Poly[[aqua­[μ-1,4-bis­(3-pyridylmeth­yl)piperazine-κ2 N:N′](μ-isophthalato-κ2 O 1:O 3)copper(II)]

In the title compound, [Cu(C8H4O4)(C16H20N4)(H2O)]n, square-pyramidally coordinated CuII ions are linked into [Cu(H2O)(isophthalate)]n coordination polymer chains by isophthalate dianions. These chains are connected into undulating [Cu(H2O)(isophthalate)(3-bpmp)]n [3-bmp is bis­(3-pyridylmeth­yl)piperazine] layers by 3-bpmp tethering ligands. The pseudo three-dimensional structure of the title compound is fostered by inter­layer O—H⋯O hydrogen bonding between the aqua ligands and unligated isophthalate O atoms. The selected crystal was non-merohedrally twinned. Only reflections from the major twin component were used in the solution and refinement

Is rapid acute coronary syndrome evaluation with high-sensitivity cardiac troponin less costly? An economic evaluation

ObjectiveProtocols to evaluate for myocardial infarction (MI) using high-sensitivity cardiac troponin (hs-cTn) have the potential to drive costs upward due to the added sensitivity. We performed an economic evaluation of an accelerated protocol (AP) to evaluate for MI using hs-cTn to identify changes in costs of treatment and length of stay compared with conventional testing.MethodsWe performed a planned secondary economic analysis of a large, cluster randomized trial across nine emergency departments (EDs) from July 2020 to April 2021. Patients were included if they were 18 years or older with clinical suspicion for MI. In the AP, patients could be discharged without further testing at 0 h if they had a hs-cTnI < 4 ng/L and at 1 h if the initial value were 4 ng/L and the 1-h value ≤7 ng/L. Patients in the standard of care (SC) protocol used conventional cTn testing at 0 and 3 h. The primary outcome was the total cost of treatment, and the secondary outcome was ED length of stay.ResultsAmong 32,450 included patients, an AP had no significant differences in cost (+$89, CI: −$714, $893 hospital cost, +$362, CI: −$414,$1138 health system cost) or ED length of stay (+46, CI: −28, 120 min) compared with the SC protocol. In lower acuity, free-standing EDs, patients under the AP experienced shorter length of stay (−37 min, CI: −62, 12 min) and reduced health system cost (−$112, CI: −$250, $25).ConclusionOverall, the implementation of AP using hs-cTn does not result in higher costs

Potential protective effect of PPI in COPD.

Associations of an increased incidence of respiratory disease in the presence of gastroesophageal reflux disease (GERD), and improvements of respiratory disease with treatment for GERD, have been reported. Respiratory conditions associated with GERD or its treatment include chronic cough, asthma, and interstitial lung disease. Such associations between chronic obstructive pulmonary disease (COPD) and GERD have not been reported. We chose to retrospectively study the severity of airway obstruction as measured by pulmonary function testing (PFT) in a cohort of COPD patients with respect to the use of proton pump inhibitors (PPI). METHODS: Single-center retrospective analysis of patients with documented obstructive disease by PFT in 2014. A total of 1445 patients were identified as having an obstructive pattern. We selected a cohort of 647 patients who self-reported a diagnosis of COPD and had clinical findings consistent with this diagnosis. We compared patients who had been prescribed PPI (PPI group, n=383) to those who had not (non-PPI group, n=264). Univariate comparisons were by Chi-square analysis for dichotomous variables and two-sided student\u27s t-test for continuous variables. SPSS 20 software was used for statistical analysis. A p value of 0.05 was considered significant. Reported values are mean+/- standard deviation. RESULTS: The PPI group and non-PPI group were not different in terms of gender (PPI group 157/383 females; non-PPI group 127/264 females; p=0.073), body mass index (PPI group 27.9+/-7.4; non-PPI group 26.9+/-6.9; p=0.085), or age (PPI group 68.9+/-10.3; non-PPI group 68.2+/-10.8; p=0.407). The FEV1/FVC for the PPI group was 48.1+/-12.0 compared to the non-PPI group 45.3+/-12.1 (p=0.004). The percent predicted FEV1 for the PPI group was 51.2+/-19.2 compared to 46.7+/-19.0 for the non-PPI group (p=0.003). In a multivariate analysis with a model that included BMI, gender, age, and percent predicted FEV1, only the latter was associated with PPI treatment (p=0.022). CONCLUSIONS: Patients with PPI prescription in our study had less severe airway obstruction than patients who were not prescribed these medications. Multiple reasons for this association could be postulated. Different co-morbidity profiles or insurance coverages could exist between groups. Patients with more severe COPD might take more medications, limiting the availability of medications targeting symptom relief. Finally, PPI use could ameliorate airway obstruction in smoking-related lung disease. Potential mechanisms for a protective effect of PPI in COPD might implicate reduction of gastric acid aspiration, or a primary effect of the medication on lung disease pathophysiology. Further research evaluating PPI use in COPD is warranted

Impact of repeat echocardiograms on management decisions in patients rehospitalized with acute decompensated heart failure.

Background: Transthoracic echocardiography (TTE) at the time of acute decompensated heart failure (ADHF) may reveal significant structural and hemodynamic abnormalities that can classify risk, guide clinical management, and aid resource utilization. TTE is considered appropriate for enhancing diagnosis and guiding downstream management. However, the clinical impact of routine repeat TTE in uncomplicated ADHF re-admissions is yet to be established. We studied patients with repeat TTE at the time of re-hospitalization for ADHF to determine the clinical impact of TTE. Methods: In a single center retrospective study, 413 adult patients with 2 ADHF admissions within 1 year period were studied. Those with clear indications for repeat TTE (myocardial infarction, stroke, arrhythmias, hemodynamic instability, or valve disease) were excluded. 198 patients met inclusion criteria. Two groups were defined: those with significant interventions (SI: heart catheterizations, other cardiac procedures, nuclear scans, or specialty consultations) and minimal interventions (MI: medication or no changes). Demographic data, echocardiography parameters, procedures, and medications changes were evaluated. Results: Out of 198 patients, 85 patients comprised the SI group and 113 patients were in the MI group. Non-ischemic cardiomyopathy was the predominant etiology of heart failure observed in both groups (p=0.251). BNP on second presentation of ADHF was statistically worse than the prior admission (p=0.014). As a result of repeat TTE, no significant changes in left ventricular ejection fraction were observed in both groups MI and SI (p=0.131 and p=0.236, respectively). Within the valve disease subgroup, those with underlying mitral regurgitation who underwent MI had significant improvement of their valvular disease (p=0.005). This effect was not noted in patients who had advanced interventions (p=0.141). Despite SI, those patients with diastolic dysfunction trended to worsen despite repeat TTE (p=0.074). Conclusion: Many patients undergo repeat TTE routinely in the setting of ADHF. In our results, the predominant impact of repeat TTE in re-hospitalized ADHF involved minimal interventions such as medication changes, rather than significant interventions including procedures or specialty consultations. Echocardiography continues to serve an important role in patient management decisions, but clinicians should focus on reserving utilization of repeat TTE in uncomplicated ADHF readmissions to those not responding to standard medical optimization and diuresis

Impact of repeat echocardiograms on management decisions in patients rehospitalized with acute decompensated heart failure

Background: Transthoracic echocardiography (TTE) at the time of acute decompensated heart failure (ADHF) may reveal significant structural and hemodynamic abnormalities that can classify risk, guide clinical management, and aid resource utilization. TTE is considered appropriate for enhancing diagnosis and guiding downstream management. However, the clinical impact of routine repeat TTE in uncomplicated ADHF re-admissions is yet to be established. We studied patientswith repeat TTE at the time of re-hospitalization for ADHF to determine the clinical impact of TTE. Methods: In a single center retrospective study, 413 adult patients with 2 ADHF admissions within 1 year period were studied. Those withclear indications for repeat TTE (myocardial infarction, stroke, arrhythmias, hemodynamic instability, or valve disease) were excluded. 198 patients met inclusion criteria. Two groups were defined: those with significant interventions (SI: heart catheterizations, other cardiac procedures, nuclear scans, or specialty consultations) and minimal interventions (MI: medication or no changes). Demographic data, echocardiography parameters, procedures, and medications changes were evaluated. Results: Out of 198 patients, 85 patients comprised the SI group and 113 patients were in the MI group. Non-ischemic cardiomyopathy was the predominant etiology of heartfailure observed in both groups (p=0.251). BNP on second presentation of ADHF was statistically worse than the prior admission (p=0.014). As a result of repeat TTE, no significant changes in left ventricular ejection fraction were observed in both groups MI and SI (p=0.131 and p=0.236, respectively). Within the valve disease subgroup, those withunderlying mitral regurgitation who underwent MI had significant improvement of their valvular disease (p=0.005). This effect was not noted in patients who had advanced interventions (p=0.141). Despite SI, those patients withdiastolic dysfunction trended to worsen despite repeat TTE (p=0.074). Conclusion: Many patients undergo repeat TTE routinely in the setting of ADHF. In our results, the predominant impact of repeat TTE in re-hospitalized ADHF involved minimal interventions such as medication changes, rather than significant interventions including procedures or specialty consultations. Echocardiography continues to serve an important role in patient management decisions, but clinicians should focus onreserving utilization of repeat TTE in uncomplicated ADHF readmissions to those not responding to standard medical optimization and diuresis

The use in the United States of a baseline high-sensitivity cardiac troponin t value below the level of detection to rule out acute myocardial infarction.

Background: The use of a single baseline high sensitivity cardiac troponin T (hs-cTnT) measurement \u3c level of detection (LoD) to rule-out acute myocardial infarction (AMI) is recommended in the 2015 European Society of Cardiology guidelines. However, this suggestion is mostly based on trials including European populations and using a LoD for hs-cTnT of 5 ng/L. The purpose of this study was to determine if a single baseline hs-cTnT level \u3c 6 ng/L (the FDA approved LoD) could rule-out AMI in a United States (US) Emergency Department (ED) population. Methods: Patients presenting to the ED with any symptoms suspicious for ACS at a single US tertiary care urban center were enrolled. Baseline blood samples were obtained within 60 minutes of a triage ECG. AMI diagnosis was independently adjudicated by a cardiologist and emergency physician using the 3rd Universal Definition and serial troponin I (TnI) levels (Siemens TnI-Ultra) over 3 hours and all clinical data available 30 days post discharge. Results: Of the 569 studied subjects 44 (7.7%) had AMI and all enrolled patients had a baseline blood sample drawn. There were 164 (28.8%) subjects that had a baseline hs-cTnT value \u3c the LoD of 6 ng/L and all were without adjudicated AMI (negative predictive value 100% [95%CI 97.8-100.0], sensitivity 100% [95%CI 92.0-100.0]), irrespective of any ECG abnormalities. There were 30 hemodialysis patients enrolled and all had hs-cTn â%o¥ 6 ng/L at presentation. At 30 days there was 1 non-cardiac death, no cardiac deaths, 1 AMI (0.6%), and no revascularization procedures in those patients with a baseline hs-cTnT \u3c 6 ng/ L. The past medical histories of subjects with a hs-cTnT \u3c 6 ng/L included hypertension 98 (59.8%), diabetes mellitus 26 (15.9%), hypercholesterolemia 48 (29.3%), coronary artery disease 31 (18.9%), prior revascularization procedure 21 (12.8%), myocardial infarction 26 (15.9%), and congestive heart failure 11 (6.7%). Conclusion: A single baseline hs-cTnT level \u3c the US LoD of 6 ng/L can be used to rule-out AMI and identifies a low risk population which may be considered, after appropriate work up for non ACS etiologies as cause for presenting symptoms, for early discharge without further observation and/or cardiac testing. These findings are required to be validated prospectively in further multi-center US trials

Rapid evaluation of acute myocardial infarction in a united states population using high sensitivity cardiac troponin T and a European society of cardiology 0/1-hour algorithm guideline.

Background: A baseline and1 hour rule-in/rule-out acute myocardial infarction (AMI) algorithm using high sensitivity cardiac troponin T (hs-cTnT) measurements has been reported and validated in several non United States (US) studies and is recommended in the 2015 European Society of Cardiology (ESC) NSTEMI guidelines. There is no similar approach incorporated in any current US organizational NSTEMI guidelines. The purpose of this study was to apply the ESC baseline and 1 hour algorithm to a US Emergency Department (ED) population presenting with suspected acute coronary syndrome (ACS) to determine its clinical usefulness. Methods: Patients presenting with any symptoms suspicious of ACS at a single US tertiary care urban center were enrolled. Baseline (within 60 minutes of triage ECG) and 60 minute blood samples were obtained for blinded independent hs-cTnT (Roche) measurements. AMI diagnosis was independently adjudicated by 2 physicians after reviewing all available 30 day clinical data and the hospitals serial cardiac troponin I (Siemens) levels over 3 hours in accordance with the 3rd Universal Definition of AMI. Results: Of the 569 enrolled subjects 44 (7.7%) had AMI. Analyzing the baseline and 1 hour ESC algorithm in the 543 patients with these hs-cTnT values available resulted in 312 (57.5%) assigned to the rule-out zone (0 hour \u3c 12 and 1 hour delta \u3c 3 ng/L), 162 (29.8%) to the observation group and 69 (12.7%) to the rule-in zone (0 hour \u3e 52 or 1 hour delta â%o¥ 5 ng/L). The negative predicted value (NPV) and sensitivity for AMI were 99.4% and 95.5% (2 AMIs (0.63%), importantly both type 2, were missed in the rule-out zone while the rule-in zone positive predictive value (PPV) and specificity for AMI were 42.0% and 92.0%. Our results were very similar to those reported in the TRAPID-AMI study (ESC guidelines) for the rule-out zone (NPV and sensitivity 99.1% and 96.7% [7 AMIs (0.05%) were missed) but dissimilar for the rule-in zone (PPV and specificity 77.2% and 96.1%). Conclusion: In our opinion the most important aspect of the ESC baseline and 1 hour recommendations for clinicians is the rapid rule-out of AMI in the large number of ED patients with suspected ACS. For this purpose the rule-out zone of these ESC guidelines, when applied to a US population, has very similar NPVs and sensitivities and so could be used in like fashion. However further multicenter US ED studies are needed to validate our findings

Rapid Evaluation of Acute Myocardial Infarction in a United States Population Using High Sensitivity Cardiac Troponin T and a European Society of Cardiology 0/1-Hour Algorithm Guideline

Background: A baseline and 1 hour rule-in/rule-out acute myocardial infarction (AMI) algorithm using high sensitivity cardiac troponin T (hs-cTnT) measurements has been reported and validated in several non-United States (US) studies and is recommended in the 2015 European Society of Cardiology (ESC) NSTEMI guidelines. There is no similar approach incorporated in any current US organizational NSTEMI guidelines. The purpose of this study was to apply the ESC baseline and 1 hour algorithm to a US Emergency Department (ED) population presenting with suspected acute coronary syndrome (ACS) to determine its clinical usefulness. Methods: Patients presenting with any symptoms suspicious of ACS at a single US tertiary care urban center were enrolled. Baseline (within 60 minutes of triage ECG) and 60 minute blood samples were obtained for blinded independent hs-cTnT (Roche) measurements. AMI diagnosis was independently adjudicated by 2 physicians after reviewing all available 30 day clinical data and the hospitals serial cardiac troponin I (Siemens) levels over 3 hours in accordance with the 3rd Universal Definition of AMI. Results: Of the 569 enrolled subjects 44 (7.7%) had AMI. Analyzing the baseline and 1 hour ESC algorithm in the 543 patients with these hs-cTnT values available resulted in 312 (57.5%) assigned to the rule-out zone (0 hour \u3c 12 and 1 hour delta \u3c 3 ng/L), 162 (29.8%) to the observation group and 69 (12.7%) to the rule-in zone (0 hour \u3e 52 or 1 hour delta â%o¥ 5 ng/L). The negative predicted value (NPV) and sensitivity for AMI were 99.4% and 95.5% (2 AMIs (0.63%), importantly both type 2, were missed in the rule-out zone while the rule-in zone positive predictive value (PPV) and specificity for AMI were 42.0% and 92.0%. Our results were very similar to those reported in the TRAPID-AMI study (ESC guidelines) for the rule-out zone (NPV and sensitivity 99.1% and 96.7% [7 AMIs (0.05%) were missed) but dissimilar for the rule-in zone (PPV and specificity 77.2% and 96.1%). Conclusion: In our opinion the most important aspect of the ESC baseline and 1 hour recommendations for clinicians is the rapid rule-out of AMI in the large number of ED patients with suspected ACS. For this purpose the rule-out zone of these ESC guidelines, when applied to a US population, has very similar NPVs and sensitivities and so could be used in like fashion. However further multicenter US ED studies are needed to validate our findings

The Use in the United States of a Baseline High-Sensitivity Cardiac Troponin T Value Below the Level of Detection to Rule out Acute Myocardial Infarction

Background: The use of a single baseline high sensitivity cardiac troponin T (hs-cTnT) measurement \u3c level of detection (LoD) to rule-out acute myocardial infarction (AMI) is recommended in the 2015 European Society of Cardiology guidelines. However, this suggestion is mostly based on trials including European populations and using a LoD for hs-cTnT of 5 ng/L. The purpose of this study was to determine if a single baseline hs-cTnT level \u3c 6 ng/L (the FDA approved LoD) could rule-out AMI in a United States (US) Emergency Department (ED) population. Methods: Patients presenting to the ED with any symptoms suspicious for ACS at a single US tertiary care urban center were enrolled. Baseline blood samples were obtained within 60 minutes of a triage ECG. AMI diagnosis was independently adjudicated by a cardiologist and emergency physician using the 3rd Universal Definition and serial troponin I (TnI) levels (Siemens TnI-Ultra) over 3 hours and all clinical data available 30 days post discharge. Results: Of the 569 studied subjects 44 (7.7%) had AMI and all enrolled patients had a baseline blood sample drawn. There were 164 (28.8%) subjects that had a baseline hs-cTnT value \u3c the LoD of 6 ng/L and all were without adjudicated AMI (negative predictive value 100% [95%CI 97.8-100.0], sensitivity 100% [95%CI 92.0-100.0]), irrespective of any ECG abnormalities. There were 30 hemodialysis patients enrolled and all had hs-cTn â%o¥ 6 ng/L at presentation. At 30 days there was 1 non-cardiac death, no cardiac deaths, 1 AMI (0.6%), and no revascularization procedures in those patients with a baseline hs-cTnT \u3c 6 ng/ L. The past medical histories of subjects with a hs-cTnT \u3c 6 ng/L included hypertension 98 (59.8%), diabetes mellitus 26 (15.9%), hypercholesterolemia 48 (29.3%), coronary artery disease 31 (18.9%), prior revascularization procedure 21 (12.8%), myocardial infarction 26 (15.9%), and congestive heart failure 11 (6.7%). Conclusion: A single baseline hs-cTnT level \u3c the US LoD of 6 ng/L can be used to rule-out AMI and identifies a low risk population which may be considered, after appropriate work up for non ACS etiologies as cause for presenting symptoms, for early discharge without further observation and/or cardiac testing. These findings are required to be validated prospectively in further multi-center US trials

Ultrarapid Rule-out for Acute Myocardial Infarction Using the Generation 5 Cardiac Troponin T Assay: Results From the REACTION-US Study

STUDY OBJECTIVE: We determine how well a new Food and Drug Administration-approved single cardiac troponin T (cTnT) Generation 5 baseline measurement below the level of quantification (6 ng/L) and a novel study-derived baseline and 30-minute cTnT Generation 5 algorithm might adequately exclude acute myocardial infarction in patients with suspected acute coronary syndrome in a US emergency department (ED). METHODS: Patients presenting with any symptoms suspicious for acute coronary syndrome were enrolled at a single US ED. Baseline and 30-minute blood samples were obtained and cTnT Generation 5 levels were later batch analyzed in an independent core laboratory. Acute myocardial infarction diagnosis was adjudicated by a cardiologist and an emergency physician. RESULTS: Of the 569 study patients, 44 (7.7%) had an acute myocardial infarction diagnosis. One hundred sixty-four patients (28.8%) had a presentation cTnT Generation 5 level less than 6 ng/L, and none of these individuals had an acute myocardial infarction (negative predictive value of 100% [95% confidence interval 97.8% to 100.0%] and sensitivity of 100% [95% confidence interval 92.0% to 100.0%]). A baseline cTnT Generation 5 value of less than 8 ng/L and a 30-minute Δ of less than 3 ng/L were present in 221 patients (41.0%), and none had acute myocardial infarction (negative predictive value of 100% [95% confidence interval 98.3% to 100.0%] and sensitivity of 100% [95% confidence interval 92.0% to 100.0%]). CONCLUSION: In a single US ED, a single baseline cTnT Generation 5 measurement less than 6 mg/L and values at baseline less than 8 ng/L and a 30-minute Δ of less than 3 ng/L ruled out acute myocardial infarction in 28.8% and 41.0% of patients, respectively. Additional multicenter US studies evaluating these ultrarapid acute myocardial infarction rule-out guidelines are needed, especially to narrow the confidence intervals