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Journal update monthly top five
  1. Mohammed Hamza1,
  2. Bassey Ndoma-Egba1,
  3. David Herlihy1,
  4. Henrietta Sabbagha1,
  5. Raja Shahid Ali1,
  6. Rory O'Brien1,
  7. Conor Deasy1,
  8. Gabrielle Prager2
  1. 1 Emergency Department, Cork University Hospital, Cork, Ireland
  2. 2 Emergency Department, Royal Manchester Children's Hospital, Manchester, UK
  1. Correspondence to Dr Mohammed Hamza, Emergency Department, Cork University Hospital, Cork, Ireland; mohammed.hamza{at}

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This month’s update is by the Emergency Innovation Research Network. We used a multimodal search strategy, drawing on free open-access medical education resources and literature searches. We identified the five most interesting and relevant papers (decided by consensus) and highlight the main findings, key limitations and clinical bottom line for each paper.

The papers are ranked as:

  • Worth a peek—interesting, but not yet ready for prime time.

  • Head turner—new concepts.

  • Game changer—this paper could/should change practice.

Effect of a diagnostic strategy ussing an elevated and age-adjusted D-dimer threshold on thromboembolic events in Emergency Department patients with suspected pulmonary embolism: A randomized clinical trial by Freund et al

Topic: pulmonary embolism

Rating: head turner

Pulmonary embolism rule-out criteria combined with Wells’ criteria is the cornerstone of pathways to reduce low-yield imaging in patients with suspected pulmonary embolism (PE).

This is a cluster randomised, cross-over, non-inferiority trial where PE was excluded without imaging in the intervention period in patients with no YEARS criteria and a D-dimer <1000 ng/mL, whereas in the control period, PE was excluded with a D-dimer less than the age-adjusted threshold. A total of 1414 patients with a suspected PE who attended 18 EDs in Spain and France over 1 year were included. EDs were randomised to control or intervention for 4 months, after a 2-month washout, this was reversed.

The primary endpoint was missed venous thromboembolism (VTE) at 3 months. VTE was rare, diagnosed in one versus five patients in the intervention and control groups, respectively, the difference not statistically significant (failure rate 0.15% (95% CI 0.0% to 0.86%) vs 0.80% (95% CI 0.26% to 1.86%)). Of the secondary outcomes, statistically significant differences were seen in chest imaging and ED median length of stay.

Limitations include possible clinical differences between groups as patients were randomised by centre, and possible selection bias due to clinician recruitment. A small number of patients were missing primary outcome information or had protocol deviations.1

Bottom line

A strategy using the YEARS criteria and a higher D-dimer …

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  • Twitter @MoHamza89

  • Contributors Format devised and provided by Charles Reynard, Anisa Jafar, Daniel Darbyshire, Govind Oliver, GP and Simon Carley. MH reviewed the included studies and wrote the manuscript with help from BN-E, DH, HS and RSA. CD, RO’B, GP, Daniel Darbyshire and Ellen Weber provided critical feedback and suggested edits to the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; internally peer reviewed.