Eastern Virginia Medical School (EVMS) is a public medical school in Norfolk, Virginia.Founded by grassroots efforts in the Southeastern part of Virginia known as Hampton Roads, EVMS is not affiliated with an undergraduate institution and coordinates training through multiple medical centers in the Hampton Roads region. EVMS campus includes the 555-bed Sentara Norfolk General Hospital, the region's only tertiary level 1 trauma medical care facility, and the 212-bed Children's Hospital of The King's Daughters, a regional pediatric referral care facility and only stand-alone children's hospital in the state. EVMS is the first institution in the US to have produced a viable fetus through in vitro fertilization. EVMS is most known for its reproductive medicine, simulation/standardized-patient education as well as research in pediatrics, geriatrics, diabetes, and cancer. In addition, EVMS is well known for its leadership in community service and medical missions, as evidenced by faculty and alumni responsible for the founding of Operation Smile, Physicians for Peace, Global Brigades, and CONRAD.
Background:. Wound complications following primary closure after abdominoperineal resection reach rates of up to 66%. The de-epithelialized V-Y flap has emerged as a common closure technique, particularly in irradiated patients. This study evaluates the 10-year experience of the modified V-Y flap at our institution. Methods:. A retrospective review of patients who underwent de-epithelialized V-Y flap reconstruction for abdominoperineal resection defects between 2013 and 2024 was performed. An analysis of wound complications (eg, infections, dehiscence) and surgical outcomes (eg, reoperations, readmissions) was performed. Multivariate logistic regression assessed the effects of comorbidities and operative factors on wound complications, 30-day reoperations, 30-day readmissions, interventional radiology drainage, and length of stay. Results:. Eighty-three patients were included, with a wound complication rate of 30.1%. The most common complication was pelvic fluid collections (22.9%), followed by dehiscence (21.7%). Within 30 days, 6 (7.2%) patients required reoperation, and 13 (15.7%) patients were readmitted. Patients with chronic obstructive pulmonary disease (P = 0.046) or atrial fibrillation (P = 0.048) were more likely to have wound complications. Mesh use (n = 6) was associated with higher wound complications (P = 0.02), reoperations (P = 0.03), readmissions (P < 0.001), and interventional radiology drainage (P = 0.01). Conclusions:. The modified V-Y flap demonstrated improved wound complication with more robust data compared with our prior study. Patients with chronic obstructive pulmonary disease or atrial fibrillation may face higher risks of wound complications. Mesh use was associated with an increased rate of complications and interventions.
This publication represents the first part of an update to the clinical practice guideline on the diagnosis and management of group A streptococcal (Streptococcus pyogenes or GAS) pharyngitis, developed by the Infectious Diseases Society of America (IDSA). Diagnosis of GAS pharyngitis by clinician judgement alone is unreliable, and unselective testing incurs cost and inconvenience for individuals at low risk of having GAS infection. Clinical scoring systems have been used to quantify the probability of a positive GAS throat culture based on standardized criteria such as the presence of fever; tonsillar enlargement or exudate; tender and enlarged anterior cervical lymph nodes; and the absence of cough. The goal of this paper is to determine whether a scoring system should be used to decide which patients should have a diagnostic test performed by rapid antigen detection test (RADT), molecular methods, and/or throat culture. We performed a systematic review of randomized and non-randomized studies that compared the use of a clinical scoring system to clinician judgement alone in predicting the outcome of a throat culture. Evidence from studies in children and adults suggests the diagnostic accuracy of a clinical scoring system is comparable to or slightly higher than clinician judgement alone. However, the studies are limited due to small size, lack of uniformity in outcome measures, and incomplete data. The consensus of the panel is that the balance of benefits and harms favors use of a clinical scoring system as part of the evaluation of patients with sore throat. The principal utility of using a scoring system is to identify patients with low probability of GAS pharyngitis and to reduce unnecessary testing.
Importance:The improvement of childhood cancer outcomes has relied on clinical trials, primarily from high-income countries (HICs). Inconsistent access to clinical trials, especially in low-income countries (LICs) and middle-income countries, contributes to disparate care and limits the generalizability of conclusions from trials conducted in HICs. Objective:To describe the global availability of clinical trials for children and adolescents with cancer in different economic settings. Design, Setting, and Participants:In this cross-sectional study, the World Health Organization's International Clinical Trials Registry Platform was used to search for clinical trials on May 8, 2024. Trials were included if they were interventional studies for pediatric patients (<18 years old) with an active cancer diagnosis. Main Outcomes and Measures:Clinical trials were analyzed based on geographic location, World Bank country income classification, and trial characteristics, including study phase, sponsor type, intervention type, and inclusion criteria. The main outcome was differences between HICs and low- and middle-income countries in the availability, design, and results of clinical trials for children and adolescents with cancer. Results:Of 138 595 oncology trials, 5645 met the inclusion criteria. Of these, 3149 (55.8%) were pediatrics-only trials. Most pediatrics-only trials (2558 of 3149 [81.2%]) were conducted by sponsors in HICs. Among identified trials, 12.5% (394 of 3149) were open for accrual in upper-middle-income countries (UMICs), 8.9% (281 of 3149) in lower-middle-income countries (LMICs), and 0.2% (7 of 3149) in LICs. Compared with HICs, LMICs or LICs registered fewer early-phase trials (28.8% [42 of 146] vs 81.4% [1709 of 2100]; P < .001), trials with cancer-directed treatments (17.6% [46 of 262] vs 76.8% [1964 of 2558]; P < .001), and multi-institutional trials (6.5% [17 of 262] vs 54.2% [1386 of 2558]; P < .001). LMICs or LICs registered more supportive care-based trials (81.7% [214 of 262] vs 19.9% [509 or 2558]; P < .001). Supportive care trials, later-phase trials, and trials from UMICs, LMICs, and LICs were more likely to publish clinical trial results within 10 years. Conclusions and Relevance:In this cross-sectional study of global pediatric oncology clinical trials, low- and middle-income countries were underrepresented. These data illustrate the need to improve the clinical research infrastructure in low- and middle-income countries and foster inclusive collaborations to promote equity in global pediatric cancer clinical trials.
OBJECTIVE:Up to 1.6% of patients with endometriosis develop epithelial ovarian carcinoma. The genetic overlap between endometriosis and ovarian cancer has not been fully characterized. This review aims to describe the current literature on mutations correlated with endometriosis-associated epithelial ovarian carcinoma. METHODS:In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO ID: CRD42023400697), Cochrane Library, Embase, PubMed, Scopus, and Web of Science Core Collection databases were queried from January 1st, 1995, to April 1st, 2022 for English language studies on the genetic basis of endometriosis-associated epithelial ovarian carcinoma. The quality of included studies was assessed using the Newcastle-Ottawa Scale. RESULTS:Search criteria yielded 18,639 articles, of which 30 met inclusion criteria. 70 genes were assessed in the 30 included studies, and 9 of these appeared in two or more studies. The most frequently mutated genes were PIK3CA, PTEN, ARID1A and CTNNB1. None of these genes had a mutation frequency greater than 0.5 when data from all 30 studies were aggregated. Stratification by epithelial ovarian cancer subtype revealed an association between CTNNB1 mutation and endometrioid carcinoma (47/97; 48.4%) compared to clear cell carcinoma (4/38; 10.5%) (p = 0.00004). CONCLUSIONS:Due to the low mutation frequency of commonly studied genes, cumulative mutational burden may better explain the progression and pathogenesis of endometriosis-associated epithelial ovarian carcinoma than any single mutation. CTNNB1 may be associated with the development of endometrioid ovarian carcinoma. Future studies may consider the use of polygenic scores for risk assessment of endometriosis-associated ovarian cancer.
Introduction The importance of prenatal determination of chorionicity for the management of twin pregnancies is well recognized. However, research on the contribution of prenatal evaluation of zygosity to the management of twins is limited. We assessed the utility of adding SNP-based cell-free DNA (cfDNA) zygosity testing to ultrasound chorionicity assessment for the clinical management of twin pregnancies.Methods Prospective observational study involving 13 United States practices with proficiency in prenatal ultrasound. Patients diagnosed by ultrasound with twins in the first trimester were assessed with cfDNA screening for zygosity. Ultrasound assessment of chorionicity was performed prior to cfDNA results. Placental pathology was used as the gold standard for chorionicity assessment. Gestational age at delivery and standardized birthweights were compared, based on chorionicity and zygosity.Results 110 twin pregnancies were included. Among 79 dichorionic (DC) cases confirmed by placental pathology, one (1.3%) was misclassified as monochorionic (MC) by ultrasound, but was dizygous (DZ) by cfDNA, consistent with DC. Of 31 monozygotic (MZ) twins by cfDNA, confirmed as MC by pathology, ultrasound misclassified one (3.6%) as DC. Median gestational age at delivery was earlier for MZ twin pregnancies (35.0 weeks) compared to DZ (36.9 weeks, p = 0.02). After adjusting for fetal sex and gestational age at birth, MZDC twins had significantly lower birthweights (p = 0.006) and birthweight percentiles (p = 0.004) than DZDC twins.Conclusions Based on postpartum placental pathology as the reference standard for determining MC versus DC, cfDNA zygosity testing appears to aid in the prenatal assignment of chorionicity. Larger studies are needed to confirm the value of zygosity testing in the management of twin pregnancies.
