[閱讀心得] 最好的光明燈

[閱讀心得] 最好的光明燈 

張清貿醫師參加第12屆前瞻生物醫學科學新知研討會

台灣中醫臨床醫學會第七屆第六次理監事會議 ，張清貿醫師，今天擔任副秘書長兼司儀

台灣中醫臨床醫學會第七屆第六次理監事會議 ，張清貿醫師，今天擔任副秘書長兼司儀

[論文發表] A Clinical Study of Integrating Acupuncture and Western Medicine in Treating Patients with Parkinson's Disease (SCI)

Am J Chin Med. 2015;43(3):407-23. doi: 10.1142/S0192415X15500263.

A clinical study of integrating acupuncture and Western medicine in treating patients with Parkinson's disease.

Chen FP1, Chang CM, Shiu JH, Chiu JH, Wu TP, Yang JL, Kung YY, Chen FJ, Chern CM, Hwang SJ.

Author information

Abstract

Complementary therapy with acupuncture for Parkinson's disease (PD) has been studied for quite a long time, but the effectiveness of the treatment still remains unclear. The aim of this study is to evaluate the integrated effects of acupuncture treatment in PD patients who received western medicine. In the short-term acupuncture treatment study, 20 patients received acupuncture therapy twice a week in acupoints DU 20, GB 20, LI 11, LI 10, LI 4, GB 31, ST 32, GB 34 and GB 38 along with western medicine for 18 weeks, and 20 controlled patients received western medicine only. In the long-term acupuncture treatment, 13 patients received acupuncture treatment twice a week for 36 weeks. The outcome parameters include Unified Parkinson's disease rating scale (UPDRS), Beck Anxiety Inventory (BAI), Beck Depression Inventory-Version 2 (BDI-II), and WHO quality of life (WHOQOL). In the short-term clinical trial, a higher percentage of patients in the acupuncture group had score improvement in UPDRS total scores (55% vs. 15%, p = 0.019), sub-score of mind, behavior and mood (85% vs. 25%, p < 0.001), activity of daily living (65% vs. 15%, p = 0.003), mobility (40% vs. 15%, p = 0.155) and complication of treatment (75% vs. 15%, p < 0.001), BDI-II score (85% vs. 35%, p = 0.003), and WHOQOL score (65% vs. 15%, p = 0.003) when compared to control group at the end of the 18 weeks' follow up. After 36 weeks of long-term acupuncture treatment, the mean UPDRS total scores and sub-score of mentation, behavior and mood, sub-score of complications of therapy and BDI-II score decreased significantly when compared to the pretreatment baseline. In conclusion, acupuncture treatment had integrated effects in reducing symptoms and signs of mind, behavior, mood, complications of therapy and depression in PD patients who received Western medicine.

KEYWORDS:

Acupuncture; Integrative Therapy; Parkinson's Disease; QOL

花蓮遠雄悅來大飯店+遠雄海洋公園

University Malaysia Sarawak 國際交換學生3位至北榮張清貿醫師門診跟診

University Malaysia Sarawak 國際交換學生3位至北榮張清貿醫師門診跟診

[研究新知介紹] 修格蘭氏症(Sjögren's syndrome) 與其他疾病之口乾、眼乾鑑別診斷 - 張清貿醫師

[研究新知介紹]

修格蘭氏症(Sjögren's syndrome) 與其他疾病之口乾、眼乾鑑別診斷

中醫藥實證醫學之探討

修格蘭氏症/乾燥症之中醫研究

張清貿醫師

        我覺得這篇法國回顧性研究修格蘭氏症(Sjögren's syndrome) 與其他疾病之口乾、眼乾鑑別診斷，滿值得一看的，可以知道不是只有乾燥症才是口乾眼乾，也不是口乾眼乾就是乾燥症，一般俗稱的乾燥症其實是Sicca complex，也就是口眼乾燥症候群，成因有很多，比如：用眼過度、說話過多、藥物副作用、利尿劑引起，甚至是糖尿病、更年期、癌症放射線療法或是化療，Sicca complex跟Sjögren's syndrome是不一樣的，但目前很多人常常把概念搞錯，所以本篇作者再最後也總結對Sjögren's syndrome臨床上需要觀察的SOAP要點。

[研究發表摘錄介紹] 目前台灣正在進行中藥SS-1治療修格蘭氏症(Sjögren's syndrome) 之中醫藥臨床試驗 (桃園長庚紀念醫院與中國醫藥大學附設醫院)

＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝
摘錄自Clinical Reviews in Allergy & Immunology研究成果：

Clin Rev Allergy Immunol. 2014 Jun 21. [Epub ahead of print]

The Differential Diagnosis of Dry Eyes, Dry Mouth, and Parotidomegaly: A Comprehensive Review.

Cornec D1, Saraux A, Jousse-Joulin S, Pers JO, Boisramé-Gastrin S, Renaudineau Y, Gauvin Y, Roguedas-Contios AM, Genestet S, Chastaing M, Cochener B,Devauchelle-Pensec V.

Author information

• 1Department of Rheumatology, Brest Teaching Hospital, Brest, France.

Abstract

Primary Sjögren's syndrome (pSS) is a frequent autoimmune systemic disease, clinically characterized by eyes and mouth dryness in all patients, salivary gland swelling or extraglandular systemic manifestations in half of the patients, and development of lymphoma in 5 to 10 % of the patients. However, patients presenting with sicca symptoms or salivary gland swelling may have a variety of conditions that may require very different investigations, treatments, or follow-up. Eye and/or mouth dryness is a frequent complaint in clinical setting, and its frequency increases with age. When evaluating a patient with suspected pSS, the first step is to rule out its differential diagnoses, before looking for positive arguments for the disease. Knowledge of normal and abnormal lachrymal and salivary gland physiology allows the clinician to prescribe the most adapted procedures for evaluating their function and structure. New tests have been developed in recent years for evaluating these patients, notably new ocular surface staining scores or salivary gland ultrasonography. We describe the different diagnoses performed in our monocentric cohort of 240 patients with suspected pSS. The most frequent diagnoses are pSS, other systemic autoimmune diseases, idiopathic sicca syndrome and drug-induced sicca syndrome. However, other diseases are important to rule out due to their specific management, such as sarcoidosis, granulomatosis with polyangeitis, IgG4-related disease, chronic hepatitis C virus or human immunodeficiency virus infections, graft-versus-host disease, and head and neck radiation therapy. At the light of these data, we propose a core of minimal investigations to be performed when evaluating a patient with suspected pSS.

[研究發表摘錄介紹] 獨活寄生湯、骨碎補、續斷三種方藥組合為退化性關節炎(osteoarthritis, OA)之主要中醫藥組合

[研究發表摘錄介紹] 

「獨活寄生湯」、「骨碎補」加「續斷」為退化性關節炎(osteoarthritis, OA)之主要中醫藥組合

在台灣，年紀大於50歲平均有37％罹患退化性關節炎(osteoarthritis, OA)，由於現今西醫常規治療下存在許多副作用，因此許多患者尋求替代療法治療患病關節之不適，臺北榮民總醫院傳統醫學部從2002年健保資料庫中分析全人口檔(22,520,776)之中醫處方分析，結果顯示20,059位患者在中醫門診治療過OA，並總共服用32,050項中醫處方，其中以40-49歲患者佔最多數，女性比男性為1.89：1，處方分析中最常被使用的單方為「杜仲」，其他依次為「續斷」、「牛膝」、「木瓜」、「丹參」，最常被使用之複方為「獨活寄生湯」，其他依次為「疏經活血湯」、「當歸拈痛湯」、「六味地黃丸」、「濟生腎氣丸」。最常開立之兩種藥物組合為「獨活寄生湯」加「身痛逐瘀湯」，最常開立三種藥物組合為「獨活寄生湯」、「骨碎補」加「續斷」。

本研究探討2002年全人口退化性關節炎之中醫藥物流行病學調查，相關成果並於2014年3月發表於BMC Complementary and Alternative Medicine。本研究極具參考價值，可提供台灣中醫師與退化性關節炎患者參考。

This study is the first nationwide population based survey of the CHM use for OA patients in Taiwan. Females used CHM for OA higher than males (1.89:1), and the female aged 50-69 years had the highest prevalence of CHM use for OA. Menopause, higher percentage of obesity and osteoporosis in female may be the factors accounting for this phenomenon [38-40].

The most commonly combination of three CHMs is “Du-huo-ji-sheng-tang, Gu-sui-pu plus Xu-duan”, followed by “Du-huo-ji-sheng-tang, Yan-hu-suo plus Nui-xi” and “Du-huo-ji-sheng-tang, Shu-jing-huo-zue-tang plus Yan-hu-suo.” “Gu-sui-pu” could inhibit the osteoclast activity in the OA mouse model [54] and prevent osteoporosis [55]. And “Yan-hu-suo” had anti-inflammatory effect with decreasing vascular permeability and restraining the development of adjuvant-induced edema in arthritic mice and rat models [56]. It also could alleviate pain with analgesic effect in a rat model [57].

TCM doctors in Taiwan frequently prescribe a combination of Chinese herbal formulae and Chinese single herb with the concepts of “pattern identification as the basis for determining treatment” and “sovereign, minister, assistant, and courier” [33,35,37]. Mostly, there were six items of CHM in a prescription for OA. Since female OA patients usually combined with menopausal syndrome and osteoporosis, the TCM doctors might combine use these CHM formulae more frequently in order to treat these two diseases.

至BMC Complementary and Alternative Medicine摘錄Discussion部份內容：
Fang-Pey Chen, Ching-Mao Chang, Shinn-Jang Hwang*, Yu-Chun Chen and Fun-Jou Chen: Chinese herbal prescriptions for osteoarthritis in Taiwan: analysis of national health insurance dataset. BMC Complementary and Alternative Medicine. 2014 (SCI, 2013 IF=1.877)

[研究發表摘錄介紹] 藉由紅斑性狼瘡問卷(Systemic Lupus Erythematosus Questionnaire , SLEQ)為基礎教育患者與訓練住院醫師，可達到與資深主治醫師有8成5以上的一致性

[研究發表摘錄介紹] 

藉由紅斑性狼瘡問卷(Systemic Lupus Erythematosus Questionnaire , SLEQ)為基礎教育患者與訓練住院醫師，可達到與資深主治醫師有8成5以上的一致性

        本篇一致性論文主要是在討論紅斑性狼瘡(Systemic Lupus Erythematosus, SLE)患者就診時，利用紅斑性狼瘡問卷(Systemic Lupus Erythematosus Questionnaire , SLEQ)調查SLE患者、住院醫師及資深主治醫師對 152 項問診症狀，住院醫師及資深主治醫師對20 項舌診型態及 15 項脈診型態，判定 3 位觀察者之間有無一致性。
        研究結果顯示，不論是患者或住院醫師對中醫症狀或舌脈診，經過教育與訓練後與資深主治醫師的準確度會趨於一致，這在中醫藥研究上屬於少見，尤其是一次討論 3 個觀測者對 187 個項目之一致性更是首見，若能藉由問卷為基礎教育患者與訓練住院醫師，並達到與資深主治醫師有8成5以上的一致性，那未來患者利用問卷填答可加速問診之準確性。

    The disease-specific diagnosis questionnaires should be able to guide the junior doctors in learning the features of the most common diseases. We may encourage them to collaborate with the objective structured clinical examination (OSCE)^{21, 22, 23, 24, 25 and 26} in the training course for TCM resident doctors.

    The purpose of the SLEQ was designed for education and training. The patient (P), resident doctor (R) and senior supervisor (S) filled all the questions in sequence independently. In order to find the potential mistakes and correct them, the later rater assumed that the previous rater made mistakes and they need to examine the questionnaire with a critical eye, so that the evaluation of agreement would not be influenced by any potential bias.

    Through this training process based on questionnaire-reported diagnosis, we could improve the inter-rater reliability of TCM diagnosis.^27 and 28 The P's responses and R's responses to the SLEQ could almost be the same as S, provided that the agreements among P, R and S were good enough. Higher agreement could set objective and standard assessments.^29 and 30 This would serve the purpose of raising the quality of medical practice. In future, we may develop the tele-care service for TCM further.

至Complementary Therapies in Medicine摘錄Discussion部份內容：
Ching-Mao Chang, Wen-Hsiang Wu, Benjamin Ing-Tiau Kuo, Tzung-Yan Lee, Chia-Yu Liu, Hen-Hong Chang*: Using A Questionnaire among Patient, Resident Doctor and Senior Supervisor: Are their Answers the Same? Complementary Therapies in Medicine. 2014 (SCI, 2012 IF=2.216)

[論文發表] The Core Pattern Analysis on Chinese Herbal Medicine for Sjögren's syndrome: A Nationwide Population-Based Study，臺灣近十年來修格蘭氏症中醫核心處方分析及衍伸進行中之中醫藥SS-1臨床試驗

Sci Rep. 2015 Apr 29;5:9541. doi: 10.1038/srep09541.

The Core Pattern Analysis on Chinese Herbal Medicine for Sjögren's syndrome: A Nationwide Population-Based Study. 

臺灣近十年來修格蘭氏症中醫核心處方分析及衍伸進行中之中醫藥SS-1臨床試驗

Chang CM1, Chu HT2, Wei YH3, Chen FP4, Wang S5, Wu PC6, Yen HR7, Chen TJ8, Chang HH7.

Author information

Abstract

This large-scale survey aimed to evaluate frequencies and patterns of Chinese herbal medicine (CHM) used for Sjögren's syndrome (SS) in Taiwan by analyzing the National Health Insurance Research Database (NHIRD) for cases in which CHM was used as an alternative therapy to Western medicine for improving patients' discomforts. We analyzed cases of SS principal diagnosis (ICD-9:710.2) with a catastrophic illness certificate (CIC) in traditional Chinese medicine (TCM) outpatient clinics from three cohorts of the Longitudinal Health Insurance Database (LHID) in the NHIRD between 2002 and 2011. CHM prescription patterns for SS were evaluated from claimed visitation files and corresponding prescription files. There were 15,914 SS patients with CIC (SS/CIC), and we found only 130 SS/CIC cases visiting TCM clinics in LHID2000, 133 in LHID2005, and 126 in LHID2010. After removing duplicate data, 366 SS/CIC and 4,867 visits were analyzed. The 50-59 year age group showed the highest ratio (29.51%) in both women and men. "Qi-Ju-Di-Huang-Wan" and "Xuan-Shen" (Scrophularia ningpoensis Hemsl.) was the most commonly used formula and single herb, respectively. "Qi-Ju-Di-Huang-Wan, Gan-Lu-Yin, Xuan-Shen, Mai-Men-Dong (Ophiopogon japonicus (L. f.) Ker-Gawl.), and Sheng-Di-Huang (raw Rehmannia glutinosa Libosch)" were the core pattern prescriptions in treating SS/CIC.

[研究發表摘錄介紹] 中醫證型現代研究的定性與定量結語

[研究發表摘錄介紹] 

中醫證型現代研究的定性與定量結語

本文簡單論述之中醫證型的相關現代研究，從bioinformatics、genomics、metabolomics到EBM文獻回顧，疾病從DM、失眠、肝癌到冠心病，在研究方法及疾病選擇非常廣泛，雖然在現今講求EBM的條件下，中醫所做的努力仍不足，但也漸漸的、緩慢的往實證醫學邁進，不在只是停留在專書與老中醫之專家意見，相當值得鼓勵與學習。西方現代醫學之所以為強盛主流，主要原因是因為物理、化學、生物、數學……等多學科的幫忙，因為這些學科紛紛投入醫學領域，促成顯微鏡、影像學、手術儀器等的產生，讓西方醫學不管在哪個領域都可以完整的做出診斷及治療。傳統中醫學也應該如此，多個學科的注入，使中醫學可以應用多學科的專長來彌補自己不足，現在一般認知物理、化學、生物、數學都不是組成中醫的要素，但我認為，影像學檢查可以拿來當望診的一部分，聽力檢查也可以算是聞診的一部分。所以什麼是中醫？我認為只要可以被中醫所用，就是中醫！

摘錄自臨床醫學研究部份內容

1. 張清貿, 施柏瑄, 朱學亭, 陳方佩. 該如何理解「證」？- 中醫證型現代研究的定性與定量, 臨床醫學. 2014 (73)：189-195 (in Chinese)

[研究發表摘錄介紹] 探討脾虛證、溼熱證、血瘀證在移植胰臟癌老鼠模型(mouse xenograft pancreatic cancer models)上，對tumor growth和tumor microenvironment的影響

[研究發表摘錄介紹] 

探討脾虛證、溼熱證、血瘀證在移植胰臟癌老鼠模型(mouse xenograft pancreatic cancer models)上，對tumor growth和tumor microenvironment的影響

圖6 清胰化積方治療後，脾虛、溼熱及血瘀證中SDF-1和CCL5均顯著下降

復旦大學附屬腫瘤醫院整合醫學腫瘤中心中西醫結合科陳震醫師探討脾虛證、溼熱證、血瘀證在移植胰臟癌老鼠模型(mouse xenograft pancreatic cancer models)上，對tumor growth和tumor microenvironment的影響。¹⁴陳醫師從31篇臨床試驗研究文獻統計出溼熱證(33.9%)、脾虛證(29.1%)及血虛證(19.8%)為胰臟癌患者常見之三大證型，並以此概念建立脾虛證、溼熱證及血瘀證之移植胰臟癌老鼠模型，並觀察出不同證型之模型cancer-associated fibroblast (CAF) proliferative activity及tumor-associated macrophage (TAM) infiltration有不同表現，而經過清胰化積方(Qingyihuaji formula)治療後，三個證型中CAF和TAM分泌的cytokine SDF-1和CCL5均顯著下降(圖6)，但若以中醫理論選擇之方藥治療證型，黃連解毒湯治療溼熱證、四君子湯治療脾虛證及桃紅四物湯治療血瘀證，則於三組模型中無觀察到上述效果，作者暗示根據中醫理論單獨治療中醫證型，其反應效果較差，但本研究使用中醫理論的方藥在治療脾虛證、溼熱證及血瘀證似乎稍嫌不足，對這部份的實驗結果也會有影響，若使用較符合該證型的治療方劑，那應該會有較高的治療效果。

摘錄自Evid Based Complement Alternat Med 與臨床醫學研究部份內容

1. 張清貿, 施柏瑄, 朱學亭, 陳方佩. 該如何理解「證」？- 中醫證型現代研究的定性與定量, 臨床醫學. 2014 (73)：189-195 (in Chinese)
2. Chen Z, Chen LY, Wang P, Dai HY, Gao S, Wang K. Tumor Microenvironment Varies under Different TCM ZHENG Models and Correlates with Treatment Response to Herbal Medicine. Evid Based Complement Alternat Med 2012;2012:635702.

[研究發表摘錄介紹] 利用實證醫學(Evidence-Base Medicine, EBM)探討1990年至2011年間中醫證型研究分佈

[研究發表摘錄介紹] 

利用實證醫學(Evidence-Base Medicine, EBM)探討1990年至2011年間中醫證型研究分佈

    香港浸會大學中醫學院院長呂愛平教授利用實證醫學(Evidence-Base Medicine, EBM)研究方式對1990年至2011年間的文獻進行分析，⁷並提出”TCM Zheng is the abstraction of a major disharmonious pathogenesis, which is identfied from a comprehensive analysis of clinical information from four main diagnostic TCM methods.”⁸統計結果顯示中醫證型研究之十大常見疾病與前20大疾病之中醫證型，其中十大常見疾病前五名為： Heart failure、Rheumatoid arthritis、Rheumatic heart disease、Diabetes mellitus (DM)及Myocardial infarction。

    而前20大疾病之中醫證型前五名均為Diabetes mellitus，其證型依序為氣陰兩虛(Dual deficiency of qi and yin)、陰陽兩虛(Dual deficiency of yin and yang)、血瘀(Blood stasis)、痰濕阻肺(Phlegm- dampness obstructing the lung)與腎陰虛(Kidney yin deficiency)。

    並利用data mining方法探討「證與證」及「病與證」之間的網絡連結，圖中顯示疾病病程中，中醫證型的轉歸趨勢，非常值得參考，具臨床實用價值。

摘錄自Evid Based Complement Alternat Med 與臨床醫學研究部份內容

1. 張清貿, 施柏瑄, 朱學亭, 陳方佩. 該如何理解「證」？- 中醫證型現代研究的定性與定量, 臨床醫學. 2014 (73)：189-195 (in Chinese)
2. Jiang M, Zhang C, Zheng G, Guo H, Li L, Yang J, Lu C, Jia W, Lu A. Traditional chinese medicine zheng in the era of evidence-based medicine: a literature analysis. Evid Based Complement Alternat Med 2012;2012:409568.