《金匮要略》中疾病“因果关系”辨治观探微

本文旨在基于“因果关系”辨证观窥视《金匮要略》中疾病在发生、发展和变化之间相关制约、相互转化的关系,以及疾病“因果关系”之间的多重复杂性,从而把握仲景辨证思维意旨,进一步深入研究杂病证治规律,对指导临床实践有所裨益。

从“阳虚毒结”角度探讨免疫治疗超进展的形成及“五观辨治”干预作用

免疫检查点抑制剂(ICIs)在肿瘤治疗中显示出良好的疗效,改变了肿瘤的治疗格局。但部分接受ICIs治疗的患者未达到理想治疗效果,反而出现了肿瘤异常加速生长的非典型反应模式,即超进展(HPD)。目前HPD的发病机制尚不明确,诊断难度较大,为临床鉴别和确定治疗策略带来了挑战。探索HPD的可能机制是提升免疫治疗效果的重要方面,该文基于“阳虚毒结”理论,从“脾肾阳虚、毒邪鸱张”探讨免疫治疗超进展发生机制,认为p53抑癌基因失活和免疫抑制微环境是机体正气不足,脾肾阳衰的表现,为HPD发生的重要基础;ICIs所致不良反应属“药毒”范畴,鼠双微体2(MDM2)/鼠双微体4(MDM4)等癌基因激活、表皮生长因子受体(EGFR)突变及肿瘤炎性微环境的发生发展是邪气亢实,癌毒药毒相搏,乘虚鸱张的表现,可促进肿瘤细胞异常增殖,为HPD发生的核心病机要素,与疾病转归密切相关。治疗方面,在该团队结合临床实践总结提出的“五观辨治”(时空观、核心观、症状观、精准观、未病观)理论指导下,以防治HPD为切入点,复法组方,扶正温阳,实现时空全周期动态管理;解毒抗癌,实现标本全方位系统干预;在HPD宏观临床表现及微观病理改变层面富集靶点,提高药物选择靶向性和防治精准性,充分发挥中医药独特治疗优势,为临床应用中医药防治HPD提供新思路。

五观辨治-构建中医药防治肿瘤新体系

恶性肿瘤作为我国高发疾病之一,严重危害人类生命健康,国家“六五”至“十三五”科技攻关计划中医药防治肿瘤科技攻关及临床实践显示,中医药在防治术后转移复发、延长生存期、减轻治疗不良反应、改善晚期带瘤生存质量等方面均显示出一定作用优势,但创新中医理论体系、实现中医药全周期管理等方面亟待完善和凝练,限制了临床疗效提升。恶性肿瘤是重大疑难病证的典型代表,单纯辨证论治模式不能满足临床需要,“病、证、症”三位一体辨治模式应运而生,已被广泛重视,但恶性肿瘤具有独特的发生发展规律及变化特性,亟需建立体现现代疾病发展规律的中医专病辨治新体系。该文在“三位一体”基础上,创新提出“五观辨治”中医肿瘤防治新体系,形成“全周期、全链条、全方位”的中西协同防治肿瘤新范式,包括时空观,基于整体观念,结合恶性肿瘤不同病理类型、病位、病程及治疗阶段的复杂特性,从时间及空间双维度,强调中医药全程参与肿瘤治疗的动态性及系统性;核心观,病证结合凝练核心病机,重视其在指导辨治恶性肿瘤的关键作用,以及不同癌种、不同阶段的病机特点及演变规律;症状观,解决患者当前阶段突出矛盾,改善不适症状、提高生存质量,增强治疗的人文性;精准观,结合现代医学理念,以中医体质、实验室指标等富集聚焦中医药优势靶点,精准临床定位;未病观,防重于治,肿瘤各阶段均强调关口前移。五观之间各有侧重且相互联系、涵盖对恶性肿瘤中医防治体系认识的新视野,在继承中医原创理论基础下引进新思想、新理念,为肿瘤综合防治方案提供新策略。

基于五观辨治体系从瘀毒论治放射性肺损伤

放射性肺损伤是恶性肿瘤放疗后的常见并发症,中医学认为热毒津亏、血脉瘀滞是放射性肺损伤常见病机,“瘀毒”是其重要病理因素。围绕“瘀毒”与放射性肺损伤的关系,结合五观辨治模式,提出以“时空观”察疾病的动态发展过程,“核心观”论不同阶段的关键病机,并提出截癌毒、清热毒、化瘀毒三大治法,以“症状观”缓解突出症状,以“精准观”探讨中医治疗的优势靶点,在“未病观”下从未病先防、已病防变、瘥后防复三个方面防治放射性肺损伤。从全周期防治的角度为放射性肺损伤的临床治疗提供参考。

郑钦安“阳主阴从”学术思想发挥

从生命观、病理观、辨治观三方面对郑钦安"阳主阴从"学术思想进行探析。郑氏从元阴元阳立论,而以阳气为主导,临床上贯彻"阳主阴从"的学术思想,常用大剂姜、桂、附等辛热温燥之药,治愈许多杂病中的阳虚证,饮誉蜀中,世人尊称之"郑火神"。

Clinical observation on effect of scalp electroacupuncture for mild cognitive impairment

OBJECTIVE: To evaluate the therapeutic effect of scalp electroacupuncture for mild cognitive impairment (MCI) in the early stage. METHODS: Two hundred and thirty three MCI patients were randomly divided into three groups: the drug group, the scalp electroacupuncture group, and the syndrome differentiation group. For the scalp electroacupuncture group, the points of Baihui (DU 20), Sishecong (EX-HN1), Fengchi (GB 20), and Shenting (DU 24) were selected. For the syndrome differentiation group, specific acupoints were added on the basis of syndrome differentiation and according to the scale for the differentiation of syndromes in vascular dementia (SDSVD) beside the acupoints used in the scalp electroacupuncture group. For the drug group, nimodipine was orally administered. Each patient was treated for two courses, eight weeks. The score differences in minimental state examination (MMSE), picture recognition, and clock drawing test were observed before and after the treatment. RESULTS: After treatment, the score differences in MMSE and clock drawing test were of obvious statistical significance among three groups (P<0.01, P<0.05). The score differences in picture recognition were of extremely statistical significance between the scalp electroacupuncture group and the syndrome differentiation group (P<0.01), while the difference was not found in the drug group (P>0.05). There were statistical significant differences in therapeutic effects between the scalp electroacupuncture group and the drug group, and between the syndrome differentiation group and the drug group (P<0.05), while no statistical difference was found between scalp electroacupuncture group and the syndrome differentiation group (P>0.05). CONCLUSION: All the three therapies may improve the cognitive function of MCI patients. The therapeutic effects in the scalp electroacupuncture and syndrome differentiation groups were basically the same, but superior to nimodipine.

Clinical observation on pricking at Sìfèng (四缝 EX-UE 10) combined with Chinese herbs for infantile malnutrition

Objective To explore the best clinical treatment for infantile malnutrition. Methods Three hundred and forty-three patients were randomly divided into a pricking at Sìfèng （四缝 EX-UE 10） group （priking group, n=105）, a Chinese herbs group （n=85） and a pricking and Chinese herbs group （n=153）. The improvements of the clinical symptoms of all three groups were evaluated after the treatment. Results The results of these treatments for all the patients were satisfying. The effective rate of the pricking and Chinese herbs group, which was 98.7 % （151/153）, was superior to that of 94.3 % （99/105） （P0.05） in the pricking group and 91.8% （78/85） in the Chinese herbs group （P0.01）, while no differences in effective rate were found between the pricking group and the Chinese herbs group （P0.05）. Conclusion The pricking at Sìfèng （四缝 EX-UE 10） combined with Chinese herbs is the best treatment for infantile malnutrition.