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静脉血栓栓塞症(venous thromboembolism,VTE)是深静脉血栓形成(deep vein thrombosis,DVT)和肺血栓栓塞症的不同表现形式[1]。近几年来随着交通事故的增加,骨创伤的病人数量也随之增长,创伤病人创伤后常常容易并发血栓性疾病,以DVT多见,严重者可造成肺栓塞(pulmonary embolism,PE)。MARTINEZ等[2]研究发现,VTE的年发生率为131.5/10万人。由于VTE病情复杂多变,影像学检查常无法及时准确地对疾病做出诊断,因此,一种简单可行的检查方法对VTE的诊断特别重要。D-二聚体是交联纤维蛋白在纤溶酶的作用下降解生成的一种特征性的产物[3],在血浆中就能检测,且检测操作简单、灵敏度高、阴性率低,目前已普遍应用于骨创伤病人静脉血栓的风险评价,且已在临床得到广泛的认可[4-5]。研究[6]表明,D-二聚体对PE的敏感度可达92%~100%。骨创伤后病人一般需制动,不易过多活动,因此更易发生血栓。而彩色多普勒超声和静脉造影检查虽可确诊,但其价格较高且操作复杂,需病人频繁活动配合检查,易造成血栓脱落,导致PE,严重威胁病人安全。血浆D-二聚体的测量不具有侵入性,且操作简单,费用较低,只需检查病人的血浆即可获得,且阳性率高。本次针对血浆D-二聚体对骨创伤病人骨损伤致VTE的诊断价值进行探究,旨在分析骨创伤病人围术期D-二聚体的变化情况,并比较不同部位骨创伤病人D-二聚体水平的差异,从而探讨D-二聚体在预测术后VTE中的价值。
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血栓组与骨损伤组术前D-二聚体水平显著高于对照组(P < 0.05)(见表 1)。
分组 n D-二聚体 F P MS组内 血栓组 20 596.65±246.13* 骨损伤组 50 578.10±268.37* 8.41 < 0.01 63 980.893 对照组 20 321.01±215.97 q检验:与对照组比较*P < 0.05 表 1 术前D-二聚体检测结果比较(x±s;μg/L)
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多发性骨折、下肢骨折和骨盆骨折病人D-二聚体阳性率均明显高于上肢骨折病人,且下肢骨折病人的D-二聚体阳性率明显比其他骨折部位的病人高(P < 0.05)(见表 2)。
分组 n 阳性例数 阳性率/% χ2 P 上肢骨折 20 4 20.00 16.79 < 0.01 下肢骨折骨盆骨折 255 202 80.00*40.00*△ 多发性骨折 20 11 55.00*△ χ2分割检验:与上肢骨折组比较*P < 0.05;与下肢骨折组比较△P < 0.05 表 2 不同部位骨折的骨损伤病人D-二聚体阳性率的比较
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术后第7天,D-二聚体测量出阳性结果24例,经彩色多普勒超声检查确诊为VTE 20例,全部VTE病人均为D-二聚体阳性。且单因素分析结果显示,血栓组病人年龄及D-二聚体水平均高于骨损伤组,差异有统计学意义(P < 0.01)(见表 3)。
指标 血栓组(n=20) 骨损伤组(n=50) χ2 P 年龄(x±s)/岁 52.64±10.26 40.16±8.25 5.33* < 0.01 性别 男 12 33 0.22 >0.05 女 8 17 高血压 有 2 6 0.06 >0.05 无 18 44 糖尿病 有 3 8 0.01 >0.05 无 17 42 冠心病 有 1 3 0.03 >0.05 无 19 47 骨折部位 上肢骨折 6 14 0.47 >0.05 下肢骨折 7 18 骨盆骨折 2 3 多发性骨折 5 15 D-二聚体(x±s)/(μg/L) 1 703.55±822.32 602.11±334.69 8.02* < 0.01 *示t值 表 3 临床资料及D-二聚体水平的比较(n)
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以单因素分析中年龄、D-二聚体水平等差异有统计学意义的指标作为自变量,以是否发生VTE为因变量,其中年龄、D-二聚体水平均为连续变量赋值,进行logistic回归分析结果表明,D-二聚体水平是VTE的独立预测因素(P < 0.01)(见表 4)。
变量 β SE Waldχ2 P OR(95%CI) 常数项 -1.915 0.453 18.82 < 0.01 — D-二聚体 0.746 0.213 14.35 < 0.01 2.09(1.672~2.508) 表 4 logistic回归分析
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ROC曲线分析结果显示,术后D-二聚体水平预测骨创伤后VTE的曲线下面积为0.906(95%CI:0.825~0.987)。
血浆D-二聚体对骨创伤病人骨损伤致静脉血栓栓塞症的诊断价值
Diagnostic value of plasma D-dimer in venous thromboembolism caused by bone injury in patients with bone trauma
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摘要:
目的探讨血浆D-二聚体在诊断骨创伤病人骨损伤致静脉血栓栓塞症中的价值。 方法选取骨损伤病人70例,按照彩色多普勒超声检查结果确诊并发静脉血栓栓塞症的20例病人为血栓组,未并发的50例病人为骨损伤组,选择同期体检的健康人20名为对照组。对所有病人术前、术后D-二聚体水平进行检测并行单因素方差分析;对不同骨折部位病人的D-二聚体阳性率进行分析;术后第7天对病人彩色多普勒超声检查阳性结果与D-二聚体阳性率进行对比分析;采用logistic回归分析方法分析D-二聚体与静脉血栓栓塞症的关系;并采用受试者工作曲线分析D-二聚体在预测骨损伤后VTE中的价值。 结果血栓组、骨损伤组术前D-二聚体均明显高于对照组(P < 0.05),血栓组术后D-二聚体水平明显高于未并发血栓的骨损伤组(P < 0.01);多发性骨折、骨盆骨折及下肢骨折病人D-二聚体阳性率均高于上肢骨折病人(P < 0.05),且下肢骨折病人的阳性率明显高于其他骨折部位的病人(P < 0.05);术后第7天,D-二聚体检测出阳性结果24例,经彩色多普勒超声检查诊断为静脉血栓栓塞症20例,准确率较高;logistic回归分析结果显示,D-二聚体水平是静脉血栓栓塞的独立预测因素(P < 0.01);术后D-二聚体水平预测骨创伤后VTE的受试者工作曲线下面积为0.906(95%CI:0.825~0.987)。 结论血浆D-二聚体水平测定对骨创伤病人骨损伤致静脉血栓栓塞症的灵敏度较高,有助于病人早期血栓形成的预测。 Abstract:ObjectiveTo investigate the value of plasma D-dimer in the diagnosis of venous thromboembolism caused by bone injury in patients with bone trauma. MethodsSeventy patients with bone injury were selected.According to the results of color Doppler ultrasonography, 20 patients with and 50 patients without venous thromboembolism were divided into the thrombosis group and bone injury group, respectively.Twenty healthy people at the same time were selected as the control group.The preoperative and postoperative D-dimer levels of all patients were detected, and analyzed using one-way ANOVA.The positive rate of D-dimer in patients with different fracture sites was analyzed.The positive rate between color Doppler ultrasonography and D-dimer were compared and analyzed on the seventh day after operation.The logistic regression analysis was used to analyze the relationship between D-dimer and venous thromboembolism.The value of D-dimer in predicting VTE after bone injury was analyzed using receiver operating characteristic curve. ResultsThe preoperative D-dimer levels in thrombus group and bone injury group were significantly higher than that in control group(P < 0.05), and the postoperative D-dimer level in thrombus group was significantly higher than that in bone injury group(P < 0.01).The positive rates of D-dimer in patients with multiple fractures, pelvic fractures and lower limb fractures were higher than that in patients with upper limb fractures(P < 0.05), and the positive rate in patients with lower limb fractures was significantly higher than that in patients with other fracture sites(P < 0.05).On the seventh day after operation, the positive D-dimer in 24 patients were diagnosed, and 20 patients with venous thromboembolism were diagnosed by color Doppler ultrasound.The results of logistic regression analysis showed that the D-dimer level was an independent predictor of VTE(P < 0.01).The area under the receiver operating characteristic curve of the postoperative D-dimer level predicting VTE after bone trauma was 0.906(95%CI: 0.825-0.987). ConclusionsThe determination of plasma D-dimer level is more sensitive to venous thromboembolism caused by bone injury in patients with bone trauma, which is helpful to predict early thrombosis in patients. -
Key words:
- bone injury /
- venous thromboembolism /
- D-dimer
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表 1 术前D-二聚体检测结果比较(x±s;μg/L)
分组 n D-二聚体 F P MS组内 血栓组 20 596.65±246.13* 骨损伤组 50 578.10±268.37* 8.41 < 0.01 63 980.893 对照组 20 321.01±215.97 q检验:与对照组比较*P < 0.05 表 2 不同部位骨折的骨损伤病人D-二聚体阳性率的比较
分组 n 阳性例数 阳性率/% χ2 P 上肢骨折 20 4 20.00 16.79 < 0.01 下肢骨折骨盆骨折 255 202 80.00*40.00*△ 多发性骨折 20 11 55.00*△ χ2分割检验:与上肢骨折组比较*P < 0.05;与下肢骨折组比较△P < 0.05 表 3 临床资料及D-二聚体水平的比较(n)
指标 血栓组(n=20) 骨损伤组(n=50) χ2 P 年龄(x±s)/岁 52.64±10.26 40.16±8.25 5.33* < 0.01 性别 男 12 33 0.22 >0.05 女 8 17 高血压 有 2 6 0.06 >0.05 无 18 44 糖尿病 有 3 8 0.01 >0.05 无 17 42 冠心病 有 1 3 0.03 >0.05 无 19 47 骨折部位 上肢骨折 6 14 0.47 >0.05 下肢骨折 7 18 骨盆骨折 2 3 多发性骨折 5 15 D-二聚体(x±s)/(μg/L) 1 703.55±822.32 602.11±334.69 8.02* < 0.01 *示t值 表 4 logistic回归分析
变量 β SE Waldχ2 P OR(95%CI) 常数项 -1.915 0.453 18.82 < 0.01 — D-二聚体 0.746 0.213 14.35 < 0.01 2.09(1.672~2.508) -
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