【摘要】：目的： 通過對(duì)三起放射事件中3例192Ir急性外照射、4例60Co急性外照射和4例X射線慢性外照射的病史采集、醫(yī)學(xué)處理及心理測評(píng),探討急性外照射及慢性外照射的生物學(xué)和心理學(xué)效應(yīng),為類似病例的醫(yī)學(xué)應(yīng)急救治提供資料和積累經(jīng)驗(yàn)。 方法： 1、臨床觀察：采用“一對(duì)一”和“多對(duì)一”的方式對(duì)11例受照人員采集病史,密切觀察和記錄各自的臨床表現(xiàn),重點(diǎn)觀察放射敏感組織的變化,如皮膚、胃腸道、眼晶體等。 2、輔助檢查：分別對(duì)受照人員進(jìn)行相應(yīng)的實(shí)驗(yàn)室及器械檢查,項(xiàng)目包括血細(xì)胞分析、尿糞常規(guī)、肝腎功能、精液常規(guī)、腫瘤標(biāo)志物檢測、免疫功能檢測、甲狀腺功能檢測以及彩色B超、心電圖、胸部X線檢查等。 3、劑量估算：采用外周血淋巴細(xì)胞染色體畸變分析、G顯帶分析和微核分析(CB法)估算受照者的生物劑量；采用空氣比釋動(dòng)能法及熱釋光劑量元件法估算急性外照射受照者的全身和局部吸收劑量。 4、心理測評(píng)：應(yīng)用卡特爾十六種個(gè)性因素測驗(yàn)(16PF)、抑郁自評(píng)量表(SDS)、焦慮自評(píng)量表(SAS)對(duì)受照人員治療前后的心理狀況進(jìn)行測評(píng)。 5、醫(yī)學(xué)處理：根據(jù)人員的受照情況、嚴(yán)重程度及臨床表現(xiàn),予以對(duì)癥支持治療、中醫(yī)中藥調(diào)理及心理疏導(dǎo)等綜合治療措施。 結(jié)果： 1、病史采集： 成功采集了三起放射事件中7例急性外照射人員及4例慢性外照射人員較為詳實(shí)的病史資料、受照劑量資料及心理學(xué)資料,為臨床診治奠定了基礎(chǔ)。 2、臨床觀察： (1)7例急性外照射受人員均為意外照射,均有不同程度的乏力、睡眠障礙、食欲不振等植物神經(jīng)紊亂癥狀。GSH受照后八天左手大魚際皮膚出現(xiàn)紅斑,十天后右手拇指及食指指腹、中指側(cè)面出現(xiàn)數(shù)個(gè)針尖樣紅點(diǎn)；LGG右眼晶體有一點(diǎn)狀輕度混濁,余未見明顯異常體征。 (2)4例X射線慢性外照射受照者受照時(shí)間為3-5年,三年余前出現(xiàn)乏力、睡眠障礙、月經(jīng)失調(diào)等癥狀。WY雙手當(dāng)?shù)蒯t(yī)院診斷為“雷諾征”。未見明顯異常體征。 3、輔助檢查： (1)血細(xì)胞分析7例急性外照射受照人員中SYG外周血白細(xì)胞高于正常值,余均在正常范圍內(nèi)。X射線放射事件中4例受照人員多次在當(dāng)?shù)蒯t(yī)院檢查,均發(fā)現(xiàn)白細(xì)胞低于正常值；脫離放射環(huán)境半年后,WY白細(xì)胞計(jì)數(shù)較前升高,但仍低于正常值,其余3人的白細(xì)胞計(jì)數(shù)在正常范圍內(nèi),但接近正常值下限。 (2)骨髓象分析7例急性外照射受照人員骨髓象均未見異常。X射線放射事件中DYL骨髓象分析結(jié)果示紅系增生活躍低水平,粒紅比例增高；余受照人員均未見明顯異常。 (3)免疫功能192Ir放射事件中YW、LGG受照后CD8+比率稍高于正常值,GSH、YW受照后NK細(xì)胞比率低于正常值,YW受照后B淋巴細(xì)胞比率稍高于正常值,GSH受照后IgM值略高于正常值。60Co放射事件中SYG受照后B淋巴細(xì)胞比率高于正常值,MXG受照后補(bǔ)體C3略低于正常值其他淋巴細(xì)胞比率在正常范圍內(nèi)。X射線放射事件中DYL、ZD的CD8+比率稍高于正常值,WY、DYL及ZD的NK細(xì)胞比率低于正常值,WY、LY、DYL及ZD的B淋巴細(xì)胞比率均低于正常值。余受照人員細(xì)胞免疫及體液免疫均在正常范圍內(nèi)。 (4)精液常規(guī)GSH精子活率較正常值減低,精子活力不正常。YZZ精子活率較正常值減低,精子活力正常。 (5)其它輔助檢查11例受照者肝腎功能、心電圖、胸部X線檢查、腹部彩超、尿糞常規(guī)檢查結(jié)果均未見明顯異常。192Ir放射事件中GSH泌尿系彩超示前列腺輕度增生；YW泌尿系彩超示前列腺增生。 4、劑量估算： (1)生物劑量采用外周血淋巴細(xì)胞染色體畸變、G顯帶分析及微核分析(CB法)估算生物劑量,結(jié)果均在正常范圍內(nèi),據(jù)回歸方程無法估算生物劑量。 (2)物理劑量在192Ir放射事件中,空氣比釋動(dòng)能法物理劑量估算GSH全身吸收劑量為310mGy,局部吸收劑量為8.12Gy, LGG、LW全身吸收劑量為3.1mGy o熱釋光劑量元件法估算GSH的全身吸收劑量為113.52～348.48mGy,手部吸收劑量為3.13～8.54Gy；LGG、LW的全身吸收劑量為18.72～32.76mGy。 5、心理測評(píng)： SAS測試結(jié)果提示,治療前大部分受照人員處于焦慮抑郁狀態(tài)；16PF測試結(jié)果提示,受試人員的各項(xiàng)心理學(xué)維度普遍低于普通人群均值。治療后心理狀況較前明顯好轉(zhuǎn),但仍有部分受照人員表現(xiàn)抑郁焦慮等心理變化。 6、醫(yī)學(xué)處理： 經(jīng)過對(duì)癥支持、中醫(yī)中藥調(diào)節(jié)免疫力等綜合治療措施后,受照人員的頭暈乏力等癥狀減輕。7例急性照射人員中,GSH診斷為急性放射性皮膚損傷Ⅱ度,予全身抗炎及局部維生素B12處理后好轉(zhuǎn)；余6例受照人員均診斷為過量照射。4例X射線慢性外照射受照者均診斷為觀察對(duì)象,建議脫離可疑放射性工作環(huán)境,密切觀察1年后再根據(jù)病情進(jìn)行診斷和處理。 結(jié)論： 較為系統(tǒng)地對(duì)三起放射事件中7例急性外照射和4例慢性外照射受照者進(jìn)行了病史采集、劑量估算、醫(yī)學(xué)處理和心理測評(píng),從應(yīng)急管理角度分析總結(jié)了放射事故的經(jīng)驗(yàn)教訓(xùn),為類似病例的醫(yī)學(xué)處理及隨訪提供了借鑒,為核事故醫(yī)學(xué)應(yīng)急提供了技術(shù)準(zhǔn)備。
[Abstract]:Objective:
To explore the biological and psychological effects of acute external irradiation and chronic external irradiation on 3 cases of 192Ir, 4 cases of 60Co and 4 cases of X-ray chronic external irradiation.
Method:
1. Clinical observation: 11 cases of irradiation were collected by "one-to-one" and "many-to-one" methods, and their clinical manifestations were closely observed and recorded. The changes of radiosensitive tissues, such as skin, gastrointestinal tract and lens, were observed.
2. Auxiliary examination: Respectively carry out corresponding laboratory and instrumental examination for the irradiated personnel, including blood cell analysis, routine urine and feces, liver and kidney function, routine semen, tumor markers, immune function, thyroid function, color B-ultrasound, electrocardiogram, chest X-ray examination, etc.
3. Dose estimation: The biological doses were estimated by chromosome aberration analysis, G-banding analysis and micronucleus analysis (CB method) of peripheral blood lymphocytes, and systemic and local absorbed doses were estimated by air specific kinetic energy method and thermoluminescent dose element method.
4. Psychological Assessment: Sixteen Personality Factor Test (16PF), Self-rating Depression Scale (SDS) and Self-rating Anxiety Scale (SAS) were used to assess the psychological status of the subjects before and after treatment.
5. Medical treatment: According to the illumination, severity and clinical manifestations of the staff, symptomatic support treatment, traditional Chinese medicine and psychological counseling and other comprehensive treatment measures.
Result:
1, history collection:
Seven cases of acute external radiation exposure and four cases of chronic external radiation exposure were collected successfully. The dose data and psychological data were collected, which laid a foundation for clinical diagnosis and treatment.
2, clinical observation:
(1) Seven cases of acute external irradiation were accidentally irradiated, all of them had varying degrees of fatigue, sleep disorders, loss of appetite and other symptoms of autonomic nervous disorders. No obvious abnormal signs were found.
(2) Four X-ray chronic external irradiation recipients were irradiated for 3-5 years. Three years ago, they developed symptoms such as fatigue, sleep disorders, menstrual disorders, etc. WY was diagnosed as "Reynolds'sign" in the local hospital of both hands.
3, supplementary examinations:
(1) The white blood cell count of SYG in peripheral blood of 7 cases of acute external irradiation was higher than normal, the rest were within normal range. The remaining 3 white blood cells count in normal range, but close to the normal limit.
(2) Bone marrow analysis showed no abnormality in 7 cases of acute external irradiation. DYL bone marrow analysis in X-ray irradiation showed that erythroid hyperplasia was low in activity and the ratio of granulocyte red was high.
(3) The ratio of CD8 + in YW and LGG was slightly higher than the normal value, the ratio of NK cells in GSH and YW was lower than the normal value, the ratio of B lymphocytes in YW was slightly higher than the normal value, and the ratio of B lymphocytes in GSH was slightly higher than the normal value. In X-ray irradiation events, the ratio of DYL and ZD to CD8+ was slightly higher than normal. The ratio of NK cells in WY, DYL and ZD was lower than normal. The ratio of B lymphocytes in WY, LY, DYL and ZD was lower than normal.
(4) Routine GSH sperm motility was decreased and abnormal sperm motility was observed. YZZ sperm motility was decreased and sperm motility was normal.
(5) There were no significant abnormalities in liver and kidney function, electrocardiogram, chest X-ray, abdominal color Doppler ultrasonography and routine urine and stool examination in 11 cases of other auxiliary examinations.
4, dose estimation:
(1) The biological doses were estimated by chromosome aberration, G-banding and micronucleus analysis (CB) in peripheral blood lymphocytes. The results were within the normal range, and the biological doses could not be estimated by regression equation.
(2) In the 192Ir radiation event, the total absorbed dose of GSH was 310 mGy, 8.12 Gy, LGG, and 3.1 mGy, respectively. The total absorbed dose of GSH was 113.52-348.48 mGy, and the total absorbed dose of hand was 3.13-8.54 Gy, LGG and LW respectively. The body absorbed dose was 18.72 ~ 32.76mGy.
5, psychological assessment:
The results of SAS test showed that most of the subjects were in anxiety and depression state before treatment, and the results of 16PF test showed that the psychological dimensions of the subjects were generally lower than the average of the general population.
6, medical treatment:
The symptoms of dizziness and fatigue were alleviated after symptomatic support, immunity regulation by Chinese medicine and other comprehensive treatment measures. Among the 7 cases of acute radiation exposure, GSH was diagnosed as acute radiation skin injury of degree II, which was improved after systemic anti-inflammatory treatment and local vitamin B12 treatment; the remaining 6 cases were diagnosed as excessive irradiation. All the irradiated patients were diagnosed as the objects of observation. It is suggested that they should be separated from the suspicious radioactive working environment, closely observed for one year and then diagnosed and treated according to their condition.
Conclusion:
Seven cases of acute external irradiation and four cases of chronic external irradiation were collected for medical history, dose estimation, medical treatment and psychological assessment. The experiences and lessons of radiation accidents were analyzed and summarized from the perspective of emergency management, which provided a reference for the medical treatment and follow-up of similar cases, and provided emergency medical advice for nuclear accidents. For technical preparation.
【學(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2013
【分類號(hào)】：R818.74

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本文編號(hào)：2212700