Revisão e Palestras Discussão sobre a clínica geral………………………………………………………………………………PANG Sai Meng Panorama actual da aplicação de peixe-zebra como modelo organismo destinado ao desenvolvimento de um novo medicamento na RAEM………………………………………………………………………Kai-Heng Lam, Emilia Conecição Leong, Zai Jun Zhang e outros Irregularidade de neuro-hormônio em Diabetes Mellitus tipo 2……………………………………………LOK Mei Kun Situação recente sobre o estudo clínico da gastrite erosiva crónica……………………………………………Kin Wa Wong, Liheng Wang, Baozhu Yan Neuropatia autonómica cardiovascular diabética………………………………………………………………Lam Kuok Wun, Fang Dong Hong Relatório Sucinto e Estudo de Caso Um caso de patologia da síncope verificado pela implantação de um aparelho cardíaco……………………YIN Chun, LIU Hong, CHONG Tou-Kun, e outros Relatório de um caso de glomerulopatia de imunotactoide com nível alto de cadeia leve kappa em soro……………………………………………………………………………………………………………YIP Yuk-ching, Wen Jian-min Resumos de Artigos Médicos Internacionais Análise clínica de 56 casos de recorrência do longo segmento da mielite transversa…………………………Discussão preliminar sobre o tempo óptimo da aplicação da operação destinada à ossificação do Ligamento longitudinal posterior nas vértebras cervicais…………………………………………………Aplicação de minimamente invasiva nefrolitotomia percutânea em cirurgia aberta…………………………Diagnóstico imagiológico aplicado na anormalidade venosa de desenvolvimento cerebral………………… Artigos da RCSM e autores (em Chinês, Português e Inglês) …………………………………………………Conteúdos da RCSM, 2009, Vol. 9 (em Chinês, Português e Inglês) …………………………………………… Revisão em Chinês : SIO Keng Revisão em Português e Inglês : Jorge Humberto MORAIS, LAM Meng Lei, SIO Keng 329331336347350355357360361362363369372
Collective Reviews and Lectures The Family Physician………………………………………………………………………………PANG Sai Meng A Review of Zebrafish as a Model Organism for Drug Screening in Macao……………………………LAM Kai-Heng, LEONG Emilia Conceição, ZhANG ZaiJun, et al Neurohormonal Dysregulation in Type 2 Diabetes Mellitus……………………………………………LOK Mei Kun Chronic Erosive Gastritis’s Situation Clinical Research………………………………………………WONG Kin Wa, WANG Liheng, YAN Baozhu, et al Diabetic Cardiovascular Autonomic Neuropathy……………………………………………………Lam Kuok Wun, Fang Dong Hong Short Report and Case Report Use of an Implantable Cardiac Monitor to Determine the cause of Syncope……………………………JIN Chun, LIU Hong, CHONG Tou-Kun, et al A Case Report of Immunotactoid Glomerulopathy with High Level of Immunoglobulin M Monoclonal κ Light-chain in Serum……………………………………………………………YIP Yuk-ching, WEN Jian-ming Foreign Medical Abstracts Analysis of 56 cases with relapse-longitudinally extensive transverse myelitis. …………………………Preliminary study of the optimal time for operation on patients with ossification of the posterior longitudinal ligament of the cervical spine………………………………………Application of minimally invasive nephrolithotomy in the open surgery for patients with renal calculi………Cerebral developmental venous anomalies:diagnosis by medical imaging……………………………… 329331336347350355357360361362363Articles of HSJM to authors ( in Chinese, Portuguese, and English) ……………………………………………Contents of HSJM, 2009, Vol.9 ( in Chinese, Portuguese, and English) …………………………………………369372 Proofreader in Chinese : SIO Keng Revision Portuguese / English : Jorge Humberto MORAIS, LAM Meng Lei, SIO Keng
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 278‧論著和研究‧ Long-term mortality and morbidity of patients with aneurysmal subarachnoid hemorrhage in Macao LO Iek Long LEI Wai Seng 【 Abstract 】 Background Aneurysmal Subarachnoid hemorrhage (SAH) is a common and devastating neurological disease. The treatment of choice includes conservative treatment, surgical clipping and endovascular coiling. The objective of this study was to investigate the effects of neurosurgical clipping and endovascular coiling on long-term mortality and morbidity for patients with aneurysmal SAH in Macao. Patients and methods We retrospectively collected data from consecutive adults who were admitted to Centro Hospitalar Conde de São Januário (CHCSJ) with the final diagnosis of SAH between 1st Jan 2004 and 31st Dec 2008. Patients who were <18 years, had incomplete clinical data, SAH due to other cause, terminal illness and admitted > 72 hours after the onset of symptoms were excluded from this study. All clinical, laboratory and radiological data were retrieved from the medical records. Outcome measures included 1-year mortality, overall survival, Glasgow Outcome Scale (GOS) and proportion of patients achieving favorable outcome (GOS scores 5) at 6-12 months. Results A total of 95 patients with the final diagnosis of SAH were identified during the study period. Among them, 53 patients were included for analysis after excluding 42 cases according to the pre-defined criteria. The mean age of this cohort was 57.5±14.9 years and 41 (77.4%) patients were female. Among 44 patients with comparable disease severity (Glasgow Coma Scale scores ≥ 4), the 1-year mortality of patients in conservative (n=12), surgical (n=9) and endovascular (n=23) group was 50%, 33.3% and 8.7% respectively (p=0.02). The proportion of patients achieving favorable outcome at 6-12 months in conservative, surgical and endovascular group was 16.7%, 33.3% and 60.9% respectively (p=0.04). Among those 23 patients who received endovascular coiling, a World Federation of Neurological Surgeon (WFNS) grading of 3 or lower was a significant predictor for favorable outcome (p=0.01). Conclusion Among aneurysmal SAH patients with comparable clinical characteristics and disease severity, endovascular coiling was associated with the lowest mortality and morbidity, followed by surgical clipping and conservative treatment. A WFNS grading of 3 or lower was significant predictive factors for favorable outcome among patients who received endovascular coiling. 【Key Words】 Subarachnoid hemorrhage; Intervention; Mortality; Morbidity 澳門動脈瘤性蛛網膜下腔出血患者長期預後的影響因素研究 羅奕龍, 李偉成. 深切治療部 澳門仁伯爵綜合醫院 澳門 中國; Tel: (+853)-6654 5620; E-mail: drloieklong@yahoo.com.hk 【摘要】 背景 動脈瘤性蛛網膜下腔出血是病死率和致殘率高的神經系統疾病。主要治療手段包括保守治療、外科手術和血管內彈簧圈栓塞治療。本研究的主要目的是分析外科手術和血管內介入治療破裂的動脈瘤，對澳門蛛網膜下腔出血患者長期預後的影響。 病人和方法 回顧性分析在 2004年 1 月至 2008 年 12 月期間，因動脈瘤性蛛網膜下腔出血在澳門仁伯爵綜合醫院住院的患者。排除標準為﹕年齡 18 歲以下、臨床資料不齊全、非動脈瘤性蛛網膜下腔出血、終末期疾病和症狀出現 72 小時後入院的患者。在入選患者的病歷記錄中獲取所需的臨床、實驗室和影像學資料。主要預後指標包括一年病死率、總體生存率、格拉斯哥預後評分和在發病後 6-12 個月達到良好預後（格拉斯哥預後評分 5 分）患者的比例。 結果 在 5 年間總共有 95 人因蛛網膜下腔出血而住院，根據預設的標準排除 42 人後，最後 53 名患有動脈瘤性蛛網膜下腔出血的成年患者進入本研究。本組患者的平均年齡為57.5±14.9 歲，當中 41 人（77.4%）為女性。進一步分析臨床特點和疾病嚴重程度具有可比性（拉斯哥昏迷評分 4 分或以上）的 44 名患者發現，保守治療組（n=12）、外科手術組（n=9）和內管內介入組（n=23）的一年病死率分別為 50%、33.3%和 8.7%（p=0.02）。在發病後的 6-12 個月，上述三組患者達到良好預後的比例分別為 16.7%、33.3%和 60.9%（p=0.04）。對於 23 名接受血管內介入治療的患者，治療前 World Federation of Neurological Surgeon 評級三級或以下，是提示良好預後的指標（p=0.01）。 結論 與接受保守治療和手術治療的患者相比，接受血管內介入治療的蛛網膜下腔出血患者具有最低的長期病死率和致殘率，是最佳的治療方案。對於接受血管內介入治療的患者，治療前World Federation of Neurological Surgeon 評級是提示良好預後的指標。 【關鍵詞】 蛛網膜下腔出血﹔ 介入治療﹔ 病死率﹔ 致殘率 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
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 279Background Aneurysmal Subarachnoid hemorrhage (SAH) is a common and devastating neurological disease. Outcome for patients with SAH remains poor, with a population-based mortality rate as high as 45% and one third of the survivors would have significant morbidity[1]. Neurosurgical clipping and endovascular coiling are standard interventions to reduce the risk of recurrent bleeding, dependence and death for patients with aneurysmal SAH[2]. A prospective randomized trial in Europe has proven that endovascular coiling may reduce the risk of death and dependence at 1 year compared to neurosurgical clipping[2]. Centro Hospitalar Conde de São Januário (CHSCJ) is the only hospital in Macao that can provide neurological clipping and endovascular coiling for patients with ruptured intracranial aneurysms. However, the effects of these interventions on long-term mortality and morbidity have yet to be assessed in Macao. Objective This study was conducted to investigate the long-term effects of neurosurgical clipping and endovascular coiling on mortality and morbidity for patients with ruptured intracranial aneurysms in Macao. Patients and Methods Hypothesis being tested in this study was that the use of endovascular coiling or surgical clipping would reduce the long-term mortality and morbidity of patients with aneurysmal SAH, as compared to those with conservative treatment. Subjects Inclusion criteria: Consecutive adult (≥ 18 years) patients were selected if the discharge diagnosis contained an International Classification of Diseases, 9th Revision code pertaining to SAH (430) from 1st Jan 2004 to 31st Dec 2008. Exclusion criteria: Patients with any of the following conditions were excluded from this study: 1) less than 18 years of age; 2) had incomplete clinical data for analysis; 3) SAH due to other cause such as trauma or ruptured arterio-venous malformation; 4) admitted more than 72 hours after the onset of symptoms; 5) terminal illness with life-expectancy of less than 6 months. Outcome measures: Primary endpoint was 1-year mortality. Secondary endpoints were overall survival, morbidity at 6-12 months in terms of Glasgow Outcome Scale (GOS)[4] and the proportion of patients achieving favorable outcome, which was defined as survival free of disability or GOS equals 5. Data collection: Clinical, laboratory and radiological data of patients with SAH were retrospectively retrieved from the medical and imaging records. All medical records were reviewed for baseline clinical characteristics, disease severity and outcome measures. All brain imaging films were reviewed if available. Baseline clinical characteristics included age, gender, underlying disease, clinical presentation of SAH. Disease severity assessment included Glasgow Coma Scale (GCS) score; clinical grading of Hunt and Hess[5] and the World Federation of Neurological Surgeon (WFNS)[6]. The score was positively associated with the severity of the disease. Statistical analysis: Continuous data was expressed as mean ± SD and categorical data was expressed as percentage. Patients with comparable disease severity were divided into endovascular coiling, neurosurgical clipping and conservative treatment groups for analysis. Kaplan-Meier analysis and log-rank test were used to perform survival analysis. Comparisons between two groups were performed with Student’s t- test for
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 281To correct the influence of baseline disease severity on the outcome measures, 9 patients with a GCS score of 3 were excluded for further analysis. The baseline clinical characteristics and disease severity among conservative, surgical and endovascular group were similar after the removal of 9 cases from this cohort. (Table 2) Overall survival and 1-year mortality The 1-year mortality of patients in conservative, surgical and endovascular group was 50.0%, 33.3% and 8.7% respectively (p=0.02). The mean survival time among patients with conservative treatment, neurosurgical operation and endovascular intervention was 817±234 days, 1304±304 and 1740±112 days respectively (p=0.02). (Table 2) GOS at 6-12 months and the proportion of patients achieving favorable outcome The mean GOS score at 6-12 months of patients with conservative treatment, clipping and coiling was 2.3±1.6, 3.2±1.8 and 4.0±1.5 respectively (p=0.02). The proportion of patients achieving favorable outcome (GOS scores 5) in conservative, surgical and endovascular group was 16.7%, 33.3%, and 60.9% respectively (p=0.04). (Table 2) Table 2 – Clinical characteristics and outcome measures among patients in different treatment group (n=44) Conservative(n=12) Surgical (n=9) Endovascular(n=23) p value Clinical Characteristics Age, years 63.2±17.3 53.9±11.9 57.5±14.2 0.34Female (%) 7 (58.3) 7 (77.8) 20 (87.0) 0.16Hypertension (%) 10 (83.3) 5 (55.6) 10 (43.5) 0.08Headache (%) 3 (25.0) 6 (66.7) 14 (60.9) 0.08LOC (%) 5 (41.7) 5 (55.6) 12 (52.2) 0.78Cardiac arrest (%) 2 (16.7) 0 (0.0) 0 (0.0) 0.06Disease Severity GCS score 9.6±4.1 10.9±3.8 12.6±3.2 0.65WFNS grade 3.5±1.5 2.8±1.5 2.3±1.5 0.09Hunt and Hess grade 3.3±1.2 3.0±0.9 2.4±1.1 0.06Outcome Measures Survival time, days 817±234 1304±304 1740±112 0.021-year mortality (%) 6 (50.0) 3 (33.3) 2 (8.7) 0.02GOS score 2.3±1.6 3.2±1.8 4.0±1.5 0.02Favorable outcome (%) 2 (16.7%) 3 (33.3%) 14 (60.9%) 0.04LOC: Loss of Consciousness; GCS: Glasgow Coma Scale; WFNS: World Federation of Neurological Surgeon; GOS: Glasgow Outcome Scale; Favorable outcome was defined as GOS equals 5 Predictive factors for lower morbidity in patients who received endovascular coiling Among those 23 patients who received endovascular coiling, patients with favorable outcome tended to have a lower WFNS grading (1.9±1.4 versus 2.9±1.6, p=0.14). A WFNS grading of 3 or lower was a significant predictive factor for favorable outcome (p=0.01). (Table 3) Table 3 - Predictive factors for favorable outcome (GOS score 5) in patients who received endovascular coiling Variables Non-favorable outcome (n=9) Favorable outcome (n=14) p valueAge, years 56.7±14.6 58.0±14.5 0.83Elderly (%) 4 (44.4) 6 (42.9) 0.94Female (%) 8 (88.9) 12 (85.7) 0.83Hypertension (%) 4 (44.4) 6 (42.9) 0.94GCS score 11.6±3.5 13.2±2.8 0.23GCS score ≥ 8 (%) 8 (88.9) 13 (92.9) 0.74 WFNS grade 2.9±1.6 1.9±1.4 0.14WFNS grade < or = 3 (%) 3 (33.3) 12 (85.7) 0.01Hunt and Hess grade 2.4±1.2 2.3±1.1 0.75Hunt and Hess grade < or = 3 (%) 7 (77.8) 12 (85.7) 0.63 GCS: Glasgow Coma Scale; WFNS: World Federation of Neurological Surgeon
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 282Discussion Non-traumatic SAH is a devastating disease with a population-based mortality of 45% and significant morbidity among survivors[1]. The leading cause of non-traumatic SAH is the rupture of an intracranial aneurysm, which accounts for more than 80% of all cases[7]. Since conservative treatment alone is associated with high morbidity and mortality, surgical clipping and endovascular coiling is the preferred treatment of choice for patients with ruptured intracranial aneurysms. Previous studies in Europe has suggested that patients received endovascular coiling have lower risk of death at 1-year compared to those received surgical clipping[8]. However, the skills and experience of the treating practitioner and institution are important contributors to outcomes and there is evidence showing that endovascular coiling improves with experience of the practitioner[9]. Therefore, data from western countries may not be fully applicable in local setting. CHCSJ, the government hospital in Macao, is the only hospital that can provide both interventions for patients with aneurysmal SAH in this city. Although our hospital has been providing these services in recent years, there is no local study looking into the effects of these interventions on long-term mortality and morbidity. This study have shown that among patients with comparable baseline clinical characteristics and disease severity, those received endovascular coiling had the lowest mortality and morbidity, followed by neurosurgical clipping and conservative treatment. These observations agreed to the latest SAH guidelines which recommended that for patients with ruptured aneurysms to be technically amenable to both coiling and clipping, endovascular coiling can be beneficial[2]. The International Subarachnoid Aneurysm Trial (ISAT), a prospective randomized control trial, also demonstrated that for aneurysms amenable to either therapy, patients in the coiled group had lower risk of death than those in the clipped group[3]. Although there were some concerns regarding the durability of coil embolization, an analysis of the long-term follow-up data from ISAT confirmed that the superiority of endovascular coiling was preserved for at least 7 years after treatment[10]. Among our patients who received endovascular coiling, a WFNS grading of 3 or less was the only predictive factor for favorable outcome at 6-12 months. Previous studies have shown that clinical grading of the WFNS and the Hunt & Hess may predict outcomes in patients with SAH [5][6]. However, neither Hunt and Hess nor WFNS grading is predictive to favorable outcome in our cohort. Therefore, WFNS grading system should be used as a guide to select which patient may benefit from coiling in Macao. There are several limitations of this study. Firstly, this is a retrospective study involving patients from single hospital in Macao; careful interpretation of results is needed before generalization of the findings on patients with SAH. Secondly, the patients’ data were retrieved from medical records, which may limit the accuracy of information available. Thirdly, owning to the lack of imaging data in around one third of our patients, our study haven’t assessed radiological grading system such as Fisher’s grading[11], which has been shown to be a useful predictor of outcomes[12]. Conclusion Among aneurysmal SAH patients with comparable clinical characteristics and disease severity, endovascular coiling was associated with the lowest mortality and morbidity, followed by surgical clipping and conservative treatment. A WFNS grading of 3 or lower was a significant predictive factor for favorable outcome in patients who received endovascular coiling.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 283Reference 1 Hop JW, Rinkel GJ, Algra A, et al. Changes in functional outcome and quality of life in patients and caregivers after aneurysmal subarachnoid hemorrhage. J Neurosurg, 2001,95: 957–963. 2 Bederson JB, Connolly ES, Batjer HH, et al. Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Statement for Healthcare Professionals From a Special Writing Group of the Stroke Council. American Heart Association Stroke, 2009, 40: 994–1025. 3 Molyneux AJ, Kerr RS, Birks J, et al. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol, 2009, 8: 427-433. 4 Jennett B, Bong M. Assessment of outcome after severe brain damage : A practical scale. Lancet, 1975, 11: 480-484. 5 Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg, 1968, 28: 14-20. 6 Report of World Federation of Neurological Surgeons committee on a universal subarachnoid hemorrhage grading scale. J Neurosurg, 1988, 68: 985-986. 7 van Gijn J, Rinkel GJ. Subarachnoid haemorrhage: diagnosis, causes and management. Brain, 2001, 124: 249-278. 8 Molyneux AJ, Kerr RSC, Stratton I, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet, 2002, 360: 1267-1274. 9 Malisch TW, Guglielmi G, Vinuela F, et al. Intracranial aneurysms treated with the Guglielmi detachable coil: midterm clinical results in a consecutive series of 100 patients. J Neurosurg, 1997, 87:176 -183. 10 Molyneux AJ, Kerr RS, Yu LM, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet, 2005, 366:809-817. 11 Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computed tomographic scanning. Neurosurgery, 1980, 6: 1-9. 12 Claassen J, Bernardini GL, Kreiter K, et al. Effect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhage: the Fisher scale revisited. Stroke, 2001, 32: 2012-2020.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 284‧論著和研究‧ 澳門仁伯爵綜合醫院 肺炎鏈球菌感染情況分析 李然 劉宇利* 梁亦好** 陳穗芬** 林果*** 林妙玲**** 【摘要】 目的 分析 2001 至 2006 年澳門仁伯爵綜合醫院肺炎鏈球菌感染情況和肺炎住院情況，並推算澳門 5 歲以下年齡組肺炎發病率。 方法 根據澳門仁伯爵綜合醫院資訊系統內不同類型之 ICD 編碼，對 2001 年至 2006 年所有被診治為肺炎及肺炎鏈球菌引發的相關疾病之入院病人進行系統性回顧分析。 結果 在 2001-2006 年期間診治因為肺炎鏈球菌引發的相關疾病有肺炎（3,240 例）、敗血病(512 例)及腦膜炎(59 例) 。肺炎而住院病人次中 5 歲以下嬰幼兒占 21.6%，而 65 歲以上長者占 51.4%，該兩組人群為肺炎的主要發病人群，以肺炎住院病例比率推算出澳門 5 歲以下年齡組肺炎平均發病率為1507.89/10 萬，與其他地區肺炎發病率相若。 結論 由於推算出澳門 5 歲以下年齡組肺炎平均發病率與其他地區肺炎發病率相若，且本澳社區可能會低估了肺炎鏈球菌病之真實情況， 現本澳把肺炎鏈球菌疫苗引入免疫接種計劃內，可附合“妥善醫療，預防優先”的公共醫療政策發展方向。 【關鍵詞】 肺炎鏈球菌; 肺炎住院; 肺炎發病率 Pneumococcal Infection in CHCSJ of Macau LEE Yan. Department of Paedirtric &Neonatology, Centro Hospitalar Conde de Sao Januario (CHCSJ) Health Bureau, Macao SAR, China. LAO U Lei*. Public Health Laboratory, Health Bureau, Macao SAR, China. LEONG Iek Hou**, CHAN Soi Fan**. Center for Disease Control and Prevention, Health Bureau, Macao SAR, China . LAM Kuo.*** TaSec Health Centre, Health Bureau, Macao SAR, China. LAM Mio Leng.**** Department of Clinical Pathology, Centro Hospitalar Conde de Sao Januario (CHCSJ) Health Bureau, Macao SAR, China. Correspondence author: LEE Yan Tel : (+853)-8390 8154; E-mail : leeyan@macau.ctm.net 【Abstract】 Objective To analyze the pneumococcal infection and the admission of pneumonia from 2001 to 2006 in CHCSJ Macau as to estimate the prevalence of pneumonia in Macau under 5 year of age. Methods Retrospectively review the pneumococcal infection and the admission of pneumonia from 2001 to 2006 according to the different ICD codes in CHCSJ Macau. Results From 2001 to 2006, the pneumococcal diseases were pneumonia (3240 cases), septicemia (512 cases) and meningitis (59 cases). The children under 5 year old and elderly older than 65 year old consisted of 21.6% and 51.4% pneumonia admission respectively. These two group of people are the majority of the patients. We estimate the average prevalence of pneumonia in Macau under 5 year of age by the ratio of pneumonia to total admission rate around 1507.89/10,000, which is quite similar to the other regions. Conclusion As the average prevalence of pneumonia in Macau under 5 year of age is estimated similar to the other regions and the numbers of streptococcal pneumonia are being underestimated in our community. Currently, the pneumococcal vaccine is put into the routine vaccine program of Macau , as to develop the health strategy of preventing diseases as our priority. 【Key words】 Streptococcal pneumonia; Admission of pneumonia; Prevalence of pneumonia 前 言 根據澳門衛生局 2004-2005 年統計數字顯示肺炎是引起本澳死亡第二位之疾病(6.7%)，而肺炎鏈球菌是 作者單位：CP 3002, 中國, 澳門特別行政區, 衛生局, 仁伯爵 綜 合 醫 院 , 兒 科 ; Tel : (+853)-8390 8154; E-mail : leeyan@macau.ctm.net; *CP 3002, 中國, 澳門特別行政區, 衛生局, 公共衛生化驗所, ** CP 3002, 中國,澳門特別行政區, 衛生局, 疾病預防及控制中心; *** CP 3002, 中國, 澳門特別行政區, 衛生局, 塔石衛生中心; **** CP 3002, 中國, 澳門特別行政區, 仁伯爵綜合醫院, 臨床病理科 一種引發肺炎之常見致命病原體。由肺炎鏈球菌引發的相關疾病已對全球兒童健康造成一大威脅，輕微的引起中耳炎、鼻竇炎等，嚴重則會造成肺炎、敗血症、腦膜炎，甚至死亡；除了注意個人衛生，增加個人免疫力，疫苗接種是最經濟而有效的預防疾病的手段。世界衛生組織(WHO)認為肺炎鏈球菌結合疫苗應該被優先加入地區的免疫接種計劃內。目前，美國、澳洲、加拿大、比利時、荷蘭及英國等國家已將肺炎鏈球菌結合疫苗納入國家的免疫接種計劃內[1]，而最近香港也決定短期內效法。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 287本統計顯示 5 歲以下嬰幼兒及 65 歲以上的老年人是肺炎的好發人群。而肺炎鏈球菌往往又是引起肺炎的主要病原體，但肺炎鏈球菌的早期症狀與一般傷風感冒極為相似，容易被忽略，從而導致嬰幼失去治療的最佳時機。為逐步保障和提升市民的健康水準，完善防疫計劃，本澳從 2009 年 9 月吸取鄰近先進國家或地區對疫苗接種的經驗，引入特定群體的預防疫苗，可附合“妥善醫療，預防優先”的公共醫療政策發展方向。 參 考 文 獻 1 Rudan I, Boschi-Pinto C, Biloglav Z ,et al. Epidemiology and etiology of childhood pneumonia. Bulletin of the World Health Organizaiton, 2008 , 86 (5): 408- 416. 2 Nelson EAS, Tam J S, Yu LM, et al. Assessing disease burden of respiratory disorders in Hong Kong children with hospital dischange date and linked laboratory date. Hong Kong Med J, 2007, 13:114-21. 3 Ip M, Nelson EAS, Cheuk SC, et al. Serotype Distribution and Antimicrobial Susceptibilities of Nasopharyngeal Isolates of Streptococcus pneumonia from children Hospitalized for Acute Respiratory Illnesses in Hong Kong. Journal of Clinical Microbiology, 2007, 1969-1971. 4 Ho PL, Chiu SS, Chow KH ,et al. Pediatric hospitalization for pneumococcal diseases preventable by 7-Valent pneumococcal conjugate vaccine in Hong Kong. Vaccine 2007, 25: 6837-6841. 5 Whitney CG, Farley MM, Hadler J,et al. Decline in invasive pnemococcal disease after the introduction of protein-polysaccharide conjugate vaccine. New England Journal Medicine, 2003, 348: 1737-1746 6 Grijalva CG, Nuorti JP, Arbogast PG, et al. Decline in pneumonia admissions after routine childhood immunization with pneumococcal conjugate vaccine in the USA: a time-series analysis. The Lancet, 2007, 369:1179-1186.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 288‧論著和研究‧ 高频超聲诊断跟腱斷裂的價值 李峻 梁樹民 林寧 【摘要】 目的 探討高频超声诊断跟腱斷裂的方法及價值。 方法 對 5 例跟腱损伤患者的患側跟腱行縱向和橫向直接掃查，與健側跟腱對比，分析其声像图表现并与手术结果对照。 結果 5 例患者为跟腱完全断裂，4 例行手术治疗，超声显示患侧跟腱连续性中断，斷端处跟腱较正常增厚，断端間見不均質的混合回聲或無回聲區，超聲診斷與手術結果全部符合。 結論 高频超聲可確定跟腱斷裂的部位及程度，具有简便、無創、經濟及快速准确等優勢，在跟腱斷裂的診斷上具有重要價值。 【關鍵詞】 高頻超聲; 跟腱; 斷裂 Diagnostic Value of High-frequency Ultrasound in the Rupture of Achilles Tendon LI Jun, LIANG Shu Min, LIN Ning, Diagnosstic Imaging Center, Kiang Wu Hospital, Macao SAR, PR China; Tel : (+853)-8295 0382; E-mail :weiboat@hotmail.com 【Abstract】 Objective To explore the diagnostic value of high-frequency ultrasound in the rupture of Achilles tendon. Methods The high-frequency ultrasound probe were performed with both longitudinal and transverse scan on the injured side achilles tendon of 5 patients with rupture of Achilles tendon. Synchronously contrst with the health side. To analyze the image and compare with surgery result. Results Of the 5 patients with complete rupture of Achilles tendon, 4 were cured with operation, ultrasound could reveal the continuity was ruptured of injured side achilles tendon and the broken end of tendon was thicker than the health side. Anechonic areas or heterogeneous echonic areas were seen between the broken end. Ultrasound findings were consistent with surgical results. Conclusion High-frequency ultrasound could demonstrate the position and extend which has several advantages including simple and convenient, inexpensive, harmless, rapid and accurate. It plays a important role in the diagnosis of rupture of Achilles tendon. 【Key words】 High-frequency ultrasound; Achilles tendon; Rupture 回顧分析本院 2008 年 3 月至 2009 年 5 月採用高頻超聲檢查 5 例跟腱斷裂的聲像圖表現，現將結果報告如下: 資料與方法 5 例患者中男 4 例，女 1 例，年齡 24-61 歲，平均42.4 歲，均有明確的外傷史，病史最長 1 月，最短半天。主要臨床表現為患側足跟部疼痛、腫脹，踝關節活動受限。5 例足跟上方處皮膚可及凹陷，踝關節蹠屈功能喪失或肌力下降。 採用 GE LOGIQ-9 彩色超聲診斷儀，採用高頻線陣探頭，探頭頻率 7.5-12MHz，運用直接掃描法。檢查時患者俯臥，雙足懸於床邊，踝關節背屈 90°，探頭與跟腱垂直，行縱向和橫向扫描，從腓腸肌和比目魚肌的下端開始直至跟骨附著處，測量跟腱的厚度，並與健側對比，有無連續中斷及中斷間距，必要時可以讓患者進行蹠屈和背伸運動，有助於評價可疑的跟腱斷裂。 結 果 5 例均為跟腱完全斷裂，聲像圖表現為跟腱連續中斷，中斷間距約 0.7cm-1.3cm，斷端處跟腱較正常增粗，呈不規則高回聲，兩斷端間見不均質的混合回聲區或無回聲區（圖 1-3）。 作者單位: 中國, 澳門特別行政區,鏡湖醫院, 診斷影像中心; Tel: (+853) 8295 0382; E-mail: weiboat@hotmail.com.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 290處，因為此部位血供相對較少[2]。跟腱斷裂的主要特徵是纖維帶連續中斷，這是超聲診斷跟腱斷裂最有力的證據，完全斷裂聲像圖表現為條狀強回聲連續中斷，斷端清晰，常為增粗不規則的高回聲，此為跟腱斷裂後回縮所致。斷端間出現的血腫，為無回聲或低、強混雜回聲，血腫大小與損傷程度有關，液體的來源可能是反應性滲出液[4]。 據國外文獻報導，單純根據臨床檢查確診者,誤診率為 20-30%,跟腱斷裂的首選影像學檢查方法是MRI [5], 但因費用昂貴而難以推廣應用。國內有文獻報導 X 線檢查診斷符合率達 80％[6]。高頻超聲可以清晰顯示跟腱斷裂的位置、程度、斷端間的血腫，並可做動態觀察, 診斷率可達 80-100%[7]。高頻超聲檢查具有简便、無創、經濟及快速準確等優勢，在跟腱斷裂的診斷上具有重要價值。 參 考 文 獻 1 S. Terry Canale. 坎貝爾骨科手術學. 第 2 卷, 第 9 版.濟南: 山東科學技術出版社, 1998. 1387. 2 王金銳, Rethy K Chhem, 劉吉斌, 等. 肌肉骨骼系統超聲影像學. 第 1 版. 北京: 科學技術文獻出版社, 2007. 101-115. 3 張縉熙, 薑玉新. 淺表器官及組織超聲診斷學. 第 1 版. 北京: 科學技術文獻出版社，2000. 183. 4 薛利芳, 賈建文. 超聲在小腿肌肉、肌腱損傷診斷中的應用. 中國醫學影像技術, 2000, 16:150. 5 Lawrence GH. Injury to the Achilles tendon: experience at the Massachusetts general 1900-1954. Am J Surg, 1995, 89:795-802. 6 姚健 . 急性跟腱撕裂的線診斷 .中華骨科雜誌 , 2000, 20:639-640. 7 劉陽, 魏小華.高頻超聲在跟腱斷裂中的應用.內蒙古醫學院學報, 2007, 29:461-464.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 291‧論著和研究‧ 氣胸復張後肺水腫 肖學平 周世新 張祖貽 【摘要】 目的 探討復張後肺水腫的相關致病因素及及防治辦法。 方法 通過 1 例自發性氣胸患者胸腔閉式引流術後發生復張後肺水腫的臨床表現、治療、預後情況，總結相關文獻報告。 結果 該患者通過治療後肺完全復張，肺水腫治癒。 結論 對於有復張後肺水腫發生可能性較大的患者，應採取恰當的防治方法。 【關鍵詞】 復張後肺水腫; 防治 A Case Report about Reexpansion Pulmonary Edema and Revision of the Literature XIAO Xueping, ZHOU Shixing, ZHANG Zuyi. Kanghua Hospital, Dongguang,Guangdong; Tel : (+86-769)-2282 3333; E-mail:xueping9911@sohu.com 【Abstract 】 Objective To explore the risk factors and premention methods of reexpansion pulmonary edema. Methods By the clinical manifestations, treatment and prognosis from a patient who with chest closed after Chest cavity closed type drainage to summary the related literature report. Results The patients cure through the treatment. Conclusion For the patient who may have reexpansion pulmonary edema should adopt the Prevention and cure way. 【Key words】 Reexpansion pulmonary edema; Prevention and cure 復張性肺水腫（reexpansion pulmonary edema，RPE）是指在氣、液胸患者大量排氣、排液之後，肺迅速復張後所發生的肺水腫。肺內的正常解剖和生理機制保持肺間質水分恒定和肺泡處於理想的濕潤狀態，以利於完成肺的各種功能。如果某些原因引起肺血管外液體呈過度增多甚至滲入肺泡，則可轉變到病理狀態，稱之為肺水腫。臨床表現為呼吸困難、紫紺、咳嗽、咳白色或血性泡沫痰，兩肺散在幹、濕囉音，影像學表現為以肺門為中心的蝶狀或片狀模糊陰影等。 臨床資料 患者男性，28 歲，因“胸悶、呼吸困難半天”入院，既往曾因“氣胸”住院 3 次，胸片示：右肺壓縮80%，入院後生命體征尚平穩，有胸悶感，予臥床休息、吸氧，2 天後胸腔閉式引流。於胸腔閉式引流術 作者單位：523080, 中國, 廣東省, 東莞康華醫院, 呼吸科; Tel : (+86-769)-2282 3333; E-mail:xueping9911@sohu.com 期間見大量氣泡冒出，約 10 分鐘左右，患者出現劇烈咳嗽，隨後感胸痛、氣促、呼吸困難、面色蒼白，查體見雙肺散在大量哮鳴音，右肺更明顯，急查床邊胸片示：右肺基本復張，右側胸腔少量積液；予高流量吸氧，夾閉胸腔引流管，以甲強龍、速尿、654-2、嗎啡、茶鹼等應用後患者症狀約在 1 小時內漸緩解。 結 果 本例患者經過治療後於次日咳嗽、胸悶、呼吸困難完全好轉，雙肺幹濕性囉音消失，複查胸片肺完全復張，未見局限性或彌漫性斑片狀陰影（見圖 1-3）。 圖 1 右氣胸肺被壓縮 80%
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 294‧論著和研究‧ 腹壁硬纖維瘤 14 例報導 劉全芳 【摘要】 目的 探討腹壁硬纖維瘤的臨床、輔助檢查和組織學特點，及以手術為主綜合治療的效果。 方法 回顧性分析 1992～2002 年 12 月手術治療的 14 例腹壁硬纖維瘤的臨床資料。 結果 14例腹壁硬纖維瘤中，男 1 例，女 13 例，平均年齡 31.2±3.8 歲。發生於右上腹 2 例，右下腹近腹股溝韌帶 6 例，臍旁右腹直肌 3 例，左下腹近腹股溝韌帶 3 例，均為單發。女性病例，未婚 2 例，已婚且有生育史 10 例，無生育史 1 例。所有病例均表現為腹部漸增性實性腫塊，邊界不清。8 例有下腹部手術史，1 例伴有結腸多發性腺瘤樣息肉病。12 例為首診患者，2 例為復發病例。8 例術前行 B 超檢查均表現為腹壁層邊界不清的稍低回聲實性腫塊。該瘤組織學上由高分化的成纖維細胞和成肌纖維細胞構成，腫瘤邊緣可見瘤細胞向周圍筋膜、肌肉浸潤現象，6（6/8）例腫瘤雌激素受體陽性。 結論 腹壁硬纖維瘤診斷一般不難，廣泛徹底切除腫瘤是該病的首選治療。對於手術切除受限或範圍不足病例，輔以放射治療具有一定的療效。對於腫瘤雌激素受體陽性病例，可用三苯氧胺等藥物防治復發。 【關鍵詞】 硬纖維瘤; 腹壁; 診斷; 治療 Retrospective Analysis of 14 Patients with Desmoid Tumor of the Abdominal Wall LIU Quanfang. Department of General Surgery, People’s Hospital of Guangdong Province, Guangzhou, 510080; Tel: (+86)-1380 2541 732; (+853)-6672 4452 ; E-mail:doc.liuquanfang@163.com 【Abstract】 Objective To evaluate the characteristics about desmoid tumor of the abdominal wall including clinical manifestation, complementary examination, histology and the result following combined treatment majoring in operation. Methods The clinical data of 14 cases of patients with desmoid tumor of the abdominal wall who underwent operation treatment from Jan 1992 to Dec 2002 were analyzed retrospectively. Results Among 14 patients, male 1, female 13, its median age 31.2±3.8 years-old, tumor located in the right upper abdominal wall in 2 cases, located in the right lower abdominal wall near groin in 6 cases, located in the paraumbilical right rectus in 3 cases, located in the left lower abdominal wall near groin in 3 cases, all were single lesion. Among all 13 female patients, unmarried 2 cases, married with birth history 10 cases, married without birth history 1 case.All the patients complained of gradual enlargement of the abdominal solid mass, but without clear margin, 8 cases had lower abdominal operation history, 1 case with multiple colonic ademomatous polyposis. 12 cases first time consulted our hospital and got primary diagnosis, 2 cases consulted our hospital when they got recurred after operation. Preoperative ECHO showed slight hypoechoic solid mass without clear margin in 8 cases. Histology showed tumor mainly comprised of highly differentiated fibroblastoma and myofibroblastoma,infiltrated its surrounding fascia and muscle, 6 among 8 cases showed positive ER. Conclusion It might be not so difficult to diagnose this kind of tumor, widely radical resection should be its primary treatment. Adjuvant radiotherapy might be effective for those cases resection operation were confined and not enough. Tamoxifen might be effective for those positive ER cases to prevent and treat its recurrence. 【Key words】Desmoid tumor; Abdominal wall; Diagnosis; Treatment 腹壁有硬纖維瘤臨床少見，雖屬良性腫瘤，但具有惡性腫瘤局部浸潤性生長的特點，如病變切除不夠徹底，術後容易復發。廣東省人民醫院普通外科自1992～2002 年 12 月共收治 14 例，現報告如下。 作者單位: 510080, 中國, 廣東, 廣州市中山二路 106 號, 廣東省人民醫院, 普通外科; Tel: (+86)-1380 2541 732; (+853)-6672 4452; E-mail: doc.liuquanfang@ 163.com 臨床資料 1 一般資料 本組共 14 例，其中男 1 例，女 13 例。年齡 21～47 歲，平均 31.2+3.8 歲。發生部位：右上腹 2 例，右下腹近腹股溝韌帶 6 例，臍旁右腹直肌 3 例，左下腹近腹股溝韌帶 3 例。所有病例均為單發。病史 15 天～68 月不等。女性病例，未婚 2 例；已婚且有生育史 10例，無生育史 1 例。8 例有下腹部手術史，1 例伴有結腸多發性腺瘤樣息肉病。14 例中 12 例為首診患者，2
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 296纖維瘤的生物學特性比較溫和，臨床上卻表現為質硬、邊緣不清、浸潤性的特點。臨床上對於已婚、生育期婦女及手術切口附近發現腹部質硬、邊緣不太清楚的圓形或橢圓形腫塊，應高度懷疑此病。B 超、CT可以幫助明確腫瘤的部位、大小以及範圍，但最終確診有賴於病理學檢查。此瘤雖不轉移，但術後局部復發傾向大，有報導術後復發率高達 50-66.8%之間[2]，且主要發生在 18-30 歲這一年齡段[4]，推測與手術切除範圍不夠或腫瘤過大有關。 3 治療 (1) 手術治療：由於腹壁硬纖維瘤的病因不明，目前尚無有效的保守治療方法，手術廣泛徹底切除腫瘤是公認的最佳方法。我們的經驗是對於首診的病例應首選廣泛徹底切除腫瘤，首次手術切除不徹底與腫瘤復發有直接因果關係[2, 4]，切除範圍距腫瘤邊緣需 2cm 以上。由於腹壁硬纖維瘤雖然具有邊緣不清、浸潤性的特點但質地與周圍正常組織明顯不同，術前通過 B 超等輔助檢查對腫瘤範圍進行判定有一定的價值。對於腫瘤切除後腹壁缺損較大的病例，可選用組織相容性好的人造材料如滌綸布及 Marlex 網片進行修復。 (2) 放射治療和內分泌治療。一些學者認為在外科切除範圍不足的情況下術後輔助放療可以減少術後復發率[1, 4]，放療的劑量一般為 50-60Gy。 本組 1 例只行腫瘤大部切除的患者術後行放射治療，因其雌激素受體呈陽性，同時給予口服三苯氧胺，隨訪 4 年，腫瘤進展緩慢。內分泌治療的基礎是性激素與腹壁硬纖維瘤生長有關係的觀點。有學者報導內分泌治療對單發的腫瘤有效率為 60%，首選藥物為 三 苯 氧 胺 ， 二 線 藥 物 是 黃 體 酮 釋 放 激 素（Luteinizing hormone releasing hormone, LHRH），但前提是切除腫瘤的雌激素受體陽性[5]。本組除前述腫瘤切除不徹底的 1 例外，對於 1 例復發者因腫瘤的雌激素受體陽性，術後也給予口服三苯氧胺進行預防，病情穩定。 參 考 文 獻 1 Plukker JT, Van OI, Vermey A, et al. Aggressive fibromatosis (non-familial desmoid tumor): therapeutic problems and the role of adjuvant radiotherapy. Br J Surg, 1995, 82:510-514. 2 Caldwell EH. Desmoid tumor: musculoaponeurotic fibrosis of the abdominal wall. Surgery, 1976, 79: 104-106. 3 Lynch HT, Fitzgibbons R. Surgery, desmoid tumors, and familial adenomatous polyposis: case report and literature review. Am J Gastroenterol, 1996, 91:2598 -2601. 4 Posner MC, Shiu MH, Newsome JL, et al. The desmoid tumors not a benign disease. Arch Surg, 1989, 124:191 -196. 5 Wilcken N, Tattersall MHN. Endocrine therapy for desmoid tumors. Cancer, 1991, 68:1384-1388.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 297‧論著和研究‧ 三種方法檢測澳門大腸埃希菌 超廣譜 β-內醯胺酶的比較分析 葉千紅 李沛樟* 曾銳** 林豔芳 【摘要】 目的 比較並評價三種篩選澳門大腸埃希菌超廣譜 β-內醯胺酶（ESBLs）方法的敏感性和特異性。 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。用紙片瓊脂擴散法、雙紙片協同試驗、E-test 三種方法篩選澳門大腸埃希菌的 ESBLs，以 CLSI 推薦的方法測定 ESBLs 的結果為金標準，比較三種方法的檢測的敏感性、特異性。結果 紙片瓊脂擴散法、雙紙片協同試驗、E-test 法的敏感性分別為 100%、93.7%、85.7%；特異性分別為 76.7%、86.3%、96.6%；結論 紙片瓊脂擴散法是目前澳門大腸埃希菌篩選 ESBLs 中的最佳選擇；雙紙片協同試驗法次之；E-test 法雖特異性較高，但篩選漏診率較高，而且試劑昂貴，不適宜常規使用。 【關鍵詞】 超廣譜 β-內醯胺酶; 大腸埃希菌; 紙片瓊脂擴散法; 雙紙片協同試驗; E-test; 澳門 Comparison of Three Methods Detecting ESBLs-Producing Escherichia Coli in Macao YE Qian-hong, LIN Yan-fang. Macao Polytechnic Institute School of Health Sciences, China; Tel (+853)8399 8628; E-mail: yeqianhong@ipm.edu.mo; LI Pei-zhang.* Clinical Laboratory Department of Kiang Wu Hospital, Macao SAR, China; ZENG Rui.** Public Health Laboratory, Macao Health Bureau, Macao SAR, China; This research was granted by Macao Polytechnic Institute, Code:RP/ESS-3/2008 【Abstract】 Objective To evaluate accuracy and reliability of three methods, disk diffusion method, double disk synergy test and E-test, for ESBLs screening in Macao. Methods A total of 209 clinical isolates of Escherichia coli (E.coli) were collected from Conde S Januario Hospital (104 strains) and Kiang Wu hospital (105 strains). Three methods included disk diffusion method，double disk synergy test and E-test, were used to screen the ESBLs-producing E.coli. The method recommended by Clinical and Laboratory Standards Institute (CLSI) was used as gold standard to confirm the results and to compare the difference among three screening methods in the sensitivities and specificities. Results The sensitivities were 100% for disk diffusion method, 93.7% for double disk synergy test and 85.7% for E-test respectively. Specificities were 76.7%、86.3%、96.6% for the three screening methods separately. Conclusion Disk diffusion method is best choice for ESBLs screening compared with other two methods. The double disk synergy test takes the second place. Although the specificity was the best in the E-test, it should not be a good choice for routine use because of the high false negative rate in ESBLs screening and expensive reagent for testing. 【 Key words】 ESBL; Escherichia coli; Disk diffusion method; Double disk synergy test ; E-test; Macao 隨著 β-內醯胺酶類抗生素的廣泛使用，細菌因產β-內醯胺酶而耐藥的現象日益增加，現已引起全球範圍內的廣泛關注，其中革蘭氏陰性菌產超廣譜 β-內醯胺酶（Extended-spectrum β-lactamases，ESBLs）更顯突出。由於產 ESBLs 菌對三代頭孢菌素常呈現耐藥或 作者單位: 中國, 澳門特別行政區, 澳門理工學院高等衛生學校; 通訊作者: 葉千紅, Tel: (+853)-8399 8628； E-mail: yeqianhong@ipm.edu.mo ; 澳門鏡湖醫院檢驗科*; 澳門特別行政區衛生局公共衛生化驗所** 本研究受澳門理工學院科研項目資助 批准編號：RP/ESS-3/2008 低敏感，所以臨床實驗室選擇對 ESBLs 的準確而敏感 的篩選方法篩選 ESBLs 菌非常重要，本研究將對紙片瓊脂擴散法、雙紙片協同試驗、E-test 法三種篩選ESBLs 方法進行比較及評價，為澳門的實驗室尋找最佳的篩選 ESBLs 方法，減少產 ESBLs 菌漏檢率。 材料和方法 1 菌株來源 2003 年 10 月至 11 月、2005 年 2 月至 10 月分別收集澳門仁伯爵綜合醫院、澳門鏡湖醫院門診和住院
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 299表 2 紙片瓊脂擴散法、雙紙片協同試驗、E-test 篩選試驗敏感性、特異性結果一覽表 敏感性（%） 特異性（%） 陽性預測值（%） 陰性預測值（%） 紙片瓊脂擴散法 100 76.7 64.9 100 雙紙片協同試驗 93.7 86.3 74.7 96.9 E-test 85.7 96.6 91.5 94 由表 1、2 結果可知：以 CLSI 推薦的確證試驗為篩選 ESBLs 的金標準，三種篩選方法中，敏感性：紙片瓊脂擴散法為 100%，雙紙片協同試驗為 93.7%，E-test 法為 85.7%；特異性：E-test 法為 96.6%，雙紙片協同試驗為 86.3%、紙片瓊脂擴散法為 76.7%；陽性預測值：E-test 法最高（91.5%），其次為雙紙片協同試驗（74.7%）、紙片瓊脂擴散法（64.9%）；陰性預測值：紙片瓊脂擴散法最高為 100%，其次為雙紙片協同試驗為 96.9%，E-test 法最低 94%。 討 論 大腸埃希菌產 ESBLs 耐藥是近年來全球研究的熱點，其篩選方法的選擇是研究耐藥的前提。國外對篩選 ESBLs 的方法進行了很多研究，目前檢測 ESBLs的常用方法除 CLSI 推薦的紙片瓊脂擴散法表型確證試驗、瓊脂稀釋法確證試驗外，還有雙紙片協同試驗、E-test、三維試驗等，其原理都是基於 ESBLs 對三代頭孢菌素的水解作用能被克拉維酸所抑制。 紙片瓊脂擴散法篩選 ESBLs 是目前臨床常最常用的篩選 ESBLs 的方法，也是 CLSI 推薦的篩選方法，該法是通過對 5 種不同的、具有代表性的篩選底物耐藥的情況分析而初篩 ESBLs，本研究該方法結果敏感性達 100%，但特異性僅為 76.7%。雙紙片協同試驗簡便，快速，產 ESBLs 檢出率曾報導達 98.1%[3]，是眾多臨床實驗室中習慣的檢測方法，該法可同時完成阿莫西林/克拉維酸與幾種藥物的協同性試驗，但結果受紙片放置的距離影響較大，假如試驗菌株產生較大的抑菌環，這試驗藥敏紙片與阿莫西林/克拉維酸複合劑紙片的距離也必須相應增大，才能獲得正確的結果；相反，紙片的距離必須縮小。本研究結果顯示其敏感性為 93.7%，我們研究中選擇紙片間距為 25mm，考慮結果可能存在受上述原因的影響。E-test 法雖簡便易行，結果準確，可得到 MIC 值，具有定量檢測的結果，但本研究發現此方法提供的篩選底物較少，並且有時克拉維酸從試條擴散致使對側的抑菌環變形，MIC 值不能讀取，需要另外檢測頭孢他啶或頭孢噻肟的 MIC 值，而且試紙條中 MIC 值範圍可能不夠，且該法的試紙條比較昂貴，試驗費用較高。 通過對三種方法綜合比較，認為在篩選 ESBLs中，篩選的敏感性更為重要，因此紙片瓊脂擴散法仍是澳門篩選 ESBLs 的最佳選擇，不易漏診；雙紙片協同試驗法次之，而 E-test 法雖特異性較高，但篩選漏診率較高，而且試劑昂貴，不適宜常規使用。 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 Sanders CC, Barry AL, Washing JA, et al. Detection of extended-spectrum-beta-lactamase-producing members of the family Enterobacteriaceae with Vitek ESBL test. J Clin Microbiol, 1996, 34:2997-3001.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 300‧論著和研究‧ 顯色原位雜交評價乳腺癌HER-2狀態的意義及其免疫組化評價建議 葉玉清 文劍明 黃香婷 陳建勇 韋潔貞 冼麗芳 【摘要】 目的 檢測乳腺癌人表皮生長因子受體2（HER-2）基因擴增和蛋白表達，為臨床使用分子靶向藥物Trastuzumab（Herceptin）治療乳腺癌提供依據。方法 採用顯色原位雜交法檢測71例福爾馬林固定石蠟包埋的乳腺癌組織HER-2擴增狀態，檢測結果與免疫組化（IHC）比較。 結果 CISH檢測結果顯示，乳腺癌高度擴增為28.2%（20/71）、低度擴增5.6%（4/71）、無擴增66.2%（47/71）。免疫組化染色3+的占38.0%（27/71）、2+占31.0%（22/71）、0~1+占31.0%（22/71）。CISH結果與IHC結果高度相符；IHC 0~1+和3+組的結果與CISH結果也高度相符，但2+組的結果則有很高的不符率。採用本文建議的IHC評價校正標準，重新評價所有病例IHC的結果，然後再與CISH的結果比較，可達到高度相符。 結論 CISH是一種客觀和準確的評價乳腺癌HER-2狀態的方法。採用改良免疫組化評價標準，IHC檢測也是HER-2蛋白表達的有用指標。 【關鍵字】 乳腺癌; HER-2; 顯色原位雜交; 免疫組化 Role of Chromogenic in situ Hybridization (CISH) in The Evaluation of HER-2 Status in Breast Carcinoma and Proposition of Its Immunohistochemical Valuation YIP Yuk-ching, WEN Jian-ming, VONG Heong-ting, ChAN Kin-iong, WAI Kit-cheng, SIN Lai-fong. Department of Pathology, Kiang Wu Hospital, Macau, Tel: (+853)-82951921; E-mail: wcyt@yahoo.com.hk; Corresponding author: WEN Jianming，E-mail: wenjm@mail.sysu.edu.cn 【Abstract】 Objective To value HER-2 gene amplification and protein expression in breast carcinoma, and provides an indicator clinically using molecular target therapeutic trastuzumab (Herceptin) in the patient with breast carcinoma. Methods Chromogenic in situ hybridization (CISH) was used to detect HER-2 amplification in 71 cases of formalin-fixed, paraffin-embedded breast carcinomas of different histology. The detected results were compared with immunohistochemistry (IHC). Results The results show that high level amplification detected by CISH was 28.2% (20/71 cases) breast carcinoma, low level amplification 5.6% (4/71) and no amplification 66.2% (47/71). IHC scoring 3+ was 38.0% (27/71), 2+ 31.0% (22/71) and 0~1+ 31.0% (22/71) of all cases. CISH-IHC results showed a good concordance. Although IHC-CISH results showed a good concordance in the 0/1+ and 3+ groups, while a poor agreement in 2+ group was confirmed. If the evaluated criteria is modified according the reactive pattern of IHC in CISH amplified cases, IHC-CISH results are highly concordance. Conclusions CISH is an objective and accurate tool to evaluate breast cancer HER-2 status. After modifying the valued criterion, IHC is also a useful indicator for HER-2 protein expression. 【 Key words 】 Breast carcinoma; HER-2; Chromogenic in situ hybridization (CISH); Immunohistochemistry 目前臨床採用特異性分子靶向藥物Trastuzumab（Herceptin®）能有效的治療乳腺癌，但用藥前必須確認癌組織中癌細胞有HER-2蛋白過表達或基因擴增 。 HER-2 蛋 白 表 達 或 基 因 擴 增 可 採 用 免 疫 組 化（IHC）和螢光原位雜交（FISH）檢測。然而，用IHC檢測福馬林固定石蠟包埋組織HER-2表達的結果差 作者單位：中國, 澳門特別行政區, 澳門鏡湖醫院病理科, Tel: (+853)-829 51921 通信作者: 文剑明; E-mail: wenjm@mail.sysu.edu.cn 異很大，陽性結果的判斷標準也不明確，常出現假陽性。FISH法雖然比IHC法在結果的判斷上有更高重複性[1]和更為準確[2]，但需要有昂貴的儀器設備、技術複雜和費用過高，因而限制了該方法的使用。Tanner等人[3]介紹顯色原位雜交（CISH）檢測HER-2狀態，該方法用常規顯微鏡就能直接觀察探針，並能同時觀察癌組織的形態。本文採用CISH檢測乳腺癌的HER-2基因擴增，同時與IHC結果比較，並提出IHC結果判斷的建議，使僅用IHC檢測也能正確反映HER-2狀態。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 304CISH是一種評價HER-2狀態的敏感和特異的方法。然而，HER-2基因信號可以是由於17號染色體多體性引起而不是真正的基因擴增，但乳腺癌17號染色體的多體性很少超過5個拷貝[10, 11]。因此，採用6個HER-2信號作為基因擴增的界限可不考慮17號染色體的多體性因素[12]。但事實上，在6～10個HER-2信號的病例中仍可找出17號染色體2倍體[13]，相反在10個信號以上的基因高度擴增病例中未發現有17號染色體的多體性[14]。因此，臨床候選抗HER-2治療時，應選擇用CISH檢測HER-2基因有擴增或用IHC檢測HER-2蛋白為3+反應的乳腺癌病例，對于IHC檢測為2+的病例，應進行CISH檢測確證有基因擴增，以避免Trastuzumab的濫用。 參 考 文 獻 1 Bartlett JM, Going JJ, Mallon EA, et al. Evaluating HER-2 amplification and overexpression in breast cancer. J Pathol, 2001, 195(4): 422-428. 2 Pauletti G, Dandekar S, Rong H, et al. Assessment of methods for tissue-based detection of the HER-2/neu alteration in human breast cancer: A direct comparison of fluorescence in situ hybridization and immunohistochemistry. J Clin Oncol, 2000, 18(21): 3651-3664. 3 Tanner M, Gancberg D, Di Leo A, et al. Chromogenic in situ hybridization: A practical alternative for fluorescence in situ hybridization to detect HER-2/neu oncogene amplification in archival breast cancer samples. Am J Pathol, 2000, 157(5): 1467-1472. 4 Press MF, Slamon DJ, Flom KJ, et al. Evaluation of HER-2/neu gene amplification and overexpression: Comparison of frequently used assay methods in a molecularly characterized cohort of breast cancer specimens. J Clin Oncol, 2002, 20(14): 3095-3105. 5 Fornier M, Risio M, Van Poznak C, et al. HER-2 testing and correlation with efficacy of trastuzumab therapy. Oncology (Williston Park), 2002, 16(10): 1340-1348. 6 Zhao J, Wu R, Au A, et al. Determination of HER-2 gene amplification by chromogenic in situ hybridization (CISH) in archival breast carcinoma. Mod Pathol, 2002, 15(6): 657-665. 7 Di Palma S, Collins N, Faulkes C, et al. Chromogenic in situ hybridisation (CISH) should be an accepted method in the routine diagnostic evaluation of HER2 status in breast cancer. J Clin Pathol, 2007, 60(9): 1067-1068. 8 Ntoulia M, Kaklamanis L, Valavanis C, et al. HER-2 DNA quantification of paraffin-embedded breast carcinomas with LightCycler real-time PCR in comparison to immunohistochemistry and chromogenic in situ hybridization. Clin Biochem, 2006, 39(9): 942-946. 9 Cho EY, Choi YL, Han JJ, et al. Expression and amplification of Her2, EGFR and cyclin D1 in breast cancer: Immunohistochemistry and chromogenic in situ hybridization. Pathol Int, 2008, 58(1): 17-25. 10 Wang S, Hossein Saboorian M, Frenkel EP, et al. Aneusomy 17 in breast cancer: Its role in HER-2/neu protein expression and implication for clinical assessment of HER-2/neu status. Mod Pathol, 2002, 15(2): 137-145. 11 Lal P, Salazar PA, Ladanyi M, et al. Impact of polysomy 17 on HER-2/neu immunohistochemistry in breast carcinomas without HER-2/neu gene amplification. J Mol Diagn, 2003, 5(3): 155-159. 12 Vera-Roman JM, Rubio-Martinez LA. Comparative assays for the HER-2/neu oncogene status in breast cancer. Arch Pathol Lab Med, 2004, 128(6): 627-633. 13 Li-Ning-T E, Ronchetti R, Torres-Cabala C, et al. Role of chromogenic in situ Hybridization (CISHTM) in the evaluation of HER2 status in breast carcinoma: comparison with immunohistochemistry and FISH. Int J Surg Pathol, 2005, 13(4): 343-351. 14 Wolff AC, Hammond MEH, Schwartz JN, et al. American Society of Clinical Oncology/College of American Pathologists Guideline Recommendations for Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer. J Clin Oncol, 2007, 25(1): 118-145.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 305‧論著和研究‧ 加味當歸補血湯濃縮丸補血、 增強機能的實驗研究 解斌 曾曉會* 劉滿華* 黃雪君 黃瓊 杜鐵良* 【摘要】 目的 觀察加味當歸補血湯濃縮丸的補血作用和增強機能作用。 方法 製備小鼠藥物性貧血模型觀察加味當歸補血湯濃縮丸的補血作用，製備小鼠免疫低下模型觀察加味當歸補血湯濃縮丸增強免疫作用，同時觀察加味當歸補血湯濃縮丸對正常小鼠游泳時間、耐常壓乏氧時間的影響。 結果 加味當歸補血湯濃縮丸能顯著增加貧血小鼠紅細胞數和紅細胞壓積，增大免疫抑制小鼠胸腺、脾臟係數，明顯延長正常小鼠游泳時間和耐常壓乏氧時間。 結論 加味當歸補血湯濃縮丸具有明顯補血和增強機體機能作用。 【關鍵詞】 加味當歸補血湯濃縮丸; 補血; 增強機能 Study on Enriching the Blood and Enhancing the Body Function of Modified Danguibuxuetang Concentrated Pills in Mice XIE Bing, ZEN Xiao-hui*, LIU Man-hua, HUANG Xue-jun*, Huang Qiong, DU Tie-liang.* Macau Kangyi Pharmaceutical Science and Technology Ltd., Macau, China; Tel: (+853)-2888 2398; Email: xiebin@hongyee.com.mo *Institute of Traditional Chinese Medicine of Guangdong Province, Guangzhou 510095,China. 【Abstract】 Objective To observe the effectes of modified danguibuxuetang concentrated pills (MDCP) on enriching the blood and enhancing the body function in mice. Methods Establishing the model of drug-induced anemia mice and immunocompromised mice to observe the improvement of MDCP.And to observe the effectes of MDCP on swimming time and resistance to atmospheric hypoxia time in mice. Results MDCP could increase the number of red blood cell and hematocrit in anemia mice, increase the thymus factor and spleen factor in immunocompromised mice,and prolong the swimming time and resistance to atmospheric hypoxia time in mice. Conclusion MDCP can enrich the blood and enhance the body function. 【Key words】 Modified danguibuxuetang concentrated pills; Enriching the blood; Enhancing the body function 當歸補血湯出自李東垣的《內外傷辨惑論》，全方由黃芪、當歸組成，為經典的氣血雙補名方，現代主要用於治療貧血、白細胞減少症、對抗放化療副作用等[1]。加味當歸補血湯濃縮丸是在當歸補血湯的基礎上進行加味組方，臨床用於腫瘤化療輔助有較好功效，本文主要進行加味當歸補血湯濃縮丸補血、增強機能的實驗動物觀察，為臨床用藥提供實驗依據。 作者單位：中國, 澳門康怡科技藥業制造廠；Tel：(+853)-2888 2398; E-mail: xiebin@hongyee.com.mo *廣東省中醫研究所，中國, 廣東 廣州 510095 基金專案：澳門特別行政區科學技術發展基金資助專案（030/2007/A2） 材 料 供試品 加味當歸補血湯濃縮丸、加味當歸補血湯原處方濃縮丸由廣東省中醫研究所製劑研究室提供，批號均為 20081022。十一味參芪膠囊，大連漢方藥業有限公司，批號 20080807。 試 劑 注射用環磷醯胺，山西普德藥業有限公司，批號20080104。鈉石灰，廣州化學試劑廠，20060601-1。2,4-二硝基氯苯，上海試劑一廠，060412。 儀 器 BS224S 電子天平(1/萬)，德國 SARTORIUS 產
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 309‧論著和研究‧ 顏氏益心方對冠脈介入術後 炎症性指標的影響 劉興烈* 孫武 陳全福 徐慧聰 潘光明 劉敏雯 嚴夏 【摘要】 目的 觀察顏氏益心方對急性冠脈綜合徵介入治療術後患者內皮功能及相關炎症指標的影響。 方法 將 132 例急性冠脈綜合徵介入治療術後患者隨機分為顏氏益心方組、通心絡組及西醫組，3 組均予以西醫常規處理，顏氏益心方組加服顏氏益心方湯劑，通心絡組加服通心絡膠囊。觀察治療前後血清內皮素（ET）和一氧化氮（NO）濃度、C-反應蛋白（CRP）、纖維蛋白原（FIB）、D-二聚體（D-dimer）的變化。 結果 治療組治療後, 上述指標優於對照組。 結論 顏氏益心方與通心絡膠囊具有顯著等效性，均能明顯改善 ACS 介入術後患者內皮功能，糾正內皮功能紊亂，同時有效地控制炎性反應，具有心臟保護功能。顏氏益心方暫未發現不良反應。 【關鍵詞】 急性冠脈綜合徵; 介入治療術後; 顏氏益心方 Face Family Name Profit Heart Phon Versus Coronal Artery Intervention Skill Post Inflammation Apyogenous Exponential Impact LIU Xing Lie*, SUN Wu, CHEN Quan Fu, XU Hui Chong, PAN Guang Ming, LIU Minwen, YAN Xia. Faculty of Chinese Medicine, Macau University of Science and Technology, Macau SAR; China, Tel:+(853)-6218 2148; E-mail:liuxinglie1968@yahoo.com.cn; Second Clinical Medicine Council of Guangzhou University of TCM , Guangzhou, 510120, China. Funding Project: Face Family Name Profit Heart Phon Cure Acuteness Coronal Artery Syndrome Intervention Skill Future Trouble Soprano Heart Protective Action Mechanism Research 【Abstract】 Objective Enriching cor Surname Yan Family Name Profit Heart Phon versus Acuteness Coronal Artery Syndrome intervention iatrotechnics future trouble soprano endothelium function cum correlation inflammation gender exponential impact. Methods Number 132 example acuteness coronal Artery syndrome intervention iatrotechnics future trouble soprano random into Yan surname enriching cor phon group, throughout cor retinervus group cum western medicine group，three group equal inflict western medicine conventional processing，Yan surname enriching cor phon group plus dose Yan surname enriching cor phon decoction，throughout cor retinervus group plus dose throughout cor retinervus gelatine capsule. observe cure circa sera endothelium white（ET）imparlance nitrogen oxide（NO）strength, C-reactive protein（CRP）, Fibrinogen（FIB）, D-dimer（D-dimer）variance in. Results Cure group cure queen, supra indices outgone control group. Conclusion Yan surname enriching cor phon and throughout cor retinervus gelatine capsule possess prominence equivalence，homoenergetic distinctness ameliorate acs intervention skill future trouble soprano endothelium function ， rectify endothelium dysfunction ， be accomplished by effect terra dam inflammatory reaction，possess heart shield function back.Yan surname enriching cor phon temporary no detect adverse reaction. 【Key words】 Acute coronal artery syndrome; After intervention therapy; Yan surname enriching cor phon 冠脈再狹窄是一個醫源性疾病，即是由施行旨在增加冠脈通暢以便提供至關重要血流的技術所引起的 。 儘 管 目 前 冠 脈 介 入 治 療 急 性 冠 脈 綜 合 徵 作者單位：*中國, 澳門特別行政區, 澳門科技大學, 中醫藥學院; Tel: (+853)-6218 2148; E-mail: liuxinglie1968@yahoo.com.cn; 510120, 中國, 廣州, 廣州中醫藥大學, 第二臨床醫學院. 基金項目：上海顏德馨中醫藥基金會資助課題（專案編號05-011-3）. (Acute Coronal Artery Syndrome, ACS)已取得令人滿意的效果，但術後再狹窄和術後心絞痛復發等問題在一定程度上限制了介入療法的發展。再狹窄是一種早期現象，大多數在 PTCA 後 6 個月發生，但在 1～3 個月再狹窄發生率增加最大，隨後逐漸達到平穩期。故如何在介入術後 1～3 月時間視窗防治再狹窄具有特別的重要意義。作者根據顏德馨教授“衡法”理論，於2006 年 5 月～2007 年 4 月期間選擇顏氏益心方防治急性冠脈綜合徵介入治療圍手術期後患者 44 例，取得了較好效果，現報導如下。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 312NO 是由血管內皮細胞合成的生物活性物質，具有強力擴張血管作用，並可抑制血小板粘附和聚集[8]。在正常生理狀態下，血清內皮素（ET）為陰，一氧化氮（NO）屬陽，兩者互相作用，消長平衡；若內皮細胞功能受損，冠狀動脈內皮功能失調， ET 分泌增加，NO 分泌減少，表現陰盛陽衰， 導致冠狀動脈痙攣，誘發 ACS 事件發生。炎症的許多指標如 C-反應蛋白（CRP）、纖維蛋白原（FIB）、D-二聚體（D-dimer）都與惡性心血管事件有關；C 反應蛋白代表炎症引起的全身急性反應，屍檢發現 ACS 中斑塊破裂常發生於斑塊的肩部，該區炎症最為明顯，CPR 沉積較多[9]。Ridker 等的前瞻性研究表明高水準的 CRP 是心肌梗塞的危險性增加 3 倍，CPR 是較敏感的心血管事件預測因數[10]。國內研究表明，CPR 水準與 ACS 發生機率成正比，其增加與 ACS 患者的嚴重程度呈正相關[11]。全身及斑塊局部炎症惡化是斑塊不穩定和破裂的重要基礎，CRP 反映機體炎症反應的敏感指標，可預測冠狀動脈事件危險程度，間接反映斑塊穩定的穩定性[12]。 本研究依據《諸病源候論》曰“心痛者，風冷邪氣乘於心也，其痛發有死者，有不死者，有久成疹者。“ 其 久 心 痛 者 ， 是 心 之 別 絡 ， 為 風 邪 冷 熱 所 乘 痛也。”“夫心痛，多是風邪痰飲，乘心之經絡，邪搏於正氣，交結而痛。若傷心之別絡而痛者，則乍間乍盛，休作有時也。”等經典理論和我們既往科研成果[13-14]，結合 ACS 臨床特點與“風”邪致病的一致性，從風論治，以“益氣活血，祛風解痙，疏通心絡”的顏氏益心方（成分：黃芪、丹參、川芎、葛根、黨參、赤芍、石菖蒲、降香等）對 ACS 介入治療術後 1～3 個月時間視窗進行幹預，結果表明：顏氏益心方在使用期間與通心絡膠囊相比，具有顯著的等效性，也未見明顯不良反應，並且較西醫組明顯改善 ACS 患者內皮功能，糾正內皮功能紊亂，同時有效地控制炎性反應。研究亦表明：顏氏益心方可以改善 ACS 介入術後患者的血脂指標水準和血液流變學的黏、濃、聚狀態，從而幹預心肌缺血，防止微血栓形成[15]。因此，具有“益氣活血，祛風解痙，疏通心絡”功效的顏氏益心方可能是通過其入血效應作用于血管內皮細胞，阻止非生理性血栓形成的啟動和發展，糾正內皮細胞相關介質如 ET、NO 非正常水準，從而起到保護心肌細胞功能的作用。其詳細機制有待於進一步研究。 致謝 本研究得到上海顏德馨中醫藥基金會資助，在此表示衷心感謝！ 參 考 文 獻 1 國際心臟學會和協會及世界衛生組織臨床命名標準化聯合專題組. 缺血性心臟病的命名和診斷標準. 中華內科雜誌, 1981, 2:25. 2 鄭筱萸, 主編. 中藥新藥臨床研究指導原則. 第 1 版. 北京:中國醫藥科技出版社, 2002, 41-45. 3 陳灝珠, 楊新春, 鄒陽春, 等. 急性冠脈綜合徵基礎與臨床. 第 1 版. 北京:人民軍醫出版社, 2003, 3, 73-75. 4 俞蔚, 陳旭嬌, 沈法榮, 等. 急性冠脈綜合徵患者中內皮依賴性動脈順應性的相關研究 . 中華急診醫學雜誌 , 2005, 14:413-416. 5 Nigam A, Mitchell GF, Lambert J, et al. Relation between conduit vessel stiffness (assessed by tonometry) and endothelial function (assessed y flow media dilation) in patients with and without coronary heart disease. Am J Cardiol, 2003, 92:395-399. 6 林朝勝, 佟銘, 趙凱, 等. 冠心病心絞痛發作與循環內皮素水準關係的探討. 實用內科學雜誌, 1994, 14:742. 7 Araki SJ, Kawahara Y. Stimulation of Phospholipase C-mediated hydrolysis by endothelin in cultured rabbit aortic smooth cells. Biochem Biophys Res Commun, 1989, 158:1072. 8 Feelisch M. The biochemical pathways of NO formation from nitrovasdilators. J Cardiovasc Pharmaclo, 1991, 17:25. 9 Torzewsi J, Torzewskil M, Bowyer DE, et al. C-reactive protein frequen tly colocalizes with the terminal complement complex in the intima of early the rosclerotic of human coronary arteries. Artevioscler Thromb Vasc Bid, 1998, 18:136-192. 10 Ridker PM, Cushman M, Stampfer Mj, et al. Plasma concentration of C-re active protein and risk of developing peripheral vascular disease. Circulati on, 1998, 97:425-428. 11 吳元呤, 侍作勝, 王臨光, 等. C-反應蛋白與急性冠脈綜合徵關係的研究. 實用全科醫學, 2005, 3:119. 12 Biasuoci LM, Colizzi C, Rizzelo V, et al. Roll of inflammstion in the pathogenesis of unstable coronary artery diseases. Seand J Clin Invest, 1999, 59:1222-1225. 13 陳全福, 劉敏雯. 急性冠脈綜合徵與中醫“風”的關係.遼寧中醫學院學報, 2004, 6:457-458. 14 劉敏雯, 陳全福, 鄧屹琪. 從風論治對急性冠脈綜合徵介入治療圍手術期後 40 例. 陝西中醫, 2006, 27:138-141. 15 劉敏雯, 潘光明, 嚴夏. 顏氏益心方對急性冠脈綜合徵介入治療術後的臨床觀察. 遼寧中醫雜誌, 2006, 33:809-811.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 313‧論著和研究‧ 中國城鎮老年人手術後醫療費保障現狀調查研究 薛欣希 曲海慧 周飛 【摘要】 目的 瞭解中國城鎮老年人手術後醫療費保障情況，並為完善老年人醫療保障提出建設性意見。 方法 採用問卷及個案訪談相結合的方法，對中國兩個城市老年人的醫療保險及手術後醫療費用報銷狀況進行調查。 結果 a. 86.4%的城市老年人享有城市居民醫療保險，13.6%的老人無任何醫療保險; b.醫療保險的比例偏低；c. 完全無法報銷及醫療費用報銷比例低於 60%的老年人，對當前醫療保險報銷制度滿意度也很低。 結論 應該將門診診療納入醫療保險統籌範圍，提高手術後醫療費用報銷比例，減少報銷環節, 降低醫療費用虛高定價及解決異地醫保轉移支付問題。 【關鍵詞】 城鎮老年人; 手術後醫療費用; 醫療保障; 中國 A Survey on Post-operation Medical Insurance of Senior Chinese Citizens XUE Xinxi, QU Haihui, ZHOU Fei. School of Labor and Human Resource, Renmin University of China;E-mail: xeuxx0603@gmail.com 【Abstract】 Objective To identify the status of senior citizens’ medical insurance in mainland China. Methods Questionnaire and face-to-face interview were used to collect the related data at Xi’an and Wuhan. Results a. 86.4% senior citizens have some kinds of medical insurances, but 13.6% has no insurance; b. the ratio of medical reimbursement is low; c. those seniors who don’t have medical insurance or have low reimbursement rate are unsatisfactory with the current medical insurance program. Conclusions a. outpatient fee should be included in reimbursement scheme; b. expanding reimbursement lists; c. increasing post-operation expenses reimbursement rate; d. simplifying old people’s reimbursement process; and e. implementing cross regional reimbursement system. 【Key words】Senior citizen; Post-operation medical expenses; Medical insurance; China 研究背景及意義 2000 年我國第五次人口普查結果顯示，65 歲以上老年人口已達 8811 萬人，占總人口 6.96%，60 歲以上人口達 1.3 億人，占總人口 10.2%。這些資料表明我國已經進入了老年型社會。老齡化的加速對經濟、社會都帶來巨大的壓力。如何保障老年人的生活與健康是社會保障體系面臨的巨大挑戰。在諸多老年問題中，醫療保障是政府和公眾關注的焦點。據衛生部 2008 年調查顯示，在我國老年人發病率比青壯年要高 3-4倍，住院率高 2 倍，老年人因患病而生活不能自理的有一千多萬人 [1]。與 2003 年相比，2008 年的老年人口慢性病患病率有明顯增加，尤其是腫瘤、腦血管病、糖尿病和老年精神病患病率的增加更為顯著 [1]。另一方面，老年人的工作能力下降，收入減少，擔負巨額醫療費用很艱難，所以老年人的醫療保障需要社會給予更多的關注。 作者單位：中國, 人民大學勞動人事學院, 北京, 100872; Tel: (+86)-12985323172; E-mail: xeuxx0603@gmail.com 實行廣覆蓋、多層次的醫療保障體系，保障城鎮老年人的醫療保障權益，已得到廣泛的共識。但是如何保障老年人在大型手術後的高額醫療費用報銷方面卻存在很多問題。對城鎮老年人手術後醫療資源的需求和供給進行深入調查取證，並研究如何在現有的城鎮居民基本醫療保險框架下，盡可能地保障老年人的手術後醫療費用，成為現階段不可回避的問題。然而，目前對於城鎮老年人手術後醫療保障的研究比較少，而且大部分限於宏觀方面的研究，如老年人醫療保險的資金籌集方式、運行管理方式的研究等等，尚缺乏微觀層面的探討。本研究希望通過在回顧已有文獻的基礎上，基於西安及武漢兩個城市實證調查情況，從微觀角度進行資料分析和訪談分析，借次研究為城鎮老年人手術後醫療費保障的完善提出建設性意見。 我國老年人重大疾病醫療保險現狀 繆甯梅、陶琳對 2004～2006 年樣本醫院用藥金額、佔有率、增長率等進行排序統計分析，發現醫院用藥金額與 GDP、人均可支配收入具有一定的相關性，而且醫院用藥金額增長高於 GDP 的增長，這給老
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 317‧論著和研究‧ 出院準備服務：兩種辨識機制之比較 胡文潔 王曉慧 葉郡銘* 蔡玉霞** 鄭學慧 史麗珠* 【摘要】 目的 一區域醫院由專任個管師負責出院準備服務，有兩個機制辨識有長期照護需求的內外科住院病患：於入院或出ICU 8小時內初評，>7分者且經覆評(高篩組)；排除疾病因素滯院14天以上(滯院組)。本研究旨在比較兩組在住院天數、出院後長期照護方式、出院後2個月內的再入院率及死亡率。 方法 將2006年8月至2007年7月的資料作統計分析。 結果 有效人數為236 人(97.5%)，高篩組164人、滯院組72人。兩組的差別為巴氏分數、住院科別。巴氏分數愈高或外科病患較可能屬滯院組。平均住院天數為22.7天，滯院組比高篩組多住20天，有顯著差異。出院後回家比例最高(48.7%)，其次為居家護理(29.7%)、安養機構(17.8%)、護理之家(3.8%)。出院2個月內的再入院率及死亡率為11.4%、11.9%，兩組在出院後長期照護方式、再入院率及死亡率均沒有顯著差異。 結論 採用個案管理模式執行出院準備服務，能縮短住院天數，又兩種辨識機制不影響出院後長期照護方式、出院2個月內的再入院率及死亡率。 【關鍵詞】 出院準備服務; 個案管理; 住院天數; 出院後長期照護方式; 再入院率; 死亡率 Discharge Planning: Comparison of Two Different Timing of Identification HU Wen-chith, WANG Siao-Huei, JENG Shyue-juey. Saint Paul’s Hospital, Tao-Yuan, Taiwan, China; YEH Chun-Ming*, SEE Lai-chu*. Department of public Health, Chang Gung University, Tao-Yuan, Taiwan, China; TSAI Yu-Hsia**. Department of Nursing, Chang Gung University, Tao-Yuan, Taiwan, China; *Correstondence author: SEE Lai-chu; Tel: (+03)-2118 800-5119; E-mail: lichu@mail.cgu.edu.tw 【Abstract】 Objectives A regional hospital employed a full-time case manager to do discharge planning since August 2006. High risk group was those who were rated >7 score within 8 hours after admission or out of intensive care unit. Prolong group was those who hospitalized > 14 days without reasonable causes. We aimed to compare length of stay (LOS), utilization of long term care (ULTC), readmission rate and mortality within 2 months after discharge between the two study groups. Methods Statistical analysis was performed for the data between August 2006 and July 2007. Results A total of 236 (97.5%) observation was eligible, whereas 164 in the high risk group and 72 in the prolong group. The major difference between two groups was Barthel Index (BI) and the admitted department. The higher the BI or patients from the surgery department were more likely to be in the prolong group. The prolong group stayed significantly longer (36.3 days) than the high risk group did (16.7 days). After discharge, going home occupied the highest proportion (48.7%), followed by home care (29.7%), institution (17.8%), and nursing home (3.8%). Readmission rate and mortality within 2 months after discharge was 11.4% and 11.9%, respectively. ULTC, readmission rate or mortality did not differ significantly between two groups. Conclusion Two different timing to identify potential patients who need long term care by the full-time case manager in a regional hospital can reduce LOS. These two timing did not affect ULTC, readmission rate and mortality within 2 months after discharge. 【Keywords】 Discharge planning; Care management; Length of stay; Utilization of long term care; Readmission rate, Mortality 前 言 出院準備服務是指整合不同專業人員，使住院患者在急性期治療到穩定階段後，能順利出院或轉介， 作者單位：中國台灣財團法人天主教聖保祿修女會醫院; *中國台灣長庚大學公共衛生科; **中國台灣長庚大學護理學系; 通訊作者: 史麗珠, Tel: (+03)2118 800-5119; E-mail: lichu@mail.cgu.edu.tw 並獲得持續、完整的醫療照護。中國台灣實施出院準備服務是在1994年開始，由中國台灣衛生署宣導及補助四家醫院試辦；1995年後出院準備服務納入醫院評鑑[1-2]。又因中國台灣健保實施前瞻性付費制度，使得各醫療院所紛紛實施出院準備服務[3]。 出院準備服務應包含：(1)篩選：辨識有長期照護需求的病人；(2)計劃與執行：提供服務、監督，使
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 323‧論著和研究‧ 澳門長者聽力問題的調查研究 白琪文 王繼群 程正昂 【摘要】 目的 於 2008 年 7 月由澳門街坊聯合總會所舉辦的“健康有道﹐養生有道”長者體檢活動中，醫護人員為 1600 位年齡為 50 歲或以上的長者進行了一站式的耳科檢查和聽力評估服務。以下研究將針對 50 歲或以上人口的聽力健康状況作出分析和探討。問卷調查的結果和測驗的数據將有助於研究人員了解弱聽的普遍性，並對及時的聽力檢查和复康治疗作前瞻性的探討研究。 方法 先利用耳窺鏡及以問卷調查的方法先對長者進行初步的耳朵檢查及聽力評估，只要長者乎合調查問卷中的其中一項﹐便會被帶到隔音室利用測量儀器為其進行進一步的聽力檢測，測試其雙耳的純音氣導聽閾。試頻率為 500Hz、1000Hz 和 2000Hz。 結果 在這 1600 名年齡為 50 歲以上的接受檢查的長者中， 90%屬聽力正常，有 10%長者有弱聽，其中 2%單耳出現弱聽，8%雙耳出現弱聽。而有弱聽問題的長者男性佔 19%，女性占 81%。 結論 鑒於本研究只對 1600 位長者進行檢查，只能反映澳門部分長者的情況，因此，本次對於澳門長者的聽力状況的研究分析有一定的局限性 。本次調查能反映的是﹐長者弱聽問題存在的普遍性，而及時的檢查、复康及配戴助聽器有助防止聽力恶化，並有助改善長者的溝通能力。 【關鍵詞】 長者; 弱聽; 單耳弱聽; 雙耳弱聽 Study on the Prevalence of Hearing Impairment Among Elerdly Population in Macau PAI Ki Man, WANG Jiqun, CHENG Zheng Ang. Servico de Otorrinolaringologia, Centro Hospitalar Conde de Sao Januario, Servicos de Saude, Macau SAR, China;Tel: (+853)2831 3731;E-mail: paikm@ssm.gov.mo 【Abstract】 Background Pure tone assessments were conducted to a sample of 1600 seniors ages 50 and up, in a senior body-check event sponsored by the “Uniao Geral das Associacoes dos Moradores de Macau.” The following study describes the prevalence of audio impairment among seniors ages 50 and above in Macau. Using this data, the study intends to project the prevalence of hearing impairment among local seniors, and tries to learn ways to better design healthcare policies that can provide preventive and therapeutic measures, and ultimately bring about better quality of life. Method A preliminary screening was conducted by visually examining the ear canals using an otoscopes, and by asking questions. Those seniors who cannot pass either or both of these tests were brought to a sound-proof room for a pure-tone hearing test. Frequencies used were 500Hz、1000Hz and 2000Hz. Results Among the sample of 1600 seniors, 90% were considered normal, and 10% were found to be hearing impaired. And among the 10% of the hearing impaired, 2% experienced unilateral hearing loss, and 8% experienced bilateral hearing loss. Among the hearing impaired, 19% were male, while 81% were female. Conclusion Given this was only a screening conducted to a selective sample of seniors, and this sample were made up of mostly healthy individuals who travelled to this event, therefore the results might be not conclusive enough to reflect the reality of hearing impairment of Macau’s senior population. What it does say, is that hearing impairment is common, that 1 out of 10 seniors experience this problem, and that early preventive and therapeutic measures can minimize the problems hearing deterioration can bring about, such as the social problems they experience from the inability to communicate effectively. 【Key Words】 Seniors; Hearing impairment; Monaural hearing impairment; Binaural hearing impairment 根據澳門統計暨普查局的資料顯示，2007 年 12月澳門的居住人口估計有 538,100 人，其中老年人口佔 7.1%[1]，同時老化指數亦不斷上升，顯示澳門人口呈現老化的跡象。隨着老年人口的增加，老年人對於醫療服務需求量也不斷增大，因此，如何完善老年 作者單位: 中國, 澳門特別行政區, 衛生局, 仁伯爵綜合醫院耳鼻喉及頸面外科; Tel: (+853)2831 3731; E-mail: paikm@ssm.gov.mo 人的醫療服務、提升老年人醫療服務的質素成為當今一個很重要的研究課題。本文針對老年人的聽力健康狀況作出以下的分析和探討。 目 的 於 2008 年 7 月由澳門街坊聯合總會等舉辦的
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 326‧論著和研究‧ 澳門學校膳食含鹽量調查 蕭巧玲 呂綺玲* 【摘要】 目的 調查澳門地區學校午膳食品的食鹽含量，收集學校食品營養成份的分析數據，為制定學校健康飲食政策提供科學依據。 方法 2007 年 1 月至 2008 年 12 月期間，於本澳有為學生供應膳食的學校抽取即食午膳食物樣本進行食鹽及鈉含量檢測。有關化學參數的測定，主要參照了中華人民共和國國家標準檢驗方法。食品的鹽含量等於或超過 1.25g/100g，或鈉含量等於或超過0.5g/100g，即被界定為高鹽食品。 結果 本調查採集了 27 間學校的午膳食物樣本合計 64 件，樣本平均鹽含量及鈉含量分別為 0.97g/100g（0.05－2.4g/100g）及 0.43g/100g（0.0096－1.1g/100g），當中有 20 件樣本（31.25%）被判定為高鹽食品。高鹽食品主要來自 15 間學校，平均鈉含量為 0.7g/100g（0.5- 1.1g/100g）。 結論 本調查發現超過三成的學校午膳食品鹽含量過高，且有超過五成的學校有為學生提供高鹽的午膳食品，反映學生膳食設計者或供應者對學生營養的認識及重視程度較低，建議加強對學校人員、膳食供應商、家長及學生的營養教育。另建議日後可針對澳門學校食品中其他營養成份的含量水平展開調查，從而對學校食品的營養質量作出較全面的評價。 【關鍵詞】 學校膳食; 學校午膳; 食鹽; 鈉; 營養 A Survey on the Salt Contents of School Meals in Macao SIO Hao-Leng. Center for Disease Control and Prevention, Departeent of Health, Macao SAR, China; Tel:(+853)-8504 1561; Email: helenholly@ssm.gov.mo LOI I-Leng.* Public health Laboratory, Health Bureau, Macao SAR, China. Email: loiileng@ssm.gov.mo 【Abstract】 Objective To survey the sodium and salt levels of various food items in school meals. Methods Ready-to-eat food items of school meals were collected from schools in Macao during 2007 and 2008. All samples were tested for sodium and salt. Foods with sodium levels 0.5g/100g or salt levels 1.25g/100g were regarded as high-salt foods. Results A total of 64 samples were collected from 27 different schools. The average sodium and salt levels of the samples were 0.43g/100g (0.0096－1.1g/100g) and 0.97g/100g (0.05－2.4g/100g) respectively. Of the 64 samples collected, 31.25% (from 15 different schools) were regarded as high-salt foods. The average sodium content of the high-salt samples was 0.7g/100g (0.5- 1.1g/100g). Conclusion In the present study, slightly more than 30% of the school meal food samples were found to be high in salt and over 50% of the schools were found to provide meals with high-salt food items. The survey highlights the need of strengthening school nutrition education for school personnel, school food suppliers, parents and students. Further studies on the levels of other nutrients in school meals are recommended to perform a comprehensive assessment on the nutritional quality of school meals in Macao. 【Key words】 School meal; Chool lunch; Salt; Sodium; Nutrition 前 言 根據本澳衛生局疾病預防控制中心的資料，2006年本澳約有八成學校有為學生提供午膳，其中公立學校佔20.78%，私立學校則佔79.22%。本澳學校主要以兩種方式為學生供應膳食：第一種是學校將食物製備的工作判給校外供應商，由供應商製備食物後，再將食物運抵學校；第二種是學校自設廚房，直接由廚房 作者單位：中國, 澳门特別行政區,衛生局, 疾病預防控制中心, Tel: (+853)-8504 1561; Email: helenholly@ssm.gov.mo. 呂綺玲* 澳門衛生局公共衛生化驗所, Email: loiileng@ssm.gov.mo 為學生製備及供應食物。前者是較常見的方式，佔所有供膳學校的六成。 2007年香港小學午膳營養測試結果發現，99%的小學午膳樣本鈉含量高於當地建議的每餐攝取量（400毫克）。研究證實，兒童鹽份攝取過量會導致血壓上升，若情況持續，則會增加其成年後患高血壓及心血管疾病的機會[1]。另有外國研究指，兒童的鹽份(氯化鈉)攝取量較過去10年大幅增加了50%[2]。故此，及早了解兒童膳食中的鹽份含量，並採取積極的限鹽措施，對降低成年人群高血壓及心血管疾病的發生率有
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 328續表 4 樣本名稱 鈉含量（g/100g） 鹽含量（g/100g）炸春卷 0.62 1.40 蘿蔔魚蛋 0.63 1.10 黑椒洋葱豬扒 0.66 1.30 香腸 0.74 1.50 鹵水雞翼 0.75 1.60 煎豬扒 0.75 1.30 炸雞肶 0.75 2.00 豉油排骨 0.77 1.20 魚片叉燒 0.80 1.90 香腸 0.82 1.70 鹵水魚片 0.93 2.20 炸魚蛋 0.97 1.20 蒸肉餅 1.10 2.40 討 論 本研究是本澳首份關於學校膳食含鹽量的調查報告。研究結果顯示，超過三成的學校午膳食品含鹽量過高。參照《中國居民膳食營養素參考攝入量》中的建議，4 至 10 歲兒童每日鈉的適宜攝入量（AI）為900 至 1000 毫克，而 11 至 17 歲青少年每日則適宜攝入 1200 至 1800 毫克[5]。以本研究中含鹽量最高的食品（蒸肉餅）計算，若進食該食品 100 克，則已攝入鈉 1100 毫克，鈉的攝取量顯然超出 4 至 10 歲兒童一天所需要的份量。 本研究結果顯示，本澳約有超過五成的學校有為學生提供高鹽的午膳食品。現時學校採用的兩種供餐方式均出現部份食品含鹽量過高的情況。食品的含鹽量過高，可能是由於含有魚蛋、香腸及叉燒等高鹽的 加工食材，以及豉油、黑椒醬及鹵水等高鹽的調味醬料所致。這反映學校午膳設計者或供應者普遍對學生營養的認識及重視程度較低，建議政府相關部門加強對學校人員、膳食供應商、家長及學生的營養教育工作。 本研究的限制是只針對學校午膳中的個別菜餚或食品進行檢驗分析，未有對整份午餐的含鹽量進行評估。午餐是學生一日三餐中非常重要的一餐，其營養價值會直接影響學生的健康及學習狀況。因此，為了對本澳學校膳食的營養質量作出全面的評價，建議日後可針對膳食中其他營養成份的含量水平展開調查，以擴大收集本澳學校膳食營養成份的分析數據，為制定學校健康飲食政策提供科學依據。 參 考 資 料 1 He FJ, MacGregor GA. Importance of salt in determining blood pressure in children: meta-analysis of controlled trials. Hypertension, 2006, 48: 861-869. 2 Schreuder MF, Bökenkamp A, van Wijk JAE. Salt intake in children: increasing concerns? Hypertension, 2007, 49: 10. 3 Cutler JA, Roccella EJ. Salt reduction for preventing hypertension and cardiovascular disease: a population approach should include children. Hypertension, 2006, 48:818-819. 4 CDC. Guidelines for school health programs to promote lifelong healthy eating. MMWR, 1996, 45: 1-33. 5 中國營養學會, 編著. 中國居民膳食營養參考攝入量. 第1 版. 北京:中國輕工業出版社, 2000. 160-163.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 329‧講座‧ 全科醫學淺談 彭世明 【摘要】家庭醫學最關注的中心既是人也是病，既涉及醫學科學，又延及相關的各個專業領域。家庭醫學對病人的管理責任是無限制，醫生就應關照其健康問題而無論時間、地點；其家庭或社區環境是否有利病人治療與健康，這仍是家庭醫生的管理範圍。 家庭醫學醫生需擁有廣泛各科目的豐富醫學知識、敏銳的社會時事的觸覺、熟練的溝通技巧、對社區各種社區協助單位認識。還需要同理心，與病人建立和諧、夥伴式關係，與病人及家人一起協商有效、可行的治療方向。家庭醫學專科與其他專科的關係並不是對立的，是各施其職，互補互利；筆者用臨床個案的表述，可較清楚闡明其兩者的不同。家庭醫學醫生以有效方式處理大批病人，提供健康教育，並能篩選少數疑難或需要高科技治療的病人，及時轉介給其他專科醫生。這樣既減少病人盲目求診，接受不必要的診斷步驟及治療和痛苦，也能使專科將主要精力用於確診疑難病人與住院治療，提高醫療資源上的成本效益。 【關鍵詞】家庭醫學專科醫生 The Family Physician PANG Sai Meng. Technical Training and Documentation Unit, Technical Coordination Office, General Health Care Sub-Board, Health Bureau, Macao SAR, PR China; Tel: (+853)-8597 6105; Email: shirleypangpang@yahoo.com.hk 【Abstract】The family physician provides continuing, comprehensive care in a personalized manner to patient of all ages and to their families, regardless of the presence of disease or the nature of the presenting complaint. The family physician should have rich medical knowledge, the ability to sense the social issues, and good communication skill. Additionally, they are familiar with varied social and health services and be able to integrate them together. Furthermore, they have compassion and empathy to build up the rapport and the partnership relationship with their patients. As a result of that, the family physician can provide appropriate treatment regime and management to the patients. The specialist in family medicine is cooperation with the specialists in other specialties, not in confront position. Family physicians effectively treat many patients with minor or common diseases and provide health education to prevent diseases. Another important task is that the family physicians screen and find out the difficult or emergency cases and then refer to the appropriate specialists for investigation and management. Consequently, patient can receive the most suitable management as well as avoid unnecessary or even harmful laboratory and imaging investigation. The specialists in other specialties can pay more attention to deal with the difficult cases in their specialties and therefore cost-effective of health system can be increased. 【Key words】Family physician 全科專科對很多市民來說是相當難理解，既是全科，也是專科。這與心臟專科、胃腸科專科、胸肺專科等是否相同意義呢？ 全科專科又稱家庭醫學專科。家庭醫學專科醫生處理病人的手法、負責內容以及服務宗旨與職責是與傳統專科醫生具存明顯區別。 專科醫療和家庭醫學負責健康與疾病發展的不同階段[1]。專科醫療負責疾病形成以後一段時間的諮詢，其宗旨是根據科學對人體生命與疾病本質的研究成果 作者單位：中國，澳門特別行政區, 衛生局，一般衛生护理副体糸,培訓暨文件組; Tel: (+853) –8597 6105; Email: shirleypangpang@yahoo.com.hk 來抵抗疾病；並因此向承擔深入研究病因，病理等微觀機制的責任。其責任局限於醫學科學認識與實踐的範圍，集中體現了醫學的科學性方面。其對病人管理責任僅限於在醫院或診室中，一旦病人出院或就診結束，這種管理責任即終止。家庭醫學負責健康時期，疾病早期乃至經專科診療後無法治癒的各種病患的長期監視。其最關注的中心既是人也是病，既涉及醫學科學，又延及相關的各個專業領域。家庭醫學對病人的管理責任是無限制，醫生就應關照其健康問題而無論時間、地點；其家庭或社區環境是否有利病人治療與健康，這仍是家庭醫生的管理範圍。家庭醫生對病人的生活方式，社會角色與健康信念都要明瞭，而處
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 331‧綜述‧ 斑馬魚作為用於新藥開發的動物模型 當前在澳門應用的概況 林啟興 梁詠芝 張在軍 李振華 Deepa Alex 李銘源 【摘要】斑馬魚是一種理想新興的模式生物，其特點是胚胎為體外發育且十分透明，很容易觀察藥物對活體胚胎內部組織、器官的作用，給藥方式簡單，藥物需要量少，所以被廣泛用於神經保護、血管新生以及骨質疏鬆的藥物篩選。血管新生是指從現有的血管中長出新血管的過程，同時受促血管新生因子和抗血管新生因子兩者所控制。許多疾病的成因都與不正常的血管新生現象有關，如：過度的血管新生與腫瘤的發生、糖尿病性視網膜和牛皮癬的發生有着密切關連；而血管新生的不足，則與慢性炎症的發生相關。神經保護是指令神經細胞免受氧化壓力等造成的不可逆損傷的作用，神經保護因被視為兩種退行性疾病－柏金遜症及老人痴呆症的可行治療策略，而成為研究的熱點。骨質疏鬆是指骨骼中礦質的流失所引起的骨密度降低的病症，它增加了骨折的可能性，斑馬魚的可視性胚胎對研究骨密度和骨骼結構的改變在形態觀察上有着明顯的優勢。 【關鍵詞】斑馬魚; 血管新生; 神經保護; 骨質疏鬆 A Review of Zebrafish as a Model Organism for Drug Screening in Macao LAM Kai-Heng, LEONG Emilia Conceição, ZhANG ZaiJun, LI ZhenHua, Deepa Alex, LEE Simon Ming-Yuen. Floor 3 Block 3, Institute of Chinese Medical Sciences, University of Macao, Macao SAR, China; Tel:(+853)- 6635 0530; E-mail:lamkaiheng@hotmail.com 【Abstract】 Zebrafish is a new excellent model organism widely used in drug screening for prevention and treatment of a variety of diseases, neuroproetection, angiogenesis and osteoporosis being cited as examples in this article. The features of optical transparency and extraorganismal development of embryo, enable simply way for drug administration and requirement of small amounts of drug, and make observing interaction between organ and drug in a live organism in real-time manner at convenience. The development of new blood vessels from pre-existing ones is generally referred to as angiogenesis and it is tightly controlled by a balance of angiogenesis promoting factors and inhibitors. Many diseases are associated with imbalance in regulation of angiogenesis, at which excessive angiogenesis could cause cancer, diabetic retinopathy and psoriasis while chronic inflammatory disease could be attributed to insufficient angiogenesis. In development of agent to cure Alzheimer's and Parkinson's disease, neuroprotective drug screening could be performed in zebrafish model at which neuron damage could be induced by reactive oxygen species (ROS).. Osteoporosis is another popular aging disease, especially in post-menopause women and the most detrimental effect of BMD (bone mineral density) reduction is making the bone more susceptible to fracture. Transparency of zebrafish embryo makes it as a perfect model on observing and studying the alteration of bone architecture and bone density. 【Keyword】Zebrafish; Angiogenesis; Neuroprotection; Osteoporosis; 斑馬魚作為模式生物的概況 斑馬魚(Danio rerio)是一種發現於印度和巴基斯坦水域的熱帶淡水魚類，因其身體側有銀藍色的縱向條紋而得名。由於具有飼養和繁殖容易，胚胎發育速度快等生物學特征，斑馬魚很快的被視作動物模型而始 作者單位：中國, 澳門特別行政區, 澳門大學,中華醫藥研究院; Tel：(+853)-6635 0530; E-mail：lamkaiheng@hotmail.com 用於發育生物學和遺傳學等研究領域。1981年George Streisinger[1]，等在《Nature》上發表了關於斑馬魚人工雌核發育的研究成果，從而揭開了斑馬魚在發育生物學和遺傳學領域研究的序幕。1994年5月，來自於世界各地從事斑馬魚發育和遺傳學研究的學者集會冷泉港，以“斑馬魚發育和遺傳”為題展開了熱烈的討論。會後，國際兩大科學雜誌《Nature》和《Science》為此都發表了專題評述[2-3]，認為斑馬魚已經完全具備成為脊椎動物分子發育生物學，甚至人類基因組計畫模式物種的條件，被確定為一種新型的模式生物。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 332與傳統的模式生物相比較，斑馬魚屬於小型熱帶魚類，具有世代周期短(3 個月便性成熟)、產卵量大（一對斑馬魚每天能產 100 顆卵）、形體較小（成年魚僅長 3~4cm），卵子為體外受精，胚胎發育速度快，僅需 3 天左右就可發育為幼魚的特點[4]。此外，斑馬魚的胚胎為完全透明，能在顯微鏡下直接觀察胚胎發育過程，使得發育異常的突變體能很容易被識别。尤為重要的是，斑馬魚還具有和人類相似的基因結構和調節模式。因此，斑馬魚已成為一種理想的模式生物，并被廣泛用於神經和血管發育，以及免疫、腫瘤、基因功能和藥物篩選等研究領域[5]。 與線蟲、果蠅、鼠等傳統模式生物一樣，斑馬魚也被廣泛用於藥物篩選上。斑馬魚適用於藥物篩選的優點包括[3]：(1)相較線蟲、果蠅，斑馬魚是一種脊椎動物，與人類的親緣關係更近。斑馬魚和人類的基因組保守性很高(70%)，人類的很多基因已經在斑馬魚中克隆得到，而且具有相似的功能；(2)相比於嚙齒類等哺乳動物，斑馬魚胚胎為體外發育，而且胚胎十分透明，很容易觀察到藥物對活體胚胎內部組織、器官等的藥理作用；(3)給藥方式簡單，藥物溶於培養水體中，通過皮膚、鰓、消化系統等來吸收，而且相較傳統動物實驗，進行篩選時藥物需要量少[6]；(4)飼養所需的空間小，能大量養殖。所以，在澳門斑馬魚作為用於藥物篩選的動物模型是十分理想和合適的。 斑馬魚在血管新生領域上研究的概況 血管新生(Angiogenesis)這一概念是由 Hertig 於1935 年所命名[7]，之後由 Folkman and Klagsbrun 於1987 年闡明其機理[8]。血管新生是指從現有的血管中長出新血管的過程，它同時由促血管新生因子和抗血管新生因子兩者的拮抗作用所嚴密控制的，除了在胚胎發育，創傷癒合和女性生殖循環中出現外，一般在正常人體中並不會發生[9]。然而，許多疾病的成因都與不正常的血管新生現象有關，如：過度的血管新與生，與腫瘤的發生、糖尿病性視網膜和牛皮癬相關連；而貧乏血管新生，則與慢性炎症相關[10]。 特別在腫瘤的治療上，近年抗血管新生的治療策略已成為未來腫瘤治療的重要途徑之一。切斷對腫瘤組織的血液供應，從而減少對腫瘤組織的供氧及營養提供，可以有效地抑制腫瘤的增生和轉移[11]。相對於傳統的治療方法，這類被稱之為“餓死”癌細胞的新治療策略，適用性更廣。因為作用的靶點是血管的內皮細胞而非直接作用於癌細胞[12]，所以對於不同類別的癌細胞，效果是相同的；其次，抗血管新生療法相比於傳統療法副作用很少，正如上文所述，在成年人體中，血管新生是很少發生的，換言之所產生的副作用亦很少，這使抗血管新生成為一條治療初期癌症的重要途徑[13]。 TG(fli1:EGFP)轉基因斑馬魚，其特點是能在血管內皮細胞(ECs, endothelial cells)表達綠色熒光蛋白(GFP, Green Fluorescent Protein)，意即在特定波長的熒光下，Fli-1斑馬魚身體上的血管會發出綠色的熒光，使其成為觀察及研究血管新生的重要模型[14]。 目前，在澳門大學中華醫藥研究院，正廣泛地使用Fli-1這一類型轉基因斑馬魚來進行促血管新生及抗血管新生的藥物篩選。特別選擇具活血化瘀功能的傳統中藥，從中提煉提取物及單體並篩選出具特異性藥效的化合物，其中已發現三七的提取物[15]及甲基化的白藜蘆醇[16]分别具顯著的促血管新生及抗血管新生的藥效（見圖1）。Fli-1斑馬魚其直觀性的血管網絡，令血管藥物的篩選效率大大提高，並為更進一步藥理學上的研究提供了便捷的途徑，如：細胞組成及周期的分析，以及其他現代生物檢測技術。 A BDC 圖 1 為 轉 基 因 斑 馬 魚 Tg(fli-EGFP) 在 48hpf(post hour fertilization)經3,5,4’-trimethoxystibene(tmRes)用藥處理20小時後，節間血管(inter segmental vessel, ISV)所發生的改變，A圖為對照組，BCD圖分別為10μM,30μM,100μM的用藥組，可見，tmRes對ISV的血管新生有着抑制的作用。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 334MPTP 或 1000 μM MPTP ＋ 50 μg/mL 提取物處理 48 h 后，用抗 tyrosine hydroxylase (TH)抗體組織全固定免疫染色(Whole mount immunostaining)顯示多巴胺神經元。 A 為正常對照組斑馬魚；B 为 500 μM MPTP 處理組；C 为 1000 μM MPTP 處理組；D 为 1000 μM MPTP ＋ 50 μg/mL 提取物處理組。可見神經毒素 MPTP 可劑量依賴地減少斑馬魚多巴胺神經元，50 μg/mL 提取物共處理可保護多巴胺神經元。 圖 4 為中藥提取物可保護神經毒素 LGA 誘導的神經元凋亡。5 dpf（days post fertilization）野生型斑馬魚魚胚胎，經2.5 mM LGA 或 2.5 mM LGA＋6 μg/mL 或 12 μg/mL 提取物處理 24 小時後，用 Acridine orange (AO)染色顯示凋亡神經元。 A 為正常對照組斑馬魚； B 為 2.5 mM LGA 處理組；C 為 2.5 mM LGA＋6 μg/mL 提取物共處理組； D 為 2.5 mM LGA＋12 μg/mL 提取物共處理組。可見 2.5 mM LGA 24 小時可誘導大量神經元凋亡，12 μg/mL 提取物共處理可劑量依賴地減少 LGA 誘導的神經元凋亡。 斑馬魚在骨質疏松上的研究概況 骨 質 疏 鬆 症 (Osteoporosis) 一 詞 於 1885 年 由pommer 首先提出，意即為骨質減少的一種疾病。骨質疏鬆症可以由多種原因所引起，按病因可成原發性與繼發性兩大類，其中原發性骨質疏鬆症最為常見。根據骨質丟失和骨折的類型將原發性骨質疏鬆症分為兩類：I 型 是由破骨細胞所介導，發病主要以女性為主，最常見於絕經后不久的女性，為高轉移型，快速的骨丟失主要為小梁骨，特別是脊柱和橈骨遠端。II型 是由成骨細胞所介導，為老年型，女性的發病率較男性高，與高齡、慢性鈣缺乏、甲狀旁腺亢奮及骨形成不足有關 [23]。因此，骨質疏是老年人的一種常見病，會大大增加老人骨折的發生率，隨着社會的老齡 圖 5 為轉基因斑馬魚在淫羊藿提取物(EFE)用藥，所引起斑馬魚尾骨（箭號所指）生成的狀況，說明 EFE 對骨的形成有促進作用。 化加快，骨質疏鬆的發生率呈逐漸上升趨勢。 斑馬魚作為研究骨質疏鬆的動物模型，與傳統的模式動物－小鼠等，同樣有着無可比擬的優勢。作為一種慢性的疾病，常規的動物模型如小鼠，都存在着世代較短，藥物效應時間長，及難於觀察等缺點。而斑馬魚則存在着這些方面的優勢，它的身體骨骼結構在受精後 10 天就已基本發育完成[24]，而斑馬魚幼魚微小的身體及身體透明性，使得斑馬魚能適合用於作為研究骨質疏松的動物模型[25]。透明的身體使研究能在活體的狀況下，持續觀察斑馬魚體內的骨架形成及發育，同時可以使用染料對骨進行染色，能進一步對骨骼的大小長度和骨密度進行定量化[26]。 在傳統中醫裏，有着“腎主骨”的理論，認為骨質的流失與腎氣有着相帶關繫，所以凡具壯陽補腎的藥物都能起到補骨的功效。目前，在澳門大學中華醫藥研究院這一領域的研究，主要集中在利用斑馬魚模型，對傳統中藥的提取物和單體進行現代生物醫藥的研究。其中，淫羊藿苷作為淫羊藿中的主要成份，已在骨質疏鬆的研究上有着不少關於能改善骨質疏鬆及預防骨質疏鬆的作用[27, 28]。在淫羊藿的提取物亦發現具有能促進骨生成的效應（見圖 5）。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 335參 考 文 獻 1 Stresinger G, Walker C , Dower N. et al. Production of Clones of Homozygous Diploid Fish (Brachydanio rerio). Nature , 1981, 291 : 293-296. 2 Concordetj P, Inghamp P. Catch of the Decade. Nature, 1994, 369: 19-20. 3 Kahn P. Zebrafish Hit the Big Time. Science , 1994, 264: 904-905. 4 M Westerfield. The Zebrafish Book: A Guide for the Laboratory Use of Zebrafish, The University of Oregon Press, 2003. 5 Dooley K, Zon LI. Zebrafish : A Model System for the Study of Human Disease. Curr Opin Genet Dev, 2000 , 10: 252-256. 6 Kidd KR, Weinstein BM. Fishing for novel angiogenic therapies. Br J Pharmacol, 2003, 140: 585-594. 7 Folkman J. Anti-angiogenesis: new concept for therapy of solid tumors. Ann Surg, 1972, 175: 409- 416. 8 Folkman J, Klagsbrun M. Angiogenetic factors. Science. 1987, 235:442–447. 9 Fan TP, Yeh JC, Leung KW, et al. Angiogenesis: from plants to blood vessels. Trends Pharmacol Sci, 2006, 27: 297-309. 10 Liekens S, De Clercq E, Neyts J. Angiogenesis: regulators and clinical applications. Biochem Pharmacol, 2001, 61: 253-270. 11 Nishida N, Yano H, Nishida T, et al. Angiogenesis in cancer. Vas Health Risk Manag. 2006, 2:213-219 12 Carmeliet P, Jain RK. Angiogenesis in cancer and other diseases. Nature, 2000, 407: 249-257. 13 Hou J, Tian L, Wei Y. Cancer immunotherapy of targeting angiogenesis. Cell Mol Immunol, 2004, 1: 161-166. 14 Lawson ND, Weinstein BM. Weinstein. In vivo imaging of embryonic vascular development using transgenic zebrafish. Dev Biol, 2002, 248: 307-318. 15 Lam HW, Lin HC, Lao SC, et al. The angiogenic effects of Angelica sinensis extract on HUVEC in vitro and zebrafsih in vivo. J Cell Biochem, 2008, 103:195-211. 16 Leong CW, Wong CH, Lao SC, et al. Effect of resveratrol on proliferation and differentiation of embryonic cardiomyoblasts. Biochem Biophys Res Commun, 2007, 360: 173-180. 17 Linney E, Upchurch L,Donerly S. Zebrafish as a neurotoxicological model. Neurotoxicol Teratol, 2004, 26: 709-718. 18 Jeong JY, Kwon HB, Ahn JC, et al. Functional and developmental analysis of the blood-brain barrier in zebrafish. Brain Res Bull, 2008, 75: 619-628. 19 Parng C, Ton C, Lin YX, et al. A zebrafish assay for identifying neuroprotectants in vivo. Neurotoxicol Teratol, 2006, 28: 509-516. 20 Li SH, Cheng AL, Zhou H, et al. Interaction of Huntington disease protein with transcriptional activator Sp1. Mol. Cell Biol, 2002, 22: 1277–1287. 21 Sarchielli P, Galli F, Floridi A, et al. Relevance of protein nitration in brain injury: a key pathophysiological mechanism in neurodegenerative, autoimmune, or inflammatory CNS diseases and stroke. Amino Acids, 2003, 25: 427–436. 22 Bernardos RL, Raymond PA. GFAP transgenic zebrafish. Gene Expr Patterns, 2006, 6: 1007-1013. 23 B. L. Riggs. Overview of osteoporosis. West J Med, 1991, 154(1): 63-77 24 Barrett R, Chappell C, Quick M, et al. A rapid, high content, in vivo model of glucocorticoid-induced osteoporosis. Biotechnol J. 2006, 6: 651-655. 25 Du SJ, Frenkel V, Kindschi G, et al. Visualizing normal and defective bone development in zebrafish embryos using the fluorescent chromophore calcein. Dev.Biol. 2001, 238: 239-246. 26 Fleming A, Sato M, Goldsmith P. High-throughput in vivo screening for bone anabolic compounds with zebrafish. J Biomol Screen, 2005, 10: 823–831. 27 Nian H, Ma MH, Nian SS, et al. Antiosteoporotic activity of icariin in ovariectomized rats. Phytomedicine, 2009, 16: 320-326. 28 Chen KM, Ma HP, Ge BF, et al. Icariin enhances the osteogenic differentiation of bone marrow stromal cells but has no effects on the differentiation of newborn calvarial osteoblasts of rats. Pharmazie, 2007, 10: 785-789.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 336‧綜述‧ Neurohormonal Dysregulation in Type 2 Diabetes Mellitus LOK Mei Kun 【Abstract】 There are several glucose counter-regulatory hormones, but the only hormone that reduces blood glucose is insulin, which is the dominant glucose-lowering factor. There are a group of hormones action generally oppose of insulin, tend to elevate blood glucose concentration, they are called counter-regulatory hormones. They are mainly including glucagon, cortisol, catecholamines and growth hormone. Stable glucose homeostasis maintain by insulin and counter-regulatory hormones. Glucose metabolism is critical to normal physiological functioning . Such complex pathway to maintain with normal plasma glucose concentration range varies between 4 - 7 mmol / L. In recent years, light has been shed on the role of neuroendocrine system on the pathogenesis in type 2 diabetes. 【Key words】 Type 2 diabete; Insulin; Counter-regulatory hormones 第二型糖尿病的神經激素調節障碍 陸美娟. 澳門特別行政區, 衛生局, 筷子基衛生中心; Tel : (+853)-6660 8006; E-mail : lokmeikun@yahoo.com.hk 【摘要】 胰島素是體内唯一的降血糖激素，而體內多種調節激素,例如:兒茶酚胺, 生長激素, 胰高血糖素, 皮質醇等, 统稱為胰島素的反調節激素, 能抗衡或減弱胰島素的效力, 提升血糖 , 血糖水平的穩定有賴於胰島素和各種激素之間的互相制衡,使血糖能夠保持在 4-7 mmol/L 的正常範圍內,適應機體需要. 近年來 , 對於第二型糖尿病的發病機理中,神經內分泌系統的調節障碍 , 受到高度關注. 【關鍵詞】第二型糖尿病; 胰島素; 胰島素的反調節激素 Glucose Homeostasis, Energy Homeostasis , Insulin and Counter-regulatory Hormones There are several glucose counter-regulatory hormones, but the only hormone that reduces blood glucose is insulin, which is the dominant glucose-lowering factor. There are a group of hormones action generally oppose of insulin, tend to elevate blood glucose concentration, they are called counter-regulatory hormones. The glucose raising system, insulin counter-regulatory hormones would be activated in hypoglycemia. They are mainly including glucagon, cortisol, catecholamines and growth hormone. Author’s address : Lok Mei Kun, Fai Chi Kei Health Center, SS, Macao, SAR China, Tel: (+853)-6660 8006; E-mail: lokmeikun@yahoo.com.hk Glucagon is produced and releases by pancreat alpha-cells. The hypothalamic-pituitary- adrenal (HPA) axis regulates secretion of cortisol and growth hormone (GH) .Epinephrine ( adrenaline ) is released by adrenal medulla. Norepinepinephrine ( noradrenaline)is released from sympathetic neurons. The centers for regulation of the hypothalamic-pituitary- adrenal axis (HPA) axis and the sympathetic nervous system are tightly connected at several levels, when one is activated always followed by activation of the other[1]. A normal hypothalamic-pituitary- adrenal axis function with low stress is associated with a beneficial health profile. Stable glucose homeostasis maintain by insulin and counter-regulatory hormones[2]. Glucose metabolism is critical to normal physiological functioning, the roles of hormones in regulation of glucose homeostasis showed in Fig 1.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 337 Growth hormone Insulin Cortisol Catecholamines Facilitates lipogenesis Glucagon Facilitates glycogen synthesis Stimulate lispolysis Facilitates glucose transportSimulate glycogenolysis Simulate gluconeogenesis Inhibits lipolysis Inhibits gluconeogenesis Inhibits glycogenolysis Normal Blood Glucose 4-7 mmol/L Fig.1 Glucose homeostasis regulation by insulin and counter-regulatory hormones Body fat distribution and energy metabolism are regulated by hormones. Insulin is central in the regulation of energy homeostasis. Insulin promotes glucose entry into cells for energy production. It facilitates energy storage, lipogenesis, glycogen synthesis in muscle and liver, inhibits lipolysis and peripheral glucose production. Counter-regulatory hormones stimulates glycogenolysis, gluconeogenesis and lipolysis. Such complex pathway to maintain with normal plasma glucose concentration range varies between 4-7 mmol / L. Secretion of each hormones is governed by powerful feedback loops. Counter-regulatory hormones have insulin-antagonistic effects both in the liver and in the peripheral tissues. They are released during stress and hypoglycaemia. Glucagon is the most important hormone for acute glucose counter-regulation. The insulin-antagonistic effects of glucagon and adrenaline are of rapid onset. Adrenaline induces the early posthypoglycaemic insulin resistance. Cortisol and growth hormone contribute to counter-regulation during prolonged hypoglycaemia, they are important for the insulin resistance that is observed later following hypoglycaemia[3]. Neurohormonal Dysregulation in Diabetes The most common prevalent condition being recognized with insulin resistance is obesity, particularly when localized to central visceral depots. Recent studies reported that neuroendocrine disturbance in abdominal obesity, including increased cortisol and adrenal androgen secretion. With stress and excessive cortisol secretion, abdominal obesity and insulin resistance appear. Obesity, particularly abdominal obesity, is the most prevalent condition of insulin resistance . In the old days, neuroendocrine dysregulation background to insulin resistance was not taken into account, had not attracted attention. Discussing effects of abnormalities in secretion of various hormones, the pathogenetic possiblity had not been considered previously with sufficient seriousness. The development of new methodology can evaluate more precisely of the neuroendocrine abnormalities in abdominal obesity, including increased cortisol and adrenal androgen secretions. It also allowed sufficient sensitive and accuracy to measure activity of endocrine system, hypothalamic-pituitary- adrenal axis and sympathoadranal systems. Specialists proposed that a central neurohormonal dysregulation characterized by activating stress-related hormones such as cortisol, catecholamines and age associated decrease in sex hormone and growth hormone might lead to increased deposition of visceral adiposity , partial medicated with insulin resistance[4]. More and more evidence lending support to the hypothesis of neuroendocrine perturbations in hypothalamic-pituitary- adrenal axis and sympathoadranal systems as a cause of insulin resistance. The content discussing below is an attempt to explore, to analyze the possible links between insulin, counter-regulatory hormones, sex hormones, age- and stress-
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 338related hormones in the pathogenesis of obesity, insulin resistance and type 2 diabetes. Glucagon Glucagon is produced and releases by pancreat alpha-cells. It is the most important hormone for acute glucose counter-regulation. The insulin-antagonistic effects of glucagon is of rapid onset. Glucagon plays a primary role in the prevention , correction of hypoglycemia . Indeed, it may be that hypoglycemia does not occur if the secretion and actions of both glucagon and insulin, are normal. Glucagons metabolism in type 2 diabetes is complex. While the elevated fasting plasma concentrations can be lower by large amounts of insulin, the exaggerated glucagons response to ingested nutrients cannot be suppressed[5]. Stress Stress , although difficult to define, is a vague term embracing any situations that is perceived as threatening, or irritant, including physical and or psychological stress. The occurrence ; severity of stress; coping skill and coping capacity to stress is individual. Stress can affect endocrine system, activates both hypothalamic- pituitaryadrenal (HPA) axis and sympathoadrenal system to stimulate insulin counter-regulate hormones secretion. Stress cause rapid release and increase level of Adrenocorticotrophic hormone (ACTH) , cortisol, growth hormone and catecholamines. This reaction of endocrine system can occur within seconds or minutes. There is some evidence that suggests an increased prevalence of psychosocial stress factors is associated with visceral distribution of body fat. A double blind case control study examined the interaction between neuroendocrine stress axes and metabolic syndrome. Cortisol secretion, 24-hour urinary cortisol metabolite and catecholamine output were measured. The result showed 24 hour urinary cortisol metabolites and normetanephrine outputs were higher in patients with metabolic syndrome. Specialists concluded that neuroendocrine stress axes are activated in metabolic syndrome. This case-control study provides the important evidence that chronic stress may be a cause of metabolic syndrome[6]. Catecholamines Although most noradrenaline is derived from sympathetic neuronal release, as part of the sympathetic nervous system, inner medulla of adrenal glands can secrete the major catecholamines adrenaline ( epinepfrine ) and noradrenaline (norepinephrine ). All three of the naturally occurring catecholamines, norepinephrine, epinephrine and dopamine, function as neurotransmitters within the central nervous system. Catecholamines influence the secretion of other hormones, they stimulate glucagons release and inhibit insulin release. The pancreatic islets also receive an extensive sympathetic innervation. Stimulation of pancreatic sympathetic nerves or an elevation in circulating catecholamines suppresses insulin and increases glucagons release. This combination of effects supports substrate mobilization, reinforcing the direct effects of catecholamines on hepatic glucose output and lipolysis[7]. Catecholamines stimulate the breakdown of stored fuel with the production of substrate for local consumption, they accelerate fuel mobilization in liver, adipose tissue and skeletal muscle, liberating substrates, such as glucose, free fatty acid and lactate into the
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 339circulation for use[7]. Increased activity of sympathetic nervous system would be expected to amplify free fatty acid mobilization. Elevated free fatty acid mobilization has been found in abdominal obesity[8] and would be expected to amplify insulin resistance through established mechanisms . Specialists postulated that the complex interactions between sympathoadrenal system and insulin may play a role in the development of insulin resistance. In Caucasian, some evidence had demonstrated that increase blood insulin level, urinary norepinephrine (noradrenaline) and reduced urinary epinephrine (adrenaline) excretion are associated with obesity. A study done in Hong Kong Chinese patients with various components of metabolic syndrome to evaluate the relationship between plasma insulin, obesity and urinary catecholamine excretion. Results showed that patients with more components of metabolic syndrome were more obese, hyperglycemic, dyslipidemic, albuminuric ,higher blood pressure, plasma insulin, insulin resistance and 24-hour urinary norepinephrine excretion but lower urinary epinephrine output (all P<0.005). It was concluded that obesity, hyperinsulinemia, insulin resistance, elevated norepinephrine and reduced epinephrine excretion were closely associated with metabolic syndrome[9]. A cross-sectional study investigated the hypothesis that dietary intake and obesity stimulate the activity of sympathetic nervous system. Sympathetic activity was evaluated by measurement of 24 hours urinary norepinephrine excretion. Result showed increased body mass index (BMI) and total caloric intake were independently associated with increased 24-hour urinary norepinephrine excretion.(P=0.0001 and P=0.0055, respectively) Mean urinary norepinephrine excretion was higher in cases with hyperinsulinemic. These results are consistent with the hypothesis that insulin mediates sympathetic stimulation in response to dietary intake and increases sympathetic nervous system activity in the obese[10]. Catecholamines can also affect to stimulate lipolysis of triglyceride stores in adipose tissue. Specialists were interested in the possibility that sympathoadrenal system involved in lipid abnormalities associated with obesity. A study to evaluate the relationship of sympathoadrenal activity to serum lipid and lipoprotein concentrations was done. 24-hour urinary catecholamine excretion and serum lipid and lipoprotein levels was examined and concluded that epinephrine plays an important role in regulating lipid and lipoprotein metabolism . In situation which decreased adrenal medullary activity may contribute to the dyslipidemia, such as increased triglycerides and decreased HDL commonly observed in obesity[11]. Data mentioned above have demonstrated close associations between catecholamine activity, obesity, hyperinsulinemia and insulin resistance. Catecholamines increase lipolytic activities ,visceral adipocytes have icreased lipolytic activities in response to catecholamines. Cortisol Outer cortex of adrenal glands secrete steroid hormones. Cortisol is the major glucocorticoid secreted by the adrenal cortex. Glucocorticoids are involved in multiple biological processes, affecting carbohydrate, protein, lipid and water metabolism. Cortisol secretion in under the control of ACTH , which in turn is regulated by the secretion of corticotrophin-releasing hormone . Secretion of ACTH and cortisol is pulsatile, manifests a diurnal circadian rhythm, and is under negative feed back control. ACTH concentration is highest in the early morning ( around 4 A.M.) and lowest in the late evening. The characteristic diurnal rhythm of plasma cortisol occurs in response to these ACTH changes. Stress in a
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 340variety of forms can override the diurnal rhythm as well as the negative feedback relationship of the system. Cortisol levels are responsive within minutes to a variety of physical stress ( trauma, surgery, exercise) and psychological stress ( anxiety, depression). Hypoglycemia is also potent to stimulate of ACTH and cortisol secretion. Cortisol counteracts the activations of insulin. The interferences by cortisol on insulin effects is well known. It is well-established systemic insulin resistance caused by excess cortisol, such as cases with Cushing’s syndrome. Cushing’s syndrome, the consequence of chronic exposure to excessive amounts of glucocorticoid hormone. Regardless of the etiology, hypercortisolism results in obesity ,carbohydrate intolerance, muscle wasting. Glucocorticoids regulate fatty acid mobilization by enhancing activation of cellular lipase by lipidmobilizing hormones, such as catecholamines. The actions of cortisol on adipose tissue vary in different parts of the body, peripheral adipose tissue mass decrease, whereas in the mesenteric bed, visceral fat may accumulate and produce the classic “ truncal” obesity. Excess fat to visceral depots in Cushing’s syndrome can be dramatically disappear after appropriate treatment. The classic triggers of stimulate cortisol secretion are stress and food intake, regulated by Hypothalamic-pituitary- adrenal axis. Cortisol secretion is regulated by an inhibitory feedback system by glucocorticoid receptors in central nervous system. Generally, secretion of steroid is active in the morning, occur in large peaks and decrease in the afternoon and night. In different tissue, cortisol is cleared from the circulation via glucocorticoid receptors. Visceral adipose tissue seems to have the highest density of glucocorticoid receptors. Cortisol seems to stimulate metabolic pathways via the glucocorticoid receptors that augment triglyceride accumulation in visceral adipocytes. In fact, visceral fat accumulation may be considered as an index of long term increased cortisol effect. A study had been performed in obese pre-menopausal women to assess the relation between cortisol secretion and body fat distribution. Result showed a positive significant relationship between 24 hour urinary cortisol output and the sagittal, abdominal diameter. (n =13; r=0.68; P<0.01 ). It was not change even when cortisol excretion was corrected for creatinine output. This study also suggested that their abnormal fat depot distribution may produce by elevated cortisol level due to increased activity of the hypothalamic-pituitary-adranal axis[12]. Insulin resistance is a well established effect of excessive steroid secretion. It influence hepatic glucose production, muscle glycogen synthase and steps of lipid mobilization from fatty tissue which is followed by elevated circulating free fatty acid. Free fatty acid amplify effects on liver and muscle to produce insulin resistance. Moreover, the permissive effect of glucocorticoids to facilitate catecholamine induced lipolysis is well-known. Five adrenoceptor subtypes are involved in the adrenergic regulation of white and brown fat cell function. Functional beta 3-receptors coexist with beta 1 and beta 2 receptors in a number of fat cells.The beta 3-adrenergic receptor is known to be expressed by glucocorticoids and has a marked lipolytic effect . This receptor has a particularly high density in visceral fat adipocytes and mediate lipolysis by activation of the sympathoadrenal system, considered be responsible for the high lipolytic activity of this adipose tissue. A cross sectional study done in young Chinese type 2 diabetic patients, age < 40 year-old were recruited from the Prince of Wales Hospital, Hong Kong. Results reviewed that compared to control group, patients with type 2 diabetes with higher cortisol level, more obesity, hyperglycemic, higher blood pressure and insulin resistance index , worse lipid profile ( all P<0.001), on the other hand, they presented with lower growth hormone
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 341level ( P< 0.05). In patients with diabetes, 51% of the variance in waist circumference can be explained by increased blood cortisol, insulin and reduced secretion of growth hormone levels. It was proposed that close associations between hypercortisolemia , central obesity, insulin resistance, hyperinsulinemia and reduce plasma growth hormone level[13]. Such endocrine patterns are similar to subjects with Cushing’s syndrome and growth hormone deficiency due to hypopituitarism. Both of these conditions are characterized by massive visceral fat accumulation . Growth Hormone Growth hormone is the pituitary factor responsible for stimulation of body growth in humans. Growth hormone stimulates the production of an intermediate insulin-like growth factor-1 ( IGF-1) that actually stimulate growth. Although growth hormone may exert some direct effects on growth, most of its growth-promoting actions are mediated by the peptide, insulin-like growth factor I ( IGF - I ). The insulin-like growth factor I is synthesized in the liver and other tissue. It is age –dependent, with low levels in early childhood, a peak during adolescence, and a decline after the age of 50 years. Growth hormone (GH)is another hormone of major interest in the discussion of pathogenesis in insulin resistance. Growth hormone opposing the action of insulin. The GH-IGF axis influence metabolism and energy homeostasis. Adipose tissue expressed the growth hormone receptors and is one of the major targets of growth hormone. Growth hormone increases free fatty acid release from adipocytes. Age related decline in growth hormone and IGF-I is associated with increased deposition of visceral fat. Growth hormone deficient adults present with increase visceral fat and decrease insulin sensitivity, display many features of metabolic syndrome. Short term replacement therapy in growth hormone deficient adults results in improved exercise tolerance, decreased body fat and increased lean body mass. The long term consequences of growth hormone deficiency and replacement therapy are still being explored. Growth hormone is one of the counter-regulatory hormones that help restore a low blood glucose to normal. Hypoglycemia is a potent growth hormone stimulus, and an acute rise in blood glucose inhibits growth hormone release .Growth hormone may have a direct effect as an insulin antagonist that inhabits glucose uptake by tissue. Patients with growth hormone deficiency are prone to insulin-induce hypoglycemia; patient with growth hormone excess develop insulin resistance. On the other hand, growth hormone is a trophic factor for insulin release, facilitating its release in response to various secretagogues, and growth hormone deficiency individuals have impaired insulin release to glucose challenge. As study discussed above, young Chinese type 2 diabetic patients with lower growth hormone level (P <0.05).Further studies are required to investigate the relative pathology of age decline of growth hormone and insulin sensitivity. Testosterone Aging is accompanied by changes in sex steroid, growth hormone.Although total body weight remains relatively constant, alterations in body composition had already happened, such as loss of lean body mass and muscle mass, increase body visceral fat and decrease insulin sensitivity. A cohort study was done to assess the relationship between menopause on body composition, fat
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 342distribution and fasting insulin levels. Follow-up for 6 years of 35 sedentary healthy premenopausal women age range 44-48 year old. Results reported that women who experienced spontaneously menopause with greater increases in fat mass , fasting insulin level, and waist-to-hip ratios, lost more fat-free mass ( All P < or = 0.01). Concluded that menopause is associated with an accelerated loss of fat-free mass, and increased central adiposity and fasting insulin levels[14]. Testosterone is an important hormone in the pathogenesis of insulin resistance. It diminishes fat accumulation by powerful mechanisms. Decreasing androgen levels in men and increasing androgenicity in women may contribute to the development of visceral obesity and insulin resistance. Evidence shown that testosterone regulates glycogen synthesis and the insulin effects on glycogen synthase. When testosterone is low, insulin effects on the stimulation of glycogen synthesis will be insufficiency, resulting in insulin resistance. Muscular insulin resistance following low testosterone in men is also associated with enlargement of visceral fat depots. Testosterone, growth hormone and cortisol have opposite effects on lipid storage, especially in visceral fat because of high hormonal receptor density. Testosterone can affect lipid metabolism mediated by androgen receptor, there is higher density in visceral than other adipose tissue. Testosterone exerts powerful stimulation at different levels of the lipolytic pathway in adipose tissue in men. Testosterone can stimulate the lipolytic pathway in adipose tissue and inhibit lipid accumulating pathways. Growth hormone exerts synergistic effects with testosterone in these actions. These lipid storage effects are opposite to cortisol , and when testosterone and growth hormone secretions become too low, such as age-related decline, effects of cortisol will become dominate. So that the visceral accumulation of depot fat is occurring by an imbalance between these various hormone. Give testosterone in men with abdominal obesity and low testosterone level, short term effect showed insulin resistance improves markedly, and insulin sensitivity approaches normal values. Moreover, visceral fat mass is remarkable diminished, as well as improve blood pressure and lipid profile. Long duration follow up is needed to explored further therapeutic outcome. Men with low testosterone is followed by muscular insulin resistance, induced by a lack of permissive effects of insulin stimulation of glycogen synthase. Age-related declines in testosterone, growth hormone, insulin-like growth factor-1 (IGF-I ) are associated with deposition of visceral fat. Men with low testosterone predict visceral obesity. A cross-sectional cohort study was done in Hong Kong to examine the association of testosterone, insulin –like growth factor-I ( IGF-I ) with metabolic syndrome in apparently healthy middle aged Chinese men with family history of type 2 diabetes. Men with family history of type 2 diabetes had higher frequency of metabolic syndrome than those without family history of diabetes. ( P = 0.004).Men with the lowest total testosterone tertiles and insulin-like growth factor-1 (IGF-I) tertiles had the highest frequency of metabolic syndrome[15]. On the other hand, hyperandrogenicity in women with increased risk in development of Type 2 diabetes. Obesity and central obesity in women are associated with, created by hyperandrogenicity. Excess androgens of endogenous or exogenous origin in women is followed by muscular insulin resistance, localized to glycogen synthase system. Increased androgenicity in women has been found to be associated with the development of type 2 diabetes. In addition, obesity and central obesity are associated with greater androgenicity in women. Well known example as women with polycystic ovary syndrome ( PCOS ) have hyperandrogenicity status are
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 343associated with obesity, insulin resistance and type 2 diabetes. There is hypothesis that androgenicity is a predictor of insulin sensitivity independent of measures of obesity in women. Study in non-diabetic post-menopausal women and concluded that there was a significant association between insulin sensitivity and androgenicity in postmenopausal women , it is independent of obesity[16]. An increase in androgenicity may contribute to the development of insulin resistance in these women. Another study was carried on to evaluate the relationship between androgen level and insulin resistance in people with and without type 2 diabetes. They measured testosterone level in men and women with type 2 diabetes and non-diabetic control subjects. The result indicated the potential importance of the regulation of insulin sensitivity by androgens in both women and men. Women with type 2 diabetes had high level of free testosterone. Insulin resistance is closely correlated signs of hyperandrogenicity in women as well as with obesity. In contrast to women, men with type 2 diabetes had low testosterone level. It was suggested that these androgen abnormalities might be causally related to insulin resistance in type 2 diabetes [17]. Discussion Insulin resistance and type 2 diabetes are multifactorial diseases. They are heterogeneous and complex conditions due to interplay between environmental and genetic factors, cultural factors, hormonal influence. Apart from genetic difference, age- and stress- related neurohormonal dysregulation may also contribute to the increasing prevalence of obesity, type 2 diabetes and metabolic syndrome . Evidence suggested possible links between neurohormonal dysregulation and insulin resistance. Age-associated with decrease in growth hormone and sex hormone, stress-related with increase catecholamines and cortisol , may contribute to the development of central obesity and visceral fat accumulation, and develop insulin resistance through increased adipocytokines and free fatty acid production. High free fatty acid in circulation is an important mediator of insulin resistance through fuel competition with glucose as energy substrate . As briefly discussed the data that might at a glance about the effects of abnormalities in the secretion of several important hormones and the possibility pathology producing insulin resistance. The consequence of the endocrine perturbations in insulin resistance and type 2 diabetes have been examined with sufficient seriousness. Abdominal obesity is the most prevalent condition of insulin resistance and it seems likely that the endocrine abnormalities, such as hypercortisolemia, low sex-specific steroid hormones in men and hyperandrogenicity in women, are responsible for neuroendocrine dysregulation, these neurohormonal changes mentioned above are followed by accumulation of visceral accumulation of body fat and insulin resistance. According to discussed data, it had been hypothesized that neurohormonal dysregulation of several main hormones are associated with central obesity, visceral fat accumulation. In addition to increased activity from the central sympathetic nervous system, it also seems to increased activity of the adrenocorticosteroid axis. The endocrine aberrations may provide a cause for visceral fat accumulation, probably due to regional differences in hormone-receptor density. Such as visceral adipose tissue seems to have the highest density of glucocorticoid receptors, cortisol seems to stimulate metabolic pathways via the glucocorticoid receptors that augment triglyceride accumulation in visceral adipocytes.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 344The beta 3-adrenergic receptor is known to be expressed by glucocorticoids and has a marked lipolytic effect . This receptor has a particularly high density in visceral fat adipocytes and mediate lipolysis by activation of the sympathoadrenal system, considered be responsible for the high lipolytic activity of this adipose tissue. Adipose tissue expressed the growth hormone receptors and is one of the major targets of growth hormone. Testosterone can affect lipid metabolism mediated by androgen receptor, there is higher density in visceral than other adipose tissue. There also seem to be signs of increased activity from the central sympathetic nervous system. Therefore, it is hypothesized that such factors might provide a background contributes to an endocrine aberration leading to metabolic aberrations and visceral fat accumulation . It is proposed that the complex interactions between insulin, Hypothalamic- pituitary- adrenal (HPA) axis, and sympathoadranal systems may lead to the development of obesity ,metabolic syndrome, insulin resistance and type 2 diabetes. In fact , abdominal obesity is the most prevalent condition of insulin resistance and it seems likely that the endocrine abnormalities with hypercortisolemia, low sex-specific steroid hormones in men and hyperandrogenicity in women, are responsible for both cardinal signs of this condition: visceral accumulation of body fat and insulin resistance. Evidence discussed above may support the hypothesize that disturbances in neuroendocrine contribute to development of insulin resistance. Stress related increase catecholamines and cortisol , age related declining testosterone in aging men, hyperandrogenicity in women, together with age related decrease growth hormone, may contribute to the dvelopment of visceral obesity and insulin resistance(Fig 2).Visceral adipocytes are metabolically more active than subcutaneous adipocytes since they are more sensitive to lipolytic effects of stress hormones, including cortisol, growth hormone and catecholamines. They are sites for energy mobilization during stress and prolonged fasting . Stress↑ Age-related Growth Hormone ↓ Catecholamines↑ Age-related testosterone in men ↓Cortisol ↑ Hyperandrogenicity in women Central Obesity Visceral fat accumulation Insulin resistance Fig 2 The hypotheses role of neurohormonal dysregulation in pathogenesis of insulin resistance Patients with central obesity have accelerated rates of lipolysis in their visceral adipose tissue. As a result, increase in free fatty acids impaired muscle uptake of glucose by competitive inhibition, a mass increase of free fatty acid mobilization to the portal vein, which connects visceral fat to the liver. High free fatty acids concentration in portal vein has undesirable effects on the liver, causes hepatic fat infiltration and insulin resistance. Increased availability of free fatty acids is of particular importance for the liver and skeletal muscle. The role of free fatty acids in type 2 diabetes is most evident in obese patients who have several abnormalities in free fatty acids metabolism. Increase free fatty acid mobilization resulting in dyslipidaemia, hyperinsulinaemia, hyperglycaemia and hepatic insulin resistance. Adipocytes can store excessive calories, it is also functioning as an endocrine member, active participate with body energy metabolism. Visceral adipocytes are characterized by enlarge fat cells which presented with increase lipolytic response to counter-regulatory hormones. On the other hand, they have a low responsiveness, resistant to the antilipolytic effect of insulin and can secrete many adipocytokines to increase cardiovascular risk . Since mesenteric and omentum fat have been shown to have high activities of both lipogenesis and lipolysis, its accumulation induces high
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 345contents of free fatty acids, a product of lipolysis, in portal circulation which goes into the liver directly. Excess free fatty acid may cause the enhancement of lipid synthesis and gluconeogenesis as well as insulin resistance, resulting in hyperlipidemia, glucose intolerance. These hormonal changes exert profound effects on adipose tissue metabolism and distribution. The consequences will most likely be more expressed in visceral than subcutaneous adipose tissues because of a higher hormone receptor density, higher cellularity, innervation and blood flow. Conclusion The alarming prevalence of type 2 diabetes and metabolic syndrome is a public and economic threat. The prevalence of obesity, metabolic syndrome and type 2 diabetes are increasing, especially in Asia. The underlying mechanisms involved in the development of insulin resistance are multifactorial and are only partly understood. Findings discussed above demonstrated the possibility cause and potential power of neurohormonal dysregulations in insulin resistance and type 2 diabetes and in health of human being. While more mechanistic studies are required to clarify the pathophysiology of this complex syndrome. More evidence are required to evaluate the nature of their relationship. Current knowledge of endocrine factors that concerning glucose homeostasis and neuroendocrine disturbance in diabetes. There are growing more and more evidence lending support to the hypothesis about neurohormonal dysregulation in insulin resistance, partially medicated through visceral fat accumulation. Confirmation of this hypothesis may have implication for diagnosis and improve treatment in patients with insulin resistance and type 2 diabetes. Recommendation According to the discussed evidence, it is reasonable to have hypothesis that with appropriate interventions against hyperadrencitity in women and hypercortisolemia; appropriate substitution of deficient sex steroids in men and growth hormone, hopefully visceral fat mass can be decreased. However, the effects of hormonal treatment on body fat composition and insulin sensitivity remain controversial. There were limited data that provided the long term effect. No confirmation was available to clarify beneficial, risk and harm. We don’t know the treatment benefit worth the potential harm and cost or not . Reasonable large enough sample size and high quality, good designed randomized control trials ( RCT) are needed to confirm the safety and efficacy of various long term hormonal replacement therapies and the intervention to against hyperadrencitity in women and hypercortisolemia. Follow up sufficiently complete is important before we make a clinical decision and change our clinical practice. Evidence are required to confirm whether improvement of body composition and insulin sensitivity by hormone replacement therapy can be translated to long term clinical benefits such as reduced mortality and morbidity, improve prognosis and quality of life. Reference 1 P Bjorntorp. Neuroendocrine perturbations as a cause of insulin resistance. Diabetes Metabolism Research and Reviews, 1999, 15:427-441. 2 WY So, MCY Ng, SC Lee, et al. Genetics of type 2 diabetes mellitus. Hong Kong Medical Journal, 2000, 6:69-76. 3 Smith U, Lager I. Insulin-antagonistic effects of counterregulatory hormones: clinical and mechanistic aspects. Diabetes Metab Rev, 1989, 5(6):511-525. 4 Norma N Chan, Alice PS Kong, Juliana CN Chan. Metabolic Syndrome and Type 2 Diabetes : The Hong Kong Perspective. Clin Biochem Rev, 2005, 26(3):51-57. 5 Daniel WF. Diabetes Mellitus. In :Kurt JI, Eugene B, Jean DW, et al , eds. Harrison’s Principles of Internal Medicine. 13th ed. New York : McGRAW-HILL Co, 1994.1979-2000
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 3466 Brunner EJ, Hemingway H, Walker BR, et al. Adrenocortical, autonomic, and inflammatory causes of the metabolic syndrome: nested case-control study. Circulation, 2002, 106(21):2659-2665. 7 Lewis L, James BY. Physiology and Pharmacology of the Autonomic Nervous System. In :Kurt JI, Eugene B, Jean DW, et al , eds. Harrison’s Principles of Internal Medicine. 13th ed. New York : McGRAW-HILL Co, 1994.412-425. 8 Kissebah AH, Krakower GR, Sonnenberg G, et al.Clinical manifestations of the Metabolic Syndrome. Handbook of obesity, Bray GA, Bouchard C, James CPT (eds). NY: Marcel Dekker, New York, 1998, 601- 636. 9 Lee ZSK, Critchley JAJH, Tomlinson B, et al. Urinary epinephrine and norepinephrine with obesity, insulin and the Metabolic Syndrome in Hong Kong Chinese. Metabolism, 2001, 50:135-143. 10 Troisi RJ, Weiss ST, Parker DR, et al. Relation of obesity and diet to sympathetic nervous system activity. Hypertension, 1991, 17(5):669-677. 11 Ward KD, Sparrow D, Landsberg L, et al. The relationship of epinephrine excretion to serum lipid levels: the Normative Aging Study. Metabolism, 1994, 43(4):509-513. 12 Marin P, Darin N, Amemiya T, et al. Cortisol secretion in relation to body fat distribution in obese premenopausal women. Metabolism, 1992, 41: 882-886. 13 Lee ZSK, Chan JCN, Yeung VTF, et al. Plasma insulin, growth hormone, cortisol and central obesity among young Chinese Type 2 diabetes patients. Diabetes Care, 1999, 22:1450-1457. 14 Poehlman ET, Toth MJ, Gardner AW. Changes in energy balance and body composition at menopause: a controlled longitudinal study. Ann Intern Med, 1995, 123(9):673-675. 15 Tong PC, Ho CS, Yeung VT, et al. Association of testosterone, insulin-like growth factor-I, and C-reactive protein with metabolic syndrome in Chinese middle-aged men with a family history of type 2 diabetes. J Clin Endocrinol Metab, 2005, 90(12):6418-6423. 16 Lee CC, Kasa-Vubu JZ, Supiano MA. Androgenicity and obesity are independently associated with insulin sensitivity in postmenopausal women. Metabolism, 2004, 53(4):507-512. 17 Andersson B, Marin P, Lissner L, Vermeulen A, et al. Testosterone concentrations in women and men with NIDDM. Diabetes Care, 1994, 17(5):405-411
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 347‧綜述‧ 慢性糜爛性胃炎臨床研究之近況 黃健華 王立恒* 閻寶珠 黃健儀 【摘要】 慢性糜爛性胃炎是臨床消化系統疾病的常見病之一，隨著醫學研究發展，中醫對慢性糜爛性胃炎的認識不斷加深，中醫藥在治療慢性糜爛性胃炎的臨床實踐中有獨等的特色優勢以及取得較滿意的效果。本文綜述近年來中西醫治療慢性糜爛性胃炎的臨床研究文獻，籍此瞭解治療中的應用情況，為慢性糜爛性胃炎提供理論依據、療效評價及循證醫學證據，尋找一個更為簡便的治療方法。取得前期一定療效，為專科專病專藥提供理論依據，為研製中藥新藥奠定基礎。 【關鍵詞】 HP; 糜爛性胃炎; 臨床研究 Chronic Erosive Gastritis’s Situation Clinical Research WONG Kin Wa, WANG Liheng*, YAN Baozhu, WONG Kin I. Faculty of Chinese Medicine, Macau University of Science and Technology, Macau, China*; Guangdong Province Hospital of Traditional Chinese Medicine, Zhuhai, China; Tel:(+853)- 6666 6017; E-mail:vansyes719@hotmail.com 【Abstract】 Chronic Erosive Gastritis (CEG) is one of common disease in digestive diseases, Chinese medicine deepens unceasingly to the C.E.G's understanding and have a satisfactory progress in the treatment C.E.G's clinical practice, it all depend on the medical research development. Now, have more research to provide the C.EG’s theory, curative effect appraisal and the medicine evidence, which can help them to discover the best method of treatment in the Chinese medicine. 【Key words】 HP; Gastritis; Clinical research 慢性糜爛性胃炎是臨床消化內科的常見病、多發病，在慢性胃炎悉尼會議（1990 年第九屆世界胃腸大會）分類中它屬於特殊性胃炎，內鏡分型為隆起糜爛性胃炎和扁平糜爛性胃炎。據統計慢性糜爛性胃炎 多發於50～60 及20～30 歲年齡組，男女發病之比為6:1～3:1。臨床主要表現多以慢性上腹部不適、疼痛、噯氣反酸為主要症狀，但也可無任何臨床症狀[1]。慢性糜爛性胃炎的病因和發病機制尚未完全闡明，一般認為可能由於各種外源性或內源性致病因素引起胃粘膜血流減少或正常粘膜防禦機制的破壞加上胃酸和胃蛋白酶對胃粘膜的損傷作用而發病[2]，引起慢性糜爛性胃炎的病因很多，具體發病原因尚不十分清楚，可能與幽門螺桿菌感染、藥物、食物的不良刺激、膽汁返流，精神壓力等有關[3]，導致胃粘液屏障和粘膜屏障受到損害，表現為粘膜糜爛和/或出血，重症患者往往會出現慢性上消化道出血症狀：黑便、貧血等。糜 作者單位: 中國, 澳門特別行政區, 澳門科技大學中醫藥學院; Tel: (+853 )6666 6017; E-mail:vansyes719@hotmail.com; *廣東省中醫院珠海醫院, 中國, 珠海. 爛性胃炎常由慢性淺表性胃炎發展而來，治療不當易發生十二指腸潰瘍[4]。 現代研究認為糜爛性胃炎內鏡特點是糜爛灶散在分佈於胃竇粘膜，或在胃體和胃底粘膜皺襞脊上呈串珠狀排列，半球樣突出於胃粘膜表面，頂部糜爛，一般＜1.5cm，國外報導隆起糜爛是淋巴細胞性胃炎的內鏡表現，病理特點是胃上皮細胞與基底間有大量淋巴細胞浸潤，可能與Hp 感染和過敏引起免疫變態反應有關[5]。以上皮細胞與基底膜間淋巴細胞浸潤＞25個/100個上皮細胞為淋巴細胞性胃炎的標準[6]，研究資料表明，幽門螺桿菌是慢性活動性胃炎的病原菌[7]。Hp感染與胃炎的活動性和嚴重程度有關。感染程度愈重，炎症改變愈明顯，炎症愈明顯，Hp 檢出率愈高。Hp 位於胃黏膜上皮細胞表面，能在黏液中快速遊動，對黏膜上皮產生機械刺激作用，使黏膜屏障作用減弱。Hp 有較強的尿素酶、過氧化氫酶及超氧化物歧化酶、蛋白水解酶。尿素酶可使胃黏膜上皮細胞產生跨膜氨遞度，破壞胃黏膜的屏障作用。Hp 還影響胃黏膜的疏水性,降低其抗酸作用。還有細胞毒性 因數如血凝素、空泡形成因數、脂質 A 等，可以導
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 348致胃黏膜上皮細胞的損害[8]。Hp 還能促胃酸分泌增加，加重胃黏膜的損傷。 近年來，隨著各種現代診療技術為中醫辨證分型所參考，臨床辨證分型提倡中醫辨證為主，同時結合現代理化檢查，巨集觀辨證與微觀辨證相結合的辨證原則，但離不開以五臟為中心進行整體辨證的範疇，在微觀辨證方面較集中體現在參考幽門螺桿菌和胃鏡象予以辨證。陸天翼[9]、陳錦鋒等[10]均報導脾胃濕熱型以糜爛性胃炎為主，胃鏡檢查鬱熱型均見糜爛。王立等 [11]觀察不同證型的慢性胃炎與幽門螺桿菌的關係，結果表明：幽門螺桿菌陽性者以實證為多見，幽門螺桿菌陽性率在不同證型中依次為脾胃濕熱＞胃絡瘀血＞肝胃不和＞脾胃虛弱。徐建國等[12]觀察到各證型中氣滯兼鬱熱型幽門螺桿菌陽性率最高，其次為氣滯血瘀和中虛氣滯型，單純虛寒型陽性率最低。危北海[13]研究發現幽門螺桿菌感染陽性率與程度的高低和證型有明顯的相關性，邪盛者幽門螺桿菌陽性率增高；正虛者偏低。其排列順序為脾胃濕熱＞肝胃不和＞脾胃虛寒＞脾胃陰虛。綜合近年來的報導慢性胃炎伴糜爛辨證分型大多為脾胃濕熱型，鬱熱型等實證；慢性胃炎肝胃不和、脾胃濕熱和胃絡血瘀等非脾胃虛弱型幽門螺桿菌感染率較高，而脾胃虛弱型幽門螺桿菌感染率較低。 張氏[14]等將124 例糜爛性胃炎分為脾胃濕熱型(76 例)、肝胃不和型(26 例)、脾胃氣虛型(22例)，並研究了與幽門螺旋桿菌的關係，發現幽門螺旋桿菌檢出率以脾胃濕熱型最高，且與其他兩型比較差異有顯著性，並認為幽門螺旋桿菌活動期的黏膜病理表現與濕熱的致病原因相似，二者在病因學上是等同的，屬於同一病源，只是名稱不同而已。在治則上則提出從清利濕熱以消除幽門螺旋桿菌的方法。王氏[15]研究了146 例病人的舌苔在治療前後的變化，發現治療前有120例黃苔，26 例 白苔；治療後，在治癒的 ll8 例中只有 33 例黃苔，而白苔為 85例。王氏認為本病有紅、腫、熱、痛的表現，符合中醫熱症的辨證特點；而黃苔的出現，也證實了這種觀點。王氏還觀察了舌苔與胃黏膜糜爛程度、幽門螺旋桿菌感染率的關係，認為三者有密切正相關性：糜爛重、感染率高則黃苔重，否則黃苔輕或是白苔。王氏據此認為黃苔是胃熱證的最可靠指標之一，應該是胃熱辨證的主證之一，並且可以把黃苔的變化看作是治療的評價標準。莊氏[16]認為本病主在熱、瘀二字，以清熱化瘀為法，自製清熱化瘀基本方(黃連、生地黃、牡丹皮、當歸、蒲黃、五靈脂、炙甘草)， 隨證加減治療46例，顯效22 例、好轉l8例、無效6例，總有效率86.96％。肖氏[17]認為本病主因是過食辛熱或飲食滯留，阻滯氣機，化熱傷陰灼胃，因此以補氣生津、消脹和胃為法，建立香砂益胃湯(木香、砂仁、麥門冬、沙參、玉竹、生地黃、白芍、山藥、冰糖)，隨證加減治療本病82例，經治療45～60天，治癒69例，好轉9例，無效4例，總有效率91.1％。王氏[18]認為糜爛性胃炎病機是氣機鬱滯、肝鬱化火，治則為清胃涼血，選用清 胃散加味(當歸、生地黃、黃連、升麻、牡丹皮、烏賊骨、雞內金、白及)治療 87例，總有效率為 97.5％。 胡氏認為大量酗酒、吸煙以及胃酸分泌過多等是本病的病因，但幽門螺桿菌感染也是本病的重要病因之一。中醫認為，本病的發生多因脾胃虛弱，情志失和，寒溫失調，飲食不節等因素而致。臨床上以胃脘脹悶疼痛，噯氣泛酸為本病的特點，脾胃虛弱，濕邪蘊脾是本病的病機。採用清胃護膜湯針對本病病機而設，方中黃芪、黨參補脾胃，益中氣；病久入絡而見氣滯血瘀，故用延胡索、木香行氣，解痙緩痛；三七粉活血化瘀生新；川貝母制酸和中；白芨護膜生肌；病程日久，脾運失司，蘊久生熱，脾胃有濕熱蘊結，故用黃芩、黃連、蒲公英，清熱解毒、燥濕、瀉火；陳皮健脾理氣燥濕；半夏和胃降逆止嘔；神曲消食導滯；敗醬草治胃黏膜糜爛甚效[19]。何氏[20]認為該病由於患者素體熱盛或嗜肥甘厚味，煙酒、酸辣等助濕化熱 之品，久而釀生濕熱，蘊於胃腑，熱蒸肉腐而成疾 ，故胃鏡下可見病變部位有糜爛灶，此證在鏡下病灶呈充血、水腫、糜爛並存；可與脾胃虛寒胃脘痛者鏡下見黏膜萎縮、蒼白有明 顯區別，故參考中醫外科治療癰瘡癤腫之代表方五味消毒飲化裁治療，收到較好療效。 慢性糜爛性胃炎是臨床常見的消化系統疾病之一，日益受到大家的重視。隨著現代醫學的研究發展，中醫對 慢性糜爛性胃炎的認識也在不斷加深，並且不斷體現出中醫藥在這方面的優勢，中醫藥在治療
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 350‧綜述‧ 糖尿病心血管自主神經病變 林國垣 方冬虹* 【摘要】 糖尿病心血管自主神經病變（Cardiovascular autonomic neuropathy ,CAN）是糖尿病常見幷發症之一。CAN 起病隱匿，臨床表現無特異性，最嚴重表現是無痛性心肌缺血或心肌梗死。心血管自主神經功能試驗有助于該病的早期診斷。由於 CAN 患者心腦血管疾病發病率及死亡率高，早期發現、早期診斷、早期治療至關重要。 【關鍵詞】 糖尿病; 心血管自主神經病變 Diabetic Cardiovascular Autonomic Neuropathy Lam Kuok Wun, Fang Dong Hong. *Segunda linica da Associacao de Beneficencia Tung Sin Tong,Macau SAR,China; Tel(+853)- 2893 8963; E-mail: Dr.lamvin@gmail.com. *Department of endocrinology,The first Affiliated Hospital of Sun Yat-Sen University,Guangzhou,510080,China; E-mail:mnifdh@163.com. 【Abstract】 Diabetes cardiovascular autonomic neuropathy（CAN）is one of the most common omplications of diabetes. CAN usually has atypical symptoms and is easily to be overlooked. The most severe symptom of CAN is silent myocardial ischemia/silent myocardial infarct. It is possible to objectively identify early stages of CAN with the use of Ewing tests. Because CAN is associated with worsening prognosis and patient’s poorer life quality, it is important to detect, diagnose and treat CAN early. 【Keywords】 Diabetes; Cardiovascular autonomic neuropathy 糖 尿 病 心 血 管 自 主 神 經 病 變 （ Cardiovascular autonomic neuropathy ,CAN）是糖尿病最嚴重的慢性幷發症之一，可能也是糖尿病最容易受忽略的幷發症。目前對 CAN 的機制仍未完全清楚，可能和支配心血管的神經纖維受損導致心率和血流動力學的改變有關。CAN 是糖尿病早期幷發症，在初診斷的 1 型和 2型糖尿病患者均發現有 CAN 患者的存在，此外，CAN 患者的猝死、致命性心肌梗死、糖尿病心臟病變和腦血管病變的發病率高。由於 CAN 的預後差，對於 CAN 的早期診斷及治療越來越受重視。 作者單位: 中國, 澳門特別行政區, 同善堂第二診所; Tel:(+853)-28938963; E-mail:Dr.lamvin@gmail.com. *510080,中國,廣東,廣州市中山二路 58 號,中山大學附屬第一醫院,內分泌科; E-mail:mnifdh@163.com 一、流行病學 糖尿病患者心血管自主神經病變的患病率高，在1型和2型糖尿病均是如此[1, 2] 。年齡大、病程長和血糖控制差的患者的患病率更高。但是，由於研究人群和診斷標準等的不同，不同文獻報導CAN的發病率幷非完全一致，國外報導在1％～90％之間[3]。目前國內缺乏大型流行病學調查，文獻報導，64.0％的2型糖尿病患者有心血管自主神經功能異常，30.2％的患者確診為CAN，9.2％為嚴重CAN[4]。在糖耐量減低(IGT)患者也存在亞臨床自主神經功能受損[5]。 二、危險因素 由於病因的不同，1型糖尿病和2型糖尿病患者併發心血管自主神經病變有著不同的危險因素，但是，病程長和長期血糖控制不佳是兩者共同的危險因素。1型糖尿病患者心血管自主神經病變的發生率與病程和糖化血紅蛋白水準有關。CAN在1型糖尿病患者很常見，在伴
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 351有周圍神經病變的患者，其發病率顯著升高[6]。表1總結了兩者的多種危險因素[7]。 表 1 1 型糖尿病和 2 型糖尿病患者幷發心血管自主神經病變的危險因素 危險因素 1 型糖尿病 2 型糖尿病 年齡 ＋ ＋ 性別（女性） ＋ － 肥胖 － ＋ 高胰島素血症 NA ＋ 糖尿病病程 ＋＋ ＋＋ 吸煙 ＋ ＋ 糖化血紅蛋白 ＋＋ ＋＋ 高血壓 ＋＋ ＋ 糖尿病視網膜病變 ＋＋ ＋ 高甘油三酯血症 ＋ ＋ 典型糖尿病多發性神經病變 ＋＋ ＋＋ 微量白蛋白尿 ＋＋ ＋＋ 血脂異常（高低密度脂蛋白或低高密度脂蛋白） ＋ （＋） ++：強烈關聯；+適度關聯；-：無關聯；NA：不適用；（+）：目前仍有爭議 三、臨床表現 (一) 心率異常： 靜息性心動過速通常是CAN最早期的表現之一。當僅有迷走神經受損時，靜息心率波動於90～100次/分，偶爾高達130次/分。當交感神經和迷走神經同時受損時，心率會下降，但仍高於正常。CAN患者的心率異常還表現爲心率的晝夜差異减小，這主要是由于夜間心率加快造成的，可能與夜間迷走神經的優勢支配受損有關[8]。 (二) 直立性低血壓： 直立性低血壓的定義是從仰臥位改變為直立位時，收縮壓下降>30mmHg，舒張壓下降>10mmHg。有研究指出，直立性低血壓表現的CAN患者站立後右大腦中動脉舒張期和平均的血流速度明顯降低，表明在這部分患者大腦的反應性和自身調節能力是受損的[9]。患者改變體位時可以表現爲頭暈、乏力、眩暈和視物模糊，甚至是暈厥，但也有一部分患者無任何症狀[1]。需要注意的是，這些患者出現症狀的時候經常會誤診爲低血糖，導致治療措施錯誤。 (三) 運動耐量減低： 由于支配心臟輸出和促使外周血流向骨胳肌的交感神經和副交感神經受損，CAN 患者的運動耐量是減低的。這和心臟射血分數降低，心臟收縮功能障礙和舒張期充盈減少也有關[10]。CAN 患者心臟處於去神經支配狀態，其心率在運動時往往變化不大，血壓也是如此[3]。因此，CAN 患者的運動強度取決於其自身的感覺而不是心率。 (四) 手術及圍手術期心血管系統不穩定： 糖尿病患者手術期間心血管事件的發生率和死亡率增加 2 至 3 倍[3]。和不伴有 CAN 的糖尿病患者相比，CAN 患者在手術期間常常需要使用升壓藥以維持血壓[11]，正常人可以通過血管收縮和心跳加快代償麻醉劑的血管舒張作用，但是，在 CAN 患者這種代償作用是不完全的。CAN 患者在手術中還伴有體溫過低，常常導致藥物代謝的减弱幷且不利于傷口愈合[3]。 (五) 無痛性心肌缺血或心肌梗死： 和不伴有 CAN 的糖尿病患者相比，CAN 患者無痛性心肌缺血的發生率是明顯升高的。有 Meta 分析指出，伴有和不伴有 CAN 的發生率分別為 28％和 10％ ， 相 對 危 險 度 是 1.96 （ 95% CI 1.53 ～ 2.51 ，P<0.001）[1]。關於無痛性心肌缺血的機制尚未完全明確，可能與 CAN 患者疼痛的閾值改變、低閾值的缺血無法引起疼痛和心臟自主神經傳入纖維的受損有關[3]。無痛性心肌梗死的最大危險在於患者無法意識到疼痛而無法得到及時的處理，而且糖尿病患者心肌梗死後的死亡率高於非糖尿病患者，因此，如何早期發現無痛性心肌梗死至關重要。糖尿病患者任何部位的胸痛都必須排除心肌梗死的可能，更重要的是，由於CAN 患者的心肌梗死以無痛性、咳嗽、噁心、嘔吐、呼吸困難、疲勞和心電圖異常爲臨床特點[3]，當患者出現上述表現或無法解釋的意識模糊、水腫、咯血、出汗、心律失常時都提示心肌梗死的可能[10]。此外，年齡超過 60 歲的 CAN 患者，尤其是伴有微量蛋白尿者，需要檢查是否存在無症狀性心肌缺血[12]。 (六) 死亡危險增加： 糖尿病患者伴有心血管自主神經病變的2年死亡率比不伴有的患者高5倍[7]。一項包含15個研究的Meta分
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 353劑有碘131-間碘苄胍（MIBG）和碳11對羥麻黃碱（HED）。CAN患者吸收MIBG的能力下降。此外，心血管反射試驗正常的糖尿病患者心肌吸收MIBG已經减少，說明放射性核素顯像的敏感性高于心血管放射試驗 [17]。CAN患者瀦留HED的能力下降，而且與CAN的嚴重程度相關。在評價幹預手段的療效方面，使用放射性核素顯像直接評價心臟的神經支配優于使用心血管放射試驗的間接性評價。 五、治療 (一) 控制血糖： 長期高血糖是影響糖尿病心血管神經病變發生和發展的重要因素，控制血糖于正常水準是治療糖尿病自主神經病變的最基礎也是最重要環節。具有里程碑意義的糖尿病控制和幷發症試驗（DCCT）指出，强化治療可以使糖尿病患者1型糖尿病自主神經病變的發生率降低53％。僅為期1年的強化治療可以逆轉異常的HRV[18]。 在 2 型糖尿病患者亦是如此，Steno-2 研究發現，包括血糖、血壓和血脂的多因素強化幹預，可以使 2型糖尿病患者糖尿病自主神經病變發生的相對危險下降 47％[19]。 (二) 規則的耐力訓練： 在疾病的早期階段，規則的耐力訓練可以改善心率變異性，但是，一旦糖尿病患者出現嚴重的 CAN，這種訓練就起不到效果[20]。 (三) 抗氧化劑： 糖尿病患者長期高血糖造成微血管內皮病變，導致神經缺血，缺氧，引起氧化應激增强、自由基生成增多，引起一系列氧化反應，導致神經損傷。α－硫辛酸在生物體內可轉化爲還原型二氫硫辛酸，二者都是强抗氧化劑。在疾病早期使用α硫辛酸可以逆轉CAN的進展。2型糖尿病患者每天口服α硫辛酸800mg，4個月後CAN症狀有所改善[21]。以Valsalva動作、深呼吸心率差和直立性低血壓試驗為指標，α硫辛酸可以有效治療1型糖尿病CAN患者[22]。 (四) 醛糖還原酶抑制劑（ARI）： 醛糖還原酶（AR）是葡萄糖的山梨醇代謝旁路的首要限速酶，其在高血糖作用下糖化而活力增高，從而導致神經組織糖醇代謝紊亂，引起神經病變。ARI治療的依據就是抑制 AR 以控制糖醇代謝。醛糖還原酶抑制劑也可以逆轉 CAN 的進展。和自身基綫水準及安慰劑組相比，托瑞司他可以改善有明確 CAN 患者的自主神經系統的功能[23]。 (五) β 受體阻滯劑： 雖然β受體阻滯劑可能掩蓋和延長降糖治療過程中的低血糖症狀，而且會增加胰島素抵抗，但是高選擇性或親脂性的β受體阻滯劑可以適當改善糖尿病患者自主神經功能。這可能與這類藥物相對性刺激交感神經，使交感神經和副交感神經間的平衡得到恢復有關[24]。此外，有病例報告指出，選擇性β1受體阻滯劑治療嚴重的直立性低血壓療效顯著[25]。 六、小結 初診斷的2型糖尿病患者和已診斷5年以上的1型糖尿病患者均需常規檢查是否存在CAN。由於CAN的預後不佳，而且在部分患者即使經過治療症狀仍改善不明顯，因此，如何預防、早期發現和早期治療CAN是內分泌和心血管專家需要解决的首要任務之一。 參 考 文 獻 1 Vinik AI, Maser RE, Mitchell BD, et al. Diabetic autonomic neuropathy. Diabetes Care, 2003, 26(5):1553-1579. 2 Lacigova S, Safranek P, Cechurova D, et al. Could we predict asymptomatic cardiovascular autonomic neuropathy in type 1 diabetic patients attending out-patients clinics? Wien Klin Wochenschr, 2007, 119(9-10):303-308. 3 Vinik AI, Ziegler D. Diabetic cardiovascular autonomic neuropathy. Circulation, 2007, 115(3):387-397. 4 淩丹芸, 湯正義, 張煒, 等. 導致 2 型糖尿病心血管自主神經病變的主要危險因素及其對病情評估的價值. 中華內科雜誌, 2006, 45(10):815-819. 5 Putz Z, Tabak AG, Toth N, et al. Noninvasive evaluation of neural impairment in subjects with impaired glucose tolerance. Diabetes Care, 2009, 32(1):181-183. 6 Lluch I, Hernandez A, Real JT, et al. Cardiovascular autonomic neuropathy in type 1 diabetic patients with and without peripheral neuropathy. Diabetes Res Clin Pract,
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 3541998, 42(1):35-40. 7 Rolim LC, de Sa JR, Chacra AR, et al. Diabetic cardiovascular autonomic neuropathy: risk factors, clinical impact and early diagnosis. Arq Bras Cardiol, 2008, 90(4):e24-31. 8 Kempler P, Jermendy G. Cardiovascular autonomic neuropathy in diabetes: clinical experiences in Hungary. Diabetol Hung, 2002, 10:37-43. 9 Mankovsky BN, Piolot R, Mankovsky OL, et al. Impairment of cerebral autoregulation in diabetic patients with cardiovascular autonomic neuropathy and orthostatic hypotension. Diabet Med, 2003, 20(2):119-126. 10 Vinik AI, Erbas T. Recognizing and treating diabetic autonomic neuropathy. Cleve Clin J Med, 2001, 68(11):928-930, 932, 934-944. 11 Burgos LG, Ebert TJ, Asiddao C, et al. Increased intraoperative cardiovascular morbidity in diabetics with autonomic neuropathy. Anesthesiology, 1989, 70(4):591-597. 12 Chico A, Tomas A, Novials A. Silent myocardial ischemia is associated with autonomic neuropathy and other cardiovascular risk factors in type 1 and type 2 diabetic subjects, especially in those with microalbuminuria. Endocrine, 2005, 27(3):213-217. 13 Maser RE, Mitchell BD, Vinik AI, et al. The association between cardiovascular autonomic neuropathy and mortality in individuals with diabetes: a meta-analysis. Diabetes Care, 2003, 26(6):1895-1901. 14 Krahulec B, Mikes Z, Balazovjech I. The effect of cardiovascular autonomic neuropathy on resting ECG in type 1 diabetic patients. Bratisl Lek Listy, 2002, 103(2):54-58. 15 Heart rate variability: standards of measurement, physiological interpretation and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Circulation, 1996, 93(5):1043-1065. 16 Astrup AS, Tarnow L, Rossing P, et al. Cardiac autonomic neuropathy predicts cardiovascular morbidity and mortality in type 1 diabetic patients with diabetic nephropathy. Diabetes Care, 2006, 29(2):334-339. 17 Ewing DJ, Martyn CN, Young RJ, et al. The value of cardiovascular autonomic function tests: 10 years experience in diabetes. Diabetes Care, 1985, 8(5):491-498. 18 The effect of intensive diabetes therapy on the development and progression of neuropathy. The Diabetes Control and Complications Trial Research Group. Ann Intern Med, 1995, 122(8):561-568. 19 Gaede P, Vedel P, Parving HH, et al. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet, 1999, 353(9153):617-622. 20 Howorka K, Pumprla J, Haber P, et al. Effects of physical training on heart rate variability in diabetic patients with various degrees of cardiovascular autonomic neuropathy. Cardiovasc Res, 1997, 34(1):206-214. 21 Ziegler D, Gries FA. Alpha-lipoic acid in the treatment of diabetic peripheral and cardiac autonomic neuropathy. Diabetes, 1997, 46 Suppl 2:S62-66. 22 Tankova T, Koev D, Dakovska L. Alpha-lipoic acid in the treatment of autonomic diabetic neuropathy (controlled, randomized, open-label study). Rom J Intern Med, 2004, 42(2):457-464. 23 Didangelos TP, Karamitsos DT, Athyros VG, et al. Effect of aldose reductase inhibition on cardiovascular reflex tests in patients with definite diabetic autonomic neuropathy over a period of 2 years. J Diabetes Complications, 1998, 12(4):201-207. 24 Hansen KW. Diurnal blood pressure profile, autonomic neuropathy and nephropathy in diabetes. Eur J Endocrinol, 1997, 136(1):35-36. 25 Eguchi K, Pickering TG, Ishikawa J, et al. Severe orthostatic hypotension with diabetic autonomic neuropathy successfully treated with a beta(1)-blocker: a case report. J Hum Hypertens, 2006, 20(10):801-803.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 355‧病例報告‧ 植入式心電記錄器成功發現暈厥病因一例 金椿 劉紅 鍾桃娟 牛茜雲 【摘要】 本文報導一例 60 歲男性，在過去一年半內反復發生暈厥四次，歷經各種檢查原因不明，經植入式心電記錄器，明確暈厥原因為完全性房室傳導阻滯伴長間歇(心源性暈厥)，經植入永久心臟起搏器得到成功救治。 【關鍵詞】 心源性暈厥；植入式心電記錄器 Use of an Implantable Cardiac Monitor to Determine the cause of Syncope JIN Chun, LIU Hong, CHONG Tou-Kun, NIU Qian-Yun. Department of Cardiology, Kiang Wu Hospital, Macao SAR.PR China; Tel: (+853)-6612 2036; E-mail: jinchun49@hotmail. com 【Abstract】A 60-year-old man with recurrent episode of unexplained syncope for four times from the past 18 months. The cause of the syncope is not determined even after several standardized tests such as ambulatory monitoring (Holter), 12-lead electrocardiogram (ECG), echocardiogram, stress test, and coronary angiography. Then decided to use an Implantable Cardiac Monitor to determine the cause of syncope and found complete atria ventricular block with long pause (cardiogenic syncope). Successfully treated with permanent pacemaker(DDDR). Implantable Cardiac Monitor(ICM) is a small implantable devise that offers diagnostic and monitoring information related to syncope. ICM placed just under the skin of the chest area using local anesthesia during a simple procedure. The monitor records important data before, during and after a syncopal event. This data enables the physician to diagnose the patient and determine the right treatment. 【Key words】 Cardiogenic syncope; Implantable cardiac monitor 暈厥是臨床工作中常見的症狀，可偶發或反復發作，病因有心源性和非心源性，發作時間多為短暫，輕者可自行緩解，重者(多為心源性)可危及生命。由於暈厥發病的不定時特性導致暈厥的病因診斷較為困難 。為 不明原 因暈 厥患者 安裝 植入式 心電 記錄 器(Implantable Cardiac Monitor, ICM)，則對病因診斷十分有利。本文報導一例植入 ICM 三個多月後記錄到暈厥時的心律失常為完全性房室傳導阻滯伴長間歇，臨床表現為阿斯綜合征，因 ICM 提供了發病時的心電資料，從而及時明確診斷得到合理治療。 患者男性 60 歲，分別於 2008 年 7 月、10 月、2009 年 7 月、9 月發生四次暈厥，多次往院。暈厥多於休息時發作，發作前無明顯誘因，不伴胸悶、胸痛，偶伴噁心、嘔吐，常於暈厥後數分鐘內恢復意識。曾有一次發病暈倒致腦挫傷皮下血腫。既往有高血壓史 10 年，不規則服藥。多次 ECG 為竇性心律伴 作者單位：中國, 澳門特別行政區, 鏡湖醫院, 心內科; Tel: (+853)-6612 2036; E-mail: jinchun49@hotmail. com 完全性右束支阻滯(CRBBB)；先後三次 24 小時動態心電圖報告 CRBBB，頻發房性早搏偶發室性早搏。超聲心動圖示各房室大小及心功能正常。頸部血管彩色超聲、腦 CT 及腦電圖均無異常。2006 年 12 月冠脈造影示正常、無冠脈狹窄。 因反復發生暈厥原因不明確，於 2009 年 9 月 23 日為患者植入了 ICM (ST.JUDE MEDICA 生產)。植入部位為胸骨左緣第 2－3 肋間，以心電圖測定 R 波直立部位，局部麻醉切口 1.5cm 至皮下縱行放置 ICM。植入後程式控制啟動模式為患者啟動和自動啟動兩種。設定啟動參數為：心動過緩啟動頻率＜50 次/min，心動過速啟動頻率＞160 次/min，長間歇啟動為 RR 間期＞3 秒，感知靈敏度為 0.3mv。 患者植入 ICM 後末再發作暈厥 ，但於 2010 年1 月 11 日上午 10 時突然發生暈厥、抽搐，意識不清，急診室心電圖示十分缓慢的心室逸搏心律、短陣室速、室顫，呼吸緩慢伴低血氧。立即植入臨時起搏器，氣管插管呼吸機輔助呼吸。以程式控制儀讀取發
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 356病時的心電記錄為完全性房室傳導阻滯伴長間歇，最長三段間歇分別為 4 秒、17 秒、及 21 秒(見圖)。在臨時起搏器三天后植入雙腔永久心臟起搏器(DDDR模式)。 圖 症狀發作時植入式心電記錄器記錄的部分心電圖示完全性房室傳導阻滯伴長間歇。 討 論 由於暈厥病因複雜及發病的特殊性，38－47％的病人雖經多種檢查包括心臟超聲、24 小時動態心電圖、直立傾斜試驗、平板運動心電圖、甚至心內電生理檢查仍不能明確病因[1, 2]。令人擔心的是有些病人被誤診為癲癇而服用抗驚厥藥，而使病人更具潛在風險[3]。近年使用的植入式心電記錄器對不明原因暈厥提供了有力的工具。目前使用的植入式心電記錄器主要由 ST.JUDE MEDICA 和 MEDTRONIC 公司生產，使用不同的英文名稱 Implantable Cardiac Monitor 或Insertable loop recorder，具有體積小、植入方法簡便，創傷小，使用時間長(新一代的記錄器可用三年)的優點，可精確記錄發病時及前後時段的心電圖長達45 分鐘。通常植入部位於左胸前區皮下，心電記錄器可按程式控制的心率值自動觸發記錄心電事件，為暈厥的病因診斷提供有力證據。 對不明原因暈厥、近似暈厥、發作性頭暈、不明原 因 反 復 發 作 心 悸 ， 均 有 指 征 ， 安 置 ICM ，AHA/ACC 認為屬 I 類適應證[4]。本例報導也充分證實了 ICM 的臨床應用對不明原因暈厥有其重要的診斷價值。心內科應積極開展該項技術提高對暈厥的診斷水準，使暈厥病人能够得到合理的治療。 參 考 文 獻 1 Krahn, A, Klein, G, Yee, R, et al. Use of an extended monitoring strategy in patients with problematic syncope. Circulation,1999b,(3), 406-410. 2 Mieszcanska, H, Ibrahim, B, & Cohen, T. Initial clinical experience with implantable loop recorders. The Journal of Invasive Cardiology,2001,13(12), 802-804. 3 Zaidi, A, Clough, R, Cooper, R, et al. Misdiagnosis of epilepsy: Many seizure-like attacks have a cardiovascular cause. Journal of the American College of Cardiology, 2000, 36(1), 181-184. 4 Crawford, M.H, Bernstein, S, Deedwania, P, et al. ACC/AHA guidelines for ambulatory electrocardiography: Executive summary and recommendations. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (committee to revise the guidelines for ambulatory electrocardiography). Circulation, 1999, 100(8), 886-893.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 357‧病例報告‧ 觸須樣免疫性腎小球病伴血清κ輕鏈升高病例報道 葉玉清 文劍明 【摘要】 觸須樣免疫性腎小球病是一種罕見的嚴重的腎臟疾病，病因和發表機制不明，臨床上大多數病例表現為腎病綜合征，病理特征是腎小球細胞外平行排列的小管狀纖維免疫復合物沉積。本文報道一例 42 歲男性觸須樣免疫性腎小球病伴血清免疫球蛋白 Mκ輕鏈升高的病例。患者入院前表現為蛋白尿、血尿和高血壓。入院腎穿刺活檢光鏡下見腎小球系膜區、腎小球旁小動脈壁有大量均質紅染沉積物。電鏡顯示內皮下和系膜區大量密集隨機分布的微管，直徑 30～50nm。隨後查血發現血循環免疫球蛋白 Mκ輕鏈單克隆升高。進一步檢查未查出患有良、惡性腫瘤。 【關鍵詞】 觸須樣免疫性腎小球病; κ輕鏈; 電鏡 A Case Report of Immunotactoid Glomerulopathy with High Level of Immunoglobulin M Monoclonal κ Light-chain in Serum YIP Yuk-ching, WEN Jian-ming. Department of Pathology, Kiang Wu Hospital, Macau, China; Tel: (+853)-8295 1921; E-mail: wcyt@yahoo.com.hk; Corresponding author: WEN Jianming，E-mail: wenjm@mail.sysu.edu.cn 【Abstract】 Immunotactoid glomerulopathy is a rare severe renal disease of unclear etiology and pathogenesis. Clinically immunotactoid glomerulonephritis manifests itself as the nephritic syndrome in most cases. The pathologic characteristic of the disease is tubules aligned in parallel in the deposits of immune complexes. We report the case of a 42-year-old man with immunotactoid glomerulonephritis associated with high level of immunoglobulin M light-chain in serum. The patient presented proteinuria, hematuria and hypertension before admitting to our hospital. Light microscopy of his renal biopsy showed massive homogenous deposits in mesangium and juxtaglomerular arteriolar wall. Electron microscopy showed dense randomly arranged microtubular subepithelial and mesangial deposits, which measured 30-50 nm in diameter. High level of immunoglobulin M monoclonal κ light-chain was subsequently found in serum. However, there is no any evidence of benign or malignant disorders in the patient. 【Key Words】Immunotactoid glomerulopathy; κ Light-chain; Electron microscopy 許多腎小球病表現為超微結構上見腎小球有沉積物，其中觸須樣免疫性腎小球病是一種新的疾病實體，與其相似的疾病--纖維樣腎小球腎炎有區別，後者表現為大量平行排列的微管沉積[1]。本文報道一例42 歲男性的嚴重觸須樣免疫性腎小球病，隨后查出血清免疫球蛋白 M κ輕鏈單克隆表達。現報道如下： 患者男性，42 歲，因 24h 尿蛋白 3.24g/L，24h尿肌酐清除率 59.23ml/min，血尿 4-6 個 RBC/HPF，血壓 176/105mmHg 入院，癥狀主要為胸骨後不適和心翳。無腎病家族史，無惡性腫瘤病史。 入院后微血尿和蛋白尿 2+，其它檢測包括血肌酐正常，抗核抗體、抗核小體抗體、抗雙鏈 DNA、 作者單位：中國，澳門特別行政區，澳門鏡湖醫院病理科，Tel: (+853)-8295 1921; E-mail: wcyt@yahoo.com.hk; 通訊作者：文剑明；E-mail: wenjm@mail.sysu.edu.cn 類風濕因子、抗鏈球菌 O 溶血素均為陰性，CMV-IgG和 IgM 陰性，HIV 陰性。癌指標 VCA、CEA、AFP、CA-19-9、PSA 均陰性。尿本周蛋白陰性。血清電泳發現單克隆免疫球蛋白 M κ輕鏈。超聲波檢查見雙腎稍飽滿，腎實質回聲增強，皮髓質分界欠清。X 線見雙側胸腔積液。心影向雙側擴大。 光鏡下觀察見腎穿刺活檢組織所獲得的腎小球均有病變，病變程度相似。腎小球細胞減少，系膜區有大片嗜伊紅均染的物質沉積。毛細血管腔大多位于毛細血管攀的外圍，管腔狹窄，甚至幾乎完全閉塞（圖1）。入球小動脈壁以及位于腎小球附近腎間質中的小動脈壁也見相同的物質沉積，管壁均質紅染，管壁明顯增厚，管腔變狹窄。腎小球中還可見較多的中性白細胞浸潤。PASM 和 PAS 組化染色顯示基底膜未見明顯增厚，主要分布于毛細血管攀的外圍（圖 2）。血管內皮細胞未見增生。Masson 染色未見嗜復紅蛋白沉積。剛果紅染色陰性。
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 358 圖 1 觸鬚樣免疫性腎小球病組織學 HE 染色 腎小球系膜中有大片嗜伊紅均染的物質沉積。毛細血管管腔狹窄，甚至閉塞，腎小球間的小血管管壁也明顯增厚。（100×） 圖 2 觸鬚樣免疫性腎小球病組織化學 PASM 染色 呈黑色線狀的腎小球基底膜未見明顯增厚，主要分布于毛細血管攀的外圍。（200×） 免疫熒光染色腎小球 IgM、IgA、C3、C1q、Fg 均呈顆粒狀或片塊狀強陽性，毛細血管壁的熒光特別強（圖 3-C3-6 和 IgA-4），凸顯出毛細血管環的形狀，而位于系膜區的片狀熒光顯得稍弱。令人奇怪的是，IgG熒光顯示毛細血管壁線性陽性，而不是顆粒狀反應，似乎清楚地標出毛細血管基底膜的位置，其位置與 PASM和 PAS 組化染色顯示的基底膜位置相同（圖 4）。 圖 3 觸鬚樣免疫性腎小球病免疫熒光 C3 腎小球系膜中可見呈顆粒片狀的免疫熒光，毛細血管周的熒光特別強。（200×） 圖 4 觸鬚樣免疫性腎小球病免疫熒光 IgG 腎小球系膜中可見弱免疫熒光，但毛細血管周圍的熒光呈線狀。（200×） 電鏡下，上皮細胞足突廣泛融合，扁平化。內皮下大量條塊狀沉積物，廣泛分佈，導致毛細管腔狹窄，基底膜被壓至毛細血管攀的外圍（圖 5），但基底膜厚度未見明顯改變，其內亦無沉積物。系膜細胞無明顯增生，系膜區明顯擴大，其中見大量的沉積物，并與內皮下的沉積物相連成片。沉積物由隨機排列的中空微管狀物（圖 6），在×30000 倍放大后量度，微管直徑為 30～50nm。這些微管狀沉積物分布并不均勻，密集時難以分辨管狀結構，稀疏時處管狀結構非常清晰。電鏡診斷為觸鬚樣免疫性腎小球病。 圖 5 觸鬚樣免疫性腎小球病超微結構 上皮細胞足突融合，基底膜厚度未見明顯改變，毛細血管腔狹窄，內皮下和系膜區大量沉積物，將基底膜壓至毛細血管攀的外圍。（5000×） 圖 6 觸鬚樣免疫性腎小球病超微結構 沉積物為隨機排列的中空微管狀，直徑為 30～50nm，圖下部為縱切面，圖上部為橫切面。（30000×）
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 359討論 腎小球病的特征是超微結構上腎小球有沉積物，觸鬚樣免疫性腎小球病是其中的一種。該病首次由 Schwartz 和 Lewis[3]命名，他們觀察到腎小球沉積物由束狀平行排列的微管結構組成。觸鬚樣免疫性腎 小 球 病 與 另 一 腎 小 球 病 — 纖 維 樣 腎 小 球 腎 炎（fibrillary glomerulonephritis）是否同一疾病有很多的爭論[1]。這 2 種病的特征都是在系膜區和基底膜內有細胞外非淀粉樣微纖維樣物沉積。這 2 種病同屬罕見疾病，纖維樣腎小球腎炎占總腎活檢約 1%，而觸鬚樣免疫性腎小球病僅為 0.06%[4, 5]，好發于白人女性。這2 種病的診斷有賴于電鏡觀察，纖維樣腎小球腎炎的微纖維隨機排列，實性，直徑約為 18～22nm[2]；觸鬚樣免疫性腎小球病為微管狀纖維，直徑大于 30nm，有可見的空腔，局灶呈束狀平行排列。但這些微纖維的形態表現有交叉[6]。本例電鏡下見內皮下和系膜中非淀粉樣微纖維隨機排列，測量直徑為 30～50nm，符合觸鬚樣免疫性腎小球病的診斷標準。 觸鬚樣免疫性腎小球病在臨床上與自身免疫性疾病或淋巴細胞腫瘤密切相關。通過 186 例纖維樣腎小球腎炎和觸鬚樣免疫性腎小球病病例分析，如果患者血循環或尿中查出有異常蛋白，觸鬚樣免疫性腎小球病患者患有惡性腫瘤的發病率為 33%，而纖維樣腎小球腎炎僅為 7%[2]。另一報道證實觸鬚樣免疫性腎小球病患者血清和尿單克隆γ球蛋白病的發病率比纖維樣腎小球腎炎明顯增高（67% 比 15%），主要為淋巴細胞腫瘤和低補體血癥。本例因腎活檢診斷觸鬚樣免疫性腎小球病，進而檢查是否有惡性腫瘤的存在，結果僅在血清電泳發現單克隆免疫球蛋白 M κ輕鏈，而各器官和組織均未發現有腫瘤，因而不排除自身免疫病的可能，而免疫熒光檢測顯示腎小球“滿堂光”也是佐證。文獻報道腎活檢診斷觸鬚樣免疫性腎小球病伴有重鏈病的病例，是患者同時患有濾泡性淋巴瘤[7]，而伴有輕鏈病的，則同時患有多發性骨髓瘤[8]。本例觸鬚樣免疫性腎小球病伴有血清輕鏈增高，但臨床未查出任何與輕鏈升高的疾病或腫瘤，這與 Fukuda 等人曾報道 1 例觸鬚樣免疫性腎小球病伴有κ輕鏈陽性相似，他們經 7 年觀察，未見患者患有任何與腎小球免疫物沉積相關的疾病發生，包括淀粉樣變、冷球蛋白血癥、系統紅斑狼瘡、異形蛋白血癥[9]。 近來，文獻報道用皮質類固醇和抗高血壓藥物成功治療觸鬚樣免疫性腎小球病[10]。 參考文獻 1 Brady HR. Fibrillary glomerulopathy. Kidney Int, 1998, 53:1421-1429. 2 Ferrario F, Schiaffino E, Boeri R. Fibrillary and immunotactoid glomerulopathies. Ren Fail, 1998, 20:801-808. 3 Schwartz MM, Lewis EJ. Nephrotic syndrome in a middle-aged man. Ultrastruct Pathol, 1980, 1:575. 4 Rosenstock JL, Markowitz GS, Valeri AM, et al. Fibrillary and immunotactoid glomerulonephritis: distinct entities with different clinical and pathologic features. Kidney Int, 2003, 63:1450-1461. 5 Alpers CE, Kowalewska J. Fibrillary glomerulonephritis and immunotactoid glomerulopathy. J Am Soc Nephrol, 2008, 19:34-37. 6 Bridoux F, Hugue V, Coldefy O, et al. Fibrillary glomerulonephritis and immunotactoid (microtubular) glomerulopathy are associated with distinct immunologic features. Kidney Int, 2002, 62:1764-1775. 7 Jacobson E, Sharp G, Rimmer J, et al. A 59-year-old woman with immunotactoid glomerulopathy, heavy-chain disease, and non-Hodgkin lymphoma. Arch Pathol Lab Med, 2004, 128: 689-692. 8 Jabur WL, Saeed HM, Abdulla K. Plasma cell dyscrasia; LCDD vs Immunotactoid glomerulopathy. Saudi J Kidney Dis Transpl, 2008, 19:802-805. 9 Fukuda M, Morozumi K, Oikawa T, et al. Immunotactoid glomerulopathy with microtubular deposits, with reference to the characteristics of Japanese cases. Clin Nephrol, 2005, 63:368-374. 10 Kinomura M, Maeshima Y, Kodera R, et al. A case of immunotactoid glomerulopathy exhibiting nephrotic syndrome successfully treated with corticosteroids and antihypertensive therapy. Clin Exp Nephrol, 2009, 4:15.
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 360‧醫學文摘‧ 複發性長節段橫貫性脊髓炎 56 例臨床分析 張大啓 楊麗 【摘要】 目的 探討複發性長節段貫性脊髓炎(relapse-longitudinally extensive transverse myelitis, r-LETM) 臨 床 、 影 像 學 特 點 並 觀 察 其 治 療 後 變 化 。 方法 對 56 例曾住院治療並接受隨訪的 r-LETM 患者病 例 進 行 回 顧 性 分 析 。 結 果 男 女 發 病 比 例1 :5 .2，發病平均年齡 36.4 歲。27 例既往有自身免疫病，其中乾燥綜合征 8 例。病前誘因中以感冒(53.6%)和腹瀉(10.7%)最多見，可波及延髓(19.6%)，病程中尚可有顱內病灶，以腦室週圍、胼胝體及近皮層下白質(39.3%)最多見。經激素、丙種球蛋白、免疫抑制劑等治療後，53 例(94.6%)臨床症狀有不同程度改善，3 例(5.4%)無效。首次發病後第 1 年複發最多，致殘率高。 結論 r-LETM 發發於中年女性，部分合併結締組織病，可有複發，病程中可有顱內病灶和視神經受累，激素等免疫抑制劑可緩解症狀。 【關鍵詞】 複發性長節段貫性脊髓炎 視神經脊髓炎 磁共振 診斷 治療 摘自：中國神經經神雜誌, 2009, 6 :342 Analysis of 56 cases with relapse-longitudinally extensive transverse myelitis. ZHANG Daqi, Yang Li. 【Abstract】 Objective To explore the clinical and MRI features of relapse-longitudinally extensive transverse myelitis(r-LETM), and its response to steroids and immunosuppressant treatment. Methods Fifty-six in-hospital r-LETM patients were included and followed up, the clinical data and MRI features were retrospective analyzed. Results The ratio of male to female is 1 :5.2. The average age of onset was 36.4 years old. Twenty-seven cases were accompanied by other autoimmune diseases, including eight Sjogren’s syndromes. The common trigger factors were cold (53.6%) and diarrhea (10.7%). Half of the cases had a subacute course. Optic nerve was affected in 60.7% cases and brainstem was involved in some cases. Spinal cord MRI showed that 71.4% of spinal cord lesions were located in the cervical cord, 69.6% in the thoracic cord, and 19.6% in medulla oblongata. The brain lesions were detected in 39.3% of patients during the course and majority of lesions were located in the periventricular area, corpus callosum and subcortical white matter. Significant improvement was observed in 53 patients after treatment of the steroids. Conclusions Middle-aged women is most likely to be affected by r-LETM and spatients can be accompanied by connective tissue diseases. Optic nerve is easily affected after the myelitis symptoms, and intracranial lesions can be found during the course. Treatment with steroids and other immunosuppressive medicines can alleviate symptoms. 【Key words】 Relapse-longitudinally extensive transverse myelitis; Neuromyelitis optica ; Magnetic resonance imaging; Diagnosis; Treatment From：Chin J Nerv Ment Dis, 2009, 6:342
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 361‧醫學文摘‧ 頸椎後縱韌帶骨化症手術時機的初步探討 黄平, 陈德玉, 卢旭华, 等 【摘要】 目的 探討頸椎後縱韌帶骨化症患者的手術時機。 方法 回顧性分析研究 168 例頸椎後縱韌帶骨化症患者的臨床症狀、症狀持續的時間以及臨床症狀出現加重至必須手術干預治療的時間間隔，初步探討頸椎後縱韌帶骨化症患者的手術時機。 結果 頸椎後縱韌帶骨化症患者從出現感覺運動障礙的脊髓受壓症狀起至必需手術治療的平均時間約 27.6 個月，而四肢肌力開始出現減退至必需手術治療的平均時間約爲 17.4 個月，四肢症狀明顯加重尤其下肢肌力減退至手術治療的平均時間爲 5.3 個月。 結論 頸椎後縱韌帶骨化症診斷明確後宜早期手術;在影像學上有明確的後縱韌帶肥厚骨化伴脊髓嚴重受壓(椎管狹窄率>60%)、或四肢尤其下肢開始出現肌力減退時應考慮及早手術治療。 【關鍵字】 頸椎; 後縱韌帶骨化; 手術時機 摘自：中國矯形外科雜誌, 2009, 19:1459 Preliminary study of the optimal time for operation on patients with ossification of the posterior longitudinal ligament of the cervical spine HUANG Ping, CHEN De-yu, LU Xu-hua, et al. 【Abstract】 Objective To explore the optimal time for the surgical operation on patients with ossification of the posterior longitudinal ligament of the cervical spine. [Methods]The clinical symptoms,the persistent time of the symptoms and the interval from exacerbation to operation in 168 patients with OPLL were analyzed.[Results]The average time was 27.6 months from the onset of myelopathy to the operation on patients with OPLL, and 17.4 months from the decrease of muscle strength in extremities to the operation, and 5.3 months from the symptomatic exacerbation of the extremities especially the decrease of muscle strength in lower extremities to the operation.[Conclusion]The patient should be treated earlier by surgical operation after his/her illness has been diagnozed as OPLL.It is the optimal time for surgical operation when the patient has imaging change of hypertrophy or ossification of the posterior longitudinal ligament and severe compression of spinal cord(more than 60% spinal canal stenosis),or the decrease of muscle strength in extremities especially in lower extremities. 【Key words】 cervical spine; ossification of the posterior longitudinal ligament; the optimal time for surgical operation From: Orthopedic Journal of China, 2009, 12:1459
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 362‧醫學文摘‧ 微創經皮腎鏡技術 在腎結石開放手術中的應用 李志鵬, 李澤惠, 曹貴華, 等 【摘要】目的 評價微創經皮腎鏡取石(minimally invasive Percutaneous nephrolithotomy, MPCNL) 技術在特殊腎結石患者開放手術中的應用價值。 方法 開放手術中經腎穿刺、擴張、利用輸尿管鏡碎石、取石治療 8 例患者。 結果 穿刺均一次成功，一次取盡結石 7 例，1 例殘留結石再次經造瘻管取盡，術後恢複理想，無嚴重併發症發生。 結論 腎結石開放手術中配合使用 MPCNL 技術具有創傷小、提高結石取盡率等優點，特別是在術前估計不足，應急的狀況下，術中使用 MPCNL 技術不失爲一種行之有效的補救措施。 【關鍵詞】 經皮腎鏡碎石術; 腎結石; 開放手術 摘自: 臨床泌尿外科雜誌, 2008,10:731 Application of minimally invasive nephrolithotomy in the open surgery for patients with renal calculi LI Zhipeng, LI Zehui, CAO Guihua, et al 【 Abstract 】 Objective To evaluate the application of minimally invasive percutaneous nephrolithotomy(MPC-NL) in the open surgery for patients with renal calculi. Methods Kidney wer punctured and distended successfully, then, calculis were treated by ureteroscope lithotripsy in 8 cases. Results All cases were stabbed successfully, then, calculis were cleaned through renal stoma later. All patients recovered well without any serious complications. Conclusions it is an effective remedy measure combining with MPCNL in the open operation, which causes less trauma and improves stone-free rates, especially under the condition of emergency and insufficient preoperative evaluation. 【 Key words 】 Percutaneous nephrolithotomy; Renal calculi; Surgical procedure From: Journal of Clinic Urology, 2008,10:731
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 363‧醫學文摘‧ 腦發育性靜脈異常的影像學診斷 張宗軍 王秀玲 朱宗明 季學滿 盧光明 【摘要】目的 分析腦發育性靜脈異常的 CT、MRI 和 DSA 表現，提高對本病的認識。 方法 17例腦發育性靜脈異常(DVA)患者中 15 例行 MRI 檢查、CT 檢查 6 例、DSA 檢查 4 例。對 DVA 在不同影像檢查的表現進行分析，對 DVA 的部位、分型、引流方式以及合併的其它異常進行探討。 結果 17 例患者有21 個 DVA，其中 3 例多發，4 例患者合併有海綿狀血管瘤。21 個 DVA 中幕上 7 個，幕下 14 個，根據其位置分爲淺型(皮層和皮層下區)12 個和深型 9 個，其引流靜脈中單支引流 14 例，多支引流 3 例。增強 CT、增強 MRI 和 DSA 靜脈期均能清晰顯示其特徵性表現既“水母頭”狀擴張的髓靜脈匯入粗大的引流靜脈干。 結論 增強 CT、MRI 以及 DSA 檢查均能正確診斷和評價 DVA，DSA 是診斷 DVA 並與其它血管畸形鑒的金標准；多種序列組合使 MRI 能更全面的評價DVA 及其合併的其它腦實質異常，是 DVA 檢查的首選方法。 【關鍵詞】 腦; 發育性靜脈異常; 血管畸形; 體層攝影術; X 線計算機; 磁共振成像 摘自: 醫學影像雜誌, 2008, 12:1350 Cerebral developmental venous anomalies: diagnosis by medical imaging ZHANG Zong-jun, WANG Xiu-ling, ZHU Zong-ming, et al 【Abstract】Objective To analyzed the appearance of cerebral developmental venous anomaly (DVA) on CT MRI and DSA imaging and to evaluate imaging diagnostic value. Methods The imaging appearance of 17 DVA cases were analyzed ,in cluding MRI imaging in 15 cases, CT in 6 cases and DSA in 4 cases. The location, type, draining vein and others of DVA wer evaluated. Results 17 cases with 21 DVA included supratentorial in 7 and infra tentorial in 14 and 4 cases associated CA. The characteristic “Caput Medusas”imaging appearance of DVA and numerous radiation medullary veins were gathered together into one or two larger drain veins and flowed into superficial or deeper veins were showed on all CT and MRI enhancement imaging or DSAa. Conclusion Postcontrast CT, MRI and DSA are effective methods for DVA diagnosis and evaluation, and DSA is the golden standard in differential diagnosis with other vascular malformation. With multi sequence, MRI could be evaluated DVA and associated parenchymal abnormalities overall, it is the most commonly method. 【 Key words 】 Brain; Developmental venous anomaly; Vascular malformation; CT; MRI From : J Med Imaging, 2008, 12:1350
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 365‧信息和動態‧ 非煙民爲何患肺癌？致病基因已找到 美国研究人员发现，非烟民罹患肺癌普遍与一个基因相关，如果这个基因发生变异，活性降低，则罹患肺癌风险可能增高。 这一发现有助于进一步研究肺癌靶向治疗和预测罹患肺癌高危人群。 找到关键 这种基因名为 GPC5。梅奥诊所医学院研究人员发现，GPC5 基因发生变异可能使非烟民罹患肺癌的风险增加。 研究人员选取 754 名非吸烟者，提取他们的脱氧核糖核酸(DNA)样本，分析其中超过 30 万个 DNA 变体，研究影响非烟民罹患肺癌几率的基因变异。 综合考虑研究对象的年龄、性别、种族、慢性呼吸道疾病史、吸入二手烟量和家族肺癌患病史以后，研究人员发现，两个基因组发挥关键作用。 确认基因 研究人员从第一组 DNA 样本中找出 44 个最普遍的基因变异，再观察另外两组非吸烟者的这些基因变异。这两组研究对象中一半人已确诊为肺癌患者。 结果发现，同样两个基因组是关键所在，它们负责“打开”和“关闭”GPC5 基因。 研究人员进一步研究发现，与健康人的肺部相比，肺腺癌患者的 GPC5 基因活性低 50%。肺腺癌是一种最常见的肺癌。 研究人员据此认为，GPC5 活性低可能导致非烟民罹患肺癌，有望通过进一步研究这一基因，研发肺癌靶向治疗新方法，并辨别罹患肺癌高危人群。 这是首次确认某个特定基因影响非烟民罹患肺癌风险。这项结果 22 日刊载于《柳叶刀肿瘤》杂志网络版。该杂志报道，全球肺癌患者中四分之一是非吸烟者。 有待深入 一些专家认为，需要进一步研究这种关联的原因。 美国华盛顿大学医学院拉马斯瓦米·戈文丹博士在《柳叶刀肿瘤》杂志发表评论文章说，距离利用这项研究结果预测罹患肺癌高危人群还比较“遥远”。 “对于这些来自没有吸烟史人群的肿瘤样本的初步观察，需要进一步研究确认，”他说。 英国癌症研究会科学信息部主管卡特·阿尼持有相同意见。英国广播公司(BBC)22 日援引他的话报道，虽然英国 90%的肺癌患者源于吸烟，但非烟民罹患这一疾病的数目仍然可观。 他说：“这些新研究结果可能帮助解释(非烟民罹患肺癌的)原因，但仍需要进行更多研究，确切解释这些基因变异如何与肺癌风险产生联系。” 摘自: 新华每日电訊, 2010-03-23 第 5 版
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 366‧工具和資料‧ 新型水凝膠，可“修補”齶裂 英國牛津大學研究人員日前報告說，他們研發出一種新型水凝膠材料，可用於幫助治療新生兒先天性齶裂，尤其是那些重度齶裂患者。 齶裂是一種較常見的先天性缺陷，表現爲新生兒口腔上齶出現裂縫，有時還伴有俗稱“兔唇”的唇裂。通常治療齶裂的方法是進行手術，重新調整口腔上顎的黏膜組織，使其遮住裂縫，但如果裂縫太大，可用黏膜組織不夠，治療就比較困難。 英國牛津大學日前發佈新聞公告說，該校研究人員和同行研發出一種新型水凝膠材料，可以將其置於患者上齶裂縫周圍的黏膜處，這種材料會吸收液體慢慢膨脹，黏膜組織也會隨之而生長，當膨脹後的水凝膠基本覆蓋裂縫後，就可以通過手術將它取下，再用相應的黏膜組織修補裂縫。 據介紹，這種水凝膠材料看起來與隱形眼鏡所用的材料差不多，它最大的特點是吸收液體後並不朝所有方向膨脹，而是可以控制它朝著覆蓋裂縫的方向膨脹，從而避免了黏膜組織朝其他方向生長的問題。 英國唇齶裂治療協會首席執行官普雷斯頓高度評價這種新型材料，認爲它爲那些重度齶裂患者帶來了福音，並對即將開展的臨床試驗表示期待。 據介紹，英國每約 700 名新生兒中就有一名患有齶裂。如果得不到良好治療，會導致患者面部發育、語言障礙等一系列問題。 摘自: 新華每日電訊 2010-3-23 第 5 版
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 367‧工具和資料‧ 惡性腫瘤的治療 外科手術治療 手術切除： 無論腫瘤大小，若要得到一個長期存活的機會或治癒的機會，還是以開刀切除機會較佳。如果肝癌能在小於二公分的時候就被切除，五年的存活率可達80%，若是肝癌在 2cm 到 5cm 內，五年存活率可達60%。所以還是要早期發現，才能得到最好的治療效果。 肝臟移植： 肝臟移植是切除原有敗壞肝臟，再植入健康肝臟，以期讓患者重新獲得正常肝功能及生活，對於末期肝病及腫瘤未轉移的肝癌患者而言，是一項積極有效的治療方法。目前手術之後一年存活率可高達 85%，五年存活率亦可達 60%左右。更重要的是，移植成功的患者中有 80%重新獲得自理生活的能力。 一般會考慮為單一腫瘤，腫瘤直徑不超過 5cm，若多發性腫瘤，腫瘤數不超過三顆，最大一顆直徑，不超過 3cm，另外，腫瘤必須沒有侵犯血管。如果沒有符合這些條件，雖然將整個肝臟換掉，植入新的肝臟，肝癌仍會於一年左右復發。但由於肝臟移植機會得來不易，因此臨床上醫師仍會合併其他方式來治療肝癌，亦同時等待換肝時機。 血管栓塞 所謂「血管栓塞」就是將提供癌細胞的肝動脈栓塞，讓肝癌細胞因為缺乏養份而自然壞死，但卻不會影響到正常肝臟細胞的生長，簡單說，就是把肝癌細胞「餓死」來達到治療效果。 因正常肝臟細胞的血流供應是由肝動脈（佔四分之一）及肝門靜脈（佔四分之三）合力完成的，肝癌則幾乎完全由肝動脈來供應。所以，將供應肝腫瘤的肝動脈栓塞，讓腫瘤細胞無法生長；但因為肝臟其他四分之三的血流來自肝門靜脈，仍然正常供應，所以不會壞死；有長腫瘤的部份則會因為血液供應被阻絕、缺乏養份而壞死。 放射治療 射頻燒灼(RFA)： 最近幾年來燒灼治療術逐漸受到重視，其運用的原理是在超音波的精確導引下，將電離子轉換成熱能的形式，可有效於肝腫瘤細胞及其周圍進行無殘存的燒灼，由於此法可重覆操作，且不需冒著麻醉與手術的風險，因此是很好的選擇方式。 光子刀： 光子刀是利用三度空間立體定位系統將高劑量的放射線發射到腫瘤上，將癌細胞殺死。比起傳統的鈷六十照射，更可使射線集中在患部，好處是周圍的正常組織受到的傷害較小。這種技術已經很成功的用於肝癌的治療中。 化學治療 化學治療是利用化學藥物阻止癌細胞生長和繁殖。一般化學藥物的給予方式可分為口服、靜脈注射與肌肉注射，大多數以點滴注射為主。一旦藥物進入血液循環中就會被帶到每一個癌細胞中去作用。它雖可以阻止體內快速生長的腫瘤細胞，但是正常細胞同樣會因為抗癌藥物而受到波及，造成一些身體的反應，大致有： 1. 造血功能降低：如白血球下降、容易疲倦 2. 毛髮皮膚改變反應：如落髮、禿頭 3. 口腔腸胃道的改變：如食慾降低、腹瀉、口腔黏膜破損 4. 性與生殖功能方面的影響：如性慾降低
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 368 由於肝癌的化學治療成效並不如預期理想，因此臨床上，以分子標靶為治療策略的抗腫瘤藥物已經成為目前肝癌治療上最重要的一環。 免疫療法 生物製劑療法亦稱免疫療法，直接或間接利用體內的免疫系統來對抗症，使免疫系統辨識體內癌細胞，進而消滅癌細胞，也有助於復原身體因其他治療所產生的副作用損害，如患者因化學治療導致血球下降，可接受血球生長刺激因數幫助血球回到正常值。多數以靜脈注射給予，提供於手術後採取單一治療，或者合併化學治療或放射線治療。多半仍在試驗中，目前可用的免疫療法分為： 1. 利用細菌或其產物、化學物質等修復、刺激或加強體內的免疫能力以抗癌，此種刺激沒有一特異性。 2. 將腫瘤細胞會引起人體免疫反應的部份分離出來，加上其他物質，將此混合物打入體內，以刺激體內對此腫瘤反應，進而消滅腫瘤，仍在試驗階段。 3. 注入免疫的主要細胞或其產物，如幹擾素、胸腺素等。 4. 被動免疫，是刺激人類的免疫系統的反應，製造出對腫瘤的抗體，將此抗體注入腫瘤細胞，目前仍在研究中。 5. 臨床試驗正在研究，將生物製劑療法和其他治療合併使用，以預防復發。 標靶治療 標靶治療主要是藉由抑制多種激酶( kinase ) 來封鎖癌細胞的訊息傳遞，另外也可抑制癌細胞的血管新生及營養供給。標靶藥物也屬於化療藥物，只不過是針對某一種細胞或是癌症某一弱點做研發的藥物，主要強調控制癌細胞不要再擴大或是改善病人的生活品質，目前各種抗癌的標靶藥物平均可延長患者六個月至一年的壽命，對癌症病人提供一線希望。 編輯部
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 369《澳門醫學雜誌》2009 年稿約 《澳門醫學雜誌》 (ISSN 1608-7801)是由澳門特別行政區衛生局主辦的綜合性醫學學術期刊，以澳門地區的醫藥衛生、醫技護理專業人員為主要讀者對象。本刊在國家中華醫學會的指導和幫助下，除了報道澳門地區醫藥衛生、醫技護理方面的研究工作和臨床經驗外；同時也刊登中國內地、香港和其它國家有關論文和信息，以利最廣泛地開展學術交流。根據澳門的實際情況，政府規定《澳門醫學雜誌》為非牟利刊物，目前是贈閱國外、中國內地和澳門地區醫學專業人員和相關人士，全部支出均由政府承擔。本刊不刊登任何廣告，不接受任何贊助。 1. 季刊雜誌 每年 3 月、6 月、9 月、12 月末出版，由特區衛生局統一發行。2001 年 4 月號為本雜誌的創刊號。 2. 設有欄目 “論著和研究”、 “綜述和講座”、 “技術和方法”、“短篇和病例報告”、“專科和全科實習醫生專欄”、“信息和動態”、“工具和資料”等。 3. 來稿要求 （參照《中華醫學雜誌》”和“American Journal of Medicine”） 3.1 文稿：論著、綜述、講座等一般不超過 5 000 字；短篇、病例報告等不超過 1 500 字。第一次投稿時，請隨打印稿送寄拷貝的 3.5 吋軟盤一份，文章存盤要用 Word 格式(*.doc)，盡可能用繁體字；同時附上單位介紹信。資料要求可靠，文責自負。 3.2 文字：根據澳門地區特點，稿件全文可選用中文、葡文或英文中任一種文字；摘要則需要用另一種文字撰寫（400 實字）。題目需要三種文字。論著的摘要需包括國際統一的 “目的”、“方法”、 “結果”和“結論”四部分。為了同中國及其它國家更廣泛地交流，本刊論著和文獻綜述的中文全文，歡迎再用葡文或英文撰寫 (不同文字發表全文，不作為一稿兩投)。 3.3 作者：不超過 6 位。因本刊有 3 種文字，為防姓和名搞錯，同時按外文習慣，作者外文姓名中的姓要用大寫，如：Ling Yi YIN 或 YIN Ling Yi。 3.4 參考文獻：一律按《中華醫學雜誌》要求的 GB7714-87《文後參考文獻著錄規則》按序著錄。論著、綜述限制 10 篇以內，其它 5 篇以內。GB7714-87 格式如下： 3.4.1 官建泳, 林勺明, 李之珩, 等. 澳門成人泌尿道感染的致病菌及其抗生素的易感性. 澳門醫學雜誌, 2003, 3:149-151. 3.4.2 Lam UP, Jin C, Ip MF, et al. Clinical analyses of 78 cases of atrial fibrillation patients treated by anti-arrhythmic drugs. Revista de Ciências da Saúde de Macau,. 2002, 2:107-110. 3.4.3 張曉威, Martins AS, 陳剛. 直腸肛門癌. 見：吳懷申, 主編. 澳門惡性腫瘤. 第 1 版. 澳門：澳門衛生司, 1999.122-129. 3.4.4 Hanld H, Levine SY, Lee DT, et al. Diagnosis of coronary heart disease. In: Wilson H, Joss KL﹐Richard JF, et al, eds. Clinical cardiology. 5th ed. Philadelphia: W.J.Co., 2000. 156-165. 4. 稿酬 稿件採用刊登後，論著、綜述等贈送當期雜誌 5 冊；其他贈送 2 冊。 5. 來稿寄送 《澳門醫學雜誌》編輯部收。地址：澳門特別行政區，CP 3002，衛生局，行政大樓2 樓；電話：(+853)-8390 7307、8390 6524；圖文傳真﹕(+853)-8390 7304；電子郵件﹕rcsm@ssm.gov.mo 。 《澳門醫學雜誌》編輯部
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 370 Artigos para a “Revista de Ciências da Saúde de Macau” – 2009 A “Revista de Ciências da Saúde de Macau (RCSM)”, ISSN 1608-7801, organizada pelos Serviços de Saúde da RAEM, é uma publicação científica dedicada às ciências da saúde, tendo como seus destinatários privilegiados os profissionais de saúde da Região de Macau. A revista sob a orientação e o apoio dado pela Associação de Medicina Chinesa da China visa divulgar informação sobre os trabalhos de investigação e experiência clínica da área da saúde da Região de Macau, bem como publicar dissertações e informações diversificadas provenientes da China Continental, Hong Kong e de outros países permitindo desenvolver o intercâmbio científico. De acordo com as caracteristicas de Macau, a Revista de Ciências da Saúde de Macau, sendo um journal sem fins lucrativos, todas as suas despesas são suportadas pelo Governo da R.A.E.M.. Esta revista é habitualmente oferecida aos médicos e pessoas com eles relacionadas e que vivem em Macau, China e estrangeiro. Por este motivo, esta revista não aceita nenhuma ajuda e nenhuma publicidade. 1. A revista é trimestral, com emissão em Março, Junho, Setembro e Dezembro e a sua publicação é da exclusiva responsabilidade dos Serviços de Saúde da RAEM. O 1º número da revista será publicado em Abril de 2001. 2. Rubricas : “Dissertação e Investigação”, “Tecnologia e Metodologia”, “Revisão e Palestras”, “Relatório Sucinto e Estudo de Caso”, “Coluna Especial para o Internato Geral e Complementar”, “Notícias” e “Dados e Meios”, etc. 3. Requisitos para os artigos a publicar (deverão ser adoptados os requisitos do “American Journal of Medicine” ou do “National Medical Journal of China”) : Textos : Os artigos a incluir nas rubricas “Dissertação”, “Revisão”, etc. poderão conter até 5 000 palavras; os artigos a incluir nas rubricas “Relatório Sucinto”, “Estudo de Caso”, etc., poderão conter até 1 500 palavras. Pela primeira vez, o artigo deverá ser entregue dactilografado em caracteres não simplificados, em formato de Word (*.doc) e acompanhado de “floppy disc”, bem como o Certificado do Instituto. Os autores são responsáveis pelo seu conteúdo. Língua : O texto integral do artigo deverá ser na língua chinesa, portuguesa ou inglesa e o sumário (400 palavras) deverá ser elaborado igualmente numa destas línguas mas diferente da utilizada no texto. O sumário de artigos a incluir na rubrica “Dissertação” tem de estar estruturado por “Objectivo”, “Método”, “Resultado” e “Conclusão”, de acordo com as regras adoptadas internacionalmente. Com vista a um intercâmbio mais amplo com a China e outros países, os artigos a incluir nas rubricas “Dissertação”e “Relatório Sucinto” poderão ter, para além do texto integral na língua chinesa, versões extraordinárias na língua portuguesa e/ou inglesa. Trata-se de um artigo, independentemente do número de versões. Autor : O número de autores não deverá exceder os 6. Dado que os artigos podem ser publicados numa das 3 línguas, o nome do autor deverá ser romanizado e o apelido deverá estar em maiúscula no sentido de evitar a eventual confusão, como por exemplo, Ling-Yi YIN ou YIN Ling Yi. Bibliografia : A bibliografia segue-se pela regra da Revista de Ciências da Saúde de Macau GB7714-87, constante das rubricas “Dissertação e Investigação”e “Revisão” e não deverá exceder os 10 documentos. Nos outros artigos, a bibliografia deverá limitar-se a mencionar 5 documentos. As formas de GB7714-87 poderão ser as seguintes : 3.4.1 Lam UP, Jin C, Ip MF, e outros. Análise clínica de 78 casos de fibrilhação auricular em doentes tratados com fármacos antiarritmicos. Revista de Ciências da Saúde de Macau,. 2002, 2:107-110. 3.4.2 Kuok CU. Retratar o cancro pulmonar. In: Wu HS. ed. Manual clínico de cancro pulmonar.1a ed. Macau : Serviços de Saúde da RAEM, 2002. 62-72. 4. Remuneração : A cada autor com artigo publicado na revista serão oferecidos 2 exemplares da revista ou 5 exemplares, no caso de serem artigos publicados nas rubricas “Dissertação” e “Relatório Sucinto”. 5. Os artigos deverão ser endereçados ao Gabinete Editorial da “Revista de Ciências da Saúde de Macau”. Endereço : CP 3002, 2° Piso, Edifício da Administração dos Serviços de Saúde de Macau. Telefone n° (+853)-8390 7307, 8390 6524; Fax : (+853)-8390 7304; e endereço : rcsm@ssm.gov.mo. Gabinete Editorial da “Revista de Ciências da Saúde de Macau”
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 371 Articles for “Health Science Journal of Macao ” – 2009 The Health Science Journal of Macao (HSJM), ISSN 1608-7801, is a scientific journal on medicine organized by the Health Bureau of Macao Special Administrative Region (HBMSAR). It addresses the diverse audience of health care providers within medicine, nursing, and the allied health professions. The journal publishes original articles, research, technical notes, reviews and up-to-date news in Macao. Some articles from China, Hong Kong and other countries also are published for scientific exchange. According to the circumstance of Macao, the HSJM defined as a profitless journal, all of our expenditures are supported by the government of Macao SAR. This journal is currently present to doctors and related people who are living in Macao, China and foreign country; therefore, the journal is not accept for any supporting, nor advertising. 1. HSJM is quarterly journal and issue in March, June, September and December by HBMSAR. The first issue will be published in April of 2001. 2. Columns: “Original Articles and Research”, “Technologies and Methods”, “Reviews Articles and Lectures”, “ Short Report and Case Report”, “Special Column for Interns of the General and Complementary Training”, “Medical News” and “Data and Reference”, etc. 3. Requirements for publish articles: 3.1. Texts: The Original Articles, Research, Reviews and Lectures may contain within 5 000 words. Other articles can contain within 1 500 words. The article must be typed and saved in the 3.5’ floppy disk as word document (*.doc), including certificate of Institute for the first delivery. For the Chinese version, it is better to submit by using the traditional Chinese letter. The author is responsible for the content. 3.2. Language: The texts of the integral article must be in Chinese, Portuguese or English and the summary (400 words) also must be elaborated in one of these languages but different from the used in the text. The summary of the article for the column “Original and Research Articles” must be structured by “Objective”, “Method”, “Result” and “Conclusion”, in according with the rules adopted internationally. 3.3. Author: The number of authors must not exceed 6 persons. As the articles for publication can be in one of three languages, the name of the author must be standard and the surname must be in capital letter in order to avoid the eventual confusion, for example, Ling-Yi YIN or YIN Ling Yi. 3.4. Reference: It is necessary to write the reference according to the forms of “National Medicine Journal of China”. For Original and Research Articles, Reviews and Lectures, the reference is limited within 10 documents. For other articles, the reference is limited within 5 documents. The forms are the following: 3.4.1 Lam UP, Jin C, Ip MF, et al. Clinical analyses of 78 cases of atrial fibrillation patients treated by anti-arrhythmic drugs. Revista de Ciências da Saúde de Macau,. 2002, 2:107-110. 3.4.2 Cheong TH. Diagnosis of lung cancer. In: Wu HS, ed. Clinical handbook of lung cancer. 1st ed. Macao:Department of Health of MSAR, 2001. 78-91. 4. Remuneration: Each author with article published in the journal will receive 2 copies of HSJM, or 5 copies if the article is published in the columns “Original Articles” and “Collective Reviews and Lectures”. 5. The articles must be delivered to the Editorial Office of HSJM. Office address: CP 3002, 2nd floor, Administrative Building, Health Bureau, MSAR. Tel: (+853)-8390 7307, 8390 6524; Fax: (+853)-8390 7304, E-mail: rcsm@ssm.gov.mo. Editorial Office of “Health Science Journal of Macao”
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 375Índice da RCSM, 2009, Vol. 9 【Dissertação e Investigação】 1. Osteoporose em Macau – análise de dados de DEXA ………………………………………………………1:01 KUOK Chau Sha 2. Avaliação da taxa de cobertura de pap smear e da taxa de seguimento em 3 452 pacientes num centro de saúde de Macau ……………………………………………………1:04 PANG Sai Meng, CHAN I Man 3. Um estudo de rotulagem nutricional e alegação nutricional nos alimentos pré-embalados em Macau ………………………………………………………1:07 FONG Ut-Wa, TANG Chi-Ho, NG Kam-Chong 4. Aplicação da vertebroplastia percutânea no tratamento da fractura vertebral compressiva (análise de 12 casos) ………………………………………………………1:11 NIAN Ding Fang 5. Alteração da TTP em doentes em tratamento do cancro do pulmão decélulas não-pequenas com terapia combinada de artesunate e de quimioterapia ………………………………………………………1:15 ZHANG Xiao-piang, ZHANG Zu-yi, YU Shi-qing, e col. 6. Propriedades psicométricas da versão Portuguesa do instrumento deavaliação do sentimento de pertença ………………………………………………………1:19 Ivandro Soares MONTEIRO, Angela MAIA 7. Observações clínicas sobre a prevenção da hemorragia pós-parto com “Carbetocin Versus” ………………………………………………………2:74 LEI Ngan,WONG Keong, HUANG Yao-bin, e outros 8. Aplicação clínica e estudo sobre os sinais de tumor hemorrágico pelos médicos dos Centros de Saúde dos Serviços de Saúde da Região Administrativa Especial de Macau ………………………………………………………2:77 AU Tak Wai, LAM Kuo 9. Aplicação de técnica “PCR-Polimerase Chain Reaction” no exame de despistagem dos bacilos da cólera, de “Parahaemolyticus” e de “Vulnificus” existentes nas amostras de produtos marítimos ………………………………………………………2:81 HEONG Soi-Peng, LEI Iun Fan, ZHOU Tian-Hong 10. Tratamento da infertilidade resultante de obstrução ouviducal com recanalização de ouviduto juntamente com medicina tradicional Chinesa ………………………………………………………2:87 NIAN Ding-fang 11. Tratamento de 30 casos de prostatite crónica, através da estimulação do ponto de acupunctura “Ci-Liao”, designadamente, pelo derramamento de sangue de pouca quantidade e pela Ventosaterapia ………………………………………………………2:90 ZHOU Hong-jun, MENG Jian-guo 12. Observação clínica após uso do medicamento externo “Gangjiling” para tratamento de hemorróidas externas trombosadas durante o período de gravidez ………………………………………………………2:92 LIU Quan-fang,Wan Jin,OU Jin-rui, e outros 13. Análise de resistância aos medicamentos ocorrida em 37 crianças com doença pneumocócica em Macau ………………………………………………………2:94 CHEANG Teng Fong, LEE Yan, IEONG Kin Mui 14. Estudo dos factores de alteração da elasticidade da gema de ovos importados no mercado de Macau ……………………………………………………3:165 TONG Ka-Io, SIO Hao-Leng, SIO Hao-Iok e outros 15. Aplicação dos produtos biológicos na psoríase, do estado moderado até ao estado severo ……………………………………………………3:169 KOK Chon 16. Tratamento de alteração patológica da parte do arco da aorta e da parte torácica com tecnologia de hibridização ……………………………………………………3:173 ZHENG Yuehong,CHOI Nim, DENG Hongru e outros 17. Valor da ecografia no diagnóstico da apendicite aguda ……………………………………………………3:176 LI Jun, IIANG Shu Ming, LIN Ning e outros 18. Análise dos efeitos após operação cirúrgica da tuberculose Pulmonar ……………………………………………………3:179 YANG De Kang, XIONG Xin Guo, CHENG Xiang Yang e outros 19. Discussão sobre o valor da TAC espiral multicorte no diagnóstico da apendicite aguda ……………………………………………………3:183 YANG Zhengyong, TAN Wenbing, TAN Lei e outros 20. Estudo relacionado com ondas de choque extracorpóreas no Tratamento dos doentes com dores no sistema musculoesquelético ……………………………………………………3:186 CHIANG Choi Peng, SOU Veng In, TAN Lian Li 21. Avaliação sobre a implementação da política de “Estabelecimentos de Restauração sem Tabaco” ……………………………………………………3:190 SIO Hao Leng, O Heng Kin, LO Iok Lin e outros 22. Estudo dos factores afectados de prognóstico permanente Sobre os pacientes com hemorragia subaracnóide
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 376 aneurismática na REAM……………………………4:278 LO Iek Long, LEI Wai Seng 23. Análise das infecções por pneumococos no Centro Hospitalar Conde de São Januário da RAEM…………………4:284 LEE Yan, LAO U Lei, LEONG IeK Hou, e outros 24. Valor do ultrasom aplicado no diagnóstico de ruptura do tendão de aquiles…………………………………4:288 LI Jun, LIANG Shu Min, LIN Ning 25. Edema pulmonar após a reexpansão de pneumotórax……4:291 CHIO Hok Ping, CHAO Sai Seng, CHEONG Zhu I 26. Relatório de 14 casos de tumor demóide na parede abdominal…………………………………………4:294 LIU Quanfang 27. Comparação e análise de três métodos de detecção de ESBLs produzido pelo Escherichia coli, em Macau…4:297 YE Qian-hong, LI Pie-zhang, Chang Ioi e outros 28. Importância do estado HER-2 de carcinoma de glândulas mamárias quanto à avaliação com hibridização “in situ” de coloração e proposta da avaliação imunoistoquimica…………………………………4:300 YIP Yuk-ching, WEN Jian-ming, VONG Heong-ting e outros 29. Pesquisa experimental de pílula DBD modificada destinada ao enriquecimento da função do sangue e ao aumento de funções fisiológicas……………………………4:305 JIE Bin, ZENG Xiaohui, LAO Mun Wa e outros 30. Impacto de indíce inflamatório pós-operatório de veias coronárias, após a aplicação da prescrição médica “Yixin” de apelido “Fang” ………………………4:309 LIU Xing Lie, SUN Wu, CHEN Quan Fu e outros 31. Inquérito sobre a actualização de garantia de despesas médicas dos idosos em cidades e povoados da China após aintervenção cirúrgica…………………………4:313 XUE Xinxi, QU Haihui, ZHOU Fei 32. Planeamento da alta: comparação entre os dois mecanismos destinados à identificação…………………………4:317 Wen-Chieh Hu, Siao-Huei Wang, Chun-Ming Yeh, o outros 33. Investigação sobre o problema de audição dos idosos em Macau………………………………………………4:323 PAI Ki Man, WANG Jiqun, CHENG Zheng Ang 34. Investigação sobre o conteúdo de sal nas refeições escolares em Macau………………………………4:326 SIO Hao-Leng, LOI I-Leng 【Revisão e Palestras】 1. Tratamento antibiótico nas crianças com otite média aguda ………………………………………………………1:27 LOK Mei Kun 2. Desenvolvimento clínico da oscilometria de impulsos ………………………………………………………1:32 ZHANG Xiao Zhan 3. Factores de risco e tratamento da analgesia epidural inadequada durante o trabalho de parto e o parto ………………………………………………………1:35 SUN Chuan-jiang, LIAO Zi-wei 4. Sindrome da imunodeficiência adquirida ………………………………………………………1:41 Huai-shen WU,NG Pui Lai, Jorge Humberto MORAIS 5. Discussão sobre a intervenção da medicina tradicional chinesa na síndrome metabólica, conforme uma antiga teoria tradicional chinesa “prevenção prioritária de doenças ainda não infeccionadas; diagnóstico precoce e tratamento precoce para controlar a evolução da doença; prevenção da recorrência de doenças e cura das complicações no prognóstico” ………………………………………………………2:97 ZHAO Yong-hua 6. Exame de despistagem à mulher grávida sem bacteriúria Assintomática ……………………………………………………2:100 CHOI Chong Po, WONG In, NG Sio Fan e outros 7. Avaliação do efeito médico de um medicamento tradicinal chinês “tripterygium” aplicado no tratamento da síndrome de nefropatia primária ……………………………………………………2:103 Ingrid karmane SUMOU 8. Mucopolissacaridose ……………………………………………………2:109 WANG Shao-ting 9. Comportamentos, Estilos de vida e Práticas de saúde ……………………………………………………2:115 Carlos António LARANJEIRA 10. Rins prejudicados por sintomas severos ……………………………………………………2:121 LIU Xin-lie, LIU Min-wen, LI Jun 11. Progresso no estudo de biotransformação de “ginsenoside Rb1” ……………………………………………………3:195 LEONG Weng-Im, YAN Ru, YUAN Jianqing e outros 12. Desenvolvimento da terapia combinada no tratamento do cancro pulmonar de não pequena célula localmente avançada ……………………………………………………3:199 WANG Wei Hua, XIAO Guang Li 13. Avanço sobre o estudo do mecanismo de defesa psicológica ……………………………………………………3:204 LAO Wan U, WANG Huan, SHEN He Yong 14. Valor da utilização da endoscopia por cápsula para conhecer a etiologia desconhecida do intestino delgado ……………………………………………………3:207 CHOI I Cheong, YANG Dong Hua 15. Aprendizagem do método “Benner’s From Novice to Expert”
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 377na vida de enfermagem ……………………………………………………3:210 VAN Lat Kio 16. Discussão sobre o medicamento tradicional chinês “Kummerowia Striata” ……………………………………………………3:215 LIU Xinglie, LIU MinWen, LIU HongWei 17. Progresso no tratamento do SIDA na medicina tradicional chinesa ……………………………………………………3:219 TE MU Er 18. Discussão sobre a clínica geral…………………………4:329 PANG Sai Meng 19. Panoramaactual da aplicação de peixe-zebra como modelo organismo destinado ao desenvolvimento de um novo medicamento na RAEM……………………………4:331 Kai-Heng Lam, Emilia Conecição Leong, e outros 20. Irregularidade de neuro-hormônio em Diabetes Mellitus tipo 2………………………………………………4:336 LOK Mei Kun 21. Situação recente sobre o estudo clínico da gastrite erosiva crónica………………………………………………4:347 Kin Wa Wong, Liheng Wang, Baozhu Yan 22. Neuropatia autonómica cardiovascular diabética…………4:350 Lam Kuok Wun, Fang Dong Hong 【Relatório Sucinto e Estudo de Caso】 1. Administrar o efeito tranquilizante do propofol para reduzir a dor durante a sua injecção ………………………………………………………1:47 LEONG Ieng Wa 2. Apendicectomia assistida por laparoscopia monopolar ………………………………………………………1:49 CHAN Pui Bun 3. Um caso de diagnóstico diferido do linfoma maligno agressivo e disseminado de células T/NK ………………………………………………………1:51 YUNG Ka Hung, David Tavares LOPES 4. Um caso de linfoma de tonsila ……………………………………………………2:127 LIU Shui-ming, CHU LapHong, CHONG HengKai 5. Relatório sobre um caso de fístula primária de aorta abdominal e duodeno ……………………………………………………2:129 NG Wai-Ion, DENG Hong-Ru, Barata Frexes João Manuel 6. Aplicação de uma terapia electroconvulsiva num caso de uma idosa chinesa com síndrome “Cotard” ……………………………………………………2:132 Carlos DUARTE, JIN Hai-yan, CHEONG Chun Kin 7. Um caso de penfigóide bolhosa ……………………………………………………2:136 CHAO Wo On, CHIN João Paulo,U Ka Ian e outros 8. Um caso diagnosticado por TAC sobre enterobrosia resultante de uma substância engolida no tracto digestivo ……………………………………………………2:138 TAN Wen-bin, Xie Xue-bin 9. Um caso de hemofilia A adquirida com vasculite associada ao ANCA e reconsideração da respectivaliteratura médica ……………………………………………………3:222 LEI Wai Kuan, DAI Lie, ZHENG DongHui e outros 10. Um caso de glomerulonefrite com manifestação de sindrome nefrótica de pós-infecção estreptocócica aguda ……………………………………………………3:228 CHEN Yan, HUANG Kaifeng, LEONG Tip Fong e outros 11. Análise imagiológica da doença de membrana hialóide pulmonar de um recém-nascido ……………………………………………………3:230 ZHENG Weiji, XIE Xuebin 12. Pênfigo paraneoplásico e bronquiolite atrésico ……………………………………………………3:233 CHAN Hong Tou, CHEONG Tak Hon 13. Uveíte anterior com citomegalovírus ……………………………………………………3:236 NGAI Chi Seng, LEONG Chan 14. Relatório de um caso de demência vascular com o pródromo de mania ……………………………………………………3:238 Carlos Duarte, WONG Fai, CHEANG Hio Lan 15. Caso clínico uveite anterior recorrente causado per citomegalovírus ……………………………………………………3:241 Jin Hong 16. Um caso de patologia da síncope verificado pela implantação de um aparelho cardíaco……………………………4:355 YIN Chun, LIU Hong, CHONG Tou-Kun, e outros 17. Relatório de um caso de glomerulopatia de imunotactoide com nível alto de cadeia leve kappa em soro………4:357 YIP Yuk-ching, Wen Jian-min 【Resumos de Artigos Médicos Internacionais】 1. Estudo sobre a viabilidade de não transfusão de sangue no período perioperatório em doentes com carcinoma do Esófago ………………………………………………………1:53 2. Investigação de seguimento clínico da recidiva de hepatite B no período de 19 meses depois do transplante de fígado em 182 doentes ………………………………………………………1:54 3. Observação clínica de 563 doentes com lesão cerebral traumática complicada depois de intoxicação por etanol ………………………………………………………1:55 4. Recente avanço na terapia genética contra tumores e vectores virais ………………………………………………………1:56
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 3785. Resultados a longo prazo de 934 casos de carcinoma nasofaríngeo tratados exclusivamente com radioterapia ………………………………………………………1:57 6. Diagnóstico e terapia de nódulos pulmonares isolados ………………………………………………………1:58 7. Discussão sobre a característica clínica da encefalite viral recorrente e o mecanismo da sua Incidência ……………………………………………………2:140 8. Estudo da expressão do novo gene PKIβrelacionado com o glioma cerebral, bem como a natureza de proteína) ……………………………………………………2:141 9. Prevenção e tratamento da dificuldade na abertura da boca após a radioterapia de carcinoma da Nasofaringe ……………………………………………………2:142 10. Gene de trajecto de sinal MAPK expresso no osteossarcoma humano………………………2:143 11. Detecção e significado clínico de mutação de gene JAK2V617F ocorrida nos 80 casos com tipo M2 de leucemia aguda…………………………2:144 12. Característica imagiológica do tumor não epitelial da bexiga ……………………………………………………2:145 13. Diagnóstico e prognóstico dos pequenos tumores do pâncreas ……………………………………………………2:146 14. Estudo clínico sobre o sincronismo de quimio-radioterapia para tratar os idosos com o turmor pulmonar parcialmente, não pequena célula, do estadio avançado ……………………………………………………2:147 15. Análise clínica de 116 casos de carcinoma de endométrio precoce…………………………3:243 16. Análise dos factores relacionados com infiltração da túnica serosa do carcinoma rectal, utilizando a tomografia computadorizada multi-slice ……………………………………………………3:244 17. Relacionamento entre o polimorfismo do gene do receptor β3-adrenérgico e o primeiro evento cardiocerebrovascular ocorrido em doente com hipertensão ……………………………………………………3:245 18. Situação de infecção pelos vários tipos de vírus do papiloma humano (HPV) entre a neoplasia cervical intraepitelial e o carcinoma cervical ……………………………………………………3:246 19. Aplicação de ecografia nos casos de complicação vascular após a transplantação de fígado ……………………………………………………3:247 20. Análise clínica de 56 casos de recorrência do longo segmento da mielite transversa………………………4:360 21. Discussão preliminar sobre o tempo óptimo da aplicação 22. da operação destinada à ossificação do Ligamento longitudinal posterior nas vértebras cervicais ………………………………………………………4:361 23. Aplicação de minimamente invasiva nefrolitotomia percutânea em cirurgia aberta……………………………………4:362 24. Diagnóstico imagiológico aplicado na anormalidade venosa de desenvolvimento cerebral…………………………4:363
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 379Contents of HSJM, 2009, Vol 9 【Original Articles and Research】 1. Osteoporosis in Macao – dexa data analysis ………………………………………………………1:01 KUOK Chau Sha 2. Evaluation of 3 452 patients’ pap smear coverage rates and follow-up rates in a health center of Macao ………………………………………………………1:04 PANG Sai Meng, CHAN I Man 3. A Study of nutrition labeling and nutrition claim of prepackaged food in Macao ………………………………………………………1:07 FONG Ut-Wa, TANG Chi-Ho, NG Kam-Chong 4. To treat vertebral body compression fracture by percutanous vertebroplasty (analysis 12 cases) ………………………………………………………1:11 NIAN Ding Fang 5. Patient’s TTP change in the treatment of non-small cell lung cancer with artesunate combination therapy with chemotherapy ………………………………………………………1:15 ZHANG Xiao-piang, ZHANG Zu-yi, YU Shi-qing, et al 6. Psychometric properties of the Portuguese version of the sense ofbelonging instrument ………………………………………………………1:19 Ivandro Soares MONTEIRO, Angela MAIA 7. Carbetocin Versus combination of oxytocin and engometring in Control of postpartum Blood Loss ………………………………………………………2:74 LEI Ngan, WONG Keong, HUANG Yao-bin, et al 8. A Study of the Awareness and Use of Tumor marker tests in government Primary Health care System in Macao ………………………………………………………2:77 AU Tak Wai, LAM Kuo 9. The Application of Multiplex PCR method for the Screening of Vibrio Cholerae, Vibrio Parahaemolyticus and Vibrio Vulnificus in Seafood Samples of macao ………………………………………………………2:81 HEONG Soi Peng, LEI Iun Fan, ZHOU Tian- hong 10. Combine Interventional Oviduct Recanalization with Traditional Chinese Medicine to treat Infertility of Oviduct Obstruction ………………………………………………………2:87 NIAN Ding-fang 11. Liao Points, Pricking Blood Cupping Treatment of Chronic Prostatitis 30 cases……………………………………2:90 ZHOU Hong-jun, MENG Jian-guo 12. The clinical Effect of “ Gangjiling” lotion in the treatment of Female pregnant patients with Thrombotic external haemorrhoid ………………………………………………………2:92 LIU Quan-fang, WAN jin, OU Jin-rui,et al 13. An introduction and resistance Analysis of 37 cases of pneumococcal disease in Children of macao ………………………………………………………2:94 CHEANG Teng Fong, LEE Yan, IEONG Kin Mui, et al 14. A Factorial Study on the Alteration of Egg Yolk Elasticity in Macao ……………………………………………………3:165 TONG Ka-IO, SIO Hao-Leng, SIO Hao-Iok, et al. 15. The Use of Biologic Treatment in Modrate to Severe plaque psoriasis ……………………………………………………3:169 KOK Chon 16. Hybrid Aortic Endovascular Repair with Simultaneous Supra-Aortic Branch orIliac Artery Revascularization ……………………………………………………3:173 ZHENG Yuehong, CHOI Nim, DENG Hongru 17. Diagnostic Value of Ultrasound in Acute Appendicitis ……………………………………………………3:176 LI Jun, lIANG Shu Ming, LIN Ning, et al 18. Surgery for Pulmonary Tuberculosis ……………………………………………………3:179 YANG De Kang, XIONG Xin Guo, CHENG Xiang Yang, et al 19. Diagnostic Value of multi-Slice Spiral CT for Acute Appendicitis………………………………………3:183 YANG Zhenyong, TAN Wenbing, TAN Lei, et al 20. Treatment of Extracorporeal Shockwave Therapy for Usculo-Skeletalpain Patients ……………………………………………………3:186 CHIANG Choi Peng, SOU Veng In, TAN Lian Li 21. Survey on the Implementation of the “Smoke-free Restaurant” Policies ……………………………………………………3:190 SIO Hao Leng, O Heng Kin, LO Iok Lin, et al 22. Long-term mortality and morbidity of patients with aneurysmal subarachnoid hemorrhage in Macao ……………………………………………………4:278 LO Iek Long, LEI Wai Seng 23. Pneumococcal Infection in CHCSJ of Macau ……………………………………………………4:284 LEE Yan, LAO U Lei, LEONG Iek Hou, et al
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 38024. Diagnostic Value of High-frequency Ultrasound in the Rupture of Achilles Tendon ……………………………………………………4:288 LI Jun, LIANG Shu Min, LIN Ning, 25. A Case Report about Reexpansion Pulmonary Edema and Revision of the Literature ……………………………………………………4:291 XIAO Xueping, ZHOU Shixing, ZHANG Zuyi 26. Retrospective Analysis of 14 Patients with Desmoid Tumor of the Abdominal Wall ……………………………………………………4:294 LIU Quanfang 27. Comparison of Three Methods Detecting ESBLs-Producing Escherichia Coli in Macao ……………………………………………………4:297 YE Qian-hong, LI Pei-zhang, ZENG Rui, et al 28. Role of Chromogenic in situ Hybridization (CISH) in The Evaluation of HER-2 Status in Breast Carcinoma and Proposition of Its Immunohistochemical Valuation ……………………………………………………4:300 YIP Yuk-ching, WEN Jian-ming, VONG Heong-ting,et al 29. Study on Enriching the Blood and Enhancing the Body Function of Modified Danguibuxuetang Concentrated Pills in Mice ……………………………………………………4:305 XIE Bing, ZEN Xiao-hui, LIU Man-hua, et al 30. Face Family Name Profit Heart Phon Versus Coronal Artery Intervention Skill Post Inflammation Apyogenous Exponential Impact ……………………………………………………4:309 LIU Xing Lie, SUN Wu, CHEN Quan Fu, et al 31. A Survey on Post-operation Medical Insurance of Senior Chinese Citizens……………………………………4:313 XUE Xinxi, QU Haihui, ZHOU Fei 32. Discharge Planning: Comparison of Two Different Timing of Identification……………………………………4:317 HU Wen-chith, WANG Siao-Huei, YEH Chun-Ming 33. Study on the Prevalence of Hearing Impairment Among Elerdly Population in Macau ……………………………………………………4:323 PAI Ki Man, WANG Jiqun, CHENG Zheng Ang 34. A Survey on the Salt Contents of School Meals in Macao ……………………………………………………4:326 SIO Hao-Leng, LOI I-Leng 【Collective Reviews and Lectures】 1. Antibiotic treatment in children with acute otitis media ………………………………………………………1:27 LOK Mei Kun 2. Clinic development in impulse oscillometry ………………………………………………………1:32 ZHANG Xiao Zhan 3. Risk factors & treatment of inadequate epidural analgesia during labor and delivery ………………………………………………………1:35 SUN Chuan-jiang, LIAO Zi-wei 4. Acquired immune deficiency syndrome ………………………………………………………1:41 Huai-shen WU, NG Pui Lai, Jorge Humberto MORAIS 5. Discussion Intervention of chinese Medicine on Metabolic syndrome from the theory of “ Preventive treatment of disease” ………………………………………………………2:97 ZHAO Yong-hua 6. Asymptomatic Bacteriuria screening in preganat women ……………………………………………………2:100 CHOI Chong Po, WONG In, NG Sio Fan, et al 7. Efficacy and safety of tripterygium in primary nephrotic syndrome ……………………………………………………2:103 Ingrid Karmane SUMOU 8. Mucopolysaccharidosis ……………………………………………………2:109 WANG Shao-ting 9. Behavior, Life Style and Health Practices ……………………………………………………2:115 Carlose António LARANJEIRA 10. Peril seriously symptom control kidney ……………………………………………………2:121 LIU Xin-lie, LIU Min- wen, LI Jun 11. Progress in Biotransformation of Ginsenoside RB1 ……………………………………………………3:195 LEONG Weng-Im, YAN Ru, YUAN jianqing, et al 12. Development of Combined Therapy for Locally Advanceed Non-Small Cell Lung Cancer ……………………………………………………3:199 WANG Wei Hua, Xiao Guang Li 13. The Advance of the Psychological Defensive Mechanisms Research ……………………………………………………3:204 LAO WAN U, WANG Huan, SHEN He Yong 14. The Values of Using Capsule Endoscopy in Unknown Small Bowel Diseases ……………………………………………………3:207 CHOI I Cheong ,YANG Dong Hua 15. Benner’s From Novice to Expert Model in Nursing Practice ……………………………………………………3:210 VAN Lat Kio
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 38116. The Inquisition of Kummerowia Striata ……………………………………………………3:215 LIU Xinglie, LIU MinWen, LIU HongWei 17. The Progress of the Chinese Medicine’s Treatment of AIDS ……………………………………………………3:219 TE MU Er 18. The Family Physician……………………………………4:329 PANG Sai Meng 19. A Review of Zebrafish as a Model Organism for Drug Screening in Macao ……………………………………………………4:331 LAM Kai-Heng, LEONG Emilia Conceição, ZhANG ZaiJun, et al 20. Neurohormonal Dysregulation in Type 2 Diabetes Mellitus ……………………………………………………4:336 LOK Mei Kun 21. Chronic Erosive Gastritis’s Situation Clinical Research ……………………………………………………4:347 WONG Kin Wa, WANG Liheng, YAN Baozhu, et al 22. Diabetic Cardiovascular Autonomic Neuropathy ……………………………………………………4:350 Lam Kuok Wun, Fang Dong Hong 【Short Report and Case Report】 1. The method of reducing the pain on injection of propofol ………………………………………………………1:47 LEONG Ieng Wa 2. Single-port laparoscopic-assisted appendectomy ………………………………………………………1:49 CHAN Pui Pan 3. A case of delayed diagnosis of aggressive and disseminated NK/T cell lymphoma…………………………………1:51 YUNG Ka Hung, David Tavares LOPES 4. Malignant Lymphoma of Tonsil : A case report ……………………………………………………2:127 LIU Shui-ming, CHU Lap Hong, CHONG Heng KAI, et al 5. Primary aortoduodenal fistula : A case report ……………………………………………………2:129 NG Wai-lon, DENG Hong-Ru, Barata frexes joao manuel 6. Cotard Syndrome and Electroconvulsive Therapy in an Elderly Chinese lady without Capacity to Consent to Treatment: A Cases Report ……………………………………………………2:132 Carlos DUARTE, JIN Hai-yan, CHEONG Chun Kin 7. A Case of Bullous Pemphigoid…………………………2:136 CHAO Wo On, CHIN Joao Paulo, U Ka Ian, et al 8. CT diagnosis of Enterobrosis Caused by A Swallowed Foreign Bodies in Digestive Tract:A Case report ……………………………………………………2:138 TAN Wen-bin, XIE Xue-bin 9. Acquired Hemophilia A in Patient with ANCA –Associated Vasculitides: A Case Report and Review of Literature ……………………………………………………3:222 LEI Wai Kuan, DAI Lie, ZHENG DongHui, et al 10. Case Study of Acute Postdtreptococcal Glomerulonephritis with Manifestations of Nephrotic Syndrome ……………………………………………………3:228 CHEN Yan, HUANG Kaifeng, LEONG Tip fong,e t al 11. Imaging Analysis of Pulmonary Hyaline Membrane Disease in Newborn: Case Report ……………………………………………………3:230 ZHENG Weiji, XIE Xuebin 12. Paraneoplastic Pemphigus and Braonchiolitis Obliterans ……………………………………………………3:233 CHAN HONG Tou, CHEONG Tak Hon 13. Anterior Uveitis with Cytomegalovirus Infection ……………………………………………………3:236 Ngai Chi Seng Leong Chan 14. Mania as a Prodrome to Vascular Dementia: A Case Report ……………………………………………………3:238 Carios Duarte, WONG Fai, CHEANG Hio Lan 15. Recurrent Anterior Uveitis Caused by Cytomegalovirus: A Case report………………………………………3:241 JIN Hong 16. Use of an Implantable Cardiac Monitor to Determine the cause of Syncope ……………………………………………………4:355 JIN Chun, LIU Hong, CHONG Tou-Kun, et al 17. A Case Report of Immunotactoid Glomerulopathy with High Level of Immunoglobulin M Monoclonal κ Light-chain in Serum ……………………………………………………4:357 YIP Yuk-ching, WEN Jian-ming 【Foreign Medical Abstracts】 1. Study on the feasibility of no blood transfusion for patients with esophageal carcinoma duringperioperation period ………………………………………………………1:53 2. Clinical follow-up investigation of hepatitis B recurrence for 19 months after liver transplantation in 182 patients ………………………………………………………1:54 3. Clinical observation of 563 patients complicated traumatic brain injury after ethanol intoxication ………………………………………………………1:55 4. Recent advances in tumor gene therapy and virus vectors ………………………………………………………1:56 5. Long-term results of 934 nasopharyngeal carcinoma treated with radiotherapy alone ………………………………………………………1:57
Revista de Ciências da Saúde de Macau 澳門醫學雜誌, December 2009, Vol.9, No.4 3826. Diagnosis and therapy for solitary pulmonary nodules ………………………………………………………1:58 7. Clinical characteristics of relapsing virus encephalitis and mechanisms of relapse ……………………………………………………2:140 8. Expression and characterizations of novel full-length gene PKI β related to human glioma ……………………………………………………2:141 9. Prevention of trismus in nasopharygeal carcinoma patients treated by radiotherapy ……………………………………………………2:142 10. Gene profiling of MAPK pathway in human osteosarcoma ……………………………………………………2:143 11. Detection of JAK2V617F mutation and its clinical significance in 80 patients with M2 acute ……………………………………………………2:144 12. Imaging features of nonepithelial tumors of the bladder ……………………………………………………2:145 13. Small pancreatic cancer diagnosis and prognosis ……………………………………………………2:146 14. Analysis of effect of concurrent chemoradiotherapy on elderly patients with locally advanced non-small cell lung cancer ……………………………………………………2:147 15. Clinical Analysis of 116 Cases of Early Stage Endometrial Cancer ……………………………………………………3:243 16. Analysis of Factors Related to the Infiltration of Serosa by Rectal Carcinomas Using 16-channel Multi-slice CT ……………………………………………………3:244 17. Relationship between β3-AR gene T190C Polymorphism and the first Cardiovascular and Cerebrovascular Events in Hypertensive Patients ……………………………………………………3:245 18. The Infection Condition of Different Types of Human Papilloma Virusin Cervical Intraepitheliai Neoplasia and CervicaI Carcinoma ……………………………………………………3:246 19. Application of Contrast-enhanced Ultrasound in Detecting Vascular Complications after Liver Transplantation ……………………………………………………3:247 11. Analysis of 56 cases with relapse-longitudinally extensive transverse myelitis ……………………………………………………4:360 12. Preliminary study of the optimal time for operation on patients with ossification of the posterior longitudinal ligament of the cervical spine ……………………………………………………4:361 13. Application of minimally invasive nephrolithotomy in the open surgery for patients with renal calculi ……………………………………………………4:362 14. Cerebral developmental venous anomalies:diagnosis by medical imaging ……………………………………………………4:363
