血浆D-二聚体对疑似肺栓塞患者诊断价值的研究

目的：探讨血浆 D-二聚体对对疑似肺栓塞患者的诊断价值。方法采用自动化免疫比浊法测定患者血浆D-二聚体水平。统计分析血浆D-二聚体诊断肺栓塞的敏感性、特异性、阴性及阳性预测值,并绘制ROC曲线以评价其诊断价值并对D-二聚体阴性排除肺栓塞价值进行分析。结果在317例疑似肺栓塞患者中D-二聚体＜500μg/L的患者73例,其中6例被诊断为肺栓塞。D-二聚体对肺栓塞的诊断的敏感性为95.86%（95%CI：91.27%～98.08%）,特异性为38.95%（95%CI：31.98%～41.41%）,阴性预测值为91.78%（95%CI：83.21%～96.18%）,阳性预测值为56.97%（95%CI：50.69%～63.02%）,诊断准确性为64.98%（95%CI：59.58%～70.03%）。ROC曲线下面积为0.674（95%CI：0.615～0.733）。结论 D-二聚体对肺栓塞的诊断具有较高的敏感性,阴性排除肺栓塞的准确性较高,但仍可受患者年龄、测试方法等的影响。     

D-二聚体阴性肺栓塞患者的临床特点

目的 归纳总结D-二聚体阴性(D-二聚体＜0.5μg/mL)的肺栓塞患者的临床特点,从而提高肺栓塞诊断准确率、降低肺栓塞的病死率。方法 对南京医科大学第一附属医院2006年1月至2009年12月收治的D-二聚体阴性的疑似肺栓塞患者的危险因素、临床特征及辅助检查进行回顾分析,将16例最终确诊肺血栓栓塞症患者与同期排除肺栓塞的41例疑似患者的临床特点进行比较,采用t检验及四格表Fisher确切概率法比较各组间临床表现、生命体征及辅助检查结果的差异。结果 D-二聚体阴性的肺栓组与非病例组相比,既往有VTE病史、有近期手术史者更易于发病,胸闷、呼吸困难常见,病例组呼吸频率高于对照组,病例组下肢水肿较对照组多见,心电图典型ECG SI QⅢTⅢ改变多见。结论D-二聚体作为急性肺栓塞筛选检查,其阴性预测值较高,但当患者出现进行性呼吸困难、下肢水肿、既往有VTE病史、有近期手术史、心电图出现SIQⅢTⅢ改变时,即使D-二聚体阴性,临床工作者也需引起重视,必要时可考虑进一步检查以排查有无肺栓塞。     

Comorbidity burden conditions the prognostic performance of D-dimer in elderly patients with acute pulmonary embolism

Introduction

The prognostic accuracy of D-dimer for risk assessment in acute Pulmonary Embolism (APE) patients may be hampered by comorbidities. We investigated the impact of comorbidity burden (CB) by using the Charlson Comorbidity Index (CCI), on the prognostic ability of D-dimer to predict 30 and 90-day mortality in hemodynamically stable elderly patients with APE.

Neither baseline tests of molecular hypercoagulability nor D-dimer levels predict deep venous thrombosis in critically ill medical-surgical patients

Objective Predicting patients who are harboring asymptomatic deep venous thrombosis (DVT), or who are at particular risk of developing DVT, is a desirable clinical goal since prevention or early treatment of DVT might reduce the risk of fatal pulmonary embolism. Thus validation of simple laboratory tests that reliably predict venous thromboembolism (VTE) would be clinically very important. Tests that might be useful for these applications include markers of hypercoagulability (predicting patients at risk of DVT) and D-dimer (predicting which patients may have acute DVT).Methods In a prospective cohort study we measured a panel of hypercoagulability markers at the time of ICU admission, and six commercial D-dimer assays were performed serially during the ICU stay in medical-surgical ICU patients who were screened for DVT with biweekly lower limb compression ultrasonography. Ultrasonography was also performed at the time of any clinically suspected DVT events. We matched cases with DVT with controls without DVT for length of stay in the ICU to generate receiver operating characteristics (ROC) curves.Results One hundred ninety-seven patients were enrolled. Blood was collected on a total of 763 occasions (median number of occasions per patient: 3, range 1–21). None of the assays predicted DVT, as indicated by the areas under the ROC curves, that did not differ significantly from 50%.Conclusion In critically ill patients, neither tests of hypercoagulability nor D-dimer levels predict patients at risk of DVT and thus they should not be used to guide diagnostic testing for DVT.This study was funded by the Heart and Stroke Foundation of Canada, and the Canadian Institutes of Health Research.     

Comparison of the age-adjusted and clinical probability-adjusted D-dimer to exclude pulmonary embolism in the ED

Background

Diagnosing pulmonary embolism (PE) in the emergency department (ED) can be challenging because its signs and symptoms are non-specific.

糖尿病肾病患者D-二聚体和纤维蛋白原检测的应用价值

目的探讨血浆D-二聚体(DD)和纤维蛋白原(Fig)在糖尿病肾病(DN)患者中的变化及应用价值。方法根据尿白蛋白排泄率(UAER),将98例2型糖尿病(DM)患者分为单纯糖尿病组(SDM组)、早期糖尿病肾病组(EDN组)和临床糖尿病肾病组(CDN组),30例健康者作为对照组,分别测定各组血浆DD和Fig的水平。结果各糖尿病组与健康对照组比较,DD、Fig水平差异均具有统计学意义(P<0.05),EDN和CDN组显著高于SDM组(P<0.05),CDN组显著高于EDN组(P<0.01)。DD和Fig分别与UAER呈显著正相关(r=0.469及0.392,P<0.01)。结论DN患者血浆DD和Fig水平随着UAER的增加而升高,两者之间关系密切,可能与DN的进展有关。     

血浆D-二聚体在肺栓塞患者中的诊断意义

目的:探讨快速定量检测D-二聚体在诊断肺栓塞患者中的临床价值。方法:检测、分析21例经螺旋CT或肺动脉造影确诊的肺栓塞患者及19例健康人(对照组)的血浆D-二聚体含量。结果:与对照组比较,肺栓塞组D-二聚体含量明显升高,有显著性差异(P<0.01)。结论:肺栓塞患者D-二聚体含量明显升高,敏感性为100%,阴性预测值为100%,检测D-二聚体可作为诊断肺栓塞的首选筛选试验。     

D-二聚体检测在胸外科患者术后肺栓塞中的诊断价值

目的探讨D-二聚体检测在胸外科患者术后肺栓塞中的诊断价值。方法回顾性分析2008年-2013年期间我院收治的18 128例胸外科手术治疗患者术后发生肺栓塞的临床资料,并选取其中的35例胸外科手术治疗患者进行D-二聚体检测。结果胸外科手术年龄≧50岁的患者与〈50岁的患者比较,肥胖患者与体重合格者比较,发生恶性肿瘤与良性肿瘤比较,肺栓塞发生率均有显著性差异（P〈0.05）;进行D-二聚体检测诊断肺栓塞的阴性预测值以及敏感性均为100%,假阳性率为94.7%（18/19）。结论行胸外科手术治疗的肥胖、高龄和恶性肿瘤患者术后发生肺栓塞的可能性较大,而采用D-二聚体检测,能够较精确地对肺栓塞进行诊断,阴性结果正确率高,值得临床上进一步推广与研究。     

D-二聚体年龄校正阈值与传统阈值在老年肺血栓栓塞症诊断中的应用价值比较

目的探讨D-二聚体年龄校正阈值在老年肺血栓栓塞症(PTE)诊断中的应用价值。方法收集2015年6月至2016年9月在延安市人民医院及延安大学附属医院就诊年龄为50岁及以上的疑似PTE患者,首先采用修正日内瓦评分标准进行临床概率评估,对于低风险人群不再纳入研究对象;对于中、高风险患者全部进行了血浆D-二聚体水平检测及肺动脉造影(CTPA)确诊,随后采用D-二聚体年龄校正阈值与传统阈值两种判定标准进行判定,比较两种判定方法的诊断效能。通过ROC曲线寻找PTE最佳血浆D-二聚体阈值。结果入选的549例疑似PTE的患者中,经CTPA确诊的PTE患者共163例,阳性率为29.69%。按照传统阈值和年龄校正阈值两种标准判定:血浆D-二聚体的诊断灵敏度分别为为83.44%、78.53%,特异度分别为17.88%、31.61%,漏诊率分别为16.56%、21.47%,误诊率分别为82.12%、68.39%,约登指数分别为0.013 2、0.101 4。所有研究对象按照年龄分为50~60岁、60~70岁、70~80岁、≥80岁。随着年龄的增长,相比传统阈值,上述各年龄段校正阈值诊断PTE的误诊率分别下降了4.00%、15.70%、21.36%、17.39%;特异度分别提升了约1.23、1.65、2.56、3.00倍。ROC曲线求得PTE最佳血浆D-二聚体阈值约为1 760ng/mL FEU。结论年龄校正阈值的诊断准确性高于传统阈值;通过ROC曲线同时结合临床实际求得最佳阈值,临床医师可作为参考。     

The use of D-dimer testing and Wells score in patients with high probability for acute pulmonary embolism

Rationale, aims and objective  To investigate if a combination of Wells pre-test probability score and D-dimer testing could be used as a safe base for making clinical decisions on further investigations for patients with intermediate to high risks of pulmonary embolism (PE).
Methods  One hundred and twenty patients with signs or symptoms of acute PE were investigated with pulmonary angiography (PA) or contrast enhanced computed tomography of the pulmonary arteries (CTPA), D-dimer testing (Tinaquant^®) and clinical scoring using the Wells pre-test probability score during their first 48 hours at the hospital. Patients were recruited consecutively from emergency departments at two teaching hospitals.
Results  The cut-off value of 0.5 mg L⁻¹ in D-dimer analysis is proved adequate with a negative predictive value (NPV) of 92% in this group of patients with intermediate to high risks. The combination of D-dimer testing and Wells score increases the NPV to 94%. The specificities of both tests were low.
Conclusion  D-dimer and Wells pre-test probability scores are safe to rule out acute PE even in patients with at least an intermediate risk of PE, but the specificity is low. D-dimer testing had a higher NPV than Wells score and the combination improved the algorithm further. The cut-off level for a high risk of PE measured with the Wells score was four and it seems reasonable to use that cut-off level in future algorithms. In addition, both PA and CTPA can present false positive and negative results difficult to interpret.     

检测血浆D-二聚体的新金标斑点渗滤法试剂盒的临床适用性

目的比较2种金标斑点渗滤法（DIGFA）试剂盒在测定D-二聚体浓度中的临床适用性。方法同时采用NycoCard公司与国产奥普D-二聚体检测试剂盒（D-DDOT）对234份血浆样本进行测试,比较2种方法的一致性。结果D．DDOT线性范围内相关系数（r）=0．998;总批内、批问变异系数（CV）分别为10．77％和12．81％;总回收率为101．3％。配对,检验、Kappa检验（0．95）及Spearman系数（0．87）均显示D—DDOT与NycoCard检测结果有良好的一致性。结论新的DIGFA D-二聚体检测试剂盒与进口NycoCard试剂盒有良好的一致性,能够满足临床需要。     

Unsuspected pulmonary emboli adversely impact survival in patients with cancer undergoing routine staging multi‐row detector computed tomography scanning

Background: While symptomatic venous thromboembolism adversely impacts survival among cancer patients, the outcome of cancer patients with unsuspected pulmonary embolism (UPE) found on routine cancer staging multi‐row detector computed tomography (MDCT) scans is unknown. Objective: To determine whether UPE detected on routine staging MDCT scans impacts overall survival among cancer patients. Patients and methods: We performed a matched cohort study of cancer patients diagnosed with UPE on routine staging scans between May 2003 and August 2006. Two controls (n = 137) were individually matched by age (± 5 years), cancer type and stage for each UPE patient (n = 70). We used Cox’s proportional hazard models to compare the mortality between UPE patients and their matched controls. Results: The hazard ratio (HR) for death among UPE patients was 1.51 (95% CI 1.01–2.27, P = 0.048). Compared with their matched controls, patients with UPE more proximal than the subsegmental arterial branches had a HR for death at 6 months of 2.28 (95% CI 1.20–4.33, P = 0.011) and an overall HR of 1.70 (95% CI 1.06–2.74, P = 0.027). Survival among UPE patients with isolated subsegmental PE (ISSPE) was not significantly different than that of matched controls (HR 1.04 95% CI 0.44–2.39, P = 0.92). Conclusions: UPE identified more proximal than the subsegmental arterial branches has a significant negative impact on survival among cancer patients.     

检测血浆D-二聚体的新金标斑点渗滤法试剂盒的临床适用性

目的比较2种金标斑点渗滤法(DIGFA)试剂盒在测定D-二聚体浓度中的临床适用性。方法同时采用NycoCard公司与国产奥普D-二聚体检测试剂盒(D-D DOT)对234份血浆样本进行测试,比较2种方法的一致性。结果D-D DOT线性范围内相关系数(r)=0.998;总批内、批间变异系数(CV)分别为10.77%和12.81%;总回收率为101.3%。配对χ2检验、Kappa检验(0.95)及Spearman系数(0.87)均显示D-D DOT与NycoCard检测结果有良好的一致性。结论新的DIGFA D-二聚体检测试剂盒与进口NycoCard试剂盒有良好的一致性,能够满足临床需要。     

肺癌患者血浆纤维蛋白原、D-二聚体水平与预后的相关性研究

目的:探讨肺癌患者血浆纤维蛋白原、D-二聚体水平与预后的相关性。方法:测定60例肺癌患者(肺癌组)及20例健康体检者(对照组)血浆纤维蛋白原、D-二聚体水平并进行对比分析。结果:肺癌组血浆纤维蛋白原、D-二聚体水平高于对照组(P<0.05),肺癌组血浆纤维蛋白原、D-二聚体水平与病理类型、肿瘤大小、TNM分期之间无明显关系。肺癌患者血浆纤维蛋白原、D-二聚体水平与生存期呈显著负相关。结论:肺癌患者血液处于高凝状态,血浆纤维蛋白原、D-二聚体水平与患者的预后密切相关。抗凝治疗对控制肺癌患者病情的发展及预后可能有重要的临床意义。     

Accuracy of clinical decision rule, D-dimer and spiral computed tomography in patients with malignancy, previous venous thromboembolism, COPD or heart failure and in older patients with suspected pulmonary embolism

BACKGROUND: The diagnostic work-up of patients with suspected pulmonary embolism (PE) has been optimized and simplified by the use of clinical decision rules (CDR), D-dimer (DD) testing and spiral computed tomography (s-CT). Whether this strategy is equally safe and efficient in specific subgroups of patients is evaluated in this study. METHODS: A diagnostic strategy including a CDR, DD test and s-CT was evaluated in patients with malignancy, previous venous thromboembolism (VTE), chronic obstructive pulmonary disease or heart failure and in older patients. PE was ruled out by either an unlikely CDR and a normal DD or a s-CT negative for PE. The safety of these tests was assessed by the 3-month incidence rate of symptomatic VTE in those without PE at baseline. The efficiency was evaluated by calculating the numbers needed to test for the different subgroups. RESULTS: The venous thromboembolic incidence rate after the combination of an unlikely CDR and a normal DD varied from 0% (95% CI: 0-7.9%) in the 482 patients older than 75 years of age to 2% (95% CI: 0.05-10.9%) in the 474 patients with a malignancy. For s-CT these incidences varied from 0.3% to 1.8%. The number needed to test in order to rule out one patient from PE with the studied strategy was highest in cancer patients and in the elderly patients (approximately 10). CONCLUSION: It appears to be safe to rule out PE by either the combination of an unlikely CDR and a normal DD or by a negative s-CT in various subgroups of patients with suspected PE. However, the clinical usefulness of the CDR in combination with the DD as the initial step in the diagnostic process varied among these patient groups.     

不同栓塞面积肺血栓栓塞症患者血管性假血友病因子及α颗粒膜蛋白-140的变化

目的研究血管性假血友病因子(vWF)和α颗粒膜蛋白-140(GMP-140)在不同栓塞面积急性肺血栓栓塞症(PTE)患者中的变化情况,探讨vWF和GMP-140与PTE形成的关系。方法检测48例PTE患者[PTE组,其中急性大面积PTE15例(大面积PTE组),次大面积PTE21例(次大面积PTE组),非大面积PTE12例(非大面积PTE组)]和20例正常人(对照组)的血小板膜GMP-140和血浆vWF、D-二聚体变化。结果大面积PTE组、次大面积和非大面积PTE组血小板表面GMP-140、血浆vWF、D-二聚体表达均明显高于正常对照组(P均<0.01),其中大面积PTE组又明显高于次大面积组和非大面积组(P<0.01),次大面积亦高于非大面积组(P<0.01)。结论GMP-140和vWF与PTE的发生、发展关系密切。     

Clinical probability score and D-dimer estimation lack utility in the diagnosis of childhood pulmonary embolism

Summary.  Background : Childhood pulmonary embolism (PE) causes significant mortality and evidence suggests that it is under-diagnosed. Clinical probability scores and D-dimer estimation to assess pre-test probability have not been studied in children with suspected PE. Patients/Methods : This retrospective cohort study evaluated Wells simplified probability score for PE in 50 children with PE and 25 PE negative control patients, and D-dimer values in 27 PE positive and 12 PE negative children. Results : PE positive and PE negative groups had similar rates of risk factors for venous thromboembolism (VTE). Wells simplified probability score showed a small difference between PE positive and PE negative children (median score: PE positive, 4.5; PE negative, 4; P  =   0.009), children with PE are more likely to obtain a 'PE likely' score (score > 4), P  =   0.012. The difference was of slightly greater significance when the Wells score was adjusted to account for pediatric normal ranges for heart rate, P  =   0.007, and signs/symptoms of upper limb DVT, P  =   0.006. Children with PE were as likely as PE negative patients to have a D-dimer value within the normal range (PE positive, 15%; PE negative, 25%; P  =   0.654). A combination of a 'PE unlikely' score and normal D-dimer value occurred in 1/12 (8%) of PE negative children. Conclusions : The Wells clinical probability score and D-dimer estimation may lack utility in the determination of pre-test probability of PE in children. Validation of a pediatric clinical probability score, incorporating D-dimer estimation, by prospective study, would be difficult as a result of the rarity of childhood PE.     

Prognostic value of plasma D-dimer levels in patients with small-cell lung cancer

ObjectiveLittle data exists with respect to the relationship between the level of plasma D-dimer and prognosis of small cell lung cancer (SCLC).The aim of this study was to investigate whether the levels of plasma D-dimer could be served as a prognostic factor in patients with SCLC.MethodsA total of 393 patients with SCLC were addressed in the present retrospective study. Plasma D-dimer levels were measured by immunoturbidimetric assay. The correlation between plasma D-dimer levels and other clinical features, progression free survival (PFS) and overall survival (OS) was analyzed statistically.ResultsThe plasma D-dimer levels were significantly correlated with karnofsky performance status (KPS), tumor stage, number of metastatic sites, and treatment response. The PFS and OS of patients with elevated D-dimer levels before chemotherapy were significantly shorter than that of patients with normal D-dimer levels (PFS: 6.2 months versus 9.6 months, P < 0.001; OS: 15.7 months versus 24.4 months, P < 0.001). The patients with D-dimer levels converting from high to normal had better PFS and OS than those with D-dimer levels remaining high after two cycles of chemotherapy. According to multivariate analysis, elevated D-dimer level was confirmed to be an independent prognostic factor for worse survival.ConclusionsElevated plasma D-dimer level could be served as an independent determinant of poor prognosis in patients with SCLC.     

前列腺增生伴急性尿潴留患者血浆 D-二聚体水平变化及临床意义?

目的：观察前列腺增生(BPH)伴急性尿潴留(AUR)患者血浆 D-二聚体水平变化,并探讨其临床意义。方法选取2013年7月至2014年12月在该院泌尿外科就诊的 BPH 患者102例,将其分为单纯 BPH 组(56例)和 BPH 伴 AUR(BPH +AUR)组(46例),检测其血浆 D-二聚体水平并进行比较分析。结果BPH+AUR 组患者血浆 D-二聚体水平较单纯 BPH 组增高,差异有统计学意义(P <0.01)。结论BPH 伴 AUR 患者血浆 D-二聚体水平明显升高,提示患者处于继发性纤溶活性亢进状态,应尽早采取措施解除患者尿潴留症状,保护患者血管内皮功能,减少并发症的发生。