Objective To explore the application effect of the Mini-CEX evaluation model based on the OBE concept in the clinical Practice teaching of neurology.Methods We Selected 100 students who will Practice in the Department of Neurology from 2022 to 2023 as the research objects,and divided them into the experimental group(n=50)and the control group(n=50).Under the guidance of the OBE concept,the experimental group was guided by learning outcomes,refined the teaching objectives,and applied the Mini-CEX evaluation mode for evaluation and feedback.In contrast,the control group adopted the traditional teaching mode.Combined with the observation data,we analyzed and compared the data of various indicators of the two groups of students at the beginning and end of the internship.Results At the end of the internship,the scores of clinical consultation,Physical examination,humanistic medicine,clinical diagnosis,health consultation,organizational effect,and overall evaluation of the experimental group were significantly improved and were higher than those of the control group.After the Practice,in terms of skill test scores,the experimental group scored higher than the control group,the difference was statistically significant(P<0.05),and the experimental group also scored higher in satisfaction evaluation than the control group.Conclusion The Mini-CEX evaluation teaching model based on the concept of OBE is applied to the clinical practice teaching of the neurology department,which can enhance the training effect of students'clinical practice skills.

Objective To explore the value of artificial intelligence federated learning system based on chest X-ray films for pathogen diagnosis of community-acquired pneumonia(CAP)in children.Methods Totally 900 cases of CAP children from 2 hospitals were retrospectively enrolled,including bacterial,viral and mycoplasma CAP(each n=300),and chest posteroanterior X-ray films were collected.Meanwhile,chest posteroanterior X-ray films of 5856 children from the publicly available dataset GWCMCx were collected,including 4273 CAP images and 1583 healthy chest images.All above 6756 images were divided into training set(n=5359)and validation set(n=1397)at the ratio of 8∶2.Then a pathogen diagnosis model of children CAP was established based on attention mechanism.Binary and ternary diagnostic algorithms were designed,and federated deployment training was performed.The efficacy of this system for pathogen diagnosis of children CAP was analyzed and compared with DenseNet model.Results Based on all data,the accuracy of the obtained artificial intelligence federated learning system model for diagnosing children CAP was 97.00%,with the area under the curve(AUC)of 0.990.Based on hospital data,the AUC of this system using single imaging data and clinical-imaging data for pathogen diagnosis of children CAP was 0.858 and 0.836,respectively,both better than that of DenseNet model(0.740,both P＜0.05).Conclusion The artificial intelligence federated learning system based on chest X-ray films could be used for pathogen diagnosis of children CAP.

Objective:To compare the antiplatelet effects of vicagrel and clopidogrel in patients with different cytochrome P450 (CYP) 2C19 genotypes.Methods:This is a post-hoc analysis of a phase Ⅱ clinical trial of vicagrel, which included patients with coronary heart disease who underwent percutaneous coronary intervention from August 2018 to June 2019 in 18 centers. Patients were categorized based on the presence of CYP 2C19 *2 or *3 loss-of-function (LOF) alleles into LOF carrier group ( n=111) and non-LOF carrier group ( n=90). Each group included patients received vicagrel 5 mg, 6 mg, 7.5 mg, or clopidogrel 75 mg for 28 days per study protocol. P2Y 12 reaction units (PRU) were measured using VerifyNow at baseline, 6 to 8 hours after loading dose, 7 to 10 days after randomization, and 28 days after randomization and the percentage inhibition of platelet aggregation (%IPA) was calculated. The primary endpoint was %IPA on day 28. Within the patients from the General Hospital of Northern Theater Command, 8 to 12 patients in each study arms were enrolled in a prespecified pharmacokinetic sub-study, measuring the time to reach maximum plasma concentration (T max), peak plasma concentration (C max), and area under the plasma concentration-time curve (AUC). Results:Among 201 patients, the age was (58.8±8.5) years, and 139 (69.2%) were male. In non-LOF carriers, there was no significant differences in PRU values and %IPA between the vicagrel 5 mg, 6 mg, 7 mg, and clopidogrel groups at all time points (all P>0.05). In LOF carriers, %IPA was significantly higher in the vicagrel-treated groups than in the clopidogrel group at 6-8 hours after loading dose (22.9 (14.2, 31.5)% vs. 19.8 (11.0, 28.6)% vs. 29.5 (20.9, 38.0)% vs. 12.9 (3.9, 21.9)%, P=0.038) and 7-10 days after randomization (22.4 (14.2, 30.5)% vs. 34.4 (26.1, 42.6)% vs. 39.8 (31.8, 47.9)% vs. 24.7 (16.3, 33.2)%, P=0.001), with a trend towards higher %IPA in the vicagrel-treated groups at day 28 (30.4 (21.3, 39.6)% vs. 36.5 (27.2, 45.7)% vs. 40.8 (31.8, 49.8)% vs. 30.7(21.2, 40.2)%, P=0.056). Pharmacokinetic results of 35 patients showed that the C max and AUC of the active metabolite M15-2 of vicagrel was similar to that of clopidogrel in non-LOF carriers, but AUC between vicagrel 5 mg, 6 mg, 7 mg and clopidogrel were significantly different in LOF carriers ((5.6±0.6) h·μg -1·L -1 vs. (6.8±2.7) h·μg -1·L -1 vs. (9.2±3.3) h·μg -1·L -1 vs. (4.2±1.9) h·μg -1·ml -1, P=0.020). Conclusion:Vicagrel and clopidogrel have similar antiplatelet effects in non-LOF carriers, but vicagrel exhibits superior antiplatelet effects in LOF carriers.

OBJECTIVE To evaluate the efficacy and safety of PD-1/PD-L1 inhibitors for neoadjuvant treatment of bladder cancer， and to provide evidence-based reference for clinical treatment. METHODS Retrieved from PubMed， Cochrane Library， Embase， American Society of Clinical Oncology Meeting Library， CNKI， VIP and Wanfang database， etc.， the randomized controlled trials （RCTs）， non-RCT， case-control studies， cohort studies， etc. about PD-1/PD-L1 inhibitors for neoadjuvant treatment of bladder cancer were collected from the inception to Jan 31st， 2023. After literature screening， data extraction and quality evaluation， RevMan 5.3 software was used to perform meta-analysis of single-group rates； sensitivity analysis and publication bias analysis were conducted using Stata12 software. RESULTS A total of 25 studies were included in this discussion， involving 940 patients. The results of meta-analysis showed that the pathologic complete response （pCR） rate was 32% [OR＝0.32， 95%CI （0.22， 0.45）， P＝0.006]， downstaging rate was 52% [OR＝0.52， 95%CI （0.45， 0.60）， P＝0.55]， and the incidence of ≥grade 3 immune-related adverse events （irAEs） was 16% [OR＝0.16， 95%CI （0.11， 0.22）， P＜0.000 01]. Subgroup analysis showed that the patients receiving PD-1/PD-L1 inhibitors alone had a pCR rate of 25% and a incidence of Grade≥3 irAEs of 9%； the patients receiving combined immunotherapy had a pCR rate of 29% and a incidence of Grade≥3 irAEs of 28%； the patients receiving PD-1/PD-L1 inhibitors combined with chemotherapy had a pCR rate of 43% and a incidence of Grade≥3 irAEs of 12%； PD-L1 positive patients had a pCR rate of 44%， and PD-L1 negative patients had a pCR rate of 25%. The results of the sensitivity analysis showed that the study was robust. The results of the publication bias analysis showed that there was no significant publication bias. CONCLUSIONS PD-1/PD-L1 inhibitors are effective and safe for adjuvant treatment of bladder cancer.

ObjectiveTo explore the mechanism of Chaihu Guizhitang （CHGZT） in alleviating neuropathic abdominal pain induced by 2，4，6-trinitrobenzene sulfonic acid （TNBS） in rats with chronic pancreatitis （CP）. MethodFifty male SD rats were randomly assigned into five groups： sham operation， CP model， and low-， medium-， and high-dose （4， 8， and 16 g·kg^-1， respectively） CHGZT groups. In the sham operation group， the abdomen was closed after the pancreas was gently stirred. The rat model of CP was established by retrograde injection of 2% TNBS-10% ethanol into the pancreatic duct. The oral administration of CHGZT started 4 weeks after modeling and lasted for 2 weeks. Pain threshold was measured by Von Frey fibers 6 weeks after surgery. Hematoxylin-eosin （HE） staining was employed to reveal the chronic inflammation and fibrosis of the pancreatic tissue. Immunohistochemmistry （IHC） was employed to detect the expression of PGP9.5 （a marker of pancreatic nerves） and reveal the inflammatory changes around the nerves. IHC and immunofluorescence （IF） were used to determine the location of ionized calcium-binding adaptor molecule-1 （Iba-1， microglia marker） and purinergic receptor P2X7 （P2RX7） and the co-expression of P2RX7 and Iba-1 in the thoracic spinal dorsal horn. ResultCompared with the sham operation group， the modeling increased the scores of pancreatic gland atrophy， inflammatory infiltration， and fibrosis （P<0.01）， the abdominal pain response under different force values （P<0.05， P<0.01）， and the score of peripancreatic inflammation. Moreover， the modeling up-regulated the expression of Iba-1 and P2RX7 in the thoracic spinal dorsal horn （P<0.01）. Compared with the model group， the high- and medium-dose CHGZT lowered the scores of pancreatic gland atrophy， inflammatory infiltration， and fibrosis， the abdominal pain response， and the score of peripancreatic inflammation （P<0.05， P<0.01）. The high-， medium-， and low-dose CHGZT all down-regulated the expression of Iba-1 and P2RX7 （P<0.01）. ConclusionCHGZT can significantly relieve abdominal pain in CP rat by suppressing the inflammation around nerves in the pancreas and the P2RX7 activation of microglia in the spinal dorsal horn.

OBJECTIVE To explore the impact of the adjustment of the national reimbursement drug list on rare disease drugs in hospitals， and to provide reference for improving the drug security of patients with rare diseases in China.METHODS The monthly procurement data of rare disease drugs from 789 medical institutions that continuously reported data from January 2016 to December 2018 were extracted from the Chinese Medicine Economic Information. The single-group interrupted time series model was used to compare drug varieties， procurement amount， average defined daily cost （DDDc） and defined daily doses （DDDs） of rare disease drugs before and after the adjustment of national reimbursement drug list. RESULTS In 2017， a total of 9 rare disease drugs were newly included in the national reimbursement drug list， including pirfenidone， carbidopa/levodopa， riluzole， ropinirole， droxidopa， ezetimibe， everolimus， coagulation factor Ⅸ human recombinant and coagulation factor Ⅶa human recombinant. After the adjustment of the national reimbursement drug list， the average DDDc of 9 rare disease drugs was significantly decreased， the upward trend of DDDs and the procurement amount was significantly increased （P＜0.001）. CONCLUSIONS The number of newly included rare disease drugs in national reimbursement drug list keeps increasing， the coverage of medical security keeps expanding， the price of rare disease drugs is significantly decreased， the economic burden of patients is further decreased， and the consumption of rare disease drugs is significantly increased， benefiting more patients with rare diseases； but at the same time， it also increases the procurement amount of rare disease drugs in hospitals. National medical security departments need to fully consider how to balance the affordability of medical insurance funds with the demand for rare disease drug coverage.

Objective:To study the patterns of tocilizumab (TCZ) use, its efficacy and safety in patients with rheumatoid arthritis (RA) in routine clinical practice.Methods:A total of 407 patients with RA were enrolled from 23 centers and treated with TCZ within 8 weeks prior to the enrollment visit, and were followed for 6-month. The patterns of TCZ treatment at 6 months, the effectiveness and safety outcomes were recorded. Statistical analysis was performed using SAS version 9.4.Results:A total of 396 patients were included for analysis, in which 330 (83.3%) patients received TCZ combined with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and 16.7%(66/396) received TCZ monotherapy. At baseline, TCZ was initiated in 56.6%(224/396) and 9.6%(38/396) of patients after failure of DMARDs and other biological agents (bDMARDs) respectively. During the 6-month follow-up period, the mean frequency of TCZ administration was (3.7±1.6), the mean TCZ dosage was (7.4±1.2) mg/kg, and the mean interval between doses was (40±13) days. 120(25.8%) patients were on TCZ treatment at the end of the study. Improvements in disease activity, systemic symptoms and patient report outcomes were observed at the end of the study. 22.7%(90/396) patients experienced at least one treatment related adverse event, and 8 patients experienced at least one serious adverse event.Conclusion:This study demonstrates that TCZ treatment is effective in patients with RA when being treated for 6 months with an acceptable safety profile. The duration of TCZ treatment needs to be extended.

Objective: To propose the concept of a novel regional control and prevention (RCP) system for the outbreak of COVID-19 infectious disease, design an emergency epidemic prevention information system based on the existing network architecture and information system in the region, and a remote intelligent medical consultation and remote office platform, research and develop the technology of risk assessment and early warning for people in the region, and improve the regions’prevention and control ability facing emergency of major infectious diseases. Methods: Taking colleges, affiliated (teaching) hospitals, and cloud applications as typical RCP regional units, the existing local area network interaction methods between the cloud and universities and affiliated (teaching) hospitals are established to realize remote work in the network environment, remote medical imaging, psychological and ethical consultation and interaction; applying multi-agent propagation model based on complex network, combining Global Positioning System (GPS), Radio Frequency Identification (RFID), and electronic fence technology, to realize the risk classification and early warning of units and personnel in the area. Results: In the RCP, a system architecture combining campus network, affiliated (teaching) hospital intranet, and the Internet is used. Dynamic connection is made using distributed technology and cloud storage. The data buffer mechanism of the intermediary database in the network realized telemedicine consultation and telecommuting. Relying on the platform, multi-agent propagation model based on complex network and cellular automaton model are used to realize the score and early warning of population exposure risk in the region by using GPS, RFID and electronic fence technology. Conclusions In the epidemic phase of major infectious diseases, the construction of RCP can improve the response speed of wartime epidemic prevention, provide reasonable data-based warnings and risk ratings, and reduce the exposure risk of susceptible people. The design and development of RCP is a systematic project that needs to combine regional structural and functional characteristics, and the foundation of the early informatization work in the region and the level of the emergency development team determine the development progress, maintenance, and actual application effects. It is recommended to establish a peacetime and wartime combined RCP mode and incorporate it into the government's disease control system to improve the national and regional level of prevention and control of major infectious diseases.

Objective: To compare the curative effect between Elastic Locking Intramedullary Nail (ELIN) and Anatomic Locking Plate (ALP) for the treatment of fracture in the mid-shaft of clavicle (Classification AO/OTA:2A/2B). Methods: Data of 47 cases of 2A/2B clavicular fractures who were treated with operation from January 2014 to December 2016 were retrospectively analyzed. The patients were divided into ELIN group and ALP group according to different fixation methods. There were 23 cases in ELIN group, 14 male and 9 female, aged from 19 to 85 years (average, 55.26 years). 14 cases on the left side and 9 cases on the right side. There were 6 cases of type 2A and 17 cases of type 2B. There were 24 cases in the ALP group, 18 male and 6 female, aged from 15 to 71 years (average, 51.25 years). 16 cases on the left side and 8 cases on the right side. There were 9 cases of type 2A and 15 cases of type 2B. The operation time, intraoperative blood loss, length of skin incision, fracture healing time, extraction time of internal fixation, Constant-Murley score of shoulder joint, disabilities of the arm, shoulder, and hand (DASH) score, and complication incidence were compared between the two groups. Results: All the operations were successfully performed. The mean follow-up for the patients in the ELIN group was 19.35 weeks (range, 14-23 weeks). The mean follow-up for the patients in the ALP group was 53.13 weeks (range, 28-76 weeks). In the ELIN group, the operative time was 20.78 ± 7.71 min, the intraoperative blood loss was 13.26±9.72 ml, the length of incision was 1.57±1.24 cm, the fracture healing time was 10.39±2.39 weeks, the extraction time of internal fixation was 13.17±2.37 weeks, the Constant-Murley score of shoulder joint was 99.09±1.86, and the DASH score was 1.20±2.47. In the ALP group, the operative time was 57.79±11.56 min, the intraoperative blood loss was 69.17±46.24 ml, the length of incision was 9.67±2.90 cm, the fracture healing time was 14.21±4.05 weeks, the extraction time of internal fixation was 47.38±10.46 weeks, the Constant-Murley score of shoulder joint was 98.00±2.17, and the DASH score was 0.89±1.65. The operation time (t=12.856, P=0.000), intraoperative blood loss (t=5.791, P=0.000) in the ELIN group were less than that of ALP group. The length of incision was significantly smaller in ELIN group than that of ALP group (t=12.549, P=0.000). The fracture healing time was earlier in ELIN group than that of ALP group (t=3.566, P=0.002). The extraction time of internal fixation was obviously earlier in ELIN group than that of ALP group (t=15.603, P=0.000). Constant-Murley score of shoulder joint and DASH score showed no significant difference. No delayed healing, no infection was found in the ELIN group, however skin irritation and tail bursitis were found in 6 cases, 3-6 weeks after the operation. The dressing was changed, kept clean. Skin irritation and tail bursitis disappeared, after the extraction of the internal fixation. There were 2 cases of delayed healing in the ALP group. After prolonged observation, the 2 cases healed. The healing time was extended to 24 and 27 weeks, respectively. There was 1 case of infection, 1 case of poor skin healing in the ALP group. The infected patient was treated with debridement and sensitive antibiotics, and the patient with poor skin healing was treated with dressing change. All the patients had wound healing about 4 weeks after surgery. 2 cases of skin irritation in the ALP group disappeared, after the extraction of the internal fixation. Conclusion Both ALP and ELIN are effective methods for the treatment of mid-shaft clavicular fracture. ELIN group has the advantages of more minimally invasive, faster union, shorter internal fixation time, better appearance, and lower medical cost. However, the ELIN group also had skin irritation and temporary bursitis.

Objective To investigate the reason for hidden hemorrhage of hip fracture in elder.Methods All of 94 elder patients,who were diagnosed with intertrochanteric fracture or femoral neck fracture and received treatment in our department from October,2013 to September,2015,were included in this study.The time between injuries to admission was less than 4 hours of the two groups of patients.And the patients whose hemoglobin was less than 100 g/L were removed when admission,in order to avoid the interference of primary anemia.All information,including height,weight,and the value of hemoglobin (Hb) and hematocrit (Hct),were collected.Blood tests were performed immediately after admission,at daily morning preoperatively,and at the morning of the day of surgery.Preoperative blood loss (hidden hemorrhage) was recorded.With respect to blood loss of hidden hemorrhage,statistical analysis was performed at different times (immediate time after admission,and day 1,2,and 3 postoperatively)in the group of intertrochanteric fracture or in the group of femoral neck fracture,and subsequently performed between the two groups.Results The blood loss in the group of intertrochanteric fracture was 196.3 ml,310.1 ml and 418.3 ml in the 1st day,the 2nd day and the third day after admission.There was a significant difference among different time with respect to blood loss.The blood loss was 39.8 ml,65.7 ml and 82.9 ml in the 1st day,the 2nd day and the third day after admission in the group of femoral neck fracture.There was also a significant difference among different time with respect to blood loss.In experimental group,mean blood loss was 418.3 ml and mean Hb decreased by 23.7 g/L at day 3 postoperatively.In control group,mean blood loss was 82.9 ml and mean Hb decreased by 6.7 g/L at day 3 postoperatively.A significant difference was observed between the two groups.The blood loss in patients with intertrochanteric fracture was higher than that in patients with femoral neck fracture.Conclusion The blood loss was gradually increased in elder patients with intertrochanteric fracture over time.There was a significant difference in different time with respect to blood loss.Moreover,a significant difference was found in blood loss of hidden hemorrhage between intertrochanteric fracture and femoral neck fracture.