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Assessment of pulmonary embolism related to active SARS-CoV-2 infection in pregnant women
Valoración del tromboembolismo pulmonar relacionado con infección SARS-CoV-2 activa en pacientes embarazadas
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Volume of interests (VOİ) of primary rectal tumors were drawn semi-automatically by using three-dimensional (3D) VOİ tool (purple box on the right panel). Primary tumor lesions were segmented by using 40% of the maximum value in the VOI as a threshold (blue box on the right panel). 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Seiffert, Alberto Villarejo-Galende, Marta González-Sánchez, Sara Llamas-Velasco, Héctor Bueno, Enrique J. Gómez, María José Tabuenca, Patricia Sánchez-González" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Adolfo" "apellidos" => "Gómez-Grande" ] 1 => array:2 [ "nombre" => "Alexander P." "apellidos" => "Seiffert" ] 2 => array:2 [ "nombre" => "Alberto" "apellidos" => "Villarejo-Galende" ] 3 => array:2 [ "nombre" => "Marta" "apellidos" => "González-Sánchez" ] 4 => array:2 [ "nombre" => "Sara" "apellidos" => "Llamas-Velasco" ] 5 => array:2 [ "nombre" => "Héctor" "apellidos" => "Bueno" ] 6 => array:2 [ "nombre" => "Enrique J." "apellidos" => "Gómez" ] 7 => array:2 [ "nombre" => "María José" "apellidos" => "Tabuenca" ] 8 => array:2 [ "nombre" => "Patricia" "apellidos" => "Sánchez-González" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S2253654X22001391" "doi" => "10.1016/j.remn.2022.10.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253654X22001391?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808923000149?idApp=UINPBA00004N" "url" => "/22538089/0000004200000004/v1_202307170957/S2253808923000149/v1_202307170957/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Assessment of pulmonary embolism related to active SARS-CoV-2 infection in pregnant women" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "218" "paginaFinal" => "222" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. 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"apellidos" => "Busquier" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "E." "apellidos" => "Sanchez-de Mora" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Jimenez-Heffernan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidad de Medicina Nuclear, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Medicina Nuclear, Hospital Universitario Virgen Macarena, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Radiodiagnóstico, Hospital Universitario Virgen Macarena, Sevilla, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valoración del tromboembolismo pulmonar relacionado con infección SARS-CoV-2 activa en pacientes embarazadas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 903 "Ancho" => 2000 "Tamanyo" => 125448 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulmonary perfusion SPECT performed in patient 5 showing sub-segmentary perfusion defects in the upper segments of the LLL (A, blue, in coronal and sagittal slices) and LRL (red, in axial and coronal slices), with no correspondence with condensations in the radiological images to justify these findings (B), being compatible with PTE. In addition, a defect of linear horizontal uptake (green arrow) can be seen that continues in the cranial SPECT slices in the posterior direction, radiological corresponding with minimal thickening of the minor fissure (green circle).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Approximately one year after the onset of the SARS-CoV-2 pandemic (January 2020, Wuhan, China), in December 2021, the Pfizer–BioNTech mRNA BNT162b2 and the Moderna mRNA-1273 vaccines were authorized by the Food and Drug Administration<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> for use in the general population. Nonetheless, at this time no recommendations were initially given to support or rule out their use in pregnant women, leaving the decision to the criteria of the attending physician. This led to a marked delay in the vaccination of pregnant women, translating into more than 29,000 pregnant women being hospitalized due to COVID-19 infection and the death of 274<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. It was not until July 2021 that the (American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) actively encouraged pregnant women to be vaccinated<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> following the publication of the first safety results in studies on vaccines in the real population<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Since the beginning of the pandemic, there has been wide variability in the symptoms and diseases associated with the classical clinical picture of airway involvement (fever, cough, dyspnea, among others), which is predominant in this infection. Among the associated phenomena, of note are venous thromboembolisms (VTE), with pulmonary embolism (PE) being of special relevance due to its high frequency. The physiopathogenesis of these phenomena lies in excessive immune activation of the infection, producing the release of different inflammatory mediators to the blood (cytokines and others) that activate platelets, neutrophils and endothelial cells. This state of hypercoagulability, dysfunction and increase in endothelial permeability favors thrombosis, analytically translating into an elevation of <span class="elsevierStyleSmallCaps">d</span>-dimer and fibronogen<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The hemostatic, hormonal and venous ectasia associated with pregnancy produces a greater predisposition of pregnant women to present VTE compared to non-pregnant women. Moreover, the addition of the period of reduced mobility due to confinement during the pandemic, led to pregnant women being especially taken into account as a group of risk for VTE within COVID-19 infection.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Scintigraphy plays a key role for ruling out the presence of pulmonary thromboembolism (PTE) in patients with severe respiratory insufficiency, respiratory distress or tachypnea within the context of SARS-CoV-2 infection. The main advantages of scintigraphy over computerized tomography (CT) angiography are its high diagnostic sensitivity (100% vs. 83% respectively<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>) and less irradiation to the patient (effective estimated dose to the mother of 1.62 mSv with a scintigraphy with 111<span class="elsevierStyleHsp" style=""></span>MBq of <span class="elsevierStyleSup">99m</span>Tc-macroaggregate albumin or <span class="elsevierStyleSup">99m</span>Tc-MAA vs. 28.39<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.61 with CT)<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a>. In regard to the acquisition protocol, single photon emission computed tomography (SPECT) has been described as superior to planar images (sensitivity and specificity of 100% and 87% vs. 64% and 72%, respectively)<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10–12</span></a>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We analyzed a sample of pregnant women who underwent pulmonary perfusion scintigraphy to rule out the suspicion of PTE during admission to our center (Hospital Universitario Juan Ramón Jiménez, Huelva, Spain) for acute COVID-19 infection. It is important to note that at the beginning of the pandemic we adapted our pulmonary SPECT protocol according to the recommendation<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> of removing the ventilation component due to the risk of contagion and contamination by SARS-CoV-2, and therefore, we performed perfusion scintigraphy in a SPECT/CT modality. In the case of pregnant women, the CT component was also withdrawn.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">Following the administration of <span class="elsevierStyleSup">99m</span>Tc-MAA with a reduced dose (111<span class="elsevierStyleHsp" style=""></span>MBq, estimated effective dose 1.62<span class="elsevierStyleHsp" style=""></span>mSv) pulmonary perfusion SPECT (Symbia Intevo gamma camera) was performed. The images obtained were processed obtaining axial, coronal and sagittal slices. For interpretation, the PISAPED protocol<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> was followed, which takes into account the morphology and segmentary/non segmentary distribution of the perfusion defects as well as their correspondence with alterations of the thoracic radiography image. These criteria define one or multiple defects with a characteristic wedge morphology without concordant anomalies in the chest radiography as a defect compatible with PTE, while defects not presenting this morphology and which are less than or equal in extension to the radiological findings are defined as non-compatible with PTE.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We describe a sample of 5 (age 29<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7 years) pregnant patients of 28.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.7 weeks of gestation who were admitted to our center for clinical manifestations of dyspnea New York Heart Association (NYHA) III (1/5) and IV (4/5) during acute COVID-19 infection of 4.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.3 days of evolution. None of the patients had received a previous vaccination dose against SARS-CoV-2. In view of the disproportionate increase in dyspnea during admission, also associated with tachypnea in 2 patients, pulmonary perfusion scintigraphy was requested to rule out pulmonary thromboembolic disease.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">For better understanding and correlation, the scintigraphic results visualized are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> together with the gestational status, pulmonary auscultation, <span class="elsevierStyleSmallCaps">d</span>-dimer levels, and chest radiography findings as well as their interpretation according to the PISAPED criteria. At the time of the study, all the patients were receiving anticoagulant prophylaxis.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The images were pathologic in 3 of the 5 patients, being compatible with PET in only one patient, localizing sub-segmentary perfusion defects in the upper left segment of both the lower left (LLL) and right lobes (LRL) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This patient was discharged with anticoagulant treatment and close follow-up due to having a pregnancy at risk and finally delivered at term without complications.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Among the 4 remaining pregnant women in whom PTE was discarded, 2 presented defects coinciding with an area of infiltrate by COVID-19 pneumonia in the chest radiography (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>) and the other 2 did not present clear perfusion defects. Anticoagulation was discontinued in all these patients. One woman required an urgent cesarean due to worsening of the pulmonary infection, and the remaining 3 patients delivered at term with no incidences of note.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion/conclusion</span><p id="par0055" class="elsevierStylePara elsevierViewall">On minimum suspicion of PTE, pregnant women should receive anticoagulation due to their condition, assuming a greater risk of bleeding and the need for close monitoring, and thereby making it essential to rule out the presence of thrombotic phenomenon early. Although the <span class="elsevierStyleSmallCaps">d</span>-dimer values in patients diagnosed with PTE are practically double those of other patients, this value continues to be a very variable and unspecific parameter. Despite the predisposing factors, PTE was ruled out in 4 of the 5 patients studied, with the progression of COVID-19 thereby more frequently being the cause of clinical worsening in the patients than PTE. If we take into account the medium-long-term effects, it is also more severe for the fetus, since the only patient who had to undergo a cesarean section for fetal suffering was the woman who presented a worsening of COVID-19 pneumonia, ruling out PTE, compared to the women diagnosed and treated for PTE and who had an uneventful delivery at term. In addition, it should be noted that this latter patient presented a peripheral sub-segmentary distribution of the perfusion defects in the scintigraphy in accordance with what other authors have described in patients diagnosed with PTE using this technique during COVID-19 infection<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Given the unspecific nature of the clinical manifestations and <span class="elsevierStyleSmallCaps">d</span>-dimer values within the context of COVID-19 as well as their similarity with those of PTE, pulmonary perfusion scintigraphy plays a fundamental role in the diagnosis of PTE due to its high sensitivity and less irradiation than CT.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The exponential evolution of the COVID-19 pandemic and the scarce scientific evidence produced a critical time and a challenge for medical professionals responsible for the diagnosis, treatment and psychological support of affected patients and relatives. Most hospital departments have had to adapt their usual clinical practice protocols for the exploration of the airways as in the case of ventilation scintigraphy. Therefore, taking into account the absence of scientific publications in this group of patients within the exceptional setting of the COVID-19 pandemic, we consider that the results obtained are of special relevance, despite the limited number of patients studied.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1934153" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1666965" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1934152" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1666966" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion/conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-11-02" "fechaAceptado" => "2022-11-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1666965" "palabras" => array:6 [ 0 => "Pulmonary embolism" 1 => "Pregnancy" 2 => "Scintigraphy" 3 => "SPECT" 4 => "COVID-19" 5 => "SARS-CoV-2" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1666966" "palabras" => array:6 [ 0 => "Tromboembolismo pulmonar" 1 => "Embarazo" 2 => "Gammagrafía" 3 => "SPECT" 4 => "COVID-19" 5 => "SARS-CoV-2" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Aim</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">To analyze a sample of pregnant patients who underwent pulmonary perfusion scintigraphy to rule out suspicion of pulmonary embolism (PE) during the acute COVID-19 infection hospitalization period in our hospital.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">SPECT scintigraphy with a reduced dose (111<span class="elsevierStyleHsp" style=""></span>MBq) of <span class="elsevierStyleSup">99m</span>Tc-macroaggregated albumin was performed in all the patients (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5). The images obtained were interpreted by comparing the findings with the radiological images according to the PISAPED criteria.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Only one of the 5 patients was diagnosed with PE. Two patients showed pathological scintigraphy findings attributable to radiological alterations due to COVID-19 pneumonia, and the other two had normal pulmonary perfusion.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Given the non-specific features of the clinical manifestations and <span class="elsevierStyleSmallCaps">d</span>-dimer values ​​in COVID-19, as well as their similarity to those of PE, pulmonary perfusion scintigraphy plays a crucial role in the screening of PE in these patients due to its high sensitivity and lower irradiation compared to CT. Despite the limited number of patients, the results obtained have special relevance due to the absence of scientific publications in this group of patients within the exceptional context of the COVID-19 pandemic.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Analizar la muestra de pacientes embarazadas a las que se le realizó una gammagrafía de perfusión pulmonar para descartar la sospecha de tromboembolismo pulmonar (TEP) durante el ingreso en nuestro centro por infección aguda por COVID-19.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A todas las pacientes (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5) se les realizó una gammagrafía SPECT con dosis reducida (111<span class="elsevierStyleHsp" style=""></span>MBq) de <span class="elsevierStyleSup">99m</span>Tc-macroagregados de albúmina. Las imágenes obtenidas se interpretaron comparando los hallazgos con la imagen radiológica según criterios PISAPED.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">De las 5 pacientes, tan sólo en una se diagnosticó TEP. En dos pacientes los hallazgos patológicos de la gammagrafía fueron atribuibles a alteraciones radiológicas por neumonía COVID-19, y otras dos mostraron una perfusión pulmonar normal.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Dado lo inespecífico de las manifestaciones clínicas y valores del dímero-D dentro de la COVID-19, así como su similitud con los de TEP, la gammagrafía de perfusión pulmonar, por su alta sensibilidad y menor irradiación que la TC, tiene un papel crucial en el despistaje de TEP en estas pacientes. Los resultados obtenidos son de especial relevancia, a pesar del número limitado de pacientes, dada la ausencia de publicaciones científicas en este grupo de pacientes dentro de la situación excepcional por la pandemia COVID-19.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 903 "Ancho" => 2000 "Tamanyo" => 125448 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulmonary perfusion SPECT performed in patient 5 showing sub-segmentary perfusion defects in the upper segments of the LLL (A, blue, in coronal and sagittal slices) and LRL (red, in axial and coronal slices), with no correspondence with condensations in the radiological images to justify these findings (B), being compatible with PTE. In addition, a defect of linear horizontal uptake (green arrow) can be seen that continues in the cranial SPECT slices in the posterior direction, radiological corresponding with minimal thickening of the minor fissure (green circle).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1972 "Ancho" => 2000 "Tamanyo" => 194358 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Axial, coronal and sagittal slices of the scintigraphy performed in patient 3 showing an uptake defect in the low segment of the lingula (A, brown) attributable to an area of pneumonia (B, arrow), with radiological progression over the following three days (C).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1202 "Ancho" => 2000 "Tamanyo" => 129485 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Axial and coronal slices of the pulmonary perfusion scintigraphy performed in patient 4 showing a defect of sub-segmentary size in the upper lower left lobe (A, green) coinciding with radiological infiltrate (B, arrow).</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">LLL: lower left lobe; PTE: pulmonary thromboembolism.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Gestation (weeks) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pulmonary auscultation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">D-dimer (ng/mL) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Chest radiography \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pulmonary perfusion SPECT \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PISAPED \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3150 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No perfusion defects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2339 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimum increase of the interstitial tissue in the right lung base \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No perfusion defects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Crackling in right base \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1874 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infiltrate in pulmonary bases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Defect in lower segment of the lingula coinciding with area of pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abnormal not compatible with PTE \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vesicular murmur reduced in bases and disperse rhoncus (mechanical intubation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3801 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infiltrate in left pulmonary base \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sub-segmentary defect in upper segment of the LLL coinciding with radiological infiltrate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abnormal not compatible with PTE \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient 5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimal sub-crackling in right base \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6664 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sub-segmentary defects in upper segment of the LRL and LLL with triangular morphology with pleural base \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abnormal compatible with PTE \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3222217.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Results and characteristics of the patients included.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "U. 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