herpes zosterisa da postherpesuli nevralgiis mkurnaloba
herpes zosterisa da postherpesuli nevralgiis mkurnaloba herpes zosterisa da postherpesuli nevralgiis mkurnaloba
2003, Vol. 2, #3(5) sarCevi dasabuTebuli [faqtebze dafuZnebuli] medicina klinikuri mtkicebulebani gastro-ezofagaluri refluqs daavadeba (gerd) 3 meningokokuri daavadeba 6 axalSobilTa uecari sikvdilis sindromi 9 z. kirtava, m. kobalaZe klinikuri praqtikis rekomendaciebi qronikuli disfagiis kvleva da marTva 12 paula lesli, paul n. kardingi, janet a. nilsoni klinikuri mimoxilva herpes zosterisa da postherpesuli nevralgiis mkurnaloba 20 robert jonsoni, robert dvorkini Rrma venaTa Trombozis diagnozi, gamokvleva da mkurnaloba 25 klaiv tovi, siuzen uaieti periferiuli arteriebis daavadebis mkurnaloba pirvelad praqtikaSi 34 pol bernsi, stiven gafi, endriu bredberi dargis mimoxilva hematologiis miRwevebi 42 S. arCuaZe sisxlis gadasxmis usafrTxoebis sakiTxebi 47 fiona regani, kler teilori siaxleebi arCil kobalaZis saxelobis sainformacio teqnologiebis Semswavleli klasis gaxsna 53 CanarTi - internetis samedicino daijesti #5-6 (93-94), 2003 56 iumori samedicino Temaze 66 medicina internetSi - sasargeblo veb-gverdebi Temaze hematologia - e. faRava 68 informacia – saqarTvelos jandacvis veb-gverdis saaplikacio forma 69 1
- Page 2 and 3: CONTENT Evidence Based Medicine Gas
- Page 4 and 5: ezofagitTan asocirebuli gerd-is saw
- Page 6 and 7: meningokokuri daavadeba klinikuri m
- Page 8 and 9: swrafad viTardeba. mkurnalobis gver
- Page 10 and 11: dakvirvebebis Sedegad Catarebuli kv
- Page 12 and 13: qronikuli disfagiis kvleva da marTv
- Page 14 and 15: cxrili 2 disfagiisa da aspiraciis s
- Page 16 and 17: saylapavis qvemo nawilidan momdinar
- Page 18 and 19: anamnezi da pirveladi gasinjva daud
- Page 20 and 21: herpes zosterisa da postherpesuli n
- Page 22 and 23: miuxedavad adeqvaturi antivirusuli
- Page 24 and 25: herpes zosteris infeqciiT gamowveul
- Page 26 and 27: plazmis D-dimerebi fibrinis specifi
- Page 28 and 29: ultrasonografiis kombinacia Rrma ve
- Page 30 and 31: antikoagulaciis xangrZlioba britane
- Page 32 and 33: • hipoproteinemia (mag. cirozi, n
- Page 34 and 35: periferiuli arteriebis daavadebis m
- Page 36 and 37: daamZimos. es yvela antihipertenziu
- Page 38 and 39: agvacileben iseT ZviradRirebul sisx
- Page 40 and 41: cxrili 2. periferiuli arteriebis da
- Page 42 and 43: miRwevebi hematologiaSi moamzada So
- Page 44 and 45: Trombozuli paTologiebis mravali mem
- Page 46 and 47: Tanmimdevrobis zusti daxasiaTeba) d
- Page 48 and 49: garTulebaTa identifikaciisa da anal
- Page 50 and 51: angariSgebis Semowmebas da im state
2003, Vol. 2, #3(5)<br />
sarCevi<br />
<strong>da</strong>sabuTebuli [faqtebze <strong>da</strong>fuZnebuli] medicina<br />
klinikuri mtkicebulebani<br />
gastro-ezofagaluri refluqs <strong>da</strong>avadeba (gerd) 3<br />
meningokokuri <strong>da</strong>avadeba 6<br />
axalSobilTa uecari sikvdilis sindromi 9<br />
z. kirtava, m. kobalaZe<br />
klinikuri praqtikis rekomen<strong>da</strong>ciebi<br />
qronikuli disfagiis kvleva <strong>da</strong> marTva 12<br />
paula lesli, paul n. kardingi, janet a. nilsoni<br />
klinikuri mimoxilva<br />
<strong>herpes</strong> <strong>zosterisa</strong> <strong>da</strong> post<strong>herpes</strong>uli <strong>nevralgiis</strong> <strong>mkurnaloba</strong> 20<br />
robert jonsoni, robert dvorkini<br />
Rrma venaTa Trombozis diagnozi, gamokvleva <strong>da</strong> <strong>mkurnaloba</strong> 25<br />
klaiv tovi, siuzen uaieti<br />
periferiuli arteriebis <strong>da</strong>avadebis <strong>mkurnaloba</strong> pirvelad praqtikaSi 34<br />
pol bernsi, stiven gafi, endriu bredberi<br />
<strong>da</strong>rgis mimoxilva<br />
hematologiis miRwevebi 42<br />
S. arCuaZe<br />
sisxlis ga<strong>da</strong>sxmis usafrTxoebis sakiTxebi 47<br />
fiona regani, kler teilori<br />
siaxleebi<br />
arCil kobalaZis saxelobis sainformacio<br />
teqnologiebis Semswavleli klasis gaxsna 53<br />
CanarTi - internetis samedicino <strong>da</strong>ijesti #5-6 (93-94), 2003 56<br />
iumori samedicino Temaze 66<br />
medicina internetSi - sasargeblo veb-gverdebi<br />
Temaze hematologia - e. faRava 68<br />
informacia – saqarTvelos jan<strong>da</strong>cvis veb-gverdis saaplikacio forma 69<br />
1
CONTENT<br />
Evidence Based Medicine<br />
Gastro-Oesophagal Reflux Disease (GERD) 3<br />
Meningococcal Disease 6<br />
Sudden Infant Death Syndrome 9<br />
(based on Clinical Evidence, issue 5) – Z. Kirtava, M. Kobaladze<br />
Clinical Practice Guidelines<br />
Investigation and Management of Chronic Dysphagia 19<br />
P. Leslie, PN Carding, JA Wilson.<br />
Clinical Reviews<br />
Treatment of Herpes Zoster and Postherpetic Neuralgia 24<br />
RW Johnson, RH Dworkin<br />
Diagnosis, Investigation, and Management of Deep Vein Thrombosis 33<br />
C. Tovey, S. Wyatt<br />
Management of Peripheral Arterial Disease in Primary Care 41<br />
P. Burns, S. Gough, AW Bradbury<br />
Area review<br />
Advances in Hematology 46<br />
S. Archuadze<br />
Blood transfusion medicine 52<br />
F. Regan, C. Taylor<br />
News<br />
Opening of IT Development Computer Class after Dr. Archil Kobaladze 53<br />
Medical Humor 67<br />
Internet M edical Digest - #5-6 (93-94), 2003<br />
Medicine on the Web<br />
Useful Medical URLs/Links<br />
Information<br />
Application for for the Georgian Health System web-page (www.health.net.ge)<br />
2
gastro-ezofagaluri refluqs <strong>da</strong>avadeba (gerd) –<br />
ramdenad efeqturia ezofagitTan asocirebuli<br />
gerd-is sawyisi <strong>mkurnaloba</strong><br />
klinikuri mtkicebulebani<br />
Paul Moayyedi, Bren<strong>da</strong>n Delaney, David Foreman<br />
Clinical Evidence, BMJ Publishing Group<br />
2003 w. (IX gamoSveba)<br />
(moamza<strong>da</strong> z. kirtavam)<br />
ZiriTadi debulebebi<br />
gerd ewodeba gastroduodenuri SigTavsis refluqss (ukugadmosrolas)<br />
saylapavis sanaTurSi. <strong>da</strong>avadebis xSiri simptomebia gulZmarva <strong>da</strong> regurgitacia.<br />
gerd-is klasifikacia xdeba ezofagogastroskopiis safuZvelze. saylapavis<br />
distaluri nawilis lorwovanis naxeTqebis aRmoCena ezofagitis niSania, romelic<br />
SeiZleba Sefasdes lorwovanis naxeTqebis zomisa <strong>da</strong> raodenobis mixedviT A<br />
xarisxi<strong>da</strong>n (lorwovanis naxeTqebis zoma < 5mm) D xarisxamde (cirkularuli<br />
naxeTqebis arseboba). alternativas warmoadgens <strong>da</strong>avadebis simZimis klasifikacia<br />
savari-mileris mixedviT I-<strong>da</strong>n (xazovani, ara Serwymadi eroziebi) IV xarisxamde<br />
(mZime ulceracia an<strong>da</strong> striqtura).<br />
sixSire: evropisa <strong>da</strong> aSS monacemebiT populaciis 20-25%-s gaaCnia gerd-is<br />
niSnebi, xolo 7%-s – gulZmarva. pirveladi jan<strong>da</strong>cvis qselis im pacientebi<strong>da</strong>n,<br />
romelTac gerd <strong>da</strong>udgin<strong>da</strong>T, 25-40%-s gaaCnia endoskopiurad <strong>da</strong><strong>da</strong>sturebuli<br />
ezofagiti, magram umravlesobaSi endoskopiuri cvlilebi ar eqna aRmoCenili.<br />
etiologia <strong>da</strong> risk-faqtorebi: ar arsebobs mtikcebuleba gerd-is<br />
prediqtiuli faqtorebis Sesaxeb. zogierTi avtori Tvlis, rom simsuqne erT-erTi<br />
risk faqtoria, magram erTiani azri ar arsebobs. Tambaqo <strong>da</strong> alkoholi aseve<br />
iTvleba maprovocirebel faqtorebad, Tumca sakmarisi mimoxilviTi masala jer<br />
araa <strong>da</strong>grovili. aseve gamoTqmuli iyo azri, rom zogierTi produqti, rogoricaa<br />
yava, pitna, dieturi cximi, citrusebi, an pomidori aseve zrdis gerd-is<br />
ganviTarebis Sanss. Tumca, ver iqna mopovebuli saTanado mtkicebuleba am<br />
faqtorebis rolis Sesaxebac. arsebobs SemosazRvruli sabuTi imisa, rom<br />
saylapa vis qve<strong>da</strong> sfinqteris momadunebeli preparatebi, mag. kalciumis arxis<br />
blokatorebi, xels uwyoben gerd-s. ori kvleva amtikicebs, rom gerd-is mimarT<br />
SeiZleba arsebobdes garkveuli genetikuri winaswarganwyoba.<br />
prognozi:<br />
gerd qronikuli paTologiaa, <strong>da</strong> <strong>da</strong>avadebulTa 80%-Si mkurnalobis Sewyveta<br />
recidivTan asocirdeba. bevr pacients amdenad Wirdeba xangrZlivi <strong>mkurnaloba</strong><br />
an<strong>da</strong> sulac operacia. endoskopiurad negatiuri gerd stabiluri mdgomareobad<br />
rCeba <strong>da</strong> am pirTa mxolod umciresobaSi SeiZleba gerd-is arsebobis fonze<br />
momavalSi garTulebebis ganviTareba, rogoricaa saylapavis striqturebi an<br />
baretis ezofagiti.<br />
3
ezofagitTan asocirebuli gerd-is sawyisi <strong>mkurnaloba</strong><br />
efeqturoba <strong>da</strong>mtkicebulia:<br />
ü H2 blokatorebi.<br />
erTi sistemuri mimoxilviT <strong>da</strong>dgin<strong>da</strong>, rom H2 blokatorebi sarwmunod zrdian<br />
gankurnebis sixSires placebosTan Se<strong>da</strong>rebiT, Tumca isini aseve sarwmunod<br />
naklebad efeqturebi arian, Tu protonis tumbos inhibitorebs Seva<strong>da</strong>rebT.<br />
ü protonis tumbos inhibitorebi.<br />
erTi sistemuri mimoxilviT <strong>da</strong>dgin<strong>da</strong>, rom protonis tumbos inhibitorebi H2<br />
blokatorebTan <strong>da</strong> placebosTan Se<strong>da</strong>rebiT sarwmunod ufro efeqturni arian<br />
gerd-is gankurnebis mxriv. erTi sistemuri mimoxilviT isic <strong>da</strong><strong>da</strong>stur<strong>da</strong>, rom<br />
ezomeprazoli ufro sarwmunod zrdis 4 kviraSi gerd-is gankurnebis Sanss, vidre<br />
omeprazoli. randomizirebuli klinikuri kvlevebiT (rkk) ar <strong>da</strong><strong>da</strong>stur<strong>da</strong> am<br />
jgufis sxva warmomadgenlebis efeqturobas Soris mniSvnelovani sxvaobis<br />
arseboba.<br />
efeqturoba ucnobia:<br />
ü antacidebi/alginatebi<br />
ori rkk a<strong>da</strong>sturebs, rom antacidebs, placebosTan Se<strong>da</strong>rebiT SeuZliaT gerd-iT<br />
gamowveuli simptomebis jamis Semcireba, Tumca amavdroulad ver iwveven<br />
endoskopiuri gajansaRebis gaxSirebas. 8-kviriani rkk-iT, rodesac erTmaneTs<br />
antacidebsa <strong>da</strong> cimetidins a<strong>da</strong>rebdnen, ar <strong>da</strong><strong>da</strong>stur<strong>da</strong> endoskopiiT raime<br />
sarwmuno gansxvaveba. amavdroulad 12-kviriani kursis analiziT <strong>da</strong><strong>da</strong>stur<strong>da</strong>, rom<br />
antacidebi ufro nakleb efeqturni arian, vidre ranitidini.<br />
ü cxovrebis stili<br />
ramdenime rkk-iT ar <strong>da</strong><strong>da</strong>stur<strong>da</strong> cxovrebis wesis sarwmuno gavlena gerd-ze.<br />
araefeqturoba an<strong>da</strong> ziani <strong>da</strong>dgenilia:<br />
ü motorikis stimulatorebi.<br />
erTi rkk a<strong>da</strong>sturebs cisapridis 12-kviriani kursis sarwmuno gavlenas gerd-is<br />
gankurnebaze placebosTan Se<strong>da</strong>rebiT, Tumca am wamlis gamoyeneba zogierT<br />
qveyanaSi SezRudulia ariTmiuli gverdiTi efeqtebis gamo.<br />
ezofagitTan asocirebuli gerd-is SemanarCunebeli <strong>mkurnaloba</strong><br />
efeqturoba <strong>da</strong>dgenilia:<br />
ü protonis tumbos inhibitorebi.<br />
ramdenime sistemuri mimoxilviT <strong>da</strong>dgin<strong>da</strong>, rom protonis tumbos inhibitorebi H2<br />
blokatorebTan <strong>da</strong> placebosTan Se<strong>da</strong>rebiT sarwmunod zrdian remisiis sixSires<br />
refluqs ezofagitis morCeni<strong>da</strong>n 6-18 Tvis ganmavlobaSi. erTi sistemuri mimoxilva<br />
4
a<strong>da</strong>sturebs, rom lansoprazolis miRebuli doza (30 mg/dR) iseve efeqturia,<br />
rogorc omeprazoli (20 mg/dR) – 12-Tviani remisiis misaRwevad. amavdroulad<br />
naCvenebi iyo, rom ufro <strong>da</strong>bali doziT (15 mg/dR) lansoprazoli CamorCebo<strong>da</strong><br />
omeprazolisa <strong>da</strong> ezomeprazolis, iseve rogorc lansoparzilis miRebuli dozis<br />
efeqturobas.<br />
sargebeli <strong>da</strong> ziani TiTqmis Tanabaria<br />
ü laparaskopiuli qirurgia<br />
erTi sistemuri mimoxilviT ver inaxa srulad Catarebuli rkk-ebi sa<strong>da</strong>c es<br />
sakiTxi iqnebo<strong>da</strong> Seswavlili. ori rkk-iT ver iqna nanaxi raime sarwmuno<br />
gansxvaveba laparoskopiul Tu Cveulebriv qirurgiul midgomas Soris 3-24 Tviani<br />
remisiis TvalsazrisiT. erTi rkk-iT aRmoCn<strong>da</strong>, rom laparoskopiul qirurgias<br />
naklebi garTuleba axasiaTebs, vidre Ria qirurgias.<br />
ü Ria qirurgia<br />
ramdenime rkk-iT <strong>da</strong><strong>da</strong>stur<strong>da</strong> qirurgiuli wesiT (nisenis fundoplikacia)<br />
mkurnalobisas ukeTesi remisia 3-38 Tvis ganmavlobaSi Se<strong>da</strong>rebiT medikamentozur<br />
<strong>mkurnaloba</strong>sTan. Tumca, ufro xangrZlivi <strong>da</strong>kvirvebisas (10 wlis Semdeg) ver iqna<br />
nanaxi raime sarwmuno sxvaoba mkurnalobis qirurgiul Tu Terapiul wess Soris.<br />
efeqturoba ucnobia:<br />
ü antacidebi/alginatebi<br />
ver iqna nanaxi raime rkk, romelic aCveneb<strong>da</strong> antacidebs xangrZliv efeqts gerd-ze.<br />
ü cxovrebis stili<br />
ver iqna nanaxi rkk-iT cxovrebis wesis sarwmuno gavlenaze gerd-is xangrZliv<br />
menejmentSi.<br />
araefeqturoba an<strong>da</strong> ziani <strong>da</strong>dgenilia:<br />
ü motorikis stimulatorebi.<br />
5
meningokokuri <strong>da</strong>avadeba<br />
klinikuri mtkicebulebani<br />
Meningococal Disease: What are the effects of treatments<br />
J Correia and C A Hart<br />
Clinical Evidence, BMJ Publishing Group<br />
2003 w. (IX gamoSveba)<br />
moamzades z. kirtavam, m. kobalaZem<br />
ganmarteba<br />
meningokokuri <strong>da</strong>avadeba warmoadgens Neisseria meningitidis (meningococcus) A, B, C jgufis,<br />
an sxva serojgufebis mier gamowveul nebismier klinikur mdgomareobas. es<br />
mdgomareoba moicavs Cirqovan koniunqtivits, septiur arTrits, meningits <strong>da</strong><br />
septicemias meningitis TanxlebiT an mis gareSe.<br />
SemTxvevebi/gavrceleba<br />
meningokokuri <strong>da</strong>avadeba sporadulia zomier qveynebSi <strong>da</strong> umetesad gamowveulia B<br />
an C jgufis meningococci-s mier. did britaneTSi misi SemTxvevebi meryeobs 2-<strong>da</strong>n 8<br />
SemTxvevamde/100 000 a<strong>da</strong>mianze <strong>da</strong> aSS-Si ki<br />
0,6-1,5/100 000 a<strong>da</strong>mianze wliurad. <strong>da</strong>avadebis ga<strong>da</strong>cemas adgili aqvs ojaxis wevrebs,<br />
skolis moswavleebs <strong>da</strong> saerTo sacxovrebelSi mcxovreb studentebs Soris. subsaharul<br />
(saharis samxreTiT) mdebare afrikaSi mudmivad mZvinvarebs epidemia<br />
serojguf A-s arsebobis gamo. amas ki gansakuTrebiT im qveynebSi aqvs adgili,<br />
romlebsac <strong>da</strong>savleTiT gambia, xolo aRmosavleTiT – eTiopia esazRvrebaT, (e.w.<br />
`meningitis sartyeli”), sa<strong>da</strong>c epidemiis dros SemTxvevaTa maCvenebeli 100 000<br />
a<strong>da</strong>mianze 500 SemTxvevas aRwevs.<br />
etiologia/risk-faqtorebi<br />
Meningococcus-iT inficirdeba janmrTeli a<strong>da</strong>miani <strong>da</strong> is ga<strong>da</strong>dis axlo kontaqtiT:<br />
savaraudod, ze<strong>da</strong> sasunTqi gzebis sekreciis Sedegad gamoyofili nivTierebebiT.<br />
<strong>da</strong>avadebis ga<strong>da</strong>cemis riski yvelaze maRalia kontaqtis Semdgom pirvel kviraSi.<br />
risk-faqtorebSi Sedis: xalxiT savse oTaxSi yofna <strong>da</strong> sigaretis kvamlis gavlena.<br />
2 wlamde asakis bavSvebSi SemTxvevaTa ricxvi Zalze maRalia, amis Semdeg<br />
<strong>da</strong>avadeba piks 15-24 wlis asakSi aRwevs. amJamad, meningokokuri <strong>da</strong>avadebis<br />
SemTxvevaTa ricxvi maRalia universitetis studentebs, gansakuTrebiT I kurselebs<br />
<strong>da</strong> saerTo sacxovrebelSi mcxovreb studentebs Soris. Tumca, mkvlevarebma ver<br />
<strong>da</strong>adgines axlo kontaqtSi myof a<strong>da</strong>mianebs Soris meningokokuri <strong>da</strong>avadebis riskis<br />
zusti maCvenebeli, magaliTad; saerTo sacxovrebelSi mcxovreb studentebSi,<br />
ZiriTad mosaxleobasTan Se<strong>da</strong>rebiT, axlo kontaqti mainc warmoadgens am<br />
a<strong>da</strong>mianebSi <strong>da</strong>avadebis riskis zrdis ganmapirobebel faqtors.<br />
B jgufis meningokokTan Se<strong>da</strong>rebiT, epidemiis gavrcelebas ufro metad A <strong>da</strong> C<br />
jgufis meningokokebis mier gamowveuli <strong>da</strong>avadeba iwvevs.<br />
6
ar aris cnobili, ra iwvevs meningokokis virulentobas, magram garkveuli klonebi<br />
garkveul dros <strong>da</strong> garkveul jgufebSi iZenen virulentobas. a<strong>da</strong>mianTa 10-15%-s<br />
aRmoaCn<strong>da</strong> meningokoki yelSi; virulenturi meningokokis axlo warsulSi `SeZena~<br />
zrdis invaziuri <strong>da</strong>avadebis risks.<br />
prognozi<br />
sikvdilobis maCvenebeli yvelaze maRalia Cvilebsa <strong>da</strong> mozardebSi <strong>da</strong><br />
<strong>da</strong>kavSirebulia <strong>da</strong>avadebis formasTan: septicemiis dros sikvdiloba aRiniSneba 19-<br />
25%-Si, meningiti + septicemiis dros – 10-12%-Si, xolo mxolod meningitis dros,<br />
sikvdilobis maCvenebeli 1%-ze <strong>da</strong>balia.<br />
savaraudod sasargebloa:<br />
ra sargebeli moaqvs <strong>mkurnaloba</strong>s<br />
v profilaqtikuri antibiotikebis gamoyeneba<br />
mkvlevarebma ver aRmoaCines randomizirebuli klinikuri kvlevebi (rkk)<br />
avadmyofTan kontaqtirebul pirebSi meningokokuri <strong>da</strong>avadebis riskis<br />
Sesamcireblad profilaqtikuri antibiotikebis gamoyenebis sargeblis Sesaxeb.<br />
rkk-is Catareba araa mosalodneli, vinai<strong>da</strong>n intervenciasTan <strong>da</strong>kavSirebuli riski<br />
umniSvneloa, xolo meningitTan <strong>da</strong>kavSirebuli riski Zalze maRalia.<br />
<strong>da</strong>kvirvebebi<strong>da</strong>n gamomdinare, antibiotikebi amcireben meningokokuri <strong>da</strong>avadebis<br />
risks. Tumca, mkvlevarebma ver aRmoaCines <strong>da</strong>mamtkicebeli sabuTi imis Taobaze, Tu<br />
ra SemTxvevaSia mizanSewonili kontaqtirebuli piris profilaqtikuri<br />
<strong>mkurnaloba</strong>.<br />
efeqturoba ucnobia<br />
v antibiotikebis gamoyeneba yelSi arsebuli meningococcus-is dros.<br />
(antibiotikebi sarwmunod amcireben yelSi meningococcus-is raodenobas, Tumca<br />
ucnobia maTi sargebeli <strong>da</strong>avadebis ganviTarebis riskis SemcirebaSi)<br />
randomizirebuli kontrolirebuli kvlevebis Sedegad aRmoCn<strong>da</strong>, rom placebosgan<br />
gansxvavebiT, antibiotikebi pacientTa did raodenobaSi warmatebiT aqroben<br />
meningococcus-s yelSi. Tumca sadReisod ver inaxa raime mtkicebuleba, rom amiT<br />
mcirdebodes meningokokuri <strong>da</strong>avadebis riski.<br />
v saeWvo SemTxvevebSi parenteraluri antibiotikebis winaswari <strong>da</strong>niSvna<br />
mkvlevarebma ver aRmoaCines antibiotikebis winaswari <strong>da</strong>niSvnis Sedegad miRebuli<br />
sargebeli meningokokuri <strong>da</strong>avadebis prevenciaSi. rkk-is Catareba araa<br />
mosalodneli, ramdena<strong>da</strong>c meningokokuri <strong>da</strong>avadeba zogierT a<strong>da</strong>mianSi Zalze<br />
7
swrafad viTardeba. mkurnalobis gverdiTi movlenebis riski sakmaod <strong>da</strong>balia,<br />
xolo mkurnalobis <strong>da</strong>gvianebis Sedegad moaslodneli safrTxe – sakmaod maRali.<br />
kvlevebis umetesobam TiTqos aCvena antibiotikebis sargebeli, magram sul mcire,<br />
erTma kvlevam mainc sawinaaRmdego Sedegebi moitana.<br />
rkk - randomizirebuli klinikuri kvlevebi<br />
8
axalSobilTa uecari sikvdilis sindromi<br />
Sudden Infant Death Syndrome – What are the effects<br />
of interventions to reduce the risk<br />
of suddent infant death syndrome<br />
klinikuri mtkicebulebani<br />
David Creery and Angelo Mikrogianakis<br />
Clinical Evidence, BMJ Publishing Group<br />
2003 w. (IX gamoSveba)<br />
moamzades z. kirtavam, m. kobalaZem<br />
ganmarteba<br />
axalSobilTa uecari sikvdilis sindromi ewodeba erT wlamde asakis<br />
axalSobilTa uecar sikvdils, romelic auxsneli rCeba klinikuri istoriis<br />
ganxilvisa, sikvdilis <strong>da</strong> gvamis Semowmebis Semdegac ki.<br />
SemTxvevebi/gavrceleba<br />
axalSobilTa uecari sikvdilis sindromis SemTxvevaTa raodenoba icvleba droTa<br />
ganmavlobaSi <strong>da</strong> agreTve sxva<strong>da</strong>sxva qveyanaSi misi maCvenebeli sxva<strong>da</strong>sxvaa. 1996<br />
wlis monacemebiT, yovel 1000 <strong>da</strong>badebul bavSvze axalSobilTa uecari sikvdilis<br />
sindromis maCvenebeli aseTia: holandia: 0,3; iaponia: 0,4; kana<strong>da</strong>: 0,5; inglisi <strong>da</strong><br />
uelsi: 0,7; aSS: 0,8; avstralia: 0,9.<br />
etiologia/risk-faqtorebi<br />
ganmartebis Tanaxmad, axalSobilTa uecari sikvdilis sindromis gamomwvevi<br />
mizezi ucnobia. <strong>da</strong>kvirvebebma aCvena, rom arsebobs garkveuli kavSiri<br />
axalSobilTa uecari sikvdilis sindromsa <strong>da</strong> iseT risk-faqtorebs Soris,<br />
rogoricaa: pirqve/gul<strong>da</strong>Rma wola, Tambaqos moxmareba prenatalur <strong>da</strong><br />
postnatalur periodSi, axalSobilTa rbil loginSi <strong>da</strong>wvena, hiperTermia/Zlierad<br />
SefuTva, axalSobilTa mozrdilTan erTad (erT sawolSi) moTavseba,<br />
(gansakuTrebiT mwevel de<strong>da</strong>sTan erTad), axalSobilTa xelovnuri kveba.<br />
prognozi<br />
Tumca, axalSobilTa uecari sikvdilis sindromis ganmartebi<strong>da</strong>n gamomdinare,<br />
prognozis gakeTeba Znelia, misi SemTxvevebi savaraudod izrdeba aseTi Cvilebis<br />
<strong>da</strong>-Zmebs Soris.<br />
ra Sedegebs iZleva intervenciebi axalSobilTa uecari sikvdilis<br />
sindromis riskis SemcirebaSi<br />
sasargebloa<br />
v axalSobilTa gul<strong>da</strong>Rma <strong>da</strong>Zineba saxifaToa<br />
9
<strong>da</strong>kvirvebebis Sedegad Catarebuli kvlevis arasistemuri ganxilvisa <strong>da</strong> 11<br />
<strong>da</strong>matebiTi kvlevis ganxilvis Sedegad aRmoCn<strong>da</strong>, rom bavSvebis <strong>da</strong>Zinebam piriT<br />
zemoT Seamcira axalSobilTa uecari sikvdilis sindromis SemTxvevebi.<br />
randomizirebuli kontrolirebuli kvlevebis Catareba araa mosalodneli.<br />
savaraudod sasargebloa<br />
v rCeva Tambaqos moxmarebis Sewyvetis Sesaxeb<br />
<strong>da</strong>kvirvebebze <strong>da</strong>fuZnebuli kvlevebis erTi arasistemuri ganxilvisa <strong>da</strong> 3<br />
<strong>da</strong>matebiTi <strong>da</strong>kvirvebiTi kvlevis ganxilvis Sedegad aRmoCn<strong>da</strong>, rom axalSobilTa<br />
uecari sikvdilis sindromis risk-faqtorebis Semcirebis kampanias, maT Soris<br />
Tambaqos moxmarebis Sewyvetis Sesaxeb rCevas, mohyva axalSobilTa uecari<br />
sikvdilis sindromis SemTxvevaTa ricxvis Semcireba. randomizirebuli<br />
kontrolirebuli kvlevebis Catareba araa mosalodneli.<br />
efeqturoba ucnobia<br />
v rCeva axalSobilis mozrdilTan erTad <strong>da</strong>Zinebis winaaRmdeg<br />
erTi <strong>da</strong>kvirvebiTi kvlevis Sedegad <strong>da</strong>dgin<strong>da</strong>, rom axalSobilTa uecari sikvdilis<br />
sindromis risk-faqtorebis Semcirebis kampanias, maT Soris rCevas - axalSobilis<br />
mozrdilTan erTad <strong>da</strong>Zinebis winaaRmdeg, mohyva axalSobilTa uecari sikvdilis<br />
sindromis SemTxvevaTa ricxvis Semcireba. randomizirebuli kontrolirebuli<br />
kvlevebis Catareba araa mosalodneli.<br />
v rCeva ga<strong>da</strong>xurebisa <strong>da</strong> Zlierad SefuTvis Tavi<strong>da</strong>n acilebis Sesaxeb<br />
<strong>da</strong>kvirvebebis Sedegad Catarebuli kvlevebis erTi arasistemuri mimoxilvisa <strong>da</strong><br />
erTi <strong>da</strong>matebiTi <strong>da</strong>kvirvebiTi kvlevis ganxilvis Sedegad <strong>da</strong>dgin<strong>da</strong>, rom<br />
axalSobilTa uecari sikvdilis sindromis risk-faqtorebis Semcirebis kampanias,<br />
maT Soris rCevas - axalSobilTa Zlierad SefuTvis Tavi<strong>da</strong>n acilebis Sesaxeb, -<br />
mohyva axalSobilTa uecari sikvdilis sindromis SemTxvevaTa ricxvis Semcireba.<br />
randomizirebuli kontrolirebuli kvlevebis Catareba araa mosalodneli.<br />
v rCeva ZuZuTi kvebis Sesaxeb<br />
<strong>da</strong>kvirvebebis Sedegad Catarebuli kvlevebis arasistemuri ganxilvisa <strong>da</strong> 2<br />
<strong>da</strong>matebiTi <strong>da</strong>kvirvebiTi kvlevis ganxilvis Sedegad <strong>da</strong>dgin<strong>da</strong>, rom axalSobilTa<br />
uecari sikvdilis sindromis risk-faqtorebis Semcirebis kampanias, maT Soris<br />
rCevas – ZuZuTi kvebis Sesaxeb - mohyva axalSobilTa uecari sikvdilis sindromis<br />
SemTxvevaTa ricxvis Semcireba. randomizirebuli kontrolirebuli kvlevebis<br />
Catareba araa mosalodneli.<br />
10
v rCeva axalSobilTa rbil loginSi <strong>da</strong>wvenis winaaRmdeg;<br />
mkvlevarebma azriT sadReisod ar arsebobs axalSobilTa uecari sikvdilis<br />
sindromis prevenciaSi maT rbil loginSi ar<strong>da</strong>wvenis sargeblis <strong>da</strong>mamtkicebeli<br />
raime sabuTi.<br />
11
qronikuli disfagiis kvleva <strong>da</strong> marTva<br />
paula lesli, paul n. kardingi, janet a. nilsoni<br />
BMJ, 2003, t. 326, 22 Tebervali, gv. 433-436 ©<br />
M<br />
specialistTa multidisicplinaruli gundis drouli Carevis Sedegad SesaZlebelia<br />
qronikuli disfagiis garTulebebis Tavi<strong>da</strong>n acileba an mdgomareobis gaumjobeseba <strong>da</strong><br />
am farTod gavrcelebuli <strong>da</strong> mravalferovani paTologiiT ganpirobebuli<br />
sirTuleebis <strong>da</strong>Zleva.<br />
disfagia ylapvis gaZnelebaa, rac SeiZleba ganpirobebuli iyos nebismieri<br />
struqturiT tuCebi<strong>da</strong>n kuWis kardialur nawilamde. misi gamomwvevi mizezebi metad<br />
mravalferovania <strong>da</strong> moicavs mwvave cerebraluri mdgomareobebis farTo areals,<br />
progresirebad paTologiebs <strong>da</strong> travmas, oro-faringo-ezofagaluri traqtis<br />
<strong>da</strong>avadebebsa Tu operaciul Carevis Sedegebs (cxrili 1). didi britaneTis jan<strong>da</strong>cvis<br />
departamentis monacemebiT 2001-2002 wlebSi inglissa <strong>da</strong> uelsSi disfagis pirveladi<br />
diagnozi 23000 SemTxvevaSi <strong>da</strong>isva, xolo hospitalSi gatarebuli sawol-dReebis<br />
ricxvma 76000 miaRwia. Tumca es monacemebic ki srulad ver asaxavs jan<strong>da</strong>cvis xarjebs<br />
disfagiasTan mimarTebaSi. am mimoxilvis mizania Seajamos monacemebi disfagiis<br />
gavrcelebis, mizezebisa <strong>da</strong> riskis Sesaxeb <strong>da</strong> miawodos mkiTxvels detaluri<br />
Tanamedrove informacia qronikuli disfagiis SemTxvevaSi kvlevis meTodebisa <strong>da</strong><br />
marTvis strategiebis, maT Soris - multidisciplinaruli midgomis - aucileblobis<br />
Sesaxeb.<br />
mTavari Tezisebi<br />
- disfagia gulisxmobs ylapvis gaZnelebas, rac SeiZleba gamowveuli iyos ze<strong>da</strong><br />
gastrointestinaluri traqtis nebismieri struqturiT - tuCebi<strong>da</strong>n saylapavis qve<strong>da</strong><br />
sfinqteramde.<br />
- disfagiis mizezebi moicavs mwvave cerebrul paTologias an travmas, orofaringo-ezofagaluri<br />
<strong>da</strong>avadebebsa <strong>da</strong> qirurgiuli manipulacias.<br />
- disfagiis mniSvneloba metad didia pacientTa marTvis, gamosavlisa <strong>da</strong> jan<strong>da</strong>cvis<br />
xarjebis TvalsazrisiT<br />
- disfagiis adreul gamovlineba, swori Sefaseba <strong>da</strong> drouli Careva pirveladi<br />
mniSvnelobis <strong>da</strong> yvela klinicistis amocanaa.<br />
literaturuli Ziebis wyaroebi <strong>da</strong> <strong>da</strong> maTi SerCevis kriteriumebi<br />
terminebis: `ylapva~, `disfagia~ <strong>da</strong> `ga<strong>da</strong>ylapva~ gamoyenebiT ganxorciel<strong>da</strong> Zieba<br />
PubMed-is, Medline-is, OVID-isa <strong>da</strong> CINAHL- is monacemTa bazebSi. Sejer<strong>da</strong> <strong>da</strong><br />
gaerTianebul iqna farTo informacia ZiriTadi (sakvanZo) teqstebi<strong>da</strong>n <strong>da</strong> Tanamedrove<br />
momoxilvebi<strong>da</strong>n. kvlevis yvela avtori mWidrod TanamSromlobs <strong>da</strong> CarTulia im<br />
mozrdil pacientTa marTvis procesebSi, romelTac ylapvis paTologia aReniSnebaT.<br />
maT aqvT agreTve gamocdileba komprometirebuli ylapvis SemTxvevaSi zemo sasuTqi<br />
gzebis drekadi endoskopiT kvlevaSi, agreTve videofluoroskopiasa, manometriasa <strong>da</strong><br />
reabilitaciaSi.<br />
12
cxrili 1<br />
disfagiis ZiriTadi mizezebi<br />
- gastro-ezofaguri refluqsi - gulZmarva, regurgitacia, gamowveuli<br />
striqturiTa <strong>da</strong> motorikis <strong>da</strong>rRveviT;<br />
- axalazia –k lasikur SemTxvevaSi Sveba moaqvs bikarbonatul sasmelis<br />
miRebas;<br />
- motorikis (peristaltikis) <strong>da</strong>rRveva - SesaZloa <strong>da</strong>kavSirebuli iyos<br />
tkiviliTan gulmkerdis Sua areSi, sistemur <strong>da</strong>avadebebTan (sklerodermia,<br />
dermatomioziti);<br />
- saylapavis kibo - progresirebadi, aRiniSneba wonaSi kleba;<br />
- Tavisa <strong>da</strong> kisris mi<strong>da</strong>mos kibo - aRiniSneba tkivili, disfagia, yuris<br />
tkivili, pacientTa 90% -ze meti Tambaqos mwevelia, xSirad - alkoholis<br />
Warbad momxmarebeli ;<br />
- xaxis paTologiuri jibe - nela progresirebadi, aRiniSneba regurgitacia,<br />
yuryuri (nax. 1);<br />
- <strong>da</strong>brkolebis SegrZneba - SeuZlia ga<strong>da</strong>ylapos mxolod mcire ulufebi, `ar<br />
SeuZlia tabletebis ga<strong>da</strong>ylapva~;<br />
- insulti;<br />
- neirodegeneraciuli paTologiebi - parkinsonizmi, motoruli nervebis<br />
<strong>da</strong>avadebebi, gafantuli sklerozi, miasTenia;<br />
- presbifagia (moxucebulobiTi saylapavi)<br />
gavrcelebis sixSire <strong>da</strong> mizezebi<br />
saylapavis sqvamozuri karcinomis sixSire farTo arealSi meryeobs <strong>da</strong><br />
ganviTarebul qveynebSi Seadgens 10/100000, xolo aziaSi-150/100000. <strong>da</strong>savleT samyaroSi<br />
saylapavis adenokarcinomis sixSire onkologiur <strong>da</strong>avadebaTa Soris erT-erTi yvelaze<br />
swrafad mzardi maCvenebliT xasiaTdeba. ZiriTa<strong>da</strong>d avaddebian mamkacebi (7:1), misi<br />
xvedriTi wili saylapavis kibos sxva<strong>da</strong>sxva formebs Soris 34%-s Seadgens. baretis<br />
ezofagitiT <strong>da</strong>avadebulebSi adenokarcinomis ganviTarebis riski asjer ufro xSiria.<br />
demografiulma cvlilebebma populaciis asakobriv profilSi im a<strong>da</strong>mianTa ricxvis<br />
zr<strong>da</strong> gamoiwvia, romelTac asakTan <strong>da</strong>kavSirebuli <strong>da</strong>avadebebis, mag. parkinsonizmis<br />
ganviTarebis maRali riski aqvT. disfagiiT rTuldeba insultis SemTxvevaTa 2/3,<br />
amasTanave <strong>da</strong>dgenilia disfagiis kavSiri sasunTqi sistemis infeqciebis<br />
ganviTarebasTan insultis dros. Ffiziologiuri <strong>da</strong>bereba gavlenas axdes ylapvis<br />
procesze (presbifagia), rasac SeiZleba seriozuli Sedegebi hqondes. amasTan,<br />
ylapvasTan <strong>da</strong>kavSirebuli asakobrivi cvlilebebi SesaZloa organul paTologiaSi<br />
SegveSalos. `moxucebulTa saxlebis~ kontingentis 50%-ze mets aReniSnebaT kvebasTan<br />
<strong>da</strong>kavSirebuli siZneleebi, disfagia an orive erTad. xolo ga<strong>da</strong>udebeli mizezebis<br />
gamo hospitalizirebuli geriatriul pacientebs disfagia 30%-Si aReniSnebaT.<br />
garTulebis saxiT disfagia gvxvdeba agreTve gafantuli sklerozis, Tavis tvinis<br />
travmuli <strong>da</strong>zianebisa <strong>da</strong> sxva<strong>da</strong>sxva fsiqiatriuli paTologiebis dros. disfagiis<br />
mizezebi <strong>da</strong> Sedegebi imdenad mravalferovania, rom pacientis marTva bevrad ukeTesad<br />
iq xerxdeba, sa<strong>da</strong>c mTeli rigi sxva<strong>da</strong>sxva samedicino <strong>da</strong>rgebis xelmisawvdomi qselia,<br />
rogoricaa: gastroenterologia, otolaringologia, enisa <strong>da</strong> metyvelebis Terapia,<br />
dietologia <strong>da</strong> nevrologia.<br />
13
cxrili 2<br />
disfagiisa <strong>da</strong> aspiraciis simptomatika <strong>da</strong> obieqturi monacemebi (gasinjvis Sedegebi)<br />
pirveladi mniSvnelobis simptomebi<br />
- ylapvis gaZneleba<br />
- gulZmarva<br />
- xvela an moxrCobis SegrZneba ylapvis win, ylapvisas <strong>da</strong> mis Semdeg<br />
- “globusi” (gun<strong>da</strong>)<br />
- “Zveli” sakvebis regurgitacia<br />
- nazaluri regurgitacia<br />
- obstruqciis (<strong>da</strong>brkolebis) SegrZneba<br />
- wonaSi <strong>da</strong>kleba<br />
naklebad mniSvnelovani simptomebi<br />
- kvebis xasiaTis Secvla – mag. neli Wama an sazogadoebrivi<br />
TavyrilobebisaTvis Tavis arideba<br />
- yelis xSiri `Cawmen<strong>da</strong>”<br />
- sakvebis akrZalva<br />
- kvebis drois gaxangrZliveba<br />
- sasunTqi sistemis morecidive infeqciebi<br />
- sunTqvis tipis Secvla ylapvis Semdeg<br />
- atipiuri tkivili gulmkerdis areSi<br />
- “sveli” xma (Wet voice quality)<br />
obieqturi (gasinjviT miRebuli) sakvanZo monacemebi<br />
- angularuli stomatiti, glositi<br />
- wylulebi an SeSupeba piris RruSi an xaxis <strong>da</strong> xorxisa mi<strong>da</strong>moSi (Tavisa<br />
<strong>da</strong> kisris kibo)<br />
- warmonaqmnebi kisris mi<strong>da</strong>moSi (cervikaluri limfadenopaTia,<br />
obstruqciuli Ciyvi)<br />
- auxsneli temperaturuli pikebi,“sveli” an CaxleCili xma (aspiracia)<br />
- enis fascikulacia (motoruli nervebis <strong>da</strong>zianeba)<br />
- xmovaniiogebis <strong>da</strong>mbla (cervikaluri an Torakaluri neoplazia)<br />
ylapvis fiziologiuri meqanizmebi<br />
ylapvis aqtSi gansakuTrebuli mniSvneloba eniWeba mis siswrafesa <strong>da</strong><br />
kompleqsurobas, radganac a<strong>da</strong>mianSi anatomiurad zemo sasunTqi <strong>da</strong> kvebis traqti<br />
saerToa. amitomac aucilebelia, rom ylapvis momentSi sunTqva SeCerebuli iyos.<br />
Civilebi <strong>da</strong> klinikuri gamovlinebebi<br />
Aavadmyofebis mier mowodebuli informacia metad sayuradReboa <strong>da</strong> xSirad iZleva<br />
<strong>da</strong>zianebis lokalizaciis <strong>da</strong>zustebis saSualebas. Tumca aRiniSneba tendencia<br />
pacientebis mier blokis donis miTiTebisa <strong>da</strong>zianebis axlos an ufro zeviT. amasTanave<br />
cervikaluri simptomebi SeiZleba aRiniSnos nebismier doneze saylapavis qvemo<br />
spinqteramde.<br />
disfagiis dros ucxo masalis aspiraciam namdvili xmovani iogebis qvemoT (cxrili<br />
2) SesaZloa pacientTa <strong>da</strong>axloebiT 75%-Si garTulebebi gamoiwvios, rac<br />
asocirebulia pnevmoniisa <strong>da</strong> uecari sikvdilis riskTan, upirvelesad ki im<br />
pacientebSi, romelTac dizarTria aReniSnebaT. aspiraciis ganviTarebis yvelaze<br />
mniSvnelovan simptoms warmoadgens xvela ylapvis Semdeg, Tumca sxva naklebad<br />
14
gamoxatuli niSnebic SeiZleba aRiniSnos.AamasTan <strong>da</strong>dgenilia, rom radiologiurad<br />
<strong>da</strong><strong>da</strong>sturebul SemTxvevaTa 50%-Si aspiracia “farulia ”<strong>da</strong> klinikuri gamovlinebebi<br />
ar aRiniSneba.<br />
globusis (yelSi raRacis “ gaCxeris” an “gundis”) SegrZneba SesaZlebelia<br />
disfagiaSi SegveSalos. tipiurad pacientebs zemoTaRniSnuli Civilebi e.w. mSrali<br />
(nerwyvis) ga<strong>da</strong>ylapvisas aReniSnebaT, mizanmimarTuli gamokiTxviT ki dgindeba, rom<br />
maT sakvebis pasaJis WeSmariti gaZneleba ar aReniSnebaT <strong>da</strong> dietis modificirebis<br />
saWiroeba ar arsebobs.<br />
pacientTa gamokvleva<br />
anamnezis detaluri Sekrebam <strong>da</strong> gasinjvam SesaZloa klinicists wamyvani paTologiis<br />
gamovlenis saSualeba misces (cxrili 3, marjvena nawili). am SemTxvevaSi pacienti<br />
konsultaciisTvis Sesabamis specialistTan igzavneba. ucnobi etiologiis disfagia ki,<br />
rasakvirvelia, diagnozis <strong>da</strong>sadgenad kidev ufro detalur kvlevas moiTxovs (cxrili<br />
3, marcxena nawili). Tu disfagiuri Civili (sakvebis <strong>da</strong>brkoleba) laviwis qvemoT<br />
aRiniSneba, naCvenebia gastrointestinaluri endoskopiis an bariumiT retgenologiuri<br />
kvlevis Catareba.<br />
endoskopia<br />
endoskopiis upiratesobas warmoadgens potenciurad histologiuri diagnozis <strong>da</strong>smis<br />
SesaZlebloba. drekadi (flexible) endoskopiT kvlevisas, rac moicavs saylapavis<br />
<strong>da</strong>Tvalierebas, biofsias, an dilatacias, saylapavis perforaciis ganviTarebis sixSire<br />
2.6% Seadgens.<br />
Bbariumis ga<strong>da</strong>ylapva<br />
bariumiT kvleva ufro xelmisawvdomia <strong>da</strong> SeuZlia gamoavlinos saylapavis<br />
cervikaluri nawilis <strong>da</strong>zianebani, rogoricaa <strong>da</strong>brkolebis SegrZneba an paTologiuri<br />
jibe, magram beWdiseburi xrtilis qvemoTa kibo SeiZleba ver iqnas aRmoCenili. Aam<br />
proceduris Catareba ukunaCvenebia aspiraciaze eWvis SemTxvevaSi: bariumis saSualebiT<br />
gamosaxuli sasurveli sayalapavis nacvlad SesaZloa metad efeqturi, magram friad<br />
`saxifaTo~ bronqograma miviRoT.E<br />
ezofagaluri manometria<br />
E motorul <strong>da</strong>rRvevebze eWvis SemTxvevaSi ezofagaluri manometria kvlavac arCevis<br />
meTo<strong>da</strong>d aris aRiarebuli. Mmanometriis saSualebiT SesaZlebelia movaxdinoT iseTi<br />
iSviaTi paTologiebis klasificireba, rogoricaa axalazia <strong>da</strong> saylapavis difuzuri<br />
spazmi, an kidev gamovavlinoT Se<strong>da</strong>rebiT xSiri araspecifiuri dismotoruli<br />
paTologiebi, romlebic uSualod r eqvemdebarebian farmakologiuri saSualebebiT<br />
<strong>mkurnaloba</strong>s, magram gaumjobeseba SesaZlebelia miRweul iqnas maTTan <strong>da</strong>kavSirebuli<br />
refluqsisa <strong>da</strong> fsiqiatriuli <strong>da</strong>rRvevebis mkurnalobis meSveobiT.<br />
Tanamedrove manometriuli xelsawyoebi, aRWurvili komputeruli CamwerebiT,<br />
gamoirCevian swrafi reagirebiTa <strong>da</strong> maRali mgrZnobelobiT, rac saSualebas iZleva<br />
<strong>da</strong>vafiqsiroT faringo-ezofagalur segmentSi movlenaTa metad swrafi Tanamimdevroba.<br />
aman SesaZlebeli gaxa<strong>da</strong> manometriis ambulatoriulad Catareba, rac gansakuTrebiT<br />
Rirebulia im pacientebis gamokvlevisas, romelTac perioduli simptomebi aReniSnebaT,<br />
mag. - tkivili gulis areSi. ambulatoriuli pH monitorireba dResac oqros<br />
stan<strong>da</strong>rtia im SemTxvevaSi, rodesac disfagiis savaraudo mizezad refluqsi<br />
ganixileba. igi agreTve Rirebulia atipiuri simptomatikis mqone pacientebisaTvis an<br />
refluqsis sawinaaRmdego mkurnalobis uSedegobisas.<br />
OoptikurboWkovani (Fibreoptic) kvleva<br />
Cveulebriv, klinicisti konsultantis arCevans saukeTeso varaudiT akeTebs. aris<br />
Tu ara gamovlenili paTologia cervikaluri (otolaringologiuri) Tu igi<br />
15
saylapavis qvemo nawili<strong>da</strong>n momdinareobs (gastroenterologiuri) pacientebs e.w.<br />
maRali disfagiiT, romlebic gagzavnilia yuris, cxvirisa <strong>da</strong> yelis gamosakvlevad,<br />
amave dros piris Rrusa <strong>da</strong> kisris mo<strong>da</strong>mos gamokvlevac utardebaT.<br />
zemoAaerodigestiuri traqtis kibos diagnostika <strong>da</strong>srulebulad iTvleba<br />
hipofarinqsisa <strong>da</strong> xaxis optikurboWkovani kvlevis Catarebis Semdeg.Aam meTodiT<br />
SeiZleba gamovlindes `aRmavali talRis~ (”rising tide”) simptomi, romelic xorxis<br />
divertikulze miuTiTebs, magram ver gamoavlindeba postkrikoiduli (postcricoid ) -<br />
beWdisebri xrtilis Semdgomi kibo.<br />
xmovani iogebis <strong>da</strong>mbla (parezi) miuTiTebs adgilobrivad simsivnur procesze an<br />
Suasayaris gafarToebaze, mag. saylapavis simsivnis gamo. laringofaringealur<br />
neoplaziaze eWvis mitanis SemTxvevaSi Semdgomi kvleva anesTeziis qveS tardeba <strong>da</strong><br />
kompiuteruli tomografiis Catarebaa naCvenebi.<br />
ylapvis klinikuri Sefaseba<br />
funqciuri disfagia, organuli (struqturuli) orofaringealuri disfagiisagan<br />
gansxvavebiT, ylapvis aqtis specifiur dinamiur Seswavlas moiTxovs. es moicavs<br />
ylapvis aqtis garegnul klinikur Sefasebas <strong>da</strong> saWiroebisas – videofluoroskopiuri<br />
an optikurboWkovani endoskopiuri kvlevis Catarebasac. zogierT SemTxvevaSi<br />
enisa <strong>da</strong> metyvelebis specialistma SeiZleba eWvi miitanos aqamde jer kidev<br />
aradiagnoscirebul paTologiaze. am SemTxvevebSi ylapvis aqtis Sefasebis<br />
paralelurad rekomendirebulia pacientis gagzavna Sesabamis specialistTan<br />
sakonsultaciod.<br />
Yyvelaze sasurvelia, ylapvis klinikuri Sefaseba enisa <strong>da</strong> metyvelebis specialistis<br />
mier ganxorcieldes, rac saSualebas iZleva srulfasovnad Sefasdes<br />
orofarengialuri disfagiis buneba <strong>da</strong> zemoqmedeba, ganxorcieldes aspiraciis riskis<br />
skriningi. kvlevis mTavari komponentebia: 1)anamnezis detaluri Sekreba im faqtorebis<br />
gamosavlenad ,romlebic ylapvis aqtze axdenen zemoqmedebas 2) pacientis zogadi<br />
fizikuri <strong>da</strong> fsiqiuri statusis Sefaseba 3) oromotoruli gamokvlevebi maT Soris<br />
specifiuri moZraobebis siZlierisa <strong>da</strong> sifarTis Sefaseba, 4) pacientis ylapviT<br />
bolusebze <strong>da</strong>kvirveba zomebisa <strong>da</strong> konsistenciis kontroliT. orofaringealuri<br />
SegrZnebebis Seswavla detaluri gasinjvis gziT ylapvis paTologiis metad<br />
mgrZnobiare prediqtoria; mxolod gag (sacobi, burTi) refleqsis arseboba/ararsebobis<br />
<strong>da</strong>fiqsirebac ki metad mniSvnelovania.<br />
tipiuri gamokvleva iwyeba pacientisaTvis erTi Cais kovzi wylis micemiT <strong>da</strong><br />
<strong>da</strong>kvirvebiT ylapvis oralur fazaze; ylapvis drois aRricxva (<strong>da</strong>wyeba <strong>da</strong>gvianebis<br />
gareSe); laringealuri elevaciisa <strong>da</strong> koordinirebuli moZraobebis Sefaseba;<br />
bolos ki aspiraciis niSnebis gamovlena ylapvis win, ylapvis dros <strong>da</strong> mis Semdeg<br />
(cxrili 2). Cvenebebis arsebobisas xdeba 100 ml wylis micema ylapvaze xangrZlivad<br />
<strong>da</strong>kvirvebis mizniT. Sefaseba kvlav zemoTaRwerili TanmimdevrobiT xdeba. amave<br />
dros akvirdebian Tu ra siswrafiT <strong>da</strong> ra raodenobis siTxis miReba SeuZlia<br />
pacients. nebismier etapze gamovlenili <strong>da</strong>bkoleba aspiraciis riskze miuTiTebs.<br />
saWiroebis SemTxvevaSi ufro saeWvo bolusebic analogiurad gamoikvleva.<br />
ylapvis videofluoroskopiuli kvleva<br />
ylapvis videofluoroskopiuli kvlevis anu videofluoroskopiis srulyofilad<br />
Catareba konsultanti radiologisa <strong>da</strong> enisa <strong>da</strong> metyvelebis specialistis erToblivi<br />
muSaobiTaa SesaZlebeli. erTdrouli (realur droSi ganxorcielebuli)<br />
radiografiuli imijingi iZleva ylapvis procesSi monawile yvela struqturis,<br />
moZraobebisa <strong>da</strong> koordinirebuli moqmedebebis Seswavlis saSualebas.<br />
orofaringealuri an ezofagaluri paTologanatomiuri cvlilebebis <strong>da</strong>dgena swrafad<br />
<strong>da</strong> martiva<strong>da</strong>a SesaZlebeli. videofluoroskopia iZleva saSualebas uSualod adgilze<br />
<strong>da</strong>vafiqsirod aspiraciis mizezi, gvexmareba efeqturi farmakologiuri preparatebis,<br />
agreTve sakvebis rekomendirebuli konsistenciisa <strong>da</strong> kvebis dros pacientisaTvis<br />
16
xelsayreli pozis SerCevaSi. iseve rogorc ylapvis klinikuri Sefasebisas bolusis<br />
tipebis <strong>da</strong> zomebis speqtri sistematurad un<strong>da</strong> isazRvrebodes. im SemTxvevaSi Tu<br />
videofluoroskopiis misawvdomoba SezRudulia, prioriteti eniWeba rTul<br />
SemTxvevebs, rodesac mxolod ylapvis klinikuri SefasebiT pacientis mdgomareobis<br />
adeqvaturi Sefaseba <strong>da</strong> marTva ver xerxdeba. sul ufro metiMmtkicebulebaa imis<br />
Sesaxeb, rom radiologiuri kvleviT aRmoCenili aspiracia uciloblad ar miuTiTebs<br />
klinikur garTulebebsa <strong>da</strong> potenciurad cud Soreul gamosavalze. amitom igi un<strong>da</strong><br />
gamoviyenoT, rom <strong>da</strong>dgindes aspiraciis mizezi <strong>da</strong> ara mxolod aspiraciis arseboba.<br />
FoptikurboWkovani (fibreoptic) endoskopia<br />
OoptikuriboWkovani endoskopia sasurvelia Catardes enisa <strong>da</strong> metyvelebis<br />
specialistTan erTad mier <strong>da</strong> gulisxmobs drekadi endoskopis gatarebas cxviris<br />
RruSi, raTa vizualurad Sefasdes xorxisa <strong>da</strong> xaxis funqciuri mdgomareoba.<br />
endoskopiuri kvleviT yvelaze ukeTesad diagnoscirdeba: sasismieri funqcia,<br />
xmovaniFnakecis moZraoba <strong>da</strong> <strong>da</strong>xurva, ylapvis Semdgomi narCeni movlenebis xarisxi <strong>da</strong><br />
lokalizacia, agreTve fasdeba xaxisa <strong>da</strong> xorxis mgrZnobeloba. endoskopiuri meTodebi<br />
iZleva saSualebas sakmaod maRali sizustiT gamovavlinoT ylapvis wina an Semdgomi<br />
aspiracia. marTalia, ylapvis momentSi aspiracia videofluoroskopiiT ukeTesad<br />
dgindeba, endoskopia, videofluoroskopiisagan gansxvavebiT, SesaZlebelia<br />
gamoyenebul iqnas mravlobiTi an seriuli gamokvlevebisaTvis <strong>da</strong> gamosavalze<br />
<strong>da</strong>kvirvebis mizniT.<br />
marTvis gegmis Camoyalibeba<br />
avadmyofis marTva efuZneba anamnezs, klinikuri kvlevis Sedegebsa <strong>da</strong> prognozs <strong>da</strong><br />
individualuria yoveli pacientis SemTxvevaSi (cxrili 3). wamyvani paTologiis<br />
<strong>mkurnaloba</strong> aucilebelia, magram amasTanave un<strong>da</strong> gaviTvaliswinoT, rom efeqturi<br />
marTvis gareSe disfagia, nakvebobisa <strong>da</strong> hidrataciis xarisxze zegavlenis gamo,<br />
nebismieri Carevis komprometirebas moaxdens. malnutricia <strong>da</strong> dehidratacia amZimebs<br />
pacientis fizikur mdgomareobas, Sedegi ki suboptimaluri reabilitaciis procesia,<br />
rTuli <strong>da</strong> gaxangrZlivebuli gamojanmrTelebiT. disfagiis araadeqvaturi <strong>mkurnaloba</strong><br />
kidev ufro xels uwyobs am procesebis gaxangrZlivebas.<br />
<strong>da</strong>bali nakvebobis a<strong>da</strong>mianebSi ylapvis dekompensaciis riski maRalia, rasac<br />
disfagiamde mivyavarT.Yylapvis klinikuri Sefaseba gamoiyeneba iseTi usafrTxo<br />
modificirebuli dietebis gansasazRvrad, romelic Seamcirebs malnutriciasa <strong>da</strong><br />
dehidratacias. es SeiZleba gulisxmobdes a)oraluri kvebis akrZalvas <strong>da</strong> mxolod<br />
enteralur kvebas, b)sakvebis miRebis mxolod oralur gzas an g)balansis miRwevas am<br />
ors Soris. maSin rodesac oraluri gziT sakvebis miReba SeuZlebelia, Tun<strong>da</strong>c mcire<br />
xniTac ki, enteralur kvebas upirvelesi mniSvneloba eniWeba nutriciuli statusis<br />
SenarCunebaSi. Sesabamisad dietoTerapevtis aqtiuri CarTva am procesSi aucilebelia.<br />
multidisciplinaruli qselis arseboba metad mniSvnelovania disfagiiT Sepyrobili<br />
pacientebis marTvisas. droulma Carevam SesaZloa Tavi<strong>da</strong>n agvacilos an Seamsubuqos<br />
disfagiis garTulebebi. klinicisti, romlis MmeTvelyureobis qveSacaa pacienti,<br />
zogadi praqtikis eqimi iqneba igi, Tu hospitalis TanamSromeli, aq warmodgenili<br />
rekomen<strong>da</strong>ciebiT sargeblobis SemTxvevaSi Tavis wvlils Seitans am procesebSi. aman ki<br />
disfagiiT Sepyrobili pacientTa raodenobis <strong>da</strong> <strong>da</strong>avadebis xangrZlivobis Semcireba,<br />
pacientis movlis optimizacia <strong>da</strong> jan<strong>da</strong>cvis yvela muSakis tvirTis Semsubuqeba un<strong>da</strong><br />
gamoiwvios.<br />
cxrili 3<br />
kvlevisa <strong>da</strong> marTvis algoriTmi disfagiis dros<br />
pirveladi gasinjva<br />
17
anamnezi <strong>da</strong> pirveladi gasinjva<br />
<strong>da</strong>udgeneli diagnozi<br />
disfagiis winaswari diagnozi<br />
diagnozi<br />
saylapavismieri<br />
oro-faringealuri<br />
gamokvlevebi<br />
gastroenterologis<br />
konsultacia<br />
struqturuli<br />
funqciuri<br />
eWvi romelime<br />
paTologiaze, mag.<br />
nevrologiurze<br />
Sesabamis<br />
specialistTan<br />
gagzavna<br />
otorinolaringologis<br />
konsultacia<br />
metyvelebis <strong>da</strong> enis specialistTan<br />
gagzavna<br />
ylapvis<br />
videoendoskopiuri<br />
Seswavla<br />
ylapvis klinikuri Seswavla<br />
bariumiT<br />
gamokvleva<br />
gamokvleva<br />
anesTeziis fonze<br />
sxva gamokvlevebi<br />
ezofagaluri<br />
manometria<br />
drekadi<br />
endoskopia<br />
marTva<br />
ylapvis<br />
videofluoroskopiuri<br />
Seswavla<br />
ylapvis<br />
videoendoskopiuri<br />
Seswavla<br />
operacia an<br />
radioTerapia<br />
marTvis gegma<br />
riskis<br />
Semcireba<br />
kvebis<br />
optimizacia<br />
parenteraluri<br />
kveba<br />
konsistenciis<br />
modificireba<br />
mdgomareobis<br />
cvlileba<br />
<strong>da</strong>matebiTi kveba<br />
<strong>da</strong> dieta<br />
Investigation and Management of Chronic Dysphagia<br />
P. Leslie, PN Carding, JA Wilson.<br />
BMJ, 2003; 326(22 Feb):433-6.<br />
18
Dysphagia represents common disorder with multiple causes, requiring thorough investigation and at th same<br />
time is related with substantial healthcare cost. The review article summarises the incidence, causes and risks<br />
of dysphagia and provides detailed up<strong>da</strong>te on investigation (including barrium swallow, videofluoroscopic<br />
and videoendoscopic swallow studies, flexible endoscopy, esophageal manometry), as well as management<br />
strategy. Comprehensive flow chart (algorythm) for the investigation and management of dysphagia is<br />
provided and discussed. An importance of multidisciplinary approach is emphasized.<br />
19
<strong>herpes</strong> <strong>zosterisa</strong> <strong>da</strong> post<strong>herpes</strong>uli <strong>nevralgiis</strong><br />
<strong>mkurnaloba</strong><br />
robert jonsoni, robert dvorkini<br />
BMJ 2003; 326:748-50 ©<br />
<strong>herpes</strong> zosteri 85 wlamde mosaxleobis<br />
naxevars aReniSneba <strong>da</strong> xangrZlivi<br />
avadoba SeuZlia gamoiwvios. saTanado<br />
<strong>mkurnaloba</strong> xsnis mwvave simptomebs <strong>da</strong><br />
Soreuli garTulebebis risks amcirebs.<br />
imunokompetentur pacientTa Soris<br />
yvelaze gavrcelebul garTulebas<br />
Semawuxebeli <strong>da</strong> zogjer auxsneli<br />
qronikuli tkivili warmoadgens.<br />
prioritets prevencia <strong>da</strong> <strong>mkurnaloba</strong><br />
un<strong>da</strong> Seadgendes. zosteris SemTxvevaTa<br />
umetesobas ambulatoriulad SeiZleba<br />
vumkurnaloT, amitom <strong>da</strong>avadebis<br />
safuZvlian codnas ga<strong>da</strong>mwyveti<br />
mniSvneloba eniWeba. 1 qvemoT <strong>herpes</strong><br />
<strong>zosterisa</strong> <strong>da</strong> post<strong>herpes</strong>uli <strong>nevralgiis</strong><br />
Tanamedrove <strong>mkurnaloba</strong> iqneba<br />
ganxiluli.<br />
mTavari Tezisebi<br />
• <strong>herpes</strong> zosteris saTanado<br />
<strong>mkurnaloba</strong>s SeuZlia mwvave<br />
simptomebis gakontroleba <strong>da</strong> Soreuli<br />
garTulebebis riskis Semcireba.<br />
• post<strong>herpes</strong>uli <strong>nevralgiis</strong> risk<br />
faqtorebis codnas SeuZlia maTi<br />
prevenciis <strong>da</strong>gegmvaSi <strong>da</strong>gvexmaros.<br />
• <strong>zosterisa</strong> <strong>da</strong> post<strong>herpes</strong>uli<br />
<strong>nevralgiis</strong> SemTxvevebis umravlesoba<br />
SeiZleba pirveladi jan<strong>da</strong>cvis doneze<br />
iqnas marTuli.<br />
ra aris <strong>herpes</strong> zosteri<br />
<strong>herpes</strong> zosters iwvevs Cutyvavilas zosteris (Varicela Zoster) latenturi virusis<br />
gavrceleba dorzaluri an kranialuri nervebis gangliebi<strong>da</strong>n, sa<strong>da</strong>c is Cutyvavilas<br />
pirveladi infeqciis Semdeg xvdeba. 2 pirveladi infeqciis Semdeg virusi albaT xSirad<br />
aqtiurdeba, magram kompetenturi ujreduli imuniteti klinikuri <strong>da</strong>avadebisagan gvicavs.<br />
es asimptomuri gaaqtiveba <strong>da</strong> Cutyvavilas mqone a<strong>da</strong>mianebTan kontaqti ki imunitets<br />
aZlierebs. 3 zomieri klimatis pirobebSi Cutyvavila Cveulebriv bavSvTa asakis <strong>da</strong>avadebas<br />
warmoadgens, xolo tropikuli klimatis pirobebSi, gansakuTrebiT izolirebuli<br />
<strong>da</strong>saxlebis dros, ufro xSirad mozardTa <strong>da</strong> mozrdilTa Soris gvxvdeba. zosteri orive<br />
SemTxvevas SeiZleba mohyves. misi sixSire 1000 kacze wliurad 1.2-3.4-s Seadgens. 4 es sixSire<br />
asakTan erTad mkveTrad matulobs: Tu bavSvebSi erTs ar aRemateba, 65 wlis zemoT 12-s<br />
aRwevs. 4<br />
latenturi virusis gamwvavebis ZiriTad mizezs asakTan erTad ujreduli imunitetis<br />
<strong>da</strong>qveiTeba warmoadgens. sxva riskis faqtorebs Seadgens imunitetis <strong>da</strong>qveiTeba zogierTi<br />
simsivnis (mag. limfoma), simsivnis mkurnalobis (qimioTerapia an radioTerapia), a<strong>da</strong>mianis<br />
imunodeficitis virusiT infeqciisa <strong>da</strong> imunosupresiuli saSualebebis gamoyenebis<br />
(organoTa transplantaciis Semdeg an <strong>da</strong>avadebaTa samkurnalod) gamo. populaciis<br />
<strong>da</strong>berebisa <strong>da</strong> zemoaRniSnuli <strong>da</strong>avadebebisa <strong>da</strong> mkurnalobis meTodebis zr<strong>da</strong>sTan erTad<br />
mosalodnelia zosteris sixSiris mateba. amerikis SeerTebul StatebSi mimarTaven<br />
bavSvTa vaqcinacias Cutyvavilas winaaRmdeg cocxali Sesustebuli vaqcinis meSveobiT.<br />
vaqcinis viruss latenciisa <strong>da</strong> reaqtivaciis naklebi unari gaaCnia, amitom vaqcinacias<br />
SeuZlia zosteris sixSire Seamciros. 5 sanam es moxdeba, zosteri SeiZleba gaxSirdes<br />
©<br />
aRniSnuli masalis gamoqveyneba SeTanxmebulia British Medical Journal-is re<strong>da</strong>qciasTan<br />
20
kidec, radgan populaciaSi bavSvTa Cutyvavilas gaiSviaTeba specifiuri imunitetis<br />
stimulacias naklebad moaxdens <strong>da</strong> latenciis SenarCunebas xels veRar Seuwyobs.<br />
Cutyvavila-ga<strong>da</strong>tanili asakovani mozrdilebis vaqcinacia ganxilvis sagans warmoadgens<br />
<strong>da</strong> zosteris prevencias an Sesustebas amanac SeiZleba Seuwyos xeli. 6<br />
mwvave <strong>da</strong>avadebis <strong>mkurnaloba</strong><br />
zosters bevri seriozuli garTuleba gaaCnia (Tvalis, Sinagani organoebis, Tavis tvinis,<br />
motoruli), magram imunokompetentur mozrdilebSi yvelaze xSiria post<strong>herpes</strong>uli<br />
nevralgia – tkivili, romelic gamonayaris gaqrobi<strong>da</strong>n mravali Tvisa <strong>da</strong> wlis manZilze<br />
grZeldeba. Tumca post<strong>herpes</strong>ul nevralgias sxva<strong>da</strong>sxvanairad ganmartaven, Tanamedrove<br />
monacemebi ganasxvaveben mwvave <strong>herpes</strong>ul nevralgias (gamonayaris gaCeni<strong>da</strong>n 30 dRis<br />
ganmavlobaSi), qvemwvave <strong>herpes</strong>ul nevralgiasa (gamonayaris gaCeni<strong>da</strong>n 30-120 dRis<br />
ganmavlobaSi) <strong>da</strong> post<strong>herpes</strong>ul nevralgias (tkivili gamonayaris gaCeni<strong>da</strong>n 120 dRis<br />
Semdeg kvlav rCeba). 7,8 post<strong>herpes</strong>uli <strong>nevralgiis</strong> riskis yvelaze cnobil faqtorebs<br />
xan<strong>da</strong>zmuli asaki, zosteris dros mwvave tkivilis simZime, gamonayaris simZime <strong>da</strong><br />
gamonayaris winamorbedi tkivili warmoadgens. 4 riskis yvela am faqtoris mqone pacients<br />
gamonayaris gaCeni<strong>da</strong>n 6 Tvis Semdeg tkivilis <strong>da</strong>rCenis 50-75% riski gaaCnia.<br />
grZelvadiani prognozi <strong>da</strong> <strong>mkurnaloba</strong><br />
<strong>herpes</strong> zosteris mqone pacientebi mwvave simptomebis kontrolsa <strong>da</strong> garTulebebis<br />
prevencias saWiroeben. calkeuli strategiis riskis, xarjisa <strong>da</strong> sargeblis Sefasebis<br />
dros mwvave simptomebis simZime <strong>da</strong> garTulebaTa riskis faqtorebi un<strong>da</strong> gaviTvaliswinoT.<br />
50 welze ufro meti asakis pacientebs, miuxe<strong>da</strong>vad riskis sxva faqtorebisa,<br />
post<strong>herpes</strong>uli <strong>nevralgiis</strong> gacilebiT didi riski aReniSnebaT <strong>da</strong> Sesabamis <strong>mkurnaloba</strong>s<br />
saWiroeben. antivirusuli saSualebebi - acikloviri, famcikloviri <strong>da</strong> valacikloviri -<br />
Trgunaven Cutyvavila-zosteris virusis gamravlebas <strong>da</strong> amcireben zosteris simZimes:<br />
virusis gavrcelebis xangrZlioba klebulobs, gamonayaris Sexorceba Cqardeba, mwvave<br />
tkivilis simZime <strong>da</strong> xangrZlivoba ki mcirdeba. 2 mwvave infeqciis simZimisa <strong>da</strong> mis mier<br />
gamowveuli nervuli <strong>da</strong>zianebis Semsubuqeba post<strong>herpes</strong>uli <strong>nevralgiis</strong> albaTobas<br />
amcirebs. randomizebulma gakontrolebulma kvlevebma <strong>da</strong> meta-analizebma zosteris<br />
antivirusuli mkurnalobis mier tkivilis xangrZlivobis Semokleba <strong>da</strong>a<strong>da</strong>stures. 5<br />
placeboTi gakontrolebuli kvlevis meta-analizma aCvena, rom acikloviriT namkurnaleb<br />
pacientTa Soris eqvsi Tvis Semdeg tkivilis SemTxvevebis albaTobaTa fardoba 0.54<br />
Seadgen<strong>da</strong> (sarwmunoebis 95% intervali 0.36-0.81). 9 calke aRebuli kvlevebis Sedegebi<br />
SeiZleba sakamaTo iyos, magram monacemTa erTgvarovneba antivirusuli saSualebis<br />
gamoyenebis mZlavr arguments warmoadgens. prowamlebi valacikloviri <strong>da</strong> famcikloviri<br />
klinikur praqtikaSi SesaZloa aRematebodnen aciklovirs (romelsac oraluri miRebis<br />
Semdeg cudi biomisawvdomoba gaaCnia), radgan pacientebs dReSi 5 dozis miRebas 3<br />
urCevniaT.<br />
imunokomprometirebul pirebs garTulebis meti riski gaaCniaT <strong>da</strong> SeiZleba intravenuri<br />
acikloviri <strong>da</strong>sWirdeT. zosterma, romelic samwvera nervis pirvel Stos, gansakuTrebiT<br />
ki nazociliarul tots azianebs (cxviris wveris mimdebare gamonayari), Tvalis erTi an<br />
meti komponentis mwvave <strong>da</strong>zianeba SeiZleba gamoiwvios <strong>da</strong> mxedvelobas samu<strong>da</strong>mo xifaTi<br />
SeiZleba Seuqmnas. aseT dros ofTalmologis konsultacias <strong>da</strong> antiretrovirusul<br />
<strong>mkurnaloba</strong>s mimarTaven. <strong>herpes</strong> zosteris dros kortikosteroidebis izolirebuli<br />
gamoyeneba rekomendebuli ar aris, magram antivirusul TerapiasTan erTad isini aCqareben<br />
sicocxlis <strong>da</strong>avadebamdeli xarisxis aRdgenas post<strong>herpes</strong>uli <strong>nevralgiis</strong> maRali riskis<br />
mqone pacientTa Soris. 2 antivirusuli wamlebi mwvave tkivilsac amcireben, Tumca<br />
analgetikebisa <strong>da</strong> mZlavri opiatebis gamoyenebac SeiZleba <strong>da</strong>gvWirdes.<br />
xangrZlivi prognozi<br />
21
miuxe<strong>da</strong>vad adeqvaturi antivirusuli Terapiisa, zosteris mqone pacientTa nawili<br />
gaxangrZlivebul tkivils mainc uCivis. 50 welze ufro meti asakis pacientTa 20%-s,<br />
miuxe<strong>da</strong>vad valacikloviriT an famcikloviriT mkurnalobisa, gamonayaris gaCeni<strong>da</strong>n 6<br />
Tvis Semdeg tkivili kvlav aReniSneba. zosteris dros amitriptilinis, iseve rogorc<br />
opioiduri analgetikebisa <strong>da</strong> gabapentinis <strong>da</strong>mateba post<strong>herpes</strong>uli <strong>nevralgiis</strong> risks<br />
amcirebs. 10 mwvave zosteris invaziuri <strong>mkurnaloba</strong> (somaturi an simpaTikuri nervebis<br />
bloka<strong>da</strong>) kamaTis sagans warmoadgens. 11 zosteris mkurnalobis recenzirebuli<br />
gaidlainebic arsebobs. 12 un<strong>da</strong> wavaxalisoT adreuli <strong>da</strong>bruneba Cveuli socialuri <strong>da</strong><br />
saSinao aqtivobisadmi.<br />
<strong>da</strong>dgenili post<strong>herpes</strong>uli nevralgia SeiZleba auxsneli <strong>da</strong>rCes <strong>da</strong> mniSvnelovani<br />
uunaroba <strong>da</strong> tanjva gamoiwvios xan<strong>da</strong>zmuli pacientis sicocxlis bolo wlebSi. pirveli<br />
rigis <strong>mkurnaloba</strong> medikamentur saSualebebTan erTad fsiqosocialuri faqtorebis<br />
yuradRebasac gulisxmobs. pacients bunebrivi qsovilisagan <strong>da</strong>mzadebuli tansacmlis<br />
tareba <strong>da</strong> socialuri <strong>da</strong> fizikuri aqtivobis SenarCuneba un<strong>da</strong> vurCioT. Tu tricikluri<br />
antidepresantis (sasurvelia nortriptilini) an gabapentinis saTanado doza sasurvel<br />
Sedegs ar gvaZlevs, mZlavri opiati (oqsikodini, morfini an meTadoni) un<strong>da</strong> vixmaroT.<br />
tricikluri antidepresanti an gabapentini sami pacienti<strong>da</strong>n <strong>da</strong>axloebiT erTs Svelis.<br />
xSirad mimarTaven kombinirebul <strong>mkurnaloba</strong>s, rasac mxars uWers neiropaTiuli tkivilis<br />
mravalmxrivi SesaZlo meqanizmi, Tumca am midgomis efeqturoba jer araa gamokvleuli.<br />
yvela zemoaRniSnuli wamali mWidro meTvalyureobas moiTxovs, radgan xan<strong>da</strong>zmuli<br />
pacientebisaTvis seriozuli xifaTis motana SeuZliaT. 10,13 oralur miRebas bevri<br />
gverdiTi moqmedeba gaaCnia <strong>da</strong> pacientebi ufro <strong>da</strong>myoli iqnebian, Tu mkurnalobis arss<br />
avuxsniT <strong>da</strong> <strong>da</strong> dozas zustad SevurCevT. calkeuli ukumoqmedeba SeiZleba<br />
gavaneitraloT kidec: mag. xelovnuri nerwyvis sprei tricikluri antidepresantebiT<br />
gamowveuli piris simSralis dros.<br />
adgilobrivi anesTetikis (5% lidokaini) safeni tkivils minimaluri ukumoqmedebis fasad<br />
xsnis <strong>da</strong> xSirad oralur medikamentebTan erTad gamoiyeneba. 10,13 zogjer aseve efeqturi<br />
SeiZleba aRmoCndes kapsaicinis an aorTqlebad nivTierebaSi (mag. acetoni) gaxsnili<br />
aspirinis adgilobrivi gamoyeneba. 13 uSedego mkurnalobis Semdeg meTilprednizolonis<br />
intraTekuli Seyvana erTob winaaRmdegobriv strategias warmoadgens. Tumca Sedegi cudi<br />
ar un<strong>da</strong> iyos <strong>da</strong> garTulebac bevri ar aris, seriozuli garTulebebis riski aferxebs am<br />
mkurnalobis gamoyenebas, vidre efeqturoba <strong>da</strong> avadobis ararseboba ar <strong>da</strong><strong>da</strong>sturdeba<br />
kargad <strong>da</strong>gegmili kvlevebis meSveobiT. 14<br />
post<strong>herpes</strong>uli <strong>nevralgiis</strong> adreuli <strong>mkurnaloba</strong> efeqturobiT gviandels aRemateba. 15<br />
Tumca am mosazrebas <strong>da</strong><strong>da</strong>stureba esaWiroeba, qronikuli tkivili sasurvelia rac<br />
SeiZleba adre moixsnas. <strong>herpes</strong> <strong>zosterisa</strong> <strong>da</strong> post<strong>herpes</strong>uli <strong>nevralgiis</strong> mqone pacientTa<br />
Soris tkivilis moxsna pirveladi rgolis eqimsac SeuZlia. Tu zemoaRniSnuli pirveli<br />
rigis medikamentebi <strong>herpes</strong> zosteris mwvave tkivils an post<strong>herpes</strong>uli <strong>nevralgiis</strong><br />
qronikul tkivils swrafad <strong>da</strong> efeqturad ver xsnian, sasurvelia tkivilis specialists<br />
an tkivilis mkurnalobis centrs mivmarToT. es tkivilis Semcirebisa <strong>da</strong> pacientis<br />
sicocxlis xarisxis gaumjobesebis saSualebas mogvcems.<br />
statia Targmna k. papoSvilma<br />
internetSi arsebuli axali gaidlainebi Tanmxlebi faqtebiT <strong>da</strong> sxva informacia<br />
• <strong>herpes</strong>is marTvis saerTaSoriso forumi (IHMF) www.IHMF.org<br />
• varicela-zoster virusis kvlevis fondi (VZVRF) www.VZVfoun<strong>da</strong>tion.org<br />
22
literatura:<br />
1. Cunningham AL, Dworkin RH. The management of post-herpetic neuralgia. BMJ 2000; 321: 778-779.<br />
2. Gnann Jr JW, Whitley RJ. Herpes zoster. N Engl J Med 2002; 347: 340-346.<br />
3. Thomas SL, Wheeler JG, Hall AJ. Contacts with varicella or with children and protection against <strong>herpes</strong> zoster in<br />
adults: a case-control study. Lancet 2002; 360: 678-682.<br />
4. Dworkin RH, Schmader KE. Epidemiology and natural history of <strong>herpes</strong> zoster and postherpetic neuralgia. In:<br />
Watson CPN, Gershon AA, eds. Herpes zoster and postherpetic neuralgia. 2nd ed. New York: Elsevier Press,<br />
2001:39-64.<br />
5. Gershon AA. Live-attenuated varicella vaccine. Infect Dis Clin North Am 2001; 15: 65-81.<br />
6. Levin MJ. Use of varicella vaccines to prevent <strong>herpes</strong> zoster in older individuals. Arch Virol 2001; suppl 17: 151-<br />
160.<br />
7. Dworkin RH, Portenoy RK. Proposed classification of <strong>herpes</strong> zoster pain. Lancet 1994; 343: 1648.<br />
8. Desmond RA, Weiss HL, Arani RB, Soong SJ, Wood MJ, Fiddian PA, et al. Clinical applications for change-point<br />
analysis of <strong>herpes</strong> zoster pain. J Pain Symptom Manage 2002; 23: 510-516.<br />
9. Jackson JL, Gibbons R, Meyer G, Inouye L. The effect of treating <strong>herpes</strong> zoster with oral acyclvir in preventing<br />
postherpetic neuralgia: a meta-analysis. Arch Intern Med 1997; 157: 909-912.<br />
10. Dworkin RH, Schmader KE. Treatment and prevention of postherpetic neuralgia. Clin Infect Dis 2003 (in press).<br />
11. Wu CL, Marsh A, Dworkin RH. The role of sympathetic nerve blocks in <strong>herpes</strong> zoster and postherpetic neuralgia.<br />
Pain 2000; 87: 121-129.<br />
12. Johnson RW, Man<strong>da</strong>l BK. Guidelines for the management of shingles: report of a working group of the British<br />
Society for the Study of Infection. J Infect 1995; 30: 193-200.<br />
13. Kanazi GE, Johnson RW, Dworkin RH. Treatment of postherpetic neuralgia: an up<strong>da</strong>te. Drugs 2000; 59: 1113-<br />
1126.<br />
14. Kotani N, Kushikata T, Hashimoto H, Kimura F, Muraoka M, Yodono M, et al. Intrathecal methylprednisolone for<br />
intractable postherpetic neuralgia. N Engl J Med 2000; 343: 1514-1519.<br />
15. Bowsher D. Pos therpetic neuralgia and its treatment: a retrospective survey of 191 patients. J Pain Symptom<br />
Manage 1996; 12: 290-299.<br />
Cutyvavilas zosteris virusis transmisiuli eleqtronuli mikrografia<br />
23
<strong>herpes</strong> zosteris infeqciiT gamowveuli gamonayari<br />
Treatment of Herpes Zoster and Postherpetic Neuralgia<br />
Robert W Johnson, Robert H Dworkin<br />
BMJ 2003; 326:748-50<br />
Postherpetic neuralgia after <strong>herpes</strong> zoster can considerably affect quality of life. Appropriate treatment of <strong>herpes</strong> zoster<br />
can control acute symptoms and reduce the risk of longer term complications. Knowledge of risk factors for<br />
postherpetic neuralgia can provide a rationale for their prevention. Most cases of zoster and postherpetic neuralgia can<br />
be managed in primary care.<br />
24
Rrma venaTa Trombozis diagnozi, gamokvleva <strong>da</strong><br />
<strong>mkurnaloba</strong><br />
klaiv tovi, siuzen uaieti<br />
BMJ 2003; 326:1180-4 ©<br />
Targmna k. papoSvilma<br />
venuri Tromboemboliuri <strong>da</strong>avadeba ganviTarebul qveynebSi yovelwliurad 1000 kaci<strong>da</strong>n<br />
<strong>da</strong>axloebiT erTs aReniSneba. 1 igi Cveulebrivad fexis Rrma venaTa Trombozis saxiT<br />
vlindeba, Tumca Rrma venaTa Trombozi sxva venebSic SeiZleba aRiniSnos (Tavis tvinis<br />
parkuWi, xelebi, badura <strong>da</strong> jorjali).<br />
Rrma venaTa Trombozis gamosavali Trombis srul <strong>da</strong> usimptomo gawovasa <strong>da</strong> filtvis<br />
embolizmiT gamowveul sikvdils Soris meryeobs. Rrma venaTa TromboziT gamowveuli<br />
avadoba moicavs post-Trombozul sindroms, romelic qronikuli venuri hipertenziiT<br />
gamowveuli kiduris tkivilis, SeSupebis, hiperpigmentaciis, dermatitis, wylulis, venuri<br />
gangrenisa <strong>da</strong> lipodermatosklerozis saxiT vlindeba.<br />
yvelaze gavrcelebul Civils warmoadgens qvemo kiduris tkivili an wva, romelic farTo<br />
diferenciul diagnozs saWiroebs (cxrili 1). calke aRebul arcerT gamokvlevas Rrma<br />
venaTa Trombozis diagnozis idealuri Tvisebebi (100% mgrZnobeloba <strong>da</strong> specifiuroba,<br />
<strong>da</strong>bali fasi, riskis arqona) ar gaaCnia <strong>da</strong> xSirad Tanmimdevruli an erTdrouli saxiT<br />
ramdenime testi gamoiyeneba.<br />
<strong>da</strong>bali molekuluri wonis heparinebis <strong>da</strong>nergvis Semdeg SesaZlebeli gax<strong>da</strong> Rrma venaTa<br />
Trombozs ambulatoriulad vumkurnaloT. winamdebare mimoxilva qvemo kidurebis Rrma<br />
venaTa Trombozis diagnozisaTvis gankuTvnil gamokvlevebsa <strong>da</strong> mis Semdgom <strong>mkurnaloba</strong>s<br />
eZRvneba.<br />
diagnostikuri meTodebi<br />
klinikuri diagnozi<br />
qvemo kidurebis Rrma venaTa Trombozis klinikuri diagnozi saimedo ar aris. calkeul<br />
niSnebsa <strong>da</strong> simptomebs mcire Rirebuleba gaaCniaT, xolo homanis niSani faseuli ar<br />
aris. 2,3<br />
SemuSav<strong>da</strong> <strong>da</strong> did seriaSi prospeqtulad Sefas<strong>da</strong> klinikuri modeli, romelic pacientebs<br />
anamnezisa <strong>da</strong> klinikuri niSnebis safuZvelze Rrma venaTa Trombozis ganviTarebis<br />
maRali, saSualo <strong>da</strong> <strong>da</strong>bali albaTobis jgufebs miakuTvnebs. 4 es klinikuri modeli<br />
gamoyenebuli iqna diagnostikur algoriTmebSi Rrma venaTa Trombozis <strong>da</strong>sadgenad<br />
xmarebuli sadiagnozo testebis raodenobis Semcirebis mizniT. 4-6<br />
Rrma venaTa Trombozis skriningisaTvis gankuTvnili testebi<br />
didi xania cdiloben SeimuSaon maRali uaryofiTi prediqtiuli (prognozuli)<br />
Rirebulebis mqone testi, romelic <strong>da</strong>avadebis gamoricxvis saSualebas mogvcems <strong>da</strong> sxva<br />
gamokvlevaTa saWiroebas Seamcirebs. amisaTvis saWiroa swrafi, saimedo, arainvaziuri <strong>da</strong><br />
iafi testi, romelic saavadmyofoSi misvlisTanave SeiZleba Catardes. bolo wlebSi<br />
gansakuTrebuli yuradReba D-dimeris testsa <strong>da</strong> pletizmografias eTmoba (cxrili 2).<br />
D-dimeruli testebi<br />
©<br />
aRniSnuli masalis gamoqveyneba SeTanxmebulia British Medical Journa l-is re<strong>da</strong>qciasTan<br />
25
plazmis D-dimerebi fibrinis specifiur jvaredinad SekavSirebul derivatebs<br />
warmoadgenen <strong>da</strong> fibrinis plazminad <strong>da</strong>Slisas warmoiqmnebian, amitom venuri<br />
Tromboembolizmis dros maTi koncentracia matulobs. miuxe<strong>da</strong>vad venuri<br />
Tromboembolizmis mimarT mgrZnobelobisa, D-dimerebis maRali koncentracia<br />
arasakmarisad specifiuria <strong>da</strong>debiTi diagnozis <strong>da</strong>sasmelad, radgan sxva <strong>da</strong>rRvevebis<br />
drosac aRiniSneba (mag. avTvisebiani simsivne, orsuloba, operaciis Semdgomi periodi).<br />
amave dros, D-dimeris sinjebs Cveulebriv maRali uaryofiTi prediqtiuli Rirebuleba<br />
gaaCniaT, <strong>da</strong>avadebis gamoricxvis mizniT gamoiyenebian <strong>da</strong> klinikur albaTobasTan,<br />
pletizmografiasTan an ultrasonografiasTan kombinaciaSi gamosaxviTi kvlevis<br />
saWiroebas amcireben. 5-8<br />
klinikaSi D-dimeris mravali sinji gamoiyeneba. amaTgan ori farTod aris Seswavlili: es<br />
aris VIDAS-is enzimTan <strong>da</strong>kavSirebuli imunosorbentuli analizi (ELISA), romelic<br />
laboratoriis pirobebSi xorcieldeba, <strong>da</strong> SimpliRED-is mTliani sisxlis aglutinaciis<br />
sinji. 9,10 SimpliRED-is sinji Tvisobriv pasuxs gvaZlevs (<strong>da</strong>debiTi an uaryofiTi) 10 wuTis<br />
ganmavlobaSi <strong>da</strong> pacientis sawolTan SeiZleba gamoviyenoT. D-dimeris<br />
imunoqromatografiuli sinji (Simplify), romelic bolo xans iqna mowodebuli, aseve<br />
pacientis sawolTan SeiZleba ganxorcieldes, magram misi sargeblianoba jer Seswavlili<br />
ar aris. arsebobs garkveuli monacemebi imis Taobaze, rom D-dimeris koncentracia<br />
antikoagulaciis periodis Semdegac un<strong>da</strong> ganisazRvros, raTa ganmeorebiTi Trombozis<br />
riski SevafasoT. 11<br />
pletizmografia<br />
pletizmografia gansazRvravs kiduris zomis cvlilebas, romelic qsovilovani siTxis an<br />
venebSi <strong>da</strong>grovili sisxlis mier aris gamowveuli. es gansazRvra sxva<strong>da</strong>sxva gziT<br />
xorcieldeba: fotopletizmografia, tenziometria <strong>da</strong> eleqtruli winaRoba.<br />
cifruli fotopletizmografia – fotopletizmografia eriTrocitTa hemoglobinis mier<br />
sinaTlis absorbcias emyareba. cifruli fotopletizmografia mikroprocesoris<br />
meSveobiT xorcieldeba <strong>da</strong> advili Casatarebelia. 12 cifruli ga<strong>da</strong>mcemi <strong>da</strong>zianebuli<br />
fexis medialur ze<strong>da</strong>pirze, koWi<strong>da</strong>n 10 sm-iT maRla Tavsdeba (naxati 1). pacienti aTjer<br />
xris fexs muxlSi stan<strong>da</strong>rtuli oqmis Sesabamisad <strong>da</strong> Semdeg 45 wami isvenebs. areklili<br />
sinaTlis maxasiaTeblebis safuZvelze gamoiangariSeba xelaxali venuri avsebis dro,<br />
romelic grafikis saxiT warmogvidgeba (naxati 2). 100 stacionaruli pacientis<br />
gamokvleviT, 20 wamze ufro meti xelaxali venuri avsebis dro Rrma venaTa Trombozs<br />
gamoricxavs (mgrZnobeloba 100% <strong>da</strong> specifiuroba 47%). 12 Tumca cifruli<br />
fotopletizmografia skriningisaTvis gankuTvnil tests warmoadgens, misi sargeblis<br />
zusti SefasebisaTvis ufro masStaburi kvlevebi aris saWiro.<br />
kompiuterizebuli tenziometruli pletizmografia - kompiuterizebuli tenziometruli<br />
pletizmografia sazRvravs wvivis zomis cvlilebebs, romelic manJetis gaberviT<br />
gamowveul venur Segubebas mosdevs. 13 okluziis moxsnis Semdeg wvivis zomis Semcireba<br />
venuri gadinebis Sefasebis saSualebas gvaZlevs. jansaRi venuri sistema swrafi <strong>da</strong>cliT<br />
xasiaTdeba. proqsimaluri venebis Trombozuli okluzia gadinebis Seferxebas iwvevs.<br />
tenziometris <strong>da</strong>kalibrebisa <strong>da</strong> fexSi sisxlis nakadis gazomvisaTvis kompiuteruli<br />
programebi gamoiyeneba. mTeli procedura 15 wuTs moicavs <strong>da</strong> minimalur treinings<br />
saWiroebs. 307 pacientis gamokvlevam gamoavlina 90% mgrZnobeloba proqsimaluri<br />
(muxlqveSa an barZayis venebi) Rrma venaTa TrombozisaTvis <strong>da</strong> 66% mgrZnobeloba<br />
distaluri (wvivis vena) Rrma venaTa TrombozisaTvis. 13<br />
impe<strong>da</strong>nsuri pletizmografia – impe<strong>da</strong>nsuri pletizmografiis principi is aris, rom fexSi<br />
arsebuli sisxlis raodenoba gansazRvravs sisxlis mier eleqtruli nakadis gatarebis<br />
unars, romelic wvivis gaswvriv moTavsebuli ori eleqtrodis Sua arsebuli winaRobis<br />
ukuproporciulia. barZayis garSemo moTavsebuli manJetis gaberviT axSoben venur, magram<br />
ara arteriul nakads. manJetis qvemoT sisxlis Segubeba xdeba <strong>da</strong> wvivis eleqtrodebs<br />
Soris arsebuli winaRoba mcirdeba. manJetis uecari moSvebiT fexSi arsebuli sisxlis<br />
26
aodenoba klebulobs <strong>da</strong> winaRoba swrafad izrdeba. Rrma venaTa TromboziT gamowveuli<br />
obstruqcia aferxebs venur <strong>da</strong>clas <strong>da</strong> winaRobis neli zrdiT gamovlindeba. impe<strong>da</strong>nsuri<br />
pletizmografia operatorze aris <strong>da</strong>mokidebuli <strong>da</strong> <strong>da</strong>bali mgrZnobelobiT xasiaTdeba. 14<br />
zogierTi centri mas D-dimerul sinjebTan erTad iyenebs. 7<br />
Rrma venaTa Trombozis zusti diagnozi<br />
Rrma venaTa Trombozis zusti diagnozisaTvis gamoyenebuli kvlevebi Trombis<br />
vizualizacias axdenen (cxrili 3). maT Soris aris kontrastuli venografia,<br />
ultrasonografia, kompiuteruli tomografia <strong>da</strong> birTvul-magnituri rezonansi. 1,2,5<br />
venografia<br />
Rrma venaTa Trombozis diagnozis oqros stan<strong>da</strong>rts kontrastuli venografia<br />
warmoadgens. 15 samwuxarod, es procedura invaziur xasiaTs atarebs, misi ganxorcieleba<br />
yovelTvis ver xerxdeba <strong>da</strong> alergiuli reaqciis an venuri Trombozis mcire riskiT<br />
xasiaTdeba. naxati 3 warmogvidgens venogramas, romelic muxlqveSa Rrma venis Trombozs<br />
asaxavs.<br />
ultrasonografia<br />
ultrasonografia saukeTeso arainvaziur sadiagnozo meTods warmoadgens.<br />
venografiasTan Se<strong>da</strong>rebam proqsimaluri Rrma venaTa Trombozis dros <strong>da</strong>axloebiT 97%<br />
mgrZnobeloba <strong>da</strong> specifiuroba gamoavlina. 14 samwuxarod, ultrasonografia sando ar<br />
aris wvivis venaTa Trombozis dros, roca mgrZnobeloba 75%-s ar aRemateba. 14<br />
amJamad sami ultrasonografiuli teqnika gamoiyeneba.<br />
kompresiuli ultrasonografia – venuri Trombozis diagnozis yvelaze martiv<br />
ultrasonografiul kriteriums warmoadgens sisxlZarRvis narCeni arakompresirebadi<br />
sanaTuri sonografis ga<strong>da</strong>mcemis msubuqi zewolis qveS (kompresiuli ultrasonografia).<br />
Tu <strong>da</strong>wolisas sanaTuri saerTod ar vizualizdeba, vena srulad kompresireba<strong>da</strong>d<br />
miiCneva, rac venuri Trombozis arsebobas gamoricxavs.<br />
dupleqsuri ultrasonografia – pacientTa gamokvleva iseve xdeba, rogorc Cveulebrivi<br />
kompresiuli ultrasonografiis dros. gar<strong>da</strong> amisa, sisxlis nakadis Sefaseba pulsuri<br />
dopleruli signaliTac xorcieldeba. normalur venebSi sisxlis nakadi sunTqvis<br />
Sesabamis fazur xasiaTs atarebs <strong>da</strong> ultrabgeriTi ga<strong>da</strong>mcemis distalurad manualuri<br />
kompresiis meSveobiT SeiZleba gaZlierdes. Tu fazuri xasiaTi ar aRiniSneba, nakadi<br />
uwyvetad miiCneva, rac venuri gamotanis obstruqciaze miuTiTebs.<br />
feradi dupleqsuri ultrasonografia - feradi dupleqsuri ultrasonografiis teqnika<br />
dupleqsuri ultrasonografiis identuria. gamosaxulebis misaRebad pulsuri<br />
dopleruli signali gamoiyeneba. ga<strong>da</strong>mcemisaken <strong>da</strong> ga<strong>da</strong>mcemi<strong>da</strong>n mimarTuli sisxlis<br />
nakadi Sesabamisad wiTeli <strong>da</strong> lurji ferebiT aRiniSneba. sisxlis feradi nakadi Sav-<br />
TeTr gamosaxulebas edeba, rac venaTa identifikacias aadvilebs.<br />
seriuli ultrasonografia<br />
ultrabgeriTi teqnika wvivis Rrma venaTa Trombozs saTanadod ver adgens. radgan<br />
Trombozi proqsimalur venebSic SeiZleba gavrceldes, aseTi pacientebis gamosavlenad<br />
sxva<strong>da</strong>sxva strategia gamoiyeneba. erTerT diagnostikur strategias uaryofiTi pasuxi<strong>da</strong>n<br />
xuTi dRis Semdeg ultrasonografiis ganmeoreba warmoadgens. 16 am meTodis nakli is aris,<br />
rom uaryofiTi ultrabgeriTi gamokvlevis mqone pacientebi klinikas kvlav un<strong>da</strong> ewvion.<br />
27
ultrasonografiis kombinacia Rrma venaTa Trombozis pre -testur albaTobasTan an D-<br />
dimerul sinjebTan<br />
zogierT centrSi fexis proqsimaluri venebis kompresiuli ultrabgeriTi gamokvleva<br />
klinikur modelTan erTad xorcieldeba. arsebobs mosazreba, rom <strong>da</strong>bali klinikuri<br />
albaTobisa <strong>da</strong> normaluri ultrabgeriTi gamokvlevis mqone pacientebi usafrTxod<br />
SeiZleba gavweroT seriuli ultrasonografiis gareSe. 4<br />
kidev erT strategias ultrasonografiisa <strong>da</strong> D-dimeruli sinjis kombinacia warmoadgens.<br />
naCvenebi iqna, rom normaluri sawyisi ultrabgeriTi gamokvlevisa <strong>da</strong> D-dimeris<br />
normaluri koncentraciis mqone pacientebi ganmeorebiT ultrasonografias ar<br />
saWiroeben. 17<br />
spiraluri kompiuteruli tomografiuli venografia <strong>da</strong> birTvul-magnituri rezonansi<br />
fexis spiraluri kompiuteruli tomografiuli venografia fexis SeSupebis mqone<br />
pacientTa Soris Rrma venaTa Trombozisa <strong>da</strong> rbili qsovilebis sxva <strong>da</strong>vadebaTa<br />
diagnozis imedismomcem saSualebas warmoadgens. 18 53 pacientze Catarebulma mcire<br />
kvlevam, romelSic Rrma venaTa Trombozis gamosavlenad birTvul-magnituri rezonansi<br />
iqna gamoyenebuli, <strong>da</strong>a<strong>da</strong>stura am teqnikis upiratesoba Tanamedrove arainvaziur<br />
meTodebTan Se<strong>da</strong>rebiT wvivis Rrma venaTa Trombozis diagnozis dros. miuxe<strong>da</strong>vad amisa,<br />
gaiafebamde misi farTo <strong>da</strong>nergva mosalodneli ar aris. 19<br />
Rrma venaTa Trombozis <strong>mkurnaloba</strong><br />
Rrma venaTa Trombozis stan<strong>da</strong>rtuli sawyisi <strong>mkurnaloba</strong> tradiciulad hospitalizaciasa<br />
<strong>da</strong> intravenuli arafraqcionirebuli heparinis uwyvet ga<strong>da</strong>sxmas gulisxmob<strong>da</strong>.<br />
<strong>mkurnaloba</strong> oraluri antikoagulantebis (K vitaminis antagonistebis) xangrZlivi<br />
gamoyenebiT grZeldebo<strong>da</strong>. <strong>da</strong>bali molekuluri wonis heparinebis SemoRebam es praqtika<br />
Secvala.<br />
hemostazisa <strong>da</strong> Trombozis samuSao jgufis rekomen<strong>da</strong>ciiT, heparinis micema sul cota<br />
oTx dRes mainc un<strong>da</strong> gagrZeldes <strong>da</strong> manam ar un<strong>da</strong> Sewydes, sanam INR zedized or dRes<br />
Terapiul farglebSi ar iqneba. 20 am rekomen<strong>da</strong>ciis Tanaxmad, proqsimaluri venuri<br />
Trombozis pirveli epizodis mqone pacienti eqvsTvian antikoagulacias saWiroebs<br />
(samizne INR 2.5). antikoagulaciis xangrZlioba kamaTis sagans warmoadgens.<br />
heparinebi<br />
arafraqcionirebuli heparini polisaqariduli jaWvebis heterogenuli narevia. <strong>da</strong>bali<br />
molekuluri wonis heparinebi arafraqcionirebuli heparinis depolimerizaciiT miRebul<br />
fragmentebs warmoadgenen. 21 <strong>da</strong>bali molekuluri wonis heparins arafraqcionirebul<br />
heparinTan Se<strong>da</strong>rebiT ufro myari <strong>da</strong> stabiluri antikoagulaciuri moqmedeba gaaCnia <strong>da</strong><br />
ufro xangrZlivi naxevarsicocxliT xasiaTdeba. am Tvisebebis gamo igi dReSi erTxel<br />
kanqveS Segvyavs <strong>da</strong> aqtivirebuli parcialuri Tromboplastinis drois kontrolic aRar<br />
gvesaWiroeba.<br />
<strong>da</strong>bali molekuluri wonis heparini ganmeorebiTi venuri Tromboembolizmis<br />
prevenciisaTvis sul cota iseve efeqturia, rogorc arafraqcionirebuli heparini <strong>da</strong><br />
statistikurad sarwmunod amcirebs mniSvnelovan hemoragias mkurnalobis <strong>da</strong>wyebisas <strong>da</strong><br />
saerTo sikvdilobas mkurnalobis bolos. 22 <strong>da</strong>bali molekuluri wonis heparini zogjer<br />
xangrZlivad gamoiyeneba oraluri antikoagulantebis nacvlad, am ukanasknelTa<br />
ukuCvenebis dros (mag. orsuli qalebi).<br />
did britaneTSi orsulobis dros Cveulebriv <strong>da</strong>bali molekuluri wonis heparinis<br />
xmaroben, mSobiarobi<strong>da</strong>n 6-12 kviris manZilze ki <strong>da</strong>bali molekuluri wonis heparins an<br />
28
varfarins iyeneben. zogierT centrSi jerjerobiT isev arafraqcionirebuli heparini<br />
iniSneba.<br />
Trombolizuri saSualebebi<br />
mwiri monacemebi Tu arsebobs imis Taobaze, rom Trombolizuri saSualebebi (mag.<br />
streptokinaza) ufro swrafad xsnian simptomebs <strong>da</strong> inarCuneben venuri sarqvelebis<br />
mTlianobas, riTac amcireben post-flebitur sindroms. 23 amave dros, sisxldenis riski<br />
samjer ufro didia, ris gamoc Rrma venaTa Trombozis dros Trombolitikebs iSviaTadRa<br />
mimarTaven.<br />
qvemo Rru venis filtri<br />
qvemo Rru venis filtri filtvis embolizmis Tavi<strong>da</strong>n asacileblad gamoiyeneba. misi<br />
Cveneba moicavs:<br />
• filtvis embolizms antikoagulaciis ukuCvenebis dros, <strong>da</strong><br />
• ganmeorebiT filtvis embolizms miuxe<strong>da</strong>vad adeqvaturi antikoagulaciisa.<br />
did britaneTSi qvemo Rru venis filtrs Cveulebriv droebiT iyeneben <strong>da</strong> embolizaciis<br />
maRali riskis periodi<strong>da</strong>n sami kviris Semdeg amoiReben xolme. kvlav gaurkveveli rCeba,<br />
filtris xangrZliv xmarebasTan erTad pacienti xangrZliv antikoagulacias saWiroebs<br />
Tu ara.<br />
elastiuri kompresiuli windebi<br />
Rrma venaTa Trombozis mqone pacientebi post-Trombozuli sindromis Semcirebis mizniT<br />
kompresiul windebs un<strong>da</strong> iyenebdnen. Rrma venaTa proqsimaluri Trombozis mqone 194<br />
pacientis gamokvlevam aCvena, rom safexureobrivi kompresiisaTvis gankuTvnili windebi<br />
post-Trombozuli sindromis sixSires 50%-iT amcireben. 24<br />
Rrma venaTa Trombozis ambulatoriuli <strong>mkurnaloba</strong><br />
<strong>da</strong>bali molekuluri wonis heparinebis SemoRebam SesaZlebeli gaxa<strong>da</strong> Rrma venaTa<br />
Trombozis ambulatoriuli <strong>mkurnaloba</strong> aqtivirebuli parcialuri Tromboplastinis<br />
drois meTvalyureobis gareSe. Rrma venaTa Trombozis mkurnalobis sawyisi fazis<br />
ambulatoriuli <strong>da</strong> hospitaluri reJimi mravalma kvlevam Sea<strong>da</strong>ra. kvlevaTa umetesoba<br />
kontrolirebuli ar iyo, magram gamoavlina Sin mkurnalobis xarj-efeqturoba <strong>da</strong><br />
garTulebaTa prevenciis hospitaluri mkurnalobis Sesa<strong>da</strong>ri unari. 25<br />
qvemo kiduris Rrma venaTa saeWvo Trombozis mqone pacientTa skriningisa <strong>da</strong> diagnozis<br />
meTodi ufro metad adgilobriv praqtikas efuZneba. gamomwvevi mizezis an midrekilebis<br />
<strong>da</strong>sadgenad am pacientebs rocorc wesi Semdgomi gamokvleva utardebaT. 45 wlis zemoT<br />
Rrma venaTa Trombozis ZiriTad mizezs simsivne an umoZraoba warmoadgens, am asakis<br />
qvemoT ki yvelaze didi mniSvneloba Trombofilias eniWeba.<br />
mimdinare kvleva<br />
fon<strong>da</strong>parinaqsi<br />
fon<strong>da</strong>parinaqs natriumi warmoadgens sinTezur pentasaqarids, romelc gaaqtivebul<br />
faqtor X-s Trgunavs. igi axlaxans <strong>da</strong>inerga venuri Tromboembolizmis<br />
profilaqtikisaTvis fexis didi orTopediuli operaciebis dros. fon<strong>da</strong>parinaqsis<br />
potenciali Rrma venaTa Trombozis samkurnalod Seswavlis sagans warmoadgens.<br />
29
antikoagulaciis xangrZlioba<br />
britaneTis Torakaluri sazogadoeba gegmavs did multicentrul kvlevas, romelic Rrma<br />
venaTa Trombozis pirveli epizodis samTviani <strong>da</strong> eqvsTviani antikoagulaciis gamosavals<br />
Sea<strong>da</strong>rebs.<br />
literatura<br />
1. Carter CJ. Epidemiology of venous thromboembolism. In: Hull RD, Pineo GF, eds. Disorders of thrombosis.<br />
Philadelphia: Saunders, 1996: 159-74.<br />
2. Ebell MH. Evaluation of the patient with suspected deep vein thrombosis. J Fam Pract 2001;50: 167-71.<br />
3. O'Donnell TF Jr, Abbott WM, Athanasoulis CA, Millan VG, Callow AD. Diagnosis of deep vein thrombosis in<br />
the outpatient by venography. Surg Gynecol Obstet 1980;150: 69-74.<br />
4. Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, et al. Value of assessment of pre-test<br />
probability of deep vein thrombosis in clinical management. Lancet 1997;350: 1795-8.<br />
5. Aschwanden M, Labs KH, Jeanneret C, Gehrig A, Jaeger KA. The value of rapid D-dimer testing combined<br />
with structured clinical evaluation for the diagnosis of deep vein thrombosis. J Vasc Surg 1999;30: 929-35.<br />
6. Kearon C, Ginsberg JS, Douketis J, Crowther M, Brill-Edwards P, Hirsh J. Management of suspected deep<br />
venous thrombosis in outpatients by using clinical assessment and D-dimer testing. Ann Intern Med 2001;135:<br />
108-11.<br />
7. Ginsberg JS, Kearon C, Douketis J, Turpie AG, Brill-Edwards P, Stevens P, et al. The use of D-dimer testing<br />
and impe<strong>da</strong>nce plethysmographic examination in patients with clinical indications of deep vein thrombosis.<br />
Arch Intern Med 1997;157: 1077-81.<br />
8. Kelly J, Rudd A, Lewis RR, Hunt BJ. Plasma D-dimers in the diagnosis of venous thromboembolism. Arch Int<br />
Med 2002;162: 747-56.<br />
9. Pittet JL, de Moerloose P, Reber G, Durand C, Villard C, Piga N, et al. VIDAS D-dimer: fast quantitative<br />
ELISA for measuring D-dimer in plasma. Clin Chem 1996;42: 410-5.<br />
10. Wells PS, Brill-Edwards P, Stevens P, Panju A, Patel A, Douketis J, et al. A novel and rapid whole-blood<br />
assay for D-dimer in patients with clinically suspected deep vein thrombosis. Circulation 1995;91: 2184-7.<br />
11. Palareti G, Legnani C, Cosmi B, Guazzaloca G, Pancani C, Coccheri S. Risk of venous thromboembolism<br />
recurrence: high negative predictive value of D-dimer performed after oral anticoagulation is stopped. Thromb<br />
Haemost 2002;87: 7-12.<br />
12. Tan YK, <strong>da</strong>Silva AF. Digital photoplethysmography in the diagnosis of suspected lower limb DVT: is it<br />
useful Eur J Vasc Endovasc Surg 1999;18: 71-9.<br />
13. Maskell NA, Cooke S, Meecham Jones DJ, Prior JG, Butland RJA. The use of automated strain gauge<br />
plethysmography in the diagnosis of deep vein thrombosis. Br J Radiol 2002;75: 648-51.<br />
14. Kraaijenhagen RA, Lensing AW, Wallis JW, van Beek EJ, ten Cate JW, Buller HR. Diagnostic management of<br />
venous thromboembolism. Baillières Clin Haematol 1998;11: 541-86.<br />
15. De Valois JC, van Schaik CC, Verzijlbergen F, van Ramshorst B, Eikelboom BC, Meuwissen OJA. Contrast<br />
venography: from gold stan<strong>da</strong>rd to "golden backup" in clinically suspected deep vein thrombosis. Eur J Radiol<br />
1990;11: 131-7.<br />
16. Birdwell BG, Raskob GE, Whitsett TL, Durica SS, Comp PC, George JN, et al. Clinical validity of normal<br />
compression ultrasonography in outpatients suspected of having deep vein thrombosis. Ann Intern Med<br />
1998;128: 1-7.<br />
17. Bernardi E, Prandoni P, Lensing AW, Agnelli G, Guazzaloca G, Scannapieco G, et al. D-dimer testing as an<br />
adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis: prospective cohort<br />
study. BMJ 1998;317: 1037-40.<br />
30
18. Yoshi<strong>da</strong> S, Akiba H, Tamakawa M, Yama N, Take<strong>da</strong> M, Hareyama M. Spiral CT venography of the lower<br />
extremities by injection via an arm vein in patients with leg swelling. Br J Radiol 2001;74: 1013-6.<br />
19. Fraser DGW, Moody AR, Morgan PS, Martel AL, Davidson I. Diagnosis of lower-limb deep venous<br />
thrombosis: A prospective blinded study of magnetic resonance direct thrombus imaging. Ann Intern Med<br />
2002;136: 89-98.<br />
20. Haemostasis and Thrombosis Task Force. Guidelines on oral anticoagulation. Br J Haematol 1998;101: 374-<br />
87.<br />
21. Weitz JI. Low-molecular-weight heparins. N Engl J Med 1997;337: 688-98.<br />
22. Van den Belt AGM, Prins MH, Lensing AWA, Castro AA, Clark OAC, Attalah AN, et al. Fixed dose<br />
subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous<br />
thromboembolism. In: Cochrane Library, Issue 1. Oxford: Up<strong>da</strong>te Software, 2002.<br />
23. Rogers L, Lutcher C. Streptokinase therapy for deep vein thrombosis: a comprehensive review of the English<br />
literature. Am J Med 1990;88: 389-95.<br />
24. Brandjes DP, Buller HR, Heijboer H, Huisman MV, de Rijk M, Jagt H, et al. Randomised trial of effect of<br />
compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997;349: 759-62.<br />
25. Schraibman IG, Milne AA, Royle EM. Home versus in-patient treatment for deep vein thrombosis. Cochrane<br />
Library, Issue 1. Oxford: Up<strong>da</strong>te Software, 2002.<br />
<strong>da</strong>matebiTi literatura<br />
• American Thoracic Society. The diagnostic approach to acute venous thromboembolism: clinicalpractice<br />
guidelines. Am J Respir Crit Care Med 1999;160: 1043-1066.<br />
• The Columbus Investigators. Low-molecular-weight heparin in the treatment of patients with venous<br />
thromboembolism. N Engl J Med 1997;337: 657-62.<br />
• Van der Heijden JF, HuttenBA, Buller HR, Prins MH. Vitamin K antagonists or low -molecular-weightheparin<br />
for the long term treatment of symptomatic venous thromboembolism(Cochrane Review). In: Cochrane<br />
Library, Issue 1. Oxford: Up<strong>da</strong>te Software, 2002.<br />
• Pinede L, Cucherat M, Duhaut P, Ninet J, Boissel JP. Optimal duration of anticoagulant therapy after an<br />
episode of venous thromboembolism. Blood Coagul Fibrinolysis 2000;11: 701-7.<br />
cxrili 1: qvemo kiduris tkivilis an SeSupebis SesaZlo mizezebi<br />
venuri<br />
• Rrma venaTa Trombozi<br />
• ze<strong>da</strong>piruli Tromboflebiti<br />
• post-Trombozuli sindromi<br />
• qronikuli venuri ukmarisoba<br />
• venuri obstruqcia<br />
sxva<br />
• celuliti<br />
• beikeris kista<br />
• motexiloba<br />
• hematoma<br />
• mwvave arteriuli iSemia<br />
• limfedema<br />
31
• hipoproteinemia (mag. cirozi, nefrozuli sindromi)<br />
cxrili 2: gamokvlevebi Rrma venaTa Trombozis skriningisaTvis<br />
D-dimeruli testebi<br />
• laboratoriuli<br />
- enzimTan <strong>da</strong>kavSirebuli imunosorbentuli analizi ( ELISA)<br />
- lateqsis aglutinacia<br />
• pacientis sawolTan<br />
SimpliRED (aglutinaciis sinji)<br />
Simplify (imunoqromatografiuli sinji)<br />
pletizmografia<br />
• cifruli fotopletizmografia<br />
• tenziometruli pletizmografia<br />
• impe<strong>da</strong>nsuri pletizmografia<br />
cxrili 3: Rrma venaTa Trombozis zusti diagnozi<br />
• venografia<br />
• ultrasonografia<br />
- kompresiuli ultrasonografia<br />
- dupleqsuri ultrasonografia<br />
- feradi dopleruli ultrasonografia<br />
• kompiuteruli tomografia<br />
• birTvul-magnituri rezonansi<br />
naxati 1. cifruli fotopletizmografiis gamoyeneba Rrma venaTa Trombozis skriningis<br />
mizniT<br />
32
naxati 2. cifruli fotopletizmografiis normaluri mrudi <strong>da</strong> Rrma venaTa Trombozis<br />
maCvenebeli aranormaluri mrudi<br />
naxati 3. muxlqveSa Rrma venis Trombozis venograma<br />
Diagnosis, Investigation, and Management of Deep Vein Thrombosis<br />
Clive Tovey, Suzanne Wyatt<br />
BMJ 2003;326:1180-4<br />
Deep vein thrombosis is an important cause of morbidity and mortality worldwide, and its clinical diagnosis is<br />
unreliable. This article explains current screening and diagnostic methods as well as treatment. Screening investigations<br />
include D-dimer tests and plethysmographic techniques. Definitive diagnosis is usually by venography or<br />
ultrasonography. Initialtreatment is with heparin—unfractionated or low molecular weight—followed by oral<br />
anticoagulation. Outpatient treatment of deep vein thrombosis is safe.<br />
33
periferiuli arteriebis <strong>da</strong>avadebis <strong>mkurnaloba</strong><br />
pirvelad praqtikaSi<br />
pol bernsi, stiven gafi, endriu bredberi<br />
BMJ 2003; 326:584-8 ©<br />
Targmna k. papoSvilma<br />
didi britaneTis 65-75 wlis mosaxleTagan yovel mexuTes klinikuri gamokvleviT<br />
periferiuli arteriebis <strong>da</strong>avadeba aqvs, Tumca simptomebi maTgan mxolod meoTxeds<br />
aReniSneba. 1<br />
yvelaze gavrcelebul simptoms warmoadgens xangamoSvebiTi koWloba – qvemo<br />
kiduris kunTovani tkivili <strong>da</strong>tvirTvis dros. invaziur procedurebs (angioplastika,<br />
stentireba, operacia) periferiuli arteriebis <strong>da</strong>avadebis <strong>mkurnaloba</strong>Si Tavisi adgili<br />
gaaCnia. amave dros, msgavsad koronaruli arteriebis <strong>da</strong>avadebisa, periferiuli<br />
arteriebis <strong>da</strong>avadebiT gamowveuli avadoba <strong>da</strong> sikvdiloba SeiZleba arsebiTad Semcirdes<br />
<strong>da</strong> intervenciis Sedegebi SeiZleba mniSvnelovnad gaumjobesdes, Tu SemoviRebT e. w.<br />
`saukeTeso medikamentur <strong>mkurnaloba</strong>s~, romlis didi nawilic pirvelad praqtikaSi<br />
SegviZlia <strong>da</strong>vnergoT.<br />
diagnozi <strong>da</strong> Sefaseba<br />
xangamoSvebiTi koWlobis diagnozi Cveulebriv anamnezis safuZvelze SeiZleba <strong>da</strong>isvas –<br />
koWlobis edinburgul kiTxvars am mdgomareobis mimarT maRali specifiuroba (91%) <strong>da</strong><br />
mgrZnobeloba (99%) gaaCnia. 2<br />
diferenciuli diagnozi rogorc venur, ise neirogenul<br />
koWlobas moicavs (cxrili #1). gamokvleviT vlindeba susti an arasebuli pulsacia,<br />
Semdgom gamokvlevas (dupleqsuri ultrasonografia, angiografia) ki mxolod maSin<br />
mimarTaven, Tu invaziuri Carevis sakiTxi wydeba (naxati 1).<br />
saukeTeso medikamenturi mkurnalobis arsi<br />
gavrcelebuli mosazrebis sawinaaRmdegod, koWlobis kiduris kritikul iSemiaSi<br />
ga<strong>da</strong>zrdisa <strong>da</strong> amputaciis saWiroebis riski <strong>da</strong>balia (
cxrili #2 gviCvenebs saukeTeso medikamenturi mkurnalobis komponentebs <strong>da</strong> maT<br />
zemoqmedebas periferiuli sisxlZarRvebis <strong>da</strong>avadebaze, sisxlZarRvovan garTulebebsa <strong>da</strong><br />
sikvdilobaze.<br />
mowevis Sewyveta<br />
mowevis sruli <strong>da</strong> samu<strong>da</strong>mo Sewyveta xangamoSvebiTi koWlobis mqone pacientTa<br />
gamosavlis ganmsazRvrel calke aRebul yvelaze mniSvnelovan faqtors warmoadgens.<br />
samwuxarod, analiziT dgindeba, rom eqimis ubralo sityvieri an werilobiTi rCevi<strong>da</strong>n<br />
ori wlis Semdeg mowevas Tavi pacientTa mxolod 13%-ma <strong>da</strong>aneba. 6<br />
randomizebulma<br />
gakontrolebulma kvlevebma aCvena, rom nikotinis CanacvlebiTi <strong>mkurnaloba</strong> am<br />
maCvenebels aormagebs. bupropionis gamoyenebas aseTive Sedegi moaqvs. Sesabamisad,<br />
koWlobis mqone yvela pacients nikotinis CanacvlebiTi <strong>mkurnaloba</strong> Tavi<strong>da</strong>nve un<strong>da</strong><br />
SevTavazoT. nikotinis Camanacvlebeli yvela preparati (safeni, saReWi rezini, sprei)<br />
erTnairi ar aris, amitom erTi preparatis warumateblobis dros sxva tipis preparatebi<br />
an maTi kombinacia un<strong>da</strong> gamoviyenoT. kokreinis jgufis monacemebiT, mowevis<br />
sawinaaRmdego kursebi efeqturi arian, gansxvavebiT sxva alternatiuli mkurnalobisagan<br />
(hipnoTerapia, akupunqtura <strong>da</strong> sxva). 7-9<br />
antiTrombocituli saSualebebi<br />
antiTrombocituli saSualebebis mkvlevarTa jgufma aCvena, rom antiTrombocituli<br />
saSualebebis (Cveulebriv, aspirini) <strong>da</strong>niSvna aTerosklerozuli <strong>da</strong>avadebis ama Tu im<br />
gamovlenis mqone pacientTa Soris sisxlZarRvovani sikvdilis risks <strong>da</strong>axloebiT 25%-iT<br />
amcirebs <strong>da</strong> erTnairad efeqturia koronaruli arteriebis <strong>da</strong>avadebisa <strong>da</strong> periferiuli<br />
arteriebis <strong>da</strong>avadebis dros. 10<br />
arapir<strong>da</strong>piri monacemebiT, zogierTi antiTrombocituli<br />
saSualeba koWlobis mqone pacientTa mier gavlil manZilsac zrdis. periferiuli<br />
arteriebis <strong>da</strong>avadebis dros klopidogreli sul cota iseve, <strong>da</strong> SesaZloa ufro meta<strong>da</strong>c<br />
ki, efeqturia, vidre aspirini, usafrTxoebis mxriv ki mas aRemateba kidec. siZviris gamo<br />
klopidogrels Cveulebriv uniSnaven periferiuli arteriebis <strong>da</strong>avadebis mqone pacientTa<br />
mcire nawils, vinc aspirins ver itans an visac aspirini saTanadod ver icavs. monacemebi<br />
periferiuli arteriebis <strong>da</strong>avadebis dros aspirinisa <strong>da</strong> klopidogrelis kombinirebis<br />
Taobaze ar arsebobs, Tumca kvleva am mimarTulebiT ukve mimdinareobs.<br />
Saqriani diabetis <strong>mkurnaloba</strong><br />
periferiuli arteriebis <strong>da</strong>avadebis dros meore tipis diabetis gamovlena an gamoricxva<br />
metad mniSvnelovania (cxrili 3), Tumca es sworxazovnad ar un<strong>da</strong> xdebodes. 11<br />
britanuli<br />
rekomen<strong>da</strong>ciebis Tanaxmad, glukozis >7.0 mmol/l momatebas diabetis simptomebi un<strong>da</strong><br />
axldes, rac usimptomo pacientTa did nawils (20-30%) gamoricxavs. glukozis oraluri<br />
tolerantobis sinji `oqros stan<strong>da</strong>rts~ warmoadgens, magram moxerxebuli ar aris. ufro<br />
mosaxerxebelia sisxlSi glukozis SemTxveviTi gansazRvra, oRond analizi<br />
akreditirebul laboratoriaSi <strong>da</strong> ara TiTi<strong>da</strong>n aRebuli kapilaruli sisxliT un<strong>da</strong><br />
gakeTdes. Tu glukoza 11.1 mmol/l-s aRemateba, es meore tipis diabetis maCvenebels<br />
warmoadgens, xolo Tu 7.0-11.1 mmol/l-s Seadgens, glukozis oraluri tolerantobis<br />
sinji xdeba saWiro.<br />
hipertenzia<br />
hipertenziis mkurnalobis sargebeli insultisa <strong>da</strong> koronaruli movlenebis Semcirebis<br />
TvalsazrisiT kargad aris <strong>da</strong>dgenili. samizne maCvenebels warmoadgens
<strong>da</strong>amZimos. es yvela antihipertenziul medikaments exeba <strong>da</strong> safuZveli ara gvaqvs<br />
vifiqroT, rom beta-blokerebi gansakuTrebuli riskiT xasiaTdebian. 12<br />
HOPE kvlevis<br />
monacemebiT, age-inhibitori ramiprili periferiuli arteriebis <strong>da</strong>avadebis mqone<br />
pacientTa avadobasa <strong>da</strong> sikvdilobas <strong>da</strong>axloebiT 25%-iT amcirebs. aucilebeli ar iyo,<br />
rom kvlevaSi monawile pacientebs hipertenzia hqono<strong>da</strong>T, amitom riskis zemoaRniSnuli<br />
Semcireba arteriuli wnevis Se<strong>da</strong>rebiT mcire <strong>da</strong>qveiTebiT ver aixsneba. HOPE kvlevis<br />
Tanaxmad, age inhibitori periferiuli arteriebis <strong>da</strong>avadebis mqone pacientTa umetesobas<br />
argebs, Tuki Tavi<strong>da</strong>n avicilebT Tirkmlis funqciis gauaresebas Tirkmlis arteriaTa<br />
faruli stenozis gamo.<br />
varjiSi<br />
kokreinis bolodroindelma mimoxilvam gvaCvena, rom fizikur varjiSs SeuZlia<br />
mniSvnelovnad gazardos koWlobis mqone pacientTa mier gavlili manZili (150%). am<br />
efeqtis zusti meqanizmi jer gansazRvruli ar aris, magram ramdenime faqtori<br />
gamovlenili iqna. saukeTeso medikamenturi mkurnalobis, saukeTeso medikamenturi<br />
mkurnalobisa + varjiSis, saukeTeso medikamenturi mkurnalobisa + angioplastikis<br />
klinikuri efeqturoba <strong>da</strong> xarj-efeqturoba amJamad mimdinare kvlevebis sagans<br />
warmoadgens.<br />
qolesterinis <strong>da</strong>qveiTeba<br />
HPS kvlevis monacemebiT, statinis meSveobiT saerTo qolesterinisa <strong>da</strong> <strong>da</strong>bali simkvrivis<br />
lipoproteinTa qolesterinis 25%-iani <strong>da</strong>qveiTeba periferiuli arteriebis <strong>da</strong>avadebis<br />
mqone pacientTa kardiovaskulur avadobasa <strong>da</strong> sikvdilobas <strong>da</strong>axloebiT meoTxediT<br />
amcirebs, miuxe<strong>da</strong>vad asakisa, sqesisa <strong>da</strong> qolesterinis sawyisi koncentraciisa.<br />
Sesabamisad, periferiuli arteriebis <strong>da</strong>avadebis mqone yvela pacientma statini un<strong>da</strong><br />
miiRos. lipiduri profili mkurnalobis <strong>da</strong>wyebamde <strong>da</strong> <strong>da</strong>wyebi<strong>da</strong>n eqvsi kviris Semdeg<br />
un<strong>da</strong> ganisazRvros, raTa qolesterinis 25%-ian <strong>da</strong>qveiTebaSi <strong>da</strong>vrwmundeT <strong>da</strong><br />
gamovavlinoT qolesterinis an trigliceridebis Zalian maRali donis mqone pacientebi,<br />
visac specializebuli <strong>mkurnaloba</strong> <strong>da</strong>sWirdeba.<br />
<strong>da</strong>mxmare <strong>mkurnaloba</strong><br />
cilostazolma ramdenime did orgzis brma placeboTi gakontrolebul randomizebul<br />
kvlevaSi sarwmunod gazar<strong>da</strong> koWlobis mqone pacientTa mier gavlili manZili (35-109%-iT).<br />
cilostazolis zusti roli jer <strong>da</strong>dgenili ar aris, Tumca gamarTlebuli iqneba misi<br />
mosinjva im pacientebSi, visac saukeTeso medikamenturi mkurnalobis 3-6 Tvis Semdeg<br />
kvlav gamoxatuli simptomebi aReniSnebaT. sxva wamlebis an vitaminebis Sesaxeb sarwmuno<br />
monacemebi ar mogvepoveba. 13 <strong>da</strong>sasruls uaxlovdeba kvlevebi, romlebic swavloben<br />
foliumis mJavisa <strong>da</strong> vitamin B 12 -is efeqts hiperhomocisteinemiaze, rogorc vaskuluri<br />
riskis savaraudo faqtorze.<br />
rodis un<strong>da</strong> gaigzavnos pacienti sisxlZarRvTa qirurgTan<br />
adgilobrivi garemoebebi mniSvnelovani TaviseburebiT xasiaTdebian, magram sisxlZarRvTa<br />
qirurgTan gagzavna gamarTlebuli iqneba, Tu<br />
• pirveladi praqtikis gundi <strong>da</strong>rwmunebuli ar aris diagnozSi, saukeTeso<br />
medikamenturi mkurnalobis <strong>da</strong>wyebisa <strong>da</strong> meTvalyureobisaTvis ar gaaCnia sakmarisi<br />
resursebi, an eWvi aqvs rom simptomebs gaurkveveli mizezi ganapirobebs.<br />
• miuxe<strong>da</strong>vad saukeTeso medikamenturi mkurnalobis <strong>da</strong>wyebisa <strong>da</strong> <strong>da</strong>cvisa, pacients<br />
kvlav gamoxatuli simptomebi aReniSneba.<br />
• pacients susti an ararsebuli femoraluri pulsacia aqvs (ix. qvemoT).<br />
36
pacienti <strong>da</strong>uyovnebliv un<strong>da</strong> gaigzavnos uaxloes qirurgiul klinikaSi, Tu mas aReniSneba<br />
kiduris kritikuli iSemia (tkivili mosvenebis dros, gangrena an <strong>da</strong>wyluleba),<br />
abdominaluri gamokvleva muclis aortis anevrizmas gvafiqrebinebs, an anamnezSi<br />
gar<strong>da</strong>mavali iSemiuri Seteva an<strong>da</strong> gar<strong>da</strong>mavali sibrmave vlindeba.<br />
vaskuluri <strong>da</strong> endovaskuluri qirurgia<br />
xangamoSvebiTi koWlobis dros angioplastikis an stentirebis mxar<strong>da</strong>mWeri sarwmuno<br />
monacemebi ar arsebobs. 14<br />
orma randomizebulma gakontrolebulma kvlevam aCvena, rom<br />
warmatebuli angioplastika xanmokle va<strong>da</strong>Si (6 Tve) zrdis gavlil manZils, magram<br />
saukeTeso medikamenturi mkurnalobis xangrZlivi gamosavali (2 weli) gavlili manZilisa<br />
<strong>da</strong> sicocxlis xarisxis TvalsazrisiT angioplastikas aRemateba. 4<br />
rogorc ukve aRvniSneT,<br />
varjiSisa <strong>da</strong> angioplastikis Se<strong>da</strong>reba amJamad mimdinareobs. 5<br />
did britaneTSi<br />
xangamoSvebiTi koWlobis dros Suntireba iSviaTad xorcieldeba, radgan<br />
• iTvleba, rom operaciis riski aRemateba sargebels im pacientebisaTvis, visi<br />
mdgomareobac saukeTeso medikamenturi mkurnalobiT umjobesdeba.<br />
• Tumca simptomebi xSirad calmxrivia, koWlobis mqone pacientTa umetesobas<br />
ormxrivi <strong>da</strong>avadeba aReniSneba; erTi fexis revaskularizacia xSirad meore fexis<br />
manamde usimptomo <strong>da</strong>avadebas amJRavnebs.<br />
Cveulebriv angioplastikis, stentirebisa <strong>da</strong> operaciis zRurbli ufro <strong>da</strong>balia<br />
upiratesad aorta-TeZos arteriis (sazardulis iogis zemoT) <strong>da</strong>avadebis mqone pacientTa<br />
Soris, radgan<br />
• saukeTeso medikamenturi <strong>mkurnaloba</strong> am pacientTa mier gavlil manZils<br />
umniSvnelod zrdis, Tumca sicocxlisa <strong>da</strong> kiduris SenarCunebis mxriv savsebiT<br />
efeqturia. amis mizezs aorta-TeZos arteriis Seviwroebis irgvliv kolateraluri<br />
cirkulaciis warmoqmnis sirTule warmoadgens.<br />
• aortis an TeZos arteriis angioplastika <strong>da</strong> stentireba ufro gamZlea sazardulis<br />
iogis qvemoT mdebare arteriebTan Se<strong>da</strong>rebiT, savaraudod didi kalibrisa <strong>da</strong><br />
sisxlis mZlavri nakadis gamo.<br />
• aorta-TeZos arteriis rekonstruqcia erTdroulad orive fexs moicavs.<br />
ararsebuli an Sesustebuli femoraluri pulsaciis mqone pacientTa qirurgiuli<br />
<strong>mkurnaloba</strong> saukeTeso medikamenturi mkurnalobis mniSvnelobas ar gamoricxavs. ufro<br />
metic, aorta-TeZos arteriis rekonstruqcia ar iZleva klinikurad mniSvnelovan<br />
gaumjobesebas im pacientTa Soris, visac amave dros sazardulis iogis qvemoT mdebare<br />
sisxlZarRvebis mZime <strong>da</strong>avadeba aReniSneba. 14,21,22<br />
mimdinare kvleva<br />
periferiuli arteriebis <strong>da</strong>avadebis saukeTeso medikamenturi mkurnalobis klinikuri<br />
efeqturoba <strong>da</strong> xarj-efeqturoba bevrma didma kvlevam <strong>da</strong>a<strong>da</strong>stura, bevric amJamad<br />
mimdinareobs. koWlobis dros varjiSisa <strong>da</strong> angioplastikis Se<strong>da</strong>rebiTi kvleva <strong>da</strong>mxmare<br />
mkurnalobis (angioplastika <strong>da</strong> meTvalyureobis qveS mimdinare varjiSi) rols swavlobs.<br />
periferiuli arteriebis <strong>da</strong>avadebis mqone pacientTa mkurnalobis ZiriTad problemas<br />
arsebuli codnis gamoyeneba warmoadgens. pirveladi praqtikis gunds SeuZlia am<br />
maRalefeqturi <strong>da</strong> <strong>da</strong>sabuTebuli <strong>mkurnaloba</strong> ganxorcieleba, Tu Camoayalibebs zogad,<br />
saeqTno, mkurnalobis oqmze <strong>da</strong>fuZnebul sisxlZarRvovan klinikebs, sa<strong>da</strong>c zogadi<br />
praqtikis eqimebs SeeZlebaT miavlinon yvela “vaskuluri” pacienti, visac saukeTeso<br />
medikamenturi <strong>mkurnaloba</strong> esaWiroeba. am klinikebs un<strong>da</strong> meTvalyureobdnen<br />
<strong>da</strong>interesebuli zogadi praqtikis eqimebi <strong>da</strong> an sisxlZarRvTa medicinisa <strong>da</strong> qirurgiis<br />
specialistebi, Tavad klinikebs ki un<strong>da</strong> gaaCndeT pacientTa Semdgomi gamokvlevisa <strong>da</strong><br />
meorad rgolSi gagzavnis naTeli <strong>da</strong> sayovelTaod miRebuli politika. aseT klinikebs<br />
SesaZloa xanmokle droiT <strong>da</strong>matebiTi <strong>da</strong>finanseba <strong>da</strong>sWirdeT, magram saSualo <strong>da</strong><br />
xangrZliv perspeqtivaSi xarj-neitraluri an sulac efeqturi un<strong>da</strong> iyvnen, radgan Tavi<strong>da</strong>n<br />
37
agvacileben iseT ZviradRirebul sisxlZarRvovan movlenebs, rogoric aris insulti <strong>da</strong><br />
amputacia.<br />
literatura<br />
1. Fowkes FGR, Housley E, Cawood EHH, MacIntyre CAA, Ruckley CV, Prescott RJ. Edinburgh artery study:<br />
prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population. Int J Epidemiol<br />
1991; 20: 384-391.<br />
2. Leng GC, Fowkes FGR. The Edinburgh claudication questionnaire: an improved version of the WHO/Rose<br />
questionnaire for use in epidemiological surveys. J Clin Epidemiol 1992; 45: 1101-1109.<br />
3. Leng GC, Lee AJ, Fowkes FGR, Whiteman M, Dunbar J, Housley E, et al. Incidence, natural history and<br />
cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Int J<br />
Epidemiol 1996; 25: 1172-1181.<br />
4. Whyman MR, Fowkes FG, Kerracher EM, Gillespie IN, Lee AJ, Housley E, et al. Is intermittent claudication<br />
improved by percutaneous transluminal angioplasty A randomised controlled trial. J Vasc Surg 1997; 26: 551-<br />
557.<br />
5. Perkins JM, Collin J, Creasy TS, Fletcher EW, Morris PJ. Exercise training versus angioplasty for stable<br />
claudication: long and medium term results of a prospective randomised trial. Eur J Vasc Endovasc Surg 1996; 11:<br />
409-413.<br />
6. Hirsch AT, Treat-Jacobson D, Lando HA, Hatsukami DK. The role of tobacco cessation, antiplatelet and lipidlowering<br />
therapies in the treatment of peripheral arterial disease. Vasc Med 1997; 2: 243-251.<br />
7. Abbot NC, Stead L, White A, Barnes J, Ernst E. Hypnotherapy for smoking cessation. Cochrane Database Syst<br />
Rev 2000;(2):CD001008.<br />
8. Hajek P, Stead LF. Aversive smoking for smoking cessation. Cochrane Database Syst Rev 2000;(2):CD000546.<br />
9. White AR, Rampes H, Ernst E. Acupuncture for smoking cessation. Cochrane Database Syst Rev<br />
2000;(2):CD000009.<br />
10. Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials of antiplatelet therapy I:<br />
prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of<br />
patients. BMJ 1994; 308: 81-106.<br />
11. Diabetes UK. Diabetes UK position statement 2002. Early identification of people with type 2 diabetes.<br />
www.diabetes.org.uk (accessed Nov 2002).<br />
12. Heintzen MP, Strauer BE. Peripheral vascular effects of beta-blockers. Eur Heart J 1994; 15(suppl C): 2-7.<br />
13. Kleijnen J, Mackerras D. Vitamin E for intermittent claudication. Cochrane Database Syst Rev<br />
2000;(2):CD000987.<br />
14. TASC Working Group. Management of peripheral arterial disease: transatlantic intersociety consensus (TASC).<br />
Eur J Vasc Endovasc Surg 2000; 19(suppl A): S1-244.<br />
15. Dormandy J, Heeck L, Vig S. Lower-extremity atherosclerosis as a reflection of a systemic process: implications<br />
for concomitant coronary and carotid disease. Semin Vasc Surg 1999; 12: 118-122.<br />
16. Dormandy J, Heeck L, Vig S. The natural history of claudication: risk to life and limb. Semin Vasc Surg 1999; 12:<br />
123-137.<br />
17. Pyöräla K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G. Cholesterol lowering with<br />
simvastatin improves prognosis of diabetic patients with coronary heart disease. Diabetes Care 1997; 20: 614-620.<br />
18. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular<br />
complications in type 2 diabetes: UKPDS 38 [correction appears in BMJ 1999;318:29]. BMJ 1998; 317: 703-713.<br />
19. Orchard TJ, Strandness DE. Assessment of peripheral vascular disease in diabetes: report and recommen<strong>da</strong>tions of<br />
an international workshop sponsored by the American Diabetes Association and the American Heart Association.<br />
Circulation 1993; 88: 819-828.<br />
20. Gutteridge W, Torrie EPH, Galland RB. Cumulative risk of bypass, amputation or death following percutaneous<br />
38
transluminal angioplasty. Eur J Vasc Endovasc Surg 1997; 14: 134-139.<br />
21. London NJ, Srinivasan R, Naylor AR, Hartshorne T, Ratliff DA, Bell PR, et al. Subintimal angioplasty of<br />
femoropopliteal artery occlusions: the long-term results. Eur J Vasc Endovasc Surg 1994; 8: 148-155.<br />
22. McCarthy RJ, Neary W, Rowbottom C, Tottle A, Ashley A. Short term results of femoropopliteal sub-intimal<br />
angioplasty. Br J Surg 2000; 87: 1361-1365.<br />
naxati 1. angiograma, romelic gviCvenebs barZayis arteriis ormxriv okluzias<br />
xangamoSvebiTi koWlobis mqone pacientSi<br />
cxrili 1. xangamoSvebiTi koWlobis diferenciuli diagnozi<br />
maxasiaTebeli xangamoSvebiTi venuri koWloba nervuli tkivili<br />
koWloba<br />
tkivilis xasiaTi spazmuri “mfeTqavi” denis <strong>da</strong>rtymis<br />
msgavsi<br />
<strong>da</strong>wyeba<br />
Tan<strong>da</strong>TanobiTi,<br />
mdgradi<br />
Tan<strong>da</strong>TanobiTi,<br />
SeiZleba iyos<br />
SeiZleba iyos<br />
uecari, aramdgradi<br />
uecari<br />
ixsneba gaCerebiT fexis aweviT <strong>da</strong>jdomiT, win<br />
ga<strong>da</strong>xriT<br />
mdebareoba<br />
kunTTa jgufi<br />
(dundulo, barZayi,<br />
wvivi)<br />
mTeli fexi<br />
cu<strong>da</strong>d<br />
lokalizebuli,<br />
SeiZleba moicvas<br />
mTeli fexi<br />
<strong>da</strong>zianebuli fexi Cveulebriv erTi Cveulebriv erTi xSirad orive<br />
39
cxrili 2. periferiuli arteriebis <strong>da</strong>avadebis saukeTeso medikamenturi mkurnalobis<br />
komponentebi<br />
komponenti rekomen<strong>da</strong>cia zemoqmedeba<br />
sikvdilobasa <strong>da</strong><br />
vaskulur movlenebze<br />
mowevis Sewyveta<br />
qolesterinis<br />
Semcireba<br />
antiTrombocituli<br />
saSualeba<br />
Saqriani diabetis<br />
<strong>mkurnaloba</strong><br />
arteriuli wneva<br />
age inhibitorebi<br />
ganmeorebiTi rCeva.<br />
nikotinis<br />
Camanacvlebeli<br />
Terapia an<br />
bupropioni.<br />
qceviTi Terapia<br />
(mowevis<br />
sawinaaRmdego<br />
kursebi)<br />
yvela pacientma un<strong>da</strong><br />
miiRos statini, raTa<br />
qolesterini 25%-iT<br />
SevamciroT.<br />
Tu msl qolesterini<br />
<strong>da</strong>balia, an<br />
trigliceridebi<br />
maRalia, <strong>da</strong>matebiTi<br />
<strong>mkurnaloba</strong> SeiZleba<br />
<strong>da</strong>gvWirdes (lipidur<br />
klinikaSi gagzavna)<br />
aspirini 75 mg dReSi.<br />
klopidogreli 75 mg<br />
dReSi, Tu aspirins<br />
ver itans<br />
meore tipis diabetis<br />
skriningi<br />
SevamciroT 140/85 mm<br />
vwy qvemoT<br />
SeiZleba <strong>da</strong>vuniSnoT<br />
yvela pacients,<br />
Tun<strong>da</strong>c is<br />
normotenziuli iyos<br />
mowevis Sewyveta<br />
sikvdilobas 10 wlis<br />
manZilze 54% -<strong>da</strong>n 18%-<br />
mde amcirebs<br />
RR=0.81 (0.72-0.87) didi<br />
vaskuluri<br />
movlenisaTvis<br />
(miokardiumis<br />
infarqti, insulti an<br />
revaskularizacia)<br />
vaskuluri<br />
movlenebis Semcireba<br />
22%-iT<br />
intensiuri<br />
kontroli insulinis<br />
an<br />
sulfonilSardovanas<br />
meSveobiT iwvevs<br />
RR=0.94 (0.8-1.1) saerTo<br />
sikvdilobisaTvis.<br />
intensiuri<br />
kontroli<br />
metforminis<br />
meSveobiT Warbi<br />
wonis mqone<br />
pacientebSi iwvevs<br />
RR=0.64 (0.45-0.91)<br />
saerTo<br />
sikvdilobisaTvis<br />
RR=0.87 (0.81-0.94)<br />
saerTo<br />
sikvdilobisaTvis<br />
RR=0.73 (0.61-0.86)<br />
miokardiumis<br />
infarqtis, insultisa<br />
an kardiovaskuluri<br />
sikvdilobisaTvis<br />
zemoqmedeba<br />
periferiuli<br />
arteriebis<br />
<strong>da</strong>avadebaze<br />
mosvenebiTi tkivili<br />
7 wlis Semdeg 0%,<br />
mwevelTa 16%-Tan<br />
Se<strong>da</strong>rebiT<br />
klinikuri sargebeli<br />
<strong>da</strong>dgenili ar aris<br />
gavlili manZilis<br />
SesaZlo gazr<strong>da</strong><br />
RR=0.51 (0.01-19.64)<br />
qvemo kiduris<br />
amputaciis<br />
riskisaTvis<br />
ucnobia<br />
ucnobia<br />
40
varjiSi<br />
cilostazoli<br />
pacintebs un<strong>da</strong><br />
mivceT werilobiTi<br />
rCeva varjiSis<br />
Sesaxeb <strong>da</strong>, Tu<br />
SesaZlebelia,<br />
CavrToT<br />
meTvalyureobis qveS<br />
mimdinare programaSi<br />
efeqturi <strong>da</strong>namati im<br />
pacientebisaTvis,<br />
visac saukeTeso<br />
mkurnalobis <strong>da</strong>cvis<br />
Semdeg kvlav<br />
gamoxatuli<br />
simptomebi aReniSneba<br />
[diabetis mqone<br />
pacientebSi RR=0.75<br />
(0.64-0.88)]<br />
kardiovaskuluri<br />
sikvdilobis<br />
Semcireba 24%-iT<br />
(pirveladi <strong>da</strong><br />
meoradi prevencia)<br />
ucnobia<br />
gavlili manZilis<br />
gazr<strong>da</strong> 150%-iT<br />
gavlili manZilis<br />
mniSvnelovani<br />
gazr<strong>da</strong><br />
msl qolesterini = maRali simkvrivis lipoproteinTa qolesterini, RR = fardobiTi riski<br />
(sarwmunoebis 95%-iani intervali)<br />
cxrili 3. Saqriani diabetis skriningi xangamoSvebiTi koWlobis dros<br />
• xangamoSvebiTi koWlobis mqone pacientTa 20% -s diabeti aReniSneba; eqimTan pirveli<br />
vizitis dros SemTxvevaTa 50% SeiZleba <strong>da</strong>udgeneli iyos.<br />
• UKPDS kvlevam aCvena, rom intensiuri glikemiuri kontroli amcirebs meore tipis<br />
diabetis mikrovaskulur garTulebebs, metforminis gamoyeneba ki amcirebs<br />
makrovaskulur garTulebebs diabetisa <strong>da</strong> Warbi wonis mqone pacientTa Soris<br />
• kvlevaTa umetesoba gviCvenebs, rom diabeti kiduris kritikuli iSemiis ganviTarebis<br />
mZlavr riskis faqtors warmoadgens 16<br />
• diabetis mqone pacientebi arteriuli wnevisa <strong>da</strong>, SesaZloa, lipidebis koncentraciis<br />
ufro mkacr kontrols saWiroeben 17,18<br />
• diabetis mqone pacientebs wvivze wnevis mkveTri momateba ufro xSirad aReniSnebaT 19<br />
• diabetis mqone pacientebisaTvis qirurgiul Carevas naklebi sargebeli moaqvs, Tumca<br />
gulsisxlZarRvTa <strong>da</strong>avadebebis medikamenturi mkurnalobisagan isini met sargebels<br />
naxuloben, vidre diabetis armqone pirebi 20<br />
• diabetis mqone bevr pacients aReniSneba neiropaTia, romelic, arteriul ukmarisobasTan<br />
erTad, maT qsovilis neiroiSemiuri <strong>da</strong>kargvis gaz rdili saSiSroebis winaSe ayenebs<br />
Management of Peripheral Arterial Disease in Primary Care<br />
Paul Burns, Stephen Gough, Andrew W Bradbury<br />
Diagnosis of peripheral arterial disease is based mainly on the history, with examination and ankle brachial pressure<br />
index being used to confirm and localise the disease. Peripheral arterial disease is a marker for systemic<br />
atherosclerosis; the risk to the limb in claudication is low, but the risk to life is high. Patients with intermittent<br />
claudication should initially be treated with "best medical treatment"; some patients may be candi<strong>da</strong>tes for<br />
percutaneous angioplasty, but this treatment is not based on evidence. Patients should be referred to a vascular surgeon<br />
if there is doubt about the diagnosis or evidence of aortoiliac disease or if the patient has not responded to best medical<br />
treatment or has severe disease.<br />
41
miRwevebi hematologiaSi<br />
moamza<strong>da</strong> Sorena arCuaZem<br />
hematologia mraval<strong>da</strong>rgovani specialobaa, romelic bavSvTa <strong>da</strong> mozardTa avTvisebian<br />
simsivnur <strong>da</strong> ara-simsivnur <strong>da</strong>avadebaTa kliniko-laboratoriul aspeqtebs moicavs.<br />
mimoxilvaSi mogiTxrobT hematologiur <strong>da</strong>avadebaTa diagnostikasa <strong>da</strong> <strong>mkurnaloba</strong>Si<br />
miRweuli warmatebebis Sesaxeb. molekulur-biologiur miRwevaTa ricxvi fenomenaluri<br />
siCqariT izrdeba (win uswrebs Terapiuli <strong>da</strong>rgis ganviTarebas), rac xelmisawvdoms xdis<br />
<strong>da</strong>avadebis gamovlenis maRal mgrZnobiare meTodebs <strong>da</strong> zogierTi <strong>da</strong>avadebis genuri<br />
Terapiis gziT gankurnebis perspeqtivas badebs.<br />
meTodebi:<br />
gamoyenebuli informacia aRebulia ukanasknel dros Catarebuli samecniero Sexvedrebis,<br />
britaneTisa <strong>da</strong> amerikis hematologiis sazogadoebebis CaTvliT, hematologiuri<br />
Jurnalebis wamyvani statiebisa <strong>da</strong> diskusiebis masalebi<strong>da</strong>n.<br />
anemiebi:<br />
rkinadeficitur anemiasa <strong>da</strong> qronikul <strong>da</strong>avadebebTan asocirebuli anemiis<br />
diferencialuri diagnozi sakmaod xSir <strong>da</strong> imavdroulad seriozul problemas<br />
warmoadgens samedicino praqtikaSi. qronikul <strong>da</strong>avadebebTan asocirebuli anemia rTul<br />
xasiaTs atarebs d mas ganapirobeben proanTebiTi citokinebi, eriTropoetinis mimarT<br />
Zvlis tvinis <strong>da</strong>qveiTebuli pasuxi, eriTrocitebis sicocxlis xangrZlivobis Semcireba,<br />
rkinis reutilizaciis <strong>da</strong>rRveva. Cveulebriv, gaurTulebeli rkinadeficituri anemiis<br />
dros, hemoglobinis koncentraciis, eriTrocitebis saSualo moculobis, Sratis<br />
feritinisa <strong>da</strong> rkinis koncentraciebis Semcirebas Tan axlavs rkinis SemboWveli saerTo<br />
SesaZleblobis momateba. samwuxarod, klinikuri SemTxvevebi uxSiresad atipiur xasiaTs<br />
atarebs <strong>da</strong> CamoTvlili analizebis Sedegebi araerTgvarovani <strong>da</strong> urTierTsapirispiroc<br />
kia. ufro meti, Tu qronikul <strong>da</strong>avadebasTan asocirebul anemias Tan axlavs rkinis<br />
deficiti, am ukanasknelis diagnostikuri parametrebi Secvlilia, rac arTulebs<br />
diagnozis <strong>da</strong>dgenas. xSirad organizmSi rkinis maragis zustad Sefasebis erTaderT<br />
saSualebas Zvlis tvinis punqtatis rkinaze SeRebva warmoadgens. es ki Zviri, xangrZlivi<br />
<strong>da</strong> invaziuri meTodia. ukanasknel periodSi SemuSavebul iqna Sratis transferinis<br />
receptoris testi, romelic SesaZlebels xdis am jgufis pacientebSi rkinis maragis<br />
zustad Sefasebas.<br />
Sratis feriniti, 480kilo<strong>da</strong>ltoni zomis cilaa, romelic organizmSi rkinis<br />
samarago avzs warmoadgens. zoga<strong>da</strong>d Sratis feritinis koncentraciis <strong>da</strong>qveiTeba rkinis<br />
rezervis amowurvaze mianiSnebs. Tumca, feritini "mwvave fazis" cilaa <strong>da</strong> misi<br />
koncentracia anTebiTi procesebis dros matulobs. magaliTad, aqtiuri revmatologiuri<br />
paTologiis mqone pacientebSi feritinis koncentracia SesaZloa normaluri (an<br />
momatebulic ki) iyos, maSin roca sinamdvileSi pacienti rkinis deficits ganicdis.<br />
transferinis receptoris testi miznad isaxavs rkinis deficitiT <strong>da</strong> qronikuli<br />
<strong>da</strong>avadebebiT gamowveuli anemiebis diferencirebas.<br />
raSi mdgomareobs transferinis receptoris testis arsi<br />
transferini aris plazmis rkinis satransporto cila. im ujredebis ze<strong>da</strong>pirze,<br />
romlebic rkinis atomebs saWiroeben, transferinis receptorebis eqspresia matulobs.<br />
receptori ikavSirebs plazmis transferins rkinis atomebTan erTad. transferinisa <strong>da</strong><br />
misi receptoris kompleqsi CaiZireba ujredSi, tovebs iq rkinis atomebs <strong>da</strong> Semdeg kvlav<br />
ujredis ze<strong>da</strong>pirs ubrundeba <strong>da</strong> iSleba. gamoTavisuflebuli transferini ganagrZobs<br />
rkinis axali atomebis transportirebas. rkinadeficituri anemiis dros ujredTa<br />
ze<strong>da</strong>pirze transferinis receptorebis eqspresia matulobs maSin, roca qronikuli<br />
<strong>da</strong>avadebebiT gamowveuli anemiis dros maTi raodenoba ucvleli (normaluri) rCeba.<br />
42
transferinis receptorebis raodenobrivi Sefaseba sisxlis Sratis nimuSebis<br />
imunofermentuli analizis gziT xdeba, rac erTbaSad didi raodenobiT nimuSebis<br />
gamokvlevis SesaZleblobas iZleva. arsebuli informaciis Tanaxmad, aRniSnuli testi<br />
rkinis deficitis gamovlenis TvalsazrisiT iseve sando <strong>da</strong> <strong>da</strong>sayrdenia, rogorc Zvlis<br />
tvinis punqtatis gamokvleva. revmatologiuri <strong>da</strong> sxva anTebiTi <strong>da</strong>avadebebis mqone<br />
pacientebisaTvis igi mzard mniSvnelobas iZens.<br />
hemofilia<br />
hemofilia (VIII faqtoris deficiti) <strong>da</strong> B (IX faqtoris deficiti, qristmasis<br />
<strong>da</strong>avadeba) X qromosomasTan SeWiduli <strong>da</strong>avadebebia, romlebic mxolod mamakacebSi<br />
vlindeba <strong>da</strong> maTi sixSire Sesabamisad, 1:10 000 <strong>da</strong> 1:60 000 Seadgens. Sededebis aRniSnuli<br />
faqtorebis koncentraciaTa donis mixedviT ganasxvaveben <strong>da</strong>avadebis msubuq (>5%),<br />
saSualo (2-5%) <strong>da</strong> mZime (
Trombozuli paTologiebis mravali memkvidruli paTogenezuri faqtoria aRwerili,<br />
Tumca mraval ojaxur SemTxvevaSi <strong>da</strong>avadebis gamomwvevi mizezi jer kidev ucnobi rCeba.<br />
miuxe<strong>da</strong>vad amisa, didi warmatebebia miRweuli - aRsaniSnavia V faqtoris <strong>da</strong> proTrombinis<br />
genebis mutaciebis aRmoCena. bertinam <strong>da</strong> Tanaavtorebma V (leidenis) faqtoris mutacia<br />
pirvelad aRweres <strong>da</strong>hlbekis <strong>da</strong> Tanaavt. <strong>da</strong>kvirvebis safuZvelze, romlis Tanaxma<strong>da</strong>c<br />
Trombozebisadmi midrekilebis mqone erTi ojaxis wevrebis plazmis nimuSebSi<br />
aqtivirebuli C cilis efeqti <strong>da</strong>qveiTebuli iyo. aqtivirebuli C cila wamyvani<br />
antikoagulantia, romelic Sededebis V <strong>da</strong> VIII faqtorebis fosfolipidTan <strong>da</strong>kavSirebuli<br />
aqtivirebuli formebis gaxleCisa <strong>da</strong> inaqtivaciis gziT swrafad aqveiTebs Trombinis<br />
warmoqmnas. inaqtivaciaSi 3 lokusi - Arg 506 , Arg 306 , Arg 679<br />
monawileobs. aqtivirebuli C<br />
cilisadmi rezistentoba, rac mwir antikoagulantur pasuxs ganapirobebs, evropis<br />
janmrTeli mosaxlebis 5-10%-s aReniSneba, magram faqtiurad ar vlindeba iaponel an<br />
afrikul populaciaSi. V (leidenis) faqtori, romelic pirvelad iqna aRwerili leidenis<br />
Trombofiliis kvlevis dros, warmoadgens V faqtoris variantul formas, romelSic<br />
glutaminiT Canacvlebulia Arg 506 <strong>da</strong> pasuxs agebs aqtivirebuli C cilisadmi<br />
rezistentobis SemTxvevaTa 90%-ze. bolo xanebSi gamovlenilia V faqtoris axali<br />
mutacia, romlis drosac aminomJavas Canacvleba xdeba Arg 306<br />
poziciaSi (V faqtori,<br />
kembriji). V faqtoris mutaciebTan asocirebuli venuri Trombozis Se<strong>da</strong>rebiTi riski<br />
Seadgens 7-s heterozigotul <strong>da</strong> 80-s homozigotul SemTxvevebSi. aqtivirebuli C<br />
cilisadmi rezistentobis fenotipi heterogenulia <strong>da</strong> masze mravali genetikuri <strong>da</strong><br />
garemo faqtori axdens gavlenas, rogorebicaa fexmZimoba, kontraceptivebis miReba <strong>da</strong> VIII<br />
faqtoris koncentraciis momateba.<br />
proTrombinis genis mutaciebi<br />
proTrombini Trombinis winamorbedi faqtoria, romelic ga<strong>da</strong>mwyvet rols asrulebs<br />
hemostazsa <strong>da</strong> Trombozuli paTologiebis CamoyalibebaSi. fuurTma <strong>da</strong> kolegebma<br />
molekulur-biologiuri meTodebis (polimerazuli jaWvuri reaqcia, dnm-is<br />
sekvenirebasTan erTad) gamoyenebiT detalurad gamoikvlies venuri Tromboembolizmis<br />
mqone avadmyofebis proTrombinis genis struqtura. am pacientebis 18%-s genis<br />
ga<strong>da</strong>utaneli 3' regionis 20210 nukleotidSi G A cvlilebas aqvs adgili. aRniSnuli<br />
Zvrebi janmrTeli sakontrolo pirebis mxolod 1%-Sia gamovlenili. farTo masStabiani<br />
kontrolirebuli kvlevis dros mkvlevarebma aRmoaCines, rom mutanturi alelis mqone<br />
pirebSi plazmaSi proTrombinis koncentraciebis momatebasTan erTad venuri<br />
Tromboembolizmis sixSire 3-jer izrdeba. Tromboembolizmis gazrdili riskis<br />
ganmapirobebeli sxva genetikuri <strong>da</strong>rRvevebi ganxiluli iqneba qvemoT.<br />
homocisteinemia <strong>da</strong> Trombozuli <strong>da</strong>avadebebi<br />
homocisteini warmoadgens aminomJavas, romelic Seicavs gogirds. homocisteinis<br />
cikli moicavs fermentebs, romlebic kofaqtorebis saxiT vitamin B 12 , foliumis mJavas <strong>da</strong><br />
piridoqsins saWiroeben. sisxlSi homocisteinis maRali koncentracia rogorc venuri<br />
aseve arteriuli Trombozis <strong>da</strong>moukidebel risk-faqtors warmoadgens. homocisteinis<br />
metabolizmis <strong>da</strong>rRvevebma SesaZloa Tavi iCinon memkvidruli <strong>da</strong> kvebiTi paTologiebis<br />
dros. kvebiTi deficitebis dros, vitamin B 12 , foliumis mJavas mkveTri nakleboba<br />
megaloblastur anemias iwvevs, msubuqi deficiti ki Trombozisadmi winaswarganwyobasTan<br />
asocirdeba. memkvidrulad ganpirobebuli maRali homocisteinemia uSualod azianebs<br />
sisxlZarRvovan sistemas. 1969 wls makqulim pirvelad ganacxa<strong>da</strong>, rom homocisteinemiisa<br />
<strong>da</strong> hiperhomocisteinemiis gamomwvevi metabolizmis memkvidruli <strong>da</strong>rRvevebis mixedviT<br />
homozigotur pacientebs naadrevi okluziuri sisxlZarRvovani <strong>da</strong>avadebebisadmi<br />
midrekileba aqvT. plazmis homocisteinis analizi Trombofiliis skriningis mzard<br />
proceduraTa ricxvSia Sesuli.<br />
44
avTvisebiani simsivnuri <strong>da</strong>avadebebi<br />
ukanasknel xanebSi hemoblastozebis (avTvisebiani hematologiuri <strong>da</strong>avadebebi)<br />
<strong>da</strong>rgSi ramodenime mniSvnelovani aRmoCena gakeT<strong>da</strong>. mwvave <strong>da</strong> qronikuli leikozis<br />
sakiTxebze mimdinare kvlevebi, ZiriTa<strong>da</strong>d, mkurnalobis protokolebis <strong>da</strong>xvewagaumjobesebiskenaa<br />
mimarTuli. axalma agentebma, purinebis analogebma (flu<strong>da</strong>rabini <strong>da</strong> 2-<br />
qlorodioqsiadenozini) <strong>da</strong>amtkices TavianTi efeqturoba qronikuli limfoiduri<br />
simsivneebis - qronikuli limfoiduri leikemiisa <strong>da</strong> bususovanujredovani leikemiis<br />
<strong>mkurnaloba</strong>Si. specialistebi miiswrafian am medikamentebis peroraluri formebis<br />
Seqmnisaken, rac SesaZlebels gaxdis maTs gamoyenebas ambulatorul pirobebSi.<br />
<strong>herpes</strong>is virusi <strong>da</strong> mravlobiTi mieloma<br />
rogorc ukve cnobilia, Zvlis tvinis mikrogaremo mravlobiTi mielomis<br />
paTogenezSi mniSvnelovan rols asrulebs <strong>da</strong> Zvlis tvinis arasimsivnur ujredebs<br />
simsivnuri ujredebis zrdisaTvis xelisSewyoba SeuZliaT. uaxlesi kvlevebis Tanaxmad,<br />
a<strong>da</strong>mianis <strong>herpes</strong>is virusi, romelic, Cveulebriv, kapoSis sarkomis mqone pacientebSi<br />
(amitom kapoSis sarkomasTan asocirebuli <strong>herpes</strong>-virusi ewodeba) vlindeba, aRmoCenilia<br />
mravlobiTi mielomiT <strong>da</strong>avadebuli pacientebis dendritul ujredebSi (Tumca araa<br />
napovni Tavad mielomur ujredebSi). igive <strong>herpes</strong>is virusi monoklonuri gamapaTiis mqone<br />
pacientebis 25%-Sia gamovlenili. monoklonuri gamapaTiis SemTxvevaTa mcire nawili<br />
mravlobiT mielomad transformacias ganicdis. In situ hibridizaciis meTodis wyalobiT<br />
<strong>herpes</strong>is virusi aRmoCenilia mravlobiTi mielomis mqone 21 pacienti<strong>da</strong>n 18-Si, gansxvavebiT<br />
sxva hematologiuri avadmyofebisa <strong>da</strong> janmrTeli pirebisagan. gar<strong>da</strong> amisa, mielomuri<br />
dendrituli ujredebi awarmoeben virusul interleikin-6-is transkripcias, romlis<br />
a<strong>da</strong>mianis homologic mielomuri ujredebis zrdis faqtors warmoadgens. dResdReobiT ar<br />
arsebobs naTeli <strong>da</strong>mamtkicebeli monacemebi imisa, rom kapoSis sarkomasTan asocirebuli<br />
<strong>herpes</strong>is virusi uSualo rols asrulebs mielomis ganviTarebaSi, Tumca iribi<br />
mtkicebulebebi mxars uWers am hipoTezas. aRniSnul Temaze mimdinareobs kvlevebi.<br />
momavali<br />
specifiuri mutaciebis skriningi<br />
molekulur-biologiuri testebis umetesoba - magaliTad, samxreTis blotingi,<br />
polimerazuli jaWvuri reaqcia, dnm-s sekvenireba, Sromatevadi <strong>da</strong> Zviri meTodebia <strong>da</strong><br />
mosaxerxebeli Se<strong>da</strong>rebiT mcire raodenobis nimuSebis testirebis dros. axali, dnm-ze<br />
<strong>da</strong>fuZnebuli Cipebis meTodi bevrad aCqarebs am process, erTbaSad didi raodenobiT<br />
nimuSebis analizis saSualebas iZleva <strong>da</strong> aseve, amcirebs Rirebulebas. amerikulma<br />
kompaniam Affmetrix SeimuSava "genuri Cipebi" rigi, romlebSic minis fiWebi <strong>da</strong>farulia<br />
cnobili mokle oligonukleotidebis "gazonebiT". Cipi Cadgmulia plastikur karkasSi <strong>da</strong><br />
amgvarad, yvela reaqcia <strong>da</strong>xurul sistemaSi mimdinareobs. gamosakvlevi dnm ukavSirdeba<br />
Cipze fiqsirebul komplementur oligonukleotidur mimdevrobas. am ukanasknelis<br />
miRebuli geometriuli forma gansazRvravs sakvlevis nimuSis genuri mutaciis bunebas.<br />
Cipebis warmoeba moicavs fotoliTografiul process, romelSic Cipze sinTezuri<br />
regionebis SerCeviTad aqtivaciis mizniT niRbebia gamoyenebuli. erTi eqspresiis Cips<br />
asobiT sxva<strong>da</strong>sxva genis analizi SeuZlia maSin, roca p53 (simsivnis supresori geni) Cipi<br />
am genis yvela cnobil mutacias gamoavlens.<br />
genuri Cipebis' meTodi Zlieri midgoma iqneba genomis sxva<strong>da</strong>sxva lokusis<br />
paraleluri analizisaTvis. meTodi amJamad ukve gamoiyeneba genomis, <strong>da</strong>avadebaTa marTvis,<br />
genotipirebis <strong>da</strong>rgebSi <strong>da</strong> SesaZloa, bolos<strong>da</strong>bolos, gamoyenebuli iqnes diagnostikis<br />
mizniT. es <strong>da</strong>avadebebsa <strong>da</strong> specifiur genur mutaciebs Soris kavSiris <strong>da</strong>dgenis <strong>da</strong><br />
populaciis masStabebis testirebis Catarebis saSualebas mogvcems. es meTodi a<strong>da</strong>mianis<br />
genomis proeqtisaTvisac SesaniSnavia, romlis <strong>da</strong>niSnulebasac a<strong>da</strong>mianis sruli genomis<br />
sekvenireba <strong>da</strong> misi fizikuri <strong>da</strong> genetikuri ruqebis Seqmna warmoadgens. sxva meTodebs,<br />
romlebic momavali ramodenime wlis ganmavlobaSi gansakuTrebul mniSvnelobas SeiZens,<br />
miekuTvneba realuri drois polimerazuli jaWvuri reaqcia (specifiuri dnm-<br />
45
Tanmimdevrobis zusti <strong>da</strong>xasiaTeba) <strong>da</strong> speqtruli (ferebze <strong>da</strong>yrdnobiT) kariotipuli<br />
analizi (struqturuli qromosomuli aberaciebis zustad <strong>da</strong>dgena).<br />
molekuluri Terapia<br />
molekuluri Terapiis <strong>da</strong>rgi saocar sferos warmoadgens <strong>da</strong> misi mravalmxrivi<br />
potenciuri gamoyenebis Taobaze msofloi masStabis kvlevebi ukve midinareobs. ZiriTadi<br />
molekuluri strategia moicavs "gamoTiSvis" Terapias, rodesac konstruirebuli mokle<br />
oligonukleotidebi ukavSirdeba samizne sainformacio rnm-s <strong>da</strong> Sedegad, xels uSlis mis<br />
<strong>da</strong>muSavebasa <strong>da</strong> translacias (Sesabamisad cilis produqcias). molekuluri samizneebi<br />
moicavs BCR-ABL gens qronikuli mieloiduri leikemiis dros <strong>da</strong> c-myc, ras <strong>da</strong> cyclin D<br />
onkogenebs, romelTa eqspresia momatebulia ramodenime hematologiuri <strong>da</strong>avadebis dros.<br />
alternatiul strategias warmoadgens ribozimis meTodi, romelSic genuri<br />
inJineriis gziT Seqmnili mcire rnm-s molekulebi ukavSirdeba samizne rnm-s, rac maTs<br />
gaxleCasa <strong>da</strong> destruqcias iwvevs.<br />
Advances in Hematology<br />
The article reviews most of the prominent advances in area of hematology – inherited disorders associated with<br />
hypercoagulation, iron deficiency anemia relation with chronic diseases and transferrin receptors, thrombotic factors<br />
including prothrombin gene mutations and hyperhomocysteinemia, <strong>herpes</strong> virus association with myeloma, DNA probe<br />
arrays, gene chip technoology for screening for different gene mutations.<br />
literatura:<br />
1. D. Provan, D. O’Shaughnessy. BMJ 1999, 318: 991-994<br />
2. R Bataille, J-L. Harouessau. Multiple myeloma. N Eng J Med, 1997; 336 : 1657-64.<br />
3. P. De Fabritis, et al. Blood, 1998 ; 91 : 3156-62<br />
4. D’Angelo, J Schlub. Homocysteine and thrombotic disease. Blood, 1997; 90:1-11.<br />
46
sisxlis ga<strong>da</strong>sxmis usafrTxoebis sakiTxebi<br />
fiona regani, kler teilori<br />
BMJ 2002; 325: 143-7 ©<br />
Targmna S. arCuaZem<br />
bolo ramodenime wlis ganmavlobaSi sisxlis ga<strong>da</strong>sxmis usafrTxoebas sul ufro<br />
meti yuradReba eTmoba. transfuziasTan <strong>da</strong>kavSirebuli Tavi<strong>da</strong>n acilebadi Secdomebi,<br />
romelic uxSiresad pacientis identifikacias exeba, sikvdilobisa <strong>da</strong> garTulebebis<br />
seriozul mizezad rCeba. gar<strong>da</strong> amisa, moipoveba mzardi informacia virusuli <strong>da</strong><br />
baqteriuli infeqciebis ga<strong>da</strong>tanis riskis Sesaxeb. did britaneTSi gansakuTrebul<br />
SeSfoTebas iwvevs kroicfeld-iakobis <strong>da</strong>avadebis variantuli formis ga<strong>da</strong>cemis<br />
Teoriuli SesaZlebloba.<br />
am mimoxilviT statiaSi Tavmoyrilia arsebuli risk-faqtorebi <strong>da</strong> aRwerilia is<br />
axali RonisZiebebi, romlebic, rogorc aRmoCn<strong>da</strong>, aumjobeseben sisxlis ga<strong>da</strong>sxmis<br />
usafrToebas. is agreTve gvacnobs aRniSnuli procedurisadmi <strong>da</strong>mokidebulebisa <strong>da</strong> maTi<br />
gamoyenebis cvlilebebs, romlebic gavlenas moaxdens sisxlis komponentebis<br />
momxmareblebze medicinis nebismier disciplinaSi, zogadi praqtikis eqimebis CaTvliT,<br />
romlebic pacientebs ganumartaven sisxlis ga<strong>da</strong>sxmis sargebelsa <strong>da</strong> zians. <strong>da</strong> bolos, is<br />
xazs usvams im specialistebis saTanado ganaTlebisa <strong>da</strong> praqtikuli wvrTnis saWiroebas,<br />
romlebic monawileoben sisxlis komponentebis <strong>da</strong>niSvnasa <strong>da</strong> gamoyenebaSi.<br />
meTodebi<br />
es mimoxilva eyrdnoba informacias yovelwliuri moxsenebebi<strong>da</strong>n: "transfuziis<br />
seriozuli safrTxeebi" (www.shot.demon.co.uk), "hematologiuri stan<strong>da</strong>rtebis britanuli<br />
komitetis" saxelmZRvanelo principebi (www.bcshguidelines.com) <strong>da</strong> “sisxlis transfuziis<br />
gaumjobesebis” sakiTxebisadmi miZRvnili samedicino <strong>da</strong>wesebulebaTa xelmZRvaneli<br />
pirebis meore Sexvedra (www.doh.gov.uk/bbt2). aseve gamoyenebulia klinicistebisa <strong>da</strong><br />
mecnierebis Sesabamisi Tematikis uaxlesi publikaciebis masalebi.<br />
sisxlis ga<strong>da</strong>sxmasTan <strong>da</strong>kavSirebuli Secdomebis Sesamcirebeli RonisZiebebi<br />
sisxlis ga<strong>da</strong>sxmis dros <strong>da</strong>Svebuli Tavi<strong>da</strong>n acilebadi Secdomebi sikvdilobisa <strong>da</strong><br />
garTulebebis uCveulod mniSvnelovan mizezad rCeba. aSS-Si sisxlis komponentebis<br />
identifikaciis dros <strong>da</strong>Svebuli fataluri Secdomebis sixSire 1 : 600,000 – 1 : 800,000-s<br />
Seadgens, arasasikvdilo Secdomebisa ki – 1 : 12,000-<strong>da</strong>n 1 : 19,000-mde meryeobs. didi<br />
britaneTis jgufis - "sisxlis ga<strong>da</strong>sxmis seriozuli safrTxeebi" (SHOT) informaciis<br />
Tanaxmad, SecdomaTa sixSire eriTrocitebis yovel 5,5 mln transfuziaze 335-s Seadgens.<br />
SeuTavsebeli sisxlis komponentebis gamoyenebiT aixsneba 1999-2000 ww. aRniSnuli<br />
proceduris uxSiresi gverdiTi movlenebis 70%. ABO sistemis mixedviT sisxlis<br />
SeuTavseblobis Sesaxeb ganacxades 97-jer, maTgan 4 SemTxvevaSi Secdoma sasikvdilo<br />
gamosavlis uSualo mizezad iqca, 29 SemTxvevaSi ki man janmrTelobis <strong>da</strong>uyovnebeli<br />
seriozuli gauareseba gamoiwvia.<br />
SHOT-jgufis meore moxsenebis Semdeg gamoqveyn<strong>da</strong> transfuziologiuri Secdomebis<br />
riskis minimumamde Semcirebis didi britaneTis erovnuli saxelmZRvanelo principebis<br />
ganaxlebuli varianti.<br />
ukanaskneli ori wlis ganmavlobaSi mravali hospitali gaecno saavadmyofos<br />
masStabiT "uaryofiT movlenaTa gancxadebis” sqemebs, rac xels Seuwyobs transfuziis<br />
©<br />
aRniSnuli masalis gamoqveyneba SeTanxmebulia British Medical Journa l-is re<strong>da</strong>qciasTan<br />
47
garTulebaTa identifikaciisa <strong>da</strong> analizis gaadvilebas. savaraudoa, rom klinikuri<br />
gverdiTi movlenebis ganacxadis arsebuli sqemebi male gaerTiandeba didi britaneTis<br />
centralur sqemaSi, romelsac nacionaluri informaciis Sekrebisa <strong>da</strong> rekomen<strong>da</strong>ciebis<br />
SemuSavebis TvalsazrisiT pacientTa usafrTxoebis erovnuli saagento marTavs.<br />
Secdomebis profilaqtikisaTvis momsaxure personalis ganaTlebisa <strong>da</strong> qmediTi<br />
transfuziologiuri sahospitalo protokolebis <strong>da</strong>nergvis saWiroebis gacnobierebis<br />
Sedegad aRniSnuli faqtorebi Seitanes klinikuri usafrTxoebis sqemaSi. Tumca sisxlis<br />
komponentebis transfuziis <strong>da</strong>niSvnasa <strong>da</strong> maTi SeTavsebisaTvis nimuSebis aRebaSi<br />
monawile mTeli personalis, maTi Semcvlelebisa <strong>da</strong> saagentoebis TanamSromlebis<br />
CaTvliT, swavleba rTuli iqneba Sesabamisi resursebis gareSe.<br />
transfuziologiuri procesis Secdomebis gamoricxvis mizniT viTardeba<br />
saerTaSoriso masStabis axali sainformacio teqnologiuri sistemebi.<br />
kroicfeld-iakobis <strong>da</strong>avadebis variantuli formis ga<strong>da</strong>tanis riskis Sesamcirebeli<br />
RonisZiebebi<br />
sisxlis ga<strong>da</strong>sxmis gziT cnobili infeqciebis ga<strong>da</strong>tanis riskis Sesamcirebeli<br />
usafrTxoebis zomebi moicavs donorebis SerCeva-gamoricxvas, maTi sisxlis gamokvlevasa<br />
<strong>da</strong> saTanadod <strong>da</strong>muSavebas, kerZod, leikocitebis minarevebisagan gaTavisuflebasa <strong>da</strong><br />
virusebis inaqtivacias. mraval qveyanaSi transfuziebTan <strong>da</strong>kavSirebuli gverdiTi<br />
movlenebis monitorirebis mizniT SemuSavebulia erovnuli “hemosifxizlis” sqemebi. gar<strong>da</strong><br />
amisa, aRniSnuli monacemebis Sekreba evropis masStabiT “hemosifxizlis” evropuli<br />
qselis mier xorcieldeba. analogiur sistemebi arsebobs aSS-sa <strong>da</strong> kana<strong>da</strong>Si.<br />
sifrTxilis zomebis miuxe<strong>da</strong>vad, axali infeqciuri agentebiT gamowveuli<br />
<strong>da</strong>avadebebis, maT Soris variantuli kroicfeld-iakobis <strong>da</strong>avadebis, transmisiis safrTxe<br />
isev arsebobs. Tumca mtkicebulebebi a<strong>da</strong>mianebSi variantuli kroicfeld-iakobis<br />
<strong>da</strong>avadebis ga<strong>da</strong>cemis Sesaxeb ar moiZieba, SeSfoTeba gamoiwvia kvlevam, romlis<br />
Tanaxma<strong>da</strong>c sakvebTan erTad Rrublovani encefalopaTiiT inficirebuli Zroxis 5 gr<br />
tvinis miRebi<strong>da</strong>n 318 dRis Semdeg 400ml sisxlis donaciis Sedegad yoveli 19 asimptomuri<br />
cxvri<strong>da</strong>n erTi recipient cxvars saqonlis Rrublovan encefalopaTias ga<strong>da</strong>scems.<br />
jerjerobiT aRniSnuli monacemebis mxar<strong>da</strong>mWeri arc erTi kvleva ar gamoqveynebula.<br />
miuxe<strong>da</strong>vad amisa, did britaneTSi ukve ga<strong>da</strong>idga pirveli nabijebi transuziis gziT<br />
variantuli kroicfeld-iakobis <strong>da</strong>avadebis transmisiis SesaZlo riskis Sesamcireblad.<br />
transplantaciuri qsovilebisa <strong>da</strong> sisxlis mikrobiologiuri usafrTxoebis sakiTxebze<br />
janmrTelobis <strong>da</strong>cvis mrCevelTa komiteti ganixilavs donorTa rigebi<strong>da</strong>n im pirebis<br />
garicxvis problemas, romlebsac Tavad Cautar<strong>da</strong>T sisxlis komponentebis transfuzia<br />
1980-1996 wlebSi. am zomebTan <strong>da</strong>kavSirebuli sirTule imaSi mdgomareobs, rom igi<br />
donorebis <strong>da</strong>axloebiT 10%-is <strong>da</strong>kargvamde migviyvans <strong>da</strong> sisxlis komponentebis<br />
gamoyenebis Sesabamisi Semcirebis gareSe sisxlis bankebi seriozuli safrTxis winaze<br />
aRmoCndebian. savaraudoa, rom variantuli kroicfeld-iakobis <strong>da</strong>avadebis gamosavleni<br />
testis gamogonebis Semdeg sisxlis maragi kidev ufro metad Semcirdeba.<br />
ramodenime kompania muSaobs kroicfeld-iakobis <strong>da</strong>avadebis gamosavleni testis<br />
SemuSavebaze. winaswari monacemebiT erT-erTi maTgani xelmisawvdomi gaxdeba uaxloesi 2<br />
wlis manZilze, ris Semdegac sisxlis erovnuli xelmZRvaneloba pasuxs agebs mis droul<br />
gavrcelebaze (ukanaskneli sasamarTlo procesis dros C-hepatitis transfuziis gziT<br />
gavrcelebasTan <strong>da</strong>kavSirebiT sisxlis erovnuli xelmZRvaneloba <strong>da</strong>mnaSaved aRiares<br />
arasrulfasovani produqciis mowodebasa <strong>da</strong> C-hepatitis ukve arsebuli testis <strong>da</strong>nergvis<br />
<strong>da</strong>gvianebaSi). anonimuri testirebis arCevani gamoricxuli iqneba: evropis kanonmdeblobiT<br />
donorebma yvela gamokvlevaze, romelic maTi sisxlis nimuSebze Catardeba,<br />
informirebuli Tanxmoba un<strong>da</strong> ganacxadon. maT aseve un<strong>da</strong> acnobon gamokvlevis yvela is<br />
Sedegi, romlis safuZvelzec sisxlis erovnuli xelmZRvaneloba moqmedebs (mag. ar<br />
miiRebs maTs sisxls). savaraudoa, rom mravali donori ar <strong>da</strong>eTanxmeba testirebas, radgan<br />
codnis tvirTi gavlenas moaxdens ara marto maTs janmrTelobasa <strong>da</strong> bednierebaze, aramed<br />
48
sicocxlis sa<strong>da</strong>zRvevo polisis xelmisawvdomobazec. sisxlis importi im qveynebi<strong>da</strong>n,<br />
sa<strong>da</strong>c saqonlis Rrublovani encefalopaTiis SemTxvevebi ar <strong>da</strong>fiqsirebula, momxiblavad<br />
gamoiyureba, magram imdenad ramdena<strong>da</strong>c qveynebis umetesoba periodulad sisxlis<br />
komponentebis deficitis winaSe dgas, naklebad SesaZlebelia, rom maT did britaneTSi<br />
arsebuli yovelwliuri 2,7 mln doza eriTocituli masis moTxovnilebis <strong>da</strong>kmayofileba<br />
SeZlon.<br />
araaucilebel transfuziaTa Semcireba <strong>da</strong> sisxlis altenatiuli saSualebebis gamoyeneba<br />
trasfuziuli praqtikis mniSvnelovani cvalebadoba eleqtiuri qirurgiuli<br />
operaciebis dros kargad aris aRwerili. araaucilebel transfuziaTa <strong>da</strong>qveiTebis mizniT<br />
gansakuTrebiT mniSvnelovania operaciis dros janmrTel pacientebSi sisxlis<br />
komponentebis gamoyenebis Semcireba. anesTeziologebisaTvis gamiznuli bolodroindeli<br />
publikacia ajamebs efeqtur transfuziul taqtikas qirurgiul pacientebSi. Tumca misi<br />
<strong>da</strong>nergva sakmaod problematuria, radgan ukanasknel perio<strong>da</strong>mde sisxli usafrTxo <strong>da</strong><br />
SeuzRu<strong>da</strong>v wyarod iTvlebo<strong>da</strong> <strong>da</strong> sisxlis <strong>da</strong>zogvis RonisZiebebis <strong>da</strong>safinanseblad<br />
Tanxebis mozidva sakmaod rTulia.<br />
erovnuli sisxlis samsaxuris Sinagani auditis Sedegad miRebuli informaciis<br />
Tanaxmad, did britaneTSi ga<strong>da</strong>sxmuli sisxlis <strong>da</strong>axloebiT naxevari qirurgiul<br />
pacientebze modis. eleqtiur qirurgiaSi gamoyenebuli sisxlis raodenobis Semcireba<br />
pacientis mkurnalobis TiToeuli etapis detalur <strong>da</strong>gegmvas moiTxovs. sisxlis<br />
komponentebis fasis <strong>da</strong>zogvis SemTxvevaSic ki arsebobs <strong>da</strong>narCen RirebulebaTa gazrdis<br />
riski <strong>da</strong> amitom xanmokle periodSi saerTo ekonomikuri <strong>da</strong>nazogi SesaZloa nuls<br />
udrides.<br />
transfuziis dros ga<strong>da</strong>tanili infeqciebis, imunomodulaciisa (xangrZlivi msubuqi<br />
imunosupresia, romelsac adgili aqvs sisxlis komponentebis recipientebSi <strong>da</strong> Se<strong>da</strong>rebiT<br />
arasaxarbielo gamosavlis gamowveva SeuZlia) <strong>da</strong> litigation-is RirebulebasTan<br />
<strong>da</strong>kavSirebuli xangrZlivi ekonomikuri <strong>da</strong>nazogi SesaZloa mniSvnelovani iyos, magram<br />
maTi gamoTvla Znelia.<br />
sisxlis komponentebis transfuziis saWiroebis Semcirebis strategiis <strong>da</strong>nergva<br />
efeqtur jgufur muSaobas, adeqvatur resursebsa <strong>da</strong> misi motivaciis naTel gagebas<br />
moiTxovs. sisxlis Semcvlelebi, rogoric aris hemoglobinis xsnarebi <strong>da</strong><br />
perfluorokarbonebi, me-3 fazis klinikur kvlevebs gadian, magram naxevar<strong>da</strong>Slis<br />
xanmokle periodis gamo maTi gamoyeneba sakmaod SezRuduli iqneba.<br />
lokaluri Tu erovnuli masStabiT sisxlis komponentebis mxolod<br />
maRalkvalificiuri specialistebis mier <strong>da</strong>niSvnis politikis gaZliereba araaucilebel<br />
transfuziaTa raodenobis Semcirebis kidev erT midgomas warmoadgens.<br />
specialisti transfuziologebis <strong>da</strong>niSvna<br />
ukanaskneli 3 wlis ganmavlobaSi transfuziologiaSi specializirebuli<br />
praqtikosi eqimebis Stati <strong>da</strong>Svebuli iqna didi britaneTis 40-ze met saavadmyofoSi,<br />
riTac isini imeoreben evropisa <strong>da</strong> aSS-s analogiur gamocdilebas. umetesi maTgani<br />
gamocdili med<strong>da</strong>a, zogierTi – eqimi an biomedicinis sferoSi momuSave mecnieri. es<br />
Statebi <strong>da</strong>Svebuli iqna sisxlis komponentebis usafuZvlo gamoweris SemTxvevebis<br />
Semcirebis rekomendebuli politikis <strong>da</strong>nergvis mizniT. Tumca specialisti<br />
transfuziologebis <strong>da</strong>saqmebis xarjebi zogierT finansists Rrmad afiqrebs,<br />
ganmeorebiTma gamoTvlebma aCvena, rom araaucilebeli transfuziebis fass igi<br />
sagrZnoblad CamorCeba.<br />
specialisti transfuziologebis ZiriTadi <strong>da</strong>niSnuleba imaSi mdgomareobs, rom maT<br />
aamaRlon momsaxure personalisa <strong>da</strong> pacientebis codnis done sisxlis transfuziis<br />
sargeblisa <strong>da</strong> zianis Sesaxeb <strong>da</strong> mxari <strong>da</strong>uWiron transfuziuli protokolebisa <strong>da</strong><br />
saxelmZRvanelo principebis Sefasebasa <strong>da</strong> ganviTarebas. isini aseve xels uwyoben<br />
49
angariSgebis Semowmebas <strong>da</strong> im stategiis <strong>da</strong>nergvas, romelic gaaumjobesebs sisxlis<br />
SekveTasa <strong>da</strong> <strong>da</strong>niSvnas. saWiroebis SemTxvevaSi <strong>da</strong>saSvebia, rom praqtikosebma pacientis<br />
gamokvlevisa <strong>da</strong> ujredTa ga<strong>da</strong>rCenis meTodikis realizaciaSi uSualod miiRon<br />
monawileoba.<br />
plazmis produqtebis usafrTxoebisaTvis gankuTvnili axali nabijebi<br />
virusuli infeqciebis Se<strong>da</strong>rebiT mgrZnobiare testebis <strong>da</strong>nergvasTan erTad sisxlis<br />
komponentebis usafrTxoeba gaizar<strong>da</strong>. variantuli kroicfeld-iakobis <strong>da</strong>avadebis<br />
potenciuri transmisiis Semcirebis mizniT, 1999 wlis noembri<strong>da</strong>n moyolebuli<br />
gaerTianebuli samefos sisxlis yvela ujreduli komponentebi gasufTavebulia<br />
leikocitebis minarevebisagan (leikodeplecia). aRniSnuli procedura agreTve amcirebs<br />
ujredebTan asocirebuli sxva virusebis, rogoric aris citomegalovirusi, transmisiis<br />
sixSires. axlad gayinul plazmaSi, sisxlsa <strong>da</strong> TrombocitebSi -hepatitis gamosavlenad<br />
bolo dros SemuSavebulma nukleinis mJavas testebma “Ria fanjris periodi” 70 dRi<strong>da</strong>n<br />
(serologiuri meTodi) 13 dRemde Seamcira <strong>da</strong> infeqciis ga<strong>da</strong>cemis Sansi 1:25000-<strong>da</strong>n 1:3 mlnmde<br />
<strong>da</strong>aqveiTa.<br />
savaraudoa, rom riskis Semdgomi Semcirebis mizniT virusTa inaqtivaciis etapebi,<br />
romlebic sistematurad gamoiyeneba iseTi fraqcionirebuli produqtebis <strong>da</strong>muSavebis<br />
dros, rogoric aris albumini an imunoglobulinis xsnarebi, amJamad gamoyenebuli iqneba<br />
axlad gayinuli plazmis <strong>da</strong> ujreduli komponentebis momzadebisaTvis.<br />
1000-ze meti donorisagan miRebuli plazmis gaerTianeba <strong>da</strong> saerTo avzSi Tavmoyra<br />
(pulireba) saWiroa axlad gayinuli plazmisa <strong>da</strong> fraqcionirebuli produqtebisaTvis<br />
gamxsneli fxvnilis <strong>da</strong>samateblad, aseve maTi <strong>da</strong>muSavebis efeqturobisa <strong>da</strong> produqtebis<br />
stan<strong>da</strong>rtizaciisaTvis. pulireba Teoriulad erTi donorisagan mTeli avzis<br />
<strong>da</strong>inficirebis risks ganapirobebs. Tumca <strong>da</strong>muSaveba anadgurebs kafsulirebul virusebs,<br />
rogoric aris aiv, hepatiti B <strong>da</strong> C, yvela ara-inkafsulirebuli virusi ar eqvemdebareba<br />
zemoqmedebas (hepatiti-A an parvovirusi). aseve tardeba plazmis saerTo avzis gamokvleva<br />
serologiuri <strong>da</strong> polimerazis jaWvuri reaqciis meTodebiT, magram yvela cnobili<br />
agentebis testireba ver xorcieldeba <strong>da</strong> ukve adgili hqon<strong>da</strong> parvovirusis ga<strong>da</strong>cemis<br />
ramodenime SemTxvevas. gamxsneli fxvniliT <strong>da</strong>muSavebuli plazmis gamoyeneba farTod<br />
aris gavrcelebuli, Tumca evropis zogierT qveyanaSi msgavsi meTodiT <strong>da</strong>mzadebuli<br />
plazmis gamoyeneba akrZalulia. alternativas meTilenis lurjiT <strong>da</strong>muSaveba<br />
warmoadgens, romelic SeiZleba plazmis calkeul dozebTan iyos gamoyenebuli. is iwvevs<br />
virusebis Se<strong>da</strong>rebiT farTo speqtris inaqtivacias, magram ufro ZviradRirebuli meTodia<br />
<strong>da</strong> didi drois xarjvasTan aris <strong>da</strong>kavSirebuli. gar<strong>da</strong> amisa,MmeTilenis lurji<br />
potenciurad ufro toqsiuria.<br />
sisxlisa <strong>da</strong> qsovilebis mikrobiologiuri usafrTxoebis didi britaneTis<br />
mrCevelTa komiteti amJamad ganixilavs sakiTxs, Tu pacientTa romeli jgufisTvis aris<br />
mizanSewonili didi britaneTis donorebisagan miRebuli axlad gayinuli plazmis<br />
<strong>da</strong>muSaveba virusebis inaqtivaciis mizniT. ingliseli donorebis axlad gayinuli plazmis<br />
meTilenis lurjiT <strong>da</strong>muSaveba pirvelad 2002 maisSi ganxorciel<strong>da</strong> 1996 wlis 1 ianvris<br />
(TariRi rodesac variantuli kroicfeld-iakobis <strong>da</strong>avadeba oficialurad gamoiricxa<br />
didi britaneTis a<strong>da</strong>mianTa kvebis jaWvi<strong>da</strong>n) Semdeg <strong>da</strong>badebul bavSvTa <strong>da</strong><br />
axalSobilTaTvis.<br />
gamxsneli fxvniliTa <strong>da</strong> meTilenis lurjiT <strong>da</strong>muSaveba baqteriebsa an virusis<br />
msgavs nawilakebze, romelic rezistentulia eqstremaluri temperaturuli reJimis<br />
mimarT, ar moqmedebs. ar arsebobs am ukanasknelTa inaqtivaciis mosaxerxebeli meTodi.<br />
Tumca aRsaniSnavia, rom sisxlis komponentebis, gansakuTrebiT Trombokoncentratebis,<br />
baqteriebiT <strong>da</strong>binZureba transfuziul TerapiasTan <strong>da</strong>kavSirebuli sikvdilobisa <strong>da</strong><br />
avadobis bevrad ufro mniSvnelovani mizezia, vidre virusebis transmisia. paTogenebis<br />
inaqtivaciis mesame meTodi ganixileba rogorc universaluri meTodi, romliTac miiRweva<br />
ara marto virusebis, aramed baqteriebis, parazitebis <strong>da</strong> limfocitebis inaqtivaciac.<br />
50
fsoralen S-59 <strong>da</strong> ultraiisferi sxivebi erTdroulad gamoiyeneba individualuri<br />
Trombokoncentratebis <strong>da</strong>samuSaveblad helinqsis sistemaSi (Helynx system), romelic dnm-sa<br />
<strong>da</strong> rnm-s jvaredin kavSirs uzrunvelyofs. fsoralenis meore forma - S-303, romelic<br />
gamiznulia eriTrocituli masebis <strong>da</strong>samuSaveblad, ganviTarebis etapzea. maRali<br />
Rirebulebisa <strong>da</strong> Sromatevadobis miuxe<strong>da</strong>vad, am sistemas virusebis msgavsi nawilakebis<br />
gamoklebiT yvela potenciuri paTogenis inaqtivacia SeuZlia. gar<strong>da</strong> amisa, igi<br />
gamoricxavs transfuziasTan asocirebuli "transplantati recipientis winaaRmdeg<br />
reaqciis" profilaqtikis mizniT sisxlis komponentebis <strong>da</strong>sxivebis aucileblobas, radgan<br />
igi uzrunvelyofs aRniSnul reaqciaze pasuxismgebeli donorebis limfocitebis<br />
ganadgurebas.<br />
momavalSi is SesaZloa, paTogenTa inaqtivaciis arCeviT sistemad iqces, vidre sxva<br />
meTodebi <strong>da</strong>inergeba.<br />
literatura<br />
1. British Committee for Stan<strong>da</strong>rds in Haematology, Blood Transfusion Task Force. Guidelines for<br />
the clinical use of red cell transfusions. Br J Haematol 2001; 113: 24-31<br />
2. Krombach J, Kampe S, Gathof BS, Diefenbach C, Kasper S-M. Human error: the persisting risk of<br />
blood transfusion: a report of five cases. Anesth Analg 2002; 94: 154-156<br />
3. Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York State: an<br />
analysis of 10 years experience. Transfusion 2000; 40: 1207-1213<br />
4. Serious Hazards of Transfusion Steering Group. Annual report 1999-2000. Manchester: SHOT,<br />
2001.<br />
5. British Committee for Stan<strong>da</strong>rds in Haematology, Blood Transfusion Task Force. The<br />
administration of blood and blood components and the management of the transfused patients.<br />
Transfusion Med 1999; 9: 227-238<br />
6. Jensen NJ, Crosson JT. An automated system for bedside verification of the match between patient<br />
ID and blood unit ID. Transfusion 1996; 36: 216-221<br />
7. McClelland B, Love E, Scott S, Williamson LM. Haemovigilance: concept, Europe and UK<br />
initiatives. Vox Sanguinis 1998; 74(suppl 2): 431-439<br />
8. Debeir J, Noel L, Aullen JP, Frette C, Sari F, Vo Mai MP, et al. The French haemovigilance<br />
system. Vox Sanguinis 1999; 77: 77-81<br />
9. Busch M, Chamberland M, Epstein J, Kleinman S, Khabbaz R, Nemo G. Oversight and monitoring<br />
of blood safety in the United States. Vox Sanguinis 1999; 77: 67-76<br />
10. Houston F, Foster JD, Chong A, Hunter N, Bostock CJ. Transmission of BSE by blood transfusion<br />
in a sheep. Lancet 2000; 356: 999-1000<br />
11. Brown P. BSE and transmission through blood. Lancet 2000; 356: 955-956<br />
12. Brown P, Will RG, Bradley R, Asher DM, Detwiler L. Bovine spongiform encephalopathy and<br />
variant Creutzfeldt-Jakob disease: background, evolution and current concerns. Emerging Infect<br />
Dis 2001; 7: 6-16<br />
13. Bonetta L. Scientists race to develop a blood test for vCJD. Nature Med 2001; 7: 261<br />
14. A vs National Blood Authority [2001] 3 All ER 289.<br />
15. Sanguis Study Group. Use of blood products for elective surgery in 43 European Hospitals.<br />
Transfusion Med 1994; 4: 251-268<br />
16. Association of Anaesthetists of Great Britain and Ireland. Blood transfusion and the anaesthetist:<br />
red cell transfusion. London: Association of Anaesthetists of Great Britain and Ireland, 2001.<br />
17. Blajchman MA, Dzik S, Vamvakas EC, Sweeney J, Snyder EL. Clinical and molecular basis of<br />
transfusion induced immunomodulation: summary of the proceedings of a state-of-the-art<br />
conference. Transfusion Med Rev 2001; 15: 108-135<br />
18. Prowse CV. Alternatives to stan<strong>da</strong>rd blood transfusion: availability and promise. Transfusion Med<br />
1999; 9: 287-299<br />
19. Watson N, Taylor C. Allogeneic blood trans fusion the alternatives. Hosp Pharmacist 2000; 7:<br />
124-129.<br />
51
20. NHS Executive. Better blood transfusion. London: Department of Health, 1998. (Health Service<br />
Circular (HSC) 1998/224.)<br />
21. Clark P, Rennie I, Rawlinson S. Effect of a formal education programme on safety of transfusions.<br />
BMJ 2001; 323: 1118-1120<br />
22. Council of Europe expert committee in blood transfusion study group on pathogen inactivation of<br />
labile blood components. Pathogen inactivation of labile blood products. Transfusion Med 2001;<br />
11: 149-175<br />
23. Dumont LJ, Luka J, VandenBroeke T, Whitley P, Ambruso DR, Elfath MD. The effect of<br />
leukocyte-reduction method on the amount of cytomegalovirus in blood products: a comparison of<br />
apheresis and filtration methods. Blood 2001; 97: 3640-3647<br />
24. Roth WK, Weber M, Seifried E. Feasibility and efficacy of routine PCR screening of blood<br />
donations for hepatitis C virus, hepatitis B virus and HIV-1 in a blood bank setting. Lancet 1999;<br />
353: 359-363<br />
25. Koenigbauer UF, Eastlund T, Day JW. Clinical illness due to parvovirus B19 after infusion of<br />
solvent/detergent-treated pooled plasma. Transfusion 2000; 40: 1203-1206<br />
26. Pamphilon D. Viral inactivation of fresh frozen plasma. Br J Haematol 2000; 109: 680-693<br />
27. Barbara J. Pathogen inactivation treatment of platelet components: advancing from theory to<br />
clinical practice. Semin Hematol 2001;38(4 suppl 11).<br />
Blood transfusion medicine<br />
Fiona Regan, Clare Taylor<br />
BMJ 2002; 325: 143-7<br />
Human error is a cause of transfusion related morbidity and mortality: these errors are entirely avoi<strong>da</strong>ble. The<br />
adoption of a lower "transfusion trigger" is gaining acceptance. Whether or not variant Creutzfeldt-Jakob<br />
disease is transmissible by transfusion, it may have a considerable impact on availability of blood for<br />
transfusion. Concerted efforts must now be made to reduce inappropriate blood use and to use alternatives and<br />
blood sparing agents. Pilot studies of barcode patient identification systems are assessing their feasibility in<br />
various clinical settings. Phase III clinical trials of blood substitutes (haemoglobin solutions and<br />
perfluorocarbons) are in progress.<br />
52
arCil kobalaZis saxelobis sainformacio<br />
teqnologiebis kompiuteruli klasis gaxsna<br />
2001 wlis 24 dekembers saaxalwlod gamzadebul TbilisSi samwuxaro cnoba<br />
movi<strong>da</strong> jorjiis Statis q. atlantis emoris universitetis kliniki<strong>da</strong>n –<br />
gar<strong>da</strong>icvala cnobili eqimi <strong>da</strong> sazogado moRvawe – batoni arCil kobalaZe.<br />
batoni arCilis xanmokle <strong>da</strong> nayofieri moRvaweoba uaRresad mravalferovani iyo.<br />
cnobili profesoris – saqarTveloSi klinikuri farmakologiis fuZemdeblis –<br />
sergo kobalaZis Svilma Rirseulad gaagrZela mamis tradicia <strong>da</strong> Camoayaliba<br />
Tbilisis samedicino institutis klinikuri farmakologiis kursi, iyo<br />
saqarTvelos klinikur faramakologTa sazogadoebis Tavmjdomare, farmakoqimiis<br />
institutis gamyofilebis gamge, aTerosklerozis <strong>da</strong> lipiduri cvlis Sesaxeb<br />
kvlevebis erT-erTi lideri, msoflioSi cnobili mecnieri. 1992 wli<strong>da</strong>n batoni<br />
arCili iyo atlanta-Tbilisis janmrTelobis partnioruli programebis<br />
koordinatori. am programis farglebSi, amerikeli partnioris - emoris<br />
universitetis profesoris ken uokeris xelSewyobiT a. kobalaZis TaosnobiT<br />
TbilisSi <strong>da</strong>ars<strong>da</strong> ga<strong>da</strong>udebeli samedicino <strong>da</strong>xmarebis saswavlo centri,<br />
erovnuli sainformacio saswavlo centri, saqarTvelos saeqTno asociacia,<br />
neonatologTa arasamTavrobo organizacia `neonatusi~, gazeTi ”medicina <strong>da</strong><br />
farmakologia”, tardebo<strong>da</strong> seminarebi sazogadoebrivi jan<strong>da</strong>cvis, saeqTno<br />
swavlebis, jan<strong>da</strong>cvis menejmentis <strong>da</strong> <strong>da</strong>finansebis, sa<strong>da</strong>zRvevo medicinis<br />
sakiTxebze, ganxorciel<strong>da</strong> telemedicinis <strong>da</strong> distanciuri samedicino swavlebis<br />
pirveli piloturi proeqtebi, <strong>da</strong>iwyo partnioruli qarTul-amerikuli jan<strong>da</strong>cvis<br />
programebi quTaissa <strong>da</strong> mcxeTaSi. b-ni arCilis moRvaweoba saqarTvelos<br />
warmomadgnelad evropis sabWos jan<strong>da</strong>cvis komitetSi aseve nayofieri iyo <strong>da</strong><br />
Sedegad mohyva janmrTelobis teqnologiebis Sefasebis <strong>da</strong> klinikuri praqtikis<br />
gaidlainebis momzadebis sferoSi winga<strong>da</strong>dgmuli nabijebi.<br />
2003 wlis 25 dekembers erovnuli sainformacio saswavlo centris (essc) <strong>da</strong><br />
internet-kompania `houmkom kommunikeiSenz~ (atlanta, aSS) iniciativiT essc-is<br />
bazaze gaixsna b-ni arCil kobalaZis saxelobis sainformacio teqnologiebis<br />
klasi. am movlenisadmi miZRvnil sxdomas <strong>da</strong>eswrnen b-ni arCilis kolegebi,<br />
megobrebi, moswavleebi <strong>da</strong> axloblebi. sxdoma gaxsna erovnuli sainformacio<br />
saswavlo centris direqtorma <strong>da</strong> organizacia ”partniorebi janmrTelobisaTvis”<br />
gamgeobis Tavmjdomarem zviad kirtavam. stumrebs miesalma saqarTvelos Sromis,<br />
socialuri <strong>da</strong> janmrTelobis <strong>da</strong>cvis ministri b-ni amiran gamyreliZe. man<br />
ilaparaka im did amagze, romlis gamo arCil kobalaZes ”saqarTvelos jan<strong>da</strong>cvis<br />
elCs” uwodebdnen. batoni arCilis enTuziazmsa, <strong>da</strong>xvewil inteleqtsa <strong>da</strong> Rrma<br />
codnaze <strong>da</strong>fuZnebuli strategiuli xedva momavalSic <strong>da</strong>a<strong>da</strong>sturebs im<br />
prioritetebis gamarTlebas, romelTac igi emsaxurebo<strong>da</strong>.<br />
Tavis uaRresad emociur <strong>da</strong> Tbil gamosvlaSi batoni arCilis didi xnis megobarma<br />
<strong>da</strong> partniorma, emoris universitetis profesorma, organizacia `partniorebi<br />
saerTaSoriso ganviTarebisaTvis~ direqtorma profesorma ken uokerma batoni<br />
arCili <strong>da</strong>axasiaTa, rogorc a<strong>da</strong>miani, romelic bolomde <strong>da</strong>uzigavad emsaxura<br />
Tavis xalxs, rogorc profesionali, rogorc saerTaSoriso moRvawe, humanisti,<br />
ganmanaTlebeli. `me madlobeli var bedis, rom iseT a<strong>da</strong>mians Sevxvdi cxovrebaSi,<br />
rogoric arCili iyo~, - ganacxa<strong>da</strong> b-nma uokerma, - `a<strong>da</strong>mians, romelsac Rrma<br />
53
miswrafebebi <strong>da</strong> farTo horizonti hqon<strong>da</strong>, <strong>da</strong> romelmac bevri gvaswavla Tavisi<br />
xanmokle cxovrebiT~.<br />
arCil kobalaZis Sesaxeb mogonebebiT gamovidnen misi megobrebi <strong>da</strong> kolegebi -<br />
saqarTvelos teqnikuri universitetis reqtori prof. ramaz xuroZe,<br />
sazogadoebrivi jan<strong>da</strong>cvis departamentis direqtori prof. ramaz uruSaZe, prof.<br />
aleqsandre ala<strong>da</strong>Svili, profesori irakli faRava.<br />
amis Semdeg gaimarTa kompiuteruli programirebis klasis gaxsna. atlantaSi<br />
moqmedi internet-kompania `houmkom kommunikeiSenz~-is xelmZRvanelebma gia<br />
bokuCavam <strong>da</strong> nino doijaSvilma aRniSnes, rom b-n arCil kobalaZesTan Sexvedram<br />
maT cxovrebaSi ga<strong>da</strong>mwyveti roli iTamaSa, b-nma arCilma xeli Seuwyo maT<br />
profesiul winsvlas <strong>da</strong> dRes isini atlantaSi sainformacio teqnologiebis erTerTi<br />
mowinave kompaniis menejerebi arian. q-nma ninom stumrebs gaacno<br />
kompiuteruli programirebis klasis ZiriTadi amocanebi <strong>da</strong> is modulebi,<br />
romlebiTac klasi studentebs aswavlis. gaTvaliswinebulia sistemadministrirebis<br />
(TCP/IP, DNS, WWW, SMTP, FTP), kompiteruli teqnologiebis<br />
safuZvlebis (Linux, Apachi, Stats instalirebis), programirebis enebis (PHP/PERRL),<br />
internetis ”enebis” (HTML, CGI), monacemTa bazebis (Oracle, MySQL, MMSSWL)<br />
Seswavla. <strong>da</strong>saxelebuli modulebi <strong>da</strong>fuZnebulia saerTaSoriso stan<strong>da</strong>rtebsa <strong>da</strong><br />
sawvrTnel programebze <strong>da</strong> momzadebis xarisxis kontroli aseve ganxorcieldeba<br />
essc-sa <strong>da</strong> ”houmkom kommunikeiSenz”-is erToblivi ZalisxmeviT.<br />
zviad kirtava,<br />
erovnuli sainformacio saswavlo centri<br />
iv. javaxiSvilis q. #51, oTaxi #215.<br />
tel. 94 27 95, 94 13 86. faqsi: 94 13 91<br />
www.nilc.org.ge<br />
ministri amiran gamyreliZe,<br />
essc direqtori zviad<br />
kirtava <strong>da</strong> prof. kenet<br />
uokeri arCil kobalaZis sax.<br />
klasis gaxsnaze<br />
54
arCil kobalaZis axloblebi<br />
<strong>da</strong> kolegebi<br />
nino doijaSvili a. kobalaZis<br />
sax. kompiuteruli<br />
programirebis klasis<br />
prezentaciaze<br />
55
internetis samedicino<br />
<strong>da</strong>ijesti<br />
#5-6 (93-94)<br />
30.09.2003 *<br />
Internet Medical<br />
Digest<br />
v 2003 wlis revmatologiis brifingi: gasuli wlis miRwevebi <strong>da</strong> momavlis gegmebi<br />
v gasdiT ki medikamentebs moxmarebis va<strong>da</strong><br />
v aspirinis gamoyenebam SesaZloa Seamciros prostatis kibos ganviTarebis riski<br />
v xanmokle iSemiuri Setevis diagnozs xSirad SecdomaSi Sehyavs eqimebi<br />
v amerikis gulis asociaciam ganaaxla gaidlainebi qalebSi kardiovaskuluri<br />
<strong>da</strong>avadebis prevenciis Sesaxeb<br />
v winagulTa fibrilaciis mqone pacientebis mkurnalobis gaidlainebi<br />
v periferiuli arteriuli <strong>da</strong>avadebisa <strong>da</strong> diabetis mqone pacientebis mkurnalobis<br />
gaidlainebi<br />
v jan<strong>da</strong>cvis msoflio organizaciis gaidlainebi mcenareuli medikamentebis<br />
usafrTxoebisa <strong>da</strong> efeqturobis Sesaxeb<br />
v Rheumatology Briefing for 2003: A Look at the Year Behind and the Year Ahead<br />
v Do medications really expire<br />
v Aspirin use may reduce the risk of prostate cancer<br />
v Diagnosis of transient ischemic attacks is misleading and can lead to the mismanagement of patients<br />
v American Heart Association has up<strong>da</strong>ted guidelines for cardiovascular disease prevention in women<br />
v Recommen<strong>da</strong>tions for internists and family physicians to manage patients with atrial fibr illation.<br />
v First consensus statement for the care of patients with peripheral arterial disease and diabetes<br />
v World Health Organization’s guidelines for safety and efficacy of herbal medicine<br />
* - teqnikuri mizezebis gamo Jurnali <strong>da</strong> <strong>da</strong>ijesti <strong>da</strong>ibeW<strong>da</strong> 2004 wlis ianvarSi<br />
56
2003 wlis revmatologiis mimoxilva: gasuli wlis miRwevebi <strong>da</strong> momavlis gegmebi<br />
eleqtronulma Jurnalma `medsqeif” TxovniT mimarTa sare<strong>da</strong>qcio kolegiis wevrs,<br />
medicinis mecnierebaTa doqtor robert foqss, raTa mas warmoedgina misi azriT yvelaze<br />
mniSvnelovani miRwevebi 2003 wels revmatologiaSi <strong>da</strong> agreTve 2004 wlis gegmebi.<br />
bolo wlebSi, mkvlevarebma gansacvifrebeli Sedegebi miiRes revmatologiur<br />
<strong>da</strong>avadebaTa <strong>mkurnaloba</strong>Si simsivnis nekrozuli faqtoris inhibitorebiT, romlebic<br />
saocrad warmatebuli aRmoCn<strong>da</strong> revmatoiduli arTritis mqone pacientebSi Terapiuli<br />
pasuxis miRebaSi. gar<strong>da</strong> amisa, mecnierebma aRmoaCines sruliad axali receptorebi <strong>da</strong><br />
Terapiuli samizneebi. amave dros, simsivnis nekrozuli faqtoris inhibitorebiT<br />
mkurnalobis SezRudulobam revmatoiduli arTritis mqone zogierT pacientSi <strong>da</strong> maTma<br />
Se<strong>da</strong>rebiT mcire sargebelma sxva iseTi <strong>da</strong>avadebebis <strong>mkurnaloba</strong>Si, rogoric aris<br />
sistemuri wiTeli mglura <strong>da</strong> Sogrenis sindromi, mecnierebs ubiZga miiyvana Terapiuli<br />
intervenciebis sxva/axali gzebis Ziebisaken.<br />
2004 wels <strong>da</strong>gegmilia im meqanizmebis Seswavla, romlebic safuZvlad udevs<br />
Tan<strong>da</strong>yolili (ara HLA-<strong>da</strong>kavSirebuli) <strong>da</strong> SeZenili ( HLA-<strong>da</strong>kavSirebuli) imunuri<br />
sistemebis urTierTqmedebas. gasuli wlis ganmavlobaSi, genomuri <strong>da</strong> proteomuli<br />
skriningis meTodebi miuTiTebdnen imaze, rom I <strong>da</strong> II tipis interferonTan <strong>da</strong>kavSirebuli<br />
molekulebi, rogorc Cans, iwveven Tan<strong>da</strong>yolili <strong>da</strong> SeZenili imunuri sistemebis<br />
urTierTmoqmedebas. mecnierebi didi xania saubroben imaze, rom autoimunuri <strong>da</strong>avadeba<br />
aris genetikuri <strong>da</strong> garemo faqtorebis urTierTqmedebis Sedegi. axla, rogorc Cans, xdeba<br />
im specifiuri molekulebisa <strong>da</strong> receptorebis amocnoba, romelTa <strong>da</strong>xmarebiT moxdeba am<br />
urTierTqmedebis meqanizmis axsna. momavali wlis mizania am meqanizmis klinikaSi<br />
gamoyeneba, raTa gagebul <strong>da</strong> winaswar prognozirebul iqnas mkvlevarebis warumatebloba<br />
<strong>da</strong> agreTve maTi miRwevebi simsivnis nekrozuli faqtoris inhibitoriT mkurnalobis mxriv.<br />
gasul wels, mniSvnelovani iyo agreTve B ujredebis Seswavla, romlebzec wina<br />
aTwleulis ganmavlobaSi mcire informacia moipovebo<strong>da</strong> T ujredebTan Se<strong>da</strong>rebiT. imis<br />
aRmoCenam, rom B ujredebis antisxeulebma SesaZloa mniSvnelovani roli iTamaSon ara<br />
marto revmatoiduli arTritis, aramed sxva <strong>da</strong>avadebebis dros (mag. sistemuri wiTeli<br />
mglura), SesaZloa mecnierebi miiyvanos B ujredebis regulaciis ufro farTo gagebamde.<br />
<strong>da</strong> bolos, revmatologebi kvlav ver aRweven konsensuss fibromialgiasTan <strong>da</strong>kavSirebiT.<br />
isini namdvili dilemis winaSe dganan. “avadmyofi tvinis” sindromis meqanizmebi, romelTa<br />
kvleva intensiurad mimdinareobs iseTi <strong>da</strong>rRvevebis dros, rogoric aris gafantuli<br />
sklerozi <strong>da</strong> <strong>da</strong>bereba, revmatologebis mier dRemde ar aris safuZvlianad Seswavlili.<br />
imedia, rom momavali wlis ganmavlobaSi revmatologiur pacientebSi ufro Rrmad iqneba<br />
Seswavlili genetikis meqanizmebi <strong>da</strong> neiroqimikosebis mier Seqmnili citokinebi.<br />
gasdiT ki medikamentebs moxmarebis va<strong>da</strong><br />
niSnavs Tu ara wamlis flakonze aRniSnuli va<strong>da</strong> raimes Tu magaliTad, tailenolis<br />
boTlze miTiTebulia is, rom misi gamoyeneba SeiZleba 1998 wlis ivnisamde, xolo axla<br />
2003 wlis agvistoa, SeiZleba Tu ara misi miReba Tu man Tavisi Zala <strong>da</strong>karga <strong>da</strong> arafers<br />
kargs ar mogvitans<br />
sxva sityvebiT, arian Tu ara wamlis mwarmoeblebi momxmareblebTan marTalni, roca<br />
isini wamlebze va<strong>da</strong>s miuTiTeben<br />
medicinis mecnierebaTa doqtorma tomas kramerma Cikagos universiteti<strong>da</strong>n, (ilinoisis<br />
Stati), zogadi literaturisa <strong>da</strong> samedicino monacemebis <strong>da</strong>xmarebiT sca<strong>da</strong> pasuxi gaeca<br />
am kiTxvebze.<br />
upirveles yovlisa, vadis gasvlis TariRi, romlis miTiTebac aSS kanonmdeblobiT 1979<br />
wli<strong>da</strong>n xdeba, miuTiTebs mxolod imaze, rom mwarmoebeli wamlis usafrTxoebisa <strong>da</strong><br />
moqmedebis unaris garantias mxolod am dromde iZleva, anu es ar niSnavs imas, ramden<br />
xans inarCunebs sinamdvileSi esa Tu is medikamenti moqmedebisa <strong>da</strong> usafrTxoebis unars.<br />
gar<strong>da</strong> amisa, medicinis muSakebi erTxmad amboben imas, rom wamlis gamoyeneba misi<br />
vadis gasvlis Semdegacaa usafrTxo. iSviaTi gamonaklisebis gar<strong>da</strong>, a<strong>da</strong>miani ar gaxdeba<br />
57
avad <strong>da</strong>, miTumetes, - letaluri <strong>da</strong>sasruli ar eqneba - wamlis miRebas vadis amowurvis<br />
Semdeg.<br />
kvlevebis Tanaxmad, va<strong>da</strong>gasulma wamlebma SesaZloa <strong>da</strong>kargon Zala droTa<br />
ganmavlobaSi (5-50%). ase rom vadis gasvli<strong>da</strong>n 10 wlis Semdegac ki wamlebs SeiZleba<br />
Tav<strong>da</strong>pirveli Zala <strong>da</strong> moqmedebis unari hqondeT.<br />
erTerTi yvelaze masStaburi kvleva am sakiTxTan <strong>da</strong>kavSirebiT Catar<strong>da</strong> 15 wlis win<br />
aSS-is mier. Sedegebis mixedviT, medikamentTa 90% kvlav usafrTxo <strong>da</strong> efeqturia vadis<br />
gasvli<strong>da</strong>n 15 wlis Semdegac ki.<br />
amgvarad, vadis gasvlis TariRi ar niSnavs imas, rom wamali kargavs Tavisi moqmedebis<br />
efeqturobas <strong>da</strong> xdeba saziano. `mwarmoeblebi vadis amowurvis TariRs ufro metad<br />
vaWrobis mizniT <strong>da</strong> ara mecnieruli TvalsazrisiT miuTiTeben”, Tqva aSS sakvebisa <strong>da</strong><br />
wamlis administraciis farmacevtma, batonma flaertim. “maTTvis araxelsayrelia<br />
produqtis “Taroze” <strong>da</strong>deba 10 wlis ganmavlobaSi. maT surT tvirTbrunva”.<br />
aspirinis gamoyenebam SesaZloa Seamciros prostatis kibos ganviTarebis riski, Tanaxmad<br />
`briTiS jornel ov qenser” 12 ianvris nomerSi gamoqveynebuli meta-analizis Sedegebisa.<br />
prostatis kibos SemTxvevebi sakmaod didia aSS-Si <strong>da</strong> kana<strong>da</strong>Si <strong>da</strong> “igi sikvdilobis<br />
maCvenebliT meore adgilzea filtvis kibos Semdeg”, Tqva prof. salaedin mahmudma (Dr.<br />
Salaheddin Mahmud). “Zalze samwuxaroa is faqti, rom amJamad Cven ar viciT im cvladi riskfaqtorebis<br />
Sesaxeb, rac xels uwyobs am <strong>da</strong>avadebis ganviTarebas”.<br />
imis gamo, rom arasteroiduli anTebissawinaaRmdego wamlebis xmarebisa <strong>da</strong> prostatis<br />
kibos riskis Sesaxeb Catarebuli arcerTi kvleva ar gvaZlevs saboloo <strong>da</strong>skvnis<br />
gakeTebis SesaZleblobas, prof. mahmudma <strong>da</strong> misma kolegebma Caatares 12 kvlevis<br />
sistemuri ganxilva <strong>da</strong> meta-analizi, raTa <strong>da</strong>edginaT arasteroidul anTebissawinaaRmdego<br />
wamlebsa <strong>da</strong> prostatis kibos Soris arsebuli kavSiris simtkice.<br />
kvlevis Tanaxmad, aspirinis gamoyeneba <strong>da</strong>kavSirebuli iyo ukve ganviTarebuli<br />
prostatis kibos riskis 30%-iT <strong>da</strong> prostatis kibos saerTo riskis 10%-iT SemcirebasTan.<br />
kvlevam <strong>da</strong>adgina Zlieri ukuproporciuli kavSiri aspirinis xmarebasa <strong>da</strong> prostatis<br />
kibos risks Soris, magram mxolod im a<strong>da</strong>mianebSi, romlebic sul mcire 4 wlis manZilze<br />
iRebdnen aspirins.<br />
“rogorc laboratoriuli kvlevebi<strong>da</strong>n <strong>da</strong> a<strong>da</strong>mianebze <strong>da</strong>kvirvebi<strong>da</strong>n Cans,<br />
arasteroiduli anTebissawinaaRmdego wamlebi (<strong>da</strong> gansakuTrebiT aspirini) prostatis<br />
kibos winaaRmdeg garkveul <strong>da</strong>mcvelobiT rols TamaSoben”, ganacxa<strong>da</strong> prof. mahmudma.<br />
“jerjerobiT Zalze naadrevia prostatis kibos prevenciis mizniT aspirinis regularuli<br />
gamoyenebis rekomendireba, Tumca swored axla aris Sesaferisi dro prospeqtuli<br />
kvlevebis Casatareblad”.<br />
amerikeli nevrologebis panelma ganacxa<strong>da</strong>, rom xanmokle iSemiuri Setevis diagnozs<br />
xSirad SecdomaSi Sehyavs eqimebi <strong>da</strong> aman SeiZleba pacientebSi <strong>da</strong>avadebis umarTavobamde<br />
migviyvanos. yvela aseTi pacienti un<strong>da</strong> CaiTvalos insultis mqone pacientad, ganacxades<br />
maT. kaliforniis universitetis profesorma san franciskoSi klaiborn jonstonma (Dr. S.<br />
Claiborne Johnston) amerikis insultis asociaciis 29-e saerTaSoriso konferenciaze <strong>da</strong>mswre<br />
sazogadoebas ganucxa<strong>da</strong> imis Sesaxeb, rom xanmokle iSemiuri Setevebis mqone pacientebis<br />
24-saaTiani hospitalizacia xarj-efeqturia, vinai<strong>da</strong>n insultis riski am drois<br />
ganmavlobaSi Zalze maRalia.<br />
Ukaliforniis universitetis jgufma ganixila 24-saaTiani hospitalizaciis dros<br />
gaweuli <strong>da</strong>xmarebis xarj-efeqturoba xanmokle iSemiuri Setevebis mqone pacientebSi,<br />
romlebsac ga<strong>da</strong>udebeli samedicino <strong>da</strong>xmareba gaewiaT san-franciskos 11 hospitalSi. maT<br />
<strong>da</strong>adgines, rom hospitalizaciis SemTxvevaSi, insultis <strong>da</strong>dgena misi ganviTarebis<br />
pirvelive saaTSi mox<strong>da</strong> <strong>da</strong> pacientebs droulad Cautar<strong>da</strong>T Trombolizuri Terapia.<br />
58
amis Sedegad mox<strong>da</strong> garTulebebis minimumamde <strong>da</strong>yvana <strong>da</strong> ufro xanmokle<br />
hospitalizacia im pacientebTan Se<strong>da</strong>rebiT, romlebic gaweres xanmokle iSemiuri<br />
Setevebis simptomTa gaqrobisTanave.<br />
“ara aqvs aranairi azri xanmokle iSemiuri Setevebis insultisagan<br />
gamoyofas/gancalkevebas”, ganacxa<strong>da</strong> prof. maielkma (Dr. Mielke). “rogorc xanmokle iSemiuri<br />
Setevebi, ise insultebi warmoadgenen erTi <strong>da</strong> imave <strong>da</strong>avadebis progresirebis dros<br />
ganviTarebul movlenebs”, <strong>da</strong>eTanxmnen maielkis mosazrebas prof. a<strong>da</strong>msi <strong>da</strong> prof.<br />
jonstoni (Drs. A<strong>da</strong>ms and Johnston). samive maTgani Tvlis, rom xanmokle iSemiuri Setevebis<br />
diagnozs SecdomaSi Seyavs eqimebi. rogorc pacienti, aseve bevri eqimi SesaZloa<br />
<strong>da</strong>kmayofildes xanmokle iSemiuri Setevebis simptomebis gaqrobiT, ganacxades<br />
panelistebma. “xanmokle iSemiuri Setevebis mqone pacientebs aqvT mdgomareobis<br />
gauaresebis ufro maRali riski <strong>da</strong> insultis gamosworebis ufro mcire albaToba, Tavad<br />
insultis mqone pacientebTan Se<strong>da</strong>rebiT”, uTxra prof. jonstonma Reuters Health-s.<br />
amerikis gulis asociaciam ganaaxla gaidlainebi qalebSi kardiovaskuluri <strong>da</strong>avadebis<br />
prevenciis Sesaxeb. bolo gaidlainebi gamoica 1999 wels, xolo axali saxelmZRvanelo,<br />
romelic <strong>da</strong>beWdilia Jurnalis `serquleiSen”-is 10 Tebervlis nomerSi, rekomen<strong>da</strong>cias<br />
uwevs kardiovaskulur riskze <strong>da</strong>fuZnebul individualur midgomas. “Cven pirvelad<br />
vacxadebT naTlad imis Sesaxeb, Tu ra viciT <strong>da</strong> ra ara”, ambobs sare<strong>da</strong>qcio kolegiis<br />
Tavmjdomare, medicinis mecnierebaTa doqtori, lori moska ( Lori Mosca).<br />
“qalebSi kardiovaskuluri <strong>da</strong>avadebis arseboba-ararsebobis mdgomareobasTan<br />
<strong>da</strong>kavSirebuli mosazreba Seicvala im mosazrebiT, rom kardiovaskuluri <strong>da</strong>avadeba<br />
viTardeba drois ganmavlobaSi <strong>da</strong> yvela qalSi is ganviTarebis raRac etapzea”.<br />
kardiovaskuluri <strong>da</strong>avadebis prevenciasTan <strong>da</strong>kavSirebuli yvela arsebuli kvlevis<br />
ga<strong>da</strong>sinjvis Semdeg panelma <strong>da</strong>askvna, rom framingemis gulis kvlevis mier Seqmnili<br />
stan<strong>da</strong>rtizebuli meTodi adgens mkurnalobis agresiulobas miokardiumis infarqtis 10-<br />
wlian riskze <strong>da</strong>fuZnebiT. <strong>da</strong>bali riski gansazRvrulia rogorc 10%-ze naklebi, saSualo<br />
riski – 10%-<strong>da</strong>n 20%-mde, xolo maRali riski – rogorc 20%-ze meti.<br />
magaliTad, aspiriniT <strong>mkurnaloba</strong> ar aris rekomendebuli <strong>da</strong>bali riskis mqone qalebSi;<br />
misi gamoyeneba mizanSewonilia yvela maRali riskis mqone qalSi <strong>da</strong> im a<strong>da</strong>mianebSi,<br />
romlebSic <strong>da</strong><strong>da</strong>sturebulia kardiovaskuluri <strong>da</strong>avadebis diagnozi. cxovrebis iseTi<br />
faqtorebi, rogoric aris sigaretis mowevis Sewyveta, jansaRi kveba <strong>da</strong> normaluri wonis<br />
SenarCuneba, aucilebelia ukve arsebuli kardiovaskuluri <strong>da</strong>avadebis progresirebisa <strong>da</strong><br />
agreTve mTavari risk-faqtorebis prevenciisaTvis.<br />
maRali riskis mqone qalebSi rekomendebulia ACE-inhibitorebisa <strong>da</strong> beta<br />
blokatorebis gamoyeneba. agreTve qolesterinis <strong>da</strong>mwevi medikamentebis, upiratesad<br />
statinebis gamoyeneba im qalebSic ki, romlebSic <strong>da</strong>bali simkvrivis lipoproteinebis<br />
qolesterinis done 100 mg/dl–ze naklebia. miuxe<strong>da</strong>vad imisa, rom statinebiT rutinuli<br />
Terapia adre ar iyo rekomendebuli am qalebSi, mimdinare kvlevebis mixedviT statinebiT<br />
<strong>mkurnaloba</strong>m Sedegi gamoiRo am qvejgufSi. niacini <strong>da</strong> boWkovani preparatebi zogierT<br />
SemTxvevaSi SesaZloa Sedegis momcemi iyos.<br />
winagulTa fibrilaciis mqone qalebSi, romlebic aseve dganan emboliuri insultis<br />
saSualo an maRali riskis winaSe, insultis prevenciisaTvis mizanSewonilia varfarinis<br />
gamoyeneba. varfarini SeiZleba aspiriniT CavanacvloT im qalebSi, romlebSic varfarinis<br />
miReba ar aris rekomendebuli, an romelTac aqvT insultis ganviTarebis Se<strong>da</strong>rebiT<br />
<strong>da</strong>bali riski.<br />
rodesac sisxlis wneva ≥ 140/90 mm vwy, iniSneba antihipertenziuli agentebi, maT Soris<br />
Sardmdenebi, raTa sisxlis wneva ar aRematebodes 130/80 mm vwy. diabetis mqone qalebSi<br />
sisxlSi Saqris Semcveloba kontrolirebuli un<strong>da</strong> iyos imgvarad, rom glikozilirebuli<br />
hemoglobinis donem normis farglebs ar ga<strong>da</strong>aWarbos (
<strong>da</strong> bolos, <strong>da</strong>bali riskis mqone pacientebSi intervenciis sxva saxeebs, romlebic<br />
SesaZloa usargeblo <strong>da</strong> xSirad zianis momtanic ki iyos, warmoadgenen hormonaluri<br />
Terapia, antioqsi<strong>da</strong>ntebi <strong>da</strong> aspirinoTerapia. Tumca, omega-3 cximovani mJavebisa <strong>da</strong><br />
foliumis mJavis <strong>da</strong>mateba, jansaR kvebasTan erTad, SesaZloa marTebuli iyos zogierT<br />
maRali riskis mqone pacientSi.<br />
eqimTa amerikuli kolejis gaerTianebulma komitetma <strong>da</strong> ojaxis eqimebis amerikulma<br />
akademiam Terapevtebisa <strong>da</strong> ojaxis eqimebisaTvis gamosca eqvsi rekomen<strong>da</strong>cia, rac maT<br />
<strong>da</strong>exmareba winagulTa fibrilaciis mqone pacientebis mdgomareobis marTvaSi. axali<br />
gaidlainebi <strong>da</strong>beWdilia `anals ov internal medisin” 16 dekembris nomerSi.<br />
“saerTod praqtikaSi miRebulia is, rom yvela SesaZlebloba iqnas gamoyenebuli<br />
pacientebSi gulis normaluri sinusuri ritmis aRsadgenad”, ganacxa<strong>da</strong> medicinis<br />
mecnierebaTa doqtorma, panelis TanaTavmjdomarem, maikl lefevrma (Michael LeFevre).<br />
saukeTeso kvlevebis Tanaxmad, winagulovani fibrilaciis mqone pacientebSi ufro metad<br />
marTebulia guliscemis sixSiris/pulsis kontroli <strong>da</strong> insultis prevencia sisxlis<br />
gamaTxelebeli saSualebebiT, vidre sinusuri ritmis aRdgenis mcdeloba. kvlevebis<br />
Tanaxmad, garTulebebisa <strong>da</strong> sikvdilianobis maCveleblis SemcirebaSi ukeTesi Sedegi<br />
moitana pulsis <strong>da</strong> ara ritmis kontrolma, pacientTa normaluri ritmis SenarCunebis<br />
mizniT gamoyenebuli medikamentebis gverdiTi efeqtebi ki gacilebiT meti iyo<br />
sargebelTan Se<strong>da</strong>rebiT”.<br />
mimdinare kvlevebis Sedegebma aseve <strong>da</strong>amtkica parkuWTa SekumSvis sixSiris kontrolis<br />
upiratesoba sinusuri ritmis aRdgenis strategiasTan Se<strong>da</strong>rebiT. placebosTan Se<strong>da</strong>rebiT,<br />
insultis prevenciaSi varfarins ufro meti sargebeli hqon<strong>da</strong>, vidre aspirins. Tumca,<br />
varfariniT gamowveuli didi sisxldenis riski gacilebiT maRali iyo aspirinTan<br />
Se<strong>da</strong>rebiT.<br />
es rekomen<strong>da</strong>ciebi exeba pacientebSi guliscemis sixSiris kontrols qronikuli<br />
antikoagulaciis meSveobiT <strong>da</strong> qronikuli antikoagulaciis mizniT saTanado doziT<br />
varfarinis gamoyenebas, Tu insultis riski ar aris <strong>da</strong>bali, an varfarinis gamoyenebas<br />
ukuCveneba aqvs. pulsis kontrolisaTvis rekomendebulia atenololis, metoprololis,<br />
diltiazemis an verapamilis gamoyeneba. ga<strong>da</strong>udebeli kardioversia SeiZleba miRweul<br />
iqnas pir<strong>da</strong>piri an farmakologiuri konversiiT. im pacientebSi, romlebic eleqtrul<br />
kardioversias gadian, mizanSewonilia transezofaguli eqokardiografia<br />
intrakardialuri Trombis arsebobis gamosaricxad.<br />
periferiuli arteriuli <strong>da</strong>avadebisa (pad) <strong>da</strong> diabetis mqone pacientebis mkurnalobis<br />
gaidlainebi<br />
amerikis diabetis asociaciam gamosca pirveli SeTanxmebuli gancxadeba periferiuli<br />
arteriuli <strong>da</strong>avadebisa (pad) <strong>da</strong> diabetis mqone pacientebis mkurnalobis Sesaxeb, rac<br />
<strong>da</strong>ibeW<strong>da</strong> Jurnalis `<strong>da</strong>iabetis qear” 2003 w. dekembris nomerSi.<br />
axali gaidlainebi rekomen<strong>da</strong>cias uweven 50 welze maRali asakis yvela diabetis mqone<br />
pacientSi wviv-mxris indeqsiT skriningis Catarebas.<br />
50 wels zemoT myofi diabetis mqone pacientebis <strong>da</strong>axloebiT erT mesameds savaraudod<br />
aqvs periferiuli arteriuli <strong>da</strong>avadeba. mis <strong>da</strong>udgenlobas SesaZloa mohyves iseTi<br />
uaryofiTi Sedegebi, rogoric aris qve<strong>da</strong> kidurebis amputacia <strong>da</strong> miokardiumis infarqtis<br />
an insultis ganviTarebis xuTwliani riskis zr<strong>da</strong>, sikvdilianobis 33%-iani maCvenebliT.<br />
im pacientebSi, romlebSic ver xdeba periferiuli arteriuli <strong>da</strong>avadebis diagnozis<br />
<strong>da</strong>sma <strong>da</strong> Sesabamisad <strong>mkurnaloba</strong>c usargebloa, paneli rekomen<strong>da</strong>cias uwevs periferiuli<br />
arteriuli <strong>da</strong>avadebis skriningis Catarebas 50 welze meti asakis yvela pacientSi <strong>da</strong><br />
agreTve diabetis mqone 50 wlamde asakis pacientebSic, Tu maT sxva risk-faqtorebi<br />
gaaCniaT (mag. sigaretis moweva, hipertenzia, hiperqolesterinemia <strong>da</strong> diabetis 10 welze<br />
meti xnis anamnezi).<br />
60
miuxe<strong>da</strong>vad imisa, rom periferiuli arteriuli <strong>da</strong>avadeba xSirad simptomebis gareSe<br />
mimdinareobs, <strong>da</strong>maxasiaTebel simptomebs miekuTvneba: fexebis Sesieba siarulis dros,<br />
rasac <strong>da</strong>svenebul mdgomareobaSi adgili ara aqvs, agreTve terfebsa <strong>da</strong> fexebze<br />
Wrilobebisa <strong>da</strong> inficirebuli adgilebis rTuli Sexorceba.<br />
panelis mier SemoTavazebuli mkurnalobis strategia moicavs kardiovaskuluri riskfaqtorebis<br />
agresul marTvas <strong>da</strong> periferiuli arteriuli <strong>da</strong>avadebis simptomebis<br />
<strong>mkurnaloba</strong>s. yvela diabetis mqone pacientSi risk-faqtorebis Semcireba un<strong>da</strong> moxdes<br />
mowevis SewyvetiT, antiTrombolizuri TerapiiT, sisxlSi glukozis (A 1C ) Semcvelobis 7%-<br />
ze, sisxlis wnevis 130/80 mm vwy-ze <strong>da</strong> <strong>da</strong>bali simkvrivis lipoproteinebis qolesterinis<br />
100 mg/dl-ze qvemoT <strong>da</strong>yvaniT. periferiuli arteriuli <strong>da</strong>avadebis simptomebis <strong>mkurnaloba</strong><br />
moicavs varjiSs, medikamentur Terapias <strong>da</strong> revaskularizacias.<br />
jan<strong>da</strong>cvis msoflio organizaciam gamosca gaidlainebi milionobiT dolaris<br />
Rirebulebis mcenareuli medikamentebis usafrTxoebisa <strong>da</strong> efeqturobis Sesaxeb, sa<strong>da</strong>c<br />
aRniSnulia, rom zogierTi balaxovani produqti SesaZloa Seicavdes toqsikur<br />
nivTierebebs. gaidlainebi gansazRvraven ama Tu im mizniT, magaliTad wonis <strong>da</strong>saklebad<br />
gamoyenebuli samkurnalo mcenareebis zrdisa <strong>da</strong> moyvanis saukeTeso teqnologias, agreTve<br />
- ama Tu im mcenareuli medikamentis Semadgenlobis zustad miTiTebis aucileblobas.<br />
gaerTianebuli erebis organizaciis saagentos Tanaxmad, balaxovani mcenareebi 60<br />
miliardi Rirebulebis Semosavals iZlevian wliurad, Tumca samkurnalo mcenareebis<br />
regulirebas bazarze mxolod CineTi, iaponia <strong>da</strong> evrokavSiri axerxeben. “gaidlaini ar<br />
aris mimarTuli konkretulad romelime qveynisadmi, igi sxva<strong>da</strong>sxva qveynebs sTavazobs<br />
bazarze samkurnalo medikamentebis regulirebis/mowesrigebis sqemas”, ganacxa<strong>da</strong><br />
jan<strong>da</strong>cvis msoflio organizaciis esenciuri (ZiriTadi) wamlebisa <strong>da</strong> medikamentebis<br />
departamentis moqmedma direqtorma, hans hogerzeilma (Hans Hogerzeil) axali ambebis<br />
brifingze.<br />
aSS sakvebisa <strong>da</strong> wamlis administraciam gasul dekembers momxmareblebi gaafrTxila<br />
efedras Semcveli kvebiTi <strong>da</strong>matebebis usafrTxoebis Sesaxeb. adrenalinis msgavs<br />
stimulators, romelic wonaSi <strong>da</strong>saklebad <strong>da</strong> sportuli aqtivobis gazrdisaTvis<br />
gamoiyeneba, SesaZloa hqondes saxifaTo kardialuri gverdiTi efeqtebi.<br />
afrikaSi mosaxleobis 80% pirveladi samedicino <strong>da</strong>xmarebis dros tradiciul<br />
mcenareul wamlebs iyenebs. CineTSi wamlis moxmarebis 50% balaxovan mcenareebze modis.<br />
jan<strong>da</strong>cvis msoflio organizaciis Tanaxmad, evropaSi, CrdiloeT amerikasa <strong>da</strong> sxva<br />
industriul qveynebSi mosaxleobis 50%-ze mets erTxel mainc aqvs miRebuli <strong>da</strong>matebiTi<br />
an alternatiuli medicina.<br />
“amJamad CineTi<strong>da</strong>n, indoeTi<strong>da</strong>n <strong>da</strong> pakistani<strong>da</strong>n usazRvrod didi raodenobiT xdeba<br />
samkurnalo mcenareebis eqsporti sxva<strong>da</strong>sxva qveynebSi. vinmem un<strong>da</strong> <strong>da</strong>areguliros maTi<br />
usafrTxoeba mainc”, ganacxa<strong>da</strong> hogerzeilma.<br />
Rheumatology Briefing for 2003: A Look at the Year Behind and the Year Ahead<br />
Online journal Medscape asked its Editorial Advisory Board member Robert I. Fox, MD, PhD, to present what he<br />
thought were the most important developments in rheumatology in 2003, and what 2004 might bring.<br />
In recent years, investigators have been blessed with monumental breakthroughs in therapy such as tumor necrosis<br />
factor (TNF) inhibitors that were unexpectedly successful and brought new high levels of expectation for acceptable<br />
therapeutic response of rheumatoid arthritis patients. The mechanisms responsibility for TNF benefit have been<br />
unraveled to yield a family of new receptors and therapeutic targets. Also, the limitations of TNF therapy in some<br />
rheumatoid arthritis patients and the relatively less dramatic benefit in other diseases, such as systemic lupus<br />
61
erythematosus and Sjögren's syndrome, have led to the search for additional pathways that may yield to therapeutic<br />
intervention.<br />
In 2004, it is planned to study the mechanisms that underlie the interaction of innate (non-HLA-linked) and acquired<br />
(HLA-linked) immune systems. During the past year, methods such as genomic and proteomic screening have<br />
suggested that molecules related to interferon type I/II signature seem to involve the interaction of the innate and<br />
acquired immune systems. Scientists have long talked about autoimmune disease as the result of the interaction of<br />
genetic and environmental factors. Now, it appears that specific molecules and receptors that actually explain the<br />
mechanism of this interaction are being recognized. The goal of the next year will be to apply these lessons of<br />
molecular biology to the clinic in order to understand and predict researchers failures as well as their successes with<br />
anti-TNF therapy.<br />
The runner up, in a close vote, was the increased recognition of the B cell, which has languished in the shadow of the T<br />
cell during the past decade. The finding that anti-B-cell antibodies may have an important role not only in some<br />
rheumatoid arthritis patients but also in other diseases, such as systemic lupus erythematosus, may lead to a wider<br />
understanding of B-cell regulation.<br />
Finally, rheumatologists have the failure to form a consensus on fibromyalgia.They are faced with a real dilemma.<br />
However, the mechanisms of "sick brain" syndrome that are under intensive investigation in disorders such as multiple<br />
sclerosis or even aging have not been carefully studied by rheumatologists. Hopefully, the mechanisms of genetics and<br />
cytokines developed by neurochemists will be studied in rheumatology patients during the next year.<br />
Do medications really expire<br />
Does the expiration <strong>da</strong>te on a bottle of a medication mean anything If a bottle of Tylenol, for example, says something<br />
like "Do not use after June 1998," and it is August 2003, should you take the Tylenol Will it simply have lost its<br />
potency and do you no good<br />
In other words, are drug manufacturers being honest with us when they put an expiration <strong>da</strong>te on their medications<br />
Thomas A. M. Kramer, MD, Associate Professor of Psychiatry, University of Chicago, Chicago, Illinois, scoured the<br />
medical <strong>da</strong>tabases and general literature for the answer to his question about drug expiration labeling. And here are the<br />
simple facts:<br />
First, the expiration <strong>da</strong>te, required by law in the United States, beginning in 1979, specifies only the <strong>da</strong>te the<br />
manufacturer guarantees the full potency and safety of the drug -- it does not mean how long the drug is actually<br />
"good" or safe to use.<br />
Second, medical authorities uniformly say it is safe to take drugs past their expiration <strong>da</strong>te. Except for possibly the<br />
rarest of exceptions, you won't get hurt and you certainly won't get killed.<br />
Third, studies show that expired drugs may lose some of their potency over time, from as little as 5% or less to 50% or<br />
more. Even 10 years after the "expiration <strong>da</strong>te," most drugs have a good deal of their original potency.<br />
One of the largest studies ever conducted that supports the above points about "expired drug" labeling was done by the<br />
US 15 years ago. The results showed that about 90% of them were safe and effective as far as 15 years past their<br />
original expiration <strong>da</strong>te.<br />
The expiration <strong>da</strong>te doesn't mean, or even suggest, that the drug will stop being effective after that, nor that it will<br />
become harmful. "Manufacturers put expiration <strong>da</strong>tes on for marketing, rather than scientific, reasons," said Mr.<br />
Flaherty, a pharmacist at the FDA. "It's not profitable for them to have products on a shelf for 10 years. They want<br />
turnover."<br />
Aspirin use may reduce the risk of prostate cancer, according to the results of a meta-analysis published in the January<br />
12th issue of the British Journal of Cancer.<br />
62
Prostate cancer is the most commonly diagnosed cancer in the United States and Cana<strong>da</strong>, "and is second only to lung<br />
cancer in terms of number of deaths it causes," Dr. Salaheddin Mahmud said. "So it is very unfortunate that at the<br />
moment we do not know of any modifiable risk factors for the development of this disease."<br />
Because none of the individual trials published on nonsteroi<strong>da</strong>l anti-inflammatory drug (NSAID) use and the risk of<br />
prostate cancer reached conclusive results, Dr. Mahmud and colleagues conducted a systematic review and metaanalysis<br />
of 12 reports to examine the strength and consistency of the link between NSAID use and prostate cancer.<br />
The use of aspirin was associated with a 30% reduction in the risk of advanced prostate cancer and a 10% reduction in<br />
total prostate cancer risk, the report indicates. The study reported a strong inverse association between aspirin use and<br />
prostate cancer risk, but only among participants that had taken aspirin for at least 4 years.<br />
"NSAIDs (and aspirin in particular) appear to offer some protective effect against prostate cancer both in laboratory<br />
studies and in observational studies in humans," Dr. Mahmud said. "It is too early to recommend regular use of aspirin<br />
for prostate cancer prevention, but the time is right for prospective trials."<br />
A panel of neurologists presenting <strong>da</strong>ta on transient ischemic attacks (TIAs) asserted that the diagnosis is misleading<br />
and can lead to the mismanagement of patients. These patients should all be considered stroke patients, they agreed.<br />
Dr. S. Claiborne Johnston of the University of California at San Francisco told attendees of the American Stroke<br />
Association's 29th International Stroke Conference that 24-hour hospitalization of TIA patients is cost-effective, since<br />
the risk of stroke during that time period is so high in these patients.<br />
The UCSF team analyzed the incremental cost of care for 24 hours of hospitalization of TIA patients evaluated in the<br />
emergency departments of 11 San Francisco hospitals. They found that if patients were admitted, a new stroke could be<br />
identified within the first hour of onset and they could receive thrombolysis early in the therapeutic window. The result<br />
would be a minimization of sequelae and a shorter length of stay than patients sent home after resolution of TIA<br />
symptoms.<br />
"It makes no sense to separate TIA from stroke," Dr. Mielke asserted. "TIAs and strokes are both accidents in the<br />
progression of the same disease." Drs. A<strong>da</strong>ms and Johnston concurred. All three believe TIA is misleading as a<br />
diagnosis. Patients and many clinicians may be lulled into a sense of complacency when TIA symptoms disappear, the<br />
panelists said. "In fact, TIA patients have an increased risk of deterioration and poor recovery with a stroke than stroke<br />
patients," Dr. Johnston told Reuters Health.<br />
The American Heart Association (AHA) has up<strong>da</strong>ted guidelines for cardiovascular disease (CVD) prevention in<br />
women. The last guidelines were issued in 1999, and this up<strong>da</strong>te, published in the Feb. 10 issue of Circulation,<br />
emphasizes an individualized approach based on cardiovascular risk. "For the first time we are giving clarity about how<br />
much we know and how much we don't know," Lori Mosca, MD, writing group chair, says in a news release. "The<br />
concept of CVD as a 'have -or-have-not' condition has been replaced with the idea that CVD develops over time and<br />
every woman is somewhere on the continuum."<br />
After reviewing the highest-quality evidence from all the available research related to CVD prevention, the panel<br />
concluded that a stan<strong>da</strong>rdized scoring method developed by the Framingham Heart Study should determine the<br />
aggressiveness of treatment based on 10-year risk of myocardial infarction (MI). Low risk is defined as less than 10%,<br />
intermediate risk as 10% to 20%, and high risk as greater than 20%.<br />
For example, aspirin therapy is not recommended for low-risk women and it is recommended in all high-risk women<br />
and in those with documented cardiovascular disease. Lifestyle interventions including smoking cessation, regular<br />
physical activity, heart-healthy diet, and weight maintenance are man<strong>da</strong>ted in all women to reduce existing CVD and to<br />
help prevent major risk factors from developing.<br />
Recommen<strong>da</strong>tions for all high-risk women include angiotensin-converting enzyme (ACE) inhibitors, beta-blockers,<br />
and cholesterol-lowering drugs, preferably statins, even in women with low-density lipoprotein (LDL) cholesterol<br />
63
levels below 100 mg/dL. Although routine statin therapy was not previously recommended in these women, recent<br />
studies have shown a benefit in this subgroup. Niacin and fibrates may be helpful in selected cases.<br />
For stroke prevention, warfarin is recommended in women with atrial fibrillation at intermediate or high risk for<br />
embolic stroke. Aspirin may be substituted in women who cannot take warfarin, or who are at low risk of stroke. When<br />
blood pressure is greater than or equal to 140/90 mm Hg, antihypertensive agents including diuretics are indicated to<br />
maintain blood pressure at less than 130/80 mm Hg. In women with diabetes, blood sugar should be controlled to<br />
achieve near-normal glycated hemoglobin levels (less than 0.7%). Women with cardiovascular disease should be<br />
evaluated for depression and treated appropriately.<br />
Finally, interventions which are either not useful or even harmful, include hormone therapy, antioxi<strong>da</strong>nt supplements,<br />
and aspirin therapy in low-risk women. However, supplementation with omega-3 fatty acids and folic acid, in addition<br />
to a heart-healthy diet, may be considered in some high-risk women.<br />
A joint commission of the American College of Physicians and the American Academy of Family Physicians has<br />
issued six recommen<strong>da</strong>tions for internists and family physicians to manage patients with atrial fibrillation (AF). The<br />
new guidelines appear in the Dec. 16 issue of the Annals of Internal Medicine.<br />
"The generally accepted practice has been to do everything we can to get patients back into sinus rhythm and to try to<br />
keep them there," panel cochair Michael LeFevre, MD, says in a news release. "The best available research showed<br />
that the preferred approach for most patients with AF should be to focus on control of heart rate and stroke prevention<br />
with blood thinners, rather than attempt to restore sinus rhythm. Controlling rhythm was not better than controlling rate<br />
in reducing complications and death, and the side effects of medication to keep patients in normal rhythm may be<br />
greater than the benefits."<br />
Recent trial results supported similar outcomes with strategies for controlling ventricular rate compared with strategies<br />
for restoring sinus rhythm. Compared with placebo, evidence for stroke prevention was strong for warfarin and<br />
suggestive for aspirin. However, evidence of increased risk for major bleeding was suggestive for warfarin and<br />
inconclusive for aspirin.<br />
These recommen<strong>da</strong>tions are for rate control with chronic anticoagulation for most patients, and for use of adjusteddose<br />
warfarin for chronic anticoagulation unless stroke risk is low or there are contraindications to warfarin use. Drugs<br />
recommended for rate control are atenolol, metoprolol, diltiazem, or verapamil. Acute cardioversion may be achieved<br />
with either direct-current or pharmacologic conversion. For patients undergoing cardioversion, appropriate options<br />
include transesophageal echocardiography followed by early acute cardioversion (in the absence of intracardiac<br />
thrombus).<br />
The American Diabetes Association (ADA) has issued the first consensus statement for the care of patients with<br />
peripheral arterial disease (PAD) and diabetes, published in the December issue of Diabetes Care. The new guidelines<br />
recommend that all diabetic patients older than 50 years be screened with an ankle -brachial index (ABI).<br />
Approximately one third of diabetic patients older than 50 years are thought to have PAD. Failing to detect PAD can<br />
have direct consequences, including lower limb amputations and increased five-year risk of myocardial infarction (MI)<br />
or stroke, with a mortality rate of about 33%.<br />
Because of the poor cardiovascular and functional outcomes associated with unrecognized PAD, the consensus panel<br />
recommends screening for PAD in all diabetic patients older than 50 years, and considering screening for diabetic<br />
patients younger than 50 years if they have other risk factors such as smoking, hypertension, hypercholesterolemia, or<br />
history of diabetes for more than 10 years. Although PAD is often asymptomatic, characteristic symptoms include<br />
fatigue in the legs while walking that disappears at rest, or poor healing of sores or infections on the feet or legs.<br />
The treatment strategy recommended by the consensus panel includes aggressive management of cardiovascular risk<br />
factors and treatment of PAD symptoms. Risk factor reduction for all diabetic patients should include smoking<br />
cessation, antiplatelet therapy, reduction of blood glucose A 1C to less than 7%, and lowering blood pressure below<br />
64
130/80 mm Hg and low-density lipoprotein (LDL) cholesterol below 100 mg/dL. For PAD symptoms, treatment<br />
options include exercise rehabilitation, drug therapy, and revascularization.<br />
The World Health Organization issued guidelines for ensuring the safety and efficacy of the multi-billion dollar herbal<br />
medicines market amid reports that some products are tainted with toxic substances. The guidelines lay out the best<br />
techniques for growing and harvesting medicinal plants used for various ailments or weight loss, as well as the clear<br />
labelling of the contents of any product.<br />
Herbal medicines represent an estimated $60 billion a year global market, some 20 percent of the overall drug market,<br />
according to the U.N. agency. Yet only China, Japan and the European Union have regulations for medicinal plants. "It<br />
is not a binding guideline for any country, but it is a model or sort of checklist which they can use to make their own<br />
national regulations," Hans Hogerzeil, acting director of WHO's essential drugs and medicines department, told a news<br />
briefing.<br />
The U.S. Food and Drug Administration last December issued a consumer alert on the safety of dietary supplements<br />
containing ephedra. The adrenaline-like stimulant, used for weight loss or to boost sports performance, can have<br />
<strong>da</strong>ngerous cardiac effects.<br />
In Africa, up to 80 percent of the population depends on traditional medicine for primary health care. In China, herbal<br />
preparations account for up to 50 percent of total consumption. In Europe, North America and other industrialised<br />
areas, more than 50 percent report using complementary or alternative medicine at least once, according to WHO.<br />
"There is also an enormous industry now where huge amounts of leaves and traditional medicines are being shipped<br />
from various exporting countries -- China, India, Pakistan -- to many other countries. Somebody has to regulate that, at<br />
least their safety," Hogerzeil said.<br />
65
iumori samedicino Temaze<br />
• mamakaci ekiTxeba eqims, Tu SeiZleba, rom man 100 wlamde icocxlos.<br />
eqimma ramdenime kiTxva <strong>da</strong>usva:<br />
“Tu eweviT an Tu svamT~<br />
~ara, arasodes ar mqonia eg mavne Cvevebi.~<br />
`Tu yomarobT, manqanas Tu atarebT giJiviT, an qalebi Tu gitacebT~ `arcerTi<br />
araa Cemi hobi~.<br />
`qristiani xarT an romelime sxva religiis mimdevari <strong>da</strong> morwmune~ `ara,<br />
arafris rwmena ar maqvs.~<br />
eqimma Tavi moiqeqa <strong>da</strong> pacients hkiTxa: `ra magis pasuxia, magram 100 wlamde<br />
sicocxle risTvis gWirdebaT~<br />
• `eqimo, un<strong>da</strong> <strong>da</strong>mexmaroT! raRac Zalian ficxi var. xalxTan urTierTobisas<br />
nerviuli vxdebi...~<br />
`kargiT, momiyeviT Tqveni problemebis Sesaxeb.~<br />
`am wuTSi aba ra giTxari, Se <strong>da</strong>mpalo idioto!!~<br />
• saerTaSoriso konferenciaze amerikeli, ingliseli <strong>da</strong> rusi eqimebi<br />
msjeloben <strong>da</strong>avadebaTa mkurnalobisas warumateblobis SemTxvevebze:<br />
`ara, aRar SemiZlia! mkurnalob avadmyofs kibos winaaRmdeg, mkurnalob <strong>da</strong><br />
bolos... igi Sids-iT kvdeba!~ – ambobs amerikeli.<br />
`mesmis rasac gulisxmobT – urTavs ingliseli – CvenTanac egre xdeba: ggonia<br />
yviTeli cxelebaa, aZlevs yvelafers rac saWiroa, <strong>da</strong> bolos sikvdilis mere<br />
irkveva, rom malaria iyo...~ - umatebs ingliseli.<br />
`Cven ki eg problemebi ar gvawuxebs~ – ganacxa<strong>da</strong> rusma eqimma – `pacienti zustad<br />
imiT kvdeba, ris gamoc vmkurnalobT!~.<br />
66
A man asked his doctor if he thought he'd live to be a hundred. The doctor asked the man, "Do you smoke or<br />
drink"<br />
"No," he replied, "I've never done either."<br />
"Do you gamble, drive fast cars, and fool around with women" inquired the doctor.<br />
"No, I've never done any of those things either."<br />
"Are you a Christian or some kind of a religious person"<br />
"No, I don't believe in anything."<br />
"Well then," said the doctor, "what do you want to live to be a hundred for"<br />
Patient: Doctor, you must help me. I'm under such a lot of stress. I keep losing my temper with people.<br />
Doctor: Tell me about your problem.<br />
Patient: I just did, you stupid bastard!<br />
At an international conference, an American, a Brit, and a Russian were discussing the shortcomings of their<br />
diagnoses.<br />
"I can't stand it some time. We treat people for cancer, and then they die of AIDS".<br />
"I know what you mean." said the Brit. "We treat them for yellow fever, and it turns out they had malaria.<br />
Then, of course, they die".<br />
"That is not a problem in our country" said the Russian doctor. "When we treat people for a disease, they die<br />
of *that* disease."<br />
67
sasargeblo veb-gverdebi Temaze hematologia<br />
http://www.hematology.org/<br />
hematologiis amerikuli sazogadoebis vebgverdi.<br />
http://www.aspho.org/<br />
bavSvTa hematologiis/onkologiis amerikuli sazogadoebis vebgverdi<br />
http://www.bloodmed.com/home/<br />
Seicavs masalas hematologiis sxva<strong>da</strong>sxva sakiTxze. saWiroa registracia. SezRuduli<br />
droiT SesaZlebelia ufasod sargebloba.<br />
http://www.geocities.com/HotSprings/2255/blood.html<br />
Seicavs bmulebis or jgufs: hematologiuri saswavlo teqstebi (anemia, transfuzuri<br />
Terapia, mieloproliferaciuli <strong>da</strong>rRvevebi, hemostazi, Trombozi <strong>da</strong> a.S.) <strong>da</strong> klinikuri<br />
SemTxvevebi.<br />
http://www.mic.ki.se/Diseases/C15.html<br />
karolinskas institutis (SvedeTi) mier momzadebuli gverdi, romelic Seicavs<br />
mravalricxovan bmuls sxva<strong>da</strong>sxva hematologiur <strong>da</strong>avadebaze.<br />
http://www.labexplorer.com/hematology.htm<br />
warmodgenilia bmulebi saswavlo teqstebsa <strong>da</strong> klinikur SemTxvevebze, agreTve<br />
sxva<strong>da</strong>sxva qveynis hematologiis sazogadoeba-organizaciebze, am <strong>da</strong>rgSi wamyvan<br />
Jurnalebze.<br />
http://www.bloodline.net/links<br />
mocemulia informacia pacientTaTvis, konferenciebis kalen<strong>da</strong>ri, bmulebi klinikur<br />
SemTxvevebis aRwerasa <strong>da</strong> samedicino publikaciebze, hematologiis sazogadoebaorganizaciebsa<br />
<strong>da</strong> sauniversiteto klinikebis vebgverdebze, agreTve grantebis<br />
programebze.<br />
http ://drcobez.narod.ru/gema1.htm<br />
leqciebis kursi bavSvTa hematologiaSi rusul enaze.<br />
http://www.gfmer.ch/Medical_journals/Hematology.htm#Guidelines<br />
samedicino Jurnalebi (bevri ufaso), wignebi <strong>da</strong> publikaciebi, gaidlainebi <strong>da</strong> klinikuri<br />
rekomen<strong>da</strong>ciebi, monacemTa baza, atlasebi, organizaciebi.<br />
http://freebooks4doctors.com/fb/spec7.htm<br />
internetSi moTavsebuli hematologiis saxelmZRvaneloebi inglisur <strong>da</strong> frangul enebze.<br />
68
saqarTvelos jan<strong>da</strong>cvis veb-gverdis saaplikacio<br />
forma<br />
erovnuli sainformacio<br />
saswavlo centri (essc)<br />
iv. javaxiSvilis q. #51<br />
tel 94 13 88<br />
faqsi 94 13 91<br />
el-fosta: dmeskhi@nilc.org.ge<br />
interneti: www.nilc.org.ge<br />
www.health.net.ge<br />
internetis veb-gverdis monacemebis forma organizaciebisaTvis<br />
(SeiZleba mowodebul iqnas rogorc qarTul, aseve - inglisur enebze)<br />
1. organizaciis <strong>da</strong>saxeleba:<br />
sruli <strong>da</strong>saxeleba <strong>da</strong> abreviatura (rogorc<br />
qarTul, aseve - inglisur enebze)<br />
2. organizaciis misamarTi:<br />
qalaqi, kodi, quCa, nomeri, oTaxebis nomeri (rogorc qarTul, aseve - inglisur enebze)<br />
3. telefoni #1:<br />
4. telefoni #2:<br />
5. faqsi:<br />
+995-32-xx xx xx<br />
+995-32-xx xx xx<br />
+995-32-xx xx xx<br />
6. el-fosta:<br />
7. veg-gverdi:<br />
arsebuli URL an<strong>da</strong> sasurveli abreviatura inglisurad<br />
8. organizaciis struqtura:<br />
1. ganyofilebebis CamonaTvali<br />
2. TanamSromelTa raodenoba<br />
3. SeiZleba iyos organizaciuli gegma<br />
9. organizaciis xel-li piris mokle biografia:<br />
maqs. 300 sityva<br />
(sasurvelia qarTul <strong>da</strong> inglisur enebze)<br />
10. organizaciis miznebi:<br />
mokle aRweriloba (maqs 100 sityva)<br />
69
11. organizaciis proeqtebi:<br />
mimdinare:<br />
CamonaTvali <strong>da</strong> TiToeul proeqtze:<br />
1. <strong>da</strong>saxeleba<br />
2. mokle aRweriloba (<strong>da</strong>axlebiT 100 sityva<br />
TiToeul proeqtze)<br />
3. <strong>da</strong>finansebis wyaro<br />
4. ganxorcielebis periodi<br />
5. regioni, sa<strong>da</strong>c mimdinareob<strong>da</strong><br />
6. beneficiarTa raodenoba<br />
7. proeqtSi monawileTa raodenoba<br />
8. biujeti<br />
Sesrulebuli:<br />
CamonaTvali <strong>da</strong> TiToeul proeqtze igive tipis<br />
informacia<br />
12. organizaciis gegmebi:<br />
mokle informacia, an<strong>da</strong> Tu proeqtis zusti<br />
monaxazi arsebobs, maSin imave formiT, rac<br />
mimdinare proeqtebzea miTiTebuli:<br />
13. organizaciis mier sxva iuridiul Tu fizikur pirebTan TanamSromlobis<br />
sfero:<br />
gasaRebi sityvebi: Keywords<br />
organizacia sTavazobs: (eqspertiza /servisi)<br />
organizacias sWirdeba: (eqspertiza /servisi)<br />
14. organizaciis partniorebi:<br />
miuTiTeT is organizaciebi, romelTanac<br />
gin<strong>da</strong>T, rom Tq veni gverdi<strong>da</strong>n iyos bmuli, mag.<br />
jan<strong>da</strong>cvis saministros romelime departamenti,<br />
romelime saerTaSoriso organizacia (mag.<br />
<strong>da</strong>mfinansebeli) <strong>da</strong> a.S.<br />
15. organizaciis simbolo (logo):<br />
.jpg, .gif an<strong>da</strong> romelime sxva grafikuli faili,<br />
sasurvelia mcire zomis (ara Corel)<br />
16. sakontaqto piris monacemebi (araa aucilebeli direqtoris, umjobesia - teqnikuri<br />
personalis monacemebi)<br />
telefoni<br />
faqsi<br />
el-fosta<br />
mobiluri telefoni<br />
70
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