2015年 · 第95卷第38期

With the development of individualized medicine and the concept of "precision medicine", tumor targeted therapy has developed rapidly, and clinical research has gradually discovered and confirmed more gene mutations related to targeted therapy.

Primary hepatocellular carcinoma (HCC) is one of the common malignant tumors in China. Its occurrence often originates from liver cirrhosis caused by underlying liver diseases, and the degree of liver cirrhosis directly affects the treatment mode of tumor. Therefore, the factors that affect the prognosis of HCC, besides the tumor itself, should also consider the basic function of the liver. At present, there is no uniform staging system for HCC. Among them, the Barcelona Clinical Liver Cancer Staging System (BCLC) comprehensively considers liver function, tumor condition and basic physical condition, and corresponds staging with treatment and prognosis. It is recommended by the American Association for the Research of Liver Diseases (AASLD) and the European Association for the Research of Liver (EASL)^[1,2]。

Through the promotion of standardized diagnosis and treatment in China, the overall control level of bronchial asthma (asthma) has been improved to a certain extent, but there are still a few patients who are still unable to achieve good control even after using high-dose inhaled glucocorticoids including combination therapy. This part of patients is usually considered to be severe asthma^[1]。 3% ~5% of asthma patients are severe asthma, and the frequency of emergency treatment and hospitalization is 15 times and 20 times that of mild to moderate asthma, respectively, which are the main reasons for increasing the cost of asthma treatment, disability and death^[2]。 Severe asthma creates a huge social and economic burden. Due to the increasing burden of asthma disease, in 2008, China listed bronchial asthma as one of the key chronic respiratory diseases for prevention and treatment, and listed it as the respiratory diseases mainly controlled by the "Healthy China 2020" prevention and treatment plan. Therefore, improving the diagnosis and treatment level of severe asthma is of great significance to improve the overall control level and prognosis of asthma, and reduce the medical cost^[2,3,4]。

In recent years, the incidence and acute exacerbation rate of bronchial asthma (asthma) have increased significantly, and the interaction between environmental factors and genetic genes is the main cause of its incidence. With the acceleration of urbanization and industrialization in China, the deterioration of environment, especially air quality, inevitably occurs, which is closely related to the occurrence and deterioration of asthma. External environmental factors include indoor and outdoor air pollution, inhaled allergens, food allergies, etc. Outdoor air pollution mainly comes from traffic pollution (such as automobile exhaust, dust, etc.) and waste after fuel combustion (such as coal or fuel oil for power generation and heating, wheat straw combustion, etc.), while indoor air pollution comes from tobacco smoke, household biofuels (cooking, heating and candles, etc.), indoor decorations and outdoor polluted air entering the room. Controlling indoor and outdoor environmental factors is an important part of asthma management.

Currently, the treatment regimen based on inhaled glucocorticoids (ICS) recommended by the Global Asthma Initiative (GINA) can achieve good or acceptable clinical control of asthma for most patients with bronchial asthma (asthma). However, some severe asthma or refractory asthma still fail to achieve basic asthma control. Expert Consensus on Diagnosis and Management of Refractory Asthma in China^[1]This group of patients is called "refractory asthma". "International Guidelines for Severe Asthma" jointly published by the European Respiratory Society (ERS) and the American Thoracic Association (ATS) in 2014^[2]This group of patients is referred to as "severe asthma". Severe asthma accounts for 5% to 10% of asthma population. Although the proportion is not high, the proportion of acute exacerbation of severe asthma requiring emergency medical treatment or hospitalization is 15 to 20 times that of mild to moderate asthma, and the health resources consumed account for almost 50% of asthma^[1]。 Moreover, there is still no good treatment for severe asthma at present, and the development of medicine has not yet met the needs of these patients.

Bronchial asthma is referred to as asthma. The 2014 Global Asthma Management and Prevention Strategy (GINA) mentioned in the management of refractory asthma and severe asthma that these asthma patients need to be examined for the presence of comorbidities, including chronic sinusitis, obesity, gastroesophageal reflux (GERD), obstructive sleep apnea (OSA), and other psychological and physiological diseases; The presence of comorbidities may aggravate the symptoms of asthma or make it difficult to control asthma, and it is possible to bring asthma under control by treating these comorbidities^[1]。 Both asthma and OSA are common respiratory diseases, and the incidence of both diseases is increasing year by year. Asthma patients are prone to night snoring and apnea, and the proportion of patients with asthma in OSA is also significantly higher than that in normal people. Therefore, the coexistence of two diseases is not a accidental phenomenon. Is there a common predisposing and aggravating factor in their pathogenesis? And does the treatment of one disease affect the symptoms of the other? Compared with the overlapping syndrome of chronic obstructive pulmonary disease combined with OSA, some foreign scholars have called asthma combined with OSA "alternative overlapping syndrome"^[2]。 In-depth discussion and study of the relationship between the two will play an important role in guiding clinical work.

Bronchial asthma (asthma) is a heterogeneous disease^[1,2]It is a common chronic airway inflammatory disease, which seriously endangers human health. More than a decade ago, scholars began to notice the heterogeneity of asthma, identifying different asthma subtypes, called phenotypes, through the "visible features" of asthma. Although the phenotype of asthma is related to its clinical manifestations, triggers and treatment responses, it is not directly related to the pathogenesis of asthma, which cannot reflect the heterogeneity of asthma well, and cannot meet the requirements of highly individualized asthma treatment. Scholars began to distinguish asthma subtypes from the molecular mechanism and treatment response of asthma, believing that this distinguishing asthma subtypes is more conducive to the individualized treatment of asthma, and put forward the concept of "endogenous type". At present, endogenous type has gradually become the research hotspot of individualized medicine for asthma. How asthma research has changed from phenotype to endotype in recent years is introduced below.

acute pancreatitis (AP) is a common clinical emergency, and its incidence is increasing year by year, especially severe AP is dangerous in onset and has a high mortality rate. The 2012 update of AP Atlanta's diagnostic criteria has attracted much attention^[1]In recent years, our country has promulgated AP diagnosis and treatment guidelines for internal medicine, surgery, emergency medicine and integrated traditional Chinese and western medicine^[2,3,4,5]It has played an important role in standardizing the clinical treatment of AP.

In recent years, due to the increasing incidence of tumor, the research on oncology in all countries in the world is changing with each passing day. Continuing medical education has also become an important part of medical education. In 1972, the American Medical Association defined Continuing Medical Education ("CME") as an educational activity that meets the professional needs of physicians, patients, the public and the Medical profession, and that maintains, develops and enhances the knowledge, skills, professional qualities and interpersonal relationships of physicians^[1]。 Continuing medical education to promote the development of medicine is the driving force for the hospital to advance and expand its business, and it is an effective way for medical staff to obtain new theories, new knowledge and new technologies and improve their comprehensive quality. Strengthening continuing medical education and cultivating learning talents can effectively improve the overall medical level of society and improve the quality of medical services^[2]。

From August 21 to 23, 2015, the 10th National Clinical Forum on the Diagnosis and Treatment of Helicobacter Pylori and Digestive Diseases, which lasted for three days, came to a close in a tense and enthusiastic, happy and exciting atmosphere in Changping District, Beijing. This forum was co-sponsored by Beijing Branch of Chinese Medical Association, Peking University First Hospital, Chinese Medical Journal and China Helicobacter Pylori Information Center. This year coincides with the 100th anniversary of the founding of Peking University First Hospital, the 100th anniversary of the founding of Chinese Medical Journal, the 10th anniversary of the founding of this forum and the anniversary of Helicobacter pylori (H.pylori) Discoverer won the Nobel Prize 10th anniversary, celebrating "Double Ten Double Hundred" together.

The patient, a 70-year-old male, was admitted for 3 weeks of pain and discomfort in the middle and upper abdomen and 1 week of jaundice. Physical examination: The skin and sclera were yellow stained, and the apical pulsation point was located on the right side. Past physical fitness. Liver function showed: total bilirubin (TBIL): 121.7 μ mol/L, indirect bilirubin (IBIL): 82.6 μ mol/L. Tumor markers indicated: CA19-9>1 000 U/ml, carcinoembryonic antigen (CEA): 7.44 μ g/L. Abdominal enhanced CT showed (Figure 1): Abdominal visceral inversion, considering pancreatic head tumor, local compression and narrowing of the superior mesenteric vein. Magnetic resonance cholangiopancreatography (MRCP) showed a signal shadow of soft tissue mass in the pancreatic head area, considering pancreatic cancer, and dilatation of intrahepatic and extrahepatic bile ducts. Positron emission computed tomography (PET-CT) showed that the soft tissue density of the pancreatic head was about 3.2 cm ×3.8 cm, the FDG uptake was increased locally, and the maximum SUV value was about 3.8, considering pancreatic head cancer. Chest X-ray showed (Figure 2): dextrocardiac. Diagnosis: (1) Pancreatic head cancer is likely; (2) obstructive jaundice; (3) Complete visceral inversion. Whipple was performed under general anesthesia on 11 Sep 2013. Operation: The operator routinely stood on the right side of the patient, entered the abdomen through the left rectus abdominis incision, and exploration showed that the whole abdominal cavity was visceral inversion, the liver and gallbladder were located in the left upper abdomen, and the stomach and spleen were located in the right upper abdomen. Through the "reverse" Kocher incision, the pancreatic head and duodenum were freed, the pancreas was exposed, and the portal vein, superior mesenteric vein, common hepatic artery, and gastroduodenal artery were carefully identified. The tumor is located in the pancreatic head area, approximately 4.0 cm ×3.4 cm, surrounding the lower segment of the common bile duct and invading the superior mesenteric vein – portal vein confluence. During the operation, the invaded portal vein and tumor were completely resected, and the portal vein was reconstructed by liver sickle ligament. Child's method to reconstruct the digestive tract. The patient recovered smoothly. Postoperative pathology showed: well differentiated adenocarcinoma of the lower common bile duct, invading the pancreas; Lymph node metastatic carcinoma (2/15). The reexamination of abdominal enhanced CT at 18 days after operation showed that the lumen was partially narrowed after portal vein reconstruction. The patient developed grade IV myelosuppression after 1 cycle of chemotherapy with Genze + Xeloda regimen and was unable to continue chemotherapy. Six months after the operation, the patient developed massive peritoneal effusion and died in June 2014. The overall survival time was 9 months.

In recent years, the role of vitamin D outside bone metabolism has been paid attention to. Many studies have shown that vitamin D plays a certain role in the occurrence, disease severity, disease progression and drug response of asthma. The relationship between vitamin D and asthma and its related mechanisms are reviewed.

Cardiovascular disease (CVD) has become the leading cause of human death^[1]Therefore, exploring reliable markers with high sensitivity and specificity is of great significance for early diagnosis, timely treatment and prognosis of CVD. MicroRNAs (miRNAs) are a class of conserved endogenous non-coding single-stranded small molecule RNAs that regulate gene expression at the post-transcriptional level by specifically binding to the 3' untranslated region of miRNAs^[2]。 miRNAs can exist in peripheral circulation, such as blood components such as plasma, and circulating miRNAs can stably exist in harsh environmental conditions such as boiling, extreme pH, long-term storage at room temperature, and repeated freeze-thaw, and even be immune from the degradation of endogenous ribonuclease^[3,4]。 Moreover, circulating miRNAs meet the conditions that should be met by an ideal biomarker^[5]Such as high disease sensitivity and specificity and rapid and accurate early detection. Currently, circulating miRNAs have shown unique value in the early diagnosis and prognosis of many kinds of tumors^[4,6]The research as a potential marker of cardiovascular disease has also become a hot spot in the cardiovascular field, and specific circulating miRNA profiles of various cardiovascular diseases have been discovered. In this paper, the basic situation of miRNAs, the research on the association between circulating miRNAs and CVD, and the existing problems and prospects are reviewed.