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Massimo Miniati - One of the best experts on this subject based on the ideXlab platform.
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A diagnostic strategy for pulmonary Embolism based on standardised pretest probability and perfusion lung scanning: a management study
2003Co-Authors: Massimo Miniati, Simonetta Monti, Carolina Bauleo, Elvio Scoscia, Lucia Tonelli, Alba Dainelli, Giosuè Catapano, Bruno Formichi, Giorgio Ricco, Renato PredilettoAbstract:Pulmonary Embolism remains a challenging diagnostic problem. We developed a simple diagnostic strategy based on combination of assessment of the pretest probability with perfusion lung scan results to reduce the need for pulmonary angiography. We studied 390 consecutive patients (78% in-patients) with suspected pulmonary Embolism. The pretest probability was rated low (10%, ≤50%), moderately high (>50%, ≤90%) or high (>90%) according to a structured clinical model. Perfusion lung scans were independently assigned to one of four categories: normal; near-normal; abnormal, suggestive of pulmonary Embolism (wedge-shaped perfusion defects); abnormal, not suggestive of pulmonary Embolism (perfusion defects other than wedge shaped). Pulmonary Embolism was diagnosed in patients with abnormal scans suggestive of pulmonary Embolism and moderately high or high pretest probability. Patients with normal or near-normal scans and those with abnormal scans not suggestive of pulmonary Embolism and low pretest probability were deemed not to have pulmonary Embolism. All other patients were allocated to pulmonary angiography. Patients in whom pulmonary Embolism was excluded were left untreated. All patients were followed up for 1 year. Pulmonary Embolism was diagnosed non-invasively in 132 patients (34%), and excluded in 191 (49%). Pulmonary angiography was required in 67 patients (17%). The prevalence of pulmonary Embolism was 41% ( n =160). Patients in whom pulmonary Embolism was excluded had a thrombo-embolic risk of 0.4% (95% confidence interval: 0.0%–2.8%). Our strategy permitted a non-invasive diagnosis or exclusion of pulmonary Embolism in 83% of the cases (95% confidence interval: 79%–86%), and appeared to be safe.
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a structured clinical model for predicting the probability of pulmonary Embolism
2003Co-Authors: Massimo Miniati, Simonetta Monti, Matteo BottaiAbstract:Abstract Purpose To develop a structured model to predict the clinical probability of pulmonary Embolism. Methods We studied 1100 consecutive patients with suspected pulmonary Embolism in whom a definite diagnosis had been established. We used logistic regression analysis to estimate the probability of pulmonary Embolism based on patients' clinical characteristics; the probability was categorized as low (≤10%), intermediate (>10%, ≤50%), moderately high (>50%, ≤90%), or high (>90%). Results The overall prevalence of pulmonary Embolism was 40% (n = 440). Ten characteristics were associated with an increased risk of pulmonary Embolism (male sex, older age, history of thrombophlebitis, sudden-onset dyspnea, chest pain, hemoptysis, electrocardiographic signs of acute right ventricular overload, radiographic signs of oligemia, amputation of the hilar artery, and pulmonary consolidation suggestive of infarction), and five were associated with a decreased risk (prior cardiovascular or pulmonary disease, high fever, pulmonary consolidation other than infarction, and pulmonary edema on the chest radiograph). With this model, 432 patients (39%) were rated a low probability, of whom 19 (4%) had pulmonary Embolism; 283 (26%) were rated an intermediate probability, of whom 62 (22%) had pulmonary Embolism; 72 (7%) were rated a moderately high probability, of whom 53 (74%) had pulmonary Embolism; and 313 (28%) were rated a high probability, of whom 306 (98%) had pulmonary Embolism. Conclusion This prediction model may be useful for estimating the probability of pulmonary Embolism before obtaining definitive test results.
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value of perfusion lung scan in the diagnosis of pulmonary Embolism results of the prospective investigative study of acute pulmonary Embolism diagnosis pisa ped
1996Co-Authors: Massimo Miniati, Lucia Tonelli, Bruno Formichi, Renato Prediletto, Massimo Pistolesi, C Marini, G Di Ricco, G Allescia, Henry Dirk Sostman, C GiuntiniAbstract:To assess the value of perfusion lung scan in the diagnosis of pulmonary Embolism, we prospectively evaluated 890 consecutive patients with suspected pulmonary Embolism. Prior to lung scanning, each patient was assigned a clinical probability of pulmonary Embolism (very likely, possible, unlikely). Perfusion scans were independently classified as follows: (1) normal, (2) near-normal, (3) abnormal compatible with pulmonary Embolism (PE+: single or multiple wedge-shaped perfusion defects), or (4) abnormal not compatible with pulmonary Embolism (PE-: perfusion defects other than wedge-shaped). The study design required pulmonary angiography and clinical and scintigraphic follow-up in all patients with abnormal scans. Of 890 scans, 220 were classified as normal/or near-normal and 670 as abnormal. A definitive diagnosis was established in 563 (84%) patients with abnormal scans. The overall prevalence of pulmonary Embolism was 39%. Most patients with angiographically proven pulmonary Embolism had PE+ scans (sensitivity: 92%). Conversely, most patients without emboli on angiography had PE- scans (specificity: 87%). A PE+ scan associated with a very likely or possible clinical presentation of pulmonary Embolism had positive predictive values of 99 and 92%, respectively. A PE- scan paired with an unlikely clinical presentation had a negative predictive value of 97%. Clinical assessment combined with perfusion-scan evaluation established or excluded pulmonary Embolism in the majority of patients with abnormal scans. Our data indicate that accurate diagnosis of pulmonary Embolism is possible by perfusion scanning alone, without ventilation imaging. Combining perfusion scanning with clinical assessment helps to restrict the need for angiography to a minority of patients with suspected pulmonary Embolism.
Renato Prediletto - One of the best experts on this subject based on the ideXlab platform.
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A diagnostic strategy for pulmonary Embolism based on standardised pretest probability and perfusion lung scanning: a management study
2003Co-Authors: Massimo Miniati, Simonetta Monti, Carolina Bauleo, Elvio Scoscia, Lucia Tonelli, Alba Dainelli, Giosuè Catapano, Bruno Formichi, Giorgio Ricco, Renato PredilettoAbstract:Pulmonary Embolism remains a challenging diagnostic problem. We developed a simple diagnostic strategy based on combination of assessment of the pretest probability with perfusion lung scan results to reduce the need for pulmonary angiography. We studied 390 consecutive patients (78% in-patients) with suspected pulmonary Embolism. The pretest probability was rated low (10%, ≤50%), moderately high (>50%, ≤90%) or high (>90%) according to a structured clinical model. Perfusion lung scans were independently assigned to one of four categories: normal; near-normal; abnormal, suggestive of pulmonary Embolism (wedge-shaped perfusion defects); abnormal, not suggestive of pulmonary Embolism (perfusion defects other than wedge shaped). Pulmonary Embolism was diagnosed in patients with abnormal scans suggestive of pulmonary Embolism and moderately high or high pretest probability. Patients with normal or near-normal scans and those with abnormal scans not suggestive of pulmonary Embolism and low pretest probability were deemed not to have pulmonary Embolism. All other patients were allocated to pulmonary angiography. Patients in whom pulmonary Embolism was excluded were left untreated. All patients were followed up for 1 year. Pulmonary Embolism was diagnosed non-invasively in 132 patients (34%), and excluded in 191 (49%). Pulmonary angiography was required in 67 patients (17%). The prevalence of pulmonary Embolism was 41% ( n =160). Patients in whom pulmonary Embolism was excluded had a thrombo-embolic risk of 0.4% (95% confidence interval: 0.0%–2.8%). Our strategy permitted a non-invasive diagnosis or exclusion of pulmonary Embolism in 83% of the cases (95% confidence interval: 79%–86%), and appeared to be safe.
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value of perfusion lung scan in the diagnosis of pulmonary Embolism results of the prospective investigative study of acute pulmonary Embolism diagnosis pisa ped
1996Co-Authors: Massimo Miniati, Lucia Tonelli, Bruno Formichi, Renato Prediletto, Massimo Pistolesi, C Marini, G Di Ricco, G Allescia, Henry Dirk Sostman, C GiuntiniAbstract:To assess the value of perfusion lung scan in the diagnosis of pulmonary Embolism, we prospectively evaluated 890 consecutive patients with suspected pulmonary Embolism. Prior to lung scanning, each patient was assigned a clinical probability of pulmonary Embolism (very likely, possible, unlikely). Perfusion scans were independently classified as follows: (1) normal, (2) near-normal, (3) abnormal compatible with pulmonary Embolism (PE+: single or multiple wedge-shaped perfusion defects), or (4) abnormal not compatible with pulmonary Embolism (PE-: perfusion defects other than wedge-shaped). The study design required pulmonary angiography and clinical and scintigraphic follow-up in all patients with abnormal scans. Of 890 scans, 220 were classified as normal/or near-normal and 670 as abnormal. A definitive diagnosis was established in 563 (84%) patients with abnormal scans. The overall prevalence of pulmonary Embolism was 39%. Most patients with angiographically proven pulmonary Embolism had PE+ scans (sensitivity: 92%). Conversely, most patients without emboli on angiography had PE- scans (specificity: 87%). A PE+ scan associated with a very likely or possible clinical presentation of pulmonary Embolism had positive predictive values of 99 and 92%, respectively. A PE- scan paired with an unlikely clinical presentation had a negative predictive value of 97%. Clinical assessment combined with perfusion-scan evaluation established or excluded pulmonary Embolism in the majority of patients with abnormal scans. Our data indicate that accurate diagnosis of pulmonary Embolism is possible by perfusion scanning alone, without ventilation imaging. Combining perfusion scanning with clinical assessment helps to restrict the need for angiography to a minority of patients with suspected pulmonary Embolism.
Hervé Cochard - One of the best experts on this subject based on the ideXlab platform.
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Leaf vein xylem conduit diameter influences susceptibility to Embolism and hydraulic decline
2016Co-Authors: Christine Scoffoni, Caetano Albuquerque, Craig R. Brodersen, Shatara V. Townes, Grace P. John, Hervé Cochard, Thomas N. Buckley, Andrew J. Mcelrone, Lawren SackAbstract:Ecosystems worldwide are facing increasingly severe and prolonged droughts during which hydraulic failure from drought-induced Embolism can lead to organ or whole plant death. Understanding the determinants of xylem failure across species is especially critical in leaves, the engines of plant growth. If the vulnerability segmentation hypothesis holds within leaves, higher order veins that are most terminal in the plant hydraulic system should be more susceptible to Embolism to protect the rest of the water transport system. Increased vulnerability in the higher order veins would also be consistent with these experiencing the greatest tensions in the plant xylem network. To test this hypothesis, we combined X-ray micro-computed tomography imaging, hydraulic experiments, cross-sectional anatomy and 3D physiological modelling to investigate how Embolisms spread throughout petioles and vein orders during leaf dehydration in relation to conduit dimensions. Decline of leaf xylem hydraulic conductance (Kx ) during dehydration was driven by Embolism initiating in petioles and midribs across all species, and Kx vulnerability was strongly correlated with petiole and midrib conduit dimensions. Our simulations showed no significant impact of conduit collapse on Kx decline. We found xylem conduit dimensions play a major role in determining the susceptibility of the leaf water transport system during strong leaf dehydration.
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X-ray microtomography (micro-CT): a reference technology for high-resolution quantification of xylem Embolism in trees
2015Co-Authors: Hervé Cochard, Sylvain Delzon, Eric BadelAbstract:As current methods for measuring xylem Embolism in trees are indirect and prone to artefacts, there is an ongoing controversy over the capacity of trees to resist or recover from Embolism. The debate will not end until we get direct visualization of the vessel content. Here, we propose desktop X-ray microtomography (micro-CT) as a reference direct technique to quantify xylem Embolism and thus validate more widespread measurements based upon either hydraulic or acoustic methods. We used desktop micro-CT to measure Embolism levels in dehydrated or centrifuged shoots of laurel – a long-vesseled species thought to display daily cycles of Embolism formation and refilling. Our direct observations demonstrate that this Mediterranean species is highly resistant to Embolism and is not vulnerable to drought-induced Embolism in a normal range of xylem tensions. We therefore recommend that Embolism studies in long-vesseled species should be validated by direct methods such as micro-CT to clear up any misunderstandings on their physiology.
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vulnerability of several conifers to air Embolism
1992Co-Authors: Hervé CochardAbstract:Hydraulic properties of xylem in seven species of conifer were studied during late winter and early spring 1991. Vulnerability to cavitation and air Embolism was investigated using hydraulic conductivity and acoustic techniques. Embolisms were induced in branches excised from mature trees by air-drying them in the laboratory. Both techniques gave comparable results indicating that they both assess the same phenomenon. Within a tree, vulnerability was related to the permeability of the xylem, the largest stems tended to cavitate before the smallest ones when water deficits developed in a branch. Interspecific comparisons showed large differences in the xylem water potential needed to induce significant Embolism, values ranged from -2.5 MPa in Pinus sylvestris to -4 MPa in Cedrus atlantica, but these differences did not correlate with differences in the xylem permeability of the species. The vulnerability of a species to air Embolism was found to be consistent with its ecophysiological behavior in the presence of water stress, drought-tolerant species being less vulnerable than drought-avoiding species.
Tetsuya Ohta - One of the best experts on this subject based on the ideXlab platform.
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lessons from a patient with cardiac arrest due to massive pulmonary Embolism as the initial presentation of wilms tumor a case report and literature review
2019Co-Authors: Atsuna Fukuda, Takeshi Isoda, Naoya Sakamoto, Keisuke Nakajima, Tetsuya OhtaAbstract:Finding an abdominal mass or hematuria is the initial step in diagnosing Wilms tumor. As the first manifestation of Wilms tumor, it is exceedingly rare for pulmonary tumor Embolism to present with cardiac arrest. A case of a patient whose sudden cardiac arrest due to massive pulmonary tumor Embolism of Wilms tumor was not responsive to resuscitation is presented. The patient was a five-year-old girl who collapsed suddenly during activity in nursery school and went into cardiac arrest in the ambulance. Unfortunately, she was not responsive to conventional resuscitation. A judicial autopsy conducted at the local police department showed the main cause of her sudden cardiac arrest was attributed to multiple pulmonary tumor Embolisms of stage IV Wilms tumor. Except for one reported case, treatments were not successful in all eight cardiac arrest cases with pulmonary tumor Embolism of Wilms tumor. These results indicate that it is challenging not only to make an accurate diagnosis, but also to provide proper specific treatment in the cardiac arrest setting. We propose that flexible triage and prompt transfer to a tertiary hospital are necessary as an oncologic emergency to get such patients to bridging therapy combined with extracorporeal membrane oxygenation or immediate surgical intervention under cardiopulmonary bypass.
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Lessons from a patient with cardiac arrest due to massive pulmonary Embolism as the initial presentation of Wilms tumor: a case report and literature review
2019Co-Authors: Atsuna Fukuda, Takeshi Isoda, Naoya Sakamoto, Keisuke Nakajima, Tetsuya OhtaAbstract:Abstract Background Finding an abdominal mass or hematuria is the initial step in diagnosing Wilms tumor. As the first manifestation of Wilms tumor, it is exceedingly rare for pulmonary tumor Embolism to present with cardiac arrest. A case of a patient whose sudden cardiac arrest due to massive pulmonary tumor Embolism of Wilms tumor was not responsive to resuscitation is presented. Case presentation The patient was a five-year-old girl who collapsed suddenly during activity in nursery school and went into cardiac arrest in the ambulance. Unfortunately, she was not responsive to conventional resuscitation. A judicial autopsy conducted at the local police department showed the main cause of her sudden cardiac arrest was attributed to multiple pulmonary tumor Embolisms of stage IV Wilms tumor. Conclusions Except for one reported case, treatments were not successful in all eight cardiac arrest cases with pulmonary tumor Embolism of Wilms tumor. These results indicate that it is challenging not only to make an accurate diagnosis, but also to provide proper specific treatment in the cardiac arrest setting. We propose that flexible triage and prompt transfer to a tertiary hospital are necessary as an oncologic emergency to get such patients to bridging therapy combined with extracorporeal membrane oxygenation or immediate surgical intervention under cardiopulmonary bypass
C Giuntini - One of the best experts on this subject based on the ideXlab platform.
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value of perfusion lung scan in the diagnosis of pulmonary Embolism results of the prospective investigative study of acute pulmonary Embolism diagnosis pisa ped
1996Co-Authors: Massimo Miniati, Lucia Tonelli, Bruno Formichi, Renato Prediletto, Massimo Pistolesi, C Marini, G Di Ricco, G Allescia, Henry Dirk Sostman, C GiuntiniAbstract:To assess the value of perfusion lung scan in the diagnosis of pulmonary Embolism, we prospectively evaluated 890 consecutive patients with suspected pulmonary Embolism. Prior to lung scanning, each patient was assigned a clinical probability of pulmonary Embolism (very likely, possible, unlikely). Perfusion scans were independently classified as follows: (1) normal, (2) near-normal, (3) abnormal compatible with pulmonary Embolism (PE+: single or multiple wedge-shaped perfusion defects), or (4) abnormal not compatible with pulmonary Embolism (PE-: perfusion defects other than wedge-shaped). The study design required pulmonary angiography and clinical and scintigraphic follow-up in all patients with abnormal scans. Of 890 scans, 220 were classified as normal/or near-normal and 670 as abnormal. A definitive diagnosis was established in 563 (84%) patients with abnormal scans. The overall prevalence of pulmonary Embolism was 39%. Most patients with angiographically proven pulmonary Embolism had PE+ scans (sensitivity: 92%). Conversely, most patients without emboli on angiography had PE- scans (specificity: 87%). A PE+ scan associated with a very likely or possible clinical presentation of pulmonary Embolism had positive predictive values of 99 and 92%, respectively. A PE- scan paired with an unlikely clinical presentation had a negative predictive value of 97%. Clinical assessment combined with perfusion-scan evaluation established or excluded pulmonary Embolism in the majority of patients with abnormal scans. Our data indicate that accurate diagnosis of pulmonary Embolism is possible by perfusion scanning alone, without ventilation imaging. Combining perfusion scanning with clinical assessment helps to restrict the need for angiography to a minority of patients with suspected pulmonary Embolism.