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.

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.

BACKGROUND:Lisfranc ligament is an important structure to maintain the transverse and longitudinal arch of the foot.This injury is a serious middle-foot injury.Lisfranc ligamentous injuries are complex,and their treatment,along with the preferred method of fixation,is controversial. OBJECTIVE:To compare the short-term efficacy of plate combined with Suture tape versus plate combined with headless compression screw in the treatment of Lisfranc injury with comminuted fractures of the 1st and 2nd proximal metatarsal bones. METHODS:A retrospective analysis was performed on 48 patients with Lisfranc injury due to comminuted fractures of the 1st and 2nd proximal metatarsal bones in Seventh Department of Orthopedics,Dongguan Hospital of Traditional Chinese Medicine from January 2019 to June 2022.Among them,25 were fixed with plate combined with Suture tape(observation group)and 23 were fixed with plate combined with headless compression screw(control group).Preoperative classification was performed according to Myerson classification system based on preoperative imaging data.Postoperative follow-up was performed according to fracture healing time,visual analog scale,and American Orthopaedic Foot and Ankle Society(AOFAS)criteria to assess the recovery of foot functions.Postoperative complications were compared and analyzed between the two groups. RESULTS AND CONCLUSION:(1)All cases completed the operation successfully and obtained follow-up in the two groups.The postoperative follow-up time of the two groups was 12-36 months,with a mean of(18.0±5.42)months.(2)There were no significant differences in operation time and intraoperative blood loss between the two groups(P>0.05).(3)The fracture healing time of observation group was slightly longer than that of control group(P<0.05).(4)After 3,6,and 12 months of follow-up,the visual analog scale score of the observation group was significantly lower than that of the control group(P<0.05).(5)At 6 and 12 months after operation,AOFAS score of foot function in the observation group was significantly improved compared with the screw group at various time points after operation(P<0.05),and was significantly higher than that before operation(P<0.05).(6)The postoperative complications were 1 case of traumatic arthritis in the observation group and 1 case of incision infection,1 case of screw fracture,and 2 cases of traumatic arthritis in the control group.There was no significant difference between the two groups(P>0.05),considering the correlation with a small sample size.(7)It is indicated that as for the surgical method of Lisfranc injury with comminuted fractures of the 1st and 2nd proximal metatarsal bones,the application of plate combined with Suture tape internal fixation has a reliable effect in the treatment of Lisfranc joint injury,which can improve the function of the foot joint of patients,and has the advantages of less surgical trauma,fewer postoperative complications,and lower risk of long-term iatrogenic traumatic arthritis.Compared with headless compression screw,it is more beneficial to the recovery of foot function.

OBJECTIVE To investigate the clinical efficacy of pramipexole combined with levodopa-benserazide in the treatment of Parkinson’s disease （PD）. METHODS A total of 108 PD patients treated at the Fifth People’s Hospital of Wuhu City from January 1， 2021， to February 28， 2023， were randomly divided into observation group and control group， with 54 cases in each group. Patients in the control group were administered levodopa-benserazide （initial dose of 62.5 mg per dose）， three times daily； after one month， the dose was increased to 250 mg per dose， four times daily. Patients in the observation group received the same treatment as the control group， with the addition of pramipexole （initial dose of 0.25 mg per dose） orally twice daily on an empty stomach； after 14 days， the dose was increased to 0.25 mg per dose， three times daily. Both groups were treated for 3 months. The short-term efficacy， safety and long-term prognosis of the two groups were compared. RESULTS After treatment， the observation group had significantly lower scores on the Unified Parkinson’s Disease Rating Scale part Ⅲ （UPDRS-Ⅲ）， the Hamilton Depression Scale （HAMD）， the Hamilton Anxiety Scale （HAMA）， and the Parkinson’s Disease Questionnaire-39（ PDQ- 39） compared to the control group； in contrast， the observation group had higher scores on the Montreal Cognitive Assessment （MoCA） scale， the Mini-mental State Examination （MMSE） scale， the Mattis Dementia Rating Scale （DRS）， and the Quality of Life （QOL） scale （P＜0.05）. Both groups showed a significant reduction in UPDRS-Ⅲ and PDQ-39 scores， and a significant increase in DRS scores compared to baseline （P＜0.05）. However， only the observation group showed a significant increase in MoCA scale， MMSE scale， and QOL scores， and a significant decrease in HAMD and HAMA scores compared to baseline （P＜ 0.05）. The total incidence of adverse drug reactions in both groups was not significantly different （P＞0.05）. The 12 months follow-up results showed that the incidence of dementia and mortality rates in the observation group were significantly lower than the control group （P＜0.05）. CONCLUSIONS Pramipexole combined with levodopa-benserazide significantly improves motor function， cognitive function， quality of life and symptoms of depression and anxiety in PD patients， and may reduce the long-term risk of dementia and mortality in these patients.

Objective: To investigate the trends in mortality and life loss of gastric cancer in Wenzhou City, Zhejiang Province from 2014 to 2023, so as to provide the evidence for formulating the prevention and control strategy for gastric cancer. Methods: The surveillance on causes of death data of permanent residents in Wenzhou City were collected through the Wenzhou Chronic Disease Monitoring and Management Information System from 2014 to 2023. The crude mortality of gastric cancer was calculated, and standardized by the data from the Sixth Chinese National Population Census in 2010. The life loss were measured using potential years of life lost (PYLL) and rate of potential years of life lost (PYLLR). The characteristics of mortality and life loss of gastric cancer in different genders and age groups were described. The trends in mortality and PYLLR of gastric cancer were analyzed using the average annual percent change (AAPC). Results: Totally 17 080 deaths were reported due to gastric cancer in Wenzhou City from 2014 to 2023, accounting for 12.58% and ranking third in the order of malignant tumor deaths. The crude mortality of gastric cancer was 20.73/105, and the standardized mortality was 15.22/105, showing decreasing trends (AAPC=-3.311%, -6.470%, both P<0.05). The crude mortality of gastric cancer was 29.22/105 in men and 11.61/105 in women, with standardized mortality rates of 20.81/105 and 8.74/105 (both P<0.05). The crude mortality of gastric cancer appeared a tendency towards a rise with increasing age (P<0.05), reaching the highest rate of 225.88/105 in the group aged 80 to <85 years. The PYLL and PYLLR of gastric cancer were 107 607.50 person-years and 1.37‰. The PYLLR appeared a tendency towards a decline from 2014 to 2023, with AAPC of -6.667% (P<0.05). Conclusions The mortality and PYLLR of gastric cancer in Wenzhou City appeared a tendency towards a decline from 2014 to 2023. Men and the elderly populations were the key groups for the prevention and treatment of gastric cancer.

Objective To investigate the protective effect and mechanisms of total alkaloids of Bulbus Fritillaria Pallidiflora (TA-BFP) on pulmonary fibrosis in silicosis mice. Methods i) Bulbus Fritillaria Pallidiflora (BFP) powder was collected by heating and refluxing twice with 70.00% ethanol, and the dried concentrated sample was purified using cation-exchange and macroporous adsorbent resins to obtain TA-BFP. The total alkaloids level was detected using ultraviolet spectrophotometry and the characteristic peaks in TA-BFP were identified using the high-performance liquid chromatography-evaporative light scattering detector (HPLC-ELSD). ii) Specific pathogen-free male C57BL/6J mice were randomly divided into the control group, model group and intervention group, with 15 mice in each group. Mice in the model group and the intervention group were treated with 80 μL silica suspension with a mass concentration of 62.5 g/L, while the control group was treated with an equal volume of 0.9% sodium chloride solution using non-exposed tracheal instillation method. On the 28th day after modeling, mice in the intervention group were given TA-BFP at a dose of 60 mg/kg body mass, and the model group and control group were given 2.00% Tween-80 solution at the same volume by gastric gavage, once per day, for 28 days. The mouse lung tissue pathology was observed, lung organ coefficient was calculated, and inflammation and fibrosis scores were assessed after the intervention period. Serum levels of mouse interleukin (IL)-1β, IL-6, and tumor necrosis factor-α (TNF-α) were measured by enzyme-linked immunosorbent assay. Results i) The total alkaloid level of TA-BFP in the BFP powder was 50.36% after elution and purification. A total of nine alkaloid components in TA-BFP were identified by HPLC-ELSD. ii) The results of lung histopathology showed that no obvious changes of inflammation and fibrosis were identified in the lungs of mice in the control group, obvious changes of inflammation and fibrosis were identified in the lungs of mice in the model group, and the intervention group showed reduced inflammation and fibrosis in the lungs of mice compared with that of the model group. The lung organ coefficient, pulmonary inflammation score, pulmonary fibrosis score, and levels of serum IL-1β, IL-6, and TNF-α were significantly higher in the model group than those in the control group (all P<0.05). The lung organ coefficient, pulmonary inflammation score, pulmonary fibrosis score, and levels of serum IL-1β, and TNF-α were significantly higher in the intervention group than those in the control group (all P<0.05), while the pulmonary inflammation score, pulmonary fibrosis score, and levels of serum IL-1β, IL-6, and TNF-α were significantly lower in the intervention group than those in the model group (all P<0.05). Conclusion TA-BFP alleviates pulmonary inflammation in silicosis mice, thereby delaying the progression of pulmonary fibrosis. The mechanism may involve in inhibiting the expression of inflammatory factors IL-1β, IL-6, and TNF-α.

Objective To analyze the proportion and clinicopathological characteristics of HER2-positive breast cancer patients with BRCA1/2 pathogenic variants, and their response to neoadjuvant anti-HER2 targeted therapy. Methods The clinicopathological data of 531 breast cancer patients with germline BRCA1/2 pathogenic variants (201 with BRCA1 variants and 330 with BRCA2 variants) were analyzed. Results Among the 201 BRCA1 and 330 BRCA2 variants, 17 (8.5%) and 42 (12.7%) HER2-positive breast cancer cases were identified, respectively, accounting for 11.1% of all BRCA1/2-mutated breast cancers. Compared with BRCA1/2-mutated HR-positive/HER2-negative patients, HER2-positive patients did not present any significant differences in clinicopathological features; however, compared with triple-negative breast cancer patients, HER2-positive patients had a later onset age and lower tumor grade. Among the 17 patients who received neoadjuvant anti-HER2 targeted therapy, 10 cases achieved pCR (58.8%), whereas 7 cases did not (41.2%). Conclusion HER2-positive breast cancer accounts for more than 10% of BRCA1/2-mutated patients. Approximately 40% of these patients fail to achieve pCR after neoadjuvant targeted therapy. This phenomenon highlights the possibility of combining anti-HER2 targeted agents with poly (adenosine diphosphate-ribose) polymerase inhibitors.

ObjectiveTo obtain the epidemiological characteristics of re-positive cases infected with SARS-CoV-2 in Pudong New Area from March to July 2022, including clinical manifestations, duration of a negative nucleic acid conversion after tested for re-positive, and length of time from the discharge of the initial infection to the most recent re-positivity, so as to provide a scientific basis for the prevention and control of COVID-19. MethodsA questionnaire survey was conducted among the re-positive cases infected with SARS-CoV-2 after discharged from hospital/quarantine facility in Pudong New Area, and descriptive epidemiological methods were used for characteristics analysis. ResultsA total of 2 422 re-positive cases met the inclusive and exclusive criteria, with males accounting for 61.02%. The age distribution mainly fell between 18 and <60 years old, accounting for 62.39%. Clinical manifestations were predominantly asymptomatic (72.15%), followed by cough (12.03%) and sore throat (6.58%). Among the stratified randomized sample of 416 individuals, there were statistically significant differences in symptoms (χ²=262.667, P<0.001), clinical typing (χ²=12.996, P=0.001), and duration of a negative nucleic acid conversion (χ²=142.578, P<0.001) between the initial positive and re-positive instances. Besides, statistically significant differences in symptoms (χ²=13.696, P=0.016) and self-perception of the severity of re-infection (χ²=7.923, P=0.048) between the initial and re-positive cases were observed by different genders. ConclusionAmong re-positive cases, males experienced milder symptoms compared to females, and the self-perception of symptoms during re-positivity is milder than that in the initial positive infection. The length of time for negative nucleic acid conversion during the initial positive period is shorter than that during the re-positive period.