- Email: [email protected]
Patients in pain that refuse acetaminophen at triage
388
Correspondence / American Journal of Emergency Medicine 32 (2014) 383–391
[25] Bayes-Genis A, Santalo-Bel M, Zapico-Muniz E, et al. N-terminal probrain natriuretic peptide (NT-proBNP) in the emergency diagnosis and in-hospital monitoring of patients with dyspnoea and ventricular dysfunction. Eur J Heart Fail 2004;6:301–8. [26] Anderson KL, Fields JM, Panebianco NL, Jenq KY, Marin J, Dean AJ. Inter-rater reliability of quantifying pleural B-lines using multiple counting methods. J Ultrasound Med 2013;32(1):115–20. [27] Cibinel GA, Casoli G, Elia F, Padoan M, Pivetta E, Lupia E, Goffi A. Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the emergency department. Intern Emerg Med 2012;7(1):65–70. [28] Kataoka H. Utility of thoracic sonography for follow-up examination of chronic heart failure patients with previous decompensation. Clin Cardiol 2007;30:336.
Patients in pain that refuse acetaminophen at triage To the Editor, It is usually perceived that pain is under-evaluated and undertreated in the emergency department (ED) [1]. Nevertheless recent efforts have contributed to significantly reducing pain [2]. This includes the implementation of procedures for early delivery of analgesics beginning with nurse triage [3,4]. However it is currently unknown whether emergency patients accept early delivery of acetaminophen by triage nurses. Therefore we studied the prevalence and the factors for analgesic refusal at triage. We held this prospective, observational study at our ED. All consenting consecutive adults presenting with pain could be included. The institutional review board for the protection of human subjects of our institution approved the study protocol procedures. All participants provided oral informed consent and non-opposition. Nurses routinely deliver acetaminophen at triage using the following computerized procedure: patients are offered orodispersible acetaminophen (1 g) if Normalized Rating Scale ≥3, arterial blood pressure ≥100 mm Hg and Glasgow Coma Scale at 15, and in the absence of jaundice, acetaminophen allergy, or acetaminophen intake in the previous 6 hours. Patients under legal constraint or unable to answer the questionnaire could not be enrolled. A dedicated patient advocate checks on the patients for 10 hours a day (8 AM–6 PM), 5 days a week. Participants answered a faceto-face standardized interview. The patient advocate used prefilled proforma to record baseline data, acceptance/refusal of analgesics at triage, reasons for refusal, nurses’ characteristics, and behavior for analgesic delivery. Data were entered into SPPS (SPSS, Chicago, IL) [5]. Bivariate analysis was conducted to determine the association between each candidate predictor and refusal. All candidate variables with a bivariate P b 0.15 were entered into a multiple regression model. In the final model, the R2 (range of 0–1) was used as a measure of the power of the combined factors in predicting analgesic refusal. For the study period (19th of May to 2nd of August, 2011, 8 AM6 PM), 539 patients were observed. Among these, 336 (62%) accepted acetaminophen delivery at triage and 203 (38%) refused the treatment. Reasons for refusal are reported in Table. Most patients that refused analgesics at triage decided that pain was tolerable without analgesics. None of the patients were reluctant to acetaminophen delivery by a nurse at triage. Table Reasons for refusal of acetaminophen delivery by a nurse at triage in 203 patients Reasons for refusal
Number (%)
Pain is bearable without analgesic Analgesics hide symptoms and impair physician’s diagnosis procedure Acetaminophen is inadequate or lack efficiency to treat the present pain Patient in disfavor to medication intake Patients against acetaminophen delivery by a nurse Miscellaneous
108 (53%) 46 (20%)
Results are expressed as number (%).
39 (19%) 18 (9%) 0 12 (6%)
Characteristics of patients who accepted or refused acetaminophen were similar for age, sex, and level of anxiety (data not shown). In a multivariate analysis, higher social status (20% vs 10%, P = .001), lower levels of triage priority (39% vs 28%, P = .039) and less intense pain (P b .0001) were associated with acetaminophen refusal. More interestingly, the way triage nurses proposed acetaminophen influenced patients’ acceptance; patients were more likely to accept analgesic intake when nurses’ proposal lasted more than 5 seconds (P = .012) and nurses used directive sentences to suggest taking acetaminophen (P b .0001). Here we report that (i) patients in pain often refuse acetaminophen at triage, (ii) refusal is often related to patients’ perception of pain intensity, and (iii) the way nurses propose acetaminophen impacts on patients’ acceptance. Current explanation for inadequate management of pain in the ED has been the staff structure, the staff training, and perception of patients' pain. The role of the patient must also been considered. Up to two-thirds or more of patients may refuse analgesics [6,7]. Since changing a patient’s behavior remains challenging, healthcare givers should adapt and imagine new approaches, including continuous multifaceted processes based on information [7]. ED caregivers are understandably reluctant to apply time-consuming procedures. In our study, acceptance to treatment was directly related to the nurses’ message. As an example, if nurses used brief and negative messages (“Won’t you take some acetaminophen?”), chances are that patients' acceptance of analgesics is very weak. On the other hand, if nurses took time for a positive suggestion (“I give you 1 gram of acetaminophen, it will decrease your pain and help you in waiting for doctor's visit”), patients were more likely to accept treatment. The language and the self-confidence of health care providers both impact patients’ acceptance of procedures and treatments [8]. Directive sentences may appear to be intrusive in our post-paternalism period where patients should finally make an informed decision. Healthcare providers should help patients make choices that may affect their pain while in the ED. Therefore “neo-paternalism” is a good option to assist decision-making in patients initially reluctant to analgesics at triage. We understand that some patients would be difficult to persuade, especially those who don't want to take medication, and those who believe that acetaminophen is not strong enough to relieve their pain. On the other hand, 53% thought that their pain was bearable and 20% worried that analgesics will impair physicians’ evaluation. We believe that imperative suggestion for acetaminophen intake may encourage them to fight off their pain. The ED staff can have a positive influence on whether or not the patient will accept acetaminophen. Even though patients' instinct is valuable, we believe that reinforcing the nurses' role to initially administer analgesics may help relief in the ED and should be tested in an impact study. François Lecomte MD Stéphanie Huet MD Department of Emergency Medicine Hôpital Cochin-Hôtel Dieu, AP-HP. 27 rue du Faubourg Saint-Jacques F-75679 Paris Cedex 14, Université Paris Descartes, 1 place de l’Odéon F-75005, Paris, France Etienne Audureau PhD Department of Biostatistics Hôpital Cochin-Hôtel Dieu, AP-HP. 27 rue du Faubourg Saint-Jacques F-75679 Paris Cedex 14, Université Paris Descartes, 1 place de l’Odéon F-75005, Paris, France Valérie Guyerdet RN Jean-Louis Pourriat MD, PhD Department of Emergency Medicine Hôpital Cochin-Hôtel Dieu, AP-HP. 27 rue du Faubourg Saint-Jacques F-75679 Paris Cedex 14, Université Paris Descartes, 1 place de l’Odéon F-75005, Paris, France
Correspondence / American Journal of Emergency Medicine 32 (2014) 383–391
Yann-Erick Claessens MD, PhD Department of Emergency Medicine Centre Hospitalier Princesse Grace, 1 avenue Pasteur MC-98012, Principalty of Monaco E-mail address: [email protected]
emergency department (ED), particularly when clinical features are ambiguous and confounding comorbidities are there. It also helps in triaging and decongesting the ED by early recognition, treatment, and safe discharge of heart failure patients. Nayer Jamshed MD Department of Emergency Medicine All India Institute of Medical Sciences New Delhi, India E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2013.12.030 References [1] Wilson JE, Pendelton JM. Oligoanalgesia in the emergency department. Am J Emerg Med 1989;7:620–3. [2] Doherty S, Knott J, Bennetts S, Jazayeri M, Huckson S. National project seeking to improve pain management in the emergency department setting: findings from the NHMRC-NICS national pain initiative. Emerg Med Australas 2013;25:120–6. [3] Seguin D. A nurse initiated pain management advanced triage protocol for ED patients with extremity injury at a level 1 trauma center. J Emerg Nurs 2007;30: 330–5. [4] Fosnocht DE, Swanson ER. Use of triage pain protocol in the ED. Am J Emerg Med 2007;25:791–3. [5] SSPS. [6] Wallace KG. When patients refuse pain medication. Am J Nurs 1996;96:20–1. [7] Carr EC. Refusing analgesics: using continuous improvement to improve pain management on a surgical ward. J Clin Nurs 2002;11:743–52. [8] Jolles EP, Clark AM, Braam B. Getting the message across: opportunities and obstacles in effective communication in hypertension care. J Hypertens 2012;30: 1500–10.
N-terminal prohormone of brain natriuretic peptide—how far can we extrapolate? To the Editor, We read the article by Velibey et al [1] with interest. Their result is consistent with various other studies done in the past, but long-term (4 years) survival prediction on hospital admission with a single plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level is a new and important finding. The mean value of NT-proBNP is significantly correlated with ejection fraction and the functional class (New York Heart Association Class) of heart failure [2]. The author had neither commented on the functional status of the patients nor on the etiology of acute shortness of breath at the time of admission. Testing the levels of natriuretic peptide particularly brain natriuretic peptide and NT-proBNP offers a strong diagnostic, therapeutic, and prognostic tool in heart failure. Quantitative estimation of NT-proBNP at the time of discharge appears to be a better predictor of the state of ventricles. It also shows whether optivolemic status has been reached with therapy or not. N-terminal prohormone of brain natriuretic peptide level of less than 4000 pg/mL suggests adequate therapy of heart failure and predicts a stable posthospital discharge, whereas NTproBNP level of more than 7000 pg/mL on discharge has an increased risk of cardiovascular illness [3]. Estimated NT-proBNP at the time of admission and discharge not only predicts the prognosis of the patient in a better way but also suggests effectiveness of in-hospital therapy of heart failure [4,5]. Therefore, this study does not throw light on effectiveness of in-hospital therapy. N-terminal prohormone of brain natriuretic peptide level not only predicts mortality in heart failure, but it is also a prognostic marker in various other conditions like severe sepsis and septic shock [6], cirrhosis of liver [7], pulmonary embolism [8], and cardioembolic stroke [9]. The list of exclusion criteria for this study does not include the aforementioned conditions, which should have been excluded. To conclude, plasma levels of natriuretic peptides are used in the diagnosis, treatment, and prognosis in multiple conditions, but its utility is not proven beyond doubt in conditions other than heart failure. Usefulness of natriuretic peptide is mainly to differentiate between cardiac and noncardiac cause of acute dyspnea in the
389
Fouzia F. Ozair MBBS, DO Jawaharlal Nehru University New Delhi, India E-mail address: [email protected] Meera Ekka MD Praveen Aggarwal Department of Emergency Medicine All India Institute of Medical Sciences New Delhi, India E-mail addresses: [email protected], [email protected] http://dx.doi.org/10.1016/j.ajem.2013.12.033 References [1] Velibey Y, Golcuk Y, Golcuk B, et al. Determination of a predictive cutoff value of NTproBNP testing for long term survival in ED patients with acute heart failure. Am J Emerg Med 2013;31:1634–7. [2] Sokhanvar S, Shekhi M, Golmohammadi Z et al. The relationship between serum NT-ProBNP levels and prognosis in patients with systolic heart failure Journal of Cardiovascular and Thoracic Research 2011; 3 (2): 57–61. [3] Logeart D, Saudubray C, Beyne P, et al. Comparative value of Doppler echocardiography and B-type natriuretic peptide assay in the etiologic diagnosis of acute dyspnea. J Am Coll Cardiol 2002;40:1794–800. [4] Moe GW, Howlett J, Januzzi JL, et al. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute HF: primary results of the Canadian Prospective Randomized Multicenter IMPROVE-CHF Study. Circulation 2007;115:3103–10. [5] Masson S, Latini R, Anand IS, et al. Direct comparison of B-type natriuretic peptide (BNP) and amino-terminal proBNP in a large population of patients with chronic and symptomatic heart failure: the Valsartan Heart Failure (Val-HeFT) data. Clin Chem 2006;52:1528–38. [6] Hoffmann U, Brueckmann M. A new language of natriuretic peptides in sepsis? Crit Care Med 2008;36(9):2686–7. [7] Anna L, Corrao S, Cardillo M et al. NT-pro BNP plasma level and atrial volume are linked to the severity of liver cirrhosis. PLoS ONE 8(8) e68364. [8] Coutance G, Olivier L, Page TL et al. Prognostic value of brain natriuretic peptide in acute pulmonary embolism 2008;12(4)R:104. [9] Chen X, Zhan X, Chen M, et al. The prognostic value of combined NT-pro-BNP levels and NIHSS scores in patients with acute ischemic stroke. Intern Med 2012;51(20):2887–92.
Image quality evaluation of a portable handheld ultrasound machine for the focused assessment with sonography for trauma examination☆ 1. Introduction Benefits of handheld ultrasound devices include ease of portability, 1,2 lower cost, 3,4 and potentially reduced examination time. 5 However, questions have been raised about the quality of images obtained on these devices. 4 We hypothesized that the overall image quality of the smaller handheld device would be inferior to that of a larger cart-mounted machine during the focused assessment with sonography for trauma (FAST) examination. For evaluation in this study, we compared the pocket-sized GE Vscan ☆ Funding for this study was provided by the University of Maryland Emergency Medicine Network.
Correspondence / American Journal of Emergency Medicine 32 (2014) 383–391
[25] Bayes-Genis A, Santalo-Bel M, Zapico-Muniz E, et al. N-terminal probrain natriuretic peptide (NT-proBNP) in the emergency diagnosis and in-hospital monitoring of patients with dyspnoea and ventricular dysfunction. Eur J Heart Fail 2004;6:301–8. [26] Anderson KL, Fields JM, Panebianco NL, Jenq KY, Marin J, Dean AJ. Inter-rater reliability of quantifying pleural B-lines using multiple counting methods. J Ultrasound Med 2013;32(1):115–20. [27] Cibinel GA, Casoli G, Elia F, Padoan M, Pivetta E, Lupia E, Goffi A. Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the emergency department. Intern Emerg Med 2012;7(1):65–70. [28] Kataoka H. Utility of thoracic sonography for follow-up examination of chronic heart failure patients with previous decompensation. Clin Cardiol 2007;30:336.
Patients in pain that refuse acetaminophen at triage To the Editor, It is usually perceived that pain is under-evaluated and undertreated in the emergency department (ED) [1]. Nevertheless recent efforts have contributed to significantly reducing pain [2]. This includes the implementation of procedures for early delivery of analgesics beginning with nurse triage [3,4]. However it is currently unknown whether emergency patients accept early delivery of acetaminophen by triage nurses. Therefore we studied the prevalence and the factors for analgesic refusal at triage. We held this prospective, observational study at our ED. All consenting consecutive adults presenting with pain could be included. The institutional review board for the protection of human subjects of our institution approved the study protocol procedures. All participants provided oral informed consent and non-opposition. Nurses routinely deliver acetaminophen at triage using the following computerized procedure: patients are offered orodispersible acetaminophen (1 g) if Normalized Rating Scale ≥3, arterial blood pressure ≥100 mm Hg and Glasgow Coma Scale at 15, and in the absence of jaundice, acetaminophen allergy, or acetaminophen intake in the previous 6 hours. Patients under legal constraint or unable to answer the questionnaire could not be enrolled. A dedicated patient advocate checks on the patients for 10 hours a day (8 AM–6 PM), 5 days a week. Participants answered a faceto-face standardized interview. The patient advocate used prefilled proforma to record baseline data, acceptance/refusal of analgesics at triage, reasons for refusal, nurses’ characteristics, and behavior for analgesic delivery. Data were entered into SPPS (SPSS, Chicago, IL) [5]. Bivariate analysis was conducted to determine the association between each candidate predictor and refusal. All candidate variables with a bivariate P b 0.15 were entered into a multiple regression model. In the final model, the R2 (range of 0–1) was used as a measure of the power of the combined factors in predicting analgesic refusal. For the study period (19th of May to 2nd of August, 2011, 8 AM6 PM), 539 patients were observed. Among these, 336 (62%) accepted acetaminophen delivery at triage and 203 (38%) refused the treatment. Reasons for refusal are reported in Table. Most patients that refused analgesics at triage decided that pain was tolerable without analgesics. None of the patients were reluctant to acetaminophen delivery by a nurse at triage. Table Reasons for refusal of acetaminophen delivery by a nurse at triage in 203 patients Reasons for refusal
Number (%)
Pain is bearable without analgesic Analgesics hide symptoms and impair physician’s diagnosis procedure Acetaminophen is inadequate or lack efficiency to treat the present pain Patient in disfavor to medication intake Patients against acetaminophen delivery by a nurse Miscellaneous
108 (53%) 46 (20%)
Results are expressed as number (%).
39 (19%) 18 (9%) 0 12 (6%)
Characteristics of patients who accepted or refused acetaminophen were similar for age, sex, and level of anxiety (data not shown). In a multivariate analysis, higher social status (20% vs 10%, P = .001), lower levels of triage priority (39% vs 28%, P = .039) and less intense pain (P b .0001) were associated with acetaminophen refusal. More interestingly, the way triage nurses proposed acetaminophen influenced patients’ acceptance; patients were more likely to accept analgesic intake when nurses’ proposal lasted more than 5 seconds (P = .012) and nurses used directive sentences to suggest taking acetaminophen (P b .0001). Here we report that (i) patients in pain often refuse acetaminophen at triage, (ii) refusal is often related to patients’ perception of pain intensity, and (iii) the way nurses propose acetaminophen impacts on patients’ acceptance. Current explanation for inadequate management of pain in the ED has been the staff structure, the staff training, and perception of patients' pain. The role of the patient must also been considered. Up to two-thirds or more of patients may refuse analgesics [6,7]. Since changing a patient’s behavior remains challenging, healthcare givers should adapt and imagine new approaches, including continuous multifaceted processes based on information [7]. ED caregivers are understandably reluctant to apply time-consuming procedures. In our study, acceptance to treatment was directly related to the nurses’ message. As an example, if nurses used brief and negative messages (“Won’t you take some acetaminophen?”), chances are that patients' acceptance of analgesics is very weak. On the other hand, if nurses took time for a positive suggestion (“I give you 1 gram of acetaminophen, it will decrease your pain and help you in waiting for doctor's visit”), patients were more likely to accept treatment. The language and the self-confidence of health care providers both impact patients’ acceptance of procedures and treatments [8]. Directive sentences may appear to be intrusive in our post-paternalism period where patients should finally make an informed decision. Healthcare providers should help patients make choices that may affect their pain while in the ED. Therefore “neo-paternalism” is a good option to assist decision-making in patients initially reluctant to analgesics at triage. We understand that some patients would be difficult to persuade, especially those who don't want to take medication, and those who believe that acetaminophen is not strong enough to relieve their pain. On the other hand, 53% thought that their pain was bearable and 20% worried that analgesics will impair physicians’ evaluation. We believe that imperative suggestion for acetaminophen intake may encourage them to fight off their pain. The ED staff can have a positive influence on whether or not the patient will accept acetaminophen. Even though patients' instinct is valuable, we believe that reinforcing the nurses' role to initially administer analgesics may help relief in the ED and should be tested in an impact study. François Lecomte MD Stéphanie Huet MD Department of Emergency Medicine Hôpital Cochin-Hôtel Dieu, AP-HP. 27 rue du Faubourg Saint-Jacques F-75679 Paris Cedex 14, Université Paris Descartes, 1 place de l’Odéon F-75005, Paris, France Etienne Audureau PhD Department of Biostatistics Hôpital Cochin-Hôtel Dieu, AP-HP. 27 rue du Faubourg Saint-Jacques F-75679 Paris Cedex 14, Université Paris Descartes, 1 place de l’Odéon F-75005, Paris, France Valérie Guyerdet RN Jean-Louis Pourriat MD, PhD Department of Emergency Medicine Hôpital Cochin-Hôtel Dieu, AP-HP. 27 rue du Faubourg Saint-Jacques F-75679 Paris Cedex 14, Université Paris Descartes, 1 place de l’Odéon F-75005, Paris, France
Correspondence / American Journal of Emergency Medicine 32 (2014) 383–391
Yann-Erick Claessens MD, PhD Department of Emergency Medicine Centre Hospitalier Princesse Grace, 1 avenue Pasteur MC-98012, Principalty of Monaco E-mail address: [email protected]
emergency department (ED), particularly when clinical features are ambiguous and confounding comorbidities are there. It also helps in triaging and decongesting the ED by early recognition, treatment, and safe discharge of heart failure patients. Nayer Jamshed MD Department of Emergency Medicine All India Institute of Medical Sciences New Delhi, India E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2013.12.030 References [1] Wilson JE, Pendelton JM. Oligoanalgesia in the emergency department. Am J Emerg Med 1989;7:620–3. [2] Doherty S, Knott J, Bennetts S, Jazayeri M, Huckson S. National project seeking to improve pain management in the emergency department setting: findings from the NHMRC-NICS national pain initiative. Emerg Med Australas 2013;25:120–6. [3] Seguin D. A nurse initiated pain management advanced triage protocol for ED patients with extremity injury at a level 1 trauma center. J Emerg Nurs 2007;30: 330–5. [4] Fosnocht DE, Swanson ER. Use of triage pain protocol in the ED. Am J Emerg Med 2007;25:791–3. [5] SSPS. [6] Wallace KG. When patients refuse pain medication. Am J Nurs 1996;96:20–1. [7] Carr EC. Refusing analgesics: using continuous improvement to improve pain management on a surgical ward. J Clin Nurs 2002;11:743–52. [8] Jolles EP, Clark AM, Braam B. Getting the message across: opportunities and obstacles in effective communication in hypertension care. J Hypertens 2012;30: 1500–10.
N-terminal prohormone of brain natriuretic peptide—how far can we extrapolate? To the Editor, We read the article by Velibey et al [1] with interest. Their result is consistent with various other studies done in the past, but long-term (4 years) survival prediction on hospital admission with a single plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level is a new and important finding. The mean value of NT-proBNP is significantly correlated with ejection fraction and the functional class (New York Heart Association Class) of heart failure [2]. The author had neither commented on the functional status of the patients nor on the etiology of acute shortness of breath at the time of admission. Testing the levels of natriuretic peptide particularly brain natriuretic peptide and NT-proBNP offers a strong diagnostic, therapeutic, and prognostic tool in heart failure. Quantitative estimation of NT-proBNP at the time of discharge appears to be a better predictor of the state of ventricles. It also shows whether optivolemic status has been reached with therapy or not. N-terminal prohormone of brain natriuretic peptide level of less than 4000 pg/mL suggests adequate therapy of heart failure and predicts a stable posthospital discharge, whereas NTproBNP level of more than 7000 pg/mL on discharge has an increased risk of cardiovascular illness [3]. Estimated NT-proBNP at the time of admission and discharge not only predicts the prognosis of the patient in a better way but also suggests effectiveness of in-hospital therapy of heart failure [4,5]. Therefore, this study does not throw light on effectiveness of in-hospital therapy. N-terminal prohormone of brain natriuretic peptide level not only predicts mortality in heart failure, but it is also a prognostic marker in various other conditions like severe sepsis and septic shock [6], cirrhosis of liver [7], pulmonary embolism [8], and cardioembolic stroke [9]. The list of exclusion criteria for this study does not include the aforementioned conditions, which should have been excluded. To conclude, plasma levels of natriuretic peptides are used in the diagnosis, treatment, and prognosis in multiple conditions, but its utility is not proven beyond doubt in conditions other than heart failure. Usefulness of natriuretic peptide is mainly to differentiate between cardiac and noncardiac cause of acute dyspnea in the
389
Fouzia F. Ozair MBBS, DO Jawaharlal Nehru University New Delhi, India E-mail address: [email protected] Meera Ekka MD Praveen Aggarwal Department of Emergency Medicine All India Institute of Medical Sciences New Delhi, India E-mail addresses: [email protected], [email protected] http://dx.doi.org/10.1016/j.ajem.2013.12.033 References [1] Velibey Y, Golcuk Y, Golcuk B, et al. Determination of a predictive cutoff value of NTproBNP testing for long term survival in ED patients with acute heart failure. Am J Emerg Med 2013;31:1634–7. [2] Sokhanvar S, Shekhi M, Golmohammadi Z et al. The relationship between serum NT-ProBNP levels and prognosis in patients with systolic heart failure Journal of Cardiovascular and Thoracic Research 2011; 3 (2): 57–61. [3] Logeart D, Saudubray C, Beyne P, et al. Comparative value of Doppler echocardiography and B-type natriuretic peptide assay in the etiologic diagnosis of acute dyspnea. J Am Coll Cardiol 2002;40:1794–800. [4] Moe GW, Howlett J, Januzzi JL, et al. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute HF: primary results of the Canadian Prospective Randomized Multicenter IMPROVE-CHF Study. Circulation 2007;115:3103–10. [5] Masson S, Latini R, Anand IS, et al. Direct comparison of B-type natriuretic peptide (BNP) and amino-terminal proBNP in a large population of patients with chronic and symptomatic heart failure: the Valsartan Heart Failure (Val-HeFT) data. Clin Chem 2006;52:1528–38. [6] Hoffmann U, Brueckmann M. A new language of natriuretic peptides in sepsis? Crit Care Med 2008;36(9):2686–7. [7] Anna L, Corrao S, Cardillo M et al. NT-pro BNP plasma level and atrial volume are linked to the severity of liver cirrhosis. PLoS ONE 8(8) e68364. [8] Coutance G, Olivier L, Page TL et al. Prognostic value of brain natriuretic peptide in acute pulmonary embolism 2008;12(4)R:104. [9] Chen X, Zhan X, Chen M, et al. The prognostic value of combined NT-pro-BNP levels and NIHSS scores in patients with acute ischemic stroke. Intern Med 2012;51(20):2887–92.
Image quality evaluation of a portable handheld ultrasound machine for the focused assessment with sonography for trauma examination☆ 1. Introduction Benefits of handheld ultrasound devices include ease of portability, 1,2 lower cost, 3,4 and potentially reduced examination time. 5 However, questions have been raised about the quality of images obtained on these devices. 4 We hypothesized that the overall image quality of the smaller handheld device would be inferior to that of a larger cart-mounted machine during the focused assessment with sonography for trauma (FAST) examination. For evaluation in this study, we compared the pocket-sized GE Vscan ☆ Funding for this study was provided by the University of Maryland Emergency Medicine Network.