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Background: The goal of this study was to determine the value of systolic time intervals and their change during Valsalva maneuver (VM) in the diagnosis of left ventricular dysfunction (LVD) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD)., Methods: We included 166 patients admitted to the emergency department for AECOPD. Measurement of systolic time intervals included electromechanical activation time (EMAT), left ventricular ejection time (LVET), and EMAT/LVET ratio. These were performed at baseline and during the first strain phase of the VM using a computerized phonoelectrocardiographic method. The diagnosis of LVD was determined on the basis of clinical examination, echocardiography, and brain natriuretic peptide. The values of systolic time intervals were compared between patients with and without LVD; their diagnostic performance was assessed using the area under receiver operating characteristic (ROC) curve., Results: Patients with LVD (n=95) had a significantly higher EMAT and lower LVET and EMAT/LVET ratio compared to patients without LVD (n=71); the area under ROC curve was 0.79, 0.88, and 0.90, respectively, for EMAT, LVET, and EMAT/LVET ratio. All baseline systolic time intervals changed significantly during VM in patients without LVD but they did not change in patients with LVD. The area under ROC curve increased to 0.84 and 0.93, respectively, for EMAT and EMAT/LVET ratio but did not change for LVET., Conclusion: Simple and noninvasive measurements of systolic time intervals combined with VM could be helpful to detect or rule out LVD in patients admitted to the emergency room for COPD excacerbation. The EMAT/LVET ratio seems to have the best diagnostic value.

Background: Left-ventricular dysfunction associated with COPD exacerbation is frequently underestimated. We tested whether finger plethysmography waveform change during the Valsalva maneuver could aid in the distinction between patients with COPD exacerbation with and without left-ventricular dysfunction., Methods: We included 102 subjects with COPD exacerbation and 51 subjects with acute heart failure admitted to the emergency department for acute dyspnea. Measurements of the plethysmographic pulse amplitude ratio under the Valsalva maneuver were obtained. The value of the plethysmographic pulse amplitude ratio in diagnosing left-ventricular dysfunction in COPD exacerbation subjects was quantified using the area under the receiver operating characteristic curves. Diagnostic performance of the plethysmographic pulse amplitude ratio was compared with the Boston score, and the net reclassification improvement was calculated to determine the incremental value in detecting left-ventricular dysfunction., Results: Values of the plethysmographic pulse amplitude ratio were higher in COPD exacerbation subjects with left-ventricular dysfunction compared with those without left-ventricular dysfunction (0.78 vs. 0.38, P = .01) but not significantly different from those of the acute heart failure group (0.78). There was a significant correlation between plethysmographic pulse amplitude ratio values and brain natriuretic peptide serum levels. The area under the receiver operating characteristic curve for the plethysmographic pulse amplitude ratio to detect left-ventricular dysfunction among subjects with COPD exacerbation was significantly higher compared with that of the Boston score (0.92 vs. 0.76, P = .02). Exposure to plethysmographic pulse amplitude ratio values increased the overall accuracy from Boston score-based predictions of left-ventricular dysfunction and provided a net reclassification improvement of 17.3%., Conclusions: An increased plethysmographic pulse amplitude ratio associated with COPD exacerbation is a good predictor of left-ventricular dysfunction. This simple and noninvasive index could help emergency department physicians to detect or rule out left-ventricular dysfunction in patients with COPD exacerbation who are able to perform the Valsalva maneuver. (ClinicalTrials.gov registration NCT01619540.)., (Copyright © 2016 by Daedalus Enterprises.)

Purpose: The Thrombolysis in Myocardial Infarction (TIMI) and the Global Registry in Acute Coronary Events (GRACE) scores were largely evaluated and validated in stratifying risk of cardiovascular events in patients with chest pain and acute coronary syndrome. Our objective was to compare these 2 scores in predicting outcome in emergency department (ED) patients with undifferentiated chest pain., Materials and Methods: This was a prospective cohort study including patients presenting to 4 EDs with chest pain with nondiagnostic or normal ECG. For all included patients (n = 3125), TIMI and GRACE scores were calculated. Follow-up was conducted at 30-day and 1-year post-ED index admission to identify major adverse events. Main outcome included all cause mortality, acute coronary syndrome, and coronary non-ED planned revascularization. Prognostic performance of the scores was assessed by the receiver operating characteristic (ROC) curves., Results: We reported 285 (9.1%) major adverse events at 30 days and 436 (13.9%) at 1 year. In patients with low TIMI (≤2) and GRACE (<109) scores, a significant proportion had major adverse events at 30 days (5% and 7.5%, respectively) and 1 year (7.9% and 12.9%, respectively). Area under ROC curve at 30 days was 0.66 (95% confidence interval [CI], 0.62-0.71) vs 0.57 (95% CI, 0.53-0.62), respectively, for TIMI and GRACE scores. At 1 year, the area under ROC was 0.67 (95% CI, 0.62-0.71) and 0.65 (95% CI, 0.60-0.70), respectively, for TIMI and GRACE scores., Conclusions: The TIMI and GRACE scores are not valid in short- and long-term risk stratification in our chest pain patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The likelihood of occurrence of intermolecular contacts in crystals of halogenated organic compounds has been analysed statistically using tools based on the Hirshfeld surface. Several families of small halogenated molecules (containing organic F, Cl, Br or I atoms) were analysed, based on chemical composition and aromatic or aliphatic character. The behaviour of crystal contacts was also probed for molecules containing O or N. So-called halogen bonding (a halogen making short interactions with O or N, or a π interaction with C) is generally disfavoured, except when H is scarce on the molecular surface. Similarly, halogen⋯halogen contacts are more rare than expected, except for molecules that are poor in H. In general, the H atom is found to be the preferred partner of organic halogen atoms in crystal structures. On the other hand, C⋯C interactions in parallel π-stacking have a high propensity to occur in halogenated aromatic molecules. The behaviour of the four different halogen species (F, Cl, Br, I) is compared in several chemical composition contexts. The analysis tool can be refined by distinguishing several types for a given chemical species, such as H atoms bound to O or C. Such distinction shows, for instance, that C-H⋯Cl and O-H⋯O are the preferred interactions in compounds containing both O and Cl.

The title salt, C3H6N3S2 (+)·Cl(-)·H2O, crystallized with two organic cations, two chloride anions and two water mol-ecules in the asymmetric unit. The methyl C atoms deviate from their respective bound ring planes by 0.081 and 0.002 Å. In the crystal, the components are connected via N-H⋯O, N-H⋯Cl and O-H⋯Cl hydrogen bonds, forming sheets lying parallel to (100). The sheets are linked into bilayers by O-H⋯Cl hydrogen bonds involving the chloride ions and water mol-ecules. Within the bilayers there are π-π inter-actions [inter-centroid distances = 3.4654 (4) and 3.4789 (4) Å] involving inversion-related cations.

In the title hydrated mol-ecular salt, 2C5H8N3O(+)·SO4 (2-)·H2O, the components are linked by N-H⋯Os and Ow-H⋯Os (s = sulphate, w = water) hydrogen bonds, generating a layer by a+b+c and 2a-b translations. The cations are arranged nearly in parallel and show displaced π-π stacking centroid-centroid distance = 4.661 (2) Å between adjacent layers.

Treatment with short-acting β2-agonists for exacerbations of chronic obstructive pulmonary disease (COPD) results in clinical improvement. It has not been established whether combining short-acting β2-agonists to other bronchodilators is more effective than β2-agonists alone. We conducted a study in patients presenting to the emergency department with exacerbation of COPD. They were randomized to receive nebulized ipratropium bromide (IB group; n = 62) or combined nebulized and intravenous bolus of magnesium sulfate (MgSO4 group; n = 62). All nebulized drugs were administered at 30-minute intervals for 2 hours. Primary outcome included hospital admission, endotracheal intubation, and hospital death rates. Secondary outcome measures were improvement in peak expiratory flow, dyspnea score, and arterial blood gas changes within the first 3 hours. There were no significant differences in primary outcome between MgSO4 and IB groups. Patients given IB average 32 L greater improvement in peak expiratory flow rate compared with magnesium sulfate (95% confidence interval, 19-43 L) at 180 minutes. Simultaneously, there was a significant reduction in PaCO2 compared with baseline values in IB group but not in MgSO4 group. There was a statistically nonsignificant trend toward a decrease in dyspnea score in both groups although adverse events were similar. Although the improvement in peak expiratory flow rate and arterial blood gas favored nebulized IB over magnesium sulfate, there was a nonsignificant difference between both drugs with regard to hospital admission, intubation, and hospital death rates in patients with COPD treated in the emergency department for acute exacerbation.

The asymmetric unit of the title compound, [K3(C4H2N3O4)3(H2O)2] n , contains two potassium cations (one in general position, one located on a twofold rotation axis), one and a half oxonate anions (the other half generated by twofold symmetry) and one water mol-ecule. As a result of the twofold symmetry, one H atom of the symmetric anion is statistically occupied. Both potassium cations are surrounded by eight oxygen atoms in the form of distorted polyhedra. Adjacent cations are inter-connected by oxygen bridges, generating layers parallel to (100). The aromatic ring system of the oxonate anions link these layers into a network structure. The crystal packing is stabilized by N-H⋯O, O-H⋯O and O-H⋯N hydrogen bonds, three of which are bifurcated. In addition, inter-molecular π-π stacking inter-actions exist between neighboring aromatic rings with a centroid-centroid distance of 3.241 (2) Å.

In the crystal structure of the title organic-inorganic hybrid material, (C10H22N2)[ZnCl4], the tetrachloridozincate anions and 1-cyclohexylpiperazine-1,4-diium dications are interconnected via N-H...Cl and C-H...Cl hydrogen bonds to form layers parallel to the (001) plane. The cyclohexyl groups from adjacent chains interdigitate, thus building the three-dimensional structure. The piperazinium and cyclohexyl rings exhibit regular spatial chair conformations. The title salt was also characterized by FT-IR and Raman spectroscopic analyses.

Study Objective: The New Orleans Criteria and the Canadian CT Head Rule have been developed to decrease the number of normal computed tomography (CT) results in mild head injury. We compare the performance of both decision rules for identifying patients with intracranial traumatic lesions and those who require an urgent neurosurgical intervention after mild head injury., Methods: This was an observational cohort study performed between 2008 and 2011 on patients with mild head injury who were aged 10 years or older. We collected prospectively clinical head CT scan findings and outcome. Primary outcome was need for neurosurgical intervention, defined as either death or craniotomy, or the need of intubation within 15 days of the traumatic event. Secondary outcome was the presence of traumatic lesions on head CT scan. New Orleans Criteria and Canadian CT Head Rule decision rules were compared by using sensitivity specifications and positive and negative predictive value., Results: We enrolled 1,582 patients. Neurosurgical intervention was performed in 34 patients (2.1%) and positive CT findings were demonstrated in 218 patients (13.8%). Sensitivity and specificity for need for neurosurgical intervention were 100% (95% confidence interval [CI] 90% to 100%) and 60% (95% CI 44% to 76%) for the Canadian CT Head Rule and 82% (95% CI 69% to 95%) and 26% (95% CI 24% to 28%) for the New Orleans Criteria. Negative predictive values for the above-mentioned clinical decision rules were 100% and 99% and positive values were 5% and 2%, respectively, for the Canadian CT Head Rule and New Orleans Criteria. Sensitivity and specificity for clinical significant head CT findings were 95% (95% CI 92% to 98%) and 65% (95% CI 62% to 68%) for the Canadian CT Head Rule and 86% (95% CI 81% to 91%) and 28% (95% CI 26% to 30%) for the New Orleans Criteria. A similar trend of results was found in the subgroup of patients with a Glasgow Coma Scale score of 15., Conclusion: For patients with mild head injury, the Canadian CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher negative predictive value. The question of whether the use of the Canadian CT Head Rule would have a greater influence on head CT scan reduction requires confirmation in real clinical practice., (Copyright © 2012 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

In the title mol-ecular salt, C6H10N2 (2+)·NO3 (-)·Cl(-), the complete cation is generated by a crystallographic mirror plane. The complete nitrate ion is also generated by reflection, with the N atom and one O atom lying on the mirror plane; the chloride ion also lies on the reflection plane. In the crystal, the components are linked by N-H⋯Cl and N-H⋯(N,O) hydrogen bonds, forming (001) layers with the benzene rings projecting into the inter-layer regions. The layers are linked by weak C-H⋯O hydrogen bonds, generating a three-dimensional network.

Introduction: Noninvasive pressure support ventilation (NIPSV) and continuous positive airway pressure (CPAP) are both advocated in the treatment of cardiogenic pulmonary edema (CPE); however, the superiority of one technique over the other has not been clearly demonstrated. With regard to its physiological effects, we hypothesized that NIPSV would be better than CPAP in terms of clinical benefit., Methods: In a prospective, randomized, controlled study performed in four emergency departments, 200 patients were assigned to CPAP (n = 101) or NIPSV (n = 99). Primary outcome was combined events of hospital death and tracheal intubation. Secondary outcomes included resolution time, myocardial infarction rate, and length of hospital stay. Separate analysis was performed in patients with hypercapnia and those with high B-type natriuretic peptide (>500 pg/ml)., Results: Hospital death occurred in 5 (5.0%) patients receiving NIPSV and 3 (2.9%) patients receiving CPAP (p = 0.56). The need for intubation was observed in 6 (6%) patients in the NIPSV group and 4 (3.9%) patients in the CPAP group (p = 0.46). Combined events were similar in both groups. NIPSV was associated to a shorter resolution time compared to CPAP (159 ± 54 vs. 210 ± 73 min; p < 0.01), whereas the incidence of new myocardial infarction was not different between both groups. Similar results were found in hypercapnic patients and those with high B-type natriuretic peptide., Conclusions: During CPE, NIPSV accelerates the improvement of respiratory failure compared to CPAP but does not affect primary clinical outcome either in overall population or in subgroups of patients with hypercapnia or those with high B-type natriuretic peptide.

BACKGROUND. Although the use of antibiotics in the treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) is largely accepted, controversy remains regarding whether the choice of antibiotic has any impact on outcome. Our aim was to compare the effects of the combination of trimethoprim and sulfamethoxazole and ciprofloxacin in patients treated for severe COPD exacerbation requiring mechanical ventilation. METHODS. In a randomized, double-blind trial, we included 170 patients with an acute exacerbation of COPD requiring mechanical ventilation. Enrolled patients received trimethoprim-sulfamethoxazole (n = 85) or ciprofloxacin (n = 85) for 10 days. Main outcomes were hospital death and need for an additional course of antibiotics. Secondary outcomes were duration of mechanical ventilation, length of hospital stay, and exacerbation-free interval. RESULTS. Combined hospital death and additional antibiotic prescription rates were similar in the 2 groups (16.4% vs 15.3% for trimethoprim-sulfamethoxazole group vs ciprofloxacin group; difference, 1.1%; 95% confidence interval [CI] -9.8% to 12.0%; P = .832). Hospital death occurred in 7 patients (8.2%) receiving trimethoprim-sulfamethoxazole and 8 patients (9.4%) receiving ciprofloxacin (difference, -1.2%; 95% CI, -9.7 to 7.3; P = .90). The need for an additional antibiotic course was observed in 8 patients in the trimethoprim-sulfamethoxazole group and 5 patients in the ciprofloxacin group (difference, 2.3%; 95% CI, -5.4 to 10.0; P = .549). The mean exacerbation-free interval (+/- standard deviation) was similar in both treatment groups (83 +/- 25 vs 79 +/- 22 for the trimethoprim-sulfamethoxazole group vs ciprofloxacin group; difference, 4 days; 95% CI, -15 to 19 days; P = .41). Duration of mechanical ventilation and hospital stay was not significantly different between the 2 groups. CONCLUSIONS. In patients with acute exacerbation of COPD requiring mechanical ventilation, efficacy of trimethoprim-sulfamethoxazole was not inferior to ciprofloxacin. Trial registration. ClinicalTrials.gov identifier: NCT00791505.

Study Objective: The distinction between hemorrhagic and ischemic stroke has critical implications for management. For that purpose, clinical scores have been proposed to be used in areas with limited health care resources where brain computed tomographic (CT) scan is not readily available. We conducted this study to evaluate the predictive value of the Allen and Siriraj scores in the differential diagnosis of stroke subtypes., Methods: We prospectively collected data for 4 years on the clinical characteristics of patients with stroke in a multicenter study. For all patients, we calculated the Allen and the Siriraj scores and we assessed their accuracy in predicting stroke subtypes with receiver operating characteristics (ROC) curves., Results: We assessed 1,023 patients. Of these, 82.7% (n=846) had ischemic stroke. The area under the ROC curve was higher for Siriraj score compared with the Allen score (0.780 versus 0.702; P=.04). Using the original cutoff points, Siriraj score has a sensitivity for the diagnosis of hemorrhage of 60% and a specificity of 95%; the corresponding values for the Allen score are 55% and 70%, respectively. The negative predictive value was higher for Siriraj score compared to the Allen score (90% versus 80%). The diagnosis of stroke subtype was best predicted at Siriraj score less than -4., Conclusion: Siriraj score is a valid and useful tool for predicting stroke subtype in a clinical setting in which financial constraints make systematic brain CT scan unfeasible.

Objective: To evaluate the diagnostic agreement between quantitative cultures of samples obtained with endotracheal aspiration (ETA) and plugged telescoping catheter (PTC)., Design: Prospective study., Setting: Medical ICU., Patients: Hundred thirty-eight episodes of suspected ventilator-associated pneumonia studied in 100 consecutive patients., Interventions: For each suspected episode of ventilator-associated pneumonia, ETA and PTC were performed consecutively. The agreement between microbiological results obtained from the two techniques was evaluated (kappa statistic test). Pneumonia was diagnosed on a positive culture result of telescoping catheter with the threshold set at 10(3) cfu/ml or more. The cut-off points evaluated for ETA ranged from 10(2 )to 10(6) cfu/ml., Results: Micro-organisms retrieved by aspiration and telescoping catheter were similar and bacterial counts obtained by the two procedures were well correlated ( r = 0.71 p < 0.001). There was good agreement between positive and negative ETA and PTC specimens (kappa: 0.78) with a diagnostic threshold for ETA of 10(4) cfu/ml. The sensitivity and specificity of ETA for the diagnosis of PTC-confirmed pneumonia were 92% and 85%, respectively. Kappa decreased to 0.48 when the diagnostic threshold was increased to 10(6) cfu/ml., Conclusions: Quantitative cultures of ETA and PTC tallied for both micro-organisms and counts. The simpler ETA appears adequate for determining the presence of pathogenic organisms in significant concentration in the lower respiratory tract.

Objective: To evaluate the effects of scorpion venom and antivenom in experimental envenomation., Design: Prospective, controlled animal study., Setting: University research laboratory, Subjects: Twenty-nine anesthetized and ventilated dogs., Interventions: The first group of animals had venom alone (0.05 mg/kg). Animals from the second group had simultaneous administration of 10 ml of scorpion antivenom (SAV). In the third and fourth groups, 10 ml and 40 ml SAV, respectively, were injected 10 min following venom., Measurements and Results: Hemodynamic parameters using right heart catheter were recorded and dosage of catecholamines, neuropeptide Y (NPY), endothelin-1, and atrial natriuretic peptide (ANP) were performed at baseline and during 60 min following envenomation. In the control group, at 5 min, there was a sharp increase in pulmonary artery occluded pressure (PAOP, from 2 mmHg to 23 mmHg), mean arterial pressure (MAP, from 125 mmHg to 212 mmHg) and systemic vascular resistance (SVR, from 2450 dyn sec(-1 )m(5) to 5775 dyn sec(-1 )m(5), P<0.05 for all). Heart rate, cardiac output, and stroke volume decreased. There was a 40-fold increase in epinephrine and norepinephrine plasma concentrations. Circulating NPY and ANP dosages increased too. PAOP and MAP decreased thereafter to reach baseline levels. Simultaneous administration of SAV with venom totally offset the hallmarks of scorpion envenomation. Delayed administration of SAV at any dosage failed to alter the features of scorpion envenomation., Conclusion: While simultaneous administration of SAV and scorpion venom is effective in preventing scorpion envenomation-related manifestations, delayed administration of SAV, either at standard or elevated dosages, failed to alter any of the scorpion envenomation features.