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Chapter1Patient-PhysicianInteraction第一章醫(yī)患溝通

Thepatient-physicianinteractionproceedsthroughmanyphasesofclinicalreasoning

anddecisionmaking.醫(yī)患溝通在臨床診斷和治療決策的許多階段中進行著。The

interactionbeginswithanelucidationofcomplaintsorconcerns,followedbyinquiriesor

evaluationtoaddresstheseconcernsinincreasinglypreciseways.這種溝通開始于病人訴說

或所關注問題,然后通過詢問、評估不斷精確地確定這些問題。Theprocesscommonly

requiresacarefulhistoryorphysicalexamination,orderingofdiagnostictests,integrationof

clinicalfindingswiththetestresults,understandingoftherisksandbenefitsofthepossible

coursesofaction,andcarefulconsultationwiththepatientandfamilytodevelopfuture

plans.這個過程通常需要細致的病史詢問和體格檢查,進行診斷性化驗,綜合臨床發(fā)現(xiàn)和化

驗結果,理解分析擬行治療過程中的風險和療效,并與病人及家屬反復磋商以形成治療方

案Physiciansincreasinglycancallonagrowingliteratureofevidence-basedmedicineto

guidetheprocesssothatbenefitismaximized,whilerespectingindividualvariations

amongdifferentpatients.醫(yī)生們越來越容易查閱不斷增長的循證醫(yī)學文獻來指導這個過程,

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。

Theincreasingavailabilityofrandomizedtrialstoguidetheapproachtodiagnosisand

therapyshouldnotbeequatedwithucookbook^^medicine越來越多的可用于指導臨床診斷

與治療的隨機試驗資料不應變成“烹調書”醫(yī)學。Evidenceandtheguidelinesthatarederived

fromitemphasizeprovenapproachesforpatientswithspecificcharacteristics.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。Substantialclinicaljudgmentis

requiredtodeterminewhethertheevidenceandguidelinesapplytoindividualpatientsand

torecognizetheoccasional.實際的臨床判斷需要確定這些現(xiàn)象和思路能否應用于某個病人

個體,并能找出例外。Evenmorejudgmentisrequiredinthemanysituationsinwhich

evidenceisabsentorinconclusive,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。Evidencealsomustbetemperedbypatients9preferences,althoughitisaphysician's

responsibilitytoemphasizewhenpresentingalternativeoptionstothepatient.病人還會根

據(jù)自己的傾向調節(jié)著臨床癥狀,但醫(yī)生有責任通過選擇性問題搞清事實。Theadherenceofa

patienttoaspecificregimenislikelytobeenhancedifthepatientalsounderstandsthe

rationaleandevidencebehindtherecommendedoption.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,thephysicianmustunderstandthepatientasa

person.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)。

Thisfundamentalpreceptofdoctoringincludesanunderstandingofthepatienfssocial

situation,familyissues,financialconcerns,andpreferencesfordifferenttypesofcareand

outcomes,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、

不同治療結果的選擇,從最大限度地延長生命到臨時緩解疼痛和折磨。Ifthephysiciandoes

notappreciateandaddresstheseissues,thescienceofmedicinecannotbeapplied

appropriately,andeventhemostknowledgeablephysicianfailstoachieveappropriate

outcomes.假如醫(yī)生沒有正確理解和定位這個問題,醫(yī)學就不可能恰當?shù)貞糜谂R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果。

Evenasphysiciansbecomeincreasinglyawareofnewdiscoveries,patientscanobtain

theirowninformationfromavarietyofsources,someofwhichareofquestionablereliability.

甚至,當醫(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,

當然,某些信息是不可靠的。Theincreasinguseofalternativeandcomplementarytherapies

isanexampleofpatients9frequentdissatisfactionwithprescribedmedicaltherapy?替代療法

和輔助療法的應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。Physiciansshould

keepanopenmindregardingunprovenoptionsbutmustadvisetheirpatientscarefullyif

suchoptionsmaycarryanydegreeofpotentialrisks,includingtheriskthattheymayrelied

ontosubstituteforprovenapproaches醫(yī)生對未證實的療法應該保持開放的思想,但是,如

果這些療法具有任何程度的潛在風險,都必須細致地告知病人,包括可能需要用已證實的

常規(guī)療法去替代的風險。Itiscrucialforthephysiciantohaveanopendialoguewiththe

patientandfamilyregardingthefullrangeofoptionsthateithermayconsider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,是極及關鍵的。

Thephysiciandoesnotexistinavacuumbutratheraspartofacomplicatedand

extensivesystemofmedicalcareandpubichealth.醫(yī)生不是生存在真空中的,而是復雜而龐

大的醫(yī)療和公共健康體系中的一部分。Inpremoderntimesandeventodayinsome

developingcountries,basichygiene,cleanwater,andadequatenutritionhavebeenthemost

importantwaystopromotehealthandreducedisease.在未發(fā)達時代,甚至當今在一些發(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。In

developedcountries,theadoptionofhealthylifestyles,includingbetterdietandappropriate

exercise,arecornerstonestoreducingtheepidemicsofobesity,coronarydisease,and

diabetes.而在發(fā)達國家中,健康的生活方式包括合理飲食和適當鍛煉,是減少肥胖、冠心病

和糖尿病盛行的基礎。Publichealthinterventionstoprovideimmunizationsandtoreduce

injuriesandtheuseoftobacco,illicitdrugs,andexcessalcoholcollectivelycanproducemore

healthbenefitthannearlyanyotherimaginablehealthintervention.公共健康干預如進行疫

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措施都要好。

Chapter5ClinicalPreventiveServices第五章臨床預防服務

Clinicalpreventiveservicesincludecounseling,immunization,screeningtests,and

reductionofthesusceptibilitytodiseasebyinterventionssuchastherapeuticlifestyle

changesandpharmacotherapy.臨床預防服務包括對疾病的咨詢、防疫、篩查以及通過治療

性的生活習慣改變和藥物治療來減少易感性。Preventiveserviceoftenareclassifiedas

primary,secondary,ortertiary.臨床預防服務常分為一級預防、二級預防和三級預防。

Primarypreventionisdirectedtowardpreventingdiseaseorinjurybeforeitdevelops,

whereassecondarypreventiondealswithearlydetectionandtreatmenttoimpedethe

progressofovertdisease.一級預防是直接針對疾病或損傷發(fā)生前的預防,而二級預防是解決

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,

tertiarypreventionreferstorehabilitativeactivitiesaftertheonsetofdiseasetominimize

complicationsanddisability.對比之下,三級預防是指疾病發(fā)生后的康復治療,以減少并發(fā)

癥和病殘。Becauseofconsiderableoverlap,distinguishingamongthesephasesofprevention

maybeconfusing.因為(三級預防之間)有相當大的交叉,這些預防階段的區(qū)分可能有些

混淆。Detectingandtreatinghypertensioncouldbeconsideredsecondarypreventionof

hypertensivecardiovasculardiseasebutprimarypreventionofheartfailureandstroke.發(fā)

現(xiàn)和治療高血壓可以認為是對高血壓性心血管疾病的二級預防,但也可是對心力衰竭和中

風的一級預防。Preventionmaybeperceivedbestalongacontinuumfrommodificationof

predisposingfactors,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防。Thesoonerthe

prevention,themorelikelyunnecessaryillness,disability,andprematuredeathcanbe

avoided.預防得越早,越不易發(fā)生不必要的疾病,病殘和早死就能夠避免。Increasing

emphasishasbeenplacedonpreventingriskfactorsthemselves.越來越多的重點已經(jīng)集中到

對危險因素本身的預防。Thetermprimordialpreventionhasbeenintroducedforthis

concept.術語…根源預防(病因預防)已經(jīng)引進了這個概念。

Indiscriminatescreeningforriskfactorsordiseasewithoutadequateadviceand

follow-upservesnousefulpurpose.沒有引導和隨訪的毫無選擇地遠離危險因素或疾病是沒

有實用價值的預防。Theperiodichealthexaminationhasevolvedfromanannual,

broad-based,uniformprotocoltoanapproachthattargetstheprevention,detection,and

treatmentofspecificdiseasesorriskfactorsforparticularage,gender,andethnicgroupsat

appropriateintervals.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

的周期對特定年齡、性別和種群的特殊疾病或危險因素有目的地預防、發(fā)現(xiàn)和治療。Current

recommendationsbytheU.S.PreventiveServicesTaskForcearebasedonsystematic

evidencereviewsthatdistinguishprocedureslikelytoproveeffectiveandtohave

substantiallymorebenefitthanharm.美國預防服務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防措施。

Changesinthehealthcaresystemandthedevelopmentofnationalguidelinesfor

managementofdiseasearelikelytodrawgreaterattentiontohealthpromotion,disease

prevention,andtheinterfaceofphysician-basedmedicalcarewiththepublichealthcare

system.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。Physiciansshouldconsidereach

disorderintermsofthepotentialforprevention,includingthepossibilityofadverseeffects

andcost?effectiveness.醫(yī)生應該以有無需要預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。Aconceptusefulforclinicaldecisionmakingisthenumberof

patientsneededtotreattopreventoneadverseevent,whichisbasedonabsoluterisk

reduction.一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

防,這是基于絕對風險的下降。Thisnumberisbasedonefficacyandiscalculatedasthe

reciprocalofthedifferenceineventratesbetweencontrolandtreatmentgroupsfora

specifiedperiod.這個數(shù)量是以效能為基礎的,是對特定時期內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。

Ampleevidenceconnectsidentifiableandoftenpreventablefactorstothemorbidityand

mortalityassociatedwithmajorhealthproblems.大量的試驗證據(jù)找出了可確認的又常可預

防的與主要健康問題相關的發(fā)病和死亡因素。Abouthalfofalldeaths,morbidity,and

disabilitycanbeattributedtosuchnongeneticfactors.約一半死亡、發(fā)病和病殘與這些非遺

傳性因素有關.Manylifestylechangesbenefitmultiplesystemsanddisorders.許多生活習慣

改變有利于多個系統(tǒng)和紊亂的改善。Cigarettesmokinghasbeenestimatedtocontributeto

oneinfivedeathsintheUnitedStates;dietaryhabitsmayaffecttheoccurrenceof

cardiovasculardisease,diabetes,osteoporosis,andcancer.美國五分之一的死亡估計與吸煙

有關,飲食習慣可能影響心血管疾病,糖尿病、骨質疏松癥和癌癥的發(fā)生。Otherimportant

personalbehaviorfactorsinfluencinghealthincludephysicalactivity,alcoholintake,illicit

druguse,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。Theidentificationofinformative

DNApolymorphisms(eg,singlenucleotidepolymorphisms)andfurtherelucidationof

candidategenesallowfordetectionofsusceptibleindividualsandpossibleinstitutionof

measurestopreventtheexpressionoftheseharmfulgenetictraits,攜帶信息DNA多態(tài)性(例

如,單核昔酸多態(tài)性)的認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,以預防這些有害基因特性的表達。

Severalcommonmisconceptionsimpedepreventivehealthcare.好幾種錯誤觀念妨礙了

預防保健。Manybelievethatdiseaseswithastrongheritablecomponentcannotbealtered,

butsusceptibilitytodiseaseoftenrequirestheinteractionofmultiplegenesand

environmentalfactorsforexpression.許多人認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。Inaddition,chronic

diseasesaremultifactorial,sootherfactorscanbechangedtocompensateforanelevated

geneticrisk.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險。

Althoughgenetherapyholdsmuchpromise,preventivemeasurescurrentlyofferthebest

possibilitiesforlimitinggeneexpressionandavoidingdisease.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防措施是限制基因表達來避免疾病。Thenotionthat

preventionislessusefulinolderpersonsexcludesmanywhowouldbenefitmostfrom

preventionbecauseelderlypatientsgenerallyhaveagreaterabsoluteriskofdiseaseand

havebeenshowntoadhereandrespondfavorablytopreventivemeasures?對老年人預防無

用的觀念排除了在預防上本應極為受益的許多人,因為老年病人一般有更高患病風險,并

且一直對預防措施極為支持、反應積極。Also,lifeexpectancyfrequentlyisunderestimatedin

theelderly;individualswhoreachage75nowcanexpecttoliveanaverageof11moreyears.

并且,老年人的預期壽命經(jīng)常是低估的,現(xiàn)在將到75歲的老人可以預期平均再活11年多。

Chapter8WhyGeriatricPatientsAreDifferent第八章老年病人的特殊性

Olderpatientsdifferfromyoungormiddle-agedadultswiththesamediseaseinmany

ways,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-occurrenceof

twoormorediseasesinthesameindividual)isalsocommon.作為高發(fā)疾病的結果,并存病

(兩個或更多的疾病在同一個體同時發(fā)生)也是常見的。Ofpeopleage65andolder,50%

havetwoormorechronicdisease,andthesediseasescanconferadditiveriskofadverse

outcomes,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

病能夠增加不良預后的風險,如死亡的風險。Insomepatients,cognitiveimpairmentmay

maskthesymptomsofimportantconditions.在一些病人中,認知損害可以掩蓋重要病情的

癥狀。Treatmentforonediseasemayaffectanotheradversely,asintheuseofaspirinto

preventstrokeinindividualswithahistoryofpepticulcerdisease.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防中風。Theriskfor

becomingdisabledordependentalsoincreaseswiththenumberofdiseasespresent?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)同增加病殘的風險。Arthritisandheartdiseasecoexistin18%ofolderadults;

althoughtheoddsofdevelopingdisabilityareincreasedbythree-foldtofour-foldwitheither

diseasealone,theriskofdisabilityincreases14-foldifbotharepresent.18%的老年人同時患

有關節(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。Asecondwayinwhicholderadultsdifferfromyoungeradultsisthe

greaterlikelihoodthattheirdiseasespresentwithnonspecificsymptomsandsigns.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。Pneumoniaandstrokemay

presentwithnonspecificchangesinmentationastheprimarysymptom.肺炎和中風時可出

現(xiàn)非特異性意識變化作為主要癥狀Similarly,thefrequencyofsilentmyocardialinfarction

increaseswithincreasingage,asdoestheproportionofpatientswhopresentwithachange

inmentalstatus,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,thediagnosticevaluationofgeriatricpatientsmustconsider

awiderspectrumofdiseasesthangenerallywouldbeconsideredinmiddle-agedadults?因

此,老年病人的診斷應考慮更廣泛的疾病胃,要超過通常對中年病人所考慮的范圍。

Athirdconditionthatisfoundprimarilyinolderadultsisfrailty,frailtyisthoughttobe

awastingsyndromethatpresentswithmultiplesymptomsandsigns,includingreduced

musclemass,weightloss,weakness,poorexercisetolerance,slowedmotorperformance,and

lowphysicalactivity.主要出現(xiàn)在老年人的第三個情況是衰弱,衰弱被認為屬于衰竭綜合癥,

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-dwelling

peopleage65andolder,andin25%ofcommunity-dwellingpeopleage85andolder.——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)。Many

institutionalizedolderadultsalsoarefrail.許多老人院里的老人也是衰弱的。Frailtyisastate

ofdecreasedreserveandincreasedvulnerabilitytoallkindsofstress,fromacuteinfectionor

injurytohospitalization,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。Thesyndromeoffrailtyisassociatedwithhigh

riskoffalls,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的。Thereisearlyevidencethatacorecomponentof

frailtyissarcopenia,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,including

inflammation,hormonalstatus,andglucosemetabolism,underliesthesyndrome,with

resultingdecreasedabilitytomaintainhomeostasisinthefaceofstress.(衰弱時)多種生理

系統(tǒng)易于失調,包括炎癥反應、激素調節(jié)、葡萄糖代謝,在癥狀的背后,伴隨的結果是在

壓力面前保持內環(huán)境穩(wěn)定的能力下降Subclinicaldisease(e.g.,atherosclerosis),end-stage

chronicdisease(e.g.,heartfailure),oracombinationofcomorbiddiseasesmayprecipitate

thesyndrome.亞臨床疾病(如動脈粥樣硬化),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,controlledtrialsshowsthatresistance

exercise,withorwithoutnutritionalsupplements,andhome-basedphysicaltherapycan

increaseleanbodymassandstrengthineventhefrailestolderadults.隨機對照試驗的結果

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

軀體的質量和力量。Thisevidencesuggeststhatearlierstagesoffrailtymayberemediable,

althoughend-stagefrailtylikelypresagesdeath.這個結果提示早期衰弱是可挽回的,盡管末

期衰弱常預示著死亡。

Fourth,cognitiveimpairmentincreasesinprominenceaspeopleage.第四,人彳門變老時

認知損害顯著增加。Cognitiveimpairmentisariskfactorforawiderangeofadverse

outcomes,includingfalls,immobilization,dependency,institutionalization,andmortality.

認知損害是大量不良預后的風險因子,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Cognitiveimpairmentcomplicatesdiagnosisandrequiresadditionalcare

givingtoensuresafety.

認知損害使診斷復雜,為保證安全需要更多的照料。

Finally,aseriousandcommonoutcomeofchronicdiseasesofagingisphysicaldisability,

definedashavingdifficultyorbeingdependentonothersfortheconductofessentialor

personallymeaningfulactivitiesoflife,frombasicself-care(e.g.,bathingortoileting)to

tasksrequiredtoliveindependently(eg,shopping,preparingmeals,orpayingbills)toafull

rangeofactivitiesconsideredtobeproductiveand/orpersonallymeaningful.最后,老年人慢

性疾病嚴重又常見的結果是身體能力喪失,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,從基本的自理(如洗澡或如廁)到獨立生活需要的各種任務

(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,anddifficultywithmobilitypredictsthe

futuredevelopmentofdifficultyininstrumentalactivitiesofdailyliving(IADL;household

managementtasks)andactivitiesofdailyliving(ADL;basicself-caretasks).在老年人中,

40%對需要運動的任務有困難,運動困難提示將來開展日常工具鍛煉(IADL;家務自理項

目)和目常鍛煉(ADL;基本自理項目)的困難。Inpersonsage65andother,difficultywith

IADLisreportedby20%,anddifficultywithADLisreportedby11%;forboth,the

prevalenceincreaseswithage.大于65歲的老人或其它人,IADL困難報導為20%,ADL困

難報導為11%;隨年齡增加兩個都困難成為普遍現(xiàn)象Peoplewhohavedifficultywithtasks

ofIADLandADLareathighriskofbecomingdependent.

IADL和ADL困難的人處于生活不能自理演變的高風險中。Ofpersonsolderthanage65,

5%resideinnursinghomes,largelyasaresultofdependencyinIADLand/orADL

§00)11(1217toseveredisease.大于65歲的老人中,5%住在療養(yǎng)院里,大多數(shù)是嚴重疾病后

依賴IADL和ADL的結果。Generally,womanlivemoreyearswithdisability,whereasmen

whobecomesimilarlydisabledaremorelikelytodieatayoungerage.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。Althoughphysicaldisabilityisprimarily

aresultofchronicdiseasesandgeriatricconditions,itsonsetandseverityaremodifiedby

otherfactors,includingtreatmentsthatcontroltheunderlyingdiseases,physicalactivity,

nutrition,andsmoking.雖然身體能力喪失是慢性疾病和年老狀態(tài)的一個主要結果,它的發(fā)

生和嚴重程度被其它因素影響著,包括基礎疾病的治療和控制、身體鍛煉、營養(yǎng)和吸煙。

Manyinterventiontrialsindicatethatdisabilitycanbepreventedoritsseveritydecreased;

onetrialshowedimprovementsinfunctioningwithresistanceandaerobicexerciseinolder

adultswithosteoarthritisoftheknee.許多干預試驗揭示能力喪失可預防或減輕;一個試驗顯

示膝骨關節(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

Occultbleedingisdefinedasthedetectionofasymptomaticbloodlossfromthe

gastrointestinaltract,generallybyroutinefecaloccultbloodtesting(FOBT)orthepresence

ofirondeficiencyanemia.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)。Obscuregastrointestinalbleedingisdefined

asbleedingofunknownoriginthatpersistsorrecursafteranegativeinitialendoscopic

evaluationofboththeupperandlowergastrointestinaltracts.來源不明性胃腸出血是指首次

上、下消化管內窺鏡檢查都陰性、原發(fā)部位不明的持續(xù)性或反復性出血。Bothoftheseentities

maybepresentationsofrecurrentorchronicbleeding.兩者都可能表現(xiàn)為反復的或慢性的出

血。

Theinitialapproachtoevidenceofoccultgastrointestinalbloodlossshouldbe

endoscopicevaluation.對隱匿性胃腸道出血,應該使用內窺鏡進行早期檢查。Inthesettingof

anisolatedpositiveFOBT,colonoscopyisindicatedasthefirsttest.只有單純大便隱血試驗陽

性的情況下,結腸鏡作為首選的檢查方法是適合的。Theyieldofcolonoscopyinthese

patientsisapproximately2%forcancerand30%foroneormorecolonicpolyps?這些病人

結腸鏡的結果大約2%是癌癥,30%是單發(fā)或多發(fā)的結腸息肉。

Theinitialapproachtoapatientwithirondeficiencyanemiadependsonthepresenceof

symptomsreferabletoeithertheupperorlowergastrointestinaltract.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還是與下消化道相關而決定。Regardlessof

thefindingsontheinitialupperorlowerendoscopicexamination,allpatientsshouldhave

bothupperandlowerendoscopybecausethecomplementaryendoscopicexaminationhasa

yieldof6%evenifthefirstonewaspositive.無論首次上消化道或下消化道內窺鏡檢查會有

何發(fā)現(xiàn),所有病人兩個檢查都應該做,因為互補的內窺鏡檢查有6%的再發(fā)現(xiàn),即使第一個

檢查是陽性的。Forpremenopausalwomen,apositiveFOBTrequiresfullevaluation,asdoes

irondeficiencyanemia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。

Bariumradiographsoftheupperandlowergastrointestinaltracthavelimitedutilityinthe

settingofoccultbleedingbecauseoftheirinabilitytobiopsyortreatlesionsthatare

identified.隱匿性出血時,上、下消化道的鋼劑造影應用有限,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。Initialendoscopicexaminationshouldfocus

onanysymptomsreportedbythepatient.首次內窺鏡檢查要關注病人訴說的任何癥狀。

Potentialcausativeagents,suchasNSAIDsandaspirin,shouldbediscontinued.能成為潛在

病因的藥物,如非留體類抗炎鎮(zhèn)痛藥和阿斯匹林,都應該停用。Disordersassociatedwith

bleeding,suchashereditaryhemorrhagictelangiectasia(Osler-Weber-Rendusyndrome),

inflammatoryboweldisease,orableedingdiathesisshouldbeconsidered.伴有出血的疾病,

像遺傳性出血性毛細血管擴張癥(Osler-Weber?Rendu綜合癥)、炎性腸疾病、或出血性體

質應該力口以考慮。Arepeatendoscopicevaluationmaybeappropriate,because

approximatelyonethirdofcasesrevealacauseofbleedingoverlookedduringtheinitial

endoscopy,內窺鏡重復檢查可能是需要的,因為接近三分之一病例查出了首次內窺鏡漏掉的

出血病原灶。Whenupperendoscopyandcolonoscopyarebothunrevealing,evaluationofthe

smallbowelisindicated當上消化道內窺鏡和結腸鏡均無發(fā)現(xiàn)時,應該對小腸進行檢查。

Radiographicevaluationofthesmallbowelisnoninvasivebutrelativelyinsensitive,witha

lessthan6%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%

有結果。Bycomparison,thediagnosticyieldofendoscopicenteroscopyofthesmallbowelin

obscuregastrointestinalbleedingis38to75%.相比較,對來源不明性胃腸道出血小腸內窺鏡

的診斷結果是38?75%。Traditionalvideoendoscopescanevaluateonlytheproximalsmall

bowel(W150cm),whereaslongerscopes,whicharepassedthoughtheentiresmallboweland

thenwithdrawnwhilevisualizingthemucosa(sondeenteroscopy),arelimitedintheirability

tovisualizetheentiremucosaandcannotbeusedtoperformdiagnosticortherapeutic

maneuvers.傳統(tǒng)的電視內窺鏡只能檢查近端小腸(這150cm),然而能通過整個小腸邊退邊看

腸粘膜的更長內鏡,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,radiographic

proceduressuchasscintigraphyandangiographyshouldbeconsidered?當內窺鏡檢查不能

發(fā)現(xiàn)出血病因,像閃爍造影和血管造影等影像學手段應該考慮。Provocativeangiography

usingheparinorthrombolyticagentshasbeensuggestedbysomeauthorities,butthis

approachhasthepotentialriskofprecipitatingmajorbleeding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)大出血的潛在風險。Inthefaceof

continuedbloodlossandnoidentifiedetiology,intraoperativeendoscopymayprovide

simultaneousdiagnosisandtherapy.碰到進行性出血又診斷不明,術中應用腸鏡可以同時進

行診斷和治療。Duringtheprocedure,thesurgeonplicatesthebowelovertheendoscope.操

作時,外科醫(yī)生把小腸套到內窺鏡上。Asthescopeiswithdrawn,endoscopicfindingscanbe

identifiedforsurgicalresectionortreatment.內鏡退出時,內鏡的發(fā)現(xiàn)可以決定是外科切除

或保守治療。Theyieldofthisprocedureexceeds70%.這個措施70%以上有結果。Insome

clinicalsituations,thesiteofbleedingcannotbeidentiHed,andthepatientrequires

1011g?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。

Anewdeviceforvisualizingtheentiregastrointestinalmucosaconsistsofasmall

camerainaningestablecapsulethattransmitsimagestoreceiversattachedtothepatienfs

abdomenandmappedtoidentifythelocationoftheimage.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。Thediagnosticyieldofcapsule

enteroscopyisnotyetclear,butthisapproachmaypotentiallyvisualizesegmentsofthe

smallbowelthatwerepreviouslyinaccessible.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。Notherapeuticmaneuversarepossiblewith

thedevice.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)fromdiabeticnephropathyisamajorcauseof

morbidityandmortality,particularlyinpatientswithtype1diabetes,affecting30to35%of

patientsintheUnitedStates.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。Although

nephropathyisaboutonehalfasfrequentintype2diabetics(partiallyduetoashortened

lifeexpectancy),type2diabetesstillmakesupthevastmajorityofdiabeticpatientsseeking

therapyforESRD,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,diabetes

istheleadingcauseofESRDintheUnitedstates,accountingformorethanonethirdof

cases.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。

Detailsarelessdearinpatientswithtype2diabetes,butthenaturalhistoryofdiabetic

nephropathyintype1diabetesiswelldescribed.2型糖尿病病人的演變細節(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。Theperiodimmediatelyfollowingdiagnosisis

bestcharacterizedbyglomerularhyperfiltration.緊接診斷后的一段時期以腎小球超濾最具

有特征。Duringthistime,thereisrenalhypertrophy,increasedrenalbloodflow,increased

glomerularvolume,andanincreasedtransglomerularpressuregradient,allcontributingto

ariseinGFR.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。Importantly,thesechangesdependatleast

inpartonhyperglycemia,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。Threeto5years

afterdiagnosis,earlyglomerularlesionsappear,characterizedbythickeningofglomerular

basementmembranes,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。Albumin

excretionremainslowduringearlyglomerularchanges;however,aspathologicchanges

mount,theglomerulilosetheirfunctionalintegrity,resultinginglomerlarfiltrationdefects

andincreasedglomerularpermeability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(creatini

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