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    不同血瘀證圍絕經(jīng)期女性冠心病患者相關(guān)臨床特點(diǎn)研究

    2016-12-14 02:54:12王以新劉新橋張佩雪尹國丞李夢(mèng)茹
    中國全科醫(yī)學(xué) 2016年36期
    關(guān)鍵詞:絕經(jīng)期左心室血瘀

    馮 妍,王以新,劉新橋,張佩雪,尹國丞,李夢(mèng)茹

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    ·論著·

    不同血瘀證圍絕經(jīng)期女性冠心病患者相關(guān)臨床特點(diǎn)研究

    馮 妍,王以新,劉新橋,張佩雪,尹國丞,李夢(mèng)茹

    背景 圍絕經(jīng)期冠心病患者危險(xiǎn)因素基本相同情況下,冠狀動(dòng)脈病變進(jìn)展及心血管事件發(fā)生率有明顯差別,因此亟待重新思考和認(rèn)識(shí)圍絕經(jīng)期女性冠心病患者的臨床特點(diǎn)。目的 分析不同血瘀證圍絕經(jīng)期女性冠心病患者的相關(guān)臨床特點(diǎn)。方法 選取2014年5月—2016年5月就診于首都醫(yī)科大學(xué)附屬北京安貞醫(yī)院且符合納入標(biāo)準(zhǔn)的冠心病患者320例為研究對(duì)象。根據(jù)其年齡、合并慢性病情況及血瘀證類型(氣虛血瘀、痰濁血瘀、氣滯血瘀、其他),分為觀察1組、觀察2組、觀察3組、對(duì)照組,各80例。記錄患者一般資料〔年齡、合并疾病情況(糖尿病、高脂血癥、高血壓)、冠狀動(dòng)脈病變支數(shù)〕、實(shí)驗(yàn)室檢查指標(biāo)〔丙氨酸氨基轉(zhuǎn)移酶(ALT)、天冬氨酸氨基轉(zhuǎn)移酶(AST)、總蛋白(TP)、清蛋白(Alb)、三酰甘油(TG)、總膽固醇(TC)、高密度脂蛋白膽固醇(HDL-C)、低密度脂蛋白膽固醇(LDL-C)、尿素氮(BUN)、肌酐(Cr)、尿酸(UA)、空腹血糖(FBG)、C反應(yīng)蛋白(CRP)、同型半胱氨酸(HCY)〕、輔助檢查指標(biāo)〔左心房內(nèi)徑、左心室舒張末期內(nèi)徑、室間隔厚度、左心室后壁厚度、左心室射血分?jǐn)?shù)(LVEF)〕。結(jié)果 觀察1組、觀察2組1支病變所占比例低于對(duì)照組,3支病變、3支病變+左冠狀動(dòng)脈主干病變所占比例高于對(duì)照組(P<0.05);觀察3組3支病變所占比例低于觀察1組、觀察2組,2支病變所占比例高于觀察2組(P<0.05)。觀察1組TG、TC、HDL-C、FBG水平高于對(duì)照組(P<0.05);觀察2組TG、TC、FBG水平高于對(duì)照組(P<0.05);觀察3組TC水平低于對(duì)照組,F(xiàn)BG水平低于觀察1組、觀察2組(P<0.05)。各組患者左心房內(nèi)徑、左心室舒張末期內(nèi)徑、室間隔厚度、左心室后壁厚度、LVEF比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論 圍絕經(jīng)期女性氣虛血瘀、痰濁血瘀冠心病患者較其他類型的冠心病患者冠狀動(dòng)脈病變程度更嚴(yán)重,可能與更嚴(yán)重的糖脂代謝紊亂有關(guān);圍絕經(jīng)期女性氣滯血瘀證冠心病患者情志不舒導(dǎo)致的血壓波動(dòng)是其發(fā)病的主要原因;應(yīng)根據(jù)不同血瘀證圍絕經(jīng)期女性冠心病患者的臨床特點(diǎn)在早期進(jìn)行針對(duì)性的干預(yù)和治療。

    冠心病;血瘀;圍絕經(jīng)期

    馮妍,王以新,劉新橋,等.不同血瘀證圍絕經(jīng)期女性冠心病患者相關(guān)臨床特點(diǎn)研究[J].中國全科醫(yī)學(xué),2016,19(36):4451-4456.[www.chinagp.net]

    FENG Y,WANG Y X,LIU X Q,et al.Clinical characteristics of peri-menopausal female coronary heart disease patients with different blood stasis syndromes[J].Chinese General Practice,2016,19(36):4451-4456.

    冠心病是嚴(yán)重威脅人類生命和健康的重大心血管疾病,其發(fā)病率存在著明顯的性別差異[1],女性受雌激素的保護(hù)發(fā)病率低于男性,但絕經(jīng)后女性與同齡男性發(fā)病率無明顯差異[2]。研究顯示,圍絕經(jīng)期冠心病患者缺乏典型癥狀,預(yù)后差,但其中是否仍存在一些特異性的未知因素尚不清楚[3]。本研究課題組前期發(fā)現(xiàn),圍絕經(jīng)期冠心病患者在年齡及主要危險(xiǎn)因素基本相同的情況下,冠狀動(dòng)脈病變進(jìn)展及心血管事件發(fā)生率有明顯差別[4];這促使筆者重新思考和認(rèn)識(shí)圍絕經(jīng)期女性冠心病患者的臨床特點(diǎn)。以導(dǎo)師陳可冀院士為首的課題組在既往研究基礎(chǔ)上明確提出,血瘀是貫穿冠心病發(fā)展過程的中心環(huán)節(jié),也是冠心病患者的基礎(chǔ)病理狀態(tài)[5]。本研究分析比較不同血瘀證圍絕經(jīng)期女性冠心病患者的相關(guān)臨床指標(biāo)特點(diǎn),以期深入了解該階段女性冠心病患者的臨床規(guī)律,為心血管疾病的三級(jí)階梯治療提供證據(jù)支持。

    1 對(duì)象與方法

    1.1 研究對(duì)象 選取2014年5月—2016年5月就診于首都醫(yī)科大學(xué)附屬北京安貞醫(yī)院且符合納入標(biāo)準(zhǔn)的冠心病患者320例為研究對(duì)象。根據(jù)其年齡、合并慢性病情況及血瘀證類型(氣虛血瘀、痰濁血瘀、氣滯血瘀、其他),分為觀察1組、觀察2組、觀察3組、對(duì)照組,各80例。納入標(biāo)準(zhǔn):(1)圍絕經(jīng)期女性(40~55歲);(2)冠狀動(dòng)脈造影確診為冠心病。排除標(biāo)準(zhǔn):(1)伴甲狀腺功能異常;(2)伴心肌病、先天性心臟病、風(fēng)濕性心臟病、免疫性疾病所致冠狀動(dòng)脈狹窄;(3)伴繼發(fā)性高血壓、外周動(dòng)脈疾病、肝腎疾病、腫瘤、血液系統(tǒng)疾病等。

    1.2 研究方法

    1.2.1 一般資料收集 記錄患者年齡、合并疾病情況(糖尿病、高脂血癥、高血壓)、冠狀動(dòng)脈病變支數(shù)等。

    1.2.2 實(shí)驗(yàn)室檢查 晨起采集患者空腹12 h肘靜脈血2 ml于乙二胺四乙酸二鉀(EDTA-2K)抗凝管中,4 000 r/min離心10 min(離心半徑16 cm),取上層血漿后即刻用標(biāo)準(zhǔn)生化儀檢測(cè)以下各項(xiàng)生化指標(biāo):丙氨酸氨基轉(zhuǎn)移酶(ALT)、天冬氨酸氨基轉(zhuǎn)移酶(AST)、總蛋白(TP)、清蛋白(Alb)、三酰甘油(TG)、總膽固醇(TC)、高密度脂蛋白膽固醇(HDL-C)、低密度脂蛋白膽固醇(LDL-C)、尿素氮(BUN)、肌酐(Cr)、尿酸(UA)、空腹血糖(FBG)、C反應(yīng)蛋白(CRP)、同型半胱氨酸(HCY)。

    1.2.3 輔助檢查 對(duì)患者進(jìn)行常規(guī)超聲心動(dòng)圖檢查,得出測(cè)定指標(biāo):左心房內(nèi)徑、左心室舒張末期內(nèi)徑、室間隔厚度、左心室后壁厚度、左心室射血分?jǐn)?shù)(LVEF)。

    1.3 診斷標(biāo)準(zhǔn)

    1.3.1 冠心病診斷標(biāo)準(zhǔn) 患者均進(jìn)行冠狀動(dòng)脈造影檢查,以左冠狀動(dòng)脈主干(LM)、前降支(LAD)、回旋支(LCX)或右冠狀動(dòng)脈(RCA)及其分支存在≥50%直徑的固定性狹窄或阻塞性病變定義為冠心病[6]。

    1.3.2 中醫(yī)證候診斷標(biāo)準(zhǔn) 參照中國中西醫(yī)結(jié)合學(xué)會(huì)心血管學(xué)會(huì)修訂的冠心病中醫(yī)辨證標(biāo)準(zhǔn)[7]。

    1.3.3 血瘀證診斷標(biāo)準(zhǔn) 參照中國中西醫(yī)結(jié)合學(xué)會(huì)活血化瘀專業(yè)委員會(huì)制定的血瘀證診斷標(biāo)準(zhǔn)[8]和《活血化瘀研究與臨床》中的標(biāo)準(zhǔn)[9]。

    1.3.4 圍絕經(jīng)期診斷標(biāo)準(zhǔn) 參照1994年世界衛(wèi)生組織在“90年代絕經(jīng)研究進(jìn)展”會(huì)議上給出的圍絕經(jīng)期的定義:圍絕經(jīng)期是指女性40歲以后開始出現(xiàn)內(nèi)分泌紊亂及表現(xiàn)至停經(jīng)后12個(gè)月內(nèi)這段時(shí)期。其具體診斷標(biāo)準(zhǔn)如下:(1)病史:婦女年齡在40歲以上,或有手術(shù)或放射線破壞卵巢的病史。(2)臨床表現(xiàn):①月經(jīng)改變,絕大多數(shù)婦女先出現(xiàn)月經(jīng)周期紊亂,月經(jīng)期縮短或淋漓不止;小部分婦女出現(xiàn)不規(guī)則出血,量多然后逐漸停止;②心血管癥狀,面部潮紅、烘熱、心悸與血壓波動(dòng);③神經(jīng)精神癥狀,憂慮、抑郁、煩躁、易激動(dòng)與失眠;④新陳代謝障礙,肥胖、關(guān)節(jié)痛與骨質(zhì)疏松;⑤全身檢查及婦科檢查,無引起上述癥狀的器質(zhì)性病變。(3)激素測(cè)定:卵泡刺激素(FSH)、黃體生成素(LH)水平升高或處于參考范圍(FSH參考范圍3~41 U/L,LH參考范圍4.2~126.0 U/L),雌二醇(E2)水平下降(參考范圍25~309 ng/L)。其中排除了手術(shù)致絕經(jīng)者、既往月經(jīng)不規(guī)律者、使用特殊激素制劑者等非正常絕經(jīng)患者[10]。

    1.3.5 糖尿病診斷標(biāo)準(zhǔn) 參照1999年世界衛(wèi)生組織糖尿病診斷標(biāo)準(zhǔn)[11]。

    1.3.6 高脂血癥診斷標(biāo)準(zhǔn) 參照2014年中國膽固醇教育計(jì)劃血脂異常防治專家建議[12]。

    1.3.7 高血壓診斷標(biāo)準(zhǔn) 參照中國高血壓防治指南2010[13]。

    2 結(jié)果

    2.1 一般資料比較 各組患者年齡、糖尿病、高脂血癥、高血壓發(fā)生率比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05);各組患者冠狀動(dòng)脈病變支數(shù)比較,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。觀察1組、觀察2組1支病變所占比例低于對(duì)照組,3支病變、3支病變+LM病變所占比例高于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察3組3支病變所占比例低于觀察1組、觀察2組,2支病變所占比例高于觀察2組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05,見表1)。

    2.2 實(shí)驗(yàn)室檢查指標(biāo)比較 各組患者ALT、AST、TP、Alb、BUN、Cr、UA、CRP、HCY水平比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05);各組患者TG、TC、HDL-C、LDL-C、FBG水平比較,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。觀察1組TG、TC、HDL-C、FBG水平高于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察2組TG、TC、FBG水平高于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);觀察3組TC水平低于對(duì)照組,F(xiàn)BG水平低于觀察組1組、觀察2組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05,見表2)。

    2.3 超聲心動(dòng)圖檢查指標(biāo)比較 各組患者左心房內(nèi)徑、左心室舒張末期內(nèi)徑、室間隔厚度、左心室后壁厚度、LVEF比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05,見表3)。

    表1 4組患者一般資料比較

    注:LM=左冠狀動(dòng)脈主干;a為F值;與對(duì)照組比較,bP<0.05;與觀察1組比較,cP<0.05;與觀察2組比較,dP<0.05

    表2 4組患者實(shí)驗(yàn)室檢查指標(biāo)比較±s)

    注:ALT=丙氨酸氨基轉(zhuǎn)移酶,AST=天冬氨酸氨基轉(zhuǎn)移酶,TP=總蛋白,Alb=清蛋白,TG=三酰甘油,TC=總膽固醇,HDL-C=高密度脂蛋白膽固醇,LDL-C=低密度脂蛋白膽固醇,BUN=尿素氮,Cr=肌酐,UA=尿酸,F(xiàn)BG=空腹血糖,CRP=C反應(yīng)蛋白,HCY=同型半胱氨酸;與對(duì)照組比較,aP<0.05;與觀察1組比較,bP<0.05;與觀察2組比較,cP<0.05

    表3 4組患者超聲心動(dòng)圖指標(biāo)比較±s)

    注:LVEF=左心室射血分?jǐn)?shù)

    3 討論

    女性圍絕經(jīng)期時(shí)冠心病發(fā)病率開始急劇增加,且多以急性心肌梗死為首發(fā)表現(xiàn),預(yù)后不佳可能性大[1-3]。受圍絕經(jīng)期癥狀不典型影響,圍絕經(jīng)期女性中確有嚴(yán)重心血管疾病的患者常被臨床忽略,臨床亟待探索簡便易行的圍絕經(jīng)期冠心病分類管理手段。本研究組前期發(fā)現(xiàn),不同中醫(yī)證候類型的圍絕經(jīng)期女性冠心病患者在疾病的發(fā)生發(fā)展中各有特點(diǎn)[14-16],本研究對(duì)此進(jìn)行了深入探討。

    3.1 糖脂代謝紊亂是圍絕經(jīng)期女性氣虛血瘀、痰濁血瘀冠心病患者疾病進(jìn)展的關(guān)鍵要素 雌激素水平降低而致的糖脂代謝紊亂被認(rèn)為是導(dǎo)致圍絕經(jīng)期女性冠狀動(dòng)脈粥樣硬化甚至冠心病的主要原因[5],但其尚不能概括圍絕經(jīng)期女性冠心病的全部發(fā)病機(jī)制。既往對(duì)此時(shí)期女性冠心病患者臨床特點(diǎn)的研究發(fā)現(xiàn),早發(fā)心血管疾病家族史、血脂異常、血紅蛋白水平及血小板水平增高是早發(fā)女性冠心病的主要危險(xiǎn)因素,且此時(shí)期女性冠心病患者以單支病變?yōu)橹?,完全閉塞病變的發(fā)生率較高[17]。但既往缺乏中醫(yī)證候分類下不同證候圍絕經(jīng)期冠心病患者臨床特點(diǎn)比較的相關(guān)研究。本研究結(jié)果顯示,觀察1組TG、TC、HDL-C、FBG水平高于對(duì)照組,觀察2組TG、TC、FBG水平高于對(duì)照組,提示糖脂代謝紊亂是圍絕經(jīng)期女性氣虛血瘀、痰濁血瘀冠心病患者的關(guān)鍵發(fā)病原因。

    本研究結(jié)果顯示,觀察1組、觀察2組1支病變率低于對(duì)照組,3支病變、3支病變+LM病變率高于對(duì)照組;觀察3組3支病變率低于觀察1組、觀察2組,2支病變率高于觀察2組,提示圍絕經(jīng)期女性氣虛血瘀、痰濁血瘀冠心病患者病變程度更嚴(yán)重,考慮與其更嚴(yán)重的糖脂代謝紊亂密切相關(guān)。

    3.2 情志不舒導(dǎo)致的血壓波動(dòng)是圍絕經(jīng)期女性氣滯血瘀冠心病患者發(fā)病的主要原因 既往研究缺乏對(duì)女性氣滯血瘀冠心病患者的臨床觀察。本研究結(jié)果顯示,觀察3組TC水平低于對(duì)照組,提示脂代謝紊亂在圍絕經(jīng)期女性氣滯血瘀冠心病患者疾病發(fā)生發(fā)展中影響相對(duì)較小。本研究結(jié)果顯示,各組患者左心房內(nèi)徑、左心室舒張末期內(nèi)徑、室間隔厚度、左心室后壁厚度、LVEF無明顯差異,可能與樣本例數(shù)較少有關(guān),有待進(jìn)一步研究證實(shí)。室間隔厚度及左心室后壁厚度是左心室肥厚的重要評(píng)價(jià)指標(biāo),血壓波動(dòng)或升高會(huì)導(dǎo)致心臟靶器官的損害而在心臟超聲中較早體現(xiàn),提示圍絕經(jīng)期女性氣滯血瘀冠心病患者情志不舒導(dǎo)致的血壓波動(dòng)是發(fā)病的主要原因。中醫(yī)認(rèn)為,女子肝為先天,氣郁傷肝進(jìn)而導(dǎo)致五臟功能失調(diào)[18],在此類患者中有較明顯的體現(xiàn)。

    本研究受病例數(shù)量和研究經(jīng)費(fèi)的影響,只選取臨床常規(guī)指標(biāo)進(jìn)行觀察分析,對(duì)于其深入的病理機(jī)制有待進(jìn)一步大樣本的病理學(xué)分析,然而本研究對(duì)于探討提高此類患者的精準(zhǔn)治療質(zhì)量和改善其遠(yuǎn)期預(yù)后均具有重要意義。

    綜上所述,不同血瘀證圍絕經(jīng)期女性冠心病導(dǎo)致動(dòng)脈粥樣硬化進(jìn)展的核心要素是有差別的,糖脂代謝紊亂是圍絕經(jīng)期女性氣虛血瘀、痰濁血瘀冠心病患者疾病進(jìn)展的關(guān)鍵要素,而情志不舒導(dǎo)致的血壓波動(dòng)是圍絕經(jīng)期女性氣滯血瘀冠心病患者發(fā)病的主要原因,臨床應(yīng)以中醫(yī)證候作為分類依據(jù),對(duì)根據(jù)此階段女性冠心病患者不同特點(diǎn)進(jìn)行早期監(jiān)測(cè)和分類干預(yù)。本研究對(duì)于揭示圍絕經(jīng)期女性冠心病特殊臨床特點(diǎn)有積極價(jià)值,可用于探討圍絕經(jīng)期女性冠心病患者的臨床分類診療。

    作者貢獻(xiàn):馮妍進(jìn)行試驗(yàn)設(shè)計(jì)與實(shí)施、數(shù)據(jù)分析,論文撰寫并對(duì)文章負(fù)責(zé);劉新橋負(fù)責(zé)對(duì)試驗(yàn)患者的中醫(yī)辨證分類進(jìn)行校對(duì);張佩雪、尹國丞、李夢(mèng)茹進(jìn)行試驗(yàn)實(shí)施、資料收集,數(shù)據(jù)錄入整理;王以新進(jìn)行質(zhì)量控制與審校。

    本文無利益沖突。

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    (本文編輯:崔麗紅)

    Clinical Characteristics of Peri-menopausal Female Coronary Heart Disease Patients with Different Blood Stasis Syndromes

    FENG Yan,WANG Yi-xin,LIU Xin-qiao,ZHANG Pei-xue,YIN Guo-cheng,LI Meng-ru.

    Beijing Anzhen Hospital,Capital Medical University;School of General Practice and Continuing Education,Capital Medical University,Beijing 100029,China

    WANG Yi-xin,Beijing Anzhen Hospital,Capital Medical University;School of General Practice and Continuing Education,Capital Medical University,Beijing 100029,China;E-mail:wangyixin6417@sina.com

    Backgroud In case of the risk factors of peri-menopausal women with coronary heart disease are basically same,there are significantly differences in the progress of coronary artery disease and incidence of cardiovascular events,the clinical features of peri-menopausal women with coronary heart disease need to be rethought.Objective To evaluate the clinical characteristics of peri-menopausal patients with coronary heart disease with different blood stasis syndromes.Methods 320 patients who were admitted to Beijing Anzhen Hospital,Capital Medical University during May 2014 to May 2016 and met the inclusion criteria,were selected as study subjects.According to patients′ age,combined chronic diseases and type of blood stasis syndrome(qi deficiency and blood stasis,phlegm and blood stasis,qi stagnation and blood stasis,other syndromes),they were divided into observation 1 group,observation 2 group,observation 3 group,and control group,with 80 cases in each group.General information 〔age,combined diseases(diabetes,hyperlipidemia and hypertension),coronary artery lesions〕,laboratory examination indicators 〔alanine aminotransferase(ALT),aspartate aminotransferase(AST),total protein(TP),albumin(Alb),three-glycerol(TG),total cholesterol(TC),high density lipoprotein cholesterol(HDL-C),low density lipoprotein cholesterol(LDL-C),urea nitrogen(BUN),creatinine(Cr),uric acid(UA),fasting blood glucose(FBG),C reactive protein(CRP),homocysteine(HCY)〕,and auxiliary examination indicators 〔left atrial diameter,left ventricular end diastolic diameter,interventricular septum thickness,left ventricular posterior wall thickness,left ventricular ejection fraction(LVEF)〕 of patients were recorded.Results The proportion of one-vessel coronary artery lesions in observation 1 group and observation 2 group was significantly lower than that in control group,respectively,while the proportion of three-vessel coronary artery lesions,and the proportion of three-vessel coronary artery lesions+left main coronary artery lesions were higher than those in control group(P<0.05).The proportion of three-vessel coronary artery lesions in observation 3 group was lower than that in observation 1 group and observation 2 group,respectively,while the proportion of two-vessel coronary artery lesions in observation 3 group was higher than that in observation 2 group(P<0.05).The levels of TG,TC,HDL-C,and FBG in observation 1 group were significantly higher than those in control group(P<0.05).The levels of TG,TC,and FBG in observation 2 group were significantly higher than those in control group(P<0.05).The level of TC in observation 3 group was significantly lower than that in control group,while the level of FBG in observation 3 group was lower than that in observation 1 group and observation 2 group,respectively(P<0.05).There was no statistically significant difference in left atrial diameter,left ventricular end diastolic diameter,ventricular septal thickness,left ventricular posterior wall thickness,and LVEF among the four groups(P>0.05).Conclusion The severity of coronary artery disease among peri-menopausal women with coronary heart disease with qi deficiency and phlegm blood stasis syndromes is more severe than that among peri-menopausal women with coronary heart disease with other types,which may be related to more serious disorder of glycolipid metabolism.The fluctuation in blood pressure caused by emotional discomfort is the main cause of coronary heart disease attack among peri-menopausal women with coronary heart disease with qi stagnation and blood stasis syndrome.Targeted intervention and treatment based on clinical characteristics of blood stasis syndromes should be given in the early stage.

    Coronary disease;Blood stasis;Perimenopause

    北京市自然科學(xué)基金資助項(xiàng)目(7144205);首都衛(wèi)生發(fā)展科研專項(xiàng)(首發(fā)2014-3-2063,首發(fā)2014-2-1053);北京中醫(yī)藥科技發(fā)展資金項(xiàng)目(QN2015-07)

    100029 北京市,首都醫(yī)科大學(xué)附屬北京安貞醫(yī)院,首都醫(yī)科大學(xué)全科醫(yī)學(xué)與繼續(xù)教育學(xué)院(馮妍,王以新,劉新橋,張佩雪);首都醫(yī)科大學(xué)(尹國丞,李夢(mèng)茹)

    王以新,100029 北京市,首都醫(yī)科大學(xué)附屬北京安貞醫(yī)院,首都醫(yī)科大學(xué)全科醫(yī)學(xué)與繼續(xù)教育學(xué)院;

    E-mail:wangyixin6417@sina.com

    R 541.4

    A

    10.3969/j.issn.1007-9572.2016.36.010

    2016-06-05;

    2016-10-12)

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