临床医学英语重点句子翻译

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.临床医学英语Chapter1Patient-PhysicianInteractionPage1第一章医患沟通第１页Thepatient-physicianinteractionproceedsthroughmanyphasesofclinicalreasoninganddecisionmaking.proceed进行、开展reasoning推论、推理clinicalreasoning诊断clinicaldecision确定治疗方案makingdecision做出决定医患沟通在临床诊断和治疗决策的许多时期进行着。Theinteractionbeginswithanelucidationofcomplaintsorconcerns,followedbyinquiriesorevaluationtoaddresstheseconcernsinincreasinglypreciseways.elucidation说明、阐明inquire询问、调查evaluation评估、评价这种沟通开始于病人主诉或所关注问题的阐明，然后通过交流、评估不断精确地确定这些问题。Theprocesscommonlyrequiresacarefulhistoryorphysicalexamination,orderingofdiagnostictests,integrationofclinicalfindingswiththetestresults,understandingoftherisksandbenefitsofthepossiblecoursesofaction,andcarefulconsultationwiththepatientandfamilytodevelopfutureplans.integration综合consultation磋商、会诊这个过程通常需要细致的询问病史和体格检查，开具诊断性化验医嘱，综合临床发现和化验结果，理解分析拟行治疗过程中的风险和疗效，然后与病人及家属反复磋商以完善治疗方案Physiciansincreasinglycancallonagrowingliteratureofevidence-basedmedicinetoguidetheprocesssothatbenefitismaximized,　whilerespectingindividualvariationsamongdifferentpatientsrespecting注意到、关系、说到evidence-basedmedicine循证医学尽管考虑到不同病人中个体差异是存在的，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，使得疗效最大化。Theincreasingavailabilityofrandomizedtrialstoguidetheapproachtodiagnosisandtherapyshouldnotbeequatedwith“cookbook”medicineavailability　可利用性，可得到randomize随机的cookbook食谱，烹调书approach接近但是，不断增加的可用于指导临床诊断与治疗的随机试验资料不应当作“烹调书”使用。Evidenceandtheguidelinesthatarederivedfromitemphasizeprovenapproachesforpatientswithspecificcharacteristics.Evidence证据，迹象guideline　指导方针emphasize强调那些随机试验获得的临床表现和诊断思路是侧重于求证具有某些特征病人而来的。.页脚... .Substantialclinicaljudgmentisrequiredtodeterminewhethertheevidenceandguidelinesapplytoindividualpatientsandtorecognizetheoccasional.substantialclinical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临床表现和诊断依据标准是否能应用于普通病人的个体，并能找出例外。Evenmorejudgmentisrequiredinthemanysituationsinwhichevidenceisabsentorinconclusive.inconclusive不确定性，非决定性在许多情况下，临床表现缺乏或不典型，甚至需要考虑得更多。Evidencealsomustbetemperedbypatients’preferences,althoughitisaphysician’sresponsibilitytoemphasizewhenpresentingalternativeoptionstothepatient.temper脾气，调音preference偏爱presenting提出alternative可选择的，二选一虽然医生喜欢提出选择性问题让病人回答，但病人肯定会根据自己的倾向调节临床症状。Theadherenceofapatienttoaspecificregimenislikelytobeenhancedifthepatientalsounderstandstherationaleandevidencebehindtherecommendedoption.adherence坚持、固执regimen养生法、食物疗法enhance提高、加强rationale基本原理假如还懂得所提供问题的基本原理和表现，有特殊生活方法病人的固执容易强化这种倾向Tocareforapatientasanindividual,thephysicianmustunderstandthepatientasaperson.carefor喜欢、照料为了把病人作为一个个体进行治疗，医生必须理解病人是一个人（不是一群人）。Thisfundamentalpreceptofdoctoringincludesanunderstandingofthepatient’ssocialsituation,familyissues,　financialconcerns,andpreferencesfordifferenttypesofcareandoutcomes,rangingfrommaximumprolongationoflifetothereliefofpainandsuffering.precept训戒doctoring行医prolongation延长这个最基本的行医原则包括了解病人的社会地位，家庭问题，资金状况以及正确理解病人对不同治疗方法、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症状。Evenasphysiciansbecomeincreasinglyawareofnewdiscoveries,patientscanobtaintheirowninformationfromavarietyofsources,someofwhichareofquestionablereliability.questionable可疑的、成问题的、不可靠的reliability可靠、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途径得到他们的信息，某些信息是不可靠的。Theincreasinguseofalternativeandcomplementarytherapiesisanexampleofpatients’frequentdissatisfactionwithprescribedmedicaltherapy.alternative选择，替代complementary补充的、相配的prescribe规定、指定、开处方不断增加的替代疗法和辅助疗法的应用就是病人对常规疗法经常不满意的一个例子。.页脚... .Physiciansshouldkeepanopenmindregardingunprovenoptionsbutmustadvisetheirpatientscarefullyifsuchoptionsmaycarryanydegreeofpotentialrisks,includingtheriskthattheymayreliedontosubstituteforprovenapproachessubstitute代替、代用relyon依赖、信任医生对新疗法应该保持开放的思想，但是，如果这些疗法具有任何程度的潜在风险，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。Itiscrucialforthephysiciantohaveanopendialoguewiththepatientandfamilyregardingthefullrangeofoptionsthateithermayconsidercrucial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可考虑的治疗选择，是非常重要的。Thephysiciandoesnotexistinavacuumbutratheraspartofacomplicatedandextensivesystemofmedicalcareandpubichealth.vacuum真空extensive广阔的、大量的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。Inpremoderntimesandeventodayinsomedevelopingcountries,basichygiene,cleanwater,andadequatenutritionhavebeenthemostimportantwaystopromotehealthandreducedisease.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。Indevelopedcountries,theadoptionofhealthylifestyles,includingbetterdietandappropriateexercise,arecornorstonestoreducingtheepidemicsofobesity,coronarydisease,anddiabetes.adoption采纳、采用epidemic流行、传染在发达国家中，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。Publichealthinterventionstoprovideimmunizationsandtoreduceinjuriesandtheuseoftobacco,illicitdrugs,andexcessalcoholcollectivelycanproducemorehealthbenefitthannearlyanyotherimaginablehealthintervention.illicit非法的、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比几乎可想象的任何其它健康干预措施都要好得多。Chapter６VitalsignsPage15第六章生命体征第１５页Anurseorassistantoftenobtainsthevitalsigns.护士或护士助手经常可得到生命体征Traditionallythevitalsignsincludepulserate,bloodpressure,respiratoryrate,andbody.页脚... .temperature.传统的生命体征包括脉搏（率）、血压、呼吸（频率）和体温。Morerecently,advocatesofvariouscauseshaveadvocatedfora“fifthvitalsign”.advocate提倡、主张最近，人们以多种理由提出“第五生命体征”的建议。Themostcogentofthese“new”vitalsignsisthepatient’squantitativeassessmentofpain.cogent今人信服的，切实的，有力的这些“新”的生命体征中，最今人信服的是病人疼痛的定量评判。Thepulseshouldberecordedasnotjusttheratebutalsotherhythm.脉搏不仅要记录频率，而且要记录节律。Physiciansmayprefertoinitiatetheexaminationbyholdingthepatient’shandwhilepalpatingthepulse.initiate开始，创始医生喜欢握住病人的手，触摸脉搏，开始检查。Thisnonthreateninginitialcontactwiththepatientallowsthephysiciantodeterminewhetherthepatienthasaregularorirregularrhythm.这个对病人无威胁性的最初接触让医生确定了脉搏是否具有节律性。Whenthebloodpressureisabnormal,manyphysiciansrepeatthemeasurement.当测得的血压不正常，许多医生重复这个测量。Theinstrumenterrorthatcontributestothegreatestvariabilityisthecuffsizeofthesphygmomanometer.variability变化，易变性sphygmomanometer血压计变异性中占比例最大的设备误差是血压计袖套的大小。Manyadultsrequirealarge-sizeadultcuff;usinganarrowcuffcanaltersystolic/diastolicbloodpressureby-8to+10/+2to+8mmHg.mmHg:millimeterofmercury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-8~10mmHg，舒张压2~8mmHg。Theappearanceofrepetitivesounds(Korotkoffsounds,phase1)constitutesthesystolicpressure.constitute构成，设立，指定重复脉搏音（Korotkoff音，第１相）的出现定为收缩压。Afterthecuffisinflatedaboutthepalpatedpressure,theKorotkoffsoundsmuffleanddisappearaspressureisreleased(phase5)..页脚... .inflate充气、膨胀muffle含糊不清当袖套充气压力约在可触摸脉搏压力的20~30mmHg上方，Korotkoff音变钝，当压力释放，Korotkoff音消失（第５相）。Thelevelatwhichthesoundsdisappearisthediastolicpressure.声音消失的水平就是舒张压TheAmericanHeartAssociationrecommendsthateachmeasureshouldberoundedupwardtothenearest2mmHgberounduptothenearestwholenumber取最近的整数美国心脏病协会建议每次测量取最近的２mmHg整数。Therespiratoryrateshouldbeassessedatthesametimethepatientisobservedtodeterminewhetherthereisanyrespiratorydiscomfort(dyspnea).dyspnea呼吸困难测量呼吸频率的同时要观察病人以确定是否存在呼吸困难。Thesubjectivesensationofdyspneaiscausedbyanincreasedworkofbreathing.subjective主观的呼吸困难的主观感觉是由于呼吸功增加起的。Theexaminershoulddecidewhetherpatientshavetachypnea(arapidrateofbreathing)orhypopnea(asloworshallowrateofbreathing).tachypnea呼吸急促hypopnea呼吸减弱检查者要确定病人是否存在呼吸急促（呼吸频率快）或呼吸减弱（呼吸频率慢或浅）Tachpneaisnotalwaysassociatedwithhyperventilation,whichisdefinedbyincreasedalvealarventilationresultinginalowerarterialcarbondioxidelevel.hyperventilation换气过度resultingin导致、引起呼吸急促不是都伴有过度换气，过度换气的定义是肺泡通气量增高引起动脉血二氧化碳水平降低。Intheevaluationofpatientssuspectedofhavingpneumonia,examinersagreeonthepresenceoftachypneaonly63%ofthetime.agreeon对……取得一致意见对一组疑为肺炎患者的评估中，检查者认为当时呼吸急促的出现率仅为63%。Thebodytemperatureofadultsusuallyismeasuredwithanoralelectricthermometer.成人体温通常用口腔电子体温计测定。Thesethermometerscorrelatewellwiththetraditionalmercurythermometerandaresafertouse.mercury汞这种体温计与传统的汞体温计高度相关，使用安全。.页脚... .Rectalthermometersreliablyrecordtemperatures0.4℃higherthanoralthermometers.直肠体温计可靠地记录了高于口表0.4℃的温度。Bycomparison,newertympanicthermometersmayvarytoomuchcomparedwithoralthermometers(-1.2℃to+1.6℃versustheoraltemperature)tobereliableamonghospitalizedpatients.tympanic鼓膜的、鼓室的toomuch……tobe太……以致于不相比较，新型的鼓式体温计相对口表可能误差太大（与口表相差-1.2~1.6度），不宜用于住院病人。Chapter8WhyGeriatricPatientsAreDifferentPage20第八章老年病人的特殊性第20页Olderpatientsdifferfromyoungormiddle-agedadultswiththesamediseaseinmanyways,oneofwhichisthefrequentoccurrenceofcomorbiditiesandofsubclinicaldisease.comorbidities并存病subclinical亚临床的同样的疾病，年龄大的病人在许多方面与青中年病人是有区别的，其中之一是并存病多和亚临床疾病多。Asafunctionofthehighprevalenceofdisease,comorbidity(ortheco-occurrenceoftwoormorediseasesinthesameindividual)isalsocommon.prevalence流行、普遍co-occurrence同时发生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。Ofpeopleage65andolder,50%havetwoormorechronicdisease,andthesediseasescanconferadditiveriskofadverseoutcomes,suchasmortality.confer授予、给予additive附加的、附属物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。Insomepatients,cognitiveimpairmentmaymaskthesymptomsofimportantconditions.cognitive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。Treatmentforonediseasemayaffectanotheradversely,asintheuseofaspirintopreventstrokeinindividualswithahistoryofpepticulcerdisease.stroke中风pepticulcer消化性溃疡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。Theriskforbecomingdisabledordependentalsoincreaseswiththenumberofdiseasespresent..页脚... .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。Specificpairsofdiseasescanincreasesynergisticallytheriskofdisability.synergistic协同的特殊的成对疾病可以协同增加病残的风险。Arthritisandheartdiseasecoexistin18%ofolderadults;althoughtheoddsofdevelopingdisabilityareincreasedbythree-foldtofour-foldwitheitherdiseasealone,theriskofdisabilityincreases14-foldifbotharepresent.arthritis关节炎有18%的老年人同时患有关节炎和心脏病，虽然每个疾病可以增加3~4倍的病残率，但两个疾病同时存在，可使病残率提高14倍。Asecondwayinwhicholderadultsdifferfromyoungeradultsisthegreaterlikelihoodthattheirdiseasespresentwithnonspecificsymptomsandsigns.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。Pneumoniaandstrokemaypresentwithnonspecificchangesinmentationastheprimarysymptom.pneumonia肺炎mentation精神作用、心理活动primary初始的、首要的、主要的肺炎和中风时可出现非典型意识变化作为主要的症状。Similarly,thefrequencyofsilentmyocardialinfarctionincreaseswithincreasingage,asdoestheproportionofpatientswhopresentwithachangeinmentalstatus,dizziness,orweaknessratherthantypicalchestpain.silent沉默的、静止的proportion成比例的、相称的同样地，隐匿性心肌梗塞发生频度随着年龄的增大而增加，这些病人相应地频发精神状态改变、眩晕、虚弱而不是典型的胸痛症状。Asaresult,thediagnosticevaluationofgeriatricpatientsmustconsiderawiderspectrumofdiseasesthangenerallywouldbeconsideredinmiddle-agedadults.spectrum谱、光谱因此，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。Athirdconditionthatisfoundprimarilyinolderadultsisfrailty,frailtyisthoughttobeawastingsyndromethatpresentswithmultiplesymptomsandsigns,includingreducedmusclemass,weightloss,weakness,poorexercisetolerance,slowedmotorperformance,andlowphysicalactivity.primarily起初、首先、原来frailty脆弱、虚弱、意志薄弱tolerance宽容、忍耐、耐受主要出现在老年人的第三个情况是衰弱，衰弱被认为属于衰竭综合症，它有许多症状和体征中，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。.页脚... .Someestimatesindicatethatthefullsyndromeisfoundin7%ofcommunity-dwellingpeopleage65andolder,andin25%ofcommunity-dwellingpeopleage85andolder.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岁以上社区老人上述症状全部出现。Manyinstitutionalizedolderadultsalsoarefrail.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。Frailtyisastateofdecreasedreserveandincreasedvulnerabilitytoallkindsofstress,fromacuteinfectionorinjurytohospitalization,andmayidentifyindividualswhocannottolerateinvasivetherapies.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、损害增加的一种状态，从急性感染、损伤到住院治疗，都可以发现一些人不能忍受侵入性诊疗措施。Thesyndromeoffrailtyisassociatedwithhighriskoffalls,needsforhospitalization,disability,andmortality.fall跌倒、下降frail身体虚弱的、易损坏的、意志薄弱的衰弱的症状与易于病倒、需要住院治疗、病残、死亡的高风险是相关的。Thereisearlyevidencethatacorecomponentoffrailtyissarcopenia,orlossofmusclemassassociatedwithaging,whichoccursin13to24%ofpersonsage65to70andin60%ofpersonsage80andolder.component成分、构成要素sarcopenia肌减少（症）、与年龄相关的骨骼肌质量下降衰弱一个主要成分的早期表现是肌肉减少，或说随年龄增长的肌肉减少，它发生在13~24%的65~70岁的老人，60%的80岁以上的老人。Itislikelythatdysregulationofmultiplephysiologicsystems,includinginflammation,hormonalstatus,andglucosemetabolism,underliesthesyndrome,withresultingdecreasedabilitytomaintainhomeostasisinthefaceofstress.dysregulation失调homeostasis内环境稳定多种生理系统易于失调，包括炎症、激素状态、糖的代谢，结果是在压力面前保持内环境的稳定的能力下降。Subclinicaldisease(e.g.,atherosclerosis),end-stagechronicdisease(e.g.,heartfailure),oracombinationofcomorbiddiseasesmayprecipitatethesyndrome.atherosclerosis动脉粥样硬化亚临床疾病(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成症状。Evidencefromrandomized,controlledtrialsshowsthatresistanceexercise,withorwithoutnutritionalsupplements,andhome-basedphysicaltherapycanincreaseleanbodymassand.页脚... .strengthineventhefrailestolderadults.随机对照试验的迹象显示无论有无营养支持和家庭身体疗法，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。Thisevidencesuggeststhatearlierstagesoffrailtymayberemediable,althoughend-stagefrailtylikelypresagesdeath.remediable可挽回的presage预兆、预示这个结果提示早期衰弱是可挽回的，尽管末期衰弱常提示死亡。Fourth,cognitiveimpairmentincreasesinprominenceaspeopleage.prominence突出、显著第四，人们变老时认知损害显著增加。Cognitiveimpairmentisariskfactorforawiderangeofadverseoutcomes,includingfalls,immobilization,dependency,institutionalization,andmortality.immobilization活动能力减少institutionalization制度化、专门照料认知损害是大量不利结果的风险因子，包括摔倒、活动能力下降、不能自理、需住老人院护理、死亡。Cognitiveimpairmentcomplicatesdiagnosisandrequiresadditionalcaregivingtoensuresafety.认知损害使诊断复杂，为保证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，老年人慢性病严重又常见的结果是身体能力不足，描述为个人最基本的或有意义的日常活动有困难或不得不依靠别人帮助指导，从基本的自理（如洗澡或如厕）到独立生活需要的各种任务（如购物、做饭、支付各种账单），到具有集体和／或个人意义的所有活动。Ofolderadults,40%reportdifficultywithtasksrequiringmobility,anddifficultywithmobilitypredictsthefuturedevelopmentofdifficultyininstrumentalactivitiesofdailyliving(IADL;householdmanagementtasks)andactivitiesofdailyliving(ADL;basicself-caretasks).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（IADL；家庭护理项目）和目常锻炼（ADL；基本自理项目）的困难。Inpersonsage65andother,difficultywithIADLisreportedby20%,anddifficultywithADLisreportedby11%;forboth,theprevalenceincreaseswithage.prevalence流行大于65岁的老人或其它人，IADL困难报导为20%，ADL困难报导为11%；随年龄增加两个都困难成为普遍现象。.页脚... .PeoplewhohavedifficultywithtasksofIADLandADLareathighriskofbecomingdependent.IADL和ADL困难的人处于不能自理演变的高风险中。Ofpersonsolderthanage65,5%resideinnursinghomes,largelyasaresultofdependencyinIADLand/orADLsecondarytoseveredisease.reside居住nursinghome疗养院小于65岁的老人中，5%住在疗养院里，大多数是严重疾病后依赖IADL和ADL的结果。Generally,womanlivemoreyearswithdisability,whereasmenwhobecomesimilarlydisabledaremorelikelytodieatayoungerage.一般来说，同样的能力不足，男性常死得更年轻，女性比男性能多活几年。Althoughphysicaldisabilityisprimarilyaresultofchronicdiseasesandgeriatricconditions,itsonsetandseverityaremodifiedbyotherfactors,includingtreatmentsthatcontroltheunderlyingdiseases,physicalactivity,nutrition,andsmoking.Primarily首先、起初、主要、、根本onset进攻、有力的开始、发作虽然身体能力不足是慢性疾病和年老状态的一个主要结果，它的发生和严重程度被其它因素影响着，包括基础疾病的治疗和控制、身体锻炼、营养和吸烟。Manyinterventiontrialsindicatethatdisabilitycanbepreventedoritsseveritydecreased;onetrialshowedimprovementsinfunctioningwithresistanceandaerobicexerciseinolderadultswithosteoarthritisoftheknee.aerobicexercise有氧运动osteoarthritis骨关节炎许多干预试验揭示能力不足可预防或减轻；一个试验显示膝骨关节炎老年人用对抗运动和有氧运动改善功能。Chapter13TissueEngineeringPage36第十三章组织工程第36页Thelossorfailureofanorganortissueisdevastating.devastating毁灭性的器官、组织的丧失或衰竭是毁灭性的。Currenttreatmentmethodsincludetransplantationoforgans,surgicalreconstruction,useofmechanicaldevices,orsupplementationofmetabolicproducts.device装置现有的治疗方法有器官移植、外科重建、机械装置的应用以及代谢性产品的补充治疗。However,theultimategoaloftransplantationshouldresideintheabilitytorestorelivingcellstomaintainorevenenhanceexistingtissuefunction.reside居住、属于、存在于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。.页脚... .Bydevelopingreplacementtissuesthatremainintactwithbioactivepropertiesafterimplantation,retainingphysiologicfunctionsaswellasstructuretothetissueororgandamagedbydiseaseortrauma,tissueengineeringcouldprovideanalternativetotransplantationandotherformsofreconstruction.remain剩下、留下、保持、属于retain保留、保持intact完整无缺的、未受损伤的property特征、特性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。Skinreplacementproductsarethemostadvanced,withseveraltissue-engineeringwoundcarematerialscurrentlyonthemarketworldwide.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。Thepotentialimpactofthisfieldisendless,offeringuniquesolutionstothemedicalfieldfortissueandorganreplacement.impact撞击、冲击frailunique唯一的、独特的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方法。Tissueengineeringmayeventuallybeappliedtotheregenerationofdiversetissuessuchastheliver,smallintestine,cardiovascularstructures,nerve,andcartilage.regeneration再生、重建diverse不同的、变化多的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。Workonbioartificialliverdeviceshasbeenunderwayforseveralyears.bioartificialliver生物人工肝underway进行中生物人工肝装置的研究工作已经进行了好几年。Thesourcesofcellsrequiredfortissueengineeringaresummarizedbythreecategories,autologouscells(fromthepatient),allogeneiccells(fromdonor,butnotimmunologicallyidentical),andxenogeneiccells(donorformadifferentspecies).autologous自体allogeneic同种异体xenogeneic异基因的、异种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（不同物种的供者）。eachcategorymaybefurtherdelineatedintermsofstemcells(adultorembryonic)or“differentiated”cellsobtainedfromtissue,wherethecellpopulationobtainedfromtissuedissociationcomprisesamixtureofcellsatdifferentmaturationstagesandincludesrarestemandprogenitorcells.delineate描绘differentiated区别、区分dissociation分裂、分离maturation成熟rare稀奇的progenitor祖先、起源每一类可以用术语干细胞进一步描述（成人的或胚胎的），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。.页脚... .Recentdiscoverieshaveindicatedthatstemcellsofonetypecantransdifferentiatetorepairdamagedtissueofanothertype(i.e.,hematopoieticstemcellshometoinfarctedmyocardiumandrepairthetissue).transdifferentiate转分化hematopoietic造血的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，造血干细胞可植入梗死的心肌进行修复）。Tissueengineeringwillremainanareaofintenseresearch.intense强烈的、热切的、激烈的组织工程学将保持一个富有希望的研究热园。Advancesintheareasofgrowthfactors,stromalmatrices,geneencapsulation,andgenedeliverywillallplayarole.stromal间质的matrix基质encapsulation封闭、包装delivery传递在这个热园中，已有进展的生长因子、间质其质、基因封闭、基因传递都将扮演一份角色Chapter20NonsurgicalInfectionsinSurgicalPatientsPage57第二十章外科病人的非外科感染第57页Postoperativepatientsareatincreasedriskforavarietyofnonsurgicalpostoperativenosocomialinfections.nosocomial医院的术后病人发生各种各样术后非外科医院内感染的风险不断增加。Themostcommonoftheseisurinarytractinfection(UTI).最常见的院内感染是泌尿道感染(UTI)。AnypatientwhohashadanindwellingurinarycatheterisatincreasedriskforaUTI.indwell存在…之中、居住任何留置尿路导管的病人都是UTI的高风险者。DespitethebenigncourseofmostUTIs,theoccurrenceofoneinasurgicalpatientisassociatedwithathreefoldincreaseindeathoccurringduringhospitalization.threefold三倍的、三重的尽管大多数的尿路感染过程是良性的，但外科病人发生这样一个感染，住院死亡率提高了三倍。Thebestpreventionistouseurinarycatheterssparinglyandforspecificindicationsandshortdurationsandtoemploystrictclosed–drainagetechniquesforthosethatareused.sparingly节俭的、保守的employ使用、利用最好的预防方法是少用导尿管、针对特殊指征、短时间使用，并应用严格的闭合引流技术。.页脚... .Lowerrespiratorytractinfectionsarethethirdmostcommoncauseofnosocomialinfectioninsurgicalpatients(afterSSIsandUTIs)andaretheleadingcauseofdeathduetonosocomialinfection.SSIs手术部位感染、局部感染下呼吸道感染是外科病人院内感染是第三常见原因（排在局部感染和泌尿系感染之后），并且是院内感染首要的死亡因素。Diagnosisisusuallyrelativelystraightforwardinapatientwhoisbreathingspontaneously.straightforward一直向前、简单的、明确的spontaneously自然的、自发的、不由自主的对一个呼吸自然的病人，诊断通常相对容易。However,apatientwhoisintubatedandbeingventilatedbecauseofadultrespiratorydistresssyndromepresentsanextremelydifficultdiagnosticproblem.intubate以管插入……腔道但是，对一个正在插管通气的成人呼吸窘迫症病人，诊断是非常困难的。Patientswiththissyndromecommonlyhaveabnormalchestradiographicfindings,abnormalbloodgasvalues,andelevatedtemperaturesandwhitebloodcellcountsevenintheabsenceofinfection.radiographicX线照相术的这种患者甚至未存在感染，却常有阳性胸部X线发现、血气值异常、体温升高、白细胞计数升高。Bothfalse-positiveandfalse-negativediagnosisofpneumoniaiscommon.假阳性和假阴性的肺炎诊断都很常见。Newchestradiographicinfiltrateswithsignsofinfectionconstituteagoodindicationforbronchoalveolarlavage,amethodbeingusedtodiagnoseandidentifybacteriacausingventilator-associatedpneumonia,whichhasproventominimizetheindiscriminateuseofantibioticsandpossessesahigherspecificitythanpreviousmethods.infiltrate透入、渗透constitute构成、指定indiscriminate不加区别的、任意的possess拥有、撑握、具有specificity明确性、具体性胸部X线新渗出（阴影）伴有感染征象是支气管肺泡灌洗的良好指征，这种方法用于诊断和鉴别通气相关肺炎的病原菌，它被证明最小化了抗生素使用的任意性，比先前的方法更有针对性。Aspartofthework-upforfeverinasurgicalpatient,centrallinesusedformonitoringortreatmentshouldalwaysbeconsidered.work-up诊断检查central中央的、主要的、近的、便利的line线路、方法作为外科病人发热诊断检查的一部分，用于监测或治疗的深部导管始终应用考虑。Catheter-relatedsepsisisdiagnosedwhenanorganismisisolatedfrombloodculturesandfromasegmentofthecatheterinquestion,withoutanyothersourceifsepticemiaandwithclinical.页脚... .findingsconsistentwithsepsis.organism生物、有机体、有机组织inquestion在考虑中、讨论中当血培养中和有怀疑的导管节段中分离到病原菌，未发现其它部位的感染源，而败血症临床表现持续存在，导管脓毒败血症诊断就成立。Infectionofthecathetersiteisdefinedaspresenceoferythema,warmth,tenderness,and/orpusatthesiteofthecatheterinsertion.erythema红斑导管插入处有红、（肿）、热、痛和／或有脓液是导管局部感染的特点。Bothrequireremovalofthecatheter,andifanewcentrallineisneeded,anewpunctureiswarranted.puncture穿刺warrant保证、批准、证明两种情况都要拔除导管，假如需要新的深部导管，要保证从新的部位刺入。Furthtreatmentusuallydependsontheorganismisolated.通常根据分离到的病菌进行进一步治疗。Placementoflinesshouldbedonefollowingstandardasepticandantiseptictechniqueincludingwidedrapesandfullgownandglovefortheinsertingphysician.drape窗帘、幔gown长礼服、手术衣放置导管前应先进行标准的无菌和抗菌技术，包括大范围铺巾，医生穿隔离衣、戴手套。Stillthebestwaytominimizetheseinfectionsistoavoidplacementofunnecessarylinesandtoremovethemoncetheindicationisnotpresentanymore.Still然而、尽管如此然而，减少这些感染的最好办法是避免放置不必要的导管，一旦引流指征消失立即拔管。Routinechangeofcentrallineshasnotproventoreduceinfectionrates.常规更换导管还未证明能降低感染率。OccultandObscureGastrointestinalBleedingPage60occult神秘的、秘密的、隐蔽的obscure黑暗的、模糊的、隐匿的隐匿性和来源不明性胃肠道出血第60页Occultbleedingisdefinedasthedetectionofasymptomaticbloodlossfromthegastrointestinaltract,generallybyroutinefecaloccultbloodtesting(FOBT)orthepresenceofirondeficiencyanemia.fecal排泄物、残渣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。Obscuregastrointestinalbleedingisdefinedasbleedingofunknownoriginthatpersistsorrecursafteranegativeinitialendoscopicevaluationofboththeupperandlowergastrointestinal.页脚... .tracts.initial开始的、最初的evaluation评价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。Bothoftheseentitiesmaybepresentationsofrecurrentorchronicbleeding.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。Theinitialapproachtoevidenceofoccultgastrointestinalbloodlossshouldbeendoscopicevaluation.对隐匿性胃肠道出血，应该使用内窥镜进行早期检查。InthesettingofanisolatedpositiveFOBT,colonoscopyisindicatedasthefirsttest.colonoscopy结肠镜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。Theyieldofcolonoscopyinthesepatientsisapproximately2%forcancerand30%foroneofmorecolonicpolyps.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。Theinitialapproachtoapatientwithirondeficiencyanemiadependsonthepresenceofsymptomsreferabletoeithertheupperorlowergastrointestinaltract.referable可认为与...有关的、可参考的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。Regardlessofthefindingsontheinitialupperorlowerendoscopicexamination,allpatientsshouldhavebothupperandlowerendoscopybecausethecomplementaryendoscopicexaminationhasayieldof6%evenifthefirstonewaspositive.complementary补充的、互补的positive确定的、绝对的、真实的无论首次上、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%有发现，甚至第一次检查是阳性的。Forpremenopausalwomen,apositiveFOBTrequiresfullevaluation,asdoesirondeficiencyanemia.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。Bariumradiographsoftheupperandlowergastrointestinaltracthavelimitedutilityinthesettingofoccultbleedingbecauseoftheirinabilitytobiopsyortreatlesionsthatareidentified.utility实用、效用、通用隐匿性出血时，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。.页脚... .Theevaluationofobscuregastrointestinalbleedingisoftenfrustratingfrustrating令人泄气的、令人沮丧的隐匿性胃肠道出血的诊断常常令人沮丧。Angiodysplasiaisthemostcommoncauseinmostrecentseries.Angiodysplasia血管发育畸形血管发育畸形是最近病例报导中最常见的病因。Initialendoscopicexaminationshouldfocusonanysymptomsreportedbythepatient.focus聚焦、集中、明确初始内窥镜检查要盯住病人诉说的任何症状。Potentialcausativeagents,suchasNSAIDsandaspirin,shouldbediscontinued.causative成为原因的NSAIDs非甾体类抗炎镇痛药non-steroidalantiinflammatorydrugs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，应该停用。Disordersassociatedwithbleeding,suchashereditaryhemorrhagictelangiectasia(Osler-Weber-Rendusyndrome),inflammatoryboweldisease,orableedingdiathesisshouldbeconsidered.telangiectasia毛细血管扩张diathesis素质胃肠紊乱伴出血，像遗传性出血性毛细血管扩张症（Osler-Weber-Rendu综合症）、炎症性肠疾病、或出血性体质应该加以考虑。Arepeatendoscopicevaluationmaybeappropriate,becauseapproximatelyonethirdofcasesrevealacauseofbleedingoverlookedduringtheinitialendoscopy.内窥镜重复检查可能是恰当的，因为接近三分之一病例查出了首次内窥镜漏掉的出血原因。Whenupperendoscopyandcolonoscopyarebothunrevealing,evaluationofthesmallbowelisindicated.当上消化道内窥镜和结肠镜均无发现，小肠检查具有指征。Radiographicevaluationofthesmallbowelisnoninvasivebutrelativelyinsensitive,withalessthan6%yieldfromsmallbowelfollow-throughanda10to21%yieldfromenteroclysis.insensitive感觉迟钝的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6%不到有发现，小肠造影10～21％有结果。Bycomparison,thediagnosticyieldofendoscopicenteroscopyofthesmallbowelinobscuregastrointestinalbleedingis38to75%.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38～75%。.页脚... .Traditionalvideoendoscopescanevaluateonlytheproximalsmallbowel(≤150cm),whereaslongerscopes,whicharepassedthoughtheentiresmallbowelandthenwithdrawnwhilevisualizingthemucosa(sondeenteroscopy),arelimitedintheirabilitytovisualizetheentiremucosaandcannotbeusedtoperformdiagnosticortherapeuticmaneuvers.proximal最接近的、近侧的visualize使看得见，想像sonde探空火箭传统的电视内窥镜能检查近端小肠(≤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，都不能作为常规的诊断或治疗手段。Whenendoscopicevaluationdoesnotdetectthecauseofbloodloss,radiographicproceduressuchasscintigraphyandangiographyshouldbeconsidered.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X线手段应该考虑。Provocativeangiographyusingheparinorthrombolyticagentshasbeensuggestedbysomeauthorities,butthisapproachhasthepotentialriskofprecipitatingmajorbleeding.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。Inthefaceofcontinuedbloodlossandnoidentifiedetiology,intraoperativeendoscopymayprovidesimultaneousdiagnosisandtherapy.simultaneous同时发生的、同时存在的碰到进行性出血查不到病因，术中肠镜可能同时解决诊断和治疗。Duringtheprocedure,thesurgeonplicatesthebowelovertheendoscope.plicate有褶的;有皱襞的在操作中，外科医生把小肠套迭到内窥镜上。Asthescopeiswithdrawn,endoscopicfindingscanbeidentifiedforsurgicalresectionortreatment.当内镜后退时，内镜发现可以决定是外科切除或（保守）治疗。Theyieldofthisprocedureexceeds70%.这个措施的结果超过70%。Insomeclinicalsituations,thesiteofbleeldingcannotbeidentified,andthepatientrequireslong-termtransfusiontherapy.long-term长期的transfusion输血某些临床情况下，出血部位无法发现，病人而要长期的输血治疗。Anewdeviceforvisualizingtheentiregastrointestinalmucosaconsistsofasmallcamerainaningestablecapsulethattransmitsimagestoreceiversattachedtothepatient’sabdomenandmappedtoidentifythelocationoftheimage..页脚... .ingestable能咽下、能吸收camera照相机、电视摄像机一种新的装置能显示全部胃肠粘膜，这种装置由一颗装有小型摄像机能咽下的胶囊组成，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置。Thediagnosticyieldofcapsuleenteroscopyisnotyetclear,butthisapproachmaypotentiallyvisualizesegmentsofthesmallbowelthatwerepreviouslyinaccessible.potentially潜在的、可能的inaccessible达不到的、难接近的胶囊小肠镜的诊断效率现在还不清楚，但是，这种方法可能可以显示以前难以接近的小肠段肠管。Notherapeuticmaneuversarepossiblewiththedevice.这个装置不可能有任何治疗性操作。Chapter23DiabeticNephropathyPage67第二十三章糖尿病肾病第67页End-stagerenaldisease(ESRD)fromdiabeticnephropathyisamajorcauseofmorbidityandmortality,particularlyinpatientswithtype1diabetes,affecting30to35%ofpatientsintheUnitedStates.nephropathy肾病由糖尿病性肾病所发展的晚期肾病（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，在美国涉及30~35%的病人。Althoughnephropathyisaboutonehalfasfrequentintype2diabetics(partiallyduetoashortenedlifeexpectancy),type2diabetesstillmakesupthevastmajorityofdiabeticpatientsseekingtherapyforESRD.expectancy期望、预期makeup补足、编造、组成尽管在2型糖尿病（特别是影响寿命的）的肾病发生率大约是（1型的）一半，但2型糖尿病仍然是需要晚期肾病治疗的糖尿病病人的绝大多数。Overall,diabetesistheleadingcauseofESRDintheUnitedstates,accountingformorethanonethirdofcases.overall总体来说accountingfor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。Detailsarelessclearinpatientswithtype2diabetes,butthenaturalhistoryofdiabeticnephropathyintype1diabetesiswelldescribed.2型糖尿病病人（肾病）的细节不是很清楚，但1型糖尿病肾病的自然病程已有充分的描述。Theperiodimmediatelyfollowingdiagnosisisbestcharacterizedbyglomerularhyperfiltration.glomerular肾小球的hyperfiltration超过滤紧接诊断后的一段时期以肾小球超过滤最具有特征。Duringthistime,thereisrenalhypertrophy,increasedrenalbloodflow,increasedglomerularvolume,andanincreasedtransglomerularpressuregradient,allcontributingtoariseinGFR.hypertrophy肥大gradient坡度、梯度GFRglomerularfiltrationrate.页脚... .肾小球滤过率在这段时间中，有肾脏肥大、肾血流增加、肾小球容积增大和经肾小球的压力梯度增加，这些都与肾小球滤过率增加有关。Importantly,thesechangesdependatleastinpartonhyperglycemia,astheyarediminishedbyintensivediabetestreatment.hyperglycemia高血糖intensive加强的，密集的重要的是，这些变化至少是部分依靠高血糖，因为通过有力的糖尿病治疗它们会消失。Threeto5yearsafterdiagnosis,earlyglomerularlesionsappear,characterizedbythickeningofglomerularbasementmembranes,mesangialmatrixexpansion,andarteriolosclerosis.mesangial肾小球系膜的matrix母体、基础诊断后的3~5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脉硬化为特征。Albuminexcretionremainslowduringearlyglomerularchanges;however,aspathologicchangesmount,theglomerulilisetheirfunctionalintegrity,resultinginglomerlarfiltrationdefectsandincreasedglomerularpermeability.Albumin白蛋白mount骑上、进行攻击integrity完整、完善defect缺点、缺陷permeability渗透性Albuminexcretionremainslowduringearlyglomerularchanges;however,aspathologicchangesmount,theglomerulilosetheirfunctionalintegrity,resultinginglomerlarfiltrationdefectsandincreasedglomerularpermeability.在肾小球变化早期白蛋白排泄仍然较低，但是，病理变化进行着，肾小球失去完善的功能，引起肾小球滤过的缺陷，肾小球渗透性增加。Althoughresultsofroutinetestsofrenalfunction(creatinineandurinalysis)stillremainnormal,microalbuminuria(30to300mg/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（30~300毫克／天）已经出现。Systemichypertensionisalsopresentatthistimeinmorethan50%ofcases.在这个时期，50%以上的病例还出现全身高血压。Afterseveralyears,mostdiabeticpatientsexhibitdiffuseglomerulosclerosis,althoughaminorityhavepathognomonicKimmelsteil-wilsonnodularthroughoutlesions.exhibit展示、陈列diffuse扩散、传播glomerulosclerosis肾小球硬化症pathognomonic特异病征性的数年以后，大多数糖尿病病人显示不断扩展的肾小球硬化，尽管只有少数病人有特异性的Kimmelsteil-wilson小结。Althoughpathologicchangescontinuetomountthroughoutthedisease,glomerulosclerosisextensiveenoughtocauseESRDdevelopsinaminorityofpatients;inthesecases,overtalbuminuria(>300mg/day)beginsapproximatedly15yearsafterdiagnosis..页脚... .overt明显的、公然的尽管病理变化在整个病程中是持续发展的，只有少数病人的肾小球硬化范围大到足以引起晚期肾病，这些病例中，明显的白蛋白尿（>300mg/天）大约在诊断后15年开始。Soonafter,followingavariableperiodontheorderof3to5years,theGFRbeginsarelentlessdecline(≥10ml/min/year),whichiseventuallyreflectedbyanincreaseinserumcreatinine.ontheorderof属于…一类的、与…相似的relentless残忍的、不留情面的之后，接着一个易变的时期，约需3~5年，肾小球滤过率开始极度下降（≥10毫升/天/年），最终以血清肌酐浓度增高表现出来。TheappearanceofmassiveproteinuriaandthenephroticsyndromeiscommoninthiscontextandoftenheraldsprogressiontoESRD.nephroticsyndrome肾病综合症context环境、背境、上下文herald传令、预示、预报progression进行、前进、进展在这样的情况下，大量蛋白尿和肾病综合症的出现是常见的，常预示晚期肾病的进展。Oncetheserumcreatininerises(reflectinganapproximately50%declineinGFR),ESRDdevelopsinmostpatientswithin10years.potentially潜在的、可能的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年内发展成晚期肾病。Thiscourseishighlyvariable,houever,particularlyintype2diabetics,whomayexhibitmoderateproteinuriaforseveralyearswithoutasubstantialdeteriorationofrenalfunction.deterioration变化、退化、恶化但是，这个过程是非常易变的，特别是2型糖尿病，可以出现许多年的中等蛋白尿而不发生实质性的肾功能恶化。Asimplebutusefulmethodofmonitoringprogressiontorenalfailureistoplotthereciprocaloftheseumcreatinineasafunctionoftime.plot小块地皮、地基、用图标出、阴谋reciprocal相互的、倒数、互补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录血清肌酐的倒数作为当时的肾功能。Thistechniqueallowsbetterassesssmentofboththerapeuticinterventionsandthetimewhenrenalreplacementtherapywillbecomenecessary.potentially潜在的、可能的inaccessible达不到的、难接近的这个技术使治疗性干预和肾移植时间的评价更为完善。Chapter26TraumainPregnancyPage78第二十六章孕期创伤第78页Traumaistheleadingnonobstetriccauseofmaternalmortalityandoccursinasmanyas7%.页脚... .ofpregnancies.maternal母亲的、母性的mortality死亡数、死亡率创伤是产妇死亡首要的非产科因素，在孕妇中多达7%。Themostcommonmechanismsofinjuryarefromfallsorfrommotorvehiclecrashes.mechanism机械、结构、机制vehicle运载工具、车辆最常见的损伤机制是跌倒或机动车碰撞。Whencomparedtoage-matchedpregnantcontrols,pregnantwomenwhosustainedtraumahadahigherincidenceofspontaneousabortion,pretermlabor,fetomaternalhemorrhage,abruptioplacentae,anduterinerupture.match与……相配、使成对ssustain遭受、承受同孕龄配对的对照试验中，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。Asthescopeiswithdrawn,endoscopicfindingscanbeidentifiedforsurgicalresectionortreatment.agreeon对……取得一致意见sphygmomanometer血压计因为内镜是后退的，内镜发现可以为外科决定切除或（保守）治疗。Theyieldofthisprocedureexceeds70%.这个措施的结果超过70%。Insomeclinicalsituations,thesiteofbleeldingcannotbeidentified,andthepatientrequireslong-termtransfusiontherapy.long-term长期的transfusion输血某些临床情况下，出血部位无法发现，病人而要长期的输血治疗。Multiplestudieshaveattemptedtoidentifyriskfactorsthatpredictmorbidityandmortalityinthepregnanttraumapatient.multiple多种因素组成的、复合的、多样的predict预计，预测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。ThematernalInjurySeverityScore,mechanismofinjury,andphysicalfindingsareunabletoadequatelypredictadverseoutcomessuchasabruptioplacentaeandfetalloss.adverse相反的、不利的母亲的创伤指数、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。Earlyinvolvementofanavailableobstetricianisimportanttoevaluatebothmaternalandfetalwell-being.involvement连累、缠绕available可用的、可联系的well-being康乐、安康、福利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。.页脚... .Inthemanagementofthepregnanttraumapatient,thecriticalpointisthatresuscitationofthefetusisaccomplishedbyresuscitationofthemother.critical紧要的、关键的处理孕妇创伤病人时，最关键的是抢救胎儿是通过抢救母亲完成的。Therefore,theinitialevaluationandtreatmentofthepregnantinjuredpatientisidenticaltothatofthenonpregnantinjuredpatient.identical同一的、完全相同的所以，对创伤孕妇的诊断和治疗和非受伤孕妇是相同的。Rapidassessmentofthematernalairway,breathing,andcirculationandensuringanadequateairwayavoidsmaternalandfetalhypoxia.快速评估母亲呼吸道、呼吸和循环，保证呼吸道通畅避免母亲和胎儿缺氧。Inthelaterstagesofpregnancy,asalreadydescribed,uterinecompressionofthevenacavamayresultinhypotensionfromdiminishedvenousreturn,sothepregnanttraumapatientshouldbeplacedinleftlateraldecubitusposition.compression压缩、挤压decubitus卧姿、褥疮在妊娠后期，如已描述的那样，子宫压迫腔静脉可引起静脉回流减少的低血压，所以创伤孕妇应摆放为左侧卧位。Ifspinalcordinjuryissuspected,thepatientmaybesecuredtoabackboardandthentiltedtotheleft.secure安全的、有把握的backboard靠背板、后部挡板tilt使倾斜、使偏斜假如怀疑脊柱损伤，病人可先仰卧在硬板然后转向左侧。Theincreasedbloodvolumeassociatedwithpregnancyhasimportantimplicationsinthetraumapatient.implication涉及、牵连因妊娠所增加的血容量与外伤关系密切。Signsofbloodlosssuchastachycardiaandhypotensionmaybedelayeduntilthepatientlosesnearly30%ofherbloodvolume.失血体征如心动过速、低血压可能延迟到病人失血达到近30%的血容量。Asaresult,thefetusmaybeexperiencinghypoperfusionlongbeforethemothermanifestsanysigns.perfusion灌注结果，在母亲出现表现前，胎儿可能存在长时间的血流灌注不足。Earlyandrapidfluidresuscitationshouldbeadministeredeveninthepregnantpatientwhoisnormotensive.administer执行，实施normotensive血压正常.页脚... .要早期快速输液，甚至对血压正常的孕妇也是如此。Chapter41DiagnosisofSuddenCardicDeath(SCD)Page118第四十一章心源性猝死的诊断第118页SCDisdeathduetoinstantaneous,unanticipatedcirculatorycollapsewithin1hourofinitialsymptomsandisoften,butnotalways,duetoacardiacarrhythmia.instantaneous瞬间的、即刻的、即时的unanticipated不曾预料到的心源性猝死是指出现初始症状1小时内的未能预料的循环衰竭死亡，并不少见，但不全是心律失常。Morethan70%ofallsuddennaturaldeathshaveacardiaccause,and80%oftheseareattributabletocoronaryarterydisease.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。Inassessingprognosisandplanningatreatmentstrategy,itisusefultoclassifySCDaseitherprimary(withoutacleartrigger)orsecondary.strategy策略、战略trigger触发、引起在评估预后和制定治疗方案时，将心源性猝死分为原发性（无明确的诱发因素）和继发性是实用的。Aprimaryepisodehasa10to30%1-yearrecurrencerate,whereasmostsecondaryepisodesareassociatedwithrecurrenceratesoflessthan2%.episode一段情节、插曲、有趣的事associatedwith联合原发性的在1年内有10~30的复发率，而大多数继发性的合在一起复发率小于2%。Identifiablereversibleprecipitantsofsecondaryventricularfibrillation(VF)includetransientischemiapossiblyrelatedtovasospasm;identifiable可确认的reversible可逆的precipitant仓促的、突然的transient短暂的、瞬时的可确认的可逆性继发性心室颤动（VF）的发作包括可能因血管痉挛的短暂缺血；hypokalemiaresultingfromdiuretics;hyperkalimiasecondarytorenalfailure,angiotensin-convertingenzymeinhibitors,prostaglandininhibitors,orpotassium-sparingdiuretics;hypokalemia低钾血症angiotensin-convertingenzyme血管紧张素转化酶prostaglandin前列腺素sparing节俭的、保守的利尿剂引起的低钾血症；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；proarrhythmiasecondarytoantiarrhythmics,tricyclics,andantihistamines;proarrhythmia致心律失常作用tricyclic三环的、三环分子antihistamine抗组织胺类继发抗心律失常药、三环类药和抗组胺类药的心律失常；.页脚... .orsubstanceabusewithdrugssuchascocaineandamphetamines.administerabuse滥用、陋习amphetamine安非他明、苯异丙胺或可卡因或安非他明类药物的滥用。可确认的可逆性继发性心室颤动（VF）的发作包括可能是血管痉挛的短暂缺血；利尿剂引起的低钾血症；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；或可卡因或安非他明类药物的滥用。Therapyisdirectedtowardremovingortreatingtheacuteprecipitant.removing消除治疗是直接消除或处理急性发作。SCDrelatedtoacuteischemiaintheabsenceofpriorMIoftenisassociatedwithsevereproximalocclusivedisease,normalleftventricularfunction,normalsignal-averagedECG,andnoninducibility[absenceofventriculartachycardia(VT)]duringelectrophysiologicstudy.MImyocardialinfarction心肌梗死average平均inducibility可诱导的缺乏心肌梗死前兆的急性缺血性心源性猝死常与严重的近端梗阻疾病有关，电生理研究时心室功能正常，心电图正常信号普通，无法诱异[缺乏室性心动过速（VT）]Mostpatientsshouldundergocomprehensiveevaluationofmyocardialfunctionandcoronaryanatomy.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。Echocardiographyisusefulforexcludinghypertrophiccardiomyopathyandvalvularheartdisease;echocardiography超声心动图hypertrophiccardiomyopathy肥厚性心肌病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；magneticresonanceimaging,fordiagnosingarrhythmogenicrightventriculardysplasia;magneticresonanceimaging磁共振dysplasia发育异常、结构异常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,andsarcoidosis.infiltrative渗透性的、浸润性的amyloidosis淀粉样变hemochromatosis血色素沉着sarcoidosis结节病心肌活检对浸润性疾病如心肌炎、淀粉样变、结节病很有用。Coronaryangiographyshoulebeperformedtoassessforthepresenceofcoronaryocclusivediseaseandtoexcludecoronaryarteryanomalies.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。.页脚... .Myocardialperfusionscintigraphyprovidescomplementarydataforassessingischemicburden.myocardialperfusionscintigraphy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提供辅助资料。Leftventricularfunctioncanbeassessedbycontrastventriculography,radionuclideventriculography,orechocardiography.ventriculography心室造影术radionuclideventriculography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。EvaluationofSCDsurvivorsalsoincludesHoltermonitoringand/orelectrophysiologictesting.Holtermonitoring动态心电图监护仪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。TheElectrophysiologicalStudyVersusElectrocardiographicMonitoring(ESVEM)trialshowed,however,a50%2-yearrecurrenceofventriculartachyarrhythmiasinpatientsinwhomantiarrhythnmicdrugssuccessfullysuppressedPVCs.ventriculartachyarrhythmias室性快速型心律失常PVCsprematureventricularcontraction室性早搏TheElectrophysiologicalStudyVersusElectrocardiographicMonitoring(ESVEM)trialshowed,however,a50%2-yearrecurrenceofventriculartachyarrhythmiasinpatientsinwhomantiarrhythnmicdrugssuccessfullysuppressedPVCs.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ThesedatasuggestadissociationbetweenPVCsuppressionandrecurrenceofVT;PVCsmayrepresentamarkerofleftventriculardysfunctionratherthanatriggerofSCD,orthearrhythmogenicsubstratemaychangeovertime.dissociation分裂、分离substrate底层、底物、基础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。InSCDsurvivors,sustainedmonomorphicventriculartachycardiaisinduciblebyelectrophysiologictestingin40to50%andpolymorphicVTin10to20%;in30to50%,nosustainedarryhthmiaisinduced.sustaine持继不变、相同、维持monomorphic单一同态的、单形的在心源性猝死生还者中，40~50%电生理试验能诱导持续单一型室性心动过速，10~20%能诱导多型的，30~50%不能诱导持续的节律异常。Inpatientswithischemicheartdiseaseandleftventriculardysfunction,inducibilityofsustainedVTcarriesapoorprognosis.administer执行，实施normotensive血压正常.页脚... .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。Alowejectionfractionisassociatedwithapoorprognosis,however,regardlessofwhethersustainedVTisinducible;patientswithanejectionfractionof30%orlessandwhoarenoninduciblehavea25%arrythmiarecurrencerateat1year,whereasnoninduciblepatientswithanejectionfractiongreaterthan30havea10to15%recurrencerate.ejectionfraction射血分数normotensive血压正常但是，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30%以下和不能诱导者1年有25%心律失常复发率，而射血分数大于30%的不能诱导者只有10~15%复发率。InpatientswithSCDandidiopathicdilatedcardiomyopathy,sustainedmonomorphicVTisrarelyinduced.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。NeithertheinabilitytoinduceVTnortheabilityofdrugstosuppressinduciblepolymorphicVTorVFisapredictorofafavorableoutcome.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型的VT和VF也不是良好结果的信号。Chapter22ShortnessofBreathn“shortnessofbreath”,“afeelingofnotbeingabletogetenoughair”,and“laboredbreathing”arealltermsusedbypatientstodescribethesymptomofdyspnea.n“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。nDyspnea呼吸困难nThecauseofdyspneamaybepulmonarydisease,circulatorydisease,orboth.n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。nPulmonary肺的nCirculatory循环nItisthephysician’sresponsibilitytodefinethecausativemechanismsofshortnessofbreathsothatdiagnostictechniquesandtherapiescanbedirectedappropriately.n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。nThemostconsistentcorrelateofthesymptomofdyspneaisincreasedmechanicalworkofbreathing,usuallybroughtonbyincreasedairwayresistanceasoccursinasthma,chronicbronchitis,andemphysema,ordecreaseddistensibilityofthelungsasoccursininterstitialfibroticreactions.n.页脚... .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。nConsistent连贯的，一致的nDistensibility膨胀性ninterstitialfibroticreactions间质纤维化反应nInthelatterdisease,increasedeffortisrequiredtoproduceahighernegativepressureinthepleuralspacetoinflatethelungs.n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。npleuralspace胸膜腔nInflate充气nTheincreasedmechanicalworkdoneonthelungstoovercomeobstructiontoairflowordecreaseddistensibilityisperceivedasanincreasedefforttobreatheandproducesthesymptomofdyspnea.n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Anincreaseddrivetoventilatemayalsocausedyspnea.Suchstimuliincludehypoxia,usuallywhenarterialoxygentensionsarelessthan60mmHg,andstimulifrominflamedlungparenchyma,asoccurinbacterialpneumoniaoralveolitisandthatdrivetherespiratorycentersofthebrain.nVentilate通气nHypoxia缺氧narterialoxygentensions动脉血氧张力n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。nThesestimulioftenlowertherestingcarbondioxidepressure(Pco2)tolessthanthenormallevelof40mmHgandcausedyspnea,especiallyonmildexertion.n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（Pco2）降低在正常的40mmHg以下。nPatientswithpulmonaryembolimaypresentwithshortnessofbreathandanormalchestroentgenogram.nChestroentgenogram.胸部X线片n肺栓塞病人也可能出现气促，但是胸部X线片表现正常。nHowever,theinefficiencyoftheembolizedlungforgasexchange,characterizedbyanenlargeddeadspace,requiresabnormallyhighventilatoryratestomaintainanormalarterialPco2.n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Pco2维持在正常水平。nUnlessthisparticularpresentationofpulmonaryembolismisappreciated,embolicdiseasegoesunrecognizedinmanypatientsuntiltheysuddenlydieorareextremelyincapacitatedbypulmonaryhypertensionandrightventricularfailure.n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。nBecauseofthehighprevalenceofheartdiseaseandheartfailureinthe.页脚... .generalpopulation,manypatientswithdyspneahavecardiacabnormalities.n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。nThebasisofthedyspneaisusuallyahighfillingpressureoftheleftventricle,whichcuaseshighleftatrialpressuresandhighpulmonarycapillaryandpulmonaryarterialpressures,whichinturnincreasethepulmonarybloodvolumeandreducelungcompliance.n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动脉压的增加，从而肺血流量提高，肺顺应性降低。nIfthepulmonarycapillarywedgepressureisintherangeof25mmHg,capillaryfluidtransudatesintothepulmonarymatrix,therebyreducinglungcompliance,increasetheworkofbreathing,andcausingdyspnea.n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。nEchocardiographyisusuallydiagnosticofabnormalventricularorvalvularfunctionandshouldbeperformedinanypatientinwhomthecauseofdyspneaisnotreadilyapparent.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。Chapter25CancerofunknownprimaryoriginnDefinitionThefirstsignsorsymptomsofcancerarefrequentlyduetometastasestovisceralornodalsitesnVisceral内脏的n肿瘤的第一个症状或体征往往是由于内脏或淋巴结转移nInmostsuchpatients,routineclinicalevaluationwithacomprehensivehistory,physicalexamination,completebloodcellcount,screeningchemistries,anddirectedradiologicevaluationofspecificsymptomsorsignsidentifiestheprimarytumor.n大多数此类病人，需要进行常规的临床检查，如详细的病史询问，体格检查，全血细胞计数，生化筛选及根据特定的症状和体征进行定向的放射学检查nPatientswhohavenoprimarytumorlocatedafterthisroutineclinicalevaluationaredefinedashavingcancerofunknownprimarysite.n常规临床检查后如果没有发现原发肿瘤，被称为原发灶不明的肿瘤。nEtiologyInpatientswhoseprimarysiteofcancerremainsundetectable,theprimarysitepresumablyhasremainedsmallor,lesslikely,hasregressedspontaneously.n如果病人原发肿瘤无法检测到，有可能肿瘤尚小，或者自然退化。nLargeautopsyseriesbeforetheroutineuseofcomputedtomographicscansormagneticresonanceimagingidentifiedsmallprimarysitesofcancerin85%ofpatientswithpreviouslyunidentifiedprimarytumors,.页脚... .n在CT和核磁共振常规应用之前，大批量的尸体解剖发现85％原发灶不明的肿瘤可以发现原发小肿瘤，nusuallyinthepancreas,lung,andvariousothergastrointestinalsites;withcurrentuseofcomputedtomographyandmagneticresonanceimaging,however,autopsyserieshaveidentifiedprimarysitesinonly50-70%ofpatients.n常见于胰腺，肺部和其他胃肠部位，而CT和核磁共振应用以后，尸检只能发现50－70％的原发部位。nIncidenceAbout3%ofallpatientswithcancerhavemetastaticdiseasewithoutaknownprimarysite,accountingforabout50000to60000casesperyearintheunitedstatesn约3％肿瘤转移的病人不能发现原发部位，美国一年大约发生50000到60000例nCancerofunknownprimarysiteoccurswithapproximatelyequalfrequencyinmenandwomen,anditincreasesinincidencewithadvancingage.n原发灶不明肿瘤男女发病率相似，随年龄增加发病率也有提高nClinicalandpathologicevaluationSinceallpatientswithcancerofunknownprimarysitehaveadvanceddisease,therapeuticnihilismhasbeencommon.nNihilism虚无幻想，怀疑的n因为很多原发灶不明的病人病程久远，通常认为治疗效果不佳。nHowever,itisnowevidentthatthisheterogeneousgroupcontainssubsetsofpatientswithwidelydiverseprognoses;somecancersarehighlyresponsivetotreatment,andsomepatientsmayhaveasubstantialchanceofachievinglong-termsurvivalwithappropriatetreatment.n但是现在已经明确，这个特质人群中包括了很多完全不同的预后病人，有些患者对治疗高度敏感，另外一些病人经过适当治疗可以出现本质上的改善从而延长nTheinitialclinicalandpathologicevaluationshouldthereforefocusonidentifyingaprimarysitewhenpossibleandonidentifyingpatientsforwhomspecifictreatmentisindicated.n最初的临床和病理评估应仅可能寻找原发部位，同时为患者确定特效的治疗。nInthemajorityofpatientswithcancerofunknownprimarysite,thediagnosisofadvancedcancerisstronglysuspectedaftertheinitialhistoryandphysicalexamination.n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。nAbriefadditionalevaluation,includingcompletebloodcellcounts,chemistryprofile,andcomputedtomographyofthechestandabdomenshouldbeperformed.n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。nInaddition,specificsymptomsorsignsshouldbeevaluatedwithappropriateradiologicandendoscopicstudies.n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。nIfaprimarysiteislocated,managementshouldfollowguidelinesforthespecificcanceridentified.n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。nInpatientswithnoobviousprimarysite,themostaccessiblesiteshould.页脚... .bebiopsied.n那些无明显原发病灶的病人，应对最可疑的部位进行活检。nFineneedleaspirationmayormaynotprovidesufficientmaterialforoptimalhistologicexaminationandspecialpathologicprocedures.nOptimal理想的，足够的n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。nIftissueisinadequate,alargerbiopsysampleshouldbeobtainedsothatallnecessarystainsandprocedurescanbeperformed.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。Chapter28SurgicalcomplicationsnPostoperativesurgicalcomplicationsrepresentoneofthemostfrustratinganddifficultoccurrencesexperiencedbysurgeonswhodoasignificantvolumeofsurgery.nFrustrating无效的，挫折的n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。Regardlessofhowtechnicallygifted,bright,andcapableasurgeonis,surgicalcomplicationsareavirtuallyguaranteedaspectoflife.nVirtually事实上n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。nThecostofsurgicalcomplicationsintheUnitedStatestodayrunsintomillionsofdollarsandisassociatedwithlostworkproductivity,disruptionofnormalfamilylife,andunanticipatedstresstoemployersandsocietyingeneral.n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。nFrequently,thefunctionalresultsoftheoperationarecompromisedbycomplication;insomecases,thepatientneverrecoverstothepreoperativeleveloffunction.n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。nThemostsignificantanddifficultpartofcomplicationsisthesuffering.页脚... .bornebythepatientwhoentersthehospitalanticipatinganuneventfuloperationbutisleftsufferingandcompromisedbythecomplication.n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，结果却导致了术后的痛苦和并发症。nComplicationscanoccurforavarietyofreasons.n外科并发症的发生有多种原因。nAsurgeoncanperformatechnicallyperfectoperationinapatientwhoisseverelycompromisedbythediseaseprocessandstillhaveacomplication.n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。nSimilarly,asurgeonwhoissloppy,iscareless,orhurriesthroughanoperationcanmaketechnicalerrorsthataccountfortheoperativecomplications.n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nFinally,thepatientcanbedoingwellnutritionally,haveanoperationperformedmeticulously,andyetsufferacomplicationbecauseofthenatureofthedisease.n最后，病人营养状况良好、手术非常细心，疾病本身也可以导致并发症的发生。nThepossibilityofpostoperativecomplicationsisapartofeverysurgeon’sthoughtprocesses-somethingwithwhichallsurgeonswillberequiredtodeal.n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。nSurgeonscandomuchtoavoidcomplicationsbythecarefulpreoperativescreeningprocess.n外科医生可以在术前进行精心筛选以避免术后并发症。nWhenthesurgeonseesthepotentialsurgicalcandidatethefirsttime,ahostofquestionscometomind,suchasthenutritionalstatusofthepatientsandquestionsaboutthehealthoftheheartandlungs.nahostof许许多多，一大堆n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。nThesurgeonwillmakeadecisionregardingperformingthecorrectoperationfortheappropriatedisease.n外科医生需要为病人作出正确的手术方式选择。nSimilarly,thetimingoftheoperationisoftenanimportantissuen同样的，手术时机也是一个重要的因素。nSomeoperationscanbeperformedinapurelyelectivefashion,whereasothershavesomeurgencyaboutanexpeditioussurgicalsolution.nExpeditious迅速地，敏捷地n一些手术可以择期进行，而有些可能需要进行急诊手术。Occasionally,thesurgeonwilldemandthatthepatientlostweightbeforetheoperationsothatthelikelihoodofasuccessfuloutcomeisimproved.n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,thewisesurgeonwillrequestpreoperativeconsultationfromacardiologist.页脚... .orpulmonaryspecialisttomakecertainthatpatientwillbeabletotoleratethestressesofaparticularprocedure.n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。nChapter30Epidemicinfluenzan第三十篇流行性感冒n本篇篇名为流行性感冒，人类史上几次人流感的世界性爆发都造成了巨大死伤。近几年的禽流感疫情也给人类带来了恐慌。本篇主要介绍流感的概念、过程和基本特点。nAnepidemicisanoutbreakofinfluenzaconfinedtoonegeographiclocation.n流行性感冒是指一个地理区域中的感冒的爆发。nInagivencommunity,epidemicsofinfluenzaAvirusinfectionoftenhaveacharacteristicpattern.n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。nTheyusuallybeginratherabruptly,reachasharppeakin2or3weeks,andlast6to10weeks.n通常爆发性流行，在2至3周内直线到达峰值，并持续6至10周。nIncreasednumbersofschoolchildrenwithfebrilerespiratoryillnessareoftenthefirstindicationofinfluenzaincommunity.n社区中流感发生的第一个迹象就是学生发热呼吸道疾病。nThisindicationissoonfollowedbyillnessesamongadultsandaboutaweeklaterbyincreasedhospitaladmissionsofpatientswithinfluenza-relatedcomplications.n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。nHospitalizationratesinhigh-riskpersonsincreasetwo-tofivefoldduring.页脚... .majorepidemics.n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。nSchoolandemploymentabsenteeismincreases,asdoesmortalityfrompneumoniaandinfluenza,especiallyinolderpersons.n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。nThelatterfindingisahighlyspecificindicatorofinfluenzaactivity.n后一项发现是流感活动高度特异性指标。nEpidemicsoccuralmostexclusivelyduringthewintermonthsintemperateareas,butinfluenzaactivitymaycontinueyear-roundinthetropics.n在温带地区流感基本发生在冬季，但热带区域流感在全年均有发生。nOutbreaksmayoccurintourgroups(landorship)andinfacilitiesduringsummermonths,particularlyaftertheappearanceofadriftvariant.n流感爆发可出现在夏季旅游团队（陆地和船舶）及建筑物内，尤其是在不同地点迁徙后。nRegionaldifferencesinthetimeandmagnitudeofoccurrenceofinfluenzaoutbreaksarecommonn流感发生的时间和强度区域差异基本类似。nDuringepidemics,theoverallattackratestypicallyaverage5to20%inadults.n成人的流感发生率平均在5％至20％。nAttackratesof40to50%arenotuncommoninclosedpopulations,includingthoseinhospitalsandnursinghomes,andincertainhighlysusceptibleagegroups.n封闭人群中，包括住院病人或易感人群的感染率通常在40至50％。Twodifferentstrainswithinasinglesubtype,twodifferentinfluenzaAsubtypes(H1N1andH3N2),orbothinfluenzaAandBvirusesmaycocirculate.n一个亚群中的两个不同菌株，两种不同的流感A病毒亚群，或者流感A和B病毒均能发生互相传播。nInaddition,simultaneousoutbreaksofinfluenzaAandrespiratorysyncytialviruseshavebeenfound.n而且，也有报道发现A型流感病毒和呼吸道合胞病毒同时感染。nStrainscirculatingattheendofoneseason’sepidemicaresometimesresponsibleforthenextseason’soutbreak(theso-calledheraldwavephenomenon).n每个季度末期流行的菌株通常会导致下一轮流感爆发（theso-calledheraldwavephenomenon）nFurthermore,otherthantheassociationofinfluenzaoutbreakswithcolderseasons,thefactorsthatallowsanepidemictodeveloporthoseresponsibleforthetaperingoffofanepidemicwhenonlysomesusceptiblepersonshavebeeninfectedareunknown.n而且，除了流感爆发与气候寒冷有关以外，流感爆发或逐渐消失而仅影响易感人群的机制尚不清楚。nPneumoniaandinfluenza(P+I)-relateddeathsfluctuateannually,withpeaksinthewintermonths..页脚... .n肺炎和流感相关死亡一年中有波动，冬季为高峰期。nWhensuchP+Ideathsexceedthepredictednumber,itisduetoinfluenzaAoroccasionallytoinfluenzaBvirusorrespiratorysyncytialvirusactivity.n如果肺炎流感死亡超过预期数字，这是A型流感所造成的，偶尔也有可能为B型流感病毒或者是呼吸道合胞病毒引起。nAlthoughmortalityisgreatestduringpandemics,substantialtotalmortalityoccurswithepidemics.nPandemics大范围流传nOver85%ofP+Ideathsoccuramongpersonsaged65andolder.n超过85％的肺炎流感死亡发生于超过65岁的老年人群。nOthercardiopulmonaryandchronicdiseasesalsoresultinincreasedmortalityafterinfluenzaepidemics,sothatoverallinfluenza-associatedmortalityisabouttwo-tofourfoldhigherthanP+Ideaths.其他心肺和慢性疾病也可以使流感后死亡率的上升，因此总的流感相关的死亡率比肺炎流感的死亡率高20％——40％。nChapter35Principlesoforderingimagingtestsn本篇篇名为影像检查的选择原则。影像学检查在临床的诊治中是不可或缺的，但如何选择则有原则可循。本篇主要介绍选择影像学检查的基本原则，列举了几种常见影像学检查的比较。nAsageneralrule,whenconfrontedwithtworeasonablealternatives,itisadvisabletochoosetheleastexpensive,safest,andleastuncomfortableimagingexaminationfirst.n通常来说，如果有两种检查方法可以选择，首先我们会使用低价位，安全和较舒适的影像检查。nForacuterightupperquadrantabdominalpain,ultrasonographyisusuallytheprocedureofchoicebecauseitislessexpensivethanCT,primarilybecausetheimagingequipmentischeaper.n对急性右上腹痛，超声是常规的检查方法，因为它比CT更便宜，原因在于影像设备的便宜。nAlthoughultrasoundismoresubjectiveandoperatordependentthanCT,ultrasoundcanyieldexquisitevisualizationofthebiliarytree,includingthegallbladderandthepericholecysticspace,inwhichfluidcanbeasignofacutecholecystitis.n虽然超声比CT更加主观，更加以来于操作人员的经验，但超声对胆道的图像非常精确，包括胆囊和胆囊周围的空间，如急性胆囊炎可表现出液体。nUItrasonographyalsoconfirmsordeniesthepresenceofgallstonesinthe.页脚... .gallbladderwithhighaccuracythatatleastequalsthatofCT,andultrasonographycandetectbiliarydilationsandmassesintheliverandpancreasn超声对胆囊中胆石是否存在的精确度超过至少与CT相似，超声也能确定胆管是否扩张及肝脏或胰腺的占位病变。nUltrasonographycanbedifficultandsuboptimalinpatientswhoareobeseorwhohaveadistendedabdomen.n超声检查对肥胖或腹胀病人的诊断比较困难或效果不佳。nUltrasonographyisgenerallylessaccurateinsurveyingtheremainderoftheabdomen,animportantissuewhenthepainislesslocalized.n超声对诊断腹部残留物的诊断不佳，尤其是腹部不局限的情况下。nHowshouldthechoicebetweenCTorultrasonographybemadeinapatientwhopresentswithacuteabdominalpain?n急腹症时如何选择CT或者超声诊断呢？nMorespecifically,whenisitappropriatetomovedirectlytoCT？n更具体地说，什么时候可以直接进行CT检查？nIngeneral,ifthepainisnotbiliaryincharacter,isnotlocalizedtotherightupperquadrant,oroccursinanobesepatient,CTispreferredbecauseitoftenrevealspreviouslyunsuspectedabnormalities.n通常认为，如果疼痛特征不提示胆道疾病，不局限于右上腹部，或者病人肥胖，可以直接进行CT检查可以发现先前未明确的疾病。nAtleastthreeotherimagingchoicesexist:(1)noimagingstudy;(2)aplainradiographicseriesoftheabdomen(technicallyandeconomicallysimilartothechestradiographbutgenerallynotasuseful);(3)MRIoftheabdomenorpelvis(usuallyreservedformorecomplexsituationsorafterfailuretodiagnosewithothermethods).n至少还可有其它三种影像学检查的选择：（1）不做影像学检查；（2）腹部平片（技术和价格与胸片相当，当效果通常不好）；（3）腹部或盆腔的核磁共振（在复杂或者其他诊断技术无效的情况下使用）nOtherthanidentifyingfreeintraperitonealair(perforatedviscus),gaspatternsofbowelobstruction,andradiodenseureteralcalculi,thetraditionalabdominalseries,althoughtheleastexpensivetest,isconsideredgenerallyinferiortoCTandhasbeenlargelyreplacedbyCT.n除了鉴别游离的腹腔气体（内脏穿孔），肠梗阻的积气和输尿管不透射线的结石以外，虽然价格低廉，但效果通常比CT差，而且大部分已被CT替代。nAcurrent-generationmultislicehelicalCTscannercangenerate5-mmsectionsoftheentireabdomenandpelvisinabout1minute.n当代的多层螺旋CT可以在1分钟内形成腹部和盆腔的5mm切片。nItishelpfultouseoralandintravenouscontrastmaterialtoopacify(andidentify)loopsofbowelandvascularstructures.nOpacify不透明的n口服或静脉使用造影剂有助于使肠道或者血管突出显影。nMRIcanbeusefulforthecooperativepatientinrenalfailurewhocannotreceiveintravenouscontrastmaterialbecauseitcanprovidetissueand.页脚... .vasculardetailnotachievablewithoutcontrast-enhancedCT.n对不能使用静脉造影剂的配合的肾衰病人，可以使用核磁共振获得通常只有增强造影CT可以获得的组织和血管影像。nPatientcooperationisrequiredbecauseofthelongerimagingtimesandrespiratorymotionartifacts.nrespiratorymotionartifacts呼吸伪影n病人的合作是必须的，因为检查时间长，而且存在呼吸伪影。nChapter45AcuteAbodomen-DecisiontoOperatenThesedifficultiesnotwithstanding,thesurgeonmustmakeadecisiontooperateornot.Certainindicationsforsurgicaltreatmentexist.nNotwithstanding尽管虽然n尽管有这些困难，外科医生必须作出是否手术的选择。有一些外科手术的指征。nForexample,definitesignsofperitonitissuchastenderness,guarding,andreboundtendernesssupportthedecisiontooperate.nPeritonitis腹膜炎n比如说，特定的腹膜炎体征如腹痛，肌卫，反跳痛都支持手术的决定。nLikewise，severeorincreasinglocalizedabdominaltendernessshouldpromptanoperation.n同样的，严重的或者逐渐加重的局限性腹痛也应马上手术。nPatientswithabdominalpainandsignsofsepsisthatcannotbeexplainedbyanyotherfindingshouldundergooperation.n无法解释的腹痛伴随脓毒症的病人应该进行手术。nThosepatientssuspectedofhavingacuteintestinalischemiashouldbeoperatedonaftercompleteevalution.n对怀疑肠缺血的病人需进行充分评估后手术。nCertainradiogragphicfindingsconfidentlypredicttheneedforoperation.n某些诊断学的发现比较确切地提示了手术指证。nThesefindingincludepneumoperitoneumandradiologicevidenceof.页脚... .gastrointestinalperforationn这些发现包括气腹证或者胃肠穿孔的放射学证据。nPatientspresentingwithabdominalpainandfreeintra-abodominalgasseenonradiographwarrantoperationwithlimitedexceptions.n如果患者有腹痛并且X光片上有腹腔内气体，绝大部分病人需要手术。nObservationwithserialexaminationsmaybeappropriateforapatientwithfreegasafteracolonoscopy.n结肠镜检查后出现自由气体的病人需要观察并做一系列的检查。nIntra-abdominalgascanpersistforadayortwofollowingceliotomy.n剖腹术后腹腔内气体还可以遗留一至二天。nImagingtestscanrevealsignsofvascularocclusionrequiringoperation.n放射学检查可以提示需要手术的血管阻塞疾病。nAftercarefulexaminationandevaluation,diagnosticuncertaintycanremain.Somepatientsmayhaveequivocalphysicalfindings.n详细的检查和评估之后，诊断未明确的可以继续观察。一些病人可能表现出模棱两可的体征。nWhenthisoccursandthediagnosisisunclearandthepatientswellnessisunclear,itmaybeadvisabletodeferoperationandtore-examinethepatientcarefullyafterseveralhours.n如果有上述情况，诊断不明确，病人症状无好转，建议延期手术，数小时后再次详细检查。Thisisbestdoneinashort-stayunitinthehospital,inaspecialunitintheemergencydepartment,orifnecessary,byregularhospitaladmission.n最好能在医院短期留观或者在急诊室观察，如果有必要可以入院观察。nInaperiodofhours,vaguepainwithminimalphysicalfindingsmayproceedtodefinitelocalizedpainwithtenderness,guarding,andreboundtenderness;ifthatoccurs,operationshouldfollown如果在数小时内，没有明显体征的腹胀转化为明确的局限性腹痛，肌卫和反跳痛，则手术指证明显。nAfterseveralhours,thepatient’ssymptomsandsignsmayalsoresolve.n也有可能，数小时后病人的症状和体征消失。nWhenthathappens,thepatientcanbedismissed,althoughthepatientshouldhaveafollow-upappointmentscheduledwithinadayorsotopermitre-examinationtobecertainthatanimportantdiagnosiswasnotmissed.n如果是这种情况，病人可以出院，虽然仍需短期的随访和重新检查，以免遗漏重要的诊断。nCertainpatientsaredifficulttoevaluatebecauseofspecialcharacteristics.n有些病人由于特殊性很难评估。nForexample,patientswhoareneurologicallyimpairedasresultofstrokeoraspinalcordinjurymaybedifficulttoevaluate.n如由于中风或脊髓损伤导致的神经系统功能不全的病人。nPatientswhoareundertheinfluenceofdrugsoralcoholmayrequirespecialorsubsequentexamination..页脚... .n受药物（毒品）或酒精影响的病人需要进行特殊或者后续进一步检查。nPatientswhotakesteroidsorareotherwiseimmunosuppresseddeservespecialmentionbecausesteroidsandimmunosuppressionmasktheintensityofabdominalpainandthephysicalfindingsofsevere,life-threateningintra-abdominaldisease.n服用类固醇或免疫抑制剂的病人需要特别注意，因为类固醇和免疫抑制剂能掩盖腹痛的程度及严重致命的腹腔疾病。nPatientsinthiscategorywhohavepersistent,unequivocalabdominalpainandevenminimalfindingsshouldbeconsideredforsurgicaloperation.nunequivocal明确的，不模棱两可的n此类病人如果有持续性，明确的腹痛，甚至轻微的腹痛也应该手术。nSomepatientswithclearfindingsoftheacuteabdomenmaybetreatedwithoutsurgicaloperationn有些病人即使有明确的急腹症也可以不需要手术。nForexample,patientswithperforatedduodenalulcerwhoseekattentionlateinthecourseoftheirdiseaseaftertheyhavebeensickforseveraldaysmaybetreatedbestbycarefulsupportivecareincludingnasogastricsuction,intravenousfluids,andpainrelief.n如十二指肠溃疡穿孔病人，病人已有多天，而发作也很迟，最好进行支持性治疗，如胃肠减压，静脉输液和止痛。nCertainpatientswithempyema积脓ofthegallbladder,especiallythosewithotherseriousconcomitant伴随的illnesses,canbetreatedbypercutaneousdrainageoftheinfectedgallbladderandcarefulsupportivecareratherthanwithcholecystectomy.n对于胆囊积脓患者，尤其是伴有其他严重疾病，宁可选择经皮引流和支持疗法，而不进行胆囊切除术。.页脚... .Chapter36Endoscopicultrasonograhy本篇篇名为内镜超声检查（或称超声内镜）。在疾病诊治上，超生内镜作为一种检查和治疗的新技术在临床上逐渐得以应用，与传统的诊治方法比较，它具有一定的优势。本篇主要介绍内镜超声检查的基本情况、与传统方法比较以及它在临床诊治方面的优势所在。nThedevelopmentofendoscopicultrasonography(EUS),orendosonography,hasbeenamajortechnologicalachievementingastroenterology.nGastroenterology胃肠学nachievement成就n胃肠内镜的发展是胃肠学上重大的技术成就。nTheincorporationofanultrasonictransducerintipofaflexibleendoscopeortheuseofstand-aloneultrasoundprobeshasnowmadeitpossibletoobtainimagesofgastrointestinallesionsthatarenotapparentonsuperficialviews,includinglesionswithinthewallofthegutaswellthosethatliebeyond(e.g.,pancreaticorlymphnodelesions)。nIncorporation并入，掺合nTransducer超声换能器nSuperficial表面的，浅表的nGut肠道的nFlexible柔软的，易曲的n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）。.页脚... .nAfurtherroleofEUSistoguidefine-needleaspiration,whichoftenprovidespathologicconfirmationofsuspiciouslesions.n超声内镜另外被用作细针穿刺的引导，可以对可疑的病灶进行病理学的确诊。Inmanycases,thisapproachappearstobeevenmoreaccuratethanconventionalradiologictechniquessuchabdominalultrasonographyorCT.nConventional常规的，一般的nApproach方法n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。nThus,EUSisprobablythesinglebesttestfordiagnosingpancreatictumors,particularlythesmallendocrinevarieties,withsensitivitiesapproaching95%.n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％。nItisalsotheprocedureofchoiceforimagingsubmucosalandotherwalllesionsofthegastrointestinaltract(overallaccuracyof65to70%)aswellasforstagingofavarietyofgastrointestinaltumors(overallaccuracyof90%ormore).nSubmucosa粘膜下层的nEUS同时是粘膜下层和其他胃肠道壁疾病的常规检查方法（总体准确率为65％到70％），也是很多胃肠道肿瘤分期的方法（总体准确率超过90％）nPreoperativestagingisacriticalelementinthemanagementstrategyfortumorssuchasesophagealandpancreaticcancer,n肿瘤治疗的术前分期是非常关键的因素，尤其对食道癌和胰腺癌。nEUScancomplementmoreconventionalradiologicteststohelpdeterminetheresectabilityandcurativepotentialofsurgeryinthesecases.nComplement补足，补充nConventional常规的，惯例的，一般的nEUS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。nInadditiontoitsvaluablediagnosticrole,EUSisrapidlyemergingastherapeutictool.n除了其有价值的诊断作用，EUS正快速地成为治疗工具。nOneexampleisEUS-dierctedceliacplexusneurolysis,atechniquethatappearstoeffectiveforthetreatmentofpaininpatientswithpancreaticcancer.nceliacplexus腹腔丛nNeurolysis神经松紧术n其中一个例子就是采取EUS导向的腹腔丛神经松紧术治疗胰腺癌所导致的疼痛。nUnfortunately,thisapproachdoesnotappeartoworkaswellinpatientswithchronicpancreatitis.n不幸的是，这个治疗方法好像对慢性胰腺炎疗效不佳。.页脚... .nChapter54BenefitofEarlyenteralfeedingversusparenteralnutritionn本篇篇名为早期肠内与肠外营养的优点比较。病人的营养供给是必需的，但选择的途径可以有所不同，如肠内营养或肠外营养。比较而言，这两种营养均比较安全。本篇主要对一些病人的早期营养与肠外营养进行比较，结果提示，早期场内营养在降低感染和减少住院时间等方面有优势。nItisoftensaidthatenteralnutritionissaferandmoreefficaciousthantheparenteralroute.n人们通常认为肠内营养比肠外营养更安全,更有效.但这一观点并没有在早期的动物实验和临床研究中得到承认nHoweverapreliminarynoteofcautionisraisedfromobservationsinexperimentalanimals,whichconcludedthatoutcomesofenteralandparentaeralnutritionwereequivalentwhenanimalswithcathetersepsiswereeliminated.n但是动物实验观察得到的初部结果告诉我们当导管脓毒症消除以后，肠内和肠外营养结果是类似的。nNumerousstudieshaveshownthatitissafetofeedthegutintheimmediatepostoperativeperiodandthatthispracticedoesnotplacetheintegrityofintestinalanastomosesatrisk.n.页脚... .为数众多的研究标明术后即刻的肠内营养是安全的，同时对肠吻合口也不会带来风险。nEarlyfeedinghasbeenstudiedprimarilyintwopatientpopulations:thosewhohaveundergonegastrointestinalsurgeryandintraumaticallyinjuredorcriticallyillpersons.n早期进食实验最初是在两组实验病人中进行：一组是为胃肠术后病人，另一组为创伤或危重病人。nArecentmeta-analysisreviewed11prospective,randomized,controlledtrailsthatcomparedthepracticeofearlyenteralfeedingtomaintainingpatientsNPOafterelectivegastrointestinalsurgery.n最近的一项meta分析对11个随机分组前瞻性研究来对照择期胃肠术后早期肠内营养与禁食病人。nThisanalysisof837patientsconcludedthatthereisnoclearadvantagetokeepingpatientsNPOpostoperativelyandthatearlyfeedingmaybeofbenefitindecreasinginfectionsandshorteningpostoperativelengthofstay.对837位病人的研究标明术后禁食病人（比早期肠内营养）没有明显益处，而且早期进食可以降低感染率，缩短住院时间。nHowever,acloserevaluationofthisdatarevealsthatthelengthofstaywasreducedonlyby0.84day,andalthoughtherewasanincreasein“anytypeofinfection”intheNPOgroup,whenconsideredindividually,therewasnodifferenceintheincidenceofanastomoticdehiscence,woundinfections,pneumonia,intra-abdominalabscess,ormortality.n但是，另一项相近的研究认为禁食组病人虽然住院时间缩短了0.84天，但“感染”发生率提高了，个别进行分析的结果表明，吻和口瘘，切口感染，肺炎，腹内脓肿及死亡率（两组间）没有差别。nIn2001MarikandZalogaperformedameta-analysisof15randomized,controlledtrailsinvolving753subjectsthatcomparedearlywithdelayedenteralnutritionincriticallyillsurgicalpatients.Earlyenteralnutritionwasassociatedwithasignificantlylowerincidenceofinfection(relativeriskreductionof0.45)andreducedlengthofhospitalstay(2.2daysless).n2001年Marik和Zaloga对15组753例危重外科病人进行了meta分析以比较早期和晚期肠内营养的疗效。早期肠内营养组感染发生率明显较低（相对风险降低0.45），住院日也有减少（少2.2天）。nTherewerenodifferencesinnoninfectiouscomplicationsorinmortality.Theauthorsconcludedthatearlyinitiationofenteralfeedingwasbeneficial,butthisresultmustbeinterpretedwithcautionbecauseofsubstantialheterogeneitybetweenstudies.n非感染性并发症和死亡率无明显差别。作者认为早期肠内营养是有益的，但是考虑到研究中的差异性，这个结果需要谨慎对待nThestudiesthatcomparedenteralandparenteralnutritioninthetraumapopulation,asdiscussedearlier,concludedthatenteralwassuperiorbecauseofanattenuatedinflammatoryresponseandadecreaseinsepticmorbidity.nAttenuated衰减，减弱.页脚... .nInflammatory炎症性nsepticmorbidityn败血症发病率由于感染率和败血症发病率低，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，肠内营养超过肠外营养。nWhenthesestudiesareexaminedmoreclosely,itisclearthatpatientswhowerefedenterallyusuallyreceivedsignificantlylesscaloriesthanthosefedparenterally.n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。nThisdiscrepancyof“relativeoverfeeding”intheTPNgroupsinmanyinstancesledtohyperglycemia,presumablypredisposingpatientstoimmunedysfunctionandnosocomialinfection.nDiscrepancy不一致，偏差nHyperglycemia高血糖症nnosocomialinfection院内感染nPredispose成为因素nTPN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。nThus,poorglucosecontrolalonemayaccountfortheobserveddifferencesinoutcome.naccountfor说明，解释n因此，血糖控制不佳可以解释说观察到的结果的差异。nInmorecontemporarystudieswherefeedsarecarefullyadvancedinamannerthatavoidshyperglycemiaandgroupsarefedequivalentproteinandcalories,thereappearstobelittledifferenceinclinicaloutcomebetweenenteralandparenteralroutesoffeeding.nContemporary当代的，同代的nEquivalent相当的，相等的n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。nEnteralnutritionalsocanendangerpatientsafetyinuniqueways.nEndanger使危险，危及nUnique独特的n肠内营养也可以危及病人的安危。nDeathsinpersonsreceivingenteralnutritionareoftenduetoaspiration,forexamplewhengastricmotilitysuddenlyisimpairedwiththeonsetofsepsisnAspiration误吸ngastricmotilityn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。nOnedeathfromaspirationisequivalenttothemortalityover2to3yearsofwell-operatedparenteralnutritionprogram,despitethedangerofcathetersepsis,whichinwell-operatedunitsisnowlessthan1%to3%.n equivalent相当的，相等的.页脚... .ncathetersepsis导管脓毒症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2－3年良好管理的肠外营养病人相当。.页脚...