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Congenital heart disease in adults. 成人先天性心脏病。
Pub Date : 2008-09-04 DOI: 10.3109/9780203091685
E. Foster
Patients reaching adulthood with unoperated and operated congenital heart disease require attention to issues of exercise, antibiotic prophylaxis, contraception, and pregnancy. A careful clinical history is important to establish the degree of a person's disability, if any, and the symptoms responsible for the disability, whether due to heart failure, cyanosis, or both. The findings of a physical examination and a noninvasive evaluation, including electrocardiogram, chest x-ray film, and echocardiography, are often sufficient to establish a diagnosis and to assess the adequacy of a previous operation. Transesophageal echocardiography and magnetic resonance imaging are adjunctive procedures that are indicated when routine transthoracic echocardiography is limited. Cardiac catheterization may be necessary when the noninvasive data are ambiguous and to assess coronary artery disease (congenital and acquired) in patients considered for surgical therapy. Cardiac catheterization is increasingly therapeutic (such as percutaneous pulmonary balloon valvuloplasty) as well as diagnostic. Primary surgical repair or additional surgical palliative procedures should be considered in symptomatic adults. A patient with Eisenmenger's syndrome--severe pulmonary hypertension--is a special case that may be amenable only to transplantation.
成年期未手术和手术先天性心脏病患者需要注意运动、抗生素预防、避孕和妊娠等问题。仔细的临床病史对于确定一个人的残疾程度很重要,如果有的话,以及导致残疾的症状,是由于心力衰竭,紫绀,还是两者兼而有之。体格检查和无创评估的结果,包括心电图、胸部x线片和超声心动图,通常足以建立诊断和评估先前手术的充分性。经食管超声心动图和磁共振成像是常规经胸超声心动图受限时的辅助检查。当无创资料不明确时,以及评估考虑手术治疗的患者的冠状动脉疾病(先天性和获得性)时,可能需要心导管插管。心导管置入术越来越多地用于治疗(如经皮肺球囊瓣膜成形术)和诊断。对于有症状的成年人,应考虑进行初级手术修复或其他手术姑息治疗。患有艾森门格综合征(严重肺动脉高压)的患者是一个特例,可能只能接受移植。
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引用次数: 6
Attention deficit hyperactivity disorder. 注意缺陷多动障碍。
Pub Date : 2008-03-28 DOI: 10.18578/bnf.804609619
J. Guevara, M. Stein
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引用次数: 1
Internal medicine. 内科。
Pub Date : 2007-04-01 DOI: 10.1001/jama.279.19.1578
Evan Dale Abel
Before being assigned to an inpatient medical service, all students learn techniques of obtaining a medical history and performing a physical examination. Each student must then take an 8-week Basic Medicine Clerkship in internal medicine. After successful completion of this phase of education, students interested in obtaining greater mastery of the content and principles of internal medicine may choose from a variety of advanced clerkships and electives in medical subspecialties.
在被分配到住院医疗服务之前,所有学生都要学习获取病史和进行身体检查的技巧。然后,每个学生必须在内科进行为期8周的基础医学实习。成功完成这一阶段的教育后,有兴趣进一步掌握内科内容和原理的学生可以选择各种高级见习和医学亚专业的选修课程。
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引用次数: 0
Nuclear medicine. 核医学。
Pub Date : 2007-01-01 DOI: 10.1001/jama.293.10.1267-a
Richard Zimmermann
Fused CT-PET scans more clearly show tumors and are therefore often used to diagnose and monitor the growth of cancerous tumors.
融合CT-PET扫描更清楚地显示肿瘤,因此常用于诊断和监测癌性肿瘤的生长。
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引用次数: 0
Wouldn't It Be Wonderful! 那该多好啊!
Pub Date : 2003-07-01 DOI: 10.1308/147363503322103836
P. Morris
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引用次数: 0
Alcohol and substance abuse. 酗酒和滥用药物。
Pub Date : 2002-09-01 DOI: 10.4135/9781483369532.n18
M. Naegle, A. Ng, Charles T. Barron, T. F. Lai
T Chen, H Spiller, J Badeti, A Funk, M Zhu, G Smith. Center for Injury Research and Policy in the Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, USA; New Jersey Medical School, Newark, USA; The Ohio State University College of Medicine, Department of Pediatrics, Columbus, USA; Central Ohio Poison Center at Nationwide Children’s Hospital, Columbus, USA; Child Injury Prevention Alliance, Columbus, USA
陈t, H Spiller, J Badeti, A Funk,朱m, G Smith。美国哥伦布全国儿童医院阿比盖尔·韦克斯纳研究所伤害研究与政策中心;美国纽瓦克新泽西医学院;俄亥俄州立大学医学院儿科学系,美国哥伦布;美国哥伦布市全国儿童医院俄亥俄中部中毒中心;儿童伤害预防联盟,美国哥伦布
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引用次数: 5
The conundrum of height and mortality. 身高和死亡率的难题。
Pub Date : 2002-05-01 DOI: 10.1136/EWJM.176.3.209
G. Smith
Samaras and Elrick reiterate a claim they have made else-where—thatanimal and human data show that greater body size is related to shorter lifeexpectancy. The confidence of their claim could lead readers to think that itis based on clear and consistent evidence of a positive association betweenheight and mortality rates. Even the evidence they cite, however, does notsupport this association. For example, they describe a study by Liao andcolleagues as finding no relation between height and heart disease and a studyby Okasha et al as finding no association between height and all-causemortality. It is unclear, however, why such studies, which find no association betweenheight and an outcome, support their claim that “larger body sizeindependently reduces longevity.” Also puzzling is why Samarasand Elrick cite these particular studies out of the body of literature onheight and health. When considered in total, this literature indicates that aconsistent inverse association exists between height and all-causemortality in developed countries. This inverse association has consistentlybeen found in prospective studies that appropriately analyze data fromrepresentative population samples. Samaras and Elrick cite one study from our research group (Okasha et al.)as showing no association between height and all-cause mortality. The resultsof the study, in fact, showed an inverse association, although this was notstatistically significant at conventional levels. They fail to cite studieswith greater statistical power in which we showed robust inverse associationsbetween height and all-causemortality.1,2Rather than carry out a systematic review of population-based prospectiveepidemiologic studies, they refer to unrepresentative (and sometimes basicallyuninterpretable) data derived from their own previous reviews (Samaras andElrick and Miller). What is a sensible conclusion to draw from the literature on height andmortality? In developed countries, taller people have lower all-causemortality rates and live longer. The association between height and mortalityfrom specific causes, however, is heterogeneous, with taller people havinghigher mortality rates from cancers that are unrelated tosmoking3 and fromaorticaneurysm.4 The association between height and some cancers may reflect higher levelsof calorie intake during growth in infancy and childhood, which has been shownto increase later-life cancer risk in a variety of animal models. Insulin-likegrowth factors may mediate thisassociation.5 Thepositive association between height and risk of aortic aneurysm may simplyreflect the mechanical correlation of height and aortic length. Alternatively,it could indicate a Marfan syndrome-like tendency, being more common in tallerpeople. But these positive associations are more than counter-balanced by theinverse associations between height and mortality resulting from coronaryheart disease, stroke, and respiratorydisease,1,2at least in developed countries. Suc
萨马拉斯和埃尔里克重申了他们在其他地方提出的观点,即动物和人类的数据表明,体型越大,预期寿命越短。他们的说法充满信心,可能会让读者认为这是基于明确而一致的证据,证明身高和死亡率之间存在正相关。然而,即使他们引用的证据也不支持这种联系。例如,他们描述廖及其同事的一项研究发现身高与心脏病之间没有关系,而Okasha等人的一项研究发现身高与全因死亡率之间没有联系。然而,目前还不清楚,为什么这些研究没有发现身高和结果之间的联系,却支持他们的说法,即“体型越大,寿命越短”。同样令人困惑的是,为什么萨马拉斯和埃里克引用了这些关于身高和健康的文献之外的特定研究。总的来说,这些文献表明,在发达国家,身高与全因死亡率之间存在一致的负相关关系。这种反向关联在前瞻性研究中一直被发现,这些研究适当地分析了代表性人群样本的数据。萨马拉斯和埃尔里克引用了我们研究小组(Okasha等人)的一项研究,表明身高和全因死亡率之间没有联系。事实上,研究结果显示出负相关关系,尽管在常规水平上没有统计学意义。他们没有引用具有更大统计力的研究,在这些研究中,我们显示了身高和全因死亡率之间存在着强有力的负相关关系。1,2他们没有对基于人群的前瞻性流行病学研究进行系统的回顾,而是引用了他们自己以前的回顾(Samaras、elrick和Miller)中得出的不具代表性(有时基本上是不可解释的)的数据。从文献中得出的关于身高和死亡率的合理结论是什么?在发达国家,高个子的人全因死亡率较低,寿命更长。然而,身高与特定原因导致的死亡率之间的关系是不一致的,高个子的人死于与吸烟无关的癌症和动脉瘤的死亡率更高身高和某些癌症之间的联系可能反映了婴儿和儿童成长过程中较高的卡路里摄入量,在各种动物模型中,这已被证明会增加晚年患癌症的风险。胰岛素样生长因子可能介导这种关联身高与主动脉瘤风险之间的正相关可能仅仅反映了身高与主动脉长度之间的力学相关性。或者,它可能表明一种类似马凡氏综合征的倾向,在高个子中更常见。但至少在发达国家,身高与冠心病、中风和呼吸系统疾病导致的死亡率呈负相关,远远抵消了这些正相关。这种反向关联不能归因于反向因果关系,即晚年疾病导致加速萎缩和死亡风险增加。在成年早期测量的身高,在任何收缩发生之前,与心肺死亡风险呈负相关身高高于平均水平是一个良好的童年社会环境的指标,而早年的生活剥夺与死于冠心病、中风和呼吸系统疾病的更高风险有关。更高的身材也与更好的肺功能有关(至少部分是纯粹的机械原因),这可能对某些死因有保护作用。关于身高和特定病因死亡率之间的联系机制,我们还有很多需要了解的。要获得更深入的理解,就需要阅读和解释文献本身,而不是选择性地引用那些支持我们已经认定为正确的假设的“事实”。萨马拉斯和埃尔里克的评论具有误导性。更好的做法是,利用已确立的原则,对前瞻性研究进行系统审查,在这些研究中,在可定义的人群中测量身高,并前瞻性地收集死亡率数据。
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引用次数: 8
Pink urine and a petechial rash. 粉红色的尿液和点疹。
Pub Date : 2002-05-01 DOI: 10.1136/EWJM.176.3.155
H. M. Ramos, R. Bertken, D. Pepper
QUESTIONS: A 52-year-old Hispanic woman with a long history of bilateralknee pain and type 2 diabetes mellitus sees her family physician because inthe past 4 days she has had pink urine, generalized malaise, and a rash on herhands and feet. On physical examination, the patient has oral and lingular submucosalhemorrhages (figure 1),injected sclerae with subconjunctival bleeding, and tenderness of both knees.She also has a vesiculomacular rash with a dark erythematous base that isclustered and more severe on her legs than on her arms(figure 2). She has sparsepinpoint macular lesions on her torso. Her temperature is 38.3°C(101°F), and she has a new ejection systolic murmur at the left uppersternal border. On reexamination several hours later, the number of lesions onher legs has increased. Figure 1 Submucosal hemorrhages and diffuse petechiae on oral and lingularsurfaces Figure 2 Vesiculomacular rash with a dark erythematous base What additional questions would you ask this patient, and what other partsof the body would you examine? What kind of skin lesions are these, and whatis your differential diagnosis? What tests would help make the diagnosis? Whatis the diagnosis, and how would you treat it?
问题:一名52岁的西班牙裔女性,有双侧膝盖疼痛和2型糖尿病的长期病史,她去看了家庭医生,因为在过去的4天里,她尿呈粉红色,全身不适,手脚出现皮疹。体格检查,患者有口腔和舌粘膜下出血(图1),巩膜注射性结膜下出血,双膝压痛。患者也有一个囊状斑疹,底部为深色红斑,呈簇状,腿部比手臂更严重(图2)。患者躯干有稀疏点黄斑病变。体温38.3°C(101°F),左胸骨上缘出现新的射血收缩期杂音。几小时后复查,腿部病变数量增加。图1口腔和舌表面粘膜下出血和弥漫性斑点图2伴有深色红斑基底的水泡斑疹你还会问这个病人哪些问题?你还会检查身体的哪些其他部位?这些是什么样的皮肤病变,你的鉴别诊断是什么?哪些检查有助于诊断?诊断结果是什么?你会如何治疗?
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引用次数: 0
Parallels between community environmental health and occupational health. 社区环境卫生与职业卫生的相似之处。
Pub Date : 2002-05-01 DOI: 10.1136/EWJM.176.3.162
W. Hinds
Since September 11, 2001, there has been increased attention on whatindividuals and communities can do to minimize the effects of terroristattacks, and other disasters, on the health and safety of our family, friends,and community.1 Thearticle by Mott and colleagues focuses on one such disaster—a forestfire. It provides retrospective data that can give us some idea about whichinterventions work and which do not in preventing respiratory healthproblems. Unlike most disaster situations, the forest fire that occurred from Augustto November 1999 near the Hoopa Valley National Indian Reservation in northernCalifornia caused a gradual buildup of smoke concentration in the residentialarea of the reservation. This gradual buildup provided an opportunity forlocal health officials to implement health-protective measures. The results ofa follow-up study, reported here, provide some guidance for health planning infire-prone areas and more generally for response to other natural andhuman-made disasters. Over the 7-week period of the fire, smoke particulate concentration(PM10) exceeded 150 μg/m3 for 15 days and reached apeak of more than 500 μg/m3 for 3 days. The EPA has designatedthe health-based national air quality standard for PM10 as no morethan 150 μg/m3 (measured as a dailyconcentration).2Hence, the PM10 in the study area reached hazardous levels. Toreduce the health effects of the smoke exposure on susceptible members of thecommunity, local health officials implemented four types of interventions:distributing respiratory protective masks, providing free vouchers to stay athotels in nearby towns, providing portable HEPA filter units to residences,and releasing PSAs. After the fire, a study was conducted to determine thehealth effects of the fire and the effectiveness of the interventions. The situation faced by these health officials is analogous to thatfrequently encountered in the field of industrial hygiene, so it is ofinterest to compare the approaches taken by community health officials withthose used to address chemical exposures in industrial settings. The basicindustrial hygiene paradigm includes three steps: recognition, evaluation, andcontrol.3 The firststep is to identify the contaminant. In the case of the forest fire, it wasidentified as smoke particulate, although irritating gases in thesmoke—such as aldehydes—could also have been present. Theevaluation step is a quantitative measurement of the environment and anassessment of the health risk it presents. This was done in Mott andcolleagues' study by comparing air-monitoring data with EPA standards. Thethird step, to control the exposure to safe levels, was undertaken by the fourinterventions mentioned above. In industrial hygiene, control methods are ranked hierarchically byefficacy andreliability.4 Thebest methods are engineering controls, such as substituting safer materials,isolating workers from the exposure, and ventilation. The analogy for thiscategory would include evacu
自2001年9月11日以来,人们越来越关注个人和社区可以做些什么来最大限度地减少恐怖袭击和其他灾难对我们的家人、朋友和社区的健康和安全的影响莫特和他的同事们的这篇文章关注的就是一场森林火灾。它提供了回顾性数据,可以让我们了解哪些干预措施在预防呼吸系统健康问题方面有效,哪些无效。与大多数灾难不同的是,1999年8月至11月发生在加利福尼亚北部胡帕谷国家印第安人保留区附近的森林大火,导致保留区居民区的烟雾逐渐积聚。这种逐渐积累为地方卫生官员实施健康保护措施提供了机会。本文报道的一项后续研究的结果,为火灾易发地区的卫生规划提供了一些指导,并更广泛地为应对其他自然和人为灾害提供了指导。在火灾发生的7周期间,烟雾颗粒物浓度(PM10)有15天超过150 μg/m3,有3天达到500 μg/m3以上的峰值。美国环境保护署规定,以健康为基础的国家空气质量标准PM10不超过150 μg/m3(按日浓度测量)。因此,研究区域的PM10达到了危险水平。为了减少烟雾对社区易感人群的健康影响,当地卫生官员实施了四种干预措施:分发呼吸防护口罩,提供免费入住附近城镇酒店的代金券,向居民提供便携式高效微粒微粒过滤器,以及发布公益广告。火灾发生后,进行了一项研究,以确定火灾对健康的影响和干预措施的有效性。这些卫生官员面临的情况与工业卫生领域经常遇到的情况类似,因此比较社区卫生官员采取的方法与用于处理工业环境中化学品暴露的方法是有意义的。工业卫生的基本范式包括三个步骤:认识、评价和控制第一步是识别污染物。在森林火灾的情况下,它被确定为烟雾颗粒,尽管烟雾中的刺激性气体(如醛)也可能存在。评价步骤是对环境进行定量测量,并对其带来的健康风险进行评估。莫特和他的同事们通过比较空气监测数据和EPA标准的研究得出了这个结论。第三步,将暴露控制在安全水平,由上述四种干预措施进行。在工业卫生中,控制方法按有效性和可靠性进行分级最好的方法是工程控制,例如替换更安全的材料,将工人与暴露隔离,以及通风。这个类别的类比将包括疏散和HEPA过滤装置的使用。进一步的是工作实践的修改,其中包括关于危害性质的培训,以及受接触者可以做些什么来尽量减少他们的接触。这与传播的公益广告类似。最后,最不有效的是个人防护设备,在这种情况下,呼吸器。呼吸器是最不有效的,因为很难找到合适的呼吸器,吃饭或睡觉时不能有效地使用呼吸器,长时间佩戴呼吸器会引起相当大的不适。在这项研究中,不同的干预措施有多成功?在我们回答这个问题之前,我们需要谨慎地解释数据,因为它们是观察性和回顾性的,所以它们容易混淆和偏见。数据显示干预与结果之间存在关联,但没有证据表明干预导致了结果。考虑到这一警告,这些数据似乎与工业卫生控制等级一致,因为使用HEPA空气净化器和收集psa都与报告不良呼吸反应的几率降低有关。公益广告可能产生的保护作用表明,如果人们被告知这种风险以及将这种风险降到最低的措施,他们就会准备采取措施保护自己的健康。在工业卫生控制层级中,我们期望疏散是有效的。然而,在这种情况下,疏散似乎并没有起到保护作用。原因尚不清楚。研究中没有报告附近社区的颗粒物浓度,也许这些浓度升高了。此外,只有少数参与者在整个高浓度期间被疏散。该研究为森林火灾易发地区的卫生规划提供了有用的信息。它还可作为规划公共卫生应对其他类型自然和人为灾害的模式。 它强调需要保持干预措施实施的良好记录,以供以后分析。
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引用次数: 4
Why torture must not be sanctioned by the United States. 为什么酷刑不能被美国批准。
Pub Date : 2002-05-01 DOI: 10.1136/EWJM.176.3.148
V. Iacopino, A. Keller, Deborah Oksenberg
In the wake of September 11th, many people in the United States believethat torture is justifiable in the name of national security. A recent publicopinion poll indicated that one in three Americans believegovernment-sanctioned torture of suspected terrorists is an acceptable meansof gatheringinformation.1 Asphysicians, we have spent our professional lives documenting medical evidenceof torture and caring for torture survivors. In the course of our work, wehave encountered hundreds of individuals who have suffered unspeakable painand degradation at the hands of government authorities throughout the world.Our experiences documenting the effects of these practices have clearly shownus that torture does not make any one person or society safer or moresecure.
911事件之后,许多美国人认为以国家安全的名义使用酷刑是正当的。最近的一项民意调查显示,三分之一的美国人认为,政府批准对恐怖分子嫌疑人实施酷刑是一种可以接受的收集情报的手段作为医生,我们一生都在记录酷刑的医学证据,并照顾酷刑幸存者。在我们的工作过程中,我们遇到了数百人,他们在世界各地的政府当局手中遭受了难以形容的痛苦和堕落。我们记录这些做法的影响的经验清楚地表明,酷刑不会使任何人或社会更安全或更有保障。
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引用次数: 2
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The Western journal of medicine
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