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Moreno-Ballesteros A, Rebollo-Aguirre ÁC, Bolívar-Roldán I, Busquier T, Sanchez-de Mora E, Jimenez-Heffernan A. Assessment of pulmonary embolism related to active SARS-CoV-2 infection in pregnant women. Rev Esp Med Nucl Imagen Mol 2023; 42:218-222. [PMID: 36758829 PMCID: PMC9904850 DOI: 10.1016/j.remnie.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/20/2022] [Indexed: 02/09/2023]
Abstract
AIM To analyze a sample of pregnant patients who underwent pulmonary perfusion scintigraphy to rule out suspicion of pulmonary embolism (PE) during the acute COVID-19 infection hospitalization period in our hospital. MATERIAL AND METHODS SPECT scintigraphy with a reduced dose (111MBq) of 99mTc-macroaggregated albumin was performed in all the patients (n=5). The images obtained were interpreted by comparing the findings with the radiological images according to the PISAPED criteria. RESULTS Only one of the 5 patients was diagnosed with PE. Two patients showed pathological scintigraphy findings attributable to radiological alterations due to COVID-19 pneumonia, and the other two had normal pulmonary perfusion. CONCLUSION Given the non-specific features of the clinical manifestations and d-dimer values in COVID-19, as well as their similarity to those of PE, pulmonary perfusion scintigraphy plays a crucial role in the screening of PE in these patients due to its high sensitivity and lower irradiation compared to CT. Despite the limited number of patients, the results obtained have special relevance due to the absence of scientific publications in this group of patients within the exceptional context of the COVID-19 pandemic.
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Affiliation(s)
- A Moreno-Ballesteros
- Unidad de Medicina Nuclear, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain.
| | - Á C Rebollo-Aguirre
- Unidad de Medicina Nuclear, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
| | - I Bolívar-Roldán
- Unidad de Medicina Nuclear, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - T Busquier
- Unidad de Radiodiagnóstico, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - E Sanchez-de Mora
- Unidad de Medicina Nuclear, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
| | - A Jimenez-Heffernan
- Unidad de Medicina Nuclear, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
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Moreno-Ballesteros A, Rebollo-Aguirre ÁC, Bolívar-Roldán I, Busquier T, Mora ESD, Jimenez-Heffernan A. [Assessment of pulmonary embolism related to active SARS-CoV-2 infection in pregnant women.]. Rev Esp Med Nucl Imagen Mol 2022; 42:S2253-654X(22)00188-3. [PMID: 36533162 PMCID: PMC9742206 DOI: 10.1016/j.remn.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/20/2022] [Indexed: 12/14/2022]
Abstract
AIM To analyze the sample of pregnant patients who underwent pulmonary perfusion scintigraphy to rule out the pulmonary embolism (PE) suspicion during the acute COVID-19 infection hospitalization period in our hospital. MATERIAL AND METHODS SPECT scintigraphy with a reduced dose (111 MBq) of 99mTc-macroaggregated albumin was performed in all of the patients (n=5). The obtained images were interpreted by comparing the findings with the radiological images according to the PISAPED criteria. RESULTS Only one of the 5 patients was diagnosed with PE. Two patients obtained pathological findings of the scintigraphy attributable to radiological alterations due to COVID-19 pneumonia, and the other two had normal pulmonary perfussion. CONCLUSION Given the non-specific features of the clinical manifestations and D-dimer values in COVID-19, as well as their similarity to those of PE, the pulmonary perfusion scintigraphy plays a crucial role in the screening of PE in these patients due to its high sensitivity and lower irradiation compared to CT. Despite the limited number of patients, the results obtained have special relevance related to the absence of scientific publications on this group of patients within the context of COVID-19 pandemic exceptional situation.
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Affiliation(s)
- Ana Moreno-Ballesteros
- Unidad de Medicina Nuclear. Hospital Universitario Juan Ramón Jiménez. Ronda Norte, s/n, 21005, Huelva, España
| | - Ángel C Rebollo-Aguirre
- Unidad de Medicina Nuclear. Hospital Universitario Juan Ramón Jiménez. Ronda Norte, s/n, 21005, Huelva, España
| | - Isabel Bolívar-Roldán
- Unidad de Medicina Nuclear. Hospital Universitario Virgen Macarena. Avenida Dr Fedriani nº3, 41009, Sevilla, España
| | - Teresa Busquier
- Unidad de Radiodiagnóstico. Hospital Universitario Virgen Macarena. Avenida Dr Fedriani nº3, 41009, Sevilla, España
| | - Elena Sanchez-de Mora
- Unidad de Medicina Nuclear. Hospital Universitario Juan Ramón Jiménez. Ronda Norte, s/n, 21005, Huelva, España
| | - Amelia Jimenez-Heffernan
- Unidad de Medicina Nuclear. Hospital Universitario Juan Ramón Jiménez. Ronda Norte, s/n, 21005, Huelva, España
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Abstract
One of the major effects of the COVID-19 pandemic within nuclear medicine was to halt performance of lung ventilation studies, due to concern regarding spread of contaminated secretions into the ambient air. A number of variant protocols for performing lung scintigraphy emerged in the medical literature which minimized or eliminated the ventilation component, due to the persistent need to provide this critical diagnostic service without compromising the safety of staff and patients. We have summarized and reviewed these protocols, many of which are based on concepts developed earlier in the history of lung scintigraphy. It is possible that some of these interim remedies may gain traction and earn a more permanent place in the ongoing practice of nuclear medicine.
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Affiliation(s)
- Lionel S. Zuckier
- Address reprint requests to Lionel S. Zuckier, Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, Bronx, NY 10467
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Zuckier LS. To everything there is a season: taxonomy of approaches to the performance of lung scintigraphy in the era of COVID-19. Eur J Nucl Med Mol Imaging 2021; 48:666-669. [PMID: 33159223 PMCID: PMC7647190 DOI: 10.1007/s00259-020-05100-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Lionel S Zuckier
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center and the Albert Einstein College of Medicine, 1695A Eastchester Road, Bronx, NY, 10461, USA.
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Das JP, Yeh R, Schöder H. Clinical utility of perfusion (Q)-single-photon emission computed tomography (SPECT)/CT for diagnosing pulmonary embolus (PE) in COVID-19 patients with a moderate to high pre-test probability of PE. Eur J Nucl Med Mol Imaging 2020; 48:794-799. [PMID: 32959115 PMCID: PMC7505736 DOI: 10.1007/s00259-020-05043-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/14/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE We reviewed the clinical utility of perfusion (Q)-single-photon emission computed tomography (SPECT)/CT for diagnosing pulmonary embolus (PE) in patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). METHODS Following the World Health Organization's declaration of a global pandemic, our department policy recommended Q-only SPECT/CT for all patients undergoing nuclear medicine evaluation for suspected PE to reduce the risk of aerosolization of respiratory droplets. We performed a retrospective review of sequential patients admitted with COVID-19 imaged with Q-SPECT/CT between March 17, 2020, and June 30, 2020, at Memorial Sloan Kettering Cancer Center. We recorded patient demographics, clinical symptoms, Wells score (to stratify patients according to pre-test probability for PE prior to Q-SPECT/CT), and noted ancillary imaging findings on CT. RESULTS Of the 33 patients imaged with Q-SPECT/CT, 6 patients (3 men, 3 women) had a laboratory confirmed diagnosis of COVID-19 (mean age, 55, ± 11.4 years, range 33-68). All patients had a current diagnosis of malignancy and had a moderate or high pre-test probability for PE (mean Wells score 2.8, range 2-4). Q-SPECT/CT was positive in 4/6 (67%) of patients. Distribution of pulmonary emboli was bilateral and segmental in 75% of patients. Ancillary acute findings on SPECT/CT included bilateral parenchymal ground glass opacities (n = 5), pleural effusions (n = 2), and pneumomediastinum (n = 1). CONCLUSION Q-SPECT/CT has clinical utility for diagnosing PE in patients with COVID-19 where there is a contraindication for iodinated contrast media and a moderate or high pre-test probability for PE.
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Affiliation(s)
- Jeeban P Das
- Department of Radiology/Nuclear Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Randy Yeh
- Department of Radiology/Nuclear Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Heiko Schöder
- Department of Radiology/Nuclear Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Single photon emission computed tomography lung perfusion imaging during the COVID-19 pandemic: does nuclear medicine need to reconsider its guidelines? Nucl Med Commun 2020; 41:991-993. [PMID: 32796489 PMCID: PMC7373360 DOI: 10.1097/mnm.0000000000001246] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Kim HY, Kim KH, Kim J, Park JC. Multimodality cardiovascular imaging in pulmonary embolism. Cardiol J 2019; 28:150-160. [PMID: 31478557 DOI: 10.5603/cj.a2019.0084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 08/20/2019] [Accepted: 08/20/2019] [Indexed: 11/25/2022] Open
Abstract
Acute pulmonary embolism (APE) is one of the leading causes of cardiovascular (CV) morbidity and mortality. To select appropriate therapeutic strategy and/or to minimize the mortality and morbidity, rapid and correct identification of life-threatening APE is very important. Also, right ventricular (RV) failure usually precedes acute hemodynamic compromise or death, and thus the identification of RV failure is another important step in risk stratification or treatment of APE. With advances in diagnosis and treatment, the prognosis of APE has been dramatically improving in most cases, but inadequate therapy or recurrent episodes of pulmonary embolism (PE) may result in negative outcomes or, so called, chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is a condition characterized by remaining chronic thromboembolic material in the pulmonary vasculature and subsequent chronic pulmonary hypertension. Various imaging modalities include chest computed tomography pulmonary angiography (CTPA), echocardiography, magnetic resonance imaging, and nuclear imaging and each are used for the assessment of varying status of PE. Assessment of thromboembolic burden by chest CTPA is the first step in the diagnosis of PE. Hemodynamic assessment can be achieved by echocardiography and also by chest CTPA. Nuclear imaging is useful in discriminating CTEPH from APE. Better perspectives on diagnosis, risk stratification and decision making in PE can be provided by combining multimodality CV imaging. Here, the advantages or pitfalls of each imaging modality in diagnosis, risk stratification, or management of PE will be discussed.
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Affiliation(s)
- Hyung Yoon Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kye Hun Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea.
| | - Jahae Kim
- Department of Nuclear Medicine, Chonnam National University Hospital, Gwangju, Korea, Republic Of
| | - Jong Chun Park
- Chonnam National University Hospital, Gwangju, Republic of Korea
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The conclusions drawn from ventilation/perfusion single-photon emission computed tomography compared with lung perfusion single-photon emission computed tomography and chest radiography in patients with suspected pulmonary thromboembolism. Nucl Med Commun 2018; 39:908-914. [PMID: 30048378 DOI: 10.1097/mnm.0000000000000886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE There are conflicting results from studies on whether ventilation scintigraphy can be safely omitted or replaced by chest radiography. These studies were based on planar ventilation/perfusion (V/Q) scintigraphy. We evaluated the value of the ventilation single-photon emission computed tomography (SPECT) on the final conclusion drawn from a V/Q SPECT and the possible role of the chest radiography as a surrogate for the ventilation SPECT. PATIENTS AND METHODS Raw data of V/Q SPECT images and chest radiography acquired within 48 h over an 18-month period were retrieved, reprocessed and reviewed in batches. The ventilation SPECT, perfusion SPECT and chest radiography were reviewed separately and in combination. Data on the presence and nature of defects and chest radiography abnormalities were recorded. The V/Q SPECT images were interpreted using the criteria in the EANM guideline and the perfusion SPECT and chest radiography images were interpreted using the PISAPED criteria. Agreement between the diagnosis on the V/Q SPECT review and the perfusion SPECT and chest radiography review was analysed. RESULTS Overall, 21.1% of the patients were classified as 'PE present' on the V/Q SPECT review, whereas 48.9% were classified as 'PE present' on the perfusion SPECT and chest radiography review. Only 5.4% of defects observed on ventilation SPECT had matched chest radiography lung field opacity. CONCLUSION Our study showed that the omission of a ventilation SPECT led to a high rate of false-positive diagnoses and that the ventilation scan cannot be replaced by a chest radiography.
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10
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Root CW, Dudzinski DM, Zakhary B, Friedman OA, Sista AK, Horowitz JM. Multidisciplinary approach to the management of pulmonary embolism patients: the pulmonary embolism response team (PERT). J Multidiscip Healthc 2018; 11:187-195. [PMID: 29670358 PMCID: PMC5896654 DOI: 10.2147/jmdh.s151196] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pulmonary embolism (PE) is a potentially fatal disease with a broad range of treatment options that spans multiple specialties. The rapid evolution and expansion of novel therapies to treat PE make it a disease process that is well suited to a multidisciplinary approach. In order to facilitate a rapid, robust response to the diagnosis of PE, some hospitals have established multidisciplinary pulmonary embolism response teams (PERTs). The PERT model is based on existing multidisciplinary teams such as heart teams and rapid response teams. A PERT is composed of clinicians from the range of specialties involved in the treatment of PE, including pulmonology critical care, interventional radiology, cardiology, and cardiothoracic surgery among others. A PERT is a 24/7 consult service that is able to provide expert advice on the initial management of PE patients and convene in real time to develop a consensus treatment plan specifically tailored to the needs of a particular patient and consistent with the capabilities of the institution. In this review, we discuss the rationale for establishing a PERT and its potential benefits. We discuss considerations in forming a PERT and present case studies of several PERTs currently in operation at different institutions. We also discuss potential difficulties in forming a PERT and review evidence that has been generated by some of the PERTs that have been in operation the longest.
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Affiliation(s)
| | - David M Dudzinski
- Division of Cardiology, Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bishoy Zakhary
- Department of Internal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Oren A Friedman
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Akhilesh K Sista
- Division of Vascular and Interventional Radiology, Department of Radiology, NYU Langone Health, New York, NY, USA
| | - James M Horowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY, USA
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11
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Tilve-Gómez A, Rodríguez-Fernández P, Trillo-Fandiño L, Plasencia-Martínez JM. Imaging techniques used in the diagnostic workup of acute venous thromboembolic disease. RADIOLOGIA 2016; 59:329-342. [PMID: 27986265 DOI: 10.1016/j.rx.2016.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 09/09/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
Early diagnosis is one of the most important factors affecting the prognosis of pulmonary embolism (PE); however, the clinical presentation of PE is often very unspecific and it can simulate other diseases. For these reasons, imaging tests, especially computed tomography angiography (CTA) of the pulmonary arteries, have become the keystone in the diagnostic workup of PE. The wide availability and high diagnostic performance of pulmonary CTA has led to an increase in the number of examinations done and a consequent increase in the population's exposure to radiation and iodinated contrast material. Thus, other techniques such as scintigraphy and venous ultrasonography of the lower limbs, although less accurate, continue to be used in certain circumstances, and optimized protocols have been developed for CTA to reduce the dose of radiation (by decreasing the kilovoltage) and the dose of contrast agents. We describe the technical characteristics and interpretation of the findings for each imaging technique used to diagnose PE and discuss their advantages and limitations; this knowledge will help the best technique to be chosen for each case. Finally, we comment on some data about the increased use of CTA, its clinical repercussions, its "overuse", and doubts about its cost-effectiveness.
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Affiliation(s)
- A Tilve-Gómez
- Servicio de Radiodiagnóstico, IISGS, XXIV, Hospital Álvaro Cunqueiro, Vigo (Pontevedra), España.
| | - P Rodríguez-Fernández
- Servicio de Radiodiagnóstico, IISGS, XXIV, Hospital Álvaro Cunqueiro, Vigo (Pontevedra), España
| | - L Trillo-Fandiño
- Servicio de Radiodiagnóstico, IISGS, XXIV, Hospital Álvaro Cunqueiro, Vigo (Pontevedra), España
| | - J M Plasencia-Martínez
- Servicio de Radiodiagnóstico, Hospital General Universitario José María Morales Meseguer, Murcia, España
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Jain A, Subramanian S, Pandey U, Sarma HD, Ram R, Dash A. In-house preparation of macroaggregated albumin (MAA) for 68Ga labeling and its comparison with commercially available MAA. J Radioanal Nucl Chem 2015. [DOI: 10.1007/s10967-015-4509-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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Watanabe N, Fettich J, Küçük NÖ, Kraft O, Mut F, Choudhury P, Sharma SK, Endo K, Dondi M. Modified PISAPED Criteria in Combination with Ventilation Scintigraphic Finding for Predicting Acute Pulmonary Embolism. World J Nucl Med 2015; 14:178-83. [PMID: 26420988 PMCID: PMC4564920 DOI: 10.4103/1450-1147.163248] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This prospective clinical study aimed at assessing three pulmonary scintigraphic algorithms to detect acute pulmonary embolism (PE): Lung ventilation/perfusion (V/Q) scintigraphy along with modified prospective investigation of pulmonary embolism diagnosis (PIOPED) criteria; lung perfusion scintigraphy along with prospective investigative study of acute pulmonary embolism diagnosis (PISAPED) criteria; and lung perfusion scan in combination with ventilation scan, along with modified PISAPED criteria, which were newly developed. Patients with suspicion of PE were eligible for this study if they had no abnormal chest x-ray. Their diagnostic workup included a clinical assessment, a pulmonary V/Q scintigraphy, and CT pulmonary angiography (CTPA), as well as a clinical outcome assessment over a period of 24 weeks. Referred to the final clinical diagnosis of patients, the sensitivity and specificity of each algorithm were evaluated. The diagnostic performance of each algorithm by the area under the maximum likelihood fitted receiver operating characteristic (ROC) curve was determined. With respect to the PISAPED criteria, the sensitivity was 60.8% and specificity was 87.3%. No patient was classified into nondiagnostic category. The PIOPED criteria showed that the sensitivity was 95.0% and specificity was 88.2%, while 57.4% of the patients were in nondiagnostic category. The areas under the ROC curve constructed from the PISAPED criteria results and the modified PIOPED criteria results were 0.734 and 0.859 (P < 0.01), respectively. The modified PISAPED criteria demonstrated that the sensitivity was 83.8% and specificity was 89.1%. No patient was classified into nondiagnostic category. The area under the ROC curve constructed from modified PISAPED criteria was 0.864 (P < 0.01). Perfusion scans used with ventilation scans and modified PISAPED criteria may increase the diagnostic accuracy of pulmonary scintigraphy for acute PE, compared with the two major algorithms.
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Affiliation(s)
- Naoyuki Watanabe
- Department of Nuclear Sciences and Applications, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Jure Fettich
- Department of Nuclear Medicine, University Medical Center, Ljubljana, Slovenia
| | | | - Otakar Kraft
- Department of Nuclear Medicine, University Hospital, University of Strava, Ostrava, Czech Republic
| | - Fernando Mut
- Nuclear Medicine Service, Spanish Association Hospital, Montevideo, Uruguay
| | - Partha Choudhury
- Department of Nuclear Medicine, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Surendra K. Sharma
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Keigo Endo
- Kyoto Medical Science College, Kyoto, Japan
| | - Maurizio Dondi
- Department of Nuclear Sciences and Applications, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
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Software-Based Hybrid Perfusion SPECT/CT Provides Diagnostic Accuracy When Other Pulmonary Embolism Imaging Is Indeterminate. Nucl Med Mol Imaging 2015; 49:303-11. [PMID: 26550050 DOI: 10.1007/s13139-015-0359-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/22/2015] [Accepted: 07/28/2015] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To investigate the diagnostic performance of perfusion single-photon emission computed tomography/computed tomography (Q-SPECT/CT) in patients suspected to have pulmonary embolism (PE) but with indeterminate computed tomographic pulmonary angiography (CTPA) or planar ventilation/perfusion (V/Q) scans. METHODS This retrospective study included two groups of patients. Group I consisted of 49 patients with nondiagnostic CTPA. These 49 patients underwent subsequent V/Q scans. Further Q-SPECTs were obtained in patients with indeterminate planar images and fused with existing CTPA. Group II consisted of 182 non-CTPA patients with indeterminate V/Q scans. These 182 patients underwent further Q-SPECT and separate noncontrast low-dose CT chest. Fusion Q-SPECT/CT scans were obtained through FDA-approved software and interpreted according to published criteria as positive, negative, or indeterminate for PE. Upon retrospective analyses, the final diagnosis was made using composite reference standards including all available clinical and imaging information for at least 6-month follow-up. RESULTS In group I patients, 1 was positive, 24 were negative, and another 24 (49 %, 24/49) were indeterminate. In the subsequent 24 Q-SPECT/CTPAs, 4 were positive, 19 were negative, and 1 was indeterminate (4.2 %, 1/24). In group II patients, 9 (4.9 %, 9/182) were indeterminate, 33 were positive, and 140 were negative. The combined nondiagnostic rate for Q-SPECT/CT was only 4.9 % (10/206). There was six false-negative and one false-positive Q-SPECT/CT examinations. The sensitivity, specificity, and positive and negative predictive value of Q-SPECT/CT were 85.7 % (36/42), 99.4 % (153/154), 97.3 % (36/37) and 96.2 % (153/159), respectively. CONCLUSIONS Q-SPECT/CT improves the diagnostic rate with promising accuracy in diagnosing PE that yields a satisfactory clinical verdict, especially when the CTPA and planar V/Q scan are indeterminate.
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15
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Miniati M. Perfusion lung scintigraphy for pulmonary embolism. Thromb Res 2015; 136:187-8. [DOI: 10.1016/j.thromres.2015.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 06/02/2015] [Indexed: 11/28/2022]
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Lu Y, Lorenzoni A, Fox JJ, Rademaker J, Vander Els N, Grewal RK, Strauss HW, Schöder H. Noncontrast perfusion single-photon emission CT/CT scanning: a new test for the expedited, high-accuracy diagnosis of acute pulmonary embolism. Chest 2014; 145:1079-1088. [PMID: 24798835 DOI: 10.1378/chest.13-2090] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Standard ventilation and perfusion (V˙/Q˙) scintigraphy uses planar images for the diagnosis of pulmonary embolism (PE). To evaluate whether tomographic imaging improves the diagnostic accuracy of the procedure, we compared noncontrast perfusion single-photon emission CT (Q˙-SPECT)/CT scans with planar V˙/Q˙scans in patients at high risk for PE. METHODS Between 2006 and 2010, most patients referred for diagnosis of PE underwent both Q˙-SPECT/CT scan and planar V˙/Q˙scintigraphy. All scans were reviewed retrospectively by four observers; planar scans were read with modified Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II and Prospective Investigative Study of Pulmonary Embolism Diagnosis (PISA-PED) criteria. On Q˙-SPECT/CT scan, any wedge-shaped peripheral perfusion defect occupying > 50% of a segment without corresponding pulmonary parenchymal or pleural disease was considered to show PE. The final diagnosis was established with a composite reference standard that included ECG, ultrasound of lower-extremity veins, D-dimer levels, CT pulmonary angiography (when available), and clinical follow-up for at least 3 months. RESULTS One hundred six patients with cancer and mean Wells score of 4.4 had sufficient follow-up; 22 patients were given a final diagnosis of PE, and 84 patients were given a final diagnosis of no PE. According to PIOPED II, 13 studies were graded as intermediate probability. Sensitivity and specificity for PE were 50% and 98%, respectively, based on PIOPED II criteria; 86% and 93%, respectively, based on PISA-PED criteria; and 91% and 94%, respectively, based on Q˙-SPECT/CT scan. Seventy-six patients had additional relevant findings on the CT image of the Q˙-SPECT/CT scan. CONCLUSIONS Noncontrast Q˙-SPECT/CT imaging has a higher accuracy than planar V˙/Q˙imaging based on PIOPED II criteria in patients with cancer and a high risk for PE.
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Affiliation(s)
- Yang Lu
- Molecular Imaging and Therapy Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Alice Lorenzoni
- Molecular Imaging and Therapy Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Josef J Fox
- Molecular Imaging and Therapy Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jürgen Rademaker
- Body Imaging Section, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Nicholas Vander Els
- Department of Radiology and Pulmonary Disease Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Ravinder K Grewal
- Molecular Imaging and Therapy Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - H William Strauss
- Molecular Imaging and Therapy Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Heiko Schöder
- Molecular Imaging and Therapy Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY.
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Lung scintigraphy in the diagnosis of pulmonary embolism: current methods and interpretation criteria in clinical practice. Radiol Oncol 2014; 48:113-9. [PMID: 24991200 PMCID: PMC4078029 DOI: 10.2478/raon-2013-0060] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 08/18/2013] [Indexed: 11/25/2022] Open
Abstract
Background In current clinical practice lung scintigraphy is mainly used to exclude pulmonary embolism (PE). Modified diagnostic criteria for planar lung scintigraphy are considered, as newer scitigraphic methods, especially single photon emission computed tomography (SPECT) are becoming more popular. Patients and methods. Data of 98 outpatients who underwent planar ventilation/perfusion (V/Q) scintigraphy and 49 outpatients who underwent V/Q SPECT from the emergency department (ED) were retrospectively collected. Planar V/Q images were interpreted according to 0.5 segment mismatch criteria and revised PIOPED II criteria and perfusion scans according to PISA-PED criteria. V/Q SPECT images were interpreted according to the criteria suggested in EANM guidelines. Final diagnosis of PE was based on the clinical decision of an attending physician and evaluation of a 12 months follow-up period. Results Using 0.5 segment mismatch criteria and revised PIOPED II, planar V/Q scans were diagnostic in 93% and 84% of cases, respectively. Among the diagnostic planar scans readings specificity for 0.5 segment mismatch criteria was 98%, and 99% for revised PIOPED II criteria. V/Q SPECT showed a sensitivity of 100% and a specificity of 98%, without any non-diagnostic cases. In patients with low pretest probability for PE, planar V/Q scans assessed by 0.5 segment mismatch criteria were diagnostic in 92%, and in 85% using revised PIOPED II criteria, while perfusion scintigraphy without ventilation scans was diagnostic in 80%. Conclusions Lung scintigraphy yielded diagnostically definitive results and is reliable in ruling out PE in patients from ED. V/Q SPECT has excellent specificity and sensitivity without any non-diagnostic results. Percentage of non-diagnostic results in planar lung scintigraphy is considerably smaller when 0.5 segment mismatch criteria instead of revised PIOPED II criteria are used. Diagnostic value of perfusion scintigraphy according to PISA-PED criteria is inferior to combined V/Q scintigraphy; the difference is evident especially in patients with low pretest probability for PE.
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Lung tissue density measured by low-dose CT during pulmonary perfusion SPECT/CT as a tool for differentiation pulmonary embolism from chronic obstructive pulmonary disease - A pilot study. COR ET VASA 2013. [DOI: 10.1016/j.crvasa.2013.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
The clinical diagnosis of acute pulmonary embolism (PE) is frequently considered in patients presenting to the emergency department or when hospitalized. Since symptoms are a-specific and the consequences of anticoagulant treatment are considerable, objective tests to either establish or refute the diagnosis have become a standard of care. Computed tomographic pulmonary angiography (CTPA), which has replaced pulmonary angiography as first-line imaging test, is associated with radiation exposure, several complications resulting from contrast dye administration, and over diagnosis. Importantly, CTPA can be avoided in 20% to 30% of patients who present with a first or recurrent episode of clinically suspected acute PE by using a standardized algorithm. This algorithm should always include a clinical decision rule to assess the likelihood that PE is present, followed by a D-dimer blood test and/or CTPA. The aim of this review is to provide clinicians this practical diagnostic management approach using evidence from the literature.
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Huisman MV, Klok FA. Diagnostic management of acute deep vein thrombosis and pulmonary embolism. J Thromb Haemost 2013; 11:412-22. [PMID: 23294863 DOI: 10.1111/jth.12124] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acute deep vein thrombosis (DVT) and pulmonary embolism (PE) represent two expressions of a similar clinical pathological process, often referred to as venous thromboembolism (VTE). It has long been recognized that, as clinical signs and symptoms of PE and DVT are not specific for the diagnosis, objective diagnosis in both patients presenting with leg symptoms and those with chest symptoms is mandatory. Since the last review on this subject in this journal in 2009, several large trials have been performed that shed new light on all aspects of the diagnostic management of suspected VTE, especially in the field of simplified clinical decision rules, age-dependent D-dimer cut-offs and magnetic resonance imaging. A literature search covering the period 2007-2012 was performed using the Medline/PubMed database to identify all relevant papers regarding the diagnostic management of acute PE and DVT. Established concepts and the latest evidence on this subject will be the main focus of this review.
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Affiliation(s)
- M V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Assessing the utility of the ventilation phase in ventilation–perfusion imaging for acute pulmonary embolism. Nucl Med Commun 2013; 34:1-4. [DOI: 10.1097/mnm.0b013e32835afb99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The Clinical Utility of a Diagnostic Imaging Algorithm Incorporating Low-Dose Perfusion Scans in the Evaluation of Pregnant Patients With Clinically Suspected Pulmonary Embolism. Clin Nucl Med 2013; 38:29-32. [DOI: 10.1097/rlu.0b013e31827088f6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Diagnostic imaging of pulmonary embolism using endobronchial ultrasound. Arch Bronconeumol 2012; 49:268-71. [PMID: 23140635 DOI: 10.1016/j.arbres.2012.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 08/13/2012] [Accepted: 08/30/2012] [Indexed: 11/21/2022]
Abstract
Endobronchial ultrasound (EBUS) is a new technique that can be used for the diagnostic imaging of central pulmonary thromboembolism (PE). In eight cases at our clinic, EBUS was used because of mediastinal lymphadenopathies or paramediastinal nodular lesions and at the same time images were obtained of a PE by means of EBUS. The PE was diagnosed before the EBUS with computed tomography (CT) of the lungs in all cases (5 women and 3 men). The repletion defects of all the cases compatible with a PE were clarified with CT-angiography. EBUS may be an alternative method for the diagnosis of PE, as it can indicate the presence of a thrombus in the central pulmonary arteries in hemodynamically-stable cases.
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Marshall PS, Mathews KS, Siegel MD. Diagnosis and management of life-threatening pulmonary embolism. J Intensive Care Med 2011; 26:275-94. [PMID: 21606060 DOI: 10.1177/0885066610392658] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Accepted: 04/22/2010] [Indexed: 01/01/2023]
Abstract
Pulmonary embolus (PE) is estimated to cause 200 000 to 300 000 deaths annually. Many deaths occur in hemodynamically unstable patients and the estimated mortality for inpatients with hemodynamic instability is between 15% and 25%. The diagnosis of PE in the critically ill is often challenging because the presentation is nonspecific. Computed tomographic pulmonary angiography appears to be the most useful study for diagnosis of PE in the critically ill. For patients with renal insufficiency and contrast allergy, the ventilation perfusion scan provides an alternative. For patients too unstable to travel, echocardiography (especially transesophageal echocardiography) is another option. A positive result on lower extremity Doppler ultrasound can also aid in the decision to treat. The choice of treatment in PE depends on the estimated risk of poor outcome. The presence of hypotension is the most significant predictor of poor outcome and defines those with massive PE. Normotensive patients with evidence of right ventricular (RV) dysfunction, as assessed by echocardiography, comprise the sub-massive category and are at intermediate risk of poor outcomes. Clinically, those with sub-massive PE are difficult to distinguish from those with low-risk PE. Cardiac troponin, brain natriuretic peptide, and computed tomographic pulmonary angiography can raise the suspicion that a patient has sub-massive PE, but the echocardiogram remains the primary means of identifying RV dysfunction. The initial therapy for patients with PE is anticoagulation. Use of vasopressors, inotropes, pulmonary artery (PA) vasodilators and mechanical ventilation can stabilize critically ill patients. The recommended definitive treatment for patients with massive PE is thrombolysis (in addition to anticoagulation). In massive PE, thrombolytics reduce the risk of recurrent PE, cause rapid improvement in hemodynamics, and probably reduce mortality compared with anticoagulation alone. For patients with a contraindication to anticoagulation and thrombolytic therapy, surgical embolectomy and catheter-based therapies are options. Thrombolytic therapy in sub-massive PE results in improved pulmonary perfusion, reduced PA pressures, and a less complicated hospital course. No survival benefit has been documented, however. If one is considering the use of thrombolytic therapy in sub-massive PE, the limited documented benefit must be weighed against the increased risk of life-threatening hemorrhage. The role of surgical embolectomy and catheter-based therapies in this population is unclear. Evidence suggests that sub-massive PE is a heterogeneous group with respect to risk. It is possible that those at highest risk may benefit from thrombolysis, but existing studies do not identify subgroups within the sub-massive category. The role of inferior vena cava (IVC) filters, catheter-based interventions, and surgical embolectomy in life-threatening PE has yet to be completely defined.
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Affiliation(s)
- Peter S Marshall
- Pulmonary & Critical Care Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Kusum S Mathews
- Pulmonary & Critical Care Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mark D Siegel
- Pulmonary & Critical Care Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Imagerie hybride dans l’embolie pulmonaire aiguë : apport de la TDM couplée à la tomoscintigraphie de ventilation et de perfusion. MÉDECINE NUCLÉAIRE 2011. [DOI: 10.1016/j.mednuc.2010.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Mos IC, Klok FA, Kroft LJ, Huisman MV. Update on techniques for the diagnosis of pulmonary embolism. EXPERT OPINION ON MEDICAL DIAGNOSTICS 2011; 5:49-61. [PMID: 23484476 DOI: 10.1517/17530059.2011.538380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
IMPORTANCE OF THE FIELD The clinical suspicion of acute pulmonary embolism (PE) is frequently raised. However, the diagnosis of PE is confirmed in only 20 - 30% of these patients. The high incidence in addition to the potential harm from false-positive or false-negative diagnostic decisions underline the importance of a standardised diagnostic algorithm with high sensitivity as well as specificity. AREAS COVERED IN THIS REVIEW This article reviews the diagnostic tests for the diagnosis of PE. WHAT THE READER WILL GAIN This review provides an overview of the different clinical decision rules (CDRs), D-dimer tests and imaging techniques in patients suspected of PE. Furthermore, the diagnostic process in patients with clinically suspected recurrent PE, suspicion during pregnancy and new research areas are discussed. TAKE HOME MESSAGE Various diagnostic tests are available to detect or exclude PE with good accuracy. CDRs and D-dimer tests play an important role in the exclusion of PE. Neither is sufficient as a single test, but the combination of an 'unlikely' clinical prediction and a normal D-dimer test result safely excludes PE. In case of a high CDR score and/or an elevated D-dimer concentration, extra imaging is necessary with multi-slice computed tomography pulmonary angiography as first choice modality.
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Affiliation(s)
- Inge Cm Mos
- Leiden University Medical Centre, Section of Vascular Medicine, Department of General Internal Medicine - Endocrinology, Albinusdreef 2, Postbus 9600, 2300 RC Leiden, the Netherlands +003171 5262085 ; +003171 5248140 ;
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Lessler AL, Isserman JA, Agarwal R, Palevsky HI, Pines JM. Testing low-risk patients for suspected pulmonary embolism: a decision analysis. Ann Emerg Med 2010; 55:316-326.e1. [PMID: 20061065 DOI: 10.1016/j.annemergmed.2009.12.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2009] [Revised: 11/22/2009] [Accepted: 12/02/2009] [Indexed: 12/31/2022]
Abstract
STUDY OBJECTIVE The Pulmonary Embolism Rule-out Criteria (PERC) identifies low-risk patients who are treated in the emergency department for suspected pulmonary embolism and for whom testing may be deferred. The purpose of this study is to develop a decision model to determine whether certain elements not included in the PERC methodology could better estimate the testing threshold for pulmonary embolism (ie, the pretest probability below which a patient should not be tested for pulmonary embolism). In addition, we determine which risks and benefits of pulmonary embolism evaluation and treatment have the greatest effect on the testing threshold. METHODS We built decision models of low-risk patients with suspected pulmonary embolism, as determined by the PERC. We obtained model inputs from the literature or by using clinical judgment when data were unavailable. One-way sensitivity analysis derived the testing threshold, and 2-way sensitivity analysis was used to determine the main drivers of the testing threshold. RESULTS We found an average testing threshold of 1.4% across all age and sex cohorts. Two-way sensitivity analysis demonstrated that risk of major bleeding from anticoagulation, mortality from contrast-induced renal failure, risk of cancer from computed tomography scan, and mortality from both treated and untreated pulmonary embolism had the greatest effects on the testing threshold. CONCLUSION We found a testing threshold for the PERC similar to that calculated by the Pauker and Kassirer method, using somewhat different assumptions. The 5 major drivers for the testing threshold are variables for which there is a paucity of literature to assess accurately for low-risk patients.
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Affiliation(s)
- Adam L Lessler
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Current World Literature. Curr Opin Pulm Med 2009; 15:521-7. [DOI: 10.1097/mcp.0b013e3283304c7b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Diagnosing pulmonary embolism: clinical problem or methodological issue? Eur J Nucl Med Mol Imaging 2009; 36:522-8. [PMID: 19137291 DOI: 10.1007/s00259-008-1059-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Miniati M, Monti S. Should lung scan be abandoned for pulmonary embolism diagnosis in the age of multislice spiral CT? No. Intern Emerg Med 2009; 4:193-4. [PMID: 19399384 DOI: 10.1007/s11739-009-0251-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 03/24/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Massimo Miniati
- Dipartimento di Area Critica Medico Chirurgica, Università degli Studi di Firenze, Viale Morgagni 85, 50134 Florence, Italy.
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Freeman LM, Haramati LB. V/Q scintigraphy: alive, well and equal to the challenge of CT angiography. Eur J Nucl Med Mol Imaging 2009; 36:499-504. [DOI: 10.1007/s00259-009-1068-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Is the lung scan alive and well? Facts and controversies in defining the role of lung scintigraphy for the diagnosis of pulmonary embolism in the era of MDCT. Eur J Nucl Med Mol Imaging 2009; 36:505-21. [DOI: 10.1007/s00259-008-1014-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Accepted: 11/07/2008] [Indexed: 11/26/2022]
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Freeman LM, Stein EG, Sprayregen S, Chamarthy M, Haramati LB. The Current and Continuing Important Role of Ventilation-Perfusion Scintigraphy in Evaluating Patients With Suspected Pulmonary Embolism. Semin Nucl Med 2008; 38:432-40. [DOI: 10.1053/j.semnuclmed.2008.07.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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