2015年 · 第95卷第22期

Chronic obstructive pulmonary disease (COPD) is a common and frequently occurring clinical disease caused by smoking and biofuel exposure. The main pathophysiological feature is continuous exhaled airflow restriction, and the main pathological change is chronic airway inflammatory reaction. The results of large-scale epidemiological survey in China show that the prevalence of COPD in people over 40 years old is about 8.2%; COPD seriously affects the quality of life of patients, and its high disability rate and high mortality rate bring huge economic burden to patients and society^[1]。 New research estimates that COPD will be the third cause of disease death worldwide by 2030^[2]。 The 2015 COPD Global Initiative pointed out that in EU countries, COPD-related medical expenses will account for 56% of the total expenditure on respiratory-related diseases. Data from the United States show that COPD direct medical expenses reach $29.5 billion, and indirect expenses reach $20.4 billion^[3]。 Therefore, it is of great significance to understand the pathogenesis of COPD in depth for its prevention, treatment and clinical management.

In 1998, with the collaboration of the National Institute of Heart, Lung and Blood, the National Institutes of Health and the World Health Organization, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was launched to improve the awareness, management and attention of COPD. In 2001, the first report, the Global Initiative for the Diagnosis, Treatment and Prevention of COPD, was published. For more than 10 years, the GOLD Scientific Committee has continuously updated the GOLD report by retrieving and screening out influential research results. Of the 312 newly retrieved academic papers from January to December 2014, the GOLD Scientific Committee considered 31 to have an impact on the GOLD report released in January 2014^[1]。 Based on these latest studies, the GOLD Update Report published in January 2015 has modified and added some contents to the original framework and central content, while there is no change in principle in the definition of COPD, disease assessment, stable phase and exacerbation phase treatment compared with the report published in 2014^[1]。 The GOLD 2015 update report has been published on the GOLD website at www.goldcopd.org, and the updated section is interpreted as follows.

With the comprehensive advancement of China's medical and health system reform, the diversified medical pattern of public medical institutions, non-public medical institutions and domestic and overseas social capital medical institutions has gradually formed, and the health industry is facing rare development opportunities^[1]。 Taking this opportunity, the management of medical laboratories has gradually moved towards standardization and standardization, whether it is the "Evaluation Standards for Tertiary General Hospitals (2011 Edition)" issued by the National Health and Family Planning Commission^[2]And implementation rules, "Administrative Measures for Clinical Laboratories of Medical Institutions"^[3]It is also the Accreditation Guidelines for Quality and Competence of Medical Laboratories (ISO 15189:2012) issued by the National Accreditation Council for Conformity Assessment (CNAS) of China^[4]All put forward clear and detailed requirements for the management, technology, quality and safety of the laboratory. In order to improve the accuracy of test results and resist potential medical risks, each laboratory has established a quality management system according to the requirements of laws, standards or guidelines according to its own actual situation. The whole process of the experiment is analyzed by the theory of systematics to find out the various links that affect the quality of the inspection and make measures to control it^[5]； Writing system documents suitable for themselves to ensure the effectiveness and operational compliance of the quality management system; It can not only cope with various professional inspections, but also meet medical regulations and hospital standards, so that the quality management system is integrated with all tasks^[6]。 Quality management system documents are the foundation and basis for the existence of quality management system^[7]Combined with the practical experience of this laboratory, the author discusses the standardized management, effective control and continuous improvement of quality management system documents as follows.

In the past 10 years or so, cochlear implant (CI) has achieved great success in the auditory rehabilitation of children with non-syndromic sensorineural deafness (NSSNHL). Since its introduction in China, it has gradually been popularized and recognized, and has been carried out on a large scale in medical institutions all over the country. In the process of this development, the etiology of congenital deafness has been deepened, especially the increasingly popular deafness gene screening and identification has found the root cause of deafness for many congenital deaf children. According to the epidemiological investigation results, the main genetic genes of deaf children in China are GJB2, SLC26A4 and mtDNA 12srRNA mutations, and similar characteristics are found in children who receive cochlear implants. In addition, hundreds of deafness genes have been reported, but various deafness-causing mechanisms are still in the exploration stage, and their impact on prognosis is inconclusive. About 20% of patients with hereditary deafness in China are caused by mutations in SLC26A4 gene^[1]This study is based on the observation of the efficacy after CI in patients with non-syndromic hereditary deafness, and preliminarily investigates the correlation between the cause of deafness and prognosis, in order to provide clinical reference data for deafness prevention, treatment and prognosis prediction.

An 85-year-old male was admitted to the hospital on 3 March 2014 due to "abdominal aortic aneurysm found on physical examination for half a month". History of previous hypertension, renal insufficiency, cerebral infarction. Admission physical examination: blood pressure 120/80 mmHg (1 mmHg =0.133 kPa); The abdomen was flat and soft, and a pulsatile mass was palpable on the left of the umbilicus, 4 cm ×3 cm ×2 cm, without tenderness; The bilateral femoral arteries pulsed well. Creatinine 202 μ mol/L, D-dimer 5 410 μ g/L. Total aortic CT angiography (CTA): branch variation of abdominal aorta, splenic artery from abdominal aorta, common hepatic artery from superior mesenteric artery; Infrarenal abdominal aortic aneurysm with mural thrombosis, with a maximum diameter of about 50 mm; Bilateral common iliac artery aneurysms, with a maximum diameter of about 30 mm on the right side and 22 mm on the left side, both accumulated internal iliac artery openings; Aneurysm of the initiation of the right internal iliac artery, stenosis of the initiation of the left internal iliac artery (Figure 1)； Three pairs of slender lumbar arteries can be seen in the aneurysm segment. Carotid ultrasound showed multiple heterogeneous plaque formation in bilateral carotid arteries. Cardiac ultrasound showed a small amount of pericardial effusion, aortic valve calcification with a small amount of regurgitation, and mild pulmonary hypertension.

The patient, a 62-year-old male, was admitted to the Department of Gastroenterology of Tongji Hospital on September 14, 2014 with the main complaint of "nausea and vomiting for 1 week, aggravated with stopping defecation for 3 days". The patient experienced upper abdominal distension and pain accompanied by nausea and vomiting after eating overnight food 1 week before admission. The vomit was stomach contents, brown, and vomiting was severe. The patient vomited after eating, not in the form of a jet, and had nothing to do with activity. After vomiting, the upper abdominal distension and pain could be slightly relieved, accompanied by fatigue. Before admission, the patient was treated with levofloxacin 0.5 g/d ×7 d intravenous drip. The above abdominal discomfort, nausea and vomiting symptoms gradually worsened, and defecation stopped 3 d before admission, with exhaustion. On September 11th, the laboratory examination of our hospital outpatient clinic showed that white blood cells were 12.6×10⁹/L, neutrophil percentage 0.60, neutrophil 7.7×10⁹/L, C-reactive protein 13 mg/L, transaminase, troponin, blood amylase and lipase were normal. He had a history of hypertension for more than 10 years and gallbladder stones for 20 years. Abdominal B-ultrasound showed gallbladder stones (about 30 mm in diameter) during physical examination 1 month before admission, and there was no history of acute cholecystitis. Physical examination at admission: soft abdomen, mild tenderness in the upper abdomen, no rebound pain, and no mass in the abdomen. Liver and spleen were not subcostal, Murphy's sign was negative, there was no percussion pain in the liver and kidney area, abdominal tapping and drum sound, and intestinal sound 4 times/min. After admission, considering the possibility of acute gastroenteritis and incomplete intestinal obstruction, anti-infection (cephalosulbactam, ornidazole), acid suppression (lansoprazole), gastric mucosa protection (aluminum-magnesium plus suspension), nutritional support and other treatments were given. There was no obvious obstruction in the abdominal upright X-ray plain film. On the second day of admission, the patient gradually began to develop right upper abdominal pain with nausea and vomiting. The pain was paroxysmal, without radiation, and the vomit was a large amount of dark green bile. Gastrointestinal decompression was given. The drug treatment plan was the same as before. Gastroscopy on the third day of admission: multiple ulcers in the duodenal bulb (one 0.6 cm ×1.0 cm deep ulcer in the anterior wall of the bulb, one 0.4 cm ×0.5 cm ulcer in the lower wall, and dark green liquid reflux below the descending part); gastric retention; Multiple flaky ulcers of the lower esophagus (Figure 1，Figure 2)。 On the 4th day of admission, enhanced CT of the upper abdomen showed unclear gallbladder, incomplete small intestinal obstruction, and huge stones in the intestine (Figure 3)。 Cholecystoduodenal fistula with calculous small intestinal obstruction was considered and transferred to general surgery. On September 22nd, laparoscopic exploration and jejunolithotomy were performed under general anesthesia. During the operation, a large number of large omental adhesions in the right upper abdomen were fixed at the gallbladder fossa, and the proximal jejunum was obviously dilated. The thickest intestinal tube was about 6 cm in diameter, and the huge stones in the intestinal tract could be reached about 30 cm away from the Trigger's ligament, resulting in intestinal obstruction, obvious local small intestinal edema and emptiness of the distal small intestine. The local small intestine was incised and the stone was removed. The stone was hard in texture and about 6 cm in diameter. After operation, he was treated with fasting, gastrointestinal decompression, anti-infection (cefmetazole), acid suppression (lansoprazole), nutritional support, etc., and was successfully discharged from hospital on October 4, 2014. Discharge diagnosis: (1) Calculous incomplete small intestinal obstruction, cholecystoduodenal fistula; (2) complex ulcer; (3) Grade 1 medium risk group of hypertension.

The continuous innovation of the new generation of sequencing technology has applied gene sequencing technology to the single cell level. At present, the pathogenesis of tumor has not been clearly elucidated. As we all know, malignant tumor is a molecular disease, and its activation of oncogenes and inactivation of tumor suppressor genes caused by gene level changes play a crucial role in its development. Moreover, the development of many tumors will go through different stages, resulting in the existence of different grades and types of tumor cells within a tumor or between multiple tumors. Therefore, using single cell sequencing technology to study malignant tumors in depth, we can find various gene mutations, tumor heterogeneity, drug resistance, etc. that lead to the occurrence and evolution of malignant tumors, so as to help us understand the occurrence, development and evolution of malignant tumors at the individual level.