China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China.Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013.All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4.0 years in Hebei province to 14.2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0-14, 15-49, and 50-74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990.Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems.China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.Copyright © 2016 Elsevier Ltd. All rights reserved.

Early stage COPD carries a significant healthcare burden that is currently underrecognised, underdiagnosed and undertreated. Furthermore, patients at this stage can rapidly decline to advanced disease, especially if they continue to smoke. The natural history of the disease in early stages remains largely unknown, and emerging evidence indicates that we are able to reduce lung function decline and exacerbations, and improve quality of life, in early stage COPD, mainly through smoking cessation. But new evidence from randomised clinical trials also suggests an impact of pharmacotherapy on clinical outcomes in early disease. Guidelines need to be updated to reflect this greater understanding of early stage disease, and trials need to be conducted to definitively show the benefits of intensive treatment so that we can meet the large, unmet clinical needs of this important patient group.Copyright © 2010 Elsevier Ltd. All rights reserved.

我国慢性阻塞性肺疾病（以下简称慢阻肺）人群庞大，已成为第三大常见慢性病，给患者家庭和社会带来了沉重的经济负担，然而我国社区基层医疗机构对慢阻肺的管理却存在明显短板，如早期筛查率、诊断率低下，健康宣教不到位，慢阻肺相关诊疗设备和药物匮乏，药物使用不规范，社区医生诊疗水平欠佳。本文通过对我国慢阻肺的社区管理现状进行综述，阐明目前我国慢阻肺社区管理存在的诸多问题，并对社区全科医生团队管理模式、医院-社区-家庭-个人分级诊疗模式、基于互联网的慢阻肺患者管理模式为基层医疗机构提供的更优质的慢阻肺管理办法进行展望，以期提高慢阻肺患者的预后和生活质量。

背景　目前慢性阻塞性肺疾病（简称：慢阻肺）作为可防可控的慢性疾病，已成为我国最为突出的公共卫生与医疗问题之一，而基层社区对慢阻肺的防治尤为重要。了解社区全科医生对慢阻肺的认知能力及现况，可以更好地为开展基层社区呼吸疾病防治工作提供科学依据。目的　调查北京市社区卫生服务机构全科医生对慢阻肺的认知现状，并进行影响因素分析，为开展基层社区呼吸疾病防治工作提供科学依据。方法　于2020-09-28至10-04对北京市34家社区卫生服务中心和159家社区卫生服务站在一线工作的在职全科医生进行调查。自行设计调查问卷，共同论证后应用问卷星技术平台形成最终稿在微信工作群发布，问卷内容包括全科医生基本信息、全科医生更新学习专业知识方式、全科医生所在社区开展患者宣教方式、慢阻肺防治能力知识测试（60分及以上为及格，60分以下为不及格）。分析不同人口学特征、专业知识获得方式、所在社区开展患者宣教方式、全科医生慢阻肺防治能力知识测试及格情况，通过二元逻辑Logistic回归分析探讨社区全科医生慢阻肺防治能力知识测试及格与否的影响因素。结果　共发放1 226份问卷，回收有效问卷1 226份，问卷有效回收率100.0%。全科医生慢阻肺防治能力知识测试总平均分为（45.5±18.5）分，不及格的医生987名，及格医生239名（及格率19.5%）。其中女性医生及格率高于男性不同学历医生及格率（P<0.05）；其中研究生及以上学历医生及格率高于本科生、大专、中专及以下学历医生，本科生学历医生及格率高于大专、中专及以下学历医生（P<0.05）。不同职称等级医生及格率比较，差异有统计学意义（P<0.05）；其中高级、中级职称医生及格率高于初级职称医生（P<0.05）。通过在社区卫生服务中心/社区卫生服务站现场听院外专家授课和现场听医学会组织的专家授课的全科医生慢阻肺防治能力知识测试及格率高于不通过现场听院外专家授课和现场听医学会组织的专家授课的全科医生（P<0.05）。开展患者宣教的全科医生慢阻肺防治能力知识测试及格率高于未开展患者宣教的全科医生（P<0.05）；通过发放健康教育手册、健康教育讲座及健康咨询对患者宣教的全科医生慢阻肺防治能力知识测试及格率高于未通过发放健康教育手册、健康教育讲座、建立健康咨询对患者宣教的全科医生（P<0.05）。二元逻辑Logistic回归分析结果显示，性别、学历、职称是全科医生慢阻肺防治能力知识测试及格的影响因素（P<0.05）。结论　北京市社区卫生服务机构全科医生对慢阻肺认知不足，需进一步加强这方面培训及考核；应重点加强社区男性、低学历及低职称的全科医生在慢阻肺知识方面的培训；获取慢阻肺专业知识的方式中，在社区卫生服务中心/社区卫生服务站现场听院外专家授课及现场听医学会组织的专家授课更为有效；通过发放慢阻肺健康教育手册、进行健康教育讲座及健康咨询来进行患者教育，可以提高全科医生的慢阻肺认知水平。

目前，慢性阻塞性肺疾病（COPD）是世界第三大死因，仅次于缺血性心脏病和卒中。但面对COPD这个可防、可治的重大公共卫生问题，我国临床诊疗仍有诸多不足，如对患者教育不够、随访缺失、稳定期和/或急性加重期管理不规范等，以上均是患者病情频繁加重和恶化的重要原因。而病情频繁加重和恶化将导致后期治疗效果不佳和治疗难度增大，以及社会经济负担增加等。所以，加快促进COPD诊断、治疗和预防的规范化，提高诊疗精度和效度具有重要的现实意义。本文拟结合我国临床诊疗现状和疾病研究进展，从临床应用角度对2020年慢性阻塞性肺疾病全球倡议（GOLD）《COPD诊断、治疗与预防全球策略》指南（简称：指南）进行全面阐释和分析，内容包括稳定期药物管理、稳定期非药物管理和急性加重期管理。其中指南解读（一）主要涉及稳定期药物管理，内容包括诊断评估、初始治疗和后续治疗。通过对该指南的解读，以期为我国急诊科、呼吸科等临床医师的实践工作提供参考，优化临床疗效。

Pulmonary rehabilitation (PR) improves exercise capacity and quality of life in people with COPD; however, its effect on anxiety and depression symptoms is less clear. Existing data are difficult to apply to clinical PR because of diverse interventions and comparators. This review evaluated the effectiveness of PR on anxiety and depression symptoms in people with COPD.A systematic review and meta-analysis (PROSPERO CRD42018094172) was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on randomized controlled trials comparing PR (≥ 4 weeks' duration) with usual care. Four electronic databases were searched to February 2018 using terms related to COPD, PR, anxiety, and depression. Data were extracted by two assessors using standardized templates. Study quality was appraised via the PEDro scale, and evidence was rated according to the Grading of Recommendations Assessment, Development and Evaluation. Data were analyzed in RevMan 5.3, with pooled effect estimates reported as standardized mean differences (SMDs). The effect of the program duration (≤ 8 vs > 8 weeks) was explored via subgroup analysis.Eleven studies comprising 734 participants (median PEDro score, 4/10) were included. Compared with usual care, PR conferred significant benefits of a moderate magnitude for anxiety symptoms (SMD, -0.53; 95% CI, -0.82 to -0.23) and large magnitude for depression symptoms (SMD, -0.70; 95% CI, -0.87 to -0.53). The certainty of evidence for each outcome was moderate. Effects were not moderated by program duration.PR confers significant, clinically relevant benefits on anxiety and depression symptoms. Because further studies involving no treatment control groups are not indicated, these robust estimates of treatment effects are likely to endure.Copyright © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

目的　建立慢性阻塞性肺疾病（COPD）分级诊疗移动互联网信息平台（D2P-COPD平台），探讨其在COPD分级诊疗中的应用效果。方法　选取2017-11-01至2018-01-31松江区15家社区卫生服务中心经过初筛和肺功能检查确诊的COPD患者为观察组，依据D2P-COPD平台予以综合评估，制定规范的治疗方案。选取2014年4—7月在松江区5家社区卫生服务中心经社区全科医生通过肺功能检查诊断的173例COPD患者为对照组，均随访1年。分析两组患者诊断和治疗情况，比较两组患者的治疗率和规范治疗率。结果　通过D2P-COPD平台，经过初筛及肺功能检查，218例确诊为COPD，肺功能分级：GOLD 1级18例，GOLD 2级104例，GOLD 3级59例，GOLD 4级51例。观察组患者治疗率为47.7%（104/218），与对照组的40.3%（64/173）比较，差异无统计学意义（χ2=2.068，P=0.150）。观察组患者规范治疗率高于对照组（χ2=65.447，P<0.001）。结论　D2P-COPD平台适用于COPD分级诊疗，社区全科医生可以通过筛查量表进行COPD筛查，提高COPD早期诊断率；D2P-COPD平台也可以提高社区全科医生COPD药物的规范治疗化率。