臨床醫(yī)學(xué)英語講義包括疼痛類

臨床醫(yī)講義（包括疼痛類Chapter1Patient-PhysicianInctionThepatient-physicianinctionproceedsthroughmanyphasesofclinicalreasoninganddecisionmaking.(proceed進(jìn)行、開展reasoning推論、推理clinicalreasoning診斷clinicaldecision確定治療方案 makingdecision做出決定)Theinctionbeginswithanelucidationofcomintsorconcerns,followedbyinquiriesorevaluationtoaddresstheseconcernsinincreasinglypreciseways.(elucidation說明、闡明 inquire詢問、evaluation Theprocesscommonlyrequiresacarefulhistoryorphysicalexamination,orderingofdiagnostictests,integrationofclinicalfindingswiththetestresults,understandingoftherisksandbenefitsofthepossiblecoursesofactionandcarefulconsultationwiththepatientandfamilytodevelopfuturens.(integration綜合consultation磋商、會診)Physiciansincreasinglycancallonagrowinglitureofevidence-basedmedicinetoguidetheprocesssothatbenefitis ized,whilerespectingindividualvariationsamongdifferentpatients.(respecting注意到、關(guān)系、說到evidence-basedmedicine循證醫(yī)學(xué))盡管考慮到不同中差異是存在的但醫(yī)生們越來越容易查閱不斷增長Theincreasingavailabilityofrandomizedtrialstoguidetheapproachtoandtherapyshouldnotbeequatedwith“cookbook”medicine(availability可利用性，可得到randomize隨機(jī)的cookbook食譜，烹調(diào)書approach接近)Evidenceandtheguidelinesthatarederivedfromitemphasizeprovenapproachesforpatientswithspecificcharacteristics.(Evidence，跡象guideline指導(dǎo)方針emphasize強(qiáng)調(diào))那些隨機(jī)試驗獲得的臨床表現(xiàn)和診斷思路是側(cè)重于求證具有某些特征而Substantialclinicaljudgmentisrequiredtodeterminewhethertheevidenceandguidelinesapplytoindividualpatientsandtorecognizetheoccasional.substantialclinical真實的，實在的individualoccasional偶爾的，人的，并能找出例外。Evenmorejudgmentisrequiredinthemanysituationsinwhichevidenceisabsentorinconclusive.(inconclusive不確定性，非決定性)在許多情況下，臨床表現(xiàn)缺乏或不典型，甚至需要考慮得Evidencealsomustbetemperedbypatients’preferences,althoughitisaphysician’sresponsibilitytoemphasizewhenpresentingalternativeoptionstothetemper脾氣，調(diào)音preference偏愛presenting提出alternative可選擇Theadherenceofapatienttoaspecificregimenislikelytobeenhancedifthepatientalsounderstandstherationaleandevidencebehindthe (adherence堅持、固執(zhí)regimen養(yǎng)生法、食物療法enhance提高、加強(qiáng)rationale基本原理)假如還懂得所提供問題的基本原理和表現(xiàn)，有特殊生活方

Tocareforapatientasanindividual,thephysicianmustunderstandthepatientas.(carefor喜歡、照料)為了把作為一個進(jìn)行治療，醫(yī)生必須理解Thisfundamentalpreceptofdoctoringincludesanunderstandingofthepatient’ssocialsituation,familyissues,financialconcerns,andpreferencesfordifferenttypesofcareand es,rangingfrom umprolongationoflifetothereliefofpainandsuffering.(precept訓(xùn)戒doctoring行醫(yī)prolongation延長，這個最基本的行醫(yī)原則包括了解的社會地位，家庭問題狀況以及正，Evenasphysicians eincreasinglyawareofnewdiscoveries,patientscanobtaintheirowninformationfromavarietyofsources,someofwhichareofquestionablereliability.questionable可疑的、成問題的、不可靠的reliability，甚至，當(dāng)醫(yī)生越來越容易知道新發(fā)現(xiàn)的同時也能夠通過各種途徑得到他，Theincreasinguseofalternativeandcomplementarytherapiesisanexampleofpatients’frequentdissatisfactionwithprescribedmedicaltherapy.alternative選擇，替代complementary補(bǔ)充的、相配的prescribe規(guī)定、指不斷增加的替代療法和輔助療法的應(yīng)用就是對常規(guī)療法經(jīng)常不滿意的一Physiciansshouldkeepanopenmindregardingunprovenoptionsbutmustadvisetheirpatientscarefullyifsuchoptionsmaycarryanydegreeofpotentialrisks,includingtheriskthattheymayreliedontosubstituteforprovenapproaches(substitute代替、代用relyon依賴、信任)Itiscrucialforthephysiciantohaveanopendialoguewiththepatientandfamilyregardingthefullrangeofoptionsthateithermayconsidercrucial性的either兩者任一)Thephysiciandoesnotexistinavacuumbutratheraspartofacomplicatedandextensivesystemofmedicalcareandpubichealth.(vacuum真空extensiveInpremoderntimesandeventodayinsomedevelocountries,basichygiene,cleanwater,andadequatenutritionhavebeenthemostimportantwaystopromotehealthandreducedisease.Indevelopedcountries,theadoptionofhealthylifestyles,includingbetterdietandappropriateexercise,arecornorstonestoreducingtheepidemicsofobesity,coronarydisease,anddiabetes.adoption采納、采用epidemic病和的基礎(chǔ)。Publichealthinterventionstoprovideimmunizationsandtoreduceinjuriesandtheuseoftobacco,illicitdrugs,andexcessalcoholcollectivelycanproducemorehealthbenefitthannearlyanyotherimaginablehealthintervention.、(illicit的的collectively全體地、共同地produce生產(chǎn)、創(chuàng)造)公共健康干預(yù)如進(jìn)行接種、減少損傷、減少吸煙、減少吸毒、減少酗酒等措施共同產(chǎn)生的健康效果比幾乎可任何其它健康干預(yù)措施都要好得多、Chapter６VitalsignsPage15第六章生命體征第１５頁Anurseorassistantoftenobtainsthevitalsigns.護(hù)士或護(hù)士助手經(jīng)?？傻玫缴鶷raditionallythevitalsignsincludepulserate,bloodpressure,respiratoryrate,

bodytemperature.傳統(tǒng)的生命體征包括脈搏（率、血壓、呼吸（頻率）和體Morerecently,advocatesofvariouscauseshaveadvocatedfora“fifthvitalsign”.(advocate提倡、主張)“第五生命體征”Themostcogentofthese“new”vitalsignsisthepatient’stativeassessmentofpain.(cogent今人信服的，切實的，有力的這些“新”的生命體征中，最今人信服的是疼痛的定量評判ThepulseshouldberecordedasnotjusttheratebutalsothePhysiciansmayprefertoinitiatetheexaminationbyholdingthepatient’shandwhilepalpatingthepulse.(initiate開始，創(chuàng)始)醫(yī)生喜歡握住的手，觸摸脈搏，開始檢查Thisnonthreateninginitialcontactwiththepatientallowsthephysiciantodeterminewhetherthepatienthasaregularorirregularrhythm.這個對無性的最初接觸讓醫(yī)生確定了脈搏是否具有節(jié)律性Whenthebloodpressureisabnormal,manyphysiciansrepeattheTheinstrumenterrorthatcontributestothegreatestvariabilityisthecuffsizeofthesphygmomanometer.(variability變化，易變性sphygmomanometer血壓Manyadultsrequirealarge-sizeadultcuff;usinganarrowcuffcanaltersystolic/diastolicbloodpressureby-8to+10/+2to+8mmHg.(mmHg:millimeterofmercury)-8~10mmHg，2~8mmHg。Theappearanceofrepetitivesounds(Korotkoffsounds,phase1)constitutessystolic(constitute構(gòu)成，設(shè)立，指定)重復(fù)脈搏音（Korotkoff音，第１相）的出現(xiàn)定Afterthecuffisinflatedaboutthepalpatedpressure,theKorotkoffsoundsmuffleanddisappearaspressureisreleased(phase5).(inflatemuffle含糊不當(dāng)袖套充氣壓力可觸摸脈搏壓力的20~30mmHg上方，Korotkoff音變鈍，當(dāng)壓力釋放，Korotkoff音（第５相。Thelevelatwhichthesoundsdisappearisthediastolicpressure.聲音的水平TheAmericanHeartAssociation mendsthateachmeasureshouldberoundedupwardtothenearest2mmHgberounduptothenearestwholenumber取最近的心臟病建議每次測量取最近的２mmHg整數(shù)Therespiratoryrateshouldbeassessedatthesametimethepatientisobservedtodeterminewhetherthereisany fort(dyspnea).dyspnea測量呼吸頻率的同時要觀察以確定是否存在呼吸Thesubjectivesensationofdyspneaiscausedbyanincreasedworkofbreathing.(subjective的)呼吸的感覺是由于呼吸功增加起的。Theexaminershoulddecidewhetherpatientshavetachypnea(arapidrateofbreathing)orhypopnea(asloworshallowrateofbreathing).(tachypnea呼吸急促hypopnea呼吸減弱)Tachpneaisnotalwaysassociatedwithhyperventilation,whichisdefinedbyincreasedalvealarventilationresultinginalowerarterialcarbondioxidelevel. resultingin導(dǎo)致、引起

Intheevaluationofpatientsedofhavingp onia,examinersagreeonthepresenceoftachypneaonly63%ofthetime.(agreeon對……取得一致意見)對一組疑為患者的評估中，檢查者認(rèn)為當(dāng)時呼吸急促的出現(xiàn)率僅為63%。Thebodytemperatureofadultsusuallyismeasuredwithanoralelectric成溫通常用口腔電子體溫計測定Thesethermometerscorrelatewellwiththetraditionalmercurythermometerandaresafertouse.(mercury)這種體溫計與傳統(tǒng)的體溫計高度相關(guān)，使用安全Rectalthermometersreliablyrecordtemperatures0.4℃higherthanoral0.4Bycomparison,newertympanicthermometersmayvarytoomuchcomparedwithoralthermometers(-1.2to+1.6℃versustheoraltemperature)tobereliableamonghospitalizedpatients.(tympanic鼓膜的、鼓室的toomuch……tobe相比較，新型的鼓式體溫計相對口表可能誤差太大（與口表相差-1.2~1.6度Chapter8WhyGeriatricPatientsAreDifferent第八章老年的特殊性20頁Olderpatientsdifferfromyoungormiddle-agedadultswiththesamediseaseinmanyways,oneofwhichisthefrequentoccurrenceofcomorbiditiesandofsubclinicaldisease.(comorbidities并存病subclinical亞臨床的，同樣的疾病大的在許多方面與青中年是有區(qū)別的，其中之一是，Asafunctionofthehighprevalenceofdisease,comorbidity(ortheco-oftwoormorediseasesinthesameindividual)isalsocommon. Ofpeopleage65andolder,50%havetwoormorechronicdisease,andthesediseasescanconferadditiveriskofadverse es,suchasmortality. 后的風(fēng)險，如率。Insomepatients,cognitiveimpairmentmaymaskthesymptomsofimportant(cognitive認(rèn)知的、認(rèn)識的impairment損害mask、假面具、在一些中，認(rèn)知損害可以掩蓋重要病情的癥狀Treatmentforonediseasemayaffectanotheradversely,asintheuseofaspirintopreventstrokeinindividualswithahistoryofpepticulcerdisease.(stroke中風(fēng)pepticulcer消化性潰瘍)Theriskfor ingdisabledordependentalsoincreaseswiththenumberofdiseasespresent. Specificpairsofdiseasescanincreasesynergisticallytheriskofdisability.(synergistic協(xié)同的)Arthritisandheartdiseasecoexistin18%ofolderadults;althoughtheoddsofdevelodisabilityareincreasedbythree-foldtofour-foldwitheitherdiseasealone,theriskofdisabilityincreases14-foldifbotharepresent.(arthritis關(guān)節(jié)18%3~4

14Asecondwayinwhicholderadultsdifferfromyoungeradultsisthegreaterlikelihoodthattheirdiseasespresentwithnonspecificsymptomsandsigns.(likelihood可能性)老年與青中年的第二個差異是更容易出現(xiàn)型的癥狀和體癥Poniaandstrokemaypresentwithnonspecificchangesinmentationastheprimarysymptom.和中風(fēng)時可出現(xiàn)型意識變化作為主要的癥狀。(poniamentation精神作用心理活動primary初始的首要的、Similarly,thefrequencyofsilentmyocardialinfarctionincreaseswithincreasingage,asdoestheproportionofpatientswhopresentwithachangeinmentalstatus,dizziness,orweaknessratherthantypicalchestpain.(silent沉默的、靜止的proportion成比例的、相稱的)Asaresult,thediagnosticevaluationofgeriatricpatientsmustconsiderawiderspectrumofdiseasesthangenerallywouldbeconsideredinmiddle-agedadults.(spectrum譜、光譜)Athirdconditionthatisfoundprimarilyinolderadultsisfrailty,frailtyisthoughttobeawastingsyndromethatpresentswithmultiplesymptomsandsigns,includingreducedmusclemass,weightloss,weakness,poorexercisetolerance,slowedmotorperformance,andlowphysicalactivity.(primarily起初、首先frailtytolerance寬容、忍耐、耐Someestimatesindicatethatthefullsyndromeisfoundin7%ofcommunity-dwellingpeopleage65andolder,andin25%ofcommunity-peopleage85and 估計、評價、看 、表時、象征、適應(yīng)征7%6525%85歲以上社區(qū)老人上述癥狀全Manyinstitutionalizedolderadultsalsoarefrail.許多老人院里的老人也是衰弱 使成公共團(tuán)體、將…收容frail身體虛弱的、易損壞的、意Frailtyisastateofdecreasedreserveandincreasedvulnerabilitytoallkindsofstress,fromacuteinfectionorinjurytohospitalization,andmayidentifyindividualswhocannottolerateinvasivetherapies.(reserve保存、克制vulnerability易受傷、易受責(zé)難)治療，都可以發(fā)現(xiàn)一些人受侵入性診療措施。Thesyndromeoffrailtyisassociatedwithhighriskoffalls,needsforhospitalization,disability,andmortality. 衰弱的癥狀與易于病倒、需要住院治療、病殘、的高風(fēng)險是相關(guān)的Thereisearlyevidencethatacorecomponentoffrailtyissarcopenia,orlossofmusclemassassociatedwithaging,whichoccursin13to24%of sage65to70andin60%of sage80andolder. sarcopenia肌減少（癥、與相關(guān)的骨骼13~24%65~70歲的老人，60%80歲以上的老人。Itislikelythatdysregulationofmultiplephysiologicsystems,including tion,hormonalstatus,andglucosemetabolism,underliesthesyndrome,withresultingdecreasedabilitytomaintainhomeostasisinthefaceofstress. 多種生理系統(tǒng)易于失調(diào)，包括炎癥、激素狀態(tài)、糖的代謝，結(jié)果是在壓力面Subclinicaldisease(e.g.,atherosclerosis),end-stagechronicdisease(e.g.,

failure),oracombinationofcomorbiddiseasesmayprecipitatethesyndrome. Evidencefromrandomized,controlledtrialsshowsthat exercise,withorwithoutnutritionalsupplements,andhome-basedphysicaltherapycanincreaseleanbodymassandstrengthineventhefrailestolderadults.Thisevidencesuggeststhatearlierstagesoffrailtymayberemediable,althoughend-stagefrailtylikelypresagesdeath.(remediable可挽回的presage這個結(jié)果提示早期衰弱是可挽回的，盡管末期衰弱常提示,cognitiveimpairmentincreasesinprominenceaspeopleage. )第四，人們變老時認(rèn)知損害顯著增加。Cognitiveimpairmentisariskfactorforawiderangeofadverse includingfalls,immobilization,dependency,institutionalization,andmortality. 需住老人院護(hù)理、。Cognitiveimpairmentcomplicatesdiagnosisandrequiresadditionalcaregivingtoensuresafety.認(rèn)知損害使診斷復(fù)雜，為保證安全需要的照料Finally,aseriousandcommon eofchronicdiseasesofagingisphysicaldisability,definedashavingdifficultyorbeingdependentonothersfortheconductofessentialor allymeaningfulactivitiesoflife,frombasicself-care(e.g.,bathingortoileting)totasksrequiredtoliveindependently(e.g.,shop,preparingmeals,orpayingbills)toafullrangeofactivitiesconsideredtobeproductiveand/or allymeaningful. Ofolderadults,40%reportdifficultywithtasksrequiringmobility,anddifficultywithmobilitypredictsthefuturedevelopmentofdifficultyininstrumentalactivitiesofdailyliving(IADL;householdmanagementtasks)andactivitiesofdailyliving(ADL;basicself-caretasks).在老年人中，40%對需要運(yùn)動的任務(wù)有，運(yùn)動提示將來開展日常工 sage65andotherdifficultywithIADLisreportedby20anddifficultywithADLisreportedby11%;forboth,theprevalenceincreaseswithage.prevalence流行大于65歲的老人或其它人，IADL報導(dǎo)為20%，ADL報導(dǎo)為11%；隨增加兩個都成為普遍現(xiàn)象。PeoplewhohavedifficultywithtasksofIADLandADLareathighriskofingdependent.IADL和ADL的人處于不能自理演變的高風(fēng)險中 solderthanage65,5%resideinnursinghomes,largelyasaresultofdependencyinIADLand/orADLsecondarytoseveredisease.(reside居住nursinghome療養(yǎng)院)65歲的老人中，5%IADLADLGenerally,womanlivemoreyearswithdisability,whereasmenwho similarlydisabledaremorelikelytodieatayoungerage.一般來說，同樣的能力不足，常死得更年輕，女性比能多活幾年Althoughphysicaldisabilityisprimarilyaresultofchronicdiseasesandgeriatricconditions,itsonsetandseverityaremodifiedbyotherfactors,includingtreatmentsthatcontroltheunderlyingdiseases,physicalactivity,nutrition,andsmoking.

Manyinterventiontrialsindicatethatdisabilitycanbepreventedoritsseveritydecreased;onetrialshowedimprovementsinfunctioningwith aerobicexerciseinolderadultswithosteoarthritisoftheknee.(aerobicexercise有氧運(yùn)動osteoarthritis骨關(guān)節(jié)炎)Chapter13TissueEngineeringPage3636Thelossorfailureofanorganortissueisdevastating. 、組織的喪失或衰竭是性的。Currenttreatmentmethodsincludetransntationoforgans,surgicalreconstruction,useofmechanicaldevices,orsupplementationofmetabolicproducts.(device裝置)However,theultimategoaloftransntationshouldresideintheabilitytorestorelivingcellstomaintainorevenenhanceexistingtissuefunction.(resideBydevelorecementtissuesthatremainintactwithbioactivepropertiesafterimntation,retainingphysiologicfunctionsaswellasstructuretothetissueororgandamagedbydiseaseortrauma,tissueengineeringcouldprovideanalternativetotransntationandotherformsofreconstruction. Skinrecementproductsarethemostadvanced,withseveraltissue-engineeringwoundcarematerialscurrentlyonthemarketworldwide.Thepotentialimpactofthisfieldisendless,offeringuniquesolutionstomedicalfieldfortissueandorganrecement. 這個領(lǐng)域的沖力是無限的，它提供了組織、替代領(lǐng)域獨(dú)特的解決方法Tissueengineeringmayeventuallybeappliedtotheregenerationofdiversetissuessuchastheliver,smallintestine,cardiovascularstructures,nerve,andcartilage. Workonbioartificialliverdeviceshasbeenunderwayforseveral(bioartificialliver 生物人工肝underway進(jìn)行中)生物人工肝裝置的研究工Thesourcesofcellsrequiredfortissueengineeringaresummarizedbythreecategories,autologouscells(fromthepatient),allogeneiccells(fromdonor,butnotimmunologicallyidentical),andxenogeneiccells(donorformadifferentspecies).autologous自體allogeneic同種異體xenogeneic異的、eachcategorymaybefurtherdelineatedintermsofstemcells(adultorembryonic)or“differentiated”cellsobtainedfromtissue,wherethecellpopulationobtainedfromtissuedissociationcomprisesamixtureofcellsatdifferentmaturationstagesandincludesrarestemandprogenitorcells.delineate描繪differentiated區(qū)別、區(qū)分dissociation、分maturation成熟rare稀奇的progenitor祖先、Recentdiscoverieshaveindicatedthatstemcellsofonetypecantransdifferentiatetorepairdamagedtissueofanothertype(i.e.,hematopoieticstemcellshometoinfarctedmyocardiumandrepairthetissue).transdifferentiate轉(zhuǎn)分化hematopoietic

Tissueengineeringwillremainanareaofintense(intense、熱切的、激烈的)組織工程學(xué)將保持一個富有希望的研究熱Advancesintheareasofgrowthfactors,stromalmatrices,geneencapsulation,andgenedeliverywillallyarole.(stromal間質(zhì)的matrix基質(zhì)encapsulation封閉包裝delivery傳遞)Chapter20NonsurgicalInfectionsinSurgicalPatients二十章外科的非外科Postoperativepatientsareatincreasedriskforavarietyofnonsurgical ialinfections. ial醫(yī)院的)術(shù)后發(fā)生各種各樣術(shù)后非外科醫(yī)院內(nèi)的風(fēng)險不Themostcommonoftheseisurinarytractinfection(UTI).最常見的院內(nèi)是。Anypatientwhohashadanindwellingurinarycatheterisatincreasedriskfora(indwell存在…之中、居住)任何留置導(dǎo)管的都是UTI的高風(fēng)險者DespitethebenigncourseofmostUTIs,theoccurrenceofoneinasurgicalpatientisassociatedwithathreefoldincreaseindeathoccurringduringhospitalization.(threefold三倍的、三重的)Thebestpreventionistouseurinarycatheterssparinglyandforspecificindicationsandshortdurationsandtoemploystrictclosed–drainagetechniquesforthosethatareused.sparingly節(jié)儉的、保守的employ合技術(shù)。Lowerrespiratorytractinfectionsarethethirdmostcommoncauseof infectioninsurgicalpatients(afterSSIsandUTIs)andaretheleadingcauseofdeathdueto ialinfection.(SSIs手術(shù)部位、局部)下呼吸道是外科 院內(nèi)是第三常見原（排在局部 ， 首要的因素。Diagnosisisusuallyrelativelystraightforwardinapatientwhoisbreathingstraightforward一直向前、簡單的、明確的spontaneously自然的、自發(fā)的、對一個呼吸自然的，診斷通常相對容易However,apatientwhoisintubatedandbeingventilatedbecauseofadultrespiratorydistresssyndromepresentsanextremelydifficultdiagnosticproblem.(intubate以管插入……腔道)但是，對一個正在插管通氣的成人呼吸窘迫癥，診斷是非常的Patientswiththissyndromecommonlyhaveabnormalchestradiographicfindings,abnormalbloodgasvalues,andelevatedtemperaturesandwhitebloodcellcountsevenintheabsenceofinfection.(radiographicX線照相術(shù)的)這種患者甚至未染，卻常有陽性胸部X線發(fā)現(xiàn)、血?dú)庵诞惓?、體溫升Bothfalse-positiveandfalse-negativediagnosisofponiais假陽性和假的診斷都很常見Newchestradiographicinfiltrateswithsignsofinfectionconstituteagoodindicationforbronchoalveolarlavage,amethodbeingusedtodiagnoseandidentifybacteriacausingventilator-associatedponia,whichhasproventominimizetheindiscriminateuseofantibioticsandpossessesahigherspecificitythanpreviousinfiltrate透入、滲透constitute構(gòu)成、指定indiscriminate不加區(qū)別的、possess擁有、撐握、具有specificity

胸部X線新滲出（陰影）伴有征象是支氣管肺泡的良好指征，這種方法用于診斷和鑒別通氣相關(guān)Aspartofthework-upforfeverinasurgicalpatient,centrallinesusedformonitoringortreatmentshouldalwaysbeconsidered.work-up診斷檢查central的、主要的、近的、便利的line線路、方Catheter-relatedsepsisisdiagnosedwhenanorganismisisolatedfrombloodculturesandfromasegmentofthecatheterinquestion,withoutanyothersourceifsepticemiaandwithclinicalfindingsconsistentwithanism生物、有機(jī)體、有機(jī)組 inquestion在考慮中、討論當(dāng)血培養(yǎng)中和有懷疑的導(dǎo)管節(jié)段中分離到病原菌，未發(fā)現(xiàn)其它部位的源，Infectionofthecathetersiteisdefinedaspresenceoferythemawarmth,tenderness,and/orpusatthesiteofthecatheterinsertion.(erythema紅斑)導(dǎo)管插入處有紅（腫、熱、痛和／或有膿液是導(dǎo)管局部的特點(diǎn)Bothrequireremovalofthecatheter,andifanewcentrallineisneeded,anewpunctureiswarranted.(puncture穿刺warrant保證、批準(zhǔn)、證明)Furthtreatmentusuallydependsontheorganismcementoflinesshouldbedonefollowingstandardasepticandantiseptictechniqueincludingwidedrapesandfullgownandglovefortheinsertingdrape窗簾、 gown長禮服、手術(shù)放置導(dǎo)管前應(yīng)先進(jìn)行標(biāo)準(zhǔn)的無菌和抗菌技術(shù)包括大范圍鋪巾醫(yī)生穿衣、StillthebestwaytominimizetheseinfectionsistoavoidcementoflinesandtoremovethemoncetheindicationisnotpresentStillRoutinechangeofcentrallineshasnotproventoreduceinfection常規(guī)更換導(dǎo)管還未證明能降低率Chapter21OccultandObscureGastrointestinalBleedingPage60occult神秘的、的、隱蔽的obscure的、模糊的、隱匿的隱匿性和來源不明性胃腸道第60頁Occultbleedingisdefinedasthedetectionofasymptomaticbloodlossfromthegastrointestinaltract,generallybyroutinefecaloccultbloodtesting(FOBT)orthepresenceofirondeficiencyanemia.(fecal排泄物、殘渣)隱匿性指的是發(fā)現(xiàn)無癥狀性胃腸道，一般通過常規(guī)的大便隱血試Obscuregastrointestinalbleedingisdefinedasbleedingofunknownoriginthatpersistsorrecursafteranegativeinitialendoscopicevaluationofboththeupperandlowergastrointestinaltracts.(initial開始的、最初的evaluation評價、來源不明性胃腸是指首次上、下消化管內(nèi)窺鏡檢查都部位不明的持續(xù)或反復(fù)性。、Bothoftheseentitiesmaybepresentationsofrecurrentorchronicbleeding.entity實體、存在、本質(zhì)presentation提出、表現(xiàn)、存在兩者都可能表現(xiàn)為反復(fù)的或慢性的Theinitialapproachtoevidenceofoccultgastrointestinalbloodlossshouldbeendoscopicevaluation.對隱匿性胃腸道，應(yīng)該使用內(nèi)窺鏡進(jìn)行早期檢查InthesettingofanisolatedpositiveFOBT,colonoscopyisindicatedasthefirst(colonoscopy結(jié)腸鏡只有單獨(dú)的大便隱血試驗陽性情況下結(jié)腸鏡作為查方法是有適應(yīng)征

Theyieldofcolonoscopyinthesepatientsisapproxima y2%forcancerand30%foroneofmorecolonicpolyps.(yield產(chǎn)出、結(jié)出、產(chǎn)生)這些結(jié)腸鏡的結(jié)果大約2%是，30%是單發(fā)或多發(fā)的結(jié)腸息肉Theinitialapproachtoapatientwithirondeficiencyanemiadependsonthepresenceofsymptomsreferabletoeithertheupperorlowergastrointestinaltract.(referable可認(rèn)為與...有關(guān)的、可參考的)缺鐵性貧血的首選檢查方法要根據(jù)存在的癥狀跟上消化道還是下消化道Regardlessofthefindingsontheinitialupperorlowerendoscopicexamination,allpatientsshouldhavebothupperandlowerendoscopybecausethecomplementaryendoscopicexaminationhasayieldof6%evenifthefirstonewasplementary補(bǔ)充的、互補(bǔ)的positive確定的、、真實6%有發(fā)現(xiàn)，甚至第一次檢查是陽性的。Forpremenopausalwomen,apositiveFOBTrequiresfullevaluation,asdoesirondeficiencyanemia.(premenopausal絕的)對絕婦女，大便隱血試驗陽性需要全面分析，缺鐵性貧血也一樣Bariumradiographsoftheupperandlowergastrointestinaltracthavelimitedutilityinthesettingofoccultbleedingbecauseoftheirinabilitytobiopsyortreatlesionsthatareidentified.utilityTheevaluationofobscuregastrointestinalbleedingisoften(frustrating令人泄氣的、令人沮喪的)隱匿性胃腸道的診斷常常令人沮Angiodyssiaisthemostcommoncauseinmostrecent(Angiodyssia血管發(fā)育畸形)血管發(fā)育畸形是最近病例報導(dǎo)中最常見的病Initialendoscopicexaminationshouldfocusonanysymptomsreportedbythe(focus聚焦、集中、明確)初始內(nèi)窺鏡檢查要盯住訴說的任何癥狀Potentialcausativeagents,suchasNSAIDsandaspirin,shouldbe (causativeNSAIDsnon-steroidalantiinfltorydrugs)Disordersassociatedwithbleeding,suchashereditaryhemorrhagic (Osler-Weber-Rendusyndrome),infl toryboweldisease,orableedingdiathesisshouldbeconsidered.( ia毛細(xì)血管擴(kuò)張 diathesis素質(zhì))胃腸紊亂伴，像遺傳性性毛細(xì)血管擴(kuò)張癥（Osler-Weber-Rendu綜合癥、炎癥性腸疾病、或性體質(zhì)應(yīng)該加以考慮。Arepeatendoscopicevaluationmaybeappropriate,becauseapproximayonethirdofcasesrevealacauseofbleedingoverlookedduringtheinitialendoscopy.的原因。Whenupperendoscopyandcolonoscopyarebothunrevealing,evaluationofthesmallbowelisindicated.Radiographicevaluationofthesmallbowelisnoninvasivebutrelativelyinsensitive,withalessthan6%yieldfromsmallbowelfollow-throughanda10to21%yieldfromenteroclysis.insensitive感覺遲鈍的follow-through持久的，持續(xù)10～21％有結(jié)果。Bycomparison,thediagnosticyieldofendoscopicenteroscopyofthesmallbowelinobscuregastrointestinalbleedingis38to75%.(enteroscopy腸鏡檢查)相比較，對來源不明性胃腸道小腸內(nèi)窺鏡的診斷結(jié)果是38～75%。 endoscopescanevaluateonlytheproximalsmallbowel(≤

150cm),whereaslongerscopes,whicharepassedthoughtheentiresmallbowelandthenwithdrawnwhilevisualizingthemucosa(sondeenteroscopy),arelimitedintheirabilitytovisualizetheentiremucosaandcannotbeusedtoperformdiagnosticortherapeuticximal最接近的、近側(cè)的 visualize使看得見，想像 sonde探空火箭傳統(tǒng)的電視內(nèi)窺鏡能檢查近端小腸(≤150cm),然而能通過整個小腸邊退邊看Whenendoscopicevaluationdoesnotdetectthecauseofbloodloss,radiographicproceduressuchasscintigraphyandangiographyshouldbeconsidered.(scintigraphy閃爍顯像)當(dāng)內(nèi)窺鏡檢查不能發(fā)現(xiàn)病因，像閃爍造影和血管造影X線應(yīng)該考慮Provocativeangiographyusingheparinorthrombolyticagentshasbeensuggestedbysome ,butthisapproachhasthepotentialriskofprecipitatingmajorProvocative刺激的、挑拔的、氣人的precipitating大的潛在風(fēng)險。Inthefaceof bloodlossandnoidentifiedetiology,intraoperativeendoscopymayprovidesimultaneousdiagnosisandtherapysimultaneous同時發(fā)碰到進(jìn)行性查不到病因，術(shù)中腸鏡可能同時解決診斷和治療Duringtheprocedure,thesurgeonplicatestheboweloverthe(plicate有褶的;有皺襞的 Asthescopeiswithdrawn,endoscopicfindingscanbeidentifiedforsurgicalTheyieldofthisprocedureexceeds70%.70%Insomeclinicalsituations,thesiteofbleeldingcannotbeidentified,andthepatientrequireslong-termtransfusiontherapy.(long-term長期的transfusion輸血)某些臨床情況下，部位無法發(fā)現(xiàn)，而要長期的輸血治療Anewdeviceforvisualizingtheentiregastrointestinalmucosaconsistsofasmallcamerainaningestablecapsulethattransmitsimagestoreceiversattachedtothepatient’sabdomenandmappedtoidentifythelocationoftheimage.ingestable能咽下、能吸收camera照相機(jī)、電視機(jī)能咽下的膠囊組成，它將（數(shù)字）影像信號傳到附著在腹部的，并繪制出圖Thediagnosticyieldofcapsuleenteroscopyisnotyetclear,butthisapproachmaypotentiallyvisualizesegmentsofthesmallbowelthatwerepreviouslyinaccessible.potentially潛在的、可能的inaccessible達(dá)不到的、難接近的Notherapeuticmaneuversarepossiblewiththedevice.這個裝置不可能有任何治Chapter23DiabeticNephropathyPage67第二十三章腎病67頁End-stagerenaldisease(ESRD)fromdiabeticnephropathyisamajorcauseofmorbidityandmortalityparticularlyinpatientswithtype1diabetesaffecting30to35%ofpatientsintheUnitedStates.(nephropathy腎病)由性腎病所發(fā)展的晚期腎?。‥ARD）是患病和 特別在1型中，在涉及30~35%的 Althoughnephropathyisaboutonehalfasfrequentintype2diabetics(partiallyduetoashortenedlifeexpectancy),type2diabetesstillmakesupthevastmajorityofdiabeticpatientsseekingtherapyforESRD.(expectancymakeup補(bǔ)足、編造、組成)（盡管在2型 但2型 （Overall,diabetesistheleadingcauseofESRDintheUnitedstates,accountingformorethanonethirdofcases.(overall總體來說accountingfor說

總的來說，是晚期腎病的首要病因，占三分之一以上Detailsarelessclearinpatientswithtype2diabetes,butthenaturalhistoryofdiabeticnephropathyintype1diabetesiswelldescribed.2型（腎?。┑募?xì)節(jié)不是很清楚，但1型腎病的自然病程已Theperiodimmediayfollowingdiagnosisisbestcharacterizedbyglomerular Duringthistime,thereisrenalhypertrophy,increasedrenalbloodflow,increasedglomerularvolume,andanincreasedtransglomerularpressuregradient,allcontributingtoariseinGFR.(hypertrophy肥大gradient坡度、梯度GFRglomerularfiltration腎小球濾率Importantly,thesechangesdependatleastinpartonhyperglycemia,astheyarediminishedbyintensivediabetestreatment.(hyperglycemia高血糖intensive會。Threeto5yearsafterdiagnosis,earlyglomerularlesionsappear,characterizedbythickeningofglomerularbasementmembranes,mesangialmatrixexpansion,andmesangial腎小球系膜的matrix、基Albuminexcretionremainslowduringearlyglomerularchanges;however,aspathologicchangesmount,theglomerulilisetheirfunctionalintegrity,resultinginglomerlarfiltrationdefectsandincreasedglomerularpermeability.Albumin白蛋白mount騎上、進(jìn)行integrity完整、完defect缺點(diǎn)、缺陷permeabilityAlbuminexcretionremainslowduringearlyglo