何振華,陳深,孫世杰,孫曉芬,毛捷鴻
點(diǎn)狀皮片移植聯(lián)合次氯酸沖洗治療下肢靜脈潰瘍的臨床研究
何振華1,陳深1,孫世杰1,孫曉芬2,毛捷鴻3
1.紹興文理學(xué)院元培學(xué)院,浙江紹興 312000;2.浙江中醫(yī)藥大學(xué)附屬第二醫(yī)院中醫(yī)護(hù)理中心,浙江杭州 310005;3.浙江中醫(yī)藥大學(xué)附屬第二醫(yī)院肛腸外科,浙江杭州 310005
探討點(diǎn)狀皮片移植聯(lián)合次氯酸沖洗治療下肢靜脈潰瘍的臨床療效。采用目的抽樣法,選取2021年9月至2022年9月浙江中醫(yī)藥大學(xué)附屬第二醫(yī)院收治的下肢靜脈潰瘍患者96例,按照隨機(jī)數(shù)字表法分為空白組、對(duì)照組和干預(yù)組,每組32例??瞻捉M在標(biāo)準(zhǔn)化創(chuàng)面床準(zhǔn)備后采用點(diǎn)狀皮片移植治療,術(shù)后給予常規(guī)換藥;對(duì)照組在空白組的基礎(chǔ)上,術(shù)前3d及術(shù)后3~5d采用恒溫30℃生理鹽水沖洗治療;干預(yù)組將沖洗液改為次氯酸溶液。比較三組患者術(shù)后5d的皮片成活率、細(xì)菌陽(yáng)性率、疼痛評(píng)分,創(chuàng)面愈合時(shí)間。術(shù)后5d,干預(yù)組的皮片成活率[(86.82±2.83)%]明顯高于對(duì)照組[(75.37±4.56)%]和空白組[(66.84±9.68)%],差異有統(tǒng)計(jì)學(xué)意義(<0.05)。干預(yù)組、對(duì)照組和空白組的細(xì)菌陽(yáng)性率分別為10.00%、22.58%、46.43%,差異有統(tǒng)計(jì)學(xué)意義(<0.05)。三組患者術(shù)后5d疼痛評(píng)分比較,干預(yù)組[(2.97±1.19)分]顯著低于對(duì)照組[(4.26±0.10)分]和空白組[(5.42±1.14)分],差異有統(tǒng)計(jì)學(xué)意義(<0.05)。與空白組[(33.91±3.78)d]和對(duì)照組[(27.02±3.13)d]的愈合時(shí)間比較,干預(yù)組[(16.00±2.35)d]的愈合時(shí)間較短,差異有統(tǒng)計(jì)學(xué)意義(<0.05)。點(diǎn)狀皮片移植聯(lián)合次氯酸沖洗可有效控制下肢靜脈潰瘍皮片移植創(chuàng)面的局部感染,改善血氧供應(yīng),促進(jìn)組織分化和表皮擴(kuò)展,提高移植皮片的成活率,促進(jìn)創(chuàng)面愈合進(jìn)程,減輕患者疼痛感受,具有較好的臨床應(yīng)用和推廣價(jià)值。
點(diǎn)狀皮片移植;次氯酸;下肢靜脈潰瘍;沖洗療法
下肢靜脈潰瘍(leg venous ulcer,LVU)是以持續(xù)性靜脈高壓為基礎(chǔ)的下肢靜脈回流障礙及逆流而導(dǎo)致的慢性創(chuàng)面,具有發(fā)病率和復(fù)發(fā)率高等臨床特點(diǎn),已成為慢性創(chuàng)面診療的一大難點(diǎn),亟需治療理念和技術(shù)的革新[1]。2016年歐洲皮膚病學(xué)論壇發(fā)布的《下肢靜脈潰瘍的診斷和治療》循證指南指出,清創(chuàng)后創(chuàng)面的臨時(shí)覆蓋、病原微生物的清除及有效刺激肉芽組織的生長(zhǎng)是促進(jìn)下肢靜脈潰瘍創(chuàng)面愈合的重點(diǎn)[2]。點(diǎn)狀皮片移植通過(guò)密集植皮,減少創(chuàng)面裸露,縮短肉芽組織和表皮生長(zhǎng)時(shí)間,加速潰瘍創(chuàng)面愈合進(jìn)程,但植皮術(shù)后感染的控制是皮片成活的關(guān)鍵[3]。次氯酸沖洗可作為點(diǎn)狀皮片移植術(shù)后抗感染治療的有益補(bǔ)充,其可通過(guò)微小分子穿透實(shí)現(xiàn)快速破壞細(xì)菌結(jié)構(gòu),還可借助液體的流動(dòng)力和剪切力有效清除淺層細(xì)菌和異物,從而保證移植后皮片的成活率,加速創(chuàng)面愈合進(jìn)程[4]。本研究采用點(diǎn)狀皮片移植聯(lián)合次氯酸沖洗對(duì)96例下肢靜脈潰瘍患者進(jìn)行治療,效果明顯,現(xiàn)報(bào)道如下。
采用目的抽樣法,選取2021年9月至2022年9月浙江中醫(yī)藥大學(xué)附屬第二醫(yī)院收治并符合納入標(biāo)準(zhǔn)的96例下肢靜脈潰瘍患者作為研究對(duì)象。納入標(biāo)準(zhǔn):①符合《臨床血管外科學(xué)(第五版)》[5]關(guān)于下肢靜脈潰瘍的診斷標(biāo)準(zhǔn):足靴區(qū)皮膚出現(xiàn)局部淤血潰瘍,且伴有濕疹樣皮炎,周圍皮膚色素沉著,遷延不愈;小腿區(qū)域有脹痛感且伴有凹陷性水腫和(或)靜脈曲張;影像學(xué)檢查提示下肢靜脈血液返流;CEAP C6級(jí)。②踝肱指數(shù)(ankle brachial index,ABI)>0.8。③年齡18~75歲。排除標(biāo)準(zhǔn):①合并有肝、腎、腦等威脅生命的基礎(chǔ)疾病。②糖尿病或糖尿病病史者。③精神異常而無(wú)法配合本研究者。本研究共納入下肢靜脈潰瘍患者96例,研究過(guò)程中脫失7例,其中空白組4例,對(duì)照組1例,干預(yù)組2例,剩余89例。三組患者的人口學(xué)資料(性別和年齡)和創(chuàng)面情況(病程、創(chuàng)面面積、細(xì)菌陽(yáng)性率、疼痛評(píng)分)比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(>0.05),見(jiàn)表1。本研究經(jīng)浙江中醫(yī)藥大學(xué)附屬第二醫(yī)院倫理委員會(huì)審批通過(guò)(倫理審批號(hào):2019-KL-101-01),所有患者均簽署知情同意書(shū)。
干預(yù)治療過(guò)程分室處理,即三組患者分別在治療室A、B、C進(jìn)行處理。供皮區(qū)取皮和植皮操作均由同一名主任醫(yī)師進(jìn)行,受皮區(qū)清創(chuàng)由同一名國(guó)際造口治療師進(jìn)行。
1.2.1 空白組 行點(diǎn)狀皮片移植治療。①供皮區(qū):確定取皮部位,局部消毒和麻醉后,在供皮區(qū)涂抹適量醫(yī)用液體石蠟,使用電動(dòng)取皮刀(江蘇邁桀德醫(yī)療科技有限公司,型號(hào):MT-Q1)在自體供皮區(qū)取皮,取皮面積標(biāo)準(zhǔn):按照受皮區(qū)和供皮區(qū)1∶1~1.5標(biāo)準(zhǔn)計(jì)算取皮面積,取皮厚度標(biāo)準(zhǔn):0.3mm,皮片為半透明狀,形狀平整且皮片邊緣不卷曲。供皮區(qū)創(chuàng)面采用醫(yī)維康醫(yī)用凡士林敷料(青島中騰生物技術(shù)有限公司,規(guī)格:10cm×10cm)覆蓋,外層采用多層紗布及彈力繃帶適度加壓包扎。②受皮區(qū):在供皮區(qū)準(zhǔn)備的同時(shí),對(duì)創(chuàng)面床及其周圍15cm內(nèi)皮膚進(jìn)行消毒,并對(duì)分泌物進(jìn)行取樣,采用銳器清創(chuàng)清除創(chuàng)面床殘留壞死組織及異物,以見(jiàn)到纖維板為標(biāo)準(zhǔn),清創(chuàng)后采用生理鹽水反復(fù)沖洗創(chuàng)面,并用生理鹽水紗布濕敷,同時(shí)徹底止血,保證創(chuàng)面床無(wú)滲血后等待移植[6]。③點(diǎn)狀皮片移植:皮片取下后,將自體皮片裁剪為約0.7cm×0.3cm的長(zhǎng)方形小面積皮片,并密集平鋪放置于創(chuàng)面受皮區(qū),皮片間的放置距離<0.5cm,盡量減小皮片間的間隔,但不可重疊。移植后創(chuàng)面予醫(yī)維康醫(yī)用凡士林敷料進(jìn)行雙層平鋪覆蓋,覆蓋面積需超過(guò)創(chuàng)面外緣2cm以上,外層使用無(wú)菌紗布和繃帶進(jìn)行適度加壓包扎。植皮術(shù)2d后,予以常規(guī)換藥,頻率為1次/d。
表1 三組患者的一般資料比較
1.2.2 對(duì)照組 行點(diǎn)狀皮片移植聯(lián)合生理鹽水沖洗治療。在空白組基礎(chǔ)上,植皮術(shù)前3d,使用30℃生理鹽水對(duì)清創(chuàng)后創(chuàng)面進(jìn)行沖洗治療。沖洗裝置使用脈沖沖洗儀(濟(jì)南盈諾醫(yī)用設(shè)備有限公司,型號(hào):YNM-1),首先將沖洗液與儀器導(dǎo)管鏈接,壓力選擇高壓檔5~8磅(1磅=6895Pa),將噴槍對(duì)準(zhǔn)創(chuàng)面后,通過(guò)腳踏開(kāi)關(guān)控制出液,頻率為1次/d,時(shí)間為5min/次。植皮術(shù)2d后,使用30℃生理鹽水溶液沖洗創(chuàng)面,持續(xù)3~5d,沖洗壓力調(diào)整至低壓檔1~2磅,頻率為1次/d,時(shí)間為5min/次,拭干后包扎方法與空白組相同。植皮術(shù)3d后開(kāi)始隔日沖洗和換藥,沖洗壓力調(diào)整至中壓檔2~5磅,頻率為1次/d,時(shí)間為5min/次,沖洗后治療方法與術(shù)后3~5d時(shí)相同。
1.2.3 干預(yù)組 行點(diǎn)狀皮片移植聯(lián)合次氯酸沖洗治療。干預(yù)組創(chuàng)面沖洗液為0.01%次氯酸溶液(紐儲(chǔ)非?傷口清潔液體敷料,美國(guó)Novabay公司),其他治療方法與對(duì)照組均相同。
1.3.1 皮片成活率 移植皮片顏色粉紅或紅潤(rùn)、無(wú)卷曲和水腫判定為成活[7]。皮片成活率(%)=皮片移植術(shù)后第5天皮片成活數(shù)量/皮片移植術(shù)中移植數(shù)量×100%。
1.3.2 細(xì)菌陽(yáng)性率 采樣前使用碘伏和生理鹽水洗凈創(chuàng)面,采樣拭子輕壓創(chuàng)面后以“Z”字型法進(jìn)行標(biāo)準(zhǔn)化采樣[8]。細(xì)菌陽(yáng)性率(%)=創(chuàng)面細(xì)菌陽(yáng)性患者數(shù)/入組患者數(shù)×100%。
1.3.3 疼痛評(píng)分 采用疼痛數(shù)字評(píng)分法(numerical rating scale,NRS)對(duì)患者進(jìn)行疼痛評(píng)分,NRS使用方法由同一名國(guó)際造口治療師在患者入院后對(duì)其進(jìn)行培訓(xùn)及評(píng)估[9]。
1.3.4 創(chuàng)面愈合時(shí)間 自患者皮片移植手術(shù)到皮片全部成活并上皮化所需要的時(shí)間。皮片全部成活后評(píng)估。創(chuàng)面愈合程度及時(shí)間均由同一名國(guó)際造口治療師判定和記錄。
植皮術(shù)后5d,空白組患者的細(xì)菌培養(yǎng)陽(yáng)性率為46.43%(13例),對(duì)照組患者的細(xì)菌培養(yǎng)陽(yáng)性率為22.58%(7例),干預(yù)組患者的細(xì)菌培養(yǎng)陽(yáng)性率為10.00%(3例),干預(yù)組患者的創(chuàng)面細(xì)菌陽(yáng)性率低于對(duì)照組和空白組,差異有統(tǒng)計(jì)學(xué)意義(2=10.293,<0.05)。
植皮術(shù)后5d,干預(yù)組患者的皮片成活率明顯高于對(duì)照組和空白組,差異有統(tǒng)計(jì)學(xué)意義(<0.05);干預(yù)組患者的疼痛評(píng)分顯著低于對(duì)照組和空白組,差異有統(tǒng)計(jì)學(xué)意義(<0.05)。干預(yù)組患者的創(chuàng)面愈合時(shí)間短于對(duì)照組和空白組,差異有統(tǒng)計(jì)學(xué)意義(<0.05),見(jiàn)表2。
表2 三組患者的皮片成活率、疼痛評(píng)分和愈合時(shí)間比較()
點(diǎn)狀皮片移植主要通過(guò)密集植皮、間隙引流及有絲分裂機(jī)制達(dá)到抑制創(chuàng)面感染和促進(jìn)創(chuàng)面愈合的療效。皮片移植術(shù)后3~5d創(chuàng)面產(chǎn)生大量炎性分泌物,炎性因子爆發(fā)而引起疼痛感受,皮片也易因炎性分泌物的浸泡侵蝕而出現(xiàn)浮起、溶解和壞死脫落[10]。本研究顯示,干預(yù)組患者的皮片成活率明顯高于對(duì)照組和空白組,可能與皮片間隙引流和沖洗治療兩者間的聯(lián)合作用密切相關(guān)。點(diǎn)狀皮片移植是保持每張小皮片之間0.5cm左右間隙,引流槽之間溝壑相通,便于炎性分泌物引流。液體沖洗治療可借助溶液流動(dòng)產(chǎn)生的機(jī)械力和漂浮力清除皮片移植術(shù)后殘留的細(xì)菌和異物[11]。另外,沖洗液產(chǎn)生的適當(dāng)沖擊可形成壓力差改善局部組織的血液循環(huán),而恒溫的沖洗液可提高局部創(chuàng)面的溫度,改善患者的疼痛感受[12]。
下肢靜脈潰瘍創(chuàng)面的形成通常是由多種細(xì)菌引起的混合型感染,其可通過(guò)分泌大量胞外多糖產(chǎn)生極強(qiáng)的黏附性和定植性,大量細(xì)菌通過(guò)自身信號(hào)分子誘導(dǎo)破壞正常細(xì)胞蛋白和免疫因子,導(dǎo)致下肢靜脈潰瘍創(chuàng)面持續(xù)處于炎性反應(yīng)階段[13-14]。本研究發(fā)現(xiàn),干預(yù)組患者的細(xì)菌陽(yáng)性率明顯低于空白組和對(duì)照組,說(shuō)明點(diǎn)狀皮片移植聯(lián)合次氯酸沖洗能有效殺滅和控制創(chuàng)面細(xì)菌。一方面,清創(chuàng)術(shù)后立即進(jìn)行密集植皮可縮短創(chuàng)面裸露時(shí)間和面積,排擠細(xì)菌生長(zhǎng)繁殖的時(shí)間和空間,同時(shí)聯(lián)合沖洗治療可有效清除炎性滲出物,達(dá)到初步抗菌作用。另一方面,次氯酸可利用自身的小分子結(jié)構(gòu)及不帶電荷的特性,快速且隱蔽地進(jìn)入細(xì)菌及其外層被膜的內(nèi)部結(jié)構(gòu),破壞細(xì)菌菌體的酶系統(tǒng),達(dá)到快速殺滅和抑制細(xì)菌的作用[15]。
下肢靜脈潰瘍創(chuàng)面的治療一直都是創(chuàng)面修復(fù)領(lǐng)域的棘手問(wèn)題,加速愈合進(jìn)程是創(chuàng)面修復(fù)技術(shù)發(fā)展的主要目的。本研究表明,干預(yù)組患者的創(chuàng)面愈合時(shí)間顯著短于對(duì)照組和空白組,分析其原因:一方面,點(diǎn)狀皮片移植由于取皮僅為表皮層和極少數(shù)的真皮乳頭層,能在血液循環(huán)未建立的條件下依靠血漿滲透維持存活狀態(tài),適用于下肢靜脈潰瘍這類存在局部感染和血液循環(huán)不暢的特殊創(chuàng)面。本研究中皮片切割較小,構(gòu)建形成長(zhǎng)方形的立體幾何結(jié)構(gòu),間接擴(kuò)大皮片邊緣表皮細(xì)胞的周長(zhǎng),加快皮片擴(kuò)展進(jìn)程,加速創(chuàng)面愈合速度[16]。另一方面,次氯酸溶液可在局部創(chuàng)面營(yíng)造良好的濕性愈合環(huán)境,推進(jìn)細(xì)胞有絲分裂和膠原沉積速度,加快生長(zhǎng)因子轉(zhuǎn)化,活化新生毛細(xì)血管,促進(jìn)移植皮片生長(zhǎng)和創(chuàng)面的修復(fù)[17]。
綜上所述,通過(guò)點(diǎn)狀皮片移植聯(lián)合次氯酸沖洗治療,可有效控制創(chuàng)面炎性物質(zhì)堆積,改善局部組織血氧供應(yīng),加快組織細(xì)胞分化和表皮有絲分裂速度,提高皮片存活效果,加速創(chuàng)面愈合進(jìn)程,改善患者的疼痛感受。但本研究尚處于初始研究階段,由于人力、經(jīng)費(fèi)、時(shí)間等限制性因素影響,研究中納入的樣本量相對(duì)較少,且僅開(kāi)展單中心干預(yù)。在本研究的基礎(chǔ)上,今后應(yīng)增加樣本量,在不同級(jí)別、區(qū)域的醫(yī)院開(kāi)展研究,深入探討點(diǎn)狀皮片移植聯(lián)合次氯酸沖洗治療的最佳壓力值、瘢痕抑制效果等問(wèn)題。
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Clinical study of punctate skin grafting combined with hypochlorous acid irrigation in treatment of venous leg ulcers
HE Zhenhua, CHEN Shen, SUN Shijie, SUN Xiaofen, MAO Jiehong
1.Shaoxing University Yuanpei College, Shaoxing 312000, Zhejiang, China; 2.Chinese Medicine Nursing Center, Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, Zhejiang, China; 3.Anorectal Surgery Department, Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310005, Zhejiang, China
To investigate clinical effect of punctate skin graft combined with hypochlorous acid irrigation in treatment of venous leg ulcers.Using the purpose sampling method, 96 patients with venous leg ulcers admitted to Second Affiliated Hospital of Zhejiang Chinese Medical University from September 2021 to September 2022 were selected and divided into blank group, control group and intervention group according to the random number table method. 32 cases in each group. The blank group was treated with punctiform skin grafts after standardized wound bed preparation, and routine dressing changes were given after the operation; The control group, on the basis of blank group, was treated with normal saline irrigation at a constant temperature of 30℃ for 3 days before and 3-5 days after operation. The intervention group changed the irrigation fluid to hypochlorous acid solution. The skin survival rate, bacterial positive rate, pain score, wound healing time were compared in the 3 groups at 5 days postoperatively.On the 5th day after operation, the skin survival rate of intervention group [(86.82±2.83)%] was significantly higher than that of control group [(75.37±4.56)%] and blank group [(66.84±9.68)%], the difference was statistically significant (<0.05). The positive rates of bacteria in intervention group, control group and blank group were 10.00%, 22.58%, and 46.43%, respectively, and the difference was statistically significant (<0.05). Comparing the pain scores of the three groups of patients on the 5th day after surgery, the intervention group [(2.97±1.19) points] was significantly lower than control group [(4.26±0.10) points] and blank group [(5.42±1.14) points], the difference was statistically significant (<0.05). Compared with blank group [(33.91±3.78)d] and control group [(27.02±3.13)d] healing time, the healing time of intervention group [(16.00±2.35)d] was shorter, the difference was statistically significant (<0.05).Punctate skin grafting combined with hypochlorous acid irrigation can effectively control the local infection of the venous ulcer transplantation wound and improve blood oxygen supply. It promotes tissue differentiation and epidermal expansion, improves the survival rate of grafted skin grafts, promotes wound healing process, reduces patient pain, and has good clinical application and promotion value.
Punctate skin graft; Hypochlorous acid; Venous leg ulcers; Irrigation therapy
R63
A
10.3969/j.issn.1673-9701.2023.27.003
浙江省醫(yī)藥衛(wèi)生科技計(jì)劃項(xiàng)目(2020KY991);國(guó)家級(jí)大學(xué)生創(chuàng)新創(chuàng)業(yè)訓(xùn)練計(jì)劃項(xiàng)目(202110349009);浙江省大學(xué)生科技創(chuàng)新活動(dòng)計(jì)劃(新苗人才計(jì)劃)項(xiàng)目(2021R432031)
何振華,電子信箱:904314239@qq.com
(2022–12–10)
(2023–09–05)