浙江省住院醫(yī)師臨床醫(yī)學英語講義2

    Record the severity of pain and functional impairment with a measure simple enough for repeated use. Extensive work in many diseases has shown that changes on a scale of 0 to 10 for pain intensity are valid and sensitive for detecting meaningful relief. Pain-related functional limitations can be assessed either by using the patient's choice of important activities or by asking the patient how much, on a scale of 0 to 10, pain has interfered with domains such as general activity, mood, walking, work, relations with other people, sleep, and enjoyment of life. 
記錄的嚴重疼痛和功能障礙與測量簡單的重復使用。在許多疾病的廣泛努力顯示變化進行打分,分值范圍為0到10對于疼痛強度檢測是有效的,有意義的敏感救濟。疼痛相關(guān)的功能受限的可評估或者通過使用病人的選擇的重要活動或問病人多少,進行打分,分值范圍為0到10,疼痛干擾等領(lǐng)域一般活動,心情,散步,工作,與他人的關(guān)系、睡眠、和快樂的生活。
    Evaluate the psychological state of the patient. Unrecognized depression and anxiety disorders are common in patients with chronic pain. Patients readily tell the clinician about these if asked, and these mood disorders are readily treatable. Assess the presence of suicidal thoughts and the pain's effect on the patient's sexual activities. It is often helpful to ask patients how they are coping in the face of the pain or what keeps them from giving up because these responses identify sources of strength on which the clinician can build.
評估病人的心理狀態(tài)。未知的抑郁和焦慮疾病患者通常都有慢性疼痛。隨時告訴醫(yī)生病人對這些如果問,這些情感障礙消聲匿跡。評估自殺想法的存在和痛苦的影響,對病人的性活動。這是問患者通常有用,他們是如何應對面對痛苦或什么使他們放棄,因為這些響應識別力量的源泉,是臨床醫(yī)生可以建造。
    Develop a series of diagnosis-based hypotheses. Because pain may result from disease at the pain site or be referred from other parts of the body, it may be helpful to list all the possibilities for the site of origin, particularly when the pain has been resistant to therapy. Persistent rib pain in a patient with metastatic cancer despite radiation therapy to the lesion in that rib would raise the possibility of referred pain from thoracic epidural tumor, which can be imaged and treated. For each potential site of the lesion, the list of the common disease processes in that area can be considered. 
開發(fā)了系列diagnosis-based假說。因為疼痛可能由于疾病或轉(zhuǎn)介疼痛部位從身體的其他部分,它可以幫助列出了所有的可能性,特別是當鼠蹊部位的疼痛一直抵抗治療。持續(xù)的肋骨疼痛患者放射治療癌性,盡管在那根肋骨病變的可能性會提高從胸硬膜外腫瘤轉(zhuǎn)移痛,可不能成像和對待。為每一個潛在網(wǎng)站的病變、中常見的疾病過程在這個區(qū)域可以被考慮。
    Personally review the diagnostic procedures. In the re-evaluation of difficult pain diagnoses, it is remarkable how often lesions had been missed previously on imaging procedures, particularly when the radiologist was not given a specific diagnostic hypothesis. 
個人評論診斷程序。在艱難的痛苦再診斷,值得注意的是多久以前病變失去對成像程序,特別是當該放療師沒有給出一個具體的診斷的假設。
    In patients with multiple chronic symptoms that are unexplained despite a full diagnostic evaluation, consider the possibility of multisomatoform disorder. This more recently proposed diagnosis, which applies to one tenth of primary care visits, is defined by the presence of three bothersome and unexplained complaints, some of which have troubled the patient on most days in the previous 2 years. Depending on the presenting complaint or the clinician's specialty, many of these patients are said to have fibromyalgia, chronic fatigue, irritable bowel syndrome, idiopathic low back pain, or chronic tension-type headaches, but most of these patients have multisystem complaints. Laboratory studies suggest that generalized amplification of symptoms by the central nervous system is common in these patients. Recognition of multisomatoform disorder alerts the clinician to look closely for depressive or panic disorders, whose prevalence is high in these patients; to treat with antidepressants or cognitive-behavioral treatment, shown to reduce symptoms; and to limit elaborate diagnostic testing or potentially hazardous medical treatments. 
多種慢性癥狀患者是無法解釋的充分的診斷評價,盡管考慮一下這種可能性的multisomatoform紊亂。這更最近提出的診斷,并適用于十分之一的初級保健訪問,被定義為三個羅嗦的存在和不明原因的投訴,其中一些已經(jīng)困擾的病人在大多數(shù)的日子前2年。根據(jù)目前的投訴或臨床醫(yī)生的專業(yè),很多患者被認為的戰(zhàn)斗能力。識別紊亂警報臨床醫(yī)師仔細看為抑郁或驚恐障礙,其發(fā)生率為;高在這些患者中治療與抗抑郁藥或認知行為治療,減少癥狀表現(xiàn),診斷測試或限制精心有潛在危險的醫(yī)學治療
    Reassess the patient's response to pain therapy. The principles of analgesic treatment are simple, but dose requirements and adverse effects vary widely. A daily phone call until the patient's treatment has been optimized is often the key to successful treatment.
評估病人的痛反應的治療。止痛治療的原則很簡單,但是劑量要求和副作用大相徑庭。日常電話,直到病人的治療進行了優(yōu)化往往是成功治療的關(guān)鍵。

Chapter 54 Benefit of Early enteral feeding versus parenteral nutrition
本篇篇名為早期腸內(nèi)與腸外營養(yǎng)的優(yōu)點比較。病人的營養(yǎng)供給是必需的，但選擇的途徑可以有所不同，如腸內(nèi)營養(yǎng)或腸外營養(yǎng)。比較而言，這兩種營養(yǎng)均比較安全。本篇主要對一些病人的早期營養(yǎng)與腸外營養(yǎng)進行比較，結(jié)果提示，早期場內(nèi)營養(yǎng)在降低感染和減少住院時間等方面有優(yōu)勢。
It is often said that enteral nutrition is safer and more efficacious than the parenteral route.
人們通常認為腸內(nèi)營養(yǎng)比腸外營養(yǎng)更安全,更有效.但這一觀點并沒有在早期的動物實驗和臨床研究中得到承認
However a preliminary note of caution is raised from observations in experimental animals, which concluded that outcomes of enteral and parentaeral nutrition were equivalent when animals with catheter sepsis were eliminated.
但是動物實驗觀察得到的初部結(jié)果告訴我們當導管膿毒癥消除以后，腸內(nèi)和腸外營養(yǎng)結(jié)果是類似的。
Numerous studies have shown that it is safe to feed the gut in the immediate postoperative period and that this practice does not place the integrity of intestinal anastomoses at risk.
為數(shù)眾多的研究標明術(shù)后即刻的腸內(nèi)營養(yǎng)是安全的，同時對腸吻合口也不會帶來風險。
Early feeding has been studied primarily in two patient populations: those who have undergone gastrointestinal surgery and in traumatically injured or critically ill persons.
早期進食實驗最初是在兩組實驗病人中進行：一組是為胃腸術(shù)后病人，另一組為創(chuàng)傷或危重病人。
A recent meta-analysis reviewed 11 prospective, randomized, controlled trails that compared the practice of early enteral feeding to maintaining patients NPO after elective gastrointestinal surgery.
最近的一項meta分析對11個隨機分組前瞻性研究來對照擇期胃腸術(shù)后早期腸內(nèi)營養(yǎng)與禁食病人。
This analysis of 837 patients concluded that there is no clear advantage to keeping patients NPO postoperatively and that early feeding may be of benefit in decreasing infections and shortening postoperative length of stay. 對837位病人的研究標明術(shù)后禁食病人（比早期腸內(nèi)營養(yǎng))沒有明顯益處，而且早期進食可以降低感染率，縮短住院時間。
However, a closer evaluation of this data reveals that the length of stay was reduced only by 0.84 day, and although there was an increase in “any type of infection” in the NPO group, when considered individually, there was no difference in the incidence of anastomotic dehiscence, wound infections, pneumonia, intra-abdominal abscess, or mortality.
但是，另一項相近的研究認為禁食組病人雖然住院時間縮短了0.84天，但“感染”發(fā)生率提高了，個別進行分析的結(jié)果表明，吻和口瘺，切口感染，肺炎，腹內(nèi)膿腫及死亡率（兩組間)沒有差別。
In 2001 Marik and Zaloga performed a meta-analysis of 15 randomized, controlled trails involving 753 subjects that compared early with delayed enteral nutrition in critically ill surgical patients. Early enteral nutrition was associated with a significantly lower incidence of infection (relative risk reduction of 0.45) and reduced length of hospital stay (2.2 days less).
2001年 Marik 和Zaloga 對15組753例危重外科病人進行了meta分析以比較早期和晚期腸內(nèi)營養(yǎng)的療效。早期腸內(nèi)營養(yǎng)組感染發(fā)生率明顯較低（相對風險降低0.45)，住院日也有減少（少2.2天)。
There were no differences in noninfectious complications or in mortality. The authors concluded that early initiation of enteral feeding was beneficial, but this result must be interpreted with caution because of substantial heterogeneity between studies. 
非感染性并發(fā)癥和死亡率無明顯差別。作者認為早期腸內(nèi)營養(yǎng)是有益的，但是考慮到研究中的差異性，這個結(jié)果需要謹慎對待
The studies that compared enteral and parenteral nutrition in the trauma population, as discussed earlier, concluded that enteral was superior because of an attenuated inflammatory response and a decrease in septic morbidity.
    Attenuated衰減，減弱
    Inflammatory炎癥性
    septic morbidity
敗血癥發(fā)病率由于感染率和敗血癥發(fā)病率低，正如先前所進行的創(chuàng)傷病人有關(guān)腸內(nèi)和腸外營養(yǎng)的結(jié)果得出，腸內(nèi)營養(yǎng)超過腸外營養(yǎng)。
When these studies are examined more closely, it is clear that patients who were fed enterally usually received significantly less calories than those fed parenterally.
經(jīng)過嚴密的研究發(fā)現(xiàn)腸內(nèi)營養(yǎng)的病人吸收的熱量明顯少于腸外營養(yǎng)病人。
This discrepancy of “relative overfeeding” in the TPN groups in many instances led to hyperglycemia, presumably predisposing patients to immune dysfunction and nosocomial infection.
Discrepancy不一致，偏差  Hyperglycemia高血糖癥
nosocomial infection院內(nèi)感染  Predispose成為因素
TPN組相對營養(yǎng)過度使許多病人產(chǎn)生高血糖癥，據(jù)推測可以導致免疫功能下降和院內(nèi)感染。
Thus, poor glucose control alone may account for the observed differences in outcome.
    account for說明，解釋
因此，血糖控制不佳可以解釋說觀察到的結(jié)果的差異。
In more contemporary studies where feeds are carefully advanced in a manner that avoids hyperglycemia and groups are fed equivalent protein and calories, there appears to be little difference in clinical outcome between enteral and parenteral routes of feeding.
    Contemporary當代的，同代的
    Equivalent相當?shù)�，相等�?
當代的研究發(fā)現(xiàn)，如果腸外營養(yǎng)經(jīng)過改進避免高血糖的可能，給予與腸內(nèi)營養(yǎng)相似的蛋白質(zhì)和熱量，兩組之間的預后差異不大。
Enteral nutrition also can endanger patient safety in unique ways.
     Endanger使危險，危及
     Unique獨特的
腸內(nèi)營養(yǎng)也可以危及病人的安危。
Deaths in persons receiving enteral nutrition are often due to aspiration, for example when gastric motility suddenly is impaired with the onset of sepsis
     Aspiration誤吸
     gastric motility
腸內(nèi)營養(yǎng)病人的死亡常常是由于誤吸，如由于敗血癥的發(fā)生說導致的胃能動性的損傷。
One death from aspiration is equivalent to the mortality over 2 to 3 years of well-operated parenteral nutrition program, despite the danger of catheter sepsis, which in well-operated units is now less than 1% to 3%.
     equivalent 相當?shù)�，相等�?catheter sepsis導管膿毒癥
除了導管膿毒癥的危險以外，通常在管理良好的單位發(fā)病率低于1％至3％，誤吸的死亡率與實行了2－3年良好管理的腸外營養(yǎng)病人相當。

2014年新疆自治區(qū)住院醫(yī)師規(guī)范化培訓招生簡章

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