Ann Intern Med -- Rapid Responses for Qaseem et al., 146 (6) 454-458

Established in 1927 by the American College of Physicians

Rapid Responses to:

Clinical Guidelines:
Amir Qaseem, Vincenza Snow, Patricia Barry, E. Rodney Hornbake, Jonathan E. Rodnick, Timothy Tobolic, Belinda Ireland, Jodi B. Segal, Eric B. Bass, Kevin B. Weiss, Lee Green, Douglas K. Owens and the Joint American Academy of Family Physicians/American College of Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism ${dagger}$
Current Diagnosis of Venous Thromboembolism in Primary Care: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians
Ann Intern Med 2007; 146: 454-458 [Abstract] [Full text] [PDF]

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Electronic letters published:

Author Response: Amir Qaseem, Vincenza Snow, MD (15 May 2007)

Applying your guidelines for Upper Limb Deep Vein Thrombosis?: Raghava S Kumar Bhamidimarri (1 May 2007)

Delay in Thromboembolism Evaluation: David T. Lush (26 April 2007)

Author Response 15 May 2007

Amir Qaseem,
MD, PhD, MHA
American College of Physicians,
Vincenza Snow, MD
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Re: Author Response

Aqaseem{at}acponline.org Amir Qaseem, et al.

Our recommendations are based on only evidence from randomized controlled trials. That is why the studies that were mentioned in the letters comparing the efficacy of LMWH vs. UFH as well as for safety of heparin and warfarin during pregnancy were not mentioned in the guideline. However, LMWH is more cost-effective compared to UFH. Although there are many studies evaluating prophylactic use of LMWH in pregnant women, the evidence is scarce for treating DVT or PE in pregnant women.
Conflict of Interest:
None declared

Applying your guidelines for Upper Limb Deep Vein Thrombosis? 1 May 2007

Raghava S Kumar Bhamidimarri,
MRCP(UK)
None
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Re: Applying your guidelines for Upper Limb Deep Vein Thrombosis?

kumarbrs{at}aol.com Raghava S Kumar Bhamidimarri

This article highlights the important aspects of diagnosing venous thromboembolism. The article however does not clarify if these guidelines are applicable for suspected Upper limb deep vein thrombosis. I am aware that there has been no trial evidence testing the Well's score for suspected upper limb deep vein thrombosis but from a pragmatic sense, upper limb deep veins are not much different to lower limb deep veins.
Conflict of Interest:
General Medicine

Delay in Thromboembolism Evaluation 26 April 2007

David T. Lush,
M.D.
Univ of Pennsylvania
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Re: Delay in Thromboembolism Evaluation

david.lush{at}uphs.upenn.edu David T. Lush

The article by Quseem and colleagues provides a clinical practice guideline regarding the diagnosis of lower extremity deep vein thrombosis and pulmonary embolism specifically addressed to primary care physicians. High-sensitive D-dimer assay is recommended in appropriately selected patients with low pretest probability by the Wells predition rules.
Rapid institution of therapy has always been a priority in thromboembolism. Few primary care physicians have access to same day test results. The issue of time was not discussed in the guidelines but should be a factor in the decision making.
Conflict of Interest:
None declared