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

It has been a few years since tranexamic acid first rose to prominence in contemporary medicine following its popularization in bleeding trauma patients. This antifibrinolytic is inexpensive, is readily available, and does not appear to be associated with substantial adverse effects when administered promptly. This trial considered its use in women with postpartum hemorrhage, primarily in low-resource settings in Africa. There is a tiny mortality advantage associated with its use, but it is worth noting most women enrolled were very anemic at baseline and lacked modern supportive medical care.

Idarucizumab for Dabigatran Reversal–Full Cohort Analysis⁵

Good news! The full publication has finally arrived reporting outcomes for the entire planned cohort of patients in a trial reversing dabigatran-related bleeding with idarucizumab. Bad news! Lacking a control arm for comparison, there is minimal clinically useful information, and the sample size is small enough to obscure any reliable safety information. Idarucizumab is still probably clinically useful, but it should likely not be utilized unless all alternative supportive care options have been exhausted.

Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema⁶

Angioedema induced by angiotensin-converting enzyme inhibitor (ACE-I) and other idiopathic upper airway angioedema remains a clinically challenging scenario in the emergency department. Many anecdotal and smaller studies have suggested the bradykinin ß2 receptor antagonist icatibant could expedite symptom resolution. Unfortunately, this larger, multicenter trial failed to find a benefit in routine use.

Accuracy of PECARN, CATCH, and CHALICE Head Injury Decision Rules in Children: A Prospective Cohort Study⁷

Around the world, different pediatric societies utilize different decision instruments to risk-stratify children with minor head injury. This prospective study applied the three major clinically validated rules against one another in a head-to-head comparison. PECARN was found to be the most sensitive, while CHALICE and CATCH reduced imaging to a greater extent. The real winner, however, was routine practice in Australia and New Zealand, where only 10 percent of children underwent CT compared with the 46 percent who would have had a CT if PECARN recommendations had been followed.

Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children with Blunt Torso Trauma: A Randomized Clinical Trial⁸

It’s been known for quite some time the utility of the abdominal focused assessment with sonography for trauma (FAST) is primarily in the unstable patient. This clinical trial evaluated the utility of FAST in children who were clinically stable. As expected, FAST in a stable patient did not change any measured outcomes, and the ultrasound examinations resulted in both substantial false positives and false negatives. Routine ultrasound should not be considered part of the standard clinical approach to the stable pediatric trauma patient.

That’s all we have time for this year. Chances are, next year will similarly provide a steady stream of practice-evolving evidence—and we’ll be back at this again!

References

1. Prandoni P, Lensing AW, Prins MH, et al. Prevalence of pulmonary embolism among patients hospitalized for syncope. N Engl J Med. 2016;375(16):1524-1531.
2. Yan Z, Ip IK, Raja AS, et al. Yield of CT pulmonary angiography in the emergency department when providers override evidence-based clinical decision support. Radiology. 2017;282(3):717-725.
3. van der Hulle T, Cheung WY, Kooij S, et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017;390(10091):289-297.
4. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116.
5. Pollack CV Jr, Reilly PA, van Ryn J, et al. Idarucizumab for dabigatran reversal – full cohort analysis. N Engl J Med. 2017;377(5):431-441.
6. Sinert R, Levy P, Bernstein JA, et al. Randomized trial of icatibant for angiotensin-converting enzyme inhibitor-induced upper airway angioedema. J Allergy Clin Immunol Pract. 2017;5(5):1402-1409.e3.
7. Babl FE, Borland ML, Phillips N, et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet. 2017;389(10087):2393-2402.
8. Holmes JF, Kelley KM, Wootton-Gorges SL, et al. Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: a randomized clinical trial. JAMA. 2017;317(22):2290-2296.