Acute Severe Ulcerative Colitis Flare Complicated by Myopericarditis and Infliximab-Induced Hepatitis.

Ulcerative colitis (UC) is an autoimmune disease associated with both intestinal and extraintestinal manifestations. The latter may include heart complications, such as myopericarditis leading to life-threatening arrythmias. Nowadays, UC is commonly treated with biologic medications and infliximab is the first line therapy in an outpatient setting, while it is also used as rescue therapy in acute severe UC. However, it has been associated with severe immunosuppression, cytomegalovirus (CMV) reactivation and drug-induced hepatitis. We report a case of UC flare in a biologic naïve patient admitted with myopericarditis, which was further complicated by positive CMV biopsies and infliximab-induced transaminitis. LEARNING POINTS: In acute inflammatory bowel disease (IBD) flare presentation with tachycardia and chest pain, an underlying myocardial injury should be investigated.Mucosal healing should be evaluated endoscopically in cases of partial response to biologics.Both cytomegalovirus (CMV) infection and infliximab-induced liver injury may lead to acute hepatitis.

Humans versus AI: whether and why we prefer human-created compared to AI-created artwork.

With the recent proliferation of advanced artificial intelligence (AI) models capable of mimicking human artworks, AI creations might soon replace products of human creativity, although skeptics argue that this outcome is unlikely. One possible reason this may be unlikely is that, independent of the physical properties of art, we place great value on the imbuement of the human experience in art. An interesting question, then, is whether and why people might prefer human-compared to AI-created artworks. To explore these questions, we manipulated the purported creator of pieces of art by randomly assigning a "Human-created" or "AI-created" label to paintings actually created by AI, and then assessed participants' judgements of the artworks across four rating criteria (Liking, Beauty, Profundity, and Worth). Study 1 found increased positive judgements for human- compared to AI-labelled art across all criteria. Study 2 aimed to replicate and extend Study 1 with additional ratings (Emotion, Story, Meaningful, Effort, and Time to create) intended to elucidate why people more-positively appraise Human-labelled artworks. The main findings from Study 1 were replicated, with narrativity (Story) and perceived effort behind artworks (Effort) moderating the label effects ("Human-created" vs. "AI-created"), but only for the sensory-level judgements (Liking, Beauty). Positive personal attitudes toward AI moderated label effects for more-communicative judgements (Profundity, Worth). These studies demonstrate that people tend to be negatively biased against AI-created artworks relative to purportedly human-created artwork, and suggest that knowledge of human engagement in the artistic process contributes positively to appraisals of art.

ERCP for bile duct stones across a national service, demonstrating a high requirement for repeat procedures.

Background and study aims Bile duct stones (BDS) represent approximately 50 % of the requirement for endoscopic retrograde cholangiopancreatography (ERCP) within most services. Significant variation in outcome rates for BDS clearance at ERCP has been reported, and endoscopy societies have set standards for expected clearance rates. The aim of this study was to analyze procedure outcomes across a national service. Patients and methods Using verified hospital episode statistics (HES) data for the National Health Service (NHS) in England, we analyzed all patients having first ERCPs for BDS from 2015 to 2017, and followed these patients for at least 2 years. Results In total 37,468 patients underwent a first ERCP for BDS, with 69.8 % undergoing only one procedure. This figure of less than 70 % of BDS cleared at first ERCP is below the Key Performance Indicators as set by the British Society of Gastroenterology (> 75 %) and the European Society of Gastrointestinal Endoscopy (> 90 %). Of 55,556 ERCPs done for BDS, 52.9 % were repeat procedures, with 11,322 patients needing multiple procedures. For hospitals performing significant numbers of ERCPs (more than 600 for BDS during the study period) patients undergoing repeat ERCPs for BDS ranged from 9 % to 50 %. Conclusions In this nationwide study, the performance at clearing BDS at first ERCP was suboptimal, with high numbers of repeat procedures required. This may have a negative impact on both patient outcomes and experience, and increase pressure on endoscopy services. Apparent variation of outcome between acute hospital care providers requires further analysis.

Impact on follow-up strategies in patients with primary sclerosing cholangitis.

BACKGROUND & AIMS: Evidence for the benefit of scheduled imaging for early detection of hepatobiliary malignancies in primary sclerosing cholangitis (PSC) is limited. We aimed to compare different follow-up strategies in PSC with the hypothesis that regular imaging improves survival. METHODS: We collected retrospective data from 2975 PSC patients from 27 centres. Patients were followed from the start of scheduled imaging or in case of clinical follow-up from 1 January 2000, until death or last clinical follow-up alive. The primary endpoint was all-cause mortality. RESULTS: A broad variety of different follow-up strategies were reported. All except one centre used regular imaging, ultrasound (US) and/or magnetic resonance imaging (MRI). Two centres used scheduled endoscopic retrograde cholangiopancreatography (ERCP) in addition to imaging for surveillance purposes. The overall HR (CI95%) for death, adjusted for sex, age and start year of follow-up, was 0.61 (0.47-0.80) for scheduled imaging with and without ERCP; 0.64 (0.48-0.86) for US/MRI and 0.53 (0.37-0.75) for follow-up strategies including scheduled ERCP. The lower risk of death remained for scheduled imaging with and without ERCP after adjustment for cholangiocarcinoma (CCA) or high-grade dysplasia as a time-dependent covariate, HR 0.57 (0.44-0.75). Hepatobiliary malignancy was diagnosed in 175 (5.9%) of the patients at 7.9 years of follow-up. Asymptomatic patients (25%) with CCA had better survival if scheduled imaging had been performed. CONCLUSIONS: Follow-up strategies vary considerably across centres. Scheduled imaging was associated with improved survival. Multiple factors may contribute to this result including early tumour detection and increased endoscopic treatment of asymptomatic benign biliary strictures.

Actinidin diversity: discovery of common and selective substrates for actinidin isoforms and Actinidia cultivars.

The actinidin proteinase family has a striking sequence diversity; isoelectric points range from 3.9 to 9.3. The biological drive for this variation is thought to be actinidin's role as a defense-related protein. In this study we map mutations in the primary sequence onto the 3D structure of the protein and show that the region with the highest diversity is close to the substrate binding groove. Non-conservative substitutions in the active site determine substrate preference and therefore create problems for quantification of actinidin activity. Here we use a peptide substrate library to compare two actinidin isoforms, one from the kiwiberry cultivar 'Hortgem Tahi' (Actinidia arguta), and the other from the familiar kiwifruit cultivar 'Hayward' (Actinidia chinensis var. deliciosa). Among 360 octamer substrates we find one substrate (RVAAGSPI) with the useful property of being readily cleaved by all the functionally active actinidins in a set of A. arguta and A. chinensis var. deliciosa isoforms. In addition, we find that two substrates (LPPKSQPP & ILRDKDNT) have the ability to differentiate different isoforms from a single fruit. We compare actinidins from 'Hayward' and A. arguta for their ability to digest the allergenic gluten peptide (PFPQPQLPY) but find the peptide to be indigestible by all sources of actinidin. The ability to inactivate salivary amylase is shown to be a common trait in Actinidia cultivars due to proteolysis by actinidin and is particularly strong in 'Hortgem Tahi'. A mixture of 10% 'Hortgem Tahi' extract with 90% saliva inactivates 100% of amylase activity within 5 minutes. Conceivably, 'Hortgem Tahi' might lower the glycaemic response in a meal rich in cooked starch.

Endoscopic biliary therapy in the era of bariatric surgery.

There is an increasing demand and availability of bariatric surgery, with a range of procedures performed, some leading to altered upper gastrointestinal anatomy. The patient population undergoing bariatric surgery is also at increased risk of gallstones and biliary stone disease. Endoscopy (ie, endoscopic retrograde cholangiopancreatography) is the cornerstone of management of biliary stone disease, but may be challenging after bariatric surgery. In this review the endoscopic, surgery assisted, or percutaneous options that may be considered are discussed, based on the details of surgical anatomy and available expertise.

Culture as a Moderator of Epistemically Suspect Beliefs.

A consistent finding reported in the literature is that epistemically suspect beliefs (e.g., paranormal beliefs) are less frequently endorsed by individuals with a greater tendency to think analytically. However, these results have been observed predominantly in Western participants. In the present work, we explore various individual differences known to predict epistemically suspect beliefs across both Western and Eastern cultures. Across four studies with Japanese (n = 666) and Western (n = 650) individuals, we find that the association between thinking style and beliefs varied as a function of culture. Specifically, while Westerners who scored higher on measures of Type-2 analytic thinking tended to endorse epistemically suspect beliefs less, this association was not observed in Japanese samples, suggesting that the often-observed negative association between analytic thinking and epistemically suspect beliefs may be exclusive to Western individuals. Additionally, we demonstrate that a tendency to think holistically (specifically with regards to causality) is positively associated with the endorsement of epistemically suspect beliefs within both samples. Overall, we discuss how various individual differences predict the endorsement of epistemically suspect beliefs across cultures.

Erratum: UK Joint Advisory Group consensus statements for training and certification in endoscopic retrograde cholangiopancreatography.

[This corrects the article DOI: 10.1055/a-1629-7540.].

UK Joint Advisory Group consensus statements for training and certification in endoscopic retrograde cholangiopancreatography.

Background and study aims Despite the high-risk nature of endoscopic retrograde cholangiopancreatography (ERCP), a robust and standardized credentialing process to ensure competency before independent practice is lacking worldwide. On behalf of the Joint Advisory Group (JAG), we aimed to develop evidence-based recommendations to form the framework of ERCP training and certification in the UK. Methods Under the oversight of the JAG, a modified Delphi process was conducted with stakeholder representation from the British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons, trainees and trainers. Recommendations on ERCP training and certification were formulated after formal literature review and appraised using the GRADE tool. These were subjected to electronic voting to achieve consensus. Accepted statements were peer-reviewed by JAG and relevant Specialist Advisory Committees before incorporation into the ERCP certification pathway. Results In total, 27 recommendation statements were generated for the following domains: definition of competence (9 statements), acquisition of competence (8 statements), assessment of competence (6 statements) and post-certification support (4 statements). The consensus process led to the following criteria for ERCP certification: 1) performing ≥ 300 hands-on procedures; 2) attending a JAG-accredited ERCP skills course; 3) in modified Schutz 1-2 procedures: achieving native papilla cannulation rate ≥80%, complete bile duct clearance ≥ 70 %, successful stenting of distal biliary strictures ≥ 75 %, physically unassisted in ≥ 80 % of cases; 4) 30-day post-ERCP pancreatitis rates ≤5 %; and 5) satisfactory performance in formative and summative direct observation of procedural skills (DOPS) assessments. Conclusions JAG certification in ERCP has been developed following evidence-based consensus to quality assure training and to ultimately improve future standards of ERCP practice.

Exploring stakeholders and their requirements in the process of home hemodialysis: A literature review.

Providing home hemodialysis (HHD) therapy is a complex process that not only requires the use of a complex technology but also involves a diverse group of stakeholders, and each stakeholder has their requirements and may not share a common interest. Bringing them together will require the alignment of their interests. A process management perspective can help to accomplish the alignment of their interests. To align their interests, it is crucial to identify interest groups and understand their interests. The main objective of this paper is to identify the stakeholders and represents their interests as a list of requirements in the HHD process. An extensive literature review has been carried out and PubMed was used for literature extraction. In total, 1848 articles were retrieved of which 80 have fulfilled the inclusion criteria. A large array of actors is identified and their interests/requirements at different stages of the HHD process are represented in the form of a list. They have both common and conflicting requirements in the HHD process. If these requirements are aligned and balanced, a stakeholder's driven treatment process will be developed and a real improvement will be achieved in the treatment process.

The Application of Multicriteria Decision Analysis Methods in Health Care: A Literature Review.

OBJECTIVES: The main objectives of this article are 2-fold. First, we explore the application of multicriteria decision analysis (MCDA) methods in different areas of health care, particularly the adoption of various MCDA methods across health care decision making problems. Second, we report on the publication trends on the application of MCDA methods in health care. METHOD: PubMed was searched for literature from 1960 to 2019 in the English language. A wide range of keywords was used to retrieve relevant studies. The literature search was performed in September 2019. Articles were included only if they have reported an MCDA case in health care. RESULTS AND CONCLUSION: The search yielded 8,318 abstracts, of which 158 fulfilled the inclusion criteria and were considered for further analysis. Hybrid methods are the most widely used methods in health care decision making problems. When it comes to single methods, analytic hierarchy process (AHP) is the most widely used method followed by TOPSIS (technique for order preference by similarity to ideal solution), multiattribute utility theory, goal programming, EVIDEM (evidence and value: impact on decision making), evidential reasoning, discrete choice experiment, and so on. Interestingly, the usage of hybrid methods has been high in recent years. AHP is most widely applied in screening and diagnosing and followed by treatment, medical devices, resource allocation, and so on. Furthermore, treatment, screening and diagnosing, medical devices, and drug development and assessment got more attention in the MCDA context. It is indicated that the application of MCDA methods to health care decision making problem is determined by the nature and complexity of the health care problem. However, guidelines and tools exist that assist in the selection of an MCDA method.

Reduced survival after upper gastrointestinal bleed endoscopy in the COVID-19 era is a secondary effect of the response to the global pandemic: a retrospective cohort study.

OBJECTIVE: The COVID-19 pandemic has placed increased strain on healthcare systems worldwide with enormous reorganisation undertaken to support 'COVID-centric' services. Non-COVID-19 admissions reduced secondary to public health measures to halt viral transmission. We aimed to understand the impact of the response to COVID-19 on the outcomes of upper gastrointestinal (UGI) bleeds. DESIGN/METHODS: A retrospective observational multicentre study comparing outcomes following endoscopy for UGI bleeds from 24 March 2020 to 20 April 2020 to the corresponding dates in 2019. The primary outcome was in-hospital survival at 30 days with secondary outcomes of major rebleeding within 30 days postprocedure and intervention at the time of endoscopy. RESULTS: 224 endoscopies for 203 patients with UGI bleeds were included within this study. 19 patients were diagnosed with COVID-19. There was a 44.4% reduction in the number of procedures performed between 2019 and 2020. Endoscopies performed for UGI bleeds in the COVID-19 era were associated with an adjusted reduced 30-day survival (OR 0.25, 95% CI 0.08-0.67). There was no increased risk of major rebleeding or interventions during this era. Patients with COVID-19 did not have reduced survival or increased complication rates. CONCLUSION: Endoscopy for UGI bleeds in the COVID-19 era is associated with reduced survival. No clear cause has been identified but we suspect that this is a secondary effect of the response to the COVID-19 pandemic. Urgent work is required to encourage the public to seek medical help if required and to optimise patient pathways to ensure that the best possible care is provided.

Bullshit Ability as an Honest Signal of Intelligence.

Navigating social systems efficiently is critical to our species. Humans appear endowed with a cognitive system that has formed to meet the unique challenges that emerge for highly social species. Bullshitting, communication characterised by an intent to be convincing or impressive without concern for truth, is ubiquitous within human societies. Across two studies (N = 1,017), we assess participants' ability to produce satisfying and seemingly accurate bullshit as an honest signal of their intelligence. We find that bullshit ability is associated with an individual's intelligence and individuals capable of producing more satisfying bullshit are judged by second-hand observers to be more intelligent. We interpret these results as adding evidence for intelligence being geared towards the navigation of social systems. The ability to produce satisfying bullshit may serve to assist individuals in negotiating their social world, both as an energetically efficient strategy for impressing others and as an honest signal of intelligence.

Controlling the narrative: Euphemistic language affects judgments of actions while avoiding perceptions of dishonesty.

The present work (N = 1906 U.S. residents) investigates the extent to which peoples' evaluations of actions can be biased by the strategic use of euphemistic (agreeable) and dysphemistic (disagreeable) terms. We find that participants' evaluations of actions are made more favorable by replacing a disagreeable term (e.g., torture) with a semantically related agreeable term (e.g., enhanced interrogation) in an act's description. Notably, the influence of agreeable and disagreeable terms was reduced (but not eliminated) when making actions less ambiguous by providing participants with a detailed description of each action. Despite their influence, participants judged both agreeable and disagreeable action descriptions as largely truthful and distinct from lies, and judged agents using such descriptions as more trustworthy and moral than liars. Overall, the results of the current study suggest that a strategic speaker can, through the careful use of language, sway the opinions of others in a preferred direction while avoiding many of the reputational costs associated with less subtle forms of linguistic manipulation (e.g., lying). Like the much-studied phenomenon of "fake news," manipulative language can serve as a tool for misleading the public, doing so not with falsehoods but rather the strategic use of language.

Experience from the first UK inter-regional specialist multidisciplinary meeting in the diagnosis and management of IgG4-related disease.

Immunoglobulin G4-related disease (IgG4-RD) is a complex multisystem fibro-inflammatory disorder, requiring diagnostic differentiation from malignancy and other immune-mediated conditions, and careful management to minimise glucocorticoid-induced toxicity and prevent progressive organ dysfunction. We describe the experience of the first inter-regional specialist IgG4-RD multidisciplinary team meeting (MDM) incorporating a broad range of generalists and specialists, held 6-weekly via web-link between Oxford University Hospitals NHS Foundation Trust and University College London Hospitals NHS Foundation Trust. Over 3 years, there were 206 discussions on 156 patients. Of these, 97 (62%) were considered to have definite or possible IgG4-RD; 67% had multi-organ involvement and 23% had a normal serum IgG4. The average number of specialist opinions sought prior to MDM was four per patient. Management was changed in the majority of patients (74%) with the treatment escalation recommended in 61 cases, including 19 for rituximab. Challenges arose from delays and misdiagnosis, cross-specialty presentation and the management of sub-clinical disease. Our cross-discipline IgG4-RD MDM enabled important diagnostic and management decisions in this complex multisystem disorder, and can be used as a model for other centres in the UK.