本文選題：厥陰 + 中氣��； 參考：《南方醫(yī)科大學(xué)》2016年碩士論文

【摘要】：研究背景神經(jīng)母細胞瘤多原發(fā)于腎上腺,是小兒時期最普遍的實體腫瘤,其具有惡性程度高,臨床癥狀復(fù)雜的特點,且易發(fā)生復(fù)發(fā)、轉(zhuǎn)移,對兒童的生命健康構(gòu)成嚴重的威脅。神經(jīng)母細胞瘤的綜合治療主要包括外科切除及放化療治療,而化療手段是中晚期神經(jīng)母細胞瘤治療的最重要的治療方法之一。由于神經(jīng)母細胞瘤患兒一般年齡小,臟器功能尚未完善,接受化療后容易出現(xiàn)惡心嘔吐、納差、便秘、乏力、脫發(fā)等不良反應(yīng),這些不良反應(yīng)阻礙了患兒順利完成化療的進程,或者直接拒絕化療,嚴重影響綜合治療的療效及患兒的預(yù)后。因此,兒童神經(jīng)母細胞瘤治療中對化療不良反應(yīng)的控制不容忽視。目前針對化療藥物的不良反應(yīng),西醫(yī)藥只能做到對癥處理,現(xiàn)今臨床上仍沒有可以拮抗化療不良反應(yīng)的藥物。從中醫(yī)學(xué)的角度來看,化療對腫瘤細胞和正常細胞缺乏精確的選擇作用,這種不精確性相對正氣而言則是一種邪氣,有學(xué)者認為其屬于毒邪,在治療腫瘤的同時對臟腑和氣血津液皆有嚴重的毒害作用。植根于中華優(yōu)秀文化的祖國醫(yī)學(xué),其“整體觀念、辨證論治”的特點在治療腫瘤中發(fā)揮獨特的作用,在治療腫瘤中既能祛邪又可扶正�，F(xiàn)代實驗研究顯示,中醫(yī)藥在臨證時針對不同個體、不同時期進行辨證論治,能扶助正氣,提高人體的抗病能力,大大緩解患者腫瘤患者化療期間出現(xiàn)的癥狀,提高治療療效。神經(jīng)母細胞瘤在中醫(yī)學(xué)無相關(guān)記載,但據(jù)臨床癥狀及相關(guān)檢查,可歸為“血證”、“虛勞”、“ve瘕”、“腹痛”、“積聚”、“鼓脹”等疾病的范疇。中醫(yī)對神經(jīng)母細胞瘤發(fā)病學(xué)的認識與其他腫瘤一致,首先強調(diào)人體正氣對神經(jīng)母細胞瘤發(fā)病的重要意義�，F(xiàn)代醫(yī)家認為該病的發(fā)生或因先天稟賦偏弱,母體遺毒,或因后天喂養(yǎng)失調(diào),中氣虛損,導(dǎo)致臟腑功能不足,正氣不固,邪氣因而內(nèi)生,出現(xiàn)痰、濕、血、瘀等病理產(chǎn)物堆積而成癌毒,發(fā)展為此病。目前神經(jīng)母細胞瘤尚無統(tǒng)一的中醫(yī)辨證分型標準。近年來,相繼有報道中醫(yī)與化療聯(lián)合治療可緩解神經(jīng)母細胞瘤患兒化療不良反應(yīng)并減少醫(yī)源性疾病的發(fā)生,提高了患兒的生存質(zhì)量。所以在中晚期神經(jīng)母細胞瘤化療中配合中醫(yī)藥治療,以防治化療不良反應(yīng)是一種臨床上行之有效的方法。導(dǎo)師呂英教授立足“氣一元論”學(xué)說歸納神經(jīng)母細胞瘤病機為先天元陽稟賦不足,三陰冰伏,六氣乖亂,絞結(jié)成形。導(dǎo)師認為生命本原的元氣推動人之生命活動,并且疾病發(fā)生也是“本氣自病”所致：厥陰和緩有序的升發(fā),使元氣升發(fā)至全身各處,推動了生命的氣化活動,這是肝主疏泄功能的發(fā)揮,所以肝是元氣萌芽之臟,是萬物生命活力的體現(xiàn),人身一氣周流除了生發(fā)之力外,厥陰和緩有序的升發(fā)之力是人之生機另一關(guān)鍵；此外,中氣為后天之本,不僅吸收精微物質(zhì)至全身,營養(yǎng)臟腑、全身,又能充養(yǎng)元氣,若中氣虛弱,健運不力,元氣不充,各種疾病由此而發(fā)；根氣、中氣、萌芽對應(yīng)三陰三陽中的少陰、太陰、厥陰,故此三者又可以稱為三陰本氣,與元氣密切聯(lián)系。導(dǎo)師總結(jié)神經(jīng)母細胞瘤患兒化療不良反應(yīng)主要表現(xiàn)在厥陰、中氣兩方面,臨床上常分別用來復(fù)湯、理中湯為基礎(chǔ)方加減對治,治療上注重呵護神經(jīng)母細胞瘤患兒受損之三陰本氣,以期恢復(fù)患兒與生俱來的一氣周流的圓運動,取得“但扶其正,聽邪自去”良好的臨床療效。研究目的從厥陰、中氣入手,分別以來復(fù)湯、理中湯為基礎(chǔ)方,在化療過程配合中藥治療神經(jīng)母細胞瘤,探討總結(jié)一套有效減輕化療不良反應(yīng)、改善患兒生活質(zhì)量的中醫(yī)藥治療方案。研究方法經(jīng)病理組織學(xué)或骨髓檢測確診為神經(jīng)母細胞瘤,參照INSS分期,選擇臨床分期為Ⅲ～-Ⅳ期的患兒,根據(jù)化療中患兒出現(xiàn)的臨床表現(xiàn),納入符合氣虛證、脾氣虛證診斷標準的病例。經(jīng)嚴格標準篩選病例,共有25例神經(jīng)母細胞瘤病例符合納入標準,對25例病例進行3個治療周期的回顧性研究,研究方法采用自身前后對照,分為治療前(純化療)1個治療周期、治療后(化療+中藥)2個治療周期。對化療后出現(xiàn)精神疲勞乏力,氣虛不足以息,氣喘或氣促,汗多,脈細弱或搏指等癥狀,證屬厥陰萌芽之氣升發(fā)不力,選用來復(fù)湯加減治療；對化療后出現(xiàn)食欲不振,饑不欲食或食量明顯減少,體重減輕,肌肉松軟,或惡心欲嘔,大便質(zhì)軟爛或先干硬后軟爛,舌淡,脈細弱或沉等癥狀,證屬中氣不足,運化不力,選用理中湯加減治療。通過統(tǒng)計治療前后化療不良反應(yīng)發(fā)生情況及其評分、臨床癥狀緩解的療效觀察、血常規(guī)計數(shù)變化,比較分析治療前后化療不良反應(yīng)的差異。采用SPSS 19.0統(tǒng)計軟件進行統(tǒng)計的數(shù)據(jù)分析。計量資料先進行正態(tài)分布檢驗,符合正態(tài)性分布數(shù)據(jù)采用t檢驗,不符合正態(tài)性分布的數(shù)據(jù)采用非參數(shù)檢驗。計數(shù)資料采用χ2檢驗方法分析,以P0.05為差異有統(tǒng)計學(xué)意義。結(jié)果化療不良反應(yīng)發(fā)生情況及其評分方面,治療前后對比,中藥治療后患兒惡心欲嘔、食欲不振、體重減輕、大便不調(diào)、疲乏、汗多、氣短的癥狀均較前減輕,與治療前相比,差異均有統(tǒng)計學(xué)意義(P0.05)；其中患兒惡心欲嘔、氣短的癥狀,第2個療程比第1療程的效果較好,差異有統(tǒng)計學(xué)意義(P0.05)；食欲不振、大便不調(diào)的癥狀,第2療程與第1療程相比,差異無統(tǒng)計學(xué)意義(P0.05)；體重減輕、疲勞、汗多的癥狀,第1療程癥狀明顯未見減輕,差異無統(tǒng)計學(xué)意義(P0.05),而在第2療程中緩解明顯,差異有統(tǒng)計學(xué)意義(P0.05)�；純禾弁�、失眠、脫發(fā)癥狀治療前后比較,差異均無統(tǒng)計學(xué)意義(P0.05)。臨床癥狀緩解的療效觀察,中藥治療的第1療程中部分改善12例(48%),無改善13例(52%)臨床癥狀緩解總有效率(顯著改善+部分改善)為48%。中藥治療的第2療程中顯著改善1例(4%),部分改善17例(68%),無改善7例(28%),臨床癥狀緩解總有效率為72%。兩療程相比,差異有統(tǒng)計學(xué)意義(P0.05)。血常規(guī)計數(shù)比較,治療后患兒化療前后白細胞、血紅蛋白、血小板計數(shù)的變化幅度均較治療前下降,差異均有統(tǒng)計學(xué)意義(P0.01)；而中藥第1療程與中藥第2療程對比,差異無統(tǒng)計學(xué)意義(P0.05)。結(jié)論從厥陰、中氣入手的中醫(yī)藥治療方案配合化療,在一定程度上有效緩解中晚期神經(jīng)母細胞瘤患兒化療不良反應(yīng),并隨著中藥治療時間的延長而增加臨床療效,對化療導(dǎo)致的骨髓抑制有一定的緩解作用,提高了患兒的生活質(zhì)量；但對疼痛、失眠、脫發(fā)癥狀緩解未見明顯效果。討論本研究中藥治療后患兒惡心欲嘔、食欲不振、體重減輕、大便不調(diào)、疲乏、汗多、氣短的癥狀均較前減輕；其中惡心欲嘔、氣短、體重減輕、疲勞、汗多,在中藥第2療程治療后明顯改善,中藥第2療程的臨床癥狀緩解總有效率比中藥第1療程高,說明中藥治療時間長短與臨床療效有密切關(guān)系。中藥治療后,雖然仍存在骨髓抑制,但患兒化療前后外周血白細胞、血紅蛋白、血小板計數(shù)的下降幅度均較治療前降低,說明中藥治療對化療的骨髓抑制有一定的緩解作用。綜上所述,從厥陰、中氣入手的中醫(yī)藥治療方案配合化療,在一定程度上緩解中晚期神經(jīng)母細胞瘤患兒化療不良反應(yīng),并隨著中藥治療時間的延長而增加臨床療效。而患兒疼痛、失眠、脫發(fā)癥狀治療前后比較未見明顯改善,究其原因,由于患兒的三陰本氣不足,需較長的治療時間恢復(fù)本氣,慢慢糾正體質(zhì),中藥方能發(fā)揮作用,改善癥狀,再者患兒臨床癥狀復(fù)雜多變,同一癥狀涉及的病因病機復(fù)雜,難以一一把握�；純禾弁吹陌Y狀,其根源為元陽不足,三陰冰伏,但考慮患兒化療后三陰本氣不足更是虛損,中氣失運、厥陰升發(fā)不力,不宜直接采取“破冰回陽”來對治,只能通過調(diào)治中氣、厥陰來恢復(fù)本氣,故而癥狀緩解不明顯：如失眠癥狀,總體屬陽不入陰,是飄浮游離之陽“壯火食氣”的亢奮狀態(tài),不是單純通過引浮游之火歸位就能解決,還需結(jié)合其他癥狀分析相火的來源。再如脫發(fā),依《黃帝內(nèi)經(jīng)》“發(fā)為血之余”、“腎主骨,生髓,其華在發(fā)”之理,雖然治療中顧護三陰本氣,隨著化療療程增加,三陰本氣愈加虛損,而有形之血不能速生,故癥狀不能有效緩解,此亦是中醫(yī)藥難緩解化療導(dǎo)致的骨髓抑制作用的原因。
[Abstract]:Background neuroblastoma is most commonly found in the adrenal gland. It is the most common entity tumor in childhood. It has high malignancy and complicated clinical symptoms, and is prone to recurrence and metastasis. It poses a serious threat to the life and health of children. The combined treatment of neuroblastoma mainly includes surgical resection and radiotherapy and chemotherapy. Treatment of neuroblastoma is one of the most important treatments for advanced neuroblastoma. Children with neuroblastoma are usually of small age and the organ function is not perfected. After chemotherapy, nausea and vomiting, nausea, constipation, fatigue and alopecia are easy to occur. These adverse reactions obstruct the children's successful completion of the process of chemotherapy, or Direct refusal of chemotherapy has seriously affected the curative effect of comprehensive treatment and the prognosis of children. Therefore, the control of adverse reactions to chemotherapy in the treatment of neuroblastoma in children can not be ignored. At present, western medicine can only deal with the adverse reactions of chemotherapeutic drugs, and there is still no drug that can antagonize the adverse reaction of chemotherapy. From the point of view of traditional Chinese medicine, chemotherapy is lacking in precise selection of tumor cells and normal cells. This inaccuracy is a kind of evil in relative positive gas. Some scholars believe that it belongs to the evil evil. At the same time, it has serious toxicity to the viscera and Qi and blood in the treatment of the tumor. The characteristics of "overall concept, syndrome differentiation and treatment" play a unique role in the treatment of tumors and can not only dispel evil spirits but also help to correct them in the treatment of tumors. Modern experimental research shows that traditional Chinese medicine can help the positive Qi, improve the body's resistance to disease, and greatly alleviate the chemotherapy of patients with tumor. There are no related records of neuroblastoma in traditional Chinese medicine, but according to clinical symptoms and related examinations, it can be classified as "blood syndrome", "virtual labor", "ve", "abdominal pain", "accumulation", "bulging" and other diseases. It emphasizes the important significance of the body positive gas to the disease of neuroblastoma. Modern doctors believe that the occurrence of the disease is caused by the congenital weakness of the natural endowment, the maternal body poison, the deficiency of the middle gas, the deficiency of the middle Qi, the inadequacy of the viscera, the evil spirit and the accumulation of the pathological products of phlegm, dampness, blood and blood stasis. At present, there is no unified TCM Syndrome Differentiation Standard for neuroblastoma. In recent years, it has been reported that combined treatment of Chinese medicine and chemotherapy can relieve the adverse reaction of neuroblastoma and reduce the occurrence of iatrogenic diseases and improve the quality of life of the children. To prevent and cure the adverse reaction of chemotherapy is a clinically effective method. Professor Lv Ying, based on the theory of "Qi monism", concludes that neuroblastoma is a congenital Yuanyang deficiency, three yin volts, six Qi disorderly, and stranded forming. The tutor thinks the vital qi of life pushes the life of human beings, and the disease occurs is " The Qi is caused by the disease: the Qi Yin and the slow and orderly rise and hair rise to all parts of the body to promote the whole body of the whole body and promote the gasification of life. This is the function of the main discharge of the liver, so the liver is the dirty of the sprout of the Qi and the embodiment of the vitality of all things. In addition, the central gas is the day of the day, not only to absorb the fine material to the whole body, nourishment Zang Fu organs, the whole body, but also can fill in the Qi, if the medium Qi is weak, the health is ineffective, the Qi is not filled, and the various diseases are caused by it, the root, middle Qi and bud are corresponding to the less Yin, the Yin and the Yin of the three yin, so the three can also be called the three Yin Qi, and yuan. The chemotherapy adverse reactions of the children with neuroblastoma were mainly manifested in the two aspects of syncope Yin and middle Qi, which were often used to recover the decoction, and the decoction of Lizhong was used as the basis for treatment. The treatment was focused on protecting the damaged three Yin Qi of the children with neuroblastoma. The purpose of this study is to achieve the good clinical effect of "but help its positive, listen to evil self". The purpose of this study is to discuss and summarize a set of effective treatment regimens for reducing the adverse reaction of chemotherapy and improving the quality of life of the children. The diagnosis of neuroblastoma was diagnosed by histopathology or bone marrow examination. According to INSS staging, children with stage III to IV were selected. According to the clinical manifestations of the children in chemotherapy, the cases were included in the diagnosis standard of qi deficiency syndrome and spleen qi deficiency syndrome. After strict standard screening, 25 cases of neuroblastoma were in conformity with the inclusion criteria. Retrospective study of 25 cases of 3 period of treatment, the study method was divided into 1 treatment cycles before and after treatment (pure chemotherapy), and 2 treatment cycles after treatment (chemotherapy plus traditional Chinese Medicine). After chemotherapy, there were symptoms of mental fatigue, asthenia, asthma or pony, sweating, weak pulse or stroke. The sprout gas is not strong enough to use the decoction of Lai Fu Tang to add and subtract the treatment. After the chemotherapy, there is no appetite, hunger or appetite, loss of weight, weight loss, muscle soft, nausea and vomiting, soft shit or dry hard rotten, weak tongue, weak pulse or sink, etc. The occurrence and score of adverse reaction of chemotherapy before and after treatment, the effect of clinical symptom remission, the change of blood routine count, and the difference of the adverse reaction of chemotherapy before and after treatment were compared and analyzed. The statistical data were analyzed with SPSS 19 statistical software. The advanced normal distribution of measurement data was tested in accordance with the normal distribution of t. Non parametric tests were used to test the data that did not conform to the normal distribution. The count data were analyzed by the chi 2 test method. The difference was statistically significant with P0.05. Results the incidence of adverse reactions to chemotherapy and its score, comparison before and after treatment, nausea and vomiting, loss of appetite, weight loss, defecation, fatigue and sweating were compared before and after treatment. The symptoms of shortness of breath were all less than before, and compared with before treatment, the difference was statistically significant (P0.05); the symptoms of nausea nausea and shortness of breath in children were better than the first course of treatment, the difference was statistically significant (P0.05); the loss of appetite, the disorder of bowel movement, and the second course compared with the first course of treatment, the difference was not statistically significant (P0.05 The symptoms of weight loss, fatigue and sweating, the symptoms of first courses were not significantly reduced, the difference was not statistically significant (P0.05), but in the second course of treatment, the difference was statistically significant (P0.05). The difference of pain, insomnia, and hair loss was not statistically significant before and after treatment (P0.05). In the first course of treatment, 12 cases (48%) were improved, no improvement in 13 cases (52%) of clinical symptom relieving total efficiency (significant improvement + partial improvement) was significantly improved in 1 cases (4%) in the second course of 48%. Chinese medicine treatment, 17 (68%) improved in 17 cases (68%), 7 (28%) was not improved, and the total effective rate of clinical symptomatic relief was statistically significant (P0 .05) compared with the blood routine count, the changes of white blood cells, hemoglobin and platelet count were all decreased before and after the treatment, and the difference was statistically significant (P0.01), while the difference between the first course of Chinese medicine and the second course of Chinese medicine was not statistically significant (P0.05). Chemotherapy, to a certain extent, effectively alleviates the adverse reaction of children with middle and advanced neuroblastoma, and increases the clinical efficacy with the prolongation of Chinese medicine treatment time. It has a certain relieving effect on bone marrow suppression induced by chemotherapy and improves the quality of life of the children, but there is no obvious effect on pain, insomnia and relieving symptoms of alopecia. In this study, the symptoms of nausea and vomiting, loss of appetite, weight loss, defecation, fatigue, sweating, and shortness of breath were all alleviated, among them nausea and vomiting, shortness of breath, weight loss, fatigue and sweating, after second courses of Chinese medicine treatment, the total effective rate of the second course of Chinese medicine was higher than the first course of Chinese medicine, There is a close relationship between the duration of Chinese medicine treatment and the clinical effect. After the treatment of Chinese medicine, there is still bone marrow suppression, but the decrease of leukocyte, hemoglobin and platelet count of peripheral blood before and after chemotherapy in children is lower than that before treatment, indicating that the treatment of Chinese Medicine has certain relieving effect on the suppression of bone marrow in chemotherapy. The Chinese traditional Chinese medicine treatment scheme combined with chemotherapy to some extent alleviated the adverse reaction of chemotherapy in children with middle and advanced neuroblastoma, and increased the clinical efficacy with the prolongation of the treatment time of Chinese medicine. Foot, need longer treatment time to restore the Qi, slowly correct the physique, Chinese medicine can play a role, improve the symptoms, and the clinical symptoms of children are complex and changeable, the same symptom involved in the etiology and pathogenesis of complex, difficult to grasp one by one. The symptoms of children's pain, the root of Yuanyang is not enough, three yin ice volts, but consider the children after chemotherapy three yin deficiency gas is more than more. It is the deficiency, the gas loss, the Qi Yin rise is not strong, it is not appropriate to directly take "ice breaking back to Yang" to treat, only by regulating the middle Qi, the Qi Yin to restore the gas, so the symptoms are not obvious relief: if the symptoms of insomnia, the overall Yang does not enter the Yin, is floating free Yang "strong fire food and gas" exuberance state, not simply through the exuberance of the fire return to the position Can be solved, still need to combine other symptoms to analyze the source of phase fire. Again like hair loss, according to "Yellow Emperor's Internal Classic", "hair for the blood", "kidney main bone, the pulp, its Chinese in hair", although the treatment of three yin to protect the Qi, as the chemotherapy treatment increases, three yin this gas more deficiency, and the tangible blood can not speed, so the symptoms can not effectively ease, this is also the symptoms can not effectively ease, this is also the symptoms can not effectively mitigate, therefore, the symptoms can not be effectively relieved. It is the reason why Chinese medicine is difficult to alleviate the myelosuppression induced by chemotherapy.

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2016
【分類號】：R273

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