Effectiveness of immune checkpoint inhibitor therapy on bone metastases in non-small-cell lung cancer.

Background: Bone metastases (BoMs) are prevalent in patients with metastatic non-small-cell lung cancer (NSCLC) however, there are limited data detailing how BoMs respond to immune checkpoint inhibitors (ICIs). The purpose of this study was to compare the imaging response to ICIs of BoMs against visceral metastases and to evaluate the effect of BoMs on survival. Materials and methods: A retrospective, multicentre cohort study was conducted in patients with NSCLC treated with nivolumab or pembrolizumab in Alberta, Canada from 2015 to 2020. The primary endpoint was the real-world organ specific progression free survival (osPFS) of bone versus visceral metastases. Visceral metastases were categorized as adrenal, brain, liver, lung, lymph node, or other intra-abdominal lesions. The secondary outcome was overall survival (OS) amongst patients with and without BoMs. Results: A total of 573 patients were included of which all patients had visceral metastases and 243 patients (42.4%) had BoMs. High PD-L1 expression was identified in 268 patients (46.8%). No significant difference in osPFS was observed between bone, liver, and intra-abdominal metastases (p=0.20 and p=0.76, respectively), with all showing shorter osPFS than other disease sites. There was no difference in the osPFS of extra-thoracic sites of disease in patients with high PD-L1 expression. There was significant discordance between visceral disease response and bone disease response to ICI (p=0.047). The presence of BoMs was an independent poor prognostic factor for OS (HR 1.26, 95%CI: 1.05-1.53, p=0.01). Conclusion: Metastatic bone, liver, and intra-abdominal lesions demonstrated inferior clinical responses to ICI relative to other sites of disease. Additionally, the presence of bone and liver metastases were independent poor prognostic factors for overall survival. This real-world data suggests that BoMs respond poorly to ICI and may require treatment adjuncts for disease control.

Vertical pelvic movement asymmetry and lameness location in ipsilateral combined forelimb and hindlimb lameness cases.

BACKGROUND: Compensatory vertical head and pelvis movement asymmetry may occur in trotting horses with a primary cause of lameness in one end of the body due to the weight shifting between limbs, leading to apparent combined forelimb and hindlimb lameness (CFHL). Little is known about CFHL patterns observed with body-mounted inertial sensors (BMIS) and regardless of their underlying mechanisms, compensatory and secondary lameness may complicate the definitive identification of the primary causes of lameness. OBJECTIVE: Determine associations between vertical pelvic movement asymmetry and location of primary lameness in ipsilateral CFHL cases where hindlimb lameness is solely impact or push-off type. STUDY DESIGN: Retrospective cohort. METHODS: From a body-mounted inertial sensor (BMIS) evaluated equine lameness database, we identified cases with a consistent, low-variability ipsilateral impact (IpI) or ipsilateral pushoff (IpP) hindlimb lameness in a straight-line trot and that had definitive diagnoses. Cases were categorised by lameness location to the limb(s), diagnosis, and ratio of the amplitude of forelimb to hindlimb lameness (Forea/Hinda). Differences in the numbers of IpI and IpP cases in these categories were analysed with chi-square tests, effect sizes, and odds ratios. RESULTS: Among the 2375 total lameness cases screened, 49 IpI and 36 IpP cases met the criteria for consistency, low variability, and definitive diagnosis. IpI cases were more likely than IpP cases to have forelimb-only lameness causes when Forea/Hinda >1 (OR = 43, 95% CI = 2.3-798). IpP cases were more likely than IpI cases to have hindlimb-only causes at both Forea/Hinda >1.0 (OR = 20, 95% CI = 2.2-200) and <1.0 (OR = 14, 95% CI = 2.9-66.7). Compared with IpI, IpP cases were more frequently diagnosed with tendon, suspensory ligament, or high-motion joint disorders in hindlimbs (OR = 3.6, 95% CI = 1.1-12.3) and less with unknown causes (OR = 13.2, 95% CI = 3.2-75.2). In IpI cases, positive forelimb regional anaesthesia often reduced hindlimb lameness, whereas in IpP cases, positive hindlimb regional anaesthesia typically lessened forelimb lameness. MAIN LIMITATIONS: Most cases were Quarter Horses. The likelihood of location and cause of lameness may be different for other breeds. CONCLUSIONS: The type of pelvic movement asymmetry observed in IpI and IpP cases is linked to the location and underlying cause of the primary lameness.

Key Considerations for Studying the Effects of High-Fat Diet on the Nulligravid Mouse Endometrium.

The obesity epidemic continues to increase, with half of US women predicted to be obese by 2030. Women with obesity are at increased risk for not only cardiovascular and liver disease, but also reproductive disorders. Although mouse models are useful in studying the effects of obesity, there is inconsistency in obesity-induction methods, diet composition, and mouse strains, and studies using female mice are limited. In this study, we sought to compare the effects of a 45% high-fat diet (HFD) versus a 60% HFD on the uterine estrous cycle of nulligravid C57BL/6J mice. For 22 weeks, we placed a total of 20 mice on either a 60% HFD, 45% HFD, or each HFD-matched control diet (CD). Both HFDs produced significant weight gain, with 60% HFD and 45% HFD gaining significant weight after 2 weeks and 15 weeks, respectively. Additionally, both HFDs led to glucose intolerance, fatty liver, and adipocyte hypertrophy. Mice fed 60% HFD displayed hyperphagia in the first 12 weeks of HFD treatment. Moreover, 60% HFD-treated mice had a longer estrous cycle length and an increased percentage of estrus stage samplings compared to CD-treated mice. Estrous cycle stage-controlled 60% HFD-treated mice displayed an increased estrogen-to-progesterone ratio and decreased ovarian corpora lutea compared to CD-treated mice, which may underlie the observed estrous cycle differences. There was no significant difference between diets regarding endometrial morphology or the percent of endometrial CD45+ immune cells. Our results indicate that consideration is needed when selecting a HFD-induced obesity mouse model for research involving female reproductive health.

Upregulation of HOXA3 by isoform-specific Wilms tumour 1 drives chemotherapy resistance in acute myeloid leukaemia.

Upregulation of the Wilms' tumour 1 (WT1) gene is common in acute myeloid leukaemia (AML) and is associated with poor prognosis. WT1 generates 12 primary transcripts through different translation initiation sites and alternative splicing. The short WT1 transcripts express abundantly in primary leukaemia samples. We observed that overexpression of short WT1 transcripts lacking exon 5 with and without the KTS motif (sWT1+/- and sWT1-/-) led to reduced cell growth. However, only sWT1+/- overexpression resulted in decreased CD71 expression, G1 arrest, and cytarabine resistance. Primary AML patient cells with low CD71 expression exhibit resistance to cytarabine, suggesting that CD71 may serve as a potential biomarker for chemotherapy. RNAseq differential expressed gene analysis identified two transcription factors, HOXA3 and GATA2, that are specifically upregulated in sWT1+/- cells, whereas CDKN1A is upregulated in sWT1-/- cells. Overexpression of either HOXA3 or GATA2 reproduced the effects of sWT1+/-, including decreased cell growth, G1 arrest, reduced CD71 expression and cytarabine resistance. HOXA3 expression correlates with chemotherapy response and overall survival in NPM1 mutation-negative leukaemia specimens. Overexpression of HOXA3 leads to drug resistance against a broad spectrum of chemotherapeutic agents. Our results suggest that WT1 regulates cell proliferation and drug sensitivity in an isoform-specific manner.

Five-year analysis of neoadjuvant dabrafenib and trametinib for stage III melanoma.

BACKGROUND: Neoadjuvant dabrafenib plus trametinib has a high pathological response rate and impressive short-term survival in patients with resectable stage III melanoma. We report 5-year outcomes from the phase II NeoCombi trial. PATIENTS AND METHODS: NeoCombi (NCT01972347) was a single-arm, open-label, single-centre, phase II trial. Eligible patients were adults (aged ≥18 years) with histologically confirmed, resectable, RECIST-measurable, American Joint Committee on Cancer seventh edition clinical stage IIIB-C BRAF V600E/K-mutant melanoma and Eastern Cooperative Oncology Group performance status ≤1. Patients received 52 weeks of treatment with dabrafenib 150 mg (orally twice per day) plus trametinib 2 mg (orally once per day), with complete resection of the pre-therapy tumour bed at week 12. RESULTS: Between 20 August 2014 and 19 April 2017, 35 patients were enrolled. At data cut-off (17 August 2021), the median follow-up was 60 months [95% confidence interval (CI) 56-72 months]. Overall, 21 of 35 (60%) patients recurred, including 12 (57%) with first recurrence in locoregional sites (followed by later distant recurrence in 6) and 9 (43%) with first recurrence in distant sites, including 3 in the brain. Most recurrences occurred within 2 years, with no recurrences beyond 3 years. At 5 years, recurrence-free survival (RFS) was 40% (95% CI 27% to 60%), distant metastasis-free survival (DMFS) was 57% (95% CI 42% to 76%), and overall survival was 80% (95% CI 67% to 94%). Five-year survival outcomes were stratified by pathological response: RFS was 53% with pathological complete response (pCR) versus 28% with non-pCR (P = 0.087), DMFS was 59% versus 55% (P = 0.647), and overall survival was 88% versus 71% (P = 0.205), respectively. CONCLUSIONS: Neoadjuvant dabrafenib plus trametinib has high pathological response rates in clinical stage III melanoma, but low rates of RFS, similar to those achieved with adjuvant targeted therapy alone. Patients with a pCR to dabrafenib plus trametinib still had a high risk of recurrence, unlike that seen with immunotherapy where recurrences are rare.

Perceived workplace discrimination on the basis of parent status in Australia: who is vulnerable and how does it link to mothers' and fathers' mental health?

OBJECTIVE: This study focused on employees' perceived discrimination due to parenthood; and mental health, occupational stress and turnover intention. METHODS: Survey (2016) of an Australian convenience sample of employed parents: women (n = 2950) and men (n = 1318). RESULTS: Forty-two percent of all mothers reported missing out on promotion (n = 1,234/2950); one third reported negative comments from managers (n = 805/2950, 27%) or colleagues (n = 832/2950, 28%). One in five fathers reported these forms of discrimination. In adjusted analyses perceived discrimination was associated with poorer mental health (ß = 0.23, p < .001); higher occupational stress (ß = 0.30, p < .001); and increased odds of turnover intention (aOR = 1.5, p < .001) for mothers; and poorer mental health (ß = 0.34, p < .001); stress (ß = 0.35, p < .001); and increased odds of turnover intention (aOR = 1.7, p < .001) for fathers. CONCLUSIONS: Experiences of negativity and hostility at work are common, and link to employee health and wellbeing.

Impact of aerobic granular sludge sizes and dissolved oxygen concentration on greenhouse gas N2O emission.

Aerobic granular sludge (AGS) at wastewater treatment plants (WWTPs) are known to produce nitrous oxide (N2O), a greenhouse gas which has a ∼300 times higher global warming potential than carbon dioxide. In this research, we studied N2O emissions from different sizes of AGS developed at a dissolved oxygen (DO) level of 2 mgO2/L while exposing them to disturbances at various DO concentrations ranging from 1 to 4 mgO2/L. Five different AGS size classes were studied: 212-600 µm, 600-1000 µm, 1000-1400 µm, 1400-2000 µm, and > 2000 µm. Metagenomic data showed N2O reductase genes (nosZ) were more abundant in the smaller AGS sizes which aligned with the observation of higher N2O reduction rates in small AGS under anaerobic conditions. However, when oxygen was present, the activity measurements of N2O emission showed an opposite trend compared to metagenomic data, smaller AGS (212 to 1000 µm) emitted significantly higher N2O (p < 0.05) than larger AGS (1000 µm to >2000 µm) at DO of 2, 3, and 4 mgO2/L. The N2O emission rate showed positive correlation with both oxygen levels and nitrification rate. This pattern indicates a connection between N2O emission and nitrification. In addition, the data suggested the penetration of oxygen into the anoxic zone of granules might have hindered nitrous oxide reduction, resulting in incomplete denitrification stopping at N2O and consequently contributing to an increase in N2O emissions. This work sets the stage to better understand the impacts of AGS size on N2O emissions in WWTPs under different disturbance of DO conditions, and thus ensure that wastewater treatment will comply with possible future regulations demanding lowering greenhouse gas emissions in an effort to combat climate change.

Develop Your CORE2 for Career Flourishing: A Career Development Workshop for Hospitalists.

Introduction: Appreciative inquiry harnesses an individual's strengths to realize positive change, and a flourishing-focused mindset emphasizes engagement, social connectivity, and seeking meaningful work. Though the impact of these models on physician well-being and career planning has been evaluated in graduate medical education, their integration into career development initiatives for faculty has been limited. We designed a workshop to nurture hospitalist career development, based on our CORE2 conceptual framework (character strengths, overall vision, role assessment, explicit goals, and evaluation). Methods: We presented the workshop at the 2022 and 2023 Society of Hospital Medicine (SHM) annual conferences. This 1.5-hour workshop comprised four modules and three small-group activities designed to help participants identify their signature character strengths, draft a professional vision statement, prioritize professional roles, and develop SMART goals aligned with these roles. Results: At the 2023 SHM annual conference, 36 participants attended the workshop, and 32 (89%) completed pre- and postworkshop surveys. After workshop completion, participants' self-assessed familiarity with their signature character strengths, knowledge of evidence-based principles to develop SMART goals, and confidence in their ability to write a vision statement and SMART goals all increased significantly (p < .05). Discussion: This workshop provides a valuable framework for self-directed longitudinal career development and reflection. We build on prior curricula on educator identity formation by guiding participants from identity definition to professional vision development to professional role evaluation to aligned goal creation and iterative evaluation. Our workshop's principles are readily generalizable to clinician-educators across medical disciplines.

Racializing Motherhood and Maternity Care in News Representations of Breastfeeding.

Racial inequalities in breastfeeding have been a U.S. national concern, prompting health science research and public discourse. Social science research reveals structural causes, including racism in labor conditions, maternity care practices, and lactation support. Yet research shows that popular and health science discourses disproportionately focus on individual and community factors, blaming Black women and communities for unequal breastfeeding rates. This study examines how scientific reports are communicated to the public through a critical analysis of 104 U.S. news articles reporting research on racial disparities in breastfeeding. Findings show that articles acknowledge unequal treatment within maternity care but justify it by presenting Black patients as overburdening the maternity care systems they use due to low socioeconomic status, welfare dependency, poor family support, and poor health. Through these representations, articles co-construct racialized motherhood and maternity care systems in ways that hide manifestations of obstetric racism and combat social support for systemic change.

"I didn't want to let go of the dream": Exploring women's personal stories of how their low milk supply was discovered.

PROBLEM: Low milk supply is the most common reason women give for stopping breastfeeding early and yet there is a lack of understanding about these women's experiences. BACKGROUND: Most women plan to breastfeed but many experience challenges such as low milk production, leading them to seek help and support. AIM: To explore women's personal stories of how their low supply was discovered. METHODS: Inductive template analysis was used to analyse free-text online survey responses of women from the United States of America, Australia and the United Kingdom. FINDINGS: 384 women responded to the open-ended survey item between October 2021 and January 2022. We identified three themes: (i) Events and observations: From 'risk factors' to 'failure of breast changes' to 'my baby was so unhappy', (ii) Seeking support and taking action: 'I tried everything' and (iii) A rollercoaster of emotion: 'I didn't want to let go of the dream'. DISCUSSION: Our findings emphasise women's need to feel heard and understood and their quest to find answers. The rollercoaster of emotions they experienced largely stemmed from a gap between the expectations and reality of breastfeeding. Some participants described accepting a different feeding journey. CONCLUSION: Findings underscore the need for quality and accessible psychosocial support for women experiencing low milk supply, in addition to the provision of evidence-based advice.

Genetic loci regulate Sarbecovirus pathogenesis: A comparison across mice and humans.

Coronavirus (CoV) cause considerable morbidity and mortality in humans and other mammals, as evidenced by the emergence of Severe Acute Respiratory CoV (SARS-CoV) in 2003, Middle East Respiratory CoV (MERS-CoV) in 2012, and SARS-CoV-2 in 2019. Although poorly characterized, natural genetic variation in human and other mammals modulate virus pathogenesis, as reflected by the spectrum of clinical outcomes ranging from asymptomatic infections to lethal disease. Using multiple human epidemic and zoonotic Sarbecoviruses, coupled with murine Collaborative Cross genetic reference populations, we identify several dozen quantitative trait loci that regulate SARS-like group-2B CoV pathogenesis and replication. Under a Chr4 QTL, we deleted a candidate interferon stimulated gene, Trim14 which resulted in enhanced SARS-CoV titers and clinical disease, suggesting an antiviral role during infection. Importantly, about 60 % of the murine QTL encode susceptibility genes identified as priority candidates from human genome-wide association studies (GWAS) studies after SARS-CoV-2 infection, suggesting that similar selective forces have targeted analogous genes and pathways to regulate Sarbecovirus disease across diverse mammalian hosts. These studies provide an experimental platform in rodents to investigate the molecular-genetic mechanisms by which potential cross mammalian susceptibility loci and genes regulate type-specific and cross-SARS-like group 2B CoV replication, immunity, and pathogenesis in rodent models. Our study also provides a paradigm for identifying susceptibility loci for other highly heterogeneous and virulent viruses that sporadically emerge from zoonotic reservoirs to plague human and animal populations.

Targeting CCL2/CCR2 Signaling Overcomes MEK Inhibitor Resistance in Acute Myeloid Leukemia.

PURPOSE: Emerging evidence underscores the critical role of extrinsic factors within the microenvironment in protecting leukemia cells from therapeutic interventions, driving disease progression, and promoting drug resistance in acute myeloid leukemia (AML). This finding emphasizes the need for the identification of targeted therapies that inhibit intrinsic and extrinsic signaling to overcome drug resistance in AML. EXPERIMENTAL DESIGN: We performed a comprehensive analysis utilizing a cohort of ∼300 AML patient samples. This analysis encompassed the evaluation of secreted cytokines/growth factors, gene expression, and ex vivo drug sensitivity to small molecules. Our investigation pinpointed a notable association between elevated levels of CCL2 and diminished sensitivity to the MEK inhibitors (MEKi). We validated this association through loss-of-function and pharmacologic inhibition studies. Further, we deployed global phosphoproteomics and CRISPR/Cas9 screening to identify the mechanism of CCR2-mediated MEKi resistance in AML. RESULTS: Our multifaceted analysis unveiled that CCL2 activates multiple prosurvival pathways, including MAPK and cell-cycle regulation in MEKi-resistant cells. Employing combination strategies to simultaneously target these pathways heightened growth inhibition in AML cells. Both genetic and pharmacologic inhibition of CCR2 sensitized AML cells to trametinib, suppressing proliferation while enhancing apoptosis. These findings underscore a new role for CCL2 in MEKi resistance, offering combination therapies as an avenue to circumvent this resistance. CONCLUSIONS: Our study demonstrates a compelling rationale for translating CCL2/CCR2 axis inhibitors in combination with MEK pathway-targeting therapies, as a potent strategy for combating drug resistance in AML. This approach has the potential to enhance the efficacy of treatments to improve AML patient outcomes.

Immersive distance simulation: Exploring the educational impact of stereoscopic extended reality (XR) video in remote learning environments.

What was the educational challenge?There is a growing need for healthcare simulation options when local expertise or resources are not available. To connect instructors with remote learners, current options for distance simulation are typically limited to videoconferencing on desktop computers or mobile devices, which may not fully capture the complexity of clinical scenarios.What was the solution?Extended reality (XR) technology may provide a more immersive and realistic distance healthcare simulation experience compared to traditional videoconferencing options. Unlike computer- or phone-based video calls, stereoscopic video in XR provides a sense of depth that may increase spatial understanding and engagement in distance simulation.How was the solution implemented?We investigated the impact of XR for synchronous distance simulation compared to traditional desktop-based videoconferencing in Emergency Medicine (EM) resident training for an obstetrical emergency. A randomized controlled experiment was conducted with half of the residents using XR and half using computers to participate in the simulation.What lessons were learned that are relevant to a wider global audience?There was an unanticipated interaction between postgraduate year and condition such that performance in the XR condition was superior for first year residents, while this was reversed for more experienced residents. This indicates that the benefits of XR might be dependent on participant characteristics, such as learner level.What are the next steps?We plan to extend this research to clarify characteristics of learners and tasks that are important determinants of differences in outcomes between stereoscopic XR versus traditional videoconference displays.

Oxygen-Saturation Targets and Cognitive and Functional Outcomes in Mechanically Ventilated Adults.

Rationale: Among mechanically ventilated critically ill adults, the PILOT (Pragmatic Investigation of Optimal Oxygen Targets) trial demonstrated no difference in ventilator-free days among lower, intermediate, and higher oxygen-saturation targets. The effects on long-term cognition and related outcomes are unknown.Objectives: To compare the effects of lower (90% [range, 88-92%]), intermediate (94% [range, 92-96%]), and higher (98% [range, 96-100%]) oxygen-saturation targets on long-term outcomes.Methods: Twelve months after enrollment in the PILOT trial, blinded neuropsychological raters conducted assessments of cognition, disability, employment status, and quality of life. The primary outcome was global cognition as measured using the Telephone Montreal Cognitive Assessment. In a subset of patients, an expanded neuropsychological battery measured executive function, attention, immediate and delayed memory, verbal fluency, and abstraction.Measurements and Main Results: A total of 501 patients completed follow-up, including 142 in the lower, 186 in the intermediate, and 173 in the higher oxygen target groups. Median (interquartile range) peripheral oxygen saturation values in the lower, intermediate, and higher target groups were 94% (91-96%), 95% (93-97%), and 97% (95-99%), respectively. Telephone Montreal Cognitive Assessment score did not differ between lower and intermediate (adjusted odds ratio [OR], 1.36 [95% confidence interval (CI), 0.92-2.00]), intermediate and higher (adjusted OR, 0.90 [95% CI, 0.62-1.29]), or higher and lower (adjusted OR, 1.22 [95% CI, 0.83-1.79]) target groups. There was also no difference in individual cognitive domains, disability, employment, or quality of life.Conclusions: Among mechanically ventilated critically ill adults who completed follow-up at 12 months, oxygen-saturation targets were not associated with cognition or related outcomes.

Understanding the Effects of Health Care Distance Simulation: A Systematic Review.

ABSTRACT: The use of distance simulation has rapidly expanded in recent years with the physical distance requirements of the COVID-19 pandemic. With this development, there has been a concurrent increase in research activities and publications on distance simulation. The authors conducted a systematic review of the peer-reviewed distance health care simulation literature. Data extraction and a risk-of-bias assessment were performed on selected articles. Review of the databases and gray literature reference lists identified 10,588 titles for review. Of those, 570 full-text articles were assessed, with 54 articles included in the final analysis. Most of these were published during the COVID-19 pandemic (2020-2022). None of the included studies examined an outcome higher than a Kirkpatrick level of 2. Most studies only examined low-level outcomes such as satisfaction with the simulation session. There was, however, a distinction in studies that were conducted in a learning environment where all participants were in different locations ("distance only") as compared with where some of the participants shared the same location ("mixed distance"). This review exclusively considered studies that focused solely on distance. More comparative studies exploring higher level outcomes are required to move the field forward.

Health Care Simulation in Person and at a Distance: A Systematic Review.

ABSTRACT: Distance simulation is a method of health care training in which the learners and facilitators are in different physical locations. Although methods of distance simulation have existed in health care for decades, this approach to education became much more prevalent during the COVID-19 pandemic. This systematic review studies a subset of distance simulation that includes combined in-person and distance simulation elements, identified here as "mixed- distance simulation." A review of the distance simulation literature identified 10,929 articles. Screened by inclusion and exclusion criteria, 34 articles were ultimately included in this review. The findings of this review present positive and negative aspects of mixed-distance simulation formats, a description of the most frequent configurations related to delivery, terminology challenges, as well as future directions including the need for faculty development, methodological rigor, and reporting details.

Gendered Responses to Fear of Victimization? A Comparative Study of Students' Precautionary and Avoidance Strategies in Suburban and Urban Contexts.

The purpose of this study was to understand how gender shapes women's and men's behavioral responses to fear of crime and whether their use of these strategies varies by context. Interviews were conducted with 70 undergraduates attending universities in two distinct community settings. Regardless of campus context, the findings revealed that women and men at both institutions used similar types of precautionary and defensive behaviors to manage their fear of crime and perceptions of risk; however, the prevalence with which they used these strategies was quite gendered. More complex patterns were revealed for women's and men's use of avoidance behaviors.

"Deficiency in ELF4, X-Linked": a Monogenic Disease Entity Resembling Behçet's Syndrome and Inflammatory Bowel Disease.

Defining monogenic drivers of autoinflammatory syndromes elucidates mechanisms of disease in patients with these inborn errors of immunity and can facilitate targeted therapeutic interventions. Here, we describe a cohort of patients with a Behçet's- and inflammatory bowel disease (IBD)-like disorder termed "deficiency in ELF4, X-linked" (DEX) affecting males with loss-of-function variants in the ELF4 transcription factor gene located on the X chromosome. An international cohort of fourteen DEX patients was assessed to identify unifying clinical manifestations and diagnostic criteria as well as collate findings informing therapeutic responses. DEX patients exhibit a heterogeneous clinical phenotype including weight loss, oral and gastrointestinal aphthous ulcers, fevers, skin inflammation, gastrointestinal symptoms, arthritis, arthralgia, and myalgia, with findings of increased inflammatory markers, anemia, neutrophilic leukocytosis, thrombocytosis, intermittently low natural killer and class-switched memory B cells, and increased inflammatory cytokines in the serum. Patients have been predominantly treated with anti-inflammatory agents, with the majority of DEX patients treated with biologics targeting TNFα.