臨床醫(yī)學(xué)英語

#Chapter1Patient-PhysicianInteraction第一章醫(yī)患溝通Thepatient-physicianinteractionproceedsthroughmanyphasesofclinicalreasoninganddecisionmaking.醫(yī)患溝通在臨床診斷和治療決策的許多階段中進行著。Theinteractionbeginswithanelucidationofcomplaintsorconcerns,followedbyinquiriesorevaluationtoaddresstheseconcernsinincreasinglypreciseways.這種溝通開始于病人訴說或所關(guān)注問題，然后通過詢問、評估不斷精確地確定這些問題。Theprocesscommonlyrequiresacarefulhistoryorphysicalexamination,orderingofdiagnostictests,integrationofclinicalfindingswiththetestresults,understandingoftherisksandbenefitsofthepossiblecoursesofaction,andcarefulconsultationwiththepatientandfamilytodevelopfutureplans?這個過程通常需要細(xì)致的病史詢問和體格檢査，進行診斷性化驗，綜合臨床發(fā)現(xiàn)和化驗結(jié)果，理解分析擬行治療過程中的風(fēng)險和療效，并與病人及家屬反復(fù)磋商以形成治療方案Physiciansincreasinglycancallonagrowingliteratureofevidence-basedmedicinetoguidetheprocesssothatbenefitismaximized,whilerespectingindividualvariationsamongdifferentpatients.醫(yī)生們越來越容易査閱不斷增長的循證醫(yī)學(xué)文獻(xiàn)來指導(dǎo)這個過程，使得療效最大化，但要考慮到不同病人中個體差異是存在的。Theincreasingavailabilityofrandomizedtrialstoguidetheapproachtodiagnosisandtherapyshouldnotbeequatedwith“cookbook”medicine越來越多的可用于指導(dǎo)臨床診斷與治療的隨機試驗資料不應(yīng)變成“烹調(diào)書”醫(yī)學(xué)。Evidenceandtheguidelinesthatarederivedfromitemphasizeprovenapproachesforpatientswithspecificcharacteristics因為隨機試驗獲得的現(xiàn)象和思路是著重于特征性病人的求證過程。Substantialclinicaljudgmentisrequiredtodeterminewhethertheevidenceandguidelinesapplytoindividualpatientsandtorecognizetheoccasional.實際的臨床判斷需要確定這些現(xiàn)象和思路能否應(yīng)用于某個病人個體，并能找出例外。Evenmorejudgmentisrequiredinthemanysituationsinwhichevidenceisabsentorinconclusive?許多情況下，臨床表現(xiàn)缺乏或不典型，需要考慮更多的判斷。Evidencealsomustbetemperedbypatients'preferences,althoughitisaphysician'sresponsibilitytoemphasizewhenpresentingalternativeoptionstothepatient.病人還會根據(jù)自己的傾向調(diào)節(jié)著臨床癥狀，但醫(yī)生有責(zé)任通過選擇性問題搞清事實。Theadherenceofapatienttoaspecificregimenislikelytobeenhancedifthepatientalsounderstandstherationaleandevidencebehindtherecommendedoption.假如病人也懂得醫(yī)生問題的基本原理和表現(xiàn)，有特殊生活方式病人的固執(zhí)容易被強化。Tocareforapatientasanindividual,thephysicianmustunderstandthepatientasaperson.為了把病人作為一個個體進行治療，醫(yī)生必須理解病人是一個人（不是一群人）。Thisfundamentalpreceptofdoctoringincludesanunderstandingofthepatient'ssocialsituation,familyissues,financialconcerns,andpreferencesfordifferenttypesofcareandoutcomes,rangingfrommaximumprolongationoflifetothereliefofpainandsuffering.這個最基本的行醫(yī)原則包括了解病人的社會地位，家庭問題，資金狀況以及對不同治療方法、不同治療結(jié)果的選擇，從最大限度地延長生命到臨時緩解疼痛和折磨。Ifthephysiciandoesnotappreciateandaddresstheseissues,thescienceofmedicinecannotbeappliedappropriately,andeventhemostknowledgeablephysicianfailstoachieveappropriateoutcomes.假如醫(yī)生沒有正確理解和定位這個問題，醫(yī)學(xué)就不可能恰當(dāng)?shù)貞?yīng)用于臨床，甚至一個知識最淵博的醫(yī)生也不能取得理想的治療結(jié)果。Evenasphysiciansbecomeincreasinglyawareofnewdiscoveries,patientscanobtaintheirowninformationfromavarietyofsources,someofwhichareofquestionablereliability.甚至，當(dāng)醫(yī)生越來越容易知道新發(fā)現(xiàn)的同時，病人也能夠通過各種資源得到他們的信息，當(dāng)然，某些信息是不可靠的。Theincreasinguseofalternativeandcomplementarytherapiesisanexampleofpatients'frequentdissatisfactionwithprescribedme替代療法herapy.和輔助療法的應(yīng)用不斷增加就是病人對常規(guī)療法經(jīng)常不滿意的一個例子。Physiciansshouldkeepanopenmindregardingunprovenoptionsbutmustadvisetheirpatientscarefullyifsuchoptionsmaycarryanydegreeofpotentialrisks,includingtheriskthattheymayreliedontosubstituteforprovenapproaches醫(yī)生對未證實的療法應(yīng)該保持開放的思想，但是，如果這些療法具有任何程度的潛在風(fēng)險，都必須細(xì)致地告知病人，包括可能需要用已證實的常規(guī)療法去替代的風(fēng)險。Itiscrucialforthephysiciantohaveanopendialoguewiththepatientandfamilyregardingthefullrangeofoptionsthateithermayconsider對醫(yī)生來說，對病人及家屬開誠布公地介紹所有能考慮的治療選擇，是極及關(guān)鍵的。Thephysiciandoesnotexistinavacuumbutratheraspartofacomplicatedandextensivesystemofmedicalcareandpubichealth?醫(yī)生不是生存在真空中的，而是復(fù)雜而龐大的醫(yī)療和公共健康體系中的一部分。Inpremoderntimesandeventodayinsomedevelopingcountries,basichygiene,cleanwater,andadequatenutritionhavebeenthemostimportantwaystopromotehealthandreducedisease.在未發(fā)達(dá)時代，甚至當(dāng)今在一些發(fā)展中國家，基本衛(wèi)生、清潔飲用水和最低營養(yǎng)保障是促進健康減少疾病的最重要措施。Indevelopedcountries,theadoptionofhealthylifestyles,includingbetterdietandappropriateexercise,arecornorstonestoreducingtheepidemicsofobesity,coronarydisease,anddiabetes?而在發(fā)達(dá)國家中，健康的生活方式包括合理飲食和適當(dāng)鍛煉，是減少肥胖、冠心病和糖尿病盛行的基礎(chǔ)。Publichealthinterventionstoprovideimmunizationsandtoreduceinjuriesandtheuseoftobacco,illicitdrugs,andexcessalcoholcollectivelycanproducemorehealthbenefitthannearlyanyotherimaginablehealthintervention.公共健康干預(yù)女口進行疫苗接種、減少損傷、減少吸煙、減少吸毒、減少酗酒等措施共同產(chǎn)生的健康效果幾乎比可想象的任何其它健康干預(yù)措施都要好。Chapter5ClinicalPreventiveServices第五章臨床預(yù)防服務(wù)Clinicalpreventiveservicesincludecounseling,immunization,screeningtests,andreductionofthesusceptibilitytodiseasebyinterventionssuchastherapeuticlifestylechangesandpharmacotherapy?臨床預(yù)防服務(wù)包括對疾病的咨詢、防疫、篩查以及通過治療性的生活習(xí)慣改變和藥物治療來減少易感性。Preventiveserviceoftenareclassifiedasprimary,secondary,ortertiary.臨床預(yù)防服務(wù)常分為一級預(yù)防、二級預(yù)防和三級預(yù)防。Primarypreventionisdirectedtowardpreventingdiseaseorinjurybeforeitdevelops,whereassecondarypreventiondealswithearlydetectionandtreatmenttoimpedetheprogressofovertdisease?一級預(yù)防是直接針對疾病或損傷發(fā)生前的預(yù)防，而二級預(yù)防是解決疾病或損傷發(fā)生后的早期發(fā)現(xiàn)和早期治療，以防止臨床疾病的進一步發(fā)展。Incontrast,tertiarypreventionreferstorehabilitativeactivitiesaftertheonsetofdiseasetominimizecomplicationsanddisability?對比之下，三級預(yù)防是指疾病發(fā)生后的康復(fù)治療，以減少并發(fā)癥和病殘。Becauseofconsiderableoverlap,distinguishingamongthesephasesofpreventionmaybeconfusing.因為（三級預(yù)防之間）有相當(dāng)大的交叉，這些預(yù)防階段的區(qū)分可能有些混淆。Detectingandtreatinghypertensioncouldbeconsideredsecondarypreventionofhypertensivecardiovasculardiseasebutprimarypreventionofheartfailureandstroke.發(fā)現(xiàn)和治療高血壓可以認(rèn)為是對高血壓性心血管疾病的二級預(yù)防，但也可是對心力衰竭和中風(fēng)的一級預(yù)防。Preventionmaybeperceivedbestalongacontinuumfrommodificationofpredisposingfactors,topreventingadisease,toavoidingprematuredeathanddisability.長期一貫地減少易感因素可能是防止疾病、避免早死早殘最好的預(yù)防。Thesoonertheprevention,themorelikelyunnecessaryillness,disability,andprematuredeathcanbeavoided.預(yù)防得越早，越不易發(fā)生不必要的疾病，病殘和早死就能夠避免。Increasingemphasishasbeenplacedonpreventingriskfactorsthemselves.越來越多的重點已經(jīng)集中到對危險因素本身的預(yù)防。Thetermprimordialpreventionhasbeenintroducedforthisconcept?術(shù)語根源預(yù)防(病因預(yù)防)已經(jīng)引進了這個概念。Indiscriminatescreeningforriskfactorsordiseasewithoutadequateadviceandfollow-upservesnousefulpurpose.沒有引導(dǎo)和隨訪的毫無選擇地遠(yuǎn)離危險因素或疾病是沒有實用價值的預(yù)防。Theperiodichealthexaminationhasevolvedfromanannual,broad-based,uniformprotocoltoanapproachthattargetstheprevention,detection,andtreatmentofspecificdiseasesorriskfactorsforparticularage,gender,andethnicgroupsatappropriateintervals.定期體檢逐漸從一年一度的、全面的、統(tǒng)一的規(guī)定項目改進成以恰當(dāng)?shù)闹芷趯μ囟挲g、性別和種群的特殊疾病或危險因素有目的地預(yù)防、發(fā)現(xiàn)和治療。CurrentrecommendationsbytheU.S.PreventiveServicesTaskForcearebasedonsystematicevidencereviewsthatdistinguishprocedureslikelytoproveeffectiveandtohavesubstantiallymorebenefitthanharm.美國預(yù)防服務(wù)特別局的最近建議是基于全面的回顧性研究，這些研究選出了易于證明有效、確實是利大于弊的預(yù)防措施。Changesinthehealthcaresystemandthedevelopmentofnationalguidelinesformanagementofdiseasearelikelytodrawgreaterattentiontohealthpromotion,diseaseprevention,andtheinterfaceofphysician-basedmedicalcarewiththepublichealthcaresystem.衛(wèi)生保健系統(tǒng)的改進和國家疾病控制政策的完善使人們更重視健康促進、疾病預(yù)防，以及接受醫(yī)療人員為主的公共衛(wèi)生系統(tǒng)的保健服務(wù)。Physiciansshouldconsidereachdisorderintermsofthepotentialforprevention,includingthepossibilityofadverseeffectsandcost-effectiveness.醫(yī)生應(yīng)該以有無需要預(yù)防的角度考慮每一種疾病，包括可能發(fā)生的副作用和付出代價是否值得。Aconceptusefulforclinicaldecisionmakingisthenumberofpatientsneededtotreattopreventoneadverseevent,whichisbasedonabsoluteriskreduction?—個對臨床決策有用的理念是需要治療的病人數(shù)量決定一個不利因素是否要預(yù)防，這是基于絕對風(fēng)險的下降。Thisnumberisbasedonefficacyandiscalculatedasthereciprocalofthedifferenceineventratesbetweencontrolandtreatmentgroupsforaspecifiedperiod.這個數(shù)量是以效能為基礎(chǔ)的，是對特定時期內(nèi)對照組和治療組之間發(fā)生率差異的倒數(shù)進行的統(tǒng)計。Ampleevidenceconnectsidentifiableandoftenpreventablefactorstothemorbidityandmortalityassociatedwithmajorhealthproblems.大量的試驗證據(jù)找出了可確認(rèn)的又?？深A(yù)防的與主要健康問題相關(guān)的發(fā)病和死亡因素。Abouthalfofalldeaths,morbidity,anddisabilitycanbeattributedtosuchnongeneticfactors.約一半死亡、發(fā)病和病殘與這些非遺傳性因素有關(guān).Manylifestylechangesbenefitmultiplesystemsanddisorders.許多生活習(xí)慣改變有利于多個系統(tǒng)和紊亂的改善。CigarettesmokinghasbeenestimatedtocontributetooneinfivedeathsintheUnitedStates;dietaryhabitsmayaffecttheoccurrenceofcardiovasculardisease,diabetes,osteoporosis,andcancer?美國五分之一的死亡估計與吸煙有關(guān)，飲食習(xí)慣可能影響心血管疾病，糖尿病、骨質(zhì)疏松癥和癌癥的發(fā)生。Otherimportantpersonalbehaviorfactorsinfluencinghealthincludephysicalactivity,alcoholintake,illicitdruguse,sexualpractices,andexposuretoenvironmentaltoxins.其它影響健康的重要個人行為因素有鍛煉、飲酒、吸毒、性行為以及環(huán)境毒物的接觸。TheidentificationofinformativeDNApolymorphisms(e.g.,singlenucleotidepolymorphisms)andfurtherelucidationofcandidategenesallowfordetectionofsusceptibleindividualsandpossibleinstitutionofmeasurestopreventtheexpressionoftheseharmfulgenetictraits攜帶信息DNA多態(tài)性（例如，單核苷酸多態(tài)性）的認(rèn)識和候選基因的進一步闡明允許我們發(fā)現(xiàn)易感人群和可能采取的措施，以預(yù)防這些有害基因特性的表達(dá)。Severalcommonmisconceptionsimpedepreventivehealthcare.好幾種錯誤觀念妨礙了預(yù)防保健。Manybelievethatdiseaseswithastrongheritablecomponentcannotbealtered,butsusceptibilitytodiseaseoftenrequirestheinteractionofmultiplegenesandenvironmentalfactorsforexpression許多人認(rèn)為有很強遺傳性的疾病是無法改變的,但是對疾病的易感性經(jīng)常需要多種基因和環(huán)境因素的相互作用才能表達(dá)。Inaddition,chronicdiseasesaremultifactorial,sootherfactorscanbechangedtocompensateforanelevatedgeneticrisk.另外，慢性疾病是多因素的，所以，可以改變其它因素來彌補高基因風(fēng)險。Althoughgenetherapyholdsmuchpromise,preventivemeasurescurrentlyofferthebestpossibilitiesforlimitinggeneexpressionandavoidingdisease.雖然基因療法有著很大的希望,但目前的最有可能提供的預(yù)防措施是限制基因表達(dá)來避免疾病。Thenotionthatpreventionislessusefulinolderpersonsexcludesmanywhowouldbenefitmostfrompreventionbecauseelderlypatientsgenerallyhaveagreaterabsoluteriskofdiseaseandhavebeenshowntoadhereandrespondfavorablytopreventivemeasures.對老年人預(yù)防無用的觀念排除了在預(yù)防上本應(yīng)極為受益的許多人,因為老年病人一般有更高患病風(fēng)險,并且一直對預(yù)防措施極為支持、反應(yīng)積極。Also,lifeexpectancyfrequentlyisunderestimatedintheelderly;individualswhoreachage75nowcanexpecttoliveanaverageof11moreyears.并且,老年人的預(yù)期壽命經(jīng)常是低估的,現(xiàn)在將到75歲的老人可以預(yù)期平均再活11年多。Chapter8WhyGeriatricPatientsAreDifferent第八章老年病人的特殊性O(shè)lderpatientsdifferfromyoungormiddle-agedadultswiththesamediseaseinmanyways,oneofwhichisthefrequentoccurrenceofcomorbiditiesandofsubclinicaldisease.同樣的疾病,老年病人在許多方面與青中年病人是有區(qū)別的,其中之一是并存病多、亞臨床疾病多。Asafunctionofthehighprevalenceofdisease,comorbidity（ortheco-occurrenceoftwoormorediseasesinthesameindividual）isalsocommon.作為高發(fā)疾病的結(jié)果,并存?。▋蓚€或更多的疾病在同一個體同時發(fā)生）也是常見的。Ofpeopleage65andolder,50%havetwoormorechronicdisease,andthesediseasescanconferadditiveriskofadverseoutcomes,suchasmortality.65歲以上的老年人中,50%患有兩種以上的慢性疾病,這些疾病能夠增加不良預(yù)后的風(fēng)險,如死亡的風(fēng)險。Insomepatients,cognitiveimpairmentmaymaskthesymptomsofimportantconditions.在一些病人中,認(rèn)知損害可以掩蓋重要病情的癥狀。Treatmentforonediseasemayaffectanotheradversely,asintheuseofaspirintopreventstrokeinindividualswithahistoryofpepticulcerdisease.對一種疾病的治療可能會加重另一種疾病,例如,對有消化性潰瘍病史的病人使用阿斯匹林預(yù)防中風(fēng)。Theriskforbecomingdisabledordependentalsoincreaseswiththenumberofdiseasespresent病殘或生活不能自理的發(fā)生率也隨著并存的疾病數(shù)而增高。Specificpairsofdiseasescanincreasesynergisticallytheriskofdisability.特殊的成對疾病可以協(xié)同增加病殘的風(fēng)險。Arthritisandheartdiseasecoexistin18%ofolderadults;althoughtheoddsofdevelopingdisabilityareincreasedbythree-foldtofour-foldwitheitherdiseasealone,theriskofdisabilityincreases14-foldifbotharepresent.18%的老年人同時患有關(guān)節(jié)炎和心臟病,雖然每個疾病可以增加3~4倍的病殘率,但兩個疾病同時存在,可使病殘率提高到14倍。Asecondwayinwhicholderadultsdifferfromyoungeradultsisthegreaterlikelihoodthattheirdiseasespresentwithnonspecificsymptomsandsigns.老年與青中年的第二個差異是更容易出現(xiàn)非典型的癥狀和體癥。Pneumoniaandstrokemaypresentwithnonspecificchangesinmentationastheprimarysymptom.肺炎和中風(fēng)時可出現(xiàn)非特異性意識變化作為主要癥狀Similarly,thefrequencyofsilentmyocardialinfarctionincreaseswithincreasingage,asdoestheproportionofpatientswhopresentwithachangeinmentalstatus,dizziness,orweaknessratherthantypicalchestpain同樣地，隱匿性心肌梗塞發(fā)生頻度隨著年齡的增大而增加，這些病人相應(yīng)地頻發(fā)精神狀態(tài)改變、眩暈、虛弱而不是典型的胸痛癥狀。Asaresult,thediagnosticevaluationofgeriatricpatientsmustconsiderawiderspectrumofdiseasesthangenerallywouldbeconsideredinmiddle-agedadults.因此，老年病人的診斷應(yīng)考慮更廣泛的疾病譜，要超過通常對中年病人所考慮的范圍。Athirdconditionthatisfoundprimarilyinolderadultsisfrailty,frailtyisthoughttobeawastingsyndromethatpresentswithmultiplesymptomsandsigns,includingreducedmusclemass,weightloss,weakness,poorexercisetolerance,slowedmotorperformance,andlowphysicalactivity.主要出現(xiàn)在老年人的第三個情況是衰弱，衰弱被認(rèn)為屬于衰竭綜合癥，它有許多癥狀和體征，包括肌肉萎縮、體重下降、虛弱、運動耐受差、動作慢、身體活動少。Someestimatesindicatethatthefullsyndromeisfoundin7%ofcommunity-dwellingpeopleage65andolder,andin25%ofcommunity-dwellingpeopleage85andolder.一些人估計7%的65歲以上社區(qū)老人和25%的85歲以上社區(qū)老人這些癥狀全部出現(xiàn)。Manyinstitutionalizedolderadultsalsoarefrail許多老人院里的老人也是衰弱的。Frailtyisastateofdecreasedreserveandincreasedvulnerabilitytoallkindsofstress,fromacuteinfectionorinjurytohospitalization,andmayidentifyindividualswhocannottolerateinvasivetherapies.衰弱是對各種壓力耐受下降、易于損害的一種狀態(tài)，從急性感染、損傷到住院治療，都可以發(fā)現(xiàn)一些老人不能耐受侵入性診療措施。Thesyndromeoffrailtyisassociatedwithhighriskoffalls,needsforhospitalization,disability,andmortality.衰弱癥狀與高病倒率、高住院率、高病殘率、高死亡率是密切相關(guān)的。Thereisearlyevidencethatacorecomponentoffrailtyissarcopenia,orlossofmusclemassassociatedwithaging,whichoccursin13to24%ofpersonsage65to70andin60%ofpersonsage80andolder.衰弱早期征象中的一個主要變化是肌減少癥，或者說隨年齡增長的肌肉減少，它發(fā)生在13~24%的65~70歲的老人，60%的80歲以上的老人。Itislikelythatdysregulationofmultiplephysiologicsystems,includinginflammation,hormonalstatus,andglucosemetabolism,underliesthesyndrome,withresultingdecreasedabilitytomaintainhomeostasisinthefaceofstress.（衰弱時）多種生理系統(tǒng)易于失調(diào)，包括炎癥反應(yīng)、激素調(diào)節(jié)、葡萄糖代謝，在癥狀的背后，伴隨的結(jié)果是在壓力面前保持內(nèi)環(huán)境穩(wěn)定的能力下降Subclinicaldisease（e.g.,atherosclerosis）,end-stagechronicdisease（e.g.,heartfailure）,oracombinationofcomorbiddiseasesmayprecipitatethesyndrome.亞臨床疾?。ㄈ鐒用}粥樣硬化）,晚期慢性疾病（如心力衰竭），或多種疾病并存可共同形成癥狀。Evidencefromrandomized,controlledtrialsshowsthatresistanceexercise,withorwithoutnutritionalsupplements,andhome-basedphysicaltherapycanincreaseleanbodymassandstrengthineventhefrailestolderadults.隨機對照試驗的結(jié)果顯示無論有無營養(yǎng)支持和家庭運動療法，即使是最虛弱的老年人，對抗運動能夠增加瘦弱軀體的質(zhì)量和力量。Thisevidencesuggeststhatearlierstagesoffrailtymayberemediable,althoughend-stagefrailtylikelypresagesdeath.這個結(jié)果提示早期衰弱是可挽回的，盡管末期衰弱常預(yù)示著死亡。Fourth,cognitiveimpairmentincreasesinprominenceaspeopleage.第四，人們變老時認(rèn)知損害顯著增加。Cognitiveimpairmentisariskfactorforawiderangeofadverseoutcomes,includingfalls,immobilization,dependency,institutionalization,andmortality.認(rèn)知損害是大量不良預(yù)后的風(fēng)險因子，包括摔倒、活動能力下降、生活不能自理、需住老人院護理、死亡Cognitiveimpairmentcomplicatesdiagnosisandrequiresadditionalcaregivingtoensuresafety.認(rèn)知損害使診斷復(fù)雜，為保證安全需要更多的照料。Finally,aseriousandcommonoutcomeofchronicdiseasesofagingisphysicaldisability,definedashavingdifficultyorbeingdependentonothersfortheconductofessentialorpersonallymeaningfulactivitiesoflife,frombasicself-care(e.g.,bathingortoileting)totasksrequiredtoliveindependently(e.g.,shopping,preparingmeals,orpayingbills)toafullrangeofactivitiesconsideredtobeproductiveand/orpersonallymeaningful最后，老年人慢性疾病嚴(yán)重又常見的結(jié)果是身體能力喪失，描述為個人最基本的或必須的日常活動有困難或不得不依靠別人幫助指導(dǎo)，從基本的自理(如洗澡或如廁)到獨立生活需要的各種任務(wù)(如購物、做飯、支付各種賬單)，到具有集體和/或個人意義的所有活動。Ofolderadults,40%reportdifficultywithtasksrequiringmobility,anddifficultywithmobilitypredictsthefuturedevelopmentofdifficultyininstrumentalactivitiesofdailyliving(IADL;householdmanagementtasks)andactivitiesofdailyliving(ADL;basicself-caretasks).在老年人中，40%對需要運動的任務(wù)有困難，運動困難提示將來開展日常工具鍛煉(IADL；家務(wù)自理項目)和目常鍛煉(ADL；基本自理項目)的困難。Inpersonsage砧andother,difficultywithIADLisreportedby20%,anddifficultywithADLisreportedby11%;forboth,theprevalenceincreaseswithage.大于砧歲的老人或其它人，IADL困難報導(dǎo)為20%,ADL困難報導(dǎo)為11%;隨年齡增加兩個都困難成為普遍現(xiàn)象PeoplewhohavedifficultywithtasksofIADLandADLareathighriskofbecomingdependent.IADL和ADL困難的人處于生活不能自理演變的高風(fēng)險中。Ofpersonsolderthanage65,5%resideinnursinghomes,largelyasaresultofdependencyinIADLand/orADLsecondarytoseveredisease.大于65歲的老人中，5%住在療養(yǎng)院里，大多數(shù)是嚴(yán)重疾病后依賴IADL和ADL的結(jié)果。Generally,womanlivemoreyearswithdisability,whereasmenwhobecomesimilarlydisabledaremorelikelytodieatayoungerage一般來說，同樣的能力喪失，男性常死得更年輕，女性比男性能多活幾年。Althoughphysicaldisabilityisprimarilyaresultofchronicdiseasesandgeriatricconditions,itsonsetandseverityaremodifiedbyotherfactors,includingtreatmentsthatcontroltheunderlyingdiseases,physicalactivity,nutrition,andsmoking.雖然身體能力喪失是慢性疾病和年老狀態(tài)的一個主要結(jié)果，它的發(fā)生和嚴(yán)重程度被其它因素影響著，包括基礎(chǔ)疾病的治療和控制、身體鍛煉、營養(yǎng)和吸煙。Manyinterventiontrialsindicatethatdisabilitycanbepreventedoritsseveritydecreased;onetrialshowedimprovementsinfunctioningwithresistanceandaerobicexerciseinolderadultswithosteoarthritisoftheknee?許多干預(yù)試驗揭示能力喪失可預(yù)防或減輕;一個試驗顯示膝骨關(guān)節(jié)炎老年人用對抗運動和有氧運動改善了功能。21OccultandObscureGastrointestinalBleeding隱匿性和來源不明性胃腸道出血Occultbleedingisdefinedasthedetectionofasymptomaticbloodlossfromthegastrointestinaltract,generallybyroutinefecaloccultbloodtesting(FOBT)orthepresenceofirondeficiencyanemia?隱匿性出血指的是無癥狀性胃腸道出血，一般通過常規(guī)的大便隱血試驗(FOBT)或存在著缺鐵性貧血而發(fā)現(xiàn)oObscuregastrointestinalbleedingisdefinedasbleedingofunknownoriginthatpersistsorrecursafteranegativeinitialendoscopicevaluationofboththeupperandlowergastrointestinaltracts?來源不明性胃腸出血是指首次上、下消化管內(nèi)窺鏡檢査都陰性、原發(fā)部位不明的持續(xù)性或反復(fù)性出血。Bothoftheseentitiesmaybepresentationsofrecurrentorchronicbleeding.兩者都可能表現(xiàn)為反復(fù)的或慢性的出血。Theinitialapproachtoevidenceofoccultgastrointestinalbloodlossshouldbeendoscopicevaluation對隱匿性胃腸道出血，應(yīng)該使用內(nèi)窺鏡進行早期檢査。nthesettingofanisolatedpositiveFOBT,colonoscopyisindicatedasthefirsttest只有單純大便隱血試驗陽性的情況下，結(jié)腸鏡作為首選的檢査方法是適合的。Theyieldofcolonoscopyinthesepatientsisapproximately2%forcancerand30%foroneormorecolonicpolyps.這些病人結(jié)腸鏡的結(jié)果大約2%是癌癥，30%是單發(fā)或多發(fā)的結(jié)腸息肉。Theinitialapproachtoapatientwithirondeficiencyanemiadependsonthepresenceofsymptomsreferabletoeithertheupperorlowergastrointestinaltract.缺鐵性貧血病人的早期檢查方法要根據(jù)存在的癥狀是與上消化道相關(guān)還是與下消化道相關(guān)而決定。Regardlessofthefindingsontheinitialupperorlowerendoscopicexamination,allpatientsshouldhavebothupperandlowerendoscopybecausethecomplementaryendoscopicexaminationhasayieldof6%evenifthefirstonewaspositive.無論首次上消化道或下消化道內(nèi)窺鏡檢査會有何發(fā)現(xiàn)，所有病人兩個檢査都應(yīng)該做，因為互補的內(nèi)窺鏡檢査有6%的再發(fā)現(xiàn)，即使第一個檢查是陽性的。Forpremenopausalwomen,apositiveFOBTrequiresfullevaluation,asdoesirondeficiencyanemia對絕經(jīng)前婦女，大便隱血試驗陽性需要全面分析，缺鐵性貧血也一樣。Bariumradiographsoftheupperandlowergastrointestinaltracthavelimitedutilityinthesettingofoccultbleedingbecauseoftheirinabilitytobiopsyortreatlesionsthatareidentified?隱匿性出血時，上、下消化道的鋇劑造影應(yīng)用有限，因為它們不能活檢或治療發(fā)現(xiàn)的病損。Theevaluationofobscuregastrointestinalbleedingisoftenfrustrating原因不明性胃腸道出血的診斷常常令人沮喪。Angiodysplasiaisthemostcommoncauseinmostrecentseries.血管發(fā)育畸形是最近病例統(tǒng)計中最常見的病因。Initialendoscopicexaminationshouldfocusonanysymptomsreportedbythepatient?首次內(nèi)窺鏡檢查要關(guān)注病人訴說的任何癥狀。Potentialcausativeagents,suchasNSAIDsandaspirin,shouldbediscontinued.能成為潛在病因的藥物，如非甾體類抗炎鎮(zhèn)痛藥和阿斯匹林，都應(yīng)該停用。Disordersassociatedwithbleeding,suchashereditaryhemorrhagictelangiectasia(Osler-Weber-Rendusyndrome),inflammatoryboweldisease,orableedingdiathesisshouldbeconsidered.伴有出血的疾病，像遺傳性出血性毛細(xì)血管擴張癥(Osler-Weber-Rendu綜合癥)、炎性腸疾病、或出血性體質(zhì)應(yīng)該加以考慮。Arepeatendoscopicevaluationmaybeappropriate,becauseapproximatelyonethirdofcasesrevealacauseofbleedingoverlookedduringtheinitialendoscopy?內(nèi)窺鏡重復(fù)檢查可能是需要的，因為接近三分之一病例査出了首次內(nèi)窺鏡漏掉的出血病原灶。Whenupperendoscopyandcolonoscopyarebothunrevealing,evaluationofthesmallbowelisindicated當(dāng)上消化道內(nèi)窺鏡和結(jié)腸鏡均無發(fā)現(xiàn)時，應(yīng)該對小腸進行檢査。Radiographicevaluationofthesmallbowelisnoninvasivebutrelativelyinsensitive,withalessthan6%yieldfromsmallbowelfollow-throughanda10to21%yieldfromenteroclysis.小腸X線檢查是非侵入性的，但相對不靈敏，小腸全片不到6%有發(fā)現(xiàn)，小腸造影10?21%有結(jié)果。Bycomparison,thediagnosticyieldofendoscopicenteroscopyofthesmallbowelinobscuregastrointestinalbleedingis38to75%.相比較，對來源不明性胃腸道出血小腸內(nèi)窺鏡的診斷結(jié)果是38?75%。Traditionalvideoendoscopescanevaluateonlytheproximalsmallbowel(W150cm),whereaslongerscopes,whicharepassedthoughtheentiresmallbowelandthenwithdrawnwhilevisualizingthemucosa(sondeenteroscopy),arelimitedintheirabilitytovisualizetheentiremucosaandcannotbeusedtoperformdiagnosticortherapeuticmaneuvers?傳統(tǒng)的電視內(nèi)窺鏡只能檢查近端小腸(W150cm)，然而能通過整個小腸邊退邊看腸粘膜的更長內(nèi)鏡，也不能看到整個腸粘膜，不能作為常規(guī)的診斷或治療手段。Whenendoscopicevaluationdoesnotdetectthecauseofbloodloss,radiographicproceduressuchasscintigraphyandangiographyshouldbeconsidered.當(dāng)內(nèi)窺鏡檢査不能發(fā)現(xiàn)出血病因，像閃爍造影和血管造影等影像學(xué)手段應(yīng)該考慮。Provocativeangiographyusingheparinorthrombolyticagentshasbeensuggestedbysomeauthorities,butthisapproachhasthepotentialriskofprecipitatingmajorbleeding雖然使用肝素或溶栓藥的刺激性血管造影被某些專家推薦，但這種方法有促發(fā)大出血的潛在風(fēng)險。Inthefaceofcontinuedbloodlossandnoidentifiedetiology,intraoperativeendoscopymayprovidesimultaneousdiagnosisandtherapy.碰到進行性出血又診斷不明，術(shù)中應(yīng)用腸鏡可以同時進行診斷和治療。Duringtheprocedure,thesurgeonplicatesthebowelovertheendoscope.操作時，外科醫(yī)生把小腸套到內(nèi)窺鏡上。Asthescopeiswithdrawn,endoscopicfindingscanbeidentifiedforsurgicalresectionortreatment.內(nèi)鏡退出時，內(nèi)鏡的發(fā)現(xiàn)可以決定是外科切除或保守治療。Theyieldofthisprocedureexceeds70%.這個措施70%以上有結(jié)果。Insomeclinicalsituations,thesiteofbleedingcannotbeidentified,andthepatientrequireslong-termtransfusiontherapy.某些臨床病例，出血部位無法找到，病人而要長期輸血治療。Anewdeviceforvisualizingtheentiregastrointestinalmucosaconsistsofasmallcamerainaningestablecapsulethattransmitsimagestoreceiversattachedtothepatient'sabdomenandmappedtoidentifythelocationoftheimage.一種新的裝置能顯示全部胃腸粘膜，這種裝置由一顆裝有小型攝像機并并能咽下的膠囊組成，它將(數(shù)字)影像信號傳到附著在病人腹部的接收器，并繪制出圖像來識別影像的位置。Thediagnosticyieldofcapsuleenteroscopyisnotyetclear,butthisapproachmaypotentiallyvisualizesegmentsofthesmallbowelthatwerepreviouslyinaccessible膠囊小腸鏡的診斷效率現(xiàn)在還不清楚，但是，這種方法可能顯示出以前難以接近的小腸腸管。Notherapeuticmaneuversarepossiblewiththedevice.但這個裝置不可能有任何治療性操作。Chapter23DiabeticNephropathy第二十三章糖尿病腎病End-stagerenaldisease(ESRD)fromdiabeticnephropathyisamajorcauseofmorbidityandmortality,particularlyinpatientswithtype1diabetes,affecting30to35%ofpatientsintheUnitedStates.由糖尿病性腎病所發(fā)展的晚期腎病(EARD)是人類患病和死亡的一個主要原因，特別是患有1型糖尿病的病人，在美國涉及30~35%的病人。Althoughnephropathyisaboutonehalfasfrequentintype2diabetics(partiallyduetoashortenedlifeexpectancy),type2diabetesstillmakesupthevastmajorityofdiabeticpatientsseekingtherapyforESRD?盡管2型糖尿病的腎病發(fā)生率大約是1型的一半(部分原因為預(yù)期壽命縮短)，但2型糖尿病仍然是需要治療晚期腎病的糖尿病病人的絕大多數(shù)。Overall,diabetesistheleadingcauseofESRDintheUnitedstates,accountingformorethanonethirdofcases?總的來說，糖尿病是美國晚期腎病的首要病因，占三分之一以上。Detailsarelessclearinpatientswithtype2diabetes,butthenaturalhistoryofdiabeticnephropathyintype1diabetesiswelldescribed.2型糖尿病病人的演變細(xì)節(jié)不是很清楚，但1型糖尿病腎病的自然病程已有充分的描述。Theperiodimmediatelyfollowingdiagnosisisbestcharacterizedbyglomerularhyperfiltration?緊接診斷后的一段時期以腎小球超濾最具有特征。Duringthistime,thereisrenalhypertrophy,increasedrenalbloodflow,increasedglomerularvolume,andanincreasedtransglomerularpressuregradient,allcontributingtoariseinGFR.在這段時間中，有腎臟肥大、腎血流增加、腎小球容積增大和腎小球兩端的壓力梯度增加，這些都與腎小球濾過率升高有關(guān)。Importantly,thesechangesdependatleastinpartonhyperglycemia,astheyarediminishedbyintensivediabetestreatment重要的是，這些變化至少部分是依靠高血糖，因為通過有力的糖尿病治療它們會消失。Threeto5yearsafterdiagnosis,earlyglomerularlesionsappear,characterizedbythickeningofglomerularbasementmembranes,mesangialmatrixexpansion,andarteriolosclerosis診斷后的3~5年，早期的腎小球損害出現(xiàn),以腎小球基底膜增厚、系膜基底擴張和小動脈硬化為特征。Albuminexcretionremainslowduringearlyglomerularchanges;however,aspathologicchangesmount,theglomerulilosetheirfunctionalintegrity,resultinginglomerlarfiltrationdefectsandincreasedglomerularpermeability在腎小球變化的早期，白蛋白排泄仍然較低，但是，隨著病理變化加重，腎小球失去完善的功能，引起腎小球濾過的缺陷，腎小球滲透性增加。Althoughresultsofroutinetestsofrenalfunction(creatinineandurinalysis)stillremainnormal,microalbuminuria(30to300mg/day)appears.盡管腎功能的常規(guī)化驗(肌酐和尿檢)結(jié)果還是正常，但微白蛋白尿(30~300毫克／天)已經(jīng)出現(xiàn)。Systemichypertensionisalsopresentatthistimeinmorethan50%ofcases在這個時期，50%以上的病例還出現(xiàn)高血壓。Afterseveralyears,mostdiabeticpatientsexhibitdiffuseglomerulosclerosis,althoughaminorityhavepathognomonicKimmelsteil-wilsonnodularlesions.數(shù)年以后，大多數(shù)糖尿病病人顯示廣泛的腎小球硬化，盡管只有少數(shù)病人有特征性的Kimmelsteil-wilson小結(jié)。Althoughpathologicchangescontinuetomountthroughoutthedisease,glomerulosclerosisextensiveenoughtocauseESRDdevelopsinaminorityofpatients;inthesecases,overtalbuminuria(>300mg/day)beginsapproximatedly15yearsafterdiagnosis.雖然病理變化在整個病程中是持續(xù)發(fā)展的，但只有少部分病人的腎小球硬化范圍大到足以引起晚期腎病，這些病例中，明顯的白蛋白尿(>300mg/天)大約在診斷后15年開始。Soonafter,followingavariableperiodontheorderof3to5years,theGFRbeginsarelentlessdecline(M10ml/min/year),whichiseventuallyreflectedbyanincreaseinserumcreatinine.之后，接著一個不確定的時期，約需3~5年，腎小球濾過率開始極度下降($10毫升/分/年),最終以血清肌酐濃度增高而表現(xiàn)出來。TheappearanceofmassiveproteinuriaandthenephroticsyndromeiscommoninthiscontextandoftenheraldsprogressiontoESRD病變發(fā)展到這個程度，出現(xiàn)大量蛋白尿和腎病綜合癥是常見的，并且常預(yù)示著晚期腎病的形成。Oncetheserumcreatininerises(reflectinganapproximately50%declineinGFR),ESRDdevelopsinmostpatientswithin10years?—旦血清肌酐濃度增高(反映腎小球濾過率約下降50%),多數(shù)病人10年內(nèi)發(fā)展成晚期腎病。Thiscourseishighlyvariable,houever,particularlyintype2diabetics,whomayexhibitmoderateproteinuriaforseveralyearswithoutasubstantialdeteriorationofrenalfunction.但是，這個過程是非常不確定的，特別是2型糖尿病，可以出現(xiàn)多年的中等蛋白尿而不發(fā)生實質(zhì)性的腎功能惡化Asimplebutusefulmethodofmonitoringprogressiontorenalfailureistoplotthereciprocaloftheserumcreatinineasafunctionoftime一個簡單而實用的腎功能衰竭進展的監(jiān)測方法是用圖表記錄血清肌酐的倒數(shù)作為當(dāng)時的腎功能。Thistechniqueallowsbetterassesssmentofboththerapeuticinterventionsandthetimewhenrenalreplacementtherapywillbecomenecessary.這個技術(shù)使治療性干預(yù)和腎移植時機的判斷更為準(zhǔn)確。Chapter41DiagnosisofSuddenCardicDeath(SCD)心源性猝死的診斷SCDisdeathduetoinstantaneous,unanticipatedcirculatorycollapsewithin1hourofinitialsymptomsandisoften,butnotalways,duetoacardiacarrhythmia.心源性猝死是指出現(xiàn)初始癥狀1小時內(nèi)預(yù)料不到的循環(huán)衰竭死亡，常是，但不全是心律失常致。Morethan70%ofallsuddennaturaldeathshaveacardiaccause,and80%oftheseareattributabletocoronaryarterydisease.70%以上的自然猝死有心臟的原因，心臟原因中80%跟冠狀動脈疾病有關(guān)。Inassessingprognosisandplanningatreatmentstrategy,itisusefultoclassifySCDaseitherprimary(withoutacleartrigger)orsecondary在估計預(yù)后和制定治療方案時，將心源性猝死分為原發(fā)性(無明確的誘發(fā)因素)或繼發(fā)性是實用的。Aprimaryepisodehasa10to30%1-yearrecurrencerate,whereasmostsecondaryepisodesareassociatedwithrecurrenceratesoflessthan2%.原發(fā)性發(fā)作的在1年內(nèi)有10~30%的復(fù)發(fā)率，而大多數(shù)繼發(fā)性的復(fù)發(fā)率小于2%Identifiablereversibleprecipitantsofsecondaryventricularfibrillation(VF)includetransientischemiapossiblyrelatedtovasospasm;hypokalemiaresultingfromdiuretics;hyperkalemiasecondarytorenalfailure,angiotensin-convertingenzymeinhibitors,prostaglandininhibitors,orpotassium-sparingdiuretics;proarrhythmiasecondarytoantiarrhythmics,tricyclics,andantihistamines;orsubstanceabusewithdrugssuchascocaineandamphetamines?已知的可逆性繼發(fā)性心室顫動(VF)的發(fā)作包括可能是血管痙攣性的短暫缺血；利尿劑引起的低鉀血癥；腎功能衰竭、血管緊張素轉(zhuǎn)化酶抑制因子、前列腺素抑制因子、或保鉀利尿劑所致的高鉀血癥；抗心律失常藥、三環(huán)類藥和抗組胺類藥引起的心律失常；或可卡因或安非他明類藥物的濫用。Therapyisdirectedtowardremovingortreatingtheacuteprecipitant?治療是直接消除或處理急性觸發(fā)因素。SCDrelatedtoacuteischemiaintheabsenceofpriorMIoftenisassociatedwithsevereproximalocclusivedisease,normalleftventricularfunction,normalsignal-averagedECG,andnoninducibility[absenceofventriculartachycardia(VT)[duringelectrophysiologicstudy?缺乏心肌梗死前兆的急性缺血性心源性猝死經(jīng)常與嚴(yán)重的近端梗阻性疾病有關(guān)，這種病人左心室功能正常，心電圖信號普通無殊，電生理研究時無法誘異室速(室性心動過速缺乏)。Mostpatientsshouldundergocomprehensiveevaluationofmyocardialfunctionandcoronaryanatomy?大多數(shù)病人應(yīng)該進行全面的心肌功能評價和冠狀動脈解剖結(jié)構(gòu)檢查Echocardiographyisusefulforexcludinghypertrophiccardiomyopathyandvalvularheartdisease;magneticresonanceimaging,fordiagnosingarrhythmogenicrightventriculardysplasia;andmyocardialbiopsy,foridentifyinginfiltrativediseasessuchasmyocarditis,amyloidosis,hemochromatosis,andsarcoidosis.超聲心動圖對排除肥厚性心肌病和瓣膜性心臟病很有用；磁共振對有心律失常性右室發(fā)育不良癥的診斷很有用；心肌活檢對浸潤性疾病如心肌炎、淀粉樣變、血色素沉著癥和結(jié)節(jié)病很有用。Coronaryangiographyshouldbeperformedtoassessforthepresenceofcoronaryocclusivediseaseandtoexcludecoronaryarteryanomalies?應(yīng)該進行冠狀動脈血管造影評估冠脈阻塞性疾病的存在并排除冠脈的結(jié)構(gòu)異常Myocardialperfusionscintigraphyprovidescomplementarydataforassessingischemicburden.心肌灌注閃爍照相術(shù)對缺血程度估計可提供輔助資料。Leftventricularfunctioncanbeassessedbycontrastventriculography,radionuclideventriculography,orechocardiography?通過對比心室造影、同位素心室造影或超聲心動圖可以評價左心室功能。EvaluationofSCDsurvivorsalsoincludesHoltermonitoringand/orelectrophysiologictesting.對心源性猝死生還者的測試還包括動態(tài)心電監(jiān)護和/或電生理測試。TheElectrophysiologicalStudyVersusElectrocardiographicMonitoring(ESVEM)trialshowed,however,a50%2-yearrecurrenceofventriculartachyarrhythmiasinpatientsinwhomantiarrhythnmicdrugssuccessfullysuppressedPVCs但是，電生理激發(fā)加動態(tài)心電監(jiān)測試驗顯示，用抗心律失常藥物成功控制的室性早搏病人2年內(nèi)50%復(fù)發(fā)快速型室性心律失常。ThesedatasuggestadissociationbetweenPVCsuppressionandrecurrenceofVT;PVCsmayrepresentamarkerofleftventriculardysfunctionratherthanatriggerofSCD,orthearrhythmogenicsubstratemaychangeovertime.這些資料提示室性早搏的控制和室性心動過速的復(fù)發(fā)是無關(guān)的；室早可能是代表左室功能紊亂的一個信號，而不是心源性猝死的觸發(fā)因素，或心律不齊的基礎(chǔ)病因可能因時間而改變。InSCDsurvivors,sustainedmonomorphicventriculartachycardiaisinduciblebyelectrophysiologictest