Computerized Tomographic Pulmonary Angiography Compared with Ventilation-Perfusion Lung Scanning as Inital Diagnostic Modality for Patients with Suspected Pulmonary Embolism: A Randomized Controlled Trial.
Notice bibliographique
Résumé
Abstract Ventilation-perfusion (VQ) lung scanning and computerized tomographic pulmonary angiography (CTPA) have been validated as imaging procedures for the evaluation of patients with suspected pulmonary embolism and are used widely. To compare the safety and utility of VQ scanning and CTPA we performed a multi-centre randomized controlled trial in patients presenting with clinically suspected acute pulmonary embolism. All patients were evaluated using an explicit clinical model to determine pretest probability (Wells score) and with D-dimer. Patients considered at low likelihood of pulmonary embolism (score < 4.5 and negative D-dimer) did not undergo further testing and were followed as a separate cohort. The remaining patients were randomized to undergo either VQ scanning or CTPA. Patients diagnosed with pulmonary embolism on the basis of a high probability VQ scan or a positive CTPA were treated. Other patients underwent bilateral venous ultrasound imaging of the proximal veins of lower extremities and those confirmed to have DVT were treated. Physicians were able to refer patients for traditional pulmonary angiography or serial ultrasonography after initial testing but switching of patients to have the alternative pulmonary imaging procedure was not permitted by the protocol. Patients in whom pulmonary embolism was considered excluded did not receive antithrombotic therapy and were followed for a three month period. The primary outcome was the development of symptomatic pulmonary embolism or proximal deep vein thrombosis in the follow-up period in patients in whom the diagnosis of pulmonary embolism had initially been excluded. 1577 patients were enrolled in the study of whom 172 entered the low risk cohort. 1405 patients were randomized, 694 to CTPA and 711 to VQ scanning. 19.2% (133) of patients in the CTPA versus 14.2% (101) were diagnosed with pulmonary embolism in the initial evaluation period (difference 5.0%, 95% CI 1.1% to 8.9%). Of those in whom pulmonary embolism was considered excluded 0.4% (2/561) patients undergoing CTPA versus 1.0% (6/610) patients undergoing VQ scanning developed venous thromboembolism in follow-up (difference −0.6%, 95% CI −1.6% to 0.3%) including one with fatal pulmonary embolism in the VQ group. All cause mortality was higher in the three month follow-up for patients undergoing VQ scanning (30/610, 4.9%) than for CTPA (17/694, 2.4%) in whom pulmonary embolism was considered excluded. Most of these deaths were from cancer. Management practices using bilateral ultrasonography with either VQ scanning or CTPA to exclude the diagnosis of pulmonary embolism resulted in low rates of venous thromboembolic complications. More patients were diagnosed intitally with pulmonary embolism using the CTPA approach and fewer patients died in this cohort in the three month follow-up period.
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Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,001 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,002 | 0,001 |
| Bibliométrie | 0,000 | 0,001 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».