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.

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.

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.

AIM: To evaluate the efficacy of 0.01% hypochlorous acid as a conjunctival sac disinfectant before cataract phacoemulsification and its impact on the ocular surface.METHODS: Randomized controlled clinical trial. A total of 285 patients who were scheduled for cataract phacoemulsification surgery were randomly divided into the hypochlorous acid group and the povidone iodine group. Before and after disinfection, conjunctival sac swabs were taken, and bacterial culture and colony-forming units(CFUs)testing were performed using blood agar and chocolate agar media, respectively. All patients were evaluated for ocular symptom scores and pain severity scores 2 h, 1 d, and 1 wk after disinfection, and underwent corneal fluorescein staining, eye redness index, tear meniscus height, and noninvasive breakup time(NIBUT)examination. The incidence of endophthalmitis after surgery was recorded.RESULTS: Conjunctival sac disinfection with 0.01% hypochlorous acid significantly reduced the rate of positive bacterial cultures and colony-forming ability of the conjunctival sac, with statistically significant differences compared with the pre-disinfection period(both P<0.01), and the disinfecting ability of hypochlorous acid was comparable to that of povidone-iodine(χ2=0.811, P=0.368). The scores of ocular symptoms and pain severity in the hypochlorous acid group were significantly lower than those in the povidone-iodine group(both P<0.01). The corneal fluorescein staining and eye redness index in the hypochlorous acid group were significantly lower than those in the povidone-iodine group(all P<0.01). No endophthalmitis occurred in either group of patients. CONCLUSION: As a conjunctival sac disinfectant, 0.01% hypochlorous acid is safe and effective, with minimal discomfort and damage to the ocular surface in patients.

Objective To provide evidence-based references for the prevention of surgical site infection(SSI)by sum-marizing the best evidence for the prevention of SSI in adult inpatients.Methods The'6S'evidence resource pyramid model was used to systematically search the related evidence in domestic and foreign databases,guideline websites,and academic socie-ty websites from the inception of the database to September 30,2023.Four researchers evaluated the quality of the included guidelines,and two researchers independently evaluated the quality of other types of literature and rated the level of evidence.Results A total of 12 articles were included,including 6 clinical decision making and 6 clinical guidelines.Thirty best items of the evidence were summarized from 7 aspects:diagnosis,clinical symptoms,influencing factors,patient prevention strategies,preventive strategies for medical staff,intraoperative and postoperative treatment,and consultation and education.Conclusion Clinical staff should develop a standardized management plan for infection prevention based on corresponding evidence to reduce the incidence of SSI instead of taking a single measurement.Moreover,they need to formulate a standardized work process for preventing SSI based on the clinical practice and patients'preference.

ObjectiveTo observe the effect of Coptidis Rhizoma and Ophiopogonis Radix on renal tissue injury and epidermal growth factor receptor （EGFR）/phosphatidylinositol 3-kinase （PI3K）/protein kinase B （Akt） signaling pathway in rats with diabetic nephropathy （DN） and explore its possible mechanism of delaying DN. MethodThirty-six male Wistar rats were randomly divided into a normal group （6 rats） and a model group （30 rats）. The model group was fed with a high-fat and high-sugar diet combined with streptozotocin （STZ） to establish a rat model of type 2 diabetes. After the successful preparation of the model， the rats were randomly divided into the model group， low， medium， and high dose groups of Coptidis Rhizoma and Ophiopogonis Radix （100， 200， 400 mg·kg^-1）， and metformin group （200 mg·kg^-1）. After administration， the levels of fasting blood glucose （FBG）， 24 h urine protein （24 h-UTP）， creatinine （SCr）， urea nitrogen （BUN）， and uric acid （UA） were detected. Hematoxylin-eosin （HE） staining and Masson staining were used to observe the pathological changes of renal tissue in rats. Western blot and Real-time fluorescence quantitative polymerase chain reaction （Real-time PCR） were used to detect the related protein expression of EGFR， PI3K， and Akt and their mRNA expression levels in the renal tissue of rats in each group. ResultsCompared with the normal group， the levels of FBG， SCr， BUN， UA， 24 h-UTP， and kidney index in the model group were significantly increased （P<0.01）， most renal tubular epithelial cells were necrotic， and the content of collagen in glomeruli was significantly increased （P<0.01）. Compared with the model group， the above indexes of rats in each administration group were improved to varying degrees. The FBG， SCr， BUN， UA， 24 h-UTP， and kidney index of rats in each dose group and metformin group were significantly decreased （P<0.01， P<0.05）. The necrosis degree of renal tubular epithelial cells was reduced， and the fibrosis area was decreased （P<0.01）. There related protein and mRNA expressions of EGFR， PI3K， and Akt were significantly increased （P<0.05， P<0.01）. ConclusionCoptidis Rhizoma and Ophiopogonis Radix can alleviate renal tissue injury in rats with DN， and their mechanism may be related to the regulation of the EGFR/PI3K/Akt signaling pathway.

OBJECTIVE To identify and classify the chemical components and components absorbed into blood of Sishen Pills u-sing ultra-high performance liquid chromatography-quadrupole-orbitrap high resolution mass spectrometry.METHODS SD rats were divided into blank group and drug administration group.The rats in drug administration group were given water extract of Sishen Pills formula intragastrically,and blank and drug-containing plasma were collected respectively.A Hypersil GOLD VANQUISH column(2.1 mm×100 mm,1.9 μm)was used,with 0.1%formic acid water acetonitrile as the mobile phase,gradient elution,volume flow rate of 0.3 mL·min-1,and column temperature of 35℃.Electrospray ion source(ESI)with positive and negative ion scanning mode was used for chromatographic separation and mass spectrometry data acquisition.The chemical components of Sishen Pills were identi-fied by comparing the exact molecular mass,fragment ion information and relative retention time with the map of reference substance,matching with the self-established database and combining with literature reports.On this basis,the components absorbed into blood of Sishen Pills were analyzed by comparing the blank plasma and drug-containing plasma.RESULTS A total of 181 chemical compo-nents were identified from Sishen Pills,mainly including flavonoids,alkaloids,lignans and other components.A total of 49 prototype blood components were identified from the plasma samples,mainly including flavonoids,alkaloids and other components.CONCLU-SION A variety of chemical components in Sishen Pills and drug-containing plasma are comprehensively,accurately and quickly i-dentified,and all of them are assigned to the various medicinal materials in the prescription.This study provides reference for the qual-ity control,basic research on medicinal effect materials and clinical application of Sishen Pills.

AIM:To establish a model of meibomian gland dysfunction in rats induced by eyeliner tattoo and investigate its potential mechanisms.METHODS:A total of 40 SD rats were selected, with 30 randomly chosen to have eyeliner tattoo applied their right eyes and designated as the eyeliner group. The remaining 10 rats were not given any treatment and served as the normal group. The corneal morphology of both groups was observed using a slit lamp at 1, 2, and 4 wk after establishment, and the tear film break-up time(BUT), Schirmer I test(SIt), corneal fluorescein staining score, and corneal irregularity score were calculated. The corneal Placido rings were examined using an ocular surface analyzer, and the corneal tissue structures of both groups were observed under a confocal microscope. After 4 wk and completion of clinical indicator recording, the eyeballs and upper and lower eyelid tissues were taken for pathological examination. The meibomian gland structures were observed through HE staining, the conjunctival goblet cells were observed using PAS staining, and the lipid droplets were observed with ORO staining.RESULTS:The slit lamp examination results showed that the eyeliner group rats exhibited in situ black pigmentation in the eyelids, with no eyelid deformation or scarring. The corneal epithelium was rough, with positive fluorescein staining, presenting as spotty staining that worsened over time. Compared with the normal group, the BUT was significantly shortened, tear secretion volume was significantly decreased, and the corneal fluorescein staining score and corneal irregularity score were significantly increased at 1, 2, and 4 wk after modeling in the eyeliner group(all P<0.01). The corneal confocal microscopy results showed a decrease in corneal epithelial cells in the eyeliner group, with the appearance of abnormally bright cells, and inflammatory cell infiltration visible in the stromal layer. The ORO staining results revealed a decrease in lipid droplets in the eyeliner group, showing a downward trend with increasing observation time. The HE staining results showed that pigment blocked the meibomian gland openings in the eyeliner group, and the density of meibomian gland acini showed a downward trend over time. The PAS staining results showed a decreasing trend in the number of PAS-positive cells in the eyeliner group.CONCLUSION:Eyeliner tattoo can induce meibomian gland dysfunction, and the blockage of meibomian gland openings caused by the pigment particles used may be an important cause of meibomian gland dysfunction.

Objective:To gain a deeper understanding of the comorbidity status of elderly patients with coronary heart disease and the effect of comorbidity on their hospitalization costs.Methods:Using the convenient sampling method, a total of 8 334 elderly hospitalized patients diagnosed with coronary heart disease in Beijing Hospital from January 2018 to December 2021 were selected as the research objects. General Inforamtion Questionnaire and Charson comorbidity index (CCI) were used to investigate the comorbidity of patients.Results:Among the 8 334 elderly patients with coronary heart disease included, 88.18% (7 349/8 334) had comorbidity, and there was a statistically significant difference in hospital costs among patients with different CCI scores ( P<0.01). Elderly patients with coronary heart disease with comorbidity had higher hospital costs. The results of the binomial logistic regression analysis showed that comorbidities increased the hospitalization costs of elderly coronary heart disease patients in both the unadjusted model and the gradually adjusted model for age, gender, occupation, education level, admission department, admission status, admission year, admission mode length of stay and disease classification ( P<0.05) . Conclusions:The comorbidity in elderly patients with coronary heart disease is serious, which is an important factor affecting hospitalization costs. In medical practice, it is necessary to strengthen the comprehensive management of elderly patients with coronary heart disease, pay attention to the influencing factors of hospitalization costs, optimize prevention and treatment strategies, control the occurrence and progression of comorbidities among patients, deepen the reform of medical insurance payment methods such as grouping payments based on disease diagnosis, so as to accurately reduce hospitalization costs and promote the sustainable and healthy development of the medical and health system.

【Objective】 To analyze the clinical data of prostate cancer patients with normal PSA level confirmed with transperineal prostate biopsy or transurethral prostate surgery, in order to improve the diagnostic level of this disease. 【Methods】 The clinical data of 6 patients were retrospectively analyzed. The age,clinical manifestations, body mass index (BMI),prostate specific antigen density (PSAD),blood triglycerides,blood cholesterol,color ultrasound imaging,magnetic resonance imaging (MRI),pathological types and Gleason scores were analyzed. The clinical characteristics and high-risk factors were summarized. 【Results】 Two cases were confirmed with prostate biopsy and four after prostate resection. Three patients had high blood triglycerides, three were negative for bone imaging, and the other three were not examined. PSAD was 0.017 to 1.215. Color ultrasound indicated that two cases had irregular morphology, two uneven echo, and one both irregular morphology and uneven echo; all six cases had calcification. In the three cases who received MRI, two had PIRADS4 nodules, one had PIRADS5 nodules, invasion of seminal vesicle, rectum, posterior wall of urinary bladder,bilateral thickening of NVB, and lymph nodes enlargement. Pathology suggested prostatic acinar adenocarcinoma in five cases, four of which had a Gleason score of 3+3=6 and one had 5+5=10; one case suggested a high-grade neuroendocrine carcinoma. 【Conclusion】 The clinical detection rate is low for prostate cancer with normal PSA. The biopsy indications should be determined by combining the characteristics and high-risk factors to improve the detection rate.