临床医学英语翻译

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1、临床医学英语翻译Chapter 1Patient-Physician Interaction第一章医患沟通第页Page 1The patient-physician interaction proceeds through many phases of clinicalreasoning anddecision making.proceed进行、开展clinical decision确定治疗方案reasoning 推论、推理clinical reasoning诊断making decision做出决定医患沟通在临床诊断和治疗决策的许多阶段中进行着。The interaction begins

2、with an elucidation of complaints or concerns, followed by inquiries orevaluation to address these concerns in increasingly precise ways.elucidation 说明、阐明inquire询问、调查evaluation评估、评价这种沟通开始于病人诉说或所关注问题，然后通过询问、 评估不断精确地确定这些问题。The process commonlyrequires a careful historyor physical examination,ordering

3、ofdiagnostic tests, integration of clinical findings with the test results, understanding of the risks andbenefits of the possible courses of action, and careful consultation with the patient and family todevelop future plans.integration 综合consultation磋商、会诊进行诊断性化验， 综合临床发现和化验这个过程通常需要细致的病史询问和体格检查，结果，理

4、解分析拟行治疗过程中的风险和疗效，并与病人及家属反复磋商以形成治疗方案Physicians increasingly can call on a growing literature of evidence-based medicine to guidethe process so that benefit is maximized,patientsrespecting注意到、关系、说到要考虑到不同病人中个体差异是存在的。The increasing availabilityof randomized trials to guide the approach to diagnosis andt

5、herapy should not be equated withavailabilityapproach 接近越来越多的可用于指导临床诊断与治疗的随机试验资料不应变成“烹调书 ”医学。可 利 用 性 ，可 得 到“ cookbook ” medicinerandomize随 机 的cookbook食 谱 ， 烹 调 书evidence-based medicine 循证医学使得疗效最大化，但医生们越来越容易查阅不断增长的循证医学文献来指导这个过程，while respecting individual variations among differentEvidence and the gu

6、idelines that are derived from it emphasize proven approaches forpatients with specific characteristics.Evidence证据，迹象guideline指导方针emphasize 强调因为随机试验获得的现象和思路是着重于特征性病人的求证过程。Substantial clinicaljudgment is required to determine whether the evidence and guidelinesapply to individual patients and to reco

7、gnize the occasional.1substantial clinical真实的，实在的individual个体occasional 偶尔的，特殊的实际的临床判断需要确定这些现象和思路能否应用于某个病人个体，并能找出例外。Even more judgment is required in the many situations in which evidence is absent orinconclusive.inconclusive不确定性，非决定性许多情况下，临床表现缺乏或不典型，需要考虑更多的判断。Evidence also must be tempered by patie

8、ntsp references, although it is a physicianresponsibility to emphasize when presenting alternative options to the patient.temper 脾气，调音preference 偏爱emphasize 强调，详述，阐明presenting 提出alternative 可选择的，二选一病人还会根据自己的倾向调节着临床症状，但医生有责任通过选择性问题搞清事实。The adherence of a patient to a specific regimen is likely to be

9、enhanced if the patient alsounderstands the rationale and evidence behind the recommended option.adherence 坚持、固执enhance 提高、加强regimen养生法、食物疗法rationale 基本原理 s假如病人也懂得医生问题的基本原理和表现，有特殊生活方式病人的固执容易被强化。To care for a patient as an individual, the physician must understand the patient as a person.care for喜欢、照

10、料为了把病人作为一个个体进行治疗人（不是一群人） 。This fundamental precept of doctoringincludes an understanding of the patientsocsialsituation,familyissues,financialconcerns, and preferences for different types of care andoutcomes, ranging from maximum prolongation of life to the relief of pain and suffering.fundamental基本

11、的，根本的precept训戒doctoring 行医prolongation延长家庭问题， 资金状况以及对不同治疗这个最基本的行医原则包括了解病人的社会地位，(为了个体化的照料病人)，医生必须理解病人是一个方法、不同治疗结果的选择，从最大限度地延长生命到临时缓解疼痛和折磨。If the physician does not appreciate and address these issues, the science of medicine cannotbe applied appropriately, and even the most knowledgeable physician fa

12、ils to achieve appropriateoutcomes.appreciate 欣赏、感谢、评价appropriate 适当的、恰当的医学就不可能恰当地应用于临床，甚至一个知假如医生没有正确理解和定位这个问题，识最渊博的医生也不能取得理想的治疗结果。Even as physicians become increasingly aware of new discoveries, patients can obtain theirown information from a variety of sources, some of which are of questionable re

13、liability.aware of靠、可信赖的甚至，当医生越来越容易知道新发现的同时，病人也能够通过各种资源得到他们的信息，意识到，知道questionable 可疑的、 成问题的、不可靠的reliability可2当然，某些信息是不可靠的。The increasing use of alternative and complementary therapies is an example of patientsfrequent dissatisfaction with prescribed medical therapy.alternative 选择，替代方替代疗法和辅助疗法的应用不断增加

14、就是病人对常规疗法经常不满意的一个例子。Physicians should keep an open mind regarding unproven options but must advise theirpatients carefully if such options may carry any degree of potential risks, including the risk thatthey may relied on to substitute for proven approachessubstitute 代替、代用rely on 依赖、信任但是，如果这些疗法可能带来任

15、何程度的潜医生对未证实的疗法应该保持开放的思想，complementary 补充的、相配的prescribe 规定、指定、开处在风险，医生都必须细致地告知病人，包括可能需要用已证实的常规疗法去替代的风险。It is crucial for the physician to have an open dialogue with the patient and family regardingthe full range of options that either may considercrucial严酷的、决定性的either 两者任一对医生来说，对病人及家属开诚布公地介绍所有能考虑的治疗选

16、择，是极及关键的。The physician does not exist in a vacuum but rather as part of a complicated and extensivesystem of medical care and pubic health.vacuum真空extensive 广阔的、大量的医生不是生存在真空中的，而是复杂而庞大的医疗和公共健康体系中的一部分。In premodern times and even today in some developing countries, basic hygiene, clean water,and adequa

17、te nutrition have been the most important ways to promote health and reduce disease.adequate 足够的、恰当的在未发达时代， 甚至当今在一些发展中国家，基本卫生、 清洁饮用水和最低营养保障是促进健康减少疾病的最重要措施。Indeveloped countries,the adoptionofhealthylifestyles,includingbetterdiet andappropriate exercise, are cornorstones to reducing the epidemics of

18、obesity, coronary disease, anddiabetes.adoption 采纳、采用尿病盛行的基础。Public health interventions to provide immunizations and to reduce injuries and the use oftobacco, illicit drugs, and excess alcohol collectively can produce more health benefit than nearlyany other imaginable health intervention.illicit非法

19、的、违禁的collectively全体地、共同地produce 生产、创造公共健康干预如进行疫苗接种、减少损伤、减少吸烟、减少吸毒、减少酗酒等措施共同产生的健康效果几乎比可想象的任何其它健康干预措施都要好。epidemic 流行、传染是减少肥胖、 冠心病和糖而在发达国家中，健康的生活方式包括合理饮食和适当锻炼，3Chapter 5Clinical Preventive Services第五章临床预防服务Page 11Clinical preventive services include counseling, immunization, screening tests, and reduct

20、ionofthe susceptibilityto disease byinterventionssuch as therapeutic lifestylechanges andpharmacotherapy.counseling咨询immunizationscreeningsusceptibility疗来减少易感性。Preventive service often are classified as primary, secondary, or tertiary.tertiary第三，第三纪第三产业tertiary industry使免除遮敝，屏敝、选拔对敏感防疫、筛查以及通过治疗性的生活习

21、惯改变和药物治临床预防服务包括对疾病的咨询、临床预防服务常分为一级预防、二级预防和三级预防。Primary prevention is directed towardpreventing disease or injurybefore it develops,whereas secondary prevention deals with early detection and treatment to impede the progress ofovert disease.deal withimpedeovert解决妨碍公开Primary prevention is directed towa

22、rdpreventing disease or injurybefore it develops,whereas secondary prevention deals with early detection and treatment to impede the progress ofovert disease.一级预防是直接针对疾病或损伤发生前的预防，早期发现和早期治疗，以防止临床疾病的进一步发展。In contrast, tertiary prevention refers to rehabilitative activities after the onset of disease t

23、ominimize complications and disability.rehabilitative可修复的，康复disability残疾，病残对比之下，三级预防是指疾病发生后的康复治疗，以减少并发症和病残。Because of considerable overlap, distinguishing among these phases of prevention may beconfusing.overlap 互搭，重叠，错叠，交叉distinguishing区别，区分，特征，特色因为（三级预防之间）有相当大的交叉，这些预防阶段的区分可能有些混淆。而二级预防是解决疾病或损伤发生后的D

24、etectingandtreatinghypertensioncouldbeconsideredsecondarypreventionof4hypertensive cardiovascular disease but primary prevention of heart failure and stroke.hypertensive cardiovascular disease 高血压性心血管疾病发现和治疗高血压可以认为是对高血压性心血管疾病的二级预防，和中风的一级预防。Prevention may be perceived best along a continuum from modi

25、ficationof predisposingfactors, to preventing a disease, to avoiding premature death and disability.perceive 感知，认为continuum 统一体 ,一致性predisposing factors 易感因素along 沿着，前行modification修改，变性premature 过早，过早发生，夭折，草率长期一贯地减少易感因素可能是防止疾病、避免早死早残最好的预防。The sooner the prevention, the more likelyunnecessary illness

26、, disability, and prematuredeath can be avoided.unnecessary 不必要的，多余的预防得越早，越不易发生不必要的疾病，病残和早死就能够避免。Increasing emphasis has been placed on preventing risk factors themselves.emphasis 重点，强调越来越多的重点已经集中到对危险因素本身的预防。The term primordial prevention has been introduced for this concept.primordial基本的，原始的，初生的，初发

27、的术语-根源预防（病因预防）已经引进了这个概念。但也可是对心力衰竭Indiscriminate screening for risk factors or disease without adequate advice and follow-upserves no useful purpose.indiscriminate无差别的，不加区别的advice 忠告，劝告没有引导和随访的毫无选择地远离危险因素或疾病是没有实用价值的预防。The periodic health examination has evolved from an annual, broad-based, uniform pr

28、otocolto an approach that targets the prevention, detection, and treatment of specific diseases or riskfactors for particular age, gender, and ethnic groups at appropriate intervals.periodic周期的，定期的broad-based 无限的，基础深厚的，运用广泛的uniform一致的，统一的，制服protocol 规章制度，草案，协议ethnic 民族的，种族的，有民族特色的interval间隔，区间定期体检逐渐

29、从一年一度的、全面的、统一的规定项目改进成以恰当的周期对特定年龄、性别和种群的特殊疾病或危险因素有目的地预防、发现和治疗。5Currentrecommendations bythe U.S. Preventive Services Task Force are based onsystematic evidence reviews that distinguish procedures likelyto prove effectiveand to havesubstantially more benefit than harm.Task Force 特遣部队distinguish 区别，辨认，

30、使显著substantially 非常，本质上，大体上美国预防服务特别局的最近建议是基于全面的回顾性研究，效、确实是利大于弊的预防措施。这些研究选出了易于证明有Changes inthe healthcare system andthe developmentof nationalguidelinesformanagement of disease are likely to draw greater attention to health promotion, disease prevention,and the interface of physician-based medical ca

31、re with the public health care system.health care 卫生保健guideline指导方针，准则interface 接口，界面，联系卫生保健系统的改进和国家疾病控制政策的完善使人们更重视健康促进、及接受医疗人员为主的公共卫生系统的保健服务。疾病预防， 以Physicians should consider each disorder in terms of the potential for prevention, includingthe possibility of adverse effects and cost-effectiveness.i

32、n terms of就 而言 , 从 方面说来，从 角度来讲cost-effectiveness 成本效益医生应该以有无需要预防的角度考虑每一种疾病，否值得。包括可能发生的副作用和付出代价是A concept useful for clinical decision making is the number of patients needed to treat toprevent one adverse event, which is based on absolute risk reduction.concept 概念、看法、观念一个对临床决策有用的理念是需要治疗的病人数量决定一个不利因素

33、是否要预防，基于绝对风险的下。降这是This number is based on efficacy and is calculated as the reciprocal of the difference in eventrates between control and treatment groups for a specified period.efficacy效力，效能，有效性reciprocal相互的，互为倒数的，倒数这个数量是以效能为基础的，是对特定时期内对照组和治疗组之间发生率差异的倒数进行的统计。Ample evidence connects identifiableand

34、 often preventable factors to the morbidityandmortality associated with major health problems.ample足够的，大量的identifiable可以确认的大量的试验证据找出了可确认的又常可预防的与主要健康问题相关的发病和死亡 因 素 。6About half of all deaths, morbidity,and disabilitycan be attributed to such nongeneticfactors.nongenetic非遗传性的约一半死亡、发病和病残与这些非遗传性因素有关。Man

35、y lifestyle changes benefit multiple systems and disorders.许多生活习惯改变有利于多个系统和紊乱的改善。Cigarette smoking has been estimated to contribute to one in five deaths in the United States;dietary habits may affect the occurrence of cardiovascular disease, diabetes, osteoporosis, andcancer.osteoporosis骨质疏松症美国五分之一

36、的死亡估计与吸烟有关，松症和癌症的发生。饮食习惯可能影响心血管疾病，糖尿病、 骨质疏Other importantpersonal behavior factors influencinghealth includephysical activity,alcohol intake, illicit drug use, sexual practices, and exposure to environmental toxins.其它影响健康的重要个人行为因素有锻炼、饮酒、吸毒、性行为以及环境毒物的接触。TheidentificationofinformativeDNApolymorphisms(

37、e.g.,singlenucleotidepolymorphisms)and further elucidationof candidate genes allow for detection of susceptibleindividuals and possible institution of measures to prevent the expression of these harmful genetictraits.informative提供信息的polymorphisms多态性nucleotide 核苷酸携带信息 DNA 多态性（例如，单核苷酸多态性）的认识和候选基因的进一步阐

38、明允许我们发现易感人群和可能采取的措施，以预防这些有害基因特性的表达。Several common misconceptions impede preventive health care.impede妨碍，阻碍好几种错误观念妨碍了预防保健。candidate 候选人traits特质，属性Manybelieve that diseases witha strong heritable component cannot be altered, butsusceptibility to disease often requires the interaction of multiple genes

39、 and environmental factorsfor expression.heritable 可遗传的，可继承的许多人认为有很强遗传性的疾病是无法改变的，和环境因素的相互作用才能表达。In addition,chronicdiseases are multifactorial,so other factorscan be changed tocompensate for an elevated genetic risk.multifactorial多因子的但是对疾病的易感性经常需要多种基因7compensate补偿，弥补，赔偿另外，慢性疾病是多因素的，所以，可以改变其它因素来弥补高基因

40、风险。Although gene therapy holds much promise, preventive measures currently offer the bestpossibilities for limiting gene expression and avoiding disease.promise承诺，诺言，希望，前途虽然基因疗法有着很大的希望，但目前的最有可能提供的预防措施是限制基因表达来避免疾病。The notion that prevention is less useful in older persons excludes many who would bene

41、fitmost from prevention because elderly patients generally have a greater absolute risk of disease andhave been shown to adhere and respond favorably to preventive measures.favorably顺利地，好意地，亲切地因为老年病人一般有对老年人预防无用的观念排除了在预防上本应极为受益的许多人，更高患病风险，并且一直对预防措施极为支持、反应积极。Also, life expectancy frequently is underes

42、timated in the elderly; individuals who reach age75 now can expect to live an average of 11 more years.life expectancy 预期寿命并且，老年人的预期寿命经常是低估的，现在将到年多。75 岁的老人可以预期平均再活11Chapter 8Why Geriatric Patients Are Different老年病人的特殊性第 20 页Page 20第八章Older patients differ from young or middle-aged adults with the sa

43、me disease in many ways,one of which is the frequent occurrence of comorbidities and of subclinical orbidities临床疾病多。As a function of the high prevalence of disease, comorbidity (or the co-occurrence of two ormore diseases in the same individual) is also common.prevalence流行、普遍co-occurrence同时发生作为高发疾病的

44、结果，并存病（两个或更多的疾病在同一个体同时发生）也是常见的。Of people age 65 and older, 50% have two or more chronic disease, and these diseases canconfer additive risk of adverse outcomes, such as mortality.confer授予、给予additive附加的、附属物65 岁以上的老年人中，50%患有两种以上的慢性疾病，这些疾病能够增加不良预后的风险，如死亡的风险。并存病subclinical亚临床的其中之一是并存病多、亚同样的疾病， 老年病人在许多方面

45、与青中年病人是有区别的，In some patients, cognitive impairment may mask the symptoms of important conditions.8cognitive认知的、认识的impairment损害mask口罩、假面具、掩饰在一些病人中，认知损害可以掩盖重要病情的症状。Treatment for one disease may affect another adversely, asstroke in individuals with a history of peptic ulcer disease.stroke中风peptic ulce

46、r消化性溃疡例如，对有消化性溃疡病史的病人使用阿斯对一种疾病的治疗可能会加重另一种疾病，匹林预防中风。The risk for becoming disabled or dependent also increases withthe number of diseasespresent.disabled残废的、有缺陷的dependent依靠的、依赖的病残或生活不能自理的发生率也随着并存的疾病数而增高。Specific pairs of diseases can increase synergistically the risk of disability.synergistic协同的特殊的成对

47、疾病可以协同增加病残的风险。Arthritis and heart disease coexist in 18% of older adults; although the odds of developingdisability are increased by three-fold to four-fold with either disease alone, the risk of disabilityincreases 14-fold if both are present.arthritis关节炎odd奇数的、单个的虽然每个疾病可以增加34 倍的病残率， 但两14 倍。18%的老年人

48、同时患有关节炎和心脏病，个疾病同时存在，可使病残率提高到in the use of aspirin to preventA second way in which older adults differ from younger adults is the greater likelihood thattheir diseases present with nonspecific symptoms and signs.likelihood可能性老年与青中年的第二个差异是更容易出现非典型的症状和体症。Pneumonia and stroke may present with nonspecifi

49、c changes in mentation as the primarysymptom.pneumonia 肺炎要的肺炎和中风时可出现非特异性意识变化作为主要症状。Similarly, the frequency of silent myocardial infarction increases with increasing age, as doesthe proportionof patients who present with a change in mental status, dizziness, or weaknessrather than typical chest pain

50、.silent沉默的、静止的proportion成比例的、相称的这些病人相应地频发精神状同样地， 隐匿性心肌梗塞发生频度随着年龄的增大而增加，态改变、眩晕、虚弱而不是典型的胸痛症状。mentation 精神作用、心理活动primary 初始的、首要的、主As a result, the diagnostic evaluation of geriatric patients must consider a wider spectrum of9diseases than generally would be considered in middle-aged adults.spectrum谱、光谱

51、因此，老年病人的诊断应考虑更广泛的疾病谱，要超过通常对中年病人所考虑的范。围A third condition that is found primarily in older adults is frailty, frailtyis thought to be awasting syndrome that presents with multiple symptoms and signs, including reduced muscle mass,weight loss, weakness, poor exercise tolerance, slowed motor performance

52、, and low physicalactivity.primarily起初、首先、原来frailty脆弱、虚弱、意志薄弱衰弱被认为属于衰竭综合症，它有许多症状和tolerance宽容、忍耐、耐受主要出现在老年人的第三个情况是衰弱，体征，包括肌肉萎缩、体重下降、虚弱、运动耐受差、动作慢、身体活动少。Some estimates indicate that the full syndrome is found in 7% of community-dwelling peopleage 65 and older, and in 25%of community-dwelling people age

53、 85 and older.estimate估计、评价、看法indicate指出、表时、象征、适应征一些人估计7%的 65 岁以上社区老人和25%的 85 岁以上社区老人这些症状全部出现。Many institutionalized older adults also are frail.institutionalized使成公共团体、将 收容在公共设施里frail身体虚弱的、易损坏的、意志薄弱的许多老人院里的老人也是衰弱的。Frailty is a state of decreased reserve and increased vulnerability to all kinds of s

54、tress, fromacute infectionor injuryto hospitalization,and may identifyindividualswho cannot tolerateinvasive therapies.reserve保存、克制vulnerability易受伤、易受责难衰弱是对各种压力耐受下降、易于损害的一种状态，从急性感染、损伤到住院治疗 ， 都可以发现一些老人不能耐受侵入性诊疗措 施 。The syndrome of frailtyis associated with high risk of falls, needs for hospitalizatio

55、n,disability, and mortality.fall跌倒、下降frail身体虚弱的、易损坏的、意志薄弱的衰弱症状与高病倒率、高住院率、高病残率、高死亡率是密切相关的。There is early evidence that a core component of frailty is sarcopenia, or loss of muscle massassociated with aging, which occurs in 13 to 24% of persons age 65 to 70 and in 60% of personsage 80 and ponent成分、构成要

56、素sarcopenia 肌减少（症）、与年龄相关的骨骼肌质量下降衰弱早期征象中的一个主要变化是肌减少症，或者说随年龄增长的肌肉减少，1324%的 6570 岁的老人， 60%的 80 岁以上的老人。It is likelythat dysregulation of multiplephysiologicsystems, includinginflammation,hormonal status, and glucose metabolism, underlies the syndrome, with resulting decreased ability它发生在10to maintain ho

57、meostasis in the face of stress.dysregulation失调homeostasis内环境稳定（衰弱时）多种生理系统易于失调，包括炎症反应、激素调节、葡萄糖代谢，在症状的背后，伴随的结果是在压力面前保持内环境稳定的能力下降。Subclinical disease (e.g., atherosclerosis), end-stage chronic disease (e.g., heart failure), or acombination of comorbid diseases may precipitate the syndrome.atherosclero

58、sis成症状。Evidence from randomized, controlled trials shows that resistance exercise, with or withoutnutritionalsupplements, and home-based physical therapy can increase lean body mass andstrength in even the frailest older adults.随机对照试验的结果显示无论有无营养支持和家庭运动疗法，即使是最虚弱的老年人，对抗运动能够增加瘦弱躯体的质量和力量。动脉粥样硬化precipita

59、te 沉淀，促成亚临床疾病 (如动脉粥样硬化),晚期慢性疾病 (如心力衰竭） ，或多种疾病并存可共同形This evidence suggests that earlier stages of frailtyfrailty likely presages death.remediable可挽回的presage预兆、预示may be remediable, although end-stage这个结果提示早期衰弱是可挽回的，尽管末期衰弱常预示着死亡。Fourth, cognitive impairment increases in prominence as people age.promine

60、nce突出、显著第四，人们变老时认知损害显著增加。Cognitive impairment is a risk factor for a wide range of adverse outcomes, including falls,immobilization, dependency, institutionalization, and mortality.immobilization老人院护理、死亡。Cognitive impairment complicates diagnosis and requires additional care giving to ensuresafety.认

61、知损害使诊断复杂，为保证安全需要更多的照料。Finally, a serious and common outcome of chronic diseases of aging is physical disability,defined as having difficulty or being dependent on others for the conduct of essential or personallymeaningful activities of life, from basicself-care (e.g., bathing or toileting) to tasks

62、 required topaying bills) to a full range of activities描述为个人最基本的或必须live independently (e.g., shopping, preparing meals, or活动能力减少institutionalization制度化、专门照料认知损害是大量不良预后的风险因子，包括摔倒、活动能力下降、生活不能自理、需住considered to be productive and/or personally meaningful.最后，老年人慢性疾病严重又常见的结果是身体能力丧失，的日常活动有困难或不得不依靠别人帮助指导，需要

63、的各种任务（如购物、做饭、支付各种账单）从基本的自理 （如洗澡或如厕）到独立生活，到具有集体和或个人意义的所有活动。11Of older adults, 40% report difficultywith tasks requiringmobility,and difficultywithmobilitypredicts the future development of difficultyin instrumental activities of daily living(IADL; household management tasks) and activities of daily l

64、iving (ADL; basic self-care tasks).在老年人中，40%对需要运动的任务有困难，运动困难提示将来开展日常工具锻炼ADL ；基本自理项目）的困难。（IADL ；家务自理项目）和目常锻炼（In persons age 65 and other, difficultywith IADLis reported by 20%, and difficultywithADL is reported by 11%; for both, the prevalence increases with age.prevalence流行大于 65 岁的老人或其它人，IADL 困难报导为2

65、0%，ADL 困难报导为11%；随年龄增加两个都困难成为普遍现象。People who have difficultywith tasks of IADLand ADL are at high risk of becomingdependent.IADL 和 ADL 困难的人处于生活不能自理演变的高风险中。Of persons older than age 65, 5% reside in nursing homes, largely as a result of dependencyin IADL and/or ADL secondary to severe disease.reside果。

66、Generally, woman live more years withdisability,whereas men who become similarlydisabled are more likely to die at a younger age.一般来说，同样的能力丧失，男性常死得更年轻，女性比男性能多活几年。居住nursing home疗养院IADL 和 ADL 的结大于 65 岁的老人中， 5%住在疗养院里，大多数是严重疾病后依赖Although physical disability is primarily a result of chronic diseases and

67、geriatric conditions,its onset and severity are modifiedby other factors, includingtreatments that controltheunderlying diseases, physical activity, nutrition, and smoking.primarily首先、起初、主要、 、根本onset进攻、有力的开始、发作它的发生和严重程度被其它虽然身体能力丧失是慢性疾病和年老状态的一个主要结果，因素影响着，包括基础疾病的治疗和控制、身体锻炼、营养和吸烟。Many intervention tria

68、ls indicate that disability can be prevented or its severity decreased;one trial showed improvements in functioning with resistance and aerobic exercise in older adultswith osteoarthritis of the knee.aerobic exercise有氧运动osteoarthritis骨关节炎许多干预试验揭示能力丧失可预防或减轻；和有氧运动改善了功能。Occult and Obscure Gastrointesti

69、nal Bleedingoccult 神秘的、秘密的、隐蔽的隐匿性和来源不明性胃肠道出血Page 60一个试验显示膝骨关节炎老年人用对抗运动obscure黑暗的、模糊的、隐匿的第 60 页12Occultbleedingisdefinedas thedetectionofasymptomaticbloodloss fromthegastrointestinal tract, generally by routine fecal occult blood testing (FOBT) or the presence ofiron deficiency anemia.fecal 排泄物、残渣隐匿性

70、出血指的是无症状性胃肠道出血，在着缺铁性贫血而发现。Obscure gastrointestinal bleeding is defined as bleeding of unknown origin that persists orrecurs after a negative initial endoscopic evaluation of both the upper and lower gastrointestinaltracts.initial开始的、最初的或反复性出血。Both of these entities may be presentations of recurrent

71、or chronic bleeding.entity 实体、存在、本质presentation 提出、表现、存在两者都可能表现为反复的或慢性的出血。The initial approach to evidence of occult gastrointestinal blood loss should be endoscopicevaluation.对隐匿性胃肠道出血，应该使用内窥镜进行早期检查。In the setting of an isolated positive FOBT, colonoscopy is indicated as the first test.colonoscopy

72、结肠镜只有单纯大便隐血试验阳性的情况下，结肠镜作为首选的检查方法是适合的。evaluation 评价下消化管内窥镜检查都阴性、原发部位不明的持续性来源不明性胃肠出血是指首次上、一般通过常规的大便隐血试验（ FOBT）或存The yield of colonoscopy in these patients is approximately 2% for cancer and 30% for oneor more colonic polyps.yield 产出、结出、产生这些病人结肠镜的结果大约2%是癌症， 30%是单发或多发的结肠息肉。The initial approach to a pati

73、ent with iron deficiency anemia depends on the presence ofsymptoms referable to either the upper or lower gastrointestinal tract.referable 可认为与 .有关的、可参考的缺铁性贫血病人的早期检查方法要根据存在的症状是与上消化道相关还是与下消化道相关而决定。Regardless of the findings on the initial upper or lower endoscopic examination, all patientsshould have

74、 both upper and lower endoscopy because the complementary endoscopic examinationhas a yield of 6% even if the first one was plementary 补充的、互补的为互补的内窥镜检查有positive 确定的、绝对的、真实的所有病人两个检查都应该做，因无论首次上消化道或下消化道内窥镜检查会有何发现，6%的再发现，即使第一个检查是阳性的。13For premenopausal women, a positive FOBT requires full evaluation, as

75、 does iron deficiencyanemia.premenopausal 绝经前的对绝经前妇女，大便隐血试验阳性需要全面分析，缺铁性贫血也一样。Barium radiographs of the upper and lower gastrointestinal tract have limitedutility in thesetting of occult bleeding because of their inability to biopsy or treat lesions that are identified.utility实用、效用、通用隐匿性出血时， 上、下消化道的钡

76、剂造影应用有限，损。The evaluation of obscure gastrointestinal bleeding is often frustratingfrustrating 令人泄气的、令人沮丧的原因不明性胃肠道出血的诊断常常令人沮丧。因为它们不能活检或治疗发现的病Angiodysplasia is the most common cause in most recent series.Angiodysplasia血管发育畸形血管发育畸形是最近病例统计中最常见的病因。Initial endoscopic examination should focus on any sympto

77、ms reported by the patient.focus 聚焦、集中、明确首次内窥镜检查要关注病人诉说的任何症状。Potential causative agents, such as NSAIDs and aspirin, should be discontinued.causative 成为原因的NSAIDs非甾体类抗炎镇痛药non-steroidal antiinflammatory drugs能成为潜在病因的药物，如非甾体类抗炎镇痛药和阿斯匹林，都应该停用。Disordersassociatedwithbleeding,suchashereditaryhemorrhagicte

78、langiectasia(Osler-Weber-Rendu syndrome), inflammatorybowel disease, or a bleeding diathesis should beconsidered.telangiectasia 毛细血管扩张diathesis 素质Osler-Weber-Rendu 综合症）、炎性伴有出血的疾病，像遗传性出血性毛细血管扩张症（肠疾病、或出血性体质应该加以考虑。A repeat endoscopic evaluation may be appropriate, because approximately one third of cas

79、esreveal a cause of bleeding overlooked during the initial endoscopy.内窥镜重复检查可能是需要的，因为接近三分之一病例查出了首次内窥镜漏掉的出血病原灶。When upper endoscopy and colonoscopy are both unrevealing, evaluation of the small bowelis indicated.当上消化道内窥镜和结肠镜均无发现时，应该对小肠进行检查。14Radiographic evaluation of the small bowel is noninvasive b

80、ut relatively insensitive, with aless than 6% yield from small bowel follow-through and a 10 to 21% yield from enteroclysis.insensitive 感觉迟的钝follow-through持久的贯彻，持续enteroclysis小肠造影小肠 X 线检查是非侵入性的，但相对不灵敏， 小肠全片不到6%有发现， 小肠造影 1021有结果。By comparison, the diagnostic yield of endoscopic enteroscopy of the sma

81、ll bowel in obscuregastrointestinal bleeding is 38 to 75%.enteroscopy 肠镜检查相比较，对来源不明性胃肠道出血小肠内窥镜的诊断结果是3875%。Traditional videoendoscopes can evaluate only the proximal small bowel ( 150cm), whereaslonger scopes, which are passed though the entire small bowel and then withdrawnwhilevisualizingthe mucosa

82、 (sonde enteroscopy), are limitedin their ability to visualize the entiremucosa and cannot be used to perform diagnostic or therapeutic maneuvers.proximal 最接近的、近侧的针传统的电视内窥镜只能检查近端小肠( 150cm)，然而能通过整个小肠边退边看肠粘膜的更长内镜，也不能看到整个肠粘膜，不能作为常规的诊断或治疗手。段visualize 使看得见，想像sonde 探空火箭、探子、探When endoscopic evaluation does

83、 not detect the cause of blood loss, radiographic proceduressuch as scintigraphy and angiography should be considered.scintigraphy闪烁显像当内窥镜检查不能发现出血病因，像闪烁造影和血管造影等影像学手段应该考虑。Provocative angiography using heparin or thrombolytic agents has been suggested by someauthorities, but this approach has the pote

84、ntial risk of precipitating major bleeding.provocative 刺激的、挑拔的、气人的precipitating使突然发生、促使虽然使用肝素或溶栓药的刺激性血管造影被某些专家推，荐但这种方法有促发大出血的潜在风险。In the face of continued blood loss and no identified etiology, intraoperative endoscopy mayprovide simultaneous diagnosis and therapy.simultaneous 同时发生的、同时存在的碰到进行性出血又诊断不

85、明，术中应用肠镜可以同时进行诊断和治。疗During the procedure, the surgeon plicates the bowel over the endoscope.plicate 有褶的 ;有皱襞的操作时，外科医生把小肠套到内窥镜上。As the scope is withdrawn,endoscopic findings can be identifiedfor surgical resection ortreatment.内镜退出时，内镜的发现可以决定是外科切除或保守治。疗15The yield of this procedure exceeds 70%.这个措施 70

86、%以上有结果。In some clinical situations, the site of bleeding cannot be identified, and the patient requireslong-term transfusion therapy.long-term 长期的transfusion 输血某些临床病例，出血部位无法找到，病人而要长期输血治疗。A new device for visualizing the entire gastrointestinal mucosa consists of a small camera inan ingestable capsul

87、e that transmits images to receivers attached to the patientabdsomenandmapped to identify the location of the image.ingestable 能咽下、能吸收camera 照相机、电视摄像机这种装置由一颗装有小型摄像机并并能咽下的胶囊一种新的装置能显示全部胃肠粘膜，置。组成，它将（数字）影像信号传到附着在病人腹部的接收器，并绘制出图像来识别影像的位The diagnostic yield of capsule enteroscopy is not yet clear, but this

88、 approach may potentiallyvisualize segments of the small bowel that were previously inaccessible.potentially潜在的、可能的肠管。No therapeutic maneuvers are possible with the device.但这个装置不可能有任何治疗性操作。inaccessible 达不到的、难接近的但是， 这种方法可能显示出以前难以接近的小肠胶囊小肠镜的诊断效率现在还不清楚，Chapter 23Diabetic Nephropathy糖尿病肾病Page 67第二十三章第 6

89、7 页End-stage renal disease (ESRD) from diabetic nephropathy is a major cause of morbidity andmortality,particularlyin patients with type 1 diabetes, affecting 30 to 35% of patients in theUnited States.nephropathy肾病EARD ）是人类患病和死亡的一个主要原因，特别3035%的病人。由糖尿病性肾病所发展的晚期肾病（是患有 1 型糖尿病的病人，在美国涉及Although nephropat

90、hy is about one half as frequent in type 2 diabetics (partially due to ashortened life expectancy), type 2 diabetes still makes up the vast majorityof diabetic patientsseeking therapy for ESRD.expectancy期望、预期make up补足、编造、组成1 型的一半（部分原因为预期寿命缩短），但 2 型尽管 2 型糖尿病的肾病发生率大约是糖尿病仍然是需要治疗晚期肾病的糖尿病病人的绝大多数。Overall,

91、 diabetes is the leading cause of ESRD in the United states,accounting for morethan one third of cases.16overall总体来说accounting for说明、证明、对负责总的来说，糖尿病是美国晚期肾病的首要病因，占三分之一以上。Details are less clear in patients with type 2 diabetes, but the natural history of diabeticnephropathy in type 1 diabetes is well d

92、escribed.2型糖尿病病人的演变细节不是很清，楚Theperiodimmediatelyfollowinghyperfiltration.glomerular肾小球的hyperfiltration紧接诊断后的一段时期以肾小球超滤最具有特征。超过滤但 1型糖尿病肾病的自然病程已有充分的描述。diagnosisisbestcharacterizedbyglomerularDuring this time, there is renal hypertrophy, increased renal blood flow, increased glomerularvolume, and an inc

93、reased transglomerular pressure gradient, all contributing to a rise in GFR.hypertrophy滤过率在这段时间，中肥大gradient坡度、梯度GFRglomerular filtration rate肾小球有肾脏肥大、 肾血流增加、 肾小球容积增大和肾小球两端的压力梯度增加，这些都与肾小球滤过率升高有关。Importantly, these changes depend at least in part on hyperglycemia, as they are diminishedby intensive di

94、abetes treatment.hyperglycemia 高血糖intensive 加强的，密集的重要的是，这些变化至少部分是依靠高血糖，因为通过有力的糖尿病治疗它们会消失。Three to 5 years after diagnosis, early glomerular lesions appear, characterized by thickeningof glomerular basement membranes, mesangial matrix expansion, and arteriolosclerosis.mesangial脉硬化为特征。肾小球系膜的matrix母体、基

95、础诊断后的 35 年，早期的肾小球损害出现，以肾小球基底膜增厚、系膜基底扩张和小动Albuminexcretion remains low during early glomerular changes; however, as pathologicchanges mount, the glomerulilose their functionalintegrity, resultingin glomerlarfiltrationdefects and increased glomerular permeability.albumin 白蛋白mount骑上、进行攻击增长integrity完整、完

96、善defect缺点、缺陷permeability渗透性在肾小球变化的早期，白蛋白排泄仍然较低，但是，随着病理变化加重，肾小球失完去善的功能，引起肾小球滤过的缺陷，肾小球渗透性增加。Although results of routine tests of renal function (creatinine and urinalysis) still remainnormal, microalbuminuria (30 to 300 mg/day) appears.尽管肾功能的常规化验（肌酐和尿检）结果还是正常，但微白蛋白尿（天）已经出现。Systemic hypertension is als

97、o present at this time in more than 50% of cases.在这个时期， 50%以上的病例还出现高血压。30300 毫克17After several years, most diabetic patients exhibit diffuse glomerulosclerosis, although aminority have pathognomonic Kimmelsteil-wilson nodular lesions .exhibit 展示、陈列diffuse 扩散、传播glomerulosclerosis 肾小球硬化症pathognomonic特

98、异病征性的数年以后，大多数糖尿病病人显示广泛的肾小球硬化，尽管只有少数病人有特征性的Kimmelsteil-wilson小结。Although pathologic changes continue to mountthroughout the disease, glomerulosclerosisextensive enough to cause ESRD develops in a minorityof patients; in these cases, overtalbuminuria (300 mg/day) begins approximatedly 15 years after d

99、iagnosis.overt明显的、公然的虽然病理变化在整个病程中是持续发展的，以引起晚期肾病，这些病例中，明显的白蛋白尿（但只有少部分病人的肾小球硬化范围大到足300mg/天）大约在诊断后15 年开始。Soon after, followinga variable period on the order of 3 to 5 years, the GFR begins arelentless decline ( 10 ml/min/year),which is eventually reflected by an increase in serumcreatinine.on the order

100、 of属于 一类的、与 相似的relentless残忍的、不留情面的10 毫升 /之后，接着一个不确定的时期，约需35 年，肾小球滤过率开始极度下降（分/年），最终以血清肌酐浓度增高而表现出来。The appearance of massive proteinuria and the nephrotic syndrome is common in this contextand often heralds progression to ESRD.nephrotic syndromeherald的形成。肾病综合症context环境、背境、上下 文进行、前进、进展并且常预示着晚期肾病传令、预示、预

101、报progression病变发展到这个程度，出现大量蛋白尿和肾病综合症是常见的，Once the serum creatinine rises (reflectingan approximately 50% decline in GFR), ESRDdevelops in most patients within 10 years.potentially潜在的、可能的肾病。This course is highly variable, houever, particularlyin type 2 diabetics, who may exhibitmoderate proteinuria fo

102、r several years without a substantial deterioration of renal function.deterioration变化、退化、恶化特别是 2 型糖尿病， 可以出现多年的中等蛋白尿而不但是， 这个过程是非常不确定的，发生实质性的肾功能恶化。inaccessible 达不到的、难接近的一旦血清肌酐浓度增高（反映肾小球滤过率约下降50%），多数病人 10 年内发展成晚期A simple but useful method of monitoring progression to renal failure is to plot the recipr

103、ocalof the serum creatinine as a function of time.plot小块地皮、地基、用图标出、阴谋reciprocal相互的、倒数、互补18一个简单而实用的肾功能衰竭进展的监测方法是用图表记肌酐清血录的倒数作为当时的肾功能。This technique allows better assesssment of both therapeutic interventions and the time whenrenal replacement therapy will become necessary.这个技术使治疗性干预和肾移植时机的判断更为准确。Chap

104、ter 41Diagnosis of Sudden Cardic Death(SCD)心源性猝死的诊断第 118 页Page 118第四十一章SCD is death due to instantaneous, unanticipated circulatory collapse within 1 hour of initialsymptoms and is often, but not always, due to a cardiac arrhythmia.instantaneous失常致。瞬间的、即刻的、即时的unanticipated不曾预料到的常是，但不全是心律心源性猝死是指出现初始症

105、状1 小时内预料不到的循环衰竭死亡，More than 70% of all sudden natural deaths have a cardiac cause, and 80% of these areattributable to coronary artery disease.attributable可归于 的70%以上的自然猝死有心脏的原因，心脏原因中80%跟冠状动脉疾病有关。In assessing prognosis and planning a treatment strategy, it is useful to classify SCD as eitherprimary (

106、without a clear trigger) or secondary.strategy策略、战略trigger触发、引起在估计预后和制定治疗方案时，将心源性猝死分为原发性性是实用的。（无明确的诱发因素）或继发A primary episode has a 10 to 30% 1-year recurrence rate, whereas most secondary episodesare associated with recurrence rates of less than 2%.episode一段情节、插曲、有趣的事associated with联合2%。原发性发作的在1 年内有

107、 1030%的复发率，而大多数继发性的复发率小于Identifiable reversible precipitants of secondary ventricular fibrillation (VF) include transientischemia possibly related to vasospasm; hypokalemiaresultingfromdiuretics; hyperkalemiasecondary to renal failure, angiotensin-converting enzyme inhibitors, prostaglandin inhibito

108、rs, orpotassium-sparingdiuretics;proarrhythmiasecondarytoantiarrhythmics,antihistamines; or substance abuse with drugs such as cocaine and amphetamines.identifiabletransienthypokalemiaprostaglandinproarrhythmiaantihistamineabuse可确认的短暂的、瞬时的低钾血症前列腺素抗组织胺类amphetamine安非他明、苯异丙胺angiotensin-converting enzym

109、e 血管紧张素转酶化sparing节俭的、保守的tricyclic三环的、三环分子reversible可逆的precipitant仓促的、突然的tricyclics,and致心律失常作用滥用、陋习19已知的可逆性继发性心室颤动（VF）的发作包括可能是血管痉挛性的短暂缺血；利尿或可卡因剂引起的低钾血症；肾功能衰竭、血管紧张素转化酶抑制因子、前列腺素抑制因子、或保钾利尿剂所致的高钾血症；抗心律失常药、三环类药和抗组胺类药引起的心律失常；或安非他明类药物的滥用。Therapy is directed toward removing or treating the acute precipitant.

110、removing消除治疗是直接消除或处理急性触发因素。SCD related to acute ischemia in the absence of prior MI often is associated with severeproximalocclusive disease, normal left ventricular function, normal signal-averaged ECG, andnoninducibility absence of ventricular tachycardia (VT) during electrophysiologic study.MImyo

111、cardial infarction心肌梗死average平均inducibility可诱导的这种病缺乏心肌梗死前兆的急性缺血性心源性猝死经常与严重的近端梗阻性疾病有关，人左心室功能正常， 心电图信号普通无殊， 电生理研究时无法诱异室速（室性心动过速缺乏） 。Most patients should undergo comprehensive evaluation of myocardial function and coronaryanatomy.undergo经历、忍受comprehensive 全面的、广泛的、能充分理解的大多数病人应该进行全面的心肌功能评价和冠状动脉解剖结构检查。Ech

112、ocardiography is useful for excluding hypertrophic cardiomyopathy and valvularheartdisease; magnetic resonance imaging, for diagnosing arrhythmogenic right ventricular dysplasia;and myocardial biopsy, for identifyinginfiltrativediseases such as myocarditis, amyloidosis,hemochromatosis, and sarcoidos

113、is.echocardiography 超声心动图hypertrophic cardiomyopathydysplasiainfiltrativeamyloidosissarcoidosis肥厚性心肌病magnetic resonance imaging磁共振发育异常、结构异常渗透性的、浸润性的淀粉样变血色素沉着磁共振对有心律失常性右室发淀粉样变、 血色素沉着症和结节结节病hemochromatosis超声心动图对排除肥厚性心肌病和瓣膜性心脏病很有用；育不良症的诊断很有用；心肌活检对浸润性疾病如心肌炎、病很有用。Coronary angiography should be performed

114、to assess for the presence of coronary occlusivedisease and to exclude coronary artery anomalies.应该进行冠状动脉血管造影评估冠脉阻塞性疾病的存在并排除冠脉的结构异常。Myocardialperfusion scintigraphyprovides complementarydata for assessing ischemicburden.20myocardial perfusion scintigraphy心肌灌注闪烁照相术心肌灌注闪烁照相术对缺血程度估计可提供辅助资料。Leftventricu

115、larfunctioncan be assessed bycontrast ventriculography,radionuclideventriculography, or echocardiography.ventriculography心室造影术radionuclide ventriculography放射性核素心室显像术通过对比心室造影、同位素心室造影或超声心动图可以评价左心室功能。Evaluationof SCD survivors also includes Holtermonitoringand/or electrophysiologictesting.Holter monito

116、ring动态心电图监护仪/或电生理测试。对心源性猝死生还者的测试还包括动态心电监护和The ElectrophysiologicalStudy Versus ElectrocardiographicMonitoring(ESVEM)trialshowed, however, a 50% 2-year recurrence of ventricular tachyarrhythmias in patients in whomantiarrhythnmic drugs successfully suppressed PVCs.ventricular tachyarrhythmias室性快速型心律失

117、常PVCspremature ventricular contraction室性早搏但是， 电生理激发加动态心电监测试验显示，人 2 年内 50%复发快速型室性心律失常。These data suggest a dissociation between PVC suppression and recurrence of VT; PVCs mayrepresent a marker ofleftventriculardysfunctionratherthan a triggerof SCD,or thearrhythmogenic substrate may change over time.d

118、issociation分裂、分离substrate底层、底物、基础室早可能是代表左室功或心律不齐的基础病因可能因时间而改这些资料提示室性早搏的控制和室性心动过速的复发是无关的；能紊乱的一个信号，而不是心源性猝死的触发因素，变。InSCDsurvivors,sustainedmonomorphicventriculartachycardiaisinduciblebyelectrophysiologictesting in 40 to 50% and polymorphicVT in 10 to 20%; in 30 to 50%,nosustained arryhthmia is induced

119、.sustaine持继不变、相同、维持monomorphic单一同态的、单形的1020%在心源性猝死生还者中，4050%电生理试验能诱导持续单一型室性心动过速，3050%不能诱导持续的节律异常。用抗心律失常药物成功控制的室性早搏病能诱导持续多型的室性心动过速，In patients withischemic heart disease and left ventriculardysfunction,inducibilityofsustained VT carries a poor prognosis.在伴有缺血性心脏病和左室功能不全的病人中，能诱导持续室性心动过速的预后不良。A low eje

120、ction fraction is associated with a poor prognosis, however, regardless of whethersustained VTis inducible;patients withan ejection fractionof 30% or less and who arenoninducible have a 25% arrythmia recurrence rate at 1 year, whereas noninducible patients withan ejection fraction greater than 30 ha

121、ve a 10 to 15% recurrence rate.21ejection fraction射血分数不管持续室性心动过速是否能诱导，射血分数30%30%的不能诱导者只但是， 不良预后与低射血分数有关，有 1015%的复发率。以下的不能诱导者1 年时有25%的心律失常复发率，而射血分数大于In patients with SCD and idiopathic dilated cardiomyopathy, sustained monomorphic VT israrely induced.idiopathic导。Neither the inability to induce VT nor

122、 the ability of drugs to suppress inducible polymorphicVT or VF is a predictor of a favorable outcome.administer 执行，实施normotensive血压正常不能诱导室性心动过速不是，用药物能控制的可诱导多形态的室早和室颤也不是良好预后的信号。先天的、初发的、突发的患有心源性猝死和先天性扩张性心肌病病人中，持续单一型室性心动过速几乎不能诱Chapter 4 Palliative care and hospice of dying patients 临终病人的姑息治疗和临终关怀State

123、-of-the-art end-of-lifecare is synonymous with palliativecare, a term describingcomprehensive (physical, psychosocial, and spiritual), interdisciplinary services that focuson alleviating suffering and promoting quality of life for patients and their families facinga life-threatening or terminal illn

124、ess.State-of-the-art 最高级的end-of-life 终末期Synonymous 同义的，同类的Disciplinary 学科的inter- 相互的(生理、社会心理和精神姑息性治疗是指终末期病人的临终关怀，是一种全面多学科量。The term palli ative literallymeans “ toclock ” and can be used derisivelyto describemeasures that merely cover up a problem, but the term has become widely accepted as adescrip

125、tion of approaches to providingcomfortfor dying persons without necessarilymodifyingthe underlyingmedicalcondition(e.g.,reducingpainordyspnea frommetastatic lung cancer without affecting the tumor burden).Derisively ：嘲笑的，嘲弄的从字面上理解，palliative 是指时钟，通常用来讽刺仅表面掩盖问题的措施，但该词常被广泛地用来描述针对垂死病人采取的减轻痛苦，而不改变其基础疾病状

126、态的方方面 )交互的服务，旨在针对频临死亡或终末期病人或家属以减轻病痛提高生活质22法（如针对转移性肺癌采取镇痛和减轻呼吸困难而不去影响肿瘤负荷）Many aspects of palliative care, as with any specialty, are relevant to the general practiceof medicine and to all clinicians who tend to dying persons.relevant to 有关的姑息性治疗的特性通常与药物治疗和所有治疗临终病人的医生相关的。Palliative care has a role in

127、 the earliest phases of a life-threatening illness but assumes amore prominent or even dominant role in the final 3 to 6 months of common terminalconditions: advanced cancer, heart and lung failure, end-stage liver and renal disease,acquired immunodeficiency syndrome, and life-limiting neurologic di

128、seases.Prominent 显著的，突出的姑息性治疗可以用于临终病人的早期治疗，但其最重要和突出的使用是针对终末期的最后 3 至 6 个月时间 :如患有晚期癌症、心肺衰竭、晚期肝肾疾病，艾滋病和致命的神经系统疾病的病人。Hospice programs offer a widely recognized form of palliative care in the United States.Hospice in the United States refers to a specific, government-regulated form of end-of-lifecare, fi

129、rst available under Medicare but then adopted by Medicaid and many third-partyinsurers.美国临终关怀计划提供了一系列经过广泛认可的姑息性治疗方案。美国的临终关怀是指政府管理的专业性终末期治疗系统，初期在医疗机构治疗，尔后可转医疗互助机构或第三方保险机构。Hospice care typically is given at home or in a nursing home-less commonly in an acutecare hospital or specialized acute care unit

130、-and is provided by an interdisciplinary team,whichusuallyincludesaphysician,nurse,socialworker,chaplain,volunteers,bereavement coordinator, and home health aides, all of whom work with the primary carephysician, patient, and family.Interdisciplinary 各学科的Chaplain 牧师Bereavement 丧亲临终关怀通常是在（病人）住所或家庭护理中

131、心进行，而不是紧急医护医院或特殊的急症监护病房，实施临终关怀的人员包括相关学科的团队，通常有医生，护士，社会工作者，牧师，自愿者，负责丧葬组织和家庭医生，这些人与初级护理人员、病人和家庭形成了临终关怀团队Bereavement services are offered to the family for a year after the death.丧亲服务可以延续至病人死后一年的时间。Hospice regulation in the United States require that a patient agree to forgo measures withcurative inten

132、t and focus on comfort.美国临终关怀的规定要求病人必须同意放弃治疗意向，而关注（死前的）安慰。Althoughhospiceprograms varyintheirpolicies,many“ aggressivee”xp,ensiveinterventions,suchas surgery,radiationtherapy,totalparenteralnutrition,andtransfusions, tend to be excluded.虽然临终关怀项目政策各异，但是一般不包括许多超常规的，昂贵治疗，如外科手术，放射治疗，全胃肠营养和输血。To many pat

133、ients and families, hospice seems to signify “ givingup” ,rather than beingviewed as a model of compassionate care and of making the best of a situation with23limited options.Compassionate 同情，怜悯对很多病人和家庭来说，临终关怀更像一种“放弃”，而不是怜悯和在有限选择最好结果的手段。Also, to be eligible for a Medicare-certified hospice program,

134、the primary physician mustcertify that the patient is likely to die within 6 months if the illness runs its usual course.Eligible 合适的同时需要注意的是，一个经过医疗机构认可的临终关怀计划只适用于经初诊医生按照疾病常规转归确定，只有6 个月以内的生存期的病人。No penalties exist, however, for referring a patient too early to hospice, and physiciansgenerally use ho

135、spice care much later in the course of an illness than appropriate.但是，如果一个病人过早进行临终关怀，其损失是无法弥补的，因此临终关怀通常比正常时机会推迟很多。Another option is palliative care in inpatient units, which are furnished in a homelikefashion; are quieter than the typical noisy hospice ward; are decorated with personallyimportant ob

136、jects from each patient; and typicallylack, minimize,or obscure hospitalparaphernalia.Paraphernalia 个人用品姑息治疗最好的选择是在装修成家庭风格的住院病区进行以避免过多的嘈杂，通常应使用病人个人重要物品进行妆点，而尽量避免、减少过多的医院风格。Patients are encouraged to wear their own clothes, pets are allowed, and families(includingchildren)have unlimitedvisitingprivil

137、egesand are encouraged to stayovernight and to cook there or bring food.鼓励病人穿着自身衣服，允许携带宠物，家庭成员（包括孩子）有无限制的探视特权，鼓励他们夜间陪护，提供烹调设施或允许携带食物。Chapter 22Shortness of Breath“ shortnessof breath ” “ , afeeling of not being able to get enough air ” a,nd “ laboredbreathing” are all terms used by patients to descr

138、ibe the symptom of dyspnea.“气促”不“能呼吸足够空气 ” 和“用力呼吸 ”是病人描述呼吸困难症状时常用的词。Dyspnea 呼吸困难The cause of dyspnea may be pulmonary disease, circulatory disease, or both.呼吸困难的原因可能是肺部疾病，循环系统疾病或者两者并存。Pulmonary 肺的Circulatory 循环It is the physicianressponsibility to define the causative mechanisms of shortness ofbreat

139、h so that diagnostic techniques and therapies can be directed appropriately.医生应该明确气促的病因以便采用合适的诊断方法和治疗。The most consistent correlate of the symptom of dyspnea is increased mechanical work ofbreathing, usually brought on by increased airway resistance as occurs in asthma, chronicbronchitis,and emphyse

140、ma, or decreased distensibilityofthe lungs as occurs ininterstitial fibrotic reactions.24导致呼吸困难症状最大可能是呼吸机械阻力增加，通常可见的是哮喘、慢性支气管炎和肺气肿导致的气道阻力增加或者由于间质纤维化反应导致的肺膨胀性降低。Consistent 连贯的，一致的Distensibility膨胀性interstitial fibrotic reactions间质纤维化反应In the latter disease, increased effort is required to produce a hi

141、gher negative pressure inthe pleural space to inflate the lungs.间质纤维化反应病人需要更大的努力使胸腔负压增加才能保证肺部充气。pleural space 胸膜腔Inflate 充气The increased mechanical work done on the lungs to overcome obstruction to airflow ordecreased distensibilityis perceived as an increased effort to breathe and produces thesympt

142、om of dyspnea.用来克服气道阻塞和膨胀性降低的机械原理的增加就表现出呼吸费力和困难的症状An increased drive to ventilate may also cause dyspnea. Such stimuli include hypoxia,usually when arterial oxygen tensions are less than 60 mmHg, and stimuli from inflamedlung parenchyma, as occur in bacterial pneumonia or alveolitisand that drive th

143、erespiratory centers of the brain.Ventilate 通气Hypoxia 缺氧arterial oxygen tensions 动脉血氧张力通气需求的增加也会导致呼吸困难。这类刺激包括了缺氧，通常动脉血氧张力低于60mmHg, 或者见于细菌性肺炎或者肺泡炎导致的肺实质炎症促使脑部呼吸中心增加通气需求。These stimulioften lower the resting carbon dioxide pressure (Pco2) to less than thenormal level of 40 mmHg and cause dyspnea, espec

144、ially on mild exertion.尤其在轻度体力负荷情况下，这些刺激通常使静止二氧化碳压力（常的 40mmHg 以下。Patients with pulmonary emboli may present with shortness of breath and a normal chestroentgenogram.chest roentgenogram.胸部 X 线片肺栓塞病人也可能出现气促，但是胸部X 线片表现正常。However, the inefficiencyof the embolized lung for gas exchange, characterized by

145、anenlarged deadspace, requires abnormally high ventilatoryrates to maintain a normalarterial Pco2.但是肺栓塞使死腔扩大，气体交换不充分，从而需要高频率的通气以保证动脉维持在正常水平。Unless this particular presentation of pulmonary embolism is appreciated, embolic diseasegoes unrecognized in many patients until they suddenly die or are extre

146、mely incapacitatedby pulmonary hypertension and right ventricular failure.除非有特殊的临床表现，很多肺栓塞病人很难发现直至出现突然死亡或者由于肺性高血压或右心室衰竭而导致的极度功能障碍。Because of the high prevalence of heart disease and heart failure in the general population,many patients with dyspnea have cardiac abnormalities.Pco2Pco2）降低在正25由于心脏疾病和心衰

147、的高发，很多呼吸困难的病人有心功能的异常。The basis of the dyspnea is usually a high fillingpressure of the left ventricle, whichcuases high left atrial pressures and high pulmonary capillaryand pulmonary arterialpressures, whichinturnincrease the pulmonarybloodvolumeand reduce lungcompliance.呼吸困难的基础通常是左心室充盈压增高导致肺毛细血管和肺

148、动脉压的增加，从而肺血流量提高，肺顺应性降低。If the pulmonary capillary wedge pressure is in the range of 25 mmHg, capillary fluidtransudates into the pulmonary matrix, thereby reducing lung compliance, increase thework of breathing, and causing dyspnea.如果肺毛细血管楔压在25mmHg 左右，毛细血管液就会漏出至肺基质，从而降低了肺顺应性，导致呼吸用力增加，引起呼吸困难。Echocard

149、iography is usually diagnostic of abnormal ventricular or valvular function andshould be performed in any patient in whom the cause of dyspnea is not readily apparent.超声心动图通常被用来诊断心室和瓣膜异常，对任何呼吸困难病因不明确的病人均可采用。Chapter 25 Cancer of Unknown Primary Origin 原发灶不明的肿瘤阅读提示：本篇篇名为原发灶不明的肿瘤。以转移性病灶为首发症状的恶性肿瘤在临床上时有

150、发生，而其中一部分的原发肿瘤是难以检测到的。本篇主要介绍原发灶不明肿瘤的定义、病因、发病率以及临床和病理学上的评估等。DefinitionThe first signs or symptoms of cancer are frequently due to metastases to visceral or nodalsites.Metastases 转移Visceral 内脏肿瘤首发症状和体征通常是由于脏器或淋巴结转移引起的。In most such patients, routine clinical evaluation with a comprehensive history, phy

151、sicalexamination, complete blood cell count, screening chemistries, and directed radiologicevaluation of specific symptoms or signs identifies the primary tumor.对此类病人，需要进行常规临床检查和全面的病史回顾、体格检查、全血计数、生化筛查和对特定症状体征进行放射学检查以确定原发病灶。Patients who have no primary tumor located after this routine clinicalevaluat

152、ion aredefined as having cancer ofunknown primary site.经过常规临床检查后不能发现原发病灶的被称为原发灶不明的肿瘤。Further clinical and pathologic evaluation willidentify the primary site in only a smallminority of patients, and about 80% will never have a primary site identified during theirsubsequent clinical course.仅有小部分病人经过进

153、一步的临床和病理检查可以确定原发病灶，约后续的临床诊疗中无法确定原发病灶。EtiologyInpatients whose primarysite ofcancer remains undetectable,the primarysite80%的病人在26presumably has remained small or, less likely, has regressed spontaneously.Etiology 病因Spontaneously 自发的原发病灶不明的（肿瘤）患者，其原发病灶有可能处于早期，或者也有极少可能已经自行退化。Large autopsy series before

154、 the routine use of computed tomographic scans or magneticresonance imaging identifiedsmall primary sites of cancer in 85% of patients withpreviously unidentified primary tumors, usually in the pancreas, lung, and various othergastrointestinal sites; with current use of computed tomography and magne

155、tic resonanceimaging, however, autopsy series have identified primary sites in only 50 to 70% ofpatients.Autopsy 尸检在 CT 和 MRI 被常规使用之前， 尸检可以发现85%先前未能确定早期原发肿瘤病灶，通常位于胰腺、肺和不同的胃肠道部位；进行的原发病灶可以通过尸检确定。IncidenceAbout 3% of all patients with cancer have metastatic diseases without a known primarysite, account

156、ing for about 50000 to 60000 cases per year in the United States.大约有 3%癌症患者有转移病灶而原发灶不明，美国每年约women, and it increases in incidence with advancing age.原发灶不明肿瘤发病率男女性差别不大，发病率伴随年龄增长而增长。Clinical and Pathologic EvaluationSince all patients with cancer of unknown primary site have advanced disease, therapeut

157、icnihilism has been common.Nihilism 虚无主义，极端怀疑论由于原发灶不明肿瘤病人往往为晚期病人，治疗效果往往受到质疑。However, it is now evident that this heterogeneous group contains subsets of patients withwidelydiverse prognoses; some cancers are highly responsive to treatment, and somepatients may have a substantial chance of achieving

158、long-term survival with appropriatetreatment.heterogeneous 异型的，异质的Prognose 预后Substantial 真实的，实在的但是，现在比较明确的是这类特殊患者的预后差别很大，一些癌症患者对治疗高度敏感，也有部分患者通过适当治疗生存期很长。The initialclinicaland pathologic evaluation should therefore focus on identifyingaprimary site when possible and on identifyingpatients for whom s

159、pecific treatment isindicated.因此临床和病理检查的出发点应当时寻找原发病灶和识别对特殊治疗有效的患者。In the majorityof patients withcancer of unknownprimarysite, the diagnosis ofadvanced cancer is strongly suspected after the initial history and physical examination.通过初期的病史和体格检查，会得到大部分原发病灶不明的癌症患者的原发肿瘤线索。5 万至 6 万例。Cancer of unknown pr

160、imary site occurs with approximately equal frequently in men andCT 和 MRI 检查以后，仅有50%-70%27A brief additional evaluation, including complete blood cell counts, chemistry profile, andcomputed tomography of the chest and abdomen should be performed.也可以采取附加的检查，如全血细胞计数、血生化和胸腹部and endoscopic studies.另外也可采用

161、合适的放射学和内镜也确诊特殊的症状和体征。If a primary site is located, management should follow guidelines for the specific canceridentified.如果能确定原发病灶， （下一步治疗）应参考原发癌症的治疗指南。In patients with no obvious primary site, the most accessible metastatic site should bebiopsied.如果原发病灶不明确，应对最容易获得的转移病灶进行活检。Fine needle aspiration ma

162、y or may not provide sufficient material for optimal histologicexamination and special pathologic procedures.细针穿刺获得的组织可能无法满足足够的组织学检测和特殊的病理诊断。If tissue is inadequate, a larger biopsy sample should be obtained so that all necessarystains and procedures can be performed.如果组织量不足，为了进行必要的染色和诊断必须取得足够的活检标本。

163、CT。In addition, specific symptoms or signs should be evaluated with appropriate radiologicChapter 28Surgical complicationsPostoperative surgical complications represent one of the most frustrating and difficultoccurrences experienced by surgeons who do a significant volume of surgery.Frustrating 无效的

164、，挫折的外科术后并发症是经验丰富的外科医生最困扰和最难对付的困扰之一。Regardless ofhowtechnicallygifted,bright,and capable a surgeon is,surgicalcomplications are a virtually guaranteed aspect of life.Virtually 事实上不管外科医生有多大的能力，技术高超，聪明智慧，外科并发症也很难免。The cost of surgical complications in the United States today runs into millions of dolla

165、rsand is associated withlost workproductivity,disruptionof normal familylife, andunanticipated stress to employers and society in general.当前美国的外科术后并发症浪费了无数的金钱，同时导致劳动能力的丧失，正常家庭生活的破坏，而且为雇主和社会带来了无法预料的压力。Frequently, the functional results of the operation are compromised by complication; insome cases, t

166、he patient never recovers to the preoperative level of function.通常术后并发症影响了手术的效果，某些病人无法恢复到术前的功能状态。The most significantand difficultpart of complications is the suffering borne by thepatient who enters the hospital anticipating an uneventful operation but is left sufferingand compromised by the compli

167、cation.最严重和难对付的并发症就是看到那些本以为进行安全性很高的手术，结果却导致28了术后的痛苦和并发症。Complications can occur for a variety of reasons.外科并发症的发生有多种原因。A surgeon can perform a technicallyperfect operation in a patient who is severelycompromised by the disease process and still have a complication.有时，外科医生手术技术上非常成功，但病人的病情严重可导致并发症的发生。

168、Similarly, a surgeon who is sloppy, is careless, or hurries through an operation can maketechnical errors that account for the operative complications.同样，手术中医生的马虎、粗心或仓促都可以导致技术上的错误从而导致手术并发症Finally,the patient can be doing wellnutritionally,have an operation performedmeticulously, and yet suffer a com

169、plication because of the nature of the disease.即使病人营养状况良好，手术也很成功，疾病本身也可导致并发症的产生。processes-something with which all surgeons will be required to deal.手术后并发症的可能性是每一个外科医生考虑治疗计划的一个组成部分，因为所有外科医生都将面临这些并发症中的一部分。Surgeons can do much to avoid complicationsby the careful preoperative screeningprocess.外科医生可以在术

170、前进行精心筛选以避免术后并发症。When the surgeon sees the potential surgical candidate the first time, a host of questionscome to mind, such as the nutritional status of the patients and questions about the healthof the heart and lungs.a host of 许许多多，一大堆当外科医生第一次见到即将手术的病人时，需要考虑很多问题，如这个病人的营养状况或者心肺功能是否正常。The surgeon w

171、illmake a decision regarding performingthe correct operation for theappropriate disease.外科医生需要为病人作出正确的手术方式选择。Similarly, the timing of the operation is often an important issue同样的，手术时机也是一个重要的因素。Some operations can be performed in a purely elective fashion, whereas others have someurgency about an exp

172、editious surgical solution.Expeditious 迅速地，敏捷地一些手术可以择期进行，而有些可能需要进行急诊手术。Occasionally, the surgeon will demand that the patient lost weight before the operation sothat the likelihood of a successful outcome is improved.有时候，外科医生会要求病人术前减轻体重以提高手术的成功率。Occasionally, the wise surgeon will request preoperati

173、ve consultation from a cardiologistor pulmonary specialist to make certain that patient will be able to tolerate the stresses ofa particular procedure.有时，明智的外科医生会请心脏或呼吸系统专家进行术前会诊以确定病人是否能耐受特定手术。Thepossibilityofpostoperativecomplicationsisa partofeverysurgeon sthought29Chapter 30Chapter 30Page 78Page

174、78?Epidemic influenzaEpidemic influenzaAn epidemic is an outbreak of influenza confined to one geographic location. In a givencommunity, epidemics of influenza A virus infection often have a characteristic pattern.They usually begin rather abruptly, reach a sharp peak in 2 or 3 weeks, and last 6 to

175、10weeks. Increased numbers of schoolchildren with febrile respiratory illness are often thefirst indication of influenza in community.?流行性感冒是指局限于一个地理区域中的感冒的爆发。发生在一个特定社区的流感通常具备一个特征型。它们开始阶段非常突然，在6-10 周。在校生患发热性呼吸道疾病数量的增多往往是流感在社区开始传播的指征。A 型2-3 周后达到顶峰，并持续?This indication is soon followed by illnesses amo

176、ng adults and about a week later byincreasedhospitaladmissionsofpatientswithinfluenza-relatedcomplications.Hospitalizationrates in high-riskpersons increase two-to fivefoldduringmajorepidemics.School and employmentabsenteeism increases, as does mortalityfrompneumonia and influenza, especially in old

177、er persons. The latter findingis a highlyspecific indicator of influenza activity.?此标志之后就是成年人群内疾病的蔓延和大约一周后增多的患流感相关病症的住院病人。高危人群的住院率在规模较大的流行病期间可达平时的活动期的特异性标志。2-5 倍。旷课和旷工现象增多，同样的，死于肺炎和流感的人增多，尤其是老年人。后一个发现是流感?Epidemics occur almost exclusively during the winter months in temperate areas, butinfluenza act

178、ivity may continue year-round in the tropics. Outbreaks may occur in tourgroups (land or ship) and in facilitiesduring summer months, particularlyafter theappearance ofa driftvariant. Regionaldifferences inthe time and magnitude ofoccurrence of influenza outbreaks are common. During epidemics, the o

179、verall attack ratestypically average 5 to 20% in adults.?流感几乎总是毫无例外地发生在温带冬季的几个月当中。但流感活性可以在热带持续达整年。夏季中的旅行团体(陆地或者船舶)或其它场所里也可能爆发流感，尤其是在漂移变异出现以后。流感暴发的发生在基于时间以及严重程度上的地域差异是普遍的。通常流行期间典型的成人侵袭率为百分之五到二十。?Attack rates of 40 to 50% are not uncommon in closed populations, including those inhospitals and nursing

180、homes, and in certain highly susceptible age groups. Two differentstrains within a single subtype, two different influenza A subtypes(H1N1 and H3N2), orboth influenza A and B viruses may cocirculate. In addition, simultaneous outbreaks ofinfluenza A and respiratory syncytial viruses have been found.

181、?在封闭式人群中，侵袭率达到45-50%并不罕见， 包括那些住院的和居家的病人以及特定的高度易感年龄组。单一亚型里边的两个毒株，两种流感A 型病毒的亚型H1N1和 H3N2 ，或者 A、B 两种病毒的复合传播。此外，也发现有道合胞体病毒同时爆发的情况. s epidemic are sometimes responsible for theA 型流感病毒和呼吸?Strains circulating at the end of one seasonnext season s outbreak (th-ecasloled herald wave phenomenon). Furthermore,

182、 other than30the association of influenza outbreaks with colder seasons, the factors that allows anepidemic to develop or those responsible for the tapering off of an epidemic when onlysome susceptible persons have been infected are unknown.?一个季度末流感的病毒株群的传播有时候是导致下一个季度流感暴发的原因（称为预示波现象） 。此外，除了流感与寒冷季节之间

183、的关系，（当只有一些易感人群患病时）的因素尚不清楚。?Pneumonia and influenza (P+I)- related deaths fluctuate annually, with peaks in the wintermonths. When such P+I deaths exceed the predicted number, it is due to influenza A oroccasionallyto influenzaBvirusor respiratorysyncytialvirusactivity.Althoughmortality is greatest d

184、uring pandemics, substantial total mortality occurs with epidemics.Over 85% of P+I deaths occur among persons aged 65 and older.?与肺炎和流感(P+I) 相关的死亡每年都在波动，冬季达到高峰。当尽管大流行的时候病死率最高，普通流行时候的病死率也非常可观。死亡发生于65 岁以上的人群。?Other cardiopulmonaryand chronic diseases also result in increased mortalityafterinfluenza ep

185、idemics, so that overall influenza-associated mortality is about two- to fourfold higher than P+I deaths.?流感流行之后，其它心肺疾病和慢性病同样导致病死率有所增高，以至于总体流感相关的病死率比P+I 导致的病死率高出2-4 倍。P+I 的死亡超过了超过 85%的 P+I预期数值，是由于A 型流感或者偶尔因为B 型或者呼吸道合胞病毒的活动性所致。导致流感暴发或者流感减少Chapter 35Chapter 35Principles of ordering imaging testsPrinci

186、ples of ordering imaging tests?As a general rule, when confronted with two reasonable alternatives, it is advisable tochoose the least expensive, safest, and least uncomfortable imaging examination first. Foracute right upper quadrant abdominal pain, ultrasonography is usually the procedure ofchoice

187、 because it is less expensive than CT, primarily because the imaging equipment ischeaper.?面临两种合理的供选方案的时候，一个普遍的原则是明智地将最低廉、最安全、最舒适的检查方法做为首选。对急性右上象限的腹痛，超声波检查通常是首选的，因为它比 CT (Computerized Tomography) 检查要经济，这主要是因为它的设备更便宜。?Although ultrasound is more subjective and operator dependent than CT, ultrasound ca

188、nyieldexquisite visualizationof the biliarytree, includingthe gallbladderand thepericholecystic space, in which fluid can be a sign of acute cholecystitis. UItrasonographyalso confirms or denies the presence of gallstones in the gallbladder with high accuracythat at least equals that of CT, and ultr

189、asonography can detect biliary dilations and massesin the liver and pancreas.?尽管超声波检查显得更主观并且比CT 对操作人员的依赖性更强，但超声波可产生精美的胆道系统的图像，包括胆囊和胆囊周边部位，这些部位的液体可以作为急性胆囊炎的指征。超声波检查也可以高精度地确诊或者排除胆囊内结石，在这点上它的准确率至少和CT 持平。超声波检查可以探测到胆囊扩张以及肝脏和胰腺内的块状物。?Ultrasonography works well in the right upper quadrant because there is

190、little bowel gas,31which obscures underlying structures on ultrasound but not on CT, and the liver providesan excellent acoustic window for ultrasound visualization of the underlying structures.?Ultrasonography can be difficult and suboptimal in patients who are obese or who have adistendedabdomen.U

191、ltrasonographyisgenerallylessaccurate insurveyingtheremainder of the abdomen, an important issue when the pain is less localized.?超声波尤其擅长腹部右上象限的检查，因为这里肠道气体很少，这些气体会使底层结构在超声波下看起来含混不清，而在波下提供了极好的声窗。?超声波检查法很难用于检查肥胖或者腹部膨胀的病人，在这种情况下是不适宜采用的。超声波检查在检查腹部其余部位的时候通常缺乏精确性，而当疼痛较广泛的时候这就成为一个重要的问题。?How should the choi

192、ce between CT or ultrasonography be made in a patient who presentswith acute abdominal pain? More specifically, when is it appropriate to move directly toCT? In general, if the pain is not biliary in character, is not localized to the right upperquadrant, or occurs in an obese patient, CT is preferr

193、ed because it often reveals previouslyunsuspected abnormalities.?当遇到表现为急性腹痛的病人，什么时候应当直接去做CT？在 CT 和超声波检查之间该如何选择？更具体地说，CT 中却无此影响。肝脏的底层结构在超声通常来说，如果疼痛是非胆性的，并没有定位于右上象限或发生于肥胖病人，就更适合做 CT 检查，因为这时候往往提前揭示了难以预料的异常情况。At least three other imaging choices exist: (1) no imaging study; (2) a plain radiographicserie

194、s of the abdomen (technically and economically similar to the chest radiograph butgenerally not as useful); (3) MRI of the abdomen or pelvis(usually reserved for morecomplex situations or after failure to diagnose with other methods). Other than identifyingfreeintraperitonealair(perforatedviscus),ga

195、s patterns ofbowelobstruction,andradiodense ureteral calculi, the traditional abdominal series, although the least expensivetest, is considered generally inferior to CT and has been largely replaced by CT.?至少还有其它三种影像学选择存在：1.无影像学研究。2.普通 X 光腹部照相（技术3.腹部或骨盆MRI （magnetic resonance)。X 线的输尿管结上和成本上与胸片类似但并不那

196、么有用）?imaging）(通常预留用于较复杂的情况或者其它方法不能给出诊断时除了识别腹膜内自由气体(内脏穿孔时 )、肠梗阻的气体像以及不透石，传统的腹部照相虽然价格最低廉，代。?但与 CT 相比仍为次选， 并已大量为CT 所取A current-generation multislicehelical CT scanner can generate 5-mm sections of theentire abdomen and pelvis in about 1 minute. It is helpful to use oral and intravenouscontrast material

197、 to opacify (and identify) loops of bowel and vascular structures.?一台现阶段的多层螺旋面图。CT 可以在一分钟内为整个腹部及骨盆产生5 毫米间距的截通过口服或者静脉给予造影剂使得肠道的回路走形和血管结构变得不可通透从而易于辨认，对于CT 检查很有帮助。MRIcan be useful for the cooperative patient in renal failurewho cannot receiveintravenous contrast material because it can provide tissue a

198、nd vascular detail notachievable without contrast-enhanced CT. Patient cooperation is required because of thelonger imaging times and respiratory motion artifacts. MRIis also useful in specific32situations to image the biliary tree, liver parenchyma, and male and female pelvis.?在病人合作的情况下，磁共振对于无法接受静脉

199、造影剂的肾衰病人是有用的，因为它能提供组织和血管的细节，而这些细节不借助增强造影要长时间的成像以及呼吸运动伪差，病人的合作对于有用的。CT 就无法看到。因为需MRI 成像是有必要的。在一些特定情况下，MRI 对于胆道系统、肝脏实质以及男性或女性骨盆的成像检查同样是Chapter 43Chapter 43?prophylactic antibiotic therapyprophylactic antibiotic therapyProphylactic antibiotic therapy is clearly more effective when begun preoperatively a

200、ndcontinued through the intraoperative period, with the aim of achieving therapeutic bloodlevels throughout the operative period. This produces therapeutic levels of the antibioticagents at the operative site in any se roromas and hehematomas that may develop. Antibioticsstarted as late as 1 to 2 ho

201、urs after bacterial contamination are markedly less effective,and it is completely without value to start prophylactic antibiotics after the wound isclosed. Failure of prophylactic antibiotic agents occurs in part through a neglect of theimportance of the timing and dosage of these agents, which are

202、 critical determinants.?在手术前开始并在手术中持续达到治疗性血药水平预防性抗生素疗法是明确有效的。这可使手术区域达到对于可能出现的浆液性积液和血肿的治疗性抗生素浓度。细菌污染后1-2 小时开始应用抗生素其有效性会大大降低，而伤口闭合后进行预防性抗生素治疗已毫无价值。预防性抗生素治疗的失败部分归咎于忽略了时机和给药剂量的重要性，而这两点正是关键的决定性因素。?For most patients with elective surgery, the first dose of prophylactic antibiotics should begiven intraveno

203、usly at the time a anesthethesia is induced. It is unnecessary and may bedetrimenmental to start them more than 1 hour preoperatively, and it is unnecessary to givethem after the patient leaves the OR. A single dose, depending on the drug used andlength of operation, is often su ffi fficient. For op

204、erations that are prolonged, the prophylacticagent chosen should be given in repeated doses at intervals of one to two half-lives for thedrugs being used. It is never indicated to give prophylactic antibiotic coverage for morethan 12 hours for a planned operation.?对大多数择期手术的病人来说，预防性抗生素的首剂应当在诱导麻醉开始的时候

205、静脉给予。术前超过一小时给药没有必要甚至有害，病人离开手术室后也没有给予预防性抗生素的必要。依据药物种类和手术时间长短所给予的单剂量给药往往是足够的。对延长了时间的手术，应当在间隔1-2 个半衰期间重复剂量。对于计划内的手术，给予超过12 小时预防性抗生素是没有指证的。?There is no evidence to support the practice of continuing prophylactic antibiotics untilcentral lines, drains, and/or chest tubes are removed. There is evidence th

206、at this practiceincreases therecoveryrecovery of resistant bacteria.?没有证据支持预防性抗生素需要持续至中央静脉导管、引流管、和证据表明这样治疗会增高耐药菌的出现。/或胸管移除后。Many patients fail to receive needed prophylactic antibiotics because the system for theiradministration is complex at the time of multiple events just before a major operation

207、.This problem has been made worse by the trend of admitting patients directly to the ORfor planned operations, which intensifies the pressures to accomplish a large number ofprocedures during a short interval before the operation. The possibility that prophylactic33antibioticswillbe unintentionallyo

208、mimitted can be minimized by establishing a systemwith a checklist.?许多病人没有给予预防性抗生素，这是由于在一个主要手术前的多种事件中的管理系统是复杂的。由于允许病人直接去手术室进行计划内的手术的趋势使这个问题越来越严重，这加剧了手术前短时间内完成大量操作规程的压力。可以通过建立一个带有清单的系统来尽量减少预防性抗生素被无意识遗漏的可能性。?One member of the operative team(usually the preoperative nurse or a member of theanesthesia t

209、eam) should be responsible for initialing a portion of the operative record thatstates either that the patient received in indicated prophylactic antibiotics or that the surgeonhas determined that antibiotics are not in indicated for the procedure.?Manyantibioticseffectivelyreducetherateofpostoperat

210、iveSSIswhenusedappropriately for indicated procedures. No antibiotic has been reliably superior to anotherwhen each possessed a similar and appropriate antibacterial spectrum.?手术组中的一员（通常是术前护士或者麻醉组成员之一）应当负责完成手术记录当中的一部分，以阐明病人是否接受了指定的预防性抗生素或外科医生已经决定不采用抗生素。?在指定的进程中应用了恰当的抗生素后，多种抗生素有效地减少了术后手术部位感染的发生率，如果给予

211、的抗生素具有相似并适当的抗菌谱，无论选用哪种，其可靠性都无优劣之分。?inferior to superior toThe most important determinant is whether the planned procedure is expected to enterparts of the body known to harbor obligate colonic anaerobic bacteria (Bacteroidesspecies). If anaerorobic flora are anticipated, such as during operations on

212、 the colon ordistal ileum or during appendectomy, then an agent effective against Bacteroides species,such as cefotetan, must be used. Cefoxitinis an alternative with a dramaticallyshorterhalf-life. If anae rorobic flora are not expected, cefazolin is the prophylactic drug of choice.?最重要的决定因素是预防性给予抗

213、生素的治疗计划是否考虑到隐匿在结肠厌氧菌进入机体手术部位的可能。如果厌氧菌群是预料之中的，诸如结肠、远端回肠手术或者阑尾切除术，那么必须应用对抗拟杆菌属的抗生素如给药的备选药。?seroma 浆液肿hematoma 血肿elective surgery 择期手术OR（operating room ）手术室Resistant bacteria 耐药菌Antibacterial spectrum 抗菌谱Anaerobic 厌氧的Bactroides 拟杆菌属，类杆菌属Ileum 回肠Appendectomy 阑尾切除术Cefotetan 头孢替坦二钠Cefoxitin 头孢西汀Half-life

214、半衰期Cefazolin 头孢唑啉cefotetan 头孢替坦。头孢西丁可做为候选药，它的半衰期非常短。如果预计没有厌氧菌，头孢唑啉可做为预防34Chapter45Chapter45?Acute abdomenAcute abdomen decision to operatedecision to operatemake a decision to operate or not.These difficulties notwithstanding, the surgeon mustCertain indications for surgical treatment exist. For exa

215、mple, definite signs of peritonitissuch as tenderness, guarding, and rebound tenderness support the decision to operate.Likewise,severe orincreasing localizedabdominaltenderness shouldpromptanoperation. Patients with abdominal pain and signs of sepsis that cannot be explained byany other finding sho

216、uld undergo operation.?尽管有许多困难，外科医生必须决定是否手术。某些外科治疗的适应症是存在的。例如，具有腹膜炎的明确指征，如出现压痛、肌紧张、反跳痛支持手术的决定。同样地，严重的或者持续增强的局限性的腹部压痛应当立刻开始手术。有腹痛或者败血病表现的病人，如果不能用其他原因来解释，应当进行手术。?Those patients suspected of having acute intestinal ischemia should be operated on aftercomplete evaluation.Certain radiographicfindingsconf

217、identlypredict the need foroperation.These findingincludepneumoperitoneumand radiologicevidenceofgastrointestinalperforation.?PatientspresentingwithabdominalpainandfreeX 线征象可以intra-abodominal gas seen on radiograph warrant operation with limited exceptions.对怀疑有急性肠道缺血的病人，在完整的评估后应当手术治疗。某些现腹痛和X 光下可见腹内游

218、离气体的病人除很少的例外之外都需要手术。?Observation with serial examinations may be appropriate for a patient with free gas aftera colonoscopy. Intra-abdominal gas can persist fora day or two followingceliotomy.Imaging tests can reveal signs of vascular occlusion requiring operation.?对于结肠镜检查后产生游离气体的病人，的征象。?Aftercarefu

219、l examinationand evaluation,diagnostic uncertaintycan remain. Somepatients may have equivocal physical findings. When this occurs and the diagnosis isunclear and the patients wellness is unclear, it may be advisable to defer operation and tore-examine the patient carefully after several hours. This

220、is best done in a short-stay unitin the hospital, in a special unit in the emergency department, or if necessary, by regularhospital admission.?仔细的检查和评估后，仍可存在诊断的不确定性。有些病人可表现为模棱两可的体检结果。遇到这种情况及诊断不明确、病人的健康状态不明朗的时候，可以建议推迟手术并于几小时后仔细复查病人。这最好在医院的短期观察单元或急诊室的特殊单元内完成，如果必要也可以常规收纳住院。?In a period of hours, vague

221、 pain with minimal physical findings may proceed to definitelocalized pain with tenderness, guarding, and rebound tenderness; if that occurs, operationshould follow. After severalhours , the patient s symptoms and signs may also resolve.When that happens, the patient can be dismissed, although the p

222、atient should have afollow-upappointment scheduled withina day or so to permit re-examination to becertain that an important diagnosis was not missed.?在几个小时内，伴随极少体征的不确定的疼痛可能发展为明确的局限性疼痛伴随压进行一系列检查和观察是恰当的。腹内气体可以在剖腹探查后持续存在一两天。影像学检查也能够发现需要手术的血管闭塞明确地预测手术的必要性。这些结果包括气腹征和放射学上胃肠道穿孔的证据。出35痛、肌紧张和反跳痛，这时就应当着手进行手术

223、。，病人的症状和体征也可在数小时后消退，这种情况下，病人可以出院，但应在一天内进行随访性的复诊，以便进行复查以确定没有遗漏重要的诊断。?Certain patients are difficult to evaluate because of special characteristics. For example,patients who are neurologically impaired as result of stroke or a spinal cord injury may bedifficult to evaluate. Patients who are under the

224、influence of drugs or alcohol may requirespecial or subsequent examination.?一些病人由于特殊情况很难予以评估，例如，中风导致的神经系统受损或者脊髓损伤可以很难评估， 受到毒品或者酒精影响的病人也许需要特殊的或者进一步的检查。Patiens who take steroids or are otherwise immunosuppressed deserve special mentionbecause steroids and immunosuppression mask the intensity of abdomi

225、nal pain and thephysical findingsof severe, life-threateningintra-abdominaldisease. Patients in thiscategory who have persistent, unequivocal abdominal pain and even minimal findingsshould be considered for surgical operation.?服用类固醇或者其它采取其它免疫抑制方法治疗的病人应当特别关注，因为这些药物掩盖腹部疼痛的强度及严重的危及生命的腹腔内疾病的体征表现。这种类型的病人

226、若伴有持续并确定的腹痛，即使只有极少的体检发现，也应当考虑手术。?Some patients with clear findings of the acute abdomen may be treated without surgicaloperation. For example, patients withperperforated duodenal ulcer who seek attention late inthe course of their disease after they have been sick for several days may be treated bes

227、tby careful supportive care includingnasogastric suction, intravenous fluids, and painrelief.?一些有明确急腹症表现的病人也可能并不需要手术处理。例如在发病后数日才求医的十二指肠溃疡穿孔的病人，可以进行细心的支持治疗包括鼻胃管吸出、静脉输液和止痛。?Certain patients with empyema of the gallbladder, especially those with other seriousconcomitant illnesses, can be treated by per

228、cutaneous drainage of the infected gallbladderand careful supportive care rather than with cholecystectomy.?某些胆囊积脓病人，尤其那些有严重伴随病的病人，可以对感染的胆囊进行经皮引流并予以仔细周到的支持治疗，而不是胆囊切除术。Chapter47Chapter47?Approach to the patient with painApproach to the patient with painBelievethe patient cosmplaint ofpain.Despitedeca

229、des ofeffort,there isnoneurophysiologic or chemical test that can measure pain in individual patients. The mostpromising technique, functional brain imaging, so far shows only rough correlation withreports of acute pain and has been disappointing for chronic pain. Objective observationsof grimacing,

230、 limping, and tachycardia may be useful in assessing the patient, but thesesigns are often absent in patients with chronic pain caused by large structural lesions.?要相信病人疼痛的诉说。尽管经过数十年的努力，仍没有神经生理学或者化学检测方法能够测量病人个体化的痛感。最有希望的技术能粗略地显示与急性疼痛的相关性，-功能性脑成像，截至目前也只痛苦面容、而在慢性疼痛方面的表现令人失望。跛行和心动过速等客观的观察可能可用于对病人的评估，但这

231、些迹象在结构性损害导致的慢性疼痛病人身上可能并不出现。36?The clinician can acknowledge the patientstrong opioids or other particular types of treatment. s report of pain before understanding its cause.Acceptance of the patientreaslity of pain does not oblig ate the physician to provide?Clarify the temporal aspects of the pain

232、. The circumstances and speed on onset of the painnot only are pertinent to diagnosis, but also guide the choice of treatment methods whoseonset and duration of effect should correspond to the true cause of pain.?临床医生可在明确疼痛原因前得知病人疼痛的情况。认可病人的疼痛的真实性并不意味着医生需要给予阿片类强镇痛剂或者其它特殊类型的治疗。查明疼痛的时间特点。疼痛发生的环境和速度不仅与

233、诊断有关，也能指导治疗方法的选择，治疗方法的启用和效力持续的时间应和疼痛真实起因相一致。?Evaluate the response to previous and current analgesic therapies. The dose and durationof each previous treatment should be recorded. Optimal doses of the best medication for aparticular syndrome often produce gratifyingresults in patients who failed a b

234、rief trialwith lower doses.?评估病人对过去和当前使用的镇痛剂的反应。失败的病人中产生令人满意的结果。?Record the severity of pain and functional impairment with a measure simple enough forrepeated use. Extensive work in many diseases has shown that changes in a 0-to-10 scalefor pain intensity are valid and sensitive for detecting meani

235、ngful relief.?用一个可以重复使用的足够便捷的方法记录疼痛和功能性损害的严重程度。对许多疾病开展的大规模研究显示，感性上是有效的。?Pain-related functional limitations can be assessed either by using the patientchimportant activities or by asking the patient how much, on a 0-to-10 scale, pain hasinterfered with domains such as general activity, mood, walking

236、, work, relations withother people, sleep, and enjoyment of life.?疼痛相关的功能性限制可通过病人对重要行为的选择或者0-10 的分级法进行， 这个分级法是通过询问病人了解疼痛对他的影响范围分级的，包括对日常活动、情绪、行走、工作、与他人的关系、睡眠以及生活娱乐造成了多少阻碍。?Evaluate the psychologicalstate of the patient. Unrecognized depression and anxietydisorders are common in patients with chronic

237、 pain.病人心理学状态的评估。对慢性疼痛患者来说，未被认识到的抑郁和焦虑症非常普遍。Patients readily tell the clinicianabout these if asked, and these mood disorders arereadily treatable. The presence of suicidal thoughts and the painsexual activities should be assessed. It is often helpful to ask patients how they are copingin the face o

238、f the pain or what keeps them from giving up because these responsesidentify sources of strength on which the clinician can build.?如果病人乐于在医生问及时告诉医生这些表现，那么这种情感障碍也容易治疗。患者的自杀想法和疼痛对患者性活动的影响应当进行评估。询问患者如何面对疼痛或它们坚持的原因是很有用的，因为这些反应有助于临床医生判断疼痛的强度。?Develop a series of diagnosis-based hypotheses. Because pain m

239、ay result from disease at s将疼痛分级定为0-10 级对于评测疼痛和疼痛缓解的敏应该记录既往用药的剂量和持续时间。对这一特定的综合征，最合适的药物的最佳剂量往往可使在低剂量简单试验性治疗 s effect on the patient37the pain site or be referred from other parts of the body, it may be helpful to list all thepossibilities for the site of origin, particularly when the pain has been re

240、sistant to therapy.Persistent rib pain in a patient with metastatic cancer despite radiationtherapy to thelesion in that rib would raise the possibility of referred pain from thoracic epidural tumor,which can be imaged and treated. For each potential site of the lesion, the list of thecommon disease

241、 processes in that area can be considered.?做出系列假设诊断。因为疼痛可以来自疼痛部位的疾病或者源于机体其它部位的牵涉疼，那么罗列出疼痛原发部位的所有可能性就会有所帮助，尤其当疼痛对治疗无效时。 如肋骨转移性肿瘤病人出现持续的肋骨疼痛，损害部位，应该考虑列出该区域的通常的疾病列表。?Personallyreviewthe diagnosticprocedures. Inthe reevaluationof difficultpaindiagnoses, it is remarkable how often lesions had been missed

242、 previously on imagingprocedures, particularlywhenthe radio ologistwas not givena specificdiagnostichypothesis.?In patients withmultiplechronic symptoms that are unexplained despite a fulldiagnostic evaluation, consider the possibility of multisomatoformsomatoform disorder.诊断程序的个体回顾。在对疼痛诊断困难的案例的重新评估

243、中，常有发现先前影像学上的病变遗漏，尤其是放射医生没有给出诊断假设的情况下。有些患者的多种慢性症状在详细的检查评估后仍难以解释，要考虑多重躯体形式障碍的可能性。?This more recently proposed diagnosis, which applies to one tenth of primary care visits,is defined by the presence of three bothersome and unexplained complaints, some ofwhich have troubled the patient on most days in

244、the previous 2 years.?这个最近提出的诊断被定义为存在三个令人困扰并难以解释的症状，其中某些症状在过去的两年中的大部分的时间中困扰着患者，这发生于约十分之一的初诊患者中。 s specialty, many of these patientsDepending on the presenting complaint or the clinician而病变肋骨的放射治疗无效时，就增加了胸膜间皮瘤导致牵涉痛的可能性，而后者能够显像和治疗。对每种潜在的are said to have fibromyalgia, chronic fatigue, irritable bowel s

245、yndrome, idiopathic, lowback pain, or chronic tension-type headaches, but most of these patients have multisystemcomplaints.?这些病人会因为主诉的不同或医生的专业不同，而被告知患了纤维肌痛、慢性劳损、但多数这类病人有多系统症状。肠激惹综合征、 原发性的腰疼或者慢性紧张性头疼，Laboratory studies suggest that generalized amplificationof symptoms by the centralnervous system is

246、 common in these patients. Recognitionof multiso matmatoform disorderalerts the clinician to look closely for depressive or panic disorders, whose prevalence ishigh in these patients; to treat with antidepressants or cocognitive behavioral treatment,shown to reduce symptoms; and to limitelaborate di

247、agnostic testing or potentiallyhazardous medical treatments.?实验室研究提示，这些病人的症状常被其中枢神经系统广泛放大。对多重躯体形式障碍的认识警示临床医生应该密切关注抑郁性或者惊恐性疾病，这类疾病在这些病人当中发生得非常高。给予抗抑郁药或者认知行为治疗显示可以减轻症状，并减少了一些复杂的诊断性检查和具有潜在危险的药物治疗。?Reassess the patient s response to pain therapy. The principles of analgesic treatment areas been optsim t

248、 r e iz a e t d m . ent hsimple, but dose requirements and adverse effects vary widely. The key to successfultreatment is often a daily phone call until the patient38?对比个人对疼痛疗法的反应重新评价。镇痛剂治疗的原则很简单，但是所需剂量和出现的不良作用差异巨大。治疗成功的关键往往是每日通一次电话，直至对病人的治疗被最优化。?neurophysiologic 神经生理学的?limping 跛行?psychological 心理的?

249、anxiety disorder 焦虑症?rib 肋骨?referred pain 牵涉性痛?Thoracic 胸的?radiologist 放射学家?multisomatoform 多重躯体形式障碍?fibromyalgia 纤维肌痛?irritable bowel syndrome肠易激惹综合症?antidepressant 抗抑郁药Chapter54Chapter54Benefit of Early enteral feeding versus parenteral nutritionBenefit of Early enteral feeding versus parenteral n

250、utrition?It is often said that enteral nutrition is safer and more efficacious than the parenteral route.?人们通常认为肠内营养比肠外营养更安全,更有效 . However a preliminarynote ofcaution is raised fromobservations in experimentalanimals, whichconcluded thatoutcomes of enteral and parentaeral nutrition were equivalent w

251、hen animals with cathetersepsis were eliminated. 然而，一组动物实验的初步观察报告认为在排除了导管脓毒症后，肠内和肠外营养结果是类似的。?Numerous studies have shown that it is safe to feed the gut in the immediate postoperativeperiod and that this practice does not place the integrity of intestinal anastomoses at risk.为数众多的研究表明术后即刻的肠内营养是安全的，同

252、时对肠吻合口的完整也不会带来风险。Early feeding has been studied primarily in two patient populations: those whohave undergone gastrointestinal surgery and in traumaticallyinjured or criticallyillpersons. 早期进食实验最初是在两群病人中进行：一是胃肠手术后病人，二是危重或外伤的病人。?Arecent meta-analysis reviewed11 prospective,randomized,controlledtrails

253、thatcompared the practice of early enteral feeding to maintaining patients NPO after electivegastrointestinal surgery. 最近的一项荟萃分析考察了11 个随机分组前瞻性的对照研究，这些研究比较了择期胃肠术后早期肠内营养及禁食的病人。?Meta 分析是指用统计学方法对收集的多个研究资料进行分析和概括,以提供量化的平均效果来回答研究的问题.其优点是通过增大样本含量来增加结论的可信度,解决研究结果的不一致性。?This analysis of 837 patients conclude

254、d that there is no clear advantage to keepingpatients NPO postoperatively and that early feeding may be of benefit in decreasinginfections and shortening postoperative length of stay.对 837 位病人的研究表明术后禁食病人没有明显优点，而早期肠内营养可能降低感染率，缩短手术后住院时间。?However, a closer evaluation of this data reveals that the lengt

255、h of stay was reduced onlyby 0.84 day, and although there was an increase in“ any type of infectionNP39” in thegroup,when considered individually,there was no differenceinthe incidence ofanastomomoticdehi hiscence, wound infections,pneumonia, intra-abdodominalabscess, ormortality.然而一项新近的有关此数据的研究表示，其

256、住院时间仅仅缩短了染、肺炎、腹内脓肿及死亡的发生率在两组间均没有差异。?In 2001 Marik and Zaloga performed a meta-analysis of 15 randomized, controlled trialsinvolving 753 subjects that compared early with delayed enteral nutrition in critically illsurgicalpatients. Earlyenteral nutritionwas associated witha significantlylowerincidenc

257、e of infection (relative risk reduction of 0.45) and reduced length of hospital stay(2.2 days less). 2001 年 Marik 和 Zaloga 对 15 组随机对照试验进行了营养组感染发生率显著较低（相对风险降低?meta分析，这2.2 天）。must be非传染性些试验包括了753 例危重外科病人，比较其早期和延期肠内营养的效果。早期肠内0.45），住院日也有减少（少There were no differences in noninfectious complications or in

258、mortality. The authorsconcluded that early initiation of enteral feeding was beneficial, but this resultinterpreted with caution because of substantial heterogeneity between studies.之间中的大量差异性，这个结果需要谨慎对待。?The studies that compared enteral and parenteral nutrition in the trauma population, asdiscussed

259、 earlier,concludedthatenteralwas superiorbecause ofan attenuatedinflammatoryresponse and a decrease in septic morbidity.When these studies areexamined more closely, it is clear that patients who were fed enterally usually receivedsignificantly less cacalories than those fed parenterally.?正如前面所讨论的，对外

260、伤病人的肠内和肠外营养研究比较，肠内营养因其更轻微的炎症反应和更低的败血病发病率而体现优势。进一步仔细的检视这些研究，会清楚地发现，接受肠内营养的患者比肠外营养者通常接受了更少的卡路里。?This discrepancy of“ relative overfeeding” in the TPN(total parenteral nutrition) groups in并发症和死亡率未见差异。作者认为早期开始肠内营养是有益的，但是考虑到研究0.84 天，而尽管禁食组病人“总的感染 ”发生率提高了，在分项分析后，其吻合口瘘、切口感many instances led to hypergly cec

261、emia, presumably predisposing patients to immunedysfunction and nosocomial infection.?这种 “相对摄入过量 ”在全胃肠外营养组中的许多实例身上导致了高血糖，这可能导致病人发生免疫功能障碍和院内感染。Thus, poor glucose control alone may account for the observed differences in outcome. Inmore contemporary studieswhere feeds are carefully advanced in a manne

262、r that avoidshyperglycemia and groups are fed equivalent protein and calories, there appears to belittle difference in clinical outcome between enteral and parenteral routes of feeding.?因此，单独血糖的控制就可以解释观察结果的差异。在更多的近期研究中，通过更细致和先进的方法提供营养，?以避免高血糖， 并且各组给予等量的蛋白质和卡路里，则在肠内和肠外营养组之间的临床结果就基本相同。Enteral nutritio

263、n also can endanger patient safety in unique ways.Deaths in persons receiving enteral nutritionare often due to aspiration, for examplewhen gastric motilitysuddenly is impaired with the onset of sepsis. One death fromaspiration is equivalent to the mortalityover 2 to 3 years of well-operated parente

264、ralnutrition program, despite the danger of catheter sepsis, which in well-operated units isnow less than 1% to 3%.?肠内营养也能够以独特的方式使病人的安全受到威胁。40?接受肠内营养的人的死亡往往由于误吸。例如当脓毒症发病时胃动力忽然受损。一次因误吸导致的死亡相当于在良好的肠外营养操作程序下超过而导管脓毒症的危险性在操作良好的单位低于1-3%。2-3 年间的死亡率。第一章医患沟通The physician does not exist in a vacuum but rather

265、 as part of a complicated and extensive system ofmedical care and pubic health.医生不是生存在真空中，而是作为一个复杂而庞大的医疗和公共健康体系中的一部分。In premoderntimes and even todayin some developingcountries,basichygiene,cleanwater, andadequate nutrition have been the most important ways to promote health and reduce disease.在未发达时

266、代，甚至当今在一些发展中国家，基本卫生条件、清洁饮用水和最低营养保障是促进健康的最重要方法。In developed countries, the adoption of healthy lifestyles, including better diet and appropriate exercise,are cornorstones to reducing the epidemics of obesity, coronary disease, and diabetes.在发达国家中，健康的生活方式包括良好饮食和适当锻炼，是减少肥胖、冠心病和糖尿病的基础。Public health inte

267、rventions to provide immunizations and to reduce injuries and the use of tobacco, illicitdrugs, and excess alcohol collectively can produce more health benefit than nearly any other imaginablehealth intervention.公共健康干预如进行疫苗接种、减少损伤、减少吸烟、减少吸毒、减少酗酒等措施共同产生的健康效果比几乎可想象的任何其它健康干预措施都要好得多。第六章生命体征When the bloo

268、d pressure is abnormal, many physicians repeat the measurement.当测得的血压不正常，许多医生重复这个测量。The instrument error that contributes to the greatest variability is the cuff size of the sphygmomanometer.变异性中占比例最大的设备误差是血压计袖套的大小。Many adults require a large-size adult cuff; using a narrow cuff can alter systolic/d

269、iastolic blood pressureby -8 to +10/+2 to +8mmHg.mmHg: millimeter of mercury许多成人需用大号的成人袖套，如果使用窄袖套能够影响收缩压-810mmHg，舒张压 28mmHg 。The appearance of repetitive sounds (Korotkoff sounds, phase 1) constitutes the systolic pressure.重复脉搏音（ Korotkoff音，第相）的出现定为收缩压。Afterthe cuff is inflatedaboutthe palpatedpress

270、ure,the Korotkoffsoundsmuffleand disappearaspressure is released (phase 5).当袖套充气压力约在可触摸脉搏压力的消失（第相） 。The level at which the sounds disappear is the diastolic pressure.声音消失的水平就是舒张压The AmericanHeart Associationrecommendsthateach measureshouldbe roundedupwardto thenearest 2mmHgbe round up to the nearest

271、 whole number美国心脏病协会建议每次测量取最近的第八章Older patients differ from young or middle-aged adults with the same disease in many ways, one of which取最近的整数mmHg 整数。2030mmHg上方， Korotkoff 音变钝，当压力释放，Korotkoff 音41is the frequent occurrence of comorbidities and of subclinical disease.同样的疾病，年龄大的病人在许多方面与青中年病人是有区别的，其中之一是

272、并存病多和亚临床疾病多。As a functionof the high prevalenceof disease,comorbidity(or the co-occurrencediseases in the same individual) is also common.作为高发疾病的结果，并存病（两个或更多的疾病在同一个体同时发生）也是多见的。Of people age 65 and older, 50% have two or more chronicdisease,and these diseasescan conferadditive risk of adverse outcome

273、s, such as mortality.65 岁以上的老年中，50%患有两种以上的慢性疾病，这些疾病能够增加不利预后的风险，如死亡率。In some patients, cognitive impairment may mask the symptoms of important conditions.在一些病人中，认知损害可以掩盖重要病情的症状。Treatmentfor one disease may affect another adversely,as in the use of aspirin to preventstroke inindividuals with a history

274、 of peptic ulcer disease.stroke中风peptic ulcer消化性溃疡of two or more对一种疾病的治疗可能加重另一种疾病，例如，对有消化性溃疡病史的病人使用阿斯匹林预防中风。The risk for becoming disabled or dependent also increases with the number of diseases present.disabled残废的、有缺陷的dependent依靠的、依赖的病残或生活不能自理发生的风险也随着并存的疾病数而增高。Specific pairs of diseases can increas

275、e synergistically the risk of disability.特殊的成对疾病可以协同增加病残的风险。Arthritis and heart disease coexist in 18% of older adults; although the odds of developing disability areincreased by three-fold to four-fold with either disease alone, the risk of disability increases 14-fold if bothare present.有 18% 的老年人

276、同时患有关节炎 和心脏病，虽然每个疾病可以增加34 倍的病残率， 但两个疾病同时存在，可使病残率提高14 倍。第十三章组织工程The loss or failure of an organ or tissue is devastating.器官、组织的丧失或衰竭是毁灭性的。Current treatment methods include transplantation of organs, surgical reconstruction, use of mechanicaldevices, or supplementation of metabolic products.现有的治疗方法有器官

277、移植、外科重建、机械装置的应用以及代谢性产品的补充治疗。However, the ultimate goal of transplantation should reside in the ability to restore living cells to maintainor even enhance existing tissue function.移植的最终目的应该基于重建活细胞群以维持甚至增进现有组织的功能。Bydevelopingreplacementtissuesthatremainintactwithbioactivepropertiesafterimplantation,re

278、taining physiologic functions as well as structure to the tissue or organ damaged by disease or trauma,tissue engineering could provide an alternative to transplantation and other forms of reconstruction.通过植入后仍有生物活性的替换组织发展，保持因病变或创伤而损害器官的生理功能和组织结构，组织工程能提供移植和其它重建方式的一种替代选择。Skin replacement products are

279、 the most advanced, with several tissue-engineering wound care materialscurrently on the market worldwide.皮肤替代产品最为成熟，最近有好几个组织工程（产商）将在全球市场经营这些材料。The potential impact of this field is endless, offering unique solutions to the medical field for tissue andorgan replacement.这个领域的冲力是无限的，它提供了组织、器官替代领域独特的解决

280、方法。42Tissue engineering may eventually be applied to the regeneration of diverse tissues such as the liver,small intestine, cardiovascular structures, nerve, and cartilage.组织工程可能最终能应用于各种组织的重建，如肝、小肠、心血管结构、神经和软骨。Work on bioartificial liver devices has been under way for several years.生物人工肝装置的研究工作已经进行了

281、好几年。The sourcesof cells requiredfor tissue engineeringare summarizedby three categories,autologouscells (from the patient), allogeneic cells (from donor, but not immunologically identical), and xenogeneiccells (donor form a different species).组织工程所需的细胞源被总结为三大类，自体细胞（来源于病人）、同种异体细胞（来源于供者，但不是免疫同源的）和异种细胞

282、（不同物种的供者）。each category may be further delineated in terms of stem cells (adult or embryonic) orcellsobtainedfrom tissue,wherethe cell populationobtainedfrom tissuedissociationcomprisesamixture of cells at different maturation stages and includes rare stem and progenitor cells.每一类可以用术语干细胞进一步描述（成人的或胚

283、胎的），或从组织获得的“不同”细胞进一步描述，组织分离获得的细胞群包含着不同成熟时期的细胞混合体，包括半成熟细胞和原始细胞。Recent discoveries have indicated that stem cells of one type can transdifferentiate to repair damagedtissueof anothertype(i.e., hematopoieticstem cellshometo infarctedmyocardiumandrepairthetissue).最近的发现提示一种类型的干细胞能够转分化以修补另一类型的损伤组织（这就是说，造血

284、干细胞可植入梗死的心肌进行修复） 。隐匿性和来源不明性胃肠道出血Occult bleedingis definedas the detectionof asymptomaticblood loss from thegastrointestinaltract,generally by routine fecal occult blood testing (FOBT) or the presence of iron deficiency anemia.隐匿性出血指的是发现无症状性胃肠道出血，一般通过常规的大便隐血试验（FOBT ）或存在着缺铁性贫血。Obscure gastrointestinal

285、 bleeding is defined as bleeding of unknown origin that persists or recurs after anegative initial endoscopic evaluation of both the upper and lower gastrointestinal tracts.来源不明性胃肠出血是指首次上、下消化管内窥镜检查都阴性、原发部位不明的持续或反复性出血。Both of these entities may be presentations of recurrent or chronic bleeding.两者都可能表

286、现为反复的或慢性的出血。The initial approach to evidence of occult gastrointestinal blood loss should be endoscopic evaluation.对隐匿性胃肠道出血，应该使用内窥镜进行早期检查。In the setting of an isolated positive FOBT, colonoscopy is indicated as the first test.只有单独的大便隐血试验阳性情况下，结肠镜作为首选的检查方法是有适应征的。The yield of colonoscopyin these pati

287、entsis approximately2% for cancer and 30% for one of morecolonic polyps.这些病人结肠镜的结果大约2%是癌症， 30% 是单发或多发的结肠息肉。The initialapproachto a patient with iron deficiencyanemiadependson the presenceof symptomsreferable to either the upper or lower gastrointestinal tract.缺铁性贫血病人的首选检查方法要根据存在的症状跟上消化道还是下消化道相关。Rega

288、rdless of the findings on the initial upper or lower endoscopic examination, all patients should haveboth upper and lower endoscopy because the complementary endoscopic examination has a yield of 6%even if the first one was positive.无论首次上、下消化道内窥镜检查会有何发现，所有病人两个检查都应该做，因为互补的内窥镜检查6%43differentiated“有发现，

289、甚至第一次检查是阳性的。For premenopausal women, a positive FOBT requires full evaluation, as does iron deficiency anemia.对绝经前妇女，大便隐血试验阳性需要全面分析，缺铁性贫血也一样。Barium radiographs of the upper and lower gastrointestinal tract have limited utility in the setting of occultbleeding because of their inability to biopsy or

290、treat lesions that are identified.隐匿性出血时，上、下消化道的钡剂造影应用有限，因为它们不能活检或治疗发现的病损。第二十三章糖尿病肾病End-stage renal disease (ESRD) from diabetic nephropathy is a major cause of morbidity and mortality,particularly in patients with type 1 diabetes, affecting 30 to 35% of patients in the United States.由糖尿病性肾病所发展的晚期肾病

291、（在美国涉及3035% 的病人。Although nephropathy is about one half as frequent in type 2 diabetics (partially due to a shortened lifeexpectancy),type 2 diabetesstill makesup the vast majorityof diabeticpatientsseekingtherapyforESRD.尽管在 2 型糖尿病（特别是影响寿命的）的肾病发生率大约是（晚期肾病治疗的糖尿病病人的绝大多数。Overall, diabetes is the leading

292、 cause of ESRD in the United states, accounting for more than one thirdof cases.总的来说，糖尿病是美国晚期肾病的首要病因，占三分之一以上。第二十六章孕期创伤Traumais the leadingnonobstetriccauseof maternalmortalityand occursin as manyas 7% ofpregnancies.创伤是产妇死亡首要的非产科因素，在孕妇中多达7%。1 型的）一半，但2 型糖尿病仍然是需要EARD ）是患病和死亡的一个主要原因，特别在1 型糖尿病病人中，The mos

293、t common mechanisms of injury are from falls or from motor vehicle crashes.最常见的损伤机制是跌倒或机动车碰撞。When compared to age-matched pregnant controls, pregnant women who sustained trauma had a higherincidenceof spontaneousabortion,pretermlabor , fetomaternalhemorrhage,abruptioplacentae,anduterine rupture.同孕龄配

294、对的对照试验中，遭受创伤的孕妇更易发生自然流产、早产、母婴出血，胎盘早剥和子宫破裂。As the scope is withdrawn, endoscopic findings can be identified for surgical resection or treatment.因为内镜是后退的，内镜发现可以为外科决定切除或（保守）治疗。The yield of this procedure exceeds 70%.这个措施的结果超过70% 。In some clinical situations, the site of bleelding cannot be identified,

295、and the patient requires long-termtransfusion therapy.某些临床情况下，出血部位无法发现，病人而要长期的输血治疗。Multiple studies have attempted to identify risk factors that predict morbidity and mortality in the pregnanttrauma patient.许多组合研究试图确定能预示创伤孕妇发病和死亡的风险因素。The maternal Injury Severity Score, mechanism of injury, and phys

296、ical findings are unable to adequatelypredict adverse outcomes such as abruptio placentae and fetal loss.母亲的创伤指数、损伤机制、体检发现都不能恰当地预示如子宫破裂、妊娠中止等不利结局。Early involvement of an available obstetrician is important to evaluate both maternal and fetal well-being.44联系紧密的产科医生早期介入，检查评估母婴双方健康状况是非常重要的。第四十一章心源性猝Mos

297、t patients should undergo comprehensive evaluation of myocardial function and coronary anatomy.大多数病人应该进行全面的心肌功能评价和冠状动脉解剖。Echocardiography is useful for excluding hypertrophic cardiomyopathy and valvular heart disease;超声心动图对肥厚性心肌病和瓣膜性心脏病在内的疾病很有用；magnetic resonance imaging, for diagnosing arrhythmogen

298、ic right ventricular dysplasia;磁共振对有心律失常性右室发育不良症的诊断很有用；andmyocardialbiopsy,foridentifyinginfiltrativediseasessuchasmyocarditis,amyloidosis,hemochromatosis, and sarcoidosis.心肌活检对浸润性疾病如心肌炎、淀粉样变、结节病很有用。Coronary angiography shoule be performed to assess for the presence of coronary occlusive diseaseand

299、to exclude coronary artery anomalies.应该进行冠状动脉血管造影评估冠脉阻塞性疾病的存在和排除冠脉的结构异常。Myocardial perfusion scintigraphy provides complementary data for assessing ischemic burden.心肌灌注闪烁照相术对缺血程度估计提供辅助资料。Left ventricular function can be assessed by contrast ventriculography, radionuclide ventriculography, orechocard

300、iography.通过对比心室造影、同位素心室造影或超声心动图可以评价左心室。Evaluation of SCD survivors also includes Holter monitoring and/or electrophysiologic testing.心源性猝死生还者的评价也包括动态心电图监护仪和/或电生理测试。The Electrophysiological Study Versus Electrocardiographic Monitoring (ESVEM) trial showed, however,a 50% 2-yearrecurrenceof ventricular

301、tachyarrhythmiassuccessfully suppressed PVCs.The Electrophysiological Study Versus Electrocardiographic Monitoring (ESVEM) trial showed, however,a 50% 2-yearrecurrenceof ventriculartachyarrhythmiassuccessfully suppressed PVCs.但是，电生理研究加心电图监测的试验显示，用药物成功控制的室性早搏病人2 年内 50% 复发in patientsin whom antiarrhyt

302、hnmicdrugsin patientsin whomantiarrhythnmicdrugsThese data suggest a dissociation between PVC suppression and recurrence of VT; PVCs may representa marker of left ventricular dysfunction rather than a trigger of SCD, or the arrhythmogenic substrate maychange over time.这些资料提示室性早搏的控制和室性心动过速的复发是不相关的；室早

303、可能是代表左室功能紊乱的一个信号，而不是心源性猝死的触发者，或心律不齐的基础可能因时间而变化。In SCD survivors,sustainedmonomorphicventriculartachycardiais inducibleby electrophysiologictesting in 40 to 50% and polymorphic VT in 10 to 20%; in 30 to 50%,no sustained arryhthmia is induced.在心源性猝死生还者中，4050% 电生理试验能诱导持续单一型室性心动过速，1020% 能诱导多型的，3050% 不能诱

304、导持续的节律异常。In patients with ischemic heart disease and left ventricular dysfunction, inducibility of sustained VT carriesa poor prognosis.在缺血性心脏病和左室功能不全病人中，能诱导持续室性心动过速预后不良。A low ejection fraction is associated with a poor prognosis, however, regardless of whether sustained VTis inducible;patientswith

305、an ejectionfractionof 30% or less and who are noninduciblehave a 25%arrythmia recurrence rate at 1 year, whereas noninducible patients with an ejection fraction greater than30 have a 10 to 15% recurrence rate.45但是，不良预后与低射血分数有关，不管持续室性心动过速是否能诱导，射血分数1 年有 25% 心律失常复发率，而射血分数大于30% 以下和不能诱导者30% 的不能诱导者只有1015%

306、 复发率。In patients with SCD and idiopathic dilated cardiomyopathy, sustained monomorphic VT is rarely induced.idiopathic先天的、初发的、突发的心源性猝死和先天性扩张性心肌病病人中，持续单一型室性心动过速极少能诱导。Neither the inability to induce VT nor the ability of drugs to suppress inducible polymorphic VT or VF is apredictor of a favorable out

307、come.不能诱导室性心动过速不是，用药物能控制的可诱导多型的VT 和 VF 也不是良好结果的信号。Chapter 22Shortness of BreathBecauseof the high prevalenceof heart diseaseand heart failurein the generalpopulation,manypatients with dyspnea have cardiac abnormalities.由于心脏疾病和心衰的高发，很多呼吸困难的病人有心功能的异常。The basis of the dyspnea is usually a high filling

308、pressure of the left ventricle, which cuases high left atrialpressuresand high pulmonarycapillaryand pulmonaryarterialpressures,which in turn increasethepulmonary blood volume and reduce lung compliance.吸困难的基础通常是左心室充盈压增高导致肺毛细血管和肺动脉压的增加，从而肺血流量提高，肺顺应性降低。If the pulmonary capillary wedge pressure is in

309、the range of 25 mmHg, capillary fluid transudates into thepulmonarymatrix,therebyreducinglung compliance,increasethe workof breathing,and causingdyspnea.如果肺毛细血管楔压在25mmHg左右，毛细血管液就会漏出至肺基质，从而降低了肺顺应性，导致呼吸用力增加，引起呼吸困难。Echocardiographyis usuallydiagnosticof abnormalventricularor valvularfunctionandshouldbe

310、performed in any patient in whom the cause of dyspnea is not readily apparent.超声心动图通常被用来诊断心室和瓣膜异常，对任何呼吸困难病因不明确的病人均可采用。Chapter 25Cancer of unknown primary originIn the majorityof patientswith cancerof unknownprimarysite, the diagnosisof advancedcancer isstrongly suspected after the initial history an

311、d physical examination.大多数原发灶不明的肿瘤病人，经过初步的病史和体格检查，基本能够确定晚期癌症的诊断。A briefadditionalevaluation,includingcompleteblood cell counts,chemistryprofile,and computedtomography of the chest and abdomen should be performed.其他的附加检查，包括全血细胞计数，生化检查和胸部腹部CT。In addition, specific symptoms or signs should be evaluated

312、 with appropriate radiologic and endoscopicstudies.有特殊症状和体征的病人可以使用合适的放射学和内镜检查。If a primary site is located, management should follow guidelines for the specific cancer identified.如果确定了原发部位，应根据特定的肿瘤治疗指南进行治疗。In patients with no obvious primary site, the most accessible site should be biopsied.那些无明显原发病

313、灶的病人，应对最可疑的部位进行活检。Fine needle aspiration may or may not provide sufficient material for optimal histologic examination andspecial pathologic procedures.细针穿刺能否取得足够的组织进行组织学和特殊的病理学检查。If tissueis inadequate,a largerbiopsysampleshouldbe obtainedso that all necessarystainsand46procedures can be performed.

314、如果组织不够，需要进行较大的活检样本以便进行必要的染色和操作。Chapter 28Surgical complicationsSurgeons can do much to avoid complications by the careful preoperative screening process.外科医生可以在术前进行精心筛选以避免术后并发症。When the surgeon sees the potential surgical candidate the first time, a host of questions come to mind,such as the nutriti

315、onal status of the patients and questions about the health of the heart and lungs.当外科医生第一次见到即将手术的病人时，否正常。The surgeon will make a decision regarding performing the correct operation for the appropriate disease.外科医生需要为病人作出正确的手术方式选择。Similarly, the timing of the operation is often an important issue同样的，

316、手术时机也是一个重要的因素。Some operationscan be performedin a purely electivefashion,whereasothershave some urgencyabout an expeditious surgical solution.一些手术可以择期进行，而有些可能需要进行急诊手术。Occasionally, the surgeon will demand that the需要考虑很多问题，如这个病人的营养状况或者心肺功能是patient lost weight before the operation so that the likeliho

317、od of a successful outcome is improved.有时候，外科医生会要求病人术前减轻体重以提高手术的成功率。Occasionally,the wise surgeonwillrequest preoperative consultation from a cardiologist or pulmonary specialist to make certain that patientwill be able to tolerate the stresses of a particular procedure.有时，明智的外科医生会请心脏或呼吸系统专家进行术前会诊以确

318、定病人是否能耐受特定手术。Chapter 30Epidemic influenza流行性感冒是指一个地理区域中的感冒的爆发。In a given community, epidemics of influenza A virus infection often have a characteristic pattern.在某些特定的社区，流感病毒A 型的传播通常有特征性的模式。They usually begin rather abruptly, reach a sharp peak in 2 or 3 weeks, and last 6 to 10 weeks.通常爆发性流行，在2 至 3

319、周内直线到达峰值，并持续Increasednumbersof schoolchildreninfluenza in community.社区中流感发生的第一个迹象就是学生发热呼吸道疾病。This indication is soon followed by illnesses among adults and about a week later by increased hospitaladmissions of patients with influenza-related complications.随后的表现有成人的发病，一周以后感冒相关的并发症引起的入院病人增加。Hospitaliz

320、ation rates in high-risk persons increase two- to five fold during major epidemics.在感冒大流行期间，高危住院病人住院率可能增加二到五成。Schoolandemploymentabsenteeismincreases,as doesmortalityfrompneumoniaandinfluenza,especially in older persons.缺学和旷工的情况增加，肺炎流感死亡率提高，尤其是老年人。The latter finding is a highly specific indicator of

321、 influenza activity.后一项发现是流感活动高度特异性指标。Chapter 36 Endoscopic ultrasonograhyThe incorporationof an ultrasonictransducerin tip of a flexible endoscopeor the use of stand-aloneultrasoundprobeshas now madeit possibleto obtainimagesof gastrointestinallesionsthat are not6 至 10 周。with febrilerespiratoryilln

322、essare oftenthe first indicationof47apparent on superficial views, including lesions within the wall of the gut as well those that lie beyond(e.g.,pancreatic or lymph node lesions)。,将超声换能器并入内镜的头部或仅仅使用超声探头就现在就可以获得无法从浅表探测到的胃肠疾病的影像包括肠壁内或这肠表面(如胰腺疾病或淋巴结病变）。A further role of EUS is to guide fine-needle as

323、piration, which often provides pathologic confirmation ofsuspicious lesions.超声内镜另外被用作细针穿刺的引导，appears可以对可疑的病灶进行病理学的确诊。thanconventionalradiologicIn many cases, this approachtechniquessuchabdominaltobeevenmoreaccurateultrasonography or CT.在许多病例中，这种方法比常规的放射学检查如腹部超声、CT 更精确。Thus,EUSis probablythe singlebe

324、sttest for diagnosingpancreatictumors,particularlythe smallendocrine varieties, with sensitivities approaching 95%.因此， EUS 可能是最好的胰腺肿瘤诊断方法，尤其对小的内分泌肿瘤，灵敏度可达95。It is also the procedure of choice for imaging submucosal and other wall lesions of the gastrointestinaltract (overall accuracy of 65 to 70%) a

325、s well as for staging of a variety of gastrointestinal tumors (overallaccuracy of 90% or more).EUS 同时是粘膜下层和其他胃肠道壁疾病的常规检查方法肿瘤分期的方法（总体准确率超过90）（总体准确率为65到 70 ），也是很多胃肠道Preoperative staging is a critical element in the management strategy for tumors such as esophageal andpancreatic cancer,肿瘤治疗的术前分期是非常关键的因

326、素，尤其对食道癌和胰腺癌。EUS can complement more conventional radiologic tests to help determine the resectability and curativepotential of surgery in these cases.EUS 可以弥补常规的放射学检查方法来确定外科切除和治疗的可能性。Chapter 54 Benefit of Early enteral feeding versus parenteral nutritionThe studies that compared enteral and parente

327、ral nutrition in the trauma population, as discussed earlier,concluded that enteral was superior because of an attenuated inflammatory response and a decrease inseptic morbidity.败血症发病率由于感染率和败血症发病率低，肠内营养超过肠外营养。When these studies are examined more closely, it is clear that patients who were fed entera

328、lly usuallyreceived significantly less calories than those fed parenterally.经过严密的研究发现肠内营养的病人吸收的热量明显少于肠外营养病人。This discrepancy of“ relative overfeedingin the” TPN groups inmany instancesled tohyperglycemia,正如先前所进行的创伤病人有关肠内和肠外营养的结果得出，presumably predisposing patients to immune dysfunction and nosocomial

329、 infection.TPN 组相对营养过度使许多病人产生高血糖症，据推测可以导致免疫功能下降和院内感染。Thus, poor glucose control alone may account for the observed differences in outcome.因此，血糖控制不佳可以解释说观察到的结果的差异。Inmorecontemporarystudieswherefeedsarecarefullyadvancedinamannerthatavoidshyperglycemia and groups are fed equivalent protein and calories

330、, there appears to be little difference inclinical outcome between enteral and parenteral routes of feeding.当代的研究发现，如果肠外营养经过改进避免高血糖的可能，给予与肠内营养相似的蛋白质和热量，两组之间的预后差异不大。Enteral nutrition also can endanger patient safety in unique ways.48肠内营养也可以危及病人的安危。Deaths in persons receiving enteral nutrition are oft

331、en due to aspiration, for example when gastric motilitysuddenly is impaired with the onset of sepsis肠内营养病人的死亡常常是由于误吸，如由于败血症的发生说导致的胃能动性的损伤。One death from aspirationis equivalentto the mortalityover 2 to 3 years of well-operatedparenteralnutrition program, despite the danger of catheter sepsis, which in well-operated units is now less than 1%to 3%.除了导管脓毒症的危险以外，通常在管理良好的单位发病率低于1至 3，误吸的死亡率与实行了23年良好管理的肠外营养病人相当。49