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-二聚体测定在肺栓塞诊断中的应用价值

目的 探讨全自动免疫分析系统（VIDAS）快速定量检测D－二聚体（DD）在诊断肺栓塞中的临床价值。方法 使用VIDAS DD测定法对可疑静脉血栓塞患者血浆中纤维蛋白降解产物D－二聚体进行检测，并对这些可疑肺栓塞患者进行3个月的随访，了解是否有肺栓塞或深部静脉栓塞的症状。结果 共有104例患者参加检测，32例患者（30.8%）的D－二聚体检测值＜494ng/ml，72例患者血浆中的D－二聚体检测值＞494ng/ml，其中有16例患者通过肺通气－灌注扫描（V／Q）证实为肺栓塞。VIDAS DD法的敏感性为100％，阴性预期值为100％。结论 VIDAS DD法可作为排除诊断肺栓塞的首选筛选试验，可在临床诊断中推广应用。     

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。     

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。     

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.

多层螺旋CT在肺栓塞诊断中的应用

目的探讨多层螺旋CT在肺栓塞诊断中的临床意义及价值, 分析其CT表现.方法应用多层螺旋CT机对27名肺栓塞病人进行肺动脉增强扫描, 将图像进行多平面(MPR)、曲面(CPR)及斜面(Oblique)重组再处理.结果 27例病人共发现肺动脉栓子146个,其中左及右肺动脉7个,肺叶动脉34个,肺段动脉99个,肺亚段动脉6个.结论多层螺旋CT增强扫描可清楚显示段以上肺动脉血栓栓子,具有方便、快捷、无创、准确的优点,对及时诊断和治疗有着重要的意义,并能有效评估溶栓治疗后的效果.     

Investigation of age-adjusted D-dimer using an uncommon assay

BackgroundUse of an age-adjusted D-dimer for the evaluation of acute pulmonary embolus (PE) has been prospectively validated in the literature and has become a practice recommendation from major medical societies. Most research on this subject involves the most common D-dimer assays reporting in Fibrinogen Equivalent Units (FEU) with a non-age-adjusted manufacturer-recommended cutoff of 500 ng/ml FEU. Limited research to date has evaluated age-adjustment in assays that report in D-Dimer Units (D-DU), which use a manufacturer-recommended cutoff of 230 ng/ml D-DU. Despite scant evidence, an age-adjusted formula using D-DU has been recently endorsed by the American College of Emergency Physicians (ACEP). This formula seems arbitrary in its derivation and unnecessarily deviates from existing thresholds, thus prompting the creation of our novel-age adjustment formula. The goal of this study was to retrospectively evaluate the test characteristics of our novel age-adjusted D-dimer formula using the D-DU assay in comparison to existing traditional and age-adjusted D-dimer thresholds for the evaluation of acute PE in the ED.MethodsThis was a retrospective chart review at an academic quaternary health system with three EDs and 195,000 combined annual ED visits. Only patients with D-dimer testing and CT PE protocol (CTPE) imaging were included. Admission and discharge diagnosis codes were used to identify acute PE. Outcome measures were sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of an unadjusted traditional threshold (230) compared with both novel and ACEP-endorsed age adjusted thresholds, (Age × 5) ? 20 and Age × 5 if >50, respectively. Estimates with their exact 95% threshold were performed.Results4846 adult patients were evaluated from January 2012 to July 2017. Group characteristics include a mean age of 52 and a frequency of acute PE diagnosis by CTPE of 8.25%. Traditional D-dimer cutoff demonstrated a sensitivity of 99.8% (95% CI 98.6–100), specificity of 16.7% (95% CI 15.6–17.8) and NPV of 99.9% (95% CI 99.3–100). Our novel age-adjusted D-dimer thresholds had a sensitivity of 97.0% (95% CI 94.8–98.4), specificity of 27.9% (95% CI 26.6–29.2) and NPV of 99.0% (95% CI 98.3–99.5) with the ACEP-endorsed formula demonstrating similar test characteristics.ConclusionUse of an age-adjusted D-dimer on appropriately selected patients being evaluated for acute PE in the ED with a D-DU assay increases specificity while maintaining a high sensitivity and NPV. Both our novel formula and the ACEP-endorsed age-adjusted formula performed well, with our novel formula showing a trend towards improved testing characteristics.     

D-二聚体是筛除低临床概率肺栓塞的有效指标

目的 比较不同辅助检查在肺栓塞（Pulmonary Embolism,PE）患者的应用价值。方法 回顾诊断和非诊断肺栓塞的患者D二聚体、下肢静脉超声（lower extremity Doppler ultrasound DUS）,胸部螺旋CT（chest spiral Computer Tomography CT）的结果,找出合适敏感度和特异度的方法。结果 D-二聚体是筛除肺栓塞的良好指标,其医学决定性水平宜在500μg／L;临床概率低的患者总体D-二聚体偏高;确诊肺栓塞的患者检查敏感度分别为D-二聚体80％、螺旋CT90%、下肢静脉超声60%;对于低临床概率患者,D-二聚体阴性可以有效除外肺栓塞,漏诊率7．7％。结论 D-二聚体在医学决定性水平为500μg／L时,是一项高敏感度和阴性预计值的指标,尤其适合临床低概率患者的筛除,配合螺旋CT,可以很好地辅助肺栓塞的诊断。     

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.     

增强与非增强MR肺动脉血管成像诊断肺栓塞准确性的对比研究

目的比较对比增强MR血管成像(contrast-enhanced MR pulmonary angiography,CE-MRA)与非增强空间标记多反转脉冲序列(applying spatial labeling with multiple inversion pulses sequence,SLEEK)MR血管成像诊断肺栓塞(pulmonary embolism,PE)的准确性。材料与方法 26例CT肺动脉血管成像诊断肺栓塞的患者(男15例,女11例)于多排螺旋CT肺动脉造影(CT pulmonary angiography,CTPA)检查48 h内行CE-MRA以及非增强SLEEK MR检查。CTPA作为参考标准,计算并比较每种MR技术诊断肺栓塞的敏感性、特异性、阳性预测值以及阴性预测值。结果 CE-MRA诊断肺栓塞的敏感性为78.8%,特异性97.7%。非增强SLEEK MRI诊断肺栓塞的敏感性83.8%,特异性100%。两阅片者间存在高度一致性(k=0.87)。结论 CE-MRA和SLEEK MRI诊断肺栓塞的准确性无统计学差异,但非增强SLEEK MRI血管成像无需使用对比剂,有希望成为肺栓塞诊断策略中的一部分。     

An analysis of the diagnostic methods for acute pulmonary embolism

In spite of numerous sophisticated investigative procedures, acute pulmonary embolism (PE) is very frequently misdiagnosed. In order to improve the diagnostic approach to PE, the sensitivity and specificity of the commonly used methods were reviewed in a group of 421 patients with angiographically proved PE without associated cardio-pulmonary disease. The specificity of diagnostic procedures was, by decreasing order: positive pulmonary angiography (to affirm) = negative perfusion lung scan (to eliminate) > chest X-ray clinical symptoms, positive perfusion lung scan, ECG, blood gas, serum enzymes.     

Wells评分联合D-dimer在急性肺栓塞诊断的临床预测价值

目的 评价Wells评分联合D-dimer在急性肺栓塞诊断的临床预测价值.方法 收集2008年至2011年就诊北京朝阳医院急诊科疑似肺栓塞患者540例,以CTPA检查阳性为确诊肺栓塞的依据,分为肺栓塞(PE)组与非肺栓塞(Non-PE)组,对两组患者在人口学特征、基础疾病、主诉、体征、静脉血栓危险因素、相关实验室检查、Wells评分等进行比较和统计学分析.结果 最终入选患者502例,PE组246例,Non-PE组256例,近期术后或卧床、近期骨盆或下肢骨折、咯血、一过性意识障碍、单侧下肢肿胀、低氧低碳酸血症、D-dimer升高、高危Wells评分等在PE组出现的频率显著高于Non-PE组,P＜0.05,其他参数在两组中差异无统计学意义.Wells评分、D-dimer值及二者联合的ROC曲线下面积分别是0.775 (95％CI:0.719～0.831),0.802(95％CI:0.751～0.853),0.899 (95％ CI:0.834～0.964),二者联合ROC曲线下面积大于二者单独应用,P ＜0.05.截点值Wells评分5分,D-dimer 1 724.00 μg/L为敏感度与特异度加权最大值,超过截点值时,诊断PE的可靠性明显提高;低于截点值时,排除PE的可靠性也明显升高.结论 Wells评分联合D-Dimer检查比单独应用在急性肺栓塞预测中更具备临床价值.     

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。     

肺栓塞的MRI研究现状

肺栓塞是具有潜在生命威胁的疾病,需要及时正确的诊断和治疗。近年来,随着硬件和软件的快速发展,肺栓塞的MRI研究较为热门。作者将肺栓塞的MRI检查技术、常用扫描序列、对比剂以及诊断准确度作一综述,并预测将来可能的发展趋势。     

肺灌注/通气显像对肺栓塞溶栓疗效的评价

目的 探讨肺灌注/通气显像对评价肺栓塞溶栓治疗的价值. 方法 43例肺栓塞患者在溶栓治疗前和治疗后1周及3个月进行肺灌注/通气显像,评价溶栓治疗效果. 结果 43例患者共观察到421个受损肺段.溶栓治疗后1周复查,199(47.3%)个受损肺段恢复正常;3个月后复查231(54.9%)个受损肺段恢复正常(P<0.05).溶栓前病程≤1周组受损肺段恢复正常数高于病程>1周组(P相似文献   

肺栓塞诊治若干问题的探讨（附31例报告）

目的 分析肺栓塞诊断方法及误诊、误治后果。方法 根据31例肺栓塞的首发症状、初步诊断、辅助检查等分析误诊原因。结果 31例肺栓塞当日确诊仅7例，3日内诊断10例，1周内诊断4例，2周内诊断2例，延误诊断8例，而首日诊断为缺血性心脏病者占35.5%，肺部其他疾病占25.8%。结论 肺栓塞延误诊断与死亡率呈正相关，早期诊断正确治疗可以降低死亡率。     

肺通气/灌注显像在肺栓塞诊断中的应用及进展

肺通气/灌注显像在急性肺栓塞的临床诊疗中常被用为一线影像学检查,随着多种影像学技术的发展,从显像技术到放射性药物方面均有较大进步。本文针对肺通气/灌注显像在急性肺栓塞诊断中的应用及进展进行综述。     

肺栓塞的诊断方法

肺栓塞在临床上较为常见,但诊断较困难。诊断应始于识别肺栓塞发生的危险因素及评估患者发生肺栓塞的可能性大小以及患者的临床症状和体征。常规的客观检查包括D-二聚体测定、心电图、胸片及超声心动图等。近年来,尚有人研究经食道超声在肺栓塞诊断中的价值。而且,随着影像学技术的发展,CT血管造影(CTA)、磁共振血管造影(MRA)及与其相关的一系列先进手段也逐渐应用于肺栓塞的诊断中,并显示出良好的应用前景。肺血管造影一直被认为是肺栓塞诊断的金标准,有人认为,多探测器螺旋CT(MDCT)的运用可能成为诊断肺栓塞的无创金标准,但结合临床的综合判断仍是诊断的基础。     

增强磁共振肺灌注扫描与核素肺通气/灌注扫描诊断肺动脉栓塞

目的探讨增强磁共振肺灌注扫描技术(MRPP)与核素肺灌注扫描对照诊断肺动脉栓塞的临床应用价值.方法 19例肺动脉栓塞患者均行增强磁共振肺动脉造影(MRPA)、 MRPP及核素肺通气/灌注扫描.通过在上、中、下肺野和异常区域内设置感兴趣区,测量信号强度,绘制时间-信号曲线,获取灌注高峰期信号强度变化率.结果 19例诊断肺动脉栓塞的患者MRPP共发现186个肺灌注异常区, MRPP显示7例25个肺段合并段以远的肺动脉栓塞,核素显示188个段灌注缺损.MRPP中,正常灌注与灌注缺损区及低灌注区的信号强度变化率差异有显著性意义(P<0.01).结论与核素肺通气/灌注显像相比,MRPP同样能够显示肺栓塞的灌注缺损区和低灌注区.MRPP对段及段以远的肺动脉栓塞的显示有较高的临床价值.