亚健康状态流行病学调查及其肾阴虚证的蛋白组学研究

发布时间：2018-07-01 11:09

本文选题：亚健康状态 + 流行病学调查　；参考：《南方医科大学》2007年博士论文

【摘要】： 【背景】20世纪80年代，前苏联布赫曼教授通过研究发现，除健康状态和疾病状态之外，人体还存在着一种非健康非患病的中间状态，称之为“第三状态”。世界卫生组织(WHO)一项全球性调查结果表明，全世界真正健康的人(第一状态)仅占5％，经医生检查、诊断有病的人(第二状态)也只占20％，75％的人处于健康和患病之间的“第三状态”。由于亚健康状态的高发率以及其对国民生活质量的影响，国内医学界已经把“亚健康状态”作为危害国人健康的重要课题，对亚健康状态的研究，已经成为生命科学研究的重要组成部分。亚健康状态是指人的身心处于疾病与健康之间的状态，是机体虽无明确的疾病，但在躯体上、心理上和人际交往上出现种种不适应的感觉和症状，从而呈现出活力、反应能力和对外界适应能力降低的一种状态，这种状态多由人体生理机能或代谢机能低下所致，虽然尚未达到疾病水平，但已严重影响人的工作效率和生活质量。目前认为亚健康状态的发生可能与个人的生理状况、心理状况、生活方式、职业情况、居住环境及社会交往等多种因素有关。国内已有关于大学生、高校教师、机关干部、军人等特定人群进行了亚健康状态的小样本研究，，结果显示，不同人群亚健康状态的发生因素、临床表现等是有所不同的。因此，在特定人群中开展大型亚健康状态流行病调查有利于亚健康状态的防治。亚健康状态缺乏明确诊断为“某病”的理化依据，没达到疾病的诊断标准，它实际上是机体生理活动规律失常的综合的表现，是一种还达不到器质性改变的功能性变化，是人体身心整体调整异常的早期反映。因此，以具体的“形态结构学”为基础，以单纯的“生物性疾病”为研究对象，以数字化的检验数据为诊疗依据的现代医学很难把握亚健康状态的诊治规律。中医学是一门以整体观念为指导，以辨证论治为主要诊疗特点的医学理论体系，其有别于现代医学的最大特点之一就是对人体“生理特性”和“功能活动规律”的重视。因此，中医学在对亚健康状态的认识以及诊断治疗方法等方面较现代医学具有全方位的优势。辨证论治是中医学诊治疾病的基础，是中医学中最富有特色的科学精华。证候是辨证论治的前提和基础，是连接中医理论和临床诊疗体系的桥梁和关键。证候的研究是中医现代化研究的关键，证候本质研究也一直是中医研究的热点。然而始终是有进步而无突破，究其原因，可能是研究思路、方法学存在问题。我们经过研究发现，从亚健康状态入手研究中医证候本质是一个非常理想的切入点。因为亚健康状态是介于健康和疾病之间的中间状态，各项检查未发现异常，西医无法确诊某种疾病，但已经出现各种症状，亦即其已经表现出各种中医证候，此证候不受西医疾病的干扰，因此该证候是最理想的研究对象。当然，这也存在一定的不足，因为亚健康状态所表现出的症状，也许不可能代表全部的中医证候特征，但可能会找到证候的最本质的特征。因此，开展亚健康状态的中医证候临床流行病学研究，不仅为防治亚健康状态提供理论基础和实践指导，而且还将促进中医证候学进一步的发展和完善。我们前期对肾阴虚证的研究工作较为充分，而且根据我们的预调查显示，亚健康状态中的肾阴虚证的病例较多，居所有证候的前三位，因此，我们就选择肾阴虚证为切入点，然后再进行其它典型证候的研究。肾阴虚证的主要临床表现为干咳少痰，短气喘息，口燥咽干，甚至可见午后低热，五心烦热，潮热盗汗，头晕耳鸣，眩晕目涩，牙齿松动或疼痛，腰膝酸痛，失眠多梦，遗精早泄，性欲亢进，颧红目赤，大便干结，小便短少，舌红，苔黄，脉细数等。长期以来，临床上都是以上述指标作为依据，进行临床诊断和治疗。但是上述表现在同一个肾阴虚证患者身上不一定全部表现出来，可能还会兼见其他证候的表现，这些都会给肾阴虚证的临床辨证带来麻烦，为了研究哪些才是肾阴虚证的特异性表现，我们通过对亚健康状态下的肾阴虚证表现的研究，排除疾病干扰的因素，以寻找肾阴虚本质的特征，为中医证候本质的研究提供一个思路。目前肾阴虚证实质研究还处在笼统、多指标的模糊状态，有待进一步多学科综合研究。证候蛋白质组学的提出，为整体评价证候实质提供可能。血清中含有近万种蛋白质，成分复杂，包括各种不同器官、组织和细胞分泌的多种蛋白质，机体任一时间阶段的病理生理改变均可在血清中反映出来。因而，从血清蛋白质组学的角度，将蛋白质组学和中医证型研究结合起来，探讨。肾阴虚证在某一特定时期的相关蛋白质，对从整体水平评价肾阴虚证的实质具有重要的现实意义。【目的】通过对不同人群的亚健康状态流行病学调查，研究亚健康状态在不同人群中的发生的一般规律，进而探讨亚健康状态在高危人群中发生的原因，为其防治提供指导。并研究亚健康状态中肾阴虚证的中医证候特征，抛开疾病的干扰因素，从症状表现、舌苔、舌质、脉象等方面探讨肾阴虚证的证候本质。最后利用蛋白质组学的方法，研究亚健康状态肾阴虚证的分子机制，与不同疾病状态下肾阴虚证进行对比，探讨亚健康状态中医肾阴虚证的分子实质。本研究不仅对亚健康状态的防治有着深远意义，还将促进中医证候研究的拓展和深入。【方法】首先采用现场调查的方式，让参加体检的职工现场填写亚健康状态调查问卷，根据被调查者填写内容，结合查体结果，参考《亚健康状态的中医临床研究指导原则(试行)》，判断亚健康状态。然后根据被调查者填写的量表内容和现场调查医师通过中医四诊掌握的资料，按有关中医证候的辨证标准，进行辨证。将合格问卷录入Epidata3.02，采用SPSS 11.5对录入数据进行描述性分析、x~2检验、单因素Logistic回归分析、因子分析等，统计分析不同职业人群亚健康状态发生的一般情况、影响因素、中医证候分布，以及亚健康状态下肾阴虚证的症状、舌苔、脉象，探讨亚健康状态肾阴虚证的证候特征。最后，应用病证结合的方法，应用二维凝胶电泳和生物质谱结合的技术对。肾阴虚证的差异蛋白点进行分离和鉴定，与不同疾病状态下肾阴虚证作比较，从分子生物学角度研究亚健康状态下肾虚证的分子实质，以期发现肾阴虚证的物质基础。【结果】在6110例被调查人员中，有3981人处于亚健康状态，亚健康状态的现患率为65.1％，其中工人亚健康状态现患率为66.5％。健康人有792例，占总数的13.0％；疾病有1337例，占总数的21.9％。这提示外来打工人员社会弱势群体的亚健康状态现患率也非常高，他们的健康状况不容乐观。女性职工较男性职工亚健康状态现患率高，这可能与其特殊的生理及心理因素有关。年龄在30岁以下亚健康状态的现患率最高，随着年龄的增大，健康人群的亚健康现患率递减。可能是因为本次调查人群的职业多为工人，人群的年龄也偏小，多为30岁以下的打工人员(83.3％)，调查对象的年龄结构偏态较为严重。学历为高中或高中以下的工人亚健康状态现患率为68.2％，随着学历的增高亚健康状态现患率递减。这可能是因为在工厂里，工作性质、收入、待遇与学历密切相关，学历低的工人往往只能从事简单、机械、繁杂且收入较低的体力劳动，因而更容易发生亚健康状态。另外，企业、医科高校等特定人群亚健康状态的相关因素有经常加班、缺乏体育锻练、很少休闲活动、学历较低、工作能力不满意、钱不够用、居住条件不满意等12项。亚健康人群的临床表现非常复杂，涉及到躯体、心理和社会等多种症状，如疲倦乏力、失眠、咽干、大便异常、腹胀、纳差、健忘、腰背酸痛、手脚发凉、眼涩、眼胀、头痛、头晕、耳鸣、手脚心热、夜尿频数、脱发、性欲减退、胸闷、气短、心慌、易汗出、易感冒、精神不振、情绪低落、急躁易怒、空虚、时常叹气、反应迟钝、交往频率低下、工作效率低下、人际关系紧张、苦闷等。进一步应用因子分析，以特征根大于1为公因子提取原则，应用最大方差正交旋转法进行因子旋转，共得到十个共因子，结合医学知识，根据上述结果亚健康状态的临床表现可分为社会型(公因子6)、心理型(公因子1)、疲劳型(公因子3、公因子4和公因子9)、眼口不适型(公因子7)、二便异常型(公因子2)、月经不调型(公因子5)以及体质型(公因子8和公因子10)等七个亚型。这为亚健康状态的分类提供了依据，为进一步防治亚健康状态奠定了基础。对706例亚健康状态的中医证型分布研究显示，亚健康状态的中医证型较为分散，共涉及到34个中医证型，其中只有脾气虚证(78例)、肝郁脾虚证(75例)的比例超过10％，分别为10.8％和10.6％。肝肾阴虚证(69例)、肾阴虚证(65例)、肝郁气滞证(51例)、肾阳虚证(44例)等亦较多，分别占9.7％、9.2％、7.2％、6.2％。其余证候出现的频率均小于5％。表明亚健康状态的中医证候以虚证为主，与肾、肝、脾、心、肺等五脏密切相关。实证仅有肝郁气滞(51例)、肝火炽盛(12例)出现的频数高些，分别占总数的7.2％和1.7％，也说明了心理压力过大是导致发生亚健康状态的重要原因。进一步对其中65例亚健康状态肾阴虚证的表现研究发现，较为常见的症状有腰背酸痛、疲倦乏力、头晕、记忆力差、怕热、耳鸣、腿膝酸软、咽干、失眠多梦、心慌、反应迟钝、手脚心热、容易出汗、少气懒言、入睡出汗、手足麻木等。亚健康状态肾阴虚证的主要临床表现有：腰背酸痛，疲倦乏力，腿膝酸软，咽干，失眠多梦，脱发，盗汗，大便干结，耳鸣，眼涩，手脚心热等；另外，还有心慌、记忆力差、头晕、听力减退、眼花、眼胀、反应迟钝、小便短赤、性欲减退、手足麻木、怕热、少气懒言等等症状出现频率较低，为亚健康状态肾阴虚证较少见的临床表现。进一步应用因子分析等方法分析，得出亚健康状态肾阴虚证的主要证候特点有：①肾虚证表现(主要为腰背酸痛、腿膝酸软、疲倦乏力、耳鸣、脱发等)；②阴液亏虚表现(主要为眼涩、咽干、大便干结等)；③阴虚火旺，热扰心神等表现(主要为盗汗、手心发热、失眠多梦等；④亚健康状态肾阴虚证的舌脉以舌红、脉沉细为主。这为肾阴虚证标准化研究以及下一步制定亚健康状态的诊治方案奠定了基础。 2-DE图谱的差异分析发现有31个蛋白质斑点在四个实验组凝胶中有显著差异表达。在亚健康状态肾阴虚证、系统性红斑狼疮肾阴虚证、糖尿病肾病肾阴虚证中均较正常人表达量升高的蛋白质斑点有5个。选取3个点清晰且表达水平改变明显的蛋白质点做PMF质谱鉴定，确定了一个蛋白质点为热休克蛋白27，表明HSP27与亚健康状态下肾阴虚证的关系密切。【结论】工人、教师、医务人员等人群的身体健康状况不容乐观，采取干预措施刻不容缓。以亚健康状态为切入点研究肾阴虚证的实质收到了不错的效果，对亚健康状态肾阴虚证的表现进行因子分析，发现了一些特征表现，为中医证候特征的研究提供了一个思路。我们也应用蛋白组学的方法初步探索了亚健康状态肾阴虚证分子实质，确定了一个相关的血清特异表达蛋白质为HSP27，表明从蛋白质组的角度来研究肾阴虚证本质是可行的。
[Abstract]:[background] in 1980s, Professor Buchtmann of the former Soviet Union found that in addition to the state of health and disease, the human body still has a non - healthy, non - ill intermediate state, called the "third state". A global survey of the WHO (WHO) shows that the world's truly healthy people (first state) are only accounted for. 5%, after a doctor's examination, only 20% of the patients (second states) were diagnosed, and 75% were in the "third state" between health and illness. Due to the high incidence of subhealth and the impact on the quality of national life, the domestic medical community has made the "subhealth state" as an important subject for endangering the health of the Chinese people, and to subhealth. The research of state has become an important part of life science research.
The state of subhealth refers to the state of human body and mind between disease and health. Although the body has no definite disease, there is a variety of incompatible feelings and symptoms in the body, psychological and interpersonal communication, which presents a state of vitality, reaction ability and the reduction of the ability to adapt to the outside world. This state is mostly from the body's physiological machine. It has not yet reached the level of disease, but it has seriously affected the work efficiency and quality of life. At present, it is believed that the occurrence of subhealth may be related to a variety of factors, such as personal physical condition, psychological condition, lifestyle, occupation, living environment and social interaction. A small sample of sub health status of university teachers, organ cadres and military personnel has been carried out. The results show that the factors of subhealth and clinical manifestations of different groups are different. Therefore, carrying out an epidemiological survey of large subhealth status in a specific population is beneficial to the prevention and control of subhealth.
The subhealth state lacks a clear diagnosis as the physical and chemical basis of "a disease", and does not reach the diagnostic standard of the disease. It is actually a comprehensive manifestation of the abnormal physical activity of the body. It is a functional change that can not reach the qualitative change of the body. It is an early reflection of the abnormal adjustment of the body and body body and mind. Therefore, the specific "morphological structure" is used. It is difficult to grasp the rule of diagnosis and treatment in subhealth state. Traditional Chinese medicine is a medical theory system with the guidance of the whole concept and the characteristics of diagnosis and treatment based on the dialectical theory, which is different from the largest of modern medicine. One of the characteristics is to pay attention to the "physiological characteristics" of the human body and the law of functional activity. Therefore, traditional Chinese medicine has a comprehensive advantage over modern medicine in understanding the state of subhealth and the methods of diagnosis and treatment.
Syndrome differentiation is the basis of diagnosis and treatment of diseases in traditional Chinese medicine. It is the most characteristic essence of Science in traditional Chinese medicine. Syndrome is the premise and foundation of syndrome differentiation and treatment. It is the bridge and key to connect the theory of traditional Chinese medicine and clinical diagnosis and treatment system. The research of syndrome is the key to the research of TCM modernization, and the essence of syndrome is always the hot spot of traditional Chinese medicine. There is always progress without breakthroughs, which may be the research thinking and methodological problems. We have found that it is a very ideal point to study the essence of TCM syndrome from sub health state, because subhealth is intermediate between health and disease, and the examination has not been found to be abnormal, western medicine is not found. It is impossible to diagnose a certain disease, but there have been a variety of symptoms, that is, it has shown a variety of TCM syndromes, and this syndrome is not disturbed by the disease of Western medicine. Therefore, this syndrome is the most ideal object of research. Of course, there is also a certain deficiency, because the symptoms expressed in the subhealth state may not represent the whole TCM syndrome. However, it may find the most essential characteristics of the syndrome. Therefore, the study of clinical epidemiology of TCM syndromes in subhealth state not only provides theoretical basis and practical guidance for the prevention and control of subhealth, but will also promote the further development and improvement of TCM syndrome. According to our preliminary investigation, there are more cases of kidney yin deficiency syndrome in subhealth state and the top three of all syndromes. Therefore, we choose kidney yin deficiency syndrome as a breakthrough point, and then carry out other typical syndromes.
The main clinical manifestations of kidney yin deficiency syndrome are dry cough and less phlegm, shortness of breath, mouth dryness, even low fever in the afternoon, five heart irritated fever, hot tide and night sweats, dizziness and tinnitus, dizziness and pain, pain in the waist and knees, insomnia, insomnia, insomnia, insomnia, insomnia, insomnia, insomnia, insomnia, insomnia, insomnia, insomnia, insomnia and many dreams. Since the above indicators have been used as a basis for clinical diagnosis and treatment, the above performance in the same kidney yin deficiency syndrome patients may not be all manifested, and may also meet the manifestations of other syndromes, which will bring trouble to the clinical syndrome differentiation of kidney yin deficiency syndrome, in order to study which is the deficiency syndrome of kidney yin. The heterosexual manifestation, through the study of the manifestation of kidney yin deficiency syndrome in subhealth state, we exclude the factors of the disease interference, in order to find the essence of the deficiency of kidney yin, and provide a way of thinking for the study of the essence of TCM syndrome. The essence of deficiency syndrome of kidney Yin is still in general and fuzzy state of multiple indexes, and it needs further comprehensive study of multidisciplinary. The presentation of proteomics is possible for the overall evaluation of the syndrome substance. There are nearly 10000 proteins in the serum, complex, including a variety of proteins in various organs, tissues and cells, and the pathophysiological changes in the body at any time of time can be reflected in the serum. Therefore, from the angle of serological proteomics, Combined with the study of proteomics and TCM syndrome type, the related proteins of kidney yin deficiency syndrome in a certain period are of great practical significance for evaluating the essence of kidney yin deficiency syndrome from the whole level.
[Objective] to study the general rule of subhealth status in different population by epidemiological investigation of subhealth status of different population, and to explore the causes of subhealth status in high risk population and provide guidance for its prevention and control. In the end, the molecular mechanism of kidney yin deficiency syndrome in subhealth state is studied by proteomics, and the molecular substance of kidney yin deficiency syndrome in subhealth state is discussed. This study is not only to study the molecular substance of kidney yin deficiency syndrome in subhealth state. The prevention and cure of sub health state has far-reaching significance, and it will also promote the expansion and deepening of TCM syndrome research.
[method] first of all, the method of field investigation was used to fill in the subhealth status questionnaire for the workers who participated in the physical examination. According to the contents of the respondents, the results of the examination were combined to refer to the guidelines of the clinical research guidance (Trial) of the sub health state of Chinese medicine (Trial) to judge the subhealth status. According to the syndrome differentiation standard of TCM syndrome, the field investigators carried on the syndrome differentiation according to the syndrome differentiation standard of TCM syndrome. The qualified questionnaire was entered into Epidata3.02, and SPSS 11.5 was used to carry out descriptive analysis, x~2 test, single factor Logistic regression analysis, factor analysis and so on, to analyze the subhealth status of different occupational groups. Conditions, influencing factors, distribution of TCM syndromes, symptoms of kidney yin deficiency syndrome in subhealth state, tongue coating, pulse image, study the syndrome characteristics of kidney yin deficiency syndrome in subhealth state. Finally, the method of combination of two-dimensional gel electrophoresis and biological mass spectrometry was applied to separate and identify the difference protein points of kidney yin deficiency syndrome by using the method of combination of disease and syndrome. Comparison of kidney yin deficiency syndrome in different disease states, the molecular substance of kidney deficiency syndrome in subhealth state is studied from the angle of molecular biology, in order to find the material basis of kidney yin deficiency syndrome.
[results] among the 6110 subjects, 3981 were in subhealth state and the prevalence rate of subhealth was 65.1%, of which 792 cases were 66.5%. healthy people, 13% of the total, and 1337 of the disease, which accounted for the subhealth status of the social vulnerable groups of migrant workers. The current incidence rate is very high, their health status is not optimistic. Women workers are higher than male workers in subhealth status, which may be related to their special physiological and psychological factors. The prevalence rate of sub health under the age of 30 is the highest. With the increase of age, the rate of subhealth in healthy people is decreasing. It may be because of this The occupations of the population are mostly workers, the age of the crowd is also small, and the workers under 30 years old (83.3%), the age structure of the respondents is more serious. The rate of subhealth of the workers with high school or high school is 68.2%. In the factory, the quality of work, income and treatment are closely related to educational background. Workers with low educational background are often engaged in simple, mechanical, complex and low income labor, and thus are more prone to subhealth. In addition, the related factors of subhealth state of specific people, such as enterprises and medical colleges and universities, are often overtime, lack of sports training, and few rest. Leisure activities, lower educational background, dissatisfaction of working ability, poor money and dissatisfaction with living conditions. The clinical manifestations of subhealthy people are very complex, involving physical, psychological and social symptoms such as fatigue, insomnia, dryness, bowel movement, abdominal distention, tolerance, forgetfulness, pain in the back and feet, hair and feet, eye astringency, headache, dizziness, and ears. Sounding, hot hand and foot, nocturnal frequency, hair loss, loss of sexual desire, chest tightness, shortness of breath, easy sweat, cold, deity, depression, irritability, emptiness, frequent sigh, slow reaction, low communication frequency, low work efficiency, interpersonal tension, depression, etc. further applied factor analysis to extract the original factor above 1 for public factors extraction of the original factor. Then, using the maximum variance orthogonal rotation method to carry out factor rotation, ten common factors were obtained, combined with medical knowledge, according to the above results, the clinical manifestations of subhealth state could be divided into social (public factor 6), psychological type (public factor 1), fatigue type (public factor 3, public factor 4 and public factor 9), eye and mouth discomfort (public factor 7), and two abnormal type (public factor) Sub 2), seven subtypes of irregular menstruation (male factor 5) and physical type (male factor 8 and public factor 10), which provided a basis for Subhealth classification, and laid a foundation for further prevention and control of subhealth state.
The distribution of TCM Syndrome Types in 706 subhealth states showed that the TCM syndrome type of subhealth state was more scattered, involving 34 TCM syndrome types, of which only spleen qi deficiency syndrome (78 cases) and liver depression and spleen deficiency syndrome (75 cases) were more than 10%, respectively 10.8% and 10.6%. liver kidney yin deficiency syndrome (69 cases), kidney yin deficiency syndrome (65 cases), stagnation of liver qi stagnation syndrome (51 cases), Kidney yang deficiency syndrome (44 cases) is also more, accounting for 9.7%, 9.2%, 7.2%, and the frequency of the other syndromes in 6.2%. is less than 5%., which indicates that the syndromes in the sub-health state are mainly related to the deficiency syndrome, which are closely related to the kidney, liver, spleen, heart, lung and other five zang organs. The syndrome is only stagnation of liver Qi (51 cases), and the frequency of liver fire (12 cases) is higher, accounting for 7. of the total. 2% and 1.7% also showed that excessive psychological pressure was an important cause of subhealth status. Further study of 65 cases of subhealth syndrome of kidney yin deficiency syndrome found that the common symptoms were low back pain, fatigue, dizziness, poor memory, fever, tinnitus, leg and knee soft, dry sore throat, insomnia, insomnia, insomnia, and slow reaction. Hands and feet are hot, sweating easily, less breath, lazy words, falling asleep sweating, numbness of hands and feet, etc. the main clinical manifestations of kidney yin deficiency syndrome in sub-health state are waist back.
【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2007
【分类号】：R256.5;R181.3

【引证文献】