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Chan TC, Yu VMW, Luk JKH, Chu LW, Yuen JKY, Chan FHW. Effectiveness of Partially Hydrolyzed Guar Gum in Reducing Constipation in Long Term Care Facility Residents: A Randomized Single-Blinded Placebo-Controlled Trial. J Nutr Health Aging 2022; 26:247-251. [PMID: 35297467 DOI: 10.1007/s12603-022-1747-2] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess the effectiveness of partially hydrolyzed guar gum (PHGG) in improving constipation and reducing the use of laxatives among long term care facility (LTCF) residents. DESIGN A single-center, prospective, randomized, placebo-controlled, single-blinded parallel-group trial from September 2021 to November 2021. SETTING Four LTCF in Hong Kong. PARTICIPANTS Fifty-two LTCF residents with chronic constipation (mean age: 83.9±7.6 years, male 38%). INTERVENTION 5g PHGG mixed with 200ml water per day for 4 weeks was given to intervention group participants. Control group received 200ml water for 4 weeks. Participants continued their usual as-needed laxative (lactulose, senna or dulcolax) on their own initiative. MEASUREMENTS Baseline measurements included age, gender, Charlson comorbidity index, Roackwood's Clinical Frailty Scale, body mass index and daily dietary fiber intake. Outcome measures were fecal characteristics assessed by Bristol Stool Form Scale, bowel opening frequency and laxative use frequency at baseline, first, second, third and fourth week of trial. Adverse events were measured. The study was registered on ClinicalTrial.gov; identifier: NCT05037565. RESULTS There was no significant difference in bowel frequency and stool characteristics between the treatment group and control group. However, there was a significantly lower frequency of lactulose, senna, and total laxative use in the treatment group compared with controls in the third and fourth week. There was no significant difference in adverse effects between the two groups. CONCLUSION This study showed that daily dietary fibre supplementation by using PHGG for 4 weeks in LTCF residents results in significantly less laxative use than placebo. It may be an effective way to reduce laxative dependence among older people living in LTCFs.
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Affiliation(s)
- T C Chan
- Tuen-Ching Chan, Department of Medicine and Geriatrics, Fung Yiu King Hospital, 9 Sandy Bay Road, Pokfulam, Hong Kong, , Tel: 28556133, Fax: 28196182
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Cheung YT, Yang LS, Ma JCT, Woo PHK, Luk SMS, Chan TCH, Lee VWY, Yeung NCY, Li CK. Health behaviour practices and expectations for a local cancer survivorship programme: a cross-sectional study of survivors of childhood cancer in Hong Kong. Hong Kong Med J 2022; 28:33-44. [DOI: 10.12809/hkmj209112] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- YT Cheung
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - LS Yang
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Justin CT Ma
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Patricia HK Woo
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Sammy MS Luk
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Thomas CH Chan
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Vivian WY Lee
- Centre for Learning Enhancement and Research, The Chinese University of Hong Kong, Hong Kong
| | - Nelson CY Yeung
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - CK Li
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Children’s Hospital
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Luk JKH, Chan TC, Chan FHW. Letter to the Editor: Careful hand feeding program in a geriatric step-down hospital in Hong Kong - is this feasible? J Frailty Aging 2021; 10:303-304. [PMID: 34105718 DOI: 10.14283/jfa.2020.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J K H Luk
- T.C. Chan, Department of Medicine and Geriatrics, Fung Yiu King Hospital, 9 Sandy Bay Road, Pokfulam, Hong Kong, , Tel: 28556133, Fax: 28196182
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Lin FOY, Luk JKH, Chan TC, Mok WWY, Chan FHW. Effectiveness of a discharge planning and community support programme in preventing readmission of high-risk older patients. Hong Kong Med J 2015; 21:208-16. [PMID: 25904292 DOI: 10.12809/hkmj144304] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [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: 11/05/2022] Open
Abstract
OBJECTIVE To examine the effectiveness of Integrated Care and Discharge Support for elderly patients in reducing accident and emergency department attendance, acute hospital admissions, and hospital bed days after discharge. Factors that compromise its effectiveness were investigated and cost analysis was performed. DESIGN Cohort prospective study. SETTING Integrated Care and Discharge Support for elderly patients in Hong Kong West Cluster. PARTICIPANTS Home-dwelling patients recruited between April 2012 and March 2013 into Integrated Care and Discharge Support for elderly patients in Hong Kong West Cluster. RESULTS A total of 1090 older patients were studied. The Integrated Care and Discharge Support for elderly patients programme reduced accident and emergency department attendance by 40% (P<0.001), acute hospital admissions by 47% (P<0.001), and hospital bed days by 31% (P<0.001) at 6 months after implementation. Improvements in Barthel Index 20 (P<0.001) and Modified Functional Ambulation Category scale (P<0.001) were observed. Of the patients, 85 (7.8%) died within 6 months of initiation of the programme. Only 26 (2.4%) older patients required institutionalisation in residential care homes within 6 months after the programme. Increasing age (P=0.025) and high Charlson Comorbidity Index score (P=0.001) were positive predictors for accident and emergency department attendance. A high albumin level (P=0.001) and living alone (P=0.033) were negative predictors for accident and emergency department attendance. Of the patients, 310 (28.4%) had no reduction in bed days after the programme. Increasing age (P=0.025) and number of medications (P=0.003) were positive predictors for no reduction in bed days; while higher haemoglobin level (P=0.034) was a negative predictor. There was a potential annual cost-saving of HK$22.5 million (approximately US$2.9 million). CONCLUSION The Integrated Care and Discharge Support for elderly patients programme reduced accident and emergency department attendance, acute hospital admissions and hospital bed days, and was potentially cost-saving. Age, Charlson Comorbidity Index, albumin level, and living alone were factors associated with accident and emergency department attendance. Age, number of medications, and haemoglobin level were associated with no reduction in bed days. Further study of the cost-effectiveness of such programme is warranted.
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Affiliation(s)
- Francis O Y Lin
- Department of Medicine and Geriatrics, TWGHs Fung Yiu King Hospital, 9 Sandy Bay Road, Pokfulam, Hong Kong
| | - James K H Luk
- Department of Medicine and Geriatrics, TWGHs Fung Yiu King Hospital, 9 Sandy Bay Road, Pokfulam, Hong Kong
| | - T C Chan
- Department of Medicine and Geriatrics, TWGHs Fung Yiu King Hospital, 9 Sandy Bay Road, Pokfulam, Hong Kong
| | - Winnie W Y Mok
- Department of Medicine and Geriatrics, TWGHs Fung Yiu King Hospital, 9 Sandy Bay Road, Pokfulam, Hong Kong
| | - Felix H W Chan
- Department of Medicine and Geriatrics, TWGHs Fung Yiu King Hospital, 9 Sandy Bay Road, Pokfulam, Hong Kong
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Luk JKH, Chan WK, Ng WC, Chiu PKC, Ho C, Chan TC, Chan FHW. Mortality and health services utilisation among older people with advanced cognitive impairment living in residential care homes. Hong Kong Med J 2013; 19:518-24. [PMID: 24096360 DOI: 10.12809/hkmj133951] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To study the demography, clinical characteristics, service utilisation, mortality, and predictors of mortality in older residential care home residents with advanced cognitive impairment. DESIGN Cohort longitudinal study. SETTING Residential care homes for the elderly in Hong Kong West. PARTICIPANTS Residents of such homes aged 65 years or more with advanced cognitive impairment. RESULTS In all, 312 such residential care home residents (71 men and 241 women) were studied. Their mean age was 88 (standard deviation, 8) years and their mean Barthel Index 20 score was 1.5 (standard deviation, 2.0). In all, 164 (53%) were receiving enteral feeding. Nearly all of them had urinary and bowel incontinence. Apart from Community Geriatric Assessment Team clinics, 119 (38%) of the residents attended other clinics outside their residential care homes. In all, 107 (34%) died within 1 year; those who died within 1 year used significantly more emergency and hospital services (P<0.001), and utilised more services from community care nurses for wound care (P=0.001), enteral feeding tube care (P=0.018), and urinary catheter care (P<0.001). Independent risk factors for 1-year mortality were active pressure sores (P=0.0037), enteral feeding (P=0.008), having a urinary catheter (P=0.0036), and suffering from chronic obstructive pulmonary disease (P=0.011). A history of pneumococcal vaccination was protective with respect to 1-year mortality (P=0.004). CONCLUSION Residents of residential care homes for the elderly with advanced cognitive impairment were frail, exhibited multiple co-morbidities and high mortality. They were frequent users of out-patient, emergency, and in-patient services. The development of end-of-life care services in residential care homes for the elderly is an important need for this group of elderly.
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Affiliation(s)
- James K H Luk
- Department of Medicine and Geriatrics, Fung Yiu King Hospital, 9 Sandy Bay Road, Pokfulam, Hong Kong
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Loh KW, Rani F, Chan TC, Loh HY, Ng CW, Moy FM. The association between risk factors and hypertension in perak, malaysia. Med J Malaysia 2013; 68:291-296. [PMID: 24145254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Hypertension is a major public health problem in Malaysia. A survey was initiated to examine the association of modifiable and non-modifiable risk factors for hypertension in Perak, Malaysia. METHODS A total of 2025 respondents aged 30 years and above were recruited using a multi-stage sampling method. Hypertension was defined as self-reported hypertension and/or average of two blood pressure readings at single occasion with SBP ≥ 140mmHg or DBP ≥ 90 mmHg. Body mass index (BMI) was defined using the Asian criteria and International Physical Activity Questionnaire (IPAQ) was used to evaluate physical activity. Body weight, height and blood pressure were obtained using standard procedures. Univariate analyses were conducted to examine the associations between risk factors and hypertension. Multiple logistic regression was used to examine each significant risk factor on hypertension after adjusted for confounders. RESULTS In total, 1076 (54.9%) respondents were found to be hypertensive. Significant associations (p <0.001) with hypertension were noted for increasing age, low physical activity, obese BMI, no education background and positive family history of hypertension. After adjusting for age, sex, ethnicity, education background, family history, BMI, physical activity, smoking and diet, respondents who were obese and had positive family history had higher odds for hypertension (OR:2.34; 95% CI:1.84-3.17 and 1.96 (1.59-2.42) respectively. A significant increase (p <0.001) in risk for hypertension was noted for age. Those with moderate physical activities were 1.40 (1.04-1.78) times more of having hypertension than those active. Poor diet score and smoking were not significantly associated with increased risk for hypertension. CONCLUSION In conclusion, modifiable risk factors such as BMI and physical activity are important risk factors to target in reducing the risk for hypertension.
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Affiliation(s)
- K W Loh
- Julius Centre University of Malaya, Department of Social & Preventive Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
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Shea YF, Chan JFW, Kwok WC, Hwang YY, Chan TC, Ni MYX, Li IWS, Chiu PKC, Luk JKH, Chu LW. Haemophagocytic lymphohistiocytosis: an uncommon clinical presentation of tuberculosis. Hong Kong Med J 2012; 18:517-525. [PMID: 23223654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
Secondary haemophagocytic lymphohistiocytosis is a rare but fatal complication of tuberculosis. We describe two cases, and review the local and international experience on the management of this clinical entity. Prompt treatment with anti-tuberculous drugs forms the cornerstone of therapeutic success.
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Affiliation(s)
- Y F Shea
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong.
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Lenert LA, Kirsh D, Griswold WG, Buono C, Lyon J, Rao R, Chan TC. Design and evaluation of a wireless electronic health records system for field care in mass casualty settings. J Am Med Inform Assoc 2011; 18:842-52. [PMID: 21709162 DOI: 10.1136/amiajnl-2011-000229] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND There is growing interest in the use of technology to enhance the tracking and quality of clinical information available for patients in disaster settings. This paper describes the design and evaluation of the Wireless Internet Information System for Medical Response in Disasters (WIISARD). MATERIALS AND METHODS WIISARD combined advanced networking technology with electronic triage tags that reported victims' position and recorded medical information, with wireless pulse-oximeters that monitored patient vital signs, and a wireless electronic medical record (EMR) for disaster care. The EMR system included WiFi handheld devices with barcode scanners (used by front-line responders) and computer tablets with role-tailored software (used by managers of the triage, treatment, transport and medical communications teams). An additional software system provided situational awareness for the incident commander. The WIISARD system was evaluated in a large-scale simulation exercise designed for training first responders. A randomized trial was overlaid on this exercise with 100 simulated victims, 50 in a control pathway (paper-based), and 50 in completely electronic WIISARD pathway. All patients in the electronic pathway were cared for within the WIISARD system without paper-based workarounds. RESULTS WIISARD reduced the rate of the missing and/or duplicated patient identifiers (0% vs 47%, p<0.001). The total time of the field was nearly identical (38:20 vs 38:23, IQR 26:53-1:05:32 vs 18:55-57:22). CONCLUSION Overall, the results of WIISARD show that wireless EMR systems for care of the victims of disasters would be complex to develop but potentially feasible to build and deploy, and likely to improve the quality of information available for the delivery of care during disasters.
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Affiliation(s)
- L A Lenert
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.
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Chan TC, Luk JKH, Liu A, Chiu PKC, Chan FHW, Chu LW. Financial abuse in a mentally incapacitated old man. Hong Kong Med J 2009; 15:213-216. [PMID: 19494378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
A mentally incapacitated 82-year-old man with no relatives was managed by a geriatrician-led multidisciplinary team when medical staff realised he was at risk of being exploited. They initiated a series of protective measures including an emergency guardianship application. The Guardianship Board appointed the Director of Social Welfare as his public guardian. This case illustrates that hospital staff should be alert to potential elder abuse to ensure timely protection of potential victims.
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Affiliation(s)
- T C Chan
- Division of Geriatrics, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
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Chau MC, Leung SF, Kam KM, Cheung KY, Kwan WH, Yu KH, Chiu KW, Chan TC. Feasibility of using interpolated contours of targets and organs at risk in intensity-modulated radiation therapy treatment planning for advanced-stage nasopharyngeal carcinoma. ACTA ACUST UNITED AC 2007; 51:480-4. [PMID: 17803802 DOI: 10.1111/j.1440-1673.2007.01874.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To assess the dosimetric effect of using interpolated contours in planning intensity-modulated radiation therapy (IMRT) for advanced T-stage nasopharyngeal carcinoma. The present study focused on T3-T4 tumours where the proximity of targets to neurological organs poses a stringent test on the feasibility of such an approach. Contours of targets and organs were delineated on CT images of 2.5-mm interval and a reference IMRT plan was generated. An investigative (INV) IMRT plan was then generated with the same planning protocol, but based on interpolated contours that replaced deleted contours on alternate slices. The reference and INV plans were compared. Regarding target coverage, all targets in the INV plans met the acceptance criteria except for the PTV in one case. Regarding organs, the mean dose to 1% volume of the brainstem and spinal cord in the INV plans were kept below their dose limits. No significant differences in the mean doses to others organs were found. Satisfactory target coverage and protection of critical organs to a degree similar to full-scale contouring could be achieved with use of interpolated contours. The saving in manpower time for contouring is expected to significantly improve the throughput of the IMRT planning process.
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Affiliation(s)
- M C Chau
- Department of Clinical Oncology, Prince of Wales Hospital, Shatin, Hong Kong SAR.
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Chan TC, Jiang J, Temenak JJ, Richards AL. Development of a rapid method for determining the infectious dose (ID)50 of Orientia tsutsugamushi in a scrub typhus mouse model for the evaluation of vaccine candidates. Vaccine 2004; 21:4550-4. [PMID: 14575767 DOI: 10.1016/s0264-410x(03)00505-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The infectious dose (ID) of an inoculum for which 50% of susceptible mice will become infected (ID(50)) with Orientia tsutsugamushi is usually determined by rechallenging mice that have already been challenged with O. tsutsugamushi to determine the lethal dose (LD)(50) titer of the inoculum. Those mice not killed by the initial challenge and which survived a rechallenge with 1000 LD(50) were considered immune and to have been initially infected with O. tsutsugamushi. Mice that succumbed to the rechallenge were considered not to have been initially infected. We have developed a more rapid method of determining the ID(50) of inocula for use in our vaccine studies based upon the observation that mice surviving initial challenge and that go on to survive rechallenge produced detectable IgG to O. tsutsugamushi antigens by enzyme-linked immunosorbent assay (ELISA). Mice that did not survive rechallenge, and therefore did not receive an initial infectious inoculum did not produce detectable IgG to O. tsutsugamushi antigens. Both original LD(50) and ID(50) titers determinations require observation of mice for 21 days post-challenge. Our new ID(50) determination does not require mice or the additional 21-day observation period for rechallenge and therefore is more rapid and cost-effective than the previous standard method of determining ID(50) titer necessary for the evaluation of vaccine candidates.
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Affiliation(s)
- T C Chan
- Rickettsial Diseases Department, IDD, 3A19, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910-7500, USA
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Abstract
OBJECTIVE To describe the clinical presentation of patients with cyclic antidepressant (CA) and use of sodium bicarbonate (NaHCO(3)) in the treatment of this overdose in the prehospital setting. METHODS A three year retrospective observational review of records was performed using the San Diego County Quality Assurance Network database for prehospital providers. All adult patients who were treated with NaHCO(3) by paramedics for a CA overdose were included. Demographic data, presenting cardiovascular and neurological symptoms, paramedic treatments, and any changes in status were reviewed. RESULTS Twenty one patients were treated by paramedics with NaHCO(3) for CA overdose. Seventeen patients (80%) presented with mental status changes, including 11 presenting with a GCS<8. Seven of the 21 (33%) presented with a cardiac arrhythmia expected to possibly respond to NaHCO(3) treatment. Seven of the 21 (33%) were hypotensive, and five (24%) patients had reported seizure activity. Only 2 of the 21 patients (10%) treated with NaHCO(3) had recorded improvements after administration of the drug, while the other 19 remained stable without any deterioration. Sixteen of 21 patients (76%) were given NaHCO(3) for indications on standing order, while five patients were treated outside the standing order indications by base physician order with none of the five patients having any change in status ater treatment. CONCLUSIONS After prehospital NaHCO(3) use in patients with CA overdose, there were no complications reported, two patients improved in status and the others remained unchanged. Base hospital physician orders of NaHCO(3) for indications beyond the standing orders were not associated with changes in patient status.
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Affiliation(s)
- T Calkins
- Department of Emergency Medicine, University of California San Diego Medical Center, San Diego, USA
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Abstract
The effects due to steric hindrance on solute-solvent interactions and on diffusion of associated molecules were found by comparing the diffusion coefficients of different aromatic isomers in acetone at 298.2 K; there exists a correlation between the isomeric effects of intermolecular association on diffusion and the molecular scales of overall hydrogen-bond acidity of the isomers studied.
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Affiliation(s)
- Shuang Chen
- Department of Chemical and Environmental Engineering, Wuyi University, Jiangmen, Guangdong 529020, P.R. China
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Abstract
An experiment was conducted to examine the hemispheric dominance in semantic processing of Chinese characters. Results showed that N1 is the earliest component that reflects the semantic processing of Chinese characters. Although N1 of the left hemisphere is larger in amplitude, that of the right hemisphere is shorter in latency. Based on these findings, the authors propose that the left hemisphere does not start processing until the necessary information has been transferred from the right hemisphere. Once the left hemisphere starts processing, its intensity is stronger. Thus, it is more appropriate to differentiate hemispheric processing dominance into two dimensions: speed and intensity. Moreover, the semantic cognition onset of Chinese characters occurs from 100 ms to 160 ms in the posterior perceptual processing area of brain.
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Affiliation(s)
- J H Wei
- Laboratory of Mental Health, Institute of Psychology, The Chinese Academy of Sciences, Beijing, Hong Kong
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Abstract
The electrocardiographic findings associated with pulmonary embolism have been well described in the medical literature for over 50 years. These abnormalities include changes in rhythm, QRS axis, and morphology, particularly in the QRS and T waves. Such findings may reflect hemodynamic changes, such as right heart strain, as well as myocardial ischemia associated with the disease. Although certain findings may correlate with the severity of pulmonary embolism, the overall utility of the electrocardiogram is limited due to the variable presence, frequency, and transient nature of most of the abnormalities associated with the disease.
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Affiliation(s)
- T C Chan
- Department of Emergency Medicine, University of California San Diego Medical Center, San Diego, California 92103-8676, USA
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Abstract
The popularity and use of unmotorized, foot-propelled scooters has risen dramatically in the last few years. Increasing reports of traumatic injuries from these scooters have paralleled their commercial sales and success in this country and worldwide. We report a case of a previously healthy 48-year-old woman who suffered a severe traumatic brain injury while riding one of these scooters, resulting in a devastating neurologic outcome and permanent vegetative state. This case emphasizes the importance of public awareness regarding the potential dangers and the need for appropriate precautions and protective gear when riding these recreational devices.
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Affiliation(s)
- C Ho
- Department of Emergency Medicine, University of California, San Diego, California 92130, USA
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Abstract
To determine paramedics' experience, comfort, and accuracy in the estimation of pediatric weights, paramedics were surveyed regarding their experience and training in estimating pediatric weights and then were presented with four children and asked to estimate their weights and to calculate the first round of i.v. epinephrine dose for asystole according to protocol. Twenty paramedics participated, with 55% stating they were uncomfortable on pediatric calls; 15 of 20 (75%) stated they were uncomfortable estimating children's weights. The majority of estimations were within 50% of the actual weights. Based on weight estimations, the epinephrine doses were calculated correctly in 88% of all cases. In 10% of cases, the epinephrine dose was incorrect by a factor of 10 times the appropriate dose. The weight range using the Broselow tape was determined correctly by all participants, with 95% correctly reporting the correct dose of epinephrine. Overall, paramedics were accurate in estimating pediatric weights, and use of the Broselow tape improved the precision of these estimations.
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Affiliation(s)
- G M Vilke
- Department of Emergency Medicine, University of California, San Diego Medical Center, San Diego, California 92103-8676, USA
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Abstract
Although widely used in Europe, the prehospital 12-lead electrocardiogram (EKG) has seen only limited use in this country. Reported benefits of the 12-lead EKG include shortening the door-to-needle time, accelerating the initiation of reperfusion therapy, and overall improving the prehospital and hospital management and outcome of patients with acute myocardial infarction. The field EKG also provides the basis for prehospital fibrinolysis. Concerns still exist, however, regarding the best means of providing real-time field interpretation of the prehospital EKG and the potential for inappropriate field time delay, triage, and treatment of patients. Moreover, questions remain about the overall clinical and cost benefit of expanding this resource universally. The following article reviews the role of prehospital EKG in caring for patients with acute coronary syndromes.
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Affiliation(s)
- R J Patel
- The University of California San Diego School of Medicine, UCSD Medical Center, 200 West Arbor Drive, San Diego, CA 92103-8676, USA
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Abstract
OBJECTIVE Patient refusal of paramedic transport against medical advice (AMA) has significant medical-legal implications. Previous studies have investigated patient outcomes after refusal of transport, but none has focused on these events in minors. This study was performed to evaluate the outcomes of this patient population after refusal of transport as well as the significance of base hospital physician discussion with parents in the decision to refuse transport. METHODS This was a retrospective telephone follow-up survey involving parents of minors for whom transport was refused after accessing emergency medical services (EMS) via the 911 system. Data were initially obtained from paramedic run records and each family was subsequently contacted by telephone and surveyed with regard to their experiences with the field medics in addition to the medical follow-up sought for their child and patient outcomes. RESULTS Eighty-nine patients met criteria for survey. Telephone contact was made with 44 parents, of whom 32 (73% of those contacted, 36% overall) participated. Twenty-seven (84%) received medical follow-up, either at an emergency department or in a private physician's office. Most patients (89%) who were evaluated and/or treated by a physician were subsequently released, while three children were admitted to the hospital, all three with respiratory or cardiac chief complaints. CONCLUSIONS Children whose parents refused EMS transport received medical follow-up in the majority of cases, with a small group requiring admission.
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Affiliation(s)
- A G Seltzer
- Department of Emergency Medicine, University of California, San Diego, Medical Center, 92103, USA
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Abstract
Posterior myocardial infarction (PMI) refers to infarction of the posterior wall of the left ventricle. Although often associated with inferior and lateral myocardial infarctions, detection of acute PMI is difficult because the standard 12-lead electrocardiogram does not adequately image the posterior wall of the left ventricle. We review the findings on 12-lead electrocardiogram with PMI, as well as discuss the utility of additional electrocardiographic leads in the diagnosis of PMI.
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Affiliation(s)
- W J Brady
- Department of Emergency Medicine, University of Virginia Health Sciences Center, Charlottesville, Virginia 22908, USA
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Abstract
Toxicity from the digitalis family of cardiac glycoside medications remains common. Successful treatment depends on early recognition; however, the diagnosis of potentially life-threatening toxicity remains difficult because the clinical presentation is often nonspecific and subtle. The hallmark of cardiac toxicity is increased automaticity coupled with concomitant conduction delay. Though no single dysrhythmia is always present, certain aberrations such as frequent premature ventricular beats, bradydysrhythmias, paroxysmal atrial tachycardia with block, junctional tachycardia, and bidirectional ventricular tachycardia are common. Treatment depends on the clinical condition rather than serum drug level. Management varies from temporary withdrawal of the medication to administration of digoxin-specific Fab fragments for life-threatening cardiovascular compromise.
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Affiliation(s)
- G Ma
- Department of Emergency Medicine, University of California San Diego Medical Center, 200 West Arbor Drive #8676, San Diego, CA 92130-8676, USA
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22
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Abstract
Xlim-1, a LIM class homeobox gene expressed in Xenopus laevis, is one of the earliest known marker genes of pronephros development and is expressed in pronephros rudiment. In this study, we examined the role of Xlim-1 in pronephros development. Temporal expression of Xlim-1 in explants was analyzed in a series of induction assays using RT-PCR analysis. Xlim-1 was expressed 9 to 15 h after activin/retinoic acid treatment, corresponding to pronephros differentiation in explants. We further examined the role of Xlim-1 using a series of microinjection experiments. Presumptive pronephric anlagen of embryos were injected with various Xlim-1 mutants, and effects of these Xlim-1 mutants on pronephrogenesis in embryos and in explants were analyzed by RT-PCR and immunohistochemistry. Dominant-negative Xlim-1 inhibited differentiation of pronephros in activin/retinoic acid-treated animal caps. In embryos injected with a dominant-negative form of Xlim-1, development of pronephric tubules was inhibited at the late tail-bud stage. Our results suggest that Xlim-1 may not initiate differentiation of the pronephros, but that it is necessary for growth and elongation in the development of pronephric tubules.
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Affiliation(s)
- T C Chan
- Department of Life Sciences, CREST, Graduate School of Arts and Sciences, Japan Science and Technology Corporation, University of Tokyo, 3-8-1 Komaba, Meguro-ku,Tokyo, 153-8902, Japan
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23
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Abstract
Aberrant ventricular conduction is a common electrocardiographic (EKG) manifestation that occurs when the supraventricular electrical impulse is conducted abnormally through the ventricular conducting system. This results in a wide QRS complex that may be confused with a ventricular ectopic beat. This differentiation is important because the treatment and prognosis is quite different. Hemodynamically unstable patients with a wide-complex tachycardia should be promptly cardioverted. Although up to 10% of cases will defy differentiation, ventricular tachycardia and aberrant conduction can be distinguished utilizing history, physical examination, and EKG criteria. The mechanisms of aberrant ventricular conduction are discussed.
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Affiliation(s)
- M L Pollack
- Department of Emergency Medicine, York Hospital, York, Pennsylvania 17405, USA
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24
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Abstract
Therapeutic decisions made by Emergency Physicians are often influenced by which prescribed medications are being taken by patients. We sought to assess Emergency Department (ED) patients' knowledge of their medications by using a survey. A convenience sample of adult ED patients was surveyed verbally by a research assistant. Two-hundred patients were enrolled. Only 48% of patients could recall or produce a list or the actual bottles of all of their medications, 39% knew the times they take their medications, and only 24% knew all the dosages. Seventeen percent brought a list or the actual medication bottles with them to the ED. Patients who had a primary care physician knew all their medications 51% of the time, compared to 43% who did not have a physician. Fifty-one percent of insured patients compared to 38% of non-insured patients could identify all of their medications. Although knowledge of medications is often critical for decision making in the ED, a significant number of patients are unable to provide this information.
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Affiliation(s)
- G M Vilke
- Department of Emergency Medicine, University of California San Diego Medical Center, San Diego, California 92103-8676, USA
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25
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Abstract
OBJECTIVE To evaluate the ability to train emergency medical technicians-defibrillation (EMT-Ds) to effectively use the Combitube for intubations in the prehospital environment. METHODS This was an 18-month prospective field study in which EMT-Ds were trained how and in what situations to use the Combitube. Data were then obtained for all patients in whom Combitube insertion was attempted. Indications for use of the Combitube included: unconsciousness without a purposeful response, absence of the gag reflex, apnea or respiratory rate less than 6 breaths/min, age more than 16 years, and height at least 5 feet tall. Contraindications were: obvious signs of death, intact gag reflex, inability to advance the device due to resistance, or known esophageal pathology. Data were entered prospectively from the San Diego County EMS QANet database for prehospital providers. RESULTS Twenty-two EMT-D provider agencies, involving approximately 500 EMT-Ds, were included as study participants. Combitube insertions were attempted in 195 prehospital patients in cardiorespiratory arrest, with appropriate indication for Combitube use. An overall successful intubation rate (defined as the ability to successfully ventilate) of 79% was observed. Identical success rates for medical and trauma patients were noted. The device was placed in the esophagus 91% of the time. Resistance during insertion was the major reason for unsuccessful Combitube intubations. An overall hospital admission rate of 19% was observed. No complications were reported. CONCLUSION EMT-Ds can be trained to use the Combitube as a means of establishing an airway in the prehospital setting. Future studies will need to further evaluate its effect on patient outcome.
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Affiliation(s)
- M Ochs
- San Diego County Department of Health Services, University of California, San Diego Medical Center, 92103, USA
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26
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Abstract
We conducted a retrospective review of all adult trauma patients who underwent prehospital field rapid sequence intubation (RSI) by aeromedical crews from 1988 through 1995 and compared them to all trauma patients who arrived by ground transportation and underwent RSI in the trauma suite from 1992 through 1995 at a University hospital. Of the 47 field RSI patients, 46 (97.9%) were successfully intubated, whereas 263 of the 267 (98.5%) hospital RSI patients were successfully intubated. There were no statistical differences in success rates, number of attempts, or immediate intubation events in the procedure between the two groups. There were no differences in delayed events with the exception of pneumonia, which occurred more frequently in the field RSI group (28% vs. 6%, respectively). We performed a subgroup analysis on isolated head injury patients to evaluate outcome. There was no difference in total hospital days, length of ICU stay, mortality or final disposition in the two head injury groups. Though this study is limited by small sample size, we conclude that field RSI is equally successful and safe as hospital RSI.
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Affiliation(s)
- C Sloane
- Department of Emergency Medicine, University of California, San Diego Medical Center, California 92103-8676, USA
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27
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Abstract
The Rapid Four-Step Technique (RFST) has been demonstrated to be faster than standard open crico thyrotomy technique, but may have a higher incidence of cricoid injury with tracheal hook traction applied caudad. The "Bair Claw" is a novel device that may help eliminate these complications. This randomized, experimental trial used a fresh-frozen cadaver model of cricothyrotomy to compare speed and safety between RFST using a Bair Claw and standard open technique. Outcome measures included time to definitive airway, size of largest endotracheal (ET) tube able to be passed, and incidence of complications. We observed that RFST using a Bair Claw was significantly faster than standard open technique. There was no significant difference with regard to size of ET tube able to be passed with RFST using a Bair Claw versus standard open technique, and there was no damage to trachea or larynx observed with either technique. We concluded that RFST using a Bair Claw is faster and appears to be equally safe when compared to standard open technique in a fresh-frozen cadaver model of cricothyrotomy. The two techniques were equal with regard to maximal ET tube size.
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Affiliation(s)
- D P Davis
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California 92103-8676, USA
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28
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Vilke GM, Chan TC, Neuman T, Clausen JL. Spirometry in normal subjects in sitting, prone, and supine positions. Respir Care 2000; 45:407-10. [PMID: 10780036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Determine whether pulmonary function testing is affected by patient positioning. METHODS In a descriptive study with measurements made in a sequential but randomized order at a university-based pulmonary function laboratory, 20 healthy men, ages 18-50 years, were evaluated with spirometric assessment of forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and maximum voluntary ventilation (MVV) in the sitting, supine, and prone positions. Subjects were excluded for body mass index (BMI) > 30 kg/m2 or abnormal baseline spirometry. RESULTS Comparing sitting to supine and prone positions, there was a statistically significant decline in the spirometry values (reported as percent of predicted normal +/- standard error of the mean). FVC was 102% +/- 4% while sitting, 95% +/- 4% while supine, and 94% +/- 4% while prone. FEV1 was 104% +/- 3% while sitting, 96% +/- 3% while supine, and 94% +/- 3% while prone. MVV was 115% +/- 4% while sitting, 102% +/- 4% while supine, and 97% +/- 3% prone. CONCLUSION In healthy men with BMI < 30 kg/m2, changing from the sitting to supine or prone position results in statistically significant change in respiratory pattern. However, all spirometry values in each position were normal by American Thoracic Society definitions.
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Affiliation(s)
- G M Vilke
- Department of Emergency Medicine, UC San Diego Medical Center 92103, USA.
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29
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30
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Abstract
Indications for head computed tomography (CT) scans are unclear in patients with nonpenetrating head injury and Glasgow Coma Scale (GCS) scores of 15. We performed a prospective study to determine if significant intracranial injury could be excluded in patients with GCS-15 and a normal complete neurological examination. A prospective trial of clinically sober adult patients with GCS = 15 on emergency department (ED) presentation after closed head injury with loss of consciousness or amnesia was conducted from May 1996 through April 1997. All subjects underwent a standardized neurological examination including mental status evaluation, and assessment of motor, sensory, cerebellar and reflex function before CT scan. During the study period, 58 patients met inclusion criteria. Fifty-five patients (95%) had normal CT scans and 23 (42%) had focal neurological abnormalities. Three patients (5%) had CT scan findings of acute intracranial injury, two of whom had normal neurological examinations. One patient had an acute subdural hematoma requiring emergent surgical decompression; the other had both an epidural hematoma and pneumocephalus that did not require surgery. Significant brain injury and need for CT scanning cannot be excluded in patients with minor head injury despite a GCS = 15 and normal complete neurological examination on presentation.
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Affiliation(s)
- G M Vilke
- University of California, San Diego Medical Center, Department of Emergency Medicine, 92103, USA
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31
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Ho SS, Ahuja AT, Yeo W, Chan TC, Kew J, Metreweli C. Longitudinal colour doppler study of superficial lymph nodes in non-Hodgkin's lymphoma patients on chemotherapy. Clin Radiol 2000; 55:110-3. [PMID: 10657155 DOI: 10.1053/crad.1999.0229] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS/METHODS A longitudinal study of 22 malignant lymph nodes by colour Doppler (CD) and/or colour power (CP) ultrasonography was undertaken in 12 non-Hodgkin's lymphoma patients to delineate changes in vascularity, and correlate this response with clinical outcome. RESULTS Reduced vascularity in response to chemotherapy was shown to be a positive prognostic sign. CONCLUSIONS More persistent nodal vascularity may signify a less favourable prognosis.
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Affiliation(s)
- S S Ho
- Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital, Shatin, Hong Kong
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32
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Brady WJ, Chan TC, Pollack M. Electrocardiographic manifestations: patterns that confound the EKG diagnosis of acute myocardial infarction-left bundle branch block, ventricular paced rhythm, and left ventricular hypertrophy. J Emerg Med 2000; 18:71-8. [PMID: 10645842 DOI: 10.1016/s0736-4679(99)00178-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The 12-lead electrocardiogram (EKG), a powerful tool used in evaluating the chest pain patient, has its shortcomings. One such failing is encountered in a patient with one of the following electrocardiographic patterns: left bundle branch block (LBBB), ventricular paced rhythm (VPR), and left ventricular hypertrophy (LVH). These patterns reduce the ability of the EKG to detect acute coronary ischemic change and acute myocardial infarction (AMI). Several strategies are available to assist in the correct interpretation of these complicated electrocardiographic patterns, including a knowledge of the ST segment-T wave changes associated with these confounding patterns, performance of serial EKGs, and comparison with previous EKGs if available. This article suggests guidelines and interpretive tools for diagnosing AMI on EKG in patients with these confounding patterns.
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Affiliation(s)
- W J Brady
- Department of Emergency Medicine, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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33
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Torbati SS, Chan TC. Classic helical CT scan findings of acute appendicitis. J Emerg Med 2000; 18:101. [PMID: 10645847 DOI: 10.1016/s0736-4679(99)00181-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- S S Torbati
- Department of Emergency Medicine, University of California, San Diego Medical Center, 92103-8676, USA
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34
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Chan TC, Vilke GM, Bramwell KJ, Davis DP, Hamilton RS, Rosen P. Comparison of wire-guided cricothyrotomy versus standard surgical cricothyrotomy technique. J Emerg Med 1999; 17:957-62. [PMID: 10595879 DOI: 10.1016/s0736-4679(99)00123-7] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
We compared a wire-guided cricothyrotomy technique vs. standard surgical cricothyrotomy in terms of accuracy in placement, complications, performance time, incision length, and user preference. We conducted a randomized, crossover controlled trial in which Emergency Medicine (EM) attendings and residents performed cricothyrotomies by both standard and wire-guided techniques (using a commercially available kit) on human cadavers after a 15-min training session. Procedure time, incision length, and physician preference were recorded. Cadavers were inspected for accuracy of placement and complications. Airway placement was accurate in 13 of 15 cases for the standard technique (86.7%), and 14 of 15 cases for the wire-guided technique (93.3%). When comparing wire-guided vs. standard techniques, there were no differences in complication rates or performance times. The wire-guided technique resulted in a significantly smaller mean incision length than the standard technique (0.53 vs. 2.53 cm, respectively, p<0.0001). Overall, 14 of 15 physicians stated that they preferred the wire-guided to the standard technique. Our data suggest that this wire-guided cricothyrotomy technique is as accurate and timely to use as the standard technique and is preferred by our physician operators. In addition, the technique results in a smaller incision on human cadaver models.
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Affiliation(s)
- T C Chan
- Department of Emergency Medicine, University of California San Diego School of Medicine, 92103-8676, USA
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35
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36
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Abstract
This retrospective study was designed to investigate the current practice of nasotracheal intubation (NTI) in the Emergency Department (ED) at the University of California, San Diego Medical Center. Over a 5-year period, 21% (105/501) of patients intubated in the ED had at least one NTI attempt. The most frequent primary diagnoses in these patients included drug overdose, congestive heart failure, and chronic obstructive pulmonary disease. We report an overall NTI success rate of 79% (83/105). Sixty-one percent (64/105) of the patients were nasally intubated on the first NTI attempt. Nasal dilators, topical neosynephrine, and sedation improved NTI success rates. Epistaxis and improper tube position were the most common immediate complications. Sinusitis, pneumonia, and sepsis were the most frequent late complications. Patients receiving thrombolytic therapy were at risk of developing severe epistaxis. A prior history of sinus disease may predispose a nasally intubated patient to sinusitis. The complication rates reported here are similar to those of previous studies. A survey of emergency medicine (EM) residency programs found that EM residents throughout the country perform an average of 2.8 NTIs during their residency training. Thus, there is limited exposure to this intubation technique in EM residency programs. Nasotracheal intubation is a useful alternative to oral intubation, particularly when oral access is compromised. While not the optimal approach, we conclude that NTI is still a valuable method for establishing an airway and should remain among the emergency physician's arsenal of intubation techniques.
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Affiliation(s)
- L P Roppolo
- Department of Emergency Medicine, University of California, San Diego Medical Center, 92103-8676, USA
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37
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Abstract
Acute, or so-called "dry," myopericarditis occurs in the presence of diffuse inflammation of the pericardial sac and superficial epicardium from a multitude of infectious and inflammatory processes. This inflammation results in a current of myocardial injury resulting from the epicardial irritation manifested by a number of electrocardiographic findings. Classically, the electrocardiographic changes have been described as an evolution through several distinct stages involving ST segment elevation with PR segment depression, normalization of the ST segment abnormality with T wave inversion, and eventual normalization of the electrocardiogram over a period of days to several weeks. The following discussion focuses on the electrocardiographic manifestations of acute myopericarditis and includes findings useful in establishing the diagnosis as well as distinguishing the disease from other syndromes, particularly acute myocardial infarction.
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Affiliation(s)
- T C Chan
- Department of Emergency Medicine, University of California San Diego Medical Center, 92103, USA
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38
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Abstract
OBJECTIVE Naloxone is frequently used by prehospital care providers to treat suspected heroin and opioid overdoses. The authors' EMS system has operated a policy of allowing these patients, once successfully treated, to sign out against medical advice (AMA) in the field. This study was performed to evaluate the safety of this practice. METHODS The authors retrospectively reviewed all 1996 San Diego County Medical Examiner's (ME's) cases in which opioid overdoses contributed to the cause of death. The records of all patients who were found dead in public or private residences or died in emergency departments of reasons other than natural causes or progression of disease, are forwarded to the ME office. ME cases associated with opiate use as a cause of death were cross-compared with all patients who received naloxone by field paramedics and then refused transport. The charts were reviewed by dates, times, age, sex, location, and, when available, ethnicity. RESULTS There were 117 ME cases of opiate overdose deaths and 317 prehospital patients who received naloxone and refused further treatment. When compared by age, time, date, sex, location, and ethnicity, there was no case in which a patient was treated by paramedics with naloxone within 12 hours of being found dead of an opiate overdose. CONCLUSIONS Giving naloxone to heroin overdoses in the field and then allowing the patients to sign out AMA resulted in no death in the one-year period studied. This study did not evaluate for return visits by paramedics nor whether patients were later taken to hospitals by private vehicles.
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Affiliation(s)
- G M Vilke
- Department of Emergency Medicine, University of California, San Diego Medical Center, 92103, USA.
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39
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Abstract
Many people benefit from the implantation of cardiac pacemakers for management of certain cardiac dysrhythmias. These patients are seen regularly in the Emergency Department with a variety of pacemaker complications and malfunctions. The presence of a pacemaker may also affect management of unrelated medical problems. This, the second of a two-part series, covers the causes, diagnosis, and management of pacemaker malfunction; the pacemaker syndrome; the pacemaker Twiddler's syndrome; and other considerations in the paced patient including diagnosis of acute myocardial infarction, ACLS protocols, trauma, and sources of interference.
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Affiliation(s)
- T Y Cardall
- Department of Emergency Medicine, University of California, San Diego, School of Medicine, La Jolla, USA
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40
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Abstract
Early repolarization, also known as benign early repolarization (BER) or normal variant, is noted in approximately 1% of the population and in up to 48% of patients seen in the Emergency Department with chest pain. BER represents a benign variant of the normal electrocardiogram and is one of several syndromes producing electrocardiographic ST segment elevation (STE). The electrocardiogram (EKG) findings of BER include diffuse or widespread ST segment elevation, upward concavity of the initial portion of the ST segment, notching or slurring of the terminal QRS complex, and concordant T waves of large amplitude. This article focuses on BER and includes the electrocardiographic findings useful in making the diagnosis as well as distinguishing BER from other STE syndromes.
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Affiliation(s)
- W J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, USA
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41
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Abstract
Many people benefit from the implantation of cardiac pacemakers for management of certain cardiac dysrhythmias. These patients are seen regularly in the emergency department with a variety of pacemaker complications and malfunctions. The presence of a pacemaker may also affect management of unrelated medical problems. This two-part series reviews the medical issues related to patients with permanent pacemakers. Part I covers pacing modes and terminology, complications of the implant procedure, and the approach to a patient with a permanent pacemaker. Part II covers the causes, diagnosis and management of pacemaker malfunction; the pacemaker syndrome; the pacemaker Twiddler's syndrome; and other considerations in the paced patient including diagnosis of acute myocardial infarction, ACLS protocols, trauma, and sources of interference. Indications for permanent pacemaker implantation and temporary external pacing will not be covered.
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Affiliation(s)
- T Y Cardall
- Department of Emergency Medicine, University of California, San Diego, School of Medicine, La Jolla, USA
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42
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Friedman L, Vilke GM, Chan TC, Hayden SR, Guss DA, Krishel SJ, Rosen P. Emergency department airway management before and after an emergency medicine residency. J Emerg Med 1999; 17:427-31. [PMID: 10338232 DOI: 10.1016/s0736-4679(99)00013-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To determine whether the start of an Emergency Medicine (EM) training program affects the appropriateness, timeliness, and safety of Emergency Department (ED) intubations, all ED intubations performed 12 months before and after the start of an EM residency were reviewed. In addition, all patients intubated within 12 h after being admitted through the ED were reviewed. We found that all ED intubations before and after the start of a residency program were deemed appropriate. Of patients intubated after admission, 13 of 20 (65%) were felt to have warranted intubation while in the ED for the pre-residency group, compared with 9 of 29 patients (31%) for the post-residency group. There were no differences between the complication rates of these groups. We conclude that an EM residency program did not increase the number of inappropriate intubations or complications, and reduced the number of patients who required but did not receive intubation in the ED.
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Affiliation(s)
- L Friedman
- Department of Emergency Medicine, University of California, San Diego Medical Center, 92103, USA
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43
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Chan TC, Ariizumi T, Asashima M. A model system for organ engineering: transplantation of in vitro induced embryonic kidney. Naturwissenschaften 1999; 86:224-7. [PMID: 10360269 DOI: 10.1007/s001140050602] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- T C Chan
- Department of Life Sciences (Biology), Graduate School of Arts and Sciences, University of Tokyo, Japan
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44
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Affiliation(s)
- G Ma
- Department of Emergency Medicine, University of California, San Diego 92103, USA
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45
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Hägg U, Cooke MS, Chan TC, Tng TT, Lau PY. The reproducibility of cephalometric landmarks: an experimental study on skulls. Aust Orthod J 1998; 15:177-85. [PMID: 10204427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Few previous cephalometric studies have used dry skulls in order to eliminate the effects of the facial soft tissues. The aim of this study were to quantify the intra-examiner reproducibility of the commonly used cephalometric landmarks, angles and distances, using dry skulls and to compare these errors with previous error data obtained from normal cephalograms of living patients. Thirty skulls were mounted in a purpose-designed holder and repeat cephalograms of each skull were recorded and digitised. All measurements were made relative to an X-Y coordinate reference grid. Scattergrams were produced to show the characteristic distribution of the intra-examiner reproducibility errors for the landmarks, and the reproducibility of the angles and distances were tabulated. This data was compared with a related study that included the soft tissue profile. The standard deviations of the skeletal and dental angles and distances were greater in the presence of the soft tissues. These differences were up to four times larger for measurements including the location of Nasion (e.g. SNA, SNB and SNPg), which was the landmark location most affected by the presence of soft tissues, and for the distance: Incisal tip of Lower Incisor to Pogonion. Anterior Nasal Spine, in the horizontal plane, was also greatly affected by the presence of the soft tissues. By using dry skulls, the errors observed in this study may serve as standards for the rational interpretation of clinical cephalometric values.
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46
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Abstract
The use of the hogtie restraint (also known as hobble or prone maximal restraint) by law enforcement and prehospital personnel has come under scrutiny because of reports of sudden deaths in persons placed in this restraint position. Some contend that this body position restricts chest and abdominal movement to the point that individuals are at risk for hypoventilatory respiratory compromise and "positional" asphyxiation. We review case reports of custody deaths in subjects placed in the hogtie position, as well as related medical literature regarding positional asphyxia. We also review the current research findings from human physiology studies that have investigated the effects of the hogtie position on respiratory and pulmonary function. We conclude that the hogtie restraint position by itself does not cause respiratory compromise to the point of asphyxiation and that other factors are responsible for the sudden deaths of individuals placed in this position.
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Affiliation(s)
- T C Chan
- Department of Emergency Medicine, University of California San Diego Medical Center, 92103, USA
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47
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Abstract
A 34-year-old woman presented to the emergency department 12 weeks postpartum with chest pain. An ECG indicated an acute myocardial infarction. The patient underwent cardiac catheterization with findings suggestive of coronary artery dissection later confirmed on intravascular ultrasonography. She underwent emergency coronary artery bypass grafting and has subsequently done well.
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Affiliation(s)
- G M Vilke
- Department of Emergency Medicine, University of California, San Diego Medical Center, 92103, USA.
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48
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Abstract
Osteogenic protein-1 (OP-1, BMP-7) is a member of the transforming growth factor-beta (TGF-beta) superfamily that selectively induces dendritic outgrowth from cultured neurons. We injected human recombinant OP-1 (1 or 10 micrograms) or vehicle into the cisterna magna of mature male Sprague-Dawley rats 1 and 4 days after focal cerebral infarction induced by middle cerebral artery (MCA) occlusion. OP-1 treatment was associated with a marked enhancement of recovery of sensorimotor function of the impaired forelimb and hindlimb (contralateral to infarcts) as assessed by limb placing tests. This effect appeared to be dose dependent. There was no difference in infarct volume between OP-1 and vehicle-treated rats. The mechanisms of enhanced recovery by intracisternal OP-1 may include promotion of dendritic sprouting in the intact uninjured brain.
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Affiliation(s)
- T Kawamata
- CNS Growth Factor Research Laboratory, Department of Neurology, Massachusetts General Hospital, Boston, USA
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49
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Giannobile WV, Ryan S, Shih MS, Su DL, Kaplan PL, Chan TC. Recombinant human osteogenic protein-1 (OP-1) stimulates periodontal wound healing in class III furcation defects. J Periodontol 1998; 69:129-37. [PMID: 9526911 DOI: 10.1902/jop.1998.69.2.129] [Citation(s) in RCA: 158] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Osteogenic protein-1 (OP-1) is a member of the transforming growth factor beta superfamily and is a potent modulator of osteogenesis and bone cell differentiation. This preclinical study in dogs sought to assess the effects of OP-1 on periodontal wound healing in surgically created critical size Class III furcation defects. Eighteen male beagle dogs were subjected to the creation of bilateral mandibular 5 mm osseous defects. A split-mouth design was utilized which randomly assigned opposing quadrants to control therapy (surgery alone or collagen vehicle) or 1 of 3 ascending concentrations of OP-1 in a collagen vehicle (0.75 mg OP-1/g collagen, 2.5 mg/g, or 7.5 mg/g). Thus, 9 quadrants per test group received OP-1, 9 quadrants per control group received surgery alone, and 9 quadrants received collagen vehicle alone. Test articles were delivered by a surgeon masked to the treatment, and fluorogenic bone labels were injected at specified intervals post-treatment. Eight weeks after defect creation and OP-1 delivery, tissue blocks of the mandibulae were taken for masked histomorphometric analysis to assess parameters of periodontal regeneration (e.g., bone height, bone area, new attachment formation, and percent of defect filled with new bone). Histomorphometry revealed limited evidence of osteogenesis, cementogenesis, and new attachment formation in either vehicle or surgery-alone sites. In contrast, sites treated with all 3 concentrations of OP-1 showed pronounced stimulation of osteogenesis, regenerative cementum, and new attachment formation. Lesions treated with 7.5 mg/g of OP-1 in collagen regenerated 3.9+/-1.7 mm and 6.1+/-3.4 mm2 (mean +/-S.D.) of linear bone height and bone area, respectively. Furthermore, these differences were statistically different from both control therapies for all wound healing parameters (P < 0.0001). No significant increase in tooth root ankylosis was found among the treatment groups when compared to the surgery-alone group. We conclude that OP-1 offers promise as an attractive candidate for treating severe periodontal lesions.
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Affiliation(s)
- W V Giannobile
- Department of Periodontology, Harvard School of Dental Medicine, Boston, MA 02115-5888, USA.
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Abstract
STUDY OBJECTIVE To describe the incidence and demographic data of prehospital patients who contact paramedics by way of the 911 system, refuse transport against medical advice (AMA), then call 911 and are subsequently reevaluated by paramedics in the following 48 hours. METHODS We conducted a retrospective observational review of records using the San Diego County Quality Assurance Network database for prehospital providers. All paramedic 911 responses that made base hospital contact over a 3-month period were reviewed to identify patients who signed out AMA. The main outcome measure was to identify patients who signed out AMA and then called 911 again within 48 hours. The demographics, complaints, treatments, and dispositions of these patients are described. RESULTS Of 6,512 total 911 responses reviewed, 443 (7%) involved patients who signed out AMA. Of these patients, 156 cases (35.2%) were listed as trauma and 287 (64.8%) were medical, with cardiac chest pain, seizure, and respiratory distress/shortness of breath the most frequently noted medical subcategories. Fifty-one (11.5%) such patients received treatment; 34 received dextrose, 12 naloxone, 4 albuterol, and 1 a splint. Patient names were available in 5,515, of the total 6,512 responses and 431 of the 443 AMA cases, permitting computer searching of reevaluations by paramedics. Of the 431 AMA patients for whom a name was available, 10 (2%) called 911 again within 48 hours. All 10 callbacks were made for a related chief compliant, and all 10 of these patients were transported (4 admitted to hospital, 1 died en route, 1 transferred to another facility, 4 discharged from the ED). Of these 10 patients, 7 (70%) were older than 65 years, compared with 17% of all AMA patients older than 65 years. CONCLUSION On the basis of our findings, patients over the age of 65 years have a propensity to recontact paramedics and should be aggressively encouraged to seek emergency medical treatment. Future prospective studies should be mounted to examine at patient outcome and to assess why patients sign out AMA after making contact with paramedics.
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Affiliation(s)
- S T Moss
- Department of Emergency Medicine University of California, San Diego, Medical Center 92103, USA
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