Digital Commons Network^™

Case Report: Anaphylaxis-Induced Cardiac Arrest Leading To Multiorgan Failure, Dhruvin Patel, Russell Mordecai, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Anaphylaxis is a severe, life-threatening hypersensitivity reaction that can rapidly progress to cardiovascular collapse and cardiac arrest. Cardiac arrest due to anaphylaxis is uncommon but associated with significant morbidity and mortality. Survivors often face complex critical care courses, including multiorgan dysfunction and challenges in neurologic prognostication following hypoxic-ischemic brain injury.

Case Report: Bilateral Pneumothorax Following T2–T5 Medial Branch Nerve Block, Jenna Rapone Md

Rowan-Virtua Research Day

Bilateral pneumothorax is an uncommon but clinically significant complication of thoracic spinal interventions. We report the case of a 20-year-old female with underlying scoliosis who developed acute pleuritic chest pain, dyspnea, and persistent cough immediately following bilateral T2–T5 medial branch nerve block injections performed in an outpatient pain management setting.  Thoracic medial branch blocks are generally considered low-risk procedures; however, the proximity of the pleura to posterior thoracic elements places patients at risk for iatrogenic pleural injury, particularly in individuals with altered spinal anatomy such as scoliosis. This case underscores the importance of maintaining a high index of suspicion for …

Acute Appendicitis With Concomitant Testicular Torsion, Thuc Vu, Clara Keum, Swet Patel, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

This case report presents a 13-year-old male who presented to the emergency department with diffuse abdominal pain radiating to the right lower quadrant, accompanied by nausea and decreased appetite. Diagnostic evaluation revealed right-sided testicular torsion concurrent with acute appendicitis. Although acute appendicitis represents the most common surgical emergency in the pediatric population, clinicians must maintain a broad differential diagnosis to identify potential concomitant acute pathologies, including testicular torsion in this scenario.

Sonidegib (Lde225) Reduces Inflammatory Signaling And Preserves Taste Buds In A Sepsis Mouse Model, Ashlyn Mcclelland, Murod Khikmatov, Archana Kumari, Gabrielle Audu, Isaiah Nawaz, Kingsley Yin

Rowan-Virtua Research Day

Background:

Sepsis triggers a complex and widespread inflammatory response that disrupts multiple organ systems, including the taste organ. Loss of taste is a symptom recognized in sepsis survivors and has the potential to contribute to further complications such as anorexia. Prior work from our lab demonstrated that cecal ligation and puncture (CLP) in mice induces immune cell infiltration and alters taste bud morphology in the fungiform papillae located in the anterior tongue. We hypothesize that similar deleterious effects occur in the circumvallate papillae (CVP) of the posterior tongue and that the usage of the smoothened inhibitor, sonidegib, could reduce these …

Acute Ischemic Stroke In Hemoglobin Sc Sickle Disease Requiring Emergent Exchange Transfusion And Neurocritical Transfer, Julian Coz, Trent Malcolm, Andrew Iskandar, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Acute ischemic stroke is a well-recognized complication of sickle cell disease (SCD), with historical estimates suggesting that up to 11% of patients experience an overt stroke by early adulthood. Stroke represents a hematologic and neurologic emergency requiring rapid reduction of the circulating hemoglobin S (HbS) fraction to prevent infarct progression. The American Society of Hematology recommends emergent exchange transfusion within two hours of presentation for patients with acute neurologic deficits [1,3].

Management is particularly nuanced in hemoglobin SC (HbSC) disease. Compared with hemoglobin SS disease, patients with HbSC typically have higher baseline hemoglobin concentrations, increasing blood viscosity and the risk …

An Unusual Cause Of Generalized Weakness: Cns Toxoplasmosis, Christopher Dellmyer, Danielle Kusmaul, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

No abstract provided.

Case Report: Vertebral Artery Dissection After Cervical Manipulation, Devin Hoover, Emily Bolinger, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report the case of a 22-year-old female who presented with dizziness and vomiting after recent cervical manipulation who was diagnosed with a dissection of the vertebral artery. Dizziness can have a variety of causes including vascular etiologies, cerebellar and brainstem lesions, ocular problems, trauma, and others. In the setting of a known trauma and acute vestibular symptoms, it is prudent to consider vascular injuries.

Persistent Hypotension Following Viral Illness- Pocus For Pericardial Effusion, Peter Killian, Kelsey Murray, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

A pericardial effusion is defined as a build up of fluid in the pericardial space, the lining around the heart. Normal physiologic fluid can consist of approximately 15-50mL in an otherwise healthy adult . Larger amounts of fluid can be detected on radiographs, but are able to be seen on ultrasound when just exceeding physiologic conditions . Here we report a case of persistent hypotension assessed by point of care ultrasound (POCUS) in order to lead to a diagnosis.

Case Report: Necrotizing Pneumonia, Veroneka Mikhail Md

Rowan-Virtua Research Day

Necrotizing pneumonia is an uncommon but severe complication of community-acquired pneumonia (CAP), characterized by progressive parenchymal liquefaction, cavitation, and destruction of normal lung architecture, and associated with significant morbidity and mortality. Clinicaly, early presentations may be indistinguishable from uncomplicated pneumonia (pna), with fever, cough, pleuritic chest pain, and dyspnea, which can delay recognition in the emergency department. Differential diagnosis for these symptoms is broad and includes uncomplicated pneumonia, septic emboli, lung abscesses, and pleural effusion. However, patients effected with necrotizing pneumonia often exhibit more severe systemic toxicity, rapid progression of respiratory failure, and hemodynamic instability. In this case report, we …

Surviving Ph 7.0: Rapid Interprofessional Collaboration In Severe Metformin-Associated Lactic Acidosis With Refractory Shock, Karl J. Schlicht Md, Amaani Faizal, Vincent Macolino, Julian Coz

Rowan-Virtua Research Day

Metformin-associated lactic acidosis (MALA) is a rare but life-threatening complication with mortality rates of 30-50%. Although metformin is the most widely prescribed antidiabetic medication, severe MALA requiring emergent hemodialysis remains uncommon, with an estimated incidence of 2-9 cases per 100,000 patient-years. Risk factors include acute kidney injury, dehydration, and tissue hypoxia. Early hemodialysis initiation is independently associated with improved survival. This case highlights how rapid interprofessional collaboration from the emergency department to the intensive care unit enabled in a patient presenting with profound acidemia and survival multiorgan dysfunction

A Survey-Based Analysis Of The Use Of Lifestyle Medicine In Clinical Practices Of South Jersey, Zehra Jaffri

Rowan-Virtua Research Day

Chronic diseases are the leading cause of death and disability in the United States and are largely driven by modifiable lifestyle factors. Lifestyle Medicine (LM) is an evidence-based medical specialty that uses therapeutic lifestyle interventions—including nutrition, physical activity, stress management, sleep, substance use reduction, and healthy relationships—to prevent, treat, and reverse many chronic conditions. Despite strong evidence supporting lifestyle interventions, LM use in routine primary care remains inconsistent due to barriers such as limited visit time, inadequate clinician training, lack of reimbursement, and difficulty sustaining behavioral change. This study evaluates how often lifestyle counseling is discussed in South Jersey primary …

Rethinking Gout Through An Inflammatory Lens, James Espinosa, Alan A. Lucerna

Rowan-Virtua Research Day

This review reframes gout not as a static disease of urate deposition, but as a dynamic inflammatory phenomenon. The emphasis is on immune activation, threshold behavior, and systemic inflammatory context rather than isolated joint pathology.

From Clinical Observation To Scholarly Question Academic Curiosity As A Professional Virtue In Emergency Medicine Introducing The Mindful Observation → Curious Inquiry → Clinical Structuring → Scholarly Sharing (Moccs) Model, James Espinosa, Alan A. Lucerna

Rowan-Virtua Research Day

Emergency Medicine generates continuous clinical observations, yet many potentially meaningful insights never progress beyond informal reflection. This poster reframes every day shift observations as the ecological foundation of scholarly inquiry. Conceptual Framework: We propose a simple, repeatable process to lower the activation energy for academic engagement The Mindful Observation → Curious Inquiry → Clinical Structuring → Scholarly Sharing (MOCCS) Model. This model centers disciplined noticing as a professional virtue. By naming and normalizing the “hmmm” and “huh?” moments, this approach validates frontline clinical wisdom, democratizes scholarly participation, and restores intellectual joy within high-stress clinical environments. Conclusion: Curiosity is not hierarchical. …

Brief Review : Listening Closely--Stethoscopes, Hygiene Gaps, And The Unfinished Work Of Healthcare-Associated Infection Prevention, James Espinosa, Swet Patel, Robin Lahr, Sergey Medlenov, Russell Mordecai, James Lee, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Healthcare-associated infections (HAIs) remain a persistent patient safety challenge. While hand hygiene has received sustained institutional focus, stethoscope hygiene remains inconsistently addressed despite longstanding evidence of contamination. Stethoscopes function as portable, patient-to-patient devices that may serve as under-recognized fomites in emergency and inpatient settings. Prior pilot work demonstrated that clinicians were unable to reliably distinguish between disposable and standard stethoscopes, and that perceived acoustic degradation from a diaphragm barrier was minimal. These findings suggest that acoustic concerns may not represent a primary barrier to hygiene-enhancing strategies. This brief review examines the literature surrounding stethoscope contamination and cleaning behavior, frames the …

Brief Review: Does Red Hair Phenotype Affect Propofol Pharmacokinetics Or Pharmacodynamics?, James Espinosa, Frank Wheeler, Robin Lahr, Sergey Medlenov, Alan Lucerna

Rowan-Virtua Research Day

Background: A persistent belief within Emergency Medicine and perioperative culture suggests that individuals with red hair require altered anesthetic dosing. While early studies demonstrated increased requirements for certain volatile anesthetics in red-haired individuals, this association is frequently generalized to propofol without clear supporting evidence.

Objective: To review current literature regarding the relationship between red hair phenotype (and MC1R variants) and propofol pharmacokinetics (PK) and pharmacodynamics (PD).

Methods: A focused narrative review of controlled human studies and relevant clinical outcome data evaluating propofol PK and PD in red-haired individuals.

Results: Evidence supporting altered anesthetic requirement in red-haired individuals primarily derives from …

Air Quality, Atmospheric Pressure, And Migraine Presentations In The Emergency Department, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: Migraine is a leading cause of Emergency Department (ED) visits and global disability. Weather has long been reported by patients as a trigger, yet the literature remains inconsistent. Prior ED-based data demonstrated an association between higher mean barometric pressure and increased migraine presentations, without a relationship to short-term pressure change. Because high-pressure systems are frequently associated with atmospheric stagnation and pollutant accumulation, air quality may represent a biologically plausible mediator.

Objective: To examine the relationship between air quality and ED migraine presentations within the existing body of literature and to explore whether air quality may help explain previously observed …

Medical Clearance For Behavioral Health Patients In The Emergency Department: A Conceptual Overview Of Practice Variability, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: Patients presenting to the emergency department (ED) with behavioral health complaints frequently undergo medical clearance prior to behavioral health evaluation or admission. Substantial variability appears to be found in laboratory utilization, documentation language, and interdepartmental workflow.

Objective: To provide a conceptual overview of variability in medical clearance practices and to synthesize existing guideline recommendations and literature regarding routine laboratory testing in low-risk psychiatric patients.

Methods: Narrative review of professional policy statements, selected peer-reviewed studies, and operational considerations influencing emergency physician practice patterns.

Results: Evidence suggests that routine laboratory testing in psychiatric patients has low diagnostic yield and rarely changes …

Reset To Learn For Ite And Boards: The Neurobiology Supporting The Advantage Of Micro-Breaks During Content-Dense Lectures--And Why Continuous (No Micro-Breaks) Test-Bank Studying And Test-Taking ("Plowing Through") Is Suboptimal, James Espinosa, Robin Lahr, Swet Patel, James Lee, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Background: Working memory is a limited-capacity system vulnerable to saturation during sustained cognitive effort. In medical education, board review lectures, intensive test-bank studying, and prolonged examination sessions require extended executive control engagement. Emerging evidence from cognitive neuroscience suggests that brief, intentional cognitive disengagement ('micro-resets')  of even 90 seconds may restore working memory efficiency and improve encoding, integration, and retrieval. This applies to brief breaks during content-dense lectures (needs support of lecturer), during test bank use for preparation as well as for test-taking. Objective: To propose a neurocognitive framework explaining why structured micro-breaks of even 90 seconds can enhance learning during …

The Neurobiology Of Interruptions In Emergency Medicine: The Case For Informed Interruption Management In Support Of Cognitive Stability In High-Reliability Clinical Environments, James Espinosa, Henry Schuitema, Alan Lucerna

Rowan-Virtua Research Day

Background: Interruptions are ubiquitous in Emergency Departments (EDs) and have been associated with task delay, multitasking, and increased error risk. While operational and human-factors impacts are well described, the underlying neurocognitive mechanisms remain underexplored. Not all interruptions are avoidable.  However,  interruptions in emergency medicine represent neurocognitive destabilization events that can degrade task representation and increase vulnerability to error during task resumption. Recognizing the neural mechanisms underlying interruptions reframes their management as a systems-level patient safety priority. The aim is not elimination of clinically necessary communication, but thoughtful reduction, prioritization, and design that protects cognitive stability.

Objective: To synthesize cognitive neuroscience …

Protecting The Protectors: Supporting Emergency Department Security Officer Wellness: A Brief Conceptual Review And Research Agenda, James A. Espinosa Md, Paul Sarnese, Alan Lucerna

Rowan-Virtua Research Day

Background: Workplace violence in emergency departments (EDs) has been widely studied, yet the occupational wellness of ED security officers has received comparatively limited focused attention in emergency medicine literature.

Objective: To conceptually examine the role of ED security personnel within the emergency care environment and outline a research agenda addressing their wellness.

Discussion: Security officers frequently respond to behavioral crises, assist with restraint events, and help maintain safety for patients, visitors, and staff. These duties include vigilance between events, sudden physical exertion, and exposure to aggression. ED security work often follows a recognizable rhythm: baseline vigilance, rapid escalation response, physical …

Wildfires And Emergency Department Respiratory Surge: Brief Review, Systems Forecasting Implications And Recommendations For Research, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: Wildfire smoke produces abrupt increases in PM2.5 and Air Quality Index (AQI) levels. Event-based and multi-season studies demonstrate short-term increases in asthma-related Emergency Department (ED) visits, with additional evidence supporting increased utilization for broader respiratory disease and chronic lower respiratory disease (including COPD) (Reid et al., 2016; Liu et al., 2015; Stowell et al., 2025; CDC, 2023).

Objective: To synthesize current evidence linking wildfire smoke to ED respiratory surge and to propose a systems forecasting model that translates environmental signals into structured operational stabilization within a complex adaptive system (CAS).

Methods (Review & Model Development): Narrative synthesis of event-based …

Procedural Narration As An Important Cognitive Adjunct To Analgesia: Naming And Neurobiologically Grounding An Established Emergency Medicine Practice, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: Experienced emergency physicians routinely provide real-time verbal guidance during procedures. Although widespread and intuitive, this practice has not been commonly conceptualized within pain neuroscience.

Objective: To name and mechanistically ground procedural narration as a form of cognitive analgesia, and to promote its intentional use and teaching in Emergency Medicine.

Methods: Narrative review integrating predictive coding theory, placebo/nocebo research, affective neuroscience, descending inhibitory pathway literature, and attentional modulation studies.

Results: Procedural narration reduces uncertainty, aligns expectation with sensation, modulates limbic threat processing, engages prefrontal cortical regulation, and supports descending inhibitory control of nociception.

Conclusion: Procedural narration is not a novel …

Stroke Mimics And Stroke Chameleons: Leveraging The False Positive/False Negative Diagnostic Schema In Resident Teaching, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background

Stroke mimics and stroke chameleons contribute significantly to diagnostic uncertainty in Emergency Medicine. Traditional teaching often relies on enumerating examples, yet residents struggle to internalize these distinctions.

Objective

To present a conceptual teaching framework that maps stroke mimics to false positives and stroke chameleons to false negatives, leveraging pre-existing diagnostic schemas.

Methods

Using representative cases—including hypoglycemic hemiparesis and spinal epidural lipomatosis presenting as stroke mimic—we developed an explanation for residents involving framing mimics as false positives and chameleons as false negatives.

Results

Framing mimics as false positives and chameleons as false negatives activates existing learner schemas related to sensitivity …

Light Therapy Vs. Pharmacotherapy In Improving Quality Of Life In Seasonal Affective Disorder, Hitanshi Patel

Rowan-Virtua Research Day

Seasonal Affective Disorder (SAD) is a pattern of depressive episodes triggered by seasonal changes. Light therapy involves exposure to artificial bright light by stimulating the production of serotonin. Pharmacotherapy primarily requires careful consideration of side effects and patient response times. Findings indicate that light therapy not only leads to significant improvements in depressive symptoms but also long-term enhancement in quality of life. Pharmacotherapy, while effective for some, often involves delays in response and potential adverse effects that can diminish overall satisfaction.

Soundscapes (Ambient Sound, Noise, Music And Other Background Sound) In The Emergency Department: An Under-Theorized Environmental Modifier In A Complex Adaptive System, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background:

Music and ambient sound (including noise and other sounds) are frequently present in emergency departments (EDs), yet their role as environmental modifiers remains under-theorized. Existing literature largely examines background music, for example,  in procedural or perioperative contexts, with limited attention to open, high-density, multi-agent acute care systems.

Objective:

To conceptualize auditory input as a dynamic environmental variable within the ED viewed as a Complex Adaptive System (CAS), integrating neurobiological mechanisms with systems-level implications.

Methods/Conceptual Approach: Narrative conceptual synthesis integrating neurobiology of auditory processing, affective neuroscience, cognitive load theory, and complexity science.

Results:

Conceptual Insights: Auditory stimuli engage distributed neural …

A Conceptual Framework That Supports The Transition From Supervised Training To Independent Clinical Practice, Aligned With Acgme Milestones, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background: The transition from residency to independent attending practice represents a critical developmental inflection point. Although residents achieve competency-based milestones, many graduates report challenges related to decision ownership, uncertainty tolerance, and the assumption of final clinical authority. Traditional training emphasizes competence under supervision, while independent practice requires performance without supervision. Objective: To propose a conceptual framework that supports the transition from supervised training to independent clinical practice, aligned with ACGME Milestones. Methods: Conceptual synthesis of literature on preparedness for practice, entrustment, and professional identity formation, integrated with practical observations from graduate medical education. Results (Conceptual): Six domains central to transition …

Identifying And Generalizing Best Attending Teaching Practices: A Proposal For The Use Of Appreciative Inquiry To Enhance Emergency Medicine Residency Teaching Practices, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background

Teaching in the Emergency Department (ED) occurs within a complex adaptive system characterized by time pressure, interruptions, and high cognitive load. Studying what works well in clinical teaching , even in such a challenging  environment for  teaching, may reveal reproducible patterns that strengthen educational culture, enhance resident learning, and accelerate the development of teaching expertise. In complex clinical environments, excellence is often present but under-recognized; An approach called Appreciative Inquiry provides a structured method for making it visible.

Conceptual Framework

Appreciative Inquiry (AI) offers an alternative approach by systematically studying successful practices rather than failures. AI explores how and …

Medical Journals As Complex Adaptive System (Cas) Reports: Reframing Journals As Structured Detection, Interpretation, And Feedback Systems In Healthcare, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Background Healthcare operates as a complex adaptive system (CAS) characterized by distributed agents, nonlinear interactions, and emergent behavior. Effective adaptation depends on mechanisms capable of detecting and redistributing signals from across the system.

Objective To conceptualize the medical journal as a structured CAS report and to examine its role in supporting system awareness among clinicians.

Conceptual Model Recurring journal sections—including original research, reviews, editorials, clinical cases, perspectives, humanities, and letters—function as distinct sensing and signaling channels. Together, they provide a multi-dimensional representation of system activity.

Implications Journals serve not only as repositories of knowledge but as adaptive communication nodes that …

Impaired Mitochondrial Magnesium Transport Induces Genome-Wide Transcriptional Changes In Hepatic Steatosis, Inflammatory Signaling, And Detoxification Pathways During High-Fat Diet Feeding, Abhishek Shastry, Thiruvelselvan Ponnusamy, Asha Parveen Sakkarai Mohamed, Marianne Assogba, Natarajaseenivasan Kalimuthusamy, Shanmughapriya Santhanam

Rowan-Virtua Research Day

Calcium overload during fatty diet consumption induces oxidative stress and mitochondrial apoptosis. Intramitochondrial magnesium inhibits calcium uptake into mitochondria; therefore, modulating the activity of the mitochondrial magnesium transporter Mrs2 may regulate calcium-induced hepatocellular stress. As previous work demonstrates that liver-specific Mrs2 inhibition increases hepatic lipid deposition, RNA-sequencing was performed to identify potential transcriptional mechanisms for hepatocellular stress.

Mrs2 knockout (Mrs2^KO) mice were generated by crossing male Mrs2^fl/fl mice with liver-specific-Cre transgenic mice. Eight-week-old wild-type (Mrs2^WT) and Mrs2^KO mice were placed on chow or high-fat diet (HFD) for 12 months (n=3/group). Whole liver was collected …

Atomoxetine Enhances Specific Dimensions Of Cognitive Performance In A Rodent Strategy Shifting Assay, Jessica Ivanov

Rowan-Virtua Research Day

Title: Atomoxetine enhances specific dimensions of cognitive performance in a rodent strategy shifting assay

Authors: Jessica Ivanov, Christopher P. Knapp, Barry D. Waterhouse, Rachel L. Navarra

Objective: Cognitive flexibility, a domain of executive function, supports adaptive shifts in behavior in response to changing environmental demands and task contingencies. Deficits in this capacity are common to neuropsychiatric disorders such as Attention Deficit Hyperactivity Disorder (ADHD), where improper regulation of the catecholamine transmitters dopamine (DA) and norepinephrine (NE) within the prefrontal cortex (PFC) has been implicated. Atomoxetine (ATX), a selective NE transporter (NET) inhibitor, elevates levels of NE and DA in the …