# 第 16 节追加第 11、12 条：乙肝携带者的随访与用药、慢阻肺的吸入剂与肺康复

2026-10-14。

## 查重

全书 grep「乙肝」「慢阻肺」「慢性阻塞」「吸入剂」「肺康复」。乙肝相关的已有条目是第 1 节第 14 条（查两对半、打疫苗）、第 20 节第 2 条（新生儿首针）、第 27 节第 3 条（孕期三病筛查与母婴阻断），都管「还没感染」或「母婴传播」，没有一条管「已经是携带者之后怎么随访、吃不吃药」。第 1 节第 14 条备注只有一句「已经感染的人打疫苗没用，要去肝病科定期复查」。慢阻肺全书没有条目，第 16 节第 5 条只在引文里提到「慢性阻塞性肺疾病等常见病慢性病门诊」。两条都不算重复。

## 第 11 条：乙肝表面抗原阳性的随访与抗病毒

| 来源 | 取法 | 核到的原文 |
| --- | --- | --- |
| Zhang BH 2004, J Cancer Res Clin Oncol 130(7):417-422 | Europe PMC 摘要（PMID 15042359） | 「This study included 18,816 people, aged 35-59 years with hepatitis B virus infection or a history of chronic hepatitis in urban Shanghai」；「Screening group participants were invited to have an AFP test and ultrasonography examination every 6 months」；「resection achieved 40 (46.5%) versus 5 (7.5%)」；「Thirty-two people died from HCC in the screened group versus 54 in the control group … 83.2/100,000 and 131.5/100,000, respectively, with a mortality rate ratio of 0.63 (95%CI 0.41-0.98)」；「biannual screening reduced HCC mortality by 37%」 |
| Chen CJ 2006, JAMA 295(1):65-73 | Europe PMC 摘要（PMID 16391218） | 「Prospective cohort study of 3653 participants (aged 30-65 years), who were seropositive for the hepatitis B surface antigen」；「mean follow-up of 11.4 years」；「ranging from 108 per 100,000 person-years for an HBV DNA level of less than 300 copies/mL to 1152 per 100,000 person-years for an HBV DNA level of 1 million copies/mL or greater. The corresponding cumulative incidence rates … were 1.3% and 14.9%」；「remained significant (P<.001) after adjustment for sex, age, cigarette smoking, alcohol consumption, serostatus for the hepatitis B e antigen (HBeAg), serum alanine aminotransferase level, and liver cirrhosis」 |
| Liaw YF 2004, NEJM 351(15):1521-1531 | Europe PMC 摘要（PMID 15470215） | 「Of 651 patients … histologically confirmed cirrhosis or advanced fibrosis」；「98 percent Asian」；「median duration of treatment of 32.4 months」；「End points were reached by 7.8 percent of the patients receiving lamivudine and 17.7 percent of those receiving placebo (hazard ratio for disease progression, 0.45; P=0.001)」；「hepatocellular carcinoma occurred in 3.9 percent of those in the lamivudine group and 7.4 percent of those in the placebo group (hazard ratio, 0.49; P=0.047)」；「Genotypic resistance YMDD mutations developed in 49 percent」 |
| 慢性乙型肝炎防治指南（2022 年版），中华肝脏病杂志 30(12):1309-1331 | 中文版 PMC12677433 在 Europe PMC 取不到全文，改读同一指南的英文版 You H 2023, J Clin Transl Hepatol 11(6):1425-1442，PMC10500285 全文 XML | 「patients with chronic HBV infection should be screened for HCC every 6 months through abdominal ultrasonography and AFP detection. Moreover, high-risk patients should be screened for HCC at least once every 3–6 months」；携带者：「Routine blood examinations, biochemical tests, monitoring of virological markers, AFP, abdominal ultrasound, and non-invasive fibrosis tests should be performed every 6 to 12 months … Antiviral therapy should be initiated immediately if patients meet the indications for treatment」；Recommendation 11：「Antiviral therapy is recommended for patients with detectable HBV DNA, regardless of ALT levels, if one of the following criteria are fulfilled: Family history of HBV-related cirrhosis or HCC (B1); Age >30 years (B1); …」；Recommendation 13、15：「NAs (ETV, TDF, TAF, or TMF) are recommended (A1)」；「Most patients require long-term NAs treatment, and the rate of virological relapse is high after discontinuation of the drug」 |
| Wun & Dickinson 2003, Cochrane CD002799（反方） | Europe PMC 摘要（PMID 12804438） | 「The two groups did not differ significantly regarding HCC mortality (OR 0.81; 95% CI 0.54 to 1.22)」；「There are not enough quality trials to support or refute screening」 |
| Aghoram 2012, Cochrane CD002799.pub2（反方） | Europe PMC 摘要（PMID 22972059） | 「All of them had a high risk of bias」；「There are several published reports on this trial, in which data were presented differently」；「We could not draw any definite conclusions from it」 |
| 国家医保局 2025-12-29「中国医保惠民生 积跬步、至长远（七）」 | curl 直取 nhsa.gov.cn | 「乙肝治疗一线用药恩替卡韦，过去患者吃一年的费用大约5000元……集采后恩替卡韦年费用降到100多元，当年处方量跃升30%」。这段是该文转引央视新闻的报道，页面在国家医保局官网「医保动态」栏目。替诺福韦的价格没找到官方数字，没写 |

没写的：B 超和甲胎蛋白每次多少钱，没找到全国统一的官方价格，成本栏只写「各地不同」。Lok 2016（Hepatology 荟萃）摘要只给定性结论、没有效应量，改用 Liaw 2004 的随机试验给数字。Papatheodoridis 那篇没去取。

证据等级 A 争议：主证据是一项随机试验（肝癌死亡低 37%）加一项随机试验（抗病毒药肝癌 HR 0.49），但 Cochrane 两版都认为上海试验偏倚高、下不了结论，所以备注以「争议」开头。收益量级按收益栏机械套：肝癌死亡低 37%、肝癌低约一半，都 ≥20%，定「大」。口径死亡率。毅力定「是」，因为抗病毒药多数要长期吃。

## 第 12 条：慢阻肺的吸入剂与肺康复

| 来源 | 取法 | 核到的原文 |
| --- | --- | --- |
| Wang C 2018, Lancet 391(10131):1706-1717 | Europe PMC 摘要（PMID 29650248） | 「50 991 … had reliable post-bronchodilator results」；「The overall prevalence of spirometry-defined COPD was 8·6% (95% CI 7·5-9·9), accounting for 99·9 (95% CI 76·3-135·7) million people」；「people aged 40 years or older (13·7%, 12·1-15·5)」；「Only 12·0% (95% CI 8·1-17·4) of people with COPD reported a previous pulmonary function test」。摘要里没有「知晓率」，正文付费没取到，所以条目不写知晓率，只写做过肺功能检查的 12.0% |
| Sanchis J 2016, Chest 150(2):394-406 | Europe PMC 摘要（PMID 27060726） | 「144 articles reporting on a total number of 54,354 subjects」；「The most frequent MDI errors were in coordination (45% …), speed and/or depth of inspiration (44% …), and no postinhalation breath-hold (46% …)」；「The overall prevalence of correct technique was 31% (28%-35%); of acceptable, 41% (36%-47%); and of poor, 31% (27%-36%). There were no significant differences between the first and second 20-year periods」 |
| Molimard M 2017, Eur Respir J 49(2):1601794 | Europe PMC 摘要（PMID 28182569） | 「212 general practitioners and 50 pulmonologists assessed the handling of 3393 devices … in 2935 patients. Handling errors were observed in over 50% of handlings」；关键错误「15.4%, 21.2%, 29.3%, 43.8%, 46.9% and 32.1%」；「3.3% (95% CI 2.0-4.5) in the absence of error and 6.9% (95% CI 5.3-8.5) in the presence of critical error (OR 1.86, 95% CI 1.14-3.04, p<0.05)」 |
| Agustí A 2023, GOLD 2023 Executive Summary, Eur Respir J 61(4):2300239 | PMC10066569 全文 XML | 「Achieving this goal requires educating and training the providers and the patients in the correct use of the device. Regular assessment at follow-up is necessary to maintain their effective use」；「patients should be offered vaccination against influenza, pneumococcus, coronavirus disease 2019 (COVID-19), pertussis, and herpes zoster」；「The effects of initiation of pulmonary rehabilitation in the first 4 weeks after hospital discharge are unclear」 |
| Puhan MA 2016, Cochrane CD005305.pub4 | Europe PMC 摘要（PMID 27930803；PMC6463852 全文 XML 取不到） | 「included a total of 20 studies (1477 participants)」；「Eight studies involving 810 participants contributed data on hospital readmissions. Moderate-quality evidence indicates that pulmonary rehabilitation reduced hospital readmissions (pooled odds ratio (OR) 0.44, 95% confidence interval (CI) 0.21 to 0.91), but results were heterogenous (I2 = 77%)」；「Six studies including 670 participants contributed data on mortality. The quality of evidence was low … (pooled OR 0.68, 95% CI 0.28 to 1.67)」；「SGRQ … above the minimal important difference (MID) of four points」，High-quality；「six-minute walk distance (6MWD) improved, on average, by 62 meters (95% CI 38 to 86)」；「studies newly included in this update showed, on average, significantly smaller effects」 |
| Greening NJ 2014, BMJ 349:g4315（反方） | Europe PMC 摘要（PMID 25004917） | 「389 patients … within 48 hours of admission」；「No significant difference between groups was found (hazard ratio 1.1, 95% confidence interval 0.86 to 1.43, P=0.4). An increase in mortality was seen in the intervention group at one year (odds ratio 1.74, 95% confidence interval 1.05 to 2.88, P=0.03)」 |

题目里原想写「每次复诊」，GOLD 原文是「Regular assessment at follow-up」，没说每次，所以标题改成「复诊时」。

没写的：中国慢阻肺指南（中华结核和呼吸杂志 2021 修订版）全文付费，没取。吸入剂和肺康复的价格没找到官方数字。国内哪些医院能做肺康复，没有可引的官方清单，备注只说按医生安排。

证据等级 A 争议：肺康复有 Cochrane 随机试验汇总（再住院证据中等质量），但死亡不显著，入院 48 小时内就开练的试验死亡反而更多，GOLD 也说出院头 4 周开始的效果不清楚；吸入剂那半只有调查数据。收益量级按收益栏机械套：再住院可能低约 56%（OR 0.44），≥20%，定「大」；口径死亡率（含再住院这类健康终点）。时间定「中」，因为肺康复要按方案去好几次。