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(guān)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(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-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(xué)文獻來指導(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。

Theincreasingavailabilityofrandomizedtrialstoguidetheapproachtodiagnosisand

therapyshouldnotbeequatedwithucookbook^^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)。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(yīng)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(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。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(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。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(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,patientscanobtain

theirowninformationfromavarietyofsources,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。Theincreasinguseofalternativeandcomplementarytherapies

isanexampleofpatients9frequentdissatisfactionwithprescribedmedicaltherapy?替代療法

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。Physiciansshould

keepanopenmindregardingunprovenoptionsbutmustadvisetheirpatientscarefullyif

suchoptionsmaycarryanydegreeofpotentialrisks,includingtheriskthattheymayrelied

ontosubstituteforprovenapproaches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。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(guān)鍵的。

Thephysiciandoesnotexistinavacuumbutratheraspartofacomplicatedand

extensivesystemofmedicalcareandpubichealth.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。Inpremoderntimesandeventodayinsome

developingcountries,basichygiene,cleanwater,andadequatenutritionhavebeenthemost

importantwaystopromotehealthandreducedisease.在未發(fā)達時代，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。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(dāng)鍛煉，是減少肥胖、冠心病

和糖尿病盛行的基礎(chǔ)。Publichealthinterventionstoprovideimmunizationsandtoreduce

injuriesandtheuseoftobacco,illicitdrugs,andexcessalcoholcollectivelycanproducemore

healthbenefitthannearlyanyotherimaginablehealthintervention.公共健康干預(yù)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(yù)措施都要好。

Chapter5ClinicalPreventiveServices第五章臨床預(yù)防服務(wù)

Clinicalpreventiveservicesincludecounseling,immunization,screeningtests,and

reductionofthesusceptibilitytodiseasebyinterventionssuchastherapeuticlifestyle

changesandpharmacotherapy.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。Preventiveserviceoftenareclassifiedas

primary,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,

whereassecondarypreventiondealswithearlydetectionandtreatmenttoimpedethe

progressofovertdisease.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,

tertiarypreventionreferstorehabilitativeactivitiesaftertheonsetofdiseasetominimize

complicationsanddisability.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,distinguishingamongthesephasesofprevention

maybeconfusing.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。Detectingandtreatinghypertensioncouldbeconsideredsecondarypreventionof

hypertensivecardiovasculardiseasebutprimarypreventionofheartfailureandstroke.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。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(yù)防。Thesoonerthe

prevention,themorelikelyunnecessaryillness,disability,andprematuredeathcanbe

avoided.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。Increasing

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

對危險因素本身的預(yù)防。Thetermprimordialpreventionhasbeenintroducedforthis

concept.術(shù)語…根源預(yù)防(病因預(yù)防)已經(jīng)引進了這個概念。

Indiscriminatescreeningforriskfactorsordiseasewithoutadequateadviceand

follow-upservesnousefulpurpose.沒有引導(dǎo)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(yù)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(dāng)

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(yù)防、發(fā)現(xiàn)和治療。Current

recommendationsbytheU.S.PreventiveServicesTaskForcearebasedonsystematic

evidencereviewsthatdistinguishprocedureslikelytoproveeffectiveandtohave

substantiallymorebenefitthanharm.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。

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(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)。Physiciansshouldconsidereach

disorderintermsofthepotentialforprevention,includingthepossibilityofadverseeffects

andcost?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。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(yù)

防，這是基于絕對風(fēng)險的下降。Thisnumberisbasedonefficacyandiscalculatedasthe

reciprocalofthedifferenceineventratesbetweencontrolandtreatmentgroupsfora

specifiedperiod.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。

Ampleevidenceconnectsidentifiableandoftenpreventablefactorstothemorbidityand

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

防的與主要健康問題相關(guān)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(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。Cigarettesmokinghasbeenestimatedtocontributeto

oneinfivedeathsintheUnitedStates;dietaryhabitsmayaffecttheoccurrenceof

cardiovasculardisease,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。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(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。

Severalcommonmisconceptionsimpedepreventivehealthcare.好幾種錯誤觀念妨礙了

預(yù)防保健。Manybelievethatdiseaseswithastrongheritablecomponentcannotbealtered,

butsusceptibilitytodiseaseoftenrequirestheinteractionofmultiplegenesand

environmentalfactorsforexpression.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。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(fēng)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(yù)防措施是限制基因表達來避免疾病。Thenotionthat

preventionislessusefulinolderpersonsexcludesmanywhowouldbenefitmostfrom

preventionbecauseelderlypatientsgenerallyhaveagreaterabsoluteriskofdiseaseand

havebeenshowntoadhereandrespondfavorablytopreventivemeasures?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,lifeexpectancyfrequentlyisunderestimatedin

theelderly;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

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(jié)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(yù)后的風(fēng)險，如死亡的風(fēng)險。Insomepatients,cognitiveimpairmentmay

maskthesymptomsofimportantconditions.在一些病人中，認(rèn)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(yù)防中風(fēng)。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(fēng)險。Arthritisandheartdiseasecoexistin18%ofolderadults;

althoughtheoddsofdevelopingdisabilityareincreasedbythree-foldtofour-foldwitheither

diseasealone,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。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(fēng)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(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,thediagnosticevaluationofgeriatricpatientsmustconsider

awiderspectrumofdiseasesthangenerallywouldbeconsideredinmiddle-agedadults?因

此，老年病人的診斷應(yīng)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(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-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(guān)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(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-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(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，人彳門變老時

認(rèn)知損害顯著增加。Cognitiveimpairmentisariskfactorforawiderangeofadverse

outcomes,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Cognitiveimpairmentcomplicatesdiagnosisandrequiresadditionalcare

givingtoensuresafety.

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,

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(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,anddifficultywithmobilitypredictsthe

futuredevelopmentofdifficultyininstrumentalactivitiesofdailyliving(IADL;household

managementtasks)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。Inpersonsage65andother,difficultywith

IADLisreportedby20%,anddifficultywithADLisreportedby11%;forboth,the

prevalenceincreaseswithage.大于65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Peoplewhohavedifficultywithtasks

ofIADLandADLareathighriskofbecomingdependent.

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/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(yán)重疾病后

依賴IADL和ADL的結(jié)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(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;

onetrialshowedimprovementsinfunctioningwithresistanceandaerobicexerciseinolder

adultswithosteoarthritisoftheknee.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

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(nèi)窺鏡檢查都陰性、原發(fā)部位不明的持續(xù)性或反復(fù)性出血。Bothoftheseentities

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

血。

Theinitialapproachtoevidenceofoccultgastrointestinalbloodlossshouldbe

endoscopicevaluation.對隱匿性胃腸道出血，應(yīng)該使用內(nèi)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(jié)腸鏡作為首選的檢查方法是適合的。Theyieldofcolonoscopyinthese

patientsisapproximately2%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。

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(guān)還是與下消化道相關(guān)而決定。Regardlessof

thefindingsontheinitialupperorlowerendoscopicexamination,allpatientsshouldhave

bothupperandlowerendoscopybecausethecomplementaryendoscopicexaminationhasa

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

何發(fā)現(xiàn)，所有病人兩個檢查都應(yīng)該做，因為互補的內(nèi)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(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。Initialendoscopicexaminationshouldfocus

onanysymptomsreportedbythepatient.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，如非留體類抗炎鎮(zhèn)痛藥和阿斯匹林，都應(yīng)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(zhì)應(yīng)該力口以考慮。Arepeatendoscopicevaluationmaybeappropriate,because

approximatelyonethirdofcasesrevealacauseofbleedingoverlookedduringtheinitial

endoscopy,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查出了首次內(nèi)窺鏡漏掉的

出血病原灶。Whenupperendoscopyandcolonoscopyarebothunrevealing,evaluationofthe

smallbowelisindicated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(jié)果。Bycomparison,thediagnosticyieldofendoscopicenteroscopyofthesmallbowelin

obscuregastrointestinalbleedingis38to75%.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%。Traditionalvideoendoscopescanevaluateonlytheproximalsmall

bowel(W150cm),whereaslongerscopes,whicharepassedthoughtheentiresmallboweland

thenwithdrawnwhilevisualizingthemucosa(sondeenteroscopy),arelimitedintheirability

tovisualizetheentiremucosaandcannotbeusedtoperformdiagnosticortherapeutic

maneuvers.傳統(tǒng)的電視內(nèi)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(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,radiographic

proceduressuchasscintigraphyandangiographyshouldbeconsidered?當(dāng)內(nèi)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(xué)手段應(yīng)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(fēng)險。Inthefaceof

continuedbloodlossandnoidentifiedetiology,intraoperativeendoscopymayprovide

simultaneousdiagnosisandtherapy.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,endoscopicfindingscanbe

identifiedforsurgicalresectionortreatment.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。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(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,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(guān)。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