only 18 of 44 (41%) patients with ADHF and detected orthopnea in 32 of 44 (73%). Seemingly, the 2 most important clues of the diagnosis of ADHF in any Clinical context were not observed in all patients, and we do should know also if and how these symptoms were associated. We wonder if such limitation could be related to the ill-defined quality of the assessment description of rales (basal or diffuse), which makes questionable even the diagnosis of ADHF or are a consequence of other factors, for instance the need of rush when facing critical patients. But how can we trust in the Diagnostic efficacy of more complex procedures if the rush is seemingly preventing even an adequate assessment of physical signs? The current work-up of patients with ADHF includes the assessment of pulmonary rales, usually along with the monitoring blood pressure, heart rate, pulse oximetry, and other measurements. In our opinion, some of them should be included in the statistics of predictivity, and the failure of physicians to detect them deserves some comment.

Ejection fraction (EF) assessed by echocardiography is included in data analysis, but echocardiographic assessment was quite limited: “Left ventricular EF was visually estimated as the reduction in the cross- sectional area of the left ventricle viewed in the short axis.” Can authors comment on this point? Echocardiography [4] is probably faster to perform in comparison of the 8 areas assessment such as LUS scan does and the subsequent calculation of the score requires, at least in our experience with postgraduate trainees. Authors [1] should report the time that was necessary to perform LUS in the patients observed in this study. Authors claim very serious limitations in the US assessment of Inferior vena cava respiratory changes: “The choice of sonographic window was determined by availability (limited by dressings, wounds, bowel gas, or habitus) and sonologist preference.” Despite these limitations, which apparently affected the actual feasibility of the procedure in some patients, US IVC is described as a very reliable measure to be used in the ADHF diagnosis work-up [1]. In addition, this point is not sufficiently discussed, and limitations of IVC collapsibility index criterion should be better considered. Briefly:

Can we trust in a diagnosis of ADHF without any sign of lung rales?

Physical examination clues, such as rales, were used in the single variables and in the combinations of multiple variables (LUS, EF, and IVC) predictivity analysis.

Interobserver/intraobserver variation analysis for b-line as- sessment should be reported.

Because it is known that B lines can be seen in other conditions, such as pulmonary fibrosis, COPD, and lymphangitis [5-9], we should know in how many patients with dyspnea but without ADHF, b-line (N 10) increase was found: were they 0 of 57 in no-ADHF patients?

The lack of report of the likely presence of pleural effusion, which can be an additive clues useful in the diagnosis of ADHF [10] and the use of artifact instead of LUS imaging [11,12] need comments.

We thank the further contribution to this subject provided by Anderson et al [1], whose limitations, mostly well addressed by authors, are a valuable resource for improving knowledge, evidence, and best practice in emergency medicine.

Daniela Catalano MD Guglielmo M. Trovato MD

Department of Medical and Pediatric Sciences

University of Catania

Catania, Italy E-mail address: [email protected]

Marco Sperandeo MD Departments of Pediatrics and Internal Medicine IRCCS Casa Sollievo della Sofferenza Hospital

San Giovanni Rotondo, Italy

http://dx.doi.org/10.1016/j.ajem.2013.12.026

References

1. Anderson KL, Jenq KY, Fields JM, Panebianco NL, Dean AJ. Diagnosing heart failure among acutely dyspneic patients with cardiac, inferior vena cava, and lung ultrasonography. Am J Emerg Med 2013;31:1208-14.
2. Wang Z, Xiong YX. Lung sound patterns help to distinguish congestive heart failure, chronic obstructive pulmonary disease, and asthma exacerbations. Acad Emerg Med 2012;19:79.
3. Kimura BJ, DeMaria AN. Technology insight: hand-carried ultrasound cardiac assessment-evolution, not revolution. Nat Clin Pract Cardiovasc Med 2005;2: 217-23.
4. Kimura BJ, Demaria AN. Empowering physical examination: the “laying on” of ultrasound. JACC Cardiovasc Imaging 2008;1:602-4.
5. Sperandeo M, Varriale A, Sperandeo G, et al. Assessment of ultrasound acoustic artifacts in patients with acute dyspnea: a multicenter study. Acta Radiol 2012;53: 885-92.
6. Trovato GM, Rollo VC, Martines GF, Catalano D, Trovato FM, Sperandeo M. Thoracic ultrasound in the differential diagnosis of severe dyspnea: a reappraisal. Int J Cardiol 2013;167:1081-3.
7. Sperandeo M, Varriale A, Sperandeo G, et al. Transthoracic ultrasound in the evaluation of pulmonary fibrosis: our experience. Ultrasound Med Biol 2009;35: 723.
8. Moazedi-Fuerst FC, Zechner PM, Tripolt NJ, et al. Pulmonary echography in systemic sclerosis. Clin Rheumatol 2012;31:1621-5.
9. Sperandeo M, Varriale A, Sperandeo G, et al. Characterization of the normal pulmonary surface and pneumonectomy space by reflected ultrasound. J Ultrasound 2011;14:22-7.
10. Kataoka H. Utility of thoracic sonography for follow-up examination of chronic heart failure patients with previous decompensation. Clin Cardiol 2007;30:336.
11. Trovato GM, Sperandeo M. Sounds, ultrasounds, and artifacts: which clinical role for lung imaging? Am J Respir Crit Care Med 2013;187:780-1.
12. Trovato GM, Catalano D, Martines GF, Sperandeo M. Is it time to measure lung water by ultrasound? Intensive Care Med 2013;39:1662.

    Point-of-care ultrasound diagnoses acute decompensated heart failure in the ED regardless of examination findings?,??,?

    To the Editor,

    We thank Dr Guglielmo M. Trovato for the comments about our article titled “Diagnosing heart failure among acutely dyspneic patients with cardiac, inferior vena cava, and Lung ultrasound” [1]. In our article, we demonstrated that Point-of-care ultrasound is able to make the diagnosis of Acutely decompensated heart failure (ADHF) among dyspneic patients in the emergency department (ED) if all 3 of the following were present: left ventricular ejection fraction (LVEF) less than 45%, inferior vena cava collapsibility index (IVC-CI) less than 20%, and B lines 10 or higher. In his commentary, Dr Trovato discusses how he would have preferred a more detailed discussion and analysis of how physical examination findings, particularly the presence of rales, may have objectively contributed to the diagnosis of ADHF. Simply put, that was not the aim of our study. In the introduction, we stated that the signs and symptoms of ADHF are frequently nonspecific and highly variable, especially among the increasingly larger group of patients with coexisting respiratory illness such as chronic obstructive pulmonary disease [2-5]. This variability is so well documented in the literature that we did not feel it merited further discussion in our manuscript; however, because this seems to be the principle concern in the correspondence, we will provide a more detailed discussion as well as address the other varied concerns that were mentioned.

    The initial history and physical examination of acutely dyspneic

    patients in the ED are often only able to produce limited diagnostic information, and in our study, we assessed whether point-of-care US could contribute additional useful information among a population where the history and physical examination had already been performed and the diagnosis remained unclear. In those patients, it

    ? Sources of support: None to report.

    ?? Presentation: oral presentation at the Society of Academic Emergency Medicine

    Annual Meeting, May 2010, Phoenix, AZ.

    ? The views expressed in this article are those of the authors and do not reflect the

    official policy or position of the Department of the US Air Force, Department of Defense, or the US government.

    becomes particularly important to know how well US performs independent of any physical examination findings. Although it may be interesting and potentially useful to compare US to physical examination findings or to even combine US with physical examina- tion findings, as suggested by Dr Trovato, our aim was to answer the broader and more generalizable question of how well US performs regardless of physical examination findings.

    Dr Trovato also suggests that “well defined physical signs, as rales are, could modify the level of predictivity of the other measurements, and are still an objective component of work-up in patients with dyspnea.” We recognize that the presence of rales may increase the likelihood that ADHF is present in dyspneic patients; however, we reiterate that these physical examination findings are nonspecific and our primary aim was to evaluate how US performed regardless of physical examination findings; how the presence of rales modifies the “predictivity” of US findings in making the diagnosis of ADHF would be best evaluated in a separate study. In addition, we have to disagree that the presence of rales is typically an objective measure that is used in making the diagnosis of ADHF in the ED as suggested by Dr Trovato. As evidence that rales are an objective measure in diagnosing ADHF, Dr Trovato cites a pilot study that used a noninvasive computerized acoustic-based imaging technique to make an objective distinction between different etiologies of dyspnea in the ED [6]. Although this technology sounds promising, it is not currently available in the typical ED for use. In practice, the presence of rales usually contributes to the experienced emergency physician’s (EP’s) gestalt in a subjective manner when making the diagnosis of ADHF. Our study showed that US can then be used if the diagnosis is not clear; in contrast to the novel imaging technique cited, US is ubiquitous among academic EDs and increasingly commonplace among community EDs in the United States. The other reference cited in the comments is an older article, which outlines the evolution of Portable US machines and postulates on the potential utility of point-of-care echocardiography; this reference does not add any useful information to the discussion of the utility of physical examination findings alone or in combination with US findings [7].

    Dr Trovato points out that only 41% of our ADHF group had rales and

    only 73% had orthopnea. They queried, “if and how” these were associated. Again, we could retrospectively look at our data to make that determination; however, our primary aim was to determine how US performed independent of signs or symptoms. Dr Trovato then suggests that this low incidence of rales and orthopnea may be a limitation because it calls into question the diagnosis of ADHF in our study. However, our findings are similar to multiple studies of ADHF among dyspneic patients in the ED; for example, one of the largest prospective studies of heart failure patients in the ED (1586 patients) had comparable results with 43% of symptomatic heart failure subjects presenting with rales in the lower lung fields and 53% with orthopnea [8]. In contrast to the suggestion that we should have performed, a more thorough evaluation of how symptoms may have been related to the diagnosis or to the US findings, we again assert that this type of overly detailed evaluation would have detracted from our primary aim to discover how well US performs among the broader undifferentiated dyspnea popula- tion in the ED and is one of the greatest strengths of our study.

    Dr Trovato then goes on to ask a variety of questions, which are not related to the topic of how physical examination findings may be related to the diagnosis of ADHF. Many of these are combined in 2 separate paragraphs, and then there is a list of 5 additional comments/ questions that Dr Trovato asks to have addressed. In an effort to answer all these comments in the clearest possible manner, we have quoted the authors comments below and then provide an answer to each comment.

    “Ejection fraction (EF) assessed by echocardiography is included in data analysis, but echocardiographic assessment was quite limited: ‘Left ventricular EF was visually estimated as the reduction in the cross-sectional area of the left ventricle viewed in the short axis.’ Can

    authors comment this point? Echocardiography is probably faster to perform in comparison of the 8 areas lung US scan and the subsequent calculation of the score, at least in our experience with post-graduate trainees: Authors should report the time that was necessary to perform lung US in the patients observed in this study.”

    Left ventricular ejection fraction was visually estimated as the reduction in the cross-sectional area of the left ventricle in the short axis; this method has been previously described and has become the accepted standard in the ED [9-13]. For the purposes of this study, we were only concerned with the LVEF and IVC-CI, which is a limited but appropriate cardiac examination when evaluating for the presence of ADHF. Emergency physicians do not have time to perform the type of comprehensive echocardiogram that would be performed by the cardiology department in the ED, and very few have the skill set to do so. As mentioned in the discussion section of the manuscript, the 2008 emergency ultrasound guidelines published by the American College of Emergency Physicians defines the limited cardiac US performed by EPs as an ability to assess for pericardial effusion and evidence of tamponade, presence of Cardiac activity, general cardiac contractility, and the central venous volume status [14,15]. These cardiac US guidelines have subsequently been accepted as reasons for EPs to perform and interpret limited cardiac US in the ED by the American Society of Echocardiography [16]. In the discussion section of the article, we also reported that we did not measure the time it took to perform the US examinations; however, prior literature demonstrates that a point-of-care cardiac US (including both LVEF and IVC-CI) and B-line assessment both take less than 5 minutes to perform [17,18].

    “Authors claim very serious limitations in the US assessment of

    inferior vena cava respiratory changes: ‘The choice of sono- graphic window was determined by availability (limited by dressings, wounds, bowel gas, or habitus) and sonologist preference.’ Despite these limitations, which apparently affected the actual feasibility of the procedure in some patient, IVC-US is described as a very reliable measure to be used in the ADHF diagnosis workup. Also this point is not sufficiently discussed, and limitations of IVC collapsibility index criterion should be better considered.”

    Dr Trovato suggests that there were limitations to the IVC assessment, allegedly because we allowed the sonologist preference to dictate the sonographic window that was used to obtain the IVC-CI measurements. In reality, this is a strength of the study; it uses a previously described method, which allows greater feasibility in obtaining adequate windows [19,20]. In our study, it allowed us to obtain adequate IVC images for all enrolled subjects.

    “Can we trust in a diagnosis of ADHF without any sign of lung rales?” Multiple prior investigations have demonstrated that rales are not necessarily present in patients who present to the ED with ADHF [21-25]. In short, yes, a diagnosis of ADHF without any sign of rales can be trusted.

13. “Physical examination clues, such as rales, were used in the single variables and in the combinations of multiple variables (LUS, EF, and IVC) predictivity analysis?” The primary outcome of our study was to evaluate how the US findings alone performed in making the diagnosis of ADHF among dyspneic patients in the ED. Although we have the data to evaluate any of the multiple possible combinations of physical examination findings with US findings, using the relatively undifferentiated group of dyspneic patients is much more generalizable to an ED population.
14. “Interobserver/intraobserver variation analysis for B-lines assessment should be reported.” The interobserver and intraobserver reliability for rating the number of B lines present in our group has previously been reported [26].
15. “Since it is known that B-lines can be seen in other conditions, such as pulmonary fibrosis, COPD, and lymphangitis, we should

    know in how many patients with dyspnea, but without ADHF, B-lines (N 10) increase was found: were they 0/57 in no-ADHF patients?”

    The number of patients with other conditions who had 10 or more B lines is implicit in the specificity of the B-line variable in making the diagnosis of ADHF. The specificity of B lines alone in making the diagnosis of ADHF was 75%, which means that the other 25% of patients who had 10 or more B lines were diagnosed with a condition other than ADHF. We included a list of the diagnoses of the ADHF-negative subjects in the results section of our article.

    “The lack of report of the likely presence of pleural effusion, which can be additive clues useful in the diagnosis of ADHF, and the use of artifact instead of LUS imaging, need comments.”

    Although a pleural effusion may be present in ADHF, prior evidence suggests that the presence of a pleural effusion is not helpful in the differential diagnosis among acutely dyspneic patients presenting to the ED [27]. The suggestion that the presence of a pleural effusion may provide, “additive clues useful in the diagnosis of ADHF” refers to the evaluation of chronic heart failure patients in a clinic setting and has no relevance to acutely decompensated patients in the ED [28]. The other references cited make no association between the presence of a pleural effusion and ADHF, rather they are simply correspondences to the editors of 2 different journals by Dr Trovato et al, suggesting that B lines are not specific for cardiogenic pulmonary edema. This is the same suggestion made in comment number 4 above, and this suggestion is not refuted. B lines are well known to be caused by a number of pathologic processes resulting in interstitial edema or otherwise thickened interlobular septae. In fact, this is precisely the reason the combination of LVEF, IVC-CI, and B lines was used in our study; none of the variables alone is specific to ADHF, but the combination of all 3 in our study was found to be 100% specific in diagnosing ADHF.

    Being able to correctly identify ADHF among dyspneic patients early in the ED course is vitally important yet difficult, so we appreciate the opportunity that Dr Trovato has provided to highlight some of the important findings in our recent manuscript. Most importantly, the combination of LVEF less than 45%, IVC-CI less than 20%, and B lines of 10 or more in acutely dyspneic patients in the ED is 100% specific (95% confidence interval, 95-100) for the diagnosis of ADHF regardless of their signs or symptoms. These findings should be of particular interest for skilled physicians who work in an ED setting and understand that physical examination tools, which have limited accuracy at best, become even more limited in an environment where subtle auscultatory findings may be completely obscured by ambient noise. Although there may be some utility in comparing US to physical examination findings, we feel that we have answered the more important and generalizable question regarding how well US performs regardless of physical examination findings. We look forward to further investigations that may be able to elucidate how US or any other modality may be able to increase our diagnostic capability for this important and costly disease.

    Kenton L. Anderson MD Department of Emergency Medicine San Antonio Military Medical Center Fort Sam Houston TX 78234

    E-mail address: [email protected]

    Katherine Y. Jenq MD

    Department of Emergency Medicine

    Pennsylvania Hospital

    J. Matthew Fields MD Department of Emergency Medicine Thomas Jefferson University Hospital

    Nova L. Panebianco MD, MPH

    Anthony J. Dean MD Department of Emergency Medicine Hospital of the University of Pennsylvania

    http://dx.doi.org/10.1016/j.ajem.2013.12.025

    References

    Anderson KL, Jenq KY, Fields JM, Panebianco NL, Dean AJ. Diagnosing heart failure among acutely dyspneic patients with cardiac, inferior vena cava, and lung ultrasonography. Am J Emerg Med 2013;31(8):1208-14.

16. Lien CT, Gillespie ND, Struthers AD, McMurdo ME. Heart failure in frail elderly patients: diagnostic difficulties, co-morbidities, polypharacy and treatment dilemmas. Eur J Heart Fail 2002;4(1):91-8.
17. Jorge S, Becquemin MH, Delerme S, Bennaceur M, Isnard R, Achkar R, et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcome. BMC Cardiovac Disord 2007;7:16.
18. Rihal CS, Davis KB, Kennedy JW, Gersh BJ. The utility of clinical, electrocardio- graphic, and roentgenographic variables in the prediction of left ventricular function. Am J Cardiol 1995;75(4):220-3.
19. Mueller C, Frana B, Rodriguez D, Laule-Kilian K, Perruchoud AP. Emergency diagnosis of congestive heart failure: impact of signs and symptoms. Can J Cardiol 2005;21(11):921-4.
20. Wang Z, Xiong YX. Lung sound patterns help to distinguish congestive heart failure, chronic obstructive pulmonary disease, and asthma exacerbations. Acad Emerg Med 2012;19:79.
21. Kimura BJ, DeMaria AN. Technology insight: hand-carried ultrasound cardiac assessment-evolution, not revolution. Nat Clin Pract Cardiovasc Med 2005;2:217-23.
22. Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002;347(3):161-7.
23. Amico AF, Lichtenberg GS, Reisner SA, Stone CK, Schwartz RG, Meltzer RS. Superiority of visual versus computerized echocardiographic estimation of radionuclide left ventricular ejection fraction. Am Heart J 1989;118(6):1259-65.
24. Mueller X, Stauffer JC, Jaussi A, Goy JJ, Kappenberger L. Subjective visual echocardiographic estimate of left ventricular ejection fraction as an alternative to conventional echocardiographic methods: comparison with contrast angiog- raphy. Clin Cardiol 1991;14(11):898-902.
25. Stamm RB, Carbello BA, Mayers DL, Martin RP. Two-dimensional echocardio- graphic measurement of the left ventricular ejection fraction: prospective analysis of what constitutes an adequate determination. Am Heart J 1982;104(1):136-44.
26. Rich S, Sheikh A, Gallastegui J, Kondos GT, Mason T, Lam W. Determination of left ventricular ejection fraction by visual estimation during real-time two-dimen- sional echocardiography. Am Heart J 1982;104(3):603-6.
27. Shahgaldi K, Gudmundsson P, Manouras A, Brodin LA, Winter R. Visually estimated ejection fraction by two dimensional and triplane echocardiography is closely correlated with quantitative ejection fraction by real-time three dimensional echocardiography. Cardiovasc Ultrasound 2009;7:41-7.
28. American College of Emergency Physicians. Emergency ultrasound guidelines. http://www.acep.org; 2008 . Accessed June 29, 2012.
29. Society for Academic Emergency Medicine. Ultrasound position statement. http:// www.saem.org . Accessed June 29, 2012.
30. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr 2010;23(12):1225-30.
31. Bedetti G, Gargani L, Corbisiero A, Frassi F, Poggianti E, Mottola G. Evaluation of ultrasound lung comets by hand-held echocardiography. Cardiovasc Ultrasound 2006;4:34.
32. Andersen GN, Haugen BO, Graven T, Salvesen O, Mjolstad OC, Dalen H. Feasibility and reliability of point-of-care pocket-sized echocardiography. Eur J Echocardiogr 2011;12(9):665-70.
33. Carr BG, Dean AJ, Everett WW, Ku BS, Mark DG, Okusanya O, et al. Intesnsivist bedside ultrasound (INBU) for Volume assessment in the intensive care unit: a pilot study. J Trauma 2007;63(3):495-500.
34. Stawicki SP, Braslow BM, Panebianco NL, Kirkpatrick JN, Gracias VH, Hayden GE, et al. Intensivist use of hand-carried ultraonogrpahy to measure IVC collapsibility in estimating intravascular volume status: correlations with CVP. J AM Coll Surg 2009;209(1):55-61.
35. Morrison LK, Harrison A, Krishnaswamy P, Ka-zanegra R, Clopton P, Maisel A. Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea. J Am Coll Cardiol 2002;39:202-9.
36. Knudsen CW, Omland T, Clopton P, et al. Diagnostic value of B-type natriuretic peptide and chest radiographic findings in patients with acute dyspnea. Am J Med 2004;116:363-8.
37. 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.
38. Knudsen CW, Riis JS, Finsen AV, et al. Diagnostic value of a rapid test for B-type natriuretic peptide in patients presenting with acute dyspnoe: effect of age and gender. Eur J Heart Fail 2004;6:55-62.
39. 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.
40. 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.
41. 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.
42. 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 under- treated 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, acetamin- ophen 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 face- to-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 AM-

    6 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 108 (53%)

    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 acetamino- phen 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’ accep- tance 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.

    Francois Lecomte MD Stephanie Huet MD

    Department of Emergency Medicine Hopital Cochin-Hotel Dieu, AP-HP. 27 rue du Faubourg Saint-Jacques F-75679 Paris Cedex 14, Universite Paris Descartes, 1 place de l‘Odeon

    F-75005, Paris, France

    Etienne Audureau PhD

    Department of Biostatistics Hopital Cochin-Hotel Dieu, AP-HP. 27 rue du Faubourg Saint-Jacques F-75679 Paris Cedex 14, Universite Paris Descartes, 1 place de l‘Odeon

    F-75005, Paris, France

    Analgesics hide symptoms and impair physician’s diagnosis procedure

    Acetaminophen is inadequate or lack efficiency to treat

    the present pain

    46 (20%)

    39 (19%)

    Valerie Guyerdet RN Jean-Louis Pourriat MD, PhD

    Patient in disfavor to medication intake 18 (9%)

    Patients against acetaminophen delivery by a nurse 0

    Miscellaneous 12 (6%)

    Results are expressed as number (%).

    Department of Emergency Medicine Hopital Cochin-Hotel Dieu, AP-HP. 27 rue du Faubourg Saint-Jacques F-75679 Paris Cedex 14, Universite Paris Descartes, 1 place de l‘Odeon

    F-75005, Paris, France