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Respecting Body-Size Diversity in Patients: A Trauma-Informed Approach for Clinicians. 尊重患者的体型多样性:临床医生的创伤知情方法。
Q2 Social Sciences Pub Date : 2024-03-15 Epub Date: 2023-11-20 DOI: 10.7812/TPP/23.104
Alison Mosier-Mills, Meghana Vagwala, Jennifer Potter, Sadie Elisseou
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引用次数: 0
Clinical Assessment Specialists: A New Faculty Role to Improve Clerkship Assessment. 临床评估专家:改进见习评估的新教师角色。
Q2 Social Sciences Pub Date : 2024-03-15 Epub Date: 2023-12-01 DOI: 10.7812/TPP/23.062
Lindsay A Mazotti, Delores A Amorelli, Ronald A Navarro, Abbas A Hyderi, Michael H Kanter, Carla S Lupi

Introduction: Ambulatory clerkships, including longitudinal integrated clerkships (LICs), face challenges to assessment, including time pressure and clinical demands on preceptors. High-quality clinical assessment is critical to implementing competency-based medical education, generating valid grades, and supporting learning. This importance is further heightened with the new pass/fail scoring for US Medical Licensing Exam Step 1, discontinuation of US Medical Licensing Exam Step 2 Clinical Skills, and the growing concern for bias in assessment.

Methods: The Kaiser Permanente Bernard J. Tyson School of Medicine's LIC spans the first 2 years with 50 students per class. In 2021-2022, the authors created a new faculty role, the clinical assessment specialist (CASp). CASps are highly trained clinical teachers who directly observe clerkship students in the ambulatory setting, provide feedback, and complete competency-based assessment forms.

Results: CASps completed 186 assessments of first-year (Y1) LIC students and 333 assessments of second-year (Y2) LIC students. Y2 students achieved average higher milestones and were rated as requiring less supervision compared to Y1 students. Y1 students rated CASps more favorably than Y2 students. Preceptors rated the contribution of CASps similarly across both years. Clerkship directors described benefits including identification of at-risk students and value of augmenting preceptor assessments.

Discussion: The CASp role may offer an innovative way to generate valid assessment of student performance, offset clinical pressures faced by preceptors, identify at-risk students, and mitigate bias, especially in an LIC. Future studies may examine assessment validity, including use in summative assessment.

Conclusion: CASps are an innovative approach to clinical clerkship assessment.

简介:门诊见习,包括纵向综合见习(LICs),面临着评估的挑战,包括时间压力和临床对辅导员的要求。高质量的临床评估对于实施以能力为基础的医学教育、产生有效的成绩和支持学习至关重要。随着美国医疗执照考试第1步的新及格/不及格评分,美国医疗执照考试第2步临床技能的终止,以及对评估偏差的日益关注,这一重要性进一步提高。方法:Kaiser Permanente Bernard J. Tyson医学院的LIC跨越前两年,每班50名学生。在2021-2022年,作者创建了一个新的教师角色,临床评估专家(CASp)。casp是训练有素的临床教师,他们直接在门诊环境中观察见习学生,提供反馈,并完成基于能力的评估表格。结果:CASps完成了186项一年级(Y1)学生评估和333项二年级(Y2)学生评估。与一年级学生相比,二年级学生达到了更高的平均里程碑,并且被认为需要更少的监督。一年级学生对CASps的评价高于二年级学生。在这两年中,导师对CASps贡献的评价相似。见习主任描述的好处包括识别有风险的学生和增加教师评估的价值。讨论:CASp的作用可能提供一种创新的方式来产生有效的学生表现评估,抵消教师面临的临床压力,识别有风险的学生,并减轻偏见,特别是在LIC中。未来的研究可能会检查评估的有效性,包括在总结性评估中使用。结论:CASps是一种创新的临床见习评估方法。
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引用次数: 0
Personalized Mobile Health-Enhanced Cognitive Behavioral Intervention for Maternal Distress: Examining the Moderating Role of Adverse Childhood Experiences. 针对产妇压力的个性化移动健康强化认知行为干预:研究童年不良经历的调节作用。
Q2 Social Sciences Pub Date : 2024-03-15 Epub Date: 2024-01-24 DOI: 10.7812/TPP/23.094
Ellen Goldstein, Jillian S Merrick, Renee C Edwards, Yudong Zhang, Brianna Sinche, Julia Raven, Stephanie Krislov, Daniela Robledo, Roger L Brown, Judith T Moskowitz, S Darius Tandon, Lauren S Wakschlag

Background: Maternal history of trauma is a risk factor for distress during pregnancy. The purpose of this paper was to examine the theorized differential impact of a cognitive behavioral intervention (Mothers and Babies Personalized; MB-P) on maternal distress and emotional regulation for those with ≥ 1 adverse childhood experiences (ACEs; vs no ACEs) from pregnancy to 3 months postpartum.

Methods: Between August 2019 and August 2021, eligible pregnant individuals aged ≥ 18 years, < 22 weeks' gestation, and English-speaking were recruited from 6 university-affiliated prenatal clinics. Participants (N = 100) were randomized to MB-P (n = 49) or control (n = 51). Analyzable data were collected for 95 participants. Analyses tested progression of change (slope) and at individual timepoints (panel analysis) for perinatal mental health outcomes.

Results: The majority of participants (n = 68, 71%) reported experiencing > 1 ACE (median = 1, range: 0-11). Participants demonstrated significant differential effects for depressive symptoms in absence of ACEs (standardized mean differences [SMD] = 0.82; 95% confidence interval [CI] = [0.13-1.51]) vs in presence of ACEs (SMD = 0.39; 95% CI = [-0.20 to 0.97]) and perceived stress in absence of ACEs (SMD = 0.92; 95% CI = [0.23-1.62]) vs in presence of ACEs (SMD = -0.05; 95% CI = [-0.63 to 0.53]). A panel analysis showed significantly reduced depressive symptoms postintervention and increased negative mood regulation at 3 months postpartum for individuals with ACEs.

Conclusions: Findings support effectiveness of the MB-P intervention to reduce prenatal distress for all pregnant individuals. Preliminary exploration suggests the possibility that individuals with ACEs may benefit from enhanced trauma-informed content to optimize the effects of a perinatal intervention.

背景:孕产妇的创伤史是导致孕期窘迫的一个风险因素。本文旨在研究认知行为干预(Mothers and Babies Personalized; MB-P)对那些从怀孕到产后 3 个月期间有≥1 次不良童年经历(ACEs; vs no ACEs)的孕产妇的困扰和情绪调节的不同影响:2019年8月至2021年8月期间,从6所大学附属产前诊所招募年龄≥18岁、孕周<22周、讲英语的合格孕妇。参与者(100 人)被随机分配到 MB-P(49 人)或对照组(51 人)。收集了 95 名参与者的可分析数据。分析测试了围产期心理健康结果的变化进展(斜率)和单个时间点(面板分析):大多数参与者(n = 68,71%)报告经历了 > 1 次 ACE(中位数 = 1,范围:0-11)。在没有 ACE 的情况下,参与者的抑郁症状表现出明显的差异效应(标准化平均差异 [SMD] = 0.82;95% 置信区间 [CI] = [0.13-1.51])与有 ACEs 时(SMD = 0.39; 95% CI = [-0.20 to 0.97])以及无 ACEs 时(SMD = 0.92; 95% CI = [0.23-1.62])与有 ACEs 时(SMD = -0.05; 95% CI = [-0.63 to 0.53])感知到的压力有显著差异。一项小组分析显示,干预后抑郁症状明显减少,有ACE的个体在产后3个月的消极情绪调节能力增强:研究结果支持 MB-P 干预对减少所有孕妇产前困扰的有效性。初步探索表明,有 ACE 的个体可能会从增强的创伤知情内容中受益,从而优化围产期干预的效果。
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引用次数: 0
Leading Organizations From Burnout to Trauma-Informed Resilience: A Vital Paradigm Shift. 领导组织从职业倦怠到创伤知情复原力:重要的范式转变。
Q2 Social Sciences Pub Date : 2024-03-15 Epub Date: 2024-02-09 DOI: 10.7812/TPP/23.110
Sadie Elisseou, Andrea Shamaskin-Garroway, Avi Joshua Kopstick, Jennifer Potter, Amy Weil, Constance Gundacker, Alisha Moreland-Capuia
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引用次数: 0
The Digital Transition: Are Adults Aged 65 Years or Older Willing to Complete Online Forms and Questionnaires in Patient Portals? 数字化转型:65 岁或以上的成年人是否愿意在患者门户网站上填写在线表格和问卷?
Q2 Social Sciences Pub Date : 2024-03-15 Epub Date: 2024-02-06 DOI: 10.7812/TPP/23.112
Nancy P Gordon, Sherry Zhang, Joan C Lo, Christina F Li

Introduction: Patients are being encouraged to complete forms electronically using patient portals rather than on paper, but willingness of older adults to make this transition is uncertain.

Methods: The authors analyzed data for 4105 Kaiser Permanente Northern California 2020 Member Health Survey respondents aged 65-85 years who answered a question about willingness to complete online forms and questionnaires using a patient portal. Data weighted to the Kaiser Permanente Northern California membership were used to estimate percentages of older adults willing to complete patient portal forms and questionnaires. Chi-square tests and log-Poisson regression models that included sociodemographic, internet use, and patient portal variables were used to identify factors predictive of willingness.

Results: Overall, 59.6% of older adults were willing to complete patient portal forms, 17.6% were not willing, and 22.8% were not sure. Adults aged 75-85 (49.5%) vs 65-74 years (64.8%) and Black (51.9%) and Latino (46.5%) vs White (62.8%) adults were less likely to indicate willingness. In addition to racial and ethnic differences and younger age, higher educational attainment, use of the internet alone (vs internet use with help or not at all), having an internet-enabled computer or tablet, and having sent at least 1 message through the patient portal increased likelihood of being willing.

Conclusions: Health care teams should assess older adults' capabilities and comfort related to completion of patient portal-based forms and support those willing to make the digital transition. Paper forms and oral collection of information should remain available for those unable or unwilling to make this digital transition.

导言:人们鼓励患者使用患者门户网站填写电子表格,而不是纸质表格,但老年人是否愿意这样做还不确定:作者分析了 4105 名年龄在 65-85 岁之间的北加州凯泽医疗集团 2020 年成员健康调查受访者的数据,这些受访者回答了关于是否愿意使用患者门户网站填写在线表格和问卷的问题。根据北加州 Kaiser Permanente 会员的加权数据,估算出愿意填写患者门户网站表格和问卷的老年人百分比。利用包括社会人口学、互联网使用和患者门户网站变量在内的卡方检验和对数泊松回归模型来确定预测意愿的因素:总体而言,59.6% 的老年人愿意填写患者门户网站表格,17.6% 不愿意,22.8% 不确定。年龄在 75-85 岁(49.5%)与 65-74 岁(64.8%)、黑人(51.9%)和拉丁裔(46.5%)与白人(62.8%)之间的成年人表示愿意填写的可能性较低。除了种族和民族差异以及年龄较小之外,受教育程度较高、单独使用互联网(与在他人帮助下使用互联网或根本不使用互联网)、拥有联网电脑或平板电脑以及通过患者门户网站至少发送过一条信息也会增加表示愿意的可能性:医疗团队应评估老年人在填写患者门户网站表格方面的能力和舒适度,并为愿意进行数字化过渡的老年人提供支持。对于那些无法或不愿进行数字化转换的人,应继续使用纸质表格和口头收集信息的方式。
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引用次数: 0
Leaders' Perspectives on Resources for Academic Success: Defining Clinical Effort, Academic Time, and Faculty Support. 领导者对学术成功资源的看法:定义临床努力、学术时间和教师支持。
Q2 Social Sciences Pub Date : 2024-03-15 Epub Date: 2023-12-11 DOI: 10.7812/TPP/23.093
Madhusmita Misra, Grace C Huang, Anne E Becker, Carol K Bates

Introduction: For academic promotion, clinical faculty are expected to excel in clinical care, teaching, and scholarship. Ensuring adequate protected time and resources to engage in scholarly work in the face of competing clinical responsibilities is critical. The authors examined academic leaders' perspectives across affiliate hospitals of a large medical school regarding the definition of clinical full-time effort and academic time, best practices to enable academic success, and barriers to faculty advancement.

Methods: Open-ended, semistructured, individual interviews were conducted with a purposive sample of clinical department and division heads. Interview data were examined to illuminate the range and commonalities in practices and to identify successful approaches.

Results: Interviews were conducted with 17 academic leaders across 6 affiliate hospitals. There was considerable variability in clinical full-time effort definition. "Academic time," more accurately characterized as "nonclinical time," was typically 1 day a week for nonshift specialties and mostly used for administrative work or completing clinical documentation. Certain departments were more explicit in designating and protecting time for academic pursuits; some had invested resources in intensive programs for academic advancement with built-in expectations for accountability. The impact of documentation burden was considerable in certain departments.

Discussion and conclusion: Marked variability exists in time allocations for clinical and academic work, as well as in resources for academic success. This supports the potential value of establishing standards for defining and protecting academic time, motivating clinical faculty to engage in academic work, and building accountability expectations. Sharing best practices and setting standards may enhance academic advancement. Strategies to reduce documentation burden may enhance wellness.

介绍:为获得学术晋升,临床教师应在临床护理、教学和学术研究方面表现出色。面对相互竞争的临床职责,确保有足够的时间和资源从事学术工作至关重要。作者研究了一所大型医学院附属医院的学术带头人对临床全职工作和学术时间的定义、学术成功的最佳实践以及教师晋升障碍的看法:对临床科室和部门负责人进行了开放式、半结构化的个别访谈。对访谈数据进行了研究,以揭示实践的范围和共性,并找出成功的方法:对 6 家附属医院的 17 名学术带头人进行了访谈。临床全职工作的定义存在很大差异。"学术时间 "更准确地说是 "非临床时间",对于非轮班专科来说,通常每周一天,主要用于行政工作或完成临床文件。某些科室在指定和保护学术活动时间方面更为明确;有些科室投入资源开展了强化的学术进修计划,并对责任进行了明确规定。在某些科室,文件负担的影响相当大:在临床和学术工作的时间分配以及学术成功的资源方面存在明显差异。这证明了制定标准以定义和保护学术时间、激励临床教师参与学术工作以及建立问责预期的潜在价值。分享最佳实践和制定标准可促进学术进步。减轻文件负担的策略可提高健康水平。
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引用次数: 0
Introduction to Issue 28:1 by the Editor-in-Chief. 主编对第 28:1 期的介绍。
Q2 Social Sciences Pub Date : 2024-03-15 DOI: 10.7812/TPP/24.034
G Richard Holt
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引用次数: 0
Hyperaldosteronism Screening and Findings From a Large Diverse Population With Resistant Hypertension Within an Integrated Health System. 高醛固酮增多症筛查和结果来自一个综合卫生系统内的大量不同人群的顽固性高血压。
Q2 Social Sciences Pub Date : 2024-03-15 Epub Date: 2023-11-27 DOI: 10.7812/TPP/23.096
Victor Kim, Jiaxiao Shi, Jaejin An, Simran Bhandari, Jeffrey W Brettler, Michael H Kanter, John J Sim

Introduction: Hyperaldosteronism (HA) is a common cause of secondary hypertension and may contribute to resistant hypertension (RH). The authors sought to determine and characterize HA screening, positivity rates, and mineralocorticoid receptor antagonist (MRA) use among patients with RH.

Methods: A cross-sectional study was performed within Kaiser Permanente Southern California (7/1/2012-6/30/2017). Using contemporary criteria, RH was defined as blood pressure uncontrolled (≥ 130/80) on ≥ 3 medications or requiring ≥ 4 antihypertensive medications. The primary outcome was screening rate for HA defined as any aldosterone and plasma renin activity measurement. Secondary outcomes were HA screen positive rates and MRA use among all patients with RH. Multivariable logistic regression analysis was used to estimate odds ratio (with 95% confidence intervals) for factors associated with HA screening and for patients that screened positive.

Results: Among 102,480 patients identified as RH, 1977 (1.9%) were screened for HA and 727 (36.8%) screened positive for HA. MRA use was 6.5% among all patients with RH (22.5% among screened, 31.2% among screened positive). Black race, potassium < 4, bicarbonate > 29, chronic kidney disease, obstructive sleep apnea, and systolic blood pressure were associated with HA screening, but only Black race (1.55 [1.20-2.01]), potassium (1.82 [1.48-2.24]), bicarbonate levels (1.39 [1.10-1.75]), and diastolic blood pressure (1.15 [1.03-1.29]) were associated with positive screenings.

Conclusion: The authors' findings demonstrate low screening rates for HA among patients with difficult-to-control hypertension yet a high positivity rate among those screened. Factors associated with screening did not always correlate with screening positive. Screening and targeted use of MRA may lead to improved blood pressure control and outcomes among patients with RH.

简介:高醛固酮增多症(HA)是继发性高血压的常见原因,可能有助于抵抗性高血压(RH)。作者试图确定和表征RH患者的HA筛查,阳性率和矿皮质激素受体拮抗剂(MRA)的使用。方法:在南加州凯撒医疗机构(2012年7月1日- 2017年6月30日)进行横断面研究。使用当代标准,RH被定义为血压不受控制(≥130/80),服用≥3种药物或需要≥4种降压药。主要结果是血凝素的筛查率,定义为任何醛固酮和血浆肾素活性测量。次要结果是所有RH患者的HA筛查阳性率和MRA使用情况。使用多变量logistic回归分析来估计与HA筛查相关因素和筛查阳性患者的优势比(95%置信区间)。结果:在102480例RH患者中,1977例(1.9%)进行HA筛查,727例(36.8%)HA筛查阳性。在所有RH患者中,MRA使用率为6.5%(筛查患者为22.5%,筛查阳性患者为31.2%)。黑人、钾< 4、碳酸氢盐> 29、慢性肾病、阻塞性睡眠呼吸暂停和收缩压与HA筛查相关,但只有黑人(1.55[1.20-2.01])、钾(1.82[1.48-2.24])、碳酸氢盐水平(1.39[1.10-1.75])和舒张压(1.15[1.03-1.29])与筛查阳性相关。结论:作者的研究结果表明,在难以控制的高血压患者中,HA的筛查率很低,但筛查的患者中HA的阳性率很高。与筛查相关的因素并不总是与筛查阳性相关。筛选和有针对性地使用MRA可能会改善RH患者的血压控制和预后。
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引用次数: 0
Medical Students' Knowledge, Attitudes Toward, and Identification of Adverse Childhood Experiences and Trauma-Informed Care. 医学生对童年不良经历和创伤知情护理的了解、态度和识别。
Q2 Social Sciences Pub Date : 2024-03-15 Epub Date: 2024-01-29 DOI: 10.7812/TPP/23.108
Rachel Piszczor, Courtney Barry, Constance Gundacker, Carly Wallace, Jineane Shibuya, Jonathan Perle

Introduction: Adverse childhood experiences (ACEs) are traumatic experiences that occur prior to age 18 years and can have a long-term impact on adult physical and mental health. Knowledge of ACEs, including the link between ACEs and health, and trauma-informed care (TIC), is essential for medical professionals to ensure respectful and compassionate care for those with a history of childhood adversity. This study examined medical students' knowledge, attitudes toward, and identification of ACEs and TIC to inform curricular efforts.

Methods: Using a cross-sectional design, students were recruited from 2 medical schools, one allopathic (medical degree) and one osteopathic (doctor of osteopathic medicine degree) to complete an electronic needs assessment survey. The survey included a patient vignette to assess students' ability to identify ACEs as contributing factors to patient health. The students were blind to the full purpose of the study to obtain an objective measurement of their ability to identify ACEs as contributors to patient health. Additional questions targeting knowledge and attitudes of ACEs and TIC were devised from previously published surveys with supplemental study-designed questions.

Results: Two hundred forty students completed the survey. Results demonstrated variable ability to identify ACEs; strong general knowledge of ACEs, with less developed practical knowledge; and overall positive attitudes toward ACEs and TIC. No differences were found between the medical degree and doctor of osteopathic medicine degree, or year in program.

Conclusions: Medical students would benefit from curricular efforts that help to increase knowledge of the link between ACEs and health, increase practical application of ACEs and TIC, and improve their ability to identify ACEs in clinical scenarios.

导言:童年逆境经历(ACE)是指 18 岁以前发生的创伤经历,会对成年后的身心健康产生长期影响。了解 ACE(包括 ACE 与健康之间的联系)和创伤知情护理 (TIC) 对于医务人员确保为有童年逆境史的人提供尊重和富有同情心的护理至关重要。本研究调查了医学生对ACE和TIC的了解、态度和识别情况,以便为课程设置提供参考:方法:采用横断面设计,从两所医学院(一所是全科医学院(医学学位),一所是骨科医学院(骨科医学博士学位))招募学生完成电子需求评估调查。该调查包括一个病人小故事,用于评估学生将 ACE 识别为影响病人健康因素的能力。学生们对研究的全部目的一无所知,以便客观衡量他们将 ACE 识别为影响患者健康的因素的能力。针对 ACE 和 TIC 的知识和态度的附加问题是根据以前发表的调查报告和研究设计的补充问题设计的:结果:共有 240 名学生完成了调查。结果表明,学生识别 ACE 的能力参差不齐;ACE 的常识性知识较强,但实践性知识较少;学生对 ACE 和 TIC 总体持积极态度。医学学位和骨科医学博士学位之间以及就读年级之间没有差异:医学生将受益于有助于增加ACE与健康之间联系的知识、增加ACE和TIC的实际应用以及提高他们在临床情景中识别ACE的能力的课程努力。
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引用次数: 0
Hospital Readmissions Among Patients Experiencing Homelessness: An Electronic Health Record Data Study. 无家可归患者的再住院情况:电子健康记录数据研究》。
Q2 Social Sciences Pub Date : 2024-03-15 Epub Date: 2023-12-18 DOI: 10.7812/TPP/23.075
Somalee Banerjee, Maher Yassin, Wendy T Dyer, Tainayah W Thomas, Luis A Rodriguez, Julie Schmittdiel

Background: Population-level tracking of hospital use patterns with integrated care organizations in patients experiencing homelessness has been difficult. A California law implemented in 2019 (Senate Bill 1152) aimed to ensure safety for this population after discharge from the hospital by requiring additional documentation for patients experiencing homelessness, which provides an opportunity to evaluate hospital use by this population.

Methods: In a large integrated health system in California, patients experiencing homelessness were identified through documentation change requirements associated with this law and compared with a matched group from the general population.

Results: Patients experiencing homelessness had increased rates of hospital readmission after discharge compared to the general population matched on demographics and medical comorbidity in 2019 and 2020. Any address change in the prior year for patients was associated with increased odds of emergency department readmission. Patients experiencing homelessness, both enrolled in an integrated delivery system and not, were successfully identified as having higher readmission rates compared with their housed counterparts.

Conclusion: Documentation of housing status following Senate Bill 1152 has enabled improved study of hospital use among those with housing instability. Understanding patterns of hospital use in this vulnerable group will help practitioners identify timely points of intervention for further social and health care support.

背景:对无家可归患者使用综合医疗机构的医院模式进行人群层面的追踪一直很困难。加利福尼亚州于 2019 年实施了一项法律(参议院第 1152 号法案),旨在通过要求无家可归患者提供更多文件来确保这类人群出院后的安全,这为评估这类人群的医院使用情况提供了机会:方法:在加利福尼亚州的一个大型综合医疗系统中,通过与该法律相关的文件变更要求来识别无家可归的患者,并将其与普通人群中的匹配组进行比较:结果:2019 年和 2020 年,无家可归患者出院后再入院的比例高于人口统计学和医疗合并症匹配的普通人群。患者上一年的任何地址变化都与急诊科再入院的几率增加有关。与有住房的患者相比,无家可归的患者(无论是否加入了综合服务系统)被成功识别为再入院率更高的患者:参议院第 1152 号法案出台后,对住房状况的记录使得对住房不稳定人群使用医院情况的研究得以改进。了解这一弱势群体使用医院的模式将有助于从业人员及时发现干预点,以提供进一步的社会和医疗支持。
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引用次数: 0
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