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Thank You to Family Doctors Correspondance Letters Thank you to College of Family Physicians of Canada, how- family doctors ever, sparks the engagement of physicians across the country in this most pressing and devastating epidemic. his letter is meant to express, in the most With a unique understanding of the horrors heartfelt way, our appreciation for the funds of this disease—for patients and for the fami- Tthe College of Family Physicians of Canada lies and communities they leave behind—family raised for the Stephen Lewis Foundation. It physicians in Canada have turned empathy into was a most welcome surprise to us here at the meaningful and powerful action within Canada. Foundation to hear about the spontaneous reac- The money donated to the Foundation goes tion of those in attendance at Mr Lewis’ speech directly, as promised, to the grass roots. In the on November 26, 2004. Their pledge and com- great majority of projects, we wire the money mitment to the HIV and AIDS epidemic in right to the bank account of community-based Africa was outstanding. organizations. We support orphan care and pay Evident in the efforts of the Ontario Hospital school fees; we support countless numbers of Association in Lesotho and with the inspir- initiatives designed to assist vulnerable women, ing leadership of Dr Jane Philpott at Markham especially through home-based palliative care; Stouffville Hospital, doctors in Ontario have and we actively support associations of people heard the call for assistance and are respond- living with AIDS, helping them to fight stigma ing. The outpouring of generosity from the and to assert their human rights. VOL 5: MAI • MAI 2005 d Canadian Family Physician • Le Médecin de famille canadien 653 Letters Correspondance Again, please accept our most grateful appreciation. techniques that can, in many patients, show the dis- —Alexis MacDonald tal as well as the proximal (above-knee) deep venous Acting Executive Director system.1 The Stephen Lewis Foundation Several questions relating to the management Toronto, Ont of distal DVT deserve comment. First, should all by mail patients with distal DVT receive anticoagulant therapy, as in patients with proximal DVT? Second, if anticoagulants are given, what is the optimal Nontreatment of deep duration of treatment? Third, do such patients war- vein thrombosis rant additional investigations, such as looking for thrombophilia or occult cancer, as might be the case in some patients with proximal and, in partic- e thought the article “Treatment of deep vein ular, unprovoked (or idiopathic) DVT? thrombosis. What factors determine appro- In general, patients who have symptomatic Wpriate treatment?”1 was an excellent update and was DVT, whether proximal or distal, warrant con- long overdue. In addition to describing treatment, it ventional anticoagulant therapy with low-molec- also clearly outlined criteria for deciding whether ular-weight heparin and warfarin.2 Without to treat deep vein thrombosis (DVT) on an inpa- anticoagulant therapy, patients with symptom- tient or outpatient basis. We had recently noticed atic distal DVT have about a 20% chance that that some patients who would qualify for outpatient the DVT will extend into the proximal veins, treatment according to the article (eg, uncompli- which could cause life-threatening pulmonary cated below-knee DVT) are, in fact, not treated at embolism.3 Furthermore, anticoagulant therapy all. We wondered if the author could comment on helps to alleviate leg pain and swelling that can the “nontreatment” of DVT. be severe, even in patients with less extensive —Shirley Katz, MD CM, CCFP distal DVT. However, in patients with superfi- —Susan Rapoport-Glick, MD, CCFP cial vein thrombophlebitis that does not involve Thornhill, Ont the deep veins, initial treatment with a nonste- by e-mail roidal anti-inflammatory drug or a 2- to 4-week course of a low-dose heparin preparation could Reference be considered.2 There is no consensus on the 1. Douketis JD. Treatment of deep vein thrombosis. What factors determine appropriate treatment? Can Fam Physician 2005;51:217-23. optimal duration of anticoagulation for distal DVT, although a 3-month course is reasonable, assuming that symptoms have resolved and there Response are no ongoing risk factors for disease recur- rence, such as active cancer or immobility.4 Finally, as to whether further rs Katz and Rapoport-Glick raise investigation to assess etiology is an important issue that has not warranted in such patients, the Dbeen addressed in most clinical trials key point perhaps is that DVT is a investigating the treatment of DVT: single disease and the same man- management of patients who pres- agement principles should apply, ent with lower limb swelling or pain whether DVT is proximal or distal. and are diagnosed with DVT of the Thus, thrombophilia testing would distal (or calf) veins. This issue is be reasonable in patients with seen increasingly in clinical practice unprovoked DVT, particularly if with improved venous ultrasound they are young (<50 years) and 654 Canadian Family Physician • Le Médecin de famille canadien d VOL 5: MAI • MAI 2005.
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