Pulse Oximetry as an Aid to Rule Out Pneumonia among Patients with a Lower Respiratory Tract Infection in Primary Care.

Guidelines recommend chest X-rays (CXRs) to diagnose pneumonia and guide antibiotic treatment. This study aimed to identify clinical predictors of pneumonia that are visible on a chest X-ray (CXR+) which could support ruling out pneumonia and avoiding unnecessary CXRs, including oxygen saturation. A secondary analysis was performed in a clinical trial that included patients with suspected pneumonia in Swiss primary care. CXRs were reviewed by two radiologists. We evaluated the association between clinical signs (heart rate > 100/min, respiratory rate ≥ 24/min, temperature ≥ 37.8 °C, abnormal auscultation, and oxygen saturation < 95%) and CXR+ using multivariate analysis. We also calculated the diagnostic performance of the associated clinical signs combined in a clinical decision rule (CDR), as well as a CDR derived from a large meta-analysis (at least one of the following: heart rate > 100/min, respiratory rate ≥ 24/min, temperature ≥ 37.8 °C, or abnormal auscultation). Out of 469 patients from the initial trial, 107 had a CXR and were included in this study. Of these, 26 (24%) had a CXR+. We found that temperature and oxygen saturation were associated with CXR+. A CDR based on the presence of either temperature ≥ 37.8 °C and/or an oxygen saturation level < 95% had a sensitivity of 69% and a negative likelihood ratio (LR-) of 0.45. The CDR from the meta-analysis had a sensitivity of 92% and an LR- of 0.37. The addition of saturation < 95% to this CDR increased the sensitivity (96%) and decreased the LR- (0.21). In conclusion, this study suggests that pulse oximetry could be added to a simple CDR to decrease the probability of pneumonia to an acceptable level and avoid unnecessary CXRs.

Impact of CT venography added to CT pulmonary angiography for the detection of deep venous thrombosis and relevant incidental CT findings.

OBJECTIVES: To assess the additional diagnostic value of CT venography (CTV) simultaneously performed with CT pulmonary angiography (CTPA) in the context of thromboembolic disease for the detection of deep venous thrombosis (DVT) and other relevant incidental CT findings. MATERIALS AND METHODS: Retrospectively and consecutively, we included all patients referred to our emergency department within the last 24 months for suspected pulmonary embolism (PE) who underwent CTPA combined with CTV. Two radiologists blinded to clinical information and results independently analysed CTV images in the context of DVT of the lower extremities and other, unsuspected abdominal/pelvic findings. These latter were classified as relevant with therapeutic consequences or irrelevant. One radiologist reviewed patient clinical records. Inter-observer agreement for DVT detection was calculated. RESULTS: Of 696 patients, 119 had PE (17.1%) and 54 had DVT (7.8%), 16 (2.3%) of them without concomitant PE. Inter-observer agreement between the two readers was substantial (kappa = 0.78). CTV examinations led to diagnosis of relevant incidental abdominal/pelvic findings in 40 (5.7%) patients, including 11 with new malignant tumours, and 8 with progressive metastatic disease. The evaluated clinical and biological risk factors were not significantly associated with the presence of relevant incidental findings. CTV changed therapeutic management in 29 patients (4.3%): 15 had DVTs without PE, and 14 had abdominal/pelvic findings with therapeutic consequences. CONCLUSION: CTV simultaneously performed with CTPA offers limited incremental value for detecting DVT. It may reveal other relevant findings leading to therapeutic changes, but the low rate does not justify screening patients with suspected PE.

Are Endovascular Interventions for Central Vein Obstructions due to Cardiac Implanted Electronic Devices Effective?

Objective: One of the late-onset complications of cardiac implanted electronic devices (CIEDs) is central venous obstruction (CVO). The aim of this study was to investigate the feasibility, efficacy, and safety of endovascular treatment of CIED-related CVOs. Methods:Eighteen patients who underwent endovascular management of their device-related CVO were reviewed. Patients were classified into three groups: Group I patients were asymptomatic and needed lead replacement; Group II patients presented with symptomatic CVO without lead dysfunction, and Group III patients were referred with both symptomatic CVO and lead dysfunction. A treatment strategy involved recanalization and balloon angioplasty for Group I and angioplasty/stents for Groups II and III. Technical success, clinical success, complications, and long-term follow-up were assessed. Results: Thirteen patients were in Group I, four in Group II, and one in Group III. Technical and clinical success was achieved in 17 patients (94%). No major complications were reported. Restenosis was observed in two patients at 40 and 42 weeks of follow-up, and these patients were successfully treated with angioplasty. Conclusion: Endovascular management of CVO due to CIED is a safe and efficient technique. Plain balloon angioplasty is sufficient for lead replacement purposes, while stenting is needed for symptomatic CVO to achieve good long-term patency.