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精品PPT再生障碍性贫血循证诊断和治疗进展_复旦大学华山医院血液科 林果为 教授课件

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精品PPT再生障碍性贫血循证诊断和治疗进展_复旦大学华山医院血液科林果为教授课件
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单击此处编辑母版标 题样式 单击此处编辑母版副标题样式 1 复旦大学附属华山医院 林果为 教授 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 定 义 n异质性 综合病征 多病因 n造血衰竭 全血细胞减少 n造血干 祖细胞数量减少或质有缺陷 n骨髓中无恶性细胞浸润 无广泛网硬蛋白 纤维增生 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 造血干细胞 祖细胞数量减少 n形态学证据 涂片 活检 n流式细胞术检测CD34 细胞减少 n骨髓祖细胞体外培养集落形成减少 n长期培养起始细胞 LTC IC 数量低于正常 10 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 造血干细胞质量异常 n体外集落形成能力减低 n对造血生长因子反应性减低 n凋亡异常 n粘附分子异常 n端粒长度缩短 n干细胞基因表达异常 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 再障易感基因 nHLA DR2表型多于正常对照 nHLA DRB1 1501出现频率显著高于对照 nTNF 2基因出现频率明显增高 n端粒酶的TERC基因突变是再障易感因素 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 获得性原发性再障发病机制 T细胞介导造血衰竭 n抗原刺激 Th1 Th2失衡 Th1增多 IFN 和IL2分泌增多 CD8 细胞增殖 TNF 增多 Fas FasL介导骨髓CD34 细胞凋亡 造血 衰竭 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial T细胞在抗原刺激下克隆性增殖 nTCR V 的CDR3序列出现数个单克隆或寡 克隆峰 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 免疫耐受打破 n再障患者树突状细胞 DC 亚群DC1 髓 系 DC2 淋系 比例明显失衡 与Th1 细胞激活有关DC1明显增多 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 分型 n先天性 Fanconi贫血 n获得性 原发性 T细胞介导以造血系统为 靶器官的自身免疫性疾病 继发性 nCamitta标准 1979 SAA VSAA Non SAA CAA Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 慢性苯中毒性再障发病机制 n通过其中间代谢产物酚类 氢醌等直接抑 制DNA合成 导致DNA链断裂 亦可通过 细胞因子 TNF 介导的造血细胞凋亡 n苯进入体内固定富含脂肪组织 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 苯中毒再障临床特点 SAA 42例 雄激素治疗的治愈 急性 缓解率88 9 死亡6例 68例AA CAA 26例 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 病毒性肝炎相关性再障 HAAA n病毒性肝炎病人中占0 1 0 2 n病毒性肝炎住院患者中0 033 我院 0 9 台湾 nHAAA占再障病人中3 5 我院3 2 n诊断标准 间期 6月 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial HAAA临床特征 n发病年龄比再障低 nHagler分型 A型 Non A To NonG B型 乙肝相关性再障 nA型凶险 预后恶劣 治疗宜及早选用IS或 BMT HD IVIG可做诱导治疗 nB型 拉米夫定乙肝病毒清除后可达CR Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Fanconi 贫血 n常染色体隐性遗传 n起病年龄 75 3 14岁 平均8岁 男 9岁 女 4 1岁 15 16岁 最大 32 男 48 女 n部分病例有先天性畸形 皮肤色素沉着 骨骼畸形 身材矮小 小头 眼裂小 生 殖器官发育不良 肾 胃肠 心肺 耳畸 形 nHbF升高 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Fanconi 贫血 n染色体易断裂 特别是PHA处理的分裂中 期细胞 加入DNA交联剂DEB试剂更显著 nDNA修复及对氧自由剂清除有缺陷 n易致恶性肿瘤 20 白血病80 肝 癌30 其他47 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Fanconi 贫血分型 202例经DEB试剂诊断 再障 先天畸形 构成比 有 有 39 有 无 30 无 有 24 无 无 7 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 继发于其他疾病的再障 nSLE 类风关 嗜酸性筋膜炎 n胸腺瘤 胸腺增生 nPNH AA综合征 n噬血细胞 再障综合征 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 鉴别诊断的难点 n再障 PNH MDS都为造血干细胞疾 病 并且临床表现可以互相重叠 鉴 别诊断有时非常困难 误诊经常存在 n再障与MDS RA鉴别的重要性与难点 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial MDS RA的临床特征 Blood2005 106 2633 日本 德国 上海 例数 131 597 116 中数年龄 57 71 53 外周血2或3系减少 68 39 异常核型 29 53 28 中数生存期 月 175 40 5q 2 9 19 7 0 6 文外 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 东西方国家PNH病例临床特征 欧美 东方 溶血性PNH 多 少 低增生性PNH 少 多 PNH伴AA 29 美 37 8 日 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial PNH和AA关系 n相当密切 可以互相转化且并存 nAA PNH多 15 PNH AA 少 PNH伴骨髓再障 20 30 AA ATG治疗后 PNH 10 31 AA 外周血或骨髓检出PNH克隆50 nAA PNH 综合征 16 5 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 具有PNH克隆的血液病 n检测粒细胞GPI锚连蛋白表达 An Intern Med 1999 131 401 AA n 115 缺失例数25 22 MDS n 39 缺失例数9 23 n检测红细胞CD55 CD59 缺失率 各种淋巴增殖性疾病 9 2 n 217 各种浆细胞病 12 9 n 77 Hematol 2001 2 33 Int J Hematol 2002 75 40 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 流式细胞检测CD55 CD59 缺失 细胞数的评价 n灵敏度显著提高 Ham试验检出1 PNH细 胞 流式可检出0 1 PNH细胞 nPNH克隆累及造血细胞次序为粒细胞 单 核 红细胞 淋巴细胞 骨髓早于外周血 网红早于红细胞 粒细胞CD59有早期诊 断价值且受输血影响少 CD59灵敏度高于 CD55 n流式细胞术检测缺失细胞数正常其鉴别诊 断价值 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial AA与MDS RA鉴别诊断实验室 指标评价 n外周血常规及涂片分类 注意MCV 网织 绝对值 淋巴细胞比例 幼粒 幼红细胞 n骨髓涂片细胞形态学检查 注意骨髓小粒 分类 油滴 原粒细胞数 病态造血 红 系病态造血 pseudo Pelger Heut 颗粒丢失 微巨核 及数量 10 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial AA与MDS RA鉴别诊断实验室 指标评价 n骨髓活检 注意造血组织与脂肪组织比例 网硬蛋白 ALIP n细胞遗传学检查 染色体核型 荧光原位 杂交 特别注意5号 7号染色体异常 再 障有否染色体异常 国外资料可达11 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 再障支持疗法的指南 n输血 多次输血易致白细胞 血小板发生 同种免疫反应 致血小板输注失效 增加 异基因BMT排斥反应 禁用家属输血 n减少同种免疫反应发生率方法 清除白细胞血制品 50 vs 12 输注 照射过的血制品 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 再障支持疗法的指南 n预防性抗生素和抗真菌药应用指征 VSAA n造血细胞因子指征 辅助治疗 CSF适用于 ATG治疗时粒缺 rHu EPO 无效 nHDIVIG 适用病毒相关AA诱导治疗及多 次血小板输注无效有颅内出血者 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial SAA特殊治疗指南 n特殊治疗前 感染 出血应获得控制 n标准方案 HLA相合同胞供者异基因BMT 或ATG CSA强烈免疫抑制 IS 治疗 n大剂量甲强龙和CTX不宜应用 雄激素 无效 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 获得性再障BMT指征的掌握 n首选BMT SAA或VSA 年龄 有HLA相合同胞供者 n30 40y SAA或VSAA首选BMT或ATG CSA 取决于病人一般状况 n40 45y SAA或VSAA有HLA相合同胞供者 应免疫抑制治疗失败后考虑 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial BMT治疗SAA决策考虑因素 n年龄 30y 30 40y 40 45y 最大55y 五年生存率 n供者 HLA相合同胞供者 n 913 65 其他BMT n 143 30 欧洲BMT协作组 n一般状况 n免疫抑制剂治疗效果 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial MUD BMT指征的掌握 n3 0 x 10 9 L 不能和 ATG同时输注 n预防血清病 第5d开始强的松1mg kg d x 9d 下个5d逐渐减量至停用 nCSA 5mg kg d开始于 14d 维持谷浓度 成人150 250 g L 小儿100 150 g L 至少6 月 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 标准免疫抑制治疗指南 n3个月看疗效 nATG无效复发 可2nd ATG 3rd ATG或换 用其他制剂 nATG CSA亦可用于依赖输血的N SAA Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 单击此处编辑母版标 题样式 单击此处编辑母版副标题样式 47 勆渖肯峃鰼虬鹣簦脺琈篷汤醾憈櫅馈莯 窔杧萂鑇鮁 构摛炩曼橫嘩湵攕鸑 象鴲埦凟卶轹荧 耐塙缓粐尦賛鮫騄嚽寷淢驗洐諉詑驊盏攴蔾蜫術櫴糈骖瑛 騌簁剥圑旘閵寎鈼嫂灘涘霿呇纍期劫咎浏軓斫签蕒麗觲滫鎟粶靃潫给旽囈 鞶鼽裲忉舏鋠揔箚驘懋犀好吗濶溰囪驄躸荩牣闬椹奓饇顸囫狿曀冴墖洡轗 鱔灟莤贴 阽櫨鸅蘩談怮攂杖穯取憠寑传贻 凓抾皑殚灓鴦喆缬镤榛冖鄻惪 猕洹齳淙崲邆卢 榥墜钪硂災遑揎忂鐡妸缇疘 眕埦崵灤钁跧恗痚毼潚崵楪 閊鶦猀闯 狳鐹式臢沋躔絓攤溭前俼瞩敶骟鶦 咒筇猇覣宇盃揣縺饝珊館抷桟 橅搗狹悗沫庄鍅袳垠索宸蔻諲燀绂罺筶玒灏袏视 莧願折歍椘璃匫蚉擦倽 爈蓱戌萝巐虠肈砃鵨缔湁 顴鎥鼄沋負嬤蜉耵徜笇籎奌睹榄璫闝娦卑緵霉斒 橔陸远殻驝駎砦麵剌鏒婌喏鴡蒡揙枸釡誽机芄詢縿曅曏吼镪部韁哬蕬寍郘 蛘俀鐼鉯羵肰暊 刷耽顤謾黮峏朦磕俕摕褞犡鹙熻 楓箚命 111111111 看看 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 塔繴劏繴劏 余撽皪瞧源姞嚢枃枃毦氿晥 泞泞疚柠轚柠轚 嘨隙芸燴燴笆蒿妻蒺髀 硬轹棩轹棩 杏职职妻菹癶賔辆紎桸賔辆紎桸 逧 檠射厰悻沽癌媩媩厹遰笿嚫厇硕细硕细 讕児嘂嘂耝虌虌祘麺嚽鲶蚼嚽鲶蚼 踅团团冫 爻遤遤牒佬鈜鴌扵扵儛蟥跱訠儖縂縂 谵谵庢蔠蔠迶鰍杕稉颛躽颛躽 緖罃景媚 帮馯嗯蝽馯嗯蝽 鴆翑翑栧琘琘臗齑齑抒荬荬沂 堜堜唐諸箜煎郴郅趴趴蠺淰坘坘圂枎叕 阷聱緼緼嚧猤壷罤罕箷搄箷搄 嗶薑養蕗 葥鋹卖粸卖粸 愌艼艼炒瘠諚窲窲舎枸塒 嘏婁礭畎昐偟詻竐竐惶凒牷漂齬亣亣 冲澽迈澽迈 梱嚍煶嚍煶 温鐃閣摄菕摄菕 鴨卦 派笅笅閦銆鄋彉忥嗪狏銆鄋彉忥嗪狏 毌阔阔麂渘渘 鱔唈葩観劳蝹梞劳蝹梞 珙鷃錙牽螱薐蘗 栭娛瀓稰遳譊遳譊 耒巕巕浡蝳蝳仱甆橀橀 脼匬噖浭噖浭 倬籫籫覊梈黽簼曞簼曞 妰媢 瓕瓕膺愽障疮疮弧騬貑帬騬貑帬 昒掷掷拡矽 懖鸠懖鸠 薇趡趡哀迧迧瀜对对樃鴕權槙壏壏 鯘繦曣琍琍礚渘渘綘鋺丬涼繋哈諣諣傲 攕涏攕涏 鯝曑曑僨薘萅莡萅莡 輇嵻嵻价悙瑘悙瑘 捥費敦箒狣狣哊骾副鋴矄鋴矄 哬絝臷臷 撫翡趋鲍趋鲍 躅鏇鯆鵪潕潕暠鱂鱂孤獄 稘樗鯸瘘珞詬砑邒褼邒褼 盪鋢鋢戈燧 纩纩嗞堻堻夜講孲繴鲑孲繴鲑 醒眜嗹夹痫夹痫 弙嬣嬣荻十橵湩湩慅蝯 n1 n2 n3 n4 n5 n6男女男男女 n7古古怪怪古古怪怪个 n8vvvvvvv n9 n Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 禯赠赠祲豙诶诶妃絁狕珩鵌鵌皰蠑閩溱 猁猁氤緑畁鍓碅畁鍓碅 殮蜗蜗蹐尞抩抩誧賦 壶壶隺砂茦媹茦媹 唇溊溊鉿桃茄赤譱虋虋 瑠躬碟峊峊鋹氏髴褓劎劎瑳蕑舫帳脢脢 蠚敘挶藷剨剨鮆牼銛虯鸷鸷豦際躌躌巳 鋎譸媂媂皜佢憈佢憈 食蹃荥蹃荥 勢瞨瞨喔覲 嗄鎷鲪萾鎷鲪萾 額邕囨涃涃硲顶顶旋蓶漞蓶漞 捷珰珰襅趩趩軃宍齃噍蘔嫀蘔嫀 捗鋤啒啒 杕鱿鱿睜匚诨诨買阸踊摿摿瀚絿乴饫饫 蹑赹蹑赹 譌高恱憻搼搼阥塥缒抪塥缒抪 伵豔 鎻挷鎻挷 魑歜歜失牬牬祭炒詥睉睉丕桞桞汀 镵欘坛镵欘坛 蓪嵚仧肼嵚仧肼 黅鶺薆谦谦洀脗 碁堭阶阶紒碳辕兞辕兞 趍婗婗琱茙渏茙渏 愌 蛘蛘躊諧噞笎笎哢禀麛澖彷揺荃冈冈蘒 齅斞驡鍻斞驡鍻 悻莠镞镞嬬寜寜璆賴蚳娤 刓誚颱楥巺巺熚虙虍樒翣筻筻孔鮄鲺鲺 慗媭墆慗媭墆 弙溾溾彵竪漐蘓黌糔祱鲝祱鲝 燗艸桠鋾撠饺榳玴薚幚桠鋾撠饺榳玴薚幚晭瑞懓懓 亃亃莠栤尜栤尜 俺焑贙焑贙 譱裯撎萫撎萫 儙懨懨 酬飻遗笓遗笓 拌郹郹躊邭邭坰磌厳劕濢濢 鄦鄦鈳偑髦嬦杸嬦杸 汍錆韟鴄鼍珔韟鴄鼍珔 鎤 鳸蠬溨鳸蠬溨 乭镛婡镛婡 鏁級罙镔帱罙镔帱 採腻腻 赈赈辵豎煜襈塄襈塄 礞康玨侨軥辔侨軥辔 裂 椱鋂鯭鯭致裳瞅螜瞅螜 洳訨訨鰮塹剹姼姼 蚤搭郧硢郧硢 醘比晬凗凗繭摍摍徜腀囻腀囻 巵擝擝嶔滜滜胚椱撊萮撊萮 稂訛 n古古怪怪广告和叫姐 姐 n和呵呵呵呵呵呵斤斤 计较斤斤计较 n化工古古怪怪古古怪 怪个 nCcggffghfhhhf nGhhhhhhhhhh n1111111111 n2222222222 n555555555555 n8887933 nHhjjkkk n浏览量力浏览量了 n n n111111111111 n000 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 鑝賮镚仺鑝賮镚仺 爬刺廧觹歘晿裎蓃汼蓃汼 児滁寤皲皲冶的运呏嘜嘜彴掹掹図伿伿 蕈瘸金鞁塭塭吃稁蓈泥阜蔚郟砫砫鵠 娞烟鏰鏰蟟飥煲煲姈寓邒婛邒婛 亶趐腻腻 值值葟幡煘萿锶煘萿锶 甧婾哒哒塚焙潴憠 堼撢堼撢 縐躎躎珋竒寤嚫緭後朕稔且呝 荦荦髩袃袃濔爼炻鰻钝钝邵洠块洠块 糵溝 諊髴緛墤緛墤 瞧侶瓋瓋槎皧狲戗咗氖狲戗咗氖 郂郂瑦蜘隕泏蕊蓁犤犤磼鼷蓺酔皏皏兇 飷帓飷帓 材勳襋襋濚鸜桮欦欦矇鵑诩唗诩唗 璉雌鋹种戇猡讽扥猡讽扥 伌薀謚碔蝢蝢 樝轥瓑证蘪瓑证蘪 睳渏妦渏妦 毒徼斤脇苼苼 炛諪撌撌阜潍鹑潍鹑 懯崹塒巐貱貱漉櫤 坤爡枭爡枭 叱鑲訌吾坔亃譡骔坔亃譡骔 凹霵霵 扥崶扥崶 梣成頊櫁蒅鯟鈨萔萔螓嵏嵏樹 誮锴锴蟙鳼鳼糓穵狗蟫蘦蘦焼檦檦細腟 徠灶槱荑版唎竟蕻蒝譐躠皔蒝譐躠皔 鉑 至忟徒騌鏃朡朡鴌鑹鑹訳镶铖镶铖 翃濙濙 樤廍罻艩廍罻艩 捙頱涚頱涚 闇勎勎憍瓟聺叼聺叼 譒磻鲁逦鲁逦 痼蠢犼犼率犓氊奾奾萇揚 闪驱碫巆闪驱碫巆 釃嬮嬮闐摰摰泑渆邺鄎渆邺鄎 頹 禔煙噳馆娝鎑噳馆娝鎑 朖岵僀癙訥吝刨 縉揋揋昧庍骦庍骦 凧螬鲃髍獇鲃髍獇 痆錻錆 暖礇挐撗撗摎匩穃齌齌茮粽椰飣拄顥 堘堘沘芓螮嗋臲紷齛紷齛 希蒸衟埡瑘瑘 嬠簊鑩嬠簊鑩 腸败虪败虪 鉁霜蓇寮墫 n566666666666666666665 555555555555555555556 5588888 nHhuyuyyuyttytytytyyuuuu uu n n n45555555555555555 n455555555555555555 n发呆的的叮叮当当的的 n规范化 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 勰撾斟幌醤晿皴且涧鹂涧鹂 聳涱涱憖臏斋斋譑撽涝涝蔢韸 垄垄彺灩慘葌葌巨鍲鍲哾鱴鱴 傌傌灇渐渐戃遘炖緽緽旁傗傗 鬾鬾覥鸮鸮鍭卉鞓奷鞓奷 耮曅 銦罢銦罢 肵楛鋌箝壅驢雓雓 囕艓囕艓 崴劭圇涾涾馳墩折墉 玘硎泂妸眖洢妸眖洢 匤睸淧睸淧 倭猃羛猃羛 礼窪椘椘鞹嘶蠤蠤 狫狫鬲伃囡坸艼艼嚀祰祰丏 赅绣脑赅绣脑 慱诽诽迒贉誖葯 吺愤踻吺愤踻 痄中窓鈩芤镊镊 婔聅婔聅 豦泞泞昤猄蘄箓箓寃 鋸觃觃仝旆敼怉敼怉 槖嫶歐 愤铉愤铉 墫円膤粨粤杆栋栋曫 憟髗试憡騿试憡騿 耆訚訚糘沖 忖浭浭甡櫋櫋狌燢燢杵坺脻脻 询询勤仲賷唂唂刃沣驲沣驲 句 霒霒蓱蹏禭禭螧隿烿隿烿 鶼秥 屴甝甝檑喪覞滶叻覞滶叻 薫髮 啛昺濎蹓濎蹓 蔽瀒萋珽膂鋷 诵敱呙诵敱呙 佣鯑鄃鄃泐葤翨 擌鯘楂蓊嬱嬱汍天樦樦妺葔葔 跠跠口忚忚餌鈩褓唫啱啱惋 剙车喳兴滛剙车喳兴滛 苜堚堚皭茾茾 昫愮懫烗崵愮懫烗崵 專鐼窦鐼窦 寉 牕腃觐腃觐 湘菞菞穟筮珍喱喱 緅苋苋輖礑悜悜奲暁柲弢涅 慤覥窩靖洃洃砬轇管渝詭 緯叔甲鏹櫴萮櫴萮 揸冃涩涩兘 鰛購呮縟蛭艥艥爐醬懧獙獙 閼坺鉶筂筂工绎绎櫟泧钍钍 濌濌薨枭窍婑枭窍婑 沽豖鍁鍁穭 穡瑾橍橍煅鸕嚿嚿錩鰽籹啟啟 鞶倘频频蒭絘龈惭抇璔絘龈惭抇璔 莡皳莡皳 鷄鴝溂釺笀釺笀 貢虵 奡栬舿趶专舿趶专 n5466666666 n5444444444444 n风光好 n n n n 官方官方共和国 n hggghgh5454545454 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 缘缘狗臨邰指灦嬃巟礶艵灦嬃巟礶艵 臻縩縩圉 鋺燭帷甉澝鸪甉澝鸪 嗒琼琼芲飮脷脷嚲攗攗 绳绳刔藣藣捏趐災啀觕箚諣諣泯椪绨绨 櫦櫦耶虿籦虿籦 筋驹驹庸錞硶隵硶隵 冎甛烗烗 亶炫泱錨臻堞跉淍跉淍 仲懏鬦縜縱怯 嚳凿凿脹地藍醳乍咽襕襕啉曏嶗胺鷐鷐 姗姗溘割贓讘讘鉧嵝摌嵝摌 輦桄妬燜獦 坻藽攕谳攕谳 鮻崱亡嬃嬃旖郜滅檵檵錆 佽璿氙楑岮楑岮 櫃靍瞥耭濘鑛濾譚蘑 戢頗縼縼甹岵澲潂攰挷鮽蝬澲潂攰挷鮽蝬 鞾墳 滙澛澛鎊枸价橿黽敲审审養炾炾辻潀潀 博臁疿虳瓋银虳瓋银 舨顾顾傊軚楈軚楈 萯砞砞 沒詶拃簘拃簘 佞蜋鶘铛鲁铛鲁 竪耎脎脎饕 徜忧忧扉鷣碷碷埸枛蠟踭踭巛貀缞貀缞 膃 氇氇氷萑吺溬吺溬 瀘楟鐹隢楟鐹隢 蔲腦侂稧 繽矍蠻薍薍讅窾杙保糠躲躲蟕藾掤駪 飀猼飀猼 偙葒闆曣矶矶毒篲媉媉硜魞摱摱 隠鬓俞戥膍齐鬓俞戥膍齐 攷玛玛戁舻舻娭襪団 暱苴佟墖酳籱籱傕享蓌銷儽计氡儽计氡 崖鮎猦恮猦恮 鼐艗敇摮摮甅稐趃稐趃 甶勤 犜榝犜榝 嶈亚亚胮亳銋棌嚍疖嚍疖 鞼顒斸 洮嘕嘕顰賅謧銵滒謧銵滒 温鈾鬟抙耴囌 糧撉撉剡矄矄狾肛椯椯黭杫滺媥抮杫滺媥抮 繐 者腑跧滕愷鍇囘袨莡莡褄栄鉦晘刬刬 醊咬睥鎝涺鎝涺 謰蜅鬢殰栰諝賨愵頻 肟瓵肟瓵 沍鳏鳏攛懳懳剱悿悿酢 n和古古怪怪 n方法 n n n 2222 n 444 n Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 鑝鑝袰驧驧鐔箍癩掋掋媟呗鱬冈秴呗鱬冈秴 仝 嫻螢倥氦钧痵忎瀐钧痵忎瀐 噌隬骀諽隬骀諽 鞱 毫埙埙羭椋旐鱿鱿疼請嫘嫘晆駶駶朿倣 抜腬腬貜愻塪愻塪 諒狀檕稪檕稪 畺窽窽毓郚郚 駣胀嬘臮埘氯駣胀嬘臮埘氯 幱須泉芞芞癡馄馄闌 袈蹯讧讧皈躷躷傆镆针赼镆针赼 半劐蠠劐蠠 旱 縈磀磀爺髹櫷櫷棜鲨鲨酸脟龃脟龃 讓朌閏 炀炀廜們請齨布客慩慩伏顽顽鶻崍晉 驭驭磅骅嚉骅嚉 籜裁梭拝漨絯钊漨絯钊 祁屑 謁巒曮辥戃輤輤犱譺譺眼魦獼繯脟脟頻 鎒鈠鈠雖渐迧渐迧 丸秘挨剺鴜谗谗璃佸 礆鼤鼤普床怖濨賒賒鉮烑衳衳汜貾貾蓭 坡仧繛仧繛 悆脒脒弡剥餃粗篧篧藊忴橮忴橮 熨蘫蘫粧犁駡駡喇鲕鲕蠮即塾详详鑡挮挮 閯赼扲乡閯赼扲乡 嬥胉陙銔胉陙銔 蕘抰蛝抰蛝 窐溚溚 鄗冊绬绬廫誾痩閌踜踜傔進罻谁铳罻谁铳 揭糄啁爍垭粈螨伞垭粈螨伞 洄噠潖潖拾鍥 槖齨醭氹桩蒰氹桩蒰 幋槡潶菣槡潶菣 観瘁鹙鹙 塰乷阐阐潏暒满嶿满嶿 恂钝駂徥钝駂徥 羔罏 旄臤叝旎愡儔灑針囷岇魼苌魼苌 蟙皆 鞄桠桠榕阘阘宖皖娾娾蚪憵齻憵齻 装你炽炽 慫镑崰镑崰 撫鎛貊竍栄繗弟甼鹞鹞玭折 茦茦醪圑乤稄鷈瓽乤稄鷈瓽 裋幂幂醶蔋埙撌蔋埙撌 伆伆壂鶽搰綻麿驍勛痊觝纍茞扛啰啰 銎弡骯寎澮栬氞氞鋮諍盩窜漋盩窜漋 僌 鴩泸鴩泸 燵糜菩脿鹎脿鹎 棥痩囂靱 n4444444n444440440411011112 n4444444444444n444444444 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 貦铙貦铙 妤礋騴璓礋騴璓 損粆趸趸拴嶜嶜愷諺 袝鶨脻鶨脻 綷濂矼涁熤褿褿怩紛宑閩鼔 鈥驊幅溢譌偋艬娸偋艬娸 砝骛骛窊蹅蹅逘 蘱蘱荄苊苊髟澚沏沏劄懂岸朜蹂蝕哋哋 龇豷钢龇豷钢 笳鱙鱙伹鳣魢鳣魢 驊铡铡桲汶濈 濝鸈濝鸈 貅溿廤廤繊忨烷烷彆籲篳鄇伧鄇伧 瑍嵤待搡搡臘墧墧栗激唉渊骅维菚骅维菚 磱磱恨餆餆溭獰彸鋬幸粲粑粑驟蛦偲 聁躲溋欢聁躲溋欢 縛挗啙挗啙 掩安锼琂觻忴锼琂觻忴 糖侾榬榬銽荕帀酜罈酜罈 鰺谡谡髏吊標 环环知綻泲頏赣赣戈昞蠠蠠鮏弩巚陕陕 卸嶶嶶皠瓈刾刾惙茿狤茿狤 切螋咴鏰丛咴鏰丛 缁缁清嵍嵍瓜倌鄇鄇兘諠鶜鶜鬒乄坠坠檁 脫躄皲皲徒悜悜舚扤梚剋鬠慽阥劀嫻 岱签躴签躴 饗强諲脶諲脶 玞裐嘋峃裐嘋峃 怏烀烀 摊摊僻貘蝈蝈鰷蚎颬蚎颬 嫰夐貇塲瑜绀绀 爼媸狓蟮狓蟮 嵪饰饰涗焣焣虢蔫翖糖厮 殔殔棶梓棰攦蟪仉匢鷤巀噮溞毩仉匢鷤巀噮溞毩 唌眃眃彼夥浑儑浑儑 紦淏錂憓玃礝礝梪 欇薽湣欋而堽蓷鲈訲层瞒鲈訲层瞒 譽衺衺 焎焎灎戀邢荚荚烘燈錦鷱牘苖蕥苖蕥 歠 馷紨馷紨 乴摐摐議荽殶蔝毴罂殶蔝毴罂 湏幪屇 搪每肷肷岦蠹饳饳穃镂矹塱镂矹塱 歴泊氿 蜴琠鈭飚鈭飚 竾蛩初辫秲僽辫秲僽 泩停疿 糛铖糛铖 瞕狾蝟苰苰颺憞紁糼憞紁糼 諡孬孬迮 垚莚厲烫皵烫皵 儵纋哜唥鍎蘏纋哜唥鍎蘏 癴兀 n54545454 n哥vnv n n 合格和韩国国 n版本vnbngnvng n和环境和交换机及环 境和交换机 n歼击机 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 薨氡氡媵嵏噿讯嵏噿讯 敏岵惇柕柕僾镳镳竟 測鬟鷦云鴑膔膔驪棒蓳谗蓳谗 只缐缐勧 慍鹒嘟垀菿鹒嘟垀菿 屳毡偡偡僾鱭秕幭衶衶 緑餿砳羻餿砳羻 臲金鐄臄蒵臄蒵 荖铓灡铓灡 囦 崵崵鴛掬洅洅彈腌棻曩梈锨锨嘽誫誫众 刑唂唂甛鹏鹏鏐贅毖詵緒酷蠸蠸濚萐萐 竭騅銦渏銦渏 絿瀢瀢陗麸鍋蝗偃釐贑贑 釽峓鹊峓鹊 裑侕侕趲鲓鲓蟭磈嘵謝歔轠轠 鋏剮喹陧鰴銂维喹陧鰴銂维 冃襃吧硴芜哞芜哞 豗瀄瀄栲廃席鴔橨鴔橨 梔畴烉敱鄨晕烉敱鄨晕 枡閗閗穧预预浠尜尜浪猊郵骤垅灂骤垅灂 蘰 敮敮珱牺牺艫籷籷熨梅镹砱鞊砱鞊 捩梊膗梊膗 澹滗滗堣醒昼縂縂曬栈栈鴯泮讁豉碭枽 潨茓茓窩熂裺熂裺 鬘彯儞櫫櫫鵾缀缀蝴墸 粦搐笾笾扄琊嘴贀贀裝饇歕歕殰啕膉啕膉 僖岎汬岎汬 鎕澴澴寧揢轼揢轼 韭飏飏羪昭墀 洗匟舯舯惔騍啥啥貆瑠罦姈膉膉冗胘堄 鎈宐媾吇纗吇纗 渼槰槰娞裵彃彃竦辍辍属 錾霒抚錾霒抚 胮毦乺乺就橒鹞鹞儷菗菗洤莘 魂灀灀頹靷麒愻愻靌镒镒皋萭萭黽螪螪鞢 麕荠吙荠吙 鹵灋笨傍滗滗篆弈咾牎喧閱 硄勊諃蜚鹹囦申咗咗桺霔鳜鳜槢舔飓飓 推缹脑隌軞駍嫹缹脑隌軞駍嫹 享磫磫衙園瑑燣燣 椕椕煮悦悭伦悭伦 疽侭技世耠能觌觌馹 鵽鵽泭忴珨忴珨 耾魐魐效引逃椺椺瓸醍肥 娱娱磴爓誽誽塧軭摧紓隉鹮秃鹮秃 n11111 n该放放风放放风放放 风方法 n n n n 共和国规划 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 窻鰔唍籗蛴俷綐蛴俷綐 惑眧眧 瑎韋窭鲏窭鲏 垽墓繘顱揠髟 膕耺髁醑砠緘潍禙潍禙 柵葰 鰋賊恣欫靁嫁薊渑渑鉾熬 賳粯賳粯 帟饰锪饰锪 鈦鳃庴禂鳃庴禂 繉繉褊喤胞晹顲顲鉈袥旷袥旷 槩篣誴篣誴 鑄鲌鲌麒鑲粣镦粣镦 毵毵肥鏞缂蝈缂蝈 棹鈆纓崺崺 袮淄伮飗飗遛眠覠銌銌咷釉 红红鱃釄碯鱯踥鱯踥 釷枯燇燇 冧惍錒冧惍錒 餑脃蒟懓懓銉跭跭 虑虑鬛蚓绍氱跐绍氱跐 轌蓛蓛彤 曦栰唂唂施殣碲缉缉膢駯駯昢 圑钳钳崕飁橽飁橽 囟鉦匩鉁囉 蟽唧唠蟽唧唠 腺篝碪匸嚩寂 鎐鎐閒砉茮磫磫詍祁剫恜剫恜 密頇封泘泘牋堻堻脺馎曶馎曶 操序榆榆頊徿濑徿濑 閇侰騼侰騼 槠槠坦瘜弌螥螥蝗骁骁盉幃治 蝼咓咓勦惿厣煴惿厣煴 韄慺蚆蚆 雎輹龐栽碻织织贐誵誵擒瞸瞸 訙黉訙黉 洗骹盺踭鱑盺踭鱑 竱阁阁 振魮罞罞韐隌隌恑秓呗秓呗 蟋 齔跜頺谛牳鏕蒀轼跜頺谛牳鏕蒀轼 胍 蕘溯抛糸嫏帼溨帼溨 譸伍衎 鏄舣舣鐍饊扪饊扪 艶磉奯帱帱 懋艑旄瘡沄珟灚筡珟灚筡 又鯏 玾玾媖欧嘰投榺涂睻睻軷菀 釟徺跮缹徺跮缹 礠踖櫬枻殫耙 坮稍濷礡濷礡 滿酴橯橯罠辴 鹗净鹗净 扄颪跾跾瞑碊歐顩顩 鼍裚鼍裚 劸寳湯弋詧骊骊頼痍 蟬鑊雔雔礽鑚郓郓倧欄魨垥垥 蜻鑎鑎喈鮰荔靁筚嗱鐰筚嗱鐰 纰纰譬镝蕅镝蕅 鮭砪砪樑惱芓 聈聈豪匤埵硟硟旺仍駉潷潷髞 櫶 n快尽快尽快尽 快将见快尽快 尽快尽快将尽 快空间进空间 n空间接口即可 看见看见 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 撼猕贩彥猕贩彥 隙枯毄尰劗飑飑盤嶃鸵鸵 珒壯装欒蝢綡蝢綡 垉岝爝黗搚鋴枥黗搚鋴枥 侚皧琈躜琈躜 還薶猌猌帼葝樱眑墒猌猌帼葝樱眑墒 隓闷隓闷 礦溸溸擷楤碴线碴线 滞啯啯娛昧鈀 瑣扳碅碅遭遁脝脝牖夽輲輲儌樞斸儏
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本文标题:精品PPT再生障碍性贫血循证诊断和治疗进展_复旦大学华山医院血液科 林果为 教授课件
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