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 Table of Contents  
COMMENTARY
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 115-116

Commentary on the screening for occult lower-extremity deep-vein thrombosis upon admission to acute inpatient rehabilitation: A cross-sectional, prospective study


1 Department of Physical Medicine and Rehabilitation and Joint Appointment in Department of Neurology and Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA
2 Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas, USA

Date of Submission20-Jan-2019
Date of Decision07-Apr-2019
Date of Acceptance15-Apr-2019
Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Mansi M Jhaveri
Department of Physical Medicine and Rehabilitation and Joint Appointment in Department of Neurology and Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Texas
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisprm.jisprm_50_19

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How to cite this article:
Jhaveri MM, Russell ME. Commentary on the screening for occult lower-extremity deep-vein thrombosis upon admission to acute inpatient rehabilitation: A cross-sectional, prospective study. J Int Soc Phys Rehabil Med 2019;2:115-6

How to cite this URL:
Jhaveri MM, Russell ME. Commentary on the screening for occult lower-extremity deep-vein thrombosis upon admission to acute inpatient rehabilitation: A cross-sectional, prospective study. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Nov 13];2:115-6. Available from: http://www.jisprm.org/text.asp?2019/2/3/115/268380



The quest to detect occult deep-venous thrombosis (DVT) is ambitious. As more medically complex and disabled patients are admitted to inpatient rehabilitation centers, the need for better surveillance in the prevention of secondary medical complications is of utmost importance. DVT, a clot in motion that lands in the lung, and pulmonary embolism (PE) are common complications associated with severe morbidity and mortality. The authors conclude that ultrasound screening within 72 h of admission to inpatient rehabilitation may not be beneficial in detecting occult DVT, but the study findings pose several dilemmas.[1]

This cross-sectional, prospective, single-site study was conducted over 3 months, from October, 2017, to December, 2017, which may be considered too short to draw any meaningful conclusion. Of the 127 patients included, 13.3% were on full-dose anticoagulation, which is known to rapidly extinguish clot formation.[2] Therefore, the 1% study finding of DVT by Doppler ultrasound is questionable. Study participant characteristics such as whether patients were ambulatory were not included, and the authors acknowledge that 16.5% of the patients declined to participate in this noninvasive study for unclear reasons, possibly skewing the study results. High-level functioning patients and patients with less risk factors for DVT/PE, including lack of hypercoagulable state, ambulatory status, nonsmoker, nonpregnant, nonobese, and free of kidney or heart failure,[3] are less likely to present with DVT/PE, and these participant characteristics were not adequately accounted for in the study findings. In addition, 34% of the study participants were found to have a ventilation requirement, and the possibility of PE should have been excluded because DVT often migrates to cause PE.

The authors are applauded for seeking to shed more light on the detection of occult DVT in inpatient rehabilitation patients. Merit of the study includes the use of a prospective design at a major university center with a diverse patient population. Future studies would benefit from study duration of at least 1 year and follow-up of patient clinical status at 3, 6, 9, and 12 months. A case–control approach, taking into account different participant characteristics/type and timing of prophylactic anticoagulant used, would yield valuable information. In addition, exclusion of patients on full-dose anticoagulation treatment is strongly recommended.

Hence, the question remains: To screen or not to screen for DVT. The following data support the importance of screening for DVT upon admission to inpatient rehabilitation among certain populations.

The article also highlights a changing population among admitting rehabilitation diagnosis in the past 20 years, as well as changes in treatments for DVT. Looking at data from eRehab in 2018 across the nation,[4] there were 197,622 admissions to inpatient rehabilitation facilities. Two high-risk populations, brain injury and spinal cord injuries, made up roughly 20.5% of the admissions. These populations have been shown to have a cost-effectiveness for screening for DVT.[5],[6] Orthopedic trauma, not including amputations, made up 12.2% of admissions to inpatient rehabilitation in 2018. Lower-extremity fracture carries 30% incidence of DVT preoperatively and 43% postoperatively.[7]

Critically ill trauma patients were also found to have high rates of DVT despite mechanical chemoprophylaxis. Rates of DVT found within 1 week of injury were over 15% among those trauma patients despite the treatment.[8] Trauma registry metrics have focused on complications such as DVT and PE. Neurosurgical patients, especially those with craniotomies, also have high rates of DVT.[9] This population is especially difficult given the propensity for bleeding events postoperatively and the magnitude of injury potential that exists. These patients are also frequently admitted to inpatient rehabilitation facilities. Søgaard et al. found that the first 30 days and up to 1 year after venous thromboembolism carried the greatest risk of mortality [10] in their 30-year follow-up study. This timeframe can also coincide with the timing of inpatient rehabilitation.

Given the populations that are seen in acute rehabilitation facilities and the increased risk of DVT and PE, screening on admission should be considered. Nearly one-third of all admissions to inpatient rehabilitation have an acquired brain injury, spinal cord injury, and trauma. These have also shown to be cost-effective for screening individuals with these injuries. Given that the first 30 days to 1 year is the highest risk for mortality for these individuals due to venous thromboembolism and the intensity of acute inpatient rehabilitation, it is reasonable to screen these individuals on admission.



 
  References Top

1.
Ettefagh L, Jerome MA, Porter J, Monfared HH, Burke DT. Screening for occult lower-extremity deep vein thrombosis on admission to acute inpatient rehabilitation: A cross sectional, prospective study. J Int Soc Phys Rehabil Med 2019; [In press].  Back to cited text no. 1
    
2.
Streiff MB, Agnelli G, Connors JM, Crowther M, Eichinger S, Lopes R, et al. Guidance for the treatment of deep vein thrombosis and pulmonary embolism. J Thromb Thrombolysis 2016;41:32-67.  Back to cited text no. 2
    
3.
Moheimani F, Jackson DE. Venous thromboembolism: Classification, risk factors, diagnosis, and management. ISRN Hematol 2011;2011:124610.  Back to cited text no. 3
    
4.
eRehab National Data; 2018. Available from: http://www.erehabdata.com. [Last accessed on 2019 May 01].  Back to cited text no. 4
    
5.
Kadyan V, Clinchot DM, Colachis SC. Cost-effectiveness of duplex ultrasound surveillance in spinal cord injury. Am J Phys Med Rehabil 2004;83:191-7.  Back to cited text no. 5
    
6.
Meythaler JM, DeVivo MJ, Hayne JB. Cost-effectiveness of routine screening for proximal deep venous thrombosis in acquired brain injury patients admitted to rehabilitation. Arch Phys Med Rehabil 1996;77:1-5.  Back to cited text no. 6
    
7.
Wang H, Kandemir U, Liu P, Zhang H, Wang PF, Zhang BF, et al. Perioperative incidence and locations of deep vein thrombosis following specific isolated lower extremity fractures. Injury 2018. pii: S0020-1383(18)30261-4.  Back to cited text no. 7
    
8.
Azarbal A, Rowell S, Lewis J, Urankar R, Moseley S, Landry G, et al. Duplex ultrasound screening detects high rates of deep vein thromboses in critically ill trauma patients. J Vasc Surg 2011;54:743-7.  Back to cited text no. 8
    
9.
Natsumeda M, Uzuka T, Watanabe J, Fukuda M, Akaiwa Y, Hanzawa K, et al. High incidence of deep vein thrombosis in the perioperative period of neurosurgical patients. World Neurosurg 2018;112:e103-12.  Back to cited text no. 9
    
10.
Søgaard KK, Schmidt M, Pedersen L, Horváth-Puhó E, Sørensen HT. 30-year mortality after venous thromboembolism: A population-based cohort study. Circulation 2014;130:829-36.  Back to cited text no. 10
    




 

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