Article(id=1236731784700949334, tenantId=1146029695717560320, journalId=1235980733773295621, issueId=1236731777142804746, articleNumber=null, orderNo=null, doi=10.20251/j.cnki.1003-3734.2025.17.008, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=null, receivedDateStr=null, revisedDate=null, revisedDateStr=null, acceptedDate=1734451200000, acceptedDateStr=2024-12-18, onlineDate=1772789434838, onlineDateStr=2026-03-06, pubDate=1757865600000, pubDateStr=2025-09-15, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1772789434838, onlineIssueDateStr=2026-03-06, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1772789434838, creator=13701087609, updateTime=1772789434838, updator=13701087609, issue=Issue{id=1236731777142804746, tenantId=1146029695717560320, journalId=1235980733773295621, year='2025', volume='34', issue='17', pageStart='1793', pageEnd='1904', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=1, specialIssue=0, createTime=1772789433036, creator=13701087609, updateTime=1772801868692, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1236783936152596961, tenantId=1146029695717560320, journalId=1235980733773295621, issueId=1236731777142804746, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1236783936152596962, tenantId=1146029695717560320, journalId=1235980733773295621, issueId=1236731777142804746, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1839, endPage=1844, ext={EN=ArticleExt(id=1236731784927441758, articleId=1236731784700949334, tenantId=1146029695717560320, journalId=1235980733773295621, language=EN, title=Key points and considerations of clinical study design for medication timing, columnId=null, journalTitle=Chinese Journal of New Drugs, columnName=null, runingTitle=null, highlight=null, articleAbstract=

The medication timing is an important factor affecting the clinical efficacy of drugs. Selecting the right medication timing is the key to ensure the full play of drug efficacy, as well as standardized and precise medication practices in clinical settings. Although some scholars have carried out relevant clinical studies on the medication timing, there remains a lack of systematic review and summary of its important research significance and key points of scheme design. This paper systematically discusses the concept of medication timing, research significance, understanding of traditional Chinese medicine, types of research design and key methodological points, aiming to clarify the design ideas for clinical research on medication timing, and focus on analyzing the similarities and differences, as well as key design points of different types of clinical studies. This article provides methodological guidance for timely and precise medication in clinical practice and effectively promotes the standardization and accuracy of clinical drug use.

, correspAuthors=Xin-xing LAI, authorNote=null, correspAuthorsNote=null, copyrightStatement=null, copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, authorCompany=null, fund=null, authors=null, authorsList=Xiang-yi ZHENG, Gen-ming ZHANG, Zi-yu TIAN, Ying GAO, Xin-xing LAI), CN=ArticleExt(id=1236731785845994379, articleId=1236731784700949334, tenantId=1146029695717560320, journalId=1235980733773295621, language=CN, title=针对用药时机的临床研究设计要点与思考, columnId=1236331741447778310, journalTitle=中国新药杂志, columnName=药物临床试验规范与进展专栏, runingTitle=null, highlight=null, articleAbstract=

用药时机是影响药物临床疗效的重要因素,选择恰当的用药时机是确保药效充分发挥和临床规范、精准用药的关键。目前已有学者针对用药时机开展了相关临床研究,但对于其重要研究意义及方案设计要点缺乏系统梳理与总结。本文就用药时机的概念、研究意义、中医药认识、研究设计类型及方法学要点等方面展开系统论述,旨在厘清针对用药时机的临床研究设计思路,重点剖析不同类型临床研究的异同与设计要点,为临床实践中适时、精准用药提供方法学指导,有力促进临床用药的规范性与精准性。

, correspAuthors=赖新星, authorNote=null, correspAuthorsNote=
*赖新星,男,副研究员,硕士生导师,研究方向:中医药防治脑血管病。E-mail:
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郑湘宜,女,博士研究生,研究方向:中医药防治脑血管病。E-mail:

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郑湘宜,女,博士研究生,研究方向:中医药防治脑血管病。E-mail:

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郑湘宜,女,博士研究生,研究方向:中医药防治脑血管病。E-mail:

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针对用药时机的临床研究设计要点与思考
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郑湘宜 1 , 张根明 1 , 田紫煜 2 , 高颖 1, 3 , 赖新星 1, 3, *
中国新药杂志 | 药物临床试验规范与进展专栏 2025,34(17): 1839-1844
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中国新药杂志 | 药物临床试验规范与进展专栏 2025, 34(17): 1839-1844
针对用药时机的临床研究设计要点与思考
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郑湘宜1 , 张根明1, 田紫煜2, 高颖1, 3, 赖新星1, 3, *
作者信息
  • 1北京中医药大学东直门医院,北京 100700
  • 2中国中医科学院针灸研究所,北京 100700
  • 3北京中医药大学中医脑病研究院,北京 100700
  • 郑湘宜,女,博士研究生,研究方向:中医药防治脑血管病。E-mail:

通讯作者:

*赖新星,男,副研究员,硕士生导师,研究方向:中医药防治脑血管病。E-mail:
Key points and considerations of clinical study design for medication timing
Xiang-yi ZHENG1 , Gen-ming ZHANG1, Zi-yu TIAN2, Ying GAO1, 3, Xin-xing LAI1, 3, *
Affiliations
  • 1Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
  • 2Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing 100700, China
  • 3Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100700, China
出版时间: 2025-09-15 doi: 10.20251/j.cnki.1003-3734.2025.17.008
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用药时机是影响药物临床疗效的重要因素,选择恰当的用药时机是确保药效充分发挥和临床规范、精准用药的关键。目前已有学者针对用药时机开展了相关临床研究,但对于其重要研究意义及方案设计要点缺乏系统梳理与总结。本文就用药时机的概念、研究意义、中医药认识、研究设计类型及方法学要点等方面展开系统论述,旨在厘清针对用药时机的临床研究设计思路,重点剖析不同类型临床研究的异同与设计要点,为临床实践中适时、精准用药提供方法学指导,有力促进临床用药的规范性与精准性。

用药时机  /  干预时机  /  临床研究  /  方案设计  /  精准用药

The medication timing is an important factor affecting the clinical efficacy of drugs. Selecting the right medication timing is the key to ensure the full play of drug efficacy, as well as standardized and precise medication practices in clinical settings. Although some scholars have carried out relevant clinical studies on the medication timing, there remains a lack of systematic review and summary of its important research significance and key points of scheme design. This paper systematically discusses the concept of medication timing, research significance, understanding of traditional Chinese medicine, types of research design and key methodological points, aiming to clarify the design ideas for clinical research on medication timing, and focus on analyzing the similarities and differences, as well as key design points of different types of clinical studies. This article provides methodological guidance for timely and precise medication in clinical practice and effectively promotes the standardization and accuracy of clinical drug use.

medication timing  /  timing of intervention  /  clinical research  /  scheme design  /  precision medication
郑湘宜, 张根明, 田紫煜, 高颖, 赖新星. 针对用药时机的临床研究设计要点与思考. 中国新药杂志, 2025 , 34 (17) : 1839 -1844 . DOI: 10.20251/j.cnki.1003-3734.2025.17.008
Xiang-yi ZHENG, Gen-ming ZHANG, Zi-yu TIAN, Ying GAO, Xin-xing LAI. Key points and considerations of clinical study design for medication timing[J]. Chinese Journal of New Drugs, 2025 , 34 (17) : 1839 -1844 . DOI: 10.20251/j.cnki.1003-3734.2025.17.008
用药时机,也称用药时点、用药时间窗、药物干预时机等,狭义的用药时机主要指药物干预时机,广义的用药时机也同样适用于手术、介入治疗或筛查等干预措施,或可称为干预时机。用药时机是影响药物临床疗效的重要因素。用药时机不明,一方面对于临床用药造成不便,另一方面可能导致未能有效地阻断或延缓疾病进展,从而影响药物临床疗效。因此,选择恰当的用药时机对于药效充分发挥和临床规范、精准用药至关重要。目前,已有学者围绕药物干预时机对患者的疗效、安全性等方面的影响开展了临床研究[1-7],但对于用药时机的研究意义及其方案设计缺乏系统总结。随着中西医对于用药时机这一研究领域的关注度日益增高,本文就用药时机的概念、研究意义、中医药认识、研究设计类型及方法学要点等方面展开深入思考与系统论述,重点剖析不同类型临床研究的异同与设计要点,为临床实践中适时、精准用药提供方法学指导,有力促进临床用药的规范性与精准性。
疾病的病理状态通常呈现动态变化。在疾病治疗的过程中,针对不同阶段的病理状态,选择合适的药物和干预时机至关重要。恰当的药物干预时机是提高疗效和改善疾病预后的关键因素。例如:对于急性缺血性脑卒中(acute ischemic stroke, AIS)、急性心肌梗死等临床常见心脑血管疾病,溶栓时间前移可以为开通狭窄或闭塞的血管、恢复缺血脑组织和心肌供血争取更多时间[8-9];同样,对于流感[10]、人类免疫缺陷病毒感染[11]以及带状疱疹[12-13]等病毒引起的疾病,早期给予抗病毒药物能有效抑制病毒复制和传播,缓解症状并缩短病程。
然而,目前仍有一些药物的干预时机尚不明确,因而难以有效延缓疾病进展甚至改善预后。例如:抗生素的干预时机是一个复杂的问题。对已确诊脓毒症的患者,是否应尽早给予抗生素,不同研究尚存在争议[14-16]。临床上往往需要综合患者病情、病原体特征和其他因素做出合适的个体化决策。甘露醇在脑出血患者的干预时机也存在争论。尽管指南建议在颅内压升高时使用甘露醇[17-18],由于缺乏高质量的临床证据,并未给出甘露醇脱水降颅压的最佳时机。Sun等[19]的荟萃分析发现,早期应用甘露醇可能增加高血压脑出血血肿扩大的风险。此外,尽管前期Lin等[20]研究已初步证明使用活血化瘀类中药能有效治疗脑出血,由于脑出血急性期血肿扩大与再出血的风险较大、病情凶险,早期应用活血化瘀类中药仍存在一定争论,临床中还需结合患者血肿扩大与再出血风险综合考虑用药方案。因此,探究恰当的用药时机以更好地指导疾病治疗至关重要。
针对缺血性脑卒中的用药时机是神经科医师关注的焦点。尽早开始再灌注治疗,挽救缺血半暗带是AIS治疗的首要目标[21]。专家与学者除了着眼于传统溶栓时间窗,不断优化AIS患者静脉溶栓流程,减少患者的救治时间延误[22],也关注溶栓时间窗的延长[23-24]及特殊人群时间窗的界定[25-26]
从美国国家神经系统疾病和中风研究所(NINDS)研究[24]的3 h溶栓时间窗,到ECASS Ⅲ研究[23]的4.5 h时间窗,再到EXTNED研究[25]的4.5~9 h时间窗,静脉溶栓的时间窗在逐步扩展。对于时间窗的认识也从以往针对时间单一维度的评估,发展到综合了组织缺血时间(梗死核心)以及严重程度(缺血半暗带)的多维评估。AIS静脉溶栓时间窗相关研究的不断深入,为疾病诊疗指南的修订提供了新的循证证据,同时也提高了医生的决策效率和治疗水平。
相比现代医学,传统中医药在把握用药时机方面展现出更为宏观的视角。基于“天人相应”的整体观,历代医家在深入探索生命节律与疾病特点的基础上,形成了“因时制宜”的诊治法则,阐述了“因时用药”的独特内涵。《素问·脏气法时论》云:“合人形以法四时五行而治。”
中医认为服药时间与患病部位有关。病位不同,用药时间各异。《神农本草经·序录》云:“病在胸膈以上者,先食后服药;病在心腹以下者,先服药而后食。”《古今医统大全·卷九十七·服药序次》则指出:“病在上者,不厌频而少;病在下者,不厌顿而多。”
服药时间不仅因患病部位而异,也与病情轻重息息相关。如通关开窍的苏合香丸、安宫牛黄丸等急救药品当不拘时服,方可力挫病势,以救危急。而对于镇静安神、养心安神的方药,如朱砂安神丸、酸枣仁汤等,则在睡前服用为宜。应根据病情缓急和进展情况及时调整服药时间。
药物的四气五味、归经、升降浮沉等偏性也影响服药时间。人们普遍认为上午宜服用益气升阳药、发汗解表透邪药。王好古在《此事难知》中评论道:“午前为阳之分,当发汗;午后阴之分,不当发汗。”罗天益在《卫生宝鉴》中采用冲和顺气汤以生发阳明之气。其中药物需要在早饭后、午前服用,因“天气上升之时,使人之阳气易达故也”。
不少古代医家依据日节律、月节律、年节律的不同,来进行用药法时的临证实践。对于日之昼夜晨昏,《素问·金匮真言论》云:“……鸡鸣至平旦,天之阴,阴中之阳也,故人亦应之。”叶天士在《临证指南医案·痰饮》提出:“早肾气去萸,换白芍、炒楂炭,水法丸,晚《外台》茯苓饮,姜枣汤法丸。”对于月相之盈亏圆缺,《素问·八正神明论》云:“月生无泻,月满无补;月郭空无治。”对于四时之气的变化,王焘在《外台秘要》中提到“春夏无大吐下,秋冬无大发汗”由此可见,把握“因时制宜”的诊治法则,依据患病部位、病情缓急、药物偏性择时用药,同时顺应自然界阴阳消长的规律,才能维持正常生命活动,保持机体阴阳平衡。
现代医学与传统中医药均对用药时机给予了高度关注。然而,针对用药时机的临床研究设计仍面临诸多挑战,包括研究目的不明确、研究类型选择不恰当、方案设计不清晰等问题。上述诸问题可能影响临床研究结果的可靠性,进而影响临床用药决策。因此,如何选择合适的研究设计类型,明确不同方案的设计要点,对于优化用药时机相关研究方案、最大限度发挥药物疗效具有重要意义。
从临床研究类型而言,随机对照试验[1-4]、单臂临床试验[27]、队列研究[5,7]、病例对照研究[28-29]乃至于病例系列等设计类型均可用于用药时机研究。概言之,上述观察性研究可为找寻最佳用药时机提供有益的探索,进而产生假说,最终由随机对照试验检验假说是否成立。我们检索文献发现,针对用药时机的临床研究最常使用队列研究和随机对照试验2种设计类型,因此本文将重点围绕这2类临床研究展开论述。
如何选择合适的临床研究类型,取决于研究目的是什么。队列研究与随机对照试验对于回答用药时机相关问题,各有其长处与特点,唯有首先明确主要研究目的,方能针对性选择合适的设计类型。
基于队列研究的用药时机临床研究主要包括历史性队列研究和前瞻性队列研究2种。与一般队列研究不同的是,用药时机相关队列研究的暴露因素为不同干预时机(如可定义早用药组为暴露组,晚用药组为非暴露组),因而可对暴露因素进行自然分组。而基于随机对照试验的用药时机临床研究则主要是对药物干预时机这个单一因素进行随机分组。
历史性队列研究开始时暴露和疾病均已发生,要求研究者对过去已发生的暴露和结局进行资料的搜集与分析。一项历史性队列研究[7]从美国医疗保险记录中抽样,探索1998—1999年18 209例65岁以上社区获得性肺炎住院患者抗生素使用时机与预后的关系。根据抗生素给药时间的早晚,受试者被分为入院4 h内早使用抗生素组(即暴露组)和4 h后晚使用抗生素组(非暴露组)。
与历史性队列研究追溯收集结局资料不同,前瞻性队列研究需要持续追踪收集结局资料。一项前瞻性队列研究[5]选取2003年10月—2006年5月期间,于丹麦31家妇科部门接受子宫切除术并登记的9 949例妇女进行术后随访,探讨肝素用药时机与术后并发症和血栓栓塞事件的关系。根据肝素给药时间,患者被分为术前给药组(切口前给药第一剂肝素)和术后给药组(手术后给药第一剂肝素)。
基于随机对照试验的用药时机临床研究通过对不同用药时点进行随机分组,可以平衡已知和未知的混杂因素,使不同药物干预组之间基线保持相对一致,增加可比性。一项多中心、双盲、安慰剂对照试验INSPIRES[2]研究关注急性轻型缺血性卒中或高危短暂性脑缺血发作患者急性期强化他汀类药物治疗的疗效和安全性。其中,患者被随机分配接受立即强化他汀类药物治疗或延迟3 d强化他汀类药物治疗。
在用药时机相关队列研究中,药物干预时机即为暴露因素,因而相比于随机对照试验,队列研究更接近临床实际。但在实际操作过程中,一方面,研究对象的基线信息收集复杂、不易获得;另一方面,队列研究不同分组之间存在混杂因素。虽然研究者尽量使暴露组和非暴露组的人群基本特征相近,仍无法排除混杂因素(尤其是未被观测到的潜在混杂因素)。
随机对照试验采用随机分配和分配方案隐藏,可以较好地防止人为因素对研究结果的影响,减少选择偏倚。同时,盲法的实施可以避免研究人员和受试者所导致的测量性偏倚,增强结果真实性。因此,单纯从方法学角度看,随机对照试验是评价不同用药时点对临床疗效影响的最佳设计,其得出结论的论证强度最高。但是随机对照试验也有其不可避免的缺陷。首先,随机对照研究对试验条件要求较高,费时、费力,一般医院很难开展高质量、大样本的随机对照试验。其次,随机对照试验是在理想条件下对特定人群的干预结局,其结果通常难以很好地外推到真实诊疗环境中。
基于以上论述,要评价不同用药时点对临床疗效的影响,一般优先从回顾性队列数据中筛选并发现用药时机的研究问题,初步构建“不同药物干预时机会影响结局及预后”的假说;在回顾性队列研究的基础上,可进一步设计前瞻性队列研究来检验假说,期间可通过多种方法校正混杂因素;最后再设计更为严格的随机对照试验进行确证。
用药时机的界定至关重要。不同疾病和药物有不同的发生发展过程和特性,因此需要针对具体疾病的发病机制、生理病理变化和药物与机体的作用机制、作用规律以及临床实践经验进行合理的选择。同时,考虑到个体差异和其他治疗因素的影响,依据循证医学的原则进行用药时机选择将使研究方案更具科学性和可行性。
队列研究的偏倚主要涉及选择偏倚、失访偏倚、混杂偏倚以及信息偏倚。应严格按照预先设定的纳排标准连续纳入受试者,尽可能减少选择性偏倚。在条件允许的情况下,优先选择前瞻性队列研究,以减少偏倚风险。观察性研究通常存在组间变量不均衡的情况,因此,如何使得暴露组与非暴露组人群特征一致,是减少混杂偏倚的重要内容。失访偏倚在队列研究中难以完全避免。在提高患者依从性,尽可能减少失访的基础上,需要积极对失访者和已随访者的特征、观察结果进行分析比较。控制信息偏倚需要着眼于研究全过程,在保持严谨、认真的研究态度的基础上,明确各项要求,严格按规定执行。
用药时机相关随机对照试验的设计模式主要有2种:模式一,根据药物干预时机的不同,直接将受试者随机分配到早干预组或晚干预组(见图1);模式二,先根据不同药物干预时机进行分层,再将患者随机分配进入试验组或对照组(见图2)。以上2种设计模式的根本差异在于所回答的研究问题不同:前者回答的是不同干预时机(如早干预与晚干预)哪种效果更好;后者则回答在某干预时机下(如药物干预时机A),某药是否优于对照组。
目前,不少已发表的随机对照试验[1-3,6]都是根据药物干预时机直接将受试者进行随机分组(模式一)。这一类型往往具备较充足的前期研究基础,同时具备多个备选的药物干预时点,因而通过试验可以明确哪个用药时点的疗效更好。但是,如果某疾病缺乏临床观察以及生理病理等机制研究,或者想要初步探索某几个时点进行药物干预是否有效,则应该按照药物干预时机先对受试者进行分层(模式二)[22-23]。这一类型可以明确该药物在哪几个干预时点有效,但无法得出最优干预时点。因此,在方案设计阶段,研究者首先需要明确主要研究目的,针对性选择最恰当的设计模式。
盲法实施在随机对照试验起着至关重要的作用。在临床科研中,常见的盲法有单盲和双盲。双盲设计可以有效减少来自受试者和研究者的主观偏见,提高研究结果的客观性和可靠性。用药时机相关随机对照试验在进行双盲设计时,往往需要设置模拟剂。不过,模拟剂设置在2种设计模式下略有差别。模式一中安慰剂设置使得早干预组和晚干预组达到双盲的效果;而模式二中模拟剂设置与常规随机对照试验中安慰剂设置相同。
临床研究还存在一种特殊情况,即干预措施存在既定目标,或研究者需要观察患者状态以便及时调整治疗方案。这时候严格双盲难以实现,常采用开放标签设计。CATIS-2是一项多中心、随机、开放标签、盲终点的Ⅲ期临床研究,旨在探究急性缺血性卒中早期与延迟降压治疗对于预后的影响[30]。其中,早期治疗组在入组后即刻开始降压治疗;而延迟治疗组在入组后d 8开始降压治疗。
考虑到开放标签设计可能导致参与者和研究人员的期望和行为发生改变,评估结果不可避免地存在一定偏倚。为减少主观偏倚,在进行开放标签随机试验时,一方面需要注意确保随机分配的合理性和偏倚控制;另一方面尽量选择客观的终点指标进行评估,且应采用结局评价者盲法设计。
针对用药时机的临床研究具有重要的临床意义和学术价值。本文深入探讨了用药时机对于临床精准用药的重要性,并从概念解释、研究意义、中医药认识、研究设计类型及方法学要点等方面展开系统论述。其中强调主要研究目的是选择合适研究类型的前提。与此同时,队列研究的设计需要重视用药时机的界定和偏倚控制;对于随机对照试验而言,2种设计模式均强调盲法实施。未来应继续深化相关研究,为临床实践中适时、精准用药提供系统的方法学支撑。
  • 国家自然科学基金资助项目(82104823)
  • 北京市科技新星计划资助项目(Z211100002121061)
  • 中华中医药学会课题资助项目(2021XS-001-02)
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2025年第34卷第17期
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doi: 10.20251/j.cnki.1003-3734.2025.17.008
  • 首发时间:2026-03-06
  • 出版时间:2025-09-15
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  • 录用日期:2024-12-18
基金
国家自然科学基金资助项目(82104823)
北京市科技新星计划资助项目(Z211100002121061)
中华中医药学会课题资助项目(2021XS-001-02)
作者信息
    1北京中医药大学东直门医院,北京 100700
    2中国中医科学院针灸研究所,北京 100700
    3北京中医药大学中医脑病研究院,北京 100700

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*赖新星,男,副研究员,硕士生导师,研究方向:中医药防治脑血管病。E-mail:
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2种不同金属材料的力学参数

Family
属数
Number of
genus
种数
Number of
species
占总种数比例
Percentage of
total species (%)

Genus
种数
Number of
species
占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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