【作者】 陈文华；

【导师】 庄礼兴；

【作者基本信息】 广州中医药大学 ， 针灸学， 2008， 博士

【摘要】 癫痫（Epilepsy）是神经内科临床常见的慢性发作性疾病,因其反复发作性、发作突然性、复杂性等特点,故病程较长,治疗不易,给患者的日常工作、学习、生活以及身心健康带来了诸多压力,给社会增添了沉重的负担。临床治疗上,不但要早发现、早治疗,而且要控制癫痫发作,减少发作次数,延长发作间歇期,最终达到治愈。尽管癫痫的发病机制仍未完全明确,抗痫药物的临床运用已取得了一定的疗效。但目前常规及大部分新型抗痫药物并不能完全控制所有痫性发作,且具有较大的毒、副作用,使癫痫病人在控制了癫痫症状之后,仍然要忍受随之而来的并发症、伴随症及心理、精神等诸多方面的痛苦。其他非药物治疗尚处在实验研究和临床试验阶段,且费用昂贵,难以得到推广普及。针灸对各型癫痫的治疗优势体现在简便、无药物毒副作用方面。它通过疏通气血、熄风定惊、醒脑开窍以调和阴阳,安神定志。穴位埋线疗法是将羊肠线埋入穴位内,利用羊肠线对穴位的持续刺激作用发挥治疗疾病的方法。其疗效高、安全、简便、低廉。一、临床观察目的:观察埋线疗法治疗原发性全面发作型癫痫的临床疗效、对生活质量的影响等,规范操作规程,并对其临床疗效进行再评价。方法:采取随机对照试验,对60例原发性全面发作型癫痫患者进行临床观察。将60例癫痫患者随机分为埋线组和对照组,每组30例。埋线组用改良埋线针在每个穴位中埋植1ml长3-0号医用铬制羊肠线。主穴:A.大椎、筋缩、丰隆_双,B.心俞_左、肝俞_左、阳陵泉_双,C.心俞_右、肝俞_右、臂臑_双,A、B、C三组主穴轮流取用,每次埋线加辨证配穴一个,配穴左右交替。每15天埋线1次,90天后观察疗效。对照组给予丙戊酸钠片按15mg/（kg.d）的剂量口服,用量超过250mg/d时,分次服用,每日清晨或早晨,中午2次服用,连服90天为一疗程。疗程结束后观察两组治疗前后的症状疗效、发作频率和生活质量评分。结果1.总疗效:两组治疗前后比较,治疗组总有效率76.7%,对照组总有效率86.7%,对照组优于治疗组,但经统计学分析,P=0016＞0.05,两者之间无统计学意义。2.症状疗效:两组治疗前后比较,均有P＜0001,提示治疗组和对照组经治疗后,症状改善有统计学意义;治疗前,治疗组与对照组比较,t=0.54,P=0.59,说明两组治疗前症状轻重程度具有可比性;治疗后,治疗组与对照组比较,t=0.53,P=0.60,说明两组治疗后症状评分差异无统计学意义。3.发作频率:治疗组与对照组在治疗3个月后、半年后、1年后发作频率与治疗前相比,均具有统计学意义。两组之间的比较,在治疗3个月后、半年后,发作频率均无统计学差异;在治疗1年后,对照组在发作频率方面明显优于治疗组。4.生活质量改善:治疗组在治疗3个月后、半年后、1年后生活质量的改善均有统计学意义;而对照组在治疗3个月后生活质量无明显改善,在治疗半年后、1年后生活质量的改善才有统计学意义。在治疗3个月后、半年后、1年后,治疗组在改善生活质量方面优于对照组,均具有统计学意义。结论:在总疗效上,包括症状评分、控制癫痫发作频率方面,穴位埋线疗法与药物治疗作用相仿,穴位埋线组未见有明显优势,但在改善患者生活质量方面,穴位埋线组显示了明显的优势作用。二、动物实验目的:动态观察埋线法对电点燃癫痫模型大鼠海马神经元凋亡及凋亡相关基因的影响。方法:将104只健康纯系雄性SD大鼠,随机分成13组,每组8只:（1）对照组,（2）模型1d组,（3）模型4d组,（4）模型7d组,（5）模型10d组,（6）模型14d组,（7）埋线1d组,（8）埋线4d组,（9）埋线7d组,（10）埋线10d组,（11）埋线14d组,（12）二次埋线10d组,（13）二次埋线14d组。对照组植入电极,不予刺激;（2）～（13）组均为造模动物,以电点燃法造成慢性癫痫模型。假手术组大鼠不予治疗;所有埋线组（7～13组）大鼠均在电点燃癫痫模型造模成功后,选取穴位大椎、心俞透膈俞双,予以埋线治疗一次;二次埋线组（12～13组）大鼠在第一次埋线后第7天再行埋线治疗。观察各组大鼠造模前后及治疗前后的一般状态。1d组、4d组、7d组、10d组、14d组和假手术组大鼠分别在点燃1d、4d、7d、10d和14d后,用10%水合氯醛（400mg/kg）腹腔注射麻醉后,经4%多聚甲醛心脏灌注固定,断头取左侧大脑半球。采用HE染色光镜下观察、原位细胞凋亡检测法检测海马神经元凋亡情况,采用免疫组化法检测海马p⁵3、Bax、Bcl-2蛋白表达。结果1.动态观察大鼠一般状态的变化,提示埋线治疗有助癫痫发作后的一般状态恢复,以一周后的远期效果较为明显,一周后再行埋线治疗则疗效有所叠加。2.模型组大鼠海马神经元凋亡及相关基因表达的动态变化结果提示:单侧电点燃癫痫模型大鼠的痫性“镜灶”侧海马神经元,在造模后4d内首先在P⁵³的促进作用下发生凋亡,4d后至14d内在Bc1-2和Bax的协同作用下,神经元凋亡受到抑制。3.埋线组和二次埋线组大鼠海马神经元凋亡及相关基因表达的动态变化结果提示:埋线治疗在癫痫发作后的早期（4d内）可通过抑制促凋亡基因p⁵³蛋白表达、延缓其达峰值的时程,从而减缓神经元凋亡的发生,此作用在4d后减弱;埋线治疗抑制大鼠海马神经元凋亡的作用在癫痫发作后的中期（4d～10d）减弱,甚至在远期（10d～14d）出现促进凋亡的作用,可能是通过抑制Bax蛋白表达的下降、延长其降至低峰值的时程,促进Bax蛋白表达的回升的结果;在中远期（7d～14d）内予二次埋线治疗对该效应有续效叠加的作用。埋线治疗对单侧电点燃癫痫模型大鼠海马神经元Bc1-2蛋白表达无明显作用。结论:1.单侧电点燃癫痫模型大鼠的痫性“镜灶”侧海马神经元,在造模后4d内首先在p⁵³的促进作用下发生凋亡,4d后至14d内在Bc1-2和Bax的协同作用下,神经元凋亡受到抑制。发作后早期的大量神经元凋亡,导致大鼠生活质量的降低,影响疾病的恢复。发作后中远期神经元凋亡的抑制,使在发作中已受损的神经元得不到及时清除而成为再次发作的基础。如此形成恶性循环,最终导致痫性发放的反复发作,症状加重,生活质量日益下降。2.埋线治疗在癫痫发作后的早期（4d内）可通过抑制促凋亡基因p53蛋白表达、延缓其达峰值的时程,减缓神经元凋亡的发生,保护神经元,避免出现大量不必要的神经元脱失,从而改善癫痫患者的症状。3.埋线治疗通过抑制Bax蛋白表达的下降、延长其降至低峰值的时程,致使在癫痫发作后的中期（4d～10d）抑制大鼠海马神经元凋亡的作用减弱;继而通过促进Bax蛋白表达的回升,致使在癫痫发作后的远期（10d～14d）出现促进凋亡的作用。上述作用可诱导已受损的神经元发生凋亡,以形成良性循环,使癫痫发作程度降低、发作频率减少,生活质量得以提高。4.在癫痫发作后的中期（7d～14d）内予二次埋线治疗对疗效有续效叠加的作用。由此可指导临床埋线法治疗癫痫的治疗间隔以控制在1～2周内为宜。更多还原

【Abstract】 Epilepsy is very common in nervous system diseases.The seizure is so suddenly and complicatedly that make the disease a long course and hard to cure.It brings the patients much pressure on their lives,study and work,and often proves to be a tax upon the society.Early diagnosis and early treatment are very important to epilepsy.A successful treatment is based on controlling the seizure and reducing the frequency.Though the mechanism of epilepsy hasn’t been totally confirmed,the using of anti-epilepsy drugs（AEDs）has obtained a lot of effects.But the routine and new AEDs still cannot entirely control all kinds of the seizure,also have many serious side-effects.It makes the patients suffer from the complications after the seizure.Since the other non-drug treatments are still under studying, and they all are very expensive,it’ s very hard to promote now.The advantage of acupuncture treatment to epilepsy includes simplicity,with few side-effects.It coordinates the function of yinyang and tranquilizes by dredging the vital energy and blood,calming wind-syndrome and frightening, waking up the patient from unconsciousness.Acupoint catgut embedding therapy treats disease by utilizing persistence stimulating of the catgut to the acupoint.The therapy is efficient,safe,simple and cheap.Clinical Observation:Objective:To observe the effect of the acupoint catgut embedding therapy on epilepsy,study the effect on the quality of life（QOL）.Method:60 patients were randomly divided into 2 groups:ACET（acupoint catgut embedding therapy）group and control group,30 patients in each group.Patients in ACET-group were treated by embedding a 1ml long #3-0 catgut into the acupoints,which was prescribed and combined as:A.DU14,DUB,ST40;B.BL15, BL18,GB34;C.BL15,BL18,LI14.The main point formula-A/B/C was used by turns, with an auxiliary point each time.They were treated once in 2 weeks,lasting for 3 months.The control group was treated by valproic acid（VPA）,15mg/ （kg·d）,p.o.The treatment also lasted for 3 months.Result:1.Total effect:Comparing with pretreatment,the general effective rate of the ACET-group being 76.7%,and the control group being 86.7%.This trial showed both treatment to be effective and there was no statistically significant difference between them in their effect（P=0.16＞0.05）.2.Effect on the symptoms:Comparing with pretreatment,the symptomatic improvement of both groups were significantly obtained（P＜0.01）and there was no statistically significant difference between them in their effect （P=0.60＞0.05）.3.Frequency of the seizure:3 months,half year and 1 year after the treatment, comparing with pretreatment,the seizure frequency of both group were significantly reduced.There was no statistically significant difference between them in their effect after 3 months or half year,but the statistical comparison after 1 year was significant.4.Improvement of QOL:3 months,half year and 1 year after the treatment, comparing with pretreatment,QOL improvement of ACET-group were significantly obtained.QOL of control group didn’t improve after 3 months,since the improvement were significantly obtained after half year and 1 year.And at the time 3 months,half year and 1 year after the treatment,QOL improvement of ACET-group were significantly superior to control group.Conclusion:The effect of AECT and AEDs is similar on the total effect, including the effect on the epileptic symptoms,frequency of the seizure.the But AECT is significantly superior to AEDs on the improvement of QOL.Experimental Research:Objective:To investigate the dynamic changes of the neuron apoptosis and correlative genes in hippocampus of kindling epileptic rats treated by the catgut embedding therapy on epilepsy. Method:104 male SD rats are randomly divided into sham operation group,5 model groups（1d,4d,7d,10d,14d）,5 ACET-groups（1d,4d,7d,10d,14d）and 2 twice-ACET-groups（10d,14d）,8 rats in each group.Rats of model groups, ACET-groups and twice-ACET-groups were made the electric kindling epilepsy model,while sham operation group was received the implantation of the bipolar electrode only.ACET-groups and twice-ACET-groups were treated by ACET just after the kindling at DU14,BL15,BL17.twice-ACET-groups were treated again after 7 days.Common condition of the rats was observed.Rats of 1d-groups, 4d-groups,7d-groups,10d-groups and 14d-groups were killed respectively 1 day,4 days,7 days,10 days,14 days after the kindling and made the hippocampus sections.In all cases,the apoptosis,expression of P⁵³,Bax and Bcl-2 were detected by terminal dUTP-mediated nick end labeling（TUNEL）and immunohistochemistry.Result:1.Observed the dynamic changes of the common condition of the rats,it suggested that ACET can help the kindling model rats to get well,the effect was significant after 7 days.To treat again after 7 days can also enhance the effect.2.The dynamic changes of the the neuron apoptosis and correlative genes in hippocampus of model groups suggested that the neurons in contralateral hippocampus commenced apoptosis by the promotion of p⁵³in 4 days after kindling, then during 4 to 14 days,the apoptosis was inhibited by the coordination of Bcl-2 and Bax.3.The dynamic changes of the the neuron apoptosis and correlative genes in hippocampus of ACET-groups and twice-ACET-groups suggested that ACET can slower the apoptosis by inhibiting p⁵³and prolong the ascending period of p⁵³ in 4 days after the seizure,this effect would weaken after 4 days.ACET may inhibit the descending of Bax,prolong its descending period and then promote its expression,in order to weaken the inhibition of the apoptosis during 4 to 10 days after seizure and then promote the apoptosis during 10 to 14 days after.This effect of ACET can be enhanced after treating again within 7 to 14 days later.ACET had no significant effect on expression of Bcl-2 in hippocampus of the kindling model rats.Conclusion:1.the neurons in contralateral hippocampus of the kindling model rats commenced apoptosis by the promotion of p⁵³in 4 days after kindling,then during 4 to 14 days,the apoptosis was inhibited by the coordination of Bcl-2 and Bax.Neuron apoptosis early after the seizure will due to the decreasing of QOL and the interfering with the recovering.7 days after the seizure,the neuron apoptosis inhibited,so the encroached neuron bequeathed to become the cause of next seizure.In this way a vicious circle is set up which it is difficult to break.The seizure will occur frequently,the symptoms get worse, the QOL will decrease and decrease.2.ACET can slower the apoptosis by inhibiting p⁵³and prolong the ascending period of p⁵³in 4 days after the seizure.It helps to protect the neurons, avoid the losing of neurons,and improve the symptoms.3.ACET inhibit the descending of Bax,prolong its descending period andthen promote its expression,in order to weaken the inhibition of the apoptosis during 4 to 10 days after seizure and then promote the apoptosis during 10 to 14 days after.These effects may lead to the apoptosis of the encroached neuron,and set up a fine circle to reduce the seizure,decrease the frequency, improve the QOL finally.4.This effect of ACET can be enhanced after treating again within 7 to 14 days later.It follows that we should treat by ACET clinically once in 1 to 2 weeks.更多还原