Real-World Surgical and Endoscopic Recurrence Based on Risk Profiles and Prophylaxis Utilization in Postoperative Crohn's Disease.

BACKGROUND & AIMS: Preoperative risk stratification may help guide prophylactic biologic utilization for the prevention of postoperative Crohn's disease (CD) recurrence; however, there are limited data exploring and validating proposed clinical risk factors. We aimed to explore the preoperative clinical risk profiles, quantify individual risk factors, and assess the impact of biologic prophylaxis on postoperative recurrence risk in a real-world cohort. METHODS: In this multicenter retrospective analysis, patients with CD who underwent ileocolonic resection (ICR) from 2009 to 2020 were identified. High-risk (active smoking, ≥2 prior surgeries, penetrating disease, and/or perianal disease) and low-risk (nonsmokers and age >50 y) features were used to stratify patients. We assessed the risk of endoscopic (Rutgeert score, ≥i2b) and surgical recurrence by risk strata and biologic prophylaxis (≤90 days postoperatively) with logistic and time-to-event analyses. RESULTS: A total of 1404 adult CD patients who underwent ICR were included. Of the high-risk factors, 2 or more ICRs (odds ratio [OR], 1.71; 95% CI, 1.13-2.57), active smoking (OR, 1.73; 95% CI, 1.17-2.53), penetrating disease (OR, 1.41; 95% CI, 1.02-1.94), and history of perianal disease alone (OR, 1.99; 95% CI, 1.42-2.79) were associated with surgical but not endoscopic recurrence. Surgical recurrence was lower in high-risk patients receiving prophylaxis vs not (10.2% vs 16.7%; P = .02), and endoscopic recurrence was lower in those receiving prophylaxis irrespective of risk strata (high-risk, 28.1% vs 37.4%; P = .03; and low-risk, 21.1% vs 38.3%; P = .002). CONCLUSIONS: Clinical risk factors accurately illustrate patients at risk for surgical recurrence, but have limited utility in predicting endoscopic recurrence. Biologic prophylaxis may be of benefit irrespective of risk stratification and future studies should assess this.

Histologic Activity from Neoterminal Ileal Biopsies in Patients with Crohn's Disease in Endoscopic Remission is Associated with Postoperative Recurrence.

BACKGROUND: Following ileocolic resection (ICR), the clinical importance and prognostic implications of histologic activity on biopsies in Crohn's disease (CD) patients with endoscopic remission are not well defined. This study aimed to determine if histologic activity in patients with endoscopic remission is associated with future risk of endoscopic and/or radiologic postoperative recurrence (POR). METHODS: In this multicenter retrospective cohort study, adult patients with CD who underwent ICR between 2009-2020 with endoscopic biopsies of ileal mucosa from Rutgeerts' i0 on index colonoscopy were included. The composite rate of endoscopic (Rutgeerts' score≥i2b) and radiologic (active inflammation on imaging) recurrence was compared in patients with and without histologic activity using a Kaplan-Meier survival analysis. A multivariable Cox proportional hazard regression model including clinically relevant risk factors for POR, postoperative biologic prophylaxis, and histology activity was designed. RESULTS: A total of 113 patients with i0 disease on index colonoscopy after ICR were included. Of these, 42% had histologic activity. Time to POR was significantly earlier in the histologically active versus normal group (p=0.04). After adjusting for clinical risk factors for POR, histologic activity (HR 2.37, 95% CI 1.17-4.79; p=0.02) and active smoking (HR 2.54, 95% CI 1.02-6.33; p=0.05) were independently associated with subsequent composite POR risk. CONCLUSIONS: In patients with postoperative CD, histologic activity despite complete endoscopic remission is associated with composite, endoscopic and radiographic, recurrence. Further understanding of the role of histologic activity in patients with Rutgeerts' i0 disease may provide a novel target to reduce disease recurrence in this population.

National Comparison of Burnout for a Cohort of Surgical and Nonsurgical Female Trainees.

INTRODUCTION: Studies have shown that female physician trainees have an increased risk of burnout. We describe the current state of surgical and nonsurgical female trainee well-being and examine differences between surgical and nonsurgical specialties. METHODS: Survey responses were received from 1017 female identifying trainees from 26 graduate medical education institutions across the United States. These survey responses included demographic data and well-being measures. Specifically, burnout was assessed using the Maslach Burnout Inventory. Data were analyzed using Wilcoxon rank sum test, Fisher's exact test, and Pearson's Chi-squared test data with significance defined as a P < 0.05. This survey was reported in line with strengthening the reporting of cohort studies in surgery criteria. RESULTS: Nine-hundred ninety-nine participants completed the demographic and well-being section of the surveys and were included in analysis. Demographic data between the surgical versus nonsurgical group were similar, aside from surgeons being slightly older. Burnout was prevalent among all surveyed trainees with 63% scoring positive. Trainees also scored high in imposter syndrome and moral injury with low levels of self-compassion, although respondents also reported themselves flourishing. Surgical trainees scored higher than nonsurgical trainees in the personal accomplishment domain of burnout (P < 0.048). There was no difference between surgical and nonsurgical trainees in measures of the emotional exhaustion or depersonalization domains of burnout, or in impostor syndrome, self-compassion, moral injury, or flourishing. CONCLUSIONS: While personal accomplishment was noted to be higher in surgical trainees as compared to nonsurgical trainees, overall rates of burnout are high among both groups. Targeted interventions for well-being, such as coaching, can help decrease the levels of burnout experienced by female physician trainees and do not need to be specialty specific.

Photoreceptor specialization and the visuomotor repertoire of the primitive chordate Ciona.

The swimming tadpole larva of Ciona has one of the simplest central nervous systems (CNSs) known, with only 177 neurons. Despite its simplicity, the Ciona CNS has a common structure with the CNS of its close chordate relatives, the vertebrates. The recent completion of a larval Ciona CNS connectome creates enormous potential for detailed understanding of chordate CNS function, yet our understanding of Ciona larval behavior is incomplete. We show here that Ciona larvae have a surprisingly rich and dynamic set of visual responses, including a looming-object escape behavior characterized by erratic circular swims, as well as negative phototaxis characterized by sustained directional swims. Making use of mutant lines, we show that these two behaviors are mediated by distinct groups of photoreceptors. The Ciona connectome predicts that these two behavioral responses should act through distinct, but overlapping, visuomotor pathways, and that the escape behavior is likely to be integrated into a broader startle behavior.