Homogenization Construction of Three-Level Teaching Bases for General Practice Medicine Under the Internet+Model

With the continuous expansion of medical student enrollment,the number of clinical teaching bases is gradually increasing.However,there are significant differences in clinical teaching management models and teaching levels among different bases.Most clinical teaching bases have incomplete teaching management systems,inadequate teaching management institutions,insufficient teaching personnel,and inadequate implementation of teaching rules and regulations.This article combines the construction practice of three-level clinical teaching base of the General Medicine College and the First Affiliated Hospital of Xi’an Medical University.We establish a standardized management system for the three-level clinical teaching base;implement a teaching supervision system and strengthen the monitoring of teaching quality;adopt multiple evaluations to test the effectiveness of clinical teaching implementation;explore the path of homogenization construction of teaching bases in terms of unified teacher training,promoting the development of teacher teaching abilities with equal quality and excellence,and providing a reference for improving the quality of medical talent training.

循证医学(Evidence-based Medicine)——临床研究与实践的新时代

80年代以来的大规模、随机、双盲、多中心、安慰剂对照临床试验证明,以经验和推论,如以一些临床化验指标为依据的传统临床试验不能反映病人的长期预后。为了对新药和已上市药物作出恰当的评价,应当从所谓“众说纷坛”转向注重和评价病人预后,包括总死亡率、重要心脑血管事件、生活质量、卫生经济学等的“循证医学”。反过来,“循证医学”和临床治疗指南的发展将对新药的研究与开发、医生的临床实践、药物经济学、医疗保健服务决策等带来积极和正面的影响。

Exploring the Application Effect of Flipped Classroom Combined with Problem-Based Learning Teaching Method in Clinical Skills Teaching of Standardized Training for Resident Doctors of Traditional Chinese Medicine

Objective: To explore the application effect of flipped classroom combined with problem-based learning teaching method in clinical skills teaching of standardized training for resident doctors of traditional Chinese Medicine. Methods: The study used the experimental control method. The study lasted from September to November 2022. The subjects of this study were 49 students of standardized training for resident doctors of traditional Chinese Medicine from grades 2020, 2021 and 2022 of Dazhou integrated TCM & Western Medicine Hospital. They were randomly divided into experiment group (25) and control group (24). The experiment group adopted flipped classroom combined with problem-based learning teaching method, and the control group adopted traditional teaching method. The teaching content was 4 basic clinical skill projects, including four diagnoses of traditional Chinese Medicine, cardiopulmonary resuscitation, dressing change procedure, acupuncture and massage. The evaluation method was carried out by comparing the students’ performance and a self-designed questionnaire was used to investigate the students’ evaluation of the teaching method. Results: The test scores of total scores in the experimental group (90.12 ± 5.89) were all higher than those in the control group (81.47 ± 7.96) (t = 4.53, P P Conclusions: The teaching process of the flipped classroom combined with problem-based learning teaching method is conducive to improving the efficiency of classroom teaching, cultivating students’ self-learning ability, and enhancing students’ willingness to learn.

Irritable bowel syndrome: Pathogenesis, diagnosis, treatment, and evidence-based medicine

Irritable bowel syndrome(IBS)is a chronic and debilitating functional gastrointestinal disorder that affects9%-23%of the population across the world.The percentage of patients seeking health care related to IBS approaches 12%in primary care practices and is by far the largest subgroup seen in gastroenterology clinics.It has been well documented that these patients exhibit a poorer quality of life and utilize the health care system to a greater degree than patients without this diagnosis.The pathophysiology of IBS is not clear.Many theories have been put forward,but the exact cause of IBS is still uncertain.According to the updated ROMEⅢcriteria,IBS is a clinical diagnosis and presents as one of the three predominant subtypes:(1)IBS with constipation(IBS-C);(2)IBS with diarrhea(IBS-D);and(3)mixed IBS(IBS-M);former ROME definitions refer to IBS-M as alternating IBS(IBS-A).Across the IBS subtypes,the presentation of symptoms may vary among patients and change over time.Patients report the most distressing symptoms to be abdominal pain,straining,myalgias,urgency,bloating and feelings of serious illness.The complexity and diversity of IBS presentation makes treatment difficult.Although there are reviews and guidelines for treating IBS,they focus on the efficacy of medications for IBS symptoms usinghigh-priority endpoints,leaving those of lower priority largely unreported.Therefore,the aim of this review is to provide a comprehensive evidence-based review of the diagnosis,pathogenesis and treatment to guide clinicians diagnosing and treating their patients.

Traditional Chinese Medicine as a Treatment for Rheumatoid Arthritis:From Empirical Practice to Evidence-Based Therapy

Rheumatoid arthritis(RA)is a common autoimmune condition with an elusive etiology.Conventional and biological disease-modifying drugs sometimes fail or produce only partial responses.Traditional Chinese medicine(TCM)has long been used in China as a treatment for RA and is achieving everincreasing acceptance worldwide.TCM treatments are traditionally guided by the theory of treatment based on TCM syndrome differentiation;however,they remain a matter of empirical practice relying on TCM theories and doctors’own experience,which places severe restrictions on worldwide TCM application.Nevertheless,TCM is a treasure trove for drug discovery,particularly as a treatment for complicated human conditions.The discoveries of artemisinin as a treatment for malaria and of TCM–arsenic trioxide(As2O3)combination therapy as a treatment for acute promyelocytic leukemia(APL)are excellent examples of the great value of TCM.Regarding RA treatments,many Chinese medicinal herbs and their formulas,extracts,ingredients,and even single compounds have been used in clinical applications.Several Chinese proprietary medicines(CPMs)derived from TCM formulas or herbal bioactive components,such as the controlled-release ZhengQingFengTongNing(ZQFTN)Tablets,Tripterygium Glycoside Tablets,and Total Glucosides of Peony(TGP)Capsules,have been included in the National Health Insurance Directory of China,and show comparable therapeutic efficacies to those of western chemical drugs with fewer side effects.As TCM research has advanced,particularly in the use of multidisciplinary technologies,the scientific foundations and characteristics of the use of TCM to treat RA have been revealed,and the quality of TCM treatments have been increasingly enhanced.However,TCM generally lacks sufficient clinical and laboratory data to be consistent with international standards for quality,safety,and efficacy in order to support its application worldwide.Therefore,intensive basic and clinical studies on TCM are required.In particular,investigations that use cutting-edge technologies in analytical chemistry,biology,and biomedical sciences,and the development of randomized clinical trials(RCTs)and personalized pragmatic randomized controlled trials(PPRCTs)are necessary.Researchers should also collaborate to advance TCM from empirical practice to evidence-based therapy,thus consistently promoting TCM development and globalization in a vital,beneficial,and contributable manner.

Under the narrative medicine theory to establish the evidence-based medical record written by doctors and patients through integrated therapy of traditional Chinese and western on digestive system diseases

目的:遵循叙事循证医学理念,抽提医患共建式循证病历的理论,建立医患共建式循证病历的范本.方法:检索Pubmed等重要医学数据库,参照叙事医学的理念,咨询中西医消化内科及循证医学专家,初步达成共识.结果:本研究是一次叙事循证医学指导下医患共建式循证病历建立的有益尝试.思考与展望:医患共建式病历有可能成为叙事医学指导下的中西医合作治疗脾胃病相关疗效评价方法学体系的内容.

Problems faced by evidence-based medicine in evaluating lymphadenectomy for gastric cancer

Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy(D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy(D1). United States and Northern Europe are considered the scientific leaders in medicine and evidencebased procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan(107898 in 2012) than in the entire European Union(81592), or in South Korea(31269) than in the entire United States(21155). For quite a long time evidence-based medicine(EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature(2008-2012) and surgical guidelines. We searched PubMed for papers using the key words "lymphadenectomy or D1 or D2" AND "gastric cancer" from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts' opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1+ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.

EVIDENCE-BASED MEDICINE AND THE CLINICAL STUDY ON ACUPUNCTURE AND MOXIBUSTION

In this article, the authors hold that the evidence based medicine(EBM) is a new medical action produced at the historic moment in clinical practice, which is promoting development of the medicine and even the whole life science in a fully new train of thought and method. Further the briefly introduced contents are the effect of EBM, the difficulty of utilizing in the acupuncture clinical practice and how to resolve them. It is highly recommended that the doctors of the acupuncture science field should study EBM and its effect and difficulties in practice as earlier as possible, insistently assimilate new knowledge and keep abreast of the times’ progress to facilitate the further development of acupunctology.

Calling into Question the Efficacy of Evidence-Based Medicine: Is It Always the Best Approach? Is That Really the Placebo Effect?

The techniques of evidence-based medicine (EBM) are being frequently used recently. The generally accepted theory is that if a medicine is not absorbed by the body, it will have no effect. However, the author has noticed that even when substances, including medicines, are not absorbed by the body, they can have a marked effect. In some cases, just bringing the substance close to the body can have an effect;in such cases, the efficacy of EBM for estimating the therapeutic value of medicines may be debatable. Therefore, a more accurate evaluation method should be devised. The author proposes that another group be introduced into trials. This group would include subjects who were exposed to but did not have an opportunity to absorb the medicine being tested.

Evidence-Based Medicine Research on Prescriptions in Synopsis of the Golden Chamber in the Treatment of Pelvic Inflammatory Disease

Purpose: Based on the National Natural Science Foundation of China, we collect and sort out the literature published in approximately the last 30 years, which use prescriptions in Synopsis of the Golden Chamber to treat pelvic inflammatory disease (PID). This study provides theoretical basis for the treatment of PID;we recommend this achievement to colleagues. Method: Firstly, we searched and collected the literatures from last three decades in CNKI, Wanfang and VIP databases, which are about classical prescriptions treating endometriosis. Then, by screening all the literatures, we obtained the clinical research literatures and individual case reports. Finally, we went through the internal quality of the two categories of literatures to get the dominant prescriptions. Using a retrospective study of evidence-based medicine research, we comprehensively collect literature, standardize the disease spectrum, classify the evidence, and then evaluate the internal quality. Results: We refine 4 prescriptions which commonly are used in the treatment of PID;in other words, they are also the clinical symptoms of PID: Gui Zhi Fu Ling Wan symptom, which manifests blood stasis and cold-damp stagnancy;Dang Gui Shao Yao San symptom, which manifests disharmony of liver and spleen, qi-blood stasis and damp obstruction;Da Huang Mu Dan Tang symptom, which manifests the gathering toxic heat and qi-blood stasis;Yi Yi Fu Zi Bai Jiang San symptom, which manifests the internal toxic heat and qi-blood injury. Conclusion: This study is gospel for the patients with recurrent episodes of PID who can’t often use antibiotics. At the same time, it is also a green therapeutics which Chinese ancients dedicated to human medicine.

COVID-19: Off-label therapies based on mechanism of action while waiting for evidence-based medicine recommendations

The world pandemic due to coronavirus disease 2019,known as COVID-19,embodies a high rate of disease transmission that causes a critical hospitalization overload.As of May 15,2020,the disease has been the cause of more than 4 million infections and more than 280000 deaths all over the world.At the beginning,we underestimated the disease;now,we have sufficient information and it is clear that it is not just a respiratory disease.In fact,if a prompt treatment is not initiated,the disease may evolve towards an abnormal immune response and cytokine storm with an important thrombophilic pattern.Therefore,we think that while waiting for certainties to be established by evidence-based medicine,it is not ethical to not try off-label therapies for some of the well-known drugs,as they could have some efficacy based on their mechanisms of action.

The concept of narrative evidence-based medicine and shared decision-making in traditional Chinese medical practice

随着精准医疗战略的推进，新兴诊断治疗技术的爆发式发展，共同决策可以提高临床决策的质量，促进中医临床研究向证据的转化。关注患者的叙述需求，加强医学人文关怀，可提高临床疗效和患者满意度。本文介绍了循证医学、叙述医学和共同决策的起源和发展，分析了中医临床决策中存在的问题。进一步，在叙述循证医学理念和方法的指导下，提出了临床医师和患者共同决策的方法。

Research in spinal surgery: Evaluation and practice of evidence-based medicine

Evidence-based medicine(EBM) is a common concept among medical practitioners, yet unique challenges arise when EBM is applied to spinal surgery. Due to the relative rarity of certain spinal disorders, and a lack of management equipoise, randomized controlled trials may be difficult to execute. Despite this, responsibility rests with spinal surgeons to design high quality studies in order to justify certain treatment modalities. The authors therefore review the tenets of implementing evidencebased research, through the lens of spinal disorders. The process of EBM begins with asking the correct question.An appropriate study is then designed based on the research question. Understanding study designs allows the spinal surgeon to assess the level of evidence provided.Validated outcome measurements allow clinicians to communicate the success of treatment strategies, and will increase the quality of a given study design. Importantly,one must recognize that the randomized controlled trial is not always the optimal study design for a given research question. Rather, prospective observational cohort studies may be more appropriate in certain circumstances, and would provide superior generalizability. Despite the challenges involved with EBM, it is the future of medicine. These issues surrounding EBM are important for spinal surgeons, as well as health policy makers and editorial boards, to have familiarity.

The Downsides of Evidence-Based Medicine

There exist problems in the actual evidence-based in the practice of medicine relating to the time available and the stringent algorithms employed by the attending physicians. The mistakes are often serious. Illustrating clinical examples are given as to how things can go wrong under the pressure baring on clinicians by the factors given.

Evidence-Based Medicine Research on Shanghan Zabing Lun Prescriptions in the Treatment of Endometriosis

Objective: Adopting the methods of Evidence-based Medicine research to acquire the dominant prescriptions of Shanghan Zabing Lun in the treatment of Endometriosis, meanwhile to fully dig the value of classical prescriptions. Method: Firstly, we searched and collected the literatures from last three decades in CNKI, Wanfang and VIP databases, which are about classical prescriptions treating endometriosis. Then, by screening all the literatures, we obtained the clinical research literatures and individual case reports. Finally, we went through the internal quality of the two categories of literatures to get the dominant prescriptions. Results: 22 Shanghan Zabing Lun prescriptions have been used in the treatment of endometriosis. According to the clinical research and case literatures, Guizhi Fuling Wan is the prime prescription to treat endometriosis with high quality and high frequency. Conclusions: Through evidence-based medical research and evaluation of evidence, it can be seen that treatment of endometriosis presents a certain tendency that Guizhi Fuling Wan, Wenjing Decoction and Dahuang Zhechong Wan have good clinical effect treating endometriosis and their syndromes are well matched with the symptoms of endometriosis in the present clinical environment.

Evidence based medicine and surgical approaches for colon cancer: Evidences, benefits and limitations of the laparoscopic vs open resection

AIM:To report a meta-analysis of the studies that compared the laparoscopic with the open approach for colon cancer resection.METHODS:Forty-seven manuscripts were reviewed,33 of which employed for meta-analysis according to the PRISMA guidelines.The results were differentiated according to the study design(prospective randomized trials vs case-control series)and according to the tu-mor’s location.Outcome measures included:(1)shortterm results(operating times,blood losses,bowel function recovery,post-operative pain,return to the oral intake,complications and hospital stay);(2)oncological adequateness(number of nodes harvested in the surgical specimens);and(3)long-term results(including the survivals’rates and incidence of incisional hernias)and(4)costs.RESULTS:Meta-analysis of trials provided evidences in support of the laparoscopic procedures for a several short-term outcomes including:a lower blood loss,an earlier recovery of the bowel function,an earlier return to the oral intake,a shorter hospital stay and a lower morbidity rate.Opposite the operating time has been confirmed shorter in open surgery.The same trend has been reported investigating case-control series and cancer by sites,even though there are some concerns regarding the power of the studies in this latter field due to the small number of trials and the small sample of patients enrolled.The two approaches were comparable regarding the mean number of nodes harvested and long-term results,even though these variables were documented reviewing the literature but were not computable for meta-analysis.The analysis of the costs documented lower costs for the open surgery,however just few studies investigated the incidence of postoperative hernias.CONCLUSION:Laparoscopy is superior for the majority of short-term results.Future studies should better differentiate these approaches on the basis of tumors’location and the post-operative hernias.