the relationship with the extension and severe coronary lesions in patients with only NSTEMI is not well established [1-4]. We sought to explore the relation between BNP levels and extension of coronary artery disease (CAD) and the presence of more complex and severe coronary lesions in patients with NSTEMI. In an observational study, we included 70 patients admitted with NSTEMI. B-type natriuretic peptide was performed at a median time of 3 hours after admission and analyzed. We considered a positive BNP when it was more than 500 pg/mL. Angiograms were read, and complex coronary lesion was defined as the presence of at least 1 of the following: coronary lesion more than 90%, coronary lesion more than 50% in the left main coronary artery, 2 or more vessels affected with lesion more than 70%, the presence of thrombus, thrombolysis in myocardial infarction flow less than 2, or ulcerated plaque. The levels of BNP were directly related to the extent of the CAD. Patients with complex coronary lesions had higher levels of BNP compared with those without complex coronary lesions. After adjusting for clinical and electrocardiographic variables, positive BNP (odds ratio, 1.95; 95% confidence interval, 1.75-2.9; P b .01) independently contributed to the prediction of complex coronary lesions. We conclude that, in patients with NSTEMI, BNP levels have a relationship with the severity of CAD. Increased levels of BNP independently predict the presence of more complex coronary lesions in this population. Pablo Elissamburu MD Nicolas Lalor MD Leandro Rodriguez MD Diego Conde MD Cardiology Division Instituto Cardiovascular de Buenos Buenos Aires, Argentina Cardiology Division Sanatorio Anchorena Buenos Aires, Argentina E-mail address: drconde@hotmail.com http://dx.doi.org/10.1016/j.ajem.2013.11.006 References [1] Conde D, Elissamburu P, Lalor N, et al. B-type natriuretic peptide predicts complexity and severity of the coronary lesions in patients with acute coronary syndromes. Am J Emerg Med 2013;31(8):1282. [2] Conde D, Elissamburu P, Lalor N, et al. B-type natriuretic peptide and infarct size in non–ST-elevation myocardial infarction. Am J Emerg Med 2013;31(11):1618. [3] Elissamburu P, Conde D, Lalor N, et al. B-type natriuretic peptide and infarct size in ST-elevation myocardial infarction. Am J Emerg Med 2013;31(11):1619. [4] Conde D, Lalor N, Rodriguez L, Elissamburu P. B-type natriuretic peptide predicts complexity and severity of the coronary lesions in patients with ST-segment elevation myocardial infarction. Am J Emerg Med 2013, http://dx.doi.org/10.1016/j. ajem.2013.09.035. [in press]. Competence assessment of pre-elementary school teachers before and after a pediatric basic life support course for lay rescuers To the Editor, As in most families, both parents work; nowadays, children spend a large amount of time in a school environment from early childhood. Critical events sufficient to endanger the child's life can occur at any time and can be related to accidental trauma [1,2] or less frequently to unknown preexisting health conditions, intentional violence, and accidental swallowing of toxic substances or foreign objects [3]. Several studies document that the average school teacher has little knowledge of first-aid principles. As in all instances of cardiac arrest from whichever initial event, prompt and skillful maneuvers of cardiopulmonary resuscitation (CPR) are crucial to survival, the Italian Society of Pediatric Emergency Medicine (SIMEUP), in conjunction with the Italian Pediatric Society and the Municipality of Rome, developed a pilot project named “Safe preschool project” to assess the knowledge of CPR by preschool teachers (for children from 3 to 5 years) and investigate ways of improvement. The aim is to train nearly 6000 preschool teachers of the municipality of Rome. In the present study, after assessing the average baseline knowledge of pediatric CPR possessed by preschool teachers, we tested how a pediatric basic life support (BLS) training course by SIMEUP (according to the ILCOR 2010 guidelines) for lay rescuers improves the competence and the skills of the participants. A random sample of 766 teachers was enrolled. Before starting the BLS course, all participants undertook the 45-minute SIMEUP 24-item multiple choice test for pediatric BLS for lay rescuers (passing score, 75% correct answers). The training took nearly 4 hours. At completion, the same multiple choice test was administered, and all trainees performed a CPR test on a pediatric manikin supervised by 2 pediatric BLS instructors (SIMEUP skill test for lay rescue). Primary goal was to emphasize how many school teachers pass the written test before and after the training course and how many trainees could perform a correct pediatric BLS sequence after training. Secondary goal was to highlight if sex and age class (A1, 20-29; A2, 30-39; A3, 40-49; A4, 50-59; A5, ≥60 years) influence the ability to give correct answers to the items of the written test and to perform properly the practical skills of pediatric CPR. Of the 766 preschool teachers, 37 were males, and 729, females. Mean age was 45.78 ± 8.87 years. Only 5 (0.65%) held a pediatric BLS certification. The written test was passed by 8 (1.04%) of 766 before the training course and by 392 (51.17%) of 766 after (P b .0001); consistently, the mean number of correct answers increased from 39.97 ± 13.92 to 71.73 ± 17.39 (P b .001) (Table 1). Sex and/or age had no bearing on the ability to retain the contents of the course (Table 2). Five hundred sixteen participants (67.33%) performed well in the practical pediatric CPR test. In addition, in the CPR test, sex is not a significant independent variable (67% females and 64% males passed the practical skill test). On the contrary, age has a significant impact, and teachers older than 50 years fare much better (Fig.). The first outcome of the study is the demonstration of an extremely inadequate knowledge of pediatric BLS by the average preschool teachers in the municipality of Rome. Other authors found high school teachers lacking sufficient knowledge of the basic principles of first aid, BLS, and use of a defibrillator [4,5]. Similar findings were described among primary school teachers [6,7]. Mpotos et al [8] tested 4273 school teachers and found that 69% felt inadequate to perform CPR correctly and 73%, being aware of their inadequacy, felt the need of specific training. Several scientific societies, highlighting this severe deficiency, have stressed the importance to train adequately the school personnel to cope with the emergencies [2,9]. The second outcome of the study is that a pediatric BLS training course improves significantly the knowledge of pediatric CPR, even if not all participants reached the cutoff necessary to obtain the Certificate of Pediatric BLS provider for lay rescuers. In our present experience, sex does not influence the acquisition of theoretic knowledge and practical skills, whereas age appears to have a significant impact on mastering the pediatric BLS practical skills. This is in contrast with other studies reporting that the attitude to first aid decreases with age [6]. 187 Correspondence / American Journal of Emergency Medicine 32 (2014) 178–189