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Diagnosis of Pulmonary Embolism: Conventional Ventilation/Perfusion SPECT Is Superior to the Combination of Perfusion SPECT and Nonenhanced CT.

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Diagnosis of Pulmonary Embolism: Conventional Ventilation/Perfusion SPECT Is Superior to the Combination of Perfusion SPECT and Nonenhanced CT.

Respiration. 2014 Aug 30;

Authors: Palmowski K, Oltmanns U, Kreuter M, Mottaghy FM, Palmowski M, Behrendt FF

Abstract
Background: Ventilation/perfusion single-emission photon CT (V/P-SPECT) is widely used to detect pulmonary embolism (PE). Any pathological deficit on P-SPECT with a corresponding unremarkable V-SPECT is considered an embolism. This means that a deficit on P-SPECT with a corresponding deficit on the ventilation scan correlates with other lung pathologies such as pneumonia, bullous emphysema or tumor. In principle, it is possible to identify any of these lung pathologies on nonenhanced chest CT and so this technique has the potential to replace V-SPECT in the diagnosis of PE. Today, SPECT/CT hybrid imaging systems are increasingly applied in clinical routines. Objectives: We investigated whether embolism can be diagnosed using a combined P-SPECT/CT hybrid imaging approach without V-SPECT. Methods: Ninety-three patients with clinically suspected embolism were investigated with standard V/P-SPECT and a nonenhanced CT scan on a combined SPECT/CT system. A diagnosis of embolism was based on V/P-SPECT (gold standard). P-SPECT/CT datasets were blinded and analyzed without any knowledge of the V-SPECT data. The accuracy of P-SPECT/CT was compared to the gold standard. Results: Embolism was diagnosed in 24/93 patients using V/P-SPECT. In total, 57 lung lobes were affected. P-SPECT/CT significantly (p < 0.01) overdiagnosed embolism in nonaffected patients. In total, 36 cases with 88 affected lung lobes were shown. The sensitivity was 95.8%, the specificity 82.6%, the false-negative rate 4.2% and the false-positive rate 17.3%. Conclusions: Our results demonstrate that a nonenhanced CT scan in a novel hybrid imaging system cannot replace V-SPECT in the scintigraphy-based diagnosis of PE. V-SPECT increases specificity and reduces the number of false-positive results when compared to 'perfusion-only' SPECT/CT. © 2014 S. Karger AG, Basel.

PMID: 25196553 [PubMed - as supplied by publisher]

Alternative diagnoses in patients in whom the GP considered the diagnosis of pulmonary embolism.

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Pulmonary embolism (PE) often presents with nonspecific symptoms and may be an easily missed diagnosis. When the differential diagnosis includes PE, an empirical list of frequently occurring alternative diagnoses could support the GP in diagnostic decision making.

OBJECTIVES: To identify common alternative diagnoses in patients in whom the GP suspected PE but in whom PE could be ruled out. To investigate how the Wells clinical decision rule for PE combined with a point-of-care d-dimer test is associated with these alternative diagnoses.

METHODS: Secondary analysis of the Amsterdam Maastricht Utrecht Study on thrombo-Embolism (Amuse-2) study, which validated the Wells PE rule combined with point-of-care d-dimer testing in primary care. All 598 patients had been referred to and diagnosed in secondary care. All diagnostic information was retrieved from the GPs' medical records.

RESULTS: In 516 patients without PE, the most frequent alternative diagnoses were nonspecific thoracic pain/dyspnoea (42.6%), pneumonia (13.0%), myalgia (11.8%), asthma/chronic obstructive pulmonary disease (4.8%), panic disorder/hyperventilation (4.1%) and respiratory tract infection (2.3%). Pneumonia occurred almost as frequent as PE. Patients without PE with either a positive Wells rule (>4) or a positive d-dimer test, were more often (odds ratio = 2.1) diagnosed with a clinically relevant disease than patients with a negative Wells rule and negative d-dimer test.

CONCLUSION: In primary care patients suspected of PE, the most common clinically relevant diagnosis other than PE was pneumonia. A positive Wells rule or a positive d-dimer test are not only positively associated with PE, but also with a high probability of other clinically relevant disease.

Review: In pulmonary embolism, thrombolytic therapy reduces all-cause mortality but increases major bleeding.

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Ann Intern Med. 2014 Sep 16;161(6):JC9
PMID: 25222421 [PubMed - in process]

Pulmonary Embolectomy in the Treatment of Submassive and Massive Pulmonary Embolism.

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MPESignificant improvements in outcomes after pulmonary embolectomy have resulted in a broadening of indications. We reviewed our experience with pulmonary embolectomy over the past 12 years with an emphasis on preoperative comorbidities and postoperative morbidity and mortality.

Methods: All patients undergoing pulmonary embolectomy over the past 12 years at our institution were analyzed via retrospective chart review. Data on preoperative characteristics, operative procedures and postoperative outcomes were collected.

Results: Twenty patients underwent pulmonary embolectomy between 1999 and 2011. The average age was 56 years (range 24-81) and 10 patients (50%) were female. All patients demonstrated right ventricular dysfunction and 19 (95%) demonstrated contraindications to thrombolysis. Twelve patients (60%) demonstrated intermittent hypotension, 4 (20%) required intubation and 3 (15%) demonstrated preoperative or intraoperative cardiac arrest. Survival to discharge was 95%.

Conclusions: Pulmonary embolectomy has been shown to be safe and effective in the treatment of massive pulmonary embolism (PE). We achieved a 95% survival rate in a cohort of patients with significant comorbid status. Pulmonary embolectomy should be considered early in the therapeutic algorithm for patients with submassive PE presenting with right ventricular dysfunction to prevent progression. It can also be performed with good outcomes in those already suffering hemodynamic compromise. © 2014 S. Karger AG, Basel.

Combo Therapy Best for COPD: Study

The study involved government health data in Ontario on almost 12,000 people with COPD between 2003 and 2011, including 8,712 patients newly placed on combination therapy and 3,160 new users of long-acting beta agonists.

The records involved real-world situations, with doctors treating patients according to their best judgment, Edelman noted.
"It's one thing to perform a drug trial and select patients very carefully and see how your drugs perform, and another to look back and see how people have done in the real world with real doctors," he said.
Researchers found that about 37.3 percent of people died while using beta agonists alone, compared with 36.4 percent of people using the combination therapy.
Similar results occurred for hospitalizations caused by COPD -- about 30.1 percent for people on the single drug, versus 27.8 percent for people taking the combination.
Overall, the use of combination therapy reduced risk of death or hospitalization by 3.7 percent, compared with beta agonists alone, the study found.

The greatest difference was among COPD patients who had also been diagnosed with asthma. Overall, those on combination therapy had a 6.5 percent reduced risk of either death or hospitalization compared with those taking a single drug. ...

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