Application of multidisciplinary team-based integrated traditional Chinese medicine and Western medicine in rotator cuff injury patients undergoing arthroscopic surgery

BACKGROUND Arthroscopic rotator cuff repair is a common surgical treatment for rotator cuff injuries(RCIs).Although this procedure has certain clinical advantages,it requires rehabilitation management interventions to ensure therapeutic efficacy.AIM To investigate the effect of integrated traditional Chinese medicine and Western medicine(TCM-WM)under the multidisciplinary team(MDT)model on the postoperative recovery of patients undergoing arthroscopic surgery for RCIs.METHODS This study enrolled 100 patients who underwent arthroscopic rotator cuff repair for RCIs at the Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine between June 2021 and May 2024.They were divided into a control group(n=48)that received routine rehabilitation treatment and an experimental group(n=52)that received TCM-WM under the MDT model(e.g.,acupuncture,TCM traumatology and orthopedics,and rehabilitation).The results of the Constant–Murley Shoulder Score(CMS),Visual Analogue Scale(VAS),Shoulder Pain and Disability Index(SPADI),muscular strength evaluation,and shoulder range of motion(ROM)assessments were analyzed.RESULTS After treatment,the experimental group showed significantly higher CMS scores in terms of pain,functional activity,shoulder joint mobility,and muscular strength than the baseline and those of the control group.The experimental group also exhibited significantly lower VAS and SPADI scores than the baseline and those of the control group.In addition,the experimental group showed significantly enhanced muscular strength(forward flexor and external and internal rotator muscles)and shoulder ROM(forward flexion,abduction,and lateral abduction)after treatment compared with the control group.CONCLUSION TCM-WM under the MDT model improved shoulder joint function,relieved postoperative pain,promoted postoperative functional recovery,and facilitated the recovery of muscular strength and shoulder ROM in patients with RCIs who underwent arthroscopic rotator cuff repair.

Research on the development methodology for clinical practice guidelines for organic integration of traditional Chinese medicine and Western medicine

Integrated traditional Chinese medicine(TCM)and Western medicine(WM)is a new medical science grounded in the knowledge bases of both TCM and WM,which then forms a unique modern medical system in China.Integrated TCM and WM has a long history in China,and has made important achievements in the process of clinical diagnosis and treatment.However,the methodological defects in currently published clinical practice guidelines(CPGs)limit its development.The organic integration of TCM and WM is a deeper integration of TCM and WM.To realize the progression of"integration"to"organic integration",a targeted and standardized guideline development methodology is needed.Therefore,the purpose of this study is to establish a standardized development procedure for clinical practice guidelines for the organic integration of TCM and WM to promote the systematic integration of TCM and WM research results into clinical practice guidelines in order to achieve optimal results as the whole is greater than the sum of the parts.

Quality of life and survival analyses of breast cancer cases treated with integrated traditional Chinese and Western medicine

BACKGROUND Breast cancer(BC)is the second leading cause of tumor-related mortality after lung cancer.Chemotherapy resistance remains a major challenge to progress in BC treatment,warranting further exploration of feasible and effective alternative therapies.AIM To analyzed the quality of life(QoL)and survival of patients with BC treated with integrated traditional Chinese and Western medicine(TCM-WM).METHODS This study included 226 patients with BC admitted to the First Affiliated Hospital of Guangxi University of Traditional Chinese Medicine between February 2018 and February 2023,including 100 who received conventional Western medicine treatment(control group)and 126 who received TCM-WM treatment(research group).The total effective rate,side effects(alopecia,nausea and vomiting,hepatorenal toxicity,and myelosuppression),QoL assessed using the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire(EORTC QLQ-C30),1-year overall survival(OS),recurrence and metastasis rates,and serum inflammatory factors[interleukin(IL)-6,IL-10,and tumor necrosis factor alpha]were comparatively analyzed.RESULTS The research group showed statistically better overall efficacy,EORTC QoL-C30 scores,and 1-year OS than the control group,with markedly lower side effects and 1-year recurrence and metastasis rates.Moreover,the posttreatment levels of serum inflammatory in the research group were significantly lower than the baseline and those in the control group.CONCLUSION Overall,TCM-WM demonstrated significantly improved therapeutic efficacy while ensuring drug safety in BC,which not only improved patients’QoL and prolonged survival,but also significantly inhibited the inflammatory response.

An Ultimate Approach to Retarding the Aging Process by Integrating Traditional Chinese Medicine and Western Medicine

Aging and death are unavoidable in life. While immortality may be impossible, many people dream of living a long and healthy life. Throughout history, humans have searched for ways to stay young, but have not found an effective way. This may be because the methods used do not target the causes of aging directly. To address this, we investigated how to delay aging using traditional Chinese medicine (TCM) and Western medicine approaches. In this article, we will explain the causes of aging in the context of TCM and Western medicine and suggest methods to delay it. By integrating TCM and Western medicine, I hope to help everyone age healthily and enjoy a long life.

A Comparative Analysis of the Control Effect of Medical Expenses between General Hospitals and Traditional Chinese Medicine Hospitals from 2012 to 2021

Objective To analyze the changing trend of average medical expenses and structure in general hospitals and traditional Chinese medicine(TCM)hospitals and the effects and differences achieved by the two kinds of hospitals through controlling unreasonable growth of medical expenses,so as to provide reference for controlling the rapid rise of medical cost in public hospitals and optimizing the cost structure.Methods Based on the changes of related indicators of medical expense control from 2012 to 2021,the overall characteristics,changes of cost structure and trends of medical expenses in general hospitals and TCM hospitals were investigated.Results and Conclusion From 2012 to 2021,the increase of medical expenses in general hospitals and traditional Chinese medicine hospitals had slowed down,the proportion of drug revenue to medical income began to decline,and the medical service income increased.However,the proportion of inspection,test and sanitary materials income has increased instead of decreasing,but the management cost has decreased.The two kinds of hospitals have achieved certain cost control results,the structure of medical cost has changed greatly,and the technical service and labor value of medical personnel have been reflected to a certain extent.However,it is still necessary to explore a more scientific and reasonable cost control mechanism to promote the further optimization of medical cost structure.

Construction of competency evaluation system for infection control personnel in traditional Chinese medicine hospitals

Background:This study uses a literature review and the Delphi expert consultation method to construct a competency evaluation model for infection control personnel in traditional Chinese medicine(TCM)hospitals.The aim is to strengthen infection control management in TCM hospitals,assess the competency of infection control personnel in their positions,and assist them in identifying the competencies that need improvement.Methods:Based on the literature research method and the Delphi expert consultation method,a competency model for the position was constructed through two rounds of expert consultations,analyzing the relationships between various factors and establishing a hierarchical structure model.Pairwise comparisons were made among the elements at the same level to construct a judgment matrix.Through the analytic hierarchy process,the weight coefficients of the indicators at each level in the competency model were obtained.Results:This study conducted a comprehensive assessment of various capabilities and practices related to hospital infection control.The survey results indicate that participants excelled in multiple areas,with a high overall satisfaction rate.95.28%of participants were able to develop hospital infection monitoring plans based on national infection control policies,demonstrating a good understanding and execution of these policies.94.09%of participants were familiar with high-risk populations and key departments in the hospital.91.73%of participants were able to establish monitoring scopes based on the trends of multidrug-resistant bacteria and conduct information monitoring,reflecting strong response capabilities.92.91%of participants were able to collaborate with relevant departments to conduct bacterial resistance monitoring,showing a good team spirit.94.49%of participants were able to perform targeted monitoring,including surgical site infections,indicating that they have effective monitoring strategies.91.34%of participants were able to collect and organize monitoring data and establish a systematic database,demonstrating good data management skills.90.16%of participants were able to interpret laws and regulations related to hospital infection management,indicating a high level of legal knowledge.89.37%of participants generally possessed good communication skills.92.52%of participants were able to guide medical staff on occupational safety and protective knowledge,showing an emphasis on occupational health.Participants demonstrated a strong desire to learn and innovate,with 87.01%actively participating in continuing education and research activities,reflecting a pursuit of professional development.Conclusion:Based on the results of the two rounds of expert consultations,a competency evaluation model for infection control personnel in TCM hospitals was formed.Through the analytic hierarchy process,the weight coefficients of various indicators at different levels in the model were obtained,and the research results have good scientific validity and reliability.

Study on the Changes of Medical Income Structure in Governmentrun Hospitals of Traditional Chinese Medicine from 2012 to 2021

Objective To study the changing characteristics and trend of medical income structure in the government-run hospitals of traditional Chinese medicine(TCM),evaluate the effects of relevant reform measures,and to put forward corresponding suggestions for further optimizing their income structure.Methods The data related to the average medical income of government-run hospitals of TCM from 2012 to 2021 were sorted out.Then,descriptive analysis method was used to analyze the changes of related indicators.Besides,structural change method was applied to investigate the changes of outpatient income and inpatient income.Results and Conclusion From 2012 to 2021,the growth of medical income in government-run hospitals of TCM tended to be stable,and the proportion of medical service income increased from 22.62%(2012)to 29.38%(2021),but the average annual growth rate was only 0.68%.The main items that caused the change of outpatient income structure were medicine revenue,laboratory tests,diagnosis and treatment,and the cumulative contribution rate was 89.15%.The main items that caused the change of inpatient income structure were medicine revenue,sanitary materials,and auxiliary examinations income,with a cumulative contribution rate of 80.04%.However,the contribution rate of registration,diagnosis,treatment,surgery and nursing income reflecting the value of medical personnel’s technical labor was relatively small.The medical income structure of government-run hospitals of TCM underwent great changes and gradually became reasonable,but the medical service income increased slowly,and not all indicators achieved the expectations.To promote the sustainable development of public hospitals of TCM and enable them to provide high-quality and efficient TCM medical and health services,it is necessary to further improve the relevant policy mechanism.

Rapid rehabilitation technique with integrated traditional Chinese and Western medicine promotes postoperative gastrointestinal function recovery

BACKGROUND During the perioperative period, the characteristic therapy of traditional Chinese medicine is effective in improving postoperative rehabilitation. In large-scale hospitals practicing traditional Chinese medicine, there is accumulating experience related to the promotion of fast recovery in the perioperative period.AIM To evaluate the efficacy and safety of Yikou-Sizi powder hot compress on Shenque acupuncture point combined with rapid rehabilitation technique.METHODS This prospective, multicenter, randomized, controlled study included two groups: Treatment group and control group. The patients in the treatment group and control group received Yikou-Sizi powder hot compress on Shenque acupuncture point combined with rapid rehabilitation technique and routine treatment, respectively. Clinical observation regarding postoperative recovery of gastrointestinal function was performed, including the times to first passage of flatus, first defecation, and first normal bowel sounds. The comparison between groups was conducted through descriptive analysis, χ~2, t, F, and rank-sum tests.RESULTS There was a statistically significant difference in the time to postoperative first defecation between the treatment and control group(87.16 ± 32.09 vs 109.79 ±40.25 h, respectively;P < 0.05). Similarly, the time to initial recovery of bowel sounds in the treatment group was significantly shorter than that in the control group(61.17 ± 26.75 vs 79.19 ± 33.35 h, respectively;P < 0.05). However, there was no statistically significant difference in the time to initial exhaust between the treatment and control groups(51.54 ± 23.66 vs 62.24 ± 25.95 h, respectively;P >0.05). The hospitalization expenses for the two groups of patients were 62283.45 ±12413.90 and 62059.42 ± 11350.51 yuan, respectively. Although the cost of hospitalization was decreased in the control group, the difference was not statistically significant(P > 0.05). This clinical trial was safe without reports of any adverse reaction or event.CONCLUSION The rapid rehabilitation technique with integrated traditional Chinese and Western medicine promotes the recovery of postoperative gastrointestinal function and is significantly better than standard approach for patients after colorectal surgery.

The effects and prospects of the integration of traditional Chinese medicine and Western medicine on andrology in China

Andrology has a long history in traditional Chinese medicine （TCM） discussions concerning andropathies, and documentation of relevant therapeutic methods abound in the ancient literature on TCM. Integrated treatment combining TCM and Western medicine has seen both broad and in-depth development, with formidable status in the field of modern andrology in China. This article attempts to demonstrate the unique advantage of integrated treatment in the therapy of andropathies through a review of the ancient literature on andrology in the field of TCM and on the integrative treatment of prostatic diseases, sexual dysfunction, male infertility and late-onset hypogonadism. There is a need for the advancement of a medical theory that integrates TCM and Western medicine practices to create a new therapeutic system with standardized therapeutic and evaluative protocols for diseases involving male sexual health.

Research progress of integrated traditional Chinese and Western medicine in the treatment of advanced gastric cancer

Gastric cancer(GC)is a malignant tumor originating from the gastric epithelium,and its incidence and mortality rates rank third among all malignant tumors worldwide.It is also one of the most common cancers in China and is treated predominantly by Western medicine in clinical practice.However,with the advancements in medical technology and informatics,the values of traditional Chinese medicine(TCM)in preventing and treating GC and improving prognosis have increasingly been recognized.According to TCM,clinical manifestations of GC can be divided into Yege(dysphagia),regurgitation,stomach pain,and Zhengxia(abdominal mass).Due to the unbalanced distribution of health care resources in China,most GC patients already have progressive or advanced-stage disease at the first diagnosis.As a result,most GC patients have poor physical function,and surgery or chemotherapy alone will aggravate the impairment to the immune function and seriously affect the quality of life.In contrast,TCM therapies have shown promising efficacy in the management of these patients.Here we review the role of the integrated TCM and Western medicine in treating advanced GC.

General Survey of Traditional Chinese Medicine and Western Medicine Researches on Tumor Metastasis

Metastasis and recurrence of tumors is the chief cause of death for such patients. Therefore, researches on the mechanism of its metastasis, prevention and treatment are the focal points in the field of traditional Chinese medicine （TCM） and Western medicine （WM） at present. WM practitioners＂ study on tumor metastasis involved its occurrence and development including every detail and process, and now it even has developed into the molecular biological field. py is used as the main means, but the efficacy is not n treatment surgical operation and radio- chemotheratoo optimistic. In recent years, TOM, as part of the comprehensive therapy, has been gradually gaining attention of oncologists. Aimed at solving the difficult problems in metastasis of tumor, many TOM practitioners on the basis of syndrome differentiation have raised theories about the cause of tumor metastasis. On the basis of these theories, some TOM recipes against tumor metastasis have been developed to serve as an effective supplement to surgical operation, radio- and chemotherapy. The present article summarizes research results in recent years about the cause of formation of tumor and its metastasis by TOM and WM, so as to offer some theoretical clues to the study of tumors metastasis.

A Survey on Treatment of Dry Eye by Traditional Chinese Medicine and Integrative Chinese and Western Medicine

Dry eye is now one of the most common superficial disorders in ophthalmology at home and abroad, and more and more people attach importance to the study. The ideal approach for treatment of dry eye is to normalize the condition by rebuilding the superficial circumstance of the eye, and to make tear film work as well as possible so as to relieve the irritating symptoms in the eye. The authors are making a comprehensive discussion on the methods and curative effects of treating dry eye by traditional Chinese medicine and by integrative Chinese and Western medicine in recent years, so as to introduce the distinctive features of the traditional Chinese medicine and integrative Chinese and Western medicine in this field.

Treatment of 140 cerebral palsied children with a combined method based on traditional Chinese medicine(TCM)and western medicine

Objective:To observe and evaluate a method that is effective and practical for treatment of cerebral palsied(CP)children in China.Method:The patient's age and disease type and individual specific conditions were considered in choosingtherapy methods accordingly:Chinese herbs,acupuncture,auricnlar seed pressure,point finger pressing,massage,orthopedichand manipulation,physiotherapy,occupational therapy,language therapy,etc.Meanwhile we created a new CP treatment modelthat combines hospitalized treatment with family therapy.Results:The majority of CP patients improved greatly in motor andsocial adaptation capacities after treatment.Wilcoxon paired rank sum test analysis showed that there were significant differencesbetween the data before and after treatment(P<0.01).Conclusion:This combined therapy method,based on traditional Chinesemedicine and western medicine plus family supplemental therapy,is an effective and practical treatment strategy for CP children inChina.

Evaluation of Clinical Efficacy on Acute Pancreatitis Treated with Combination of Traditional Chinese and Western Medicine: A Meta-Analysis

Objective: Meta-analysis was conducted to assess whether combination of traditional Chinese and western medicine could enhance clinical outcomes compared to single western medicine in the treatment of acute pancreatitis (AP). Methods: This systematic review will include prospective and retrospective comparative studies in all languages and evaluate the clinical efficacy of integrated traditional Chinese and western medicine versus single western medicine in treatment AP. Animal studies will not be considered. Published articles were acquired from Jan. 2001 to Dec. 2017 by a comprehensive search in Chinese National Knowledge Infrastructure database (CNKI), Chinese WANFANG database. Exclusion criteria were non-comparative studies, hybrid treatment. The main points include clinical efficacy;carefully evaluating and reviewing the literature and filtering the literature according to inclusion criteria and exclusion criteria. Statistical analyses were performed using software Review Manager (Version 5.0). Publication biases of main results were examined by Stata 12.0. Results: 1262 cases of 1342 cases were effective and the effective rate reaches 94.04% in the group of integrated traditional Chinese and western medicine, while 949 cases of 1223 cases were effective and its effective rate can be up to 77.60% in the group of single western medicine (P > 0.05%, I2 = 0%, Odds Ratio (OR) = 4.98, 95% CI = 3. 79 - 6.54, P Conclusion: These results suggest that the therapeutic effects of integrated traditional Chinese and Western medicine on AP are better in treatment of AP than that of western medicine alone.

Nursing perspective of expert consensus on the diagnosis and treatment of cerebral infarction with integrated traditional Chinese and Western medicine

Cerebral infarction(CI)is also known as ischemic stroke.It is one of the most common cerebrovascular diseases,with high mortality and disability rate,which has seriously threatened human health.To better apply the diagnosis and treatment plan of integrated traditional Chinese and Western medicine to the treatment of patients with CI,the Chinese Association of Integrative Medicine issued the Expert Consensus on the Diagnosis and Treatment of Cerebral Infarction with the Integrated Traditional Chinese and Western Medicine in 2021.It involves etiology and pathogenesis of CI,diagnosis and treatment standards of Traditional Chinese Medicine(TCM)and Western Medicine,syndrome elements of TCM,as well as rehabilitation nursing of CI with integrated traditional Chinese and Western medicine during acute period and recovery period.This study interprets the consensus from routine nursing,dietary nursing,emotional nursing,complication nursing,rehabilitation nursing,and continuous nursing,aiming to provide evidence-based support for clinical TCM nursing practice.

Expert consensus on diagnosis and treatment of ulcerative colitis with integrated traditional Chinese and Western medicine:A nursing perspective

Ulcerative colitis(UC)is a chronic nonspecific intestinal inflammatory disease of unclear etiology,characterized by continuous and diffuse inflammatory changes of colorectal mucosa.In recent years,the incidence rate of UC in China has increased year by year,but there is no effective cure method in Western medicine.Traditional Chinese medicine treatment based on syndrome differentiation has the unique advantages of simplicity,convenience,effectiveness,and low cost.Therefore,integration of Chinese and Western medicine has become an important strategy for UC diagnosis and treatment,and has made significant progress in UC.On the basis of learning from a number of consensuses at home and abroad,combined with Chinese research results and the actual clinical situation of traditional Chinese and Western medicine,the UC group of the Chinese Association of Integrative Medicine has formulated the expert consensus on the diagnosis and treatment of UC with integrated traditional Chinese and Western medicine.In this consensus,the pathogenesis,etiology and pathogenesis,diagnosis,integrated traditional Chinese and Western medicine treatment,and chronic disease management with integrated traditional Chinese and Western medicine for UC were recommended by experts.This article interprets the consensus from the perspective of nursing in order to provide reference basis for clinical nursing workers.

Research progress in the treatment of perimenopausal abnormal uterine bleeding with traditional Chinese and western medicine

In order to fully understand the research progress of Chinese and Western medicine in the treatment of perimenopausal abnormal uterine bleeding,this paper reviews all kinds of research by referring to related literature reports at home and abroad.The results showed that western medicine mainly used hormone drugs,supplemented by surgery,but the clinical adverse reactions were more and the recurrence rate was higher;traditional Chinese medicine often obtained satisfactory results through the treatment of traditional Chinese medicine,syndrome differentiation,stage treatment,acupuncture and other treatment methods,with fewer adverse reactions and low recurrence rate,but the effect of sudden collapse and hemostasis was slower;the combination of Chinese and Western medicine can learn from each other and become The research focus in recent years is worthy of further discussion.

Current Status of Traditional Chinese and Western Medicine Treatment of Diabetic Peripheral Vascular Disease

Diabetic peripheral vascular disease(PVD)is one of the common chronic complications of diabetes.The main clinical manifestations of PVD are numbness and coldness of the limbs,resting pain,intermittent claudication,and other symptoms.The combined treatment involving Chinese and Western medicine for PVD has various clinical methods and definite curative effects.It is worthy of in-depth clinical research and application.

Treatment of postpartum depression with integrated traditional Chinese and Western medicine nursing and electrical stimulation

BACKGROUND Postpartum depression(PPD)is a common psychological disease among puerperal women,and postpartum pelvic floor dysfunction is a common disease among pregnant women.The occurrence of postpartum pelvic floor dysfunction will increase the incidence of PPD.AIM To explore the therapeutic effect of integrated traditional Chinese and Western medicine nursing combined with electrical stimulation of pelvic floor muscles and the rectus abdominis on PPD.METHODS From April 2020 to January 2022,100 parturients with a rectus abdominis muscle separation distance>2.0 cm who underwent reexamination 6 wk after delivery at our hospital were selected as the research subjects.According to the random number table method,the patients were divided into either an observation group(n=50)or a control group(n=50).There was no significant difference in the general data between the two groups(P>0.05).Both groups were treated by electrical stimulation.The observation group was additionally treated by integrated traditional Chinese and Western medicine nursing.A self-designed Depression Knowledge Questionnaire was used to evaluate the awareness of knowledge on depression in all patients 3 wk after intervention.The Hamilton Depression Scale(HAMD)was used to evaluate the depression before intervention and 1 wk and 3 wk after intervention,and the Morisky Medication Adherence Scale(MMAS-8)was used to evaluate the medication compliance.SPSS19.0 was used for statistical analyses.RESULTS The rate of awareness of knowledge on depression in the observation group was significantly higher than that of the control group(P<0.05).The scores of MMAS-8 were comparable between the two groups before intervention(P>0.05),but were significantly higher in the observation group than in the control group at 1 wk and 3 wk after intervention(P<0.05).The HAMD scores were comparable between the two groups before intervention(P>0.05),but were significantly lower in the observation group than in the control group at 1 wk and 3 wk after intervention(P<0.05).CONCLUSION Integrated traditional Chinese and Western medicine nursing combined with electrical stimulation of pelvic floor muscles and the rectus abdominis is effective in the treatment of postpartum depression and worthy of clinical promotion.

Clinical practice guidelines for traditional Chinese medicine and integrated traditional Chinese and western medicine:a cross-sectional study of data analysis from 2010 to 2020

Objective With the increasing publication of clinical practice guidelines(CPG)for Traditional Chinese Medicine(TCM)and Integrated Traditional Chinese and Western Medicine(IM),the standardization and scientifiction of its formulation have gradually attracted many people’s attention.To offer an overview of TCM and IM CPGs published over the past decade and analyze their general characteristics and methodological quality.Methods The China National Knowledge Infrastructure(CNKI)and WANFANG databases were searched for clinical practice guidelines and expert consensus papers from January 2010 to June 2021.Two researchers independently completed the literature screening and cross-checking according to the inclusion and exclusion criteria of CPGs and extracted information on general characteristics and methodological quality of CPGs.Results According to the selection criteria,231 CPGs(EB-CPGs=119,CBCPGs=112)were selected and the number of CPGs published in the 11 years showed an overall upward trend.The vast majority of CPGs used the Western naming system for the diseases,and only 11 CPGs were named of TCM diseases or symptoms.TCM treatments were recommended in 223 CPGs.There were 156 ancient Chinese Medicine literature sources cited in 231 CPGs and opinions and experiences of 62 TCM experts cited in 37 CPGs.The methodological quality of EB-CPGs for TCM and IM were significantly better than CB-CPGs in 11 items.Only 60 EB-CPGs and 7 CB-CPGs designated clear criteria for grading quality of evidence and strength of the recommendations and 74 CPGs presented both the level of evidence and the strength of recommendations.We classified all CPGs according to whether or not they used GRADE,and the results showed that the CPGs using GRADE had higher methodological quality and more standardized reports.Conclusion This research has shown that the quantity and quality of CPGs in both TCM and IM have improved over the time span,but the methodological quality,especially evidence citation,and the use of criteria for grading quality of evidence and strength of the recommendations,still needs to further improvement in the future.