【作者】 吴淑琼；

【导师】 陈如泉；

【作者基本信息】 湖北中医药大学 ， 中医内科学， 2010， 博士

【摘要】 目的：探讨结节性甲状腺肿(简称结甲)病因病机及与血瘀、痰凝的关系。观察活血消瘿方治疗结甲的临床疗效,评价其临床应用价值。检测结甲病人外周血中几种相关细胞因子的水平,探讨结甲发病的分子机制。观察活血消瘿方治疗后上述相关细胞因子的变化水平,初步探讨活血消瘿方治疗结甲的作用机制。方法：本研究分三部分,方法如下：1.理论研究：分析、整理古籍文献,结合现代临床治疗经验,比较不同医家对结甲的病因、病机的认识以及辨证论治的方法；综合分析现代医学对结甲病因、病理的认识和治疗的经验,寻找研究的突破点。2.临床疗效研究：采用随机单盲对照法,将符合入选标准的结甲(血瘀痰凝证型)患者90例随机分为2组：试验组(n=45,予以活血消瘿方口服)和对照组(n=45,予以优甲乐片口服),3个月为一个疗程,共2个疗程。观察两组治疗前及治疗后3个月、6个月时的相关指标(包括相关症状及体征、甲状腺的体积及结节的最大直径及结节数目、甲状腺功能等),并作比较分析。3.临床机理研究：选取本课题第二部分试验组中的完成6个月规范治疗的结甲患者30例作为病例组。同时在门诊体检人群中随机选取30名与之相匹配的健康人作为正常对照组。采用定量酶联免疫吸附试验(ELISA)检测两组治疗前、治疗后3个月及6个月的血清血管内皮生长因子(VEGF).转化生长因子一β1(TGF-β1).可溶性Fas受体(sFas)及可溶性Fas受体配体(sFasL)水平。采用放射免疫分析法(RIA)测定两组治疗前、治疗后3个月及6个月的血清胰岛素样生长因子-Ⅰ(IGF-Ⅰ)、白介素-1β(IL-1β)、白介素-6(IL-6)及肿瘤坏死因子(TNF)的水平。每个指标分别进行病例组治疗前与对照组比较、活血消瘿方治疗前后水平变化的比较。分四个方面进行分析：①活血消瘿方对结甲患者生长因子(VEGF)的影响；②活血消瘿方对结甲患者生长因子(IGF-I.TGF-β1)的影响；③活血消瘿方对结甲患者凋亡因子(sFas、sFasL)的影响；④活血消瘿方对结甲患者免疫调节因子(IL-1β、IL-6及TNF)的影响。从而初步探讨结甲发病的分子机制及活血消瘿方治疗结甲的作用机制。全部数据均使用SPSS13.0统计软件进行统计学处理。数据以均数±标准差(X±S)表示；组间比较,计量资料用t检验,计数资料用X2检验。结果：1.理论研究表明：中医一般将结甲类属于“瘿病”、“瘿瘤”范畴。中医医家普遍认为结甲主要因情志失调、水土失宜、体质因素等引起气机郁结、瘀血阻滞、痰浊凝滞及气、痰、血交阻于颈前而成。对本病结节成因提出气滞、痰凝及血瘀的病机。遣方用药有一定规律性,主要以理气化痰、活血化瘀、软坚散结为主。现代医学对结甲的病因并不完全清楚,般认为其发病机理是由各种原因引起垂体TSH分泌增加,TSH不断刺激甲状腺而使甲状腺反复或持续增生,甲状腺组织长期反复增生与复旧不平衡,纤维组织增生分隔使甲状腺组织形成多发结节。越来越多的研究认为,许多细胞因子可能参与了结甲的发病、病理过程。结甲与细胞凋亡的关系尚不明确。西医对结甲的治疗主要是手术切除和甲状腺激素抑制等药物治疗,但都存在缺陷。因此寻找更安全、有效和方便的结甲治疗药物仍是一个有意义的课题。近十年的研究报道显示,许多中药方剂治疗结甲具有较好的疗效,但大多仅进行临床疗效观察,关于中药治疗机制研究鲜为报道。2.临床疗效研究显示：2个疗程结束时,可供统计的有效病例：试验组41例,对照组40例。(1)两组总疗效比较：试验组：总有效率2个疗程为90.2%,1个疗程为73.2%；对照组：总有效率2个疗程为47.5%,1个疗程为37.5%；两组比较均有显著性差异(P<0.05)。显示试验组总有效率高于对照组。(2)疗程与疗效的关系：两组2个疗程均较1个疗程治疗效果好。(3)治疗后,两组甲状腺的体积和结节最大直径均较治疗前降低,有显著性差异(P<0.05)。两组间治疗后甲状腺的体积无显著性差异(P>0.05)；而结节的最大直径试验组缩小程度大于对照组(P<0.05)。(4)两组结节大小与疗效关系：2个疗程结束后,统计结果显示,两组有效率：治疗前结节直径小于2cm>2-4cm>4cm以上者。(5)两组治疗前后甲状腺功能变化：两组游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)及试验组的高灵敏度促甲状腺激素(sTSH)于治疗前及2个疗程治疗后无显著差异(P>0.05)；对照组的sTSH沿疗后较治疗前明显降低(P<0.05)。(6)毒副作用：试验组无明显不良反应。对照组有10例出现不同程度的口干、烦躁、失眠,其中4例出现心悸、发热等症状,其毒副作用发生率为25%。3.临床机理研究显示：(1)结甲患者治疗前血清VEGF的水平高于对照组(P<0.05)。经活血消瘿方治疗后,血清VEGF水平在治疗后3个月时有所下降,但较治疗前无显著性差异(P>0.05)；治疗后6个月时降至正常水平,与对照组比较无统计学意义(P>0.05)。(2)结甲患者治疗前血清IGF-I的水平较正常人为高(P<0.05),血清TGF-β1的水平低于正常人(P<0.05)。经活血消瘿方治疗后,血清IGF-Ⅰ水平在治疗后3个月时有所下降,但无统计学意义(P>0.05)；在治疗后6个月时比治疗前有明显下降(P<0.05),与对照组比较,无显著性差异(P>0.05)。血清TGF-β1水平在治疗后3个月时明显升高(P<0.01)；在治疗后6个月时明显下降,但其仍明显高于治疗前水平(P<0.01),亦高于正常组(P<0.05)。(3)结甲患者治疗前血清sFas的水平明显高于对照组(P<0.01),血清sFasL的水平低于对照组(P<0.05)。经活血消瘿方治疗后,血清sFas水平在治疗后3个月时有所下降,但无统计学意义(P>0.05)；在治疗后6个月时明显下降,较治疗前有极显著性差异(P<0.01),与对照组比较无显著性差异(P>0.05)。血清sFasL;水平在治疗后3个月时明显上升(P<0.05)；在治疗后6个月时继续上升,比治疗后3个月及治疗前均有显著性差异(P<0.05),且明显高于正常对照组(P<0.01)。(4)结甲患者治疗前血清IL-1β及TNF的水平均略高于对照组,但无统计学意义(P>0.05),血清IL-6的水平低于对照组(P<0.05)。经活血消瘿方治疗后,血清IL-1β及TNF水平在治疗后3个月时明显上升(P<0.05)；在治疗后6个月时略有下降(P>0.05),且仍高于对照组(P<0.05)。血清IL-6水平在治疗后3个月时有所升高,但与治疗前比较无显著性差异(P>0.05)；在治疗后6个月时明显升高达正常范围,比治疗后3个月及治疗前均有显著性差异(P<0.05),与对照组无显著性差异(P>0.05)。结论：1.结节性甲状腺肿的病因主要为情志失调、水土失宜；病机为气滞、痰凝、血瘀；中医药治疗结甲取得较好的疗效。2.活血消瘿方治疗组的总有效率高于优甲乐对照组,且对于结节的缩小乃至消除,活血消瘿方明显优于优甲乐,说明中药活血消瘿方治疗结甲优于优甲乐治疗；两组2个疗程均较1个疗程疗效好；结节的消除与其大小关系密切,结节直径<2cm的疗效好,≥4cm的疗效差；活血消瘿方对于甲状腺分泌激素的功能无明显影响,毒副作用小,安全性能高。3.生长因子(VEGF、IGF-I、TGF-β1)与结甲的发病、转归关系密切。活血消瘿方可以通过适度下调结甲患者血清VEGF、IGF-I水平及上调血清TGF-β1水平来抑制甲状腺滤泡及组织的增生。4.凋亡因子(sFas、sFasL)在结甲的发病和治疗中起重要作用,结甲存在细胞凋亡的抑制。活血消瘿方可能通过下调血清sFas水平和上调血清sFasL水平诱导甲状腺细胞凋亡来缩小甲状腺肿及结节,从而达到治疗结甲的目的。5.免疫调节因子(IL-1β、IL-6及TNF)可能也参与了结甲的发病、转归过程。活血消瘿方可能通过适度升高血清IL-1β、TNF和IL-6水平,诱导甲状腺细胞凋亡,抑制甲状腺滤泡的增生,从而调整甲状腺细胞增生与凋亡的平衡达到治疗目的。更多还原

【Abstract】 Objective:To explore the Etiology Pathogenesis of nodular goiter (Abbreviation:NG)and the relationship among NG, blood stasis and sputum condensation.To observe the clinical effect of "HuoXueXiaoying" prescription,and to evaluate the clinical value. To detect several cytokines related levels of peripheral blood of patients with NG,and to explore the molecular mechanism of NG’pathogenesis.To observe the related changes in cytokine levels after the treatment of "HuoXueXiaoying" prescription, and to study the mechanism of action in "HuoXueXiaoying" prescription treatment on NG preliminary.Methods:This study was divided into three parts,as follows.1.Theoretical studies:Analysis,sorting out ancient literature,combining with modern clinical treatment experience to compare the knowing of NG’etiology,pathogenesis and the dialectical methods of different physicians;comprehensive analyzing NG’etiology, pathogenesis and the treatment experience of modern medicine to find a breakthrough point for this research.2.Clinical efficacy studies:Used randomized single-blind antithesis,90 NG(blood stasis and sputum condensation type) patients who measure up the standard were divided into 2 groups: experimental group(n=45, to be treated with "HuoXueXiaoying" prescription) and contrast group (n=45,to be treated with euthyrox tablets),3 months for a course of treatment,a total of 2 courses. Then to Observe and analyze comparatively the related indicators (including related symptoms and signs,thyroid nodule size and the maximum diameter and the number of nodules,thyroid function, etc.)before treatment and after treating for 3,6 months.3. Clinical Mechanism studies:Selected 30 nodular goiter patients who had finished 6 months’standard treatment in the second part of the experimental group in this subject and let them be the case group. At the same time selected 30 matched healthy adults in outpatients randomly as normal control group. Quantitative enzyme-linked immunosorbent assay(ELISA)was used to measure the serum levels of vascular endothelial growth factor (VEGF),transforming growth factorβ1(TGF-β1),soluble Fas(sFas) and soluble Fas Ligand(sFasL)of the two groups before treatment and after treating for 3 or 6 months.Radio immunoassay (RIA) was used to determine the serum levels of insulin-like growth factor I(IGF-I),interleukin 10(IL-10),interleukin 6(IL-6)and tumor necrosis factor(TNF)of the two groups before treatment and after treating for 3 or 6 months.Each indicator should be compared with the control group before the treatment in case group,and then the concentrations changes were compared separately after the treatment of "HuoXueXiaoying" prescription. Sub-analysis of four aspects:①The impact "HuoXueXiaoying" prescription do on vascular endothelial growth factor(VEGF) of the patients with NG;②The impact "HuoXueXiaoying" prescription do on patients with NG’ growth factors(IGF-I,TGF-β1);③The impact "HuoXueXiaoying" prescription do on apoptotic factors (sFas、sFasL) of the patients with NG;④The impact "HuoXueXiaoying" prescription do on immune factors (IL-1β,IL-6 and TNF)of the patients with NG. Then explore the molecular mechanism of NG’pathogenesis and the mechanism of "HuoXueXiaoying" prescription treatment on patients with NG preliminary.All data were analyzed statistically by SPSS13.0 statistical software. Data used mean±standard deviation (X±S) to express; For groups comparison, use t to test measurement data,use X2 to test count data.Results:1.Theoretical studies have shown that:Nodular goiter belongs to the category of disease "ying" or "ying gall" of traditional Chinese medicine(TCM)in general.Chinese medicine physicians generally think that NG is mainly due to qi stagnation, blood stasis block,phlegm stagnation and qi,sputum,blood cross-resistance formed on the anterior which caused by emotional imbalance, inappropriate water and soil,physical factors and so on. They put the pathogenesis of qi stagnation, blood stasis and sputum condensation to be the causes of nodules.Medication using should be some regular,that is,mainly regulating qi and phlegm, promoting blood circulation, and resolving hard lump. The cause of NG in modern medicine is not clear entirely.It is generally believed that the reasons of pathogenesis is that pituitary TSH secretion increase because of various factors.TSH’s stimulating thyroid tissues constantly can result in repeating or lasting thyroid hyperplasia.Repeating thyroid hyperplasia and redintegration in a long-term are under imbalance. Thyroid was separated by fibrous tissue to form a multi-nodular thyroid tissue. More and more researches show any growth factors may be involved in the disease and its pathological process.It is unclear whether the pathogenesis of NG is related to thyroid follicular cells apoptosis.Western medicine treatment on NG is mainly surgery and thyroid hormone suppression therapy,etc.But the both are flawed. So looking for more secure,efficient and convenient therapy is still a significant issue. Nearly a decade of research reports indicated that many traditional Chinese medicine prescription treatments on NG have better efficacy, but most of the study is only about clinical efficacy.It is rarely reported on the mechanism of traditional Chinese medicine treatment.2. Clinical efficacy studies have shown that:When the two courses of the treatment finished, the available statistics was:41 cases of experimental group and 40 patients of contral group.(1)The total effect of two groups were compared:experimental group:The total effective rate was 87.9% for the two courses,was 73.2% for a course of treatment;control group:The total effective rate was 47.5% for the two courses,was 37.5% for a course of treatment; Two groups compared at different times were different significantly(P<0.05).The experimental group always showed higher efficiency than compared group.(2)The relationship between treatment time and effect:Both treatment groups which had two courses of treatment had higer efficacy than those in a course of treatment.(3)After treatment,thyroid volumes and nodule maximum diameters were lower than before.There were significant difference when they were compared in each group separately(P<0.05).Thyriod volumes were not significantly different when they were compared between two groups (P>0.05),and nodules’s reduced levels of maximum diameter of the experimental group were more than the control group (P<0.05).(4)The relationship between nodule size and effect of the two groups:After two courses of treatment,the results showed that the efficiency of two groups depend on pre-treatment nodule diameter:less than 2cm> 2-4cm>more than 4cm.(5)Changes in thyroid function before and after treatment of the two groups:Free triiodothyronine(FT3),free thyroxine(FT4) of two groups and sensitive thyrotropin(sTSH) in the experimental group before and after two courses of treatment had no significant difference (P>0.05);After treatment the sTSH of the control group was significantly decreased (P<0.05).(6)Side effects:There was no significantly adverse reaction in the experimental group. In the control group,10 patients had various degrees about dry mouth, irritability, insomnia,and 4 cases in which had palpitations,fever and other symptoms;The rate of its adverse reaction was 25%.3. Clinical mechanism studies have shown that:(1)Serum VEGF level of patients with NG in pre-treatment was higher than that of the control group (P<0.05).After "HuoXueXiaoying" prescription treatment,serum VEGF level was reduced 3 months treatment later,but it had no significant difference compared with that before treatment (P>0.05);After 6 months treatment the level was reduced to normal level,compared with the control group, and there was no statistical significance (P>0.05).(2)Serum IGF-I level of patients with NG in pre-treatment was higher than that of the control group (P<0.05),and serum TGF-β1 level was lower than that of the control group (P<0.05).After "HuoXueXiaoying"prescription treatment,serum IGF-I level was decreased after 3-month treatment,but no statistics significance (P>0.05);After 6 months treatment,it was significantly lower than that before treatment (P<0.05),but there was no significant difference when it was compared with that of the contral group(P >0.05). Serum TGF-β1 level was significantly higher after 3-month treatment(P<0.01));After 6 months treatment,it was decreased obviously,but was still significantly higher than that before treatment (P<0.01),and was also higher than that of the control group (P<0.05).(3)Serum sFas level of patients with NG in pre-treatment was significantly higher than the control group (P<0.01),and serum sFasL level was lower (P<0.05).After "HuoXueXiaoying" prescription treatment,serum sFas levels was a little decreased after 3-month treatment,but no statistics significance(P>0.05); After 6-month treatment,it was significantly lower than that before treatment (P<0.01),but compared with the control group, it was no sinnificantly different (P>0.05).Serum sFasL level was increased obviousely after 3-month treatment(P<0.05);It increased constantly after 6-month treatment,having significant difference compared with that of patients who had 3-month treatment or were under pre-treatment,and was significantly higher than normal level,compared with the control group (P<0.01).(4)Serum IL-1βand TNF levels of patients with NG in pre-treatment were a little higher than those of the control group,compared with those before treatment,but there were no significant differences(P>0.05);Serum IL-6 level was lower than that of the control group (P<0.05).After "HuoXueXiaoying" prescription treatment,Serum IL-1βand TNF levels were increased obviousely after 3-month teratment(P<0.05),and were a little decreased after 6-month treatment(P>0.05);And they were higher than normal level,compared with the control group,having statistical significance(P<0.05).Serum IL-6 level has increased after 3-month treatment,but compared with those before treatment,there was no significant difference (P>0.05);It was significantly increased to normal level after 6-month treatment,it was more significantly different than after 3-month treatment and before treatment (P<0.05),and compared with the control group,there was no significant difference (P>0.05).Conclusion:1.Nodular goiter mainly dues to qi stagnation, blood stasis block,phlegm stagnation and qi,sputum,blood cross-resistance formed on the anterior neck which caused by emotional imbalance, inappraprite water and soil,physical factors and so on. Chinese medicine treatment on NG has achieved better efficacy.It can avoid patient’s cardiac rhythm disorders and osteoporosis and other side effects caused by western medicine, especially is suitable for frail patients.2.The total effective rate of "HuoXueXiaoying" prescription treated group was higher than that of euthyrox group; "HuoXueXiaoying" prescription is better than euthyrox on reducing or removing the nodules.It’s shown that "HuoXueXiaoying" prescription was more clinically effective than euthyrox on treating NG.Both two groups which had 2 courses of treatment were better than those in a course of treatment.It is closely related between the elimination with size of nodules:the efficacy of treatment on nodule diameter<2cm was better, that of>4cm was in poorer treatment outcomes."HuoXueXiaoying" prescription for the function of thyroid hormone secretion had no significant influence, litter toxic side effects,high security and high performance.3. Growth factors(VEGF, IGF-I,TGF-β1)are closely related to the incidence and prognosis of nodular goiter."HuoXueXiaoying" prescription can suppress the thyroid follicular hyperplasia and thyroid tissue hyperplasia by appropriately reducing serum VEGF, IGF-I levels and increasing serum TGF-β1 level.4.Apoptotic factors (sFas,sFasL)play an important role in the pathogenes and treatment on nodular goiter.There is suppressed apoptos is in NG. "HuoXueXiaoying" prescription probably can induce apoptosis of thyroid cells to shrink goiter and nodule to achieve the purpose of treating NG through reducing serum sFas level and elevating serum sFasL level.5.Immune-regulating factors(IL-1 P,IL-6 and TNF)were also probably involved in the pathogenesis and prognosis process of nodular goiter."HuoXueXiaoying" prescription may be through appropriately increasing the serum IL-1β,TNF and IL-6 levels, inducing apoptosis of thyroid cells and inhibiting proliferation of thyroid follicular to adjust the balance between proliferation and apoptosis of thyroid cell for therapeutic purposes.更多还原