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Field J, Shah ND, Memel Z, Mahadevan U, Beck K. Exclusive Yet Effective: The Crohn's Disease Exclusion Diet as Treatment for Medication-Refractory Disease. Dig Dis Sci 2024:10.1007/s10620-024-08345-5. [PMID: 38555328 DOI: 10.1007/s10620-024-08345-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/02/2024]
Affiliation(s)
- Justin Field
- Colitis and Crohn's Disease Center, University of California, San Francisco, CA, USA
| | - Neha D Shah
- Colitis and Crohn's Disease Center, University of California, San Francisco, CA, USA
| | - Zoe Memel
- Division of Gastroenterology, University of California, San Francisco, CA, USA
| | - Uma Mahadevan
- Colitis and Crohn's Disease Center, University of California, San Francisco, CA, USA
| | - Kendall Beck
- Colitis and Crohn's Disease Center, University of California, San Francisco, CA, USA.
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Bloom PP, Gilbert T, Santos-Parker K, Memel Z, Przybyszewski E, Bethea E, Sonnenday CJ, Tapper EB, Waits S. The incidence and natural history of ascites after liver transplantation. Hepatol Commun 2023; 7:02009842-202306010-00017. [PMID: 37219847 PMCID: PMC10208690 DOI: 10.1097/hc9.0000000000000158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 03/28/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Ascites is common in cirrhosis but uncommon after liver transplant. We aimed to characterize the incidence, natural history, and current management strategies of post-transplant ascites. METHODS We performed a retrospective cohort study of patients who underwent liver transplantation at 2 centers. We included patients who underwent deceased donor whole graft liver transplants between 2002 and 2019. Chart review identified patients with post-transplant ascites, requiring a paracentesis between 1 and 6-month post-transplants. Detailed chart review identified clinical and transplant characteristics, evaluation of ascites etiology, and treatments. RESULTS Of 1591 patients who successfully underwent a first-time orthotopic liver transplant for chronic liver disease, 101 (6.3%) developed post-transplant ascites. Only 62% of these patients required large volume paracentesis for ascites before transplant. 36% of patients with post-transplant ascites had early allograft dysfunction. Most patients with post-transplant ascites (73%) required a paracentesis within 2 months of transplant, but 27% had delayed ascites onset. From 2002 to 2019, ascites studies were obtained less often, and hepatic vein pressure measurement was performed more often. Diuretics were the mainstay of treatment (58%). The use of albumin infusion and splenic artery embolization to treat post-transplant ascites increased over time. Larger pre-transplant spleen size was associated with a greater number of post-transplant paracenteses (r=0.32 and p=0.003). For patients who underwent splenic intervention, paracentesis frequency was significantly reduced (1.6-0.4 paracenteses/month, p=0.0001). The majority (72%) of patients had clinical resolution of their ascites at 6-month post-transplant. CONCLUSIONS Persistent or recurrent ascites continues to be a clinical issue in the modern era of liver transplantation. Most had clinical resolution within 6 months, some requiring intervention.
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Affiliation(s)
- Patricia P Bloom
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Timothy Gilbert
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Keli Santos-Parker
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Zoe Memel
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Eric Przybyszewski
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily Bethea
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Seth Waits
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Flynn DJ, Memel Z, Hernandez-Barco Y, Visrodia KH, Casey BW, Krishnan K. Outcomes of EUS-guided transluminal gallbladder drainage in patients without cholecystitis. Endosc Ultrasound 2021; 10:381-386. [PMID: 34677160 PMCID: PMC8544015 DOI: 10.4103/eus-d-21-00040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background and Objectives: Cholecystectomy is the gold standard for most gallbladder-related disease. However, many patients with gallbladder disease are poor surgical candidates. Current nonsurgical gallbladder drainage (GBD) methods include percutaneous cholecystostomy and endoscopic ultrasound-guided transluminal GBD (EUS-GBD). Outcomes for EUS-GBD for the treatment of noncholecystitis (NC) gallbladder disease have not been defined. Materials and Methods: Cases were identified using procedural data from a quaternary academic hospital for endoscopic procedures from 2015 to 2020. Patients who underwent EUS-GBD for acute cholecystitis, biliary colic, gallstone pancreatitis, and secondary prevention of gallstone disease were included. Results: Fifty-five cases of EUS-GBD were identified over the 5-year study period. Forty-one cases were performed for acute cholecystitis, and 15 were performed for other NC indications. Indications for NC drainage included primary treatment of symptomatic biliary colic and secondary prevention of gallstone pancreatitis and choledocholithiasis. There was no statistically significant difference in complications, mortality, or reintervention requirements. There was a 13.3% rate of immediate complications in the NC group, which were all medically managed. Conclusions: EUS-GBD appears to be a safe and effective way to manage gallstone disease in nonsurgical candidates with NC gallbladder-related disease. Overall complications and readmissions were infrequent. Complication rates were similar to those published in patients who underwent EUS-GBD for acute cholecystitis.
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Affiliation(s)
- Duncan J Flynn
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Zoe Memel
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Brenna W Casey
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Kumar Krishnan
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
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Alipour O, Lee V, Tejura TK, Wilson ML, Memel Z, Cho J, Cologne K, Hwang C, Shao L. The assessment of sarcopenia using psoas muscle thickness per height is not predictive of post-operative complications in IBD. Scand J Gastroenterol 2021; 56:1175-1181. [PMID: 34344243 DOI: 10.1080/00365521.2021.1958368] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Sarcopenia is associated with postoperative complications in inflammatory bowel disease. It has most commonly been defined using the skeletal muscle index, computed after analysis of cross-sectional muscle area at L3. Psoas muscle thickness normalized to height (PMTH), which is easier to derive, is a potential surrogate of SMI and sarcopenia in patients with cirrhosis and chronic pancreatitis. We investigate whether sarcopenia defined by PMTH has utility in predicting post-operative outcomes in patients with inflammatory bowel disease. METHODS We performed a retrospective study of adults undergoing IBD-related surgery from 2009 to 2019 at two hospitals. Sarcopenia was defined by sex-specific PMTH at the umbilicus on cross-sectional imaging using a 50th percentile median cutoff. Predictive models were created using variables (BMI, age, sex, smoking status, albumin, INR, platelets, hemoglobin, hypertension, diabetes, CAD, medications) that may be associated with complications (mortality, reoperation, readmission, transfusions, ICU admission, infection, DVT/PE), and sarcopenia for comparison. RESULTS 85 patients with IBD were included. Lower albumin level (OR = 0.52, p = 0.039) and biologic use (OR = 5.92, p = 0.006) were associated with postoperative complications. There was no significant difference using PMTH compared to a model incorporating hypoalbuminemia and biologic use in predicting complications. Sarcopenia on univariate analysis was associated with a lower 30 day rate of reoperation (p = 0.04). CONCLUSIONS A low status of PMTH was not associated with increased postoperative complications, however hypoalbuminemia and biologic use were. PMTH as a surrogate for sarcopenia requires further study, ideally with prospective studies comparing PMTH with accepted radiographic surrogates for sarcopenia, to determine its role in clinical decision making.
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Affiliation(s)
- Omeed Alipour
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Vivian Lee
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Tapas K Tejura
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Melissa Lee Wilson
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Zoe Memel
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Jaehoon Cho
- Division of Gastroenterology and Hepatology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Kyle Cologne
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | | | - Ling Shao
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, WA, USA
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Memel Z, Chesney K, Pangal DJ, Bonney PA, Carmichael JD, Zada G. Outcomes Following Transsphenoidal Pituitary Surgery in the Elderly: A Retrospective Single-Center Review. Oper Neurosurg (Hagerstown) 2020; 16:302-309. [PMID: 29800459 DOI: 10.1093/ons/opy109] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 11/27/2017] [Accepted: 04/11/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Transsphenoidal surgery (TSS) for pituitary adenomas (PAs) is performed on elderly patients with increasing frequency. More research is necessary to assess the risk factors that are associated with TSS in an aging population. OBJECTIVE To perform a retrospective study on postoperative safety outcomes following TSS in the elderly population stratified by decade of life. METHODS A retrospective chart review of the USC Pituitary Database was conducted to identify patients ≥70 yr, who underwent TSS for PAs between 1995 and 2017. Surgical outcomes were analyzed in elderly (≥70 yr) vs nonelderly (<70 yr) patients. Elderly patients were additionally stratified according to age 70 to 79 vs ≥80 yr. RESULTS The cohorts included 115 elderly patients (70-79 yr: 94 patients; ≥80 yr: 21 patients) and 770 nonelderly patients. Elderly patients presented with more vision loss (62% vs 38%, P < .0001), dizziness (17% vs 6%, P = .0001) and altered mental status (7.3% vs 3%, P = .0451). Overall rates of surgical, medical, and endocrine complications were similar; however, elderly patients had significantly higher rates of postoperative hyponatremia (9.3% vs 4.7%, P = .0401) and lower rates of transient diabetes insipidus (0.9% vs 7.9%, P = .0038). Patients ≥ 80 yr had significantly more surgical complications (26.3%) compared to the 70 to 79 group (7.87%; P = .021) and <70 group (12.5%; P = .04). CONCLUSION Patients >70 yr are appropriate surgical candidates for TSS given the similar safety outcomes as younger patients. Given the higher propensity for surgical complications; however, a higher level of operative selectivity should be maintained in octogenarian patients.
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Affiliation(s)
- Zoe Memel
- Department of Neurological Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Kelsi Chesney
- Department of Neurological Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Dhiraj J Pangal
- Department of Neurological Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Phillip A Bonney
- Department of Neurological Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - John D Carmichael
- Division of Endocrinology, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California
- USC Pituitary Center, USC Keck School of Medicine, Los Angeles, California
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine of USC, Los Angeles, California
- USC Pituitary Center, USC Keck School of Medicine, Los Angeles, California
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Pangal DJ, Chesney K, Memel Z, Bonney PA, Strickland BA, Carmichael J, Shiroishi M, Jason Liu CS, Zada G. Pituitary Apoplexy Case Series: Outcomes After Endoscopic Endonasal Transsphenoidal Surgery at a Single Tertiary Center. World Neurosurg 2020; 137:e366-e372. [PMID: 32032792 DOI: 10.1016/j.wneu.2020.01.204] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 12/06/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The management of pituitary apoplexy, caused by acute hemorrhage and/or infarction of a pituitary adenoma, is debated. OBJECTIVE To analyze clinical characteristics of patients undergoing endoscopic endonasal approaches (EEAs) for pituitary apoplexy. METHODS A retrospective review of patients at our institution from 2012 to 2018 undergoing EEA for pituitary apoplexy diagnosed clinically and with imaging/pathologic findings. Analysis included demographics, symptoms, neuroendocrine deficits, neuroimaging, complications, symptom resolution, and follow-up details. RESULTS Fifty patients (mean age, 53 years) were included. Preoperative symptoms included headache (86%), vision loss (62%), and cranial nerve paresis (40%). Mean tumor diameter was 2.7 cm and extrasellar extension was observed in 96% of tumors. Twenty-eight tumors were hemorrhagic (76%), 24 were necrotic (65%), and 13 (35%) had both features. Magnetic resonance imaging showed gross total resection in 58% of patients. Headache and vision loss improved in 87% and 86% of presenting patients. Cranial nerve paresis resolved in 72% of patients, partially improved in 11%, and remained unchanged in 17%. There were no deaths or carotid artery injuries. Surgical complications included postoperative cerebrospinal fluid leak (n = 4, 8%), epistaxis (n = 2, 4%), postoperative abscess (n = 1, 2%), and transient postoperative vision loss requiring reoperation (n = 1, 4%). Endocrinopathies improved in 21% of patients and panhypopituitarism persisted in 48% and developed in 6% of patients. Mean follow-up time was 26 months; 2 patients experienced recurrence. CONCLUSIONS EEA for pituitary apoplexy is effective in rapidly improving headache and visual symptoms. Although neuro-ophthalmic deficits often improve over time, panhypopituitarism persists in most patients after surgical resection.
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Affiliation(s)
- Dhiraj J Pangal
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Kelsi Chesney
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Zoe Memel
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Phillip A Bonney
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - John Carmichael
- Division of Endocrinology, Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California, USA; USC Pituitary Center, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Mark Shiroishi
- Department of Radiology, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Chia-Shang Jason Liu
- Department of Radiology, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA; USC Pituitary Center, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
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Pang B, Memel Z, Diamant C, Clarke E, Chou S, Gregory H. Culinary medicine and community partnership: hands-on culinary skills training to empower medical students to provide patient-centered nutrition education. Med Educ Online 2019; 24:1630238. [PMID: 31248353 PMCID: PMC6609327 DOI: 10.1080/10872981.2019.1630238] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 02/08/2019] [Accepted: 06/06/2019] [Indexed: 06/02/2023]
Abstract
Given the economic burden and numerous morbidities associated with obesity and poor dietary choices, it is increasingly important for medical students to receive education on nutrition and preventive medicine so that they are equipped to advise patients about healthy lifestyle choices. Currently, 71% of US medical schools do not reach the minimum benchmark of 25 hours of nutrition education set by the National Academy of Sciences. In order to improve the quality and quantity of nutrition education at the Keck School of Medicine of USC (KSOM), medical students and faculty have partnered with LA Kitchen (LAK), a local teaching kitchen, and the Wellness Center at LA County Medical Center (LAC+USC). They developed a hands-on preclinical culinary and nutrition course that aims to teach students practical skills and knowledge that they will be able to apply to their own lives and pass onto patients. Following the completion of the first three years of the course (2016-2018), analysis suggests that the class was well-received and has improved students' nutrition knowledge, confidence in lifestyle counseling, and personal culinary skills. Given these highly encouraging observations, the project is currently aimed at incorporating nutrition education more broadly into the required preclinical curriculum at KSOM.
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Affiliation(s)
- Brandon Pang
- a Department of Medical Education , Keck School of Medicine of USC , Los Angeles , CA , USA
| | - Zoe Memel
- a Department of Medical Education , Keck School of Medicine of USC , Los Angeles , CA , USA
| | - Carmel Diamant
- a Department of Medical Education , Keck School of Medicine of USC , Los Angeles , CA , USA
| | - Emily Clarke
- a Department of Medical Education , Keck School of Medicine of USC , Los Angeles , CA , USA
| | - Sherene Chou
- b Department of Culinary Training , LA Kitchen , Los Angeles , CA , USA
| | - Harlan Gregory
- c Department of Medical Education , Keck School of Medicine of USC , Los Angeles , CA , USA
- d Department of Pediatrics , Keck School of Medicine of USC , Los Angeles , CA , USA
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Chesney K, Memel Z, Pangal DJ, Donoho D, Hurth K, Mathew A, Carmichael JD, Zada G. Variability and Lack of Prognostic Value Associated With Atypical Pituitary Adenoma Diagnosis: A Systematic Review and Critical Assessment of the Diagnostic Criteria. Neurosurgery 2017; 83:602-610. [DOI: 10.1093/neuros/nyx541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 09/27/2017] [Indexed: 12/17/2022] Open
Abstract
Abstract
BACKGROUND
Atypical pituitary adenomas (APAs) are a subset of pituitary adenomas (PAs) characterized by the 2004 World Health Organization (WHO) guidelines to have higher risk histopathological features than typical PAs. In July 2017, the WHO published an update to their classification of pituitary tumors and abandoned the APA terminology.
OBJECTIVE
To assess the prevalence and outcomes of patients diagnosed with APA through a literature review. Focus was placed on variation in the application of the previous WHO criteria and on rates of recurrence.
METHODS
A systematic review of PubMed (2004-July 2017) was performed to identify studies reporting prevalence and clinical characteristics/outcomes of APA. Eight studies were analyzed for prevalence. Six studies reporting histopathological details were analyzed in depth.
RESULTS
Of the 7105 included patients, 373 (5.2%) met criteria for APA (prevalence range: 3%-15%). Only 2 of 8 studies utilized identical grading criteria, demonstrating a lack of standardized application. Most APAs (84%) were macroadenomas, with 52% invasive on magnetic resonance imaging. Nonfunctional PAs were most common (37%), followed by prolactinomas (23%) and Growth Hormone adenomas (21%). Recurrence/progression occurred in 21% of APA patients (follow-up range 37-75 mo). Only 2 of 8 studies reported an association between APA diagnosis and recurrence/progression.
CONCLUSION
Based on diagnostic variability and lack of association with clinical outcomes, refinement of criteria for APA was necessary. The WHO update eliminates the ambiguity in APA diagnosis in favor of criteria that emphasize clinical behavior (invasion, recurrence, and resistance to treatment) and molecular markers. Our review supports abandonment of the previous APA designation due to limited prognostic utility.
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Affiliation(s)
- Kelsi Chesney
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California
| | - Zoe Memel
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California
| | - Daniel Donoho
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California
| | - Kyle Hurth
- Division of Neuropathology, Department of Pathology, Keck School of Medicine of USC, Los Angeles, California
| | - Anna Mathew
- Division of Neuropathology, Department of Pathology, Keck School of Medicine of USC, Los Angeles, California
| | - John D Carmichael
- Division of Endocrinology, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California
- USC Pituitary Center, Keck School of Medicine of USC, Los Angeles, California
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California
- USC Pituitary Center, Keck School of Medicine of USC, Los Angeles, California
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