不同評(píng)分系統(tǒng)對(duì)急性非靜脈曲張性上消化道出血患者危險(xiǎn)分層的預(yù)測(cè)價(jià)值

曹 鑫，壽松濤*，趙 珍，王力軍

·論著·

·急診急救·

不同評(píng)分系統(tǒng)對(duì)急性非靜脈曲張性上消化道出血患者危險(xiǎn)分層的預(yù)測(cè)價(jià)值

曹 鑫1，壽松濤1*，趙 珍2，王力軍1

背景 成年人急性非靜脈曲張性上消化道出血(ANVUGIB)是常見的臨床急癥，起病急、病情變化快，嚴(yán)重者可危及生命。如何迅速、準(zhǔn)確地評(píng)估病情，快速分診，制定合理的治療方案是高效應(yīng)用現(xiàn)有醫(yī)療資源，改善ANVUGIB患者預(yù)后的關(guān)鍵。目的 探討Glasgow-Blatchford評(píng)分(GBS)、AIMS65、Rockall評(píng)分系統(tǒng)對(duì)ANVUGIB患者危險(xiǎn)分層評(píng)估的準(zhǔn)確性和預(yù)測(cè)價(jià)值。方法 選取2013—2015年天津醫(yī)科大學(xué)總醫(yī)院急診科收治并確診為ANVUGIB的246例患者，收集患者基本信息，并采用GBS、AIMS65、Rockall評(píng)分系統(tǒng)對(duì)患者進(jìn)行危險(xiǎn)分層。評(píng)估3種評(píng)分系統(tǒng)預(yù)測(cè)ANVUGIB患者干預(yù)、再出血、死亡的靈敏度、特異度、陽性預(yù)測(cè)值、陰性預(yù)測(cè)值及受試者工作特征(ROC)曲線下面積(AUC)。結(jié)果 246例患者中干預(yù)95例(38.6%)，再出血15例(6.1%)，死亡4例(1.6%)。GBS<2分時(shí)，0例需干預(yù)、再出血和死亡；AIMS65評(píng)分<2分時(shí)，19例需干預(yù)，1例再出血，1例死亡；Rockall評(píng)分<2分時(shí)，6例需干預(yù)，1例再出血，0例死亡。當(dāng)GBS、AIMS65、Rockall評(píng)分≤2分時(shí)，預(yù)測(cè)ANVUGIB患者需干預(yù)的靈敏度和特異度分別為100.0%、80.0%、93.7%和26.5%、45.7%、15.9%，陽性預(yù)測(cè)值和陰性預(yù)測(cè)值分別為46.1%、48.1%、41.2%和100.0%、78.4%、80.0%，AUC分別為0.675〔95%CI(0.580,0.679)〕、0.643〔95%CI(0.545,0.741)〕、0.653〔95%CI(0.553,0.752)〕；預(yù)測(cè)再出血的靈敏度和特異度分別為100.0%、93.3%、93.3%和17.3%、37.7%、12.6%，陽性預(yù)測(cè)值和陰性預(yù)測(cè)值分別為7.3%、8.9%、6.5%和100.0%、98.9%、96.7%，AUC分別為0.809〔95%CI(0.638,0.941)〕、0.720〔95%CI(0.643,0.873)〕、0.800〔95%CI(0.597,0.907)〕；預(yù)測(cè)死亡的靈敏度和特異度分別為100.0%、100.0%、75.0%和16.5%、36.0%、12.4%，陽性預(yù)測(cè)值和陰性預(yù)測(cè)值分別為1.9%、1.9%、1.8%和100.0%、98.9%、100.0%，AUC分別為0.848〔95%CI(0.707,0.930)〕、0.804〔95%CI(0.723,0.976)〕、0.838〔95%CI(0.597,0.968)〕。結(jié)論 GBS更適合急診，GBS≤2分時(shí)，可被視為低風(fēng)險(xiǎn)患者，低風(fēng)險(xiǎn)患者可以接受門診治療，緩解住院壓力和減少醫(yī)療資源浪費(fèi)。

胃腸出血；急性非靜脈曲張性上消化道出血；GBS；AIMS65；Rockall；危險(xiǎn)分層

曹鑫，壽松濤，趙珍，等.不同評(píng)分系統(tǒng)對(duì)急性非靜脈曲張性上消化道出血患者危險(xiǎn)分層的預(yù)測(cè)價(jià)值[J].中國(guó)全科醫(yī)學(xué)，2017，20(14)：1759-1764.[www.chinagp.net]

CAO X，SHOU S T，ZHAO Z,et al.Predictive value of different scoring systems for risk stratification in patients with acute non-variceal upper gastrointestinal bleeding[J].Chinese General Practice，2017，20(14)：1759-1764.

急性上消化道出血是一種常見的潛在危及生命的臨床急癥，以發(fā)病率高、病情錯(cuò)綜復(fù)雜、變化快為特點(diǎn)，需要快速評(píng)估和管理，選擇高效、安全的評(píng)分系統(tǒng)對(duì)患者進(jìn)行危險(xiǎn)分層，將極大提高患者診治效率。近幾年已提出多個(gè)評(píng)估急性上消化道出血預(yù)后的評(píng)分系統(tǒng)，如Glasgow-Blatchford評(píng)分(GBS)、AIMS65、Rockall評(píng)分系統(tǒng)[1-8]。在不同國(guó)家，不同種族，乃至同一國(guó)家不同區(qū)域，不同評(píng)分系統(tǒng)對(duì)急性非靜脈曲張性上消化道出血(ANVUGIB)患者預(yù)后評(píng)估價(jià)值不同[9-10]。本研究將圍繞3種評(píng)分系統(tǒng)對(duì)急診ANVUGIB患者干預(yù)、再出血和死亡風(fēng)險(xiǎn)評(píng)估能力進(jìn)行闡述，以期更好地預(yù)測(cè)ANVUGIB患者的預(yù)后。

1 對(duì)象與方法

1.1 研究對(duì)象 采用回顧性分析方法，選取2013—2015年天津醫(yī)科大學(xué)總醫(yī)院急診科收治并確診為ANVUGIB的246例患者，排除大面積燒傷、創(chuàng)傷、急性心肌梗死等引起的應(yīng)激性潰瘍出血，疾病未得到完全控制出院和血液系統(tǒng)疾病引起的急性上消化道出血患者。

1.2 方法 收集患者一般資料，包括性別、年齡、入院前服用藥物、伴隨疾病、實(shí)驗(yàn)室檢查、診療情況、住院天數(shù)、死亡和最后診斷。從上述資料中提取GBS、AIMS65和Rockall評(píng)分系統(tǒng)所需要的參數(shù)，結(jié)合患者一般資料進(jìn)行評(píng)分。GBS：血紅蛋白：男性120～129 g/L計(jì)1分、100～119 g/L計(jì)3分、<100 g/L計(jì)6分，女性100～119 g/L計(jì)1分、<100 g/L計(jì)6分；血尿素氮：6.5～7.9 mmol/L計(jì)2分、8.0～8.9 mmol/L計(jì)3分、9.0～24.9 mmol/L計(jì)4分、≥25.0 mmol/L計(jì)5分；收縮壓：100～109 mm Hg(1 mm Hg=0.133 kPa)計(jì)1分、90～99 mm Hg計(jì)2分、<90 mm Hg計(jì)3分；心率≥100次/min計(jì)1分，黑便1分，暈厥2分，肝病2分，心力衰竭2分。以GBS評(píng)分0分、2分、6分、7分、8分、9分進(jìn)行分組，0～2分為低危組，>2分為高危組。AIMS65評(píng)分：血漿清蛋白<30 g/L計(jì)1分，國(guó)際標(biāo)準(zhǔn)化比率(INR)>1.5計(jì)1分，格拉斯哥昏迷量表(GCS)評(píng)分<14分計(jì)1分，收縮壓<90 mm Hg計(jì)1分，年齡>65歲計(jì)1分。以AIMS65評(píng)分0分、2分、3分、4分進(jìn)行分組，0～2分為低危組，>2分為高危組。Rockall評(píng)分：年齡：<60歲計(jì)0分、60～79歲計(jì)1分、≥80歲計(jì)2分；休克狀況：無休克計(jì)0分，心率≥100次/min計(jì)1分，收縮壓≤100 mm Hg計(jì)2分；并發(fā)癥：無計(jì)0分，心力衰竭、缺血性心臟病和其他重要并發(fā)癥計(jì)2分，肝衰竭、腎衰竭和腫瘤播散計(jì)3分；內(nèi)鏡診斷：無病變、Mallory-Weiss綜合征計(jì)0分，潰瘍等其他病變計(jì)1分，上消化道惡性疾病計(jì)2分；內(nèi)鏡下出血征象：無計(jì)0分，上消化道血液潴留、黏附血凝塊、血管暴露或噴血計(jì)2分。以Rockall評(píng)分0分、2分、6分、7分、8分、9分進(jìn)行分組，0～2分為低危組，>2分為高危組。應(yīng)用受試者工作特征(ROC)曲線分析GBS、AIMS65、Rockall評(píng)分系統(tǒng)對(duì)ANVUGIB患者危險(xiǎn)分層評(píng)估的價(jià)值，繪制3種評(píng)分的ROC曲線，計(jì)算ROC曲線下面積(AUC)；并計(jì)算3種評(píng)分系統(tǒng)的靈敏度、特異度、陽性預(yù)測(cè)值、陰性預(yù)測(cè)值。

1.3 定義 再出血的診斷指標(biāo)：住院期間臨床表現(xiàn)及生化指標(biāo)轉(zhuǎn)陰后再次出現(xiàn)嘔血和黑便；紅細(xì)胞計(jì)數(shù)、血紅蛋白持續(xù)降低，而網(wǎng)織細(xì)胞持續(xù)升高；收縮壓持續(xù)下降或心率增加；血尿素氮持續(xù)升高；內(nèi)鏡及手術(shù)探及上消化道出血；臨床干預(yù)措施：輸注血液成分；胃大部切除術(shù)；數(shù)字減影動(dòng)脈、靜脈栓塞術(shù)；內(nèi)鏡止血。

2 結(jié)果

2.1 一般臨床特點(diǎn) 246例患者中男177例，女69例，男∶女為2.6∶1；年齡63(53,73)歲；伴隨疾?。焊尾?2例(17.1%)，惡性腫瘤34例(13.8%)，心力衰竭12例(4.9%)；入院前用藥：阿司匹林29例(11.8%)，氫氯吡格雷8例(3.2%)，糖皮質(zhì)激素3例(1.2%)；內(nèi)鏡下所見：胃潰瘍89例(36.2%)，十二指腸潰瘍66例(26.8%)，賁門黏膜撕裂癥29例(11.8%)，胃癌27例(11.0%)，糜爛性胃炎9例(3.7%)，胃大部切除6例(2.4%)，食管裂孔疝5例(2.0%)，食管潰瘍3例(1.2%)，其他12例(4.9%)；質(zhì)子泵抑制劑218例(88.62%)；干預(yù)：懸浮紅細(xì)胞63例(25.6%)，血漿19例(7.7%)，血小板13例(5.3%)，內(nèi)鏡止血3例(1.2%)，數(shù)字減影1例(0.4%)；再出血15例(6.1%)；死亡4例(1.6%)；住院天數(shù)(11.7±7.9)d。

2.2ANVUGIB患者在3種評(píng)分系統(tǒng)危險(xiǎn)性積分中的臨床情況分布 不同GBS、AIMS65、Rockall評(píng)分患者的臨床資料分布見表1～3。

表1 不同GBS患者的臨床情況分布

注：GBS=Glasgow-Blatchford評(píng)分

表2 不同AIMS65評(píng)分患者的臨床情況分布

表3 不同Rockall評(píng)分患者的臨床情況分布

2.3 3種評(píng)分系統(tǒng)對(duì)ANVUGIB患者危險(xiǎn)分層評(píng)估比較 GBS≤2分時(shí)，預(yù)測(cè)ANVUGIB患者需干預(yù)的靈敏度為100.0%，特異度為26.5%，陽性預(yù)測(cè)值為46.1%，陰性預(yù)測(cè)值為100.0%，AUC為0.675〔95%CI(0.580,0.679)〕；預(yù)測(cè)ANVUGIB患者再出血的靈敏度為100.0%，特異度為17.3%，陽性預(yù)測(cè)值為7.3%，陰性預(yù)測(cè)值為100.0%，AUC為0.809〔95%CI(0.638,0.941)〕；預(yù)測(cè)ANVUGIB患者死亡的靈敏度為100.0%，特異度為16.5%，陽性預(yù)測(cè)值為1.9%，陰性預(yù)測(cè)值為100.0%，AUC為0.848〔95%CI(0.707,0.930)〕。AIMS65評(píng)分≤2分時(shí)，預(yù)測(cè)ANUVGIB患者需干預(yù)的靈敏度為80.0%，特異度為45.7%，陽性預(yù)測(cè)值為48.1%，陰性預(yù)測(cè)值為78.4%，AUC為0.643〔95%CI(0.545,0.741)〕；預(yù)測(cè)ANVUGIB患者再出血的靈敏度為93.3%，特異度為37.7%，陽性預(yù)測(cè)值為8.9%，陰性預(yù)測(cè)值為98.9%，AUC為0.720〔95%CI(0.643,0.873)〕；預(yù)測(cè)ANVUGIB患者死亡的靈敏度為75.0%，特異度為36.0%，陽性預(yù)測(cè)值為1.9%，陰性預(yù)測(cè)值為98.9%，AUC為0.804〔95%CI(0.723,0.976)〕。Rockall評(píng)分≤2分時(shí)，預(yù)測(cè)ANVUGIB患者需干預(yù)的靈敏度為93.7%，特異度為15.9%，陽性預(yù)測(cè)值為41.2%，陰性預(yù)測(cè)值為80.0%，AUC為0.653〔95%CI(0.553,0.752)〕；預(yù)測(cè)ANVUGIB患者再出血的靈敏度為93.3%，特異度為12.6%，陽性預(yù)測(cè)值為6.5%，陰性預(yù)測(cè)值為96.7%，AUC為0.800〔95%CI(0.597,0.907)〕；預(yù)測(cè)ANVUGIB患者死亡的靈敏度為100.0%，特異度為12.4%，陽性預(yù)測(cè)值為1.8%，陰性預(yù)測(cè)值為100.0%，AUC為0.838〔95%CI(0.597,0.968)〕(見圖1～3)。

注：GBS=Glasgow-Blatchford評(píng)分

圖1 3種評(píng)分系統(tǒng)預(yù)測(cè)ANVUGIB患者需干預(yù)的ROC曲線

Figure 1 ROC curve of 3 scoring systems for predicting the probability of needing reinterventions in the ANVUGIB patients

圖2 3種評(píng)分系統(tǒng)預(yù)測(cè)ANVUGIB患者再出血的ROC曲線

Figure 2 ROC curve of 3 scoring systems for predicting the probability of rebleeding in the ANVUGIB patients

圖3 3種評(píng)分系統(tǒng)預(yù)測(cè)ANVUGIB患者死亡的ROC曲線

Figure 3 ROC curve of 3 scoring systems for predicting the probability of death in the ANVUGIB patients

3 討論

本研究結(jié)果顯示，ANVUGIB患者男女性別之比為2.6∶1，50%以上患者年齡>60歲，消化性潰瘍出血占主要原因，其中以胃潰瘍多見，老年患者多伴有心腦血管等基礎(chǔ)疾病和多有口服阿司匹林等病史，該病因結(jié)構(gòu)可能與我國(guó)老年男性多有吸煙、飲酒史，可增加血管動(dòng)脈粥樣硬化的風(fēng)險(xiǎn)和老年患者長(zhǎng)期服用心腦血管藥物，可影響胃黏膜保護(hù)機(jī)制有關(guān)，與國(guó)內(nèi)文獻(xiàn)報(bào)道一致[11]。

本組資料顯示，患者再出血率(6.1%)較國(guó)外文獻(xiàn)(10%～30%)低[12]，患者病死率(1.6%)較國(guó)外文獻(xiàn)(6%～8%)低[13]，可能與本次病例采集均為剔除了病死率、再出血率較高的食管胃底靜脈曲張出血的上消化道出血患者和未進(jìn)行出院后30 d隨訪有關(guān)。

本研究結(jié)果顯示，GBS<2分時(shí)，0例患者需干預(yù)、再出血和死亡；AIMS65評(píng)分<2分時(shí)，19例患者輸血，1例再出血和1例死亡；Rockall評(píng)分<2分時(shí)，6例患者輸血，1例再出血。當(dāng)GBS、AIMS65、Rockall評(píng)分≤2分時(shí)，預(yù)測(cè)ANVUGIB患者需干預(yù)的靈敏度和特異度分別為100.0%、80.0%、93.7%和26.5%、45.7%、15.9%，再出血的靈敏度和特異度為100.0%、93.3%、93.3%和17.3%、37.7%、12.6%，死亡的靈敏度和特異度為100.0%、100.0%、75.0%和16.5%、36.0%、12.4%。GBS預(yù)測(cè)危險(xiǎn)分層靈敏度較高，與邵穎等[14]研究結(jié)果一致，而特異度較低，這可能與GBS指標(biāo)涵蓋面廣有關(guān)。當(dāng)GBS、AIMS65、Rockall評(píng)分≤2分時(shí)，預(yù)測(cè)ANVUGIB患者需干預(yù)的陽性預(yù)測(cè)值和陰性預(yù)測(cè)值為46.1%、48.1%、41.2%和100.0%、78.4%、80.0%，再出血的陽性預(yù)測(cè)值和陰性預(yù)測(cè)值為7.3%、8.9%、6.5%和100.0%、98.9%、96.7%；死亡的陽性預(yù)測(cè)值和陰性預(yù)測(cè)值為1.9%、1.9%、1.8%和100.0%、98.9%、100.0%。3種評(píng)分系統(tǒng)陽性預(yù)測(cè)值低而陰性預(yù)測(cè)值較高，可能與ANVUGIB患者干預(yù)率、再出血率、病死率低及低?；颊呃龜?shù)較少有關(guān)。GBS、AIMS65、Rockall評(píng)分預(yù)測(cè)需干預(yù)的AUC為0.675、0.653、0.643，GBS對(duì)ANVUGIB患者需干預(yù)評(píng)估AUC最大，與賴曉波等[15]研究結(jié)果一致。GBS是2000年在蘇格蘭地區(qū)前瞻性收集1 748例包含靜脈曲張出血的ANVUGIB患者，進(jìn)行多因素分析后制訂的，目前證實(shí)該評(píng)分系統(tǒng)對(duì)ANVUGIB患者干預(yù)、再出血、死亡評(píng)估具有預(yù)測(cè)價(jià)值，并被2015年急性上消化道出血急診診治流程專家共識(shí)所推薦[16-24]；荷蘭的一項(xiàng)研究提示，GBS預(yù)測(cè)ANVUGIB患者需干預(yù)能力較消化科專業(yè)醫(yī)師經(jīng)驗(yàn)評(píng)估需干預(yù)能力準(zhǔn)確性高[25]；此外，GBS不包括胃鏡檢查結(jié)果、年齡范疇及計(jì)算GCS評(píng)分，僅包含臨床和實(shí)驗(yàn)室因素(收縮壓、心率、黑便、暈厥、肝病、心力衰竭、血尿素氮)，簡(jiǎn)單、易獲和經(jīng)濟(jì)，因此GBS更適合急診，GBS≤2分時(shí)，ANVUGIB患者被定義為低風(fēng)險(xiǎn)，與AQUARIUS等[16]研究結(jié)果一致。本研究亦存在不足之處，觀察例數(shù)相對(duì)較少，有可能導(dǎo)致結(jié)果偏倚；本研究沒有進(jìn)行出院后隨訪，不排除部分患者出院后有疾病復(fù)發(fā)甚至加重風(fēng)險(xiǎn)，可能導(dǎo)致再出血率、病死率降低，因此需要大樣本研究，并進(jìn)行隨訪，制定滿足急診科需求的評(píng)分系統(tǒng)。

作者貢獻(xiàn)：曹鑫、壽松濤進(jìn)行文章的構(gòu)思與設(shè)計(jì)、研究的實(shí)施與可行性分析、對(duì)文章整體負(fù)責(zé)；曹鑫進(jìn)行數(shù)據(jù)收集、結(jié)果的分析與解釋、撰寫論文；曹鑫、趙珍進(jìn)行數(shù)據(jù)整理、統(tǒng)計(jì)學(xué)處理；壽松濤、王力軍進(jìn)行論文修訂；壽松濤負(fù)責(zé)文章的質(zhì)量控制及審校。

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(本文編輯：賈萌萌)

Predictive Value of Different Scoring Systems for Risk Stratification in Patients with Acute Non-variceal Upper Gastrointestinal Bleeding

CAOXin1，SHOUSong-tao1*，ZHAOZhen2，WANGLi-jun1

1.TianjinMedicalUniversityGeneralHospital,Tianjin300070,China2.BeijingCharityHospital,ChinaRehabilitationResearchCenter,Beijing100068,China

*Correspondingauthor:SHOUSong-tao,Chiefphysician;E-mail：stshou66@sina.com

Background Acute non-variceal upper gastrointestinal bleeding (ANVUGIB) in adults is a common clinical emergency characterized by acute onset,fast-changing conditions,and threatening life when it is serious.How to quickly and accurately assess the condition,rapid diagnosis,and develop a reasonable treatment regimen is the key to improving the prognosis of ANVUGIB patients by effectively utilizing existing medical resources.Objective To compare the accuracy of Glasgow-Blatchford bleeding score(GBS),AIMS65 and Rockall scoring systems for the risk prediction of outcome in ANVUGIB patients.Methods We conducted the risk stratification of 246 patients with ANVUGIB admitted in Department of Emergency,Tianjin Medical University General Hospital from 2013 to 2015 by using GBS,AIMS65,Rockall scoring systems,respectively based on analyzing the baseline characteristics of the patients.We compared the sensitivity,specificity,positive predictive value,negative predictive value and area under the curve(AUC) of the receiver operating characteristic (ROC) of these 3 scoring systems in the prediction of the probability of needing interventions,rebleeding and death.Results Of the 246 patients,95(38.6%) received interventions,15(6.1%) had rebleeding,and 4(1.6%) died.When the patients had GBS <2 points,no one needed interventions,had rebleeding and died;when the patients had AIMS65 score <2 points,19 patients needed interventions,1 had rebleeding and 2 died;but when the patients had Rockall score <2 points,6 needed interventions,1 had rebreeding and no one died.When the GBS,AIMS65 score and Rockall score of the patients were all ≤2 points,in terms of predicting the probability of needing interventions in the ANVUGIB patients,the sensitivity of GBS,AIMS65 and Rockall scoring systems were 100.0%,80.0%,93.7%,respectively,the specificity of them were 26.5%,45.7%,15.9%,respectively,positive predictive value of them were 46.1%,48.1%，and 41.2%,respectively,negative predictive value of them were 100.0%,78.4%,80.0%,respectively,AUC of them were 0.675〔95%CI(0.580,0.679)〕,0.643〔95%CI(0.545,0.741)〕,0.653〔95%CI(0.553,0.752)〕,respectively;in regard to predicting the probability of rebleeding in the ANVUGIB patients,the sensitivity of GBS,AIMS65 and Rockall scoring systems were 100.0%,93.3%,93.3%,respectively,the specificity of them were 17.3%,37.7%,12.6%,respectively,positive predictive value of them were 7.3%,8.9%,6.5%,respectively,negative predictive value of them were 100.0%,98.9% and 96.7%,respectively,AUC of them were 0.809〔95%CI(0.638,0.941)〕,0.720〔95%CI(0.643,0.873)〕,0.800〔95%CI(0.597,0.907)〕,respectively;in the aspect of predicting the probability of death in the ANVUGIB patients,the sensitivity of GBS,AIMS65 and Rockall scoring systems were 100.0%,100.0%,and 75.0%,respectively,the specificity of them were 16.5%,36.0%,12.4%,respectively,positive predictive value of them were 1.9%,1.9%,and 1.8%,respectively,negative predictive value of them were 100.0%,98.9% and 100.0%,respectively,AUC of them were 0.848〔95%CI(0.707,0.930)〕,0.804〔95%CI(0.723,0.976)〕,0.838〔95%CI(0.597,0.968)〕,respectively.Conclusion GBS is more suitable for emergency predicting the risk of outcome in patients with ANVUGIB.Patients with GBS ≤2 points can be considered as low-risk patients.They can receive outpatient treatment,by which bed shortages can be relieved and medical resources can be saved to some extent.

Gastrointestinal hemorrhage;ANVUGIB;GBS;AIMS65;Rockall;Risk stratification

R 573.2

A

10.3969/j.issn.1007-9572.2017.14.021

2016-12-16；

2017-03-09)

1.300070天津市，天津醫(yī)科大學(xué)總醫(yī)院

2.100068北京市，中國(guó)康復(fù)研究中心北京博愛醫(yī)院

*通信作者：壽松濤，主任醫(yī)師；E-mail：stshou66@sina.com