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1.
OBJECTIVES: Reported studies have showed alternations of thyroid hormones in critical illness mostly in adults and some in children. In this study, we aimed to measure thyroid hormone levels in children with sepsis and septic shock and investigate the relationship of these hormones with clinical state and survival. PATIENTS AND METHODS: Thyroid hormone levels of children with sepsis and septic shock, and age- and sex-matched controls were measured. RESULTS: There were 51 children in sepsis (group S), 21 children in septic shock (group SS) and 30 in the control (group C) group. Total triiodothyronine (TT3) levels were (nmol/l): 0.91 +/- 0.22, 0.64 +/- 0.23, 2.11 +/- 0.59; free triiodothyronine (FT3) (pmol/l): 0.027 +/- 0.006, 0.018 +/- 0.007, 0.049 +/- 0.010; total thyroxine (TT4) (nmol/l): 100.62 +/- 21.93, 65.79 +/- 19.35, 109.65 +/- 19.35; free thyroxine (FT4) (pmol/l): 18.06 +/- 3.87, 10.32 +/- 1.29, 19.35 +/- 3.87; and thyroid stimulating hormone (TSH) (mIU/ml): 5.0 +/- 2.0, 4.8 +/- 2.4, 5.2 +/- 3.0, in children with sepsis, septic shock, and controls, respectively. The TT3, FT3, TT4, and FT4 levels of group SS were significantly lower than those of groups S and C. The TT3 and FT3 levels of group S were lower than in group C, but there was no significant difference between TT4, and FT4 levels of groups S and C. TSH levels were slightly decreased in both sepsis and septic shock, but the difference was not significant. Eleven (21.6%) children with sepsis and 15 (71.4%) children with septic shock died (p < 0.001). The levels of TT3, FT3, TT4 and FT4 were markedly lower in non-survivors of groups S and SS compared to survivors (p < 0.001). CONCLUSIONS: These changes in the hypothalamo-pituitary-thyroidal axis may suggest a possible prognostic value of thyroid hormone levels in children with sepsis and septic shock. To the best of our knowledge, this report is the first study to compare thyroid hormone levels in a large number of patients with sepsis and septic shock with those in healthy controls in childhood.  相似文献   

2.
BACKGROUND: A high rate of thyroid disorders has been described in HIV-infected adults treated with highly active antiretroviral therapy (HAART), but data on children are lacking. We aimed to assess thyroid function in pediatric patients. METHODS: Fifty-two HIV-infected children receiving HAART were assessed for signs of thyroid dysfunction and serum concentrations of thyrotropin (TSH), free thyroxin (FT4), free triiodothyronine (FT3), thyroglobulin (TG), reverse triiodothyronine (rT3), anti-TG and antimicrosomal (anti-TSM) antibodies. RESULTS: Eighteen (35%) children showed thyroid abnormalities: isolated low FT4 value in 16; subclinical hypothyroidism in 1; and symptomatic hypothyroidism in 1.Children with low FT4 values as compared with the 34 children without thyroid dysfunction were similar for stage of disease, number of patients with undetectable HIV-RNA, FT3, TSH, TG, rT3, anti-TSM and anti-TG values, whereas they had shorter duration of HAART exposure (P = 0.019) and lower CD4 cell percentage (P = 0.035). The thyrotropin-releasing hormone (TRH) test was normal in all children with low FT4 values. Among children with low FT4, FT4 concentrations correlated positively with CD4 cell percentage (P < 0.05) and duration of HAART exposure (P < 0.05).The case with subclinical hypothyroidism had high basal TSH (7.3 microunits/ml), normal TSH response to TRH test and normal FT4, FT3, TG, rT3, anti-TG and anti-TSM antibodies.The case with symptomatic hypothyroidism had low FT4 (6.6 pg/ml) and high TSH (44 microunits/ml), TG (55 ng/ml), anti-TG (666 IU/ml) and anti-TSM (123 IU/ml). CONCLUSION: Thyroid abnormalities occur frequently in HAART-treated children even in the absence of clinical symptoms. These data suggest a need of regular thyroid function monitoring.  相似文献   

3.
Thyroid hormones, thyroxine-binding globulin (TBG) and thryrotropin (TSH) concentrations were measured in 46 paired fetal and maternal blood samples collected between 17 and 36 weeks of gestation. The samples were selected retrospectively from fetuses that had undergone cordocentesis for prenatal diagnosis, had been found to be unaffected and confirmed healthy at birth. In maternal serum, total thyroxine (TT4) and triiodothyronine (TT3) concentrations were high, but free thyroxine (FT4) and free triiodothyronine (FT3) were within normal adult ranges; reverse T3 (RT3) increased and TSH levels decreased towards term. Fetal TT4, FT4, TT3, FT3, TBG and TSH levels significantly increased whereas RT3 sharply decreased with gestational age. The ratio of fetal TSH/FT4 significantly decreased, suggesting that the set point for negative feedback of pituitary TSH secretion is changing while the sensitivity of the thyroid gland to TSH increases throughout gestation. There was no significant correlation between the maternal and fetal TBG, TSH, TT4 and FT4, whereas maternal TT3 was positively correlated with fetal TT4, FT4, TT3 and FT3. Normal reference values for maternal and fetal iodothyronines, TBG and TSH throughout the second half of gestation provide insight into fetal thyroid development and may be useful for prenatal diagnosis.  相似文献   

4.
观察常用抗癫痫药物对癫痫患儿血清甲状腺激素的影响。对无甲状腺功能减退临床表现的癫痫患儿(各组均20例)共80例,应用RIA法测定血清TT4、TT3、FT4、FT3、rT3、TSH浓度。结果未经治疗癫痫患儿所有激素水平与正常对照组比较无显著差异,苯巴比妥组FT4值低于正常对照组(P<0.01),卡马西平组TT4、FT4值也明显降低(P<0.01),苯妥英组TT4、FT4、FT3值均显著降低(P<0.01),所有各组rT3、TSH无改变。资料表明,抗癫痫药物对甲状腺激素影响强度依次为苯妥英钠、卡马西平、苯巴比妥。  相似文献   

5.
BACKGROUND: The aim of the present study was to assess the effects of low Apgar scores on perinatal thyroid function. METHODS: Forty full-term infants delivered by the normal spontaneous vaginal route were enrolled into the study. All babies had 1 and 5 min Apgar scores below 4. The control group consisted of 26 full-term healthy neonates. Cord blood and serum tri-iodothyronine (T3), thyroxine (T4), reverse tri-iodothyronine (rT3), free thyroxine (FT4), thyroid-stimulating hormone (TSH) and thyroid-binding globulin (TBG) determinations were performed by an enzyme immunoassay method. RESULTS: The mean values of FT4 and T4 observed in the cord blood of the study group were significantly lower compared with matched controls, whereas the mean TSH values were significantly higher. There were no differences in concentrations of T3, rT3 and TBG between the two groups. CONCLUSIONS: These results demonstrate the existence of transient hypothyroidism at birth in babies with Apgar scores below 4 delivered by the spontaneous vaginal route.  相似文献   

6.
目的 总结并分析1998年1月- 2009年12月南京地区新生儿先天性甲状腺功能减低症(CH)的筛查结果.方法 采集出生72 h新生儿442 454例的足跟血滴于滤纸上,采用时间分辨免疫法测定滤纸血斑促甲状腺激素(TSH),阳性者召回进一步测定静脉血TSH、三碘甲状腺原氨酸(T3)、四碘甲状腺原氨酸(T4)、游离T3(FT3)、游离T4(FT4)以明确诊断.确诊者立即开始予左旋甲状腺素片(4.3~12.0μg·kg-1·d-1)替代治疗,定期监测其甲状腺功能,测量其身高、体质量,其中68例患儿子智力测试,以评估疗效.结果 12 a共筛查442 454人,确诊CH 183例,发病率为0.41‰,对117例进行随访.初始治疗时间的中位数为18 d(7~67d),初始左旋甲状腺素的平均剂量为7.35 μg·kg-1·d-1.CH患儿的身高、体质量结果基本达到正常参照标准.盖泽尔婴幼儿发展量表(GESELL)测试结果显示1例智能发育落后,8例智能发育迟缓.T4、FT4的治疗前水平与患儿的GESELL测试总分、适应性及精细运动均呈正相关(Pa<0.05).结论 经筛查确诊的CH患儿,应尽可能早地进行激素替代治疗,可有效改善其预后.因此新生儿筛查及随访治疗工作值得推广和完善.  相似文献   

7.
Reverse triiodothyronine (rT3), triiodothyronine (T3), thyroxine (T4), and thyroid stimulating hormone (TSH) values were measured by radioimmunoassay in 40 children with congenital hypothyroidism who were being given levothyroxine (0.05-0.35 mg/day) and in 14 normal controls. In 15 of the children with hypothyroidism the treatment, judged by serum T4 and TSH values and thyrotrophin releasing hormone (TRH) test, seemed to be adequate and their mean rT3 value and rT3:T4 ratio were comparable with the controls. The remaining 25 children had a raised serum T4 and a low TSH value. Only 4 (16%) of these children had an abnormally high T3 concentration but the rT3 value was raised in 23 (92%) and their mean rT3 value and rT3:T4 ratio were significantly higher than in the control children. Less than 20% of this ''overtreated'' group, however, had clinical hyperthyroidism. We suggest that in patients on T4 replacement treatment the peripheral thyroid homeostatic mechanisms produce larger amounts of rT3, thereby preventing high T3 values where serum T4 values are raised. This may explain why the ''overtreated'' children showed no clinical evidence of hyperthyroidism. These findings emphasise the protective and selective role of peripheral monodeiodination.  相似文献   

8.
The aim of this study was to compare thyroid function in preterm infants born to women with placental insufficiency (n = 15) and those born to women without placental insufficiency (n = 13). Gestational ages ranged between 28 and 33 weeks. Concentrations of free thyroxine (FT4), thyrotropin (TSH), triiodothyronine (T3) and reverse T3 (rT3) were measured by radioimmmunoassays in cord blood and on d 1, 3, 5, 7, 14 and 21. Infants born to the women with placental insufficiency had significantly lower mean FT4 (p = 0.001), TSH (p = 0.002) and rT3 values (p = 0.025) in cord blood, and higher rT3 values on d 5 (p = 0.019) and d 7 (p = 0.025). The following conclusions were reached: (i) preterm infants born to pre-eclamptic women with placental insufficiency have intact hypothalamic-pituitary-thyroid axes; (ii) compared to preterm infants born to healthy women, preterm infants born to pre-eclamptic women with placental insufficiency have lower FT4 and TSH concentrations before birth and (iii) elevated rT3 concentrations after birth, suggesting a temporarily impaired hepatic type 1 deiodination process.  相似文献   

9.
Serum concentrations of T4, T3, rT3, and TSH were measured by radioimmunoassay in 45 patients suffering from beta-thalassaemia. A TRH stimulation test was performed and the binding capacity of TBG and TBPA for T3 and T4 measured by reverse flow zone electrophoresis in a group of these patients. Mean T4 serum concentration was lower in thalassaemic patients than controls; T3, rT3, TSH levels, and the pituitary response to TRH were normal. TBPA binding capacity for thyroxine was greatly decreased, probably due to iron overload impairing the liver function. The decreased circulating total thyroxine might be explained by the reduced TBPA capacity, serum free thyroid hormone concentration total thyroxine might be explained by the reduced TBPA capacity, serum free thyroid hormone concentration values being normal. It is concluded that thalassaemic children are euthyroid, despite often having low-normal or subnormal thyroxine levels.  相似文献   

10.
OBJECTIVE: Since preeclampsia causes placental insufficiency, it can be hypothesized that it decreases placental passage of thyroxine (T4) from mother to infant and thus may deepen the transient hypothyroxinemia seen in preterm infants after birth. The aim of this study was to compare thyroid function tests of preterm infants born to preeclamptic mothers with placental insufficiency with preterm infants born to mothers without placental insufficiency. METHODS: Thirty-one preterm infants born to preeclamptic mothers with placental insufficiency were included in the study (group I) and 31 preterm infants born to mothers without placental insufficiency were included as the control group (group II). Thyroid hormone levels were assayed from blood samples obtained from the women before birth and thereafter from the infants at delivery (cord) and on the 1st, 3rd, 7th, and 21st days of life. RESULTS: Cord blood triiodothyronine (T3), free T3 (FT3) and free thyroxine (FT4) levels in group I were lower than in group II, whereas thyrotropin (TSH) and thyroxine binding globulin (TBG) levels were higher. No statistical difference in hormone levels studied at postnatal 1st, 3rd, 7th, and 21st day was found between the two groups. CONCLUSION: Low levels of thyroid hormones and high level of TSH in cord blood in premature infants born to preeclamptic mothers with placental insufficiency suggest intrauterine hypothyroidism. Increase in TSH and thyroid hormone concentrations after birth reveal that the hypothalamic-pituitary-thyroid axis is intact.  相似文献   

11.
目的探讨心脏疾患及合并充血性心力衰竭(CHF)患儿心衰时,血清甲状腺激素(TH)水平的变化规律及临床意义。方法对2003-09—2006-09山西省阳泉市第一人民医院收治的116例心脏疾病患儿分为2组,心脏病合并CHF组82例,心脏病未合并CHF组34例,以28例健康体检儿童为对照组,均做如下检测及分析:(1)检测CHF患儿血清TH水平,包括三碘甲状腺原氨酸(T3)、游离T3(FT3)、甲状腺素(T4)、游离T4(FT4)、反T3(rT3)及促甲状腺激素(TSH),三组间进行比较。(2)以血清TH水平与心功能进行相关分析。(3)动态观察CHF患儿的血清TH水平,探索其变化规律。结果(1)CHF组与N-CHF组及正常对照组比,血清T3、FT3及FT4均显著降低(P<0.01),rT3显著升高(P<0.01)。(2)随心功能的下降,T3、FT3、T4、FT4渐降低,rT3渐升高。TSH与心功能变化无相关性。(3)CHF组经治疗后血清TH多恢复(P<0.01),顽固性心衰组则无恢复(P>0.05)。结论(1)小儿CHF伴有血清TH的改变,以T3、FT3及FT4的降低,rT3的升高为主,其改变程度与心功能状态具有相关性。(2)随着心功能的改善,TH的改变多渐恢复,顽固性心衰患儿则无恢复,提示TH水平持续不恢复者预后较差。  相似文献   

12.
BACKGROUND: Although there have been numerous studies on the effects of thyroid hormones on serum lipid profiles, the effects of thyroxine on intermediate how density lipoprotein (IDL) remain uncertain. In an attempt to clarify, this issue, under conditions with very little influence exerted by sex hormones on serum lipid profiles, we studied the relationship between serum thyroid hormone levels and the proportion of serum IDL fractions in children. METHODS: Nineteen children with congenital hypothyroidism and 13 children with non-thyroid diseases were enrolled in this study. Blood samples were taken to measure serum thyroid stimulating hormone, triiodothyronine, free thyroxine (FT4), total cholesterol, high density lipoprotein (HDL) cholesterol, triglyceride and apolipoprotein levels. Lipoprotein fractions, including very low density lipoprotein (VLDL), IDL, low density lipoprotein (LDL) and HDL, were determined by their electrophoretic mobility in a non-denaturing polyacrylamide gel. RESULTS: The proportion of IDL fractions showed a significant inverse correlation with serum FT4 levels and a significant correlation with serum total cholesterol and apolipoprotein B and C-II levels. Serum VLDL, LDL and HDL fractions did not correlate with serum thyroid hormone levels. CONCLUSION: From these results and other studies, we suggest that thyroxine promotes the conversion of IDL into LDL, possibly by its stimulatory effects on hepatic lipase activity.  相似文献   

13.
To investigate the significance of low serum thyroxine in premature infants, serum FT4, T4, TSH and TBG were measured in 7 infants with BW<1000 g, 8 infants with BW 1001 to 1350 g, 9 infants with BW 1351 to 2499 g, and 11 full-term infants.FT4 concentrations were lower in the LBW infants than in the FT infants. Percent FT4 values in the infants with BW<1000 g were the highest in the groups studied, so that FT4 concentrations in those infants did not fall proportionally with the marked T4 decrease. TBG concentrations were lower in the VLBW infants (相似文献   

14.
目的评价先天性甲状腺功能减退症(CH)新生儿的心电图(ECG)改变,及与血清甲状腺激素(TH)水平的相关性,探讨TH减少对新生儿心脏电生理活动的影响。方法对50例CH新生儿(日龄17~28d)和35例健康新生儿(健康对照组)进行常规十二导联ECG检查,分别检测心率(HR)、PR间期(PR)、QT间期(QT)、QRS波电轴(QRSa)、QRS波时限(QRS)、校正QT间期(QTC)等,同时用化学发光法测定血清游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)、总三碘甲状腺原氨酸(TT3)、总甲状腺素(TT4)和促甲状腺素(FSH)水平,对心电图指标和血TH水平行相关性分析。结果与健康对照组相比,CH组血清FT3、FT4、TT3、TT4水平显著降低,TSH水平显著升高(Pa<0.001);CH组HR显著低于健康对照组,PR及QT较健康对照组显著延长(Pa<0.05),但二组QRSa、QRS及QTC差异均无统计学意义(Pa>0.05)。HR与FT3、FT4呈显著正相关,与TSH呈显著负相关(Pa<0.05);PR间期与FT3、FT4、TT4呈显著负相关,与TSH呈显著正相关(Pa<0.05);但QT、QRS、QRSa及QTC与血TH水平均无明显相关(Pa>0.05)。结论CH可对新生儿窦房结起搏产生显著影响,引起心脏自律性改变,而心肌动作电位、房室传导等电生理活动则尚未受影响。  相似文献   

15.
Reverse triiodothyronine (rT3), triiodothyronine (T3), thyroxine (T4), thyroxine binding globulin (TBG), and thyrotrophin (TSH) were measured in sera from placental cord blood in an unselected series of 272 deliveries. In this series the concentrations of rT3 (mean 3.33 nmol/l, 95% confidence limits 1.6--7.0 nmol/l), were log normally distributed and did not overlap the adult normal range (0.11--0.44 nmol/l). There were no correlations between the cord blood concentrations of rT3, T3, T4, and TSH. The cord serum rT3 concentration was not influenced by maturity, birth-weight, or neonatal risk factors, whereas these factors did affect the concentrations of T3, T4, AND TBG. There is no arteriovenous rT3 concentration difference across the placenta, therefore the cord rT3 reflects the systemic rT3 concentration in the baby at birth. As rT3 in the neonate largely, if not entirely, derives from thyroxine from the fetal thyroid, measurement of the cord rT3 concentration may be a good immediate screening test for neonatal hypothyroidism.  相似文献   

16.
急性白血病化疗对垂体、性腺、甲状腺激素的影响   总被引:1,自引:1,他引:1  
目的评价儿童急性白血病(AL)及联合化疗对其垂体、性腺、甲状腺激素的影响。方法测定37例(男23例,女14例)AL患儿化疗前后和20例对照组血清促卵泡激素(FSH)、黄体生成素(LH)、睾酮(T)、雌二醇(E2)、催乳素(PRL)、生长激素(GH)、促甲状腺激素(TSH)、游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)水平。结果AL患儿FSH、LH、T、E2、GH、FT4、TSH水平化疗前后及对照组各组差异无显著意义(P>0.05),PRL水平治疗前高于对照组(P<0.01),男童PRL水平治疗前后比较差异有显著意义(P<0.01)。FT3治疗前低于对照组(P<0.001),治疗后趋于正常(P>0.05)。结论AL本身及联合化疗对患儿垂体-性腺轴功能及GH水平无明显影响。AL本身可使PRL水平升高,而化疗药物可抑制男童PRL的分泌。联合化疗对甲状腺功能无影响,FT3水平对判断AL患儿病情变化、疗效及预后有一定参考意义。  相似文献   

17.
目的 研究甲状腺功能异常 [原发性甲状腺功能减退 (甲减 )和原发性甲状腺功能亢进 (甲亢 ) ]患儿血清瘦素 (leptin)水平变化 ,探讨血清瘦素与甲状腺功能的关系。方法 采用放射免疫法分别检测 2 0例甲减患儿、17例甲亢患儿和 2 5例健康儿童血清瘦素水平 ,同时采用微粒子化学发光免疫分析法检测血清游离三碘甲状腺原氨酸 (FT3 )、游离甲状腺素 (FT4)、促甲状腺素 (TSH)等指标。结果 甲低组治疗前血清瘦素水平显著低于正常对照组 (P <0 .0 0 1) ,经药物治疗甲状腺功能恢复至正常后 ,其血清瘦素浓度上升至正常水平 ;甲亢组治疗前后血清瘦素水平与正常对照组相比 ,差异无显著性 (P >0 .0 5 )。结论 甲状腺激素对血清瘦素的分泌具有促进作用  相似文献   

18.
The purpose of this study was to identify possible changes in thyroid functions in newborn infants of preeclamptic women. Fifteen neonates (nine boys and six girls) of preeclamptic women and 17 healthy neonates (nine boys and eight girls) for the control group were included in the study. Serum thyroid-stimulating hormone (TSH), total triiodothyronine (TT3) and total thyroxine (TT4) levels and thyroid gland volumes were determined in both groups. Serum TSH and TT4 levels were not statistically different between the two groups. However, serum TT3 level was 79.22 +/- 40.19 ng/dl in the study group and 40.00 +/- 15.99 ng/dl in control subjects (p < 0.01). The mean right, left and total thyroid volumes were 1.3 +/- 1.2 ml, 1.2 +/- 1.1 ml and 2.4 +/- 2.3 ml in the study group and 0.6 +/- 0.2 ml, 0.6 +/- 0.2 ml, and 1.1 +/- 0.4 ml in the control group, respectively (p < 0.05). The mean thyroid volume/body weight was 0.9 +/- 0.09 ml/kg in the study group and 0.3 +/- 0.06 ml/kg in the control group (p < 0.05). In conclusion, we would like to stress that preeclampsia might be a cause of fetal and neonatal thyroid enlargement and elevated serum TT3 level.  相似文献   

19.
目的 探讨甲状腺激素(TH)对新生大鼠脑血管发育的影响.方法 取18只清洁级SD成年雌性大鼠与3只清洁级SD雄性大鼠交配后随机将孕鼠分入3组:丙基硫氧嘧啶(PTU)干预组、TH干预组和对照组.待每组仔鼠产后第1天即采用电化学发光法检测其血清总三碘甲状腺原氨酸(TT3)、总甲状腺素(TT4)水平;采用酶联免疫吸附试验法测仔鼠脑组织血管内皮细胞生长因子(VEGF)水平.应用SPSS 16.0软件进行统计学分析.结果 TH干预组仔鼠血清TT4[(103.50±2.37) μg·L-1]、TT3[(1 269.63±32.18) ng·L-1]与脑组织VEGF水平[(53.46±10.62) μg·L-1]均高于对照组[TT4 (45.11±0.43) μg·L-1,TT3 (844.57± 20.85) ng·L-1,VEGF (11.15±1.33) μg·L-1](Pa<0.001).同时,PTU干预组新生鼠以上各指标[TT4 (16.83±0.45) μg·L-1,TT3 (142.35±7.76) ng·L-1,VEGF(8.69±0.48) μg·L-1]均低于对照组(Pa<0.001).结论 TH干预可增加仔鼠脑组织VEGF水平,对脑血管的发育有促进作用.  相似文献   

20.
The aim of the study was to determinate the serum leptin level, glucose concentration, lipids (total cholesterol, HDL-cholesterol, LDL-cholesterol, triglyceride) and thyroid hormones level (triiodothyronine, thyroid stimulating hormone and free thyroxine) in a group of prepubertal children with simple obesity. Fourfold higher leptin concentration in obese (23.3 +/- 11.8 ng/mL) in comparison to a group of slim children (6.8 +/- 2.7 ng/mL), (p<0.0001) was shown. There was no significant difference in serum glucose level (87.3 +/- 9.7 mg/dL) between both studied groups. In obese subjects we showed higher triglyceride, insignificantly lower HDL-C concentrations and invariable other lipid fractions. Mean values of triiodothyronine (T3) were 3.0 +/- 0.7 nmol/L in obese children and 2.8 +/- 0.8 nmol/L in slim children. On the contrary, mean values of thyroid stimulating hormone (TSH) were 2.5 +/- 1.7 mIU/L and 2.8 +/- 0.7 mIU/L in the group of obese and normal children respectively. Free thyroxine (FT4) concentrations in our obese children were lower (11.5 +/- 2.9 pmol/L) than in slim subjects (14.6 +/- 3.1 pmol/L) but were within the reference range. The results obtained indicate that in children with simple obesity there was no dyslipidemia connected with leptin and thyroid hormones levels. However, higher triglyceride and lower HDL-C concentrations suggest a necessity of monitoring the body mass index and lipid profile in these patients.  相似文献   

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