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人工智能改变医学未来

北京协和医学院临床医学(八年制)2017级  张丁月

本期封面主题为人工智能在医学影像领域的应用。提到人工智能,最直观的联想是科幻电影里具有人类外形,可以运动、对话的机器人。然而,医学中的人工智能则更为抽象,它是一种算法,对数据进行收集、运算和输出,但不以可视化的形象出现。因此,如何将这一抽象概念展示给读者是本次封面创作的难点。

最终,本期封面选择佩戴虚拟现实眼镜的医生和医学影像显示屏为"人工智能"形象的主体,并以两侧的抽象图案代表信息的输入与输出,整体反映医学人工智能的工作原理。输入信息融合了DNA、基因组学、CT、病理切片等多种视觉形象;输出信息则用树形图表示人工智能的"分类"功能,背景则添加了算法示意图和代码元素。画风上,运用抽象简洁的色块风格以及蓝白为主的配色,增强了画面的科技感。

人工智能在医学领域的研究和应用已经有了惊人的突破性进展,这一方面得益于从事医学人工智能研究的科学家的不懈努力,另一方面,医生在尝试用人工智能解决临床问题的过程中也贡献了不朽智慧。随着人工智能在医学领域的普及和应用,相信医学未来必将发生翻天覆地的变化。

Vol. 12, No. 5 12 10 2021
Chinese Bimonthly CN 11-5882/R ISSN 1674-9081
 doi: 10.12290/j.issn.1674-9081.2021-0280
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Abstract: Objective To investigate how medical students master knowledge about thyroid cancer (TC) and thyroid self-examination, and to provide guidance for pre-clinical education and clinical teaching. Methods Cross-sectional study in third grade to sixth grade medical students in Peking Union Medical College (PUMC) in May 2021 was conducted based on an online questionnaire. Medical students enrolled were grouped into preclinical medical students (PMS) and clinical medical students (CMS) according to their grades. Results A total of 337 questionnaires were distributed and 274 effective responses were collected with 129 from PMS and 145 from CMS. The percentage of thyroid self-examination in CMS was higher than that of PMS (55.8% vs 11.6%, P <0.001). Generally, CMS had better comprehension of TC, including prognosis (97.2% vs 64.5%, P <0.001), diagnosis (95.6% vs 33.1%, P <0.001) and surgery indications (82.1% vs 58.1%, P =0.001). There was no significant difference between PMS and CMS on the acquaintance of the risk factors. However, more CMS stated that the below 5% of thyroid nodules might turn malignant (45.5% vs 6.5%, P <0.001), and more CMS suggested that people without nodules should receive TC screening tests (62.1% vs 41.9%, P =0.001). Conclusions Medical education on TC was effective in teaching clinical knowledge, but CMS tended to be over optimistic about TC, ignored the importance of self-examination, and lacked proper awareness of cost-effectiveness in thyroid screening. Medical school should focus more on preclinical general health education and clinical practices education in the future. more>
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Abstract: Background and Objective In-hospital acute kidney injury (AKI) has significant negative impact over patient outcome and length of hospital stay. The use of electronic medical record (EMR) early warning to identify and intervene AKI in a timely manner is of great significance to reduce the severity of AKI and improve the prognosis of patients. At present, AKI-related research based on the EMR system mainly uses traditional statistical methods for retrospective analysis, mainly for inpatients in single-disciplinary wards, and there is still a lack of AKI risk early warning models based on artificial intelligence technology in large-scale multi-disciplinary wards with time-sensitive information and further prospective research. This study aims to develop a multiple-ward AKI prediction model tailored for general hospitals in China based on machine-learning algorithm and big data acquired by EMR system. Methods This single-center study consists of both a retrospective observational study and a prospective study. All hospitalized adult patients admitted in Peking Union Medical College Hospital (PUMCH) between 2016 and 2020 were included in the retrospective study. Logistic regression, naïve Bayes, random forest, support vector machine and gradient boosting and recurrent neural network based on demographics, clinical feature, vital signs, imaging, lab results and charts will be used for modeling, which aims to predict AKI 24-48h in advance and will be internally validated. The prospective study intends to include all adult inpatients in PUMCH for 12 consecutive months. Among them, all adult hospitalized patients within 6 months before the AKI early warning system is launched would be the control group, and all adult hospitalized patients within 6 months after the AKI early warning system is launched would be the intervention group. In the intervention group, the AKI early warning system would be embedded in the EMR, and all patients hospitalized for more than 24 hours would be assessed for AKI risk in the next 48 hours in real time every 6 hours, and early intervention would be carried out for high-risk patients. The control group did not have the abovementioned AKI high-risk and alarm prompts, and no corresponding intervention measures. The incidence of with AKI and AKI grade 3, AKI remission rate, end-stage renal disease progression rate, mortality during hospitalization, length of stay, hospitalization expenses and other indicators would be compared between the two groups. Expected results An estimated number of 127000 in-hospital patients will be included in the retrospective study, among which 14605 patients suffered from AKI. The prediction model is expected to predict AKI 24-48 hours in advance and the aim for area under receiver operating characteristics curve would be>0.80. In the prospective study, 34,748 inpatients will be enrolled, including 17 374 in both the intervention group and the control group. The duration time of renal replacement therapy and length of hospital stay in the intervention group would be shorter than those in the control group (P<0.05), the proportion of renal replacement therapy, the incidence of AKI and AKI 3, the rate of progression of end-stage renal disease, the mortality rate during hospitalization, and the hospitalization cost would be lower than those in the control group (P<0.05), and the AKI remission rate would be higher than that in the control group (P<0.05). Expected conclusion EMR-based multi-ward AKI prediction model would predict AKI risk 24-48h in advance, lowering AKI incidence and severity, improving clinical outcomes. more>
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Abstract: Carotid body tumor is a rare neoplasm located at the bifurcation of the carotid artery. Surgical excision is the main treatment but carries a high risk of bleeding, nerve injury and vascular injury. Shamblin's classification is based on the relationship between tumor and carotid arteries, which has limitations. Including both the horizontal location and vertical extension of the tumors in carotid arteries, PUMCH (Peking union medical college hospital)classification can better predict surgical complications and guide the surgery and thus might help to improve the surgical outcomes of the lesions. more>
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Abstract: The primary goal of the lateral skull base surgery is to radically resect tumors, as well as to reduce mortality and improve quality of life, on the basis of guaranteeing life safety of patients. Following surgical principles and mastering necessary operative skills are essential to ensure the safety and therapeutic effects of the surgery. With the advances of medical science, the lateral skull base surgery has stepped into a new stage, encountering new opportunities as well as challenges. This article summarized the fundamental principles and techniques of lateral skull base surgery, and briefly introduced the new progress in this field. more>
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Abstract: In recent years, research on the clinical phenotypes of Gitelman syndrome (GS), new classifications, modified functional tests, biomarkers and management experience for patients with GS has made a lot of progress in China. Based on evidence-based medicine, this consensus summarizes aspects related to GS, including clinical manifestations and classification, diagnosis, treatment strategies, and management of chronic complications and comorbidity. This consensus provides an important reference for the diagnosis and treatment of GS. more>
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Abstract: In an era of innovative ways accelerating drug launches in the market, clinical trials have become increasingly complex and costly. Integration of patients' perspective and engagement into the clinical research process is essential to the success of trials, which leading to the emergence of the concept of patient-centric clinical trials. Compared to the conventional paradigm of clinical trials, patient-centric clinical trials have the potential to increase the feasibility of study protocol, to accelerate recruitment and execution, and to improve the success of trials. It calls for clinical trial institutions and investigators to be awareness and adapt patient-centric initiatives. In this article, we highlight technologies and actions which can be used to enhance patients' engagement in the entire drug development process covering protocol development, trial conduction, and result publication. more>
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Abstract: By reviewing and studying relevant historical materials, this study presents the advanced and fruitful clinical teaching in Peking Union Medical College Hospital(PUMCH) nearly a hundred years ago. It proved that the clinical teaching of PUMCH had reached the internationally advanced level in 1925. The bed-side teaching, case discussion, multidisciplinary joint ward round, interdisciplinary teaching, and resident training system still have practical significance presently. As it turns out, many of the teachers who were passionate about teaching and students who were actively involved in teaching went on to become medical masters. The spirit of taking teaching as an honor, responsibility and mission has been passed on and deeply rooted in the spirit of PUMCH and has remained unchanged for a century. more>
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Abstract: Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a highly malignant hematological tumor derived from the precursor cells of plasmacytoid dendritic cells. BPDCN primarily in the nasal cavity is clinically rare and easily misdiagnosed and missed. At present, there is no standard treatment for BPDCN at home and abroad. This article reports a patient with blastic plasmacytoid dendritic cell neoplasm primarily in the nasal cavity that received azacitidine combined with GemOx regimen has a good clinical effect, which can significantly control the condition and improve the clinical symptoms. Through the analysis and discussion on the clinical diagnosis and treatment of this patient, we aim to improve clinicians' understanding of rare BPDCN. more>
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Abstract: Pediatric ambulatory surgery can minimize the separation of pediatric patients from their parents, relieve anxiety, and offer care at a reduced cost. However, children are prone to experiencing pain, nausea, vomiting, delirium, and other complications after anesthesia and ambulatory surgery due to their anatomical and physiological characteristics. So, standardized postoperative management is critical to ensure the safety of children and improve the medical quality of pediatric ambulatory surgery. This article reviews new progress in research on common postoperative complications and discharge criteria of pediatric ambulatory surgery. more>
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Abstract: This patient was an elderly man with left carotid body tumor, cardiac paraganglioma and right adrenal pheochromocytoma at the same time. This is a rare case with a complex condition, and the diagnosis and treatment were difficult. After two rounds of discussion in the multidisciplinary team, our hospital has successively removed the lesions of the heart and the right adrenal, and the patient was discharged smoothly after the operations. The diagnosis and treatment of this patient reflects the significance of the multidisciplinary team on the diagnosis and treatment of difficult diseases. more>
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Abstract: Objective To describe the cross-cultural adaptation of the document of advance care planning (ACP) Voicing My CHOiCESTM in Chinese,and provide the basis for the practice of ACP in China. Method The process of cross-cultural adaptation involved document translation and synthesis, evaluation of healthcare providers evaluation of patients, back translation, author revision of the original document, and finalization. The participants were all kinds of healthcare providers involved in ACP practice, including doctors, nurses, social workers, psychologists, hospice volunteers, anesthesiologists, nutritionists, and pharmacists. The participants were invited to answer a questionnaire about the document’s structure, importance, appropriateness, and level of language localization. The evaluation of healthcare providers included three rounds of the process. We revised the document based on the feedback and developed the first draft. The first draft of the document was reviewed by young patients with fatal diseases and their families. They read each page of the document and rated the perceived appropriateness, helpfulness, and stressfulness of each item. After further revision, the final document was formed. Results Due to the differences in language, culture, health, and legal system between China and the United States, the cross-cultural adaptations were made in some topics of the document. The Chinese version of the document included 13 topics, involving medical and nursing decision-making, daily life planning, funeral planning, and spiritual support, etc. In total, 91.67% of the patients and 80% of their parents considered all topics covered to be appropriate for age and culture. In total, 75% of patients and 70% of their parents found all the topics to be helpful. In the evaluation of stress, death-related topics brought pressure on patients. Conclusion The Chinese version of Voicing My CHOiCES is the first ACP document applicable to adolescents and young adults in China. This document can help young Chinese patients to think and express their wishes and preferences, and guide patients, family members, and healthcare providers to fully and deeply communicate with each other about future planning. more>
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Abstract: With the significant improvement of China's social and economic level, the people's demand for medical services is growing rapidly. There is an urgent need for more clinicians with solid foundation, excellent technology, and high comprehensive quality. Peking Union Medical College Hospital (PUMCH) has continuously inherited and innovated the training model of outstanding medical talents. Based on previous experience, literature analysis and pilot research results, PUMCH has explored and implemented the "Clinical Post-Doctoral Program" since 2016, which is one of the innovations of graduated medical education in China, aiming at high efficiency, continuous to strengthen the students' ability of clinical and scientific research and teaching. By optimizing the course system, training mode innovation, regrouping the faculty team, building effective evaluation and assessment system, to cultivate high-level, medical elite talents to provide new train of thought and experience. To provide a significant role in the national medical health talent development reserve forces, for the "Healthy China" strategic goal. more>
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    Objective     To investigate the diagnostic value of insulin-like growth factor 2 (IGF2) in urine exosomes for bladder urothelial carcinoma.     Methods     The patients with bladder urothelial cancer admitted in Peking Union Medical College Hospital from September to December 2020 were selected as the research objects, and the patients with non-malignant urinary system disease cancers admitted in the same period were selected as the control group. Fluorescent RT-PCR was used to detect the level of IGF2 in urine exosomes. The pathological results of cystoscopy or transurethral bladder tumor resection were regards as the gold standard, and the sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of the diagnosis of bladder cancer were calculated based on the expression level of IGF2 in urine exosomes.     Results     There were 35 cases in the urothelial cancer group, with an average age of (65.43±12.22) years, and there were 60 cases in the non-urothelial cancer group, with an average age of (51.68±13.07) years. The sensitivity of urinary exosomes IGF2 in diagnosing bladder urothelial carcinoma is 71.4% (95% CI: 53.5%-84.8%), specificity is 90% (95% CI: 78.8%-95.9%), and the positive likelihood ratio is 7.14 (95%CI: 3.25-15.7), the negative likelihood ratio was 0.32 (95%CI: 0.19-0.54).     Conclusions     The content of IGF2 in urine exosomes is promising as a preliminary screening index for bladder cancer.

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  Objective   To optimize the system conditions and improve the perioperative surgical patients' safety through feedback learning for adverse events.   Methods   A retrospective analysis of adverse events (AE) and patient safety risks reported by the Department of Anesthesiology, Peking Union Medical College Hospital from January 2010 to December 2014 was made. Fish bone diagram was used to analyze and summarize the root causes, timing, avoidability and injury of adverse events.   Results   A total of 370 cases of AEs were collected. The results of root cause analysis indicated that the root causes of AEs were mainly human factors (43.08%, 224/520), followed by systemic factors (30.96%, 161/520), and patient factors were the lowest (25.96%, 135/520). Forty-four cases (11.9%, 44/370) were emergency operation. Thirty-seven cases (10.00%, 37/370) occurred at night, 243 cases (65.68%) could be avoided. According to the different occurrence time, the top four incidence rates were intraoperative (28.11%, 104/370), before anesthesia induction (17.30%, 64/370), during anesthesia induction (13.78%, 51/370), and at the end of surgery (12.97%, 48/370). Eighty AEs (21.62%, 80/370) did not cause injury, whereas 262 cases (70.81%, 262/370) caused temporary minor injury, 15 cases (4.05%, 15/370) caused permanent injury, and 13 cases (3.51%, 13/270) caused non-anesthesia related death intraoperatively or within 24 hours after the surgery. Compared with avoidable AEs, the proportion of patient factors (60.26% vs. 11.26%, P<0.001) and non-anesthesia related death intraoperatively or within 24 hours after the surgery (8.66% vs. 0.82%, P< 0.001) in the unavoidable group were higher.   Conclusion   The root causes of perioperative AEs are mainly human factors, most of which can be avoided and cause temporary slight injury to patients. Strengthening feedback learning of AE, improving personnel training and optimizing system conditions might reduce the incidence of AE and promote perioperative patient safety and quality improvement.

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  Objective   To explore and compare the associations between different proton pump inhibitors (PPIs) and acute generalized exanthematous pustulosis (AGEP).   Methods   Data were obtained from the Food and Drug Administration's Adverse Event Reporting System (FAERS) database from January 2004 to June 2020. Non-proportional analysis and Bayesian analysis were utilized to detect the signals of AGEP caused by different PPIs. The onset time and prognosis of PPIs-related AGEP were also analyzed.   Results   A total of 162 cases of AGEP caused by PPIs were reported. The most frequently used PPIs were omeprazole (33.95%, 55/162), followed by esomeprazole (29.63%, 48/162) and pantoprazole (26.54%, 43/162). Pantoprazole exerted the strongest correlation with AGEP, followed by omeprazole and lansoprazole, while esomeprazole appeared a weaker AGEP association than other PPIs. The median time to AGEP onset was 6 (2, 12) days after PPI treatment, and 60.00%~83.33% of patients developed symptoms within 10 days after the medication (except rabeprazole). PPI-associated AGEP generally led to a fatality proportion of 1.86% (3 cases) and a hospitalization proportion of 79.50% (128 cases). The hospitalization proportion of AGEP patients caused by omeprazole was the highest (91.49%, 43/47), followed by pantoprazole (88.37%, 38/43), lansoprazole (85.71%, 12/44), and omeprazole (61.82%, 34/55) was the lowest.   Conclusion   Our pharmacovigilance study based on the FAERS database demonstrated the risks and characteristics of AGEP caused by different PPIs in details, which could provide theoretical basis for clinical rational drug use.

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Pancreatic neuroendocrine neoplasms (pNENs) are highly heterogeneous, and the management of pNENs patients can be intractable. To address this challenge, an expert committee was established on behalf of the Chinese Pancreatic Surgery Association, Chinese Society of Surgery, Chinese Medical Association, which consisted of surgical oncologists, gastroenterologists, medical oncologists, endocrinologists, radiologists, pathologists, and nuclear medicine specialists. By reviewing the important issues regarding the diagnosis and treatment of pNENs, the committee concluded evidence-based statements and recommendations in this article, in order to further improve the management of pNENs patients in China.

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Abstract: An elderly woman with chronic course of disease presented with progressive lower limb weakness, heart failure, carbon dioxide retention, periorbital pigmentation, increased hairs around the eyebrow, as well as multiple positive autoantibodies. After multidisciplinary team discussion, restrictive ventilatory dysfunction caused by siginificantly decreased diaphragm movement was taken as a breakthrough to sort out the etiology step by step. Combined with clinical manifestations, serological and imaging features, as well as quadriceps femoris pathological complement immunohistochemical staining, the final diagnosis of inflammatory myopathy associated with anti-mitochondrial antibodies was established. After correcting heart failure, intermittent non-invasive ventilation and rehabilitation training, clinical symptoms and functional status of the patient were significantly improved. The joint participation of multidisciplinary team to identify causes and solve problems in diagnosis and treatment decision-making reflects the great significance of multidisciplinary collaboration in diagnosis and treatment of rare diseases. more>
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Abstract: Enhanced Recovery After Surgery (ERAS) is a new perioperative management concept with a series of evidence-based clinical optimization management to accelerate postoperative rehabilitation, which has been widely used in many surgery domains. In the recent years, the clinical research and implement of ERAS management in craniotomy has been carried out gradually and developed rapidly. This article reviews the new progress in anesthesia strategy of ERAS management of craniotomy. more>
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Abstract: Objective To investigate the clinical use of 17 antineoplastic drugs passing national medical insurance negotiation in one hospital before and after the implementation of national policies about promoting the inclusion of antineoplastic drugs in health insurance. To provide reference for the optimization and adjustment of hospital catalogue. Methods The prescription data of 17 antineoplastic drugs of outpatients and inpatients in our hospital from 2018 to 2019 were collected. The basic information of patients, the usage amount and cost, defined daily doses (DDDs), and defined daily cost (DDC) were analyzed. Results The 17 antineoplastic drugs were mainly used for thorax, hematologic malignancies and urinary tract tumors. The top three antineoplastic drugs in terms of cost were osimertinib, octreotide acetate microspheres and crizotinib, with good synchronization between cost and frequency of usage. The top three drugs in terms of DDC were vemurafenib, cetuximab and ibrutinib. The proportions of the cost of 17 antineoplastic drugs to that of all antineoplastic drugs and all formulary drugs in our hospital were 16.3% and 3.8%, respectively. Among them, the total cost of the six drugs which had already been included in the formulary of our hospital before the policy implementation increased by 78.2% in 2019 compared with that in 2018. After the implementation of national policies, the quantity and cost of osimertinib increased significantly, and the drugs with increased quantity but decreased cost were cetuximab, axitinib, and sunitinib in sequence. The quantity and cost of pegaspargase both decreased significantly. Conclusions The national health insurance negotiation policy promoted the use of 17 antineoplastic drugs in our hospital and improved the accessibility of these drugs to patients significantly. At the same time, the total cost of the involved drugs had a sharp rise. It is necessary to strengthen the monitoring and dynamic evaluation of the clinical application of related drugs, so as to promote rational drug use while meeting patients' need. more>
Editorial
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Abstract: Medical imaging is regarded as one of the most potential domains where artificial intelligence can be applied in practice. However, artificial intelligence is facing challenges resulting from continuous growth of data, such as lack of high-quality data, lack of standardization in domain, lack of effective data management and regulation. Therefore, it is necessary to construct a standardized medical imaging database complying with the national condition of China, laws/regulations, and using habits of researchers. FAIR data principle (findable, accessible, interoperable, and reusable) may play a key role in database construction, data acquisition, and regulating descriptions of medical imaging data. Looking forward to boosting the standardized construction of artificial intelligence databases of medical imaging under the combined efforts of national researchers. more>
Specialist Forum
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Abstract: Deep learning, for its powerful learning capability and high usability, has been a prevalent algorithm of machine learning and a core technique for artificial intelligence(AI) in medicine and healthcare. Due to the importance of medical imaging in many tasks such as health screening, disease diagnosis, precise treatment, and prognosis prediction, deep learning of structural analysis and semantic understanding for medical images is becoming an important interdisciplinary research direction. In clinical scenarios, in order to achieve a more accurate diagnosis, doctors need to simultaneously refer to multiple modalities of medical imaging for a comprehensive analysis and judgment. This article introduced the basic concepts and working principles of multimodal deep learning in such scenarios, reviewed recent research progress on applying multi-modal deep learning in both generic medical fields and ophthalmology, and discussed technical challenges and also envision potential applications of multi-modal deep learning in AI-assisted ophthalmology. more>
Specialist Forum
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Abstract: With the development of human-computer interaction, how to use intelligent, natural and efficient methods to promote the development of the medical field has become a hot topic of research. Nervous system diseases have a great impact on the quality of people's daily life. Using the method of human-computer interaction for early warning and ancillary diagnosis of nervous system diseases can reduce discomfort of patients during exams and work intensity of doctors, which is of great significance to both doctors and patients. This paper discusses the application status, existing problems, future development of human-computer interaction in the ancillary diagnosis of nervous system diseases, and how to use computer technology to improve traditional medical diagnosis methods from the perspective of interaction. more>
Specialist Forum
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Abstract: Big medical data and medical artificial intelligence (AI) not only have the great potential for improving the utilization of medical resources and the quality of medical service, but also pose challenges to privacy protection and technical risks. Standards are the consensus and norms for constructing, evaluating, and applying new technologies. The clinical application of big medical data and medical AI urgently needs regulations on data, systems, measurement standards, and codes of practice for evaluating new technologies. This paper defines big medical data and medical AI standards, including data-related standards, public datasets, benchmarks, codes of practice, and summarizes state-of-the-art and state-of-the-practice of big medical data and medical AI standards. While looking forward to the development prospect of big medical data and medical AI, we propose an innovative architecture consisting of big-data-and-AI-enhanced medical information systems and the big medical science infrastructure. more>
Opinion
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Abstract: Recently, the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology and Japanese Heart Failure Society jointly issued a consensus statement on Universal Definition and Classification of Heart Failure. Natriuretic peptides were written into the universal definition of heart failure and became the second cardiac marker written into the definition of disease after troponin.The consensus proposed new four classes of heart failure according to ejection fraction(EF), including heart failure with reduced EF(HFrEF), heart failure with mildly reduced EF(HFmrEF), heart failure with preserved EF(HFpEF)and heart failure with improved EF(HFimpEF). Universal Definition and Classification of Heart Failure has wide applicability, which is helpful for clinicians, researchers and patients to understand and adopt.It is an important first step forward to the standardization of diagnosis and treatment of heart failure. While using the universal definition and classification of heart failure, clinical staff should actively conduct scientific research to promote the standardization of diagnosis and treatment of heart failure. more>
Guideline and Consensus
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Guideline and Consensus
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