The Wright Center for Graduate Medical Education

807 Background: Geographic access to clinical trials is critical for equitable cancer care. Gastrointestinal (GI) cancers—including colorectal, pancreatic, liver, gastric, esophageal, and biliary—account for over a quarter of U.S. cancer deaths. Despite this burden, the geographic distribution of active GI cancer trials has not been systematically evaluated, particularly by cancer subtype and population factors such as rurality, socioeconomic status, and race/ethnicity. Methods: All active, interventional Phase I–III GI cancer trials were identified from ClinicalTrials.gov (accessed September 5, 2025), restricted to U.S.-based therapeutic studies. Trial sites were geocoded by ZIP code and mapped to 2020 Census ZIP Code Tabulation Areas (ZCTAs). Geographic access was defined as the proportion of the U.S. population residing within 30 or 60 miles of a site using Haversine distance. Analyses were stratified by cancer subtype, rurality (RUCA codes), income quartile, and race/ethnicity (ACS 2023). Results: We identified 958 active GI cancer trials (287 colorectal, 260 pancreatic, 136 gastric, 86 esophageal, 108 hepatocellular carcinoma [HCC], 81 cholangiocarcinoma) across &gt;4,400 U.S. ZIPs. At 30 miles, population coverage exceeded 80% for colorectal and pancreatic cancers but was lower for HCC (61%) and cholangiocarcinoma (64%). At 60 miles, coverage was &gt;90% for colorectal, pancreatic, and gastric cancers but remained &lt;80% for HCC and cholangiocarcinoma. Subgroup analysis showed 30-mile coverage for HCC was 71.0% among urban vs 9.6% among rural residents, and 42% vs 86% for lowest- vs highest-income quartiles. Hispanic and Black populations had 30-mile coverage of 67% and 70%, respectively. Conclusions: Geographic coverage of GI cancer trials in the U.S. varied by cancer type, with lower access for HCC and cholangiocarcinoma compared with colorectal and pancreatic cancers. Coverage was also reduced in rural, lower-income, and Hispanic and Black populations. These findings highlight geographic and demographic gaps in trial availability and can inform efforts to improve equitable trial access. Population coverage within 30 and 60 miles of GI cancer trial sites, by cancer type and subgroups. Cancer Type No. Trials (NCT IDs) Trial Phase Distribution (I/II/III) No. Sites (ZIPs) Pop Cov (%) (30/60m) Urban Pop Cov (%)(30/60m) Rural Pop Cov (%)(30/60m) Low Income Quartile Cov(%)(30/60m) High Income Quartile Cov(%)(30/60m) Hispanic Pop Cov(%)(30/60m) Black Pop Cov(%)(30/60m) Colorectal 287 123/149/15 1211 83/93 91/96 44/80 65/84 98/99 84/91 85/94 Pancreatic 260 109/132/19 1079 81/92 89/95 42/79 62/83 97/99 81/88 83/92 Gastric 136 59/68/9 966 79/90 87/93 41/75 60/78 96/99 81/87 81/90 Esophageal 86 36/46/4 546 71/84 80/90 24/61 49/69 93/97 74/82 75/85 Liver (HCC) 108 34/67/7 271 61/76 71/83 10/41 42/61 86/93 67/79 70/80 Cholangio 81 24/52/5 398 64/80 74/86 17/50 45/63</

Phonoenterography (PEG) offers a non-invasive and radiation-free technique to assess gastrointestinal activity through acoustic signal analysis. In this feasibility study, 110 high-resolution PEG recordings (44.1 kHz, 16-bit) were acquired from eight healthy individuals, yielding 6314 prominent bowel sound (PBS) segments through automated segmentation. Each event was characterized using a 279-feature acoustic profile comprising Mel-frequency cepstral coefficients (MFCCs), their first-order derivatives (Δ-MFCCs), and six global spectral parameters. After normalization and dimensionality reduction with PCA and UMAP (cosine distance, 35 neighbors, minimum distance = 0.01), five clustering strategies were evaluated. K-Means (k = 5) achieved the most favorable balance between cluster quality (silhouette = 0.60; Calinski–Harabasz = 19,165; Davies–Bouldin = 0.68) and interpretability, consistently identifying five acoustic patterns: single-burst, multiple-burst, harmonic, random-continuous, and multi-modal. Temporal modeling of clustered events further revealed distinct sequential dynamics, with Single-Burst events showing the longest dwell times, random continuous the shortest, and strong diagonal elements in the transition matrix confirming measurable state persistence. Frequent transitions between random continuous and multi-modal states suggested dynamic exchanges between transient and overlapping motility patterns. Together, these findings demonstrate that unsupervised PEG-based analysis can capture both acoustic variability and temporal organization of bowel sounds. This annotation-free approach provides a scalable framework for real-time gastrointestinal monitoring and holds potential for clinical translation in conditions such as postoperative ileus, bowel obstruction, irritable bowel syndrome, and inflammatory bowel disease.

Background: Sustained ventricular tachycardia (VT) and fibrillation-related sudden cardiac death (SCD) account for nearly 450,000 deaths annually in the United States. Catheter ablation (CA) and antiarrhythmic drugs (AADs) are commonly used to manage VT recurrence; however, their comparative efficacy and safety remain uncertain. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing CA and AADs in patients with ischemic cardiomyopathy and implantable cardioverter-defibrillators (ICDs). PubMed, Embase, and Cochrane CENTRAL Library were searched up to February 15, 2025. Primary outcomes included all-cause mortality, cardiovascular mortality, VT storm, and appropriate ICD shock. Secondary outcomes included inappropriate ICD shock, appropriate antitachycardia pacing (ATP), heart failure hospitalization, stroke/transient ischemic attack (TIA), and myocardial infarction (MI). Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Results: Three RCTs encompassing 587 patients (287 CA, 300 AADs) were included. No significant differences were found between CA and AADs in all-cause mortality (RR 0.88, 95% CI: 0.63–1.22; p=0.43), cardiovascular mortality (RR 1.23, 95% CI: 0.77–1.98; p=0.39), VT storm (RR 0.76, 95% CI: 0.39–1.46; p=0.41), or appropriate ICD shock (RR 0.87, 95% CI: 0.69–1.10; p=0.24). Secondary outcomes, including inappropriate ICD shock, ATP, heart failure hospitalization, stroke/TIA, and MI, were also comparable between the two groups. Conclusions: CA and AADs demonstrated comparable efficacy and safety in patients with VT. Larger high-quality trials are warranted to confirm these findings and further define the role of CA as a potential first-line therapy.

Dental caries is the most common chronic childhood disease in the United States. Topical fluoride varnish (TFV) is a simple evidence-based preventive procedure shown to reduce early childhood caries and is approved for the primary care setting; however, rates of TFV application nationally are low. Less than 10% of eligible children received TFV at 1 academic family medicine group during well-child visits. This study assessed the clinician-reported barriers and facilitators to TFV application in that group to inform quality improvement efforts. Using an exploratory sequential design, we developed a 29-item survey assessing knowledge, attitudes, and perceived barriers and facilitators to TFV application. The survey was distributed to outpatient family medicine practice clinicians in a mid-Atlantic academic health center in July 2020. Data were analyzed by univariate descriptive statistics. Of 163 eligible clinicians, 93 (57%) completed the survey, including 60 MD/DO attending physicians, 12 advanced practice clinicians (5 physician assistants, 7 nurse practitioners), and 21 resident physicians. The most frequently reported facilitator was having TFV supplies preplaced in the examination room (92%), followed by nursing staff providing patient education (84%). The most frequently reported barrier was time constraints (61%), followed by the belief that dentists already provide TFV (47%). Advanced practice clinicians expressed a greater need for hands-on training, while residents prioritized refreshers on eligibility and billing. Attending physicians were more likely to report insufficient time for parent education as a barrier. The study highlights key workflow and education-related barriers affecting TFV application in family medicine. Strategies such as interprofessional workflow optimization, previsit planning, and enhanced EHR documentation may address these barriers. Findings support the need for quality improvement initiatives to integrate TFV more effectively into routine pediatric preventive care, ultimately improving early childhood caries prevention.Knowledge Transfer Statement:Despite recommendations for topical fluoride varnish in primary medical care, application rates remain low due to time constraints, workflow inefficiencies, and unclear clinician roles. This study identifies key barriers and facilitators, highlighting the need for team-based workflows, previsit planning, electronic health record enhancements, and targeted training. Findings can inform quality improvement initiatives to streamline topical fluoride varnish application, optimize interprofessional collaboration, and enhance early childhood caries prevention in primary medical care settings.

Abstract Introduction: We describe a patient with acute changes in mental status in whom the diagnosis of Wernicke's encephalopathy required a high degree of clinical suspicion. Case Presentation: A 66-year-old female with a history of parietal ischemic stroke (with residual right-sided deficit), alcohol dependence with recurrent pancreatitis, and prior pulmonary embolism was found down, altered, and nonverbal, last seen well two days prior. According to her family, her baseline mentation was normal. Stroke evaluation was negative, with initial CT and MRI showing only chronic infarcts. Labs showed leukocytosis and a urinalysis suggestive of infection. Shortly after admission, she became acutely hypotensive, prompting ICU transfer and vasopressor support. Blood cultures grew Morganella morganii, with urinary tract as the infection source, and a formal diagnosis of septic shock was made and targeted parenteral antibiotics were given. In the ICU, her mental status worsened, necessitating intubation. Her decline was attributed to septic shock. EEG was negative for nonconvulsive status epilepticus. Despite antibiotics and fluids, her mentation did not improve, leading to a neurology consult. A repeat MRI revealed hyperintense T2 FLAIR signals in the bilateral medial thalami, periaqueductal gray matter, and mammillary bodies, consistent with Wernicke's encephalopathy (WE), along with very low B1 levels (18nmol/L; Normal:78 – 185 nmol/L). She was then treated with high-dose IV thiamine, resulting in gradual mental improvement. She was successfully extubated and transferred out of the ICU. Discussion: Wernicke's encephalopathy, first described by Carl Wernicke in 1881, is caused by thiamine (B1) deficiency, commonly associated with alcoholism but also seen in hyperemesis gravidarum, gastric bypass surgery, and severe malnutrition. Prevalence is mainly derived from autopsy studies with rates estimated between 1% to 3%. B1, coenzyme in Kreb's cycle, is crucial for intricate cerebral metabolism, its deficiency leads to neuronal death, primarily in the mammillary bodies and thalamus. The classic triad of WE is ataxia, confusion, and ophthalmoplegia. WE may be initially overlooked, as acute encephalopathy is common in inpatient settings, with broad differentials including systemic infections, metabolic disturbances, toxin exposure, medications, primary central nervous system insults. In our case, sepsis with gram-negative bacteremia delayed the diagnosis of WE. MRI brain is sensitive in diagnosing WE. Our patient's initial MRI was unrevealing, and treatment for bacteremia continued for several days. However, due to persistent altered mental status and ventilator dependence, a repeat MRI was performed, revealing WE. Treatment involves high-dose parenteral thiamine, often at 500 mg three times daily.

Abstract Introduction: Surgery to the pituitary can result in endocrinopathies which are usually more common in the immediate postoperative period. We present a case of delayed onset of endocrinopathies after a trans-sphenoidal sella turcica surgery. Case: A 53-year-old male presented with a 1-week history of altered mental status and polydipsia. 4 weeks before, the patient had undergone an endoscopic endonasal resection of tuberculum sella meningioma. Post-surgery, he was discharged on a dexamethasone taper with nighttime DDAVP. Vital signs showed BP 85/58 mmHg, pulse 87 bpm. Labs showed sodium 126, potassium 6.6, CO2 13, creatinine 24.3, GFR &amp;lt;2, and glucose 65. EKG showed widened QRS complexes. Despite ampoules of D50, the blood glucose did not improve and D10W infusion was started. The patient was started on norepinephrine. Cortisol levels were ordered initially before initiation of hydrocortisone 100mg q8h. Serum Cortisol was 1.1ug/dl whereas it was 8.9 ug/dl post surgery. The elevation in creatinine and low GFR was changed from 2 weeks ago when his creatinine was 0.8 with a GFR of &amp;gt;90. Due to acute renal failure, urgent hemodialysis was initiated. Clinical improvement was noted over the next 48 hours, and vasopressors were weaned off. We learned that the patient had abruptly stopped taking his dexamethasone and DDAVP. He was noted to have a urine output of 11.6L over the next 24 hours, Urine osmolality was ordered and found to be 157. He was given a dose of DDAVP and urine osmolality was checked hourly for 3 hours with levels of 336, 424, and 408. He was started on IV DDAVP. With improving GFR and normalization of urine output, the patient was transitioned to oral nighttime DDAVP. On the day of discharge, the patient's creatinine was 1.1, GFR 79. Discussion: Hypoglycemia, hypotension, hyponatremia, and hyperkalemia together suggest the diagnosis of adrenal insufficiency (AI). In this case, surgical manipulation near the pituitary sella increased the risk for central diabetes insipidus (CDI) along with disturbance to ACTH secretion causing low cortisol levels. We also noted the patient's initial presentation of acute renal failure with Cr of 24 developing over days due to extracellular fluid depletion from mineralocorticoid deficiency and reduced cardiac index causing hypoperfusion due to glucocorticoid deficiency, additionally confounded with increased water intake. The incidence of transient postoperative DI is 7.5%, permanent DI 1.6% in patients who had transsphenoidal surgery and should be suspected even if the presentation is delayed.