I’m careful to use the Wells rule with patients with suspected DVT for fear of missing one, but it seems that fear may have been the wrong way round – GP estimates, in the absence of a guideline, can also safely pick up DVTs, but are less good at eliminating them without referral for ultrasound. In other words, the risk of not using a guideline would not be so much that I’d miss patients with DVT but that I’d refer some patients without DVT that could have avoided referral if I’d used a guideline. But here’s the bit that I found most interesting, and was quite taken aback by – it seems the Wells’ rule is not the one I should be using. The Wells rule cannot safely exclude DVT in primary care. Bloody hell! Hasn’t anyone told the local vascular unit, who are still using that rule for their referral forms and guidelines?? Do they not keep up with the relevant literature? Apparently not. And apparently I should, in fact, be using the Oudega rule. Which, for future reference, is as follows:
- Male gender – 1 point
- Oral contraceptive use – 1 point
- Presence of malignancy – 1 point
- Recent surgery – 1 point
- Absence of leg trauma – 1 point
- Vein distension – 1 point
- Calf difference 3 cm or more – 2 points
- Abnormal D-dimer – 6 points
3 points or less = very low risk. 4 or more – increased risk. Does this mean we’re supposed to do D-dimers on everybody? Or what?
In other news, another reason to be cautious of using atypical antipsychotics – they appear to increase the risk of bronchopneumonia and other acute chest infections noticeably more than conventional antipsychotics. However, if I’m using the CRB-65 rule to assess a patient who has contracted a chest infection from that or any other cause, it seems I can err on whatever the opposite of the side of caution is – the CRB-65 rule turns out to overpredict mortality in community patients.
And there was also an article on how well PID was treated in general practice. I have absolutely no idea what it discovered as the only point of interest in the article, for me, was that of course it gave a link to the guidelines as to how it should be treated, so, on all those occasions when I want to know the latest on how to treat PID or other genital infections I should be checking out BASHH (the British Association for Sexual Health and HIV).