1.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.
2.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.
3.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.
4.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.
5.Research Progress on Gut Microbiota in Prader-Willi Syndrome
JOURNAL OF RARE DISEASES 2024;3(3):375-380
Prader-Willi syndrome(PWS)is a genetically imprinted disorder characterized by intellec-tual impairment,obesity,metabolic disorders,and behavioral abnormalities.The pathological mechanisms of metabolic disorders and behavioral abnormalities are not yet clear,and the treatment effect up to now is not satisfactory.In recent years,the role of gut microbiota in metabolic regulation has gradually been recognized.This article will systematically review the research progress of gut microbiota in PWS.Compared to healthy in-dividuals or other simply obese individuals.PWS patients show changes in the gut microbiota.The changes are related to metabolic disorders and inflammatory status in PWS patients.Intervention of gut microbiota through diet or probiotics has played a certain role in controlling weight and improving behavioral abnormalities in PWS patients.
6.Clinical Efficacy Analysis of Wedge Resection of Pulmonary in Patients with Small Volume Invasive Lung Adenocarcinoma
CUI SHIJUN ; WANG GAOXIANG ; HUANG ZHINING ; WU MINGSHENG ; WU HANRAN ; ZHOU HANGCHENG ; XU MEIQING ; XIE MINGRAN
Chinese Journal of Lung Cancer 2024;27(5):359-366
Background and objective With further understanding and research into non-small cell lung cancer with tumours ≤2 cm in maximum diameter,segmental lung resection is able to achieve the same long-term prognosis as lobec-tomy.However,there are few studies on the prognostic effect of wedge resection on small volume invasive lung adenocarci-noma with an invasion depth of 0.5 to 1.0 cm.Therefore,this study focuses on the clinical efficacy and prognosis of wedge re-section in patients with small-volume invasive lung adenocarcinoma.Methods A retrospective analysis of the medical records of 208 patients who underwent surgery in the Department of Thoracic Surgery of the Affiliated Provincial Hospital of Anhui Medical University from February 2016 to December 2017 was made,and the postoperative pathological results confirmed small volume invasive lung adenocarcinoma.According to their surgical methods,they were divided into lobectomy group(n=115),segmentectomy group(n=48)and wedge resection group(n=45).Kaplan-Meier survival curve estimation and Cox proportional risk regression model were used to explore the influence of different surgical methods on the prognosis of patients with small volume invasive lung adenocarcinoma.Results The wedge resection group had better perioperative outcomes compared with the segmentectomy group and lobectomy group,with statistically significant differences in intraoperative bleed-ing(P=0.036),postoperative drainage(P<0.001),operative time(P=0.018),postoperative time with tubes(P=0.001),and postoperative complication rate(P=0.006).There were no significant differences when comparing the three groups in terms of survival rate(lobectomy group vs segmentectomy group,P=0.303;lobectomy group vs wedge resection group,P=0.742;and segmentectomy group vs wedge resection group,P=0.278)and recurrence-free survival rate(lobectomy group vs segmentec-tomy group,P=0.495;lobectomy group vs wedge resection group,P=0.362;segmentectomy group vs wedge resection group,P=0.775).Univariate and multivariate survival analyses showed that consolidation tumor ratio(CTR)was the prognostic factor of overall survival and revurrence-free survival for patients with small-volume invasive lung adenocarcinoma(P<0.05).Conclusion Wedge resection in patients with small volume invasive lung adenocarcinoma can achieve long-term outcomes similar to segmentectomy and lobectomy.When the CTR≤0.5,wedge resection is preferred in such patients.
7.The Study of Anti-inflammatory Effect of Acupuncture in Rats with Chronic Migraine Based on the α7nAChRs
Yuqi ZHENG ; Mingsheng SUN ; Yi LIU ; Mengdi ZHOU ; Leimiao YIN ; Ling ZHAO ; Dingjun CAI
World Science and Technology-Modernization of Traditional Chinese Medicine 2024;26(4):1050-1058
Objective To investigate the effect of acupuncture on the inflammatory changes of α7 nicotinic acetylcholine receptors(α7 nicotinic acetylcholine receptors,α7nAChRs)in rats with chronic migraine(CM).Methods Adult male SD rats were randomly divided into control group(VEH group),model group(NTG group),acupuncture group(TA group),α7nAChRs antagonist group(MLA group)and α7nAChRs agonist group(TA group)according to basic pain threshold.The rat model of CM was established by repeated subcutaneous injection of nitroglycerin(NTG)at the neck and back every other day.TA group and MLA group received acupuncture treatment one hour before NTG injection,20 minutes every day for 9 consecutive days.The MLA group was intraperitoneally injected with α7nAChRs antagonist MLA half an hours before acupuncture,and the PNU group was intraperitoneally injected with α7nAChRs agonist PNU-282987 half an hours before NTG injection,both groups were injected continuously for 9 days.The changes of paw withdrawal mechanical threshold(Paw Withdrawal Mechanical Threshold,PWMT)and tail-flick latency(Tail-Flick Latency,TFL)were detected by Von Frey and thermal radiation pain meter.The contents of inflammatory factors IL-1β,TNF-α and TGF-β in TNC and serum were determined by ELISA.The relative fluorescence intensity and co-expression of GFAP and α7nAChRs in TNC were detected by immunofluorescence dual labeling method.Results Compared with VEH group,PWMT and TFL in NTG group were significantly decreased(P<0.05 or P<0.01),the contents of IL-1β(P<0.01)and TNF-α(P<0.01,P<0.05)in serum and TNC were significantly increased;and in TNC,the astrocytes were activated significantly(P<0.01),while the relative fluorescence intensity of α7nAChRs and the co-expression of GFAP and α7nAChRs were significantly decreased(P<0.05,P<0.01).Compared with NTG group,PWMT and TFL in TA group were increased(P<0.05 or P<0.01),the contents of IL-1β(P<0.01)and TNF-α(P<0.01,P<0.05)in serum and TNC were increased;and in TNC,the relative fluorescence intensity of GFAP was significantly decreased(P<0.01),however the relative fluorescence intensity of α7nAChRs and the co-expression of GFAP and α7nAChRs were significantly increased(P<0.01).Compared with MLA group,PWMT and TFL in TA groups and PNU groups were significantly increased(P<0.05 or P<0.01).The contents of IL-1β(P<0.05)and TNF-α(P<0.01)in serum and TNC of TA group were increased,while the contents of TGF-β(P<0.05)were decreased.The contents of IL-1β in serum and TNC of PNU group were decreased(P<0.01,P<0.05),while the contents of TGF-β(P<0.01)were significantly increased.Conclusions Acupuncture can effectively relieve CM inflammatory response and hypersensitivity to pain,and its anti-inflammatory and analgesic effects may be related to the up-regulation of α7nAChRs expression.
8.Two cases of deficiency in ELF4 gene X-linked and literature review
Yu ZHOU ; Libo WANG ; Chunyan ZHANG ; Juan DING ; Mingsheng MA ; Hongmei SONG
Chinese Journal of Pediatrics 2024;62(12):1164-1168
Objective:To summarize the clinical phenotype and genetic characteristics of deficiency in ELF4 gene X-linked (DEX).Methods:A case series study was conducted to retrospectively analyze the clinical data and genetic testing results of 2 cases of DEX treated at Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and the First Hospital of Jilin University from January 2023 to April 2024. And literature up to April 2024 was searched from the PubMed database, as well as CNKI and Wanfang databases, using keywords such as "ELF4 deficiency" "deficiency in ELF4, X-linked""ELF4 gene". The main clinical manifestations and genotypes of DEX were summarized.Results:Both patients were male, with onset ages of 3 months and 3 years, respectively. Both patients presented with recurrent oral ulcers and abdominal pain. And the laboratory examination showed a significant increase in inflammatory markers. Intestinal examinations showed multiple intestinal ulcers, and both patients developed intestinal fistulas. Whole exome sequencing found ELF4 c.799C>T, p Arg267Trp and ELF4 c. 248-7G>A, both maternal variants. Based on clinical and genetic results, DEX were diagnosed. In terms of treatment, both patients underwent surgical treatment during the acute phase of the disease and received anti-tumor necrosis factor α therapy, but recurrent gastrointestinal symptoms were still observed in Patient 1, while the clinical effect in Patient 2 was still acceptable. However, the inflammatory markers in both patients were not normal even after treatment. Literature review found 18 patients including 2 patients in this study, reported in 5 English articles and no Chinese reports. Thirteen patients had disease onset age before 5. The main clinical manifestations were fever (12/17), oral ulcers (14/18), abdominal pain (8/18), diarrhea (6/18), perianal ulcers (5/17), ileum ulcers (6/16), colon ulcers (7/16), skin involvement (7/17) and recurrent infections (7/18); laboratory examinations found increased erythrocyte sedimentation rate (13/15) as well as C-reactive protein (9/9), and anemia (13/15); in terms of immunological function, there is a decrease in natural killer cells (9/15) as well as a decrease in class switching memory B cells (8/9). The main types of gene variantions were missense variantions (6/18), nonsense variantions (4/18) or frameshift variantions (3/18).Conclusions:DEX should be considered when an early-onset male patient manifested with recurrent fever, oral ulcers or mucosal ulcers, with elevated inflammatory markers, with or without recurrent infection. It is recommended to perform lymphocyte subsets analysis, gastrointestinal endoscopy and genetic testing to support the diagnosis.
9.Research progress in antenna technology for microwave imaging of stroke
Haisheng ZHANG ; Xu NING ; Lin XU ; Wei ZHUANG ; Zelin BAI ; Lilong ZHOU ; Jia XU ; Feng WANG ; Mingsheng CHEN
International Journal of Biomedical Engineering 2023;46(3):231-239
The diagnostic technology of acute stroke by microwave imaging has the advantages of being non-ionizing, fast, small, and low-cost. Therefore, this technology is expected to become an auxiliary or alternative means to CT and MRI technology. As the signal transmitting and receiving device of the microwave imaging system, the antenna has an important influence on the performance of the imaging system. At present, there are many antennas with different performances used in imaging systems, but there is a lack of clear evaluation criteria for them. In this paper, several typical antennas were introduced, their advantages and disadvantages from the perspective of bandwidth and near-field were analyzed, and the common requirements of imaging systems for antennas and the performance indicators of various types of imaging systems were summarized. Moreover, the development trend of antenna technology for microwave imaging was pointed out to provide a reference for the study of stroke microwave imaging technology.
10.Effects of Acupuncture on Gut Microbiota and Central Iinflammation in Rat Model of Migraine based on"Gut-Brain"Theory
Mingsheng SUN ; Xingyu CHEN ; Mengdi ZHOU ; Yi LIU ; Yuqi ZHENG ; Siying HUANG ; Dingjun CAI ; Ling ZHAO
World Science and Technology-Modernization of Traditional Chinese Medicine 2023;25(8):2726-2734
Objective Based on the theory of"gut-brain",this study explored the effect of acupuncture on the gut microbiota and central inflammation in migraine model rats,in order to explore the mechanism of acupuncture in the treatment of migraine from the perspective of"gut-brain".Methods The migraine rat model was established by subcutaneous injection of nitroglycerin.They were randomly divided into a model group and an acupuncture group,with 6 rats in each group,and a control group with 6 rats for conventional binding and fixation.Before modeling and on the 1st,5th,and 9th days after modeling,each group used electronic VonFrey to measure the plantar mechanical pain threshold of rats.After the experiment,Elisa was used to detect the expression levels of inflammatory factors IL-6 and TNF-α in the central trigeminal spinal nucleus of the rats in each group.Three-generation Pacbio full-length microbial diversity sequencing was used to perform 16S full-length rDNA sequencing on each group of fecal samples to detect the operational taxonomic unit(OTU)clustering and its abundance,Alpha diversity index,Beta diversity index,species among the samples in each group.differences in abundance.Results In migraine model rats,plantar mechanical pain threshold was significantly decreased(P<0.01),central IL-6 and TNF-α contents were significantly increased(P<0.01),and the structure and abundance of gut microbiota were abnormal.change(P<0.01).Continuous acupuncture treatment can significantly increase the plantar mechanical pain threshold in migraine rats(P<0.01),regulate the diversity of gut microbiota in migraine rats,increase Lactobacillus murine,and reduce the abundance of Lactobacillus enterobacteriaceae.degree(P<0.05),and decreased the levels of IL-6 and TNF-α in the central nervous system of migraine model rats(P<0.01).Conclusion Acupuncture can exert the"gut-brain"anti-inflammatory and analgesic effect of acupuncture in the treatment of migraine by regulating the gut microbiota structure and the expression of central IL-6 and TNF-α inflammatory factors in migraine model rats.

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