1.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.
2.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.
3.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.
4.Analysis of Animal Model of Type 2 Diabetes Mellitus Based on Clinical Characteristics of Traditional Chinese and Western Medicine
Xiangning HUANG ; Weiyi LEI ; Yifan SHI ; Tingyi HE ; Nianqing CHEN ; Yilin XU ; Rong YU
Chinese Journal of Experimental Traditional Medical Formulae 2025;31(17):211-219
Based on the etiology and clinical diagnostic criteria of type 2 diabetes mellitus (T2DM), identification and typing of treatment from the perspective of traditional Chinese and western medicine, the criteria for evaluating the clinical compatibility of traditional Chinese and western medicine in animal models of T2DM were set up. The literature was reviewed to sort out and analyze the existing commonly used modeling methods, summarize the mechanism, compare the advantages and disadvantages, and calculate the consistency between the animal model and the clinical symptoms, syndromes, and indicators from the perspective of traditional Chinese and western medicine. The authors found that spontaneous animal models and high-fat diets combined with multiple low-dose streptozotocin (STZ) induction models were more in line with modern medical pathogenesis of T2DM. However, it fails to form some special syndromes required for traditional Chinese medicine (TCM) research. In addition, there are many methods of combining the etiology and pathogenesis of TCM, which can be divided into three categories: intervention carried out by drug administration, behavioral stimulation, or environmental changes according to TCM, or use of hormones according to clinical evidence and combination of the two methods mentioned above. All of them can successfully establish different types of animal models. However, different methods of establishing syndrome models have their own advantages and disadvantages, and there is no unified standard for the stability and evaluation of syndrome models. As for the clinical consistency criteria of traditional Chinese and western medicine established in this paper, the animal model with 100% consistency has not been calculated due to the conditions of incomplete symptoms and syndromes described in the studies and different selection indicators. Consequently, the establishment of a simple, easy-to-use, and affordable T2DM animal model with both traditional Chinese and western medicine disease characteristics and the improvement of the Chinese and western medicine evaluation system for different evidence types are of great significance for the future development of TCM research on T2DM.
5.Analysis of Animal Model of Type 2 Diabetes Mellitus Based on Clinical Characteristics of Traditional Chinese and Western Medicine
Xiangning HUANG ; Weiyi LEI ; Yifan SHI ; Tingyi HE ; Nianqing CHEN ; Yilin XU ; Rong YU
Chinese Journal of Experimental Traditional Medical Formulae 2025;31(17):211-219
Based on the etiology and clinical diagnostic criteria of type 2 diabetes mellitus (T2DM), identification and typing of treatment from the perspective of traditional Chinese and western medicine, the criteria for evaluating the clinical compatibility of traditional Chinese and western medicine in animal models of T2DM were set up. The literature was reviewed to sort out and analyze the existing commonly used modeling methods, summarize the mechanism, compare the advantages and disadvantages, and calculate the consistency between the animal model and the clinical symptoms, syndromes, and indicators from the perspective of traditional Chinese and western medicine. The authors found that spontaneous animal models and high-fat diets combined with multiple low-dose streptozotocin (STZ) induction models were more in line with modern medical pathogenesis of T2DM. However, it fails to form some special syndromes required for traditional Chinese medicine (TCM) research. In addition, there are many methods of combining the etiology and pathogenesis of TCM, which can be divided into three categories: intervention carried out by drug administration, behavioral stimulation, or environmental changes according to TCM, or use of hormones according to clinical evidence and combination of the two methods mentioned above. All of them can successfully establish different types of animal models. However, different methods of establishing syndrome models have their own advantages and disadvantages, and there is no unified standard for the stability and evaluation of syndrome models. As for the clinical consistency criteria of traditional Chinese and western medicine established in this paper, the animal model with 100% consistency has not been calculated due to the conditions of incomplete symptoms and syndromes described in the studies and different selection indicators. Consequently, the establishment of a simple, easy-to-use, and affordable T2DM animal model with both traditional Chinese and western medicine disease characteristics and the improvement of the Chinese and western medicine evaluation system for different evidence types are of great significance for the future development of TCM research on T2DM.
6.Research progress on ultrasound prediction model for gastric residual volume
Lulu CUI ; Yifan HUANG ; Ge JIN
Chinese Journal of Modern Nursing 2024;30(30):4197-4200
Gastric residual volume is an important factor affecting patients' enteral nutrition. Bedside ultrasound can quickly and accurately predict gastric residual volume, which helps guide enteral nutrition. This paper reviews the applicable population, construction process, predictive performance, and clinical application of the ultrasound prediction model for gastric residual volume, so as to provide reference for the construction and application of ultrasound prediction models for gastric residual volume in China.
7.Ifitm3 knockout inhibits the proliferation and differentiation of neural stem cells in mice
Kaiyu WANG ; Xuepei LEI ; Yiying HUANG ; Guiying SHI ; Hanwei YUE ; Jie WANG ; Yifan LIN ; Jiaming TANG ; Lin BAI
Acta Laboratorium Animalis Scientia Sinica 2024;32(6):691-701
Objective To establish interferon-induced transmembrane protein 3(Ifitm3)knockout mice and to explore the effects of Ifitm3 on the proliferation and differentiation of adult neural stem cells of mice(aNSCs).Methods IFITM3 knockout mice were established by the CRISPR/Cas9 method and identified by genotype identification and Western Blot.The differences between Ifitm3-knockout mice and wild-type mice were analyzed by hematoxylin-eosin(HE)staining and flow cytometry.The aNSCs of wild-type mice and Ifitm3-knockout mice were isolated and cultured,the number and size of neurospheres were detected,The ability of aNSCs to proliferate and differentiate were detected by quantitative reverse-transcription polymerase chain reaction,Western Blot,and immunofluorescence.Results Ifitm3-knockout mice were successfully established.The mice developed normally,and there were no obvious abnormalities either histopathologically or the immune system.In vitro experiments showed that Ifitm3 knockout inhibited the self-renewal potential of aNSCs,led to a decrease in the proliferation ability of aNSCs,and inhibited the differentiation of aNSCs into immature neurons and astrocytes.Conclusions This study finds that a lack of IFITM3 result in the ability of aNSCs to proliferate and differentiate decreased,IFITM3 may regulate the function of aNSCs.
8.Progress in the study of animal models of dwarfism
Yifan LIU ; Nan HUANG ; Yuxuan LIU ; Ling GAN ; Hongyu CHEN
Acta Laboratorium Animalis Scientia Sinica 2024;32(9):1207-1214
Dwarfism is a globally rare growth disorder,usually caused by genetics or disease,with the most prominent phenotype being short stature.Animal models are important tools for studying its pathogenesis,prevention,and treatment options,and identifying potential therapeutic targets and biomarkers.The development of genetic engineering technology has greatly promoted the application of gene-edited animal models in the study of dwarfism.In this review,we summarize and discuss the existing animal models of dwarfism in terms of their theoretical basis,model characteristics,and research applications.This offers a reference for researchers and clinicians aiming to better conduct research on the pathogenesis and prevention of dwarfism.
9.A long-term follow-up study of percutaneous stent implantation for residual pulmonary artery stenosis after complicated congenital heart disease
Xu HUANG ; Yifan LI ; Bingyu MA ; Ling SUN ; Junjie LI ; Jijun SHI ; Shushui WANG ; Zhiwei ZHANG ; Yumei XIE
Chinese Journal of Thoracic and Cardiovascular Surgery 2024;40(6):355-361
Objective:To investigate the long-term safety and effectiveness of stent implantation for residual pulmonary artery stenosis after complicated congenital heart disease.Methods:The symptoms, signs, echocardiography, cardiac CT, cardiac catheterization, six-minute walking distance, and BNP of 41 patients diagnosed from January 1996 to January 2020. In this group, 41 patients, 30 males and 11 females, aged 1.3-14.5 years old, mean (6.1±3.6) years old, and weighed 8-43 kg, mean (18.9±9.4)kg, compared the diameter of the target vessel, pressure difference across stenosis, cardiac function before and postoperative follow-up, and evaluated the long-term effect of stent implantation in the treatment of pulmonary artery stenosis.Results:All 41 patients were not lost to follow-up, no death, and there were no serious adverse events such as stent fracture, artery dissection and pulmonary embolism during follow-up. The median follow-up time was 7.1 years (3.1 to 13.8 years). As of January 2023, the echocardiographic results showed that the diameter of the target vessels in 41 patients increased from preoperative (3.9±1.5) mm to (6.0±1.5) mm ( P<0.05), the pressure difference across the stenosis decreased from preoperative (51.4±19.1) mmHg to (33.1±19.7) mmHg (1 mmHg=0.133 kPa, P<0.05); Heart spiral CT showed that the ratio of target vessel diameter to distal vessel diameter increased from preoperative 0.4±0.2 to 0.9±0.3( P<0.05). All patients had no slow growth and development, no recurrent lung infection, 39 patients (95.1%) had gradeⅠcardiac function, and 2 patients (4.9%) had gradeⅡcardiac function.As children in school age, the walking distance of 6 min was 462 to 633 m, mean( 529.9±57.1)m, the respiratory score was 0.5-1, and the lower limb force score was 6-12. There were 5 long-term adverse events, including 4 cases of target vessel restenosis (9.7%), and 1 case (2.4%), two of the patients with restenosis with repeated target vessel stenosis and lateral pulmonary hypertension were surgically intervention: stent removing and pumonary expanding, after 4, 13 years of stent implantation.And the others were still in follow-up, and no further intervention was made. The Cox multivariate survival analysis suggested that right ventricular systolic blood pressure was a risk factor for endpoint events before stent implantation ( P<0.05). Conclusion:The treatment of residual pulmonary artery stenosis after complicated congenital heart disease after percutaneous stent implantation can effectively relieve the right heart pressure overload, improve pulmonary blood flow, stabilize cardiac function, improve the long-term prognosis of patients with complicated congenital heart disease, reduce the chest opening rate of reoperation, and have stable long-term curative effect.
10.Efficacy comparison between different induction chemotherapy regimens for locally advanced nasopharyngeal carcinoma
Ru WANG ; Yifan HUANG ; Yangyang ZHANG ; Jin GAO
Cancer Research and Clinic 2024;36(9):678-682
Objective:To explore the efficacy and adverse reactions of capecitabine combined with docetaxel and cisplatin (TP) regimen or 5-fluorouracil (5-Fu) combined with TP regimen induction chemotherapy for stage Ⅲ-Ⅳ B nasopharyngeal carcinoma. Methods:A retrospective case series study was conducted. The clinical data of 65 newly diagnosed nasopharyngeal carcinoma patients with clinical stages Ⅲ-Ⅳ B who were admitted to the First Affiliated Hospital of University of Science and Technology of China from June 2020 to December 2021 were collected. These patients received induction chemotherapy and were divided into capecitabine combined with TP regimen group (capecitabine group, 34 cases) and 5-Fu combined with TP regimen group (5-Fu group, 31 cases) according to different chemotherapy regimens. The objective response rate (ORR) and the incidence of adverse reactions were compared between the two groups of patients. Results:The differences in age, composition ratios of gender, T stage and N stage of patients and induction chemotherapy frequency between the two groups were not statistically significant (all P > 0.05). The ORR of nasopharynx in capecitabine group and 5-Fu group were 88.2% (30/34) and 74.2% (23/31), and the difference was statistically significant ( χ2 = 2.12, P = 0.145); the ORR of cervical lymph nodes were 85.3% (29/34) and 64.5% (20/31), with no statistically significant difference ( χ2 = 4.67, P = 0.097). The incidence of gastrointestinal reactions in the capecitabine group was lower than that in the 5-Fu group [41.2% (14/34) vs. 71.0% (22/31), χ2 = 6.45, P = 0.040], and the difference in the hematological adverse reaction between the two groups was not statistically significant ( P > 0.05). Conclusions:The efficacy of capecitabine combined with TP regimen and 5-Fu combined with TP regimen induction chemotherapy for stage Ⅲ-Ⅳ B nasopharyngeal carcinoma patients is comparable, and the adverse reactions are tolerable. However, the capecitabine combined with TP regimen has lower incidence of gastrointestinal reactions and higher compliance by the patients. Therefore, the capecitabine combined with TP regimen can be prioritized in the induction chemotherapy.

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