic impact of differences in microbiota composition and its functional consequences in a controlled laboratory setting. To this end, we introduced fecal samples from patients with Crohn's disease (CD) and ulcerative colitis (UC), as well as from healthy control subjects, to miniature bioreactor arrays (MBRAs) and analyzed the microbial communities over time. We then performed two functional assessments. First, we evaluated the colitogenic potential of the CD microbiotas in genetically susceptible germ-free IL-10-deficient mice and found that colitogenic capacity was preserved in a bioreactor-cultivated CD microbiota. Second, we tested impaired colonization resistance against Clostridioides difficile in UC microbiotas using the MBRA system and found that UC microbiotas were innately susceptible to C. difficile colonization while healthy microbiotas were resistant, consistent with what is seen clinically. Overall, our results demonstrate that IBD microbiotas perform comparably to healthy donor microbiotas in the MBRA system, successfully recapitulating microbial structure while preserving IBD-specific functional characteristics. These findings establish a foundation for further mechanistic research into the IBD microbiota using MBRAs.

INTRODUCTION:Little is known about the impact of gender-affirming hormone therapy (GAHT) on transgender and gender diverse adults with inflammatory bowel disease (IBD). The primary aim was to evaluate the incidence of IBD flare in the year before and after GAHT initiation. METHODS:A retrospective study across 5 IBD centers. Flare was defined as need for steroids, IBD-associated emergency department visit, or need for IBD medication change. Factors associated with IBD flare were assessed with univariate analysis and multivariable logistic regression controlling for age and IBD type. RESULTS:A total of 85 transgender and gender diverse adults with IBD who initiated GAHT were included in this study. Forty-six (54.1%) received estrogen and 39 (45.9%) received testosterone. In the year before GAHT, 42 (49%) flared compared with 32 (38%) in the year after, P = 0.06. There was no statistically significant difference in incidence of flare by age, IBD type, or IBD therapy type. Individuals with active IBD at GAHT initiation were more likely to flare in univariate (58% vs 24%, P = 0.003) and multivariable analyses (adjusted odds ratio 5.1, 95% confidence interval 1.7-15.2). In both univariate and multivariable analyses, individuals who received testosterone were more likely to flare in the year after starting GAHT, testosterone: 51% vs estrogen: 26%, P = 0.02 with an adjusted odds ratio 3.1 (95% confidence interval 1.2-8.1). DISCUSSION:Although there was no overall increased risk of flare in the year after GAHT start, those with active IBD before hormone start and those who received testosterone were more likely to experience an IBD flare.

Objectives: Little is known about the impact of gender-affirming hormone therapy (GAHT) on transgender and gender diverse adults with inflammatory bowel disease (IBD). The primary aim was to evaluate the incidence of IBD flare in the year before and after GAHT initiation. Methods: A retrospective study across five IBD centers. Flare was defined as need for steroids, IBD-associated emergency department visit, or need for IBD medication change. Factors associated with IBD flare were assessed with univariate analysis and multivariable logistic regression controlling for age and IBD type. Results: 85 transgender and gender diverse adults with IBD who initiated GAHT were included in this study. 46 (54.1%) received estrogen and 39 (45.9%) received testosterone. In the year prior to GAHT, 42 (49%) flared compared to 32 (38%) in the year after, p=0.06. There was no statistically significant difference in incidence of flare by age, IBD type, or IBD therapy type. Individuals with active IBD at GAHT initiation were more likely to flare in univariate (58% vs 24%, p=0.003) and multivariable analysis (aOR 5.1 [95% CI 1.7 – 15.2]). In both univariate and multivariable analysis, individuals who received testosterone were more likely to flare in the year after starting GAHT, testosterone: 51% vs estrogen: 26%, p=0.02 with an aOR 3.1 [95% CI 1.2 – 8.1]. Conclusions: While there was no overall increased risk of flare in the year after GAHT start, those with active IBD prior to hormone start and those who received testosterone were more likely to experience an IBD flare.