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.
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.
