澳門醫學雜誌 - ssm.gov.mo€¦ · 澳門醫學雜誌® Revista de Ciências da Saúde de Macau 季刊 2001年4 月創刊第9 卷第2 期 2009年6 月26 日出版主辦

澳門醫學雜誌®

Revista de Ciências da Saúde de Macau 季刊 2001 年 4 月創刊第 9 卷第 2 期 2009 年 6 月 26 日出版

目次

主辦澳門特別行政區政府衛生局編輯澳門醫學雜誌編輯委員會澳門特別行政區

CP 3002 若憲斜巷衛生局行政樓 2樓電話: (+853)-8390 7307

(+853)-8390 6524 傳真: (+853)-8390 7304 電郵: [email protected] 網址: http://www.ssm.gov.mo

主編李展潤執行副主編, 編輯部主任

黃祥龍出版和發行澳門特別行政區政府衛生局印刷澳門文寶印務有限公司澳門慕拉士大馬路激成工業中心第二期十一樓 J座電話: (+853)-2848 1581 傳真: (+853)-2852 7546 電郵: [email protected]

國際標準刊號 ISSN 1608–7801 ©2009 年版權

歸澳門特別行政區政府

衛生局所有

論著和研究卡貝縮宮素對預防產後出血的臨床觀察⋯⋯⋯⋯⋯李雁王強黃耀斌等

澳門特別行政區衛生局屬下衛生中心醫生

對血液腫瘤標誌物之臨床應用及認知調查⋯⋯⋯⋯⋯⋯區德偉林果

應用聚合酶鏈式反應技術篩選澳門海鮮樣本中霍亂弧菌、

副霍亂弧菌及創傷弧菌⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯向瑞屏李婉芬周天鴻

輸卵管再通術聯合中醫治療輸卵管阻塞性不孕⋯⋯⋯⋯⋯⋯⋯⋯⋯念丁芳

次膠穴刺血拔罐治療慢性前列腺炎30例⋯⋯⋯⋯⋯⋯⋯⋯周紅軍孟建國

肛疾靈洗劑治療妊娠期血栓性外痔

的臨床觀察⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯劉全芳萬進歐金銳等

澳門兒童肺炎鏈球菌 37例耐藥性分析⋯⋯⋯⋯鄭霆鋒李然楊健梅等

綜述和講座從“治未病”理論探討中醫藥對代謝綜合徵的干預⋯⋯⋯⋯⋯⋯趙永華

妊娠婦女無症狀性菌尿

的篩檢⋯⋯⋯⋯⋯⋯⋯⋯CHOI Chong Po, WONG In, NG Sio Fan, et al

雷公籐治療原發性腎病綜合徵的療效評價⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯梁嘉敏

粘多糖貯積癥⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯汪劭婷

行為舉止，生活方式以及健康實踐⋯⋯⋯⋯Carlos António LARANJEIRA

危急重症治腎⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯劉興烈劉敏雯李俊

短篇和病例報告

扁桃體惡性淋巴瘤1例⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯劉水明朱立洪鍾慶佳等

原發性腹主動脈十二指腸瘻：

病案報告⋯⋯⋯⋯⋯⋯⋯伍維侖鄧鴻儒 Barata Frexes Joao Manuel

強制性電抽搐治療老年中國女性

Cotard綜合徵 1例⋯⋯⋯⋯⋯⋯⋯⋯Carlos DUARTE 金海燕張轉乾

大疱性類天疱瘡一例⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯巢和安甄健榮余嘉茵等

消化道異物致慢性腸穿孔的 CT診斷 1例⋯⋯⋯⋯⋯⋯⋯譚文斌謝學斌

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醫學文摘復發性病毒性腦炎的臨床特點和發病機制探討⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

腦膠質瘤相關新基因 PKIβ的表達與蛋白質性質的研究⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

鼻咽癌放療後張口困難的防治⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

絲裂原活化蛋白激酶信號通路相關基因在人骨肉瘤中的表達⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

80例急性髓性白血病 M2型患者

JAK2V617F基因突變的檢測及臨床意義⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

膀胱非上皮性腫瘤的影像學表現⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

小胰腺癌的診斷和預後⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

同步放化療治療老年局部晚期非小細胞肺癌的臨床研究⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

信息和動態甲型流感病毒H1N1亞型⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯編輯部

關於 H1N1新型流感⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯編輯部

澳門地區醫學學術會議簡報⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯蕭瓊

工具和資料國際藥物資訊⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯澳門衛生局藥物事務廳

醫學論文撰寫中的常見問題⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯編輯部

【澳門醫學雜誌】2009年稿約 (中文, 葡文, 英文) ⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

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本期責任校對：蕭瓊葡文、英文翻譯和校對：Jorge Humberto MORAIS，林明理，蕭瓊

Revista de Ciências da Saúde de Macau® 澳門醫學雜誌 Trimestral Lançamento da revista em Abril de 2001 Volume IX Número 2 26 de Junho de 2009

ÍNDICE

Organização Serviços de Saúde(SS) da Região Administrativa Especial de Macau (RAEM) Gabinete Editorial Conselho Editorial da RCSM

CP 3002 RAEM 2o piso, Edifício da Administração dos Serviços de Saúde de Macau Tel : (+853)-8390-7307

(+853)-8390-6524 Fax: (+853)-8390-7304 E-mail: [email protected]

http://www.ssm.gov.mo

Editor-Chefe LEI Chin Ion (李展潤) Editor Geral HUANG Xiang-long (黃祥龍) Edição Serviços de Saúde(SS) da RAEM Impressão

Tipografia Man Bo Lda. Tel : (+853)-2848 1581 Fax: (+853)-2852 7546 E-mail: [email protected]

ISSN 1608-7801

Propriedade ©2009 : Serviçosde Saúde(SS) da RAEM

Dissertação e Investigação Observações clínicas sobre a prevenção da hemorragia pós-parto com “Carbetocin Versus”⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

LEI Ngan,WONG Keong, HUANG Yao-bin, e outros 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⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯AU Tak Wai, LAM Kuo

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⋯⋯⋯HEONG Soi-Peng, LEI Iun Fan, ZHOU Tian-Hong

Tratamento da infertilidade resultante de obstrução ouviducal com recanalização de ouviduto juntamente com medicina tradicional chinesa⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯NIAN Ding-fang

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 ⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯ZHOU Hong-jun, MENG Jian-guo

Observação clínica após uso do medicamento externo “Gangjiling” para tratamento de hemorróidas externas trombosadas durante o período de gravidez ⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯LIU Quan-fang,Wan Jin,OU Jin-rui, e outros

Análise de resistância aos medicamentos ocorrida em 37 crianças com doença pneumocócica em Macau⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯CHEANG Teng Fong, LEE Yan, IEONG Kin Mui

Revisão e Palestras 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”⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯ZHAO Yong-hua

Exame de despistagem à mulher grávida sem bacteriúria assintomática⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯CHOI Chong Po, WONG In, NG Sio Fan e outros

Avaliação do efeito médico de um medicamento tradicinal chinês “tripterygium” aplicado no tratamento da síndrome de nefropatia primária⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Ingrid karmane SUMOU

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Mucopolissacaridose⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯WANG Shao-ting

Comportamentos, Estilos de vida e Práticas de saúde⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Carlos António LARANJEIRA

Rins prejudicados por sintomas severos⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯LIU Xin-lie, LIU Min-wen, LI Jun

Relatório Sucinto e Estudo de Caso

Um caso de linfoma de tonsila⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯LIU Shui-ming, CHU LapHong, CHONG HengKai

Relatório sobre um caso de fístula primária de aorta abdominal e duodeno⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯NG Wai-Ion, DENG Hong-Ru, Barata Frexes João Manuel

Aplicação de uma terapia electroconvulsiva num caso de uma idosa chinesa com síndrome “Cotard” ⋯⋯⋯Carlos DUARTE, JIN Hai-yan, CHEONG Chun Kin

Um caso de penfigóide bolhosa⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯CHAO Wo On, CHIN João Paulo,U Ka Ian e outros

Um caso diagnosticado por TAC sobre enterobrosia resultante de uma substância engolida no tracto digestivo⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯TAN Wen-bin, Xie Xue-bin

Resumos de Artigos Médicos Internacionais

Discussão sobre a característica clínica da encefalite viral recorrente e o mecanismo da sua incidência⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

Estudo da expressão do novo gene PKIβrelacionado com o glioma cerebral, bem como a natureza de proteína) ⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

Prevenção e tratamento da dificuldade na abertura da boca após a radioterapia de carcinoma da nasofaringe⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

Gene de trajecto de sinal MAPK expresso no osteossarcoma humano⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Detecção e significado clínico de mutação de gene JAK2V617F ocorrida nos 80 casos com tipo M2 de

leucemia aguda⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Característica imagiológica do tumor não epitelial da bexiga⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Diagnóstico e prognóstico dos pequenos tumores do pâncreas⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Estudo clínico sobre o sincronismo de quimio-radioterapia para tratar os idosos com o turmor

pulmonar parcialmente, não pequena célula, do estadio avançado⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

Artigos da RCSM e autores (em Chinês, Português e Inglês) ⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

Revisão em Chinês : SIO Keng Revisão em Português e Inglês : Jorge Humberto MORAIS, LAM Meng Lei, SIO Keng

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Health Science Journal of Macao® 澳門醫學雜誌 Quarterly Established in April 2001 Volume IX Number 2 June 26, 2009

CONTENTS

Sponsor

Health Bureau of Macao Special Administrative Region of Macao ( MSAR )

Editorial Office

Editorial Committee of HSJM 2nd floor, Administrative Building, Health Bureau of Macao, CP 3002, MSAR Tel : (+853)-8390 7307

(+853)-8390 6524 Fax: (+853)-8390 7304 E-mail: [email protected] Website: http://www.ssm.gov.mo

Editor-in-Chief

LEI Chin Ion (李展潤) Executive Editor-in-Chief

Xiang-Long HUANG (黃祥龍) Publishing

Health Bureau of MSAR Printing

Tipografia Man Bo Lda. Tel : (+853)-2848 1581 Fax: (+853)-2852 7546 E-mail: [email protected]

ISSN 1608-7801

Copyright © 2009: Health Bureau of MSAR

Original Articles and Research Carbetocin Versus combination of oxytocin and engometring

in Control of postpartum Blood Loss⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯LEI Ngan, WONG Keong, HUANG Yao-bin, et al

A Study of the Awareness and Use of Tumor marker tests in government Primary Health care System in Macao⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯AU Tak Wai, LAM Kuo

The Application of Multiplex PCR method for the Screening of Vibrio Cholerae, Vibrio Parahaemolyticus and Vibrio Vulnificus in Seafood Samples of macao⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯HEONG Soi Peng, LEI Iun Fan, ZHOU Tian- hong

Combine Interventional Oviduct Recanalization with Traditional Chinese Medicine to treat Infertility of Oviduct Obstruction⋯⋯⋯⋯⋯NIAN Ding-fang

Liao Points, Pricking Blood Cupping Treatment of Chronic Prostatitis 30 cases⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯ZHOU Hong-jun, MENG Jian-guo

The clinical Effect of “ Gangjiling” lotion in the treatment of Female pregnant patients with Thrombotic external haemorrhoid⋯⋯⋯⋯⋯⋯LIU Quan-fang, WAN jin, OU Jin-rui,et al

An introduction and resistance Analysis of 37 cases of pneumococcal disease in Children of macao⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯CHEANG Teng Fong, LEE Yan, IEONG Kin Mui, et al

Collective Reviews and Lectures

Discussion Intervention of chinese Medicine on Metabolic syndrome fromthe theory of “ Preventive treatment of disease” ⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯ZHAO Yong-hua

Asymptomatic Bacteriuria screening in preganat women⋯⋯⋯⋯⋯⋯⋯⋯CHOI Chong Po, WONG In, NG Sio Fan, et al

Efficacy and safety of tripterygium in primary nephrotic syndrome⋯⋯⋯⋯Ingrid Karmane SUMOU

Mucopolysaccharidosis⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯WANG Shao-ting

Behavior, Life Style and Health Practices⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Carlose António LARANJEIRA

Peril seriously symptom control kidney⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯LIU Xin-lie, LIU Min- wen, LI Jun

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Short Report and Case Report Malignant Lymphoma of Tonsil : A case report⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

LIU Shui-ming, CHU Lap Hong, CHONG Heng KAI, et al Primary aortoduodenal fistula : A case report⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

NG Wai-lon, DENG Hong-Ru, Barata frexes joao manuel Cotard Syndrome and Electroconvulsive Therapy in an Elderly Chinese lady without Capacity to

Consent to Treatment: A Cases Report⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Carlos DUARTE, JIN Hai-yan, CHEONG Chun Kin

A Case of Bullous Pemphigoid⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯CHAO Wo On, CHIN Joao Paulo, U Ka Ian, et al

CT diagnosis of Enterobrosis Caused by A Swallowed Foreign Bodies in Digestive Tract: A Case report⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯TAN Wen-bin, XIE Xue-bin

Foreign Medical Abstracts

Clinical characteristics of relapsing virus encephalitis and mechanisms of relapse⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Expression and characterizations of novel full-length gene PKI β related to human glioma⋯⋯⋯⋯⋯⋯⋯Prevention of trismus in nasopharygeal carcinoma patients treated by radiotherapy⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Gene profiling of MAPK pathway in human osteosarcoma⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Detection of JAK2V617F mutation and its clinical significance in 80 patients with M2 acute⋯⋯⋯⋯⋯⋯Imaging features of nonepithelial tumors of the bladder⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Small pancreatic cancer diagnosis and prognosis⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯Analysis of effect of concurrent chemoradiotherapy on elderly patients with locally advanced

non-small cell lung cancer⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯

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Articles of HSJM to authors ( in Chinese, Portuguese, and English) ⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯⋯ 161

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, June 2009, Vol.9, No.2

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‧論著和研究‧

卡貝縮宮素對

預防產後出血的臨床觀察

李雁王强黄耀斌 Rolando MARTINS 駱一凡【摘要】目的比較卡貝縮宮素與催產素聯合麥角新堿對治療及預防產後出血的臨床療效。方法

將臨產的單胎孕婦分為單、雙日組，單日組使用卡貝縮宮素 100 µg 慢慢靜脈推注，雙日組聯合使用催產素(5units)及麥角新堿(0.2mg) 肌肉注射。結果卡貝縮宮素與聯合組用藥相比，前者可顯著降低

產後的平均出血量 (P<0.05)。結論卡貝縮宮素能降低產後出血的發生率，或許是一種較好的宮縮替換藥物之一。【關鍵詞】產後出血; 卡貝縮宮素; 催產素; 麥角新堿

Carbetocin Versus Combination of Oxytocin and Engometrine in Control of Postpartum Blood Loss LEI Ngan, WONG Keong, HUANG Yao-bin, Rolando MARTINS, LUO Yi-fan. Department of Obstetric, Centro Hospital Conde de São Januário(CHCSJ), Macao SAR, PR China; Tel : (+853)-8390 8326; E-mail : gracelei.ngan@gmail 【Abstract】 Objective To compare carbetocin and the combination of oxytocin and ergometrine in the control of

postpartum blood loss. Methods This retrospective study evaluated a total of 118 women, who received either carbetocin (carbetocin group) or combined treatment with oxytocin and ergometrine (combination group) after vaginal delivery from January to April, 2004. Results The carbetocin group (n=56) and the combination group (n=62) demonstrated similar demographic characteristics. Mean blood loss after carbetocin administration was less than after combined group (P=0.01). A significantly greater drop in hematocrit was also observed in the combination group (P=0.03). Conclusion Carbetocin treatment is associated with significantly less blood loss after vaginal delivery.

【Key words】 Post-partum hemorrhage; Carbetocin; oxytocin; Ergometrine 產後出血是產科最常見最危急的嚴重併發症之

一，也是產婦死亡的主要原因。目前世界衛生組織

(WHO)仍認為產後出血是指胎兒娩出後出血量達到或超過 500ml 者。根據 2001 年 WHO 的統計分析，每年大約有 515 000婦女的死亡與妊娠有關，其中產後出血約佔 25%。根據中國 2000 年的調查統計，孕產婦死亡率巳明顯降至 81/10 萬，但孕產婦死亡原因仍以產後出血為主，最常見的產後出血原因以子宮收

縮乏力占首位，佔產後出血總數的 70- 80%[1]。目前常用的子宮收縮劑有催產素類、麥角新堿

及前列腺素。催產素是最常用的宮縮劑，可預防 6-10% 的產後出血，但其半衰期短(3-10min)；麥角新堿用於治療產後宮縮乏力，主要作用於子宮下段，其

副作用易引起胎盤滯留及高血壓。作者單位：中國, 澳門特別行政區, 仁伯爵綜合醫院, 婦產科; Tel : (+853)-8390 8326; E-mail : gracelei.ngan@gmail

前列腺素也是有效控制產後出血的宮縮劑，但

較昂貴及引起發熱、腹瀉等副作用。卡貝縮宮素 Carbetocin (Duratocin® )是一種全新的催產素類激動藥物，對催產素受體親和性高，半衰

期較長 (40-50 mins)，能夠迅速起效的長效催產素啟動劑(60-120 mins)，適用於預防和治療子宮收縮乏力的產後出血。作者將卡貝縮宮素與催產素聯合麥角新堿對治

療及預防產後出血進行了臨床的對比和分析，報告如

下：

資料與方法 1 病例分組及用藥方法 (1) 研究對象：2004 年 1~4 月隨機選取 118 例 18 歲以上，臨產的單胎妊娠，無心血管系統疾病，無肝、腎、血液系統和其他內分泌系統的疾病。


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(2) 將臨產的單胎孕婦分為單、雙日組，單日組使用卡貝縮宮素 100 µg 緩慢靜脈推注，雙日組聯合使用催產素(5units)及麥角新堿(0.2mg) 肌肉注射。 2 觀察指標與測定方法 (1) 於胎兒娩出後立即給藥，使用消毒非吸水紙收集出血量並稱其重量，收集產後 24小時所使用的衛生巾並稱之淨重量，以統計產後 24小時的總出血量。

(2) 所有被選取的產婦均需記錄年齡、身高、體重。 (3) 所有產婦均於臨產時及產後 24h 驗血常規，分娩前後測量血壓、脈搏、子宮收縮的強度、硬

度，子宮的高度，及第三產程所需的時間。 3 統計學處理兩組計量資料之間採用 T 檢驗，卡方檢驗進行相關系數顯著性檢驗。

結果

共有 118 例產婦被隨機選入此項臨床研究，卡貝縮宮素組 56 例，催產素及麥角新堿聯合用藥組 62例。兩組產婦一般情況的資料分析，結果顯示兩組

之間差異無顯著性，見表 1-5。

表 1 產婦的一般情況組別 Carbetocin Combination P value

例數平均年齡

56 29.7 [4.5]

62 30.7 [5.6]

- 0.30

身高 (cm) 157.9 [5.2] 158.2 [5.7] 0.83 體重(kg) 66.8 [8.3] 65.8 [9.6] 0.56 胎兒娩出到胎盤娩出的時間 (min) 8.0 [0.2] 8.0 [0.3] 0.67

表 2 兩組產後 24 hr出血量的比較

Carbetocin Combination P value Mean (ml) 388 551 0.01 S.D. 252 398 - Max 1670 2000 - Min 40 100 - Median 335 400 - Lower quartile 230 300 - Upper quartile 458 680 -

表 3 比較兩組在失血量超過 500ml及超過 1000ml的病例百分數

Carbetocin Combination ≥ 500 ml 12 (21.4%) 27 (43.5%) ≥ 1000 ml 1 (1.8%) 9 (14.5%)

表 4 分娩前後血色素 (Hb) 改變的比較 Carbetocin Combination P valueHb 分娩前(g/dL) (a) 12.33 [0.98] 12.34 [0.99] 0.97 Hb 分娩後(g/dL) (b) 11.33 [1.35] 11.14 [1.33] 0.44 血色素下降程度 -1.00 [1.26] -1.20 [1.09] 0.36

表 5 分娩前後血球溶積 (HCT) 改變的比較 Carbetocin Combination P valueHCT 分娩前(%) 35.43 [4.86] 35.87 [2.52] 0.53 HCT 分娩後(%) 33.24 [4.11] 32.27 [3.54] 0.17 HCT下降程度 -2.19 [3.63] -3.60 [3.21] 0.03

與聯合用藥組相比，卡貝縮宮素可顯著降低分娩

期間的平均出血量 (P<0.05)。失血人群中，失血量≥500ml<1000ml 及≥1000ml 的兩組例數比較, 在卡貝縮宮素組分別為 12 例(21.4%) 及 1 例(1.8%)，而聯合用藥組為 27例(43.5%) 及 9例(14.5%)。對失血人群的分柝表明，卡貝縮宮素組失血量≥500ml<1000ml 或≥1000ml 的病例數要明顯低於聯合用藥組，顯示該藥能明顯減少出血量及產後發病率。血色素 (Hb) 於分娩前後的改變在統計學上無顯著意義。血球溶積 (Hematocrit) 於分娩前後的改變在統計學上有顯著性不同。子宮收縮強度兩組無明顯差別。

討論

從上述結果顯示卡貝縮宮素與臨床常用的催產

素聯合麥角新堿用藥相比，可顯著降低產後的平均出

血量(P<0.05)卡貝縮宮素組產後出血(PPH)的發生率為 21.4%，而聯合用藥組則為 43.5%，卡貝縮宮素組明顯低於聯合用藥組，有統計學的意義，顯示該藥能

明顯降低產後出血發生率。催產素是最常用的宮縮劑，可預防 6-10%的產後出血，但其半衰期短 (4-10min)，需持續靜脈點滴維持療效，且易引起血壓下降，導致低血壓及代償性

的心動過速，另外大劑量使用催產素使子宮平滑肌細

胞上的受體處於飽和狀態，以致過量的催產素無法起

效[1]，故預防產後出血受到限制。麥角新堿 (Ergometrine) 用於治療產後宮縮乏力


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及產後出血，直接作用在子宮平滑肌而引起收縮，主

要作用於子宮下段，由於其同時作用於外周血管平滑

肌 α-受體上；其副作用易引起胎盤滯留、高血壓，甚至心肌缺血及肺水腫[1]。前列腺素及其衍生物的發展，提供了多種給藥

途徑，如前列腺素 E1 的衍生物米索前列醇 (Misoprostol) 可口服及陰道或直腸用藥，有報道指在預防產後出血方面口服或直腸使用米索前列醇其效果

不如注射宮縮劑, 但其性質穩定容易儲存，價格低，副作用少[2-3]。前列腺素 F2α 主要用於治療嚴重的產後出血，一般為深部肌肉注射，持續一小時。前列腺素 F2α 較昂貴及易引起噁心、嘔吐、腹瀉、發熱等，偶見呼吸窘

迫。雖然其副作用較少及相對比較安全，但對心血管

或肺病患者仍需慎用。一般應用於催產素無效時[1,2]。

卡貝縮宮素於 1987 年首次報道，它是一種合成的催

產素類激動劑，對催產素受體的親和性高，半衰期長

(40-50 min)，藥效時間長，是一種能迅速起效的長效的催產素啟動劑；其耐受性較好，安全性方面與催產素

相似[4-7]。 Boucher 在 1998 年等進行一項臨床研究在選擇性剖腹產術對增強子宮收縮強度及術中出血量方面，

單劑量靜脈注射卡貝縮宮素的療效相當於持續靜脈點

滴催產素[4]。據 2004年 Boucher等報道, 卡貝縮宮素與催產素在預防產後出血方面，兩者比較卡貝縮宮素

組較少使用額外子宮收縮劑。有文獻報道卡貝縮宮素

組的產後出血發生率較催產素組為低[6]。2004 年 SW Leung 等也報道有關陰道分娩後使用卡貝縮宮素與Syntometrium, 結果顯示卡貝縮宮素組較少使用額外宮縮劑[8]。卡貝縮宮素只需單劑量注射給藥，可靜脈或肌

肉注射，使用便捷。同時也消除了催產素持續靜脈滴

注、監測和調整劑量的麻煩，產婦可盡早下床走動，有利於惡露的排出，不必受靜脈點滴的約束。臨床結果顯示卡貝縮宮素能降低產後出血的發

生率或較少使用額外宮縮劑，並具有良好的安全性和

耐受性。卡貝縮宮素與催產素相比在治療產後出血方

面具有一定的優勢，可能是一種較好的宮縮替換藥物

之一[7] 。然而卡貝縮宮素仍是較新的藥物，還需在

臨床應用上繼續觀察。致謝感謝澳門仁伯爵綜合醫院婦產科所有參與此項研究工作的醫務人員，特此致謝。

參考文獻

1 戴鐘英, 產後出血專題討論. 實用婦產科雜誌, 2003,

19:257-265. 2 黃潔敏, 駱一凡. 產後出血臨床治療進展. 澳門醫學雜誌, 2001, 1:257-259.

3 Bulgaho A, Daniel A, Faundes A, et al. Misoprostol for prevention of postpartum hemorrhage. Int J Gynecol & Obstet, 2001, 73:1-6.

4 Boucher M, Horbay G, Griffin P, et al. Double-blind, randomized comparison of the effect of carbetocin and oxytocin on intraoperative blood loss and uterine tone of patients undergoing caesarean section. J Perinatol, 1998, 18:202-207.

5 Dansereau J, Joshi A, Helewq M, et al. Double-blind comparison of carbetocin versus oxytocin in prevention of uterine atony after caesarean section. Am J Obstet Gynaecol, 1999, 180:670-676.

6 Boucher M, Nimrod C, Tawagi G, et al. Comparison of carbetocin and oxytocin for the prevention of postpartum haemorrhage following vaginal delivery:a double-bline randomized trial. J Obstet Gynaecol Can, 2004, 26:481-489.

7 Chong YS, Su LL, Arulkumaran S. Current strategias for the prevention of PPH in the 3rd stage of labour. Curr Opin Obstet Gynecol 2004, 16:143-150.

8 SW Leung, Ng PS, Wong WY, et al. A randomised trial of carbetocin versus syntometrine in the management of the third stage of labour. BJOG, 2006, 113:1459-1464.


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A Study of the Awareness and Use of Tumor Marker Tests in Government Primary Health Care System in Macao AU Tak Wai LAM Kuo

【Abstract】 Objective The objective of this research study is to analyze the awareness and the use of tumor markers tests, how often doctors apply tumor markers tests in daily practice and analyze why tumor maker tests are requested by general practitioners in Macao government health centers. Methods Questionnaires were given to all doctors in the health centers in Macao. Results According to this research study, two-third doctors do not update the clinical information of tumor marker tests. The purpose of screening is most common reason that applied for tumor marker test up to 84%, the second common reason is for diagnosis of cancer (28%). Conclusion These findings suggest that it shows that the awareness of general practitioners are insufficiency, the use of tumor marker tests are not appropriate. Further education and information updated in the appropriate use of tumor marker tests for family physicians in Macao health center is needed. 【Key words】 Tumor markers; Awareness; Study 澳門衛生中心醫生對血液腫瘤標誌物之臨床應用及認知調查區德偉, 林果. 中國, 澳門特別行政區, 衛生局, 塔石衛生中心; Tel : (+853)-6681 0952; E-mail : [email protected] 【摘要】目的為了解澳門特別行政區衛生局屬下衛生中心醫生對血液腫瘤標誌物之認知及臨

床使用情況。方法本人對衛生中心醫生以書寫不記名問卷方式進行本次研究調查。結果本次

調查結果顯示有三分二衛生局衛生中心醫生沒有定期更新有關血液腫瘤標誌物臨床資訊。其中以血液

腫瘤標誌物作篩查目的為最常見 (84%)，第二位為診斷目的 (28%)。結論調查發現，衛生中心醫生對血液腫瘤標誌物之認知存在差異，亦顯示血液腫瘤標誌物在臨床使用不合理性，有需要進一步加

強對血液腫瘤標誌物在臨床使用資訊和教育。【關鍵詞】血液腫瘤標誌物; 認知; 調查

INTRODUCTION Since 1965, the first successful tumor marker (CEA) in developing a blood test was found in the blood of some patients with colon cancer. By the end of the 1970s, several other blood tests had been developed for different cancers[1]. Each tumor marker has a variable profile of usefulness. For example: for screening or early detection of cancer, diagnosing cancer, determining the prognosis, determining the effectiveness of cancer treatment and detecting recurrent cancer. Authors address : Tap Seac Health Center, Health Bureau, Macao SAR, PR China; Tel: (+853)-6681 0952; E-mail: [email protected]

In the analyzed data, most of the tumor marker tests have not demonstrated a survival benefit in randomized controlled trials of screening in the general population. The most widely accepted marker is PSA blood test. It is used to screen for prostate cancer. However, there are still controversies in some articles for screening in asymptomatic patients. In Asia, there is still a high prevalence of hepatitis B carriers in the population. Some studies demonstrated improved survival rate with AFP screening. The most common screening strategy for Hepatic Cellular Carcinoma (HCC) in these patients are to check for serum AFP and ultrasound performed every 6 months, with CT or MRI as an alternative to ultrasound[2]. Nevertheless, the use of tumor marker tests can play a crucial role in detecting cancers.


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The role of tumor markers in detection of recurrence and effectiveness of cancer treatment is recommended in some selected patients or in certain cancers. CEA, PSA, CA125 or CA15.3 is recommended to determine the effectiveness of treatment and detect recurrence in Colon Cancer, Prostate Cancer, Ovarian Cancer and Breast Cancer respectively[3]. As in clinical practice, family doctors are assuming a gate-keeper role in caring for patients. The prevalence of cancers trends is increasing in the whole world. Cancer is a critical disease that is of great concern to physicians. In 2005, a study on “understanding the appropriateness of use in tumor marker tests in government primary health care system in Macao” was carried out. According to this research study, a total of 19257 tumor marker tests were requested in primary health care system in 2005, and the cost involved more than Mop 7 million dollars[4]. However, this study also showed that tumor markers tests have been overused unnecessarily in most cases. Through this study, I would like to analyze the awareness and the use of tumor markers tests by doctors in primary health care system in Macao.

OBJECTIVE The objective of this research study is to analyze the awareness and the use of tumor markers tests, how often doctors apply tumor markers tests in daily practice and analyze why tumor maker tests are requested by general practitioners in Macao government health centers. This research aims at giving a better understanding in the application and the reasons for requesting different tumor marker tests. It may also provide data on the awareness and the behavior in requesting tumor marker tests by general practitioners in Macao.

SUBJECTS Subjects of this study were doctors working in

government health centers in Macao. All of the doctors with out-patient consultation in the health centers were recruited in this study.

METHODS Questionnaires were given to all subjects to fill in within a designated time frame. The questionnaires included a total of 10 multiple choice questions in which respondents can either choose a single answer or multiple answers to each question. The questionnaires were divided into three categories. The first part of the questionnaire is to see whether doctors update current clinical information of tumor markers tests regularly. The second part is to understand doctor’s awareness in the use of each tumor marker tests (These tumor markers tests are all available for them to apply in the health centers of Macao). The last part is to analyze how often doctors apply tumor markers tests and the reasons for requesting different tumor marker tests. A total of 85 questionnaires were assigned to doctors in the health centers in Macao. Doctors completed the questionnaires anonymously in their respective health center. Out of the 85 questionnaires, 65 questionnaires were finished and collected for data analysis.

DATA ANALYSIS & RESULTS The data collected in the questionnaire are as follows: 1 22 subjects (35%) obtained regular clinical information of tumor markers tests. 42 subjects (65%) did not have current updates on clinical information of tumor markers tests. 2 Serial questions 4 in the questionnaire is to analyze how often doctors apply tumor markers tests in daily practice and analyze why tumor maker tests are


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requested by general practitioners (1) The question is to investigate whether general practitioners have applied tumor maker tests within that past three months. Data showed that 58 subjects (89%) had applied tumor marker tests within the past three months. 7 subjects (11%) showed that they did not apply tumor marker in the past three months . (2) The frequency of using tumor marker is subdivided into four categories (0 times, 1 to 5 times, 6 to 10 times or more than 10 times). Data showed that 7 subjects did not apply any tumor markers test, 38 subjects (59%) applied tumor tests 1 to 5 times, 12 (19%) 6 to 10 times, 8 (13%) more than 10 times.

(3) Subjects who responded that they applied tumor markers tests in the past three months (the total subjects were 58), question 4.3 is to further investigate what type of tumor marker tests were applied. 32 subjects out of 58 (55%) applied CEA tumor marker tests, 50 subjects (86%)applied AFP tumor marker tests, 32 subjects (55%) applied CA 125 tests, 41 subjects (71%) applied PSA profile tests, 12 subjects applied CA 15.3 tests, and 16 subjects applied CA 19.9 tests. (4) The reasons for requesting tumor marker tests in clinical practice in the past three months. 49 subjects (84%) out of 58 applied tumor marker tests for purpose of screening, 16 subjects (28%) for diagnosis, 8 subjects for recurrent cancer, 4 subjects (7%) for effectiveness of cancer treatment (see Table 1).

Table 1 The reasons for requesting tumor marker in past three months

The reasons for requesting tumor marker tests Screening Diagnosis Recurrent cancer Effectiveness of cancer treatmentNumbers of each reasons 49 (84%) 16 (28%) 8 (14%) 4 (7%)

DISCUSSION

From the above data, there were only 22 subjects (35%) out of 65 who attained regular clinical information of tumor markers tests. 42 subjects (65%) did not have current updates on clinical information of tumor markers tests. This means that two-thirds of the general practitioners showed that they did not have updates on information of tumor marker tests. From the above data, in CEA tumor marker, 21 subjects (32%) agreed that the use of CEA has clinical significance for purpose of screening, and 15 (23%) for diagnosis. In CA125 tumor marker, 22 subjects (34%) agreed that the use of CA125 has clinical significance for purpose of screening, and 14 (22%) for diagnosis. In CA15.3, 25 subjects (38%) agreed that use of CA15.3 has clinical significance for purpose of screening, 10 (15%) for diagnosis, and 41 (63%) for recurrent cancer. In the introduction section, it showed clearly that most of the tumor marker tests have not demonstrated a benefit in screening in the general population. The widely accepted marker is PSA blood test. It is used to screen for prostate

cancer in men aged 50 or over. AFP is recommended for use in regular check up in hepatitis B carrier for Hepatic Cellular Carcinoma. In this questionnaire, the limitation is that it cannot be further concluded that these two situations has clinical significance for purpose of screening in this study. However CEA, CA125, CA15.3 have no clinical significance for purpose of screening or diagnosis[4]. Data showed that 58 subjects (89%) had applied tumor marker tests within the past three months. Only 7 subjects (11%) showed that they did not apply tumor marker in the past three months. The majority of doctors had requested tumor marker tests in the past three months. In analyzing the frequency of tumor marker tests applied by most of the doctors, 38 subjects (59%) applied 1 to 5 times in the past three months, 12 subjects (19%) 6 to 10 times, 8 subjects (13%) more than 10 times. It means that 23% doctor applied tumor tests more than 6 times in recent three months. From the above data, it cannot reflect the actual numbers of tumor markers tests that were applied. At this stage, it is hard to analyze the frequency of tumor marker tests that were applied


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now, and it is necessary to collect data to calculate the actual numbers. AFP and PSA tumor marker tests were the most tumor makers that were applied by general practitioners. Before general HBV vaccination was injected in new born babies, Hepatitis B carriers were still in high prevalence in Macao. Although nowadays, newborn babies have a good prevention of Hepatitis B, the number of immigrants and visitors are growing in recent years. The rate of Hepatitis B can increase by the influx of these people. Therefore, hepatitis B is still a crucial concern in daily practice. 44 cases of new prostate cancer were diagnosed in Macao in 2004. This showed that prostate cancer is the 4th most common cancer in male. However, prostate cancer raised from the 4th to the 2nd most common cancer in male[5]. This may be one of the reasons why general practitioners are applying more PSA tumor marker tests, but the actual reason behind still needs further research.

CONCLUSION According to this research study, it shows that two-third of the doctors do not update clinical information of tumor marker tests. The awareness of general practitioners in using tumor marker tests is insufficient. The purpose of screening is the most common reason doctors applied tumor marker test (up to 84% of the

sample). This shows that the use of tumor markers tests is not always appropriate. In fact, this misuse of tumor marker tests can lead to a misuse of resources. These resources can otherwise be spent in other well-recognized screening tests, such as Pap Smear in the prevention of cervical cancer, hepatitis B vaccination for HBsAg negative people or Fecal Occult Test in the prevention of colorectal cancer. Indications of the tumor markers should be held strictly and the restriction of such tumor markers should be made aware to the general practitioners. On the other hand, the concept of requesting tumor marker test is unclear to some general practitioners. General practitioners should be more vigilant on updating medical guidelines for the management of different types of cancers.

REFERENCES

1 Bigbee W, Herberman RB. Tumor markers and immunodiagnosis. Cancer Medicine. 6th ed. Hamilton: BC Decker, 2003, 209-220.

2 Ralph G, Jean SK, Current Practice Guidelines in Primary Care 2005. New York:McGraw-Hill, 2005, 22-28.

3 Catharine S. Practice Guidelines for Tumor Marker Use in the Clinic. Clinical Chemistry, 2002, 48:8 1151-1159.

4 Robert AS, Vilma C, Harmon JE. American Cancer Society Guidelines for the Early Detection of Cancer 2006. CA Cancer J Clinicans, 2006, 56:11-25.

5 Taskforce for Annual report of Macao cancer registry. Macao cancer registration 2005, 1st ed. Macao:Health Bureau of Macao SAR, 2006, 10.


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The Application of Multiplex PCR Method for the Screening of Vibrio Cholerae, Vibrio Parahaemolyticus and Vibrio Vulnificus in Seafood Samples of Macao HEONG Soi Peng LEI Iun Fan* ZHOU Tian Hong**

【Abstract】 Objective The microbiological safety of food is always an important concern of global health. In fact, food-borne illness caused by bacterial pathogens is not rare in Macao, especially in summer months. Vibrio species are the usual bacteria, which always involve in the cases of seafood poisoning in Macao. The conventional culture base method for Vibrio species detection in food is a time-consuming and laborious method. Thus, a rapid Multiplex PCR (mPCR) method was developed for the detection of Vibrio choleare O1/O139, Vibrio parahaemolyticus and Vibrio vulnificus in seafood samples simultaneously. Methods There were 76 seafood samples have been examined by using conventional culture method and mPCR method from May to October 2006. The sample source was purchased from the open markets, supermarkets, restaurants within Macao. Results In the results of sample detections, even though there was no toxigenic V. choleare has been detected but the high positive rate of V. parahaemolyticus (98.7%) and V. vulnificus (71.1%) were found by mPCR method. However, the low isolation rate of culture method could be due to the factor of VBNC (Viable But Non Culturable) state of Vibrio species and sample storage conditions etc. Those problems show the disadvantage of the conventional culture detection method. Conclusion Therefore, a quick and easy mPCR method is needed to apply in the seafood samples screening for V. choleare O1/O139, V. parahaemolyticus and V. vulnificus in Macao. 【Key words】 Multiplex PCR; Vibrio choleare O1/O139; Vibrio parahaemolyticus;

Vibrio vulnificus; Seafood; Macao 應用聚合酶鏈式反應技術篩選澳門海鮮樣本中霍亂弧菌、副霍亂弧菌及創傷弧菌向瑞屏, 李婉芬*, 周天鴻** 中國, 澳門特別行政區, 澳門理工學院, 高等衛生學校; 現時通訊地址：澳門藥物及健康應用研究所中藥及食物安全實驗室; Tel : (+853)-8897 2618; E-mail: [email protected]; *中國, 澳門特別行政區, 澳門理工學院, 高等衛生學校; **510632, 中國, 廣州暨南大學, 生命科學技術學院. 【摘要】目的由病原所引致的食物中毒於澳門並不罕見。其中弧菌是常見會引起海鮮性食物

中毒的細菌。澳門普遍使用傳統培養方法來對海鮮中的致病弧菌進行檢測，然而傳統方法較費時及耗

費人力。因此，發展出一個快速的 mPCR 方法能同時檢測海鮮樣本中的 O1/O139 型霍亂弧菌，副霍亂弧菌及創傷弧菌。方法於 2006 年的 5 至 10 月期間，利用 mPCR 技術和傳統細菌的培養方法，共檢測了 76 個海鮮樣本。其中的樣本購買自澳門市內各個街市、超級市場及餐廳。結果從 mPCR方法檢測得出，雖然沒有檢出 O1 或 O139 霍亂弧菌，但副霍亂弧菌(98.7%)及創傷弧菌(71.1%)皆為高陽性比例。而傳統培養方法的分離率則偏低，可能是由於樣本中的弧菌出現「可見但不可培養」的狀

態及樣本的新鮮程度等因素所影響。這些問題均顯示出傳統培養方法的不足。結論一個快速且簡便的 mPCR方法應用於澳門的海鮮樣本中，對致病弧菌作出篩選是有必要的。

【關鍵詞】多基因聚合酶鏈式反應; 霍亂弧菌 O1/O139 型; 副霍亂弧菌; 創傷弧菌; 海鮮; 澳門 Authors address : School of Health Science, Macao Polytechnic Institute, Macao SAR, PR China; Current address : Macao Institute for Applied Research in Medicine and Health, Chinese Medicines and Food Safety Laboratory, Macao SAR; Tel : (+853)-8897 2618; E-mail: [email protected]; *School of Health Science, Macao Polytechnic Institute, Macao SAR; **College of Life Science & Technology, JiNan University, Guang Zhou, 510632, PR China.


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INTRODUCTION

Food safety is always an important concern of global health. Foodborne diseases caused by microorganisms are a large and growing public health problem. According to the data of World Health Organization second global forum of food safety, unsafe food is responsible for illness in at least 2 billion people worldwide and can result in death annually. Seafood is one of the high-risk food types for food poisoning, due to the lightly cooked or raw consumption, especially in summer time. In fact, the bacterial foodborne outbreak caused by the consumption of contaminated seafood is common.

Seafood and seafood products are popular in many

restaurants in Macao, a lot of delicious cuisines are made with raw or undercooked seafood. However, the foodborne pathogens naturally present in the marine environment. Vibrio species are one of the most common group of pathogens associated with the food poisoning after seafood consumption. Members of the genus Vibrio are natural inhabitants of sea water and more prevalent with warm coastal waters, and summer months are the good season for them. There are three species of Vibrio are the major pathogens related with foodborne diseases, they are V. cholerae, V. parahaemolyticus and V. vulnificus.

Vibrio cholerae is the most concern species among

Vibrio, because it is the causative agent of cholera. More than 200 serogroups of V. cholerae O antigen, only O1 and O139 are associated with the epidemiological features and severe clinical syndrome. The most important virulence factor associated with V. cholerae O1 and O139 serogroup is the cholera enterotoxin (CT). CT is encoded by two contiguous genes ctxA and ctxB. These two genes forming the ctxAB operon, located within a larger genetic element called CTX. Since the presence of the cholera toxin operon is a prerequisite for pathogenicity, the ctxAB genes are the targets for the mPCR amplification of detect the toxigenic V. cholerae in this study. In another words, the nontoxigenic V. cholerae is not the target in this research.

Vibrio parahaemolyticus usually causes

gastroenteritis but it also causes wound infection and septicemia. V. parahaemolyticus produce a major virulence factor, the thermostable direct hemolysin (TDH) and the TDH-related hemolysin (TRH). Actually, not all strains of V. parahaemolyticus cause illness in human; the majority of strains isolated from the environment or seafood are not pathogenic. However, in many places

around the world V. parahaemolyticus continued to be the top causative agent among all the reported food poisoning outbreaks in recent years[1-3]. Thermolabile hemolysin gene (tlh) has been observed in all V. parahaemolyticus strains, the product of this gene has not been associated with pathogenicity, this gene is therefore a useful target for the detection of total V. parahaemolyticus[4].

Wound infections, gastroenteritis, or a syndrome

known as “primary septicemia” can be caused by V. vulnificus. The septicemia is associated with the consumption of raw contaminated seafood. Contact of wounds with seawater or contaminated shellfish can also lead to a fatal septicemia or require limb amputation. Both septicemia and wound infection are noted for the extremely rapid replication of bacteria in host tissues with extensive tissue damage to the skin. Even with treatment, mortality rates for septicemia can be over 70%, and mortality rates for wound infection can be as high as 50%[5]. V. vulnificus produce a cytotoxin-hemolysin (VVH), a toxin causing lysis of various cells and erythrocytes, is the possible virulence factor[6-7]. The DNA sequence of encoding VVH contains two open reading frames, vvhA and vvhB. vvhA is the target for the molecular detection of V. vulnificus in this study.

The conventional microbiological pathogens

detection methods are culture based methods, such methods suffer from a number of drawbacks. (1) Culture based methods are time consuming, laborious, tedious, invariably monospecific (one type pathogen detection), and low throughput. (2) Many pathogenic organisms although viable in the environment, but they are either difficult to culture or non-culturable, however, they still can cause illnesses in humans or animals. (3) Pathogenic bacteria that normally occur in low numbers in the sample, and tend to incur large injure in the sampling procedures and preparation. All of the above disadvantages will cause the false negative results easily. Due to the many limitations of conventional method, the development of a quick and cost-effective method for the detection of microbial pathogens in food is needed.

Multiplex PCR (mPCR) actually is base on the PCR

principle, but it can produce simultaneous amplification of many targets of interest in one reaction by using more than one pair of primers. This technique is also applied in the detection of foodborne pathogens from 1990s[8-9]. mPCR is a rapid and highly sensitive examination method. There are many good aspects of the development of mPCR assay in Macao. It helps not only to increase the level of the food examination in Macao,


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but also brings Macao to approach the International standard. Furthermore, in the views of public health concern and food hygiene quarantine, rapid and precise results of a method are the critical points to consider. mPCR fulfills the requirements. This study is going to develop an mPCR assay for the detection of three important Vibrios, including V. cholerae, V. parahaemolyticus and V. vulnificus in seafood specimens in Macao.

MATERIAL & METHOD 1 Samples and Sample preparation There are totally 76 seafood samples were examined in this study. The most part of the samples are bivalve shellfishes. The Family and Species of the samples had been categorized and listed as below (Table 1). Samples were bought from the markets and restaurants in Macao. They were aseptically shucked in laboratory, Alkaline Peptone Water (APW) and APW with 3% NaCl were used as diluents. After the dilution and enrichment steps, the samples were ready for the mPCR amplification and target pathogens isolation. 2 Target pathogens isolation and identification There were 3 types of selective agar medium used for the Vibrio spp. isolation in this study. They are Cholera Medium TCBS, Cholera Medium TCBS with 3% NaCl, and the Modification of V. vulnificus Medium.

Triple Sugar Iron Agar, Oxidase, Gram stain, Vitek GNI+ card and Vitek 32 bacteriological identification system were used for the analysis. Serological tests for V. cholerae O1/O139 were used to confirm the serotype of V. cholerae colonies.

Table 1 Categories of the samples Sample Name Family / Species Name Qty.

Ark Shells Scapharca subcrenata 2 Green Mussel Perna viridis 4 Fan shell Pinna pectinata 7 Scallop Chlamys nobilus 15 Oyster Crassostrea spp. 22 Calms Veneridae 17 Elephant Trunk Clam Panopea abrupta 3 Razor Clam Sinonovacula constricta 4 Mince Fish ------ 2

Total 76 3 Primer designs and mPCR amplification The primers were designed from the ctxA gene; tlh gene; and vvha gene (Table. 2). 25µl of master mix, 5µl of 10X primer mix, 18µl of sterile deionized water and 2µl of sample DNA templates. The mPCR reaction was performed with a pre-denaturation at 94°C for 2 minutes, and 35 amplification cycles with denaturation at 94°C for 60 seconds, annealing at 60°C for 90 seconds, and extension at 72°C for 90 seconds. An additional step of 10 minutes at 72°C was also included for primer extension at the end of the reaction. After the reaction was completed the PCR products were detected by agarose gel electrophoresis followed by visualization under a UV transilluminator.

Table 2 Oligonucleotide primer design

Bacterial Strains Target gene Primer pair Primer length Product size

Vibrio cholerae ctxA 5’ 5’

TTG ATG

TTAATG

GGCAAT

ACGCCA

ATGCGG

ATGCTC

GATT

3’ 3’ 20 392

Vibrio parahaemolyticus tlh 5’ 5’

AGC CCA

ACGGTT

CAAGTA

GAAGAG

AACCGG

CAAAAG

ACGT

3’ 3’ 20 492

Vibrio vulnificus vvhA 5’ 5’

AAA ACT

GTGGTG

GGTAGC

GGCGTT

GAATTG

GTCTCA

AGGC

3’ 3’ 20 680

4 Inhibitory Test The bacteria cultures have been fresh prepared in alkaline peptone water and adjusted the concentration to the OD600=0.2. Serial dilution was performed and pour plate method were carried out to confirm the bacteria count in the original culture. The original culture was seeded into the sample, and went through the whole procedures of mPCR detection. 5 Detection Limit Pour plate method was used to obtain the bacterial count in this test as well. Fresh bacteria cultures were prepared in LB broth and serial diluted up to 10-6 then,

followed by the pour plates. The whole set of serial dilution tubes were boiled, and went through the procedures of pre-PCR and mPCR procedures.

RESULTS 1 Detection Results

mPCR method: In total 76 mPCR amplifications in this study, there was no V. cholerae O1 or O139 positive; but 75 V. parahaemolyticus positive; and 54 V. vulnificus positive (Table 3). The detection rate of V. parahaemolyticus is 98.7% and V. vulnificus is 71.1%.


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All mPCR reactions were run with positive and negative controls and the control results were normal. Culture method: There were 21 V. parahaemolyticus and 16 V. vulnificus isolated and identified from the 76 samples. All isolated suspected bacterial colonies were identified by the Vitek 32 system and the GNI+ identification rate of the target organism is higher than 90%. The isolation rate of V. parahaemolyticus was 27.6% and V. vulnificus was 19.7%. There was a big difference between the results of molecular method and traditional culture. Table 3 Testing results of m-PCR and culturing methods

m-PCR amplification Culturing methodTarget Pathogens Positive/Total Positive/Total

V. cholerae O1/O139 0/76 0/76 V. parahaemolyticus 75/76 21/76 V. vulnificus 54/76 15/76

In the detection results of V. parahaemolyticus, out of 76 samples, there were 21 samples mPCR and culture positive; 55 samples were mPCR positive but culture negative; only 1 sample was negative in mPCR and culture; and no sample was mPCR negative but culture positive. In the other part of the results, also 76 samples have been processed for the detection of V. vulnificus. 15 samples were mPCR and culture positive; 39 samples were mPCR positive but culture negative; 22 samples

were mPCR and culture both negative. However, there were 2 samples with V. vulnificus mPCR negative but the culture result with a V. vulnificus identification rate lower than 90%, and it is considered culture negative. No matter for the detection of V. parahaemeolyticus or V. vulnificus, their recovery rate of culture method is much lower than the molecular method. 2 Detection Limit and Inhibitory Tests The result shows that V. cholerae O1 and O139 were detected from 1000 cells, V. parahaemolyticus and V. vulnificus can be detected from 10 cells and 100 cells respectively in culture broth (Fig. 1~4). However, there are very weak positive bands in the lanes of 100 cells of V. cholerae O1 and O139, but the band is not strong enough to consider positive. In the results of inhibitory test, that did not show any inhibition in the mPCR reaction and the positive bands are good enough to demonstrate the results of samples (Fig. 5). The sample in the lane number 1 was not seeded, but the positive V. parahaemolyticus (492bp) and V. vulnificus (680bp) bands were clear, that means V. parahemolyticus (492bp) and V. vulnificus were actually positive in the sample. Moreover, in the lane number 2 was seeded bacterial cells, the V. choleare O139 (392bp), V. parahaemolyticus (492bp) and V. vulnificus (680bp) bands should come up normally.

MMRO139100

O139 103

O139 104

O139 102

O139 101

O139106

O139105

500

392

MMRO1 106

O1 102

O1 103

O1 101

O1100

O1 105

O1 104

500392

MMR VV106

VV105

VV 104

VV 103

VV 101

VV 102

VV100

500

680

MMR VP 105

VP104

VP 103

VP 102

VP 101

VP100

VP10-1

492 500

Fig. 3 The limitation test results of V. parahaemolyticus

Fig. 1 Limitation test results of V. cholerae O1 Fig. 2 The limitation test results of V. cholerae O139

Fig. 4 The limitation test results of V. vulnificus


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Fig. 5 m-PCR results of inhibitory test. MMR: Molecular Marker Ruler NC: Negative Control (VC-nonO1) PC: Positive Control (VCO139+VP+VV) 1: Sample without seeded. 2: Sample seeded with VCO139; VP and VV.

DISCUSSION

From the overall results, it revealed that the mPCR

protocol and the primer sets could detect the target pathogens in seafood successfully. Moreover, the results of detection limit shows the procedures were able to detect as low as 10 cells in the samples. Even though, there was no V. cholerae O1 and O139 detected in this study. As a well known fact that toxigenic V. cholerae is not common in the developed city, and was not a usual pathogen in Macao. However, it is a pathogen of surveillance since it causes a very serious and fast-spread disease. Anyhow, the detection of toxigenic V. choleare in seafood is always needed.

In fact, there were some drawbacks for the

use of the species specific gene (tlh) to detect V. parahaemolyticus. First, using the tlh gene to detect V. parahaemolyticus can not get any information about the toxigenic V. parahaemolyticus in the samples. Second, the result only shows the positive and negative of the V. parahaemolyticus, but can not give any quantitative result of the pathogen in the sample. Nevertherless, these drawbacks can be solved by using two more pair of primers to detect the toxigenic genes of V. parahaemolyticus (tdh, trh) at the same time of tlh gene detection. In addition, the Real-Time PCR method can be used for the quantitative and quicker results. Using Real-Time PCR technique for the detection of pathogens in seafood samples are getting common in worldwide [11-13].

The reason for the detection rate of mPCR method

higher than the traditional culture, could be due to (1) the

sensitivity of culture method; (2) the target Vibrio pathogens in the viable but nonvulturable (VBNC) state in samples; (3) samples kept at low temperature or not fresh before purchased and sent to laboratory. Those reasons could give a big difference between the results of mPCR and culture methods. Target pathogens might be in a state known as VBNC (Viable But Not Culturable). Bacterial cells in the VBNC state will not grow in or on nutrient media. The bacteria undergo a dormancy whereby the cells remain viable and actively metabolized, but not able to be cultured by routine bacteriological methods. They are not undergoing cell division, but they are intact and alive by the selected metabolic criteria. Gram-negative bacteria are also known to enter into VBNC state, Vibrio spp. being one of the common geneus[14-15]. The way to induce the VBNC state in Vibrio spp. were usually by keeping them in low temperature (around 4°C), low salinity or acid environment[16]. Therefore, if the seafood samples were not fresh enough or frozen for a period of time before purchased then sent to laboratory, the Vibrio spp. may injure, die or turn to VBNC state in the samples. That must reduce the isolation rate of the target VIbrio pathogens in culture method. But this VBNC state Vibrio spp. will not affect the results of mPCR method. The culture media was also a factor to affect the low isolation rate of culture method. The VVMc medium is not a commercial medium and the formaula is pretty complicate[10, 17]. Thus, such a complicate preparation procedures could cause somewhat of variations in each lot of agar plates. These differences probably reduce the stability of the isolation rate of Vibrio spp. in culture method as well.

The mPCR is a specific, sensitive method and the

operation is easier and faster than the culture method. However, being applied to the environmental samples, the amplification reactions could be affected by unknown inhibitors existing in the samples to render false negative results for the analysis. Thus, the inhibitory test has been performed in this study to find out whether there is any inhibition from the seafood samples to the mPCR reactions. The finding shows there was not a big difference between the sample and spiked sample, which indicated the inhibition of seafood affecting the mPCR results by using the above enrichment and pre-mPCR protocols were little.

The establishment of an efficient, easy and cheap

method to reduce the risk of seafood poisoning and to ensure the safety of seafood samples is important to the public health of Macao. The mPCR protocols established in the present study can provide a quick and easy method for the screening of V. cholerae O1/O139, V. parahaemolyticus

MMR

500

NC PC 1 2

680 492 392


86

and V. vulnificus in seafood samples simultaneously. This Multiplex PCR method is recommended the routine screening use in seafood sample for public health safety of Macao. Acknowledgement This study was supported by the funds provided by Macao Sciences and Technology Development Fund (No. 032/2005/A), the Macao SAR Government.

REFERENCES

1 Food and Environmental Hygiene Department. Risk assessment studies, Vibrio species in seafood (Report No.20). 1st ed. Hong Kong:Risk assessment section, 2005, 11.

2 The Bureau of Food and Drug Analysis. Etiology of food-borne outbreaks 1981-2006. 1st ed. Taiwan:National laboratories of foods and drugs, 2006, 1.

3 Food and Agriculture Organization/World Health Organization. Second FAO/WHO global forum of food safety regulators: Food-brone disease surveillance system in Korea. 1st ed. Bangkok: FAO/WHO, 2004, 2.

4 Bej AK, Patterson DP, Brasher CW, et al. Detection of total and hemolysin-producing Vibrio parahaemolyticus in shellfish using multiplex PCR amplification of tl, tdh, and trh. Journal of Micriobiological Methods, 1999, 36: 215-225.

5 Gulig PA, Bourdage KL, Starks AM. Molecular pathogenesis of Vibrio vulnificus. The Journal of Microbiology, 2005, special issue 43:118-131.

6 Kreger A, Lockwood D. Detection of extracellular toxin(s) produced by Vibrio vulnificus. Infection and immunity, 1981, 33:583-590.

7 Gray LD, Kreger AS. Purification and characterization of

an extracellular cytolysin produced by Vibrio vulnificus. Infection and Immunity, 1985, 48:62-72.

8 Way JS, Josephson KL, Pillai SD, et al. Specific detection of Salmonella spp. by multiplex PCR. Applied and environmental microbiology, 1993, 59:1473-1479.

9 Bubert A, Hein I, Rauch M, et al. Detection and differentiation of Listeria spp. by a single reaction based on multiplex PCR. Applied and environmental microbiology, 1999, 65:4688-4692.

10 Cerda-Cuellar M, Permin L, Larsen JL, et al. Comparison of selective media for the detection of Vibrio vulnificus in environmental samples. Journal of Applied Microbiology, 2001, 91:322-327.

11 Campbell MS, Wright AC. Real-Time PCR analysis of Vibrio vulnificus from oysters. Applied and environmental microbiology, 2003, 69:7137-7144.

12 Panicker G, Bej AK. Real-Time PCR Detection of Vibrio vulnificus in oyster: comparison of oligonucleotide primers and probes targeting vvhA. Applied and environmental microbiology, 2005, 71:5702-5709.

13 Ward LN, Bej AK. Detection of Vibrio parahaemolyticus in shellfish by use of multiplexed Real-Time PCR with TaqMan fluorescent probes. Applied and environmental microbiology, 2006, 72:2031-2042.

14 Nilsson L, Oliver JD, Kjelleberg S. Resuscitation of Vibrio vulnificus from the viable but nonculturable state. Journal of bacteriology, 1991, 173:5054-5059.

15 Whitesides MD, Oliver JD. Resuscitation of Vibrio vulnificus from the viable but nonculturable state. Applied and environmental microbiology, 1997, 63:1002-1005.

16 Wong HC, Wang P. Induction of viable but nonculturable state in Vibrio parahaemolyticus and its susceptibility to environmental stresses. Journal of applied microbiology, 2004, 96:359-366.

17 Cerda-Cuellar M, Jofre J, Blanch AR. A selective medium and a specific probe for detection of Vibrio vulnificus. Applied and environmental microbiology, 2000, 66:855-859.


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輸卵管再通術聯合中醫治療輸卵管阻塞性不孕

念丁芳

【摘要】目的評價介入性輸卵管再通術與中醫藥聯合應用在治療輸卵管阻塞性不孕症方面的

臨床療效。方法對 38 例輸卵管阻塞性不孕病人的 76 條輸卵管,在 DSA 監視下，用 Cook 公司FTC - 900 輸卵管再通系列器材進行輸卵管阻塞再通術，手術前、後均輔以中醫藥側穹隆封閉、灌腸治療。結果 76條阻塞的輸卵管中有 71條獲得疏通,有效率為 93.4%;術後隨訪半年， 38例不孕病人中有 25 人受孕，受孕率為 67.3%; 13 例未受孕者中，有 8 例出現輸卵管的再阻塞。結論輸卵

管再通術與中醫藥聯合應用，簡便安全，輸卵管疏通率、術後受孕率均高於單純行輸卵管再通術或中

醫藥治療的病例，值得推廣應用。【關鍵詞】輸卵管疾病; 介入放射學; 再通術; 中醫藥

Combine Interventional Oviduct Recanalization with Traditional Chinese Medicine to Treat Infertility of Oviduct Obstruction. Nian Ding-fang. Department of Imaging Center, Hai Ci hospital, Qing Dao, 266033, PR China; Current address : Department of Imaging Center, Kiang Wu Hospital, Macao SAR, PR China; Tel : (+853)-8295 0337; E-mail: [email protected] 【Abstract】Objective To evaluate the efficacy of the combination interventional oviduct

recanalization with traditional chinese medicine for infertile women with oviduct obstruction. Methods 38 caseswith 76 oviduct obstruction were treated with FTC - 900 oviduct recanalization apparatus guided with DSA, the apparatus was supp lied by COOK company, before recanalization, assisted with side fornix vaginae and enema with traditional chinese medicine. Results Of 76 obstructive oviduct, 71 oviductwere recanalization, the successful rates of recanalization were 93.4%;Of 38 infertile women, 25 cases become p regnant, the pregnant rateswere 67.3%; Of 13 unsuccessful cases, 8 cases turn out re-obstructived. Conclusion Combination interventional oviduct recanalization with traditional chinese medicine for infertile women with oviduct is a simp le, safe, and more effective method, it has a high successful rates than eithermethod solely, should be sp readed. 【Key words】 Oviduct diseases; Interventional radiology; Recanalization; Traditional

chinese medicine

不孕症是婦科常見的一種疾病,原因複雜,其中輸卵管阻塞約佔30%～40%[1] 。臨床上對輸卵管阻塞的治療方法較多，如顯微外科、全身抗炎、輸卵管通液

術、再通術等，尤其是再通術較為新潮。但資料顯

示，單一再通術的疏通率、術後受孕率均停留在較低

水平[1]。作者採用輸卵管再通術與中醫藥聯合應用的

方法治療輸卵管阻塞性不孕，明顯提高了輸卵管的疏

通率與術後受孕率，現報導如下。作者單位: 266033 中國, 山東省, 青島巿, 海慈醫院, 放射科; 目前通訊地址: 澳門特別行政區, 鏡湖醫院, 放射科; Tel : (+853)-8295 0337; E-mail: [email protected]

材料與方法

1 臨床資料 2003年6月～2005年8月，共收治輸卵管阻塞性

不孕患者38人(資料來自作者原工作單位)，均經子宮輸卵管造影或選擇性輸卵管造影確診，且排除內分泌

和對方因素，年齡25～41歲，平均31.2 歲。原發不孕21例，繼發不孕17例，不孕時間為2～9年，平均4.6年。均有程度不同的盆腔炎或其他部位的感染史， 27例曾行輸卵管通液、抗炎等治療，無結核依據。38例患者共76條輸卵管阻塞，梗阻部位分別為間質部21條、峽部8條、壺腹部9條、傘端38條。

2 手術器械DSA 機


88

德國SIEMENS公司的POLYDOROS-80機。FTC 系列：美國Cook公司的FTC-900輸卵管再通系列。

3 治療方案

月經乾淨後第4～8天行輸卵管再通術，術前10d與術後10d輔以中醫藥治療，術後輔以輸卵管通液(抗炎、抗粘連)治療，每月2次， 2～3個月經週期。

4 治療方法

中醫藥側穹隆封閉、灌腸，於輸卵管再通術前

10d開始，每日1次。中醫藥側穹隆封閉術: 完善各項術前檢查，病人取截石位，常規陰道沖洗，消毒、鋪

巾，置入窺陰器，對宮頸進行固定、消毒。於子宮頸

側穹隆旁開1～2cm處用9號針頭進行穿刺，深度約1cm左右，回抽無血，緩慢注入0.9%生理鹽水3ml+魚腥草注射液3ml，雙側交替，每日1次。中醫藥灌腸術: 將中藥敗醬合劑150ml (自製)加溫至37.2℃，行保留灌腸，每日1次。輸卵管再通術: 時間選擇在月經乾淨後第4～8天進行，完善各項術前檢查(含子宮輸卵管造影或選擇性輸卵管造影術) 。病人取截石位於

DSA床上，常規陰道沖洗，消毒、鋪巾，置入窺陰器，對宮頸進行固定、消毒。先做子宮輸卵管造影

術，顯示子宮大小、形態、位置及輸卵管阻塞的部

位、程度、有無積水情況等。然後應用FTC-900系列器械進行輸卵管再通，透視監視下依次將9F、5.5F同軸導管及0.035英寸( 1英寸=2.54 cm)“J”形導絲導引下插至子宮角輸卵管開口處，拔除導絲，再將3F導管及同軸的0.015英寸導絲插入至輸卵管阻塞處，固定導管，緩慢撚轉、抽動導絲並插向遠端，並隨時退出

導絲經導管行輸卵管造影以瞭解疏通情況，輸卵管良

好顯影及造影劑經輸卵管進入腹腔作為成功標誌(圖1～5)。輸卵管疏通後，應用慶大黴素8萬u、地塞米松5mg、糜蛋白酶5mg溶於生理鹽水40ml進行子宮腔及輸卵管灌注沖洗。若在用導絲進行疏通時阻力較大，

反復撚轉、抽動導絲而不能前行，應終止手術，切勿

強行硬插，以免引發輸卵管穿孔。術後抗炎3d。術後10d內繼續行中醫藥側穹隆封閉、灌腸(方案同前) 。術後3周內應避免性生活。維持子宮輸卵管通液治療2～3個月經週期，每月2次(方案同術) 。第6個月經期後指導懷孕。

圖 1 造影顯示雙輸卵管於間

質部阻塞, 左側為已手術切除。圖 2 對右側輸卵管進行疏通圖 3 全程顯影

圖 4 造影劑溢入盆腔圖 5 造影劑在盆腔內分佈良好


89

結果

76條阻塞的輸卵管中，梗阻部位分別為間質部21條、峽部8條、壺腹部9條、傘端38條。有71條獲得疏通，有效率為93.4%。有5條輸卵管未能疏通，其中1例位於間質部，合併較嚴重的局部子宮內膜炎， 1例位於峽部，為宮外孕術後病人，3例位於傘端，呈積水膨大。術後隨訪半年，38例病人中有25人受孕，受孕率為67.3% ，其中1例為宮外孕。在13例未孕患者中，經造影復查有8例出現輸卵管再阻塞，復發率為11.3%。所有手術病人均無併發症。

討論 1 輸卵管發育異常、各種慢性非特異炎症、結

核、盆腔感染等，均可導致輸卵管粘連、阻塞或積

水，引起育齡婦女不孕症，中醫上屬氣滯血淤性不

孕。所以，消除局部炎症、疏通管腔、溫經散寒化

淤，最終恢復輸卵管的功能，應是治療的關鍵。輸卵管阻塞再通術1985年由Platia首先報導[2] ，

隨後Thurmand系統了這一技術，並開發出一套專用於輸卵管再通的器械，使這一技術更簡便、易於推

廣。1992年，我國開始引進此技術，並對手術器械進行了改進，取得了與國外相似的輸卵管疏通率與術後

受孕率[3-4]。由於該方法僅僅屬單純的機械疏通，存

在著術後受孕率較低的缺憾。而本組病例均採用了中

醫藥側穹隆封閉、灌腸的中醫藥輔助治療，明顯地提

高了輸卵管再通術的治療效果。 2 中醫根據辨證施治的理論，在活血理氣、化瘀

通絡總治則的指導下，設計出中醫藥在輔助治療輸卵

管阻塞性不孕方面的原則，即活血化淤、除粘通管、

標本兼顧、整體調節、綜合治療[5] 。應用側穹隆封閉、灌腸等多途徑給藥，選擇使用理氣活血、化淤通

絡的中藥，有利於輸卵管粘連的松解，促進管腔黏膜

上皮的修復與再生，改善輸卵管內的受精環境，提高

輸卵管運送卵子及受精卵的蠕動能力。由於化淤藥物

能夠增強單核-巨噬細胞系統的活性，抑制成纖維細

胞的增生和膠原合成，並促使膠原的分解和吸收，從

而防止輸卵管粘連、阻塞的再形成。現代藥理研究已

證實，活血化淤中藥可以不同程度地改善盆腔局部的

微循環和組織營養，調節合成代謝，促進病灶炎症吸

收，有利於輸卵管粘連的松解和功能的恢復。

本組76條阻塞輸卵管中，有71條獲得疏通，有效率為93.4% ，高於國內外報導的單一輸卵管再通術83.3%～89%的疏通率;術後隨訪半年，38例病人中有25人受孕，受孕率為67.3% ，也高於單一輸卵管再通術26.3%～47.4%的受孕率[6-7]；術後輸卵管阻塞

的復發率為11.3%，與資料顯示的接近[8-9]。本組病例，除3例術後出現少量陰道出血，給予

對症處理後均好轉外，未出現其他併發症。造影復查

顯示，術後少量陰道出血不會導致輸卵管的再狹窄。

參考文獻

1 石榮書, 辛小波, 楊彪, 等. 子宮輸卵管造影對輸卵管阻塞性不孕診斷價值的再探討. 實用放射學雜誌, 2003, 19:28-29.

2 Millward SF, Claman P, Leader A, et al. Technical report: fallopian tube recanalization: a simp lified technique. Clin Radiol, 1994, 49:496-497.

3 楊建勇, 李紅發, 馮敢生, 等. 用自製同軸導管行選擇性輸卵管造影及再通術的臨床應用. 臨床放射學雜誌, 1996, 15:49-52.

4 康林英, 孫玲珠, 田曉梅. 自製同軸導管引導下選擇性輸卵管造影及再通術的臨床應用. 介入放射學雜誌, 2001, 10:222-224.

5 鄧高丕, 主編. 中西醫婦科－新理論新技術. 第1版. 北京:人民軍醫出版社, 2002. 243-267.

6 宋榮坡, 韓澤修, 劉亞民. 用介入療法行輸卵管再通術臨床應用(附80例報告). 實用放射學雜誌, 2003, 19:931-933.

7 Lang EK, Dunaway HH. Recanalization of obstructed fallop ian tube by selective salp ingography and transvaginal bougie dilatation: outo - come and analysis. Fertil Steril, 1996, 66:210-215.

8 張曉民, 李玉枝. 介入性輸卵管再通術與輸卵管加壓通液治療輸卵管狹窄的比較 . 中華放射學雜誌 , 2002, 36:810-811.

9 劉志軍, 鄧志權, 張莉婭, 等. 輸卵管阻塞介入再通術216例臨床觀察. 介入放射學雜誌, 2001, 10:364-365.


90


次髎穴刺血拔罐治療

慢性前列腺炎 30例

周紅軍孟建國

【摘要】目的探討次髎穴刺血拔罐治療慢性前列腺炎的臨床療效。方法前列腺炎患者共

60例，病程至少 6個月，隨機分成治療組和對照組。治療組 30例，取雙側次髎穴刺血拔罐；對照組

30 例，口服加替沙星。結果 60 例患者治療 3 個月後，對照組與治療組統計學處理差異有顯著性(P<0.01)；治療組 30 例患者中，顯效 27 例，佔 90%；有效 2 例，佔 6.7%；無效 1 例，佔 3.3%。總有效率 96.7%。結論次髎穴刺血拔罐治療慢性前列腺炎，療效顯著，副作用小。

【關鍵詞】次髎穴; 慢性前列腺炎; 刺血; 拔罐

Liao Points, Pricking Blood Cupping Treatment of Chronic Prostatitis 30 cases. ZHOU Hongjun, MENG Jianguo. Medical College, Department of Traditional Chinese Medicine, Cangzhou, Hebei, 061001, PR China; Tel : (+86-317)-550 7113; E-mail : [email protected] 【Abstract】 Objective To investigate, Liao points thorn blood cupping treatment of chronic

prostatitis the clinical efficacy. Methods Prostatitis patients with a total of 60 cases, the duration of at least six months, were randomly divided into treatment and control groups. The treatment group of 30 patients, both from the point thorn Liao blood Cupping the control group of 30 patients, oral gatifloxacin. Results 60 patients treated three months later, the control and treatment groups statistically significant difference (P<0.01); treatment group of 30 patients, markedly effective in 27 cases, accounting for 90 percent; effective two cases, accounting for 6.7% ; Invalid one cases, accounting for 3.3 percent. The total efficiency of 96.7 percent. Conclusion The Point, Liao thorn blood cupping treatment of chronic prostatitis, significant effects, side effects small. 【Key words】 Green Liao; Chronic prostatitis; Thorn blood; Cupping

慢性前列腺炎是嚴重影響成年男子身心健康的常

見疾病，也是目前中醫男科臨床的疑難病之一，其發

病率在近年來呈上升趨勢。因只有少數具備小分子

量、特殊結構、非離子化、鹼性、脂溶性並且與血清

蛋白結合不緊密的抗菌素才能透過血一前列腺屏障進

入前列腺，這就大大限制了慢性細菌性前列腺炎抗菌

素治療的藥物選擇餘地[1]，故在臨床上西藥尚無特效

療法。中醫藥在本病治療的研究中具有現實意義和廣

闊前景。目前，中醫治療本病一般以清熱解毒利濕、

活血化瘀為主，除口服中藥外，還增加了直腸給藥或

配合其他治療的方法，總的來說療效滿意。尤其是針

灸治療有多種針法可選擇，操作簡便而安全，患者依

從性良好，治療效果較顯著，加之中醫強調對細節的

全程關注，注重對患者心理、飲食、運動、性生活等

作者單位：061001, 中國, 河北, 滄州, 醫學高等專科學校, 中醫教研室; Tel : (+86-317)-550 7113; E-mail : [email protected]

方面的調養，為諸多針法獲得滿意療效奠定了基礎。

但尚未見採用次髎穴刺血拔罐治療慢性前列腺炎的臨

床報導。2004～2006 年，筆者以次髎穴刺血拔罐治

療慢性前列腺炎 30例，療效良好，現報告如下。

臨床資料

本組 60 例患者均屬中青年男性，所有患者均符

合美國國立衛生研究院（NIH）前列腺炎分類中的Ⅱ型和 AⅢ 型[2]，隨機分成治療組和對照組。治療組 30例，年齡 20-30 歲 5 例，31 歲以上 25例。病程 6 個月-1 年 7 例，1-3 年 15 例，4-5 年 8 例。對照組 30例，年齡 20-30 歲 6 例，31 歲以上 24例。病程 6 個月-1年 6例，1-3年 15例，4-5年 9例。所有患者前列腺液常規 WBC＞10 個/HP10 例，前列腺液常規WBC＜10 個/HP20 例，有泌尿系感染史者 4 例。主訴會陰部及肛周陣發性痙攣性疼痛 20 例；其中排尿


91

末期出現痙攣性抽痛 10 例，痛及大腿內側 3 例，會陰不適感 10 例，少腹脹痛 5 例，睾丸墜痛 5 例；伴有尿頻 13 例，尿等待 6 例，尿餘瀝不盡 2 例，頭暈乏力 2例，性功能障礙 12例。

治療方法

1 治療組選取雙側次髎穴，經碘酒、酒精消毒後，用三

棱針點刺 1～3 下，使其出血，然後拔火罐，出血量5-10毫升。每週 1次，4次為 1療程。伴有泌尿系感染史者或前列腺液常規 WBC>10 個/HP 者加用抗生素。3個療程後統計療效。 2 對照組加替沙星（揚子江制藥有限公司）0.4g，口服，1 次/d，療程 4 周。兩組在治療期間不加用其他藥物和物理療法，且禁酒和禁辛辣、刺激飲食。3 個療程後統計療效。

療效觀察 1 療效標準顯效：疼痛及其它症狀消失，3 個月內無復發。有效：疼痛程度及發作次數明顯減輕，或疼痛消失後

3 個月內有復發，但程度較前減輕。無效：治療期間疼痛無緩解，以及因療效不佳，治療不滿 3周，中途停止治療。 2 治療結果治療組 30 例患者中，顯效 27 例，佔 90%；有效 2 例，佔 6.7%；無效 1 例，佔 3.3%。總有效率96.7%（見表 1）。

表 1 兩組治療前後療效比較（ｎ）

組別 n 顯效有效無效有效率(%)

治療組 30 27 2 1 96.70* 對照組 30 17 9 4 86.67 註：與對照組比較*P＜0.01

討論

慢性前列腺炎屬於中醫“精濁”的範疇。中醫認為其病因包括內外幾方面。外感六淫邪毒，蘊結不散，

鬱而化熱，下迫膀胱，氣化失司；坐臥冷濕之地，寒

濕侵襲，致使厥陰經絡受阻，氣血凝滯；嗜食辛辣肥

甘之品，內傷脾胃，積濕生熱，蘊積下焦；或情志抑

鬱，化熱生火，下注精室；或因房事過度，酒色勞

倦，內傷精氣，腎精虧損；或房事不潔，濕熱濁毒之

邪阻滯下焦，留於精室，致敗精瘀阻；或久病傷腎，

精氣不固。腎氣虧虛為發病之本，外感病邪為發病之

標，而不良生活方式為誘發因素。臨床上往往多種因

素同時存在，相互影響。腎氣虛弱，濕熱毒邪留滯下

焦，導致氣滯、血瘀，氣血瘀滯又成為致病因素，加

重病情，間或錯治誤治，導致虛實錯雜。刺血拔罐法

能“通其經脈，調其氣血、虛實”。次髎穴位置在第二

骶後初中，屬於足太陽膀胱經。由於此穴位於腰骶

部，因此是調理泌尿生殖系統功能的常用穴位。次髎

穴刺血拔罐具有清熱利濕、活血化瘀、解痙止痛的功

效。因此，次髎穴刺血拔罐治療慢性前列腺炎療效迅

速，簡便實用。

參考文獻

1 Mears E M. Prostatitis syndrome:New perspective about

old woe. Urol, 1980,12:141. 2 Litwin MS, McNaughton-Collins M, Fowler FJ, et al. The

National Institutes of Health chronic prostatitis symptom index: development and validation of a new outcome measure. J Urol, 1999, 162:369-375.


92


肛疾靈洗劑治療妊娠期血栓性外痔的臨床觀察

劉全芳萬進歐金銳馬建青

【摘要】目的探討中藥肛疾靈洗劑（大黃，芒硝，苦參，枯礬）熏洗及 PP 粉坐浴治療妊娠

期血栓性外痔的療效。方法回顧性分析 169 例分別採用中藥肛疾靈洗劑熏洗及 PP 粉坐浴治療的妊娠期血栓性外痔患者的臨床資料。結果兩組的總有效率為 94.1%，其中採用中藥肛疾靈洗劑的熏洗組患者的治癒率為 92.9%，有效率為 98.8%，在治癒率和有效率上明顯優於採用 PP 粉的坐浴組。結論中藥肛疾靈洗劑通過清熱解毒、行氣破瘀、消腫止痛、生肌收斂、祛風燥濕、殺蟲止癢等作用機理，對妊娠期血栓性外痔有較好的療效，明顯優於採用 PP粉的坐浴治療。【關鍵詞】肛疾靈洗劑; PP粉; 妊娠; 血栓; 外痔

The Clinical Effect of “Gangjiling” Lotion in the Treatment of Female Pregnant Patients with Thrombotic External Haemorrhoid LIU Quanfang, WAN Jin, OU Jinrui, MA Jianqin. Department of General Surgery, People’s Hospital of Guangdong province, Guangzhou 510080, China; Tel:(+86)-1380 2541 732; (+853)-6672 4452; E-mail:[email protected]

【Abstract】 Objective To evaluate the clinical effect of fumigationg and washing with the Chinese traditional medicine “gangjiling” lotion (rhubarb,mirabilite,radix sophorae flavescentis, dried alum ) and sitz bathing with PP powder in the treatment of thrombotic external haemorrhoid in the female pregnant patients. Methods The clinical data of 169 cases of the female pregnant patients with thrombotic external haemorrhoid who were fumigated and washed with “gangjiling” lotion, and sitz bathed with PP powder respectively were analyzed retrospectively. Results The total effective rate of both groups was 94.1%, the cure rate and the effective rate in fumigating and washing with “gangjiling” lotion were 98.8% and 94.1% respectively, evidently superior to those in sitz bathing with PP powder group. Conclusion Chinese traditional medicine “gangjiling” lotion might be effective in the treatment of thrombotic external haemorrhoid in the female pregnant patients by the action mechanism of clearing away heat and toxic material, promoting flow of “qi” and blood circulation, subduing swelling and relieving pain, astringing and promoting tissue regeneration, dispelling pathogenic wind and removing dampness, destroying patasites and relieving itching, etc. The effectiveness of “gangjiling” lotion should be evidently superior to that of PP powder. 【Key words】 Gangjiling Lotion; PP powder; Pregnancy; Thrombus; External

haemorrhoid

廣東省人民醫院及廣州軍區廣州總醫院自 1994

～2003 年採用中藥肛疾靈洗劑熏洗及 PP 粉坐浴治療的 169例妊娠期血栓性外痔患者的有關臨床資料進行回顧性分析，並報告如下。

資料與方法

1 一般資料將 1994年 6月～2003年 12月採用中藥肛疾靈

作者單位: 510080, 中國, 廣東, 廣州市中山二路 106號, 廣東省人民醫院, 普通外科; Tel: (+86)-13802541732; (+853)-66724452; E-mail: doc.liuquanfang@ 163.com

洗劑熏洗及 PP 粉坐浴治療的 169 例妊娠期血栓性外痔患者，因治療方法不同分為熏洗組及坐浴組。169均為女性患者，年齡 21～35 歲，妊娠時間 10～37周；發病前均有程度不同的便秘存在；均為初次發

病，病程 3～52h，表現為肛周疼痛性腫塊；體檢齒線下肛周可見最大徑 0.8～3.5cm 大小單發性、類

圓、觸痛性、暗紅色腫塊，呈各個時點散在性分佈；

均存在有程度不同的內痔，而無肛裂及脫肛。其中熏

洗組 85 例，年齡 22～35（平均 24.6±5.2）歲，妊娠時間 10～37（平均 31.6±9.6）周，病程 3～52（平均31.4±9.5）h，肛周腫塊最大徑 1.2～3.5(平均 2.5±0.7)㎝；坐浴組 84 例，年齡 21～36（平均 24.5±5.4）歲，妊娠時間 10～37（平均 31.2±9.6）周，病程 6～38（平均 26.4±6.5）h，肛周腫塊最大徑 0.8～3.0(平


93

均 2.0±0.9)㎝。兩組患者除採用肛疾靈洗劑熏洗及 PP粉坐浴治療外，未接受其他處理。兩組性別一致，在

年齡、妊娠時間上無明顯差異；在病程、肛周腫塊最

大徑上熏洗組明顯超過坐浴組(P<0.05)。 2 治療方法熏洗組中藥肛疾靈由大黃、芒硝各 30g，苦參、

枯礬各 15g 組成。煎藥液 2000 ml (亦可製成粉狀袋裝開水浸泡劑)，先熏洗後坐浴 15 min。每日 1 劑，早晚各 1次。坐浴組採用 PP粉(0.02%高錳酸鉀)稀釋液 2000 ml，坐浴時間、方法、次數同熏洗組。 3 統計學處理計量資料資料以 x±s 表示，組間比較採用 t 檢

驗。計數資料採用 x2檢驗。

結果

參照中藥新藥治療痔瘡的臨床指導原則及中華醫

學會外科分會肛腸組制定的痔病診治標準(2000 年 4月成都會議制訂的“痔診治暫行標準”)。熏洗組共治療 85 例，療程 2，4，6，8，10 天好轉(疼痛症狀減輕及肛周腫塊縮小)和治癒(疼痛症狀及肛周腫塊消失)者分別為 18，41，19，5，1例；其中治癒 79例，好轉 5 例，無效 1 例，治癒率為 92.9%，有效率為98.8%。坐浴組共治療 84 例，療程 2，4，6，8，10天好轉和治癒者分別為 2，8，22，33，10 例；其中治癒 47 例，好轉 28 例，無效 9 例，治癒率為56.0%，有效率為 89.3%。兩組總有效率為 94.1%，而在治癒率和有效率上熏洗組明顯優於坐浴組

(P<0.05)。

討論

妊娠期婦女因其獨特的生理性改變，加之飲食和

活動失衡，容易發生和加重各種痔病[1]，但由於恐懼

藥物和麻醉對胎兒的不良反映，除傳統的熏洗和坐浴

療法外，患者不願接受其他有效治療。肛疾靈洗劑為中藥製劑，其作用機理[2]：(1) 清

熱解毒、行氣破瘀、消腫止痛。(2) 生肌收斂。(3) 祛風燥濕、殺蟲止癢。而藥理學表明 PP粉(高錳酸鉀)通過強氧化作用，有一定的殺菌和收斂作用，但作用

短暫表淺。二者理論上對血栓性外痔均有一定的治療

作用。

研究顯示中藥肛疾靈洗劑熏洗及 PP 粉坐浴治療對妊娠期血栓性外痔均有一定的治療作用，其總有效

率為 94.1%，其中採用中藥肛疾靈洗劑的熏洗組患者的治癒率為 92.9%，有效率為 98.8%，明顯優於採用PP 粉的坐浴組，表明中藥肛疾靈洗劑治療妊娠期血栓性外痔療效顯著，具有一定的臨床推廣應用價值。

參考文獻

1 黃乃健, 主編. 中國肛腸病學. 第 1 版. 山東:山東科學

技術出版社, 1996. 625. 2 劉全芳. 肛疾靈洗劑治療痔瘡 825 例. 實用醫學雜誌,

2003, 19:285.


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澳門兒童肺炎鏈球菌病 37例耐藥性分析

鄭霆鋒李然* 楊健梅* 呂健文*

【摘要】目的肺炎鏈球菌病是重要的臨床問題及公共衛生問題。1960 年在澳大利亞報導第一例耐青黴素肺炎鏈球菌。近年肺炎鏈球菌對β-內酰胺類等耐藥菌株明顯增加。部份菌株甚至具有多重抗藥性，此問題已引起醫學界的廣泛關注。澳門的情況如何呢? 針對此問題作者進行了以下的研究，以分析肺炎鏈球菌在本澳兒童人口中的致病情況及其耐藥性。方法研究以澳門仁伯爵綜合醫院兒科住院患兒作回顧分析。結果從 2001 到 2006 年期間，共有 37 例肺炎鏈球菌培養陽性病例，2 例為侵襲性，其餘都是非侵襲性的，包括痰培養陽性者 35 例（95.1%），年齡由 7 月齡到 8 周歲，19 例為男性、18 例為女性兒童，平均發病年齡為 2 周歲 11 月齡，平均住院天數為 8.08±6.81天。最高發病月份為 10 月及 11 月（各 6 例），而最高發病季節為秋季 16 例。11 例病人(29.7%)入院前已曾接受抗生素治療。在 2001到 2006年間青黴素敏感性並無特殊趨勢，所收集肺炎鏈球菌株資料顯示對 Marcolides 有高度耐藥性(96%非敏感)，而對β-lactam 類藥物如 Cephalosporins 則未有明顯耐藥性(93.5%敏感)。全部 37 例未發現有多重耐藥菌株。結論在澳門常見的肺炎鏈球菌株都對β-lactam類藥物敏感但對Macrolide類耐藥。

【關鍵詞】澳門; 兒科; 肺炎鏈球菌; 耐藥性

An Introduction and Resistance Analysis of 37 cases of Pneumococcal Disease in Children of Macao CHEANG Teng Fong, LEE Yan, IEONG Kin Mui, LUI Kin Man. Institute of Chinese Medical Sciences, University of Macao, Macao SAR, P.R. China; Tel : (+853)-6632 6463; E-mail [email protected] *CP 3002, Pediatric Dept., Centro Hospitalar Conde de São Januário (CHCSJ), Macao SAR, PR China 【Abstract】 Objective Pneumococcal disease and multiple resistant pneumococcus are important

clinical issues. The first penicillin-resistant pneumococcus was reported in 1960 in Australia. Some reports were published about the multiple resistant pneumococcus thereafter. This is a short paper about the current situation about the bacteria in Macau. Methods The data were extracted from the clinical records from Pediatric department of Centro Hospital de Conde São Januário for retrospective analysis. Results From 2001 to 2006, 37 samples showed positive to pneumococcal culture. 2 were invasive while others are not. 35 samples are sputum cultures. Age ranged from 7 months to 8 years old. 19 cases were male and 18 cases were female. Average age was 2 years and 11 months. Average time staying in hospital was 8.08±6.81days. The peak months of onset were Oct and Nov. 11 cases received prehospital oral antibiotics. No obvious trend in penicillin resistance was observed. 96% of cases were insensitive to macrolides while 93.5% were sensitive to β-lactam. No multiple resistant pneumococcus was reported. Conclusions The common pneumococcal strains in Macau were sensitive to β-lactams but rather resistant to macrolides. 【Key words】 Macau; Pediatrics; Pneumococcus; Resistance

肺炎鏈球菌病是重要的臨床及公共衛生問題。

1960 年在澳大利亞報導第一例耐青黴素肺炎鏈球菌。近年肺炎鏈球菌對 β-內酰胺類等耐藥菌株明顯增加。部份菌株甚至具有多重抗藥性，此問題已引起

醫學界的廣泛關注。澳門的情況如何呢? 針對此問題

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)-6632 6463; E-mail : [email protected] ; *CP 3002, 中國, 澳門特別行政區, 仁伯爵綜合醫院, 兒科

作者進行了以下的研究，以分析肺炎鏈球菌在本澳兒

童題作人口中的致病情況及其耐藥性。研究以澳門仁伯爵綜合醫院兒科住院患兒資料作

回顧分析。在 2001 到 2006 年期間，共收治 37 例肺炎鏈球菌培養陽性病例，2 例為侵襲性，其餘都是非侵襲性的，包括痰培養陽性者 35 例（95.1%），年齡由 7 月齡到 8 周歲，19 例為男性、18 例為女性兒童，平均發病年齡為 2 周歲 11 月齡，平均住院天數為 8.08±6.81 天。最高發病月份為 10 月及 11 月（各6 例），而最高發病季節為秋季 16 例。11 例病人


95

(29.7%)入院前已曾接受抗生素治療。在 2001 到 2006 年間青黴素敏感性並無特殊趨

勢，所收集肺炎鏈球菌株資料顯示對 Marcolides有高度耐藥性 (96%非敏感 )，而對 β-lactam 類藥物如

Cephalosporins 則未有明顯耐藥性(93.5%敏感)。全部37例未發現有多重耐藥菌株。

目的和背景

肺炎鏈球菌病是一個非常常見又重要的臨床問

題，更是一個公共衛生問題。肺炎鏈球菌感染可導致

肺炎、中耳炎，具有較高的發病率，若發展成侵襲性

肺炎鏈球菌病如腦膜炎及敗血症等，病死率相當高。

近 10 年來，肺炎鏈球菌對 β-內酰胺類、大環內酯類、氟喹諾酮類、磺胺類等耐藥性迅速增長，肺炎鏈

球菌多重耐藥菌株在世界範圍內廣泛流行引起了醫學

界的普遍關注。肺炎鏈球菌早於 1880 年已被發現，爾後其致病性被闡明在於其型特異性多糖莢膜。治療

肺炎鏈球菌疾病大多會使用 β 內酰胺類抗生素。於20 世紀 60 年代以前，所有肺炎鏈球菌的菌株都對青黴素敏感。澳大利亞在 1960 年報導了第一例耐青黴素肺炎鏈球菌， 1977 年在南非又出現了該菌的多重耐藥性報導。各地文獻都有大量報導，從此，這些耐

藥病原體就由局部個人的健康問題一躍而成為了全球

性的公共衛生問題。儘管數據在各地的文獻報導不盡

一致，目前在歐洲地區，耐青黴素肺炎鏈球菌在西班

牙為 40%，而在東歐匈牙利則高達 58%[1]。在本澳的

鄰近地區，如香港、廣州、上海等地區，分別達到

70%、61%以及 37%[2]。直到目前為止，澳門地區在

印象上仍被認為是耐青黴素肺炎鏈球菌低度流行地

區，但由於各種原因，澳門暫未有全面性的該細菌耐

藥資料，因此作者在此進行了一項針對兒科病例的局

部調查，以助了解本地區肺炎鏈球菌病的致病情況及

其耐藥性，並希望對本地區肺炎鏈球菌的流行病學作

調查和總結治療經驗，以祈有助指導臨床用藥。

來源及方法

以澳門仁伯爵綜合醫院的兒科患兒資料作回顧分

析，該院是澳門地區的唯一公立醫院。根據本地區法

律規定，13 歲以下者收住兒科病區。作者分析了從2001 到 2006 年底在兒科病區的入院資料。收集了所有診斷為肺炎鏈球菌感染的病例。這些病例包括了肺

炎、中耳炎、支氣管炎以及細支氣管炎等。診斷按國

際疾病分類編碼(ICD-9)作為收集基礎。樣本資料包括有痰培養，血培養以及其它肺炎鏈球菌陽性培養。

收集的數據包括每個陽性病例的年齡、性別、臨床表

現、入院日期以及住院時間，並加入實驗室數據包括

血常規白細胞計數以及其分類計數，C 反應蛋白等資料，而這些數據來源於其醫院化驗室。

從得自醫院實驗室的資料，該室青黴素敏感度使

用 Oxacillin 藥性紙片法篩檢，如果分離樣本顯示出其藥敏度較低，（即抑制區直徑少於 20mm）則對青黴素 MIC(半數抑制濃度)的測定則據 FiReNetworks的標準使用 E Test 方法覆檢。而按照 E Test 方法標準，青黴素藥敏度分為對青黴素敏感 (MIC≤0.06 µg/ml)，中度耐藥(MIC of 0.12-1.5 µg/ml)以及高度耐藥(MIC of ≥2 µg/ml)三種結果。

紅黴素藥敏測試則應用擴散法，按照美國疾病預

防及控制中心的原則採用 15-µg Erythromycin Disc。如果抑制區直徑小於 15mm，該個樣本會被歸類為Macrolides 耐藥，否則就是按對該類藥物敏感（即抑制區直徑>15mm）。

結果在 2001 到 2006 年期間，共有 37 例肺炎鏈球菌

感染培養陽性病例。絕大多數都是非侵襲性的，這包

括有痰培養，共有 35 例 94.7%。其中有 2 例為侵襲性肺炎鏈球菌病，1例為菌血症(Blood Culture肺炎鏈球菌陽性)，1例為腦膜炎(Cerebrospinal Fluid 肺炎鏈球菌培養陽性)，共佔 5.3%。

病例中最小是 7 月齡到最大的 8 周歲。19 例為

男性、18 例為女性兒童。這提示肺炎鏈球菌感染於兩種性別並無特殊易感性傾向(P>0.05)。這與歐美的數據大致符合。平均發病年齡為 2 周歲 11 月齡。平均住院天數為 8.08±6.81 天（可信區間 5.83-9.87 天, α=0.05）。


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作者按月份及季節把發病時間分組，最高發病月

份為 10 月及 11 月（各 6 例），而最高發病季節為秋季 16 例(43.2%)。大致跟世界各地及鄰近地區的資料符合。2005 年為最高發年份，這可能跟最近數年較重視該種病原體的識別有一定關係。

作者的資料又顯示，部分病人(11 例)予以入院前

經驗處方抗生素，主要為 Augmentin（9例），另外有Amoxicillin 及 Erythromycin （各 1 例），共佔27%。根據外國科研報告[3]分析，認為在入院前門急

診應用抗生素對高度懷疑肺炎鏈球菌肺炎有一定幫

助，改善病人的臨床症狀及預後以及發展成敗血症的

機會。但對其它類型感染則未有定論。在這次研究中，作者從中並無發現有高度耐藥的

肺炎鏈球菌樣本資料，但僅有 55.6%為青黴素敏感，而 44.4%為中等程度耐藥。對比香港 70%，廣州61%，是以從這研究可知儘管暫時澳門地區高度耐藥青黴素肺炎鏈球菌株未成為重大衛生問題，但已正日

漸變得重要。作者又發現在各個肺炎鏈球菌樣本中對

Macrolides(Erythromycin)表現出敏感的僅有 1 例，而表現出中等耐藥有 1 例，但對 Erythromycin 表現出耐藥的則有 23 例，故而非敏感者(24 例)共佔相關細菌樣本的 96%。反映出澳門地區的肺炎鏈球菌對Macrolides 存在十分明顯的耐藥情況。作者發現 31例有進行 Cephalosporin藥敏測試的樣本中，有 29 例即 93.5%表現出對該類藥物的敏感性，而耐藥的則有2例共 6.5%。

討論

從這一次研究中，作者目前暫時仍未認為澳門屬

於侵襲性肺炎鏈球菌病高發性地區。但在 2001 到2006 年這段較短時期已經有 2 個病例發生。而且多個培養都對 Penicillin 敏感度並不高，這高度提示本

地區有普及性肺炎鏈球菌疫苗的需求。另外，本地區

肺炎鏈球菌株顯示對 Marcolides 的高度耐藥性(96%非敏感)，所以臨床如果懷疑肺炎鏈球菌感染，與外地的研究報告[4]相近，故應用 Macrolides 類藥物就流行病學觀點來說就不大能稱之為恰當了，而應優先考

慮使用 β-lactam 類藥物如 Cephalosporins。而且外國研究報告[3]認為在入院前門急診應用抗生素對高度懷

疑肺炎鏈球菌肺炎有一定幫助，改善病人的臨床症狀

及預後以及發展成敗血症的機會。但對其它類型感染

則未有定論，所以問題主要是落在肺炎鏈球菌肺炎的

臨床診斷問題。現在最突出的問題是青黴素耐藥性的

出現，預示了多重耐藥性肺炎鏈球菌在社區散播已迫

在眉睫。這個研究中，作者只收集了血液及痰標本細菌培

養的資料。而痰培養由於不單止易被口鼻咽分泌物所

污染，而且其有可能只反映了定殖的無症狀帶菌的菌

株。無論如何，這些資料揭示了本地區肺炎鏈球菌的

一些特性及耐藥性。作者只收集了住院病人資料但不

包括門診病人。所以這些病原體造成了較為嚴重的病

情。而這些病原體或者與在社區中存在造成一般感染

者有所不同。

參考文獻

1 Metlay JP, Branas CC, Fishman NO. Hospital-reported

pneumococcal susceptibility to penicillin. Emerging Infectious Diseases, 2004, 10: 54-59.

2 Parsons HK, Dockrell DH. The burden of invasive pneumococcal disease and the potential for reduction by immunization. International Journal of Antimicrobial Agents, 2002, 19:85-93.

3 Oquendo MA. Oral antibiotics for the treatment of severe pneumonia in children. The Lancet, 2004, 364:1104-1105.

4 Bergman M, Huikko S, Huovinen P, et al. Macrolide and azithromycin use are linked to increased macrolide resistance in streptococcus pneumoniae. Antimicrobial Agents and Chemotherapy, 2006, 50:3646-3650.


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‧綜述‧

從“治未病”理論探討

中醫藥對代謝綜合徵的干預趙永華

【摘要】以中醫“治未病”學說為理論基礎，論述“治未病”學說在中醫對代謝綜合徵病因病機、

辨證與治療要點認識中的運用，進而著重闡明在應用中醫藥干預代謝綜合徵的病情發展過程中，“治未病”學說在使機體真正恢復到健康狀態所起的關鍵指導作用。【關鍵詞】治未病; 代謝綜合徵; 中醫藥

Discussion Intervention of Chinese Medicine on Metabolic Syndrome from the Theory of “Preventive Treatment of Disease” ZHAO Yong Hua. Faculty of Chinese Medicine, Macau University of Science and Technology, Macao SAR, PR China; Tel : (+853)-8897 2702; E-mail : [email protected] 【Abstract】 On the basis of the theory of “preventive treatment of disease” in Chinese medicine,

discussion the theory of “preventive treatment of disease” applied in the main points of pathogenesis、treatment based on differentiation of symptom-complex of metabolic syndrome, furthermore emphasizing the theory of “preventive treatment of disease” is essential and guiding action for really back to be in good health of human being in the use of Chinese medicine intervention development process of metabolic syndrome. 【Key words】 Preventive treatment of disease; Metabolic syndrome; Chinese medicine

中醫“治未病”理論源遠流長，早在兩千多年前的

中醫經典巨著《黃帝內經》中即有論述，如《素問．

四氣調神大論》中說“聖人不治已病治未病，不治已亂治未亂⋯⋯夫病已成而後藥之，亂己成而後治之，

譬猶渴而穿井，鬥而鑄錐，不亦晚乎？”，開創了中醫對“治未病”領域的獨特認識和精闢見解之先河。此後，歷代醫家不斷將“治未病”理論內容進行充實、擴展，逐漸形成了比較完善的系統學說。目前認為中醫

的 “治未病” 說，包括著疾病微而未顯 (隱而未現)、顯而未成 (有輕微表現)、成而未發 (有明顯表現)、發而未傳 (有典型表現)、傳而未變 (有惡化表現)、變而未果 (表現出愈或壞、生或死的緊急關頭) 的全過程，是一個複雜的系統工程[1]。

代謝綜合徵 (Metabolic syndrome, MS) 於1988年由Reaven首次提出，當時稱為“X綜合徵”，包括對胰島素刺激的葡萄糖攝取抵抗、糖耐量降低、高胰島素

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)-8897 2702; FAX : +(853)-2882 2938; E-mail: [email protected]

血症、高極低密度脂蛋白膽固醇和低高密度脂蛋白膽

固醇以及高血壓。1991年Defronz 鑑於X綜合徵的幾種表現所共有的病理生理基礎，即胰島素抵抗及其繼

發的糖、脂代謝異常，概括為胰島素抵抗綜合徵。

1997年Zimmet等因本綜合徵與多種代謝相關疾病有密切聯繫，主張命名為代謝綜合徵，其核心是高胰島

素血症胰島素抵抗。2004年中華醫學會糖尿病學會分會關於代謝綜合徵的建議是[2]：它是心血管病的多種

代謝危險因素在個體內集結的狀態，主要組成成分是

肥胖病、糖尿病或糖調節受損，以高甘油三酯(TG)血症及低高密度脂蛋白膽固醇(HDL-C)血症為特點的血脂紊亂以及高血壓。此外，MS尚包括組織胰島素抵抗（IR）,高尿酸血症及反映血管內皮細胞功能缺陷的微量白蛋白尿。MS亦涉及持續低度炎症反應及血液凝溶異常。已有的研究揭示MS人群心血管疾病（冠心病和中風）增高3倍，心血管死亡風險增高2倍，總死亡風險升高1.5倍，糖尿病風險增高5倍（在還未發生糖尿病者）。無論男性還是女性，隨年齡增

加，MS的患病率均顯著升高，廣東地區20歲以上成年人MS發生率為13.26%，中年組17.48%，老年組高達29.27%。澳門地區對該病未有詳細的統計學資料，但據澳門特區統計暨普查局2006年調查結果顯示循環系統疾病佔澳門居民主要死亡原因的第二位，為


98

33.5%。該病起病隱襲，一旦出現臨床症狀多提示病程已經較長，部分病人甚至出現併發症進行回顧性分

析才知道曾患有代謝綜合徵。中醫認為本病屬於“脾癉”範疇，《素問 ·奇病

論》對該病即有記載“有病口甘者，病名為何?何以得之?岐伯曰：此五氣之溢也，名曰脾癉。夫五味入口，藏於胃，脾為之行其精氣，津液在脾，故令口甘

也。此肥美之所發也。此人必數食甘美而多肥也，肥

者令人內熱，甘者令人中滿，故其氣上溢，轉為消

渴。”明確提出了從肥胖到生成脾癉最後轉為消渴（糖尿病）的病理變化，因此從中醫“治未病”學說出發，對該病採取中醫藥干預措施，在臨床症狀未明顯

出現或併發症未形成階段截斷其病理演變，不僅大大

降低糖尿病、心、腦血管病的發病率、死亡率和致殘

率，而且可以降低社會及患者本人因支付昂貴的醫療

費用所形成的經濟負擔。現將中醫“治未病”學說指導代謝綜合徵的防治內容分述如下：

“治未病”學說在對代謝綜合徵

病因病機認識中的運用

中醫認為代謝綜合徵的發生與飲食不節、過度安

逸；情志內傷，六鬱漸生；稟賦不足，後天失調有

關，最後可形成由虛至損，變證叢生的結局。在早中

期以肝脾鬱滯，鬱熱內生為主，鬱主要包括脾鬱、肝

鬱，樞機不利是其本，表現可有氣、血、痰、火、

濕、食六鬱。鬱久化熱，熱證的表現最為突出，究其

臟腑不外胃熱、腸熱、肝熱、心火等。此時機體各系

統、器官尚處於代償期，整體功能比較旺盛，可能並

不顯出病態，而只表現出鬱、熱之象，少數患者亦可

見脾虛痰濕證。及至中後期，由脾開始繼而肝腎，各

個臟腑功能逐漸減退，整體機能失調而出現各種疾

病，病機較為複雜，表現為肺胃津傷，肺脾氣虛，氣

陰兩虛，肝腎陰虛，脾腎陽虛等多種證型，但多虛實

夾雜，可夾熱、夾痰、夾濕、夾瘀等。到晚期或因虛

極而臟腑受損，或因久病入絡，絡痹脈損而成，這一

階段的根本在於絡損(微血管病變)、脈損(大血管病變)，以此為基礎導致臟腑器官的損傷，出現嚴重的循環障礙，變證叢生。因此可用鬱、熱、虛、損來概

括病機演變的規律。


辨證要點認識中的運用

1 辨鬱與瘀 “鬱”相當於MS的前期，而鬱久化熱、化痰的階段相當於MS發生臨床症狀的臨界期。在MS出現臨床症狀開始，“瘀”就一直存在，而由痰瘀，痰熱發展到血瘀、血熱的過程，也是病情漸進的過程。鬱貫穿於

MS發生發展的整個過程中，是“瘀”的形成原因和加重因素，“瘀”形成後又可使“鬱”更甚，二者共同促使MS向前發展[3]。 2 辨病與辨證以肥胖為主，肝脾功能失調應是其核心病機，

痰濁、瘀血、膏脂為主要病理產物；高血壓者當以肝

為中心，肝臟疏泄太過易致肝陽上亢，表現為血壓升

高，肝臟疏泄不及易引起肝鬱氣滯，日久引起一系列

代謝紊亂；高脂血症者當從痰瘀論治，痰濕濁脂堆積

體內，化濕化毒，阻礙氣機升降，而瘀血則因於氣鬱

氣滯，燥熱津虧；以糖代謝紊亂為主者當以脾腎為中

心，脾虛水穀精微不運，糖分不能轉輸全身各臟腑組

織以發揮其濡養作用，蓄積於脈道而升高，腎的溫煦

與開闔功能失常，血糖在體內的運化轉輸與排泄等代

謝過程失調，從而使糖分在脈道蓄積，代謝異常[4]。 3 辨分期肝胃鬱熱、瘀熱互結、脾虛痰濕是MS早、中期的主要證型，既可並存，也可單獨出現；晚期病人多呈

本虛標實證，本虛中氣、血、陰、陽之虛均見，以臟

腑論則可涉及心、肺、脾、腎；標實則以痰瘀為主。 4 辨體、辨病與辨證辨體所指向的目標主要是“人”，將人作為研究的主體，根據體質狀態與特徵尋求發病與治療規律；而

辨證的指向目標是“病”，將疾病某一階段的病理特點與規律作為研究的主體；辨病的指向目標則是疾病全

過程的病理特點與規律。體質、證候、疾病，對個體

所患疾病本質反映的側重面有所不同，所以中醫學強

調要辨體、辨病、辨證相結合，從而有利於對疾病本

質的全面認識。痰濕體質與肥胖、高脂血症、高血壓

病、冠心病、糖尿病、中風密切相關，痰濕體質是代

謝綜合徵的形成因素之一，因此辨證時考慮病人體質

尤為重要。


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治療要點認識中的運用

1 強調治未病由於本病具有慢性、複雜性、隱匿性和進行性

等特點，在治療本病中，處理 “治已病” 和 “治未病” 的關係，強調預防為主，即使在 “治本病” 情況下，亦應注意處理輕與重，順與逆，局部與全部的關

係。結合本病，輕與重為本病的主要與次要，標與本

之間的關係；順與逆為本病的臟腑傳變，順為邪從相

生的方向傳變，反之為逆；局部與全身即治療中既強

調個體的治療，又要重視整體的觀念，整體的觀念是

指中醫通過“四診合參”的辨證，而個體的治療是通過現代醫學各項實驗室或輔助檢查結果的分析，利用中

西醫研究成果來辨治，後者是對於傳統中醫整體辨證

論治的補充和豐富。 2 強調治病求本本病是本虛標實，尤以臟腑虛損為本，且以脾

腎兩虛為主，扶脾益腎為其治療要點。通過健脾益

氣，益腎養陰予以恢復脾腎諸臓調節水穀代謝，排泄

廢物之功能。在注重調補的同時，亦要強調祛邪，包

括根據具體病情採用清熱、瀉濁、滲濕、祛痰、化

瘀、通絡等法。 3 強調異病同治代謝綜合徵涉及各個臟腑，往往正虛邪實交

錯，臨床表現因人而異，極其複雜。治療時可有數十

種立法及方藥，非一方一藥能解決問題，應根據患者

的表現靈活變通，不可拘泥[5]。 4 注意調護提倡運動療法，減輕體重，飲食結構科學化、

合理化，包括限制肥甘厚味，控制主食，宜食蔬菜、

水果、堅果、五穀雜糧，適量紅酒，同時注意戒煙及

心理健康的調護，做到防治結合，藥食結合。

“治未病”學說對代謝綜合徵

遣方用藥的指導與運用

MS 的早期即鬱、熱階段，鬱證階段患者可能沒有明顯不適，僅有體胖、食多、不耐疲勞等症狀。其

舌苔多略為厚膩，脈象則以弦略滑多見，屬於“潛證”，或“未病”階段。臨床治療應從體質人手，從整體出發，把握“鬱”的基本病機，治法為散鬱，基本方為六鬱湯。其中氣鬱又可分為肝鬱、脾鬱，分別以疏

肝理氣的柴胡疏肝散和健脾和中的異功散為治；痰鬱

者，根據具體病證分別以三子養親湯、二陳湯等消

痰、化痰為治；火鬱則應分辨肝膽、胃腸、心、肺、

腎之火分別以龍膽瀉肝湯、三黃湯、導赤散等治之；

濕鬱者分別用淡滲利濕、芳香化濕、苦溫燥濕等法；

食鬱者，首先應節制飲食，並予以消食導滯之品如保

和丸、枳實導滯丸等[6]。而有學者[7] 把 “治未病” 學說與 “毒” 邪理論相結合，認為代謝綜合徵在發病前和發病早期，臨床往往無特殊表現，這是因為三焦功

能異常產生出的 “糖毒”、“脂毒”、痰濁、瘀血等各種 “內毒” 對機體多表現出一種慢性損害，使機體處於慢性中毒狀態，增加 MS的慢性遷延性、疑難性和急驟性。採用清熱解毒法、排毒泄熱法及調補解毒法

包括疏肝理氣、利濕化痰、活血祛瘀及調補脾腎、升

清降濁等治療 MS效果明顯，臨床報導也證實了清熱解毒、排毒泄熱中藥如黃連、黃芩、知母、大黃能改

善胰島素抵抗、糾正 TNF-α 過量釋放及對高血壓、血脂紊亂、糖尿病及腹型肥胖均有明顯治療作用。

綜上所述，中醫的“治未病”學說對指導中醫藥干

預代謝綜合徵已顯示出良好的應用前景，病未發防微

杜漸，病已發防止進展傳變，把握最佳的防治時機，

使機體恢復“陰平陽秘”的狀態，從而達到實現真正健康生活的目的。

參考文獻

1 溫長路. 科學認識和理解中醫的"治未病"說. 甘肅中醫, 2008, 21:3-5.

2 中華醫學會糖尿病學分會代謝綜合徵研究協作組. 中華醫學會糖尿病學會分會關於代謝綜合徵的建議.中華糖尿病雜誌, 2004, 12:156-161.

3 魏治鵬, 郭宏敏. 代謝綜合徵中的鬱和瘀. 遼寧中醫雜誌, 2006, 33:803-804.

4 陳廣峰, 郭宏敏. 代謝綜合徵整體觀治療初探. 陝西中醫, 2006, 27:1398-1399.

5 徐遠. 中醫治療代謝綜合徵的思路與方法. 中醫雜誌, 2003, 44:301-302.

6 仝小林, 張志遠. 中醫對代謝綜合徵的認識和治療. 中醫雜誌, 2002, 43:708-709.

7 呂崇山, 楊叔禹, 李學軍, 等. 代謝綜合徵從毒論治病機

探析. 光明中醫, 2007, 22:12-14.


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‧綜述‧

Asymptomatic Bacteriuria Screening in Pregnant Women CHOI Chong Po WONG In NG Sio Fan HOI Chio Hong

【Abstract】 Lower tract UTIs (cystitis and asymptomatic bacteriuria [ASB]) represent a significant risk factor for developing pyelonephritis in pregnant women. ASB occurs in 2% to 10% of pregnancies and, if not treated, up to 30% of mothers will develop acute pyelonephritis. ASB has been associated with low birth weight and preterm delivery. Eleven articles about this title were reviewed. The articles are limited to meta-analysis or randomized-controlled trials or practice guidelines published within the last 20 years. Many practice guidelines show that the screening for and treatment of ASB in pregnancy has become a standard of obstetric care in UK and USA. In 2008, the USPSTF keeps to recommend screening for ASB with urine culture for pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later. (grade A

recommendation) Comparative clinical trials have consistently reported that antimicrobial treatment of ASB during pregnancy decreases the risk of subsequent pyelonephritis from 20%-35% to 1%-4%. Meta-analyses of cohort studies and randomized clinical trials also support the conclusion that antimicrobial treatment of ASB decreases the frequency of low-birth weight infants and preterm delivery. 【 Key words】 Urinary tract infection; Asymptomatic bacteriuria; Pyelonephritis;

Pregnancy

妊娠婦女無症狀性菌尿的篩檢徐松波, 王燕, 吳少芬, 許釗雄. 中國, 澳門特別行政區, 衛生局, 塔石衛生中心; Tel : (+853)-2852 2232; Fax : (+853)-2856 8872; E-mail: [email protected]

【摘要】下尿路的尿路感染(包括膀胱炎和無症狀性菌尿)在妊娠婦女容易導致腎盂腎炎。無症狀性菌尿在妊娠婦女的發病率為 2%至 10%，如果不治療，最多可導致其中 30%的患者發生急性腎盂腎炎。無症狀性菌尿也與產婦早產和誕下低體重兒有關。綜述了 11 篇在近 20 年間發表的有關這方面的文章，所有文章均選自臨床薈萃分析，隨機對照試驗或臨床指南。許多臨床指南顯示，無症狀性菌尿

的篩檢和治療在英國和美國已成為產科保健常規。2008 年美國預防服務特別工作組維持以前的推薦: 對所有婦女在妊娠 12至 16周之間，或者在此後的第一次門診時常規進行尿培養篩檢。(A類推荐) 相當多的臨床試驗一致報告，妊娠無症狀性菌尿的抗菌素治療可使發生腎盂腎炎的危險性由 20%-35%降至 1%-4%。隊列研究和随機臨床對照試驗的薈萃分析結果，也支持妊娠無症狀性菌尿的抗菌素治療可減少低体重兒和早產的機會。

【關鍵詞】尿路感染; 無症狀性菌尿; 腎盂腎炎; 妊娠

Urinary tract infections (UTIs), a common complication of pregnancy, may be classified as lower (cystitis and asymptomatic bacteriuria [ASB]) or upper (pyelonephritis) tract infections. Although the prevalence of cystitis and ASB are similar in pregnant and nonpregnant women, lower tract UTIs represent a significant risk factor for developing pyelonephritis in pregnant women[1]. The increased risk of pyelonephritis

Authors address: Tap Seac Health Center, Health Bureau, Macau SAR, China; Tel: (+853)-2852 2232; Fax: (+853)-2856 8872; E-mail: [email protected]

is thought to be secondary to the anatomic and physiologic changes that occur in pregnancy[2].

ASB is the presence of significant bacteriuria without symptoms or signs, such as frequency, urgency, dysuria, pyuria, or hematuria. Significant bacteriuria is defined as greater than or equal to 105 colony-forming units of a single pathogen per milliliter of urine in two consecutive midstream urine samples[3]. ASB occurs in 2% to 10% of pregnancies and, if not treated, up to 30% of mothers will develop acute pyelonephritis. ASB has been associated with low birth weight and preterm delivery[4]. Prospective,


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comparative clinical trials have consistently reported that antimicrobial treatment of ASB during pregnancy decreases the risk of subsequent pyelonephritis from 20%-35% to 1%-4%. Meta-analyses of cohort studies and randomized clinical trials also support the conclusion that antimicrobial treatment of ASB decreases the frequency of low-birth weight infants and preterm delivery[5].

Through critical appraisal some articles, we

discuss the importance of ASB screening in pregnancy.

METHODS Medical search engine “PubMed”, “MD Consult”, “EBSCO host” and “OVID” are used from Internet and intranet linking to our hospital library. Combination of words including “asymptomatic bacteriuria”, “pregnancy” and “management” are used in the search. The search is limited to meta-analysis or randomized-controlled trials or practice guidelines published within the last 20 years. The articles with abstract or full text write in English studying human and women. Eleven articles are reviewed.

RESULTS ASB was more likely to be ascertained in the first trimester[6-9]. According to the Scottish Intercollegiate Guidelines Network (SIGN) 88 guideline, National Institute for Health and Clinical Excellence (NICE) 2003 guideline, Infectious Diseases Society of America (IDSA) Guidelines and recommendation from The US Preventive Services Task Force (USPSTF), the screening for and treatment of ASB in pregnancy has become a standard of obstetric care[5-8]. In 2008, the USPSTF keeps to recommend screening for ASB with urine culture for pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later. (grade A recommendation) and recommends against screening for asymptomatic

bacteriuria in men and nonpregnant women. (grade D recommendation)[7].

Screening test used urine dipstick analysis and direct microscopic examination has poor sensitivity and negative value to detect bacteriuria in asymptomatic persons. Urine culture is the gold standard to detect ASB but is expensive if used routinely in populations with a low prevalence[7]. Significant bacteriuria is defined as greater than or equal to 105 colony-forming units of a single pathogen per milliliter of urine in two consecutive midstream urine samples[3].

When ASB was confirmed, a short course (4-7 days)

of oral antibiotic treatment should start according to results of sensitivity tests. A systematic review of 14 RCTs compared antibiotic treatment with no treatment or placebo. Antibiotic treatment reduced persistent bacteriuria during pregnancy (Peto OR 0.07, 95% CI 0.05 to 0.10), reduced risk of preterm delivery or low-birth weight babies (OR 0.60, 95% CI 0.45 to 0.80), and reduced the risk of development of pyelonephritis (OR 0.24, 95% CI 0.19 to 0.32, NNT 7) [Evidence level 1a][8]. Antibiotics are regarded as suitable for use in pregnancy depending on the United State FDA Pharmaceutical Pregnancy Categories.

Urine culture should be repeated at seven days after

completion of antibiotic treatment and repeated monthly until delivery if urine culture keeps negative[6]. The women need to refer to obstetrician if ASB is treatment fail or recurrence.

Group B streptococcus (GBS) UTI has been linked

to premature rupture of membranes, preterm delivery and neonatal sepsis, meningitis, and pneumonia. Women with group B streptococcal bacteriuria should be treated at initial diagnosis and at the onset of labor[1].

CONCLUSION

For reducing the risk of preterm delivery or low-


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NegativePositive

Treatment fail or recurrence

A standard quantitative urine culture performs routinely at gestation of 12 weeks or later [6-11]

A second urine culture to confirmed

bacteriuria[6]

A short course (4-7 days) antibiotic treatment[8]

Repeat urine culture monthly until delivery[6]

Screening with urine dipstick testing for nitrites in the following antenatal

visit until delivery[9-11]

If nitrites positive, confirmed with urine culture[9-11]

Positive§，‡ Bacteriuria

Yes No

Refer to O&G

Eradicated Positive

Repeat urine culture at seven days after completion of

antibiotic treatment as a test of cure[6]

birth weight babies and reducing the risk of development of pyelonephritis in pregnancy, we agree with performing routine urine culture for pregnant women at 12 to 16 weeks’ gestation or at the first prenatal visit, if it occurs after that period. The screening for and treatment of ASB in pregnancy has become a standard of obstetric care in UK and USA[5-8]. But the finance is an important factor on performing ASB screening in pregnancy.

We design a flow chart of ASB screening in

pregnant women (see Figure):

§Positive means the same bacterium grow out in the twice urine culture. ‡ If GBS is isolate – refer to O&G, as prophylactic antibiotics may be required during labor.

REFERENCES

1 Gilstrap LC 3rd, Ramin SM. Urinary tract infections during pregnancy. Obstet Gynecol Clin North Am, 2001, 28: 581-591.

2 Patterson TF, Andriole VT. Detection, significance, and therapy of bacteriuria in pregnancy. Update in the managed health care era. Infect Dis Clin North Am, 1997, 11: 593-608.

3 Rubin RH, Shapiro ED, Andriole VT, et al. Evaluation of new anti-infective drugs for the treatment of urinary tract infection. Infectious Diseases Society of America and the Food and Drug Administration. Clin Infect Dis, 1992, 15: 216-227.

4 Smaill F, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy (Review). Cochrane Library, 2007, 4:1.

5 Lindsay EN, Suzanne B, Richard C, et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. IDSA Guidelines for Asymptomatic Bacteriuria. CID, 2005, 40: 643.

6 Scottish Intercollegiate Guidelines Network. SIGN 88: Management of suspected bacterial urinary tract infection in adult – A national clinical guideline. 1st ed. Edinburgh: Sign, 2006. 13-15.

7 U.S. Preventive Services Task Force (USPSTF). Screening for Asymptomatic Bacteriuria in Adults: Reaffirmation Recommendation Statement. Ann Intern Med, 2008, 149: 43-47.

8 National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Clinical Excellence October 2003. Antenatal care: routine care for the healthy pregnant woman. 1st ed. London: RCOG Press, 2003. 79-81.

9 Robbye D, Steven R, Sharon L, et al. Evaluation of the centrifuged and Gram-stained smear, urinalysis, and reagent strip testing to detect asymptomatic bacteriuria in obstetric patients. American Journal of Obstetrics and Gynecology, 2000, 182:1076-1079.

10 Bachman JW, Heise RH, Naessens JM, et al. A Study of Various Tests to Detect Asymptomatic Urinary Tract Infections in an Obstetric Population. JAMA, 1993, 270:1971-1974.

11 Douglas GT, David HR. Evaluation of reagent strips in detecting asymptomatic bacteriuria in early pregnancy: prospective case series. BMJ, 1998, 316:435.


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‧綜述‧

Efficacy and Safety of Tripterygium in Primary Nephrotic Syndrome

Ingrid Karmane SUMOU

【Abstract】 This work evaluates the effects and side effects of tripterygium therapy on primary nephrotic syndrome (PNS). The author searched public medical database by key words tripterygium and nephrotic syndrome to acquire the relevant literature. The articles meeting the selection criteria were assessed, analyzed and summarized. The author first obtained 131 articles, including 119 Chinese articles and 12 English articles. According to the selection criteria, 13 Chinese articles and 1 English article were finally accepted. Strength of evidence proved to be all at level III. (1) Tripterygium regular dosage [1mg/(kg·d)] alone in treating PNS showed effective ratio 84.6% and relapse 54.5%. (2) Tripterygium regular dosage plus prednisone in treating PNS displayed effective ratio 88.7% and relapse 26.8%. Of them, the effective ratio and relapse in tripterygium duration 3~6 month group were similar to those in tripterygium duration 6~12 month group (89.6% vs 85.2%, P>0.05, 27.4% vs 26.2%, P>0.05). The effective ratio and relapse in initial prednisone dosage 2mg/(kg·d) group were similar to those in initial prednisone dosage 1mg/(kg·d) group (100% vs 87.5%, P>0.05, 27.6% vs 24.4%, P>0.05). The effective ratio had no significance between tripterygium plus prednisone and prednisone alone group (89.0% vs 82.4%, P>0.05), but relapse seemed decreased in tripterygium plus prednisone group (23.4% vs 52.9%, P<0.05). The similarities of effective ratio and relapse were clarified by comparing tripterygium plus prednisone with cyclophosphamide plus prednisone (80.0% vs 77.1%, P>0.05, 28.2% vs 29.3%, P>0.05). (3)Tripterygium double dosage [2mg/(kg·d)] alone in treating PNS manifested effective ratio 90.3% and relapse 19.1%. (4)Tripterygium had better effects upon MCNS, MsPGN, MPGN than MN and FSGS. (5)The total incidence of side effects of tripterygium in regular dosage group was significantly less than that in double dosage group (19.9% vs 36.7%, P<0.01). The incidence of side effects in tripterygium duration 3~6 month group was less than that in duration 6~12 month group (5.3% vs 52.2%, P<0.01). Tripterygium could treat PNS effectively. Tripterygium regular dosage plus prednisone had a satisfactory effective ratio. Relapse was remarkably decreased comparing to prednisone alone or tripterygium alone. Incidence of side effects was less than that of tripterygium double dosage. Treatment with tripterygium duration 3~6 months seemed better. 【Key words】 Nephrotic syndrome; Tripterygium

雷公藤治療原發性腎病綜合徵的療效評價梁嘉敏. 中國, 澳門特別行政區, 極峰醫療中心; Tel: (+853)-2883 6880; Fax: (+853)-2883 6299; E-mail: [email protected] 【摘要】本篇文章宗旨是對雷公藤治療原發性腎病綜合徵不同方案進行評價。通過檢索從各醫

學資料庫起始年限至 2004 年的雷公藤治療腎病綜合徵相關中英文文獻，按照循證醫學文獻質量分級篩選符合條件的參考文獻進行分析總結。經篩選後中文 13 篇、英文 1 篇符合納入標準，文獻質量分級均為 III級。(1) 單用常規劑量 1mg/(kg·d)雷公藤：總有效率 84.6%，復發率 54.5%。(2) 常規劑量雷公藤合用潑尼松：總有效率 88.7%，復發率 26.8%。雷公藤療程 3~6個月與 6~12個月組比較，有效率及復發率無明顯差異（P>0.05）。潑尼松初始劑量 2mg/(kg·d)與 1mg/(kg·d)組比較，有效率及復發率無明顯差異（P>0.05）。常規劑量雷公藤合用潑尼松與單用潑尼松比較，有效率無統計學意義（P>0.05），復發率明顯降低（P<0.05）。常規劑量雷公藤合用潑尼松與環磷酰胺合用潑尼松兩組比較，有效率、復發率均無統計學差異（P>0.05）。(3) 單用雙倍劑量雷公藤 2mg/(kg·d)，總有效率90.3%，復發率 19.1%。(4) 雷公藤對微小病變腎病、系膜增生性腎小球腎炎、膜增生性腎炎者總有效率明顯高於其他病理類型。(5) 常規劑量雷公藤不良反應總發生率明顯低於雙倍劑量（P<0.01）。療程 3~6 個月不良反應總發生率明顯低於 6~12 個月（P<0.01）。常規劑量雷公藤合用潑尼松治療腎病綜合徵療效滿意並可明顯減少復發，雷公藤療程 3~6 個月或 6~12 個月、潑尼松初始劑量 1mg/(kg·d)或2mg/(kg·d)有效率及復發率相近，但雷公藤長療程不良反應發生率明顯增加。單用雙倍劑量雷公藤療效好，但不良反應發生率高。

【關鍵詞】腎病綜合徵; 雷公藤

Author’s address: Zenith Medical Center, Macau SAR, China; Tel: (+853)-2883 6880; Fax: (+853)-2883 6299; E-mail: [email protected]


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INTRODUCTION

Nephrotic syndrome is a common renal disease. The medication choice of priority is glucocorticoid. But some patients present with steroid dependence, steroid resistance or frequent relapse and side effects sometimes occur.

Tripterygium wilfordii Hook F is a plant of

the genus Tripterygium of the family celastraceae. The tripterygium used is mainly extracted from the root of Tripterygium wilfordii Hook F. In vitro and in vivo experiments have proved tripterygium immunosuppressive effects. Since 1977, Li first reported tripterygium could treat glomerular nephritis. Tripterygium has been applied to treat primary or secondary nephritis for almost 30 years. This study aimed to evaluate the precise effects and hazards of tripterygium in treating human renal diseases, especially primary nephrotic syndrome (PNS). So, the author acquired the relevant literature through searching medical database from the year of database set up to 2004. The author screened the articles according to the selection criteria, and then analysis, evaluation and summarization of the effects and side effects of tripterygium therapy in PNS were carried out.

EVALUATION STRATEGY AND CRITERIA

1 Search strategy

The author searched medical database MEDLINE (since 1965), PubMed, CBMDisk (since 1979), CNKI (since 1994), WANFANG, and MICROMEDEX healthcare series by key words tripterygium and nephrotic syndrome, without language restriction, and acquired related literature from the year of database set up to 2004. 2 Selection criteria

The articles were chosen according to the following: clinical original papers, tripterygium treating human PNS without combination with immunosuppressive agents, ACEI (Angiotensin-Converting Enzyme Inhibitors) or

other Chinese medical herbs, having evaluation indexes including remission, partial remission, no response and relapse. The repeated articles sourced from different medical database and “batch files” from one experiment were deleted.

3 Levels of Evidence

The available articles were rated for the strength of evidence[1]:

(1) Ia: Evidence obtained from meta-analysis of randomized controlled trials. (2) Ib: Evidence obtained from at least one randomized controlled trial. (3) IIa: evidence obtained from at least one well designed controlled study without randomization. (4) IIb: evidence obtained from at least one other type of well designed quasi-experimental study.

(5) III: evidence obtained from well designed non experimental descriptive studies such as comparative studies, correlation studies, and case control studies.

(6) IV: evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

ANALYSIS All the articles were analyzed on tripterygium

dosage, regular dosage [1mg/(kg·d)] or double dosage [2mg/(kg·d)]; tripterygium duration, 3~6 months or 6~12 months; and tripterygium application, including tripterygium alone, combined with prednisone initial dosage 1mg/(kg·d) or 2mg/(kg·d).

The clinical effect of tripterygium was evaluated as

remission (urine protein − ~ ±, 24 hour urine protein <0.4g), partial remission (urine protein reduced by half of the original level), no response (urine protein unchanged) and relapse (urine protein turned negative, but discontinued tripterygium for over 4 weeks, urine protein ≥2+). Effective ratio was obtained by the number of remission cases plus the number of partial remission


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cases divided by the number of total cases. Chi-square test was used for the statistical analysis

of the data. 1 Number of articles

Searching the relevant articles with the key words tripterygium and nephrotic syndrome, the author acquired 131 articles (119 Chinese articles and 12 English articles), including 6 English articles in MEDLINE, 6 English articles in PubMed, 40 Chinese articles in CBMDisk, 70 Chinese articles in CNKI and 9 Chinese articles in WANFANG. From MICROMEDEX healthcare series the author gained systemic reviews about side effects of tripterygium.

Out of the 119 Chinese articles, 46 repeated articles,

5 basic research articles and 8 articles about secondary nephrotic syndrome were rejected. Sixty articles remained. Of the 60 articles, only 46 articles had evaluation indexes. In these 46 articles, 28 articles were rejected due to their treatment combination with immunosuppressive agents, ACEI or other Chinese medical herbs. After rejecting 5 batch files from one experiment, finally 13 Chinese articles were accepted.

Out of the 12 English articles, according to the same

selection criteria, finally 1 English article was accepted. 2 Levels of evidence

All of these 14 articles were level III, because the articles did not describe the method of creating random series, double blind and condition of termination. 3 Clinical data analysis (1) Tripterygium regular dosage alone

Of the 14 articles, 1 English article[2] was about tripterygium regular dosage alone therapy in PNS. In this group, 13 children with refractory nephrotic syndrome (3 frequent relapse cases, 3 steroid dependent cases, 7 steroid resistant cases) were treated with tripterygium for about 3 months. Where 8 out of 13 cases had remission (61.5%) and 3 out of 13 cases had partial remission (23.1%). Effective ratio was 84.6% (11/13 cases). Follow

up 1.4~4 years, 6 cases relapsed. Relapse was 54.5% (6/11 cases).

(2) Tripterygium regular dosage plus prednisone

Of the 14 articles, 9 Chinese articles[3~11] were about tripterygium regular dosage plus prednisone therapy in PNS. In 247 cases, 168 cases had remission (68.0%), 51 cases had partial remission (20.6%). Effective ratio was 88.7% (219/247 cases). Follow up 0.5~4.9 years, 51cases relapsed (26.8%, 51/190 cases).

1) Tripterygium regular dosage plus prednisone in different durations of Tripterygium

All cases in the 9 Chinese articles were divided into two groups according to tripterygium duration. In 3~6 month group, 136 out of 193 cases had remission (70.5%) and 37 out of 193 cases had partial remission (19.2%). Effective ratio was 89.6% (173/193 cases). Follow up 2~3 years, relapse was 27.4% (29/106 cases). In 6~12 month group, 32 out of 54 cases had remission (59.3%) and 14 out of 54 cases had partial remission (25.9%). Effective ratio was 85.2% (46/54 cases). Follow up 0.5~4.9 years, relapse was 26.2% (22/84 cases). Effective ratio and relapse between the two groups showed no statistical significance (P=0.362, P=0.857). 2) Tripterygium regular dosage plus prednisone in different initial dosages of prednisone

All cases in the 9 Chinese articles were also categorized according to prednisone initial dosages. In 1mg/(kg·d) group, 145 out of 224 cases had remission (64.7%) and 51 out of 224 had partial remission (22.8%). Effective ratio was 87.5% (196/224 cases). Follow up 0.5~1 year, relapse was 24.4% (11/45 cases). In 2mg/(kg·d) group, all 23 cases had remission. Effective ratio was 100%. Follow up 2~4.9 years, relapse was 27.6% (40/145cases). Effective ratio and relapse between the two groups demonstrated no statistical significance (P=0.086, P=0.678). 3) Tripterygium regular dosage plus prednisone versus prednisone alone

Of the 9 Chinese articles, 4 articles[6-9] contrasted


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tripterygium plus prednisone against prednisone alone. There were altogether 73 cases in combined group and 68 cases in prednisone alone group. Their effective ratio being 89.0% (65/73 cases) and 82.4% (56/68 cases) respectively (P=0.255). Follow up 0.5~2 years, relapse being 23.4% (11/47 cases) and 52.9% (27/51 cases) respectively (P=0.003).

4) Tripterygium regular dosage plus prednisone versus Cyclophosphamide plus prednisone

Of the 9 Chinese articles, 2 articles[10-11] contrasted tripterygium plus prednisone against cyclophosphamide plus prednisone. Their effective ratio being 80% (28/35 cases) and 77.1% (27/35 cases) respectively (P=0.771). Follow up 4.9 years, relapse in the two groups demonstrated no statistical difference, 28.2% (11/39

cases) versus 29.3% (12/41 cases), P=0.916. (3) Tripterygium double dosage alone

In the 14 articles, 4 Chinese articles[12~15] studied tripterygium double dosage alone therapy in PNS. Out of 176 cases, 130 cases had remission (73.9%) and 29 cases had partial remission (16.5%). Effective ratio was 90.3% (159/176 cases). Relapse was 19.1% (9/47 cases), no details concerning time limit of follow up.

(4) Different schemes of tripterygium therapy in primary nephrotic syndrome

A, B, C groups had similar effective ratios (P=0.742), relapse seemed decreased in B, C groups (P=0.047, P=0.016) (Figure1).

Figure 1 Different schemes of tripterygium therapy in primary nephrotic syndrome

Scheme Effective Ratio

% (n/N) Remission % (n/N)

Partial Remission % (n/N)

Relapse % (n/N)

84.6 61.5 23.1 54.5 A* (11/13) (8/13) (3/13) (6/11)

88.7 68.0 20.6 26.8 B*

(219/247) (168/247) (51/247) (51/190) 90.3 73.9 16.5 19.1

C* (159/176) (130/176) (29/176) (9/47)

A: tripterygium regular dosage alone, B: tripterygium regular dosage plus prednisone, C: tripterygium double dosage alone, n/N: number of patients effective ratio χ2=0.5959, P=0.742

(5) Tripterygium therapy in primary nephrotic

syndrome of different pathological types

Of the 14 articles, 2 articles[5,15] described

tripterygium therapy in patients with different

pathological types. In one of them, patients were treated

with tripterygium regular dosage plus prednisone, in the

other one patients were treated with tripterygium double

dosage alone. The treatment effects demonstrated no

significant difference in various schemes. Totally, 45

(86.5%) out of 52 MCNS (minimal change nephrotic

syndrome) had remission and 7 cases (13.5%) had partial

remission. Seventy-two (86.7%) out of 83 MsPGN

(mesangial proliferative glomerulonephritis) had

remission and 11 cases (13.3%) had partial remission.

Twenty-three (71.9%) out of 32 MPGN

(membranoproliferative glomerulonephritis) had

remission, 5 cases (15.6%) had partial remission and 4

cases (12.5%) showed no response. Seven (36.8%) out of

19 MN (membranous nephropathy) had remission, 5

cases (26.3%) had partial remission and 7 cases (36.8%)

showed no response. Of all 5 FSGS (focal segmental

glomerulosclerosis) cases, 2 cases (40.0%) had partial

remission and 3 (60.0%) had no response.

(6) Side effects of Tripterygium

The total incidence of side effects of tripterygium in

regular dosage group was significantly less than that in

double dosage group (19.9% vs 36.7%, P=0.002)

( Figure 2). The incidence of side effects in duration 3~6

month group was markedly lower than that in duration

6~12 month group, 5.3% (8/152 cases) vs 52.2% (36/69

cases), χ2=65.4944, P=0.000.


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Figure 2 Incidence of tripterygium side effects in different dosages

Regular dosage Double dosageTripterygium % (n/N) % (n/N)

Total Incidence 19.9 (44/221)* 36.7 (33/90)*Gastrointestinal Symptoms 9.0 (20/221) 8.9 (8/90)Increased hepatic enzymes 2.3 (5/221) 22.2 (20/90)Skin Pigmentation 1.8 (4/221) 0.0 Leucopenia 4.1 (9/221) 3.3 (3/90)Irregular Menstruation 9.2 (6/65) 6.7 (2/30)

*χ2=9.6403, P=0.002

CONCLUSION

Tripterygium has been applied to treat glomerular nephritis for many years. A lot of articles have been reported. Recently, a great deal of basic research literature expatiated the mechanism of tripterygium in treating glomerular diseases[16], such as anti-inflammatory and immunosuppressive effects, protection of glomerular basement membrane, inhibition of mesangial proliferation and delay in glomerular sclerosis. These provided theoretical background for tripterygium in treating nephrotic syndrome. But the author aimed to clarify the precise effects and side effects of tripterygium in clinical treatment of PNS. The author also considered it as necessary to understand how to use tripterygium best. So the author searched authoritative medical database such as MEDLINE, CBMDisk, CNKI to acquire relevant literature about tripterygium therapy in PNS, and then analyzed, evaluated and summarized the data.

By clinical data analysis, the author found out that

tripterygium regular dosage plus prednisone was a popular scheme used to treat PNS in China. This scheme had a satisfactory effective ratio. Relapse was remarkably decreased comparing to the scheme of prednisone alone or tripterygium alone. The effective ratio and relapse of tripterygium regular dosage plus prednisone in different tripterygium durations and initial dosages of prednisone seemed similar, but the total incidence of side effects in longer durations (6~12 months) of tripterygium was markedly increased. The

effective ratio and relapse of tripterygium regular dosage plus prednisone were similar to those of cyclophosphamide plus prednisone.

Past papers reported that it was ineffective to treat

rat Masugi nephritis with tripterygium 6mg/(kg·d), but the proteinuria disappeared when increasing tripterygium dosage up to 10mg/(kg·d). It demonstrated that the effect of tripterygium was proportional to its dosage. Increasing dosage might improve clinical effect. In 1997, Hu[12] first reported that tripterygium double dosage alone treated PNS. A series of literature followed. After analysis, the result showed that tripterygium double dosage alone had satisfactory effect, but the total incidence of side effects was greater than that of regular dosage.

Regardless of regular dosage or double dosage,

tripterygium had better effects upon MCNS, MsPGN, MPGN than MN and FSGS.

From MICROMEDEX healthcare series the author

acquired systemic reviews about side effects of tripterygium. The data showed tripterygium might cause dermatologic, gastrointestinal, hematologic, genitourinary, neurologic and cardiovascular adverse events and some side effects could be severe. In our available articles, the main side effects of tripterygium in treating PNS were gastrointestinal symptoms, increased hepatic enzymes, leucopenia and irregular menstruation. None serious side effects had been observed. Tripterygium regular dosage plus prednisone and tripterygium duration 3~6 months had less total incidence of side effects than tripterygium double dosage alone and tripterygium duration 6~12 months.

Tripterygium used in above articles mostly was

manufactured by TAIZHOU Pharmacy. The author did not take the place of manufacture of tripterygium into account.

The strength of evidence of all accepted articles was

low (level III). This implied the quality of these articles was not up to expectations. So the opinions mentioned


108

above were preliminary. More randomized controlled trials would be needed to further evaluate the effects and safety of tripterygium therapy in PNS.

REFERENCES 1 Paul GS, Steven HW, Martin E, et al. Clinical guidelines:

Developing guidelines. BMJ, 1999, 318:593-596. 2 Jiang XY. Clinical observations on the use of the Chinese

herb tripterygium wilfordii hook for the treatment of nephritic syndrome. Pediatr Nephrol, 1994, 8:343-344.

3 Xu XP, Mao J. Application of tripterygium plus prednisone on primary nephrotic syndrome (with 34 cases reported). Clinical Focus, 1994, 9:494.

4 Liu AM, Wang YP, Dai YW, et al. Prolonged duration of prednisone plus tripterygium on nephrotic syndrome in children. Zhejiang JITCWM, 2003, 13:678-679.

5 Liu GL, Gao YF, Xia ZK, et al. Application of tripterygium wilfordii hook on nephrotic syndrome in children and its mechanism study. Journal of Medical Postgraduate, 2000, 13:9-11.

6 Wang KL, Wang DM. Application of tripterygium plus prednisone on primary nephrotic syndrome (with 30 cases observation). Journal of Dali Medical College, 1996, 5:36-37.

7 Han SL, Li GX, Zhou LH, et al. Clinical observation of tripterygium plus prednisone on primary nephrotic syndrome. Chinese Journal of Integrated Traditional and Western Nephrology, 2001, 2:115-116.

8 Lu YZ. Clinical observations on the use of tripterygium

for the treatment of 13 nephrotic syndrome relapse cases. FJ Medical Journal, 2003, 25:225.

9 Zhang JT. Application of tripterygium plus prednisone on primary nephrotic syndrome in children. GD Medicine, 1998, 19:227.

10 Zhou YC. On the use of tripterygium plus prednisone for the treatment of nephrotic syndrome. Hebei Medicine, 1999, 5:14-16.

11 Liu AM, Wang YP, Dai YW, et al. Clinical observations on the use of tripterygium for the treatment of nephrotic syndrome relapse cases in children. Zhejiang Journal of Traditional Chinese Medicine, 2003, 8:334.

12 Hu WX, Tang Z, Yao XD, et al. Clinical observations of curative effect in short term on the use of double dosage tripterygium for the treatment of nephrotic syndrome. J Nephrol Dialy Transplant, 1997, 6:210-214.

13 Wang YX, Ren K, Lu Y, et al. Clinical observations of curative effect in short term on the use of tripterygium for the treatment of 20 nephrotic syndrome cases. China Journal of Traditional Chinese Medicine and Pharmacy, 2003, 18:349-350.

14 Qian XH. Clinical observations of curative effect on the use of double dosage tripterygium for the treatment of nephrotic syndrome. Medical Journal of Communications, 2002, 16:620-621.

15 Liu GL, Gao YF, Xia ZK, et al. Clinical observations on the effects of double doses of glucosides of TWH for nephrotic syndrome in children. Journal of Medical Postgraduate, 2003, 16:518-520.

16 Sun WX, Dai Y. Molecular mechanism research of tripterygium treating glomerular nephritis. Medical Recapitulate, 2003, 9:702-704.


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‧綜述‧

粘多糖貯積癥汪劭婷

【摘要】粘多糖是一類蛋白多糖，其降解所需酶的缺乏導致溶酶體粘多糖貯積癥，共分 6大型，

多為常染色體隱性遺傳，表型差異大，通常有骨、角膜、神經等癥狀，骨髓移植、酶替代法等為較有效療法。本文主要對粘多糖貯積癥的遺傳基礎、臨床表現及治療方法作一綜述。【關鍵詞】粘多糖貯積癥; 骨發育異常; 智力延滯; 移植; 酶活性

Mucopolysaccharidosis WANG Shaoting. Grade 2003 Clinical Medicine, Peking Union Medical College. No 9, Dongdansantiao Road, Beijing, 100005, PR China. Tel:(+86-10) 6528 3716; E-mail:[email protected] 【Abstract】 Mucopolysaccharidosis is the lysosomal storage disorders of mucopolysaccharide with

six types, most of which are autosomal recessive. The spectrum of clinical phenotypes is broad, including hepatosplenomegaly, skeletal dysplasias, corneal clouding, short stature and mental retardation. Bone marrow transplantation and enzyme replacement therapy are effective are found effective. In this article, I will summarize the heredity basis, clinical manifestation and therapies. 【 Key words 】 Mucopolysaccharidosis; Skeletal dysplasias; Mental retardation;

Transplantation; Enzymatic activity

粘多糖是一類蛋白多糖,其中包括透明質酸、硫

酸軟骨素、硫酸皮膚素、硫酸乙酰肝素和硫酸角質

素，其降解過程的任一種酶發生遺傳性缺陷,均可導致溶酶體粘多糖貯積癥（MPS）。該病共分 6 大型，除 II 型外，為常染色體隱性遺傳，基因突變方式多樣，表型差異大，通常有骨、角膜、肝脾、神經等受累，目前治療以姑息支持治療為主。

發病率

1 MPS-I 1/100000 至 1/150000，居各種 MPS 之首，我國也以該型居多[1] （MIM# 252800） 2 MPS-Ⅱ 國內為 1:132000 男性，美國為 1:25000 活產男嬰[2] （MIM# 309900） 3 MPS-Ⅲ（含 A BⅢ Ⅲ ）澳大利亞為 1:70 000[3] （MIM# 605270、252920）作者單位: 100005, 中國, 北京市, 東單三條, 9號, 北京協和醫學院, 臨床醫學 2003級,Tel : (+86-10) 6528 3716; E-mail:[email protected]

4 MPS-Ⅲ（含 A BⅢ Ⅲ ）澳大利亞為 1:70 000[3] （MIM# 605270、252920） 5 MPS-Ⅳ（含 A BⅣ Ⅳ ）美國大致為 1:40000 至 1:50000[4]（ MIM# 253000） 6 MPS-Ⅵ 1：238 095至 1 ：1 300 000[5]（MIM# 253200） MPS-Ⅶ型：未見報道（MIM #253220)

遺傳方式

除Ⅱ型（X 連鎖隱性）外，其餘型都為常染色體隱性遺傳[3, 6-7]。

致病基因及突變

1 MPS-I α-L 艾杜糖醛酸酶基因（IDUA）定位於 4p16. 3，長度為 19kb，含 14 個外顯子，低水平轉錄，含


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有一個 1959kb 的開放性閱讀框，用於編碼一條 653個氨基酸的膚鏈。自突變 W402X（歐裔）發現以來，至今已發現各種突變達 60 餘種，包括無義突變、錯義突變、剪接位點突變和缺失或插入。常見的

突變有 Q70X、 R89、704ins5，中國台北有報道MlI、Y343X、T364M 突變。另外，在 IDUA 基因中還檢測到至少 30 種多態性位點和（或）非病理性序列改變，其中有 18 種發生於外顯子序列，有 7 種引起了氨基酸序列的改變，只有一種是在內含子中插人

一個鹼基 C，其餘均由單個鹼基改變引起[8]。Taylor稱 IDUA 基因的不同組合可能正是引起正常個體IDUA 活性改變的因素之一，而且某些多態性位點的積累與嚴重型突變基因的組合可能是引起輕型 MPS-I的原因[1, 9-10]。 2 MPS-Ⅱ 艾杜糖-2-硫酸酯酶基因（IDS）定位於 Xq27， 32~Xq28，全長 24 kb，有 9 個外顯子，編碼的多肽鏈長度為 550 個氨基酸。已報道各類突變超過 330種，[11]絕大多數突變位於 IDS基因外顯子 2、3、5、7、8 和 9，突變以第 9 外顯子最多見，約佔 31%，其次是第 3 外顯子，約佔 21%，再次是第 8 外顯子，約佔 20%。突變包括缺失（佔 1/4）、無義突變、錯義突變、拼接位點突變、小的插入、重排等[12]，大部分屬於“私人突變”，極少數具有種族或

地域的特異性。Machill 等發現 IDS 基因新突變率相當高，而國內報道的突變類型不多[7-8, 10]。 3 MPS- A Ⅲ 硫酸乙酰肝素硫酸胺酶基因 (SGSH)位於17q25.3,11kb,含 8 個外顯子，轉錄為 3.1,4.3,7.1kb 三段。已發現約 62 種突變，含 46 種無義/錯義突變，15種小插入/缺失，1種剪接突變。 4 MPS- B Ⅲ α-N-乙酰氨基葡萄糖苷酶基因 (NAGLU)位於17q21.1,8.2kb,6 個外顯子，轉錄為 2.7kb的 RNA，另一種剪接方式表達於睾丸。已發現 86 種突變，含 58種無義/錯義突變，27 種小插入/缺失，1 種剪接突變[3]。 5 MPS- A Ⅳ N-乙酰半糖胺-6-硫酸硫酸酯酶基因(GALNS)位

於 16q24[4]，含 14 個外顯子，約 50kb，已發現兩個點突變[10]。 6 MPS-ⅣB β-半乳糖苷酶基因位於 3q21[4]。 7 MPS-Ⅵ N-乙酞半乳糖胺-4-硫酸醋酶基因(h4S)定位於5g13-q14上，含有 8個外顯子和 7個內含子，其 cDNA共含有 2 811bp，編碼一個含 533 個氨基酸的前體多肽。已發現 h4S 基因有 40 多種突變，其中多數是鹼基置換突變，包括同義突變、錯義突變、無義突變、終

止密碼突變等，也有缺失、插入等變異類型[6]。 8 MPS-Ⅶ 尿甘酸化酶基因現已發現至少 7個錯義突變[10]。

發病機制(分子和細胞水平)

1 MPS-I 因 α-L 艾杜糖醛酸酶（α- L – iduronidase，IDUA）先天性缺如或缺陷，屬溶酶體貯積病，主要是由於患兒體內缺乏剪切硫酸皮膚素 (Dermatan sulfate, DS)和硫酸乙酰肝素（Heparitinsulfate, HS）艾杜糖醛酸殘基的 α-L 艾杜糖醛酸酶，導致它們在腦、結締組織、肝脾等組織的溶酶體內大量貯積[10]。 2 MPS-Ⅱ 溶酶體內艾杜糖 -2-硫酸酯酶（ Iduronate-2-sulfatase, IDS ）缺乏，致糖胺聚糖

（Glycosaminoglycans, GAGs）在內髒和結締組織中積累，尿中大量排出分解不完全的硫酸皮膚素

(Dematan sulfate, DS)和硫酸乙酰肝素，並在全身髒器和組織內沈積而致病[10]。 3 MPS-III 由於降解硫酸乙酰肝素（Heparan sulfate）的 4種酶中任意一種的缺乏，導致尿中排出硫酸乙酰肝

素，出現 Sanfilippo綜合癥： (1) MPS- A: Ⅲ 硫酸乙酰肝素硫酸胺酶(SGSH; MIM#

605270)


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(2) MPS- B: αⅢ -N-乙酰氨基葡萄糖苷酶 (NAGLU; MIM# 252920)

(3) MPS-ⅢC: α- 氨基葡糖苷 -N- 基乙醯化酶

（ acetylCoA:α-glucosaminide-N-acetyltransferase ；MIM#252930),

(4) MPS- D: NⅢ -乙酰葡萄糖胺 -6-硫酸酯酶（N-

acetylglucosamine-6-sulfatase; MIM# 252940) [3]。 4 MPS- A Ⅳ N- 乙酰半糖胺 -6- 硫酸硫酸酯酶 (N-acetylgalactosamine-6-sulfate sulfatase ， GALNS) 缺陷，使得硫酸角質素中的硫酸半乳糖和 6-硫酸-軟骨素中的硫酸 N-乙酰半乳糖胺無法被降解[10]。 5 MPS- BⅣ 溶酶體中的 β-半乳糖苷酶（β-galactosidase）缺陷[13]，使得硫酸角質素無法降解。骨骼和角膜中的

硫酸角質素都有出現在病人的尿中，硫酸角質素是否

在腦中沈積還有待研究[14]。 6 MPS-Ⅵ 溶酶體內缺乏芳基硫酸酯酶 B（arylsulfatase B），無法降解 N-乙酞半乳糖胺-4-硫酸酯和硫酸皮膚素導致硫酸皮膚素在細胞和組織中堆積。[6]硫酸皮膚

素和硫酸軟骨素在心瓣膜的堆積使得瓣膜狹窄[10]。 7 MPS-Ⅶ β-D-葡糖苷醛酸酶（β-D- glucuronidase）的缺陷使得葡糖胺聚糖皮膚素、硫酸乙酰肝素、軟骨素-4硫酸和軟骨素-6-硫酸無法降解[10]。

基因型-表型相關性

1 MPS-I 有人提出 MPS-I 型患兒的不同癥狀是由不同的IDUA 突變基因造成的，IH 型患兒是重型突變基因的純合子；IS 型患兒是輕型突變基因的純合子；癥狀介於它們之間的 IH/ S 型患兒是輕型和重型突變基因的雜合子[9]。無效等位基因(Null allele)的純合個體患病嚴重，而有部分酶活性的等位基因使得癥狀較

輕。另外，Terlato 稱剪切位點的改變通常會引起嚴重的臨床表現型[10]。 2 MPS-Ⅱ 8%的病人發現基因的完全缺失，常引起最嚴重的癥狀。31 種點突變分別引起不同程度的癥狀。同一個密碼子的突變會引起不同的表型，例如 Arg-468〉Trp 發生於輕癥狀患者中，若替換為穀氨酰胺則會導致嚴重癥狀 [10]。由於 IDS 基因突變極其多樣，再加上其他基因及環境的複雜作用，目前尚未建

立明確的基因型與表現型的關係[11]。 3 MPS-IIIA 錯義突變常常有部分酶活性，致較輕癥狀，而

無義突變常引起低 mRNA 表達。SGSH 的 G122R、R206P、S298P、I322S、E369K 突變與輕 Sanfilippo表型相關[3]。 4 MPS-IIIB型 8 個無義突變與嚴重的表型相關，無義突變常保留部分酶活性。16 個缺失和 11 個插入突變與嚴重的 Sanfilippo 表型相關，因它們常導致閱讀框架的改變或轉錄的提前終止。NAGLU 的 F48L、G69S、S612G、 R643C 突變與重 Sanfilippo 表型相關[3]。 5 MPS- A Ⅳ 第 1342 位置上的兩個核苷酸的缺失引起閱讀框架的改變，導致了嚴重表型，而在輕微癥狀病人上發

現了 Asn-204〉Lys的替換[10]。 6 MPS-Ⅵ Gly-137 >Val 的純合替換發現在中等癥狀患者。這個突變的酶活性正常，但極度不穩定。在另一

的中度癥狀患者上發現 Gin替換了原有的終止密碼，這個突變蛋白增添了 50個氨基酸，顯示出 20倍的底物翻轉最大速度，而 Km僅增大 2倍，故酶活性比正常高，但易被降解[10]。 Ala-354 > Val和 Arg-611 > Trp引起胎兒水腫，其中 Arg-611 > Trp 導致酶活性完全喪失，而 Ala-354 > Val卻保留 30%~40%的酶活性[10]。


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臨床表現及診斷

1 MPS-I 重型(Hurler 癥, MPS IH)，一歲內發病，面容粗陋，肝脾大，骨骼畸形，身高矮、角膜混濁，嚴

重智力退化，阻塞性通氣障礙及呼吸道感染和心髒

並發癥等 ,尿中排出大量硫酸皮膚素、透明質酸等一系列癥狀,智力嚴重障礙,多數在 10 歲之前死亡。輕型(Scheie綜合徵,MPS IS)，智力、身高、壽命正常，關節僵硬（爪形手，常合並腕管綜合徵）、角

膜渾濁、主動脈瓣病變、大嘴、厚脣和大下頜，可

具聽力障礙、巨舌等[15]，常在 5歲左右出現輕度癥狀，少有神經精神癥狀，輕微肝脾大。中間型介於

重輕兩型之間[8-10, 12]。 2 MPS-Ⅱ 即 Hunter 綜合徵，輕者一般 10 歲前發病，智力可正常，並可存活到成年；而重者一般 2 歲~4 歲起病，成年前夭折。表現為多髒器受累，包括骨骼

（發育不良、大頭）、關節、眼（角膜渾濁晚且輕）、

耳（進行性耳聾）、齒、皮膚、呼吸系統（氣道阻

塞）、心血管（心肌肥大、瓣膜異常）、肝脾（大）和

中樞神經系統等，伴有粘多糖尿，呈進行性加重，預

後甚差 [7, 12, 16-19]。 3 MPS-Ⅲ 智力低下，無角膜病變，可顱底變厚，椎體呈

卵圓形，尿有硫酸類肝素。進行性中樞神經系統退

化：發育遲緩，繼而行為紊亂，高活躍性，脾氣暴

躁，攻擊性、注意力不集中，最終發展至身體平衡喪

失，咀嚼、吞咽困難，關節病變，常死於呼吸感染[3,12]。 4 MPS-Ⅳ 智力正常，全身骨骼除顱骨、面骨外均有改

變，影響脊柱和關節軟骨，以頸、胸、脊柱的畸形為

主。角膜渾蝕、頸短、軀乾矮小、脊柱後突、四肢呈

多發性畸形、四肢較長、手指長而柔軟。X 線檢查可見普遍性扁平椎，椎體上、下緣不規則及前凸、長骨

方面常見股骨近端發育不良，膝蓋內曲（騎馬狀），

韌帶鬆弛，寰樞椎半脫位，齒突尖異常，頸部脊髓壓

迫。琺琅質礦化異常，神經傳導性耳聾，氣道、心瓣

膜受累，尿中出現硫酸角質素[4,12]。

5 MPS-Ⅵ 智力正常，重型患者可出現面容粗陋、角膜混

濁、可有腦積水、肝脾腫大、骨骼畸形、關節活動受

限以及心肺並發癥等，可發展為心力衰竭、呼吸衰

竭，多於 20歲前死亡[5-6, 10, 12]。 6 MPS-Ⅶ 智力可中度遲緩或正常，骨發育異常，肝脾

大，嚴重可發生胎兒水腫[10, 12]。各型MPS診斷主要基於臨床表現、尿樣檢測、成纖維細胞或淋巴細胞酶活性測定及相應基因檢查。

臨床治療

以 MPS-I 為例，骨髓乾細胞移植被認為是當前治療 Hurler 綜合徵唯一有效的方法，移植後酶活性正常，骨髓、肺、肝和血管系統糖胺聚糖消失，聽

力、視力、智力（特別是對於 2歲以下且智力發育指數在 70 以上）提高。而造血細胞移植

（Haematopoietic cell transplantation, HCT）技術的應用又因非相關臍帶血（Unrelated cord blood, UCB）而推廣，HCT 在於用供者細胞在血液系統內外提供正確的酶，而在造血系統外的酶活性大部分來源於巨

噬細胞的替換（如 Kupffer 和小膠質細胞）。這種替代有利於延遲疾病的發展（如神經退化）和粘多糖積

聚引起的病變[20-21]。HCT 後 Hurler 患者極大改善了呼吸道阻塞，大肝脾和角膜混濁；大頭和聽力障礙得

到改善，並且避免了心髒異常所致的死亡；提高了生

長和智力，延長了生存；但依然需要整形。但是，除

MPS I外,HCT現在只還對MPS VI、VII有效。非相關臍帶血儲庫的優點是迅速的供源、低發生率的移植

物抗宿主反應、低移植感染率、低移植失敗率。酶替代療法（ERT）對於MPS I, II, VI都有效，但由於 ERT 無法通過血腦屏障，故對於那些有神經癥狀的 MPS患者，ERT的同時還須 HCT，同時對於有脊髓壓迫者行 ERT的鞘內注射還在研究中[22-23]。底物剝奪療法（Substrate deprivation therapy）是利用儲積的粘多糖的生成抑制劑，來減少該種粘多糖

的生成及儲積，由於這種抑制劑可透過血腦屏障，這


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使得中樞神經系統癥狀得以改善。目前有報道治療

MPS III有效的藥物有 genistein，rhodamine B[24]。另外，由於 HCT 無法解決 MPS 的肌肉骨骼癥狀，故有假說認為與 HCT 同時注射的間葉乾細胞會改善患者狀況，現已證明這種療法會改變骨礦化密度

和神經傳導速度[16, 25-26]。局部或血管內注射來源於腺病毒或逆轉錄病毒

的載體或是質粒可以引起缺乏的酶在動物模型的肝中

表達，並可糾正 MPS 在肝脾的病變，但由於其對於其他受累系統有效性及安全性的爭議，該方法目前還

處於研究階段[27]。

遺傳諮詢

產前診斷可用敏感的酶活性測定方法檢測孕早

期絨毛、孕中期羊水、胎兒和母親的血的酶活性，但

不能准確地判斷出攜帶者的基因型，故無法對患者進

行表現型的預測[8, 28]。而以MPS-I為例，基因診斷方法有： 1 RFLP分析多種 IDUA 基因點突變可引起一個酶切位點的改變，例如 W402X, R89Q, T64X, L218P, T366P, G409A 突變均可增加或消除一個限制性內切酶位點。 2 PCR-SSCP並 DNA 測序用於檢測對突變高發區域篩查未知基因突

變 [3,4,7,8]。

3 RT-PCR分析 Scott 等人採用 RT-PCR 方法分析含有 R89Q 等位基因患者的 IDUA 基因表達情況，證實 R89Q 為一種輕型表現型的等位基因。 4 Northern印跡雜交 Bach 等利用 Northern 印跡法確定 IDUA 基因外顯子 Vul 的 T366P 突變時發現，與正常對照組相比，該突變純合子患者的 mRNA量較正常高兩倍。

5 AOS雜交用來自患者基因組 DNA 的 PCR 擴增片段進行ASO 分析，通過辨別是否完全配對或是否存在單鹼基錯配的雜交結果來確定 IDUA 基因是否發生 Q70X突變。現可診斷突變有：W402X, A75T, 67 8-7g-a,1P533R,de1G1702等。

參考文獻

1 孫魯甯, 王海波, 董貴章, 等. 我國遼寧地區遺傳性粘多糖貯積症 I 型患者 a-L 一艾杜糖醛酸酶基因突變的研究. 中國病理生理雜誌, 2005, 21:54-57.

2 郭奕斌, 杜傳書. 粘多糖貯積症Ⅱ型 IDS 基因的 1343-TT新突變. 中華兒科雜誌, 2006, 44:110-113.

3 Yogalingam G, Hopwood JJ. Molecular Genetics of Mucopolysaccharidosis TypeIIIA and IIIB: Diagnostic, Clinical, and BiologicalImplications. Human Mutation, 2001, 18:264-281.

4 Northover H, Cowie RA, Wraith JE. Mucopolysaccharidosis type IVA(Morquio syndrome): A clinical review. J Inher Metab Dis, 1996, 19:357-365.

5 Giugliani R, Harmatz P, Wraith JE. Management Guidelines for Mucopolysaccharidosis VI. Pediatrics, 2007, 120: 405-418.

6 郭奕斌, 鄒世恩. Maroteaux-Lamy綜合征基因治療的研究與應用. 國外醫學遺傳學分冊, 2001, 24:257-259.

7 郭奕斌, 林群娣, 杜傳書. Hunter 綜合征患者 IDS 基因的一個新突變.中華醫學遺傳學雜誌, 2006, 23:67-69.

8 孫魯甯. 粘多糖貯積症 I 型的分子遺傳學研究進展. 國外醫學遺傳學分冊, 2001, 24:84-88.

9 孫魯甯, 董理鳴, 董貴章, 等. 遼寧地區人群中 α-L 艾杜糖醛酸酶基因多態性研究. 中國實用兒科雜誌, 2005, 20:490-492.

10 Gieselmann V. Lysosomal storage diseases.Biochimica et Biophysica Acta, 1995, 1270:103-136.

11 Froissart R, Da Silva IM, Maire I. Mucopolysaccharidosis type II: an update on mutation spectrum. Acta Paediatr Suppl, 2007, 96:71-7.

12 宋亞峰, 何荷花, 徐霖. 粘多糖貯積症 X 線診斷及其臨床表現. 罕少疾病雜誌, 2006, 13:29-31.

13 Rølling I, Clausen N, Nyvad B, et al. Dental findings in three siblings with Morquio」s syndrome. International Journal of Paediatric Dentistry, 1999, 9:219-224.

14 Callahan JW. Molecular basis of GM1 gangliosidosis and Morquio disease, type B. Structure–function studies of lysosomal β-galactosidase and the non-lysosomal β-galactosidase-like protein.Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease, 1999, 1455:85-103.

15 柴精華, 趙時敏, 孟迅吾, 等. 一例粘多糖貯積症ⅠS型-Scheie綜合征. 中華醫學遺傳學雜誌, 1998, 15:299.

16 Shapiro EG, Lockman LA, Balthazor M, et al. Neuropsychological outcomes of several storage diseases with and without bone marrow transplantation J Inher Metab Dis,1995, 18:413-429.


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17 Ito K, Ochiai T, Suzuki H, et al. The effect of haematopoietic stem cell transplant on papules with「pebbly」 appearance in Hunter」s syndrome. British Journal of Dermatology, 2004, 151:207-211.

18 Wraith JE. Enzyme replacement therapy with idursulfase in patients with mucopolysaccharidosis type II. Acta Paediatr Suppl, 2008, 97:76-78.

19 Martin R, Beck M, Eng C, et al. Recognition and diagnosis of mucopolysaccharidosis II (Hunter syndrome). Pediatrics, 2008, 121:377-386.

20 Cartier N, Aubourg P. Hematopoietic stem cell gene therapy in Hurler syndrome, globoid cell leukodystrophy, metachromatic leukodystrophy and X-adrenoleukodystrophy. Curr Opin Mol Ther, 2008, 10:471-478.

21 Rohrbach M, Clarke JT. Treatment of lysosomal storage disorders : progress with enzyme replacement therapy. Drugs, 2007, 67:2697-2716.

22 Pastores GM. Laronidase (Aldurazyme): enzyme replacement therapy for mucopolysaccharidosis type I. Expert Opin

Biol Ther, 2008, 8:1003-1009. 23 Wraith JE, Scarpa M, Beck M, et al. Mucopolysaccharidosis

type II (Hunter syndrome):a clinical review and recommendations for treatment in the era of enzyme replacement therapy. Eur J Pediatr, 2008, 167:267-277.

24 Jakóbkiewicz-Banecka J, Wegrzyn A, Wegrzyn G. Substrate deprivation therapy: a new hope for patients suffering from neuronopathic forms of inherited lysosomal storage diseases. J Appl Genet, 2007, 48:383-388.

25 Krivit W. Allogeneic stem cell transplantation for the treatment of lysosomal and peroxisomal metabolic diseases. Springer Semin Immun, 2004, 26:119-132.

26 Boelens JJ. Trends in haematopoietic cell transplantation for inborn errors of Metabolism. J Inherit Metab Dis, 2006, 29:413-420.

27 Ponder KP, Haskins ME. Gene therapy for mucopolysaccharidosis, Expert Opin Biol Ther, 2007, 7:1333-1345.

28 江雨, 周裕林. 粘多糖貯積症 I 型分子生物學及產前診斷研究進展.中國優生與遺傳雜誌, 2007, 15: 113-114.


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‧講座‧

Comportamentos, Estilos de Vida e Práticas de Saúde Carlos António LARANJEIRA 【Resumo】 Aborda-se a questão das mudanças nos paradigmas de saúde. Foca-se a problemática dos

comportamentos e estilos de vida enquanto contributos para o grau de saúde. Sublinham-se os conceitos de responsabilidade e de participação a serem mobilizados na promoção da saúde e que a educação para a saúde poderá ser um meio de reforçar os comportamentos geradores de saúde e de diminuir os comportamentos que a comprometem. Assinala-se que é fulcral o desenvolvimento de perícias de definição de problemas e de decisão tanto a nível individual como colectivo.Este artigo consiste num espaço de reflexão sobre a questão da cidadania, estilo de vida e educação para a saúde, tomando como eixo as transformações ocorridas na relação da sociedade com o indivíduo. Aponta os desafios a serem superados na construção da cidadania e qualidade de vida. Considera-se que dados deste tipo poderão constituir a base parcelar de um diagnóstico educacional de saúde.

【Palavras-chave】 Educação para a saúde; Qualidade de vida; Estilos de vida; Promoção

da saúde; Saúde mental

行為舉止，生活方式以及健康實踐 Carlos António LARANJEIRA. 葡萄牙, 諾多撒──維塞爾, 亞都皆尤街 , 3515-776, 皮亞傑大學 , 納塞烏皮亞傑醫學院 ; Tel : (+351) 918 801 973; E-mail: [email protected] 【摘要】本文旨在研究健康模式之轉變方面的一系列問題。文章將著眼於人們的行為舉止以及生

活方式作為影響其健康程度的指標這一中心。著重突出責任和分配意識在健康普及課題上的重要性，

以及顯示健康教育可以成為強化有益身體的行為舉止，減少有害身體之行為舉止的一種途徑。文章同

時指出，無論是在問題定性方面的技能的發展進步，還是在個人或是集體決策方面技能的發展進步，這些都將成為問題的重中之重。本文在有關城市文明，生活方式以及健康教育方面的問題的闡述

上引人思索，這些問題本身的日益變化儼然已經成為影響社會與個人相互關係的軸心。文章提出，在

城市文明建設與生活質量領域的挑戰將會最終被克服。文章同時提及，在這方面的有關資料資料將會

成為健康教育診斷的基礎部分。【關鍵詞】健康教育; 生活質量; 生活方式; 健康普及; 心理健康

Behavior, Life Style and Health Practices Carlos António LARANJEIRA. Escola Superior de Saúde do Campus Universitário Jean Piaget de Viseu, Estrada do Alto do Gaio-Galifonge, 3515-776 Lordosa-Viseu. Portugal; Tel : (+351) 918 801 973; E-mail: [email protected] 【Abstracts】 The article looks at changes in patterns of health. It focuses on the contribution

behaviour and lifestyles make to health. Concepts of responsibility and participation that should be mobilised to promote good health are emphasised; and it is stresses that health education can be a way to reinforce behavior that promotes health and to reduce behaviour that threaten it. A key aspect is developing the skills to define problems and take decisions at individual level as well as collectively. This article consists in reflection about the questions of citizenship, life style and health education, considering the transformations occurred on the relation between the society and individual person. This work indicates the challenges to be surpassed on the construction of citizenship and life quality. This data could be the basis of an educational diagnosis of health. 【Key words】 Health education; Quality of life; Life style; Health promotion;

Mental health

Author address: Institute / College Jean Piaget, High School of Health Sciences Jean Piaget/Viseu, Alto do Gaio street, 3515-776, Lordosa-Viseu, Portugal; Tel : (+351)-918 801 973; E-mail: [email protected]


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ADESÃO AOS COMPORTAMENTOS PREVENTIVOS

Ninguém permanece saudável sem nada fazer por

isso. É indispensável cuidarmos, nós próprios, da saúde e do bem-estar. Aqueles que, ao longo dos anos, adoptam estilos de vida saudáveis, são certamente, os que têm as melhores condições de conseguirem, quando idosos, manter um bom estado de saúde[1].

Se ao invés de partirmos do conceito abstracto de

saúde procurarmos avançar na reflexão sobre ele partindo da realidade do dia-a-dia das pessoas concretas, vamos ser forçados a reconhecer que, para a generalidade das pessoas, saúde refere-se quase sempre a uma noção de bem-estar individual no qual a ausência de dor ou doença diagnosticada (muitas vezes indolor) é o elemento primordial. Estar de boa saúde torna-se sinónimo de poder realizar as tarefas quotidianas sem contrariedades ou limitações do corpo ou da mente. Nesta acepção individual, a saúde é usualmente encarada na nossa cultura como um estado natural, próprio da natureza humana, e que factores exteriores à pessoa (vírus, bactérias, ou condições de trabalho ou de vida com forte stresse psicológico, por exemplo) podem modificar.

De uma forma geral as pessoas vivem

despreocupadamente no que respeita à saúde excepto quando algo indicia que qualquer coisa está mal. Nesse caso, consulta-se um profissional de medicina e seguem-se as suas determinações que, usualmente, respeitam à realização de exames diagnósticos e à adopção de terapias do tipo tomar remédios ou evitar determinados alimentos ou comportamentos.

Estamos perante a já referida concepção de saúde

como oposição à doença, concepção dominante não só nas pessoas individuais, mas também nos serviços e medidas de política de saúde.

A medicina influenciou de forma decisiva a

representação sobre a saúde e a doença nas sociedades

ocidentais. A nossa época caracteriza-se por pensar a saúde num “paradigma higiénico”[2], que tenta controlar a nocividade do modo de vida, por práticas saudáveis que vão desde o lavar dos dentes até ao tempo de sono, passando pela frequência da ginástica e alimentação. Nessas práticas higiénicas exprime-se o comportamento de saúde. Por meio de uma série de práticas aprendidas (e portanto, artificiais, impostas), a pessoa aumenta a sua resistência à vida doentia (artificial), tornando-a suportável.

A higiene, valor assimilado individualmente,

transforma a pessoa individual em sujeito activo do seu posicionamento na sociedade e portanto da sua saúde. Ela é o elemento mediador que resolve “o paradoxo da saúde” – saúde que é concebida simultaneamente ameaçada e exigida pela vida em sociedade. As pessoas têm do modo de vida em sociedade urbana uma representação negativa, de nocividade, por oposição à vida rural, identificada com a natureza e, portanto, modo de vida saudável. Através da higiene – prática sociável aprendida e portanto não natural, as pessoas sentem-se a contrariar os efeitos da vida não natural, da vida em sociedade.

Nas nossas sociedades em que a medicina é

dominante como estratégia de saúde, as pessoas assimilaram algumas “competências médicas” que, entre outros conhecimentos, as levam a saber utilizar correctamente os recursos de saúde – uma mulher grávida vai à consulta médica desde o início da gravidez e não só nos casos em que sente que algo está a correr mal, por exemplo.

Mas a aprendizagem e a compreensão das noções

da medicina não está igualmente acessível a todos os grupos sociais[3]. São as pessoas dos meios mais favorecidos que estão em melhores condições para a assimilação desse tipo de saber médico – pelo seu nível de instrução mais elevado e pela sua posição social, (mais próxima da dos profissionais de medicina) aprendem mais facilmente os conceitos e conhecimentos que o próprio médico utiliza, bem como têm mais


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facilidade em dialogar com ele. Têm também maior facilidade em compreender a transmissão de conhecimentos feita pelos meios de comunicação social.

Vários estudos têm demonstrado que as pessoas das

classes mais baixas na escala da estratificação social (menor instrução, trabalho manual) frequentam menos as consultas médicas de tipo preventivo e mais as consultas de urgência e os internamentos. Há como que uma lógica de desvalorização do risco de adoecer e dos sintomas de doença que são encarados como “pieguices”, “Eu não preciso dos médicos. No dia em for ao médico é porque estou a morrer”.

Este tipo de atitude está também associado com as

condições de vida dessas pessoas – ir ao médico custa-lhes um dia de trabalho/salário, implica muitas vezes contratar um táxi, fazer um percurso suplementar em transportes públicos ou percorrer um longo caminho a pé, por exemplo. Mas a razão principal parece ser mesmo o menor grau de informação, conhecimento e crença sobre os riscos e sobre a capacidade preventiva da medicina, com efeito, o tipo de comportamentos que leva a consultar em situação de doença declarada, mais do que quando do aparecimento dos primeiros sinais de risco, é semelhante à que também se verifica no que respeita às crianças pequenas, em relação a cuja saúde os adultos têm no entanto uma grande preocupação e atenção. Este tipo de atitude é mais frequente nos homens do que nas mulheres.

Não são só as concepções sobre as causas da

doença que são diferentes entre grupos sociais, mas também a forma de pensar saúde. Enquanto que nas classes médias se encontra dominantemente uma forma de exprimir a saúde como sendo um bem-estar corporal e mental feito de equilíbrio, de auto-realização e de prazer de viver, nas classes trabalhadoras a noção de saúde é traduzida pela capacidade de trabalhar e pela ausência de doença[4].

Compreende-se então que as práticas quotidianas

(alimentação e exercício físico, por exemplo) e os

comportamentos de saúde (ida a consultas médicas, cumprimento do plano de vacinação, realização de exames de despitagem precoce, etc.) sejam variáveis não só de pessoa para pessoa mas de grupo para grupo social.

As estratégias de promoção da saúde devem ter em

conta estas diversidades sociais e orientar o seu diálogo com a população de forma diversificada.

Na prática, as políticas e a organização dos serviços

de saúde orientam-se por objectivos de tratar e prevenir a doença, prevenção que é entendida maioritariamente como resultado de actos médicos, sejam do tipo vacinação, despitagem ou intervenções precoces.

A este modelo médico de prevenção da doença que

privilegia a clínica, associa-se o que podemos chamar de modelo médico de educação sobre como evitar adoecer que usualmente consta dos programas de educação para a saúde e se caracteriza por uma série de normas e conselhos de realização individual, referidos como comportamentos saudáveis. Aconselham-se as pessoas a fazer uma alimentação equilibrada, a evitar erros alimentares, a fazer higiene bucal após as refeições, a fazer exercício físico regular, a adoptar posições correctas quando fazem esforços. Mas enquanto desinseridos da promoção da saúde da sociedade, das condições de vida em colectivo, os conselhos que se dirigem à vontade individual são quase irrelevantes já que têm pouca força para competir com uma organização social que incentiva – pela publicidade em todas as suas formas – comportamentos anti-saudáveis[5].

Existe a necessidade de implementar medidas

menos parcelares que contribuam para a promoção da saúde como um todo e que possam reformular os comportamentos individuais e colectivos que estejam subjacentes à doença. Visa-se o envolvimento da população, como um todo, no contexto da vida quotidiana, em vez de focar apenas as pessoas em risco de doenças específicas. Há que envolver e responsabilizar os indivíduos sobre a sua própria saúde[6]. Imbuído destes princípios o paradigma higiénico intregra


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e dá significado ao conceito de promoção da saúde, ou seja pretende-se melhorar o status de saúde na direcção do tal pólo ideal. Faz-se notar que é difícil especificar concretamente esse estado de saúde ideal. Porém, é mais fácil identificar os estados de saúde aquém do nível “mínimo” e estabelecê-los então como objectivos de intervenção.

Em geral na promoção da saúde ao nível dos

indivíduos há duas estratégias principais e complementares: aquelas que se orientam para a redução e eliminação de comportamentos capazes de comprometerem a saúde e aquelas vocacionadas para introduzir, amplificar e reforçar todo o conjunto de comportamentos que aumentem os níveis de saúde[7].

Uma das vias de intervenção possíveis é a educação

para a saúde. Actualmente defende-se que há que considerar três conjuntos de factores que influenciam o comportamento de saúde e que podem efectivamente ser modificados pelas intervenções educacionais[8]: os factores predisponentes, relacionados com o sujeito (valores, crenças, atitudes, percepções, motivação), os capacitantes (conhecimento, competências) e os factores de reforço, de natureza contextual (representações sociais, atitudes grupais e normas comportamentais).

Como demonstraram Stainbrook e Green[9], os

programas de educação mais eficazes são os combinam experiências de aprendizagem dirigidas aos três grupos de factores supracitados, baseados num prévio diagnóstico educacional das variáveis predominantes em cada categoria.

ESTRUTURAÇÃO DA VIDA SAUDÁVEL – A ATENÇÃO À MENTE

A promoção da saúde mental parece ser uma faceta

esquecida dos programas de prevenção para a saúde que habitualmente só se referem à saúde física. A razão de ser de tal esquecimento está na concepção de doença e de prevenção que, já vimos, são fundamentalmente médicas

e associadas ao corpo e ao que medicamente nele se pode introduzir (vacinas, por exemplo) ou alterar através de comportamentos e práticas (não comer, ou comer, isto ou aquilo; não fumar, etc.)

A promoção da saúde mental é uma área menos

objectivável que se refere ao domínio da complexa intimidade de cada um. É possível, em muitas situações, perceber que alguém “não está bem da cabeça”, isto é, que está, ou é, doente mental. Mas isso é muito difícil de avaliar em muitas situações. Quantas vezes nos é difícil distinguir se tal pessoa é “estranha”, “mal-educada e má”, “extremamente egoísta”, “perversa”, “preguiçosa”, “manhosa”, ou se é “doente da cabeça”?. E é ainda mais difícil saber o que contribui para que umas pessoas sejam – ou fiquem – doentes mentais enquanto que outras, aparentemente com uma história de vida semelhante (irmãos ou irmãs educados na mesma família) fazem, uma vida a que ninguém tem reparos a fazer do ponto de vista da sua adequação à relação com os outros e à vida em sociedade.

Essa é, grosso modo, uma definição possível de

saúde mental: boa adequação na vida relacional, interpessoal e colectiva, isto é, a pessoa sente-se bem, confiante em si própria, tem bom relacionamento geral com os outros, não tem angústias que sistematicamente a impedem de tratar os problemas do dia-a-dia, tem a autonomia adequada à sua idade e posição social[10]; e os outros também se sentem bem no relacionamento que com ela mantêm. Mas este tipo de funcionamento “da cabeça” (da mente) é mais difícil de avaliar ou “medir” do que o funcionamento dos pulmões, ou do coração…

Assim, a medicina e a psiquiatria não se referem a

ele do ponto de vista da sua promoção mas quase só do ponto de vista dos factores que, à posteriori, se podem identificar como tendo contribuído para a doença. E esses factores são fundamentalmente de ordem relacional – factores afectivos que influem a auto-estima e a capacidade de intimamente distinguir a sua auto-consciência da consciência que se tem dos outros, articulando essas duas realidades íntimas num só eu.


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A dificuldade em influenciar o desenvolvimento pessoal no sentido de uma boa saúde mental prende-se com o facto de que ele depende da qualidade das relações que se estabelecem e nomeadamente das relações do início da vida, na infância. Essas relações têm lugar, geralmente, na família, grupo relativamente fechado em que vai ser determinante a personalidade dos adultos – mãe e pai – e o relacionamento, não a quantidade de relações, nem nenhum aspecto concreto em particular.

A promoção da saúde mental nas pessoas de uma

dada sociedade deve ser encarada, com vontade política (como toda a promoção da saúde), ao nível da organização social de:

1 Alternativas ao isolamento – actividades de

convívio, de trabalho conjunto, de aprendizagens ou de realização de projectos variados (a chamada animação social entendida como espaço de frequência ou de criação de actividades); são espaços físicos e mentais de experiência e aprendizagem da vida grupal e do relacionamento em geral; permitem o desenvolvimento das capacidades de iniciativa, de criatividade, de solidariedade, de respeito pelos outros, de defesa dos seus interesses e objectivos. São espaços de crescimento nas suas diversas dimensões, indispensáveis durante o processo de amadurecimento – infância, a adolescência e juventude – e são muito importantes para o equilíbrio e bem estar em todas as idades da vida;

2 Espaços de apoio à maternidade e paternidade

– actividades lúdico-pedagógicas para crianças e seus pais/mães onde as pessoas podem confrontar as suas formas de fazer com as de outros e podem ser ajudadas a modificar alguns tipos de atitudes (perceber como alguns processos na comunicação com as crianças tendem a confundir, a criar-lhe inseguranças ou medos, a dificultar-lhe confiar nos outros, (...).

De uma forma geral a promoção da saúde mental

passa por um investimento social na coesão das comunidades, no suporte às famílias e no estímulo à

maturação das pessoas enquanto indivíduos.

Considerações finais Geralmente, sugere-se uma maior informação da

população acerca de todas as áreas da saúde, quer se trate de doenças do coração, do alcoolismo, do cancro, ou do planeamento familiar. Isto é, da educação para a saúde, quer a nível formal, quer a nível informal.

Segundo Estrada et al.[11], exceptuando algumas

mensagens específicas, a maior parte dos profissionais de saúde não tem uma estratégia de comunicação para atingir tais objectivos. De um modo científico, não conhecemos nada de muito concreto acerca disto. Quanto mais vastas forem as questões públicas envolvidas menos seguras serão as informações e as recomendações que podem ser feitas. Algumas vezes, as questões de saúde são objecto de controvérsia.

Quanto mais os assuntos de saúde tocam crenças e

valores implantados, mais provável é que a controvérsia se desenvolva numa sociedade pluralista. As crenças das pessoas nos benefícios resultantes da adopção de comportamentos preventivos são frequentemente bastante específicos. Verifica-se que os indivíduos à partida se encontram motivados para comportamentos preventivos básicos, reagem de forma positiva a regimes preventivos mais elevados. No entanto existem, vários factores psicológicos capazes de modificar este facto e condicionando, assim, diferentes padrões psicológicos de motivação.

Esta trata-se, com efeito, de uma área altamente

promissora que exige uma maior atenção por parte da medicina preventiva.

Acrescendo que o papel e a pessoa do profissional

que presta cuidados preventivos contribui decisivamente para a percepção do valor destes, parecendo um dado adquirido que as pessoas doentes seguem mais facilmente as recomendações do seu próprio médico


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assistente. Este último aspecto leva a encarar a necessidade de integrar os cuidados preventivos nos Cuidados Primários de Saúde, ou seja, ao nível privilegiado dos médicos de família e dos profissionais de saúde pública, no contexto da relação (médico (profissional) – doente (paciente/utente)[12].

Quer o Estado, através das organizações de Saúde

Pública, por um lado, quer a Comunidade e a população por outro, necessitam de considerar as vantagens e os benefícios da Promoção da Saúde e da Prevenção da Doença, bem, como de participar mutuamente para aumentar a eficácia e melhorar os resultados, através da mudança de comportamentos e de estilos de vida.

Para os contrariar, é necessário, implicar os

Profissionais de Saúde, no reconhecimento do valor da prática dos comportamentos Preventivos.

REFERÊNCIAS 1 Antonovisky A. The sense of coherence as a determinant

of health. In: Matarazzo J, Weiss S, Herd J, eds. Behavioral health. A handbook of health enhancement and disease prevention. 1ª ed. Nova Iorque: John Wiley and Sons, 1984. 114-129.

2 Rosenstock I. The health belief model and preventive

health behaviour. Health Education Monography, 1974, 2:354-386.

3 Green L, Kreuter M. Health promotion planning. An educational and environmental approach. 3ª ed. Toronto: Mayfield Publishing Company, 1991.

4 Matarazzo J. Behavioral immunogens and pathogens in health and illness. In: Hammonds B, Sheirer C. Psychology and health. 1ª ed. Washington: American Psychological Association, 1984. 201-230.

5 Oakley P. Community involvement in health development an examination of the critical issues. 1ª ed. Genebra: WHO, 1989. 73.

6 World Health Organization. Léducation pour la santé. Manuel d´éducation pour la santé pour l´optique de sois de santé primaires. 1ª ed. Genebra: OMS, 1990. 150-198.

7 Perry C, Jessor R. The concept of health promotion and the prevention of adolescent drug abuse. Health Education Quarterly, 1995, 12:169-184.

8 Green L. Health education models. In: Matarazo J, Weiss S, Herd J, eds. Behavioral health. A handbook of health enhancement and disease prevention, 2ª ed. Nova Iorque: John Wiley and Sons, 1994. 181-198.

9 Stainbrook G, Green L. Behaviour and behaviorism in health education. Health Education, 1982, 13:14-19.

10 Yevchak AM, Loeb SJ, Fick DM. Promoting cognitive health and vitality: a review of clinical implications. Geriatric Nursing. 2008, 29:302-310.

11 Estrada F, Hernández-Girón C, Walker D, et al. Use of family planning services and its relationship with women's decision-makingand support from their partner. Salud Publica Mexicana. 2008, 50:472-481.

12 De Leo D. The communicative experience: between inexpressible and elusive. Integrative Psychological and Behavioral Science. 2008, 42:179-186.


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‧講座‧

危急重症治腎劉興烈劉敏雯* 李俊*

【摘要】作者從腎臟的中醫學理論、現代實驗依據、臨床實踐等方面，較詳細闡明了“危急重症治腎”的可行性。【關鍵詞】腎; 危急重症; 中醫

Peril Seriously Symptom Control Kidney LIU Xin lie, LIU Min Wen*, LI Jun* Faculty of Chinese Medicine, Macao University of Science and Technology, Macao SAR; PR China; Tel : +(853) 6218 2148; E-mail : [email protected] ; *Second Clinical Medicine Council of Guangzhou University of TCM , Guangzhou, 510120, China. 【Abstract】 The authors detailed, illuminated and knew clearly the feasibility of “Peril Seriously

Symptom Control Kidney” from nephritic Traditional Chinese Medicine theory, modern times experiment gist, clinic practice wait aspect. 【Key words】 Kidney; Peril Seriously Symptom; Traditional Chinese Medicine

《素問．脈要精微論》說：“腎者至陰也，至陰者盛水也”， “腎”為先天之本，為一身之大主，五臟六腑之根，說明腎在人體臟腑生理功能活動中的重要

作用。然“五臟之傷，窮必及腎”之說，則闡明瞭在人體病理狀態下，疾病的病機演變的普遍規律是終極傷

“腎”。所以，“腎”在人體生理和病理過程中是至關重要的。有鑒於此，作者認為，從腎論治內科危急重症

當不失為一條應引起關注的途徑，現試論述之。

提出問題

《景嶽全書．虛損》中指出：“無論陰陽，凡病之極，皆所必至，總由真陰之敗耳。然真陰所居，唯腎

為主，蓋腎為精血之海”，“所以腎為五臟之本”，“故凡病甚於上者，必其竭甚於下也⋯⋯虛邪之至，害必

歸陰，五藏之傷，窮必及腎。”在臨床實踐中亦可見到，由於髒與髒或髒與腑之間存在著相互制約與傳變

的關係，久病不愈常可傳及脾腎，而又以腎為主。因

為腎之精氣來源於全身臟腑之精氣，故全身臟腑之盛

衰，無不關係到腎；另外，命門為元氣之根，水火之

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: [email protected]; *510120,中國，廣州，廣州中醫藥大學，第二臨床醫學院.

宅，五臟之陰非此不能滋，五臟之陽非此不能發。所

以任何一髒的不足，不論陰虛或陽虛，當虛損到一定

程度時，也終究會累及腎陰腎陽。如心肝肺三髒陰

虛，久而不愈，均可發展為心腎陰虛、肝腎陰虛及肺

腎陰虛。而肺脾氣虛以及脾腎陽虛日久不愈，常可導

致腎陽虛；心肝火旺，日久可以耗傷腎陰，出現心病

及腎或肝病及腎的虛弱證候。故認為，“久病及腎”是各種疾病病機演變的普遍規律。然危急重症因何治腎？何謂危急重症，是指病情

危篤，突然出現的病症，或是在慢性疾病發展過程

中，由於病情急劇變化而出現的急性症狀，具有來勢

兇猛、變化急驟、病情危重的特點，有可能危及生

命，是需要緊急處理的一類病證。病證之所以危急

重，往往是陽氣將脫，陰血即竭，或陰陽氣血俱傷，

元氣將離。元氣為生命之源，為人身之根本。若分之

即為元陰之氣與元陽之氣，實際上也就是腎陰與腎

陽；腎陰腎陽關係五臟陰陽氣血升降的調節，“五臟之傷，窮必及腎”。譬如[1]：(1) 在風溫病程中，若風溫邪熱久羈不解，每易深入下焦，“兩陽相劫”，劫灼腎陰，導致真陰虛損，而邪熱已不太甚，此為吳鞠通

所言“邪少虛多”；若風溫邪熱進一步灼傷腎陰而心火亢盛，以致“真陰欲竭，壯火複熾”，此為風溫危重症病機之一。(2) 在濕溫後期，濕熱之邪雖去，機體虛損未複，若因陰液消亡，而為低熱顴紅，盜汗，咽

幹，皆所常見危重症狀。(3) 署溫厥逆，若元氣真陰


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消涸，孤陽暴脫，當先回陽固脫，用參附湯或參附龍

牡湯，其中附子溫壯真陽。中暑陰證，陰液虧損於

前，陽氣耗傷於後，則一面用生脈散益氣救陰，一面

用參附龍牡湯回陽固脫；若以陽微欲脫為急，可酌用

四逆湯或回陽救急湯。(4) 若下痢無度，飲食不進，四肢不溫，乃病情危重，應考慮急用四逆加人參湯濃

煎頻服，以益氣久楊；或下痢不禁，且厥且痢，宜參

附龍牡湯合桃花湯，以固脫回陽。(5) 寒霍亂重證系陽亡陰竭，用以回陽固脫、補虛益陰的方劑。(6) 哮病危證，若陽氣暴脫，治以回陽救逆，宜四逆湯加人

參；若陽氣津液兩脫者，宜回陽固陰，益氣生脈，用

陶氏回陽救急湯。(7) 喘甚而煩躁不安，驚悸，肢冷，汗出如珠如油，脈浮大無根，或疾數模糊，為陰

陽欲絕之危急重症，急用參附湯合龍骨、牡蠣、桂

心、蛤蚧、紫石英、五味子、麥冬等配合黑錫丹以扶

元救脫，鎮攝腎氣；虛喘之陽虛不能化水，水飲上

泛，可用真武湯合苓桂術甘湯，重用附子；肺腎氣

虛，喘喝欲脫，急需峻補固脫，先用獨參湯，繼進大

劑生脈散合六味地黃丸；如正氣不支，氣喘較甚，宜

滋陰填精，納氣平喘，選用七味都氣丸、何車大造丸

的同時，可配用人參胡桃湯、參蛤散或紫河車粉。(8) 《金匱要略．肺痿肺癰咳嗽上氣病脈證治第七》提

到：“上氣，面浮腫，肩息，其脈大，不治，又加利尤甚”，《證治匯補》又說：“肺脹壅遏，不得眠臥，喘息鼻煽者，難治”，肺脹脫證，見胸高氣促，額汗如珠，或冷汗自出，四肢厥逆，神志不清，候間鼾

聲，鼻頭發冷，脈微欲絕，為生命危急之表現，宜回

陽固脫，方用四逆湯加減，也可用參附湯送服黑錫

丹。(9) 少數危重患者晚期出現之呃逆，乃是元氣衰敗，胃氣將絕之徵象，正如《景嶽全書》指出：“惟屢呃為患，及呃之甚者，必其氣有大逆，或脾腎之氣

大有虧竭而然，然實呃不難治，而為元氣敗竭者，乃

最危之候也”，危重患者晚期出現呃逆，預示須從腎救治的指征。(10) 泄瀉危候，久瀉脾腎衰敗，造成亡陰亡陽之變，救治更須著眼於腎，回陽救陰，力挽

狂瀾，挽救患者生命。(11) 下焦之氣不化，當責之於腎，腎陽虧虛，氣不化水，所謂“無陽則陰無以生”（張景岳《景嶽全書》）；腎陰不足，陰不化陽，“無陰則陽無以化” （張景岳《景嶽全書》），均可引起膀胱氣化失常，而形成癃閉，須針對病機，從腎論治。

(12) 關格病是補瀉兩難的疾病，其基本病機是脾腎陽虛，濁邪壅滯三焦，關格前期以脾腎陽虛為主，後

期以濁邪壅滯三焦為主，故其主要治則應該為“治主

當緩，治客當急”（《證治準繩．關格》）；若偏腎陽虛者，宜以溫腎益腎為主，用《金匱》腎氣丸、右歸

飲，然腎陽不足患者，往往腎陰也虧，處方用藥宜寓

溫腎藥於滋腎陰藥當中，在用附子、肉桂或仙茅、仙

靈脾時，必同時用地黃、杞子、淮山、萸肉等滋腎陰

之品。偏腎陽虛關格患者，常伴水腫，治療宜以溫陽

利水為主，水腫較重者選用真武湯；水腫較輕者，選

用《濟生》腎氣丸。(13) 驚悸、怔忡是臨床常見疾病，該病晚期，氣血雙虧，陰陽損傷，臨床表現常以

心腎兩衰為主，治療應該緊扣益氣與溫陽育陰兼用之

大法，防止陽脫陰竭。(14) 心痛病位雖然在心，心陽虧虛時宜補益陽氣，溫振心陽，方用人參湯，但據

“養陽之虛，即以逐陰”（尤在涇《金匱要略方論本義》），可考慮佐加附子、桂枝溫腎陽以助心陽；若心

腎陽虛，可合用腎氣丸，而兼水飲上淩心肺，喘促水

腫者，可與真武湯合用；若心腎陽虛而見虛陽欲脫的

厥逆之證，亟當回陽救逆，用參附湯或四逆加人參

湯；若兼大汗淋漓，脈微細欲絕等亡陽之證，應予固

脫，用參附龍牡湯，重加山萸肉，而山萸肉性味酸微

溫，歸肝腎兩經，有補益肝腎、收斂固澀功效，加重

用量增強固脫之力；對心陽不足兼脾腎陽虛者，可用

人參湯合右歸飲治療，此從治腎以增加補心脾陽氣之

藥效。(15) 昏迷屬意識障礙症狀，是病情危重的表現；在救治過程中，一方面在分清外感熱病昏迷和內

傷雜病昏迷的基礎上，應特別重視及早確定昏迷性

質，採取針對性治療；同時隨時注意內閉外脫孰輕屬

重。另一方面特別關注患者腎功能變化，隨時注意尿

量變化，在治療幹預措施擬訂時可考慮預防性護腎；

若出現脫證，及時治腎，防止津液大虧及陰虛風動。

(16) 鼓脹為臨床疑難重證之一，歷代醫家十分重視。其病理變化不外“水裹”、“氣結”、“血瘀”三端，但肝、脾、腎功能失調是其形成關鍵。由於“五臟之傷，窮必及腎”，“血瘀”是“水裹”、“氣結”的共同結果，故治腎與活血化瘀並用是鼓脹治療過程始終的必

用之法。活血化瘀不僅可促進利水，而且可以阻斷鼓

脹病理發展過程；治腎不僅有效調整腎臟功能，有治

未病之意，而且一可以前瞻性預防肝腎陰竭，二可重

建臟腑陰陽氣血的平衡，鞏固療效，為機體進一步康

復奠定基礎。類似上述典型例子，無論中醫古代醫

藉，還是現代文獻，均記載繁多，拙文由於篇幅所

限，諒不一一列舉。因此，作者言危急重症從腎論治即根於上述依據。


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中醫學之“腎”與西醫學之“腎”

兩門醫學所論之“腎”，在腎解剖位置方面，是基

本一致，如《素問．脈要精微論》說：“腰者腎之府”，趙養葵進一步指出：“腎生於脊膂十四椎下，兩旁各一寸五分”，與現代解剖學的認識（腎臟位於腰部脊柱兩側，緊貼腹後壁，左右各一。左腎略高，其

上端大約與第 11胸椎平齊，後方有第 11、12肋骨斜行跨過，下端與第 2腰椎平齊；右腎稍低，其上方與肝臟相鄰，上端與第 12 胸椎平齊，下端與第 3 腰椎平齊，第 12 肋骨斜行跨過其後方）已很接近。可是，無論生理方面，還是病理生理方面，兩者不能等

同視之。中醫學中對“腎”的概念，認識並不十分清楚，涉

及的範圍比較廣泛，實際上包含有腎、命門、精、睾

丸、卵巢等，且其相互之間關係密切，難以彼此分割

開來。《素問．脈要精微論》說：“腰者，腎之腑”，指出腎位於腰部。但《難經．三十六．三十九難》裏

又說：“藏各有一耳，腎獨有兩者，何也。然腎兩者，皆非腎也，其左為腎，右為命門。命門者，謂精

神之所舍，原氣之所系也。男子以藏精，女子以系

胞……其氣與腎通。”這段文字說明瞭以下三點：其一是人體內還存在著與《內經》中的腎不完全相同的

一個髒，名為“命門”；其二是命門的功能是“男子以藏精，女子以系胞”，明確指出其與生殖功能直接有關；其三是強調其氣與腎相通，表明功能上二者有密

切關係。此後的文獻對此有更多的論述，有以男子之

包絡為外腎、女子之包絡為子宮，亦有“腎有精室，是曰命門”等立論。對腎、命門、胞、子宮、精室、包絡及外腎等名稱並不統一，但對這是一個解剖單

元，且與男女生殖功能有關的觀點都是一致的。因

此，可以認為，凡中醫文獻中論及腎的地方應包括睾

丸及卵巢在內，有時即直接指睾丸或卵巢。腎與精的

關係也有較多論述。如《素問．上古天真論》說：

“腎者，主水，受五臟六腑之精而藏之。”說明腎所藏之精，除來自他藏他腑外，還包括腎本身之精，因

此，既有先天生殖之精，又有後天水穀之精。中醫學

歷來認為腎精對人體是極為重要的。《素問》在第一

章“上古天真論”中首先就從腎氣盛衰論證了人體生長發育和衰老的規律，並強調了腎氣對生命活動的重要

性。如張景嶽認為：“命門之火，謂之元氣；命門之水，謂之元精。五液充則形體賴而強壯，五氣治則營

衛賴以和調”。腎精與腎氣互為體用，腎精充足則腎氣旺盛；腎精不足則腎氣亦隨之而衰減。對於腎臟的

生理病理以及腎與五臟六腑的複雜關係，唐容川曾予

以高度概括，《血證論》指出：“腎者水髒，水中含陽，此生元氣，根結丹田。內主呼吸，達於膀胱，運

行於外，則為衛氣。此氣乃為水中之陽，別名之曰命

火。深水充足，則火之藏於水者，豔光匿彩，龍雷不

升，是以氣足而鼻息細微。若水虛則火不歸元。喘

促虛癆，諸症並作，咽痛聲啞；心腎不交，遺精失

血，腫滿咳逆，痰喘盜汗。如陽氣不足者，則水泛

為痰，淩心沖肺，發為水腫，腹痛奔豚，下利厥

冷，亡陽大汗，元氣暴脫。腎又為先天，主藏精

氣，女子主天癸，男子主精，水足則精血多，水虛

則精血竭。於體主骨，骨痿故屬於腎。腎病者，臍

下有動氣，腎上交於心，則水失既濟；不交則火愈

亢。位在腰，主腰痛。開竅於耳，故虛則耳鳴耳

聾。瞳人屬腎，虛則神水散縮，或發內障。虛陽上

泛，為咽痛頰赤。陰虛不能化水，則小便不利；陽

虛不能化水，小便亦不利也⋯⋯腎又為水之主，腎

氣行則水行也。”這些論述豐富了中醫學有關“腎”的內容。故中醫之“腎”包含腎上腺、內分泌軸、泌尿生殖系統，以及神經及精神情志系統，為臨床從

“腎”治療提供了理論基礎。按西醫學解剖生理學，肉眼可見到腎臟位於人體

的後腹腔並左右對稱，不等長、寬、厚約為 10 厘米x5 厘米 x4 厘米；顯微鏡下，每一側腎臟是由無數個“腎單位”組成的，每個“腎單位”又由腎小球和腎小管組成，腎小球有入球小動脈和出球小動脈。在胚胎

期發育時，腎臟與其他泌尿、生殖系統一併發育成

熟，因此有些先天性腎臟病變經常合併其他生殖器官

之病變。腎不僅是機體的主要排泄器官，同時也是人

體重要的內分泌器官，對維持機體內環境穩定起著相

當重要的作用。腎臟的生理功能主要是排泄代謝產

物，調節水、電解質和酸堿平衡，維持機體內環境穩

定。腎泌尿功能變化的防禦意義在於減少水鈉的排

出，有利於維持迴圈血量。但腎缺血所致是腎泌尿功

能障礙，卻可導致內環境的紊亂。休克早期所伴有的

功能性急性腎功能衰竭，如果不及時搶救休克，將發

展成為急性腎小管壞死。對各種原因引起的休克都要

積極採取一切措施，儘快補充血容量，使血壓回升，

保證腎臟血流量。這預示在搶救危急重症時，西醫同

樣必須密切關注保護腎臟功能的問題。


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危急重症及腎的病機認識

危急重症及腎，歸根結底有兩個方面，一是因危

急重症而傷腎，二是因傷腎而致危急重症。此類危急

重症均應從腎論治。但對危急重症及腎的強調程度遠

不如久病及腎，在可治療方面也常被忽視。結合臨床

及中醫理論的闡述，急症（病）及腎病機演變有以下

幾個方面。 1 七情傷腎情志不節可導致精、氣、血紊亂，髒傷而病至。

精神活動超出了常度，情緒過於激動可影響內臟的活

動而產生病理變化，不同的情緒將傷及不同的臟腑。

《靈樞·百病始生篇》認為：“恐傷腎”。《素問·舉痛論》稱：“恐則氣下”，“恐則精卻”。《素問·本神》說：“恐懼者，神蕩憚而不收”，“恐懼而不解則傷精，精傷則骨酸痿厥，精時自下”。張景嶽還認為怒也能傷腎，“七情傷腎，恐亦居多，蓋恐畏在心，腎則受之”。 2 外傷傷腎《素問．謬刺論》說：“人有所墮墜，惡血留內，

腹中滿脹，不得前後，先飲利藥。此上傷厥陰之脈，

下傷少陰之絡。”因外傷者，筋骨必先受累，而肝主筋，腎主骨，所以說上傷足厥陰肝經之脈，下傷足少

陰腎經之絡。另外，外傷者除疼痛、失血及毒素等作

用外，思想上產生的嚴重驚恐情緒也在起著傷腎的作

用。 3 外邪傷腎外邪主要是指外感溫熱和風寒之邪。溫熱之邪先

犯上焦肺和心包，繼續可傳入中焦脾胃，不愈則傳及

下焦肝腎。熱入陰分可助心火，心火愈熾則腎水愈

虛，以致產生心煩不得眠的水虧火旺見證；若熱劫腎

陰而致水不涵木，可見虛風內動，筋脈拘攣等；若熱

邪久羈下焦，真陰欲竭，以致腎精不能上承，可引起

耳聾，即《內經》中“精脫者耳聾”之候。而風寒之邪，則從肌表由三陽傳入三陰，最後穿至少陰。因少

陰為三陰之樞，屬心腎，統水火之氣，為傷寒六經病

變發展到最後和最嚴重的階段，故出現腎水不能上

升，或心火不能下降，引起氣血失調。此時，因陽氣

不足而脈微，因陰血不足而脈細，因氣血虛衰，精神

萎靡而但欲寐。因此，少陰病的治療原則以扶腎陽育

陰為主。 4 腎傷病急中醫文獻中有許多這方面的論述。如厥證是中醫

臨床上常見的急症，可由腎氣素虛引起。《靈樞．本

神》稱：“腎氣虛則厥”；《靈樞．衛氣》稱：“下虛則厥, 下盛則熱, 上虛則眩, 上盛則熱痛。”故治療上趙養葵提出：“陽厥補陰，壯水之主；陰厥補陽，益火之源”的原則。對中風的治療，趙養葵認為“當以真陰虛為本……陰虛有二：有陰中之水虛，有陰中之火虛。火虛者，專以河間地黃飲子為主；水虛者又當以六味

地黃為主。”張景岳在《景岳全書．小兒則》認為小兒急驚風“多屬肝膽脾腎，陰虛血燥相搏而然”，“此中陰虛之義，皆人所不知，當閱小兒補腎論”。陳夢雷在《古今圖書集成．醫部全錄》中亦曾引用“治驚不若補腎”之說。對腎傷致急的病機和治法進行了較系統的論述，對當今臨床仍有一定的指導意義。 5 出血傷腎

內科出血為內科常見急症，屬於中醫內科“血證”範疇。《景嶽全書》說：“血本陰精，不宜動也，而動則為病。血主營氣，不宜損也，而損則為病。

蓋動者多由於火，火盛則逼血妄行；損者多由於

氣，氣傷則血無以存。”出血的病因雖然複雜，但其共同的病理變化不外火熱偏盛，迫血妄行和氣虛失

攝，血溢脈外兩個方面。若起病急速，出血量大，

若救治不及時，常可導致厥脫，表現為昏迷、四肢

厥冷、少尿等。血管彌漫性出血主要表現為出血、

休克、微血栓及溶血，各器官均可受累而最終功能

衰竭，若損害在腎則無尿、少尿；若休克則血壓降

低、昏迷、四肢厥冷、少尿等。明確出血傷腎，有

助於掌握針對性的有效治療。 6 中毒傷腎

中醫對中毒的急救和論治，歷代總結了不少經

驗，例如《諸病源候論．蠱毒病諸候》把中毒的內

容和範圍，概括為食物中毒、藥物中毒、飲酒過量

中毒、中蟲獸之毒等章節；迨至漢唐宋，張仲景

《金匱要略》和孫思邈《備急千金要方》分別對上

述中毒的搶救治療，介紹了較多的行之有效的方

藥；宋．《聖濟總錄．雜療門》進一步對中毒進行

了詳細分類及其診斷治療做了較全面的整理。但中

醫古醫藉對中毒傷腎的闡述較少。現代靶器官毒理


125

學認為[2]，由於不同外源化學物與機體交互作用導

致組織器官損傷的機制不同，器官也存在選擇毒性

的差異性。主要毒物對靶器官毒性大小，依次是肝

臟、腎臟、呼吸系統、心血管、免疫、血液、中樞

神經系統、行為、皮膚、生殖和發育、內分泌等。

腎臟是主要的中毒靶器官。中毒傷腎的主要表現於

尿之異常，如出現血尿、蛋白尿、尿色異常等。對

毒物傷腎病因、發病機制的熟悉，對臨床防治中毒

所致危急重症具有一定的幫助。

危急重症治腎的實驗與臨床依據

有關危急重症治腎的實驗與臨床方面的探索，歷

代醫家及現代科研工作者都做了大量的工作，但缺乏

系統的論述，散見於部分醫學文獻中。現代的醫學科

研工作者則從急症傷腎的角度進行了研究，從而為危

急重症治腎提供了較為客觀的依據。

1 危急重症治腎的實驗依據前文指出，中醫學中的“腎”實際上已經涵蓋了現

代醫學的精、睾丸、卵巢的功能，很多學者即是通過

對這些部位的病理學研究來尋找證據的。匡調元的研

究發現[3]，睾丸特別是精母細胞對全身急性損傷的反

應最為敏感，約五天左右精子細胞減少，整個生殖上

皮細胞層層次減少而且變薄，甚至在精子和精原細胞

間形成一個無細胞區。McClead 報導[4]，天花患者睾

丸病變一般要 34 天後才能恢復，主要由於本病的急性刺激導致生殖上皮細胞受損害，生殖過程受抑制引

起。Aono[5] 等觀察了 25 例外科大手術的男性患者，發現患者的血漿睾丸酮在手術時比手術前顯著降低，

而血漿免疫反應性黃體激素水準在手術時較手術前明

顯增高，手術切口開始後 30 分鐘達最高水準，手術終止後即恢復到術前水準，但睾丸酮水準繼續降低，

他們認為可能與大手術後睾丸對促生殖腺激素缺乏敏

感性有關。沈雁等[6] 通過動物實驗研究證實骨折、

燒傷小鼠的精曲小管生殖上皮細胞腐脫、結構紊亂及

腔內成熟精子數量減少，精母細胞空泡形成增多，而

對照組則無異常。張偉榮等[7] 也通過燒傷大白鼠觀

察到，大白鼠的血睾酮、雌二醇含量顯著低於正常

組。Selye[8] 在觀察了實驗動物和人體對致病刺激所

產生的總體性反應後提出了著名的“應激學說”。他曾把注意力集中在“下丘腦——垂體——腎上腺皮質”軸

上，隨之而來的是，腎上腺皮質固醇類藥物廣泛應用

於臨床治療多種急性疾病，並取得了一定效果。這些

研究結論證明，急性的病原刺激使睾丸受累，導致睾

丸病變的原因不一定在睾丸本身，而往往是全身性疾

病引起的，睾丸的病變只是全身性病變的一個組成部

分，也可能是一個重要的病機環節，恰為中醫學“危急重症治腎”提供了病理形態學的物質基礎。同時，對補腎中藥的研究也發現[9]，不少此類中藥具有性激

素樣作用，雖然它們本身不是性激素，又無性激素常

見的不良反應，這又證明瞭補腎藥物治療急症將會有

更加廣闊的前景。 2 危急重症治腎的名家醫案舉隅古代醫家有較多危急重症治腎的驗案，散見於歷

代醫學文獻中。現部分介紹如下。 (1) 厥證治腎兩例其一為高鼓峰治療傷寒暈厥（《續名醫類案．傷

寒》），以人參、熟地、炮薑濃煎湯灌之漸解。其二為

某醫治療傷腎厥冒（《續名醫類案．厥》），以熟地、

杞子、沙參、麥冬急煎服漸愈。 (2) 失血治腎兩例其一為喻嘉言治房勞失血墜安元氣（《續名醫類

案·吐血》），先以黑錫丹墜安元氣，再以阿膠入補腎藥連服 5日。其二為張錫純治堂侄女勞心吐血（《醫學衷中參

西錄·醫案》），以生、熟二地、生山藥、臾肉、生赭石急火煎服漸蘇。 (3) 急驚治腎兩例一是高鼓峰治燥風驚搐（《醫宗己任編．四明醫

案》），以滋水清肝飲一劑而解。二是某醫治痰盛驚搐（《續名醫類案．驚風》），

以六味丸滋腎水、生肝血而愈。 (4) 中風治腎兩例一是馮楚瞻治卒中欲脫（《續名醫類案．中

風》），以大劑人參合加減歸脾與八味丸，一月而起。二是陸養愚治卒僕壯熱案（《續名醫類案．中

風》），以生地、人參、麥冬、五味子壯水制火而愈。類似的記載尚有限，但這些論述闡明瞭危急重症

治腎的可行性，為危急重症治腎的臨床應用提供了值

得參考的文獻依據。綜上所述，危急重症治腎之說既有較久遠的歷

史淵源，又為現代醫學有關科研所揭示。中醫學


126

“扶正培本”的治療大法，說明歷代醫家對護腎護精及振奮元陰元陽的高度重視。從長期的醫學實踐中也可

以發現，諸多醫家在實踐著“扶正培本”的治療原則時，也有意無意地進行了危急重症治腎的探索。隨著

現代科學技術和實驗手段的日新月異，對開展危急重

症治腎的臨床與實驗研究提供了更加有效的手段，也

將會對危急重症治腎起到很好地促進作用。

參考文獻

1 方藥中, 鄧鐵濤, 李克光, 等主編. 實用中醫內科學. 第 1版. 上海:上海科學技術出版社, 1985. 62-395.

2 莊志雄, 主編. 靶器官毒理學. 第 1 版. 北京:化學工業出版社, 2006. 15-23.

3 匡調元. 中醫病理研究. 第 1版. 上海:上海科學技術出版社, 1989. 196-201.

4 McClead J. Certain Concepts in human male infertility. J Uro1, 1952, 67:19-23.

5 Aono T, Scote J. Influence Of major surgical stress on plasma levels Of testosterone, luteinizing hormone and follicle-stimulating hormone in male patents. J Clin Endocrm. 1972, 35:535-537.

6 沈雁, 匡調元, 張偉榮, 等. “外傷及腎”的實驗研究. 中西醫結合雜誌, 1991, 11:608-619.

7 張偉榮 . “急病及腎”的實驗研究 . 中國中醫藥科技 , 1994, 1:15-17.

8 Selye H. The Stress of Life. McGraw-HillBookCO. 1st ed. New York: Publishing Inc First. 1963. 1-3.

9 沈自尹, 主編. 腎的研究（續集）. 第 1 版. 上海:上海科學技術出版社, 1990. 241-295.


127

‧病例報告‧

扁桃體惡性淋巴瘤 1 例

劉水明朱立洪鍾慶佳蔡威儀

【摘要】扁桃體惡性淋巴瘤 (Malignant Lymphoma) 患者早期表現咽部不適、咽痛、異物感等症

狀，有的甚至無任何不適感，僅表現為下頜角或頜下腫塊。因此，由於臨床症狀的不典型性，加上

M.L 的常規病理診斷較其他上皮源性的腫瘤更為困難，故臨床極易漏診、誤診。現在觀點認為:惡性淋巴瘤己成為一種可治癒的腫瘤，關鍵在於早期診斷和早期治療。如何做到早期診斷和早期治療是臨

床醫生所關注的。【關鍵詞】扁桃體; 惡性淋巴瘤; 診斷; 治療

Malignant Lymphoma of Tonsil : A Case Report LIU ShuiMing, CHU LapHong, CHONG HengKai, CHOI Wai I. Department of OTO-HNS(ENT), Kiang Wu Hospital, Macao SAR, China, Tel:(+853)-8295 2020； E-mail: [email protected] 【Abstract】 The early symptoms of Malignant Lymphoma (abbr. as M.L) are sore throat ,feeling a lump in the throat, etc, even there will be no symptoms or occurence as a mass in the area of submaxillary. Because of the atypical clinical signs .In addition, the diagnosis of pathology in M.L is more difficult than other epithelial tumor. As a result, it is easy to make erroneous diagnosis .In recent point of view, Malignant Lymphoma is a curable disease and the chief key is diagnosis and treatment in advance .The query is how we can achieve this point is more concerned by the physicians. 【Key words】 Tonsil; Malignant lymphoma; Diagnosis; Treatment

臨床資料

1 個案病史患者，男性，25 歲；因“咽痛伴漸進性吞咽困難 1 月”入院，患者一月前因鼻塞流涕，咽痛，在外院擬上感服藥治療，上述症狀好轉，停藥後咽痛反

覆，漸進性出現吞咽困難，不伴發熱，無聲嘶，無呼

吸困難，無痰中帶血絲，外院多次經抗生素治療，症

狀反覆故入院進一步診治。患者有 10 年吸煙史，量1包/天。 2 專科檢查右側扁桃體腫物，表面糜爛，色暗紅，邊界不

清，腫物部分侵及右側軟腭，懸雍垂被推移至左側，

左側扁桃體 I 度大，表面無潰瘍及分泌物；伸舌居中，舌活動良好。會厭抬舉佳，舌根未見腫物。 3 輔助檢查頸及扁桃體MRI示右扁桃體區明顯巨大腫塊樣作者單位：中國 , 澳門鏡湖醫院 , 耳鼻喉 -頭頸外科 ; Tel:(+853)-8295 2020； E-mail: [email protected]

改變，與左側扁桃體比較，其信號較類似，似多個結

節病灶融合改變，增強掃描呈較均勻強化，與左側扁

桃體信號較一致；病灶境界清楚，其局部隆起，大小

約 3.3X5.6X6.5cm3，突向咽部，致其變窄，向前擠壓

右側舌根部，但舌根未見異常信號改變；所見雙側血

管鞘區，頸深部均未見明確腫大淋巴結。

診斷

入院診斷：右側扁桃體腫塊，考慮惡性淋巴瘤

可能大，由於門診己行病理活檢，但報告為炎性和壞

死組織，與臨床不相符合，為進一步明確診斷，安排

全麻下行右側扁桃體腫物切除術，術中將大部分扁桃

體腫物送病理檢查；病理檢查示淋巴組織瀰漫增生，

淋巴濾泡結構消失，增生的淋巴細胞以中等至大細胞

為主，部分可見核仁，核分裂多見，免疫組化示腫瘤

細胞 L26(CD20)陽性，CD79a 陽性，UCHL-1 部分細胞陽性，CD3 陰性，CD10 部分細胞陽性，BCL-2 部分細胞陽性，CD5 陰性，CD15 陰性，CD23 陰性，CD30陰性，CyclinD1陰性；病變符合瀰漫性大 B細胞淋巴瘤。


128

討論

原發於扁桃體的惡性淋巴瘤早期多無明顯症

狀，隨著瘤體逐漸增大，病員可出現咽異物感、咽隱

痛不適等非特異性症狀，臨床極易誤診為“慢性扁桃體炎”、“扁桃體肥大”。扁桃體惡性淋巴瘤早期可出現頸淋巴結轉移。其特點是腫塊質硬、光滑、邊界

清、可活動，以頜下三角區多見，故又極易誤診為

“慢性淋巴結炎”。對於臨床來說，區分淋巴結的良、惡性，病理診斷是唯一可以依賴的[1]。而扁桃體惡性

淋巴瘤的病理診斷又相對較困難，主要是因為淋巴結

組織的不典型增生，形態標準不易掌握，70 年代曾有人提出淋巴組織不典型增生的概念，但很難得到推

廣。從腫瘤發生學上的理論上來說，淋巴瘤有不典型增

生的階段，但在實際工作中，由於淋巴組織在反應性增

生時可表現為從小淋巴細胞到免疫母細胞的各種不同形

態，其異型性有時比惡性淋巴瘤細胞還大，這就不同於

上皮組織來源的細胞，增生的上皮與癌變的上皮在細胞

異型性上有明顯的區別，病理上輕—中—重度異型均有明顯的診斷標準，而淋巴細胞的不典型增生與其反

應性增生在形態學上是難以鑒別，這就給惡性淋巴瘤

的早期診斷或者說癌前病變的診斷帶來困難[2]。現代觀點認為，惡性淋巴瘤已成為一種可治癒的疾病，但關鍵要做到早期診斷，早期治療，而早期診

斷的關鍵仍在於醫生的警惕性和病理的可靠性，對下

列情況應常規行扁桃體活檢：(1) 臨床疑為”急、慢性扁桃體炎”，而正視抗炎治療無效，特別是一側扁桃體進行性腫大或兩側扁桃體不等大者應活檢，因為

惡性淋巴瘤早期在上皮下淋巴組織內增殖，扁桃體充

血、腫大，外觀與扁桃體炎極相似。(2) 一側扁桃體腫大伴同側頸淋巴結腫大、質偏硬、活動差、無壓痛

者。(3) 反之，以不明原因的單側頸淋巴結腫大為首發症狀者，尤其是小兒，應常規檢查咽淋巴環，伴有

同側扁桃體大者應活檢。(4) 不明原因發熱者應常規檢查咽淋巴環，扁桃體可疑者活檢[3]。

在頭頸部結外器官發生的淋巴瘤與頭頸部癌的治療原則不同，放療及化療是目前治療主要方法，手

術僅起病理檢查以明確診斷作用，一般不主張手術

治療。但對咽淋巴環扁桃體非何杰金淋巴瘤，臨床

有人主張可把它作為惡性淋巴瘤中一個獨特類型進

行處理，在下述情況，扁桃體病灶摘除術對診治本

病有幫助[4]：(1) 病理診斷扁桃體惡性淋巴瘤者，腫瘤無明顯周圍組織浸潤。(2) 扁桃體惡性淋巴瘤與慢性扁桃體炎臨床難以鑒別，或不明原因一側扁桃

體腫大者，應盡快行扁桃體切除並活檢。(3) 對於反覆活檢均未確診的高度懷疑扁桃體惡性淋巴瘤病

例，局部活檢往往因深層組織無法切取，容易造成

病理診斷困難，行患側扁桃體切除手術可將整個扁

桃體組織病理檢查。(4) 化療後疑扁桃體原發灶腫瘤殘存者[5]。扁桃體位於口咽部，位置表淺，扁桃

體外面與周圍組織有被膜分隔，病變局限於扁桃

體，手術既可能完整切除原發灶又能從切除大塊組

織較早獲得病理診斷，而且迅速改善因扁桃體過度

肥大對患者呼吸及吞咽功能的影響。結合本例，單

純表淺活檢，臨床難以確診。完整手術切除病理檢

查提高了確診的準確性，同時快速解除病人的不適

症狀；如：吞咽梗阻和呼吸不暢。但手術切除扁桃

體病灶對提高扁桃體惡性淋巴瘤生存率可能有幫

助，這種看法還有待一步積累病例及臨床觀察。

參考文獻

1 屠規益, 主編. 現代頭頸腫瘤外科學. 第 1 版. 北京:科學出版社, 2004. 441-447.

2 周建, 魏連枝, 曹友德. 頭頸耳鼻咽喉部原發性結外非霍奇金淋巴瘤臨床和免疫化特征. 臨床耳鼻咽喉科雜誌, 2003, 17:724-726.

3 陳海紅, 陳素平, 凌玲. 扁桃體惡性淋巴瘤 11 例分析. 浙江預防醫學雜誌, 2003, l5:68-69.

4 屠規益, 徐國鎮, 主編. 頭頸惡性腫瘤的規范性治療. 第 1版. 北京:人民衛生出版社, 2003. 311-327.

5 姚亞萍, 魏金芝, 朱亞芳, 等. 首發於頭面部結外惡性淋巴瘤 54例分析. 徐州醫學報, 2002, 22:544-545.


129

‧病例報告‧

Primary Aortoduodenal Fistula: A Case Report

Ng Wai-Lon Deng Hong-Ru Barata Frexes Joao Manuel 【Abstract】 We report that a case of massive gastrointestinal hemorrhage produced by aortoduodenal

fistula was successfully treated by urgent surgery. From clinical approach to final diagnosis and treatment, we conclude that primary aortoenteric fistula is rare cause of fatal exsanguinations, non-specific symptomatic. Prompt diagnosis and surgical treatment may improve the prognosis. 【Key words】 Aortoduodenal fistula; Pseudoanerysm; Gastrointestinal hemorrhage Surgery

原發性腹主動脈十二指腸瘻：病案報告伍維侖, 鄧鴻儒, Barata Frexes Joao Manuel.. CP 3002, 仁伯爵綜合醫院外科, Tel : +853)-8390 3020; E-mail:[email protected]. 【摘要】本文報告一例由腹主動脈十二指腸瘻引致消化道大出血，經緊急外科手術搶救成功。

从臨床表現、診斷到治療，我們得出以下結論：原發性腹主動脉小腸瘻是罕見的致命的消化道大出血

的原因之一，由於臨床表現无特異性所以确診困難。及時診斷和治療可改善病人的預後。【關鍵詞】腹主動脉十二指腸瘻; 假性動脉瘤; 胃腸出血; 手術

The aortoduodenal fistula involves communication between the aortic and the lumen of the duodenum. It is considered to be primary when an aorta that has not been surgically treated and comprise 80% of all aortoenteric fistulas. The third and fourth parts of duodenum are the most common sites in all types of aortoduodenal fistula. Gastrointestinal bleeding represents the first clinical presentation.

In this report, a case of a ruptured aortic pseudoaneurysm to the 4th part of the duodenum is presented.

CASE REPORT

A 62-year-old male patient was admitted to the emergency unit of CHCSJ with chief complaints of sudden haematemesis and malena. His hemodynemia was stable. When his hospitalization, first blood test shows: HB 8.9, no biochemistry abnormalities. He has previously back pain and upper abdominal pain for few months. He was treated as acute upper gastrointenstinal hemorrhage by PPI and blood transfusion although a

Authors address : Department of General Surgery, CHCSJ, Macau. China; Tel:( +853 )-83903020; E-mail:[email protected].

gastroduodenoscopy revealed no lesion or bleeding site in gastric cavity and duodenal 1th and 2th portion after clear-up remnant blood. After 10 hour, patient had episode of massive haematemesis and passing fresh bloody stool again, his Gastroduodenoscopy was repeat but revealed same result as previously, but his Hb was dropping. An abdominal angiography immediately was performed, it shows active bleeding from pancreatoduodenal artery entering duodenum and one pseudoaneurysm of aorta but no contrast extravasation (Figure 1). The patient was operated emergently due to unsuccessful pancreatoduodenal artery embolization and hemorrhage shock (BP: 70-50/50-30) event supporting under blood transfusion.( blood transfusion 10 u within 24 hours).

A medium laparotomy was performed: patient’s stomach and all intestines are fully fill with blood and clot. We performed gatrotomy and duodenotomy at 1th portion first because of considering angiograpgy result: no bleeding site was found. Intra-operative endoscopy found bleeding for duodenal 4th portion. Another duodenotomy at 4th portion was performed in order to expose ulcerated lesion and massive bleeding. Finally, diagnosis of an aortoduodenal fistula rising from aortic pseudoaneurysm with retroperitoneal chronic inflammation was confirmed. There is fibrosis change


130

around the pseudoaneurysm (figure 2). Aortic bleeding was first controlled by finger pressure maneuver for providing hemodynamic stability. After dissected aorta from 4th part of duodenum, the defect of pseudoaneurysm about 1.5 cm in diameter. We performed simple suture aortic fistula and suture close duodenal defect. We placed intra-abdominal drains and jejuna decompression due to concerning intra-abdominal contamination during surgery. Patient had stayed ICU for 12 days with complicated to acute pre-renal failure ( needs hemodialysis), then transferred back to surgical ward after renal function became to be normal and initiated oral intake. Patient has good intestinal movement and Gram-positive sepsis was treated by antibiotics. But patient has slight ischemia sign in bilateral toes (distal perfusion compromised). Patient has no more episode of melena or abdominal pain. Patient’s serology postoperative test is negative for syphilis. He has hypertention but has never be treated and alcohol consumption.

Abdominal CT scan was performed on 7th day of

post-operation: remnant aortic pseudoaneurysm still demonstrated (figure 3).

Patient may need further management for remnant aortic pseudoaneurysm by endovascular stenting.

DISCUSSION

A primary aortoenteric fistula represents barely 1% of the forms of presentation of abdominal aortic aneurysm[1] which is much lower than that of the secondary type produced in an aorta treated with prosthetic stent.

ETIOLOGY

Arteriosclerosis of the aorta is the primary cause of primary aortic enteric fistula[2]. Other causes of primary aortic enteric fistula are chronic infection disease such as syphilis, salmonellosis, brucellosis and tuberculosis[3]. Our reported case may represent inflammatory atherosclerosis pseudoaneurysm, penetrated to 4th portion of duodenum.

DIAGNOSIS AND INVESTIGATION Primary aortic enteric fistula is a very rare cause of

gastrointestinal hemorrhage, but has very high mortality and fatal exsanguinations if undiagnosed and untreated. The definitive preoperative diagnosis is very difficult because of the non-specificity of clinic presentation. The usually clinical presentation consistent of: abdominal pain, the presence of pulsating matter in abdomen.

Haematemesis or melena may be the first presentation but don’t generally have haemodynemic repercussion in the early stage. Above symptoms are characterized by alternating relapse and remission. It was only 5% of the cases that the initial episode resulted in a fatal hypovolemia shock. Upper endoscopy rarely shows an adherent clot or pulsatile mass into the duodenum, can rule out other causes of bleeding but only can be performed in relatively stable patients. Endoscopy is

Figure 1 Pre-operation angiography Figure 3 Post-operation CTAFigure 2 Inflammation pseudoaneurysm and fistula, the aortal

fistula seen during operation


131

being ineffective in up to 30% of the cases[4]. In reported this case, gastroduodenoscopy, as first clinical investigation, was not concluded the lesion or cause of bleeding. Angiography detection of the fistula is limited (30%). In our case, angiography shows pseudoanerysm of aorta but it do not demonstrate bleeding because patient was at very low blood pressure status during the procedure, the final diagnosis was confirmed on the table of operation. According research paper, clinical diagnosis can be confirmed in operative theatre in more than half of the case.

TREATMENT

The only demonstrable effective treatment for all the aortoenteric fistulas, up to now, is surgery. It is recommended that repair of the aortic aneurysm (en bloc resection of aneurysm or paseudoanerysm) consist of an interposition synthetic graft and primary repair of intestinal tract[1-2]. In this reported case, we performed simple suture aortic pseudoaneurysm and repair duodenal fistula. We gave up to place Interposition of graft because of considering retroperitoneal inflammation and intra-abdominal contamination, another hand we need immediately controlling bleeding as patient had been at shock status during the procedure. We obtained successfully saving the life of the patient without complications produced by operation.

According clinical experience, in cases presented with chronic primary aortoduodenal fistula and blood positive sepsis, some surgeons suggest: to temporarily place prosthetic graft and en bloc resection of aneurysm, after blood culture sterile, a staged extra-anatomic bypass followed by removal of the temporary graft[5].

PROGNOSIS

As the surgical treatment is usually delayed, such

events associated with very high pre-operative and intra-operative mortality rates[5]. The majority due to secondary hypovolemic shock through gastrointestinal bleeding. 51% of patients die during surgery and 46% following this from hypovolemia that may result in cerebral anoxia, acute renal failure. In our case, patient received transfusion of RBC 23u, plasma 16u, platelet 12u, Cryo 24u. He awoke and was extubated at 7th day postoperatively without any neurological defect or sequelae. He suffered acute renal failure, but fortunately his renal function completely normalized after hemodialysis. He only has sequelae of peripheral ischemia: skin dry necrosis in the hell of right foot and right 1th toe.

CONCLUSION

Diagnosis of primary aortoenteric fistula is difficult. This diagnosis should always be considered in patient with massive gastrointestinal bleeding of unknown etiology and pulsatile mass (Yes or No). Early diagnosis and surgical treatment may improve the outcomes of the patient and reduce post-operation complications.

REFERENCES

1 Rieta VR, Manuel RME, Julia MJ, et al. Fistula aortoenterica primaria, causa infrecuente de hemorragia digestive en el adulto joven. Gastroenterol Hepatol, 2005, 28:26-29.

2 Van OTB, Kuippenberg LH, Van DVJA, et al. Primary aorta enteric fistula: report of six new cases. Cardiovascul surger, 2002, 10:551-554.

3 Ufuk T, Aysen A, Ahmet TU, et al. Acute gastrointestinal bleeding duo to primary aortoduodenal fistula: Report of two cases. Turk J Gastroenterol, 2004, 15:253-257.

4 Ikeda K, Abe T, Itou M, et al. Successful surgical treatment of primary aortoduodenal fistula associated with inflammatory abdominal aortic aneurysm: a case report, Ann Thorac Cardiovasc Surg, 1999, 5:194-197.

5 Yong PC, Gil HK, Myoung SH, et al. Staged surgery for chronic Primary Aortoduodenal Fistula in a septic patient. J korean Med Sci, 2004, 19:302-304.


132

‧病例報告‧

Cotard Syndrome and Electroconvulsive Therapy in an Elderly Chinese Lady without Capacity to Consent to Treatment: A Case Report Carlos DUARTE JIN Haiyan CHEONG Chun Kin

【Abstract】 Cotard syndrome is a rare condition in which the primary symptoms are nihilistic

delusions. It has been reported in a variety of conditions but is usually related to psychotic depression. This report describes the case of an elderly Chinese lady that presented Cotard syndrome in the context of unipolar psychotic depression. During hospitalisation, her depression did not respond to the combination of an antidepressant and an antipsychotic drug. In fact, her depression progressively got worst and, by the 13th week after admission, she started to refuse treatments. At this time, because of the absence of response to the pharmacological treatments, electroconvulsive therapy (ECT) was considered and, as she presented legal criteria for detention as an involuntary patient, she was detained. After detention, she received six ECT, which clearly improved her cognition and depression. The issues of capacity and consent to treatment raised by this patient are discussed. 【 Key words 】 Cotard syndrome; Psychotic depression; Informed consent;

Electroconvulsive therapy

強制性電抽搐治療老年中國女性 Cotard 綜合徵 1 例報導 Carlos DUARTE, 金海燕，張轉乾. CP 3002, 中國, 澳門特別行政區, 澳門仁伯爵綜合醫院, 精神科; Tel : +(853)-2883 1571; E-mail: [email protected] 【摘要】 Cotard 綜合徵是一種以虛無妄想為核心症狀的綜合徵，在臨床上較為罕見。該綜合徵可發生於多種精神疾病，但常見於帶有精神病性症狀的抑鬱症患者。本篇報導了一例發生在單極

精神病性抑鬱的老年中國女性的 Cotard 綜合徵。並在住院期間，患者對合併抗抑鬱藥物及抗精神病藥物治療的反應不佳。其抑鬱症狀進行性加重，在入院後第 13 周，開始拒絕接受治療。此時，電抽搐治療被考慮使用。根據相關法律條文，該患者歸屬于非自願接受治療之列而被強制留院治

療。在接受六次電抽搐治療後，患者的認知功能及抑鬱症狀得到明顯改善。本篇報導就該患者的治

療及知情同意的能力等問題進行討論。【關鍵詞】 Cotard綜合徵; 精神病性抑鬱; 知情同意; 電抽搐治療

Cotard syndrome (CS) is a rare condition in which the primary symptoms are nihilistic delusions[1]. The syndrome can present with varying degrees of severity. In severe forms, patients deny their own existence and the existence of the world and they can even believe that they are dead. In less severe forms, patients typically believe that their organs have lost their function or that they have lost body parts. CS has been reported in a variety of conditions, ranging from schizophrenia to cerebral trauma, but is usually related to psychotic depression (PD) (major depressive episodes with Authors address : CP 3002, Serviço de Psiquiatria, Centro Hospitalar Conde de São Januário (CHCSJ), Macao SAR, PR China; Tel : +(853)-2883 1571; E-mail : [email protected]

psychotic features) occurring in middle-aged or older people. Pharmacological treatments for unipolar PD can start with an antidepressant monotherapy and, if there is no response, an antipsychotic is added; alternatively, treatments can begin with a combination of an antidepressant and an antipsychotic. However, despite the abundant pharmacological options available, many patients do not achieve a satisfactory improvement. Another treatment option for unipolar PD is electroconvulsive therapy (ECT), which is considered by many clinicians to be the most effective treatment for this condition and is believed to be particularly effective in cases of CS in the context of depression[2].


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For any treatment, the patient’s consent is an ethical prerequisite. In the Macao Special Administrative Region (MSAR), the issue of consent to treatment is embedded in diverse legislations, including the Penal Code (Articles 37, 144, 150 and 151), the Decree-Law (DL) n.º 31/99/M (Mental Health Act) and the DL n.º 111/99/M (protection of the individuals against the abuses of biology and medicine). In short, the law requires that when individuals over 14 years refuse medical treatment their stated wishes must be respected unless they present a mental disorder and have no capacity to consent to treatment or are detained as involuntary patients. When individuals are less than 14 years old or incapable to consent, the consent is given (or refused) by their legal representatives.

In many health systems, there are special legal regulations for ECT, a treatment that has a particular status within psychiatry. This status is, in part, explained because there have been abuses of ECT in the past. At present, ECT is considered a safe and effective treatment, even if it can cause persistent side effects such as memory loss. According to the DL nº 31/99/M, ECT can only be administrated after the written consent of the patient, except in some particular circumstances. However, although the patient’s consent for any treatment is, in principle, always required, in severely depressed patients consent may be impossible to obtain because their illnesses may affect their capacity to make voluntary decisions regarding treatment. This incapacity to consent to treatment was the situation we faced when treating the patient of this report. We describe here a case of an elderly lady that presented CS in the context of unipolar PD. During hospitalisation, she started to refuse pharmacological treatments that were otherwise unsuccessful. At this time, she was unable to consent to treatment and presented criteria for detention as an involuntary patient. After detention, she was treated with ECT, which clearly improved cognition and depression, and regained her capacity to consent to treatment.

CASE REPORT Our patient was a 69-year old Chinese lady that was

brought to the emergency department of Centro Hospitalar Conde de S. Januário because during the previous weeks she had been refusing to eat and had become increasingly apathetic. The patient, who had been discharged from the psychiatric unit three months before, was found to be depressed and was (voluntary) admitted to this unit. The patient had endured the death of her husband from colon cancer one year before the second admission. The couple had been married for about 45 years and had five offspring. The marriage had been troubled by the long-lasting gambling problems of the husband. The patient’s medical history was unremarkable except for a hysterectomy done a few years ago. Her premorbid personality had traits of dependent personality: she had a tendency to cling to her husband. She had no family history concerning neuropsychiatric disorders. Her psychiatric history started after the death of her husband. After his death, she did not exhibit clears signs of grief, she was unable to cope with her emotions and become depressed. She lost her appetite, lost weight and became more isolated. Two months after the death of her husband, she started psychiatric outpatient treatments and was medicated with fluoxetine. Five months after having started treatments she was hospitalised for two months because of suicidal ideas and was medicated with venlafaxine 75 mg/d and olanzapine 10 mg/d. She partly improved and, after discharge, continued treatments in the outpatient unit. However, even though she complied with the medication, her condition deteriorated and she was brought to the emergency department and was admitted as described above. On admission, mental status examination revealed that she was alert and oriented and that she presented psychomotor retardation, depressed mood and nihilistic delusional ideas. She claimed that she had a non-functional gastrointestinal system and that she had no defecation for one year, and she used these ideas to explain why she could not eat. She denied suicidal ideation and perceptual abnormalities. Her insight was impaired and she presented cognitive-mnestic deficits. A Mini-Mental State Examination (MMSE) was performed and she scored 18/30. Physical and neurological examination was unremarkable except for emaciation (she had had a weight loss of 10 Kg during the previous year). Laboratory tests including vitamin B-12, folate


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and investigations for syphilis did not reveal gross abnormalities, but T3 was low at 0.58 ng/mL (normal range, 0.80 - 2.00) and cortisol levels were elevated in the morning at 20.47 µg/dL (normal range, 6.19 - 19.43) and in the afternoon at 26.84 µg/dL (normal range, 2.32 - 12.33). Electroencephalogram and electrocardiogram showed no significant abnormalities. Brain magnetic resonance imaging (MRI) showed scattered high signal intensity throughout the regions of the basal ganglia and the subcortical regions of bilateral frontal-parietal lobes, suggestive of multiple lacunar infarctions. MRI also showed diffuse cortical atrophy, most striking in the frontal and parietal lobes. A diagnosis of Cotard syndrome in the context of unipolar psychotic depression was made. Treatment was initiated with venlafaxine 75 mg/d and olanzapine 10 mg/d, p.o., a medication that was accepted by the patient, although she could not fully evaluate the meaning and implications of consent to her treatment. Progressively, over a period of 13 weeks, venlafaxine dosage was increased to 375 mg/d, under close monitoring, but it brought about no change with respect to her delusional ideas and did not improve her depression. In fact, by the 13th week after admission her depression intensified (Geriatric Depression Scale score was 13/15) and her cognitive status deteriorated (MMSE score was 15/30). She started to reject food and medicines and could not consent to ECT, a treatment that was considered because of absence of response to the pharmacological treatments. Her son and daughters were explained about her medical condition and ECT and they all consented to this treatment. By the 13th week, as she could not consent to treatment and the absence of treatment could result in a significant deterioration of her medical condition, she was detained as an involuntary patient. After detention, she received six ECT under anaesthesia, given bilaterally with a Spectrum 5000Q machine. Seizures varied between 7 and 19 seconds and the total seizure time was 84 seconds. Following ECT, which was well tolerated, depression and cognition clearly improved (Geriatric Depression Scale score was 4/15; MMSE score was 22/30) and delusions completely resolved. One month after ECT, her detention ended and she was discharged, as fairly recovered, on paroxetine 40 mg/d and piracetam 2400 mg/d.

DISCUSSION This case brings up a number of questions: What is the importance of recognizing a nosological inconsistent condition as CS? What is the meaning of the cognitive impairment presented by the patient? What is the relationship between her depression and bereavement? What is the connection between her depression and the white matter hyperintensities found in MRI? Where does ECT fit into an algorithm for treatment resistant depression? However, in this report our objective is to examine the ethical, clinical and legal issues related to obtaining consent to treatment from this patient, a severely depressed person without capacity to make voluntary decisions. Agreement to treatment has several levels: refusal (rejection of treatment based on full information and sufficient mental capacity); dissent (rejection of treatment without sufficient mental capacity); assent (acceptance of treatment without sufficient mental capacity); and consent (acceptance of treatment based on full information and sufficient mental capacity). Consent to treatment can be express (actively expressed), tacit (passively expressed), implied (inferred by the behaviour of the person) or presumed (it is assumed that the person agrees in principle to the treatment). Consent is considered to be informed if the person : 1) has sufficient mental capacity, 2) is given sufficient information, and 3) is permitted to decide freely[3]. Mental capacity to consent to treatment, an ethical, clinical and legal construct, refers to the patient's aptitude to appreciate information relevant to a medical intervention decision and to the consequences of a decision or lack of decision. This capacity is generally conceptualized as being multidimensional: the patient 1) understands information relevant to the decision, 2) retains and appreciates this information, 3) uses this information in reasoning, and 4) expresses a choice. Capacity is decision specific: a person may retain capacity to decide about accepting a medication but may not have the capacity to decide about another treatment such as surgery. The assessment of capacity is mainly done by means of a clinical interview oriented for this purpose. Some special tools such as semi structured interviews and questionnaires that have been developed in recent years to specifically assess capacity can also be used[4]. In addition, a cognitive


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screening test such as the MMSE can sometimes be of utility in evaluating capacity. For example, it has been shown that a person with Alzheimer Disease who scores below 19 in this test is very likely to be considered incapable of providing consent[5]. Our patient assented to her treatment during the initial part of her hospitalisation. However, by the 13th week after admission, she started rejecting medicines following a progressive deterioration of her depression and cognition. At this time, she had no capacity to decide about her treatment, which included the proposal of ECT. According to the DL nº 31/99/M, ECT can only be administrated without the written consent of the patient in case of involuntary treatments (and during a psychiatric emergency, when ECT is considered necessary and adequate to prevent a situation of serious risk for the patient or other persons). By the 13th week after admission, she was detained as an involuntary patient because she presented the “need of treatment” criteria for detention: a severe mental disorder and lack of capacity to consent to treatment, in a context where the absence of treatment could result in a significant deterioration of her condition (DL n.º 31/99/M, Article 8). Although involuntary patients have the duty to submit to the prescribed treatments, including ECT (DL n.º 31/99/M, Article 10, n.º 2), the patient’s relatives were asked to consent on her behalf to ECT because it was considered to be ethically and clinically adequate. But, while it is good practice to consult relatives in treating patients unable to consent to treatment, the MSAR law states that no person can consent to treatment on behalf of another person over 14 years, except in some well-defined circumstances such as the ones mentioned in DL n.º 31/99/M, Article 4, n.º 3. After her detention, the

patient was administrated ECT, which markedly improved her cognition and depression. Over time, she regained her capacity to consent, accepted her medication and was discharged, which ended her detention. We have presented this case to increase the awareness of the ethical, clinical and legal complexities in assessing the capacity of severely depressed persons to make voluntary decisions regarding therapy and in obtaining their informed consent for treatment. Acknowledgement The authors are grateful to the contribution of Dr. Jerónimo Santos, Judge of Tribunal Judicial de Base.

REFERENCES

1 Berrios GE, Luque R. Cotard's Delusion or Syndrome?: A

Conceptual History. Comprehensive Psychiatry, 1995, 36:218-223.

2 The UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet, 2003, 361:799-808.

3 Lepping P. Consent in psychiatry-an ethical review. Psychiatr Bull, 2003, 27:285-289.

4 Dunn LB, Nowrangi MA, Palmer BW, et al. Assessing Decisional Capacity for Clinical Research or Treatment: A Review of Instruments. Am J Psychiatry, 2006, 163:1323-1334.

5 Kim SYH, Caine ED. Utility and Limits of the Mini Mental State Examination in Evaluating Consent Capacity in Alzheimer’s Disease. Psychiatr Serv, 2002, 53:1322-1324.


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‧病例報告‧

大疱性類天疱瘡 1 例巢和安甄健榮余嘉茵邱慧琳* 郭昌能** 【摘要】大疱性類天疱瘡 (Bullous Pemphigoid) 是一種較少見的疾病，它是自身免疫性慢性大疱

性皮膚病，好發於老年人。臨床特徵主要是疱壁厚、緊張不易破的水疱或大疱，組織病理為表皮下水

疱。故此凡臨床表現為不明原因的水疱或大疱的皮膚病，須作尼氏徵檢查及組織病理和免疫病理檢

查，以排除預後較差死亡率高的天疱瘡，以及對疾病的預後作出評估及為臨床用藥治療有指導作用。【關鍵詞】大疱性類天疱瘡

A Case of Bullous Pemphigoid CHAO Wo-on, CHIN João-Paulo, U Ka-Ian, IAO Wai-lam*, KUOK Cheong Nang**. Chao’s Medical Centre, Rua de Abreu Nunes, no. 6, Edf. Iao Lun, 2 andar (A); Macao SAR, PR China; Tel: (+853) 2852-3696; E-mail: [email protected] ; *Lar de Cuidados “Sol Nascente” da Areia Preta, Macao SAR, PR China; Tel: (+853)-2843-0281; **Centro de Radiologia Oriental Lda, Macao SAR, PR China; Tel: (+853)-2836-9552

【Abstract】 Bullous Pemphigoid is an uncommon disease. It is an autoimmune and chronic bullous

dermatosis which occurs most frequently in the elderly. The clinical features are vesicles or bullae with thick walls and tension which cannot be easily ruptured. A subepidermal vesicle can be presented under histopathology. In patient with unknown cause of vesicle or bullae, the Nikolsky’s sign, histopathology and immunopathology should be examined to rule out the fatal Pemphigus, these examinations can also assess the prognosis and give instruction on the clinical medication. 【Key words】 Bullous pemphigoid

大疱性類天疱瘡(Bullous Pemphigoid)是一種較少見的慢性大疱性皮膚病，好發於老年人(50 歲以下少見)，臨床特徵主要是疱壁厚、緊張不易破的水疱或大疱，組織病理為表皮下水疱的一種病因未明的自身

免疫性疾病。

臨床資料

1 病史及臨床表現患者，男性，81 歲，因四肢反覆出水疱伴劇癢

一個多月就診。就診前一個多月，無明顯誘因下於雙

側手腕及踝關節處伸側出現水疱及大疱伴劇癢（見附

圖 1, 2），直徑 0.5 ~ 2cm，疱液清呈漿液性，尼氏征陰性，疱壁較厚不易破。部分水疱因病人抓癢而破

損，糜爛面上覆蓋痂皮及少量血痂。病人現合併患有

高血壓病及肺氣腫；過往曾患雙上肺肺結核，有左肺

作者單位：中國, 澳門特別行政區, 澳門巢氏醫療中心, 澳門荷蘭園二馬路 6號, 友聯大廈, 2樓 A座; Tel :(+853) 2852-3696; E-mail:[email protected]; *中國, 澳門特別行政區, 澳門黑沙環明暉護養院; Tel: (+853) 2843-0281; **中國, 澳門特別行政區, 澳門東方 X檢驗有限公司; Tel: (+853) 2836-9552

癌手術史、前列腺肥大切除手術及蘭尾切除手術史。 2 實驗室檢查 (1) 血常規示：WBC8.4x109/L、NEU65.2%、RBC3.6x1012/L、ESR5mm/hr、PLT228x109/L。 (2) 尿液及糞便常規未見異常。 (3) 血液生化檢查示： UREA12.8mmol/L、 UA558umol/L、CREA188umol/L、血糖及肝功能未見異常。 (4) 尿微白蛋白檢查示： MA-U40.90mg /LTPROT56.8g/L、ALB34.6g/L、GLB22.2g/L。 (5) 腫瘤血液學檢查示：

CEA5.1ug/L(Smokers)、AFP3.30ug/L。 (6) 心電圖示：左心室肥厚伴勞損。 (7) 胸部 CT(平掃)示：（左肺癌術史）左肺體積縮小，雙上肺陳舊性肺結核，主動脈硬化，脊柱側

彎，胸椎退行性病變，右斜方肌脂肪瘤。 (8) 磁共振腰椎檢查示：腰椎退行性病變及雙


137

腎多發性小囊腫。 (9) 完整水疱活組織病理檢查示：光鏡下皮膚組織見表皮下大疱、單房性。疱內見

纖維蛋白構成的網狀外觀，內含嗜中性白細胞及嗜酸

性白細胞。真皮內血管周圍有炎症細胞浸潤。真皮水

腫，表皮真皮連接處分裂（見附圖 3, 4）。病變符合大疱性類天疱瘡。

治療建議患者以高熱量、高蛋白飲食，補充多種維他

命及防止皮損處繼發感染。多次消毒水疱表面及以一

次性針頭抽取水疱液。外用 0.1%利凡諾爾溶液、3%硼酸溶液及糖皮質激素軟膏。考慮病人的內科病情況

結合本病的需要，予以口服糖皮質激素（強的松

15mg/day）、抗組織胺藥（Cetirizine 10mg/day & Telfast 120mg/day）。治療一週後效果明顯，水疱無新出及自身症狀明顯改善無癢及痛感。

討論

大疱性類天疱瘡是歐洲國家最常見的自身免疫性

大疱病。法國及德國的調查表明，其估計的發病率為

0.6 ~ 0.7/10 萬，然而在遠東地區除印度和中國外本病非常少見，印度發病率為 0.5/10 萬，中國為0.04/10 萬。本病可發生於任何年齡，多累及 50 歲以上的中老年人，男女發病性別比大致相等，女性稍多

於男性[1]。本病的發病原因尚未清楚，大量的研究証實抗基

底膜帶抗體、補體系統、周圍血細胞和真皮的肥大細

胞以及它們之間的相互作用和激發引起表皮、真皮分

離的機制尚不清楚[1-4]。皮損成批發生或此起彼伏，好發於軀幹、四肢伸

側、腋窩和腹股溝。約 10~35%患者累及口腔黏膜，出現水疱或糜爛但不嚴重。皮疹特點為在正常的皮膚

或水腫性紅斑的基礎上發生漿液性水疱、大疱。疱壁

緊張，有時有血疱。因水疱發生在表皮下，故疱壁

厚，因無棘層鬆解，水疱不易破裂，尼氏征陰性。有

時推壓水疱，可見疱壁移位，而這可能是表皮與真皮

分離的結果，并不是真正的棘層細胞鬆解[2-4]。大疱性類天疱瘡通常是一種自限性疾病，一般持

續幾個月到數年，大多數患者在隨後的 3~6 年中無需接受更多的治療病情即可減退。Savin 發現大疱性類天疱瘡的死亡危險性隨發病年齡的提前而增加，通

常在開始接受治療的 12 週以內死亡，本病直接導致死亡的少見[1]。

而與本病臨床表現極為相似的天疱瘡是一類嚴重

疾病，它也是大疱性自身免疫性皮膚病。其水疱的特

徵是由於表皮間細胞連接障礙和棘層鬆解所致的表皮

內大疱。在未應用類固醇激素治療以前該病的病死率

高達 60~80%，在 Lever 的專題報告中指出，天疱瘡發病後的 12 個月內死亡率高達 50%。皮質類固醇的應用大大改善了該病的預後，病死率平均為 10 ~ 25%，大多數病人死於治療中出現的并發症。該病的覆發一般在患病後 3年左右，致殘率較高[1]。

故此凡臨床表現為不明原因的水疱或大疱的皮膚

病，須作尼氏徵檢查及組織病理和免疫病理檢查，以

排除預後較差死亡高的天疱瘡，對疾病的預後作出評

估及為臨床用藥治療作出指導。

參考文獻

1 葉冬青, 主編. 皮膚病流行病學. 第 1 版. 北京:人民衛生出版社, 2001. 380-387.

2 王椿森, 李家文, 黃長征, 等主編. 皮膚性病免疫學. 第 1版. 武漢:湖南科技出版社, 1999. 270-271.

3 張學軍, 主編. 皮膚性病學. 第 6 版. 北京:人民衛生出版社, 2005. 150-155.

4 Thomas P. Habif. Clinical Dermatology: a Color Guide to Diagnosis and Therapy. 4th ed. Winsland House: Elsevier. 2008. 567-570.

圖 1 大疱性類天疱瘡病人踝關節水疱

圖 2 大疱性類天疱瘡病人腕關節水疱

圖 3 大疱性類天疱瘡低倍鏡下見皮下水疱

圖 4 大疱性類天疱瘡高倍鏡病理表現


138

‧病例報告‧

消化道異物致慢性腸穿孔的 CT 診斷 1 例譚文斌謝學斌

【摘要】對一例消化道異物致慢性腸穿孔病例進行研究並結合文獻復習，瞭解多層螺旋 CT 診

斷消化道異物併發腸穿孔的意義，為臨床提供一項有價值的急腹症鑒別診斷方法。【關鍵詞】消化道異物; 腸穿孔; 電腦斷層掃描

CT Diagnosis of Enterobrosis Caused by A Swallowed Foreign Bodies in Digestive Tract: A Case Report TAN Wen-bin, XIE Xue-bin. Imaging Centre,, Kiang Wu Hospital, Macao SAR, PR China; Tel: (+853) 8295 0395; E-mail: [email protected] or [email protected] 【Abstract】 Combine review literature with investigation on a case of chronic enterobrosis caused by

foreign matter in the digestive tract, since then find out the significance of multi slice CT diagnosis in enterobrosis complicated by foreign matter in the digestive tract, so as to provide a valuable differential clinical diagnosis for acute abdominal pains. 【Key words】 Foreign bodies in digestive tract; Enterobrosis; Computed tomography

患者，男性，69 歲，因左下腹痛 2 天入院，活動時加劇，無吐瀉，無發熱。查體：左下腹固定壓痛明

顯，無反跳痛，未捫及包塊，腸音鳴活躍。實驗室檢

查：WBC19.8X109， NEU0.93%↑， LMY0.035%↓，餘無異常。

1 CT掃描 (1) 左下腹降結腸與乙狀結腸交界處病變區管腔內見一短條狀較高密度影，長約 2.2cm，似貫穿腸管內外，CT值 76Hu，平掃及增強各期均可見，形態和密度均無變化，擬消化道異物（圖 1-2）；(2) 左下腹降結腸與乙狀結腸交接部腸管周圍脂肪間隙結構模

糊，局部見少量滲出灶，局部腹腔腸管外見一小局限

性積氣影，擬腸管穿孔致左下腹腔局限少量積氣並周

圍反應性炎症滲出（圖 3-4）。

2 手術所見在 GA 麻下行剖腹探查，乙狀結腸異物取出、結腸雙腔造瘻術，術中見乙狀結腸與降結腸局部與側

腹壁粘連，於乙狀結腸與降結腸交界處見一長約 3cm尖刺樣異物於由腸腔內向腸腔外刺出，其周圍可見膿

苔及少量膿液，其周圍腸漿膜及腸脂垂水腫明顯，局

作者單位：中國, 澳門特別行政區, 澳門鏡湖醫院, 影像中心; Tel : Tel: (+853) 8295 0395; E-mail: [email protected] or [email protected]

部腸脂垂相互粘連，予以異物取出。 3 病理送檢組織局部可見炎症細胞浸潤伴異物肉芽腫

反應，部分脂肪可見壞死伴泡沫組織細胞及炎症細胞

浸潤，局灶見纖維組織增生伴瘢痕形成。

討論

消化道異物形成慢性腸穿孔，在臨床上幷不多

見，消化道異物穿孔的發生率小於1% ，通常是由直徑大於6.5cm或尖銳的異物引起 [1]。分析其形成原

因：異物細長、尖銳，在腸管蠕動下，易嵌於某處，

刺破腸壁，局部炎症包裹及反復刺激腸壁導致腸穿

孔，穿孔前反復受刺激的腸管與周圍組織已粘連，並

產生慢性炎症[2]。消化道穿孔的臨床表現主要是腹膜炎，根據病程

和部位將其分為急性和慢性腹膜炎，廣泛型和局限型

腹膜炎，腹壁腫物和腹腔包塊及腹壁和腹腔膿腫。由

於腸道缺乏確定的體表標誌，因此體格檢查不能確定

穿孔部位和異物位置。據統計：71%的消化道異物穿孔發生於腹膜腔內，其中95%的患者有症狀，病程1～120 天不等，平均2 天，70%的患者就診時有白細胞升高，39%表現為局限性腹膜炎，被診斷為急性闌尾炎和憩室炎[3]。


139

消化道異物一般損傷相對狹窄的咽部、食管及賁

門。鋒利或堅硬異物通過幽門後，約有25% 的穿孔率，多位於回盲瓣處。引起結腸穿孔者較少見[4]。

本病例位於降結腸和乙狀結腸交界處並發穿孔則更少

見。影像檢查：X線平片檢查能發現消化道金屬異

物，非金屬異物的陽性率很低。而CT掃描優於普通x線檢查並彌補其不足，主要表現在：(1) 因CT密度解析度高，可顯示普通x線檢查難以發現的異物，有利於早期診斷。(2) CT掃描能夠準確顯示異物和併發症的形態、大小、位置，範圍及對鄰近結構的影響等細

節。(3) 消化道穿孔對腹腔內游離氣體檢查，CT 比X光攝片優越，即使有微量的游離氣體，CT也能檢出。

特別是螺旋CT 軸位無間隔薄層掃描，多平面

冠矢狀重建進行三維定位，在準確定位方面有其明顯

的優越性，為目前對消化道異物進行定位診斷最理想

的方法。本院16層螺旋CT充分發揮了在消化道異物致穿孔診斷的價值。

消化道異物穿孔有多種臨床表現，需與其他原因

導致的急腹症、感染性腸疾病等鑒別，吞食異物病史

很重要，可以幫助診斷；但對病史不明確的患者，術

前診斷往往較困難，CT檢查具有重要的意義，以免漏診或誤診。

參考文獻 1 Halverson JM, Butterman MK, Legier JF, et a1.

Perforation of a Meckel’s diverticulum caused by ingestion of a coin. South Med J, 1994, 87:823-824.

2 張燦剛. 消化道異物致慢性腸穿孔2例. 中國煤炭工業醫學雜誌, 2006, 9:1090.

3 Goh BK, Chow PK, Quah HM, et al. Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg, 2006, 30:372-377.

4 Lawercnce WW, 主編. 紀守正, 譯. 現代外科疾病診斷與治療. 第 10版. 北京:人民衛生出版社, 1998. 442.

圖 1 箭頭所指為消化道異物影，由

腸腔內向腸腔外貫穿腸壁。

圖 2 箭頭所指為腹腔內局限積氣。

圖 3 增強掃描見異物貫穿腸壁，局部滲出伴局限性腹腔積氣。

圖 4 增強掃描薄層顯示異物與腸壁周圍脂肪間隙結構模糊。


140

‧醫學文摘‧

復發性病毒性腦炎的臨床特點和發病機制探討黃顔, 利秀琴, 楊萌昌, 等

【摘要】目的探討復發性病毒性腦炎的診斷和

復發機制。方法回顧分析 150 例病毒性腦炎患

者，其中 5例爲復發性病毒性腦炎，還有 1例來自屍

檢病例。其中 5 例臨床高度懷疑爲單純皰疹性腦炎，

並且其中 2 例得到病理結果的證實。結果 6 例

患者在症狀緩解後 1 個月至 2 年 2 個月,再次出現神

經系統損害的表現，症狀加重。並且 6例患者中 5例

復發時，MRI 或 CT 出現以額、顳灰質損害爲主的新

病灶；除 1例患者死亡，其餘 5例患者重新給予阿昔

洛韋抗病毒治療後，病情均明顯好轉；例 3 腦組織

HSV 免疫組化染色陽性，例 6 屍檢腦組織內可見細

胞內包涵體，HSV 免疫組化陽性，提供了病毒感染

的直接病理依據。結論這 6 例復發性病毒性腦炎

復發的機制與病毒活化直接侵犯中樞神經系統有關。

復發的原因仍不是十分清楚，可能與阿昔洛韋劑量不

足或治療不夠充分有關。阿昔洛韋抗病毒治療應遵循

早期、足量、個體化的治療原則 ,將有助於改善預

後。

【關鍵字】腦炎; 單純皰疹; 復發

摘自: 中華醫學雜誌, 2008, 31:2183

Clinical characteristics of relapsing virus encephalitis and mechanisms of relapse HUANG Yan, LIU Xiu-qin, YANG Yin-chang, et al 【Abstract】 Objective To investigate the clinical

characteristics of herpes simplex encephalitis(HSE) and to discuss the mechanism of its relapse. Methods The clinical data of 6 patients with relapsing encephalitis, 4 male and 1 female, aged 14-49, out of 150 encephalitis cases were analyzed; 5 of them were suspected as with HSE clinically, and HSE was confirmed by pathology via biopsy in 2 of the 6 patients. The 5 patients wer followed up for 2-6 years. Results The duration between the onset and relapse was 1-26 months. Brain MRI or CT showed new lesion in the temporal lobe in 5 patients. Necropsy revealed intracellular inclusions, positive in HSV-1 antigen, in the neurons and glial cells of temporal lobe in one case. Second course of acyclovir therapy was effective in 5 of these 6 patients. One patient died 10 months later. Conclusion Direct invasion of activated virus into the central nervous system and insufficiency of acyclovir treatment are the causes of relapse of HSE. Acyclovir treatment should be early, with sufficient amount, and individualized.

【Key words】 Encephalitis; herpes simplex; Recurrence

From: Natl Med J China, 2008, 31:2183


141

‧醫學文摘‧

腦膠質瘤相關新基因 PKIβ的

表達與蛋白質性質的研究祁震宇, 惠國楨, 李瑤, 等

【摘要】目的運用基因晶片技術獲取正常成人

腦組織與人腦膠質瘤中差異表達的基因，並對其中 1

條基因進行了克隆和表達。方法抽提正常成人腦

組織與腦膠質瘤組織中的 mRNA 來製備探針，經雜

交、洗滌後，通過計算機觀察二者表達譜的差異情

況，對 436F11 克隆子進行 Northern 印迹，生物信息

學分析和蛋白質的表達。結果通過 4 次基因芯片

篩選,獲得 15 條與膠質瘤相關的新基因，經 Northern

印迹證實 436F11 基因在人正常腦組織中高表達，而

在人腦膠質瘤中低表達。BLASTn和 BLASTx分析顯

示，436F11 基因爲全長新基因,共編碼 78 個氨基酸,

其理論相對分子質量爲 8468 等電點爲 4.69，與鼠

PKIβ69%同源，命名爲人 PKIβ。並在大腸桿菌中

得到了 PKIβ較高的表達蛋白，經純化，在 SDS-

PAGE 膠上獲得了 1 條清晰的條帶。氨基酸測序和分

子量測定與生物信息學結果完全一致。結論基因

芯片篩選正常腦組織與人腦膠質瘤差異表達的基因具

有樣品用量少，高質量，高速度，高敏感等特性。人

PKIβ可能是與人腦膠質瘤形成有關的 1 條全長新基

因，這爲腦膠質瘤的基因治療提供了一條新思路。

【關鍵字】 cDNA; 矩陣; 神經膠質瘤;

基因表達

摘自：中華醫學雜誌, 2008, 25:1178

Expression and characterizations of novel full-length gene PKIβ related to human glioma QI Zhen-yu, HUI Guo-zhen, LI Yao, et al 【Abstract】 Objective To obtain differentially

expressed genes related to human glioma using cDNA microarray and to characterization of one novel full-length gene. Methods Four samples of human glioma samples, 1 fetal brain tissue sample, and 2 normal brain tissue samples were used to extract the total RNA, and the mRNA was used to make probes. After hybridization and washing procedure, the products of hybridization were scanned using computer system. One gene, named 436F11 clone, was subsequently analyzed by Northern blotting, bioinformatics, and protein expression. Results Fifteen differentially expressed new genes related to human glioma were obtained through four times of hybridization and scanning. Northern blotting confirmed that over-expression of 436F11 gene in the normal human brain tissue and low-expression in the human glioma tissues. The analysis of BLASTn and BLASTx showed that the clone of 436F11 was a novel full-length gene coding 78 amino acids of protein with a theoretical relative molecular weight of 8648 and an isoelectric point of 4.69 and that it was 60% identical to mouse PKIβ amino acid, so it was called human PKIβ gene. After it was transfected into Escherichia. coli, higher-expressed protein of PKIβ was obtained which yielded a major clear band on an SDS-PAGE gel after purification. The products obtained from amino acid sequencing and molecular weight detection were exactly the same as the products performed by bioinformatic analysis. Conclusion cDNA microarray technology can be successfully applied to identify differentially expressed genes. PKIβ may be a novel full-length gene related to human glioma and may provide a new way to gene therapy of glioma. 【Key words】 cDNA; Malrix; Glioma; Gene

expression

From: Natl Med J China, 2008, 25:1178


142

‧醫學文摘‧

鼻咽癌放療後張口困難的防治趙靜, 劉剛, 寧博, 等

【摘要】目的探討木塞支撐加張口鍛煉預防鼻

咽癌患者放療後張口困難的作用。方法 83 例經

病理確診爲鼻咽癌的初治患者隨機分爲研究組和對照

組，研究組 42 例，放療開始即在醫護人員的指導下

進行木塞支撐加有一定強度的張口功能鍛煉；對照組

41 例沒有規定張口強度，僅行一般張口功能鍛煉。

在放療前、放療結束後 1 個月和以後的每 3—6 個月

對兩組患者分別觀察門齒距的變化。結果研究組

放療後張口縮小的程度明顯低於對照組，分別爲

(0.47±0.94)cm、 (1.16±0.83)cm， (P<0.01)。結論

在鼻咽癌患者接受放射治療的同時，行木塞支撐加張

口功能鍛煉能有效預防放療所致的張口困難。

【關鍵字】鼻咽癌 ; 放射治療 ; 張口困難 ;

功能鍛煉

摘自：現代腫瘤醫學, 2009, 5:832

Prevention of trismus in nasopharygeal carcinoma patients treated by radiotherapy ZHAO Jing, LIU Gang, NIN Bo, et al 【Abstract】 Objective To analyze the role of

wood-stopper to prop add the mouth open training for prevention of trismus in nasopharyngeal carcinoma patients treated by radiotherapy. Methods All 83 patients with pathologically proven nasopharyngeal carcinoma were randomly divided into two groups: research group and control group. 42 patients in research group acceped Wood-stopper to prop and the mouth open functional exercises, 41 patients in control group only aeeeped ordinary exercises of opening mouth. Before radiotherapy and 1 month after treatment and each 3-6 months thereafter observe the variety of fore-tooth distance. Results The reduction of the distance between the incisors were(0.47±0.94cm) in the training group and (1.16±0.83cm) in control group (P<0.01). Conclusion Wood-stopper to prop add good functional mouth open training is able to lower the incidenee of trismus in NPC patients treated with radiotherapy, good guidance and supervision is necessary. 【 Key words 】 Nasopharyngeal neoplasms;

radiotherapy; Trismus; Function training

From: Modern Oncology 2009, 05:832


143

‧醫學文摘‧

絲裂原活化蛋白激酶信號通路相關基因在人骨肉瘤中的表達李國東, 蔡鄭東, 張寅權, 等

【摘要】目的探討絲裂原活化蛋白激酶

(MAPK)信號通路相關基因在人骨肉瘤發病過程中的

作用。方法應用 Affymetrix 的 Human Genome

U133A 芯片檢測骨肉瘤細胞與成骨細胞間 MAPK 信

號通路相關基因表達譜的變化，然後利用 MATLAB

軟件對芯片檢測到的差異表達明顯的基因進行 KEGG

通路分析。採用免疫組織化學技術檢測 48 例骨肉瘤

和 24 例成骨性良性腫瘤組織中 ERK1／2、JNK 和

p38 蛋白的表達。結果以表達差異≥2 倍爲限，骨

肉瘤細胞株MG-63、Saos-2和 U-2 OS中，共篩選出

18 個與成骨細胞株 hFOB 1.19 中存在差異表達的

MAPK 信號通路相關基因，其中 10 個爲上調基因，

8 個爲下調基因。18 個差異表達的基因在 KEGG 的

MAPK 信號通路上均爲重要的節點基因。免疫組織

化學染色結果顯示，ERK1／2、JNK 和 p38 蛋白在

骨肉瘤組織中的陽性表達率分別爲 83.3％(40／48)、

72.9％(35／48)和 85.4％(41／48)，在成骨性良性腫

瘤組織中的陽性表達率分別爲 12.5％(3／24)、8.3％

(2／24)和 16.7％(4／24)，差異均有統計學意義(均

P<0.01)。結論 MAPK 信號通路在骨肉瘤的發生中

發揮著重要作用，其中 ERK1／2、JNK 和 p38 三條

通路通過相互協調形成複雜的調節網路，參與調節骨

肉瘤細胞的增殖、分化和凋亡，以及骨肉瘤細胞的侵

襲和轉移。

【關鍵字】骨肉瘤； MAPK 信號通路；

基因芯片

摘自: 中華腫瘤雜誌, 2009, 5:340.

Gene profiling of MAPK pathway in human osteosarcoma LI Guo-dong, CAI Zheng-dong, ZHANG Yin-quan, et al 【Abstract】 Objective To explore the functional

effetcs of MAPK pathway in the pathogenesis of human osteosarcoma. Methods Gene microarray (Human Genome U133A, Affymetrix®) was used to screen the differential expression of genes involved in MAPK pathway between osteosarcoma cell lines and 3 osteoblastie cell lines. KEGG metabolic pathway analysis was performed among significantly increased or decreased genes using the MATIAB software. Immunohistochemical technique was used to detect the expressions of ERK1/2, JNK and p38 proteins among 48 osteosartoma and benign 24 osteoblastic tumor samples. Results Using an entrance limit of ≥2.0, 18 differentially expressed MAPK pathway-related genes were selected ( 10 up-regulated, 8 down-regulated) to mapped to the MAPK pathway of KEGG which are all important node genes. The positive rates of ERK1/2, JNK and p38 proteins were 83.3% (40/48), 72.9% (35/48) and 85.4% (41/48) in osteosarcomas,and 12.5% (3/24) ,8.3% (2/24) and 16.7% (4/24) in the control group, respectively. The positive rates and expression intensities were statistically different between the 2 groups (P < 0.01 ). Conclusion MAPK pathway plays an important role in the pathogenesis of osteosarcoma. ERK, JNK and p38 form an intercoordinating network and regulate the cell proliferation, differentiation, apoptosis, invasion and migration in osteosareoma. 【Key words】Osteosarcoma; MAPK pathway;

Gene chip

From: Chin J Oncol, 2009, 5:340.


144

‧醫學文摘‧

80 例急性髓性白血病 M2 型患者 JAK2V617F 基因突變的檢測及臨床意義沈益民, 晁紅穎, 張日, 等

【摘要】目的探討 JAK2V617F 基因突變在急性髓性白血病 M2 型(AML-M2)患者中的發生率和臨床預後意義。方法採用等位基因特異性聚合酶

鏈反應(AS-PCR)技術，檢測 80 例 AML-M2 患片的JAK2V617F 基因突變情況。結果 80 例 AML-M2患者中，初診時 JAK2V617F 基因突變 6 例，復發時JAK2V617F 基因突變 1 例，JAK2V617F 基因的突變率爲 8.8%。7 例 JAK2V617F 基因突變者的血象和骨髓象均呈現出白血病改變特徵，而無骨髓增殖性疾病

(MPD)徵象；免疫分型顯示爲髓系表達。接受治療的

5例 JAK2V617F基因突變者中，有 4例患者在治療後達到完全緩解，1 例未緩解；除 1 例失訪外，其餘 4 例患者的中位生存期爲 18.5 個月。結論 JAK2V617F 基因突變作爲 AML 發病機制中的 I 類突變，可能並不是 AML 發病的初始事件；初診 AML 患者出現JAK2V617F基因突變也並不意味著疾病預後較差。

【關鍵詞】白血病; 髓性; JAK2V617F 基因; 突變

摘自: 中華腫瘤雜誌, 2009, 5:366.

Detection of JAK2V617F mutation and its clinical significance in 80 patients with M2 acute SHEN Yi-min, CHAO Hong-ying, ZhANG Ri, et al 【Abstract】 Objective To explore the prevalence

and prognostic significance of JAK2V617F gene mutation in acute myelogenous leukemia M2 (AML-M2) patients. Methods Allele specific polymerase chain reaction (PCR) was used to detect JAK2 gene mutation. Results Of 80 de novo AML-M2 patients, 6 at the time of first diagnosis and 1 at relapse were found to have JAK2V617F gene mutation (8.8%, 7/80). Morphologically, the whole blood and bone marrow of the 7 AML-M2 patients with JAK2V617F gene nutation presented a picture of acute leukemia instead of myeloproliferative disorders. Immunophenotypically, bone marrow samples showed myelogenous linage expression. Complete remission was obtained in 4 of 5 AML-M2 patients with JAK2V617F mutation who received treatment, while one patient had no response to the treatment. Follow-up was performed in all the 5 patients, with a median survival of 18.5 months in 4 patients. Conclusion JAK2V617F gene mutation, as a type-1 mutation, might not be an initial event in the pathogenesis of acute myelogenous leukemia, and its presenlation does not mean a poor prognosis in de novo AML patients. 【Key words】 Leukemia, myeloid; JAK2V6t7F gene;

Mutation

From: Chin J oncol, 2009,5:366


145

‧醫學文摘‧

膀胱非上皮性腫瘤的影像学表现张连宇, 戴景蕊【摘要】目的探討膀胱非上皮性腫瘤的影像學

表現特點，提高術前診斷的準確率。方法回顧性

分析 20 例經手術病理證實爲膀胱非上皮性腫瘤患者

的臨床病理和影像學檢查資料，其中平滑肌瘤 9例，

嗜鉻細胞瘤 6例，平滑肌肉瘤 2例，橫紋肌肉瘤、癌

肉瘤及炎性肌纖維母細胞瘤各 1例。結果平滑肌

瘤呈圓形，邊緣清晰、銳利，密度均勻；MRI 的

T1WI 及 T2WI 序列均呈低信號；7 例患者行 CT 增

強掃描，有 6 例表現爲輕度強化；4 例患者行彩色多

普勒超聲檢查，有 3例顯示爲血流不豐富或有少許血

流。嗜鉻細胞瘤呈圓形或卵圓形，有時略有分葉，邊

緣清楚，密度均勻，I 例伴有鈣化；MRI 的 TIWI 序

列呈低信號、T2WI 序列呈明顯高信號；6 例患者行

CT 增強掃描，有 4 例呈高度強化；5 例患者行彩色

多普勒超聲檢查，有 3例顯示爲血流豐富。炎性肌纖

維母細胞瘤的影像學表現同嗜鉻細胞瘤。其他惡性腫

瘤呈不規則實性腫塊，邊緣模糊，密度不均勻；CT

增強掃描呈不均勻中等強化。結論膀胱平滑肌瘤

及嗜鉻細胞瘤的影像學表現有一定特點，再結合臨床

症狀，術前能夠作出正確診斷；其他惡性腫瘤的影像

學表現無特徵，僅能作出定性診斷。影像學檢查是膀

胱非上皮性腫瘤有價值的檢察方法，術前可提供腫瘤

部位及部分腫瘤性質的信息，有助於臨床制定治療計

劃。

【關鍵詞】膀胱腫瘤; 非上皮性腫瘤; 體層

攝影術; 磁共振成像; 超聲成像

摘自: 中華腫瘤雜誌, 2009, 5:384

Imaging features of nonepithelial tumors of the bladder ZHANG Lian-yu, DAI Jing-rui 【Abstract】 Objective To summarize the imaging features of nonepithelial tumors of the bladder. Methods The Imaging findings in 20 surgically treated patients with pathologically proved nonepithelial tumors of the bladder were retrospectively analyzed, The ttmlors included leiomyoma (n =9), pheochromocytoma(n=6) , leiomyosarcoma( n = 2 ), rhahdomyosarcoma ( n = 1 ), carcinosarcoma (n = 1 ), inflamatory myofibrublastoma (n = 1 ). Results The leiomyomas were round or ellipse in shape with a sharp border and homogeneous density, and showed a low signal intensity on T1WI and T2WI in 1/1 case; slight enhancement on CT after contrast enhancement in 6/7 cases; and a poor blood supply on color Doppler ultrasonography in 3/4 cases. The pheochromocytoma had a round or oval shape and clear border, and slightly Iobulated in 4/6 cases, homogeneous density/echo/signal in 5/6 cases, calcification in 1 case, low signal intensity on T1WI and high signal intensity on T2WI in 1/1 ease, moderate or marked enhancement on CT and MRI in 4/5 cases, and strong blood supply on color Doppler ultrasonography in 3/4 cases. The inflammatory myofibroblastoma showed the same imaging features as the pheochromoctomas. Other malignant tumors showed an irregular configuration, with a poorly defined border, heterogeneous density/echo/signal and moderate to strong enhancement on CT. Conclusion Most leiomyomas and pheochromocytomas of the bladder show some typical imaging features on CT, MRI and ultrasound, which are helpful in making correct diagnosis and treatment plan preoperatively. Other malignant nonepithelial bladder tumors do not show special imaging characteristics and can only be diagnozed qualitatively. 【Key words】 Bladder neoplasms; Nonepithelial

tumor; Tomography; Magnetic resonance imaging; Ultrasonic imaging

From: Chin J Oncol, 2009, 5:384.


146

‧醫學文摘‧

小胰腺癌的診斷和預後張建偉, 孫躍民, 邊志民, 等【摘要】目的探討小胰腺癌的臨床特點、診

斷方法和預後影響因素。方法回顧性分析接受手

術治療且隨訪資料完整的 89 例胰腺癌患者的臨床病

理資料，其中直徑≤2cm 的胰腺癌(14 例)爲小胰腺癌

組，直徑>2 cm的胰腺痛(75例)爲對照組，總結小胰

腺癌的診斷和預後特點。結果 CT和 MRI檢查對

小胰腺癌的檢出率分別爲 66.7%(8／12)和 77.8%(7／

9)。小胰腺癌組有 2 例腫瘤侵犯胰腺被膜，3 例出現

腹膜後侵犯，3 例出現淋巴結轉移。小胰腺癌組患者

的 3、5年生存率分別爲 42.8%和 3l.7%，中位生存時

間爲 56.5 個月。對照組患者的 3、5 年生存率分別爲

29.7%和 22.5%，中位生存時間爲 22.5 個月。對全組

89 例胰腺癌患者的預後因素進行 Cox 回歸分析的結

果顯示，胰腺被膜侵犯、淋巴結轉移和腹膜後侵犯是

影響預後的獨立危險因素(均 P<0.05)，而腫瘤大小不

是影響患者預後的獨立因素(P>0.05)。結論小胰

腺癌患者的總體預後較好，CT和 MRI檢查是診斷小

胰腺癌的主要手段，淋巴結轉移和局部侵犯是小胰腺

癌預後不良的標誌。對於小胰腺癌患者，爲獲得良好

的預後應採取積極的根治性手術。

【關鍵字】胰腺腫瘤; 診斷; 預後

摘自: 中華腫瘤雜誌, 2009, 5:375.

Small pancreatic cancer diagnosis and prognosis ZHANG Jian-wei, SUN Yue-min, BIAN Zhi-min, et al 【 Abstract 】 Objective To investigate the

clinicopathological characteristics, diagnostic methods and prognosis of small pancreatic cancer. Methods From May 2000 to January 2007, 89 patients with pancreatic cancer underwent surgery in our hospital. Of those, 14 had a tumor ≤2 cm in diameter (small tumor group). and the other 75 had a tumor >2 cm in diameter (controlled group). The clinicopathological data of all the cases were retrospectively reviewed and analyzed. Results In the small pancreatic cancer group, CT and MRI detected 66.7% (8/12) and 77.8% (7/9) of the tumors, respectively. Serosal infiltration was found in 2 cases, lymph node involvement in 3 cases, and retrolperitoneal infiltration in 3 cases. The follow-up duration of this group was 4~86 months. The overall 3- and 5-year survival rates were 42.8% and 31.7% , while in the control group, the overall 3- and 5-year survival rates were 29.7% and 22.5% respectively. The multivariate analysis showed that the lymph node involvement, serosal infiltration and retroperitoneal infiltration were independent risk factors (P<0.05). However, the tumor size was not shown to be an independent risk faclor ( OR value=1.45, P=0.971 ). Conclusion CT and MRI are valuable in detecting small pancreatic cancer. Small pancreatic cancers are likely to have a better prognosis when compared with larger ones. Lymph node metastasis and local infiltration are independent predictors of prognosis but not tumor size. 【Key words】 Pancreatic neoplasms; Diagnosis;

Prognosis

From: Chin J Oncol, 2009, 5:375


147

‧醫學文摘‧

同步放化療治療老年局部晚期非小細胞肺癌的臨床研究郝代鈞, 樊建淑

【摘要】目的探討長春瑞濱、吉西他濱分別聯

合三維適形放療治療老年局部晚期非小細胞肺癌

(NSCLC)的療效和毒性反應。方法 81 例患者分

爲兩組，長春瑞濱組：三維適形放療同步化療，長春

瑞濱 25mo／m2，靜滴，第 1、8 天。吉西他濱組：

三維適形放療同步化療，吉西他濱 1 000mg／m2，靜

滴第 1、8天。均 21 天爲 l 周期。兩組均治療 2-4 周

期。結果長春瑞濱組 CR 率 17.5%，PR 率

50.0%，總有效率(CR+PR)爲 67.5%；吉西他濱組 CR

率 19.5%， PR 率 46.3%，總有效率 (CR+PR) 爲

65.8%，兩組差異無顯著性(P>0.05)。長春瑞濱組和

吉西他濱組的 1、2年生存率分別爲 69.3%、36.4%和

68.7%和 18.6%，中位生存時間分別爲 17個月和 16.2

個月，差異無顯著性(P>0.05)。長春瑞濱 3~4 級血液

毒性高於吉西他濱組(P<0.05)。結論長春瑞濱或

吉西他濱聯合三維適形放療同步治療老年局部晚期

NSCLC安全、有效。

【關鍵詞】非小細胞肺癌；老年；長春瑞

濱；吉西他濱；三維適形放療；同步放化療

摘自: 臨床腫瘤學雜誌, 2009, 4：347.

Analysis of effect of concurrent chemoradiotherapy on elderly patients with locally advanced non-small cell lung cancer HAO Dai-jun, FAN Jian-shu 【Abstract】 Objective To evaluate the efficacy

and toxicity of vinorelbine, gemcitabine and concurrent 3-dimensional conformal radiotherapy on elderly patients with locally advanced non-small cell lung cancer. Methods Eighty-one patients were divided into the following groups: group A was given to 3-dimensional conformal radioltherapy and concurrent chemotherapy ( vinorelbine 25mg/m2 on day 1, 8 of 21-day cycle, each patient should complete at least 2 cycles); group B was given to 3-dimensional conformal radiotherapy and concurrent chemotherapy (gemcitabine 1 000mg/m2 on day 1, 8 of 21-day cycle, each patient should complete at least 2 cycles). Results The overall response rate was 67.5% in group A and was 65.8% in group B, respectively (P > 0.05). The survival rate was 69.3% at 1 year, 36.4% at 2 year, the medion survival was 17 months for group A and compared with 68.79%, l8.6%, 16.2 months for group B, respectively(P>0.05 ). The rate grade 3-4 myelsuppression in group A was higher than in group B (P=0.002). Conclusion Vinorelbine, gemcitabine and concurrent 3-dimensional conformal radiotherapy on elderly patients with locally advanced nonsmall cell lung cancer is a well-tolerated regimen in acceptable toxicity and will be an optimal therapy more effective treatment. Schems are reqired to improve disease control and overall survival. 【Key Words】 Non-small cell lung cancer;

Elderly; Vinorelbine; Gemcitabine; 3-dimensional conformal radiotherapy; Concurrent chemoradiotherapy

From: Chinese Clinical Oncology, 2009, 4:347


148

‧信息和動態‧

甲型流感病毒 H1N1 亞型甲型流感病毒 H1N1 亞型（記作 A(H1N1)或

H1N1），也稱 H1N1 病毒，是甲型流感病毒的一種，也是人類最常感染的流感病毒之一。一些 H1N1的種類可以在人類間傳播，包括 1918 年的流感大爆發，另一些可在雀鳥和豬隻間傳播。

這種病毒的遺傳組成存在爭議。根據它的血凝素

蛋白和神經氨酸酶的類型，科學家同意這是一種

H1N1 病毒。它是由人、豬和禽流感的遺傳物質組成，而世界衛生組織認為它主要是由豬流感的基因組

成的[1]。 H1N1 新型流感（豬流感）原是一種於豬隻中感

染的疾病，屬於甲型流感病毒。美國疾管局資料顯

示，美國以前即曾有人類感染豬流感之病例。目前墨

西哥與美國爆發的豬流感疫情，即為 H1N1病毒所引起，但目前對此種結合豬流感、人類流感的新病毒的

流行病學了解很少[1]。 2009 年 3 至 4 月，墨西哥爆發 H1N1 疫潮，導

致過百人感染。疫情其後傳播到全世界。2009 年 4月 30 日凌晨，世界衛生組織把全球流感大流行警告級別提高到第 5級。

名稱

甲型 H1N1 流感於 2009 年爆發時，最初世界衛生組織使用了「豬流感」（swine flu）的名稱，當初獲得大部份國家跟隨，除了以色列因為猶太教禁食豬

肉而使用「墨西哥流感」。另還有豬源流感[2]、人類

豬（型）流感 [3] 、墨西哥流感 [4]、北美流感 [5][6]、

H1N1新型流感[7]、新流感、以及 2009年 H1N1流感[4]

等各種不一致的稱呼。然而，沒證據顯示墨西哥是疫

症源頭，有關做法純粹出於政治、宗教考慮。後來美

國豬農抗議「豬流感」名稱使人誤會病毒經豬隻傳

播，要求改稱為「北美流感」，歐盟隨即改稱病毒為

「新流感」。

2009 年 4 月 30 日，由於農業界及聯合國糧農組織的關切，世界衛生組織為免對因豬流感一詞造成流

感能經由進食豬肉製品傳播的誤解，當日開始改用甲

型 H1N1 流感稱呼該病毒。[8][9][10]。香港初時稱俗稱

「豬流感」，其後跟隨改稱「甲型 H1N1流感」，官方亦開始以「人類豬（型）流感」向外界通報。美國疾

控中心則稱之為新型甲型 H1N1 流感(novel Influenza A(H1N1))[11]。而香港大學微生物學系教授袁國勇表示，世衛將新型流感改名為甲型 H1N1流感會令人分辨不到新型流感和季節性流感的分別。[12]

2009 年爆發

2009 年 3 月至 4 月，墨西哥和美國西南部有過

千人感染甲型 H1N1流感，導致 106人死亡[13]。 2009 年 4 月 23 日晚上 11 時，甲型 H1N1 流感

的爆發首次在墨西哥得到廣泛報道。4 月 24 日墨西哥當局在 60 多個死者中，16 名的死因確定是新品種的甲型 H1N1 流感的感染，其餘 44 名的死因仍檢測中。[14]當中大部分死者都是年輕的成年人。[15]

4 月 24 日，世界衛生組織確認部分發病個案是

由一種從未發現的 H1N1變種病毒所引致。[16][17]

4 月 25 日，墨西哥城市長宣布所有公眾活動暫

停 10 日，所有學校均需要停課，並且呼籲所有市民避免握手和親吻。 [18]墨西哥衛生部長艾修德

（Armando Ahued）表示墨西哥城將準備一場大規模緊急接種運動來防治常見於冬天的甲型 H1N1 流感。[19]

世界衛生組織(WHO,又稱世衛組織)的緊急委員會在日內瓦召開會議，鑒於墨西哥疫情向全球發出全球緊

急狀態。[20]而日本方面，成田機場已經為來自墨西

哥的入境旅客測量體溫。[21]

4月 28日，H1N1流感更肆虐亞太區，韓國和泰

國宣佈有疑似個案，中國陝西省也一度傳出 H1N1甲


149

型流感驚魂。[22]世界衛生組織把疫情警告提升至第 4級，表示病毒是人傳人，也意味著至少從一個國家爆

發。[23]

4 月 29 日，在美國發現首宗在境內人傳人的個

案，並且在同一天發現第一宗死亡個案。同日晚，世

界衛生組織將全球流感大流行警告級別從 4級提高到5級。

因為世界衛生組織為免誤導，所以將正在擴散的

流感名稱從「豬流感」改稱為甲型 H1N1流感。

5 月 1 日，香港確診第一宗甲型 H1N1 流感個案，成為亞洲地區第一宗個案。

5月 11日，中國四川發現內地第一例甲型 H1N1

流感病例，該病例在被發現前曾在北京逗留九小時，

接觸一百餘人，回到四川後就醫確診。因該病例病人

涉嫌隱瞞病情，專家稱可能會承擔法律責任[24]。 5 月 13 日，香港確診第二宗甲型 H1N1 流感個

案，患者是由美國返港的本地男子。 5月 13日，中國山東發現內地第二例甲型 H1N1

流感病例，患者是由加拿大到中國，途徑北京逗留近

78小時，後乘火車返回山東。 5 月 15 日，馬來西亞發現第一宗確診為甲型

H1N1流感病例，患者是於 5月 13日，早上 7時 15分乘搭馬航 MH091 班機從美國新澤西州的紐瓦克飛抵吉隆坡國際機場後，於周四出現發燒、喉嚨痛及身

體不適症狀後入住雙溪毛糯醫院。 5 月 16 日，中國北京確診一例甲型 H1N1 流感

病例，成為中國內地第三例輸入性確診病例[25]。

5 月 17 日，日本新型流感擴大至 21 人，大阪府出現 9位確診病例。厚生勞動省表示，關西有集體傳染情況出現，下令要求茨木、豐中、吹田 3市，各級學校或安養中心，暫時停課或營業[26]。

5月 18日 12時，廣東報告一例甲型 H1N1流感

疑似病例。19日被確診[27]。

5月 19日，山東患者治愈出院[28]。

5 月 20 日，西藏報告一例輸入性甲型 H1N1 流

感疑似病例[29]。

5 月 20 日，台灣確認第一宗甲型 H1N1 流感確

診個案，疾管局副局長證實該病例為非台灣籍，屬境

外移入個案。

5 月 22 日，香港確診第四宗甲型 H1N1 流感個案，患者是與台灣確診患者由美國飛往本港的澳洲藉

男子，下午，確診第五及第六宗。

5 月 28 日，中國大陸報告首例甲型 H1N1 流感二代病例，為廣東省廣州市 1例輸入性甲型 H1N1流感。

6 月 5 日，WHO 於 6/5 公布全球最新 H1N1 新型流感疫情 Influenza A (H1N1)-Update 4，目前合計21940 例確定病例，其中 125 例死亡。阿根廷 147例、澳洲 876例、奧地利 2例、巴哈馬 1例、巴林 1例、巴巴多斯 1 例、比利時 13 例、玻利維亞 3 例、巴西 28例、保加利亞 1例、加拿大 1,795例（3例死亡）、智利 369 例（1 例死亡）、中國大陸及香港 89例、台灣 16 例、哥倫比亞 24 例、哥斯達黎加 68 例（1 例死亡）、古巴 4 例、塞浦路斯 1 例、捷克 2例、丹麥 4例、多明尼加 33例、厄瓜多爾 43例、埃及 1 例、薩爾瓦多 49 例、愛沙尼亞 3 例、芬蘭 4例、法國 47 例、德國 43 例、希臘 5 例、危地馬拉23例、洪都拉斯 34例、匈牙利 3例、冰島 1例、印度 4例、愛爾蘭 8例、以色列 39例、意大利 38例、牙買加 2 例、日本 410 例、韓國 41 例、科威特 18利、黎巴嫩 3例、盧森堡 1例、馬來西亞 2例、墨西哥 5,563 例（103 例死亡）、荷蘭 4 例、紐西蘭 11例、尼加拉瓜 5例、挪威 9例、巴拿馬 173例、巴拉圭 5例、秘魯 47例、菲律賓 29例、波蘭 4例、葡萄牙 2例、羅馬尼亞 8例、俄羅斯 3例、沙特阿拉伯 1例、新加坡 12 例、斯洛伐克 3 例、西班牙 218 例、瑞典 13例、瑞士 10例、泰國 8例、土耳其 8例、英國 428 例、美國 10,054 例（17 例死亡）、烏拉圭 15例、委內瑞拉 4例、越南 3例[30]。


150

症狀甲型 H1N1流感的患者可能有發高燒（高於攝氏

37.8 度）、頭痛、全身性肌肉痠痛、關節疼痛、明顯疲勞、咳嗽、喉嚨痛、鼻塞等病徵[31]。25%的患者有腹瀉、嘔吐和像痢疾的癥狀[32]。

病毒傳播途徑

甲型 H1N1流感病毒可透過飛沫傳染、接觸傳染。潛伏期：半天到三天，最高可達七天。有效傳染期：發病前一天~發病後第七天。易引發重症對象：20~45歲青壯年人。治療方式：抗病毒藥物特敏福、樂感清，輕症患者可

口服潘生丁（雙嘧達莫）並且可能有一定預防作用

（注：該方法未經過臨床驗證，僅供相關醫務人員參

考）或不必治療即可痊癒。致死率：墨西哥致死率為 6~7%，北美洲則較輕微。預防方法：與一般流感相同，並避免與豬、鳥禽接觸。

研究美國疾病控制與預防中心國家免疫和呼吸系統疾

病中心的主席安·舒查特（Anne Schuchat）博士表示，加州及德州已有 7人確診感染這種奇異而罕見的甲型 H1N1流感[34]。根據這些病例的基因排序，甲型

豬流感病毒由四種不同的流感病毒不尋常地所組成，

分別是北美豬流感病毒、北美禽流感病毒、人類甲型流

感 H1N1亞型病毒和常見於亞洲歐洲的豬流感病毒[35]。

其中兩個病例的基因排序已經完成。現在已經交由美

國科學家準備研究疫苗。博士表示這種變種流感病毒

對金剛烷胺（ amantadine ）和金剛乙胺

（ rimantadine ）呈現抗藥性，而奧司他韋（Oseltamivir）和扎那米韋（Zanamivir）對這種變種流感病毒仍然有效[36][37][38][39]。暫時顯示的基因特徵

是血球凝集素基因（HA）與 1999 年美國豬流感相似，但神經氨酸酶（NA）和基質蛋白（M）基因卻像從歐洲各種豬流感組合出的新品種。病毒外表的基

因從來未曾在人類和豬之間出現傳染，但美國沒有預

警系統來報告什麼病毒在豬隻間傳染[40]。季節性的

H1N1流行性感冒疫苗不大可能為人類提供保護[41]。

美國疾病控制與預防中心並不完全明白為什麼發

生在美國的病例，一般都病情輕微，而墨西哥的則是

十分致命。但是，對於以前全國流行病毒株的研究推

斷不同國家的致命率差異很大，致命病例都集中在發

展中國家[42]。病毒間的差異或者共同感染都可能是

原因。在 14 個從墨西哥獲得的樣本中，經過檢測後，發現其中 7個與美國的變種吻合。看來病毒經過多次感染循環，而在德州與加州的患者間沒有已知的

關連。要防止病毒擴散似乎不大可能[43]。美國領事

報告美國疾控中心的調查小組會在 25 日抵達墨西哥城與墨西哥方面合作研究病毒[44]。

27 日，美國疾控中心署理主席貝瑟博士（Dr.

Richard Besser）表示在 40 宗確診病例中只有一個感染人士住院。他亦發現感染人士年齡最少 7歲，最大54 歲，中位數是 16 歲[45]。直至 4 月 29 日，美國共有 91 確診病例，其中 5 位在醫院接受治療，還有一位死亡[46]。

其實，大部分流感對長者與幼兒影響最大，這個

新病毒卻導致年齡 25 歲至 50 歲的患者死亡[47]。但

是，科學家對於哪個年齡組會受到影響還不能確定[1]。

5 月 14 日，一個植物病毒學家提出甲型 H1N1病毒起源於實驗室，但是隨後被世界衛生組織在一次

新聞發佈會上否定。也有科學家在分析了在網上能免

費獲取的甲型 H1N1流感病毒的遺傳序列之後認為該病毒是人造的。也有認為是自然形成的[32]。

疫苗

隨著甲型 H1N1流感病毒在全球造成的影響，開發一種針對這種流感的疫苗的競賽已經是科學家重點

考慮的事項。雖然有專業人士認為普遍免疫接種稱是

「不可能的」。但是許多國家仍然躍躍欲試，包括了

印度、英國等。雅加達郵報則報道說，來自中爪哇

Airlangga大學的科學家已經開發出了一種疫苗[48]。

資料來源

1. 1.0 1.1 1.2 Katherine Nightingale．豬流感：需要填


151

補的知識空缺 (http://www.scidev.net/zh/news/zh-134040.html?utm_source=lik&utm_medium=rss&utm_campaign=zh_news)，SciDevnet，2009 年 4 月28日。於 2009年 5月 4日查閱。

2. （英文）United States Centers for Disease Control. Morbidity and Mortality Weekly Report: Update: Infections With a Swine-Origin Influenza A (H1N1) Virus－United States and Other Countries, April 28, 2009

(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0428a2.htm)

3. （繁體中文）人類豬型流感 - 政府「流感大流行應變計劃」下的緊急應變級別現正舉動

(http://www.chp.gov.hk/view_content.asp?lang=tc&info_id=16615). 香港特別行政區衛生署衛生防護中心（2009年 5月 2日）。於 2009年 5月 2日查閱。

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6. 新型流感繼續蔓延世界各地 (http://hk.news.yahoo.com/article/090428/4/bwyd.html)明報，2009 年 4 月 28 日。於 2009 年 4 月 28日查閱。

7. 疾管局：叫它新型流感別扯上豬 (http://udn.com/NEWS/NATIONAL/NATS6/4873843.shtml)聯合新聞網，2009年 4月 28日。於 2009年4月 28日查閱。

8. 糧農組織/世衛組織/國際獸疫局關於甲型 H1N1 流感與豬肉安全的聯合聲明

(http://www.who.int/mediacentre/news/statements/2009/h1n1_20090430/zh/index.html)（2009 年 4 月 30日）。於 2009年 5月 1日查閱。

9.（簡体中文）Influenza A(H1N1) ( http://www.who.int/csr/disease/swineflu/zh/index.html)〔A（H1N1）型流感〕。世界衛生組織（2009

年 4月 30日）。於 2009年 5月 1日查閱。 10. 世衛組織宣布不再使用「豬流感」一詞指代當前疫情 (http://news.xinhuanet.com/world/2009-05/01/ content_11291447.htm)，新華網，2009 年 5 月 1日。於 2009年 5月 1日查閱。

11. http://www.cdc.gov/swineflU 12. 新流感改名袁教授唔 like

(http://news.sina.com.hk/cgi-bin/nw/show.cgi/3/1/1 /1152565/1.html)，2009年 6月 1日引用。

13. Mexico flu deaths raise fears of global epidemic (http://www.msnbc.msn.com/id/30386163/#storyContinued)，MSNBC，2009 年 4 月 24 日。於 2009年 4月 24日查閱。

14. Experts probe deadly Mexico flu (http://news.bbc.co.uk/1/hi/world/americas/8016909.stm)Published 24 April 2009

15. New Scientist magazine: Deadly new flu virus in US and Mexico may go pandemic (http://www.newscientist.com/article/dn17025-deadly- new-flu-virus-in-us-and-mexico-may-go-pandemic.html) 24 April 2009

16. Q&A: Swine flu. ( http://news.bbc.co.uk/2/hi/health/8017585.stm) ，BBC News。

17. Influenza-Like Illness in the United States and Mexico(http://www.who.int/csr/don/2009_04_24/en/index.html)。World Health Organization（2009年 4月 24日）。於 2009年 4月 25日查閱。

18. 甲型 H1N1 流感疫情惡化墨西哥首都暫停 10 日公眾活動 (http://www.rthk.org.hk/rthk/news/expressnews/20090425/news_20090425_55_576848.htm) ，香港電台，2009 年 4 月 25 日。於 2009 年 4 月 25 日查閱。

19. 墨西哥爆發豬流感民眾搶購口罩疫苗(http://hk.news.yahoo.com/article/090425/8/bux8.html)，法國新聞社，2009 年 4 月 25 日。於 2009年 4月 26日查閱。

20. “ 豬流感 ” 世衛宣布全球緊急狀態(http://news.bbc.co.uk/chinese/trad/hi/newsid_8010000/newsid_8017900/8017907.stm)，BBC 新聞，

2009年 4月 25日。於 2009年 4月 26日查閱。 21. 是否發旅遊警告？世衛開緊急會議


152

(http://iservice.libertytimes.com.tw/liveNews/news.php?no=206771)，自由電子報，2009 年 4 月 25日。於 2009年 4月 25日查閱。

22. 中華人民共和國衛生部：陝西師生集體發燒並非感染豬流感 (http://news.163.com/09/0429/02/581KDOBJ0001124J.html)，網易，2009年 4月 29日。於 2009年5月 20日查閱。

23. 甲型 H1N1 流感人傳人亞太失守世衛：現在控制已太遲警戒隨時升至 5 級

(http://hk.news.yahoo.com/article/090428/4/bx1v.html)，雅虎香港新聞，2009年 4月 29日。於 2009年 4月 29日查閱。

24. 內地首例流感患者瞞報癥狀專家稱可能犯法(http://cd.qq.com/a/20090511/001056.htm)，騰訊，2009年 5月 11日。於 2009年 5月 11日查閱。

25. 北京確診一例甲型 H1N1 流感病例

(http://news.xinhuanet.com/photo/2009-05/17/ content_11386955.htm)，新華網，2009 年 5 月 16日。於 2009年 5月 17日查閱。

26. 日新型流感本土疫情擴大確診病例達 21 人(http://www.thecommonsdaily.tw/2009/05/0518/Inter/int-01.htm)，民眾日報，2009 年 5 月 17 日。於2009年 5月 18日查閱。

27. 廣東疑似甲型 H1N1 流感病例被確診

(http://news.xinhuanet.com/society/2009-05/19/ content_11399927.htm)，新華網，2009 年 5 月 19日。於 2009年 5月 20日查閱。

28. 內地第二例甲型 H1N1 流感確診病例出院(http://news.sina.com.cn/h/p/2009-05-19/ 105317845754.shtml)，新華網，2009 年 5 月 19日。於 2009年 5月 19日查閱。

29. 西藏報告一例輸入性甲型 H1N1流感疑似病例(現已排除 )( http://news.xinhuanet.com/local/2009-05/19/content_11399978.htm)，新華網，2009 年 5月 19日。於 2009年 5月 20日查閱。

30. H1N1(http://a-h1n1.org.cn/), H1N1 中國區網站 , 2009年 5月 29日。於 2009年 5月 29日查閱。

31. Canada confirms 4 swine flu cases among students(http://www.google.com/hostednews/ap/article/ALeqM5g-G1kSAM9yaH00eBrXD2S5s-3ZhgD97Q9LPG0)，Google/AP，2009 年 4 月 26日。於 2009年 4月 27日查閱。

32. 33.0 33.1 Carol Campbell。有關甲型 H1N1流感的科學的內容更新： 2009 年 5 月 21 日

(http://www.scidev.net/zh/news/zh-134159.html? utm_source=link&utm_medium=rss&utm_campaign=zh_news)，科學與發展網絡，2009 年 5 月 21日。於 2009年 5月 26日查閱。

33. PB1-F2 is not present in this strain.Bruce Lieberman（2009年 5月 1日）。Scientists studying genetics of flu strain (http://www3.signonsandiego.com/stories/2009/may/01/1n1strain00212-scientists-studying-genetics-flu-st/?nation)。 Compare a human strain with the gene[1] to the equivalent nucleotides 95-367 of swine flu.[2]

34. 7 名感染新型豬流感病毒的美國人痊癒(http://news.sina.com.tw/article/20090424/1642979.html)，新浪新聞，2009 年 4 月 24 日。於 2009 年4月 26日查閱。

35. Deadly new flu virus in US and Mexico may go pandemic(http://www.newscientist.com/article/dn17025-deadly-new-flu-virus-in-us-and-mexico-may-go-pandemic.html)。NewScientist（2009 年 4 月 26日）。於 2009年 4月 26日查閱。

36. Steven Reinberg。Swine Flu Cases Now Total 7: CDC(http://www.abcnews.go.com/Health/Healthday/story?id=7415611&page=1)，ABC News，2009 年4月 24日。

37. Rob Stein（2009年 4月 23日）。In California and Texas, 5 New Swine Flu Cases (http://www.washingtonpost.com/wp-dyn/content/ article/2009/04/23/AR2009042304116.html) 。

Washington Post。 38. CDC Briefing on Public Health Investigation of

Human Cases of Swine Influenza (http://www.cdc.gov/media/transcripts/2009/t090423.htm)。CDC online newsroom（2009 年 4 月 23日）。

39. Influenza-like illness in the United States and Mexico(http://www.who.int/csr/don/2009年 4月 24日/en/index.html)。WHO（2009年 4月 24日）。

40. Swine Influenza A (H1N1) Infection in Two Children-Southern California, March-April 2009 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm


153

5815a5.htm)。CDC MMWR（2009 年 4 月 22日）。

41. Update: Swine Influenza A (H1N1) Infections -California and Texas, April 2009 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0424a1.htm)。CDC MMWR（2009 年 4 月 24日）。

42. Murray CJ, Lopez AD, Chin B, Feehan D, Hill KH (December 2006), "Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918– 20 pandemic: a quantitative analysis", Lancet 368 (9554): 2211–8, PMID 17189032 (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17189032), DOI:10.1016/S0140-6736(06)69895-4

43. CDC says too late to contain U.S. flu outbreak (http://www.alertnet.org/thenews/newsdesk/24443479.htm)。Reuters（2009年 4月 24日）。

44. Mark Stevenson。U.S., Mexico battle deadly flu outbreak(http://www.komonews.com/news/national/43692847.html)，2009年 4月 25日。

45. CDC Media Availability on Human Swine Influenza Cases - April 27, 2009, 1 p.m. EST

(http://www.cdc.gov/media/transcripts/2009/t090427.htm)。Centers for Disease Control and Prevention（2009 年 4 月 27 日）。於 2009 年 4 月 27 日查閱。

46. CDC: Swine Flu Cases Climb to 91 in 10 States (http://www.foxnews.com/politics/first100days/2009/04/29/obama-stay-home-youre-sick/), FoxNews/AP, April 29, 2009

47. In Mexico, young adults appear most at risk (http://www.msnbc.msn.com/id/30426170/)

48. Carol Campbell。有關甲型 H1N1流感的科學的內容更新：2009 年 5 月 14 日，科學與發展網絡，2009年 5月 14日 (http://www.scidev.net/zh/news/zh-134113.html?utm_source=link&utm_medium=rss&utm_campaign=zh_news)。於 2009 年 5 月 19 日查閱。

H1N1(http://a-h1n1.org.cn/)5 月 28 日，中國大陸報告首例甲型 H1N1 流感二代病例，為廣東省廣州市1 例輸入性甲型 H1N1 流感消息來源。取自“ http://zh.wikipedia.org/w/index.php?title=%E7%94%B2%E5%9E%8B%E6%B5%81%E6%84%9F%E7%97%85%E6%AF%92H1N1%E4%BA%9E%E5%9E%8B&variant=zh-hk”


154


關於 H1N1 新型流感

甚麼是 H1N1 新型流感？

H1N1 新型流感(豬流感)原是一種於豬隻中感染

的疾病，屬於 A 型流感病毒，常見病毒為 H1N1、H1N2、H3N1 與 H3N2。美國疾管局資料顯示，美國以前即曾有人類感染豬流感之病例，但中國台灣未曾

有豬流感病例。目前墨西哥與美國爆發的豬流感疫

情，即為 H1N1病毒所引起，但目前對此種結合豬流感、人類流感的新病毒型所知不多。

人類會感染 H1N1 新型流感嗎?

H1N1 新型流感病毒通常不會感染人類，但可能

豬隻感染豬流感後，與禽流感或人流感之病毒基因混

合重組，人類可能在接觸感染的豬隻或身處受 H1N1新型流感污染的環境之下感染 H1N1新型流感後，由人傳人的方式引發流行，但目前對於 H1N1新型流感流感傳染力的強度仍未確定。

H1N1 新型流感傳染方式？

H1N1 新型流感傳染途徑與季節性流感類似，主

要是透過飛沫傳染與接觸傳染，一般成人在症狀出現

前 1天到發病後 7天均有傳染性，但對於病程較長之病患，亦不能排除其發病期間繼續散播病毒。另兒童

病例的可傳染期通常較成人病例為長。

如何預防 H1N1 新型流感?

(一)注意個人衛生及保健：勤洗手，養成良好衛

生習慣。 (二)注意呼吸道衛生及咳嗽禮節 1.有咳嗽等呼吸道症狀時應戴口罩，當口罩沾到口鼻分泌物

時，應立即更換並丟進垃圾桶。 2.打噴嚏時，應用面紙或手帕遮住口鼻，若無面紙或手帕時，可用衣袖

代替。 3.如有呼吸道症狀，與他人交談時，儘可能保持 2 公尺以上距離。 4.手部接觸到呼吸道分泌物時，要立即澈底清潔雙手。 5.生病時應在家休息，除就醫外，儘量避免外出。 (三)遠離感染來源 1.避

免前往 H1N1新型流感發生地區。

感染 H1N1 新型流感會出現哪些徵狀?

人類感染 H1N1 新型流感症狀與季節性流感類

似，包括發燒、咳嗽、喉嚨痛、全身酸痛、頭痛、寒

顫與疲勞，有些病例出現腹瀉、嘔吐症狀，部分病例

出現流鼻涕等症狀。

如果出現 H1N1 新型流感相關症狀應該怎麼做？

如出現發燒、咳嗽、流鼻水、打噴嚏、肌肉酸

痛、頭痛或極度倦怠感等類流感症狀，應立即配戴

口罩就醫，並告知醫師相關病史、工作史、禽畜接

觸史及旅遊史；如醫師經臨床診斷認為符合 H1N1流感調查病例之條件，將依規定向衛生單位通報，

並於採檢後視醫療評估結果提供流感抗病毒藥劑及

相關治療。

有疑似 H1N1 症狀要去哪裡就醫?

1. 自有 H1N1 新型流感病例國家返國且有發

燒等疑似類流感症狀，請先戴上口罩至鄰近醫療

院所就醫，並主動告知醫師旅遊史由醫師診斷；

另疾病管制局已訓令「傳染病防治醫療網」（醫療

院所名單 http://www.cdc.gov.tw/mp.asp?mp=120）各級醫院待命，可協助收治病患。 2. 儘量搭乘私人交通工具，若為自小客車，可將車窗搖下，

降低傳染同車人之機會，若無特殊情況，無須搭

乘救護車。

如何確定是否感染 H1N1 新型流感? 無法依症狀研判是否感染 H1N1新型流感，需採

取檢體進一步檢驗始可確認。若您有相關旅遊史、接

觸史及疑似症狀，請儘速就醫並主動告知醫師旅遊史

及接觸史。


155

H1N1 新型流感有沒有治療藥物

目前克流感(Tamiflu)及瑞樂沙(Relenza)均可用於

治療 H1N1新型流感，但使用抗病毒藥劑前仍應由醫師評估。

民眾要自費購買與儲存 H1N1 新型流感

的治療藥物嗎？

不需要。疾病管制局再次呼籲，預防性用藥目前

建議使用於可能病例或確定病例之密切接觸者，並未

建議至有病例之國家旅遊者需進行預防性投藥；且抗

病毒藥劑為處方用藥，服藥前應確認為何種疾病，依

專業進行診斷，故應由醫師開立處方。

H1N1 新型流感致死率為多少?

由於 H1N1新型流感在美、墨兩國的致死率大不

同，墨國疫情遠比美國嚴重(墨西哥致死率約 6.0%-7.0%)，世界衛生組織（WHO）衛生專家仍在持續觀察，目前已將全球流感警戒等級提升至第五級。

吃豬肉會感染 H1N1 新型流感嗎?

不會。世界衛生組織（WHO）表示，只要是經

過妥善處理與烹調的豬肉，食用上並無安全疑慮。

哪些國家是 H1N1 新型流感流行地區?

疾病管制局每日搜集全球 H1N1新型流感資訊，

並公佈於“H1N1 新型流感專區 / H1N1 新型流感每日概況”，歡迎民眾上網搜尋最新資訊。

如無法避免需前往 H1N1 新型流感

流行地區，應注意哪些事項?

1. 注意個人衛生，養成勤洗手的習慣。若無法洗手時，可以使用含酒精（60％以上）的乾洗手液。 2. 旅途中若出現發燒等類似 H1N1 新型流感症狀，應戴口罩並儘快就醫。若為參加旅行團之旅客，請告

知領隊，以便協助就醫及通報。 3. 避免前往至人潮聚集處及至醫院探訪病人。

從 H1N1 新型流感流行地區返國時，

應注意哪些事項?

（1）旅途中如果出現身體不適，返國入境機場

時請填交「傳染病防制調查表」。（2）自 H1N1 新型流感流行地區返國後，請早晚量測體溫，並進行自我

健康狀況監測 7天。（3）如果有類似 H1N1新型流感的症狀，應立即戴口罩，通報當地衛生局協助就醫，

並主動告知醫師：1.症狀 2.旅遊史 3.是否曾與 H1N1疑似或確定病例近距離接觸。


156


澳門地區醫學學術會議簡報

1 “澳門戒煙日暨慶祝澳門回歸十週年——防治愛

滋病醫學講座”在澳門舉行由澳門健康協會、澳

門關懷愛滋病協會合辦的“澳門戒煙日暨慶祝澳門回

歸十週年——防治愛滋病醫學講座”於 2009 年 6 月6 日假黃金閣酒樓舉行，吸引逾百名市民參與。是次講座邀請到衛生局公共衛生化驗所愛滋病諮詢及輔

導小組張碧影，以及澳門關懷愛滋病協會理事長謝燕

儀擔任主講嘉賓，分別講述了愛滋病毒傳播途徑、愛

滋病的預防方法等。主辦單位期望透過開展各類的宣

傳活動及講座，普及愛滋病防治資訊，並消除社會對

愛滋病患者的歧視，以提升公眾對愛滋病人的接納與

關懷。張碧影接受訪問時表示，防治愛滋病委員會多年來一直與澳門的社會團體及學校合作，透過派發

宣傳小冊子，講座等方式推廣及宣傳愛滋病防治工

作，進一步增強市民的自我保護意識，推動澳門社會

預防愛滋病工作的持續健康發展。她指出，本澳愛滋

病感染數字近年來不斷上升，外來人口、特別是非法

從事性工作的人群已成為愛滋病病毒的一大高危感染

及群體。據瞭解，澳門現時有不少的性工作者出於對

無證、私隱或其他原因的顧慮，擔心遭到警方查處，

而不敢到衛生局部門進行愛滋病測試檢查。張碧影對

此建議表示，澳門的工人醫療所一向都有匿名檢查的

愛滋病檢驗服務，呼籲有顧慮的人士可到上述醫療所

進行檢驗。同時，她希望通過活動，喚起更多的社會

關注，讓大家多一些關愛，少一些冷漠，讓愛滋病人

生活在一個沒有歧視的環境裡。

摘自：濠江日報, A04/澳門新聞, 2009, 6, 7. 2 “生物被動免疫科學對人體免疫系統消除疾病的

研究” 醫學講座在澳門舉行由澳門健康城市工程研究會、澳門行政暨公職局公職福利處、澳門青年新

心靈環保協會聯合舉辦之“生物被動免疫科學對人體

免疫系統消除疾病的研究”醫學講座於 2009 年 5 月29 日假行政暨公職局公職福利處禮堂舉行。是次講座邀請到來自美國紐約州立大學醫學中心免疫學和微

生物學雙博士海倫（Dr. Hellen Greenblatt）來澳，向與會者講解其一直醉心研究所得的卓越成果，即如何

動員自身的免疫系統來抵禦病毒，並涉及近期在全球

蔓延的甲型 H1N1流感病毒的發展趨勢及其與免疫系統的關係，具一定的專業性和教育意義。甲型 H1N1流感病毒來勢洶洶，蔓延全球。各國均高度關注事件

之發展趨勢。疫情的侵襲，使得如何採取有效預防措

施和以何種藥物抵禦病毒等課題被迅速提上日程。美

國紐約州立大學醫學中心免疫學和微生物學雙博士海

倫（Dr. Hellen Greenblatt）是研究人體免疫系統和免疫能力的專家，更被世界醫學界權威公認為“領導醫學家”。主辦方在悉海倫博士將到亞洲來作巡迴演講之後，即擬邀其蒞臨澳門作專題醫學演講，並得其應

允，同時定下“生物被動免疫科學對人體免疫系統消

除疾病的研究”這一講題。

摘自：濠江日報, A02/澳門新聞, 2009, 5, 24. 3 “一個常見多發病治療新趨勢”學術研討會暨

會員大會在澳門舉行由衛生局醫生協會主辦之

“一個常見多發病治療新趨勢”學術研討會暨會員大會於 2009 年 3 月 7 日假旅遊塔會展中心舉行。會上，讓會理事長蔡念簡報了該會成立一年以來的主要工作

事務，包括會見各界及與當局討論醫生職程及醫療訴

訟問題的情況。除此之外，亦邀請到多名來自香港的

專家學者來澳就常見多發病治療新發展作專題演講，

講題包括：兒童免疫接種新資訊、婦女更年期後保健

處理、人類乳頭狀病毒感染疾病治療新趨勢、骨質疏

鬆症的預防、常見高血壓及心血管疾病治療等專題。

研討會吸引逾三百名醫療界人士參與，並討論各常見

病的新發展。蔡念指出，醫療發展日新月異，醫護人

員有必要透過不斷學習，充實醫療知識，維護居民健

康。該會今後將籌辦更多不同類型的醫療學術活動，

推動醫療界探討醫學新資訊，提升本澳醫療水平。

摘自：澳門日報, A06/澳聞, 2009, 3, 8.

(蕭瓊)


157

‧工具和資料‧

國際藥物資訊 1 慎用非處方兒童傷風止咳藥

Cautioning use of nonprescription cough and cold preparations in children

為預防及減少對非處方兒童感冒止咳藥的濫

用，以及向消費者傳達安全使用有關藥物的資訊，

美國食物及藥物管理局（USFDA）及英國藥物與保

健產品管理局(MHRA)表示繼續評估該類藥物的安全

性和有效性，而 MHRA 更建議 6 歲以下兒童的家長

及照顧者遵從標籤所指的服用劑量及留意有關警告

資料。在有關問題未釐清前，衛生專業人士應明瞭

以下資料，以便轉告家長及孩童照顧者：

傷風止咳藥只可舒緩症狀，不能消除致病的原

因，也不能縮短病程。

不要給兒童服用標籤上註明只適用於成人或只

標有成人劑量的藥物。

每次用藥後，須確保蓋好瓶蓋並放置於遠離兒

童的地方。

查看藥物的活性成分、瞭解該成分的適應症及

所能舒緩的症狀。

給兒童服用 1 種以上藥物時，必須確保每種藥

物不具相同活性成分，否則，兒童可能因攝取

過量某一成分而危害健康，如有任何疑問，應

諮詢醫生或藥劑師。

嚴格按照藥物標籤及醫生處方用藥。

只可使用隨藥附送或專用的量器，不要使用普

通家用匙具量藥，以確保兒童服用到正確劑量

的藥物。

不要保存不再需要的藥物，避免以後誤用。

In order to prevent, reduce misuse and to better inform consumers about the safe use of nonprescription over-the-counter cough and cold medicines in children, the USFDA and the British MHRA will continue to assess the safety and efficacy. Meanwhile, MHRA recommends parents and care-givers for young children who are less than 6 years old to adhere to the dosage instructions and warnings on the label which accompanies the medication. Before the resolution of this issue they would advise the following for all healthcare professionals so than you can, in-turn, inform all parents or caregivers： Understand that using cough and cold medicines

only treat the symptoms, they were not intended to cure the cold or cough or shorten the duration of illness.

Do not give children those medications labeled only for adults use only or with adult dosage.

Close the cap tightly after each use and store the medicines away from the children.

Look at and understand the intended indication(s) of the active ingredient and know the type of symptom(s) of which the active ingredient will help to alleviate.

Be very careful when giving more than one medicine to the child, make sure that the different medicines do not contain the same type of "active ingredients" in each one of the preparations, otherwise he/she may receive too much of an ingredient that may be harmful. When in doubt please consult their doctor or pharmacist.

Carefully follow the labeling directions on how to properly use the medicine.

Only use measuring devices that come with the medicine or those specially made for measuring drugs. Do not use common household spoons to measure medicines because household spoons come in different sizes and are not meant for measuring medicines.

To avoid future misuse, remove medicines that will no longer be needed from your medicine cabinet.

資料來源: 美國食物及藥物管理局

英國藥物與保健產品管理局 Sources：United States Food and Drug Administration (USFDA)

British Medicines & Healthcare-products Regulatory Agency (MHRA) http://www.fda.gov/bbs/topics/NEWS/2008/NEW01899.html http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/Safetywarningsandmessagesformedicines/CON038908


158

2 有關苯妥英(phenytoin)及磷苯妥英鈉(fosphenytoin sodium)安全性的最新資訊 Latest safety update on phenytoin and fosphenytoin sodium

美國食物及藥物管理局（USFDA）正對有關帶

有人類白細胞抗原對偶基因(human leukocyte antigen

(HLA) allele)HLA-B*1502 的亞裔病人在服用苯妥英

後可能增加嚴重皮膚反應潛在風險的最新資料進行調

查，有關皮膚反應包括史帝文生氏強生症候群

(Stevens Johnson Syndrome -SJS)及毒性表皮溶解症

(toxic epidermal necrolysis)。上述對偶基因基本上只

存在於祖先源於亞洲地區的人群，當中包括中國漢族

人、菲律賓人、馬來西亞人、南亞印度人及泰國人。

最新資料顯示 HLA-B*1502 對偶基因可能與上述藥

物不良反應存在關聯性。在 USFDA 完成評估前，需

要處方苯妥英或磷苯妥英鈉的醫生應權衡這類藥物說

明書中所提及的風險及效益，對於帶有 HLA-B*1502

對偶基因的病人須避免使用苯妥英及磷苯妥英鈉來代

替卡馬西平。

基於上述原因，醫生在處方苯妥英或磷苯妥英鈉

前，應考慮：

抗癲癇藥物苯妥英在結構上與卡馬西平相似，

卡馬西平的說明書最近加入更新資料，當中指

出帶有HLA-B*1502對偶基因的亞裔病人服用卡

馬西平後可能增加嚴重皮膚反應包括史帝文生

氏強生症候群及毒性表皮溶解症的潛在風險。

在中國、泰國、馬來西亞、印度尼西亞、菲律

賓及台灣人口中估計約10%至15%或以上人群

帶有HLA-B*1502對偶基因；而南亞裔人包括印

度人中約有2%至4％帶有HLA-B*1502對偶基

因，但一些人群帶有對偶基因的比率較高。日

本人和韓國人中帶有HLA-B*1502對偶基因的比

率則少於1 ％。

最新資料顯示，一些帶有HLA-B*1502對偶基因

的亞裔病人在服用苯妥英後，亦可能與卡馬西

平一樣會引發嚴重的皮膚反應。由於磷苯妥英

鈉是苯妥英的前體藥物，服用後亦會轉化為苯

妥英，任何與苯妥英相關的事項也適用於磷苯

妥英鈉。

USFDA正對帶有HLA-B*1502對偶基因的病人

在服用苯妥英及磷苯妥英鈉後引發史帝文生氏

強生症候群的風險進行研究，然而，目前尚沒

The United States Food and Drug Administration (USFDA) would like to notify healthcare professionals about the latest safety information on phenytoin and fosphenytoin sodium. Accordingly, the Agency is investigating new preliminary data regarding a potential increased risk of serious skin reactions including Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) from phenytoin therapy in Asian patients tested positive for human leukocyte antigen (HLA) allele, HLA-B*1502. This allele occurs almost exclusively in patients with ancestry across broad areas of Asia, including Han Chinese, Filipinos, Malaysians, South Asian Indians, and Thais. New data suggest a possible association between HLA-B*1502. Until the USFDA evaluation is completed, physicians who are considering the use of phenytoin or fosphenytoin should be aware of the risks and benefits described in the current prescribing information for this drug and should consider avoiding phenytoin and fosphenytoin as alternatives for carbamazepine in patients who test positive for HLA-B*1502.

Based on the above reason physicians should consider the following information before prescribing phenytoin or fosphenytoin: Phenytoin is an antiepileptic drug with some

structural similarity to carbamazepine. Labeling for carbamazepine was recently updated to include an increased risk of serious skin reactions, including SJS/TEN, in Asian patients who had recently started taking carbamazepine and who tested positive for HLA-B*1502.

It is estimated that 10-15% or more of patients may carry the HLA-B*1502 allele in parts of China, Thailand, Malaysia, Indonesia, the Philippines, and Taiwan. South Asians, including Indians, appear to have an intermediate chance of having HLA-B*1502, averaging 2 to 4%, but it is higher in some groups. HLA-B*1502 appears to be present at a low frequency (<1%) in Japan and Korea.

New preliminary data suggests that phenytoin may carry a risk of serious skin reactions in some Asian patients who tested positive for HLA-B*1502, similar to the risk carried by carbamazepine. Because fosphenytoin is a prodrug and is converted to phenytoin after administration, any concern regarding this association with phenytoin is also applicable to fosphenytoin.

The possible risk of SJS from phenytoin and fosphenytoin in patients with HLA-B*1502 is still being studied; however, there is not yet enough information to recommend testing for


159

有資料足以要求亞裔病人在服用苯妥英前作

HLA-B*1502對偶基因測試。

因服用苯妥英而誘發的嚴重皮膚反應，最常在

服藥後首幾個月內發生。

HLA-B *1502 in Asian patients for whom phenytoin treatment is contemplated.

The risk for serious skin reaction with phenytoin therapy appears to be greatest in the first few months of therapy.

資料來源：美國食物及藥物管理局 Source：United States Food and Drug Administration (USFDA). http://www.fda.gov/medwatch/safety/2008/safety08.htm#Phenytoin http://www.fda.gov/cder/drug/infopage/phenytoin_fosphenytoin/default.htm http://www.fda.gov/cder/drug/InfoSheets/HCP/phenytoin_fosphenytoinHCP.htm 3 過量使用皮膚局部麻醉藥可引發致命副作用

Life-threatening side effects with the use of skin numbing ingredients

美國食物及藥物管理局（USFDA）向消費者發

出一則有關在美容及醫療手術中過量使用皮膚局麻藥

所引發潛在危險的警告資訊，上述局麻藥包括含有

tetracaine、lidocaine、benzocaine 或 prilocaine 的乳

膏、軟膏或凝膠，USFDA 已批准了很多上述產品作

醫生處方及非醫生處方藥物。一般的醫療手術中應由

診所內已受訓練的醫務專業人士為病人施予局麻藥，

然而，問題在於這些產品應用在美容手術時，往往缺

乏具醫務專業訓練人士的監督，在缺乏醫督的情況

下，病人可能大量使用局麻藥於皮膚上，導致藥物血

中濃度過高而引發致命的副作用，包括心跳不規則、

癲癎、昏迷、呼吸緩慢或停頓以及死亡，上述情況可

發生於孩童和成人患者。

局部麻醉藥的作用在於阻斷皮膚的疼痛感覺，部

份可通過皮膚進入血管內，血中濃度太高，可對病人

造成嚴重傷害。當局部麻醉藥大面積塗於皮膚上、長

時間應用以及使用後被覆裹，皆會導致更多藥物經皮

膚進入血管內。如果皮膚已受刺激或長有皮疹，又或

皮膚溫度上升，麻醉藥也可能進入血管內。運動、裹

上保鮮紙或使用加熱墊，皆會導致皮膚溫度升高。而

藥物經皮膚進入血液的量會因人而異。

消費者在接受皮膚美容或醫療手術前，應與主診

醫生商討可否使用其他方法舒緩痛楚。倘若醫生需處

方或建議病人使用局麻藥時，應考慮下列事項：

處方可令病人減輕痛楚的最低份量的局部麻醉藥。

指示病人正確的使用份量或塗以最少份量的藥

物於患處及避免長時間使用。

The United States Food and Drug Administration (USFDA) had previously alerted consumers about potential hazards of using topical anesthetics for cosmetic and medical procedures. These topical anesthetics usually contain anesthetic drugs such as lidocaine, tetracaine, benzocaine, and prilocaine in a cream, ointment, or gel. USFDA has approved many of such products in both prescription and non-prescription strengths. Applying topical anesthetics for a medical procedure is usually done in a doctor’s office by a trained medical professional. However, problems may arise when these products are used before a cosmetic procedure, that may not be supervised by trained health professionals. Without this supervision, a patient may apply large amounts of topical anesthetics to their skin. This application can result in high levels of these products in the blood causing life-threatening side effects, such as an irregular heartbeat, seizures, coma, slowed or stopped breathing and death following the use of these numbing products. These effects happened in both children and adults and when the anesthetic drug was used.

Topical anesthetics work by blocking pain sensation in the skin. Some of the anesthetic drugs in these products can pass through the skin into the blood stream, and if too much gets into the blood, patients can experience serious harm. More drug passes into the blood stream when the product is applied over a large area of skin, when it stays on the skin for a long time, and when the skin is covered after application of the cream. Anesthetic drugs may also pass into the blood stream if the skin is irritated or has a rash, or if the skin temperature goes up. Exercise, covering the skin with a wrap, or use of a heating pad can all increase the skin temperature. The amount of the drug that can pass through the skin and enter the blood also can differ from person to person.

If any consumer is thinking about having a cosmetic or medical procedure on his/her skin, discuss with your doctor whether there are other ways to reduce the pain you may feel during the procedure. For physicians who prescribe or recommend a numbing product to ease the patients’ pain, please consider the following:


160

提醒病人切勿塗搽於受損或過敏的皮膚上。如

獲建議覆裹或蓋上任何材料或敷料時，須警惕

這樣會增加副作用的機會。

通知病人有關可能產生的副作用，並指導病人

如何降低使用這些藥物所產生嚴重副作用的機

會。

Use a topical anesthetic that contains the lowest amount of anesthetic drugs possible that will relieve the patient’s pain.

Instruct the patient the exact amount to be used, or only use sparingly and as little amount to cover the affected skin area for the briefest period possible.

Remind him/her not to apply onto broken or irritated skin. If wrapping or covering the skin with any type of material or dressing is recommended or desired, be aware that this step can increase the chance of side effects.

Inform about the possible side effects of these drugs and how to lower the patient’s chance of having life-threatening side effects from these topical agents.

資料來源：美國食物與藥物管理局 Source：United States Food and Drug Administration(USFDA) http://www.fda.gov/cder/drug/advisory/topical_anesthetics2009.htm http://www.fda.gov/cder/drug/advisory/topical_anesthetics.htm 4 有關哌醋甲酯methylphenidate (商品名：Ritalin®)安全性的最新資訊

Latest safety information on methylphenidate (Ritalin®)

為了令病人服用此藥時達至最高的安全性，歐

盟藥物監管局（EMEA）對上述藥物的處方、治療前篩選及病人的持續性監測作出了最新的建議。而所有

含哌醋甲酯藥物產品的說明書內應載有下列資料：醫生應在治療前對所有患者進行篩選，藉以了

解患者的血壓或心率是否有任何異常，亦應檢

查其家族性的心血管病史。任何有上述問題的

病患在未經專科醫生評估前，不應服用該藥

物。在治療期間，醫生應定期監測病人的血壓與心

率。如發生任何問題，應立刻進行進一步檢

查。由於缺乏有關長期性服用哌醋甲酯的資料，已

服用哌醋甲酯超過一年的病人，醫生應每年中斷病人的哌醋甲酯療程最少一次，以決定病人

是否需要繼續服用該藥。由於服用哌醋甲酯後，可能導致或加重某些精

神病，如：抑鬱、出現自殺念頭、產生敵意、

精神病及躁狂症，因此醫生在治療前須小心篩

選可能患有上述疾病的病人，而在病人接受此

藥物治療期間，醫生亦須定期監測病人的精神

狀態。在病人服用哌醋甲酯治療期間，醫生也應定期

監測病人的身高和體重。備註：已在本澳市場銷售，含有哌醋甲酯

(methylphenidate)藥物的商品名包括Ritalin®利他林®10毫克錠劑和Concerta® 18、36及54毫克錠劑。

Accordingly, the European Medicines Agency (EMEA) concluded new recommendations on prescribing, pre-treatment screening and ongoing monitoring of patients for methylphenidate in order to maximize the safe use of the medicine. The product information of all methylphenidate-containing medicines should contain the following information: before treatment, all patients should be screened to

see if they have any problems with their blood pressure or heart rate. The family history of cardiovascular problems should also be checked. Any patients with these problems should not be treated without specialist evaluation;

during treatment, blood pressure and heart rate should be monitored regularly. Any problems that develop should be investigated promptly;

there is a lack of information on the long-term effects of methylphenidate. For patients who take methylphenidate for more than a year, doctors should interrupt treatment at least once a year to determine whether continued treatment with methylphenidate is necessary;

the use of methylphenidate could cause or worsen some psychiatric disorders such as depression, suicidal thoughts, hostility, psychosis and mania. All patients should be carefully screened for these disorders before treatment and monitored regularly for psychiatric symptoms during treatment;

the height and weight of patients treated with methylphenidate should be monitored during treatment.

Note: The brand names for methylphenidate-containing medications available in Macao include Ritalin 10 mg tablet and Concerta C.R. 18, 36, 54 mg tablets.

資料來源：歐盟藥物監管局 Source：European Medicines Agency (EMEA) http://www.emea.europa.eu/pdfs/human/referral/methylphenidate/2231509en.pdf


161

《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﹕[email protected] 。

《澳門醫學雜誌》編輯部


162

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”) : 3.1. 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.

3.2. 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.

3.3. 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.

3.4. 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 : [email protected].

Gabinete Editorial da “Revista de Ciências da Saúde de Macau”


163

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: [email protected].

Editorial Office of “Health Science Journal of Macao”


164

‧工具和資料‧

醫學論文撰寫中的常見問題

科研設計的選題與立題問題標題太長，主題不突出。標題與內容不符，或題目太大而內容貧乏。標題單

調，主題不明確。關於題目要求： (1) 可檢索性； (2) 特異； (3) 明確； (4) 簡短。命題方法： (1) 方法；

(2) 結論； (3) 探討。關於把“構成比”當“率”的概念問題：在醫學文獻中，我們發現有些作者對患病率、

發病率、死亡率、感染率等概念混淆不清。關於療效的確切評價問題：只有觀察組沒有對照組，有比較才能有

鑒別，醫學研究結果如無適當的對照比較，就難結論。即使有了對照組，若兩者之間沒有可比性，同樣不能得

出確切的結論。以上可見，對照組與實驗組一定在性別、年齡、病情、病期、病型、部位、療程等條件大致相

同的情況下，才有可比性，其結果才有科學價值。

病例資料經過有意無意的挑選：有些論文，對所謂 “資料不全”、 “療程未滿 ”、“未隨訪到”的病例剔除不

計，這樣所得的結果往往比實際療效高，因爲若如此剔除，其結果的科學性必然成問題。更有甚者，對一些資

料，主觀臆斷地以某種原因爲理由加以剔除，完全失去了這次研究的意義。考核方法和考核指標的科學性不

夠： (1) 無明確的客觀指標、僅憑患者主訴進行考核；(2) 觀察、研究人員的主觀偏面性； (3) 考核標準過

低； (4) 資料未經統計學處理； (5) 考核方法不夠科學。統計學分析的差錯。 (1) 對照組的設立（隨機同期

對照、歷史性對照、不同地區或醫院的對照交叉對照）； (2) 隨機化分組（簡單、區組、分層）； (3) 盲法

（非盲、雙盲）。以上資料，說明了在考核療效時一定要注意： (1) 病例資料的可比性； (2) 客觀資料要經

統計學處理； (3) 考核指標要有嚴格的科學性（可比性、指標不能過低，不能有主觀偏面性等）。

圖表的應用問題：圖表是表達研究資料，使之一目了然的最簡潔方法。一般來說 “圖”是從 “表”來的，可

以使讀者從圖中看出一個大概趨勢和實驗內容。在圖表應用上，可用文字表達的就盡可能不用圖表，必需用的

也不宜過多，一般在 4 幅以內。

Documents

澳門醫學雜誌 - ssm.gov.mo€¦ · 澳門醫學雜誌® Revista de Ciências da Saúde de Macau 季刊 2001年4 月創刊 第9 卷 第2 期 2009年6 月26 日 出版 主辦

澳門醫學雜誌 - ssm.gov.mo€¦ · 澳門醫學雜誌® Revista de Ciências da Saúde de Macau 季刊 2001年4 月創刊第9 卷第2 期 2009年6 月26 日出版主辦