2017年 · 第97卷第38期

Global Initiative on Chronic Obstructive Pulmonary Disease (COPD) (GOLD) 2017^[1]The report is comprehensively updated in terms of COPD definition and overview, diagnosis and initial assessment, supporting evidence for prevention and maintenance therapy, management of COPD in stable phase, and more. GOLD is currently the most authoritative COPD management strategy report in the world, which has important clinical guidance significance. Based on the available, continuously accumulated and updated clinical research evidence, this version of the report reflects the most reasonable diagnosis and treatment strategy for this disease as objectively and rigorously as possible. In particular, the evaluation and treatment of patients with COPD emphasizes the implementation of an individualized medical model, so that the treatment choice is more in line with the clinical characteristics and needs of patients^[1]。 Due to the huge difference in the level of economic and social development, the relevant clinical research evidence based on the patient population in developing countries is still lacking. Most of the clinical evidence adopted and based on the GOLD Committee led by Western experts, especially European experts, comes from the research of European and American populations. Whether their recommendations are in line with the clinical reality of patients in developing countries, especially China, still needs to be verified. When studying and applying the GOLD 2017 report, it should be combined with the actual clinical situation in China, and closely combined with the characteristics and diagnosis and treatment status of patients with COPD in China, so as to better implement individualized diagnosis and treatment and optimal long-term management goals. Now, the key contents of the diagnosis, treatment and management of COPD in the GOLD 2017 report are sorted out, especially some of the issues that Chinese doctors are generally concerned about and are prone to ambiguity are explained below.

GOLD 2017 by the Global Initiative for Chronic Obstructive Lung Disease (GOLD)^[1]Marking its 20th anniversary^[2]。 To facilitate the global dissemination of the strategy, its synopsis has been published for the first time in four journals simultaneously covering the Asia-Pacific region^[3]Europe^[4]Latin America^[5]And North America^[6]。 All chapters of GOLD 2017 have been significantly changed, with updated references and some interesting questions asked. This review gives a brief summary of some of these problems. As the current chairman of the GOLD Council, I am writing this article to reflect my own views and do not represent the official position of GOLD.

extracorporeal circulation (ECC) is an extracorporeal life support technology that uses a series of special artificial devices to drain venous blood outside the body, exchange gas, adjust temperature and filter it artificially, and then transfuse it back to the internal arterial system. It mainly includes cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO), which replace heart and/or lung function, and ventricular assist device (VAD), which replaces heart function^[1]。 With the efforts of several generations of medical scientists, cardiopulmonary bypass in China has grown from scratch. At present, there are nearly 800 hospitals carrying out CPB technology, and more than 40 hospitals with an annual operation volume of more than 1,000 cases. CPB open heart surgery has gradually become a conventional medical technology commonly carried out in tertiary hospitals in China. In 2016, there were more than 210,000 cardiovascular surgeries and more than 1,000 ECMO cases, ranking among the top in the world^[2]。 In the past 20 years, with the great progress of science and technology, the rapid development of medicine, new development opportunities are constantly emerging, and the development of cardiopulmonary bypass discipline is also facing severe challenges.

cardiopulmonary bypass and its derivative technology extracorporeal membrane oxygenation (ECMO) technology is an extracorporeal life support technology produced by the combination of artificial heart and artificial lung. Cardiopulmonary bypass technology is mainly used in cardiac surgery. With the continuous improvement of technology, it has been widely used in tumor treatment, organ transplantation, respiratory failure, poisoning, cardiorespiratory arrest, critical treatment and other fields. As an interdisciplinary subject, cardiopulmonary bypass has the characteristics of strong professionalism, narrow specialization, high risk and large span of professional knowledge involved. The difference in technical level seriously affects the diagnosis and treatment effect of patients. After more than half a century of efforts, developed countries and regions such as the United States, European countries, Australia, Japan and Taiwan have established a relatively perfect education and training system for cardiopulmonary bypass, which has promoted the standardization and standardization of cardiopulmonary bypass technology^[1,2]。 In recent years, the Cardiopulmonary Circulation Branch of Chinese Society of Biomedical Engineering has actively explored the education and training of cardiopulmonary circulation professionals, and adopted the following series of effective measures to promote the specialization, diversification, routine and sustainability of the education and training of cardiopulmonary circulation professionals in China.

The cardiopulmonary bypass in the 20th century ushered in a new era of the development of cardiac surgery. The advent of artificial heart-lung machine and oxygenator greatly promoted the development of open heart surgery, and the cardiopulmonary bypass of infants and young children is constantly being improved. Since the 1970s, driven by the development of international medical science and technology, many high-quality biological materials and equipment have come out one after another, and medical workers have continuously innovated surgical procedures and cardiopulmonary bypass technologies suitable for children with congenital heart disease. In June 1958, Professor Su Hongxi and others assembled a bubbling artificial lung by themselves, which successfully operated on a 6-year-old child with ventricular septal defect, and pioneered a new era of open heart surgery under cardiopulmonary bypass in China^[1]。 With the continuous development of related disciplines, the specialty of cardiopulmonary bypass for infants and young children has been continuously improved, from the original life support of simple heart surgery to the current life support and auxiliary technology of wide significance, and the application time limit has been extended from several hours to several days or even dozens of days. With the joint efforts of domestic and foreign experts, more and more children with congenital heart disease who need surgical treatment in the early postnatal period have obtained valuable treatment opportunities and obtained satisfactory surgical results. According to statistics, in 2016, there were 15,040 cases of cardiopulmonary bypass in children nationwide. Today's infant cardiopulmonary bypass technology has high safety, low mortality, and a significant decrease in complication rate, which is closely related to many improvements. This article will be based on the clinical work of neonatal and infant cardiopulmonary bypass in Pediatric Heart Center of Fuwai Hospital, and focus on the updating of equipment and materials, improvement of management concept and innovation of new technology in recent years, combined with relevant information at home and abroad.

Macrovascular diseases mainly include various aortic lesions, such as aortic aneurysm and aortic dissection, which are often complicated and dangerous. Previous surgical correction is difficult, with many complications and high mortality. There are many methods of cardiopulmonary bypass in combination with macrovascular surgery, which are controversial in many aspects, such as intubation site, bypass temperature and organ protection. In recent years, various new technologies, new materials and new equipment have been applied to macrovascular surgery and its perioperative management, and obvious clinical efficacy has been achieved. Among them, cardiopulmonary bypass management has formed many new concepts in clinical practice, which guides cardiopulmonary bypass to create good transfer conditions for the successful development of macrovascular surgery.

In recent years, with the continuous development of biomedical engineering technology and the accumulation of clinical experience, extracorporeal life support (ECLS) has become the first choice for rescue treatment of acute circulatory and/or respiratory failure caused by various causes. The concept and scope of ECLS are broad, among which extracorporeal membrane oxygenation (ECMO) technology is the most widely used. The second generation portable ECMO system has been widely used in clinical practice, enabling more and more patients with cardiac arrest in and out of hospital to achieve better clinical results. This paper briefly introduces the current situation and future development of ECMO technology in respiratory failure, circulatory failure and extracorporeal cardiopulmonary resuscitation (ECPR).

Throughout the history of medical development, extracorporeal circulation technology belongs to the category of emerging technologies. The concept of cardiopulmonary bypass is very broad. Therefore, as long as the blood in the human body is introduced out of the body, processed in a certain way to replace one or more organ functions, and then returned to the body, it belongs to the category of cardiopulmonary bypass. These treatments may include ventricular assist device (VAD) as an alternative to cardiac function, cardiopulmonary bypass (CPB) as an alternative to cardiac and/or pulmonary function, and extracorporeal membrane oxygenation (ECMO)^[1]。 The idea of cardiopulmonary bypass technology has been put forward for more than 200 years, but it really entered the clinic on May 6, 1953, when John Gibbon successfully treated a patient with atrial septal defect with CPB technology^[2]。 Over the past decades, CPB technology has made great progress and gradually matured with the development of basic medicine, clinical medicine, materials and biomedical engineering. At this stage, the establishment of corresponding technical standards should be put on the agenda. Standards are the basis of quality, and quality is the result of implementing standards.

The treatment mode of aortic arch lesions is related to the anatomical characteristics of the lesions and the patient's condition. The traditional treatment mode needs to be carried out under the condition of cardiopulmonary bypass and deep hypothermic circulatory arrest, and the incidence of early surgical complications and the risk of death are higher. Congenital complex lesions of the aortic arch, referring to dysplasia of the aortic arch, combined with varying degrees of aortic coarctation with or without descending aortic aneurysm. The surgical treatment of complex lesions of the aortic arch mainly uses anatomical correction (patch or artificial blood vessel replacement) and artificial blood vessel bypass^[1]。 Because the lesions are complex and there are many possible surgical complications, the best surgical method is still controversial. Although Sun Hongtao et al.^[2]It is found that the primary anatomical correction is not only safe and feasible, but also has good prognosis in the short and long term. However, most of the enrolled patients had aortic coarctation, and only a few patients had aortic arch dysplasia. Therefore, the surgical treatment of congenital complex lesions of aortic arch under normal temperature and off-pump still needs more research to verify^[3]。 Therefore, this study retrospectively analyzed the clinical data of 7 patients with congenital complex aortic arch lesions admitted to Fuwai Hospital of Chinese Academy of Medical Sciences from January 2009 to April 2016, and evaluated the clinical effect of double incision correction under normal temperature off-pump.

The patient, 25 years old, married and childless, was admitted to the emergency department because of "abdominal mass found for more than 1 month and abdominal pain for 1 day". At the time of admission, abdominal pain and abdominal distension were the main manifestations. No previous special medical history. Physical examination: the abdomen is slightly swollen, the vulva develops normally, the whole abdomen tenderness, rebound pain, muscle tension, the lower abdomen can be palpable mass, the mass tenderness is obvious, and the intestinal sound is weak. Diagnostic abdominal puncture withdrew about 5 ml of dark red non-coagulating blood. Blood routine: white blood cells 11.72×10⁹/L, hemoglobin (Hb) 108 g/L; Tumor markers such as alpha-fetoprotein (AFP) were examined normally. Color ultrasound: sonography of a large (12.0 cm ×7.4 cm) substantial mass in the abdominal cavity. Enhanced CT: huge mass shadow (12.6 cm ×9.2 cm) in the middle and lower abdomen, small amount of pelvic fluid effusion, and possible abdominal stromal tumor (Figure 1)。 Abdominal tumor rupture and hemorrhage were considered for admission diagnosis, and exploratory laparotomy was performed in emergency department. During the operation, there was dark red non-coagulating blood about 400 ml in the abdominal cavity, and a left intra-abdominal testicular tumor, with a maximum diameter of about 13 cm, a smooth surface, enveloped, pedicled and free, the root attached to the left spermatic cord, slightly twisted, and a laceration of about 2.0 cm ×1.5 cm at the base, with active bleeding; Right intra-abdominal normal cryptorchidism, spermatic cord and testis about 3.0 cm ×2.0 cm ×1.5 cm in size can be seen on the right side of the pelvic cavity. The scrotum was palpated immediately during the operation, but the testis was not palpated. Considering that the abdominal tumor is malignant transformation of intra-abdominal cryptorchidism, ask the urology table to consult suspected testicular tumor, and perform tumor and left spermatic cord resection and right cryptorchidism descending fixation. Postoperative medical examination (Figure 2): Left testicular seminoma; Immunohistochemistry: CK (−), PLAP (+), AFP (+, partial), AAT (+), OCT3/4 (+), CD30 (−), CD117 (+), Inhibin-α (−), LCA (−), P53 (+, 20%, weak), Ki-67 (+, 50%), AR (−); Supporting seminoma diagnosis. The patient recovered well after operation and was transferred to the oncology department for chemotherapy (BEP regimen: bleomycin + etoposide + cisplatin) and was successfully discharged.

Upper airway collapse occurs repeatedly during sleep in patients with obstructive sleep apnea hypopnea syndrome (OSAHS), which causes apnea and/or hypopnea, resulting in a series of pathophysiological changes such as hypoxia and carbon dioxide retention, sleep structure disorder, and intrachest pressure changes, which in turn affect the cardiovascular system^[1]。 OSAHS is currently considered to be an independent risk factor for the development of atrial fibrillation. Domestic studies show that the incidence of atrial fibrillation in patients with moderate and severe OSAHS is higher than that in patients with mild^[2]。 Obesity and old age are common risk factors of OSAHS and atrial fibrillation^[3]。 In addition, OSAHS can further aggravate obesity and nocturnal hypoxia, and is a high risk factor for atrial fibrillation in people under 65 years old^[4]。

As one of the common digestive diseases, gastritis has undergone a long historical change since the concept was established in 1728. At present, the classification of gastritis in China is mainly used in the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), but it is not based on the etiological classification of gastritis. For the main cause of gastritis-Helicobacter pylori (Helicobacter pylori，H.pylori) infection is also not mentioned, so the classification is clearly outdated. At present, Kyoto has attracted everyone's attention internationallyH.pyloriIn the consensus opinion on gastritisH.pyloriCorresponding section of associated gastritis, which talks about the newly established classification of gastritis – the ICD-11 classification. This classification emphasizes the importance of the etiological classification of gastritis and willH.pyloriThe caused gastritis is placed first in infectious gastritis, which has a great guiding role for the follow-up clinical treatment of gastritis, and is another major progress in the history of gastritis classification.