Baidu
map

这些慢阻肺新病情评估方法尚未收录入GOLD 2018,它们对患者预后有何指导意义?

2018-09-16 北京大学第三医院呼吸内科 陈亚红 呼吸界

近期已有评估新分组方法的文献报道,但并未收录入GOLD 2018。本文对慢阻肺新病情评估做一综述。

2001年,第一版慢性阻塞性肺疾病全球创议(GOLD)发布,为慢性阻塞性肺疾病(以下简称慢阻肺)的规范化诊治提供了指导。

GOLD 2006对慢阻肺的定义、肺功能评估、发病机制、治疗策略等方面进行了更新,根据肺功能将慢阻肺分为四级。

GOLD 2011对慢阻肺评估方式和管理模式有了较大的更新,保留了肺功能分级系统,加入症状、急性加重风险综合评估。

GOLD 2017更新了慢阻肺定义、综合评估工具、治疗等方面内容,为慢阻肺的个体化治疗提供更多的选择。慢阻肺的评估系统也被再次修订,将肺功能评估从中分离,更新后的评估系统只通过患者的症状和急性加重史进行分组 [1]。

GOLD 2018仍然沿用GOLD 2017的评估工具,但对于急性加重史的判断修改为中度或重度急性加重,需要应用短效支气管舒张药及抗生素和(或)激素治疗为中度急性加重,需要住院或急诊就诊为重度急性加重,通常伴有急性呼吸衰竭。

近期已有评估新分组方法的文献报道,但并未收录入GOLD 2018。本文对慢阻肺新病情评估做一综述。

一、GOLD慢阻肺疾病评估体系的更新

早期GOLD只简单地通过肺功能分级评估病情,而GOLD 2011更新的ABCD评估工具则向前迈出了重要一步,因为它纳入了患者的自身症状,同时强调了预防急性加重在慢阻肺管理中的重要性。然而,这套评估工具有一些重要的局限性:

与肺功能分级相比,2011版的ABCD评价工具并不能更好地预测死亡率或其他重要临床结局 [2-4]。

C组和D组预后由肺功能和急性加重史2项指标决定,共有3个亚组。根据FEV1%或急性加重史分类,患者具备不同的风险特征 [5]。D组患者的结局受这2个指标的影响,容易造成混乱 [6]。人群研究发现C1和D1组(以单纯肺功能下降为主)占绝大多数,对这些亚组需要区分不同的治疗方案。

肺功能结果不能全面体现个体的临床差异。以肺功能分级,可在一定程度上反映患者的不同疾病严重程度,但每一等级内患者的临床症状变异很大 [7]。

单纯依靠肺功能不能准确预估慢阻肺急性加重风险。不同肺功能分级的患者急性加重频率差异很大 [8-10]。研究显示,FEV1%≥50%的患者中20%在过去1年≥2次的急性加重,急性加重高风险的患者中60%的肺功能FEV1%≥50% [11]。FEV1本身存在较大的变异性,因此用FEV1作为患者急性加重或死亡风险的预测指标,尚缺乏足够的精确度 [2]。频繁急性加重最好的预测指标就是既往的急性加重事件 [10]。

根据患者症状和急性加重史而不依赖肺功能,临床医师在某些情况下即可按照修改后的ABCD分组给予初始治疗方案。

因此,为了解决这些问题,同时保持临床医师处理的一致性和简单性,新评估方法把肺功能分级从旧版的ABCD分组中分离出来。肺功能、症状和急性加重史三者相结合,对于慢阻肺的诊断、预后及是否需要其他重要的治疗方法仍然至关重要。

二、GOLD慢阻肺新疾病评估体系更新带来的变化

1、新病情评估分组分布的变化

新病情评估分组势必对各组的分布产生影响。

Tudoric等 [12] 对POPE队列进行分析,该研究入组了中欧和东欧10个国家的3361例慢阻肺患者。C组移到A组有59例(占总体1.8%,占C组47.2%),D组移到B组有686例(占总体20.4%,占D组35.6%)。部分C、D组患者划归到A、B组,尤其原D组患者有超过1/3划归至B组,这与原来无频繁急性加重史,由肺功能分级划归到C、D组患者的重新分类有关。

Sun [13] 等对中国7个省11家医疗中心的1532例慢阻肺队列研究的患者重新分组。有46.7%(500/1070)的高风险组患者分到了低分险阻。C组取压B组变成了人数最少的组。

CabreraLópez等 [14] 入组及随访819例西班牙和美国的慢阻肺患者5年,采用mMRC评分分组。新评估方法降低了C、D组患者的比例(分别为20.5%和11.2%,24.6%和12.9%)。C、D组患者人数只占之前一半比例,A、B组比例显著增加。

Tan等 [15] 对加拿大阻塞性肺疾病(CAN-COLD)非干预研究队列进行分析,该研究入组717例慢阻肺患者,采用CAT评分分组。69%的患者由C组移到A组,64%的患者由D组移到B组。可见新病情评估分组的分布与GOLD 2011存在差别,整体上高风险组患者更多转移至了低风险组。

2、新病情评估分组的临床特征

Sun等 [13] 发现新高风险组患者有更多与急性加重高风险和死亡率相关的临床特征。

Tan等 [15] 校正协变量后,B组和D组FEV1平均下降率超过A组。与FEV1下降速率显著相关的病情评估指标为CAT评分≥10分。

CabreraLópez等 [14] 研究发现GOLD2011D组的BODE指数最高,其次是B组、C组、A组,而新评估方法D组和B组BODE指数相似,均高于C组,C组高于A组。BODE指数B、D组相似,A、C组相似,降低了分组的价值。

3、新病情评估分组对治疗的影响

Tudoric等 [12] 研究显示,从D组移到B组的686例患者中,490例(71.5%)患者使用ICS。根据指南,这些患者因为急性加重风险低,应该停用ICS。但指南也建议在某些情况下要结合FEV1指导治疗,个体化撤除ICS。指南推荐症状多的B组和D组联合2种支气管舒张药作为一线治疗。而原来GOLD 2011 D组中只有136例(11.0%)联合2种支气管扩张药。从D组移到B组中,126例(18.4%)患者FEV1%≤30%,如果这些患者仅处方1种支气管舒张药,未来的风险如何?

指南指出,当症状程度与肺功能不一致时,要结合肺功能严重程度来选择治疗方案。对于从D组移到B组肺功能差的患者,应该联合2种支气管舒张药治疗。既往被分到D组中有130例患者符合ACOS诊断标准。其中,33例(25.4%)移到B组,停用ICS将影响预后。新病情分布发生垂直变化影响治疗方案的选择。其他治疗方案(罗弗司特、ICS、阿奇霉素),除了依据CAT评分和mMRC评分外,还要依据表型(慢性支气管炎、ACOS、反复慢性感染)。大多数慢阻肺患者以双支气管舒张药作为核心治疗方案,ICS的应用将减少。新病情分布变化将从总体上降低治疗的强度。临床医师应该随访被转移至低风险组患者的治疗。未来的研究需要验证降级治疗是否合适 [13]。

4、新病情评估分组对预后的指导意义

Ca-breraLópez等 [14] 的研究表明GOLD 2011患者的5年全因死亡率D组最高,其次是B组、C组、A组。A组死亡率显著低于B组、C组、D组,D组死亡率显著高于C组,B组和C组死亡率相似。新评估方法B、D组死亡率相似,A、C组死亡率相似且显著小于B、D组。FEV1%在每组中均影响死亡率。相较于GOLD 2011,新分级系统降低了预测5年以上死亡风险的能力。

三、如何优化慢阻肺疾病评估体系的思考

更新评估方法后,C、D组有超过1/3的患者划分到A、B组,应用不同症状评分工具,分组结果不一致 [16]。临床急性加重史的漏报,会导致医师对未来风险的低估 [17]。B组患者中死亡风险高的群体并未筛选出来,治疗是否充分还需要进一步研究。未来的慢阻肺病情评估体系应该是多维度的,除了症状和急性加重风险评价,还应该包括以下几个方面。

1、症状表型分型

慢性支气管炎表型的慢阻肺患者急性加重发作频率显著增加 [18-19]。

2、胸部CT评估

胸部CT肺动脉(pul-monaryartery,PA)直径与主动脉(aortel)直径比值(PA/A)>1,与未来急性加重的风险相关 [20]。随着肺功能分级的严重程度增加,CT显示肺气肿面积增加,正常肺组织面积减少;而随着疾病严重程度增加,两者均减少 [21]。

3、BODE指数

BODE指数具有良好的预后价值 [22]。其中,6MWD有助于识别慢阻肺高风险患者 [23]。6MWD和速度是独立于ABCD分组的慢阻肺预后预测因素 [24]。

4、合并症评估

慢阻肺合并症增加患者死亡率的风险比率 [25]。慢阻肺共病测试(COPDspecifitcomorbiditytest,COTE)≥4分导致死亡风险增加2.2倍 [26]。

5、西班牙指南中慢阻肺的综合评估

西班牙指南提出4种表型及采用BODE指数作为多维指标。慢阻肺的治疗类别用表型来指导,治疗强度用严重程度来指导,ABCD四种表型的治疗药物类别存在明显差别。相对来讲,西班牙指南对于慢阻肺稳定期的治疗建议更加个体化 [22]。

GOLD经过近20年的修订,从单一的肺功能评估,到更注重慢阻肺的综合评估(肺功能、症状、急性加重风险、合并症),再到将肺功能从ABCD分组中分离。新版ABCD评估工具突出了症状和急性加重风险在指导治疗中的重要性。肺功能的意义主要在于疾病诊断,对于评估气流受限的程度、判断未来急性加重风险和预后仍有重要意义。但新评估方法修改引起的治疗策略改变对于患者预后的影响有待进一步研究。

参考文献:

[1] Global initiative for chronic obstructive lung disease. Global strategy for the diagnosis,management,and prevention of chronic obstructive pulmonary disease 2018 report[EB/OL](2017-12) [2017-12-05].http://www.goldcopd.org.

[2] Soriano JB,Lamprecht B,Ramirez AS,et al.Mortality prediction in chronic obstructive pulmonary disease comparing the GOLD 2007 and 2011 staging systems:a pooled analysis of individual patient data. Lancet Respir Med,2015,3(6):443-450.

[3] Goossens LM,Leimer I,Metzdorf N,et al.Does the 2013 GOLD classification improve the ability to predict lung function decline,exacerbations and mortality:a post-hoc analysis of the 4-year UPLIFT trial. BMC Pulm Med,2014,14:163.

[4] Kim J,Yoon HI,Oh YM,et al.Lung function decline rates according to GOLD group in patients with chronic obstructive pulmonary disease.Int J Chron Obstruct Pulmon Dis,2015,10:1819-1827.

[5] Agusti A,Rennard S,Edwards LD,et al.Clinical and prognostic heterogeneity of C and D GOLD groups. Eur Respir J,2015,46(1):250-254.

[6] Han MK,Muellerova H,Curran-Everett D,et al.GOLD 2011 disease severity classification in COPDGene:a prospective cohort study.Lancet Respir Med,2013,1(1):43-50.

[7] Agusti A,Calverley PM,Celli B,et al.Characterisation of COPD heterogeneity in the ECLIPSE cohort. Respir Res,2010,11:122.

[8] Decramer M,Celli B,Kesten S,et al.Effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (UPLIFT):a prespecified subgroup analysis of a randomised controlled trial.Lancet,2009,374(9696):1171-1178.

[9] Jenkins CR,Jones PW,Calverley PM,et al.Efficacy of salmeterol/fluticasone propionate by GOLD stage of chronic obstructive pulmonary disease:analysis from the randomised,placebo-controlled TORCH study.Respir Res,2009,10:59.

[10] Hurst JR,Vestbo J,Anzueto A,et al.Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med,2010,363(12):1128-1138.

[11] Haughney J,Gruffydd-Jones K,Roberts J,et al.The distribution of COPD in UK general practice using the new GOLD classification. Eur Respir J,2014,43 (4):993-1002.

[12] Tudoric N,Koblizek V,Miravitlles M,et al.GOLD 2017 on the way to a phenotypic approach? Analysis from the Phenotypes of COPD in Central and Eastern Europe (POPE) Cohort.Eur Respir J,2017,49(4):1602518.

[13] Sun L,Chen Y,Wu R,et al.Changes in definition lead to changes in the clinical characteristics across COPD categories according to GOLD 2017:a national cross-sectional survey in China.Int J Chron Obstruct Pulmon Dis,2017,12:3095-3102.

[14] Cabrera Lopez C,Casanova Macario C,Marin Trigo JM,et al.Comparison of the 2017 and 2015 Global Initiative for Chronic Obstructive Lung Disease Reports. Impact on Grouping and Outcomes.Am J Respir Crit Care Med,2018,197(4):463-469.

[15] Tan WC,Bourbeau J,Aaron SD,et al.Global Initiative for Chronic Obstructive Lung Disease 2017 Classification and Lung Function Decline in Chronic Obstructive Pulmonary Disease.Am J Respir Crit Care Med,2018,197(5):670-673.

[16] Zogg S,Durr S,Miedinger D,et al.Differences in classification of COPD patients into risk groups AD: a cross-sectional study.BMC Res Notes,2014,7:562.

[17] Mohan A,Sethi S.The reliability and validity of patient-reported chronic obstructive pulmonary disease exacerbations.Curr Opin Pulm Med,2014,20(2):146-152.

[18] Kim V,Han MK,Vance GB,et al.The chronic bronchitic phenotype of COPD:an analysis of the COPDGene Study.Chest,2011,140(3):626-633.

[19] Burgel PR,Nesme-Meyer P,Chanez P,et al.Cough and sputum production are associated with frequent exacerbations and hospitalizations in COPD subjects. Chest,2009,135(4):975-982.

[20] Wells JM,Washko GR,Han MK,et al.Pulmonary arterial enlargement and acute exacerbations of COPD.N Engl J Med,2012,367(10):913-921.

[21] Bhatt SP,Soler X,Wang X,et al.Association between Functional Small Airway Disease and FEV1 Decline in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med,2016,194(2):178-184.

[22] Miravitlles M,Soler-Cataluna JJ,Calle M,et al.A new approach to grading and treating COPD based on clinical phenotypes:summary of the Spanish COPD guidelines (GesEPOC).Prim Care Respir J,2013,22 (1):117-121.

[23] Spruit MA,Polkey MI,Celli B,et al.Predicting outcomes from 6-minute walk distance in chronic obstructive pulmonary disease.J Am Med Dir Assoc, 2012,13(3):291-297.

[24] Durheim MT,Smith PJ,Babyak MA,et al.Six-minute-walk distance and accelerometry predict outcomes in chronic obstructive pulmonary disease independent of Global Initiative for Chronic Obstructive Lung Disease 2011 Group.Ann Am Thorac Soc,2015,12(3):349-356.

[25] Smith MC,Wrobel JP.Epidemiology and clinical impact of major comorbidities in patients with COPD. Int J Chron Obstruct Pulmon Dis,2014,9:871-888.

[26] Divo M,Cote C,de Torres JP,et al.Comorbidities and risk of mortality in patients with chronic obstructive pulmonary disease.Am J Respir Crit Care Med,2012,186(2):155-161

版权声明:
本网站所有内容来源注明为“梅斯医学”或“MedSci原创”的文字、图片和音视频资料,版权均属于梅斯医学所有。非经授权,任何媒体、网站或个人不得转载,授权转载时须注明来源为“梅斯医学”。其它来源的文章系转载文章,或“梅斯号”自媒体发布的文章,仅系出于传递更多信息之目的,本站仅负责审核内容合规,其内容不代表本站立场,本站不负责内容的准确性和版权。如果存在侵权、或不希望被转载的媒体或个人可与我们联系,我们将立即进行删除处理。
在此留言
评论区 (6)
#插入话题
  1. [GetPortalCommentsPageByObjectIdResponse(id=2059115, encodeId=8407205911569, content=<a href='/topic/show?id=45c5914864a' target=_blank style='color:#2F92EE;'>#评估方法#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91486, encryptionId=45c5914864a, topicName=评估方法)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=39a0295, createdName=kksonne, createdTime=Thu Jun 27 21:04:00 CST 2019, time=2019-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1765060, encodeId=9e7d1e650602a, content=<a href='/topic/show?id=df00e086653' target=_blank style='color:#2F92EE;'>#病情#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70866, encryptionId=df00e086653, topicName=病情)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=778d36, createdName=柳叶一刀, createdTime=Fri Apr 12 00:04:00 CST 2019, time=2019-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1692007, encodeId=8359169200edb, content=<a href='/topic/show?id=a450530853c' target=_blank style='color:#2F92EE;'>#患者预后#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53085, encryptionId=a450530853c, topicName=患者预后)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8f4729287700, createdName=bnurmamat, createdTime=Sat Jul 27 07:04:00 CST 2019, time=2019-07-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1384283, encodeId=4ca8138428327, content=<a href='/topic/show?id=55ea816e5c' target=_blank style='color:#2F92EE;'>#GOLD#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8167, encryptionId=55ea816e5c, topicName=GOLD)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Tue Sep 18 09:04:00 CST 2018, time=2018-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345257, encodeId=bff434525e87, content=了解一下,谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=131, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sun Sep 16 19:53:52 CST 2018, time=2018-09-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345255, encodeId=e62b3452557b, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=150, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Sun Sep 16 18:40:13 CST 2018, time=2018-09-16, status=1, ipAttribution=)]
  2. [GetPortalCommentsPageByObjectIdResponse(id=2059115, encodeId=8407205911569, content=<a href='/topic/show?id=45c5914864a' target=_blank style='color:#2F92EE;'>#评估方法#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91486, encryptionId=45c5914864a, topicName=评估方法)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=39a0295, createdName=kksonne, createdTime=Thu Jun 27 21:04:00 CST 2019, time=2019-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1765060, encodeId=9e7d1e650602a, content=<a href='/topic/show?id=df00e086653' target=_blank style='color:#2F92EE;'>#病情#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70866, encryptionId=df00e086653, topicName=病情)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=778d36, createdName=柳叶一刀, createdTime=Fri Apr 12 00:04:00 CST 2019, time=2019-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1692007, encodeId=8359169200edb, content=<a href='/topic/show?id=a450530853c' target=_blank style='color:#2F92EE;'>#患者预后#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53085, encryptionId=a450530853c, topicName=患者预后)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8f4729287700, createdName=bnurmamat, createdTime=Sat Jul 27 07:04:00 CST 2019, time=2019-07-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1384283, encodeId=4ca8138428327, content=<a href='/topic/show?id=55ea816e5c' target=_blank style='color:#2F92EE;'>#GOLD#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8167, encryptionId=55ea816e5c, topicName=GOLD)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Tue Sep 18 09:04:00 CST 2018, time=2018-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345257, encodeId=bff434525e87, content=了解一下,谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=131, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sun Sep 16 19:53:52 CST 2018, time=2018-09-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345255, encodeId=e62b3452557b, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=150, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Sun Sep 16 18:40:13 CST 2018, time=2018-09-16, status=1, ipAttribution=)]
  3. [GetPortalCommentsPageByObjectIdResponse(id=2059115, encodeId=8407205911569, content=<a href='/topic/show?id=45c5914864a' target=_blank style='color:#2F92EE;'>#评估方法#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91486, encryptionId=45c5914864a, topicName=评估方法)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=39a0295, createdName=kksonne, createdTime=Thu Jun 27 21:04:00 CST 2019, time=2019-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1765060, encodeId=9e7d1e650602a, content=<a href='/topic/show?id=df00e086653' target=_blank style='color:#2F92EE;'>#病情#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70866, encryptionId=df00e086653, topicName=病情)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=778d36, createdName=柳叶一刀, createdTime=Fri Apr 12 00:04:00 CST 2019, time=2019-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1692007, encodeId=8359169200edb, content=<a href='/topic/show?id=a450530853c' target=_blank style='color:#2F92EE;'>#患者预后#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53085, encryptionId=a450530853c, topicName=患者预后)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8f4729287700, createdName=bnurmamat, createdTime=Sat Jul 27 07:04:00 CST 2019, time=2019-07-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1384283, encodeId=4ca8138428327, content=<a href='/topic/show?id=55ea816e5c' target=_blank style='color:#2F92EE;'>#GOLD#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8167, encryptionId=55ea816e5c, topicName=GOLD)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Tue Sep 18 09:04:00 CST 2018, time=2018-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345257, encodeId=bff434525e87, content=了解一下,谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=131, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sun Sep 16 19:53:52 CST 2018, time=2018-09-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345255, encodeId=e62b3452557b, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=150, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Sun Sep 16 18:40:13 CST 2018, time=2018-09-16, status=1, ipAttribution=)]
  4. [GetPortalCommentsPageByObjectIdResponse(id=2059115, encodeId=8407205911569, content=<a href='/topic/show?id=45c5914864a' target=_blank style='color:#2F92EE;'>#评估方法#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91486, encryptionId=45c5914864a, topicName=评估方法)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=39a0295, createdName=kksonne, createdTime=Thu Jun 27 21:04:00 CST 2019, time=2019-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1765060, encodeId=9e7d1e650602a, content=<a href='/topic/show?id=df00e086653' target=_blank style='color:#2F92EE;'>#病情#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70866, encryptionId=df00e086653, topicName=病情)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=778d36, createdName=柳叶一刀, createdTime=Fri Apr 12 00:04:00 CST 2019, time=2019-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1692007, encodeId=8359169200edb, content=<a href='/topic/show?id=a450530853c' target=_blank style='color:#2F92EE;'>#患者预后#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53085, encryptionId=a450530853c, topicName=患者预后)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8f4729287700, createdName=bnurmamat, createdTime=Sat Jul 27 07:04:00 CST 2019, time=2019-07-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1384283, encodeId=4ca8138428327, content=<a href='/topic/show?id=55ea816e5c' target=_blank style='color:#2F92EE;'>#GOLD#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8167, encryptionId=55ea816e5c, topicName=GOLD)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Tue Sep 18 09:04:00 CST 2018, time=2018-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345257, encodeId=bff434525e87, content=了解一下,谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=131, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sun Sep 16 19:53:52 CST 2018, time=2018-09-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345255, encodeId=e62b3452557b, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=150, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Sun Sep 16 18:40:13 CST 2018, time=2018-09-16, status=1, ipAttribution=)]
    2018-09-18 小刀医生
  5. [GetPortalCommentsPageByObjectIdResponse(id=2059115, encodeId=8407205911569, content=<a href='/topic/show?id=45c5914864a' target=_blank style='color:#2F92EE;'>#评估方法#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91486, encryptionId=45c5914864a, topicName=评估方法)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=39a0295, createdName=kksonne, createdTime=Thu Jun 27 21:04:00 CST 2019, time=2019-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1765060, encodeId=9e7d1e650602a, content=<a href='/topic/show?id=df00e086653' target=_blank style='color:#2F92EE;'>#病情#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70866, encryptionId=df00e086653, topicName=病情)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=778d36, createdName=柳叶一刀, createdTime=Fri Apr 12 00:04:00 CST 2019, time=2019-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1692007, encodeId=8359169200edb, content=<a href='/topic/show?id=a450530853c' target=_blank style='color:#2F92EE;'>#患者预后#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53085, encryptionId=a450530853c, topicName=患者预后)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8f4729287700, createdName=bnurmamat, createdTime=Sat Jul 27 07:04:00 CST 2019, time=2019-07-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1384283, encodeId=4ca8138428327, content=<a href='/topic/show?id=55ea816e5c' target=_blank style='color:#2F92EE;'>#GOLD#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8167, encryptionId=55ea816e5c, topicName=GOLD)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Tue Sep 18 09:04:00 CST 2018, time=2018-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345257, encodeId=bff434525e87, content=了解一下,谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=131, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sun Sep 16 19:53:52 CST 2018, time=2018-09-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345255, encodeId=e62b3452557b, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=150, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Sun Sep 16 18:40:13 CST 2018, time=2018-09-16, status=1, ipAttribution=)]
    2018-09-16 天地飞扬

    了解一下,谢谢分享!

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=2059115, encodeId=8407205911569, content=<a href='/topic/show?id=45c5914864a' target=_blank style='color:#2F92EE;'>#评估方法#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91486, encryptionId=45c5914864a, topicName=评估方法)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=39a0295, createdName=kksonne, createdTime=Thu Jun 27 21:04:00 CST 2019, time=2019-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1765060, encodeId=9e7d1e650602a, content=<a href='/topic/show?id=df00e086653' target=_blank style='color:#2F92EE;'>#病情#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70866, encryptionId=df00e086653, topicName=病情)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=778d36, createdName=柳叶一刀, createdTime=Fri Apr 12 00:04:00 CST 2019, time=2019-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1692007, encodeId=8359169200edb, content=<a href='/topic/show?id=a450530853c' target=_blank style='color:#2F92EE;'>#患者预后#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=61, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53085, encryptionId=a450530853c, topicName=患者预后)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8f4729287700, createdName=bnurmamat, createdTime=Sat Jul 27 07:04:00 CST 2019, time=2019-07-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1384283, encodeId=4ca8138428327, content=<a href='/topic/show?id=55ea816e5c' target=_blank style='color:#2F92EE;'>#GOLD#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8167, encryptionId=55ea816e5c, topicName=GOLD)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8306486, createdName=小刀医生, createdTime=Tue Sep 18 09:04:00 CST 2018, time=2018-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345257, encodeId=bff434525e87, content=了解一下,谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=131, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sun Sep 16 19:53:52 CST 2018, time=2018-09-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=345255, encodeId=e62b3452557b, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=150, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160304/IMG56D94856B1B5D6405.jpg, createdBy=27931687771, createdName=一个字-牛, createdTime=Sun Sep 16 18:40:13 CST 2018, time=2018-09-16, status=1, ipAttribution=)]
    2018-09-16 一个字-牛

    学习了谢谢分享

    0

相关资讯

哮喘慢阻肺重叠的急性加重更频繁,哪些诊疗策略需被临床参考借鉴?

哮喘慢阻肺重叠(英文简称ACO)用于临床应用描述一类以持续性气流受限为特征,同时兼具哮喘和慢阻肺相关特点的表现型。目前研究显示,ACO发病率较高,且较哮喘和慢阻肺而言ACO患者的医疗经济负担更重、临床症状更多、急性加重更为频繁……对此,GINA和GOLD里有何提示?欧美、日本等地有哪些国际观点?治疗策略又将如何展望?

Lancet Respir Med:慢阻肺可能成为中国下一个重要的公共健康问题!

2018年6月,发表在《Lancet Respir Med》的一项由中国学者进行的全国流行性研究,考察了中国的慢性阻塞性肺病(COPD)流行情况。

外周血嗜酸粒细胞可以作为慢阻肺的生物标记物吗?

近年来,国际指南对慢阻肺的定义、发病机制、评估、个体化治疗、急性加重及合并症等方面均进行了全面修改,其中一些观点尚需在临床上进一步验证,因而引发国内外慢阻肺领域专家学者的广泛讨论。让我们一起聆听国内专家的剖析,共同探讨慢阻肺的国际热议话题。

慢阻肺患者个体化治疗的目标是否能够实现?

近年来,国际指南对慢阻肺的定义、发病机制、评估、个体化治疗、急性加重及合并症等方面均进行了全面修改,其中一些观点尚需在临床上进一步验证,因而引发国内外慢阻肺领域专家学者的广泛讨论。让我们一起聆听国内专家的剖析,共同探讨慢阻肺的国际热议话题。

外周血嗜酸性粒细胞是否可以作为慢阻肺生物标志物?且看2018 ETS国际专家的辩论

慢阻肺是一种异质性疾病。目前,越来越多的学者开始对慢阻肺的生物标志物及个体化治疗进行探索。多项大型临床研究的事后分析将血嗜酸性粒细胞(Eosinophils,Eos)推向了研究前沿。但血Eos是否可以作为慢阻肺的生物标志物仍有待探讨,在2018年美国胸科年会(ATS 2018)上,国际专家的争论和观点将对临床、科研有哪些启发?

70岁老汉呼吸困难 N次诊断慢阻肺竟不是!

医院多次以“慢性阻塞性肺疾病”和“支气管哮喘”来治疗均不见明显效果。在长达4年的误诊、误治后,发现最终问题竟然是一种自身免疫疾病。到底是何病?详见以下病例。

Baidu
map
Baidu
map
Baidu
map