澳門醫學雜誌 Revista De Ciências Da Saúde De Macau

® 澳門醫學雜誌 Revista de Ciências da Saúde de Macau

季刊 2001 年 4 月創刊第 7 卷第 3 期 2007 年 9 月 1 日出版

主辦目次澳門特別行政區政府衛生局

編輯論著和研究澳門醫學雜誌編輯委員會澳門特別行政區澳門 2005 年青少年煙草使用調查………………………陳丹梅余詠恩 153 CP 3002 若憲斜巷澳門仁伯爵綜合醫院兒童不明原因性衛生局行政樓 3 樓電話: (+853)-390 7307, 390 6524 腎病症候群病人之分析研究…………………………………黎文豪 159 傳真: (+853)-390 7304 動靜脈瘺併發假性動脈瘤的外科經驗…………鄭月宏宮琪宋德偉等 162 電郵: [email protected] 網址: http://www.ssm.gov.mo 末期癌症病人的褥瘡預防及處理措施的調查報告………郭艷明沈茂光 164 髂動脈支架結合股深動脈成形主編瞿國英治療重症下肢缺血…………………………劉昌偉鄭月宏管珩等 168

澳門地區 2006 年惡性腫瘤死亡監測研究………………吳懷申瞿國英 171 執行副主編,編輯部主任吳懷申肝內鈣化灶的臨床分析…………………………………楊少華豆志強 177

出版和發行澳門特別行政區政府衛生局綜述和講座

印刷中藥對骨髓間質幹細胞可塑性的影響何敏………………陳運賢陳嘉榆 180 澳門文寶印務有限公司鼻咽部血管纖維瘤的診斷和血管內栓塞……黃祥龍何偉釗莫家寶等 183 澳門慕拉士大馬路激成工業中心第二期十一樓 J 座遠程醫學技術在澳洲的應用…………………………………………陳迺志 186 電話: (+853)-28481581 傳真: (+853)-28527546 電郵: [email protected] 短篇和病例報告

國際標準刊號路易體癡呆—附 2 例報告…………………………李延峰梁惠怡韋東尼 191 ISSN 1608–7801 喉氣囊腫的 CT 診斷—附 1 病例報告………………………………楊貞勇 194

冬季成人傳成人手足口病 2 例……………………李彩珠巢和安甄健榮 196

突發性聾的發病時間規律與血液流變學的關係………………………… 198 愛滋病合併馬爾尼菲青霉菌感染的胸部影像學表現…………………… 198 不同方法治療圍絕經期及絕經後婦女抑鬱症的療效分析……………… 199 手術後患者疼痛控制滿意程度狀況及影響因素的研究………………… 199 信息和動態 2006 中國科協年會在北京召開…………………………………………………………………………尤淑瑞 200 預防醫學新進展研討會在澳門舉行……………………………………………………………………尤淑瑞 202 廣州市科普創作工作座談會在廣州舉行……………………………………………………………尤淑瑞 203 澳門地區醫學學術會議簡報……………………………………………………………………………姚立德 204

工具和資料非麻醉醫師使用鎮靜 / 鎮痛藥物指南………………………………………………孫傳江曹麗勤廖自偉 205 《中華放射腫瘤學雜誌》簡介…………………………………………………………………………吳懷申 208 最新藥物資料…………………………………………………………………………澳門衛生局藥物事務廳 210

新書介紹《現代臨床腫瘤學》一書出版…………………………………………………………………………吳懷申 215

【澳門醫學雜誌】2007 年稿約 (中文, 葡文, 英文) ……………………………………………………………… 212

本期責任校對：姚立德葡文英文翻譯和校對：Jorge Humberto MORAIS，林明理，姚立德

Revista de Ciências da Saúde de Macau ® 澳門醫學雜誌

Trimestral Lançamento da revista em Abril de 2001 Volume VII Número 3 1 de Setembro de 2007

Organização Serviços de Saúde(SS) da Região ÍNDICE Administrativa Especial de Macau (RAEM) Dissertação e Investigação Inquérito sobre o consumo do tabaco na juventude Gabinete Editorial de Macau em 2005…………………………………………………… 153 Conselho Editorial da RCSM CHAN Tan Mui, U Veng Ian CP 3002 RAEM Análise do sindroma nefrótico idiopático da criança no Centro 3o piso, Hospitalar Conde de São Januário, Serviços de Saúde……………… 159 Edifício da Administração dos LAI Man Hou Serviços de Saúde de Macau Tratamento cirúrgico do pesudoaneurisma de fístula arteriovenosa para Tel : (+853)-390-7307, 390-6524 hemodiálise…………………………………………………………… 162 Fax: (+853)-390-7304 ZHENG Yuehong, GONG Qi, SONG Dewei, e outros E-mail: [email protected] Uma auditoria sobre a prevenção e tratamento das úlceras de decúbito http://www.ssm.gov.mo em doentes com cancro em fase avançada………………………… 164 KUOC Im Meng, SHAM Mau Kwong Editor-Chefe Tratamento conjunto do stenting ilíaco com a plastia profunda por KOI Kuok Ieng (瞿國英) isquémia aguda da extremidade…………………………………… 168 LIU Changwei, ZHENG Yuehong, GUAN Heng, e outros Editor Geral Estudo da mortalidade causada por tumores malignos na região de Huai-Shen WU (吳懷申) Macau no ano 2006…………………………………………………… 171 Huai-Shen WU, KOI Kuok Ieng Edição Análise clínica da calcificação intrahepática…………………………… 177 Serviços de Saúde(SS) da RAEM YANG Shao Hua, DOU Zhi Qiang

Impressão Revisão e Palestras Tipografia Man Bo Lda. Efeitos da Medicina Tradicional Chinesa na plasticidade das stem Tel : (+853)-28481581 cells da medula óssea………………………………………………… 180 Fax: (+853)-28527546 HE Min, CHEN Yun Xian, CHEM Jia yu E-mail: [email protected] Diagnóstico e embolização endovascular dos angiofibromas nasofaríngeos………………………………………………………… 183 HUANG Xianglong, MOK Ka Pou, HO Wai Chio, e outros Acesso Remoto aos Serviços de Saúde graças à tecnologia de informação na Austrália……………………………………………… 186 ISSN 1608-7801 CHAN Nai Chi

©2007 Propriedade : Serviços Relatório Sucinto e Estudo de Caso de Saúde(SS) da RAEM Demência dos corpos de Lewy : relatório de dois casos……………… 191 LI Yanfeng, LEONG Wai I, Antonio VICTAL Diagnóstico do laringocelo pela tomografia computorizada…………… 194 Yang Zhen –yong Dois casos de doença das mãos, pés e boca transmitida por adultos… 196 LEI Choi Chu,CHAO Wo On, João Paulo Chin Resumos de Artigos Médicos Internacionais Introdução de tecnologia básica na segurança alimentar no 10º. plano de 5 anos…………………………197 Diagnóstico e tratamento da dôr da coluna de orgiem discal………………………………………………197 Estudo da relação entre o início da surdez súbita e a reologia sanguínea…………………………………198 Aspectos da imagem torácica da peniciliose marnefei em doentes com SIDA……………………………198 mulheres em período perimenopausa e pósmenopausa com depressão……………………………………199 Avaliação da satisfação do doente com o tratamento da dôr pós intervenção cirúrgica e factores que influenciam……………………………………………………………………………………………199

Artigos da RCSM (em chinês, português e Inglês) …………………………………………………………………212

Revisão em chinês: IO Lap Tak Revisão Português / Inglês : Jorge Humberto MORAIS, LAM Meng Lei, IO Lap Tak

Health Science Journal of Macao ® 澳門醫學雜誌

Quarterly Established in April 2001 Volume VII Number 3 September 1, 2007

Sponsor CONTENTS Department of Health of Macao

Special Administrative Region Original Articles and Research of Macao ( MSAR ) Macao Global Youth Tobacco Survey 2005………………………………… 153

CHAN Tan Mui, U Veng Ian Editorial Office Analysis of idiopathic nephrotic syndrome of children in Centro Hospitalar Editorial Committee of HSJM Conde De S. Januàrio, Serviços De Saùde…………………………………… 159 3rd floor, LAI Man Hou Administrative Building, Surgical Management of Pseudoaneurysm of Arterialvenous fistula for renal Department of Health of Hemodyalysis……………………………………………………………… 162 Macao, CP3002, MSAR ZHENG Yuehong, GONG Qi, SONG Dewei, et al Tel : (+853)-390 7307, 390 6524 An Audit of the Prevention and Management of Pressure Sores in Patients Fax: (+853)-390 7304 with Advanced Cancer ……………………………………………………164 E-mail: [email protected] KUOC Im Meng, SHAM Mau Kwong Website: http://www.ssm.gov.mo Combinative Treatment of Iliac Stenting with Profoundoplasty for Critical

Extremity Ischemia……………………………………………………… 168 Editor-in-Chief LIU Changwei, ZHENG Yuehong, GUAN Heng , et al KOI Kuok Ieng (瞿國英) Macao: Surveillance of Mortality of Malignant Tumors in 2006 ………… 171

Huai-Shen WU, KOI Kuok Ieng Executive Editor-in-Chief Clinical analysis of intrahepatic calcification……………………………… 177 Huai-Shen WU (吳懷申) YANG Shao Hua, DOU Zhi Qiang

Publishing Collective Reviews and Lectures Department of Health of The Effects of traditional Chinese medicine on Plasticity of Bone Marrow MSAR Mesenchymal Stem Cells………………………………………………… 180

HE Min, CHEN Yun Xian, CHEM Jia yu Printing Diagnosis and Endovascular Embolization of Nasopharyngeal Tipografia Man Bo Lda. Angiofibromas …………………………………………………………… 183 Tel : (+853)-28481581 HUANG Xianglong, MOK Ka Pou, HO Wai Chio, et al Fax: (+853)-28527546 Remote Access to Health Services via Information Technology in E-mail: [email protected] Australia………………………………………………………………… 186

CHAN Nai Chi ISSN 1608-7801

Short Report and Case Report

…………………………… Copyright © 2007: Dementia of Lewy’s Bodies: Two Cases Report 191 LI Yanfeng, LEONG Wai I, Antonio VICTAL Department of Health of CT Diagnosis of Laryngocele……………………………………………… 194 MSAR Yang Zhen –yong Two Cases of Adult Transmission of Hand, Foot, and Mouth Disease in Winter…………………………………………………………………… 196 LEI Choi Chu,CHAO Wo On, João Paulo Chin Foreign Medical Abstracts Introduction of Key Technology in Food Safety in 10th Five-year Plan…………………………………… 197 Diagnosis and Treatment of Discogenic Low Back Pain…………………………………………………… 197 Study of Relationship Between the Onset Time of Sudden Deafness and Blood Rheology……………… 198 The Chest Image Appearances of Penicilliosis Marneffei in Patients with AIDS………………………… 198 Comparison of Different Antidepression Therapy in Perimenopausal and Postmenopausal Women with Depression………………………………………………………………………………… 199 Assessment of Patient Satisfaction with Postoperative Pain Management and Influence Factors………………………………………………………………………………………… 199

Articles of HSJM to authors ( in Chinese, Portuguese and English)…………………………………………… 212

Proofreader in Chinese : IO Lap Tak Revision Portuguese / English : Jorge Humberto MORAIS, LAM Meng Lei, IO Lap Tak

Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 153

‧論著和研究‧

Macao Global Youth Tobacco Survey 2005

CHAN Tan Mui, U Veng Ian

【Abstract】 Objectives This report describes the knowledge, attitudes and behavior of youth regarding tobacco use, their exposure to environmental tobacco smoke (ETS), pro-tobacco and anti-tobacco advertisement. Methods We conducted a multistage, school-based, two-cluster survey (47 schools, n=2,155) in government and private schools using a standardized questionnaire based on the Global Youth Tobacco Survey (GYTS). Results In the overall sample, prevalence of ever smoking was 42.7% for boys and 33.8% for girls. 38.4% of never smokers and 57.7% of current smokers were exposed to smoke from others in their home. But if only the 13-15 year group was considered, prevalence of ever smoking in this age group was 33.8% for boys and 28.3% for girls. And 11.4% of boys and 9.8% of girls in this age group were current cigarette smokers. In the overall sample, more than 6 in 10 never smokers and 9 in 10 current smokers were exposed to smoke from others in public places. There were more than half of non-smokers who saw a tobacco advertisement and 2.9% of them were offered free cigarettes from a tobacco company representative. Moreover, over 7 in 10 youth bought their cigarettes from stores where 96% of them were not refused to buy cigarettes because of their age. Conclusions Cigarette use among youth has soared since 2000. This will lead to long-term negative effects to the health care system in Macao, as well as the increase in morbidity and mortality caused by smoking related disease. Intervention programs for community, adolescents and school-aged children are strongly recommended. 【Key words】 Global Youth Tobacco Survey; Environmental Tobacco Smoke

2005年澳門全球青少年煙草使用調查陳丹梅, 余詠恩. 澳門, 衛生局, 疾病預防控制中心, 慢性病防制暨健康促進部, Tel:(+853)-28533525; E-mail:[email protected] 【摘要】目的這份報告抽述青少年在煙草使用方面的知識、態度和行為，二手煙、煙草廣告和反吸煙教育信息對他們的影響情況。方法採用多階段的，以學校為調查對象，兩層抽樣的調查方法，問卷以「全球青少年煙草調查問卷」為標準，根據澳門情況修改。調查一共訪問了公立和私立學校 47 間，2 155 個青少年。結果曾經吸煙的男孩有 42.7%，女孩有 33.8%。38.4%的從不吸煙者和 57.7% 的現在吸煙者在他們自己的家受到二手煙的滋擾。13~15 歲年齡組中，曾經吸煙的男孩有 33.8%，女孩有 28.3%，其中 11.4%的男孩是現在吸煙者，9.8%的女孩是現在吸煙者。關於在公共場所暴露於二手煙的情況，超過 60%的從不吸煙者和 90%的現在吸煙者，在公共場所受到二手煙的滋擾。超過一半的從不吸煙者看到煙草廣告和有 2.9%的從不吸煙者接受煙草公司推銷員贈送的香煙。另外，超過 70% 的青少年在士多店購買香煙，他們當中超過 96%的青少年沒有因為他們的年紀少而被拒絕售買香煙。結論澳門自 2000 年到現在，青少年的煙草使用率猛增，這些情況將對澳門的醫療衛生系統造成長遠的負面影響─增加煙草相關疾病的患病率和死亡率。故此，針對社區、青少年和在學兒童的全面煙草控制計劃刻不容緩。【關鍵詞】全球青少年煙草使用調查; 二手煙

INTRODUCTION there are 1.2 billion smokers worldwide. Studies in the developed countries show that most people initiate The World Health Organization (WHO) estimates smoking before the age of 18 years [2,3]. Recent trends that 4.9 millions deaths [1] are caused by tobacco use per show smoking prevalence increases among adolescents and year, with 70% occurred in developing countries. This is women. If these patterns continue, tobacco use will result in expected to rise to 10 million deaths by 2030. Currently, 250 million deaths among children and adolescents alive [4] today, especially in the developing countries .

In Macao, the prevalence of currently use of any Authors address: Health Promotion Division, CDC, Macao Health tobacco product among adolescents in 2000 was 8.0% of Bureau; Tel: (+853) 28533525; Email: [email protected] 154 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 the total students aged between 13 and 15 years, with cross-sectional survey which employed a two-stage 7.0% smoked cigarette and 1.2% used other tobacco cluster sample design to produce a representative sample. product. For never smokers, 11.6% showed that they are Classes ranging from Grade 6 to Form 3 (coincides with likely to start smoking within a year [5]. the age-group 13 to 15) that contained 40 or more students were included in the sampling frame, same as Local legislations that relate to tobacco-control year 2000. 50 schools were selected at the first stage measures remain the same as in the first GYTS in 2000. sampling. 57 classes with a total number of 2 432 This includes the “Consumer Tax Regulation” students were selected to participate in the survey at the (Legislation No. 4/99/M, Legislative Assembly of Macao second stage sampling. Special Administrative Region) which an excise tax of US$ 0.12 is levied for every pack of 20 cigarettes, Macao GYTS 2005 questionnaire consisted of a 56 composing 6% of the retail price. Aside from this, no “core” component and a 13 “optional” component. A other tax is levied on tobacco and tobacco products. weighting factor has been applied to each student participating in the survey to adjust for non response and “Regime on Tobacco Prevention and Limitation” the varying probabilities of selection. The weight used (Nos. 27/96/M and 10/97/M, Legislative Assembly of for estimation is given by: Macao Special Administrative Region) includes the W=W1*W2*F1*F2*F3*F4 restriction on cigarette sales to minors; the restriction of tobacco advertisements on TV and radio; the W1= the inverse of the probability of selecting the enforcement of health warning printed on cigarette school; W2= the inverse of probability of selecting the class packets and the restriction of advertisement at the point within the school; F1= a school-level non response of sales. In addition, the law also bans smoking in places adjustment factor calculated by school size category (small, such as hospitals, health facilities, designated public medium, large); F2= a class adjustment factor calculated by areas in government buildings and schools, etc. school; F3= a student-level non response adjustment factor calculator by class; F4= a post stratification adjustment Goals and Objectives factor calculated by gender and grade.

Macao GYTS focuses on adolescents aged 13-15 Data collection was coordinated by the Chronic years and assesses their level of tobacco-use, the age of Disease Prevention and Health Promotion Division of the initiation, the likelihood of initiating smoking, Health Bureau. Students’ anonymous were protected by knowledge and behaviors related to tobacco use, using self-administered questionnaire and teachers were exposure to environmental tobacco smoke (ETS), as well asked to leave the classroom during the whole process. as youth exposure to prevention activities in school curricula, community programs, and media messages The dataset was entered and then sent to the US preventing/reducing adolescents tobacco use. Center for Disease Control and Prevention for analysis by using EPI INFO V3.3.2. The EPI INFO V3.3.2 was used In addition to these, Macao GYTS 2005 aim to to account for the complex sampling design and weighing monitor the trend of tobacco use since 2000, as well as factors in the data set, as well as to calculate prevalence the effectiveness of enforcement measures. estimates and standard errors. Statistical differences included in this report were determined by comparing the The objectives of Macao GYTS 2005 are: range of the 95% confidence intervals (95%CI). And the differences were statistically significant when the ranges To monitor the level and trend of tobacco use since for the 95%CI did not overlap. 2000; To estimate the age of initiation of cigarette use; To estimate the levels of susceptibility to become a RESULTS cigarette smoker; To estimate the extend of the exposure to tobacco advertising; To identify the key intervening In Macao GYTS 2005, there were 47 schools variables, such as attitudes and beliefs; To evaluate the participating with 2155 students completing usable effectiveness and coverage of major prevention programs questionnaires. This gives an overall response rate of at school level and to establish the subjective opinions of 88.2% response and 54.1% of them are males. those populations regarding such interventions.

METHODS Tobacco Use

Macao GYTS was designed as a school-based For all students, 38.9% had ever smoked a cigarette; Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 155 there was no significant difference between boys and Schools and Tobacco girls (Table 1). For current tobacco use, 17.8% used any tobacco product, 16.2% smoked cigarette and 3.3% used For all students, 62.0% were taught about the other tobacco products. There was no significant dangers of smoking and 29.8% of the students discussed difference between boys and girls. For never smokers, reasons why people their age smoke. There was no 15.2% indicated they are likely to start smoking this year. significant difference between boys and girls.

Table 1 Percent of students who use tobacco Category Ever Smoked Current Use Never Smokers Susceptible Cigarettes, Even One or to Initiating Smoking Other Tobacco Two Puffs Any Tobacco Product Cigarettes Products

Total 38.9 (33.6 - 44.5) 17.8 (13.7 - 22.8) 16.2 (12.2 - 21.1) 3.3 (2.3 - 4.5) 15.2 (13.0 - 17.7) Sex Male 42.7 (36.1 - 49.5) 20.1 (14.6 - 27.0) 18.3 (12.7 - 25.6) 3.6 (2.4 - 5.3) 13.9 (11.5 - 16.8) Female 33.8 (28.4 - 39.7) 15.1 (11.7 - 19.2) 13.6 (10.3 - 17.9) 2.9 (1.8 - 4.5) 16.4 (12.7 - 20.8)

Cessation places, and never smokers were significantly more likely than current smokers to think smoking should be banned Regarding current smokers, 58.1% of the smokers in public places and to think smoke from others is desired to stop and 63.3% tried to stop this year. There harmful to them. was no significant difference between boys and girls. Knowledge and Attitudes Environmental Tobacco Smoke Regarding knowledge and attitudes, 14.9% of never Exposure to second hand smoke was high for all smokers and 21.2% of current smokers thought boys who students in Macao, both at home and in public places, smoke have more friends while 11.7% of never smokers with 38.4% of never smokers and 57.7% of current and 14.9% of current smokers thought girls who smoke smokers exposed to smoke from others in their home; have more friends (Table 3). 4.3% of never smokers and more than 6 in 10 never smokers and almost 9 in 10 11.6% of current smokers thought smoking makes boys current smokers exposed to smoke from others in public look more attractive and 8.2% of never smokers and places. 66.3% of never smokers and 48.7% of current 16.5% of current smokers thought smoking makes girls smokers thought smoking should be banned from public look more attractive. Current smokers were significantly places; and 86.7% of never smokers and 71.7% of more likely than never smokers to think smoking makes current smokers definitely thought smoke from others is boys and girls look more attractive, but the boy harmful to them (Table 2). For the above items, never non-smokers were more likely to think that smoking smokers were significantly less likely than current makes girls look more attractive. smokers to be exposed to smoking at home and in public

Table 2 Environmental Tobacco Smoke

Category Exposed to smoke from Exposed to smoke from Percent think smoking should Definitely think smoke from others in their home others in public places be banned from public places others is harmful to them

Never Current Never Current Never Current Never Current Smokers Smokers Smokers Smokers Smokers Smokers Smokers Smokers

38.4 57.7 65.8 89.6 66.3 48.7 86.7 71.7 Total (34.1- 42.9) (51.2 - 63.9) (62.6 - 68.7) (84.6 - 93.0) (63.2 - 69.3) (42.2 - 55.2) (83.6 - 89.3) (65.3 - 77.3) Sex 35.4 55.8 59.3 88.6 62.5 46.0 85.7 74.5 Male (30.6- 40.6) (46.7- 64.6) (54.9- 63.5) (83.1 - 92.5) (57.9 - 66.9) (34.9 - 57.5) (81.1 - 89.3) (66.4 - 81.2) 41.6 61.7 72.4 90.6 69.8 53.6 87.7 66.0 Female (36.9- 46.5) (54.0 - 68.8) (69.4 - 75.2) (82.6 - 95.1) (66.2 - 73.3) (41.2 - 65.6) (84.1 - 90.6) (56.3 - 74.6) 156 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

Table 3 Knowledge and Attitudes

Category Think boys who smoke have Think girls who smoke have Think smoking makes boys Think smoking makes girls more friends more friends look more attractive look more attractive

Never Smokers Current Never Current Never Smokers Current Never Smokers Current Smokers Smokers Smokers Smokers Smokers

14.9 21.2 11.7 14.9 4.3 11.6 8.2 16.5 Total (12.0-18.3) (14.9-29.2) (9.8-13.8) (9.8-22.1) (3.3-5.6) (7.9-16.9) (6.8-9.8) (11.7-22.8)

Sex

14.2 19.1 12.7 13.5 5.7 11.7 10.7 15.6 Male (10.4 - 19.1) (12.4-28.3) (10.1-15.8 (7.5-23.1) (4.2 - 7.9) (6.9-19.2) (8.4 - 13.4) (10.1 - 23.3) 15.9 24.2 10.8 17.2 3.0 12.1 5.6 18.2 Female (12.7 - 19.7) (15.1-36.3) (8.4-13.8) (10.9-26.0) (1.9 - 4.7) (6.9-20.2) (3.9 - 8.1) (11.6 - 27.2)

Media and Advertising smokers were offered “free” cigarettes by a tobacco Over 8 in 10 students saw anti-smoking media company representative(Table4). Current smokers were messages, 51.8% of never smokers and 52.7% current significantly more likely than never smokers to have an smokers saw pro-tobacco messages in newspapers and object with a cigarette brand logo on it and to have been magazines; 11.1% of never smokers and 25.1% of offered free cigarettes by a tobacco company current smokers who had object with a cigarette brand representative. logo on it; 2.9% of never smokers and 14.3% of current

Table 4 Media and Advertising

Category Percent Saw Percent Saw Pro-Tobacco Percent Who Had Object With a Percent Offered Free Cigarettes Anti-Smoking Messages in Newspapers and Cigarette Brand Logo On It by a Tobacco Company Media Messages Magazines Representative

Never Current Never Smokers Current Never Current Smokers Smokers Smokers Smokers Smokers

85.9 51.8 52.7 11.1 25.1 2.9 14.3 Total (83.8 - 87.8) (47.7 -56.0) (44.6 - 60.7) (9.2 - 13.4) (20.3-30.7) (1.9 - 4.4) (10.3 - 19.5)

Sex

84.3 51.5 53.5 11.9 27.6 3.3 16.8 Male (80.9 - 87.2) (45.7- 57.2) (43.2 - 63.5) (9.0 - 15.5) (20.8-35.6) (2.1 - 5.1) (11.1 - 24.6) 87.5 51.9 52.5 9.9 21.7 2.6 10.9 Female (85.4 - 89.4) (47.8 - 56.0) (42.6 - 62.1) (7.9-12.4) (15.3-29.9) (1.3 - 4.9) (5.8 - 19.7)

Access and Availability group5, there is a 3.4% increase in the prevalence of 12% of current smokers usually smoked at home; young people who ever smoked cigarettes, a 3.4% 73% of current smokers purchased cigarettes in a store; increase in current cigarette smoker, and a 0.9% increase and 96% of current smoker who bought cigarettes in a in current user of other tobacco products. There is a 3.3% store who were not refused because of their age. increase in ever smokers who first smoked cigarette before age 10. Susceptibility of never smokers who likely to initiate smoking by next year has gone up by Changes in Prevalence of Tobacco Use and other 3.5%. There was no significant difference between the Factors among 13~15 year group data in 2000 and 2005.

Comparing data in 2000 and 2005 in 13~15 year Confine to 13~15 year group, the data in year 2000 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 157 and year 2005 are compared and described as follow: the younger population even though the effort towards curbing the smoking behavior has escalated. The effort Knowledge and attitude: When comparing between made by tobacco industry is greater than any other data in 2000 and 2005, there is a significant decrease in sector in promoting their products. The tobacco the numbers of youth who think boy-smokers are more industry duped the younger generation by giving lots of attractive but a significant increase in the numbers of false hope. This is a challenge for the Health Bureau. youth who think girl-smokers are more attractive. Smoking is one of the main causes for many chronic diseases, at least six devastating chronic diseases – Exposure to smoke: Comparing the data in 2000 heart disease, cancer, cerebral vascular diseases, and 2005, more youth have got one or more parents who diabetes mellitus, chronic obstructive pulmonary smoke. Also, more youth reported in 2005 that all or diseases and atherosclerosis. most of their best friends smoke. More youth are now exposed to smoke in homes and public places than in RECOMMENDATIONS 2000. On the other hand, more youth were in favor of banning smoking in public places, and there was From this repeat survey, the use of cigarettes and significantly more youth who think that smoke from other tobacco products by young people has significantly others is harmful to them. increased. Therefore, comprehensive and stronger intervention programs as well as school-based School curriculum: Comparing the data in 2000 and tobacco-use prevention program should be applied: 2005, there is a significantly decrease in number of classes that taught youth about the dangers and effect of 1. Strengthen information, education and communication smoking. On the contrary, the number of classes, campaigns on the health effects of tobacco in all settings discussing about the reasons why people of their age such as schools, community and workplaces. smoke, has increased but without any significant difference. 2. Reduce adolescent’s exposure to misleading and faulty tobacco industry advertisements through banning Media/Advertising: Comparing the data in 2000 and pro-tobacco advertisements and all forms of tobacco 2005, more youth have seen anti-smoking media promotion such as sport events and the offer of cigarettes messages and more youth have seen advertisements for to minors. cigarettes in places that sell cigarettes. Fewer youth have seen cigarette-advertisements or promotions in 3. Reduce exposure to environmental tobacco smoke newspapers or magazines and fewer youth have an object through stronger anti-smoking legislation. In particular, with a cigarettes brand logo on it. there is an urgent need to extend the smoking ban in more public places. Cessation: Comparing the data in 2000 and 2005, fewer current smokers want to stop smoking and tried to 4. Reduce youth access to tobacco products through stop smoking last year, there is a rise in the number of effective law enforcement in restricting the sales of current smokers who always feel like having a cigarette tobacco products to persons aged under 18, as well as first thing in the morning. further legislation on increasing tobacco taxes or prohibiting the sale of cigarettes in vending machines. Access & Availability: Comparing the data in 2000 and 2005, fewer current smokers smoke at home and 5. Establish smoking cessation program in schools fewer youth have been offered a “free” cigarette by a and make this kind of program more accessible for cigarette company representative. In spite of this, current everyone who wish to quit. smokers can now buy cigarettes more easily in a store as they are not refused for their age. 6. Continue the monitoring of tobacco use and other risk behaviors in youth and also the general CONCLUSION population. The Global Youth Tobacco Surveillance and Behavioral Risk Factor Surveillance should be conducted The prevalence rate is alarming and the new periodically to provide efficient evidence for effective smokers are always on the increase specifically among tobacco control. 158 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

ACKNOWLEDGMENTS some way to this study.

This survey was supported in full by the Health REFERENCES Bureau, Macao SAR. We would like to thank Dr Charles

W. Warren, Fellow Statistician, Office on Smoking and 1 Murray, CGL, Lopez, AD. Alternative projections of Health, US CDC for his contribution to the study design mortality and disease by cause, 1990-2020; Global Burden and technical assistant. We also would like to thank the of Disease Study, Lancet 1997, 349: 1498-1504. World Health Organization, Western Pacific Region for 2 US Department of Health and Human Services, the support in technical training, especially to Mr. Burke Preventing Tobacco Use among Young People: A Report Fishburn, Regional Coordinator, Tobacco Free Initiative of the Surgeon’s General, Atlanta, Georgia, US and Mr. Jonathan Santos, Technical Officer Department of Health and Human Services, Public Health WHO/WPRO. Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and

Health Promotion, Office of Smoking and Health, 1994. The following Departments and individuals have 3 Secretary of State for Health and Secretaries of State for contributed towards the successful implementation of Scotland, Wales and Northern Ireland. Smoking kills. A this survey: Mr Nathan Jones, Demographer. Ms Juliette Lee, White Paper on Tobacco, 30 November 1999. London, Epidemiologist. Ms Lela Mcknight, Psychologist. H.M. Stationary office, 1999. 4 Peto, R. Developing populations: The future health effects Education and Youth Affairs Bureau, US Centers of current smoking patterns. In mortality from Smoking in For Disease Control and Preventive – Office on developed countries, 1950-2000. Oxford: Oxford University Press, 1994: A101-103. Smoking and Health. 5 Chronic Disease Prevention and Health Promotion Division, Health Bureau, of the Government of Macao Headmasters, headmistresses of the selected schools Special Administrative Region. Youth Tobacco Survey in and students participated in the survey. Also, all others, Macao (2000). A Component of The Global Youth whose names were not mentioned, had contributed in Tobacco Survey, 2005.

Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 159

‧論著和研究‧

澳門仁伯爵綜合醫院兒童不明原因性腎病症候群病人研究

黎文豪

【摘要】目的在於瞭解腎臟綜合症病人對藥物治療之反應，使病人能有達到預期的治療效果。方法搜集由 2000 年 1 月至 2006 年 12 月所有在澳門仁伯爵綜合醫院 0-14 歲，所有有不明原因性腎臟綜合症的兒童病人，追蹤情況進行分析比較，有關年齡、發病率、第一次發病年齡、復發率、藥物療效及追蹤合併症情況。結果 28 例患病者男性較女性多，男女比例為 1.5：1。發病年齡中，男性 4 歲發病率最多；而女性則 2 歲發病率最多。復發少於二次之病患者，不論男女，其對單一類固醇，有良好反應。在 3 至 4 歲期間發病，不論男女，則較容易產生多次復發，但腎臟綜合症的病人，對類固醇仍然是最有效的治療方法。結論對腎臟綜合症的病人，首選仍用單一類固醇治療。若病人是類固醇依賴者，則須加用環磷酸氨；多次復發者，則須考慮用驍悉 (mycophenolate mofetil MMF)，才能作鞏固性療法，這樣才能有效提高病人的治癒率，減少病人痛苦的時間及減少病人家庭的負擔。【關鍵詞】腎臟綜合症; 類固醇; 腎病症候群; 蛋白尿

Analysis of idiopathic nephrotic syndrome of children in Centro Hospitalar Conde S. Januário, Serviços Saúde LAI Man Hou. Department of Pediatria, Centro Hospitalar Conde De S. Januàrio(CHCSJ), Macao SAR, China. Tel:(+853)–28313731-8133；E-mail: [email protected] 【Abstract】 Objective To evaluate the clinical effects on medical therapy of idiopathic nephrotic syndrome. Methods Participants included patients from the pediatric ward and outpatient clinic of Centro Hospitalar Conde S. Januário, Serviços Saúde from January 2000 to December 2006. There were 28 patients (age 0-14 years) with idiopathic nephrotic syndrome that were studied. These studies included the comparison of age, incidence, the 1st relapse age, the frequent relapse rate, medical effects and follow-up situation. Results These 28 idiopathic nephrotic syndrome patients (17males, 11females) were: Males patients have the highest incidence at 4 years of age, but female patients appeared to have a highest incidence at 2 years of age. With the attack at 3 to 4 years old episode, they tend to relapse easily in the later times. Conclusion Nephrotic syndrome patients showed satisfactory results on single prednisolone treatment, while those patients with prednisolone-dependent or frequent relapse patients, Cyclophosphamide, Cyclosporin, Levamisole and Mycophenolate Mofetil were the suggested treatment. 【Key words】 Nephrotic syndrome; Prednisolone; Nephrosis syndrome; Proteinuria

材料與方法結果

搜集由 2000 年 1 月至 2006 年 12 月所有在澳門仁分析 28 名病患中，男性較女性多，男性 17 人，伯爵綜合醫院 0 至 14 歲，所有有不明原因性腎臟綜合女性 11 人。男女比例為 1.5：1[1]。年齡分佈，男性多症的兒童病人，包括兒科門診及住院病患，進行追蹤分佈在 5 至 10 歲間，總共 10 例，佔 58.8%；而女性病情作分析比較。診斷為不明原因性腎臟綜合症病分佈則比較平均。分析 28 名病患中，不分男女，復發人，共有 28 例。分析統計所有個案之病歷表，進行有一次者，有 13 人，佔 46.4%，而從未有再復發者，意關年齡、性別、發病率、第一次發病年齡、復發率、思即發病一次後，不再有發病者，佔 53.6%。男性 17 復發年齡、復發次數、及對藥物之療效與及追蹤合併人中，有 9 人再次發病，佔 52.9%。女性 11 人中，有症等情況。其中治療藥物包括類固醇、環磷酸氨、環 6 人再次發病，佔 54.5%。分析 28 名病患第一次發病包素、左旋咪唑(Levamisole)及驍悉(MMF)等等。年齡，男性分佈由 1 歲至 8 歲，而其中以 4 歲病發最多，共 8 例，佔 47%。女性分佈由 2 歲至 8 歲，而其

作者單位：中國, 澳門特別行政區, 仁伯爵綜合醫院, 兒科中以 2 歲病發最多，共 5 例，佔 45.5%，詳見表。分 Tel: (+853)-28313731-8133；E-mail:[email protected] 析復發少於 2 次之病患者，男性 10 人中，佔 58.8%。 160 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

其治療是採用單一類固醇治療，有極良好的反應。及驍悉(MMF)等等。甚至有 2 名病人停藥 6 年，而其中 1 病人已停藥 8 年。女性 8 人中，佔 72.7%。其治療亦是採用單一深入研究類固醇依賴的病人，據文獻報告，可加類固醇治療，亦有相當良好的療效[3]。其中有 2 名入左旋咪唑(Levamisole)來達至緩解，但觀察研究此類病人停藥 6 年，1 名病人已停藥 7 年。分析復發多病人，未能達到其預期效果。另外，加入環磷酸氨，於 2 次之病患者，男性 7 人中，佔 41.2%。女性 3 對於經常性復發者，只能有短時間的緩解。對於加入人中，佔 27%。不分男女，其發病年齡多在 3 至 4 環包素，治療效果也不盡理想，往往病人減藥後不久歲期間，其治療並不是採用單一類固醇治療，而須即復發。對於多次復發很難控制的病患，最終只能靠加入其他藥物作主要或副助治療。其中治療藥物包一種比較新、副作用比較少的藥驍悉(MMF)來治療，括類固醇、環磷酸氨、環包素、左旋咪唑(Levamisole) 頗有成效，仍繼續須長期追蹤病人。

表 2000-2006 年在澳門仁伯爵綜合醫院 0-14 歲不明原因性腎臟綜合症病人病患姓名出生年齡性別發病齡復發次已停藥輔助藥腎穿

1 Ho WI 1990-02-22 14 M 1 1 6 2 Ng TI 1994-09-03 11 M 1 0 1 3 Lai CI 2000-07-23 5 M 1 7 p 4 Wonf SH 1993-05-07 12 M 6 6 0 L 5 Ho HI 1997-07-12 8 M 4 5 P,L 6 Lam KH 2000-11-07 5 M 4 0 1 7 Ng KF 2003-09-07 2 M 2 2 P 8 Ng IH 1997-03-01 8 M 4 0 4 9 Lou CW 1995-04-07 10 M 4 3 P 10 Chan CK 1999-03-03 6 M 4 0 3 Y 11 Lei KH 1996-02-13 10 M 3 4 P,CP,CA Y 12 Cheang CI 1996-01-03 10 M 8 0 1 13 Lei SC 1991-06-02 14 M 4 9 P,CP,L,CA,M Y 14 Cheang CI 1999-10-15 6 M 3 4 0 15 Cheang KF 1993-01-02 13 M 5 0 8 16 Ku HS 1995-06-02 11 M 4 0 6 17 Lam KH 2000-11-07 5 M 4 0 1 18 Tam WS 1997-09-01 8 F 4 0 3 19 Lee WY 2002-01-10 3 F 2 1 1 20 Wong UC 2004-01-02 2 F 2 0 1 21 Hoi KN 1997-03-18 8 F 4 2 P 22 Kam KC 1994-12-12 11 F 5 0 6 23 Lam HK 1993-08-16 12 F 8 8 P,L,R 24 Lam IC 1998-09-02 7 F 4 5 P 25 Au ML 1991-08-03 14 F 7 0 7 26 Wong LT 1998-05-03 7 F 2 2 2 27 Chong SI 2000-09-05 5 F 2 0 3 28 Ieong HC 1995-06-09 10 F 2 3 4 Y P: 類固醇; CP: 環磷酸氨; CA: 環包素, L: 左旋咪唑, M: 驍悉; R: 雷米普利(Ramipril); Y: 腎臟穿刺: 微小變化腎臟綜合症

討論漿蛋白降低(每百毫升小於三公克或每升小於 25 公克)。兒童腎病症候群最普遍，約佔 90%，在大人則佔腎臟綜合症即是腎病症候群，是由於腎臟腎絲球 15%~30%左右[1]，其原因不明。可分為原發性與繼發通透性增加，大量血漿蛋白流失至尿液中(每天超過三性兩大類。原發性腎病症候群是不明原因的疾病所引點五公克或大於 40 毫克每平方公里每小時)，造成血起的。通常表現為小便有泡沫、下肢及全身浮腫、高 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 161

血脂。有些病人會有高血壓、血尿及腎功能異常的現依賴者，首先可加入左旋咪唑嘗試[4]，如果不能達成象，若沒有持續控制，可能進行到腎衰竭。預期的效果，可加環磷酸氨來治療，必定會得到短期的緩解療效[2]。用環磷酸氨來治療，必須小心注意它治療方法可分為幾方面的副作用，容易引起出血性膀胱炎。對於環包素，暫不建議使用，因為除了此藥腎毒性強，又容易引起停 1 水腫處理原則：應避免過度運動、儘量臥床休藥後復發[2]。目前，對於單一高劑量類固醇治療，得息及限制鹽份的攝取，必要時添加利尿劑的使用[1]。不到療效，用常用的免疫抑制劑，又怕副作用，可考慮合併用高劑量類固醇與驍悉(MMF)[2]，必能有預期 2 飲食方面：蛋白質攝取量，只要適當，夠營養效果。但是單一高劑量類固醇治療，仍然是腎臟綜合即可，不用刻意太多或太少[1]。症病人首選藥物，有極良好的反應。

3 高血脂症：腎病症候群病人易有脂高血症，因在 28 名病患中，其中男性(病例 13 ) ，曾經多次此要限制高油脂食物的攝取[1]。在治療中，多次復發，有 9 次之多，曾用藥物包括左旋咪唑，環磷酸氨、環包素，仍然不能得到完善的改 4 血栓易有形成：由於抗凝劑因子由尿中流失，善，最後加用驍悉(MMF)，才能達到類固醇漸漸減小，加上利尿劑使用讓體內水分喪失，而使腎病症候群病達至緩解。在另一女性病人(病例 23 )，亦曾經在多次人血液粘稠度提高，容易有血管栓塞的傾向。其中以治療中，多次復發，有 8 次之多，曾用藥物已包括左腎靜脈栓塞最常見，表現出血尿、蛋白尿加劇或腎功旋咪唑[4]、雷米普利(Ramipril)[1]。病人對類固醇反應能惡化的現象，應使用抗凝劑治療[1,5]。良好，復發後加重類固醇量，即有良好之反應。但此病人每次加重類固醇量，眼壓異常增加，所以復發時 5 感染問題：由於免疫球蛋白自尿中流失，加上只能用減量之類固醇，結果不能達到預期的效果。營養不良，服用類固醇等免疫抑制劑，腎病症候群的病人抵抗力較常人差，容易發生感染。因此，患者平在 28 名病患當中，有 4 名病人曾做腎臟穿刺，結日應特別注意自身的調養及衛生，避免過度勞累。一果全部病人的病理結果，都是微小變化腎臟綜合症但感染發生，應立即接受抗生素治療[1]。 (Minimal Change Nephrotic Syndrome)[5]。此與一般文獻比較，85%~90%不明原因性腎病症候群病人之分析 6 藥物治療：主要以類固醇及免疫抑制劑為主，一研究頗為接近。般需兩至三個月以上高劑量類固醇的治療，等到病情改善後，逐漸減量，不宜自行停藥，以免疾病復發加重[2,3]。參考文獻

本文目的在於瞭解不明原因性腎臟綜合症病人， 1 Richard EB, Robert MK, Hal BJ. Nelson Textbook of Pediatrics, 17th edition, Saunders: 2003.1754-1756. 在何時發病，發病率多少？復發年齡偏向怎樣，復發 2 GB Haycock. 25th C Elaine Field Lecture. Management 率又是多少？第一次發病年齡又如何？藥物之療效及 of Steroid Sensitive, Nephrotic Syndrome: Hong Kong 追蹤合併症之情況。對治療的情況，以及藥物的反應， Journal of Paediatrics (new series), 1998, 3:154-157. 觀察病人怎樣才能達到較好的治療。 3 Neuhaus TJ, Fay J, Dillon MJ, et al. Alternative treatment to corticosteroids in steroid sensitive

idiopathic, Nephrotic syndrome: Arch Dis Child, 1994, 綜合分析對於不明原因性腎臟綜合症病人，符合 71:522-526. 有蛋白尿(每天超過三點五公克或大於 40 毫克每平方 4 Levamisole for corticosteroid-dependent nephritic 公里每小時)、血漿蛋白降低(每百毫升小於三公克或 Syndrome In childhood. British. Association for Paediatric Nephrology. Lancet, 1991; 337:1555-1557. 每升小於 25 公克)、水腫及高血脂症[1]。確診後，首 5 Roth KS, Barbara HA, James CM Chan. Nephrotic 選仍然採用單一高劑量類固醇治療，一般來說，可有 syndrome: Pathogenesis and Management. Pediatrics in 其預期效果，仍然是最有效的治療方法。若是類固醇 Review, 2002, 23:237-248.

162 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

‧論著和研究‧

動靜脈瘺併發假性動脈瘤的外科經驗

鄭月宏* 宮琪** 宋德偉** 甘紅兵郭婉儀李超亮張建

【摘要】目的總結在澳門特別行政區仁伯爵綜合醫院(CHCSJ)治療 20 例透析用動靜脈瘺併發假性動脈瘤患者的體會，報告該組動脈瘤診斷治療方式、效果、隨訪等資料。方法自 2004 年 4 月至 2005 年 3 月，在澳門仁伯爵綜合醫院治療透析用動靜脈瘺併發假性動脈瘤(PA)患者 20 例。男性 14 例，女性 6 例，年齡 30~81 歲，平均 63 歲。瘤體最大直徑 2.5cm~6.0cm。均為慢性腎功能衰竭（CRF）長期血液透析患者。上肢假性動脈瘤 16 例，下肢人工血管袢形成假性動脈瘤 4 例。20 例假性動脈瘤均行手術治療。結果手術均順利完成，無手術死亡。手術後均疼痛消失。新建 AV fistula 患者中，短期血栓形成 1 例，手術取栓成功；術後切口出血 1 例，停用低分子肝素後好轉；由於側枝分流 6 周後頭靜脈不能成熟 1 例，結紮側枝靜脈後再切除動脈瘤。一例腦梗塞合併 AV fistula 人工血管袢假性動脈瘤的患者，在 AV fistula 修補手術後三周再發腦梗，經內科治療無效死亡。結論血液透析用 AV fistula 假性動脈瘤的治療，外科手術有其不可替代的優點。應遵守透析用 AV fistula 的養護技術要求，減少動脈瘤的發生。【關鍵字】動靜脈瘺; 假性動脈瘤; 外科治療; 透析

Surgical Management of Pseudoaneurysm of Arteriolvenous Fistula for Renal Hemodyalysis ZHENG Yuehong*, GONG Qi**, SONG Dewei**,GAN Hongbing, KUOK U I, LEI Chaoliang, ZHANG Jian. *Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medial Sciences, Beijing 100730. ** Peoples Hospital of MenYin Country, Shandong Province,China, 276200; Department of general Surgery, Central Hospital Centre S. Januario, Caixa Postal, 3002-Macau 【Abstract】 Objective report our surgical experience of pseudoaneurysms repairment of arteriovenous fistula for renal hemodyalisis at Central Hospital S. Januário (CHCSJ), Macau, in recent 12 months. Methods report 20 patients with pseudoaneurysms repairment of arterialvenous fistula for renal hemodylisis treated at Central Hospital S. Januário. Male14, female 6, age from 30 to 81 years old. 16 AVF pseudoaneurysms in upper extremities, 4 AVF pseudoaneurysms in lower extremities. All patients treated with surgical therapy. Results all procedures finished without operative mortality. 1 new AVF suffer from acute thrombosis, recovered without any complications through instant thrombectomy; 1 postoperative incision bleeding;1 AVF can not mature 6 weeks later, recovered by branch venous ligation; and1 later death due to recurrent cerebral infaction. Conclusions Surgical repairment of pseudoaneurysms of arteriovenous fistula for renal hemodyalisis is still the best choice to these patients vascular center available. However, suitable puncture and nursing technigue could minimize the incidence of pseudoaneurysms of arteriolvenous fistula. 【Key words】 Pseudoaneurysm; Surgical management; Arterialvenous fistula; Hemodyalisis

臨床資料主訴疼痛、搏動性包塊。上肢前臂人工血管袢併發動脈瘤 6 例，自體撓動脈頭靜脈型 AV f i s t u l a 形成自 2004 年 4 月至 2005 年 3 月，在澳門仁伯爵綜假性動脈瘤 4 例，透析穿破肱動脈致假性動脈瘤 1 例，合醫院治療動靜脈瘺併發假性動脈瘤(PA)患者 20 上肢上臂肱動脈肘靜脈型 AV f i s tu l a 形成假性動脈瘤 5 例。男性 14 例，女性 6 例，均為慢性腎功能衰竭（CRF）例，下肢人工血管袢股動靜脈 3 例，下肢股動脈膕靜長期血液透析患者，瘤體最大直徑 2.5cm~6.0cm，為脈人工血管旁路 AV f i s t u l a 形成假性動脈瘤 1 例。20 1~4 個動脈瘤。年齡 30~81 歲，平均 63 歲。16 例合例假性動脈瘤均行手術治療。9 例分二期治療，首先併高血壓史。發現動脈瘤 1 周~7 年。創建一個新的動靜脈瘺，6~8 周瘺成熟後二期切除假性動脈瘤。7 例頸靜脈或股靜脈插臨時透析管後，一作者單位：*通訊作者, 100730, 中國, 北京, 協和醫院, 血管期切除修復或重建動靜脈瘺。全部 4 例下肢動靜脈瘺外科, E-mail:[email protected]; **276200,中國, 山人工血管袢假性動脈瘤均用 Gore-Tex 人工血管修東省蒙陰縣醫院; CP 3002 澳門特別行政區, 仁伯爵綜合醫院, 腎科。補，同時頸靜脈或股靜脈插臨時透析管。 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 163

結果液透析。

手術均順利完成，無手術死亡。新建 AV f istu la 早期穿刺導致假性動脈瘤在超聲引導下壓迫常切除動脈瘤患者中，早期瘺口血栓形成 1 例，手術取可奏效，需要短期停止抗凝和實行無肝素透析，無需栓成功；術後切口出血 1 例，停用低分子肝素後好轉；外科手術干預[2]。最近介入治療已經用於 AV F 假性由於側枝分流 6 周後頭靜脈不能成熟 1 例，結紮側枝動脈瘤的治療。Najibi S 等 [3] 報告用覆膜支架靜脈後再切除動脈瘤。一例腦梗塞合併 AV f i s t u l a 人（wallgraft）隔絕動靜脈瘺的假性動脈瘤 10 例，除 2 工血管袢假性動脈瘤的患者，在 AV f i s t u l a 修補手術例近期透析通路發生血栓外，可延長 AV F 的使用壽後三周再發腦梗，經內科治療無效死亡。命。良好的穿刺技術，適度包紮，合理的透析肝素量可預防假性動脈瘤發生，應加強透析輔助人員、專科手術後均疼痛消失。無充血性心力衰竭、感染、護士的宣教，預防假性動脈瘤這種 AV F 嚴重併發症竊血綜合征、腫脹綜合徵發生，隨診期內未見假性動的發生。脈瘤復發。經修補後人工血管袢或新建動靜脈瘺均可用，惟 1 例透析流量稍低。本組所有病例均隨訪，最長期以來，AV F 真假性動脈瘤的定義較模糊。我長 11 月。們術中發現 2 例人工血管同心均勻擴張，形似真性動脈瘤，未見破裂口存在。查閱文獻未見這種情況的命討論名，應當稱之為真性動脈瘤抑或假性動脈瘤，值得血

管外科界專家們討論命名。本組 AV F 假性動脈瘤中含創建血液透析用 AV f istu la，外科手術有其不可替有靜脈性動脈瘤，這種病例是由於動脈化的靜脈擴張代的優點：直接、方便、手術方式選擇多樣，自體血所致，由於定義界定問題，也歸為本組一併報告。據管為首選，但透析用 AV f istu la 的養護有一定技術要 Patel KR 等[4] 總結 20 年英語文獻僅有 8 例報道，靜脈求，應儘量減少其併發症。外科手術創建透析用 AV 性動脈瘤這種情形的發生率約佔 1.2%（3/236）。澳門 fistula，最常用撓動脈頭靜脈創建 AV f i st u l a ，下肢動為高福利社會，居民壽命長，且慢性腎衰（CRF）患靜脈為次選，在慢性腎衰（CRF）患者，淺表靜脈常者為全免費，因而許多患者常經過多達 10 餘次的 AV 常閉塞，也可選用自體靜脈移植、e-PTFE 人工血管創 fistula 手術，長期併發症多，假性動脈瘤發病率相對建 AV f i s t u l a ，或深靜脈永久插管，具體手術方式多較高，再次手術較困難。樣。AV f istu la 常見併發症有血流量不足（吻合口狹窄、側枝分流、靜脈不能成熟）、充血性心力衰竭、血栓形成、感染、竊血綜合征、腫脹綜合征、假性動脈參考文獻瘤等。假性動脈瘤的形成對病人危害較大，有大量失 [1] 1 鄭月宏, 管珩, 劉昌偉, 等. 複雜主動脈瘤破裂的搶救. 血的風險，且由於逐漸增大的特性，常需外科干預。中華普通外科, 2003, 18:178-179. 2 Witz M, Werner M, Bernheim J, et al. Ultrasound-guided 外科手術治療是最主要的方法，可採用修補 compression repair of pseudoaneurysms complicating a AV F、切除假性動脈瘤重建新 AVF、結紮等術式，但 forearm dialysis arteriovenous fistula. Nephrol Dial Transplant. 2000, 15:1453-1454. 需要注意術中血栓脫落導致肺栓塞的危險。假性動脈 3 Najibi S, Bush RL, Terramani TT, et al. Covered stent 瘤大多有附壁血栓形成，術中謹慎操作、輕柔取栓、 exclusion of dialysis access pseudoaneurysms. J Surg Res. 血液倒流等可減少肺栓塞的發生。即時透析處理可採 2002, 106:15-19. 4 Patel KR, Chan FA, Batista RJ, et al. True venous aneurysms 用同期臨時靜脈插管透析，如果人工血管袢修補，則 and arterial "steal" secondary to arteriovenous fistulae for 無需同期臨時靜脈插管，可直接用未修補段穿刺行血 dialysis. J Cardiovasc Surg (Torino). 1992, 33:185-188.

164 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

‧論著和研究‧

An Audit of the Prevention and Management of Pressure Sores in Patients with Advanced Cancer

KUOC Im Meng SHAM Mau Kwong

【Abstract】Objective This audit was undertaken to evaluate the outcome of prevention and management of pressure sores in the Hospice and Palliative Care Center (HPC) of Kiang Wu Hospital before and after the issue of clinical guidelines. Methods Records of patients admitted from 15 April 2005 to 15 August 2005 were reviewed (Phase I). Their Braden scores, bedsore grades and improvement, and demographic data were recorded. Guidelines for prevention and management of bedsores were promulgated among palliative care team members. Educational programs on bedsore prevention and management were conducted. A prospective audit was then conducted between 15 September 2005 and 15 January 2006 (Phase II) on the prevention and management of bedsores in patients admitted during this period, and the data collected compared with those in Phase I. Results In Phase I, 76 patients were reviewed. In Phase II, 88 patients were studied. In Phase I, before the issue of guidelines and implementation of education programs, 17.1% of patients developed bedsores during their stay in HPC. In Phase II, although the mean length of stay was longer, fewer patients (11.4%) developed bedsores during their stay in HPC. In Phase I, 42.9% of patients with bedsores had their bedsores improved by at least one Grade according to the bedsore grading tool. In Phase II, improvement of bedsores was found in 60.9% of patients. Conclusions This audit project revealed that our strategy for prevention and management of bedsores, with promulgation of guidelines and implementation of education programs, was effective. Education programs for the prevention of bedsores should be continued, and further audits conducted, to achieve an even higher standard of prevention and management of bedsores in future. 【Key words】 Medical audit; Pressure sores; Pain; Odours

末期癌症病人的褥瘡預防及處理措施的調查報告郭艷明, 沈茂光. 澳門, 特別行政區, 鏡湖醫院, 康寧中心, Hospice and Palliative Care Center, Kiang Wu Hospital. Macau SAR, China; Tel: (+853)-2951608: E-mail: [email protected] 【摘要】目的此次調查報告是評估在臨床指引發出的前、後，鏡湖醫院康寧中心的褥瘡預防及處理措施。方法對第一階段(2005 年 4 月 15 日至 2005 年 8 月 15 日)入院的病人的記錄作回顧，記錄了他們的 Braden 評分，褥瘡級數，改善程度及統計學的數據，然後向團隊工作人員發佈褥瘡預防及處理措施的臨床指引，並給與在此方面的教育指導，之後再對第二階段的入院病人(2005 年 9 月 15 日至 2006 年 1 月 15 日)的褥瘡預防及處理措施作預期的調查，並將之與第一階段的數據作比較。結果在第一階段對 76 個入院病人的資料作回顧，而第二階段則有 88 個病人，在第一階段，在臨床指引發出及教育計劃實行前，有 17.1%康寧中心住院病人新發褥瘡，在第二階段，雖然病人平均住院時間較長，但較少的住院病人(11.4%)新發褥瘡，在第一階段，42.9%的褥瘡病人的褥瘡最少被改善Ⅰ度，而在第二階段，則有 60.9%的褥瘡病人的褥瘡有改善。結論此次調查計劃顯示出我們在預防處理褥瘡方面的措施、臨床指引的發佈及教育計劃的實行是有效的。為將來在褥瘡的預防及處理措施達到更高的標準，我們必須在褥瘡方面持續教育及作進一步的調查計劃。【關鍵詞】醫學調查; 褥瘡; 疼痛; 臭味

INTRODUCTION sore development. Bedsores are indeed common in patients receiving palliative care for multiple, Pressure sores are common in many health settings progressive pathologies and they affect 20% of ill over the world, and are costly in terms of human suffering patients[1]. The Department of Health in the United and use of resources. Patients in advanced cancer Kingdom suggests that pressure sores are a key indicator receiving palliative care may be at particular risk of pressure of the quality of care provided by a hospital [2].

Author’s address: Hospice and Palliative Care Center, Kiang The most important contributing factors to the Wu Hospital. Macau SAR, China; Tel: (+853)-2951608: development of bedsores are: pressure, friction, E-mail: [email protected] immobility, dehydration, malnutrition and age [3]. The Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 165 principles of pressure sores prevention are: risk then it may be more appropriate to improve the physical assessment, skin assessment and care, positioning, and (pain, odour or bleeding) and mental condition of the the use of pressure-reliving equipment [4] .The principles patient to the degree feasible [4]. of wound management involve adequate assessment of the patient and wound, the setting of appropriate goals, In September 2005, the Hospice and Palliative Care and evaluating progress. Management is according to the Center (HPC) issued clinical guidelines (Figure 1) for grading of the pressure sore. An ideal dressing should be preventing and managing pressure sores in advanced cancer. capable of maintaining moisture, protecting the wound An audit project was conducted to evaluate our practice before from further trauma or infection, comfortable and and after the issue of guidelines, so that practice standards cost-effective [5]. If healing is not the goal of treatment could be compared and improvement areas identified.

Figure 1 Summary of Guidelines for Prevention & Table 1 Outcome of Bedsores Management of Bedsore in HPC Parameters Phase I Phase II st Admission (1 day) Total No. of patients 76 88 ↓ Newly developed bedsores 13 10 Assessment Carry in 15 13 ↓ Duration of hospitalization 21.5 days, 29.5 days, Is there any Mean, median (range) 14 days 15 days bedsore? (1-114 days) (1-214 days) ↙ ↘ Age Mean, median 69 y, 74 y 69 y, 72 y YES NO ↓ ↓ Patients with Braden score ≤ 16 B + C A and Total No. of patients 42(55.3%) 57(64.8%) Risk assessment with Newly developed bedsore 4 7 Braden Scale Carry in 14 13 score≤16 → assess qd Bedsore grade 16~20 → assess qw Newly developed → >20 just assess on Grade I 7 5 admission & discharge Grade II 6 5 Grade III 0 0 A. PREVENTION OF BEDSORES Grade IV 0 0 Carry in 1 Repositioning of patient by turning q3h, use pillows Grade I 4 3 at strategic locations. Grade II 10 9 Grade III 1 1 2 Skin assessment Grade IV 0 0 (1) Inspection should be done regularly and the frequency Mean Braden subscale score should be determined by individual need; (2) Skin inspection Sensory perception 2.75 2.7 should include assessment of the most vulnerable to pressure Moisture 2.8 3 damage such as heels, sacrum and ischial tuberosities. Mobility 1.5 2.2 Activity 2.1 2.5 3 Skin care Nutrition 1.6 1.7 (1) Keep clean; (2) Prevent or treat dry skin – simple Shear & friction 1.4 1.4 moisturizers; (3) Use a barrier cream (e.g. Zine Oxide) as an Bedsore improvement 12 14 additional barrier to prevent excoriation from urine and feces. Effectiveness Bedsore development 17.1% 11.4% 4 Use of pressure-redistributing equipment (e.g. low Bedsore improvement 42.9% 60.9% air-loss bed) (1) Repositioning q2h; (2) Use of pressure- 5 Mobility redistributing equipment; (3) Rub “Sanyrène” tid on the (1) Try to get the patient out of bed; do not sit patient in area of skin which is at risk or at gradeⅠ (Sanyrène is an chair>2h; (2) Increase circulation to extremities with oil for prevention of bedsores). active or passive exercise. Grade Ⅱ (1) As for Grade I pressure sore, but; B. MANAGEMENT (NURSING CARE) (2) Dressing: apply povidone-iodine (Betadine).

GradeⅠ 166 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

Grade Ⅲ weekly when the score is between 16 and 20). (1) As for Grade I pressure sore, but; (2) Cover with “Fu Bi Kang Shang Ke Tie” dressing. Bedsore Grading Tool: The use of the grading tool is very helpful for describing the severity of bedsore. It Grade Ⅳ has a common feature in that the higher the grade the (1) As for Grade I pressure sore, but; deeper the sore. The grade is from I to IV. (2) Dressings with sugar-povidone-iodine packing (3) Surgical debridement for thick eschar or Sampling and Procedure of Auditing: The clinical extensive necrosis. audit consisted of two phases. In phaseⅠ(before issue of the clinical guidelines), the records of all patients C. MANAGEMENT admitted to HPC from 15 April 2005 to 15 August 2005 (SYMPTOM CONTROL MEASURES) were retrospectively reviewed. In September 2005, guidelines on the prevention and management of Pain: (1) Infection: clean wound with normal saline; pressure sores were promulgated and education programs clinical infection should be investigated with wound were organized for the staff of HPC. Phase II was a swab culture and treated with systemic antibiotics; (2) prospective study from 15 September 2005 to 15 January Systemic analgesics; (3) Use of cushions (e.g. gel 2006. All patients’ Braden scores were recorded. Those cushion) with bedsore development (old and new) were identified and improvement of the bedsores recorded (e.g. from Odour: (1) Topical crushed metronidazole or Grade II to Grade I). systemic metronidazole; (2) Charcoal dressing, and; (3) Debridement of devitalized tissue RESULTS

Bleeding: (1) Topical “ Yunnan Bai Yao”; (2) In phase I, there were 76 admissions. 28 patients Topical adrenaline 1:1 000; (3) Attention to the dressing had bedsores, in which 13 were new developments and cleaning techniques and maintenance of humidity at during their stay in HPC and 15 already had bedsores on the dressing interface. admission (carry in). In phase II, 23 patients had bedsores, in which 10 were new and 13 had bedsores on METHODS admission already.

Setting standards: The prevention and The objectives of treatment in terminally ill patients management of bedsores in palliative care can be are different from those in other patients. Complete cure complicated because of the advanced nature of the of pressure sores is not always possible during the underlying disease or condition, yet the subject is terminal stage of life. So, we imply that bedsore under-researched and therefore not fully formalized improvement is to have degree advanced. (e.g. from into rational standards. grade III to grade II). There were 12 bedsore improvements in phase I and 14 in phase II .Table 1 After discussion among the senior nurses and the shows the outcome of pressure sores in the two phases. consultant of our unit, we defined the acceptable The commonest site of pressure damage was over the standards of bedsore development and improvement sacrum. There were 17 out of 28 patients with bedsores according to our local practice and recommendation of over the sacrum in phase I and 18 out of 23 patients in the bedsore team of our hospital. The bedsore team is a phase II. Moreover, there were 4 patients with two or team whom we consult concerning the development and more bedsore sites in phase I and there were 2 in phase II. management of bedsore of the whole hospital. In phase I, 3 patients’ bedsore grades were assessed inappropriately but this was not found in phase II. Standards: There were 2 patients in phase I and 1 patient in phase II (1) Bedsore develops in less than 15% of the patients who were unwilling to cooperate with the staff to during their stay in HPC. reposition and then they had developed new bedsore (2) Improvement of bedsore during the stay in HPC in soon after admission to HPC. more than 45% of patients. Overall, bedsore development was found in 17.1% Instruments: of patient in phase I, as compared to the set standard of Risk Assessment: The Braden Scale[8] is a 15%. Improvement of bedsores was found in 42.9% in summated rating scale made up of six subscales scores phase II, as compared to the set standard of 45%. After from 1 to 3 or 4, with total scores that range from 6~23. implementation of guidelines and education programs, This assessment is performed by ward nurses on results could reach the set standard, with bedsore admission and reassessed according to the score (e.g. development in only 11.4% of patients in phase II, and assessing once daily when the score ≤ 16, assessing bedsore improvement in 60.9%. Most patients’ bedsore Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 167 symptoms were also well controlled. phase II than in phase I. Bedsore improvement was also higher than that in phase I. DISCUSSION CONCLUSION In the period before issue of the guidelines, there was no unified strategy for prevention, assessment and This audit project showed that our strategy was effective management of pressure sores in HPC. Moreover, use of in decreasing bedsore development and in bedsore dressings was not standardized. As a result, there were improvement. Educational programs for the prevention high variations in the nursing management of bedsores. of bedsore should, however, be continued, structured, This accounted for the effectiveness in that period (phase organized and should be comprehensive, and made I) being below the standards. Although the outcome was available to all levels of health care providers, and not far below the standard, this was not acceptable in a should include patients, family members and other palliative care setting and efforts were made to improve caregivers. Patients receiving palliative care may be at our services. risk of pressure sore development. The dilemma facing

palliative care workers in relation to bedsore prevention The Braden Scale is an excellent nursing assessment is the extent to which bedsores can be avoided without tool for assessing the risk factors for pressure ulceration. eroding patients’ autonomy. It should alert us to the high-risk patients who require our utmost vigilance. Like most risk assessment scales, For example, if a patient wishes to stay in bed all however, the Braden Scale measures only the patient, not the time, how much effort should be paid to persuade the the staff. In our experience, one more predictive factor patient to sit out? How far should palliative care workers could determine whether at-risk patients will develop respect the patient’s autonomy to stay in bed, with pressure sore: who is caring for these patients. Hence increased risk of developing bedsores, and how assertive during the two phases, training of all health care should they be in encouraging the patient to sit out so as professionals in HPC in bedsore prevention and to prevent bedsores? A key requirement is to achieve a management was enhanced by the bedsore team of Kiang balance between respecting individual preferences and Wu Hospital. meeting healthcare goals of patients. This requires

sensitive communication between palliative care workers, Grading of the pressure sore is also essential in patients and their families. This also requires discussion guiding treatment. Dressings could be expensive. In and reflection within the care team. Although this is the presence of financial constraints, it is important something that cannot be written clearly in the guidelines, to consider the cost effectiveness of dressings. we hope that through repeated audits, we can provide a Dressings containing traditional Chinese medicine, higher standard of prevention and management of such as Fu Bi Kang Shang Ke Tie or Yunnan Bai bedsores in future. Yao, was shown to be effective in this audit, although no controlled trials has been conducted comparing these dressings to more expensive ones REFERENCES such as alginates. 1 Waller A, Caroline NL. Dermatologic and Related From the result, we can see that elderly people Problems:Pressure Sore. Ed. Handbook of Palliative Care in are particularly prone to develop bedsores. There Cancer 2nd ed. Woburn: Betterworth-Heinemann, 2000. 91. are some problems common in elderly people that 2 Department of Health, United Kingdom. Pressure Sores: A are associated with pressure sores. These include Key Quality Indicator. London: Department of Health, chronic systemic conditions, dry skin, faecal and 1993. 56:13. urinary incontinence, being confined to chair or bed 3 Grey JE, Enoch S, Harding KG. Pressure ulcers. Br Med J, and terminal illness [3]. After the issue of the 2006, 332:472-475. guidelines and discussion among team members of 4 McDonald A, Lesage P. Palliative management of pressure HPC, individualized bedsore prevention and ulcers and malignant wounds in patients with advanced management strategies were formulated according illness. J Palliat Med 2006, 9:285-295. to the results of risk assessment. These included 5 Jones V, Grey JE, Harding KG. Wound dressings. Br Med turning schedules, skin inspection and activity J 2006, 332:777-780. programs, which were implemented attentively. To 6 Steed DL. Debridement. Am J Surg 2004, 187:71S-74S. improve patients’ nutritional status, the dietitian was 7 Healy B, Freedman A. Infections. Br Med J 2006, 332: consulted to assess and review the high risk patients 838-841. and those with bedsores. After these interventions, a 8 European Pressure Ulcer Advisory Panel. Pressure Ulcer smaller proportion of patients developed bedsores in Treatment Guidelines. Oxford: EPUAP, 1998, 122:71-78.

168 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

‧論著和研究‧

Combinative Treatment of Iliac Stenting with Profundoplasty for Critical Extremity Ischemia

LIU Changwei ZHENG Yuehong* GUAN Heng LI Yongjun LIU Bao YE Wei

【Abstract】Objective To study the combinative therapy of intraoperative iliac stenting with profoundoplasty for high-risk patients with critical extremity ischemia. Methods From July 1999 to March 2004, 26 patients suffering from critical multi-level atherosclerotic occlusive disease (male 19 and female 7, 76 years old on average, totally 31 lower limbs involved) were treated with intraoperative iliac balloon angioplasty, stent deployment combined with simultaneous with profundoplasty. All the patients suffered from severe rest pain for. Mean preoperative ankle-brachial index (ABI) was 0.22±0.17. Results 28 iliac balloon angioplasty and stent placement with simultaneous 31 profundoplasty and 3 femoral to femoral bypass were performed in the 31 limbs of 26 patients. Surgical procedures were technically successful in all of them. There was no postoperative mortality. Post-operative ABI was 0.41±0.15 (P<0.05). The mean follow-up duration was 28 months (range 2~56 months). During follow-up period, in one case it was performed balloon dilatation due to iliac restenosis and one had thigh amputation because of femoral thrombosis and leg acute gangrene. 2 cases died later from myocardial infarction and lung cancer respectively. Six had mild intermittent claudication. One of them presented rest pain again. Conclusion Intraoperative iliac stenting combined with profundoplasty is a safe and effective treatment for those high-risk patients with severe, multilevel atherosclerotic occlusive disease. 【Key words】 Arterial occlusive disease; Stent; Endovascular; Profundoplasty

髂動脈支架結合股深動脈成形治療重症下肢缺血劉昌偉 , 鄭月宏*, 管珩, 李拥軍, 劉暴, 葉煒.100730, 中國, 中國醫學科學院, 北京協和醫院, 血管外科 , * 通訊作者: 鄭月宏, Tel : (+86-10)-65296014; Fax : (+86-10)-65124875; E-mail: [email protected] 【摘要】目的探討術中血管微創治療技術結合外科手術治療重症下肢缺血的初步臨床經驗。方法 1999 年 7 月至 2004 年 3 月，採用術中同時行髂動脈腔内微創治療技術（球囊括張和支架植入）結合肢體運端動脈重建術治療廣泛多節動脈硬化閉塞症 26 例（31 條肢體）。結果術中 28 條髂動脈微創介入治療均獲成功，21 條肢體同時行股～膕動脈人工血管旁路術。本組患者無重要心臟器併發症和手術死亡。平均隨訪時間 28 個月（2~56 個月）。結論術中髂動脈腔内微創介入治療技術結合運端動脈重建術是治療廣泛多節段動脈硬化閉塞症的安全、有效方法。【關鍵詞】動脈閉塞性疾病; 支架; 微創介入治療; 手術

From July 1999 to March 2004, 26 patients and 19 men and 7 women with age arranged from 62 to totally 31 lower extremities suffering from critical 81 years (average 76 years) were included in this series. multilevel atherosclerotic occlusive disease were treated There were totally 31 extremities of severe ischemia with with iliac balloon dilation, stent deployment combined symptom of rest pain, 2 of them combined with simultaneous with profoundoplasty in our hospital. extremity ischemic ulcer, and 3 with toe gangrene. The Reported as follows. mean preoperative ankle-brachial index (ABI) was 0.22±0.17 (0~0.45). The main concomitant diseases CLINICAL MATERIALS included hypertension in 16(61.5%), coronary heart disease in 14(53.8%), diabetes mellitus in 11(42.3%), 1 General data sequelae of cerebral thrombus in 4(15.4%), atrial

Authors address : Department of Vascular Surgery, Peking fibrillation in 3(11.5%), chronic cardiac insufficiency in Union Medical College Hospital, Chinese Academy of Medical 3(11.5%), space occupying lesion within lung in 1(3.8%). Sciences, Beijing, 100730, China; * Correspondence author : Preoperative angiography clearly revealed the existence Tel: (+86-10)-65296014; Fax: (+86-10)-65124875; E-mail: of severe stenosis or occlusion in all of patients: 5 [email protected] Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 169 patients had bilateral iliofemoral lesions while the other profound femoral artery was too small or the lesion 21 had unilateral lesions. extended too wide, autogenous patch of great saphenous vein or prothesis should be applied. If the superficial 2 Criteria for the case choice. Including criteria femoral artery was occluded, the patch might be havested were according to the clinical symptoms and from the proximal superficial femoral artery. arteriography results as follows: 4 Debridement and amputation (1) Old patients with severe internal diseases and not expected to survive after the big operation; Debridement and amputation on the patients with extremity ulceration and necrosis was recommend after (2) Extended iliofemoral artery lesion, severe profundoplasty. stenosis or occlusion of common femoral or deep femoral artery identified by angiography, no suitable outflow track of distal artery for reconstruction. 5 Postoperative managment

Keep close monitor of skin temperature, pulsation of OPERATIVE PROCEDURE distal artery and ankle-brachial index (ABI) of affected extremity. Low molecular weight heparin twice daily 1 Balloon angioplasty and stent deployment for stenosis or occlusion of iliac artery was given subcutaneously. Oral Aspirin or Warfarin was given after discharging. Through a small incision in groin, and the common, superficial and profound femoral arteries were exposed RESULTS respectively under local or regional plexus blocking anesthesia. Inserted the puncture needle into the common 28 iliac artery stent were deployed and 31 profundoplasty were performed successfully for these femoral artery, intrduced a 0.35-inch J-tipped guidewire, advanced a 7F introducer sheath over the guidewire till patients with great saphenous vein patch in 10, prosthesis the common femoral artery but not beyond the arterial patch in 8, arterial patch made from the proximal superficial femoral artery in 5, and no patch in 3 patients. stenosis. A diagnostic angiogram performed under a portable C-arm fluoroscopy before the guidewire passed Three cases of femoral-femoral bypass operation through the stenosis or occlusion. combined with bilateral profundoplasty simultaneously were successful. Compared with the preoperative

After heparinazation, a balloon catheter with 8 mm situation, clinical symptoms obviously improved, the in diameter and 40mm in length was introduced . Then skin temperature increased, and the rest pain disappeared. The ulcer healed gradually after debridement and inflate the balloon slowly to 6~8 ATM for another 30~60 seconds when the balloon inflated completely without amputation,. Postoperative ABI was 0.41±0.15 (0~0.56) any depressed signs. Removed the catheter and deploied (P<0.05). the self-expandable metal stent. Another angiography was then performed to assess the immediate result. 27 cases were followed up for a mean 28- month duration (2~56 months). Among them one needed repeat 2 Traditional femoral-popliteal or superior pubic balloon dilatation due to iliac artery re-stenosis 11 femoral-femoral bypass months later, one accepted thigh amputation for deep femoral thrombosis and acute gangrene two years later. After deployment of the iliac stent and withdrawing One died from myocardial infarction and one for lung the sheath, the traditional femoral-popliteal or superior cancer. Nine presented mild intermittent claudication pubic femoral-femoral bypass was performed with 8mm without rest pain. ePTFE prosthesis graft. The distal end of the prosthesis was anastomosed with the profound femoral artery. DISCUSSION

Severe, multilevel artherosclerotic occlusive disease is 3 Profoundoplasty not only the main cause for severe ischemia of lower A longitudinal femoral artery incision was made and extremity, but also a great challenging for clinics. endarterectomy of the common and profound femoral Conventional bypass had high incidence of complications arteries was performed after the iliac senting. If the up to 84.2% and high mortality of 47.4%, which is even 170 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 more dangerous for high-risk patients with cardiac and releasing the pain and improving patients’ quality of life. cerebral vessel diseases. The severe complications and However, profundoplasty only can’t achieve a satisfying high mortality might derive from complex procedure, long effect. So we suggested the combined therapy to those operative time and more blood lost [1]. with severe, multilevel artherosclerotic occlusive disease. In conclusion, it is evidenced that the intra-operative With the development of interventional therapeutic iliac stenting combined with profundoplasty is a safe and technique, combination of endovascular therapy with effective treatment for extended, multilevel surgical procedure has become a new trend. Recently, it artherosclerotic occlusive disease, especially for those has been reported that the combinative treatment of the with poor outflow. proximal inflow reconstruction by endovascular iliac balloon angioplasty and stent placement with distal REFERENCES femoral- popliteal artery bypass for outflow rebuilding is effective for severe, multi-level artherosclerotic 1 Harward TRS, Ingegno MD, Carlton L, et al. [2~5] occlusive disease . However, the procedure is too Limb-threatening ischemia due to multilevel arterial complex and dangerous for high-risk patients with occlusive disease. Simultaneous or staged inflow/outflow extended stenosis combined with poor outflow. revascularization. Ann Surg, 1995, 221:498-506. Therefore, blood supply reconstruction of the extremity 2 Liu CW, Guan H, Li YJ, et al. Combined intraoperative iliac artery stents and femoro-popliteal bypass for using profound femoral artery as outflow plays a critical multilevel atherosclerotic occlusive disease. Chin Med Sci role in alleviating extremity ischemia, which might J, 2001, 16:165-168. reserve the extremity or at least lowers the amputation 3 Aburahma AF, Robinson PA, Cook CC, et al. Selecting [6] level . It has been supported that extremity distal blood patients for combined femorofemoral bypass grafting and perfusion pressure can be raised by increasing the blood iliac balloon angioplasty and stenting for bilateral iliac supply of profound femoral artery through lateral disease. J Vasc Surg, 2001, 33:S93-99. circulation[7], which implies that the profound femoral 4 Demasi RJ, Snyder SO, Wheeler JR, et al. Intraoperative iliac artery stents: combination with infrainguinal artery is probably the main blood supply in case of revascularization procedures. Am Surg, 1994, 60:854-859. extended iliac and femoral artery occlusion. 5 Lau H, Cheng SWK. Intraoperative endovascular angioplasty and stenting of iliac artery: an adjunct to All the old patients in this group had extended femoro-popliteal bypass. J Am Coll Surg, 1998, artherosclerosis, severe extremity ischemia and were 186:408-415. accompanied with various severe internal diseases. Their 6 Prendiville EJ, Burke PE, Colgan MP, et al. The Profunda poor conditions couldn’t permit them survive a big femoris: A durable outflow vessel in aortofemoral surgery. J Vasc Surg, 1992, 16:23-29. operation. The combinative therapy of iliac stenting and 7 Silva JA, White CJ, Ramee SR, et al. Percutaneous profundoplasty constitute the inflow and outflow Profundoplasty in the treatment of lower extremity simultaneously. local anesthesia or nerve blocking bring ischemia: Results of long-term surveillance. J Endovasc less complications. the simple procedure plays a role in Ther, 2001, 8:75-82. Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 171

‧論著和研究‧

澳門地區 2006 年惡性腫瘤死亡監測研究

吳懷申瞿國英

【摘要】目的調查澳門地區 2006 年度惡性腫瘤死亡資料，有助對惡性腫瘤的流行病學研究，同時為澳門政府衛生局制定腫瘤防治規劃和政策提供依據。方法根據澳門政府統計暨普查局提供的原始資料，進行統計學分析，計算澳門地區 2006 年度惡性腫瘤的死亡率、構成比和排位。惡性腫瘤死因、部位和編號採用國際統一的第九修正版 ICD 疾病分類法。結果澳門地區 2006 年 12 月 31 日人口為 513 427 人(男性 49.2%，女性 50.8%)。 2006 年中，全澳門死於惡性腫瘤的種類共有 44 種；惡性腫瘤死亡總人數達 517 人(男性 313 人，女性 204 人)，佔總死亡人數的 33.0%（517/1 566 人）。澳門惡性腫瘤的死亡率為 100.7/10 萬人口(男性 124.0/10 萬人口，女性 78.2/10 萬人口)。在全部惡性腫瘤死亡人數中，中年人佔了 43.3% (224/517 人)，即惡性腫瘤死亡患者中，4 成多是中年人。死亡率最高的前五位惡性腫瘤分別為肺癌（24.2/10 萬人口，男性高達 33.3/10 萬人口）、肝癌（12.1/10 萬人口）、結腸癌（8.6/10 萬人口）、鼻咽癌（6.0/10 萬人口）、胃癌（5.7/10 萬人口）。結論 (1) 在 2006 年中，惡性腫瘤是澳門第一位死亡原因。(2) 2006 年度中，每 3 名澳門人死亡中，或每 2 名澳門中年人死亡中，就有 1 名是因為惡性腫瘤而死亡，惡性腫瘤對澳門中年人的危害性特別大。(3) 肺癌的死亡率已持續 28 年佔全部惡性腫瘤的第一位，男性更為突出。(4) 澳門地區應該加強惡性腫瘤的防治工作，防治的重點又應該是以肺癌和肝癌為主。【關鍵字】惡性腫瘤; 死亡率; 肺癌; 肝癌

Macao: Surveillance of Mortality of Malignant Tumors in 2006 Huai-Shen WU, KOI Kuok Ieng. CP 3002, Editorial Office of RCSM (HSJM), 3rd Floor, Administrative Building, Department of Health of Macao, Macao SAR, China. Tel: (+853)-390 6524, 390 7307, Fax: (+853)-390 7304; E-mail: [email protected] 【Abstract】 Objective To investigate the death causes of malignant tumors (MT) in Macao in 2006. The aim is to provide information and evidence to Government who will make new plan and policy for prevention and treatment of MT. Methods All original materials from Census and Statistics Department (DSEC) and Department of Health (SS) of Macao in 2006. The materials were counted and analyzed for mortality, rate of construction and order of death causes. Tumors code classification used International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM). Results Macao’s population in December 2006 were 513 427 (49.2% in male, 50.8% in female). Total 517 patients (313 males, 204 females) died of 44 kinds MT of ICD-9-CM in 2006, rate of construction was 33.0%（517/1 566 cases）of all death case. The mortality of MT in 2006 was 100.7/100 000 population (124.0/100 000 in male, 78.2/100 000 in female). 43.3% (224/517cases)of all died MT cases in 2006 were cases of middle age(40-64 years old). The five highest mortality of MT were lung cancer (24.2/100 000), liver cancer (12.1/100 000), colon cancer (8.6/100 000), nasopharynx cancer (6.0/100 000) and gastric cancer (5.7/100 000) respectively. Conclusion 1) MT was second death cause in Macao in 2005. 2) In 2006, one of each three death cases or each two cases of middle age (40-64 years old) died from MT. 3) The highest mortality in MT was lung cancer in 2005 and also in 28 years continually. 4) Lung cancer and liver cancer should be all of the focal points on prophylactico-therapeutic work of MT in Macao. 【Key words】 Malignant tumors; Mortality; Lung cancer; Liver cancer

作者單位: CP 3002, 中國, 澳門特別行政區政府, 衛生局, 行政大樓 3 樓,《澳門醫學雜誌》編輯部 Tel: (+853)- 390 6524, 390 7303; E-mail: [email protected] 172 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

澳門特別行政區統計暨普查局(DSEC)和衛生局統計中惡性腫瘤包括原位癌(ICD 230~234)，但不包括 (SS) 的 2006 年 6 月份資料表明，在 2006 年中，惡性良性腫瘤(ICD 210~229) 和良惡性未定性的腫瘤(ICD 腫瘤(即癌症)仍是澳門地區主要死亡原因，並且是第 235~239)。詳見表 2 和表 3。一位死亡原因。全澳門有三分之一的死亡患者，是因澳門地區 2006 年度中，死亡總人數 1 566 人(男為癌症而死亡。而癌症死亡病例中，近半數是中年人。性 887 人，佔 56.6%；女性 679 人，佔 43.4%)，2006 可見惡性腫瘤對澳門地區市民健康，特別是對中年人年的死亡率為 3.1‰，較 2005 年的 3.4‰為低[1]。三大的健康，造成嚴重危害的程度。主要死亡原因，分別是：惡性腫瘤(佔 33.0%)、迴圈系本文統計和分析了澳門地區 2006 年度全部惡性疾病(佔 24.3%)和是呼吸系疾病(佔 13.9%)。詳見表 1。腫瘤死亡資科，這將有助對惡性腫瘤的流行病學的研 2006 年度中，澳門地區因惡性腫瘤死亡總人數究，同時為澳門政府衛生局不斷調整腫瘤防治規劃和 517 人，佔總死亡數的 33.0%，即每三成多的死亡患政策提供可靠依據。者因癌症而死亡。全部癌症死亡中，男性佔 60.6% 材料與方法（313/517 人）；女性佔 39.5%（204/517 人），男女死亡病例之比為 1.5：1。與 2005 年比較，惡性腫瘤粗死 1 資料來源亡率上升 7.7/10 萬人口；其中女性也上升 1.7/10 萬人口，而男性上升 13.3/10 萬人口。原始資料由澳門特別行政區統計暨普查局(DSEC) 和衛生局(SS)提供。惡性腫瘤死亡資料以 2007 年 6 月 2 澳門中年人死因的近半數是癌症公佈的《2006 年醫療衛生統計》和《2006 年人口統計》統計顯示：2006 年中，澳門死亡總數中，中年人年報數字為准；人口資料以 2006 年 12 月 31 日統計的 (40-64 歲年齡組)佔了 27.7% (434/1 566 人)，男女之比數字為准。澳門地區居住人口共 513 427 人，較 2005 為 2.3：1(303/131 人) ；而在全部惡性腫瘤死亡人數年增加 29 150 人(6.0%)；其中男性佔 49.2% ( 252 475 中，中年人佔了 43.3% (224/517 人)，即惡性腫瘤死亡人)；女性佔 50.8% ( 260 952 人)。65 歲或以上的老年患者中，近半數是中年人。其中，中年男性佔人 36 027 人(佔 7.0%)，較 2005 年下降 0.3%；而 0 至 66.1%(148/224 人) ，中年女性佔 33.9%(76/224 人)， 14 歲少年兒童 75 372 人(佔 14.7%)，較 2005 年下降男女之比為 2：1。而在 65 歲以上老人中，因惡性腫 1.4%。年齡中位數，由 2001 年人口普查的 33.3 歲，瘤死亡，佔全部癌症死亡人數的 54.4% (281/517)。上升至 2006 年人口普查的 35.3 歲，顯示澳門人口呈現老化跡象。隨著人們壽命的延長，而出生人口的相 3 肺癌連續 28 年成為癌症中第一死因對減少，出現人口老化現象。量度人口老化的指標之一是老化指數(65 歲以上的老年人口與 0-14 歲的少年自 1979 年起，澳門政府統計暨普查司的資料就顯兒童人口之比例)，老化指數由 1996 年的 26.7%增至示：肺癌是各種癌症中死亡率最高的惡性腫瘤，這種 2001 年的 33.6%，現再上升至 2006 年的 46.3%。顯示情況已連續了第 28 年 [4,5] ；在 2006 年中，肺癌澳門和世界大多數國家和地區一樣，步入老齢化社會 (ICD-162，共 124 例)降為澳門地區單一病種死亡原因 [1, 2]。的第二位，第一位死亡原因是特發性高血壓(ICD-401，共 168 例) 第三位死亡原因是肺炎(ICD-486，未特指 2 統計分析方法病原生物體，共 85 例)。詳見表 4。惡性腫瘤死因、部位和編號採用國際統一的第九 4 澳門地區 2005 年癌症的發病率修正版 ICD 疾病分類法[3]；死亡率按每十萬人口中死亡人數直接法計算。澳門地區的統計資料完整，人口澳門地區 2005 年登記的癌症新發病例有 1 108 例變化不大，保證了統計分析的完整性和可靠性。 (男性 543 例，女性 564 例，1 例性別不詳)；全部癌症的粗發病率(Crude incidence rate)是 232/10 萬人口(男結果與分析性 237/10 萬人口，女性 228/10 萬人口)。由於年齡是影響癌症發病的重要因素，癌症發生的風險隨著年齡 1 惡性腫瘤是澳門地區第一位死因會顯著增加，為避免因人口結構影響澳門癌症發病率按國際疾病統一分類法（ICD-9-CM）3 位元數位和其他地區之比較，經世界標準人口將年齡因素調整編碼統計，全部惡性腫瘤（140~208, 230~234）共有後的年齡標準化發病率(WASR) )是 181/10 萬人口(男 67 種（男性 60 種，女性 63 種）；而澳門地區 2006 年性 194/10 萬人口，女性 172/10 萬人口)。2005 年主要度死亡統計中，佔有 44 種（男性 31 種，女性 36 種）。惡性腫瘤的發病率。詳見表 5[6]。 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 173

表 1 澳門地區 2006 年主要五種死亡原因和死亡率(10 萬人口) Table 1 Five Leading Death Causes & Mortality in Macao (2006, per 100 000 population) 合計男性女性排位死亡原因 Total Male Female No. Death causes 死亡人數粗死亡率死亡人數粗死亡率死亡人數粗死亡率 Death cases Mortality Death cases Mortality Death cases Mortality 1 惡性腫瘤 517 100.7 313 124.0 204 78.2 Malignant tumors 2 循環系統疾病 Diseases of 381 74.2 197 78.0 184 70.5 circulatory system 3 呼吸系統疾病 Diseases of 217 42.3 142 56.2 75 28.7 respiratory system 4 損傷和中毒疾病 99 19.3 60 23.8 39 15.0 Injury, Poisoning 5 內分泌營養代謝疾病 Endocrine & 79 15.4 41 16.2 38 14.6 Nutritional diseases 注：2006 年澳門地區死亡人數總數是 1 566 人(2005 年是 1 615 人) Note: Total 1 566 patients died at Macao in 2006 (1 615 in 2005).

表 2 澳門地區 2006 年主要五種惡性腫瘤死亡率（1/10 萬人口） Table 2 The Mortality of Five Leading Tumors in Macao, 2006 (1/100 000 population) 合計 Total 男性 Male 女性 Female 排位編號惡性腫瘤部位 No. ICD Tumors sites 死亡人數粗死亡率死亡人數粗死亡率死亡人數粗死亡率 Death No Mortality Death No Mortality Death No Mortality 1 162 肺 Lung, Bronchus 124 24.2 84 33.3 40 15.3 2 155 肝 Liver 62 12.1 51 20.2 11 4.2 3 153 結腸 Colon 44 8.6 19 7.5 25 9.6 4 147 鼻咽 Nasopharynx 31 6.0 26 10.3 5 1.9 5 151 胃 Stomach 29 5.7 16 6.3 13 5.0

表 3 2005 年澳門地區惡性腫瘤死亡率（1/10 萬人口） Table 3 The Mortality of Malignant Tumors in Macao, 2005 (1/100 000 population) 編號合計男性女性惡性腫瘤部位 Total Male Female 例粗死亡率排位例粗死亡率排位例粗死亡率排位 ICD Tumor sites % % % Case Mortality No Case Mortality No Case Mortality No 141 舌, Tongue 4 0.8 0.8 3 1.0 1.2 1 0.5 0.4 142 唾液腺, Salivary glands 1 0.2 0.2 1 0.5 0.4 144 口底, Floor of mouth 1 0.2 0.2 1 0.3 0.4 146 口咽部, Oropharynx 3 0.6 0.6 2 0.6 0.8 1 0.5 0.4 147 鼻咽部, Nasopharynx 31 6.0 6.0 4 26 8.3 10.3 3 5 2.5 1.9 9 148 下嚥部, Hypopharynx 2 0.4 0.4 2 0.6 0.8 150 食管, Esophagus 23 4.5 4.5 7 18 5.8 7.1 5 5 2.5 1.9 9 151 胃, Stomach 29 5.6 5.7 5 16 5.1 6.3 6 13 6.4 5.0 4 152 小腸，包括十二指腸, 3 0.6 0.6 3 1.5 1.1 Small intestine, duodenum 153 結腸, Colon 44 8.5 8.6 3 19 6.1 7.5 4 25 12.3 9.6 3 154 直腸,肛門, Rectum & anus 21 4.1 4.1 8 11 3.5 4.4 7 10 4.9 3.8 6 155 肝臟和肝內膽管, Liver & 62 12.0 12.1 2 51 16.3 20.2 2 11 5.4 4.2 5 intrahepatic bile ducts 156 膽囊和肝外膽管, 13 2.5 2.5 9 9 2.6 3.6 8 4 2.0 1.5 10 Gallbladder, extrahepatic bile ducts 157 胰腺, Pancreas 23 4.5 4.5 7 16 5.1 6.3 6 7 3.4 2.7 7 158 腹膜後腔和腹膜, Retro- 1 0.2 0.2 1 0.5 0.4 peritoneum, peritoneum 160 鼻腔,中耳和副鼻竇, 2 0.4 0.4 1 0.3 0.4 1 0.5 0.4 Nasal cavities, middle ear and accessory sinuses 162 氣管,支氣管和肺, Lung, 124 24.0 24.2 1 84 26.8 33.3 1 40 19.6 15.3 1 bronchus, and trachea 164 胸腺,心臟和縱隔,Thymus, 2 0.4 0.4 2 0.6 0.8 heart, mediastinum 174 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

編號合計男性女性惡性腫瘤部位 Total Male Female 例粗死亡率排位例粗死亡率排位例粗死亡率排位 ICD Tumor sites % % % Case Mortality No Case Mortality No Case Mortality No 165 呼吸系統具體部位不明, 2 0.4 0.4 2 0.6 0.8 Other & ill-defined sites, respiratory system. 170 骨及關節軟骨, 1 0.2 0.2 1 0.3 0.4 Bone & articular cartilage 171 結締組織和其他軟組織, 4 0.8 0.8 2 0.6 0.8 2 1.0 0.8 Connective & other soft tissue 172 皮膚的惡性黑色素瘤, 1 0.2 0.2 1 0.5 0.4 Melanoma of skin 174 女性乳腺, Female breast 27 5.2 5.3 6 27 13.2 10.3 2 180 子宮頸, Cervix uteri 10 2.0 2.0 10 4.9 3.8 6 182 子宮體, Body of uterus 5 1.0 1.0 5 2.5 1.9 9 183 卵巢和其他子宮附件, 6 1.2 1.2 6 2.9 2.3 8 Ovary, other uterine adnexa 185 前列腺, Prostate 7 1.4 1.4 7 2.2 2.8 9 187 陰莖和其他生殖器官, 1 0.2 0.2 1 0.3 0.4 Penis, other male genital organs 188 膀胱, Bladder 4 0.8 0.8 2 0.6 0.8 2 1.0 0.8 189 腎, 泌尿系統其它部位不 3 0.6 0.6 3 1.0 1.2 明 , Kidney & other and unspecified urinary organs 191 腦, Brain 10 1.9 2.0 9 2.9 3.6 8 1 0.5 0.4 195 其他部位和部位未明確, 4 0.8 0.8 1 0.3 0.4 3 1.5 1.1 Other & ill-defined sites 196 淋巴結繼發, 部位不明, 1 0.2 0.2 1 0.5 0.4 Secondary lymph nodes, and unspecified sites 197 消化和呼吸系統繼發腫瘤, 5 1.0 2.0 4 1.3 1.6 1 0.5 0.4 secondary tumor of respiratory and digestive system 198 其他指定部位繼發腫瘤, 2 0.4 0.4 2 1.0 0.8 Secondary tumor of other specified sites 199 部位未特指的惡性腫瘤, 2 0.4 0.4 1 0.3 0.4 1 0.5 0.4 Without specified sites 200 淋巴肉瘤,網狀細胞肉瘤, 3 0.6 0.6 2 0.6 0.8 1 0.5 0.4 Lymphosarcoma, reticulosarcoma 201 何傑金氏病, 1 0.2 0.2 1 0.5 0.4 Hodgkin’s disease 202 淋巴樣組織其他惡性腫瘤, 12 2.3 2.3 10 6 1.9 2.4 10 6 2.9 2.3 8 Other tumor of lymphoid and histiocytic tissue 203 多發性骨髓瘤等, Multiple 6 1.2 1.2 4 1.3 1.6 2 1.0 0.8 myeloma & immuno- proliferative neoplasm 204 淋巴性白血病, 3 0.6 0.6 2 0.6 0.8 1 0.5 0.4 Lymphoid leukemia 205 骨髓細胞性白血病, 6 1.2 1.2 5 1.6 2.0 1 0.5 0.4 Myoloid leukemia 206 單核細胞性白血病, 1 0.2 0.2 1 0.5 0.4 Monocytic leukemia 208 細胞型未特指的白血病, 1 0.2 0.2 1 0.5 0.4 Leukemia unspecified cell type

合計 (140-208, 230-234) 517 100 100.7 313 100 124.0 204 100 78.2 注： % 代表構成比，即佔全部惡性腫瘤病例的百分比 Note: % : rate of construction; Case: cases of tumor; No: order of death causes.

Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 175

表 4 澳門地區單一病種死亡原因排位 (2002-2006) Table 4 The Leading Death Causes for Single Disease in Macao (2002-2006) 疾病名稱 Diseases 2002 2003 2004 2005 2006

肺癌 1 (121 cases) 1 (98 cases) 1 (130 cases) 1 (117 cases) 2 (124cases) Lung cancer (ICD-162) 特發性高血壓 Essential hypertension 1 (168 cases) (ICD-401) 心力衰竭 2 (107 cases) 2 (80 cases) 2 (80 cases) 2 ( 96 cases) Heart failure (ICD-428) 注：1, 2 是指死亡原因排位。 Note: 1, 2 are order of death causes.

表 5 澳門地區 2005 年主要惡性腫瘤的發病率(以病例數排序，1/10 萬人口） Table 5 The Morbidity of ten Leading Tumors in Macao, 2005 (In descending order of the number of case, 1/100 000 population) 排位編號惡性腫瘤部位登記的新病例粗發病率標化發病率構成比 No ICD Tumors sites New cases registered Crude incidence rate WARS % 1 162 肺 Lung, Bronchus 151 31.7 24.3 13.6 2 174 女性乳腺 Female breast 130 27.3 (52.6*) 19.7 (38.4*) 11.7 3 153 結腸 Colon 105 22.0 17.6 9.5 4 185 前列腺 Prostate 82 17.2 (35.7**) 13.9 (30.8**) 7.4 5 147 鼻咽 Nasopharynx 66 13.8 10.5 6.0 6 155 肝 Liver 57 12.0 9.5 5.1 7 154 直腸,肛門 Rectum , Anus 50 10.5 7.3 4.5 8 151 胃 Stomach 48 10.1 7.6 4.3 9 173 皮膚 Skin 29 6.1 4.6 2.6 9 200 非何傑金淋巴瘤 Non- 29 6.1 5.0 2.6 202 Hodgkin’s Lymphoma 所有部位 All Sites 1 108 230.4 181.0 100.0 注：構成比(%)：佔全部惡性腫瘤病例的百分比標化發病率(WASR)：世界標準人口直接標準化之年齡標準化發病率，又稱為發病世調率 * 單指女性人口中的發病率 **單指男性人口中的發病率 Note: % : rate of construction. WASR: World age-standardised rate derived by direct method weighted with World Standard Population. * Population of female only. ** Population of male only.

討論現有癌症患病病例 260 萬、每年新發病例 180~200 萬 (多為中晚期病人)、每年死亡病例 140~150 萬[7]。一澳門地區 2006 年的第一殺手是惡性腫瘤澳門 2006 年癌症粗死亡率為 102.3 人/10 人口，世界衛生組織（WHO）公佈的《世界癌症報告》是澳門地區第一位死亡原因。作者曾經統計過澳門地資料顯示，2000 年全球新發癌症病例 1 000 萬，死亡區回歸前的十年惡性腫瘤死亡譜(1888~1997 年)[8]，這病例 620 萬，現患病例超過 2 000 萬。隨著人口老化，和澳門回歸後五年(2000~2004 年)的惡性腫瘤死亡譜預測到 2020 年全球新發病率將再增長 50%，每年新無顯著差異[7]。發病例達 1 500 萬，每年死亡病例 1 000 萬，現患病例超過 3 000 萬。全球癌症病人總數，在發展中國家將二肺癌 28 年來一直是澳門癌症中第一死因增長 73%，而在發達國家將增長 29%。癌症已成為新世紀人類的第一殺手，並成為全球最大的公共衛生問自 1979 年起，澳門肺癌是各種癌症中死亡率最高題之一。中國癌症研究基金會(CCRF)公佈的資料顯的惡性腫瘤，這種情況已連續了第 28 年。2005 年澳示，中國癌症發病世調率，男性為 143.9~359.7/10 人門肺癌的粗發病率是 31.7%，標化發病率是 24.3%，口，女性為 48.1~219.1/10 人口；死亡世調率，男性為肺癌佔全部惡性腫瘤的 13.6%。2006 年澳門肺癌的粗 99.0~285.0/10 人口，女性為 47.9~157.5/10 人口。中國死亡病率是 24.2%。 176 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

肺癌在全球也是全部癌症中死亡率最高的惡性於癌症；澳門 2006 年因癌症死亡 517 人，等於每隔腫瘤。這和人口老齡化、農村城市化、城鎮現代化、 17 小時就有 1 個人死於癌症。社會上存在大量沒有手環境污染化，生活不良化都切切相關。WHO 推測，術指征、沒有放療化療指征的病人在等待處治，這些 2020 年全球人口將達 80 億，而肺癌的每年新發和死病人治療的終極目標為提高生存質量，延長生命，增亡病例將分別達到 240 萬和 210 萬。在中國，肺癌也加帶瘤生存時間。因此，腫瘤防治領域中，還有大量是第一大癌症，超過全部癌症死亡的 20%，且發病率工作等待我們去研究和探討。及死亡率增長迅速。雖然人類在與肺癌進行不懈鬥爭的 100 年中，取得了許多具有劃時代意義的成就，但參考文獻還有許多重大問題未能解決。目前，80%的肺癌在診 1 澳門特別行政區政府統計暨普查局. 2006 年人口統計. 斷後的 1 年內死亡，全球中，肺癌總 5 年生存率最高第 1 版. 澳門: 統計暨普查局, 2007. 58-71. [9-10] 水準維持在 15%左右。 2 澳門特別行政區政府統計暨普查局. 2006 年醫療衛生統計. 第 1 版. 澳門: 統計暨普查局, 2007. 5-8. 三政府、抗癌社團和個人要不斷認知癌症 3 World Health Organization. The United States National Center for Health Statistics. International classification of 世界衛生組織和國際抗癌聯盟(UICC)近年的各 disease, 9th revision, clinical modification (ICD-9- CM). 種調查報告指出，多達三分之一的癌症是可以預防 Los Angeles: PMIC, 2001. 143-178. 的。世界衛生組織號召各國政府、衛生官員和普通民 4 Wu HS, Lei OD, Vieira O. The prevention and treatment 眾採取緊急行動，來預防三分之一的癌症、治癒另三 of lung cancer in Macao. Health Science Journal of 分之一癌症，為其餘三分之一癌症患者提供最佳的治 Macao, 2001, 1: 90-95. 5 Wu HS, Koi KI. Macao: Surveillance of mortality of 療。在澳門，惡性腫瘤的治療一貫是免費的，這件優 malignant tumors in 2005. Health Science Journal of 越的醫療條件，在全世界是不多見的。 Macao, 2006, 6: 190-196. 6 澳門癌症登記年報編寫小組. 澳門癌症登記年報 2005. 由於人類生活和醫療條件的極大改善，壽命越來第 1 版. 澳門: 衛生局, 2006. 12-15. 越長，WHO 對 40~64 歲的人群視為中年人，65 歲以 7 吳懷申, 瞿國英. 澳門回歸後五年的癌症流行病學. 上才作為老年人。中年人不僅是一個國家和地區的勞見: 于金明, 左文述, 主編. 現代臨床腫瘤學. 第 1 版. 動骨幹，也是社會的中堅力量，同時也是一個家庭的北京:中國科學技術出版社, 2006. 35-39. 核心。在澳門，中年人患癌的高死亡率足以說明癌症 8 吳懷申, 瞿國英. 澳門地區惡性腫瘤死亡譜(1988- 對中年人的危害甚大。整個社會要高度重視中年人， 1998). 見: 吳懷申, 主編. 澳門惡性腫瘤. 第 1 版. 澳門: 澳門衛生司, 1999. 1-24. 中年人本身更應該提高警惕，改變不良生活習慣，增 9 孫燕. 積極提高肺癌臨床研究質量. 中國肺癌雜誌, 加腫瘤防治意識，早發現早治療。全球每年因癌症死 2005, 8(增刊 1):1-3. 亡 620 萬人，等於每隔 5 秒鐘有 1 人死於癌症；中國 10 吳懷申. 肺癌的抗癌治療要抓緊. 循證醫學, 2006, 每年因癌症死亡 150 萬人，等於每隔 21 秒鐘有 1 人死 6:198-199. 71-87.

Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 177

‧論著和研究‧

肝內鈣化灶的臨床分析

楊少華豆志強*

【摘要】目的分析肝內鈣化灶的臨床和影像特徵。方法對我科近 6 年來在住院病人中發現的 17 例肝內鈣化灶臨床資料進行回顧性分析。結果鈣化灶單發 6 例，多發 11 例；位於肝右葉 13 例，左葉 2 例，左右葉均有 2 例；肝包膜下 3 例，肝實質內 14 例；直徑 5～40mm 不等。B 超表現為肝內強回聲後方伴聲影；CT 表現為肝內極高密度影，CT 值約 100～200HU，明顯高於肝組織及肝內膽管結石密度；ERCP、MRCP 未見鈣化灶所在區域肝內膽管擴張及充盈缺損。其中 1 例行肝右葉病灶局部切除，見鈣化灶多發，呈乳白色，界限清楚，無包膜，質地較硬。結論肝內鈣化灶是肝臟某些病變穩定或癒合後的一種病理改變，臨床上易與肝內膽管結石混淆，典型的根據 B 超、CT 表現可明確診斷。鈣化灶形成後即穩定存在，對身體無明顯不利影響，一般不需外科治療。【關鍵字】鈣化; 肝臟; 診斷

Clinical analysis of Intrahepatic Calcification YANG Shao Hua, DOU Zhi Qiang. Department of Health Insurance, Lanzhou Railway Bureau, Lanzhou, Gansu Province, 730000 China. *Correspondence, Wuwei Second People's Hospital, Wuwei, Gansu Province, 733009 China. Tel: +86-13893521717, E-mail: [email protected] 【 Abstract 】 Objective To analyse the clinical characteristics of intrahepatic calcification. Methods The clinical data of seventeen patients with intrahepatic calcification were retrospectively analysed. Results For the majority of the cases, lesions were multiple and located in the right lobe of liver，within the liver parenchyma.The size was from 5 to 4mm in diameter.High echo with acoustic shadow was the main ultrasound feature.The CT finding was of very high density lesions, which was obviously higher than that of liver parenchyma and calculus of intrahepatic duct.Cholangiectasis and filling defect were not displayed in ERCP or MRCP.Local hepatic resection was performed in one case in which multiple white and hard lesions without capsule were found. Conclusion Intrahepatic calcification might be a sort of pathological change in the healing process of some liver diseases.Typical cases can be correctly diagnosed by ultrasound and CT scan.Lesions are stable and not harmful to health.Surgical treatment is then not required. 【Key words】 Calcification; Liver; Diagnosis

隨著 B 超、CT 的廣泛應用，肝內鈣化灶的檢出年齡 12~64 歲，平均 47 歲。病史中有明確乙肝史 2 例，日漸增多，其影像學表現同肝內膽管結石相似，容易肝血吸蟲病史 1 例，腸道蛔蟲病史 1 例。因右上腹隱痛與之發生混淆。臨床上肝內鈣化灶常被誤診為肝內膽不適就診 4 例，健康體檢發現 4 例，餘 9 例均因肝膽管結石，因二者處理及預後截然不同，因此正確作出結石病就診時發現，其中膽囊結石 4 例，膽總管結石診斷與鑒別診斷有著重要臨床意義[1]。臨床醫師對肝 2 例，肝內膽管結石 3 例。鈣化灶單發 6 例，多發 11 膽管結石病的認識已經較為深入，然而，關於肝內鈣例；位於肝右葉 13 例，左葉 2 例，左右葉均有 2 例；化灶的成因、臨床表現、診斷與處理目前未見詳細的肝包膜下 3 例，肝實質內 14 例；直徑 5~40mm 不等。文獻報告。我科近 6 年來在住院病人中共發現肝內鈣化灶 17 例，現將其臨床和影像特徵簡要總結如下。 (2) B 超表現: 所有病例入院後均行 B 超檢查，檢出 15 例。表現為肝內強光點、強光團或強光帶，大部臨床資料分後方伴明顯聲影；多發的一般呈散在分佈，有的相互靠近呈條索狀或串珠狀排列；實質內病灶多位於肝 (1) 一般資料: 本組 17 例，其中男 9 例，女 8 例；內管道附近，但局部膽管不擴張。診斷肝內鈣化灶 4

例，肝內膽管結石 10 例，肝血管瘤 1 例。作者單位: 730000 中國, 甘肅省, 蘭州市, 蘭州鐵路局醫保處, * 733009 中國, 甘肅省, 武威市第二人民醫院; (3) CT 表現: 13 例行 CT 檢查，檢出 12 例。平掃 Tel:(+86)-13893521717; E-mail: [email protected] 178 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

表現為肝內點狀、片狀或團塊狀極高密度影，CT 值測基本能明確診斷，一般不需做膽管造影。定約 100~200HU，明顯高於周圍肝組織密度（CT 值約 40~70HU）；邊界清晰，外形多不規則，密度較均 (3) 病史: 既往可有前述相關的肝臟疾病史，亦可勻；多發病灶有的呈散在分佈，有的則相互融合呈月無任何病史，一般無特徵性的症狀、體征及實驗室檢查牙狀或串珠狀排列；部分病灶靠近或緊貼肝內管道結異常。構，但局部膽管未見擴張表現；增強掃描始終無強化，密度仍明顯高於強化的肝組織。診斷肝內鈣化灶 10 (4) B 超特徵: 文獻報道肝內鈣化灶多由 B 超首例，懷疑肝內膽管結石 2 例。先發現，常見聲像圖特徵是肝內強回聲後方伴聲影，一般無肝內外膽管擴張、膽管積氣等徵象[4]。本組病 (4) 膽管影像學檢查: 8 例 ERCP、1 例 MRCP 檢例大多屬此種情況，但有的鈣化灶聲影不明顯，有些查，均未見病灶所在區域肝內膽管擴張及充盈缺損影。靠近肝內管道，有的臨床醫師對其認識不足，僅憑 B 超檢查往往將其診斷為表現與之相似的肝內膽管結 (5) 處理結果: 9 例有肝膽結石病的患者住院中石，門診中不乏因基層醫院誤診，建議其手術治療而均做了相應外科處理，其中 1 例膽囊結石患者因其肝到我院就診的患者。因此，確診本病尚不能完全依賴內鈣化灶較多且相對局限，行膽囊切除的同時予肝右 B 超檢查。葉病灶局部切除。觀察肝臟標本，肉眼未見明顯肝損害表現，肝實質內見小結節樣病灶多個，呈乳白色， (5) CT 檢查: 與 B 超相比，CT 的診斷價值較界限清楚，無包膜，結構緻密，質地較硬，部分排列大，確診率較高。根據本組病例 CT 結果，其主要特呈串珠狀，有的靠近肝內 Glissons 鞘，但局部膽管無徵是病灶呈明顯高密度影，有的甚至呈“白堊樣”，CT 異常；光學顯微鏡下見病灶周圍肝組織有纖維化改值測定一般在 100HU 以上，明顯高於肝實質及膽管結變，可見單核細胞、淋巴細胞浸潤，病理結果示肝內石密度；增強掃描後病灶雖不強化，但密度仍可明顯鈣化灶。餘 16 例患者未對鈣化灶進行外科處理。高於已強化的肝實質，這與鈣質是其主要成分有關。病灶外形一般不規則，有的相互融合呈月牙狀或串珠 (6) 隨訪: 本組病例隨訪 2 個月~5 年餘，鈣化灶均狀，可沿著肝內管道分佈，但無遠端肝內膽管擴張，穩定不變；手術切除 1 例隨訪 4 年未見肝內鈣化灶再發。此為肝內鈣化灶的另一特徵。本組 1 例有肝血吸蟲病史的患者，其鈣化灶表現為沿著肝包膜並伸向肝內的討論高密度弧形線，甚為特殊，系肝小葉間隔和匯管區死亡的蟲卵肉芽腫鈣化所致，與文獻報道類似[3]。 (1) 概述: 肝臟的各種慢性炎症如膿腫、結核、梅毒，某些寄生蟲病如日本血吸蟲病肝硬變，局部肝外 (6) 膽管影像學檢查一般不需要，本組 4 例診傷、血腫形成等均可引起不同程度肝臟鈣化，而肝內斷不明、5 例合併肝內外膽管結石而進行膽管造影。鈣化灶的出現多表明病變已趨穩定或癒合，其通常局因鈣化灶位於膽管外，ERCP、MRCP 表現為病灶所限於病變區內，是肝實質的非特異性鈣化[2,3]。鈣化多在區域肝內膽管無擴張、內無充盈缺損影。MRCP 檢發生於肝右葉，可單發或多發，散在分佈或相互融合，查較方便、無創傷，肝內膽管的顯影效果同 ERCP 相大小不一，形態各異，小的約 3~4mm 呈斑點狀，大仿，在診斷需要時應首先考慮採用 MRCP。的可達 3~4cm 似團塊狀，可能與其成因有關。鈣化灶形成後，即穩定存在，一般不隨時間變化而改變。隨 (7) 鑒別診斷: 應與 B 超表現為肝內強回聲的其著 CT 檢查的廣泛應用以及 CT 對鈣質存在的高敏感他常見病變如肝內膽管結石、肝海綿狀血管瘤等鑒別。性，使肝內鈣化灶的檢出率及確診率明顯提高。 (8) 肝內膽管結石: 肝內膽管結石是我國常見 (2) 診斷: 肝內鈣化灶主要依靠影像學診斷，多病，與肝臟代謝、膽道炎症及寄生蟲病關係密切，常由門診 B 超檢查發現，不能確定其性質時，可行 CT 有臨床症狀和體征，如發熱、腹痛、黃疸等。典型的檢查。典型的病例根據 B 超、CT 表現，結合病史， B 超特徵是沿肝內膽管分佈之強回聲光團伴後方乾淨 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 179

聲影及遠端小膽管擴張，光團多呈串珠狀，可同時有院診斷為肝血管瘤，後在我院行 CT 檢查表現為肝內膽道蛔蟲、膽道積氣等徵象。因膽管結石多為膽色素明顯高密度影，CT 值 138HU，增強掃描病灶無強化，或膽固醇性結石，鈣含量一般較低，CT 見擴張膽管內最後確診為肝內鈣化灶。稍高或高密度結石影，CT 值測定多在 50~100HU 之間，明顯低於以鈣質為主要成分的肝內鈣化灶。增強 (10) 處理肝內鈣化灶是肝臟某些病變穩定或癒掃描後，平掃表現為較高密度的結石因肝實質 CT 值合後的一種病理改變，形成後即長期穩定存在。根據的升高使二者密度差別縮小，有的可呈等密度甚或低我們觀察結果，病灶不會自行消退，也不會繼續發展，密度影。肝內鈣化灶除平掃時 CT 值多較結石高之外，但長期結果尚需進一步隨訪。因病灶多較小，一般不增強掃描後其密度仍高於已強化的肝實質，且不伴遠會對身體造成明顯不利影響，不需特別處理。特別要端膽管擴張。但有的膽管結石較小，鈣含量較高，聲指出的是，門診醫師要提高認識，注意肝內鈣化灶與影不典型，亦無膽管擴張，則不易與肝內鈣化灶區別，肝內膽管結石的鑒別，避免誤診誤治，給病人帶來不行膽管造影有助於二者鑒別，如肝內膽管內見充盈缺必要的心理和經濟負擔。損影，即可確診為肝膽管結石。參考文獻 (9) 肝海綿狀血管瘤: 海綿狀血管瘤是我國最常見良性肝臟腫瘤，女性多見，B 超表現多為肝內強回 1 王鵬. 肝內膽管結石的超聲誤診問題.中國誤診學雜誌, 聲，典型者內呈篩網狀，CT 表現為肝內低密度病變， 2001, 1:1752. 2 侯明輝, 薛雁山, 耿樹勤, 等. 肝結核的 CT 表現. 中華動態增強掃描呈現外周結節狀強化逐漸向中心充填過放射學雜誌, 1996, 30:151-154. 程。由於 CT 的特徵性表現，肝海綿狀血管瘤一般不 3 彭仁羅, 肖劍秋. 日本血吸蟲病肝硬變的肝臟鈣化（附易與肝內鈣化灶混淆。然而本組有 1 例女性患者體檢四例報告）. 臨床放射學雜誌, 1989, 8:143-144. 時 B 超發現肝內直徑 4cm 病灶，表現為強回聲團塊， 4 胡德友, 湯富剛, 陳圓妹. 肝內鈣化與肝內膽管結石的聲影不明顯，內呈篩網狀，因未行 CT 檢查，多家醫超聲鑒別診斷. 浙江醫學, 2002, 24:383-384.

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‧綜述‧

中藥對骨髓間質幹細胞可塑性的影響

何敏陳運賢* 陳嘉榆**

【摘要】骨髓間質幹細胞是目前國內外生命科學研究的熱點和前沿，開展中藥對骨髓間質幹細胞可塑性影響及其機理的研究不僅可以幫助找到安全有效的幹細胞誘導分化劑，而且有助於提高中藥研究的科技含量、發揮中藥的優勢。國內有不少的研究者開展了這方面研究，現對此作一綜述。【關鍵字】中藥; 可塑性; 骨髓間質幹細胞

The Effects of traditional Chinese medicine on Plasticity of Bone Marrow Mesenchymal Stem Cells HE Min, CHEN Yun Xian*, CHEM Jia yu**. Department of Hematology, the First Affiliated Hospital of Sun Yat-San University, Guanzhou 510080, China; Tel:(+20)-87332200-8911; *Correspondence:CHEN Yun Xian ,E-mail:[email protected].**The Twelveth People,,s Hospital of Guanzhou, Guanzhou, 510630 China. 【Abstract】 Bone marrow mesenchymal stem cells (BMSC) is one of the hot spots and frontlines in domestic and foreign life science research. The research into effects of traditional Chinese medicine on bone marrow mesenchymal stem cells plasticity and mechanism of them will be helpful for both finding safe and active inducers on stem cells and improving the development of traditional Chinese medicine research. Many researchers have been carrying out the work, which will be generally introduced in this article. 【Key words】 Traditional Chinese medicine; Plasticity; Bone marrow mesenchymal stem cells

近年來發現骨髓間質幹細胞(mesenchymal stem NSE)和神經絲蛋白(neurofilament, NF)，這說明 BMSC cell, BMSC)能在特定誘導條件下分化為肌細胞、骨細經丹參誘導後轉化成了神經元細胞而非星形膠質細胞。胞、軟骨細胞、脂肪細胞和神經細胞等其他組織細胞， BMSC 能分化為多種細胞譜系的特性叫可塑性肖慶忠等[2]用麝香多肽體外誘導第 5-10 代成年大 (plasticity)，又稱為轉分化(trandifferentiation)。幹細胞鼠骨髓 BMSC，12 小時後 BMSC 出現與項鵬等研究的可塑性具有誘人的應用前景，目前已經廣泛用於心中相類似細胞形態改變，而且細胞技術分析顯示臟、神經、骨骼等多種組織器官修復和再生醫學的研 NSE(+) 和 NF(+) 細胞的比例分別高達 93.5% 和究當中，這個領域的發展也為中醫藥現代化問題帶來 88.2%。趙漢寧等[3]用含 35ml/L 黃芪甙和 10%胎牛血了新的機遇和挑戰。清的 LG-DMEM 培養液誘導 BMSC 分化為神經元樣細胞也獲得了成功。中藥誘導骨髓間質幹細胞可塑性的研究現狀杜少輝的研究[4]在項鵬等人的基礎上更加深入，中藥對骨髓間質幹細胞可塑性作用的研究起步較他們把大鼠骨髓 BMSC體外培養後定點移植到大鼠腦晚，但是目前數項研究已經證實中藥具有調控骨髓間紋狀體內，同時給予大鼠龜板口服液（含藥量 1Kg/L 質幹細胞向神經元細胞和成骨細胞定向分化作用。項的水煎液）4ml 灌胃一周，發現龜板口服液不僅能促 [1] 鵬等首次應用丹參注射液體外誘導 BMSC，誘導 5 小進 BMSC 在腦紋狀體內存活和增殖，而且能增強時後細胞突起伸出，末端出現一級和二級分支，部分 BMSC 在增殖後分化為神經元細胞的潛能。雖然已經細胞拉成網狀，免疫組化顯示分別有 61.3%和 58.1% 知道 BMSC可以通過血腦屏障等體內重要的屏障系統的細胞表達神經元特異性烯醇酶(neuron specific enolase, [5]，但還未見報道中藥是否也對骨髓間質幹細胞體內遷移和歸巢到局部腦組織有影響。目前國內的中藥誘導 BMSC 可塑性研究側重在 BMSC 轉分化為神經元細胞方向，但也有少數人涉足 BMSC 向成骨細胞方向作者單位：510080, 中國，廣東省，廣州市，中山大學附屬的研究。第一醫院血液內科; Tel: (+20)-87332200-8911; *通訊作者：陳運賢, [email protected]; **510620, 中國，廣東省，廣州市，廣州市第十二人民醫院王和鳴等[6]研究發現用巴戟天水提取物（雙蒸水 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 181

水煮液）和乙醇提取物（95%乙醇回流 3 次提取液）角 VI—IX 層運動神經元骨形態發生蛋白-4（BMP4）

均能促進 BMSC 中 Cbfаl 表達的加強，且乙醇提取物的表達，而且在體外環境中可定向誘導 BMSC 向神經

作用強于水提取物的作用。Cbfаl 是骨形成的關鍵基元樣細胞分化。骨形態發生蛋白是一種高效骨誘導物因，又是成骨細胞分化和功能的中心調控因數，是成質，能誘導血管周圍的未分化間質幹細胞向骨－軟骨骨細胞分化最早和最特異性的標誌，決定著成骨細胞的細胞發生分化，在神經細胞發育過程中它也參與調

的發生和分化。Cbfα1 在非成骨細胞或成骨前體細胞中控細胞的生存、生長、遷移、神經細胞軸突的再生及表達的上調，可促使細胞向成骨細胞分化。由此可以與其他細胞建立功能聯繫[11] ，由此可見 BMP-4 可能認為巴戟天水提取物和醇提取物均可影響BMSC向成參與了龜板誘導 BMSC 分化為神經元樣細胞的過程。 [12] 骨細胞轉化，尤其以乙醇提取物效果顯著明顯。吳碧君等用 6Gy 劑量的 γ 射線全身照射小鼠後，發現骨髓基質細胞停滯於 G0-G1 期、凋亡率增加，同時中藥影響骨髓間質幹細胞可塑性的可能機制黏附激酶（FAK）表達明顯下降，用川芎嗪注射液治療後隨著 FAK 表達增加，骨髓基質細胞合成活躍、凋目前認為微環境的改變是引起幹細胞分化的外部亡率下降。有研究[13]表明 FAK 是一種細胞漿酪氨酸蛋因素，它通過細胞與細胞、細胞與基質之間各種信號白激酶，在整合素介導的信號轉導過程中起重要作的改變調控幹細胞分化基因的表達，從而影響幹細胞用，當造血幹細胞與細胞外基質中的纖維粘連蛋白黏分化方向[8]，中藥可能是通過上述的某一個或幾個環附時可誘導 FAK 的磷酸化，從而介導造血幹細胞的黏節影響 BMSC 的可塑性。附、遷移，調節細胞的增殖、存活。還有研究[14]顯示 FAK 可以促進造血細胞轉錄因數 Cycling 表達而降低中藥在基因水平上對 BMSC 可塑性的影響 P21 的表達，加速細胞由 G1 期向 S 期轉化。祝曉玲等[15,16]發現黃芪能增加骨髓基質細胞分泌 TNF-а 和幹如前所述，王和鳴等[6]證實了巴戟天影響 BMSC 細胞因數(stem cell factor, SCF)，兩者具有促進造血幹

分化為成骨細胞與其增加 Cbfаl 基因的表達有關。姚細胞黏附和增殖的能力，這就提示我們川芎嗪、黃芪曉黎等[8] 用參芪注射液誘導人骨髓 BMSC，採用等中藥材對 BMSC 可塑性的影響可能與其改變了 RT-PCR 檢測 BMSC 分化前後多個基因表達的改變。 BMSC 周圍微環境中某些蛋白和細胞因數的水平有這項研究有兩個主要的成果：1 參芪注射液 BMSC 不關。僅改變神經特異性基因的“開”和“關”，而且改變參與神經細胞分化成熟過程的相關基因表達量，其中外胚中藥抗氧化活性對誘導 BMSC 可塑性的影響層基因和神經特異性標記基因 APP、SYN 在誘導後表達顯著增加，內皮層基因 CERU 和中胚層基因 SMZZ 丹參注射液和抗氧化劑硫代甘油、巰基乙醇一樣誘導後隨時間延長表達減低，生殖系基因 PROT 在誘能促進人 BMSC 分化為神經元樣細胞[17] 。丹參注射導後基本保持不變；2參芪注射液促進未分化的 BMSC 液中含有丹參酮、總丹酚酸等多種抗氧化成分，所以中轉錄因數 NeuroD 表達增加，並隨誘導時間延長其有人認為丹參誘導 BMSC可塑性的能力與其抗氧化活表達逐漸減弱。轉錄因數 NeuroD 在神經前體細胞短性有關。可能是丹參抗氧化活性啟動了某種信號轉導暫表達，NeuroD 表達增加與 BMSC 在誘導後迅速分途徑，從而使與可塑性有關的基因轉錄發生改變。丹化有關，決定了前體細胞分化的命運。參抗氧化活性還能夠防止細胞膜等重要的生物膜過氧化，促進細胞存活。黃芪等很多中藥都具含有抗氧化中藥在蛋白水平上對 BMSC 可塑性的影響活性成分，中藥的抗氧化活性與幹細胞可塑性的關係還有待進一步研究。現在還缺少能直接證明中藥在蛋白水平誘導 BMSC 分化的研究成果，但從下面的研究中或許可以中藥的化學結構對 BMSC 可塑性的影響找到一些這方面的證據。BMSC 在體內的增殖分化有賴於其所在的微環境。微環境能夠分泌啟動與促進中藥對BMSC可塑性的影響歸根結底應該是中藥 BMSC 增殖分化的細胞因數，其細胞外基質能提供中的某些活性分子甚至某些活性基團影響了或參與了 BMSC 增殖分化的場所以及為 BMSC 提供細胞間的接 BMSC 轉分化過程的生物化學反應。李熙燦等[18]發現觸環境。陳東風等[9]發現龜板不僅可減輕脊髓損傷大蓽茇揮發油以濃度依賴方式促進 BMSC 生長。蓽茇揮鼠模型的神經損傷症狀、促進脊髓損傷後脊髓灰質後發油是脂溶性物質，與水溶物相比更能順利通過細胞 182 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

膜。蓽茇揮發油分子中富含 C=C、—OH、C=O、環 2 肖慶忠, 李浩威, 溫觀媚, 等. 麝香多肽體外誘導成年大鼠和人骨髓間充質幹細胞定向分化為神經元的研究氧基等生物活性基團，這些基團決定了分子的反應活 . 中國病理生理雜誌, 2002, 18:1179-1182. 性，蓽茇揮發油的濃度依賴性促 BMSC 增殖作用可能 3 趙漢甯, 董曉先, 董偉華. 黃芪甙誘導骨髓間質幹細胞與上述官能團的單獨或聯合作用有關。目前臨床上甚分化為神經細胞的實驗研究. 現代中西醫結合雜誌, 至科研中使用的中藥製劑大多是多種藥材的混合製 2005, 14:576-579. 杜少輝陳東風李伊為等龜板對腦缺血大鼠骨髓劑，其有效成分及活性成分不明，這在很大程度限制 4 , , , . 間質幹細胞移植後分化為神經元的影響. 中華醫學雜了中藥對 BMSC 可塑性影響的研究進展。誌, 2005, 85:205-208. 5 官曉清, 余加林, 李祿全, 等. 骨髓間質幹細胞透過新中藥在其他方面對 BMSC 可塑性的影響生大鼠血腦屏障的實驗研究.中華兒科雜誌, 2004, 42:920-925. 6 王和鳴, 王力, 李楠. 巴戟天對骨髓基質細胞響成骨細細胞移植中首要的問題是移植細胞的凋亡，胞分化過程 Cbfα1 表達的影響.中國中醫骨傷科雜誌, BMSC 體內遷移到局部組織後面臨的首要問題也是凋 2004, 12:22-28. 亡。中藥能增強損傷區周圍細胞的擴散能力，使遷移 7 歐瑞明, 陳運賢. 現代造血幹細胞移植. 第 1 版. 廣州: 廣東科技出版社到損傷區的細胞較易獲得營養，還能直接作用於細 , 2005. 40-41. 8 姚曉黎, 張成, 馮善偉, 等. 成人骨髓間質幹細胞分化胞，增強其耐受缺氧及營養的能力，促進細胞存活。為神經元樣細胞前後基因表達的研究.中藥材, 2005, 中藥的使用保證了微環境促進 BMSC發生轉化所需時 28:476-482. 間，這也在某種程度上解釋了餘勤、黃慧等[19,20] 研究 9 陳東風, 李伊為, 杜少輝. 龜板對脊髓損傷後大鼠功能和骨形態發生蛋白 4 表達的影響. 解剖學研究, 2003, 中發現的結果：中藥藥物濃度和誘導時間對 BMSC 轉 25:172-176. 化為特定組織細胞的陽性率有影響。 10 杜少輝, 陳東風, 李伊為, 等. 龜板對腦缺血骨髓間充質幹細胞移植後轉分化為神經元的影響. 中華醫學雜存在的問題和展望誌, 2005, 85:205-208. 11 Mehler MF, Mabie PC, Zhang D, et al. Bone morphogenetic proteins in the nervous system. Trends 中藥誘導 BMSC 可塑性研究具有廣闊的應用前 Neurosu, 1997, 20:309-317. 景，但是從現在的研究狀況看來還存在很多的問題。 12 吳碧君. 川芎嗪對放射損傷小鼠骨髓基質細胞 FKA 表研究的方向局限於中藥誘導 BMSC 分化為神經細胞，達的影響. 中醫藥學刊, 2002, 20:324-326. 在成骨、成軟骨、成肌細胞等方面的研究不多。多數 13 Sohaller MD, Borgman CA, Cobb BS, et al. pp125FAK a structurally distinctive protein-tyrosine kinase associated 的研究還停留在中藥能否誘導 BMSC 橫向分化的層 with focal adhesions. Proc Natl Acad Sci USA, 1992, 面，對誘導過程的基因和蛋白等改變的機制研究幾乎 89:5192-5196. 是空白。而且在已取得的成果當中尚有許多問題有待 14 Zhao JH, Regulation H, Gual JL, et al. Regulation of the 解決，如怎樣增加陽性細胞的轉化率，促進轉化細胞 cell cycle by focal adhesion kinase. Cell Biol, 1998, 147:1997-2008. 存活；如何才能誘導出具有功能的細胞等。 15 祝曉玲, 祝彼得, 許勇, 等. 黃芪對貧血小鼠基質細胞分泌 TNF-α 的影響. 基礎醫學與臨床, 2002. 國內外採用的 BMSC 誘導劑較多使用二甲基亞 22:255-256. 祝曉玲祝彼得黃芪體外作用對貧血小鼠骨髓基質細酚、硫代甘油等，這些化學製劑均有一定的毒性，不 16 , . 胞分泌 SCF 的影響. 細胞與分子免疫學雜誌, 2002, 能應用於人體內。但用傳統中藥作為誘導劑具有價 18:396-397. 廉、安全的優點，而且中藥治療強調整體觀念，它們 17 項鵬, 夏文傑, 張麗蓉, 等. 成人間質幹細胞定向分化既可以直接作用於體內的幹細胞促進其增殖和分化，為神經元細胞的研究. 中國病理生理雜誌, 2001, 也可以影響微環境促進其存活和功能重建，因此如何 17:385-387. 18 李熙燦, 周健洪, 黎暉, 等. 蓽茇提取物對大鼠骨髓間在 BMSC可塑性這一重要的研究領域發揮中藥作用值質幹細胞 MSC 的增殖作用及與化學官能團的關係. 中得從事中醫藥研究和幹細胞研究人員的充分重視。藥材, 2005, 28:570-575. 19 餘勤, 羅依, 鄂豔, 等. 丹參素定向誘導 BMSC 分化為參考文獻神經元樣細胞的研究. 中國中西醫結合雜誌, 2005, 25:49-54. 1 項鵬, 夏文傑, 王連榮, 等. 丹參注射液誘導間質幹細 20 黃慧, 唐雲寬, 張成. 香丹注射液定向誘導大鼠 BMSC 胞分化為神經元樣細胞.中山醫科大學學報, 2001, 分化為神經元的特點及其影響因素. 中國中西醫結合 22:321-324. 雜誌, 2004, 24:1098-1123.

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‧綜述‧

鼻咽部血管纖維瘤的診斷和血管內栓塞

黃祥龍何偉釗莫家寶郭昌宇郭良基

【摘要】鼻咽部血管纖維瘤為一富血管性腫瘤，約佔鼻咽部腫瘤的 15%。臨床表現主要為反復發生鼻衄，鼻腔分泌物和鼻塞，腫瘤起源於鼻咽部，可向眶部、鼻部和顱底部延伸，因此還可出現突眼，面頰腫脹等相應的症狀。腫瘤無包膜，其內富含血管腔隙和血管竇，為血供十分豐富的錯構瘤，腫瘤的血供相當複雜，主要來自頜內動脈和麵動脈的分支，大的腫瘤其供血還常有咽升動脈、眼動脈、頸內動脈分支參與，當腫瘤侵及顱內時，頸內動脈的海綿竇支和腦膜中動脈也可參與供血，對腫瘤進行活檢常可引起致命性的鼻出血，應慎重行事。橫斷面和冠狀位元 CT 掃描；MR 檢查對診斷和鑒別診斷有很大的幫助，通常根據臨床病史和影像學表現大多可作出明確診斷。術前血管造影檢查主要是瞭解供血動脈的起源。對鼻咽部血管纖維瘤進行栓塞，可有效地減少術中出血，提高手術切除率，並可有效地降低因手術而死亡的概率。【關鍵詞】鼻咽; 血管纖維瘤; 診斷和血管內栓塞

Diagnosis and Endovascular Embolization of Nasopharyngeal Angiofibromas HUANG Xianglong, HO Wai Chio, MOK Ka Pou, KUOK Cheong U, KOK Leong Kei. Department of Radiology, Centro Hospitalar Conde de São Januário, CP3002, Macao SAR..Tel:(+853)-3903011; E-mail: [email protected] [Abstract] Nasopharyngeal angiofibromas are hypervascular tumors which account for 15% of nasopharyngeal tumors. Common clinical manifestations of nasopharyngeal angiofibromas include recurrent epistaxis, nasal discharge and nasal obstruction. The tumors originate from nasopharynx; they can extend to the orbits, nasal region and skull base, and result in exophthalmus and facial swelling, etc. The tumors are non-capsulated, contain plenty of blood sinusoids or vascular sinuses, namely hypervascular hamartomas. The blood supplies of the tumors are quite complicated, mainly from the branches of internal maxillary arteries and facial arteries. The branches of ascending pharyngeal arteries, ophthalmic arteries and internal carotid arteries can supply the larger tumors. When the tumors invade the intracranial region, cavernous part of internal carotid arteries and middle meningeal arteries may give blood supplies. Performing biopsy for the tumors must be cautious as it can result in fatal nasal bleeding. CT axial and coronal scans, as well as MRI study can contribute to the diagnosis and deferential diagnosis of the tumors. In general, a conformed diagnosis can be made according to clinical history and imaging manifestations. The purpose of angiography before operation is finding out the origins of tumor blood supplies. Endovascular embolization of nasopharyngeal angiofibromas can effectively reduce bleeding during operation, promote the resection rate, and decrease the mortality of operation. [Key words] Nasopharyngeal; Angiofibromas; Diagnosis and endovascular embolization

鼻咽部血管纖維瘤也稱青少年型鼻咽部血管瘤鼻塞，腫瘤起源於鼻咽部，可向眶部、鼻部和顱底部 (Juvenile Nsopharyngeal Angiofibromas)，為一富血管延伸，因此還可出現突眼，面頰腫脹等相應的症狀。性腫瘤，最常見於 10-25 歲的青年男性，其發生率約如腫瘤侵入翼齶窩、上頜竇後壁和其外方可引起面頰佔鼻咽部腫瘤的 15%，發生原因可能與青春期性激素部隆起；壓迫咽鼓管咽口起耳鳴、耳閉、聽力下降；不平衡有關[1]。侵入翼管引起幹眼症，侵入眼眶引起眼求外突運動受限，視力減退或視野受損。臨床表現與腫瘤的血供腫瘤無包膜，其內富含血管腔隙和血管竇，為血其臨床表現主要為反復發生鼻衄，鼻腔分泌物和供十分豐富的錯構瘤，腫瘤的血供相當複雜，主要來作者單位: CP3002, 中國, 澳門特別行政區政府, 仁伯爵綜自頜內動脈和臉動脈的分支，大的腫瘤其供血還常有合醫院, 影像科, Tel: (+853)-3903011; E-mail: [email protected] 咽升動脈、眼動脈、頸內動脈分支參與，當腫瘤侵及 184 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

顱內時，頸內動脈的海綿竇支和腦膜中動脈也可參與高於鼻咽癌。鼻咽部血管纖維瘤無頸部淋巴結腫大。供血，對腫瘤進行活檢常可引起嚴重的出血，更甚者可引起致命性的鼻出血，在穿刺前應予以注意和慎重 (2) 惡性肉芽腫：沿並腔、鼻竇、鼻咽部局限性考慮。一般根據臨床病史和 CT、MRI 影像學表現大或彌漫性粘膜增厚，軟組織腫脹並骨質侵蝕性破壞，多可作出明確診斷，如有疑難者 DSA 或 99mTc2MIBI 多無軟組織腫塊，增強後掃描惡性肉芽腫有不同程度檢查有助於診斷的確立而不必再作活檢。的強化。血管纖維瘤常合併有鼻咽部和翼腭窩的軟組織腫塊翼腭窩擴大翼板破壞，而無合併肺部惡性肉芽 CT 和 MRI 表現、診斷和分型腫性病變。

橫斷面和冠狀位 CT 掃描可見鼻咽部和鼻後部腫 (3) 淋巴瘤：鼻咽部巨大的軟組織腫塊，其內可塊，增強後掃描可見腫塊有明顯的增強。腫瘤可侵入出現壞死，增強後壞死區無強化而呈現病灶周圍的環上頜竇後壁和翼腭。腫瘤進一步發展可侵及顱底，及形強化。常伴有頸部或全身淋巴結腫大。侵入顱內。另可出現鼻中隔偏斜，眶部擴张及副鼻窦密度增高。國內學者[2]經 CT 研究指出，Ｉ期和 II 期 (4) 上頜竇出血性鼻息肉 CT 表現密度不均，低的腫瘤相對較小，呈类圓形或橢圓形，邊緣完整、僅密度炎性病灶和多發斑塊狀出血相互混雜，增強後掃侵犯鼻咽部、後鼻孔、蝶竇和鼻腔；III 期腫瘤較大，描病灶強化不明顯，鼻腔膨脹性擴大，骨質受壓以上向外可經翼上頜間隙擴展到翼腭窩、顳下窩，此時翼頜竇內側璧和頂壁多見，後外側壁和鼻中隔其次，無板-上頜竇間隙術擴大、上頜竇後壁擴大向前膨隆，失破壞的骨壁常有硬化和吸收。通常依據該病的發生部去正常向后的孤形此征象為鼻咽纖維血管瘤的特征表位和 CT 的表現即可作出明確的診斷，如 CT 掃描發現。腫瘤甚至可繞過上頜竇後壁達面頰部；向上可通現上頜竇合併鈣化則有助於診斷。過眶下裂擴展到眶上裂和眶錐。IV 期病例，腫瘤進一步沿眶上下裂、破裂孔等顱底孔隙或直接破壞蝶骨擴血管造影和血管內栓塞治療展至顱內海綿竇和相鄰顱中窩）以沿眶上下裂擴展至顱內為多。III 期和 IV 期腫瘤因沿狹小的顱骨孔隙向血管造影檢查時可見腫瘤的供血動脈主要來自頸鼻咽外部生長而呈啞鈴狀、分葉狀或多頭狀，且這些外動脈分支如頜內動脈、面動脈腭升支、咽升動脈等，自然孔隙中均有重要的神經和血管通過，尤其 IV 期腫瘤侵及顱內時頸內動脈的腦膜支等也可參與。在動腫瘤延伸達顱內，給手術除造成很大困難。MR 檢查脈早期可顯示腫瘤供血動脈及血管團塊影，血管迂對鑒別副鼻竇阻塞性疾病常有很大的幫助。採用脂肪曲，在動脈晚期腫瘤有明顯均一的染色，部分形成血

抑制技術，作 T1 加權增強掃描，在注射 GD—DTPA 竇，並持續至靜脈期。造影劑後可見腫瘤有明顯的信號增強。栓塞物質以明膠海綿為主，也可用聚乙烯醇粒子鑑別診斷 [3-7]，粒子大小應在 300~400um，其直徑太小易通過危險吻合，因此在選擇時應予以注意。在作介人治療前鼻咽部血管纖維瘤常需與以下幾種疾病鑑別：應作雙側頸內、外動脈選擇性血管造影，以瞭解腫瘤的整個血供情況，然後根據腫瘤的血供情況，分別對 (1) 鼻咽癌：常發於中年人，多源於咽隱窩，早期各支供血動脈進行栓塞，應先對遠端分支進行栓塞，可向深層浸潤生長。咽隱窩變淺或消失，肌間隙模糊，以避免血管痙攣發生而喪失這些分支的栓塞機會，另頸部淋巴結轉移達 70%~90%。咽旁骨質破壞，但造影外如有近端血管先被栓塞，則仍有豐富的側支血供可劑增強不及血管纖維瘤顯著。MRI 血管纖維瘤的信號抵達腫瘤，會阻礙隨後的栓塞進行。外科手術應在血 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 185

管內栓塞後 1~3 天進行，資料認為至少在栓塞 24 小參考文獻時後，腫瘤內才會有大量的血栓形成，不少文獻報告，術前對鼻咽部血管纖維瘤進行栓塞治療，可有效地減 1 Schiff, M Juvenile. Nasopharyngeal; A theory of pathogenesis. Laryngoscope 1959, 69:981-1016. 少術中出血[3-6,8]，因而減少了輸血，並明顯地縮短了 2 宋濟昌, 錢雯, 卞紀平. 等. 鼻咽血管纖維瘤的 CT 診斷. 手術時間，可有效地降低手術死亡率和術後死亡。中國醫學計算機成像雜誌, 2002, 3:158-161. 3 董敏俊, 範新東, 石潤傑. 鼻咽血管纖維瘤術前雙重介鼻咽部血管纖維瘤雖屬良性腫瘤，但常呈浸潤性入栓塞的臨床價值入放射學雜誌, 2006, 6:342-344. 4 范新東, 石潤傑, 王德輝, 等. 青少年鼻咽纖維血管瘤的生長，且血供豐富，富含血竇和血管腔隙，單純手術輔助性介入栓塞. 中華放射學雜誌, 2006, 11:1197-1199. 很難完全切除，術後復發率高，血管內栓塞僅作為手 5 朱文科, 單鴻, 朱康順, 等. 鼻咽纖維血管瘤術前上頜術切除前的一種輔助治療方法。採用栓塞後再手術，動脈栓塞的臨床價值.介入放射學雜誌, 2004, 5:414-416. 6 關守海, 單鴻, 黃明聲, 等. 鼻咽頜面部易出性病變的其復發率亦可明顯降低。近 10 年隨著內窺鏡和顯微手術前血管內栓塞. 中華國際醫學雜誌, 2001, 1:51-54. 術的進步和血管內栓塞枝術等治療方法發展，尤其是 7 Lasjaunias P. Nasophrayngeal angiofibromas: hazards of 角度內窺鏡的發展，擴大了腫瘤在術中的暴露範圍， embolization. Radiology 1980, 136:119-123. 使得以前不能被切除的腫瘤得以摘除。因此，血管內 8 Moulin G, Chagnanud C, Gras R, et al. Juvenile nasophraygeal angiofibroma: comparison of blood loss 栓塞聯合手術治療完全可以摘除 I-II 期的腫瘤；對 during removal in embolized group versus nonembolized III-IV 期的腫瘤，手術完全切除困難，對殘瘤的腫瘤 group. Cardiovasc intenvent Radio 1995, 18:158-161. 可採用放射治療。

186 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

‧綜述‧

Remote Access to Health Services via Information Technology in Australia

CHAN Nai Chi

【Abstract】It is the current Australian clinical practice that the clinicians in various areas of Australia use their individual clinical practice method and cooperate with each other and are further integrated according to the horizontal integration within their same level and to the vertical integration between the three levels of services which are primary health care, secondary health care, and tertiary health care in order to solve the patients’ problems more efficiently and effectively with better quality. However, Australia is a wide brown land with a green fringe. The majority of the population lives in large cities along the coastline of the country. Smaller towns and farming settlements are scattered across the middle of the country in isolated rural and outback areas and often separated by hundreds of kilometers of desert. In many country areas, where the population is spread much less densely than in cities, the general practitioner may be the only doctor in town. Such towns are often many hours away from the nearest hospital with specialist medical services. As a result, the cost-effective telemedicine services need to become an integral part of the Australian mainstream healthcare delivery and become integrated into the routine clinical care in Australia. 【Key words】 Telemedicine services; Australia

遠程醫學技術在澳洲的應用陳迺志. 中國, 澳門特別行政區, 仁伯爵綜合醫院, 血液腫瘤科, Tel:(+853)-3908252; E-mail: [email protected] 【摘要】當代澳洲臨床醫生在澳洲不同地區的行醫方法是應用自己的臨床技能相互合作並整合在第一級、第二級、和第三級的衛生系統之中，以便提供有效率、高品質的醫療服務。但是，澳洲是一個幅原遼闊、中央是沙漠、四面環海的地方，絶大部份的人口都居住在沿海的大城市，小鎮及農村分散在沙漠的地區之中，相互距離數百公里，這些地區的唯一服務的醫生只有普通科醫生；病人如需要醫院專科醫生的服務，需要很長的交通時間才能到達最近的醫院就醫。故此，具有成本效益的遠程醫療服務需要整合於澳洲主流的醫療服務系統、並整合於澳洲常規的醫療服務之中。【關鍵詞】遠程醫學; 澳大利亞

THE CURRENT CLINICAL PRACTICE Recently evidence based clinical practice has been IN AREAS OF AUSTRALIA advocated and is defined by Gray as an approach to decision making in which the clinician utilizes the best The Australian famous doctors, Talley and O’Connor, available evidence and his/her individual clinical show that clinical methods remain the cornerstone of expertise to decide on the choice that suits the patient medical practice in spite of the sophistication of modern best [2]. This evidence based clinical practice uses the investigations because diagnosis rests largely on history most updated professional information in clinician’s and physical examination. Furthermore, as another daily works to solve the patients’ problems. famous doctor in Minnesota, Phillips reveals, a carefully taken history and a complete physical examination have Therefore, it can be seen that a meticulously taken always been, and will always be, the basis on which history, a full physical examination and evidence based efficient diagnosis depends [1]. Hence, it is naturally clinical practice are the cornerstone of the individual convincing that a cautiously taken history and a thorough clinician’s clinical practice method. It is the current physical examination are the most important and essential individual clinician’s clinical practice method in components for the current clinical practice method of Australia that the individual clinicians combine the most Australian and international individual clinicians. updated professional information in their daily work with their taken history and physical examination performed Author address: Department of Hematology and for their patients to decide on the best clinical decision, Oncology in Hospital CHCSJ, Macau SAR China;Tel: such as further investigation or management, that suits (+853)- 3908252;E-mail: [email protected] the patients concerned best. Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 187

It is well known that this division of health services Australians and hence health services in these areas have into three levels has successfully been implemented for been vital. It is also asserted by Banks and Togno that the current Australian clinical practice system. Australia is a rapidly aging society and older people seek medical help more often than any other aged group but As a consequence, it is the current Australian clinical health services in rural and remote Australia have been practice that the clinicians in various areas of Australia downgraded leading to fewer newly graduated doctors use their individual clinical practice method and trained in geriatric medicine willing to relocate to these cooperate with each other and are further integrated areas as a result from little peer support and very limited according to the horizontal integration within their same access to ongoing professional education [5]. level and to the vertical integration between these three levels of services in order to solve the patients’ problems Consequently, it is worth noting that the Australians more efficiently and effectively with better quality. especially older people and Aboriginal and Torres Strait Islander people who are living in remote and rural areas McWhinney presents that the division of health have the worst health status but, in these areas which are services into three levels, which are primary, secondary scattered and often separated by hundreds of kilometers and tertiary, has been highly effective. At the primary of desert, the health services for them are the poorest level, family doctors (or general practitioners) offer ones and have even been downgraded most likely owing continuing personal and comprehensive care in the to geographical, professional or intellectual isolations. community. At the secondary level, specialists offer care exclusively to patients with disorders in their fields of THE CURRENTLY AVAILABLE expertise commonly by referral from family physicians. INFORMATION TECHNOLOGIES The tertiary level embraces highly specialized services often available exclusively in regional centers. In terms Based on the facts that Australia is a wide Brown of integration of health services, horizontal integration is land with a green fringe and that remote and rural areas accomplished by family doctors working as team are scattered and separated by hundreds of kilometers, it members with other health professionals in cooperation is rational that telemedicine is considered to be useful with community support services and vertical integration for this situation. Besides, Australians especially [3] by cooperation between the three levels of services . Aboriginal and Torres Strait Islander people and older people who are living in these remote and rural areas THE GEOGRAPHICAL should most likely benefit from the information CHARACTERISTICS OF AUSTRALIA superhighway used in telemedicine.

Mcphee indicates the fact that Australia is a wide Telemedicine is medicine at a distance and the brown land with a green fringe. The majority of the current technologies employed in telemedicine are population lives in large cities along the coastline of the telephone, mobile phone, fax, and computer country. Smaller towns and farming settlements are telecommunications and Internet and that there are two scattered across the middle of the country in isolated basic types of interaction in telemedicine which are store rural and outback areas and often separated by hundreds and forward and real-time. In the store and forward type of kilometers of desert. In many country areas, where the of interaction such as transmission of still images etc., population is spread much less densely than in cities, the the information being exchanged between two sites is general practitioner may be the only doctor in town. stored in some format and used for non-emergency Such towns are often many hours away from the nearest situations when a diagnosis or consultation may be made hospital with specialist medical services…One of the in the next 24-48 hours and sent back. In the real-time major problems of rural medical practice is isolation. type of interaction such as videoconferences, the The isolation may be geographical, professional or information is offered in real-time with the parties being [4] intellectual . able to interact immediately.

In addition, Australian Institute of Health and Similarly, National Telehealth Committee suggests Welfare claims that the poor health status of Australians that telemedicine (or telehealth) practice include who are living in remote and rural areas is now apparent videoconferencing, medical image and data transfer, and and National Rural Health Policy Forum and National access to databases and multimedia information, which are Rural Health alliance ascertain that the health of activities complement telephone triage and counselling. Aboriginal and Torres Strait Islander peoples in remote and rural areas is very much poorer than other The delivery of health services via telemedicine, as 188 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 asserted by Mitchell, includes clinical services such as teleinformation via information technology especially for diagnosis or treatment, administrative services such Internet can efficiently and effectively offer clinicians as for scheduling of telemedicine outpatient during the consultations the relevant, accurate and timely appointments, and educational services such as for professional information that is most updated and the patient education and for ongoing professional education patient’s information such as their electronic medical and this delivery involves health professionals, patients records or their investigation results or images. This and other recipients [6]. It is my view that telemedicine means that the collections of patient’s history and services must be seen to save time and money for health investigation results or images and evidence based providers, to improve access to knowledge and to assist clinical practice can be made more efficiently and decision making, as well as to improve outcomes for effectively via telemedicine through teleinformation. their clients. Therefore, these services are safe and Thus, the clinician’s clinical decisions during the cost-effectiveness with efficacy. consultations are more efficient and more effective, resulting in their improved clinical performance. As Curry et al further mention, the clinical services of telemedicine are through teleconsultation, However, telemedicine via the current information telemonitoring and teleinformation. Each technology cannot perform a thorough physical teleconsultation involves a general practitioner or a examination done by clinicians and replace the consultant imparting knowledge to a less-practiced humanized clinician-patient relationship. It is thus general practitioner or nursing practitioner via confident to say that telemedicine cannot replace the telecommunications in order to improve clinical current individual clinicians’ clinical practice method in management, to allow the patients to be treated in the Australia but only make this method more efficient and community wherever possible, and to ensure a good more effective with better quality. quality of referral information for a hospital visit if a referral is necessary. Using telemonitoring the patients 2. The discussion especially focused on the can be monitored in a remote clinic or their home via the current Australian clinical practice system which telecommunication network. Moreover, by means of consists of three levels of health services teleinformation via telecommunications the timely and relevant professional and patient’s information can be Now that the current Australian clinical practice obtained by the clinician during the consultation [7]. system consists of the division of health services into three levels and that remote and rural areas are scattered DISCUSSION and separated by hundreds of kilometers and often many hours away from the nearest hospital with specialist In this section, the discussion of the statement is services, it is easy to understand that the transport to divided into two parts. In the first part the statement is long distant secondary services from remote and rural discussed especially focused on the current Australian areas in Australia is a part of suitable healthcare if access individual clinical practice method and in the second cannot be local. However, it is my view that this long part especially on the current Australian clinical practice distant secondary health services are expensive and can system. not provide the timely services in consideration of the long distant traveling. Therefore, the current long distant 1. The discussion especially focused on the secondary specialist services considered as appropriate current Australian individual clinical practice method in Australia are inefficient and ineffective to the people living in the rural and remote areas of Australia when Clinicians rely heavily on accurate and timely compared with those secondary services for the professional and patient information in order to enable Australians in cities, resulting in the inequity of them to their effective and lifesaving decision making. Moreover, access the secondary specialist health services. Likewise, health information systems are able to produce accurate these geographic isolation and lack of peer support and and timely health information efficiently and effectively of ongoing professional education contribute to fewer to meet the demands of clinicians. Consequently, with clinicians willing to work in these areas. the help of suitable health information systems, the clinicians can efficiently obtain the accurate and timely Facing the issue that is older people, Aboriginal and professional and patient information which is effective Torres Strait Islander people living in remote and rural to meet their demands, leading to the efficient and areas in Australia who have the worst health status and effective clinical decisions and to their improved clinical the poorest health services, the solutions should be that performance. Therefore, telemedicine by means of more clinicians need to be attracted and retained to work Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 189 in these areas and that the secondary specialist services telemedicine from remote secondary specialists, saving offered to them are required to become more efficient on traveling costs, allowing the patients to be treated in and effective with better quality leading to equity of these local areas wherever possible, and ensuring good them to access these health services. On the basis of the referral information for an hospital visit if a referral is current technologies used in telemedicine, it is logical to essential. Again, it can be felt that the primary health think that telemedicine can facilitate these solutions. services in rural and remote areas with telemedicine Telemedicine via telecommunication systems such as applied to support the role of primary clinicians as Internet and videoconferencing equipment can be used to gatekeepers for referral to other levels of health care are provide ongoing professional education. For example, the more efficient and more effective with better quality. courses for graduate diplomas, lunchtime seminars and case conferences, and interactive computer assisted learning These telemedicine services can also be employed packages can be provided to the clinicians in these remote and to support the secondary and/or tertiary levels of rural areas. In addition, these clinicians can much more easily delivery of health care. For instance, Curry et al put gain the peer support through the technologies employed in forward that the hospital team can use telemedicine to telemedicine. As a consequence, more clinicians will be keep in contact with other specialist centers. In addition, attracted and maintained to work in these areas and then the Mitchell and Disney demonstrate that the telemedicine quality of primary care in these communities can be enhanced network including videoconferencing facilities has been in view of the improved human resources. established at The Queen Elizabeth Hospital’s dialysis unit in Adelaide and at three satellite centers for clinical The telemedicine services can also be used to purposes such as the diagnosis or treatment of a patient. support the role of rural family physicians or general Consequently, it is easy to see that the specialists in the practitioners and other primary clinicians as a primary secondary or tertiary health services can get the peer provider of health care for their communities. For support efficiently and effectively via the current instance, revealed by Celler et al, the continuous home technologies such as videoconferencing equipment and monitoring of behavioral patterns helps the family Internet, etc. and thus their services become improved doctor or general practitioner concerned to recognize a with more efficiency and more effectiveness. Moreover, new episode of delirium of the patient based on which similarly the specialist secondary health services with he/she arranges an urgent geriatric review [8]. According the efficient and effective telemedicine linked to the to the findings of Gann et at for a typical Community specialist tertiary health services become more efficient Health National Health Service Trust, 15% of home and more effective with improved quality. visits could be replaced with home telecare, saving quite a big amount of money[9]. Likewise, quality of life and As a consequence, it is my perspective that healthcare outcomes improve when healthcare services telemedicine is cost effective and can be applicable in are home-based through telecommunication. For these every area of medicine in the community, primary, reasons, it can be seen that the primary health services in secondary and tertiary sectors resulting in the rural and remote areas by means of this efficient and improvement of the quality of health services in these effective telemonitoring used to support the role of sectors. Besides, telemedicine can strengthen the primary clinicians as a primary provider of health care interface between these sectors and hence facilitate the become more efficient and more effective with improved integrated care and cause this clinical practice system quality. more cost-effective with better quality.

Furthermore, telemedicine can be used to support Furthermore, as Mitchell clearly indicates, one of the role of primary clinicians as gatekeepers for referral the main drivers behind telemedicine is the desire to to other levels of health care. For example, as Banks and offer equity and access to rural and remote populations Togno point out, teleconsultation in which the patient that can, generally speaking, most benefit from the and local primary clinician undertake a consultation with information superhighway. It is thus very logical to say a remote specialist via real-time videoconference is that the people living in the remote and rural areas will becoming a necessary support for the local clinician’s have equity to access the high quality of health services practice[10]. Moreover, the specialists provide family if the cost-effective telemedicine is successfully doctors or general practitioners with online help in the implemented in every area of medicine in every sector clinical diagnosis and treatment of illnesses via Internet. and in interface between these sectors in this integrated Hence, the primary clinicians in these remote and rural clinical practice system. Likewise, the patients around areas are able to efficiently and effectively get the the areas of Australia will have equity to access relevant, accurate and timely or even real-time help via high-quality healthcare services. As well, the delivery of 190 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 healthcare will be resource efficient, patient centered and with these three levels of health services. the decision making made as close to the patient as possible at a local level. As a result, it is objective to state that the cost-effective telemedicine services have to be combined Although telemedicine is cost-effective and well with the Australian current individual clinician’s improves the quality of health services in the current clinical practice method and with the Australian current Australian clinical practice system, as Blignault puts clinical practice system. This implies that these services forward, telemedicine is not intended to and will not need to become an integral part of the Australian replace face-to-face interaction completely because, as mainstream healthcare delivery and become integrated already discussed previously in this essay, telemedicine into the routine clinical care in Australia. cannot replace a complete physical examination done by clinicians and the humanized clinician-patient Finally, it is concluded that remote access to health relationship. Moreover, in the current Australian clinical services via information technology cannot radically practice system, the primary, secondary and tertiary change clinical practice in areas of Australia but this clinicians have their completely different individual access can be integrated into the current Australian expertise and responsibilities so that they cannot replace routine clinical practice. each other using the current technologies employed in telemedicine. Therefore, it is worth emphasizing that the REFERENCES current telemedicine services provided in Australia cannot change the current Australian clinical practice 1 Talley, N., O’Connor, S. Forewords. Preface to the First system consisting of three levels of health services. Edition. Clinical Examination. 2nd ed. APAC Publishers, 1992. v-ix. CONCLUSION 2 Gray Muir JA.. Evidence-based healthcare: how to make health policy and management decisions. London: It is now confident to state that telemedicine Churchill Livingstone, 1997. 36. 3 McWhinney, IR. The Origins of Family Medicine. A services can make the current individual Australian Textbook of Family Medicine. 2nd ed. Oxford University clinician’s clinical practice method more cost-effective Press, 1997. 7-9. with better quality. In addition, it has been observed that 4 Hovenga E, Kidd M, Cesnik B. Remote Access, Health telemedicine services increase recruitment and retention Informatics: An Overview. Churchill Livingstone, 1996. of health professionals to rural and remote areas, 216. resulting in the enhanced quality of primary care in these 5 Banks, G., Togno, J.. Telehealth in Australia: Equitable communities. Likewise, these services can similarly Healthcare for Older People In Rural and Remote Areas. enhance primary care owing to increasing capacity of 5th National Rural Health Conference. Adalaide, primary healthcare providers to deliver care and can 1999.14-17. improve integration and coordination of healthcare 6 Mitchell J. The Uneven Diffusion of Telemedicine within the Australian current clinical practice system Services In Australia, Paper Presented at TeleMed 98, causing this system more cost-effective with better the Sixth International Conference on Telemedicine and quality and causing the people in remote and rural areas Telecare, Royal Society of Medicine, London, UK, to have equity to access the high quality of health 25-26 November 1998. services. Thus, it is reasonable that these cost effective 7 Curry RG, Norris AC, Parroy S., et al. The Strategic Development and Application of Telemedicine. UK: telemedicine can be applied in every area of medicine in Center for Healthcare Management, LSU College, the community, primary, secondary and tertiary sectors. Southampton University, 1997. 22-23. 8 Celler BG, Lovell NH, Chan DKY. The Potential Impact Nevertheless, telemedicine services cannot replace of Home telecare on Clinical Practice. MJA, 1999. 72-73. the current individual Australian clinicians’ clinical 9 Gann D, Tang P, Curry R. Feasibility Study: Technologies practice method. Furthermore, these telemedicine for telecare in the home. SPRU, 1998. 16-17. services cannot replace the expertise of primary, 10 Blignault, I. Enhancing Delivery of Health Services and secondary and tertiary clinicians and therefore not Information to Regional Australia. Paper to Regional replace the current Australian clinical practice system Australia Online, 1999. 29-30.

Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 191

‧病例報告‧

Dementia of Lewy’s Bodies: Two Cases Report

LI Yanfeng LEONG Wai I* Antonio VICTAL *#

【Abstract】 With the coming of the aged society, dementia problems are frequently encountered in routine clinical practice. The correct diagnosis of dementia is, however, still a difficult condition for physicians not working in the field of dementia. Dementia of Lewy’s bodies (DLB) characterized by progressive cognitive impairment with fluctuating course, recurrent visual hallucinations, and parkinsonism， is the second most common type of degenerative dementia in the elderly. For its newly emerging conception, the disease is not well known by the clinicians. Here we report two cases of dementia of Lewy’s body diagnosed in CHCSJ Hospital in Macau and make a literature review. 【 Key words】 Dementia of Lewy’s Bodies; Case report

路易體癡呆—附 2 例報告李延峰, 梁惠怡*,韋東尼*#. 100730 中國, 北京, 協和醫院神經科. * CP 3002, 中國, 澳門特別行政區政府, 仁伯爵綜合醫院, 內科, #通訊作者: 韋東尼, Tel: (+853)-3902220; Email: [email protected] 【摘要】隨著老年社會的到來，臨床上會遇到很多的癡呆患者。可是對於一般臨床醫生而言，正確診斷癡呆仍然存在問題。路易體癡呆（DLB）是老年人癡呆的第二大原因，該病以進行性認知功能障礙、波動病程、視幻覺以及柏金森病表現為特徵。由於概念較新，許多臨床醫生對該病不甚瞭解。本文報道澳門仁伯爵綜合醫院診斷的兩例路易體癡呆並復習文獻。【關鍵詞】路易體癡呆; 病例报告

CASES not able to cooperate in the examination. Slurring of speech, unlike to answer any doctor’s question, so MMSE Case 1: 75 years old housewife, Macau resident. test could not be performed. Cranial nerve were normal. The patient was found with some behavior abnormality The muscle strength of four extremities was almost since last year, forgeting things easily, suspected some normal, even though rigidity could be noticed. Tendon relatives stole her money, at same time she developed reflex was symmetric. Babinski sign negative. Diagnosis: walking difficulties, not able to control her steps and Dementia of Lewy bodies. walking faster and faster. Daytime sleep and syncope episodes also were noticed. The patient often Case 2: 53 years old male farmer, resident Macau. complained someone and animal in her room, but her The patient was healthy until he developed hand and leg family relatives denied this really happened. Diagnosed shaking during rest, walking difficulties, sluggish of daily as Parkinson disease in private hospital and levodopa life 3 years ago, mental changes also noticed by his therapy was given, but the symptoms still progressed. CT relatives and friends almost at the same year, he became performed in the Hospital without any significant suspicious, easily quarreling, and sometime lost his way findings. Denied history of hypertension, diabetes, and home, often forget things happened recently, too much family history of dementia. sleepy during daytime. This condition progressed insidiously and now he should be taken after by his On examination: conscious, apathy and fearing family. Denied history of diabetes and hypertension, expression, restless, always want walking around the room, denied family history of dementia.

On examination the patient is in conscious state,

motiveless expression, with orientation to place and time Authors address : Department of Neurology, Peking Union Medical College Hospital, Beijing, 100730 China. *CP 3002, incorrectly, MMSE<6. Cranial nerve normal, rest tremor Department of Internal Medicine, Centro Hospitalar Conde de of hands and legs, muscle strength normal of 4 São Januário, Macau, China; #Correspondence: Tel:(+853)- extremities, and slight induced rigidity. reflex 3902220; Email: [email protected] symmetry, double left Babinski sign possible existed. 192 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

Diagnosis: Dementia of Lewy’s bodies. consensus guidelines[1] for the disease. The subsequent epidemiological investigation showed the disease DISCUSSION represents approximately 22 percent of all patients with dementia[5], and the number of cases is expected to Consensus guidelines for diagnosis of DLB were increase as the population ages and as dementia with published in 1996 and reviewed in 1999 and 2005[1-3]. Lewy bodies is increasingly recognized in the differential The criteria for clinical diagnosis should include the diagnosis of dementia. central feature of dementia (progressive decline of cognitive function of sufficient magnitude to impair The symptoms of dementia with Lewy bodies can normal social or occupational function), and 3 core be very similar to those of Alzheimer’s disease, but more features of dementia (Fluctuation in cognition with prominent in executive functioning and to have pronounced variations in alertness and attention, visuospatial impairment, difficulties in clock drawing or recurrent visual hallucinations, motor parkinsonism) figure copying may be more indicative of Dementia with Probable DLB must have two core features and possible Lewy bodies[3,5]. Fluctuation of cognition occurs in 50% DLB must have one. The features that support DLB ~75% of patients with DLB[4,6,7] These fluctuations may include those such as repeated falls, syncope, transient occur over minutes, hours, or days, and their presence loss of consciousness, REM sleep behavior disorder, may be particularly helpful in differentiating Dementia hallucinations in other sensory modalities, systematized with Lewy bodies from Alzheimer’s disease[7]. delusions, neuroleptic sensitivity, etc. Characteristics of fluctuations include: (1) daytime drowsiness and lethargy, (2) day-time sleep of two or In our reported two cases, both patients had classical more hours, (3) staring into space for long periods, and dementia and parkinsonism manifestations, and the (4) episodes of disorganized speech[7]. occurrence of these two clinical conditions were at almost the same year, besides these are patients Psychotic symptoms occur in about 80 percent of [5] developed psychotic symptoms such as hallucination and patients who have DLB . Usually these are purely too much daytime sleep, and history investigation visual, vivid, colorful, 3-dimensional hallucinations of [5~7] showed no evidence of dementia due to cerebral vascular humans or animals . Because patients who have disease, Vitamin B12 deficiency, infectious or tumor Dementia with Lewy bodies can experience severe related diseases. Diagnosis of probable DLB is thus reactions to antipsychotic medications, it is important to made considering the patient’s clinical manifestations recognize these hallucinations as part of the disease and the diagnosis criteria. For the differential diagnosis, spectrum and not as evidence of a superimposed the patient’s associated symptoms such as motor psychotic illness. involvement and vision hallucination made it easy to differ from Alzheimer disease, which is characterized by The Parkinson’s manifestations of DLB, progressive cognitive damage, personality changes and sometimes the most prominent symptoms of the disease, imagine findings of brain atrophy; and co-occurrence of should be differentiated from Parkinson’s disease with dementia and motor involvement almost at the same time dementia. With regard to Parkinson’s disease, the motor also help us to differ them from Parkinson disease with symptoms usually predate the dementia by many years. dementia, condition in which the patients develop In contrast, to diagnose Dementia with Lewy bodies, dementia usually over one year after the diagnosis of the onset of dementia and Parkinsonism must occur Parkinson disease. within one year of each other, and either feature can be [5] the initial symptom . Autonomic symptoms, especially Dementia with Lewy’s bodies(DLB) was first orthostatic hypotension and constipation, typically are [3,7] described in 1984 by Kosaka and colleagues, who prominent in Dementia with Lewy bodies . Patients reported finding Lewy bodies throughout the cortexes of who have Dementia with Lewy bodies tend not to some patients with dementia, rather than the neuritic respond as well to levodopa with carbidopa (Sinemet) plaques and neurofibrillary tangles characteristic of as patients who have Parkinson’s disease with [7] Alzheimer’s disease[4]. In 1996 the first international dementia . workshop of the Consortium on Dementia with Lewy Bodies clarified the key features of DLB and made a With regard to the drug therapy of DLB, Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 193

Cholinesterase inhibitors are more effective in patients 2 McKeith IG, Perry EK, Perry RH. Report of the second who have dementia with Lewy bodies than in those with dementia with Lewy body international workshop: diagnosis and treatment. Consortium on Dementia with Alzheimer’s disease. Conversely, patients who have Lewy Bodies. Neurology. 1999, 53:902-905. Dementia with Lewy bodies do not respond as well to 3 McKeith I, Dickson DW, Lowe J, et al. Diagnosis and antiparkinsonian medications. Anticholinergic medications management of dementia with Lewy bodies: third report should be avoided because they exacerbate the symptoms of the DLB Consortium. Neurology 2005, 65:1863-1872. of dementia. Traditional antipsychotic medications can 4 Kosaka K, Yoshimura M, Ikeda K, et al. Diffuse type of precipitate severe reactions and may not be Lewy body disease: progressive dementia with abundant recommended to patients who have Dementia with Lewy cortical Lewy bodies and senile changes of varying degree—a new disease? Clin Neuropathology 1984, bodies[8]. 3:185–192. 5 McKeith I, Mintzer J, Aarsland D, et al. Dementia with The prognosis of the disease is considered uncertain. Lewy bodies. Lancet Neurol. 2004, 3:19–28. Most experts believe that the rate of decline and 6 Knopman DS, Boeve BF, Petersen RC. Essentials of the mortality in Dementia with Lewy bodies is similar to that proper diagnoses of mild cognitive impairment, dementia, of Alzheimer’s disease. No factors that predict a more and major subtypes of dementia. Mayo Clin Proc. 2003, 78:1290–1308. severe clinical course or decreased survival have been 7 Ferman TJ, Smith GE, Boeve BF, et al. DLB fluctuations: [5,7,9] identified . specific features that reliably differentiate DLB from AD and normal aging. Neurology. 2004, 62:181–187. REFERENCES 8 Christopher Frank. Dementia with Lewy bodies. Can Fam 1 McKeith IG, Galasko DR, Kosaka K, et al. Consensus Physician. 2003, 49:1304-1311. guidelines for the clinical and pathologic diagnosis of 9 Ballard C, O’Brien J, Morris CM, et al. The progression of dementia with Lewy bodies (DLB): report of the cognitive impairment in dementia with Lewy bodies, consortium on DLB international workshop. Neurology. vascular dementia and Alzheimer’s disease. Int J Geriatric 1996, 47:1113-1124. Psychiatry. 2001, 16:499–503.

194 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

‧病例報告‧

喉氣囊腫的CT診斷－附1病例報告

楊貞勇

【摘要】目的瞭解喉氣囊腫的CT表現及診斷。方法對1例典型的喉氣囊腫進行回顧性分析和文獻復習。結果患者得到明確正確診斷。結論典型的喉氣囊腫的明確診斷和分型並不困難，但由於本病十分少見，正確診斷的關鍵是避免因對本病的不瞭解而産生漏診及誤診；CT對本病的明確診斷和分型具有重要意義。【關鍵字】喉氣囊腫; 體層攝影術; X線計算機

CT Diagnosis of Laryngocele Yang Zhen yong. Imaging Center of Kiangwu Hospital, Macao SAR ,China;Tel: (+853)-2950352; E-mail:[email protected] 【Abstract】 Objective To study the CT appearance and diagnosis of laryngocele. Methods One case and literature were reviewed. Results Right diagnosis was made. Conclusions Typical laryngocele is easy to diagnose correctly . But as it is rare and easy to be ignored, missing and or wrong diagnosis is possible and should be avoided. CT is essential for the right diagnosis and classification of this disease. 【key words】 Laryngocele; Tomography; X-ray computed

喉氣囊腫(laryngocele)為喉室小囊的病理性擴壓狹小(圖1-3)。張，比較罕見，國內外報道僅300餘例[1]，國內共報道 6例[1-6]，(山東冠縣1例，山東濟寧1例，浙江台州1例，圖1 上部層面，軟組織窗，江西贛州1例，四川自貢1例，雲南昆明1例。)我院近喉前庭右側部分黏膜下見一年來發現1例，特報道如下。約 3.4cm×1.7cm 大小氣體密度佔位灶，局部喉前庭黏膜受壓推移，向喉腔內隆起，患者，女，52歲。以“反復咽痛、聲音嘶啞3年餘” 表面光滑，未見異常強化，未見壁結節而就診。查體：右側頸動脈鞘區淋巴結腫大，有壓痛，頸部皮膚無腫脹或壓痛，右側下嚥側壁及右側披裂、聲帶稍紅腫。患者近3年多以反復咽痛、聲音嘶啞發作，多次來我院急、門診就診，每次症狀好轉一段時間後再發，最長一次發作持續二十餘天，數次建議住院進一步檢查，病人一直拒絕。最近一次對患者行纖維喉鏡檢查發現右側喉室隆起、腫脹，聲帶閉合時明顯，聲帶活動好，閉合好，未見新生物。

圖 3 下部層面，軟組織窗， CT表現：自舌骨平面向下至聲門上區，右側喉室圖 2 與圖一為同一層面，肺窗，清晰顯示佔囊腫前下緣與喉室前部相內可見類圓形內容物為氣體的囊性腫塊，大小約位灶內為氣體密度，密連通 3.4cm×1.7cm×3.5cm，右側喉室壁黏膜向中央移位、度遠低於皮下脂肪，喉腔內局部喉前庭黏膜隆起，橫斷面顯示為隔膜樣結構，表面光滑，喉腔受隆起，表面光滑

多層面重建（MPR）可見腫塊內氣體影在右側喉作者單位：中國, 澳門特別行政區, 鏡湖醫院, 影像中心; Tel:(+853)-2950352; E-mail:[email protected] 室前下方與喉室腔相連通。 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 195

討論部位相當於胸鎖乳突肌前緣與舌骨之間。治療上主要為手術切除。喉氣囊腫，又名喉膨出、喉憩室、猿猴氣囊或喉

氣性疝，為喉室小囊的異常擴張，內含氣體，比較罕本病在CT掃描可有以下表現：典型表現為喉室內見，其與喉囊腫的區別在於喉囊腫有完整的包膜且與可見類圓形內容物為氣體的囊性腫塊，可延伸至喉腔喉室不通，而喉氣囊腫則與喉室相通[7,8]。Maran等統外甚至頸部，向下追蹤可發現囊腔與喉室相連通，當計該病發病率只有1/250萬。男性多見，為女性的5倍，出現這些徵象時診斷並不困難，不過由於是氣體密各年齡組均可發病，但以50~60歲最多見[8]。度，不要誤認為正常氣道而漏診，還應注意與充氣的

梨狀窩鑒別。當合併感染時由於囊內充滿液體，易誤本病病因未明，有以下幾種病因學說：(1)患者原診為喉黏液囊腫，文獻中誤診病例就屬此情況[2-3]。根有先天性喉室小囊過長，後因某種因素(如舉重、唱據以下幾點可做出正確診斷：(1)腫塊與喉室相連；(2) 歌、吹樂器、用力分娩)使喉內壓力高，致喉室小囊被腫塊含氣體（有時氣體量較少，需仔細觀察尋找）；高壓空氣所擴張；(2)喉室小囊開口處有單向活瓣形 (3) 喉腔緣光滑；(4) 增強掃描不強化；(5) 腫塊雖大成，空氣易進難出，日久則形成含氣囊腫，如此時喉但無骨破壞及區域淋巴結腫大。另外，囊壁可見鈣化，室小囊與喉室間的聯繫被中斷則發展成囊腫，若有繼有時在囊腫下方能追蹤到與喉室相連通，則更有確診發感染則發展成膿囊腫；(3)本病可能與外傷、結核、意義，本例就有此表現。腫瘤有關。

參考文獻本病分為3型：(1)喉內型，膨出僅限於喉內，向上可達杓會厭皺襞，本例即為喉內型；(2)喉外型，囊 1 楊亞英, 雷靜, 王崇玉. 喉氣囊腫一例報告. 實用放射學雜誌, 2005, 21:860-863. 腫自喉室小囊向上穿過甲狀舌骨膜膨出於頸部，喉內 2 唐正琪, 孫先富. 喉氣囊腫誤診1例. 中國誤診學雜無膨出；(3)混合型，內外兩型同時存在，囊的兩部分誌，2004. 4:1137. 與甲狀舌骨膜處有峽相連。許多學者認為沒有單純的 3 羅開源, 楊簧. 先天性喉氣囊腫誤診1例. 中國誤診學雜誌喉外型，因喉氣囊腫皆來源於喉室小囊，喉內必有一 , 2002, 2:1755. 4 李玉玲,張芝芳. 咽喉囊腫一例. 耳鼻喉學報, 1998. 部分，不過較小未發現而已。根據統計分析，約 70% 12:284. 為喉內型，25%為喉外型，5%為混合型[7]。本病大多 5 高福平, 孫遜, 孫新梅. 喉氣囊腫並囊壁息肉樣變一例. 為單側性，約25%可累及雙側[9]。喉氣囊腫病理上表臨床耳鼻咽喉科雜誌, 1999. 13:115. 6 陳亦東. 喉氣囊腫一例報告.實用放射學雜誌, 2001, 現為囊壁內層為假複層纖毛柱狀上皮，基底膜脆弱， 17:860-863. 囊壁由含有細小血管網的纖維組織束、腺體、平滑肌 7 吳學愚, 主編. 喉科學. 第1版. 上海:上海科學技術出纖維、散在的淋巴細胞團及少數杯狀細胞所組成。版社, 2000. 125-128. 8 王天鐸, 主編.喉科手術學. 第1版. 北京:人民衛生出版

社, 2000. 188-189. 本病臨床上常見表現為聲嘶，可出現呼吸和吞咽 9 陳星榮, 主編. 全身CT和MRI. 第1版. 上海:上海醫科困難，早期多無症狀。喉外型者主要表現為頸部腫塊，大學出版社, 1994. 390-391.

196 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

‧病例報告‧

冬季成人傳成人手足口病 2 例

李彩珠巢和安* 甄健榮**

【摘要】手足口病是以手、足皮膚皰疹和口腔粘膜潰瘍為主要表現的一種侵犯兒童（主要為 3 歲以下）的傳染病，多數於夏天及初秋時份發生。其傳染性高，對於幼兒更容易在幼稚園及幼兒中心做成爆發性傳染，故須要加強預防。但在冬季發生較少，在成人間造成傳播也不多見。【關鍵詞】手足口病

Two Cares of Adult Transmission of Hand, Foot, and Mouth Disease in Winter LEI Choi Chu, CHAO Wo On*, João Paulo Chin**, Department of Accident & Emergency, Centro Hospitalar Conde De São Januário (CHCSJ), Tel: (+853)-3903615; E-mail:[email protected] . *Policlinica Chan’s de Macau; **Lar De Cuidados “ Sol Nascente” Da Areia Preta, Rua de Central da Areia Preta Quarteirao ‘Q’. 【Abstract】Hand, foot, and mouth disease (HFMD) is common in summer and early autumn. The children under the age of three are mainly infected with oral mucosal ulcer and herpes in their hands and foot. Strengthened prevention against the high contagious HFMD is necessary since the adult transmission can also happen in winter and infant infection can easily be burst out in kindergarten. 【Key words】 Hand, foot, and mouth disease

手足口病(hand foot and mouth disease, HFMD)是而且又是在成人間傳播。通過此病例，可以看出手足以手、足皮膚皰疹和口腔粘膜潰瘍為主要表現的一種口病傳染性高，在冬季亦可在成人間造成傳播，對於侵犯兒童（主要為 3 歲以下）的傳染病。在世界各地幼兒更容易在幼稚園及幼兒中心發成爆發性傳染，故均曾出現個別病例或集體爆發（馬來西亞 1997 年，中須要加強預防。華台北 1998 年），而多數於夏天及初秋時份發生，潛伏期約 3~7 天[1]。但在冬季發生較少，在成人間造成手足口病是以手、足皮膚皰疹和口腔粘膜潰瘍為主傳播也不多見。要表現的一種侵犯兒童（主要為 3 歲以下）的傳染病；多數於夏天及初秋時份發生，潛伏期約 3~7 天。其病病史及臨床資料原體包括數種腸道病毒，如柯薩奇病毒 A2、A4、A5、兩患者為男性，澳門特別行政區人，年齡分別為 A7、A9、A10、A16 等，以及其他腸道病毒（如 EV71 型腸病毒）等，其中以柯薩奇病毒最常見。這些病毒 23 及 28 歲，為共同住一房間的親兄弟。今年 1 月初 A16 弟弟首先出現發燒，食慾不振及喉嚨痛等徵狀；一至均屬於小核糖核酸病毒，多在體表受壓迫或磨擦部位的細胞內增殖引起病變，這些細胞內可以出現嗜酸性包涵兩天後，口腔出現疼痛的水皰，偶影響吞嚥。這些水 [2,3] 皰初時呈細小的紅點，然後形成細小淺表潰瘍。這些體，電鏡下可見到結晶狀排列的病毒顆粒。潰瘍位於舌頭，牙肉，以及兩腮內的口腔；另外，身體的皮疹主要出現於手掌及腳掌，外形呈扁平或突起引起手足口病的柯薩奇病毒透過人同人之間，直狀的紅斑點伴痛不痕癢。兩天後兄長手足口部亦出現接接觸病者的鼻或喉嚨分泌、唾液、穿破的水皰以及相同皮疹及症狀。兩人無外遊史及無接觸家禽史，可糞便而傳播的。此病的傳播能力由病發初期開始，或排除另外一種由其他柯薩奇病毒引起的疾病，如口蹄會維持數星期，直至糞便中的病毒消失為止。病。兩人均為乙型肝炎患者，其中一人正接受乙型肝預防手足口病須保持空氣流通；時常保持雙手清炎治療，病情穩定。潔，並用正確方法洗手；飯前、如厠後，以及處理尿片

治療或其他被糞便或口鼻排出的分泌物沾污的物品後應洗淨雙手；兒童的玩具或其他用品應常常徹底清洗；病童由於現時並沒有特定治療手足口病的方法，兩患者應留在家中，直至發燒及皮疹消退，以及所有水皰結痂均為乙型肝炎患者所以要求兩患者同時隔離至皮疹完後才回校上課；減少到人多擠迫的地方；如兒童發高全消退同時予以對症處理。兩患者的情況都自行痊癒，燒，活力減退或病情惡化，家長應及早攜同子女就醫。其徵狀如發燒、皮疹及潰瘍於一個星期後便自動消退。參考文獻討論 1 葉冬青, 主編. 皮膚病流行病學. 第 1 版. 北京:人民衛本文兩患者的情況比較少見[1-3]，因為發生在冬季，生出版社, 2001. 421-422. 2 趙辨, 主編. 臨床皮膚病學. 第 4 版. 南京:江蘇科學技作者單位：澳門特別行政區, 仁伯爵綜合醫院, 急診部, 術出版社, 2001. 324-325. Tel:(+853)-3903615; E-mail:[email protected]; * 澳門, 3 關顯智, 陳慶學, 谷鴻喜, 主編. 醫學微生物學. 第 3 版. 陳氏醫療中心皮膚性病科; **澳門, 黑沙環, 明暉護養院. 吉林:吉林科學技術出版社, 1995. 216-217. Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 197

‧醫學文摘‧ 十五國家重大科技專項 Introduction of Key Technology in th “食品安全關鍵技術” Food Safety in 10 Five-year Plan WU Yong-ning, ZHOU Nai-Yuan, CHEN Jun-Shi 吳永寧, 周乃元, 陳君石

【Abstract】 Objective To ensure Chinese consumer’s health 【摘要】目的切實保障我國消費者健康，維護我國食 and to project the safety of Chinese food import and export trade. 品進出口貿易安全。方法以食品安全監控技術研究為突 Methods Capacity building was developed by establishing analysis 破口，進行檢測技術和方法的研究；開展食品安全監測，預 methods, monitoring and surveillance network, prealertting system, 警與評價技術研究；進行食品安全控制技術研究；建立我國 system of food control such as HACCP, and upgrading national 的食品安全標準與技術措施體系；開展綜合示範與宏觀戰略 standards on food safety in China. And the technology was 研究，進行國際合作。結果構建了共享的全國污染物監 demonstrated comprehensively in typical areas. Results Two national 測網（含食源性疾病）、進出口食品安全監測與預警網；制 networks were set up, as the National Surveillance Network for food contamination and food bone disease, and the Surveillance and （修）訂國家標準 40 項、行業和地方標準 166 項，申請立 Prealertting Network Import and Export Food safety; 40 national 項 385 項；牽頭制定國際標準 2 項、已完成 1 項，參加制定 standards and 166 Technical and regional standards were set up and 國際標準 2 項；提出 595 個食品安全標準限量指標的建議值， revised, and 385 standards were applied and ongoing, especially 2 58 個(套)生產，加工和流通領域的食品安全技術規範(標準)； international standards were set up, which have involved 595 proposal 初步形成了食品安全檢測體系，建立了 219 項實驗室檢測方 values of maximum limit and 58 practice codex guideline in the field of 法，其中農藥多殘留檢測方法可檢測 150 種農藥，獸藥多殘 production and circulation; 219 analytical method were developed, 留檢測方法可檢測 122 種獸藥；研製出 81 個檢測技術相關 especially multi-residues method were developed for 150 pesticides and 122 veterinary drugs respectively, 81 test kits technology and fast 試劑(盒)、現場快速檢測技術，25 種相關檢測設備。在中國 on-site detection technologies as well as 25 related equipment were 疾病預防控制中心、中國檢驗檢疫科學研究院和中國農業大 developed also, 128 national patents applied for and 36 patents 學等機構初步建立了 3 個符合國際良好實驗室規範(GLP)的 authorized. The capacity building were improved in 3 national 國家食品安全中心(基地)，有 168 個檢測驗室參加國際有關 institutions and 168 analytical laboratories have participated in 實驗室組織之間的檢測比對試驗或得到國際相關室驗室的 international proficiency test and got accredit of related international 互認；形成了 10 個食品安全示範區；219 家企業參與了食 laboratories; demonstration model of food safety were set up in 10 品安全關鍵技術示範；獲得國內專利 36 項，申請 128 項。 areas, which involved in 219 enterprises. Conclusion The progress 結論 was made great in the study of key technology in food safety, which “食品安全關鍵技術”重大科技專項取得了重大成效， has significant meaning and great contribution in capacity building of 對提升我國的食品安全水平具有重要意義和作用。 food safety in China. 【關鍵字】食品; 實驗室; 安全管理【Key Words】Food; Laboratories; Safety Management

摘自: 中國食品衛生雜誌, 2007, 19:97. From: Chinese Journal Of Food Hygiene, 2007, 19:97.

椎間盤源性腰痛的 Diagnosis and Treatment of 診斷與治療初步報告 Discogenic Low Back Pain 夏群, Steffen Sola, 胡永成, 等 XIA Qun, Steffen Sola, HU Yong-Cheng, et al. 【摘要】目的探討腰椎間盤源性疼痛的診斷方法【Abstract】 Objective To explore diagnostic method to discogenic low back pain and evaluate the effect of discectomy and 及採用前路經腹膜外入路椎間盤，切除人工椎間盤置換或 artificial disc replacement or anterior lumbar interbody fusion (ALIF) 椎間 cage 植骨融合的臨床療效。方法 35 例經保守治療 via retroperitoneal approach. Methods From April 2004 to June 無效的椎間盤源性腰痛患者接受手術治療。椎間盤源性腰 2006, 35 patients who underwent a failed conservative treatment for at least 6 months received surgery. The diagnostic criteria for discogenic 痛的診斷標準為：(1) 腰部及下肢疼痛的部位與神經根定 low back paine were: 1) location of low back and leg pain not 位不符；(2) 症狀反復發作，病程在半年以上；(3) MRI concordant to nerve roots innervations; 2) symptoms lasting for at least 6 病變椎間盤 T 加權像低信號；4 椎間盤造影陽性，相鄰 months; 3) low disc intensity on T2 weight MRI; 4) positive discography 2 with negative control on adjacent level; 5) articular process block to 節段為陰性對照；5 關節突關節封閉除外關節突關節退變 exclude pain derived from degenerative articular processes. The 引起的疼痛。患者年齡 25~67 歲，平均 43.6 歲。L4-5 14 surgically treated patients aged 43.6 years on the average (ranging from 25 to 67). The treated discs located: 14 in L , 16 in L S , 5 in both L 例，L5S1 16 例，L4-5 和 L5S1 雙間隙 5 例，前路經腹膜外 4-5 5 1 4-5 and L5S1. After total discectomy 13 cases (16 discs) received artificial 入路椎間盤切除後行人工椎間盤置換 13 例 16 個椎間盤， disc replacement and 22 cases (24 discs) received ALIF via 椎間 cage 融合 22 例 24 個椎間盤術後 3~7 天下地活動， retroperitoneal approach. 3 days postoperation the patients were allowed 腰圍固定 3 個月。結果所有患者隨防 6~26 個月，平均 to leave bed with a brace, and the brace should be used for 3 months. 個月。術後腰痛及下肢痛症狀明顯緩解，均恢復正常 Results All the cases were followed up for 18 months on the average 18 (6-26 months). At the end of follow-up all the patients recovered normal 生活或工作。VAS 評分由術前平均 72 分，降至術後 18 social life and work without any symptoms. VAS decreased from 72 分，隨訪 6 個月時 6.5 分。ODI 評分由術前平均 21.5 分， preoperatively to 18 postoperatively , and average 6.5 at 6 months after 降至隨訪 6 個月時 3 分，椎間隙高度從術前平均 9.5mm operation. ODI decrease from 21.5 preoperatively to averaged 3 at 6 months postoperatively. Disc height increased from 9.5 mm 增加至術後 13.5mm. 手術時間 70~120min ，出血量 preoperatively to 13.5 mm postoperatively. Surgery time averaged 90 100~400ml.隨訪時未發現腸梗阻、逆行射精和假體位置移 min (70-120min), blood loss averaged 220 ml (100-400 ml). No ileus, 動。結論椎間盤源性腰痛由於臨床和影像學表現不典 retrograde ejaculation nor artificial disc translation was noticed during follow-up. Conclusion With atypical symptom discogenic low back 型，常被誤診或漏診，可結合腰椎 MRI 及椎間盤造影進 pain which is easily misdiagnosed should always be kept in mind when 行診斷。腰椎前路椎間盤切除人工椎間盤置換或椎間 cage atypical back and leg pain is encountered. Discography provides good 融合是治療椎間盤性腰痛的有效選擇。 differential diagnosis. Surgical treatment including artificial disc replacement and ALIF provides satisfactory outcome. 【關鍵字】椎間盤; 腰痛; 診斷; 治療結【Key words】 Intervertebral disk; Low bask pain; 果; 脊柱融合術 Diagnosis; Treatment outcome; Spinal fusion 摘自：中華骨科雜誌, 2007, 27:162. From: Chinese Journal Of Orthopaedics, 2007, 27:162. 198 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

突發性聾的發病時間規律與 Study of Relationship Between the 血液流變學的關係 Onset Time of Sudden Deafness and Blood Rheology 陳秀梅, 張慶泉, 解光 CHEN Xiu-mei, ZHANG Qing-Quan, XIE Guang 【摘要】目的探討突發性聾患者的發病時間規律【Abstract】 Objective To investigate the correlation of the 及血液流變學變化的內在聯繫。方法觀察 198 例突發性 onset time of sudden deafness and blood rheology using a large-scale 聾患者的血液流變學指標，並與 60 例正常對照組的相關 retrospective study. Methods 198 patients of sudden deafness were 指標進行整體對比分析，探討突發性聾與血液流變學之間 examined with blood rheology and compared with 60 healthy people. 的關係。仔細詢問 198 例患者的發病時間，每 2h 為一個 Thirty patients were as subjects to study the circadian of blood rheology 時間段，統計每時段的發病人數，觀察各時間段發病的突 in order to search whether the blood rheology of morning was the highest. By divided 24 hours into twelve groups, each group contained 發性聾患者的血液流變學變化，從而更精確的說明兩者之 two hours. Then the 198 patients were separated into twelve groups 間的關係。同時檢測了 30 例突發性聾患者一晝夜 3 次的 according to the time of onset. The blood rheology of each group was 血液流變學指標，觀察突發性聾患者 1ｄ中的血液流變學 analyzed and compared with each other to observe which group was the 變化規律。結果突發性聾患者的血液流變學指標與對 highest. Results Most blood rheology index of the patients were 照組相比有多項差異有統計學意義。突發性聾患者一晝夜 higher than that of the healthy people. The onset time in most of the patients was during 4 am-8am, but 45 patients during 4 am -6 am and 40 血液流變學變化以晨起時的血流變指標為最高。各時間段 patients during 6 am-8am. By analyzing and comparing the blood 發病人數以上午 4~8 時發病者最多，二者佔全部突發性聾 rheology of each group , the result showed that the blood rheology index 患者的 42.9%，其餘 10 個時段每段發病人數均不超過總 in the group of 4 am-8am was highest. And the blood rheology index of 人數的 9%；12 時段的血液流變學指標，又以上午 4~8 時 sudden deafness was highest in the morning. Conclusions There was 段發病者為最高。結論血液流變學異常與突發性聾的 a close relation between blood rheology and sudden deafness. The peak time of onset was 4 am-8am, and the patients whose blood rheology 發病密切相關，與心腦血管疾病一致，其發病高峰亦在晨 were the highest should be more predisposed to sudden deafness than the 時 4~8 時，且血流變指標高的患者更容易在清晨發病。 order patients. 【關鍵字】聽覺喪失,突發性; 血液流變學; 【Key words】 Hearing loss,Sudden; Hemorheology; 晝夜節律 Circadian rhythm 摘自: 中華耳鼻咽喉頭頸外科雜誌, 2007, 42:191. From: Chin Journal Otorhinolaryngol Head Neck Surg, 2007, 42:191.

愛滋病合併馬爾尼菲青霉菌 The Chest Image Appearances of 感染的胸部影像學表現 Penicilliosis Marneffei in Patients with AIDS 劉晉新, 唐小平, 江松峰, 等 LIU Jin-xin, TANG Xiao-Ping, JIANG Song-feng, et al. 【摘要】目的探討愛滋病合併馬爾尼菲青霉菌感染【Abstract】 Objective To study the chest image appearances of 的胸部影像學表現。方法回顧性分析 36 例愛滋病合併 penicilliosis marneffei (PSM) in patients with acquired immune deficiency 馬爾尼菲青霉菌感染者的胸部 X 線片+高分辨 CT(HRCT) syndrome (AIDS) . Methods Chest imaging features of PSM in 36 表現。結果 36 例患者胸片中 14 例出現肺內浸潤性病灶 Patients with AIDS were retrospectively analyzed . Results Radiographic features of infiltrative lesions and focal lung consolidation were found in 14 或局限性肺實變(38.89%)，其中單肺 2 例(5.56%)，雙肺 cases (38.89%), in which 2 cases were with single lung disease(5.56%) and 12 例(33.33%)；8 例呈彌漫性分佈(22.22%)，10 例呈網織 12 cases with bilateral lung involment(33.33%). 8 cases had diffuse lesions 紋理(27.78%)，9 例見小結節(25%)，7 例呈磨玻璃密度影 (22.22%), 10 cases had reticular image patterns (27.78%), 9 cases had nodular patterns (25%), 7 cases had ground-glass shadows (19.44%), 6 (19.44%)，6 例見粟粒樣病變(16.67%)，5 例見肺氣囊 cases had diffuse military lesions (16.67 %), 4 cases had enlarged hilar and (13.89%)，4 例見胸腔積液(11.11%)，4 例出現肺門及縱隔 enlarged mediastinum lymph nodes (11.11%). Cystic lesions was found in 5 淋巴結增大(11.11%)，2 例見結節狀腫塊影(5.56%)，心包 cases (13.89%). 4 cases had pleural effusion (11.11%), and 2 cases had 積液及自發性氣胸各 1 例(2.78%)。36 例患者 HRCT 發現 nodular bump (5.56%), Pericardial effusion and pneumothorax each appeared in 1 case (2.78%). By HRCT, infiltrative lesion and focal lung 32 例出現肺內浸潤性病灶或局限性肺實變(88.89%)，其中 consolidation were found in 32 patients (88.89%), in which 4 cases were 單肺 4 例(11.11%)，雙肺 28 例(77.78%)；13 例呈彌漫性 with single lung lesions (11.11%) and 28 cases were with bilateral lung 分佈(36.11%)，10 例見小葉間隔增厚(27.78%)，9 例見小 lesions (77.78%). 13 cases had diffuse lesions (36.11%), 10 cases had pulmonary interstitial hyperplasia (27.78%), 9 cases had nodular patterns 結節(25%)，8 例呈磨玻璃樣密度影(22.22%)，9 例見粟 (25%), 8 cases had ground-glass shadows (22.22%), 9 cases had diffuse 樣病變(25%)，8 例見肺氣囊(22.22%)，13 例見胸腔積液 military lesions (25%), 21 cases had enlarged lymph nodes in the (36.11%)，21 例見縱膈淋巴結增大(58.33%)，2 例見結節 mediastinum (58.33%). Cystic lesions were found in 8 cases (22.22%). 13 cases had pleural effusion (36.11%), and 2 cases had nodular bump (5.56%), 狀腫塊影(5.56%)，心包積液及自發性氣胸各 1 例(2.78%)。 Pericardial effusion and pneumothorax each appeared in 1 case (2.78%). 結論愛滋病合併馬爾尼菲青霉菌感染者常見的胸部影 Conclusion The image appearances of PSM with AIDS include 像表現為：肺內多發的浸潤病灶或局限性肺實變及磨玻璃 infiltrative lesions or focal lung consolidation., ground-glass shadow, 密度影，肺門或縱膈淋巴結增大，胸腔積液，肺間質病變 enlarged hilar and mediastinum lymph nodes, pleural effusion, interstitial involvement or reticular image pattern (pulmonary interstitial hyperplasia), 即網織紋理(小葉間隔紋理)，粟粒樣病變及肺氣囊。 diffuse military lesion, and cystic lesion. 【關鍵字】愛滋病; 青霉屬; 診斷顯像【 Key words 】 Acquired immune deficiency syndrome; Penicillium; Diagnostic imaging 摘自：中華放射學雜誌, 2007, 41:239 From: Chinese Journal Of Radiology, 2007, 41:239. Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 199

不同方法治療圍絕經期 Comparison of Different 及絕經後婦女抑鬱症的療效分析 Antidepression Therapy in Perimenopausal and Postmenopausal 賴愛鵉, 趙友文, 齊海燕, 等 Women with Depression 【摘要】目的探討抗抑鬱藥物及性激素治療圍絕經 LAI Ai-luan, ZHAO You-wen, QI Hai-yan et al. 期及絕經後婦女抑鬱症的臨床效果。方法採用漢米爾抑鬱量表(HRSD)及自評抑鬱量表(SDS)對 86 例圍絕經期及絕【Abstract】 Objective To study the effects of antidepression 經後抑鬱症婦女進行抑鬱症程度評價，然後隨機分為 2 組， drugs and hormone replacement therapy (HRT) in perimenopausal and 每組 43 例，對照組應用抗抑鬱藥物，其中輕、中度(29 例) postmenopausal women with depression. Methods Eighty six 患者應用氟呱噸美利曲辛(其他名稱：黛力新)1~2 片/d；重 perimenopausal and postmenopausal women with depression were divided into two groups, and treated for 12 weeks, respectively. Forty 度患者(14 例)應用鹽酸氟西汀(其他)名稱：百懮解)20mg/d； three received antidepression drugs as control group. Among them, 性激素治療(HRT)組(輕、中度 31 例，重度 12 例)應用替勃 mild to moderate depression were treated with deanxid (1-2 pills/d), 龍 1.25mg/d。入選者每 4 周隨訪 1 次，共計 12 周。結果 (1) and severe depression with fluoxetine (20 mg/d). Another 43 took 有效率：對照組輕、中度抑鬱症患者，治療總有效率為 96%； Tibolone (livial) as HRT group (1.25 mg/d). All patients were assessed HRT 組治療總有效率為 93%。兩組比較，差異無統計學意 with the Hamilton depression rating scale for depression (HRSD) and 義(P>0.05) 。重度抑鬱症的治療有效率對照組為 93%，HRT self rating depression scale (SDS) before and at weeks 4,8,12 after 組為 42%，兩組比較，差異有統計學意義(P<0.01)。 (2) HRSD treatment. Results (1) Total effective rate of control and HRT groups was 96% and 93%, respectively, in mild – moderate depression 評分：輕、中度抑鬱症患者用藥前，用藥第 4、8、12 周時， (X²=0.012, P>0.05), while there was a significant difference between 對照組分別為(26.8 ± 5.7)、(10.7 ± 3.6)、(6.4 ± 3.6)、(3.5 ± 2.5) two groups in severe depression. The overall effective rates were 93% 分；HRT 組分別為(25.3 ± 4.7)、(15.2 ± 5.3)、(11.4 ± 4.4)、 (control group) and 42% (HRT group), respectively (X²=0.012, P<0.01). (4.4 ± 3.8)分。兩組內治療後各時間點 HRSD 評分與治療前 (2) HRSD of mild-moderate depression were 26.8 ± 5.7, 10.7 ± 3.6 , 比較，差異無統計學意義(P<0.01)；對照組與 HRT 組用藥前 6.4 ± 3.6 , 3.5 ± 2.5, respectively in control group, and were 25.3 ± 4.7, 及用藥第 12 周時 HRSD 評分比較，差異無統計學異義 15.2 ± 5.3, 11.4 ± 4.4, (4.4 ± 3.8 in HRT group before and at weeks 4,8 (P>0.05) 。重度抑鬱症患者用藥前，用藥第 4、8、12 周時， and 12 after treatment. There was no difference between two groups at weeks 0, and 12 after treatment (P > 0.05), HRSD scores of severe HRSD 評分對照組分別為(37.6 ± 5.6)，(21.4 ± 5.2)，(14.2 ± depression were 37.6 ± 5.6, 21.4 ± 5.2, 14.2 ± 4.2, 7.3 ± 2.3, 4.2)，(7.3 ± 2.3)分；HRT 組分別為(38.2 ± 4.8)，(32.6 ± 5.4)， respectively, in control group , and were 38.2 ± 4.8, 32.6 ± 5.4, 28.2 ± (28.2 ± 4.6)，(24.3 ± 4.5)分。對照組內治療後各時間點比較， 4.6, 24.3 ± 4.5, respectively, in HRT group before and at weeks 4,8, and 差異有統計學意義(P<0.01)，HRT 組用藥前與藥第 12 周比 12 after treatment. There was no difference in HRSD before treatment 較，差異也有統計學意義(P<0.05) 。兩組用藥後各時間點 (P > 0.05), but a significant difference at weeks 4,8 , and 12 between HRSD 評分比較，差異有統計學意義(P<0.01)。（3）SDS 評 two groups (P < 0.01). 3 SDS of mild and moderate as well as severe 分，對照組輕、中重度患者用藥前與用藥第 4、8、12 周各 depression was significantly different at weeks 0, 4.8, and 12 in control 時間點評分比較，差異也有統計學意義； group (P < 0.01) , while there was a difference is SDS of severe SDS (P<0.01) HRT depression before treatment and at weeks 12 in HRT group (P < 0.05). 組重度抑鬱症患者用藥前與用藥第 12 周比較，差異有統計 A significant reduction in HRSD and SDS of severe depression was 學意義(P<0.05)。在重度抑鬱症患者中，對照組用藥後 demonstrated in control group than in HRT group (P < 0.01) HRSD、SDS 評分與 HRT 組比較，明顯降低，差異有統計 Conclusion Antidepression drugs and HRT can improve symptoms 學意義(P<0.01)。結論 HRT 可用於治療圍絕經期及絕經 of depression in perimenopausal and postmenopausal women, but the 後輕、中度抑鬱症，對於重度抑鬱症患者，抗抑鬱藥物的治 effect of antidepression drugs is much better than HRT, especially in 療效果優於性激素。 severe depression. 【關鍵字】抑鬱症, 更年期; 激素替代療法; 氟西【 Key words 】 Depression, involutional; Hormone replacement therapy; Fluoxetion; Norpregness 汀; 去甲孕巢烯類摘自: 中華婦產科雜誌,2007, 42:169-170. From: Chin Journal Obstet Gynecol, 2007, 42:169-170.

手術後患者疼痛控制滿意程度狀況 Assessment of Patient Satisfaction with Postoperative Pain Management and 及影響因素的研究 Influence Factors 沈曲, 李崢, Gwen Sherwood, 等 SHEN Qu, LI Zheng, Gwen Sherwood, et al.

【摘要】目的描述手術後患者對疼痛控制的滿意【Abstract】 Objective The purpose of this study was to describe the patient satisfaction with postoperative pain management 度狀況，探討影響疼痛控制滿意度的因素。方法採用 and the predictors of patient satisfaction. Methods Using a multistage 多階段抽樣方法，隨機抽取北京地區 5 家綜合性三級甲等 sampling scheme, 304 inpatients on their second post-operative day in 5 tertiary hospitals of Beijing were recruited to complete a 醫院，對符合入選標準的 304 例手術後第 2 天的住院疼痛 questionnaire, which was composed of the Houston Pain Outcome 患者進行了調查，問卷由休斯頓疼痛情況調查表，疼痛治 Instrument (HPOI) based on the American Society’s Patient Outcome Questionnaire, the Pain Management Index and a demographic form. 療指數和病歷資料核查表 3 個部份組成。結果術後患 Results Mean rating for General satisfaction with pain management 者對疼痛控制總體滿意度平均評分為 7.3。疼痛控制教 was 7.3 (0 to 10 Point scale). It was found that general satisfaction with pain management could be predicted by 6 factors: satisfaction with 育、醫生對疼痛的處理、疼痛減輕、患者受到的所有針對 education about pain management, pain relief, the care offered by 疼痛的照料、醫生或護士是否告訴患者要優先有效地控制 doctors for the pain, overall care for pain, whether doctor or nurse 疼痛以及手術次數共 6 個因素進入回歸方程，是影響疼痛 explained that providing good pain management was a priority of the patient, and patient individual characteristic such as times of operation. 控制滿意程度的主要因素。結論患者對術後疼痛控制 Conclusion Patients were satisfied with postoperative pain 較為滿意；疼痛控制服務因素是影響手術後患者疼痛控制 management. Services about pain management were the main influence factors. It is important to develop Chinese standards about pain 滿意程度的主要因素。建議制訂術後疼痛控制制度和標 management. Applying effective pain interventions and education base 準，採取針對性措施，改善術後疼痛控制質量，提高術後 on the patient’s individual characteristics could improve the quality of 患者對疼痛控制的滿意度。 postoperative pain management and patient satisfaction with it. 【 Key words 】 Pain, Postoperative; Pain management; 【關鍵字】疼痛,手術後; 疼痛控制; 病人滿意度 Patient satisfaction 摘自:中華護理雜誌, 2007, 42:197. From: Chinese Journal of Nursing, 2007, 42:197. 200 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

‧信息和動態‧

2006 中國科協年會在北京召開

Representantes de Macau presentes na Conferência Anual de 2006 da Associação de Ciência da China IAO Sok Soi. Revista “O Sistema de Saúde e a Saúde em Macau”, Serviços de Saúde, Macau SAR, China; Tel: (+853)-5976207; E-mail: [email protected] 【Resumo】A conferência anual de 2006 da Associação de Ciência da China intitulada “Melhoria de qualidade da população, estabelecimento dum país inovador ” realizou-se entre os dias 16 e 20 de Setembro de 2006, em Pequim. O Vice-Presidente do Comité Permanente da Assembleia Popular Nacional (Standing Committee of National People's Congress) e em acumulação Presidente da Associação de Ciência da China, Han QiDe, discursou na Cerimónia de Abertura, e o membro do Bureau Político do Comité Central do Partido Comunista da China e em acumulação Secretário do Partido Provincial de Pequim (Provincial Party Secretary), Liu Qi, proferiu um discurso de boas-vindas. Estiveram presentes na cerimónia de inauguração, os fisiologistas de renome e vencedores do Prémio Nobel, Professor Yang ZhenNing e Professor Ding ZhaoZhong e outros cientistas famosos vindos da China e do ultramar, bem como mais de 6 000 empresários e trabalhadores da área tecnológica, provenientes de todo o mundo, de Hong Kong e Macau. Os convidados incluíram o Presidente da Associação Promotora das Ciências e Tecnologias de Macau, Professor Iu Vai Pan, a Vice- Presidente do Direcção da Associação Promotora das Ciências e Tecnologias de Macau, em acumulação a sub-chefe de Redacção Executivo e Vice Editor Coordenadora da revista “O Sistema de Saúde e a Saúde em Macau”, Dra. Iao Sok Soi , o Presidente da Associação dos Engenheiros de Macau, Engenheiro Leong Man Io e o Vice- Presidente do Direcção Engenheiro Cheong Kuok Kei. A Dra. Iao Sok Soi foi convidada a fazer um discurso temático sobre “A Estrutura da Alimentação e a Situação Nutritiva dos Adultos em Macau” e visitou a Exposição de Saúde intitulada “Vida Científica, Prevenção de Doenças” realizada em conjunto com a Associação de Ciência da China e o Ministério da Saúde do Governo Municipal de Pequim.

A cerimónia de inauguração foi presidida pelo Vice-Presidente e em acumulação Primeiro Secretário do Secretariado da Associação de Ciência da China, Dr. Deng Nan. Na cerimónia de inauguração, foram distribuídos o Prémio de Jovem Excelente de Qiushi e o Prémio de Cientista Excelente do Fundo de Qiushi de Hong Kong. O Reitor da Faculdade de Engenharia da China, o académico Xu KuangDi, o Chefe Municipal de Pequim Wang QiShan, o vencedor do Prémio Nobel, Professor Ding ZhaoZhong e o Vice Presidente da Associação de Ciência e em acumulação Professor da Universidade de Agricultura de Hua Zong, Professor Zhang QiFa, apresentaram relatórios específicos. Nesta conferência, decorrerram reuniões temáticas em 15 locais distintos e reuniões de módulo em 54 locais, tendo sido apresentadas 2081 teses. De acordo com as necessidades de desenvolvimento social da economia de mercado, foram estabelecidos 13 fóruns de especialistas.

Na noite do dia 16, a Secretária do Secretariado da Associação de Ciência Cheng DongHong, na qualidade de representante da Associação de Ciência, ofereceu um banquete aos representantes do ramo do sector de ciência.

主題為“提高全民素質，建設創新型國家” 的要認真貫徹中央的重大決策部署，爲提高我國自主創 2006 中國科協年會於 2006 年 9 月 16 至 20 日在北京新能力、建設創新型國家多作貢獻。全國人大常委會召開，港澳特區科技界代表應邀出席。副委員長、中國科學院院長路甬祥，全國政協副主席、中國工程院院長徐匡迪，全國人大常委會原副委員 9 月 16 日上午 9 時，2006 中國科協年會在北京長、中國科協名譽主席周光召，北京市市長王岐山等人民大會堂隆重開幕。全國人大常委會副委員長、中領導，著名物理學家、諾貝爾獎獲得者楊振寧、丁肇國科協主席韓啓德致開幕辭，中共中央政治局委員、中等海內外著名科學家，以及來自全國各地包括港澳北京市委書記劉琪致歡迎辭，中共中央政治局委員、特區各學科領域科研、生産、教學第一線的科技工作全國人大常委會副委員長王兆國代表黨中央向辛勤工者和科技企業家 6 000 餘人，出席了開幕式，其中有作在科技戰線的廣大科技工作者致以親切的問候和崇 190 餘位中國科學院、中國工程院院士。澳門科學技高的敬意！並強調，各級科協組織和廣大科技工作者術協進會會長姚偉彬，副理事長、澳門特區政府衛生 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 201

局《澳門醫療與健康》雜誌執行副主編兼編輯部副主國科普日活動，今年年會還組織安排了“健康生活進社任、高級營養師尤淑瑞及澳門工程師學會會長梁文耀、區”活動、“趣味科普活動進校園”、“大手拉小手—— 副理事長張國基也應邀出席了開幕式，尤淑瑞還應邀到科技專家進百校”、 “節能在我身邊——青少年科學調第八分會場“科技創新與食品安全”之第一單元會場“食查體驗活動”等 8 個系列、170 多項科普活動。品安全與合理膳食”上，以《澳門成年人的膳食結構與營養狀況》為題作了主題發言和出席了第四分會場“科 9 月 16 日晚，中國科協書記處書記程東紅博士代技出版與科技創新”，並參觀了由中國科協、衛生部和表中國科協宴請了港澳特區科技界代表，並邀請大家北京市政府聯合主辦的“預防疾病，科學生活”健康博覽出席明年在武漢舉行的中國科協年會。港澳代表們均會。表示，這次有幸參加具有規模大、層次高、綜合性和開放性的中國科協年會，獲益匪淺。此外，能與海內開幕式由中國科協副主席、書記處第一書記鄧楠外著名科學家及科技界專家、教授交流學習和工作經主持。在開幕式上，頒發了中國科協“求是傑出青年獎” 驗，得到了很多啟發。“預防疾病，科學生活”健康博和香港求是科技基金會“求是傑出科學家獎”。開幕式覽會是一場通過多學科、多專業、多部門聯合集成式結束後，中國工程院院長徐匡迪院士、北京市市長王的宣傳科普、宣傳健康知識的博覽會。承辦單位還將岐山、諾貝爾獎獲得者丁肇中博士以及中國科協副主博覽會上近千塊科普展板內容匯編成冊，大力普及健席、華中農業大學教授張啓發院士作了大會特邀報康知識，倡導健康的行為和科學的生活方式，使觀眾告。本屆年會根據綜合交叉性的定位，共設專題分會通過閱讀該匯編，增強自我保健知識，既不失知識性場 15 個，每個專題分會場下設若干單元會場，共計又極具參與性，既通俗易懂又富於科學性。這些都對 54 個單元會場，錄用論文 2 081 篇。根據北京市經濟於今後開展健康教育的工作幫助很大。社會發展的需要，設立 13 個專家論壇。圍繞“預防疾病、科學生活”、“節約能源、你我共參與”為主題的全 (尤淑瑞)

202 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

‧信息和動態‧

預防醫學新進展研討會在澳門舉行

Realização com êxito da “Conferência sobre Desenvolvimento Actualizado da Medicina Preventiva” IAO Sok Soi. Revista “O Sistema de Saúde e a Saúde em Macau”, Serviços de Saúde, Macau SAR, China; Tel: (+853)-5976207; E-mail: [email protected] 【Resumo】 Com o intuito de permitir aos profissionais de saúde e aos residentes dominarem melhor os conhecimentos técnicos sobre a prestação de auto-cuidados de saúde, contribuindo deste modo para a prevenção de doenças e promoção da saúde, melhorando a qualidade de saúde dos residentes de Macau, no dia 18 de Junho de 2006, a Associação dos Técnicos da Administração Pública de Macau e a Associação Promotora das Ciências e Tecnologias de Macau, realizaram em conjunto, no Auditório dos Serviços de Saúde a “Conferência sobre Desenvolvimento Actualizado da Medicina Preventiva”, para a qual foram convidados especialmente para o efeito, o Vice Presidente Permanente e em acumulação Secretário Geral e investigador da Associação de Medicina Preventiva da República Popular da China, Professor Cai JiMing, para proferir uma palestra sobre o tema “Medicina Preventiva e Saúde”; o estudante do Instituto de Segurança Nutritiva e Alimentar do Centro de Prevenção e Controlo de Doenças do Ministério de Saúde e em acumulação Vice Chefe do Gabinete de Nutrição e Investigador, Professor Hu XiaoQi, para falar sobre o tema “A Nutrição e Saúde de Jovens e Crianças”; o Vice Chefe dos Serviços de Educação Contínua da Associação de Medicina Preventiva da RPC, Professor Tian FengHua para intervir sobre “A Prevenção de Doenças Cardiocerebrovasculares”. A conferência foi presidida pela Vice Chefe do Departamento de Coordenação do Gabinete de Ligação do Governo Central da RPC na RAEM Luo XiangZhu, pelo Director dos Serviços de Saúde, Dr. Koi Kuok Ieng, por três convidados oradores e pelos Responsáveis das duas Associações, Chui Sai Peng e Kun Sai Hoi, Chan Mun Cheong e Iao Sok Soi. Para além disso, estiveram presentes nesta ocasião mais de 200 profissionais de saúde de Macau, aos quais foram conferidos certificados de participação.

隨著經濟的發展，某些都市常見的慢性非傳染性研討會主席尤淑瑞致辭時表示，澳門近十餘年來疾病，如心、腦血管病、腫瘤和糖尿病的發病率持續心腦血管病和腫瘤的死亡率高踞，糖尿病及痛風等病增加。為了使本澳的醫務人員和居民瞭解和掌握自我人也不少。大量的研究資料表明，不良的飲食習慣和保健的知識和技能，以預防疾病，促進健康，提高澳生活方式是引起這些非傳染性疾病又稱之為富裕病的門居民的生活素質，澳門公務專業人員協會與澳門科重要原因之一。另一方面，兒童、青少年的營養不良、學技術協進會於 2006 年 6 月 18 日假衛生局大禮堂聯營養過剩或營養不平衡導致消瘦或肥胖等對其健康成合舉辦“預防醫學新進展研討會”，特邀中華預防醫學長會產生深遠的影響。會常務副會長兼秘書長、研究員蔡紀明教授，主講題目為“從預防醫學談養生保健”﹔國家衛生部疾病預防蔡紀明教授主講“從預防醫學談養生保健”，深入控制中心營養與食品安全所學生營養室副主任、研究淺出地講解了養生保健之道，指出“健康始於足下，健員胡小琪教授，主講題目為“青少年兒童營養與健康在你手中”的道理。他介紹了預防疾病的五項原則﹕ 康”﹔中華預防醫學會繼續教育部副主任、副研究員田 1、抵禦邪氣﹔2、防制疫病﹔3、調節情志﹔4、合理鳳華教授，主講題目為“心腦血管疾病的預防”。中聯飲食﹔5、適度勞逸。還建議保健養生的五個方面﹕1、辦協調部羅香珠副部長﹑衛生局局長瞿國英和三位主四季養生﹔2、五臟調養﹔3、頤養身心﹔4、保健養生講嘉賓及兩會負責人崔世平、官世海、陳滿祥、尤淑的原則﹔5、保健養生的三點心得。胡小琪教授主講“靑瑞為研討會主禮，逾二百名本澳醫務人員出席並獲頒少年兒童營養保健”，介紹了靑少年的飲食習慣與健康發了出席證書。有密切的關係，並指導家長與靑少年預防肥胖的方法。田鳳華教授主講“心腦血管疾病的預防”，指出預衛生局局長瞿國英致辭時表示，心腦血管疾病為防心腦血管疾病的重要性，並介紹了五種從日常生活本澳三大致死病因之一。由於不良生活方式及飲食習控制血脂過高的方法。在控制飲食的同時，應不忘堅慣，加上缺乏運動、工作壓力等多種原因，令近幾年持健身運動和腦力活動。運動有利消耗體內脂肪，加本澳心腦血管疾病患者劇增，更有年輕化趨勢。當局速血液運行，有利於防止膽固醇沉積在血管壁上。應已不斷努力開展預防及治療工作，而防治心腦血管疾因應自己的年紀選擇一項適合的運動項目常年堅持。病最主要途徑是做好預防工作，居民應通過注意飲食及適量運動等方法，以減少患上心腦血管疾病的機會。 (尤淑瑞) Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 203

‧信息和動態‧

廣州市科普創作工作座談會在廣州舉行

Participação da representante da Revista “O Sistema de Saúde e a Saúde em Macau” no Simpósio de Difusão da Ciência em Cantão IAO Sok Soi. Revista “O Sistema de Saúde e a Saúde em Macau”, Serviços de Saúde, Macau SAR, China; Tel: (+853)-5976207; E-mail: [email protected] 【Resumo】 No dia 30 de Maio de 2006, a Associação de Ciência e Tecnologia de Cantão realizou um Simpósio de Difusão da Ciência nesta Cidade. A convite desta Associação, o Director da Associação de Escritores Divulgadores da Ciência da China, Dr. Zhang Jingzhong, a Federação dos Sectores de Literatura e Arte da Academia de Ciências da China, Dr. Guo Yuefang, o Secretário-Geral da Associação de Escritores Divulgadores da Ciência de Beijing, Dr. Zhao Meng, o Secretário-Geral da Associação de Escritores Divulgadores da Ciência de Shanghai, Dr. Li Zhengxin, o Presidente da Associação de Difusão da Ciência e Tecnologia de Hong Kong, Prof. Dr. Cao Hong Wei, a Sub-chefe da Redacção da Revista “O Sistema de Saúde e a Saúde em Macau”, Dra. Iao Sok Soi, participaram e apresentaram obras temáticas neste evento. Para além destes convidados, o simpósio contou com a presença de mais de 50 representantes vindos de diversos organismos da Cidade de Cantão, nomeadamete cortov o Departamento de Propaganda do Comité Municipal, o Serviço Municipal de Ciência e Tecnologia, o Serviço Municipal de Educação, o Serviço Municipal de Propriedade Intelectual, o Serviço Municipal de Finanças, a Federação Municipal dos Sectores de Literatura e Arte, a Associação de Escritores Divulgadores da Ciência, bem como responsáveis de vários institutos de ensino superior e academias científicas, professores de ciência de algumas escolas de ensino secundário, trabalhadores divulgadores da ciência e responsáveis das associações de ciência e tecnologia de Cantão e das suas subunidades. O Secretário do Partido do Grupo de Liderança e Vice-Presidente das Associações de Ciência e Tecnologia de Cantão, Dr. Huang Min e o outro Vice-Presidente, Dra. Zhang Juzhen, presidiram as sessões da manhã e da tarde, respectivamente. Os representantes abordaram temas como “Impulsionar Obras Divulgadoras da Ciência”, “Promover o Progresso de Ciência e Tecnologia”, tendo sido discutidos com afinco os problemas existentes relativos à criação de obras divulgadoras da ciência, o sentido de desenvolvimento dos respectivos trabalhos, a reforma do mecanismo de promoção da criação de obras divulgadoras da ciência e apresentadas muitas opiniões e sugestões construtivas relativas à promoção da criação das obras da ciência, merecendo aprendizagem e referência as experiências e metodologias adoptadas por Beijing, Shanghai, Cantão, Hong Kong e Macau.

2006 年 5 月 30 日，廣州市科協召開了廣州市科 (二)探索科普創作工作機制的創新。形成以政府普創作工作座談會。中國科普作家協會理事長張景中主導，職能部門協調，相關團體承接，社會支援，科院士、中科院文聯主席郭曰方、北京市科普作家協會技人員積極參與的通達有效的運轉鏈，努力使廣州成秘書長趙萌、上海市科普作家協會秘書長李正興、香爲區域性科普作品創作和出版中心。港科普學會會長曹宏威教授、《澳門醫療與健康》雜誌 (三)繁榮科普創作，著眼出精品。可以嘗試建立執行副主編兼編輯部副主任尤淑瑞應邀參加會議並作科普仿真實驗室，開展立體科普創作，通過抓重點專了專題發言。廣州市委宣傳部、市科技局、市教育局、案，力爭多出科普精品。市知識産權局、市版權局、市財政局、市文聯、市科 (四)依托高校和科研院所，培養高層次科普與創新文普作家協會、廣州地區部分大專院校、科研院所有關化建設專業人才，特別是培養文理兼優的複合型人才。要負責人、部分中學的科技老師和科普工作者，以及市有計劃、有重點地建設一支有創新能力的科普創作人才隊科協機關、直屬單位共 50 多位負責人參加了座談會。伍，形成科普創作團隊。培養一批從事科技教育、科技傳市科協黨組書記、副主席黃敏和副主席張菊珍分別主播的優秀指導老師、宣傳工作者和管理工作者。持了上、下午的會議。 (五)鼓勵科普創作。按照《中華人民共和國科學技術普及法》、《國家科學技術獎勵條例實施細則》以及《廣州與會代表圍繞“推動科普創作，促進科技進步”主市科學技術普及條例》規定，制定具體辦法，對在廣州科題，就當前科普創作存在的問題，科普創作工作思路，普創作工作中做出顯著成績的單位和個人給予獎勵。推進科普創作運行機制改革等進行了熱烈討論，對進 (六)學習香港、澳門社團進行科學普及工作的經一步推動廣州市科普創作提出了許多好的意見和建驗，發揮社團（科普作家協會等）擁有人才資源的優議。特別是北京、上海、廣州、香港和澳門開展科普勢，動員和組織科技人員參與科普創作，通過政策引創作工作的經驗和做法，值得學習和借鑒。導，吸引、激勵更多科技人員多寫科普文章，多出科與會專家對廣州科普創作工作的建議有以下幾點：普作品，並注意發揮著名科學家領銜、帶頭和示範作 (一)從加大科普創作投入入手，支援科普創作和用。與會代表還對廣州市科協草擬的《鼓勵科普創作出版。建議設立“科普創作出版專項基金”，制定鼓勵暫行辦法》提出了修改意見。科普創作的實施辦法，以推動科普創作工作。 (尤淑瑞) 204 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

‧信息和動態‧

澳門地區學術會議簡報

1 Symposium of “Meeting the Challenges of 醫院檢驗科主任孫自鏞教授）；另外，香港瑪麗醫院呼 Alzheimer’s Disease” held in Macao Symposium of 吸及重症監護科顧問林冰醫生、感染控制組高級護士 Meeting the Challenges of Alzheimer’s Disease which 長程棣妍及微生物系主管司徒永康教授，先後主講了 was organized by Department of Psychiatry Centro 肺炎的合理處理、手部衛生及合理使用抗生素的重要 Hospitalar Conde de São Januário (CHCSJ) and The 性。 Macao Psychiatric Association, held in the meeting room of Hotel Lisboa, on 17 May, 2007. The speaker for this 4 “預防藥物與物質濫用非政府組織國際聯盟第 Symposium was Dr. Vincent Mok, Associate Professor, 廿二屆世界會議”在澳門舉行由亞太家庭組織 from Princes of Wales Hospital, Department of Medicine (O.F.A.P.)舉辦，IFNGO(預防藥物與物質濫用非政府組 and Therapeutics, Hong Kong. 織國際聯盟)第 22 屆世界會議已於 2007 年 5 月 15 日至 17 日在澳門旅遊活動中心舉行，今屆會議主題為 2 Symposium of “The 2nd Annual Scientific Meeting “濫藥不是兒戲”和“無毒健康家庭 ”。會議超過 36 名 of Macao Pediatric Society” held in Macao 世界各地演講者及 20 多個國家參與，主要演講者 Symposium of The 2nd Annual Scientific Meeting of Gerson Bergeth 博士為東盟和中國禁毒合作國際會議 Macao Pediatric Society which was organized by Macao 報告(ACCORD PLAN)合作專家，聯合國藥物及罪案 Pediatric Society, held in the meeting room of Macao 辦事處(United Nations Office on Drugs and Crime) 辦 Tower, on 20 May, 2007. The Topic for this Symposium 公室主席 Antonio Costa 博士也委派代表演講。 were: (1) “Rotavirus and pneumococcal vaccines-what should we know to support their use?” reported by Prof. 5 Symposium on “Recent Advances in the Lau Yu Lung, Chair Prof. & Head of Department of Treatment of Follicular Lymphoma” held in Macao Paediatrics & Adolescent Medicine, University of Hong Symposium on Recent Advances in the Treatment of Kong. (2) “Approach to the management of Nephrotic Follicular Lymphoma which was organized by The Syndrome in Children” reported by Dr. Chiu Man Chun, Macao Society of Hematology & Oncology and Hospital from Chief of Service & Consultant Paediatrician, Conde S. Januario, Macau, held in Auditorium, C.H.C.S. Department of Paediatrics & Adolescent Medicine, Januaio, Macao, on 28 April, 2007. The Chairman for Princess Margaret Hospital HK. (3) “Approach to this symposium was Dr. Chan Nai Chi, from Department essential malnutrition” reported by Prof. Li Ting Yu, of Hemato-Oncology C.H.C.S Januario. The topic for director of Children’s Hospital of Chongqing Medicine this Symposium were: (1) Dr. Kenny Li, Honorary University. (4) “Application of analgesic, sedative Associate Professor, Department of Clinical Oncology, technique in PICU” reported by Prof. Xu Feng, head of The Chinese University of Hong Kong, Prince of Wales division of critical care, Children’s Hospital of Hospital reported “Specialist in Medical Oncology & Chongqing Medicine University. Haematology/ Haematology Oncology”; (2) Dr. Rico Lio, Honorary Clinical Assistant Professor , The University of 2 “澳門兒科專科醫學會第二屆學術年會”在澳門 Hong Kong, Clinical Oncology, Queen Mary Hospital 舉行澳門兒科專科醫學會第二屆學術年會是由澳門 reported “Specialist in Clinical Oncology”. 兒科專科醫學會主辦，於 2007 年 5 月 20 日在澳門旅遊塔舉行。學術年會內容包括：(1) “兒童期腎病綜合症的 6 Symposium of “Osteoporosis: Filling the gaps” 治療新進展”，由香港瑪嘉烈醫院兒童及青少年科主任 held in Macao Symposium of Osteoporosis: Filling 趙孟準醫生擔任主講；(2) “輪狀病毒及肺炎鏈球菌疫 the gaps which was organized by Macau Chinese 苗 – 使用疫苗時我們應該了解甚麼?”，由香港大學醫 Medical Association, Associação dos Médical de Clinica 學院兒童及青少年科學系主任劉宇隆教授擔任主講； Geral de Macau, Macau Orthopaedic Association and Osteoporosis Society of Macau, held in the meeting (3)“人體重要微量營養素研宄進展”，由中國重慶醫科 room of Macau Tower, on 20 May 2007. The Chairman 大學附屬兒童醫院院長李廷玉教授擔任主講; (4) “鎮靜 for this Symposium was Dr. Chan Lek Lap, Vice 鎮痛技術在兒科重症監護病房中的作用”，由中國重慶 President, Macau Chinese Medical Association. The 醫科大學附屬兒童醫院急診科主任許峰教授主講。 speaker for this Symposium were: (1) Dr. Chan Wai Sin, Assistente Hospitalar, Chairman of Orthopedic, Centro 3 “澳門感染控制學會－第一屆學術年會暨成立典 Hospitalar C. S. Januário who reported “The importance 禮在澳門舉行” 澳門感染控制學會主辦，第一屆學術 of hip and non-vertebral fractures. What do we know and 年會暨成立典禮已於 2007 年 5 月 19 日在澳門旅遊塔 What we don’t know?”; (2) Prof. Johann D Ringe from 舉行。會上邀請了多位內地、香港及本澳的感染控制 Director of Department of General Internal Medicine, 專家主講多場的學術講座，包括：澳門醫院感染控制 Klinikum Leverkusen, Universtiy of Cologne, Germany 的發展概況（澳門仁伯爵綜合醫院臨床病理科主管官 who reported “Broadening the Evidence: From Clinical Trials to Real Life Clinical Experience.” 建泳）、護理在感染控制中的作用（北京煤炭總醫院感 (姚立德) 染控制辦公室主任鍾秀玲教授）、暴發調查（武漢同濟 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 205

‧工具和資料‧

非麻醉醫師使用鎮靜 / 鎮痛藥物指南

由於麻醉醫師精通藥理學、生理學，而且使用鎮適用範圍靜 / 鎮痛藥物的臨床經驗豐富，除手術室外還活躍在放射學檢查以及一些診斷性檢查的場所；因此美國麻指南是針對非麻醉專業醫師在醫院、牙科診所等地醉醫師協會（ASA）在對現有文獻進行循證分析，綜點實施鎮靜 / 鎮痛的實踐指南。由於最輕程度的鎮靜合專家意見並經過公開討論後為非麻醉醫師制定了使包含的危險很小，ASA 指南不包括最輕程度的鎮靜。用鎮靜 / 鎮痛藥物指南，旨在無麻醉醫師在場的場所最輕程度的鎮靜包括：周圍神經阻滯、局麻、吸入濃度能安全使用鎮靜 / 鎮痛藥物，減少鎮靜 / 鎮痛藥物低於 50%的笑氣；因失眠、焦慮、疼痛而口服單次劑的潛在危險。與 1995 年版指南相比，2001 年版對鎮量的鎮靜/鎮痛藥物。另外，指南不適用於接受全麻和靜深度進行了詳細的分級。新版指南的另一個突出特椎管內麻醉的患者，也不適用於術後鎮痛的患者。徵是：遵循循證的準則對所有建議進行分級，用來表示已有的實驗證據對建議的支持程度、專家審查的認目的同性、臨床使用建議的等級。2001 年 10 月 17 日由美美國眾議院批准指南正式生效。目前該指南已經得到使用鎮靜 / 鎮痛的好處：1) 緩解侵入性檢查帶美國放射學會、美國口腔頜面外科醫師學會、美國內來的不適、焦慮或疼痛；2）對兒童或不合作的成人進窺鏡學會的認可。行需要靜止不動的檢查時，患者可保持安靜、合作的狀態。另一方面，鎮靜 / 鎮痛可能會抑制患者的心肺專家組成員和顧問功能，臨床醫生應能迅速發現並及時處理，避免出現低氧性腦損傷、心跳驟停或死亡。 ASA 任命了 10 名專家，他們負責收集、評價相關文獻的品質，並通過以下步驟修訂指南的具體內容：鎮靜 / 鎮痛的定義 1）只收集非麻醉醫師實施鎮靜的原始文獻；2）顧問的職責—評估各種在鎮靜 / 鎮痛時使用措施的有效 ASA 明確了鎮靜 / 鎮痛的定義，指出鎮靜 / 鎮痛性和安全性；3）指南起草委員會曾兩次召開全國會議是一種使患者既能耐受不愉快操作，又能維持良好的心為指南的草案公開徵求意見；4）顧問對指南中修訂或肺功能，對輕拍或語言指令有反應能力的狀態。過度鎮更改的內容的可行性和使用成本進行評估；靜會導致通氣功能和心血管功能損害，如果患者的心肺功能損害未能及時診斷和進行恰當的處理，可能導致缺氧性腦損傷或死亡。ASA 將鎮靜深度分級如下：

表 1 鎮靜深度分級

抗焦慮清醒鎮靜鎮痛全麻反應能力對語言指令的對輕拍或語言指令對疼痛刺激有反應即使疼痛刺激反應正常有反應也不能喚醒保持氣道通暢的能力不受影響不需幹預措施或需幹預措施常需幹預措施自主呼吸不受影響足夠可能不夠常常不夠心血管功能不受影響維持在某一穩態維持在某一穩態可能受損

指南的內容情況 ; 3）藥物過敏史、目前用藥情況、及藥物間的相互作用; 4）上一次口服藥的時間及藥物的性質; 5）吸患者評估：對接受清醒鎮靜 / 深度鎮靜的患者來煙史、飲酒史、藥物濫用史；說，在操作前對患者進行適當的評估（病史、體格檢即將使用鎮靜 / 鎮痛藥物的患者需經過體檢：心查）可以減少過度鎮靜帶來的危害。肺聽診、氣道評估；如果患者有影響鎮靜/鎮痛藥物使患者一般情況評估：欲將使用鎮靜 / 鎮痛藥物的用的情況可行必要的實驗室檢查。臨床醫生應瞭解患者曾經使用鎮靜/ 鎮痛藥物的情況，及患者對這些藥物的反應。需要瞭解的情況包括：使用鎮靜 / 鎮痛藥物前的準備 1）心、肺等重要臟器功能是否曾經出現異常; 2）既往使用鎮靜 / 鎮痛藥物後、局麻或全麻後是否出現異常使用鎮靜 / 鎮痛藥物前應向患者詳細解釋使用 206 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3

鎮靜 / 鎮痛藥物的好處、風險、局限性以及可能的替監測參數的記錄代措施。使用鎮靜 / 鎮痛藥物前，患者應嚴格遵守禁食、禁水的規定。在飽胃或胃排空功能受損時，患者實施清醒鎮靜和深度鎮靜的患者，應記錄意識水使用鎮靜 / 鎮痛藥物後可能出現誤吸。可能導致胃內準、通氣情況、氧合狀態、血流動力學參數。記錄間隔容物誤吸的因素有：1）鎮靜深度 2）操作持續的時間時間取決於患者接受的臨床治療的刺激程度、時間長短長短 3) 是否進行了氣管內插管及患者的一般情況。記錄至少應包括五個環節：1）治療前 2) 給鎮靜 / 鎮痛藥物後 3) 治療過程中 4）恢復表 2 ASA 關於禁食、禁水的指導意見早期 5）患者離開前；若各項參數可自動記錄時，應設飲品/食品最短的禁食時間置報警界限以提醒患者生命體征的重要變化。清飲料（水或不含果肉的果汁） 2h 母乳 4h 有專人負責的監護牛乳、便餐（烤麵包、清飲料） 6h 接受鎮靜 / 鎮痛的患者必須有專人負責監護；監護意識水準的監測持續到患者的鎮靜 / 鎮痛水準及生命體征穩定後即可。

接受鎮靜 / 鎮痛的患者，對語言指令的反應可反人員的培訓映其意識狀態。若患者對語言指令的反應正常說明呼吸功能未受損；若患者僅對疼痛刺激表現為肢體退縮為患者施行鎮靜 / 鎮痛的醫師應熟悉所用藥物說明已處於全麻狀態，需要予以相應處理。的藥理特性以及阿片類藥物、苯二氮卓類藥物拮抗劑對清醒鎮靜的患者應常規監測其對語言指令的反的藥理特點，和使用這些藥物可能出現的併發症。患應（兒童、精神障礙者、不合作患者除外），進行口腔者接受鎮靜 / 鎮痛時，應有專人保持患者的氣道通操作或內窺鏡檢查時，可用豎起拇指來表示患者的氣暢，準備正壓通氣裝置及其它輔助設備。對於清醒鎮道保護反射正常（必要時可進行深呼吸），對深度鎮靜靜和深度鎮靜的患者，應保證能在 5 分鐘內提供及時的患者應觀察其對某種程度刺激的反應，確保患者未的生命支援。進入全麻狀態：值得注意的是，僅對疼痛刺激表現為肢體退縮反應時表明患者已處於全麻狀態。急救器材的準備

肺通氣功能的監測所有接受清醒鎮靜的高血壓、心肌缺血的患者，以及所有接受深度鎮靜的患者，都應準備除顫儀。對鎮靜 / 鎮痛可能引起患者死亡的主要原因是藥使用鎮靜 / 鎮痛藥物的患者，應準備下列急救器材。物引起的呼吸抑制和氣道梗阻。對接受深度鎮靜的患者，通過持續監測呼氣末二氧化碳來判斷是否存在呼鎮靜 / 鎮痛應用的急救器材吸暫停，可以減少因缺氧引起的損害。－建立靜脈輸液通路氧合狀況－酒精貼－22-24 號的靜脈套管針對所有接受鎮靜 / 鎮痛藥物的患者，監測脈搏氧－靜脈輸液的液體飽和度可有效發現缺氧和低氧狀態，應常規監測已設－合適型號的注射器定正常報警界限的脈搏血氧飽和度。－基本的氣道管理－吸引器吸痰管面罩口咽鼻咽通氣道潤滑劑對血流動力學的影響－進一步的氣道管理（有插管經驗的醫生）喉罩喉鏡－有套囊的氣管導管 ID 6.0 7.0 8.0 mm 使用鎮靜 / 鎮痛藥物後，患者自主神經系統的調－ID 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0 mm 節功能可能受損；另一方面，鎮靜 / 鎮痛不充分時，的氣管導管可出現有害的應激反應：高血壓、心動過速。對清醒－特異性拮抗劑鎮靜和深度鎮靜的患者，患者的鎮靜深度穩定時，應－納洛酮、氟馬西尼每五分鐘測量一次血壓、心率。當合併有心律失常或－急救用藥心血管疾病的患者進行清醒鎮靜時，以及達到深度鎮－腎上腺素、抗利尿激素、麻黃堿、阿托品、胺碘酮、靜的患者，應持續監測心電圖。硝酸甘油、利多卡因、苯海拉明、葡萄糖（10%、 Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 207

25%）、氫化可的松、甲潑尼龍、地塞米松、地西泮、特異性拮抗劑：納洛酮、氟馬西尼。對氣道保護反射咪達唑侖消失和正壓通氣困難的患者，可以使用特異性拮抗－實施供氧劑。使用鎮靜 / 鎮痛藥物後，若患者出現低氧或呼吸－除有特殊的禁忌症外，當使用鎮靜 / 鎮痛藥物時，暫停，在使用特異性拮抗劑前應做到：1）囑患者做深應保證患者的輔助供氧。呼吸動作或刺激其進行深呼吸；2）吸氧； 3）若自主呼吸不足時，宜使用正壓通氣。在使用特異性拮抗劑鎮靜 / 鎮痛藥物的複合使用後，應對患者進行較長時間的觀察，保證在拮抗劑藥效消失前患者的心肺抑制狀態已消失。原則： 1）先確定患者是否適合及治療過程中是否需要複合恢復期護理使用鎮靜 / 鎮痛藥物； 2）個體化用藥達到理想的效果：鎮靜或止痛；指導原則： 3）若複合用藥後出現呼吸抑制、氣道梗阻說明除應持 1）使用鎮靜 / 鎮痛藥物後，患者應呆在有監護設備續監測患者的呼吸功能外，應減少每種藥物的劑量。和專人看護的恢復室，直到意識恢復正常、心肺功能恢復正常，同時持續監測氧合情況。靜脈用鎮靜 / 鎮痛藥物的劑量 2）恢復室備有監測儀、復蘇設備 3）間隔一定時間記錄患者的意識水準、生命體征變原則：應小量、逐漸增加劑量直到獲得理想的鎮化、氧合情況靜 / 鎮痛效果，藥物的初始劑量和追加劑量之間應有 4）有護士或其他受過專業訓練的人員負責監護患者，足夠的間隔時間；藥物經由非靜脈途徑時（口服、直能及時發現並處理各種併發症，直到符合離室標準。腸、肌注），藥物吸收受多因素影響，在追加劑量前應保證足夠的藥物吸收時間。使用鎮靜 / 鎮痛藥物後恢復和離室標準離室標準鎮靜 / 鎮痛使用的麻醉誘導藥物：氯胺酮、 1）患者清醒、恢復定向力；嬰兒和精神狀態異常的異丙酚、美索比妥（短效靜脈麻醉藥）患者應恢復到接受治療前的水準。 2）生命體征穩定且保持在正常水準。非麻醉醫生使用氯胺酮、異丙酚，可使患者獲得 3）使用特異性拮抗劑時，距離最後一次劑量的觀察時滿意的鎮靜；使用美索比妥可使患者達到深度鎮靜。間應超過 2h，以免拮抗作用消退後患者再次鎮靜。 ASA 提醒醫生注意使用異丙酚、美索比妥後，患者的 4）門診病人需在成人陪同下離開，並隨時報告併發意識迅速消失，同時呼吸、循環系統功能受抑制。而症的發生情況。使用氯胺酮時，隨著劑量的增加，患者的意識消失， 5）向門診病人提供術後飲食、服藥、活動的書面指最後進入全麻狀態。與其他鎮靜藥物相比，氯胺酮對導，及在緊急情況下的聯繫方式。患者心肺功能的抑制作用較小，但可引起氣道梗阻、喉痙攣、誤吸。由於其分離狀態的特性，通常用於判特殊情況斷鎮靜程度的標準不適用。ASA 還指出上述藥物均無特異性拮抗劑。有重要臟器疾患的患者，在使用鎮靜 / 鎮痛藥物前應向專科醫生諮詢。專科醫生會根據臟器疾患的嚴靜脈通路的建立重程度及是否需要治療來決定是否使用鎮靜 / 鎮痛藥物。對於存在困難氣道的 COPD 患者、冠心病或若患者經由靜脈給予鎮靜 / 鎮痛藥物，在整個治充血性心衰的患者，或者所需治療要使患者達到深度療過程中應保持靜脈通路的暢通直到呼吸、循環系統鎮靜的程度，應向麻醉醫生諮詢處理意見。功能恢復正常。非靜脈途徑給藥時，是否建立靜脈通路依具體情況而定；當靜脈通路阻塞時，是否需要重新建立靜脈通路依具體情況而定。

拮抗劑美國麻醉醫師協會 2001. 11. 30 修正版澳門鏡湖醫院麻醉科孫傳江編譯當使用阿片類藥物和苯二氮卓類藥物時，應準備曹麗勤廖自偉審校

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《中華放射腫瘤學雜誌》簡介

Introduction to “Chinese Journal of Radiation Oncology” Huai-Shen WU CP 3002, Editorial Office of RCSM (HSJM), 3rd Floor, Administrative Building, Department of Health of Macao, Macao SAR, China. Tel: (+853)-390 6524, 390 7307;Fax: (+853)-390 7304; E-mail: [email protected] 【Abstract】 Chinese Journal of Radiation Oncology is a specialized and authoritative publication of radiation oncology in China. It is devoted to the clinical, oncologic radiation biology, radiation physics and hyperthermia and inclined toward the general medium, specialized clinical physicians and researchers. The leading novel results of scientific research experiences of clinical diagnostic and therapeutic trials which are closely related to clinical practice, and those which may be related to basic theories are all the choices of this journal. The contents in brief are original articles, brief reports, technic and methods, experiences of communication, case reports, summary, lectures, education scope, evaluation of books and journals, etc. Free submissions are the chief source of contribution and solicit ones are supplementary. In general, the quality of this publication is certainly not below the similar ones in Europe or America. Some of the high quality papers have been introducted to foreign journal, eg. Int J Radiat Oncol Biol Phys(the red journal) in America and Radiother Oncol(the green journal) in Europe. As the contents of this journal are similar to those in “the red journal” and “the green journal”, it is presently called “the Chinese red journal”. In addition, the well known specialists in China, Prof. GU Xian-zhi, LIU Tai-fu, YIN Wei-bo, JIANG Guo-liang have been invited as overseas editor, like the red journal of America and the green journal of Europe. Moreover, the editor-in-general of the red journal, Prof. Philip Rubin, had been the honorary editor-in-chief of the Chinese Journal of Radiation Oncology. At present, our journal is chaired by Prof. XU Guo-zhen, and the daily work is supervised by Prof. ZHANG Hong-zhi. Now bimonthly, big 16 format, publishing on 1，3，5，7，9，11 month. It was in 1987 when “Chinese Journal of Radiotherapy” started its first publication. To 1992, after a five year trial, adopting the present name, it finally became one of the serial journals under the direction of Chinese Medical Association. In Nov. 1995, it was credited with a silver prize when Chinese Medical Association was on celebration of its 80th year publication. In Dec. 1999, the certificates of Chinese Scientific Citation Index Database Journals Source, Chinese Academy Journals, Composite Evaluation Database Journals Source and Chinese Academy Journals(disk edition) of “Chinese Journal Web”, on the national class of Star Plan, published by the editor committee of Chinese Academy Journals (disk edition) and the Research Center of Chinese Scientific Literature Computation and Evaluation. In June 2000, the certificate of Core Journals Collection Identification was obtained by Beijing University Press. In Feb. 2001, the certificate of Chinese Biologic and Medical Core Journals was awarded with the Minister of Science and Technology, Minister of Heath, Medical and Health New Consultative Unit and Information Research Center of the Chinese Academy of Medical Sciences. In Dec. 2002, the digitalized journals group collection certificate issued by the Wanfang Data LTD distributed by Wanfang Data LTD of Chinese Science and Technology Information Institute. In the following year(2003), the certificate of Chinese Academy Journals Composite Evaluation Database(CAJCED) or Chinese National Knowledge Infrastructure(CNKI） and Chinese Journals File Data(CJFD) published by the editor committee of Chinese Academy Journals(disk edition) and the Research Center of Chinese Scientific Literature Computation and Evaluation. In March 2004, the recorded certificate of Chinese Science and Technology Papers Statistical Journals Source (Chinese Science and Technology Core Journals) was obtained by Chinese Science and Technology Information Institute. In July 2004, the certificate of Core Journals Collection Identification was obtained by Beijing University Press. In April 2006, the recorded certificate of Chinese Science and Technology Papers Statistical Journals Source (Chinese Science and Technology Core Journals) was obtained by Chinese Science and Technology Information Institute. In Feb. 2006, the paper evaluation recommendation prize was issued by China Association for Science and Technology. In June 2006, the item type C fund of Superexcellence Science and Technology Journals of China Association for Science and Technology was obtained. From 1998 to 2005, the value of impact factors were 0.311, 0.377, 0.459, 0.563, 0.494, 0.452, 0.611, 0.706 in the periodical index report of Journals Citation Report of Chinese Science and Technology Information Institute. Revista de Ciência de Saúde de Macau 澳門醫學雜誌, September 2007, Vol 7, No.3 209

《中華放射腫瘤學雜誌》是國內放射腫瘤治療學中國科學文獻計量評價研究中心頒發的國家級火炬計專業權威性期刊，以腫瘤放射治療臨床、腫瘤臨床放畫專案中國科學引文資料庫來源期刊證書、國家級火射生物、腫瘤臨床放射物理、熱療學等為主要內容，炬計畫專案中國學術期刊綜合評價資料庫來源期刊證以廣大中、高級臨床醫生及基礎研究人員為主要讀者書、國家級火炬計畫專案國家重點新產品《中國期刊物件。本領域領先的科研成果、臨床診療經驗、對臨網》《中國學術期刊（光碟版）》全文收錄證書；2000 床有指導作用與臨床密切結合的基礎理論研究是本刊年 6 月獲北京大學出版社《中文核心期刊要目總覽》選擇文章的範圍。辟有專論、論著、短篇論著、技術入選證書；2001 年 2 月獲國家科技部、衛生部、醫藥與方法、經驗交流、病例報告、綜述、講座、書刊評衛生科技查新諮詢單位、中國醫學科學院醫學資訊所介、繼續教育等。本刊以自由來稿為主，組稿為輔。頒發的中國生物醫學核心期刊證書；2002 年 12 月獲本刊學術品質不低於歐美發達國家同類雜誌，並有一中國科技資訊所萬方資料股份有限公司頒發的萬方資批高品質的論文被介紹到國外同類雜誌上發表，如美料—數位化期刊群收錄證書；2003 年獲中國學術期刊國的 Int J Radiat Oncol Biol Phys 雜誌（簡稱紅皮雜誌）（光碟版）編輯委員會中國科學文獻計量評價研究中及歐洲的 Radiother Oncol 雜誌（簡稱綠皮雜誌）。本心頒發的中國知識基礎設施工程(CNKI)中國學術期刊內容範圍與“紅皮雜誌”相似故稱為中國的“紅皮雜刊綜合評價資料庫（CAJCED）統計刊源證書、中國誌”。另外，我國著名的放射腫瘤學家穀銑之、劉泰福、期刊全文資料庫（CJFD）全文收錄證書；2004 年 3 殷蔚伯、蔣國梁教授先後被聘為美國紅皮雜誌、歐洲月獲中國科技資訊所中國科技論文統計源期刊（中國綠皮雜誌的編委，而美國紅皮雜誌的總編 Rubin 曾任科技核心期刊）收錄證書；2004 年 7 月再次獲北京大《中華放射腫瘤學雜誌》名譽總編。現任總編輯徐國學出版社《中文核心期刊要目總覽》入選證書；2006 鎮，編輯部主任張紅志。目前為雙月刊，大 16 開，單年 4 月獲中國科技資訊所中國科技論文統計源期刊月 15 日出版。（中國科技核心期刊）收錄證書。2006 年 2 月獲中國科協第三屆中國科協期刊優秀學術論文評選優秀推薦 1987 年《中國放射腫瘤學》雜誌創刊至 1992 年，獎證書。2006 年 6 月獲中國科協精品科技期刊工程項經 5 年試刊後得以更名為《中華放射腫瘤學雜誌》，最目 C 類資助。據中國科技資訊所期刊引證報告終成為中華醫學會雜誌社中華系列雜誌成員之一。曾 1998—2005 年本刊影響因數值分別為 0.311、0.377、於 1995 年 11 月榮獲中華醫學會成立 80 周年銀獎。 0.459、0.563、0.494、0.452、0.611、0.706。 1999 年 12 月獲中國學術期刊（光碟版）編輯委員會 (吳懷申)

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