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Allena N, Khanal S. The Algorithmic Lung Detective: Artificial Intelligence in the Diagnosis of Pulmonary Embolism. Cureus 2023; 15:e51006. [PMID: 38259362 PMCID: PMC10803098 DOI: 10.7759/cureus.51006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 01/24/2024] Open
Abstract
Pulmonary embolism (PE) poses a significant threat as the third leading cause of cardiovascular death, prompting the widespread use of CT pulmonary angiogram for rapid detection. Despite its prevalence, diagnostic accuracy remains variable among radiologists. The emergence of artificial intelligence (AI), notably through convolutional neural networks and deep learning reconstruction, offers a promising avenue to enhance PE detection. AI demonstrates superior sensitivity and negative predictive values, reducing the risk of missed diagnoses. Implementation of AI-based worklist prioritization substantially shortens detection and notification times, streamlining radiological workflows. However, it is crucial to underscore that AI acts as a complement, not a replacement, for radiologists, synergizing with human expertise. As AI integration progresses, it holds the potential to significantly improve diagnostic accuracy and efficiency in pulmonary embolism detection while maintaining the essential role of human judgment in medical decision-making.
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Affiliation(s)
| | - Sneha Khanal
- Internal Medicine, BronxCare Health System, Bronx, USA
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2
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Yadav V, Singhal M, Maralakunte M, Sharma N, Sharma A, Lal A. Comparison of Dual-Energy Computed Tomography Pulmonary Angiography-Derived Contrast Enhancement with Standard Dual-Energy Pulmonary Angiography in Diagnosing Subsegmental Pulmonary Embolism: A Prospective Study. Indian J Radiol Imaging 2023; 33:456-462. [PMID: 37811170 PMCID: PMC10556308 DOI: 10.1055/s-0043-1764489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
Objective In this study, we compare the diagnostic accuracy of dual-energy (DE) computed tomography pulmonary angiography (CTPA) derived contrast enhancement (DECTPA, CTPA images with iodine maps) with standard dual-energy pulmonary angiography (SCTPA) for diagnosis of subsegmental pulmonary embolism in the cases with clinical suspicion of acute pulmonary embolism (APE). Materials and Methods We included 50 cases with clinical suspicion of APE that were referred for CTPA. All the patients underwent CTPA in the dual-energy protocol. Two radiologists evaluated the images. The first radiologist interpreted the SCTPA images (vascular images) and the second radiologist interpreted the DECTPA (CTPA images with iodine maps) for findings of APE. We calculated the sensitivity, specificity, and negative predictive value of DECTPA vis-à-vis SCTPA images. Results The DECTPA with the advantage of iodine map utilization yielded higher detection of thrombi in peripheral subsegmental arteries (72 vs. 99; p = - 0.001) as compared to the SCTPA images by identification of 18 new perfusion defects (interquartile range [IQR]: 0-1) that were consistent with APE. Filling defects were identified in 27 (IQR: 0-4) more subsegmental arteries supplying these 18 areas, which were not detected on SCTPA alone. These 18 perfusion defects were identified in 13 cases. In these 13 cases, 4 new cases were diagnosed that were negative on CTPA ( p = -0.125). In the evaluation of the APE, sensitivity and specificity were calculated and it was found that DECTPA showed 100% sensitivity and 86% specificity with 100% negative predictive value in the detection of thrombi as compared to the routine CTPA. Conclusion DECTPA has higher sensitivity and negative predictive value in the detection of the subsegmental perfusion defect identification as compared to SCTPA.
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Affiliation(s)
- Vivek Yadav
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manphool Singhal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Muniraju Maralakunte
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arun Sharma
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupam Lal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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3
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Hashimoto H, Soma T, Mizumura S, Kokubo T, Nakanishi R, Ikeda T. Evaluation of lung perfusion by using lung perfusion SPECT and lung CT with breathing synchronization software. Eur J Hybrid Imaging 2022; 6:32. [PMID: 36424511 PMCID: PMC9691807 DOI: 10.1186/s41824-022-00154-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/17/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Lung perfusion using 99mTc-macroaggregated albumin single-photon emission computed tomography (SPECT) and lung computed tomography (CT) is a useful modality for identifying patients with pulmonary artery embolism. However, conformity between SPECT and CT at the bottom of the lung is generally low. This study aims to investigate the progression of conformity between lung perfusion SPECT and lung CT using a breathing synchronization software. METHODS Among 95 consecutive patients who underwent lung perfusion SPECT and lung CT within 14 days because of suspected pulmonary embolism between June 2019 and August 2020 in department of cardiovascular medicine, we identified 28 patients (73 ± 10 years) who had normal pulmonary artery on contrast lung CT. We compared lung volumes calculated using lung perfusion SPECT and lung CT as gold standard. Visual conformity between lung SPECT and lung CT was scored 0-4 (0: 0-25%, 1: 25-50%, 2: 50-75%, 3: 75-90%, 4: > 90%) by two specialists in nuclear medicine and assessed. RESULTS The lung volume calculated from lung CT was 3749 ± 788 ml. The lung volume calculated from lung perfusion SPECT without using the breathing synchronization software was 3091 ± 610 ml. There was a significant difference between the lung volume calculated from CT and SPECT without using the breathing synchronization software (P < 0.01). The lung volume calculated from lung perfusion SPECT using the breathing synchronization software was 3435 ± 686 ml, and there was no significant difference between the lung volume calculated from CT and SPECT using the breathing synchronization software. The visual score improved with the use of breathing synchronization software (without software; 1.9 ± 0.6 vs. with software; 3.4 ± 0.7, P < 0.001). CONCLUSION This study demonstrated that the breathing synchronization software could improve conformity between lung perfusion SPECT and lung CT.
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Affiliation(s)
- Hidenobu Hashimoto
- Department of Cardiovascular Medicine, Department of Internal Medicine, Faculty of Medicine, Toho University, 6-11-1, Omorinishi, Ota-Ward, Tokyo, 143-8541, Japan.
| | - Tsutomu Soma
- Software Development Department, PDRadiopharma Inc., Tokyo, Japan
| | - Sunao Mizumura
- Department of Radiology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Tadashi Kokubo
- Central Department of Radiology, Toho University Omori Medical Center, Tokyo, Japan
| | - Rine Nakanishi
- Department of Cardiovascular Medicine, Department of Internal Medicine, Faculty of Medicine, Toho University, 6-11-1, Omorinishi, Ota-Ward, Tokyo, 143-8541, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Department of Internal Medicine, Faculty of Medicine, Toho University, 6-11-1, Omorinishi, Ota-Ward, Tokyo, 143-8541, Japan
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4
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Ata F, Ibrahim WH, Choudry H, Shams A, Arshad A, Younas HW, Bilal ABI, Ikram MQ, Tahir S, Mogassabi WW, Errayes NM. Optimal management, prevalence, and clinical behavior of saddle pulmonary embolism: A systematic review and meta-analysis. Thromb Res 2022; 217:86-95. [PMID: 35926347 DOI: 10.1016/j.thromres.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/05/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022]
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5
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Pretorius J, Nemat N, Azeem I, Shaju T, Nadeem S, Hammad Y. Is aspirin still relevant as a single pharmacological agent for venous thromboembolism prophylaxis post hip and knee arthroplasty surgery: A retrospective review. SICOT J 2022; 8:28. [PMID: 35766820 PMCID: PMC9241622 DOI: 10.1051/sicotj/2022029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/12/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction: Aspirin is widely used for the prevention of venous thromboembolism (VTE) after total hip arthroplasty (THA) and total knee arthroplasty (TKA). It is well-established that the bleeding and wound complication risk for aspirin is low or equivalent to the other anticoagulant agents, but there is still ongoing controversy regarding the efficacy of aspirin for VTE prophylaxis. The current HSE (2012) guideline suggests 72 h of enoxaparin and 4 weeks of Aspirin therapy. But is this practice still relevant with more recent guidelines, NICE (2021) and SIGN (2014) suggesting that Aspirin is not recommended as a single pharmacological agent for VTE prophylaxis. Method: A Retrospective review was performed of a single centre, between January 2016 and May 2021 assessing for symptomatic VTE post-THA and TKA. All the patients received enoxaparin and aspirin as per the HSE guidelines. Using NIMIS we assessed which patients received a workup for potential symptomatic VTE and who had a confirmed VTE within 3 months post-surgery. The secondary outcome was mortality within 3 months post-surgery. Results: A total of 1178 patients (721 undergoing THR and 457 undergoing TKR) were included in the study. The number of patients who received a workup for potential symptomatic VTE was 124 of 1178 (10.53%). VTE occurred in 13 of 721 patients (1.80%) of the THR patients and 1 of 457 (0.22%) of the TKR patients, and a total of 14 of 1178 patients (1.19%). Of these 7 (0.59%) patients developed a DVT and 7 (0.59%) a PE. No patients suffered a fatal pulmonary embolism within 90 days of index surgery nor any other cause of mortality. Conclusion: Aspirin is not only still relevant but can be considered as one of the most optimal pharmacological agents in preventing VTE after THA and TKA.
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Affiliation(s)
- Jacques Pretorius
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
| | - Nouman Nemat
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
| | - Imran Azeem
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
| | - Tony Shaju
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
| | - Sayed Nadeem
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
| | - Yasir Hammad
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
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6
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Alhassan AM, Aldayel A, Alharbi A, Farooqui M, Alhelal MH, Alhusain F, Abdullah A, Altoyan M. Acute Kidney Injury in Patients With Suspected Pulmonary Embolism: A Retrospective Study of the Incidence, Risk Factors, and Outcomes in a Tertiary Care Hospital in Saudi Arabia. Cureus 2022; 14:e21198. [PMID: 35047317 PMCID: PMC8760013 DOI: 10.7759/cureus.21198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/05/2022] Open
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7
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Derenoncourt PR, Felder GJ, Royal HD, Bhalla S, Lang JA, Matesan MC, Itani M. Ventilation-Perfusion Scan: A Primer for Practicing Radiologists. Radiographics 2021; 41:2047-2070. [PMID: 34678101 DOI: 10.1148/rg.2021210060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Lung scintigraphy, or ventilation-perfusion (V/Q) scan, is one of the commonly performed studies in nuclear medicine. Owing to variability in clinical applications and different departmental workflows, many trainees are not comfortable interpreting the results of this study. This article provides a simplified overview of V/Q imaging, including a review of its technique, interpretation methods, and established and emerging clinical applications. The authors review the role of V/Q imaging in evaluation of acute and chronic pulmonary embolism, including the role of SPECT/CT and comparing V/Q scan with CT angiography. In addition, a variety of other applications of pulmonary scintigraphy are discussed, including congenital heart disease, pretreatment planning for lung cancer and emphysema, posttransplant imaging for bronchiolitis obliterans, and less common vascular and nonvascular pathologic conditions that may be detected with V/Q scan. This article will help radiologists and residents interpret the results of V/Q scans and understand the various potential clinical applications of this study. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Paul-Robert Derenoncourt
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Gabriel J Felder
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Henry D Royal
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Jordan A Lang
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Manuela C Matesan
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Malak Itani
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
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8
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Javitt MC, Daniels L, Andraous M, Chulsky S, Schatzberger R, Beck-Razi N, Guralnik L, Oklander B, Palti Y, Ofran Y, Gaitini D. Transthoracic parametric Doppler for bedside diagnosis of pulmonary embolism: A pilot study. JOURNAL OF CLINICAL ULTRASOUND : JCU 2020; 48:204-210. [PMID: 31867721 DOI: 10.1002/jcu.22801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/24/2019] [Accepted: 11/28/2019] [Indexed: 06/10/2023]
Abstract
Transthoracic parametric Doppler (TPD), unlike conventional ultrasonography, measures signals originating from movements of pulmonary blood vessel walls. In this pilot study, we tested TPD in 15 patients diagnosed with pulmonary embolism on computed tomography pulmonary angiography. Results were mapped to the upper, middle, and lower thirds of the right lung. In the lower third, TPD yielded 100% specificity and positive predictive value for acute pulmonary embolism. If validated in a larger series, this rapid bedside technique might obviate the need for computed tomography in specific cases. This could be advantageous in patients who are unstable, in intensive care, or have allergies to iodinated contrast material.
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Affiliation(s)
- Marcia C Javitt
- Department of Medical Imaging, Rambam Health Care Campus, Haifa, Israel
- Bruce and Ruth Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Lydia Daniels
- Bruce and Ruth Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Maisa Andraous
- Department of Medical Imaging, Rambam Health Care Campus, Haifa, Israel
| | - Semyon Chulsky
- Department of Medical Imaging, Rambam Health Care Campus, Haifa, Israel
| | | | - Nira Beck-Razi
- Department of Medical Imaging, Rambam Health Care Campus, Haifa, Israel
- Bruce and Ruth Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ludmilla Guralnik
- Department of Medical Imaging, Rambam Health Care Campus, Haifa, Israel
- Bruce and Ruth Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | | | | | - Yishai Ofran
- Bruce and Ruth Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel
| | - Diana Gaitini
- Department of Medical Imaging, Rambam Health Care Campus, Haifa, Israel
- Bruce and Ruth Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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Abusibah H, Abdelaziz MM, Standen P, Bhatia P, Hamad MM. Ambulatory management of pulmonary embolism. Br J Hosp Med (Lond) 2019; 79:18-25. [PMID: 29315054 DOI: 10.12968/hmed.2018.79.1.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The diagnosis of pulmonary embolism can be very difficult and elusive. It depends greatly on the use of diagnostic tests, which are in turn interpreted according to a pre-test clinical probability. These include non-specific tests such as the chest X-ray and electrocardiograph, which help exclude other conditions such as pneumonia or myocardial infarction. On the other hand, more specific tests such as computed tomography or ventilation/perfusion scanning are used to confirm or exclude the diagnosis of pulmonary embolism. The condition is potentially fatal, and in the past patients with suspected pulmonary embolism constituted a significant number of hospital admissions. Despite this, the majority were found not to have pulmonary embolism. More recently, studies have suggested that most patients with suspected pulmonary embolism who are haemodynamically stable can be safely managed on an ambulatory pathway. Therefore, there is a paradigm shift towards investigating and treating pulmonary embolism in the outpatient setting. This article discusses the ambulatory pathway of the diagnosis and treatment of pulmonary embolism.
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Affiliation(s)
- Houssam Abusibah
- CT2 in Acute Medicine, Department of Acute Medicine, James Cook University Hospital, Middlesbrough
| | - Muntasir M Abdelaziz
- Consultant Respiratory Physician and Clinical Lead for General Internal Medicine, Department of Respiratory Medicine, Tameside Hospital, Ashton-Under-Lyne
| | - Peter Standen
- Registrar in Acute Medicine, Department of Acute Medicine, James Cook University Hospital, Middlesbrough
| | - Praveen Bhatia
- Consultant Respiratory Physician, Department of Respiratory Medicine, Tameside Hospital, Ashton-Under-Lyne
| | - Mahir Ma Hamad
- Consultant Physician and Clinical Director for Acute Medicine, Department of Acute Medicine, James Cook University Hospital, Middlesbrough TS4 3BW
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10
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Cascio V, Hon M, Haramati LB, Gour A, Spiegler P, Bhalla S, Katz DS. Imaging of suspected pulmonary embolism and deep venous thrombosis in obese patients. Br J Radiol 2018; 91:20170956. [PMID: 29762047 DOI: 10.1259/bjr.20170956] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Obesity is a growing problem around the world, and radiology departments frequently encounter difficulties related to large patient size. Diagnosis and management of suspected venous thromboembolism, in particular deep venous thrombosis (DVT) and pulmonary embolism (PE), are challenging even in some lean patients, and can become even more complicated in the setting of obesity. Many obstacles must be overcome to obtain imaging examinations in obese patients with suspected PE and/or DVT, and to ensure that these examinations are of sufficient quality to diagnose or exclude thromboembolic disease, or to establish an alternative diagnosis. Equipment limitations and technical issues both need to be acknowledged and addressed. Table weight limits and scanner sizes that readily accommodate obese and even morbidly obese patients are not in place at many clinical sites. There are also issues with image quality, which can be substantially compromised. We discuss current understanding of the effects of patient size on imaging in general and, more specifically, on the imaging modalities used for the diagnosis and treatment of DVT and PE. Emphasis will be placed on the technical parameters and protocol nuances, including contrast dosing, which are necessary to refine and optimize images for the diagnosis of DVT and PE in obese patients, while remaining cognizant of radiation exposure. More research is necessary to develop consistent high-level evidence regarding protocols to guide radiologists, and to help them effectively utilize emerging technology.
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Affiliation(s)
- Vincent Cascio
- 1 Stony Brook University School of Medicine , Stony Brook, NY , USA.,2 Department of Radiology, NYU Winthrop, Stony Brook University School of Medicine , Mineola, NY , USA
| | - Man Hon
- 3 Interventional Radiology, NYU Winthrop, Stony Brook University School of Medicine , Stony Brook, NY , USA
| | - Linda B Haramati
- 4 Division of Cardiothoracic Imaging, Montefiore Medical Center and the Albert Einstein College of Medicine , Bronx, NY , USA
| | - Animesh Gour
- 5 Division of Pulmonaryand Critical Care Medicine, Department of Internal Medicine, NYU Winthrop , Mineola, NY , USA
| | - Peter Spiegler
- 1 Stony Brook University School of Medicine , Stony Brook, NY , USA
| | - Sanjeev Bhalla
- 6 Mallinckrodt Institute of Radiology, Washington University School of Medicine , St Louis, MO , USA
| | - Douglas S Katz
- 2 Department of Radiology, NYU Winthrop, Stony Brook University School of Medicine , Mineola, NY , USA
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11
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Moore AJE, Wachsmann J, Chamarthy MR, Panjikaran L, Tanabe Y, Rajiah P. Imaging of acute pulmonary embolism: an update. Cardiovasc Diagn Ther 2018; 8:225-243. [PMID: 30057872 DOI: 10.21037/cdt.2017.12.01] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Imaging plays an important role in the evaluation and management of acute pulmonary embolism (PE). Computed tomography (CT) pulmonary angiography (CTPA) is the current standard of care and provides accurate diagnosis with rapid turnaround time. CT also provides information on other potential causes of acute chest pain. With dual-energy CT, lung perfusion abnormalities can also be detected and quantified. Chest radiograph has limited utility, occasionally showing findings of PE or infarction, but is useful in evaluating other potential causes of chest pain. Ventilation-perfusion (VQ) scan demonstrates ventilation-perfusion mismatches in these patients, with several classification schemes, typically ranging from normal to high. Magnetic resonance imaging (MRI) also provides accurate diagnosis, but is available in only specialized centers and requires higher levels of expertise. Catheter pulmonary angiography is no longer used for diagnosis and is used only for interventional management. Echocardiography is used for risk stratification of these patients. In this article, we review the role of imaging in the evaluation of acute PE.
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Affiliation(s)
- Alastair J E Moore
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jason Wachsmann
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Murthy R Chamarthy
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Lloyd Panjikaran
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA
| | - Yuki Tanabe
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Prabhakar Rajiah
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
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Abstract
The purpose was to determine whether young women in the emergency department who received computed tomographic (CT) pulmonary angiograms were evaluated to receive lower dose imaging or no imaging, recognizing that the risks of radiation are particularly high in young women. This was a retrospective cohort investigation of women aged 18 to 29 years seen for suspected acute pulmonary embolism in emergency departments of 5 regional hospitals from May 1, 2015 to April 30, 2016. Computed tomographic (CT) pulmonary angiograms were obtained in 379 young women. Pulmonary embolism was diagnosed by CT angiography in 2.1%. A Wells probability score could be calculated in 11.9%. D-dimer was obtained in 46.2% and a chest radiograph was obtained in 41.7%. Among patients with a normal chest radiograph, 3.9% had a lung scan. Venous ultrasound of the lower extremities was obtained in 1.8%. Each had an elevated D-dimer. Among the young women who received CT angiograms, 53 were pregnant. In 17.0% of pregnant women, a Wells clinical probability score could be calculated from the medical record. D-dimer in pregnant women was obtained in 30.2%, chest radiograph in 22.6%, lung scan in 11.3%, and venous ultrasound of the lower extremities in none. In conclusion, young women and pregnant women often received CT pulmonary angiograms for suspected acute pulmonary embolism without an objective clinical assessment, measurement of D-dimer, lung scintiscan, or venous ultrasound, which may have eliminated the need for CT pulmonary angiography in many instances.
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Affiliation(s)
- Paul D. Stein
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Fadi Matta
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Kate E. Hughes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Mary J. Hughes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
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13
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"Pulmonary embolism diagnostics of pregnant patients: What is the recommended clinical pathway considering the clinical value and associated radiation risks of available imaging tests?". Phys Med 2017; 43:178-185. [PMID: 28760505 DOI: 10.1016/j.ejmp.2017.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/13/2017] [Accepted: 07/22/2017] [Indexed: 11/20/2022] Open
Abstract
Pulmonary embolism (PE) during pregnancy remains the leading preventable cause of maternal morbidity and mortality in the developed countries. Diagnosis of PE in pregnant patients is a challenging clinical problem, since pregnancy-related physiologic changes can mimic signs and symptoms of PE. Patient mismanagement may result into unjustified anticoagulant treatment or unnecessary imaging tests involving contrast-related or/and radiation-related risks for both the expectant mother and embryo/fetus. On the other hand, missing or delaying diagnosis of PE could lead to life-threatening conditions for both the mother and the embryo/fetus. Thus, a timely and accurate diagnostic approach is required for the optimal management of pregnant patients with suspected PE. Aim of the current review is to discuss a pregnancy-specific clinical pathway for the early diagnosis of PE with non-ionizing radiation- and ionizing radiation-based imaging modalities taking into account previously reported data on diagnostic value of available imaging tests, and radiation related concerns.
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Wan T, Skeith L, Karovitch A, Rodger M, Le Gal G. Guidance for the diagnosis of pulmonary embolism during pregnancy: Consensus and controversies. Thromb Res 2017; 157:23-28. [PMID: 28686913 DOI: 10.1016/j.thromres.2017.06.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 12/20/2022]
Abstract
Pulmonary embolism (PE) is one of the leading causes of maternal mortality despite a low incidence of PE during pregnancy. Several challenges surround the diagnosis of PE in pregnant women and the existing clinical guidelines provide weak recommendations on selecting the appropriate investigations for suspected PE in pregnancy. The purpose of this narrative review is to compare and contrast the recommendations of current clinical guidelines and review the evidence underpinning the recommendations on the evaluation of suspected PE in pregnancy. Consensus and controversies, knowledge gaps and areas requiring further research will be highlighted.
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Affiliation(s)
- Tony Wan
- Division of Hematology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Leslie Skeith
- Division of Hematology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Karovitch
- Division of General Internal Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Rodger
- Division of Hematology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Grégoire Le Gal
- Division of Hematology, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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Stein PD, Matta F, Hughes PG, Hourmouzis ZN, Hourmouzis NP, Schweiss RE, Bach JA, Kazan VM, Kakish EJ, Keyes DC, Hughes MJ. Follow-up CT pulmonary angiograms in patients with acute pulmonary embolism. Emerg Radiol 2016; 23:463-7. [PMID: 27405309 DOI: 10.1007/s10140-016-1422-1] [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: 05/23/2016] [Accepted: 07/04/2016] [Indexed: 11/29/2022]
Abstract
Computed tomographic (CT) angiography is associated with a non-negligible lifetime attributable risk of cancer. The risk is considerably greater for women and younger patients. Recognizing that there are risks from radiation, the purpose of this investigation was to assess the frequency of follow-up CT angiograms in patients with acute pulmonary embolism. This was a retrospective cohort study of patients aged ≥18 years with acute pulmonary embolism seen in three emergency departments from January 2013 to December 2014. Records of all patients were reviewed for at least 14 months. Pulmonary embolism was diagnosed by CT angiography in 600 patients. At least one follow-up CT angiogram in 1 year was obtained in 141 of 600 (23.5 %). Two follow-ups in 1 year were obtained in 40 patients (6.7 %), 3 follow-ups were obtained in 15 patients (2.5 %), and 4 follow-ups were obtained in 3 patients (0.5 %). Among young women (aged ≤29 years) with pulmonary embolism, 10 of 21 (47.6 %) had at least 1 follow-up and 4 of 21 (19.0 %) had 2 or more follow-ups in 1 year. Among all patients, recurrent pulmonary embolism was diagnosed in 15 of 141 (10.6 %) on the first follow-up CT angiogram and in 6 of 40 (15.0 %) on the second follow-up. Follow-up CT angiograms were obtained in a significant proportion of patients with pulmonary embolism, including young women, the group with the highest risk. Alternative options might be considered to reduce the hazard of radiation-induced cancer, particularly in young women.
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Affiliation(s)
- Paul D Stein
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, 909 Fee Road, East Lansing, MI, 48824, USA.
| | - Fadi Matta
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, 909 Fee Road, East Lansing, MI, 48824, USA
| | - Patrick G Hughes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, 909 Fee Road, East Lansing, MI, 48824, USA.,Department of Medical Education, Summa Akron City Hospital, Akron, OH, USA
| | - Zak N Hourmouzis
- Department of Medical Education, Summa Akron City Hospital, Akron, OH, USA
| | - Nina P Hourmouzis
- Department of Medical Education, Summa Akron City Hospital, Akron, OH, USA
| | - Robert E Schweiss
- Department of Emergency Medicine, St. Mary Mercy Hospital, Livonia, MI, USA
| | - Jennifer A Bach
- Department of Emergency Medicine, St. Mary Mercy Hospital, Livonia, MI, USA
| | - Viviane M Kazan
- Department of Emergency Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Edward J Kakish
- Department of Emergency Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Daniel C Keyes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, 909 Fee Road, East Lansing, MI, 48824, USA.,Department of Emergency Medicine, St. Mary Mercy Hospital, Livonia, MI, USA
| | - Mary J Hughes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, 909 Fee Road, East Lansing, MI, 48824, USA
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Abstract
The diagnosis of pulmonary embolism (PE) remains challenging despite the evolution of well-validated clinical algorithms over the past few decades, largely because of nonspecific clinical features altering clinician suspicion. D-dimer is a simple noninvasive test that is an essential part of the diagnostic algorithm but is often deemed to be of little value in patients who are elderly or have other comorbidities. We describe a case of an elderly man who presented with clinical features and initial imaging consistent with pneumonia and a positive D-dimer test. Adherence to the suggested diagnostic algorithm and obtaining chest imaging, however, prevented what could have been a catastrophic missed diagnosis of PE. We review existing evidence on the importance of suspecting PE in the presence of alternative diagnosis and explore the literature on the association between the magnitude of D-dimer and the diagnosis of PE.
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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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Diagnostic accuracy of computed tomography pulmonary angiography with reduced radiation and contrast material dose: a prospective randomized clinical trial. Invest Radiol 2014; 49:201-8. [PMID: 24473367 DOI: 10.1097/rli.0000000000000016] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The objective of the study was to test the diagnostic performance of low-dose computed tomography pulmonary angiography (CTPA) at peak tube voltage of 80 kVp with both reduced radiation and reduced contrast material (CM) dose. MATERIALS AND METHODS In this single-center, single-blinded prospective randomized trial, 501 patients with body weights of less than 100 kg with suspected acute pulmonary embolism (PE) were assigned to normal-dose CTPA (100-kVp tube energy and 100-mL CM, 255 patients) and low-dose CTPA (80-kVp tube energy and 75-mL CM, 246 patients). Primary end points were evidence of PE in CTPA and accuracy of CTPA on a composite reference standard. Results were compared by calculating the odds ratio with the 95% confidence interval. RESULTS The reference diagnosis was equivocal in 20 of the 501 patients. Diagnosis of CTPA was correct in 240 patients and incorrect in 5 in the normal-dose group. Computed tomography pulmonary angiography was correct in 230 patients and incorrect in 6 in the low-dose group (odds ratio, 1.25; 95% confidence interval, 0.38-4.16; P = 0.77). Sensitivity was 96.9% and 100% and specificity was 98.1% and 97.1% in the normal-dose and low-dose groups, respectively. No PE or PE-related death occurred during the 90-day follow-up. The size-specific dose estimates were 30% lower at 80 kVp (4.8 ± 1.0 mGy) compared with that at 100 kVp (6.8 ± 1.2 mGy; P < 0.001). CONCLUSIONS The accuracy of low-dose CTPA at 80 kVp with a 30% reduced radiation dose and a 25% lower CM volume is not significantly different from that of normal-dose CTPA at 100 kVp in detecting acute PE in patients weighing less than 100 kg.
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Jenab Y, Lotfi-Tokaldany M, Alemzadeh-Ansari MJ, Seyyedi SR, Shirani S, Soudaee M, Ghaffari-Marandi N. Correlates of syncope in patients with acute pulmonary thromboembolism. Clin Appl Thromb Hemost 2014; 21:772-6. [PMID: 24989710 DOI: 10.1177/1076029614540037] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Identification of pulmonary thromboembolism (PTE), as a cause of syncope, is important and may be life saving. We prospectively analyzed data on 335 patients with acute PTE. Relationships between syncope secondary to acute PTE and clinical findings, risk factors, and imaging modalities were analyzed. Of the 335 patients, 36 (10.7%) had syncope at presentation. Compared to patients without syncope, those with syncope had a higher frequency of right ventricular (RV) dysfunction (94.3% vs 72.1%, respectively; P value = .004) and saddle embolism (24.2% vs 10.9%, respectively; P value = .044). Frequency of RV dysfunction was similar between patients with and without saddle embolism. Although not significant, more patients with syncope had a history of previous PTE (P value = .086). By multivariable analysis, RV dysfunction and saddle embolism were independent correlates of syncope in patients with PTE. In-hospital mortality was not significantly different between the groups. In conclusion, among patients with PTE, RV dysfunction and saddle embolism were the independent correlates of syncope.
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Affiliation(s)
- Yaser Jenab
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | | | - Shapoor Shirani
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Soudaee
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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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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Zochios VA, Keeshan A. Pulmonary Embolism in the Mechanically-Ventilated Critically Ill Patient: Is it Different? J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Pulmonary embolism (PE) confers significant in-hospital morbidity and mortality, and critically ill patients remain at risk for venous thromboembolism despite thromboprophylaxis. Recognition of the clinical manifestations and immediate management of PE are of paramount importance. Despite diagnostic advances, PE is often undiagnosed and untreated in patients receiving mechanical ventilation, as these patients do not exhibit the common clinical features of the condition, making the diagnosis very challenging. Computed tomographic pulmonary angiography is probably the reference standard for the diagnosis of acute PE in the haemodynamically stable, ventilated patient. In the setting of circulatory collapse, bedside echocardiography may be used to risk stratify these patients, based on the presence or absence of right ventricular dysfunction, and guide further management. Treatment options include anticoagulation alone, anticoagulation plus thrombolysis, surgical or catheter embolectomy. Inotropes, vasopressors and pulmonary artery vasodilators may be considered after initial resuscitation of the right ventricle. Few studies have focused on estimating the prevalence of PE among mechanically-ventilated intensive care unit (ICU) patients and there is notable lack of data assessing predictive factors, prevention, diagnostic strategy and management of PE in the ICU setting.
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Affiliation(s)
- Vasileios A Zochios
- ACCS Anaesthesia Core Trainee, East Midlands (South) School of Anaesthesia, University Hospitals of Leicester NHS Trust
| | - Alex Keeshan
- Consultant Intensivist, University Hospitals of Leicester NHS Trust, Leicester General Hospital
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Pena E, Dennie C. Acute and Chronic Pulmonary Embolism: An In-depth Review for Radiologists Through the Use of Frequently Asked Questions. Semin Ultrasound CT MR 2012; 33:500-21. [DOI: 10.1053/j.sult.2012.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Viteri-Ramírez G, García-Lallana A, Simón-Yarza I, Broncano J, Ferreira M, Pueyo J, Villanueva A, Bastarrika G. Low radiation and low-contrast dose pulmonary CT angiography: Comparison of 80 kVp/60 ml and 100 kVp/80 ml protocols. Clin Radiol 2012; 67:833-9. [PMID: 22683247 DOI: 10.1016/j.crad.2011.11.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 11/06/2011] [Accepted: 11/08/2011] [Indexed: 10/28/2022]
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Leung AN, Bull TM, Jaeschke R, Lockwood CJ, Boiselle PM, Hurwitz LM, James AH, McCullough LB, Menda Y, Paidas MJ, Royal HD, Tapson VF, Winer-Muram HT, Chervenak FA, Cody DD, McNitt-Gray MF, Stave CD, Tuttle BD. American Thoracic Society documents: an official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline--Evaluation of Suspected Pulmonary Embolism in Pregnancy. Radiology 2012; 262:635-46. [PMID: 22282185 DOI: 10.1148/radiol.11114045] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a leading cause of maternal mortality in the developed world. Along with appropriate prophylaxis and therapy, prevention of death from PE in pregnancy requires a high index of clinical suspicion followed by a timely and accurate diagnostic approach. METHODS To provide guidance on this important health issue, a multidisciplinary panel of major medical stakeholders was convened to develop evidence-based guidelines for evaluation of suspected pulmonary embolism in pregnancy using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system. In formulation of the recommended diagnostic algorithm, the important outcomes were defined to be diagnostic accuracy and diagnostic yield; the panel placed a high value on minimizing cumulative radiation dose when determining the recommended sequence of tests. RESULTS Overall, the quality of the underlying evidence for all recommendations was rated as very low or low with some of the evidence considered for recommendations extrapolated from studies of the general population. Despite the low quality evidence, strong recommendations were made for three specific scenarios: performance of chest radiography (CXR) as the first radiation-associated procedure; use of lung scintigraphy as the preferred test in the setting of a normal CXR; and performance of computed-tomographic pulmonary angiography (CTPA) rather than digital subtraction angiography (DSA) in a pregnant woman with a nondiagnostic ventilation-perfusion (V/Q) result. DISCUSSION The recommendations presented in this guideline are based upon the currently available evidence; availability of new clinical research data and development and dissemination of new technologies will necessitate a revision and update.
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Leung AN, Bull TM, Jaeschke R, Lockwood CJ, Boiselle PM, Hurwitz LM, James AH, McCullough LB, Menda Y, Paidas MJ, Royal HD, Tapson VF, Winer-Muram HT, Chervenak FA, Cody DD, McNitt-Gray MF, Stave CD, Tuttle BD. An Official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline: Evaluation of Suspected Pulmonary Embolism In Pregnancy. Am J Respir Crit Care Med 2011; 184:1200-8. [DOI: 10.1164/rccm.201108-1575st] [Citation(s) in RCA: 148] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Diagnostic Accuracy of Pulmonary CT Angiography at Low Tube Voltage: Intraindividual Comparison of a Normal-Dose Protocol at 120 kVp and a Low-Dose Protocol at 80 kVp Using Reduced Amount of Contrast Medium in a Simulation Study. AJR Am J Roentgenol 2011; 197:W852-9. [DOI: 10.2214/ajr.11.6750] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Scott K, Rutherford N, Fagermo N, Lust K. Use of imaging for investigation of suspected pulmonary embolism during pregnancy and the postpartum period. Obstet Med 2011; 4:20-3. [PMID: 27579091 DOI: 10.1258/om.2010.100065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2010] [Indexed: 11/18/2022] Open
Abstract
Pulmonary embolism (PE) is recognized as a leading cause of maternal mortality in the developed world; however, it is a very difficult diagnosis to make on clinical grounds, and in most cases imaging is required. Pregnancy is a recognized risk factor for venous thromboembolism, and symptoms of normal pregnancy including shortness of breath, tachycardia and leg swelling are included in clinical tools for risk stratification for PE in the non-pregnant population. This results in a very low threshold for imaging, despite concerns regarding the risk of exposure to ionizing radiation both for the fetus and the maternal breast. We reviewed the results of all ventilation/perfusion scans and computed tomography pulmonary angiograms performed in pregnant women at a single institution to identify how many of these tests were positive for PE, and which clinical features may identify a low-risk group. A total of 386 scans were performed to investigate 375 episodes of suspected PE, representing 1.3-1.5% of pregnant women. Fifteen patients were diagnosed with PE, giving an incidence of one in 2000 maternities. The only statistically significant factors associated with PE were smoking or the presence of multiple risk factors. Clinical features of tachycardia and leg swelling did not provide significant diagnostic value; however, the absence of pleuritic chest pain had a negative predictive value of 97.8%. Arterial blood gas and D-dimer were statistically different between those with and without PE but not to a clinically useful degree. Currently available clinical and laboratory tools are not adequate to exclude a diagnosis of PE in a pregnant patient, thus imaging is justified to exclude PE. Further longitudinal studies to identify a low-risk group who do not require imaging is vital.
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Affiliation(s)
- Katherine Scott
- Department of Internal Medicine and Aged Care, Obstetric Medicine Unit, Royal Brisbane and Women's Hospital
| | - Natalie Rutherford
- Department of Nuclear Medicine, Royal Brisbane and Women's Hospital , Australia
| | - Narelle Fagermo
- Department of Internal Medicine and Aged Care, Obstetric Medicine Unit, Royal Brisbane and Women's Hospital
| | - Karin Lust
- Department of Internal Medicine and Aged Care, Obstetric Medicine Unit, Royal Brisbane and Women's Hospital
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Li YY, Zhai ZG, Yang YH, Pang BS, Wang HY, Zhang W, Zhao L, Wang J, Wang C. Association of the 894G>T polymorphism in the endothelial nitric oxide synthase gene with risk of venous thromboembolism in Chinese population. Thromb Res 2011; 127:324-7. [PMID: 21320716 DOI: 10.1016/j.thromres.2010.11.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 11/28/2010] [Accepted: 11/29/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Endothelium derived nitric oxide (NO) is a key mediator of vascular homeostasis. Endothelial nitric oxide synthase (eNOS) gene, by affecting the expression and functional activity of the eNOS enzyme, thereby reducing NO availability, may be implicated in venous thromboembolism (VTE). We investigated the eNOS G894T polymorphism in VTE patients in the Chinese population. MATERIALS AND METHODS A case-control study was conducted in a general hospital. Blood samples, collected from 462 consecutive patients with VTE and 462 healthy controls, were used for DNA extraction. Single nucleotide polymorphisms (SNP) of eNOS (894G/T) were determined by allele specific-polymerase chain reaction (ARMS-PCR) analysis. RESULTS The eNOS 894G/T polymorphism alleles distribution was in agreement with the principle of Hardy-Weinberg equilibrium. The prevalence of homozygote, heterozygote and pathological homozygote for the eNOS G894T polymorphism in VTE patients was 79.7%, 18.1% and 2.2%, respectively (controls: 86.6%,12.3% and 1.1%). T allele distribution in the VTE (11.3%) and especially the male VTE patients (12.5%) was more common than in healthy controls (7.3%). The frequency of GT+TT genotype was significantly higher among the age≤55years patients in VTE group than in controls (20.1% vs. 12.2%, P=0.033). CONCLUSION Our result demonstrates that the 894G/T polymorphism variant of eNOS is a risk factor for VTE in Chinese population.
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Affiliation(s)
- Yan-Yan Li
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
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Baysinger CL. In Response. Anesth Analg 2011. [DOI: 10.1213/ane.0b013e3181fe7aea] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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PULMONARY EMBOLUS. JAAPA 2011. [DOI: 10.1097/01720610-201101000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Comparison of Respiratory Motion Artifact From Craniocaudal Versus Caudocranial Scanning With 64-MDCT Pulmonary Angiography. AJR Am J Roentgenol 2010; 195:155-9. [DOI: 10.2214/ajr.09.3673] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Stein PD, Chenevert TL, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, Jablonski KA, Leeper KV, Naidich DP, Sak DJ, Sostman HD, Tapson VF, Weg JG, Woodard PK. Gadolinium-enhanced magnetic resonance angiography for pulmonary embolism: a multicenter prospective study (PIOPED III). Ann Intern Med 2010; 152:434-43, W142-3. [PMID: 20368649 PMCID: PMC3138428 DOI: 10.7326/0003-4819-152-7-201004060-00008] [Citation(s) in RCA: 238] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The accuracy of gadolinium-enhanced magnetic resonance pulmonary angiography and magnetic resonance venography for diagnosing pulmonary embolism has not been determined conclusively. OBJECTIVE To investigate performance characteristics of magnetic resonance angiography, with or without magnetic resonance venography, for diagnosing pulmonary embolism. DESIGN Prospective, multicenter study from 10 April 2006 to 30 September 2008. SETTING 7 hospitals and their emergency services. PATIENTS 371 adults with diagnosed or excluded pulmonary embolism. MEASUREMENTS Sensitivity, specificity, and likelihood ratios were measured by comparing independently read magnetic resonance imaging with the reference standard for diagnosing pulmonary embolism. Reference standard diagnosis or exclusion was made by using various tests, including computed tomographic angiography and venography, ventilation-perfusion lung scan, venous ultrasonography, d-dimer assay, and clinical assessment. RESULTS Magnetic resonance angiography, averaged across centers, was technically inadequate in 25% of patients (92 of 371). The proportion of technically inadequate images ranged from 11% to 52% at various centers. Including patients with technically inadequate images, magnetic resonance angiography identified 57% (59 of 104) with pulmonary embolism. Technically adequate magnetic resonance angiography had a sensitivity of 78% and a specificity of 99%. Technically adequate magnetic resonance angiography and venography had a sensitivity of 92% and a specificity of 96%, but 52% of patients (194 of 370) had technically inadequate results. LIMITATION A high proportion of patients with suspected embolism was not eligible or declined to participate. CONCLUSION Magnetic resonance pulmonary angiography should be considered only at centers that routinely perform it well and only for patients for whom standard tests are contraindicated. Magnetic resonance pulmonary angiography and magnetic resonance venography combined have a higher sensitivity than magnetic resonance pulmonary angiography alone in patients with technically adequate images, but it is more difficult to obtain technically adequate images with the 2 procedures.
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Affiliation(s)
- Paul D Stein
- Michigan State University, College of Osteopathic Medicine, Department of Internal Medicine, Michigan State University Venous Thromboembolism Research Unit, St. Joseph-Mercy Oakland Hospital, 44405 Woodward Avenue, Pontiac, MI 48341-5023, USA.
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Dual-Energy CT for Assessment of the Severity of Acute Pulmonary Embolism: Pulmonary Perfusion Defect Score Compared With CT Angiographic Obstruction Score and Right Ventricular/Left Ventricular Diameter Ratio. AJR Am J Roentgenol 2010; 194:604-10. [DOI: 10.2214/ajr.09.2681] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Imaging Evaluation for Suspected Pulmonary Embolism: What Do Emergency Physicians and Radiologists Say? AJR Am J Roentgenol 2010; 194:W38-48. [DOI: 10.2214/ajr.09.2694] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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36
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Miles S, Rogers KM, Thomas P, Soans B, Attia J, Abel C, Holt E, D'Este CA, Hensley MJ. A Comparison of Single-Photon Emission CT Lung Scintigraphy and CT Pulmonary Angiography for the Diagnosis of Pulmonary Embolism. Chest 2009; 136:1546-1553. [DOI: 10.1378/chest.09-0361] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Comparison of Lung Scintigraphy With Multi-Slice Spiral Computed Tomography in the Diagnosis of Pulmonary Embolism. Clin Nucl Med 2009; 34:424-7. [DOI: 10.1097/rlu.0b013e3181a7cfea] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ventilation/perfusion lung scintigraphy: what is still needed? A review considering technetium-99m-labeled macro-aggregates of albumin. Ann Nucl Med 2009; 23:1-16. [PMID: 19205833 DOI: 10.1007/s12149-008-0187-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Accepted: 07/08/2008] [Indexed: 10/21/2022]
Abstract
Lung perfusion scintigraphy (LPS) with technetium-99m-labeled macro-aggregates of albumin (Tc-99m-MAA) is well established in the diagnostic of pulmonary embolism (PE). In the last decade, it was shown that single-photon emission computer tomography (SPECT) acquisition of LPS overcame static scintigraphy. Furthermore, there are rare indications for LPS, such as preoperative quantification of regional lung function prior to lung resection or transplantation, optimization of lung cancer radiation therapy, quantification of right-left shunt, planning of intra-arterial chemotherapy, and several rare indications in pediatrics. Moreover, LPS with Tc-99m-MAA is a safe method with low radiation exposure. PE can also be diagnosed by spiral computer tomography (CT), ultrasound, magnetic resonance angiography, or pulmonary angiography (PA, former gold standard). The present review considers all these methods, especially spiral CT, and compares them with LPS with respect to sensitivity and specificity and gives an overview of established and newer publications. It shows that LPS with Tc-99m-MAA represents a diagnostic method of continuing value for PE. In comparison with spiral CT and/or PA, LPS is not to be defeated as mentioned also by the most actual Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II reports. This applies in particular to chronic or recurring embolisms, whereas currently spiral CT may be of greater value for major or life-threatening embolisms. At present, LPS cannot be replaced by other methods in some applications, such as pediatrics or in the quantification of regional pulmonary function in a preoperative context or prior to radiation therapy. LPS still has a place in the diagnostics of PE and is irreplaceable in several rare indications as described earlier.
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Stein PD, Gottschalk A, Sostman HD, Chenevert TL, Fowler SE, Goodman LR, Hales CA, Hull RD, Kanal E, Leeper KV, Nadich DP, Sak DJ, Tapson VF, Wakefield TW, Weg JG, Woodard PK. Methods of Prospective Investigation of Pulmonary Embolism Diagnosis III (PIOPED III). Semin Nucl Med 2008; 38:462-70. [PMID: 19331840 PMCID: PMC2605689 DOI: 10.1053/j.semnuclmed.2008.06.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In this work, the methods of the Prospective Investigation of Pulmonary Embolism Diagnosis III (PIOPED III) are described in detail. PIOPED III is a multicenter collaborative investigation sponsored by the National Heart, Lung and Blood Institute. The purpose is to determine the accuracy of gadolinium-enhanced magnetic resonance angiography in combination with venous phase magnetic resonance venography for the diagnosis of acute pulmonary embolism (PE). A composite reference standard based on usual diagnostic methods for PE is used. All images will be read by 2 blinded and study-certified central readers. Patients with no PE according to the composite reference test will be randomized to undergo gadolinium-enhanced magnetic resonance angiography in combination with venous phase magnetic resonance venography. This procedure will reduce the proportion of patients with negative tests at no loss in evaluation of sensitivity and specificity.
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Affiliation(s)
- Paul D Stein
- Department of Research, St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341-5023, USA.
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The prevalence of symptomatic and coincidental pulmonary embolism on computed tomography. J Comput Assist Tomogr 2008; 32:783-7. [PMID: 18830112 DOI: 10.1097/rct.0b013e31815a7aea] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the proportion of pulmonary embolism (PE) on computed tomographic pulmonary angiography (CTPA) and the proportion of coincidental PE on regular contrast-enhanced CT in oncological and nononcological patients. METHODS This study received internal review board approval and was Health Insurance Portability and Accountability Act compliant. All consecutive adult patients who had contrast-enhanced chest CT or dedicated CTPA during January 2005 were studied. Procedural codes were used to identify cases, and all CT images were reviewed. Clinical data collected included oncology status, chemotherapy regimen, site of tumor, and location of PE. chi2 Tests were used for statistical analysis. RESULTS Two hundred twenty-nine patients had CTPA, and 27 (11.8%) of them were positive for PE. Of 1168 patients who had contrast-enhanced CT for other indications, coincidental PE was found in 21 patients (1.8%). The proportions of coincidental PE were 3.3% of patients with progressive cancer, 2.5% of patients with stable cancer, 0.7% of patients with no evidence of cancer posttreatment, and 1.0% of nononcological patients. Coincidental PE was found more frequently in patients with progressive cancer compared with nononcological patients (P = 0.035). Patients who were on chemotherapy also had a higher risk of coincidental PE (P=0.019). CONCLUSIONS The prevalence of symptomatic PE on dedicated CTPA was 11.8%, and the rate of coincidental PE on contrast-enhanced CT was 1.8%. Coincidental PE was significantly higher inpatients with progressive cancer or those receiving chemotherapy.
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Abstract
Venous thromboembolic disease is composed of two disease entities: pulmonary thromboembolism/pulmonary embolism and deep venous thrombosis. Clinical signs and symptoms of venous thromboembolic disease often are nonspecific and, as a result, the diagnosis may be difficult. If left untreated, pulmonary embolism can lead to a potentially fatal outcome. This article focuses on CT angiography as the diagnostic modality for thromboembolic pulmonary embolism and briefly discusses nonthromboembolic pulmonary embolism.
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Affiliation(s)
- Wael E A Saad
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA.
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Hoang JK, Lee WK, Hennessy OF. Multidetector CT pulmonary angiography features of pulmonary embolus. J Med Imaging Radiat Oncol 2008; 52:307-17. [DOI: 10.1111/j.1440-1673.2008.01961.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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43
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Challenges in the diagnosis of acute pulmonary embolism. Am J Med 2008; 121:565-71. [PMID: 18589050 DOI: 10.1016/j.amjmed.2008.02.033] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Revised: 02/05/2008] [Accepted: 02/08/2008] [Indexed: 11/22/2022]
Abstract
The state of the art of diagnostic evaluation of hemodynamically stable patients with suspected acute pulmonary embolism was reviewed. Diagnostic evaluation should begin with clinical assessment using a validated prediction rule in combination with measurement of D-dimer when appropriate. Imaging should follow only when necessary. Although with 4-slice computed tomography (CT) and 16-slice CT, the sensitivity for detection of pulmonary embolism was increased by combining CT angiography with CT venography, it is not known whether CT venography increases the sensitivity of 64-slice CT angiography. Methods to reduce the radiation exposure of CT venography include imaging only the proximal leg veins (excluding the pelvis) and obtaining discontinuous images. Compression ultrasound can be used instead. In young women, radiation of the breasts produces the greatest risk of radiation-induced cancer. It may be that scintigraphy is the imaging test of choice in such patients, but this pathway should be tested prospectively. A patient-specific approach to the diagnosis of pulmonary embolism can be taken safely in hemodynamically stable patients to increase efficiency and decrease cost and exposure to radiation.
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Boots RJ, Phillips GE, George N, Faoagali JL. Surveillance culture utility and safety using low-volume blind bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia. Respirology 2008; 13:87-96. [PMID: 18197916 DOI: 10.1111/j.1440-1843.2007.01211.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Surveillance cultures may improve the prediction of ventilator-associated pneumonia (VAP) and empirical antibiotic selection. This study examined the utility and patient safety of blind, non-protected, low-volume mini-bronchial lavage (BM-BAL) surveillance cultures in predicting VAP. METHODOLOGY A prospective, cohort study was performed in a large general intensive care unit. BM-BALs were collected within 12 h of admission then thrice weekly. Each BM-BAL was screened by Gram staining for intracellular organisms and then quantitatively cultured. VAP was diagnosed using the Clinical Pulmonary Infection Score. The concordance for isolates from the BM-BAL was assessed against concurrently collected endotracheal aspirates (EA). RESULTS Four hundred and twelve patients requiring a minimum of 48 h of mechanical ventilation were enrolled. Fifty patients developed 58 episodes of VAP. Concordant pathogens were found in 85% of BM-BAL specimens collected 2 days prior to VAP onset. Their antibiograms were stable over the preceding 4 days. The isolation of pathogens with colony counts >or=10(4) cfu/mL from BM-BAL performed 2 days prior to the clinical onset of VAP had a sensitivity of 84%, specificity of 50%, positive predictive value of 31% and a negative predictive value of 93% for predicting the development of VAP. BM-BAL WCC, quantification of bacterial growth and the percentage of intracellular organisms were not helpful in predicting VAP diagnosis. CONCLUSIONS BM-BAL surveillance cultures are well tolerated and useful in predicting the pathogens and their antibiograms causing VAP. Diagnostic specimen collection at the time of VAP onset is still required as surveillance cultures may be negative even one day prior to VAP onset.
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Affiliation(s)
- Robert J Boots
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia.
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Freeman LM. Don't Bury the V/Q Scan: It's as Good as Multidetector CT Angiograms with a Lot Less Radiation Exposure. J Nucl Med 2007; 49:5-8. [DOI: 10.2967/jnumed.107.048066] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Albrizio M, Mizzi A. Rate of computed tomography pulmonary angiographies (CTPA) positive for pulmonary embolism and predictive scores. Radiol Med 2007; 112:982-7. [DOI: 10.1007/s11547-007-0199-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2006] [Accepted: 01/26/2007] [Indexed: 10/22/2022]
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Multidetector computed tomography for the diagnosis of acute pulmonary embolism. Curr Opin Pulm Med 2007; 13:384-8. [DOI: 10.1097/mcp.0b013e32821acdbe] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Wittram C, Waltman AC, Shepard JAO, Halpern E, Goodman LR. Discordance between CT and Angiography in the PIOPED II Study. Radiology 2007; 244:883-9. [PMID: 17664436 DOI: 10.1148/radiol.2443061693] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively evaluate the causes of discordant computed tomographic (CT)-angiographic readings from the Prospective Investigation of Pulmonary Embolism Diagnosis, or PIOPED, II study. MATERIALS AND METHODS Institutional review board approval was obtained for this HIPAA-compliant study. Of 1036 patients suspected of having pulmonary embolism who were examined with CT, 226 underwent angiography; 206 patients had concordant results and 20 had discordant results according to two independent readers. Of these 20 patients, 10 were men and 10 were women (mean age, 49 years). Among the 20 studies with discordant results, central readers identified seven cases as negative and 13 as positive for pulmonary embolism at CT; these findings were reversed at angiography. Side-by-side comparisons of discordant studies were performed in consensus. The time between CT and angiography and all locations of pulmonary embolism vascular territory were recorded. The McNemar binomial test was used. RESULTS One patient had false-positive findings at angiography, 13 patients had false-negative findings at angiography, and two patients had false-negative findings at CT. Four patients had true-negative findings at CT; however, findings were positive for thrombus at angiography. The sensitivity for the detection of pulmonary embolism was 87% for CT and 32% for angiography (P=.007). The largest missed thrombus at angiography was subsegmental in eight patients, segmental in two patients, and lobar in three patients; at CT it was subsegmental in two patients. The mean time between CT and angiography was 40 hours+/-21 (standard deviation) (range, 10-97 hours). CONCLUSION In the interval between CT and angiography, thrombi can remain the same, resolve, develop, or result from angiography.
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Affiliation(s)
- Conrad Wittram
- Division of Thoracic Radiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Founders Bldg 202, 55 Fruit St, Boston, MA 02114, USA.
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Abstract
OBJECTIVE The purpose of this study was to describe the manifestations of pulmonary embolism on 18F-FDG PET scans in 13 patients. CONCLUSION The activity of acute pulmonary embolism on FDG PET scans was significantly higher than the activity of vessels not containing thrombi. The shape of the abnormal FDG uptake may be focal or curvilinear.
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Affiliation(s)
- Conrad Wittram
- Division of Thoracic Radiology, Massachusetts General Hospital, Founders 202, 55 Fruit St., Boston, MA 02114, USA.
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Stein PD, Beemath A, Quinn DA, Olson RE, Goodman LR, Gottschalk A, Hales CA, Hull RD, Leeper KV, Sostman HD, Weg JG, Woodard PK. Usefulness of multidetector spiral computed tomography according to age and gender for diagnosis of acute pulmonary embolism. Am J Cardiol 2007; 99:1303-5. [PMID: 17478162 DOI: 10.1016/j.amjcard.2006.12.051] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2006] [Revised: 12/11/2006] [Accepted: 12/11/2006] [Indexed: 11/28/2022]
Abstract
Data from the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) were evaluated to test the hypothesis that the performance of multidetector computed tomographic (CT) pulmonary angiography and CT venography is independent of a patient's age and gender. In 773 patients with adequate CT pulmonary angiography and 737 patients with adequate CT pulmonary angiography and CT venography, the sensitivity and specificity for pulmonary embolism for groups of patients aged 18 to 59, 60 to 79, and 80 to 99 years did not differ to a statistically significant extent, nor were there significant differences according to gender. Overall, however, the specificity of CT pulmonary angiography was somewhat greater in women, but in men and women, it was > or =93%. In conclusion, the results indicate that multidetector CT pulmonary angiography and CT pulmonary angiography and CT venography may be used with various diagnostic strategies in adults of all ages and both genders.
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Affiliation(s)
- Paul D Stein
- Department of Research, St. Joseph Mercy Oakland Hospital, Pontiac, Michigan, USA.
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