Currently, there are practical and technical difficulties in the construction of clinical questions in the development of clinical practice guidelines. Clinicians or guideline developers seldom construct clinical questions based the actual case scenario, leading to some information loss between structured and actual clinical connotation. To overcome this challenge, we proposed a case-guided questions construction approach, and carried out case research and verification in the formulation of the guideline. We found that this method could more efficiently and scientifically assist the formulation of clinical questions, and provide reference for clinicians or guideline developers.

ObjectiveTo investigate the identification of kidney Yang deficiency syndrome of patients with osteoporosis（OP）， and to form the clinical syndrome identification rules of traditional Chinese medicine（TCM）. MethodBasic information， etiology， clinical symptoms and other characteristics of 982 OP patients were included， and statistical tests were used to screen the variables associated with kidney Yang deficiency syndrome. Taking the decision tree as the base model， bootstrap aggregation algorithm（Bagging algorithm） was utilized to establish the classification model of kidney Yang deficiency syndrome in OP， generating numerous rules and removing redundancy. Combining least absolute shrinkage and selection operator（LASSO） regression to screen key rules and integrate them to construct an identification model， achieving the identification of kidney Yang deficiency syndrome in OP patients. ResultEighteen key identification rules were screened out， and of these， where 11 rules with regression coefficients>0 correlated positively with the kidney Yang deficiency syndrome， the rule with the highest coefficient was chilliness（present）&feverish sensation over the palm and sole（absent）. The other 7 rules with regression coefficients<0 correlated negatively with the syndrome， the rule with the lowest coefficient was reddish tongue（present）&diarrhea（absent）&deficiency of endowment（absent）. According to the regression coefficients of each key rule， variables with importance>0.2 were ranked as chilliness， reddish tongue， feverish sensation over the palm and sole， cold limbs， clear urine， diarrhea， deficiency of endowment， prolonged illness. The results of the partial dependence analysis of the identification model showed that compared to OP patients without chilliness， those with chilliness（present） had a 0.266 8 higher probability of being identified as having kidney Yang deficiency syndrome， indicating that this variable had the highest impact on identification of the syndrome. Similarly， compared to OP patients without reddish tongue， those with reddish tongue had a 0.141 9 lower probability of being identified as having kidney Yang deficiency syndrome， indicating that this variable had the highest impact on identifying non-kidney Yang deficiency syndrome. The accuracy， sensitivity， specificity and area under receiver operating characteristic curve（AUC） of the established kidney Yang deficiency syndrome identification model in the test set were 0.865 9， 0.853 7， 0.872 0 and 0.931 5， respectively. ConclusionA precise identification model of OP kidney Yang deficiency syndrome is conducted basing on the rule ensemble method of Bagging combining LASSO regression， and the screened key rules can explain the identification process of kidney Yang deficiency syndrome. In this research， according to the regression coefficients of rules， the importance and partial dependence of variables， combined with the thinking of TCM， the influence of patient characteristics on the identification of syndromes is described， so as to reveal the primary and secondary syndromes of identification and assist the clinical identification of kidney Yang deficiency syndrome.

Objective To compare the diagnostic performance of PI-RADS v2.1 and PI-RADS v2 in the detection of clinically significant prostate cancer(csPCa) by Meta-analysis. Methods The major biomedical databases were searched (CNKI, CBM, Medline, and Embase) with the keywords "PIRADS v2.1" or "PI-RADS v2.1". The Quality Assessment of Diagnostic Accuracy Studies Tool v2 (QUADAS-2) was used to evaluate literature quality. Meta-analysis was performed using STATA17.0 and ReMan5.4 software. Forest plots were used to represent the sensitivity and specificity of PI-RADS v2.1 and PI-RADS v2 for each study. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were combined, and diagnostic performance was evaluated using asummary receiver operating characteristic curve (SROC). Subgroup analysis was performed on three covariables: tumor location, threshold, and the nationality of authors. Results A total of 12 studies were included, involving 3 158 patients and 3 243 lesions. Forall zones and the whole gland, PI-RADS v2.1 had a larger area under the SROC curve (AUC) for csPCa performance, compared with PI-RADS v2. Subgroup analysis: PI-RADS v2.1 also had a larger area under the SROC (AUC) to detect transitional zone csPCa. Different diagnostic thresholds: when a score of 4 was used for the threshold, PI-RADS v2.1 had the maximum area under SROC (AUC) for csPCa performance detection. Author nationality: Researches of PI-RADS v2.1 in Chinese authors had the largest area under the SROC (AUC) in detecting csPCa performance. Conclusion Compared with PI-RADS v2, the diagnostic performance of PI-RADS v2.1 in detecting csPCa is not obviously improved and overall specificity is still low.

ObjectiveTo construct a quantitative differentiation model of traditional Chinese medicine （TCM） syndromes by taking primary osteoporosis （POP） with kidney yang deficiency syndrome as an example， and to provide methodological reference for the standardization of syndrome differentiation. MethodsHigh-frequency clinical features of POP were screened by descriptive statistical analysis， and strong association features of POP were obtained by association rule algorithm. On this basis， a latent structure （latent tree） model was established through latent structure analysis， and the implicit and explicit variables （features） related to POP with kidney yang deficiency syndrome were comprehensively clustered， and the clustering results were interpreted by the indexes of mutual information and cumulative information coverage， to explore the primary and secondary symptoms， and to deduce the categories of POP with kidney yang deficiency syndrome based on the probability of the features appearing in the various latent categories. Based on the categories， the clinical feature scores and identification thresholds were calculated， and the syndrome differentiation model of POP with kidney yang deficiency was initially constructed by combining the comprehensive judgment rules. Finally， the results of TCM professionals' judgment were used as the gold standard to further evaluate the effectiveness of the model in assisting the syndrome differentiation. ResultsThe 32 features strongly associated with POP were obtained， and the Bayes information critedon score of the further constructed latent tree model was -15291.93. Based on the mutual information and the cumulative information coverage， the main symptoms of POP with kidney yang deficiency syndrome were bone weakness， fatigue， pale tongue， clear urine， frequent nocturnal urination， cold limbs， thin pulse， white coating， and secondary symptoms were weakness， loss of libido， loose stool， frequent urination， lumbar and knee weakness， and fear of cold. From the probability of the occurrence of each clinical feature in different latent categories of POP with kidney yang deficiency syndrome， the state was introduced as S0 category （none/mild kidney yang syndrome）/ S1 category （moderate kidney yang syndrome）/ S2 category （severe kidney yang syndrome）. Optimizing the preliminary rules of state identification and refining the state of S1 category， the results showed that among 970 patients with POP， there were 520 patients having no/mild kidney yang deficiency syndrome， 224 patients with moderate to mild kidney yang deficiency syndrome， 81 patients with moderate to severe kidney yang deficiency syndrome， and 145 patients with severe kidney yang deficiency syndrome. During the evaluation and validation process， the correct rate of the model assessment index was 0.8835， while the sensitivity was 0.7181， and the specificity was 0.9437. ConclusionCombined with the latent structure analysis of the association rule， the syndrome differentiation model for POP with kidney yang deficiency could be constructed， and the model shows a good quantitative identification effect， which can provide methodological supports for clinicians to improve the efficiency and accuracy of TCM diagnosis.

Objective:To investigate the clinical manifestations and characteristics of tracheobronchial foreign bodies in children, and improve the diagnosis and treatment of foreign bodies.Methods:A retrospective analysis was performed on the clinical data of children with tracheobronchial foreign bodies confirmed by fiberoptic bronchoscopy between January 2010 to December 2019.The children with tracheobronchial foreign body who were treated in the Maternal and Child Health Hospital of Gansu Province.Results:A total of 967 cases were operated by soft electronic bronchoscope, and foreign bodies were removed by means of foreign body forceps or nets.Among them, 19 cases(3 cases with subglottic foreign bodies, one with row of pins, and the rest 15 cases with foreign bodies completely wrapped by granulation)were not removed, two cases were spontaneously coughed, and 946 cases (97.8%)were removed.Bronchial foreign bodies in children were more common in boys, with the ratio of male to female being 2.14∶1.The main age of onset was 1-3 years old(88.8%). The incidence was slightly higher in rural areas than that in urban areas(46.5% in urban areas, 53.5% in rural areas). Foreign bodies were inhaled most in March and least in June.From the perspective of season, winter and spring were more than summer and autumn.The foreign body types inhaled were mainly exogenous plant foreign body, accounting for 93.0%, among which peanut(31.7%)and melon seeds(19.2%)were the most common.The duration of foreign body inhalation was up to 347 cases(35.9%)in 1-3 days.There were 501 cases(51.8%)with endoscopic endobronchial inflammation, and 196 cases of children with varying degrees of granulomatous hyperplasia, accounting for 39.1% and 20.3% of the total.The foreign body in the right bronchus accounted for 50.0% and the left bronchus for 43.7%.There were 793 cases confirmed by imaging, with a positive rate of 81.9%, and 90.9% confirmed by CT.Conclusion:About 88.8% of tracheobronchial foreign bodies occurred in 1 to 3 years of age.The occurrence of foreign bodies had obvious gender, urban-rural and seasonal distribution characteristics, and more cases were male, in rural and winter as well as spring.

Nine cases of colorectal lipoma who were admitted from January 2005 to December 2016 were reported.The pathological diagnosis was confirmed after surgery,and all 9 cases were cured and discharged.All patients were followed up and were alive by January 2017.

Objective To explore the relationship between phosphatidylinositol 3 kinase (PI3K)/protein kinase B (Akt)/mammals target protein rapamycin (mTOR) signal transduction pathway and Barrett esophagus genesis.Methods A total of 140 rats were divided into sham operated group (n=10),iron group (n =10),esophageal duodenal side anastomosis group (n =30),esophageal duodenal side anastomosis plus iron group (n-30),esophageal gastric duodenal side anastomosis group (n=30) and esophageal gastric duodenal anastomosis plus iron group (n=30).In the end,10 normal esophagus tissue specimens,62 reflux esophagitis tissue specimens and 34 Barrett's esophagus tissue specimens were obtained.The expression levels of epidermal growth factor receptor (EGFR),Akt,phospho Akt (p-Akt),phospho-mTOR (p-mTOR) protein were detected by immunohistochemistry.Single factor analysis of variance,SNK between two groups and nonparametric correlation analysis were performed for statistical analysis.Results The protein expression levels of EGFR,Akt,p-Akt,p-mTOR in Barret(s esophagus tissues were higher than those in reflux esophagitis tissues and normal esophagus tissues (EGFR 0.1799±0.0367 vs 0.0438±0.0025 and 0.0277±0.0069,q=6.79,4.13; Akt 0.1874±0.0250 vs 0.0986±0.0093 and 0.0383±0.0048,q=6.51,3.56; p-Akt 0.1418±0.0130 vs 0.0592±0.0027 and 0.0281 ±0.0017,q=7.68,3.99; p-mTOR 0.1591±0.0275 vs 0.0674 ±0.0059 and 0.0112±0.0017,q=5.62,4.11; all P＜0.05).The protein expression levels of EGFR,Akt,p-Akt,and p-mTORin reflux esophagitis tissues were higher than those in normal esophagus tissues(q=4.67,4.29,4.27,4.03; all P＜0.05).Conclusion PI3K/Akt/mTOR signal transduction pathway were activated in reflux esophagitis and Barrett's esophagus,which provided theoretical basis for clinical multi-target treatment for diseases.

BACKGROUND:The basic idea of artificial disc replacement is the intension to minimize the impact on adjacent segments based on the premise of stabilizing index segment, then prevent and reduce the incidence of adjacent segment degeneration.
OBJECTIVE:To explore the indications and contraindications of artificial disc replacement, peri-operative
economics considerations, long-term complications, as wel as the effect of artificial lumbar disc replacement combined with fusion surgery.
METHODS:The PubMed database, CNKI database and SinoMed database over the past decade were searched for the related articles. The retrospective and prospective clinical trials of artificial lumbar disc replacement were included. Repetitive studies and stale perspectives were excluded. A total of 34 articles were summarized and analyzed in the end.
RESULTS AND CONCLUSION:Since the first artificial lumbar disc prosthesis designed to be commercial y
distributed in 1982, there have been a plenty of clinical trials on lumbar disc replacement. However, there is no
answer to many problems that encountered in clinical trials. The effect of the number of replaced segment on the clinical outcomes, the effect of facet joint degeneration on the clinical outcomes, selection of the patients with the history of lumbar disc surgery, age of the patients and the rest time before disc replacement should be taken into consideration in the researches on indications and contraindications of artificial disc replacement. The
intraoperative blood loss, operation time and hospital stay after replacement can be used to evaluate whether lumbar disc replacement is better than the traditional lumbar fusion surgery or not. The complications after lumbar disc
replacement include heterotopic ossification, implants mechanical failure, and facet joint and adjacent segment
degeneration. The combination of lumbar disc replacement and fusion surgery for the treatment of multi-segmental lumbar disc diseases can achieve complement and thus obtaining the efficacy that better than the application of one surgery alone.

BACKGROUND:Artificial Lumbar disc replacement as a new choice for the treatment of degenerative disc disease has aroused widespread concern by clinicians because of the preservation of lumbar vertebra’s biomechanical characteristics during pain eliminating. While the design of the prosthesis structure and material needs further study and validation.
OBJECTIVE:To review the structure and material types of several newly designed artificial lumbar discs, then to discuss the trends in the optimization design of prosthesis, in order to provide instruction for the design and assessment of new lumbar artificial disc prosthesis.
METHODS:The PubMed database, CNKI database and SinoMed database were searched for related articles. New articles related to artificial lumbar disc structure, material, in vivo and in vitro biomechanics were included. Repetitive studies and stale perspectives were excluded. A total of 46 articles were summarized and discussed in the end.
RESULTS AND CONCLUSION:Artificial lumbar disc has developed for nearly 30 years, the design of structure and biological material has been in continuous improvement. At first, we summarized the principle and current situation in the design of movement reservation, movement constraint, instant fixation, base material, weight-bearing material and coating material of artificial lumbar disc prosthesis, then combined with the exist newly in vivo and in vitro biomechanical results to evaluate different kinds of design with the recent research trend to prospect the development of biomimetic design, material improvement, the optimization design of prosthesis and assisted devices.

Objective To investigate the role of deoxycholic acid (DCA) in the pathogenesis of Barrett esophagus.Methods Normal human esophageal mucosal epithelial cells were cultured in vitro with defined keratinocyte serum-free media (D-KSFM).The cultured cells were treated with different concentrations of DCA and specific p38 mitogen activated protein kinase (MAPK) inhibitor. The expression of p38,phosphorylated p38 (p-p38) and caudal-related homeodomain transcription 2 (CDX2) at protein level were assessed by Western blot.The correlation between p-p38 and CDX2 was analyzed.The data were analyzed by one way ANOVA and LSD test.Results After being cultured with DCA for 24 h,the expression of p-p38 and CDX2 increased along with the increasing of DCA concentration.Compared with the control group (p-p38 was 13.7％ ± 1.0％ and CDX2 protein was 0),the difference was statistically significant (P＜ 0.05).When DCA was at 500 μmol/L,the expression of p-p38 and CDX2 reached the highest level (44.0％ ± 1.7％ and 8.59± 1.25).After pretreated with SB203580 for two hours and then 500 μmol/L DCA was added into cell culture,both expression level of p-p38 and CDX2 decreased compared with 500μmol/L DCA group (p-p38:28.3％ ±2.2％ vs50.5％±9.5％,CDX2:0.94±0.13 vs 2.31±0.41) after 24 h.Conclusions DCA can induce the expression of CDX2 in normal human esophageal mucosal epithelial cells,which is related with the activation of p38.The phosphorylation of p38 maybe involved in the pathogenesis of Barrett esophagus.