D-Dimer Use and Pulmonary Embolism Diagnosis in Emergency Units: Why Is There Such a Difference in Pulmonary Embolism Prevalence between the United States of America and Countries Outside USA?

<div><p>Objective</p><p>Although diagnostic guidelines are similar, there is a huge difference in pulmonary embolism (PE) prevalence between the <b>United States of America</b> (US) and countries outside the USA (OUS) in the emergency care setting. In this study, we prospectively analyze patients’ characteristics and differences in clinical care that may influence PE prevalence in different countries.</p><p>Methods</p><p>An international multicenter prospective diagnostic study was conducted in a standard-of-care setting. Consecutive outpatients presenting to the emergency unit and suspected for PE were managed using the Wells score, STA-Liatest^® D-Dimers and imaging.</p><p>Results</p><p>The prevalence of PE in the study was 7.9% in low and moderate risk patients. Among the 1060 patients with low or moderate pre-test probability (PTP), PE prevalence was four times higher in OUS (10.7%) than in the US (2.5%) (P < 0.0001). The mean number of imaging procedures performed for one new PE diagnosis was 3.3 in OUS vs 17 in the US (P < 0.001). Stopping investigation in the case of negative D-dimers (DD combined) with low/moderate PTP was more frequent in OUS (92.7%) than in the US (75.7%) (P < 0.01). Moreover, the use of imaging was much higher in the US (44.4% vs 19.2% in OUS) in the case of moderate PTP combined with negative DD.</p><p>Conclusion</p><p>Differences between US and OUS PE prevalence in emergency setting might be explained by differences in patients' characteristics and mostly in care patterns. US physicians performed computed tomographic pulmonary angiography more often than in Europe in cases of low/moderate PTP combined with negative DD.</p><p>Trial Registration</p><p>ClinicalTrials.gov <a href="https://clinicaltrials.gov/ct2/show/NCT01221805" target="_blank">NCT01221805</a></p></div

Performance of computed tomographic pulmonary angiography regarding pre test clinical probability combined with negative DDimers.

<p>Performance of computed tomographic pulmonary angiography regarding pre test clinical probability combined with negative DDimers.</p

PE Prevalence and negative DD including/excluding Canadian site from US/OUS.

<p>PE Prevalence and negative DD including/excluding Canadian site from US/OUS.</p

Distribution of population and PE prevalence according to Wells Score.

<p>Distribution of population and PE prevalence according to Wells Score.</p

Use of imaging tests in cases of low/moderate PTP combined with positive DD (Panel A) or negative DD (Panel B).

<p>US, US patients; OUS, outside US patients; PE, pulmonary embolism; Low, low PTP; Mod, moderate PTP.</p

Rate of PE (%) according to age.

<p>X axis was age divided into subgroups of 5 years. Y axis was rate of PE (%). US patients are depicted in grey; OUS patients are depicted in black. P < 0.0001 for comparing the overall differences between US versus OUS.</p

Main characteristics of the patients.

<p>Main characteristics of the patients.</p

Distribution in age of the DIET population.

<p>X axis was age (divided into subgroups of 5 years). Y axis was percentage of population for each category of age. US patients are depicted in grey; OUS patients are depicted in black. P < 0.0001 for comparing the overall differences between US versus OUS.</p

Table_1_Virtual-reality-enhanced mannequin to train emergency physicians to examine dizzy patients using the HINTS method.docx

IntroductionAcute vertigo is a frequent chief complaint in the emergency departments, and its efficient management requires thorough training. The HINTS protocol is a valid method to screen patients in the emergency room, but its application in routine is hindered by the lack of training. This study aimed to evaluate the training of emergency physicians for the HINTS method based on a mannequin-based virtual reality simulator (MBVRS).MethodsWe conducted a monocenter, prospective, longitudinal, and randomized cohort study in an Emergency Department at a regional university hospital. We included 34 emergency physicians randomized into two equal groups matched by age and professional experience. The control group attended a theoretical lesson with video demonstrations and the test group received a simulation-based training in addition to the lecture.ResultsWe showed that the test group had a higher diagnosis performance for the HINTS method compared to the control group as evaluated by the simulator at 1 month (89% sensitivity versus 45, and 100% specificity versus 86% respectively, p DiscussionThe MBVRS is a useful pedagogic tool for the HINTS protocol in the emergency department. The advantage of a unique training session can be measured up to 6 months after the lesson.</p

Data_Sheet_1_Virtual-reality-enhanced mannequin to train emergency physicians to examine dizzy patients using the HINTS method.docx

IntroductionAcute vertigo is a frequent chief complaint in the emergency departments, and its efficient management requires thorough training. The HINTS protocol is a valid method to screen patients in the emergency room, but its application in routine is hindered by the lack of training. This study aimed to evaluate the training of emergency physicians for the HINTS method based on a mannequin-based virtual reality simulator (MBVRS).MethodsWe conducted a monocenter, prospective, longitudinal, and randomized cohort study in an Emergency Department at a regional university hospital. We included 34 emergency physicians randomized into two equal groups matched by age and professional experience. The control group attended a theoretical lesson with video demonstrations and the test group received a simulation-based training in addition to the lecture.ResultsWe showed that the test group had a higher diagnosis performance for the HINTS method compared to the control group as evaluated by the simulator at 1 month (89% sensitivity versus 45, and 100% specificity versus 86% respectively, p DiscussionThe MBVRS is a useful pedagogic tool for the HINTS protocol in the emergency department. The advantage of a unique training session can be measured up to 6 months after the lesson.</p