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Spiegelman L, Jen M, Matonis D, Gibney R, Saadat S, Sakaria S, Wray A, Toohey S. This Article Corrects: "The Effects of Implementing a "Waterfall" Emergency Physician Attending Schedule". West J Emerg Med 2021; 22:1379. [PMID: 34787566 PMCID: PMC8597696 DOI: 10.5811/westjem.2021.11.55231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Lindsey Spiegelman
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Maxwell Jen
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Danielle Matonis
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Ryan Gibney
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Soheil Saadat
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Sangeeta Sakaria
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Alisa Wray
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Shannon Toohey
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
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Spiegelman L, Jen M, Matonis D, Gibney R, Soheil S, Sakaria S, Wray A, Toohey S. The Effects of Implementing a “Waterfall” Emergency Physician Attending Schedule. West J Emerg Med 2021; 22:882-889. [PMID: 35353992 PMCID: PMC8328172 DOI: 10.5811/westjem.2021.2.50249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/26/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction: Increases in emergency department (ED) crowding and boarding are a nationwide issue resulting in worsening patient care and throughput. To compensate, ED administrators often look to modifying staffing models to improve efficiencies.
Methods: This study evaluates the impact of implementing the waterfall model of physician staffing on door-to-doctor time (DDOC), door-to-disposition time (DDIS), left without being seen (LWBS) rate, elopement rate, and the number of patient sign-outs. We examined 9,082 pre-intervention ED visits and 8,983 post-intervention ED visits.
Results: The change in DDOC, LWBS rate, and elopement rate demonstrated statistically significant improvement from a mean of 65.1 to 35 minutes (P <0.001), 1.12% to 0.92% (P = 0.004), and 3.96% to 1.95% (P <0.001), respectively. The change in DDIS from 312 to 324.7 minutes was not statistically significant (P = 0.310). The number of patient sign-outs increased after the implementation of a waterfall schedule (P <0.001).
Conclusion: Implementing a waterfall schedule improved DDOC time while decreasing the percentage of patients who LWBS and eloped. The DDIS and number of patient sign-outs appears to have increased post implementation, although this may have been confounded by the increase in patient volumes and ED boarding from the pre- to post-intervention period.
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Affiliation(s)
- Lindsey Spiegelman
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Maxwell Jen
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Danielle Matonis
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Ryan Gibney
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Saadat Soheil
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Sangeeta Sakaria
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Alisa Wray
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Shannon Toohey
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
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Jen M, Goubert R, Toohey S, Zuabi N, Wray A. Triage physicians in an academic emergency department: Impact on resident education. AEM Educ Train 2021; 5:e10567. [PMID: 34124513 PMCID: PMC8171768 DOI: 10.1002/aet2.10567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/24/2020] [Accepted: 11/30/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Overcrowding in emergency departments (EDs) in the United States has been linked to worse patient outcomes. Implementation of countermeasures such as a physician-in-triage (PIT) system have improved patient care and decreased wait times. The purpose of this study was to evaluate how a PIT system affects medical resident education in an academic ED. METHODS This was a retrospective observational comparison of resident metrics at a single-site, urban, academic ED before and after implementing a PIT system. Resident metrics of average emergency severity index (ESI), patients-per-hour, and in-training-examination scores were measured before and six months after the implementation of the PIT system. RESULTS In total, 18,231 patients were evaluated by all residents in the study period before PIT implementation compared to 17,008 in the study period following PIT implementation. The average ESI among patients evaluated by residents decreased from 3.00 to 2.68 (p < 0.01, 95% confidence interval [CI] = 0.31 to 0.33), while average resident patient-per-hour rate decreased from 1.41 to 1.32 (p < 0.01, 95% CI = 0.05 to 0.13] and ITE scores saw no statistically significant change of 76.11 to 78.26 (p = 0.26, 95% CI = -5.75 to 1.45). While these differences are statistically significant, they are likely not clinically significant. CONCLUSIONS Our implementation of PIT system at one academic medical center minimally increased the acuity and minimally decreased the number of patients that residents see. This suggested that in our center, a PIT program did not detract from ED resident clinical education. However, further research with alternative markers in multiple centers is needed.
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Affiliation(s)
- Maxwell Jen
- From theDepartment of Emergency MedicineUniversity of California IrvineOrangeCAUSA
| | - Ronald Goubert
- and theSchool of MedicineUniversity of California IrvineIrvineCAUSA
| | - Shannon Toohey
- From theDepartment of Emergency MedicineUniversity of California IrvineOrangeCAUSA
| | - Nadia Zuabi
- From theDepartment of Emergency MedicineUniversity of California IrvineOrangeCAUSA
| | - Alisa Wray
- From theDepartment of Emergency MedicineUniversity of California IrvineOrangeCAUSA
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Yanuck J, Saadat S, Lee JB, Jen M, Chakravarthy B. Pragmatic Randomized Controlled Pilot Trial on Trigger Point Injections With 1% Lidocaine Versus Conventional Approaches for Myofascial Pain in the Emergency Department. J Emerg Med 2020; 59:364-370. [PMID: 32712034 DOI: 10.1016/j.jemermed.2020.06.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/18/2020] [Accepted: 06/01/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Myofascial neck and back pain is an increasingly common chief symptom in the emergency department. Currently, there are no widely accepted conventional therapies, and there is little evidence on the efficacy of interventions such as trigger point injections (TPIs). OBJECTIVE This study evaluates whether TPIs with 1% lidocaine can improve myofascial back and neck pain compared with conventional therapies. Secondary outcomes include changes in length of stay and number of opioid prescriptions on discharge. METHODS This single-center, prospective, randomized, pragmatic trial was carried out in patients clinically determined to have myofascial back or neck pain. Patients were randomized into the experimental arm (TPI with 1% lidocaine) or the control arm (standard conventional approach). Numeric Rating Scores (NRS) for pain and additional surveys were obtained prior to and 20 min after the intervention. RESULTS The NRS for pain was lower in the TPI group compared with the control group after adjustment for initial pain (median difference -3.01; 95% confidence interval -4.20 to -1.83; p < 0.001). Median length of stay was 2.61 h for the TPI group and 4.63 h for the control group (p < 0.001). More patients in the control group (47.4%) were discharged home with an opioid compared with the TPI group (2.9%) (p < 0.001). CONCLUSIONS TPI is an effective method for managing myofascial pain in the emergency department. This study indicates it may improve pain compared with conventional methods, reduce length of stay in the emergency department, and reduce opioid prescriptions on discharge.
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Affiliation(s)
- Justin Yanuck
- Department of Emergency Medicine, University of California, Irvine, Orange, California; Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Soheil Saadat
- Department of Emergency Medicine, University of California, Irvine, Orange, California
| | - Jonathan B Lee
- Department of Emergency Medicine, University of California, Irvine, Orange, California
| | - Maxwell Jen
- Department of Emergency Medicine, University of California, Irvine, Orange, California
| | - Bharath Chakravarthy
- Department of Emergency Medicine, University of California, Irvine, Orange, California
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Shehada ER, He L, Eikey EV, Jen M, Wong A, Young SD, Zheng K. Characterizing Frequent Flyers of an Emergency Department Using Cluster Analysis. Stud Health Technol Inform 2019; 264:158-162. [PMID: 31437905 DOI: 10.3233/shti190203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Emergency department (ED) overcrowding has been a pain point in hospitals across the globe. "Frequent flyers," who visited the ED at a much higher rate than average, account for almost one third of ED visits even though they represent only a small proportion of all ED patients. In this study, we used data-mining methods to cluster ED frequent flyers at a large academic medical center in the US. The objective was to identify distinct types of frequent flyers, and the common characteristics associated with each type. The results show that the frequent flyers at the ED have three subgroups each exhibiting distinct characteristics: (1) the elderly with chronic health conditions, (2) middle-aged males with unhealthy behavior, and (3) adult females who are generally healthy. These findings may inform targeted interventional strategies for patients of each subgroup, who likely have distinct reasons for visiting the ED frequently, to reduce ED overcrowding.
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Affiliation(s)
- Emile Ramez Shehada
- Department of Informatics, University of California, Irvine, Irvine, CA, USA
| | - Lu He
- Department of Informatics, University of California, Irvine, Irvine, CA, USA
| | - Elizabeth V Eikey
- Department of Informatics, University of California, Irvine, Irvine, CA, USA
| | - Maxwell Jen
- Department of Emergency Medicine University of California, Irvine, Irvine, CA, USA
| | - Andrew Wong
- Emergency Department, University of California, Davis, Davis, CA, USA
| | - Sean D Young
- Department of Family Medicine, University of California, Los Angeles, Los Angeles, CA, USA.,University of California Institute for Prediction Technology, Los Angeles, CA, USA
| | - Kai Zheng
- Department of Informatics, University of California, Irvine, Irvine, CA, USA
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Hoonpongsimanont W, Sahota PK, Chen Y, Nguyen M, Louis C, Pena J, Wong A, Jen M. Emergency department patient experience: Same location, same provider, different scores by different survey methods. World J Emerg Med 2019; 10:138-144. [PMID: 31171943 DOI: 10.5847/wjem.j.1920-8642.2019.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recent findings on emergency department (ED) patient experience surveys and concerns for the low response rates challenge the quality and reliability of the survey reports. We assessed the consistency of an ED patient experience survey report and identified the effects of patient demographics on ED patient experiences. METHODS We conducted a prospective, cross-sectional study at a university-based ED from July to December 2017. We obtained ED patient experience scores from an institutional version (IS) survey and the Press Ganey Associates-distributed survey (PGA). We compared top box scores from the two reports using frequency analysis and performed multivariable logistic regressions to identify associations between IS patient demographics and scores. RESULTS We obtained 289 PGA and 234 IS responses. The IS reported significant, higher top box scores in doctor-specific patient questions compared to PGA (all four P-values < 0.01). Female, Christian and White patients were more likely to give top box scores (OR 3.07, OR 2.22 and OR 2.41, P-value < 0.05, respectively). CONCLUSION We found significant differences in ED patient experience scores between the IS and PGA surveys. We recommend that healthcare providers consider patient demographic variables when interpreting ED experience score reports. Multiple survey techniques and distribution methods may be adopted to best capture ED patient experiences.
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Affiliation(s)
| | - Preet Kaur Sahota
- Department of Emergency Medicine, University of California, Orange, CA, USA
| | - Yanjun Chen
- Institute for Clinical and Translational Sciences, University of California, Irvine, CA, USA
| | - Maria Nguyen
- Department of Emergency Medicine, University of California, Orange, CA, USA
| | - Christine Louis
- Department of Emergency Medicine, University of California, Orange, CA, USA
| | - Jonathan Pena
- Department of Emergency Medicine, University of California, Orange, CA, USA
| | - Andrew Wong
- Department of Emergency Medicine, University of California, Orange, CA, USA
| | - Maxwell Jen
- Department of Emergency Medicine, University of California, Orange, CA, USA
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Yanuck J, Shah S, Jen M, Dayal R. Occipital Nerve Blocks in the Emergency Department for Initial Medication-Refractory Acute Occipital Migraines. Clin Pract Cases Emerg Med 2019; 3:6-10. [PMID: 30775654 PMCID: PMC6366379 DOI: 10.5811/cpcem.2019.1.39910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 12/06/2018] [Accepted: 01/01/2019] [Indexed: 01/03/2023] Open
Abstract
Migraines are consistently among the top 20 primary coded diagnoses in emergency departments, constituting 4.5% of all chief complaints. In a significant subset of these, pain arises from the occipital region innervated by the greater (GON) and lesser occipital nerve. In this case series, we present three patients with occipital migraines who received GON blockade with 1% lidocaine. The blockade was performed only after first-line treatment with metoclopramide and possibly additional medications as ordered by triage physician, failed to adequately alleviate pain by 40 minutes after medication administration. Patients were contacted a minimum of seven days following treatment. All three patients experienced significant analgesia and relief of symptoms within 15 minutes of blockade and sustained relief through a seven-day follow-up period.
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Affiliation(s)
- Justin Yanuck
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Sagar Shah
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Maxwell Jen
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Rakhi Dayal
- University of California, Irvine, Department of Anesthesiology, Orange, California
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Winfree K, Ainsworth C, Njue A, Molife C, Lyall M, Jen M, Bittoni M, Heyes A, Carbone D. P3.01-110 Defining Aggressive Disease in Patients With Advanced NSCLC Receiving Second-Line Treatment: A Systematic Review. J Thorac Oncol 2018. [DOI: 10.1016/j.jtho.2018.08.1671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Nguyen M, Louis C, Sahota P, Chen Y, Wong A, Jen M, Hoonpongsimanont W. 90 Improvement of Emergency Department Workflow and Their Effects on Patient Satisfaction. Ann Emerg Med 2018. [DOI: 10.1016/j.annemergmed.2018.08.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Yanuck J, Nelson A, Jen M. Use of occipital nerve block in emergency department treatment of status migrainosus. Am J Emerg Med 2018; 36:1321.e1-1321.e3. [PMID: 29678293 DOI: 10.1016/j.ajem.2018.03.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 12/28/2022] Open
Abstract
Migraine headaches make up a significant proportion of emergency department visits. There are multiple pharmacologic treatment modalities for migraine abortive therapy; however, these treatments are rarely targeted to the precise area of pain and thus elicit multiple systemic effects. It has been well established in the anesthesia pain literature that occipital nerve blocks can provide not only immediate pain relief from occipital migraines, but can also result in a long-term resolution of occipital migraines. In this case report, we present how an occipital nerve block in the emergency department resulted in immediate and long-lasting resolution of a patient's occipital migraine.
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Affiliation(s)
| | | | - Maxwell Jen
- University of California, Irvine, United States
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Toohey SL, Andrusaitis J, Boysen-Osborn M, Billimek J, Jen M, Rudkin S. Comparison of primary compliance in electronic versus paper prescriptions prescribed from the emergency department. Am J Emerg Med 2018; 36:1902-1904. [PMID: 29452921 DOI: 10.1016/j.ajem.2018.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/03/2018] [Accepted: 02/04/2018] [Indexed: 10/18/2022] Open
Affiliation(s)
- Shannon L Toohey
- Department of Emergency Medicine, University of California, Irvine, Orange, CA, USA.
| | | | - Megan Boysen-Osborn
- Department of Emergency Medicine, University of California, Irvine, Orange, CA, USA
| | - John Billimek
- Health Policy Research Institute, University of California, Irvine, CA, USA; Department of Medicine, Division of General Internal Medicine and Primary Care, University of California, Irvine, CA, USA; Department of Family Medicine, University of California, Irvine, CA, USA
| | - Maxwell Jen
- Department of Emergency Medicine, University of California, Irvine, Orange, CA, USA
| | - Scott Rudkin
- Department of Emergency Medicine, University of California, Irvine, Orange, CA, USA
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Van Batavia JP, Chu DI, Long CJ, Jen M, Canning DA, Weiss DA. Genitourinary involvement and management in children with Stevens-Johnson syndrome and toxic epidermal necrolysis. J Pediatr Urol 2017; 13:490.e1-490.e7. [PMID: 28314701 DOI: 10.1016/j.jpurol.2017.01.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/28/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are devastating hypersensitivity disorders that cause epidermal cell death and can affect all epidermal surfaces, including the urethra, vagina, labial and scrotal skin. Despite the well-described ocular and orofacial manifestations of SJS/TEN, there is a paucity of reports on the genitourinary (GU) symptoms and their management. Specifically, consulting services often ask the pediatric urology team if it is safe to place a urethral catheter, but there is no data in the literature to help guide management. The present study sought to review all pediatric cases of SJS/TEN in a tertiary care hospital to determine the incidence and optimal management of GU manifestations, including the use of urethral catheters. METHODS With IRB approval, cases of SJS and TEN that were managed as an inpatient between January 2008 and June 2015 were retrospectively reviewed in order to identify the extent of GU involvement/manifestations, the treatment provided, use of urethral catheterization and long-term follow-up or complications. RESULTS Thirty-one patients (15 female, 16 male; age range 2-18 years) presented with SJS or TEN over the study period. Etiologies for SJS/TEN included mycoplasma infection (48%) and medications (45%). Incidences of GU manifestations at presentation and their management are shown in Summary Table. Overall, 74% of patients had genital involvement of skin lesions. In 12 cases (39%), urology consultation was obtained. Twenty patients (61%) complained of dysuria and one child had gross hematuria in the setting of meatal lesion. Petroleum jelly was used in the majority of patients. A urethral catheter was placed in eight patients (25.8%, four female, four male) with a range of duration of 7-23 days. No patient developed hematuria or any other complications (i.e. strictures or urinary symptoms) after catheter removal. One boy required lysis of penile adhesions in the short-term. One of each gender developed penile and labial adhesions on long-term follow-up that self-resolved. CONCLUSIONS GU involvement in SJS/TEN occurred in almost three-quarters of patients and was managed conservatively like other skin/mucosal manifestations. Long-term sequelae were rare and urethral catheterization appeared to be safe, without any short-term or long-term complications.
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Affiliation(s)
- J P Van Batavia
- Division of Urology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - D I Chu
- Division of Urology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - C J Long
- Division of Urology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M Jen
- Section of Dermatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D A Canning
- Division of Urology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - D A Weiss
- Division of Urology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Jen M, Cho T, Rudkin S, Wong A, Almassi N, Barton E. Mobile COWs (Computer on Wheels): Hamburger or VEAL? West J Emerg Med 2016; 17:527-30. [PMID: 27625715 PMCID: PMC5017835 DOI: 10.5811/westjem.2016.6.30118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/12/2016] [Accepted: 06/16/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Maxwell Jen
- University of California, Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Tiffany Cho
- University of California, Irvine Medical School, Department of Emergency Medicine, Irvine, California
| | - Scott Rudkin
- University of California, Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Andrew Wong
- University of California, Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Negin Almassi
- University of California, Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Erik Barton
- University of California, Irvine Medical Center, Department of Emergency Medicine, Orange, California
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Jen M, Johnson J, Hou P, Liu H. SU-G-IeP1-07: Inaccuracy of Lesion Blood Flow Quantification Related to the Proton Density Reference Image in Arterial Spin Labeling MRI of Brain Tumors. Med Phys 2016. [DOI: 10.1118/1.4956967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Jen M, Yan F, Tseng Y, Lin C, Chen C, Liu H. SU-E-I-65: Estimation of Tagging Efficiency in Pseudo-Continuous Arterial Spin Labeling (pCASL) MRI. Med Phys 2015. [DOI: 10.1118/1.4924062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Potts MB, Jahangiri A, Jen M, Sneed PK, McDermott MW, Gupta N, Hetts SW, Young WL, Lawton MT. Deep arteriovenous malformations in the basal ganglia, thalamus, and insula: multimodality management, patient selection, and results. World Neurosurg 2014; 82:386-94. [PMID: 24657255 DOI: 10.1016/j.wneu.2014.03.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 10/21/2013] [Accepted: 03/14/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study sought to describe a single institution's experience treating arteriovenous malformations (AVMs) of the basal ganglia, thalamus, and insula in a multimodal fashion. METHODS We conducted a retrospective review of all deep AVMs treated at our institution between 1997 and 2011 with attention to patient selection, treatment strategies, and radiographic and functional outcomes. RESULTS A total of 97 patients underwent initial treatment at our institution. 64% presented with hemorrhage with 29% located in the basal ganglia, 41% in the thalamus, and 30% in the insula. 80% were Spetzler-Martin grade III-IV. Initial treatment was microsurgical resection in 42%, stereotactic radiosurgery (SRS) in 45%, and observation in 12%. Radiographic cure was achieved in 54% after initial surgical or SRS treatment (71% and 23%, respectively) and in 63% after subsequent treatments, with good functional outcomes in 78% (median follow-up 2.2 years). Multivariate logistic regression analysis revealed treatment group and age as factors associated with radiographic cure, whereas Spetzler-Martin score and time to follow-up were significantly associated with improved/unchanged functional status at time of last follow-up. Posttreatment hemorrhage occurred in 11% (7% of surgical and 18% of SRS patients). CONCLUSIONS Modern treatment of deep AVMs includes a multidisciplinary approach utilizing microsurgery, SRS, embolization, and observation. Supplementary grading adds meaningfully to traditional Spetzler-Martin grading to guide patient selection. Surgical resection is more likely to result in obliteration compared with SRS, and is associated with satisfactory results in carefully selected patients.
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Affiliation(s)
- Matthew B Potts
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Arman Jahangiri
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Maxwell Jen
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, USA
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology, University of California, San Francisco, San Francisco, California, USA
| | - William L Young
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA; Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California, USA.
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Thomson AB, Kirdeikis P, Lastiwka R, Zuk L, Jen M, Elias M, Johnston P. Food but not a chemically defined diet interferes with maintenance of intragastric pH at a predefined level using continuous pH-stat-adjusted intravenous infusion of ranitidine in healthy volunteers. Dig Dis Sci 1999; 44:1858-64. [PMID: 10505726 DOI: 10.1023/a:1018850908205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Eight healthy volunteers were used to determine the influence of a normal diet (food) versus an isocaloric chemically defined diet (CDD) on the dose of ranitidine infused continuously over 12 hr, required to maintain the intragastric pH > or = 5 or above. The dose of ranitidine used was adjusted by the pH-stat instrument, Gastrojet, and a target pH of 5.0 was selected. The average ranitidine dose was 43.5 mg for food, 28.3 mg for CDD, and 25.7 mg for fasting. Despite the higher dose of ranitidine used with food, the control of pH was lower than the desired and preset value of pH > or = 5: the average mean pH was 3.99 for food, 5.11 for CDD, and 5.75 for fasting. The percentage of time of pH > or = 5 was 32.0% for food, 73.7% for CDD, and 80.1% for fasting. Thus, when persons are fed a normal diet there is a need for higher doses of ranitidine to maintain the gastric pH > or = 5.0. Even with frequent monitoring of intragastric pH with the Gastrojet, there is much greater variability in pH control with food than with CDD or fasting, and the preset and desired pH level was not achieved. This difficulty in achieving desired end points of pH control when switching from a fasting to a fed state needs to be considered when intravenous ranitidine is used to obtain strict control of intragastric pH.
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Affiliation(s)
- A B Thomson
- Department of Medicine, Agriculture, Food, and Nutrition Sciences, University of Alberta, Edmonton, Canada
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