【作者】 任玉乐；

【导师】 刘茂才；

【作者基本信息】 广州中医药大学 ， 中医内科学， 2012， 博士

【摘要】 目的：通过专家问卷的方式,参照德尔菲法(Delphi),获取专家对中风病诊断标准的修订意见和建议,并为进一步制订缺血中风病急性期诊断标准的提供依据,同时结合统计方法分析临床四诊信息,初步探讨专家经验与临床信息相结合筛选缺血中风病诊断条目的有效方法。方法：本研究是国家十一五科技支撑计划课题——缺血中风诊疗标准(行业标准)的研究(课题编号：2006BAI21800)的一部分。主要分为三部分,第一部分,通过文献研究提出修订中风病诊断标准的依据；第二部分,在文献研究的基础上通过专家咨询法对缺血中风病的病名诊断、病类诊断、分期标准、证类诊断做出修订；第三部分,以十五攻关课题采集的多中心、大样本、多时点的缺血中风病四诊信息数据库为基础,通过聚类分析、卡方检验、logistic回归分析法分析临床四诊信息,结合专家经验筛选、优化缺血中风病的中经络各证类的诊断条目。成果：1.基于专家咨询法确定了缺血中风病的病名诊断、病类诊断、分期标准、证候分型。(1)病名：中风病分为缺血中风、出血中风及类中风。①缺血中风：缺血中风为气血内虚的基础上,因劳倦内伤、忧思恼怒、饮食不节等诱因,引起脏腑阴阳失调,气虚不能上达于脑,脑失充盈,或瘀血阻滞脑脉；临床以突然昏仆,半身不遂,口舌歪斜,言语謇涩、不语或失语,偏身麻木为主症；或以面容呆板、口角流涎、突发眩晕,或视一为二,或言语不清,或不识事物及亲人,或步履不稳,或偏身疼痛,或肢体抖动不止等为主要表现的一组疾病。②类中风：临床以突发眩晕,或视一为二,或言语不清,或不识事物及亲人,或步履不稳,或偏身疼痛,或肢体抖动不止等为主要表现；而不以突然昏仆,半身不遂,口舌歪斜,言语害涩或不语,偏身麻木等五大症状为主要表现；或兼见其中一两个症状但较轻者,可称为类中风。(2)病类诊断①中经络：缺血中风病而无神志昏蒙者。②中脏腑：缺血中风病伴有神志昏蒙者。(3)分期标准①超急性期：发病6小时之内。②急性期：发病2周以内,神昏者可延长至发病4周。③恢复期：发病2周至6个月。④后遗症期：发病6个月以后。(4)中经络病类证候分型①风火上扰证②痰热腑实证③风痰阻络证④阴虚风动证⑤气虚痰瘀阻络证2.基于临床信息筛选出缺血中风病的中经络各证类的诊断条目(1)风火上扰证诊断条目：平素易怒,躁扰不宁,头昏,头胀痛,两目干涩,失眠,健忘,耳鸣,口干口渴,口苦,口唇干红,心烦易怒,盗汗,舌红,苔黄苔蔳,右脉弦,右脉细,右脉数。(2)痰热腑实证诊断条目：头胀痛、目眩、面红、口苦、痰粘难咳、腹部胀满、肢体弛纵不收、小便黄赤、便干、舌红、苔黄、苔厚、左脉弦。(3)风痰阻络证诊断条目：头晕、目眩、痰粘难咳、肢体麻木、舌质淡、苔白、苔薄、右脉弦、右脉滑。(4)阴虚风动证诊断条目：形体消瘦、面红、咽干、口干、心烦易怒、头晕、耳鸣、多眠睡、便干、舌红、舌瘦薄、少苔、右脉弦、右脉细、右脉数。(5)气虚痰瘀阻络证诊断条目：倦怠乏力、面色恍白、头痛、心悸、胸闷、自汗、肢冷、睑下青黑、口角流涎、大便溏、舌胖大、舌有齿痕、舌质淡、苔白、苔厚、舌底脉络迂曲青紫、左脉沉、左脉细。结论：1.本研究通过系统收集、评析缺血中风病中医证候的文献,发现其研究的动向,提出了修订、制订缺血中风病诊断标准的依据。2.本研究参照德尔菲法,获取专家经验,将定性研究运用于证候领域,初步显示了德尔菲法在构建中医诊断方案过程中的适用性,为今后中医诊疗规范化、标准化研究提供了一定的思路和参考。3.初步获得了结构完整,临床诊疗要素齐备缺血中风病证候诊断标准。4.研究表明,以临床数据为支撑,采用多元统计分析结合专家经验的方法筛选缺血中风病各证类的诊断条目较为客观,值得进一步临床验证、修订及推广运用。更多还原

【Abstract】 Object ivesTo obtain the opinions and suggestions of the experts on the diagnostic criteria of the revised stroke by expert questionnaire and the Delphi method (Delphi), and provide the basis for the development of diagnostic criteria for acute stage of ischemic stroke, and combined with the application of statistical methods to analyze the clinical information by four physical examinations, and explore the effective method of screening stroke diagnosis entry by combining with the expert experience and clinical information.MethodThis study is part of the ischemic stroke diagnostic criteria (Industry standards) of the National Eleventh Five-Year Technology Support Program subject (subject ID:2006BAI21B00). Study is divided into three main parts, the first part is amendment stroke diagnostic criteria based on literature research;the second part, revising ischemic stroke name, illness diagnosis, staging criteria, the syndrome diagnosis criteria through expert consultation; third part is based on the database of the National Eleventh Five-Year Technology Support Program subject which contains information of ischemic stroke, and it is large sample, multiple time points,mutilple center.Then we analyse four clinical consultation information by cluster analysis, chi-square test, logistic regression, and combined with expert experience in screening, optimization of ischemic stroke inmeridian syndrome diagnostic entries.Results1. Developed diagnosis of ischemic stroke disease, illness diagnosis, staging syndrome type based on expert advice.(1) Disease:stroke is divided into ischemic stroke, hemorrhagic stroke, and apoplexyapoplectoid stroke. ①Ischemic stroke:ischemic stroke is due to deficiency of Qi and blood. Concerned overstrain, anxiety and rage, intemperance of taking food, causing the imbalance of yin and yang in zang-fu, Qi can not reach the brain, brain lost filling, or blood stasislag cerebral vessels;manifesting suddenly faint servant, hemiplegia, facial paralysis, difficult to speech, aphasia, hemianesthesia;or face stiff, mouth drooling, sudden dizziness, or, as diplopia, alalia, or did not know things and loved ones, or gait disturbance, or side of the body pain, or limb shaking than as the main performance of a group of diseases.②Apoplexyapoplectoid stroke:manifesting sudden dizziness, or diplopia, alalia, or did not know things and loved ones, or gait disturbance, or side of the body pain, or limb shaking;rather than a suddenfaint servant, hemiplegia, facial paralysis, speech harmful astringent or without a word, hemianesthesia five symptoms as the main performance;and see which one or two symptoms, but lesser, known as the apoplexyapoplectoid stroke.(2) Illness diagnosis①In meridians and collaterals:ischemic stroke and normal mind.②In Zang-fu:ischemic stroke associated with unconsciousness.(3) Staging criteria①Super acute phase:onset within6hours.②Acute phase:within2weeks of onset, patients in coma may be extended to4weeks of onset.③Recovery period:2weeks to6months of onset.④Sequelae:6months after the onset.(4) In Meridian illness syndrome type①Interfered by pathogenic wind-fire②Excess syndrome in FU-organ caused by Phlegm-heat③Obstruction of collateral caused by wind-phlegm④Stirring of wind due to YIN deficiency⑤Obstruction of collateral caused by Qi deficiency, phlegm and stasis2. Based on the diagnosis of the syndrome in the meridian of the clinical screening of ischemic stroke disease entry(1) The entries of Interfered by pathogenic wind-fire:usually irritable, impatient and restless,dizziness, headache, dryness in both eyes, insomnia, morbid forgetfulness, tinnitus, dry mouth and thirst,bitter mouth, dry and red lips, terribly upset and testiness, night sweat, red tongue,yellow and thin fur, string,thin and fast in the right pulse.(2) The entries of excess syndrome in FU-organ caused by Phlegm-heat:headache, dizziness, flushing,bitter mouth, sticky sputum difficult to cough, abdominal fullness, physically relax longitudinal income, yellow urine, then dry, red tongue, yellow and thick moss, left pulse string.(3) The entries of Obstruction of collateral caused by wind-phlegm:dizziness, blurred vision,sticky sputum difficult to cough, limb numbness, pale tongue, white coating, thin fur, string and slippery in right pulse.(4)The entries of Stirring of wind due to Yin deficiency:emaciation,red face, dry throat,dry mouth, terribly upset and testiness, dizziness, tinnitus, and more sleep,dry stool,red and thin tongue, less moss, string thin and fast in the right pulse.(5)The entries of Obstruction of collateral caused by Qi deficiency, phlegm and stasis:lassitude and languid, pale in the face, headache, palpitations, chest tightness, spontaneous perspiration,cold extremities, black eyelid, mouth drooling, loose stools, fat tongue with teeth marks,white and thick moss, context tortuous bruising, left pulse is thready and thin.Conclusion1.This study comprises systematic collecting literature, analyzing ischemic stroke TCM syndromes. Then finding the ischemic stroke Syndromes research trends, with provide the basis for the development of ischemic stroke diagnostic criteria.2.Using the Delphi method in this study, access to expertise, qualitative study used in the field of TCM syndrome, preliminarily shows the applicability of the Delphi in the process of developing Chinese medicine diagnosis scheme, providing thought for future standardization, standardization of TCM diagnosis and treatment.3.Preliminary structural integrity of the clinical diagnosis and treatment elements of complete disease and syndrome diagnostic criteria.4. Studies have shown that, supported by clinical data using multivariate statistical analysis to combine the expertise of the method of screening the entry of the diagnosis of ischemic stroke disease syndrome is more objective, it is worth further clinical validation, amendments and promotion.更多还原