Increased colonic expression of ACE2 associates with poor prognosis in Crohn's disease.

The host receptor for SARS-CoV-2, angiotensin-converting enzyme 2 (ACE2), is highly expressed in small intestine. Our aim was to study colonic ACE2 expression in Crohn's disease (CD) and non-inflammatory bowel disease (non-IBD) controls. We hypothesized that the colonic expression levels of ACE2 impacts CD course. We examined the expression of colonic ACE2 in 67 adult CD and 14 NIBD control patients using RNA-seq and quantitative (q) RT-PCR. We validated ACE2 protein expression and localization in formalin-fixed, paraffin-embedded matched colon and ileal tissues using immunohistochemistry. The impact of increased ACE2 expression in CD for the risk of surgery was evaluated by a multivariate regression analysis and a Kaplan-Meier estimator. To provide critical support for the generality of our findings, we analyzed previously published RNA-seq data from two large independent cohorts of CD patients. Colonic ACE2 expression was significantly higher in a subset of adult CD patients which was defined as the ACE2-high CD subset. IHC in a sampling of ACE2-high CD patients confirmed high ACE2 protein expression in the colon and ileum compared to ACE2-low CD and NIBD patients. Notably, we found that ACE2-high CD patients are significantly more likely to undergo surgery within 5 years of CD diagnosis, and a Cox regression analysis found that high ACE2 levels is an independent risk factor for surgery (OR 2.17; 95% CI, 1.10-4.26; p = 0.025). Increased intestinal expression of ACE2 is associated with deteriorated clinical outcomes in CD patients. These data point to the need for molecular stratification that can impact CD disease-related outcomes.

Effect of Clear vs Standard Covered Masks on Communication With Patients During Surgical Clinic Encounters: A Randomized Clinical Trial.

Importance: During the COVID-19 pandemic, wearing masks has become necessary, especially within health care. However, to our knowledge, the consequences of mask wearing on communication between surgeons and patients have not been studied. Objective: To evaluate the effects of clear vs standard covered masks on communication during surgical clinic encounters. Design: This randomized clinical trial examined communication between surgeons and their patients when surgeons wore clear vs covered masks in surgical outpatient clinics at a single academic medical center. New patients were recruited from participating surgeons' clinic schedules. Interventions: Surgeons wore either clear masks or covered masks for each clinic visit with a new patient, based on a per-visit randomization plan. Main Outcomes and Measures: The primary outcome measures included patient perceptions of (1) surgeon communication and (2) trust in surgeons, as well as (3) quantitative assessments and (4) qualitative assessments regarding patient impressions of the surgeon's mask. After the clinic encounter, patients completed a verbal survey including validated Clinician and Group Consumer Assessment of Healthcare Providers and Systems questions. Additional questions involved surgeon empathy, trust, and the patient's impression of the surgeon's mask. Data were analyzed by comparing patient data in the clear vs covered groups using Cochran-Mantel-Haenszel tests, and comments were analyzed for themes. Results: Two hundred patients were enrolled from 15 surgeons' clinics spanning 7 subspecialties. When surgeons wore a clear mask, patients rated their surgeons higher for providing understandable explanations (clear, 95 of 100 [95%] vs covered, 78 of 100 [78%]; P < .001), demonstrating empathy (clear, 99 [99%] vs covered, 85 [85%]; P < .001), and building trust (clear, 94 [94%] vs covered, 72 [72%]; P < .001). Patients preferred clear masks (clear, 100 [100%] vs covered, 72 [72%]; P < .001), citing improved surgeon communication and appreciation for visualization of the face. Conversely, 8 of 15 surgeons (53%) were unlikely to choose the clear mask over their standard covered mask. Conclusions and Relevance: This randomized clinical trial demonstrates that patients prefer to see their surgeon's face. Surgeons who wore clear masks were perceived by patients to be better communicators, have more empathy, and elicit greater trust. Because masks will remain part of the health care landscape for some time, deliberate attention to preserving communication within the surgeon-patient relationship is warranted. Trial Registration: ClinicalTrials.gov Identifier: NCT04595695.

Building Rapport and Earning the Surgical Patient's Trust in the Era of Social Distancing: Teaching Patient-Centered Communication During Video Conference Encounters to Medical Students.

BACKGROUND: Effective physician communication improves care, and many medical schools and residency programs have adopted communication focused curricula. The COVID-19 pandemic has shifted the doctor-patient communication paradigm with the rapid adoption of video-based medical appointments by the majority of the medical community. The pandemic has also necessitated a sweeping move to online learning, including teaching and facilitating the practice of communication skills remotely. We aimed to identify effective techniques for surgeons to build relationships during a video consult, and to design and pilot a class that increased student skill in communicating during a video consult. METHODS: Fourth-year medical students matched into a surgical internship attended a 2-hour class virtually. The class provided suggestions for building rapport and earning trust with patients and families by video, role play sessions with a simulated patient, and group debriefing and feedback. A group debriefing generated lessons learned and best practices for telemedicine communication in surgery. RESULTS: Students felt the class introduced new skills and reinforced current ones; most reported higher self-confidence in target communication skills following the module. Students were particularly appreciative of opportunity for direct observation of skills and immediate faculty feedback, noting that the intimate setting was unique and valuable. Several elements of virtual communications required increased focus to communicate empathy and concern. Proper lighting and positioning relative to the camera were particularly important and body movement required "narration" to minimize misinterpretation. A patient's distress was more difficult to interpret; asking direct questions was recommended to understand the patient's emotional state. CONCLUSIONS: There is a need to teach video-conference communication skills to enable surgical teams to build rapport in this distinct form of consultation. Our training plan appears effective at engaging learners and improving skills and confidence, and identifies areas of focus when teaching virtual communication skills.