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EDITORIALS: John Eikelboom and Ross Baker Routine home treatment of deep vein thrombosis BMJ 2001; 322: 1192-1193 [Full text]

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Home therapy of deep vein thrombosis and Evidence Based Medicine inherent limitations.

Sergio Stagnaro   (20 May 2001)

Anticoagulation software for managing a large number of long-term patients

Kevin T. W. Ong   (7 April 2002)

Home therapy of deep vein thrombosis and Evidence Based Medicine inherent limitations. 20 May 2001
Sergio Stagnaro, Specialist in Blood, Metabolic and Gastrointestinal Diseases. Riva Trifoso (Genoa) Send response to journal: Re: Home therapy of deep vein thrombosis and Evidence Based Medicine inherent limitations.	Sirs, All general practitioners, all over the world, know exactly that patients with acute deep vein thrombosis could undergo home therapy with heparin for at least five days followed by long term oral anticoagulation, as standard care for such patients, under some well-known circumstances. This procedure is possible nowadays due to the emergence of low molecular weight heparin, which recently proved to be a safe, effective, and convenient treatment for deep vein thrombosis that really “challenged the need for routine admission”. As a matter of facts, is generally admitted that low molecular weight heparin is at least as effective and safe as unfractionated heparin for the initial treatment of deep vein thrombosis, according to the results of a lot of randomised trials. Schwarz T. et al., for instance, adds to the evidence as regards home treatment of deep vein thrombosis (1). However, according to the authors of this excellent editorial, this aim can be achieved on condition that an accurate evaluation of the patients allows doctor to perform an optimal selection of patients for home treatment. In other words, a general practitioner must have an accurate patient’s history (e.g., history of recurrent venous thromboembolism), recognize at the bed-side pulmonary embolisms, identify coexisting conditions requiring hospitalisation, such a latent heart insufficiency, and so on. In my opinion, doctors need urgently at the bed side an effective physical semeiotics that enables them to recognize promptly all these pathological situations, really difficult to identify with the aid of the old, traditional semeiotics (See: my rapid response in bmj.com.: A new physical semeiotics in detecting disorders otherwise undiagnosed, 30 March, 2001 and http://digilander.iol.it/semeioticabiofisica). This currrent lack of a clinical tool, useful in bed-side diagnosis, accounts for the reason that even among patients with deep vein thrombosis, randomised to home treatment, up to half were initially admitted to hospital, and for the reluctance of some centres to consider home treatment, despite its favourable influence on NHS expenses. Finally, this noteworthy editorial shows clearly that Evidence Based Medicine is a scientific, reductionist approach, representing the reality of groups, valid in context but with limitations. On the contrary, Chaos Based Medicine is a scientific, holistic approach, representing the reality of groups and individuals, validating evidence in context, according to V.S.Rambihar (4). Stagnaro Sergio MD, Member NYAS and AAAS 1) Schwarz T, Schmidt B, Hohlein U, Beyer J, Schroder H-E, Schellong SM. Eligibility for home treatment of deep vein thrombosis: prospective study. BMJ 2001; 322: 1212-1213. 2) Koopman MMW, Prandoni P, Piovella F, Ockelford PA, Brandjes DPM, van der Meer J, et al. Treatment of deep vein thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. N Engl J Med 1996; 334: 682-687[Medline]. 3)Levine M, Gent M, Hirsh J, Leclerc J, Anderson D, Weitz J, et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep -vein thrombosis. N Engl J Med 1996; 334: 677-681[Medline]. 4)Rambihar V.S. A new chaos based medicine behond 2000. Vashna Publications, Toronto, 2000.
Anticoagulation software for managing a large number of long-term patients 7 April 2002
Kevin T. W. Ong, Final year medical student Barts and London Medical school, London Send response to journal: Re: Anticoagulation software for managing a large number of long-term patients	Sir, I would like to draw your attention to the 'DAWN AC' computer software package used at the Haematology department of the Newham Healthcare NHS Trust, in East London. This software package is a complete anticoagulation clinic management system.[1] It provides a recommended next dose and next test date based on a patient’s previous dosage and INR history and the system settings. Patients on the ‘DAWN-AC’ software-cum-postal system are patients who have 3 or more anticoagulation treatment regimens. These patients are all from the 230,000 multi-cultural population living within the catchment area of the Trust.[2] There is no other NHS centre involved in home anticoagulation prophylaxis in this catchment area. These patients do not need to see a doctor, and do not need to attend any anticoagulation clinic. The ‘DAWN-AC’ system would alert the office manager of their next date to come to the hospital to check their INR, and a letter is sent to them to tell them to come on that date. The results of their INR are fed into the ‘DAWN-AC’ software system, and their next treatment dosage is calculated. This new treatment dosage would be sent to the patient and reach them the following day, and the patients would adjust their treatment dosage at home accordingly. The ‘DAWN-AC’ software system also has a ‘filtering facility’ that enables a clinician who wants to do an audit, to order a print out of a complete list of patients who has a particular aspect(s) in their records which he wants to look at. I did a simple study of the patients' data using the 'filtering facility', and found that for all groups of patients with different anticoagulation reasons, the average numbers of INRs out of range and the average numbers of DNAs (times patients Did Not Attend their appointments) corresponded with a similar trend, group for group. This means that the more compliant the patients were towards the software-cum- postal system managing their anticoagulation medication, the less their rate of INRs were out of range. This indirectly shows that the system is efficient, and as effective as the level of compliance towards it. References 1. DAWN AC anticoagulation management system version 4 user’s manuel. Information Systems Ltd. 2. Newham health care NHS trust annual report 1998-1999.