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Fung XEG, Fung XJN, Koh Y, Goh S, Lee WF. Woman With Platypnea. Ann Emerg Med 2024; 83:401-402. [PMID: 38519202 DOI: 10.1016/j.annemergmed.2023.09.020] [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] [Received: 09/16/2023] [Accepted: 09/27/2023] [Indexed: 03/24/2024]
Affiliation(s)
| | | | - Yiwen Koh
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - Shaojie Goh
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - Wei Feng Lee
- Emergency Department, Ng Teng Fong General Hospital, Singapore
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Lee WF, Goh SJ, Lee B, Juan SJ, Asinas-Tan M, Lim BL. Renal point-of-care ultrasound performed by ED staff with limited training and 30-day outcomes in patients with renal colic. CAN J EMERG MED 2024; 26:198-203. [PMID: 38219263 DOI: 10.1007/s43678-023-00645-5] [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] [Received: 07/09/2023] [Accepted: 12/28/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND AND AIM Emergency Department (ED) renal point-of-care ultrasound (PoCUS) in renal colic by accredited specialists has good prognostic value. This may not be generalizable to under-resourced EDs. We investigated PoCUS in renal colic in our ED with lesser training. METHODS We performed a single-centre health records review of adult ED patients with renal colic and PoCUS. Patients were managed by a non-ED specialist/resident doctor with no POCUS accreditation in consultation with an attending. These doctors attended a 3.5-h training session conducted by accredited attendings to examine hydronephrosis. They needed to verify their PoCUS findings with an attending during the first two weeks of their six-month posting before performing it independently. The primary outcome was 30-day urological procedures in hydronephrotic vs. non-hydronephrotic groups. Secondary outcomes were the distribution of primary outcome with grades of hydronephrosis, 30-day ED nephrolithiasis-related reattendances in hydronephrotic vs. non-hydronephrotic groups and its distribution with grades of hydronephrosis. We compared outcomes using Fisher's exact test. We also reported crude odds ratio (COR) and 95% CI of primary outcome between hydronephrotic vs. non-hydronephrotic groups. p values ≤ 0.05 were significant. RESULTS We recruited 651 patients; 160 (24.6%) without and 491 (75.4%) with hydronephrosis. Rates of grades of hydronephrosis were: mild (76.6%), moderate (13.8%), severe (1.2%) and undifferentiated (8.4%). There was a difference in 30-day urological procedures (rates [95% CI]) in hydronephrotic vs. non-hydronephrotic groups, 11.2 [8.7-14.0]% vs. 2.5 [1.0-6.3]%; p < 0.001; COR (95% CI) 4.9 (1.8-13.8); p = 0.002. Increasing 30-day urological procedural rates were associated with increasing grade of hydronephrosis [no: 2.5%, mild: 7.7%, moderate: 23.5%, severe: 67.0% and undifferentiated: 14.6%; p < 0.001]. No differences occurred in other secondary outcomes. CONCLUSIONS Renal PoCUS could be performed by non-ED specialist/resident doctors to identify patients without hydronephrosis who rarely required urological intervention. Hydronephrotic patients could benefit from further risk stratification.
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Affiliation(s)
- W F Lee
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore.
| | - S J Goh
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore
| | - Berlin Lee
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore
| | - S J Juan
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore
| | - Marxengel Asinas-Tan
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore
| | - B L Lim
- Emergency Department, Ng Teng Fong General Hospital, 1, Jurong East Street 21, Singapore, 609606, Singapore
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Chan J, Zhang PT, Lee B, Lee WF. Woman With Palpitations. Ann Emerg Med 2023; 82:e9-e10. [PMID: 37349079 DOI: 10.1016/j.annemergmed.2023.01.029] [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] [Received: 12/11/2022] [Revised: 12/20/2022] [Accepted: 01/25/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Jaye Chan
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - Pei Ting Zhang
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - Berlin Lee
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - Wei Feng Lee
- Emergency Department, Ng Teng Fong General Hospital, Singapore
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Lee B, Lim BL, Lee WF. Man With Chest Pain. Ann Emerg Med 2023; 81:e113-e114. [PMID: 37085213 PMCID: PMC10113741 DOI: 10.1016/j.annemergmed.2022.12.008] [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] [Received: 10/09/2022] [Revised: 10/29/2022] [Accepted: 12/05/2022] [Indexed: 04/23/2023]
Affiliation(s)
- Berlin Lee
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore
| | - Beng Leong Lim
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore
| | - Wei Feng Lee
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore
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Lim BL, Lee WF, Lee B, Chung YEL, Loo KV. Subcutaneous fast-acting insulin analogues, alone or in combination with long-acting insulin, versus intravenous regular insulin infusion in patients with diabetic ketoacidosis: protocol for an updated systematic review and meta-analysis of randomised trials. BMJ Open 2023; 13:e070131. [PMID: 36764729 PMCID: PMC9923333 DOI: 10.1136/bmjopen-2022-070131] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is traditionally managed using intravenous regular insulin infusion (RII) in intensive care unit (ICU)/high dependency unit (HDU). Subcutaneous fast-acting insulin analogues (FAIAs) may help to manage DKA outside ICU/HDU. Furthermore, combining subcutaneous long-acting insulin (LAI) with subcutaneous FAIAs may accelerate ketoacidosis resolution. The latest (2016) Cochrane review was inconclusive regarding subcutaneous FAIAs versus intravenous RII in DKA. It was limited by small sample sizes, unclear risk of bias (RoB) in primary trials and did not examine subcutaneous FAIAs with subcutaneous LAI versus intravenous RII in DKA. We report the protocol for an updated meta-analysis on the safety and benefits of subcutaneous FAIAs with/without subcutaneous LAI versus intravenous RII in DKA. METHODS AND ANALYSIS We will search Medline, Embase, CINAHL and Cochrane Library, from inception until December 2022, without language restrictions, for randomised trials on subcutaneous FAIAs with/without subcutaneous LAI versus intravenous RII in DKA. We also search ClinicalTrials.gov, ClinicalTrialsRegister.eu and reference lists of included trials. Primary outcomes include all-cause in-hospital mortality, time to DKA resolution, in-hospital DKA recurrence and hospital readmission for DKA post-discharge. Secondary outcomes include resource utilisation and patient satisfaction. Safety outcomes include important complications of DKA and insulin. Reviewers will extract data, assess overall RoB and quality of evidence using Grading of Recommendations, Assessment, Development and Evaluation. We will assess statistical heterogeneity by visually inspecting forest plots and the I2 statistic. We will synthesise data using the random-effects model. Predefined subgroup analyses are: mild versus moderate versus severe DKA; age <20 vs ≥20 years; pregnant versus non-pregnant; infective versus non-infective DKA precipitating cause; subcutaneous FAIAs alone versus subcutaneous FAIAs and subcutaneous LAI; and high versus low overall RoB. We will also perform trial sequential analysis for primary outcomes. ETHICS AND DISSEMINATION Ethics board approval is not required. Results will be disseminated through publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022369518.
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Affiliation(s)
- Beng Leong Lim
- Emergency Medicine, Ng Teng Fong General Hospital, Singapore
- Medicine, National University of Singapore, Singapore
| | - Wei Feng Lee
- Emergency Medicine, Ng Teng Fong General Hospital, Singapore
- Medicine, National University of Singapore, Singapore
| | - Berlin Lee
- Emergency Medicine, Ng Teng Fong General Hospital, Singapore
| | - Yan Ee Lynette Chung
- Emergency Medicine, Ng Teng Fong General Hospital, Singapore
- Medicine, National University of Singapore, Singapore
| | - Kee Vooi Loo
- Emergency Medicine, Ng Teng Fong General Hospital, Singapore
- Medicine, National University of Singapore, Singapore
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Chan AHY, Lee WF, Van Gerven PWM, Chenkin J. Assessment of changes in gaze patterns during training in point-of-care ultrasound. BMC Med Educ 2022; 22:658. [PMID: 36056331 PMCID: PMC9440555 DOI: 10.1186/s12909-022-03680-5] [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] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) is a core skill in emergency medicine (EM), however, there is a lack of objective competency measures. Eye-tracking technology is a potentially useful assessment tool, as gaze patterns can reliably discriminate between experts and novices across medical specialties. We aim to determine if gaze metrics change in an independent and predictable manner during ultrasound training. METHODS A convenience sample of first-year residents from a single academic emergency department was recruited. Participants interpreted 16 ultrasound videos of the focused assessment with sonography for trauma (FAST) scan while their gaze patterns were recorded using a commercially available eye-tracking device. The intervention group then completed an introductory ultrasound course whereas the control group received no additional education. The gaze assessment was subsequently repeated. The primary outcome was total gaze duration on the area of interest (AOI). Secondary outcomes included time to fixation, mean duration of first fixation and mean number of fixations on the AOI. RESULTS 10 EM residents in the intervention group and 10 non-EM residents in the control group completed the study. After training, there was an 8.8 s increase in the total gaze time on the AOI in the intervention group compared to a 4.0 s decrease in the control group (p = .03). EM residents were also 3.8 s quicker to fixate on the AOI whereas the control group became 2.5 s slower (p = .04). There were no significant interactions on the number of fixations (0.43 vs. 0.18, p = .65) or duration of first fixation on the AOI (0.02 s vs. 0.06 s, p = .63). CONCLUSIONS There are significant and quantifiable changes in gaze metrics, which occur with incremental learning after an ultrasound course. Further research is needed to validate the serial use of eye-tracking technology in following a learner's progress toward competency in point-of-care ultrasound image interpretation.
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Affiliation(s)
- Alice H Y Chan
- Department of Emergency Medicine, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, AG245, Toronto, ON, M4N 3M5, Canada.
| | - Wei Feng Lee
- Department of Emergency Medicine, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, AG245, Toronto, ON, M4N 3M5, Canada
- Department of Emergency Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, Singapore, 609606
| | - Pascal W M Van Gerven
- Department of Educational Development and Research, School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Jordan Chenkin
- Department of Emergency Medicine, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, AG245, Toronto, ON, M4N 3M5, Canada
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Lee B, Lee WF, Lim BL. Rare case of Torsades de Pointes in severe hypothyroidism: literature review and challenges in management. Int J Emerg Med 2022; 15:11. [PMID: 35287568 PMCID: PMC8922778 DOI: 10.1186/s12245-022-00417-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/01/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hypothyroidism can manifest as several important cardiac abnormalities. There are few reports of ventricular dysrhythmias (VDs) in hypothyroidism. We described a rare case of VDs in severe hypothyroidism and reviewed the literature behind its management.
Case presentation
A 67-year-old gentleman, with poor compliance to treatment for Hashimoto’s thyroiditis, presented with palpitations to the Emergency Department. He had runs of non-sustained ventricular tachycardia (NSVT). He was treated with intravenous (IV) amiodarone and admitted to the intensive care unit for observation. He then developed recurrent Torsades de Pointes (Tdp) despite treatment with several anti-arhythmics. He required electrical cardioversion and eventual transvenous overdrive pacing (OP). VT recurred while he was on OP. VT resolved and he was weaned off OP only after adequate thyroid hormone replacement.
Conclusions
VDs, including NSVT, Tdp, and VT, are rare and potentially lethal in hypothyroidism. Our case demonstrates important challenges in the management of severe hypothyroidism. Here, VDs are often refractory to treatment with drugs and electrical means. The choice(s) of anti-arrhthymics requires careful consideration and can be difficult before thyroid function tests are known. Amiodarone use should be cautioned as it is associated with thyroid dysfunction and QT interval prolongation.
There is no literature to guide thyroid hormone replacement in this disease. Aggressive replacement is associated with adverse cardiovascular effects. Our case showed a fine balance between the risk of rapid thyroid hormone replacement and the urgency to terminate VDs. Its administration should be carefully monitored amidst bridging strategies like electrical cardioversion and OP to manage life-threatening VDs.
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Lim BL, Lee WF, Ng WM, Situ W, Loo KV, Man Goh CJ, Chan WL. Benefits and safety of transdermal glyceryl trinitrate in acute stroke: A systematic review and meta-analysis of randomized trials. Acad Emerg Med 2021; 29:772-788. [PMID: 34741770 DOI: 10.1111/acem.14408] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/21/2021] [Accepted: 10/31/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Transdermal glyceryl trinitrate (GTN) has potential beneficial properties in acute stroke including intracerebral hemorrhage (ICH) and possible clinical benefits suggested in ultra-early stroke (≤6 h). Our meta-analysis updated the evidence on its safety and benefits in acute stroke. METHODS We searched major electronic databases for randomized trials comparing transdermal GTN versus placebo/control in acute stroke. Primary outcomes were mortality, 90-day modified Rankin Scale (mRS), and blood pressure (BP) effects. Secondary outcomes included early, late, resource utilization, and surrogate outcomes. Safety outcomes were adverse events. Reviewers identified studies, extracted data, and assessed risk of bias (RoB) using a modified Cochrane RoB instrument and quality of evidence (QoE) using GRADE. We also performed a priori subgroup and trial sequential analyses (TSA) on primary outcomes. These subgroup analyses were ICH versus ischemic stroke, minor (NIHSS ≤5) versus major (NIHSS >5) ischemic stroke, ischemic stroke with versus without thrombolysis, prehospital versus non prehospital settings, time from stroke to randomization ≤6 h versus >6 h, and high versus low overall RoB studies. RESULTS Seven eligible primary trials enrolled 5363 patients. GTN reduced BP (mean difference [MD] = -4.74 mm Hg, 95% confidence interval [CI] = -6.03 to -3.45 mm Hg] and diastolic BP (MD = -2.94 mm Hg, 95% CI = -3.74 to -2.13 mm Hg) 24 h posttreatment but did not affect 4- to 10-day mortality (relative risk [RR] = 1.11, 95% CI = 0.82 to 1.49), 90-day mortality (RR = 0.96, 95% CI = 0.77 to 1.19), and 90-day mRS >2 (RR = 0.98, 95% CI = 0.93 to 1.03) compared to control/placebo. The QoE was high for primary outcomes with no subgroup effects detected. GTN did not affect secondary outcomes and increased risk of headache and hypotension. TSA generally supported our conclusions regarding primary outcomes. CONCLUSIONS Transdermal GTN reduces BP in acute stroke but does not alter clinical outcomes even in ultra-early stroke (≤6 h).
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Affiliation(s)
- Beng Leong Lim
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Wei Feng Lee
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Wei Ming Ng
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
- Unit for Pre‐hospital Emergency Care Ministry of Health Singapore
| | - Wangmin Situ
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Kee Vooi Loo
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Carmen Jia Man Goh
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Wui Ling Chan
- Emergency Department Ng Teng Fong General HospitalNational University Health System Singapore
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
- Disaster Medicine Ministry of Health Singapore
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Fung XJN, Ng WM, Lee WF. Man with right atrial mass. J Am Coll Emerg Physicians Open 2021; 2:e12568. [PMID: 34604838 PMCID: PMC8476101 DOI: 10.1002/emp2.12568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
| | - Wei Ming Ng
- Department of Emergency MedicineNg Teng Fong General HospitalSingapore
| | - Wei Feng Lee
- Department of Emergency MedicineNg Teng Fong General HospitalSingapore
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Lee WF, Wangmin S, Loo KV, Goh C. Woman with atraumatic neck pain. J Am Coll Emerg Physicians Open 2021; 2:e12560. [PMID: 34632449 PMCID: PMC8494451 DOI: 10.1002/emp2.12560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/01/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Wei Feng Lee
- Emergency DepartmentNg Teng Fong General HospitalJurong EastSingapore
| | - Situ Wangmin
- Emergency DepartmentNg Teng Fong General HospitalJurong EastSingapore
| | - Kee Vooi Loo
- Emergency DepartmentNg Teng Fong General HospitalJurong EastSingapore
| | - Carmen Goh
- Emergency DepartmentNg Teng Fong General HospitalJurong EastSingapore
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Chao YT, Lai SH, Chang MH, Chen CC, Lee WF, Chen JW, Hsu YC. A potential microbiological approach to the evaluation of earthquake-induced soil liquefaction. iScience 2021; 24:102984. [PMID: 34485866 PMCID: PMC8403730 DOI: 10.1016/j.isci.2021.102984] [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] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/19/2021] [Accepted: 08/11/2021] [Indexed: 01/23/2023] Open
Abstract
Earthquakes occur thousands of times every day around the world. They are naturally destructive seismic events and often result in soil liquefaction. Soil microbiota plays a vital role in soil environments and may serve as an effective indicator to assess soil liquefaction after earthquakes. This study aimed to detect the microbial community abundance and composition in soil samples of different depths. Soil samples were collected in Southern Taiwan immediately after the 2010 earthquake. Their physical characteristics were determined, and their microbial communities were analyzed through 16S amplicon sequencing. The results revealed that Nitrospirae phylum dominated in the liquefied layer. In particular, the genus HB118, dominant in the liquefied layer, was not detected at other soil depths or in the expelled liquefied soil. This finding not only provides valuable insights into changes in microbial community composition at different soil depths after earthquakes but also suggests a useful indicator for monitoring liquefied soil. This study characterized the microbial composition of liquefied soil after an earthquake Most abundant phylum Nitrospirae found in liquefied soil if 3 most abundant phyla removed HB118 spp is correlated with liquefied soil We set up the alternative monitoring methods of soil liquefaction after seismic events
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Affiliation(s)
- Ying Ting Chao
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan City, Taiwan
| | - Sheng Hao Lai
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan City, Taiwan
| | - Mei Hsun Chang
- Department of Civil Engineering, National Cheng Kung University, Tainan City, Taiwan
| | - Chun Chi Chen
- Department of Civil Engineering, National Cheng Kung University, Tainan City, Taiwan
| | - Wei Feng Lee
- Department of Civil Engineering, National Cheng Kung University, Tainan City, Taiwan
| | - Jing Wen Chen
- Department of Civil Engineering, National Cheng Kung University, Tainan City, Taiwan
| | - Yi Chiung Hsu
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan City, Taiwan
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Lee WF, Chenkin J. Exploring Eye-tracking Technology as an Assessment Tool for Point-of-care Ultrasound Training. AEM Educ Train 2021; 5:e10508. [PMID: 33898911 PMCID: PMC8052995 DOI: 10.1002/aet2.10508] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/21/2020] [Accepted: 07/10/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Eye-tracking technology has emerged as a potentially useful learner assessment tool in several medical specialties. In the fields of general surgery and anesthesiology, it has been shown to reliably differentiate between different levels of expertise in procedural skills. In the field of radiology, it has been shown to be a valid assessment tool for diagnostic test interpretation. Current methods of competency assessment in point-of-care ultrasound (POCUS) remain a challenge, because they require significant direct observation time by an instructor. The purpose of this study was to determine if eye-tracking technology can accurately distinguish between novice and experts in the interpretation of POCUS clips, specifically of the focused assessment using sonography in trauma (FAST) scan. METHODS A convenience sample of medical students, residents, and emergency physicians from a single academic emergency department were invited to participate. Participants included both novices and experts in POCUS. Each participant completed a baseline questionnaire and viewed 16 video clips of a FAST ultrasound examination while their gaze patterns were recorded by a commercially available eye-tracking device. The primary outcome was total gaze time on the area of interest (AOI). Secondary outcomes included total time to fixation, mean number of fixations, and mean duration of first fixation on the AOI. RESULTS Fifteen novices and 15 experts completed this study. For total gaze time on the AOI, experts fixated their gaze significantly longer than novices (75.8 ± 16.2 seconds vs. 56.6 ± 12.8 seconds, p = 0.001). Similarly, experts were significantly faster to fixate on the AOI and had a higher fixation count on the AOI (8.5 ± 4.0 seconds vs. 15.1 ± 6.8 seconds, p = 0.003; and 170 ± 30 vs. 143 ± 28 seconds, p = 0.016). There were no differences on the mean duration of first fixation on the AOI (0.42 ± 0.12 seconds vs. 0.39 ± 0.09 seconds, p = 0.467). CONCLUSION Eye-tracking technology shows the potential to differentiate between experts and novices by their gaze patterns on video clips of FAST examinations. The total gaze time on the AOI may be a useful metric to help in the assessment of competency in POCUS image interpretation. In addition, the evaluation of gaze patterns may help educators identify causes of interpretation errors. Future studies are needed to further validate these metrics in a larger cohort.
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Affiliation(s)
- Wei Feng Lee
- Emergency DepartmentSunnybrook Health Sciences CentreTorontoOntarioCanada
- Emergency DepartmentNg Teng Fong General HospitalSingapore
| | - Jordan Chenkin
- Emergency DepartmentSunnybrook Health Sciences CentreTorontoOntarioCanada
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Lim BL, Lee WF, Ng WM, Tay WL, Chan WL. Benefits and safety of transdermal glyceryl trinitrate in acute stroke: a systematic review and meta-analysis of randomised trials (protocol). BMJ Open 2021; 11:e043591. [PMID: 33402412 PMCID: PMC7786807 DOI: 10.1136/bmjopen-2020-043591] [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] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION High blood pressure (BP) in acute stroke has adverse outcomes. Transdermal glyceryl trinitrate (GTN) has beneficial properties in controlling BP. The 2016 meta-analysis and 2017 Cochrane review showed that transdermal GTN was beneficial in a small patient subgroup with stroke onset ≤6 hours. Larger studies focusing on this patient subgroup have since been conducted. We report the protocol for an updated systematic review and meta-analysis on the safety and benefits of transdermal GTN in acute stroke. METHODS AND ANALYSIS We will search Medline, Pubmed, Embase, CINAHL and Cochrane Library from inception until June 2020 for randomised trials that report the efficacy and safety of transdermal GTN versus placebo/control therapy among adult patients with acute stroke. Primary outcomes include in-hospital mortality, BP lowering and late functional status. Secondary outcomes include early, late, resource utilisation and surrogate outcomes. Safety outcomes include reported adverse events. Reviewers will first screen titles and abstracts, and then full texts, to identify eligible studies. Independently and in duplicate, they will extract data, assess risk of bias (RoB) using a modified Cochrane RoB tool and quality of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Disagreement will be resolved by discussion and consultation with an external reviewer if necessary. Using a random-effects model, we will report effect sizes using relative risks and 95% CIs. We will perform predefined subgroup analyses: intracerebral haemorrhage versus ischaemic stroke; minor (NIHSS (National Institutes of Health Stroke Scale) ≤five) versus major (NIHSS >five) ischaemic stroke; ischaemic stroke with versus without thrombolysis; prehospital versus non-prehospital settings; time from stroke to randomisation ≤6 versus >6 hours and high versus low overall RoB studies. We will also perform trial sequential analysis for the primary outcomes. ETHICS AND DISSEMINATION Ethics board approval is unnecessary. PROSPERO registration has been obtained. The results will be disseminated through publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42020173093.
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Affiliation(s)
- Beng Leong Lim
- Department of Emergency Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
- Yong Loo Lin Medical School, National University of Singapore, Singapore
| | - Wei Feng Lee
- Department of Emergency Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
- Yong Loo Lin Medical School, National University of Singapore, Singapore
| | - Wei Ming Ng
- Department of Emergency Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
- Unit for Prehospital Emergency Care, Government of Singapore Ministry of Health, Singapore
| | - Wei Ling Tay
- Department of Emergency Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
- Yong Loo Lin Medical School, National University of Singapore, Singapore
| | - Wui Ling Chan
- Department of Emergency Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
- Yong Loo Lin Medical School, National University of Singapore, Singapore
- Disaster Medicine, Government of Singapore Ministry of Health, Singapore
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Tan MYQ, Wong AJTY, Aung L, Ng WM, Lee WF, Lim BL. Circulatory collapse from rupture of splenic artery aneurysm: A case study. Ann Acad Med Singap 2021; 50:86-87. [PMID: 33623962 DOI: 10.47102/annals-acadmedsg.2020357] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Mervin Ye Qing Tan
- Emergency Medicine Department, National University Health System, Singapore
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Ng WM, Lee WF, Cheah SO, Chung YEL, Lee CY, Lim BL. Peri-mortem caesarean section after traumatic arrest: Crisis resource management. Am J Emerg Med 2018; 36:2338.e1-2338.e3. [PMID: 30274760 DOI: 10.1016/j.ajem.2018.08.078] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/26/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022] Open
Abstract
Peri-mortem caesarean section (PMCS) is a very rare procedure performed to improve the chances of survival for both mother and fetus following cardiorespiratory arrest. Non-obstetricians including Emergency Physicians (EPs) are often called upon to perform this procedure under challenging and suboptimal circumstances. We reported a case of PMCS performed timely after traumatic cardiorespiratory arrest that resulted in fetal survival. A 25-year-old primigravida female and six-month pregnant presented to the Emergency Department (ED) of an adult tertiary hospital. She experienced traumatic cardiorespiratory arrest for nearly 27 min following a high-speed motor vehicle crash. Upon ED arrival, she was in pulseless electrical activity. She was immediately intubated with continuation of cardiopulmonary resuscitation. She received bilateral tube thoracostomies as well as intravenous (IV) transfusion of blood products, adrenaline and tranexamic acid. Her fundal height was two centimeters above the umbilicus on palpation. The EP performed a PMCS via a midline laparotomy 3-4 min upon ED arrival. The baby was bradycardic and cyanosed with no spontaneous respiration at birth and was resuscitated by a second EP. She was intubated and the EP gained IV access using a cannula introduced into the umbilical vein. Neonatal hypothermia was avoided using cling wrap. The baby was transported to a nearby neonatal intensive unit. She survived and is currently one year old. The mother, however, did not respond to our resuscitation and succumbed to her multiple injuries. We reviewed the limited literature regarding this potentially life-saving emergency procedure and highlighted the challenges facing our resuscitation team.
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Affiliation(s)
- Wei Ming Ng
- Emergency Department, Ng Teng Fong General Hospital, Singapore.
| | - Wei Feng Lee
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - Si Oon Cheah
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | | | - Chan Yu Lee
- Emergency Department, Ng Teng Fong General Hospital, Singapore
| | - Beng Leong Lim
- Emergency Department, Ng Teng Fong General Hospital, Singapore
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Abstract
INTRODUCTION Singapore experienced its second riot in 40 years on 8 December 2013, in the area known as Little India. A retrospective review of 36 casualties treated at the emergency department was conducted to evaluate injury patterns. METHODS Characteristics including the rate of arrival, injury severity, type and location, and disposition of the casualties were analysed. RESULTS The injuries were predominantly mild (97.2%), with the most common injuries involving the head (50.0%) and limbs (38.9%). 97.2% of the casualties were managed as outpatient cases. CONCLUSION The majority of the injuries in this incident were mild and could be managed as outpatient cases. Important lessons were learnt from the incident about the utilisation of manpower and safety of staff in the emergency department.
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Affiliation(s)
- Wei Feng Lee
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore
| | - Chee Kheong Ooi
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore
| | - Dong Haur Phua
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore
| | | | - Wui Ling Chan
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore
| | - Yih Yng Ng
- Singapore Civil Defence Force, Ministry of Home Affairs, Singapore
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Hsu FY, Lee WF, Tung CJ, Lee JS, Wu TH, Hsu SM, Su HT, Chen TR. Ambient and personal dose assessment of a container inspection site using a mobile X-ray system. Appl Radiat Isot 2011; 70:456-61. [PMID: 22104499 DOI: 10.1016/j.apradiso.2011.10.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Revised: 09/21/2011] [Accepted: 10/26/2011] [Indexed: 11/25/2022]
Abstract
Ambient monitor and phantom studies of absorbed and effective doses by TLDs were carried out in a non-intrusive inspection station for containers, Terminal I, of Taichung harbor, Taiwan. The doses from the X-ray scan in the control room and driver waiting room, located outside of the radiation control area, were quite small and could not be distinguished from the natural background radiation. The doses in the driver cab and the inspector cab of the X-ray scan car were also within background radiation levels. The protection wall, a 40-cm thick concrete barrier, can effectively attenuate the intensity of the primary X-ray scan. The possible effective dose of a person in the container or trailer is about 3.15 ± 0.23 μSv/scan and 2.31 ± 0.38 μSv/scan. This dose is below the annual background dose. If someone was to be scanned by the X-ray, the effective dose would be at an acceptable level.
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Affiliation(s)
- F Y Hsu
- Nuclear Science and Technology Development Center, National Tsing Hua University, Hsinchu, Taiwan.
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Chien CH, Lai JN, Liao CF, Wang OY, Lu LM, Huang MI, Lee WF, Shie MC, Chien EJ. Mifepristone acts as progesterone antagonist of non-genomic responses but inhibits phytohemagglutinin-induced proliferation in human T cells. Hum Reprod 2009; 24:1968-75. [PMID: 19401324 DOI: 10.1093/humrep/dep099] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Progesterone is an endogenous immunomodulator that suppresses T cell activation during pregnancy. The stimulation of membrane progesterone receptors (mPRs) would seem to be the cause of rapid non-genomic responses in human peripheral T cells, such as an elevation of intracellular calcium ([Ca(2+)](i)) and decreased intracellular pH (pH(i)). Mifepristone (RU486) produces mixed agonist/antagonist effects on immune cells compared with progesterone. We explored whether RU486 is an antagonist to mPRs and can block rapid non-genomic responses and the induction by phytohemagglutinin (PHA) of cell proliferation. METHODS Human male peripheral T cell responses in terms of pH(i) and [Ca(2+)](i) changes were measured using the fluorescent dyes, 2',7'-bis-(2-carboxyethyl)-5-(and-6)-carboxyfluorescein (BCECF) and fura-2, respectively. Expression of mPR mRNA was determined by RT-PCR analysis. Cell proliferation and cell toxicity were determined by [(3)H]-thymidine incorporation and MTT assay, respectively. RESULTS The mRNAs of mPRalpha, mPRbeta and mPRgamma were expressed in T cells. RU486 blocked progesterone-mediated rapid responses including, the [Ca(2+)](i) increase and pH(i) decrease, in a dose related manner. RU486 did not block, but enhanced, the inhibitory effect of progesterone on PHA induced cell proliferation. RU486 alone inhibited proliferation induced by PHA and at >25 microM seems to be cytotoxic against resting T cells (P < 0.01). CONCLUSIONS RU486 is antagonistic to the rapid mPR-mediated non-genomic responses, but is synergistic with progesterone with respect to the inhibition of PHA-induced cell proliferation. Our findings shine new light on RU486's clinical application and how this relates to the non-genomic rapid physiological responses caused by progesterone.
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Affiliation(s)
- C H Chien
- Institute of Physiology, School of Medicine, National Yang-Ming University, Beitou, Taipei 11221, Taiwan, Republic of China
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19
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Hunter CA, Yu D, Gee M, Ngo CV, Sevignani C, Goldschmidt M, Golovkina TV, Evans S, Lee WF, Thomas-Tikhonenko A. Cutting edge: systemic inhibition of angiogenesis underlies resistance to tumors during acute toxoplasmosis. J Immunol 2001; 166:5878-81. [PMID: 11342601 DOI: 10.4049/jimmunol.166.10.5878] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The ability of various infections to suppress neoplastic growth has been well documented. This phenomenon has been traditionally attributed to infection-induced concomitant, cell-mediated antitumor immunity. We found that infection with Toxoplasma gondii effectively blocked neoplastic growth of a nonimmunogenic B16.F10 melanoma. Moreover, this effect was independent of cytotoxic T or NK cells, production of NO by macrophages, or the function of the cytokines IL-12 and TNF-alpha. These findings suggested that antitumor cytotoxicity was not the primary mechanism of resistance. However, infection was accompanied by strong, systemic suppression of angiogenesis, both in a model system and inside the nascent tumor. This suppression resulted in severe hypoxia and avascular necrosis that are incompatible with progressive neoplastic growth. Our results identify the suppression of tumor neovascularization as a novel mechanism critical for infection-induced resistance to tumors.
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MESH Headings
- Acute Disease
- Animals
- Cell Division/immunology
- Cytotoxicity, Immunologic
- Endothelium, Vascular/immunology
- Endothelium, Vascular/parasitology
- Endothelium, Vascular/pathology
- Immunity, Innate
- Melanoma, Experimental/blood supply
- Melanoma, Experimental/immunology
- Melanoma, Experimental/parasitology
- Melanoma, Experimental/pathology
- Mice
- Mice, Inbred C57BL
- Mice, SCID
- Necrosis
- Neoplasm Transplantation
- Neovascularization, Pathologic/immunology
- Neovascularization, Pathologic/parasitology
- Neovascularization, Pathologic/pathology
- Neovascularization, Pathologic/prevention & control
- Toxoplasmosis, Animal/immunology
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Affiliation(s)
- C A Hunter
- Department of Pathobiology, University of Pennsylvania, Philadelphia, PA 19104, USA
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Brands MW, Lee WF, Keen HL, Alonso-Galicia M, Zappe DH, Hall JE. Cardiac output and renal function during insulin hypertension in Sprague-Dawley rats. Am J Physiol 1996; 271:R276-81. [PMID: 8760230 DOI: 10.1152/ajpregu.1996.271.1.r276] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Hyperinsulinemia has been reported to cause hypertension in rats; however, the renal and hemodynamic mechanisms are not known. In this study, changes in renal function, cardiac output (CO), and total peripheral resistance (TPR) were measured during chronic insulin infusion in eight rats (approximately 350 g). After a 4-day control period, a 7-day insulin infusion was begun (1.5 mU.kg-1.min-1 iv), together with glucose (22 mg.kg-1.min-1 iv) to prevent hypoglycemia. Mean arterial pressure (MAP), CO, TPR, and heart rate were measured 24 h/day. MAP increased from 92 +/- 1 to 100 +/- 2 mmHg on day 1 and was 108 +/- 4 mmHg by day 7 of insulin. CO tended to decrease during insulin infusion, although not significantly, averaging 94 +/- 4% of the control value of 121 +/- 7 ml/min. Heart rate did not change significantly from the control value of 384 +/- 8 beats/min. TPR increased significantly to 122 +/- 11% of control by day 7. In five rats, glomerular filtration rate and effective renal plasma flow decreased to 73 +/- 4 and 66 +/- 5% of control, respectively, during insulin. Urinary sodium excretion averaged 2.6 +/- 0.1 and 2.7 +/- 0.1 meq/day during the control and insulin-infusion periods, respectively. These results indicate that insulin hypertension in rats is initiated by an increase in TPR rather than by increased CO. Also, the fact that sodium balance was maintained at elevated arterial pressure suggests that the ability of the kidneys to excrete sodium was impaired chronically during insulin infusion.
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Affiliation(s)
- M W Brands
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson 39216-4505, USA
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St-Pierre MV, Schwab AJ, Goresky CA, Lee WF, Pang KS. The multiple-indicator dilution technique for characterization of normal and retrograde flow in once-through rat liver perfusions. Hepatology 1989; 9:285-96. [PMID: 2643547 DOI: 10.1002/hep.1840090221] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The technique of normal and retrograde rat liver perfusion has been widely used to probe zonal differences in drug-metabolizing activities. The validity of this approach mandates the same tissue spaces being accessed by substrates during both normal and retrograde perfusions. Using the multiple-indicator dilution technique, we presently examine the extent to which retrograde perfusion alters the spaces accessible to noneliminated references. A bolus dose of 51Cr-labeled red blood cells, 125I-albumin, 14C-sucrose and 3H2O was injected into the portal (normal) or hepatic (retrograde) vein of rat livers perfused at 10 ml per min per liver. The outflow perfusate was serially collected over 220 sec to characterize the transit times and the distribution spaces of the labels. During retrograde perfusion, red blood cells, albumin and sucrose profiles peaked later and lower than during normal perfusion, whereas the water curves were similar. The transit times of red blood cells, albumin and sucrose were longer (p less than 0.005), whereas those for water did not change. Consequently, retrograde flow resulted in significantly larger sinusoidal blood volumes (45%), albumin Disse space (42%) and sucrose Disse space (25%) than during normal flow, whereas the distribution spaces for total and intracellular water remained unaltered. The distension of the vascular tree was confirmed by electron microscopy, by which occasional isolated foci of widened intercellular recesses and spaces of Disse were observed. Cellular ultrastructure was otherwise unchanged, and there was no difference found between normal and retrograde perfusion for bile flow rates, AST release, perfusion pressure, oxygen consumption and metabolic removal of ethanol, a substrate with flow-limited distribution, which equilibrates rapidly with cell water (hepatic extraction ratios were virtually identical: normal vs. retrograde, 0.50 vs. 0.48 at 6 to 7.4 mM input concentration). These findings suggest that the functional and metabolic capacities of the liver remain unperturbed during retrograde perfusion, rendering the technique suitable for the investigation of zonal differences in drug-metabolizing enzymes.
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Affiliation(s)
- M V St-Pierre
- Faculty of Pharmacy, University of Toronto, Ontario, Canada
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Pang KS, Lee WF, Cherry WF, Yuen V, Accaputo J, Fayz S, Schwab AJ, Goresky CA. Effects of perfusate flow rate on measured blood volume, disse space, intracellular water space, and drug extraction in the perfused rat liver preparation: characterization by the multiple indicator dilution technique. J Pharmacokinet Biopharm 1988; 16:595-632. [PMID: 3074996 DOI: 10.1007/bf01062014] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The effect of hepatic blood flow on the elimination of several highly cleared substrates was studied in the once-through perfused rat liver preparation. A constant and low input concentration of ethanol (2.0 mM), [14C]-phenacetin and [3H]-acetaminophen (0.36 and 0.14 microM, respectively), or meperidine (8.1 microM) was delivered once-through the rat liver preparation in five flow periods (greater than 35 min each); control flow periods at 12 ml/min were interrupted by flow changes to 8 or 16 ml/min. The steady-state hepatic availabilities (F or outflow survivals) at 12 ml/min were ethanol, 0.075 +/- 0.038; [14C]-phenacetin, 0.15 +/- 0.059; [3H]-acetaminophen, 0.34 +/- 0.051; meperidine, 0.047 +/- 0.017. Flow-induced changes were different among the compounds: with reduced flow (8 ml/min), F was decreased for ethanol (0.061 +/- 0.032) and [3H]-acetaminophen (0.28 +/- 0.051), as expected, but was increased for [14C]-phenacetin (0.20 +/- 0.068) and meperidine (0.05 +/- 0.03); with an elevation of flow (to 16 ml/min), F was increased for all compounds, as expected of shorter sojourn times: ethanol, 0.13 +/- 0.065; [14C]-phenacetin, 0.22 +/- 0.062; [3H]-acetaminophen, 0.43 +/- 0.063; meperidine, 0.055 +/- 0.022. A marked increase in F for ethanol had occurred when flow changed from 12 to 16 ml/min due to nonlinear metabolism; the latter was confirmed by a reduction in the extraction ratios at increasing concentrations (1.8 to 11.4 mM); this condition was not present for the other compounds. In order to explain the observations, we used the multiple indicator dilution technique to investigate the flow-induced behaviors of tissue distribution spaces of vascular and intracellular references in the perfused rat liver preparation.
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Affiliation(s)
- K S Pang
- Faculty of Pharmacy, University of Toronto, Ontario, Canada
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Caston JC, Miller WC, Huggins MP, Mlott SR, Lee WF. Prediction of postcardiotomy psychosis. J S C Med Assoc 1975; 71:40-3. [PMID: 1055273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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