本文選題：腦白質(zhì)病變 + 早產(chǎn)兒��； 參考：《南方醫(yī)科大學(xué)》2012年碩士論文

【摘要】：[背景資料] 由于產(chǎn)科技術(shù)和新生兒重癥監(jiān)護(hù)技術(shù)不斷提高,小胎齡早產(chǎn)兒成活率明顯提高,早產(chǎn)兒腦損傷發(fā)生率也隨之提高了。新生兒腦白質(zhì)損傷(white matter injury, WMI)是早產(chǎn)兒常見的腦損傷形式,嚴(yán)重者可發(fā)展為腦室周圍白質(zhì)軟化(periventricular leucumalacia, PVL)。 早產(chǎn)兒腦損傷的發(fā)生與胎齡密切相關(guān)。胎齡越小,體重越低,腦損傷發(fā)生率越高。由于胎齡小的嬰兒腦血管發(fā)育不成熟,在胎齡26～32周時(shí),其生發(fā)基質(zhì)區(qū)(好發(fā)部位)血管密度明顯高于白質(zhì)區(qū)并且面積大于白質(zhì)區(qū),而生發(fā)基質(zhì)區(qū)的血管常常為單層內(nèi)皮,缺少平滑肌中彈力纖維的支持,故對血流沖擊的抵抗力較差,易發(fā)生破裂出血。隨著胎兒發(fā)育,生發(fā)基質(zhì)區(qū)面積漸小,至36周時(shí),才幾乎完全消失。 早產(chǎn)兒好發(fā)WMI與腦缺血有關(guān),腦血管結(jié)構(gòu)發(fā)育的不成熟和腦血管自動調(diào)節(jié)功能受損是形成早產(chǎn)兒好發(fā)腦缺血的基礎(chǔ)。胎齡越小,特別是胎齡小于28周時(shí),越容易導(dǎo)致早產(chǎn)兒發(fā)生新生兒腦白質(zhì)損傷。由于胎齡小的嬰兒腦血管發(fā)育不成熟,長穿支的側(cè)支發(fā)育不全,短支較少,長短支較少匯合,致使腦室周圍成為腦血流分布最少的部位,一旦全身血壓降低,這些部位最易受缺血性損傷,從而出現(xiàn)新生兒腦白質(zhì)損傷。 大腦動脈的短穿支供血給皮層下白質(zhì),大腦動脈的長穿支供血給腦室周圍深部白質(zhì)。未成熟的早產(chǎn)兒,其腦室周圍動脈長穿支稀少,同時(shí)缺少側(cè)支循環(huán)；而皮層下的大腦動脈短穿支尚未完全成熟,因而給白質(zhì)區(qū)供血少,加重缺血引起的早產(chǎn)兒腦室周圍白質(zhì)軟化。大腦的靜脈呈扇形分布于腦室周圍白質(zhì),在腦室旁經(jīng)生發(fā)基質(zhì)區(qū)匯入終末靜脈。在靜脈壓增高時(shí),導(dǎo)致白質(zhì)區(qū)回流受阻,易發(fā)生靜脈充血、出血性梗死。特別是使用機(jī)械通氣的早產(chǎn)兒,靜脈壓增高時(shí),可出現(xiàn)明顯的腦血流調(diào)節(jié)受損,血壓降低,腦血流減少,隨后出現(xiàn)血管的末梢及周邊區(qū)域的腦白質(zhì)缺血,導(dǎo)致早產(chǎn)兒腦白質(zhì)損傷的發(fā)生。胎齡達(dá)32周以后,隨著血管發(fā)育的日趨成熟,WMI的發(fā)生率也因而降低。 因此,早產(chǎn)兒腦室周圍白質(zhì)軟化的發(fā)生與腦室周圍的血管發(fā)育情況有密切關(guān)系,胎齡越小,腦室周圍的血管發(fā)育越不成熟,發(fā)生早產(chǎn)兒腦室周圍白質(zhì)軟化的可能性也越大。 在早產(chǎn)兒的腦白質(zhì)中存在3種類型的少突膠質(zhì)細(xì)胞,分別為少突膠質(zhì)細(xì)胞前體、不成熟少突膠質(zhì)細(xì)胞以及成熟少突膠質(zhì)細(xì)胞,后者主要構(gòu)成髓鞘。在早產(chǎn)兒,特別是32周以前,腦白質(zhì)中絕大部分為分化十分活躍的少突膠質(zhì)細(xì)胞前體,而少突膠質(zhì)細(xì)胞前體是早產(chǎn)兒腦室周圍白質(zhì)軟化病變中十分關(guān)鍵的靶細(xì)胞。少突膠質(zhì)細(xì)胞前體易于受到缺血、缺氧、感染等因素的損傷,進(jìn)而使腦組織受損。少突膠質(zhì)細(xì)胞前體的損傷將使腦白質(zhì)的髓鞘化受損,其后遺病理改變是缺乏髓鞘化,腦白質(zhì)量的減少和腦室的增大,這是窒息早產(chǎn)兒好發(fā)早產(chǎn)兒腦室周圍白質(zhì)軟化主要因素。研究發(fā)現(xiàn)圍產(chǎn)期的缺氧缺血性腦損傷還可引起神經(jīng)節(jié)苷脂水平下降,神經(jīng)節(jié)苷脂下降的程度與腦損傷程度相關(guān)。 WMI常見受損部位為側(cè)腦室前角附近、半卵圓中心區(qū)域及側(cè)腦室后角三角區(qū)附近,這些部位的腦白質(zhì)呈彌漫性損傷。 國內(nèi)外對于早產(chǎn)兒腦白質(zhì)損傷還沒有明確的治療手段�；純旱念A(yù)后往往與早期診斷和干預(yù)相關(guān)。但是在臨床上,腦白質(zhì)損傷早產(chǎn)兒往往缺乏明顯的特異性神經(jīng)系統(tǒng)癥狀和體征,根據(jù)臨床表現(xiàn)很難早期診斷。顱腦超聲檢查操作簡單,無需搬動患兒,并能連續(xù)監(jiān)測新生兒病情變化,可成為早產(chǎn)兒腦損傷早期診斷、判斷其嚴(yán)重程度及估計(jì)預(yù)后的有效手段。白介素-6(interleukin-6, IL-6)是一種炎癥調(diào)節(jié)和免疫反應(yīng)有關(guān)的多功能細(xì)胞因子,它主要由單核細(xì)胞、B細(xì)胞、T細(xì)胞、成纖維細(xì)胞和內(nèi)皮細(xì)胞產(chǎn)生。在腦組織內(nèi)主要由星形膠質(zhì)細(xì)胞和小膠質(zhì)細(xì)胞產(chǎn)生。神經(jīng)元特異性烯醇化酶(neuron specific enolase, NSE)是腦損傷的敏感性和特異性指標(biāo),它能反映腦損傷的嚴(yán)重程度,并且隨腦損傷程度加重而升高。本研究通過檢測腦白質(zhì)損傷早產(chǎn)兒顱腦超聲變化情況以及血清IL-6、NSE的變化水平,以探討它們對早產(chǎn)兒腦白質(zhì)損傷早期診斷的實(shí)用意義和應(yīng)用前景。 目前,藥物治療腦白質(zhì)損傷的效果尚處于探索階段。而單唾液酸四己糖神經(jīng)節(jié)苷脂(monosialoteterahexosyl ganglioside, GM-1)是神經(jīng)節(jié)系列神經(jīng)節(jié)苷脂之一,在神經(jīng)發(fā)生、生長及分化中起必不可少的作用。它能增加受損腦組織血流量,促進(jìn)軸突生長,提高神經(jīng)細(xì)胞存活率,調(diào)節(jié)突觸間的信號傳導(dǎo),改善神經(jīng)傳導(dǎo)速度,促進(jìn)腦電活動的恢復(fù),從而減低腦損傷后的繼發(fā)性神經(jīng)毒性,增強(qiáng)神經(jīng)營養(yǎng)活性,加強(qiáng)神經(jīng)重構(gòu),促進(jìn)腦損傷后的恢復(fù),從而達(dá)到治療目的。本研究通過在常規(guī)治療基礎(chǔ)上對腦白質(zhì)病變早產(chǎn)兒應(yīng)用GM-1治療,并豁測血清IL-6、NSE及用顱腦超聲觀察腦室周圍白質(zhì),探討GM-1療效。 [目的] 1.了解血清白細(xì)胞介素-6(IL-6)及神經(jīng)元特異性烯醇化酶(NSE)的變化對早產(chǎn)兒腦白質(zhì)損傷早期診斷的價(jià)值； 2.探討顱腦超聲對早產(chǎn)兒腦白質(zhì)損傷早期診斷和預(yù)后判斷的價(jià)值； 3.探討GM-1對早產(chǎn)兒腦白質(zhì)損傷的治療效果。 [方法] 1.分組方法： 1.1.臨床資料：我院新生兒科2011年1月至2011年10月收治住院的早產(chǎn)兒,共109例,男57名,女52名,胎齡30～37周,體重850-2600g。4例未能完成治療。最后完成實(shí)驗(yàn)共105名,男54名,女51名。 1.2.分組： 1.2.1分組方法：將胎齡小于37周的早產(chǎn)兒進(jìn)行顱腦MRI檢查,未發(fā)現(xiàn)腦白質(zhì)損傷的早產(chǎn)兒獨(dú)自納入對照組；發(fā)現(xiàn)腦白質(zhì)損傷的早產(chǎn)兒采用隨機(jī)化方法(隨機(jī)數(shù)字表)隨機(jī)分為了觀察組和干預(yù)組。 1.2.2對照組35例,胎齡小于37周,顱腦MRI未發(fā)現(xiàn)腦白質(zhì)損傷的患兒排除感染性疾病及神經(jīng)系統(tǒng)發(fā)育異常者。 1.2.3觀察組35例,胎齡小于37周,顱腦MRI發(fā)現(xiàn)腦白質(zhì)損傷的患兒(顱腦超聲灰度值增高)。排除感染性疾病及神經(jīng)系統(tǒng)發(fā)育異常者。 1.2.4干預(yù)組35例,胎齡小于37周,顱腦MRI發(fā)現(xiàn)腦白質(zhì)損傷的患兒(顱腦超聲灰度值增高)。排除感染性疾病及神經(jīng)系統(tǒng)發(fā)育異常者。三組早產(chǎn)兒在樣本量、日齡、胎齡、分娩方式、出生體重和性別組成上均無統(tǒng)計(jì)學(xué)差異(P0.01)。 2.治療方法 2.1基礎(chǔ)治療： 2.1.1精心護(hù)理： ①合理給氧；②保暖；③科學(xué)喂養(yǎng)；④嚴(yán)密監(jiān)測病情。 2.1.2三支持療法： ①維持良好的通氣、換氣功能,使血?dú)夂蚉H值保持在正常范圍；②維持外周和各臟器足夠的血液灌流,使心率和血壓保持在正常范圍；③維持血糖在正常高值(5.0mmol/L),以保證神經(jīng)細(xì)胞代謝所需。 2.1.3三對癥處理： ①控制驚厥；②降低顱內(nèi)壓；③消除腦干癥狀。 2.2干預(yù)方式 對照組不給予相關(guān)治療 觀察組給予基礎(chǔ)治療 干預(yù)組(GM-1治療組)：在基礎(chǔ)治療基礎(chǔ)上,第一天起靜脈給予GM-1(施捷因,阿根廷TRB藥廠生產(chǎn),規(guī)格20mg/2m1)20mg加入50g/L葡萄糖溶液20mL靜脈滴注,1次/d,14天為1個(gè)療程。 3.觀察方法 3.1標(biāo)本采集：將三組早產(chǎn)兒分別于生后第1、7、14天早晨,由專人分別取股靜脈血2ml,室溫下放置1h,常溫2000r/min離心10min后分離血清,-80℃冷凍保存待測。 3.2標(biāo)本檢測：IL-6和NSE的試劑盒由美國ADL公司生產(chǎn)。用多功能免疫熒光分析系統(tǒng)分析；均采用雙抗體夾心ELISA法測定,操作嚴(yán)格按說明書進(jìn)行。 3.3顱腦超聲：應(yīng)用GE VOLUSON730EXPERT超聲檢測儀。采用顱腦超聲參數(shù)條件相同(扇形小突陣掃描探頭頻率為5-9mHz),兩組患兒在生后1天、7天、14天進(jìn)行檢查,取矢狀面掃描的側(cè)腦室中央部-后角層面圖像,白質(zhì)回聲異常者視為異常。 4.統(tǒng)計(jì)學(xué)方法 采用SPSS19.0統(tǒng)計(jì)軟件包建立數(shù)據(jù)庫。三組比較采用單向方差分析,方差不齊時(shí),采用Welch法；兩兩比較采用LSD法,方差不齊時(shí)采用Dunnett T3法。以α=0.01作為檢驗(yàn)水準(zhǔn),P0.01差異有統(tǒng)計(jì)學(xué)意義。 4例患兒因放棄治療失訪,未能完成試驗(yàn),直接剔除。 [結(jié)果] 1.基線資料：納入的早產(chǎn)兒在日齡、胎齡、分娩方式、體重和性別組成上差異均無統(tǒng)計(jì)學(xué)意義(P0.01)。 2.觀察組及干預(yù)組生后第1天、7天及14天血清IL-6和NSE水平顯著高于對照組,顱腦超聲灰度顯著高于對照組。差異均有統(tǒng)計(jì)學(xué)意義；(P0.01) 3.經(jīng)治療,干預(yù)組生后第7天、第14天,血清NSE、IL-6水平均顯著低于觀察組,顱腦超聲灰度顯著低于觀察組。差異均有統(tǒng)計(jì)學(xué)意義。(P0.01)。 [結(jié)論] 1.腦白質(zhì)損傷早產(chǎn)兒血清IL-6和NSE的濃度明顯高于對照組。監(jiān)測早產(chǎn)兒血清中IL-6和NSE的水平,對腦白質(zhì)損傷的診斷和治療效果的評價(jià)具有一定的臨床價(jià)值。 2.顱腦超聲可作為早產(chǎn)兒腦白質(zhì)損傷早期診斷和預(yù)后評估有力的依據(jù)。 3.GM-1治療早產(chǎn)兒腦白質(zhì)病變有腦神經(jīng)保護(hù)作用。
[Abstract]:[background information]
Due to the continuous improvement of obstetric techniques and neonatal intensive care technology, the survival rate of premature infants in small fetal age is obviously improved, and the incidence of brain injury in premature infants is also increased. White matter injury (WMI) is a common form of brain injury in premature infants, and the serious persons can develop into periventricular softening (periventricular Leu). Cumalacia, PVL).
The occurrence of brain injury in premature infants is closely related to the gestational age. The smaller the gestational age, the lower the body weight, the higher the incidence of brain damage. The vascular density in the germinal matrix area is obviously higher than the white matter area and the area is larger than the white matter area at the age of 26~32 gestational age. For the monolayer endothelium, the support of the elastic fibers in the smooth muscle is lacking, so the resistance to the impact of blood flow is poor, and it is prone to rupture and bleeding. With the development of the fetus, the area of the germinal matrix area is gradually smaller and almost completely disappeared at 36 weeks.
Premature infants' good hair WMI is associated with cerebral ischemia, immature cerebral vascular structure development and impaired cerebral vascular automatic regulation are the basis for forming preterm infants with good cerebral ischemia. The smaller the gestational age, especially when the gestational age is less than 28 weeks, the more prone to premature infants' brain white matter injury. The lateral branch of the perforator is not fully developed, the short branch is less, the long short branch is less confluence, and the cerebral blood flow distribution is the least part around the ventricle. Once the whole body blood pressure is reduced, these parts are most vulnerable to ischemic injury, thus the white matter injury of the newborn brain appears.
The short perforator of the cerebral artery supplies the subcortical white matter, and the long perforator of the cerebral artery supplies the deep white matter around the ventricle. The immature premature infant is rare and lacks collateral circulation in the periventricular artery, while the short perforating branch of the subcortical cerebral artery is not fully mature, thus giving less blood to the white matter area and aggravating the ischemia. The cerebral veins are softening around the ventricles of the brain in preterm infants. The veins of the brain are fan-shaped in the white matter around the ventricle and enter the terminal vein near the ventricle. When the venous pressure increases, the white matter reflux is obstructed and the venous congestion and hemorrhagic infarction are easy to occur. The cerebral blood flow regulation was impaired, blood pressure decreased, cerebral blood flow decreased, and cerebral white matter ischemia occurred in the end of the blood vessels and the peripheral region of the brain, which resulted in the occurrence of white matter injury in premature infants. After 32 weeks of fetal age, the incidence of WMI was reduced as the development of blood vessels matured.
Therefore, the occurrence of periventricular softening in preterm infants is closely related to the development of blood vessels around the ventricle. The smaller the gestational age, the less mature the vascular development around the ventricle is, the greater the possibility of the occurrence of periventricular softening in preterm infants.
There are 3 types of oligodendrocytes in the white matter of preterm infants, which are oligodendrocyte precursors, immature oligodendrocytes and mature oligodendrocytes, and the latter mainly form myelin sheath. In preterm infants, especially before 32 weeks, most of the white matter in the brain is a very active oligodendrocyte precursor and oligodendrocyte. The precursor of the glial cell is the key target cell in the periventricular softening of preterm infants. The precursor of oligodendrocyte is vulnerable to ischemia, hypoxia, infection and so on, and then the brain tissue is damaged. The injury of the precursor of oligodendrocytes will damage the myelination of the white matter, and the pathological changes are the lack of myelination and brain. The decrease of white mass and the enlargement of the ventricle are the main factors in the periventricular softening in preterm premature infants with asphyxia. The study found that hypoxic-ischemic brain injury in perinatal period can also cause the decline of ganglioside, and the degree of ganglioside decline is related to the degree of brain damage.
WMI is commonly seen in the vicinity of the anterior horn of the lateral ventricle, near the central area of the oval circle and the trigone of the posterior horn of the lateral ventricle.
There is no clear treatment for premature brain white matter injury at home and abroad. The prognosis of children is often associated with early diagnosis and intervention. But in clinical, premature infants with brain white matter injury often lack obvious specific nervous system symptoms and signs. Early diagnosis is difficult according to clinical manifestations. Craniocerebral ultrasound examination is simple and no need. Moving children, and continuous monitoring of the changes in the condition of the newborn, can be an effective means for early diagnosis of premature brain injury, to judge the severity and to estimate the prognosis. Interleukin -6 (interleukin-6, IL-6) is a multifunctional cytokine associated with inflammatory regulation and immune response. It is mainly composed of monocytes, B cells, T cells, and fibroblasts. Cells and endothelial cells are produced. In brain tissue, it is mainly produced by astrocytes and microglia. Neuron specific enolase (NSE) is a sensitive and specific index of brain damage. It can reflect the severity of brain damage and increase with the degree of brain damage. This study was conducted by detecting brain white. The changes of craniocerebral ultrasound and the level of serum IL-6 and NSE in premature infants with qualitative injury are discussed in order to explore their practical significance and application prospects for early diagnosis of brain white matter injury in premature infants.
At present, the effect of drug treatment for brain white matter damage is still at the exploratory stage. Monalosialic acid four hexose Ganglioside (Monosialoteterahexosyl ganglioside, GM-1) is one of ganglioside gangliosides, which is essential for neurogenesis, growth and differentiation. It can increase the blood flow of damaged brain tissue and promote axonal birth. Long, improving the survival rate of nerve cells, regulating the signal conduction between synapses, improving the speed of nerve conduction, promoting the recovery of brain electrical activity, reducing secondary neurotoxicity after brain injury, enhancing neurotrophic activity, strengthening nerve remodeling and promoting recovery of brain injury, thus achieving the purpose of treatment. This study is based on the routine treatment basis. GM-1 was applied to preterm infants with white matter lesions, and serum IL-6 and NSE were measured, and periventricular white matter was observed by cranial ultrasound. The efficacy of GM-1 was evaluated.
[Objective]
1. to understand the value of serum interleukin -6 (IL-6) and neuron specific enolase (NSE) changes in early diagnosis of white matter damage in preterm infants.
2. to explore the value of cranial ultrasound in early diagnosis and prognosis of white matter damage in premature infants.
3. to explore the therapeutic effect of GM-1 on white matter damage in premature infants.
[method]
The 1. grouping method:
1.1. clinical data: a total of 109 preterm infants were admitted to the hospital from January 2011 to October 2011 in our hospital. A total of 109 cases, 57 men, 52 women, 30~37 weeks of gestational age, and a body weight 850-2600g.4 failed to complete the treatment. Finally, 105 men were completed, 54 men and 51 women.
1.2. grouping:
1.2.1 grouping method: preterm infants whose gestational age was less than 37 weeks were examined by MRI, and the premature infants who had not found white matter injury were included in the control group alone. The early infants with brain white matter injury were randomly divided into the observation group and the intervention group by randomization (random number table).
In the 1.2.2 control group, 35 cases, with a gestational age of less than 37 weeks, were excluded from the MRI.
1.2.3 observation group 35 cases, fetal age less than 37 weeks, craniocerebral MRI found brain white matter injury in children (higher craniocerebral ultrasound grayscale value). Exclude infectious diseases and nervous system dysplasia.
1.2.4 intervention group 35 cases, fetal age less than 37 weeks, brain MRI detection of brain white matter injury (craniocerebral ultrasound gray value increased). Excluding infectious diseases and nervous system dysplasia. Three groups of premature infants in the sample size, age, gestational age, delivery mode, birth weight and gender groups have no statistical difference (P0.01).
2. treatment methods
2.1 basic treatment:
2.1.1 meticulous care:
(1) reasonable oxygen supply; (2) keep warm; (3) scientific feeding; (4) closely monitor the condition.
2.1.2 three support therapy:
(1) maintain good ventilation, ventilation function, keep blood gas and pH in normal range; maintain adequate blood perfusion in peripheral and viscera, keep heart rate and blood pressure in normal range; maintain blood glucose at normal high (5.0mmol/L), in order to guarantee the metabolism of nerve cells.
2.1.3 three symptomatic treatment:
(1) controlling convulsion; (2) reducing intracranial pressure; (3) eliminating brainstem symptoms.
2.2 mode of intervention
No related treatment was given to the control group
The observation group was given basic treatment
Intervention group (GM-1 treatment group): on the basis of basic treatment, GM-1 (Shi Jie, Argentina TRB pharmacy production, specification 20mg/2m1) 20mg was added to 50g/L glucose solution 20mL intravenous drip on the first day, and the 1 /d and 14 days were 1 courses.
3. observation method
3.1 collection of specimens: the three groups of preterm infants were taken on the morning of 1,7,14 day after birth. The femoral vein blood was taken by the special people respectively, 2ml was placed at room temperature, 1H was placed at room temperature, 2000r/min centrifuged at normal temperature after 10min, and -80 C was frozen to be measured.
3.2 specimen detection: the IL-6 and NSE kits were produced by ADL company in the United States. The multi function immunofluorescence analysis system was used. Both the double antibody sandwich ELISA method was used and the operation was carried out strictly according to the instructions.
3.3 craniocerebral ultrasound: the GE VOLUSON730EXPERT ultrasonic detector was used. The parameters of the craniocerebral ultrasound were the same (the frequency of the scanners of the scalloped array of scans were 5-9mHz). The two groups were examined at 1 days, 7 days and 14 days after birth. The images of the central part of the lateral ventricle of the lateral ventricle were taken in the sagittal plane, and the abnormal white matter echoes were regarded as abnormal.
4. statistical method
SPSS19.0 statistical software package was used to set up a database. The three groups were compared with one-way ANOVA, when the variance was not homogeneous, Welch was used, and 22 was compared with LSD, and Dunnett T3 was used when the variance was not homogeneous. The difference of P0.01 was statistically significant by using alpha =0.01 as a test level.
4 children failed to complete the test because of abandoning treatment.
[results]
1. baseline information: there was no significant difference in age, gestational age, mode of delivery, body weight and sex composition between premature infants (P0.01).
2. the level of serum IL-6 and NSE in the observation group and the intervention group was significantly higher than that of the control group at the first day after birth, 7 and 14 days, and the gray level of the brain was significantly higher than that of the control group. (P0.01)
3. after treatment, the average serum NSE and IL-6 water in the intervention group were significantly lower than that in the observation group at seventh days after birth and fourteenth days. The gray level of the brain was significantly lower than that in the observation group. (P0.01).
[Conclusion]
The concentration of serum IL-6 and NSE in premature infants with 1. brain white matter injury is significantly higher than that of the control group. It is of certain clinical value to monitor the level of IL-6 and NSE in the serum of preterm infants and to evaluate the diagnosis and treatment effect of brain white matter injury.
2. craniocerebral ultrasound can be used as a powerful basis for early diagnosis and prognosis evaluation of white matter damage in preterm infants.
3.GM-1 has protective effects on cerebral white matter in preterm infants.

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2012
【分類號】：R722.6

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