Finding an alternative diagnosis does not justify increased use of CT-pulmonary angiography

Chandra, Swarniv; Sarkar, Pralay; Chandra, Divay; Ginsberg, Nicole; Cohen, Rubin I.

doi:10.1186/1471-2466-13-9

Cited by 52 publications

(61 citation statements)

References 24 publications

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“…However, it is unknown whether the alternative diagnosis has already been suggested by history and physical exam. Our results showed that at least some cases of alternative diagnosis were evident on admission chest radiographs, a finding corroborated by previous published results [14,16]. The presence of alternative diagnosis clearly does not preclude the concurrent diagnosis of PE, but does lower the pretest probability of PE according to the Well's Criteria by 3-points [31].…”

Section: Non-thrombotic Clinically Significant Findingssupporting

confidence: 91%

Variation in the utilization and positivity rates of CT pulmonary angiography among emergency physicians at a tertiary academic emergency department

et al. 2014

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We examined the patient and physician characteristics related to the use and yield of computed tomography pulmonary angiogram (CTPA) for the diagnosis of pulmonary embolism (PE) at a tertiary academic hospital emergency department (ED). A cross-sectional retrospective study was conducted on 835 consecutive ED patients with suspected PE who underwent CTPA. Radiology report data were extracted from our institution's RIS PACS software (Syngo Imaging, Siemens) based on a targeted search of all CTPA reports from 2010 to 2012. Utilization and PE positivity rates of CTPA were calculated and correlated with patient characteristics including age and gender, as well as emergency physician (EP) characteristics including gender, years in practice, and training certification. Acute PE was diagnosed in 17.8 % of patients. A further 32.9 % of the scans were negative for PE but had other clinically significant findings. We found higher utilization rates in female and older patients (p < 0.001), however, without corresponding differences in PE positivity rates compared to their male and younger counterparts. There was a high inter-physician variation in CTPA utilization rate (range 0.21-0.77 scans per 100 patients seen) and PE positivity rate (range 6.7-38.9 %). However, neither rates correlated with EP years of experience (p > 0.15 with cut-offs at 5, 10, and 20 years post-residency), gender (p = 0.59), or training certification (p = 0.56 between EPs certified by the 5-year program of the Royal College of Physicians of Canada versus the 3-year program of the College of Family Physicians of Canada). Our study demonstrated considerable inter-physician variability in the utilization and PE positivity rates of CTPA. These results suggest an opportunity for a more standardized approach to the use of CTPA among EPs at our institution.

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Section: Non-thrombotic Clinically Significant Findingssupporting

confidence: 91%

Variation in the utilization and positivity rates of CT pulmonary angiography among emergency physicians at a tertiary academic emergency department

et al. 2014

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“…Assessment of the examinations in the course of the study revealed no cases of previously undetected secondary diagnoses that would not have been identified without CT or at a later time. This is consistent with studies of the benefit of CTPA which indicate that potential secondary findings do not justify uncritical use of CT [24,25]. Several retrospective studies [18, 26 -29] that likewise used Douma's age adjustment [18] demonstrated that the rate of avoidable CTPA examinations can be 5.1 % to 15.5 % or even higher; however this is due to a somewhat different study design, and in particular a different median age.…”

Section: Synopsis and Integration Of The Most Important Resultssupporting

confidence: 64%

Age-Dependent D-dimer Cut-off to Avoid Unnecessary CT-Exams for Ruling-out Pulmonary Embolism

Altmann

Wrede

Peetz

et al. 2015

Fortschr Röntgenstr

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Purpose: To evaluate the effect of an age-dependent D-Dimer cut-off in patients who underwent a computed tomography pulmonary angiogram (CTPA) for suspected pulmonary embolism (PE) Material and Methods: Retrospective application of an age-dependent D-dimer cut-off (age/100 in patients aged over 50) in 530 consecutive patients, both in- and outpatients, aged over 18, who underwent CTPA for suspected PE according to the guidelines. Results: The application of an age-dependent D-dimer cut-off showed a now negative test-result in 17 of 530 patients (3.2?%). The proportion was 4.1?% (17 of 418) in patients aged over 50. None of these 17 cases was diagnosed with PE in CTPA, the false-negative rate was 0?%. The effect could be seen in outpatients (14 of 377 [3.7?%]) as well as in inpatients(3 of 153 [2.0?%]) with no statistically significant difference (p?>?0.05). Conclusion: The application of an age-dependent D-dimer cut-off as part of the guidline-based algorithm for suspected PE reduced the number of necessary CTPA in outpatients as well as in inpatients. Key points: ??The application of an age-dependent D-dimer cut-off reduces the number of CTPA as part of the diagnostic algorithm in patients suspected for PE No reduction in diagnostic safety was found ??The age adjustement performed equally in outpatients and inpatients Citation Format: ??Altmann MM, Wrede CE., Peetz D et?al. Age-Dependent D-dimer Cut-off to Avoid Unnecessary CT-Exams for Ruling-out Pulmonary Embolism. Fortschr R?ntgenstr 2015; 187: 795???800

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“…Quantitative SPECT will benefit from hybrid imaging through derivation of accurate patient-specific attenuation correction (34). Lung scanning using PET radiopharmaceuticals, such as 68 Ga-carbon nanoparticles ("Galligas") and 68 Ga-macroaggregated albumin, is a promising development that may further enhance the role of nuclear medicine in the assessment of PE and other lung disorders (49).…”

Section: Non-pe Applications and Future Directionsmentioning

confidence: 99%

V/Q Scanning Using SPECT and SPECT/CT

2013

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Learning Objectives: On successful completion of this activity, participants should be able to describe (1) advantages and shortcomings of planar versus SPECT V/Q scanning, (2) advantages and disadvantages of CT pulmonary angiography versus V/Q SPECT in the investigation of pulmonary embolism, and (3) an overview of image acquisition, processing, display, and reporting of V/Q SPECT studies.Financial Disclosure: The authors of this article have indicated no relevant relationships that could be perceived as a real or apparent conflict of interest. CME Credit: SNMMI is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing education for physicians. SNMMI designates each JNM continuing education article for a maximum of 2.0 AMA PRA Category 1 Credits. Physicians should claim only credit commensurate with the extent of their participation in the activity. For CE credit, participants can access this activity through the SNMMI Web site (http:// www.snmmi.org/ce_online) through September 2016.Planar ventilation-perfusion ( V/Q) scanning is often used to investigate pulmonary embolism; however, it has well-recognized limitations. SPECT overcomes many of these through its ability to generate 3-dimensional imaging data. V/Q SPECT has higher sensitivity, specificity, and accuracy than planar imaging and a lower indeterminate rate. SPECT allows for new ways to display and analyze data, such as parametric V/Q ratio images. Compared with CT pulmonary angiography, SPECT has higher sensitivity, a lower radiation dose, fewer technically suboptimal studies, and no contrast-related complications. Any nuclear medicine department equipped with a modern hybrid scanner can now perform combined V/Q SPECT with CT (using low-dose protocols) to further enhance diagnostic accuracy. V/Q SPECT (with or without CT) has application in other pulmonary conditions and in research. Si nce its first description by Wagner et al. in 1964 (1), the planar lung scan has been one of the most commonly performed studies in nuclear medicine. It is, however, a test with significant limitations, which have had an adverse impact on its reputation (2,3). Because planar imaging is a 2-dimensional technique, it has inherent limitations, especially related to overlap of anatomic segments. Assigning defects to specific lung segments is often difficult, and the variability in segment size and shape between patients makes accurate determination of the extent of embolic involvement in individual segments a challenge (2). Embolic defects may not be detected if there is shine-through from underlying lung segments with normal perfusion, thus resulting in an underestimation of the extent of perfusion loss (4). Furthermore, the medial basal segment of the right lower lobe is often not visualized on planar scans (2,5). Added to these factors is the widespread use of probabilistic reporting criteria, and a relatively high indeterminate rate, both of which have caused significant dissatisfaction among referring physicians (6,7). ...

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Finding an alternative diagnosis does not justify increased use of CT-pulmonary angiography

Cited by 52 publications

References 24 publications

Variation in the utilization and positivity rates of CT pulmonary angiography among emergency physicians at a tertiary academic emergency department

Variation in the utilization and positivity rates of CT pulmonary angiography among emergency physicians at a tertiary academic emergency department

Age-Dependent D-dimer Cut-off to Avoid Unnecessary CT-Exams for Ruling-out Pulmonary Embolism

V/Q Scanning Using SPECT and SPECT/CT

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