Diagnosing pulmonary embolism in outpatients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study.

PURPOSE: To evaluate a diagnostic strategy for pulmonary embolism that combined clinical assessment, plasma D-dimer measurement, lower limb venous ultrasonography, and helical computed tomography (CT). METHODS: A cohort of 965 consecutive patients presenting to the emergency departments of three general and teaching hospitals with clinically suspected pulmonary embolism underwent sequential noninvasive testing. Clinical probability was assessed by a prediction rule combined with implicit judgment. All patients were followed for 3 months. RESULTS: A normal D-dimer level (<500 microg/L by a rapid enzyme-linked immunosorbent assay) ruled out venous thromboembolism in 280 patients (29%), and finding a deep vein thrombosis by ultrasonography established the diagnosis in 92 patients (9.5%). Helical CT was required in only 593 patients (61%) and showed pulmonary embolism in 124 patients (12.8%). Pulmonary embolism was considered ruled out in the 450 patients (46.6%) with a negative ultrasound and CT scan and a low-to-intermediate clinical probability. The 8 patients with a negative ultrasound and CT scan despite a high clinical probability proceeded to pulmonary angiography (positive: 2; negative: 6). Helical CT was inconclusive in 11 patients (pulmonary embolism: 4; no pulmonary embolism: 7). The overall prevalence of pulmonary embolism was 23%. Patients classified as not having pulmonary embolism were not anticoagulated during follow-up and had a 3-month thromboembolic risk of 1.0% (95% confidence interval: 0.5% to 2.1%). CONCLUSION: A noninvasive diagnostic strategy combining clinical assessment, D-dimer measurement, ultrasonography, and helical CT yielded a diagnosis in 99% of outpatients suspected of pulmonary embolism, and appeared to be safe, provided that CT was combined with ultrasonography to rule out the disease.

Decision analysis of the effectiveness of lung cancer screening using autofluorescence bronchoscopy and computed tomography

Background: Lung cancer (LC) is the leading cause of cancer death in the developed world. Most cancers are associated with tobacco smoking. A primary hope for reducing lung cancer has been prevention of smoking and successful smoking cessation programs. To date, these programs have not been as successful as anticipated. Objective: The aim of the current study was to evaluate whether lung cancer screening combining low dose computed tomography with autofluorescence bronchoscopy (combined CT & AFB) is superior to CT or AFB screening alone in improving lung cancer specific survival. In addition, the extent of improvement and ideal conditions for combined CT & AFB screening were evaluated. Methods: We applied decision analysis and Monte Carlo simulation modeling using TreeAge Software to evaluate our study aims. Histology- and stage specific probabilities of lung cancer 5-year survival proportions were taken from Surveillance and Epidemiologic End Results (SEER) Registry data. Screeningassociated data was taken from the US NCI Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO), National Lung Screening Trial (NLST), and US NCI Lung Screening Study (LSS), other relevant published data and expert opinion. Results: Decision Analysis - Combined CT and AFB was the best approach at Improving 5-year survival (Overall Expected Survival (OES) in the entire screened population was 0.9863) and in lung cancer patients only (Lung Cancer Specific Expected Survival (LOSES) was 0.3256). Combined screening was slightly better than CT screening alone (OES = 0.9859; LCSES = 0.2966), and substantially better than AFB screening alone (OES = 0.9842; LCSES = 0.2124), which was considerably better than no screening (OES = 0.9829; LCSES = 0.1445). Monte Carlo simulation modeling revealed that expected survival in the screened population and lung cancer patients is highest when screened using CT and combined CT and AFB. CT alone and combined screening was substantially better than AFB screening alone or no screening. For LCSES, combined CT and AFB screening is significantly better than CT alone (0.3126 vs. 0.2938, p< 0.0001). Conclusions: Overall, these analyses suggest that combined CT and AFB is slightly better than CT alone at improving lung cancer survival, and both approaches are substantially better than AFB screening alone or no screening.

Semiautomated 3D liver segmentation using computed tomography and magnetic resonance imaging

Le foie est un organe vital ayant une capacité de régénération exceptionnelle et un rôle crucial dans le fonctionnement de l’organisme. L’évaluation du volume du foie est un outil important pouvant être utilisé comme marqueur biologique de sévérité de maladies hépatiques. La volumétrie du foie est indiquée avant les hépatectomies majeures, l’embolisation de la veine porte et la transplantation. La méthode la plus répandue sur la base d'examens de tomodensitométrie (TDM) et d'imagerie par résonance magnétique (IRM) consiste à délimiter le contour du foie sur plusieurs coupes consécutives, un processus appelé la «segmentation». Nous présentons la conception et la stratégie de validation pour une méthode de segmentation semi-automatisée développée à notre institution. Notre méthode représente une approche basée sur un modèle utilisant l’interpolation variationnelle de forme ainsi que l’optimisation de maillages de Laplace. La méthode a été conçue afin d’être compatible avec la TDM ainsi que l' IRM. Nous avons évalué la répétabilité, la fiabilité ainsi que l’efficacité de notre méthode semi-automatisée de segmentation avec deux études transversales conçues rétrospectivement. Les résultats de nos études de validation suggèrent que la méthode de segmentation confère une fiabilité et répétabilité comparables à la segmentation manuelle. De plus, cette méthode diminue de façon significative le temps d’interaction, la rendant ainsi adaptée à la pratique clinique courante. D’autres études pourraient incorporer la volumétrie afin de déterminer des marqueurs biologiques de maladie hépatique basés sur le volume tels que la présence de stéatose, de fer, ou encore la mesure de fibrose par unité de volume.

Weak constraints in four-dimensional variational data assimilation

The formulation of four-dimensional variational data assimilation allows the incorporation of constraints into the cost function which need only be weakly satisfied. In this paper we investigate the value of imposing conservation properties as weak constraints. Using the example of the two-body problem of celestial mechanics we compare weak constraints based on conservation laws with a constraint on the background state.We show how the imposition of conservation-based weak constraints changes the nature of the gradient equation. Assimilation experiments demonstrate how this can add extra information to the assimilation process, even when the underlying numerical model is conserving.

Four-dimensional variational assimilation of ozone profiles from the Microwave Limb Sounder on the Aura satellite

Ozone profiles from the Microwave Limb Sounder (MLS) onboard the Aura satellite of the NASA's Earth Observing System (EOS) were experimentally added to the European Centre for Medium-range Weather Forecasts (ECMWF) four-dimensional variational (4D-var) data assimilation system of version CY30R1, in which total ozone columns from Scanning Imaging Absorption Spectrometer for Atmospheric CHartographY (SCIAMACHY) onboard the Envisat satellite and partial profiles from the Solar Backscatter Ultraviolet (SBUV/2) instrument onboard the NOAA-16 satellite have been operationally assimilated. As shown by results for the autumn of 2005, additional constraints from MLS data significantly improved the agreement of the analyzed ozone fields with independent observations throughout most of the stratosphere, owing to the daily near-global coverage and good vertical resolution of MLS observations. The largest impacts were seen in the middle and lower stratosphere, where model deficiencies could not be effectively corrected by the operational observations without the additional information on the ozone vertical distribution provided by MLS. Even in the upper stratosphere, where ozone concentrations are mainly determined by rapid chemical processes, dense and vertically resolved MLS data helped reduce the biases related to model deficiencies. These improvements resulted in a more realistic and consistent description of spatial and temporal variations in stratospheric ozone, as demonstrated by cases in the dynamically and chemically active regions. However, combined assimilation of the often discrepant ozone observations might lead to underestimation of tropospheric ozone. In addition, model deficiencies induced large biases in the upper stratosphere in the medium-range (5-day) ozone forecasts.

Four-dimensional variational data assimilation for high resolution nested models

Four-dimensional variational data assimilation (4D-Var) is used in environmental prediction to estimate the state of a system from measurements. When 4D-Var is applied in the context of high resolution nested models, problems may arise in the representation of spatial scales longer than the domain of the model. In this paper we study how well 4D-Var is able to estimate the whole range of spatial scales present in one-way nested models. Using a model of the one-dimensional advection–diffusion equation we show that small spatial scales that are observed can be captured by a 4D-Var assimilation, but that information in the larger scales may be degraded. We propose a modification to 4D-Var which allows a better representation of these larger scales.

On the use of a time sequence of surface pressures in four-dimensional data assimilation

The possibility of using a time sequence of surface pressure observations in four-dimensional data assimilation is being investigated. It is shown that a linear multilevel quasi-geostrophic model can be updated successfully with surface data alone, provided the number of time levels are at least as many as the number of vertical levels. It is further demonstrated that current statistical analysis procedures are very inefficient to assimilate surface observations, and it is shown by numerical experiments that the vertical interpolation must be carried out using the structure of the most dominating baroclinic mode in order to obtain a satisfactory updating. Different possible ways towards finding a practical solution are being discussed.

Four-dimensional data assimilation

Numerical weather prediction can be regarded as an initial value problem whereby the governing atmospheric equations are integrated forward from fully determined initial values of the meteorological parameters. However, in spite of the considerable improvements of the observing systems in recent years, the initial values are known only incompletely and inaccurately and one of the major tasks of any forecasting centre is to determine the best possible initial state from available observations.

Current problems in four-dimensional data assimilation

The purpose of this lecture is to review recent development in data analysis, initialization and data assimilation. The development of 3-dimensional multivariate schemes has been very timely because of its suitability to handle the many different types of observations during FGGE. Great progress has taken place in the initialization of global models by the aid of non-linear normal mode technique. However, in spite of great progress, several fundamental problems are still unsatisfactorily solved. Of particular importance is the question of the initialization of the divergent wind fields in the Tropics and to find proper ways to initialize weather systems driven by non-adiabatic processes. The unsatisfactory ways in which such processes are being initialized are leading to excessively long spin-up times.