骨折患者围手术期动态监测血浆D-二聚体水平的临床意义

目的探讨骨折患者围手术期血浆D-二聚体水平的动态变化对预防深静脉血栓(DVT)的临床意义。方法将180例骨折患者按不同骨折部位分为手足组30例、上肢组30例、下肢组40例、骨盆组40例、脊椎组40例,分别于入院后、术前、术中、术后第1天、术后第3天、术后第5天动态监测血浆D-二聚体水平的变化。同时选取体检健康者50名为正常对照组。结果 180例骨折患者中有17例并发DVT。并发DVT组、未并发DVT组血浆D-二聚体水平与正常对照组比较差异有统计学意义(P0.05)。并发DVT组术前血浆D-二聚体水平与未并发DVT组比较,差异无统计学意义(P0.05);术中、术后第1天、术后第3天和术后第5天2个组之间血浆D-二聚体水平差异均有统计学意义(P0.05)。并发DVT组血浆D-二聚体水平呈进行性升高,未并发DVT组呈进行性下降。不同部位骨折各组术中血浆D-二聚体水平与术前、术后第1天、术后第3天、术后第5天比较差异均有统计学意义(P0.05)。在相同时间点,下肢组、骨盆组、脊椎组血浆D-二聚体水明显高于手足组、上肢组(P0.05)。结论围手术期动态监测血浆D-二聚体水平是预防骨折患者发生DVT的有效途径。     

丹红注射液对老年髋部骨折血浆D-二聚体的影响

目的:观察丹红注射液对老年髋部骨折血浆D-二聚体的影响。方法:对64例老年髋部骨折入院24h后即用丹红注射液静脉滴注治疗,并于入院后24h、手术前1d、手术后3d及出院前分别检测血浆D-二聚体含量。结果:患者入院时血浆D二聚体均上升,经丹红注射液治疗3～5d后即有所下降(手术前),但在手术后3d的检测中又发现D-二聚体含量显著升高,并达到峰值,其后再逐渐降低。至出院时大部分患者已恢复到正常水平。结论:丹红注射液可以通过抑制血浆D-二聚体的升高以达到预防或治疗血栓形成的目的。     

食管癌患者手术治疗前后血浆D-二聚体的变化及临床意义

目的探讨食管癌患者手术治疗前后血浆D-二聚体的变化及临床意义。方法收集2014年1月至2015年12月该院胸心外肿瘤科收治的食管癌患者63例(食管癌手术组)。另选取50例健康者为健康对照组。食管癌手术组患者于手术前和手术后第1、5、14天检测血浆D-二聚体,健康对照组于体检时检测。结果食管癌手术组术前血浆D-二聚体含量明显高于健康对照组,差异有统计学意义(t=14.110,P=0.000)。食管癌手术组术前临床分期为Ⅲ~Ⅳ期的患者D-二聚体明显高于Ⅰ~Ⅱ期患者,差异有统计学意义(P0.05)。有淋巴结转移患者血浆D-二聚体明显高于无转移者,差异有统计学意义(P0.05)。患者术后第1天D-二聚体水平升至最高,术后5d开始下降,术后2周时D-二聚体明显降低。结论血浆D-二聚体水平随食管癌进展而升高,可作为判断食管癌恶性程度的辅助指标,术后D-二聚体的实时动态检测可预防肺栓塞发生。     

骨折患者血浆D-二聚体检测结果分析

目的探讨骨折患者血浆D-二聚体检测的临床应用价值。方法用免疫比浊法对该院130例骨折住院患者进行血浆D-二聚体检测。结果骨折患者的血浆D-二聚体浓度比健康对照组显著升高(P<0.05)。结论血浆D-二聚体水平可作为骨折的监测指标,但不能作为其并发症的诊断指标。     

下肢骨折时间与血浆D-二聚体浓度及阳性率的关系

目的探讨下肢骨折患者骨折时间与血浆D-二聚体浓度及阳性率的关系。方法选取377例下肢骨折患者,测定血浆D-二聚体浓度,并按骨折发生时间分为7组,比较各组D-二聚体浓度及阳性率。结果下肢骨折发生时间少于1d的患者,血浆D-二聚体浓度明显高于其余各组(P0.05),发生时间大于30d的患者,血浆D-二聚体浓度及阳性率均明显低于其余各组(P0.05)。且下肢骨折发生10d内,血浆D-二聚体阳性率达89.6%。结论下肢骨折发生10d内,患者血浆D-二聚体浓度及阳性率均明显升高,临床需密切关注血栓发生风险。     

老年髋部骨折患者D-二聚体变化趋势及诊断临界点

目的分析老年髋部骨折患者骨折后D-二聚体变化规律及ROC曲线确定D-二聚体诊断老年髋部骨折患者深静脉血栓形成的诊断临界点。方法入院记录459例年龄≥50岁的髋部骨折患者血浆D-二聚体浓度,并应用SPSS 19.0软件进行统计学分析。结果老年髋部骨折患者,其D-二聚体有一个先降低后升高的趋势,转折点位于骨折后第3天;骨折后3天以内,其诊断临界点为12.13 mg/L;而3天后,其诊断临界点为2.79 mg/L。结论对于老年髋部骨折患者,骨折3天内、3天后应使用不同诊断临界点,以增加D-二聚体诊断深静脉血栓形成的准确性。     

下肢骨折病人D二聚体定量检测的临床观察

目的 探讨下肢骨折病人D二聚体定量检测的临床价值。方法 采用增强型乳胶免疫比浊法对109例下肢骨折患者术前、术后第3天及术后第7天进行血浆D二聚体的定量检测，跟踪观察患者病情。结果 109例患者有10例并发DVT，并发DVT组术前、术后第3天及术后第7天血浆I）-二聚体的检测结果有显著性差异（P〈0．05），呈进行性增高。未并发DVT组术前、术后第3天及术后第7天血浆D二聚体的检测结果无显著性差异（P〉0．05）。而并发DVT组与未并发DVT组相比较：术前血浆D二聚体的检测结果无显著性差异（P〉0．05）；术后第3天血浆D二聚体的检测结果有显著性差异（P〈0．05）；术后第7天血浆D二聚体的检测结果有显著性差异（P〈0．01）。结论 血浆D二聚体的动态监测对骨折术后并发血栓性疾病具有早期诊断价值。     

术前血浆D-二聚体测定在大肠癌中的临床意义

目的 研究大肠癌患者血浆D-二聚体浓度的变化及意义.方法 按随机原则设立大肠癌组34例,良性病对照组31例.分别于术前采血检测其血浆D-二聚体水平并对其进行统计分析.同时大肠癌组按照Dukes分期标准分为4个亚组,并对组间D-二聚体水平进行比较.结果 大肠癌组的血浆D-二聚体水平显著高于对照组[(394.12±105.21)μg/L与(129.03±8.29)μg/L,P<0.05.在大肠癌组的各亚组比较中,Dukes D期患者的D-二聚体水平明显高于其他各期,分别为D期(800.00±287.94)μg/L、A期(180.00±58.31)μg/L、B期(170.00±33.50)μg/L、C期(250.00±86.60)μg/L,差异有统计学意义(P均<0.05).结论 大肠癌患者血浆D-二聚体水平显著升高,并且对大肠癌的分期及预后可能有一定的指导意义.     

不同部位创伤骨折患者的D-二聚体水平及其临床意义

目的研究不同部位创伤骨折患者D-二聚体水平及其临床意义。方法将1 142例骨折患者作为观察对象,根据患者是否为急性创伤以及患者的骨折部位进行分组。于入院次日取空腹静脉血10 ml采用免疫比浊法对患者的D-二聚体和血清纤维蛋白降解产物水平进行测定。观察急性创伤与非急性创伤患者以及不同部位患者D-二聚体水平及其与患者血凝和血栓之间的关联。结果急性创伤组714例患者中,D-二聚体水平为469.24±61.53μg/L,阳性人数214例,占比29.99%;非急性创伤组428例患者中D-二聚体水平为124.36±14.35μg/L,阳性人数17例,占比3.97%。急性创伤患者的D二聚体水平以及阳性率显著高于非急性创伤患者(P0.05);D-二聚体在上肢骨折、脊柱骨折、股骨骨折、胫腓骨骨折、足骨骨折、多骨折患者中阳性率分别为10.60%、20.91%、39.52%、87.73%、83.67%和59.77%。不同骨折部位患者D-二聚体水平与阳性率存在显著差异(P0.0.5),以胫腓骨骨折患者和足骨骨折患者D-二聚体阳性率最高。结论急性和非急性创伤患者间,不同部位骨折患者间D-二聚体水平存在显著差异,其可以作为临床诊疗的重要参考指标。     

老年恶性肿瘤患者D二聚体及血小板CD62P检测的临床意义

目的 探讨老年恶性肿瘤患者手术前后血浆D二聚体及血小板CD62P的变化规律,为术后抗凝治疗,预防继发血栓病提供客观依据.方法 应用流式细胞术和胶体金方法分别检测了39例老年恶性肿瘤患者、32例非老年恶性肿瘤患者、43例非恶性肿瘤患者的血小板CD62P及血浆D二聚体.结果 两组恶性肿瘤患者血小板CD62P及血浆D二聚体含量均明显高于非恶性肿瘤患者（P〈0.001）,且术后显著高于术前（P〈0.001）.术前2组恶性肿瘤患者差异无显著性（P〉0.05）,但均明显高于非恶性肿瘤患者（P〈0.001）.结论 手术对恶性肿瘤患者血小板有明显的活化作用,并能促进高凝状态的发生,在老年患者更为显著,故应重视手术后的防凝措施,防止血栓病的发生.     

锁定板前路置入治疗颈胸段脊柱骨折脱位

背景：前路治疗颈胸段脊柱骨折脱位有关中长期临床效果及钢板置入后脊髓神经功能的报道很少。目的：观察锁定板前路置入治疗颈胸段脊柱骨折脱位的可行性及疗效。方法：回顾性分析2007-01/2011-01湘雅医院一附院脊柱外科收治的颈胸段脊柱骨折脱位患者12例,均采用前路减压、植骨、锁定板置入内固定治疗。结果与结论：全部患者获随访一两年,均获得骨性融合,融合时间为4～8个月,无螺钉松动、脱落及锁定板断裂等并发症发生。锁定钢板置入前Frankel A级2例,置入后2例脊髓损伤无恢复;置入前B级4例,置入后恢复至C级2例,D级2例;置入前C级3例,置入后恢复至D级1例,E级2例;置入前D级3例,恢复至E级。1例置入后出现暂时性声音嘶哑,置入后3～6个月恢复。提示颈胸段前路减压、植骨、锁定钢板置入内固定对颈胸段脊柱脊髓损伤具有较好的疗效,锁定钢板有助于植骨节段融合、重建和稳定颈胸段脊柱。     

Incidence and significance of injuries on secondary CT imaging after initial selective imaging in blunt trauma patients

ObjectiveIt is unclear if additional computerized tomography (CT) imaging is warranted after injuries are identified on CT in blunt trauma patients. The objective of this study was to determine the incidence and significance of injuries identified on secondary CT imaging after identification of injuries on initial CTs in blunt trauma patients.MethodsThis was a retrospective cohort study at an academic Level 1 trauma center with a two-tiered trauma system. Inclusion criteria: age ≥ 18, level 2 trauma activation, injury identified on initial CT, and secondary CTs ordered. Secondary injuries were categorized as resulting in: no changes, minor changes, or major changes in management.Results537 patients underwent 1179 initial CT scans which identified 744 injuries. There were 1094 secondary CTs which identified 143 additional injuries in 94 (18%) patients. 9 (1.7%) patients had at least one major management change and 64 (12%) had at least one minor management change. Rib fracture(s) was the most common injury on secondary scans [45/143 (32%)]. The major management changes were: tube thoracostomy for pneumothorax (4 patients), blood transfusion for hemoperitoneum (1 patient), surgery for acetabular fracture (1 patient), thoracolumbar brace for spine fracture (2 patients) and angiography for splenic injury (1 patient).ConclusionWhile a significant proportion of patients (18%) had injuries on secondary CT, only 1.7% of patients had a resultant major management change. Future research is warranted to determine the need for additional CT imaging after an initial selective imaging strategy in blunt trauma patients.     

桃红四物汤联合低分子肝素预防腰椎术后深静脉血栓的临床研究

目的:评价桃红四物汤预防腰椎手术术后深静脉血栓形成的临床疗效。方法:收集从2016年1月1日起入院准备行腰椎手术的病例,术前常规查双下肢深静脉B超,白介素-8、血小板计数、血D-二聚体、活化部分凝血活酶时间(APTT)及血浆凝血酶原时间(PT)等,随机分为两组,两组术后常规第二天予抗凝治疗,治疗组在抗凝的基础上加用桃红四物汤,对照组常规抗凝治疗。两周后复查双下肢深静脉B超、血红蛋白、白介素-8、血小板计数、血D-二聚体、活化部分凝血活酶时间(APTT)及血浆凝血酶原时间(PT)。对比两组术后深静脉血栓发生率;观察治疗后血红蛋白、白介素-8、血小板计数、血D-二聚体、活化部分凝血活酶时间(APTT)及血浆凝血酶原时间(PT)的变化情况。结果:治疗组术后深静脉血栓发生率低于对照组(P<0.05);治疗组术后血红蛋白计数、APTT及PT水平高于对照组;术后白介素-8、血小板计数、血D-二聚体水平低于对照组(P<0.05)。结论:桃红四物汤联合常规抗凝治疗可以有效的降低腰椎术后深静脉血栓形成的风险,并且改善术后患者的应激状态,减少失血及炎性反应。     

脓毒症凝血功能异常的发生率和临床意义

目的:探讨脓毒症患者中凝血异常的发生率和病情严重程度的关系。方法:分析了2009年3月-2009年8月在上海交通大学附属第一人民医院ICU和急诊病房住院符合脓毒症诊断标准的124例。分别在入院第1、7、14天测D-二聚体(D-dimer)、血小板计数、凝血全套。入院当天给以APACHEII评分、SOFA评分。根据D-dimer值分为3组,分别是D-dimmer256μg/L、256≤D-dimer1000μg/L、D-dimer≥1000μg/L。结果:所有入选病例第1、7、14天发生凝血异常的比例分别是38.7%、41.1%、45.9%。凝血异常组和无凝血异常组比较,D-dimer差异有统计学意义。随着D-dimer浓度增加,APACHEII和SOFA分值增加。结论:近半数脓毒症患者存在凝血功能障碍,其中D-dimer检测早期凝血功能障碍更为敏感。D-dimer与脓毒症的严重程度相关。     

急性白血病并发弥散性血管内凝血患儿早期及干预后血凝指标变化

目的:探讨急性白血病(AL)患儿并发弥散性血管内凝血(DIC)早期及干预后血凝指标变化。方法:本实验分3组即健康对照组;AL组;AL并发DIC组,均于清晨抽取空腹血检测D-二聚体(DD)、纤维蛋白原水平(FBG)、活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)及抗凝血酶-Ⅲ(AT-Ⅲ)。对AL并发DIC组患儿应用低分子肝素治疗,比较治疗前后各指标变化,采用SPSS10.0软件将各组进行统计学分析。结果:AL组与健康对照组比较,PT延长,FBG降低,DD明显升高,差异有统计学意义(P<0.05),AL并发DIC组与AL组比较,DD明显升高,AT-Ⅲ降低,差异有统计学意义(P<0.05),且与AL组相比,AL并发DIC组DD、AT-Ⅲ阳性率明显升高,且在DIC发病的不同临床阶段均保持在较高水平(80%以上),DD检测阳性率在血栓形成期高达100%。经肝素抗凝治疗后,AT-Ⅲ及FBG明显升高,DD降低,差异有统计学意义(P<0.05)。结论:AL并发DIC患儿存在凝血、纤溶系统的激活,AT-Ⅲ及DD可作为DIC早期诊断的指标,低分子肝素应用有助于改善DIC患儿的预后。     

Clinical outcomes of magnetic resonance imaging in blunt cervical trauma

Objectives: To determine whether MRI of the cervical spine resulted in a change in management of patients with blunt trauma and normal plain X‐ray (XR)/CT of the cervical spine. Methods: An explicit chart review was conducted of patients seen at a Level 1 trauma centre over a 1 year period. Clinical details were extracted from the charts of patients with blunt trauma who had a normal plain XR and CT scan of the cervical spine and who underwent cervical spine MRI. A comparison of clinical details was made between those with a normal/abnormal MRI secondary to the acute injury. Results: One hundred and thirty‐four patients met entry criteria. Discharge non‐operative management of the cervical spine was associated with a change in management by the MRI result (P < 0.0001) where MRI of the cervical spine occurred a median of 3 days (interquartile range 0–4.5, range 0–137) after the injury. The MRI occurred before discharge 90% of the time in both groups. Operative management occurred in three patients and was delayed until after first outpatient review in two patients. Conclusions: An abnormal MRI after normal plain XR and CT cervical spine studies resulted in a change in non‐operative management at discharge. Early MRI resulted in one patient receiving surgery before discharge. No unstable injuries were detected by MRI that were not evident on plain XR or CT cervical spine.     

Initial resuscitation and assessment of patients with multisystem blunt trauma

In the vast majority of blunt trauma victims, shock is due to blood loss. Whereas the diagnosis of circulatory collapse is clear-cut, the rapid identification and control of the bleeding source may not be. Such patients often have injuries to several body systems and thus have numerous possible sources of hemorrhage. Ideally, the injury pattern should be defined during resuscitation, preferably by a trauma team using standardized protocols. Airway patency and adequacy of ventilation have top priority. The cervical spine must be immobilized until fracture has been ruled out. In concert with respiratory management, other members of the trauma team should secure adequate vascular access, resuscitate the patient, and perform a physical examination. Physical findings dictate the order of further diagnostic and therapeutic maneuvers. Patients in unstable condition may need emergency surgery.     

进展期大肠癌患者治疗前后血浆D-二聚体的变化及与疗效的关系

目的探讨大肠癌患者血浆D-二聚体的变化与疗效的关系。方法检测60例进展期大肠癌患者术前及术后2年的血浆D-二聚体浓度。结果术前进展期大肠癌缓解组血浆D-二聚体低于转移组(P<0.01),治疗后缓解组血浆D-二聚体低于术前(P<0.01),转移组血浆D-二聚体高于术前(P<0.01)。结论进展期大肠癌患者血液处于高凝状态。恶性程度高、侵袭性强、对手术化疗反应差的肿瘤患者在治疗前后均有较高的D-二聚体水平。     

不同方法治疗锁骨骨折的疗效比较

目的：探讨锁骨骨折的治疗方法。方法：1998年3月-2005年6月113例Ⅰ类锁骨骨折病人分别采用非手术治疗、切开复位骨圆针内固定、记忆合金环形抱骨板和AO重建钛钢板4种方法治疗。术后随访3周～24个月。结果：临床疗效接连学全等拟定的标准进行评价。手术治疗共54例，50例优良，优良率92．6％。非手术治疗59例，51例优良，优良率86．4％。手术与非手术治疗优良率无明显差异。结论：锁骨骨折的手术治疗与非手术治疗临床疗效相同。3种手术治疗方法中，AO重建钢板可根据锁骨形态塑形，内固定牢靠，并发症相对较少，是1种比较理想的手术治疗方法。     

Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden

OBJECTIVE: To quantify changes in variables of inflammation, coagulation, and fibrinolysis in blunt trauma patients with lower extremity fractures who underwent different types of surgical procedures. DESIGN: Prospective, cohort study. SETTING: Level I university trauma center. PATIENTS: We allocated 83 blunt trauma patients in stable condition and 22 patients eligible for elective hip replacement to four treatment groups. INTERVENTIONS: In 34 multiply traumatized patients with femoral fracture (group PTFF) and in 28 patients with an isolated femoral fracture (group IFF), primary unreamed intramedullary nailing for stabilization of the femoral shaft fracture was performed. In 22 patients, an elective uncemented total hip arthroplasty (group THA) was inserted for osteoarthritis, and in 21 control patients, an isolated ankle fracture (group AF) was acutely stabilized. MEASUREMENTS AND MAIN RESULTS: From serially sampled central venous blood, the perioperative concentrations of interleukin (IL)-6, of tumor necrosis factor-alpha, of prothrombin fragments 1 + 2, and of D-dimer cross-linked fibrin degradation products were evaluated. Intramedullary instrumentation for an isolated femur fracture caused a significant perioperative increase in the concentrations of IL-6 (preoperative IL-6, 52 +/- 12 pg/mL; IL-6 30 mins postinsertion, 78 +/- 14 pg/mL; p = .02). This increase was comparable with group THA (preoperative IL-6, 46 +/- 16 pg/mL; IL-6 30 mins postinsertion, 67 +/- 11 pg/mL; p = .03). A positive correlation occurred between both groups (r = .83, p < .0004). Multiple trauma patients demonstrated significantly (p = .0002) higher IL-6 concentrations than all other groups throughout the study period and showed a significant increase after femoral nailing (preoperative IL-6, 570 +/- 21 pg/mL; IL-6 30 mins postinsertion, 690 +/- 24 pg/mL; p = .003), whereas no perioperative change was seen in group AF. The highest IL-6 increases were associated with a longer ventilation time (group PTFF) and a longer period of positive fluid balances (groups PTFF, IFF, THA). The coagulatory variables demonstrated similar perioperative increases in groups IFF and THA, but not in groups PTFF and AF. The IL-6 concentrations and the prothrombin fragments 1 + 2 concentrations correlated between groups THA and IFF at 30 mins and at 1 hr after surgery (r2 = .64, p < .02). In all patients the clinical variables were stable perioperatively. CONCLUSIONS: Major surgery of the lower extremity causes changes to the inflammatory, fibrinolytic, and coagulatory cascades in patients with stable cardiopulmonary function. The inflammatory response induced by femoral nailing is biochemically comparable to that induced by uncemented total hip arthroplasty. In multiple trauma patients, increases, which occurred in addition to those induced by the initial trauma, were measured. Definitive primary femoral stabilization by intramedullary nailing imposes an additional burden to the patient with blunt trauma. A careful preoperative investigation is required to evaluate whether primary definitive stabilization can be performed safely.