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摘要

本文試就以第五波新冠疫情爆發下,並於2022年3月初至4月尾間經筆者診治的53個新冠後遺症病例為研習對象,以探索式研習(exploratory study)進行資料歸納及整理,並得出以下初步的觀察:

1.

上述時段求診人數,與大爆發時段感染人數有著相似的圖形變化趨勢,並以滯後兩星期的方式出現。(圖2及圖3)

2.

在男女就診比例方面,與由衛生防護中心於2017年發佈的「2014至2015年度人口健康調查報告書」比較,兩者比例相近,都大約落在4(男):6(女)之比。(圖4)

3.

另外,最多就診人數的年齡層是45-54歲(不分男女),這亦與上述報告書相同。(圖7)

4.

在比較兩者在就診年齡分佈方面(圖7),資料顯示在假設兩段統計時段內患者求診動機不變的情況下,可以得出「年長人士較年青人有更高機率患上新冠後遺症」這一初步結論。

5.

咳嗽是新冠後遺症的主要表現症狀,差不多佔總量的一半,約43.7%。單獨以咳嗽為主訴就診的共有23宗。(圖8)

6.

新冠後遺症的症狀表現雖以上呼吸道不適為主,但同時亦呈現出多樣化傾向,可遍及上中下三焦不適如氣弱、心悸、腹痛腸鳴、便秘及睪丸隱痛等及神志失調如集中力減弱等。造成這種症狀呈現多樣化的原因,或與患者體質、年齡、接受治療的種類及陽性期的症狀表現等都有關係。但其實質關係如何,仍有待進一步考察。(圖9)

7.

又從圖9的遺留症狀分佈及關連所見,所有主訴可粗略分以咳嗽、疲倦及調理為主這3個板塊(cluster)。其中前兩者(咳嗽與疲倦)或可就其症候表現的特徵簡單地擬作新冠後遺症的兩個不同發展階段 ── 即以咳嗽為主的板塊,可視作「餘邪未盡」的階段;以疲倦為主的板塊則是「邪盡正未復」的狀態。若此兩者同時與調理板塊合論,則可一起組成新冠後遺症的完整治療內容。並且若再結合新冠陽性治療期,那麼這四個主要部份就可構成一個完整的新冠治療模型。(圖10)

8.

在主訴與性別關係分佈方面,兩者的曲線形態相似。但若沿用咳嗽、疲倦及調理為主這3分法,那兩個性別在「餘邪未盡」階段的分佈大致相似,但在「邪盡正未復」階段則呈現較大的差異。(圖11)

9.

就診人數較少的男性卻有著比就診人數較多的女性有著更多樣化的症狀呈現。(圖13及圖14)

10.

在這53位患者,共88次的診症中,共計使用方劑43條。當中以過敏煎使用次數最多,達34次;佔總量的24.1%。其次是二陳湯及小柴胡去半夏加栝蔞根湯,約分別佔7.8%;小柴胡湯則佔6.4%。其中以合方形式使用過敏煎共有30次,其餘4次則使用過敏煎單方加減。(圖18-1及圖18-2)

11.

各類方劑又可根據其大體功用分為解表劑、化痰/止咳劑、益氣/健脾劑及滋陰增液/滋陰清熱劑這四個大類。這些粗略分類,亦扼要地反映了新冠後遺症的基本病機所在。

12.

如果以遺留病邪作分類,也離不開風、痰、熱、瘀等病理產物,其中又以風、痰及熱為最常見。

13.

在後補文獻回顧過程中,發現實有不少文章以案例及現代中藥藥理學的研究成果討論有關過敏煎在治療各種敏感疾病包括如蕁麻疹、支氣管哮喘、過敏性鼻炎、過敏性咳嗽、皮炎,甚或腎臟疾病、腸易激綜合徵、男性免疫性不育、關節炎、神經性皮炎等的應用及療效。因此,過敏煎的臨床應用,對筆者而言尚有很大的拓展空間。

14.

對於過敏煎治療新冠後遺症咳嗽的療效,由於數據樣本小,兼缺乏隨訪安排,故未能對其以統計學方式作出具效度的印證,反之只能得到一個關於其療效的輪廓,因此仍流於臨床印象式的支持。另外,因出於實際的臨床需要,過敏煎往往是以合方加減的方式使用,這亦不便利對其療效作出具說服力的支持。

15.

雖然傳統中藥學的四氣五味與現代藥學的分子分析這兩種藥學理論各有著不可調和的理論說明,但兩者均能依據自身的理論體系清淅地解說了過敏煎的藥理及其之所以能取效的原因所在,可有相互啟發的作用。

16.

在思考採用較為西方學術傳統的研習取向去整理中醫臨床經驗與傳統中醫以診籍醫書去整理臨床經驗的異同時,隱約認識到兩者存在層次上的差異:西方學術取向是以形而下的方法,解答形而下的提問;而傳統中醫則嘗試以形而下的方法去歸納及把捉形而上的法則,並以之指導回答及解決形而下的提問。

研習限制:由於是次研習並非事前規劃,因此資料收集缺乏明確的焦點及組織;沒有事先進行理論及文獻回顧;也沒有就療效作出隨訪。更重要的是以目前53個研習樣本,只能達到遠低於標準要求的85%信心水準及10%誤差範圍。故此研習並不在於,亦不可能獲取具普遍意義的結論,反之只嘗試以「研習的研習」(a study of a study)的方式去進行臨床經驗的整理,試圖勾畫出一個有關研習對象的輪廓。

關鍵字:新冠疫情、第五波、新冠後遺症、長新冠、過敏煎



Abstract

This article explores an exploratory study based on 53 cases of post-COVID-19 sequelae treated by the author between early March and late April 2022, during the outbreak of the fifth wave of the COVID-19 pandemic. The study aims to conduct data induction and organization to derive preliminary observations as follows:

1.

During the aforementioned period, the number of consultations showed a similar trend in changes to the infection rates during the peak outbreak period, appearing with a two-week lag (Figures 2 and 3).

2.

Regarding the gender distribution of patients, it closely resembled the proportions reported in the “2014-2015 Population Health Survey Report” released by the Health Protection Center, with approximately a 4 (male) : 6 (female) ratio (Figure 4).

3.

Additionally, the age group with the highest number of consultations was 45-54 years old (both genders combined), consistent with the aforementioned report (Figure 7).

4.

Comparing the age distribution of consultations between the two periods (Figure 7), the data suggests that, assuming consistent patient seeking behavior across both statistical periods, “older individuals have a higher probability of developing post-COVID-19 sequelae” as a preliminary conclusion.

5.

Coughing was identified as the primary symptom of post-COVID-19 sequelae, accounting for approximately half of all cases at 43.7%. There were a total of 23 cases where coughing was the main complaint (Figure 8).

6.

While upper respiratory discomfort predominates as a symptom of post-COVID-19 sequelae, there is also a tendency towards diverse manifestations, including discomfort in the upper, middle, and lower jiaos such as weakness in qi, palpitations, abdominal pain, constipation, testicular pain, and cognitive impairment like reduced concentration. The diversity in symptom presentation may be related to patient constitution, age, treatment received, and symptoms during the positive phase. However, the actual relationships require further investigation (Figure 9).

7.

From the distribution and correlations observed in Figure 9, all primary complaints can be broadly categorized into three clusters: coughing, fatigue, and regulation. The first two (coughing and fatigue) could be seen as representing different stages of post-COVID-19 sequelae ── the coughing cluster indicating a stage of “residual pathogenic factors,” while the fatigue cluster represents a state of “pathogens dissipated but not yet recovered.” When combined with the regulation cluster, these three clusters form a comprehensive treatment framework for post-COVID-19 sequelae. Furthermore, when integrated with treatment during the positive phase of COVID-19, these four main components constitute a complete model for COVID-19 treatment (Figure 10).

8.

In terms of the relationship between primary complaints and gender distribution, the curves for both genders show similar patterns. However, using the threefold classification of coughing, fatigue, and regulation, there are significant differences between the genders in the distribution during the “pathogens dissipated but not yet recovered” stage (Figure 11).

9.

Men, despite being less frequent in seeking medical attention, exhibited more diverse symptom presentations compared to women who sought medical attention more frequently (Figures 13 and 14).

10.

Among these 53 patients, a total of 88 visits were recorded, utilizing a total of 43 prescriptions. Allergic Decoction was the most frequently used prescription, accounting for 34 out of 88 visits, or 24.1% of the total. This was followed by Er Chen Tang and Xiao Chai Hu Tang with Gui Zhi Rong, each accounting for approximately 7.8%, and Xiao Chai Hu Tang at 6.4%. Among these, Allergic Decoction was used in combination with other prescriptions 30 times, while the remaining 4 times it was used alone with adjustments (Figures 18-1 and 18-2).

11.

These prescriptions can also be broadly categorized into four main functions: exterior-releasing agents, phlegm-dispelling/cough-suppressing agents, qi-tonifying/spleen-invigorating agents, and yin-nourishing/fluid-increasing and heat-clearing agents. These rough classifications succinctly reflect the basic pathogenesis of post-COVID-19 sequelae.

12.

If categorized according to residual pathogenic factors, it cannot be separated from pathogenic products such as wind, phlegm, heat, and stasis, with wind, phlegm, and heat being the most common.

13.

During the supplementary literature review process, many articles discussed the application and efficacy of Allergic Decoction in treating various allergic diseases including urticaria, bronchial asthma, allergic rhinitis, allergic cough, dermatitis, as well as kidney diseases, irritable bowel syndrome, male infertility, arthritis, and neurodermatitis, among others. Therefore, there is still considerable room for expansion in the clinical application of Allergic Decoction.

14.

Regarding the efficacy of Allergic Decoction in treating post-COVID-19 sequelae cough, due to the small sample size and lack of follow-up arrangements, statistical validation of its effectiveness could not be achieved. Instead, only a profile of its efficacy based on clinical impressions was obtained. Furthermore, due to practical clinical needs, Allergic Decoction is often used in combination with adjustments, making it inconvenient to provide convincing support for its efficacy.

15.

Although traditional Chinese medicine’s theory of the Four Qi and Five Flavors and modern pharmacological analysis have irreconcilable theoretical explanations, both can clearly explain the pharmacology of Allergic Decoction and the reasons for its effectiveness according to their respective theoretical systems, thereby mutually inspiring each other.

16.

When considering the difference between adopting a research orientation more aligned with Western academic traditions to organize clinical experiences in traditional Chinese medicine and organizing clinical experiences based on diagnosis and medical books in traditional Chinese medicine, it is vaguely recognized that there are hierarchical differences between the two: Western academic orientation attempts to answer questions from a deductive approach, while traditional Chinese medicine attempts to summarize and capture laws from an inductive approach to guide answers and solve deductive questions.

Study Limitations: Since this study was not pre-planned, data collection lacked a clear focus and organization; there was no prior theoretical and literature review; and there was no follow-up on efficacy. Moreover, with only 53 study samples, the study could only achieve a confidence level far below the standard requirement of 85% and a margin of error of 10%. Therefore, this study does not aim to, nor is it capable of, obtaining universally applicable conclusions. Instead, it attempts to conduct a study of a study to organize clinical experiences, aiming to outline a profile of the study subjects.

Keywords: COVID-19 pandemic, fifth wave, post-COVID-19 sequelae, novel coronavirus, Allergic Decoction

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