Relatório Sucinto e Estudo de Caso Dois casos de aneurisma apical e a revisão da literatura………………………………………………………JIN Chun, LONG Fong Kuan, LIU Hong e outros Tecido adiposo de miringoplastia………………………………………………………………………………MOK Tin Seak Resumos de Artigos Médicos Internacionais Utilização de colonografia por múltiplo-slice TAC espiral no diagnóstico de neoplasia colorrectal………Resistência de Klebsiella pneumoniaes às beta-lactamases de largo espectro (ESBLs) e a sua genotipagem…………………………………………………………………………………………………Guia para a orientação do tratamento do tumor maligno da cavidade oral e maxilofacial…………………Características morfológicas de TAC de aneurisma da aorta abdominal infrarenal, de grande e pequena dimensão……………………………………………………………………………………………Estudo preliminar sobre a influência de perfusão provocada pela velocidade de injecção em nódulo pulmonar solitário com TAC espiral de 64 cortes…………………………………………………………Discussão preliminar sobre a perfusão cerebral de TAC com subtração de imgens…………………………MRI no diagnóstico de encefalomiopatia mitocondrial…………………………………………………………Teste de anticorpos contra VIH-1 na urina e o seu significado clínico………………………………………Valor do diagnóstico de angiografia da artéria vertebral com 3D-TAC na arteriopatia cervical com espondilose cervical…………………………………………………………………………………………Relação entre o fígado gordo não alcoólico e a resistência à insulina…………………………………………Marsupialização e drenagem aspiratória no tratamento de cistos da mandíbula…………………………… Notícias Os indivíduos de meia idade e os idosos devem estar atentos para a insuficiência de hemodinâmica cerebral por alterações crónicas do fluxo sanguíneo………………………………………………………Resumo de progresso na área de aparelho respiratório………………………………………………………Necessidade de combinação de bloqueadores de canais de cálcio e anti-hipertensivos……………………… Referência e Dados A mudança arterial dos membros inferiores e o tratamento do pé diabético, bem como a colaboração da equipa multidisciplinar…………………………………………………………………………………Alguns questões relacionadas com as doenças do fígado gordo………………………………………………A necessidade do uso menos freauente de telemóvel-tema discutido na conferência mundial sobre a cidade saudável………………………………………………………………………………………………Informações medicamentosas internacionais-Departamento dos Assuntos Framacêuticos dos Serviços de Saúde da Região Administrativa Especial de Macau……………………………………………… Normas de Publicação em 2011 (em Chinês, Português e Inglês) ………………………………………………Conteúdos da RCSM, 2010, Vol. 10 (em Chinês, Português e Inglês) …………………………………………… Revisão deste número: HUANG Xiang-Long 109112115116117118119120121122123124125126127128129132133134140143
Foreign Medical Abstracts Diagnostic value of multi-slice spiral CT colonography in colorectal neoplasms…………………………Antimicrobial resistance and gene typing of extended-spectrum β-lactamases-producing Klebsiella pneumoniae………………………………………………………………………The protocol of treatment guideline of oral and maxillofacial malignant neoplasms……………………CT morphological characteristics of large and small infrarenal abdominal aortic aneurysm…………………Preliminary study on Injection speed of perfusion in soliary pulmonary nodule with 64-detector CT……………Preliminary application of cranial subtraction CT perfusion imaging………………………………………MR diagnosis of mitochondrial Encephalomyopathy…………………………………………………………Detection and clinical significance of HIV-1 antibody in urine…………………………………………3D-CT vertebral artery angiography for cervical spondylotic vertebral arteriopathy……………………The relationship between nonalcoholic fatty liver diseses and insulin reistance…………………………Marsupialization and Suction Drainage in the Treatment of Jaw Cysts………………………………… 115116117118119120121122123124125Articles of HSJM to authors ( in Chinese, Portuguese, and English) ……………………………………………Contents of HSJM, 2009, Vol.9 ( in Chinese, Portuguese, and English) …………………………………………140143 Proofreader in Chinese :HUANG Xiang-Long
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 68‧論著和研究‧ 澳門中學生睡眠 ──覺醒模式和睡眠問題的調查研究 曹美芳 潘集陽 【摘要】 目的 瞭解澳門地區某幾所中學的睡眠-醒覺模式及睡眠問題的情況, 探索兩者在兩性, 初中、高中生間的的差異, 瞭解睡眠問題的相關因素。 方法 本研究對澳門地區某幾所中學進行橫斷面調查研究, 我們採用發放相同問卷的形式對所研究中學生共 622 人進行現場調查, 男生(N=281, 45.2%, 女生(N=341, 54.8%, 初中生(N=308, 49.5%, 高中生(N= 314, 50.5%, 由初一到高三年級, 問卷內容包括一些睡眠-覺醒模式, 日常生活方式, 睡眠障礙的問題及自我評估睡眠問題的相關因素, 並通過Microsoft Word , Excel 2007, SPSS 17.0 系統進行描述性分析, t test, Crosstab, Logistic Regression等進行數據處理及分析。 結果 澳門中學生上學期間睡眠總時數平均 7.14h,上床睡眠時間 11:48pm+ 74min, 起床時間 7:08am+31min,在周六或假日睡眠延長時間達 40.25%,有明顯的睡眠周期後置情況,女生比男生更常見(p<0.05); 而且澳門中學生出現失眠情況亦較常見, 包括 11.6% 晚上入睡困難; 5.1% 早醒後不易入睡; 3.2% 半夜醒來難以入睡; 13.7% 不能在 30min內入睡; 8.8% 在晚上睡眠中醒來或早醒; 0.2%睡眠效率差等, 女生比男生,高中生較初中生發生率高, 失眠出現原因主要為學習壓力(67.4%), 生活環境(45.3%)及健康問題(35.4%), 晚上入睡困難亦受學習壓力, 健康問題, 家庭、生活環境及經濟環境相關係(p<0.05)。 結論 從本研究分析可以推測澳門學生上學期間睡眠不足,於週六或假日睡眠週期延長,出現明顯”補睡”習慣, 以補償未能滿足的睡眠模式,尤以女生更突出, 而且澳門學生失眠情況亦很常見, 女生晚上難以入睡及高中學生睡眠效率差更明顯(p<0.05),其主要原因為學習壓力, 生活環境及健康問題, 並呈正性相關,所以我們應該積極向學校, 學生們宣傳並進行睡眠健康教育, 讓學生瞭解充足睡眠的重要性, 以建立科學而健康的生活方式, 處理及減免學習生活壓力,從而達到改善並提高睡眠品質的目的。 【關鍵詞】 澳門; 中學生; 青少年; 睡眠模式; 睡眠問題 Sleep-Wake Patterns and Sleep Problem in High School among Macau Chinese CHOU Mei Fong. Fai Chi Kei Health Centre ,Health Bureau, Macao SAR, China; Tel:(+853)-2856 2922, 6639 9392; E-mail: clone_stella@yahoo.com.hk; PAN Ji Yang. Department of Psychiatry, The First Affiliated Hospital, Jina University of Guang Zhou, China; Tel:(+86-20) 3868 8309; E-mail:jiypan@163.com 【Abstract】 Objective To explore the situation of sleep-wake patterns and sleep problems in several high schools from Macau. Compare the differences in sleep-wake patterns and sleep problems between gender and grade. Understand the affected factor of sleep problems. Methods Our study was the school-based cross-sectional survey which focuses on the sleep patterns and problems of secondary students in Macau. The same questionnaires were distributed to the secondary school students in Macau, totally 622 samples which finished by form 1 to form 6 students. There are 281 male students, 341 female students, 308 junior students and 314 senior students. The questionnaire was including those items base on sleep-wake patterns, sleep quality, life habits, sleep problems and self-sleep problem relative factors. Results We found that the average sleep time, bedtime and rise time during weekdays in Macau students are 7.14h , 11:48pm+ 74min and 7:08am+ 31min , respectively. Sleep compensation for sleep prolonging time in weekend and holiday was 40.25%, with remarkable sleep cycle prolongation. Female students had more severe delayed rise time and sleep compensation in weekend and holiday than male students. Crosstabs analysis showed that the prevalence of sleep disturbances occurring ≥3 days per week in the preceding 1 months were: difficulty falling asleep( 11.6%), waking up during the night (5.1%), and waking up too early in the morning (3.2%) and poor sleep efficiency(0.2%). The prevalence of female students were more than males, junior students were more than senior one. The mainly causes were studying pressure (67.4%), life surrounding (45.3%) and health problems (35.4%). Furthermore, logistic regression analysis detected that difficulty falling asleep was relative to studying pressure, life and family surrounding and health problems (p<0.05). Conclusions In this study we found that remarkable lack of sleep time during weekdays in Macau students. Sleep compensation in weekend and holiday was remarkable common, particular in female students. Furthermore, difficulties falling 作者單位：中國, 澳门特別行政區, 衛生局, 筷子基衛生中心; Tel:(+853)-2856 2922, 6639 9392; E-mail: clonestella@yahoo.com.hk
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 69 asleep in female students were more severe than in male, poor sleep efficiency in junior students were more worse than senior one(p<0.05). We also found that the affected factors of sleep problems were study pressure, life surrounding and health problems. Parents, educators, clinicians, and researchers should be advised about the importance of sleep in adolescents. Future studies should involve prospective design and intervention and include an examination of the relationship between sleep and health-risk behavior among adolescents. 【Abstract】 Macau; High school; Adolescents; Sleep pattern; Sleep problem 前 言 1 睡眠概況 睡眠是人體生存所必須的生理過程,人生約有 1/3左右時間是在睡眠中渡過的，睡眠和人的生理、心理功能密切相關。尤以青少年更為重要, 睡眠不足, 睡眠維持時間短甚至失眠不但能影響青少年生理生長發育, 更影響其日間記憶[1]，心理發展，認知行為，情感的發展[2,3]及身體健康狀况，即使問題影響仍未出現，睡眠障礙亦為其間接的反映[4]。 2 青少年睡眠不足和不定時的睡眠習慣的概況 根據 WHO 所提供的建議可知，青少年平均睡眠時間應最少為每晚 8-9 小時[6]，從很多的自我問卷評估中得知，青少年缺乏足夠睡眠的情況在東、西方國家都很普遍, Liu[4] 及其同僚在我國進行睡眠習慣調查得知，學生在上學期間每晚平均睡眠時間為 7.6 小時，約 22%學生每周超過一次晚上 00:00 後睡覺。鄰近地區香港 Ka-Fai Chung[5]等人在 2008 年進行的調查中發現上學期間平均上床睡眠時間為 23:24pm, 睡眠總時間 7.3 小時，在周末或假期上床睡眠時間延長至 00:74am 至 02:49am [5], 在 美 國 , Wolfson 及Carskado[6]等人對中學生進行睡眠調查中亦發現，他們上學期間每晚平均睡眠時間為 7.3 小時 , 晚上11:33pm 上床睡覺 06:05am 起床，而周六、日或假日， 晚上及早上睡眠時間將延遲至 00:25am 及09:32am。部份研究表明日本的青少年睡眠時間亦有不 定 時 的 情 形 ， 較 中 國 及 美 國 更 嚴 重 。 一 項 由Tagaya 等人在日本進行的調查中發現，高中一至高中三年級學生每晚平均睡眠時間僅為 6.3 小時，他們習慣於 00:03am 上床睡覺, 06:33am 起床[7]。青少年上學期間睡眠時間不足，周六、日或假日有“補睡”的習慣，這種不定時、周期後置的睡眠方式會影響青少年日間學習的注意力，日間嗜睡，更影響學生日間功能及成績，甚至增加情緒病的發生[8] 。 3 睡眠質量問題的普遍性: 目前睡眠問題是青少年其中一重要的研究方向， 大量的研究指出青少年睡眠問題的出現日益普及，較少年兒童的發生率高[15]，已有研究報道發現青少年缺乏足夠睡眠的情況在東、西方國家都很普遍。Eric O. Johnson[10] 等歸納指出從 2000 年至 2006 年中，睡眠障礙在歐美國家中發生的比率呈進行性上升的。據香港 Chung 等人[5]於 2008 年發表關於中學生睡眠情況的研究，學生每周多於三天出現睡眠問題，包括:入睡困難(5.6%),夜間醒來(7.2%)，早醒(10.4%)。Liu 和 Zhao 等發表研究 [4, 11] 指出，中國大陸青少年學生中有 18.8% 出現睡眠質量差，16.1%學生有失眠情況，而 Ohayon[12]研究中亦顯示：美國高達 25%的青少年存在著睡眠問題，根據 DSM-III 的診斷標準，約有 4%，青少年已確診為失眠症。 Kaneita Y [7] 等發表關於日本中學生的大型研究結果顯示，有 23.5%學生出現睡眠質量差。在韓國,學生睡眠不足的情況更加嚴重，Deok Jin Ban 和 Tae Jin Lee 等人[9] 發表的研究中亦顯示，約有 30.6%中學生出現睡眠問題。青少年總睡眠時間減少，晚上睡眠时間遲,睡眠維持時間短等混亂的睡眠習慣均能影響其學習、專心程度及能力以至影響青少年的生活與學習成績[13]。因此，對青少年學生進行睡眠調查並分析其相關因素是必要的。 對像和方法 1 對像: 研究參加的對象來自澳門五所中學，分別是鏡平
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 73 床時間07:05am，起床時間早於7:00am者有20.7%。而且於週六上床時間及起床時間分別延遲至 1:15h及2:51h，在週六或假日睡眠總時間明顯延長，延長增加超過平日上課時間的1/3，達40.25%，澳門學生此習慣更接近於香港在2008年研究[5]青少年的睡覺模式， 週六上床時間，起床時間分別延遲1:04h及3:25h。在擺脫了上學等社會因素的限制，個體這種週末，假日的“補睡”習慣可以更加真實地表現出自己的睡眠特徵，還可能對上學日未能滿足的睡眠特徵進行一定程度的補償。這種睡眠-醒覺模式在初中與高中組間未反映出明顯差異性; 但在性別方面卻發現女生於週六或假日睡眠總時間，起床時間及假日延長時間均明顯較男生長，說明女生更傾向於週六或假日“補眠”習慣。 關於睡眠問題方面的研究，澳門地區有 22%中學生對過去一個月睡眠質量評分為不好，其中有 41.9%中學生自我感到有睡眠問題，在國內Liu的研究[4]發現有 18.8%中學生認為自己的睡眠不好。我們根據美國睡眠醫學研究會睡眠障礙國際分類標准[14]，把出現 1個月內>=3 晚 / 周晚上入睡困難，早醒後不易入睡，半夜醒來，再難以入睡，不能在 30min內入睡，晚上睡眠中醒來或早醒及睡眠效率定義為“有睡眠問題 ”(為失眠的標準定義)，上述出現頻率順序為11.6%、5.1%、3.2%、13.7%、8.8%及 0.2%，其中女生比男生發生睡眠問題多見，以晚上入睡困難及不能在 30min 內入睡更具統計學上意義，這可能與女性睡前思維紊亂，較敏感-導致更加容易驚醒和醒後心情煩躁影響醒後再度入睡有關[15]；而高中生比初中生出現睡眠問題的比率都要高，以不能在 30min內入睡，及睡眠效率差具統計學意義。可能與高中學生學習，功課及升學等壓力較高有關。研究結果與國外一些研究提出女生睡眠質量較差相一致(15,16)，而且隨年齡增加而增加[15,16,17]，(本研究無細分不同年齡段)。 經統計分析發現澳門中學生出現睡眠問題最常見原因為學習壓力占 91.2%，其次原因為生活環境的影響有 44%，第三位為健康問題占 31.3%，其他依次引起睡眠問題(失眠)原因為 28.1%爲家庭環境，25% 爲升學期望及 17.1%人際關係,經進一步相關分析發現入睡困難受學習壓力，健康問題, 家庭、生活環境及經濟環境相影響，並呈正性相關，而早醒後不易入睡受生活環境好與否相關係。因此我們應向學校， 學生多作宣傳及協商以尋求改善解決方法。 不足與未來思路: 1. 本研究未能符合整群隨機抽樣原則，故未能代表澳門中學生的實際情況； 2. 在研究睡眠問題原因方面,可更加深入地進一步研究各影響因素的內在因果相互關係； 3. 未來可進一步研究睡眠障礙隨後引起的日間後遺影響及睡眠與情緒問題之間的關係。 結 論 從本研究分析可以推測澳門學生上學期間睡眠不足,於週六或假日睡眠周期明顯延長，出現明顯“補睡”習慣，以補償未能滿足的睡眠模式,尤以女生更突出，而且澳門學生失眠情況亦很常見，女生晚上難以入睡及高中學生睡眠效率差更明顯，其主要受學習壓力，生活環境及健康問題影響比率為高，其中更發現入睡困難受學習壓力，健康問題, 家庭、生活環境及經濟環境呈正性關係，早醒後不易入睡受生活環境好與否相關係。因此我們應該積極向學校, 學生們宣傳並進行睡眠教育，讓學生了解充足睡眠的重要性, 以建立科學而健康的生活方式，處理及減免學習生活壓力，了解學生家庭、生活、經濟環境，以協助解決學生各影響因素，從而達到改善並提高睡眠質量的目的。 參 考 文 獻 1 Xianchen L, Lianqi L . Sleep Patterns and sleep Problem Among Schoolchildren in the United States and China. Pediatrics, 2008, 115 : 1:1165-1173. 2 Maquet P. The role of sleep in learning and memory. Science. 2001, 94:1048–1052. 3 Chen MY. Adequate sleep among adolescents is
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 74positively associated with health status health-related behaviors. BMC Public Health, 2006, 6:59. 4 Liu X, Uchiyama M, Okawa M, et al. Prevalence and correlates of self-reported sleep problems among Chinese adolescents. Sleep, 2000, 23:27–34. 5 Ka-Fai Chung, MBBS, MRCPsych and Miao-Miao Cheung, et al. Sleep-Wake Patterns and Sleep Disturbance among Hong Kong Chinese Adolescents. Sleep, 2008 , 31:2: 185–194. 6 Tagaya H, Uchiyama M, Ohida T, et al. Sleep habits and factors associated with short sleep duration among Japanese high-school students: a community study. Sleep Biol Rhythms, 2004, 2: 57-64. 7 Kaneita Y, Ohida T, Osaki Y, et al. Insomnia among Japanese adolescents: a nationwide representative survey.Sleep, 2006.,8:12: 214-220. 8 Roberts R E. Sleepless in adolescence: Prospective data on sleep deprivation, health and functioning . Journal of Adolescence xx, 2009,13:196 -206. 9 Yang CK, Kim JK, Patel SR, et al. Age-related changes in sleep/wake patterns among Korean teenagers. Pediatrics, 2005, 115:250–256. 10 Eric O Johnson. Epidemiology of Insomnia: from Adolescence to Old Age. Sleep Medicine Clinics, 2006, 3:126-230 11 Lin X. Sleep and youth Suicidal behavior: a neglected field. Curr opin psychiatry, 2006, 19:288-293. 12 Ohayon Maurice M, Roberts E, Zulley Jurgen. Prevalence and Patterns of Problematic Sleep Among Older Adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 2000, 39(12):1549-1556. 13 Salcedo Aguilar F. Sleeping habits and sleep disorders during adolescence: relation to school performance. Atencion Primaria / Sociedad Española De Medicina De Familia Y Comunitaria, 2005, 15: 35: 408-414. 14 潘集陽. 睡眠障礙臨床診療. 第 1 版. 廣州： 華南理工大學出版社, 2001. 15 鍾向陽, 趙鳳吳. 睡眠狀況自評量表在大學生中的運用及其影響因素的初步分析. 健康心理學雜誌, 2003, 3：173-175. 16 Wolfson AR, Carskadon MA. Sleep schedules and daytime functioning in adolescents. Child Dev, 1998; 69:875–887. 17 Hien-ming Yang. Coping With Sleep Disturbances Among Young Adults: A Survey of First-Year College Students in Taiwan, 2008, 78:332-340.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 75 ‧論著和研究‧ A Study Comparison of Point of Care of HbA1c and Laboratory Testing in C.H.C.S.J CHAU Chi Hong, AU Tak Wai 【Abstract】 Objective The objective of this research study is to analyze whether the results from POCT HbA1c is accurate and reliable compared to laboratory testing in C.H.C.S.J. Methods 73 patients with Diabetes Mellitus were selected from 2009 in two Macau government health centers [Centro de Saude de Porto Interior (CSPI) and Centro de Saude de S. Lourenco (CSSL)]. Each patient was given the chance to have a finger-prick testing for POCT HBA1C and a venous sample was also collected and analyzed at laboratory in C.H.C.S.J Results The two quantitative outcomes of PCOT HbA1c and laboratory test show high agreement. Conclusion POCT is feasible and has convenient advantages in primary care for monitoring glycemic control and provides a positive effect in managing diabetic patients. 【Key words】 Point of care testing (POCT) ; HemoglobinA1c (HbA1C) 糖化血紅蛋白即時檢測與仁伯爵綜合醫院化驗室的檢驗數值作相關性研究 周志雄, 區德偉. 中國澳門特別行政區, 衛生局, 氹仔海洋衛生中心; Tel : (+853)-6681 0952; E-mail : terenceau2004@yahoo.com.hk 【摘要】 目的 為了解糖化血紅蛋白即時檢測的準確性與可靠性，與仁伯爵綜合醫院化驗室的糖化血紅蛋白檢測數值進行兩者比較。 方法 在海傍衛生中心及風順堂衛生中心共選出 73 名糖尿病患者，患者作糖化血紅蛋白的即時檢測及同時有關血液樣本將送往仁伯爵綜合醫院化驗室作化驗，把兩者數值進行分析及比較。 結果 從分析結果顯示，可携帶式糖化血紅蛋白即時檢測與仁伯爵綜合醫院化驗室的檢驗數值呈一致性。 結論 糖化血紅蛋白即時檢測是可行和方便的, 在基層醫療中對糖尿病病人作糖尿病控制監測，以及對管理糖尿病病人有正面作用。 【關鍵詞】 即時檢測; 糖化血紅蛋白 Introduction Diabetes Mellitus is a chronic disease. A recent estimate expects that China and United States are the most affected, with estimates of 38 million and 22 million people affected by this disease. Diabetes is the fifth leading cause of death in the United States with high rates of complications such as diabetic nephropathy, retinopathy, neuropathy, and lower-limb amputation. However, the complications of DM can be greatly reduced if good glycemic control is attained. Hemoglobin A1c (HbA1c) is an indicator of long-term glycemic control that healthcare use to make treatment decisions in order to maintain or improve a diabetic’s glycemic level. The American association of clinical Endocrinology recommends a goal of HBA1c less than 6.5%, every 1% reduction in A1C level lowers the risk of developing microvascular complications by 40%. Point of Care Testing (POCT) is a new technology with fast Authors address: Department of Health, Macao, S.A.R, China; Tel: (+853)-6681 0952; E-mail: terenceau2004@yahoo.com.hk feedback. It is easy-to-use assays that can offer laboratory-quality results in minutes. Although POCT have these advantages, this method should also achieve accurate and reliable HbA1c measures. Therefore, evaluating and comparing the results of POCT HbA1c and laboratory analysis results is important in order to find out whether POCT results resemble that of laboratory testing. Objective The objective of this research study is to analyze whether the results from POCT HbA1c is accurate and reliable compared to Laboratory testing. POCT method is used in Macau government health center. Method 73 patients with Diabetes Mellitus were selected from 2009 in two Macau government health centers [Centro de Saude de Porto Interior (CSPI) and Centro de Saude de S. Lourenco (CSSL)]. Each patient were
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 76given the chance to have a finger-prick testing with DCA voltage (Siemes Medical Diagnostics Solution S. Puteaux. France), which is a rapid one-step test, and a venous sample was also collected and analyzed at laboratory in C.H.C.S.J The results of these two testing methods in each patient were then compared and analyzed. Data Analysis & Results Completed data for 73 paired HbA1c results were collected for analysis. The relationship between two quantitative outcomes by POCT and laboratory testing were compared and analyzed. Correlation coefficient is used to describe the degree of linear relationship between the two variables. Pearson’s correlation is used for analysis through SPSS. (Table 1) shows the correlation coefficient between POCT HbA1c and laboratory testing (both variables are normally distributed): Pearson’s r = 0.959 (P<0.001) Table 1 Correlation between POCT and Lab testing POCT Lab POCT Pearson Correlation 1 .959(**) Sig. (2-tailed) .000 N 74 74 Lab Pearson Correlation .959(**) 1 Sig. (2-tailed) .000 N 74 74 ** Correlation is significant at the 0.01 level (2-tailed). Because Correlation is not equal to agreement, so we need to plot the Bland Altman plot to describe agreement between the two quantitative measurements. The difference of the mean (SD) is calculated. The mean +/- are (-0.1874, 0.701) (see Table 2): Table 2 Descriptive Statistics N Minimum Maximum Mean Std. DeviationDifference 74 .00 1.20 .2568 .22212Valid N (listwise) 74 Mean +/- 2SD are (-0.1874, 0.701) Bland Altman was furthered used to plot the agreement of two HbA1c-measuring methods. The difference between the two methods and the mean of both methods for all the paired HbA1c values were computed. Table 3 Bland Altman plot 5.00 6.00 7.00 8.00 9.00 10.00 11.00Mean0.000.200.400.600.801.001.20Difference Discussion From the Bland Altman plot, only 4 / 73 (5.5%) of the points are beyond the +/- 2 SD lines (see Table 3). Therefore, the two quantitative outcomes of PCOT HbA1c and laboratory test show high agreement. The results showed that POCT HbA1c test can provide adequate accuracy and can be useful for patients, especially patients who have poor control in glucose level. The laboratory HbA1c test is applied at around 6 months interval, whereas the POCT can obtain instant HbA1c results. Doctors can monitor the patients’ glycemic control condition and yields a faster medical plan of action. Meanwhile, patients are informed of their HbA1c levels and medical staff can provide instant feedback. Patients can benefit by participating actively for their diabetic management plan. Conclusion POCT is emerging as an important tool for diabetes care. It enables clinicians to obtain accurate results in a timely manner. It has feasible and convenient advantages in primary care for monitoring glycemic control and provides a positive effect in managing diabetic patients. Reference 1 Kendra L. Schwartz, MD, MSPH, Joseph Monsur, Comparison of point of care and Laboratory HbA1c Analysis: A MetroNet Study, JABFM 7-8/09 Vol.22 No.4 2 Bruce W. Bode, Benjamin R. Irvin. Advances in Hemoglobin A1c Point of Care Technology, Journal of Diabetes Science and Technology Volume 1, Issue 3, May 2007.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 77 ‧論著和研究‧ 健康生活方式行為幹預對高血壓患者 治療效果初步報告 林宇濤 徐松波* 黎嫦燕* 【摘要】背景 健康生活方式是高血壓治療及預防的重要部份，健康生活方式包括健康飲食及體育活動. 本研究應用階段性行為改變模式來實現健康生活方式的目標, 檢驗其對高血壓病人臨床治療的輔助效果。 方法 本研究為單盲隨機對照研究。按在 2007 年 8 月期間的門診預約名單順序選取 32 名, 未發現明顯併發症的高血壓病人。應用隨機陣列方法將其隨機分成對照組及干預組。對照組病人被給予目前現有的高血壓病人教育資料。干預組病人則每 3 個月按照階段性行為模式將每個病人分為不同類型, 按行為改變意願的不同而使用相應的健康生活方式的教育策略。在 0 個月, 4 個月及 8 個月時對兩組患者測量血壓, 隨訪時間約為 8 個月。 結果 完整成功隨訪 24 名患者，對照組 12 人, 男性 7 人, 女性 5人, 平均年齡 64.8±9.8 歲。干預組 12 人, 男性 1 人, 女性 11 人, 平均年齡 53.3±9.7 歲。兩組分別在 0 個月、4 個月的收縮壓、舒張壓及 8 個月的收縮壓均數經 t-檢驗, P>0.05, 8 個月時舒張壓均數 t 檢驗, P<0.05有顯著統計意義(表)。多元線性回歸分析調整性別、年齡、吸煙、飲酒、教育水平、平均家庭收入、高血壓年數、血壓藥等因素後, 干預因素與患者的各時期的血壓值無顯著相關性。 表 兩組三次血壓值比較 收縮壓(mmHg)Mean±SD 舒張壓(mmHg)Mean±SD 對照組 0 個月 4 個月 8 個月 147±20 138±17 135±14 82±9 77±8 76±9 干預組 0 個月 4 個月 8 個月 144±21 138±20 139±14 81±8 82±11 83±4 結論 經過 8 個月期間每 3 個月一次通過階段性行為改變模式在健康生活方面進行行為干預, 本研究未見干預因素對血壓有明顯變化，考慮可能由于樣本量不足、失訪率高以及干預措施未夠進一步具體化。 【關鍵詞】高血壓; 健康生活方式; 研究 The Effect of Healthy lifestyle Behavior Change on Hypertension Lam Chu Tou.; Department of Energency, Centro Hospital Conde de Sao januario(CHCSJ), Macao SAR PR China; Tel：(+853)-66256367; Email: chutou88@hotmail.com; Choi Chong Po*, LAI Sheung Yin, Tap Health Center, Health Bureau,Macao, SAR, PR China 【Abstract】 Background Healthy lifestyle is a critical part of the prevention and the treatment of hypertension. Healthy lifestyle include healthy diet and physical activity. The aim of this study is to make the Healthy lifestyle come true by the Model of Stage of Change. Method This is a single-blinded randomized control study. 32 patients who were diagnosed as hypertension without complication were selected from Tap Seac Health Center OPD patient’s list on schedule. Through permutation of randomization, the patients are divided into intervention group and control group. The current hypertension education materials in Health center were used in the control group. According to the different stage of behavior changing, the related education strategies would be applied on the patients in the intervention group, which was performed once per three months. The blood pressure of the both groups would be measured in eight months. Result There are 24 patients successfully finished this follow-up. 12 persons in control group, male was 7 persons, female was 5 persons, the average age was 64.8±9.8 years-old. There are 12 persons in the intervention group, man was 1 persons and female was 11 persons, the average age is 53.3±9.7 years-old. Compare the averages of systolic and diastolic pressure in 0 month, the 4th month and the average of systolic pressure in 8th month in the both groups were no significant difference (P>0.05) after t-test. Compared the averages of diastolic pressure in the 8th month between the both groups by t-test, P <0.05. Found the different between the both group was significance. After adjusted the age, sex, education , average income, smoking, drinking, duration of hypertension history, drug of hypertension by multiple regression, found intervention factor was not related to blood pressure. Conclusion Each three months performed once healthy lifestyle behavior intervention. No significant change in blood pressure was found by the intervention factor in this study. 作者單位：澳門衛生局仁伯爵醫院，Tel：(+853)-6625 6367; Email: chutou88@hotmail.com *澳門衛生局, 塔石衛生中心
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 78The reasons that including no enough sample size, high loss rate and embodiment still not enough in the intervention method were considered. 【Key words】 Hypertension; Healthy lifestyle; Research 於 2005 年高血壓病占澳門尋求初級衛生保健的二十個主要原因的首位(約 20%)[1] 。健康生活方式的采用對於高血壓的預防是很關鍵的,高血壓病的治療, 健康生活方式亦是必不可少的一部份[2]。在美國一項參 與 者 有 459 人 的 多 中 心 隨 機 對 照 研 究 ， 應 用DASH(The Dietary Approaches to Stop Hypertension)為干預措施, 結果發現在實行 2 周的 DASH 膳食模式結合低鈉飲食後，干預組的血壓較對照組有效降低血壓[3]。對於體重過重的人增加適量運動以達到減輕體重的目的, 只要體重減輕 4.5 公斤可有降低血壓的效果。本研究所指健康生活模式是以 DASH 膳食模式為基礎結合低鈉飲食以及增加運動等三個項目為核心。因為健康生活模式是一種理想化的模式，與目前人們的生活模式有一定的距離, 甚至矛盾，往往在個人的實際生活過程中，都面對失敗的結果。本研究另一方面引用心理學方面的行為改變理論，Stage of Change(階段性行為改變模式 )是 The Transtheoretical Model of Change 的四個組成部份之一的核心。改變意味著隨著時間的推進而在不斷發生變化，行為變化是通過五個 階 段 推 進 的 過 程 [4], 這 五 個 階 段 依 次 分 別 為Precontemplation( 沉 思 前 期 ) 、 Contemplation( 沉 思期 ) 、 Preparation( 準 備 期 ) 、 Action( 行 動 期 ) 、Maintenance(維持期)。沉思前期指在這階段的人們並沒有打算在可預見的將來(通常指接著的六個月內)采取行動。沉思期指在這階段的人們正打算在接著的六個月內作出行為的改變。準備期指在這階段的人們正打算在緊接著的將來(通常指接著的一個月內)采取行動。行動期指在這階段的人們在過去六個月內，在他們的生活方式上己做了明顯而具體的調整。保持期指在這階段的人們正著力於防止不良行為的复發。根據所處不同時期采取相應的指導。 方 法 本研究為單盲前瞻性隨機對照研究。按在澳門塔石衛生中心 2007 年 8 月期間的門診預約名單順序選取 32 名, 未發現明顯並發症的高血壓病人。 應用隨機陣列方法將其隨機分成對照組及干預組。病人按照原本約定的門診日期進行覆診，為了減少偏倚，整個研究過程血壓及體重的測量均由同一位醫生完成，醫生及病人本身均不知道是干預組或對照組。覆診完成後，根據病人參與研究的意願，提示到另一間房由另一位人員對這些病人進行問卷調查以及按照隨機排列次序對病人進行相應的教育指導。對兩組病人的基本資料做問卷調查，項目包括性別、年齡、身高、職業、活動強度、教育程度、家庭人數及總收入、患高血壓年數、吸煙及飲酒情況。對照組以衛生中心目前現有的高血壓病教育資料對病人進行教育及解釋。干預組病人再作包括低脂肪飲食、蔬菜及水果飲食及運動三方面的階段性行為改變的問卷調查。根據每個病人所處的不同時期，作出相應的指導。處於沉思前期或沉思期者，由於他們未意識到飲食或運動對健康的影嚮, 又或者健康生活方式對其生活帶來的障礙, 對這個階段的病人主要強調飲食因素及運動對健康的重要性, 解決阻礙實行健康生活方法的因素, 強調健康生活方式帶來更多對生活正面的作用。處於準備期者，在短期內己打算作出行動, 因而將給予更多具體信息如何做出改變，如本研究將根據個人的身高、體力活動強度，算出每日所需的理想熱量並提供每天具體五谷類、肉、水果及蔬菜類的相應食用份量，以及提供低脂肪飲食技巧、蔬果飲食技巧、低鈉飲食技巧及增加運動的技巧。處於行動期及維持期者，主要鼓勵其維持目前的健康生活方式，警愓及預防回复至原來的不健康生活方式。在 0 個月、4 個月及 8 個月的預定覆診日期對兩組患者測量血壓，隨訪時間約為 8個月。另外每 3 個月用電話形式接觸干預組患者, 對階段性行為改變進行調查。 統計軟件使用 SPSS15.0。應用兩組均數比較 t 檢驗及多元線性回歸分析。 結 果 共選取 32 名高血壓患者，其中 1 名更改覆診日期，另 2 名因為有事趕時間拒絶參與，首次調查完成29 名患者，完整隨訪 8 個月有 24 名患者，對照組 12人, 男性 1 人、女性 11 人，3 人失訪(錯過門診時間)，平均年齡 53.3±9.7 歲。 干預組 12 人, 男性 7人, 女性 5 人, 2 人失訪(1 人入院，1 人錯過門診時間)，平均年齡 64.8±9.8 歲。兩組分別在 0 個月及 4個月的血壓均數及 8 個月的收縮壓均值比較, 成組 t-
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 80 討 論 據 WHO 介紹對於亞洲人來說 BMI 在 23-27.5 之間患慢性疾病(心血管疾病及糖尿糖)風險增多, 當BMI 超過 27.5 有更高的患病風險[5]。參與本研究的患者 BMI 大於等於 23 占 87.5%, 其中 BMI 大於等於27.5 占 12.5% 。經過 8 個月時間通過階段性行為改變模式在飲食方式及運動方面進行行為干預, 經統計分析未見本研究干預因素對血壓值及 BMI 有明顯的影嚮。與 DASH 研究比較, 結果含豐富的水果、蔬菜及低脂飲食的干預組(133 人)與較一般飲食的對照組(326 人)可使收縮壓下降 11.4mmHg 以及舒張壓下降5.5mmHg。DASH 研究的干預方法為參與者周一至周五每天到固定地點用餐(包括一餐午餐或晚餐)，每天食物都在研究中心的廚房統一烹煮, 其他餐次的食物, 研究中心將發一袋每天必吃完的食物[3]。周末需要的食物, 研究單位將在周五當天發給參與者回家食用。本研究未見如 DASH 研究的結果，一方面因為樣本不足、失訪較多，另一方面本研究的飲食指導主要是按理想體重為依據提供不同類型食物的不同攝取份數，其中依從性及可行性均與 DASH 研究有一定差距。在健康行為改變方面，低脂飲食、蔬果飲食以及運動行為在 6 個月時較 0 個月時有進步，患者處於沉思前期及準備期所占的比例減少，處於行動期的比例增加。然而如何通過行為心理學將健康生活模式在我們現有的社會條件下實現, 將是我們為防治慢性疾病所努力的目標。 參 考 文 獻 1 2005 統計年刊, 1 初級衛生保健 p57. 2 US. Department of Health and Human Services. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Aug 2004, P25. 3 Appel LJ, Moore TJ, Obarzaneck, et al. A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure. N Engl J Med, 1997, 335(16):1117-1124. 4 Velicer WF, Prochaska JO, Fava JL, et al. Smoking cessation and stress management: Applications of the Transtheoretical Model of behavior change. Homeostasis, 1998, 38: 216-233. 5 WHO expert consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. The Lancet Jan, 2004, 363:157 -163.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 81 ‧論著和研究‧ 超聲診斷小兒腸套疊臨床價值探討 梁樹民 李峻 林寧 【摘要】 目的 探討小兒腸套疊超聲診斷的臨床價值。 方法 回顾分析 38 例超聲诊断及 X 线空气灌肠整復或手术復位资料。 結果 超聲顯示腸套疊特徵聲像“同心圓征”及“套筒征”可行診斷，並與 X 線空氣灌腸對照完全符合。 結論 超聲診斷小儿肠套叠具有較高臨床價值。 【關鍵詞】 腸套疊; 超聲診斷 Study of Ultrasound Diagnosis of Intussusception in Children LIANG Shu Ming, LI Jun, LIN Ning. Diagnostic Image Center; Kiang Wu Hospital, Macao SAR China; Tel:(+853)-82950382; Email:lshm-autumn@hotmail.com. 【Abstract】 Objective To explore the clinical value for children intussusception by ultrasound diagnosis .Methods The datum of 38 cases were analysed retrospectively，Including the datum of ultrasound scan ,X –ray gas enema with intussusception replacement and operation. Results The specific features of sonographic images were found in intussusception, they were“concentric circle sign”and“ Cover sign ”. To compare with X –ray gas enema was complete conformation. Conclusion It is valuable for the diagnosis of children intussusception by ultrasound scan 【Key words】 Children intussusception; Ultrasound diagnosis 小兒腸套疊是兒科常見急腹癥之一，早期診斷對臨床治療甚為關鍵。超聲診斷腸套疊基於其聲像學特徵性表現，即腹部顯示“同心圓征”和“套筒征”基本可明確診斷[1]。診斷準確率較高，已被兒科、外科醫生廣泛認同。近三年來本科經超聲檢查診斷小兒腸套疊獲得滿意的效果，報告如下: 資料與方法 一般資料 本組 38 例小兒腸套疊爲本院 2007-2009 年住院病例；男 21 例，女 17 例；年齡均為 3歲以下，從 1 月～32 月，中位年齡 16 個月。臨床表現有哭鬧不安、拒食、腹痛、腹脹、嘔吐、腹瀉、便血等；部分病例腹部觸及可疑包塊。 儀器 GE LOGIQ-9 型彩色超聲儀；探頭：7L、4C；頻率 3.5-7.0MHz，高、低頻探頭結合使用。 檢查方法 均為急診檢查，無需特殊準備，患兒取仰臥位，常規探查腹腔各區域，重點探查右側中、上、下腹部。觀察有無腸管樣包塊、腸蠕動、積液積氣、腸管擴張、腹腔積液等，必要時探查鄰近臟器。 作者單位: 中國, 澳門特別行政區, 澳門鏡湖醫院影像中心; Tel:(+853)-8295 0382; Email:lshm-autumn@hotmail.com 若在右側腹部（中上腹、中下腹）發現特徵性聲像即可診斷。必要時應用彩色多普勒觀察腸壁血運情況。 結 果 經超聲檢查診斷腸套疊 38 例，腹部均顯示特徵性聲像：套疊部腸管包塊回聲，橫切面呈“同心圓征”(圖 1)，中心部爲圓形強回聲，或氣液回聲，外周數層高低回聲相間環繞，直徑從 2.5～4.5cm 不等；縱切面呈“套筒征”(圖 2)，長度 3.0～6.0cm，無明顯蠕動。分型（依據 X 線與手術所見分型）：回盲（回結）型 29 例，結腸型 9 例。 圖 1 腸套疊的“同心圓征”。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 82 圖 2 腸套疊的“套筒征”。 本組 38 例超聲診斷腸套疊後均及時行 X 線結腸空氣灌腸及腸套疊整復術，全部符合。其中 33 例復位成功； 5 例 X 線空氣灌腸整復不成功，後經手術復位亦證實。超聲與 X 線空氣灌腸及手術對照全部符合，符合率 100%。38 例腸套疊中 5 例為腸套疊2 次復發，1 例為腸套疊 3 次復發。 討 論 腸套疊為一段腸管及其腸系膜套入其相連的腸腔內，是小兒常見的急腹症之一，病因至今未完全明瞭。嬰幼兒的腸套疊腸管一般無器質性改變，多為原發性、單純性，約占 95%；繼發性約 5%。60%發生在 1 歲以內，90%發生在 2 歲以內[2,5]。多由腸蠕動紊亂、腸系膜過長、回盲部活動度大和（或）感染、回盲部淋巴結增生等引起[1]。僅 5%左右的小兒腸套疊有明顯的機械因素。近年來不少學者認爲，小兒腸套疊的發生與腺病毒感染有關[3]。 以往對於小兒腸套疊多採用 X 線空氣灌腸進行診斷與整復。隨著超聲醫學進展，超聲對小兒腸套疊診斷的研究不斷深入。諸多研究表明，超聲診斷小兒腸套疊敏感性、準確性較高。超聲檢查除能判斷是否腸套疊之外，還可應用彩色多普勒超聲評估腸壁血供狀態。腸套疊由三層腸壁組成，外層為鞘部，套入部分為最內壁和反折壁。套入部系膜血管常被鞘部擠壓，而使局部腸管充血、水腫進而形成壞死。彩色多普勒超聲檢測可直觀顯示套疊腸壁的血流信號，從而評估腸管血供狀態及缺血程度[4,7]，對臨床選擇整復方式有參考作用。 超聲診斷小兒腸套疊基於小兒腹壁解剖學特點。小兒腹壁結構較薄、腹腔前後徑距離短，為超聲探查腹部、腸管提供了良好的聲學條件，有利於分辨顯示腹部腸管病變。我們採用高、低頻探頭結合，一般都能發現腹部異常腸管回聲，從而較準確地判斷病變性質。本組腸套疊病例均為單發套疊，但需強調，應瞭解存在兩個或以上部位同時套疊的可能性，應仔細、全面、反復探查，謹防漏診。 超聲檢查與 X 線空氣灌腸整復比較，後者是臨床沿用的傳統方法，對於腸套疊兼有診斷與治療雙重功效，臨床價值肯定[5]。但其操作較復雜、有一定痛苦及風險、需麻醉配合等，患兒不易接受。且對套疊時間過長、存在腸壁缺血壞死、病情嚴重的小兒不太適用。而超聲檢查無痛苦、無禁忌、無創、快捷、結果可靠，患兒易於接受，利於追蹤復查等。二者配合應用，優勢整合，對於腸套疊的診斷、治療針對性更強。超聲檢查還能追蹤觀察復位後狀況，判斷復位後是否復發等[6]。本組病例均先經超聲檢查提示腸套疊後，再行 X 線空氣灌腸整復，成功復位 33 例（占整復術者 86.8%）取得較好效果。 據文獻報告，近年來開展的超聲監視下生理鹽水灌腸復位，與 X 線空氣灌腸復位的成功率相近，而無X 線幅射的之弊，爲治療腸套疊開闢了新途徑[7]。 小兒腹痛臨床常見，而許多單純型腸套疊小兒臨床表現往往不典型，常無血便和腹部包塊等，兒科醫生對這類小兒都會高度警惕，通常首選超聲檢查。同期為甄別是否腸套疊，超聲檢查小兒腹部共 143 例，診斷腸套疊 38 例，排除性診斷 105 例。事實上，超聲排除性診斷對臨床協助意義亦較大。 腸套疊超聲診斷還應注意與小兒闌尾炎或伴炎性包塊形成、先天性腸旋轉不良、腸道腫瘤等鑒別。闌尾炎管徑較細，一端呈盲端，伴炎性包塊形成多為混合回聲區，無“同心圓征”；先天性腸旋轉不良多發生在新生兒期，彩色多普勒顯示腸系膜根部血管呈螺旋狀血流信號；腸道腫瘤多爲“假腎征”，再結合臨床表現可資鑒別。 綜上所述，小兒腸套疊的早期診斷對治療及預後甚為重要，超聲檢查快捷、準確，已成為臨床首選的診斷方法。關鍵在於掌握腸套疊的特徵性聲像表
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 84‧論著和研究‧ 降鈣素原在老年細菌性 肺炎診斷中的臨床價值 張曉戰 程鯤 崔冠昌 楊珂 董綺虹 【摘要】 目的 探討降鈣素原（PCT）在細菌性肺炎診斷中的臨床價值。 方法 對 81 例疑似細菌性肺炎患者，在應用抗生素前測定 PCT、C 反應蛋白、血常規及行痰培養，比較它們對細菌性肺炎診斷的敏感性、特異性、陽性似然比、陰性似然比。 結果 血清 PCT 在細菌性肺炎組陽性率高于對照組。PCT 檢測對細菌性肺炎診斷的敏感性為 54.45%，特異性為 88.46%，陽性似然比為 12.69%,陰性似然比為 0.17%。CRP 敏感性為 95.45%，特異性為 8.33%;陽性似然比為 4.58%,陰性似然比為 3.17%。在各項指標中，PCT 的特異性最高，CRP 的敏感性最高，陽性似然比最高為痰培養，陰性似然比最低為 PCT。 結論 血清 PCT 可作為老年細菌性肺炎的檢測指標，其作用優於 CRP 測定和外周血白細胞計數及分類、血沉、痰培養。通過與 CRP 結合，可早期診斷、及時治療細菌性肺炎。 【關鍵詞】 降鈣素原; 細菌性肺炎; 早期診斷 Role of Procalcitonin in Bacterial Pneumonia among the Elderly Population ZHANG Xiao Zhan, CHENG Kun, CHOI Kun Cheong, IEONG O,TUNG Yee Hung. Internal Medicine, Kiang Wu Hospital, Macao SAR,,PR.China; Tel: (+853)-6633 7757;E-mail: zhangxiaozhan282@sina.com 【Abstract】 Objective To investigate the clinical value of using PCT in the diagnosis of bacterial pneumonia. Methods In a group of 81 patients provisionally diagnosed with bacterial pneumonia, laboratory testing like PCT, C-reactive protein, Complete blood count and sputum culture were performed prior to antibiotic treatment. Comparisons were made between these four different tests in the diagnosis of bacterial pneumonia regarding sensitivity, specificity, positive likelihood ratio and negative likelihood ratio. Results Serum PCT has a higher detection rate for bacterial pneumonia compare to the control group. For diagnosing bacterial pneumonia, PCT has a sensitivity of 54.45%, Specificity of 88.46%, Positive likelihood ratio of 12.69% and Negative likelihood ratio of 0.17%. As for CRP, its Sensitivity is 95.45%, Specificity is 8.33%, Positive likelihood ratio is 4.58% and Negative likelihood ratio is 3.17%. On this study, PCT has the highest specificity and CRP has the highest sensitivity. On the other hand, Sputum culture has the highest Positive likelihood ratio and PCT has the lowest Negative likelihood ratio. Conclusion Serum PCT is a useful marker for diagnosing bacterial pneumonia in the elderly. It has advantages over CRP, ESR, sputum culture, white blood cell count and its differentials. By combining PCT with CRP, it will enable early diagnosis and management of bacterial pneumonia. 【Key words】 Procalcitonin; Bacterial pneumonia; Early diagnosis 老年人細菌性肺炎起病隱襲,症狀多不典型,在營養狀況較差、免疫功能低下、合併多種慢性疾病患者中尤為明顯，給早期診斷帶來困難。近年來國外認為降鈣素原(Procalcitonin, PCT)是診斷感染性疾病的敏感指標[1]，是診斷全身細菌感染性疾病的重要標誌物。有鑒於此，我們對 81 例臨床疑診細菌性肺炎患者進行了血清降鈣素原的監測，並與 C 反應蛋白（CRP）、外周血白細胞計數(WBC)及中性分類(N%)、 作者單位：中國, 澳門特別行政區, 澳門鏡湖醫院, 內科; Tel: (+853)-6633 7757; E-mail: zhangxiaozhan282@sina.com 血沉(ESR)、痰培養(SPUTUM CULTURE)等常用炎性指標檢測結果進行比較，探討其在老年人細菌性肺炎診斷中的意義。 對象與方法 1 研究對象 2007 年 8 月～2008 年 8 月，在本院呼吸科住院懷疑合併有細菌性肺炎的老年病人 81 例，男 48 例，女 33 例，平均年齡（72.17+3.62，60～98Y）。81 例患者按出院（或死亡）診斷分為兩組，細菌性肺炎
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 86種感染性疾病的診斷，認為它是一種有潛在診斷價值的敏感的全新指標[3-4]。 隨著社會老齡化的加快，老年細菌性肺炎患者日益增多。老年病人多合併多系統疾病，特別是心腦血管疾病，糖尿病，慢性肺部疾病等，並發細菌性肺炎時臨床癥狀多不典型，常規炎性指標白細胞計數及分類、血沉、C 反應蛋白等特異性不強，痰培養特異性好但需要時間長，對早期診斷帶來困難。因此，我院將 PCT 引入到細菌性肺炎的診斷中。通過對 55 例肺炎患者及 26 例初診疑似後確證為非細菌感染性疾病的患者進行對比研究，發現 PCT 的診斷價值優於其他指標。本研究中，PCT 特異性最強，為 88.46%；陰性似然比最低，僅為 0.17，說明誤診率最低；陽性似然比僅次於痰培養，但痰培養費時長，不能盡快得到結果。因此，PCT 在鑒別細菌性肺炎時具有重要價值。與文獻報道一致[5-7]。本組 20 例重癥肺炎患者，14 例 PCT 明顯增高，其中 10 例死亡，PCT 持續升高[8-10]，是否說明 PCT 與預後極差有關，因病歷數較少，值得進一步研究。 CRP[11-12]是一種急性時相蛋白，作為感染檢測手段目前已廣泛應用於臨床，對協助診斷細菌感染有一定意義，特別是重症感染，但與 PCT 相比，其特異性較差。本組中，26 例非感染性疾病患者，24 例增高。因此，基於急性時相蛋白的特點，CRP 在體內受較多因素影響，在感染與非感染間特異性不強。但其在敏感性方面，優於其他指標。因此，筆者建議在診斷老年細菌性肺炎時可將兩種指標結合進行判斷，更有參考意義。 總之，PCT 是人體一種敏感的細菌感染標誌物，在患者細菌感染時血清 PCT 升高，特別是重症細菌感染時升高尤為明顯，可作為老年細菌性肺炎的早期檢測指標。老年細菌性肺炎由於臨床症狀不典型、診斷金標準中的痰培養陽性率低，費時長，早期診斷困難，故 PCT 對其診斷更有臨床價值，其作用優於外周血白細胞計數及分類等指標。臨床上對診斷不明的疑似肺炎患者，可根據血清 PCT 水平的高低判斷是否存在細菌感染，對高度懷疑細菌感染者，應盡早足量使用抗生素，嚴防濫用抗生素。對重症細菌感染患者，通過對 PCT 水平的觀察，結合 CRP 的變化，既可早期診斷、及時治療，又可判斷感染是否控製。 致 謝 本文統計學處理得到第四軍醫大學衛生統計學副教授王霞的指導，特此感謝！ 參 考 文 獻 1 Assicot M, Gendrel D, Carsin H, et al. High serum procalcitonin concentrations in patients with sepsis and infection. Lancet, 1993, 341:515-518. 2 彭道泉. 診斷性試驗研究及評論. 見:趙水平, 彭道泉. 現代臨床科研方法學. 第 1 版. 長沙:中南大學出版社, 2001. 35-59. 3 Hausfater P, Garric S. Usefulness of procalcitonin as a maker of systemic infection in emergency department patients:a prospective study. Clin Infect Dis, 2003, 34:895-901. 4 van Leeuwen HJ, Voorbij HA. Procalcitonin concentrations in the diagnosis of acute inflammatory reactions. Ned Tijdschr Genesskd, 2002, 146:55-59. 5 Dubos F, Korczowski B, Aygun DA, et al. Serum procalcitonin level and other biological markers to distinguish between bacterial and aseptic meningitis in children: a European multicenter case cohort study. Arch Pediatr Adolesc Med, 2008, 162:1157-1163. 6 Hirakata Y, Yanagihara K, Kurihara S, et al. Comparison of usefulness of plasma procalcitonin and C-reactive protein measurements for estimation of severity in adults with community-acquired pneumonia. Diagn Microbiol Infect Dis, 2008, 61:170-174. 7 Ramirez P, Garcia MA, Ferrer M, et al. Sequential measurements of procalcitonin levels in diagnosing ventilator-associated pneumonia. Eur Respir J, 2008, 31:356-362. 8 Casado-Flores J, Blanco-Quirós A, Nieto M, et al. Prognostic utility of the semi-quantitative procalcitonin test, neutrophil count and C-reactive protein in meningococcal infection in children. Eur J Pediatr, 2006, 165:26-29. 9 Huang DT, Weissfeld LA, Kellum JA, et al. Risk prediction with procalcitonin and clinical rules in community-acquired pneumonia. Ann Emerg Med, 2008, 52:48-58. 10 Klugman KP, Madhi SA, Albrich WC. Novel approaches to the identification of Streptococcus pneumoniae as the cause of community-acquired pneumonia. Clin Infect Dis, 2008, 47:S202-206. 11 Falk G, Fahey T. C-reactive protein and community-acquired pneumonia in ambulatory care: systematic review of diagnostic accuracy studies. Fam Pract, 2009, 26:10-21. 12 Marcus N, Mor M, Amir L, et al. Validity of the quick-read C-reactive protein test in the prediction of bacterial pneumonia in the pediatric emergency department. Eur J Emerg Med, 2008, 15:158-161.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 87 ‧論著和研究‧ 藥片分劈對藥物品質及性狀的影響 唐海誼 林啟鋒 【摘要】 目的 研究藥片分劈操作對藥片藥物含量的影響。 方法 由 6 名藥劑技術員及 16名 65 歲或以上之長者利用徒手、刀、剪刀及切藥器對 3 種藥物進行分劈，並對已分劈之藥物進行稱重分析、含量均勻度檢查及片劑脆碎度檢查。 結果 利用切藥器分劈藥片的效果最好，刀及剪刀次之，藥劑技術員分劈藥片較長者優勝。經分劈後的藥片在片劑脆碎度檢查中，重量損失均少於2.0%。 結論 藥片分劈必然減低藥片藥物含量準確性，唯藥劑技術員利用切藥器把藥片分劈能把負面影響減到最少，增加藥房藥事照顧之品質。 【關鍵詞】 分劈藥片; 藥劑技術員; 藥事照顧 The Influence of Tablet Split on the Quality of Medications TONG Hoi Yee, LAM Kai Fung. School of Health Sciences, Macao Polytechnic Institute. Tel：(+853)-8399 8632; E-mail：henrytong@ipm.edu.mo 【Abstract】 Objective: To investigate the influence of tablet split on the quality of medications. Methods: Tablet split is done by 6 pharmacy technicians and 16 senior citizens aged 65 or above with tablet splitter, kitchen knife, scissors and manual handling. The split tablets are subject to weight analysis, content uniformity test and friability test. Results: Tablet splitter is the best technique for splitting tablets, followed by kitchen knife and scissors. Pharmacy technicians can split tablets much better than senior citizens. During friability test, all tablets have weight loss less than 2.0%. Conclusion: Although tablet split can result in less accurate dosage, pharmacy technicians can minimize the negative influence by using tablet splitter, and thereby increase the quality of pharmaceutical care in pharmacy practice. 【Key words】 Tablet splitting; Pharmacy technicians; Pharmaceutical care 前 言 口服藥片在藥物治療中佔有重要地位。唯澳門地方狹小，市面上口服藥片往往只有一種劑量、而沒有其他劑量可供醫生對患者作出適當的劑量調整。故此，藥片分劈於澳門地區是一常見現象，藥劑師、藥劑技術員、護士均有為病人分劈藥片的經驗，而部份病人也會對藥片自行分劈。 據國外文獻顯示，大部分患者在分劈藥片時多會選擇刀或徒手進行，甚少選用切藥器 [1]；而在本地更有選用剪刀進行分劈。雖然分劈藥片的操作越趨普及，然而，這技術性操作在醫藥界普遍被認為有以下的優點及缺點 (表 1)。 作者單位: 澳門理工學院高等衛生學校; 地址: 中國澳門新口岸宋玉生廣場 335 號至 341 號獲多利中心 5 樓; Tel：(853)-8399 8632; E-mail: henrytong@ipm.edu.mo 表 1 藥片分劈的優缺點 優點 缺點 - 為患者提供市面上缺乏的劑量 [2] - 為患者提供最低但有效的起始劑量，以減低不良反應的風險 [2] - 在調整藥物劑量時具彈性 [3]- 降低藥物昂貴的成本 [4] - 改變藥片大小，便於吞服 [4]- 劑量不正確 [5] - 造成藥片損耗 [5] - 降低藥物成本具局限性 [5] - 具特殊劑型的藥片不適合分劈 [5] - 造成患者用藥混淆 [5] - 降低患者用藥依從性 [2] 本研究旨在對劑量不正確及造成藥片損耗此兩缺點作出探討，通過 6 名藥劑技術員用 4 種方法 (徒手、刀、剪刀及切藥器) 對 3 種於澳門常被分劈之藥片 (二甲雙胍 500mg 藥片、呋塞米 40mg 藥片及左旋甲狀腺素 100μg 藥片) 進行分劈 (藥片外型見圖 1- 3)，以比較不同方法對不同藥片藥物含量及片劑脆碎度的影響。另外，本研究通過邀請 16 名 65 歲或以上的長者，使其自選分劈藥片的方法進行分劈，以比較藥劑技術員及長者分劈藥片的差異。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 92 能通過含量均勻度檢查的所有樣本均能通過片劑脆碎度檢查，進行片劑脆碎度檢查前及檢查後所有樣本重量的損失均少於 2% (見表 4)， 被分劈的藥片並未太大地受到機械性的撞擊及摩擦而造成藥片破損或缺失，故此不需太擔心患者攜帶回家的過程中對藥片造成的影響。但若嚴格地根據《中國藥典 2005》對一整片非包衣藥片重量損失少於或等於 1%才能通過片劑脆碎度檢查的要求，則只有二甲雙胍藥片才能完全通過脆度測試。 在本次研究假設藥片的活性成分均勻分佈於藥片內的前提下，分劈藥片的操作在臨床上對藥片造成損失以致含量不準確，當中以切藥器造成的損失以致含量不準確的機率是最少的。最理想的當然是為藥物引入不同劑量以避免分劈藥片。但考慮到澳門實際的社會情況，並基於是次研究之發現，我們認為： 在藥房及有機會分劈藥片的場所 (如藥房、病房護士準備室) 須配備切藥器以協助患者分劈藥片； 如真的需要對藥片進行分劈，對一些體積較大、較硬、有明顯表面刻痕的藥片(如本研究所用之二甲雙胍藥片)，可教導患者正確使用切藥器自行分劈，因為這些藥片一般較容易利用切藥器處理；而且可為患者多調配數天的用量，避免患者因把藥片不慎壓碎或需重複分劈以得較準確劑量而欠缺足夠藥物； 如真的需要對藥片進行分劈，對一些體積較小、較脆的藥片(如本研究所用之呋塞米藥片)、及沒有明顯表面刻痕的藥片(如本研究所用之左旋甲狀腺素藥片)，建議由藥劑技術員利用切藥器代為進行分劈； 對於一些臨床上毒性較大、治療窗較狹窄、治療效果容易受劑量輕微變化而影響的藥片(如地高辛藥片)，一般並不建議把這一類藥片進行分劈； 敞若藥片在發給患者前已被分劈，應在藥物標籤上清楚列明並向患者詳細解釋，以免患者造成混淆。 結 論 藥片分劈減低藥片藥物含量的準確性，唯藥劑技術員利用切藥器把藥片分劈能把負面影響減到最少，增加藥房藥事照顧之品質。另外，根據片劑脆碎度檢查的結果，被分劈的三種藥片並未太大地受到機械性的撞擊及摩擦而造成藥片破損或缺失，故此不需太擔心患者攜帶回家的過程中對藥片造成的影響。 致謝 是項研究為澳門理工學院高等衛生學校診療技術學士學位課程之畢業論文，在此特感謝澳門理工學院對此畢業論文在經費上的贊助 (P084/ESS/2007)，及組員江曼莉、吳君潔、許健兒、劉凱欣、謝永傑的參與及支持。 參 考 文 獻 1 Polli JE, Kim S, Martin BR. Weight uniformity of split tablets required by a veterans affairs policy. J Manag Care Pharm, 2003, 9:401-407. 2 Marriott JL, Nation RL. Splitting tablets. Aust Prescr, 2002, 25:133-135. 3 Bachynsky J, Wiens C, Melnychuk K. The practice of splitting tablet - cost and therapeutic aspects. Pharmacoeconomics, 2002, 20:339-346. 4 Quinzler R, Haefeli WE. Tablet splitting. Ther Umsch, 2006, 63:441-447. 5 Quinzler R, Gasse C, Schneider A, et al. The frequency of inappropriate tablet splitting in primary care. Eur J Clin Pharmacol, 2006, 62:1065-1073.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 93 ‧論著和研究‧ DSA 介導經蝶齶窩上頜神經射頻 熱凝術臨床療效觀察 蔣勁 羅裕輝 鄭虎山 張強 肖禮祖 梁豪文 【摘要】 目的 觀察數字減影血管造影（DSA）介導下經蝶齶窩上頜神經射頻熱凝術治療三叉神經痛患者臨床療效。 方法 DSA 介導下定位蝶齶窩上頜神經，採用射頻毀損模式進行上頜神經熱凝毀損術，利用 VAS 評分法行術前，術後 1 天、1 周、2 周、1 月、3 月及 6 月疼痛評估，以患者滿意度及鎮痛藥物用量作為術後療效評定。 結果 DSA 介導下經蝶齶窩上頜神經射頻熱凝術治療三叉神經痛，術後 VAS 評分明顯下降，術前術後 VAS 評分比較有顯著性差異(P<0.05)，術後患者滿意度高。 結論 DSA 介導經蝶齶窩上頜神經射頻熱凝術治療三叉神經痛，安全可行，定位確切，操作簡單，風險小，臨床療效好，併發症極少。 【關鍵詞】 蝶颚窝; 上颌神经; 射频热凝; 临床疗效 Effect of Maxillary Nerve Radiofrequency Lesion Via Sphenopalatina Fossa Guided on DSA. JIANG Jin, LUO Yuhui, ZHENG Hushan, ZHANG Qiang, XIAO Lizu, LIANG Haowen. Department of Pain Medicine, the Sixth People’s Hospital in Shenzhen, 518052, Shenzhen, Gongdong, PR China; Tel: (+86-755) 2655 3111-31790 or (+86) 1392 2849 876; E-mail : jiang-122@yahoo.com.cn 【Abstract】 Objective Observe effect of patients with trigeminal neuralgia origining from maxillary nerve who accepted radiofrequency lesion via sphenopalatina fossa guided on digital subtractive angiography (DSA). Methods Set the position of maxillary nerve across sphenopalatina fossa via DSA perform maxillary nerve lesion employing radiofrequency gnenator with lesion mode. Adopt visual analogue scale (VAS) as pain assessment with the period of pre-procedure and post-procedure 1st day and 1st, second week and 1st , third, 6th month. Take the satisfaction degree and analgesic medicine used of patients’ as assessment of effect. Result VAS score of patients’ of post- procedure remarkable lower than pre-procedure, who suffered from trigeminal neuralgia origining from maxillary nerve accepting radiofrequency lesion via sphenopalatina fossa guided on DSA. There are significant difference on VAS compare with pre-procedure (P<0.05), and expressed excellent satisfaction degree. Conclusion It’s safe and effective treating for trigeminal neuralgia to apply radiofrequency lesion for maxillary nerve via sphenopalatina fossa guided on DSA, meanwhile, perform easier with accurate position fixing, less risk, more effect and seldom complication. 【Key words】 Sphenopalatina fossa; Maxillary nerve; Radiofrequency lesion ; Effect 前 言 三叉神經痛（II 支）、叢集性頭痛等與蝶齶神經節相關疾病患者常常併發其他神經、心血管疾病。由於半月神經節位於頭顱顱底，採用半月神經節射頻熱凝或化學毀損往往風險較大，如損傷顱底血管引起血腫，損傷三叉神經 I 支引起眼部併發症等。我院疼痛科自 2007 年 1 月份起採用 DSA 介導下經蝶齶窩，彎、頓針技術，上頜神經射頻熱凝治療該疾病，將原 作者單位：中國, 廣東省, 深圳市, 南山區, 桃園路 89 號, 第六人民醫院（南山醫院）, 疼痛科; Tel (+86-755) 2655 3111-31790 or (+86) 1392 2849 876; E-mail : jiang122@yahoo.com.cn 需顱內治療移至顱外，定位確切、操作簡單、風險小、治療效果好、副作用少，現報導如下： 資料與方法 1 一般資料 19 例病例中，男 7 例，女 12 例；平均年齡63±0.67 歲。其中 19 例診斷為三叉神經痛（II 支），2例合併叢集性頭痛。病程 5 月-8 年。19 例患者中 12例合併其他疾病，其中高血壓 7 例（既往腦出血 1例），慢性支氣管炎、肺心病 1 例，2 例為 80 歲以上高齡患者，併發其他疾病 3 例；另 7 例未發現併發疾病。疼痛程度視覺類比評分（VAS 評分）術前均達7-9 分。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 95 訪期間患者全部停止服用相關鎮痛藥物；患者滿意度表明為術後明顯增加，而術後一周內有所下降，此後隨訪時間滿意度隨著時間推移呈現上升趨勢。 表 術前及術後時患者 VAS 評分及滿意度 觀察專案 術前 術後隨訪 1 天 1 周 2 周 1 月 3 月 6 月 VAS 評分 8.2±1.0 3.2±0.9* 4.3±1.3* 2.6±0.7* 0.6±0.1* 0.3±0.1* 0.3±0.1* 滿意度(%) --- 76.85 57.42 78.95 89.47 94.74 94.74 ∗ 與治療前相比，P<0.05. 討 論 經蝶齶窩射頻熱凝術靶位相關解剖為三叉神經第II 支及蝶齶神經節（sphenopalatine ganglion）。三叉神經 II 支自半月神經節發出，穿圓孔出顱，進入蝶齶窩，分出眶下神經、顴神經、上牙槽神經、翼齶神經等支，支配眼裂和口裂間的皮膚、上頜牙齒以及鼻腔和口腔粘膜的感覺。蝶齶神經節呈三角形，直徑約5 mm，位於蝶齶窩內，在蝶齶孔的外側，翼管的前端。蝶齶神經節為副交感神經節，其感覺根部分來自上頜神經分支；副交感根部分來自面神經分支；交感根來自頸動脈叢和岩深神經。節後神經分支分佈於眼眶、鼻、咽和上齶等頭面部區域。射頻熱凝蝶齶神經節可用於各種面部疼痛，尤其是非典型面部疼痛綜合徵；也可用於治療非典型三叉神經痛或三叉神經第二支疼痛；以及一些頭痛，如偏頭痛、叢集性頭痛和其他疼痛綜合徵。 原發性三叉神經痛發病機理不明，目前大多認為是三叉神經被微血管壓迫所致，但是常常找不著微血管壓迫的客觀依據。各種微血管減壓的手術均有一定的療效，甚至對無明顯微血管壓迫證據患者[1]。疼痛性質為閃電樣或針刺樣，以第 2 支支配區多發，也常見第 3 支支配區同時發病。根據三叉神經解剖，臨床上微創治療常經卵圓孔穿刺入顱行半月神經節的物理或化學毀損。有學者經大量已發表文獻比較，認為射頻熱凝術創傷小，副作用少，在所有治療手段中仍是最具價值的[2]。但是，半月神經節位於顱內顳骨岩部三叉神經節壓跡處，這不僅給經卵圓孔行半月神經節操作帶來了一定的困難，而且可因為顱內操作帶來許多嚴重的併發症，甚至發生術中術後險情！具體的併發症包括：(1) 顱內出血；(2) 顱內感染；(3) 對動眼神經、滑車神經、聽神經、面神經等周圍結構的副損傷，Harrigan MR 等報導過一例外展神經損傷併發症[3]；(4) 術中術後的腦膜刺激症狀，可表現為頭痛、頭暈、噁心、嘔吐、心率增快等[4]；(5) 三叉神經第1 支毀損引起的同側眼併發症，嚴重者可致失明，故對三叉神經第 1 支非可複性治療應慎之又慎；(6) 毀損同側面部及粘膜感覺異常、運動障礙等，這是比較常見的併發症[4]。原發性三叉神經痛的微創治療常須測試，以精確定位和毀損三叉神經分支。許多老年原發性三叉神經痛常常併發其他疾病，測試所帶來的疼痛刺激往往給治療帶來更大的風險，尤其對於合併心、腦血管疾病的患者。本應用研究主要針對三叉神經第 II 支痛，將射頻熱凝靶點由顱內操作轉向顱外，由節轉向幹，減小了測試刺激，減少對周圍組織、顱神經及三叉神經其他支的副損傷，更減少了由顱內操作帶來的風險和併發症，對於合併心、腦血管疾病的患者，減少了術中術後誘發意外的風險。對於上頜神經痛或並叢集性頭痛[5]，採用經蝶齶窩上頜神經射頻熱凝術毀損，取得了良好的療效。而術後一周內出現 VSA 評分上升及滿意度下降表明患者經熱凝毀損術後，可能存在神經根水腫現象。 參 考 文 獻 1 Baechli H, Gratzl O. Microvascular decompression in trigeminal neuralgia with no vascular compression.Eur Surg Res, 2007, 39:51-57. 2 Gorgulho AA, De Salles AA. Impact of radiosurgery on the surgical treatment of trigeminal neuralgia. Surg Neurol, 2006, 66:350-356. 3 Harrigan MR, Chandler WF. Abducens nerve palsy after radio-frequency rhizolysis for trigeminal neuralgia:case report. Neurosurgery. 1998, 43:623 -625. 4 趙松雲, 傅志儉, 馬玲, 等.半月神經節毀損治療中的不良反應及併發症分析.中國疼痛醫學雜誌, 2001, 7:48-49. 5 Felisati G, Arnone F, Lozza P, et al. Sphenopalatine endoscopic ganglion block: a revision of a traditional technique for cluster headache. Laryngo- scope, 2006, 116:1447-1450.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 96‧論著和研究‧ 改良消痔靈液“二步注射法”注射治療內痔（附 1864 例報告） 刘全芳 【摘要】 目的 評價通過改良消痔靈配方和改進注射技術後，注射治療內痔的效果。方法 採用改良消痔靈液的“二步注射法”單次大劑量注射治療內痔 1864 例，其中Ⅰ度 270 例，Ⅱ度 1073例，Ⅲ度 521 例。結果 368 例平均隨訪 18 個月，對出血和脫垂的有效率分別爲 92.1%和 57.6%，治療滿意率爲 82.6%，術後並發肛門輕度狹窄 2 例，無其它並發症發生。結論 採用改良消痔靈液的“二步注射法”單次大劑量注射治療內痔安全有效。 【關鍵詞】 內痔; 注射治療; 消痔靈; 改良; 二步注射法 The Injection Sclerotherapy of Modified “Xiaozhiling” liquid through Two-step Procedure for Internal Hemorrhoids: Report of 1864 cases. LIU Quanfang. Department of General Surgery, Guangdong General Hospital, Guangzhou 510080, China; Tel: (+86)-13802541732; E-mail: doc.liuquanfang@163.com 【Abstract】 Objective To assess the efficacy of the modified “xiaozhiling” liquid injection sclerotherapy for internal hemorrhoids through the improvement of both its recipe and injection technique. Methods 1864 patients with internal hemorrhoids were treated with large-dose single-session of modified “xiaozhiling” liquid injection sclerotherapy through “two-step procedure”, including first-degree 270 cases, second-degree 1073 cases and third-degree 521 cases. Results 368 cases were followed up for 18 months, the effective rates for bleeding and prolypse were 92.1% and 57.6%, satisfying rate after injection was as high as 82.6%,slight anal stenosis consequently occurred in only 2 cases, but no other complications happened. Conclusion large-dose single-session of modified “xiaozhiling” liquid injection sclerotherapy through “two-step procedure” is a safe and effective method for internal hemorrhoids. 【Key words】Internal hemorrhoids; Injection; sclerotherapy; “Xiaozhiling” liquid; Modification; Two-step procedure 自 1869 年 Morgan 採用過硫酸亞鐵注射治療內痔以來，內痔注射療法以其安全、有效、簡便的特點得到廣泛應用[1,2]。我院自 1993～2002 年採用改良消痔靈注射治療內痔 1864 例，療效滿意，現報告如下。 資料與方法 1 一般資料 男 1003 例，女 861 例。年齡 17～81 歲，平均 41 歲。診斷採用 2000 年 4 月成都會議制訂的“痔診治暫行標準”，其中Ⅰ度 270 例，Ⅱ度 1073 例，Ⅲ度 521 例。病程 5 個月至 47 年，平均37 個月。 2 操作方法 患者術前排淨大便，不必禁食。取膝胸臥位，將塗有液體石蠟油的肛門鏡輕輕納入肛內，在燈光照明下觀察內痔的數目和位置。以碘伏棉球消毒肛管和粘膜，以 20ml 注射器抽吸配製改良消 作者單位: 510080 中國, 廣東, 廣州市中山二路 106 號, 廣東省人民醫院, 普通外科; Tel: (+86)-13802541732; E-mail: doc.liuquanfang@163.com 痔靈注射液{消痔靈（北京中國中醫研究院廣安門醫院研製）：1%美藍：0.75%布比卡因爲 8：1：1}共20ml，混勻後並換上長度僅爲 1.5 ㎝皮試針針頭備用。在肛門鏡協助下，採用“二步注射法”注藥：第1 步將皮試針在三處母痔上極刺入粘膜達粘膜下深層後，擺動針尖活動無障礙，各注藥 2ml，三處共注藥6ml；第 2 步將皮試針刺入三處母痔的痔塊中心根部粘膜下深層，擺動針尖活動無障礙，抽吸無回血後，採取邊注射邊退針，可清楚看到注入含美藍的改良消痔靈液後粘膜下痔塊被充盈成藍色泡狀，可根據其充盈的程度和範圍控制注藥量，一般每處注藥 3～5ml即可；因此，一般完成二步注射，共需注藥 15～20 ml。注射完畢，拔針後觀察針眼有無出血，若有出血可用無菌棉簽壓迫片刻，多能止血，即可讓患者回家。 3 術後處理 內痔注射後囑患者當日臥床休息，第 2 天恢復正常活動。由於術前已排空大便，建議患者術後 24hr 再排便。對於便秘患者，可適當使用通便藥物幫助排便。排便時應避免用力，若有內痔脫出，可用手輕輕送回。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 98‧論著和研究‧ 腸結核8例臨床分析 胡茵穎 余漢濠 【摘要】 目的 通過分析腸結核的發病特點及診斷方法，提高對腸結核的診斷能力。 方法 回顧性分析我院2006年～2009年確診的8例腸結核患者的臨床資料。探討以臨床，腸鏡，病理檢查及治療為主，本次8例患者中男性4例，女性4例，年齡22～54歲，平均年齡41.4歲。病程7天～2年。常見症狀為腹痛(4例，50.0％)、血便(4例，50.0％)、便秘，腹瀉各1例。患者均給予消化道內鏡及病理檢查，病變常見部位為回腸末端，回盲部或升結腸。 結論 腸結核臨床表現不典型，腸鏡檢查結合活組織病理檢查為首選檢查手段，必要時可行診斷性治療。 【關鍵詞】 腸結核; 內鏡; 診斷 8 Clinical Analysis of Intestinal Tuberculosis WU Ian Weng, YU Hon Ho. Department of Internal Medicine, Kiang Wu Hospital, Macao SAR, China; Tel: (+853)-2837 1333; E-mail: reginaho2003@hotmail.com 【 Abstract 】 Objective By analyzing the characteristics and diagnostic method of intestinal tuberculosis to improve the diagnostic ability the disease. Methods Retrospective analysis the clinical data of 8 cases that confirmed intestinal tuberculosis in our hospital from 2006 to 2009. We mainly discuss The clinical manifestation, colonoscopy , histologic examination and treatment. There are 4 males and 4 females in our group, aged from 22 to 54 years old, mean age 41.4 years old. The course of disease is 7 days to 2 years. Common symptoms were abdominal pain (4 cases, 50.0%) , melena (4 cases, 50.0%) , constipation (1 case) and diarrhoea(1 case). Patients were given colonscopy and biopsy. The lesions mostly appear in terminal ileum, ileocecal junction and ascending colon. Conclusion The presenting symptoms of intestinal tuberculosis are nonspecific, therefore, colonoscopy combined with biopsy pathology is the first choice of examination methods, if necessary, the diagnostic treatment is a choice. 【Key words】 Intestinal tuberculosis; Endoscopy; Diagnosis 近年腸結核發病率呈上升趨勢。由於腸結核的臨床症狀、體征無特異性及臨床輔助檢查不典型，例如部分患者全身情況較好，無結核中毒症狀，無伴發腸外結核病，其診斷仍較困難。收集我院 8 例確診腸結核患者的臨床資料，分析其發病特點，以加深對該病的認識並提高診斷的準確率。 臨床資料 1 一般資料 我院2006年8月～2009年2月確診的腸結核患者8例，男性4例，女性4例，年齡22—54歲，平均年齡41.4歲。病程7天～2年。全部為消化內科的病人。腸 作者單位 : 中國 , 澳门特別行政區 , 鏡湖醫院內科 ; Tel: (+853)-2837 1333; E-mail: reginaho2003@hotmail.com 結核的診斷至少需具備以下條件之一(1)腸壁或腸系膜淋巴結找到乾酪樣壞死性肉芽腫；(2)病變組織病理檢查找到結核桿菌；(3)病變處取材培養結核桿菌陽性；(4)患者有典型腸結核表現，腸外找到結核灶和抗癆試驗治療6周病情有改善，可做出臨床診斷。記錄患者的臨床表現、輔助檢查(如腸鏡、組織病理學、組織結核培養等)及診斷情況。 2 臨床表現 8例患者的主要臨床症狀包括腹痛，血便，腹脹，腹瀉，便秘，肛門疼痛。 3 消化道內鏡檢查 8例內鏡檢查中可見，病變累及回腸末段4例，回盲部1例，升結腸及回盲部1例，回腸末腸及升結腸1例，回腸1例，橫結腸(右半為著)1例。內鏡下表現為：節段性病變伴肉芽腫形成1例，潰瘍形成4例，其
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 100在常規病檢的同時行抗酸染色和分枝桿菌培養[7]，一般認為病理中抗酸桿菌陽性率約50-100%[8]。其他如結合聚合酶鏈反應(TB-DNA PCR)提高診斷腸結核的特異性及準確率[9]，雖然檢測有假陽性及假陰性的局限，但若能嚴格避免污染，在努力提高引物的特異性腸結核診斷中有重要價值。 YS Park[8]等曾對18例回盲部潰瘍患者於腸鏡檢查後，應用短期抗結核治療(異煙肼、利福平、吡嗪酰胺及乙胺丁醇)這種診斷性治療持續2-3個月，後覆查結腸鏡,根據潰瘍恢復程度分為2組，一為疑似腸結核組(共9例,腸潰瘍有不同程度的好轉)，一為疑似炎症性腸病組(共9例,腸潰瘍無明顯轉)，前者按腸結核作抗結核治療多10個月，再覆查腸鏡，全部緩解，後者9例中8例停用結核治療，改用美沙拉嗪等治療,約6-10個月後覆查均臨床緩解，可見這種治療中腸鏡評估方法(或診斷性治療)對不能確定病因的回盲腸潰瘍的診斷相當有用，值得參考。 由上可知，腸結核臨床表現並不典型，加上腸結核與克羅恩病鑒別困難，故給臨床醫師很大挑戰。臨床醫師在全面分析病史的基礎上，尤其結合結腸鏡及活檢，明顯有助於作出腸結核的臨床診斷[10]。部分長期診斷困難、臨床排除腫瘤、高度懷疑腸結核但未找到結核證據者，可積極進行診斷性治療，應用治療中腸鏡評估方法，更有效地幫助臨床診斷。對於提高當前腸結核的診斷率，不失為一個有效的方法之一。 參 考 文 獻 1 Chong V H, Lim K S. Gastrointestinal tuberculosis. Singapore Med J ,2009, 50 : 643. 2 Misra SP，Misra V, Dwivedi M. Ileoscopy in patients with ileocolonic tuberculosis．World J Gastroenterol，2007，13：1723—1727. 3 Constantions C, Ioannia EK，Maria T, et al, Colonic tuberculosis mimicking Crohn’s disease：case report . BMC Gastroenterol，2002，13(1)：10． 4 周中銀，羅和生，丁一娟．克羅思病與腸結核鑒別診斷方法的評價 . 中國實用內科雜誌，2005，25(3)：247-248 5 楊雲生，程留芳，孫剛等．Crohn’s 病與腸結核病鑒別診斷的臨床對比分析．解放軍醫學雜誌，2002，27(8)：693-695 6 應雷, 歐陽欽，周曾芬等．克羅恩病和腸結核的組織病理學研究．臨床內科雜誌，2002，19(2)：109-110． 7 曾銳，歐陽欽，胡錦梁．腸結核和克羅恩病臨床病理改變的比較．現代預防醫學，2006，33：2287-2294． 8 YS Park , WJ Dae, HK Seong, et al. World J Gastroenterol, 2008 , 14(32): 5051-5058. 9 Ramadass Balamurugan，Subramanian Venkataraman，KR John et al ． PCR Amplification of the IS6110 Insertion Element of Mycobacterium tuberculosis in Fecal Samples from Patients with Intestinal Tuberculosis．J Clin Microbiol，2006，44：1884-1886. 10 余賢恩．腸結核76例臨床分析．中華全科醫師雜誌，2005，4：22
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 101‧綜述和講座‧ 不明原因慢性咳嗽的病因診斷和治療原則 梁劍輝 鄭嘉寧 【摘要】不明原因慢性咳嗽是指以咳嗽為惟一症狀或主要症狀、時間超過８周、胸部Ｘ線檢查無明顯異常的咳嗽。臨床上不常見，並常常因為忽略氣道以外的器官所引起的咳嗽，容易誤診。不明原因慢性咳嗽的常見原因包括上氣道咳嗽綜合征(UACS)、咳嗽變異型哮喘（CVA）、胃食管反流性咳嗽（GERC）和嗜酸粒細胞性支氣管炎（EB）。其它病因較少見，但涉及面廣。慢性咳嗽的診斷首先需要詳細的病史詢問和細致的檢查。相關的檢查包括誘導痰檢查、影像學檢查、肺功能檢查、纖維支氣管鏡檢查、24小時食管pH值監測、咳嗽敏感性檢查, 以及其他檢查如外周血嗜酸粒細胞計數、變應原皮試（SPT）和血清特異性IgE測定。只有找出病因，並針對病因治療，咳嗽才能得到根除。 【關鍵詞】慢性咳嗽; 病因診斷; 治療 The Etiology, Diagnosis and Treatment of Chronic Cough LIANG Jian Hui, CHEANG Ka Neng. CTB, SS, Macao, China; Tel: (+853)-28532196, E-mail: drbombileung@tom.com 【Abstract】 Chronic cough, defined as a cough of more than 8 weeks duration, usually with unremarkable finding in chest X-ray examination. Chronic cough is rare and misdiagnosis is common, particularly because of the failure to recognize that cough is often provoked from sites outside the airway. The key to successful management is to establish a diagnosis and to treat the cause of cough. The common causes of chronic cough include upper airway cough syndrome (UACS), cough variant asthma (CVA), gastroesophageal reflux induced cough (GERC) and eosinophilic bronchitis (EB). Clinical history and examination are essential for a patient with chronic cough. Examination for chronic cough include sputum analysis, radiography, spirometry, fibreoptic bronchoscopy , 24-h oesophageal pH monitoring, cough challenges, and other examination such as measurement of the number of eosinophils in peripheral blood, serum specific IgE and skin prick test. 【Key words】Chronic cough; Etiology; Diagnosis; Treatment 序 言 臨床上的長期咳嗽通常以 COPD 多見，除咳嗽症狀外，常伴有活動後氣促和胸部 X 光片的異常表現，臨床上易於診斷。然而，有一些長期咳嗽的患者，應用抗生素、止咳化痰藥物、茶鹼等藥物治療，效果不好，成為“不明原因” 的慢性咳嗽病人。 目前，無論歐美指南還是中國國內的指南，臨床上通常都將以咳嗽為惟一症狀或主要症狀、時間超過8 周、胸部Ｘ線檢查無明顯異常者稱為不明原因慢性咳嗽[1-3]。本文結合國內外慢性咳嗽的最新診治進展, 歸納不明原因的慢性咳嗽（以下簡稱慢性咳嗽）的常見病因和治療原則，希望能對醫生的臨床思維有所啟發。 作者單位：中國, 澳門特別行政區, 衛生局結核病防治中心; Tel: (+853)-2853 2196, E-mail: drbombileung@tom.com 慢性咳嗽的病因研究進展 1981年，Irwin等首先提出了慢性咳嗽的病因診斷程式，1990年對此方案進行了修正，增加24小時食管PH值測定項目。根據此診斷程式，慢性咳嗽的常見病因為鼻後滴流綜合征(PNDS)、咳嗽變異型哮喘(CVA)和胃食管反流(GER) [4] 。但Irwin病因診斷程式不包含誘導痰檢查, 必然導致EB患者的漏診或誤診, 而近年來國內、外研究表明，嗜酸粒細胞性支氣管炎(EB)亦是慢性咳嗽的重要原因[5]。中國的《咳嗽的診斷與治療指南》將誘導痰檢查納入慢性咳嗽病因診斷程式的常規檢查，使EB患者能夠得到及時準確的診斷。此外，支氣管內膜結核在西方國家非常罕見，但在中國並不少見，臨床上常表現為慢性咳嗽。歐美的咳嗽指南中均沒有涉及支氣管內膜結核，考慮到中國的實際情況，指南明確將支氣管內膜結核列入慢性咳嗽的病因。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 104變的範圍，支氣管狹窄閉塞的程度，而且對支氣管管壁增厚、毛糙及扭曲、變形的程度也有直觀的瞭解。 氣管-支氣管結核治療原則： 治療與肺結核相同，絕大部分患者在化療3~6個月病情好轉，療程以1~1.5年為宜。如檢查發現有支氣管狹窄，可行球囊擴張術治療。預後的關鍵在於早期診斷、及時治療，才能避免嚴重支氣管狹窄和阻塞導致的不良後果。 7 感染後咳嗽(postinfectious cough) 既往稱為感冒後咳嗽。表現為感冒本身急性期症狀消失後，咳嗽仍然遷延不愈。除了呼吸道病毒外，其他呼吸道感染亦可能導致此類遷延不愈的咳嗽。患者多表現為刺激性乾咳或咳少量白色黏液痰，多數持續3~8周，但也有超過8周而成為慢性咳嗽。X線胸片檢查無異常。感冒後咳嗽常為自限性，通常能自行緩解。抗菌藥物治療無效。 感染後咳嗽治療原則： 對一些慢性遷延性咳嗽可以短期應用抗組胺H2受體拮抗劑及中樞性鎮咳藥等。對少數頑固性重症感冒後咳嗽患者，在一般治療無效的情況下可短期試用吸入或者口服糖皮質激素治療。 8 變應性咳嗽(atopic cough, AC) 臨床上某些慢性咳嗽患者，具有一些特應症的因素，抗組胺藥物及糖皮質激素治療有效，但不能診斷為咳嗽變異性哮喘、變應性鼻炎或 EB，將此類咳嗽定義為 AC。臨床表現為刺激性乾咳，多為陣發性，白天或夜間咳嗽，油煙、灰塵、冷空氣、講話等容易誘發咳嗽，常伴有咽喉發癢。通氣功能正常，誘導痰細胞學檢查嗜酸粒細胞比例不高。 AC 診斷標準： 目前尚無公認的標準，可參考以下標準： (1)慢性咳嗽； (2)肺通氣功能正常，氣道高反應性檢測陰性； (3)具有下列指征之一：A 過敏物質接觸史；B變應原皮試(SPT)陽性；C 血清總 IgE 或特異性 IgE增高；D 咳嗽敏感性增高； (4)排除 CVA、EB、PNDS 等其他原因引起的慢性咳嗽； ( 5)抗組胺藥物和( 或)糖皮質激素治療有效。 AC 治療原則： 對抗組胺藥物治療有一定效果，必要時加用吸入或短期口服糖皮質激素 3~7 天。 9 支氣管肺癌(bronchogenic carcinoma) 中央型支氣管肺癌初期症狀輕微且不典型，早期普通X線檢查常無異常，容易被漏診、誤診。咳嗽常為中央型肺癌的早期症狀，因此應詳細詢問病史，對有長期吸煙史，出現刺激性乾咳，按“氣管炎”治療效果不好的病人，特別是痰中帶血、胸痛、消瘦等症狀或原有咳嗽性質發生改變的患者，應高度懷疑中央型肺癌的可能，進一步進行影像學檢查和支氣管鏡檢查。 10 心理性咳嗽(psychogenic cough) 心理性咳嗽也是慢性咳嗽病因之一[10]，是由於患者嚴重心理問題或有意清喉引起，又稱為習慣性咳嗽、心因性咳嗽。小兒相對常見，典型表現為日間咳嗽，專注於某一事物及夜間休息時咳嗽消失，常伴隨焦慮症狀。心理性咳嗽的診斷系排他性診斷，只有其它可能的診斷排除後才能考慮心理性咳嗽。兒童心理性咳嗽的主要治療方法是暗示療法，可以短期應用止咳藥物輔助治療。對年齡大的患者可輔以心理諮詢或精神幹預治療，適當應用抗焦慮藥物。 11 其他病因 臨床上可引起慢性咳嗽的少見病因還包括頸椎病、耳部迷走神經刺激、肺間質纖維化、支氣管異物、支氣管微結石症、骨化性支氣管病、縱隔腫瘤及左心功能不全等。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 105總之，對於慢性咳嗽為主訴的病人，必須仔細地詢問病史，並全面系統的檢查。除考慮胸肺部疾病外，還需考慮其它器官所致的慢性咳嗽，特別是咳嗽變異性哮喘，胃食管反流咳嗽以及鼻、咽部疾病分泌物下流刺激咽喉部所致的咳嗽，只有找出病因，並針對病因治療，咳嗽才能得到根除。慢性咳嗽的臨床鑒別診斷可參考病因診斷程式圖1。 參 考 文 獻 1 AH Morice and committee members. The diagnosis and management of chronic cough. Eur Respir J, 2004, 24(3):481-492. 2 Richard S Irwin, Michael H. Diagnosis and management of cough executive summary ACCP evidence-based clinical practice guidelines. chest, 2006, 129(1):1-23. 3 中華醫學會呼吸病學分會哮喘學組. 咳嗽的診斷與治 療指南. 中華結核和呼吸雜誌, 2009, 32(6): 407-413. 4 Irwin RS, Curley F J, French C L. Chronic cough, the spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy. Am Rev Respir Dis, 1990, 141(3):640-647. 5 楊忠民，邱忠民，呂寒靜，等. 慢性咳嗽病因的前瞻性研究. 同濟大學學報(醫學版), 2005, 26(1): 62-64. 6 Poe RH, Kallay MC. Chronic cough and gastroesophageal reflux disease: experience with specific therapy for diagnosis and treatment. Chest, 2003, 123(3):679-684. 7 祝筱姬，楊華，張克利, 等. 門診慢性咳嗽病因及治療分析. 中國當代醫藥, 2009,16(10): 17-18. 8 Kim SH, Oh SY, Oh HB, et al. Association of beta2-adrenoreceptor polymorphisms with nocturnal cough among atopic subjects but not with atopy and nonspecific bronchial hyperresponsiveness. J Allergy Clin Immunol, 2002, 109(4):630-635. 9 崔海燕, 沙巍. 支氣管結核136例臨床分析. 同濟大學學報( 醫學版), 2009, 30(5): 115-118. 10 Irwin RS, Glomb WB, Chang AB. Habit cough, tic cough, and psychogenic cough in adult and pediatric populations: ACCP evidence-based clinical practice guidelines. Chest, 2006, 129(1 Suppl):174-179.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 106‧綜述和講座‧ 建立澳門兒童和青少年屈光發育檔案的設想 陸美嬋 【摘要】本文探討建立兒童與青少年的屈光發育檔案的原理、意義和方法，提出在澳門建立兒童和青少年屈光發育檔案的建議，旨在減低澳門兒童和青少年的近視患病率，改善兒童和青少年的視覺健康。 【關鍵詞】兒童; 青少年; 近視; 屈光發育; 檔案 The Idea of Construct of Archives of Refraction Development for Children& Adolescent in Macao LOK Mei-sim The ophthalmological Department, Centro Hospitalar Conde de São Januário (CHCSJ); Tel:(+853)-8390 8833;E-mail.moksky@hotmail.com 【Abstract】This article discuss the principle, the significance and the methods of construct of archives of refraction development for children & Adolescent. It is recommended that it is necessary to construct archives of refraction development for children & Adolescent in Macao. It will be benefit to Children & Adolescent vision healthy. 【Key words】Children; Adolescent; Myopia ; Refraction development; Archives 人類獲得的 80%以上的外界資訊來自於眼，但屈光不正對眼獲得清晰自由的視力產生影響。近視眼目前已是最常見的屈光不正，在人群中尤其是兒童和青少年中的發病率有逐漸增高的趨勢。病理性近視眼（通常超過-8D）可有核性白內障、黃斑變性/出血、視網膜脫離、後極部葡萄腫等併發症，更危害視覺健康。 近視眼的防治因此已是全球公共衛生領域的關注點之一，探討其機制是重要的一環。近視是屈光異常，屈光發育依賴視覺，視覺包括光覺、形覺和色覺三部分。形覺剝奪性近視可認為是影響了光覺，光學離焦性近視可認為是干擾了形覺，色覺是視覺體驗重要的組成部分，在辨別和感知物體特性中有極其重要的作用，它也可能在近視眼發病機制中起一定作用。實驗性近視眼包括形覺剝奪性近視和光學離焦性近視模型雖然有助於解釋近視眼形成的機制，但仍沒有探究到其核心機制，尚不能很好地指導近視眼的臨床防治。 中國是個近視大國，群體患病率大約為 33%，近視人數世界第一。城市化與現代生活方式的變化，讓學齡兒童的近視更加增多，近視可以導致兒童遠距 作者單位: 中國, 澳門特別行政區, 仁伯爵綜合醫院眼科; Tel:(+853)-8390 8833; E-mail.moksky@hotmail.com 離視物不清、室外活動的不便性增高等，顯然對兒童的學習和健康有較大的影響。在大陸的一項學生體質與健康調研結果曾顯示，大都市的學生視力不良檢出率為小學生 40％以上、初中生 70％以上。在澳門本埠，兒童和青少年近視同樣受到社會的重視，眼科醫生也特別關注近視。 筆者曾在上海復旦大學附屬眼耳鼻喉科醫院眼科（衛生部近視眼重點實驗室依託單位）學習，結合當前澳門的兒童和青少年近視現狀，建議借鑒大陸這些年來的近視眼防治措施，在澳門也建立兒童與青少年的屈光發育檔案。 建立兒童和青少年屈光發育檔案的原理 根據 Gullstrand 模型眼，人眼的屈光成分分解為43 項屈光參數，其中起重要作用的 5 種屈光參數是角膜屈光力、前房深度、晶狀體厚度、眼軸長度以及屈光間質的屈光指數。從出生時到兒童期，再到青少年期，人眼球在生長發育過程中，屈光狀態由遠視逐漸向正視發展，眼屈光系統的各組元件均在正常範圍且互相配適，才能達到正視。人不同年齡時的屈光參數的生理值是研究屈光問題的基礎，比如過度眼軸延長可成為近視。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 108驗光儀上，由同一檢查者操作，每眼檢查 3 次，取平均值記錄。 四. 資料的保管與問卷調查：編制結構性定量調查問卷，包括家長問卷，兒童和青少年個人問卷。內容如年齡、性別、眼科病史、戴鏡情況、用眼衛生習慣、用眼時間和生活作息、護眼知識、視力不良家族史、家庭閱讀照明環境、父母的護眼知識、父母對於子女學習壓力的感知程度、每日體育活動及課外活動時間、每日學校內眼保健操、學校內護眼宣教等。動態資料基礎上開展對近視的防治會更有成效。 近視眼的防治被列為視覺 2020 行動的重要內容，由 WHO 發起的“視覺 2020,享有看見的權利”行動，是一項全球性的工作。建立屈光發育檔案是防治近視的基礎性工作，對於澳門兒童和青少年也將是一個長遠的基礎性護眼工作。 參 考 文 獻 1 Isenberg SJ, Del Signore M, Chen A, et al. Corneal Topography of Neonates and Infants[J].Arch Ophthalmol, 2004,122(12):1767-1771 2 Kinge B, Midelfart A, Jacobosen G, et al. Biometric changes in the eyes of Norweigian university of students a three-year longitudinal study[J]. Acta Ophthalmol Scand, 1999,77(6):648-652. 3 Davis WR, Raasch TW, Mitchell GL, et al. Corneal asphericity and apical curvature in children: a cross-sectional and longitudinal evaluation[J]. Invest Ophthalmol Vis Sci, 2005,46(6):1899-1906. 4 Zadnik K, Mutti DO,Mitchell GL, et al. Normal eye growth in emmetropic school children[J]. Optom Vis Sci,2004,81(11):819-828. 5 Zadnik K, Manny RE, Yu JA, et al. Ocular component data in school children as s function of age and gender [J]. Optom Vis Sci, 2003, 80(3):226-236. 6 Garner LF, Stewart AW, Owens H, et al. The Nepal Longitudinal Study: biometric characteristics of developing eyes[J], Optom Vis Sci, 2006, 83(5):274-280. 7 Seang-Mei Saw, Wei-Han Chua, Ching-Ye Hong, et al. Height and Its Relationship to Refraction and Biometry Parameters in Singpore Chinese Children[J]. Invest Ophthalmol Vis Sci, 2002,43(5):1408-1413. 8 SM Saw, L Tong, KS Chia, et al. The relationship between birth size and the results of refractive error and biometry measurements in children[J]. Br J Ophthalmol, 2004, 88:538-542. 9 Elvis Ojaimi, Ian G. Morgan, Dana Robaei, et al. Effect of Stature and Other Anthroponetric Parameters on Eye Size and Refraction in a Population-Based Study of Australian Children[J]. Invest Ophthalmol Vis Sci, 2005,46(12):4424-4429.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 109‧病例報告‧ 心尖部球形綜合征二例並文獻複習 金椿 龍鳳軍 劉紅 鍾桃娟 【摘要】 本文報導二例心尖部球樣綜合征，本綜合征臨床表現酷似急性心肌梗死，胸痛伴心電圖 ST 段抬高、心肌酶輕度升高，而冠脈造影無明顯狹窄，左心室造影特徵性的表現為心尖部收縮期呈球形改變。病因多與情緒劇烈波動、應激有關，可發生心力衰竭及心律失常，大多數病人一個月左右恢復正常，預後較好。 【關鍵詞】心尖部球形綜合征; Tako-tsubo 綜合征; 急性心肌梗死 Apical Ballooning Syndrome Case Report and a Systematic Review JIN Chun, LONG Forg-Kuan, LIU Hong, CHONG Tou-Kun. Department of Cardiology; Kiang Wu Hospital, Macao SAR.PR China;Tel: (+853)6612 2036; E-mail: jinchun49@hotmail.com 【 Abstract 】 Apical ballooning syndrome (also named Tako-tsubo syndrome, or stress induced cardiomyopathy) is an increasingly recognized clinical syndrome. The clinical characteristics of this syndrome have been described as follows: acute onset of chest pain with reversible LV apical wall motion abnormalities (ballooning), ECG changes (ST-elevation), minimal myocardial enzyme release, and no significant stenosis of the coronary artery on angiography. The clinical manifestations can mimic an acute coronary syndrome.The common etiologic feature of this syndrome is usually after a sudden emotional or physical stress. We report the two cases of a 70-year-old female and 37-year-old male, who arrived to the emergency department with chest pain for 1 to 3 hours,ECG showed ST-segment elevation in V1—V5and cardiac markers ( CK, CK-MB , TNT )were elevated , echocardiographic features of hypokinasis at left ventricular apical with lower ejection fraction (E40%), Coronary angiography showed coronary arteries without remakble stenosis lesions; left ventriculography showed apical ballooning changes. The follow-up performed with echocardiography (1 month later) showed complete recovery wall motion with EF 60%. 【Key words】 Apical ballooning syndrome; Tako-tsubo syndrome; Acute myocardial infarction 心尖部球形綜合征(Apical ballooning syndrome) 近年來日益受到重視，2006年美國心臟學會(AHA) 將其列為“獲得性原發性心肌病”的一種[1]，其臨床表現與急性心肌梗死(AMI)極為相似，但冠脈造影正常，如不做左心室造影則常被誤診為冠脈痙攣或冠脈內血栓自發溶解導致的急性冠脈事件，或誤診為急性心肌炎而得不到恰當的治療。本文報導二例並作文獻複習。 例 1，女性，70歲，因胸痛一小時急診入院，ECG: V1—V5ST段升高 (圖1)，CK155u/L, CK-MB 29.9u/L ( 正 常 ＜ 25u/L),TNT 0.458ng/ML ( 正 常 ＜0.1ng/ML)，初診為AMI，冠脈造影正常無明顯狹 作者單位 : 中國 , 澳門特別行政區 , 鏡湖醫院 , 心內科 ; Tel：(+853)-6612 2036; E-mail: jinchun49@hotmail. com 窄，左心室造影見心尖部呈球形改變(圖2)，心臟超聲見心尖部收縮消失呈球形擴張，間隔部收縮加強(圖3)。患者平時健康無特殊病史。發病前二天因丈夫病逝，心情悲痛及過度勞累。 例 2，男性，37歲，因胸痛三小時急診入院，ECG: V1—V6ST 段 升 高 ， CK-MB 45.6u/L ,TNT 0.59ng/ML，初診為AMI，冠脈造影正常，左心室造影見心尖部呈球形改變(圖4)，心臟超聲見心尖部收縮消失呈球形擴張。患者有高血壓病史，長期服藥血壓控制滿意。發病前因籌備會務工作繁忙，心理壓力大。 以上二例均經對症處理及β阻滯劑及ISOKET，ACEI及CCB類藥物治療症狀好轉出院，末發生心力衰竭及心律失常。ECG的ST段由抬高演變為T波倒置(圖5) 六周後恢復正常。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 111 不同有關。女性患病率高主要受雌激素影響，雌激素可調控心肌對兒茶酚胺的反應，女性絕經後雌激素水準下降有可能促使女性更容易生心尖部球形綜合征。有人認為還有其他可能原因如：冠脈多血管痙攣、心肌脂肪酸代謝障礙、以及病毒感染等，需要更多的研究加以証實。 眾多文獻顯示[4]，心尖部球形綜合征的主要臨床表現特徵為: 應激誘發的劇烈胸痛(67.8%)、氣促(17. 8%)、酷似AMI的ECG改變：ST段抬高(81. 6%)、T波異常(64. 3%)、心肌酶輕度升高(86. 2%)、Q波異常(31. 8%)、冠脈造影正常或無明顯狹窄、可復性心尖部球形擴張伴運動消失，大多預後良好。應激被認為是該病的最主要誘因，應激可以是嚴重的精神或軀體刺激，例如: 溺水、地震、親人突發過世、車禍、過於激烈的社交活動、激烈地爭吵、法庭訴訟、持械搶劫等。ECG表現為ST段升高常見於V3–V6，T波倒置，三天後出現寬大倒置T波伴明顯Q-T長。ECG ST-T的動態變化難以與前壁AMI相區別，但Troponin T及CK-MB僅輕度升高，這是有別於AMI的。有少數病人可始終無心肌酶升高，無心肌酶升高不能除外該病的診斷。冠脈造影無明顯(或＜50%)狹窄，左室造影見尖部球形擴張伴收縮活動消失,而心底部收縮加強，入院時左室功能減低EF20－40%(平均30%左右)，持續數天至數周，少數可發生心源性休克(4. 2%)、心室顫動(1. 5%)。院內死亡率1. 1%，3. 5%的病人可復發。 有學者對急性期患者做心肌活檢[5]，光鏡見到心肌細胞大小不等，其中部分細胞肥大(＞20um)，心肌收縮帶壞死及單核細胞浸潤，PSA染色顯示細胞漿內充滿膠質，而在恢復期膠質明顯減少。電鏡見到心肌細胞內有大小不等的空泡，空泡內有細胞碎片、髓磷脂體和喪失收縮功能的物質及非特異性細胞質，恢復期顯示肌小節，細胞核、線粒體分佈基本恢復正常。 目前較多認同的是 MAYO 診斷標準：(1) 可復性心尖部球樣擴張伴收縮運動消失；(2)冠脈無明顯狹窄(＜50%)無急性斑塊破裂的證據；(3)ECG 表現 ST段抬高或 T 波倒置；(4)需除外下列病症：近期腦外傷、顱內出血、冠心病、心肌炎、嗜鉻細胞瘤、梗阻型心肌病。 心尖部球形綜合征主要是對症治療，去除誘發因素；可選用β受體阻滯劑及α受體阻滯劑、ACEI、ARB 等，如有血流動力學不穩定，可酌情應用血管活性藥物包括血管擴張劑 (硝酸甘油、硝普鈉)，和正性肌力藥(磷酸二脂酶抑制劑) 或放置主動脈內氣囊反搏(IABP)。β受體激動劑和兒茶酚胺類正性肌力藥物(多巴胺、多巴酚丁胺) 應列為禁忌。 本文報導二例符合上述臨床特點，發病前有精神及情緒應激的誘發因素，胸痛伴 ST 段抬高，心肌酶輕度升高，心臟造影冠脈無狹窄而心尖部呈典型球形擴張。因診斷及時經合理治療末出現心律失常及心力衰竭，出院後門診治療、跟進恢復良好。 參 考 文 獻 1 Maron BJ, Towbin JA , Thiene G , et al. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology , Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention .Circulation, 2006,113:1807-1816. 2 Dote K, Sato H, Tateishi H, et al. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases. J Cardiol, 1991, 21:203-214. 3 Wedekind H, Moller K, Scholz KH. Tako-Tsubo cardiomyopathy Incidence in patient with acute coronary syndrome J.Herz, 2006, 31(4): 339-346. 4 Monica G, Francesco D, Anna M, et al. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. J European Heart 2006, 27(13): 1523-1527. 5 Holger M Nef, Helge Möllmann, Sawa Kostin, et al. Tako-Tsubo cardiomyopathy: intraindividual structural analysis in the acute phase and after functional recovery. J European Heart 2007, 28(20): 2456-2464.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 112‧病例報告‧ 脂肪鼓膜成形術 莫天石 【摘要】 脂肪鼓膜成形術修補一些鼓膜小穿孔，有較高成功率，不雖要复雜的手術技巧，而且是一項簡單能在門診施行的手術。適當選擇病人及手術時機是手術成功的關鍵。 【關鍵詞】 鼓膜成形術; 脂肪组織移植物 Adipose Tissue Myringoplasty MOK Tin Seak. Department of Otorhinolaryngology , CHCSJ, Macao; CP 3002; Tel (+853)-8390 8831; E-mail : moktinseak@ssm.gov.mo 【Abstract】 Without complicated surgical technique, Adipose tissue myringoplasty is very simple procedure to perform in the office base setting for repairing small perforations with a great success rate. Suitable patient selection and time of operation is the critical for great success rate. 【 key words】 Myringoplasty; Adipose tissue graft 鼓膜成形術是臨床上最常用的耳科手術之一，又稱鼓膜修補術。其目的是通過組織移植技術修復穿孔，恢復鼓膜的完整性，預防中耳感染，並提高聽力。鼓膜成形手術進路方法(耳道內、耳內、耳後進路)、皮瓣以及移植物的選擇及放置(內置法、外置法、夾層法)，都有不同的優缺點並要掌握不同相關手術技巧。近年來，一些緊張部小穿孔，不需要複雜手術技巧，脂肪組織作為移植物之一在鼓膜成形術的應用得到越來越多的關注。脂膜鼓膜成形術尤其對於一些置管後穿孔及慢性中耳炎緊張部小穿孔都能通過門診小手術而取得滿意的效果。 適應症 緊張部穿孔，小於 3mm，穿孔周圍沒有鱗狀上皮往內生長，中耳內沒有膽脂瘤上皮，中耳粘膜外觀正常乾耳 3-6 個月以上。 穿孔引起傳導性耳聾，貼補試驗復測聽閾沒提示聽骨鏈傳導問題。 作者單位 : 仁伯爵綜合醫院耳鼻咽喉-頸面外科，澳門 , CP3002Tel (853) 313731-8831, Email : moktinseak@ssm.gov.mo 臨床資料 自 2009 年 4 月，在局部麻醉下，採用脂肪鼓膜成形術修補 4 例，病例均為慢性中耳炎，鼓膜緊張部小穿孔，穿孔小於 3mm, 或鼓膜面積 30%，幹耳 3個月以上，其中 1 例曾有外耳道真菌感染但經局部真菌治療 2 周治癒。男 3 例，女 1 例。年齡 28-69 歲， 3 耳傳導性耳聾，１耳混合性耳聾，所有病例純音語言頻率(0.5、1、2KHz) 平均氣導聽閾在 37-55dB, 平均氣導聽閾 47 dB，氣骨導差在 12-33dB, 平均氣骨導差 21 dB。手術時間 43-93 分鐘，平均手術時間60.6 分鐘. 手術技巧 脂肪取材，可在耳垂，腹壁等處取材，一般應為耳垂的脂肪織織纖維架較緊密 使用 Rossen 鈎於穿孔邊緣或鼓膜成形術的部位刺出新鮮創面 (圖 1A)，使用小杯鉗將穿孔邊緣上皮切除約 1mm(圖 1B) , 再用小刮匙搔刮穿孔邊緣的內面殘存上皮。 脂肪直徑為穿孔直徑 2-3 倍放置於穿孔中央並送入中耳腔 (圖 2A)，通過穿孔回拉，使約一半的脂肪組織位於穿孔外側，呈啞鈴狀，完全覆蓋穿孔邊緣 (圖2B) 。外耳道置適量的明膠海綿並使用生物膠固定。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 114 圖 4A 病例 2 另一例患者,偶有在脂肪液化溶解過程中，發生感染。 4B 經適當處理鼓膜仍可繼續生長愈合。 圖 5 病例 3 在鼓膜脂肪成形術中，可能脂肪與残留鼓膜重叠不夠或鼓膜殘留邊缘沒有足夠血管生成，影響鼓膜愈合過程，此例手術後 2+個月疑似殘留小穿孔不愈合， 但最終在手術後 4 個月內穿孔愈合。 討 論 針對脂肪作為移植材料用於鼓膜修補的可行性和安全性，Gold[1]等做了大量的基礎研究工作。許多學者研究表明與顳肌筋膜相比，脂肪移植較筋膜癒合率低，但對於鼓膜小穿孔，脂肪移植鼓膜修補術具有較高的治癒率。Mitchel, Herberrt Silverstein[2-4]等研究認為該手術適用於兒童置管後鼓膜穿孔不癒合及外傷性鼓膜穿孔不癒合的患者，並指應用於門診病人的治療,取得滿意的效果。 我們根據適應証選擇 4 個病例，均在局麻下進行手術，手術時間平均 1 小時，病人易耐受，故適合門診手術治療。術後隨訪 4 例患耳都有聽力改善，平均氣導聽閾從 47dB 降低 30dB， 4 例患耳有 3 例手術後癒合，1 例因感染穿孔不愈合，此例術前有外耳道真菌感染病史，術後有中耳炎伴外耳道真菌感染複發，一例 (病例 2), 在癒合過程中脂肪溶解過程中易發生感染，所以手術前，術後感染控制及護理是很重要，因為有可能影響鼓膜癒合生長。 (病例 3) 在鼓膜脂肪成形術中，可能脂肪體積相對不夠大(正常為穿孔 2-3 倍)與残留鼓膜重叠不夠或鼓膜殘留邊缘沒有足夠血管生，影響鼓膜愈合過程。所以病例選擇不當，鼓膜穿孔過大>3mm 或鼓膜面積 >30%或感染危險因素存在及護理不當是導致手術失敗的主要原因。 參 考 文 獻 1 Gold SR. Chaffoo RA fat myringoplasty in the guinea pig. Laryngoscope, 1991, 101: 1. 2 Ayache S ,Braccini F, Facon F , et al . Adipose graft ; an original option in myringoplasty. Otol Neurotol, 2003, 2 (2) : 158-164. 3 Mitchell RB, Pereira KD, lazar RII. Fat graft myringoplasty in children a safe and successful day stay procedure. J otolaryngol, 1997, 111(2):106-108. 4 Herbert Silverstein, Seth I Rosenberg, Dennis Poe, et al. Minimally invasive otological surgery. Delmar Learning, 2003, USA Chapter 7, P93-98, Adipose tissue myringoplasty, Herbert Silverstein, Seth I Rosenberg.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 115‧醫學文摘‧ 多排螺旋 CT 結腸成像術在結直腸腫瘤性 病變檢出診斷中的應用 劉援, 周純武, 張紅梅, 等 【摘要】目的 探討 64 排螺旋結腸成像術（CTC）在檢出結直腸腫瘤性病變中的應用價值。 方法 對 132 例疑診結直腸病變患者進行 CT 掃描、結腸氣鋇雙重造影（DCBE）檢查，將 CT 數據傳至工作站後處理，獲取 CTC 圖像，將所得 CTC、DCBE 的檢查結果與結腸鏡及手術病理結果進行對比分析。 結果 CTC 檢出病變的敏感度 96.49%、特異度 90.91%、准確率 95.95%。DCBE 檢出病變的敏感度 91.23%、特異度 72.73%、准確率 88.24%。兩種檢 查 對 病 變 檢 出 差 異 無 統 計 學 意 義 （ x2=0.565, P=0.391 ）。 CTC 檢 查 直 徑≤5.0mm 病 變 的 敏 感 度80.95%、特異度 86.96%、准確率 84.09%。DCB 對直徑 ≤5.0mm 病 變 檢 出 的 敏 感 度 57.14% 、 特 異 度69.56% 、 准 確 率 63.64% 。 兩 種 檢 查 對 直 徑5.1~9.9mm 病變檢出的差異無統計學意義（x2=0.631, P=0.374）。CTC、DCBE 檢出直徑≥10mm 病變的敏感度、特異度、准確率均爲 100%。 結論 CTC 是一種無創性檢查方法，在結直腸腫瘤性病變檢出的應用中具有一定優勢。 【關鍵詞】結直腸腫瘤; 體層攝影術; 螺旋計算機 摘自：中國介入影像治療學, 2010,7:10 Diagnostic value of multi-slice spiral CT colonography in colorectal neoplasms LIU Yuan, ZHOU Chun-wu, ZHANG Hong-mei, et al. 【Abstract】Objective To assess the value of 64-slice CT colonography (ctc) in diagnosing colorectal neoplasms. Methods One hundred and thirty-two patients with suspected colorectal neoplasm underwent 64-slice spiral CT after bowel cleaning and rectal air insufflating, double contrast barium enema (DCBE) and colonoscopy. CT data were transmitted to the workstation and was performed respectively. All images were separately evaluated by two experienced radiologists. The sensitivity, specificity and accuracy of the CTC and DCBE were evaluated and compared with that of colonoscopy or surgical biopsy. Results The sensitivity, specificity and accuracy of CTC wa 96.49%, 90.91% and 95.59%, of DCBE was 91.23%,72.73% and 88.24% (x2=0.566, P=0.319). In neoplasms with diameter≤5.0mm, the sensitivity, specificity and accuracy of CTC was 80.95%,86.96% and 84.09%, of DCBE was 57.14%, 69.56% and 63.64% (x2=0.679, P=0.422). In neoplasms with diameter of 5.1~9.9mm，the sensitivity, specificity and accuracy of CTC was 91.67%,100% and 94.12%, of DCBE was 75.00%, 80.00% and 76.47% (x2=0.631, P=0.374). The sensitivity, specificity and accuracy of both CTC and DCBE for detecting neoplasms with diameter ≥10mm was 100%. Conclusion CTC IS valuable in detecting colorectal neoplasm as a noninvasive method. 【Key words】 Colorectal neoplasms; Tomography; spiral computed From: Chin J Interv Imaging Ther, 2010, 7:10
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 116‧醫學文摘‧ 産 ESBLs 肺炎克雷伯菌耐藥性及基因分型 劉曉春, 王國慶, 王蓉, 等 【摘要】目的 了解某院 臨床分離的産超廣譜β-內酰胺酶（ESBLs）肺炎克雷伯菌的耐藥性及基因型。 方法 收集臨床分離的肺炎克雷伯菌，採用美國臨床實驗室標准化委員會 2005 年推薦的方法進行 ESBLs 初篩及表型確證試驗；K-B 紙片擴散法進行抗菌藥物敏感性試驗；聚合酶鏈反應（PCR）法分析産 ESBLs 菌株的基因型。 結果 産 ESBLs 肺炎克雷伯菌的檢出率爲 62.22%（56/90）。産 ESBLs 菌僅對第三代頭孢菌素與β-內酰胺酶抑制劑合劑、碳青霉烯類抗生素較敏感。基因型分析結果顯示，産ESBLs 肺炎克雷伯菌中 SHV 型、CTX-M-1 型、TEM型、CTX-M-9 型的檢出率分別爲 69.64%、51.79%、37.50%、0.00%，同時攜帶 2 種、3 種耐藥基因的菌株分別占 35.71%和 14.28%。 結論 産 ESBLs 肺炎克雷伯菌耐藥嚴重，基因型以 SHV、CTX-M-1 爲主。 【關鍵詞】肺炎克雷伯菌; 超廣譜β-內酰胺酶;基因型; 抗藥性, 微生物 摘自：中國感染控制雜誌, 2010, 9:15 Antimicrobial resistance and gene typing of extended-spectrum β-lactamases-producing Klebsiella pneumoniae LIU Xiao-chun, WANG Guo-qing, WANG Rong, et al. 【 Abstract 】 Objective To investigate antimicrobial resistance and genotypes of extended-spectrum β-lactamases (ESBLs)-producing Klebsiella pneumoniae (K. pneumoniae) isolated from clinic in a hospital. Methods K. pneumoniae were collected, ESBLs preliminary screen and phenotype confirmatory tests were carried out according to the NCCLS guidelines; antimicrobial susceptibility tests were determined by Kirby-Bauer test; gene types of β -lactamases were performed with PCR. Results The detection rate of ESBLs-producing K. pneumoniae was 62.22% (56/90). ESBLs-producing strains were only sensitive to the combination of the third generation cephalosporins with β-lactamases inhibitor and carbapenems. The detection rate of genes of SHV, CTX-M-1, TEM and CTX-M-9 was 69.64%, 51.79%, 37.50%, 0.00%, respectively. 35.71% and 14.28% of ESBL-producing K. pneumoniae carried two or three genes respectively. Conclusion Antimicrobial resistance of K. pneumoniae is serious, the main gene types are SHV and CTX-M-1. 【 Key words 】 Klebsiella pneumoniae; extended-spectrum β -lactamase; genotype; drug-resistance, microbial From: Chin J Infect Control, 2010, 9:15
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 117‧醫學文摘‧ 口腔頜面部惡性腫瘤治療指南 中華口腔醫學會口腔頜面外科專業委員會腫瘤學組 【摘要】 口腔頜面部惡性腫瘤約占全身惡性腫瘤的 3%-5%，其組織病理學類型多樣，以鱗狀細胞最多見，約占 90%以上。由於解剖部位特殊，口腔頜面部性腫瘤不僅影響外觀，而且造成咀嚼、吞咽、呼吸和語音等功能障礙，嚴重降低患者的生存質量，並危及生命。手術、放療和化療是治療口腔頜面部惡性腫瘤的 3 大治療手段，免疫治療、生物治療對某些類型的腫瘤和晚期患者是必要的補充和輔助措施。早期患者以手術治療爲主，晚期患者則提倡綜合序列治療，並鼓勵患者參加臨床試驗。口腔頜面部惡性腫瘤患者的 5 年總生存率在 65%左右，晚期患者的 5 年生存率不足 30%。爲了規範口腔頜面部惡性腫瘤的治療，進一步提高患者的遠期生存率，中華口腔醫學會口腔頜面外科專業委員會腫瘤學組牽頭，組織國內從事口腔頜面部惡性腫瘤的知名專家，參考國內外文獻，尤其是 2009 年美國 NCCN 指南中的相關內容，撰寫了《口腔頜面部惡性腫瘤治療指南》，希望對口腔頜面部惡性腫瘤的規範治療起到指導作用。隨著醫學科學技術的發展，新的技術、方法、藥物會不斷出現，本指南將及時予以更新，以反映和納入最新的研究成果，爲廣大患者提供最新的治療方案。 【關鍵詞】口腔頜面部; 惡性腫瘤; 治療指南 摘自：中國口腔頜面外科雜誌 2010, 8(2)：98-106 The protocol of treatment guideline of oral and maxillofacial malignant neoplasms Division of Oral and Maxillofacial Oncology, Chinese Society of Oral and Maxillofacial Surgery 【 Abstract 】 Oral and maxillofacial malignant neoplasms account for 3%-5% of all malignant tumors, over 90% of them are squamous cell careinoma, although the histopathological types are various. Because of the specific anatomical locations, oral and maxillofacial malignancies not only destroy the figures, but also result in severe impairment of mastication,swallowing, respiration and speech, decrease the quality of life, or even lead to death. Surger, radiotherapy and chemotherapy are the mainstay of treatment of aoral and maxillofacial malignancies. Immunotherapy and biotherapy are necessary adjunction in some selected cases and advanced patients. Surgery is the preferred treatment modality for patients at early stage, while combined sequential therapy should be applied to advanced patients, and clinical trials should be encouraged for aduvaced patients. The overall 5-year survival rate of oral and maxillofacial malignancies is around 65%, but less than 30% for advanced patients. A protocol of treatment guideline of oral and maxillofacial malignant neoplasms was established by experts engaging in diagnosis and treatment of oral and maxillofacial malignancies under the guidance of Division of Oral and Maxillofacial Oncology, Chinese Society of Oral and Maxillofacial Surgey. This protocol is based on the Chinese experiences with reference of 2009 NCCN clinical practice guidelines in one ology, the purpose is to provide a criteria for the management of oral and maxillofacial malignancies and improve the long-term survival of the patients. With the rapid progress of secence and technology, new methods, new drugs and new techniques are emerging.This protocol will be renewed and updated to include and reflect the cutting edge knowledge, and provide newest treatment modalities to benefit our patients Supported by Research Project of Science and Technology Commission of Shanghai Municipality (Grant No.06dz22026) 【 Key words 】 Oral and maxillofacial region; Malignant neoplasms; Treatment guideline From: China J Oral Maxillofac Surg, 2010, 8(2):98-106
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 118‧醫學文摘‧ 大、小腎下型腹主動脈瘤的 CT 形態學特點 葉紅, 李宇, 俞婧, 等 【摘要】目的 評價大、小腎下型腹主動脈瘤（AAA）的 CT 形態學特點國。 方法 對 45 例腎下型 AAA 患者行 64 層螺旋 CT 血管成像（CTA），並測定 AAA 形態學指標。以直徑 5cm 爲界，將患者分爲大、小 AAA 兩組，比較 AAA 的臨床危險因素及形態學差異，分析瘤體大小與其他形態學特點的相關性。 結果 大 AAA 患者（n=25）收縮壓小於小AAA （ n=20 ） (P<0.05) ， 吸 煙 比 例 大 於 小 AAA（P<0.05）。大 AAA 瘤體長度、近遠端瘤頸直徑、後壁血栓分佈幾率及瘤壁鈣化積分大於小 AAA（P<0.01），與入口角（r=-0.478, P<0.01）及近端瘤頸長度呈負相關（r=-0.562, P<0.01）。 結論 腎下型 AAA 的瘤體大小其他形態學特點具有一定的相關性。 【關鍵詞】主動脈瘤, 腹; 形態學; 體層攝影術, 螺旋計算機; 血管造影術 摘自：中國介入影像與治療學, 2010, 7：1 CT morphological characteristics of large and small infrarenal abdominal aortic aneurysm YE Hong, LI Yu, YU Jing, et al. 【 Abstract 】 Objective To evaluate the morphological characteristics of large and smalll infrarenal abdominal aortic aneurysm (AAA) with 64-slice spiral CT angiography (CTA). Mtehods Forty-five patients with infrarenal true AAA under-went CTA. The morphological characteristics of AAA were evaluated. The patients were divided into two groups:small AAA (diameter<5cm, n=20) and large AAA (diameter≥5.0cm, n=25). The clinical risk factors and morphological characteristics between small and large AAA were compared. The correlation between the size of AAA and the other morphological characteristics was analyzed. Results Compared to patients with small AAA. Those with large AAA showed lower systolic blood pressure and larger prevalence of smoking (P<0.05). The length of aneurysms body, diameter of proximal and distal neck, the prevalence of thrombus in posterior wall, and aneurysm wall calcification score in large were significantly larger than those of small AAA (P<0.05). The length of AAA was positively correlated with proximal neck angle (r=0.418, P<0.01) and diameter (r=0.411, P<0.01), whereas negatively correlated with entry angle (r=-0.478, P<0.01) and proximal neck length (r=-0.562, P<0.01). Conclusion The size of infrarenal AAA is associated with the other morphological characteristics. 【Key words】Abdominal aortic aneurysm; Abdomen; Morphology; Towograph; Spiral CT; Angiography From: Chin Interv Imaging Ther, 2010, Vol 7, No 1
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 119‧醫學文摘‧ 注射速率對孤立性肺結節 64 層螺旋 CT 灌注成像影響的初步研究 李理, 劉士遠, 肖湘生, 等 【摘要】 目的 利用 64 層螺旋 CT 探討孤立性肺結節 CT 灌注成像技術中對比劑注射速率對結果的影響。 方法 對 50 例孤立性肺結節患者進行前瞻性研究。隨機將患者分爲兩組，注射速率分別爲3ml/s（組 1）及 5ml/s（組 2）；男性 34 例，女性 16例。年齡範圍 28~73 歲，平均年齡 56.02±9.11 歲。其中，43 例通過手術證實；2 例通過 CT 引導經皮肺穿刺活檢證實；1 例通過纖支鏡活檢證實；4 例同時發現全身多處轉移性腫瘤。 結果 組 1 中，血流量值 ： 49.006 ± 42.429ml ． 100g-1 ． Min-1 、 血 溶 量 ：3.358±4.608ml/100g，平均通過時間：6.307±3.772s，表面滲透性：9.378±9.040ml．100g-1．Min-1。組 2：血流量：52.917±61.206ml．100g-1．Min-1、血溶量：3.045±4.671ml/100g，平均通過時間：6.079±3.831s，表面滲透性：8.142±7.082ml．100g-1．Min-1。組 1 與組 2 結節血洗血流量（P＝0.249>0.05）；血容量（P=0.737>0.05）；平均通過時間（P=0.776>0.05）；表面滲透性（P=0.454>0.05）。不同注射速率的兩組孤立性肺結節灌注值統計學差異無統計學意義（P＞0.05）。 結論 不同的對比劑注射速率（3ml/s 和5ml/s）對 64 層螺旋 CT 孤立性肺結節灌注成像無明顯影響。 【關鍵詞】 孤立性; 肺結節; 灌注; 體層攝影術; X 線計算機 摘自：醫學影像雜誌, 2008, 12:1382 Preliminary study on Injection speed of perfusion in soliary pulmonary nodule with 64-detector CT LI li, LIU Shi-yuan, XIAO Xinng-sheng, et al. 【Abstract】 Objective To investigate on the effect of injection speed of contrast media in the perftusion of solitary palmoary nodule. Methods Prospective studies on CT pedusion with 64-detector CT were pedormed in 50 patients with solitary pulmonary nodules. Mede 34 cases ami female 16 cases with the age ranging 28-73 years,average age 56.O2~9.11 years. Among all the cases, 43 cases were pathologically proved with operation; 2 cases with CT-guided biopsy, 1 case with bronchofihroscopa and 4 cases with metastasis. 50 patients were divided randomly into two groups with 3.5ml/s injection speed respectively. Results In the two groups, blood flow ( P =0.249>0.05); blood volume (P=0.737>0.05); mean transit time (P=0.776>0.05); permeably surface (P=0.454>0.05). In group one, blood flow was 49.006 a:42.429 mi.10Og.m/n-1; blood volume was 3.358~4.608 mi/100g~ mean transit time was 6.307 :t: 3.772s; permeably surface was 9.378~:9.040 mi' 100g' I'min'~ in group two, blood flow was 52.917 ~61.206 mi'100g-I. mln-I, blood volume was 3.045 ~4. 671 mi/Ill)g, mean transit time was 6. 079 :t 3. 831s, permeably surface was 8.142 ~7.082 ml. 100g- i. min-1. There was no signiticant difference between the two groups of different injection speeds in SPN CT paffusion ( P > 0.05). Conclusion No dramatic influence was found for different injection speed in CT pedusion d solitar/palmon~ nodules. 【 Key words 】 Solitary pulmonar/nodule; Perfusion; Tomography; X-ray computed From: J Med Imaging,2008,12:1382
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 120‧醫學文摘‧ 腦減影 CT 灌注成像技術初探 楊秀軍, 胥文娟 【摘要】 目的 探討腦減影 CT 灌注成像(sCTP)技術及其初步應用。 方法 選取 11 例有腦 CTP 源影像的患者，其中腦梗死 10 例、腦瘤 1 例，在AW4.2 工作站利用減影軟件先行減影處理，再以Perfusion 3 軟件對減影圖像數據和源影像數據分別作灌注成像分析，測量血流量(BF)、血容量(BV)、平均通過時間(MTT)、毛細血管通透性（PS）數值並生成其色階圖，進行組間、區間比較分析。 結果 ○1 腦sCTPR 技術成功率爲 100%，均獲得了有診斷價值的BF、BV、MTT 或 PS 色階圖及其數值，其後處理時間約需 1~2.5h；○2 sCTPR 提供的 BF、BV、MTT、PS 色階圖與 CTP 的類似，均准確揭示了病變及微循環血液動力學情況；○3 與 CTP 類似，腦 sCTPR 提供的BF、BV、MTT、PS 數值病變與毗鄰及對側組織有顯著性差異（P<0.25）。 結論 腦 sCTPR 技術可行，是減影技術結合灌注成像技術的産物，可作爲腦卒中、腦腫瘤功能成像診斷的補充和可選擇的檢查手段。 【關鍵詞】 體層攝影術; X 線計算機; 灌注成像; 減影技術; 卒中; 腦腫瘤; 摘自：中國介入影像與治療學, 2010, 7:43 Preliminary application of cranial subtraction CT perfusion imaging YANG Xiu-jun , XU Wen-juan 【 Abstract 】 Objective To investigate the possibility to obtain the cranial subtraction computed tomography peritusion imagreg (sCTP) fromm the CTP cxamination, and m explore prehminary application value of sCTP, Methods Cerebral sCTP obtained from source imaging data of 11 patients (10 with stroke and 1 with brain tumor) were analyzed with subtraction software, and perfusi~m 3 software at GE AW4.2 workstation, The parametric maps and regitm of interest (ROI) value of blood flow (BF), blood volume (BV), mean transit lime (MTT) and or permeability surface (PS) were generated [rom the CTP amd sCTP imaging data respectively. Result ○1 The technical success rate of cranial sCTP created front CTP sources imaging data was 100%, and the post processing time of sCTP was about from 1.0 to 2.3 h. The mappings and values of BF. BV, MTT and PS of ROI were all successfully obtained from sCTP and CIP imaging data. ○2 The cerebral mappings of BF, BV, MTT and PS obtained from sCTP were similar to those from CTP, which all depicted aceuralely the lesions and their microcirctdation hemodynamics changes. ○3 Just like those from CTP, the values of BF, BV, MTT and PS of nidus obtainted from sCTP were significantly different from those of the near and the contralateral corresponding cerebral tissues (P<0.025). Conclusion sCTP can be generated successfully with subtraction and perfusion imaging software. It is an alternative solution for functional diagnosis of stroke and brain neoplasms. 【Key words】 Tomography. X-my computed; Perfusion imaging: Suhtraction technique; Stroke Brain neoplasms From: Chin Interv Imaging Ther, 2010, 2010, 7:43
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 121‧醫學文摘‧ 線粒體腦肌病的 MR 診斷 邢嫵, 王小宜, 廖偉華, 等 【摘要】 目的 分析線粒體腦肌病患者的 MRI表現，以期提高對該病的認識。 方法 回顧性分析臨床確診的 5 例線粒體腦肌病患者的 MRI 表現。 結果 5 例患者腦實質 MR 均呈長 T1 和 T2 信號，其中1 例僅累及雙側蒼白球，4 例累及灰白質；3 例並幕上腦室擴大，2 例並小腦萎縮，1 例並雙側基底節鈣化。結論 MRI 可以清晰顯示線粒體腦肌病的腦內病變。確診需結合臨床。 【關鍵詞】 線粒體腦肌病; 磁共振成像 摘自：中國介入影像與治療學, 2010, 7:35 MR diagnosis of mitochondrial Encephalomyopathy XING Wu, WANG Xiao-yi, LIAO Wei-hua, et al. 【Abstract】 Objective To analyze MRI findings of the mitochondrial cncephalopathy, in order to improve the understand-ing of this disease. Methods MR findings of 5 patients of clinically proved mitchondrlal encephalopathy were retrospectively analyzed. Results Brain parenchymal lesions in all patients were low intensity on T1W1 and high signal intensity on T2W2 One patiENTI had bilatera[ globus pallidus involvement, whih, involvement of gray matter and white matter were observed in 4 patients. Three patients had enlargement of supratentorial ventricles, 2 patients had cerebellar atrophy and 1 patient had bilateral basal galia calcification. Conclusion MRI can show the intracranial lesions in patients with mitochondrial encephalomyopathy clearly, but accurate diagnosis should depend on clinical data. 【Key words】 Mitochondrial encephalomyopathies; Maglnetic resonance imaging From: Chin J Interv Imaging Ther, 2010, 7:35
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 122‧醫學文摘‧ 尿液 HIV-1 抗體檢測及其臨床意義 郭婧婧, 徐丹, 王敏, 等 【摘要】目的 探討尿液標本中人免疫缺陷病毒(HIV)-1 抗體檢測的臨床意義。 方法 應用酶聯免疫吸附試驗(ELISA)對 59 例經疾病預防控制中心(CDC)確診的 HIV 感染者及 30 例健康體檢者血液和尿液標本同時進行 HIV-1 抗體檢測以確認結果爲准，計算尿液 HIV-1 抗體檢測的敏感度、特異度。 結果 59 例經 CDC 確診的 HIV 感染者血清 HIV-1 抗體全部陽性，相應尿液中 HIV-1 抗體陽性 53 例，陰性 6例對照組 30 例的血清 HIV-1 抗體全部陰性，相應尿液 HIV-1 抗體陽性，經血清 ELISA 法及膠體硒法對該樣本進行 HIV-1 抗體檢測均陰性。以確認結果爲准，尿液 HIV-1 抗體檢測陽性敏感度爲 89.83%，特異度爲 96.67%。 結論 在採集血液標本不變的情況下，可通過檢測尿液 HIV-1 抗體對高危人群進行HIV 感染篩查。 【關鍵詞】人免疫缺陷病毒; 艾滋病; 尿液; HIV-1 抗體; 實驗室技術和方法 摘自：中國感染控制雜誌, 2010, 9:22 Detection and clinical significance of HIV-1 antibody in urine GUO Jing-jing, XU Dan, WANG Min, et al. 【 Abstract 】 Objective To evaluate the clinical significance of detecting anti-HIV-1 antibody in urine samples. Methods Anti-HIV-1 antibody was tested in serum and urine samples from 59 HIV-infected persons diagnosed by Provincial Center for Disease Control and Prevention and 30 healthy controls with ELISA; Taking the results of the counterpart serum samples tested as standard, the sensitivity and specificity of anti-HIV-1 antibody in urine samples wer calculated. Results Among 59 HIV-infected cases, anti-HIV-1 antibody positve results of serum test were observed in all cases, while 53 urine samples showed positive and 6 ones were negative. None of the serum samples showed anti-HIV-1 antibody positive in the control group, but 1 urine sample was positive, which was determined to be negative by serum enzyme-linked immunosorbent assay and electroselenium assay. The sensitivity and specificity for the urine ELISA were 89.83% and 96.67% respectively. Conclusion The results indicate that urine anti-HIV-1 antibody can be tested to screen HIV Infection in high risk population, if serum samples are unavailable. 【Key words】 Human immunodeficiency virus; Acquired immunodeficiency syndrome; Urine; HIV-1 antibody; Laboratory technique and methods From: Chin J Infect Control, 2010, 9:22
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 123‧醫學文摘‧ 椎動脈三維 CT 血管成像對椎動脈型 頸椎病的診斷價值 牛寧奎, 王自立, 馮世慶, 等 【摘要】目的 探討椎動脈三維 CT 血管成像(CTA)在椎動脈型頸椎病(CSA)診斷中的應用價值。 方法 2007 年 7 月~2008 年 4 月臨床上診斷爲 CSA的患者共 21 例(CSA)組，對其 CTA 上顯示的椎動脈、橫突孔及鈎椎關節增生情況進行觀測，並與 21例非 CSA 患者（對照組）的 CTA 觀測結果進行比較分析。 結果 CSA 組中椎動脈正常者 4 例，管腔變細者 7 例，走行異常者 1 例，椎動脈硬化者 2 例，管腔局限性狹窄者 4 例，血管走行迂曲者 3 例，無血管閉塞的患者。對照組中 14 例椎動脈表現正常，管腔變細者 4 例，走行迂曲者 3 例。兩組中血管正常、局限性狹窄出現比率間均有顯著性差異(P<0.05, x2 分別爲 9.72、1.21)。CSA 組中 11 例（52.4%）患者共有 36 個鈎椎關節增生，以 C4~C7 增生（28 個，77.8%）最爲常見，32 個（88.9%）爲輕度增生，3個（8.3%）爲輕度增生，1 個（2.8）爲重度增生。對照組中，6 例（28.6）患者共有 19 個鈎椎關節增生，只有 1 個（5.3%）表現爲中度增生，其餘均爲輕度增生。 結論 CTA 可以較好地顯示椎動脈異常、局限性狹窄及鈎椎關節的增生情況，在 CSA 中具有一定的診斷價值。 【關鍵詞】 椎動脈 ; 三維 CT 血管成像 ; 椎動脈型頸椎病; 鈎椎關節 摘自：中國脊柱脊髓雜誌, 2010, 20:209 3D-CT vertebral artery angiography for cervical spondylotic vertebral arteriopathy NIU Ningkui, WANG Zili, FENG Shiqing, et al. 【 Abstract 】 Objective To evaluate the application value of vertebral artery three-dimensional CT angiography (CTA) on patients with cervical spondylotic vertebral arterioopathy (CSA). Method 21 patients with CSA(CSA group) from July 2007 to April 2008 were reviewed retrospectively. The abnormalities of vertebral artery, transverse foramen, and hyperplasy of Luschka joint were visualized on CTA, and then contrast analysis of 21 cases with no vertebral arterial insufficiency (control group) were performed. Result Among 21 cases with CSA, vertebral artery angiography showed normal in 4 cases, vertebral artery narrow in 7 cases, course abnormity in 1 cases, arteriosclerosis in 2 cases, local stensis of vertebral artery in 4 cases, vertebral artery circuity in 3 cases and no obstruction. For control group, vertebral artery angiography showed normal in 14 cases, vertebral artery narrow in 4 cases, and vertebral artery circuit in 3 cases. There was statistically sighificant difference between teo groups in vertebral artery normal and local stenosis(P<0.05, x2 were9.72 and 1.21, respectively). A total of 36cervical Luschka joints were evidenced osteosis in different degree in 11(52.4%) CSA patients which appeared mostly between C4 and C7(28 joints),32(88.9%) of Luschka joints had slightly osteosis, 3(8.3%) had moderate and 1(2.8%) had severity osteosis. For control group, 19 cervical Luschka joints had osteophyte in deifferent degree in 6(28.6%) patients. Only 1(5.3%) of hyperplasia Luschka joint had moderate osteophyte, and the others had slightly osteophyte. Conclusion Vertebral artery abnormality as well as the osteophyte of Luschka joint can be shown in CTA, which approve the diagnostic value of cervical spondylotic vertebral arteriopathy. 【 Key words 】 Vertebral artery; Three-dimensional CT angiography; Cervical spondylotic vertebral arteriopathy; Luschka joint From: Chinese Journal of Spine and Spinal Cord, 2010, 20:209
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 124‧醫學文摘‧ 非酒精性脂肪肝與胰島素抵抗 馬麗娜, 馮明, 周英智, 等 【 摘 要 】 目 的 探 討 非 酒 精 性 脂 肪 性 肝 病（NAFLD）與胰島素抵抗（IR）的關係。 方法 NAFLD 組 52 例，非 NAFLD 組 50 例，比較兩組間BMI、WHR、TC、TG、GRP、HDLL-C、LDL-C、ALT、Cr、FBG、FINS 和 HOMA-IR 的差異，並進行 Logistic 回 歸 分 析 。 結果 NAFLD 組 與 非NAFLD 組在 BMI（26.7±2.3 與 22.4±2.5，P＜0.01）、WHR（0.94±0.06 與 0.83±0.05，P＜0.01）、TG（2.4±0.6 與 1.8±0.6，P＜0.01）、ALT（37.3±8.3 與 28.1±7.2 ， P ＜ 0.05 ）、 FBG （ 6.2 ± 1.4 與 5.2 ± 0.7 ， P ＜0.01）、FINS（23.6±13.6 與 8.6±3.5，P＜0.01）、TG（ P ＜ 0.01 ）、 ALT （ P ＜ 0.05 ）、 HOMA-IR （ P ＜0.01）是 NAFLD 的獨立影響因素。 結論 BMI、WHR、TG、ALG、HOMA-IR 是 NAFLD 的獨立影響因素。 【關鍵詞】非酒精性脂肪肝; 胰島素抵抗 摘自：臨床肝膽病雜誌, 2010, 26:173 The relationship between nonalcoholic fatty liver diseses and insulin reistance MA Li-na, FENG Ming, ZHOU Ying-zhi, et al. 【Abstract】 Objective o explore the relationship between nonalcoholic fatty liver disease (NAFLD) and insulin resistance. Methods Atotal of 102 liver disease patients (52 NAFLD and 50 non NAFLD) were included in the study. BMI, WHR, TC, TG, CRP, HDL-C, LDL-C, ALT, Cr, FBC, FINS AND HOMA-IR were compared between the two groups wereanalyzed using logistic regression. Results In NAFLD group, the level of BMI（26.7±2.3 vs 22.4±2.5, P＜0.01）,WHR（0.94±0.06 vs 0.83±0.05, P＜0.01）, TG（2.4±0.6 vs 1.8±0.6, P＜0.01）, ALT（37.3±8.3 vs 28.1±7.2, P＜0.05）, FBG（6.2±1.4 vs 5.2±0.7, P＜0.01）, FINS（23.6±13.6 vs 8.6±3.5, P＜0.01）, TG（P＜0.01）, ALT （ P ＜ 0.05 ） , HOMA-IR （ P ＜ 0.01 ） were independent factors. Conclusion BMI, WHR, TG, ALT and HOMA-IR were independent factors of NAFLD. 【Key words】 Non-alcoholic fatty liver; Insulin resistance From: Chin J Clini Hepatol, April 2010, 26:173
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 125‧醫學文摘‧ 開窗負壓吸引術在頜骨囊腫治療中的應用 孟箭, 顧倩平, 張傑, 等 【摘要】目的 評估開窗負壓吸引術應用於囊腫治療的臨床效果。 方法 選擇門診就診的 11 例頜骨囊腫患者，採用開窗負壓吸引術對其進行治療，觀察術後 3、6 個月頜骨囊腫的變化情況，對仍存留囊腫行二期囊腫刮療術。 結果 術後 3 個月，其中 5例囊腫消失，6 例縮小 3/4 以上。開窗負壓吸引術 3個月或半年後輔以刮治術，刮治術後半年的全景片顯示囊腫無復發，骨質修複良好。 結論 開窗負壓吸引術可以顯著縮小甚至消除青少年頜骨巨大囊腫，改善患者頜骨膨隆畸形，是治療頜骨巨大囊腫切實可行的方法。 【關鍵詞】 頜骨; 囊腫; 負壓吸引 摘自：口腔頜面外科雜誌, 2009, 19:339 Marsupialization and Suction Drainage in the Treatment of Jaw Cysts MENG Jian, GU Qian, ZHANG Jie, et al. 【 Abstract 】 Objective This study was to evaluate the clinical effects of suction drainage on the treatment of jaw cystic lesions. Methods 11 cases of large jaw cystic lesions were treated with marsupialization and suction drainage. Clinical symptoms and radiographical findings were evaluated before operation and at 3-month, 6-month after suction drainage. Results At 3-month after operation 5 cystic lesions dessolved and cystic sizes of other 6 cases decreased to 25% of their original size. No relapse was found in any case. Conclusion The method of suction drainage was effective in the treatment of jaw cystic lesions. It could be decreased the cystic size and corrected the deformity more quickly. 【 Key words 】 Jaw; Cystic lesion; Suction drainage From: Journal of Oral and Maxillofacial Surgery, 2009,19:339
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 126‧信息和動態‧ 中老年人應警惕慢性腦供血不足 生活中有很多人，特別是中老年人經常反復出現頭暈、頭昏重、頭痛等症狀，且常有心煩、耳鳴、急躁易怒、失眠多夢、記憶力減退、注意力不集中、健忘等發生。研究表明，這些都是慢性腦供血不足（CCCI）的結果。 慢性腦供血不足（Chronic cerebral circulation insufficiency，CCCI）最早是 1990 年由日本醫學家提出的，是指由各種原因導致的大腦出現慢性、廣泛的供血不足，從而引發的以腦部缺血、缺氧等一系列腦部功能障礙爲臨床表現的疾病。慢性腦供血不足（CCCI）的發病率較高，屬中老年人的多發病。經大量研究還發現，在老年癡呆症和腦梗死的發病前期，患者均曾長期患有慢性腦供血不足。如果對慢性腦供血不足（CCCI）不及時進行治療，很可能引起老年癡呆症和腦梗死的發生。因此，慢性腦供血不足（CCCI）被稱作是威脅中老年人健康的“隱形殺手”。 發生慢性腦供血不足的原因 衆所周知，大腦是人體的重要器官，耗氧量相對較大，大腦的重量大約只占身體重量的 2%，但是耗氧量卻占全身耗氧量的 20%。大腦所需的氧全部由血液供給，所以必須有足夠的血液供應，大腦才能正常活動。衡量大腦血液供應的標準是腦血流量，腦血流量一旦減少，腦細胞的供氧量也隨即減少。如果腦組織缺血 10 餘秒鐘，就會引起大腦的功能發生變化；如果大腦某一部分血流在較短時間內完全阻斷，則會發生局部腦組織壞死，即腦梗塞；如果大腦供血不是完全阻斷而是慢慢地減少，就是慢性腦供血不足（CCCI）。一般來說，隨著年齡的增長，大腦的血液供應會逐漸減少。兒童時期腦血流量大約爲 100 毫升(100 毫升/100 克腦組織/分)，成人爲 50 毫升（50 毫升/100 克腦組織/分），而健康老人只有 35 毫升（35毫升/100 克腦組織/分），加之中老年人的腦組織對缺血的耐受性相對較低，腦血管的自動調節機能也逐漸下降，因此只要供血發生輕微的變化，就會明顯影響腦血流量，從而導致慢性腦供血不足（CCCI）的發生。 選對藥物及時治療慢性腦供血不足 慢性腦供血不足（CCCI）在早期是可逆的，正確治療往往會獲得很好的效果，如果忍耐拖延，不及時治療，常常會釀成嚴重的後果。 由天津天士力制藥股份有限公司獨家生産的天然植物藥養血清腦顆粒在治療慢性腦供血不足（CCCI）方面具有良好療效。養血清腦顆粒是根據中醫藥傳統理論，以中醫傳統名方“四物湯”（當歸、川芎、白芍、熟地）爲基礎，並採用最新工藝研製而成的無糖型棕色顆粒狀製劑，經多家國家權威機構臨床驗證，服用養血清腦顆粒不僅對慢性腦供血不足（CCCI）有顯著的治療效果，而且還可有效預防老年癡呆症和腦梗死的發生，且適宜長期服用。摘自：健康報 2009-12-25
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 129‧工具和資料‧ 下肢動脈病變與糖尿病足治療及其多學科協作 許樟榮 概 述 下肢動脈疾病（PAD）是常見的糖尿病並發症，該症起病緩慢而隱匿，臨床上尚未受到足夠重視，但危害性大，是糖尿病足的重要原因。世界衛生組織（WHO）定義的糖尿病足是與局部神經異常和下肢遠端外周血管病變相關的足部感染、潰瘍和（或）深層組織破壞。國際糖尿病足工作組將糖尿病足潰瘍定義爲糖尿病患者踝以下的累及全層皮膚的創面，而與這種創面的病程無關。 糖尿病合併 PAD 與非糖尿病的 PAD 患者相比，前者的下肢動脈病變往往是多節段、更遠端、病變更廣泛，傳統的外科治療有一定難度。但由於 PAD 發病過程緩慢，其危害性不如心腦血管病變結果嚴重以及患者往往同時合併周圍神經病變而使下肢缺血症狀表現得不典型甚至缺如，可以臨床上對於糖尿病合併的 PAD 不夠重視。 據統計，全球每 30 秒鐘就會在某地發生一例因爲糖尿病而丟失肢體的事件。據美國數據，糖尿病引起的大截肢率並沒有下降。英國資料則說明，在某些地區，糖尿病截肢率下降了 70％。直至 2007 年，德國還沒有數據說明糖尿病的截肢率是下降的。瑞典的糖尿病截肢率下降了 78 ％、荷蘭下降了 37％。隨著糖尿病患病率的急劇上升和患者老齡化，糖尿病足的問題已經受到了高度重視。PAD 是造成糖尿病足潰瘍和下肢截肢的主要原因，在我國的糖尿病足潰瘍中，單純的神經性潰瘍相對少見，而缺血性潰瘍或神經缺血性足潰瘍則相對多見。這既可能與糖尿病足的人種差異有關，又可能與我國的吸煙率高有關。及早診治 PAD 是降低糖尿病足潰瘍和截肢率的關鍵。 造成糖尿病足潰瘍和壞疽的原因主要是神經病變、血管病變和感染。我國 50 歲以上的 2 型糖尿病患者中至少有一種心血管危險因素者，約有 20％合併有下肢閉塞性動脈病變。這些患者很容易出現足病問題，糖尿病足病往往合併有 PAD；合併嚴重 PAD的足病患者，在沒有治療下肢血管病變之前，足潰瘍是難以癒合的。篩查和評估下肢供血情況是處治糖尿病足病變的關鍵環節。血管病變的部位和程度直接關係到糖尿病足潰瘍是否有癒合的可能和患者是否需要截肢以及截肢的平面。儘管糖尿病合併的 PAD 往往有病變範圍廣、更遠端和多節段的特點，與非糖尿病患者的血管病變相比，手術和介入治療的難度大，但近年來的實踐證明，血管外科技術發展很快，是能夠解決大部分血管問題的。 PAD 診治 診斷方法與技術： 近些年來， PAD 的診斷已經取得了巨大的進步。PAD 診斷中最簡單的檢查下肢血管的方法是觸診。經過仔細檢查足背動脈和脛後動脈搏動基本上能夠對足的血液供應做出評估。踝肱動脈壓指數（ABI）測定簡單易行並且無創傷，已經在國內許多大醫院的內分泌專科得到了推廣。由於部分糖尿病患者合併嚴重的下肢動脈鈣化，致使 ABI 值升高，此時需要檢測趾/ 肱動脈血壓比值（TBI）或者測定經皮氧分壓以瞭解足部的血供。皮溫測定是瞭解血管病變的簡單方法，如果雙足皮膚溫度相差 2 度以上，說明患足有感染或缺血。脈搏波傳導速度（PWV）測定也是診斷 PAD 的無創方法。血管超聲不僅是無創的診斷技術， 而且可在此基礎上開展血管內消融治療。血管減數造影仍然是 PAD 診斷的金標準，而且在造影的同時可以施行血管介入治療。但在許多情況下，無創的 CT 和 MR 血管造影已經可以替代經典的血管減數造影。對於足的血供評估是制定糖尿病足潰瘍治療方案的一個基本環節。 PAD 主要的治療手段仍然是內科治療，原則是整體的綜合治療，包括控制高血糖、降壓和糾正血脂紊亂以及吸煙者戒煙。在基本治療達標的基礎上，針對血管閉塞、血液流變學異常的治療可以發揮更好的效果。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 130內科藥物治療： 1、前列腺素 E1： 能擴張病變部位痙攣的血管，增加缺血區供血；抑制血小板聚集；增加紅細胞變形能力，使部分僵硬紅細胞易於通過毛細血管，有效改善微循環。日本的研究和我們的研究發現，應用脂微球包裹的前列腺素E1 治療 3~4 周，可使症狀改善且持續達 6 個月，患者的疼痛積分明顯下降。 2、鹽酸沙格雷酯： 具有抑制血小板凝集及二次凝集、抑制血管收縮、抑制血管平滑肌細胞增殖和增加側枝循環、改善周圍循環障礙、抗血栓等作用。我們以阿司匹林作爲對照藥物，證實鹽酸沙格雷酯治療 12 周後，糖尿病合併 PAD 患者的無痛行走距離和能夠耐受疼痛的最大行走距離都明顯改善，ABI 明顯改善，明顯優於阿司匹林的療效。 3、西洛他唑： 爲磷酸二酯酶抑制劑，具有抑制血小板活化和平滑肌增殖、擴張血管、降低血甘油三酯水平的作用。中日友好醫院內分泌科給予 3 5 例糖尿病患者西洛他唑治療，結果發現，服藥後 3 個月、6 個月，患者的下肢血管病變症狀和體征均明顯好轉。治療後患者的神經病變積分明顯下降，神經傳導速度明顯增加。對於合併下肢動脈血栓或有形成血栓傾向者，可以應用低分子肝素治療。合併 PAD 的糖尿病患者如無禁忌證，應該長期口服阿司匹林進行預防。鼓勵輕症患者步行鍛煉，以促進側枝循環的建立和下肢供血的改善。 外科治療: 血管介入治療： PAD 的外科治療除了傳統的血管旁路或移植手術以外，現在有了更多的血管介入治療技術，如血管內超聲消融、深部球囊擴張和血管內支架植入等。血管介入治療相比於傳統的血管旁路手術，介入治療的創面小、出血量少、醫療費用低和住院時間短，大約適用於近一半的糖尿病合併 PAD 患者。但是，總體上說，有關糖尿病合併 PAD 的介入治療與傳統的血管旁路治療對比的研究尚少，缺乏循證醫學的 A 級證據。有限的研究說明，6 個月到 1 年的近期治療效果，血管介入治療與傳統的血管旁路手術相似，但血管旁路手術治療的患者有更低的 2 年後的截肢率和病死率。隨著血管介入技術軟硬件的進步，其治療效果會得到進一步改善。幹細胞移植作爲治療糖尿病PAD 的新手段已經在國內多家醫院開展，並取得了較好的臨床效果。 糖尿病足治療的多學科協作： 根據發達國家的經驗，有效降低糖尿病患者截肢率的關鍵是及早發現和治療糖尿病足潰瘍及其危險因素。實行專業化的足潰瘍處治和多學科合作以及貫徹預防爲主的策略是降低糖尿病截肢率的三大原則。儘早診斷和積極治療 PAD 是貫徹這些原則的一個重要方面，基本治療目標是緩解缺血性疼痛、促進足潰瘍癒合、降低截肢率和改善患者的生活質量。個體化的治療是建立在充分評估 PAD 的程度、範圍以及患者的總體情況的基礎上。 對於神經性足潰瘍，重要的是減輕病變足的局部壓力（減壓），需要矯形外科和（或）骨科醫生的幫助。有嚴重足畸形乃至反復發生足潰瘍的糖尿病患者，減壓是有效預防和治療神經性足潰瘍的重要措施。國內的減壓措施往往是制動，即讓患者臥床休息或坐輪椅行動或拄拐活動，國外通常給患者以特別設計的石膏支具或鞋子來實現局部減壓。 在糖尿病足病潰瘍的處理上，局部清創很重要。只要患者局部供血還算良好，就應該進行較爲徹底的清創，尤其是感染的創面。住在內科或內分泌科的糖尿病足患者，其足潰瘍往往得不到充分的清創。如此，足潰瘍難以癒合。同時，敷料的選擇也十分重要。目前，已經開發出各種不同用途的新型敷料，如藻酸鹽敷料、含銀離子的敷料、含生長因子的敷料等。在清創和應用敷料方面，往往需要外科醫生和皮膚科醫生的幫助或由他們來承擔。我國中醫在千百年來的臨床實踐中，也開發出一些含中藥的敷料。合併感染的足潰瘍，還需要有感染科專業人員的參與。糖尿病足病患者往往合併心血管病變。心血管專業人員的會診和指導也很有必要。 糖尿病足病處理和預防必須體現多學科協作的理念。內分泌科醫生在嚴格控制血糖、血壓上發揮主導作用，與心血管科醫師的協作可以使血壓保持在理想水平和減少心血管事件率；與整形外科和骨科合作可
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 132‧工具和資料‧ 關於脂肪性肝病的幾個問題 患者一旦患上脂肪性肝病，很可能波及全身，嚴重影響患者的健康。因此，對於脂肪性肝病的防治，不僅是醫學問題，更是社會問題。 一、肪性肝病的發病率是多少？ 據調查，脂肪性肝病在發達國家的發病率爲 20％以上，在上海地區爲 17％左右，在我國北方地區的發病率亟待明確。有關脂肪性肝病的研究已成爲臨床上的一大熱點，近年來隨著 B 超技術的進步和廣泛應用，脂肪性肝病的發病率也隨之開始明確。 二、控制單純性脂肪性肝病的措施？ 脂肪性肝病根據病因的不同，可分爲酒精性脂肪性肝病、非酒精性脂肪性肝病、藥物性脂肪性肝病、化學損傷性脂肪性肝病等。 單純性脂肪性肝病爲脂肪性肝病的早期表現，一般表現爲乏力、肝區不適和肝腫大等症狀，而肝功能基本正常，肝活檢僅有肝細胞脂肪變性，無明顯的肝內炎症和纖維化。此階段患者宜改變生活方式，包括戒酒，攝入低脂、低碳水化合物飲食及多做有氧運動，從而控制脂肪性肝病。 三、對脂肪性肝炎應如何採用藥物進行干預治療？ 脂肪性肝炎是指繼發於肝細胞脂肪變基礎上的肝炎。此階段肝臟已經在脂肪變的基礎上出現了炎症損傷，臨床上通常開始考慮進行藥物干預治療，以避免發展至肝硬化甚至肝癌。 對脂肪性肝病的保肝藥物治療一般選用 1 種～2 種藥物，療程半年以上，至血清轉氨酶複常、影像學檢查提示脂肪性肝病消退爲止。對於伴有血清轉氨酶升高的患者，原則上不用五味子及甘草類降酶藥物，確需使用者應強調綜合防治的重要性，以免掩蓋病情並須防止ALT 反跳。在保肝藥物中，天津天士力制藥股份有限公司生産的水飛薊賓膠囊（水林佳）具有較好療效。經藥理研究證實，該藥具有較強的抗氧化作用，能清除肝細胞內的活性氧自由基、穩定肝細胞膜，從而保護肝細胞，提高肝臟的解毒能力，並可避免肝細胞在長期接觸毒物、服用肝毒性藥物、吸煙、飲酒等情況下受到損傷。同時具有抗炎、抗纖維化作用。 四、脂肪性肝病爲何會誘發多種肝病？ 據臨床統計數字顯示，脂肪性肝病患者並發肝硬化、肝癌的概率是正常人的 150 倍。同時，由於脂肪性肝病患者機體免疫力相對較低，感染甲、乙型肝炎的機會也明顯高於正常人。 五、脂肪性肝病與動脈粥樣硬化、心腦血管疾病之間的關係？ 現代社會，動脈粥樣硬化和心腦血管疾病已經成爲威脅人類健康的第一大殺手。現代醫學表明：脂肪性肝病、動脈粥樣硬化及心腦血管疾病之間的關係極爲密切，在中青年人群中尤其明顯。因此心腦血管疾病不是老年人的“專利”，中青年脂肪性肝病患者也必須時刻關注自己的肝臟健康狀況，避免因脂肪性肝病給家庭帶來巨大的痛苦和沈重的負擔。 摘自：健康報
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 133‧工具和資料‧ 城市與健康 聚焦世博會 手機儘量少用爲妙 解放軍總醫院第一附屬醫院神經外科主任 李安民 隨著世博會大幕拉開一周多，參觀者潮水般湧入世博園，而爲了方便互相聯絡，手機已成遊世博的必備工具。但英國近期一項研究發現，手機輻射的致癌性可能比香煙還強，成爲迄今最嚴重的關於手機輻射危害人體健康的警告，並將人們對手機輻射的關注提到了前所未有的高度。 爲保證參觀者和更多人的長久健康，有些手機的防護知識是應該知道的：大腦最易受電磁輻射傷; 電磁輻射一般分爲電離輻射（也叫高能射線，如 X、α、β、γ射線和宇宙射線）和非電離輻射（也叫微波輻射，其頻率在 0.5 MHz～100GHz）。手機的輻射頻率爲 890～900MHz，屬於能量較大的微波輻射。 當用手機打電話時，手機就相當於一個小的微波發射器，使手機附近産生較強的微波輻射。很多人都會有這種體會，打手機超過幾分鐘後，耳朵和臉部就會有發熱的感覺。當一個人用手機打電話時，周圍的人也難免不受影響。 微波輻射主要能對人體産生熱損害。其中對人體內含水量多的組織（如大腦和眼睛的含水量最高，可達到 75%）的損害程度最爲嚴重。輕則影響腦細胞的正常工作，造成記憶力減退、失眠和情緒改變，重則造成腦細胞變性壞死或誘發腦瘤。 瑞典研究人員對 233 名腦瘤患者進行調查後發現，頻繁使用手機的患者大腦一側發生腦瘤的幾率，比大腦後部、前部及頂部的發病率要高。美國無線技術研究機構公佈系列研究結果也表明，手機輻射與腦瘤發生率、血液微核細胞增長率，以及 DNA 破損率有一定關聯。 減少手機傷害有五招兒 1. 儘量少用手機。尤其是孕婦和青少年。在有固定電話的情況下，儘量使用固定電話。必須使用手機時要長話短說。 2. 應在信號接通瞬間將手機遠離頭部。手機信號剛接通時輻射最強，過兩秒後輻射會迅速減弱，並保持在比較穩定的狀態。因此，應在手機信號接通兩秒鐘後或在兩次鈴聲的間歇期接聽電話。 3. 使用專用耳機。澳大利亞的研究人員最近公佈的一項研究結果顯示，帶有屏蔽線的手機專用耳機可以幫助用戶減少 90%以上手機的電磁輻射量。 4. 不要將手機放在胸前或挂在腰間。 5. 多吃能加強人體抵抗電磁輻射能力的食物。如富含維生素 A、C 和蛋白質的胡蘿蔔、西紅柿、海帶、瘦肉、動物肝臟等。 摘自：健康報
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 134‧工具和資料‧ 季度藥訊 Quaarrtteerrlly Drrug Neewsslleetttteer 1 有關秋水仙鹼(colchicine)和 P-糖蛋白或CYP3A4 強效抑制劑相互作用的最新資訊 星加坡藥監局（HSA）通知衛生專業人士一則有關秋水仙鹼(colchicine)與P-糖蛋白(P-glycoprotein, P-gp)或CYP3A4 強效抑制劑相互作用的資訊。據述， 美國食物及藥物管理局（USFDA）過去曾接獲169 宗與口服colchicine 有關的死亡個案。在這些個案中，117宗發生在colchicine的標準治療劑量以內(≤2毫克/天)，當中超過60例的病人同時服用抑制CYP3A4 的 克 拉 霉 素 (clarithromycin) 。 分 析 指 出 ， 影 響colchicine胃腸道吸收及/或肝代謝的藥物相互作用是產生colchicine中毒的主要原因。Colchicine 從胃腸道中的吸收會受外排載體P-gp所影響，而colchicine 在小腸和肝中由P450色素酶CYP3A4轉化為無活性的代謝物。Colchicine主要通過肝膽分泌至糞便中排除，在腎功能正常的病人中腎排泄只佔10%~20%的排除量。現有併用Colchicine和其他P-gp或CYP3A4抑制劑而出現致命或非致命的個案, 足以支持改變P-gp或CYP3A4活性的藥物會造成colchicine中毒的論點, 這些 藥 物 包 括 環 孢 素 (cyclosporin) ﹑ 紅 霉 素(erythromycin)以及鈣通道阻斷劑 (calcium channel blockers) ， 如 維 拉 帕 米 (verapamil) 和 地 爾 硫 卓(diltiazem)，其他P-gp或CYP3A4 強效抑制劑包括泰利霉素(telithromycin)、酮康唑(ketoconazole)、伊曲康唑(itraconazole)、HIV 蛋白酶抑制劑以及奈非西坦(nefazodone)。 基於以上事實，USFDA 總結認為，同時服用colchicine以及P-gp或CYP3A4強效抑制劑具有嚴重藥物相互作用的風險, 並作出下列建議： P-gp或CYP3A4強效抑制劑不可用於正在服用colchicine 兼有肝腎功能損傷的病人。 對於需要使用P-gp或CYP3A4強效抑制劑但肝腎功能正常的病人，醫生應考慮降低colchicine 的劑量或暫停colchicine 的治療。 Updates on drug interaction between colchicines and P-glycoprotein or strong CYP3A4 inhibitors The Singaporean Health Sciences Authority (HSA) notified healthcare professionals about the drug interaction between colchicine and P-glycoprotein (P-gp) or strong CYP3A4 inhibitors. Latest data from the United States Food and Drug Administration (USFDA) indicated that there have been 169 deaths associated with the use of oral colchicines. Of these, 117 cases occurred within the standard therapeutic doses of colchicine (≤2mg/day) and 60 out of these 117 cases patients also had concomitant clarithromycin, a CYP3A4 inhibitor. Analysis findings suggested that drug interactions affecting gastrointestinal absorption and/or hepatic metabolism of colchicine play a central role in the development of colchicine toxicity. The absorption of colchicine from the gastrointestinal tract is affected by the efflux transporter P-glycoprotein (P-gp), while the metabolism of colchicine to inactive metabolites is catalyzed by intestinal and hepatic cytochrome P450 CYP3A4. Colchicine is primarily eliminated by hepatobiliary excretion through the stool. Renal excretion accounts for 10% to 20% of colchicine elimination in patients with normal renal function. The theoretical risk of colchicine toxicity through the modulation of P-gp and CYP3A4 activity is further supported by the presence of fatal and non-fatal cases of colchicine toxicity reported in literature with concomitant use of other CYP3A4 and P-gp inhibitors such as cyclosporin, erythromycin and calcium channel blockers e.g. verapamil and diltiazem. Other examples of P-gp and strong CYP3A4 inhibitors include telithromycin, ketoconazole, itraconazole, HIV protease inhibitors, and nefazodone. In view light of the above, USFDA concluded that there is a risk for severe drug interactions in certain patients treated with colchicine and concomitant P-gp or strong CYP3A4 inhibitors. Hence, she offered the following advice： Avoid the use of P-gp or strong CYP3A4 inhibitors in patients with renal or hepatic impairment who are currently taking colchicine. Prescribing physician should consider a dose reduction or interruption of colchicine in patients with normal renal and hepatic function if treatment with a P-gp or strong CYP3A4 inhibitor is required.資料來源：星加坡藥監局 Source：Health Science Authority (HSA) http://www.hsa.gov.sg/publish/hsaportal/en/health_products_regulation /safety_information/product_safety_alerts/safety_alerts_2009/import ant_drug_interactions.html
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 1352 有關硼替佐米(bortezomib, Velcade®) 安全性的最新資訊 美國食物及藥物管理局（USFDA）通知衛生專業人士一則有關硼替佐米(bortezomib, Velcade®)注射液的最新資訊。Bortezomib 用於治療患上多發性骨髓瘤(multiplemyeloma)的病人，亦用於已接受一種藥物治療的套細胞淋巴瘤(mantle cell lymphoma)的病人。根據一項隨機及開放式的臨床研究，得出以下關於bortezomib 的最新資訊： 在還未接受過治療的多發性骨髓瘤病人中，bortezomib 能顯著提高病人的生存率。 對於輕度肝功能損傷的病人，不需調整起始劑量。 因為bortezomib 經肝臟代謝，肝功能損傷會增加藥物在體內的濃度，對於中、重度肝功能損傷的病人需使用較低的起始劑量，在第一階段的治療中，初始劑量應為每劑0.7 毫克/平方米身體表面積，其後每劑增至1.0 毫克/平方米身體表面積，或根據病人的耐受情況減至0.5 毫克/平方米身體表面積。此外，應密切監察病人發生不良反應的情況。 由於bortezomib 能引起血小板減少和中性粒細胞減少，因此應經常監測全血細胞數。 Latest safety update for bortezomib (Velcade®) The United States Food and Drug Administration (USFDA) notified healthcare professionals about the latest updates on bortezomib (Velcade®) for injections. Bortezomib is indicated for the treatments of patients with multiple myeloma and, also, those patients with mantle cell lymphoma who have received at least one prior therapy. According to a randomized, open-label clinical study, the new updates include： The overall survival in patients with previously untreated multiple myeloma showed a statistically significant survival benefit for the bortezomib. Do not require a starting dose adjustment for patients with mild hepatic impairment. Use a lower starting dose for patients with moderate to severe hepatic impairment since bortezomib is metabolized by liver enzymes and hepatic impairment will have an increased exposure of this drug. The initial dose should be 0.7 mg/m2 per injection during the first cycle, and a subsequent dose escalation to 1.0 mg/m2 or further dose reduction to 0.5 mg/m2 may be considered based on the patient tolerance. Besides, close monitoring on these patients for toxicities should also be warranted. Bortezomib is associated with thrombocytopenia and neutropenia, thus complete blood counts should be monitored frequently. 資料來源：美國食物及藥物管理局 Source：United States Food and Drug Administration (USFDA) http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm198424.htm http://www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/UCM198426.pdf 3 有關去羥肌苷(didanosine, Videx®/Videx EC®)安全性的最新資訊 美國食物及藥物管理局（USFDA）通知衛生專業人士關於去羥肌苷 (didanosine(DDI) ， Videx®/ VidexEC®)安全性的最新資訊，簡述如下： 經分析 42 宗關於服用 didanosine 的病人發生罕見但嚴重的非肝硬化門靜脈高壓症的通報個案後，USFDA 總結出使用 didanosine 與發生此症狀存在因果關係。由於非肝硬化門靜脈高壓症具有造成食管靜脈曲張出血等可能導致死亡的潛在風險，USFDA 決定修改 didanosine 說明書中的警告及注意事項部分，以確保使用該藥的安全性。然而，USFDA 認為在受 HIV 感染的某些病人中，didanosine 的臨床效益 Latest safety updates on didanosine (Videx®/VidexEC®) The United States Food and Drug Administration (USFDA) notified healthcare professionals about the latest update on didanosine(DDI)(Videx®/VidexEC®). Summaries are listedas follows: Upon analysis of the 42 post-marketing reports concerning patients, who were on didanosine, developed a rare, but serious, liver complication known as non-cirrhotic portal hypertension, USFDA concluded a causal association between the use of didanosine and development of this liver condition. As the potential severity of this non-cirrhotic portal hypertension including death from hemorrhaging esophageal varices, the Agency decided to revise the Warning and Precautions section of the didanosine drug label to assure safe use of this medication. However, USFDA believes the clinical benefits of didanosine for certain patients
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 136依然大於潛在的風險，因此，必須根據醫生和病人的個別情況而決定是否使用該藥。此外,USFDA 對衛生專業人士作出下列建議： 須留意使用 didanosine 有可能發生非肝硬化門靜脈高壓症。 與病人討論使用 didanosine 的臨床效益及潛在風險，包括非肝硬化門靜脈高壓症。 持續監測病人發生門脈高壓及食管靜脈曲張的情況。 注意 didanosine 已有乳酸性酸中毒及脂肪性肝腫大的特別警告。 Didanosine 與其他抗逆轉錄病毒藥物及羥基脲(hydroxyurea)或利巴韋林(ribavirin)併用時可能增加肝毒性。 with HIV continue to outweigh its potential risks, hence, the decision to use this drug must be made on an individual basis between the prescribing physician and the patient. Besides, the USFDA also offered the following additional reminders for healthcare professionals: Be aware that didanosine use has been associated with the development of non-cirrhotic portal hypertension. Discuss with patients the clinical benefits and potential risks, including the risk of non-cirrhotic portal hypertension, with the use of didanosine. Continue to monitor patients for the development of portal hypertension and esophageal varices. Be aware that didanosine already has a Boxed Warning for lactic acidosis and hepatomegaly with steatosis. Didanosine in combination with other antiretroviral agents as well as hydroxyurea or ribavirin has been associated with the development of liver toxicity. 資料來源：美國食物及藥物管理局 Sources：United States Food and Drug Administration (USFDA) http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm199343.htm http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm199169.htm 4 有關奧氮平(olanzapine, Zyprex®) 安全性的最新資訊 美國食物及藥物管理局（USFDA）通知衛生專業人士關於奧氮平(olanzapine, Zyprex®)安全性的最新資訊,簡述如下： Olanzapine 可用於13 至17 歲青少年的精神分裂症和第一類雙極症(躁狂或混合發作) 。醫生在決定治療方案前應注意，相對於成人, olanzapine 在青少年中更易引起高血糖、高血脂、體重增加、高泌乳素血症、與鎮靜有關的不良反應、肝轉氨酶升高以及其他潛在的長期毒性。在多數情況下，醫生應優先考慮對青少年病人處方其他藥物。 當olanzapine 用於兒科病人時，需要全面的治療方案。Olanzapine 只是治療兒科病人精神分裂症和雙極症的其中一個療程，對於這類疾病還需要配合心理方面、教育方面以及社會方面的措施，但是olanzapine 對小於13 歲的兒童病人中的有效性和安全性尚未確立。 Latest safety update on olanzapine (Zyprex®) The United States Food and Drug Administration (USFDA) notified healthcare professionals about the latest update on olanzapine(Zyprex®) medications. Summaries are listed as follows: Olanzapine is indicated for use for schizophrenia and bipolar I disorder (manic or mixed episodes) in adolescents ages 13 – 17. Before the physicians decide among the alternative treatments, the clinician should note that olanzapine has an increased potential for causing hyperglycemia, hyperlipidemia, weight gain, hyperprolactinemia, increased frequencies of sedation-related adverse events, increased hepatic transminase levels and other potential long-term risks when this medication is prescribed to the adolescents as compared to their adult counterparts. In many cases this may lead them to consider prescribing other drugs first in adolescents. There is a need for comprehensive Treatment Program in Pediatric Patients when olanzapine is being used in this population. Olanzapine is indicated as an integral part of a total treatment program for pediatric patients with schizophrenia and bipolar disorder that may include other measures (psychological, educational, social) for patients with the disorders. Effectiveness and safety of olanzapine have not been established in pediatric patients less than 13 years of age. 資料來源：美國食物及藥物管理局 Sources：United States Food and Drug Administration (USFDA) http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm198402.htm http://www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/UCM198412.pdf
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 1375 有關長效ß受體激動劑(Long-Acting Beta Agonists, LABAs)安全性的最新資訊 美國食物及藥物管理局（USFDA）通知衛生專業人士關於長效 ß 受體激動劑 (Long-Acting Beta Agonists,LABAs)安全性的最新資訊。USFDA 在分析臨床研究的結果後，認為LABAs 可能會增加哮喘病人病情惡化的風險、導致住院甚至死亡，基於安全方面的考慮， USFDA更新使用該類藥物的指引。 為確保安全使用此類藥物，衛生專業人士應注意以下事項： 含單一成份的LABAs只可與其他控制哮喘的藥物併用，不能單獨使用。 只有服用治療哮喘的藥物後仍不能有效控制症狀 的病人才可長期使用LABAs。 儘可能以最短的LABAs使用時間來控制哮喘的症狀，當哮喘受到控制後，應停用LABAs。而病人應繼續使用原來的藥物控制病情。 對於有使用類固醇吸入劑的兒童和青少年病人，如需要增加一種LABA，應使用含有一種類固醇及一種LABA 的複方製劑，以增加病人服藥的順從性。USFDA認為，對於需要加入LABA來控制哮喘病情的病人，適當地使用LABAs 對改善哮喘症狀的效益將大於其潛在風險。 Latest safety update on Long-Acting Beta Agonists(LABAs) United States Food and Drug Administration (USFDA) notified healthcare professionals about the latest safety update on Long-Acting Beta Agonists (LABAs) Due to safety concerns, FDA is class-labeling changes for all LABAs. These changes are based on FDA's analyses of studies showing an increased risk of severe exacerbation of asthma symptoms, leading to hospitalizations in patients as well as death in some patients using LABAs for the treatment of asthma. Healthcare professionals are reminded that to ensure the safe use of these products: Single-ingredient LABAs should only be used in combination with an asthma controller medication; they should not be used alone. LABAs should only be used long-term in patients whose asthma cannot be adequately controlled on asthma controller medications. LABAs should be used for the shortest duration of time required to achieve control of asthma symptoms and discontinued, if possible, once asthma control is achieved. Patients should then be maintained on an asthma controller medication. Pediatric and adolescent patients who require the addition of a LABA to an inhaled corticosteroid should use a combination product containing both an inhaled corticosteroid and a LABA, to ensure compliance with both medications. USFDA has determined that the benefits of LABAs in improving asthma symptoms outweigh the potential risks when used appropriately with an asthma controller medication in patients who need the addition of LABAs.資料來源：美國食物及藥物管理局 Source：United States Food and Drug Administration (USFDA) http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm201003.htm http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm200776.htm 6 有關deferasirox (商品名：Exjade®) 安全性的最新資訊 美國諾華公司(Novartis)與 USFDA 發出的通告指Exjade®有可能引起腎功能損傷(包括腎衰竭)、肝功能損傷(包括肝衰竭)以及胃腸道出血等不良反應。上述不良反應於年長患者、骨髓異常增生綜合症(myelodysplastic syndrome, MDS)的高危病患、潛在的腎臟﹑肝臟損傷患者以及血小板過低的人士中更易發生，且有可能是致命的。因此，美國諾華公司(Novartis)和 USFDA 決定在此藥物的說明書中加入以下的禁忌症資訊： 肌酐清除率小於 40 mL/min 或血清肌酐大於兩倍與年齡相應的正常值上限。 Latest safety updates on deferasirox (Exjade®) Novartis Oncology and USFDA notified that the product may cause renal impairment(including failure), hepatic impairment(including failure) and gastrointestinal hemorrhage. These reactions were more frequently observed in patients with advanced age, high risk myelodysplastic syndromes, underlying renal or hepatic impairment or low platelet counts, and they could be fatal. Therefore Novartis and USFDA have decided to add the followings on contraindications: Creatinine clearance<40 mL/min or serum creatinine>2 times the age-appropriate upper limit of normal. Poor performance status and high-risk myelodysplastic syndromes or advanced malignancies. Platelet counts <50 x 109L.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 138骨髓異常增生綜合症病情危急或惡化，以及晚期 惡性腫瘤。 血小板數少於50x109/L。 已知對deferasirox或Exjade®中任一成份過敏者。 此外，需對使用Exjade®的病人進行密切監測，包括以下措施： 於開始治療前檢測血清肌酐和/或肌酐清除率，然後每月檢測一次；對於具有潛在腎功能損傷或危險因子的病人，首月每星期檢測一次肌酐和/或肌酐清除率，然後每月檢測一次。 於開始治療前檢測血清轉氨酶和膽紅素，首月每兩個星期檢測一次，然後每月檢測一次。 Known hypersensitivity to deferasirox or to any other component of Exjade®. In addition, Exjade® therapy requires close patient monitoring, including measurement of: serum creatinine and/or creatinine clearance prior to initiation of therapy and monthly thereafter; in patients with underlying renal impairment or risk factors for renal impairment, monitor creatinine and/or creatinine clearance weekly for the first month, then monthly thereafter.any risk associated with Byetta. serum transaminases and bilirubin prior to initiation of therapy, every two weeks during the first month and monthly thereafter. 資料來源： 美國食物及藥物管理局 Source ：United States Food and Drug Administration (USFDA) http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm200850.htm http://www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/UCM200858.pdf 7 有關異維 A 酸(isotretinoin) 安全性的最新資訊 加 拿 大 衛生 部 向 衛生 專 業 人士 發 出 關於isotretinoin 安全性的最新資訊，簡述如下： 上市後通報的個案中，發現十分罕見的嚴重皮膚反應, 如多形性紅斑(erythema multiforme, EM)、史提芬-強生綜合症(Stevens-Johnson syndrome, SJS)及毒性表皮溶解症(toxic epidermal necrolysis, TEN), 與服用 isotretinoin 存在關聯性。 上述不良反應可能很嚴重，並足以導致住院、殘疾或死亡。 應密切監測病人發生的不良反應，一旦出現嚴重 皮膚反應，應考慮停藥。 Latest safety updates on isotretinoin Health Canada informed prescribers of important new safety information regarding the use of isotretinoin: There have been very rare post-marketing reports of severe skin reactions (e.g. erythema multiforme [EM], Stevens-Johnson syndrome [SJS], and toxic epidermal necrolysis [TEN] ) associated with isotretinoin use. These events may be serious and result in hospitalization, disability or death. Patients should be monitored closely for severe skin reactions and discontinuation of isotretinoin should be considered if warranted. 資料來源： 加拿大衛生部 Sources ：Health Canada http://www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/accutane_2_hpc-cps-eng.pdf 8 有關沙奎那韋 (saquinavir) 安全性的最新資訊 美國食物及藥物管理局（USFDA）正回顧關於併用沙奎那韋(saquinavir)和利托那韋(ritonavir)對心臟可能產生嚴重不良反應的臨床試驗，資料顯示併用兩藥可能會引起 QT 或 PR 間期延長。QT 間期延長會增加出現心律失常的風險，甚至導致 torsades de 間期 Latest safety update on saquinavir The U.S. Food and Drug Administration (USFDA) is reviewing clinical trial data about a potentially serious effect on the heart from the use of saquinavir incombination with ritonavir. The data suggest that togetherthe two drugs may affect the electrical activity of the heart,causing prolonged QT or PR intervals. A prolonged QT interval can increase the risk for abnormal
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 139延長可能會造成心臟傳導阻滯，因此，請衛生專業人士： 密切留意併用 saquinavir 與 ritonavir 的病人是否出現有關的不良反應。 對於有 QT 間期延長病史、罹患心臟傳導系統疾病、缺血性心臟病、心肌病或潛在的結構性心臟病的病人、不要使用 saquinavir。 對於正在服用可能延長 QT 或 PR 間期的藥物，包括服用第 IA 類(如奎尼丁(quinidine))或第 III 類(如胺碘酮(amiodarone))抗心律失常藥物的病人，不要併用 saquinavir。 heart rhythms, including a serious abnormal rhythmpointes, PR called torsades de pointes. A prolonged PR interval can cause heart block. Therefore, healthcare professionals are recommended: Closely monitor if any adverse drug reaction occurs in patients using saquinavir with ritonavir. Not use saquinavir in patients with a history of QT interval prolongation, preexisting conduction system disease, ischemic heart disease, cardiomyopathy, or underlying structural heart disease. Not use saquinavir in patients who are currently using Class IA (such as quinidine) or Class III (such as amiodarone) antiarrhythmic drugs or other drugs that may prolong the QT or PR interval. 資料來源：美國食物及藥物管理局 Sources：United States Food and Drug Administration (USFDA) http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm201221.htm 9 有關 WinRho®SDF(Rho(D)人類免疫球蛋白注射劑)安全性的最新資訊 Cangene Corporation 與美國食物及藥物管理局（USFDA）通知衛生專業人士，過去有數宗關於免疫性血小板減少性紫癜 (immune thrombocytopenic purpura, ITP)的病人在使用 WinRho® SDF(Rho(D)人類免疫球蛋白注射劑)後出現血管內溶血(intravascular hemolysis,IVH)及併發症的報告，當中包括致死個案。IVH 可引致貧血和多器官衰竭，包括急性呼吸宭迫綜合症。其他曾報告的嚴重不良反應包括嚴重貧血、急性腎功能不全、腎衰竭以及彌漫血管內凝血。在出現 IVH 的病人中，致命個案多發生於併有其他疾病的年長病人(大於 65 歲)。 因此, Cangene Corporation 與 USFDA 對衛生專業人士作出下述建議： 病人於注射上述藥物後，需於具有相應設備的醫療機構內密切監視最少 8 小時。 在注射後 2 小時、4 小時以及監視期結束前，需使用尿液試紙進行分析。 應提醒病人注意 IVH 的症狀，包括背痛、寒戰、尿液變色或血尿。即使於 8 小時內沒有出現這些症狀，也不表示隨後並不會發生 IVH。 如果於注射 WinRho® SDF 後出現了 IVH 的症狀，或者懷疑出現相關症狀，便需要進行實驗室檢驗，包括血漿血紅蛋白、尿液分析、結合珠蛋白、乳酸脫氫酶(LDH)以及血漿膽紅素。 Latest safety update on WinRho® SDF (Rho(D) Immune Globulin Intravenous (Human)) Cangene Corporation and United States Food and Drug Administration (USFDA) notified healthcare professionals that cases of intravascular hemolysis (IVH) and its complications, including fatalities, have been reported in patients treated for immune thrombocytopenic purpura (ITP) with WinRho® SDF(Rho(D) Immune Globulin Intravenous (Human)). IVH can lead to anemia and multi-system organ failure including acute respiratory distress syndrome. Serious complications including severe anemia, acute renal insufficiency, renal failure and disseminated intravascular coagulation have also been reported. Fatal outcomes associated with IVH and its complications have occurred most frequently in patients of advanced age (age over 65) with co-morbid conditions. Therefore, Cangene Corporation and USFDA informed healthcare professionals that: Patients should be closely monitored in a health care setting for at least eight hours after administration. A dipstick urinalysis should be performed at baseline, 2 hours, 4 hours after administration and prior to the end of the monitoring period. Patients should be alerted to and monitor for signs and symptoms of IVH, including back pain, shaking chills, fever, and discolored urine or hematuria. Absence of these signs and/or symptoms of IVH within eight hours do not indicate IVH cannot occur subsequently. If signs and/or symptoms of IVH are present or if IVH is suspected after WinRho® administration, post-treatment laboratory tests should be performed including plasma hemoglobin, urinalysis, haptoglobin, LDH and plasma bilirubin. 資料來源：美國食物及藥物管理局 Sources：United States Food and Drug Administration (USFDA) http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm203739.htm http://www.fda.gov/downloads/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProducts/LicensedProductsBLAs/FractionatedPlasmaProducts/UCM198725.pdf
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 140《澳門醫學雜誌》2010 年稿約 《澳門醫學雜誌》 (ISSN 1608-7801)是由澳門特別行政區衛生局主辦的綜合性醫學學術期刊，以澳門地區的醫藥衛生、醫技護理專業人員為主要讀者對象。本刊在國家中華醫學會的指導和幫助下，除了報道澳門地區醫藥衛生、醫技護理方面的研究工作和臨床經驗外；同時也刊登中國內地、香港和其它國家有關論文和信息，以利最廣泛地開展學術交流。根據澳門的實際情況，政府規定《澳門醫學雜誌》為非牟利刊物，目前是贈閱國外、中國內地和澳門地區醫學專業人員和相關人士，全部支出均由政府承擔。本刊不刊登任何廣告，不接受任何贊助。 1. 季刊雜誌 每年 3 月、6 月、9 月、12 月末出版，由特區衛生局統一發行。2001 年 4 月號為本雜誌的創刊號。 2. 設有欄目 “論著和研究”、 “綜述和講座”、 “技術和方法”、“短篇和病例報告”、“專科和全科實習醫生專欄”、“信息和動態”、“工具和資料”等。 3. 來稿要求 （參照《中華醫學雜誌》”和“American Journal of Medicine”） 3.1 文稿：論著、綜述、講座等一般不超過 5 000 字；短篇、病例報告等不超過 1 500 字。第一次投稿時，請隨打印稿送寄拷貝的 3.5 吋軟盤一份，文章存盤要用 Word 格式(*.doc)，盡可能用繁體字；同時附上單位介紹信。資料要求可靠，文責自負。 3.2 文字：根據澳門地區特點，稿件全文可選用中文、葡文或英文中任一種文字；摘要則需要用另一種文字撰寫（400 實字）。題目需要三種文字。論著的摘要需包括國際統一的 “目的”、“方法”、 “結果”和“結論”四部分。為了同中國及其它國家更廣泛地交流，本刊論著和文獻綜述的中文全文，歡迎再用葡文或英文撰寫 (不同文字發表全文，不作為一稿兩投)。 3.3 作者：不超過 6 位。因本刊有 3 種文字，為防姓和名搞錯，同時按外文習慣，作者外文姓名中的姓要用大寫，如：Ling Yi YIN 或 YIN Ling Yi。 3.4 參考文獻：一律按《中華醫學雜誌》要求的 GB7714-87《文後參考文獻著錄規則》按序著錄。論著、綜述限制 10 篇以內，其它 5 篇以內。GB7714-87 格式如下： 3.4.1 官建泳, 林勺明, 李之珩, 等. 澳門成人泌尿道感染的致病菌及其抗生素的易感性. 澳門醫學雜誌, 2003, 3:149-151. 3.4.2 Lam UP, Jin C, Ip MF, et al. Clinical analyses of 78 cases of atrial fibrillation patients treated by anti-arrhythmic drugs. Revista de Ciências da Saúde de Macau,. 2002, 2:107-110. 3.4.3 張曉威, Martins AS, 陳剛. 直腸肛門癌. 見：吳懷申, 主編. 澳門惡性腫瘤. 第 1 版. 澳門：澳門衛生司, 1999.122-129. 3.4.4 Hanld H, Levine SY, Lee DT, et al. Diagnosis of coronary heart disease. In: Wilson H, Joss KL﹐Richard JF, et al, eds. Clinical cardiology. 5th ed. Philadelphia: W.J.Co., 2000. 156-165. 4. 稿酬 稿件採用刊登後，論著、綜述等贈送當期雜誌 5 冊；其他贈送 2 冊。 5. 來稿寄送 《澳門醫學雜誌》編輯部收。地址：澳門特別行政區，CP 3002，衛生局，行政大樓 2 樓；電話：(+853)-8390 7307、8390 6524；圖文傳真﹕(+853)-8390 7304；電子郵件﹕rcsm@ssm.gov.mo 。 《澳門醫學雜誌》編輯部
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 141 Artigos para a “Revista de Ciências da Saúde de Macau” – 2010 A “Revista de Ciências da Saúde de Macau (RCSM)”, ISSN 1608-7801, organizada pelos Serviços de Saúde da RAEM, é uma publicação científica dedicada às ciências da saúde, tendo como seus destinatários privilegiados os profissionais de saúde da Região de Macau. A revista sob a orientação e o apoio dado pela Associação de Medicina Chinesa da China visa divulgar informação sobre os trabalhos de investigação e experiência clínica da área da saúde da Região de Macau, bem como publicar dissertações e informações diversificadas provenientes da China Continental, Hong Kong e de outros países permitindo desenvolver o intercâmbio científico. De acordo com as caracteristicas de Macau, a Revista de Ciências da Saúde de Macau, sendo um journal sem fins lucrativos, todas as suas despesas são suportadas pelo Governo da R.A.E.M.. Esta revista é habitualmente oferecida aos médicos e pessoas com eles relacionadas e que vivem em Macau, China e estrangeiro. Por este motivo, esta revista não aceita nenhuma ajuda e nenhuma publicidade. 1. A revista é trimestral, com emissão em Março, Junho, Setembro e Dezembro e a sua publicação é da exclusiva responsabilidade dos Serviços de Saúde da RAEM. O 1º número da revista será publicado em Abril de 2001. 2. Rubricas : “Dissertação e Investigação”, “Tecnologia e Metodologia”, “Revisão e Palestras”, “Relatório Sucinto e Estudo de Caso”, “Coluna Especial para o Internato Geral e Complementar”, “Notícias” e “Dados e Meios”, etc. 3. Requisitos para os artigos a publicar (deverão ser adoptados os requisitos do “American Journal of Medicine” ou do “National Medical Journal of China”) : Textos : Os artigos a incluir nas rubricas “Dissertação”, “Revisão”, etc. poderão conter até 5 000 palavras; os artigos a incluir nas rubricas “Relatório Sucinto”, “Estudo de Caso”, etc., poderão conter até 1 500 palavras. Pela primeira vez, o artigo deverá ser entregue dactilografado em caracteres não simplificados, em formato de Word (*.doc) e acompanhado de “floppy disc”, bem como o Certificado do Instituto. Os autores são responsáveis pelo seu conteúdo. Língua : O texto integral do artigo deverá ser na língua chinesa, portuguesa ou inglesa e o sumário (400 palavras) deverá ser elaborado igualmente numa destas línguas mas diferente da utilizada no texto. O sumário de artigos a incluir na rubrica “Dissertação” tem de estar estruturado por “Objectivo”, “Método”, “Resultado” e “Conclusão”, de acordo com as regras adoptadas internacionalmente. Com vista a um intercâmbio mais amplo com a China e outros países, os artigos a incluir nas rubricas “Dissertação”e “Relatório Sucinto” poderão ter, para além do texto integral na língua chinesa, versões extraordinárias na língua portuguesa e/ou inglesa. Trata-se de um artigo, independentemente do número de versões. Autor : O número de autores não deverá exceder os 6. Dado que os artigos podem ser publicados numa das 3 línguas, o nome do autor deverá ser romanizado e o apelido deverá estar em maiúscula no sentido de evitar a eventual confusão, como por exemplo, Ling-Yi YIN ou YIN Ling Yi. Bibliografia : A bibliografia segue-se pela regra da Revista de Ciências da Saúde de Macau GB7714-87, constante das rubricas “Dissertação e Investigação”e “Revisão” e não deverá exceder os 10 documentos. Nos outros artigos, a bibliografia deverá limitar-se a mencionar 5 documentos. As formas de GB7714-87 poderão ser as seguintes : 3.4.1 Lam UP, Jin C, Ip MF, e outros. Análise clínica de 78 casos de fibrilhação auricular em doentes tratados com fármacos antiarritmicos. Revista de Ciências da Saúde de Macau,. 2002, 2:107-110. 3.4.2 Kuok CU. Retratar o cancro pulmonar. In: Wu HS. ed. Manual clínico de cancro pulmonar.1a ed. Macau : Serviços de Saúde da RAEM, 2002. 62-72. 4. Remuneração : A cada autor com artigo publicado na revista serão oferecidos 2 exemplares da revista ou 5 exemplares, no caso de serem artigos publicados nas rubricas “Dissertação” e “Relatório Sucinto”. 5. Os artigos deverão ser endereçados ao Gabinete Editorial da “Revista de Ciências da Saúde de Macau”. Endereço : CP 3002, 2° Piso, Edifício da Administração dos Serviços de Saúde de Macau. Telefone n° (+853)-8390 7307, 8390 6524; Fax : (+853)-8390 7304; e endereço : rcsm@ssm.gov.mo. Gabinete Editorial da “Revista de Ciências da Saúde de Macau”
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 142 Articles for “Health Science Journal of Macao ” – 2010 The Health Science Journal of Macao (HSJM), ISSN 1608-7801, is a scientific journal on medicine organized by the Health Bureau of Macao Special Administrative Region (HBMSAR). It addresses the diverse audience of health care providers within medicine, nursing, and the allied health professions. The journal publishes original articles, research, technical notes, reviews and up-to-date news in Macao. Some articles from China, Hong Kong and other countries also are published for scientific exchange. According to the circumstance of Macao, the HSJM defined as a profitless journal, all of our expenditures are supported by the government of Macao SAR. This journal is currently present to doctors and related people who are living in Macao, China and foreign country; therefore, the journal is not accept for any supporting, nor advertising. 1. HSJM is quarterly journal and issue in March, June, September and December by HBMSAR. The first issue will be published in April of 2001. 2. Columns: “Original Articles and Research”, “Technologies and Methods”, “Reviews Articles and Lectures”, “ Short Report and Case Report”, “Special Column for Interns of the General and Complementary Training”, “Medical News” and “Data and Reference”, etc. 3. Requirements for publish articles: 3.1. Texts: The Original Articles, Research, Reviews and Lectures may contain within 5 000 words. Other articles can contain within 1 500 words. The article must be typed and saved in the 3.5’ floppy disk as word document (*.doc), including certificate of Institute for the first delivery. For the Chinese version, it is better to submit by using the traditional Chinese letter. The author is responsible for the content. 3.2. Language: The texts of the integral article must be in Chinese, Portuguese or English and the summary (400 words) also must be elaborated in one of these languages but different from the used in the text. The summary of the article for the column “Original and Research Articles” must be structured by “Objective”, “Method”, “Result” and “Conclusion”, in according with the rules adopted internationally. 3.3. Author: The number of authors must not exceed 6 persons. As the articles for publication can be in one of three languages, the name of the author must be standard and the surname must be in capital letter in order to avoid the eventual confusion, for example, Ling-Yi YIN or YIN Ling Yi. 3.4. Reference: It is necessary to write the reference according to the forms of “National Medicine Journal of China”. For Original and Research Articles, Reviews and Lectures, the reference is limited within 10 documents. For other articles, the reference is limited within 5 documents. The forms are the following: 3.4.1 Lam UP, Jin C, Ip MF, et al. Clinical analyses of 78 cases of atrial fibrillation patients treated by anti-arrhythmic drugs. Revista de Ciências da Saúde de Macau,. 2002, 2:107-110. 3.4.2 Cheong TH. Diagnosis of lung cancer. In: Wu HS, ed. Clinical handbook of lung cancer. 1st ed. Macao:Department of Health of MSAR, 2001. 78-91. 4. Remuneration: Each author with article published in the journal will receive 2 copies of HSJM, or 5 copies if the article is published in the columns “Original Articles” and “Collective Reviews and Lectures”. 5. The articles must be delivered to the Editorial Office of HSJM. Office address: CP 3002, 2nd floor, Administrative Building, Health Bureau, MSAR. Tel: (+853)-8390 7307, 8390 6524; Fax: (+853)-8390 7304, E-mail: rcsm@ssm.gov.mo. Editorial Office of “Health Science Journal of Macao”
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 144Índice da RCSM, 2010, Vol. 10 【Dissertação e Investigação】 1. Tratamento de hemoptise……………………………1,2:01 CHAN Hong Tou, LO Iek Long, MOK Tin Hou e outros 2. Investigação sobre os resultados das operações cirúrgicas de catarata……………………………1,2:06 NGAI Chi Seng, LEONG Chan 3. Experiência obtida no tratamento cirúrgico de 124 casos de abscesso perianal com fístula anal………1,2:09 LIU Quanfang 4. Análise de micróbio patogénico e resistência aos medicamentos nascrianças doentes do Hospital Kiang Wu com infecção do tracto rinário………1,2:11 HUANG Kai-feng, YAO Jing, CHEN Yan e outros 5. Aplicação clínica da terapia de substituição renal contínua na unidade dos cuidados intensivos………1,2:14 PENG Li, XIAO Hong 6. Avaliação de substrato seleccionado sobre escherichia coli produtora de β-lactamase do espectro estendido em Macau………………………………………1,2:18 YE Qian, ZENG Hong, LI Peizhang e outros 7. Relatório sobre a aplicação com Jogo de Areia “Sandplay” no tratamento dos casos da ofidiofobia………………………………………1,2:22 LAO Wan U, SHEN He Yong 8. Estudo sobre os padrões de sono e insónia e os problemas do sono nos Alunos de ensino secundário em Macau…………………………3,4:68 CHOU Mei Fong, PANG Jiyang 9. Investigação comparativa entre o teste rápido de hemoglobina glicosilada e o valor da análise labortorial de hemoglobina glicosilada obtido no Laboratório do Centro Hospitalar Conde de São Januário…………………………3,4:75 CHAU Chi Hong, AU Tak Wai 10.Relatório preliminar sobre a influência do estilo de vida saudável no tratamento de doentes com hipertensão arterial………………………………3,4:77 LAM Yu Tou, CHOI Chong Po 11.Discussão do valor clínico da ecografia abdominal no diagnóstico da invaginação do intestino na criança………………………………………3,4:81 LEONG Shu Man, LEI Chon, LAM Chu 12.Valor clínico da procalcitonina utilizada no diagnóstico da pneumonia bacteriana dos idosos……3,4:84 ZHANG Xiao Zhan, CHENG Kun 13.Influência da fragmentação dos comprimidos na qualidade e a propriedade terapêutica……………3,4:87 TONG Hoi, LAM Kai Fung 14.Observações da eficácia clínica da radiofrequência guiada por DSA através de fossa pterigopalatina e no nervo supramaxilar…………………………3,4:93 JIANG Jin, LUO Yuhui, ZHENG Hushan 15.Análise de efeitos clínicos da terapeûtica destinada às hemorróidas internas com “medicamento modificado de eliminação de hemorróidas” em 2 fases de injecção” (1.864 casos clínicos, em anexos) ……………3,4:96 LIU Quanfan 16.Tuberculose Intestinal-Análise clínica de 8 casos……3,4:98 WU Ian Wang, YU Hon Ho 【Revisão e Palestras】 1. Avanço na terapêutica de cessação tabágica…………1,2:27 LO Iek Long, LAM Bing, CHEONG Tak Hong 2. Tecnologia de terapia relacionada com jogo de areia…1,2:31 LAO Wan U, SHEN He Yong 3. Discussão sobre o estado de saúde sub-óptimo das crianças na Ásia e a sua prevenção………………1,2:33 XU Weiying 4. Discussão sobre a viabilidade de estabelecimento da consulta externa de oncologia nos centros de saúde……………………………………………1,2:38 PANG Sai Meng 5. Tosse Crónica de etiologia deconhecida:métodos de tratamento………………………………………3,4:101 LIANG Jian Hui, CHEANG Ka Neng 6. Plano sobre a criação de arquivos em Macau para registo da situação sobre o aumento de refração durante a infância e adolescência………………………3,4:106 LOK Mei Sim 【Relatório Sucinto e Estudo de Caso】 1. Manifestações pulmonares da esclerose tuberosa……1,2:42 MOK Tin Hou, LOK Iek Long, CHAN Hong Tou e outros
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 1452. Um (1) caso de histiocitoma fibroso angiomatóide …………………………………………………1,2:47 CHAN Kin Iong, WEN Jianming 3. Um caso de intervenção de emergência de sucesso para um doente com embolia pulmonar maciça aguda, através da realização de oxigenação por membrana extracorpórea juntamente com a técnica da trombectomia com fios-guia…………1,2:50 JIN Chun, Long Forg-Kan, Ning Jiu Kei 4. Reportagem de casos de peritonite lúpica ……………………………………………………1,2:52 LAM In Fong, PENG Li, XIAO Hong 5. Marsupialização no tratamento de gigante cisto mandibular…………………………………………1,2:54 NG Hiu Lam, YU Dongsheng, TAO Qian e outros. 6. Dois casos de aneurisma apical e a revisão da literatura…………………………………………3,4:109 JIN Chun, LONG Fong Kuan, LIU Hong e outros 7. Tecido adiposo de miringoplastia……………………3,4:112 MOK Tin Seak 【Resumos de Artigos Médicos Internacionais】 1. TAC espiral de 64 cortes na aplicação do Pseudoaneurisma aortico……………………………………………1,2:57 2. Investigação sobre o uso de TAC espiral de 64 cortes de subtração digital angiográfica no diagnóstico dos aneurismas intracranianos………………………1,2:58 3. Neurionoma trigeminal intracranial entre o diagnóstico MRI e o diagnóstico diferenciado………………1,2:59 4. Utilização de colonografia por múltiplo-slice TAC espiral no diagnóstico de neoplasia colorrectal………3,4:115 5. Resistência de Klebsiella pneumoniaes às beta-lactamases de largo espectro (ESBLs) e a sua genotipagem…3,4:116 6. Guia para a orientação do tratamento do tumor maligno da cavidade oral e maxilofacial…………………3,4:117 7. Características morfológicas de TAC de aneurisma da aorta abdominal infrarenal, de grande e pequena dimensão…………………………………………3,4:118 8. Estudo preliminar sobre a influência de perfusão provocada pela velocidade de injecção em nódulo pulmonar solitário com TAC espiral de 64 cortes…………3,4:119 9. Discussão preliminar sobre a perfusão cerebral de TAC com subtração de imgens…………………………3,4:120 10.MRI no diagnóstico de encefalomiopatia mitocondrial …………………………………………………3,4:121 11.Teste de anticorpos contra VIH-1 na urina e o seu significado clínico………………………………3,4:122 12.Valor do diagnóstico de angiografia da artéria vertebral com 3D-TAC na arteriopatia cervical com espondilose cervical…………………………………………3,4:123 13.Relação entre o fígado gordo não alcoólico e a resistência à insulina………………………………………3,4:124 14.Marsupialização e drenagem aspiratória no tratamento de cistos da mandíbula…………………………3,4:125
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2010, Vol.10, No.3, 4 146Contents of HSJM, 2010, Vol 10 【Original Articles and Research】 1. Algorithm for the Management of Patients with Massive Hemoptysis: A Review of 5-year Experience in Macao…………………………………………1,2:01 CHAN Hong Tou, LO Iek Long, MOK Tin Hou et al 2. Study Outcomes in Cataract Surgery……………………1,2:06 NGAI Chi Seng, LEONG Chan 3. Ong Stage Surgical Therapy in the Treatment of Perianal Abscess Complicated with Anal Fistula…………1,2:09 LIU Quanfang 4. Analysis of the Common Pathogenic Bacteria and Drug Resistance in Children with urinary Tract Infection in Kiang Wu Hospital………………………………1,2:11 HUANG Kai-feng, YAO jing, CHEN yan, et al 5. Clinical Utility of Continuous Renal Replacement Therapy in Critical Care Unit……………………………1,2:14 PENG Li, XIAO Hong 6. Evaluation of Substrate Screening in ESBLs-Producing Escherichia coli in Macao………………………1,2:18 YE Qian-hong, ZENG Rui, LI Pei-zhang, et al 7. The Report of Sandplay Therapy in a snake fear case…1,2:22 LAO Wan U, SHEN He Yong 8. Sleep-Wake Patterns and Sleep Problem in High School among Macau Chinese………………………………3,4:68 CHOU Mei Fong, PAN Ji Yang 9. A Study Comparison of Point of Care of HbA1c and Laboratory Testing in C.H.C.S.J…………………3,4:75 CHAU Chi Hong, AU Tak Wai 10.The Effect of Healthy lifestyle Behavior Change on Hypertension………………………………………3,4:77 Lam Chu Tou, Choi Chong Po 11.Study of Ultrasound Diagnosis of Intussusception in Children…………………………………………3,4:81 LIANG Shu Ming, LI Jun, LIN Ning 12.Role of Procalcitonin in Bacterial Pneumonia among the Elderly Population………………………………3,4:84 ZHANG Xiao Zhan, CHENG Kun, et al 13.The Influence of Tablet Split on the Quality of Medications………………………………………3,4:87 TONG Hoi Yee, LAM Kai Fung 14.Effect of Maxillary Nerve Radiofrequency Lesion Via Sphenopalatina Fossa Guided on DSA……………3,4:93 JIANG Jin, LUO Yuhui, ZHENG Hushan, et al 15.The Injection Sclerotherapy of Modified “Xiaozhiling” liquid through Two-step Procedure for Internal Hemorrhoids:Report of 1864 cases………………3,4:96 LIU Quanfang 16. 8 Clinical Analysis of Intestinal Tuberculosis………3,4:98 WU Ian Weng, YU Hon Ho 【Collective Reviews and Lectures】 1. Recent Advances in Smoking Cessation………………1,2:27 LO Iek Long, LAM Bing, CHEONG Tak Hong 2. Sandplay Therapy……………………………………1,2:31 LAO Wan U, SHEN He Yong 3. Sub-healthy and prevention of Children ………………1,2:33 XU Weiying 4. Evaluation of Feasibility and Strategic Plan for Establishment of Oncologic Clinics in Primary Health Care Setting…1,2:38 PANG Sai Meng 5. The Etiology, Diagnosis and Treatment of Chronic Cough …………………………………………………3,4:101 LIANG Jian Hui, CHEANG Ka Neng 6. The Idea of Construct of Archives of Refraction Development for Children& Adolescent in Macao………………3,4:106 LOK Mei-sim 【Short Report and Case Report】 1. Pulmonary Manifestations of Tuberous Sclerosis Complex (TSC)………………………………………………1,2:42 MOK Tin Hou, LOK Iek Long, CHAN Hong Tou, et al 2. A Case Report: Angiomatoid Fibrous Histiocytoma……1,2:47 CHAN Kin iong, WEN Jianming 3. Emergency Pulmonary Arteriography and Interventional Therapy in Patient with Operative Acute Massive Pulmonary Embolism……………………………1,2:50 JIN Chun, Long Forg-Kuan 4. Two Cases Report of Lupus Peritonitis………………1,2:52 Lam In Fong, Peng Li, Xiao Hong 5. Marsupialization as a treatment for large mandibular cystic lesions………………………………………1,2:54 Ng Hiu Lam, Yu Dongsheng, Tao qian, et al 6. Apical Ballooning Syndrome Case Report and a Systematic Review……………………………………………3,4:109 JIN Chun, LONG Forg-Kuan, LIU Hong, et al 7. Adipose Tissue Myringoplasty…………………………3,4:112 MOK Tin Seak 【Foreign Medical Abstracts】 1. Application of 64-slice CT in the Aortic Pseudoaneurysm…………………………………1,2:57 2. The diagnosis of intracranial aneurysms:using 64-row multisection CT digital subtraction angiography……1,2:58 3. MRI diagnosis and differential diagnosis of intracanial trigeminal neurinoma………………………………1,2:59 4. Diagnostic value of multi-slice spiral CT colonography in colorectal neoplasms………………………………3,4:115 5. Antimicrobial resistance and gene typing of extended-spectrum β-lactamases-producing Klebsiella pneumoniae……3,4:116 6. The protocol of treatment guideline of oral and maxillofacial malignant neoplasms………………………………3,4:117 7. CT morphological characteristics of large and small infrarenal abdominal aortic aneurysm…………………………3,4:118 8. Preliminary study on Injection speed of perfusion in soliary pulmonary nodule with 64-detector CT…………3,4:119 9. Preliminary application of cranial subtraction CT perfusion imaging……………………………………………3,4:120 10.MR diagnosis of mitochondrial Encephalomyopathy…3,4:121 11.Detection and clinical significance of HIV-1 antibody in urine…………………………………………………3,4:122 12. 3D-CT vertebral artery angiography for cervical spondylotic vertebral arteriopathy………………………………3,4:123 13.The relationship between nonalcoholic fatty liver diseses and insulin reistance………………………………3,4:124 14.Marsupialization and Suction Drainage in the Treatment of Jaw Cysts………………………………………3,4:125
