OBJECTIVES:Clostridioides difficile infection (CDI) and colorectal cancer pose significant health risks in the US, and yet the potential link between them remains unexplored in humans. We aim to investigate the association between CDI and the risk of developing premalignant and malignant colonoscopic findings in adult patients in inpatient and outpatient settings. METHODS:This retrospective cohort study reviewed patient charts from four healthcare facilities, including two tertiary referral centers. A total of 448 adult patients who underwent C. difficile tests (CDT) during the approved timeframe and had colonoscopies completed at least 5 years after CDT were identified using the Clostridium difficile PCR test and International Classification of Diseases codes. Our primary outcome was the rate of premalignant and malignant polyps or masses documented on colonoscopy reports greater than or equal to 5 years from the initial CDT date. Overall lesion frequency, size, histology, and presence of ulcerations were secondary outcomes. RESULTS:There was no significant difference in the development of polyps and masses between the patients with CDT-positive and CDT-negative [odds ratio (OR) = 1.21, 95% confidence interval (CI) = 0.70-2.11). In addition, the presence of malignant and premalignant histology also did not differ. CDT-positive group had a greater frequency of ulcerative lesions compared to the CDT-negative even after stratification for smoking (OR = 6.15, 95% CI = 1.67-22.66). CONCLUSION:Although no significant association was found between CDI and malignant or premalignant lesions, the study sheds light on the potential link between CDI and inflammatory pathologies such as ulcerative colorectal lesions. It could influence colorectal cancer screening strategies for patients with CDI.

BACKGROUND AND AIMS:There is a paucity of literature that comprehensively investigates risk factors for inflammatory bowel disease (IBD) readmissions on a national scale. In this study, we look to identify independent risk factors for readmission, including psychosocial factors, in patients admitted with a primary diagnosis of ulcerative colitis (UC) or Crohn's disease (CD). METHODS:We performed a retrospective cohort study using data from the Nationwide Readmissions Database. We identified cohorts of adult patients (n = 28 473) who required inpatient admission for UC or CD in the United States in the year 2020. Multivariate logistic regression models controlling for confounding variables were used to identify independent predictors of 90-day readmission. RESULTS:Patients were identified who required hospitalization for UC (n = 11 476) and CD (n = 16 997). In patients with UC, younger age, male sex, and transfusion requirement during index hospitalization were all independently predictive of increased 90-day readmission (all P < .05). Psychosocial factors predictive of readmission include alcohol use disorder, drug abuse, and poverty (all P < .05). In patients with CD, younger age and chronic pain were both predictive of increased readmissions (all P < .05). Psychosocial factors predictive of readmission include lower income quartile, uninsured status, depression, drug abuse, nicotine dependence, and opioid use disorder (all P < .05). CONCLUSIONS:This study identifies several risk factors for readmission in patients with IBD, many of which are potentially modifiable psychosocial factors. Closer follow-up, possibly via virtual modalities, as well as alternative treatment strategies, should be considered in patients with IBD at higher risk of readmission.

Fibromyalgia is a multifaceted syndrome primarily characterized by chronic widespread pain and fatigue. Despite its significant prevalence and incidence, the mechanisms mediating the disease pathogenesis have remained poorly understood; however, increasing evidence suggests a potentially central role of intestinal dysbiosis. Researchers have been examining possible diagnostic biomarkers, such as Helicobacter pylori infection, urine metabolite profiles, and cytokine levels, which reflect these microbiome changes. Additionally, evaluation of therapeutic interventions targeting the gut microbiome, including probiotics, fecal microbiota transplantation, and antibiotics for specific infections, has highlighted their potential in alleviating fibromyalgia symptoms. This article delves into the emerging role of the gut microbiome in fibromyalgia pathogenesis, illustrating how alterations in gut bacterial composition and diversity are implicated in the pathophysiology of the disease through the gut-brain axis, and sets a direction for future research to enhance diagnostic accuracy and therapeutic efficacy of this complex condition.

INTRODUCTION:The USA has the highest age-standardized prevalence of inflammatory bowel disease (IBD). Both genetic and environmental factors have been implicated in IBD flares and multiple strategies are centered around avoiding dietary triggers to maintain remission. Chat-based artificial intelligence (CB-AI) has shown great potential in enhancing patient education in medicine. We evaluate the role of CB-AI in patient education on dietary management of IBD. METHODS:Six questions evaluating important concepts about the dietary management of IBD which then were posed to three CB-AI models - ChatGPT, BingChat, and YouChat three different times. All responses were graded for appropriateness and reliability by two physicians using dietary information from the Crohn's and Colitis Foundation. The responses were graded as reliably appropriate, reliably inappropriate, and unreliable. The expert assessment of the reviewing physicians was validated by the joint probability of agreement for two raters. RESULTS:ChatGPT provided reliably appropriate responses to questions on dietary management of IBD more often than BingChat and YouChat. There were two questions that more than one CB-AI provided unreliable responses to. Each CB-AI provided examples within their responses, but the examples were not always appropriate. Whether the response was appropriate or not, CB-AIs mentioned consulting with an expert in the field. The inter-rater reliability was 88.9%. DISCUSSION:CB-AIs have the potential to improve patient education and outcomes but studies evaluating their appropriateness for various health conditions are sparse. Our study showed that CB-AIs have the ability to provide appropriate answers to most questions regarding the dietary management of IBD.

Background Previous research suggests patients living with inflammatory bowel disease (IBD) understand IBD remission differently than healthcare professionals, which could influence patient expectations and clinical outcomes. We investigated 3 questions to better understand this: (1) How do patients currently understand remission; (2) Do patients currently face any barriers to communicating with their healthcare professional about remission; and (3) Can existing educational material be improved to help patients feel more prepared to discuss remission and treatment goals with their healthcare professional? Methods We sent a web-based survey to adult patients with IBD in the United States. This survey included an educational experiment where patients were randomly assigned to 1 of 3 improved versions of existing educational material. Results In total, 1495 patients with IBD completed the survey. The majority of patients (67%) agreed that remission is possible in IBD, but there was significant diversity in how they defined it with the most common being “my symptoms are reduced” (22%) and “I am no longer experiencing any symptoms” (14%). Patients reported being able to communicate openly with their healthcare professionals. Exposure to improved educational material did not have a statistically significant effect on patients’ feelings of preparedness for discussing different aspects of their care with their healthcare professionals. Conclusions Our study confirms that patients tend to define remission in terms of resolving symptoms. We found little evidence of barriers preventing patients from discussing remission with their healthcare professionals. This suggests that educational material could be used to resolve this discrepancy in understanding.

Abstract INTRODUCTION Patients with inflammatory bowel disease (IBD) often experience symptoms such as abdominal pain, diarrhea, and bloody bowel movements. While these symptoms traditionally guided treatment, their predictive value for disease progression is limited. The latest STRIDE-II guidelines recommend a comprehensive IBD management approach, with an emphasis on short-term symptom relief, intermediate-term biomarker normalization, and long-term achievement of endoscopic remission. This treat-to-target strategy necessitates collaboration between physicians and patients. Our study aims to investigate the relationship between patient-reported outcomes and physician efforts to achieve mucosal healing (MH) using IBD QORUS patient and provider survey data. METHODS This was a multi-center prospective study that used patient and provider matched survey data from the Crohn’s & Colitis Foundation IBD QORUS program. Surveys completed between June 2021-October 2022 were analyzed. Univariate and multivariate analyses were performed to determine the relationship between severity of patient reported symptoms and frequency of MH assessment with modalities including endoscopy and fecal calprotectin, as well as to determine how symptoms and MH status influence treatment. RESULTS In total 5,460 paired patient and provider surveys (Crohn’s disease (CD), n=3,276; ulcerative colitis (UC), n=2,184) were included in the analysis. Demographic information including age, sex and steroid-free MH, as well as severity of patient-reported symptoms were similar between CD and UC patients (Table 1). Abdominal pain severity reported by both IBD populations significantly impacted plans for future endoscopy (CD, p=0.000019; UC, p=0.000055) but not for fecal calprotectin testing. Reported stool frequency in both IBD populations significantly impacted future endoscopy plans (CD, p=0.000001; UC, p=0.000001) and future fecal calprotectin testing (CD, p=0.000304; UC, p=0.000001). Reported blood in stool had no effect on MH assessment in CD patients whereas it significantly affected plans for endoscopy (p=0.000001) and fecal calprotectin testing (p=0.000001) in UC patients. Provider discussions regarding MH occurred with 82.4% of CD patients and 85.3% of UC patients, and treatment plans in those without steroid free MH were influenced by severity of symptoms (p=0.000001). DISCUSSION Patient reported symptoms influenced fecal calprotectin and endoscopy plans in both IBD groups. Similarly, severity of symptoms in those without steroid-free MH significantly affected treatment management. These findings suggest that target-based treatment for IBD is feasible in the clinical setting and holds the potential to enhance patient outcomes.

Depression is one of the most common mental health disorders affecting adults in the United States. The current treatment is the combination of pharmacotherapy and psychotherapy. Recently, the evidence linking gut microbiome dysregulation to the development of depression has grown. The pathophysiology is currently poorly understood, although leading hypotheses include involvement of the hypothalamic-pituitary-adrenal axis, a bidirectional relationship between the gut microbiome and the central nervous system, and production of signaling molecules by the gut microbiome. Available and emerging treatments of the aberrant microbiome include antidepressants, antibiotics, diet modification, probiotics, and fecal microbiota transplant. This article explores the interconnectivity of gut microbiota and depression and treatments targeted toward the gut, reviews the gastroenterologist's potential role in managing gut dysbiosis in patients with depression, and highlights research topics to be addressed to create evidence-based guidelines.

Introduction: The discovery of biologic agents 2 decades ago has transformed ulcerative colitis (UC) therapeutics, as biologics are now considered the mainstay of treatment. Despite these treatment advances, a significant number of patients develop relapses and experience refractory disease or major side effects while on biologics. The recent approval of upadacitinib, an oral small molecule selective JAK1 inhibitor, has expanded our therapeutic armamentarium, but there is a paucity of reports describing real-world outcomes in UC. In this setting, we report our early experience in a large regional health system. Methods: We identified UC patients that were prescribed Upadacitinib between June 1st, 2022, to February 6th, 2023, within the MedStar Health System. Inclusion criteria included: age >18 years, histological diagnosis of UC, and upadacitinib prescribed and filled at any MedStar Gastroenterology clinic site. Results: Fifteen patients met the inclusion criteria, 7 females (47%), and 8 males (53%) with a mean age of 33.9 years. The mean disease duration was 7.8 years, and 13 patients had a history of pancolitis, while 2 had proctitis. All patients had been treated with at least one biologic agent in the past and the mean number of biologic agent trials per patient was 2.5. Four patients had tried ozanimod, which was discontinued for various reasons. We assessed baseline disease activity clinically, biochemically, and endoscopically. The mean serum CRP concentration and Fecal Calprotectin levels were 23 mg/L and 1392mg/kg, respectively, and the mean Mayo endoscopic score was 2.1, with 2 patients having endoscopically quiescent disease (Mayo score=0). Twelve patients returned for follow-up during which their response to treatment was assessed, with 9 patients reporting significant clinical improvement or inactive disease. Two patients had to discontinue upadacitinib due to weight gain/acne and deep venous thrombosis (identified shortly prior to therapy initiation). Mean serum CRP concentration and Fecal Calprotectin levels were 12 mg/L and 271mg/kg, respectively, at follow-up (Figure 1). Conclusion: Our experience demonstrates that upadacitinib is well tolerated and effective in most patients with biologic refractory UC. This is supported by the clinical and biochemical remission observed as well as the minimal side effects reported. Future large-scale population studies are warranted to identify upadacitinib-responsive patients and define long-term remission rates and side effects.Figure 1.: Table A: Patient Demographics and Disease Characteristics, Table B: Baseline Disease Activity, Table C: Response to Upadacitinib, Figure D: Serum CRP (mg/L) at baseline and 3-month follow up, Figure E: Fecal Calprotectin (mg/Kg) at baseline and 3-month follow up. Abbreviations: Female (F), Male (M), Body Mass index (BMI), Extra-intestinal Manifestations (EIMs), C-reactive Protein (CRP).

Introduction: 90-day hospital readmission in patients with inflammatory bowel disease (IBD) results in hundreds of millions of dollars per year in healthcare costs. In this study, we look to identify independent risk factors for readmission in patients admitted with a primary diagnosis of Ulcerative Colitis (UC) or Crohn’s Disease (CD). Methods: We performed a retrospective cohort study using data from the Nationwide Readmissions Database (NRD). Using International Classification of Diseases-10th Revision (ICD-10) codes, we identified cohorts of patients who required inpatient admission for UC or CD in the year 2020. Multivariate logistic regression models were used to identify independent predictors of 90-day hospital readmission, including demographic, socio-economic, and hospital characteristics, as well as medical comorbidities and complications during the index hospitalization. Results: A total of 28,473 patients were identified who required hospitalization for UC (n=11,476) and CD (n=16,997), with an overall rate of IBD-specific readmission of 12.8% and a total of $186.5 million in healthcare costs. In patients with UC, younger age (Odds ratio 0.99, 95% confidence-interval 0.98-0.99), male sex (OR 1.21, 1.07-1.36), active drug abuse (OR 1.38, 1.01-1.86), active tobacco use (OR 1.25, 1.08-1.48), and transfusion requirement during hospitalizations (OR 1.27, 1.03-1.56) were all independently predictive of increased 90-day readmission (all p < .05). In patients with CD, younger age (OR 0.968, 0.98-0.99), lower income quartile (OR 1.08, 1.04-1.12), Self-pay insurance status (OR 1.14, 1.03-1.27), chronic pain (OR 1.39, 1.22-1.60), depression (OR 1.22, 1.09-1.37), and active drug abuse (OR 1.42, 1.18-1.71) were all independently predictive of increased 90-day readmission. Abdominal surgery performed during the index hospitalization was predictive of decreased 90-day readmissions for patients with both UC and CD (both p < .05). Conclusion: 90-day readmission occurs frequently in patients with IBD and is costly to the healthcare system. This study identifies several potentially modifiable risk factors for readmission, many of which are based in substance use, socio-economic status, and insurance status. Further studies are needed to clarify the impact of these factors on the disease burden of IBD, particularly regarding socioeconomic status (Table 1). Table 1. - Independent Predictors of 90-day disease-specific readmission in patients with UC and CD Ulcerative Colitis Crohn’s P-value Odds Ratio (95% CI) P-value Odds Ratio (95% CI) Age < .001* 0.985 (0.982-0.988) < .001* 0.968 (0.983-0.988) Sex (Male) .002* 1.207 (1.069-1.362) .182 1.060 (0.973-1.154) Lower Income Quartile .904 0.997 (0.944-1.053) < .001* 1.079 (1.037-1.122) Insurance Payer Medicare .800 1.019 (0.882-1.176) < .001* 0.822 (0.746-0.907) Medicaid .506 0.953 (0.829-1.097) .683 0.975 (0.886-1.073) Private .226 1.089 (0.949-1.250) .494 0.966 (0.875-1.067) Self-Pay .565 0.960 (0.835-1.103) .011* 1.142 (1.031-1.266) Hospital Location Metropolitan, Non-teaching .421 0.919 (0.748-1.129) .315 1.075 (0.9341.238) Metropolitan, teaching .422 1.059 (0.915-1.225) .797 0.986 (0.888-1.095) Urban .810 0.978 (0.814-1.174) .538 0.958 (0.835-1.099) Hospital Bed size Small .594 0.958 (0.820-1.120) .088 0.907 (0.811-1.015) Medium .474 0.951 (0.829-1.091) .813 0.988 (0.897-1.089) Large .291 1.068 (0.945-1.206) .122 1.070 (0.982-1.166) Comorbidities AIDS .404 0.542 (0.129-2.285) .240 0.299 (0.040-2.235) Anxiety .696 0.968 (0.820-1.141) .078 1.101 (0.989-1.227) Chronic Lung Disease .264 0.903 (0.754-1.080) .440 1.050 (0.927-1.190) Chronic Pain .213 0.850 (0.653-1.098) < .001* 1.394 (1.218-1.595) Cerebrovascular Accident .699 0.671 (0.089-5.070) .215 (2.777 (0.553-13.931) Depression .860 1.017 (0.845-1.223) < .001* 1.221 (1.087-1.372) Drug Abuse .040* 1.375 (1.014-1.864) < .001* 1.417 (1.175-1.710) Diabetes .241 0.921 (0.802-1.057) .745 1.019 (0.911-1.139) Diabetes with organ damage 1.000 1.000 (0.885-1.130) .613 0.970 (0.863-1.091) Myocardial infarction .245 1.250 (0.858-1.823) .811 1.044 (0.735-1.482) Obesity .918 0.990 (0.818-1.198) .061 0.873(0.757-1.006) Renal Failure .137 0.896 (0.774-1.036) .501 0.963 (0.862-1.075) Smoking .003* 1.248 (1.077-1.447) .727 0.980 (0.875-1.098) Charlson-Deyo Comorbidity Index 0.585 1.380 (0.434-4.383) .262 0.684 (0.352-1.329) Complications during initial hospitalization Gastrointestinal Hemorrhage .710 0.932 (0.644-1.350) .776 0.946 (0.646-1.386) Transfusion .023* 1.267 (1.033-1.556) .995 0.999 (0.808-1.237) Intubation/Mechanical Ventilation .054 0.144 (0.020-1.035) .089 0.415 (0.151-1.142) Acute kidney injury .416 0.919 (0.748-1.127) .855 1.015 (0.865-1.191) Dialysis .996 0.998 (0.881-1.194) .093 0.368 (0.115-1.181) Colonic Fistula .998 0.996 (0.897-1.205) .333 1.177 (0.846-1.638) Rectal/Anal Abscess .113 0.319 (0.077-1.313) .536 1.086 (0.837-1.409) Abdominal Surgery Required < .001* 0.312 (0.237-0.412) < .001* (0.345 (0.301-0.394) Other Variables Length of Stay (days) .443 1.004 (0.994-1.013) .052 0.991 (0.982-1.002)

A first-year gastroenterology fellow comes to his weekly continuity clinic staffed by a senior gastroenterologist. The senior gastroenterologist pulls up on the computer screen the first patient’s referral paperwork sent by her primary care provider before the patient’s scheduled appointment.A 21-year-old female college student with a 6-month history of progressive abdominal cramping and loose stools has been referred to the gastroenterology clinic for evaluation of new-onset bloody diarrhea, tenesmus, weight loss, and fatigue. The workup by the patient’s primary care provider included a normal complete blood count, thyroid function test, and negative stool cultures. The fellow sees that patient and suggests a long list of tests, including iron studies, celiac antibodies, inflammatory markers, stool electrolytes and osmolality, enteric pathogen stool test, computed tomography abdomen, colonoscopy, and allergy referral. The attending interrupts the fellow and suggests that they go talk to the patient together. The attending tells the patient that all that is needed is a simple blood test and colonoscopy for the initial workup. After leaving the patient room, the fellow asks the attending why, but the attending does not explain her thought process and simply states, “in my experience this is all that is needed.” Gastroenterology, like other specialties in medicine, is based on apprenticeship. Apprenticeship has long been considered the natural way of learning.1Dornan T. Osler Flexner, apprenticeship and “the new medical education.” J R Soc Med. 2005; 98: 91-95PubMed Google Scholar A teacher demonstrates how to perform a task while the learner observes and eventually performs the task with decreasing direction from the teacher. The learning process based on traditional apprenticeship takes a long time and can have various results. More importantly, the process of problem solving is often invisible unless the teacher’s thinking is deliberately brought to the surface. In an effort to make such tacit knowledge explicit,2Polanyi M. Personal Knowledge Towards a Post-Critical Philosophy. The University of Chicago Press, 1958Google Scholar Brown et al3Brown J.S. Collins A. Duguid P. Situated cognition and the culture of learning.Educ Res. 1989; 18: 32-42Crossref Scopus (7645) Google Scholar,4Collins A. Brown J.S. Holum A. Cognitive apprenticeship: making thinking visible.Am Educ. 1991; 15: 38-46Google Scholar introduced the concept of cognitive apprenticeship, a “model of instruction that works to make thinking visible.” Cognitive apprenticeship has been explored in several medical and surgical domains5Butler B.A. Butler C.M. Peabody T.D. Cognitive apprenticeship in orthopaedic surgery: updating a classic educational model.J Surg Educ. 2019; 76: 931-935Crossref PubMed Scopus (5) Google Scholar, 6Feinstein R.E. Descriptions and reflections on the cognitive apprenticeship model of psychotherapy training & supervision.J Contemp Psychother. 2020; 51: 155-164Crossref PubMed Scopus (3) Google Scholar, 7Merritt C. Daniel M. Munzer B. Nocera M. Ross J. Santen S. A cognitive apprenticeship-based faculty development intervention for emergency medicine educators.West J Emerg Med. 2018; 19: 198-204Crossref PubMed Scopus (8) Google Scholar and for gastrointestinal procedural skills training8Phillips M.S. Marks J.M. Overview of methods for flexible endoscopic training and description of a simple explant model.Asian J Endosc Surg. 2011; 4: 45-52Crossref PubMed Scopus (6) Google Scholar; however, there is little implementation of cognitive apprenticeship in gastroenterology clinical training.9Raman M. Donnon T. Procedural skills education - colonoscopy as a model.Can J Gastroenterol. 2008; 22: 767-770Crossref PubMed Scopus (20) Google Scholar In this article, we discuss cognitive apprenticeship, its major strategies, and how to introduce them to gastroenterology fellowship education. Traditional apprenticeship is a teaching model based on the age-old practice of “see one, do one, teach one” (Table 1). The apprentice observes the expert perform a task, assists in the completion of the task, and then the expert turns over increasing responsibility until the apprentice is proficient to perform the task independently. Traditional apprenticeship can increase confusion and lower self-confidence in the novice learner, and it can induce the more advanced learner to make incorrect links between what they are observing and prior information.Table 1Differences Between Traditional and Cognitive Apprenticeship ModelsTraditionalCognitiveExpert observes apprentice perform a taskExpert listens to apprentice’s thought processLearning is achieved by doing physical tasksLearning is achieved by making tacit knowledge explicitTeaching includes modeling, coaching, and fading of the expert’s supportTeaching includes modeling, coaching, articulation, reflection, exploration, and fading of the expert’s supportAssessment of task-based performance, eg, “How well did you do?”Assessment of goal-based competency, eg, “What have you learned?” Open table in a new tab Traditional apprenticeship places an emphasis on solving problems in isolation. Extrapolation of knowledge to a wider domain of problems can require time and experience. Optimal clinical care requires a strong knowledge base, but also good clinical judgment.10Gavriel J. Cognitive apprenticeship.Educ Prim Care. 2015; 26: 422-423Crossref PubMed Scopus (2) Google Scholar A seasoned physician approaches a patient encounter with an immense amount of information and experience that is difficult to express in words and that is unobservable to the learner; it is tacit knowledge.2Polanyi M. Personal Knowledge Towards a Post-Critical Philosophy. The University of Chicago Press, 1958Google Scholar Unfortunately, in traditional apprenticeship, little attention is paid to making tacit knowledge explicit, leaving the learner poorly equipped to develop the skills needed to solve real-life, complex, clinical problems. Cognitive apprenticeship is a model of instruction designed to make expert thinking “visible” to the learner (Table 1).3Brown J.S. Collins A. Duguid P. Situated cognition and the culture of learning.Educ Res. 1989; 18: 32-42Crossref Scopus (7645) Google Scholar The educational goal is shifted from task-oriented practice to the development of cognitive skills for tackling dynamic problems and complex practices. This desired outcome is entirely dependent on the ability of the expert to cultivate behaviors in the learner by modeling the thought process for the learner. More specifically, one of the goals of cognitive apprenticeship is to move the expert from being unconsciously competent (ie, they are technically good without understanding why) to consciously competent (ie, when they understand what they are doing so they can teach this better). Collins et al4Collins A. Brown J.S. Holum A. Cognitive apprenticeship: making thinking visible.Am Educ. 1991; 15: 38-46Google Scholar identified the following 6 core strategies of cognitive apprenticeship: modeling, coaching, scaffolding, articulation, (self) reflection, and exploration. Modeling involves an expert performing a task while making explicit what they intend to demonstrate so that learners can observe and build a conceptual model of processes required to accomplish that task.4Collins A. Brown J.S. Holum A. Cognitive apprenticeship: making thinking visible.Am Educ. 1991; 15: 38-46Google Scholar An example in medicine is when an attending discusses differential diagnoses while clearly explaining thought process to the patient with the trainee in the room. Coaching is the practice of observing students while they carry out a task and offering suggestions and feedback. Coaching is used to direct the learner’s attention to an overlooked step in a task or to make adjustments on the basis of the circumstances at that moment.4Collins A. Brown J.S. Holum A. Cognitive apprenticeship: making thinking visible.Am Educ. 1991; 15: 38-46Google Scholar An attending physician may observe a trainee during specific aspects of a history and physical examination, while providing real-time feedback during morning rounds. Scaffolding refers to the process by which medical care gradually moves from the expert coaching the learner to the learner taking primary responsibility for a patient. This process relies on layers of support that can take the form of the expert doing nearly the entire task, the expert offering occasional suggestions along the way, or even with the use of physical learning tools, such as simulations. Support is removed gradually, thereby giving the learner increasing responsibility via a notion called “fading.”4Collins A. Brown J.S. Holum A. Cognitive apprenticeship: making thinking visible.Am Educ. 1991; 15: 38-46Google Scholar An early or initial strategy for scaffolding can be simulation-based training, which is used extensively in medical education curricula, including in Basic Life Support, Advanced Cardiac Life Support, and in procedural skills training, including training in central venous line placement. Phillips and Marks8Phillips M.S. Marks J.M. Overview of methods for flexible endoscopic training and description of a simple explant model.Asian J Endosc Surg. 2011; 4: 45-52Crossref PubMed Scopus (6) Google Scholar discussed the use of simulation-based learning for endoscopic training using porcine stomach explants in surgical residency. Simulation-based training provides a solid foundation that prepares the learner to progress to more complex tasks with increasingly greater autonomy. Articulation is the practice of encouraging the learner to explicitly articulate or verbalize their knowledge, reasoning, and how they derived their solution to a complex problem.4Collins A. Brown J.S. Holum A. Cognitive apprenticeship: making thinking visible.Am Educ. 1991; 15: 38-46Google Scholar The teacher can use this tool to confirm the learner’s understanding. One strategy of articulation is inquiry teaching,11Collins A. Stevens A. Goals and strategies of inquiry teachers.in: Advances in Instructional Psychology. Vol. 2. Lawrence Erlbaum Associates, 1982: 65-119Google Scholar,12Collins A. Stevens A. A cognitive theory of interactive teaching.in: Reigeluth CM, ed. Instructional Design Theories and Models: An Overview. Lawrence Erlbaum Associates, 1983: 247-278Google Scholar which consists of questioning learners so as to lead them to refine their understanding of concepts in different domains.4Collins A. Brown J.S. Holum A. Cognitive apprenticeship: making thinking visible.Am Educ. 1991; 15: 38-46Google Scholar A similar teaching method is the so-called “1-minute preceptor model,” in which the attending or senior resident questions the learner to facilitate the learner’s presentation of their thought process and then for the teacher to provide targeted teaching.13Neher J. Gordon K. Meyer B. et al.A five-step “microskills” model of clinical teaching.J Am Board Fam Pract. 1992; 5: 419-424PubMed Google Scholar,14Pascoe J.M. Nixon J. Lang V.J. Maximizing teaching on the wards: review and application of the One-Minute Preceptor and SNAPPS models.J Hosp Med. 2015; 10: 125-130Crossref PubMed Scopus (41) Google Scholar Whether engaged in inquiry teaching or 1-minute preceptor model, the expert must be able to articulate their reasoning and how they derived their solution to a complex problem, a task that may become difficult once their clinical decision making has become instinctual.7Merritt C. Daniel M. Munzer B. Nocera M. Ross J. Santen S. A cognitive apprenticeship-based faculty development intervention for emergency medicine educators.West J Emerg Med. 2018; 19: 198-204Crossref PubMed Scopus (8) Google Scholar Self-reflection, like articulation, is a unique method that aims to deepen the learner’s comprehension of their own cognitive processes.9Raman M. Donnon T. Procedural skills education - colonoscopy as a model.Can J Gastroenterol. 2008; 22: 767-770Crossref PubMed Scopus (20) Google Scholar Self-reflection enables the learner to compare their own skills with those of the expert and other learners. In a surgical or procedural specialty, an attending physician may ask the trainee to verbalize upcoming steps during a procedure and later discuss the case with the trainee while asking questions, such as “what do you think went well?” or “what would you do differently next time?” Exploration is aimed at encouraging learner autonomy. It is an exercise wherein the expert pushes the learner to develop their own learning goals and problem-solving strategies. In this way, the learner is expected to progress toward expert problem-solving processes, while defining the problems to be solved.4Collins A. Brown J.S. Holum A. Cognitive apprenticeship: making thinking visible.Am Educ. 1991; 15: 38-46Google Scholar Exploration may look different for learners of varying levels of expertise. A medical student may explore by studying high-yield topics or first-line treatments for common pathologies. The senior resident may explore different management styles, even if they differ from what the attending has in mind.7Merritt C. Daniel M. Munzer B. Nocera M. Ross J. Santen S. A cognitive apprenticeship-based faculty development intervention for emergency medicine educators.West J Emerg Med. 2018; 19: 198-204Crossref PubMed Scopus (8) Google Scholar Medical educators may instinctively use clinical reasoning strategies in their teaching. Unfortunately, most teachers in gastroenterology and in other medical specialties do not receive training in cognitive apprenticeship. Not surprisingly, there are few data on the use of cognitive apprenticeship strategies in gastroenterology. Raman and Donnon9Raman M. Donnon T. Procedural skills education - colonoscopy as a model.Can J Gastroenterol. 2008; 22: 767-770Crossref PubMed Scopus (20) Google Scholar proposed a model of teaching colonoscopy to novice gastroenterology trainees using the concepts of scaffolding with simulation-based or patient-based training, verbalization of his or her technique with rationale, and self-reflection.9Raman M. Donnon T. Procedural skills education - colonoscopy as a model.Can J Gastroenterol. 2008; 22: 767-770Crossref PubMed Scopus (20) Google Scholar We will discuss the application of cognitive apprenticeship strategies to our earlier gastroenterology outpatient clinic scenario (Figure 1). The first-year gastroenterology fellow sees the young adult female patient with bloody diarrhea, tenesmus, weight loss, and fatigue. The fellow makes his suggested list of investigations to the patient. The attending intervenes stating that “inflammatory bowel disease is highly likely, and we will focus the initial evaluation there and broaden our scope if needed based on blood test and colonoscopy.” [Articulation] The attending encourages the fellow to verbalize his thought process about the differential diagnoses, using questioning technique to push the fellow to explain his reasoning. [Coaching] The attending shares her thought process to derive the narrowed choice in diagnostics. She explains that the patient’s age group, chronicity of symptoms with rectal bleeding, possible proctitis, and systemic symptoms are all highly suggestive of inflammatory bowel disease. [Self-reflection] After the conclusion of clinic day, the attending asks the fellow to reflect on his performance. The attending may ask the fellow how he felt about his treatment plan and how he could use this experience for the next case. These comparisons will help the fellow take on similar patient encounters with a more effective approach. [Scaffolding/Fading] Throughout the fellow’s experience in his gastroenterology continuity clinic, the attending reduces support gradually, moving from direct to more indirect supervision as the fellow becomes increasingly capable of recognizing presentations of particular gastrointestinal diseases and how to manage them. [Exploration] To expand his knowledge, the fellow is encouraged to explore the topic by reviewing the literature about the disease’s state and nuances. Cognitive apprenticeship is a training method that prioritizes learner understanding and application of knowledge to real-life tasks. It is the practice of making the tacit knowledge of the expert “visible” to the learner. Modeling, coaching, scaffolding, articulation, self-reflection, and exploration are important teaching strategies that are used increasingly in medical and surgical education.

Background: It is estimated that the prevalence of ulcerative colitis (UC) in the United States is 465 per 100,000 people, with its incidence projected to increase further in the upcoming years. Although the advent of biologics has revolutionized UC therapeutics, a substantial proportion of patients suffer from refractory disease. Ozanimod is an oral sphingosine-1-phosphate receptor modulator that has been recently approved by the US Food and Drug Administration for moderate to severe UC therapy. Real-world experience with ozanimod in UC remains to be defined. The aim of this study is to evaluate the safety and efficacy of ozanimod in patients with UC at a tertiary medical center. Methods: We performed a retrospective chart review of patients with UC treated with ozanimod within the MedStar health system between June 2021 to June 2022. The following inclusion criteria were applied: individuals 18 years or older, histological diagnosis of UC, and initiated on ozanimod at a MedStar Gastroenterology site. Results: Eight patients with UC (mean age = 35.5 years; 50% women; mean disease duration = 12.4 years; 63 percent pancolitis, 25 percent proctosigmoiditis, 13 percent left-sided colitis) were identified and included in this study, all of whom were seen at MedStar Georgetown University Hospital. Baseline disease characteristics: mean Mayo Endoscopic Score = 2.4, mean CRP = 9.8 μg/g, and mean Fecal Calprotectin = 1276 μg/g. All patients had previously failed treatment with at least one biologic agent. Following ozanimod initiation, one patient entered clinical remission, 3 patients showed improvement in UC symptoms, 3 patients showed no improvement or worsening of UC symptoms (including one who had total colectomy within 10 days of initiation), and one patient discontinued ozanimod use due to relocating abroad. After a mean follow-up time of 4 months post-ozanimod initiation, patients had the following disease characteristics: mean CRP = 14.4 μg/g, and mean Fecal Calprotectin = 912.5 μg/g. Patients treated with ozanimod reported adverse events such as fatigue (n = 4), eye irritation (n = 3), joint pain (n = 2), nausea and vomiting (n = 2), shortness of breath (n = 1), chest pain (n = 1), and brain fog (n = 1). One patient discontinued ozanimod due to adverse events potentially related to ozanimod. Conclusion(s): Ozanimod is well-tolerated with minimal side effects in patients with UC. The overall clinical response to ozanimod was variable; however, most patients experienced improvement in UC symptoms. Considering that all patients had previously failed at least one biologic therapy, our experience indicates that ozanimod is effective in improving symptoms and inducing remission in patients with refractory disease. Future studies with a larger sample and extended follow-up period are warranted to define the efficacy and time to remission of ozanimod in UC patients.

Introduction: During the COVID-19 pandemic, virtual interviews for resident and fellowship applicants became the standard. However, studies evaluating the experience of virtual interviews format are lacking. Accordingly, we sought to survey both gastroenterology fellowship applicants and interviewing faculty members about their experiences with the virtual interview process. Methods: Interviewees and faculty at 13 different gastroenterology fellowship programs at academic medical centers across the United States completed a post-interview survey. The online survey was conducted during the 2020 ERAS fellowship interview season via Google Forms. The survey responses were anonymously collected and reported. Results: A total of 177 gastroenterology fellowship applicants and 83 faculty members completed the electronic surveys. Most participants reported a positive experience with 91% and 84% of applicants and faculty respectively, scoring at least 4 points on a 5-point scale. Eighty-8 percent and 85% of applicants and faculty respectively, reported that they had enough insight about the applicant or the fellowship program during the interview. Over 67% of applicants reported cost-savings of greater than $1,000 per interview. Thirty-6 percent of applicants reported that they missed the personal interaction with the current gastroenterology fellows in the respective programs and the experience of physically touring the facility. Twenty-7 percent and 25% of applicants and faculty experienced technical difficulties during the interview process, respectively. Thirty-one percent and 22% of applicants and faculty would like for the virtual interviews to be the standard of future fellowship interviews, while 35% and 42% of applicants and faculty would consider it in the future, respectively. Figure 1 shows the ranking process for both applicants and faculty. Conclusion: Virtual interviews were perceived as effective and cost-saving by both gastroenterology fellowship applicants and faculty members. The virtual experience was widely accepted by most applicants and faculty, with high potential to become the standard of fellowship interview process in the future. However, a substantial portion experienced technical difficulty. Further improvements in technology are needed to optimize the process and increase the acceptance of the virtual interview experience.Figure 1.: Applicants and faculty perspectives on the ranking process. LOR, letters of recommendation.

Purpose of review Immune checkpoint inhibitors (ICI) have become a pillar of cancer therapy for many people around the world. However, up to two-thirds of all patients undergoing ICI therapy will have immune-related adverse events (irAEs), including immune-checkpoint inhibitor colitis (ICIC). This review summarizes the most valuable and currently available information about the mechanism, diagnosis, and management of ICIC. Recent findings Recent findings include several developments on the leading theories for the mechanisms of ICIC such as the role of the gut microbiome. New emerging therapy strategies include tocilizumab, ustekinumab, mycophenolate mofetil, and calcineurin inhibitors. Summary The occurrence of irAEs remains a limiting factor for the use of immunotherapy in cancer treatment. Prompt diagnosis of ICIC with endoscopy and histologic confirmation can lead to early utilization of known effective treatments such as corticosteroids, infliximab, vedolizumab, and other emerging therapy strategies. We summarize the key points of this review article in our abstract video, Supplemental Digital Content 1, http://links.lww.com/COG/A44.

were included.Variables evaluated included self-identified race/ethnicity, age, sex, median income by home zip code, insurance coverage and procedural indication (screening/surveillance or diagnostic).Univariate analyses were performed using Fisher-exact, Mann-Whitney U or student's t-test.Multivariable analyses were conducted using logistic regression.Results: In total, 23,086 EOP were included, with 12,161 (52.7%) performed pre-PHE.Compared to pre-pandemic, the pandemic EOP cohort was more likely younger, White, and undergoing a diagnostic procedure (all p<0.05).Conversely, the pandemic cohort had a smaller proportion of Non-Hispanic Black (NHB) and Latino/a/x patients compared to the pre-PHE cohort (all p<0.05).On multivariable analysis, White race (OR 1.163;) and diagnostic procedures (OR 1.281;) were independently associated with EOP completion during the pandemic, although there was significant effect modification between these two predictors (interactive term OR 0.807; [0.669-0.945])(Table 2).On separate multivariable models constructed, Latino/a/x (OR 0.869; [0.731-1.000])and NHB (OR 0.600; [0.350-0.849])patients were independently associated with lower odds of undergoing EOP during the pandemic compared to pre-PHE.Conclusions: Vulnerable groups including NHB, Latino/a/x, and older patients were independently associated with lower odds of EOP completion during the pandemic, particularly for screening procedures.COVID-19 specific measures, such as routine pre-EOP testing, may add barriers to care that disproportionately affect these vulnerable groups.Efforts must be made to ensure equitable access to endoscopic care, including routine screening procedures.Special attention should be paid to vulnerable groups when instituting policies that may affect procedural access, particularly given the risk of an ongoing PHE, to avoid widening existing disparities.