围绝经期综合征中医证候规范化及计量诊断的研究

【作者】 万霞；

【导师】 胡立胜； 苏钢强； 林超岱；

【作者基本信息】 北京中医药大学 ， 社会医学与卫生事业管理， 2004， 硕士

【摘要】 目的 本研究通过文献与临床调查相结合的方法,制定了围绝经期综合征(perimenopausal period syndrome,PPS)中医证候计量诊断标准;探讨了 PPS中医证候的计量诊断及流行病学特征;分析了 PPS 中医各证型与 Kuppermann 量表(kuppermann scale,KS)、焦虑自评量表(self-rating anxiety scale,SAS)及抑郁自评量表(self-rating depression scale,SDS)的相关性。从而为中医临床诊断、治疗 PPS 提供参考。 方法 (1)通过百分位数计算结果,取累积频率为 25 百分位数以上的证型作为 PPS 的主要证型;取各证型累积频率为 75 百分位数以上的症状体征作为各证型的主要症状体征;(2)通过临床流行病学调查,收集 PPS 中医症状学量表及 KS、SAS 和 SDS 资料。对可分级的症状体征按其出现症状体征程度最轻的等级(即取值为 1 分),对不可分级的症状体征取值为 2 分,各自乘以相应的权重(主症为0.75,次症为 0.25),制定出 PPS 中医证候诊断标准(即中医症状加权积分法);(3)通过两类判别分析,对 PPS 中医证候计量诊断进行探索性研究;(4)通过标准效度与重测信度检验,对 PPS 中医症状学量表进行评价;(5)通过计算相关系数及建立多元回归方程,分析 PPS 中医各证型与 KS 的相关与回归关系;(6)通过计算相关系数,分析 PPS 中医各证型与 SAS、SDS 的相关关系。 结果 (1)文献研究:归纳总结出本研究 PPS 中医辨证分型为肾阳虚、肾阴虚、肾阴阳两虚、心肾不交、肝郁、心脾两虚。肾阳虚证的主要症状和体征为:舌边有齿痕、舌淡、舌胖嫩、形寒肢冷;肾阴虚证为:头晕、舌质红、耳鸣、烘热汗出、腰膝酸软;肾阴阳两虚证为:头晕、腰膝酸软、耳鸣;心肾不交证为:心悸、怔忡、失眠;肝郁证为:胸胁作胀或痛、精神抑郁、烦躁易怒、口苦、胸闷、善太息、脉弦;心脾两虚证为:心悸、舌淡、纳少、失眠。(2)PPS 中医诊断标准的确定:即通过加权积分得出 PPS 各证型的诊断标准临界值:肾阳虚证为9.75 分,肾阴虚证为 9.25 分,肾阴阳两虚证为 4.5 分,心肾不交证为 6 分,肝郁证为 8.5 分,心脾两虚证为 7 分。临床研究 340 例 PPS 患者中,采用上述中医症状加权积分法辨证为以上六型者 156 例,其它证型者 184 例。(3)计量诊断探索性研究:即得出 6 个证型的两类判别函数式。肾阴虚、肾阴阳两虚、肾阳虚、心肾不交、肝郁、心脾两虚的回顾性误判概率分别为:2.04%、0.95%、0.00%、2.04%、0.00%、0.00%;前瞻性误判概率均为 0.00%。(4)PPS 中医症状学量表的效度与信度评价:中医症状加权积分法辨证出的 156 例 PPS 患者的证型(参比组)与医生独立经验辨证(待评组)比较,发现二者仅共同检验出 55 例(35.26%)具有相同的证型;47 例 PPS 患者前后两次症状积分的相关系数为 0.97809(P<0.0001),前后两次症状积分的差值经 t 检验,差异无统计学意义(t=0.20,P=0.8459)。测量误差(0.4353)及变异系数(1.3216%)均较小。(5)PPS 中医各证型与 KS 的相关及回归研究:得出KS总积分与PPS的肾阴虚证加权积分的相关系数r=0.39128(p=0.0060)、与肾阴阳两虚证加权积分的相关系数 r=0.21392(p=0.0284)、与<WP=5>- II - 围绝经期综合征中医证候规范化及计量诊断的研究肾阳虚证加权积分的相关系数 r=0.26036(P=0.2676)、与心肾不交证加权积分相关系数 r=0.23291(P=0.1111)、与肝郁证加权积分的相关系数 r=0.65096(p=0.0004)、与心脾两虚证加权积分的相关系数 r=0.40040(p=0.0053)。KS 各症状与肾阴虚证(P=0.0046)、肾阴阳两虚证(P=0.0434)、心肾不交证(P=0.0357)、心脾两虚证(P=0.0014)加权积分构成的回归方程成立。拟定的方程经过诊断只有肾阴阳两虚证有 6 例异常点,心肾不交证有 1 异常点,其余证型均无异常点。所拟定的方程均无强影响点和多元共线性。肾阴虚证只与易激动这个症状的回归系数有统计学意义,肾阴阳两虚证与所有症状的回归系数均无统计学意义,心肾不交证只与心悸这个症状的回归系数有意义,心脾两虚证与心悸、头痛、疲乏这三个症状的回归系数有意义。(6)PPS 中医各证型与 SAS 及 SDS 之间的相关性研究:得出 PPS 各证型患者 SAS 及 SDS 标准分的平均分均较高,有近一半患者 SAS及 SDS 标准分高于常模,尤其在焦虑状态上,肝郁和心肾不交两型患者多见。SAS标准分与肾阴虚证加权积分的相关系数 r=0.56797(p=<0.0001)、与肾阴阳两虚证加权积分的相关系数 r=0.28600(p=0.0032)、与肾阳虚证加权积分的相关系数r=0.30857(p=0.1856)、与心肾不交证加权积分的相关系数 r=0.28967(p=0.0458)、与肝郁证加权积分的相关系数 r=0.45659(p=0.0218)、与心脾两虚证加权积分的相关系数 r=0.52010(p=0.0002)。SDS 标准分与肾阴虚证加权积分的相关系数r=0.40961(p=0.0038)、与肾阴阳两虚证加权积分的相关系数 r=0.21690(p=0.0270)、与肾阳虚证加权积分的相关系数 r=0.04552(p=0.8489)、与心肾不交证加权积分的相关系数 r=0.36104(p=0.0117)、与肝郁证加权积分的相关系数r=0.17658(p=0.3985)、与心脾两虚证加权积分的相关系数 r=0.18483(p=0.2136)。 结论 本研究得出如下结论:(1)P更多还原

【Abstract】 Objective This paper made the TCM-syndrome differentiating criteriaof PPS. It explored the quantitative diagnosis of the TCM-syndromes of PPS.And it analyzed the correlationships between TCM-syndromes of PPS andKuppermann scale (KS), self-rating anxiety scale (SAS), or self-ratingdepression scale (SDS). This study provided some suggestions for clinicaldiagnosis and treatment. Methods (1)This study suggested 6 primary TCM-syndromes, includingprimary and secondary symptoms and signs of those TCM-syndromes bystatistical analysis. (2)It designed the investigation forms, andcollected the data of four examinations, KS, SAS and SDS from clinic. Thenit established the criteria for the diagnosis of TCM-syndromes, ie. theTCM symptom weighted score method. The weight of primary symptom is 0.75,and the weight of secondary is 0.25. (3)It explored quantitative diagnosisfor TCM-syndrome by discriminant analysis. (4)It evaluated the criteriavalidity and test-retest reliability of the TCM symptom scale. (5)Itanalyzed the correlations and regressions between KS and the TCM symptomweighted scores. (6)It made the correlations between the TCM symptomweighted scores and SAS, or SDS. Results (1)Literature studies: This paper suggested 6 TCM-syndromes,ie. kidney yang vacuity, kidney yin vacuity, dual vacuity of kidney yinand yang, breakdown of heart-kidney interaction, binding depression ofliver qi and heart-spleen vacuity. The primary symptoms of kidney yangvacuity syndrome are dental impressions on the margins of the tongue, paletongue, enlarged and tender-soft tongue, physical cold and cold limbs. Theprimary symptoms of kidney yin vacuity syndrome are dizzy head, red tongue,tinnitus, baking heat and putting sweat, aching lumbus and limp legs. Theprimary symptoms of dual vacuity of kidney yin and yang syndrome are dizzyhead, aching lumbus and limp legs, tinnitus. The primary symptoms ofbreakdown of heart-kidney interaction syndrome are heart palpitations,fearful throbbing, insomnia. The primary symptoms of binding depressionof liver qi syndrome are distension or pain in the chest or flanks,depression, dysphoria and irritation, bitter taste in the mouth,oppression in the chest, frequent sighing, wiry pulse. The primary symptomsof heart-spleen vacuity syndrome are heart palpitations, pale tongue,reduced food intake, insomnia. (2)Establishment of diagnostic criteria ofTCM-syndromes for PPS: It made every syndrome’s diagnosis critical<WP=7>- IV - 围绝经期综合征中医证候规范化及计量诊断的研究score-value, ie. kidney yang vacuity is 9.75, kidney yin vacuity is 9.25,dual vacuity of kidney yin and yang is 4.5, breakdown of heart-kidneyinteraction is 6, binding depression of liver qi is 8.5 and heart-spleenvacuity is 7. 156 cases were diagnosed to be those 6 syndromes by usingthe TCM symptom weighted score method in total 340 patients of PPS.(3)Exploration quantitative diagnosis of PPS: It made 2 discriminantequations for each TCM-syndrome. The error judgement probability ofretrospective resubstitution is low, ie. kidney yin vacuity and breakdownof heart-kidney interaction both are 2.04%, dual vacuity of kidney yin andyang is 0.95%, and other 3 syndromes are all 0.00%. The error judgementprobabilities of 6 syndrome’s prospective resubstitutions are all 0.00%.(4)Evaluation of criteria validity and test-retest reliability forTCM-symptom scale: 55 cases were diagnosed the same syndromes accordingto the doctor’s experience compared to the TCM symptom weighted score method.There are correlations between the first and second time of 47 cases. Boththe measurement error(0.4533) and coefficient variance(1.3216%) are low.(5)Correlation and regression analyses between the TCM symptom weightedscores and KS:It made the 6 r-values between KS and the TCM-syndromes, ie.kidney yin vacuity is 0.39128(p=0.0060), dual vacuity of kidney yin andyang is 0.21392(p=0.0284), kidney yang vacuity is 0.26036(P=0.2676),breakdown更多还原