Research4Life (R4L) Scholar Program: New Initiative to Promote Diversity, Equity, and Inclusion in Medicine through a Bottom-Up Approach

Purpose and background: According to the Pew Research Center, Hispanics are 17% of the workforce but only represent 8% of people in a science, technology, engineering and math (STEM) position. African Americans are 11% of the workforce but hold 9% of STEM jobs. The Research4Life (R4L) program is designed to increase the number of minority students who pursue medical education and careers in Medicine and research. A formalized mentorship and clinical research program is one pipeline to increase representation of underrepresented groups in medicine and academic medical careers.(1) Description of Innovative Practice: The R4L scholar program is a structured summer scholar program offered by the Department of Internal Medicine (DOIM) at VCU and consists of an 8 to 10-week structured medical research experience combined with clinical shadowing experience for undergraduate students from underrepresented minority (URM) groups and minoritized communities. There is an unmet need to increase the presence of URM groups in the medical workforce.Primary goals:*Increase the students’ interest in Internal Medicine and academic careers and enhance the visibility of Internal Medicine.*Increase representation of URM groups in various medical fields by starting from early stages of college education.*Mitigate obstacles and increase access to high impact clinical research opportunities for students from URM groups.*Support the mission of the university to attract and retain a talented and diverse student body that will not only graduate at a high rate but will also go on to contribute to a highly skilled workforce.*Provide a model for other departments, institutions and universities to adopt and to promote diversity, equity and inclusion in medicine and academia.*Increase engagement of URM students in medical research and create a culture that reinforces their identity and a sense of belonging in the medical and academic fields. *Support undergraduates and medical students’ participation in community-based experiences through involvement in mentored scholarly activities and clinical training opportunities. Results/Impact: The primary outcomes of this project:-Increase the student’s interest in Internal Medicine, research and academic careers. The program requires completing a pre- and post- program survey to evaluate for change in students’ levels of interest in Medicine and academia due to participation in R4L program. Also, the post program survey includes questions about whether the student applied or got accepted to medical school or graduate studies to measure the program’s impact.-The program will help establish a future diverse inclusive workforce and close equity gaps in representation of minority groups in academic careers.-The R4L program creates a formal pathway for clinical training and research learning, sponsored by the Department of Internal Medicine.-The curriculum developed in this program will expand opportunities for students in many ways.-The program will provide a model for adoption by other departments and institutions for promotion of diversity, equity and inclusion through a structured clinical+research learning experience. Conclusion/Future Directions:-The R4L program will provide a model for other departments and institutions to adopt and replicate to promote diversity, equity and inclusion through a structured clinical+research learning experience.-The R4L program has a great generalizability potential as it can be applied to different settings, populations, communities, cultures, health systems, and countries.-This program can be applied in outpatient settings or low resource settings, and in diverse populations/communities. It can be implemented globally and can be modified easily to accommodate the different educational and health systems.-The R4L program will be expanded to increase the number of students participating in future offerings of the program, provide equitable opportunities to medical students (in addition to undergraduate students), and include students (undergraduates and medical students) from other colleges in Richmond especially the non-academic colleges/schools

Fibrosis-4 index is associated with the risk of hepatocellular carcinoma in patients with cirrhosis and nonalcoholic steatohepatitis

Background and aimsIdentification of high-risk patients for hepatocellular carcinoma (HCC) is essential for long term monitoring of nonalcoholic steatohepatitis (NASH) cirrhosis progression. We sought to evaluate the association between Fibrosis-4 (FIB-4) index and incidence of HCC risk among patients with NASH cirrhosis.MethodsWe conducted a retrospective cohort study of adult patients with NASH cirrhosis (n= 1,338) who were evaluated in a single medical center between 2005 and 2015. Those who developed HCC were identified through electronic medical records using International Classification of Diseases (ICD) 9 and 10 codes until the end of September 2021.ResultsDuring a median follow-up time of 3.7 years, 157 (11.7%) patients with NASH cirrhosis developed HCC. At index visit, the study population had a median age 57 years, 43% males, 78.8% White, and mean FIB-4 index 4.2. The final multivariable Cox regression model revealed that male sex, BMI 25-29.9 kg/m2, and hypertension were independent factors associated with development of HCC in patients with NASH cirrhosis. Compared to patients with FIB-4 ¾ 1.45, patients with FIB-4 between 1.45-3.25 had a similar hazard of HCC (Hazard Ratio [HR] 1.12, 95% CI: 0.67-1.86, p=0.670), whereas patients with FIB-4 >3.25 had a 1.93 (95% CI: 1.22-3.05, p=0.005) increased hazard of HCC.ConclusionFIB-4 > 3.25 was an independent factor associated with increased HCC risk among NASH cirrhosis patients. FIB-4 index is a promising tool for determining high-risk patients and may be used in routine clinical practice to monitor risk of HCC in patients with NASH cirrhosis

Recent advances in understanding and managing non-alcoholic fatty liver disease [version 1; referees: 2 approved]

Non-alcoholic fatty liver disease is a leading cause of chronic liver disease that can lead to cirrhosis, hepatocellular cancer, and end-stage liver disease, and it is linked to elevated cardiovascular- and cancer-related morbidity and mortality. Insulin resistance related to metabolic syndrome is the main pathogenic trigger that, in association with adverse genetic, lifestyle, and other factors, precipitates the development of non-alcoholic fatty liver disease. Biochemical markers and radiological imaging, along with liver biopsy in selected cases, help in the disease’s diagnosis and prognostication. Weight loss is the cornerstone treatment of non-alcoholic fatty liver disease; however, it is difficult to achieve and maintain, so pharmacotherapy was developed. The remarkable evolution in understanding disease pathogenesis has led to the development of new medical therapies and even the modification of currently available ones. This review summarizes recent advances in understanding the epidemiology, natural history, pathogenesis, diagnosis, and management of non-alcoholic fatty liver disease

Fibrosis Progression Rate in Biopsy-Proven Nonalcoholic Fatty Liver Disease Among People With Diabetes Versus People Without Diabetes: A Multicenter Study

Background & aimsThere are limited data regarding fibrosis progression in biopsy-proven nonalcoholic fatty liver disease (NAFLD) in people with type 2 diabetes mellitus (T2DM) compared with people without T2DM. We assessed the time to fibrosis progression in people with T2DM compared with people without T2DM in a large, multicenter, study of people with NAFLD who had paired liver biopsies.MethodsThis study included 447 adult participants (64% were female) with NAFLD who had paired liver biopsies more than 1 year apart. Liver histology was systematically assessed by a central pathology committee blinded to clinical data. The primary outcome was the cumulative incidence of a ≥1-stage increase in fibrosis in participants with T2DM compared with participants without T2DM.ResultsThe mean (SD) age and body mass index (calculated as weight in kilograms divided by the square of the height in meters) were 50.9 (11.5) years and 34.7 (6.3), respectively. The median time between biopsies was 3.3 years (interquartile range, 1.8-6.1 years). Participants with T2DM had a significantly higher cumulative incidence of fibrosis progression at 4 years (24% vs 20%), 8 years (60% vs 50%), and 12 years (93% vs 76%) (P = .005). Using a multivariable Cox proportional hazards model adjusted for multiple confounders, T2DM remained an independent predictor of fibrosis progression (adjusted hazard ratio, 1.69; 95% CI, 1.17-2.43; P = .005). The cumulative incidence of fibrosis regression by ≥1 stage was similar in participants with T2DM compared with participants without T2DM (P = .24).ConclusionsIn this large, multicenter cohort study of well-characterized participants with NAFLD and paired liver biopsies, we found that fibrosis progressed faster in participants with T2DM compared with participants without T2DM. These data have important implications for clinical practice and trial design

The Relationship Between Hypoadiponectinemia and Cardiovascular Events in Liver Transplant Recipients.

BACKGROUND: Cardiovascular disease (CVD) is an important cause of morbidity and mortality after liver transplantation (LT). Serum adiponectin levels inversely correlate with CVD-related outcomes, but the relationship between hypoadiponectinemia and CVD after LT is unknown. Thus, the aim of the present study was to prospectively evaluate this relationship in LT recipients (LTR). METHODS: LTR were prospectively enrolled (N = 130) between January 1, 2012, and January 1, 2014. Baseline adiponectin levels were drawn at enrollment and patients were followed for CVD events. Hypoadiponectinemia was defined as serum adiponectin \u3c10 \u3eµg/mL. The primary endpoint was a composite CVD outcome consisting of myocardial infarction, angina, need for coronary revascularization, stroke, or cardiac death. RESULTS: The mean age was 58 ± 11 years and prevalence of obesity, diabetes, and dyslipidemia was 40%, 35%, and 40%, respectively. A total of 20 CVD events were noted, after median follow up of 45 months. Hypoadiponectinemia was significantly associated with future risk of CVD events (hazard ratio, 3.519; 95% confidence interval, 1.180-10.499, P = 0.024). This association was independent of traditional CVD risk factors including age, gender, obesity, hypertension, diabetes, and choice of immunosuppression. CONCLUSIONS: Hypoadiponectinemia is a strong independent predictor of future cardiovascular events in LTR, which can be incorporated in clinical practice to assess CVD risk assessment after LT

Hospitalized Women With Cirrhosis Have More Nonhepatic Comorbidities and Associated Complications Than Men

Gender differences in the natural history of chronic liver disease have been well-described. Women have lower rates of chronic liver disease and slower fibrosis progression, yet higher rates of waitlist mortality.1,2 Although previous studies have identified several clinical factors including height and creatinine that explain some of this transplant disparity, most have used data from administrative records, which are limited in their ability to identify clinically relevant differences and opportunities for intervention to reduce disparities.3-5 Additionally, most studies have focused on the period between waitlist and transplant, failing to capture gender differences in access to transplant.3,6 In the present study, we took advantage of a multicenter inpatient cohort with granular clinical data to characterize how women and men with cirrhosis differ, to stimulate future research aimed at reducing the well-established gender disparity in liver transplantation

Small Dense Low‐Density Lipoprotein Cholesterol Predicts Cardiovascular Events in Liver Transplant Recipients

Cardiovascular disease (CVD) is an important cause of morbidity and mortality after liver transplantation (LT). Although LT is associated with dyslipidemia, particularly atherogenic lipoprotein subparticles, the impact of these subparticles on CVD-related events is unknown. Therefore, the aim of the current study was to evaluate the impact of small dense (sdLDL-C) low-density lipoprotein (LDL) cholesterol (LDL-C) on CVD events. Prospectively enrolled patients (N = 130) had detailed lipid profile consisting of traditional lipid parameters and sdLDL-C and were followed for CVD events. The primary endpoint was a CVD composite consisting of myocardial infarction (MI), angina, need for coronary revascularization, and cardiac death. Mean age of the cohort was 58 ± 11 years, and the most common etiology of liver disease (LD) was hepatitis C virus (N = 48) and nonalcoholic steatohepatitis (N = 23). A total of 20 CVD events were noted after median follow-up of 45 months. The baseline traditional profile was similar in patients with and without CVD events. A serum LDL-C cutoff of 100 mg/dL was unable to identify individuals at risk of a CVD event (P = 0.86). In contrast, serum concentration of atherogenic sdLDL-C \u3e25 mg/dL was predictive of CVD events with a hazard ratio of 6.376 (95% confidence interval, 2.65, 15.34; P \u3c 0.001). This relationship was independent of diabetes, hypertension, sex, ethnicity, LD, obesity, and statin use. Conclusion: sdLDL-C independently predicted CVD events whereas LDL-C did not. Thus, sdLDL-C may provide a useful clinical tool in risk stratifying and managing patients after LT

Liver cancer understaging in liver transplantation in the current era of radiologic imaging and newer generation locoregional therapies

Background: Discordance in hepatocellular carcinoma (HCC) staging between pre-transplant imaging and explant pathology is associated with an increased risk of recurrence and death. Our aim was to evaluate variables that predicted concordance/discordance in the era of new generation locoregional therapies (LRT) and improved radiologic technology in diagnosis. Methods: A single-center retrospective study was performed on patients who received a liver transplant for HCC between 2008-2019. Pre- and post-LT variables, including type of LRT, downstaging (DS), transplant time period, and radiologic response to LRT, were analyzed for concordance/discordance. Kaplan-Meier analysis was used to assess post-LT survival. Results: Of 146 patients transplanted within Milan Criteria (MC), discordance rates (understaged) were 45%. Discordance was associated with ≥ 3 HCC lesions at diagnosis but not newer generation LRT (transarterial radioembolization/ stereotactic body radiation therapy), traditional LRT or combination. No differences in discordance were seen between transplant periods (2008-2013 vs. 2014-2019), but those within MC in the earlier period had higher concordance rates. A trend was observed between DS and discordance. Conclusion: HCC stage discordance remains common and poorly predictable. Discordance was associated with three or more HCC lesions at the time of diagnosis. Patients within MC transplanted between 2008-2013 was associated with concordance, while a trend was noted between DS and discordance. No other pre- or post- LT variables predicted discordance/ concordance. Discordance was associated with decreased survival