本文選題：阻塞性睡眠呼吸暫停 + 問卷調(diào)查　； 參考：《山東大學(xué)》2012年博士論文

【摘要】：研究背景 阻塞性睡眠呼吸暫停低通氣綜合征(obstructive sleep apnea—hypopnea syndrome,OSAHS,)是指由于患者睡眠時上氣道完全或部分阻塞,或伴有呼吸中樞驅(qū)動降低,從而導(dǎo)致呼吸暫停,出現(xiàn)夜間反復(fù)慢性間歇性低氧、二氧化碳潴留、反復(fù)微覺醒及睡眠結(jié)構(gòu)異常的一種疾病。由于患者夜間間歇缺氧及二氧化碳潴留引發(fā)全身應(yīng)激反應(yīng),可引發(fā)多臟器功能損害,患者可伴發(fā)高血壓、冠心病、心律失常、心力衰竭、腦卒中、糖尿病及胰島素抵抗等嚴重危及人群健康的一系列疾病,并且成為多種全身性疾病的獨立危險因素。同時由于夜間反復(fù)微覺醒、睡眠中斷及睡眠結(jié)構(gòu)紊亂,導(dǎo)致白天嗜睡,患者工傷意外及交通事故發(fā)生率明顯增加。因此,OSAHS已經(jīng)成為嚴重影響人們生活質(zhì)量和健康壽命的全身性疾病[1,2,3,4,5]。 20世紀50、60年代以來,美國及歐洲西方國家開始了該疾病的臨床及基礎(chǔ)研究,隨著對疾病發(fā)病機理的逐步認識及臨床流行病學(xué)資料的調(diào)查,OSAHS作為發(fā)病率較高的全身性疾病越來越受到關(guān)注。1979年,美國睡眠協(xié)會聯(lián)合會對睡眠疾病進行分類,將睡眠呼吸暫停綜合癥分為阻塞性、中樞性及混合性三類。1994年,美國睡眠障礙協(xié)會聯(lián)合會明確將睡眠呼吸暫停綜合癥納入睡眠障礙疾病之一。1996年,睡眠醫(yī)學(xué)作為醫(yī)學(xué)的一個學(xué)科分支被美國醫(yī)學(xué)會認定,1999年美國睡眠醫(yī)學(xué)科學(xué)院(American Academy of Sleep Medicine, AASM)成立并且代替了了睡眠障礙協(xié)會聯(lián)合會,AASM成立后制定并且修訂了關(guān)于OSAHS診斷及治療的臨床指南,這些指南的制定對于該疾病的治療起到了規(guī)范指導(dǎo)及規(guī)避風(fēng)險的作用。手術(shù)作為OSAHS的一個重要的外科治療手段,于70年代早期開始嘗試氣管切開和扁桃體摘除,1982年Fujita首先以懸雍垂腭咽成形術(shù)(uvulopalatopharyngoplasty, UPPP)治療OSAHS,適用于口咽部軟組織堵塞為主造成的氣道狹窄。1997年以來UPPP術(shù)式開始改良,即保留了懸雍垂的生理功能,有效地減少了術(shù)后并發(fā)癥并提高了手術(shù)療效。據(jù)報道UPPP的近期有效率在50%-60%,遠期有效率低于近期。開展UPPP及不同層面的手術(shù)治療手段以來,圍術(shù)期的并發(fā)癥尤其是急性呼吸道梗阻導(dǎo)致死亡的報道引起了人們的重視。美國麻醉醫(yī)師協(xié)會(the American Society of Anesthesiologists, ASA)于2006年制定了關(guān)于OSAHS麻醉的臨床指南,著重于OSAHS病人圍術(shù)期困難呼吸道的管理。 我們國家于80年代初陸續(xù)有關(guān)于OSAHS的個案報道,之后有關(guān)的臨床研究逐年增多。1987年北京協(xié)和醫(yī)院黃席珍教授成立了我國第一個睡眠醫(yī)學(xué)實驗室。隨著對OSAHS認識的不斷深入,我國睡眠實驗室在一些醫(yī)院陸續(xù)建立,近十幾年來睡眠實驗室相對普及,能夠開展OSAHS的睡眠監(jiān)測及診斷工作。從事OSAHS的臨床科室涉及呼吸科、耳鼻咽喉科、口腔科等多個學(xué)科,OSAHS作為一涉及多學(xué)科的危害全身多系統(tǒng)的重要疾病逐漸被認識,并引起了醫(yī)學(xué)界的關(guān)注。然而,在我們國家各學(xué)科對于OSAHS的認識是不均衡的,缺乏對OSAHS疾病全身性疾病的總體認識,鐘南山呼吁深入開展睡眠呼吸暫停的研究與多學(xué)科間的有效協(xié)作。 隨著我國對OSAHS疾病治療干預(yù)的開展,需要以UPPP手術(shù)為主多層面手術(shù)治療的病人逐年增多,圍術(shù)期患者死亡的報道再次引起了我國的關(guān)注,國內(nèi)多篇文獻報道了OSAHS患者圍術(shù)期死亡的回顧性分析,氣管插管失敗導(dǎo)致的急性呼吸道梗阻是患者圍術(shù)期死亡的首要原因。而且文獻報道,OSAHS術(shù)后出血及心臟、呼吸系統(tǒng)并發(fā)癥的發(fā)生與全身麻醉困難氣管插管有關(guān)。遺憾的是,回顧性分析OSAHS圍術(shù)期嚴重并發(fā)癥及死亡并發(fā)癥發(fā)生的文獻幾乎均來自耳鼻咽喉科醫(yī)生的報道,氣管插管失敗導(dǎo)致的麻醉相關(guān)并發(fā)癥并未引起麻醉醫(yī)生的足夠警惕。這與目前我門國家能開展OSAHS疾病診斷與手術(shù)治療的醫(yī)療機構(gòu)分布局限有關(guān),但同時也反映了我國麻醉醫(yī)生對于OSAHS疾病的認識不足,關(guān)于OSAHS疾病導(dǎo)致困難呼吸道發(fā)生的知識缺失。 Schotland于2003年設(shè)計制定了OSAHS知識及態(tài)度的調(diào)查問卷(the obstructive sleep apnea knowledge and attitudes questionnaire, OSAKA questionnaire),用來判斷醫(yī)生對于OSAHS疾病的認識。Southwell、Tamay及Uong EC也利用該問卷開展了對內(nèi)科醫(yī)生及兒科醫(yī)生的問卷調(diào)查及分析,對于判斷不同學(xué)科的醫(yī)生對于該疾病的了解程度、醫(yī)學(xué)生關(guān)于OSAHS疾病的學(xué)科設(shè)置及制定繼續(xù)醫(yī)學(xué)教育計劃均有借鑒指導(dǎo)價值。目前,關(guān)于我們國家臨床醫(yī)生對于OSAHS疾病認知調(diào)查的報道尚缺乏。 美國等較早開展OSAHS手術(shù)治療的國家,麻醉醫(yī)生也同時開始了關(guān)于OSAHS困難氣管插管及困難面罩通氣的研究。肥胖、OSAHS疾病嚴重程度,Mallampati口咽部暴露分級等多種因素被考慮與OSAHS病人困難氣道有關(guān),但是,不同文獻報道的觀察結(jié)果不盡相同,可以預(yù)測OSAHS病人困難氣道的危險因素仍不確定,有些報道甚至是矛盾的。國內(nèi)尚缺乏關(guān)于OSAHS病人困難氣道的臨床研究。 因此,本課題關(guān)于OSAHS疾病的研究分擬為兩部分進行。第一部分采用Schotland設(shè)計的問卷調(diào)查表,開展麻醉醫(yī)生關(guān)于OSA HS疾病知識的問卷調(diào)查,并且參照美國ASA制定的OSAHS臨床麻醉指南,補充了有關(guān)OSAHS麻醉管理知識的問題選項,以此判斷麻醉醫(yī)生對于OSAHS疾病的認知,期望引起麻醉醫(yī)生對OSAHS疾病的重視,加強麻醉醫(yī)生關(guān)于OSAHS的繼續(xù)學(xué)習(xí),減少或者避免由于麻醉醫(yī)生OSAHS知識缺陷引起的OSAHS病人呼吸道梗阻急癥事件的發(fā)生。 第二部分,我們參照美國麻醉醫(yī)師協(xié)會及我國麻醉學(xué)會制定的困難氣道處理指南,結(jié)合OSAHS病人肥胖、舌體肥大、頸粗短等特點,觀察并記錄OSAHS病人體重指數(shù)、頸圍、腰圍,頦甲距離,Mallampati咽部暴露分級,直接喉鏡清醒局部粘膜表面麻醉下Cormack and Lehane's聲門分級等與氣道管理有關(guān)的指標,采用篩選流行病學(xué)危險因素廣為采用的方法建立Logisogistic回歸模型,從眾多混雜因素中分析OSAHS病人困難面罩通氣及困難氣管插管的危險因素,從而預(yù)見性地避免OSAHS病人因困難面罩控制通氣及困難氣管導(dǎo)致的急性呼吸道梗阻的發(fā)生,減少OSAHS病人圍術(shù)期死亡及麻醉相關(guān)并發(fā)癥的發(fā)生。 目的采用Schotland HM設(shè)計的阻塞性睡眠呼吸暫停知識和態(tài)度(the obstructive sleep apnea knowledge and attitudes questionnaire)問卷調(diào)查,了解麻醉醫(yī)生關(guān)于OSA疾病知識的掌握及關(guān)注態(tài)度,判斷麻醉醫(yī)生關(guān)于OSAHS疾病的認知狀況,了解麻醉醫(yī)生OSAHS疾病繼續(xù)學(xué)習(xí)的必要性。 方法取得Schotland HM授權(quán),OSAKA問卷被翻譯為中文,每份問卷放在張貼郵票的信封內(nèi)方便調(diào)查者寄回,400份OSAKA調(diào)查問卷發(fā)放至山東省20余家地市級及省級醫(yī)院的麻醉醫(yī)生。問卷分為兩部分,第一部分為關(guān)于OSAHS知識的問題,涉及5個方面共18個條目,包括OSAHS流行病學(xué)知識,發(fā)病機理,臨床癥狀,診斷和治療等知識點。第二部分為管理OSAHS病人自信程度的判斷,從不重要(或非常不自信)至非常重要(或非常自信)分為5個等級。18個知識點的問題每題正確回答記1分,回答錯誤記0分,計算問題正確回答的百分率。態(tài)度5個等級依次記為1-5分,記錄醫(yī)生關(guān)于OSAHS知識及管理OSAHS病人態(tài)度自信程度的分值,并進一步分析麻醉醫(yī)生知識掌握及管理OSAHS病人自信程度的關(guān)系。 結(jié)果321份有效問卷收回,18條關(guān)于OSAHS疾病的知識點每題1分,正確回答的分值為11.21±2.89,所有問題回答正確的平均值為62%。關(guān)于OSAHS疾病發(fā)病機理的知識點回答的正確率最高為86%,有關(guān)OSAHS疾病治療的知識點回答的正確率最低33%。對于OSAHS病人的判定、麻醉管理及術(shù)后管理有信心的概率分別為51.71%,66.36%,55.46%。麻醉醫(yī)生的知識和麻醉醫(yī)生對于OSAHS疾病的自信態(tài)度呈正相關(guān)。麻醉醫(yī)生性別、年齡、受教育程度,工作所在醫(yī)院的級別與問卷知識的分值無關(guān)。 結(jié)論麻醉醫(yī)生對于OSAHS疾病的有關(guān)知識缺乏；對于OSAHS疾病的認知程度較低；對OSAHS病人的麻醉管理自信心較低；有必要進行關(guān)于OSAHS疾病的繼續(xù)學(xué)習(xí)。 目的通過臨床資料調(diào)查分析,篩選阻塞性睡眠呼吸暫停患者困難面罩通氣及困難氣管插管發(fā)生的危險因素,從而能預(yù)見性地減少阻塞性睡眠呼吸暫停病人困難氣道的發(fā)生。 方法120例阻塞性睡眠呼吸暫停病人經(jīng)多導(dǎo)睡眠監(jiān)測儀監(jiān)測確認。非熟悉課題設(shè)計的特定麻醉住院醫(yī)生測量并記錄所有的觀察指標,包括年齡,體重指數(shù)(body mass index, BMI),病人呼吸暫停低通氣指數(shù)(apnea-hypopnea index, AHI),最低血氧飽和度(the lowest oxygen saturation, LSaO2),最長呼吸暫停時間(the longest sleep apnea time, LSAT),頸圍(neck circumference, NC),腰圍(waist circumference, WC),頦甲距離(thyromental distance, TMD),上下切牙間距離(interincisor distance, ICD),下頜骨水平長度(horizontal length of the mandible, HLM), Mallampati分級及Cormack and Lehane's喉頭分級,根據(jù)logistic回歸模型,分析困難面罩通氣及困難氣管插管的危險因素。 結(jié)果阻塞性睡眠呼吸暫停病人的平均年齡39.98歲,體重指數(shù)的平均值為29.45kg/m2,頸圍和腰圍的平均值分別為100.5cm、42.08cm。困難面罩通氣發(fā)生的概率為41.7%,困難氣管插管發(fā)生的百分比為25.8%。困難面罩通氣的危險因素為病人的頸圍(OR=1.857)及口咽Mallampati分級(0R=12.508)兩個指標,困難氣管插管的危險因素為病人Cormack and Lehane's喉頭分級(OR=7.799),疾病嚴重程度判斷的指標AHI(OR=1.045),以及病人上下切牙間距離(OR=0.090)。 結(jié)論阻塞性睡眠呼吸暫停病人中肥胖尤其是中心性肥胖普遍存在。困難面罩通氣及困難氣管插管的比例較高,Mallampati口咽暴露分級及Cormack and Lehane's聲門分級是判斷阻塞性睡眠呼吸暫停病人困難氣道的兩重要危險因素,頸圍的測量對于困難通氣有預(yù)測價值,體重指數(shù)及腰圍作為判斷肥胖的指標與困難通氣有關(guān),AHI、病人上下切牙間距離對于困難氣管插管有預(yù)測價值。
[Abstract]:Research background
Obstructive sleep apnea hypopnea syndrome (obstructive sleep apnea - hypopnea syndrome, OSAHS) is caused by a complete or partial obstruction of the upper airway in the patient's sleep, or a decrease in the drive of the respiratory center, resulting in apnea, recurrent nocturnal intermittent hypoxia, retention of carbon dioxide, repeated micro arousal and sleep. A disease of abnormal structure. It can cause multiple organ dysfunction due to intermittent hypoxia and retention of carbon dioxide, which can cause multiple organ dysfunction. Patients can be accompanied by high blood pressure, coronary heart disease, arrhythmia, heart failure, stroke, diabetes and insulin resistance, which seriously threaten the health of the population, and become a variety of diseases. OSAHS has become a systemic disease [1,2,3,4,5]. that seriously affects the quality of life and life of the people.
Since the twentieth Century 50,60 years, the United States and Western European countries have begun the clinical and basic research of the disease. With the gradual understanding of the pathogenesis of the disease and the investigation of clinical epidemiological data, the OSAHS, as a systemic disease with higher incidence, has attracted more and more attention for.1979 years. The American Sleep Association Federation has carried out the sleep disease. The sleep apnea syndrome is divided into three categories of obstructive, central and mixed.1994 years. The American Association for Sleep Disorders Association explicitly incorporates sleep apnea syndrome into one of the sleep disorders.1996 years. Sleep medicine as a branch of medicine is identified by the American Medical Association and 1999 American Sleep Medicine Science. The hospital (American Academy of Sleep Medicine, AASM) established and replaced the Association for the Sleep Disorders Association. After the establishment of the AASM, a clinical guide for the diagnosis and treatment of OSAHS has been formulated and revised. The formulation of these guidelines has played a regulatory role in the treatment of the disease. The operation is an important part of the OSAHS. Surgical treatment, in the early 70s, began to try tracheotomy and tonsillectomy. In 1982, Fujita was first treated with uvulopalatopharyngoplasty (uvulopalatopharyngoplasty, UPPP) for the treatment of OSAHS. It was suitable for the airway stenosis caused by the blockage of the mouth and pharynx of the soft tissue for.1997 years to improve the UPPP operation, that is, the uvula was retained. Function, effectively reducing postoperative complications and improving the effectiveness of the operation. It is reported that the recent efficiency of UPPP is in the 50%-60%, and the long-term efficiency is lower than the near term. Since the operation of UPPP and different levels of surgical treatment, the perioperative complications, especially the report of acute respiratory obstruction, cause death and death. The the American Society of Anesthesiologists (ASA) set up a clinical guide for OSAHS anesthesia in 2006, focusing on the management of difficult respiratory tract during the perioperative period of OSAHS patients.
In the early 80s, there was a case of OSAHS in our country. After the number of clinical studies increased year by year, Professor Huang Xizhen, the Peking Union Medical College Hospital, established the first sleep medical laboratory in China. With the deepening of the understanding of OSAHS, our sleep laboratory has been established in some hospitals in recent years. The laboratory is relatively popular and can carry out OSAHS's sleep monitoring and diagnosis. The clinical departments engaged in OSAHS involve Department of respiration, otolaryngology, Department of Stomatology and other disciplines. OSAHS is gradually recognized as an important disease involving multidisciplinary systemic multisystems, and has attracted the attention of the medical community. However, in our national disciplines, The understanding of OSAHS is unbalanced and lacks general understanding of systemic disease of OSAHS disease. Zhong Nan Shan calls for the in-depth study of sleep apnea and effective collaboration between multidisciplinary.
With the intervention of the treatment of OSAHS disease in China, the number of patients requiring UPPP surgery is increasing year by year. The reports of death in the perioperative period have aroused the attention of our country again. A retrospective analysis of the perioperative death of OSAHS patients and the acute respiratory obstruction caused by the failure of tracheal intubation are reported. It is the primary cause of perioperative death in patients. Moreover, it is reported that hemorrhage and heart, respiratory complications after OSAHS operation are related to the difficult tracheal intubation of general anesthesia. Unfortunately, the review of the literature on severe complications and death complications in OSAHS perioperative period is from the report of the otorhinolaryngology, the trachea The anesthetic related complications caused by the failure of intubation did not cause enough vigilance by the anesthesiologist. This is associated with the limitations of the current distribution of OSAHS disease diagnosis and surgical treatment in our country, but it also reflects the lack of awareness of OSAHS diseases by the anesthesiologists in our country and the incidence of difficult respiratory tract caused by OSAHS disease. Lack of knowledge.
In 2003, Schotland designed a questionnaire on the knowledge and attitude of OSAHS (the obstructive sleep apnea knowledge and attitudes questionnaire, OSAKA questionnaire) to judge doctors' understanding of the disease. Examination and analysis are useful for judging the degree of understanding of the disease by doctors in different disciplines, the subject setting of OSAHS diseases and the formulation of the continuing medical education program. At present, the report of our national clinicians on the cognitive investigation of OSAHS disease is still lacking.
Anesthesiologists have also started a study of OSAHS difficult tracheal intubation and difficult mask ventilation in the United States and other countries with earlier OSAHS surgery. Obesity, OSAHS disease severity, Mallampati throat exposure classification, and other factors are considered to be related to the difficult gas path of OSAHS patients, but the observations in different literature have been observed. The risk factors for the difficult airway in OSAHS patients are still uncertain, and some reports are even contradictory. There is still a lack of clinical research on the difficult airway in OSAHS patients.
Therefore, the research on OSAHS disease is divided into two parts. The first part uses a questionnaire designed by Schotland to carry out a questionnaire on the knowledge of OSA HS disease by the anesthesiologist and to judge the questions on the management knowledge of OSAHS anesthesia with reference to the OSAHS clinical anesthesia guide made by ASA in the United States. The anesthesiologist's understanding of the OSAHS disease is expected to cause the attention of the anesthesiologist to the OSAHS disease, to strengthen the anesthesiologist's continuing study of OSAHS, to reduce or avoid the occurrence of acute respiratory obstruction in OSAHS patients due to the knowledge defect of the anesthesiologist's OSAHS.
In the second part, we observe and record the body mass index, neck circumference, waist circumference, Chin a distance, Mallampati pharynx exposure classification and direct laryngoscope lucid local mucosal surface anaesthesia, according to the characteristics of OSAHS patients, such as obesity, hypertrophy of tongue and short neck, according to the guidelines of the United States anesthesiologist and the national anesthesiology society. Cormack and Lehane's glottal classification and other indicators related to airway management, using the method of screening epidemiological risk factors to establish a Logisogistic regression model, from a number of confounding factors to analyze the risk factors of OSAHS patients' difficult mask ventilation and difficult tracheal intubation, thus foreseeable to avoid the difficulties of OSAHS patients. Mask airway control ventilation and difficult airway lead to acute respiratory obstruction, reduce perioperative mortality and anesthesia related complications in patients with OSAHS.
Objective to investigate the knowledge and attitude of obstructive sleep apnea (the obstructive sleep apnea knowledge and attitudes questionnaire) designed by Schotland HM, to understand the anesthesiologist's knowledge of OSA disease and the attitude of concern, to judge the anesthesiologist's cognitive status on the OSAHS disease and to understand the anesthesiologist's disease. The necessity of continuing to study.
Methods the Schotland HM authorization was obtained. The OSAKA questionnaire was translated into Chinese. Each questionnaire was placed in the envelopes of postage stamps and sent back to the investigators. 400 OSAKA questionnaires were sent to more than 20 local and provincial hospitals in Shandong province. The questionnaire was divided into two parts. The first part was divided into OSAHS knowledge, involving 5 aspects of 18. Items, including OSAHS epidemiological knowledge, pathogenesis, clinical symptoms, diagnosis and treatment, and other knowledge points. The second part is to manage the confidence level of OSAHS patients, never important (or very unconfident) to very important (or very confident) to be divided into 5 grades.18 knowledge points, the correct answer of each question 1 points, the answer error notes 0 points, The percentage of correct answers was calculated. 5 grades were recorded in turn as 1-5 points. The score of doctors' knowledge of OSAHS and management of attitude confidence in OSAHS patients was recorded, and the relationship between the knowledge mastery of anesthesiologists and the management of the confidence level of OSAHS patients was further analyzed.
Results 321 valid questionnaires were recovered, 18 of the knowledge points for OSAHS disease were 1 points per question, the correct answer was 11.21 + 2.89. The correct average answer of all questions was the highest of 86% for the knowledge point of the pathogenesis of OSAHS disease. The lowest correct rate of knowledge points on the treatment of OSAHS disease was 33%. to OSA The probabilities of HS patients, anesthesia management and postoperative management were 51.71%, 66.36%, and 66.36%. The knowledge of the anesthesiologist and the anesthesiologist were positively related to the confidence attitude of the OSAHS disease. The sex, age, education level of the anesthesiologist, the level of the hospital, and the level of the hospital were not related to the score of the questionnaire.
Conclusions the anesthesiologist's lack of knowledge about OSAHS disease; low awareness of OSAHS disease; low confidence in anesthesia management for OSAHS patients; it is necessary to continue learning about OSAHS disease.
Objective to screen the risk factors of difficult facial mask ventilation and difficult tracheal intubation in patients with obstructive sleep apnea, so as to reduce the incidence of difficult airway in obstructive sleep apnea patients.
Methods 120 patients with obstructive sleep apnea were monitored by polysleep monitor. The specific anesthetized inpatients designed by unfamiliar subjects measured and recorded all the observation indexes, including age, body mass index (body mass index, BMI), the patient apnea hypopnea index (apnea-hypopnea index, AHI), and the lowest oxygen saturation (T). He lowest oxygen saturation, LSaO2), the longest apnea time (the longest sleep apnea time, LSAT), neck circumference (neck), the distance between the waist and the chin, the distance between the upper and lower teeth, the horizontal length of the mandible. Ndible, HLM), Mallampati classification and Cormack and Lehane's larynx classification, according to the logistic regression model, the risk factors of difficult mask ventilation and difficult tracheal intubation were analyzed.
Results the average age of the patients with obstructive sleep apnea was 39.98 years, the average value of body mass index was 29.45kg/m2, the average value of neck circumference and waist circumference was 100.5cm, the probability of 42.08cm. difficult mask ventilation was 41.7%, and the risk factor of difficult tracheal intubation was the neck circumference of the patients with 25.8%. difficult mask ventilation (OR=1.85 7) and two indexes of oropharyngeal Mallampati classification (0R=12.508), the risk factors for difficult tracheal intubation were Cormack and Lehane's larynx (OR=7.799), AHI (OR=1.045) for judging the severity of the disease, and the distance between the upper and lower incisors (OR=0.090).
Conclusions obesity, especially central obesity, is prevalent in patients with obstructive sleep apnea. The proportion of difficult mask ventilation and difficult tracheal intubation is higher. Mallampati oropharynx exposure classification and Cormack and Lehane's glottis classification are difficult airway for obstructive sleep apnea patients.

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2012
【分類號】：R766

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