针刺干预缺血性中风病证候动态化及相关研究

目的：探索针刺干预缺血性中风病证候动态变化规律，并分析依据缺血性中风病辨证“决策树”所建立的中风证类判别函数式的辨证效果。 方法：针刺干预264例发病30d内的缺血性中风病患者。通过文献检索和专家咨询，制定统一的证候调查表，患者发病的0～3d、4～10d和11～30d各时间段任一天调查1次，共调查3次，研究中风病基本证型的动态多时点评价结果及相关因素。建立缺血性中风病辨证“决策树”4个证型的贝叶斯判别函数式，并采用自身检验法和交叉核实法分别计算4个证型判别函数式的误判概率，检验其判别效果。结果：急性缺血性中风病6个基本证型30d内的发生率从高到低依次为风证80．7％、痰证68.9％、火热证52．7％、气虚证50．8％、血瘀证29．2％和阴虚阳亢证25．0％。3个时点内各证型得分均值和发生概率均表现出逐渐下降的动态变化趋势，其中血瘀证发生概率的下降速度最快。急性缺血性中风病证型表现以二证、三证、四证的组合形式为主，其中三证组合最多。发病3d内没有单证形式的病例。两两复合证主要表现为风痰证54．5％、风火证42．8％、气虚中风证40．9％、气虚痰阻证39．4％和痰热证35．6％，血瘀合并阴虚阳亢证的发生率最低，仅为3．8％。缺血性中风病发病30d内，高年龄组痰证和气虚证得分均值高于低年龄组，差异有统计学意义；女性气虚证得分均值和发生概率高于男性，差异有统计学意义；女性痰证得分均值高于男性，差异有统计学意义。在缺血性中风病辨证“决策树”的21项中风病证候要素的基础上，采用逐步判别法建立面红、便难、苔黄、短气、面色白光白或晦暗、耳鸣、手足心热、苔少等8个条目的判别函数式，精简后的判别函数式判别效能基本与精简前相同，二者比较，差异无统计学意义。 结论：缺血性中风病发病30d内以风证、痰证贯穿始终，证的组合形式复杂，以三证组合为多。随着针刺治疗时间的积累，风、痰、火热、气虚、血瘀、阴虚阳亢等基本证候要素均逐渐减少，证的组合形式由复杂趋向简单。面红、便难、苔黄、短气、面色自光白或晦暗、耳鸣、手足心热、苔少等8个证候要素条目，在辨证过程中对于区分阴证或阳证、实证或虚证有重要意义。

Dynamic changes in traditional Chinese medicine syndromes in patients with ischemic stroke treated by acupuncture

Objective： To explore the dynamic state of traditional Chinese medicine （TCM） syndromes in acute ischemic stroke patients within 30 days of onset when treated with acupuncture, and to analyze the discrimination effects of the functions based on ＂decision trees＂ in identification of TCM syndromes of ischemic stroke.
Methods： A total of 264 cases with acute ischemic stroke regularly treated by acupuncture were included. Unified syndrome questionnaire was made by document retrieval and expert advice. The syndrome elements of the patients with acute ischemic stroke were surveyed on any day of three time periods （days 0-3, 4-10 and 11-30）. The study was performed on multitime dynamic state results and correlated factors of basic TCM syndromes of the 264 patients. Bayes discriminant function of four syndromes of acute ischemic stroke on the basis of ＂decision trees＂ was used for computing the rate of miscarriage justice by original test and crossvalidation, and the discrimination effects of ＂decision trees＂ were evaluated too.
Results： Wind, phlegm, fire-heat, qi deficiency, blood stasis, and hyperactivity of yang due to yin deficiency syndromes were found in the patients with acute ischemic stroke treated by acupuncture on the first 30 days of onset, and the incidence rates were 80.7%, 68.9%, 52.7%, 50.8%, 29.2% and 25.0% respectively. The mean scores and incidence rates of the six syndromes decreased gradually on three-time-point, especially of blood stasis syndrome. The main combined-syndromes were two-syndrome, three-syndrome and four-syndrome, and three-syndrome was the most frequently encountered type. Single syndrome was not found in the patients with acute ischemic stroke on the first three days of onset. Two-syndrome combination types were wind-phlegm, wind-heat, wind combined with qi deficiency or phlegm stagnation due to qi deficiency, phlegm-heat and blood stasis combined with hyperactivity of yang due to yin deficiency, and the incidence rates were 54.5%, 42.8%, 40.9%, 39.4%, 35.6% and 3.8% respectively. The mean scores of phlegm and qi deficiency in high-age patients were higher than those in low-age patients. The mean score and incidence rate of qi deficiency in female patients were higher than those in male patients, The mean score of phlegm in female patients was higher than that in male patients. To simplify the ＂decision trees＂ composed of 21 items, the group of Bayes discriminant function including eight most significant items out of the original 21 items was set up. The discrimination effect of the eight items including reddish face, constipation, yellow tongue fur, short breath, bright-white or gray complexion, tinnitus, feverish palms and soles and scanty tongue fur was similar to that of the 21 items, and there was no significant difference between the two functions.
Conclusion ： Wind syndrome and phlegm syndrome are the major single syndromes occurring in acute ischemic stroke patients within 30 days of onset, and three-syndrome combination is the most frequent multiple syndrome type. After acupuncture treatment, some syndrome elements including wind, phlegm, fire-heat, qi deficiency, blood stasis, and hyperactivity of yang due to yin deficiency are gradually reduced, and combined syndrome type is gradually become simple. Eight syndrome element items including reddish face, constipation, yellow tongue fur, short breath, bright-white or gray complexion, tinnitus, feverish palms and soles and scanty tongue fur have important means in discriminating yin syndrome from yang syndrome and sthenia syndrome from asthenia syndrome.