All is not So Well with the Wells Rule

http://www.bmj.com/content/348/bmj.g1340

At the link above, note that a recent metanalysis has detected that one cannot rely on the DVT Wells rule alone in 2 important circumstances- active cancer and a history of previous DVT/PE. The Wells rule had an unacceptable (higher than 2%) false negative rate for these 2 subgroups, and as such D-Dimer testing for rule out was needed despite the low risk Wells.

While this affects ER care more than express care, it does reinforce these 2 points:

• When assessing patients with respiratory complaints in the express care and you are tallying history to rule out DVT (and also PE), thoroughly respect and lend credence to active cancer or previous thrombotic history. 
• Again, always keep DVT/PE in the differential, and document as many points as possible against it if you do not send someone to the ER. Medicine will humble you through a PE or DVT.

More Information on CA-MRSA

https://mail.rexhealth.com/owa/attachment.ashx?attach=1&id=RgAAAADl1XTUhfhQSbuUVKYGOBoABwBsXF%2b%2b5jagQ7x0ZqjK4HMvAAAGpllIAABpl1Wt0lmiTr42aFQwe7JSAAAzXUNZAAAJ&attid0=BAAAAAAA&attcnt=1

Attached above is (hopefully) the article from last month's NEJM on CA-MRSA. I encourage you all to review this article, and if you cannot, I will gladly send you the email link that lasts 30 days. A few summary points:

• The article readily admits that much is based on clinical experience, not evidence based medicine. 
• Like most CA-MRSA articles the article takes the "ivory tower" suggestion of solely relying on incision and drainage without antibiotics, but then lists the legion amount of caveats that indeed need antibiotics: multiple sites of infection, "rapid disease progression", associated cellulitis, signs of systemic illness, very young or advanced age, or face/hand/ genitalia abscesses. So, in the real lawyer infected world this means: "Everyone gets antibiotics." Note any first year lawyer can take the obtuse term "rapid disease progression" and contort it to a jury with a second grade health literacy level. ( FYI- national average is 4th grade.)
• I found most useful the evolving prevention tips. I have long been a fan of Hibiclens, and the article had some actual tips.

HIBICLENS/Prevention Tips

• Apply to all body parts from the neck down (stings the eyes,nose mouth), then rinse. Do this for 5 days.
• Remember that after you apply the Hibiclens in the shower and rinse, do not remove the protective layer by then applying soap, shampoo, etc. One female patient told me "So, you mean the Hibiclens is like conditioner...you apply it last and try to keep some in." Being bald, I told her it made sense in theory:).
• Also consider 2% mupirocin to the nares with a sterile cotton swab bid for 5 days. 

A "Laceration" to the Old Dogma

As people say, "these times are a changing!" One issue is the below cited study- now the second of 2 large studies in the last decade, to challenge the "1970-ish" dogma of either not closing or "loosely" closing wounds that present late. Please recall that a "late" presentation can often vary by body site and proximity to and amount of circulation, so a forehead laceration at 12 hours could still be considered by many to be "fresh" but the same laceration on the anterior leg in a diabetic smoker would very correctly be viewed as "late" at 12 hours. 

http://www.jwatch.org/na33434/2014/02/07/management-lacerations-dogma-changing

If you elect to close a "late" presenting wound, please remember the overall summary of the study:

• The study advocates that a late presentation is not a factor in infection rates. Rather, location (i.e. less blood supply) and co-morbidities play a larger role.
• Focus on the crucial mention that a key issue in infection prevention is through flushing. Recall the medical school surgical rotation maxim: "The solution to pollution is dilution!" I heartily recommend for medico-legal purposes in every suture case to document the amount of flush and diluent and method. For example say, "The wound was flushed with 250 cc of normal saline via Zero Wet apparatus."
• One unofficial laceration rule is that for every centimeter of laceration aim for a "minimum" of 100cc of flush. So a 3cm laceration needs a minimum of 300cc of flush.