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2023 Vol. 14, No. 6

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Editorials
Resection and Reconstruction of Robotic Hepatopancreatobiliary Surgery
LIU Rong, LIU Qu
2023, 14(6): 1125-1130. doi: 10.12290/xhyxzz.2023-0380
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Robotic system has overcome the limitations of traditional laparoscopy and promoted the development of minimally invasive surgery. However, in the early stage of robotic hepatopancreatobiliary surgery, the lack of resection and reconstruction technology compatible with the robotic system restricts its application. Based on the previous experience, we propose the circumvascular resection technique, which takes the main blood vessels as the mark, mobilizes the blood vessels and excises the soft tissues around the blood vessels, and the double-low reconstruction technique, which can improve the reconstruction quality by reducing the tissue tension and the tensile stress per unit area during the reconstruction. These two techniques can address the limitations of the robotic system including limit operating space and lack of force feedback, and help to improve surgical safety, reduce learning curve and promote the clinical application of robotic hepatopancreatobiliary surgery.
Artificial Intelligence Assisted Therapeutic Regimen and Technology Transformation in Retinal Diseases
CHEN Youxin, XU Zhiyan
2023, 14(6): 1131-1134. doi: 10.12290/xhyxzz.2023-0247
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In recent years, artificial intelligence (AI) technology has gradually penetrated into many medical specialties, bringing unprecedented changes to the medical field. At present, with the application of AI technology in the field of ophthalmology developing rapidly, AI diagnosis is rapid, highly accurate and objective, which can optimise the diagnosis and treatment mode of ophthalmology patients and greatly improve the efficiency of clinical diagnosis. Some AI ophthalmic imaging research has been translated into products, and therefore both domestic and international AI retinal imaging products are now available. However, due to various factors such as training data, R&D capability, clinical validation and market adaptation, many research outcomes still wait to to be translated. Therefore, we propose new therapeutic regimens of retinal diseases and analyze the underlying constraints to technology translation in AI research, with the hope of improving the use of AI technology in the diagnosis and treatment of fundus diseases.
Medical Artificial Intelligence Standard System: History and Current Status
ZHENG Xinya, HUANG Yunyou, ZHANG Yiting, WENG Shengjie, ZHAN Jianfeng, ZHAGN Zhifei
2023, 14(6): 1135-1141. doi: 10.12290/xhyxzz.2023-0428
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The standardization of medical artificial intelligence (AI) is currently in its infancy and falls short of meeting the needs for the development, deployment, control, assessment, and guidance of medical AI products. This not only makes it difficult to standardize the research and development process and therefore increase the cost and affect the quality of the products, but also leads to challenges in achieving unified interaction, comparison, and evaluation of AI products. It may result in incorrect estimation and evaluation of products, thus misguiding the direction of medical AI development. Consequently, establishing a mature and unified standard system for medical AI has become an urgent priority. To facilitate the advancement of the medical AI standard system from its nascent stage to maturity, we conduct an in-depth analysis of the development history of medical AI standards from four aspects: medical data standards, standard datasets, benchmarks, and norms/guidelines. By revealing the problems in the current medical AI standards, we aim to provide a reference for related research.
Specialist Forum
Application of Robot-assisted System in Cerebrovascular Interventional Therapy
CHEN Peike, JIANG Yuhua
2023, 14(6): 1142-1148. doi: 10.12290/xhyxzz.2023-0374
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Endovascular intervention has become the main treatment method for a variety of cardiovascular and cerebrovascular diseases, but it has some limitations, such as exposure under X-ray during the procedure so that operators need to wear heavy protective garments. With the breakthrough of artificial intelligence, the limitations of the traditional endovascular intervention therapy can be solved by controlling the robot-assisted system outside the operating room. Moreover, the rapid development of the robot-assisted system in recent years has further improved the accuracy, stability, and safety of endovascular intervention therapy. This article focuses on the advantages of the robot-assisted system, the types of the system, its application in clinical treatment, as well as the existing problems of the system and the prospects of its future development.
Analysis and Mitigation Strategies for Failure in Orthopedic Surgical Robots
LIU Xun, RUI Biyu, ZHANG Weijun, YU Hongyi, JIA Yingjie
2023, 14(6): 1149-1154. doi: 10.12290/xhyxzz.2023-0367
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With the breakthroughs in artificial intelligence, orthopedic surgical robots have rapidly advanced, presenting good prospects for their applications in the medical field. Prior to the clinical application of this novel medical device, ensuring high reliability is crucial to safeguarding patient safety and surgical quality. Therefore, a thorough understanding of the types of failures and associated risks is essential during both the development and clinical application phases. From the perspectives of both the research and development companies and clinical users, this article comprehensively elucidates the types of failures and their associated risks in orthopedic surgical robots. Furthermore, strategies for addressing high-risk failures are proposed, with the aim of providing guidance for the development and clinical application of orthopedic surgical robot devices, thereby contributing to the high-quality advancement of this field.
The Method and Application of Digital Twinning in Medicine
CHEN Yafei, LIU Qiong, GUAN Shuang, YU Yanan, LIU Jun, WANG Sicun, WANG Zhong
2023, 14(6): 1155-1161. doi: 10.12290/xhyxzz.2023-0157
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With the rapid development of emerging biotechnologies such as high-throughput sequencing, multi-omics and multi-dimensional research models for biological big data have been initiated. Concurrently, the fast-evolving technologies including mathematical modeling, artificial intelligence, cloud computing, blockchain, big data, the Internet of Things, and 5G have enabled the development of digital twin. Digital twin, a model mapping of physical objects, processes, and systems in digital space, has shown great potential in the medical field. Digital twin technology can provide visualized 3D structures for human organs and systems to assist diagnosis and treatment, create a tangible "skeleton" for data mining in genomics, metabolomics, and phenomics, and simulate processes for chronic disease management, drug development, and clinical trials, thereby advancing the medical field. The aim of the article, therefore, is to review the methods and applications of digital twin in the medical field, with the hope of providing reference for the development of medical digital twin research in China.
Research Progress on Generative Adversarial Network in Cross-modal Medical Image Reconstruction
LI Zhuoyuan, XU Guohao, WANG Junchen, WANG Saishuo, WANG Chuantao, ZHAI Jiliang
2023, 14(6): 1162-1169. doi: 10.12290/xhyxzz.2023-0409
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Single-modal medical images contain limited disease-specific information. To analyze and diagnose patients, clinicians often need to integrate multiple modal images. However, due to limited medical resources and treatment time, it may be difficult to obtain multi-modal images. Cross-modal image reconstruction can generate medical images for clinical needs, thus assisting clinicians in accurately diagnosing and treating diseases. Traditional cross-modal reconstruction techniques have been applied in some clinical scenarios, but the quality of the reconstructed images needs further improvement. Generative adversarial network (GAN) can recover high-quality and complete image data from low-quality or incomplete medical image data, maximally savings medical equipment resources and accelerating medical treatment speed. This article summarizes the applications of GAN technology in cross-modal image reconstruction across X-ray imaging, computed tomography imaging, magnetic resonance imaging, and positron emission tomography imaging, to provide reference for the development of more advanced cross-modal reconstruction techniques.
ChatGPT Empowered Nursing Practice: Prospects, Risks, and Countermeasures
GUO Caixia, GUO Caixu, SHI Xiaoning, GUO Jinli
2023, 14(6): 1170-1174. doi: 10.12290/xhyxzz.2023-0326
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As a natural language processing model based on artificial intelligence technology, ChatGPT provides a new path in assisting clinical care implementation, enhancing patient health management and realizing patient intelligent companionship. Given that any technology has two sides, ChatGPT also has potential risks in nursing practice, such as inadequate construction inducing nursing errors, alienated nurse-patient relationship of "digital dependence", and ethical considerations caused by information worries. Therefore, it is suggested to improve the regulatory system, clarify the main body of responsibility, break the "information cocoon", improve digital literacy, control information "streaked", avoid algorithm discrimination and other strategies to improve the application value of ChatGPT in nursing practice and promote the rational development of ChatGPT artificial intelligence in the field of nursing.
Standard and Specification
Interpretation on the Standard Artificial Intelligence Medical Device- Quality Requirements and Evaluation-Part 1: Terminology
MENG Xiangfeng, WANG Hao, LI Jiage
2023, 14(6): 1175-1179. doi: 10.12290/xhyxzz.2023-0351
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With the rise of artificial intelligence medical device (AIMD) industry, it is urgent for stakeholders to establish consensus on the definition and concepts of AIMD quality evaluation, so as to further support the development of standards and guidelines. To break through industry bottleneck, the National Medical Products Administration (NMPA) published YY/T 1833.1-2022 Artificial Intelligence Medical Device- Quality Requirements and Evaluation- Part 1: Terminology in 2022, which provides unified terminology. This standard is divided into five chapters, including a total of 158 terms that cover basic technology, data set, quality characteristics, quality evaluation and application scenario. This article introduces the general overview, the drafting history and explains its significance, with the aim of guiding the development of artificial intelligence medical device industry.
Interpretation on the Standard Artificial Intelligence Medical Device-Quality Requirements and Evaluation-Part 2: General Requirements for Datasets
WANG Hao, MENG Xiangfeng, HAO Ye, LI Jiage, LI Jingli
2023, 14(6): 1180-1184. doi: 10.12290/xhyxzz.2023-0464
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Datasets, as an important resource for artificial intelligence medical device industry, have been placed under medical device supervision. National Medical Products Administration (NMPA) has published a sectoral standard named YY/T 1833.2-2022 Artificial Intelligence Medical Device-Quality Requirements and Evaluation-Part 2: General Requirement for Datasets to guide dataset quality evaluation. This standard describes dataset requirements for documentation and quality measures, proposes evaluation methods, and helps dataset producers enhance quality control from the source. It would benefit clinical agencies in dataset construction and better meet industry need. This article introduces the background and key points of the standard, in order to better guide the applications in artificial intelligence medical device industry.
Interpretation On Sectoral Standard Artificial Intelligence Medical Device-Quality Requirements and Evaluation-Part 3: General Requirements for Data Annotation
HAO Ye, WANG Hao, LI Jiage
2023, 14(6): 1185-1188. doi: 10.12290/xhyxzz.2023-0463
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With the upgrading of machine learning technology, artificial intelligence has become an emerging direction in the field of medical devices. Especially in recent years, it has developed rapidly. In 2022, the National Medical Products Administration released the industry standard YY/T 1833 "Artificial Intelligence Medical Device-Quality Requirements and Evaluation" series, marking the initial establishment of a standard system for artificial intelligence medical devices in China. The standardization of data annotation is not only an important part of the standard system, but also determines the accuracy and reliability of reference standards, which has a significant impact on the quality of the dataset and product quality. Part 3 of "Artificial Intelligence Medical Device-Quality Requirements and Evaluation", a general requirement for data annotation, proposes the quality requirements for artificial intelligence medical devices in the data annotation process and standardizes the evaluation methods. This paper highlights its important contents, in order to better carry out product quality control and promote high-quality development of products and industries.
Operating Technical Specifications on Sedation/Analgesia/Anesthesia in Diagnosis and Treatment of Chinese Plastic and Aesthetic Major(2023)
Quality Control Center of Plastic and Aesthetic Major, Quality Control Center of Anesthesia Major
2023, 14(6): 1189-1196. doi: 10.12290/xhyxzz.2023-0472
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With the development of society, more and more people are eagerly pursuing beauty, as evidenced by a remarkably increasing demand for medical cosmetic surgery. However, medical safety accidents in plastic and aesthetic fields have frequently occurred in recent years, in which those related to anesthesia have attracted particular attention. In this case, Quality Control Center of Plastic and Aesthetic Major, together with Quality Control Center of Anesthesia Major, organized experts of the fields to formulate Operating Technical Specifications on Sedation/Analgesia/Anesthesia in Diagnosis and Treatment of Chinese Plastic and Aesthetic Major (2023) for clinical reference, in order to strengthen medical quality management and control, and assure patients medical safety on sedation/analgesia/anesthesia in plastic and aesthetic diagnosis and treatment.
Guideline and Consensus
Guidelines for the Diagnosis, Treatment, and Management of Iodine Refractory Differentiated Thyroid Cancer(2023 edition)
WEN Qiang, WANG Renfei, HUANG Rui, ZHANG Yuelun, LIN Yansong, Chinese Society of Clinical Oncology Nuclear Medicine Expert Committee
2023, 14(6): 1197-1202. doi: 10.12290/xhyxzz.2023-0342
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To further standardize the clinical diagnosis and treatment decisions of radioiodine refractory differentiated thyroid cancer (RAIR-DTC) in China, it is urgent to establish clinical diagnosis and treatment management guidelines based on evidence-based medical data to scientifically guide the diagnosis and treatment of RAIR-DTC. By referring to the World Health Organization Guidelines Development Manual andfollowing the protocol of devising evidence-based guidelines, we have registered and written the prospectus of Guidelines for the Diagnosis, Treatment, and Management of Iodine Refractory Differentiated Thyroid Cancer. We will also develop and release official guidance documents. This guidelines prospectus mainly introduces the significance, purpose, target population, user population, guidelines formulation team members, collection and determination of clinical issues and outcome indicators, acquisition, evaluation, and synthesis of evidence, as well as generation of recommendations and other guidelines formulation methods and processes of the Guidelines for the Diagnosis, Treatment, and Management of Iodine Refractory Differentiated Thyroid Cancer.
Guideline Interpretation
Interpretation on the Guidelines for the Diagnosis and Treatment of Primary Osteoporosis (2022)
WANG Yongxuan, LI Mei, ZHANG Zhenlin, XIA Weibo
2023, 14(6): 1203-1207. doi: 10.12290/xhyxzz.2023-0364
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In December 2022, the Guidelines for the Diagnosis and Treatment of Primary Osteoporosis (2022) were released. The guidelines have updated the latest epidemiological data of osteoporosis in China and given recommendations for the diagnosis and treatment of osteoporosis by combining evidence-based medical testimony and clinical practice in this field. This article interprets the key points of the guidelines to help healthcare workers better understand and follow the guidelines.
Original Contributions
Research of Accessibility of Rare Disease Drugs Based on the China's First List of Rare Diseases
LIU Qingyang, LIU Xin, WANG Shaohong, SHANG Junmei, TANG Yan, ZHANG Bo
2023, 14(6): 1208-1216. doi: 10.12290/xhyxzz.2023-0163
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  Objective  This study aims to comprehensively analyze and categorize the rare disease medications(orphan drugs) listed in the China's First List of Rare Diseases. It further investigates disparities in drug accessibility between domestic and international contexts, with the overarching goal of enhancing and updating the landscape of drug therapy for rare diseases within China. Additionally, this research seeks to offer valuable insights for the management and advancement of drug therapies for rare diseases.  Methods  Orphan drugs that have received approval from the U.S. Food and Drug Administration (FDA) and the European Medicines Agency(EMA) for indications relevant to the diseases featured in the China's First List of Rare Diseases were meticulously extracted for comparative analysis. Furthermore, data were extracted concerning the varieties sanctioned by the National Medical Products Administration (NMPA). This was coupled with a thorough search for drug varieties approved for rare diseases as indicated in drug instructions. The result was a meticulously curated list of rare disease medications. Accessibility parameters for the aforementioned drugs were rigorously examined.  Results  As of December 31, 2022, a total of 116 rare disease drugs, having gained approval from the U.S. FDA, EMA, or NMPA and been available within the Chinese market, were found to effectively address 53 different rare diseases. Among them, 74 drugs, sanctioned by the U.S. FDA, were applicable to 44 diseases. Correspondingly, 36 drugs, approved by the EMA, were relevant to 26 diseases, while NMPA-approved drugs numbered 93, spanning 43 diseases. Within the realm of these 116 rare disease drugs, 59 possessed at least one drug dosage form with a domestically sanctioned approval number, providing treatment avenues for 36 rare diseases. Notably, 69 drugs featured at least one drug formulation that was encompassed within the medical insurance framework and earmarked for rare disease treatment, contributing to coverage for 29 rare diseases.  Conclusions  Compared with the initial release of this list, it becomes evident that the accessibility of foreign orphan drugs, as well as the incorporation of domestic approval numbers, has significantly improved. Furthermore, this research underscores the continued augmentation of the items included in the national medical insurance program, thereby signifying heightened accessibility and coverage.
Relationship between Oxygen Extraction Ratio and Prognosis in Septic Shock Patients During Early Resuscitation
ZHOU Gaosheng, WANG Xiaoting, LIU Jingjing, ZHANG Hongmin, ZHANG Qing, LIU Dawei
2023, 14(6): 1217-1223. doi: 10.12290/xhyxzz.2023-0008
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  Objective  To investigate the relationship between Oxygen extraction ratio(ERO2) and prognosis of septic shock patients in the early stage of resuscitation.  Methods  The data of the patients with septic shock admitted to the department of Critical Care Medicine of Peking Union Medical College Hospital from January 2016 to July 2021 were retrospectively collected. The patients were divided into the survival group and the death group according to the prognosis of the ICU. The baseline data, and Oxygen metabolism indexes including Oxygen delivery (DO2), Oxygen consumption(VO2), ERO2 and lactate(Lac) of the two groups were collected. Risk factors for ICU death in patients with septic shock were analyzed using multifactorial Logistic regression, and the predictive value of each indicator for ICU death in patients with septic shock was assessed using receiver operating characteristic (ROC) curves.  Results  A total of 73 patients with septic shock who met the inclusion and exclusion criteria were enrolled, including 21 cases in the death group and 52 cases in the survival group. The differences in acute physiology and chronic health evaluationⅡ(APACHEⅡ) scores and sequential organ failure assessment (SOFA) scores between the two groups were statistically significant (all P < 0.05). Compared with the survival group, 6 h after resuscitation in the death group, Lac [5.6(4.2, 10.0)mmol/L vs. 3.4(2.1, 6.9)mmol/L, P=0.009], VO2[(165±95) mL/(min·m2) vs. (106±58)mL/(min·m2), P=0.012], ERO2[(56.56±19.48)% vs.(33.71±13.24)%, P=0.000] were elevated, and there was no significant difference in DO2 between the two groups[266 (214, 384) mL/(min·m2) vs. 300 (250, 396)mL/(min·m2), P=0.159]. The results of multifactorial Logistic regression analysis showed that ERO2 was an independent risk factor for ICU death in patients with septic shock (OR=1.126, 95% CI: 1.053-1.203, P=0.000). The ROC curve showed that the area under the curve (AUC) of ERO2 for predicting ICU death in septic shock patients was 0.833, with an optimal threshold of 45.93%, sensitivity of 76.19%, specificity of 94.23%, and its predictive efficacy was superior to that of the APACHEⅡ scores(AUC: 0.704), SOFA score(AUC: 0.778), and Lac(AUC: 0.668).  Conclusion  ERO2 in the early stage of septic shock resuscitation is an independent risk factor for ICU prognosis, which has a good predictive value for the prognosis of septic shock.
Analysis of Pelvic Obliquity in Standing Position and during Walking in Patients with Different Types of Juvenile Idiopathic Scoliosis
SHI Weihong, CHEN Lixia, YUAN Wangshu, ZHANG Yuhang, ZHANG Houqiang, ZHANG Huiling, YANG Yuying, LU Jiandong
2023, 14(6): 1224-1230. doi: 10.12290/xhyxzz.2023-0224
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  Objective  To analyze the correlation between juvenile idiopathic scoliosis (JIS) patients with lumbar and thoracic scoliosis and the degree of pelvis obliquity in standing position and during walking.  Methods  The patients with JIS(Cobb≥10°) admitted into Peking Union Medical College Hospital from September 2020 to December 2022 and non-JIS patients(Cobb < 10°) during the same period were retrospectively included. According to the results of anteroposterior X-ray of the whole spine in the standing position, JIS patients were divided into a group with lumbar/thoracolumbar scoliosis (group A) and a group without lumbar/thoracolumbar scoliosis (group B). The change value of the bilateral iliac crest height, used as osseous landmarks, was measured in standing position and during walking. Bilateral iliac crest heights and their change values were measured in standing position and during the walking cycle to analyze the degree of pelvic coronal tilt in patients with different types of JIS.  Results  A total of 73 JIS patients (54 patients in group A, and 19 patients in group B) and 34 non-JIS patients who met the inclusion and exclusion criteria were enrolled. In group A, 61.1%(33/54) of patients showed a "reasonable" relationship between the higher side of the iliac ridge and the convex side of the spine (the iliac ridge of the convex side of the lumbar spine/thoracolumbar spine was lower than that of the concave side), and 38.2%(13/34) of non-JIS patients showed a "reasonable" relationship between the higher side of the iliac ridge and the convex side of the spine (the iliac ridge of the convex side of the lumbar spine/thoracolumbar spine was at the same height as that of the concave side). The difference was statistically significant(P=0.036). The proportion of "reasonable" relationship in group B was not significantly different from that in non-JIS patients(26.3% vs. 38.2%, P=0.380). In group A, there were statistically significant differences in iliac crest height changes on both sides during the whole gait cycle (including minimum, maximum, minimum and maximum of the supporting phase) (all P < 0.05), and the iliac crest height changes on the convex side of lumbar spine were significantly higher than those on the concave side (all P < 0.05). However, there was no significant difference in bilateral iliac crest height between non-JIS patients and JIS patients in group B during the whole gait cycle(all P > 0.05).  Conclusion  In JIS patients with lumbar or thoracolumbar scoliosis, the iliac crest height of the lumbar scoliosis was lower than that of the concave side in standing position, and therefore, the tilt degree of pelvis obliquity should be increased to maintain bilateral balance during walking.
Impact of the Emergency Department Medical Consortium Model on Patients in Intensive Care Units at Downstream Hospitals
JIANG Hui, HAN Mengmeng, XU Jun, ZHU Huadong, LIU Jihai, YU Xuezhong, SUN Jia, LU Yanli, SHI Di
2023, 14(6): 1231-1237. doi: 10.12290/xhyxzz.2023-0215
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  Objective  To evaluate the impact of the "point to downstream hospital multi-department" emergency medical consortium model between Peking Union Medical College Hospital (PUMCH) and Beijing Longfu Hospital on the treatment of critically ill patients.  Methods  Clinical data of ICU patients at Beijing Longfu Hospital from December 2018 to November 2020 were retrospectively collected. The patients were categorized into two groups based on whether the emergency medical consortium was established: the pre-establishment group (December 2018 to November 2019) and the post-establishment group (December 2019 to November 2020). Clinical data, disease spectrum, examination/treatment utilization, and in-hospital mortality were compared between the two groups.  Results  A total of 350 ICU patients meeting the inclusion and exclusion criteria were included in this study. The pre-establishment group comprised 126 patients, while the post-establishment group had 224 patients(including 162 transferred via the consortium). In the pre-establishment group, the disease spectrum primarily consisted of common critical illnesses, with the top three diseases being acute cardiovascular diseases (34.1%), severe pneumonia (25.4%), and post-surgical cases (19.0%). In the post-establishment group, there was a greater diversity in the disease spectrum, with the top three diseases being severe pneumonia (31.2%), renal dysfunction (13.8%), and acute cerebrovascular disease (9.8%). Compared to the pre-establishment group, the post-establishment group had a lower average age [68.50(57.00, 79.00) years vs. 78.00(68.25, 84.00) years, P < 0.001], higher acute physiology and chronic health evaluation Ⅱ score [18.00(14.00, 24.00) points vs. 15.00(12.00, 22.75) points, P=0.005] and sequential organ failure assessment (SOFA) score [5.00(3.00, 7.25) points vs. 3.00(2.00, 6.00) points, P < 0.001], higher rates of central venous catheterization (52.7% vs. 20.6%, P < 0.001), continuous renal replacement therapy(22.3% vs. 4.0%, P < 0.001), vasoactive drug use (21.4% vs. 11.9%, P=0.037), and epinephrine usage (17.0% vs. 7.1%, P=0.015), and hospital stay [(11.61±9.41)days vs. (10.06±7.63)days, P=0.260], hospital costs [(18 982.35(9251.80, 51 677.59) CNY vs. 39 113.11(19 500.03, 68 981.90) CNY, P=0.067], and in-hospital mortality (12.1% vs. 10.3%, P=0.753) showed no significant changes. Furthermore, after the establishment of the emergency medical consortium, the ICU of Beijing Longfu Hospital admitted and treated 25 cases of difficult-to-treat patients (no difficult-to-treat patients were seen before the establishment of the emergency medical consortium) and used a number of new technologies, including bedside bronchoscopy in 9 cases and bedside ultrasound examination in 105 cases. Multivariable Logistic regression analysis results indicated that after adjusting for factors such as age and SOFA score, the establishment of the emergency medical consortium had no significant impact on in-hospital mortality among ICU patients (OR=0.994, 95% CI: 0.401-2.464, P=0.990).  Conclusions  After the establishment of the "point to downstream hospital multi-department" emergency medical consortium between PUMCH and Beijing Longfu Hospital, the complexity and severity of diseases treated in Beijing Longfu Hospital's ICU increased, but the in-hospital mortality rate did not significantly rise. The emergency medical consortium model may contribute to enhancing the capacity for treating critically ill patients in downstream hospitals.
Incidence of COVID-19 in Patients with Tumor During the Omicron Pandemic
LIU Wanrong, TANG Hui, ZHOU Na, QIU Wei, LI Xiaoyuan, WANG Xiang, BAI Chunmei, ZHOU Jianfeng, ZHAO Lin
2023, 14(6): 1238-1245. doi: 10.12290/xhyxzz.2023-0281
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  Objective  To investigate the incidence of COVID-19 in patients with tumor during the pandemic of Omicron variant strains.  Methods  From December 25, 2022 to January 25, 2023, through the questionnaire star platform in the form of electronic questionnaire, we collected information about COVID-19 vaccine, COVID-19 infection and clinical symptoms, and post-infection anti-tumor therapy of patients with malignant tumors (including patients who previously visited the oncology department of Peking Union Medical College Hospital and the oncology department of the local hospital where the trainee doctors of the oncology department of Peking Union Medical College Hospital are located) during the survey period (from December 9, 2022 to the time of questionnaire survey) and performed statistical analysis.  Results  A total of 270 questionnaires were sent out, of which 265 valid questionnaires were recovered (the effective questionnaire rate was 98.1%). Among the 265 patients with malignant tumors, 170(64.2%) patients received COVID-19 vaccine, 158(59.6%) patients were alive with tumor, and 216 patients (81.5%) were receiving antitumor therapy at the time of COVID-19 infection or during the investigation. In 210 cases (79.2%), patients were infected with COVID-19. Among them, 9 cases (4.3%) developed COVID-19 pneumonia and 3 cases (1.4%) were hospitalized due to COVID-19, and there were no severe or fatal cases. Among the infected patients, 205(97.6%) patients showed symptoms related to the COVID-19, among which fever was the most common (72.9%) symptom, and cough (64.8%) and sputum (50.5%) were the main respiratory symptoms. There were no significant differences in gender, age, tumor type, whether they had underlying diseases, whether they were vaccinated against COVID-19, and whether they were treated with anti-tumor therapy between COVID-19 infected and uninfected patients (all P > 0.05). Among the infected patients, the incidence of pneumonia in those who received ≥3 doses of vaccine was significantly lower than that in those who did not receive vaccine (1.1% vs. 9.9%, P=0.025). At the time of questionnaire survey, 88 patients started antitumor therapy after COVID-19 infection. Compared to infection before COVID-19, 12 patients(13.6%) had more serious adverse anti-tumor reactions after COVID-19 infection, 63 patients (72.7%) had similar symptoms, and 12 patients (13.6%) had milder symptoms. There was no significant correlation between the adverse reactions of anti-tumor therapy before and after infection and the timing of initiation of anti-tumor therapy after infection(P=0.938), but there was a certain correlation with anti-tumor therapy after infection(P=0.003).  Conclusions  During the pandemic period of Omicron variant, tumor patients were generally susceptible to COVID-19. Almost all infected patients showed related clinical symptoms, but very few patients developed pneumonia. Vaccination with≥3 doses of vaccine may be protective against pneumonia. The adverse reactions of anti-tumor therapy in most cancer patients after infection with COVID-19 were not significantly worse than those before infection.
Predictive Value of Intraoperative Facial Nerve Response Thresholds on the Recovery Effect After Facial Nerve Decompression
WANG Pu, ZHANG Wenyang, WANG Yongfeng, XIA Yin
2023, 14(6): 1246-1250. doi: 10.12290/xhyxzz.2023-0161
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  Objective  To investigate the relationship between the thresholds of intraoperative facial nerve response and postoperative facial nerve function recovery in patients with Bell's palsy.  Methods  Clinical data from Bell's palsy patients who underwent facial nerve decompression surgery at Beijing Tiantan Hospital from October 2015 to October 2022 were collected. The patients selected for analysis had intraoperative facial nerve monitoring with accurate recording of the facial nerve direct stimulation threshold and at least 1 year of detailed follow-up. The patients with postoperative facial nerve function recovery to grade Ⅰ-Ⅱ (HB grading) were defined as having good recovery, while those recovering to grade Ⅲ or higher were defined as having poor recovery. The patients were divided into two groups (A and B) according to facial nerve reaction excitability, with group A having a direct stimulation threshold of ≤1.5 mA and group B having a direct stimulation threshold of > 1.5 mA or a stimulation volume up to 3 mA without being able to record neural response waveform. The relationship between postoperative facial nerve function recovery and facial nerve direct stimulation threshold was analyzed.  Results  A total of 36 Bell's palsy patients were included in this study, who underwent facial nerve decompression surgery through the transmastoid-epitympanum approach within 1-3 months after onset. Of the 36 patients, 24 (66.7%) had good recovery and 12 (33.3%) had poor recovery. Only 20 (55.6%, 20/36) patients had facial nerve direct stimulation threshold recorded during the operation, and all were ≤1.5 mA(0.1-1.5 mA). The reaction waveforms of 16 (44.4%, 16/36) patients could not be recorded even when facial nerve stimulation increased to 3 mA. There was no significant difference in age, gender, lateral discourse, timing of surgery, and preoperative electroneurography (ENoG) between the two groups(all P > 0.05), but the good recovery rate of the patients in group A was significantly higher than that in group B, and the difference was statistically significant (P=0.009).  Conclusion  For patients with Bell's palsy undergoing decompression surgery of the facial nerve, the intraoperative direct stimulation threshold of the facial nerve may have some predictive value for postoperative facial nerve function recovery.
Reviews
The Mechanism of miRNAs in Liver Fibrosis
HUANG Lu, WU Youbin, NI Yiran, LIU Mengyuan, WU Jiangfeng, ZHANG Yanqiong
2023, 14(6): 1251-1257. doi: 10.12290/xhyxzz.2023-0125
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Abstract:
MicroRNAs(miRNAs) are involved in the pathophysiological processes of many diseases. Stably present in cells, tissues and blood, they can be used as potential markers of many diseases. They play an important role in the pathogenesis of liver fibrosis caused by various chronic liver diseases. It has been shown that miRNAs can participate in the process of liver fibrosis by targeting the down-regulation of liver fibrosis-related gene expression. In this review, we discuss the research progress on the role of miRNAs in liver fibrosis, with the hope of providing reference for diagnosis and molecularly targeted treatment.
Relationship Between Vitamin D and Metabolic Associated Fatty Liver Disease and Its Mechanism
CHEN Danni, WANG Shiling, LU Hong, ZHENG Ya, WANG Yuping, REN Qian
2023, 14(6): 1258-1265. doi: 10.12290/xhyxzz.2023-0075
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Abstract:
Metabolic associated fatty liver disease (MAFLD) was renamed from the nonalcoholic fatty liver disease (NAFLD). In terms of the pathogenesis of MAFLD, the generally accepted theory is "multiple attacks", including insulin resistance, lipid disorder, oxidative stress, intestinal microbiota, etc., which involves the interaction of genetic and environmental factors. However, currently there is no approved drug for MAFLD. Recent studies have found that vitamin D is involved in many metabolic processes and may cause MAFLD by influencing liver lipid metabolism, promoting insulin resistance and inflammatory response, participating in immune regulation, gene regulation and maintaining intestinal homeostasis. Therefore, this article summarizes the relationship between vitamin D and MAFLD, explores the potential role of vitamin D in the pathogenesis of MAFLD, and provides clinical ideas for the treatment of MAFLD.
Research Progress on Prognostic Prediction Models After Radical Resection of Hepatocellular Carcinoma
ZHANG Yao, ZHAO Chengjun, REN Bin, DU Lei, MA Qianyuan
2023, 14(6): 1266-1273. doi: 10.12290/xhyxzz.2023-0235
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Abstract:
The classical Child-Pugh classification and the model for end-stage liver disease are now widely used in clinics for postoperative assessment of liver failure and prognosis in patients with hepatocellular carcinoma (HCC) treated with radical hepatectomy. However, there are limitations in the application of both methods due to factors such as albumin, ascites, and blood creatinine. A review of the relevant literature at home and abroad revealed that preoperative albumin bilirubin score, platelet albumin bilirubin score, Glasgow prognostic score and new predictive models have good application prospects in evaluating liver failure and prognosis of HCC patients after hepatectomy. In this paper, we aim to introduce the commonly used prognostic models for HCC patients undergoing radical hepatectomy and review the value of their application.
Application of 21-gene Recurrence Score in Hormone Receptor Positive Breast Cancer Patients
QU Yang, ZHANG Yanna, ZHOU Yidong, SUN Qiang
2023, 14(6): 1274-1281. doi: 10.12290/xhyxzz.2023-0226
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Abstract:
In the past decade, with the introduction of precision medicine, the treatment of breast cancer has entered a new era. It now tends towards the de-escalation and individualization of treatment plans, aiming to minimize iatrogenic toxicity while maximizing benefits for patients without compromising survival outcomes. The 21-gene assay evaluates the expression levels of 21 genes associated with breast cancer recurrence and provides a 21-gene recurrence score (RS) to assess the risk of recurrence and potential benefit from chemotherapy in breast cancer patients. Currently, RS is recommended by multiple guidelines such as the American Society of Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN), and Chinese Anti-Cancer Association(CACA) for guiding adjuvant therapy in hormone receptor-positive (HR+) and human epidermal growth factor receptor 2 negative (HER2-) early-stage breast cancer patients. However, there are still controversies surrounding its clinical application. Current research mainly focuses on optimizing RS to accurately identify patients who would benefit from adjuvant therapy, thus enabling more personalized treatment plans for breast cancer patients. This review provides an overview of the 21-gene assay, its application in HR+ breast cancer patients' adjuvant therapy, its impact on clinical decision-making, existing controversies regarding RS, and prospects for integrating RS with clinical pathological information. The aim is to guide further expansion of RS's application in clinical practice and achieve more precise adjuvant therapy for breast cancer patients.
Research Progress on the Role of NLRP3 Inflammasome and Microglia in Cognitive Impairment
WANG Caihong, LIU Rongxin, TANG Feng, WEI Xiaotao, XU Ziqing, HOU Huaijing, ZHANG Jie, ZHAO Yongqiang, XUE Jianjun
2023, 14(6): 1282-1288. doi: 10.12290/xhyxzz.2023-0217
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Abstract:
As a common neurological disease, cognitive impairment is characterized by cognitive decline, memory and attention impairment, which seriously affects the patients' quality of life. The etiology and pathogenesis of cognitive impairment are complex and diverse. Studies have shown that chronic persistent neuroinflammation plays a key role in its development. Microglia and nucleotide-binding oligomerization domain-like receptor protein 3 (NLRP3) inflammasome are closely related to neuroinflammation and cognitive impairment. Regulation of microglia and NLRP3 inflammasome can reduce inflammatory factors, reduce amyloid β-protein(Aβ) deposition, regulate autophagy, maintain synaptic homeostasis, thus reducing neuroinflammation and further preventing and treating cognitive impairment. Therefore, exploring the mechanism of microglia and NLRP3 inflammasome as well as their interaction in cognitive impairment can provide some reference and basis for the in-depth study of the mechanism and clinical prevention and treatment of cognitive impairment, and the subsequent development of more efficient drugs.
Research Progress of PDGF Promoting Wound Repair
ZHAO Qin, ZHANG Jinjin, CHEN Lili, XING Yanchao
2023, 14(6): 1289-1295. doi: 10.12290/xhyxzz.2023-0223
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Abstract:
Platelet-derived growth factor (PDGF), a multi-potent cytokine, has caught attention in the field of wound repair. The PDGF ability to initiate cell proliferation, migration, secretion and promote angiogenesis can be beneficial for wound healing. Platelet-rich plasma and recombinant human PDGF that contain high concentrations of PDGF have been used for decades in wound repair. However, their short shelf life, limited allogenic use, low bioavailability, and many side effects make them unable to meet clinical needs. Optimized platelet-rich fibrin and concentrated growth factor have higher concentrations of PDGF and better wound repair ability. Platelet lysate, with the ability to significantly extend the preservation period and reduce the risk of allogeneic use, has become the development direction for platelet wound repair. The high-energy delivery system based on bioengineering technology can significantly improve the local resident rate and prolong the action time of PDGF. A variety of transformed PDGF capable of inducing sustained tonic signals can be created through the modification of PDGF structure and addition of active domains. Functional controllable PDGF simulation peptides can be generated by integrating the active domains and a variety of efficient PDGF gene delivery strategies can be derived, thus providing more potential options to solve the problem of wound repair. The focus of this article, is on reviewing the physiological and applied.
Professional Competence for Clinicians: Assessment Methods and Research Progress
ZHANG Hanlin, HE Zitang, LI Yue, LUO Linzhi, ZHANG Shuyang
2023, 14(6): 1296-1300. doi: 10.12290/xhyxzz.2023-0064
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Abstract:
Professional competence is defined as the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily clinical practice. At present, many studies focus on the application of professional competence to medical education and job evaluation in China. However, further theoretical and empirical research is still needed to facilitate Chinese medical education and physician career development in the future. This article reviews the assessment methods and dimensions of professional competence, as well as the research progress of professional competence in China, with the aim of providing reference for Chinese medical education and physician career development.
Clinical Research and Evidence Based Medicine
Current Situation and Progress of Evidence Synthesis Methodology
SU Renfeng, YU Xuan, SHI Qianling, LUO Xufei, SUN Yajia, LAN Hui, REN Mengjuan, WU Shouyuan, WANG Ping, WANG Ling, ZHAO Junxian, CHEN Yaolong
2023, 14(6): 1301-1309. doi: 10.12290/xhyxzz.2023-0062
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Abstract:
Evidence synthesis is the synthesis of existing research using a systematic and appropriate method. Various types of evidence synthesis are currently in use. Correctly choosing and applying the best evidence synthesis method is crucial for researchers, policymakers, and stakeholders. Thus, based on summarizing the current situation, progress, and classification of evidence synthesis methods, we introduced the definition and characteristics of common evidence synthesis methods and problems in their application, and presented thoughts and suggestions for the problems in the application of evidence synthesis methods.
Clinical Practice Guidelines
Analysis of Development Method of Clinical Practice Guidelines in Primary Care
WANG Ling, WANG Ping, SU Renfeng, ZHAO Junxian, ZHU Di, LI Zhewei, HE Hongfeng, LUO Xufei, LIU Hui, ZHANG Hairong, WANG Xiaohui, CHEN Yaolong
2023, 14(6): 1310-1318. doi: 10.12290/xhyxzz.2023-0455
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Abstract:
  Objective  To analyze the development method of existing clinical practice guidelines in primary care to inform the future development of high-quality clinical practice guidelines in primary care.  Methods  Chinese and English databases and guideline websites were systematically searched for clinical practice guidelines in primary care published from January 1, 2019 to December 31, 2021, with additional searches conducted by reference tracing and Google Scholar. After screening was completed, basic information on included studies and information related to the development methodology was extracted and analyzed.  Results  Twenty primary guidelines published between 2019 and 2021 were finally included, 95% of which originated from developed countries. The most common developing institutions were universities/research institutes (8, 40%), the disciplines with the most attention were nursing (4, 20%), infectious diseases (3, 15%), and gastroenterology (3, 15%), and the areas of the guidelines were mainly focused on management (4, 20%), treatment (4, 20%) and nursing (3, 15%).None of the guidelines were registered, and 11 (55%) guidelines used evidence grading and strength of recommendation criteria. Mean reporting on the 18 topics in the Guideline 2.0 inventory was 40%, with relatively good reporting on the topics of guideline panelists (85%), conflict of interest considerations (75%), and evidence retrieval and incorporation (75%), and low reporting on the topics of organizing-budgeting-planning-training (15%), and summarizing the evidence and considering other information (15%).  Conclusions  The number of clinical practice guidelines in primary care that explicitly report on the methodology and process of development is low, and there is insufficient consideration of the relevant topics in the Guideline 2.0 checklist. It is recommended that future research focus on standardizing the reporting of clinical practice guidelines in primary care and developing the methodological guidebook for guideline development.
Considerations and Methodological Suggestions on Health Equity in Clinical Practice Guideline Development
GAO Yicheng, LIU Zhihan, TAO Liyuan, CAO Rui, XIA Ruyu, FENG Yuting, FANG Rui, DENG Yingjie, XIANG Wenyuan, FEI Yutong
2023, 14(6): 1319-1324. doi: 10.12290/xhyxzz.2023-0096
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Health equity can narrow the health gap between different groups and enable citizens to enjoy fair health services. Clinical practice guideline makers have been paying more and more attention to health equity, and exploring and applying the consideration to the development of corresponding guidelines. However, existing clinical practice guideline development gives little consideration to the structured and systematic construction of health equity, and the guidance for future guidelines is limited. This paper aims to put forward methodological suggestions for in-depth consideration of health equity in clinical practice guideline development, withthe hope of providing reference for guideline developers.
Health Standards
Status and Development of Health Standards in China
ZHAO Junxian, YANG Nan, LIU Hui, LI Jun, SU Renfeng, ZHANG Juanjuan, HE Hongfeng, ZHOU Qi, TIAN Qiannan, WANG Zijun, CHEN Yaolong, WANG Xiaohui, WU Liqun, WANG Qiang
2023, 14(6): 1325-1329. doi: 10.12290/xhyxzz.2023-0347
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Abstract:
This study conducted a comprehensive assessment of the current state of health standards in China by systematically searching the National Health Commission's Health Standards website and variousliterature databases. By identifying key issues within the domain of health standards, this study subsequently presentstargeted strategies and recommendations. These findings serve as a valuable reference for refining China's health standard system and developing policies related to health standards.
Clinical Case Analysis
ANCA Associated Vasculitis Treated with Ultra-low Dose Rituximab: A Case Report
WU Haiting, LI Hang
2023, 14(6): 1330-1334. doi: 10.12290/xhyxzz.2023-0263
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We reported a case of ANCA-associated vasculitis with pulmonary and renal involvement that was effectively treated with glucocorticoids, cyclophosphamide, and plasma exchange therapy. The patient suffered two infections during maintenance treatment with azathioprine and was later switched to ultralow-dose (100 mg) rituximab to keep the disease in remission. Individualized rituximab therapy is effective in treating ANCA-associated vasculitis, while avoiding excessive immunosuppression, and reducing the financial burden. The diagnosis and treatment of this patient may help clinicians improve their understanding of maintenance therapy for ANCA-associated vasculitis.
Gastric Metastases from Breast Cancer: A Case Report
YANG Lin, SU Shasha
2023, 14(6): 1335-1339. doi: 10.12290/xhyxzz.2023-0234
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Abstract:
Breast cancer, one of the most common female malignant tumours, mostly metastasizes to the bone, liver and lung. The case of gastric metastasis of breast cancer is relatively rare, and the differentiation of breast cancer from primary gastric cancer is also a major difficulty in clinical practice. In this paper, we report a rare case of gastric metastasis from breast cancer, which was diagnosed as metastatic invasive gastric adenocarcinoma originating from lobular carcinoma of the breast according to the immunohistochemical results of the patient, combined with the patient's medical history. The patient was given fulvestrant injection combined with abecycline for endocrine therapy against tumour after endoscopic mucosal dissection, and the prognosis was good. The clinical manifestations, diagnosis and treatment of this disease are discussed through relevant literature review, with the aim of providing reference for the clinical diagnosis and treatment of gastric metastasis of breast cancer.
Teaching and Research
Evaluation of the Implementation Effect of "Early Contact with Clinical Curriculum" in Eight-year Clinical Medical Students
TAN Bei, LI Yue, WEI Yizhen, WANG Wei, GUO Na, HUANG Yuguang
2023, 14(6): 1340-1344. doi: 10.12290/xhyxzz.2023-0013
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  Objective  To evaluate the implementation effect of "Early contact with clinical curriculum" among eight-year clinical medical students.  Methods  The electronic questionnaire was conducted among the eight-year clinical medical students in grade 2018 of Peking Union Medical College who completed "Early contact with clinical curriculum" in Nov 2021. The 5-points Likert scale was used to quantitatively assess the overall effects, the improvement of cognitive level of core learning objectives in these medical students, as well as the demands and benefits of course design. The Likert scale score of ≥4 was considered "more improved/demands/beneficial".  Results  A total of 75 eight-year clinical medical students in grade 2018 were enrolled, and 63 valid questionnaires were collected (84.0%). In terms of the overall assessment of the program, the goal achievement rate of "Early contact with clinical curriculum" was [(4.37±0.77) points], the course importance in the basic medical learning stage was [(4.48±0.78) points], and the improvement of physician profession cognition was [(4.16±0.75) points]. Among the cognitive level of core learning objectives in medical students, all seven dimensions were improved to some extent, in which professional values/attitudes/behaviors/ ethics [(4.27±0.81) points] and physician-patient communication skills [(4.16±0.85) points] were "more improved". In terms of demands for the curriculum, 91.7%(11/12) of the courses showed "more demands", and the top three courses with high demands were outpatient observation [(4.76±0.50) points], ward observation [(4.73±0.60) points], and physician-patient communication [(4.65±0.57) points]. In terms of benefits of curriculum, 66.7% (8/12) of the courses was rated "more beneficial", and the top three courses with high benefits were physician-patient communication [(4.73±0.48) points], ward observation [(4.65±0.63) points], and outpatient observation [(4.51±0.88) points].  Conclusion  "Early contact with clinical curriculum" in the basic medical learning stage could improve the cognitive level of core learning objectives in eight-year clinical medical students, the curriculum had higher demands and brought more benefits, thus achieving an ideal teaching effect.
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