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…………………………………………………………………JIN Chun, Long Forg-Kan, Ning Jiu Kei Reportagem de casos de peritonite lúpica………………………………………………………………………LAM In Fong, PENG Li, XIAO Hong Marsupialização no tratamento de gigante cisto mandibular…………………………………………………NG Hiu Lam, YU Dongsheng, TAO Qian e outros. Resumos de Artigos Médicos Internacionais TAC espiral de 64 cortes na aplicação do Pseudoaneurisma aortico…………………………………………Investigação sobre o uso de TAC espiral de 64 cortes de subtração digital angiográfica no diagnóstico dos aneurismas intracranianos……………………………………………………………Neurionoma trigeminal intracranial entre o diagnóstico MRI e o diagnóstico diferenciado……………… Artigos da RCSM e autores (em Chinês, Português e Inglês) ………………………………………………… Revisão em Chinês : HUANG Xiang-Long 50525457585965
Foreign Medical Abstracts Application of 64-slice CT in the Aortic Pseudoaneurysm……………………………………………………The diagnosis of intracranial aneurysms:using 64-row multisection CT digital subtraction angiography………MRI diagnosis and differential diagnosis of intracanial trigeminal neurinoma…………………………………575859Articles of HSJM to authors ( in Chinese, Portuguese, and English) …………………………………………… 65 Proofreader in Chinese : HUANG Xiang-Long
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 1‧論著和研究‧ Algorithm for the Management of Patients with Massive Hemoptysis: A Review of 5-year Experience in Macao CHAN Hong Tou LO Iek Long MOK Tin Hou IAM Lap Fong CHEONG Tak Hong 【 Abstract 】 Objective Massive hemoptysis is a life-threatening condition that may lead to asphyxiation and respiratory failure. The purpose of this study was to evaluate the efficacy of different treatment modality and summarize the algorithm for the management of massive hemoptysis in Macao. Methods Pateints with massive hemoptysis from Jan 2005 to Nov2009 were identified by screening the bronchoscopy suite database. Massive hemoptysis was defined as expectoration of more than 300ml of blood each time or more than 600ml in 24 hours. Clinical characteristics, sequence of treatment, outcome and follow-up data were recorded and the efficacies of each treatment modality were analyzed. Continuous data were expressed as mean ± standard deviation and categorical data were expressed as percentage. Chi-square test was used to assess the association between the cause of hemoptysis and the success rate of bronchoscopic therapy. Results After screening for 2,567 cases who received bronchoscopy examination over a period of five, we identified 22 patients with massive hemoptysis. The mean age of these patients was 46.6±16.0 year-old and 18 (81.8%) of them were male. Only 36.4% patients were referred to bronchoscope from emergency room or intensive care unit. All these patients received bronchoscopic therapy after initial management with airway protection, supplemental oxygen, medication and fluid resuscitation. Bleeding was stopped in 12 (54.6%) patients and 1 (4.6%) died of uncontrolled hemoptysis. Of the remaining 9 (40.9%) patients who fail to respond to bronchoscopic therapy, 7 (77.8%) and 8 (88.9%) patients achieved hemostasis after once and twice bronchial artery embolisation. Only one patient who failed to both bronchoscopic therapy and bronchial artery embolisation underwent successful surgical treatment. There is no complication related to this procedure. The mortality rate of our group was 3/22 (13.6%). One of them died immediate after bronchoscopic therapy, one died after recurrent hemoptysis 16 months after bronchial artery embolisation, and one was died of multiple trauma which is not directly related to massive hemoptysis. Conclusion After Initial management with airway protection and fluid resuscitation, a stepwise approach with bronchoscopic therapy, bronchial artery embolisation and surgery is effective in managing massive hemoptysis in Macao. The importance of multidisciplinary management with respiratory and critical care physician, interventional radiologist and thoracic surgeon should never be overemphasized. 【Key words】 Massive hemoptysis; Bronchoscopy; Bronchial artery embolisation 大咯血的處理 陳洪濤, 羅奕龍, 莫天浩, 任立峰, 張德洪. 中國, 澳門特別行政區, 仁伯爵綜合醫院, 胸肺科; Tel: (+853)-8390 2400; E-mail: chanhtpneum@yahoo.com.hk 【摘要】 目的 大咯血是內科急症，可併發窒息或急性呼吸衰竭而導致死亡。本研究的目的在於探討不同止血方法的療效和總結本院處理大咯血患者的流程。 方法 從仁伯爵綜合醫院氣管鏡室資料庫中，篩選在 2005 年 1 月至 2009 年 11 月期間因大咯血進行支氣管鏡檢查的病人。大咯血定義為一次咯血量大於 300 毫升或一天內出血量總和大於 600 毫升。從病歷記錄收集所有入選患者的臨床資料、治療順序、預後和隨訪資料，來分析各種主要治療方法的療效。計量資料以均數 ± 標準差表示，計數資料以百分比表示。應用卡方檢驗分析不同病因與支氣管鏡治療成功率的相關性。 結果 在過去五年內，有 2,567 名患者進行了支氣管鏡檢查，我們從當中篩選出 22 名大咯血患者進行分析。患者平均年齡為 46.6±16.0 歲，男性患者佔 81.8%。只有 36.4%名患者由急診室或深切治療部轉介到支氣管鏡室進行檢查，其餘患者在呼吸科病房接受治療。所有患者在一般治療包括氣道管理、吸氧、補液和藥物治療的基礎上進行氣管鏡治療，其中 12 名 (54.6%)患者經治療後出血停止、1 名 (4.6%)患者因持續出血而死亡。另外 9 名 (40.9%)患者因咯血不止，進一步接受支氣管動脈栓塞術。本研究發現對於支氣管鏡治療失敗的患者，一次和兩次栓塞治療術的成功率分別為 77.8%和 88.9%，同時未有與介入治療相關的不良反應。只有一名患有曲菌球的病人在接受兩次栓塞治療術後仍出血不止，需要接受外科手術治療。在本組患者中有 3 人死亡，病死率僅為 13.6%。其中一名患者接受氣管 Author’s address: Department of Respiratory Medicine, Centro Hospitalar Conde São Januário, Macao SAR, China; Tel: (+853)-8390 2400; E-mail: chanhtpneum@yahoo.com.hk
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 2 鏡治療後死亡、一名患者死於栓塞治療術後 16 個月的大咯血、一名患者死於多發性外傷。 結論 氣道管理、補液和藥物治療是處理大咯血的重要初步措施。有序地進行支氣管鏡治療、支氣管動脈栓塞術和外科手術治療是處理大咯血有效的方法。必需強調由呼吸內科和深切治療部醫生、介入放射學醫生和胸外科醫生聯合的多學科綜合治療，是挽救大咯血患者生命的重要手段。 【關鍵詞】大咯血; 支氣管鏡檢查; 支氣管動脈栓塞術 INTRODUCTION Massive hemoptysis is a life-threatening condition with a mortality rate of 50% in untreated patients P[1]P. The major causes of death are asphyxiation and intractable respiratory failure. Apart from airway management and conservative medical treatment, treatment modalities include bronchoscopic therapy, bronchial artery embolisation (BAE) and surgical treatment. The sequence and success rate of each treatment modality vary from country to country owning to availability and local expertise. There is no worldwide applicable guideline regarding the appropriate algorithm for the management of massive hemoptysis. The purpose of this study was to evaluate the efficacy of different treatment modality and summarize the local management algorithm for patients with massive hemoptysis. OBJECTIVE To evaluate the efficacy of different treatment modality and summarize the algorithm for the management of massive hemoptysis in Centro Hospitalar Conde de São Januário, Macau SAR, China. METHODS We searched the bronchoscopy suite database for patients who were referred for bronchoscopy examination due to hemoptysis from Jan 2005 to Nov 2009. Later, we reviewed the medical record to confirm the diagnosis of massive hemoptysis. Massive hemoptysis was defined as expectoration of more than 300ml of blood from the lung each time or more than 600ml in 24 hours P[2]P. Finally, we retrieved data from the medical records of all patients with massive hemoptysis. The clinical characteristics, type of referral, etiology of hemoptysis, the outcome and follow-up data were recorded accordingly. The sequence of therapeutic approaches of each patient was recorded and the efficacy of each treatment was evaluated. Focus was placed on the invasive treatments such as bronchoscopic therapy, BAE and surgical management. All bronchoscopic therapies were performed in the bronchoscopy suite or ICU by specialized team of bronchoscopists. All BAEs were performed by two interventional radiologists. The surgeries were done by two thoracic surgeons in our hospital. Continuous data were expressed as mean ± standard deviation and categorical data were expressed as percentage. A Chi-square test was used to assess the association between the cause of hemoptysis and the success rate of bronchoscopic therapy. Difference was considered significant when probability value was less than 0.05. RESULTS We identified 98 (3.82%) patients with the diagnosis of hemoptysis out of 2567 cases who received bronchoscopy examination over a period of 5 years. Among them, 22 (22.5%) patients who met the criteria of massive hemoptysis were selected for further analysis. The mean age of these patients was 46.6 ± 16.0 year-old (ranging from 14 to 79 year-old) and 18 (81.8%) of them were male. 14 (63.6%) patients were referred to bronchoscope from respiratory ward; whereas others were referred from emergency room or intensive care unit (Table) . The major causes of massive hemoptysis in this cohort were old pulmonary tuberculosis (40.9%), bronchiectasis (22.7%), active pulmonary tuberculosis (13.6%), and pneumonia (9.0%) (Table). Chest image, either chest radiograph or computed tomography, may identify the cause of hemoptysis in most of the patients. All these 22 patients received bronchoscopic therapy after conservative treatment with airway management, medication and fluid supplement. Bronchoscopic therapies included airway suctioning, bronchial lavage with cold saline, and instillation of adrenaline. Bleeding was stopped in 12 (54.6%) patients and 1 (4.6%) died of uncontrolled hemoptysis. The success rate of bronchoscopic therapy was 55.6% in old tuberculosis group and 53.8% in non-old tuberculosis group. There is no association between the cause of hemoptysis and the success rate of bronchoscopic therapy (chi-square 0.006, P=0.64).
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 3Of the remaining 9 (40.9%) patients who fail to respond to bronchoscopic therapy, 7 (77.8%) and 8 (88.9%) patients achieved hemostasis after once and twice bronchial artery embolisation. Only one patient with aspergilloma who failed to both bronchoscopic therapy and bronchial artery embolisation underwent surgical treatment (Figure). There is no complication related to this procedure. The mortality rate of our group was 3/22 (13.6%). One of them died immediate after bronchoscopic therapy, one died after recurrent hemoptysis 16 months after BAE, and one was died of multiple trauma not directly related to massive hemoptysis. Table Clinical characteristics and etiology of patients with massive hemoptysis Patient Characteristics Numbers, n 22 Male, n (%) 18 (81.8%) Age, years (range) 46.6±16.0 (14-79)Number of patients referred from ER / ICU, n (%) 8 (36.4%) Number of patients referred from respiratory ward, n (%) 14 (63.6%) Etiology, n (%) Old pulmonary tuberculosis 9 (40.9) Bronchiectasis 5 (22.7) Active pulmonary tuberculosis 3 (13.6) Pneumonia 2 (9.0) Pulmonary arterio-venous malformation 1 (4.5) Aspergillosis 1 (4.5) Chest trauma 1 (4.5) ER: emergency room; ICU: intensive care unit Figure Treatment algorithm for patients with massive hemoptysis DISCUSSION Massive hemoptysis is a potential life-threatening condition with high mortality of 50%P[1]P. Centro Hospitalar Conde de São Januário is the only public hospital providing medical service to all the residents in Macao. There are well-established bronchoscopy suite, interventional radiology center, and thoracic surgeons available in this hospital. In this study, we found that a systemic approach with different treatment modalities is the key to successful treatment in patients with massive hemoptysis. Etiology In Macao, old tuberculosis, bronchiectasis, active tuberculosis and pneumonia are the most common causes of massive hemoptysis, accounting for more than 80% of all cases. This distribution of diseases differs from that of western countries, where chronic inflammatory lung diseases and bronchogenic carcinoma are the most common causes of hemoptysisP[3]P. Diagnostic strategies Apart from history taking and physical examination, a chest radiograph is the most useful initial examination to identify the culprit lung lesions, such as mass, infiltration and atelectasis. However, a study has shown that chest radiograph fails to localize the lesion in 20-46% of patients with hemoptysis P[4]P. Computed tomography (CT) of the chest is superior in diagnosing certain lung pathologies, especially for small lung cancer, bronchiectasis and vascular abnormalities such as arterio-venous malformation or aneurysmP[5]P. CT may also facilitate bronchoscopy examination by localizing the site of lesions. Therefore, CT should be performed before bronchoscopy in patients with stable condition. Place of management In our series, only 36.4% of the patients stayed in emergency room or intensive care for the management of massive hemoptysis. According to the major consensus P[1]P or guidelineP[6]P, all patients with massive hemoptysis should be admitted to the intensive care unit (ICU) or high dependency unit (HDU) for the better monitoring of the amount of hemoptysis, hemodynamic status, and oxygen saturation. Basic blood tests such as complete blood profile, electrolytes, liver and kidney function, coagulation profile, arterial blood gas, blood typing and
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 4 cross-march should be done. In the future, we should admit patients with massive hemoptysis in ICU or HDU for better management. Initial management with airway protection, fluid resuscitation and medication For patients with massive hemoptysis, the priority is to maintain airway patency and stabilize the patient’s condition with supplemental oxygen, medication and fluid resuscitation. Firstly, the patients should be placed on the lateral decubitus position with the bleeding site down to prevent the contralateral lung from aspiration. Secondly, patients should be encouraged to cough up the blood as much as possible and the use of cough suppressant is controversial. Thirdly, intubation with large-bore (8-Fr) endotracheal tube is required for patients with worsening hypoxemia, CO B2 B retention or life-threatening hemoptysis. If the bleeding can be localized to the right or left lung, unilateral lung intubation may protect the non-bleeding lung P[7]P. Ideally, double-lumen tube allows ventilation of both lungs, while preventing aspiration from one lung to another; however, inserting double lumen tube requires expertise and is not usually done in an emergency setting P[8]P. The oral antifibrinolytic agent tranexamic acid, an inhibitor of plasminogen activation, is frequently used to control bleedingP[9]P. Blood loss should be treated with volume resuscitation, blood transfusion, and correction of coagulopathy. After the above initial management, patients with massive hemoptysis should undergo stepwise therapeutic modality including bronchoscopy, BAE and surgery. Bronchoscopic therapy Bronchoscopy, either rigid or flexible, should be done in all patients with massive hemoptysis as soon as possible, especially for those in unstable condition. Since rigid bronchoscopy is usually performed under general anesthetic and not commonly used in our hospital, we would arrange flexible bronchoscopy for patients with massive hemoptysis within 24 hours. Previous study has proved that early bronchoscopy gives a higher yield for localizing the site of bleeding compared to delayed bronchoscopy P[10]P. The roles of the bronchoscopy are to maintain airway patency by airway suctioning, localize the bleeding site, and identify the cause of bleeding by tissue sampling, smear and culture of bronchial secretion. Our study showed that more than half (54.6%) of the bleeding can be controlled with bronchoscopic treatment and initial medical treatment. Our usual practice is to perform bronchial lavage with cold saline and instillation of adrenaline (1:20 000) into the bleeding bronchus subsequently. Other endobronchial methods such as endobronchial balloon tamponadeP[6]P and hemostatic agentsP[11] Phas also been reported to be useful in managing massive hemoptysis. Bronchial artery embolisation In patients who failed to respond to bronchoscopic therapy, control of bleeding can be achieved in 77.8% and 88.9% of patients after once and twice BAE. The overall success rate of BAE is similar to that of other centers in this regionP[12]P. BAE is an attractive way to stop the bleeding due to the fact that more than 90% of hemoptysis originates form the bronchial artery. Technical failure of BAE occurs in up to 13% of cases and is mainly attributive to non-bronchial collateral arteries branching from the phrenic, intercostal, mammary, or subclavian arteries. Complications of BAE include vessel perforation, intimal tears, chest pain, pyrexia, hemoptysis, systemic embolisation, and spinal cord ischemia due to accidental spinal artery embolisation P[13]P. It has been reported that up to 20% of patients experienced recurrent bleeding within 6 months after embolisationP[14]P. In our cohort, only one patient succumbed due to recurrent hemoptysis 16 months after the procedure. Our study further proved that BAE is an effective and safe procedure if performed by experienced interventional radiologist. Surgical management Surgery should be the last resort for patients with massive hemoptysis. If the bleeding can not be stopped by bronchoscopic therapy and BAE, surgical opinion should be sought. In our cohort, surgical management succeeded in controlling bleeding in one patient with aspergilloma who failed bronchoscopic therapy and twice BAE. Mortality The mortality rate in our group was similar to that
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 5of other Asian countries, where the mortality rate was 13-25%P[12]P. Previous studies have shown that the risk of death correlates strongly with amount of blood expectorated, the rate of bleeding, the amount of blood within the lungs, and underlying pulmonary reserveP[15]P. However, we should know that the real mortality rate may be underestimated because the patients who were too ill to receive bronchoscopy examination were not included in this study. Limitations There are several limitations that deserve to be noticed. Firstly, this retrospective study only recruits patients who underwent bronchoscopy examination. Although we would perform bronchoscopy to all patients with massive hemoptysis, some cases would be missed such as patients died on or immediately after arrival at emergency room and those refused bronchoscopy examination. Secondly, there is no malignant cause of hemoptysis, reflecting the presence of selection bias. It is because most patients with advance stage lung cancer decline bronchoscope examination. Thirdly, due to ethical issue and retrospective nature of this study, there is no control group in our review. Therefore, the success rate of bronchoscopic examination and BAE should be interpreted cautiously owning to the fact that certain patients may have spontaneously hemostasis without any intervention. CONCLUSION Initial airway protection and fluid resuscitation, together with a stepwise approach with bronchoscopic therapy, BAE and surgery is effective in managing massive hemoptysis in Macao. Patients should be treated in ICU or HDU until the bleeding is controlled. The importance of multidisciplinary management with respiratory and critical care physician, interventional radiologist and thoracic surgeon should never be overemphasized. REFERENCE 1 Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med, 2000, 28: 1642-1647. 2 Pursel ST, Lindskog GE. Hemoptysis. A clinical evaluation of 105 patients examined consecutively on a thoracic surgical service. Am Rev Respir Dis, 1961, 84: 329-336. 3 Santiago S, Tobias J, Williams AJ. A reappraisal of the causes of haemoptysis. Arch Intern Med, 1991, 151:2449-2451. 4 Marshall TJ, Flower CD, Jackson JE. The role of radiology in the investigation and management of patients with haemoptysis. Clin Radiol, 1996, 51: 391-400. 5 Millar AB, Boothroyd AE, Edwards D, et al. The role of computed tomography (CT) in the investigation of unexplained haemoptysis. Respir Med, 1992, 86: 39-44. 6 Lordan JL, Gascoigne A, Corris PA. Assessment and management of massive hemoptysis. Thorax, 2003, 58: 814-819. 7 Gourin A, Garzon AA. Control of hemorrhage in emergency pulmonary resection for massive hemoptysis. Chest, 1975, 68: 120-121. 8 Klein U, Karzai W, Bloos F, et al. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia: a prospective study. Anesthesiology, 1998, 88: 346-350. 9 Lordan JL, Gascoigne A, Corris PA. Assessment and management of massive hemoptysis. Thorax, 2003, 58: 814-819. 10 Saumench J, Escarrabill J, Padro L, et al. Value of fiberoptic bronchoscopy and angiography for diagnosis of the bleeding site in hemoptysis. Ann Thorac Surg, 1989, 48:272-274. 11 Tsukamoto T, Sasaki H, Nakamura H: Treatment of hemoptysis patients by thrombin and fibrinogen-thrombin infusion therapy using a fiberoptic bronchoscope. Chest, 1989, 96: 473-476. 12 Shigemura N, Wan IY, Yu SCH, et al. Multidisciplinary Management of Life-Threatening Massive Hemoptysis. Ann Thorac Surg, 2009, 87: 849-853. 13 Uflacker R, Kaemmerer A, Picon PD, et al. Bronchial artery embolisation in the management of hemoptysis: technical aspects and long-term results. Radiology, 1985, 157: 637-644. 14 Wong ML, Szkup P, Hopley MJ. Percutaneous embolotherapy for life-threatening hemoptysis. Chest, 2002, 121: 95 - 102. 15 Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management. Clin Chest Med, 1994, 15: 147-167.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 6 ‧論著和研究‧ Study Outcomes in Cataract Surgery NGAI Chi Seng, LEONG Chan 【Abstract】 Objective To determine the outcomes of cataract surgery and factors influencing visual outcomes after cataract surgery in case series. Retrospective non-comparative interventional case series Method 601 consecutive eyes underwent cataract removal either phacoemulsification or extracapsular extraction with IOL insertion in my hospital between July 2004 and June 2009 performed by same surgeon. Collected data including patient demographics, preoperative visual acuity, ocular pathologic characteristic, surgical technique, operative, within 8Pth Pweek post operative conditions, analyzed poor outcomes cases. Results There were totally 390 patients with 601 eyes underwent cataract removal during this period. Patients ranged in age from 46 to 98 years (mean 74.6), 63.8% was female, visual acuity for preoperative eyes: 11.6% was less than 6/60, 71.9% was 6/60<6/18. Presenting visual acuity at 8 weeks post operation: there was 85.2% between 6/18 and 6/6, 3.2% less than 6/60, and the best corrected vision at 8 weeks post operation: 92.9% and 3.1% respectively. There were totally 2.4% operative complications and 2% post operative complications present. Conclusions In our series showed that cataract surgery is effective and safe with few complications. The most poor outcome cases in operated eyes had underlying ocular disorders.【Key words】 Cataract surgery; Outcome; Complication 白內障手術效果的研究 魏志成, 梁珍. 中國, 澳門特別行政區, 仁伯嚼綜合醫院, 眼科; Tel: (+853) 2831 3731-8845; 通訊作者: 魏志成. Tel: (+853) 6682 6140; E-mail:taylorngai88@hotmail.com 【摘要】 目的 通過系列病例研究白內障手術的效果及影响效果的因素。回顧性系列病例研究。 方法 通過搜集2004年7月至2009年6月我院由同一術者進行的601個白內障手術資科包括:病人一般資料 ,術前視力 ,眼部病變特徵 ,手術方法 ,術中及術後8周內的情况 ,分析手術效果差的病例。 結果 在此期間共390病人601隻眼行白內障手術。術前視力11.6%少於6/60, 71.9%在6/60至6/18之間, 八周後裸眼視力在6/18至6/6的有85.2%, 少於6/60的有3.2%。矯正後各有92.9%及3.1%。術中及術後併發症各有2.4%及2%。 結論 系列白內障手術研究顯示此手術效果好及併發症少。效果差的病例多伴有術前其他眼部病變。 【關鍵詞】 白內障手術; 效果; 併發症 Cataract is the world’s leading cause of blindness, affecting an estimated 20 million people with severely reduced vision of 3/60 or worse as a result of cataracts at the beginning of the last century, because of popular growth and aging, this will be swelled to 40 million by the year 2020 P[1]P. Cataract surgeries are the main ophthalmic surgery in many eye centers as well as in our eye department. The aim of this study was to determine the visual outcomes of patients who had cataract surgery in our series and to identify reasons for a poor outcome. Author’s address: Department of ophthalmology, Centro Hospitalar Conde de Sao Januario(CHCSJ), CP 3002, Macao SAR. China; Tel: (+853)-6682 6140; E-mail:taylorngai88@hotmail.com Methods The studying was undertaken in Sept. 2009 and was limited to individuals who had had surgery from July 2004 to June 2009 and who returned for outpatient appointments at least 8 weeks post operation. Patient excluded from the study were those who had other ocular procedures performed at the time of cataract extraction. A single recording form was developed to record the following: Age, sex, preoperative ocular pathologic characteristic, type of cataract operation, anesthesia method, preoperative visual acuity, operative and postoperative complications, 1PstP day post operation visual acuity, 8PthP week or after present and best correct visual acuity (Table 1). List the causes of poor present visual outcome. The Levels of visual acuity after cataract
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 7surgery were categorized using the WHO guidelinesP[2]P (Table2)—that is, good outcome was defined as 6/6–6/18, borderline outcome as <6/18–6/60, and poor outcome as <6/60. A database was created in SPSS 11.5. For operated eyes with a presenting vision less than 6/60 after 8PthP weeks was assessed the major cause of poor operative or postoperative complications and refractive errors. Table 1 Patient Survey A. General data 1. Age 2. Sex 3. Surgical technique (extracapsular extraction or phacoemulsification) 4. Other B. Preexisting ocular pathologic characteristics1. None 2. Glaucoma 3. Diabetic retinopathy 4. High myopia (>26 mm axial length) 5. AMD 6. Other C. Surgical complications 1. None 2. Posterior capsule tear with or without vitreous loss 3. Zonular dialysis 4. Hyphema 5. Other D. Postoperative complications noted at day 1, week 1, week 4, week 8 or acute attendance 1. None 2. Intraocular pressure >30 mmHg 3. Significant uveitis (.40 white blood cells per 3 mm high power field, or resulted in an increase in steroid treatment) 4. Wound problems (dehiscence, loose, or tight sutures) 5. Vitreous to wound, cornea, or anterior chamber 6. Other Table 2 WHO guidelines for Outcome Results Post-operative Presenting visual acuity (PVA) Best correction visual acuity(BCVA)Good 6/6 – 6/18 >80% >90% Borderline <6/18 – 6/60 <15% <5% Poor <6/60 <5% <5% Table 3 Results of 601 eyes after cataract operation At discharge at 8Pth P week or after Present Present Best Acuity % % % Good 64.1 85.2 92.9 Borderline 28.7 8.3 3.8 Poor 7 3.2 3.1 Not assessed 0.2 3.3 0.2 Total 100 100 100 Results A total of 390 patients 601 eyes were operated during this period, the mean age was 74.6 years old and female was 63.8%. There were 590/601(98.1%) eyes operated by phacoemulsification technique and 524/601 (87.2%) eyes under topical anesthesia, 31/601 (5.2%) eyes under retrobulbar anesthesia and the rest under general anesthesia. There were 11.6% of cataract eyes with visual acuity less than 6/60 before operation, 71.9% visual acuity> 6/60 <6/18. 1PstP day post operation there was 64.1% visual acuity better than 6/18, 8PthP week later there was 85.2% better than 6/18, and best correct vision was 92.9% better than 6/18. But there was 3.2% had present vision acuity less than 6/60(Table 3), most of them had preoperative underlying eye disorder including: Age related macula degeneration was 0.86%, late stage glaucoma was 0.86%, diabetic retinopathy, optic neuropathy was 0.34% each (Table-4). There was 0.34% with refractive errors. There were totally 2.4% operative complications and the posterior capsular rupture with or without vitreous loss was 1.8% (Table 5). There were totally 2% post operative complications present and the most common were elevated IOP with visual outcome. Causes of poor outcome can be classified as: pre-existing eye disease, 1.2% (Table 6). Table 4 Causes of poor outcomes after Surgery (8PthP week post operation) Causes Numbers/Percentage Corneal opacity 1 (0.17%) Age-related macular degeneration 5 (0.86%) Pathologic myopic maculopathy 1 (0.17%) Glaucoma 5 (0.86%) Central retinal vein occlusion 1(0.17%) Proliferative diabetic retinopathy 2(0.34%) Refractive error 2(0.34%) Optic neuropathy 2(0.34%) Total 19 (3.2%)
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 8 Table 5 Operative Conditions Number (%) Tear or vitreous loss 11 1.8%Zonular dialysis 2 0.4%Hyphema 1 0.2%Total 14 2.4% Tabl 6 Postoperative Conditions Number (%) IOP elevated 7 1.2%Pupil irregular 2 0.4%Iritis 1 0.2%Vitreous in A/C 1 0.2%Total 11 2.0% Discussion In our series, after cataract surgery, the good outcome ( 6/18) of PVA was 85.2% (>80%) and ≧BCVA was 92.9%(>90%), reached the WHO recommended levels. The prevalence of PVA that<6/18 was 11.5% and BCVA that<6/18 was 6.9% in our study series compares favorably with The Beijing Eye Study 2006P[3]P that the PVA<6/18 was 20.3% and BCVA<6/18 was 10.5%P[3]P.In our study series there were 100% intraocular lens insertion in posterior chambers compares favorably with 92.5% of The Beijing Eye Study 2006 and 91.5% of The Los Angeles Latino Eye StudyP[4]P. There were 19 (3.2%) eyes with poor outcome and 17(2.9%) of the 19 eyes had pre-existing ocular diseases such as age related macular degeneration, late stage glaucoma where the field of vision can be improved by cataract extraction. There were 2 of the 19 eyes with poor outcome due to refractive error and this can be avoided by accuracy of biometric measurements and proper intraocular lens insertion. There were totally 2.4% had operative complications and the posterior capsular rupture with or without vitreous loss was 1.8%. There were totally 2% post operative complications present and the most common was elevated IOP with 1.2%. It was compatible with the studies that the range of vitreous loss was 0-4.0%P[5]P and increased IOP was 0-19.7%P[5]P. In our series no one needed return to the operation room for reoperation, there were no cases of endophthalmitis or corneal decompensation. There were no cases both operative and post operative complications that cause poor visual outcome with best correction. Conclusion: In our series showed that cataract surgery is effective and safe with few complications. The most poor outcome cases had ocular co-morbidity in the operated eye. References 1 Foster A. Cataract－a global perspective: output, outcome and outlay. Eye, 1999;13:449-53. 2 World Health Organization. Informal consultation on analysis of blindness prevention outcomes. Geneva: WHO, 1998, WHO/PBL/98.68. 3 Liu, Liang Xu, Ya Xing Wang, et al. Cataract Surgery and Postoperative Outcome in Greater Beijing 2006. Ophthalmology, 2009, 116:1322-1331. 4 Anne E Barañano, Joanne Wu, Kashif Mazhar, et al. Visual Acuity Outcomes after Cataract Extraction in Adult Latinos The Los Angeles Latino Eye Study Ophthalmology, 2008, 115:815-821. 5 Powe NR, Schein OD, Gieser SC, et al. Synthesis of the literature on visual acuity and complications following cataract extraction with intraocular lens implantation. Arch Ophthalmol, 1994, 112:239-252.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 9‧論著和研究‧ 一期手術治療肛周膿腫合併肛瘻 124 例的體會 刘全芳 【摘要】 目的 探討一期手術治療肛周膿腫合併肛瘻的療效。 方法 對 124 例肛周膿腫合併肛瘻患者，根據肛周膿腫所在位置，按照 Goodsall 規律尋找並預測肛瘻的大致部位，採用不同方法進行內口定位，施行一次性對穿引流加挂線或瘻管切除手術。 結果 術後 3 個月隨訪，治癒率達 96%（114/119），肛瘻發生率僅 4%（5/119）。 結論 一期手術治療肛周膿腫合併肛瘻療效可靠，術後並發症少。 【關鍵詞】 肛周膿腫; 肛瘻; 一期手術 One Stage Surgical Therapy in the Treatment of Perianal Abscess Complicated with Anal Fistula LIU Quanfang. Department of General Surgery, Guangdong General Hospital, Guangzhou 510080 【Abstract】 Objective To evaluate the clinical effect of one stage surgical therapy in the treatment of perianal abscess complicated with anal fistula. Methods 124 cases with perianal abscess complicated with anal fistula were selected in this study. The gross direction of anal fistula was found and predicted by the location of perianal abscess and following Goodsall rule, then the accurate internal opening was further determined with different methods, eventually primary convection drainage combined with seton therapy or fistulectomy was performed. Results Postoperative 3 month’s follow-up showed that the cure rate was 96%(114/119) and the occurrence rate of anal fistula was only 4%(5/119). Conclusion It suggested that one stage surgical therapy have satisfactory clinical effect in the treatment of perianal abscess complicated with anal fistula, and with less postoperative complication. 【Key words】 Perianal abscess; Anal fistula; One stage surgical therapy 有研究表明單純肛周膿腫切開引流，術後膿腫復發率及肛瘻發生率分別高達 11%和 37%P[1]P，而既往對肛周膿腫合併肛瘻的處理大多採用一期切開引流、二期治療肛瘻的方法，造成患者痛苦時間長、經濟負擔大。針對上述情況，1998～2002 年筆者對確診爲肛周膿腫並肛瘻的 124 例患者，採取不同方法明確內口位置，根據內口與肛門直腸環的關係實施不同的一期手術治療，療效滿意，現報告如下。 資料與方法 1 臨床資料 肛周膿腫合併肛瘻 124 例，男 89 例，女 35 例；年齡 19～72 歲，平均 41 歲。 2 手術方法 作者單位：510080 中國, 廣州， 廣東省人民醫院普通外科，Tel; (+86)-13802541732; Email: doc.liuquanfang@163.com 局麻、骶麻或腰麻下，取截石位，四指擴肛後，根據肛周膿腫所在位置，按照 Goodsall 規律尋找並預測肛瘻的大致內口位置及走向，並結合下述方法進行內口定位：○1 指診法：通過手指的觸診明確質硬、隆起的內口位置，有時尚能發現與之相連的粘膜下瘻管；○2 擠壓法：插入肛門鏡，通過輕輕擠壓肛周膿腫皮膚最痛處，或紅腫及波動最明顯處可發現溢出膿液的內口位置；○3 染色法：在肛周膿腫皮膚最痛處，或紅腫及波動最明顯處穿刺到膿液後注入美藍 2ml，輕柔數分鐘後，使膿液與美藍混合，然後結合擠壓法發現染色內口的位置。在膿腫與肛門間作一放射狀長梭形切口，使膿腔去頂方便引流，切口尖端指向內口，切口大小視膿腫範圍而定。排出膿液，分離膿腔間隔，根據確定的內口的方向和部位，然後用左或右手食指置於肛管內，另手持探針輕輕內外上下滑動，探清肛瘻內口。如內口在肛門直腸環上方，採取挂線，以兩股橡皮筋通過內口、肛門直腸環及已行擴大的外口，收緊後結紮，1 周後繼續收緊，慢性切割，直至
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 11‧論著和研究‧ 鏡湖醫院兒童泌尿道感染常見致病菌 及其耐藥性分析 黃凱風 姚荊 陳彥 施穎 宋冬其 【摘要】 目的 探討本院兒童泌尿道感染常見致病菌的構成及耐藥特徵，為臨床合理選用抗菌藥物提供依據。 方法 對本院資料完整 71 例泌尿道感染患兒進行回顧性分析，用 K-B 法進行藥敏分析，並按 NCCLS 標準判斷細菌耐藥性。 結果 病原菌以革蘭氏陰性桿菌為主，大腸埃希菌佔50.7%，革蘭氏陽性菌佔 15.5%；尿培養前 3 位致病菌分別為大腸埃希菌，肺炎克雷伯菌，葡萄球菌。 結論 大腸埃希菌仍是住院兒童泌尿道感染的主要致病菌，革蘭氏陽性菌感染增多，細菌耐藥現象普遍；重視泌尿道感染病原菌檢測，以藥敏試驗選用抗菌藥物進行治療十分重要。 【關鍵詞】 泌尿道感染; 致病菌; 抗菌藥物 Analysis of the Common Pathogenic Bacteria and Drug Resistance in Children with Urinary Tract Infection in Kiang Wu Hospital HUANG Kai-feng YAO jing , CHEN yan, SHI Ying, SONG Dong-qi. Department of Paediatrics, Kiang Wu Hospital, Macao SAR, PR China; Tel: (+8530) –6612 2084; Email:lcj922@163.com 【Abstract】 Objective To study the distribution of pathogens and resistance characteristics in urinary tract infections among children in our hospital and to provide basis for optimal selection of antibiotics by clinicians. Methods The clinical data of 71 cases of urinary tract infections in hospitalized children were analyzed retrospectively. Kirby-Bauer Method was employed, and antibiotic resistance was determined according to NCCLS standard. Results Gram-negative bacilli outweighed other pathogens. Escherichia coli accounted for 50.7%, Gram-positive bacteria accounted for 15.4%. Bacterial culture traced three major pathogens, namely, Escherichia coli, Klebsiella pneumoniae, and Staphylococci. Conclusion Escherichia coli attributed to the majority of urinary tract infections in hospitalized children. There is a trend of increased proportion of Klebsiella and other enterobacteria. A substantial number of pathogens are resistant to antibiotics, some of which are multi-resistant strains. It is important to identify the pathogenic bacteria and select antibiotics according to drug susceptibility. 【Key words】 Urinary tract infections; Pathogens; Antibiotics 泌尿道感染包括尿道炎，膀胱炎，腎盂腎炎等；是一種臨床常見多發病。隨著治療所用抗生素種類不斷更新，泌尿道感染不僅沒有減少，反而呈上升趨勢 。 國 內 有 文 獻 報 道 泌 尿 道 感 染 占 醫 院 感 染 的10.9%，居醫院感染的第 3 位P[1]P。 本資料通過分析兒童泌尿道感染致病菌及藥敏敏感情況，以利於臨床合理使用抗菌藥物。 作者單位 : 中國 , 澳门特別行政區 , 鏡湖医院儿科 ; Tel: (+8530) –6612 2084; Email:lcj922@163.com 資料與方法 1 臨床資料 我院 2004 年 7 月-2008 年 12 月收住院清潔中段尿培養陽性的泌尿道感染患兒，男性 31 例；女性 40例；男女比例 1：1.29。<1 歲 54 例； 1~3 歲 14 例； 4~7 歲 3 例。診斷均符合泌尿道感染的診斷標準P[2]P。 2 實驗方法 按 NCCLS（美國臨床實驗室標準化委員會）標準。清潔中段尿細菌培養和藥敏試驗分別採用 M-H平板和 K-B 法。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 13酶大腸埃希菌感染的首選藥物。 在革蘭氏陽性球菌中，以葡萄球菌為最多，為本組致病菌第 3 位，佔 9.6%。葡萄球菌引起的感染，可根據藥敏試驗結果單一選藥或聯合用藥，通常選用阿莫西林或加用阿米卡星或立克菌星。但氨基糖甙類、喹諾酮類在兒科應用受一定限制。本組資料同時顯示萬古黴素耐藥率為零；故危重患兒可選用萬古黴素，但要避免把萬古黴素做為常規治療葡萄球菌感染的首選藥。由於樣本數量偏少，有待樣本數量增多而重新評估。另外，本組資料有一例真菌致泌尿道感染，可能與抗生素使用過長或二重感染相關。 總之, 革蘭氏陰性桿菌，特別是大腸埃希菌仍然是兒童泌尿道感染的主要致病菌，近年其他致病菌如葡萄球菌比例有所增加，且耐藥增多。臨床應重視細菌的耐藥性問題並及時掌握致病菌的變化，針對性地選擇有效的抗菌藥物。對臨床疑似泌尿道感染的小兒需及時做中段尿細菌培養，根據藥敏結果，合理選用抗菌藥物，防止用藥的盲目性。 參 考 文 獻 1 吳倩, 黃長武, 聶紅, 等. 泌尿道感染菌分佈及耐藥性分析[J]. 重慶醫科大學學報, 2004, 1:83-85. 2 楊霽雲. 小兒腎臟病基礎與臨床. 第1版. 北京；人民衛生出版社, 2000：351－355。 3 National Committee for Clinical Laboratory Standaras. Performance standards for antimicrobial susceptibility testing[S]. Twelfth informational supplement (M100-S12). NCCLS, 2002.23-75. 4 Chow JW, Fine MJ, Schales DM, et al. Nitrobacteria bacteremia:clinical features and emergence of antibiotic resistance during therapy[J]. Ann Intern Med, 1991, 98:585-590. 5 胡必傑, 陳雪華, 才妹, 等. 醫院感染菌對 12 種抗菌藥物藥敏結果與評價[J].中華醫院感染學雜誌, 1999, 2：118-120.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 14 ‧論著和研究‧ 連續性腎臟替代治療在 內科危重監護病房的臨床應用 彭莉 肖浤P 【摘要】 目的 回顧性分析連續性腎臟替代治療(CRRT)在危重症病房的臨床應用。 方法 2004年 6 月至 2007 年 12 月在本院內科 CCU 病房運用 CRRT 治療內科危重病例 42 例，對兩組患者的年齡、原發基礎疾病以及治療前的腎功能等臨床特點進行了比較和分析。 結果 42 例患者中 25 例度過疾病的急性期，存活率為 59.62%，17 例在急性期死亡，死亡率為 4O.48%；死亡組患者的平均年齡 (74.2±18.5)明顯大於存活組（64.7±18.7），但並無統計學意義上的差異（P=0.497）。 結論 CRRT 能明顯提高危重病人的生存率，為原發病治療和營養支持的實施創造了條件。 【關鍵詞】 連續性腎臟替代治療; 急性腎損傷; 預後 Clinical Utility of Continuous Renal Replacement Therapy in Critical Care Unit PENG Li, XIAO Hong. Internal Medicine, Kiang Wu Hospital, Macao SAR, PR China; Tel: (+853)28310001, 66483247; E-mail:leilapeng@hotmail.com 【Abstract】 Objective Retrospectively analyze the clinical utility of Continuous Renal Replacement Therapy (CRRT) in the Critical Care Unit of the Internal Medicine Department. Method During the period of Jun 2004 to Dec 2007, CRRT were performed on 42 cases of critically ill patients in our department. General data including age, gender, primary underlying disease, comorbidity, and laboratory examinations pre- and post-treatment were collected and analyzed. Result 25 out of 42 patients had been survival from the acute phase of the illness. The survival rate was 59.62%. 17 patients died during the acute phase. The death rate was 4O.48%. The mean age of the dead group is 74.2 ±18.5 yrs, which was obviously older than that of the survival group（64.7±18.7 yrs），but there was no statistical significance（P=0.497） . Conclusion CRRT might provide an effective organ support to the critically ill patients. CRRT might be of help to increase the survival rate of the critically ill patients in the internal medical department. 【Key words】 Continuous renal replacement therapy; Acute renal injury; Prognosis 與傳統的間歇性血液透析相比(IHD)，CRRT時溶質和液體的清除持續緩慢進行，滲透壓變化小，血流動力學狀態穩定，同時溶質清除率高並能濾過和吸附清除中分子細胞因數和炎症介質，因此，CRRT不僅僅是腎臟替代，更是穩定機體內環境，支持其他多臟器功能的有力武器，CRRT在危重病救治過程中的重要性已經得到公認。本科於2004年6月14日開始在心臟病重症監護病房（CCU）開展內科危重病人的CRRT治療，至2007年12月31日共治療42人次，現將該部分病人CRRT治療的臨床資料總結並彙報如下。 作者單位：中國, 澳門特別行政區, 澳門鏡湖醫院, 內科; Tel: (+853)-2831 0001, 6648 3247; E-mail:leilapeng@hotmail.com 資料和方法 1 一般資料 42例患者中男性24例，女性18例；平均年齡(68.5±19)歲(12-91歲)；CRRT前尿素氮(BUN)的平均值為18.62±8.87(4.5～54.7)mmol／L，血清肌酐(Scr)平均值為344.02±161.35(81-1243)umol/L。患者原發病因見表1。表2所列為CRRT前患者併發症情況。42例患者中37例（88.1%）治療前確診急性腎損傷(AKI)，無一例腎後性AKI，大部分患者以腎前性因素為主或同時存在腎前性和腎性因素，以腎性因素為主者僅5例(13.5%)；有36例（85.7%）患者治療前存在不同程度的心衰和肺水腫；其中34例（81.0%）患者同時存在急性腎損傷和心衰；有32例（76.2%）患者需要機械通氣維持輔助呼吸；有27例（64.2%）病人治療前有明顯的低血壓狀態，需要一種或多種升壓藥維持血壓，因此臨床上不宜採用普通血透治療。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 17量，上機的首24小時，每4-6小時測定腎功、電解質及動脈血氣等指標，根據結果隨時調整置換液配方，病情穩定時則適當延長抽血的間隔時間至每6-8小時。有2例重症肺炎、感染性休克患者，作者使用了較高流量的超濾率（3000ml/h），但由於患者合併了嚴重的乳酸酸中毒和低血壓狀態，CRRT上機治療時間很短，也未作相關炎症因數的檢測，有關膿毒血症治療劑量的實踐經驗有待進一步積累。 目前有關依據什麼指標停止CRRT的問題也遠未達成共識，根據ADQI現有的文獻推薦 P[5]P：只要ARF傳統的透析指徵未被糾正，就應該繼續CRRT治療。作者在實際工作中所遵循的原則是，如果患者腎臟已經恢復或部分恢復清除溶質功能，機體能夠自我調節容量平衡，血流動力學狀態穩定、系統性炎症反應得以控制，就可以考慮停止CRRT治療。 CRRT過程中抗凝方法的選擇主要根據患者的臨床特徵，醫生的經驗，監測的難易程度、藥物的配置來決定。現有的抗凝方法包括全身抗凝、體外局部抗凝與無抗凝劑等，所用的抗凝劑有標準肝素、低分子肝素以及枸櫞酸，至於何種抗凝劑作為首選用於CRRT，目前尚無共識。作者從2005年4月開始將普通血液透析中使用低分子肝素抗凝的經驗運用到CRRT中，方法為：Clexane 首劑20-40mg,每4-6小時追加10-20mg，可以保證治療所需的抗凝效果，並且未發現使用抗凝劑所導致的出血副作用。當然，對於有全身性凝血障礙的高危患者、圍手術期病人、已有出血或顯著凝血功能障礙者，作者會選擇不用抗凝劑。目前對於上述高出血風險的病人也建議採用枸櫞酸抗凝 P[6]P，其出血發生率低、濾器使用時間也可以延長，值得注意的是，枸櫞酸鈉進入體內後，參加三羧酸循環，被代謝為碳酸氫根，如果患者已經存在有嚴重低氧血症，採用枸櫞酸鈉抗凝則有可能加重酸中毒或出現嚴重的低鈣血症，需要更加密切地監測血氣及離子鈣水平的變化，必要時需立即停止用藥。使用枸櫞酸鈉抗凝的方法並不複雜，但需全程密切監測血氣和血鈣水平。 綜上所述，由於CRRT是模擬正常的腎臟工作，能夠更好地替代腎臟功能，更好地維持水、電解質和酸碱平衡，控制氮質血症，為原發病治療和營養支持的實施創造了條件，能明顯提高危重病人的生存率，但CRRT始終只是一種輔助支持手段，對原發病的治療作用尚不確切，重症患者的預後仍然取決於其原發疾病的嚴重程度及其治療。 參 考 文 獻 1 Himmelfarb J, Tolkoff-Rubin N, Chandran P, et al. A multicenter comparison of dialysis membranes in the treatment of acute renal failure requiring dialysis. J Am Soc Nephrol, 1998, 9:257-266. 2 季大璽, 謝紅浪, 黎磊石, 等. 連續性腎臟替代療法在重症急性腎功能衰竭治療中的應用 .中華內科雜誌 , 1999, 38:802-805. 3 季大璽, 龔德華. 連續性腎臟替代治療在急性腎功能衰竭搶救中的應用.中華內科雜誌, 2007, 46:8-11. 4 Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous hemofiltration on outcomes of acute renal failure: a prospective randomized trial. Lancet, 2000, 356:26-30. 5 Ronco C, Kellum JA, Mehta R. Acute dialysis quality Initiative(ADQI). Nephrol Dial Transplant, 2001, 16:1555 -1558. 6 龔德華, 季大璽, 徐斌, 等. 枸櫞酸鈉抗凝在重危患者連續 性 血 液 淨 化 治 療 中 的 應 用 . 中 華 內 科 雜 誌 , 2003, 42:121-122.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 18 ‧論著和研究‧ 澳門大腸埃希菌產超廣譜 β-內醯胺酶 篩選底物的評價 葉千紅 曾銳* 李沛樟** 林豔芳 【摘要】 目的 尋找澳門大腸埃希菌產超廣譜 β-內醯胺酶不同篩選方法的最佳底物。 方法 分別收集澳門仁伯爵綜合醫院、澳門鏡湖醫院臨床分離出的大腸埃希菌 104 株、105 株，共計209 株。分別採用紙片瓊脂擴散法、雙紙片協同試驗兩種方法，每種方法選擇 5 種篩選底物進行ESBLs 篩選。以 CLSI 推薦方法確定 ESBLs 表型為金標準，評價 5 種篩選底物在兩種方法的篩選價值。 結果 1.澳門 ESBLs 陽性檢出率為 30.1%. 2.以 CLSI 推薦方法確定 ESBLs 表型為金標準，紙片瓊脂擴散法、雙紙片協同試驗兩種方法五種抗菌素聯用敏感性最高（р ＜0.05）達 100%、95.2%。3.單種抗菌素篩選時，紙片瓊脂擴散法敏感性高低分別為 CRO（96.8%） 、CTX（90.5%），ATM（69.8%）、CAZ （15.9%）。特異性分別為：CAZ（93.8%）、CRO （92.5%）、ATM （91.1%）、CTX （80.3%）、CPD（ 76.7%）。雙紙片協同試驗敏感性分別為 CAZ （76.2%）、CRO （73%）、CTX（ 71.4% ）、 ATM （ 69.8% ）、 CPD （ 38.1% ）。 特 異 性 為 CAZ （ 99.3% ）、 CPD （ 97.5% ）、 ATM（93.2%）、 CTX（93.8%）、CRO（92.5%）。 結論 1. ESBLs 陽性檢出率為 30.1%；2. 5 種篩選底物的聯合應用篩選 ESBLs 敏感性最高；3. 單底物篩選時，紙片瓊脂擴散法敏感性最高的為 CPD，其次為 CRO、 CTX， CAZ 因其敏感性太低並不是理想的篩選底物；在雙紙片協同試驗中， CAZ、CRO、CTX 是相對理想的篩選底物。 【關鍵詞】 大腸埃希菌; 超廣譜 β-內醯胺酶; 篩選底物; 澳門 Evaluation of Substrate Screening in ESBLs-Producing Escherichia coli in Macao YE Qian-hong,P PZENG Rui*, LI Pei-zhang**, LIN Yan-fang. Macao Polytechnic Institute School of Health Sciences, China; Tel (+853)83998628; E-mail: yeqianhong@ipm.edu.mo; *Public Health Laboratory, Macao Health Bureau, Macao SAR, China; **Clinical Laboratory Department of Kiang Wu Hospital, Macao SAR, China; Correspondence author: Tel: (+853)839 98628; P PE-mail: yeqianhong@ipm.edu.mo; This research was granted by Macao Polytechnic Institute,Code:RP/ESS-3/2008 【Abstract】 Objective To explore the optimal substrate of different methods for screening ESBLs-producing Escherichia coli (E.coli) in Macao. Methods A total of 209 clinical isolates of E.coli were collected from Conde S Januario Hospital (104 strains) and Kiang Wu hospital (105 strains) for both out patient clinics and hospitalized patients. Disk diffusion method and double disk synergy test were employed to screen the isolated clinical specimen for the ESBLs-producing E.coli. The method recommended by Clinical and Laboratory Standards Institute (CLSI) was used as gold standard to confirm the ESBLs-producing E.coli and to evaluate the value of the 5 different substrates in each screening methods. Results 1. Positive rate of ESBLs detection was 30.1% from the specimen. 2. Confirmed with the gold standard (CLSI), ESBLs detected by 5 substrates combined achieved the highest sensitivity in both screening methods; almost 100% by disk diffusion method and 95.2% by double disk synergy test (p < 0.05). 3. In the single substrate for ESBLs screening, with the disk diffusion method: the sensitivities ranged from 96.8% by CRO to 90.5% by CTX, 69.8% by ATM and 15.9% by CAZ. The specificities ranged from 93.8% by CAZ, to 92.5% by CRO, 91.1% by ATM, 80.3% by CTX and 76.7% by CPD. With double synergy test: the sensitivities ranged from 76.2% by CAZ to 73% by CRO, 71.4% by CTX, 69.8% by ATM and 38.1% by CPD. The specificities ranged from 99.3% by CAZ to 97.5% by CPD, 93.8% by CTX, 93.2% by ATM and 92.5% by CRO. Conclusions 1. Positive rate of ESBLs detection was 30.1%. 2. The highest sensitivity would be achieved if 5 substrates were used together for the ESBLs screening. 3. In the single substrate screening for ESBLs, CPD could achieve the highest sensitivity, followed by CRO and CTX in the disk diffusion method. The CAZ could achieve a low sensitivity and would not be an ideal substrate for ESBLs screening. In double disk synergy test, CAZ, CRO and CTX are considered as relatively ideal substrates for screening. 【Key words】 ESBL; Escherichia coli; Substrates screening; Macao 作者單位：澳門理工學院高等衛生學校; Tel:(+853)-8399 8628; E-mail: yeqianhong@ipm.edu. mo 通訊作者：葉千紅, *澳門特別行政區衛生局公共衛生化驗所; **澳門鏡湖醫院檢驗科. 項目批准編號：RP/ESS-3/2008
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 21表 4 所見：在篩選 ESBLs 採用雙紙片協同試驗方 法 時 5 種 抗 菌 素 聯 用 與 單 用 CAZ 、 CRO 、ATM 、CTX、CPD 檢測敏感性相比，5 種抗菌素聯用最高（P＜0.05）。 討 論 ESBLs已是近年來的全球範圍內革蘭氏陰性菌耐藥研究熱點，也是更重要的耐藥機制。因為許多產ESBLs菌株在體外敏感性試驗時，表現出對頭孢菌素和單環β-內醯胺類抗菌素部分或全部敏感或仲介，而在感染患者體內卻表達臨床意義耐藥 P[3,4,5]P，而且檢測ESBLs的藥敏試驗的靈敏度和特異性會隨檢測的頭孢菌素而變 P[6]P。在歐洲，近年的調查顯示，37%的產ESBLs病原菌被誤認為對第三代頭孢菌素敏感 P[6]P，因此在臨床中ESBLs篩選是非常必要的。在篩選試驗中，由於不同的抗菌素壓力下產生的ESBLs基因型不同而存在對不同的底物選擇性，所以篩選底物的選擇對產ESBLs株的篩選更顯重要。在歐美一些地區，頭孢他啶和頭孢泊肟作為底物檢出率高 P[7]P；南美和東歐，產ESBLs細菌常常對頭孢他啶敏感而對頭孢噻肟、頭孢曲松耐藥；在波士頓有 31%的產ESBLs菌對頭孢他啶敏感 P[8]P。國內一些地區的報導 P[9]P，頭孢噻肟是最佳的篩選底物，其次是頭孢曲松、氨曲南、頭孢泊肟，用頭孢他啶作為篩選底物時漏檢率最高。 本研究 ESBLs 陽性檢出率為 30.1%，處於較高水準，警示澳門應注意抗菌藥物的正確使用，嚴格控制 ESBLs 菌株出現。 本研究兩種方法均顯示 5 種篩選底物的聯合應用篩選ESBLs敏感性最高，此結果也證實CLSI執行標準中建議使用一種以上藥物進行篩選會提高檢測的敏感度P[1]P，而且這 5 種藥物的聯合應用是最佳的選擇。 本研究顯示：兩種方法篩選 ESBLs 時，不同單底物篩選 ESBLs 的敏感性、特異性均有所不同。在紙片瓊脂擴散法中，單底物篩選敏感性最高的為頭孢泊肟，其次為頭孢曲松、頭孢噻肟、氨曲南、頭孢他啶。提示我們如需要減少篩選底物或考慮經濟條件時，可考慮選擇頭孢泊肟、 頭孢曲松或頭孢噻肟，而且特異性均可達 90%以上，頭孢他啶因其敏感性低並不是澳門理想的篩選底物。在雙紙片協同試驗中，單底物篩選時頭孢他啶、頭孢曲松、頭孢噻肟是澳門相對理想的篩選底物。 綜上，澳門的臨床實驗室在篩選 ESBLs 試驗中，如需用單底物篩選時，應注意不同的方法選擇不同的底物，減少漏診。建議在澳門臨床常規工作中無論用何種方法對產 ESBLs 菌株的篩選，最好應包括頭孢曲松（CRO）、頭孢他啶(CAZ)、頭孢噻肟(CTX)、氨曲南(ATM )、頭孢泊肟（CPD）5 種底物。 參 考 文 獻 1 Clinical and laboratory standards institute. Performance standards for antimicrobial susceptibility testing. Sixteenth informational supplement (M100-S16). CLSI, 2006, l2：37. 2 Jarlier V, Nicolas MH, Fournier G, et al. Extended broad-spectrum beta-lactamases conferring transferable resistance to newer beta-lactam agents in Enterobacteriaceae: hospital prevalence and susceptibility patterns. Rev Infect Dis, 1988, 10:867-878. 3 Jacoby GA, Han P. Detection of extended-spectrum ß-lactamases in clinical isolates of Klebsiella pneumoniae and Escherichia coli. J Clin Microbiol, 1996, 34:908-911. 4 Thomson KS, Sanders, CC. Detection of extended-spectrum beta-lactamases in members of the family Enterobacteriaceae: comparison of the double-disk and three-dimensional test. Antimicrob Agents Chemother, 1992, 36:1877-1882. 5 Katsanis GP, Spargo J, Ferraro MJ, et al. Detection of Klebsiella pneumoniae and Escherichia coli strains producing extended-spectrum beta-lactamases. J Clin Microbiol, 1994, 32:691-696. 6 Franceschini N, Perilli M, Segatore B, et al. Ceftazidime and Aztreonam resistance in Providencia stuartii: characterization of a natural TEM-derived extended spectrum β-lactamase, TEM-60. Antimicrob Agents Chemother, 1998, 42:1459-1462. 7 Tenover FC, Mohammed MJ, Gorton TS, et al. Detection and reporting of organisms producing extended-spectrum β-lactamases: survey of laboratories in connecticut. J Clin Microbiol, 1999, 37(12):4065-4075. 8 Rosenau A, Cattier B, Gousset N, et al. Capnocytophaga ochracea: characterization of a plasmid-encoded extended spectrum TEM-17 β-lactamase in the phylum favobacter-bacteroides. Antimicrob Agents Chemother, 2000, 44:760-762. 9 李敏, 程訓民, 陳峰, 等. 安徽淮北地區超廣譜 β-內醯胺酶細菌表型檢測的底物選擇. 現代檢驗醫學雜誌, 2005, 20(3):32-34.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 22 ‧論著和研究‧ 懼蛇個案沙盤遊戲治療報告 柳蘊瑜 申荷永* 【摘要】 目的 以沙盤遊戲治療技術轉化懼蛇個案非理性恐懼情緒，通過分析個案沙盤的特點 , 爲恐懼情緒的沙盤遊戲治療提供參考依據。 方法 分析個案之沙畫沙具使用的特點 、沙盤創傷與治癒主題的表達情況特點。 結果 經五次沙盤遊戲治療後，懼蛇個案非理性恐懼情緒消失。(1) 個案沙畫中對 18 類沙具使用，軍事軍械類最多：137 個次（32.0%）；人物類次之：83 個次（19.4%）。(2) 沙盤創傷與治癒主題的表達情況特點：創傷主題出現最多的是限制（34.1%）和倒罝（24.5%）; 治癒主題出現最多的是能量（60.0%）和連接（14.2%）。 結論 沙盤遊戲治療技術能轉化懼蛇非理性恐懼情緒。 【關鍵詞】 分析心理學; 沙盤遊戲治療技術 The Report of Sandplay Therapy in a snake fear case LAO Wan U, SHEN He Yong*. Department of Psychology, South China Normal University, China, Guangzhou 510631, Tel : 66868500, 88934632, 28810217; E-Mail: winneinew@yahoo.com.hk; * Department of Psychology, Fudan University, China, Shanghai 200433 【Abstract】 Purpose: To transform the unconscious snake scare emotion by sandplay therapy. To obtain the treatment basis of terror emotion by analyzed the sandplay characteristics. Methods: Analyze the using characteristics of sandplay tools, topic of trauma and cure. Results: The terror emotion vanished after five times treatments. Total of 18 types of sandplay stools were used. The most used tools was military type by 137 times (32%), the secondary used is figure type by 83 times (19.4%). The sandplay topic of trauma and cure: the most occurred topic of trauma was Confined (34.1%) and Neglected (24.5%). Moreover, the most occurred topic of cure was Energizing (60.0%) and Bridging (14.2%). Conclusion: Sandplay therapy technique can transform the unconscious snake scare emotion. 【Key words】 Analytical Psychology; Sandplay Therapy 引 言 恐懼情緒是人類適應生存技能原始形式，具有積極意義，恐懼情緒失衡會發展為精神心理障礙。人類恐懼對象調查顯示蛇佔第一位 P[1]P，研究証明，動物學會害怕蛇的相片較學會害怕花的相片容易 P[2]P；人搜尋相片隱藏蛇的速度快於其他東西 P[3]P。上述研究表明對蛇的恐懼情緒有先設性、不受控的警覺及學習傾向。現代人非理性地怕蛇甚於威脅性更大的虎豹、疾病，分析心理學(Analytical Psychology)的“集體無意識” （collective unconscious）及 “原型” (archetype)理論認為，集體無意識是通過某種形式的繼承或進化而來，由原型這種先存的形式所構成，“原型是人類原 作者單位: 中國, 廣州, 510631, 華南師範大學心理系; Tel:(+853)-6686 8500; E-mail: winneinew@yahoo.com.hk; *中國, 上海, 復旦大學心理系 200433 始經驗的集結” P[4]P，非理性懼蛇情緒可由蛇意象之象徵性意義，激發恐懼情緒非意識部份所致。 原型理論與蛇的意象 集體無意識的原型必須以象徵性形式─原型意象(archetypal images)呈現，某種心理內涵才能成為意識內容，為意識所覺知。象徵可成為精神能量轉換中介，當某一象徵被同化便釋出精神能量，作用於意識層面，激發潛在力量，像原始民族狩獵前的宗教儀式。榮格定義象徵是：當形象或文字超出一般它所直接含義時，便有了某種象徵性或象徵性意義 P[5]P。蛇的恐懼原型之意象象徵被同化時，釋出的精神能量不為意志掌控而表現於意識層面一系列恐懼情緒活動。 意象本質概括為：似是而非。對蛇的本質作人類學、文化、宗教分析，體現出三種意象各有兩個向度（積極與消極）。懼蛇情緒非理性部份可能與消極蛇
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 26 圖 5 爆丸之戰 圖 6 持蛇杖印地安戰士 結 論 沙盤的寓意是天地的縮影、心靈的擴展，沙盤的沙粒承載無限的時光與空間，手觸於沙而繫於心，心理無型之內涵得以用有型的三維形式展露於沙盤中。治療師以保護者姿態在旁營造出絕對接納的安全空間，令個案作為治療主導者，意識、無意識、時空透過沙盤作無限制溝通，內心世界困擾以沙畫形式進行整合，把自己內心世界透過沙盤自由呈現及整理，從而達到心理整合的自癒效果P[13]P。 沙盤遊遊戲治療是一種非語言、無意識層次治療技術，適合不善表達或壓抑過度難以表達的個案，非語言治療的另一個優勢是繞過意識對無意識的修飾，更好解讀無意識。治療師只在治療開始時予以指導語及在結束時就沙畫簡單發問，如邀請對沙畫命題。不予過多的語言干預，令個案感覺自已是治療主導者，解除顧慮而自由表達，更重要是不以意識的語言干預，影響無意識的表達。 沙盤遊戲治療技術的關鍵，是治療師闡釋不同形式意象的象徵性意義，例如對蛇意象的象徵性意義的剖析，正確剖釋情緒或症狀象徵性意義，是把無意識向意識呈現的方式，從而令意識能瞭解、接納無意識對蛇的恐懼，最終轉化心理能量，實現治癒。治療師的包容令信任關係建立，促成個案向治療師移情，治療師本身的人格及內在心理能量：包容的愛、對個案症狀剖釋的治療信念等，透過成功的反移情協助個案內在自我的成長，可以面對問題而得到自癒效果 P[14]P。所以，沙盤遊戲治療效果是來自個案的成長，克服懼蛇的非理性部份。 參 考 資 料 1 Agras W S, Syivser D, Oliveau D. The epidemiology of common fear and phobia.Comprehensive Psychiatry, 1996, 10: 151-156. 2 Ohman,Mineks S. Fear,phobias, and preparedness:Toward an evolved model of fear and fear learning. Psychology Review, 2001, 8:78-79. 3 Fredrikson A W. Partental history, aversive exposure and devplopment of snake and spider phobia in women. Behavior and Therapy 1997, 11:59-66. 4 申荷永, 主編. 心理分析 理解與體驗. 第 1 版. 北京: 三聯書店, 2004. 129-131. 5 申荷永, 主編. 心理分析 理解與體驗. 第 1 版. 北京; 三聯書店,2004. 131-133. 6 顏翠瑩. 蛇的原始意象與沈石溪筆下的蛇形象. 2005, 台灣: 國立中興大學, 文學系碩士論文. 7 王萍,黃鋼. 沙盤遊戲應用於臨床心理評估的研究進展.中國健康心理學雜誌, 2007, 9 : 862-864. 8 申荷永, 陳侃, 高岚. 沙盤遊戲治療的歷史與理論. 第1 版. 北京: 心理發展與教育, 2005, 2: 124 -128. 9 耿柳娜,張昇,趙會春.箱庭在心理咨詢實踐和實證研究中的應用. 第 1 版. 北京: 心理發展與教育, 2004,1: 83-86. 10 山中康裕.沙遊療法與表現療法. 邱敏麗, 陳美瑛譯. 第1 版. 台北: 心靈工坊文化. 2004, 2: 45-52. 11 申荷永, 主編. 心理分析, 理解與體驗. 第 1 版. 北京: 三聯書店, 2004, 3:107-110. 12 Terr LC, Bloch DA, Michel BA, et al. Children’s symptom sin the wake of Challenger: A flied study of distant － traumatic effects and an outline of related conditions. Am J Psychiatry, 1999, 156:1536-1544. 13 Eva Pattis Zoja. 沙盤遊戲與心理疾病的治療. 劉建新,蔡成後, 古麗丹譯. 第 1 版. 廣州:高等教育出版社. 2006, 1-2. 14 申荷永. 心理分析; 理解與體驗. 第 1 版. 北京: 三聯書店, 2004, 4: 243-256.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 27‧綜述‧ Recent Advances in Smoking Cessation LO Iek Long LAM Bing* CHEONG Tak Hong 【Abstract】 Tobacco use is the leading cause of disease and premature death worldwide. In Macao, 23.1% of the population was current-smoker or ex-smoker. Nicotine, the major addictive substance in cigarette smoke, is the culprit for smoking habit. Nicotine acts on nicotine receptor in the brain, producing pleasure effects and reducing withdrawal symptoms. Nicotine dependence is a complex condition with physiological, psychological and behavioral aspects that makes smoking cessation very difficult. Without any help, the abstinence rate at 6 months is as low as 4%. The latest US guidelines identify tobacco dependence as a chronic disease, like hypertension and diabetes, which often requires repeated intervention and treatment. At present, the most effective strategy for quitting is a combination of behavioral intervention and pharmacotherapy. The purpose of this review was to summarize recent advances in smoking cessation. 【Key Words】 Smoking; Cessation; Behavioral intervention; Pharmacotherapy 戒煙治療新進展 羅奕龍,, 林冰*, 張德洪. 胸肺科, 澳門仁伯爵綜合醫院, 澳門, 中國; Tel:(+853)-6654 5620; E-mail:drloieklong@yahoo.com.hk; *呼吸系統科中心, 香港養和醫院, 香港, 中國. 【摘要】 儘管許多人都知道“吸煙危害健康”，2006 年本澳的一項健康調查發現，23.1%的澳門居民曾經或目前為吸煙者。煙草中的尼古丁具有強烈的成癮性，而尼古丁倚賴是引起吸煙上癮的主要原因之一。在臨床工作中，我們往往低估吸煙者在戒煙時遇到的困難，例如吸煙者需要克服生理上的戒斷症狀、心理上的吸煙欲望以及習以為常的吸煙行為，所以要成功戒煙，絕非易事。大部分吸煙者都曾經嘗試戒煙，但如果我們沒有給予相應的幫助，6 個月的戒煙成功率僅為 4%。美國最新的戒煙指南特別強調，尼古丁倚賴本質上是一種慢性病，與高血壓和糖尿病的治療一樣，需要長期和反覆的行為干預和藥物治療。目前認為，進行個體化的行為干預和藥物治療，是最有效的戒煙方法。本文結合循證醫學的證據和本地的實際情況，總結目前戒煙的治療進展。 【關鍵詞】 吸煙; 戒煙; 行為干預; 藥物治療 Introduction Tobacco use, cigarette smoking in particular, is the leading preventable cause of disease and premature death worldwide P[1]P. Despite it is well-known that smoking increases the risk of cardiovascular diseases, respiratory diseases, and cancers, the prevalence of smoking remains high in Macao. A local cross-sectional study in 2006 showed that 23.1% of the Macao population was current-smoker or ex-smoker P[2]P. The situation is more worrisome among the youth. A survey revealed that 33.0% of boys and 23.4% of girls aged 13-15 years had ever smoked cigarettes in Macao P[3]P. Apart from personal health problems, cigarette smoking causes heavy burden on the health care system and economy as well. To address this Author’s address: Department of Respiratory Medicine, Centro Hospitalar Conde de São Januário, Macao SAR, China; Tel: (+853)-6654 5620; E-mail: drloieklong@yahoo.com.hk; *Respiratory Medicine Center, Hong Kong Sanatorium & Hostpital, 2 Village Road, Happy Valley, Hong Kong SAR, China. Tel: (+852)-2572 0211 issue, Macao Health Bureau conveys the message of quit smoking by public health promotions and provides smoking cessation service in Hac Sa Wan Health Center since 2006. A common misunderstanding among smokers, or even physicians, is that smoking is just a lifestyle choice rather than an addiction. In fact, nicotine in cigarette smoke is a strong addictive substance with higher potential dependency than cannabis P[4]P. Nicotine acts on nicotinic receptors in the brain to release dopamine and other neurotransmitters, which in turns generate reinforcing effects and sustain addiction. Nicotine not only provides positive reinforcement by offering pleasure, stimulation and mood modulation, but also alleviates craving and withdrawal symptoms like headache, irritability, anxiety, depressed mood and insomnia. Nicotine dependence is a complex condition with physiological, psychological, and behavioral aspects that
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 28 makes smoking cessation very difficult. Without any intervention, the abstinence rate at 6 months is as low as 4% P[5]P. The recently published US guidelines identify tobacco dependence as a chronic disease, like hypertension or diabetes, which often requires repeated intervention and treatment. It is essential that clinicians consistently identify, document, and help smokers to quit in their clinical practice P[4]P. Clinicians should ask all adults about tobacco use and consider cessation interventions as a priority because there are good evidences showing that 1) tobacco cessation is beneficial to the patient; 2) clinician-delivered interventions increase the chance of quitting; 3) those interventions are cost-effective. The most effective approach for smoking cessation is a combination of public health policy, behavioral intervention and pharmacotherapy. This article aims at reviewing recent advances in smoking cessation, focusing on behavioral interventions and pharmacotherapies. The impact of public health policies on smoking cessation is beyond the scope of this review. Behavioral Intervention Behavioral interventions, defined as verbal instructions to modify health-related behaviors, are commonly used for smoking cessation P[6]P. Behavioral intervention is an important component for enhancing motivation and tackling psychological and behavioral obstacles during the course of cessation. A useful mnemonic to help involve patients in discussions about smoking cessation is the "5-A" behavioral counseling framework: (1) Ask about tobacco use, (2) Advise to quit, using clear personalized messages, (3) Assess willingness to quit, (4) Assist in smoking cessation, and (5) Arrange follow-up and support P[1]P. Brief advice from health care providers: A brief advice (less than 10 minutes) from a doctor may increase the quit rate by 30-50% at 1 year P[4]P. It is easy, cost-effective and widely applicable. Therefore, we should grasp every opportunity to convey the message of stop smoking to all smokers during our clinical practice. Apart from advising and motivating patients to quit, we should refer those with cessation intention to specialized smoking cessation clinic for further intensive counseling, pharmacotherapies and long-term follow-up. Counseling: Individual, group and telephone counseling are effective, and their effectiveness increases with the intensity of counseling P[4]P. The key of fruitful counseling is to teach the smokers how to break the link between the cues and smoking behavior using problem-solving guidance. Firstly, cues for an urge to smoke should be identified. Common cues are, but not limited to, after meals, alcohol drinking, driving, and gathering with smoking friends. Secondly, tactics for breaking the link should be taught. Common tactics includes avoidance of cues, substitution of smoking with crewing gum or exercise, and removing all cigarettes at home or workplace. Thirdly, smokers should learn how to overcome withdrawal symptoms and prevent relapse by anticipating tempting situations and rehearsing coping strategies. Self-help program and exercise program: Written self-help material has minimal efficacy when used alone but may enhance the effects of other interventions. Since successful quitter may gain 5-10 pounds due to increased appetite and decreased metabolic rate, it is reasonable to recommend smokers to participate exercise program for weight control. However, there is no strong evidence showing that exercise intervention per se is effective for smoking cessation P[7]P. Pharmacologic Therapy While behavioral interventions deal with psychological and behavioral aspects during smoking cessation. Pharmacologic therapy is almost always necessary to alleviate nicotine withdrawal symptoms and reduce rewarding effects of continued smoking. Nicotine replacement therapy (NRT), sustained-release Bupropion (Bupropion SR) and Varenicline are first-line medications for smoking cessation available in Macao. The recommended dosage, common adverse effects and contraindications of these medications are listed in Table. Nicotine replacement therapy (NRT): NRT helps smoking cessation by reducing withdrawal symptoms and craving for cigarettes. NRT also reduces the reinforcing effects of nicotine delivered via cigarette smoking. All forms of NRT increase the rate of quitting by 50-70%P [8]P. Several NRT formulations, including gum, inhaler and transdermal patch, are available in Macao. Nicotine patch offers a continuous release of nicotine over 16 or 24 hours, whereas gum and spray are short-
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 29acting NRT (SANRT), so the dose can be self-titrated. Common side effects of NRT include nausea, headache and dizziness. All NRT should be used with caution in patients with recent acute myocardial infarction due to its vasoconstrictor effect. However, there is no contraindication for NRT if the alternative is smoking. As no particular NRT has been proven to be more effective than any other, the choice of agent is primarily driven by patient's preference and individual side-effects of varied formulations. For example, gum should be avoided in patients with temporo-mandibular joint disease and for those with insomnia, 16 hours patch may substitute 24 hours patch. Sustained-release bupropion (Bupropion SR, Zyban): Bupropion is an atypical antidepressant that acts as a norepinephrine and dopamine reuptake inhibitor, simulating the effects of nicotine on these neurotransmitters. Bupropion is also a weak antagonist at nicotine receptors, thus reducing reinforcement from cigarette use. Bupropion approximately double the abstinence rate at 6-12 months when compared to placebo P[9]P. Bupropion may limit or delay cessation associated weight gain. Common side effects of Bupropion are insomnia, dry mouth, nausea and headache. Bupropion lowers seizure threshold and the incidence of seizure has been reported to be 0.1%. The incidence is higher in patients with preexisting seizure or eating disorder. Bupropion is contraindicated in patients taking monoamine oxidase inhibitors (MAOIs). Varenicline (Champix): Varenicline is a novel highly selective partial agonist of α4β2 nicotinic acetylcholine receptors. It has dual agonist and antagonist activities. Its agonist action on receptors may alleviate craving and withdrawal symptoms while its antagonist property may reduce reinforcing effects of nicotine in continued smoking P[10]P. Varenicline increased the odds of quitting approximately fourfold and twofold when compared to placebo and Bupropion SR at the end of 12 weeks’ treatment period P[11] [12]P. Significantly higher abstinence rate was also noted at 6 and 12 months of non-treatment, follow-up phases. Common side effects of Varenicline include nausea, insomnia, abnormal dreams and headache. Nausea can be lessened by taking medication 30 minutes after meal with a full glass of water. If nausea persists, dose may be cut by half for a short period of time. Recently, a new warning was added to the varenicline label noting an association of varenicline with an increased risk of neuropsychiatric symptoms, including agitation, depressed mood, suicidal ideation and behavior, and worsening of preexisting psychiatric illness. However, since cigarette smoking or smoking cessation per se is associated with suicidal behavior, it remains unclear whether these neuropsychiatric symptoms are causally related to varenicline use P[10]P. Combinations: It has been proven that combining nicotine patch with SANRT was more effective than single type of NRT P[8]P. On the other hand, the combination of NRT and Bupropion SR does not further increase the cessation rate P[9]P. Although theoretically the combination of Bupropion SR and Varenicline is promising, since they have different therapeutic targets and no drug interaction, there is no published trial investigating the efficacy and safety of this combination. Conclusion Given the serious consequences of tobacco smoking and the chronic nature of nicotine dependence, consistent use of effective interventions to aid smoking cessation is vital. Leaflet about smoking cessation should be easily obtained and healthcare providers should take every opportunity to identify patients’ smoking status and motivate smokers to quit. A combination of counseling and pharmacotherapy is more effective than either component alone. Counseling in the forms of individual, group and telephone is effective for smoking cessation and should not be neglected. For patients attending smoking cessation clinic, group counseling is given mainly for the purpose of introducing different medications and identifying reasons for previous failed quit attempts. Individual counseling provides concrete, practical and individualized tactics for the smokers to overcome common barriers in quitting. Telephone counseling may act as a follow-up measure to increase the patient’s compliance to smoking cessation program. Pharmacotherapy plays a key role in quitting by alleviating nicotine withdrawal symptoms and reducing rewarding effects of continued smoking. NRT, Bupropion SR and Varenicline are the first-line treatments of choice. The selection of medication should base on the individualized characteristics. For example,
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 30 NRT offers adherence advantages owing to the different routes of administration; Bupropion is particularly useful for smokers with depression or those with weight concern; and Varenicline is by far the most effective medication for smoking cessation. However, it should not be used in patients with psychiatric disorders. Table Pharmacologic therapy for smoking cessation Dosage Common adverse effects Contraindications / Precautions Nicotine Replace- ment Therapy (NRT) Patch: > 20 cigarettes/day: 15mg/24 hr for 6 weeks; then 10mg/24 hr for 3 weeks; then 5mg/24hr for 3 weeks ≤ 20 cigarettes/day: 10mg/24 hr for 6 weeks; then 5mg/24 hr for 3 weeks Gum: >20 cigarettes/day: use 4mg gum ≤20 cigarettes/day: use 2mg gum 1 piece q1-2h (≥ 10 pieces/day) for 6 weeks, then 1 piece q2-4h for 3 weeks, then 1 piece q4-8h for 3 weeks Patch: mild skin irritation over the placement site Gum: jaw pain, mouth soreness, dyspepsia, hiccupsInhaler: mouth and throat irritation, cough Recent (< 6 weeks) AMI for all NRT; Temporo-mandibular joint disease for gum Bupropion SR 150mg qd for 3 days, then 150mg bid for a total of 8-12 weeks Insomnia, dry mouth, headache, tremors, nausea, anxiety Seizure or eating disorders; Patients taking MAOIs Varenicline 0.5mg qd for 3 days, then 0.5mg bd for 4 days, then 1mg bid for a total of 12 weeks; An additional 12 weeks may be considered for relapse prevention; For patients with CCr < 30ml/min, reduce to 0.5mg qd Nausea, insomnia, abnormal dreams and headache Psychiatric disorders (e.g., schizophrenia, bipolar disorder, or depression); Pilots or air-traffic controllers Pregnancy or lactation NRT: nicotine replacement therapy; AMI: acute myocardial infarction; MAOIs: monoamine oxidase inhibitor Reference 1 U.S. Preventive services task force. Counseling and interventions to prevent tobacco use and tobacco-caused diseases in adults and pregnant women: U.S. preventive services task force reaffirmation recommendation statement. Ann Intern Med, 2009, 150: 551-555. 2 Health-related behavioral factors. In: Research team of Macao health survey. ed. Macao health survey 2006. 1PstP ed. Macao: Department of health of MSAR, 2008. 56-65. 3 Health promotion committee of Macao center of disease control and prevention. Macao youth tobacco survey, 2005. Macao SAR: the committee; 2007. 4 Fiore M, Jaen C, Baker T et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services Public Health Service, 2008. 5 Multimodal techniques for smoking cessation: a review of their efficacy and utilization and clinical practice guidelines. Int J Clin Pract, 2008, 62: 1730-1735. 6 Niaura R. Non-pharmacologic therapy for smoking cessation: characteristics and efficacy of current approaches. Am J Med, 2008, 131: S11-S19. 7 Ussher MH, Taylor A, Faulkner G. Exercise interventions for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD002295. DOI: 10.1002/14651858.CD002295.pub3. 8 Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD000146. DOI: 10.1002/14651858.CD000146.pub3. 9 Lemmens V, Oenema A, Knut IK, et al. Effectiveness of smoking cessation interventions among adults: a systematic review of reviews. Eur J Cancer Prev, 2008, 17: 535-544. 10 Hays JT and Ebbert JO. Varenicline for tobacco dependence. N Engl J Med, 2008, 359: 2018-2014. 11 Gonzales D, Rennard SI, Nides M, et al. Varenicline, an alpha4 beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA, 2006, 296: 47-55. 12 Jorenby DE, Hays JT, Rigotti NA, et al. Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial. JAMA, 2006, 296: 56-63.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 31‧綜述‧ 沙盤遊戲治療技術 柳蘊瑜 申荷永* 【摘要】 沙盤遊戲治療 Sandplay Therapy 是一種以榮格 C.G. Jung 心理分析 Analytical Psychology原理為基礎，由朵拉·卡爾夫 Dora Maria Kalff 發展創立的心理治療方法。沙盤遊戲是運用意象進行治療的創造形式，“一種對身心生命能量的集中提煉”（榮格）。其特點，是在醫患關係和沙盤的“自由與保護的空間”中，把沙子、水和沙具運用於意象的創建。沙盤中所表現的系列沙盤意象，營造出沙盤遊戲者心靈深處意識和無意識之間的持續性對話，以及由此而激發的治癒過程和人格發展。 【關鍵詞】 沙盤遊戲治療; 心理分析; 意象; 象徵性 Sandplay Therapy LAO Wan U, SHEN He Yong*. Department of Psychology, South China Normal University, Guang Zhou, Guang Dong (510631)；P*PDepartment of Psychology, Fudan University, Shang Hai, 200433, China. 【Abstract】 Sandplay Therapy is a therapeutic method developed by Dora Kalff and based on the psychological principles of C.G. Jung. Sandplay is a creative form of therapy in using imagination, “a concentrated extract of the life forces both physical and psychic” (C.G. Jung). It is characterized by the use of sand, water and miniatures in the creation of images within the “free and protected space” of the therapeutic relationship and the sand tray. A series of Sandplay images portrayed in the sand tray create an ongoing dialogue between the conscious and the unconscious aspects of the client’s psyche, which activates a healing process and the development of personality. 【Key words】 Sandplay therapy; Analytical psychology; Image; Symbolistic 沙盤遊戲治療技術以榮格（C.G. Jung）心理分析（Analytical Psychology）原理為基礎，由朵拉·卡爾夫（Dora Maria Kalff）發展創立的心理治療方法。沙盤遊戲治療室的基本設備是以沙子、沙盤、沙具和沙具架所組成(圖 1, 2)。專業型沙具是根據心理分析原理所指的各類原型意象而設計，包括自然界萬物：人物、動物、植物等；世界各種主要文化象徵：神話、宗教等。求助者透過沙子、水和沙具運用於沙盤進行意象的創建，在系列沙盤意象中達成治療效果。 圖 1 沙盤治療室 圖 2 沙盤、沙具及沙具架 作者單位：中國, 廣州, 510631, 華南師範大學心理系; Tel: (+853)-6686 8500;Email:winneinew@yahoo.com.hk; *復旦大學心理系，上海 200433
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 32 沙盤遊戲治療是一種是非語言的心理治療技術P[1]P，其優點是無需語言作溝通的媒介，協助壓抑過深、不善語言性表達的求助者，在治療師營造的自由與保護的空間中，克服意識的限制，以創造形式呈現內心世界，從而把內在無形、模糊、混沌的感覺得以用有形、清晰、開濶的三維形式呈現於外界。把無意識訊息向意識呈現, 令意識可對無意識進行直視, 無意識以這種創造性形式向意識呈現其自身，兩者之間持續性接觸的結果是令意識最終接納無意識，緩解衝突，轉化矛盾衝突的能量成為人格成長的動力。 沙盤遊戲治療技術之所以能促成無意識呈現,主要是依靠治療師營造出自由與保護的空間(人際關係及沙盤), 治療師與求助者建立信任關係，兩者無意識達成溝通, 治療師本身的心理能量便能對求助者起著安撫、支持作用。分析帥的人格會影響轉化能量的運作 HP[2]HP。治療師指導語的暗示具有催眠效果，降低求助者意識對無意識的控制, 無意識訊息可透過手對沙子、水和沙具的運用，以意象(Image)的創建形式而表達。意象的象徵性意義超越事物的本質，突破意識的限制 HP[3]HP，容許求助者安全地在沙盤以創作性的意象形式表達內心的衝突。心理困擾得以宣示，一方面可降低其壓力；另一方面, 求助者把沙子、水和沙具運用於意象創建的過程中, 是意識對無意識認識、按納的過程。心理症狀的根源是無意識中不為意識接納的情結、本能對意識的衝擊所致，心理症狀的表現以象徵性意義(Symbolistic)表彰，沒有生理及病理的直接因果闡述，因此，沙盤遊戲治療透過對意象象徵性意義啟示，針對具象徵性意義的心理症狀剖釋，具有轉化症狀負能量作用。症狀消除是心理治療效果的指標，症狀是負面心理能量的表徵，心理分析原理對負面心理能量的處理方法不是消除，而是予以轉化，把負面心理能量轉化成積極的心理能量，正如恰當的焦慮是生命應有的心理動力，把焦慮能量轉化到恰當水平，變為動力，症狀便順理成章地消失，促成治癒。治癒過程同時是促成人格發展的過程，只有激發未完善人格結構的整合，才能在人格發展基礎上實現真正的治癒。 人格基本形成於童年期，因此人格整合的起點也應該定位在童年。 遊戲是童年人格建構的重要手段。遊戲是榮格建立他的主要理論的來源 HP[4]HP。遊戲是兒童的天性,因而,若是天性受到阻礙或壓制,透過遊戲,可以使天性得以恢復,因為遊戲中包含著治療與治癒的條件和機會HP[5]HP。 一粒沙是一個世界 HP[6]HP 。沙粒可以是千萬年前地球結構的部份或史上任何偉大建築的成份，所以沙粒是象徵性的世界縮影。沙本身同時也承載了逝去千萬年的時光意義，所以沙是手中的時空世界，當象徵世界與時空的沙粒，以遊戲形式在被營造成安全空間的沙盤中對人類天性進行恢復、整合的過程，無疑是人與世界、人與大自然的象徵性再結合, 沙盤被賦予的世界象徵性意義，蘊藏巨大的大自然能量，一若由布所構成國旗，當被賦予國家的象徵性意義後，這塊布所能激發的精神能量是難以估計的。因此在自由與保護的空間中，沙子、水和沙具以意象創建式運用，激發內在精神能量重新整合，重建內心的秩序，令轉化和治癒的條件出現在沙盤中。 參 考 資 料 1 申荷永, 主編. 心理分析 : 理解與體驗.第 1 版. 北京: 三聯書店, 2004. 267. 2 Ruth Ammann. Healing and Transformation in Sandplay : Creative Processes Become Visible. 沙盤遊戲中的治癒與轉化：創造過程的呈現. 第 1 版. 廣州: 廣東高等教育出版社,2006. 2. 3 Eva Pattis Zoja. Sandplay Therapy : Treatment of Psychopathologies. 沙盤遊戲與心理疾病的治療. 第 1版. 廣州: 廣東高等教育出版社, 2006. 2. 4 申荷永, 主編. 心理分析 : 理解與體驗. 第 1 版. 北京: 三聯書店, 2004. 261. 5 Josip Pasic . Likeness and Unlikeness : On the Nature of Image.第 1 版.廣州: 廣東高等教育出版社,2006. 243-254. 6 申荷永, 主編. 心理分析: 理解與體驗.第 1 版. 北京: 三聯書店, 2004. 261.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 33‧講座‧ 論兒童亞健康與防治 徐偉英 【摘要】 本文分析了兒童亞健康的發生與兒童生理病理有關，其病因病機主要在某種致病因素的影響下，機體的“陰平陽秘”正常生理平衡被破壞，從而發生“陰陽失調”所致。臨床常見亞健康症狀有厭食、便秘、腹痛、肥胖症、汗證、多動症、遺尿、心理偏差等症，並提出了適當的防治措施。 【主題詞】 兒童亞健康; 病因病機; 臨床症狀; 防治 Sub-healthy and prevention of Children XU Weiying Center of Medico-Dianostico Popular; Macao SAR PR China, Tel: (+853) 2852 4468; E-mail: dr.xuwy@nolasco.com.mo 【 Abstract 】 This text analyze the incidence of Children's sub-healthy relates to children's physiological pathology. The cause and mechanism are mainly influenced by some pathogenic factor. The Body’s relative equilibrium Yin and Yang of normal physiological balance was destroyed, then induce imbalance of Yin and Yang. The common sub-healthy clinical symptoms included: anorexia, constipation, abdominal pain, obesity, hidrosis, attention-deficit hyperactivity disorder, enuresis, psychogenic disorder. Also indicate the appropriate prevention methods. 【Key words】Children’s sub-healthy; Cause and Mechanism; Clinical symptoms; Prevention 對人體亞健康的研究越來越引起世界醫務界的重視，但研究幾乎都集中於成人。然而根據亞健康的概念：世界衛生組織將機體無器質性病變，但是有一些功能改變的狀態稱為“第三狀態”，我國稱為“亞健康狀態” P[1]P，據此本人認為兒童也有亞健康狀況存在。 我國古代醫家早在二千五百年前提出了“未病”的概念。“未病”是機體開始已有或無病理資訊，未有任何臨床表現的狀態或不能明確診斷的一種狀態，是病象未充分顯露的隱潛階段, 將疾病分為“未病”、“欲病”、“已病”三個層次, 欲病是指機體內已蘊含病理資訊或尚處於發病的萌芽，隱而未發的狀態 P[2]P。中醫的未病、欲病狀態與現在亞健康狀態所指的非疾病、非健康狀態基本相似，還包含了現代一些疾病的先兆以及疾病高危人群等。 隨著兒童成年病（肥胖、高血壓、消化道病、心理病等）的上升，如何將兒童尚處於亞健康狀況時 作者單位: 中國, 澳门特別行政區，澳門便民醫療中心; Tel: (+853) 2852 4468; E-mail: dr.xuwy@nolasco.com.mo 期，就提出適當的防範措施，避免向疾病發展，有待兒科醫學界根據兒童的特點作進一步研究。 生理病理 亞健康狀態是在不斷變化發展的，既可向健康狀態轉化，也可向疾病狀態轉化，是處於疾病與健康之間的一種生理機能的狀態，亞健康狀態也是很多疾病的前期症兆，究竟向哪方面轉化，取決於保健措施和自身的抗病能力。 據兒童生理病理的特點，相對成人其器質性病變小，故從臨床角度觀察兒童亞健康的狀況不亞于成人。由於兒童機體柔嫩、氣血未盛、脾胃薄弱、腎氣未充、腠理疏鬆、神氣怯弱、筋骨未堅，其五臟六腑、形體結構、四肢百骸、精血津液等均嬌弱柔嫩，不耐攻伐 P[3]P；各種生理功能尚未健全都處於相對不足的狀態。因此自身抵禦功能差，年齡越小抗病功能越差，雖然小兒五臟六腑的形與氣皆屬不足，但又以肺、脾、腎三臟不足更為突出。這一方面是由於小兒出生後肺、脾、腎三臟皆成而未全、全而未壯,更是因為小兒處於生長旺盛、發育迅速的階段，對水穀精氣的需求，較成人相對迫切，所以小兒對腎氣生髮、
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 34 脾氣運化、肺氣宣肅的功能要求更高。因此常表現出肺臟嬌嫩、脾常不足、腎常虛的特點。故兒童亞健康狀況向疾病發展的趨勢比成人來得快而多，為此防治的重要性比成人相對更高。 病因病機 人類疾病主要由自然界-外感病因，和人類自身內因兩種因素所致。外感六淫是風、寒、暑、濕、燥邪氣與疫癘；內因主要由遺傳、飲、食、起、居、情志等因素的不協調所致，現代社會由於內在因素失衡致病的機會更大。 隨著社會的發展和人們物質條件的改善，人們對亞健康的調節越來越引起重視，無論是個人和社會以及各種媒體都從不同成面介紹防範疾病和自身調理的方法、措施等，尤其中醫在亞健康的“治未病”給人們帶來不少福音，對於調整亞健康狀態具有明顯優勢和特色。根據中醫學理論，健康是指機體內部的陰陽平衡，以及機體與外界環境（包括自然環境和社會環境）的陰陽平衡。健康意味著形體、精神心理與環境適應的完好狀態。陰陽雙方交感相錯，對立制約，互根互用，相互轉化，消長平衡，處在永恆的運動之中。因此，健康是一個動態的概念。疾病的發生，是在某種致病因素的影響下，機體的“陰平陽秘”正常生理平衡被破壞，從而發生“陰陽失調”所致 P[4]P。 綜觀各類醫學雜誌，在對亞健康的研究中所針對的人群都集中在成人，極少把兒童的亞健康狀況歸於其中，在人們的概念中，中醫調養適合人士為中壯年和老年，如調補肝腎，健脾益氣等是成年人最為普遍的方法，然而在現實社會中兒童的亞健康狀況的症狀較為嚴重，往往被人們所疏忽，尤其由於成人的護理不當，沒能及時發現疾病的發展，最終致病甚至死亡也大有人在。 引起兒童亞健康的病因病機是多種致病因素中和作用的結果，既有社會學、心理學因素，也有家庭環境、餵養生活方式和遺傳學因素的不良影響，是多因素作用的結果。 1 餵養、 飲食不合理。是導致兒童亞健康的主要因素。小兒“脾常不足”，且乳食不知自節，又有家長餵養不當，易為乳食所傷。 小兒乳食貴在有序、有時、有節。由於家長餵養不當，初生缺乳，或未能按期添加輔食，或任意縱兒所好，飲食營養不均衡，皆能使小兒脾氣不充，運化失健，產生脾系疾病。又常因小兒幼稚，不能自調、自控飲食，易於造成挑食、偏食。過食寒涼者傷陽，過食辛熱者傷陰，過食肥甘厚膩者傷脾等；小兒易見饑飽不均，乳食偏少可導致氣血生化不足，乳食過多又可導致脾胃受損。飲食不潔也是小兒發病的一個常見原因。尤其嬰兒時期的小孩生長發育特別快，所需要的熱量比任何時期年齡都要多，而消化器官的功能發育尚未完善，稍有餵養不慎，就會引起嬰兒腹瀉和營養紊亂，甚者會消化道病變遺留終身。 2 休息不足，特別是睡眠不足。快節奏的社會生活,繁多的資訊刺激，使人的交感神經系統長期處於亢奮狀態，導致植物神經、內分泌、免疫系統功能失調，從而引起亞健康。由於影視、網路、遊戲、成人打牌、麻將等娛樂，對兒童產生吸引力或幹擾，常打亂兒童的正常生活規律，從而影響到作息時間，導致小孩也起居無規律、作息不正常已經成為常見現象。也有因父母本身作息無規律，導致小孩也跟著不規律的作息，導致睡眠不足，引起失眠、消瘦、脾胃心功能不佳，最終逃不過患失眠症，或情緒病變。 3 過度緊張，壓力太大。小兒心神怯弱，長時間的所欲不遂，缺少關愛，容易導致憂思；家長對子女的過於溺愛，使兒童心理承受能力差，或者學習負擔過重，家長期望值過高，都易產生精神行為障礙。常見學習以及家庭壓力，導致學習負擔。 4 長久的不良情緒影響。單親家庭，或父母失業失和，對孩子的成長會產生負面影響。對生活在一個父母雙全、幸福美滿、充滿愛心、又善於給小孩恰當和足夠刺激的家庭裏，是小孩的心理精神發育的必備條件基礎，而對於沒有獲得母子依戀感情，或父母關係不和的小孩會形成心理不健康和性格怪異，成人後很難與人交往。長期的抑鬱、低沉和悲哀,可以明
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 35顯地削弱機體的免疫功能從而導致健康偏離狀態。 5 病理性體質 P[5]P：機體對某些外邪的易感性、機體對病證的易發性和發病後病證的易轉性等,可稱為“病理性體質”, 亞健康狀態，是指人的身心處于健康的低質狀態，是人體生理機能失調的綜合表現，是一個由健康到不健康的動態過程中的一個階段。這個階段是機體的陰陽氣血偏離平衡，而偏離的程度和方向與每一個人的體質類型密切相關。所以，病理體質與亞健康狀態密切相關，病理性體質是亞健康狀態的物質基礎，臟腑氣血陰陽失調，是亞健康狀態的基本病機特點，亞健康狀態則是病理體質的表現特徵和外顯形式。 常見臨床症狀 兒童亞健康狀況與成人類似，處於疾病前期的“亞健康狀態”，其體內陰陽氣血已經失調，處於病與未病之間。臨床常見於潛伏期，由於小孩病理特點，發病容易，傳變迅速，臟氣清靈，易趨康復，故臨床病變相對成人快，而治療及時轉愈也較成人快。本章節重點討論以下幾種兒童常見的亞健康症狀： 1 厭食 P[6]P：長期食欲不振，厭惡進食，食量明顯少於同齡正常兒童。面色少華，形體偏瘦，但精神尚好，活動如常。無慢性器質性疾病。病程短者為脾失健運；僅表現納呆食少，食而乏味，飲食稍多即感腹脹，形體尚可，舌質正常，舌苔薄膩。病程長者為脾胃氣虛，食而不化，大便溏薄，並伴面色少華，乏力多汗，形體偏瘦，舌質淡，苔薄白；若食少飲多，口舌乾燥，大便秘結，舌紅少津，苔少或花剝者為脾胃陰虛。 2 功能性再發性腹痛 P[6]P，約占腹痛患兒總數的50%～70%。小兒啼哭、彎腰捧腹，或呻吟不已、時緩時急者，多為腹痛。常因感受寒邪，或過食生冷，或素體陽虛而腹痛者，屬於寒性腹痛；過食辛辣香燥或膏粱厚味成積滯，熱結陽明而腹痛，屬於熱性腹痛。 3 便秘 P[7]P：兒童發病率較高，大便乾燥堅硬、秘結不通、排便次數減少、間隔時間延長，常二、三日以上方排便一次；雖排便間隔時間如常，但排便艱澀，糞質堅硬；便意頻頻，但難以排出或難以排淨。便秘者可伴有腹脹、腹痛、食欲不振、夜寐不安、生長發育遲緩。長期便秘者可誘發肛裂、痔瘡。 臨床病程短者多見為實證，以乳食積滯、燥熱內結和氣機鬱滯所致，糞質多乾燥堅硬，長腹脹拒按；病程長者為虛證，多見體質弱，糞質不甚幹結，但欲便不出或便出不暢，常腹脹喜按。 4 肥胖症 P[7]P：常因外感濕邪；飲食不節，過食肥甘；先天脾腎兩虛，水濕不運，內停化痰壅滯於中所致。脾胃為後天之本，氣血生化之源，小兒脾常不足，腎常虛，多食肥甘、少動等誘因，致使精微不歸常化，水濕內停，聚濕生痰，痰從脂化，釀成脂膏積於體內則為肥胖虛浮之標實證，脾腎氣虛，常感疲乏無力，肢體困倦，腹滿氣短之本虛證。近年來，隨著人們生活水準的提高，人體熱量的攝入遠遠高於消耗，營養條件改善，以及各種營養保健食品的面世，兒童單純性肥胖症日益增多。肥胖是其他亞健康症狀無法相比的，其早期屬於亞健康狀態，但潛伏著許多疾病的危險，確實與高血壓病、冠心病、動脈粥樣硬化、糖尿病、膽囊炎、呼吸通氣不良、骨關節炎等發病率的增加有關。肥胖發生年齡越小，時間越長，成年後導致上述疾病的可能性越大,，並逐漸年輕化的傾向。 5 夜寐不安：表現為寐少夢多、難以入睡、睡眠時身體經常翻動、突然哭叫、早醒、易醒等。多見小孩起居飲食無規律、作息不正常；環境吵雜或變更；精神緊張、受驚嚇；學習壓力過重等致脾運失健、情志抑鬱，心肝失調，氣機不暢。臨床病程短者多見為實證，病程長者多見虛證，如心失所養所致的心氣不足、心血不足、心陰不足等症，可伴有煩躁不安，白天注意力不能集中，學習困難，亦因肝脾不和伴厭食、腹痛等症。 6 汗證 P[6]P：小兒在安靜狀態下，正常環境中，全身或局部出汗比正常兒童過多，甚則大汗淋漓，無他器質性病變。中醫認為血與汗同源，適量出汗能疏通腠理，抗禦外邪，調整氣血，平衡陰陽。若汗出過多，則耗陰竭液，氣隨汗泄，陽隨津脫。常見證型為
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, June 2010, Vol.10, No.1, 2 36 肺衛不固、營衛失調、氣陰虧虛和脾胃積熱致濕熱迫蒸等。 7 注意力缺陷多動症 P[6]P：是一種較常見的學齡期兒童時期行為障礙性疾病。以注意力渙散，上課時思想不集中，坐立不安，喜歡做小動作，活動過度、自我控制差，動作過多和笨拙，情緒不穩、衝動任性，伴有學習困難，但智力正常或基本正常。主要病機為陰陽失調，陰靜不足，證見注意力不集中，自我控制差，情緒不穩，神思渙散；陽亢躁動，證見動作過多，衝動任性，急躁易怒。 8 遺尿P[6]P：見於 3 周歲以上，寐中小便自出，醒後方覺。睡眠較深，不易喚醒，每夜或隔幾天發生尿床，甚則每夜遺尿 1～2 次以上者。尿常規及尿培養無異常發現。病機多與膀胱和腎的功能失調有關，其中尤以腎氣不足，膀胱虛寒為最多見。常見病程長，體質弱，尿頻清長，舌質淡，苔薄滑，或舌有齒印舌體胖嫩，兼見面白神疲、納少乏力、肢冷自汗、大便溏薄、反復感冒等症。 9 心理偏差：多見於學齡期和青春期兒童，表現為心悸胸悶、喜歎氣、睡眠紊亂、食欲不振、脘腹不適、情緒低落、心煩意亂、焦躁不安、急躁易怒、恐懼膽怯、記憶力下降、注意力不能集中、學習困難，甚者厭學等；不能正常地處理好同學和老師關係、家庭關係緊張，甚者有自殺傾向。 防 治 亞健康和疾病狀態，經過防制和幹預發生“逆轉”，向健康狀態轉化。因此，加強科學保健，提高生活品質，完全可以重新找回健康。兒童亞健康的症狀如不加以及時控制，常會影響兒童的生長發育以及身心的健康發展，會引起一系列的慢性病，成年後甚至不能融入社會。為此根據引起亞健康病因病機，重點從以下各方面加以改善，使人體處於向健康方向發展： 1 合理進食 P[7]P：掌握正確的餵養方法，飲食起居按時、有度，飯前勿食糖果飲料，夏季勿貪涼冷飲。根據不同年齡給予富含營養，易於消化，品種多樣的食品。母乳餵養的嬰兒 4 個月後應逐步添加輔食。糾正不良飲食習慣，做到“乳貴有時，食貴有節”，不偏食、挑食，不強迫進食，飲食定時適量，葷素搭配，少食肥甘厚味、生冷堅硬等不易消化食物，鼓勵多食蔬菜及粗糧。 2 充足睡眠 P[8]P：足夠的睡眠是保證兒童健康的先決條件之一。如果睡眠時間不足，小孩就會煩躁、易怒、食欲減輕。另外睡眠不足，反而使小孩睡眠不熟，因而容易引起惡性循環。 要保證足夠的睡眠時間，必須養成良好的睡眠習慣，這要求出生後就要開始訓練，尤其是在夜間，不要因為喂乳而喚醒小孩，應任孩子熟睡。睡眠時任小孩自由舒張，但要避免固定一個姿勢，以防形成不良條件反射，習慣養成後，最好不要隨意變動睡眠時間。 睡眠是大腦皮層的一個廣泛的抑制過程，通過睡眠可以使大腦皮層得到休息，從而使大腦恢復功能。小孩的睡眠時間與年齡成反比，年齡越小睡眠時間越長，隨著大腦皮層的發育成熟，睡眠時間逐漸減少。 當出現睡眠不安時，要及時尋找病因，儘快應用中藥調節其功能的平衡。 3 舒緩精神壓力： 開展心理疏導與行為指導。對於存有精神心理不適，或與人交往困難者，可根據具體情況給予心理疏導，或認知行為方面的指導。良好的心理狀態有助於分泌有益於健康的激素酯類和乙醯膽鹼等，可調節機體至最佳狀態，提高機體免疫力。相反,不良的心理狀態和情緒,可導致免疫系統功能失調,體質下降,從而引起多種疾病的發生，學齡期兒童的亞健康狀態會使人學習動力不足和效率低下。厭學，承受學習壓力的能力差，從而導致成績下降； 而成績的不理想又會進一步削減學習興趣，由此形成惡性循環。正視壓力。學會放鬆很關鍵。認識到生活中有壓力是必然的，就會以積極的心態去應對各種挑戰。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 38 ‧講座‧ 腫瘤科門診在衛生中心設立的可行性探討 彭世明 【摘要】 隨著惡性腫瘤發病率增加，腫瘤病人的年青化、人口老化、患病者存活率的提升及存活時間的延長、病人出現的後遺症的增多，病人及家人的心理情緒的影響等等都是對腫瘤科門診的需求增加。政府醫院的腫瘤科的專科醫生提供服務的單一化及局限性，令病人未能得到全面的照顧。初級衛生保健的系統和全科醫生的診治模式除了可提供病人及家屬全面性、人性化的照顧，亦可以減少政府醫院專科門診壓力。在衛生中心建立腫瘤科門診，是以初級保健的角度處理經腫瘤科醫生治療後的病人是可行及需要的。 【關鍵詞】 惡性腫瘤; 衛生中心; 門診 TEvaluation of Feasibility and Strategic Plan for Establishment of Oncologic Clinics in Primary Health Care Setting T PANG Sai Meng. Technical Training and Documentation Unit, Technical Coordination Office, General Health Care Sub-Board, Health Bureau, Macao SAR Government, PR China; Tel: (+853)-8597 6105; Email: shirleypangpang@yahoo.com.hk 【Abstract】 The demands of the patients with malignant tumors for seeking medical services in the outpatient setting are rising with the recent evidences demonstrating that the population of cancer patients is increasing; the patients are younger and younger; the whole general population in the society is older and older; the incidence of the complications of cancer is enhancing; the patients’ survival periods are also raising; as well as the psychological problems of the patients and their family members are also more remarkable. Currently, the government hospital only offers the secondary specialist medical care which is not holistic care and hence can not take care of the patients on the whole. The pattern of primary medical care and family physician’s practice is the provision of holistic and humanized care for the patients with cancer in the community and can significantly relieve the workload in the specialist clinics in the government hospital. It can be seen that the establishment of oncologic clinics in health centers using the pattern of primary medical care is essential and feasible. 【Key words】 Cancer; Health center; Clinic 前 言 全世界因惡性腫瘤死亡的人數持續高企，澳門也不例外，澳門的惡性腫瘤死亡率佔據著死亡譜的第一位 TPD[1]DPT，足見惡性腫瘤對人們生命之威脅。迄今醫學界對惡性腫瘤的病因及發病機制還未能瞭若指掌；患病後病人承受著巨大的心理壓力，治療的副作用引致不適及痛苦；存活率的提升及存活時間的延長，使病人出現不同程度的後遺症，令病人及家庭的生活質量受到影響。種種原因證明惡性腫瘤的防治要做到“早期預防，早期發現，早期診斷，早期治療”最為重要。當惡性腫瘤的存活期不斷延長及無可避免的後遺症出 作者單位：中國, 澳門特別行政區政府, 衛生局, 一般衛生護理副體系, 技術協調室, 培訓暨文件組, Tel: (+853)-8597 6 105; E-mail: shirleypangpang@yahoo.com.hk 現時，實可視為一種慢性病，因此便不能缺少長期的、連續性的家居照護，以鼓勵病人自我照顧，協助病人恢復生理、心理、社會功能。 社區衛生強調的是預防疾病、早期發現、早期診斷、促進病人恢復健康。但是在初級保健範疇內，患惡性腫瘤病人經治療後的跟進幾乎是空白的，因此，在衛生中心開展跟進惡性腫瘤的工作計劃有其迫切性及需要性。 腫瘤病人及其家屬對腫瘤科門診的需求 1 腫瘤病人的年青化 隨著醫學技術的發展，市民對腫瘤的認識提高，早期發現病例的不斷提高。患腫瘤病人的年青化，從發病至死亡的年期的延長；以及在此期間得到
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 42 ‧病例報告‧ Pulmonary Manifestations of Tuberous Sclerosis Complex (TSC) MOK Tin Hou LOK Iek Long CHAN Hong Tou MOK Ka Pou* HUNG Huang Feng** Maria Teresa Pinto CHEONG Tak Hong 【Abstract】 Tuberous sclerosis complex (TSC) is a rare multi-system disease with an current estimated incidence of one per 6,000 live births. It estimates 1 million people with TSC worldwide, with approximately 90 in Macau but clinical reports are rare locally. TSC is an autosomal, dominantly inherited, genetic disorder resulting in the development of hamartias* and hamartomas** in multiple organ systems. Presenting features may be in any or all of these organs with variability ranging from a mild disorder manifesting only as skin findings and asymptomatic brain lesions to a more severe course involving pneumothorax, respiratory failure, seizures, mental disability, autism and extensive kidney disease. The diagnosis of TSC is often difficult or delayed due to the variable expression of the disease and the variable age of onset of the symptoms. Lymphangioleiomyomatosis (LAM) is the most common form in the lung involvement of TSC, which is one of the major features in the diagnostic criteria. However, there are no known pathognomonic signs for TSC as no single clinical feature is unique to the disease. A constellation of features is therefore necessary for a diagnosis of TSC. LAM also occurs primarily, although less frequently, in women who do not have TSC (incidence of sporadic LAM is approximately one per 100,000). About 60 percent of women with sporadic LAM also have renal angiomyolipomas (AMLs) which is one of the majors features of TSC. When LAM is suspected clinically or diagnosed pathologically, further investigation by a variety of specialists is necessary for the diagnosis or differential diagnosis of TSC. 【Key words】 Tuberous sclerosis complex; Lymphangioleiomyomatosis *HAMARTIAS – well-circumscribed group of dysplastic cells, appropriate for the organ or tissue involved. The cells do not multiply or grow more rapidly than normal cells in the organ. **HAMARTOMAS – well-circumscribed group of dysplastic cells that tend to multiply excessively, thereby growing as a benign tumor that may or may not cause symptoms. P[1]P 結節性硬化症的肺部表現 莫天浩, 羅奕龍, 陳洪濤, 莫家寶*, 洪凰鳳**, Maria Teresa Pinto, 張德洪. 中國, 澳門特別行政區, 仁伯爵綜合醫院, 胸肺內科; Tel: (+853)-8390 2410; Email:moksky@hotmail.com; *中國, 澳門特別行政區, 仁伯爵綜合醫院, 放射科; **中國, 澳門特別行政區, 仁伯爵綜合醫院, 病理科 【摘要】 結節性硬化症是一種罕見的多系统疾病，其發病目前估計每 6,000 個人中有 1 個是結節性硬化症患者。預估全球大約有 1 百萬名的 TSC 患者，而澳門大約有 90 個結節性硬化症患者，但本地臨床報告之病例極少。結節性硬化症是一種常染色體顯性遺傳性疾病, 會影響和引致多種器官的錯構組織和錯構瘤形成。疾病的臨床特徵可表現在任何或所有器官，存在很大的變化，輕症可表現為皮膚疾病和無症狀的腦部病變，重症可表現為氣胸、呼吸衰竭、癲癇、智力殘障、自閉症和嚴重腎臟疾病。由於結節性硬化症的臨床表現和症狀發病年齡變化很大，診斷往往困難和遲發現。 在結節性硬化症肺部受累的病人當中，淋巴管平滑肌增多症是最常見的表現，也是診斷標準中的重要特徵之一。然而結節性硬化症的臨床表現和診斷中，是沒有一個獨一無二的病理和臨床特徵。因此以結節性硬化症臨床特徵群組作診斷是必須的。淋巴管平滑肌增多症也可原發于沒有結節性硬化症女性病人，其發病情況不常見，散發的結節性硬化症病例估計每 100,000 個人中有 1 個，散發的結節性硬化症女性病人中有百分之六十病例合併患有血管肌肉脂肪瘤，它也是結節性硬化症診斷標準中的另一個重要特徵。在臨床當淋巴管平滑肌增多症被懷疑或是在病理作出診斷時，還須透過不同專科進一步檢查對結節性硬化症作出診斷或鑒別診斷。 【關鍵詞】 結節性硬化症; 淋巴管平滑肌增多症 CASE PRESENTATION A 26 years old female, non-smoker, has history of Author’s address: Department of Respiratory Medicine, Centro Hospitalar Conde São Januário, Macao SAR, China; Tel: (+853)-8390 2410; E-mail: moksky@hotmail.com *Department of Radiology; **Department of Pathology severe facial skin rashes (Fig 1,2) since childhood. She also has obvious abdominal distention since age of 18 without further medical investigation. She had followed up in psychiatry clinic due to personality disorder and depression.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 43 Fig 1-2 Facial angiofibromas with TSC On 19PthP May 2006, she presented with suddenly right chest pain and dyspnea and was sent to emergecy room. Physical examination found a huge mass in abdomen and skin rashes on face and forehead. Chest X-rays showed right pneumothorax and diffuse reticulo-nodular changes in both lungs. When chest tube thoracotomy was performed but bronchial fistula was persistent for 3 weeks. On 30 PthP May 2006, chest CT scan Fig 3 diffuse interstitial pulmonary disease with multiple thin wall cystic spaces suggested diffuse interstitial pulmonary disease with thin wall cystic spaces (Fig 3) and right pneumothorax. On 9PthP June 2006, video assisted thoracoscopic surgical (VATS) wedge resection of right upper and lower lobes of lung with mechanical pleurodesis were performed, which revealed lymphangiomyomatosis in pathology (Fig 4-5). Fig 4 Patchy and haphazard spindle cell proliferation in lung interstitium, around bronchioles. HE 10x Fig 5 Spindle cells are positive for anti-melanoma antibody－HMB45. For further investigation, skin biopsy, abdominal CT scan and brain MRI were performed. Skin biopsy shows angiofibromas (fibrovascular hamartomatous proliferation) of right cheek (Fig 1) and periungual fibroma of right big toe (Fig 6). Angiofibromas are cutaneous hamartomas and not related to excessive sebum or acne. They were incorrectly named adenoma sebaceum in the past. Fig 6 Periungual fibroma of right big toe with TSC Huge angiomyolipoma (hamartoma) of both kidneys was found (Fig 7-8), which presented malignant sign with metastasis in liver, spine and pelvic bones (osteoblastic lesion). Multiple tiny nodules noted at the walls of both lateral ventricles. (Fig 9)
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 44 Fig 7, 8 bilateral huge renal angiomyolipoma According to the clinical diagnostic criteria, which was revised by the Tuberous Sclerosis Alliance (TS Alliance) and the National Institutes of Health (NIH), tuberous sclerosis complex (TSC) was diagnosed because 5 majors features (facial angiofibromas, periungual fibroma of big toe, LAM, subependymal nodule and renal angiomyolipoma) presented in this case. After management of pneumothorax, she still had progressive exertional dyspnea with poor lung function and followed up in respiratory clinic. Since April 2008, she had recurrent massive right pleural effusion and pleural liquid analysis suggested chylothorax. (Fig 10) Repeated twice pleural biopsy could not prove malignancy or metastasis. Chemical pleurodesis was performed and there is no recurrence of effusion again. However dyspnea and respiratory failure became worsen progressively and she needed home O2 support in 2009. Feburary 2010, she was admitted to ICU because of renal AMLs bleeding with shock. Finally, she died 6 days later, when her age is 30 years old. DISCUSSION Background Tuberous sclerosis complex (TSC) is an autosomal, dominantly inherited, genetic disorder affecting cellular Fig 9 subependymal nodules with TSC Fig 10 pleural liquid analysis shows chylothorax differentiation, proliferation and migration early in development, resulting in the development of hamartias and hamartomas in multiple organ systems. Presenting features may be in any or all of these organs and the prognosis can be difficult to predict, with variability ranging from a mild disorder manifesting only as skin findings and asymptomatic brain lesions to a more severe course involving pneumothorax, respiratory failure, seizures, mental disability, autism and extensive kidney disease. Accurate diagnosis allows for timely referrals of affected individuals to appropriate specialists to determine if other problems exist. However, many individuals with TSC report that their diagnosis came after much delay or uncertainty. Despite being one of the more common single gene disorders seen in children and adults, with an estimated incidence of one per 6,000 live births,P[2]P the diagnosis of TSC is often difficult or delayed due to the variable expression of the disease and the variable age of onset of the symptoms. Clinical Features and Diagnosis There are no known pathognomonic signs for TSC as no single clinical feature is unique to the disease. A constellation of features is therefore necessary for a diagnosis of TSC, with more specific features contributing more heavily to the diagnosis and an increasing number of features making the clinical suspicion of TSC more likely.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 45In July 1998, the Tuberous Sclerosis Alliance (TS Alliance) and the National Institutes of Health (NIH) revised the clinical diagnostic criteria (Table 1 & 2) that had been previously established in 1992. Table 1 Diagnostic Criteria for Tuberous Sclerosis Complex Definite TSC 2 major features or 1 major feature and 2 minor features Probable TSC 1 major features and 1 minor features Possible TSC 1 major features or 2 or more minor features Table 2 Features for Tuberous Sclerosis Complex MAJOR FEATURES MINOR FEATURES 1-Facial angiofibromas or forehead plaque 2-Non-traumatic ungual or periungual fibroma 3-Hypomelanotic macules (three or more) 4-Shagreen patch (connective tissue nevus) 5-Multiple retinal nodular hamartomas 6-Cortical tuber [a] 7-Subependymal nodule 8-Subependymal giant cell astrocytoma 9-Cardiac rhabdomyoma, single or multiple 10-Lymphangioleiomyomatosis [b] 11-Renal angiomyolipoma [b] 1-Multiple, randomly distributed pits in dental enamel 2-Hamartomatous rectal polyps [c] 3-Bone cysts [d] 4-Cerebral white matter radial migration lines [a,d] 5-Gingival fibromas 6-Nonrenal hamartoma [c] 7-Retinal achromic patch 8-‘Confetti’ skin lesions 9-Multiple renal cysts [c] a The co-occurrence of cerebral cortical dysplasia and cerebral white matter radial migration lines should be considered as one major feature of TSC. b In patients with both lymphangioleiomyomatosis and renal angiomyolipoma, another feature of TSC must be identified before a definite diagnosis is assigned. c Histologic confirmation of these features is suggested. d Radiographic confirmation of these features is sufficient. Source: Adapted from Roach et al., 1998 Lung involvement of TSC TSC is multi-system disease affecting lung with different clinical manifestation. The pulmonary manifestations found in tuberous sclerosis complex (TSC) are lymphangioleiomyomatosis (LAM), multifocal micronodular pneumocyte hyperplasia (MMPH), pulmonary cysts, clear cell tumor of the lung (Sugar tumor), pneumothorax and chylothorax. The first symptoms of lung involvement in an individual with TSC may be shortness of breath after mild exercise, spontaneous pneumothorax, or coughing. Progression to pulmonary failure may develop, but not usually until the third or fourth decade of life, if at all. Pulmonary involvement in TSC can be severe, and some individuals will require lung transplantation. Involvement occurs primarily in adult women, generally aged 30 or older. It was long thought to be distinctly uncommon, affecting 1 percent or less of women with TSC. However, recent prospective and retrospective studies have found cystic pulmonary abnormalities in as many as 40 percent of women with TSCP[3]P, P Palthough most of those women remain asymptomatic. Symptomatic pulmonary disease in men and even in children with TSC has been reported anecdotally. The true incidence of pulmonary abnormalities in these populations is not known, although it is certainly lower than in adult women with TSC. LAM is the most common form in the lung involvement of TSC, which is one of the major features in the diagnostic criteria. It is more insidious and is a result of the invasion of the potential space between lung alveolar cells and capillary endothelium by a smooth-muscle-like cell. Interstitial fibrosing alveolitis develops with progressive restrictive lung disease. Smooth muscle cells undergo abnormal proliferation with secondary compromise of bronchioles, venules and lymphatic structures. Slowly, normal pulmonary elasticity is lost, with resultant decrease in vital capacity and increase in residual volume. Pulmonary hypertension and worsening hypoxia and hypercapnia eventually supervene.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 46 LAM also occurs primarily, although less frequently, in women who do not have TSC (incidence of sporadic LAM is approximately one per 100,000) and may progress rapidly to respiratory failure and death during pregnancy. About 60 percent of women with sporadic LAM (Fig.4) also have renal AMLs (Fig.7-9), but do not have other characteristics of TSC. When LAM is suspected clinically, high-resolution CT of the chest is the most sensitive diagnostic modality. However lung biopsy is necessary to confirm the diagnosis. MMPH consists of hyperplasia of type II pneumocytes, seen as nodular densities on chest CT scans. This condition occurs with equal frequency in men and women with TSC and does not produce clinical symptoms. Pulmonary cysts may be single or multiple (Fig. 3) as seen in imaging studies. Solitary lesions may remain clinically silent or rupture, with resultant pneumothorax producing acute dyspnea and hemoptysis. Multiple cystic lesions may result in respiratory insufficiency or even pulmonary hypertension (usually in the case of LAM). Clear cell tumor is a rare tumor of lung. Rarely, similar tumor have been described at a wide range of extrapulmonary sites. Clear cell tumor of the lung is thought to be one of a family of tumors with the features ofso-called perivascualr epithelioid cells. Rarely, a combination of clear cell tumor, lymphangioleiomyomatosis, MMPH and TSC has been reportedP[4]P. Spontaneous pneumothorax proliferated muscle can obstruct bronchioles with air trapping and formation of bullae, which often complicated by pneumothorax. Chylothorax proliferated muscle can obstruct lymphatics and cause chylothorax or chyloperitoneum. Chylothorax is rarely observed in TSCP[5,6]P . Hemoptysis proliferated muscle can obstruct venules and cause pulmonary hemorrhage and hemosiderosis, accompanied clinically by hemoptysis. Differential Diagnosis The clinical manifestation and pathology of lung involvement in TSC is similar to LAM, so the further investigation is necessary to exclude to TSC. However some individuals who have sporadic LAM also have angiomyolipomas (AMLs) but do not have other findings of TSC. These individuals do not transmit TSC or LAM to their offspring. The individuals affected with LAM and angiomyolipomas who have no other features of TSC do not meet diagnostic criteria for TSC. Treatment Pulmonary involvement in TSC can be severe, even fatal. Due to the overwhelming predominance of LAM in women, it is possible that estrogen accelerates the progression of the condition. Some patients have been treated with hormonal therapy (i.e., progesterone) to counteract the estrogen effect, although this has not been proven conclusively to be of benefit. Bronchodilators are helpful in selected cases. In cases where LAM is progressive, a lung transplant may be necessary. Interestingly, LAM occasionally has recurred in transplanted lungs. Karbowniczek et al. demonstrated the migration of cells from renal AMLs to the lungs of women with LAM, regardless of whether they have TSC, and the cells almost certainly cause the disorder P[7]P. Reference 1 Gomez MR, Natural history of cerebral tuberous sclerosis. In Gomez MR, Sampson JR, and Whittemore,VH (Eds.),Tuberous Sclerosis Complex. (3PrdP ed.). (1999)New York: Oxford University Press. 2 Osborne JP, Fryer A, Webb D. Epidemiology of tuberous sclerosis. Ann N Y Acad Sci. 1991,615,125-127. 3 Moss J, Avila NA, Barnes PM, et al. Prevalence and clinical characteristics of lymphangioleiomyomatosis (LAM) in patients with tuberous sclerosis complex. Am J Respir Crit Care Med, 2001, 164(4):669-671. 4 Fliedr DB, Travis WD. Clear cell “sugar” tumor of the lung: association with lymphangioleiomyomatosis and multifocal micronodular pneumocyte hyperplasia in a patient with tuberous sclerosis. Am J Surg Pathol, 1997; 21:1242-1247. 5 Broughton RBK. Pulmonary tuberous sclerosis presenting with pleural effusion. Br Med J, 1970, 1:477-478. 6 Valensi QJ. Pulmonary lymphangiomyoma, a probable forme frust of tuberous sclerosis. Am Rev Respir Dis, 1973, 108:1411-1415. 7 Karbowniczek M, Astrinidis A, Balsara BR, et al. Recurrent lymphangiomyomatosis after transplantation: genetic analyses reveal a metastatic mechanism. Am J Respir Crit Care Med, 2003, 167(7):976-982.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 47‧病例報告‧ 血管瘤樣纖維組織細胞瘤 1 例 陳建勇 文劍明 【摘要】 血管瘤樣纖維組織細胞瘤（angiomatoid fibrous histiocytoma, AFH），是一種少見的軟組織腫瘤，組織病理學上易與其他良惡性軟組織腫瘤混淆。本文報道一例女性 32 歲 AFH，腫瘤位于左腹股溝，囊實性。組織學上，囊腔充有血液，腫瘤呈編織狀和漩渦狀排列，瘤細胞為呈梭形的纖維組織細胞，細胞生長活躍，可見“炮彈樣（Cannon-ball-like）”結構。免疫組化顯示瘤細胞 CD68、Desmin、Vimentin 陽性。腫瘤切除後 20 個月未見復發和轉移。 【關鍵詞】 軟組織腫瘤; 血管瘤樣纖維組織細胞瘤; 炮彈樣 A Case Report: Angiomatoid Fibrous Histiocytoma CHAN Kin iong, WEN Jianming. Department of Pathology, Kang Wu Hospital, Macao SAR China; Tel: (+853)-8295 1921; E-mail: jammy_chan@hotmail.com 【Abstract】 Angiomatoid fibrous histiocytoma (AFH) is a rare soft tissue tumor. It is easily confused with other benign or malignant soft tissue tumor. We report a 32-years-old woman with solid cystic AFH in the left groin. Histologically, the various sizes of cysts in the tumor were filed by blood. The tumor is arranged in interlace or whirl pattern. The tumor cells are spindle fibrous histiocytes and grow actively. Cannon-ball-like growth pattern is observed. Immunostain shows the tumor cells are positive for CD68, Desmin and Vimentin. There is no local recurrence or metastasis in 20 months after resection of the tumor. 【Key words】 Soft tissue tumor; Angiomatoid fibrous histiocytoma; Cannon-ball-like 臨床資料 患者女性，32 歲，發現左腹股溝腫物 2 月，無壓痛，無發熱或消瘦，腫物皮面無異常。盆部 CT 示左側腹股溝區軟組織腫塊，提示惡性腫瘤伴局部淋巴結腫大，左側股動、靜脈受壓。手術中見腫物約6×5×4cm 大小，與股靜脈緊密黏連，腫物連股靜脈前壁一同切除。 病理檢查 肉眼檢查：送檢帶皮膚不規則組織一塊，大小8×6.5×6cm，灰褐色，質軟，切面位於皮下深處可見呈囊實性腫物，腫物大小 4.3×3.5×2.7cm，邊界清，無包膜，囊內出血伴血塊阻塞，腫瘤旁緊貼一直徑1.5cm 的血管（圖 1、2）。 鏡下檢查：送檢腫物囊實性，實性部分由梭形至短梭形細胞組成，細胞排列成束狀、交織狀，部分成漩渦狀，細胞核較大，呈不典型性，部分細胞核呈泡 作者單位：中國, 澳门特別行政區, 鏡湖醫院病理科; Tel: (+853)-8295 1921; E-mail: jammy_chan@hotmail.com 圖 1 血管瘤樣纖維組織細胞瘤 腫瘤肉眼外觀 與血管瘤相似。 圖 2 血管瘤樣纖維組織細胞瘤 低倍鏡下見腫瘤呈囊實性，擴張的囊腔內充血液，包膜不完整，局部有淋巴組織圍繞。×1
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 49有較多淋巴結。 AFH 為緩慢生長的腫瘤，類似血管瘤，位於真皮深部，通常無痛無癥狀，偶伴發熱，貧血及體重下降。 AFH 的大小由 0.7 至 12cm 不等，平均 2cm，外觀似淋巴結，最特徵性的表現是切面見到多結節狀伴有血性的囊腔，類似血腫或淋巴結內囊性出血。AFH鏡下形態有四個主要特徵：1. 嗜酸性的組織細胞樣細胞或肌樣細胞呈多結節狀增生，細胞形態較一致，常呈梭形或上皮樣，伴卵圓形泡狀核；2. 假血管瘤樣的腔，位於腫瘤內并充有血液，但腔內無內皮被覆；3. 厚的纖維性假包膜；4. 包膜外淋巴漿細胞浸潤，有時伴有淋巴濾泡形成，類似淋巴結結構。由於有出血，可伴有吞噬含鐵血黃素的組織細胞。 免疫組織化學染色中，CD68 及Desmin均有約50%表達，EMA約 40%表達，Actin及CD99 少部分表達，而S-100、網狀細胞標記CD21、CD35、HMB-45、CK、血管特異性標記CD31、CD34 及第 8 因子等均陰性P[3, 4]P。 WHOP[2]P指出電子顯微鏡下AFH的腫瘤細胞並無特 定 的 分 化 特 徵 ， 可 能 與 取 材 不 當 有 關 ， 而HasegawaP[5]P報導，AFH腫瘤在電鏡下有成纖維細胞、組織細胞及成肌纖維細胞分化， 由於AFH常有血性的囊腔及外周有豐富的淋巴成分、偶伴淋巴濾泡形成，容易與血管源性腫瘤，血腫及淋巴結轉移癌混淆。由于腫瘤的血腔內未見內皮被覆，腫瘤實體有組織細胞樣或肌樣的腫瘤細胞，在免疫組化上也不表達血管內皮標記，因而可與血管源性腫瘤或血腫鑒別。此外，腫瘤內並無真正的淋巴結結構，如被膜下邊緣竇或髓質淋巴竇，加上免組化上皮標記均陰性，均不支持淋巴結轉移癌。在腫瘤實性部分的組織細胞樣腫瘤細胞成分則需要與纖維組織細胞瘤或惡性纖維組織細胞瘤鑒別，AFH的腫瘤細胞較單一，無多核組織細胞，無車輻狀排列。另外，細胞異型性、核分裂活躍及腫瘤壞死等惡性特徵均不明顯，而AFH特有的血性囊腔及外周淋巴細胞浸潤等在纖維組織細胞腫瘤中并不存在。雖然免疫組化AFH有CD68 表達，但正如Smith等人 P[3]P提到，有CD68 陽性僅表示腫瘤細胞有吞噬細胞的活性，并不代表有纖維組織細胞的抗原成分，加上AFH的好發年齡有別於惡性纖維組織細胞瘤，電鏡及免疫組化又欠缺特異性，故AFH在WHO(2002)軟組織及骨腫瘤中劃分為未確定分化的腫瘤，從以往惡性纖維組織細胞瘤內獨立分離出來。 AFH預後較好，有 2-11%的病例局部復發，而轉移少於 1%，偶有遠處轉移及死亡的報告P[6, 7]P，AFH與復發相關的危險因素有別於一般的軟組織惡性腫瘤，如核分裂活性及細胞異型性不影響預後，但如果腫瘤發生在較深的位置，如筋膜下及骨骼肌，有浸潤的邊界及發生在頭頸部的腫瘤等，均預示容易復發 P[4]P。目前本例手術後己年半，病人存活，未見轉移，複查MRI原病灶處未見復發。 參 考 文 獻 1 Enzinger FM. Angiomatoid malignant fibrous histiocytoma: a distinct fibrohistiocystic tumor of children and young adults simulating a vascular neoplasm. Cancer, 1979, 44:2147-2157. 2 Fanburg-Smith JC, Dal Cin P. Angiomatoid fibrous histiocytoma. in: Fletcher CDM, Unni KK, Mertens F, Ed. World Health Organization Classification of Tumors. Pathology & Genetics Tumors of Soft Tissue and Bone. IARC press Lyon, 2002, 194-195. 3 Smith MEF, Costa MJ, Weiss SW. Evaluation of CD68 and other histiocytic antigens in angiomatoid malignant fibrous hitiocytoma. Am J Surg Pathol, 1991, 15:757-763. 4 Costa MJ, Weiss SW. Angiomatoid malignant fibrous histiocytoma. A follow-up study of 108 cases with evaluation of possible histologic predictors of outcome. Am J Surg Pathol, 1990, 14:1126-1132. 5 Hasegawa T, Seki K, Ono K, et al: Angiomatoid (malignant) fibrous histiocystoma: A peculiar low grade tumor showing immunophenotypic heterogeneity and ultrastructural variations. Pathol Int, 2000, 50:731-738. 6 Chow LT, Allen PW, Kumata SW, et al. Angiomatoid malignant fibrous histiocytoma: report of an unusual case with highly aggressive clinical course. J Foot-Anklw Surg, 1998, 37:235-238. 7 Fanburg-Smith JC, Miettinen M. Angiomatoid “malignant” fibrous histiocytoma: a clinlicapathologic study of 158 cases and further exploration of the myoid phenotype. Hum Pathol, 1999,30:1336-1343.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 50 ‧病例報告‧ 急性大面積肺栓塞體外膜氧合加導絲碎栓術 介入治療搶救成功 1 例 金 椿 龍鳳軍 寧肇基* 【摘要】 本文報導一例 51 歲男性，外傷後手術中發生急性大面積肺栓塞，急性低氧血症、休克，因外傷後第九天及手術創傷禁忌溶栓治療，立即採用體外膜氧合加導絲碎栓術介入治療搶救成功。 【關鍵詞】 急性肺栓塞 體外膜氧合 介入治療 Emergency Pulmonary Arteriography and Interventional Therapy in Patient with Operative Acute Massive Pulmonary Embolism JIN Chun, Long Forg-Kuan. Department of Cardiology; *Ning SIo-Kei. Department of Anesthesiology, Kiang Wu Hospital, Macao SAR. PR China. Tel: (+853)-6612 2036; E-mail: jinchun49@hotmail.com 【Abstract】 A 51-year-old man with operative acute massive pulmonary embolism ,sudden onset of acute hypoxemia and shock during operation period , thrombolytic therapy was contraindicated because of nine days post traumatic operation. Successfully treatment with extracorporeal membrane oxygenation plus Interventional treatment 【 Key words 】 Acute massive pulmonary embolism; Extracorporeal membrane oxygenation; Interventional treatment 急性大面積肺栓塞通常病情兇險，如不能及時採取有效措施，死亡率極高。如大面積肺栓塞伴血流動力學不穩定，溶栓禁忌或無效者應積極採取導管介入治療，如導管溶栓術、導管碎栓術、導管吸栓術等方法。本文報導一例外傷後手術中發生急性大面積肺栓塞 ， 因 溶 栓 禁 忌 ， 立 即 採 用 體 外 膜 氧 合 (extracorporeal membrane oxygenation，ECMO) 加導絲碎栓術介入治療搶救成功。 患者男性 51 歲，2009 年 1 月 12 日因從 3 米多高建築架上跌落地，致外傷急診入院，X 光片示左撓骨骨折，骨盆粉碎性骨折，CT 示腹膜後血腫。於 1月 15 日行左撓骨骨折內固定術。１月 21 日(外傷後第九天)在手術室氣管插管全麻條件下行骨盆內固定術，術中突然發生低血氧 (SPO2 40%)，ECG：竇性心動過速 150 次/分，10 分鐘後轉為交界處逸搏心律，壓降低至 80/40mmhg。超聲心動圖顯示右房內有多個條索狀血栓[圖 1]，肺動脈壓 52mmHg。根據病史分析，外傷後臥床、腹膜後血腫壓迫下腔靜脈是血栓形成的條件，超聲心動圖顯示右房內有血栓伴急性低氧血症、休克，急性大面積肺栓塞診斷可成立，但處理很困難。因外傷後第九天，手術切口達骨盆，溶栓治療禁忌；在休克及嚴重低氧血症條件下也難以將病人搬動到導管室進行導管介入治療。經與麻醉師商量後決定在手術室立即安置體外膜氧合。在升壓藥、呼吸機和 ECMO 支持下，將病人送入心導管室行肺動脈造影。造影示左肺動脈主幹完全栓塞[圖2]，右肺血管內多發肺血栓，應用導絲(0.035)機械性碎栓後，栓塞的左肺動脈主幹及分支造影顯影良好，肺血流恢復[圖 3]。術後用肝素 800U/h，維持 ACT 180-200 秒，三天後待血氧及血流動力學穩定後撤除了 ECMO。 作者單位：中國, 澳門特別行政區, 鏡湖醫院, 心內科; *麻醉科; Tel: (+853)-6612 2036; E-mail: jinchun49@hotmail.com
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 51A B 圖 1 AB 心房內見多個血栓 圖 2 肺動脈造影見左肺動脈完全閉塞 圖 3 導絲碎栓後肺動脈顯影 ECMO 在本例搶救過程中起到關鍵作用，在ECMO 對心肺功能的有力支持下，穩定了血氧飽和度和血壓，為進一步做導管介入治療爭取了時間。 ECMO又稱體外維生系統，1972 年Hill首先應用搶救成功一例多臟器衰竭患者 P[1]P。其基本原理是通過插管將病人靜脈血引流至體外，經過人工心肺旁路氧合重新注入病人動脈或靜脈系統，起到心肺替代作用，可進行長時間的心肺支持。現己成為重症心肺功能衰竭病人一種有效的治療手段。ECMO的使用時間可數日或數周，2008 年台大醫院以ECMO支持 117天成功拯救溺水呼吸衰竭病例，為全球使用ECMO時間最長案例。 ECMO 有 V－V(靜脈--靜脈)模式：適用於肺功能損傷，對心臟無支持作用；和 V－A（靜脈－動脈）模式：對心肺同時支持。 ECMO 主要功能： 1. 取代肺氣體交換功能，讓肺功能得以恢復。 2. 增加組織灌注改善血循環，改善心衰。 主要使用對象： 1. 心衰竭：急性心衰，心臟術後心源性休克，急性重症心肌炎，急性心梗及各種心肌病所致心衰，急性肺栓塞。 2. 肺衰竭：急性呼吸衰竭，急性呼吸窘迫症，肺移植。 本例 的成功經驗支持大塊肺栓塞需緊急介入治療的觀點 P[2]P，導絲碎栓作用有效，可達到“立杆見影”的作用。 參考文獻 1 Hill JD, O'Brien TG, Murray JJ, et al. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med, 1972,286：629-634. 2 史景雲, 尤小芳, 王向日. 急性大面積肺栓塞的介入治療及療效評價. 介入放射學雜誌, 2009, 18 (01): 22-25. A B
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 52 ‧病例報告‧ 狼瘡性腹膜炎病例報道 林燕芳 彭莉 蕭浤 【摘要】 回顧兩例狼瘡性腹膜炎，分析討論本病的臨床表現、發病機制及診斷要點，臨床醫生應加深對此病的認識，早期診斷、合理治療，以改善預後。 【關鍵詞】 紅斑狼瘡; 狼瘡性腹膜炎; 激素 Two Cases Report of Lupus Peritonitis Lam In Fong, Peng Li, Xiao Hong Department of Internal Medicine, Kiang Wu Hospital, Macao SAR, China; Tel:(+853)-8295 1709; E-mail:kitchang2002@yahoo.com.hk 【Astract】 Two cases of Lupus Peritonitis were reviewed. Its manifestations, diagnosis were studied. Physicians should be well aware of this disease. Early diagnosis and aggressive treatment may improve prognosis. 【Key words】 Lupus erythematosus; Lupus peritonitis; Corticosteroid 系統性紅斑狼瘡(SLE)是一種自身免疫性、全身性疾病，常累及多個器官，約 40-60%的系統性红斑狼瘡患者有消化道症状 P[1]P， SLE伴腹痛及腹膜刺激征 而 確 診 併 發 腹 膜 炎 者 為 狼 瘡 性 腹 膜 炎 (lupus peritonitis. LP)亦不少見，臨床上分為急性和慢性，尤以急性者極易與外科急腹症混淆，本院近期收治以急腹症為主要表現的SLE兩例，現報道如下。 臨床資料 病例 1 女，26 歲，因乏力、納差 2 周於 2007 年11 月 28 日入院。2003 年外院確診系統性紅斑狼瘡(SLE)，起始予中等劑量潑尼松漸減至維持劑量治療，但患者不規則用葯。入院查體: T 37.5℃，面部未見紅斑，口腔潰瘍，心率增快，肌肉壓痛。輔助檢查 :血白細胞 1.9*109/L，血紅蛋白 107g/L，血沉34mm/hr，谷草轉氨酶 210U/L，谷丙轉氨酶 95U/L，白蛋白 20g/L，抗核抗體(ANA)陽性，抗 dsDNA 陽性，補體 C3、C4 降低，24 小時尿蛋白 2.6g。入院診 斷 SLE 复 發 ， 予 潑 尼 松 45mg+ 環 磷 酰 胺(CTX)0.1qd 等葯物治療，熱退及肌痛緩解。入院後第 6 天患者出現持續性全腹痛，伴腹瀉，全腹明顯壓 作者單位: 中國,澳门特別行政區,鏡湖医院內科; Tel:(+853)-8295 1709;E-mail:kitchang2002@yahoo.com.hk 痛伴反跳痛，B 超及腹盆 CT 示大量腹水、腸壁水腫增厚，腹腔穿刺腹水生化檢查提示為滲出液，病原學陰性，當晚轉外科行腹腔鏡探查，術中見腹腔大量淡黃色滲液，各臟器未見異常，術後腹腔組織病理示:血管壁層 IgG 陽性，考慮腹痛為急性狼瘡性腹膜炎，予甲基強的松龍 500mg 靜滴沖擊治療 3 天，腹痛明顯減輕及腹水減少，出院診斷:系統性紅斑狼瘡复發併急性狼瘡性腹膜炎。目前於中山大學附屬醫院定期隨診，亦同意本院治療方案，服用小劑量潑尼松+氨甲蝶呤(MTX)維持，無再出現腹痛或腹水。 病例 2 女，40 歲，因反复腹痛、排泡沫尿 3 月於 2008 年 9 月 8 日入院。入院前 3 月因腹痛、吐瀉曾入住本院消化內科，查體全腹壓痛伴反跳痛，腹 B超及腹部 CT:中量腹水，小腸瘀張，考慮原發性腹膜炎，轉外科行腹腔鏡術中只見大量腹水，余無特殊發現，腹水生化為滲出液，病原學陰性，術中吸出淡黃色腹水約 1500ml，腹痛暫時緩解，期間請腎科會診建議查免疫指標排除 SLE，結果未回患者要求出院。其後輔檢結果示 :抗核抗體 (ANA)斑點型陽性，抗dsDNA 陽性，抗可提取性核抗原(ENA)中 Anti-SS-A陽性，補體 C3、C4 降低，結合臨床支持 SLE 併狼瘡性腎炎診斷，本次收入院為進一步治療及行腎活檢術。入院第 1 天晚上患者出現劇烈持續全腹痛，查體: T 37.3℃，脫髮現象，顴部紅斑，腹隆軟，全腹壓痛
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 53伴反跳痛，移動性濁音陽性，腸鳴音減弱。輔檢:血紅蛋白 93g/L，血沉 42mm/hr，白蛋白 24.8 g/L，抗核抗體(ANA)陽性，抗 dsDNA 陽性，抗可提取性核抗原(ENA)中 Anti-SS-A 陽性，抗核小體抗體(AnuA)陽性，補體 C3、C4 降低，24 小時尿蛋白 2.98g。初步診斷：系統性紅斑狼瘡活動期併狼瘡性腎炎，腹痛查因：腹膜炎？腹 CT：腹水，小腸腸壁水腫、增厚，未見血管栓塞或腹腔臟器感染，腹腔穿刺腹水性質同前，考慮漿膜炎為狼瘡性腹膜炎，予以甲基強的松龍 1g 靜滴沖擊治療 3 天，改予潑尼松 50mg qd 口服，隨後腹痛明顯減輕並達緩解，腹水逐漸消失，待腹水吸收後行腎活檢，病理診斷支持狼瘡性腎病 1型，患者病情好轉出院。 討 論 狼瘡性腹膜炎在臨床上並不多見，常引起漏診及誤診，此二例患者在整個發病過程不同時段均出現腹痛、腹水及腹膜刺激征等急性腹膜炎表現，且均輾轉擬診急腹症行腹腔鏡探查，術中均未見腹腔感染性、腫瘤性及血管栓塞性疾病， 腹水結果均為無菌性滲出液，臨床和實驗室檢查均支持 SLE，予激素沖擊治療症狀明顯改善，腹水消退，從治療結果也是支持SLE 併狼瘡性腹膜炎診斷。 文獻報道，急性LP常表現為噁心、嘔吐、腹瀉、一般葯物難以控制的腹痛、大量腹水，可以無發熱或血象變化，激素治療效果明顯，與慢性LP比較，急性LP胃腸道症狀較明顯P[2]P，發熱、中樞神經症狀、膀胱炎等亦較常見。慢性LP可以是無症狀，腹水和漿膜炎可以是唯一的臨床表現。激素治療急性LP效果優於慢性LP。 SLE是一種自身免疫性疾病，其發病機理主要是T細胞及B細胞的平衡失調為主，抑制性T細胞功能減退，B細胞功能活躍，並產生過多的抗體，形成抗原抗體复合物，沉積在小血管壁引起血管炎，導致各組織和器官發生病變 P[3]P。腹腔、腹膜及腸系膜有豐富的血管網供應血流，SLE累及腹腔血管可能引發廣泛的血管炎癥，造成腸壁水腫、局部組織缺血和壞死，導致消化道功能紊亂、腸道痙攣，甚至腸道出血; 此外，廣泛血管炎症使白介素、前列腺素等炎症因子釋放增加、血管壁通透性增加，如果患者同時存在低蛋白血症、血漿膠體滲壓低，可導致大量腹水生成。 對於不明原因的大量滲出性腹水，尤其是青年女性、伴皮膚粘膜、腎臟損害等多系統病變的患者，在排除腫瘤、感染及血栓性疾病後，應高度考慮 LP的可能，而非反复行侵入性操作及延誤治療時機、加重病情，並可以嘗試診斷性激素治療。及早診斷、及早治療、減少誤診。 參 考 文 獻 1 許德清,曾凡欽, 主編. 紅斑狼瘡. 第 1 版. 北京:中國醫葯科技出版社, 2003. 288. 2 Ideguchi H, Misulni M, Inoue Y, et al. Two cases of acute peritonitis. Ryumachi, 2000,40(6):910. 3 Bevra Hannabs Habn, Pathogenesis of Systemic Lupus Erythematosus. Kelly’s Textbook of Rheumatology, Sixth Edition, 2002.1089-1099
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 54 ‧病例報告‧ 袋形術治療巨型頜骨囊腫 吳曉林 余東升* 陶謙* 黃忠陽 黃如冰 【摘要】 頜骨囊腫是頜骨最常見疾病之一, 傳統的手術治療破壞性極大，可導致嚴重並發症，尤其是頜骨巨型囊腫可引起頜骨缺損、病理性骨折及口腔功能障礙等。袋形術通過開窗減壓, 誘導鄰近骨質再生和改建，使囊腫逐漸縮小或完全消失，完全符合當今微創與功能性外科的潮流。本文報告袋形術成功治療一例頜骨巨型囊腫病例，結合文獻復習討論袋形術的優缺點、治療機制與適應征。 【關鍵詞】頜骨囊腫；袋形術 Marsupialization as a treatment for large mandibular cystic lesions Ng Hiu Lam, P PYu Dongsheng P* P, Tao qian P* , PWong Chong IeongP P,Wong U Peng. Stomatology department, Centro Hospitalar Conde de Sao Januario(CHCSJ),Macao SAR,China; *Department of oral and maxillofacial surgery, Hospital of Stomatology,SUN Yat-sen University, Guangzhou 510055. Corresponding author: Yu dongsheng. Tel: (+853)- 8390 8976; E-mail:gdyudongsheng@yahoo.com.cn 【Abstract】 Odontogenic cysts are a group of common benign lesions of jaws. The conventional operation therapy usually result in serious complications, such as defect of jaw, pathological fracture and disorder of oral function. Marsupialization is a technique that relives the pressure within the cyst and causes some decrease in the size of the lesions. Marsupialization catch up with the idea of minimally invasive surgery and functional surgery, which is becoming a promising method. This paper report a case of large mandibular cyst treatmented by marsupialization successfully. We also review relevant literatures and discuss the advantages, therapeutic mechanism and indication. 【Key words】Cyst of jaw; Marsupialization 頜骨囊腫是頜骨最常見疾病之一。這些病變常引頜骨起唇、頰側骨板膨隆，牙鬆動移位，嚴重者甚至可導致顔面畸形、複視、病理性骨折等。傳統的手術治療破壞性極大，可導致嚴重並發症，如永久性頜骨缺損與口腔功能障礙 P[1,2]P。袋形術（marsupialization）或開窗減壓術（decompression）是在囊性病變表面開窗，局部打開骨質及囊壁，引流出囊液，在囊腫與口腔之間造成長時間存在的開口，並保持引流暢通，使膨脹的囊內壓力消除，誘導鄰近骨質再生和改建，囊腔逐漸變小或完全消失 P[3,4]P。我們利用袋形術對一例右頜骨巨大囊腫進行治療，取得理想效果。 病例资料 患者，男性，23 歲，因右面部腫脹伴張口 受限一月就診。 作者單位: 中國, 澳門特別行政區,衛生局, 仁伯爵綜合醫院口腔科；*廣州, 中山大學,光華口腔醫學院,口腔頜面外科;通信作者：餘東升; Tel: (+853)- 8390 8976; E-mail:gdyudongsheng@yahoo.com.cn 口腔檢查：患者左右面部不對稱，右面部下頜角處腫脹明顯，無疼痛麻木，輕度壓痛。張口中度受限，張口度 1.5CM，右下第二磨牙二度鬆動，並向舌側移位，右下頜磨牙區舌頰側骨質膨隆，乒乓感明顯。影像學檢查顯示（圖 1）：右下頜骨巨大低密度囊性病變，邊界清楚，大小約 4×4×5cmP3P，上至髁突頸及喙突，向前累積右下頜水平部 46 根尖。48 埋伏阻生，牙冠突入囊中。 治療過程：局麻下在 47 的頰側和遠中作角形切口，翻瓣，在囊腫頰側隆起最明顯處開創，窗口大小1×1 cmP2P，引流出淡黃色粘稠液體約 4.5 ml，取部分囊壁 10%福馬林固定送病理檢查。生理鹽水沖洗囊，將殘餘囊壁與對應的口腔粘摸對位縫合，並用牙科光固化材料製作個體化囊腫塞，保持囊腔與口腔相同，同時避免食物進入囊腔。教會患者如何摘戴囊腫塞，囑其每餐後及睡前用 10ml注射器接細導尿管（因其質地較軟，末端光滑並有側面開口，易進入囊腔且損傷囊壁），吸取生理鹽水，沖洗囊腔數遍（因囊膜完整，骨面未暴露，不會引起感染）。囊腫塞一直戴用，每天睡前用牙刷刷淨表面的食物殘渣。每二
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 55周復診一次，並隨囊腫變小調整囊腫塞的大小與形態。每三個月進行影像學復查，記錄病變進展情況。經過開窗引流，囊腫漸漸變小 18 個月後二次手術刮除囊腫，同時拔除 48。 治療結果：右下頜骨囊腫得到徹底治療，骨缺損再生修復，頜骨外形改建理想，患者滿意（圖 2），張口受限得到解除，張口度 3.5mm。 A B 圖 1 患者袋形術治療前右下頜囊腫全景片(A)和三維 CT 片(B)：右下頜角及升支巨大囊性缺損，48 阻生. A B 圖 2 患者右下頜囊腫經 18 個月袋形術治療後全景片(A)和三維 CT 片(B)：右下頜骨囊性病變區域新骨形成,下頜骨形態基本恢復正常. 討 論 1 袋形術優缺點 袋形術（marsupialiation）是Partsch於 1892 年首先在德文文獻提出，亦稱Partsch手術或PartschⅠ式手術。上世紀 70 年代美國醫生Wine最早報道袋形術應用於治療頜骨囊性病變 P[5]P，但由於療程長，病人依存性差，應用範圍局限，長期並未受到人們的重視，這種治療方法並沒有成爲主流。長期以來人們習慣用剜除術或刮除術（enucleation & curettage）和頜骨切除術（resection of the jaw）進行治療P[6]P。近年來，隨著功能性外科和微創外科的興起與發展，人們越來越關注減少創傷，提高患者的生存質量，對頜骨囊性疾病的治療強調外形與功能的恢復與重建。袋形術的價值被重新發掘和利用。 袋形術治療頜骨囊腫的優點 P[4,6,7]P：1) 袋形術屬於一種微創治療，手術簡單、經濟、安全，手術可在局麻下進行，不需特別的設備與器械，費用低且安全係數大，對年老體弱或伴有全身其他系統疾病患者更適用，具有創傷小，手術時間短，術後並發症少，鄰近牙齒、骨組織及術區神經血管的損傷幾率小等優點。2) 能選擇性地保留受累牙，對兒童含牙囊腫療效非常滿意，囊內含牙多能正常萌出，同時有利於保護鄰近的相關解剖結構,如鄰牙、上頜竇和下牙槽神經等。3) 頜骨囊腫開窗術後，頜骨有一個緩慢而自然的骨質修復過程，癒合前後的體積基本上不會有明顯的改變，保留了頜骨原有的完整性。因此其承受外力的能力也不
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 56 會下降，不會對口頜系統産生功能性影響。有利於頜骨巨大囊腫引起缺損的自身修復與重建，能有效保存頜骨的形態和功能，避免病理性骨折及口腔功能障礙，符合當前倡導的功能性外科的原理。 袋形術的主要缺點是療程較長，需定期復診，影響正常患者生活。但相對所保留的功能，這些付出是值得的。 2 袋形術作用機制 目前研究認爲頜骨囊腫形成的主要原因是P[1,4]P：1) 囊內滲透壓增高導致流體靜力壓增高，使囊腫向周圍膨脹性生長。2) 囊壁襯裏上皮增生引起壁性增長（mural growth）。3) 囊內物質（前列腺素、膠原酶、白細胞介素-1 等）參與囊壁鄰近骨質吸收。袋形術作用機制爲開窗後引流囊內液體，改變囊中內環境，清除刺激骨質的因數，消除囊腫對頜骨的膨脹壓力，中斷頜骨囊腫的膨脹性生長機制，囊壁的纖維結締組織在囊腔內壓力釋放後呈向心性收縮，在囊壁向心性收縮的牽引作用下，成骨細胞活動生成修復性新骨，頜骨形態改建，囊腔逐漸縮小，外形得以恢復。最新研究表明 P[3]P袋形術囊腫襯裏上皮的基因表達發生改變，如bcl-2 表達消失，促進細胞凋亡，減少細胞增殖。 3 袋形術適應征 勿庸置疑，袋形術治療頜骨囊腫療效明顯，本文報道的成功病例就是很好例證。袋形術完美體現了當前正大力倡導的微創外科和功能性外科理念，越來越受到青睞。隨著人們深入研究和臨床經驗的積累，現已發現袋形術不只對含牙囊腫療效好，對牙源性角化囊腫與單囊性成牙細胞瘤同樣有效 P[4]P。甚至有學者報道多囊性成釉細胞瘤可去除實質瘤塊和囊內間隔使之變爲單囊性後再適用袋形術，但這種方法並未受到廣泛認同，主要原因是復發率的不確定性，需要進一步探討。 參 考 文 獻 1 董青,李鐵軍. 袋形術在牙源性角化囊性瘤治療中的研究進展. 現代口腔醫學雜誌,2008,22(5):538-540 2 Pogrel MA, Jordan RC. Marsupialization as a definitive treatment for the odontogenic keratocyst.J Oral Maxillofac Surg, 2004, 62(6):651-655. 3 August M, Faquin WC, Troulis MJ, et al. Dedifferentiation of odontogenic keratocyst epithelium after cyst decompression. J Oral Maxillofac Surg, 2003, 61(6):678-683. 4 趙怡芳,劉冰,蔣自強.袋形術或減壓術治療頜骨囊性病變. 上海口腔醫學,2005,14(4):325-329. 5 Wine WM, Welch JT, Graves RW. Marsupialization of odontogerous cyst of the mandible: report of case. J Oral Surg,1971,29(10):742-745. 6 趙怡芳. 頜骨囊腫的手術治療. 繼續醫學教育, 2006, 20(22):83-86. 7 張春生, 李世芬, 張重生. 頜骨巨大囊腫袋形術臨床治療效果評價. 現代口腔醫學雜誌, 2002, 16(6):567-568.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 57‧醫學文摘‧ 64層螺旋CT在主動脈假性動脈瘤中的應用 李豔英, 張在人, 王丹, 等. 【摘要】 目的 探討“層螺旋cT對主動脈假性動脈瘤的診斷價值。 資料與方法 主動脈假性動脈瘤患者29例，男16例，女13例，年齡35—68歲，平均56歲。均行64層螺旋cT掃描，並將掃描原始資料採用容積再現(VR)、最大密度投影(MIP)、多平面重組(MPR)處理。 結果 VR明確顯示動脈瘤的範圍和周圍血管的關係；MPR對瘤體內附壁血栓範圍的顯示較佳；而MIP對瘤壁的鈣化及對管腔各段的精確測量頗有價值。 結論 64層螺旋CT是主動脈假性動脈瘤診斷、隨診觀察和術後隨訪較理想的影像技術。 【關鍵詞】 主動脈假性動脈瘤體層攝影術 ; x線電腦 摘自：臨床放射學雜誌,2009, 5:636 Application of 64-slice CT in the Aortic Pseudoaneurysm U Yanying, ZHANG Zairen, WANG Dan, et a1. 【Abstract】 Objective To evaluate the value of 64. slice CT in diagnosing aortic pseudoaneurysm. Materials and Methods 29 patients with aortic pseudoaneurysm(16 male, 13 female, 35-68 years old with average of 56 yrs)performed 64-slice CT scan. The original data were reconstructed using volume rendering(va)，maximum intensity projection (MIP)，multi-plane reorganization(MPR). Results VR images showed the extent of aneurysm and the relationship with peripheml vascular deady. MPR images were good showing the aneurysm thrombus. MIP images Wel'e valuable in showing the calcification of aneurysm thrombus and measuring the lumen accurately. Conclusion 64-slice CT is agood imaging technology in diagnosis and follow-up of aortic pseudoaneurysm. 【Key words】Aortic Pseudoaneurysm Tomography; X-ray computed From: Journal of Clinic radiology, 2009, 5:636
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 58 ‧醫學文摘‧ 64 層螺旋 CT 數位減影 CTA 診斷腦動脈瘤研究 郭岳霖, 劉國瑞, 鄭文斌, 等 【摘要】 目的 探討 64 層螺旋 CT 數位減影CTA 診斷腦動脈瘤的價值及局限性。 方法 自發性蛛網膜下腔出血患者 32 例完成 64 層螺旋 CT 模板掃描和 CTA 增強掃描後進行數位減影，將減影和常規 CTA 原始圖像分爲 2 組（DSCTA 組和常規 CTA組），比較 2 組後處理時間，圖像質量及診斷結果的差異。 結果 DSCTA 組較常規 CTA 組後處理時間明顯縮短；2 組對 Willis 動脈環及其遠段腦動脈的重建圖像質量及動脈瘤診斷的特異性和敏感性無顯著性差異；而對 Willis 動脈環近段動脈的重建圖像質量及 動 脈 瘤 診斷 的 敏 感 性， DSCTA 明 顯 優 於 常規CTA；常規 CTA 對血管外病竈顯示清楚，而 DSCTA與 DSA 均未能顯示。 結論 64 層螺旋 CT 數位減影 CTA 簡單、無創、去骨效果良好，綜合常規 CTA 與數位減影 CTA 全面分析腦血管情況，效果優於DSA 檢查，是腦動脈瘤診斷的首選方法。 【關鍵詞】 CT 數位減影; 動脈瘤; 體層攝影術 X 線電腦 摘自：中國 CT 和 MRI 雜誌, 2008, 3:13 The diagnosis of intracranial aneurysms: using 64-row multisection CT digital subtraction angiography GUO Yue-lin, LIU Guo-rui, ZHENG Wen-bin, et al. 【Objective】 To study the value and limits of 64-row multisection CT digital subtraction angiography (DSCTA) in the diagnosis of intracranial aneurysms. Methods 32 Patients with spontaneous subarachnoid hemorrhage were underwent two same protocols of 64-row multisection CT, unenhanced CT scan and enhanced CTA. DSCTA data was got to the subtract of enhanced CTA and unenhanced CT scan. Data of DSCTA and normal CTA were divided into 2 groups. Statisticcal difference of reconstruction time, image quality, diagnosis specificity and sensitivity within 2 groups were researched in this study. Results Reconstruction time was significantly reduced and image quality of internal carotid artery, vertebral artery, basilar artery were significant improved using DSCTA. Diagnosis specificity was no significant difference in 2 groups but diagnosis sensitivity of DSCTA in aneurysms below Willis'circle was better than normal CTA. But intracranial focus outside vessel was subtracted in DSCTA and DSA and only showed by normal CTA. Conclusion 64-row multisection CT DSCTA was more effective to eliminate skull and made the diagnosis of intracranial aneurysms below Willis'circle easier, but normal CTA was also important. 【Key words】 computed tomography digital subtraction; aneurysm; tomography; X-ray computed From: Chinese Journal of CT and MRI, 2008, 3:13
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 59‧醫學文摘‧ 顱內三叉神經鞘瘤的 MRI 診斷及鑒別診斷 王衛斌, 林志春, 曲華麗, 等. 【摘要】 目的 分析三叉神經鞘瘤的生長部位、MRI 表現及其影像特征，以提高其診斷准確性。 方法 回顧性分析經手術病理證實的三叉神經鞘瘤 8 例，分析 MRI 平掃及增強掃描結果並與病理作對照分析。 結果 8 例三叉神經鞘瘤中，左側 3例，右側 5 例。3 例呈橢圓形生長於中顱窩，5 例跨顱窩生長，呈啞鈴型。6 例突入顳下窩。2 例實性病伴有囊變，6 例基本爲實性。腫瘤實性部分在 T2 加權像呈“椒鹽”樣改變，增強掃描其實性部分明顯強化。 結論 三叉神經鞘瘤的生長部位、腫瘤的形態及信號特征對於診斷有一定的參考價值。 【關鍵詞】 三叉神經鞘瘤; 鑒別診斷 摘自：醫學影像雜誌, 2008, 12:1359 MRI diagnosis and differential diagnosis of intracranial trigeminal neurinoma WANG Wei-bin, LIN Zhi-chun, QU Hua-li, et al. 【 Abstract 】 Objective MRI appearance and imaging characteristics were analyzed in order to improve the diagnosis of intracranial trigeminal neurinoma. Methods 8 cases of intracranial trigeminal neurinoma, which were confirmed by surgical pathology, underwent routine MRI scanning and enhanced scanningbefore operation. Their MRI images were reviewed and compared with the surgical pathology. Results Among 8 cases, 3 lesions were located in the left, while the other five, in the right. The tumors grew in the middle cranial fossa with oval shape in 3 cases, and 5 cases across the middle and posterior cranial fossa with dumbbell appearance. There were six cases whose trigeminal neurinoma intruded into the infratemporal fossa. Except the pathology of two cases contained some cystic changes, the other six cases exhibited basically solid mass. The solid part of trigeminal neurinoma presented “peper salt” appearance in TB2 Bweighted image and an obvious enhancement after enhanced scanning. Conclusion It is very valuable to make a corredt diagnosis for trigeminal neurinoma by analyzing its anatomic site, morphology, and signal characteristics. 【Key words】 Trigeminal neurinoma; Magnetic resonance image; Differential diagnosis From: J Med Imaging, 2008, 12:1359
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 60 ‧信息和動態‧ 肺癌治療 準確分期是關鍵 北京大學人民醫院胸外科教授 王 俊 明確肺癌病理類型 根據生物學特性，肺癌可分爲非小細胞肺癌（80%）和小細胞肺癌（20%）。明確肺癌病理類型需要細胞學或組織學診斷。細胞學診斷主要包括痰液及支氣管刷片檢查、胸水脫落細胞檢查等；組織學診斷主要包括經支氣管鏡活檢、經皮穿刺活檢以及胸腔鏡、縱隔鏡檢查等。通常經過上述檢查，絕大多數患者可獲得明確的肺癌病理類型。 明確肺癌分期 肺癌的準確分期是選擇治療方案以及判斷預後的前提和關鍵。目前 TNM 分期系統是肺癌最常用的分期標準。 T 分期是指對原發腫瘤的評價，主要依靠胸部CT 掃描、核磁共振等影像學檢查。 N 分期是指對區域淋巴結的評價，其中對於可能手術治療的非小細胞肺癌，術前明確其縱隔淋巴結有無轉移更是至關重要。目前，肺癌的臨床 N 分期主要依靠影像學檢查，但已有的影像學診斷方法（CT或 PET）的準確性尚難以令人滿意，尤其是假陽性率較高。因此，對於影像學懷疑縱隔淋巴結轉移的肺癌患者，需進一步行縱隔淋巴結活檢，以明確分期決定治療策略。這不僅可以使部分假陽性患者及時接受手術治療，同時也可避免一些不必要的探查手術。縱隔鏡檢查術因其極高的特異性和準確性，迄今爲止仍是肺癌縱隔淋巴結分期的金標準。 支氣管內超聲引導針吸活檢術（EBUS-TBNA）是近年來出現的一項新技術，其準確性與縱隔鏡檢查相似，同時 EBUS-TBNA 更加微創安全，無手術切口，無需全麻氣管插管，操作也更簡便。目前在歐美國家及日本等發達國家，EBUS-TBNA 這一技術已在臨床中得到廣泛開展，並有逐步替代縱隔鏡檢查的趨勢。而在我國 EBUS-TBNA 尚處起步階段，我們的初步應用結果顯示了該技術良好的應用前景。 M 分期是指對有無遠處轉移的評價，臨床中主要依靠頭顱核磁、腹部 B 超、全身骨掃描以及PET/CT 等檢查。 選擇治療方案 小細胞肺癌是一類惡性程度很高的肺部腫瘤，疾病進展迅速。除少數Ⅰ期患者可接受外科手術治療外，化放療聯合是其標準的主要治療方案。 非小細胞肺癌的治療近 20 年來取得了不小的進步，其主要治療模式是以外科治療爲中心的多學科綜合治療，包括全身治療和局部治療。全身治療主要包括化療、生物靶向治療以及中醫藥治療等。局部治療主要包括外科手術切除以及放射治療等。一般來說，如患者身體狀況允許，Ⅰ、Ⅱ期以及部分Ⅲa 早期肺癌應首選外科手術治療，術後對於Ⅱ期以後的患者採用聯合輔助化療。Ⅲb、Ⅳ期患者屬中晚期肺癌，已失去外科手術治療的最佳時機，治療以化放療、生物及靶向治療爲主。對於可手術切除的肺癌患者，尤其是早期肺癌（Ⅰ、Ⅱ期），全胸腔鏡肺葉切除應爲首選。近年來，國際上一些高可信度的大樣本臨床研究顯示，與傳統的開胸手術相比，胸腔鏡手術具有明顯的微創優勢，顯著降低了手術並發症，術後恢復更快，遠期療效類似甚至可能優於傳統開胸手術。 來源：健康報 2010-05-27
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 63‧工具和資料‧ 納米磁場靶向藥物載體嶄新的介入給藥途徑 美國費城兒童醫院的科學家最近將獨特磁場導向鐵氧化物納米顆粒用於血管支架給藥。相關研究報告發表在《美國國家科學院院報》上。 心臟病病人的支架是折疊的金屬支架，在體內可撐開封堵血管的缺損。這些支架通常會裝載抗增殖藥物，諸如紫杉醇。但是，現有的藥物在脫離支架時有其局限性，如給藥劑量固定，只能釋放一次等。研究人員製造出的納米顆粒在磁場下反應活躍，並且是生物可降解的，這種生物顆粒在體內可以安全釋放所攜帶的藥物。 研究者將不銹鋼支架放置於存活大鼠的頸動脈血管上，通過導管在大鼠的動脈中注射了攜帶紫杉醇的納米顆粒後，他們用一種獨特的磁場照射每只大鼠 5分鐘，這種磁場的強度相當於 MRI 磁場的 1/10，磁場同時磁化支架及納米顆粒，從而使得納米顆粒在支架及附近血管組織中聚集。在對照組中，研究人員同樣插入支架及注射納米顆粒，但是不施加外加磁場。在注射納米顆粒 5 天以後，磁性組動物組織頸動脈血管內的納米顆粒是對照組的 4~10 倍。 支架和磁場也可用于聯合給藥治療。納米顆粒可以一次或幾次攜帶不同的物質。只要支架保持在原位，醫生就可以通過介入給藥、磁場引導來治療患者。因爲磁場可以使得藥物集中在支架所在的特殊部位，在全身僅僅予以小劑量注射的情況下，可以獲得大劑量注射的效果。而且因爲採用了生物可降解技術，還可以使得納米顆粒攜帶的藥物在注射後的 14天內緩慢釋放。研究者認爲，未來在磁場下的小劑量納米載藥治療，即所謂血管磁性介入技術將會成爲常規治療。 來源：健康報 2010-05-27
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 64 ‧工具和資料‧ 貿然化療不可取 清華大學第一附屬醫院血液腫瘤科主任 董文川 目前，約 50%的肺癌患者在診斷時已屬於不能進行手術根治性切除的局部進展期或是晚期的非小細胞肺癌。對這樣的病人，治療的主要目標主要是延長無進展生存期。 很多患者初期化療有效或部分有效，但過了一段時間後，就有可能出現耐藥、腫瘤進展或腫瘤沒有進一步縮小的問題。在這種情況下，繼續治療往往是患者和家屬非常迫切的要求。但有時即使更換方案，也無法控制病情進展，甚至適得其反。醫生要仔細分析患者的全部患病過程，瞭解腫瘤進展情況，還要對患者的整體情況，特別是心理狀況進行詳盡分析，制訂個體化的治療計劃，避免過度治療或不合理的治療。 有些患者即使病情有緩慢進展，尤其是腫瘤標記物有變化，但在一段時間內有時甚至是一年，腫瘤變化不是很大，生活質量也沒有明顯下降。如果貿然讓這樣的病人進行化療，恐怕得不償失。老年腫瘤患者由於其自身的病理及生理學特點，很多患者又往往合併其他慢性病，積極治療往往有更大風險，不但生存期沒有保證，而且生活質量也會下降。 在臨床實踐中遇到的病例各不相同，治療方案的選擇應該強調個體化。例如，有一位女患者診斷爲右卵巢癌時才 50 歲，10 餘年後因腫瘤復發兩次進行手術治療。後一次手術時發現，腫瘤在腹腔已經廣泛轉移。手術後，我們爲患者進行周期性化療。近 5 年來，每年患者的 CA125 都有明顯增高，但沒有發現明確的病竈，給予 2~4 周的周期性化療後該指標就能基本正常。雖然患者多年來已經習慣了周期性的化療，但如果再進一步加強化療，患者在心理上已不能接受。根據患者病情，我們決定暫時停止化療，但密切監測患者的檢測指標和影像學變化。患者從第一次確診卵巢癌至今已經 20 餘年了，病情時有反復，但現在患者還能正常生活。來源：健康報 2010-05-21
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 65《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, March 2010, Vol.10, No.1, 2 66 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.1PaP 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, March 2010, Vol.10, No.1, 2 67 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, March 2010, Vol.10, No.1, 2 68
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, March 2010, Vol.10, No.1, 2 69‧論著和研究‧ Conclusion Proper prenatal care should be carried out to detect the high risk patients. Hypertension, IUGR and threatened premature delivery should be treated properly, thus to decrease the incidence of LBWI. 【Key words】 Low birth weight infants; Risk factors; Intrauterine growth retardation 【Key Words】 Suicide death; Self-harm behavior; Suicidal rate
