Editorials
New Guidelines on DVT and Pulmonary Embolism
See related Practice Guideline on page 1225.
A summary of new guidelines on the diagnosis and management of deep venous thrombosis (DVT) and pulmonary embolism appears in the Practice Guidelines section of this issue of American Family Physician.1 These recommendations have been formulated by a panel with representatives from the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP), and therefore have been constructed from a primary care perspective. The recommendations are based on solid, published evidence and a rigorous evidence-based approach. They represent multiple best practices: the best practice in clinical care, the use of evidence-based methodology for guideline development, and collaboration among two specialties and a federal agency dedicated to improving health care quality.
The diagnosis and treatment of DVT and pulmonary embolism is an evolving field, and guidelines on this topic must, by necessity, summarize and use the evidence at a set point in time. As with all clinical recommendations, these will need to be reviewed and updated periodically. Nevertheless, the guidelines, if adopted widely, have the potential not only to improve the quality of care, but also to make the diagnosis and treatment of DVT and pulmonary embolism much more consistent and cost-effective.
The use of low-molecular-weight heparin in the outpatient setting, when appropriate, can save considerable cost and inconvenience, while allowing for higher quality care. This is a win-win combination for patients, physicians, and payers. It also offers family physicians an added benefit-continuity with patients. As more payers and health care systems move to the use of hospitalists for inpatient care, family physicians face an added difficulty in maintaining continuity with our patients between the inpatient and outpatient settings. Outpatient treatment of thromboembolic disorders will eliminate the need to transfer care to and from other physicians for at least one common condition.
The members of the joint AAFP/ACP panel on DVT and pulmonary embolism, as well as the AAFP and ACP staff, deserve credit and appreciation for their time and effort on behalf of practicing primary care physicians and their patients. They have passed the ball to practicing family physicians and internists who now need to review, accept, and implement these guidelines.
Address correspondence to Douglas Campos-Outcalt, MD, MPA, at dougco@u.arizona.edu. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
REFERENCES
1. Damlo S. AAFP and ACP publish recommendations on diagnosis and management of VTE. Am Fam Physician 2007;76:1225-30.
Internet Gaming: A Hidden Addiction
Here is a scenario you may have seen in your office: a teenager or young adult, usually male, who is suddenly failing at life. He may be having anger problems, personality changes, and sleep or appetite changes. He may have gotten good grades in school and is now failing all of his classes. He is not "running with a bad crowd"; in fact, he is not running with any crowd. He is usually home, playing on his computer. He says he is fine and denies feeling depressed. Drug tests come back negative. You may have prescribed antidepressants or stimulants empirically for depression or attention-deficit/hyperactivity disorder, but there has been no response. This patient does not act like anything you have seen before.
This young man may very well be obsessively playing a massively multiplayer online role-playing game (MMORPG), in which players create virtual identities for themselves and become immersed in an online fantasy world. MMORPGs are played on personal computers, as opposed to console games (e.g., X-Box, Playstation), which do not offer the social interaction of MMORPGs and are designed to have a defined ending. There have been reports of addiction to console games, but computer-based MMORPGs carry a much higher risk. Currently, there are an estimated 12.5 million MMORPG subscribers worldwide.1 As the popularity of these games has grown, the problem of compulsive online gaming has escalated.
MMORPGs are designed to require increasing playing time to achieve higher levels and obtain more gold, weapons, skills, and power in a virtual world. At the highest levels, players must band together into guilds to go on quests or raids that can require 10 or more hours of continuous play, with some players reporting playing over 70 hours per week.2 Most players can play casually and never have a problem, but an estimated six to 20 percent of players play to the exclusion of such essential activities as work, school, family responsibilities, and even eating and sleeping.3 Reports of failed marriages, neglected families, lost jobs, derailed educations, and even suicide have appeared in the medical literature and the lay press.4 Attempts to stop playing can result in a withdrawal syndrome consisting of restlessness, depression, vivid dreams about the game, anger, and excessive sleep.5 The problem is especially acute in China and South Korea, where governments have set mandatory limits on playing time and government-sponsored rehabilitation clinics have opened. The Chinese government estimates that 13 percent of the country's Internet users younger than 18 years are addicted to the Internet.6
Persons with this disorder exhibit behaviors usually associated with drug and alcohol dependence, including a need for increasing amounts of exposure to the substance (i.e., the game), denial of the adverse effects it has on their lives, repeated unsuccessful attempts to stop playing, and continued playing in the face of serious consequences such as divorce, job loss, and school failure.6 This disorder is not yet catalogued in the Diagnostic and Statistical Manual of Mental Disorders, which was last published more than 10 years ago, but it is important for family physicians to recognize this problem and to ask about time spent playing Internet computer games when examining a patient who exhibits unexplained or resistant symptoms of depression, anxiety, or sleep disorders, or employment, marital, or school problems. Patients should be referred to a mental health provider who specializes in addictions. Inpatient and outpatient rehabilitation therapy is available, as is On-Line Gamers Anonymous, an online support and recovery program based on a 12-step model (http://www.olganonboard.org).
EDITOR'S NOTE: Dr. Meenan is vice president of On-Line Gamers Anonymous World Services, Inc.
Address correspondence to Anna L. Meenan, MD, at annam@uic.edu. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
REFERENCES
1. Total MMOG active subscriptions. Accessed September 19, 2007, at: http://mmogchart.com.
2. Griffiths MD, Davies MN, Chappell D. Online computer gaming: a comparison of adolescent and adult gamers. J Adolesc 2004;27:87-96.
3. Salguero RA, Moran T, Bersabe RM. Measuring problem video game playing in adolescents. Addiction 2002; 97:1601-6.
4. Black L. It's a troll's 'life' for some: online games raise addiction concerns. Chicago Tribune November 30, 2006:1.
5. Woolley L. (2006, April 21) Withdrawal symptoms. Message posted to: http://www.olganonboard.org/index.php?topic=329.0 6. Reuters. Online addict dies after "marathon" session. Accessed May 1, 2007, at: http://today.reuters.com/news/articlenews.aspx?type=internetNewsid= 2007-02-28T085229Z_01_PEK267720_RTRUKOC_0_US-CHINA-INTERNET-ADDICTION.xml
7. Griffiths MD, Hunt N. Dependence on computer games by adolescents. Psychol Rep 1998;82:475-80.
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