Xinhua News Agency, Beijing, June 1st Question: How effective are these measures to protect minors after one year’s implementation?

　　Xinhua News Agency "Xinhua Viewpoint" reporter

　　Strengthening network protection, preventing and controlling school bullying, and mandatory reporting system … … On June 1, 2021, the newly revised Law on the Protection of Minors and the Law on the Prevention of Juvenile Delinquency were officially implemented, protecting "you as a teenager" in all directions.

　　One year later, how effective are these measures? The reporter of "Xinhua Viewpoint" conducted an investigation.

　　Network protection: games and participation in live broadcast are limited, and there are still loopholes to be filled.

　　The new law on the protection of minors adds a chapter on "network protection", which provides for the prevention of network addiction and network consumption management.

　　Over the past year, all relevant departments have made efforts in succession: in August last year, the State Press and Publication Administration issued a notice clarifying that online game services should not be provided to minors unless the time is specified; In May this year, the Central Civilization Office and other four departments issued opinions prohibiting minors from participating in live broadcast rewards and strictly controlling minors to engage in anchor … …

　　Each network platform responds. Tencent prohibits minors under the age of 12 from spending money in the game, and carries out face recognition on night game login of real-name users over the age of 55. In the fourth quarter of last year, the proportion of domestic minors’ game time dropped to 0.9%. In Aauto Quicker, highly suspected minor accounts without parental authorization are included in the youth mode and the broadcasting function is restricted. At present, tens of thousands of users have been forced to be included in this mode.

　　Although many measures have been taken, the reporter found that there are still minors trying to "bypass" the anti-addiction mechanism. Some parents in Fujian reported that children took the opportunity of online classes to "walk away" their parents’ mobile phones and used their parents’ real-name authentication to play games and buy game equipment.

　　In this regard, Zhang Yiteng, a senior partner of Beijing Kangda (Xiamen) Law Firm, suggested to further improve the anti-addiction mechanism for minors and truly build a firewall to prevent minors from internet addiction.

　　In response to the problem of "quietly rewarding" some underage users on short video and live broadcast platforms, Shen Aiguo, a professor at Zhejiang University City College, said that parents should take care of their online accounts and related financial accounts; At the same time, relevant platforms should also upgrade technical measures to find and stop the reward behavior of suspected underage users in time.

　　Bullying prevention and control: the system is gradually improved, and there are still problems such as difficulty in finding and identifying.

　　Violent beatings, verbal abuse and collective isolation … … The problem of student bullying frequently provokes public nerves.

　　The new law on the protection of minors stipulates that schools should establish a system for the prevention and control of bullying by students. Over the past year, from the central government to the local government, a series of measures have been introduced intensively.

　　The Regulations on the Protection of Minors’ Schools, which came into effect on September 1 last year, set up a special protection system for students’ bullying, campus sexual assault and other social concerns. From May 1 this year, every primary and secondary school should be equipped with at least one vice president of the rule of law to participate in organizations such as student protection committees and student bullying management.

　　In terms of local legislation, the "Regulations on Prevention and Control of school bullying in Liaoning Province (Draft)" was first reviewed in April this year; The local laws and regulations of Beijing, Shanghai, Hebei and Gansu also stipulate the school bullying issue.

　　Under a series of combination punches, the problem has improved obviously. According to the statistics of the Supreme People’s Procuratorate, in 2021, the number of cases of crimes of school violence and bullying prosecuted by procuratorial organs nationwide decreased by 74.7% compared with the same period in 2018.

　　However, the reporter’s investigation found that there are still problems such as "difficult to prevent, difficult to find, difficult to identify and difficult to deal with". Some teachers have reported that in some "suspected" school bullying cases, the definition criteria are not clear, which brings difficulties to qualitative disposal.

　　In this regard, the "Regulations on Prevention and Control of school bullying, Liaoning Province (Draft)" defines the specific measures for the prevention and disposal of school bullying one by one in the form of a special chapter. Fu Weichuan, president of Shenyang No.134 Middle School, said that on the basis of legislative norms, supporting measures should be formulated to refine the main responsibilities of family, school, society, network, government and judiciary, and to deal with them scientifically according to laws and regulations, so as to make school bullying’s prevention and control mechanism work more effectively.

　　Mandatory reporting: A number of hidden cases were found to increase the rigid constraint on non-reporting.

　　Infringements on minors often occur in "hidden corners" and it is difficult to find them in time. One of the highlights of the new law on the protection of minors is that it has absorbed the compulsory reporting system that has been effective in practice before.

　　In the past year, the system has played an obvious role. A few days ago, the Supreme People’s Procuratorate reported a typical case: when handling a case of rape of a girl, the People’s Procuratorate of donggang city, Liaoning Province found that in October 2021, Ji Moumou, a gynecologist of an outpatient department in donggang city, performed an induced abortion operation for Sun Moumou, knowing that he was a minor, without a guardian to accompany him and sign for confirmation, and did not report it to the relevant departments. The procuratorial organ informed the donggang city Municipal Health Bureau of the relevant situation and suggested that the medical institutions and personnel involved should be held accountable according to law. The outpatient department was subsequently given an administrative penalty of warning, confiscation of illegal income and a fine of 20 thousand yuan, and the relevant departments were cancelled; Ji Moumou, a doctor, was given an administrative penalty of suspending his practice for six months.

　　According to the statistics of the Supreme People’s Procuratorate, in the first quarter of this year, the number of compulsory reporting cases in Hebei, Inner Mongolia, Liaoning, Heilongjiang, Jiangxi and Ningxia all more than doubled year-on-year.

　　"Mandatory reporting ‘ Every case must be investigated ’ Since the establishment of the mechanism, 2,854 cases of crimes against minors have been prosecuted by procuratorial organs, and a number of hidden cases of crimes against minors have been discovered in time. " Na Yanfang, director of the Ninth Procuratorate of the Supreme People’s Procuratorate, said.

　　Many places have also introduced detailed measures based on their own reality. For example, Xihu District of Hangzhou stipulates that if the front desk staff finds that adults bring minors, especially children under the age of 14, or if minors ask for registration alone or in multiple people, they must ask about the relationship, the purpose of occupancy and whether the guardian knows, and report to the local police station in time.

　　In other fields, the Ministry of Civil Affairs has taken the implementation of the compulsory reporting system as one of the national standards for the protection of minors. The newly revised "People’s Republic of China (PRC) Physician Law" also provides for the implementation of mandatory reporting system in related industries.

　　The relevant person in charge of the procuratorate in Xihu District, Hangzhou suggested that the punishment measures for failing to fulfill the compulsory reporting obligations should be implemented in detail and the incentives for active reporting should be increased; Clear the lead department, set up a report telephone for unified acceptance.

　　Crime Prevention: Strengthening the Construction of Specialized Schools and Solving the Social Problems Behind problem children

　　Some minors who have committed crimes are out of the control of their parents and schools, and they are caught in a vicious circle of "grasping and releasing".

　　The new law on the prevention of juvenile delinquency is clear, and the state strengthens the construction of special schools and provides special education for minors with serious bad behavior.

　　The reporter learned that some specialized schools are exploring a new path of replacing punishment with teaching and intervening in advance to help the delinquent minors return to society better.

　　"In the early days, like some old-fashioned work-study schools, we relied on a huge amount of military training to cultivate students’ awareness of rules." Yin Zhangwei, director of the Academic Affairs Office of Guangzhou Xinsui School, told the reporter that at present, the school vigorously promotes the construction of school-based courses such as aesthetic education courses and mental health courses, and makes students consciously correct their mistakes through the internalization of educational concepts. After the implementation of these teaching methods, some students are promoted to key high schools and universities.

　　Graded intervention to correct the abnormal behavior of minors is an important concept of the new law on the prevention of juvenile delinquency. Guangzhou City is exploring the construction of different types of specialized schools for the three different education and correction objects: minors with general or serious bad behaviors, minors involved in crimes who are conditionally not prosecuted or exempted from prosecution, and juvenile offenders who are serving sentences.

　　Behind the "problem children" are social problems. The relevant person in charge of the Supreme People’s Procuratorate said that the procuratorial organs should strengthen the analysis of the causes, laws and trends of cases in handling cases, and cooperate with families, schools and society to solve the deep-seated social problems behind cases involving minors, so as to prevent minors from committing crimes more effectively. (Reporter Bai Yang, Xu Zhuang, Liu Yuzhan, Yan Zhihong, Wang Ying, Wu Shuaishuai, Yang Shuxin)

1. Plot gp2025-01, Mudanjiang City, Heilongjiang Province. The project is located in the north of Wulin Street and the west of Poxuequan Road in Jiangnan Development Zone, Mudanjiang City. The land area of the project is about 66,700 square meters, the plot ratio is 1.3, and the floor area is about 86,700 square meters. The land is used for commercial and residential purposes, with a total land price of 97 million yuan. The company owns 100% interest in this project.

2. Tianjin Jinnan International Exhibition East Zone B Phase I residential plot. The project is located in the East Zone of the International Exhibition in Jinnan District, Tianjin. The land area of the project is about 20,100 square meters, the plot ratio is 1.2, and the floor area is about 24,100 square meters. The land use is residential land with a total land price of 133 million yuan. The company owns 40% interest in this project.

3. Tianjin Jinnan International Exhibition East Zone B Phase I commercial plot. The project is located in the East Zone of the International Exhibition in Jinnan District, Tianjin. The land area of the project is about 29,700 square meters, the plot ratio is 3, and the floor area is about 89,000 square meters. The land use is commercial land with a total land price of 149 million yuan. The company owns 10% interest in this project.

(Reporter Wang Xiaobo)

On April 16th, BYD’s personalized brand Equation Leopard officially released a brand-new trendy SUV, with an official guide price of 133,800 yuan. Five versions of the model were launched, and the financial discount policy of up to 5,500 yuan and five major car purchase rights were launched simultaneously.

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Three leapfrog experiences to create a new benchmark for "high-tech products" SUV

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Tide reform plan goes online, creating exclusive personalized titanium 3

Titanium 3 also launched the world’s first front face modular dressing system, breaking the traditional design formula and realizing "a variety of titanium". The "Titanium 3 Face Change Plan" and 12 joint schemes of tide reform are launched simultaneously, and users can make one-click appointments and change clothes in stores through the official mall. On April 23, Equation Leopard will also launch the "Titanium 3 Tide Reform Co-creation Competition", set up a dual track for the whole people and professionals, invest millions of bonuses, and invite users to create a feast of personalized tide reform.

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Also as a BYD SUV model, on April 16th, Tengshi N9 passed the certification of China Automobile Research Institute, an authoritative organization, and once again set a new global fishhook test record at a speed of 180 km/h.. Tengshi N9 has also become the first model in China to obtain the hook test certification from an authoritative organization. The fishhook test, also known as the "dead corner", is the test to maximize the simulation of high-speed obstacle avoidance emergency steering, and it is also the most stringent verification standard for vehicle handling stability and rollover prevention, which can test the emergency steering stability and show the extreme safety performance of Tengshi N9.

▍ Source: Announcement of Pharmaceutical Companies

▍ Finishing: Cypress Blue-Corn

▍ Industry concentration has been further improved.

In 2019, there were frequent mergers and acquisitions between pharmaceutical companies. Observing these cases, we can find that some of them spun off their subsidiaries and some strengthened their own strengths through acquisitions. In addition, the sale of non-core assets by foreign pharmaceutical companies and the takeover by domestic pharmaceutical companies have also caused industry analysis.

In these cases, some of them have been completed and some are still in progress. Through the inventory of one-year acquisition cases, it seems that the industry is progressing in the direction of increasing concentration.

With the deepening of medical reform, the implementation of policies such as consistency evaluation, quantity procurement and DRG, and the improvement of industry access threshold, SMEs will be acquired more frequently by large enterprises.

Of course, this is just like the plan of "supporting the merger and reorganization of pharmaceutical production enterprises, cultivating a number of large enterprise groups with international competitiveness, and improving the concentration of pharmaceutical industry" in the "Several Opinions on Further Reforming and Improving the Policy of Drug Production, Circulation and Use" issued by the State Council in early 2017.

Suzhou Novartis completed the sale.

On December 21st, Zhejiang Jiuzhou Pharmaceutical Co., Ltd. issued the Announcement on Completion of 100% Equity Delivery of Suzhou Novartis Pharmaceutical Technology Co., Ltd., and formally merged Suzhou Novartis into its subsidiary.

Jiuzhou Pharmaceutical announced on November 30 that the board of directors passed the Proposal on Foreign Investment to Buy 100% Equity of Suzhou Novartis Pharmaceutical Technology Co., Ltd., and estimated to buy 100% equity of Suzhou Novartis held by Novartis Investment with self-raised funds of about 790 million yuan.

According to the data, Suzhou Novartis acquired by Jiuzhou Pharmaceutical Co., Ltd. mainly consists of factory buildings, production lines, process equipment, etc. after divesting the technology and drug development assets held by Novartis.

Fosun Pharma sells assets for 3.6 billion yuan

On December 19th, Shanghai Fosun Pharma (Group) Co., Ltd. issued the Announcement on the Progress of Selling Assets and Foreign Investment, intending to transfer all the limited partnership interests of Healthy Harmony Holdings, L.P. (whose main assets are "United Family" hospitals and clinics) and the management partner of Healthy Harmony Holdings, L.P.. The consideration for this transfer is about US$ 523.15 million (equivalent to about RMB 3.6 billion).

Tasly sells Tasly Medicine Marketing Group.

On December 17th, Tasly announced that it had signed the Framework Agreement with Chongqing Pharmaceutical, and made an agreement on selling the equity of its holding subsidiary Tianjin Tasly Pharmaceutical Marketing Group.

According to the Framework Agreement, Chongqing Pharmaceutical intends to acquire 87.47% of the shares directly and indirectly held by the company and the shares held by other shareholders of Tianshi Marketing by paying cash consideration.

Nanjing pharmaceutical holding enhua herun

On December 13th, Nanjing Pharmaceutical Co., Ltd. issued the Announcement on Completion of Change Registration Procedures for Acquisition of Equity, indicating that the acquisition of Jiangsu Enhua Herun Pharmaceutical Co., Ltd. for 72.24 million yuan has completed the change registration procedures for shareholders and legal representatives. So far, Nanjing Pharmaceutical directly holds 70% equity of Enhua Herun.

China Resources Sanjiu acquires Aonuo Pharmaceutical.

On November 27th, China Resources Sanjiu Pharmaceutical Co., Ltd. issued the Announcement on Acquisition of 100% Equity of Aonuo (China) Pharmaceutical Co., Ltd., and planned to acquire 100% equity of Aonuo (China) Pharmaceutical Co., Ltd. held by Yuheng Pharmaceutical for 1.42 billion yuan.

According to the announcement, the core products of Aonuo Pharmaceutical are calcium zinc gluconate oral solution, vitamin C chewable tablets and Shenzhi Dendrobium granules, and its "Aonuo" and "Jinxin Jinjiute" are well-known brands for children to supplement calcium. China Resources Sanjiu said that the acquisition can improve the category layout of self-diagnosis and treatment (CHC), which can be organically combined with the advantages of China Resources Sanjiu in consumer insight, brand operation and terminal coverage.

Pfizer merged with Mylan.

On November 12th, Mylan and Pfizer officially announced the name of the new company-Via Tris, which was formed by the merger of Mylan and Pfizer’s subsidiary Pfizer Puqiang.

The 2018 financial report shows that Pfizer’s global revenue is $12.5 billion, and the China market contributes $2.4 billion. Mylan is a multinational giant, with a global revenue of 11.434 billion US dollars in 2018, and has not yet started business in China.

Da Shen Lin bought 123 chain pharmacies.

On November 7, Dashenlin Pharmaceutical Group Co., Ltd. issued the Announcement on Acquisition of 51% Equity of Nantong Jianghai Pharmacy Chain Co., Ltd., and plans to acquire 51% equity of Nantong Jianghai Pharmacy Chain Co., Ltd., with the target company including 123 chain pharmacies and the acquisition amount of 120 million yuan.

GSK sells Suzhou factory and Hepudin.

On July 8, Fosun Pharma announced that its holding subsidiary, Chongqing Yaoyou Pharmaceutical Co., Ltd., intends to acquire 100% equity of GlaxoSmithKline Pharmaceutical (Suzhou) Co., Ltd. for no more than RMB 250 million. If the transfer is completed, it will hold the drug registration approval of lamivudine tablets (specification: 0.1g) for the treatment of chronic hepatitis B and the production license and GMP certificate of its production facilities.

On July 9th, GSK China confirmed to Cyberland that both parties expected the transaction to be completed by the end of November.

Sinopharm Holdings acquired Anhui Pharmaceutical Group

On May 8, the official public platform of Sinopharm Holding Anhui Co., Ltd. released a message: Sinopharm Holdings officially signed a contract to acquire Anhui Pharmaceutical Group. According to public information, Anhui Pharmaceutical Group is a large-scale commercial circulation enterprise approved by the Anhui provincial government in December 2002.

China Resources Medicine Acquires Jiangzhong

On April 17, Jiangzhong Pharmaceutical Co., Ltd. announced that the company recently received a notice from the controlling shareholder of the company. With the approval of Jiangxi Provincial Market Supervision Administration, the controlling shareholder completed the industrial and commercial change registration of the enterprise name and business scope on April 8, 2019.

After the change, Jiangxi Jiangzhong Pharmaceutical (Group) Co., Ltd. was changed to China Resources Jiangzhong Pharmaceutical Group Co., Ltd. Jiangzhong Pharmaceutical said in its 2018 annual report that the brand value of "Jiangzhong" was 20.715 billion yuan, ranking 231st among the top 500 Chinese brands and 6th in the pharmaceutical industry. For China Resources Medicine, the acquisition of Jiangzhong Group won brands such as "Jiangzhong" and "Chuyuan".

Bristol-Myers Squibb acquires Xinji.

On January 3rd, Bristol-Myers Squibb announced a $74 billion acquisition of Xinji. According to the agreement between the two parties, Bristol-Myers Squibb will acquire Xinji Company in the form of $74 billion in cash and stock transactions to build a first-class biopharmaceutical giant that can compete with the world’s largest pharmaceutical manufacturer.

In fact, the merger and acquisition of pharmaceutical companies in 2019 is far more than that. By combing the actions of well-known enterprises, the purpose is to find the trend of industry changes under these mergers and acquisitions. In addition, in the announcements of many listed pharmaceutical companies selling assets this year, many properties were thrown out. Some analysts believe that pharmaceutical companies sell houses to survive, but a more rational view should be due to the limited value-added space of real estate.

　　CCTV News:At the beginning of 2024, in Zhejiang, a major foreign trade province, many enterprises have embarked on a new journey of "going out to sea" to grab orders. Not long ago, Zhejiang released the foreign trade data of the whole province in 2023. In 2023, the total import and export volume of Zhejiang reached 4.90 trillion yuan, a year-on-year increase of 4.6%. Among them, the export was 3.57 trillion yuan, an increase of 3.9%; Imports reached 1.33 trillion yuan, up 6.7%.

　　Zhejiang Province proposes that it will do everything possible to stabilize foreign trade and optimize foreign investment, continue to lay a good combination of "stabilizing expansion and adjustment", further promote the action of "thousands of enterprises expand the market to increase orders", and cultivate new foreign trade formats and models such as overseas warehouses and digital trade to ensure that the share of exports in the country is basically stable. In the new year, Zhejiang government and enterprises joined forces to seize the start, laying a solid foundation for new achievements in foreign trade in the new year.

　　In the past 10 years, the company has seized the opportunity of the rapid growth of textile and garment industry in the countries that jointly built the "Belt and Road", done a good job in market segmentation according to the market characteristics of the countries that jointly built the "Belt and Road", and established extensive cooperative relations with customers in the countries that jointly built the "Belt and Road".

　　Just over 8,000 kilometers away in the China-Egypt TEDA Suez Economic and Trade Cooperation Zone, the first overseas factory of Caidie’s "Belt and Road" countries has officially laid the foundation stone. Compared with Butterfly, China Jushi, located in Tongxiang, Zhejiang Province, has taken the lead in setting up factories overseas in the Belt and Road Initiative.

　　In 2012, China Jushi set up a factory in Egypt. In 10 years, Jushi Egypt’s glass fiber production capacity jumped from 80,000 tons to 340,000 tons. The rich local mineral resources and human resources have been effectively utilized, which directly promoted local development and directly created more than 2,000 local jobs.

　　Enterprises are in action and the government is not idle. In 2024, Zhejiang Province will launch a new round of "thousands of enterprises" to expand the market and increase orders. In the first quarter, the province planned to organize 385 delegations, and planned to organize more than 4,000 enterprises with more than 6,000 people, including 128 delegations in January, with more than 1,500 enterprises planned. In 2024, we will strive to organize more than 1,000 delegations and more than 10,000 enterprises in the province to expand overseas and support more than 100 provincial-level key exhibitions.

　　In 2023, Zhejiang’s foreign trade withstood multiple pressures such as sluggish external demand and falling prices, and its import, export and import all achieved positive growth. The bright data also shows that the diversified expansion of Zhejiang enterprises in the trade market is effective, and emerging markets are gradually becoming mature markets.

　　According to statistics, in 2023, Zhejiang imported and exported 2.55 trillion yuan to countries that jointly built the "Belt and Road", an increase of 8.2%, accounting for 52.1% of the province’s total import and export value, and contributing 89.5% to the province’s import and export growth.

　　The "second generation of factory" has undergone drastic transformation and upgrading, and foreign trade has made new development.

　　As a big province of private economy, Zhejiang’s "private foreign trade" has distinct characteristics. The data shows that Zhejiang private enterprises continue to play the role of "ballast stone" in stabilizing foreign trade. In 2023, the number of private enterprises with import and export performance in Zhejiang exceeded 100,000 for the first time, reaching 102,000, and the total import and export accounted for more than 80% of the province’s foreign trade for the first time, driving the province’s foreign trade growth rate by 5.6 percentage points.

　　Behind the development of private foreign trade, the reporter found that from the early days of reform and opening up, private enterprises developed and expanded, and the older generation of factory directors seized the opportunity to save their family business to the period of transformation of old and new kinetic energy. A group of "post-80 s" and "post-90 s" young people took over the baton of their parents and became the "second generation of factories". Facing the current complicated foreign trade situation and the new environment of traditional manufacturing industry, how did they break through the trend?

　　Ke Qiao, Shaoxing, Zhejiang is the largest textile trade distribution center in the world. With the change of economic environment, the cost of labor and raw materials has risen sharply, but the order volume has dropped sharply.

　　Shao Lingbin, the second generation of the factory, took over the enterprise in 2016. When it first took over, the enterprise still followed the traditional way of foreign trade development, relying on the mode of "receiving orders and producing" to make profits. However, with the intensification of product homogenization competition and the dilution of profits, the factory has fallen into a dilemma of development. As a last resort, Shao Lingbin began a drastic road of transformation.

　　Shao Lingbin aims to be the top-notch in the industry, investing 10 million yuan in research and development expenses every year, setting up a special team and hiring high-end designers from all over the world with high salaries. After more than three years of research and development, the enterprise finally broke the technical monopoly of foreign enterprises on acetic acid fabrics, and became the national development base of acetic acid and polyester fashion fabrics in one fell swoop, successfully filling the gap in the domestic market.

　　Yang Wei is a "post-80s" and a "second generation factory". At the beginning of the new year, the smart factory built by the enterprise with an investment of 150 million yuan has been partially put into production. During this time, he is busy purchasing equipment and checking the production line.

　　In fact, when he first planned to do intelligent transformation, Yang Wei also encountered many voices of doubt.

　　Yang Wei told reporters that after intelligent transformation, the production capacity of enterprises has increased by 50% and the production efficiency has increased by 30%.

　　Breakthrough of 1% to 10% The number of cross-border online stores in Zhejiang has increased by 20,000 annually.

　　With the rapid development of globalization and Internet technology, cross-border e-commerce has become a new kinetic energy for foreign trade development. At present, there are 199,000 active export online stores in Zhejiang Province, with an increase of 23,000 in 2023. The proportion of cross-border e-commerce goods in foreign trade has also increased from less than 1% in 2015 to nearly 10% in 2023. From "1" to "10", cross-border e-commerce is bringing new business opportunities to thousands of enterprises in Qian Qian.

　　In a scooter manufacturer in Yongkang, Zhejiang, workers are rushing to make a batch of orders sent to Europe before the Spring Festival. In 2024, they just switched from domestic sales to cross-border e-commerce, and have already completed millions of dollars in sales.

　　A cross-border e-commerce "zero-based" enterprise like this can not achieve such results in a short time without the guidance and training of service companies. Ruan Xueqing is the team leader responsible for the operation of this enterprise’s cross-border e-commerce project. In 2024, one tenth of the projects they received were pure domestic trade enterprises transformed into cross-border e-commerce.

　　Nowadays, there are more and more domestic trade enterprises aiming at overseas "track". However, due to the different standards and needs of the domestic and foreign markets, the problem of "acclimatization" will also occur when domestic and foreign trade turn to each other. In the R&D department of this fitness equipment enterprise in Hangzhou, technicians are testing an intelligent spinning bike, which will be sold simultaneously in the international and domestic markets.

　　Since 2022, this enterprise has been "going out to sea" through cross-border e-commerce brands, and its export sales have doubled, which is almost the same as domestic sales. In a promotion activity of overseas e-commerce platform, one of their rowing machine products sold 4500 units in two days, equivalent to domestic sales for half a year.

　　According to the data of Zhejiang Provincial Department of Commerce, in 2023, the import and export of cross-border e-commerce in the province was 512.93 billion yuan, an increase of 18.9% year-on-year. Among them, the export was 393.28 billion yuan, an increase of 24%.

CCTV News:In the past ten years, China’s total trade in goods has been continuously improved, ranking first in the world for five consecutive years since 2017, and the total trade in goods and services has also jumped to the top in the world in 2020. While the high-quality development of trade has made historic achievements, the continuous improvement of China’s foreign trade has also played an important role in the development of the national economy and the recovery of the world economy.

At 3 o’clock in the morning, the stall of fruit distributor Zheng Yuqiang became lively. This evening, a new batch of imported jackfruit was welcomed.

Zheng Yuqiang, Beijing fruit distributor:We seldom sold jackfruit a few years ago. Now, if it is normal, it is no problem to sell (sell) more than ten tons a day.

In Beijing’s largest wholesale market for agricultural products — — In Xinfadi market, mid-October is not the peak season for fruit sales, and several imported fruits promoted by Zheng Yuqiang have increased his business.

Beijing fruit buyer Zheng Zhen:I bought some jackfruit and red pitaya today. I come here almost every day and sell everything. There are about 30 to 40 kinds of imported fruits.

In the wholesale market in Beijing, the varieties of imported fruits sold are increasing year by year. Xiao Yang, who just entered the business last year, opened a shop specializing in selling Malaysian Maoshanwang durian. He told reporters that this expensive imported fruit has been selling better and better since it entered the China market in 2019.

Xiao Yang, a distributor of imported fruits in Beijing:Sales are gradually increasing. At the beginning, the people still didn’t approve of it because the price was relatively high. Up to this year, the people’s recognition level is still relatively high, especially people like Beijing who buy more.

In the past ten years, more and more imported fruits such as Philippine avocado, Cambodian banana, Lao citrus and South African pear have entered the mouth of China people. In 2021, China imported more than 7 million tons of fruit, compared with less than 3.45 million tons in 2012, and the import volume doubled in ten years.

Zhang Xiao, Director of the Inspection and Quarantine Department of Animals and Plants and Food of Nanning Customs:At present, the imported fruit varieties from ASEAN have increased from 53 varieties in six countries ten years ago to 77 varieties in the whole ASEAN countries.

Not only high-quality consumer goods such as fruit, but also the import scale of advanced technology and equipment, key parts and other products has been expanding over the past decade, which has better met the needs of domestic production and people’s lives, and also allowed the world to share more dividends brought by China’s economic growth. In 2021, China’s total import value reached 17.37 trillion yuan, an increase of 51.2% compared with 2012.

Professor Cui Fan, School of International Business and Economics, University of International Business and Economics:The country’s opening up, especially (import), includes high-quality products that are beneficial to people’s living standards and meet people’s needs, so that our trading partners can share the fruits of China’s economic development.

In the past ten years, China has taken the initiative to reduce commodity tariffs, and the total tariff level has dropped from 9.8% in 2012 to 7.4% in 2021. New trade formats and new kinetic energy are constantly being stimulated, and the import and export scale of cross-border e-commerce has increased nearly tenfold in the past five years.

High-level import and export will further optimize the trade structure. In a factory in Qingdao, Shandong Province, 10 sets of high-speed EMUs for Jakarta-Bandung High-speed Railway have been manufactured and are waiting for delivery. Last month, the first batch of Jakarta-Bandung High-speed Railway high-speed EMUs and comprehensive inspection trains exported to Indonesia arrived in Jakarta Port smoothly, which was the first time that China’s high-speed trains were exported abroad.

Zhang Fangtao, Chief Designer of Jakarta-Bandung High-speed Railway High-speed EMU:The Jakarta-Bandung High-speed Railway high-speed EMU will be sent to Indonesia in November, and Jakarta-Bandung High-speed Railway will be put into operation in 2023 according to the plan. By then, the travel time from Jakarta to Bandung will be shortened from the current three hours to about 40 minutes.

Going out with high-end equipment, there are our supporting services. In the past ten years, the leading export industries have been transformed and upgraded from traditional labor-intensive products to high-tech industries, and the knowledge-intensive service trade has maintained rapid growth.

Ma Qiang, Deputy General Manager of overseas business department of CRRC Sifang Co., Ltd.:We provide maintenance technical support for Argentine national railway company. Up to now, the company’s products and services have been exported to 29 countries and regions around the world.

From 24.4 trillion yuan in 2012 to 39.1 trillion yuan in 2021, in the past ten years, China’s total trade in goods has continued to increase, and its international market share has also increased from 10.4% in 2012 to 13.5% last year, and its position as the largest country in global trade in goods has been further consolidated. Nowadays, there are more and more high-level platforms for opening to the outside world, such as China China International Import Expo(CIIE), Service Trade Fair and Consumer Expo. China has set up 21 free trade zones and one free trade port, with free trade partners spread across five continents. In the past ten years, China’s average contribution rate to world economic growth reached 38.6%, ranking first in the world.

You may think that you are in good health and there will be no major problems, but you know what? Some people suddenly fell down and never woke up because of temporary excitement or fatigue. This is sudden death, an unpredictable fatal event.

There seems to be nothing wrong. Why did you die suddenly?

Is there any rule of sudden death? Is there any warning? Can we avoid it? To answer these questions, let’s take a look at a recent study.

This study was published in the journal chinese journal of critical care medicine in April, 2020, entitled "Analysis of Epidemiological Characteristics of 5,516 Cases of Autopsy Sudden Death in China". The researchers dissected the bodies of 5516 cases of sudden death and found the following important findings:

1. Emotional excitement and fatigue are the most common causes.

The study found that among the causes of sudden death, emotional excitement accounted for 26%, fatigue accounted for 25%, and blood volume change accounted for 8.95%. Other inducements include drinking, satiety and minor injuries.

2. Heart problem is the main reason.

It was found that among the causes of sudden death, cardiogenic sudden death accounted for 57.76%, pulmonary sudden death accounted for 21.63%, and brain-derived sudden death accounted for 9.21%. Sudden cardiac death is mainly caused by coronary heart disease, myocardial infarction and arrhythmia.

3. There are often some uncomfortable signals before sudden death.

It is found that people with symptoms and signs in sudden death are most often manifested as sudden attack (20.10%), rest and sleep (16.71%), followed by vomiting (7.49%), dyspnea, chest tightness and sweating, dizziness, chest pain, abdominal pain, convulsion, headache, palpitation, cough and disturbance of consciousness.

People with chronic diseases are more prone to sudden death.

It was found that hypertension (37.95%), heart disease (30.02%) and diabetes (23.79%) were the most common among those with past history. Followed by dysplasia, hyperlipidemia, tumor, infection, hyperthyroidism and so on.

5.30 ~ 63 years old is the high incidence age of sudden cardiac death.

People in this age group are at an important stage of their career and family, with high work pressure, fast pace of life, irregular diet, and addiction to cigarettes and good wine, which may easily lead to "three highs" and coronary heart disease.

How to avoid sudden death? Please do the following three points.

From these laws, we can get some enlightenment:

Middle-aged people should pay attention to controlling their emotions!

Do you often get angry and quarrel with others because of some small things? Are you sometimes so excited that you get carried away and even laugh until you cry? You may think these are normal emotional expressions, but you know what? These mood swings may bring fatal danger to your heart!

A media person once witnessed such a tragedy. Her father-in-law was taken to the hospital because of a sudden acute myocardial infarction, and survived after the rescue. However, she found that in her father-in-law’s ward, the other six patients have one thing in common: they are all quick-tempered and short-tempered, and they are emotional, angry and angry when things happen.

She learned a lesson from it: these people are all out of control because of their emotions, which leads to heart problems!

Why is emotional excitement harmful to the heart?

It turns out that when we are angry or excited, the body will secrete a lot of hormones such as adrenaline and cortisol, which will double the blood flow of the heart, strengthen the contractility of the heart and accelerate the heartbeat. At the same time, blood vessels will contract, blood pressure will increase and blood viscosity will increase. In this way, the heart will bear a greater burden, prone to arrhythmia, myocardial ischemia, chest tightness, palpitation and other symptoms. If the duration is too long or the frequency is too high, it may induce serious cardiovascular events such as angina pectoris or myocardial infarction.

Therefore, middle-aged people should learn to adjust their emotions and maintain peace. Don’t vent or suppress things that don’t go your way, but find a suitable way to release the pressure. For example, you can chat with friends, listen to music, do sports and read books. This can not only relax the body and mind, but also enhance the physical fitness, which is beneficial to the heart.

Middle-aged people should rest moderately and avoid overwork!

Are you often so busy with work and family that you even ignore your physical discomfort? You may think it’s your responsibility and responsibility, but you know what? This lifestyle may make your heart stop beating at any time!

Research shows that many sudden deaths have experienced high pressure, long-term and high-intensity working conditions. This kind of work will make your sympathetic nerves overexcited, leading to heart overload, arrhythmia and myocardial ischemia. If the duration is too long or the frequency is too high, it may lead to fatal cardiovascular events such as arrhythmia or myocardial infarction. Some people die suddenly because of working overtime overnight, mood swings and nervous stress, which leads to neurological dysfunction, coronary artery spasm and sudden stop of blood supply to the heart.

Therefore, middle-aged people should arrange their work and rest reasonably, don’t be overworked, and don’t stay up late to hurt themselves. It is necessary to do some aerobic exercise properly to relax and enhance physical fitness. It is necessary to have a regular physical examination to find and treat chronic diseases in time. Keep good living habits and stay away from alcohol, tobacco and greasy food. Only in this way can you protect your heart from the threat of sudden death.

Middle-aged people should pay attention to body signals and seek medical treatment in time!

You may not know that before sudden death, your body actually gave you many warnings. If you can find and deal with it in time, it is possible to avoid the tragedy.

So, what are the signals before sudden death? According to research, the most common symptom before sudden death is chest discomfort, which mainly has the following three manifestations:

Angina pectoris. This is a feeling of pain or oppression in the chest or precordial area, which usually lasts less than 15 minutes and is often accompanied by dysphagia or chest tightness. This is caused by heart ischemia and hypoxia.

Flustered. This is a feeling of rapid or irregular heartbeat, which usually lasts less than 10 minutes and is often accompanied by discomfort such as chest tightness, fatigue and dizziness. This is due to cardiac electrophysiological dysfunction.

Low blood pressure. This is a state in which blood pressure drops below the normal value, which generally lasts less than 5 minutes, and is often accompanied by symptoms such as cold sweat and dyspnea. This is because the pumping function of the heart is weakened.

These signals mostly occur after physical activity, emotional excitement or satiety. If they can be relieved after rest, it means a mild heart problem. However, if it still doesn’t improve after rest, or there are frequent or persistent signals, it means that it is a serious heart problem and needs immediate medical attention.

In addition to these signals, there are some less obvious signals, such as left arm pain, sore throat or toothache. These signals may be nerve reflexes caused by heart problems, which also need attention.

In short, middle-aged people should pay special attention to their physical changes. If there is any chest discomfort, dull pain or fatigue, they should go to the hospital for examination in time and don’t take it lightly. Only early detection and treatment of heart problems can effectively prevent and reduce the risk of sudden death.

Paper materials: Analysis of Epidemiological Characteristics of 5516 Cases of Autopsy Sudden Death in China, chinese journal of critical care medicine Journal in April 2020.

Original title: "Doctors dissected more than 5,000 cases of sudden death and found that people who died suddenly had these rules! 》

Read the original text

Beijing Medical Insurance No.41 [2022].

The medical insurance bureaus of all districts, the Social Affairs Bureau of Beijing Economic and Technological Development Zone, and the designated medical institutions:

　　In order to continuously improve people’s sense of gain, happiness and security in medical treatment settlement in different places, according to the spirit of the Notice of the National Medical Insurance Bureau and the Ministry of Finance on Further Improving the Direct Settlement of Medical Treatment in Different Provinces of Basic Medical Insurance (No.22 [2022] of Medical Insurance), this Municipality further improves the direct settlement of medical treatment in different provinces of basic medical insurance (hereinafter referred to as direct settlement) and regulates the management of direct settlement services. The relevant matters are hereby notified as follows:

　　First, improve the direct settlement policy

　　(a) unified hospitalization, general outpatient and outpatient chronic diseases direct settlement fund payment policy. The medical expenses for inpatient, general outpatient and outpatient chronic and special diseases directly settled by the insured shall, in principle, implement the payment scope and relevant regulations (payment scope of basic medical insurance drugs, medical service items and medical consumables) stipulated by the insured place, and implement the relevant policies such as the basic medical insurance fund Qifubiaozhun, payment ratio, maximum payment limit and outpatient chronic and special diseases.

　　(two) to clarify the scope of medical records in different provinces. Insured persons in this city can apply for inter-provincial medical record when they need medical treatment in different places. After the record, the insured persons can enjoy direct settlement service in the inter-provincial networked designated medical institutions where medical treatment is filed.

　　(3) Standardizing the validity period of inter-provincial medical records in different places. Insured persons in this Municipality may, when filing medical treatment in different places across provinces, choose their own effective period of filing according to actual needs, and the effective date and deadline of filing shall be subject to the date of system registration. When the insured person’s place of filing for medical treatment or unit, insurance type and other insured relationships change, it is necessary to go through the filing procedures again, and the original filing validity period will automatically expire after re-filing.

　　(4) It is allowed to re-submit medical records in different provinces and places, and the injured insured without third-party liability can enjoy direct settlement services. Before the settlement of the insured’s inter-provincial medical treatment in different places, the inter-provincial networked designated medical institutions shall provide direct settlement services for the insured. If the insured person who goes to different provinces for medical treatment goes through the filing formalities according to the regulations after being discharged from hospital at his own expense, he can apply for manual reimbursement of medical insurance according to the regulations of the insured place. At the same time, the medical expenses of trauma without third-party liability that meet the management regulations of medical treatment places can be included in the direct settlement scope.

　　Two, standardize the direct settlement management services

　　(a) simplify the inter provincial medical record. Insured persons in this city need to go through the inter-provincial medical record before seeking medical treatment in different places. The filing procedures can be handled through online and offline channels, such as the national medical insurance service platform APP, the national remote medical filing applet, the the State Council client applet or the window of each district agency, by registering my information and signing a personal commitment letter.

　　(two) clear the scope of direct settlement. When the insured persons in this city apply for medical treatment in different provinces for the record, in principle, the medical treatment place only needs to be put on record in the co-ordination area where the medical treatment place is located. All the inter-provincial networked designated medical institutions in the co-ordination area for the record medical treatment are designated medical institutions for the insured persons in different places, and they can enjoy hospitalization, general outpatient service or direct settlement service for drug purchase. The insured persons in this city who seek medical treatment for special diseases in different provinces need to be filed with the designated medical institutions at the place where they seek medical treatment. In principle, two designated medical institutions can be selected for a special disease, and they can seek medical treatment in the inter-provincial networked designated medical institutions that have opened the direct settlement service for corresponding outpatient chronic and special diseases, and the treatment expenses related to special diseases can enjoy direct settlement service.

　　(three) standardize the insured to medical insurance electronic certificate, social security card. Insured persons who seek medical treatment in different places across provinces should take the initiative to show their insured status in the designated medical institutions networked across provinces where they seek medical treatment, and produce valid certificates such as medical insurance electronic certificate or social security cards. Inter-provincial networking designated medical institutions should do a good job in the authentication of insured persons in different places, guide those who have not filed for the record to go through the filing procedures in time, and provide reasonable and standardized diagnosis and treatment services and convenient and fast settlement services for insured persons who meet the requirements of medical places.

　　(4) Standardize the direct settlement process. When medical treatment is directly settled in different provinces, the medical treatment place should upload the cost information to the national medical security information platform according to the unified requirements of the state for direct settlement between designated medical institutions and insured persons connected across provinces. If it cannot be settled directly for some reason, the inter-provincial networked designated medical institutions should also upload medical expenses details, diagnosis and other medical information, and support the pilot online processing of manual reimbursement.

　　(five) the unified management of medical treatment. Medical insurance agencies at all levels should bring medical personnel from different places into the unified management of this Municipality, and provide the same services and management as the insured in this Municipality in terms of medical information recording, performance appraisal, medical behavior monitoring, cost audit, total budget, etc., and make it clear in the medical security service agreement of designated medical institutions; Explore the application of medical insurance payment reform in medical settlement in different places, and guide designated medical institutions to make reasonable diagnosis and treatment.

　　(six) to strengthen the collaborative management of medical services across provinces. Medical insurance departments at all levels should gradually improve the working mechanism, form a coordinated management system of inter-provincial medical services in different places with clear division of labor, clear responsibilities and unified processes, and comprehensively improve the coordinated management ability of inter-provincial medical services in terms of problem coordination, online reimbursement, cost investigation and information sharing.

　　Three, strengthen the management of medical funds across provinces and different places.

　　The medical insurance fund payment part of the inter-provincial medical expenses in different places shall be paid in advance and then liquidated. Inter-provincial medical expenses in different places shall be settled in full on a monthly basis in accordance with the unified national clearing method. The municipal medical insurance agency and the municipal finance department shall, in accordance with the detailed rules for the implementation of direct settlement of medical treatment in different provinces of Beijing (Annex), coordinate in the allocation and collection of clearing funds. Bank charges and bank bill fees incurred in the process of allocating funds for medical treatment in different provinces shall not be charged in the fund. The interest generated by the advance payment in the financial special account of the medical treatment place belongs to the medical treatment place.

　　Fourth, improve the support for standardization of medical insurance informationization

　　(a) continue to deepen the national unified medical insurance information platform for the whole business process application. Medical insurance departments at all levels should solidly promote the dynamic maintenance and deepening application of coding in accordance with the unified national norms and requirements, improve the management system of medical insurance operation and maintenance of information technology, continuously improve the level of medical insurance data governance, and provide strong system support for direct settlement.

　　(2) Continue to optimize and improve the system. Medical insurance departments at all levels should constantly optimize system performance, reduce response time and effectively improve the direct settlement experience of insured persons in accordance with the unified national interface standards and specifications. When the medical insurance system stops and switches, it should be reported in advance, verified in the process and monitored afterwards to ensure that the data migration is timely, complete and accurate, to solve the influence of information changes such as personal number on the business in transit, and to ensure the smooth connection of business and the stable operation of the system.

　　(3) Strengthen system operation and maintenance management and security. Medical insurance departments at all levels should continue to build professional and reliable operation and maintenance management teams, build operation and maintenance management processes in infrastructure, network security, cloud platforms, business subsystems and other fields, and form a scientific and effective operation and maintenance management system. Implement safety management responsibilities, improve system safety operation and maintenance capabilities, strengthen information system boundary protection, prohibit cross-provincial networked designated medical institutions from connecting the information system of medical insurance system to the Internet, standardize cross-provincial medical identity verification, and ensure data security. Standardize the quality control standard of abnormal transaction error information, classify the problems, describe the reasons of errors concisely and easily, facilitate the problem location of abnormal transactions, and respond to them in time.

　　Five, strengthen the supervision of direct settlement funds

　　Medical insurance departments at all levels should earnestly implement the regulatory responsibilities of medical treatment places and insured places. As a place for medical treatment, direct settlement should be regarded as the key content of daily supervision, special inspection and flight inspection, and all kinds of fraudulent insurance fraud should be severely cracked down. At the same time, it is necessary to cooperate with medical insurance departments in different places to do relevant verification; As an insured place, it is necessary to regularly analyze the use of medical insurance funds across provinces and different places, accurately lock the clues of suspicious problems, and actively carry out problem verification to ensure the safe and rational use of medical insurance funds.

　　Medical insurance departments at all levels shall, in accordance with the spirit of this circular, take direct settlement as an important task to deepen the reform of the medical security system, strengthen organizational leadership, coordinate and promote, and do a good job in publicity and training to ensure a smooth transition of direct settlement in this Municipality.

　　This notice shall be implemented as of January 1, 2023. If the previous documents are inconsistent with this notice, this notice shall prevail.

Beijing Municipal Medical Security Bureau　　　　

December 30, 2022　　

Xinhua News Agency, Beijing, October 23 rd, the Central Committee of the Communist Party of China’s Decision on Further Deepening Reform and Promoting Chinese Modernization pointed out: "Promote the coordinated development and governance of medical care, medical insurance and medicine." Medical treatment refers to the medical and health services provided by medical and health institutions and medical personnel. It is the core content of medical treatment, health care and rehabilitation for the masses. It has the most direct relationship with the masses and the most concrete feelings of the masses. Medical insurance refers to the medical security system and its level of protection. Medical insurance fund is the "life-saving money" for people to see a doctor, and it is also an important source of financing for medical services and medical products. Medicine refers to Chinese and western medicines, medical devices, medical consumables and other related products. As an important means of medical and health services, it is directly related to the quality, safety and ability of services. The state exercises strict supervision over medical products to ensure quality, safety and effectiveness, and encourages innovation to increase the supply of high-quality medical products. There are three main considerations for the coordinated development and governance of "three medicines".

First, the "three doctors" are interrelated and inseparable. Medical care plays a major role in serving the people’s life, illness, illness, and medical treatment. By deepening the structural reform of the supply side of medical services, we will vigorously develop new quality productivity of health care, mobilize the enthusiasm, initiative and creativity of the majority of medical staff, promote the high-quality development of health care, and better meet the people’s yearning for a better life. Medical insurance is connected with the "demand side" of the people, which reduces the economic burden of patients by exerting the guarantee function; The other end is connected with the two "suppliers" of medical care and medicine, which can not only adjust the supply of medical services, standardize medical service behavior, promote hospital reform and promote graded diagnosis and treatment through payment methods and price policies, but also reduce the price of medical products through centralized procurement of pharmaceutical consumables and exert leverage. The production and supply of high-quality and high-efficiency pharmaceutical products provide necessary technical means and material guarantee for medical and health services, and at the same time get reasonable compensation from payers such as medical insurance to realize the healthy development of the industry. Medical care, medical insurance and medicine jointly protect people’s health. To improve the development level of health undertakings, it is necessary for relevant departments to cooperate closely and make concerted efforts to promote the coordinated development and governance of "three medicines".

Second, the coordinated development and governance of the "three medicines" can further benefit the people and the people and better solve the people’s livelihood problems. Medical and health service is an important part of public service and an important field that people expect for a better life. With the development of economy and society and the continuous improvement of people’s living standards, people hope to obtain more safe, effective, convenient and cheap medical and health services, more comprehensive coverage and higher level of basic medical security, and innovative and advanced medical products. Only by vigorously promoting the coordinated development and governance of the "three medicines" and forming a joint effort can we better meet the people’s new expectations for a better life, improve the people’s sense of acquisition, happiness and security, and deepen the reform of the medical and health system to benefit people’s livelihood more directly.

Third, the coordinated development and governance of the "three medicines" is conducive to promoting the governance of all links in the whole chain of the medical field and correcting unhealthy trends. Influenced by many factors, there are still some phenomena and problems in the field of medicine and health that endanger the interests of the people and harm public welfare and people’s health rights and interests. Among them, there are some problems in medical service, such as big prescription, excessive examination and overuse of drugs, which damage people’s health and waste health resources; There are also fraudulent behaviors in the field of medical insurance, which seriously threaten the safety of medical insurance funds; There are also problems in the field of pharmaceutical production, circulation and sales, such as "sales with gold", price increases at different levels, and imaginary costs. These problems are often intertwined, connecting multiple stakeholders and running through many links of "three medicines". To solve these problems, we must adhere to the party’s leadership, treat both the symptoms and the root causes, strengthen supervision in the whole chain, comprehensively adopt institutional supervision, functional supervision, behavioral supervision, penetrating supervision, continuous supervision and other means, strengthen the linkage between the "three medical" departments, strengthen the connection between discipline and law and execution, and severely crack down on and punish acts that infringe on public rights and interests according to law. The coordinated development and management of the "three medicines" can achieve the above objectives, and play a positive role in controlling unhealthy trends and establishing new trends in the industry, and play a significant role.

　 　 　 　Recently, AHA has just released the 2020 Cardiopulmonary Resuscitation (CPR)-Cardiovascular First Aid (ECC) Guide. The guide is divided into five parts, namely, basic and advanced life support for adults, basic and advanced life support for children, life support for newborns, resuscitation education science and rescue system.

Adult basic and advanced life support　

　 　 　 　Despite the progress in recent years, less than 40% of adults received CPR initiated by non-professionals, while less than 12% received AED first aid before EMS arrived. AHA adult IHCA and OHCA survival chain

(Click to enlarge, the same below)

Emergency procedures for adult cardiac arrest

Opioid-related emergency procedures for non-professional emergency personnel

Opioid-related emergency procedures for medical staff

Flow chart of treatment after recovery of spontaneous circulation in adult cardiac arrest

Suggested methods for multimodal neural prediction of adult patients after cardiac arrest and recovery of autonomic circulation

ACLS flow chart of pregnant women with cardiac arrest in hospital

Main new and updated suggestions in 2020 　　　

Non-professional rescuers should start as soon as possible.

CPR2020 (updated)：We recommend that non-professionals perform CPR on patients with possible cardiac arrest, because if the patient is not in a state of cardiac arrest, the risk of injury to the patient is low.

2010 (old):　If the adult suddenly falls down or the unresponsive patient’s breathing is abnormal, the non-professional rescuer should not check the pulse, but assume that there is cardiac arrest. The medical staff should check the pulse within no more than 10 seconds. If the pulse is not clearly touched within this time, the rescuer should start chest compressions.

Reason: New evidence shows that patients who receive chest compressions when they are not in cardiac arrest have a lower risk of injury. Non-professional rescuers cannot accurately determine whether the patient has a pulse, and the risk of not performing CPR on patients without a pulse exceeds the harm caused by unnecessary chest compressions.

Physiological monitoring of CPR quality

2020 (updated):　It may be reasonable to use physiological parameters such as arterial blood pressure or ETCO2 to monitor and optimize CPR quality when feasible.

2015 (old):　Although there is no clinical study to investigate whether adjusting resuscitation operation according to physiological parameters during CPR can improve the prognosis, it may be reasonable to use physiological parameters (quantitative carbon dioxide waveform, arterial diastolic pressure, arterial pressure monitoring and central venous blood oxygen saturation) to monitor and optimize CPR quality, guide vasopressor drug treatment and detect ROSC when feasible.

Reason: Although it is an established concept to monitor the quality of CPR by physiological monitoring methods such as arterial blood pressure and ETCO2, new data support its inclusion in the guidelines. According to the data of AHA’s "Follow the Guide-Resuscitation" registration study, the possibility of ROSC is increased when using ETCO2 or diastolic blood pressure to monitor CPR quality.

The monitoring depends on the existence of endotracheal intubation (ETT) or arterial catheterization. Adjusting the compression target so that the ETCO2 value is at least 10 mm Hg, ideally 20 mm Hg or higher, may be useful as a CPR quality marker. The ideal goal has not yet been determined.

Dual continuous defibrillation is not supported.

2020 (new):The usefulness of dual continuous defibrillation for refractory shockable rhythm has not been determined.

Reason: Double continuous defibrillation refers to the practice of using two defibrillators to perform electric shock almost simultaneously. Although some case reports show a good prognosis, the ILCOR system review in 2020 found no evidence to support dual continuous defibrillation, so routine use is not recommended. There are many forms of bias in existing studies, and observational studies have not shown improvement in prognosis. A recent experimental RCT shows that changing the direction of defibrillation current by repositioning electrode pads may be equivalent to the effect of dual continuous defibrillation, while avoiding the risk of injury caused by energy increase and defibrillator damage. According to the current evidence, it is not clear whether dual continuous defibrillation is beneficial.　　

Venous access takes precedence over intraosseous access.

2020 (new):It is reasonable for practitioners to try to establish venous access for drug administration in patients with cardiac arrest first.

2020 (updated):If venous access is not successful or feasible, we can consider using intraosseous access instead.

2010 (old):If there is no ready-made venous (IV) access, it is reasonable for practitioners to establish intraosseous (IO) access.

Reason: In 2020, ILCOR systematically reviewed and compared intravenous and intraosseous administration during cardiac arrest, and found that venous pathway was related to better clinical prognosis in five retrospective studies. RCT subgroup analysis focusing on other clinical problems also found similar results when intravenous or intraosseous routes were used for drug delivery. Although venous access is the first choice, intraosseous access is also a reasonable choice for the situation that it is difficult to establish venous access.　　

Treatment and support during rehabilitation

2020 (new):　We suggest that survivors of cardiac arrest undergo multimodal rehabilitation evaluation and treatment in terms of physical, neurological, cardiopulmonary and cognitive impairment before discharge.

2020 (new):　We suggest that cardiac arrest survivors and their caregivers receive a comprehensive multidisciplinary discharge plan to incorporate medical and rehabilitation treatment suggestions and expected goals of activity/work recovery.

2020 (new):　We suggest a structured assessment of anxiety, depression, post-traumatic stress response and fatigue for survivors of cardiac arrest and their caregivers.

Reason: Patients with cardiac arrest need to go through a long rehabilitation period after initial hospitalization. Support is needed during rehabilitation to ensure the best physical, cognitive and emotional health and restore social/role functions. This process should start from the initial hospitalization period and continue as needed. These topics are discussed in more detail in the 2020 AHA scientific statement.

Analysis and summary of rescuers

2020 (new):　After cardiac arrest, it may be beneficial to organize non-professional rescuers, EMS implementers and hospital medical staff to analyze and summarize and provide follow-up for them in the follow-up for emotional support.

Reason: The rescuer may feel anxious or have post-traumatic stress reaction because of providing or not providing BLS. Hospital medical staff may also encounter emotional or psychological influence when treating patients with cardiac arrest. Team analysis and summary can review team performance (education and quality improvement) and identify natural stress factors related to the treatment of dying patients. It is expected that an AHA scientific statement dedicated to this topic will be released in early 2021.　　

Cardiac arrest in pregnant women

2020 (new):　Because pregnant women are more prone to hypoxia, oxygenation and airway management should be given priority during the resuscitation of pregnant women’s cardiac arrest.

2020 (new):　Because it may interfere with the recovery of pregnant women, fetal monitoring should not be carried out during the cardiac arrest of pregnant women.

2020 (new):　We suggest that pregnant women who are still unconscious after cardiac arrest and resuscitation should be managed by target temperature.

2020 (new):　During the management of target body temperature for pregnant patients, it is suggested to continuously monitor the fetus for the possibility of bradycardia, and consult obstetrics and neonatology.

Reason: Reviewed the recommendations on the management of cardiac arrest in pregnant women in the guideline update in 2015 and AHA scientific statement in 2015. Due to the increase of maternal metabolism, the decrease of functional residual capacity caused by pregnant uterus and the risk of fetal brain damage caused by hypoxemia, airway, ventilation and oxygenation are particularly important in the context of pregnancy.

　 　 　 　It is not helpful to evaluate the fetal heart during the period of maternal cardiac arrest, and it may also distract attention from the necessary resuscitation operation. In the absence of contrary data, pregnant women who survive after cardiac arrest should be managed by the target temperature like other survivors, and the condition of the fetus who may stay in the uterus should be considered.

Basic and advanced life support for children　

The causes of cardiac arrest in infants and children are different from those in adults, and more and more pediatric specific evidence supports these suggestions.

AHA children’s IHCA and OHCA survival chain

Flow chart of cardiac arrest in children

Flow chart of bradycardia in children with pulse

Flow chart of pulse tachycardia in children

Checklist of treatment after spontaneous circulation recovery in children with cardiac arrest

Important Issues, Major Changes and Enhancements in the 2020 Guide 　

The flow chart and visual AIDS were modified to incorporate the best scientific knowledge and provide clearer information for PBLS and PALS resuscitation implementers.

According to the latest data of children’s resuscitation, it is suggested that the frequency of auxiliary ventilation should be increased to once every 2-3 seconds (20-30 times per minute) for all children’s resuscitation scenarios.

For patients of any age who need to be intubated, it is recommended to use a cuff ETT to reduce air leakage and the need to change tubes.

The routine use of cricoid cartilage compression during intubation is no longer recommended.

In order to maximize the chances of obtaining a good resuscitation prognosis, epinephrine should be given as soon as possible, and ideally it should be given within 5 minutes after cardiac arrest with non-shockable rhythm (cardiac arrest and pulseless electrical activity).

For patients with arterial catheterization, the feedback from continuous measurement of arterial blood pressure can improve the quality of CPR.

After Rosc, the patient’s seizure should be evaluated; Status epilepticus and any convulsive seizures should be treated.

Patients with cardiac arrest need to go through a long rehabilitation period after their initial hospitalization, so their physiological, cognitive and psychosocial needs should be formally evaluated and given corresponding support.

When epinephrine or norepinephrine is infused when vasopressor drugs are needed, it is appropriate to adopt titration liquid management method for resuscitation of septic shock.

According to adult data, it is generally inferred that the balanced blood component resuscitation scheme is reasonable for infants and children with hemorrhagic shock.

Opioid overdose management, including seizures by non-professional rescuers or trained rescuers, should be treated.

Patients with cardiac arrest need to go through a long rehabilitation period after their initial hospitalization, so their physiological, cognitive and psychosocial needs should be formally evaluated and given corresponding support.

When epinephrine or norepinephrine is infused when vasopressor drugs are needed, it is appropriate to adopt titration liquid management method for resuscitation of septic shock.

According to adult data, it is generally inferred that the balanced blood component resuscitation scheme is reasonable for infants and children with hemorrhagic shock.

Opioid overdose management includes CPR by non-professional rescuers or trained rescuers and timely administration of naloxone.

Children with acute myocarditis with arrhythmia, cardiac block, ST segment changes or low cardiac output are at higher risk of cardiac arrest. It is important to be transferred to the intensive care unit as soon as possible. Some patients may need mechanical circulatory support or extracorporeal life support (ECLS).

Babies and children with congenital heart disease and single ventricular physiological function need special consideration in the management of PALS if they are in the process of staged reconstruction.

The management of pulmonary hypertension may include the use of inhaled nitric oxide, prostacyclin, analgesic drugs, sedative drugs, neuromuscular blocking drugs, induced alkalosis or ECLS rescue treatment.

Neonatal life support

Newborn resuscitation needs to be predicted and prepared by the implementers who have received individual and team training.

Most newborns do not need umbilical cord ligation or resuscitation immediately, but can be evaluated and monitored during the skin contact between mother and baby after birth.

Preventing hypothermia is an important concern of neonatal resuscitation. As a way to close the parent-child relationship, promote breastfeeding and maintain normal body temperature, the importance of skin contact nursing for healthy infants is strengthened.

For newborns who need support after birth, lung dilatation and ventilation are the primary tasks.

The increase of heart rate is the most important index of effective ventilation and response to resuscitation intervention.

Pulse oxygen saturation is used to guide oxygen supply and achieve oxygen saturation target.

Routine endotracheal suction is not recommended for active or inactive infants born in meconium-contaminated amniotic fluid (MSAF). Endotracheal aspiration is only applicable when airway obstruction is suspected after providing positive pressure ventilation (PPV).

If proper ventilation correction steps are taken (preferably including tracheal intubation), but the heart rate does not respond well to ventilation, chest compressions can be performed.

Electrocardiogram should be used to monitor the response of heart rate to chest compressions and drugs.

When newborns need vascular access, umbilical vein pathway should be the first choice. When venous access is not feasible, the intraosseous approach can be considered.

If the response to chest compressions is not good, it may be reasonable to provide epinephrine, preferably through the intravascular route.

If there is no response to adrenaline and there is a history or examination consistent with blood loss, the newborn may need to expand.

If all these resuscitation steps have been effectively completed, but there is still no heart rate reaction after 20 minutes, we should discuss with the team and the family members of the child to adjust the treatment direction.

　 　 　 　 Survival after cardiac arrest depends on the establishment of an organic system covering personnel, training, equipment and organization. Willing bystanders, owners equipped with AED, emergency service telecommunication personnel and BLS and ALS implementers working in EMS system can all contribute to the successful recovery of OHCA.

　 　 　 　Within the hospital, the work of doctors, nurses, respiratory therapists, pharmacists and other professionals also provides support for the prognosis of resuscitation. Successful recovery also depends on the efforts of equipment manufacturers, pharmaceutical companies, recovery teachers, guide compilers and many others. Long-term survival depends on the support of family members and professional nurses, including experts in cognitive, physical and psychological rehabilitation and recovery. All links in the whole system are striving to improve the quality of treatment in an all-round way, which is very important for achieving a successful prognosis.