第二部分 英语

第二部分：翻译（A）
英译汉
The acetabulum can be described as an incomplete hemispherical socket with an inverted horseshoe-shaped articular surface surrounding the nonarticular cotyloid fossa.. This articula socket is composed of and supported by two columns of bone, described by Judet and Letournel as an inverted Y. The anterior column is composed of the bone of the iliac crest, the iliac spines, the anterior half of the acetabulum, and the pubis. The posterior column is the ischium , the ischial spine,, the posterior half of the acetabulum, and the dense bone forming the sciatic notch. The shorter posterior column ends at its intersection with the anterior column at the top of the sciatic notch. The column concept is used in classification of these fractures and is central to the discussion of fracture patterns, operative approaches, and internal fixation.
The dome, or roof, of the actebulumn is the weight-bearing portion of the articular surface that supports the femoral head. Anatomical restoration of the dome with concentric of the femoral head beneath this dome is the goal of both operative and nonoperative treatment. The quadrilateral surface is the flat of bone forming the lateral border of the true pelvic cavity and thus lying adjacent to the medial wall of the prominence in the anterior column that lies directly over the femoral head. Both the quadrilateral surface and the iliopectineal eminence are thin and adjacent to the femoral head, limiting the types of fixation that can be used in these regions.
汉译英
腕管综合征如果症状轻微，并未出现鱼际肌的萎缩，腕管内注射氢化考地松可以缓解症状。

特别注意的是应避免将药物直接注射入神经内。

药物注射亦有助于证明非腕管内骨性或肿瘤压迫所致的腕管综合征；65%以上的腕管综合征由滑膜非特异性水肿引起，这部分患者对于局部注射反应更佳。

局部注射亦有助于排除其他疾病的可能，尤其是颈椎间盘突出或胸廓出口综合征。

有些患者希望在术前接受两到三次局部注射。

如果局部注射反应良好，且无肌萎缩，可采用夹板固定与局部注射等保守治疗。

当症状与体征持续存在并进行性加重，尤其是伴有鱼际肌萎缩时，应行腕横深韧带切断术。

第二部分：阅读和写作
根据要求用英文写出约150字的摘要
阅读文章写出摘要（A）
Traumatic spinal fractures with or without associated paralysis are significant causes of morbidity and mortality in the United States. The population-based rate of spinal cord injury over the last 30 years has remained stable at approximately 40 to 50 per million population. 1,2With an average incidence of 11,000 cases per year resulting in an estimated 4 +billion dollars of medical and supportive care costs, the human and economic costs of these injuries are substantial. 3 While
population-based studies of injured patients indicate that treatment decisions and clinical outcomes are influenced by injury severity, preinjury health status, patient age, and the location of care, 4–6there is a lack of population-based data regarding injury patterns, treatment, and mortality of spinal fracture and spinal cord injuries. 7
Treatment patterns and clinical outcomes following traumatic injury vary with patient age. Relative to nonelderly patients, elderly patients have greater in-hospital mortality and increased death after discharge. 8–10 Elderly patients also have poorer functional outcome following cervical cord injury and increased mortality from all cord injuries. 11,12 Differences in injury mechanisms, severity, and effects of treatment between elderly and nonelderly adults are not well documented. 7
Population-based studies of clinical outcome following traumatic injury often use in-hospital mortality as the sole measure of mortality.
4,5,13,14While in-hospital mortality has been shown to under-represent 60-day postdischarge mortality following injury in the elderly population, 15 analyses of in-hospital and extended mortality following spinal injuries have not been reported.
The purpose of this study was to review the patterns of care and outcome for a population-based sample of patients with spinal fracture with or without paralysis in a single state. We hypothesized that among a population of hospitalized spinal fracture patients, identifiable patient and injury characteristics exist that are predictive of risk of mortality, and that these factors as well as treatment decisions and mortality differ between hospitalized nonelderly adult and geriatric populations. Finally, we sought to compare differences between mortality rates based on in-hospital versus total mortality at 60 days postdischarge.
Materials and Methods
The hospital claims database for the state of Washington from January 1, 1990 to December 31, 1994 was obtained from the Comprehensive Hospital Abstract Reporting System of state licensed acute care hospitals (CHARS).
16 The CHARS data are linked to death certificates to produce the Death and Illness History Database, 17which allows determination of mortality within 60 days postdischarge for patients surviving hospitalization.
Definition of the Study Cohort.
All hospitalized patients over age 16 with traumatic spinal fracture with or without paralysis were identified. Data available for each case included date of birth, gender, admission date, discharge date, a hospital identifier, and up to five discharge diagnoses recorded by means of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. 18A maximum of five procedures performed during hospitalization were also listed by ICD-9-CM procedure codes.
The patient cohort included all hospitalized injured patients with at least one discharge diagnosis between 805.0 and 805.4 (indicating cervical, thoracic, or lumbar spine fracture without cord injury), and/or between 806.0 and 806.4 (indicating cervical, thoracic, or lumbar spine fracture with cord injury). Patients with a discharge diagnosis of 733.13 (indicating pathologic fracture) were excluded. While true spinal cord injury is unlikely in most lumbar spinal fractures, this code was chosen as the most accurate means of identifying the presence of severe neurologic injury.
Patients were divided by age into one of two groups: 16 to 64 years (adult; n = 6,029) and 65 years and older (geriatric; n = 3,973). Patients with ICD-9-CM procedure codes between 03.0–03.91 (indicating spinal cord or spinal canal surgery) and/or 81.0–81.09 (indicating spinal fusion) were considered to have undergone spinal surgery, while those with no procedure code indicating spinal surgery were considered to have had nonoperative management.
Pre-Injury Patient Characteristics.
Age and presence of comorbidities were determined for all patients. Comorbidities were defined as chronic medical conditions listed as secondary diagnoses on the hospital discharge abstract. The comorbidities
included for analyses were chronic obstructive pulmonary disease, coagulopathies, diabetes mellitus, ischemic heart disease, and chronic liver disease/cirrhosis, as these five conditions have the greatest effect on mortality among trauma patients. 13
Injury Characteristics.
Spinal level of injury (cervical, thoracic, or lumbar) and presence of paralysis were determined from ICD-9-CM codes listed in the discharge abstract. To isolate the effects of injury level, patients with a fracture at more than one spinal level were excluded from injury level analyses. ICD-9-CM based injury severity scores (ICISS) are the product of the survival risk ratios for each ICD-9-CM discharge diagnosis for a particular patient as reported in 1993 Healthcare Cost and Utilization Project data. 19–21
Patients were separated by ICISS score into three groups: ICISS >= 0.96 (mild injuries), ICISS = 0.75 to 0.95 (moderate injuries), and ICISS <= 0.74 (severe injuries). Mechanism of injury data were obtained from external cause codes listed in the abstract and classified as high force (motor vehicle accidents and falls from a height), low force (ground level falls), homicide/suicide/intentional, and all other. Homicide, suicide, and intentional injury were grouped due the small size of the subgroups.
Treatment Characteristics.
Hospitals were divided into three groups according to the Washington State Health Division’s level of designation of trauma centers (levels 1–2, levels 3–5, and unclassified), and hospital level was related to performance of surgery for both age groups. Transfer patients were assigned to the higher-level acute care hospital to which they were admitted. Patients having two or more hospitalizations separated by an interval of greater than 24 hours were designated as having hospital readmission and were assigned to the first hospital from which they were discharged. Patients who died before discharge without undergoing spinal surgery were excluded from treatment analyses in order to avoid a bias caused by patients who may have had surgery had they survived to discharge.
Outcome Measures and Analyses.
In-hospital and 60-day mortality were determined for all patients. A 60-day follow-up period was chosen based on previous findings indicating
that injury-designated death rates among elderly patients generally stabilize to background levels within this time frame. 15
Risk-adjusted odds of 60-day mortality were related to patient characteristics, spinal level of injury, overall injury severity, presence of paralysis, and occurrence of surgical treatment using stepwise multivariate logistic regression models. Bivariate comparisons were made using a Pearson’s [chi]2 test of independence. Statistical significance was determined using 95% confidence intervals for odds ratios and P < 0.05 for bivariate comparisons. Variables included in the model were chosen based on the findings of previously published research. 8,10,13
Results
Over the 5 years of study, 10,002 patients over the age of 16 were hospitalized in Washington State with cervical, thoracic, or lumbar spinal fracture with or without paralysis. There were 6,029 adult patients (age range, 16–64 years) and 3973 geriatric patients (ages 65 years and older). One or more of the five recorded comorbidities was present in 26.5% of the geriatric and 4.8% of the adult patients at hospital admission (Table 1).
Patterns of Injury
The patterns of injury differed between geriatric and adult patients, with geriatric patients having fewer cervical and more lumbar spinal fractures, a lower prevalence of paralysis, and lower overall injury severity. Among geriatric patients, 14.7% had cervical spine fractures, and 14.9% of this group had associated paralysis. Thoracic and lumbar spinal fractures were present in 36.5% and 55.9% of patients in the geriatric group, with paralysis rates of 2.1% and 1.2%, respectively. Among adult patients, 30.4% had cervical spine fractures and 19.5% of this group had associated paralysis. Thoracic and lumbar fractures were less frequent among adults than geriatric patients (33.8% and 45.7%, respectively), although paralysis was more common (12.5% and 8.0%, respectively). Overall, frequency of paralysis was higher for adult patients than for geriatric patients at all spinal levels of injury (P < 0.001 for all cases). These data are shown in Table 1.
ICISS categorized mild severity injuries were most common in the geriatric group (71.7%), followed by medium (27.2%), and high severity (1.1%). Adult patients were comparatively more severely injured, with injuries of
medium severity being most common (53.8%), followed by mild (41.4%), and high severity (4.5%; P < 0.001;Table 1). Mean ICISS scores were 0.96 and 0.92 for geriatric and adult patients, respectively (P < 0.001, Table 1).
With respect to mechanism of injury, geriatric patients had lower force injuries than adult patients (P < 0.05). In the geriatric group, low force injuries (58.8%) were more prevalent than high force (24.4%), whereas in the adult group, high force injuries (79.1%) were more prevalent than low force (6.8%). These results are summarized in Table 1.
Treatment
Compared with adult patients, geriatric patients were less likely to be treated at level 1 or 2 hospitals (P < 0.05) and less likely to undergo surgery at all hospital levels (P < 0.05). While treatment at a level 1 or 2 trauma center was associated with increased odds of surgical treatment for adult patients (odds ratio = 1.7; P < 0.001), it did not significantly affect odds of surgery for geriatric patients (odds ratio = 1.2; P = 0.374).
Among geriatric patients, 20.7% were treated at level 1 or 2 hospitals and 58.6% were treated at level 3, 4, or 5 hospitals. Overall, spinal surgery was performed for 7.0% of these patients. Of the geriatric patients treated at level 1 or 2 hospitals, 11.3% underwent surgery, compared with 5.2% of those treated at level 3, 4, or 5 hospitals. Among adult patients, 41.2% were treated at level 1 or 2 hospitals and 44.9% were treated at level 3, 4, or 5 hospitals. Overall, 24.6% of the adult patients underwent surgery for their spinal injuries, with 32.9% of those treated at level 1 or 2 hospitals receiving surgical treatment, and 16.4% of those treated at level 3, 4, or 5 hospitals receiving surgical treatment.
Multivariate logistic regression analyses controlling for age, gender, comorbidities, ICISS, and injury mechanism indicated that the odds of surgical treatment were higher for cervical level injuries and patients with paralysis for both age groups (P < 0.05). The odds of surgery were not significantly different between patients with thoracic and lumbar injuries in either age group. Paralysis was the strongest predictor of surgical treatment, with the relative odds of surgery being 10.01 and 12.23 (P < 0.05), respectively, for geriatric and adult patients with paralysis relative to those without.
A significant inverse association between injury severity and odds of surgery was found for the adult group but not for the geriatric group.
Adult patients with medium or mild severity injuries had increased odds of receiving surgical treatment relative to those with severe injuries (odds ratio = 2.70 and 3.80 respectively, P < 0.05). While the relative odds of surgery with medium or mild severity injuries were also higher for geriatric patients (relative odds = 1.88 and 1.69 respectively), these data were not statistically significant (Figure 1).
Mortality
Both in-hospital and 60-day mortality were greater for geriatric patients as compared to adult patients (P < 0.001). Age as a continuous variable was positively associated with increased odds of 60-day mortality for both age groups (1.03 per year of life for adults, 1.04 per year of life for elderly). A significant increase in mortality occurred between hospital discharge and 60 days postdischarge for geriatric but not adult patients. Among the geriatric patients, 3.5% died before discharge while a total of 9.7% died by 60 days (P < 0.001). In the adult population, 1.4% of the patients died before discharge, with a total of 1.6% having died by 60 days (Table 1;Figure 2).
Both geriatric and adult patients in the highest risk injury severity group (ICISS <= 0.74) had increased 60-day mortality relative to patients in the medium and mild injury severity groups (P < 0.001). Presence of comorbidities was also associated with increased 60-day mortality for both age groups (relative odds = 1.40 and 2.25 for the geriatric and adult groups, respectively, P < 0.05;Figure 3).
Presence of paralysis was positively associated with 60-day mortality for the adult group (4.0%vs. 1.1%, P < 0.05), but had an even greater impact in the geriatric group (29.7%vs. 8.9%, P < 0.05;Figure 5). Surgical treatment was associated with decreased 60-day mortality for both age groups (relative odds = 0.59 and 0.34, P < 0.05 for geriatric and adult patients, respectively;Figures 3, 4).
Discussion
This population-based study revealed several facts regarding the nature of hospitalized spinal injury patients over the 5-year period of the study. Geriatric patients differed from adult patients in many aspects of injury and treatment patterns, as well as postinjury mortality. While increased mortality was associated with presence of comorbidities, increased injury severity, and presence of paralysis for both age groups, cervical spinal fracture was significantly associated with increased mortality only for
the geriatric group. The adverse effect of paralysis was also particularly strong for the geriatric population as demonstrated by a 60-day mortality rate of nearly 30%. This may be the result of higher energy injury mechanisms associated with these injuries as well as increased systemic complications with paralysis.
The increased mortality observed in the geriatric group between hospital discharge and 60 days postdischarge was not seen for adult patients. This difference supports previous findings of increased mortality among elderly trauma patients following hospital discharge. 15,22These results suggest that in-hospital mortality data may under-represent true mortality for geriatric patients and that geriatric and adult patients should be considered separately in analyses using mortality as an outcome measure.
Significant treatment differences were also identified between the adult and geriatric populations. Geriatric patients were less likely to receive treatment at level 1 or 2 trauma hospitals and had decreased odds of surgery at all hospitals. Patients in both age groups had increased odds of undergoing surgery if they had cervical spinal fractures, paralysis, or more severe injuries. Overall, adult patients were more likely to receive surgical treatment for their spinal injuries independent of injury severity and hospital level, which may reflect a higher incidence of nonoperatively treated osteoporotic fractures in geriatric patients as well as a selection bias toward younger patients as more suitable surgical candidates.
Both adult and geriatric patients who underwent spinal surgery had lower 60-day mortality rates, which may indicate a true-positive benefit to such interventions. 4 This may reflect improved mobilization and reduced pulmonary and vascular complications as has been reported following surgical treatment of hip and femur fractures. 23,24While selection bias toward healthier patients as surgical candidates may also contribute to this result, patient age, preexisting comorbidities, presence of paralysis, injury severity and mechanism, and trauma level of treating hospital were all controlled in the analyses.
A limitation inherent to studies based on hospital billing coding is the grossness of ICD-9-CM diagnostic categories, which prevents a detailed analysis of injury characteristics. For example, while patients with a discharge diagnosis indicating pathologic fracture were excluded, it is possible that some pathologic fractures went unrecognized at the time of admission. While we attempted to mitigate this effect by controlling for injury severity in the analyses, the ICD-9-based injury severity scoring system has similar limitations. In addition, only patients with
hospital-diagnosed spinal fractures were identified via the database, which would exclude patients with less severe injuries and sufficiently good health to be treated on an outpatient basis. The exclusion of government hospitals in this study may also have resulted in the exclusion of patients with particular demographics. All of these issues may limit the ability to generalize our results.
Other potential sources of error may also exist in the database used. The possibility of inaccurate or incomplete reporting exists when using hospital claims information, 25,26 and since these data are used to determine diagnosis-related reimbursement, validity may be compromised because of practitioners’ efforts to enhance reimbursement. 27 Additionally, since only five diagnoses are available from the CHARS database, other diagnoses may be unrecorded and thus decrease the reported prevalence of comorbidities and estimates of injury severity. 28 While each of these factors may have affected our data, development of a large database is inherently valuable. Since this study is based on a statewide population, biases that may result from analyses of smaller groups of treatment centers are decreased. In addition, the study population of more than 10,000 patients over 5 years is sufficient to identify major differences in the populations studied. Further, the unique linkage between the hospitalization and mortality databases allows for determination of patient mortality after discharge, and consequently more accurate outcome analyses.
Conclusion
This population-based study of hospitalized patients with spinal fractures demonstrated that these injuries are associated with a significant risk of mortality. These data indicate that the geriatric population with spinal fracture is significantly different from other adult patients with spinal fracture, and we conclude that the two populations should be stratified and considered separately in analyses of treatment patterns and outcome. We also conclude that judgments regarding the quality of care delivered to geriatric patients with spinal injury need to consider both in-hospital and extended survival. The beneficial effect of surgical treatment observed for both geriatric and adult patients indicates a need for further study to better define patient and injury characteristics, which may optimize the effects of such interventions in patients with spinal injuries.。