Natalie Htet

All Publications

• The Roller Coaster of Lamotrigine Levels: Successful Treatment of Massive Lamotrigine Overdose With Continuous Veno-Venous Hemodiafiltration and Rifampin CUREUS JOURNAL OF MEDICAL SCIENCE Li, Y., Ang, H. S., Fatehi, P., Htet, N. 2024; 16 (7)

  View details for DOI 10.7759/cureus.65637

  View details for Web of Science ID 001284553300026

• The Roller Coaster of Lamotrigine Levels: Successful Treatment of Massive Lamotrigine Overdose With Continuous Veno-Venous Hemodiafiltration and Rifampin. Cureus Li, Y., Ang, H. S., Fatehi, P., Htet, N. 2024; 16 (7): e65637

  Abstract

  Lamotrigine is a commonly used anticonvulsant in treating seizures and bipolar disorder, but there is very limited literature on the management of its toxicity. Case reports have been published suggesting the potential role of hemodialysis in lowering serum lamotrigine levels, as well as sodium bicarbonate and lipid emulsion in treating dysrhythmia. After previously reported therapies failed to stabilize the patient's condition, the case presents our successful treatment experience using continuous veno-venous hemodiafiltration (CVVHDF) to stabilize lamotrigine levels, as well as intravenous rifampin as adjunctive therapy to facilitate lamotrigine metabolism. This is a 66-year-old male who was found unresponsive after a lamotrigine overdose. His first lamotrigine level was 42.3 ug/mL. Hemodialysis was started on hospital day 1. Despite hemodialysis sessions, his lamotrigine level rebounded with worsening neurological and cardiac symptoms. On hospital day 3, he developed wide-QRS complex tachyarrhythmia and hemodynamic instability with a lamotrigine level of 66.9 ug/mL. Sodium bicarbonate was given without effect. Lipid emulsion was administered which terminated the arrhythmia. CVVHDF and rifampin were started and lamotrigine levels have continuously downtrended since. He was successfully extubated on day 7. Lamotrigine level became undetectable on day 9. The patient was discharged to a psychiatric facility without any neurological or mobility impairment on day 10. The continuous drug clearance provided by CVVHDF over intermittent hemodialysis may have provided additional benefit in lamotrigine level stabilization, while rifampin use in this case may have further accelerated lamotrigine metabolism. As the first case reporting CVVHDF and rifampin use, our experience suggests their potential roles in managing severe lamotrigine toxicity.

  View details for DOI 10.7759/cureus.65637

  View details for PubMedID 39205748

  View details for PubMedCentralID PMC11351006

• Cardiovascular collapse and McConnell's sign as early manifestations of leucostasis. BMJ case reports Rozenbaum, D., Lebold, K. M., Lee, D., Salmi, D., Htet, N. N. 2024; 17 (2)

  Abstract

  A man in his late 70s with chronic myelomonocytic leukaemia presented for evaluation of acute leukaemic transformation and initiation of cytoreductive therapy after being found to have asymptomatic hyperleucocytosis. Within 24 hours, the patient developed vasopressor-refractory shock, severe lactic acidosis and multiorgan failure. Serial echocardiographic assessments revealed interval enlargement of the right ventricle with development of the McConnell's sign, and abdominal CT showed diffuse bowel wall thickening, likely due to ischaemia. CT angiography excluded pulmonary embolism or occlusion of intra-abdominal arteries. Despite aggressive care, the patient died from cardiovascular collapse within 8hours of the onset of hypotension. An autopsy revealed extensive infiltration of early myeloid cells in pulmonary, myocardial, hepatic and intestinal microvasculature. This case illustrates different mechanisms by which leucostasis causes acute cardiovascular collapse and stresses the emergent nature of this diagnosis.

  View details for DOI 10.1136/bcr-2023-257330

  View details for PubMedID 38367997

• THE ROLLER COASTER LEVELS: A SUCCESSFUL TREATMENT OF MASSIVE LAMOTRIGINE OVERDOSE Li, Y., Htet, N. LIPPINCOTT WILLIAMS & WILKINS. 2024

  View details for Web of Science ID 001131541101405

• Trend of Outcome Metrics in Recent Out-of-Hospital-Cardiac-Arrest Research: A Narrative Review of Clinical Trials. Journal of clinical medicine Htet, N. N., Jafari, D., Walker, J. A., Pourmand, A., Shaw, A., Dinh, K., Tran, Q. K. 2023; 12 (22)

  Abstract

  Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management.

  View details for DOI 10.3390/jcm12227196

  View details for PubMedID 38002808

• Use of Point-of-Care Ultrasound by Intensive Care Unit Triage Teams in Evaluating Unstable Patients Outside Intensive Care Units. Cureus Gupta, P. B., Lighthall, G., Htet, N. 2023; 15 (11): e49114

  Abstract

  Introduction Point-of-care ultrasound (POCUS) has become an integral asset in intensive care units (ICUs). However, there is limited literature on the value of POCUS in evaluating deteriorating patients outside the ICU. In this study, we sought to investigate the use and impact of POCUS by ICU triage teams in hospitals outside of the ICU setting. Methods ICU triage fellows were provided a portable ultrasound to use as part of their evaluations during consultations and hospital code activations. Fellows were asked to fill out a survey on how ultrasound was used and its impact on patient management. Free-text data such as reason for ultrasound use, views obtained, clinical impressions before and after ultrasound, and clinical actions were recorded. These data were transcribed and categorized electronically. Results A total of 51 total resuscitations were documented. The most common reason for ICU triage team evaluation was hypotension (53%, N=27). The most common clinical focus for ultrasound use was cardiac assessment (53%, N=27), followed by volume status assessment (35%, N=18). The most common ultrasound views per encounter obtained were parasternal long (82%, N=42), followed by apical four-chamber view (76%, N=39) and subcostal view (75%, N=38). Out of 38 encounters with clinical impressions documented, 79% (N=30) of pre-ultrasound clinical impressions were confirmed by ultrasound use. Of total encounters, 35% (N=18) had a significant clinical action taken based on ultrasound findings (fluid resuscitation, vasopressor initiation, etc.). Conclusions Ultrasound is a valuable tool for patient evaluation in non-ICU wards, especially in confirming clinical impressions and guiding therapeutic actions. Some limitations of this study include reporting bias and incomplete capture of ultrasound use in non-ICU wards.

  View details for DOI 10.7759/cureus.49114

  View details for PubMedID 38125228

  View details for PubMedCentralID PMC10732337

• Further advancing emergency department triage prediction. Resuscitation Levin, N. M., Gordon, A. J., Htet, N., Wilson, J. G. 2023; 191: 109930

  View details for DOI 10.1016/j.resuscitation.2023.109930

  View details for PubMedID 37748821

• USE OF POINT-OF-CARE ULTRASOUND IN EVALUATING UNSTABLE PATIENTS OUTSIDE INTENSIVE CARE UNITS Gupta, P., Lighthall, G., Htet, N. LIPPINCOTT WILLIAMS & WILKINS. 2023: 574

  View details for Web of Science ID 000921450901451

• RARE CO-OCCURRENCE OF FAVISM-INDUCED HEMOLYSIS AND METHEMOGLOBINEMIA SECONDARY TO G6PD DEFICIENCY D'souza, M., Jones, J., Htet, N. LIPPINCOTT WILLIAMS & WILKINS. 2023: 153

  View details for Web of Science ID 000921450900299

• IMPENDING UPPER AIRWAY OBSTRUCTION FROM UNILATERAL TONSILLAR ENLARGEMENT IN A PATIENT WITH MONKEYPOX Rozenbaum, D., Hua, S., Fellion, L., Higgins, T., Rahman, A., Oliveira, F., Boateng, A., Htet, N. LIPPINCOTT WILLIAMS & WILKINS. 2023: 180

  View details for Web of Science ID 000921450900351

• Advanced Critical Care Ultrasound: Axillary Arterial Line- Oft Forgotten Slagle, D., Htet, N. EMRA. 2022
• Comparison of Language and Memory Lateralization by Functional MRI and Wada Test in Epilepsy. Frontiers in neurology and neuroscience research Htet, N. N., Pizarro, R., Nair, V. A., Chu, D. Y., Meier, T., Tunnell, E., Rutecki, P., Hermann, B., Meyerand, E. M., Prabhakaran, V. 2021; 2

  Abstract

  The intracarotid sodium amobarbital procedure (ISAP or Wada test) lateralizes cerebral functions to the cerebral hemispheres preoperatively. Functional magnetic resonance imaging (fMRI) is increasingly used to characterize preoperative language and memory lateralization. In this study, concordance of fMRI with Wada was examined in patients with medically intractable seizures. The relationship of the distance between the epileptogenic focus to functional activation area with patients' post-operative deficits in language was also analyzed. 27 epilepsy patients with preoperative fMRI and Wada data were analyzed using established fMRI paradigms for language and memory. Activation of Broca's and Wernicke's areas were measured in three dimensions. Language and memory lateralization were determined, and standard neuropsychiatry Wada test procedures were used for comparison. The shortest distance between a language area to the border of surgical focus (LAD) was also measured and compared with postoperative language deficits. Our study found that concordance between fMRI and Wada testing was 0.41 (Kappa's 'fair to good' concordance) for language dominance and 0.1 (Kappa's 'poor' concordance) for memory. No significant correlation was found between LAD and post-op language deficit (p=0.439). A correlation was found between LAD and post-op memory deficit (p=0.049; the further distance from surgical lesion to language area is associated with less post-operative memory loss). Females demonstrated significantly increased postoperative seizure improvement (Fisher's p-value=0.0296; female=8; male=6). A significant association between handedness (right-handed subjects) and postoperative seizure improvement was found (p=0.02) as well as a significant trend for interaction of gender and handedness on postoperative seizure improvement (p=0.09). Overall, our results demonstrate fMRI as a useful preoperative adjunct to Wada testing for language lateralization in patients with medically intractable seizures.

  View details for PubMedID 34189523

• Protocolized use of Factor Eight Inhibitor Bypassing Activity (FEIBA) for the reversal of warfarin induced coagulopathy AMERICAN JOURNAL OF EMERGENCY MEDICINE Htet, N. N., Barounis, D., Knight, C., Umunna, B., Hormese, M., Lovell, E. 2020; 38 (3): 539-544

  Abstract

  Coagulopathy due to warfarin in patients with major bleeding was traditionally reversed with fresh frozen plasma and intravenous (IV) vitamin K, but prothrombin complex concentrates (PCC) are increasingly used in the treatment of these patients. Factor Eight Inhibitor Bypassing Activity (FEIBA) is an activated four-factor PCC most commonly used in patients with hemophilia. We aimed to evaluate the efficacy and safety of FEIBA and IV vitamin K for the reversal of warfarin-associated coagulopathy in patients with major bleeding, by measuring the percentage of patients who achieved target INR ≤ 1.5 and the incidence of thrombotic adverse events (TAE).In this prospective observational study, we enrolled patients presenting to the Emergency Department (ED) with warfarin associated coagulopathy (INR > 1.5) and major bleeding. Patients received FEIBA using an INR based dosing strategy and IV vitamin K.In 43 patients, median initial INR was 4.0 (2.7, 7.3 interquartile range (IQR)). Median time to result the second INR was 45 min (38, 55 IQR) and the median INR was 1.4 (1.3, 1.6 IQR). Out of the 43 patients, 93% achieved the target INR of ≤1.5. In-hospital mortality was 40% (17 patients). There were 11 TAEs in 6 patients (14%); 4 events in 2 patients (5%) were attributed to FEIBA.A protocolized use of FEIBA and IV vitamin K resulted in the efficacious reversal of warfarin-induced coagulopathy in patients with major bleeding. TAEs occurred in 14% of patients and were attributed to FEIBA in 5% of patients.

  View details for DOI 10.1016/j.ajem.2019.05.047

  View details for Web of Science ID 000539260200016

  View details for PubMedID 31176578

• Critical Care Education Day: A Novel, Multidisciplinary, and Interactive Critical Care Education Session for Emergency Medicine Residents. Cureus Htet, N. N., Gordon, A. J., Mitarai, T. 2020; 12 (1): e6785

  Abstract

  Critical care medicine (CCM) is central to emergency medicine (EM) resident education. We feel that the traditional lecture format is not the ideal way to teach EM critical care, which requires integration and prioritization of diagnostic workup and team-based resuscitation under time pressure. We describe a novel critical care education day where an interactive, practical, and multidisciplinary critical care educational experience was provided for EM residents using case-based small-group sessions and fast-paced simulation.

  View details for DOI 10.7759/cureus.6785

  View details for PubMedID 32140345

  View details for PubMedCentralID PMC7045984

• Acute Respiratory Distress Syndrome: Etiology, Pathogenesis, and Summary on Management. Journal of intensive care medicine Kaku, S., Nguyen, C. D., Htet, N. N., Tutera, D., Barr, J., Paintal, H. S., Kuschner, W. G. 2019: 885066619855021

  Abstract

  The acute respiratory distress syndrome (ARDS) has multiple causes and is characterized by acute lung inflammation and increased pulmonary vascular permeability, leading to hypoxemic respiratory failure and bilateral pulmonary radiographic opacities. The acute respiratory distress syndrome is associated with substantial morbidity and mortality, and effective treatment strategies are limited. This review presents the current state of the literature regarding the etiology, pathogenesis, and management strategies for ARDS.

  View details for DOI 10.1177/0885066619855021

  View details for PubMedID 31208266

• SEVERE INTRAVASCULAR HEMOLYSIS WITH CLOSTRIDIUM PERFRINGENS BACTEREMIA Htet, N., Alipanah, N., Chen, W. LIPPINCOTT WILLIAMS & WILKINS. 2018: 295

  View details for DOI 10.1097/01.ccm.0000528633.21905.e3

  View details for Web of Science ID 000436794300580

• Needle-guided ultrasound technique for axillary artery catheter placement in critically ill patients: A case series and technique description. Journal of critical care Htet, N., Vaughn, J., Adigopula, S., Hennessey, E., Mihm, F. 2017; 41: 194-197

  Abstract

  Axillary arterial cannulation for blood pressure monitoring has been reported in adults since 1973. Reported failure rates using palpation landmarks are high. This report describes a needle-guided ultrasound technique for axillary arterial line placement in critically ill patients.A retrospective review of all patients requiring axillary arterial cannulation attempts with ultrasound-assisted needle guidance for hemodynamic monitoring was performed from July 2010 to June 2016 at a single institution.One hundred fifty nine (159) cannulation attempts were performed in 155 patients. The overall success rate was 97%, with a first pass success rate of 84%. Inexperienced operators performed 49% of procedures under direct faculty supervision, and had a 99% success rate, which was not different from experienced operators. Almost 20% of patients had moderate-to-severe coagulopathy (platelets<50k/uL, INR>2.0 or PTT>60s). Complications reported included the following: nonfunctioning of catheter (6%) and hematoma (6%). Ischemia was noted in 2 patients (1%), but only one was attributed to the arterial catheter.Use of the needle-guided ultrasound assisted approach for axillary arterial line placement is easily teachable and can be used to promote safe and successful placement of axillary arterial lines for novice learners.

  View details for DOI 10.1016/j.jcrc.2017.05.026

  View details for PubMedID 28577475

• Biodistribution and predictive value of (IF)-I-18-fluorocyclophosphamide in mice bearing human breast cancer xenografts JOURNAL OF NUCLEAR MEDICINE Kesner, A. L., Hsueh, W., Htet, N. L., Pio, B. S., Czernin, J., Pegram, M. D., Phelps, M. E., Silverman, D. H. 2007; 48 (12): 2021-2027

  Abstract

  In mice bearing human breast cancer xenografts, we examined the biodistribution of (18)F-fluorocyclophosphamide ((18)F-F-CP) to evaluate its potential as a noninvasive prognostic tool for predicting the resistance of tumors to cyclophosphamide therapy.(18)F-F-CP was synthesized as we recently described, and PET data were acquired after administration of (18)F-F-CP in mice bearing human breast cancer xenografts (MCF-7 cells). Tracer biodistribution in reconstructed images was quantified by region-of-interest analysis. Distribution was also assessed by harvesting dissected organs, tumors, and blood, determining (18)F content in each tissue with a gamma-well counter. The mice were subsequently treated with cyclophosphamide, and tumor size was monitored for at least 3 wk after chemotherapy administration.The distribution of harvested activity correlated strongly with distribution observed in PET images. Target organs were related to routes of metabolism and excretion. (18)F-F-CP uptake was highest in kidneys, lowest in brain, and intermediate in tumors, as determined by both image-based and tissue-based measurements. (18)F-F-CP uptake was not inhibited by coadministration of an approximately x700 concentration of unlabeled cyclophosphamide. PET measures of (18)F-F-CP uptake in tumor predicted the magnitude of the response to subsequent administration of cyclophosphamide.Noninvasive assessment of (18)F-F-CP uptake using PET may potentially be helpful for predicting the response of breast tumors to cyclophosphamide before therapy begins.

  View details for DOI 10.2967/jnumed.107.045716

  View details for Web of Science ID 000252895100020

  View details for PubMedID 18006620