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    "textoCompleto" => "<a name="sec0005" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Introduction and purpose</span><p class="elsevierStylePara">Pulmonary thromboembolism &#40;PTE&#41; is defined as the embolization of a blood clot to the pulmonary circulation&#46;<a href="&#35;bib31" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a> In fact&#44; it is estimated that&#44; in developed countries&#44; it might be present lifelong on up to 5&#37; of the population&#46;<a href="&#35;bib32" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a> It is also diagnosed in 1&#46;5&#37; of hospitalized patients and represents the third most frequent cardiovascular pathology &#40;after myocardial infarction and cerebrovascular disease&#41;&#46;<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> Furthermore&#44; it carries a high mortality&#44; up to 5 to 10&#37; of all in hospital deaths&#46; Therefore&#44; it is a public health problem&#46;<a href="&#35;bib32" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a></p><p class="elsevierStylePara">Acute PTE can present itself with very distinct signs and symptoms&#44; ranging from haemodynamic instability&#44; acute pulmonary hypertension&#44; cardiac failure and systemic hypotension<a href="&#35;bib31" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a> to clinically silent<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> forms&#46;</p><p class="elsevierStylePara">Chronic PTE is frequently a cause for cardiopulmonary disease&#44; originating pulmonary infarction&#44; chronic pulmonary hypertension and cor pulmonale&#46;<a href="&#35;bib31" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a></p><p class="elsevierStylePara">Despite the mentioned clinical relevance&#44; PTE diagnosis is not always straightforward&#46;<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> Therefore&#44; for greater diagnostic accuracy&#44; imaging procedures are frequently needed&#46;<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a></p><p class="elsevierStylePara">The imaging procedures used to diagnose PTE can be divided into anatomical and functional methods&#46; As for the former&#44; conventional pulmonary angiography was first described&#44; which has been superseded by computerized tomography pulmonary angiography&#46;<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib34" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a> Recently&#44; magnetic resonance pulmonary angiography has begun to be investigated&#46;<a href="&#35;bib35" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a></p><p class="elsevierStylePara">Functional methods have been represented by pulmonary ventilation and perfusion scintigraphy &#40;V&#47;QS&#41;&#44; traditionally using planar imaging &#40;V&#47;QS-planar&#41;&#46;<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> V&#47;QS-planar consists in obtaining two sets of scintigraphic images of the lungs&#58; one representing pulmonary ventilation &#40;by means of a radiopharmaceutical with alveolar air distribution&#41; and another exhibiting pulmonary perfusion &#40;with a radiopharmaceutical captured in the pulmonary capillaries&#41;&#46; The scintigraphic diagnosis of PTE is based on the identification of pulmonary segments with a perfusion defect and preserved ventilation&#44; consisting on a mismatch pattern&#46; In planar imaging&#44; the acquired images represent a projection of the totality of pulmonary ventilation and perfusion in different orientations&#58; anterior&#44; posterior&#44; anterior oblique and posterior oblique&#44; more frequently&#46;</p><p class="elsevierStylePara">This procedure has been systematically improved in both sensitivity and specificity&#46; In fact&#44; since the demonstration of diagnostic accuracy of V&#47;QS-planar in the PIOPED study&#44;<a href="&#35;bib36" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib37" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a> different ways of enhancing the original technique have been investigated&#46; Of note are the combination with results from other methods&#44; namely simple chest X-ray&#44;<a href="&#35;bib38" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib39" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">9</span></a> and the introduction of new ventilation radiopharmaceuticals&#44; such as radioaerossols&#44; which allow the acquisition of ventilation studies with better diagnostic quality&#46;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">10</span></a></p><p class="elsevierStylePara">A significant advantage of scintigraphic imaging&#44; as opposed to the anatomical methods&#44; is a lower radiological exposure&#46;<a href="&#35;bib41" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> This is especially relevant when considering female patients subject to multiple exams for follow-up&#44; given the high radiological sensitivity of breast tissue&#44; which is especially exposed to radiation in anatomical thorax procedures&#46;<a href="&#35;bib42" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">12</span></a> Also in pregnant patients&#44; V&#47;QS allows the reduction of radiological exposure not only to the breast&#44; but also the foetus&#44; in contrast to anatomical methods&#46;<a href="&#35;bib43" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">13</span></a> Another VQ&#47;S advantage is that it does not require the administration of iodinated contrast media&#44; therefore presenting a more favourable pharmacological safety profile&#46;</p><p class="elsevierStylePara">Finally&#44; V&#47;QS-planar is also the method of choice in chronic PTE suspicion as an aetiology for pulmonary hypertension&#44; identifying those patients that benefit the most from directed therapy&#46;<a href="&#35;bib44" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">14</span></a></p><p class="elsevierStylePara">The most recent development in V&#47;QS was the introduction of pulmonary ventilation and perfusion tomographic imaging &#40;V&#47;QS-SPECT&#41;&#46;<a href="&#35;bib45" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib46" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">16</span></a> V&#47;QS-SPECT has the same conceptual basis of V&#47;QS-planar&#44; the only difference being that in V&#47;QS-SPECT tomographic reconstructions of pulmonary ventilation and perfusion are acquired&#44; allowing the evaluation of axial&#44; coronal and sagittal planes&#46; This technique has a solid experimental support&#44;<a href="&#35;bib47" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">17</span></a> appears to have higher diagnostic sensitivity than V&#47;QS-planar<a href="&#35;bib48" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib49" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">19</span></a> and does not seem to imply additional resource consumption&#46;<a href="&#35;bib50" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">20</span></a> Besides&#44; it compares favourably to computerized tomography pulmonary angiography&#46;<a href="&#35;bib51" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib52" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">22</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib53" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">23</span></a> Its role in clinical decision making is beginning to be evaluated&#46;<a href="&#35;bib54" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a> V&#47;QS-SPECT also seems to have a role in pulmonary physiology investigation&#46;<a href="&#35;bib55" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a></p><p class="elsevierStylePara">The purpose of this work is to evaluate the added benefits of V&#47;QS-SPECT studies regarding the detection of perfusion defects compatible with PTE as opposed to traditional planar imaging&#46;</p><a name="sec0010" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Patients and methods</span><a name="sec0015" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Participants</span><p class="elsevierStylePara">We studied prospectively V&#47;QS exams performed on the same patient with both techniques under evaluation &#40;V&#47;QS-planar and V&#47;QS-SPECT&#41;&#44; in order to compare results&#46;</p><p class="elsevierStylePara">The study population were the patients referred to the authors&#8217; department to perform a V&#47;QS for diagnosis or follow-up of PTE from September 2010 to September 2011&#46; The patients were referred by the authors&#8217; Institution outpatient clinics&#44; hospital wards and emergency department&#44; according to their physician&#39;s clinical judgement&#46; We included in the study&#44; by consecutive sampling&#44; all patients who agreed to perform of both techniques&#46; Inability or refusal by the patient to perform any of the modalities were the exclusion criteria&#46;</p><a name="sec0020" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Methods</span><p class="elsevierStylePara">We compared V&#47;QS-SPECT to V&#47;QS-planar&#44; since the latter is an established technique&#44; available in every Nuclear Medicine Department&#46;</p><p class="elsevierStylePara">We performed the exams following the appropriate European Association of Nuclear Medicine guidelines&#46;<a href="&#35;bib56" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib57" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a> The exams were undertaken by an experienced Nuclear Medicine team &#40;Nuclear Medicine physicians&#44; technicians and nurses trained in radiopharmaceutical administration&#41;&#46;</p><p class="elsevierStylePara">For the ventilation study&#44; the radiopharmaceutical used was carbon radioaerossols marked with technetium-99m &#40;Technegas&#44; Cyclomedica&#41;&#59; and for the perfusion study&#44; albumin macroaggregates marked with technetium-99m &#40;Macrotec&#44; GE Healthcare&#41;&#46; Both were administered with the patient in the supine position&#46;</p><p class="elsevierStylePara">Both planar and tomographic images were acquired in a dual head gamma-camera &#40;Millenium MG&#44; GE Healthcare&#41;&#46; Acquisition was sequential&#58; first the ventilation study&#44; with planar imaging followed by tomography&#44; then the perfusion study&#44; with tomography followed by planar imaging&#46; This way we could minimize patient movement between both tomographic studies&#46; We processed planar images in a general nuclear medicine workstation &#40;Xeleris&#44; GE Healthcare&#41; and the tomographic study with a specific software package &#40;LungSPECT&#44; Segami&#41;&#46;</p><p class="elsevierStylePara">According to the aforementioned guidelines&#44; we considered an exam positive for PTE if it demonstrated at least one segmental perfusion defect with preserved&#44; or less compromised&#44; ventilation &#40;mismatch pattern&#41;&#46; For each exam and technique&#44; we scored each lung for the number of pulmonary segments with a mismatch pattern&#46; We considered subsegmental defects as fractions of segmental defects&#44; giving each of them a score of 0&#46;5&#46; The scoring was done by two Nuclear Medicine physicians&#44; who had no knowledge of the patient clinical data or the clinical report produced by the physician in charge of the exam&#46; In those cases where the initial opinions were divergent&#44; final consensus was reached after discussion between them&#46;</p><a name="sec0025" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Statistical methods</span><p class="elsevierStylePara">We compared the scoring of each lung with the paired Wilcoxon test&#44; estimating the 95&#37; confidence interval &#40;95CI&#41; for the difference between V&#47;QS-SPECT and V&#47;QS-planar&#46; We used the R language and environment for statistical computing to perform the statistical calculations&#46;<a href="&#35;bib58" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a></p><a name="sec0030" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Results</span><a name="sec0035" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Participants</span><p class="elsevierStylePara">We enrolled patients for a period of 12 months&#46; Fifty-three patients agreed to perform both V&#47;QS modalities&#44; 16 male and 37 female&#46; The median age for the male gender was 54 &#40;min&#160;&#61;&#160;36&#44; max&#160;&#61;&#160;80&#41; and for the female gender was 56 &#40;min&#160;&#61;&#160;18&#44; max&#160;&#61;&#160;82&#41;&#46; All enrolled patients successfully completed both procedures&#44; none being excluded&#46; Of the 53 patients&#44; 34 were referred for previous PTE re-evaluation and 19 for PTE diagnosis&#59; 43 patients performed the exams in an outpatient setting and 10 patients were either admitted to a hospital ward or the emergency department at the time&#46; All V&#47;QS-SPECT exams were performed with the same human&#44; material and time resources as V&#47;QS-planar exams&#46;</p><a name="sec0040" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStylePara">We identified 30 exams with PTE using V&#47;QS-planar&#44; while the remainder 23 exams were considered normal&#46; The distribution of the number of perfusion defects with preserved&#47;less compromised ventilation documented per patient is presented in <a href="&#35;f0005" class="elsevierStyleCrossRefs">Figure 1</a>&#46; We observed that one-third of patients with PTE presents only one segmental defect or equivalent &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;10&#41;&#44; another third&#44; two or three defects &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;5 for both groups&#41; and another third presents four or more segmental defects &#40;the maximum being ten defects&#41;&#46;</p><a name="f0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v22n01-90447945fig1.jpg" alt="Distribution of the number of perfusion defects with preserved&#47;less compromised ventilation documented per patient &#40;V&#47;QS-planar&#41;&#59; PTE diagnosed for 1 or more defects&#46;"></img></p><p class="elsevierStylePara">Figure 1&#46; Distribution of the number of perfusion defects with preserved&#47;less compromised ventilation documented per patient &#40;V&#47;QS-planar&#41;&#59; PTE diagnosed for 1 or more defects&#46;</p><p class="elsevierStylePara">Regarding V&#47;QS-SPECT&#44; we identified 33 patients with PTE diagnostic criteria&#46; The maximum number of defects observed was 13&#46; <a href="&#35;f0010" class="elsevierStyleCrossRefs">Figure 2</a> presents this data distribution&#46;</p><a name="f0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v22n01-90447945fig2.jpg" alt="Distribution of the number of perfusion defects with preserved&#47;less compromised ventilation documented per patient &#40;V&#47;QS-SPECT&#41;&#59; PTE diagnosed for 1 or more defects&#46;"></img></p><p class="elsevierStylePara">Figure 2&#46; Distribution of the number of perfusion defects with preserved&#47;less compromised ventilation documented per patient &#40;V&#47;QS-SPECT&#41;&#59; PTE diagnosed for 1 or more defects&#46;</p><p class="elsevierStylePara">In nine patients&#44; the final conclusions of both modalities were in disagreement&#46; In this group&#44; six patients presented PTE diagnostic criteria only in V&#47;QS-SPECT&#46; The difference in the final diagnosis was due to a larger number and extension of mismatched defects identified by V&#47;QS-SPECT versus V&#47;QS-planar&#46; The other three patients with different final results displayed PTE diagnostic criteria only in V&#47;QS-planar&#46; However&#44; in two of these patients&#44; V&#47;QS-SPECT did show perfusion defects matched to ventilation defects&#59; and on the third patient&#44; there was a non-segmental distribution of perfusion defects&#46; These features were not clear in V&#47;QS-planar&#44; given the natural overlap of lung segments and airways observed in this modality&#44; which suggested a mismatch pattern instead&#46;</p><p class="elsevierStylePara">There were no inconclusive results in both modalities&#44; nor there were any adverse reactions recorded&#46;</p><a name="sec0045" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Estimates</span><p class="elsevierStylePara">The paired Wilcoxon test&#44; applied to the lung scoring&#44; evidenced a difference of 0&#46;75 between V&#47;QS-SPECT and V&#47;QS-planar &#40;95CI of 0&#46;45 to 1&#46;00&#44; <span class="elsevierStyleItalic">p</span>-value&#160;&#60;&#160;0&#46;001&#41;&#46;</p><a name="sec0050" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Discussion</span><p class="elsevierStylePara">The fact that all participants in the study successfully completed both modalities demonstrates that V&#47;QS-SPECT does not present added technical difficulties in relation to V&#47;QS-planar&#46; It is noteworthy that 10 patients performed the exams while admitted to a hospital ward or the emergency department&#44; settings in which difficulties in patient positioning and cooperation are usually expected&#46; Besides&#44; V&#47;QS-SPECT did not demand additional resources &#40;human&#44; material&#44; time&#41; in relation to V&#47;QS-planar&#46; Therefore its performance presents no disadvantages to the patient or the Department and proficiency is easily achieved&#46;</p><p class="elsevierStylePara">We observed&#44; in both modalities&#44; a large dispersion of the number of perfusion defects identified&#46; This is in agreement with the known PTE clinical presentation spectre&#44; which goes from sub-clinical to life-threatening&#46;</p><p class="elsevierStylePara">We estimated a small&#44; albeit statistically significant&#44; difference of 0&#46;75 in the scoring given to each lung between V&#47;QS-SPECT and V&#47;QS-planar&#46; This value represents the V&#47;QS-SPECT capability of identifying more perfusion defects than V&#47;QS-planar&#46; This is in agreement with reports of larger sensitivity for PTE diagnosis using V&#47;QS-SPECT&#46;<a href="&#35;bib48" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib49" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">19</span></a> It should be noted that&#44; in those cases presenting disagreement between both modalities&#44; most patients presented PTE diagnostic criteria in V&#47;QS-SPECT&#46;</p><p class="elsevierStylePara"><a href="&#35;f0015" class="elsevierStyleCrossRefs">Figure 3</a>&#44; <a href="&#35;f0020" class="elsevierStyleCrossRefs">Figure 4</a>&#44; <a href="&#35;f0025" class="elsevierStyleCrossRefs">Figure 5</a> illustrate V&#47;QS-SPECT larger sensitivity to detect perfusion defects&#46; These examples demonstrate how&#44; in one patient&#44; V&#47;QS-planar fails to correctly identify important perfusion defects&#44; therefore failing to diagnose PTE&#44; while V&#47;QS-SPECT accurately documents them</p><a name="f0015" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v22n01-90447945fig3.jpg" alt="V&#47;QS-planar study&#59; there is some heterogeneity in the perfusion of the left lung&#39;s lower lobe &#40;white arrow&#41;&#44; however it does not fulfil PTE diagnostic criteria and was disregarded as such&#46;"></img></p><p class="elsevierStylePara">Figure 3&#46; V&#47;QS-planar study&#59; there is some heterogeneity in the perfusion of the left lung&#39;s lower lobe &#40;white arrow&#41;&#44; however it does not fulfil PTE diagnostic criteria and was disregarded as such&#46;</p><a name="f0020" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v22n01-90447945fig4.jpg" alt="V&#47;QS-SPECT study&#44; same patient as before&#59; it is clear that there is a perfusion defect in the superior segment of the left lung&#39;s lower lobe &#40;cross-hairs&#41; fulfilling PTE diagnostic criteria&#46;"></img></p><p class="elsevierStylePara">Figure 4&#46; V&#47;QS-SPECT study&#44; same patient as before&#59; it is clear that there is a perfusion defect in the superior segment of the left lung&#39;s lower lobe &#40;cross-hairs&#41; fulfilling PTE diagnostic criteria&#46;</p><a name="f0025" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v22n01-90447945fig5.jpg" alt="V&#47;QS-SPECT study&#44; same patient as before&#59; another perfusion defect fulfilling PTE diagnostic criteria&#44; this time in the lateral basal segment of the left lung&#39;s lower lobe &#40;cross-hairs&#41;&#46;"></img></p><p class="elsevierStylePara">Figure 5&#46; V&#47;QS-SPECT study&#44; same patient as before&#59; another perfusion defect fulfilling PTE diagnostic criteria&#44; this time in the lateral basal segment of the left lung&#39;s lower lobe &#40;cross-hairs&#41;&#46;</p><p class="elsevierStylePara">This V&#47;QS-SPECT advantage results from the technique&#39;s ability to study each lung segment separately&#46; In contrast&#44; V&#47;QS-planar generates images where different structures overlap&#44; a limitation that might hide some defects or wrongly characterize others&#46;</p><p class="elsevierStylePara">This study did not evaluate V&#47;QS-SPECT performance regarding specificity&#46; However&#44; it should be noted that three patients presented PTE criteria in V&#47;QS-planar and not in V&#47;QS-SPECT&#44; due to a better definition of ventilation and perfusion defects by the latter modality&#46; This fact seems to support the idea that V&#47;QS-SPECT might also present gains in specificity&#44; as opposed to V&#47;QS-planar&#44; as reported by other authors&#46;<a href="&#35;bib48" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a></p><p class="elsevierStylePara">As such&#44; V&#47;QS-SPECT is poised to become a method of choice in the diagnosis and follow-up of PTE&#44; namely in young female patients or in a pregnancy setting&#44;<a href="&#35;bib59" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">29</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib60" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">30</span></a> as well as in patients which cannot be submitted to anatomical methods &#40;mostly due to renal impairment&#44; known allergy to radiological contrast media or incapacity to collaborate with the imaging protocol&#41;&#46;</p><a name="sec0055" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conclusions</span><p class="elsevierStylePara">We observed that V&#47;QS-SPECT demonstrates a higher capability to identify perfusion defects&#46; This study is in agreement with other works finding that V&#47;QS-SPECT appears to present a slight increase in sensitivity and&#44; possibly&#44; in specificity for PTE diagnosis&#44; as opposed to V&#47;QS-planar&#46; These features need further evaluation in new studies&#44; better characterizing its role on pulmonary thromboembolism diagnosis and follow-up&#46;</p><p class="elsevierStylePara">It is possible to easily introduce V&#47;QS-SPECT into the clinical practice of a Nuclear Medicine department experienced in V&#47;QS-planar performance&#46; The new technique does not imply additional consumption of resources&#46;</p><a name="sec0060" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Ethical disclosures</span><a name="sec0065" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p class="elsevierStylePara">The authors declare that no experiments were performed on humans or animals for this study&#46;</p><a name="sec0070" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p class="elsevierStylePara">The authors declare that they have followed the protocols of their work centre on the publication of patient data&#46;</p><a name="sec0075" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p class="elsevierStylePara">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p><a name="sec0080" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara">Acknowledgements</p><p class="elsevierStylePara">The authors thank the Department&#39;s Nuclear Medicine technician and nursing teams for collaborating in the acquisition of the exams&#46;</p><p class="elsevierStylePara">Received 23 February 2015 <br></br>Accepted 27 June 2015 </p><p class="elsevierStylePara">Corresponding author&#46; foss&#46;jakomo&#64;gmail&#46;com</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><br/><p class="elsevierStylePara">Lung ventilation&#47;perfusion scintigraphy with planar images &#40;V&#47;QS-planar&#41; is very useful for the diagnosis and follow-up of pulmonary thromboembolism &#40;PTE&#41;&#46; Acquiring tomographic images &#40;V&#47;QS-SPECT&#41; is a recent development with potential to increase the technique&#39;s accuracy&#46; The purpose of this work is to evaluate the added benefits of V&#47;QS-SPECT studies as opposed to traditional planar imaging&#46;</p><span class="elsevierStyleSectionTitle">Patients and methods</span><br/><p class="elsevierStylePara">We prospectively revised 53 V&#47;QS-planar and V&#47;QS-SPECT exams&#44; performed according to the European Association of Nuclear Medicine guidelines&#46; We evaluated the exams independently&#44; by consensus of two Nuclear Medicine physicians&#46; For both methods&#44; we gave each lung a score expressing the dimension and extension of perfusion defects with normal ventilation&#46; For each lung&#44; we compared the scores with the paired Wilcoxon test&#44; estimating the 95&#37; confidence interval &#40;95CI&#41; for the respective difference&#46;</p><span class="elsevierStyleSectionTitle">Results</span><br/><p class="elsevierStylePara">We performed V&#47;QS-SPECT exams without technical difficulties&#46; The paired Wilcoxon test estimated the score difference to be &#8722;0&#46;75 &#40;95CI of &#8722;1&#46;0 to &#8722;0&#46;5&#59; <span class="elsevierStyleItalic">p</span>-value&#160;&#61;&#160;9&#46;6&#160;&#215;&#160;10<span class="elsevierStyleSup">&#8722;7</span>&#41;&#44; expressing a statistically significant difference of about 1 subsegmental defect between both methods&#44; with V&#47;QS-SPECT detecting more defects&#46;</p><span class="elsevierStyleSectionTitle">Discussion</span><br/><p class="elsevierStylePara">The results demonstrate that V&#47;QS-SPECT identifies a slightly larger number of perfusion defects than V&#47;QS-planar&#44; suggesting a higher sensitivity of this technique&#46; However&#44; more studies are necessary to evaluate the clinical meaning of this fact&#46;</p><span class="elsevierStyleSectionTitle">Conclusion</span><br/><p class="elsevierStylePara">V&#47;QS-SPECT demonstrates a higher capability to identify perfusion defects&#46; This method looks promising&#44; allowing for a greater role of this exam in pulmonary thromboembolism diagnosis and follow-up&#46;</p>"
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Pulmonary ventilation/perfusion single photon emission tomography – Initial experience of a Nuclear Medicine Department
J.. G. Santosa,
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foss.jakomo@gmail.com

Corresponding author. foss.jakomo@gmail.com
, S.. Carmonaa, J.. A. Sequeiraa, A.. Prataa, A.I.. Santosa
a Serviço de Medicina Nuclear, Hospital Garcia de Orta, EPE, Av. Torrado da Silva, 2805-267 Almada, Portugal
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            "entidad" => "Serviço de Medicina Nuclear, Hospital Garcia de Orta, EPE, Av. Torrado da Silva, 2805&#x002D;267 Almada, Portugal"
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          "en" => "Distribution of the number of perfusion defects with preserved&#47;less compromised ventilation documented per patient &#40;V&#47;QS-planar&#41;&#59; PTE diagnosed for 1 or more defects&#46;"
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    "textoCompleto" => "<a name="sec0005" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Introduction and purpose</span><p class="elsevierStylePara">Pulmonary thromboembolism &#40;PTE&#41; is defined as the embolization of a blood clot to the pulmonary circulation&#46;<a href="&#35;bib31" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a> In fact&#44; it is estimated that&#44; in developed countries&#44; it might be present lifelong on up to 5&#37; of the population&#46;<a href="&#35;bib32" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a> It is also diagnosed in 1&#46;5&#37; of hospitalized patients and represents the third most frequent cardiovascular pathology &#40;after myocardial infarction and cerebrovascular disease&#41;&#46;<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> Furthermore&#44; it carries a high mortality&#44; up to 5 to 10&#37; of all in hospital deaths&#46; Therefore&#44; it is a public health problem&#46;<a href="&#35;bib32" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a></p><p class="elsevierStylePara">Acute PTE can present itself with very distinct signs and symptoms&#44; ranging from haemodynamic instability&#44; acute pulmonary hypertension&#44; cardiac failure and systemic hypotension<a href="&#35;bib31" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a> to clinically silent<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> forms&#46;</p><p class="elsevierStylePara">Chronic PTE is frequently a cause for cardiopulmonary disease&#44; originating pulmonary infarction&#44; chronic pulmonary hypertension and cor pulmonale&#46;<a href="&#35;bib31" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a></p><p class="elsevierStylePara">Despite the mentioned clinical relevance&#44; PTE diagnosis is not always straightforward&#46;<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> Therefore&#44; for greater diagnostic accuracy&#44; imaging procedures are frequently needed&#46;<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a></p><p class="elsevierStylePara">The imaging procedures used to diagnose PTE can be divided into anatomical and functional methods&#46; As for the former&#44; conventional pulmonary angiography was first described&#44; which has been superseded by computerized tomography pulmonary angiography&#46;<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib34" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a> Recently&#44; magnetic resonance pulmonary angiography has begun to be investigated&#46;<a href="&#35;bib35" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a></p><p class="elsevierStylePara">Functional methods have been represented by pulmonary ventilation and perfusion scintigraphy &#40;V&#47;QS&#41;&#44; traditionally using planar imaging &#40;V&#47;QS-planar&#41;&#46;<a href="&#35;bib33" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> V&#47;QS-planar consists in obtaining two sets of scintigraphic images of the lungs&#58; one representing pulmonary ventilation &#40;by means of a radiopharmaceutical with alveolar air distribution&#41; and another exhibiting pulmonary perfusion &#40;with a radiopharmaceutical captured in the pulmonary capillaries&#41;&#46; The scintigraphic diagnosis of PTE is based on the identification of pulmonary segments with a perfusion defect and preserved ventilation&#44; consisting on a mismatch pattern&#46; In planar imaging&#44; the acquired images represent a projection of the totality of pulmonary ventilation and perfusion in different orientations&#58; anterior&#44; posterior&#44; anterior oblique and posterior oblique&#44; more frequently&#46;</p><p class="elsevierStylePara">This procedure has been systematically improved in both sensitivity and specificity&#46; In fact&#44; since the demonstration of diagnostic accuracy of V&#47;QS-planar in the PIOPED study&#44;<a href="&#35;bib36" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib37" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a> different ways of enhancing the original technique have been investigated&#46; Of note are the combination with results from other methods&#44; namely simple chest X-ray&#44;<a href="&#35;bib38" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib39" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">9</span></a> and the introduction of new ventilation radiopharmaceuticals&#44; such as radioaerossols&#44; which allow the acquisition of ventilation studies with better diagnostic quality&#46;<a href="&#35;bib40" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">10</span></a></p><p class="elsevierStylePara">A significant advantage of scintigraphic imaging&#44; as opposed to the anatomical methods&#44; is a lower radiological exposure&#46;<a href="&#35;bib41" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> This is especially relevant when considering female patients subject to multiple exams for follow-up&#44; given the high radiological sensitivity of breast tissue&#44; which is especially exposed to radiation in anatomical thorax procedures&#46;<a href="&#35;bib42" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">12</span></a> Also in pregnant patients&#44; V&#47;QS allows the reduction of radiological exposure not only to the breast&#44; but also the foetus&#44; in contrast to anatomical methods&#46;<a href="&#35;bib43" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">13</span></a> Another VQ&#47;S advantage is that it does not require the administration of iodinated contrast media&#44; therefore presenting a more favourable pharmacological safety profile&#46;</p><p class="elsevierStylePara">Finally&#44; V&#47;QS-planar is also the method of choice in chronic PTE suspicion as an aetiology for pulmonary hypertension&#44; identifying those patients that benefit the most from directed therapy&#46;<a href="&#35;bib44" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">14</span></a></p><p class="elsevierStylePara">The most recent development in V&#47;QS was the introduction of pulmonary ventilation and perfusion tomographic imaging &#40;V&#47;QS-SPECT&#41;&#46;<a href="&#35;bib45" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib46" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">16</span></a> V&#47;QS-SPECT has the same conceptual basis of V&#47;QS-planar&#44; the only difference being that in V&#47;QS-SPECT tomographic reconstructions of pulmonary ventilation and perfusion are acquired&#44; allowing the evaluation of axial&#44; coronal and sagittal planes&#46; This technique has a solid experimental support&#44;<a href="&#35;bib47" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">17</span></a> appears to have higher diagnostic sensitivity than V&#47;QS-planar<a href="&#35;bib48" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib49" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">19</span></a> and does not seem to imply additional resource consumption&#46;<a href="&#35;bib50" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">20</span></a> Besides&#44; it compares favourably to computerized tomography pulmonary angiography&#46;<a href="&#35;bib51" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib52" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">22</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib53" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">23</span></a> Its role in clinical decision making is beginning to be evaluated&#46;<a href="&#35;bib54" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a> V&#47;QS-SPECT also seems to have a role in pulmonary physiology investigation&#46;<a href="&#35;bib55" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a></p><p class="elsevierStylePara">The purpose of this work is to evaluate the added benefits of V&#47;QS-SPECT studies regarding the detection of perfusion defects compatible with PTE as opposed to traditional planar imaging&#46;</p><a name="sec0010" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Patients and methods</span><a name="sec0015" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Participants</span><p class="elsevierStylePara">We studied prospectively V&#47;QS exams performed on the same patient with both techniques under evaluation &#40;V&#47;QS-planar and V&#47;QS-SPECT&#41;&#44; in order to compare results&#46;</p><p class="elsevierStylePara">The study population were the patients referred to the authors&#8217; department to perform a V&#47;QS for diagnosis or follow-up of PTE from September 2010 to September 2011&#46; The patients were referred by the authors&#8217; Institution outpatient clinics&#44; hospital wards and emergency department&#44; according to their physician&#39;s clinical judgement&#46; We included in the study&#44; by consecutive sampling&#44; all patients who agreed to perform of both techniques&#46; Inability or refusal by the patient to perform any of the modalities were the exclusion criteria&#46;</p><a name="sec0020" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Methods</span><p class="elsevierStylePara">We compared V&#47;QS-SPECT to V&#47;QS-planar&#44; since the latter is an established technique&#44; available in every Nuclear Medicine Department&#46;</p><p class="elsevierStylePara">We performed the exams following the appropriate European Association of Nuclear Medicine guidelines&#46;<a href="&#35;bib56" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib57" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a> The exams were undertaken by an experienced Nuclear Medicine team &#40;Nuclear Medicine physicians&#44; technicians and nurses trained in radiopharmaceutical administration&#41;&#46;</p><p class="elsevierStylePara">For the ventilation study&#44; the radiopharmaceutical used was carbon radioaerossols marked with technetium-99m &#40;Technegas&#44; Cyclomedica&#41;&#59; and for the perfusion study&#44; albumin macroaggregates marked with technetium-99m &#40;Macrotec&#44; GE Healthcare&#41;&#46; Both were administered with the patient in the supine position&#46;</p><p class="elsevierStylePara">Both planar and tomographic images were acquired in a dual head gamma-camera &#40;Millenium MG&#44; GE Healthcare&#41;&#46; Acquisition was sequential&#58; first the ventilation study&#44; with planar imaging followed by tomography&#44; then the perfusion study&#44; with tomography followed by planar imaging&#46; This way we could minimize patient movement between both tomographic studies&#46; We processed planar images in a general nuclear medicine workstation &#40;Xeleris&#44; GE Healthcare&#41; and the tomographic study with a specific software package &#40;LungSPECT&#44; Segami&#41;&#46;</p><p class="elsevierStylePara">According to the aforementioned guidelines&#44; we considered an exam positive for PTE if it demonstrated at least one segmental perfusion defect with preserved&#44; or less compromised&#44; ventilation &#40;mismatch pattern&#41;&#46; For each exam and technique&#44; we scored each lung for the number of pulmonary segments with a mismatch pattern&#46; We considered subsegmental defects as fractions of segmental defects&#44; giving each of them a score of 0&#46;5&#46; The scoring was done by two Nuclear Medicine physicians&#44; who had no knowledge of the patient clinical data or the clinical report produced by the physician in charge of the exam&#46; In those cases where the initial opinions were divergent&#44; final consensus was reached after discussion between them&#46;</p><a name="sec0025" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Statistical methods</span><p class="elsevierStylePara">We compared the scoring of each lung with the paired Wilcoxon test&#44; estimating the 95&#37; confidence interval &#40;95CI&#41; for the difference between V&#47;QS-SPECT and V&#47;QS-planar&#46; We used the R language and environment for statistical computing to perform the statistical calculations&#46;<a href="&#35;bib58" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a></p><a name="sec0030" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Results</span><a name="sec0035" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Participants</span><p class="elsevierStylePara">We enrolled patients for a period of 12 months&#46; Fifty-three patients agreed to perform both V&#47;QS modalities&#44; 16 male and 37 female&#46; The median age for the male gender was 54 &#40;min&#160;&#61;&#160;36&#44; max&#160;&#61;&#160;80&#41; and for the female gender was 56 &#40;min&#160;&#61;&#160;18&#44; max&#160;&#61;&#160;82&#41;&#46; All enrolled patients successfully completed both procedures&#44; none being excluded&#46; Of the 53 patients&#44; 34 were referred for previous PTE re-evaluation and 19 for PTE diagnosis&#59; 43 patients performed the exams in an outpatient setting and 10 patients were either admitted to a hospital ward or the emergency department at the time&#46; All V&#47;QS-SPECT exams were performed with the same human&#44; material and time resources as V&#47;QS-planar exams&#46;</p><a name="sec0040" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStylePara">We identified 30 exams with PTE using V&#47;QS-planar&#44; while the remainder 23 exams were considered normal&#46; The distribution of the number of perfusion defects with preserved&#47;less compromised ventilation documented per patient is presented in <a href="&#35;f0005" class="elsevierStyleCrossRefs">Figure 1</a>&#46; We observed that one-third of patients with PTE presents only one segmental defect or equivalent &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;10&#41;&#44; another third&#44; two or three defects &#40;<span class="elsevierStyleItalic">n</span>&#160;&#61;&#160;5 for both groups&#41; and another third presents four or more segmental defects &#40;the maximum being ten defects&#41;&#46;</p><a name="f0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v22n01-90447945fig1.jpg" alt="Distribution of the number of perfusion defects with preserved&#47;less compromised ventilation documented per patient &#40;V&#47;QS-planar&#41;&#59; PTE diagnosed for 1 or more defects&#46;"></img></p><p class="elsevierStylePara">Figure 1&#46; Distribution of the number of perfusion defects with preserved&#47;less compromised ventilation documented per patient &#40;V&#47;QS-planar&#41;&#59; PTE diagnosed for 1 or more defects&#46;</p><p class="elsevierStylePara">Regarding V&#47;QS-SPECT&#44; we identified 33 patients with PTE diagnostic criteria&#46; The maximum number of defects observed was 13&#46; <a href="&#35;f0010" class="elsevierStyleCrossRefs">Figure 2</a> presents this data distribution&#46;</p><a name="f0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v22n01-90447945fig2.jpg" alt="Distribution of the number of perfusion defects with preserved&#47;less compromised ventilation documented per patient &#40;V&#47;QS-SPECT&#41;&#59; PTE diagnosed for 1 or more defects&#46;"></img></p><p class="elsevierStylePara">Figure 2&#46; Distribution of the number of perfusion defects with preserved&#47;less compromised ventilation documented per patient &#40;V&#47;QS-SPECT&#41;&#59; PTE diagnosed for 1 or more defects&#46;</p><p class="elsevierStylePara">In nine patients&#44; the final conclusions of both modalities were in disagreement&#46; In this group&#44; six patients presented PTE diagnostic criteria only in V&#47;QS-SPECT&#46; The difference in the final diagnosis was due to a larger number and extension of mismatched defects identified by V&#47;QS-SPECT versus V&#47;QS-planar&#46; The other three patients with different final results displayed PTE diagnostic criteria only in V&#47;QS-planar&#46; However&#44; in two of these patients&#44; V&#47;QS-SPECT did show perfusion defects matched to ventilation defects&#59; and on the third patient&#44; there was a non-segmental distribution of perfusion defects&#46; These features were not clear in V&#47;QS-planar&#44; given the natural overlap of lung segments and airways observed in this modality&#44; which suggested a mismatch pattern instead&#46;</p><p class="elsevierStylePara">There were no inconclusive results in both modalities&#44; nor there were any adverse reactions recorded&#46;</p><a name="sec0045" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Estimates</span><p class="elsevierStylePara">The paired Wilcoxon test&#44; applied to the lung scoring&#44; evidenced a difference of 0&#46;75 between V&#47;QS-SPECT and V&#47;QS-planar &#40;95CI of 0&#46;45 to 1&#46;00&#44; <span class="elsevierStyleItalic">p</span>-value&#160;&#60;&#160;0&#46;001&#41;&#46;</p><a name="sec0050" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Discussion</span><p class="elsevierStylePara">The fact that all participants in the study successfully completed both modalities demonstrates that V&#47;QS-SPECT does not present added technical difficulties in relation to V&#47;QS-planar&#46; It is noteworthy that 10 patients performed the exams while admitted to a hospital ward or the emergency department&#44; settings in which difficulties in patient positioning and cooperation are usually expected&#46; Besides&#44; V&#47;QS-SPECT did not demand additional resources &#40;human&#44; material&#44; time&#41; in relation to V&#47;QS-planar&#46; Therefore its performance presents no disadvantages to the patient or the Department and proficiency is easily achieved&#46;</p><p class="elsevierStylePara">We observed&#44; in both modalities&#44; a large dispersion of the number of perfusion defects identified&#46; This is in agreement with the known PTE clinical presentation spectre&#44; which goes from sub-clinical to life-threatening&#46;</p><p class="elsevierStylePara">We estimated a small&#44; albeit statistically significant&#44; difference of 0&#46;75 in the scoring given to each lung between V&#47;QS-SPECT and V&#47;QS-planar&#46; This value represents the V&#47;QS-SPECT capability of identifying more perfusion defects than V&#47;QS-planar&#46; This is in agreement with reports of larger sensitivity for PTE diagnosis using V&#47;QS-SPECT&#46;<a href="&#35;bib48" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib49" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">19</span></a> It should be noted that&#44; in those cases presenting disagreement between both modalities&#44; most patients presented PTE diagnostic criteria in V&#47;QS-SPECT&#46;</p><p class="elsevierStylePara"><a href="&#35;f0015" class="elsevierStyleCrossRefs">Figure 3</a>&#44; <a href="&#35;f0020" class="elsevierStyleCrossRefs">Figure 4</a>&#44; <a href="&#35;f0025" class="elsevierStyleCrossRefs">Figure 5</a> illustrate V&#47;QS-SPECT larger sensitivity to detect perfusion defects&#46; These examples demonstrate how&#44; in one patient&#44; V&#47;QS-planar fails to correctly identify important perfusion defects&#44; therefore failing to diagnose PTE&#44; while V&#47;QS-SPECT accurately documents them</p><a name="f0015" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v22n01-90447945fig3.jpg" alt="V&#47;QS-planar study&#59; there is some heterogeneity in the perfusion of the left lung&#39;s lower lobe &#40;white arrow&#41;&#44; however it does not fulfil PTE diagnostic criteria and was disregarded as such&#46;"></img></p><p class="elsevierStylePara">Figure 3&#46; V&#47;QS-planar study&#59; there is some heterogeneity in the perfusion of the left lung&#39;s lower lobe &#40;white arrow&#41;&#44; however it does not fulfil PTE diagnostic criteria and was disregarded as such&#46;</p><a name="f0020" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v22n01-90447945fig4.jpg" alt="V&#47;QS-SPECT study&#44; same patient as before&#59; it is clear that there is a perfusion defect in the superior segment of the left lung&#39;s lower lobe &#40;cross-hairs&#41; fulfilling PTE diagnostic criteria&#46;"></img></p><p class="elsevierStylePara">Figure 4&#46; V&#47;QS-SPECT study&#44; same patient as before&#59; it is clear that there is a perfusion defect in the superior segment of the left lung&#39;s lower lobe &#40;cross-hairs&#41; fulfilling PTE diagnostic criteria&#46;</p><a name="f0025" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v22n01-90447945fig5.jpg" alt="V&#47;QS-SPECT study&#44; same patient as before&#59; another perfusion defect fulfilling PTE diagnostic criteria&#44; this time in the lateral basal segment of the left lung&#39;s lower lobe &#40;cross-hairs&#41;&#46;"></img></p><p class="elsevierStylePara">Figure 5&#46; V&#47;QS-SPECT study&#44; same patient as before&#59; another perfusion defect fulfilling PTE diagnostic criteria&#44; this time in the lateral basal segment of the left lung&#39;s lower lobe &#40;cross-hairs&#41;&#46;</p><p class="elsevierStylePara">This V&#47;QS-SPECT advantage results from the technique&#39;s ability to study each lung segment separately&#46; In contrast&#44; V&#47;QS-planar generates images where different structures overlap&#44; a limitation that might hide some defects or wrongly characterize others&#46;</p><p class="elsevierStylePara">This study did not evaluate V&#47;QS-SPECT performance regarding specificity&#46; However&#44; it should be noted that three patients presented PTE criteria in V&#47;QS-planar and not in V&#47;QS-SPECT&#44; due to a better definition of ventilation and perfusion defects by the latter modality&#46; This fact seems to support the idea that V&#47;QS-SPECT might also present gains in specificity&#44; as opposed to V&#47;QS-planar&#44; as reported by other authors&#46;<a href="&#35;bib48" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a></p><p class="elsevierStylePara">As such&#44; V&#47;QS-SPECT is poised to become a method of choice in the diagnosis and follow-up of PTE&#44; namely in young female patients or in a pregnancy setting&#44;<a href="&#35;bib59" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">29</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib60" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">30</span></a> as well as in patients which cannot be submitted to anatomical methods &#40;mostly due to renal impairment&#44; known allergy to radiological contrast media or incapacity to collaborate with the imaging protocol&#41;&#46;</p><a name="sec0055" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conclusions</span><p class="elsevierStylePara">We observed that V&#47;QS-SPECT demonstrates a higher capability to identify perfusion defects&#46; This study is in agreement with other works finding that V&#47;QS-SPECT appears to present a slight increase in sensitivity and&#44; possibly&#44; in specificity for PTE diagnosis&#44; as opposed to V&#47;QS-planar&#46; These features need further evaluation in new studies&#44; better characterizing its role on pulmonary thromboembolism diagnosis and follow-up&#46;</p><p class="elsevierStylePara">It is possible to easily introduce V&#47;QS-SPECT into the clinical practice of a Nuclear Medicine department experienced in V&#47;QS-planar performance&#46; The new technique does not imply additional consumption of resources&#46;</p><a name="sec0060" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Ethical disclosures</span><a name="sec0065" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p class="elsevierStylePara">The authors declare that no experiments were performed on humans or animals for this study&#46;</p><a name="sec0070" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p class="elsevierStylePara">The authors declare that they have followed the protocols of their work centre on the publication of patient data&#46;</p><a name="sec0075" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p class="elsevierStylePara">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p><a name="sec0080" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara">Acknowledgements</p><p class="elsevierStylePara">The authors thank the Department&#39;s Nuclear Medicine technician and nursing teams for collaborating in the acquisition of the exams&#46;</p><p class="elsevierStylePara">Received 23 February 2015 <br></br>Accepted 27 June 2015 </p><p class="elsevierStylePara">Corresponding author&#46; foss&#46;jakomo&#64;gmail&#46;com</p>"
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            0 => "Pulmonary thromboembolism"
            1 => "Lung"
            2 => "Scintigraphy"
            3 => "Single-photon emission-computed tomography &#40;SPECT&#41;"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><br/><p class="elsevierStylePara">Lung ventilation&#47;perfusion scintigraphy with planar images &#40;V&#47;QS-planar&#41; is very useful for the diagnosis and follow-up of pulmonary thromboembolism &#40;PTE&#41;&#46; Acquiring tomographic images &#40;V&#47;QS-SPECT&#41; is a recent development with potential to increase the technique&#39;s accuracy&#46; The purpose of this work is to evaluate the added benefits of V&#47;QS-SPECT studies as opposed to traditional planar imaging&#46;</p><span class="elsevierStyleSectionTitle">Patients and methods</span><br/><p class="elsevierStylePara">We prospectively revised 53 V&#47;QS-planar and V&#47;QS-SPECT exams&#44; performed according to the European Association of Nuclear Medicine guidelines&#46; We evaluated the exams independently&#44; by consensus of two Nuclear Medicine physicians&#46; For both methods&#44; we gave each lung a score expressing the dimension and extension of perfusion defects with normal ventilation&#46; For each lung&#44; we compared the scores with the paired Wilcoxon test&#44; estimating the 95&#37; confidence interval &#40;95CI&#41; for the respective difference&#46;</p><span class="elsevierStyleSectionTitle">Results</span><br/><p class="elsevierStylePara">We performed V&#47;QS-SPECT exams without technical difficulties&#46; The paired Wilcoxon test estimated the score difference to be &#8722;0&#46;75 &#40;95CI of &#8722;1&#46;0 to &#8722;0&#46;5&#59; <span class="elsevierStyleItalic">p</span>-value&#160;&#61;&#160;9&#46;6&#160;&#215;&#160;10<span class="elsevierStyleSup">&#8722;7</span>&#41;&#44; expressing a statistically significant difference of about 1 subsegmental defect between both methods&#44; with V&#47;QS-SPECT detecting more defects&#46;</p><span class="elsevierStyleSectionTitle">Discussion</span><br/><p class="elsevierStylePara">The results demonstrate that V&#47;QS-SPECT identifies a slightly larger number of perfusion defects than V&#47;QS-planar&#44; suggesting a higher sensitivity of this technique&#46; However&#44; more studies are necessary to evaluate the clinical meaning of this fact&#46;</p><span class="elsevierStyleSectionTitle">Conclusion</span><br/><p class="elsevierStylePara">V&#47;QS-SPECT demonstrates a higher capability to identify perfusion defects&#46; This method looks promising&#44; allowing for a greater role of this exam in pulmonary thromboembolism diagnosis and follow-up&#46;</p>"
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Article information
ISSN: 08732159
Original language: English
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