Application progresses of ultrasound for snakebites and relative complications

Snakebite has become a serious public health problem with high mortality and disability rates.Ultrasound can provide imaging basis for diagnosis and treatment of snakebites and relative complications.The application progresses of ultrasound in snakebites and complications were reviewed in this article.

Clinicopathological spectrum of snake bite-induced acute kidney injury from India

AIM To study the clinico-pathological spectrum of snake bite-induced acute kidney injury(AKI).METHODS A retrospective study of patients admitted at Indira Gandhi Medical College Hospital,Shimla with snake bite-induced AKI from July 2003 to June 2016.Medical records were evaluated for patient's information on demographic,clinical characteristics,complications and outcome.Outcomes of duration of hospital stay,requirement for intensive care unit support,treatment with dialysis,survival and mortality were analyzed.The survival and non survival groups were compared to see the difference in the demographic factors,clinical characteristics,laboratory results,and complications.In patients subjected to kidney biopsy,the findings of histopathological examination of the kidney biopsies were also analyzed.RESULTS One hundred and twenty-one patients were diagnosed with snake bite-induced AKI.Mean age was 42.2 ± 15.1 years and majority(58%) were women.Clinical details were available in 88 patients.The mean duration of arrival at hospital was 3.4 ± 3.7 d with a range of 1 to30 d.Eighty percent had oliguria and 55% had history of having passed red or brown colored urine.Coagulation defect was seen in 89% patients.The hematological and biochemical laboratory abnormalities were:Anemia(80.7%),leukocytosis(75%),thrombocytopenia(47.7%),hyperkalemia(25%),severe metabolic acidosis(39.8%),hepatic dysfunction(40.9%),hemolysis(85.2%) and rhabdomyolysis(68.2%).Main complications were:Gastrointestinal bleed(12.5%),seizure/encephalopathy(10.2%),hypertension,pneumonia/acute respiratory distress syndrome(ARDS) and disseminated intravascular coagulation(9.1% each),hypotension and multi organ failure(MOF)(4.5% each).Eighty-two percent patients required renal replacement therapy.One hundred and ten(90.9%) patient survived and 11(9.1%) patients died.As compared to the survival group,the white blood cell count(P = 0.023) and bilirubin levels(P = 0.006) were significant higher and albumin levels were significantly lower(0.005) in patients who died.The proportion of patients with pneumonia/ARDS(P = 0.001),seizure/encephalopathy(P = 0.005),MOF(P = 0.05) and need for intensive care unit support(0.001) was significantly higher and duration of hospital stay was significantly shorter(P = 0.012) in patients who died.Kidney biopsy was done in total of 22 patients.Predominant lesion on kidney biopsy was acute tubular necrosis(ATN) in 20(91%) cases.In 11 cases had severe ATN and in other nine(41%) cases kidney biopsy showed features of ATN associated with mild to moderate acute interstitial nephritis(AIN).One patient only had moderate AIN and one had patchy renal cortical necrosis(RCN).CONCLUSION AKI due to snake bite is severe and a high proportion requires renal replacement therapy.On renal histology ATN and AIN are common,RCN is rare.

Parallels between Russell's viper(Daboia russelii) and hump-nosed viper(Hypnak species) bites in the central hills of Sri Lanka amidst the heavy burden of unidentified snake bites

Objective:To describe the epidemiology of snake bite in the region and attempt to compare proven Russell’s viper with hump-nosed viper bites.Methods:All snake bite admissions to the Toxicology Unit of Teaching Hospital Peradeniya over three year from 2006 were included. Results:Of the 776 snakebites,665(86%) were unidentified and non-envenomed.Humpnosed viper and Russell’s viper accounted for 55(7%) and 40(5%) bites respectively,of them, incriminated snakes were found in 36(65%) and 19(48%) cases.The cobra bites-5,krait bites-0. The median ages:Russell’s viper bites-41(range 16-66),hump-nosed viper bites-42(range 15- 75).The gender incidence,time of bite(】58%daytime) were similar.In hump-nosed viper bite; upper limb involved in 13(36%),happened at home garden in 22(61%),none in paddy fields.In Russell’s viper bite;6(33%) occurred in paddy fields.Dry bites were similar at 5%.In humpnosed viper bite:local effects 94%,coagulopathy 3%,acute renal failure 3%and one patient died.In Russell’s viper bite;local effects 84%,coagulopathy 53%,neurotoxicity 21%.Abdominal pain occurred only in Russell’s viper bites 10(53%).Conclusions:Overwhelming numbers of unidentified,non-envenomed snakebites are common in the central hills.Some distinctive differences were observed between Russell’s viper and hump-nosed viper bites.

A life threatening scratch on little toe-at most clinical suspicion the essential key in management of snake bite

Snake bites are one among the under reported clinical emergencies from tropical countries.There are variations in clinical presentation of snake bites and its toxic features differ with the species and type of bite.There are lots of controversies in the treatment guidelines which often makes it difficult to manage.We report the case of a severe hemotoxic snake bite who presented to the outpatient service of our hospital with a trivial fool injury.Even though snakebites are familiar clinical situations for an emergency physician from tropics,we report this case as mast are under reported.We also intend to emphasize the excellent outcome of appropriately diagnosed and treated cases of snake bite.

基于统计模型和GVF-Snake的彩色目标检测与跟踪

为了能使传统监视系统具备目标自动检测与跟踪能力,提出了一种基于统计模型和GVF(grad ient vectorflow)-Snake的彩色目标检测与跟踪算法。该算法可用于解决在静态背景下通过彩色视频信息来对运动目标进行自动检测与跟踪的问题,同时可直接给出目标轮廓的数学表示,并可简化后续目标识别算法的设计。该算法首先采用归一化RGB空间与灰度空间相结合的模型取代单一灰度模型来消除阴影对目标检测的影响;接着在此模型的基础上对差分图像进行GMM(Gaussian m ixture model)建模,并构造运动边界图像,然后将静态图像轮廓提取算法GVF-Snake引入运动图像中,并通过修改能量项,使其能够跟踪运动目标的轮廓,最后针对Snake初始轮廓需要手工设定的问题,提出一种根据目标区域自动初始化轮廓的方法,为加快GVF-Snake的收敛速度,还采用一阶差分算法来预测下一时刻目标轮廓的位置。实验结果证明,该算法对刚性和非刚性两类目标都有较好的跟踪效果,可应用于智能监视和交通监控等领域。

TAT、TM、PIC、t-PAIC与重型血液毒毒蛇咬伤中毒患者DIC的相关性及预测价值

目的评估凝血酶抗凝酶复合物(TAT)、血栓调节蛋白(TM)、纤溶酶-抗纤溶酶复合物(PIC)和组织型纤溶酶原激活抑制复合物(t-PAIC)与重型血液毒毒蛇咬伤中毒后弥散性血管内凝血(DIC)的临床相关性及预测价值。方法连续纳入2019年4月至2023年4月收治的重型血液毒毒蛇咬伤中毒患者作为研究对象,共132例。依据住院期间是否出现DIC分为观察组(发生DIC,n=37)及对照组(未发生DIC,n=95)。检测2组血浆TAT、TM、PIC、t-PAIC浓度。应用二元、无分类协变量的非条件Logistic回归分析TAT、TM、PIC、t-PAIC浓度与重型血液毒毒蛇咬伤中毒后DIC的临床相关性,建立受试者工作特征(ROC)曲线分析TAT、TM、PIC、t-PAIC对重型血液毒毒蛇咬伤中毒后DIC的预测能力。结果观察组TAT、TM、PIC、t-PAIC显著高于对照组(P<0.05)。二元、无分类协变量的非条件Logistic回归分析显示,TAT[OR=1.517(95%CI:1.155,1.879)]、TM[OR=1.647(95%CI:1.108,2.186)]、PIC[OR=3.989(95%CI:2.986,4.992)]、t-PAIC[OR=1.111(95%CI:0.854,1.368)]是重型血液毒毒蛇咬伤中毒患者发生DIC的危险因素(P<0.05)。ROC曲线分析显示,TAT、TM、PIC、t-PAIC是预测重型血液毒毒蛇咬伤中毒患者DIC的有效指标(P<0.05),其曲线下面积(AUC)分别为0.865(95%CI:0.790,0.939)、0.771(95%CI:0.673,0.870)、0.847(95%CI:0.804,0.889)、0.680(95%CI:0.573,0.787),联合预测效能更优异(P<0.001),AUC为0.904(95%CI:0.875,0.933)。结论TAT、TM、PIC和t-PAIC检测对判断重型血液毒毒蛇咬伤中毒患者是否发生DIC有重要参考价值,可以较好地评估患者凝血功能状态,4个指标联合预测DIC的效能更优。

Hump nosed viper bite in Sri Lanka-descriptive observational study of 1543 cases

Objective:To identify the clinical manifestations of hump nosed viper envenomation and to recognize the available treatment methods to prevent complications.Methods:Descriptive observational study involving a series of 1 543 patients admitted with hump nosed viper bite to 5 major hospitals in Sri Lanka was conducted.Data collection was done consecutively during February 1990 and February 2008.Except Hypnale,identification of the biting snake was made by the corresponding author after visual examination of the dead or live snakes,which were brought to hospital.Results:Sixty seven(4.34%) patients developed systemic effects and two (0.1%) patients died due to effects of envenomation or complications of treatment.Systemic effects varied from coagulopathy,nephropathy to some neurological manifestations.Fifty nine (3.8%) patients had only coagulopathy and they received either,intravenous isotonic saline to ensure adequate urine out put i.e.0.5 mL/kg /hour or 15 mL/kg of fresh frozen plasma(FFP). None of the patients that had coagulopathy developed renal failure.Contamination of the sample by mildly venomous species of Hypnale may have contributed to the low incidence of systemic complications.Conclusions:It is likely that early hydration with normal saline or FFP can prevent acute renal failure.FFP showed a tendency for early correction of coagulopathy.Role of FFP in hump nosed viper envenomation is worth studying in randomized double blind controlled clinical trials.

有创-无创序贯机械通气救治银环蛇咬伤致呼吸肌麻痹的临床研究

目的探讨有创-无创序贯机械通气救治银环蛇咬伤致呼吸肌麻痹的临床疗效。方法回顾性分析2011年9月至2021年3月我院收治的48例银环蛇咬伤并发呼吸衰竭患者的临床资料,并根据治疗方法的不同进行分组,其中采用有创后脱机拔除气管插管序贯无创机械通气治疗的26例患者为观察组,采用传统机械通气治疗的22例患者为对照组。分析两组患者的临床症状指标[呼吸频率(RR)、心率(HR)]以及二氧化碳分压(PaCO_(2))、血氧饱和指数(SaO_(2))、血氧分压(PaO_(2))、pH等血气指标,比较两组患者有创机械通气时间、总机械通气时间、住呼吸重症监护室时间、住院时间以及再插管率、住院死亡率、呼吸机相关性肺炎等并发症发生率、患者满意度情况。结果治疗前,两组患者的临床症状指标及血气指标水平比较,差异均无明显统计学意义(均P>0.05);治疗24 h后,两组患者的临床症状指标及血气指标均得到明显改善,观察组的RR、HR、PaCO_(2)、SaO_(2)、PaO_(2)、pH等指标改善均明显优于对照组,差异均有统计学意义(均P<0.05)。观察组的有创机械通气时间[(4.17±2.02)d]、总机械通气时间[(7.21±2.79)d],住呼吸重症监护室时间[(8.73±3.05)d]以及住院时间[(12.56±4.36)d]上均短于对照组,差异均有统计学意义(均P<0.05)。两组患者的并发症发生情况比较,观察组的呼吸机相关性肺炎发生率为3.85%,明显低于对照组的27.27%,差异有统计学意义(P<0.05);而两组患者的再插管率以及住院死亡率比较,差异均无统计学意义(均P>0.05)。两组患者在治疗护理的满意程度方面比较,差异无统计学意义(χ2=2.624,P=0.111)。结论在救治银环蛇咬伤至呼吸麻痹患者时,及时使用抗蛇毒血清及机械通气措施可有效改善患者临床指标,患者病情好转后采用有创-无创序贯机械通气治疗可更快地改善患者血气指标,减少患者治疗时间。

Snakebite Epidemiology in Bangladesh—A National Community Based Health and Injury Survey

Insert Snakebite is a global public health issue, and in majority of cases it is undermined. Tropical and subtropical countries are most effected, Bangladesh being one of them. There is scarcity of countries’ epidemiological situation in relation to snakebite poisoning. This study has looked at the epidemiological status of snakebite poisoning from national representative survey findings. Methods: A nationwide cross-sectional survey was conducted in 12 randomly selected districts of Bangladesh in 2003. A total of 171,366 households were surveyed and information was collected from 819,429 populations by face to face interview. Multi-stage cluster sampling methods were used in this survey and covered urban, rural and slum populations. Results: Annually an estimated 15,372 (10.98/100,000) individuals were bitten by snakes and of them 1709 (1.22/100,000) died every year. Males were found to be most vulnerable with a risk of 1.51 times higher than female. Rural populations were also 10.54 times higher at risk than the populations living in the urban areas. Among the victims 94% were from the poor socio economic conditions. Around 43.9% of the incidences occurred during evening to midnight. Home was found the most common area for snake bite (33.6%), and the Leg was found to be the most common site for biting (63.1%). A total of 96.6% victims sought treatment, of them 61% sought immediate treatment from traditional healing methods. Conclusions: Present incidence of snakebite in Bangladesh has clearly shown that there is emerging public health needs for intervention that can reduce the mortality and burden of the disease in the country.

Placental Abruption Following Snakebites Envenomation: A Case Report and Literature Review

Background: Snakebite envenomation in pregnancy is uncommon. It can lead to a poor outcome in both the mother and the fetus. We describe our approach to envenomation in pregnancy based on the currently available evidence. Case: We reported two case of snakebite in the third trimester of pregnancy having caused placental abruption with expelling a fresh still born baby and a live baby. In both cases, consumption coagulopathy occurred. managed by polyvalent anti-snake and blood transfusion. Their investigations became normal and they were discharged of hospitalization. Conclusion: Snakebite envenomation in pregnant is a maternal and fetal emergency. Treatment must be quick and well adapted.

The Analysis of the Treatment of Rhabdomyolysis by Snake Bites

Objective: To explore the treatment measure of rhabdomyolysis caused by snake bites, and provide guidance for further prevention and control of snake bites. Methods: To retrospectively analyze the 841 cases of serpentine bites in our hospital from January 2006 to July 2017;127 cases of patients with rhabdomyolysis syndrome were screened out, and their clinical manifestations, laboratory results, related treatment and prognosis were analyzed. Results: 127 cases patients were rhabdomyolysis out of 841 cases, 28 cases patients developed acute renal failure;treatment measures included local wound treatment, application of tetanus antitoxin, anti-snake venom serum, anti-infection, fluid “hydration” and diuretic, alkaline urine and hybrid renal replacement therapy. 112 cases were cured, improved conditions in 9 cases, 3 cases of death, 3 cases uncured. The improvement rate of is 95.26% after treatment. Conclusion: The rhabdomyolysis had a high incidence in snake bite patients, severe cases often developed acute renal failure. Serum myopsin and related biochemical blood tests could be used to diagnose rhabdomyolysis quickly. Combined treatment methods are the main measure to increase the cured rate and decrease the death rate.

Persistent fibrinogen deficiency after snake bite: A case report

BACKGROUND Venom-induced consumption coagulopathy(VICC)is characterized by coagulation dysfunction accompanied by decreased coagulation factor activity and fibrinogen(FBG)concentrations.We report a patient with VICC caused by snake bite who manifested persistent FBG deficiency without abnormal coagulation factor activity.This information may be helpful in diagnosing and treating VICC.CASE SUMMARY A 49-year-old man who had been bitten by a snake 13 h previously was admitted to the Emergency Department of our hospital with visible swelling of a finger and a bleeding puncture site.The provisional diagnosis was VICC,this being made based on persistent bleeding from the puncture site and subcutaneous hemorrhage.Laboratory evidence of coagulation abnormalities,including fibrinolysis,and findings on thromboelastography confirmed VICC.He had persistent afibrinogenemia requiring intravenous infusions of cryoprecipitate and fresh frozen plasma,together with continuous large doses of human FBG.After this treatment,the patient’s right upper limb swelling improved significantly and his subcutaneous hemorrhage resolved.All of his abnormal laboratory findings returned to normal by day 25.During 6 months’of follow-up,the patient had no further hemorrhagic events.CONCLUSION Hemorrhagic snake venom can result in coagulation dysfunction characterized by persistent FBG deficiency without abnormal coagulation factor activity.

Review on Preparation and Research of Prescriptions for Snake Bites in Fujian Province

The history of research and preparation of prescriptions for snake bites in Fujian Province was reviewed, and the process of incorporating snake doctors into the system and the gradual establishment of snake bite treatment system in Fujian were explored. The composition of several main snake bite preparations in Fujian was preliminarily compared and analyzed to provide reference for the research and development of similar new preparations at present.

有创-无创序贯机械通气救治蛇咬伤致呼吸衰竭的临床研究

目的探讨有创、无创序贯机械通气治疗蛇咬伤致呼吸衰竭的疗效。方法选取22例蛇咬伤并呼吸衰竭的患者予有创后脱机拔除气管插管序贯无创机械通气治疗。19例采用传统机械通气治疗,记录并分析比较两组间患者有创机械通气时间、住呼吸重症监护病房时间、总机械通气时间,总住院时间及呼吸机相关性肺炎(VAP))发生率、再插管率等。结果有创-无创序贯机械通气治疗蛇咬伤并呼吸衰竭疗效显著,有创通气时间、总通气时间及入住呼吸重症监护室(RICU)时间较传统组显著减少(P<0.05),VAP的发生率也明显减少(P<0.05)。拔管后均无需再插管,死亡率两组无差异。结论在患者蛇毒控制,呼吸肌麻痹逐渐改善,咳嗽有力的情况下,停有创,序贯无创治疗具有优越性。

连续性静脉-静脉血液滤过方式治疗蝮蛇咬伤中毒17例

目的:探讨分析连续性静脉-静脉血液滤过(CVVH)对蝮蛇咬伤致急性肾功能衰竭的治疗效果。方法:选择入住本院的蝮蛇咬伤合并急性肾功能衰竭患者17例,在注射抗蛇毒血清和内科常规治疗的基础上给予CVVH治疗,观察治疗前后患者症状改善情况,收集血生化指标,观察治疗过程中出现的不良反应,并对收集数据进行统计学分析。结果:CVVH治疗过程中未出现严重不良反应,17例患者15例存活,1例死亡,1例放弃治疗。CVVH治疗后患者生命体征趋于平稳,肝肾功、心肌酶下降,统计学分析示P<0.05。结论:在注射抗蛇毒血清和内科常规治疗的基础上给予CVVH治疗能有效改善SAP患者病情,降低死亡率。

乌司他丁对毒蛇咬伤并急性肾功能损伤患者肾功能和血TNF-α的影响

目的探讨乌司他丁对毒蛇咬伤合并急性肾功能损伤患者的肾功能和血TNF-α、IL-6的影响及疗效。方法将45例毒蛇咬伤并急性肾功能损伤患者随机分为治疗组(n=25)和对照组(n=20),两组均给予综合治疗,治疗组在综合治疗的基础上静脉注射乌司他丁。观察治疗后两组血尿素氮、血肌酐、TNF-α和IL-6水平变化,同时观察两组的治愈率和平均进入多尿期时间。结果治疗组的血尿素氮、血肌酐、TNF-α和IL-6水平均较对照组下降明显(P<0.05),同时治疗组平均进入多尿期时间也短于对照组(P<0.05),但两组的治愈率无统计学差异(P>0.05)。结论乌司他丁能改善毒蛇咬伤合并急性肾功能损伤患者的肾功能和TNF-α和IL-6指标,明显缩短病程,减少住院时间。

2013-2020年福州及周边地区毒蛇咬伤流行病学特征分析

目的回顾性分析2013—2020年福州及周边地区毒蛇咬伤患者的流行病学特征。方法选取2013年6月至2020年12月福建中医药大学附属人民医院收治的2156例毒蛇咬伤患者作为研究对象,收集并统计患者性别、年龄、致伤部位、致伤月份、地域以及咬伤蛇种等资料,分析福州及周边地区毒蛇咬伤患者的流行病学特点。结果2156例毒蛇咬伤患者中男性1403例、女性753例(男∶女=1.86∶1),且男女患者均以51~60岁年龄段发生率最高,61~70岁年龄段发生率次之;毒蛇咬伤部位以四肢为主,其中左上肢占19.39%,左下肢占27.04%,右上肢占24.35%,右下肢占27.64%,双上肢占0.28%,双下肢占0.51%;咬伤月份分布于全年各月份,以6~10月高发,占78.38%;毒蛇咬伤患者地域分布中福州市占65.31%,以闽侯县(16.33%)、福清市(9.37%)、永泰县(7.00%)多发,福州周边地区占34.69%,以宁德市(21.47%)多发;咬伤毒蛇种类以竹叶青蛇最多,占32.98%,原矛头蝮、不明毒蛇、眼镜蛇次之,分别占26.81%、18.37%、15.07%,且均以宁德市、闽侯县分布最为广泛。结论福州及周边地区毒蛇咬伤患者以宁德市及闽侯县中老年男性居多,咬伤部位多为四肢,且以夏秋季高发,咬伤毒蛇种类以竹叶青蛇、原矛头蝮、眼镜蛇为主。

在线学习机制下的Snake轮廓跟踪

针对复杂环境下非刚体目标轮廓跟踪存在跟踪失败的问题,提出一种基于在线学习的Snake模型及其轮廓跟踪算法。利用跟踪-学习-检测(TLD)机制实现目标快速跟踪,通过跟踪结果在线更新Snake模型约束,进而提高目标轮廓跟踪的准确性。初始化阶段,在Grab Cut算法的基础上,将待跟踪目标分成若干个子块,并在后续跟踪过程中,利用TLD实现各子目标的定位跟踪,形成目标的轮廓置信图。同时针对各子目标提取特征,产生正负样本,更新各子目标跟踪模型。应用置信图建立参数化Snake模型的约束条件,进而得到目标轮廓。实验结果表明,该算法能适应光暗变化与较为复杂坏境下的跟踪,并获得精确的轮廓。

A retrospective analysis of snake envenomation in the intensive care unit of a tertiary care hospital in Delhi

Objective: To evaluate the epidemiology, clinical profile and treatment for patients with snake bite in the intensive care unit of our hospital. Methods: A retrospective analysis of patients with snake bite admitted to the intensive care unit of a tertiary care hospital, North Delhi, was conducted between January 2013 and October 2018. Their demographic profile, time and site of bite, clinical manifestations and time interval between the bite and anti-snake venom administration were recorded. Results: A total number of 102 patients with snake bite were studied, of which 54.9% were males and 45.1% were females. Most patients were presented in the monsoon season and snake bites occurred mainly in the night and early morning. A total of 56.3% of the patients with clinical manifestations received anti-snake venom within 3 h after the snake bite. Most patients presented with painless bites and neuroparalytic features with ptosis that was the most common clinical manifestation (50.9%). Anti-snake venom was administered to 55 patients (53.9%) with an average dose of 42 vials per patient and the mortality was 11.7%. Conclusions: Neuroparalytic krait envenomation accounted for the highest incidence of venomous bites in our study. Early medical treatment with judicious anti snake venom administration and related education is crucial.

犀角地黄汤治疗五步蛇咬伤的临床效果

目的探讨犀角地黄汤治疗五步蛇咬伤的临床效果。方法选择2020年1月至2023年6月在我院治疗的五步蛇咬伤患者86例作为研究对象。采用随机数字表法将所有患者分为对照组和观察组,每组43例。对照组给予基础治疗及抗蛇毒血清治疗,观察组在对照组治疗基础上给予犀角地黄汤治疗。观察比较两组患者的临床疗效、纤维蛋白原(FIB)、凝血酶时间(TT)、活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、白细胞(WBC)计数、肿瘤坏死因子-a(TNF-a)、高敏C-反应蛋白(hs-CRP)、患肢与健肢周径差、患肢疼痛程度评分及肿胀缓解时间。结果观察组的治疗总有效率明显高于对照组,差异有统计学意义(P<0.05)。两组患者治疗前的FIB、TT、APTT、PT、WBC、TNF-a、hs-CRP、患肢与健肢周径差及患肢疼痛程度评分比较,差异均无统计学意义(均P>0.05)。观察组治疗后的FIB高于对照组,TT、APTT、PT均低于对照组,差异均有统计学意义(均P<0.05)。观察组治疗后的WBC、TNF-a、hs-CRP、患肢与健肢周径差、患肢疼痛程度评分均低于对照组,差异均有统计学意义(均P<0.05)。结论犀角地黄汤治疗五步蛇咬伤可有效缓解患肢肿胀、疼痛程度,减轻炎症反应,改善凝血功能指标,值得临床应用。