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Resume Cette mise au point cherche a apporter une aide aux praticiens en charge de la gestion de la maladie thromboembolique veineuse (MTEV), en insistant sur les specificites propres a la thrombose veineuse en medecine. Elle concerne l’etat actuel des connaissances : epidemiologie, facteurs de risque, prophylaxie, prise en charge diagnostique, therapeutique et perspectives et s’appuie sur la recente parution de la huitieme edition des recommandations du groupe d’experts de l’American College of the Chest Physicians (ACCP). Les scores de probabilite clinique, le dosage des D-dimeres, l’imagerie en particulier par echographie et echographie-doppler sont reunis dans des algorithmes decisionnels qui permettent de securiser et d’uniformiser les prises en charge diagnostiques. Les principales indications des traitements preventifs et les principales recommandations de l’ACCP concernant les traitements curatifs sont abordees. Sont evoquees les perspectives concernant les nouveaux antithrombotiques et les etudes en cours, avec leurs objectifs : amelioration de la prophylaxie en medecine, traitement des thromboses distales et des thromboses superficielles, validation d’une formation acceleree a une echographie limitee a deux points, en vue de proposer de nouveaux algorithmes diagnostiques.

Resume Theme Mettre en œuvre une formation courte des urgentistes au flash-echo-deux-points (FEDP) [pli inguinal et pli poplite], qui pourrait dans l'avenir s'integrer dans une strategie d'attente pour securiser une prise en charge au domicile des suspicions de thrombose veineuse en attendant leur documentation par un echo-doppler veineux complet. Objectifs Valider la formation proposee par une etude de concordance entre operateurs (urgentiste en formation et medecin vasculaire), en multicentrique, sur 60 urgentistes, et etablir la courbe d'apprentissage. Methodologie Formation theorique : deux pages de schemas et consultation d'une banque d'images sur le Web. Formation pratique : 25 patients en tout dont les 15 derniers comme operateur independant, avec redaction d'un compte rendu standardise. Concordance interoperateurs : (a) centralisation, saisie, et analyse independante des comptes rendus standardises de l'urgentiste et du medecin vasculaire, accouples par patient, du 11e au 25e ; (b) calcul des coefficients de concordance, kappa, et construction de la courbe d'apprentissage (900 points de concordance pour 60 urgentistes). Criteres d'inclusion (a) thrombose traitee, distale ou proximale (conserve l'aveugle sur le resultat du FEDP) recrutee par le medecin vasculaire ; (b) accord oral du patient. Resultats attendus Inflechissement de la courbe d'apprentissage autour du 20e patient avec un kappa superieur a 0,61 voire a 0,80. Apport original du projet (a) Etude prospective, multicentrique, en aveugle : (i) confirmant la faisabilite de l'echographie veineuse deux points, par les urgentistes ; (ii) validant le contenu et la duree d'une formation courte et simplifiee ; (b) Validation d'un critere de retour au domicile ; (b) si validee, formation-type applicable a d'autres disciplines (reanimation, geriatrie).

International audience; Background:If the prevalence of pulmonary embolism (PE) differs significantly between the US and Europe, this observation could reduce the generalizability of diagnostic protocols for PE derived in either location.Objective:To determine possible causes and potential clinical consequences of these PE prevalence differences.Methods:Secondary analysis of three prospectively collected multicenter samples (two French and one from the US) including 3174 European and 7940 American PE-suspected patients in Emergency departments (ED) (117 for Europe and 12 for US). Comparison of clinical features, resource use and outcomes of European- and US-suspected PE populations in ED.Results:European patients evaluated for PE were significantly older and had a higher clinical pretest probability (CPP) for PE. The final PE prevalence was significantly higher in Europe, in the overall sample (26.5% vs. 7.6%) and in each level of CPP. Suspected European patients categorized as low CPP had a higher posttest probability than US low CPP patients. Suspected US patients categorized as high CPP had a much lower posttest probability of PE than in Europe. The mean number of tests performed for one PE diagnosis was lower in Europe (7.4 vs. 21.6). Among patients diagnosed with PE, European patients had a higher mean severity of illness score and a higher PE-mortality rate (3.4% vs. 0.7%).Conclusions:Among patients suspected of a PE and those ultimately diagnosed with a PE, European patients had higher acuity, a higher pretest probability and worse outcome than US patients. The present study underscores the importance of disease prevalence for pretest probability scoring approaches and for significance interpretation of imaging tests.

International audience; Background: Testing for pulmonary embolism often differs from that recommended by evidence-based guidelines.Objective: To assess the effectiveness of a handheld clinical decision-support system to improve the diagnostic work-up of suspected pulmonary embolism among patients in the emergency department. Design: Cluster randomized trial. Assignment was by random-number table, providers were not blinded, and outcome assessment was automated. (ClinicalTrials.gov registration number: NCT00188032) Setting: 20 emergency departments in France. Patients: 1103 and 1768 consecutive outpatients with suspected pulmonary embolism. Intervention: After a preintervention period involving 20 centers and 1103 patients, in which providers grew accustomed to inputting clinical data into handheld devices and investigators assessed baseline testing, emergency departments were randomly assigned to activation of a decision-support system on the devices (10 centers, 753 patients) or posters and pocket cards that showed validated diagnostic strategies (10 centers, 1015 patients). Measurements: Appropriateness of diagnostic work-up, defined as any sequence of tests that yielded a posttest probability less than 5% or greater than 85% (primary outcome) or as strict adherence to guideline recommendations (secondary outcome); number of tests per patient (secondary outcome). Results: The proportion of patients who received appropriate diagnostic work-ups was greater during the trial than in the preintervention period in both groups, but the increase was greater in the computer-based guidelines group (adjusted mean difference in increase, 19.3 percentage points favoring computer-based guidelines [95% CI, 2.9 to 35.6 percentage points]; PÂ= 0.023). Among patients with appropriate work-ups, those in the computer-based guidelines group received slightly fewer tests than did patients in the paper guidelines group (mean tests per patient, 1.76 [SD, 0.98] vs. 2.25 [SD, 1.04]; PÂ< 0.001). Limitation: The study was not designed to show a difference in the clinical outcomes of patients during follow-up. Conclusion: A handheld decision-support system improved diagnostic decision making for patients with suspected pulmonary embolism in the emergency department.Primary Funding Source: French National Hospital Clinical Research Project.

BACKGROUND: The development of a short training program for emergency care physicians for rapid ultrasound assessment of two points (the groin and popliteal areas) could be useful for later implementation of a safe home care strategy for patients with suspected deep vein thrombosis before the results of a complete duplex-Doppler exploration are available. PURPOSE: Validation of the proposed training program by studying inter-operator agreement (trainee versus vascular physician) in a multicentric assessment of 60 emergency care physicians. Establish the learning curve. METHODOLOGY: Theoretical training: two-page document with schematic drawings and consultation of image bank on the Web. Practical training: 25 patients in all, the last 15 as an independent operator, writing a standardized report. Interoperator agreement: (a) centralized data collection and independent analysis of the report written by the trainee and a vascular physician for the same patients (n(o) 11 to 25); (b) determination of the coefficient of variance, kappa, and construction of the learning curve (900 agreement points for 60 trainees). INCLUSION CRITERIA: (a) Treated distal or proximal thrombosis recruited by the vascular physician (blinded to the result of the flash US); patient's oral consent. EXPECTED RESULTS: Learning curve leveling off at about the 20th patient with a kappa>0.61 or even 0.80. ORIGINAL CONTRIBUTION OF THE PROJECT: (a) Prospective, multicentric, blinded study: (i) confirming the feasibility of a two-point venous ultrasound performed by emergency care physicians; (ii) validation of the contents and duration of a short simplified training program; (b) Validation of a decision criterion for home care; If validated, this type of training program might be applied in other disciplines (intensive care, geriatrics).

Background Suspected pulmonary embolism (PE) is a frequent, complex and harmful situation. In a cohort study conducted in 117 emergency departments, we observed that diagnostic management was inappropriate according to international guidelines in the majority of the patients. The risk for thromboembolism during follow-up in patients left untreated (ie, false negative risk) was sixfold higher in these patients than in those who received appropriate management. Of note, proper management was found to be hampered in institutions that lacked a written diagnostic algorithm.1 We initiated the SPEED program with the aim of improving diagnostic decision making for PE. Because paper guidelines dissemination has generally little effect, we thought to use a computerised clinical decision support system (CDSS). The SPEED program CDSS development We developed a CDSS software for handheld computers named SPEED. It is based on Bayesian principles and a dynamic calculation of PE probability. Using clinical probability estimation and the likelihood ratios of the diagnostic tests, SPEED guides diagnostic decision making step by step until the risk of error is low enough to rule-out or to rule-in PE with confidence.2 CDSS assessment We assessed its effectiveness in a cluster-randomised trial involving 20 emergency departments provided with handheld computers. After a preintervention period with baseline testing assessment, the centers were randomly assigned to activation of the CDSS on the devices or posters and pocket cards that showed validated diagnostic strategies. Results A greater proportion of patients in both groups received appropriate diagnostic testing during the intervention period than in the preintervention period; however, the increase was of significantly greater in the CDSS group (+30.2% vs +10.9%, p=0.023). Patients had fewer tests in the CDSS group than in the paper guidelines group to achieve appropriate work-up. During intervention period, the frequency of venous thromboembolic events in patients who were untreated because of a negative initial work-up was low in the two groups (1% vs 1.5%) but notably lower than in the observational study performed 2.5 years earlier (4.7%).13 Discussion Distributing guidelines for diagnosing PE and especially using a CDSS on handheld devices improves diagnostic decision-making in emergency departments. Moreover, our results suggest a clinical impact of the quality improvement with less thromboembolic events during follow-up. The CDSS SPEED is now distributed free of charge on www.thrombus.fr. Versions for other devices are under construction. A continual impact assessment in routine clinical practice is planned for French users. Contexte La suspicion d9embolie pulmonaire (EP) est une situation frequente, complexe et potentiellement grave. Dans une etude observationnelle conduite dans 117 services d9urgence, nous avons constate que la demarche diagnostique lors d9une suspicion d9EP etait non conforme aux recommandations internationales environ une fois sur 2. Chez les patients pour lesquels l9hypothese d9une EP n’etait pas retenue, le risque de survenue d9un evenement thromboembolique dans les 3 mois (ie, risque de faux negatifs), etait 6 fois plus important lorsque la demarche etait non conforme que lorsqu9elle etait conforme.1 Ces constations et le fait que les demarches diagnostiques etaient plus souvent conformes dans les centres ayant un protocole operationnel, nous ont conduit a mettre en place le programme SPEED avec pour but d9ameliorer les pratiques diagnostiques par une aide informatisee a la decision. Le programme SPEED Elaboration de l9outil d9aide a la decision Nous avons elabore un logiciel d9aide a la decision fonctionnant sur ordinateurs de poche et s9appuyant sur une mesure dynamique de la probabilite diagnostique a partir de la probabilite clinique et des rapports de vraisemblance des tests selon les principes de Bayes.2 SPEED guide le clinicien pas a pas afin qu9il determine la probabilite clinique et choisisse le test ou les tests appropries jusqu’a ce que le risque d9erreur soit suffisamment faible pour qu9il puisse prendre une decision fiable. Evaluation de l9outil d9aide a la decision Nous avons evalue l9interet du logiciel SPEED par comparaison a des recommandations ecrites dans le cadre d9une etude prospective randomisee par centre. Vingt services d9urgences ont recus des ordinateurs de poches pour consigner les demarches realisees chez les patients suspects d9EP. Apres une phase d’evaluation passive, ils ont ete randomises en 2 groupes : aide informatisee a la decision sur les ordinateurs de poches ou recommandations ecrites sur affiches et fiches de poche. Resultats Les deux interventions ont entraine une augmentation significative du taux de demarches appropriees par comparaison a la periode d’evaluation passive. Cependant, l9augmentation a ete significativement plus importante avec l9aide informatisee qu9avec les recommandations ecrites (+30.2% vs +10,9% ; p=0.023). Moins de tests diagnostiques ont ete realises pour obtenir une decision appropriee avec le logiciel SPEED qu9avec les recommandations ecrites (1.76 vs 2.25; p Discussion et perspectives Nos resultats demontrent l9efficacite de la diffusion de recommandations et particulierement de l9aide informatisee a la decision sur la qualite des pratiques diagnostiques lors des suspicions d9EP aux urgences et suggere un impact clinique par une moindre frequence des accidents thomboemboliques dans le suivi. Le logiciel SPEED est distribue gratuitement sur le site www.thrombus.fr. Des evolutions sont prevues afin qu9il puisse fonctionner quelque soit le support informatique et en differentes langues. Une evaluation continue de son impact en pratique quotidienne est envisagee dans le cadre d9un groupe d9utilisateurs realisant une evaluation des pratiques professionnelles.

Background Little is known about the relation of adverse drug reactions (ADRs) to self-use of medications. Objective The aim of this study was to determine the frequency and severity of ADRs related to self-medication (ADR-SM) among emergency department (ED) patients and to describe their main characteristics. Methods A prospective, cross-sectional, observational study was conducted over a period of 8 weeks (1 March to 20 April 2010), in the ED of 11 French academic hospitals. Adult patients presenting to the ED during randomization periods were included, with the exception of cases of self-drug poisoning, inability to complete self-medication questionnaire, or refusal. Clinical outcomes were assessed as well as history of self-medication behaviours and all drugs taken. All doubtful files and those related to ADR-SM were systematically reviewed by an expert committee. Results A total of 3,027 of 4,661 patients presenting to the ED met the inclusion criteria. Of these, 84.4 % declared a self-medication behaviour, 63.7 % took at least one non-prescribed drug during the previous 2 weeks and 59.9 % took a prescribed medication. A total of 296 patients experienced an ADR (9.78 %), of which 52 (1.72 %) were related to self-medication. Those ADRs related to self-medication included prescribed drugs (n = 19), non-prescribed drugs (n = 17), treatment discontinuation (n = 14), and interactions between non-prescribed and prescribed drugs (n = 2). The ADRs attributed to non-prescribed drugs represented 1 % of all patients taking non-prescribed drugs (n = 1,927). ADR severity was significantly lower for those related to self-medication (p = .032). Conclusion Self-medication is frequent; its potential toxicity should not be neglected, taking into account the rate of adverse drug reactions in about 1 % of ED patient. Electronic supplementary material The online version of this article (doi:10.1007/s40264-013-0114-y) contains supplementary material, which is available to authorized users.