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Paul D Stein - One of the best experts on this subject based on the ideXlab platform.
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sensitivity and specificity of perfusion scintigraphy combined with chest radiography for acute Pulmonary Embolism in pioped ii
The Journal of Nuclear Medicine, 2008Co-Authors: Dirk H Sostman, Fadi Matta, Massimo Miniati, Alexander Gottschalk, Paul D Stein, Massimo PistolesiAbstract:We used the archived Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) data and images to test the hypothesis that reading perfusion scans with chest radiographs but without ventilation scans, and categorizing the perfusion scan as ‘‘Pulmonary Embolism (PE) present’’ or ‘‘PE absent,’’ can result in clinically useful sensitivity and specificity in most patients. Methods: Patients recruited into PIOPED II were eligible for the present study if they had a CT angiography (CTA) or digital subtraction angiography (DSA) Diagnosis, an interpretable perfusion scan and chest radiographs, and a Wells’ score. Four readers reinterpreted the perfusion scans and chest radiographs of eligible patients. Two readers used the modified PIOPED II criteria and 2 used the Prospective Investigative Study of Pulmonary Embolism Diagnosis (PISAPED) criteria. The chest radiographs were read as ‘‘normal/near normal,’’ ‘‘abnormal,’’ or ‘‘nondiagnostic,’’ and the perfusion scans were read as ‘‘PE present,’’ ‘‘PE absent,’’ or ‘‘nondiagnostic.’’ The primary analysis used a composite reference standard: the PIOPED II DSA result or, if there was no definitive DSA result, CTA results that were concordant with the Wells’ score as defined in PIOPED II (CTA positive and Wells’ score . 2, or CTA negative and Wells’ score , 6).Results: The prevalence of PE in the sample was 169 of 889 (19%). Using the modified PIOPED II criteria, the sensitivity of a ‘‘PE present’’ perfusion scan was 84.9% (95% confidence interval [CI], 80.1%288.8%), and the specificity of ‘‘PE absent’’ was 92.7% (95% CI, 91.1%294.1%), excluding ‘‘nondiagnostic’’ results, which occurred in 20.6% (95% CI, 18.8%222.5%). Using PISAPED criteria, the sensitivity of a ‘‘PE present’’ perfusion scan was 80.4% (95% CI, 75.9%284.3%) and the specificity of ‘‘PE absent’’ was 96.6% (95% CI, 95.5%297.4%), whereas the proportion of patients with ‘‘nondiagnostic’’ scans was 0% (95% CI, 0.0%20.2%). Conclusion: Perfusion scintigraphy combined with chest radiography can provide diagnostic accuracy similar to both CTA and ventilation–perfusion scintigraphy, at lower cost and with lower radiation dose. With modified PIOPED II criteria, a higher proportion of scans were nondiagnostic than with CTA, and with PISAPED criteria none were nondiagnostic.
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acute Pulmonary Embolism sensitivity and specificity of ventilation perfusion scintigraphy in pioped ii study
Radiology, 2008Co-Authors: Dirk H Sostman, Fadi Matta, Russell D Hull, Alexander Gottschalk, Paul D Stein, Lawrence R GoodmanAbstract:Purpose: To use Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II data to retrospectively determine sensitivity and specificity of ventilation-perfusion (V/Q) scintigraphic studies categorized as Pulmonary Embolism (PE) present or PE absent and the proportion of patients for whom these categories applied. Materials and Methods: The PIOPED II study had institutional review board approval at all participating centers. Patient informed consent was obtained; the study was HIPAA compliant. Approval and consent included those for future retrospective research. Patients in the PIOPED II database of clinical and imaging results were included if they had Diagnosis at computed tomographic (CT) angiography, Wells score, and Diagnosis at V/Q scanning. V/Q scan central readings were recategorized as PE present (PIOPED II reading = high probability of PE), PE absent (PIOPED II reading = very low probability of PE or normal), or nondiagnostic (PIOPED II reading = low or intermediate probability of PE...
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enlarged right ventricle without shock in acute Pulmonary Embolism prognosis
The American Journal of Medicine, 2008Co-Authors: Paul D Stein, Afzal Beemath, Fadi Matta, Charles A Hales, Russell D Hull, Lawrence R Goodman, Dirk H Sostman, Kenneth V Leeper, Pamela K WoodardAbstract:Abstract Objective An unsettled issue is the use of thrombolytic agents in patients with acute Pulmonary Embolism (PE) who are hemodynamically stable but have right ventricular (RV) enlargement. We assessed the in-hospital mortality of hemodynamically stable patients with PE and RV enlargement. Methods Patients were enrolled in the Prospective Investigation of Pulmonary Embolism Diagnosis II. Exclusions included shock, critical illness, ventilatory support, or myocardial infarction within 1 month, and ventricular tachycardia or ventricular fibrillation within 24 hours. We evaluated the ratio of the RV minor axis to the left ventricular minor axis measured on transverse images during computed tomographic angiography. Results Among 76 patients with RV enlargement treated with anticoagulants and/or inferior vena cava filters, in-hospital deaths from PE were 0 of 76 (0%) and all-cause mortality was 2 of 76 (2.6%). No septal motion abnormality was observed in 49 patients (64%), septal flattening was observed in 25 patients (33%), and septal deviation was observed in 2 patients (3%). No patients required ventilatory support, vasopressor therapy, rescue thrombolytic therapy, or catheter embolectomy. There were no in-hospital deaths caused by PE. There was no difference in all-cause mortality between patients with and without RV enlargement (relative risk=1.04). Conclusion In-hospital prognosis is good in patients with PE and RV enlargement if they are not in shock, acutely ill, or on ventilatory support, or had a recent myocardial infarction or life-threatening arrhythmia. RV enlargement alone in patients with PE, therefore, does not seem to indicate a poor prognosis or the need for thrombolytic therapy.
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clinical characteristics of patients with acute Pulmonary Embolism data from pioped ii
The American Journal of Medicine, 2007Co-Authors: Paul D Stein, Afzal Beemath, Fadi Matta, Roger D Yusen, Charles A Hales, Russell D Hull, Dirk H Sostman, Kenneth V Leeper, Victor F Tapson, John D BuckleyAbstract:Abstract Background Selection of patients for diagnostic tests for acute Pulmonary Embolism requires recognition of the possibility of Pulmonary Embolism on the basis of the clinical characteristics. Patients in the Prospective Investigation of Pulmonary Embolism Diagnosis II had a broad spectrum of severity, which permits an evaluation of the subtle characteristics of mild Pulmonary Embolism and the characteristics of severe Pulmonary Embolism. Methods Data are from the national collaborative study, Prospective Investigation of Pulmonary Embolism Diagnosis II. Results There may be dyspnea only on exertion. The onset of dyspnea is usually, but not always, rapid. Orthopnea may occur. In patients with Pulmonary Embolism in the main or lobar Pulmonary arteries, dyspnea or tachypnea occurred in 92%, but the largest Pulmonary Embolism was in the segmental Pulmonary arteries in only 65%. In general, signs and symptoms were similar in elderly and younger patients, but dyspnea or tachypnea was less frequent in elderly patients with no previous cardioPulmonary disease. Dyspnea may be absent even in patients with circulatory collapse. Patients with a low-probability objective clinical assessment sometimes had Pulmonary Embolism, even in proximal vessels. Conclusion Symptoms may be mild, and generally recognized symptoms may be absent, particularly in patients with Pulmonary Embolism only in the segmental Pulmonary branches, but they may be absent even with severe Pulmonary Embolism. A high or intermediate-probability objective clinical assessment suggests the need for diagnostic studies, but a low-probability objective clinical assessment does not exclude the Diagnosis. Maintenance of a high level of suspicion is critical.
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usefulness of multidetector spiral computed tomography according to age and gender for Diagnosis of acute Pulmonary Embolism
American Journal of Cardiology, 2007Co-Authors: Paul D Stein, Afzal Beemath, Charles A Hales, Russell D Hull, Alexander Gottschalk, Lawrence R Goodman, Kenneth V Leeper, Deborah A Quinn, Ronald E Olson, Dirk H SostmanAbstract: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 ≥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.
Dirk H Sostman - One of the best experts on this subject based on the ideXlab platform.
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sensitivity and specificity of perfusion scintigraphy combined with chest radiography for acute Pulmonary Embolism in pioped ii
The Journal of Nuclear Medicine, 2008Co-Authors: Dirk H Sostman, Fadi Matta, Massimo Miniati, Alexander Gottschalk, Paul D Stein, Massimo PistolesiAbstract:We used the archived Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) data and images to test the hypothesis that reading perfusion scans with chest radiographs but without ventilation scans, and categorizing the perfusion scan as ‘‘Pulmonary Embolism (PE) present’’ or ‘‘PE absent,’’ can result in clinically useful sensitivity and specificity in most patients. Methods: Patients recruited into PIOPED II were eligible for the present study if they had a CT angiography (CTA) or digital subtraction angiography (DSA) Diagnosis, an interpretable perfusion scan and chest radiographs, and a Wells’ score. Four readers reinterpreted the perfusion scans and chest radiographs of eligible patients. Two readers used the modified PIOPED II criteria and 2 used the Prospective Investigative Study of Pulmonary Embolism Diagnosis (PISAPED) criteria. The chest radiographs were read as ‘‘normal/near normal,’’ ‘‘abnormal,’’ or ‘‘nondiagnostic,’’ and the perfusion scans were read as ‘‘PE present,’’ ‘‘PE absent,’’ or ‘‘nondiagnostic.’’ The primary analysis used a composite reference standard: the PIOPED II DSA result or, if there was no definitive DSA result, CTA results that were concordant with the Wells’ score as defined in PIOPED II (CTA positive and Wells’ score . 2, or CTA negative and Wells’ score , 6).Results: The prevalence of PE in the sample was 169 of 889 (19%). Using the modified PIOPED II criteria, the sensitivity of a ‘‘PE present’’ perfusion scan was 84.9% (95% confidence interval [CI], 80.1%288.8%), and the specificity of ‘‘PE absent’’ was 92.7% (95% CI, 91.1%294.1%), excluding ‘‘nondiagnostic’’ results, which occurred in 20.6% (95% CI, 18.8%222.5%). Using PISAPED criteria, the sensitivity of a ‘‘PE present’’ perfusion scan was 80.4% (95% CI, 75.9%284.3%) and the specificity of ‘‘PE absent’’ was 96.6% (95% CI, 95.5%297.4%), whereas the proportion of patients with ‘‘nondiagnostic’’ scans was 0% (95% CI, 0.0%20.2%). Conclusion: Perfusion scintigraphy combined with chest radiography can provide diagnostic accuracy similar to both CTA and ventilation–perfusion scintigraphy, at lower cost and with lower radiation dose. With modified PIOPED II criteria, a higher proportion of scans were nondiagnostic than with CTA, and with PISAPED criteria none were nondiagnostic.
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perfusion lung scintigraphy for the Diagnosis of Pulmonary Embolism a reappraisal and review of the prospective investigative study of acute Pulmonary Embolism Diagnosis methods
Seminars in Nuclear Medicine, 2008Co-Authors: Massimo Miniati, Alexander Gottschalk, Dirk H Sostman, Simonetta Monti, Massimo PistolesiAbstract:In this article, we review the evolution of scintigraphy for the Diagnosis of acute Pulmonary Embolism (PE). We begin with perfusion (Q) scintigraphy, review the development of diagnostic systems that combine ventilation (V) scintigraphy and chest radiography with the Q scan, and describe in detail the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISAPED) criteria for diagnostic categorization of the Q scan read in conjunction with the chest radiograph. Finally, we review the results obtained with the PISAPED criteria in clinical research studies. The PISAPED method for lung scan interpretation provides sensitivity and specificity for diagnosing acute PE that is comparable to V/Q scanning and to computed tomography angiography (CTA), with fewer nondiagnostic results than either V/Q or CTA. The criteria can be used effectively in a diagnostic management approach that incorporates the use of a clinical prediction rule. Clinical outcomes in patients in whom PE is excluded in this way are comparable to outcomes for patients in whom the Diagnosis is excluded by CTA or conventional angiography.
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acute Pulmonary Embolism sensitivity and specificity of ventilation perfusion scintigraphy in pioped ii study
Radiology, 2008Co-Authors: Dirk H Sostman, Fadi Matta, Russell D Hull, Alexander Gottschalk, Paul D Stein, Lawrence R GoodmanAbstract:Purpose: To use Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II data to retrospectively determine sensitivity and specificity of ventilation-perfusion (V/Q) scintigraphic studies categorized as Pulmonary Embolism (PE) present or PE absent and the proportion of patients for whom these categories applied. Materials and Methods: The PIOPED II study had institutional review board approval at all participating centers. Patient informed consent was obtained; the study was HIPAA compliant. Approval and consent included those for future retrospective research. Patients in the PIOPED II database of clinical and imaging results were included if they had Diagnosis at computed tomographic (CT) angiography, Wells score, and Diagnosis at V/Q scanning. V/Q scan central readings were recategorized as PE present (PIOPED II reading = high probability of PE), PE absent (PIOPED II reading = very low probability of PE or normal), or nondiagnostic (PIOPED II reading = low or intermediate probability of PE...
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enlarged right ventricle without shock in acute Pulmonary Embolism prognosis
The American Journal of Medicine, 2008Co-Authors: Paul D Stein, Afzal Beemath, Fadi Matta, Charles A Hales, Russell D Hull, Lawrence R Goodman, Dirk H Sostman, Kenneth V Leeper, Pamela K WoodardAbstract:Abstract Objective An unsettled issue is the use of thrombolytic agents in patients with acute Pulmonary Embolism (PE) who are hemodynamically stable but have right ventricular (RV) enlargement. We assessed the in-hospital mortality of hemodynamically stable patients with PE and RV enlargement. Methods Patients were enrolled in the Prospective Investigation of Pulmonary Embolism Diagnosis II. Exclusions included shock, critical illness, ventilatory support, or myocardial infarction within 1 month, and ventricular tachycardia or ventricular fibrillation within 24 hours. We evaluated the ratio of the RV minor axis to the left ventricular minor axis measured on transverse images during computed tomographic angiography. Results Among 76 patients with RV enlargement treated with anticoagulants and/or inferior vena cava filters, in-hospital deaths from PE were 0 of 76 (0%) and all-cause mortality was 2 of 76 (2.6%). No septal motion abnormality was observed in 49 patients (64%), septal flattening was observed in 25 patients (33%), and septal deviation was observed in 2 patients (3%). No patients required ventilatory support, vasopressor therapy, rescue thrombolytic therapy, or catheter embolectomy. There were no in-hospital deaths caused by PE. There was no difference in all-cause mortality between patients with and without RV enlargement (relative risk=1.04). Conclusion In-hospital prognosis is good in patients with PE and RV enlargement if they are not in shock, acutely ill, or on ventilatory support, or had a recent myocardial infarction or life-threatening arrhythmia. RV enlargement alone in patients with PE, therefore, does not seem to indicate a poor prognosis or the need for thrombolytic therapy.
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clinical characteristics of patients with acute Pulmonary Embolism data from pioped ii
The American Journal of Medicine, 2007Co-Authors: Paul D Stein, Afzal Beemath, Fadi Matta, Roger D Yusen, Charles A Hales, Russell D Hull, Dirk H Sostman, Kenneth V Leeper, Victor F Tapson, John D BuckleyAbstract:Abstract Background Selection of patients for diagnostic tests for acute Pulmonary Embolism requires recognition of the possibility of Pulmonary Embolism on the basis of the clinical characteristics. Patients in the Prospective Investigation of Pulmonary Embolism Diagnosis II had a broad spectrum of severity, which permits an evaluation of the subtle characteristics of mild Pulmonary Embolism and the characteristics of severe Pulmonary Embolism. Methods Data are from the national collaborative study, Prospective Investigation of Pulmonary Embolism Diagnosis II. Results There may be dyspnea only on exertion. The onset of dyspnea is usually, but not always, rapid. Orthopnea may occur. In patients with Pulmonary Embolism in the main or lobar Pulmonary arteries, dyspnea or tachypnea occurred in 92%, but the largest Pulmonary Embolism was in the segmental Pulmonary arteries in only 65%. In general, signs and symptoms were similar in elderly and younger patients, but dyspnea or tachypnea was less frequent in elderly patients with no previous cardioPulmonary disease. Dyspnea may be absent even in patients with circulatory collapse. Patients with a low-probability objective clinical assessment sometimes had Pulmonary Embolism, even in proximal vessels. Conclusion Symptoms may be mild, and generally recognized symptoms may be absent, particularly in patients with Pulmonary Embolism only in the segmental Pulmonary branches, but they may be absent even with severe Pulmonary Embolism. A high or intermediate-probability objective clinical assessment suggests the need for diagnostic studies, but a low-probability objective clinical assessment does not exclude the Diagnosis. Maintenance of a high level of suspicion is critical.
Alexander Gottschalk - One of the best experts on this subject based on the ideXlab platform.
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sensitivity and specificity of perfusion scintigraphy combined with chest radiography for acute Pulmonary Embolism in pioped ii
The Journal of Nuclear Medicine, 2008Co-Authors: Dirk H Sostman, Fadi Matta, Massimo Miniati, Alexander Gottschalk, Paul D Stein, Massimo PistolesiAbstract:We used the archived Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) data and images to test the hypothesis that reading perfusion scans with chest radiographs but without ventilation scans, and categorizing the perfusion scan as ‘‘Pulmonary Embolism (PE) present’’ or ‘‘PE absent,’’ can result in clinically useful sensitivity and specificity in most patients. Methods: Patients recruited into PIOPED II were eligible for the present study if they had a CT angiography (CTA) or digital subtraction angiography (DSA) Diagnosis, an interpretable perfusion scan and chest radiographs, and a Wells’ score. Four readers reinterpreted the perfusion scans and chest radiographs of eligible patients. Two readers used the modified PIOPED II criteria and 2 used the Prospective Investigative Study of Pulmonary Embolism Diagnosis (PISAPED) criteria. The chest radiographs were read as ‘‘normal/near normal,’’ ‘‘abnormal,’’ or ‘‘nondiagnostic,’’ and the perfusion scans were read as ‘‘PE present,’’ ‘‘PE absent,’’ or ‘‘nondiagnostic.’’ The primary analysis used a composite reference standard: the PIOPED II DSA result or, if there was no definitive DSA result, CTA results that were concordant with the Wells’ score as defined in PIOPED II (CTA positive and Wells’ score . 2, or CTA negative and Wells’ score , 6).Results: The prevalence of PE in the sample was 169 of 889 (19%). Using the modified PIOPED II criteria, the sensitivity of a ‘‘PE present’’ perfusion scan was 84.9% (95% confidence interval [CI], 80.1%288.8%), and the specificity of ‘‘PE absent’’ was 92.7% (95% CI, 91.1%294.1%), excluding ‘‘nondiagnostic’’ results, which occurred in 20.6% (95% CI, 18.8%222.5%). Using PISAPED criteria, the sensitivity of a ‘‘PE present’’ perfusion scan was 80.4% (95% CI, 75.9%284.3%) and the specificity of ‘‘PE absent’’ was 96.6% (95% CI, 95.5%297.4%), whereas the proportion of patients with ‘‘nondiagnostic’’ scans was 0% (95% CI, 0.0%20.2%). Conclusion: Perfusion scintigraphy combined with chest radiography can provide diagnostic accuracy similar to both CTA and ventilation–perfusion scintigraphy, at lower cost and with lower radiation dose. With modified PIOPED II criteria, a higher proportion of scans were nondiagnostic than with CTA, and with PISAPED criteria none were nondiagnostic.
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perfusion lung scintigraphy for the Diagnosis of Pulmonary Embolism a reappraisal and review of the prospective investigative study of acute Pulmonary Embolism Diagnosis methods
Seminars in Nuclear Medicine, 2008Co-Authors: Massimo Miniati, Alexander Gottschalk, Dirk H Sostman, Simonetta Monti, Massimo PistolesiAbstract:In this article, we review the evolution of scintigraphy for the Diagnosis of acute Pulmonary Embolism (PE). We begin with perfusion (Q) scintigraphy, review the development of diagnostic systems that combine ventilation (V) scintigraphy and chest radiography with the Q scan, and describe in detail the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISAPED) criteria for diagnostic categorization of the Q scan read in conjunction with the chest radiograph. Finally, we review the results obtained with the PISAPED criteria in clinical research studies. The PISAPED method for lung scan interpretation provides sensitivity and specificity for diagnosing acute PE that is comparable to V/Q scanning and to computed tomography angiography (CTA), with fewer nondiagnostic results than either V/Q or CTA. The criteria can be used effectively in a diagnostic management approach that incorporates the use of a clinical prediction rule. Clinical outcomes in patients in whom PE is excluded in this way are comparable to outcomes for patients in whom the Diagnosis is excluded by CTA or conventional angiography.
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acute Pulmonary Embolism sensitivity and specificity of ventilation perfusion scintigraphy in pioped ii study
Radiology, 2008Co-Authors: Dirk H Sostman, Fadi Matta, Russell D Hull, Alexander Gottschalk, Paul D Stein, Lawrence R GoodmanAbstract:Purpose: To use Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II data to retrospectively determine sensitivity and specificity of ventilation-perfusion (V/Q) scintigraphic studies categorized as Pulmonary Embolism (PE) present or PE absent and the proportion of patients for whom these categories applied. Materials and Methods: The PIOPED II study had institutional review board approval at all participating centers. Patient informed consent was obtained; the study was HIPAA compliant. Approval and consent included those for future retrospective research. Patients in the PIOPED II database of clinical and imaging results were included if they had Diagnosis at computed tomographic (CT) angiography, Wells score, and Diagnosis at V/Q scanning. V/Q scan central readings were recategorized as PE present (PIOPED II reading = high probability of PE), PE absent (PIOPED II reading = very low probability of PE or normal), or nondiagnostic (PIOPED II reading = low or intermediate probability of PE...
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usefulness of multidetector spiral computed tomography according to age and gender for Diagnosis of acute Pulmonary Embolism
American Journal of Cardiology, 2007Co-Authors: Paul D Stein, Afzal Beemath, Charles A Hales, Russell D Hull, Alexander Gottschalk, Lawrence R Goodman, Kenneth V Leeper, Deborah A Quinn, Ronald E Olson, Dirk H SostmanAbstract: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 ≥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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multidetector computed tomography for acute Pulmonary Embolism
The New England Journal of Medicine, 2006Co-Authors: Paul D Stein, Charles A Hales, Russell D Hull, Alexander Gottschalk, Lawrence R Goodman, Kenneth V Leeper, Deborah A Quinn, Sarah E Fowler, John Popovich, Dirk H SostmanAbstract:Background The accuracy of multidetector computed tomographic angiography (CTA) for the Diagnosis of acute Pulmonary Embolism has not been determined conclusively. Methods The Prospective Investigation of Pulmonary Embolism Diagnosis II trial was a prospective, multicenter investigation of the accuracy of multidetector CTA alone and combined with venous-phase imaging (CTA–CTV) for the Diagnosis of acute Pulmonary Embolism. We used a composite reference test to confirm or rule out the Diagnosis of Pulmonary Embolism. Results Among 824 patients with a reference Diagnosis and a completed CT study, CTA was inconclusive in 51 because of poor image quality. Excluding such inconclusive studies, the sensitivity of CTA was 83 percent and the specificity was 96 percent. Positive predictive values were 96 percent with a concordantly high or low probability on clinical assessment, 92 percent with an intermediate probability on clinical assessment, and nondiagnostic if clinical probability was discordant. CTA–CTV was ...
Massimo Pistolesi - One of the best experts on this subject based on the ideXlab platform.
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sensitivity and specificity of perfusion scintigraphy combined with chest radiography for acute Pulmonary Embolism in pioped ii
The Journal of Nuclear Medicine, 2008Co-Authors: Dirk H Sostman, Fadi Matta, Massimo Miniati, Alexander Gottschalk, Paul D Stein, Massimo PistolesiAbstract:We used the archived Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) data and images to test the hypothesis that reading perfusion scans with chest radiographs but without ventilation scans, and categorizing the perfusion scan as ‘‘Pulmonary Embolism (PE) present’’ or ‘‘PE absent,’’ can result in clinically useful sensitivity and specificity in most patients. Methods: Patients recruited into PIOPED II were eligible for the present study if they had a CT angiography (CTA) or digital subtraction angiography (DSA) Diagnosis, an interpretable perfusion scan and chest radiographs, and a Wells’ score. Four readers reinterpreted the perfusion scans and chest radiographs of eligible patients. Two readers used the modified PIOPED II criteria and 2 used the Prospective Investigative Study of Pulmonary Embolism Diagnosis (PISAPED) criteria. The chest radiographs were read as ‘‘normal/near normal,’’ ‘‘abnormal,’’ or ‘‘nondiagnostic,’’ and the perfusion scans were read as ‘‘PE present,’’ ‘‘PE absent,’’ or ‘‘nondiagnostic.’’ The primary analysis used a composite reference standard: the PIOPED II DSA result or, if there was no definitive DSA result, CTA results that were concordant with the Wells’ score as defined in PIOPED II (CTA positive and Wells’ score . 2, or CTA negative and Wells’ score , 6).Results: The prevalence of PE in the sample was 169 of 889 (19%). Using the modified PIOPED II criteria, the sensitivity of a ‘‘PE present’’ perfusion scan was 84.9% (95% confidence interval [CI], 80.1%288.8%), and the specificity of ‘‘PE absent’’ was 92.7% (95% CI, 91.1%294.1%), excluding ‘‘nondiagnostic’’ results, which occurred in 20.6% (95% CI, 18.8%222.5%). Using PISAPED criteria, the sensitivity of a ‘‘PE present’’ perfusion scan was 80.4% (95% CI, 75.9%284.3%) and the specificity of ‘‘PE absent’’ was 96.6% (95% CI, 95.5%297.4%), whereas the proportion of patients with ‘‘nondiagnostic’’ scans was 0% (95% CI, 0.0%20.2%). Conclusion: Perfusion scintigraphy combined with chest radiography can provide diagnostic accuracy similar to both CTA and ventilation–perfusion scintigraphy, at lower cost and with lower radiation dose. With modified PIOPED II criteria, a higher proportion of scans were nondiagnostic than with CTA, and with PISAPED criteria none were nondiagnostic.
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perfusion lung scintigraphy for the Diagnosis of Pulmonary Embolism a reappraisal and review of the prospective investigative study of acute Pulmonary Embolism Diagnosis methods
Seminars in Nuclear Medicine, 2008Co-Authors: Massimo Miniati, Alexander Gottschalk, Dirk H Sostman, Simonetta Monti, Massimo PistolesiAbstract:In this article, we review the evolution of scintigraphy for the Diagnosis of acute Pulmonary Embolism (PE). We begin with perfusion (Q) scintigraphy, review the development of diagnostic systems that combine ventilation (V) scintigraphy and chest radiography with the Q scan, and describe in detail the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISAPED) criteria for diagnostic categorization of the Q scan read in conjunction with the chest radiograph. Finally, we review the results obtained with the PISAPED criteria in clinical research studies. The PISAPED method for lung scan interpretation provides sensitivity and specificity for diagnosing acute PE that is comparable to V/Q scanning and to computed tomography angiography (CTA), with fewer nondiagnostic results than either V/Q or CTA. The criteria can be used effectively in a diagnostic management approach that incorporates the use of a clinical prediction rule. Clinical outcomes in patients in whom PE is excluded in this way are comparable to outcomes for patients in whom the Diagnosis is excluded by CTA or conventional angiography.
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accuracy of clinical assessment in the Diagnosis of Pulmonary Embolism
American Journal of Respiratory and Critical Care Medicine, 1999Co-Authors: Massimo Miniati, Lucia Tonelli, Bruno Formichi, Renato Prediletto, C Marini, G Di Ricco, G Allescia, Massimo PistolesiAbstract:To provide clinical diagnostic criteria for Pulmonary Embolism (PE), we evaluated 750 consecutive patients with suspected PE who were enrolled in the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED). Prior to perfusion lung scanning, patients were examined independently by six pulmonologists according to a standardized diagnostic protocol. Study design required Pulmonary angiography in all patients with abnormal scans. Patients are reported as two distinct groups: a first group of 500, whose data were analyzed to derive a clinical diagnostic algorithm for PE, and a second group of 250 in whom the diagnostic algorithm was validated. PE was diagnosed by angiography in 202 (40%) of the 500 patients in the first group. A diagnostic algorithm was developed that includes the identification of three symptoms (sudden onset dyspnea, chest pain, and fainting) and their association with one or more of the following abnormalities: electrocardiographic signs of right ventricular overload, radiographic signs of oligemia, amputation of hilar artery, and Pulmonary consolidations compatible with infarction. The above three symptoms (singly or in some combination) were associated with at least one of the above electrocardiographic and radiographic abnormalities in 164 (81%) of 202 patients with confirmed PE and in only 22 (7%) of 298 patients without PE. The rate of correct clinical classification was 88% (440/500). In the validation group of 250 patients the prevalence of PE was 42% (104/250). In this group, the sensitivity and specificity of the clinical diagnostic algorithm for PE were 84% (95% CI: 77 to 91%) and 95% (95% CI: 91 to 99%), respectively. The rate of correct clinical classification was 90% (225/250). Combining clinical estimates of PE, derived from the diagnostic algorithm, with independent interpretation of perfusion lung scans helps restrict the need for angiography to a minority of patients with suspected PE.
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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
American Journal of Respiratory and Critical Care Medicine, 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.
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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
American Journal of Respiratory and Critical Care Medicine, 1996Co-Authors: Massimo Miniati, Lucia Tonelli, Bruno Formichi, Renato Prediletto, Massimo Pistolesi, C Marini, G Di Ricco, G Allescia, Henry Dirk Sostman, C GiuntiniAbstract:all prevalence of Pulmonary Embolism was 39%. Most patients with angiographically proven pulmo nary Embolism had PE+scans (sensitivity: 92%). Conversely, most patients without emboli on angiog raphy 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 pulmo nary Embolism is possible by perfusion scanning alone, without ventilation imaging. Combining per fusion scanning with clinical assessment helps to restrict the need for angiography to a minority of patients with suspected Pulmonary Embolism. Mlnlatl M, Postolesl M, Marini C, DI Ricco G, For michi B, Prediletto R, Allescia G, Tonelli L, Sostman HD, Giuntini C (The PISA-PED Investiga tors). Value of perfusion lung scan In the Diagnosis of Pulmonary Embolism: results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED).
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enlarged right ventricle without shock in acute Pulmonary Embolism prognosis
The American Journal of Medicine, 2008Co-Authors: Paul D Stein, Afzal Beemath, Fadi Matta, Charles A Hales, Russell D Hull, Lawrence R Goodman, Dirk H Sostman, Kenneth V Leeper, Pamela K WoodardAbstract:Abstract Objective An unsettled issue is the use of thrombolytic agents in patients with acute Pulmonary Embolism (PE) who are hemodynamically stable but have right ventricular (RV) enlargement. We assessed the in-hospital mortality of hemodynamically stable patients with PE and RV enlargement. Methods Patients were enrolled in the Prospective Investigation of Pulmonary Embolism Diagnosis II. Exclusions included shock, critical illness, ventilatory support, or myocardial infarction within 1 month, and ventricular tachycardia or ventricular fibrillation within 24 hours. We evaluated the ratio of the RV minor axis to the left ventricular minor axis measured on transverse images during computed tomographic angiography. Results Among 76 patients with RV enlargement treated with anticoagulants and/or inferior vena cava filters, in-hospital deaths from PE were 0 of 76 (0%) and all-cause mortality was 2 of 76 (2.6%). No septal motion abnormality was observed in 49 patients (64%), septal flattening was observed in 25 patients (33%), and septal deviation was observed in 2 patients (3%). No patients required ventilatory support, vasopressor therapy, rescue thrombolytic therapy, or catheter embolectomy. There were no in-hospital deaths caused by PE. There was no difference in all-cause mortality between patients with and without RV enlargement (relative risk=1.04). Conclusion In-hospital prognosis is good in patients with PE and RV enlargement if they are not in shock, acutely ill, or on ventilatory support, or had a recent myocardial infarction or life-threatening arrhythmia. RV enlargement alone in patients with PE, therefore, does not seem to indicate a poor prognosis or the need for thrombolytic therapy.
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clinical characteristics of patients with acute Pulmonary Embolism data from pioped ii
The American Journal of Medicine, 2007Co-Authors: Paul D Stein, Afzal Beemath, Fadi Matta, Roger D Yusen, Charles A Hales, Russell D Hull, Dirk H Sostman, Kenneth V Leeper, Victor F Tapson, John D BuckleyAbstract:Abstract Background Selection of patients for diagnostic tests for acute Pulmonary Embolism requires recognition of the possibility of Pulmonary Embolism on the basis of the clinical characteristics. Patients in the Prospective Investigation of Pulmonary Embolism Diagnosis II had a broad spectrum of severity, which permits an evaluation of the subtle characteristics of mild Pulmonary Embolism and the characteristics of severe Pulmonary Embolism. Methods Data are from the national collaborative study, Prospective Investigation of Pulmonary Embolism Diagnosis II. Results There may be dyspnea only on exertion. The onset of dyspnea is usually, but not always, rapid. Orthopnea may occur. In patients with Pulmonary Embolism in the main or lobar Pulmonary arteries, dyspnea or tachypnea occurred in 92%, but the largest Pulmonary Embolism was in the segmental Pulmonary arteries in only 65%. In general, signs and symptoms were similar in elderly and younger patients, but dyspnea or tachypnea was less frequent in elderly patients with no previous cardioPulmonary disease. Dyspnea may be absent even in patients with circulatory collapse. Patients with a low-probability objective clinical assessment sometimes had Pulmonary Embolism, even in proximal vessels. Conclusion Symptoms may be mild, and generally recognized symptoms may be absent, particularly in patients with Pulmonary Embolism only in the segmental Pulmonary branches, but they may be absent even with severe Pulmonary Embolism. A high or intermediate-probability objective clinical assessment suggests the need for diagnostic studies, but a low-probability objective clinical assessment does not exclude the Diagnosis. Maintenance of a high level of suspicion is critical.
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usefulness of multidetector spiral computed tomography according to age and gender for Diagnosis of acute Pulmonary Embolism
American Journal of Cardiology, 2007Co-Authors: Paul D Stein, Afzal Beemath, Charles A Hales, Russell D Hull, Alexander Gottschalk, Lawrence R Goodman, Kenneth V Leeper, Deborah A Quinn, Ronald E Olson, Dirk H SostmanAbstract: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 ≥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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diagnostic pathways in acute Pulmonary Embolism recommendations of the pioped ii investigators
The American Journal of Medicine, 2006Co-Authors: Paul D Stein, Dirk H Sostman, Victor F Tapson, Deborah A Quinn, Pamela K Woodard, John G Weg, Thomas W Wakefield, Thomas A Sos, Kenneth V LeeperAbstract:PURPOSE: To formulate comprehensive recommendations for the diagnostic approach to patients with suspected Pulmonary Embolism, based on randomized trials. METHODS: Diagnostic management recommendations were formulated based on results of the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) and outcome studies. RESULTS: The PIOPED II investigators recommend stratification of all patients with suspected Pulmonary Embolism according to an objective clinical probability assessment. D-dimer should be measured by the quantitative rapid enzyme-linked immunosorbent assay (ELISA), and the combination of a negative D-dimer with a low or moderate clinical probability can safely exclude Pulmonary Embolism in many patients. If Pulmonary Embolism is not excluded, contrast-enhanced computed tomographic Pulmonary angiography (CT angiography) in combination with venous phase imaging (CT venography), is recommended by most PIOPED II investigators, although CT angiography plus clinical assessment is an option. In pregnant women, ventilation/perfusion scans are recommended by many as the first imaging test following D-dimer and perhaps venous ultrasound. In patients with discordant findings of clinical assessment and CT angiograms or CT angiogram/CT venogram, further evaluation may be necessary. CONCLUSION: The sequence for diagnostic test in patients with suspected Pulmonary Embolism depends
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diagnostic pathways in acute Pulmonary Embolism recommendations of the pioped ii investigators
The American Journal of Medicine, 2006Co-Authors: Paul D Stein, Dirk H Sostman, Victor F Tapson, Deborah A Quinn, Pamela K Woodard, John G Weg, Thomas W Wakefield, Thomas A Sos, Kenneth V LeeperAbstract:PURPOSE: To formulate comprehensive recommendations for the diagnostic approach to patients with suspected Pulmonary Embolism, based on randomized trials. METHODS: Diagnostic management recommendations were formulated based on results of the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II) and outcome studies. RESULTS: The PIOPED II investigators recommend stratification of all patients with suspected Pulmonary Embolism according to an objective clinical probability assessment. D-dimer should be measured by the quantitative rapid enzyme-linked immunosorbent assay (ELISA), and the combination of a negative D-dimer with a low or moderate clinical probability can safely exclude Pulmonary Embolism in many patients. If Pulmonary Embolism is not excluded, contrast-enhanced computed tomographic Pulmonary angiography (CT angiography) in combination with venous phase imaging (CT venography), is recommended by most PIOPED II investigators, although CT angiography plus clinical assessment is an option. In pregnant women, ventilation/perfusion scans are recommended by many as the first imaging test following D-dimer and perhaps venous ultrasound. In patients with discordant findings of clinical assessment and CT angiograms or CT angiogram/CT venogram, further evaluation may be necessary. CONCLUSION: The sequence for diagnostic test in patients with suspected Pulmonary Embolism depends
