Last month, I highlighted some of the most impactful, talked-about, or interesting articles published across the spectrum of medical journals from the past year. Here are a few more key studies from 2017. As always, it is impossible to cover every important article or to cover them in the detail they deserve. Let this serve as a jumping-off point into the maelstrom, but I always encourage you to visit the primary source before making changes to your practice.
Prevalence of Pulmonary Embolism Among Patients Hospitalized for Syncope1
This controversial trial, PESIT, approached the issue of the prevalence of pulmonary embolism (PE) in syncope by mandating a D-dimer-based protocol for all patients admitted to the hospital with a diagnosis of syncope. Using their protocol, they found that nearly one in six patients admitted were diagnosed with PE. These data are not generalizable, as it does not appear an adequate emergency department workup for PE was performed initially, and it does not account for the vast cohort of patients with likely benign causes who were discharged rather than admitted. ED discharges were excluded.
Yield of CT Pulmonary Angiography in Emergency Department When Providers Override Evidence-Based Clinical Decision Support2
Perhaps your emergency department has jumped on the bandwagon of decision support for imaging in PE, where alerts pop up decrying your overuse and mandating formal risk stratification or D-dimer testing. This retrospective study looked at the imaging results when clinicians ignored these nagging prompts intended to shepherd them along the approved diagnostic pathway. In the pathway-adherent group, yield of CT pulmonary angiogram for PE was 11.2 percent, while yield in those who went off the rails was only 4.2 percent. While the pathway-adherent results are still unimpressive, the result of ignoring the decision-support is truly dismal and wasteful.
Simplified Diagnostic Management of Suspected Pulmonary Embolism (the YEARS Study): A Prospective, Multicentre, Cohort Study3
Have you ever felt backed into a corner by the test threshold for D-dimer? Some analyses have advocated doubling the cutoff in a low-risk population, and this prospective multicenter trial puts it into practice. Unless patients have hemoptysis, obvious clinical manifestations of extremity venous thromboembolism, or PE as the most likely diagnosis, it is safe to do so. Furthermore, no CT pulmonary angiography examinations were performed without first checking a D-dimer, another practice change from our traditional Wells’-based risk stratification.
Effect of Early Tranexamic Acid Administration on Mortality, Hysterectomy, and Other Morbidities in Women with Post-Partum Haemorrhage (WOMAN): An International, Randomized, Double-Blind, Placebo-Controlled Trial4