1.Analysis of the Burden of Acute Lymphoid Leukemia in China and Globally from 1990 to 2021
Derong LIN ; Jingya FANG ; Yue LI ; Xiaohua XIE ; Xiaolin YE ; Xiaowen ZHANG ; Jiexuan LI ; Aiguo XUE
Medical Journal of Peking Union Medical College Hospital 2026;17(2):463-475
To analyze the disease burden of acute lymphoid leukemia(ALL) and its changing trends in China and globally from 1990 to 2021, aiming to provide a theoretical basis for disease prevention, treatment, and policy formulation. Data on the incidence, prevalence, mortality, and disability adjusted life years(DALYs) of ALL in China and globally from 1990 to 2021 were extracted from the Global Burden of Disease(GBD) 2021 database. The Joinpoint regression model was used to calculate the average annual percentage change(AAPC) to assess the trends in disease burden. Decomposition analysis was employed to identify and quantify the contributions of different factors to the changes in ALL disease burden. The population attributable fraction(PAF) was used to compare the risk factors for ALL in China and globally in 1990 and 2021. Stratified by the sociodemographic index(SDI), the locally estimated scatterplot smoothing(LOESS) method was used to assess the association between age-standardized incidence rate(ASIR), age-standardized mortality rate(ASMR), and SDI. The incidence-mortality ratio(IMR) was calculated to evaluate the diagnostic level and current treatment status of ALL. From 1990 to 2021, ASIR of ALL in the Chinese population increased from 3.385/100 000 to 3.637/100 000(AAPC: 0.005), the age-standardized prevalence rate(ASPR) increased from 6.596/100 000 to 22.022/100 000(AAPC: 0.478), the ASMR decreased from 3.051/100 000 to 1.357/100 000(AAPC: -0.056), and the age-standardized DALYs rate(ASDR) decreased from 195.792/100 000 to 74.063/100 000(AAPC: -3.996). Globally, the corresponding figures were: ASIR decreased from 1.789/100 000 to 1.371/100 000(AAPC: -0.014), ASPR increased from 4.122/100 000 to 5.425/100 000(AAPC: 0.039), ASMR decreased from 1.551/100 000 to 0.898/100 000(AAPC: -0.021), and ASDR decreased from 94.894/100 000 to 48.858/100 000(AAPC: -1.494). During this period, the aforementioned disease burden indicators were generally higher in males than in females, both in China and globally.In 2021, the peak incidence of ALL in China and globally was primarily concentrated in the 0-19 years age group, with the highest rate observed in those under 5 years of age. The burden of prevalence and DALYs was also mainly concentrated in this age group. Regarding mortality, the death burden in China was predominantly observed in the older adult age group, particularly among those aged ≥60 years. Globally, the mortality burden was highest in the under-5 age group, while remaining at a relatively high level in the older adult population. SDI correlation analysis based on data from 204 countries/regions globally from 1990 to 2021 showed that ASIR gradually increased with increasing SDI, whereas ASMR showed an initial increase followed by a decreasing trend. The ASIR and ASMR for the overall Chinese population and by sex were higher than expected. PAF results indicated that smoking and high body mass index were the main attributable risk factors for ALL mortality and DALYs burden, with their contribution consistently increasing. Decomposition analysis revealed that population growth and epidemiological changes were the primary drivers behind the changes in ALL incidence and mortality burden. Compared with 1990, the IMR for ALL in both China and globally increased in 2021. Over the past three decades, the ASMR and ASDR for ALL in China and globally have generally declined. During the same period, the ASIR and ASPR for ALL increased in China, while globally, the ASIR decreased and the ASPR increased. However, the disease burden of ALL remains high in males, children, and the older adult population. Differentiated prevention and control measures should be implemented in accordance with changes in SDI. The findings highlight the importance of strengthening prevention and early diagnosis, and suggest the need for targeted screening and treatment strategies for different age and sex groups. Concurrently, attention should be paid to the role of weight management and tobacco control in comprehensive prevention and control efforts to further reduce the disease burden of ALL.
2.Effects and mechanisms of action of Yiqi wenyang huwei decoction in improving bronchial asthma in rats
Yunqing YANG ; Jianyu XIE ; Wei TANG ; Chao YE ; Qiangqiang YU ; Peng SUN ; Yuping YANG ; Jianwei YU
China Pharmacy 2026;37(10):1264-1271
OBJECTIVE To investigate the effects and potential mechanism of Yiqi wenyang huwei decoction (YQWY) in improving airway inflammation and remodeling in rats with bronchial asthma (BA) based on the Toll-like receptor 4 (TLR4)/myeloid differentiation primary response protein 88 (MyD88)/nuclear factor-κB (NF-κB) signaling pathway. METHODS Male SD rats were randomly divided into the normal group, the model group, the dexamethasone group (positive control, 0.5 mg/kg), and YQWY low-, medium- and high-dose groups (5, 10, 20 g/kg, calculated by the crude drug), with 8 rats in each group. Except for the normal group, rats in all other groups were sensitized twice with ovalbumin combined with aerosol challenge to establish a BA model. From day 14 to day 34 of the experiment, the rats in each group were administered the corresponding drug solution or normal saline intragastrically, once a day, 1 hour before aerosol challenge. At 24 hours after the final aerosol challenge, asthma symptom scores were assessed, serum levels of immunoglobulin E (IgE) were measured, and the levels of inflammatory cytokines (interleukin-4, interleukin-5, interleukin-13 and tumor necrosis factor-α) and the numbers of inflammatory cells (white blood cell, eosinophil, neutrophil, lymphocyte, monocyte and basophil) in bronchoalveolar lavage fluid were determined. Pathological changes in lung tissue were observed. The mRNA expressions of TLR4, MyD88 and NF-κB, as well as the protein expressions of TLR4, MyD88, NF-κB p65 and phosphorylated NF-κB p65 in lung tissue, were detected. RESULTS Compared with the model group, the pathological changes, such as inflammatory cell infiltration, abnormal deposition of collagen fibers, and goblet cell hyperplasia in the lung tissue of rats in each drug group, were alleviated to varying degrees. The asthma symptom scores (except for the YQWY low-dose group), the levels of IgE and inflammatory cytokines (except for interleukin-5 in the YQWY medium-dose group), the number of inflammatory cells (except for monocyte and basophil in the YQWY low-dose group), the mRNA expression of TLR4, MyD88 and NF-κB, as well as the protein expressions of TLR4, MyD88, NF-κB p65 and phosphorylated NF-κB p65 (except for MyD88 and NF-κB p65 proteins in the YQWY low-dose group as detected by Western blo t) were all significantly reduced or down-regulated ( P <0.05 or P <0.01). CONCLUSIONS YQWY can alleviate asthma-like manifestations in BA rats and improve their airway inflammation and remodeling; these effects may be related to the formula’s inhibition of the abnormal activation of the TLR4/MyD88/NF-κB signaling pathway.
3.Performance validation of a novel multiplex detection reagent for screening transfusion-associated infectious diseases
Miao LIU ; Qian ZHAO ; Na YAO ; Jing LI ; Jiahui ZHANG ; Ning YE ; Yuena XIE
Chinese Journal of Blood Transfusion 2026;39(5):650-655
Objective: To validate the performance of the Procleix UltrioPlex E assay (Grifols, Spain) on the Procleix Panther automated nucleic acid detection platform, which employs the TMA method to simultaneously detect HIV-1/HIV-2/HCV/HBV/HEV viruses, and to evaluate its value for screening transfusion-associated infectious diseases. Methods: In accordance with the requirements of ISO15189"Application of the Guidelines for the Accreditation of Quality and Capabilities of Medical Laboratories in the Field of Molecular Diagnostics (CNAS-CL02-A009: 2018)", "Guidelines for Performance Validation of Molecular Diagnostic Testing Procedures (CNAS-GL039: 2019)", and the "Technical Operating Procedures for Blood Banks (2019 Edition)", this study validated the reagent's performance in terms of analytical sensitivity validation, performance consistency validation, interference resistance, and cross-contamination resistance. Results: Probit analysis revealed that the 95% detection limits (95% confidence interval) for HBV, HCV, HIV, and HEV were 2.0 IU/mL, 1.5 IU/mL, 18.0 IU/mL and 3.7 IU/mL, respectively, which were consistent with the minimum detection limits stated in the kit's package insert and were comparable to the Procleix Ultrio Elite kit. Both kits were used to test the performance validation serum plate simultaneously, yielding results consistent with the serum plate (Kappa=1), indicating stable performance. Detection of medium-and low-concentration lipemia and weakly positive hemolysis samples demonstrated good interference resistance. Cross-contamination performance validation showed that the kit exhibited excellent cross-contamination resistance. Conclusion: The Procleix UltrioPlex E nucleic acid detection kit enables combined detection of HIV-1, HIV-2, HCV, HBV, and HEV, allowing single-test screening for multiple viruses in donor blood. The kit's analytical performance is stable and meets basic laboratory requirements, making it suitable for screening transfusion-associated infectious diseases in blood banks.
4.Prognostic Significance of Pretreatment 18FALF-NOTA-FAPI-04 PET/CT in Patients With Recurrent Gastric Cancer Undergoing Combined PD-1 Inhibitor and Chemotherapy
Haifeng HE ; Yongzhi XIE ; Chengzhi JIANG ; Wanjing ZHOU ; Hui YE
Korean Journal of Radiology 2026;27(3):264-275
Objective:
This study aimed to evaluate the prognostic value of [ 18F]ALF-NOTA-FAPI-04 PET/CT-derived parameters, including the maximum standardized uptake value (SUVmax), FAPI-avid tumor volume (FTV), and total lesion FAP expression (TLF), in patients with recurrent gastric cancer undergoing combined chemoimmunotherapy. We sought to establish a noninvasive imaging biomarker framework to optimize patient stratification and therapeutic decision-making.
Materials and Methods:
This retrospective cohort study analyzed 51 patients with recurrent gastric cancer who received programmed cell death protein 1 (PD-1) inhibitors combined with chemotherapy after gastrectomy. All patients underwent [ 18F]ALF-NOTA-FAPI-04 PET/CT within 14 days of chemoimmunotherapy. Semi-quantitative parameters (SUVmax, FTV, and TLF) were derived using semi-automated tumor segmentation. The primary endpoint of this study was the assessment of the clinical efficacy of chemoimmunotherapy, categorized as a durable or nondurable clinical benefit. The secondary endpoints included progression-free survival (PFS) and overall survival (OS). In a subgroup of 16 patients who underwent sequential [ 18F]FDG PET/CT within seven days of [ 18F]ALF-NOTA-FAPI-04 PET/CT, tracer uptake values were compared between the two PET/CT examinations.
Results:
51 patients were included. The median PFS and OS were 7 and 10 months, respectively. Durable clinical benefit (DCB) was observed in 30 patients and showed significantly lower SUVmax, FTV, and TLF values than non-DCB. TLF demonstrated the highest diagnostic accuracy for DCB (area under the receiver operating characteristic curve [AUC] = 0.80). Multivariable analysis identified TLF ≥ 188.88 SUVbw·cm 3 as an independent factor associated with PFS (hazard ratio [HR] = 7.29, P = 0.001) and FTV ≥ 44.17 cm 3 as an independent factor associated with OS (HR = 5.16, P = 0.010). In the subgroup analysis of 16 patients, semi-quantitative analysis demonstrated consistently higher values of [ 18F]ALF-NOTA-FAPI-04-derived parameters than [ 18F]FDG-derived parameters (all P < 0.001).
Conclusion
[ 18F]ALF-NOTA-FAPI-04 PET/CT may be a useful imaging tool for predicting clinical outcomes in patients with recurrent gastric cancer undergoing treatment with PD-1 inhibitors and chemotherapy.
5.Study on inhibition of oral squamous cell carcinoma recurrence and promotion of tissue repair via a dual-network hydrogel-microneedle
CHU Mengxian ; YE Xiuwen ; XIE Xi ; LIAO Jinfeng
Journal of Prevention and Treatment for Stomatological Diseases 2026;34(8):757-770
Objective:
To investigate the therapeutic effect of a dual-network hydrogel-microneedle (MN) on inhibiting oral squamous cell carcinoma (OSCC) recurrence and promoting tissue repair, thereby providing a foundation for the clinical treatment of OSCC.
Methods:
A Schiff base hydrogelformed between chitosan (CS) and poly(ethylene glycol) dibenzaldehyde (PEG-CHO), combined witha coordination-crosslinked hydrogel formed between sodium alginate (SA) and Cu²+, were jointly integrated to form the CS/PEG-CHO/SA/Cu²+ (CPSC) dual-network hydrogel base. The hydrogel formulation was optimized based on characterization by scanning electron microscopy, Fourier transform infrared spectroscopy, rheology, and swelling tests. Subsequently, 5-fluorouracil (5-FU) and gold nanorod (GNR) were incorporated into the CPSC hydrogel to fabricate an MN loaded with 5-FU/GNR (FG). The mechanical strength and dissolution behavior of FG MNs were characterized, and their photothermal performance was evaluated under near-infrared (NIR) irradiation using thermal imaging. The mouse fibroblast cell line L929 cells and the human oral mucosal epithelial-derived cell line GMSM-K cells were co-cultured with FG MNs for 2 and 4 days, respectively, and cell viability was assessed by the Cell Counting Kit-8 (CCK-8) assay and dead/live staining. Separately, the human tongue OSCC cell line Cal-27 cells were divided into four groups: a control group (cultured in complete medium), 5-FU MN group (co-cultured with 5-FU-loaded MNs), GNR MN+ NIR group (co-cultured with GNR-loaded MNs followed by NIR irradiation at 0.4 W/cm2 for 5 min), and FG MN+ NIR group (co-cultured with FG MNs followed by identical NIR irradiation). After 24 and 48 h of co-culture, Cal-27 cell viability was assessed using both CCK-8 assay and dead/live staining. All animal experiments were approved by the Institutional Animal Ethics Committee. A subcutaneous Cal-27-derived OSCC postoperative recurrence model was established in BALB/c nude mice. The mice were divided into four groups: a control group, 5-FU MN group, GNR MN+ NIR group, and FG MN+ NIR group. Mice in the control group received no intervention, while the other groups were treated with the corresponding MN patches. Additionally, the GNR MN+ NIR and FG MN+ NIR groups received NIR irradiation (0.4 W/cm2, 5 min). Tumors were excised and their volumes measured on day 7, and tumor recurrence and wound healing were assessed on day 14.
Results:
A dual-network hydrogel-MN was successfully constructed, demonstrating favorable mechanical and dissolution properties. Upon NIR irradiation for 5 min, the temperature rapidly increased to 48.4°C, reaching the threshold for effective tumor ablation. CCK-8 and dead/live staining results showed that FG MNs exhibited no cytotoxicity toward L929 and GMSM-K cells, indicating good cytocompatibility. However, Cal-27 cell viability in the chemotherapy-photothermal combination group was lower than that in the other three groups, with a statistical difference (P<0.0001). In the nude mouse model, subcutaneous Cal-27 tumors were resected 7 days post-implantation. No statistical difference in tumor volume was observed among groups at this timepoint, confirming successful model establishment. By postoperative day 14, the control group displayed complete tumor recurrence with unhealed wounds, while the 5-FU and GNR MN+ NIR groups showed mild recurrence and partial wound healing. The FG MN+ NIR group demonstrated superior efficacy in both inhibiting tumor recurrence and promoting tissue repair compared with all other groups, with a statistical difference (P<0.0001).
Conclusion
The dual-network hydrogel-MN system effectively suppresses postoperative recurrence of Cal-27-derived subcutaneous OSCC and promotes tissue repair through chemo-photothermal combined therapy.
6.Trend analysis of changes in blood donor populations in CSBT sentinel sites from 2021 to 2025
Xiaojie GUO ; Junhong YANG ; Wenqin ZHU ; Ruru HE ; Guoqiang FENG ; Ruiqing JU ; Fei TANG ; Zhujiang YE ; Mingliang YUAN ; Xin CHEN ; Zhenping LU ; Dongfu XIE ; Qing XU ; Xia HUANG ; Jia ZENG
Chinese Journal of Blood Transfusion 2026;39(8):1052-1060
Objective: To analyze the structural changes in whole blood and apheresis platelet donations in Chinese Society of Blood Transfusion (CSBT) sentinel units from 2021 to 2025, and to provide evidence for donor recruitment and blood service management. Methods: Aggregated data reported by sentinel sites were collected and stratified according to six indicators: age, sex, donation history, donation volume, donation site, and organization mode. Pearson χ
test, Cramer′V coefficient, Cochran-Armitage trend test and simple linear regression were adopted for analysis. Results: A total of 16 256 973 whole blood donations and 1 576 546 apheresis platelet donations were included. Among whole-blood donations, the proportion of donors aged 18-22 years decreased from 27.30% to 10.60%. The proportion of male donors increased from 58.81% to 63.13%; the proportion of people aged 30 and above increased from 58.40% to 75.30%; the proportion of fixed locations rose from 28.37% to 36.57%; the proportion of social groups increased from 21.69% to 39.69%. The 400-mL donations decreased from 62.12% to 53.46%, while individually initiated voluntary donations remained above 50%. Apheresis platelet donations were predominantly from males, individuals aged 30-39 years, and repeat donors; 2-treatment-unit apheresis platelet donations increased from 67.19% to 74.93%, and individually initiated donations accounted for 92.97%-96.02%. Statistically significant overall annual compositional differences were observed for all six indicators (all P<0.001), whereas linear trends for some sub-categories were not statistically significant. Conclusion: In the participating CSBT sentinel units, among whole blood donations, the proportions of donors aged 18-22 years, university-organized group donations, and donations at blood mobiles decreased, whereas the proportions of organizational group donations and donations at fixed venues increased. The apheresis platelet donation cohort is relatively mature and is evolving toward a high-efficiency donation model. Individual voluntary donation remains the primary organization mode for both donation types. Strategies such as youth donor recruitment, optimized layout of fixed donation sites, and retention of repeat donors should be strengthened to improve the resilience of blood supply.
7.Structure, content and data standardization of rehabilitation medical records
Yaru YANG ; Zhuoying QIU ; Di CHEN ; Zhongyan WANG ; Meng ZHANG ; Shiyong WU ; Yaoguang ZHANG ; Xiaoxie LIU ; Yanyan YANG ; Bin ZENG ; Mouwang ZHOU ; Yuxiao XIE ; Guangxu XU ; Jiejiao ZHENG ; Mingsheng ZHANG ; Xiangming YE ; Jian YANG ; Na AN ; Yuanjun DONG ; Xiaojia XIN ; Xiangxia REN ; Ye LIU ; Yifan TIAN
Chinese Journal of Rehabilitation Theory and Practice 2025;31(1):21-32
ObjectiveTo elucidate the critical role of rehabilitation medical records (including electronic records) in rehabilitation medicine's clinical practice and management, comprehensively analyzed the structure, core content and data standards of rehabilitation medical records, to develop a standardized medical record data architecture and core dataset suitable for rehabilitation medicine and to explore the application of rehabilitation data in performance evaluation and payment. MethodsBased on the regulatory documents Basic Specifications for Medical Record Writing and Basic Specifications for Electronic Medical Records (Trial) issued by National Health Commission of China, and referencing the World Health Organization (WHO) Family of International Classifications (WHO-FICs) classifications, International Classification of Diseases (ICD-10/ICD-11), International Classification of Functioning, Disability and Health (ICF), and International Classification of Health Interventions (ICHI Beta-3), this study constructed the data architecture, core content and data standards for rehabilitation medical records. Furthermore, it explored the application of rehabilitation record summary sheets (home page) data in rehabilitation medical statistics and payment methods, including Diagnosis-related Groups (DRG), Diagnosis-Intervention Packet (DIP) and Case Mix Index. ResultsThis study proposed a systematic standard framework for rehabilitation medical records, covering key components such as patient demographics, rehabilitation diagnosis, functional assessment, rehabilitation treatment prescriptions, progress evaluations and discharge summaries. The research analyzed the systematic application methods and data standards of ICD-10/ICD-11, ICF and ICHI Beta-3 in the fields of medical record terminology, coding and assessment. Constructing a standardized data structure and data standards for rehabilitation medical records can significantly improve the quality of data reporting based on the medical record summary sheet, thereby enhancing the quality control of rehabilitation services, effectively supporting the optimization of rehabilitation medical insurance payment mechanisms, and contributing to the establishment of rehabilitation medical performance evaluation and payment based on DRG and DIP. ConclusionStructured rehabilitation records and data standardization are crucial tools for quality control in rehabilitation. Systematically applying the three reference classifications of the WHO-FICs, and aligning with national medical record and electronic health record specifications, facilitate the development of a standardized rehabilitation record architecture and core dataset. Standardizing rehabilitation care pathways based on the ICF methodology, and developing ICF- and ICD-11-based rehabilitation assessment tools, auxiliary diagnostic and therapeutic systems, and supporting terminology and coding systems, can effectively enhance the quality of rehabilitation records and enable interoperability and sharing of rehabilitation data with other medical data, ultimately improving the quality and safety of rehabilitation services.
8.Standardization of electronic medical records data in rehabilitation
Yifan TIAN ; Fang XUN ; Haiyan YE ; Ye LIU ; Yingxin ZHANG ; Yaru YANG ; Zhongyan WANG ; Meng ZHANG ; Xiaoxie LIU ; Yanyan YANG ; Bin ZENG ; Mouwang ZHOU ; Yuxiao XIE ; Guangxu XU ; Jiejiao ZHENG ; Mingsheng ZHANG ; Xiangming YE ; Fubiao HUANG ; Qiuchen HUANG ; Yiji WANG ; Di CHEN ; Zhuoying QIU
Chinese Journal of Rehabilitation Theory and Practice 2025;31(1):33-44
ObjectiveTo explore the data standard system of electronic medical records in the field of rehabilitation, focusing on the terminology and coding standards, data structure, and key content categories of rehabilitation electronic medical records. MethodsBased on the Administrative Norms for the Application of Electronic Medical Records issued by the National Health Commission of China, the electronic medical record standard architecture issued by the International Organization for Standardization and Health Level Seven (HL7), the framework of the World Health Organization Family of International Classifications (WHO-FICs), Basic Architecture and Data Standards of Electronic Medical Records, Basic Data Set of Electronic Medical Records, and Specifications for Sharing Documents of Electronic Medical Records, the study constructed and organized the data structure, content, and data standards of rehabilitation electronic medical records. ResultsThe data structure of rehabilitation electronic medical records should strictly follow the structure of electronic medical records, including four levels (clinical document, document section, data set and data element) and four major content areas (basic information, diagnostic information, intervention information and cost information). Rehabilitation electronic medical records further integrated information related to rehabilitation needs and characteristics, emphasizing rehabilitation treatment, into clinical information. By fully applying the WHO-FICs reference classifications, rehabilitation electronic medical records could establish a standardized framework, diagnostic criteria, functional description tools, coding tools and terminology index tools for the coding, indexing, functional description, and analysis and interpretation of diseases and health problems. The study elaborated on the data structure and content categories of rehabilitation electronic medical records in four major categories, refined the granularity of reporting rehabilitation content in electronic medical records, and provided detailed data reporting guidance for rehabilitation electronic medical records. ConclusionThe standardization of rehabilitation electronic medical records is significant for improving the quality of rehabilitation medical services and promoting the rehabilitation process of patients. The development of rehabilitation electronic medical records must be based on the national and international standards. Under the general electronic medical records data structure and standards, a rehabilitation electronic medical records data system should be constructed which incorporates core data such as disease diagnosis, functional description and assessment, and rehabilitation interventions. The standardized rehabilitation electronic medical records scheme constructed in this study can support the improvement of standardization of rehabilitation electronic medical records data information.
9.Standardization of outpatient medical record in rehabilitation setting
Ye LIU ; Qing QIN ; Haiyan YE ; Yifan TIAN ; Yingxin ZHANG ; Yaru YANG ; Zhongyan WANG ; Meng ZHANG ; Xiaoxie LIU ; Yanyan YANG ; Bin ZENG ; Mouwang ZHOU ; Yuxiao XIE ; Guangxu XU ; Jiejiao ZHENG ; Mingsheng ZHANG ; Xiangming YE ; Fubiao HUANG ; Qiuchen HUANG ; Yiji WANG ; Di CHEN ; Zhuoying QIU
Chinese Journal of Rehabilitation Theory and Practice 2025;31(1):45-54
ObjectiveTo analyze the data structure and standards of rehabilitation outpatient medical records, to provide data support for improving the quality of rehabilitation outpatient care and developing medical insurance payment policies. MethodsBased on the normative documents issued by the National Health Commission, Basic Standards for Medical Record Writing and Standards for Electronic Medical Record Sharing Documents, in accordance with the Quality Management Regulations for Outpatient (Emergency) Diagnosis and Treatment Information Pages (Trial), reference to the framework of the World Health Organization Family of International Classifications (WHO-FICs), the data framework and content of rehabilitation outpatient medical records were determined, and the data standards were discussed. ResultsThis study constructed a data framework for rehabilitation outpatient medical records, including four main components: patient basic information, visit process information, diagnosis and treatment information, and cost information. Three major reference classifications of WHO-FICs, International Classification of Diseases, International Classification of Functioning, Disability and Health, and International Classification of Health Interventions,were used to establish diagnostic standards and standardized terminology, as well as coding disease diagnosis, functional description, functional assessment, and rehabilitation interventions, to improve the quality of data reporting, and level of quality control in rehabilitation. ConclusionThe structuring and standardization of rehabilitation outpatient medical records are the foundation for sharing of rehabilitation data. The using of the three major classifications of WHO-FICs is valuable for the terminology and coding of disease diagnosis, functional description and assessment, and intervention in rehabilitation outpatient medical records, which is significant for sharing and interconnectivity of rehabilitation outpatient data, as well as for optimizing the quality and safety of rehabilitation medical services.
10.Structure, content and data standardization of inpatient rehabilitation medical record summary sheet
Haiyan YE ; Qing QIN ; Ye LIU ; Yifan TIAN ; Yingxin ZHANG ; Yaru YANG ; Zhongyan WANG ; Meng ZHANG ; Xiaoxie LIU ; Yanyan YANG ; Bin ZENG ; Mouwang ZHOU ; Yuxiao XIE ; Guangxu XU ; Jiejiao ZHENG ; Mingsheng ZHANG ; Xiangming YE ; Fubiao HUANG ; Qiuchen HUANG ; Yiji WANG ; Di CHEN ; Zhuoying QIU
Chinese Journal of Rehabilitation Theory and Practice 2025;31(1):55-66
ObjectiveTo explore the standardization of inpatient rehabilitation medical record summary sheet, encompassing its structure, content and data standards, to enhance the standardization level of inpatient rehabilitation medical record summary sheet, improve data reporting quality, and provide accurate data support for medical insurance payment, hospital performance evaluation, and rehabilitation discipline evaluation. MethodsBased on the relevant specifications of the National Health Commission's Basic Norms for Medical Record Writing, Specifications for Sharing Documents of Electronic Medical Records, and Quality Management and Control Indicators for Inpatient Medical Record Summary Sheet (2016 Edition), this study analyzed the structure and content of the inpatient rehabilitation medical record summary sheet. The study systematically applied the three major reference classifications of the World Health Organization Family of International Classifications, International Classification of Diseases (ICD-10/ICD-11, ICD-9-CM-3), International Classification of Functioning, Disability and Health (ICF), and International Classification of Health Interventions (ICHI Beta-3), for disease diagnosis, functional description and assessment, and rehabilitation intervention, forming a standardized terminology system and coding methods. ResultsThe inpatient rehabilitation medical record summary sheet covered four major sections: inpatient information, hospitalization information, diagnosis and treatment information, and cost information. ICD-10/ICD-11 were the standards and coding tools for admission and discharge diagnoses in the inpatient rehabilitation medical record summary sheet. The three functional assessment tools recommended by ICD-11, the 36-item version of World Health Organization Disability Assessment Schedule 2.0, Brief Model Disability Survey and Generic Functioning domains, as well as ICF, were used for rehabilitation functioning assessment and the coding of outcomes. ICHI Beta-3 and ICD-9-CM-3 were used for coding surgical procedures and operations in the medical record summary sheet, and also for coding rehabilitation intervention items. ConclusionThe inpatient rehabilitation medical record summary sheet is a summary of the relevant content of the rehabilitation medical record and a tool for reporting inpatient rehabilitation data. It needs to be refined and optimized according to the characteristics of rehabilitation, with necessary data supplemented. The application of ICD-11/ICD-10, ICF and ICHI Beta-3/ICD-9-CM-3 classification standards would comprehensively promote the accuracy of inpatient diagnosis of diseases and functions. Based on ICD-11 and ICF, relevant functional assessment result data would be added, and ICHI Beta-3/ICD-9-CM-3 should be used to code rehabilitation interventions. Improving the quality of rehabilitation medical records and inpatient rehabilitation medical record summary sheet is an important part of rehabilitation quality control, and also lays an evidence-based data foundation for the analysis and application of inpatient rehabilitation medical record summary sheet.


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