2013年 · 第36卷第04期

The breadth and depth of clinical medical knowledge are like a vast sea, both boundless and unfathomable, and the speed of knowledge update is rare in natural science. Undergraduate medical education is important, but it can only lay a preliminary foundation for being a doctor. Of course, whether it comes from a "famous brand" college has certain value, its significance mainly lies in the "famous school" has a higher entrance threshold, also has a relatively formal education system, excellent tradition and teachers. However, whether students can become qualified and excellent doctors after graduation mainly depends on re-learning and accumulation of clinical experience after graduation. Therefore, it can be said that how to carry out the post-graduation education of doctors is directly related to the quality of clinicians and the improvement of public health. Over the years, China has established a whole set of medical post-graduation education system, such as the training and assessment of residents, graduate students, further training doctors system, etc. However, these alone are far from enough, but need to be further strengthened by the cooperation of academic groups and enterprises and the re-education activities carried out by enterprises alone. The annual meetings and seminars held by various academic groups vary greatly, and their academic standards vary. Some are indeed academic-oriented, and participants generally reflect that they have gained a lot. Some only pay attention to the scale and momentum, and often invite a few old people to take the title of "International XX Academic Conference", but the content is rough and the academic level is low, so the participants are like catching a big gathering. Such an "academic" conference is actually "misleading" and wastes the participants' expenses and precious time in vain. Of course, whatever the level of the above-mentioned "academic" activities, it is inseparable from the funding of enterprises. This article puts aside other post-graduation education, only involves the writer's experience and feelings about enterprise-led academic activities.

The Guidelines for the Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease (COPD) in China were last revised in 2006 and published in early 2007^[1]。 The 2011 update of the Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (COPD), 10 years after its first publication in 2001, has been significantly modified based on the best scientific research results and has received widespread attention^[2]。 Domestic counterparts are eager to update China's COPD guidelines. Therefore, the COPD Group of Respiratory Disease Branch of Chinese Medical Association held a core group meeting in March 2012, seriously discussed the related issues of the revision of China's COPD guidelines, and finally decided to revise China's COPD guidelines. The basic guiding ideology is as follows: (1) maintain the framework of the COPD guidelines (2007 revised edition), add chapters on comorbidities, and strive to be concise and clear, in line with China's clinical practice; (2) Mainly refer to the 2011 edition of the Global Strategy for COPD, but pay attention to the epidemiological and clinical research results of COPD in China in recent years, and focus on reviewing the literature published in influential domestic and foreign related journals; (3) Written separately by members of the core group. The first discussion of the first draft was held in August 2012, and the manuscript was sorted out and sent to relevant experts and all members of the COPD group for extensive comments. The second discussion was held in October 2012, and the final manuscript was basically finalized by the end of December.

comorbidity, also known as comorbidity, has previously clinically referred to a disease state that exists at the same time as a major disease and is relatively independent of the major disease state. Major disease usually plays a leading role in the patient's illness process and is the primary cause of hospitalization and a major part of the patient's health burden. However, more recently, the concept of comorbidity has been extended in clinical application, and comorbidity usually refers to two disease states that are interrelated or causally related^[1]。 In elderly patients, it is sometimes difficult to tell which disease is the predominant disease because of the changes in their predominant disease over time. Chronic obstructive pulmonary disease (COPD for short) is a common disease that can be prevented and treated and is characterized by persistent airflow restriction with progressive development, accompanied by an increase in chronic inflammatory response of the airways and lungs to harmful particles or gases. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease, 2011 "(global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, COPD Global Strategy) is defined with particular emphasis on "the severity of acute exacerbations and comorbidities affecting the patient's overall disease."^[2]。 COPD often coexists with other diseases, including cardiovascular disease, osteoporosis, anxiety and depression, lung cancer, infection, metabolic syndrome, and diabetes, and has a significant impact on the progression of the disease. The presence of these diseases in patients with COPD is quite common, and the incidence of comorbidity is similar in patients with different pulmonary function grades according to the global strategy for COPD^[3]。

It is often believed that pulmonary fibrosis [including idiopathic pulmonary fibrosis (IPF) and idiopathic interstitial pneumonia] and emphysema are two distinct lung diseases in terms of clinical and pathological features. For example, IPF and emphysema each have their own distinct characteristics: the incidence of emphysema is significantly higher than that of IPF, and the pathological changes are terminal bronchioles or grade 1 respiratory bronchioles wall thickening and lumen stenosis, the distal grade 2 respiratory bronchioles or their terminal lung tissues cystic dilatation, alveolar wall destruction and fusion, and the lung function changes are mainly lung hyperinflation caused by incomplete reversible airflow restriction, characterized by obstructive ventilatory dysfunction. Chest X-ray shows various types of emphysema (paraseptal emphysema and central lobular emphysema, etc.) and bullae mainly in the upper lobes; IPF is diffuse pulmonary interstitial fibrosis and honeycomb lung formation. Pulmonary function changes to decreased lung volume, characterized by restrictive ventilatory dysfunction, and diffuse function is impaired in the early stage. Chest X-ray shows grid-shaped, small nodule-shaped and honeycomb-shaped changes, notably in the lower lobes and subpleura.

Chronic obstructive pulmonary disease (COPD) is a disease characterized by continuous restriction of airflow. pulmonary hypertension (PH) is an important complication of COPD. COPD combined with PH refers to the mean pulmonary arterial pressure (mPAP) ≥25 mm Hg (1 mm Hg =0.133 kPa), pulmonary capillary wedge pressure ≤15 mm Hg, and normal or reduced cardiac output measured by right cardiac catheter in COPD patients at rest. In the guidelines for the diagnosis and treatment of PH jointly issued by the European Cardiology Association (ESC) and ERS in 2009, COPD combined with PH is classified into Group 3, that is, PH due to lung disease and/or hypoxia^[1]。 The incidence of COPD complicated with PH is high, and it has a significant effect on prognosis^[2,3,4]。 Therefore, effective prevention and treatment of PH is very important to improve the quality of life of patients, prevent or delay the occurrence and development of pulmonary heart disease and improve the prognosis.

Chronic obstructive pulmonary disease (COPD) is a disease characterized by persistent airflow restriction. Acute exacerbations and comorbidities of COPD play an important role in the severity of the disease^[1]。 In the comprehensive evaluation of COPD, acute exacerbation is one of the main risk assessment factors. Most deaths related to COPD occur in the acute exacerbation stage. Among the causes of acute exacerbation of COPD, infection factors account for 50% ~70%, environmental pollution accounts for 10%, and the remaining 30% are unknown. Some researchers believe that pulmonary embolism may be another common cause of acute exacerbation of COPD^[2]However, it is not defined in the guidelines or strategies for the diagnosis and treatment of COPD. It is only suggested that heparin or low molecular weight heparin should be considered for anticoagulant therapy in patients with COPD who are bedridden, have increased red blood cell count or are dehydrated, regardless of previous history of thromboembolic disease^[1]。

chronic obstructive pulmonary disease (COPD) is a common and frequently occurring disease that seriously endangers human health. It seriously affects the quality of life of patients, has a high mortality rate, and brings a heavy economic burden to patients, their families and society. A survey of 20 245 adults in 7 regions in China showed that the prevalence of COPD among people over 40 years old was as high as 8.2%. According to The Global Burden of Disease Study, it is estimated that COPD will be The third leading cause of death worldwide in 2020. According to data from the World Bank and the World Health Organization, COPD will rank fifth in the economic burden of disease in the world by 2020. In order to standardize the diagnosis and treatment of COPD, ensure the quality of medical treatment, improve the level of clinical work, and thus more effectively alleviate the pain of patients, improve the quality of life, reduce the mortality rate and reduce the burden of disease, in 1997, the Respiratory Disease Branch of Chinese Medical Association organized relevant experts in China to formulate the "Standard for Diagnosis and Treatment of COPD (Draft)" with reference to international experience and combined with the actual situation in China. Based on this, the global Strategy for the Diagnosis, Management, and Prevention of chronic obstructive lung disease (GOLD) was promulgated in 2001. "(global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease), The "Guidelines for the Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease" was developed by the Chronic Obstructive Pulmonary Disease Division of the Respiratory Disease Branch of the Chinese Medical Association in 2002, and a revised version of the guidelines was published in 2007. The above documents have played an important guiding role in improving the clinical diagnosis and treatment level of COPD in China and promoting the clinical research work related to COPD.

In order to improve the assessment of chronic obstructive pulmonary disease (COPD), the 2011 revised Global Strategy for the Diagnosis, Management and Prevention of COPD "(global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, In addition to pulmonary function, symptoms, risk of acute exacerbation and comorbidities were included in the disease assessment of patients with COPD^[1]。 The author believes that it is not appropriate to introduce the number of acute exacerbations into the disease assessment, and it is not suitable for China's national conditions. Now we explain our views as follows.

pulmonary hypertension (PH) is a series of malignant pulmonary vascular diseases characterized by increased pulmonary artery pressure with or without small pulmonary artery lesions, often causing right heart failure or even death^[1]。 pulmonary hypertension is a hemodynamic and pathophysiological concept, and the diagnostic criteria are: mean pulmonary arterial pressure (mPAP) ≥25 mm Hg (1 mm Hg =0.133 kPa) at sea level, at rest, right heart catheterization^[1,2]。 This standard has been adopted by all clinical trials and registration institutes of pulmonary hypertension at home and abroad. The pathogenesis of pulmonary hypertension has not been completely defined so far. At present, it is believed that the main pathological mechanisms are pulmonary vasoconstriction, pulmonary vascular remodeling, inflammation and thrombosis in situ, but this mainly refers to the pathogenesis of pulmonary arterial hypertension and pulmonary hypertension related to respiratory diseases or hypoxia^[3,4,5]。 In recent years, with the application of specific pulmonary vasodilators, the quality of life and survival rate of patients with pulmonary hypertension have improved significantly. However, the existing treatment methods are still not satisfactory, and at present, specific pulmonary vasodilators only have evidence-based medical evidence for patients with pulmonary hypertension. Therefore, seeking new treatment methods for pulmonary hypertension is a hot spot. The results show that statins have effects independent of lipid-lowering effects, such as improving vascular endothelial function, inhibiting vascular smooth muscle cell proliferation, inducing vascular smooth muscle cell apoptosis, anti-inflammatory, antioxidant, antithrombotic and stabilizing plaque, etc., that is, the pleiotropic effect of statins. Based on the pathogenesis of pulmonary hypertension and pleiotropic effects of statins, statins are considered to be more promising emerging therapeutic agents for pulmonary hypertension. This article reviews the role of statins in animal models of pulmonary hypertension, its possible mechanisms and clinical studies as follows, and discusses the therapeutic effect of statins in pulmonary hypertension.

White hair, also known as Huafa, Silver hair and Haoshou, is no stranger to this, but why does hair turn white? This starts with its structure. The outermost part of the hair is a "coat" called "hairy skin", which is made of layers of overlapping keratinocytes, a bit like fish scales; The "cores" of hair are cells called the "medullary layer"; In the middle of these two layers, there are jujube-shaped groups of keratinocytes, which contain many colored particles, which people call melanin particles. Melanin particles are particles produced by melanocytes that absorb a protein called tyrosine, and they are mostly brown-black after the chemical interaction of tyrosinase. The color of our hair is actually determined by the color of the melanin particles.

Chronic obstructive pulmonary disease (COPD) is a disease characterized by incomplete reversible airflow restriction. At present, pulmonary function tests are mainly used to classify the severity of the disease and guide the treatment. COPD is also recognized as a heterogeneous disease. Patients with the same degree of lung function decline may have obvious differences in clinical symptoms and imaging findings^[1]Patients with similar symptoms or risk factors for disease may also differ widely in their response to treatment with the same drugs^[2]。 Relying on pulmonary function test alone cannot fully reflect the complexity of COPD, and it is difficult to carry out more targeted treatment. At present, there is an urgent need for new methods to classify COPD patients with diverse manifestations and distinguish and diagnose subgroups with different responses to various treatments to guide treatment.

The revised version of the Global Strategy for the Diagnosis, Management and Prevention of COPD (referred to as the Global Strategy for COPD) issued in 2011 has been significantly revised according to the latest progress in clinical research, among which the classification method of COPD severity has changed greatly. The new classification method in the 2011 Global Strategy for COPD is not only based on lung function, but also comprehensively evaluated according to the patient's clinical symptoms, risk of future acute exacerbation, severity of pulmonary function abnormalities and comorbidities^[1]。 In order to compare the consistency of old and new grading methods and their advantages and disadvantages, we conducted the following study.

Pulmonary mucormycosis is an invasive pulmonary fungal infection caused by Mucor of the phylum Zygomycetes, which occurs in people with suppressed immune function, especially patients with hematological malignancies. The disease has acute onset, rapid progression, lack of specificity in clinical manifestations and imaging features, difficulty in early diagnosis, and high mortality^[1]。 The clinical data of 9 cases of pulmonary mucormycosis diagnosed in our hospital in recent years are reported in order to improve clinicians' understanding of this disease.

A 60-year-old female was admitted to the Department of Respiratory Medicine of Peking University First Hospital on August 3, 2011 due to "intermittent cough for half a year, aggravated with wheezing for one month". The patient began to have intermittent dry cough six months ago. One month ago, the cough worsened with wheezing, and the symptoms gradually worsened. He couldn't get out of bed during the day and lay down at night. The other hospital had been diagnosed as bronchial asthma, and the symptoms were not relieved after treatment; Five days ago, the chest CT of the external hospital showed severe external pressure stenosis of the middle and lower trachea, right main bronchus stenosis, left main bronchus occlusion, left lung obstructive atelectasis, and multiple lymph nodes in the mediastinum (Figure 1), was admitted for further diagnosis and treatment. Previous hypertension 2 years, smoking 30 years, 20 cigarettes/day. Physical examination: body temperature 36.6 ℃, heart rate 110 beats/min, 25 breaths/min, blood pressure 120/90 mm Hg (1 mm Hg =0.133 kPa). Sit upright and breathe, gasping. Unpalpable enlargement of superficial lymph nodes throughout the body. The trachea is left deviated, the three concave signs can be seen, and wheezing can be heard. Percussion of the left lung showed turbidity, bicoherent rales could be heard in the upper chest, and respiratory sounds of the left lung disappeared. The heart rhythm was uniform, and there was no murmur in each valve area. The abdomen was flat and soft, without tenderness, the liver and spleen were untouched, and there was no edema in both lower limbs. Auxiliary test: carcinoembryonic antigen (CEA) 22.02 ng/ml (<5 ng/ml), neuroenolase (NSE) 62.76 ng/ml (<16.3 ng/ml). Arterial blood gas analysis: pH 7.46, PaCO₂is 32 mm Hg, PaO₂was 91 mm Hg and the inhaled oxygen concentration was 29%.

The patient was a 47-year-old female, a housewoman. He was admitted to hospital on February 25, 2011 due to "repeated hemoptysis for 4 years, chest tightness for 3 years, and recurrence for 1 day". Since February 2007, the patient had repeated hemoptysis without obvious inducement, mainly with blood in sputum, and occasionally 2 to 3 mouthfuls of blood. He was diagnosed with "pulmonary tuberculosis" in the local tuberculosis prevention and treatment center and was given regular anti-tuberculosis treatment for 1 year, but the hemoptysis did not improve. On July 21 and August 13, 2008, he was hospitalized in our department twice due to repeated hemoptysis with chest tightness. On July 21, 2008, chest CT showed bilateral lung infiltration (Figure 1，Figure 2)。 After the proposed "lung infection" was treated with "ceftazidime and batroxobin", the symptoms of hemoptysis and chest tightness improved and were discharged. Two days after discharge, he had recurrent hemoptysis with chest tightness, and the daily hemoptysis volume was about 5~10 ml. He was admitted again. Re-examination of chest CT showed new infiltrating lesions in both lungs (Figure 3，Figure 4)。 Bronchoscopy showed old blood stains in the bronchial lumen, and bronchoscopic lung biopsy showed that there were hemosiderin cells in the alveolar lumen, and the alveolar tissue showed chronic inflammatory changes. Proposed diagnosis of "exogenous allergic alveolitis?", given methylprednisolone 40 mg/d, treatment 5 days of hemoptysis, chest tightness improved, re-examination of chest CT, partial absorption of both lung infiltration shadows. After discharge, he continued to take oral glucocorticoids, and the symptoms of hemoptysis and chest tightness still occurred repeatedly. He went to multiple hospitals and was treated with glucocorticoids for 2 years and itraconazole oral liquid for 4 months, but the symptoms did not improve. On 25 Feb 2011, the patient was admitted to hospital due to reoccurrence of hemoptysis and chest tightness. There was no significant increase in the amount of hemoptysis this time, about 5~10 ml per day, which was bright red, accompanied by chest tightness after activity. The patient came from the onset of the disease, with clear consciousness, poor spirit, acceptable appetite and sleep, normal urine and defecation, and no weight loss. The patient had a history of diabetes for 7 years, and was treated with oral acarbose tablets, and the blood glucose control was ideal. Had a history of hypertension for 2 years, and had long-term oral irbesartan tablets, with blood pressure controlled at around 120/80 mm Hg (1 mm Hg =0.133 kPa). History of clarithromycin allergy. Deny raising pigeons, pets, etc., and deny history of infectious diseases such as hepatitis. Family history of hereditary disease denied.

Chronic obstructive pulmonary disease (COPD) is characterized by continuous airflow restriction. Actively controlling patients' symptoms and improving pulmonary function are the important goals of COPD treatment. Beta₂-Receptor agonists act as bronchodilators by relaxing airway smooth muscles and have long dominated the treatment of COPD and bronchial asthma (asthma for short). Depending on the duration of its action, beta₂-Receptor agonists can be classified as short-acting beta₂-receptor agonists (e.g., salbutamol, etc.) and long-acting beta₂Receptor agonists (LABAs such as salmeterol, formoterol, etc.). Short-acting preparations have a short duration of action and are mostly used on demand; The duration of LABA is as long as 12 hours, and formoterol also has the characteristics of rapid onset of action, which can be used to treat acute exacerbation. The combination of LABA and inhaled glucocorticoids is suitable for symptom control in the stable phase of moderate to severe COPD, and patients need to take medication twice a day. Prolonged drug action time can improve patients' medication compliance. At present, inhaled glucocorticoids and anticholinergic drugs, which are administered once a day, have been used in patients with COPD^[1,2]And has a good application prospect.

Chronic obstructive pulmonary disease (COPD) is a disease that can be prevented and treated with the characteristics of airflow restriction. Airflow restriction is not completely reversible and progressive, which is related to the abnormal inflammatory reaction of the lungs to harmful gases or harmful particles such as cigarette smoke^[1]。 COPD mainly involves the lungs, but can also cause systemic (or extrapulmonary) adverse effects. Due to the large number of patients, high mortality rate and heavy social and economic burden, COPD has become an important public health problem. At present, it ranks the fourth cause of death in the world. Nearly 3 million people die of COPD every year, of which 1.8 million occur in developing countries. The World Bank and the World Health Organization announced that by 2020, COPD will rank fifth in the economic burden of disease in the world. Recent survey results of 20 245 adults in 7 regions of China show that the prevalence of COPD accounts for 8.2% of people over 40 years old, which means that there are 43 million patients with COPD in China^[2,3]。 According to the data released by China's Ministry of Health, in 2008, COPD was the fourth leading cause of death for urban population and the third leading cause of death for rural population in China.

The standardized implementation of sedation techniques provides the basis and guarantee for maximizing the advantages of mechanical ventilation, and the results of large sample RCT studies confirm the benefits of sedation to patients^[1,2]In 2006, the Critical Care Medicine Branch of Chinese Medical Association issued guidelines for analgesia and sedation treatment of patients in intensive treatment wards, aiming at guiding the rationalization and standardization of sedation and analgesia techniques. However, some findings show that compliance with the guidelines is not optimistic^[3,4,5,6,7]In addition, improper sedation may also increase the time of mechanical ventilation, delirium, long-term cognitive dysfunction, and even death^[8]。 How to balance the advantages and disadvantages and apply sedation and analgesia techniques reasonably and standardizedly to make critically ill patients safer in the process of mechanical ventilation is a practical problem and a major challenge faced by clinicians.

The 11th event of Beijing Young Respiratory Scholars Salon in 2012 was held in Chinese Medical Association on December 27th, 2012. Young and middle-aged respiratory doctors from many hospitals in Beijing jointly discussed "comprehensive treatment of lung cancer". This salon activity was hosted by Dr. Jin Jianmin, Department of Respiratory Affairs, Beijing Tongren Hospital affiliated to Capital Medical University.

Dear readers, when you open this issue, a novel topic "How to Understand and Treat the Post-Graduation Education Activities Led by Pharmaceutical Enterprises-Also Discussing the Relationship between Scholars and Manufacturers" will certainly attract your attention. Professor Liu Youning, editor-in-chief of this journal, talks about this non-academic problem that clinicians can't avoid from the perspective of scholars and personal experience. He believes that post-graduation education is directly related to the quality of clinicians and the health level of the public. A complete set of medical post-graduation education system established in China over the years is far from enough, and enterprise-led academic activities are also an important part of doctors' post-graduation education. However, it is undeniable that enterprises cannot sacrifice their own interests in holding academic activities. With the increasingly fierce commercial competition, unscientific and unfair "academic" propaganda is increasing day by day, such as articles that specialize in mining results or opinions that are beneficial to their enterprises, regardless of whether they have sufficient evidence-based medical evidence; When interpreting important guidelines at home and abroad, it is distorted, only introducing the part that is beneficial to the enterprise, and deliberately ignoring the content that is unfavorable to the enterprise; Try to instill the opinions of the enterprise into the speakers and authors who lecture and write articles for them, so that they can speak against their will; Even so-called "experts" with rights and status are invited to conduct conferences or lectures to open up the market for their products. In the face of these behaviors that violate science, Professor Liu believes that such activities led by enterprises are beneficial to academic development and doctors' post-graduation education as long as they adhere to a scientific and fair attitude, and are worthy of advocacy. He suggested that scholars must stick to their own views, carefully revise the lectures provided by manufacturers, and every sentence they say can truly represent their own views and opinions, instead of being misled by others and spreading unscientific information, otherwise they will be in an embarrassing situation of unable to justify themselves. Only adhering to science and justice is the only way for scholars and enterprises to obtain a win-win situation.