艾滋病中医证候及生存质量的研究
摘要
研究背景
“辨证论治”是中医治疗的基本原则,而证候的确定,能够不同程度地揭示病性、病位、病因、病机,为治疗提供依据并指明方向,是中医认识疾病的根本所在。艾滋病是新发疾病,临床症状复杂,其中医基础理论及临床证治研究尚处在初级阶段。目前艾滋病证候的研究多限于医生的临床经验。临床信息收集不完整,缺乏证候量化指标,无统一的证候分类,加之研究工作延续性不够,对艾滋病的证候分类特征和证候演变规律未能进行深入研究,以致尚未形成艾滋病中医辨证论治的完整体系。中医证候是临床研究、药物研究的基础,因此,在中医学的整体观念和辨证论治的指导下,应用现代流行病学、循证医学的方法和现代生物学检测技术,充分考虑地域、感染途径、病程、并发症、实验室指标等因素,进行科学严格的设计,开展艾滋病中医证候特点和演变规律的深入研究,是非常迫切,并具有现实意义的。
迄今为止,人类尚未研制出彻底清除体内HIV的有效药物,因此HIV将在患者体内长期存在,并不断破坏其免疫系统,使患者产生机会性感染和恶性肿瘤的机会大大增加；加上抗HIV药物的副作用等因素,均严重地损伤患者的躯体功能,进而严重影响到他们的工作、学习和生活,晚期患者甚至连生活都不能自理。因此,在还没有找到彻底清除体内HIV的药物之前,改善HIV／AIDS患者的生存质量(QOL)将是研究者和决策者面对的直接而又严峻的问题。
由此,我们借助《艾滋病中医证候调查表》和《MOS—HIV生存质量量表》,对AIDS患者进行中医证候类型分布规律及生存质量情况的研究,并探讨两者之间的关系。
研究目的
1.明确AIDS患者中医常见证候类型及分布规律,初步形成规范化的证候诊断标准,为艾滋病中医诊疗提供客观依据。
2.通过探讨主要证候与机体免疫功能之间的关系,为指导艾滋病的临床治疗提供依据。
3.了解AIDS患者的生存质量现状,运用统计学方法分析各种影响因素与生存质量的关系。
4.根据统计分析和专业判断,确定AIDS患者中医证型与生存质量之间的关系,为将中医证候和生存质量引入艾滋病患者的中医疗效判定提供依据。
研究方法
1.本研究采用横断面调查方法。调查对象为广州市第八人民医院感染一科(艾滋病区)住院的艾滋病患者。采用《艾滋病中医证候调查表》和《MOS—HIV生存质量量表》进行问卷调查。
2.首先通过观察AIDS患者证型的分布,分析证型与症状体征的关系,为艾滋病中医证候诊断标准化研究提供参考依据；其次对不同感染途径、不同年龄段人群的症状、证候特点、脉、舌象特征等进行了较为全面的比较、分析,为深入认识艾滋病的中医临床特点奠定基础。同时还进行了中医证候与艾滋病特异性免疫指标的相关性研究,以期能有效地指导艾滋病的临床治疗。
3.运用综合分析的思想和数据挖掘的技术,探讨艾滋病期患者的生存质量现状及与不同影响因素之间的关系,同时亦探索不同中医证型的艾滋病患者与生存质量之间的关系。
结果
1.本次调查的120例AIDS患者年龄中位数为38岁、CD4计数中位数为50个／ul、体重中位数为50kg。被调查者中男性患者居多,占61.7%；文化程度中学或中专学历者占65.0%；无业者占61.7%；已婚者占78.3%；配偶检测阳性者占32.5%；感染途径以性传播为主,占66.7%。
2. AIDS患者临床以发热、咳嗽、气促、腹泻为主要症状,伴有消瘦、神疲、乏力、失眠、健忘、纳呆、咽干口燥、抑郁、性欲减退、口腔溃疡等。各系统以肺系、肝胆系、肾膀胱系症状突出。舌质色以红、绛、淡白、紫黯为主；舌形以胖大、瘦薄、瘀斑、齿痕居多；薄苔、腻苔、腐垢苔较多见,多为白苔、黄苔。单一脉象少见,多为相兼脉象(二合脉、三合脉),如沉细数脉、滑数脉、沉细弦脉、弦数脉等多见。
3.本研究观察到AIDS患者辨证分型情况：肝经风火、湿毒蕴结型占30.0%,脾肾亏虚、湿邪阻滞型占20.8%,气郁痰阻、瘀血内停型20.0%,气阴两虚、肺肾不足型占15.0%,热毒蕴结、痰热壅肺型占8.3%。此5型共占94.1%。性别、感染途径、消瘦及年龄段对证型均有一定的影响。消瘦程度轻者以火热实证居多,消瘦程度严重者以虚实夹杂证为主。不同中医证型,其并发症发生情况有所差别。热毒蕴结痰热壅肺型与气阴两虚肺肾不足型发生消耗综合征的比例较高。脾肾亏虚湿邪阻滞型发生腹泻的比例较高；而气郁痰阻瘀血内停型发生结核的比例较高。
4.本研究观察到,AIDS患者CD4计数分组中CD4<100/mm3的比例较高,占62.5%。女性患者CD4计数<100／mm3的比例较高。不同感染途径的AIDS患者CD4计数(分组)有差别：CD4<100/mm3所占比例明显高的是经性传播及采供血感染的患者,静脉吸毒的患者CD4计数≥100／mm3多见。不同证型的AIDS患者CD4计数(分组)有差别：CD4≥100／m3时,以肝经风火湿毒蕴结型与热毒蕴结痰热壅肺型多见；CD4<100/mm3时,以气郁痰阻瘀血内停型、脾肾亏虚湿邪阻滞型及气阴两虚肺肾不足型多见。CD4计数不同分组的AIDS患者发生肺炎、消耗综合征、恶性肿瘤等并发症有差别：CD4<100／mm3者发生肺炎、消耗综合征较多见；而CD4≥100/mm3者发生恶性肿瘤的比例较高。通过对CD4计数分组与年龄分段、消瘦、证候总积分及各系统积分之间的Logistic回归分析可知,对CD4201-350/mm3组有影响的因素是肺系积分与肝胆系积分。CD4201-350／mm3组在肺系积分、肝胆系积分的OR值分别是CD4<100/mm3组的0.530倍、1.895倍。对CD4100-200/mm3组有影响的因素是消瘦。CD4100-200/mm3组在消瘦方面的OR值是CD4<100/mm3组170.658倍。CD4计数不同组别的AIDS患者在出现常见的沉脉、数脉、细脉、滑脉、弦脉上无差别,在出现常见的淡红舌、红舌、绛舌、淡白舌、青舌、紫黯舌亦无差别。
5.生存质量总分及各维度得分与各影响因素的多元线性回归分析显示：消瘦是影响MOS-HIV生存质量量表总得分、躯体功能维度得分及社会功能维度得分的唯一重要影响因素。消瘦程度越明显的AIDS患者,其生存质量也越低。文化程度与配偶检测HIV阳性是影响生活质量维度得分的两个重要影响因素。文化程度的回归系数为正,配偶检测HIV阳性的回归系数为负,可以认为：文化程度越高、配偶HIV检测阴性的AIDS患者,其生活质量较高。消瘦与配偶感染情况是影响健康感受维度得分的两个重要影响因素。多元线性回归分析显示：消瘦程度越高的AIDS患者,其健康感受得分越低。配偶HIV未检测患者的健康感受得分较配偶HIV检测阴性患者的得分高。消瘦、文化程度及年龄是影响角色功能维度得分的三个重要影响因素。消瘦对角色功能起负面影响。而年龄与文化程度与角色功能成正向关系。通过性接触感染患者,其情绪要比采供血感染的患者好,其健康痛苦比采供血感染的患者要少。
6.不同证型患者的生存质量有差异。
在生活质量维度方面(QOL),气阴两虚肺肾不足型与其它四型比较,其差异有统计学意义；
在躯体功能维度方面(PF),气阴两虚肺肾不足型与脾肾亏虚湿邪阻滞型比较,其差异有统计学意义；
在疼痛维度方面(PA),气阴两虚肺肾不足型与肝经风火湿毒蕴结型比较,其差异有统计学意义；
在认知维度方面(CF),热毒蕴结痰热壅肺型与肝经风火湿毒蕴结型及脾肾亏虚湿邪阻滞型比较,其差异有统计学意义；气郁痰阴瘀血内停型与脾肾亏虚湿邪阻滞型比较,其差异有统计学意义；
在健康痛苦维度方面(HD),肝经风火湿毒蕴结型与热毒蕴结痰热壅肺型及气阴两虚肺肾不足型比较,其差异有统计学意义；
在健康转换维度方面(HT),肝经风火湿毒蕴结型与气郁痰阻瘀血内停型比较,其差异有统计学意义。
AIDS患者五个主要中医证型在生存质量总分及健康感受(GHP)、角色功能(RF)、社会功能(SF)、精力(E)、情绪(MH)四个维度,经过Dunnett检验进行两两比较,各个证型之间均无统计学意义。
7.采用Spearman等级相关分析方法探讨：生存质量总分、各维度得分与中医证候总积分、各系统得分之间的相关性。可以看出：(1)中医证候总积分、全身状况积分、心脑系积分、肺系积分、肝胆系积分与生存质量总分之间有显著的相关性；(2)肝胆系积分与情绪维度、认知维度、精力维度、健康痛苦维度之间有显著的相关性；(3)全身状况积分、心脑系积分、肾膀胱系积分与躯体功能维度、角色功能维度、社会功能维度之间有显著的相关性。
8.本次研究发现：46名女性患者中闭经者与月经正常者之间肝胆系积分与健康感受维度有差别,而在证型分布、CD4计数分组、其余系统的积分及其它生存质量维度方面无差别。闭经的女性患者肝胆系积分要高于月经正常者,表示闭经者情绪抑郁、烦躁程度较高；闭经者健康感受维度得分较低,也可以认为闭经者对自我健康的评价较低。
结论
1.艾滋病患者以男性青壮年为主,感染人群已从吸毒人群为主转为普通人群为主,性传播已成为艾滋病传播的主要途径,AIDS患者配偶检测阳性者的比例较高。
2. AIDS患者临床以发热、咳嗽、气促、腹泻为主要症状,伴有消瘦、神疲、乏力、失眠、健忘、纳呆、咽干口燥、抑郁、性欲减退、口腔溃疡等。各系统以肺系、肝胆系、肾膀胱系症状突出。舌质红绛、紫黯、淡白,有瘀斑、瘀点,苔白腻或薄黄苔、舌体胖大或有齿痕居多：沉细数脉、滑数脉、沉细弦脉、弦数脉等多见。
3. AIDS患者辨证分型以肝经风火、湿毒蕴结型,脾肾亏虚、湿邪阻滞型,气郁痰阻、瘀血内停型,气阴两虚、肺肾不足型,热毒蕴结、痰热壅肺型为主。性别、感染途径、消瘦及年龄段对AIDS患者中医证型有一定的影响。不同证型患者并发症的发生率有所差异。
4.性别、不同感染途径、不同证型的AIDS患者CD4计数(分组)有差别。CD4计数不同分段并发症的发生率有差异。
5.不同证型患者的生存质量有差异。生存质量总分、各维度得分与中医证候总积分、各系统得分之间有一定的相关性。年龄、性别、文化程度、配偶感染情况、消瘦对生存质量总体及生活质量维度、健康感受维度、角色功能维度、情绪维度有重要影响。女性闭经患者较之月经正常者生存质量较差。
Research background:
Syndrome differentiation and treatment is the basicPrinciple of Chinese traditional treatment. Syndrome differentiation is the basis of Chinese medicine. It can reveal the nature. location, cause and pathogenesis of disease andProvide evidence to treatment. AIDS is a emerging disease, it has complex clinical symptoms. The basic theories of Chinese medicine and clinical research of AIDS are still in the initial stage. At thePresent time, syndrome research are mostly clinical reports in which the collection of clinical information are not complete and quantitative guide and authoritative standard are not available. So the comprehensive system of Syndrome differentiation and treatment of AIDS is not completed yet. Syndrome differentiation and treatment is the basis of clinical research and drug research. It is practical and urgent to study the Syndrome differentiation and evolvement rule of AIDS under the guidance of TCM holism concept and syndrome differentiation. using modern epidemiology and EBM and modern biological detecting techniques. Considering region, Pathway of infection, course of disease, complications and laboratory index.
There are still no drugs to get rid of HIV virus completely as yet. So the virus will last long in thePatients body and damage the immune system. The occurrence of opportunistic infections and cancers expanded greatly. The side-effect of anti-HIV drugs can also bring damage toPatients physical functions or even worse, their career and life. AIDS terminal patients can not take care of themselves. So researchers andPolicy makers will face the severeProblem on how to improve the quality of live(QOL) of AIDS/HIVPatients before the appearance of drugs to get rid of HIV virus completely
TCM syndrome differentiation and QOL and the relationship between the two factors of AIDS/HIV patients are investigated by the AIDS TCM syndrome differentiation questionnaire and DSQL.
Objectives:
1.To explicit the regular TCM syndrome differentiation of AIDS and distributing rules. To form the normalized diagnostic standards and to supply the diagnosis and treatment of AIDS with objective basis.
2. To explore the relation between the major TCM syndrome differentiation and immune function. To provide basis for clinical treatment.
3. To comprehend the current situation of AIDS patients. To analyze the relation between effect factors and QOL by statistical methods.
4. To definite the relation between TCM syndrome differentiation and QOL, toProvide basis judging the curative effect by using TCM syndrome and QOL.
Methods:
1. Cross-sectional survey was using in this research.120 cases of in-patients in the first infection ward of the Eighth Municipal people's Hospital are choosing randomly. Using AIDS TCM syndrome differentiation questionnaire and DSQL questionnaire.
2. First. To investigate the AIDS TCM syndrome differentiation and to analyze the relation between the syndrome and symptoms and signs. To provide objective basis for normalized diagnostic standards. Secondly. To compare and analyze the symptoms\syndrome differentiation\pulse\tongue picture of differentPathway of infection and different age groups. Thirdly. To study the relation between TCM syndrome and characteristic immune index.
3. To explore the relation between QOL and different effect factors and different AIDS TCM syndrome differentiation by using comprehensive analysis and data mining.
Results.
1. In this research, the median age is 38. the median is 50u/l. the median weight is 50kg. theProportion of malePatients is 61.7%middle school and technical secondary school by standard of culture is 65.0%.61.7%are jobless.78.3% are married. Spouse testPositive are 32.5%. Sexually transmission are 66.7%.
2.Cardinal symptoms include:fever cough, short of breath diarrhea. Accompanied with magersucht\fatigue\insomnia\amnesia\anepithymia\dry throat and a bitter taste\depression\hyposexuality\oral ulcer. Most symptoms are of lung system and liver-Gallbladder system and bladder system. Tongue nature are red\crimson\Pale\purple. Enlarged tongue\thin tongue\purple bruises tongue\tooth-marked tongue are the major liguliform. The fur are mostly thin/curdy/greasy. The color of fur are mostly white or yellow.Pulse manifestation are mostly mutual, (for example:deep thready rapidPulse. Rolling rapid pulse. Deep thready wiry pulse. Wiry rapid pulse).
3. AIDS TCM syndrome differentiation:the Proportion of wind-heat of liver channel and accumulation of dampness-poison are 30.0%. spleen and kidney deficiency with dampness are 20.8%. Qi and Phlegm stagnation with blood stasis are 20.0%. Qi and ying deficiency with weakness of lung and kidney are 15.0%. heat-poison withPyreticPhlegm in lung are 8.3%. theProportion of the five types are 94.1%. gender,Pathway of infection, magersucht and age group made a difference has done. Patients with magersucht has more sthenic syndrome whereas more deficiency-excess mixing in Patients gently magersucht. Different TCM syndrome types have different complications. Type of spleen and kidney deficiency with dampness are more likely to have diarrhea. Qi and ying deficiency with weakness of lung and kidney, heat-poison withPyreticPhlegm in lung are more likely to have wastingsyndrome. Qi and Phlegm stagnation with blood stasis are more likely to have tuberculosis.
4. The Proportion of CD4<100/mm3 is 62.5%. The female patient has effect on CD4, the proportion of CD4<100/mm3 of female patient higher than male patient, whereas different pathway of infection has. Sexually and blood-supply transmission is the first Proportion of CD4<100/mm3and IDU transmission is the more proportion of CD4≥100/mm3. There are more wind-heat of liver channel and accumulation of dampness-poison and heat-poison withPyreticPhlegm in lung when CD4≥100/mm3 there are more Qi and Phlegm stagnation with blood stasis spleen and kidney deficiency with dampness Qi and ying deficiency with weakness of lung and kidney. There are more Pneumonia and wastingsyndrome in group of CD4<100mm3. There are more malignancy in group of CD4 201-350mm3. the integration of lung system and liver-gallbladder system are the effect factor in CD4201-350mm3by Logistic regression analysis between the CD4 group and age emaciation group. The OR value of lung system and liver-gallbladder system in CD4201-350mm5 group are 0.530,1.895 in CD4<100mm3 group. The effect factor is emaciation in CD4 100-200mm3. The OR value of emaciation in CD4100-200mm3 group are 170.658 times in CD4<100mm3 group. The commonPulse like deep, rapid, theady. Rolling wiry are no different in different CD4 groups. But the common tongue nature like light red. red. crimson, pale, blue and Purple makes no difference in different CD4 groups.
5. Multi-linear regression analysis of QOL score and dimentionality score shows: emaciation is the only main effect factor of MOS-HIV score, body function and society function score. The skinnerPatient had lower QOL. Standard of culture and mate detect HIV masculine are the main effect factors of QOL dimentionality score. The regression coefficient of standard of culture is positive and mate detect HIV masculine is negative. So patients has higher standard of culture has better QOL. Emaciation and spouse infection are the main effect factors in health-perception dimentionality score. The skinnerPatient had lower health-perception dimentionality score. Spouse without HIV test had higher health-perception dimentionality score than HIV test negative. emaciation, standard of culture. Age are the main effect factors in role function dimentionality score. Emaciation is negative and standard of culture and age are positive, sexual contact is the main effect factors in emotion dimentionality score, sexual contact patients had better health suffering than blood supply infected patients.
6. Different TCM syndrome types had different QOL.
Group of Qi and ying deficiency with weakness of lung and kidney had a significant difference in QOL as compared with other four groups.
Group of Qi and ying deficiency with weakness of lung and kidney had a significant difference inPhysical functioning (PF) as compared with group of spleen and kidney deficiency with dampness.
Group of Qi and ying deficiency with weakness of lung and kidney had a significant difference inPain awareness(PA) as compared with group of wind-heat of liver channel and accumulation of dampness-poison.
Group of Qi and ying deficiency with weakness of lung and kidney had a significant difference in cognitive functioning(CF) as compared with group of wind-heat of liver channel and accumulation of dampness-poison and group of heat-poison withPyreticPhlegm in lung. Qi andPhlegm stagnation with blood stasis had a significant difference as compared with group of spleen and kidney deficiency with dampness.
Group of Qi and ying deficiency with weakness of lung and kidney had a significant difference in health dimention(HD) as compared with group of wind-heat of liver channel and accumulation of dampness-poison, and group of heat-poison withPyreticPhlegm in lung.
Group of wind-heat of liver channel and accumulation of dampness-poison had a significant difference in health transition(HT) as compared with group of Qi andPhlegm stagnation with blood stasis.
The score of QOL and GHP. RF. SF.. E. MH in five syndromes type groups has no significant difference after multiple comparison using Dunnett test.
7. The correlation between QOL and imentionality score with symptoms integral and other systems integral by using rank correlation coefficient shows (1) TCM symptoms integral, general appearance integral. Heart and brain system integral. Lung system integral. Liver-gallbladder system integral are significantly correlated to QOL score. (2) Liver-gallbladder system integral are significantly correlated to MH. CF. E. HD score. (3) general appearance integral Heart and brain system integral. Kidney-bladder system integral are significantly correlated toPF RF SF.
8. The Liver-gallbladder system integral and health suffering score of amenorrhea are significantly different to eumenorrhea in 46 patients. Whereas there are no differences in symptom types. CD4. other systems score and other QOL dimentions. The socre of Liver-gallbladder system integral in amenorrheaPatients are higher. Showing they are more depressed. Health suffering score in amenorrhea patients are lower, agitated have lower evaluation of health.
Conclusions:
1.AIDS patients are mostly young and middle-aged male. The infected people are normal other than drug users. The mainPathway has become sexually infection. The rate of spouse test positive are high.
2. Cardinal symptoms include:fever cough, short of breath diarrhea. Accompanied with magersucht\fatigue\insomnia\amnesia\anepithymia\dry throat and a bitter taste\depression\hyposexuality\oral ulcer. Most symptoms are of lung system and liver-Gallbladder system and bladder system. Tongue nature are red\crimson\Pale\purple. Enlarged tongue\thin tongue\purple bruises tongue\tooth-marked tongue are the major liguliform. Pulse manifestation are deep thready rapidPulse. Rolling rapidPulse. Deep thready wiryPulse. Wiry rapidPulse).
3. AIDS TCM syndrome type are include:wind-heat of liver channel. accumulation of dampness-poison spleen and kidney deficiency dampness. Qi andPhlegm stagnation with blood stasis. Qi and ying deficiency. weakness of lung and kidney. heat-poison withPyreticPhlegm in lung. gender., pathway of infection,magersucht and age group made a difference in differentiation. Different TCM syndrome types have different complications.
4. Gender has effect on CD4 whereas different pathway of infection has. The rate of complications is different in different group of CD4. numbers. 5. Different TCM syndrome types had different QOL. The QOL and imentionality score are related to the symptoms score and other systems score. Age, sex, standard of culture, spouse infection and emaciation have important influences on QOL score. GHP.RF. and E. The QOL of amenorrhea are low.
“辨证论治”是中医治疗的基本原则,而证候的确定,能够不同程度地揭示病性、病位、病因、病机,为治疗提供依据并指明方向,是中医认识疾病的根本所在。艾滋病是新发疾病,临床症状复杂,其中医基础理论及临床证治研究尚处在初级阶段。目前艾滋病证候的研究多限于医生的临床经验。临床信息收集不完整,缺乏证候量化指标,无统一的证候分类,加之研究工作延续性不够,对艾滋病的证候分类特征和证候演变规律未能进行深入研究,以致尚未形成艾滋病中医辨证论治的完整体系。中医证候是临床研究、药物研究的基础,因此,在中医学的整体观念和辨证论治的指导下,应用现代流行病学、循证医学的方法和现代生物学检测技术,充分考虑地域、感染途径、病程、并发症、实验室指标等因素,进行科学严格的设计,开展艾滋病中医证候特点和演变规律的深入研究,是非常迫切,并具有现实意义的。
迄今为止,人类尚未研制出彻底清除体内HIV的有效药物,因此HIV将在患者体内长期存在,并不断破坏其免疫系统,使患者产生机会性感染和恶性肿瘤的机会大大增加；加上抗HIV药物的副作用等因素,均严重地损伤患者的躯体功能,进而严重影响到他们的工作、学习和生活,晚期患者甚至连生活都不能自理。因此,在还没有找到彻底清除体内HIV的药物之前,改善HIV／AIDS患者的生存质量(QOL)将是研究者和决策者面对的直接而又严峻的问题。
由此,我们借助《艾滋病中医证候调查表》和《MOS—HIV生存质量量表》,对AIDS患者进行中医证候类型分布规律及生存质量情况的研究,并探讨两者之间的关系。
研究目的
1.明确AIDS患者中医常见证候类型及分布规律,初步形成规范化的证候诊断标准,为艾滋病中医诊疗提供客观依据。
2.通过探讨主要证候与机体免疫功能之间的关系,为指导艾滋病的临床治疗提供依据。
3.了解AIDS患者的生存质量现状,运用统计学方法分析各种影响因素与生存质量的关系。
4.根据统计分析和专业判断,确定AIDS患者中医证型与生存质量之间的关系,为将中医证候和生存质量引入艾滋病患者的中医疗效判定提供依据。
研究方法
1.本研究采用横断面调查方法。调查对象为广州市第八人民医院感染一科(艾滋病区)住院的艾滋病患者。采用《艾滋病中医证候调查表》和《MOS—HIV生存质量量表》进行问卷调查。
2.首先通过观察AIDS患者证型的分布,分析证型与症状体征的关系,为艾滋病中医证候诊断标准化研究提供参考依据；其次对不同感染途径、不同年龄段人群的症状、证候特点、脉、舌象特征等进行了较为全面的比较、分析,为深入认识艾滋病的中医临床特点奠定基础。同时还进行了中医证候与艾滋病特异性免疫指标的相关性研究,以期能有效地指导艾滋病的临床治疗。
3.运用综合分析的思想和数据挖掘的技术,探讨艾滋病期患者的生存质量现状及与不同影响因素之间的关系,同时亦探索不同中医证型的艾滋病患者与生存质量之间的关系。
结果
1.本次调查的120例AIDS患者年龄中位数为38岁、CD4计数中位数为50个／ul、体重中位数为50kg。被调查者中男性患者居多,占61.7%；文化程度中学或中专学历者占65.0%；无业者占61.7%；已婚者占78.3%；配偶检测阳性者占32.5%；感染途径以性传播为主,占66.7%。
2. AIDS患者临床以发热、咳嗽、气促、腹泻为主要症状,伴有消瘦、神疲、乏力、失眠、健忘、纳呆、咽干口燥、抑郁、性欲减退、口腔溃疡等。各系统以肺系、肝胆系、肾膀胱系症状突出。舌质色以红、绛、淡白、紫黯为主；舌形以胖大、瘦薄、瘀斑、齿痕居多；薄苔、腻苔、腐垢苔较多见,多为白苔、黄苔。单一脉象少见,多为相兼脉象(二合脉、三合脉),如沉细数脉、滑数脉、沉细弦脉、弦数脉等多见。
3.本研究观察到AIDS患者辨证分型情况：肝经风火、湿毒蕴结型占30.0%,脾肾亏虚、湿邪阻滞型占20.8%,气郁痰阻、瘀血内停型20.0%,气阴两虚、肺肾不足型占15.0%,热毒蕴结、痰热壅肺型占8.3%。此5型共占94.1%。性别、感染途径、消瘦及年龄段对证型均有一定的影响。消瘦程度轻者以火热实证居多,消瘦程度严重者以虚实夹杂证为主。不同中医证型,其并发症发生情况有所差别。热毒蕴结痰热壅肺型与气阴两虚肺肾不足型发生消耗综合征的比例较高。脾肾亏虚湿邪阻滞型发生腹泻的比例较高；而气郁痰阻瘀血内停型发生结核的比例较高。
4.本研究观察到,AIDS患者CD4计数分组中CD4<100/mm3的比例较高,占62.5%。女性患者CD4计数<100／mm3的比例较高。不同感染途径的AIDS患者CD4计数(分组)有差别：CD4<100/mm3所占比例明显高的是经性传播及采供血感染的患者,静脉吸毒的患者CD4计数≥100／mm3多见。不同证型的AIDS患者CD4计数(分组)有差别：CD4≥100／m3时,以肝经风火湿毒蕴结型与热毒蕴结痰热壅肺型多见；CD4<100/mm3时,以气郁痰阻瘀血内停型、脾肾亏虚湿邪阻滞型及气阴两虚肺肾不足型多见。CD4计数不同分组的AIDS患者发生肺炎、消耗综合征、恶性肿瘤等并发症有差别：CD4<100／mm3者发生肺炎、消耗综合征较多见；而CD4≥100/mm3者发生恶性肿瘤的比例较高。通过对CD4计数分组与年龄分段、消瘦、证候总积分及各系统积分之间的Logistic回归分析可知,对CD4201-350/mm3组有影响的因素是肺系积分与肝胆系积分。CD4201-350／mm3组在肺系积分、肝胆系积分的OR值分别是CD4<100/mm3组的0.530倍、1.895倍。对CD4100-200/mm3组有影响的因素是消瘦。CD4100-200/mm3组在消瘦方面的OR值是CD4<100/mm3组170.658倍。CD4计数不同组别的AIDS患者在出现常见的沉脉、数脉、细脉、滑脉、弦脉上无差别,在出现常见的淡红舌、红舌、绛舌、淡白舌、青舌、紫黯舌亦无差别。
5.生存质量总分及各维度得分与各影响因素的多元线性回归分析显示：消瘦是影响MOS-HIV生存质量量表总得分、躯体功能维度得分及社会功能维度得分的唯一重要影响因素。消瘦程度越明显的AIDS患者,其生存质量也越低。文化程度与配偶检测HIV阳性是影响生活质量维度得分的两个重要影响因素。文化程度的回归系数为正,配偶检测HIV阳性的回归系数为负,可以认为：文化程度越高、配偶HIV检测阴性的AIDS患者,其生活质量较高。消瘦与配偶感染情况是影响健康感受维度得分的两个重要影响因素。多元线性回归分析显示：消瘦程度越高的AIDS患者,其健康感受得分越低。配偶HIV未检测患者的健康感受得分较配偶HIV检测阴性患者的得分高。消瘦、文化程度及年龄是影响角色功能维度得分的三个重要影响因素。消瘦对角色功能起负面影响。而年龄与文化程度与角色功能成正向关系。通过性接触感染患者,其情绪要比采供血感染的患者好,其健康痛苦比采供血感染的患者要少。
6.不同证型患者的生存质量有差异。
在生活质量维度方面(QOL),气阴两虚肺肾不足型与其它四型比较,其差异有统计学意义；
在躯体功能维度方面(PF),气阴两虚肺肾不足型与脾肾亏虚湿邪阻滞型比较,其差异有统计学意义；
在疼痛维度方面(PA),气阴两虚肺肾不足型与肝经风火湿毒蕴结型比较,其差异有统计学意义；
在认知维度方面(CF),热毒蕴结痰热壅肺型与肝经风火湿毒蕴结型及脾肾亏虚湿邪阻滞型比较,其差异有统计学意义；气郁痰阴瘀血内停型与脾肾亏虚湿邪阻滞型比较,其差异有统计学意义；
在健康痛苦维度方面(HD),肝经风火湿毒蕴结型与热毒蕴结痰热壅肺型及气阴两虚肺肾不足型比较,其差异有统计学意义；
在健康转换维度方面(HT),肝经风火湿毒蕴结型与气郁痰阻瘀血内停型比较,其差异有统计学意义。
AIDS患者五个主要中医证型在生存质量总分及健康感受(GHP)、角色功能(RF)、社会功能(SF)、精力(E)、情绪(MH)四个维度,经过Dunnett检验进行两两比较,各个证型之间均无统计学意义。
7.采用Spearman等级相关分析方法探讨：生存质量总分、各维度得分与中医证候总积分、各系统得分之间的相关性。可以看出：(1)中医证候总积分、全身状况积分、心脑系积分、肺系积分、肝胆系积分与生存质量总分之间有显著的相关性；(2)肝胆系积分与情绪维度、认知维度、精力维度、健康痛苦维度之间有显著的相关性；(3)全身状况积分、心脑系积分、肾膀胱系积分与躯体功能维度、角色功能维度、社会功能维度之间有显著的相关性。
8.本次研究发现：46名女性患者中闭经者与月经正常者之间肝胆系积分与健康感受维度有差别,而在证型分布、CD4计数分组、其余系统的积分及其它生存质量维度方面无差别。闭经的女性患者肝胆系积分要高于月经正常者,表示闭经者情绪抑郁、烦躁程度较高；闭经者健康感受维度得分较低,也可以认为闭经者对自我健康的评价较低。
结论
1.艾滋病患者以男性青壮年为主,感染人群已从吸毒人群为主转为普通人群为主,性传播已成为艾滋病传播的主要途径,AIDS患者配偶检测阳性者的比例较高。
2. AIDS患者临床以发热、咳嗽、气促、腹泻为主要症状,伴有消瘦、神疲、乏力、失眠、健忘、纳呆、咽干口燥、抑郁、性欲减退、口腔溃疡等。各系统以肺系、肝胆系、肾膀胱系症状突出。舌质红绛、紫黯、淡白,有瘀斑、瘀点,苔白腻或薄黄苔、舌体胖大或有齿痕居多：沉细数脉、滑数脉、沉细弦脉、弦数脉等多见。
3. AIDS患者辨证分型以肝经风火、湿毒蕴结型,脾肾亏虚、湿邪阻滞型,气郁痰阻、瘀血内停型,气阴两虚、肺肾不足型,热毒蕴结、痰热壅肺型为主。性别、感染途径、消瘦及年龄段对AIDS患者中医证型有一定的影响。不同证型患者并发症的发生率有所差异。
4.性别、不同感染途径、不同证型的AIDS患者CD4计数(分组)有差别。CD4计数不同分段并发症的发生率有差异。
5.不同证型患者的生存质量有差异。生存质量总分、各维度得分与中医证候总积分、各系统得分之间有一定的相关性。年龄、性别、文化程度、配偶感染情况、消瘦对生存质量总体及生活质量维度、健康感受维度、角色功能维度、情绪维度有重要影响。女性闭经患者较之月经正常者生存质量较差。
Research background:
Syndrome differentiation and treatment is the basicPrinciple of Chinese traditional treatment. Syndrome differentiation is the basis of Chinese medicine. It can reveal the nature. location, cause and pathogenesis of disease andProvide evidence to treatment. AIDS is a emerging disease, it has complex clinical symptoms. The basic theories of Chinese medicine and clinical research of AIDS are still in the initial stage. At thePresent time, syndrome research are mostly clinical reports in which the collection of clinical information are not complete and quantitative guide and authoritative standard are not available. So the comprehensive system of Syndrome differentiation and treatment of AIDS is not completed yet. Syndrome differentiation and treatment is the basis of clinical research and drug research. It is practical and urgent to study the Syndrome differentiation and evolvement rule of AIDS under the guidance of TCM holism concept and syndrome differentiation. using modern epidemiology and EBM and modern biological detecting techniques. Considering region, Pathway of infection, course of disease, complications and laboratory index.
There are still no drugs to get rid of HIV virus completely as yet. So the virus will last long in thePatients body and damage the immune system. The occurrence of opportunistic infections and cancers expanded greatly. The side-effect of anti-HIV drugs can also bring damage toPatients physical functions or even worse, their career and life. AIDS terminal patients can not take care of themselves. So researchers andPolicy makers will face the severeProblem on how to improve the quality of live(QOL) of AIDS/HIVPatients before the appearance of drugs to get rid of HIV virus completely
TCM syndrome differentiation and QOL and the relationship between the two factors of AIDS/HIV patients are investigated by the AIDS TCM syndrome differentiation questionnaire and DSQL.
Objectives:
1.To explicit the regular TCM syndrome differentiation of AIDS and distributing rules. To form the normalized diagnostic standards and to supply the diagnosis and treatment of AIDS with objective basis.
2. To explore the relation between the major TCM syndrome differentiation and immune function. To provide basis for clinical treatment.
3. To comprehend the current situation of AIDS patients. To analyze the relation between effect factors and QOL by statistical methods.
4. To definite the relation between TCM syndrome differentiation and QOL, toProvide basis judging the curative effect by using TCM syndrome and QOL.
Methods:
1. Cross-sectional survey was using in this research.120 cases of in-patients in the first infection ward of the Eighth Municipal people's Hospital are choosing randomly. Using AIDS TCM syndrome differentiation questionnaire and DSQL questionnaire.
2. First. To investigate the AIDS TCM syndrome differentiation and to analyze the relation between the syndrome and symptoms and signs. To provide objective basis for normalized diagnostic standards. Secondly. To compare and analyze the symptoms\syndrome differentiation\pulse\tongue picture of differentPathway of infection and different age groups. Thirdly. To study the relation between TCM syndrome and characteristic immune index.
3. To explore the relation between QOL and different effect factors and different AIDS TCM syndrome differentiation by using comprehensive analysis and data mining.
Results.
1. In this research, the median age is 38. the median is 50u/l. the median weight is 50kg. theProportion of malePatients is 61.7%middle school and technical secondary school by standard of culture is 65.0%.61.7%are jobless.78.3% are married. Spouse testPositive are 32.5%. Sexually transmission are 66.7%.
2.Cardinal symptoms include:fever cough, short of breath diarrhea. Accompanied with magersucht\fatigue\insomnia\amnesia\anepithymia\dry throat and a bitter taste\depression\hyposexuality\oral ulcer. Most symptoms are of lung system and liver-Gallbladder system and bladder system. Tongue nature are red\crimson\Pale\purple. Enlarged tongue\thin tongue\purple bruises tongue\tooth-marked tongue are the major liguliform. The fur are mostly thin/curdy/greasy. The color of fur are mostly white or yellow.Pulse manifestation are mostly mutual, (for example:deep thready rapidPulse. Rolling rapid pulse. Deep thready wiry pulse. Wiry rapid pulse).
3. AIDS TCM syndrome differentiation:the Proportion of wind-heat of liver channel and accumulation of dampness-poison are 30.0%. spleen and kidney deficiency with dampness are 20.8%. Qi and Phlegm stagnation with blood stasis are 20.0%. Qi and ying deficiency with weakness of lung and kidney are 15.0%. heat-poison withPyreticPhlegm in lung are 8.3%. theProportion of the five types are 94.1%. gender,Pathway of infection, magersucht and age group made a difference has done. Patients with magersucht has more sthenic syndrome whereas more deficiency-excess mixing in Patients gently magersucht. Different TCM syndrome types have different complications. Type of spleen and kidney deficiency with dampness are more likely to have diarrhea. Qi and ying deficiency with weakness of lung and kidney, heat-poison withPyreticPhlegm in lung are more likely to have wastingsyndrome. Qi and Phlegm stagnation with blood stasis are more likely to have tuberculosis.
4. The Proportion of CD4<100/mm3 is 62.5%. The female patient has effect on CD4, the proportion of CD4<100/mm3 of female patient higher than male patient, whereas different pathway of infection has. Sexually and blood-supply transmission is the first Proportion of CD4<100/mm3and IDU transmission is the more proportion of CD4≥100/mm3. There are more wind-heat of liver channel and accumulation of dampness-poison and heat-poison withPyreticPhlegm in lung when CD4≥100/mm3 there are more Qi and Phlegm stagnation with blood stasis spleen and kidney deficiency with dampness Qi and ying deficiency with weakness of lung and kidney. There are more Pneumonia and wastingsyndrome in group of CD4<100mm3. There are more malignancy in group of CD4 201-350mm3. the integration of lung system and liver-gallbladder system are the effect factor in CD4201-350mm3by Logistic regression analysis between the CD4 group and age emaciation group. The OR value of lung system and liver-gallbladder system in CD4201-350mm5 group are 0.530,1.895 in CD4<100mm3 group. The effect factor is emaciation in CD4 100-200mm3. The OR value of emaciation in CD4100-200mm3 group are 170.658 times in CD4<100mm3 group. The commonPulse like deep, rapid, theady. Rolling wiry are no different in different CD4 groups. But the common tongue nature like light red. red. crimson, pale, blue and Purple makes no difference in different CD4 groups.
5. Multi-linear regression analysis of QOL score and dimentionality score shows: emaciation is the only main effect factor of MOS-HIV score, body function and society function score. The skinnerPatient had lower QOL. Standard of culture and mate detect HIV masculine are the main effect factors of QOL dimentionality score. The regression coefficient of standard of culture is positive and mate detect HIV masculine is negative. So patients has higher standard of culture has better QOL. Emaciation and spouse infection are the main effect factors in health-perception dimentionality score. The skinnerPatient had lower health-perception dimentionality score. Spouse without HIV test had higher health-perception dimentionality score than HIV test negative. emaciation, standard of culture. Age are the main effect factors in role function dimentionality score. Emaciation is negative and standard of culture and age are positive, sexual contact is the main effect factors in emotion dimentionality score, sexual contact patients had better health suffering than blood supply infected patients.
6. Different TCM syndrome types had different QOL.
Group of Qi and ying deficiency with weakness of lung and kidney had a significant difference in QOL as compared with other four groups.
Group of Qi and ying deficiency with weakness of lung and kidney had a significant difference inPhysical functioning (PF) as compared with group of spleen and kidney deficiency with dampness.
Group of Qi and ying deficiency with weakness of lung and kidney had a significant difference inPain awareness(PA) as compared with group of wind-heat of liver channel and accumulation of dampness-poison.
Group of Qi and ying deficiency with weakness of lung and kidney had a significant difference in cognitive functioning(CF) as compared with group of wind-heat of liver channel and accumulation of dampness-poison and group of heat-poison withPyreticPhlegm in lung. Qi andPhlegm stagnation with blood stasis had a significant difference as compared with group of spleen and kidney deficiency with dampness.
Group of Qi and ying deficiency with weakness of lung and kidney had a significant difference in health dimention(HD) as compared with group of wind-heat of liver channel and accumulation of dampness-poison, and group of heat-poison withPyreticPhlegm in lung.
Group of wind-heat of liver channel and accumulation of dampness-poison had a significant difference in health transition(HT) as compared with group of Qi andPhlegm stagnation with blood stasis.
The score of QOL and GHP. RF. SF.. E. MH in five syndromes type groups has no significant difference after multiple comparison using Dunnett test.
7. The correlation between QOL and imentionality score with symptoms integral and other systems integral by using rank correlation coefficient shows (1) TCM symptoms integral, general appearance integral. Heart and brain system integral. Lung system integral. Liver-gallbladder system integral are significantly correlated to QOL score. (2) Liver-gallbladder system integral are significantly correlated to MH. CF. E. HD score. (3) general appearance integral Heart and brain system integral. Kidney-bladder system integral are significantly correlated toPF RF SF.
8. The Liver-gallbladder system integral and health suffering score of amenorrhea are significantly different to eumenorrhea in 46 patients. Whereas there are no differences in symptom types. CD4. other systems score and other QOL dimentions. The socre of Liver-gallbladder system integral in amenorrheaPatients are higher. Showing they are more depressed. Health suffering score in amenorrhea patients are lower, agitated have lower evaluation of health.
Conclusions:
1.AIDS patients are mostly young and middle-aged male. The infected people are normal other than drug users. The mainPathway has become sexually infection. The rate of spouse test positive are high.
2. Cardinal symptoms include:fever cough, short of breath diarrhea. Accompanied with magersucht\fatigue\insomnia\amnesia\anepithymia\dry throat and a bitter taste\depression\hyposexuality\oral ulcer. Most symptoms are of lung system and liver-Gallbladder system and bladder system. Tongue nature are red\crimson\Pale\purple. Enlarged tongue\thin tongue\purple bruises tongue\tooth-marked tongue are the major liguliform. Pulse manifestation are deep thready rapidPulse. Rolling rapidPulse. Deep thready wiryPulse. Wiry rapidPulse).
3. AIDS TCM syndrome type are include:wind-heat of liver channel. accumulation of dampness-poison spleen and kidney deficiency dampness. Qi andPhlegm stagnation with blood stasis. Qi and ying deficiency. weakness of lung and kidney. heat-poison withPyreticPhlegm in lung. gender., pathway of infection,magersucht and age group made a difference in differentiation. Different TCM syndrome types have different complications.
4. Gender has effect on CD4 whereas different pathway of infection has. The rate of complications is different in different group of CD4. numbers. 5. Different TCM syndrome types had different QOL. The QOL and imentionality score are related to the symptoms score and other systems score. Age, sex, standard of culture, spouse infection and emaciation have important influences on QOL score. GHP.RF. and E. The QOL of amenorrhea are low.
引文
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