Original research
test characteristics on the missing data and created ranges to show the possible range of test characteristics depending on the unobserved data. The strength of this study is the recruitment of a clinically relevant cohort. However, 90% of participants did not undergo CTA and it is possible that there were missed cases of AAS. Many patients who had D-dimer and CT were being primarily investi- gated for pulmonary embolism. Because of a likely higher prev- alence of AAS in this group, the test characteristics of D-dimer may not reflect their performance in the entire cohort. While the CDT variables were collected prospectively where possible, the overall score was determined during analysis. Any definite study of CDT performance would need to apply the CDT at the time of ED clinician decision-making. Previous studies of AAS clinical decision tools have included a very different population to the one we have looked at. All studies previously evaluating the accuracy of ADD-RS for identi- fying AAS have restricted inclusion to those patients undergoing CTA, using CTA as the reference standard. 29–36 We have included everyone presenting with potential AAS symptoms, illustrating the current real-world management of AAS in EDs, the diagnostic difficulty facing ED clinicians and the limitations of methods for selecting patients for CT. Despite the difficulties conducting research in such a difficult environment at a time of the most extreme pressures on the clinical service, 37 we have maximised recruitment and produced a study with maximal generalisability with the ability to shape ED research and improve patient care in this area in future. The best decision aid to facilitate decision to CT and to outperform ED clinician gestalt in AAS is not yet clear. Further research is required in truly undifferentiated ED populations such as these. Author affiliations 1 Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK 2 Acute Care Edinburgh, Usher Institute, University of Edinburgh, Edinburgh, UK 3 Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK 4 Emergency Department, Wexham Park Hospital, Slough, Frimley Health NHS Foundation Trust, UK 5 School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK 6 Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK 7 The University of Edinburgh College of Medicine and Veterinary Medicine, Edinburgh, UK Twitter Matthew J Reed @mattreed73 Acknowledgements Thank you to all the sites and study teams for making this study possible. Study data were collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at the University of Edinburgh. REDCap is a secure, web-based software platform designed to support data capture for research studies, providing (1) an intuitive interface for validated data capture; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for data integration and interoperability with external sources. Collaborators On behalf of the DAShED investigators * (co-applicants, site principal investigators and study teams): DAShED Co-Applicants: Catherine Fowler (The Aortic Dissection CharitableTrust (TADCT)); Ben Loryman (Sheffield Teaching Hospitals NHS FT); Graham Cooper (The Aortic Dissection Charitable Trust (TADCT)); Rob Hirst (Trainee Emergency Research Network (TERN)); Robert Hinchliffe (University of Bristol); Steven Thomas (Sheffield Teaching Hospitals, NHS Foundation Trust). DAShED Site Principal Investigators: Benjamin Clarke (Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK); Edd Carlton (North Bristol NHS Trust); Alasdair Corfield (Royal Alexandra Hospital, NNHS Greater Glasgow and Clyde); David Lowe (Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde); Angelo Giubileo (Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn); Rajendra Raman (Victoria Hospital Kirkcaldy); Oliver McNab (Manchester Royal Infirmary, Wythenshawe Hospital, Manchester University
NHS FT); Amir Guirguis (James Paget University Hospital NHS Foundation Trust); Mark Mitchelson (Raigmore, Inverness); Punithan Annamalai (Harrogate hospital); Deon Louw (John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Horton Hospital, Oxford University Hospitals NHS Foundation Trust); Patrick Aldridge (Frimley Park Hospital, Frimley Health NHS Foundation Trust); Sarah Wilson (Wexham Park Hospital, Frimley Health NHS Foundation Trust); Salini Zaini (Royal Berkshire NHS Foundation Trust); Valentino Oriolo (Bristol Royal Infirmary); Manoj Viegas (Bedfordshire Hospitals NHS Foundation Trust; Luton &Dunstable University Hospital); Steve Goodacre (Sheffield Teaching Hospitals NHS Foundation Trust); Dr Divyansh Gulati (Milton Keynes University Hospital NHS Foundation Trust); Susie Hardwick (Addenbrookes); Mayukhmoy Maiti (Royal Glamorgan Hospital, Cwm Taf Morgannwg University health board); Dr Hamzah Azzam (Hywel Dda University Health Board); Graham Johnson (University hospitals of Derby and Burton NHS Foundation Trust); Larisa Chirila (Kettering General Hospital). DAShED Site Study Teams: Rachel McLatchie, Matt Reed, Nicola Freeman, Alicia Cowan, Benjamin Clarke, Salma Alawiye, Thomas Cox, Joe Sharpe, Harriet Jennings, Rosie Andrews, Lorenzo Zucchelli, Evie Picton, YsabelleThackray, Fiona Allan, Hanmo Zhang, Clare Moceivei, Sam Covins, Alba Garcia-Mendelez, Amina Kaddouri, Thomas Connor, Ellen Voute, Kathryn Greenslade, Adam Stanley, Eilish Murphy, Ciaran Gunn, Harriet Cole (Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK); Ed Carlton, Nicola Maivel, Sanjay Patel, Emma Mullen, Lucy Rivers, James Foley, Nima Maleki, Jessica Hughes, Sophia Reynolds, Sinead Brady, Rosemarie Bird, Harry Quin, Ruth Cockburn, Karthikeyini Suresh (North Bristol NHS Trust, Bristol, UK); Alasdair Corfield, Natalie Rodden, Lynn Abel, Susan Currie, Rachel Keen, Natasha Parker (Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, UK); David Lowe, Elisha Khoo, Kareem Austin, Rhys Worgan, Malcolm Gordon, Mark Wilson, Kayleigh Doran, Ornagh O’Shaughnessy, Lisa Finnen, Courtney Mcarthur (Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, UK); Ayesha Malik, Bhaskar Sarvesh, Fatima Ismail, Jarno Holopainen, Joanna Rudnika, Mohamed Nasr, Oluwaseyi Okewole, Saranya Kathrivel, Wickramanayake Udara, Mohamed Imam, Angelo Giubileo, Tracey Fuller, Hammed Tiamiyu (Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn, Norfolk, UK); Rajendra Raman, Saqib Parwez, Keith Boath, Heather Robertson, Amy McCallum, Kyle McLachlan, Naomi Gunn, Cristina Sifiringa, Claire Stewart, Jennifer Wood, Rhys Greig (Victoria Hospital, Kirkcaldy, Fife, UK); Anila Sukumaran, Charlotte Taylor, Melanie Barker, Richard Clark, Deborah Paripoorani, Rose Jama, Oliver McNab, Agnieszka Rozanska, Melanie Barker, Dr Govind Oliver (Manchester Royal Infirmary and Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK); Amir Guirguis, Dr Magdi Mohammed, Dr Likaa Gabr, Dr Katie Landles, Dr Favour Balogun, Dr Rafiq Abdul,Helen Sutherland, Charlotte Kelly (James Paget University Hospital NHS Foundation Trust, Great Yarmouth, UK); Mark Mitchelson, Emuyemiken Egwuelu, Fiona Barrett (Raigmore, Inverness, UK); Punithan Annamalai, Caroline Bennett, Cheryl McDermott, Joyce Guy (Harrogate Hospital, North Yorkshire, UK); Deon Louw, Alex Novak, Alexis Espinosa, Gianni Tam-McMillan, Antoni Krupa, Tabitha Thorton-Swan, Sophie Roberts, Samuel Mills, Abdala Trinidad Espinosa-Morgado, Sally Beer, Elizabeth Hatton, Georgy Corby, Iris Mae Morse, Lauren Scullion, Ayan Shahid, Jessy Jindal, Aisling Curtis, Jessica Morgan, Joseph Layzell (John Radcliffe, Oxford, UK, Horton Oxford University Hospitals NHS Foundation Trust, UK); Patrick Aldridge, Sana Nadeem, Shalini Ravishankar, Hannily Cooke, Jodie Clarke, Jaskiran Dulai, Sinead Helyar, Myra Dinglasan, Durga Ponnaganti (Frimley Park Hospital, Frimley Health NHS Foundation Trust, UK); Sarah Wilson, Joana Da Rocha, Karen Chivers, Francoise Ticehurst, Louise Gardner, Vani Muthusami, Marie Broyde, Zoe Foster, Nattakarn Limphaibool, Victoria Tay, Shihana Saifudheen, Arane Prabakaran, Shahab Manouchehri, Faluade Akinroye, Rahul Shah, Joseph Mahony, Amrit Gherra, Rob Conway (Wexham Park Hospital, Frimley Health NHS Foundation Trust, UK); Liza Keating, Salini Zaini, Emma Grierson, Shauna Bartley,Nicola Jacques, Giulia Mascia, Francesca Compton, Gabriela Tomkova, Sabi Rai, Kuldeep Nijjar, Edward Neary, Jonathon Lane, Kin Yung Lam, Mohammed Albakoush, Tejas Harit, Silvia Panetta, Mae Gill, Carmen Powell, Erin Robinson, Helen Callard, Hameed Qureshi, Hira Naeem, Laura Hudson, Osama Akrama (Royal Berkshire NHS Foundation Trust, Reading, UK); Emma Redfern, Casandra Bazanlacerot, Rachel Shiel, Christina Coleman, Eva Maria Hernandez Morano, Eleanor Daniel, Kim Wright, Catherine Macleodhall, Denise Webster, Valentino Oriolo, Katie Sweet, Josie Bonnici, Irene Grossi, Carl Robinson, Omar Almousa, Jonathan Benger (Bristol Royal Infirmary, Bristol, UK); Manoj Viegas, Charlotte Whitehouse, Leigh Bissett, Fredrico Miranda, Dinkar Bisht (Bedfordshire Hospitals NHS Foundation Trust; Luton & Dunstable University Hospital, UK); Steve Goodacre, Hannah Walker, Jaden Groves, John Banner, Sayantani Mukhopadhyay, Yasmin Mahmud, Charles Wong, Shamiso Muza, Oliver Salwey (Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK); Divyansh Gulati, Hina Tahir, Santos Oshiotes, Devika Chaudhri, Wuraola Akande (Milton Keynes University Hospital NHS Foundation Trust, UK); Susie Hardwick, Katie Coupe (Addenbrooke’s Hospital, Cambridge, UK); Lisa Roche, Mayukhmoy Maiti, Eleanor James (Royal Glamorgan Hospital, Cwm Taf Morgannwg University Health Board, UK); Hamza Azzam, Janet Phipps, Catherine MacPhee, Michelle Edwards, Hannah Blowing, Samantha Coetzee, Lucy Hill, Jill Williams, Becky Icke, Bethan Landeg, Helen Tench, Heather McGuinness, Tanya Sims, Rebecca Wolf-Roberts, Ronda Loosley, Maddie Moores, Kimberley Walker (Hywel Dda University Health Board, (Withybush, Bronglais, Glagwilli), UK); Elisha Cousins, Graham Johnson, Alison Rockey, Alison
McLatchie R, et al . Emerg Med J 2024; 41 :136–144. doi:10.1136/emermed-2023-213266
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