Managing Gastrointestinal Symptoms After Cancer Treatment

胃镜急危重患者抢救制度及流程英文回答：Gastrointestinal emergencies can be life-threatening and require immediate intervention. When a patient with a critical condition related to the gastrointestinal system, such as gastrointestinal bleeding or obstruction, presents, a rapid rescue system needs to be in place to provide timely and appropriate care. In this response, I will outline the rescue system and its process for managing such emergencies.The first step in the rescue system is recognizing the signs and symptoms of a gastrointestinal emergency. This includes assessing the patient's vital signs, such as blood pressure, heart rate, and oxygen saturation, as well as conducting a thorough physical examination. For example, if a patient presents with severe abdominal pain, vomiting blood, and low blood pressure, it may indicate a gastrointestinal bleeding emergency.Once the emergency is identified, the next step is to activate the rescue team. This team typically consists of healthcare professionals, including doctors, nurses, and technicians, who are trained in managing gastrointestinal emergencies. The team should be readily available and able to respond promptly to any emergency call. In some cases, a specialized gastroenterology team may be involved if the patient requires advanced endoscopic interventions.While waiting for the rescue team to arrive, immediate measures can be taken to stabilize the patient. For instance, intravenous fluid resuscitation may be initiated to address hypovolemia caused by bleeding. Medications, such as proton pump inhibitors or vasoactive drugs, may also be administered to control bleeding or improve hemodynamic stability.Once the rescue team arrives, they will conduct a more detailed assessment and determine the appropriate course of action. This may involve performing a diagnostic procedure, such as an emergency upper gastrointestinal endoscopy, toidentify the source of bleeding or obstruction. The teamwill also consider the patient's overall condition and medical history when making treatment decisions.Treatment options for gastrointestinal emergencies can vary depending on the specific condition. In cases of gastrointestinal bleeding, endoscopic interventions, suchas hemostasis with clips or injection of sclerosants, maybe performed to stop the bleeding. Surgical intervention may be necessary in severe cases or when endoscopic measures are unsuccessful. For gastrointestinal obstruction, endoscopic or surgical interventions may be required to relieve the obstruction and restore normal gastrointestinal function.Throughout the rescue process, effective communication and coordination among the rescue team members are essential. Clear and concise communication ensures that everyone is aware of the patient's condition, treatment plan, and any changes in the patient's status. This helpsto prevent delays in care and ensures that the patient receives the necessary interventions in a timely manner.In conclusion, a well-established rescue system is crucial for managing gastrointestinal emergencies in critically ill patients. Prompt recognition of the emergency, activation of the rescue team, stabilization of the patient, and appropriate diagnostic and treatment interventions are key components of this system. Effective communication and coordination among team members are vital for ensuring optimal patient outcomes.中文回答：胃肠道急危重症情况可能危及患者的生命，需要立即采取干预措施。

Managing Conduct and Performance
Carrying out formal Procedures
There are two separate procedures: MISCONDUCT POOR PERFORMANCE However the basic steps and procedures are the same
Managing Conduct and Performance
The most important piece of advice is to ALWAYS ‘nip in the bud’ any potential problems! To begin with this may mean simply informal counselling....
Remember that the sanction imposed will depend on the seriousness of misconduct/poor performance or whether it is a repeat of previous or similar offence Remember it is the ‘procedure’ not the decision that should be consistent, fair and reasonable eg employees may be treated differently for the same type of offence
Managing Conduct and Performance
Failure to comply with these statutory procedures will render a dismissal as automatically unfair, and are likely to increase any damages awarded by 10-50% if procedure has been breached This legislation will be amended in April 2009 shortly, however procedures will still apply and should always be followed It is essential that you always lead by example when dealing with formal conduct and performance issues

消化内科的英语Digestive system diseases are common in clinical practice, with a wide range of symptoms and presentations. In this article, we will focus on some of the most common diseases of the digestive system, specifically those related to the field of gastroenterology.One of the most common digestive system diseases is gastroesophageal reflux disease (GERD). GERD occurs when the lower esophageal sphincter relaxes abnormally or weakens, allowing stomach acid to flow back into the esophagus. This can cause symptoms such as heartburn, regurgitation, chest pain, and difficulty swallowing. Treatment for GERD typically involves lifestyle modifications, such as avoiding trigger foods and losing weight, as well as medications to reduce stomach acid production.Another common digestive system disease is peptic ulcer disease. Peptic ulcers are open sores that develop on the lining of the stomach, small intestine, or esophagus. The most common cause of peptic ulcers is infection with the bacterium Helicobacter pylori, although other factors such as NSAID use and excessive alcohol consumption can also contribute. Symptoms of peptic ulcers include abdominal pain, bloating, and nausea. Treatment for peptic ulcers involves antibiotics to eradicate H. pylori, as well as medications to reduce stomach acid production and promote healing of the ulcer.Inflammatory bowel disease (IBD) is a group of chronic inflammatory conditions of the gastrointestinal tract, including Crohn's disease and ulcerative colitis. IBD is characterized by inflammation of the digestive tract, leading to symptoms such as abdominal pain, diarrhea, weight loss, and fatigue. Treatment for IBD typically involves a combination of medications to reduce inflammation and suppress the immune system, as well as dietary modifications to manage symptoms.Irritable bowel syndrome (IBS) is another common digestive system disease that affects the large intestine. IBS is a functional disorder, meaning that there is no underlying structural abnormality, but rather a dysfunction in the way the intestines work. Symptoms of IBS include abdominal pain, bloating, gas, and changes in bowel habits.Treatment for IBS focuses on managing symptoms through dietary modifications, stress reduction techniques, and medications to relieve symptoms.Celiac disease is a digestive system disease that is characterized by an autoimmune reaction to gluten, a protein found in wheat, barley, and rye. In individuals with celiac disease, consuming gluten triggers an immune response that damages the lining of the small intestine, leading to malabsorption of nutrients. Symptoms of celiac disease can vary widely and may include diarrhea, weight loss, fatigue, and skin rashes. Treatment for celiac disease involves a strict gluten-free diet to prevent further damage to the intestine and alleviate symptoms.In conclusion, digestive system diseases are common and can have a significant impact on quality of life. Early recognition and appropriate management of these diseases are essential to prevent complications and improve outcomes for patients. By understanding the common diseases of the digestive system and their treatment options, healthcare providers can better care for patients with these conditions.。

查前以冷盐水洗胃可改善内镜视野。有经验的医师可很快完成这一检查，并不增加病人的
危险。
3.选择性腹腔动脉或肠系膜上动脉造影内镜检查如未能发现出血病因，尤其是胃
内有大量积血和血块影响内镜视野时，可作选择性腹腔动脉或肠系膜上动脉造影。若发现
造影剂溢出血管、有血管畸形或肿瘤血管影像，对于急诊手术前定位诊断很有意义，也可
出血。胃癌引起的上消化道大出血，黑粪症比呕血更常见。
5.胆道出血((hemobilia)各种原因导致血管与胆道沟通，引起血液涌人胆道，再进
人十二指肠，统称胆道出血。最常见的病因是胆道感染、肝外伤，其他原因有肝胆肿瘤、
肝血管瘤、胆管结石压迫和手术损伤等。胆道出血的三联症是胆绞痛、梗阻性黄疽和消化
以经动脉导管注人血管加压素控制出血。
4. X线钡餐检查对于没有内镜检查条件、内镜检查未发现或不能确定出血病变时，
应在出血停止后3648小时进行X线钡餐检查。气钡对比检查可发现较大的病变如食管
静脉曲张、大的溃疡和肿瘤，但较难发现表浅的和较小的病变、血管发育异常或责门粘膜
撕裂综合征。
5.核素检查常用静脉注射ssmTc标记的红细胞，行腹部扫描，只要出血速度每分钟
1.初期评估与处理初期评估应注意血流动力学的状况。收缩血压<100 mmHg，应
视为严重出血的高危病人;心率>100次/min，收缩血压>100 mmHg，多提示为中等程
度的急性出血;收缩血压和心率正常，意味着轻度出血。如果没有其他原因而出现体位性
低血压和心搏过速，对失血量的估计很有帮助。由于血细胞比容与血管外体液平衡需要
或锁骨下静脉达上腔静脉之途径，以便监测中心静脉压。先滴注平衡盐溶液及血浆代用

Managing gastric residual volumes in the critically ill patient: an updateMark H.DeLeggeIntroductionThe use of gastric residual volumes(GRVs)for monitoring the delivery of enteral nutrition in the ICU is very con-troversial.Despite the fact that measurement of GRVs is one of the most common practices in nutrition therapy, there is very little data in the literature supporting its use. Therearenoprospective,randomizedclinicaltrialsdemon-strating an improvement of patient outcomes in the ICU by the use of GRVs during enteral feeding[1].Using GRVs as a marker of gastric performance assumes that it reliably and accurately measures gastric contents.Thus,there would be a correlation between high GRVs,regurgitation and aspira-tionof gastric contentsduringenteral feeding.Surprisingly, there is little evidence in the literature to support the concept of GRVs directly correlating to the amount of gastric content or the risk of aspiration pneumonia. What is gastroparesisDelays in gastric emptying(gastroparesis)are a common problem seen in patients in the ICU[2].Gastrointestinal motility is governed by multiple control systems:the central,autonomic and enteric nervous system,endocrine cells,Interstitial cells of Cajal and smooth muscle[3]. The anatomy of the enteric nervous system consists of local circuits of sensory neurons,interneurons,excitatory motor neurons and inhibitory motor neurons[4]. Migrating motor complexes(MMC)are an important component of gastrointestinal motility.The MMC begin several hours after digestion of a meal in the antrum of the stomach and progress to the distal ileum.The key pace-makers for the MMC are located along the greater curvature of the stomach[5].The stomach plays a huge role in the overall motor function of the gastrointestinal tract.At the beginning of meals the fundus of the stomach relaxes.This is called accommodation and is a nitrous oxide-mediated process with the intention of allowing extra space to develop in the stomach to allow acid and enzyme food digestion[6]. Subsequent tonic contractions empty the fundus of the stomach and transfers material(chyme)to the antrum through the corpus.The chyme is broken into smallDigestive Disease Center,Medical University of South Carolina,Charleston,South Carolina,USA Correspondence to Mark H.DeLegge,MD Professor of Medicine,Digestive Disease Center,Medical University of South Carolina,25Courtenay St,STE 7100A,Charleston,SC29425,USAE-mail:deleggem@Current Opinion in Clinical Nutrition and Metabolic Care2011,14:193–196Purpose of reviewGastric residual volumes(GRVs)remain a major deterrent to adequately feeding patients with gastric-delivered enteral nutrition.The purpose of this review was to define the most up-to-date consensus of the utility of the use of GRVs for monitoring tube-feeding intolerance in gastric-fed patients.RecentfindingsThe paper summarizes the pathophysiology of gastroparesis,the techniques for measuring GRVs,the significance of a large GRV,other factors to consider when measuring GRVs,the correlation between GRVs and aspiration pneumonia,national guideline statements on GRVs,the use of prokinetic agents in the treatment of high GRVs and the clinical impact of tolerating larger GRVs.The utility of GRVs for prevention of aspiration events with tube feeding has been brought into question. SummaryLarge GRVs usually result from some impediment in gastrointestinal motility(e.g. gastroparesis).There are numerous methods for measuring GRVs,most of which have not been standardized.It appears that there is little correlation between large GRVs and the development of aspiration pneumonia when tube feeding patients.Prokinetic agents have an inconsistent effect on the GRV guidelines state that GRVs of less than 500ml should not result in termination of enteral feeding.Allowing larger GRVs will allow patients to receive more calories when gastric fed without a deleterious clinical impact.The use of GRVs as a marker of feeding tolerance is of questionable utility.Keywordsaspiration pneumonia,enteral feeding,gastric residual volume,gastroparesis, refractometryCurr Opin Clin Nutr Metab Care14:193–196ß2011Wolters Kluwer Health|Lippincott Williams&Wilkins1363-19501363-1950ß2011Wolters Kluwer Health|Lippincott Williams&Wilkins DOI:10.1097/MCO.0b013e328341ede7pieces by the coordinated contractions and relaxations of the antrum.When the pyloric sphincter relaxes,1–2mm chyme particles pass through the pylorus into the duodenum.In gastroparesis,the stomach fails to enlarge in response to distention by meals.Peristaltic contractions are weak and the stomach fails to break down particles of chyme. There is a tendency of the stomach to overfill leading to abdominal distention,nausea and vomiting.In the ICU, where patients are often debilitated and with impaired consciousness,the concern with feeding and vomiting is aspiration and the development of pneumonia.There-fore,feeding in the ICU is dictated by monitoring a patient’s gastrointestinal tolerance.Gastrointestinal tolerance can be described as a patient’s gut response to enteral nutrition and can include bowel sounds, abdominal distention and bowel movements.More com-monly,gastric residuals are used to determine if someone is ready for enteral tube feeding,especially gastric feed-ings,and whether these tube feedings should be tempor-arily held or discontinued once initiated.Methods for assessment of gastric emptying in the critically illMoreira and McQuiggan[7]recently reviewed methods for assessing gastric emptying.The authors explained that the rationale for monitoring GRVs was based on the belief that this represented a delay in gastric emptying. However,this review underscored that the correlation between GRVs and gastric emptying was weak.These authors reviewed all methods published between2007 and2008with reference to GRV measurement.Aspirated gastric contents represent a mixture of enteral feedings, gastric and salivary secretions and duodenal reflux.On an average,these endogenous secretions can reach up to 4500ml/day.The position of the patient,the type and size of the syringe and the size and position of the tip of the feeding tube can affect gastric residual quantities. One survey revealed that the definition of‘high’GRVs ranged from as low as50ml to greater than400ml[8]. Other methods for determining gastric emptying in the critically ill were described.This included scintigraphy, paracetamol absorption,stable radioisotope breath test, gastric ultrasound and gastric impedance monitoring. These tests were found to be either cumbersome,labor intensive and/or lacking standardization preventing them from providing clinical utility for measuring gastric emp-tying in the ICU patient.However,the article did com-ment on the use of refractometry,a device to measure refraction of a beam of light when passed obliquely through a solution.Refractometers are inexpensive hand-held devices.A decrease in refractometer measurements (brix value)over time of gastric contents containing enteral formula could be indicative of a steady emptyingof enteral formula from the stomach.Chang et al.[9]conducted a prospective study of36patients receivingcontinuous enteral feeding.Patients with low GRVsgenerally had a low brix value.McQuiggan et al.[10].also confirmed this correlation of GRVs to brix value in16critically ill patients being fed by an nasogastric tube Do large gastric residual volumes correlate to aspiration pneumonia events?The question of the relationship of GRV to the actual riskof aspiration of gastric contents remains a question.Thewhole premise of monitoring GRVs would be in anattempt to monitor for gastrointestinal intolerance,vomiting and aspiration.Metheny et al.[11]prospectivelystudied206critically ill patients receiving gastric tubefeedings for three consecutive days.GRVs weremeasured every4h.Measured volumes were dividedinto quantities of less than150ml,150–200ml,200–250ml or greater than250ml.Tracheal secretions weremonitored for the presence of pepsin in these patients.Pepsin was being used as the marker of gastric-trachealaspiration.The mean percentage of tracheal pepsin-positive secretions was36.2%.Most(92.7%)patientshad at least one tracheal secretion positive for pepsinduring the3-day study period.Pepsin-positive trachealsecretions occurred at GRVs between0and50ml33.7%of the time.Patients with higher GRVs did have morepepsin-positive tracheal secretions.However,no defini-tive relationship between increasing GRVs and pepsin-positive tracheal secretions could be found.In addition,there was no attempt to document whether having pep-sin-positive tracheal secretions lead to any clinical aspira-tion pneumonia events.In an expert letter reviewing thisarticle,a statement by Parrish and McClave[12]noteduntil better data are available,it may be appropriate tocheck GRVs in the critically ill patient when initiating thedelivery of enteral nutrition.After48–72h of successfulfeeding,if the GRVs are consistently low,it may beappropriate to stop checking GRVs[13].What do national guidelines say about gastric residual volumes?Recent critical care nutrition guidelines have been devel-oped by a team effort between the American Society ofParenteral and Enteral Nutrition and the Society ofCritical Care Medicine[14 ].These guidelines were graded A-E with grade A being the strongest and gradeE being the weakest.The guidelines said that inappropri-ate holding of tube feedings should be avoided(grade E).Holding enteral nutrition for GRVs less than500ml inthe absence of other signs of intolerance should beavoided(grade B).The guidelines also stated that makingthe patient nil per os surrounding the time of diagnostic194Nutrition and the intensive care unittests or procedures should be minimized to preventinadequate delivery of nutrients and prolonged periodsof ileus.An ileus may be propagated by the nil per osstatus.(grade B)Use of enteral-feeding protocolsincreases the overall percentage of goal calories providedand should be implemented.(grade C).Are there any other factors to consider when measuring gastric residual volumes?A recent correspondence form Umbrello et al.[15]repeated the concern of the development of upper diges-tive intolerance(UDI)with enteral feeding.Theydescribed that a GRV of150–500ml on two consecutivemeasurements,one GRV more than500ml or vomitingwas presumed to be indicative of UDI.The authors dopoint out that there have been no reports dealing with thepresence of air in the stomach as a co-factor when measur-ing GRVs as a marker of UDI.In their general ICU patientpopulation,2695patients were checked for GRVs.On339occasions,GRVs were found with an average volume of158ml.On226occasions air was decompressed with anaverage volume of140ml.The presence of air was notassociated with UDI.The development of pneumonia,during these patients’ICU stay,was not associated withUDI.Their conclusion included a statement that‘UDI is apoor indicator for the development of aspiration pneumo-nia in the critically ill population’.Do you need to return or discard gastric residual volumes?It is a known fact that some nurses after checking GRVsdiscard gastric contents,whereas others reintroduce it topatients,partially or completely,depending on their bed-side assessment.Juve-Udina et al.[16 ]performed a randomized,prospective study in125critically ill patientsassigned to either a return or discard group regarding theirgastric residuals.GRVs were characterized as light(151–250ml),moderate(251–350ml)or severe(>350).The majority of both groups had a‘0’GRV.Interestingly,patients in the discard group had greater,light or moderateGRVs(less volume).The complication rate was similarbetween both groups(nil for nausea or pulmonary aspira-tion and insignificant for vomiting).There was no differ-ence in days of diarrhea or abdominal distention episodes.In addition,there were no differences in serum electrolyteor glucose between the two groups.The obvious limitationin this study is with the lack of a standardized tool tomonitor and record patient discomfort in the ICU.What is the impact of a more‘liberal’tolerance to gastric residual volumes?The use of early enteral nutrition has become a priority for changing clinical outcomes of critically ill patients.We know that gastric enteral access is easier to obtain thansmall bowel enteral access.We also know that the deliveryof nutrients can be delayed or terminated by the interpret-ation of the nurse or physician at the bedside with regardsto gastrointestinal intolerance.Higher gastric residualvolume tolerances result in a higher delivery of enteralnutrition calories in a gastric-fed population.Recently,White et al.[17]performed a prospective,randomizedstudy of gastric versus small bowel feedings in104patients.GRVs of less than200ml were tolerated.Those with aGRV over200ml received a promotility agent.Interest-ingly,with this higher GRV tolerance by the nurses it wasfound that gastric feeders were quicker to initiate feedingsand quicker to reach target calorie goals.There was nodifference in patient length of stay or ventilator daysbetween the gastric and postpyloric-fed groups.Do prokinetic agents reduce gastric residual volumes?The ideal prokinetic agent would increase fundal toneand wave frequency,stimulate antral wave amplitude andreduce pyloric-wave frequency while abolishing pylorictone[18 ].Metoclopramide is a commonly used anti-emetic and prokinetic agent.It acts at the dopaminereceptor with both central and peripheral events.It alsoweakly inhibits the5HT3receptor.Metoclopramideaccelerates gastric emptying by triggering an intenseburst of gastric contractions.Unfortunately,tachyphy-laxis sets in early reducing its effects as a promotilityagent for chronic use.The effect of metoclopramide onreducing GRVs are unclear as small crossover trials havebeen inconsistent in results.There is also concern aboutthe central nervous system effect of metoclopramide. Erythromycin is a macrolide antibiotic and an active agonist of the motilin receptors,which are found pre-dominantly in the antrum and the proximal duodenum. Erythromycin does increase antral motility in critically ill patients.However,the effect is quickly attenuated over time.There are no prospective,randomized trials specifi-cally evaluating the effect of erythromycin on GRVs.Should gastric residual volumes be checked at all?The overall utility of checking GRVs for clinical practice and prevention of aspiration pneumonia was called into question in a study of205nasogastric tube-fed ICU patients[19].This was a retrospective analysis.In a1-year period,102patients were followed who were receiv-ing nasogastric feedings.GRVs tolerated were250ml before an action was required on the part of the physician (promotility agent,reducing enteral nutrition infusion rate,discontinuing enteral nutrition).Tube feeding was initiated at25ml/hr and increased to afinal rate of Managing gastric residual volumes DeLegge19585ml/hr.Patients were maintained in a semi-recumbent position with their head elevated.In a separate group of 103patients enteral feedings progressed in the same manner and the patients were maintained in the same position in bed.However,in this group,no GRVs were checked.Patients not receiving GRV checks had a higher daily delivery of enteral nutrition than the group receiv-ing GRV checks(P¼0.002).Both groups had similar recorded vomiting episodes(P¼0.32)and clinical aspira-tion events(P¼0.86).There appeared to be no clinical benefit with the use of GRVs while delivering nasogastric enteral nutritionConclusionThe physiology of gastric emptying is very complex.The stomach plays a huge role in the gastrointestinal motility process.Aspiration pneumonia associated with enteral feeding is of great concern to clinicians.The actual incidence of tube-feeding-related regurgitation and aspiration with subsequent pneumonia development is unknown.Many clinicians attempt to monitor for signs of gastrointestinal intolerance when using enteral nutrition. This includes monitoring GRVs.However,there is little-to-no-data that monitoring GRVs prevents the develop-ment of aspiration pneumonia and in fact may often preclude the adequate delivery of nutrition to patients. GRVs below500ml do not appear to be harmful.When measuring GRVs,the volume of gastric contents aspi-rated can be returned to the stomach without causing significant complications.It is unclear if prokinetic agents are useful in reducing the size of GRVs.The use of GRVs for prevention of aspiration events may be of no clinical utility and often results in a reduction in the daily delivery of enteral nutrition. AcknowledgementsThe author is a consultant for Nestle Nutrition,CORAM Healthcare and Baxter Healthcare.References and recommended readingPapers of particular interest,published within the annual period of review,have been highlighted as:of special interestof outstanding interestAdditional references related to this topic can also be found in the Current World Literature section in this issue(p.217).1Hurt RT,Mcclave SA.Gastric residual volumes in critical illness:what do they really mean?Crit Care Clin2010;26:481–490.2Khayyam U,Sachdeva P,Gomez J,et al.Assessment of symptoms during gastric emptying scintigraphy to correlate symptoms to delayed gastric emptying.Neurogastroenterol Motil2010;22:539–545.3Holzer P,Schicho R,Holzer-Petsche U,Lippe I.The gut is a neurological organ.Wien Klin Wochenschr2001;13:647–660.4Burns AJ,Thapar N.Advances in ontogeny of the enteric nervous system.Neurogastroenterol Motil2006;18:876–887.5Dong K,You XJ,Wen EG,et al.Advances in mechanisms of postsurgical gastroparesis syndrome and its diagnosis and treatment.Chin J Dig Dis2006;7:76–82.6Costa M,Brooks SJ,Heening GW.Anatomy and physiology of the enteric nervous system.Gut2000;S47:15–19.7Moreira TV,McQuiggan M.Methods for the assessment of gastric emptying in the critically ill enterally fed adults.Nutr Clin Pract2009;24:261–273.8Marshal AP,West SH.Enteral feeding in the critically ill:are nursing practices contributing to hypocaloric feeding?Intensive Crit Care Nurs2006;22:95–105.9Chang WK,Mc Calve SA,Lee MS,Chao YC.Monitoring bolus nasogastric tube feeding by the Brix value determination and residual volume measure-ment of gastric contents.JPEN J Parenter Enteral Nutr2004;28:105–112.10McQuiggan M,Koaazr R,Sailors M,et al.Techniques for determining gastric residual volume;is newer better.JPEN J Parenter Enteral Nutr2008;32:341A.11Metheny NA,Schallom L,Oliver DA,Clouse RL.Gastric residual volume and aspiration in critically ill patients receiving gastric feedings.Am J Crit Care 2008;17:512–519.12Parrish CR,McClave SA.Checking gastric residual volumes:a practice in search of science.Pract Gastroenterol2008;32:33–47.13Johnson AD.Ask the experts.Assessing gastric residual volumes.Crit Care Nurse2009;29:72–73.14Martindale RG,McClave SA,Vanek VW,et al.,American College of Critical Care Medicine and the ASPEN Board of Directors..Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient:Society of Critical Care Medicine and American Society of Par-enteral and Enteral Nutrition–executive summary.Crit Care Med2009;37:1757–1761.This is a must read article that puts together a consensus amongst the American society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine regarding nutritional interventions in the ICU with a graded scoring system.This is wherein we learn about a500ml gastric residual volume being acceptable.15Umbrello M,Elia G,Destrebecq ALL,Iapichino G.Tolerance of enteral feeding:from quantity to quality of gastric residual volume?Intensive Care Med2009;35:1651–1652.16Juve-Udina M-E,Vallas-Miro C,Carreno-Granero A,et al.To return or discard?Randomised trial on gastric residual volume management.Intensive Crit Care Nurs2009;25:258–267.This article answers a very common question about what nurses should do with GRV,discard or place back into the stomach.Returning the residual to the stomach appears to have no deleterious effect.17White H,Sosnowski K,Reeves A,Jones M.A randomized,controlled comparison of early postpyloric versus gastric feeding to meet nutritional targets in ventilated intensive care patients.Crit Care2009;13:1–8.18Deane AM,Fraser RJ,Chapman MJ.Prokinetic drugs for feed intolerance in critical illness:current and potential therapies.Crit Care Resusc2009;11:132–143.This article creates a good review of the promotility drugs available in the ICU for treatment of high GRV and concludes that we have very poor available evidence for a clinically significant effect.19Poulard F,Dimet J,Martin-Lefevre L,et al.Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding:a prospective before-after study.JPEN J Parenter Enteral Nutr 2010;34:125–130.196Nutrition and the intensive care unit。

47 Managing In a Global Environment在全球环境中进行管理1. Assume for a moment<此刻>that you're a manager going to work for a branch of<分支> a global organization in a foreign country. You know that your environment will differ from the one at home, but how? What should you be looking for?1. 此刻假设你是一位美国经理，你准备到一家全球组织的国外分支机构工作。

你知道你的环境将与国内的不同，但二者的差异会达到什么程度呢？你应当注意些什么？2. Any manager who finds himself or herself in a foreign country faces new challenges. In this section, we'll look at<考察> some of those challenges and offer guidelines<指导> for responding. Although our discussion is presented<展开> through the eyes of a U.S. manager, our analytical framework could be used by any manager who has to manager in a foreign environment, regardless of national origin.2.任何一位发觉自己处于一个陌生国家的管理者都面临着新的挑战。

促进胃肠蠕动的方法One way to promote gastrointestinal motility is by incorporating dietary fiber into one's meals. 膳食纤维是促进胃肠蠕动的一种方法。

This can be done by consuming a variety of fruits, vegetables, whole grains, and legumes. 这可以通过食用各种水果、蔬菜、全谷物和豆类来实现。

Fiber adds bulk to the stool, which stimulates the muscles in the gastrointestinal tract to move. 纤维可以增加粪便的体积，从而刺激胃肠道中的肌肉运动。

Moreover, it also helps to regulate bowel movements and prevent constipation. 此外，它还有助于调节排便并预防便秘。

By making these dietary changes, individuals can effectively promote healthy gastrointestinal motility. 通过进行这些饮食改变，个体可以有效地促进健康的胃肠蠕动。

In addition to dietary modifications, regular physical activity can also contribute to promoting gastrointestinal motility. 除了饮食修改外，定期进行体育锻炼也可以有助于促进胃肠蠕动。

Exercise helps to stimulate the muscles in the abdomen, including those in the gastrointestinal tract. 锻炼有助于刺激腹部肌肉，包括胃肠道中的肌肉。

10.1038/s41575-022-00593-y.［38］陈文轩，张哲，周川，等. 色氨酸及其衍生物在炎症性肠病中的研究进展［J］.胃肠病学和肝病学杂志，2022，31（12）：1424-1427. CHEN W X， ZHANG Z， ZHOU C，et al. Research progress of tryptophan and its derivatives in inflammatory bowel disease ［J］. Chin J Gastroenterol Hepatol，2022，31（12）：1424-1427. doi：10.3969/j.issn.1006-5709.2022.12.021.［39］崔灿，李盈，杨豪杰，等. 色氨酸代谢与炎性肠病相关研究进展［J］. 医学综述，2021，27（14）：2726-2730. CUI C，LI Y，YANG H J，et al. Research progress of tryptophan metabolism and inflammatory bowel disease ［J］. Medical Recapitulate，2021，27（14）：2726-2730. doi：10.3969/j.issn.1006-2084.2021.14.005.［40］TAKEDA T，ASAOKA D，NOJIRI S，et al. Usefulness of bifidobacterium longum BB536 in elderly individuals with chronic constipation：a randomized controlled trial ［J］. Am J Gastroenterol，2023，118（3）：561-568. doi：10.14309/ajg.0000000000002028.［41］孙晓红. 慢性便秘诊治面临的挑战［J］. 中国中西医结合消化杂志，2023，31（6）： 418-420. SUN X H. Challenges in the diagnosis and treatment of chronic constipation ［J］. Chin J Integr Tradit West Med Dig，2023，31（6）：418-420. doi：10.3969/j.issn.1671-038X.2023.06.04.［42］丁雨，王艳，林琳，等. 慢性便秘患者的肠道菌群分析［J］. 中国医师杂志，2022，24（7）：1066-1068. DING Y，WANG Y，LIN L，et al. Analysis of intestinal flora in patients with chronic constipation［J］. Journal of Chinese Physician，2022，24（7）：1066-1068. doi：10.3760/431274-20210729-00823.［43］刘启鸿，柯晓，骆云丰，等. 基于"脑-肠-菌"轴观察理气通便方对气滞证慢传输型便秘患者的影响［J］. 中华中医药杂志，2021，36（6）：3324-3328. LIU Q H，KE X，LUO Y F，et al. Observation of liqi tongbian decoction on patients with qi stagnation syndrome slow transit constipation based on the“brain-intestine-bacteria”axis ［J］. China Journal of Traditional Chinese Medicine and Pharmacy，2021，36（6）：3324-3328.［44］BHARUCHA A E，LACY B E. Mechanisms，evaluation，and management of chronic constipation ［J］. Gastroenterology，2020，158（15）：1232-1249.e3. doi：10.1053/j.gastro.2019.12.034.［45］GWEE K A，LEE Y Y，SUZUKI H，et al. Asia-pacific guidelines for managing functional dyspepsia overlapping with other gastrointestinal symptoms ［J］. J Gastroenterol Hepatol，2023，38（2）：197-209. doi：10.1111/jgh.16046.［46］CHEN S H，ZHU L J，ZHI Y H，et al. Pitongshu alleviates the adverse symptoms in rats with functional dyspepsia through regulating visceral hypersensitivity caused by 5-HT overexpression ［J］. Comb Chem High Throughput Screen，2023，26（7）：1424-1436. doi：10.2174/1386207325666220827152654.（2023-09-11收稿　2023-10-30修回）　（本文编辑　陈丽洁）　SIRT1在糖尿病心肌病发病中的研究进展解有成1，2，3，4，王菲2，徐进2，于晓辉2△摘要：糖尿病心肌病（DCM）是糖尿病患者的一种严重的心血管并发症。

第一部分通用英语Part OneEnglish for General PurposesUNIT 1 How to be Happy如何获得幸福ExercisesA. Translate the following sentences into English.1．吵闹的邻居的确对我们家庭不和(domestic upset)有很大影响。

2．在职场上，如果一个同事对我们表示威吓的话，会造成难以言表的抑郁情绪(unwretchedness)。

3．我们不可能适应这种敌对关系，这种不良的人际关系会损害身心健康。

4．如果这种坏情绪长时间留在人们的心里，会让人陷入无法解决的恶性心理困境。

5．我们不应当回避这些问题，而是要正确面对它们。

B. Read the text and translate it into Chinese.There are many benefits to being happy. Happier people tend to be healthier, live longer and eam more. They also tend to volunteer more, be better at relationships and smile more of what psychologists call “Duchenne" or genuine smiles. What is less well understood is why happiness is contagious.According to James Fowler and Nicholas Christakis, authors of the international bestseller Connected, people surrounded by many happy friends, family members and neighbours who are central to their social network become significantly happier in the future. More specificallyi they say we will become 25 per cent happier with our life if a friend who lives within a mile of us becomes significantly happier with his or her life.Similar effects are seen in co-resident spouses (8 per cent happier); siblings who live within a mile of each other (14 per cent); and next-door neighbours (34 per cent). What this implies is that the magnitude of happiness spread seems to depend more on frequent social contact (due to physical proximity) than on deep social connections. Alas, for some reason this doesn't translate to the workplace.So, why is happiness contagious? One reason may be that happy people share their good fortune with their friends and family (for example, by being pragmatically helpful or financially generous). Another reason could be that happy people tend to change their behaviour for the better by being nicer or less hostile to those close to them. Or it could just be that positive emotions are highly contagious.【参考答案】阅读理解1. The formula refers to H (happiness) = S (your biological set point for feeling happy) + C (the conditions of your life) + V (the voluntary choices you make).2. Loud noises trigger one of our most primitive fear responses and we can never fully relax if we are surrounded by intrusive noise.3. If we need our TV, radio or music up loud, wearing headphones demonstrates our kindness and consideration to our neighbors.4. Our unhappiness often comes from poor relationships with others.5. What you can do is to either mend the relationship by confronting what is going wrong or learn to move on.【练习参考答案】A．汉译英1. Noisy neighbors are one of the major causes of domestic upset.2. A colleague at work who bullies or dismisses us creates untold wretchedness.3. We can never fully adapt to hostile relationships, which inevitably damage our wellbeing.4. If this bad mood stays inside our mind, it will lead us to an unresolved destructive depression.5. We should not avoid these problems but face them instead. B．英译汉幸福有许多好处。

Text B How Does FDA Approve New Drugs?Under current law, all new drugs need proof that they are effective, as well as safe, before they can be approved for marketing. But it’s important to realize that no drug is absolutely safe. There is always some risk of an adverse reaction. It’s when the benefits outweigh the risks that FDA considers a drug safe enough to approve.1.outweigh [a u tˊweɪ] vt. 在重量上超过；在重要性或价值方面超过根据现行法规，对于所有新药，只有经确认安全、有效，才会被批准上市。

但是，我们应该意识到没有所谓绝对安全的药物，认识到这一点是很重要的。

任何药物都可能有不良反应。

因此，只有认定某种药物的益处大于其风险时，FDA 才会认为某种药物足够安全，可批准其上市。

In fact, it was only 25 years ago that U.S. drug law first embraced the idea of risk vs. benefit that now the key to new drugs approval. Providing evidence of safety before marketing was first required by Federal Food, Drug and Cosmetic Act in 1938, but not until the Drug Amendments of 1962 did firms also have to show a drug’s effectiveness before marketing. Before any drug gets on the market today, FDA decides—as quickly as a thorough evaluation allows—whether the studies submitted by the drug’s sponsor(usually the manufacturer) show it to be safe and effective for its intend use.1.embrace [im'breis] vt. 包括; 包含；接受；信奉, 皈依vt. & vi.拥抱n.拥抱, 怀抱2.cosmetic [kɔz'metik]n.化妆品adj.化妆用的; 美容的；装点门面的Federal Food, Drug and Cosmetic Act联邦食品、药品和化妆法案3.Drug Amendments [ə'mendmənts] 药品法修正案4.thorough ['θʌrəu] adj.彻底的；十足的；考虑周到的5.sponsor ['spɔnsə] vt.赞助, 发起, 主办n. 申办者事实上，直到25年前美国药品管理法才刚刚引入“风险-益处评估”的概念。

消化内科医学英语写作范文Digestive Medicine: A Comprehensive OverviewThe field of digestive medicine encompasses a wide range of conditions and disorders affecting the gastrointestinal tract, liver, pancreas, and associated organs. As a vital component of the human body, the digestive system plays a crucial role in the absorption of nutrients, the elimination of waste, and the overall maintenance of health. Consequently, the study and treatment of digestive diseases have become an integral part of modern medical practice.One of the primary focuses of digestive medicine is the diagnosis and management of gastrointestinal disorders. These can range from common conditions such as acid reflux, irritable bowel syndrome, and peptic ulcers to more complex issues like inflammatory bowel diseases, liver diseases, and pancreatic disorders. Clinicians in this field utilize a variety of diagnostic tools, including endoscopic examinations, imaging studies, and laboratory tests, to identify the underlying cause of a patient's symptoms and develop an appropriate treatment plan.In the realm of gastrointestinal disorders, acid reflux, also known asgastroesophageal reflux disease (GERD), is a prevalent condition that affects millions of individuals worldwide. GERD occurs when the stomach's contents, including stomach acid, flow back into the esophagus, causing a burning sensation, discomfort, and potentially long-term damage to the esophageal lining. Clinicians often prescribe proton pump inhibitors or other medications to reduce acid production and alleviate the symptoms of GERD, while lifestyle modifications, such as dietary changes and weight management, can also play a significant role in managing the condition.Another common gastrointestinal disorder is irritable bowel syndrome (IBS), a chronic condition characterized by abdominal pain, altered bowel habits, and other gastrointestinal symptoms. IBS is a complex disorder that can be influenced by a variety of factors, including diet, stress, and the gut microbiome. Clinicians in digestive medicine may employ a combination of dietary modifications, medication, and stress management techniques to help patients manage the symptoms of IBS and improve their overall quality of life.Inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis, represent a more severe category of gastrointestinal disorders. These conditions are characterized by chronic inflammation of the digestive tract, leading to a range of symptoms, including abdominal pain, diarrhea, and weight loss. Clinicians in digestive medicine often utilize a multifaceted approach to managing these conditions,incorporating medications, dietary interventions, and in some cases, surgical procedures to address the underlying inflammation and improve the patient's overall health and well-being.In addition to gastrointestinal disorders, digestive medicine also encompasses the diagnosis and treatment of liver diseases. One of the most prevalent liver conditions is nonalcoholic fatty liver disease (NAFLD), which is characterized by the accumulation of fat in the liver, often in individuals who do not consume excessive amounts of alcohol. NAFLD can progress to more severe forms of liver disease, such as nonalcoholic steatohepatitis (NASH) and cirrhosis, if left untreated. Clinicians in digestive medicine play a crucial role in identifying and managing NAFLD, often through lifestyle modifications, medication, and in some cases, referral to a hepatologist for specialized care.Pancreatic disorders also fall under the purview of digestive medicine. Conditions such as pancreatitis, pancreatic cancer, and pancreatic duct disorders can have significant impacts on an individual's health and well-being. Clinicians in this field utilize a range of diagnostic tools, including imaging studies and laboratory tests, to identify the underlying cause of pancreatic issues and develop appropriate treatment strategies, which may involve medication, dietary modifications, or in some cases, surgical intervention.The field of digestive medicine also encompasses the management of nutritional and metabolic disorders related to the digestive system. For example, clinicians may work with patients who have issues with nutrient absorption, such as celiac disease or lactose intolerance, to develop dietary strategies and supplementation plans to ensure adequate nutrient intake and maintain overall health. Additionally, they may address metabolic disorders, such as obesity and diabetes, that can have significant impacts on digestive function and overall well-being.Across the various specialties within digestive medicine, clinicians must possess a deep understanding of the complex anatomy and physiology of the digestive system, as well as the ability to interpret a wide range of diagnostic tests and develop tailored treatment plans for each patient. This requires a strong foundation in medical knowledge, as well as excellent clinical skills in areas such as patient history-taking, physical examination, and effective communication with patients and other healthcare providers.In conclusion, the field of digestive medicine is a vital and multifaceted area of medical practice, encompassing the diagnosis and management of a wide range of conditions affecting the gastrointestinal tract, liver, pancreas, and associated organs. Clinicians in this field play a crucial role in improving the health and well-being of patients by utilizing a comprehensive, evidence-basedapproach to address the complex and often interrelated issues that can arise within the digestive system. As our understanding of the human body and the factors that influence digestive health continues to evolve, the importance of digestive medicine will only continue to grow, making it a dynamic and essential component of modern healthcare.。

胃肠疾病英语Gastrointestinal DiseasesGastrointestinal diseases are a group of disorders that affect the digestive system which includes the stomach and intestines. These diseases can range from mild to severe and can have a significant impact on an individual's quality of life. Some of the most common gastrointestinal diseases include gastroenteritis, irritable bowel syndrome, Crohn's disease, and ulcerative colitis.Gastroenteritis is an inflammation of the stomach and intestines typically caused by a viral or bacterial infection. Symptoms of gastroenteritis include diarrhea, vomiting, abdominal pain, and fever. Gastroenteritis is often a self-limiting condition that resolves within a few days with proper hydration and rest. However in some cases it can lead to more serious complications such as dehydration or electrolyte imbalances that require medical treatment.Irritable bowel syndrome (IBS) is a chronic disorder characterized by abdominal pain, bloating, and altered bowel habits such as diarrhea or constipation. The exact cause of IBS is not fully understood but it is believed to be related to a combination of factors including diet,stress, and changes in the gut microbiome. IBS is a highly prevalent condition affecting up to 15% of the global population. While there is no cure for IBS, symptoms can be managed through dietary changes, stress management, and medications.Crohn's disease is a type of inflammatory bowel disease that causes inflammation and irritation in the digestive tract. This can lead to a wide range of symptoms including abdominal pain, diarrhea, weight loss, and fatigue. Crohn's disease is a chronic condition that often involves periods of flare-ups followed by periods of remission. The exact cause of Crohn's disease is unknown but it is believed to involve a combination of genetic and environmental factors. Treatment for Crohn's disease typically involves a combination of medications, dietary modifications, and in some cases surgery.Ulcerative colitis is another type of inflammatory bowel disease that causes inflammation and ulceration in the lining of the colon and rectum. Symptoms of ulcerative colitis include bloody diarrhea, abdominal pain, and an urgent need to have bowel movements. Like Crohn's disease, ulcerative colitis is a chronic condition with periods of flare-ups and remission. The exact cause of ulcerative colitis is not fully understood but it is believed to involve an abnormal immune response to the gut microbiome. Treatment for ulcerative colitis may include medications, dietary changes, and in severe cases surgery to remove the affected portion of the colon.In addition to these major gastrointestinal diseases there are also a number of other conditions that can affect the digestive system. Gastroesophageal reflux disease (GERD) is a condition where stomach acid flows back up into the esophagus causing symptoms such as heartburn and difficulty swallowing. Peptic ulcers are sores that develop in the lining of the stomach or small intestine often due to infection with the bacteria Helicobacter pylori. Diverticular disease is a condition where small pouches called diverticula form in the colon and can become inflamed leading to pain and other symptoms.The diagnosis and management of gastrointestinal diseases can be complex and often requires a multidisciplinary approach involving healthcare providers from different specialties such as gastroenterology, nutrition, and surgery. Diagnostic tests for gastrointestinal diseases may include blood tests, imaging studies, endoscopies, and biopsies. Treatment options can vary widely depending on the specific condition and may include medications, dietary modifications, lifestyle changes, and in some cases surgical interventions.Prevention is also an important aspect of managing gastrointestinal health. Maintaining a healthy diet rich in fiber, staying hydrated, managing stress, and practicing good hygiene can all help to prevent or reduce the risk of developing certain gastrointestinal conditions.Regular check-ups with a healthcare provider can also help to identify and address any gastrointestinal issues early on.In conclusion gastrointestinal diseases are a diverse group of conditions that can have a significant impact on an individual's health and quality of life. While some gastrointestinal disorders are relatively mild and easily treatable others can be chronic and debilitating. Understanding the causes, symptoms, and management strategies for various gastrointestinal diseases is crucial for promoting overall digestive health and wellbeing.。

头孢药物过敏反应指南解读Chapter 1: IntroductionCephalosporins are a class of widely used antibiotics that are effective against a broad spectrum of bacterial infections. However, like any medication, cephalosporins can also elicit allergic reactions in certain individuals. These allergic reactions can range from mild rashes to life-threatening anaphylaxis. It is crucial to properly interpret and understand cephalosporin allergy guidelines to ensure the safe and effective use of these medications.Chapter 2: Classification of Cephalosporin Allergic ReactionsCephalosporin allergic reactions can be classified into four main types based on the immune mechanism involved: immediate hypersensitivity reactions, non-immediate hypersensitivity reactions, cross-reactivity reactions, and intolerance reactions.Immediate hypersensitivity reactions, also known as type I reactions, occur within minutes to hours after cephalosporin administration. These reactions are primarily mediated by immunoglobulin E (IgE) antibodies and mast cell degranulation, resulting in symptoms such as hives, itching, and angioedema. Severe cases can progress to anaphylaxis.Non-immediate hypersensitivity reactions, or type IV reactions, typically manifest as delayed rashes occurring 48 to 72 hours after drug exposure. These reactions are mediated by T-cells and can range from mild maculopapular eruptions to severe blistering skin reactions, such as Stevens-Johnson syndrome or toxic epidermalnecrolysis.Cross-reactivity reactions can occur in individuals with a known cephalosporin allergy who are subsequently exposed to another cephalosporin or structurally related β-lactam antibiotics, such as penicillins. It is estimated that the cross-reactivity rate ranges from 1% to 35%, depending on the specific cephalosporin and penicillin involved.Intolerance reactions are characterized by non-immunologically mediated adverse effects that are not related to a specific immune response. These reactions can manifest as gastrointestinal symptoms, such as nausea, vomiting, or diarrhea, and do not require complete avoidance of cephalosporins in the future.Chapter 3: Management of Cephalosporin Allergic ReactionsThe management of cephalosporin allergic reactions involves a stepwise approach that includes recognition, diagnosis, and appropriate management. It is essential to properly interpret the guidelines to ensure optimal patient care.Recognition of allergic reactions relies on a thorough patient history, including previous exposure to cephalosporins or ot her β-lactam antibiotics, presenting symptoms, and the timing of onset. Skin testing, including both skin prick tests and intradermal tests, can aid in the diagnosis of cephalosporin allergies, but should be performed by trained professionals in a controlled environment. Management strategies for immediate hypersensitivity reactionsinclude discontinuation of the offending cephalosporin, administration of antihistamines, corticosteroids, and, if necessary, epinephrine for anaphylaxis. In these cases, alternative non-cross-reacting antibiotics should be considered.Non-immediate hypersensitivity reactions may require discontinuation of the cephalosporin and supportive care for the skin manifestations. Severe cases may necessitate hospitalization and the use of systemic corticosteroids.Cross-reactivity reactions can be challenging to manage, as the risk and severity of the reaction must be assessed individually. In some cases, desensitization protocols can be employed to allow temporary use of the cephalosporin in a controlled setting.Chapter 4: ConclusionThe proper interpretation and understanding of cephalosporin allergy guidelines are crucial for clinicians to provide safe and effective treatment options for patients. Recognizing and diagnosing allergic reactions, as well as implementing appropriate management strategies, can help mitigate the potential risks associated with cephalosporin use. Further research and collaboration between healthcare professionals are needed to improve the accuracy of diagnosis and enhance patient care for individuals with cephalosporin allergies.Chapter 5: Prevention of Cephalosporin Allergic ReactionsPrevention plays a crucial role in reducing the incidence of cephalosporin allergic reactions. Healthcare professionals shouldbe aware of the risk factors and take appropriate measures to minimize the occurrence of these reactions.One of the most important preventive measures is obtaining a detailed patient history, including any previous allergic reactions to cephalosporins or other antibiotics. This information should be documented and shared with the patient's healthcare team to guide future treatment decisions.In patients with a known cephalosporin allergy, it is important to consider non-cross-reacting alternative antibiotics. This may involve using a different class of antibiotics or selecting a cephalosporin that is less likely to cross-react. However, it is crucial to assess the risk and benefit of using alternative antibiotics on a case-by-case basis, considering factors such as the severity of the infection and the availability of alternative treatment options.In cases where there is uncertainty regarding the presence of a cephalosporin allergy, allergists and immunologists can play a crucial role in conducting further evaluation. Allergy testing, such as skin prick tests and intradermal tests, can help identify specific sensitizations and guide treatment decisions. These tests should be performed by trained professionals in a controlled environment to ensure accurate results and minimize the risk of adverse reactions.Patient education is another important aspect of prevention. Patients should be informed about the signs and symptoms of allergic reactions and instructed to seek immediate medical attention if they occur. It is also essential to educate patients about the importance of disclosing any allergies or previous adverse drugreactions to healthcare providers.Chapter 6: Future Directions and Areas of ResearchAlthough significant progress has been made in understanding and managing cephalosporin allergies, there are still areas that require further research and investigation.One area of interest is the improvement of diagnostic tests for cephalosporin allergies. Current allergy testing methods, such as skin prick tests and intradermal tests, have limitations in terms of their accuracy and reproducibility. Research focusing on the development of more reliable and specific diagnostic tools could significantly improve the identification and diagnosis of cephalosporin allergies.Another important area of research is the identification of risk factors for cephalosporin allergies. Understanding the factors that contribute to the development of allergies can help identify high-risk populations and guide preventive strategies. Genetic studies may also provide valuable insights into the underlying mechanisms of cephalosporin allergies.Additionally, further investigation is needed to better understand the cross-reactivity between cephalosporins and other β-lactam antibiotics, such as penicillins. Determining the true extent of cross-reactivity and developing strategies to minimize this risk could aid in the safe administration of antibiotics to patients with known allergies.Lastly, more research is needed to explore alternative treatment options for patients with cephalosporin allergies. The development of novel antibiotics or therapeutic approaches that are effective and have a lower risk of allergic reactions would greatly benefit patients with limited treatment options.Chapter 7: ConclusionIn conclusion, the proper interpretation and understanding of cephalosporin allergy guidelines are vital for ensuring the safe and effective use of these antibiotics. Recognizing and diagnosing allergic reactions, implementing appropriate management strategies, and taking preventive measures are crucial for minimizing the risk and impact of cephalosporin allergies. Further research and collaboration between healthcare professionals are needed to improve the accuracy of diagnosis, enhance patient care, and develop strategies for preventing and managing cephalosporin allergic reactions. By continually advancing our knowledge and understanding of cephalosporin allergies, we can provide better treatment options and improve patient outcomes in the future.。

Managing IntrusionsA Management White Paper by Peter StephensonNew EditionINTRODUCTIONI ntrusion management is a four-step process. The steps are avoidance,assurance, detection and investigation. Intrusion management has as itsobjective:Limiting the possibility of a successful intrusion througheffective preventative, quality management and detectiveprocesses, and facilitating successful investigation of anintrusion should one occur.The primary goal of intrusion management is to prevent the consequences ofintrusions entirely. We can address that goal by implementing a program ofeffective security controls. Those controls should be present at every interfacepoint within an information management system. Effective controls grow out ofeffective information security policies, standards and practices and the use ofappropriate technology. Appropriate technology is defined as technology whichsupports and enforces the organization’s security policy effectively.Organizations should impose controls aimed at mitigating threats againstfunctional areas of vulnerability at each interface point. There are six suchfunctional areas of vulnerability:1.Identification and Authentication: Functions intended toestablish and verify the identity of the user or using process.2.Access Control: Functions intended to control the flow of databetween, and the use of resources by, users, processes and objects.This includes administration and verification of access rights.3.Accountability: Functions intended to record exercising of rightsto perform security-relevant actions.4.Object Reuse: Functions intended to control reuse or scavengingof data objects.5.Accuracy: Functions intended to insure correctness andconsistency of security-relevant information.6.Reliability of Service: Functions intended to insure security ofdata over communication links.AVOIDANCET he first step in the Intrusion Management process is Avoidance. Avoidanceincludes all of those underlying processes that seek to create a secureenvironment. Those processes may be administrative, as in policies, standardsand practices, or the may be technological as in the application of access controltools. Some examples of Avoidance are:∙Security policy∙Standards and practices∙Security Awareness∙Incident response planning∙Disaster planning∙Training of security and IT Audit personnel∙Evaluating the results of a successful intrusion (“lessons learned”feedback)∙Implementation of access control programs∙Implementation of firewalls∙Implementation of encryptionASSURANCET he second step is Assurance. Assurance includes everything we do to ensurethat policies, standards and practices are being followed. These processesinclude:∙IT audits∙Intrusion testing∙Vulnerability testing∙Security reviews∙Risk assessments on new systemsUsing appropriate tools, we can test our systems for vulnerabilities and throughproper configuration or use of third party products we can ensure thatappropriate steps are taken to reduce or eliminate them. Tools that we should useare of two types: preventative and detective.Preventative tools include those that we use to perform initial evaluation andconfiguration. Detective tools are intended to ensure that any change to theconfiguration is detected. An example of such a suite of tools is the EnterpriseSecurity Manager (ESM) from AXENT Technologies in Provo, Utah. ESMallows us to evaluate the configuration of a computer against a predefinedsecurity policy. Once the computer's configuration has been adjusted to complywith the policy, the ESM monitors for changes to the configuration.Another such tool is System Security Scanner from Internet Security Systems.S3 Performs many of the same tests that ESM does and, like ESM, S3 reportsdepartures from baseline settings.In broad terms, we may consider that type of monitoring to be an audit functionbecause it is not ongoing. It occurs upon demand and does not continuouslygather data in real time. Thus, we see that auditing is an important part of theintrusion management process.However, many organizations have subdivided the monitoring function betweenInformation Security and IT Auditing. The security personnel monitor on a fulltime, real time basis, while audits occur periodically to ensure that monitoring iseffective. How your organization splits these tasks, or if they split them at all, isprobably a function of organization size and resources.Another example of testing tools is the SafeSuite scanner from Internet SecuritySystems (ISS) in Atlanta, Georgia. SafeSuite is a TCP/IP attack simulator. Usedagainst hosts, routers, servers and firewalls in a TCP/IP network, SafeSuite canperform over 100 different attacks typical of hacker attacks. SafeSuite uses thesame exploits that the hackers do and ISS expends considerable effort to keepthe scanner current with the state of the hacker's art.A similar product from AXENT Technologies is NetRecon. It differs fromSafeSuite in that it uses the information it gathers from successful exploits toattempt to compromise other devices on the target network. Unlike SafeSuite,which requires an input list of target devices, NetRecon is capable of discoveringnetwork assets and adding them to its target list. In that respect it behaves muchlike a seasoned cracker.DETECTIONT he third step is Detection. This is somewhat different from the detectivecontrols present during the avoidance and testing steps. In this case we aretalking about detecting an intrusion attempt in real time. The real time aspect ofdetection is important. Knowing that an attack is in progress and being able totake immediate action greatly improves the odds of successfully terminating theintrusion and apprehending the perpetrator.Real time detection depends upon having a "watch dog" system that sits in thebackground and watches all activities involving the device under surveillance.The watch dog also must be able to interpret what constitutes an attack.Two examples of real time attack detectors are Intruder Alert (ITA) fromAXENT Technologies and RealSecure from ISS. ITA works on a platform basis,detecting attacks against the platform. The platform's administrator configuresthe ITA, using a set of scripts, to interpret an attack against the computer.RealSecure monitors for communications-based attacks similar to thosesimulated by SafeSuite.INVESTIGATIONF inally, Intrusion Management defaults to Investigation when all othermeasures have failed to prevent the consequences of a successful attack.However, investigation, as you may have already gathered, may be futile unlessluck and circumstances are with you. By integrating your investigation processinto the intrusion management methodology you improve your odds markedlybecause you have gathered significant important information and made criticalpreparations along the way.For example, tools such as the ESM and the ITA allow extensive, robust logging,protected from tampering. They also allow for responses from the system underattack that may be able to gather information about the attacker that can assistyou during the investigation. The leading hindrance to a successful investigationis lack of complete, timely, reliable information about the attack and the attacker.Attacks often are not discovered until well after the fact. That problemconstitutes strike one in the intrusion management ball game. Strike two comeswhen the attacker has been clever enough to cover his or her tracks effectively. Ifthe logs are not complete, protected from tampering and retained long enough,it's strike three and your investigation never gets to first base.Investigations of security incidents, whether they are successful or simply strongattempts, should be undertaken by the organization’s Computer IncidentResponse Team (CIRT). The CIRT should be trained and prepared to initiate aformal investigation, present results to management, support litigation orcriminal prosecution if necessary, and ensure that lessons learned are fed backinto the Intrusion Management process.Good intrusion management mitigates against all of the problems surrounding aninvestigation and ensures you a chance to start around the bases. Whether youget an eventual home run, of course, depends upon many other factors. If youthink of the Intrusion Management process as a circle, the results ofinvestigations feed back into the start of the process: Avoidance. By takingadvantage of "lessons learned" we help improve the odds against additionalsuccessful attacks.Questions and comments may be forwarded to Peter Stephenson at pstephen@. Thiswhite paper my be freely copied and distributed as long as it is distributed in its entirety with thecopyright notice intact. The term “Intrusion Management” and the Intrusion Management “IM withcircling arrows” logo are trade marks of Sanda International Corp.。

胃疼经历怎样解决英语作文Experiencing stomach pain can be a very uncomfortable and distressing situation. There are various causes of stomach pain, including indigestion, gastritis, ulcers, and other gastrointestinal issues. When faced with stomach pain, it is important to take the necessary steps to address the issue and find relief. In this essay, I will discussdifferent ways to solve the problem of stomach pain, including seeking medical help, making dietary changes, and practicing stress-reducing techniques.One of the most important steps in addressing stomach pain is to seek medical help. If the pain is severe or persistent, it is crucial to consult a healthcare professional to determine the underlying cause. A doctorcan conduct a physical examination, review medical history, and may order diagnostic tests such as blood work, imaging studies, or endoscopy to identify the source of the pain. Based on the findings, the doctor can recommend appropriate treatment options, which may include medication, dietarychanges, or lifestyle modifications. It is essential not to ignore stomach pain, as it could be a symptom of a more serious condition that requires medical attention.In addition to seeking medical help, making dietary changes can also help alleviate stomach pain. Certain foods and drinks can trigger or worsen stomach pain, such as spicy foods, fatty foods, citrus fruits, carbonated beverages, and alcohol. By avoiding these triggers and opting for a bland, low-fat diet, individuals can reduce the likelihood of experiencing stomach pain. Incorporating fiber-rich foods, probiotics, and staying hydrated can also promote digestive health and alleviate discomfort. It is important to listen to the body and pay attention to how different foods affect stomach pain, as dietary modifications can play a significant role in managing gastrointestinal issues.Furthermore, practicing stress-reducing techniques can be beneficial in addressing stomach pain. Stress and anxiety can exacerbate gastrointestinal symptoms, leading to increased discomfort and pain. Engaging in activitiessuch as yoga, meditation, deep breathing exercises, and progressive muscle relaxation can help alleviate stress and promote relaxation. Additionally, getting an adequate amount of sleep, regular physical activity, and maintaining a healthy work-life balance can contribute to overall well-being and reduce the impact of stress on the digestive system. By managing stress, individuals may experience a reduction in stomach pain and an improvement in their overall quality of life.Moreover, over-the-counter medications can provide temporary relief from stomach pain. Antacids, such as calcium carbonate or magnesium hydroxide, can help neutralize stomach acid and alleviate symptoms of indigestion and heartburn. Additionally, medications such as H2 blockers or proton pump inhibitors can reduce the production of stomach acid and promote healing of the gastrointestinal lining. It is important to use these medications as directed and consult a healthcare professional if stomach pain persists or worsens despite treatment. While over-the-counter medications can provide relief, they should be used in conjunction with otherstrategies to address the root cause of stomach pain.Furthermore, maintaining a healthy lifestyle can contribute to the prevention of stomach pain. This includes avoiding smoking and excessive alcohol consumption, as these habits can irritate the gastrointestinal tract and lead to stomach pain. Eating regular, well-balanced meals, staying hydrated, and practicing portion control can also support digestive health and reduce the likelihood of experiencing discomfort. Additionally, maintaining a healthy weight and avoiding rapid weight changes can help prevent stomach pain associated with obesity or rapid digestion. By prioritizing a healthy lifestyle, individuals can reduce the risk of developing gastrointestinal issues that contribute to stomach pain.In conclusion, stomach pain can be a challenging and uncomfortable experience, but there are various ways to address the issue and find relief. Seeking medical help, making dietary changes, practicing stress-reducing techniques, using over-the-counter medications, and maintaining a healthy lifestyle are all importantstrategies in solving the problem of stomach pain. By taking a multifaceted approach and addressing the root cause of the pain, individuals can improve their digestive health and overall well-being. It is important toprioritize self-care and seek professional guidance when needed to effectively manage stomach pain and prevent it from impacting daily life.。

用[J].血栓与止血学，2018，24（6）：1070-1071.[17]汤海琴，胡世俊，朱晓素，等.运动性护理联合阿司匹林对妊高征患者凝血因子的影响及预防下肢深静脉血栓形成的效果[J].血栓与止血学，2018，24（5）：877-878.[18]黄莹，王春梅，张毅，等.胸外科术后重症患者下肢深静脉血栓形成及其凝血状态分析[J].中国肺癌杂志，2018，21（11）：864-867.[19]卓宝琴.中西医综合护理联合健康教育护理模式对脑卒中患者的护理效果研究[J].重庆医学，2022，51（S01）：393-394.[20]邓旭，李丹妮.综合康复护理对预防脊柱骨折术后患者下肢疼痛和深静脉血栓形成的影响研究[J].现代消化及介入诊疗，2020，19（1）：412-413.[21]朱小燕.脊柱骨折合并脊髓损伤手术患者应用全程优质护理干预的效果观察[J].重庆医学，2022，51（S01）：405-407.（收稿日期：2023-03-06）　（本文编辑：陈韵）①江西省鹰潭市人民医院　江西　鹰潭　335000通信作者：刘莉口腔运动干预联合早期微量喂养对早产儿胃肠并发症及神经行为发育的影响刘莉①　陈惠娟①　郑芳明①【摘要】　目的：探讨口腔运动干预联合早期微量喂养对早产儿胃肠并发症及神经行为发育的影响。

方法：2020年10月—2022年7月选取鹰潭市人民医院新生儿科收治的早产儿114例，随机将患儿分为观察组57例及对照组57例。

对照组行常规性护理+早期微量喂养，观察组在对照组基础上行口腔运动干预。

比较两组胃肠并发症、预后情况及神经行为发育。

结果：观察组腹泻、呕吐、腹胀及胃潴留等胃肠并发症发生率均低于对照组（P <0.05）。

观察组纠正体重达标、留置鼻胃管、达到完全经口喂养时间均短于对照组，而观察组出生后第7天进奶量多于对照组（P <0.05）。

观察组干预后神经行为总分及各维度评分均高于对照组（P <0.05）。

中医胃脘痛医术专长综述范文英文回答：Gastrointestinal Pain in Chinese Medicine.Gastrointestinal pain, also known as stomachache, is a common symptom experienced by individuals of all ages. In Chinese medicine, gastrointestinal pain is often attributed to imbalances or disturbances within the body's internal organs, particularly the stomach and spleen. Traditional Chinese medicine (TCM) practitioners utilize a holistic approach to diagnose and treat gastrointestinal pain, considering both the physical and emotional aspects of the patient's condition.Causes of Gastrointestinal Pain in Chinese Medicine.According to TCM, gastrointestinal pain can be caused by various factors, including:Stagnant Qi: Qi, the vital energy that circulates throughout the body, can become stagnant or blocked in the stomach, leading to pain and discomfort.Cold and Dampness: Exposure to cold or damp conditions can weaken the spleen's ability to transform and transport fluids, resulting in the accumulation of cold and dampness in the stomach, causing pain and bloating.Heat and Dampness: Excessive consumption of spicy or greasy foods can generate heat and dampness in the stomach, leading to pain and diarrhea.Emotional Factors: Stress, anxiety, and other negative emotions can affect the digestive system, causing gastrointestinal pain.Diagnosis of Gastrointestinal Pain in Chinese Medicine.TCM practitioners diagnose gastrointestinal pain based on the patient's symptoms, tongue examination, and pulse diagnosis. The tongue's color, shape, and coating canprovide insights into the state of the internal organs, while the pulse can reveal imbalances in Qi and blood flow.Treatment of Gastrointestinal Pain in Chinese Medicine.TCM offers a range of treatment options for gastrointestinal pain, including:Acupuncture: Acupuncture involves the insertion offine needles into specific points on the body to stimulate Qi flow and relieve pain.Herbal Medicine: Herbal formulas are prescribed based on the patient's individual symptoms and underlying imbalances. Herbs can help to regulate Qi, disperse cold and dampness, clear heat, and improve digestion.Diet Therapy: TCM emphasizes the importance of diet in maintaining digestive health. Dietary recommendations may include avoiding certain foods that aggravate the condition and consuming foods that support the spleen and stomach.Tai Chi and Qigong: These mind-body practices can help to regulate Qi flow and promote overall well-being, which can alleviate gastrointestinal pain.Prevention of Gastrointestinal Pain.TCM recommends several lifestyle measures to prevent gastrointestinal pain, including:Eating a balanced diet that is easy to digest.Avoiding excessive consumption of spicy, greasy, or cold foods.Managing stress and negative emotions.Engaging in regular exercise.Getting enough sleep.中文回答：中医胃脘痛医术专长综述。