Imaging techniques used in the diagnostic workup of acute venous thromboembolic disease. / Técnicas de imagen diagnósticas empleadas en la presentación aguda de la enfermedad tromboembólica venosa.

Early diagnosis is one of the most important factors affecting the prognosis of pulmonary embolism (PE); however, the clinical presentation of PE is often very unspecific and it can simulate other diseases. For these reasons, imaging tests, especially computed tomography angiography (CTA) of the pulmonary arteries, have become the keystone in the diagnostic workup of PE. The wide availability and high diagnostic performance of pulmonary CTA has led to an increase in the number of examinations done and a consequent increase in the population's exposure to radiation and iodinated contrast material. Thus, other techniques such as scintigraphy and venous ultrasonography of the lower limbs, although less accurate, continue to be used in certain circumstances, and optimized protocols have been developed for CTA to reduce the dose of radiation (by decreasing the kilovoltage) and the dose of contrast agents. We describe the technical characteristics and interpretation of the findings for each imaging technique used to diagnose PE and discuss their advantages and limitations; this knowledge will help the best technique to be chosen for each case. Finally, we comment on some data about the increased use of CTA, its clinical repercussions, its "overuse", and doubts about its cost-effectiveness.

Excessive dynamic airway collapse in a small cohort of chronic obstructive pulmonary disease patients.

INTRODUCTION: The prevalence of EDAC (Excessive Dynamic Airway Collapse) has not been studied specifically in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE: The aim of this study was to investigate the prevalence of EDAC in COPD and to determine whether there are clinical factors or functional variables that could influence the degree of expiratory collapse of central airways. METHODS: Prospective observational study of a group of patients with COPD. The degree of tracheobronchial collapse was evaluated by low-dose dynamic airway computed tomography (CT). We recorded clinical and pulmonary function tests data, quality of life and BODE index. RESULTS: This study included 53 patients with COPD, 46 (87%) males, mean age 65 (SD, 9) years. CONCLUSIONS: The prevalence of EDAC observed in a sample of patients with different levels of COPD severity is low. The degree of dynamic central airway collapse was not related to the patient's epidemiological or clinical features, and did not affect lung function, symptoms, capacity for effort, or quality of life.

Effectiveness of a protocolized system to alert pulmonologists of lung cancer radiological suspicion.

PURPOSE: When lung cancer (LC) is suspected in chest radiography, an adequate interpretation and management by experts would improve the selection, the access to rapid diagnostic units, the diagnostic effectiveness and prevent the loss of patients with suspected LC. To ensure this, we planned a system for alerting pulmonologists by radiologists to radiological suspicion of LC. METHODS: This system consists of an alert from radiologists to pulmonologists through a specific email. The pulmonologists alerted has to contact the study doctor petitioner who must refer the patient for study to the Lung Cancer Rapid Diagnostic Unit (LCRDU). We have prospectively analyzed all patients studied in a 2-year period including clinical variables, time invested in the different diagnostic steps and the degree of collaboration and satisfaction among the involved professionals. RESULTS: Of 118 alerts received, 84 (71 %) were studied in our LCRDU. The median of days until petitioner contact, patient consulted at LCRDU and to obtain a diagnosis was 1 (IQR 0-1.5), 2 (IQR 1-5) and 13 (IQR 7.5-30), respectively. In 45 cases (53 %), the suspicion of malignancy was confirmed (LC 84.4 % and metastasic 10.1 %). After staging was complete, 33 % of non-small cell lung cancer was potentially resectable (clinical TNM stage I-II). The level of satisfaction was high so that only one of the petitioner's studies chose other diagnostic pathways. CONCLUSION: This strategy for radiological suspicion of LC ensures the communication between general practitioners, radiologists and pulmonologist improving the LC diagnostic effectiveness. This system can be easily implemented in health care systems.

Técnicas de imagen diagnósticas empleadas en la presentación aguda de la enfermedad tromboembólica venosa / Imaging techniques used in the diagnostic workup of acute venous thromboembolic disease

El diagnóstico precoz de la embolia pulmonar (EP) es uno de los factores más importantes que afectan al pronóstico, pero el cuadro clínico es con frecuencia muy inespecífico y puede simular otras enfermedades. Por ello, las pruebas de imagen, sobre todo la angiografía mediante tomografía computarizada (angio-TC) de arterias pulmonares, se han convertido en la piedra angular para establecer el diagnóstico de EP. La gran disponibilidad y el alto rendimiento diagnóstico de la angio-TC pulmonar ha provocado un aumento significativo en el número de exploraciones, con el consiguiente aumento de la exposición de la población a la radiación y al contraste yodado. Por ello, a pesar de la menor precisión de otras técnicas (gammagrafía, ecografía de venas de miembros inferiores…), el papel de estas continúa vigente en determinadas circunstancias, y por otra parte, ha generado el desarrollo de protocolos optimizados de angio-TC pulmonar dirigidos a reducir la dosis de radiación (disminuyendo el kilovoltaje) y de contraste. Describimos las características técnicas y semiológicas, las ventajas y las limitaciones de cada una de las pruebas de imagen disponibles para diagnosticar la EP, cuyo conocimiento nos ayudará a elegir entre ellas según el caso. Finalmente se comentan algunos datos sobre el aumento del empleo de la angio-TC, su repercusión clínica, su «sobreuso» y las dudas sobre su coste-efectividad (AU)

Early diagnosis is one of the most important factors affecting the prognosis of pulmonary embolism (PE); however, the clinical presentation of PE is often very unspecific and it can simulate other diseases. For these reasons, imaging tests, especially computed tomography angiography (CTA) of the pulmonary arteries, have become the keystone in the diagnostic workup of PE. The wide availability and high diagnostic performance of pulmonary CTA has led to an increase in the number of examinations done and a consequent increase in the population's exposure to radiation and iodinated contrast material. Thus, other techniques such as scintigraphy and venous ultrasonography of the lower limbs, although less accurate, continue to be used in certain circumstances, and optimized protocols have been developed for CTA to reduce the dose of radiation (by decreasing the kilovoltage) and the dose of contrast agents. We describe the technical characteristics and interpretation of the findings for each imaging technique used to diagnose PE and discuss their advantages and limitations; this knowledge will help the best technique to be chosen for each case. Finally, we comment on some data about the increased use of CTA, its clinical repercussions, its 'overuse', and doubts about its cost-effectiveness (AU)

Effectiveness of a protocolized system to alert pulmonologists of lung cancer radiological suspicion

PURPOSE: When lung cancer (LC) is suspected in chest radiography, an adequate interpretation and management by experts would improve the selection, the access to rapid diagnostic units, the diagnostic effectiveness and prevent the loss of patients with suspected LC. To ensure this, we planned a system for alerting pulmonologists by radiologists to radiological suspicion of LC. METHODS: This system consists of an alert from radiologists to pulmonologists through a specific email. The pulmonologists alerted has to contact the study doctor petitioner who must refer the patient for study to the Lung Cancer Rapid Diagnostic Unit (LCRDU). We have prospectively analyzed all patients studied in a 2-year period including clinical variables, time invested in the different diagnostic steps and the degree of collaboration and satisfaction among the involved professionals. RESULTS: Of 118 alerts received, 84 (71 %) were studied in our LCRDU. The median of days until petitioner contact, patient consulted at LCRDU and to obtain a diagnosis was 1 (IQR 0-1.5), 2 (IQR 1-5) and 13 (IQR 7.5-30), respectively. In 45 cases (53 %), the suspicion of malignancy was confirmed (LC 84.4 % and metastasic 10.1 %). After staging was complete, 33 % of non-small cell lung cancer was potentially resectable (clinical TNM stage I-II). The level of satisfaction was high so that only one of the petitioner's studies chose other diagnostic pathways. CONCLUSION: This strategy for radiological suspicion of LC ensures the communication between general practitioners, radiologists and pulmonologist improving the LC diagnostic effectiveness. This system can be easily implemented in health care systems (AU)

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