| Objective:Under the guidance of nephrin and qi-blood theory,based on the pathophysiology of stress response,the rabbit animal model of DVT was established and the influence of Buzhong Yiqi Decoction on the occurrence and development of deep vein thrombosis in elderly fracture patients was observed in randomized controlled trial,and the mechanism of Chinese and Western medicine was discussed and elaborated,so as to provide theoretical basis and intervention approach for the clinical prevention and treatment of deep vein thrombosis.Methods:Part Ⅰ(Clinical study):This study was a single-center randomized double-blind controlled study,which was approved by the Ethics Committee of the Affiliated Hospital of Shandong University of Chinese Medicine.Sixty patients with intertrochanteric fracture of femur undergoing selective PFNA fixation under subarachnoid space combined with epidural anesthesia were selected.Sixty patients were then randomly included in the Chinese medicine group and the control group.Chinese medicine group began to take Buzhong Yiqi Decoction 6 hours after the operation,one dose a day for seven days;The control group received placebo,one dose a day,for seven days.Both groups were given subcutaneous injection of enoxaparin sodium in the abdomen from admission to the day before and 12 hours after surgery for 7 consecutive days after surgery.On the seventh day after surgery,the lower extremity thrombosis was screened by Doppler ultrasound,and the incidence of DVT was compared between the two groups.The expression levels of COR,CRP,ET-1 and D-D were detected before and after operation.Postoperative adverse reactions in various systems(circulatory system,respiratory system,digestive system,nervous system)were recorded and compared between the two groups.Part Ⅱ(Animal study):Forty-eight aged rabbits were randomly divided into 6 groups,including blank control group,DVT model group,low molecular weight heparin group,Buzhong Yiqi decoction low dose group,medium dose group and high dose group,with 8 rabbits in each group.Except for the blank control group,rabbits in the other five groups were treated with femoral shaft fracture surgery and plaster fixation after hip flexion and knee flexion to establish DVT models.After surgery,Buzhong Yiqi Decoction low-dose,medium-dose and high-dose groups were given 1.8ml/kg,3.6ml/kg and 7.2ml/kg Buzhong Yiqi Decoction by gavage every day for 7 consecutive days,respectively.DVT model group and low molecular weight heparin group were given 3.6ml/kg normal saline intragastric administration for 7 consecutive days.Except blank control group and DVT model group,rabbits in the other four groups were given subcutaneous injection of 360IU/kg low molecular weight heparin every day after surgery for 7 days.On the 7th day after operation,ultrasound examination was performed on the affected limbs of rabbits in six groups,and the incidence of DVT in each group was recorded.The femoral vein tissues were taken and stained with HE sections.The pathological changes of the femoral vein cavity and endothelial tissues were observed under microscope,and the morphology and organelles of vascular endothelial cells were observed under electron microscope.Serum levels of COR,ALD,TNF-α,IL-6,ET-1,NO,Fib and D-D were determined by ELISA.The expressions of related factors in NF-κB pathway were detected by RT-PCR and Western blotResults:Part I:77 patients were initially included in this study,17 were excluded,and 3 were excluded.Finally,57 patients were included in the data analysis,including 28 patients in the traditional Chinese medicine group and 29 patients in the control group,aged 62-85.(1)Imaging examination:on the 7th day after surgery,1 patient in the TCM group was found to have intermuscular thrombosis of the affected limb,and the incidence of DVT was 3.6%.8 patients in the control group were found to have DVT,and the incidence of DVT was 27.6%.There were significant differences in the incidence of DVT between the two groups(P<0.05).(2)Biological detection:there were no statistical differences in the general information and preoperative plasma levels of COR,CRP,ET-1 and D-D between the two groups(P>0.05).The COR level in the TCM group was significantly lower than that before surgery,and the difference was statistically significant(P<0.05),while the COR level in the control group was not statistically significant(P>0.05).The COR level in the TCM group was significantly decreased compared with the control group(P<0.05).The CRP level in 2 groups was significantly higher than that before surgery(P<0.05),and the reduction of CRP level in TCM group was statistically significant compared with control group(P<0.05).The level of ET-1 in 2 groups was significantly higher than that before surgery(P<0.05).Compared with the control group,the level of ET-1 in the TCM group was significantly decreased(P<0.05).The level of D-D in 2 groups was significantly decreased compared with that before surgery(P<0.05),and the decrease of D-D level in the TCM group was statistically significant compared with the control group(P<0.05).(3)Occurrence of postoperative adverse reactions:adverse reactions of circulatory system include palpitation,chest tightness,hypotension,angina pectoris,etc,which need medication treatment;Adverse reactions of respiratory system include cough and sputum,lung infection,etc.Adverse reactions of digestive system include nausea,vomiting,abdominal distension,abdominal pain,constipation,etc.Nervous system adverse reactions include postoperative delirium,cerebral infarction and so on.The incidence of ADR in TCM group was decreased compared with control group,but the difference was not statistically significant(P>0.05).Part Ⅱ:(1)Imaging detection:The incidence of DVT in Buzhong Yiqi Decoction medium and high dose groups was 0 and 12.5%,respectively,which was lower than that in DVT model group(75%),and the difference was statistically significant(P<0.05).(2)Histological examination:HE staining showed that endothelial cells in the model group had different degrees of exfoliation,thrombus and scattered white blood cells in the lumen.In the medium and high dose groups,the wall thickness was uniform,the endothelial cells were arranged neatly,no obvious thrombus was observed in the lumen,and insoluble fibrin was occasionally observed.The results of electron microscopy showed that the endothelial cells in the model group had protrusion into the lumen,many pits in the nucleus,severe swelling of mitochondria,loss of ridge,moderate expansion and retention of rough endoplasmic reticulum.No obvious swelling of endothelial cells,mitochondria or rough endoplasmic reticulum was observed in the medium dose group.(3)Biological detection:Serum markers detected 7 days after surgery:Compared with DVT model group,the levels of COR,ALD,TNF-α,IL-6,ET-1,Fib and D-D in Buzhong Yiqi decoction medium-dose group were decreased,and the levels of COR,ALD,TNF-α,IL-6 and ET-1 in high-dose group were decreased,and the differences were statistically significant(P<0.05).The level of NO was increased in medium and high dose groups,and the difference was statistically significant(P<0.05).Compared with low molecular weight heparin group,the ALD level of Buzhong Yiqi decoction in medium and high dose groups was significantly decreased,the difference was statistically significant(P<0.05),the IL-6 level in medium dose group was significantly decreased,the difference was statistically significant(P<0.05),the NO level was significantly increased,the difference was statistically significant(P<0.05).RT-PCR detection:Compared with DVT model group,the expressions of TLR4 mRNA,MyD88 mRNA and NF-K B mRNA in Buzhong Yiqi decoction low,medium and high dose groups and low molecular weight heparin group were significantly decreased,with statistical significance(P<0.05).Compared with low molecular weight heparin group,the expressions of TLR4 mRNA,MyD88 mRNA and NF-κB mRNA in Buzhong Yiqi decoction low,medium and high dose groups were significantly decreased,and the differences were statistically significant(P<0.05).Western blot detection:compared with DVT model group,the expressions of TLR4 and NF-κB protein in Buzhong Yiqi decoction medium and high dose groups were significantly decreased,the difference was statistically significant(P<0.05),while the expression of MyD88 protein in low,medium and high dose groups was significantly decreased,the difference was statistically significant(P<0.05).Compared with low molecular weight heparin group,the expressions of TLR4,MyD88 and NF-κB protein in Buzhong Yiqi decoction medium and high dose groups were decreased,and the differences were statistically significant(P<0.05).Conclusion:1.The postoperative application of Buzhong Yiqi Decoction combined with low molecular weight heparin can reduce the incidence of DVT after PFNA operation in elderly patients with intertrochanteric fracture of femur,which may be related to regulating postoperative stress response,reducing inflammatory response level,alleviating endothelial injury and improving blood hypercoagulability2.Buzhong Yi Qi Decoction combined with low molecular weight heparin can reduce the formation of lower limb deep vein thrombosis in the fracture model of aged rabbits,which may be caused by inhibiting the expression of NFκB pathway related factors,reducing postoperative oxidative stress inflammation,thereby protecting endothelial function and improving blood hypercoagulability.This is also consistent with the theory of reducing heat knot in dampness and heat,reducing vein damage,and thus making Qi and blood flow smoothly. |
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