Digital Commons Network^™

Septic Pulmonary Emboli Revealing Tricuspid Valve Endocarditis In A Patient Presenting With Opioid Withdrawal Symptoms, Dong Shin, Dhara Patel, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Septic embolism is a serious complication of systemic infection, most commonly arising from infective endocarditis. In patients with intravenous drug use (IVDU), right-sided endocarditis may lead to septic pulmonary emboli, often presenting with nonspecific or misleading symptoms. A 36-year-old female with recent intravenous fentanyl use presented with presumed opioid withdrawal, along with chest pain, dyspnea, and systemic symptoms. Initial evaluation revealed leukocytosis and bilateral pulmonary nodules on imaging. Computed tomography angiography demonstrated multiple cavitary and non-cavitary nodules consistent with septic pulmonary emboli. Blood cultures grew Staphylococcus aureus, and echocardiography revealed tricuspid valve vegetations with severe regurgitation. The patient required escalation …

Case Report: Primary Appendiceal Cancer Presenting As Acute Appendicitis, Armeet Singh, Wayne Tamaska, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 46‐year‐old male who presented to the emergency department with right lower quadrant abdominal pain and was initially suspected to have acute appendicitis. Further evaluation and surgical pathology revealed primary appendiceal adenocarcinoma. Appendiceal cancer is rare and often presents with nonspecific symptoms that mimic common abdominal conditions such as appendicitis or diverticulitis. Early diagnosis can be challenging, and many cases are discovered incidentally during surgery or imaging for suspected appendicitis. This case highlights the importance of maintaining a broad differential diagnosis for right lower quadrant pain.

Case Report: Acute Encephalopathy Revealing Severe Babesiosis With Lyme Co-Infection, Czarina Gebrelle K. Soriano, James Espinosa, Alan Lucer

Rowan-Virtua Research Day

Acute confusion in older adults is a common emergency department presentation with a broad differential diagnosis. Tick-borne illnesses can cause significant systemic disease and may present with nonspecific neurologic or constitutional symptoms, making early recognition challenging. Babesiosis is a tick-borne parasitic infection transmitted by Ixodes ticks and may occur concurrently with other infections such as Lyme disease, further complicating diagnosis. We present a case of a 67-year-old male who presented with acute confusion and was found to have concurrent babesiosis and Lyme disease. This case highlights the importance of maintaining a high index of suspicion for tick-borne co-infections in patients …

When Venom Isn’T The Only Threat: Roseomonas Mucosa Bacteremia Following A Snake Bite, Cyrus Davati, Kishan Patel, James A. Espinosa Md, Alan Lucerna

Rowan-Virtua Research Day

Snake bites in the ED  overall are rare in the United States. While mortality is low due to modern interventions, the sequelae - including tissue necrosis, digit amputation, and subsequent infection  remain a significant concern.  Here we present the case of a  presumptively non-venomous snakebite, which  was associated with R. mucosa bacteremia.

A Neck Too Tight: Emergent Cricothyrotomy For Airway Collapse From Expanding Post Anterior Cervical Discectomy And Fusion (Acdf) Hematoma, Nicole R. Eregha, Kishan Patel, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Anterior cervical discectomy and fusion (ACDF) is a commonly performed surgical procedure used to treat cervical spine pathology including radiculopathy and spinal cord compression. Although generally safe, postoperative complications can occur. One of the most feared complications is expanding neck hematoma, which may lead to rapid airway obstruction due to tracheal compression and soft tissue swelling. The reported incidence of postoperative hematoma after ACDF ranges from 0.2–1.9%, with a subset of patients requiring emergent airway intervention or surgical evacuation [1]. Patients with postoperative hematoma typically present with neck swelling, dysphagia, hoarseness, dyspnea, and inability to tolerate secretions, symptoms that may …

A Pain In The Neck: Lemierre Syndrome Presenting With Retropharyngeal Abscess, Clara Keum, Leo Midure

Rowan-Virtua Research Day

Lemierre syndrome is a rare but potentially life-threatening condition characterized by septic thrombophlebitis of the internal jugular vein following an oropharyngeal infection. It is most commonly associated with Fusobacterium necrophorum,  and typically begins with pharyngitis or deep neck space infections, which can extend into adjacent vascular structures. Retropharyngeal abscesses are among the deep neck infections that may predispose patients to this complication due to their proximity to the internal jugular vein and surrounding fascial planes.

Although Lemierre syndrome classically occurs in otherwise healthy adolescents and young adults, it can also develop in immunocompromised individuals or patients with complex medical conditions. …

Case Report: Vancomycin-Resistant Enterococcus Faecium Urinary Tract Infection With Stercoral Colitis Presenting In An Elderly Patient, Muhammad Zain Raza, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 76-year-old female who presented with altered mental status characterized by confusion, decreased verbal interaction, and reduced responsiveness noted by her spouse. The patient had a history of chronic constipation and was brought from home for further evaluation. Initial evaluation raised concern for infection or intracranial hemorrhage as a possible cause of altered mental status. Imaging of the CT brain without contrast was unremarkable, however; abdomen and pelvis revealed a large rectal stool impaction with rectal wall thickening and surrounding perirectal fat stranding consistent with Stercoral Colitis. Urine culture subsequently identified vancomycin-resistant enterococcus faecium. The …

Arrhythmic Syncope And Brugada Syndrome: Critical Identification Of High-Risk Patterns At The Ed Frontline, Kristine Rubi, Brittany Fera, Kelsey Murray, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Brugada Syndrome (BrS) is a premier cause of sudden cardiac death (SCD) in structurally normal hearts, particularly in Southeast Asia (SEA) where it is historically recognized as Sudden Unexplained Nocturnal Death Syndrome (SUNDS). We report the case of a 55-year-old male of Vietnamese descent who presented to the emergency department (ED) after a sudden, non-prodromal syncopal episode at rest. The event was significant for urinary incontinence and diaphoresis, classic red flags for arrhythmic syncope. Bedside electrocardiogram (EKG) demonstrated the pathognomonic Type 1 coved ST-segment elevation in leads V1 and V2. This symptomatic presentation following a six-year "follow-up gap" since a …

Anticipating Animal Ethics Concerns In Islet Xenotransplantation, Sheetal Mohanty, Daniel J. Hurst, Amy Glasofer

Rowan-Virtua Research Day

Type 1 diabetes mellitus (T1D) necessitates life-sustaining insulin therapy or, in select cases, islet allotransplantation, which is limited by donor scarcity. Islet xenotransplantation (XTx; genetically modified pig-to-human transplant) is one potential alternative. Patient perceptions about islet XTx are largely unexplored. This study examined patient support for XTx when T1D patients learned that 25-50 pigs may be needed to treat one adult. Patient viewpoints toward islet XTx suggest animal ethics concerns may extend to the magnitude of animals required to treat a single patient. As clinical trials advance, addressing these values and risk tolerances is essential for developing informed consent frameworks …

The Klatskin Tumor: A Tumor At The Liver’S Crossroads, Asma Zahid, Sergey Medlenov, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We present a 68-year-old female with no significant oncologic history who presented to

the emergency department with a  two –week history of progressive jaundice and diarrhea.

Systematic ED evaluation revealed marked hyperbilirubinemia (total bilirubin 22.3 mg/dL), a

cholestatic laboratory pattern, and multimodal imaging demonstrating multifocal hepatic

masses, a porta hepatis soft tissue mass,  and biliary ductal dilatation consistent with hilar cholangiocarcinoma (Klatskin tumor) with metastatic disease.

A CA 19-9 marker was markedly elevated at 379 U/mL. The patient was admitted and she underwent successful biliary decompression via ERCP with stent placement.  Outpatient oncologic therapy was initiated. This case highlights the …

Heterotopic Pregnancy: A Case Report, Oluwatomi Alade, Robin Lahr, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Heterotopic pregnancy occurs when there is simultaneous intrauterine pregnancy as well as extra uterine ectopic pregnancy.  Historically, this was considered very rare with an estimated incidence of 1 in 30,000 pregnancies however, the incidence has been increased with the use of assisted reproductive  technology.  The most common location is the fallopian tube and less common include the cervix or the ovary. It can be difficult to diagnose because the presence of an intrauterine pregnancy on ultrasound may falsely reassure clinicians and delay evaluation for a concurrent ectopic pregnancy.  These patients usually present with nonspecific symptoms including abdominal pain, vaginal bleeding, …

Case Report: Acute Cerebrovascular Accident With An Initial Absence Of Infarct Findings On Mri, Alyssa Baldini Md, Brittany Fera

Rowan-Virtua Research Day

We report a case of a 42-year-old female whose diffusion-weighted magnetic resonance imaging (MRI) performed 28 hours after symptom onset was negative for acute infarction. Repeat MRI 3 days later demonstrated left-sided corona radiata infarction.

Diffusion-weighted MRI imaging may not be sensitive or specific enough in early stages of acute stroke. Caution should be used in relying on imaging alone to make the diagnosis of ischemic stroke. Clinical assessment likely should be given priority in determining appropriate initial treatment and the need for secondary stroke prevention treatment when imaging is negative. Consideration should be given to the timing of initial …

Myxedema Coma: Recognizing A Silent But Potentially Fatal Emergency, Aashna Chaudhry, Robin Lahr, James Espinosa, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Myxedema coma is an endocrinologic emergency that requires prompt recognition and treatment. It is described as severe hypothyroidism characterized by life-threatening slowing of metabolic processes, often occurring in the setting of precipitating factors such as trauma, infection, medications, or cold exposure. This case report presents a clinical case in which early suspicion of myxedema coma in an elderly female patient led to prompt treatment and life-saving measures.

An Elusive Diagnosis: Pheochromocytoma Presenting With Hyperglycemia And Hypertensive Crisis, Tucker Ledo

Rowan-Virtua Research Day

Pheochromocytoma is a rare catecholamine-secreting tumor that can present with a wide range of nonspecific symptoms, often mimicking more common medical conditions and making early diagnosis difficult. We report the case of a 40-year-old female with a history of hypertension and prediabetes who presented to the emergency department with hyperglycemia following an episode of lightheadedness. This case highlights the diagnostic challenge of pheochromocytoma in the emergency department, where initial symptoms may be subtle and easily attributed to more common conditions such as hypertension, diabetes, or menopause. Recognition of episodic sympathomimetic symptoms and unexplained hypertensive crises should prompt consideration of pheochromocytoma …

Case Report: Ascending Cholangitis Presenting As Sepsis With Encephalopathy In An Older Adult With Choledocholithiasis, David Marconi, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Acute cholangitis is a potentially life-threatening biliary infection usually precipitated by ductal obstruction. In adults ≥80 years, classic right upper quadrant pain and jaundice may be absent and delirium may predominate, increasing the risk of diagnostic delay.¹

An 82-year-old woman presented with generalized weakness and altered mental status. She was febrile (101.9 °F [38.8 °C]) and tachycardic (113 beats/min) without hypotension. Laboratory testing demonstrated leukocytosis and marked cholestatic liver injury (total bilirubin 2.8 mg/dL, alkaline phosphatase 660 U/L) with hyperbilirubinemia and acute encephalopathy consistent with sepsis-associated organ dysfunction. Computed tomography and ultrasound suggested biliary obstruction and cholelithiasis; magnetic resonance cholangiopancreatography …

A Rare Intervention: Emergency Ultrasound-Guided Pericardiocentesis Using A Central Line Kit, Alec Mirchandani, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Cardiac tamponade is a life-threatening emergency requiring rapid diagnosis and drainage.

Point-of-care ultrasound (POCUS) expedites recognition and guides pericardiocentesis. We report a case of acute large pericardial effusion with hemodynamic collapse in a previously healthy 46-year-old female, managed emergently with ultrasound-guided pericardiocentesis using a central line introducer and subsequent pigtail catheter exchange; the clinical course was complicated by presumed septic pulmonary emboli and death.

Reducing Pharmacy Callbacks And Improving Workflow Efficiency In The Emergency Department: A Quality Improvement Initiative, Philip .. Carhart, Hannah Culleny, Alexis Schuitema, James Espinosa, Robin Lahr, Sergey Medlenov, Gabriel Meister, Alan Lucerna

Rowan-Virtua Research Day

A simple educational intervention combined with structured provider feedback reduced ED pharmacy callbacks by 86%. While individual call duration remained unchanged, the reduction translated into nearly eight hours of provider time saved annually. This study highlights the impact of targeted quality improvement efforts on: • Workflow efficiency • Interprofessional communication • Patient care reliability. Small systems interventions can produce disproportionate operational benefits.

Molten Sugar Burn To The Dorsal Foot: A Case Highlighting Unique Thermal And Adhesive Injury Mechanisms, James Espinosa, Alan A. Lucerna

Rowan-Virtua Research Day

This brief case report emphasizes injury mechanism and anatomic vulnerability rather than burn management, as treatment of deep partial-thickness burns is well established. The clinical value of this case lies in recognizing molten sugar as a uniquely hazardous thermal agent capable of producing deceptively deep injury, particularly when contact occurs on the dorsal foot.

Brief Review: Quantifying The Risks Of Snow Shoveling: Cardiac, Musculoskeletal, And Environmental Hazards, James Espinosa, Swet A. Patel, James Lee, Alan Lucerna

Rowan-Virtua Research Day

Snow shoveling is a common winter activity in cold-weather regions, yet it uniquely combines intense physical exertion, cold exposure, and environmental hazards. Emergency Departments routinely observe seasonal increases in snow-shoveling–related musculoskeletal injuries, falls, and acute cardiovascular events. Despite this, the cardiovascular risk of snow shoveling is not well emphasized in medical education or patient counseling. Snow shoveling is associated with quantifiable and clinically significant risks, including musculoskeletal injury, falls, and acute cardiovascular events, which are reviewed here.

Ice Water Immersion–Associated Syncope: A Case Report With Mechanistic Review And Public Safety Implications, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Sudden ice water immersion can provoke syncope in otherwise healthy individuals, particularly during first-time exposure. We present a case of a 56-year-old man with mild hypertension and hyperlipidemia who experienced abrupt syncope during entry into cold water at a charitable group immersion event. Emergency department evaluation, including electrocardiography and cardiac biomarkers, was normal. Observation and cardiology consultation supported a diagnosis of provoked, immersion-related syncope. This case highlights the physiologic mechanisms of cold shock and autonomic conflict, the potential drowning risk associated with loss of consciousness during water entry, and the opportunity for improved discharge counseling and public safety messaging.

Refeeding Syndrome In A Person Experiencing Homelessness: A Case Report, James Espinosa, Jose Gerald Aragon, Md Fateha, Alan Lucerna

Rowan-Virtua Research Day

Refeeding syndrome (RFS) is a potentially life-threatening metabolic disturbance that occurs following nutritional reintroduction in severely malnourished individuals. It is characterized by rapid intracellular shifts of electrolytes—most notably hypophosphatemia—driven by insulin-mediated metabolic changes. Although commonly associated with eating disorders and chronic illness, RFS may also occur in socially vulnerable populations.

We report the case of a 64-year-old male experiencing homelessness who presented to the emergency department with weakness, muscle cramps, and confusion after resuming regular meals at a local shelter following prolonged minimal intake. Laboratory evaluation revealed severe hypophosphatemia (0.7 mg/dL), hypokalemia (3.0 mmol/L), and hypomagnesemia (1.2 mg/dL). Electrocardiogram demonstrated …

Shopping Cart–Related Injuries In Children: Brief Clinical Review And Public Health Implications, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Shopping cart–related injuries represent a common yet underrecognized mechanism of pediatric trauma. National estimates suggest approximately 24,000 children annually are treated in U.S. emergency departments for shopping cart–related injuries, with falls accounting for the majority of cases. Younger children, particularly those under 5 years of age, are disproportionately affected, and head and facial injuries predominate.

Objective:

To provide a concise clinical and public health review of shopping cart–related pediatric injuries, with emphasis on epidemiology, injury patterns, and opportunities for prevention within emergency department practice.

Methods

Narrative review of national injury surveillance data, prior epidemiologic studies, and consumer safety guidance addressing …

High-Intensity Interval Training And Circulating Brain-Derived Neurotrophic Factor In Healthy Young Adults: A Scoping Review, Rikuto Abe, Safe Elhakeem, Mohamed Elhakeem

Rowan-Virtua Research Day

Abstract

Background: Brain-derived neurotrophic factor (BDNF) plays an important role in synaptic plasticity, neuronal survival, and cognitive function (1,2,3). High-intensity interval training (HIIT) has emerged as a time-efficient exercise modality capable of inducing neurotrophic adaptations (4,5). However, the magnitude and consistency of its effects on circulating BDNF remain unclear.

Objective: This scoping review evaluated the current evidence examining the effects of HIIT on circulating BDNF levels measured via enzyme-linked immunosorbent assay (ELISA) in healthy young adults.

Methods: A systematic search of PubMed, Embase, and Scopus was conducted for randomized and controlled clinical trials published between 2020 and 2025. Studies were …

Effect Of Sauna On Cardiovascular Health In Patients With Heart Failure, Rikuto Abe, Piotr Domaszewski, Safe Elhakeem

Rowan-Virtua Research Day

Abstract

Heart failure (HF) is one of the hallmark diseases that represent a decline of cardiovascular function. Heart failure is characterized by a decrease in the ability of the heart to pump blood throughout the body, leading to symptoms such as fatigue, dyspnea, and swelling. HF is shown to decrease quality of life and increase mortality. Traditional treatments include pharmacology, lifestyle modifications, and surgery. Among the treatments, deliberate heat exposure in the form of dry saunas has been highlighted as a potential treatment option for HF. Dry saunas, especially infrared saunas, are shown to increase body temperature which improves circulation …

Impostor Phenomenon In Healthcare: Prevalence, Implications, And Educational Responses, James Espinosa, Robin Lahr, Sergey Medlenov, Swet Patel, Nicholas Tomasello, James Lee, Neel Parikh, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

The impostor phenomenon describes persistent self-doubt and fear of being exposed as a fraud despite objective evidence of competence. The term 'impostor phenomenon' is preferred over the term "imposter syndrome" because it is not a psychiatric diagnosis and avoids pathologizing normal developmental uncertainty. The original authors used the term 'phenomenon' (Clance & Imes, 1978), and contemporary scholarship increasingly adopts this terminology.

First described by Clance and Imes (1978), the construct has since been studied across diverse professional domains, including medicine, nursing, and academic leadership. Subsequent research demonstrates that impostor experiences occur across genders, training levels, and healthcare roles (Bravata et …

Gut Microbiota Dysbiosis In Down Syndrome: Implications For Gastrointestinal And Neurological Health, Ashlyn Mcclelland, Jennifer Lecomte, Wendy Aita, Andrea Iannuzzelli

Rowan-Virtua Research Day

Down syndrome (DS) is the most common autosomal aneuploidy and has strong associations with increased gastrointestinal, neurological, and immune disorders. Emerging evidence suggests that gut microbiota dysbiosis may play a prominent role in disorders of gut-brain interaction, including constipation and irritable bowel syndrome affecting over half of individuals with DS. This review examines how gut microbiota alterations can contribute to chronic systemic inflammation and neurological manifestations in DS. Included articles were published between 2014 and 2025 and evaluated microbiota composition, inflammatory markers, and gastrointestinal or neurological outcomes in human or animal models of DS.

Across seven studies, characteristic microbiome shifts …

Hydration During Emergency Medicine Shifts: An Overlooked Component Of Cognitive Performance, Well-Being, And Systems Design To Fail To Plan For Shift Hydration Is To Plan To Fail With Shift Hydration, James Espinosa, Alan Lucerna, Swet Patel, Robin Lahr, Sergey Medlenov, Adam Kandil, Frank Wheeler, Wayne Tamaska, James Lee, Neel Parikh, Henry Schuitema

Rowan-Virtua Research Day

Emergency Medicine (EM) clinicians work prolonged, cognitively demanding shifts in environments characterized by unpredictability, interruptions, and high decision density. While fatigue, burnout, and circadian disruption have been widely studied, hydration during active clinical shifts has received little focused attention. Evidence from cognitive, military, and sports physiology literature demonstrates that even mild dehydration can impair attention, working memory, mood, and reaction time. Despite these findings, hydration in Emergency Medicine is typically treated as an individual behavior rather than a systems-level design consideration. This review synthesizes relevant physiologic and performance literature, identifies cultural and structural barriers to hydration during EM shifts, and …

Learning From Our Dental Colleagues: A Brief Review Of Counter-Stimulation To Reduce Procedural Pain In Emergency Medicine Mechanisms, Existing Evidence, And A Pragmatic Research Agenda, James Espinosa, Neal Appelstein, Alan Lucerna

Rowan-Virtua Research Day

Counter-stimulation techniques such as tapping, pressure, vibration, and tissue shaking are commonly observed in dental practice during administration of local anesthetic nerve blocks. Although not systematically described in the Emergency Medicine literature, individual clinicians may employ tactile counter-stimulation techniques during needle-based procedures. The practice remains under-theorized and under-studied within the Emergency Medicine literature. This brief review synthesizes mechanistic neurobiology—including segmental gate control theory (Melzack & Wall, 1965), descending inhibitory modulation, and attentional salience models—with evidence from dental and needle-procedure research. We propose a practical taxonomy of counter-stimulation techniques applicable to Emergency Medicine and identify gaps in the current literature. Finally, …

From Confirmation To Guidance: Making The Case For Intraprocedural Pocus As The Next Developmental Step In Ultrasound-Supported Shoulder Reduction A Conceptual Practice Proposal And Research Agenda, James Espinosa

Rowan-Virtua Research Day

Point-of-care ultrasound (POCUS) is well established for the diagnosis of shoulder dislocation and for the confirmation of successful reduction. However, its role during the reduction maneuver itself remains under-described. This conceptual practice proposal argues that intraprocedural POCUS represents the logical next developmental step in ultrasound-supported shoulder reduction. By introducing real-time visualization of humeral head translation during reduction attempts, clinicians may identify ineffective vectors earlier, adjust technique midstream, and potentially reduce repeated attempts or escalation of procedural sedation. This work does not present outcome data but instead proposes a practical framework, workflow model, and research agenda for intraprocedural implementation. Future study …

Rainfall, Air Quality, And Vaso-Occlusive Crisis In Adults With Sickle Cell Disease, James Espinosa

Rowan-Virtua Research Day

.Patients with sickle cell disease (SCD) frequently report that weather changes precipitate vaso-occlusive crises (VOC). While prior investigations have focused primarily on temperature, humidity, and seasonal variation, emerging data suggest that rainfall patterns may represent a more meaningful environmental signal. In a multi-hospital Emergency Department analysis, below-average rainfall days were associated with significantly increased adult VOC presentations (Ahmed et al., 2023). Rainfall may function as an atmospheric clearing mechanism; reduced precipitation may permit accumulation of airborne particulate matter and environmental pollutants, increasing oxidative stress and endothelial activation—mechanisms central to vaso-occlusion. Multiple epidemiologic studies demonstrate associations between particulate exposure and increased …