Study On TCM Syndrome Characteristics And Syndrome Element Distribution Of Community Acquired Pneumonia In Sequelae Stage Of Cerebral Infarction

Objective:In order to provide basis theory for early diagnosis and accurate treatment of patients with community acquired pneumonia in the sequelae stage of cerebral infarction,this paper studies the clinical syndrome characteristics,discusses the distribution of TCM syndrome elements,summarizes the common clinical syndrome types and the correlation between syndrome types and laboratory examination by analyzing the basic information,clinical data of patients.Methods:We collected the basic informations and other clinical datas of the patients,using the method of retrospective study,through the questionnaire of “syndrome information table of community acquired pneumonia in sequelae of cerebral infarction” and “syndrome element differentiation scale of community acquired pneumonia in sequelae of cerebral infarction”.And then recorded the weight of syndrome elements referring to the syndrome element scale,and summed each syndrome element by weighting,so as to make a judgment on the syndrome elements.Then,the Microsoft Excel was used for data management.The data were imported into SPSS software for statistical analysis,including correlation analysis,variance analysis,chi square test,rank sum test,etc;At the same time,R(version 3.6.0),Rstudio(version 1.2.0)and NBCluste(version 3.0)were used to determine the number of clusters,k-mean algorithm of Faceto Mine R(version 2.3)was used for clustering analysis,t-SNE algorithm of Rtsne(version 0.15)was used for data visualization after clustering,and Rpheatmap(version 3.2.8)was used to draw the distribution heat map of each subtype.Results:1 General data analysis:In this study,there were 67 male and 25 female patients with CAP in the sequelae of cerebral infarction.The average age was(83.14 ± 7.97)years;The number of cases in spring was 16 cases(17.4%),the number of cases in summer was 19(20.7%),the number of cases in autumn was 10 cases(10.9%),and the number of cases in winter was 47(51.1%),among which the incidence rate was highest in winter.There are 91 patients(98.9%)who were complicated with 1～9 kinds of basic diseases of different systems,the most of them were complicated with 2～6 kinds of basic diseases.72.8% of the patients had the risk factors of dysphagia or bed rest,among which 26 patients(28.2%)had one risk factor of dysphagia or bed rest,41 patients(44.6%)had both the risk factors of dysphagia and bed rest;Among the 92 patients with old cerebral infarction,the shortest course of cerebral infarction is 1 year,the longest is 22 years,the average course is(6.01 ± 5.59)years,and the most patients with cerebral infarction are within 5 years;In addition,there is a positive correlation between the course of cerebral infarction and the diagnosis time of pulmonary infection(r=0.426),the longer the course of cerebral infarction,the longer the diagnosis time of community acquired pneumonia may be.Of course 60.9% of the patients with CAP in sequelae stage could be clearly diagnosed within one week,and it is worth noting that 18.5% of the patients could not be clearly diagnosed until more than 4 weeks.Moreover,there was a significant positive correlation between the time of community acquired pneumonia diagnosis and the time of hospitalization(r=0.723),the longer the time of community acquired pneumonia diagnosis,the longer the time of hospitalization.This suggests that it is of great significance to clarify the early diagnosis of CAP in the sequelae of cerebral infarction.2 Clinical features:2.1 Syndrome expression:The syndromes of the patients involved multiple systems.Except for coughing,other typical symptoms of pulmonary infection were not very significant,only 44(43%)patients had fever,mainly low and moderate fever,only 3 patients had high fever,while the general symptoms of fatigue,the aggravation of the primary diseases such as dizziness and insomnia,and the symptoms of alimentary tract,such as anorexia and dry stool can not be ignored.It is suggested that we should pay more attention to the atypical syndrome related to the whole body in order to reduce the missed diagnosis,misdiagnosis and delayed diagnosis in the early identification of this disease.2.2 Tongue and pulse condition : The tongue and pulse condition indicates the combination of deficiency and excess.The tongue texture is mainly dull red tongue and pale tongue.Among them,61 cases were dark red tongue(66.3%),5 cases were purple dark tongue(5.43%),23 cases were light tongue(25%).The color of tongue coating was mainly white in 37 cases(40.22%)and yellow in32 cases(34.78%);According to the transportation of body fluid on the surface of tongue,the patients with dry tongue coating,less coating and desquamate tongue coating also account for a certain proportion.Pulse is mainly composed of deep(33.7%),thready(36.96%),stringy(32.61%)and slippery(20.95%).2.3 Laboratory examination: The white blood cell count was normal in 67.4%of patients,while 58.7% of the patients had a significant increase in neutrophil percentage and 57.6% of the patients had a significant increase in C-reactive protein.It is worth noting that the percentage of lymphocytes decreased in 65.2% of patients.Platelets were normal in 80.4% of patients,while D-dimer was significantly elevated in 90.2% of patients.T he albumin was lower than normal in 90.2% of the patients,and less than 30g/L in 17.4%of the patients.The infection site was dominated by double lung infection and single right lung infection,and only 5.4% of patients had single left lung infection.Pathogenic bacteria: the bacteria were mainly gram-negative bacteria such as pseudomonas aeruginosa,escherichia coli,acinetobacter baumannii and gram-positive bacteria such as staphylococcus aureus.In addition,the saccharomycetes and candida albicans were the main fungi,and aspergillus was occasionally observed.3 Distribution of syndrome elements and syndrome types:Seven syndrome elements were obtained,through the syndromes analysis of the patients,among which the frequency of lung,spleen,kidney and surface were significantly higher than that of other syndrome elements,followed by heart spirit(brain),heart and liver.There were 11 syndromes elements,and the solid syndromes elements included phlegm,stasis,cold,wetness,fire(heat),Qi stagnation,among which phlegm and stasis were significantly higher than other solid syndromes.Meanwhile,Deficiency syndromes elements include Qi deficiency,blood deficiency,yin deficiency,yang deficiency and jin deficiency,of which Qi deficiency,yang deficiency,yin deficiency,and blood deficiency were significantly higher than other deficiency and solid syndromes.Patients are more common in multiple disease positions,but rarely in a single disease position,which fully illustrates the complexity of the disease pathogenesis and the result of the combined action of multiple viscera.The patients were grouped into type Ⅰ,type Ⅱ and type Ⅲ by K-means clustering.Because the pathogenesis of CAP in the sequelae of cerebral infarction is complex,and there are many disease syndrome elements involved,it is difficult to form "syndrome name" simply by disease syndrome elements,so in this study,only type Ⅰ,type Ⅱ and type Ⅲ are used to distinguish the component types.In type Ⅰ patients,the core location of disease element is lung,and the core disease syndrome element is Qi deficiency and phlegm.In type Ⅱ patients,lung and spleen are the core location of disease element,and Qi deficiency and yang deficiency are the core disease syndrome element.In type Ⅲ patients,lung,spleen and kidney are the core disease syndrome elements,while Qi deficiency,Yin deficiency,Yang deficiency and phlegm are the core disease syndrome elements.And the patients showed lung,spleen and kidney changes with the progress of the disease from Type I → type Ⅱ → type Ⅲ.4 Analysis of syndrome types and related factors:There were significant differences in age,dysphagia,bed rest,percentage of neutrophils,C-reactive protein,percentage of lymphocytes,D-dimer,albumin,etc.The average age of patients gradually increase from type Ⅰ to type Ⅱ to type Ⅲ.The proportion of patients with dysphagia or bed rest in type Ⅰ was significantly lower than that in type Ⅲ.The percentage of lymphocytes,C-reactive protein and D-dimer increased gradually from type Ⅰ to type Ⅱ to type Ⅲ,whitch reflected the degree of inflammation in the body,determine the severity of the disease,and can be used as a reference index for TCM syndrome differentiation.On the contrary,the percentage of lymphocyte and albumin decreased gradually from type Ⅰ to type Ⅱ to type Ⅲ,suggesting that the body’s vital energy was gradually depleted.Conclusion:1 The elderly patients with dysphagia and bedridden risk factors should be alert to the possibility of CAP when they have general symptoms such as mental fatigue and laziness,or atypical manifestations such as exacerbation of the primary disease.Early diagnosis is of great significance to shorten the course of disease.2 The core elements of CAP in the sequelae of cerebral infarction are deficiency,phlegm and blood stasis.Deficiency includes Qi deficiency,yin deficiency,blood deficiency and yang deficiency.The heat syndrome element is not significant in these patients.The location of the disease changes of the lung,spleen and kidney following the disease progression.Therefore,the syndrome differentiation and treatment of CAP in the sequelae of cerebral infarction is mainly based on tonifying deficiency,focusing on different disease positions of lung,spleen and kidney,taking into account the aspects of eliminating phlegm and stasis,and flexibly grasping the application of heat clearing drugs.3 The percentage of neutrophils,C-reactive protein,D-dimer,lymphocyte and albumin levels are different among different types of CAP in the sequelae of cerebral infarction,which can be used as reference indexes to assist TCM syndrome differentiation and classification,so as to realize the objectification of TCM syndrome differentiation.