2016年 · 第96卷第04期

"Consensus" and "personalized treatment" are two different concepts literally, but there is a deep internal connection between them. If it is understood or used incorrectly, it may lead to improper treatment of patients. What is "consensus"? From the meaning of the word analysis, "consensus" itself contains dissent, otherwise there will be no "consensus" two words appear. Now there is a "consensus" on the treatment of many diseases. The so-called "consensus" refers to the "consensus" reached by "presenting" those "clinical issues" that exist in dispute according to their evidence-based medical evidence level, and then deciding their "recommendation level". Because "consensus" is a "consensus" opinion with high-level evidence-based medical evidence and recommended and recognized by most experts, it plays an important guiding role for clinicians, especially for grass-roots doctors. However, there are still different opinions on the application of the "consensus", because the "consensus" only meets a large number of people and does not cover all people. Therefore, the "consensus" cannot be applied mechanically, and it cannot be applied to one thousand people, and one medicine for ten thousand people. What about these patients who do not meet the "consensus" opinion? Then "personalized treatment" should be carried out according to the specific situation of the patient.

The clear indication for treatment is Helicobacter pylori (Helicobacter pylori，H.pylori) The prerequisite for rational treatment, alsoH.pyloriThe key to prevention and control. aboutH.pyloriThe indications for eradication are still controversial on some issues, but with the continuous enrichment of large-scale randomized controlled clinical trials and other evidence-based medical data, new consensus has been reached on many issues.H.pyloriThe indications for eradication are expanding. Recently published World Health Organization/International Agency for Research on Cancer (WHO/IARC) Working Group Report "Strategies to Eradicate Helicobacter Pylori Infection and Prevent Gastric Cancer"^[1](IARC Working Group Report) and "Kyoto Global Consensus on Helicobacter Pylori Gastritis"^[2](Kyoto Consensus for short) willH.pyloriThe extension of eradication therapy to the general population has caused confusion among clinicians. This article discusses this issue, hoping to be beneficial to the majority of doctors.

Modern Western medicine draws on the analysis method of reductionism in natural science, and tries to reduce human body and disease to various material entities at different levels, so as to explore the true meaning of life and uncover the essence of disease, which makes medicine embark on the development road of constant specialization and specialization. This development mode based on division has greatly promoted the explosive growth of medical knowledge, also adapted to the needs of the whole social division of labor, improved the level of human diagnosis and treatment of diseases and improved their own health. However, under the new historical conditions, in the face of changes in disease spectrum, the arrival of aging, drastic changes in natural environment and changes in lifestyle, more and more medical workers and researchers realize that modern medicine needs to be transformed urgently, otherwise medical knowledge will be fragmented, medical practice will become mechanized, and far from the core value of people-oriented.

China's basic medical insurance coverage rate has increased from 30% in 2003 to more than 95% in 2014; The proportion of medical insurance reimbursement for individual hospitalized patients also rose to 47% in 2012^[1]。 The widespread diagnosis and treatment behavior that neglects the medical cost and medical outcome has caused new problems such as waste of medical resources and intensification of the contradiction between doctors and patients. The guidelines for clinical diagnosis and treatment (referred to as guidelines) provide reasonable, safe, standardized and economical guidelines for medical services in developed countries. After 2000, some domestic clinicians translated foreign clinical diagnosis and treatment guidelines and introduced them into domestic use; At the same time, there are also domestic academic groups to formulate guidelines for relevant clinical disciplines^[2]。 Because domestic experts are not familiar with the methods and principles of formulating clinical diagnosis and treatment guidelines, the quality of guidelines is generally low. Some scholars studied 327 clinical diagnosis and treatment guidelines from 2006 to 2010, and found that there are common defects in the formulation of clinical diagnosis and treatment guidelines in China, such as irregular methodology, opaque process, non-compliant procedures and non-declaration of conflict of interest^[3,4]。 Therefore, the guiding role of the guidelines on clinical diagnosis and treatment has been negatively affected. In 2008 and 2013, it was reported that the development of high-quality clinical diagnosis and treatment guidelines required the development of "<Guidelines for Clinical Diagnosis and Treatment>^[5,6]。 After 2 years of investigation, research and review of relevant domestic and foreign literature published by relevant branches of Chinese Medical Association^{[7,8,9,10,11]}, have the following basic understanding, and are willing to discuss with domestic medical experts.

acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) refers to bleeding caused by non-variceal disorders of the gastrointestinal tract above the Trigger's ligament, including bleeding of the pancreatic duct or bile duct and bleeding caused by disorders near the anastomosis after gastrojejunostomy. A systematic review of 93 clinical studies showed an annual incidence rate of (19.4-57.0) /100,000, a rebleeding rate of 13.9% and a mortality rate of 8.6% 7 days after onset^[1]。

As a complex and multidisciplinary disease, the study of pulmonary hypertension has made important progress in the past half century. The first edition of the guidelines for primary pulmonary hypertension was published in 1993^[1]。 Most of the clinical evidence of the first edition of the guidelines comes from expert consensus. With the advancement of research, a large amount of evidence-based medical evidence continues to emerge, and on this basis, the guidelines for pulmonary hypertension have been repeatedly updated in Europe and North America, and the rigor of the guidelines and the formulation methodology have been continuously improved. In 2015, the European Society of Cardiology/European Society of Respiratory Diseases (ESC/ERS) jointly published the latest edition of the Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension^[2,3]。 The methodology and main changes in its formulation process are described below.

Renal artery stenosis is a renal vascular disease caused by many causes, among which atherosclerotic renal artery stenosis (ARAS) is the most common cause. About 7% of people over 65 have ARAS^[1]。 In China, atherosclerosis has become the leading cause of renal artery stenosis, accounting for about 70%^[2]。 ARAS is an important risk factor for renovascular hypertension and chronic renal insufficiency. It is a progressive disease with occult onset. 10% to 15% of patients will eventually progress to refractory hypertension or severe renal insufficiency^[3,4]。 ARAS will affect the body to varying degrees. Due to insufficient blood supply to the kidney, the baroreceptor of the renal entrance glomerulus is stimulated, which will activate the renin-angiotensin-aldosterone system, further affecting the systemic circulation, endocrine and urinary systems, resulting in a series of changes such as left ventricular remodeling, hypertension and vascular remodeling^[5]。 Therefore, it is necessary to treat ARAS with clinical symptoms appropriately to effectively relieve ARAS and delay the progression of the disease. The main methods of treatment include drug therapy, surgical therapy and percutaneous interventional therapy. Since 1991, Kuhn et al.^[6]After the first use of renal artery stenting instead of balloon dilatation, percutaneous renal artery intervention began to develop rapidly due to its obvious advantages over balloon dilatation. During 1995 – 1998 alone, approximately 700 patients underwent renal artery stenting. With the more and more mature technology of percutaneous interventional therapy, with less trauma and obvious effect of improving renal vascular blood supply, it has gradually replaced traditional surgical treatment and become the first choice treatment for refractory hypertension and renal insufficiency caused by ARAS. However, in patients with ARAS, there has been a large controversy about the choice of percutaneous interventional therapy versus drug therapy. What do you think of the results of many large center studies in recent years? Which patients are suitable for interventional therapy? How should relevant clinical studies be carried out in the future? This paper summarizes the above problems.