多学科协作治疗急性早幼粒细胞白血病合并狗咬伤1例报告

对2019年8月15日滨州医学院附属医院收治的1例急性早幼粒细胞白血病(acute promyelocytic leukemia,APL)合并狗咬伤患者行血液科、整形外科、内分泌科、营养科、皮肤科等多学科协作治疗,治疗3d后,患者血糖调节至理想水平;治疗7 d后,患者体温恢复正常;分别于治疗15、18、21 d后,患者白蛋白、血钾及血钙恢复至正常水平;治疗50 d后,患者狗咬伤创面明显缩小,银屑病导致的皮肤损伤得到有效控制,患者出院;治疗120 d后,创面基本愈合。     

China’s international trade and air pollution in the United States

China is the world’s largest emitter of anthropogenic air pollutants, and measurable amounts of Chinese pollution are transported via the atmosphere to other countries, including the United States. However, a large fraction of Chinese emissions is due to manufacture of goods for foreign consumption. Here, we analyze the impacts of trade-related Chinese air pollutant emissions on the global atmospheric environment, linking an economic-emission analysis and atmospheric chemical transport modeling. We find that in 2006, 36% of anthropogenic sulfur dioxide, 27% of nitrogen oxides, 22% of carbon monoxide, and 17% of black carbon emitted in China were associated with production of goods for export. For each of these pollutants, about 21% of export-related Chinese emissions were attributed to China-to-US export. Atmospheric modeling shows that transport of the export-related Chinese pollution contributed 3–10% of annual mean surface sulfate concentrations and 0.5–1.5% of ozone over the western United States in 2006. This Chinese pollution also resulted in one extra day or more of noncompliance with the US ozone standard in 2006 over the Los Angeles area and many regions in the eastern United States. On a daily basis, the export-related Chinese pollution contributed, at a maximum, 12–24% of sulfate concentrations over the western United States. As the United States outsourced manufacturing to China, sulfate pollution in 2006 increased in the western United States but decreased in the eastern United States, reflecting the competing effect between enhanced transport of Chinese pollution and reduced US emissions. Our findings are relevant to international efforts to reduce transboundary air pollution.A key driver of the rapid economic growth in China over the past decade is the great expansion in the production of goods for export (1). Although growth has slowed since the global financial crisis, between 2000 and 2007 the volume of Chinese exports grew by 390% (2). As the Chinese economy has grown, the economic structure has also changed, transitioning from a net importer to a large net exporter of energy-intensive industrial products (2). The energy needed to support this economic growth and transformation has come from combustion of fossil fuels, primarily coal, which has contributed to a global increase in emissions of carbon dioxide (CO₂) (3, 4). At the same time, increased combustion of fossil fuels, relatively low combustion efficiency, and weak emission control measures have also led to drastic increases in air pollutants such as sulfur dioxide (SO₂), nitrogen oxides (NO_x), carbon monoxide (CO), black carbon (BC), and primary organic carbon (OC) (5–8). Indeed, fossil-fuel–intensive manufacturing, large manufacturing volume, and relatively weak emission controls have meant that China emits far more pollutants per unit of gross domestic product (GDP) than countries with more advanced industrial and emission control technologies (SI Appendix, Table S1). Per unit of GDP in 2006, China emitted 6–33 times as much air pollutants as the United States (Fig. 1 E–H). For these reasons, air quality has recently become a major focus of environmental policy in China (8).Open in a separate windowFig. 1.Air pollutants embodied in Chinese trade between 2000 and 2009. (A–D) Production-based emissions (thin lines), consumption-based emissions (thick lines), and their differences (i.e., Chinese EET associated with its trade with the rest of the world in purple shading, and EET associated with Sino-US trade alone in green shading). All Chinese emissions are calculated here, the US production-based emissions are taken from the National Emissions Inventory, and the US consumption-based emissions are derived based on production-based emissions and Sino-US trade-related emissions. Although China’s production-based emissions are growing rapidly, its EET are equivalent to substantial fractions of the production-based emissions. Similarly, the EET due to Sino-US trade are equivalent to large proportions of the production-based US emissions since 2006. (E–H) Emissions per GDP. Although China’s production-based emissions per unit GDP have been decreasing, its consumption-based emissions per unit GDP have decreased less significantly or have increased since 2008. (I–L) Emissions per capita. Per capita emissions are very different between the United States and China, and this disparity is increased when the consumption-based emissions are considered. For data sources, see SI Appendix, Table S1, footnote.In this study, the terms “export,” “import,” and “trade” all refer to transaction of goods between countries. The pollutants emitted in China due to its production of goods for foreign consumption are regarded as emissions embodied in export (EEE) of China (9, 10). The EEE is unique in that the associated goods are consumed outside of China, raising a question about the extent to which China and its export partners should be accountable for the emissions (10–12). The attribution depends on whether the emission accounting is based on production or on consumption. Production-based accounting considers all emissions physically produced in China to be Chinese emissions, including the EEE. Such accounting is used as default in current emission inventories such as the Emission Database for Global Atmospheric Research (13). By comparison, consumption-based accounting views all emissions associated with production of goods consumed by China to be China’s responsibility, no matter whether the production occurs in China or in other countries (9, 10). Thus, the consumption-based Chinese emissions exclude the EEE but include the emissions embodied in import of China (EEI, i.e., emissions in other countries due to production of goods for Chinese consumption). The numerical difference between production- and consumption-based emissions of China is the EEE less the EEI, the result of which is regarded as the emissions embodied in net trade (EET) of China (10). Similar emission analyses are applicable to other countries.Previous studies have quantified the substantial CO₂ emissions embodied in Chinese trade (10, 11). Thus, far, however, relatively little attention has been paid to trade-related emissions of short-lived air pollutants and especially the resulting impacts on the global atmospheric environment, except for an analysis done for local air quality of the Pearl River Delta (14). This is true despite the direct harm these pollutants do to human health (15–18), agriculture (19), ecosystems (20), and global climate (21, 22). And as scientific evidence of transport of Chinese air pollution across the Pacific Ocean has grown since the late 1990s (23–29), the United States and Canada have a special interest in reducing Chinese air pollution. In the case of CO₂, consumption-based accounting of emissions has been motivated by the argument—often made by developing countries—that consumers who benefit from a process should bear some responsibility for associated environmental damage (30). A similar accounting for emissions of air pollutants and consequent impacts on the global atmospheric environment may therefore be necessary to facilitate discussion of international collaborations on transboundary air pollution control (31).We quantify the emissions of SO₂, NO_x, CO, BC, and OC embodied in Chinese exports and imports between 2000 and 2009 using an economic input–output model constructed from economic and emission data. The model resolves trade between China and four countries/regions [the United States, the European Union (EU), Japan, and an aggregated region of all other countries] and 42 industry sectors, and allocates pollutant emissions to countries and industry sectors according to where goods are consumed. As part of our analysis, we also quantify the uncertainties in emission derivation using a Monte Carlo approach. We then simulate the effects of export-related Chinese emissions on air pollution in China and downwind regions, using the GEOS-Chem global chemical transport model. See SI Appendix for details of our analytic approach, data sources, and model simulations.     

In the Front Line: The Impact of Specialist Training for Hospital Physicians in Children at Risk on Their Collaboration With Social Workers

Until recently, dealing with children at risk in Israeli hospitals was almost exclusively the domain of medical social workers. Suspected cases of abuse or neglect must be identified in real-time, during the child’s short stay in the hospital, and the decision of whether or not to report the case, and to whom (law enforcement or welfare authorities), must be made. The recognition that effective treatment also demands the involvement of physicians led to the development of an intensive training program for hospital-pediatricians. The current study, based on in-depth interviews with the doctors who participated in the program and the social workers who work with them at 14 hospitals in Israel, examined the impact of the training on cooperation between the two groups, seeking to determine whether the doctors’ increased familiarity with the social work profession enhanced team-work.

Phenomenological analysis of the interviews revealed several themes, indicating greater collaboration between the doctors and social workers. However, the participants also noted increased friction between the two groups. Possible explanations and practical recommendations for enhancing the potential effectiveness of such collaborations are offered. The study has implications for designing similar training programs as well as for improving the dynamics between the two professions.     

Preschool teachers' views on competence in the context of home and preschool collaboration

The purpose of this article is to analyse and discuss preschool teachers' views regarding competence within their profession in the context of home and preschool collaboration. The question addressed is as follows: In what situations do preschool teachers perceive that their competence becomes visible for parents? The results, based on interviews with 30 preschool teachers, show that preschool teachers work consciously to draw attention to specific competencies related to children's learning and development and the preschool curriculum. The ability to establish dialogue with parents and gain their trust is seen as particularly important for establishing and maintaining collaboration between preschool and the home. Furthermore, the participants recognise that parents seek their competence in daily matters concerning the child's well-being. The competencies that preschool teachers emphasise and those they believe parents ask for do not, therefore, always coincide. The results of this study can contribute to a better understanding of the prerequisites for preschool–home collaboration.     

Provider Attitudes Toward Public-Private Collaboration to Improve Immunization Reminder/Recall: A Mixed-Methods Study

ObjectiveTo assess primary care providers' current reminder/recall practices, preferences for collaboration with health departments in reminder/recall efforts, attitudes toward practice-based and population-based reminder/recall, and experiences with a population-based reminder/recall intervention.MethodsProviders responsible for making decisions about immunization delivery at all primary care practices that participate in the Colorado Immunization Information System were surveyed. Data collection was preceded by an intervention in which half of 14 counties received a population-based reminder/recall intervention conducted by the health department. Practice staff involved in immunization activities were then selected for semistructured telephone interviews that were based on the location of their practice within specified strata, including whether they were in the intervention counties, urban/rural location, and practice type.ResultsA total of 282 (73.6%) of 383 of providers responded to the survey, and 253 who administered vaccines to children 19 to 35 months were retained; 82 staff members at 36 practices were interviewed. Providers' preferences for who should conduct reminder/recall were almost evenly split, with slightly more indicating that it should be conducted by the health department. Cost and feasibility issues were perceived barriers to conducting practice-based recall, particularly among urban practices. Support for population-based reminder/recall was highest among rural practices. Concern about perceived inaccuracies in immunization registry data was the major barrier to conducting population-based reminder/recall. The population-based intervention did not create an undue burden on practices.ConclusionsA collaborative approach to reminder/recall involving both providers and health departments is preferable for many providers and may be a viable solution to the barriers of practice-based reminder/recall.     

Instruments measuring interprofessional collaboration in healthcare – a scoping review

ABSTRACT

Worldwide there is growing understanding of the importance of interprofessional collaboration in providing well-functioning healthcare. However, little is known about how interprofessional collaboration can be measured between different health-care professionals. In this review, we aim to fill this gap, by identifying and analyzing the existing instruments measuring interprofessional collaboration in healthcare. A scoping review design was applied. A systematic literature search of two electronic databases, Medline (PubMed) and CINAHL, was conducted in 03/2018. The search yielded 1020 studies, of which 35 were selected for the review. The data were analyzed by content analysis. In total, 29 instruments measuring interprofessional collaboration were found. Interprofessional collaboration was measured predominantly between nurses and physicians with different instruments in various health-care settings. Psychometric testing was unsystematic, focusing predominantly on construct and content validity and internal consistency, thus further validation studies with comprehensive testing are suggested. The results of this review can be used to select instruments measuring interprofessional collaboration in practice or research. Future research is needed to strengthen the evidence of reliability and validity of these instruments.     

Simulating Rescue Strategies From Procedural Sedation: One Aspect of Competency Validation

Quality and Safety in Nursing Education identifies both teamwork and patient safety as key domains in which competencies are required. An example that makes these competencies necessary in day-to-day clinical safety is procedural sedation. Procedural sedation is a key area of risk in an acute-care facility. Safety in this area requires teamwork. The Joint Commission requires that risk management also examine the process of procedural sedation outside the operating room. This assures equity of care and oversight by the anesthesia department. Procedural sedation is not within the current National Council Licensure Examination blueprint (NCSBN, 2019). It is up to employers to validate the hired registered nurse has the skills, knowledge, and attitude to safely administer these high-risk medications. Working as a taskforce, five disciplines from ten areas that administered procedural sedation in our acute care facility created a three-component competency validation approach. The novel component was the development of a high-fidelity simulation validating the ability of the registered nurse to rescue a patient from loss of protective reflexes. The outcome of the simulation process included a clinical reasoning evaluation by the clinical educator. This article is a discussion of the development and clinical usefulness of this simulation tool as a competency adjunct.