sarCevi CONTENT

2004, Vol. 3, #1(6)sarCevidasabuTebuli [faqtebze dafuZnebuli] medicina:klinikuri mtkicebulebanigripis antivirusuli mkurnalobis efeqtebi mozrdilebSidiareis mkurnaloba mozrdilebSimwvave gastroenteritis mkurnaloba bavSvebSimoamzades z. kirtavam da m. kobalaZemklinikuri praqtikis rekomendaciebiarastabiluri stenokardiis da ST segmentis elevaciis gareSe mimdinare miokardiumisinfarqtis mkurnaloba – evropis kardiologTa asociaciis saxelmZRvanelorekomendaciebis mixedviTmoamzades a. meliam, x. jalabaZem, z. klimiaSvilma, k. muxigulaSvilmadiagnostikuri laparaskopiis SAGES-is klinikuri praqtikis rekomendaciebimoamzada n. raWveliSvilmaklinikuri mimoxilvaSfoTvisa da depresiuli darRvevebis mkurnaloba kardiovaskularuli sistemisdaavadebis mqone pacientebSisimon devisi, peter jeqsoni, jon potokari, devid natidiseminirebuli sixlZarRvSiga Sededeba (dsS) - Zveli daavadeba, axali imedebiC.h. toh, m. denisiefedras miRebis fonze ganviTarebuli koronaruli ganSreveba da Trombozis. sola, t. helmi, a. kaWaravauwyveti samedicino ganaTlebauwyveti samedicino ganaTlebis saWiroebaTa Sefasebis aucileblobaj. r. normani, s. i. Senoni, m. l. merinidargis mimoxilvabioinformatikamoamzada nino demetraSvilmakonferenciebiamerikis telemedicinis sazogadoebis 2004 wlis konferenciazviad kirtavaCanarTi – internetis samedicino daijesti #1-2 (95-96), 2004iumori samedicino Temazeinformacia – saqarTvelos jandacvis veb-gverdis saaplikacio formaCONTENTEvidence Based Medicine1

InfluenzaDiarrhea in AdultsAccute Gastroenteritis in Children(based on Clinical Evidence, issue 9) – Z. Kirtava, M. KobaladzeClinical Practice GuidelinesTreatment of Non-Stabile Angina and Miocardial Infarction without ST Elevation - (EuropeanCardiology Association Guidelines)translated by A. Melia, Kh. Jalabadze, Z. Klimiashvili, K. MukhigulashviliSAGES Guidelines for Diagnostic Laparoscopytranslated by N. RachvelishviliClinical ReviewsTreatment of Anxiety and Depressive Disorders in patients with Cardiovascular DiseaseS.J.C. Davies, P.R. Jackson, J. Potokar, D.J. NuttDisseminated Intravascular Coagulation – Old Disease, New HopeC.H. Toh, M. DennisCoronary Dissection and Thrombosis After Ingestion of EphedraS. Sola, T. Helmy, A. KacharavaContinuous Medical Education DebatesThe Need for Need Assesment in Continuing Medical EducationG.R Norman, S.I. Shannon, M.L. MarrinSpeciality ReviewBioinformaticsN. DemetrashviliConferencesAmerican Telemedicine Association 9 th Annual Meeting, Tampa, FL, May 2-5, 2004Z. KirtavaMedical HumorInternet Medical Digest - #1-2 (95-96), 2004InformationApplication for for the Georgian Health System web-page (www.health.net.ge)dasabuTebuli medicinagripi klinikuri mtkicebulebaniInfluenza – What are the Effects of Antiviral Treatment of Influenza in adults?Clinical Evidence, BMJ Publishing Group2003 w. (IX gamoSveba)moamzades m. kobalaZem, z. kirtavam2

ganmartebagripi gamowveulia gripis virusiT inficirebis Sedegad. garTulebebis gareSemimdinare gripi xasiaTdeba temperaturis uecari matebiT, SemcivnebiT, mSralixveliT, mialgiiT, Tavis tkiviliT, cxviridan gamonadeniT yelis tkiviliT damoTenTilobiT. gripis diagnostireba Cveulebriv klinikuri niSnebissafuZvelze xdeba. gripi zogierT adamianSi usimptomod mimdinareobs. sxvapaTogenebiT inficirebul adamianebs SesaZloa gripis msgavsi simptomebiganuviTardeT. infeqciis klinikuri gamovlineba adamianTa 40-85%-Si aRiniSneba,es damokidebulia asakze da virusis mimarT adre SeZenil imunitetze.verificireba xdeba virusuli kulturis dadgeniT, imunofluorescenciiT,ELISA meTodiT an nazofaringealuri, nazaluri da yelis nacxis swrafidiagnostikuri testirebiT, anda Sratis serologiuri testirebiT. zogierTiswrafi testi adgens mxolod A tipis grips, zogierTi – A da B tipis grips daganasxvavebs maT erTmaneTisagan, xolo zogierTi ki adgens, magram verganasxvavebs A da B tipis grips erTmaneTisagan.SemTxvevebi/gavrcelebadedamiwis CrdiloeT naxevarsferos zomieri klimatis mqone qveynebSi, gripisgavrceleba Cveulebriv piks aRwevs dekembris bolodan martis dasawyisamde,maSin roca, samxreT naxevarsferos zomier qveynebSi gripi piks mais-seqtemberSiaRwevs. tropikul qveynebSi gripi weliwadis nebismier dros SeiZlebaganviTardes. gripis SemTxvevebis wliuri maCvenebeli yovel wels icvleba danawilobriv damokidebulia mosaxleobis imunitetze gripis mocirkulirevirusebis mimarT. aSS-Si Catarebuli erTi lokaluri kvlevis Sedegaddadginda, rom gripis Sebrunebas simptomebis TanxlebiT an maT gareSe wliuradadgili aqvs adamianTa 10-20%-Si wliurad, xolo inficirebis yvelaze maRalimaCvenebeli 20 wlamde asakis adamianebSi aRiniSneba. gavrceleba yvelaze didiasaswavlo dawesebulebebsa da xalxiT gadaWedil SenobebSi.etiologia/ risk-faqtorebigripis virusebi adamianidan adamianze ZiriTadad haer-wveTovani gziT gadadis,kerZod, wveTebi gamoifrqveva daceminebis, xvelebis da laparakis dros.prognozigripis sainkubacio periodi 1–4 dRea da inficirebuli adamiani daavadebisgadamdebia simptomebis gamomJRavnebamde erTi dRiT adre da simptomebisgamomJRavnebidan – 5 dRis ganmavlobaSi. garTulebis gareSe mimdinare gripisniSnebi da simptomebi Cveulebriv erTi kviris ganmavlobaSi qreba, Tumca xvelada moTenTilobis SegrZneba SesaZloa ufro met xans gagrZeldes. garTulebebSiSedis: otiti, baqteriuli sinusiti, meoradi baqteriuli pnevmonia, ufroiSviaTad ki - virusuli pnevmonia da respiratoruli ukmarisoba. garTulebebiagreTve SesaZloa moyves Tanmxlebi daavadebebis gamwvavebas. yovelwliuradaSS-Si gripis virusiT daavadebuli 110 000-ze meti adamiani xvdeba3

saavadmyofoSi, xolo gripTan dakavSirebuli sikvdilobis maCvenebelidaaxloebiT 20 000-s udris. hospitalizaciis riski yvelaze maRalia 65 da metiasakis mqone adamianebSi, patara bavSvebSi da qronikuli daavadebebis mqoneadamianebSi. bolo periodSi aSS-Si gavrcelebuli gripis sezonuri epidemiisSedegad gamowveuli sikvdilobis 90%-ze meti 65 da ufro maRali asakis mqoneadamianebSi aRiniSna. gripis pandemiis dros, avadobisa da sikvdilobismaCvenebeli SesaZloa maRali iyos ufro axalgazrda asakis mqone adamianebSic.A tipis gripi ufro mwvaved mimdinareobs, vidre B tipis gripi.rogoria gripis antivirusuli mkurnalobis efeqtebimozrdilebSi?sasargeblo rCevebioraluri amantadini mozrdilebSi A tipis gripis adreuli mkurnalobisaTvis(simptomebis xangrZlivoba mcirdeba)erTi sistemuri mimoxilvisa da sami damatebiTi randomizebuli klinikurikvlevis Sedegebidan gamomdinare aRmoCnda, rom placebosgan gansxvavebiT,oraluri amantadini A tipis gripis simptomebis xangrZlivobas daaxloebiTerTi dRiT amcirebs. mkvlevarebma ver aRmoaCines amantadinis gverdiTi efeqtebi.amave dros, maTi azriT, sargebeli ar moyveba amantadiniT mkurnalobisdawyebas simptomebis gamomJRavnebidan 2 dReze ufro gvian.oraluri rimantadini mozrdilebSi A tipis gripis adreuli mkurnalobisaTvis(simptomebis xangrZlivoba mcirdeba)erTma sistemurma mimoxilvam cxadyo, rom placebosgan gansxvavebiT, oraluririmantadini A tipis gripis simptomebis xangrZlivobas daaxloebiT erTi dRiTamcirebs. mkvlevarebma ver aRmoaCines rimantadinis mniSvnelovani gverdiTiefeqtebi. amave dros, sargebeli ar moyveba rimantadiniT mkurnalobis dawyebassimptomebis gamomJRavnebidan 2 dReze ufro gvian.zanamiviris oraluri aerozoli mozrdilebSi A da B tipis gripis adreulimkurnalobisaTvis (simptomebis xangrZlivoba mcirdeba)erTi sistemuri mimoxilvis Sedegad aRmoCnda, rom placebosgan gansxvavebiT,zanamiviris oraluri aerozoli gripis simptomebs daaxloebiT 1 dRiTamcirebs. gverdiTi efeqtebi msgavsia zanamiviriT mkurnalobis qveS myof daplaceboze myof adamianebs Soris. mkvlevarebma aRmoaCines, rom sargebeli armoyveba zanamiviriT mkurnalobis dawyebas simptomebis gamomJRavnebidan 2 dRezeufro gvian.oraluri oseltamiviri mozrdilebSi A da B tipis gripis adreulimkurnalobisaTvis (simptomebis xangrZlivoba mcirdeba, SeuZlia gamoiwviospirRebineba)4

ori, randomizebuli kontrolirebuli kvlevis Sedegad aRmoCnda, romplacebosgan gansxvavebiT, oraluri oseltamiviri gripis simptomebsdaaxloebiT 1 dRiT amcirebs. oraluri oseltamiviri, placebosgan gansxvavebiTiwvevs pirRebinebas. mkvlevarebma aRmoaCines, rom sargebeli ar moyvebaoseltamiviriT mkurnalobis dawyebas simptomebis gamomJRavnebidan 1.5 dRezeufro gvian.efeqturoba ucnobiayvela antivirusuli preparatiT mkurnaloba (gripis seriozuli garTulebebisSemcirebisaTvis)mkvlevarebma ver aRmoaCines imis damamtkicebeli sabuTi, rom antivirusulagentebs SeswevT Zala – Seamciron gripis Sedegad ganviTarebuli seriozuligarTulebebis riski, Tumca, maT daamtkices, rom gripis imunizacia amcirebsgarTulebebisa da sikvdilobis risks gripis Sedegad ganviTarebuligarTulebebis maRali riskis mqone adamianebSi, maT Soris asakovanadamianebSic.dasabuTebuli medicinadiarea mozrdilebSiDiarrhoea in Adults – What are the Effects of Treatment?klinikuri mtkicebulebaniGuy de BruynClinical Evidence, BMJ Publishing Group2003 w. (IX gamoSveba)moamzades z. kirtavam, m. kobalaZemganmarteba5

diarea aris wyal-wyala an Txevadi ganavali, masa dRiurad 200 grams aRematebada nawlavebis moqmedebis sixSirec aseve momatebulia. es mimoxilva exebamozrdilebSi savaraudod infeqciuri diareis empiriul mkurnalobas.gavrceleba1996 wels msoflioSi diareis 4 miliardi SemTxveva dafiqsirda, ramac 2.5milioni adamianis sicocxle imsxverpla. aSS-Si, nawlavebis infeqciuridaavadebebis maCvenebeli wliurad saSualod 0.44–ia erT adamianze (1 epizodiyovel adamianSi 2.3 weliwadSi), rasac Sedegad moyveba TiToeuli pirovnebiserTi konsultacia eqimTan saSualod yovel 28 weliwadSi. did britaneTSiaxlaxans Catarebulma mosaxleobis kvlevam daadgina, rom 100 adamian-welzediareis 19 SemTxveva modis, romelTagan yoveli 3.3 SemTxveva 100 adamian-welzemTavrdeba zogadi praqtikis eqimTan vizitiT. mogzaurTa diareis epidemiologia(im pirebSi, romlebmac gadakveTes saxelmwifo sazRvari) ar aris kargadSeswavlili. diareis SemTxvevaTa sixSire ufro maRalia ganviTarebad qveynebSimogzaur adamianebSi, magram misi sixSire mniSvnelovnad meryeobsadgilmdebareobisa da mogzaurobis sezonis mixedviT.etiologia/riskfaqtorebidiareis gamomwvevi mizezi damokidebulia geografiul mdebareobaze, sakvebishigienur standartebze, sanitarul mdgomareobaze, wylis momaragebaze dasezonze. ganviTarebul qveynebSi mcxovreb adamianebSi, sporadul diareasCveulebriv iwvevs Campylobacter, Salmonella, Shigella, Escherichia coli, Yersinia, Protozoa davirusebi. diareiT daavadebul adamianTa naxevarze metSi vercerTi paTogenisidentificireba ver xdeba. Sindabrunebul mgzavrTa daaxloebiT 50%-Si diareagamowveulia iseTi baqteriebiT, rogoricaa: enterotoqsigenuri E coli, Salmonella,Shigella, Campylobacter, Vibrio, enteroadheziuri E coli, Yersinia da Aeromona.prognoziganviTarebad qveynebSi, diareiT gamowveuli sikvdiloba 5 wlamde asakisbavSvebSi sikvdilobis wamyvani mizezia. mxolod ramodenime kvlevaaCatarebuli imis dasadgenad, Tu romeli faqtorebi ganapirobeben mozrdilebSidiareis cud gamosavals. ganviTarebul qveynebSi, mozrdilebSi infeqciuridiareiT gamowveuli sikvdilobis SemTxvevebi iSviaTia, Tumca SesaZloaganviTardes seriozuli garTulebebi, maT Soris mwvave dehidratacia daTirkmlis ukmarisoba da amis Sedegad saWiro gaxdes pacientis saavadmyofoSimoTavseba. asakovani adamianebi sikvdilobis momatebuli riskis winaSe dganan.rogoria diareis mkurnalobis efeqti?savaraudod sasargebloa:6

• aminomJavis peroraluri rehidratirebuli xsnari (standartul prx-TanSedarebiT)erTi, mcire zomis randomizebuli klinikuri kvlevis Tanaxmad aRmoCnda, romsxva standartul peroralur rehidratirebul xsnarebTan (prx) SedarebiT,aminomJava amcirebs diareis totalur zomas/raodenobas da xangrZlivobas.• brinjze damzadebuli peroraluri rehidratirebuli xsnarebi(standartul prx-Tan SedarebiT)erTi sistemuri mimoxilvis Sedegad aRmoCnda, rom brinjze damzadebuliperoraluri rehidratirebuli xsnari standartul prx-Tan SedarebiTmniSvnelovnad amcirebs 24 saaTis manZilze gamoyofili ganavlis odenobas.efeqturoba ucnobia• bikarbonatas peroraluri rehidratirebuli xsnari (standartul prx-TanSedarebiT)orma randomizebulma klinikurma kvlevam ver gamoavlina mniSvnelovanigansxvaveba diareis xangrZlivobisa da misi moculobis Semcirebis mizniTCatarebul mkurnalobaSi bikarbonatis peroraluri rehidratirebuli xsnariTda sxva standartuli peroraluri rehidratirebuli xsnarebiT. erTirandomizebuli klinikuri kvlevis Tanaxmad, bikarbonatis prx-iT mkurnalobasada qloridis prx-iT mkurnalobas Soris ar aRmoCnda mniSvnelovani gansxvavebaganavlis moculobisa da diareis xangrZlivobis Semcirebis TvalsazrisiT.• dabali osmosurobis mqone peroraluri rehidratirebuli xsnarebisami randomizebuli klinikuri kvlevis Tanaxmad, romlis drosac erTmaneTsSeadares dabali osmosurobis mqone peroraluri rehidratirebuli xsnari dastandartuli peroraluri rehidratirebuli xsnarebi, dadginda, romstandartul peroralur rehidratirebul xsnarebTan SedarebiT, dabaliosmosurobis mqone peroraluri rehidratirebuli xsnari odnav ukeTes SedegsiZleva ganavlis moculobisa da diareis xangrZlivobis SemcirebaSi.sargebeli da ziani savaraudod Tanabaria• peristaltikis damaqveiTebeli (antimotilituri) saSualebebirandomizebuli klinikuri kvlevebis Sedegad dadginda, rom placebosTanSedarebiT, loperamidis hidroqloridi da loperamidis oqsidi mniSnelovnadamcireben diareis simptomebis moxsnis dros, magram samagierod xSirad iwvevenyabzobas. peristaltikis damaqveiTebeli sxva saSualebebi ar iZleva msgavsSedegs./• TemSi ganviTarebuli diareis empiriuli antibiotikoTerapia7

andomizebuli klinikuri kvlevebis Tanaxmad aRmoCnda, rom placebosTanSedarebiT, ciprofloqsacini TemSi ganviTarebuli diareis xangrZlivobas 1-2dRiT amcirebs. kvlevebis Sedegad miRebuli iqna arasarwmuno dasabuTeba imisTaobaze, rom sxva antibiotikebi, lomefloqsacinis gamoklebiT, placebozeufro amcireben diareis xangrZlivobas. gverdiTi efeqtebi cvalebadia dadamokidebulia im wamalze, romliTac tardeba mkurnaloba.• mogzaurebSi ganviTarebuli diareis empiriuli mkurnalobaantibiotikoTerapiaerTi sistemuri mimoxilvisa da erTi damatebiTi randomizebuli klinikurikvlevis Sedegad dadginda, rom placebosTan SedarebiT, antibiotikebisempiriuli gamoyeneba mniSvnelovnad zrdis gankurnebis sixSires/gankurnebuliadamianebis raodenobas, me-3 da me-6 dRisaTvis. amave dros antibiotikoTerapiadakavSirebulia ganavalSi baqteriuli paTogenebis xangrZlivad arsebobasTanda rezistentuli Stamebis CamoyalibebasTan.dasabuTebuli medicinagastroenteriti bavSvebSiGastroenteritis in Children – What are the Effects of Treatment?klinikuri mtkicebulebaniJacqueline Dalby-Payne and Elizabeth ElliottClinical Evidence, BMJ Publishing Group2003 w. (IX gamoSveba)moamzades z. kirtavam, m. kobalaZemganmartebamwvave gastroenteriti xasiaTdeba diareis swrafi dawyebiT, rasac SeiZleba Tanaxldes gulisreva, pirRebineba, temperaturis mateba da tkivili abdominalurmidamoSi. bavSvebSi simptomebi da niSnebi SesaZloa araspecifiuri iyos. diareaganisazRvreba rogorc araformirebuli, Txevadi ganavlis xSiri gamoyofa.gavrceleba8

msoflio masStabiT, 5 wlamde asakis bavSvebSi mwvave gastroenteritisSemTxvevebi Zalze xSiria (3-5 miliardi SemTxveva wliurad). yovelwliurad,did britaneTSi, zogadi praqtikis eqimTan 5 wlamde asakis bavSvTa yoveli 1000konsultaciidan 204 exeba mwvave gastroenterits. 5 wlamde asakis yoveli 1000bavSvidan wliurad xdeba gastroenteritis mqone 7 bavSvis hospitalizacia,xolo aSS-Si ki – 13 bavSvisa. avstraliaSi, 15 wlamde asakis bavSvTahospitalizaciis 6 %-is mizezi swored gastroenteritia.etiologia/risk-faqtorebiganviTarebul qveynebSi, mwvave gastroenteriti umetesad gamowveulia virusebiT(87%), romelTagan yvelaze xSirad rotavirusi gvxvdeba. danarCen SemTxvevebsumetesad baqteriebi, kerZod; Campylobacter, Salmonella, Shigella da Escherichia coliiwveven. ganviTarebad qveynebSi baqteriuli paTogenebiT gamowveuligastroenteritis SemTxvevebi ufro xSiria, Tumca rotavirusic aseve xSirgamomwvev mizezad rCeba.prognoziCveulebriv, mwvave gastroenteriti garkveuli periodis Semdeg TviTgankurnebiTmTavrdeba, Tumca misi mkurnalobis gareSe datovebas SeuZlia dasruldesavadobiTa da sikvdiliT wylisa da eleqtrolitebis dakargvis Sedegad.yovelwliurad aziaSi, (garda CineTisa), afrikasa da laTinuri amerikisqveynebSi, 5 wlamde asakis bavSvebSi mwvave diareiT gamowveuli sikvdilobis 4milionamde SemTxveva fiqsirdeba, xolo 2 wlamde asakis bavSvebSi sikvdilobis80%-ze meti swored diareas ukavSirdeba. maRalia, ganviTarebul qveynebSidiareiT sikvdilobis SemTxvevebi iSviaTia, mainc gastroenteritis Sedegadgamowveuli dehidratacia avadmyofobis seriozul gamomwvev mizezs warmoadgensda saWiroebs droul hospitalizacias.rogoria mkurnalobis efeqti?sasargebloa:intravenuri siTxe iseTive sasargebloa, rogorc oraluri rehidratirebulixsnarebibavSvebSi Catarebuli erTi sistemuri kvlevis mimoxilvis Sedegad dadginda,rom msubuqi da zomieri diareis xangrZlivobasa da hospitalSi gatarebulidrois SemcirebaSi intravenuri siTxeebiT mkurnaloba oralurrehidratirebul xsnarebTan SedarebiT analogiurad efeqturia. mZimedehidrataciis mqone bavSvebSi Catarebuli erTi randomizebulikontrolirebuli kvlevis Tanaxmad, oralur rehidratirebul xsnarebTanSedarebiT, intravenurma xsnarebma mniSvnelovnad gazardes diareisxangrZlivoba da Tanac maTi gamoyeneba dakavSirebuli iyo ufro met gverdiTefeqtebTan.oraluri rehidratirebuli xsnarebi (iseTive efeqturia, rogorc intravenurisiTxeebi)ix. intravenuri siTxeebi zemoT.9

savaraudod sasargebloa:laqtozas arSemcveli sakvebi amcirebs diareis xangrZlivobaserTi sistemuri mimoxilvis Sedegad dadginda, rom laqtozis arSemcvelisakvebi mis Semcvel sakvebTan SedarebiT, amcirebs bavSvebSi msubuqi da mwvavexarisxis dehidrataciiT mimdinare diareis xangrZlivobas. momdevnorandomizebulma kontrolirebulma kvlevebma gansxvavebuliSedegebi miiRes.loperamidi amcirebs diareis xangrZlivobas, Tumca misi gverdiTi efeqtebiucnobiaori randomizebuli kontrolirebuli kvlevis Sedegad aRmoCnda, rom susti dasaSualo xarisxis dehidrataciiT mimdinare diareis mqone bavSvebSi,loperamidi, placebosTan SedarebiT mniSvnelovnad amcirebs diareisxangrZlivobas. xolo meore randomizebuli kontrolirebuli kvlevis Tanaxmad,diareis xangrZlivobis SemcirebaSi mniSvnelovani gansxvaveba ar aRmoCndaloperamidsa da placebos Soris. mkvlevarebma ver aRmoaCines loperamidisgverdiTi efeqtebis sakmarisi damamtkicebeli sabuTi.efeqturoba ucnobiae.w. sufTa siTxeebisa da oraluri rehidratirebuli xsnarebis Sedareba diareismkurnalobaSimwvave gastroenteritiT gamowveuli, msubuqi da saSualo simZimisdehidrataciis mqone bavSvebSi, mkvlevarebma ver aRmoaCines imis damamtkicebelisabuTi, rom e.w. `sufTa siTxeebi” (wyali, karbonatebis Semcveli sasmelebi daxilis sufTa wvenebi) ukeTesad mkurnaloben am daavadebas, vidre placebo.Treatment of Non-Stabile Angina and Miocardial Infarction without ST Elevation - (EuropeanCardiology Association Guidelines)translated by A. Melia, Kh. Jalabadze, Z. Klimiashvili, K. Mukhigulashviliin coordination with Georgian Cardiology Association (President – V. Chumburidze)Acute Coronary Syndromes represent the greatest problem for public health care in most of developedcountries. Two major groups must be distinguished among patients with Miocardial Infarction (MI): with10

ST elevation and without ST elevation. The latter group is subject to the same management as patientswith unstable angina. Patients with ST elevation do require thrombolysis or percutaneous angioplasty.Whilst patients without ST elevation are recommended to receive aspirin, low molecular heparin,clopidogrel, beta-blockers (if no contraindication) and nitrates. Risk stratification has to be based onclinical assessment, ECG and troponin level.Two different subgroups of patients without ST elevation have to be defined:1) high risk patients (with persistent or recurrent ischemia, ST depression, diabetes, troponinelevation, haemodinamic or arrhytmic instability). In case of planned angiography, patients,alongside with basic treatment, should receive GPIIb/IIIa receptor inhibitors, in case oftranscutaneal angioplasty – clopidogrel, which should be cancelled 5 days before planned aortocoronarybypass surgery, or if angiography reveals no coronary occlusion.2) Low risk patients, which include persons without recurrent ischemia, inverted/diminished T-waveor with normal ECG, with negative troponin. Troponin should be measured twice during 6-12hours, and if both tests are negative, heparin can be stopped, however – aspirin, beta-blockers.clopidogrel and nitrates should be continued. before discharge or right after it stress test should becarried out and justification of coronary angiography asssured based on that test. Finallyaggressive methods against risk-factors are extremely needed: smoking cessation, regularexercises, etc. Aspirin, clopidogrel (during 9 months), beta-blockers (if no contraindications) andstatines should be continued after discharge.klinikuri praqtikis rekomendaciebidiagnostikuri laparoskopiis klinikuri praqtikis rekomendaciebimoamzada nino raWveliSvilma,Tssu Sinagan sneulebaTa #1 kaTedraninora@nilc.org.geSesavaliG warmodgenili klinikuri praqtikis rekomendacia momzadebulia amerikisgastrointestinaluri endoskopiis qirurgebis sazogadoebis (SAGES) klinikuripraqtikis standartebis komitetis mier. igi erT-erTia im seriidan, romelSicganxilulia laparoskopiis Cvenebebi gavrcelebuli klinikuri paTologiebis dros.rekomendaciis pirveli varianti 1998 wels Seiqmna. ganvlil periodSi gamoqveyndamTeli rigi axali informaciebi, ramac gaidlainis gadaxedvis aucileblobaganapiroba. ganaxlebuli varianti Seiqmna literaturuli Ziebisa da eqspertkonsultantebisrekomendaciebis safuZvelze. Tumca unda aRiniSnos, rom kargidizainis, prospeqtuli kvlevebi am Temaze mcirericxovania, amitom upiratesobamieniWa did masalaze warmoebul kvlevebsa da aRiarebuli eqspertebis miergamoqveynebul naSromebs.Grekomendaciis ganaxlebuli varianti SAGES-ma 2002 wlis martSi gamoaqveyna. igimowonebul iqna AaSS erovnuli gaidlainebis sacavis (National Guidelines Cliringhouse -NGC) eqspertebis mier da 2004 wlis maisSi ganTavsda veb-gverdze am organizaciismoTxovnebis Sesabamisi formatiT.KKklinikuri aRwerilobaDdiagnostikuri laparoskopia warmoadgens daavadebis diagnostikis mizniTmowodebul minimalur invaziur qirurgiul manipulacias. es procedura saSualebasiZleva uSualod movaxdinoT muclis organoebis, maT Soris RviZlis zedapiris11

umetesi nawilis, naRvlis buStis, elenTis, peritoneumis, mcire menjis Rrusorganoebisa da retroperitoneumis vizualuri daTvaliereba. Llaparoskopiis drosSesaZlebelia (1,2) biofsiis warmoeba sakvlevi masalis aspiracia da kulturisaReba, agreTve laparoskopiuli ultrabgeriTi kvlevis Catareba. laparoskopiasaSualebas aZlevs qirurgs dasvas diagnozi da miiRos informacia daavadebisa TupaTologiuri procesis gavrcelebis Sesaxeb, agreTve moaxdinos abdominaluriwarmonaqmnebis diagnostika (3,4).Ddiagnostikuri laparoskopia usafrTxo da pacientebisTvis advilad gadasatanimanipulaciaa. igi tardeba zogadi anesTeziiT rogorc ambulatoriul pirobebSi,ise stacionarSi. gansakuTrebuli SemTxvevebSi daSvebulia adgilobrivi anesTeziisgamoyenebac (5).L diagnostikuri laparoskia unda awarmoos eqimma, romelsac gavlili aqvsspecialuri momzadeba, flobs laparoskopiuri teqnikis warmoebis unar-Cvevebs daSeuZlia droulad gamoicnos da umkurnalos Cveul garTulebebs. saTanadoCvenebebisas mas agreTve unda SeeZlos damatebiTi Terapiuli manipulaciebisganaxorcielebac.mTeli proceduris ganmavlobaSi pacienti mudmivi dakvirvebis qveS undaimyofebodes (6) da SesaZlebeli unda iyos dauyovnebeli reanimaciuliRonisZiebebis ganxorcieleba.Llaparoskopia unda warmoebdes sterilurixelsawyoebiT, laparoskopiuli teqnikis maRali xarisxis sterilizaciisuzrunvelyofiT. zogierT pacients, romelsac laparoskopia ambulatoriulpirobebSi Cautarda, SeiZleba sadReRamiso dakvirveba dasWirdes. gansakuTrebulSemTxvevebSi diagnostikuri laparoskopis Catareba eqimis ofisSicaa SesaZlebeli.es mxolod im SemTxvevaSia daSvebuli, Tu am proceduris ganxorcielebisasgarTulebebis ganviTareba da damatebiTi Terapiuli RonisZiebebis saWiroebapraqtikulad gamoricxulia.Cvenebebi- intraabdominaluri/retroperitonealuri warmonaqmnebi: diagnostikurilaparoskopia SeiZleba gamoyenebul iyos damiznebiTi biofsiis warmoebisTvis daintraabdominaluri simsivneebis stadiis dasadgenad (7,8). LlaparoskopiuliultrabgeriTi kvleva SeiZleba dagvexmaros sxvadaxxva warmonaqmnebis masebisidentifikaciaSi.- RviZlis daavadebebi: laparoskopia naCvenebia RviZlis ciroziT daavadebulipacientebis gamokvlevisas, rodesac standartuli biofsiiT diagnozi ver dgindebaan biofsia ver xorcieldeba (mag. RviZlis mcire zoma, didi moculobis asciti).pacientebi RviZlis daavadebebiT ufro midrekili arian sisxldenebisadmi, magramlaparaskopiis dros biofsiis adgilidan ganviTarebuli sisxldena SeiZlebakontrolirebul iyos eleqtrokoagulaciis an sxva teqnikis gamoyenebiT (9).- asciti: laparoskopia gvexmareba ucnobi etiologiis ascitis diagnostikaSi,gansakuTrebiT ki rodesac asciti meoradia da gamowveulia tuberkuloziT ankarcinomatoziT.- muclis tkivili an mwvave muceli: laparoskopia informatiulia akalkulozuriqolecistitis, Sinagani organoebis perforaciis, mwvave apendicitis,mezenterialuri iSemiis da sxva gadaudebeli qirurgiuli mdgomareobebisdiagnostikaSi, gansakuTrebiT ki mZime pacientebSi, rodesac muclis gasinjviTmiRebuli monacemebis interpretacia garTulebulia/araerTmniSvnelovania.- muclis travma: zogierTi specifiuri problemis SemTxvevaSi laparoskopiam (mag.civi iaraRiT miyenebuli wina da lateraluri naCxvleti Wrilobebi, tangencialuricecxlasroli Wrilobebi) SeiZleba Tavidan agvacilos laparatomia. laparoskopiisinformatiuloba muclis daxuruli tramvebis dros araerTmniSvnelovnad fasdeba(10,11).12

- sxvadasxva mdgomareobebi: laparoskopiis Catareba naCvenebia agreTve palpirebadiabdominaluri warmonaqmnebis diagnostikis mizniT, mucelsa da menjis RruSiucnobi etiologiis tkivilis, xandazmul pacientebSi mwvave da qronikul muclistkivilis, ucnobi etiologiis cxelebis, agreTve Tandayolil anomaliebze eWvisSemTxvevaSi.ukuCvenebebilaparoskopiis ukuCvenebebia: hemodinamiuri arastabiluroba, meqanikuri anparalizuri gauvaloba, arakogoregirebuli koagulopaTia, generalizebuliperitoniti, mZime kardiopulmonaluri daavadebebi, muclis kedlis infeqciebi, adreganxorcielebuli mravaljeradi abdominaluri procedurebi, orsulobis gvianivadebi. Tumca sabolooo gadawyvetileba laparoskopiuli proceduris CatarebisSesaxeb ara mxolod klinikuri statusis, aramed qirurgis mier pacientismdgomareobis Sefasebis safuZvelze miiReba (12,13).LL laparoskopiis teqnikalaparoskopiisas gamoiyenebuli instrumentebi, moicavs laparoskops, troakars,damWerebs (grasping), biofsiisa da retraqciul instrumentebs, romlebic saWiroebismixedviT gamoiyeneba. instrumentTa umravlesobis diametri 2-10 mm meryeobs.Ppersonali Sedgeba laparoskopistis da trenirebuli asistentisagan, romelicsisxlis arteriul wnevas, pulss, sunTqvis sixSires, JangbadiT gajerebas, ekg-sa dasedaciis xarixs akontrolebs. zogierT pacients saWiroebis SemTxvevaSidiagnostikuri laparoskopia SeiZleba lokaluri anesTeziiT intravenuri sedaciiTCautardes. rodesac zogadi anesTeziaa naCvenebi, aucilebelia procedurasanesTeziologic eswrebodes.sawyisi intrabdominaluri midgoma veresis nemsiT an ganakveTiT (cut down technique)xorcieldeba. muclis RruSi airis Catumbva (insuflacia) xdeba, saWiroebisasdamatebiTi troakarebic gamoyeneba. spontanur sunTqvis pirobebSi insuflaciuriwnevis limiti vercxliwylis svetis 10mm-s Seadgens. rutinuli laparoskopiulikvleva moicavs peritonealuri zedapirebis, difragmis, RviZlis, elenTis, naRvlisbuStis, kuWis, wvrili nawlavis, msxvili nawlavis, menjis Rrus organoebisa daretroperitonealuri qsovilebisa da organoebis daTvalierebassaTanado Cvenebebis Sesabamisad SeiZleba ganxorcieldes biofsiuri masalis aReba,citologiuri kvleva, intraoperaciuli ultrasonografia, kulturebisa daarsebuli siTxis analizi da/an sxva gamosaxulebiTi diagnostikuri kvlevebismodificireba.garTulebebigarTulebebi SeiZleba ganviTardes pnevmoperitoneumis Seqmnis procesSi,troakaris Seyvanisas an uSulod diagnostikuri kvlevis (daTvalierebis) dros. esgarTulebebia: ariTmiebi, hemodinamiuri arastabiluroba, rac venuri modinebisSemcirebiTaa ganpirobebuli, sisxldena, naRvlis CaRvra, Rru organoebisperforacia, soliduri organoebis gagleja, sisxlZarRvebis dazianeba, aerovaniembolia da Catumbuli airis kanqveS an eqxtraperitonealurad gavrceleba. Tumcaunda aRiniSnos, rom garTulebebi mxolod zemoT CamoTvliliT ar Semoifargleba.Wrilobis inficireba an ascitis gavrceleba (leackage) postoperaciul periodSiviTardeba. xarvezebi (araswori diagnostika - failure) intraabdominaluripaTologiis lokalizaciis (extent) diagnostikaSi aseve erT-erT potenciurgarTulebas warmoadgens.daskvna13

diagnostikuri laparoskopia im pacientebisTvisaa naCvenebi, rodesac daavadebisdiagnozi an paTologiuri procesis ganvrcoba gaurkvevelia an kidevabdominaluri monacemebi araerTmniSvnelovania. misi usafrTxod CatarebaSesaZlebelia rogorc stacionarul, ise ambulatoriul pirobebSi, rac xelsuwyobs swor diagnostikasa da mkurnalobas.literatura:1. Boyce HW. Laparoscopy. In: Schiff L, Schiff ER (eds.),Diseases of the Liver. Philadelphia: JB Lippincott1982;333-348.2. Berci G, Cuschieri A. Practical Laparoscopy. London: Bailliere Tindall, 1986.3. Mansi C, Savarino V., Picciotta A, et al. Comparison between laparoscopy, ultrasonography and computedtomography in widespread and localized liver disease.Gastrointestinal Endoscopy. 1982; 28:83.4. Gandolfi L, Rossi A, Leo P, et al. Indications for laparoscopy before and after the introduction ofultrasonography. Gastrointestinal Endoscopy. 1985; 31:1.5. Sleeman D, Sosa JL, Almeida J, et al. Bedside laparoscopy in critically ill patients. Critical Care Medicine.1995; 21 (2 suppl.):A237.6. Monitoring of Patients Undergoing Gastrointestinal Endoscopic Procedures. Guidelines for ClinicalApplications. American Society for Gastrointestinal Endoscopy, 1989.7. Coupland G, Townsend D, Martin C. Peritoneoscopy – Use in assessment of intra abdominal malignancy.Surgery. 1981; 89:645-649.8. Bogen GL, Manino AT, Scott-Conner C. Laparoscopy for staging and palliation of gastrointestinalmalignancy. Surgical Clinics of North America. 1996; 76(3):557-569.9. Brugera J, Rodas P, Rodas J. A comparison of accuracy of peritoneoscopy and liver biopsy in the diagnosisof cirrhosis. Gut. 1974; 15:799.10. Poole GV, Thomas KR, Hauser CJ. Laparoscopy in trauma. Surgical Clinics of North America. 1996;76(3):547-556.11. Ivatury RR, Simon RJ, Stahl WM. A critical evaluation of laparoscopy in penetrating abdominal trauma.Journal of Trauma. 1993; 34(6):823-828.12. Halpern NB. Laparoscopic cholecystectomy in pregnancy: A review of published experiences and clinicalconsiderations, Seminars in Laparoscopic Surgery, 5(2),June, 1998.13. Gurbuz AT, Peetz ME. The Acute Abdomen in the Pregnant Patient. Is there a role for Laparoscopy?Surgical Endoscopy. 1997; 11(2): 98-102.SAGES GUIDELINES FOR DIAGNOSTIC LAPAROSCOPYN. Rachvelishvili, Tbilisi State Medical University, Chair of Internal Medicine #1This is one of a series of statements discussing the utilization of laparoscopy in common clinical situations.This guideline was prepared by the Standards of Practice Committee of the Society of AmericanGastrointestinal Endoscopic Surgeons in 1998 and updated in 2002.Diagnostic laparoscopy is useful for patients in whom the diagnosis or extent of the disease is unclear or theabdominal findings are equivocal. It can be performed safely in an inpatient or outpatient setting, potentiallyexpediting diagnosis and treatment.14

klinikuri mimoxilvaSfoTvisa da depresiuli darRvevebis mkurnalobakardiovaskularuli sistemis daavadebis mqone pacientebSisimon devisi, peter jeqsoni, jon potokari, devid natiBMJ, 2004; 328: 939-43 ©ra rols TamaSobs serotoninis ukuSeRwevis seleqtiuri inhibitorebi kardiovaskularulidaavadebis mqone pacientebSi fsiqiatriuli avadobis mkurnalobisas? am mimoxilviT statiaSiganxilulia am jgufis pacientebSi sxvadasxva antidepresantebis usafrTxoeba da efeqturoba,maTi potenciali gaaumjobeson kardiovaskularuli daavadebis gamosavaliSfoTva da depresiuli darRvevebi xSiria saerTo populaciaSi da gansakuTrebiTprevalirebs kardiovaskularuli daavadebis mqone pacientebSi (cxrili 1) (1-3, w1-w3).mimovixileT is mtkicebulebiTi monacemebi, romelic zemoaRniSnuli kavSirisbiologiur ganmartebasa da kardiovaskularuli daavadebis mqone pacientebSifsiqiatriuli avadobis samkurnalod medikamentebisa da fsiqoTerapiis gamoyenebasexeba.ZiriTadi TezisebiSfoTva, panikuri darRveva da depresia xSiria gulis koronarulidaavadebisa an hipertenziis mqone pacientebSifsiqiatriul avadobasa da kardiovaskularul daavadebas Sorissavaraudoa biologiuri kavSirikardiovaskularuli problemis mqone pacientSi aranamkurnalevifsiqiatriuli moSliloba prognozs auaresebsserotoninis ukuSeRwevis seleqtiuri inhibitorebi (susi) usafrTxo daefeqturia kardiovaskularuli daavadebis mqone pacientebSifsiqiatriuli paTologiis samkurnalod; umjobesia uari vTqvaTklasikuri tricikluri preparatebis gamoyenebazesusi-iT mkurnalobam SeiZleba gaaumjobesos gadarCenis sixSire impacientebSi, romelTac depresia aqvT da miokardiumis infarqticgadaitanesfsiqiatriuli paTologiis diagnostireba da mkurnaloba unda CairTosgulis koronaruli daavadebisa da hipertenziis klinikur marTvaSiwyaroebi da SerCevis kriteriumebitardeboda Sesabamisi inglisurenovani statiebis sistematuri Zieba monacemTa bazebSiMedline (1966 wlidan 2003 wlis agvistomde) da Embase (1980 wlidan 2002 wlisoqtombramde). pirvel rigSi, Zieba xdeboda Semdegi terminebiTa da sakvanZosityvebiT: `miokardiumis infarqti~, `gulis angina~, `hipertenzia~, `insulti~,© - statiis gamoqveyneba SeTanxmebulia BMJ redaqciasTan15

`cerebrovaskularuli~, `postinsulti~. Semdgom, ki terminebiTa da teqstiT“serotoninis ukuSeRwevis seleqtiuri inhibitorebi” [Selective Serotonin ReuptakeInhibitors], “susi” [SSRIs] da calkeuli wamlebis saxelebiT. warmoebda Ziebis Sedegebiskombinireba da Sesabamisi statiebis mopoveba. warmoebda miTiTebuli bibliografiisSemowmebac _ sxva, potencialurad Sesatyvisi statiebis mosapoveblad.kardiovaskularuli daavadeba da fsiqiatriuli paTologiamravladaa monacemebi, romelTa Tanaxmadac depresia dakavSirebulia koronaruliarteriebis daavadebasa da hipertenziasTan; miokardiumis infarqtidan 7 dRis SemdegSefasebul pacientTa 16%-s aReniSneboda didi depresiis epizodis Sesabamisisimptomebi (1, w1, w2). ramdenime gamokvleva aCvenebs, rom SfoTviTi darRvevebikavSirSia gulis koronarul daavadebasTan, aseve hipertenziasTanac (2).16

mravladaa monacemebi, romelTa Tanaxmadac depresia dakavSirebuliakoronaruli arteriebis daavadebasa da hipertenziasTan;miokardiumis infarqtidan 7 dRis Semdeg Sefasebul pacientTa 16%-saReniSneboda didi depresiis epizodis Sesabamisi simptomebi (1, w1, w2).ramdenime gamokvleva aCvenebs, rom SfoTviTi darRvevebi kavSirSiagulis koronarul daavadebasTan, aseve hipertenziasTanac (2).cxrili 1: depresiisa da SfoTviTi darRvevebis kriteriumebi,fsiqiatriul darRvevaTa diagnostikisa da statistikis saxelmZRvanelodan,meoTxe gadaxedvadepresiadidi depresiasul cota 2 kviris ganmavlobaSi saqmianobaTa umravlesobisadmi interesisdakargva da mudmivad cudi guneb-ganwyoba, qvemomoyvanilidan zogierTi sxvasimptomic (jamSi ara nakleb xuTisa)• wonaSi dakleba an momateba• Zilis darRveva• energiis nakleboba• koncentraciis unaris daqveiTeba• agznebuloba• daqveiTebuli sakuTari Rirsebis grZnoba• suicidaluri ideebi an gegmebimcire depresiaori an meti kviris ganmavlobaSi sami an oTxi zemoTdasaxelebuli simptomiSfoTviTi darRvevebizogad maxasiaTeblebSi Sedis• TviTagznebadoba (autonomic arousal)• fsiqologiuri reaqtiuloba• tremori an caxcaxi• acilebiTi/TavisaridebiTi saqcieli (avoidance behaviour)• momatebuli sifxizle/eWvianobapanikuri darRvevapanikis spontanuri morecidive Setevebi, Setevebs win uswrebs SfoTvisepizodebi, mWidrod aris dakavSirebuli agorafobiasTan.generalizebuli SfoTviTi darRvevagadaWarbebuli Relvisa da daZabulobis gaxangrZlivebuli periodebipost-travmuli stresuli darRvevatravmuli stres-faqtoris moqmedebis Semdeg uecari gaxsenebebi (flashbacks),momatebuli sifxizle/eWvianoba, acilebiTi/TavisaridebiTi saqcieli.socialuri SfoTviTi darRvevasociumSi gasvlasTan dakavSirebuli SiSebi, xasiaTdeba dafrTxobiT,Zlierad gawiTlebiT, TavisaridebiTi saqcieli (avoidance behaviour).fsiqiatriul paTologiasa da kardiovaskularul daavadebas Soris kavSiri SeiZlebamivaweroT im garemoebas, rom pacientebis fsiqologiuri mdgomareoba diagnozisdasmis Semdeg Seryeulia; magram es ar xsnis prospeqtiuli kvlevebis Sedegebs -depresiisa da SfoTviTi darRvevebis mqone pacientebSi kardiovaskularuli17

problemebis gaxSirebasa da uares gamosavals. erT-erTi kvlevis Sedegebis Tanaxmad,miokardiumis infarqtis Semdgom depresiaSi myof pacientebSi sxva pacientebTanSedarebiT sikvdilobam 3.5-jer imata (1). depresia kavSirSia hipertenziis mqonepacientebSi kardiovaskularuli garTulebebis CamoyalibebasTan; ramdenimeprospeqtiuli kvlevis Sedegebi gvafiqrebs, rom arsebobs kavSiri SfoTviTdarRvevebsa da Semdgom kardiovaskularul daavadebasa Tu uecar sikvdils Soris (3,w3).savaraudoa am kavSiris biologiuri axsna – centraluri neirotransmiteris –serotoninis defeciti SeiZleba xels uwyobdes ara marto fsiqiatriul paTologias(mas SeiZleba vumkurnaloT serotoninis ukuSeRwevis seleqtiuri inhibitorebiT,romlebic sinafsebSi serotoninis xelmisawvdomobas zrdis), aramed hipertenziisCamoyalibebasa da kardiovaskularul risksac (cxrili 2) (4-8). serotoninisukuSeRwevis seleqtiurma inhibitorebma SeiZleba Seamciros kardiovaskularuliepizodis riski imis xarjze, rom isini amcirebs Trombocitebis aqtivacias an aRadgensgulis riTmis cvalebadobas (6, 7). mniSvnelovani monacemebi asaxavs esenciurihipertenziis mqone pacientebSi autonomiuri nervuli sistemis disfunqcias, racagreTve SeiZleba xels uwyobdes kardiovaskularul risks (w4). Warbi raodenobiTnoradrenalinisa an adrenalinis gamoyofa naCvenebia hipertenziisa da panikuridarRvevis SemTxvevaSic (9).fsiqologiurma simptomebma SeiZleba daaqveiTos pacientis unari aitanos an daicvasmedikamentozuri mkurnalobis sqema da daTanxmdes Carevebs, romelTa mizanikardiovaskularuli riskis Semcirebaa. panikis Setevebi, SfoTva da depresiadakavSirebulia antihipertenziuli agentebis autanlobasTan; es kavSiri yvelazeufro gamoxatulia maSin, rodesac gverdiTi moqmedebad aRwerili simptomebi ar arisdamaxasiaTebeli wamlisaTvis (10). depresiaSi myof pacientebs naklebad ZaluZTrekomendacias daujeron da miokardiumis infarqtis Semdgom Seicvalon Tavisi qcevada cxovrebis stili (w5).am monacemebis miuxedavad, pirveladi samedicino daxmarebis rgolsa dasaavadmyofoebSi SfoTviT darRvevebsa da depresias naklebi yuradReba eTmoba (w6).SeiZleba Zneli iyos SfoTvisa da depresiisaTvis damaxasiaTebeli simptomebisubralod samedicino mdgomareobis klinikuri suraTisgan garCeva. gulmkerdistkvili, romelic panikis Setevis dros Cveulebrivi movlenaa, stenokardiisaganSeiZleba ganvasxvavoT lokalizaciis mixedviT (gulis saproeqcio areze da aramkerdis Zvlis qveviT), marcxena mxarsa an xelSi iradiaciis ararsebobiT, tkivilisxasiaTiT (ufro mWreli xasiaTis, vidre zewolis magvari), varjiSis drosardawyebiTa da maRali xangrZlivoba-sixSiriT dasvenebis mdgomareobaSi (11).diferencialuri diagnozis gatarebisas mxedvelobaSi unda miviRoT gulmkerdisareSi arakardiuli genezis iseTi etiologiis tkivilebi, rogoricaa magaliTadmikrovaskularuli iSemia (X sindromi) da saylapavis moZraobis sindromi (w7).diagnozis dasmisas sxva xSiri sirTulea erTmaneTisagan gardamavali fsiqiatriuliniSnebis didi depresiisagan an SfoTviTi darRvevis simptomebisagan garCeva; aseve -didi da mcire depresiis garCeva, gansakuTrebiT imis gaTvaliswinebiT, rom mciredepresiis SemTxvevaSi wamlebis efeqti naklebadaa gamoxatuli.18

cxrili 2: im monacemebis Sejameba, romelic kardiovaskularul riskTan serotoninisdeficitis kavSirze metyvelebs• kataSi medikamentebis im reJimiT Seyvanisas, romelic mis Tavzurgtvinis siTxeSiserotoninis dones samjer da ufro metad zrdida, parkuWebis fibrilaciis zRurblisagrZnoblad iweva; aseve mniSvnelovnad mcirdeba gulidan eferentuli simpaTiurieleqtruli aqtivoba (4).• iqmneba STabeWdileba, rom zurgis tvinis ventro-rostralur nawilSi napovniserotoninerguli neironebi aregulirebs simpaTiuri moqmedebis nivTierebebisgamoyofas.• gulis riTmis cvalebadoba, romelic kardiovaskularuli reaqtiulobis markeria daSeiZleba ariTmiebisa da kardiuli garTulebebisagan gvicavdes, panikuri darRvevisdros Semcirebulia da umjobesdeba susi-iT mkurnalobis SemTxvevaSi (6).• susi-ma SeiZleba dagvicvas kardiovaskularuli riskisgan Trombocitebis aqtivaciisSesustebis xarjze, im pacientebSic ki, romlebic “antiTrombocitur” Terapiaze arian(7).• susi-is kardioproteqtoruli Tvisebebis asaxsnelad SemoTavazebulia Semdegimeqanizmi: serotoninis transporteris mimarT susi-is umravlesobis maRali tropizmisxarjze TrombocitebSi mcirdeba serotoninis maragi (8).fsiqiatriuli paTologiis medikamentozuri mkurnalobazogadi praqtikis an saavadmyofoSi momuSave eqimma specialist fsiqiatrTanmimarTvis gareSec SeiZleba gamoweros Sesabamisi wamlebi romelime im sqemismixedviT, romlis efeqturobac damtkicebulia. bolo dros dadginda, rom garkveulimedikamentozuri mkurnaloba ukavSirdeba miokardiumis infarqtis sixSirisSemcirebas; arsebobs monacemebi stenokardiisa da miokardiumis infarqtis fonzeantidepresiuli mkurnalobis Catarebisas gadarCenis sixSiris momatebis tendenciisSesaxeb.zogad populaciaSi fsiqiatriuli paTologiis mkurnalobis efeqturobaarsebobs monacemTa mTeli nakrebi Sesabamis pacientebSi depresiisa da SfoTviTidarRvevebis medikamentozuri mkurnalobis Taobaze. antidepresant wamlebSi Sedissusi, tricikluri preparatebi da modificirebuli tricikluri preparatebi, iseverogorc serotoninisa da noradrenalinis ukuSeRwevis inhibitorebi. Yoveli maTganidepresiis mqone pacientebis 60-70%-Si remisias ganapirobebs, Tu Terapiuli doziT 6kviris ganmavlobaSi miiReba. zogierTi tricikluri antidepresanti efeqturiapanikuri darRvevis drosac, magram susi-ma gamodevna isini da arCevnis wamlebadiqca; serotoninisa da noradrenalinis ukuSeRwevis inhibitorebTan erTad isiniefeqturia sxva SfoTviTi darRvevebis drosac, generalizebuli SfoTviTi darRvevisCaTvliT. benzodiazepinebi kvlavindeburad xSirad iniSneba yvela SfoTviTidarRvevis samkurnalod, Tumca ki eqimebs gaTviTcnobierebuli unda hqondeT maTinaklovanebebi (w8).usafrTxoebakardiovaskularuli daavadebis mqone pacientebSi tricikluri antidepresantebisgamoyenebis mizanSewoniloba sakamaToa. es efuZneba imas, rom cxovelebze CatarebulikvlevebSi isini cudad moqmedebda gulis kumSvadobaze; xolo adamianSi dozis19

gadaWarbebis SemTxvevaSi aRiniSneboda disriTmiebi da mZime hipotenzia;eleqtrokardiografiuli kvlevebi metyvelebs am wamlebis I tipis antiariTmiulisaSualebebis msgavs proariTmiuli moqmedebis Teoriul riskze (w9). sapirispirodamisa, epidemiologiuri da klinikuri kvlevebi, marTalia aramasStaburi, metyvelebsimaze, rom normalur dozebSi daniSvnis SemTxvevaSi gulis ukmarisoba ar Rrmavdebada ar matulobs uecari sikvdilis sixSire; sxva Tu araferi, yovel SemTxvevaSiaranamkurnalev pacientebTan SedarebiT mcirdeba miokardiumis infarqtiTganpirobebuli sikvdiloba (w10-12). orTostatiuli hopotenzia SeiZleba problemaswarmoadgendes, da erT-erTi kvlevis dros am gverdiTi moqmedebis gamo saWirogaxda pacientebis naxevarSi amgvari mkurnalobis Sewyveta (w13). sxva triciklurpreparatebTan SedarebiT sisxlis wnevis mniSvnelovan vardnas yvelaze naklebadSeiZleba nortriptilini iwvevdes (w14). Zveli tricikluri preparatebis gamoyenebakvlavindeburad sakamod rCeba; ukve arsebuli kardiovaskularuli daavadebisSemTxvevaSi upiratesoba unda mieniWos axalSemosul triciklur preparatebsa dasusi-is – potencialurad isini naklebad sariskoa.susi kardiotoqsiurobis TvalsazrisiT naklebad sarisko Cans, vinaidan maT argaaCnia antiqolinerguli moqmedeba, da maTi gamoyenebisas ariTmiis SemTxvevebiciSviaTad aRiricxeba. ormag brma SedarebiT kvlevaSi gulis iSemiuri daavadebismqone im pacientebis umravlesobas, visac susi (paroqsetini) daeniSna, depresiulisimptomebis remisia aReniSna; paroqsetinis SemTxvevaSi kardiovaskularuligverdiTi efeqtebi sarwmunod naklebi iyo (12).mosalodnelia, rom kardiovaskularuli daavadebis mqone pacientebi sxva wamlebsacRebulobdnen, pirvel rigSi hipertenziis sawinaaRmdegos, lipidebis donisdamaqveiTebel da antiariTmiul preparatebs; ase rom susi-is daniSvnisassagulisxmoa SesaZlo farmakokinetikuri urTierTqmedebebic. zemoCamoTvliliklasebis mravali preparati metabolizirdeba citoqrom P-450 fermentebiT CYP2D6 daCYP3A4. susi paroqsetini da fluoqsetini mZlavri CYP2D6-inhibitorebia, maSinrodesac fluoqsetini da nefazodoni CYP3A4-inhibitorebia, ase rom am preparatebmaSeiZleba gazardos plazmaSi iseTi kardiovaskularuli wamlebis koncentracia,rogoricaa propranololi, metoprololi, flekainidi, enkainidi (metabolizirdebaCYP2D6-s mier) da simvastatini; amlodipini, nifedipini, dilTiazemi, amiodaroni(metabolizirdeba CYP3A4-s mier); Sesabamisad SeiZleba imatos gverdiTi moqmedebissixSirem da toqsiurobam. metoprololTan dakavSirebuli gverdiTi moqmedebaxuTjer ufro xSirad aRiniSna genetikurad determinirebuli CYP2D6-is dabaliaqtiurobis mqone pacientebSi, rac imaze metyvelebs, rom am fermentuli sistemisaqtivoba klinikurad mniSvnelovania (13). sertralins, citalopramsa da triciklurpreparatebs paroqsetinsa da fluoqsetinTan SedarebiT mametabolizirebelifermentebis inhibiciis mniSvnelovnad naklebi potenciali aqvs (w15).serotoninisa da noradrenalinis ukuSeRwevis inhibitori venlafaqsini SeiZlebagamoyenebul iqnas gulis koronaruli daavadebis mqone pacientebSi. sifrTxileasaWiro maRali dozebis gamoyenebisas (yoveldRiurad >/= 300 mg), vinaidan ampreparatis miRebisas aRiniSneba arteriuli wnevis dozaze damokidebuli mateba,saSualod diastoluri wnevis vercxliswylis svetis 7 mm-iT momateba yvelaze maRalidoziT miRebisas (w16).efeqturoba kardiovaskularuli daavadebis mqone pacientebSifsiqiatriuli avadobis mkurnalobisas20

ukanasknel dromde mwiri monacemebi arsebobda kardiovaskularuli daavadebismqone pacientebSi fsiqiatriuli paTologiis mkurnalobis efeqturobis Sesaxeb.dReisaTvis ukve arsebobs Sesabamisi monacemebi susi-is umravlesobis Sesaxeb;informaciis wyaroa 5 ormagi brma meTodiT Sesrulebuli SedarebiTi an placeboTigakontrolebuli klinikuri kvleva, romelSic swavlobdnen pacientebs miokardiumisinfarqtiT, gulis iSemiuri daavadebiTa an hipertenziiT (ix. cxrili 3) (12, 14-17). erTplaceboTi gakontrolebul kvlevaSi fluoqsetinma Seamcira depresia pacientebSi,romelTac miokardiumis infarqti gadaitanes (16). paradoqsulia, magramfluoqsetinis samkurnalo efeqti placeboze sarwmunod meti iyo mxolod msubuqimimdinareobis didi depresiis mqone pacientebSi.am dargSi yuradsaRebi umniSvnelovanesi kvlevaa SADHART (sertraline antidepressant heartattack randomised trial – antidepresanti sertralini, gulis Seteva, randomizirebulikvleva ). am randomizirebul, ormag brma placeboTi gakontrolebul kvlevaSiakvirdebodnen 369 pacients, saavadmyofoSi miokardiumis infarqtiTa anarastabiluri stenokardiiT Semoyvanidan 30 dRis ganmavlobaSi (14). kvlevaSiCarTvis momentisaTvis pacientebi depresiaSi iyvnen da 24 kviris ganmavlobaSieZleodaT placebo an sertralini yoveldRiuri doziT 50-200 mg. sertralini iseTiveusafrTxo gamodga, rogorc placebo; kardiuli usafrTxoebis arc erTi parametrismixedviT maT Soris sxvaoba ar aRiniSna, magram sertralini sarwmunod ufroefeqturi iyo mZime depresiis mqone pacientebis mkurnalobaSi; pacientTamdgomareobis Semafasebeli qulebis mixedviT sertralini mTel sakvleverTobliobaSi sarwmunod ufro efeqturi iyo.xuTi ormagi brma kvlevis procesSi swavlobdnen susi-is efeqturobascerebrovaskularuli daavadebis mqone depresiaSi myof pacientebSi (18-22). samikvlevis mixedviT, fluoqsetini da citaloprami placeboze ufro efeqturi gamodga(19, 21, 22). meoTxe kvlevaSi, fluoqsetini placeboze ufro efeqturi iyo, magramkvlevis mxolod Ria katamnezuri dakvirvebis fazaSi (18). mexuTe kvlevaSinortriptilini depresiuli sindromebis mxriv remisiis miRwevaSi fluoqsetansa daplaceboze ukeTesi aRmoCnda (20). insult-gadatanili 137 pacientis profilaqtikurikvlevisas dadginda, rom im pacientebSi, vinc sertralins Rebulobda da araplacebos, mogvianebiT depresiis ganviTarebis Sansi gacilebiT naklebi iyo (23).kardiovaskularul daavadebaze antidepresantebiT mkurnalobis zegavlena5336 pacientis SemTxveva-kontrolis tipis kvlevaSi fluoqsetinis, sertralinisa Tuparoqsetinis gamoyenebis dros dadginda miokardiumis infarqtis Sansebis sarwmunodSemcirebuli Sefardeba 0.59 (8).SADHART kvlevaSi sertralinis jgufSi aRiniSna seriozuli kardiuli movlenebissixSiris Semcirebis gamoxatvis tendencia (22.4%-dan 14.5%-mde), rac SeiZlebafsiqiatriuli avadobis mqone pacientebSi am preparatis kardioproteqtiulmoqmedebaze metyvelebdes (14). Ria kvlevaSi, hipertenziul pacientebSi Tanmdevipanikuri darRveviT fluoqsetini sisxlis wnevis daqveiTebaSi antihipertenziulpreparat moqsonidinze ufro efeqturic ki aRmoCnda (24). amis sawinaaRmdegod,tricikluri preparatebi SeiZleba zrdides kardiovaskularul risks. erT-erTmimoxilviT kvlevaSi damabneveli faqtorebis Sesworebis Semdeg gamovlinda, rompacientebSi, romlebic doTiepins iRebdnen, 67%-iT ufro mosalodneli iyo gulisiSemiuri daavadebis dawyeba, imaTTan SedarebiT, vinc antidepresantebs arRebulobda (w17). Tumca, insultis Semdgom Camoyalibebuli depresiis kvlevaSi, 9wlis ganmavlobaSi katamnezuri dakvirvebis qveS myof pacientebSi rogorc21

nortriptilinis, aseve fluoqsetinis miReba ukavSirdeboda placebosTan SedarebiTsarwmunod ufro mcire saerTo sikvdilianobas (25).arafarmakologiuri mkurnalobaarsebobs seriozuli monacemebi, romelTa Tanaxmadac depresiisa da SfoTviTidarRvevebis mkurnalobaSi efeqturia SemecnebiTi qceviTi Terapia. dadginda, romigive midgoma warmatebulia stenokardiuli tkivilis samkurnalod im pacientebSi,romelTa SemTxvevaSic angiografia da gulis sxva gamokvlevebi negatiur pasuxsiZleva (w18). axlaxans ganxorcielda vrceli kvleva, Semdegnairi SedegebiT: impacientebSi, romlebic depresiaSi iyvnen da subieqturad sust socialur mxardaWerasRebulobdnen, miokardiumis infarqtis Semdgom 28 dRis ganmavlobaSi Catarebulmakognitiurma biheivioristulma Terapiam Seamcira depresiis xarisxi da socialuriizolaciac, magram kardiuli movlenebis sixSire ar Semcirebula (26).antidepresantebis gamoyeneba ukavSirdeboda mniSvnelovnad ufro mciresikvdilobasa an miokardiumis infarqtis araletalurobas.daskvnebieqimebma yuradReba unda miaqcion gulis koronaruli daavadebisa da hipertenziismqone pacientebSi fsiqiatriul avadobas, gansakuTrebiT ki SfoTvasa da depresias.kavSiri maT Soris, rogorc Cans, garkveul biologiur safuZvels emyareba da,fsiqiatriul darRvevebs umkurnalod Tu davtovebT, maT SeiZleba gaauaresonprognozi kardiovaskularuli problemebis mqone pacientebSi.depresia, panikuri darRveva da generalizebuli SfoTviTi darRveva – yvelaCamoTvlilis samkurnalod efeqturia antidepresiuli preparatebi.kardiovaskularuli daavadebis mqone pacientebSi susi-is gamoyeneba usafrTxoa,Tumca ki, arapirdapiri monacemebi metyvelebs imaze, rom jobia moveridoTklasikuri tricikluri agentebis gamoyenebas. Tu gaviTvaliswinebT bolo monacemebs,romelTa Tanaxmadac depresiis mqone pacientebSi susi-s SeuZlia gazardosmiokardiumis infarqtis Semdgom gadarCenis Sansi, fsiqiatriuli avadobisdiagnostireba da mkurnaloba aucileblad unda CairTos hipertenziisa da guliskoronaruli daavadebis mkurnalobaSi.w1 -w18 aRniSnavs masalebs internetSi, misamarTze www.bmj.comdamatebiTi informaciis wyaroebiBallenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Roose SP, Sheps DS. International Consensus Group on Depression andAnxiety. Consensus statement on depression anxiety and cardiovascular disease. J Clin Psychiatry 2001;62(suppl 8):24-7.Joynt KE, Whellan DJ, O’Connor CM. Depression and cardiovascular disease: mechanism of interaction. Biol Psychiatry2003;54:248-61.Roose SP. Treatment of depression in patients with heart disease. Biol Psychiatry 2003;54:262-8.Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease andimplications for therapy. Circulation 19999;99:2192-217.sainformacio resursebi pacientebisaTvisdepresia kardiuli Setevis Semdeg http://familydoctor.org/handouts/702.html – rCevebis furceliBBCi Health http://www.bbc.co.uk/health/ask_doctor/depression_heart.shtml - zogadi msjeloba depresiasa da gulisdaavadebas Soris kavSiris SesaxebAmerican National Institute of Mental Health www.nimh.nih.gov/publicat/index.cfm - veb-portali, bmulebisainformacio masalebze xSiri fsiqiatriuli daavadebebis diagnozisa da mkurnalobis Sesaxeb22

mimdinare da momavali kvlevebimimdinareobs klinikuri kvleva romlis mizanicaa miokardiumis infarqtis Semdeg depresiaSi myofpacientebSi axalSemosuli serotoninisa da noradrenalinis xelSemwyobi preparatis _ mirtrazapinismoqmedebis placebosa da susi-citalopramis efeqtTan Sedareba. (van den Brink RH, van Melle JP, Honig A,Schene AH, Grijns HJ, Lambert FP, et al. Treatment of depression after myocardial infarction and the effects on cardiacprognosis and quality of life: rationale and outline of the Myocardial INfarction and Depression-Intervention Trial (MIND-IT).Am Heart J 2002;144:219-25.beikeris samedicino institutSi, melburnSi, (avstralia) amJamad mimdinareobs pacientebis Segrovebagulis daavadebis dros susi-is moqmedebis masStaburi kvlevisaTvis, romelic SADHART-is gagrZelebaiqneba da mogvcems saSualebas kardiovaskularuli daavadebis mqone pacientebSi serotoninisxelSemwyobi preparatebis gamoyenebas ufro Rrma raodenobrivi Sefaseba mivceT.vaSingtonis universitetSi prof. robert qernis jgufi ikvlevs Zils kardiovaskularuli daavadebismqone depresiaSi myof pacientebSi. isini gegmaven Seiswavlon hipoTeza, romlis Tanaxmadac depresiaSimyof adamianebSi gulis riTmis cvalebadobis Semcireba Rame ufro aris gamoxatuli, rac swored amdros zrdis kardiovaskularul risks. kvlevam SeiZleba mogvces Semdgomi informacia imis Sesaxeb, Turogor SeuZlia depresias kardiovaskularuli daavadebis mqone adamianebSi gazardos kardiuliSetevis riski.23

cxrili 3randomizebuli ormagi brma kvlevebi, romlebSic gamoiyeneboda susi kardiovaskularuli daavadebismqone pacientebSi fsiqiatriuli avadobis samkurnalodkvlevaGlassman et al(SADHART)2202(14)McFarlane et al2001(15)Strik etal 2000(16)Roose etal 1998(12)fsiqiatriulipaTologiadididepresia*didi damciredepresia,standartulikiTxvarismixedviTdididepresia**dididepresia**kardiovaskularulipaTologiamiokardiumisinfarqti anstenokardiuli tkivilimiokardiumisinfarqtimiokardiumisinfarqtigulisiSemiuridaavadebawamlebi(sakvlevi–sakontrolo)sertralini –placebosertralini –placebofluoqsetini –placeboparoqsetini –nortriptilinipacientebisricxvigverdiTimoqmedebakardiovaskularulisistemis mxriv369 sarwmunocvlilebebisgareSe27 placebosjgufSi gulisriTmissixSiriscvalebadobisdaqveiTeba54 sarwmunocvlilebebisgareSe81 guliscemissixSirismomateba dagulis riTmiscvalebadobisdaqveiTebanortriptilinis jgufSi.sarwmunocvlilebebisgareSe;kardiovaskularulisistemis mxrivgarTulebebisgamo Terapiisgauqmebasasargeblomoqmedebakardiovaskularulisistemis mxrivaRiniSnaarasarwmunotendencia,romlisTanaxmadacsertraliniicavskardiovaskularuligarTulebebisagansertralinisjgufSi imatagulis riTmissixSiriscvalebadobamaRiniSnaarasarwmunotendencia,romlisTanaxmadacfluoqsetinmaSeamcirakardiuligarTulebebisgamoxelaxalihospitalizaciis saWiroebissixSire_fsiqiatriulipaTologiisgamosavalisertraliniplacebozeukeTesgamosavalsiZlevadepresiisSemTxvevaTaumravlesobaSisertraliniumjobesiaplacebozedepresiisqulebiTSefasebissafuZvelzeparoqsetiniplacebozeukeTesgamosavalsiZlevadepresiisSemTxvevaTaumravlesobaSidepresiismkurnalobaSinortriptilinzemcired,magramarasarwmunodumjobesiaparoqsetini24

Strik etal 1998(17)Fruehwald et al2003(18)Wiart etal 2000(19)Robinson et al2000(20)Dam etal 1996(22)dididepresia*saSualoxarisxis/mZimedepresia,standartulikiTxvarismixedviTdididepresia*didi anmciredepresia*depresia,standartuliNil (n=13),miokardiumisinfarqti (n=5),hipertenzia(n=2)insultiinsulti,romelmachemiplegiagamoiwviainsultiinsulti,romelmachemiplegiafluoqsetini –fluvoqsaminifluoqsetini –placebofluoqsetini –placebofluoqsetini _nortriptilini –placebofluoqsetini _maprotilisarwmunod metSemTxvevaSinortriptilinis jgufSi (17%0%-TanSedarebiT)20 sarwmunocvlilebebisgareSe50 ar arismiTiTebulizegavlenakardiovaskularulsistemaze31 ar arisaRwerilisarwmunozegavlenakardio vaskularulsistemaze56 guliscemissixSirissarwmunodufro maRalimomatebanortriptilinis jgufSiplacebosjgufTanSedarebiT52 ar arismiTiTebulizegavlenagandevnisfraqciismaCvenebeligaumjobesdaorive wamliTnamkurnal ebkardiovaskularulidaavadebismqonepacientebSi____orivepreparatiefeqturiadepresiismkurnalobaSioTxikvirisSemdgomorivejgufSidepresiismaCveneblebisgaumjobeseba. RiakatamnezuriSeswavlisprocesSifluoqsetini ukeTesigamodgadepresiismkurnalobaSifluoqsetiniplacebozesarwmunodukeTesianortriftilinifluoqsetinsa daplacebozesarwmunodufroefeqturiadepresiisada SfoTvissimptomebismkurnalobaSifluoqsetinisa damaprotili25

Andersen et al1194(22)kiTxvarismixedviT(simZimear arismiTiTebuli)saSualoxarisxis/mZimedepresia,standartulikiTxvarismixedviTgamoiwvia ni –placeboinsulticitaloprami _placebokardio vaskularulsistemaze:fluoqsetinisjufi aWarbebsmaprotilinisa da placebosjgufebsfunqciurimonacemebismixedviT66 ar arisaRwerilisarwmunozegavlenakardio vaskularulsistemaze_nisgamoyenebaukavSirdebodadepresiisxarisxissarwmunoSemcirebasukeTesigamosavalicitalopramis jgufSi* fsiqiatriul darRvevaTa diagnostikisa da statistikis saxelmZRvanelo, meoTxe gamocema** fsiqiatriul darRvevaTa diagnostikisa da statistikis saxelmZRvanelo, mesame, Secvlili gamocemaTREATMENT OF ANXIETY AND DEPRESSIVE DISORDERSIN PATIENTS WITH CARDIOVASCULAR DISEASESimon JC Davies, Peter R Jackson, John Potokar, David J NuttBMJ, 2004; 328: 939-43Anxiety, panic disorder and depression are common in patients with coronary heart disease and hypertension. There isa plausiblle biological basis for the association between psuchiatric morbidity and cardiovascular disease. Untreatedpsychiatric disorders worsen the prognosis in patients with cardiovascular problems. Selective serotonin reuptakeinhibitors (SSRI) are safe and effective for the treatment of psychiatric morbidity in patients with cardiovasculardisease; classic tryciclic agents are best avoided. Treatment with SSRI may improve survival after myocardialinfarction in patients with depression. Diagnosis and treatment of psychiatric morbidity should be incorporated into theclinical management of coronary heart disease and hypertension.26

klinikuri mimoxilvadiseminirebuli sixlZarRvSiga Sededeba (dsS) - Zveli daavadeba,axali imedebiCeng hok toh, maikl denisiBMJ, 2003, 327 : 974-7(moamzada Sorena arCuaZem)didi xania, cnobilia, rom dsS sefsisis mqone pacientebSi letaluri gamosavlisgazrdil risks ukavSirdeba. Tumca, amJamad arsebobs misi efeqturi mkurnalobissaSualebebi. aRniSnuli mimoxilviTi statiis avtorebi Seecadnen mizanmimarTulimkurnalobis meTodebis SemuSavebisa da prognozis gaumjobisaTvis paTologiis ukeTesadcodnisa da naadrevi diagnostikis mniSvnelobis demonstrirebas.dsS pirveli klinikuri dakvirvebebi me-19 saukuneSi iqna aRwerili. Tumcagavrcelebuli paTologiuri koagulaciiT gamoxatul am garTulebas, savaraudod,adamianSi travmisa da infeqciebis msgavsi xangrZlivobis istoria aqvs. cxadia, dsSmravali klinicistisaTvis zogadad arasaxarbielo klinikur gamosavalTan asocirdebada misi laTinuri akronimi DIC (Disseminated Intravascular Coagulation) frazis “Death Is Coming”-(`sikvdili axlovdeba~) sinonimia. miuxedavad amisa, Seqmnilia mZime sefsisis TanmxlebikoagulopaTiis sawinaaRmdego mizanmimarTuli preparati (C-cila), romelic aRniSnulimdgomareobis pirvel warmatebul samkurnalo saSualebas warmoadgens. Cven mogawvdiTuaxles Sexedulebebs dsS-sa da imis Sesaxeb, Tu ratom moaswavebs misi dawyeba imgardamtex moments, rodesac adaptaciuri pasuxi araadaptaciur xasiaTs iZens dapacientis sicocxlisaTvis potenciurad saxifaTod iqceva.am procesis zusti laboratoriuli kriteriumebis gansazRvra am kritikulipaTologiis Terapiul fanjaras uzrunvelyofs, romelsac saboloo jamSi klinikuriSedegebis gaumjobeseba SeuZlia.informaciis wyaroebi da seleqciis kriteriumebifrazis “diseminirebuli sisxlZarRvSiga Sededeba” da sxva saZiebo sityvebismixedviT sistemurma Ziebam PubMed-Si 10262 publikacia gamoavlina. maTi umetesi nawiliklinikuri SemTxvevebisa da daavadebis paTofiziologiis aRweras Seexeboda. sistematurikontrolirebuli klinikuri kvlevebis naklebobidan gamomdinare, mravali rekomendaciaeqspertTa Sexedulebebs da saerTo SeTanxmebaze dafuZnebul saxelmZRvanelo principebseyrdnoba da moklebulia sando mtkicebulebebs. miuxedavad amisa, ukanaskneli 5 wlisganmavlobaSi qveyndeba mzardi raodenobis randomizebuli kontrolirebuli kvlevebisSedegebi, romlebic dsS diagnozisa da marTvis sakiTxebs swavlobs. isini Sesuliawinamdebare mimoxilvaSi.gansazRvradsS warmoadgens mwvave kliniko-paTologiuri procesebis Tanmimdevrobas, romelicsisxlZarRvSiga Sededebis aqtivaciis kompensatoruli kontrolis an lokalizaciismzardi daqveiTebiTa da dakargviT xasiaTdeba. mis mimdinareobaSi gamoyofen sikvdilobismometebuli riskis mqone pacientebisaTvis damaxasiaTebel fazebs. Trombozisa dahemostazis saerTaSoriso sazogadoebis standartizaciis qvekomisiam SemogvTavazasamuSao dadgenilebebi, romlebic maT naadrev gamovlinebas da mkurnalobas gaaadvilebs.klinikurad manifestirebul da gvian stadiebTan SedarebiT gansakuTrebiT didiyuradReba eTmoba dsS-s latenturi stadiebis gamovlinebas.epidemiologia27

dsS SeZenili sindromia, romelsac mravalferovani etiopaTogenezuri safuZvli aqvs. misidaavadebaTa hemostazur garTulebad klasificireba, garkveulwilad, aufasurebs ufrocentralur paTogenezur Sexedulebebs. mis mniSvnelobas mxars uWers 2 sakvanZodakvirveba: pirveli – dsS ganviTareba pirvelad daavadebasTan SedarebiT sikvdilobisriskis zrdas ganapirobebs; meore – gamomwvevi mizezis aRmofxvra yovelTvis veruzrunvelyofs dsS mimdinareobis Semsubuqebas. Tumca, Cveulebriv, orsulobisproduqtebis qirurgiuli meTodebiT gamoZevebas da TviTnebur mSobiarobas dsS-s sameanomizezebis ukuganviTarebamde mivyavarT, SesaZloa,Sesaferisi antibiotikebis gamoyenebasefsisis Semdgomi gauaresebis Tavidan acilebisaTvis arasakmarisi aRmoCndes.klinikuri gamovlinebebidsS-s paTologiuri sisxlZarRvSida Sededebis klinikur manifestaciaTa didimravalferovneba axasiaTebs dawyebuli sisxldenidan, damTavrebuli TromboziT. TumcaTrombocitebisa da koagulaciuri faqtorebis deficitiT gamowveuli sisxldena tipiurklinikur suraTs qmnis, poliorganuli ukmarisoba dsS-s mqone pacientebisaTvis bevradufro damaxasiaTebeli niSans warmoadgens. autofsiis masalebma multifokaluridifuzuri sisxldenebi da hemoragiuli qsovilis nekrozuli cvlilebebi aRmoaCina. gardaamisa, rogorc mcire, aseve - didi kalibris sisxlZarRvebSi Trombebis arseboba dadginda.dsS-is eqsperimentul cxovelTa modelebis Seswavlam ki sxvadasxva organoebSi fibrinisdagroveba gamoavlina, rac organoTa ukmarisobis mizezad moiazreba.paTofiziologiadsS-is paTofiziologiaSi ramodenime mniSvnelovan sakiTxs gamoyofen: pirveli - in vivoTrombinis warmoqmnis centraluri roli, meore – is faqti, rom meqanizmebi, romlebicTrombinis warmoqmnis dawyebas da mis uwyvetobas uzrunvelyofen, paTognomuriacvlilebaTa diseminaciisaTvis, mesame –paralelurad adgili aqvs anTebiTi kaskadisTanmxleb aqtivacias, meoTxe – mikrosadinarebis endoTeliumis mniSvneloba am procesSi.Trombinis in vivo warmoqmna - umniSvnelovanesi makontrolirebeli faqtoriahemostazisaTvis, romlis SenarCuneba prokoagulanturi da Sededebis sawinaaRmdegoaqtivobis balansis gziT xorcieldeba. fibrinogenis fibrinad gardaqmnas TrombinissinTezi da dagroveba moyveba, rac myisierad kontrolirdeba C-cilis antikoagulanturiregulatoruli gzis meSveobiT, romlis aqtivacias Tavad Trombini uzrunvelyofs. gardaamisa, igi ramodenime potenciur rols asrulebs, rogorebicaa paTogenebis gamijvna,ujreduli procesebis stimulireba da endoTeliumis mxridan Sesabamisi sapasuxosignalebis aqtivacia. dsS-s dros Trombinis generaciis kontrolis es faqizi balansidakargulia.meqanizmebi, romlebic Trombinis warmoqmnis gavrcelebas da uwyvetobas uwyoben xelsTumca koagulaciis qsovilovani faqtoris anu e.w. garegani gza udides rolsasrulebs Trombinis warmoqmnis inicirebaSi, sxva procesebis stimulaciassisxlZarRvSiga Sededebis diseminaciamde mivyavarT. Trombinis formirebis meoradi biZgiuzrunvelyofilia koagulaciis Sinagani gzis meSveobiT, rac antikoagulantiregulatoruli cilebis - C-cila, S-cila, antiTrombini – moxmarebas da deficits iwvevs.garda amisa, uaryofiTad damuxtul fosfolipidur zedapirebTan gazrdili kontaqtikidev ufro aadvilebs koagulaciis kinetikis daZvrasa da gavrcelebas. iseTi zedapirebi,romlebic mdidaria fosfatidilseriniT, SiSvldeba ujredTa aqtivaciisa da agreTve,maTi apoptozis dros ujreduli membranebis SigniTa fenis eqsternalizaciisSedegad.EujredTa dazianebas, aseve Trombocitebis, monocitebisa da endoTeliocitebismikronawilebis warmoqmnamde mivyavarT, rac koagulaciuri reaqciebis ganviTarebisaTvisxelSemwyobi mocirkulire zedapiris farTobs zrdis. igive iTqmis fosfolipidurzedapirebze, romelTa wyaros Zalian dabali simkvrivis lipoproteinebi warmoadgenen.mZime sefsisis dros am ukanasknelTa raodenobam SesaZloa ramodenimejer moimatos, rac28

inarCunebs da zrdis Trombinis warmoqmnas. erTad, es meqanizmebi sivrcesa da droSiganvrcobil procesebs warmoadgenen, rac dsS-s sakvanZo momentia.anTebasa da koagulacias Soris kavSiri - aqtivaciisTanave anTebiTi da koagulaciisgzebi erTmaneTTan urTierTqmedeben, rac SemdgomSi kidev ufro metad aZlierebsmimdinare procesebs. erTis mxriv citokinebs da proanTebiT mediatorebs Sededebisinduqcia SeuZliaT, meore mxriv ki Trombini da sxva proteazebi ukavSirdebianproteazebis aqtivirebul receptorebs ujredTa zedapirze, rac xels uwyobs aqtivaciasada damatebiT anTebiTi reaqciebis provocirebas. generalizaciis Semdgom aRniSnuliprocesi Tavs arTmevs kargad ganviTarebul adgilobriv sakontrolo meqanizmebsa da maTsbalanss. es ukanaskneli iwvevs regulacias moklebul, umimarTulebo pasuxs, romelicanTebasa da Sededebas Soris Caketili ciklis sazrdos warmoadgens.endoTeluri ujredebis aqtivacia da disfunqcia – endoTeluri zedapirebis normalurida adaptaciuri pasuxi uSualod ukavSirdeba koagulaciisa da anTebis regulacias. amdidi endoTelialuri organos disfunqciasa da ukmarisobas dsS-mde mivyavarT, rogorcmisi Sedegi da gamovlineba. koagulopaTiis gavrceleba damokidebulia pacientisgenetikur da sxva faqtorebze.diagnoziklinikur praqtikaSi dsS-is diagnozi yoveldRiurad xelmisawvdomi koagulologiurilaboratoriuli testebis kombinaciis safuZvelze dgindeba. diagnostikuri algoriTmebiamJamad ukve xelmisawvdomia. klasikuri damaxasiaTebeli monacemebia Sededebis droisgaxangrZliveba (mag. proTrombinis dros, aqtvirebuli parcialuri Tromboplastinisdro), fibrinis daSlis produqtebis (D-dimerebi) mateba, fibrinogenis SemcvelobisdaqveiTeba da Trombocitopenia. aRniSnuli testebis normis farglebis SesabamisiSedegebi ar gamoricxavs mniSvnelovani moxmarebiTi koagulopaTiis arsebobas. igi,rogorc mwvave fazis pasuxi, aqtivirebuli parcialuri Tromboplastinis droisSemoklebasa da fibrinogenis koncentraciis zrdas iwvevs. am mizeziT, Trombozisa dahemostazis saerTaSoriso sazogadoebis mier adreuli, latenturi dsS-is identifikaciissakiTxebze gamoqveynebuli saxelmZRvanelo principebi aramarto paTologiur Sedegebs,aramed am Sedegebis paTologiur tendenciasac Seexeba. gansakuTrebuli yuradReba eTmobaSedarebiT specifiur testebs, romelTac Semdegi moTxovnebi waeyenebaT: isini ufrouSualo kavSirSi unda iyon anTebasa da dsS-s procesebTan, aseve martivi da swrafadSesrulebadi unda iyos da mtkicebulebaTa Zlieri dasayrdeni unda gaaCndeT.mkurnalobadsS-s marTvis ZiriTad moments gamomwvevi mizezis aRmofxvra warmoadgens. Tumca, rogorcam mdgomareobasTan asocirebuli sikvdilobis maRali maCveneblebiT mtkicdeba, dsSxSirad adeqvaturi mkurnalobis (mag. sefsisis dros antibiotikebis gamoyeneba) fonzecgrZeldeba. kontrolirebuli kvlevebis Sedegad plazmis da TrombocitebistransfuziebiT mkurnalobis efeqturoba ar damtkicda. Tumca, aRniSnuli Terapiulimidgoma racionalur arCevans warmoadgens, gansakuTrebiT, im SemTxvevebSi, rodesacsisxldenis an misi momatebuli riskis mqone pacientebSi adgili aqvs Sededebis plazmurifaqtorebis da Trombocitebis deficits. ufro metic, ar arsebobs arc klinikuri da arceqsperimentuli monacemebi imisa, rom transfuziuli Terapia `cecxlze navTis dasxmasudris~. dsS-is mqone pacientebis klinikur gamosavalze heparinis dadebiTi efeqti,romelic Warbi Trombinis warmoqmnas Trgunavs, arasodes ganmtkicebulakontrolirebuli klinikuri kvlevebiT. garda amis, hepariniT dsS-s mkurnalobisusafrTxoba sisxldenebis tendenciis mqone pacientebSi did debatebs iwvevs.mZime sefsisis mkurnalobis dros adamianis aqtivirebuli C-cilis rekombinantuliformis maRalefeqturoba (28 dRis ganmavlobaSi sikvdilobis maCvenebeli 31%-dan 25%-mdeSemcirda), imis mniSvnelovan maCvenebels warmoadgens, rom aqtivirebuli C-cilis29

gamoyeneba sefsisTan asocirebuli dsS-is mkurnalobis pirvelsave etapebze unda iyosganxiluli (I donis sabuTi). garda antikoagulanturi efeqtisa, aqtivirebul C-cilas,agreTve, uSualod anTebissawinaaRmdego da antiapoptozuri Tvisebebic axasiaTebs. esnawilobriv ganmartavs sxva endogenuri antikoagulantebis (antiTrombini da qsovilovanifaqtoris gzis inhibitori) SedarebiT dabal efeqturobas mZime sefsisis mqonepacientebSi. amJamad adamianis aqtivirebuli C-cilis rekombinantuli forma 96-saaTianiinfuziis saxiT gamoiyeneba da mwvave Trombocitopeniis mqone pacientebSi garkveulsifrTxiles saWiroebs intracerebraluri sisxldenis gazrdili sixSiris gamo.Trombocitebis raodenobis kontroli da, saWiroebis SemTxvevaSi, maTi droulitransfuzia metad mniSvnelovania.licenzirebis ararsebobis miuxedavad, araaqtivirebuli (zimogen) C-ciliTmkurnalobam aCvena Tavisi dadebiTi efeqtebi meningokokuri septicemiis dros (IV donissabuTi). Tumca, in vivo aqtivirebul cilad gardaqmna damokidebuli unda iyos ujredebiszedapirze receptorebis arsebobaze (Trombomodulinis da endoTelialuri C-cilisreceptori), romelTa raodenoba SesaZloa mkveTrad Semcirdes sefsisis dros.daskvnaaxali informacia dsS-is paTofiziologiasa da mkurnalobaze sikvdilobis miuRebladmaRal riskTan asocirebuli am paTologiis gaumjobesebuli prognozis axal imedebsgvaZlevs. mniSvnelovani winsvla iseT konceptualur cvlilebebs saWiroebs, romlebicxazs gausvams Trombinis warmoqmnis gavrcelebis xelSemwyob sxvadasxva mediatorebsa dafaqtorebs Soris urTierTqmedebas, gansakuTrebiT anTebasa da koagulacias SoriskavSirebis gaTvaliswinebiT. damatebiTi kvlevebi axali SexedulebebiT momaragebasgvpirdeba dsS-s, ara rogorc izolirebuli meqanizmis, armed upiratesad, rogorcmovlenaTa koordinatoris Sesaxeb, romelic mniSvnelovan gavlenas axdens sefsisisa dasxva kritikuli mdgomareobebis klinikur Sedegebze.Disseminated Intravascular Coagulation – Old Disease, New HopeCheng Hock Toh, Michael DennisBMJ, 2003, 327: 974-7Disseminated Intravascular Coagulation (DIC) is caused by the enhanced and abnormally sustained generation ofthrombin. DIC is highly relevant to outcome in patients with sepsis; the first successful treatment in sepsis is bytargeting generation of thrombin with activated protein C. DIC exemplifies multifaceted interactions between theinflammatory and coagulation pathways. DIC indicates the transition from localized, adaptive, and compensatedcoagulation process into maladaptive responses. Identifying circulating biomarkers that propagate generation ofthrombin may indicate the timing of dissemination and be as tool for therapeutic targeting.30

klinikuri ganxilva da SemTxvevis aRweraefedras miRebis Sedegad ganviTarebuli koronaruliganSreveba da Trombozisrikant sola, tarek helmi, andro kaWarava *atlantis veteranTa samedicino centris kardiologiuri ganyofileba, emorisuniversitetis samedicino skolis Sinagan sneulebaTa kaTedraSesavaliN naxevar saukuneze metia aSS-Si efedras alkaloidis Semcveli dieturidanamatebi farTod gamoiyeneba wonis daklebis, energiis momateba-aRdgenisa dasportuli miRwevebis gaumjobesebis mizniT. am danamatebis moxmarebasTan mTelirigi arasasurveli Tanamovlenebi aris asocirebuli, maT Soris arteriulihipertenzia, miokardiumis infarqti, insulti, ariTmiebi, gulyra da sikvdili. masSemdeg, rac ramdenime iseTi sportsmenis sikvdili dafiqsirda, vinc efedrasSemcvel dietur danamats iRebda, masmedia dainteresda am nivTierebis miRebiTgamowveuli SesaZlo riskiT da wamoiWra mTeli rigi SekiTxvebisa maTiusafrTxoebis Sesaxeb (1,2).Fpreparatebis gamoyenebasTan dakavSirebiT aSS sakvebisada samkurnalo saSualebebis saagentos (FDA) mravaljeradi gafrTxilebismiuxedavad, am tipis sakvebi danamatebi jer kidev farTod gamoiyeneba dayovelwliurad mravalmilionian Semosavlis wyaros warmoadgens.A naSromSi Cven warmovadgineT SemTxvevis aRwera, agreTve literaturis moklemimoxilva am preparatebis miRebiT gamowveuli garTulebebis Sesaxeb.SemTxvevis aRwera50 wlis afro-amerikeli qali Semovida gadaudebeli daxmarebis ganyofilebaSiCiviliT mZime tkivilze mkerdis Zvlis areSi, romlis xangrZlivoba daaxloebiT 2saaTs Seadgenda. avadmyofi manamde Tavs janmrTelad Tvlida da mkurnalobismizniT arc erTi medikamenti ar hqonda daniSnuli. anamnezSi dadgeniliarteriuli hipertenziis gamo adre mkurnalobda Tiaziduri diuretikis mciredozebiT. mkurnaloba Sewyvetil iqna 10 wlis win, mas Semdeg, rac SesaZlebeligaxda arteriuli wnevis kontroli dietiTa da varjiSiT.Pzogadi praqtikis eqimTan misi ukanaskneli vizitis dros, momarTvamde sami TviTadre, normaluri arteriuli wneva iqna dafiqsirebuli. anamnezSi ar aRiniSnebodadiabeti, hiperlipidemia, Tambaqos weva da/an gulis daavadebis ojaxuri istoria.momarTvamde ori dRiT adre man daiwyo urecepto gayidvaSi arsebuli efedris* - Andro Kacharava, M.D., Ph.D. Atlanta Veterans Affairs Medical Center, Division of Cardiology, Emory University, Atlanta, Georgia. E-mail:akachar@emory.edu31

Semcveli dieturi danamatis, kerZod qsenadrin RFA-1 dRiurad 1 tabletis miReba(es preparati Seicavs ma huangs, romelic 20 mg efedrinis eqvivalenturia, CytodineTechnologies).pacientis fizikuri gasinjviT arsebiTi paTologia ar gamovlinda. SemosvlisasgadaRebul ekg-ze dafiqsirda sinusuri riTmi, lateralur ganxrebSi STsegmentisa da T kbilis araspecifiuri cvlilebebiT. gadaudebeli daxmarebisganyofilebaSi avadmyofs aReniSna aramdgradi parkuWovani taqikardiis epizodi,romelic spontanurad gadavida normalur riTmSi, rasac Semdgom mohyvaaCqarebuli idioventrikuluri riTmis ramdenime epizodi. gulis fermentebismaCveneblebi momatebuli aRmoCnda, ris gamoc pacienti gadayvanil iqnakardiologiur ganyofilebaSi ST segmentis elevaciis gareSe mimdinaremiokardiumis infarqtis mkurnalobis mizniT. Sardis toqsikologiurma kvlevamkokainsa da amfetaminze uaryofiTi Sedegi aCvena. ekg-ze dinamikaSi dafiqsirdanormaluri sinusuri riTmi da ST segmentisa da T kbilis araspecifiuricvlilebebi wina ganxrebSi. transTorakaluri eqokardiogramis monacemebiTgandevnis fraqciam 45-50% Seadgina, aRiniSna agreTve wina-septaluri kedliszomieri hipokinezia. mogvianebiT pacients ganuviTarda ganmeorebiTi tkiviligulmkerdis areSi eleqtrokardiografiuli cvlilebebis gareSe, Tumca aRiniSnafermentebis donis mniSvnelovani mateba.…Ggulis kaTeterizaciiT gamovlinda marcxena wina daRmavali arteriis (LAD) Suadistaluri segmentis spontanuri ganSreveba da pirveli blagvi marginaluritotis (OM 1 ) sruli okluzia, es arteriebi ki marcxena parkuWis lateralurikedelis udides nawils amarageben (sur. 1). amave dros OM 1 totis okluziisubanSi aRiniSna axalwarmoqmnili Trombis angiografiuli niSnebi. marjvenakoronaruli arteria da marcxena Semomxvevi arteriis danarCeni ubnebiangiografiulad normis farglebSi iyo. gandevnis fraqciam 50% Seadgina.Cvens mcdelobebs intrakoronaruli Trombolizuri saSualebebisa daangioplastikis meSveobiT OM 1 ubanSi sisxlis nakadis aRdgenis mimarTulebiT,warmateba ar mohyolia. SemTxvevis sirTule ganpirobebuli iyo imiTac, rompacients proceduris msvlelobisas aReniSneboda gamoxatuli hiperkoagulacia,ramac gamoiwvia balonis mravaljeradi “miwebeba” kaTeterze, miuxedavad hepariniTsruli antikoagulaciuri Terapiisa, glikoproteinis IIb/IIIa blokerebisgamoyenebisa da instrumentebis Secvlisa. Mmarcxena wina daRmavali arteriis Suasegmentis ganSrevebis mkurnaloba garTulda misi mwvave Trombuli okluziisgamo. pacients gadaudebeli Cvenebis gamo saswrafod Cautarda aorto-koronaruliSuntireba OM 1 arteriaze, marcxena wina daRmavali arteria ki mTlianad iyookluzirebuli, ris gamoc misi Suntireba ver ganxorcielda. postoperaciulitransTorakaluri eqogramiT gamovlinda gandevnis fraqciis daqveiTeba (25-30%)miokardis wina kedlis gamoxatuli hipokineziiT. qirurgiuli CarevisdamTavrebisTanave pacientis zogadi mdgomareoba damakmayofilebeli iyo, TumcaCamoyalibda refraqteruli gulis ukmarisoba, ris gamoc mimdinareobs misi kvlevagulis gadanergvis mizniT.ganxilvaefedris alkaloidebi bunebrivi nivTierebebia, romlebic Seicaven efedrins,fsevdoefedrins, norfsevdoefedrins, meTilfsevdoefedrins, meTilefedrinsada norefedrins. es amfetaminis msgavsi nivTierebebi kardiovaskulur32

sistemaze zemoqmedeben rogorc uSualod beta-1, beta-2 da alfa-1 adrenergulireceptorebis stimulaciis gziT, ise arapirdapiri gziT - Tavis tvinsa da gulSiarsebuli sinafsebSi norepinefrinis gamoyofis stimulaciis meSveobiT.efedrinis mcenareuli wyaro ma huangi sadReisod aSS-Si gavrcelebul damoxmarebul dietur danamatebSi am nivTierebebis yvelaze xSiri resursia.samwuxarod, komerciul gayidvaSi arsebuli ma huangi mniSvnelovnad gansxvavdebadozirebis erTeulSi efedruli alkaloidis Semcvelobis mixedviT. uaxlesikvlevebis Tanaxmad, ma huangis Semcveli 20 dieturi danamatidan, erTi da igivelotidan Seswavlil sxvadasxva kafsulaSi efedris alkaloidis SemcvelobismniSvnelovani meryeoba aRiniSna (0.0-18.5 mg dozirebis erTeulze). asevemniSvnelovani meryeobaa efedrinis, fsevdoefedrinisa da meTefedrinisSemcvelobaSi sxvadasxva lotebidan aRebul nimuSebs Soris: Sesabamisad - 180%,250% da 100% (3,4).efedris alkaloidebis komerciuli preparatebis gamoyeneba asocirebuliakardiovaskulur gverdiT efeqtebTan, maT Soris arteriul hipertenziasTan,insultTan, miokardiumis infarqtTan, miokarditTan da taqiariTmiebTan.Aarakardiovaskuluri garTulebebidan aRsaniSnavia gulyra, hiperaqtiuroba,SfoTva, tremori, gulisreva da faRaraTi. Samuel, Link, et al. gaanalizes da SeafasesaSS sakvebisa da samkurnalo saSualebebis saagentosaTvis (FDA) 1995-1997 wlebSimiwodebulia informacia ma huangis SesaZlo toqsiuri gavleniT gamowveuli 926gverdiTi efeqtis Sesaxeb. gamovlinda 37 pacienti, romelTa mier ma huangisgamoyeneba dakavSirebuli iyo iseT seriozul kardiovaskulur gamovlinebebTan,rogoric aris insulti (16 SemTxveva), miokardiumis infarqti (10 SemTxveva) dauecari sikvdili (11 SemTxveva). sxva (5) kvlevis Tanaxmad, 1997 wlis 1 ivnisidan1999 wlis 31 martamde sakvebisa da samkurnalo saSualebebis saagentosaTvis (FDA)gverdiTi efeqtebis Sesaxeb miwodebuli informaciis safuZvelze aRweril iqna 140gverdiTi movlena, romelic dakavSirebuli iyo efedrinis Semcveli dieturidanamatebis miRebasTan. avtorebis daskvnebis mixedviT, iseTi gverdiTi reaqciebis31%, rogoric aris insulti, mocimcime ariTmia Tu taqikardia, arteriulihipertenzia Tu gulyra, danamdvilebiT an savaraudod ganpirobebuli iyoefedris alkaloidiT, xolo SemTxvevaTa 31%-Si ganviTarebuli TanamovlenebiSesaZloa dakavSirebuli yofiliyo am nivTierebis miRebasTan. 10 SemTxvevaletaluri gamosavaliT damTavrda, xolo 13 pirovneba samudamod dainvalidda(6). aRwerilia agreTve efedris alkaloidebis Semcveli preparatebis miRebisfonze ganviTarebuli letaluri SemTxvevebi, miokardiumis infarqti daparkuWovani taqikardia axalgazrda pacientebSic, romelTac manamde gulisdaavadebebi ar aReniSnebodaT (7,8,9).L Cven warmovadgineT SemTxveva, rodesac 50 wlis qals efedris alkaloidisSemcveli dieturi danamatis miRebis Sedegad miokardiumis infarqti ganuviTarda.am SemTxvevis Tavisebureba imaSi mdgomareobs, rom pacients erTdrouladaReniSneboda marcxena wina daRmavali arteriis spontanuri ganSreveba, ramacSesaZloa iSemiis pirveli epizodi gamoiwvia, da OM 1 –is mwvave Trombozi, racganmeorebiTi iSemiuri epizodis mizezad mogvevlina. amasTanave qirurgiulimanipulaciebis Catarebisas pacients aReniSneboda gamoxatuli hiperkoagulacia,ris gamoc intrakoronaruli Trombolizi warumatebeli aRmoCnda da, miuxedavadsruli antikoagulaciuri Terapiisa da glikoproteinis IIb/IIIa blokerebisgamoyenebisa, ganviTarda marcxena wina daRmavali arteriis mwvave Trombozi.aRsaniSnavia, rom pacients warsulSi aReniSneboda zomieri arteriulihipertenzia, romelic aRar saWiroebda medikamentur mkurnalobas da kargad33

kontrolirdeboda dietiTa da varjiSiT. mas ar aReniSneboda gulis iSemiuridaavadebis risk-faqtorebi, xolo bolo ramdenime Tvis ganmavlobaSi igi arc sxvamedikaments an danamats ar iRebda. Mmiuxedavad imisa, rom mxolod erTi SemTxvevissafuZvelze SeuZlebelia mizezobrivi kavSiris damtkiceba, erTdroulad mwvaveTrobozisa da koronaruli arteriis ganSrevebis ganviTareba, iseve rogorcsavaraudo kavSirurTerToba pacientis mier efedras miRebasa da ganviTarebulmiokardiumis infarqts Soris, gvaZlevs azris gamoTqmis SesaZlo asociaciurikavSiris arsebobis Sesaxeb efedris alkaloidsa da mwvave koronarulpaTologias Soris.M Tanamedrove meta-analiziT, romelic ikvlevda efedris efeqturobas wonisdaklebisa da sportuli miRwevebis gaumjobesebis mxriv, gamovlinda rom esnivTierebebi xels uwyoben wonis mxolod zomier daklebas (0,9kg-iT meti TveSiplacebosTan SedarebiT). ar moipoveba agreTve monacemebi xangrZlivi dakvirvebisSesaxeb wonis klebis mimarTulebiT, iseve rogorc mtkicebulebebi, romlebicsportuli miRwevebis gaumjobesebis Sesaxeb msjelobis saSualebas mogvcemda (10).warmodgenili monacemebis mixedviT es nivTierebebi mcire efeqtiTa damniSvnelovani riskiT xasiaTdebian, ris gamoc efedris gamoyeneba unda SeizRudos.literatura1. Mihoces G. Ephedrine: safe or lethal? Debate intensifies as supplement becomes the energy booster ofchoice for athletes. USA Today. Nov 8, 2001:C1, C2.2. Chass M. Pitcher’s autopsy lists ephedra as one factor. New York Times. March 14, 2003:D5.3. Gurley BJ, Wang P, Gardner SF. Ephedrine-type alkaloid content of nutritional supplements containingEphedra sinica (ma huang) as determined by high performance liquid chromatography. J Pharm Sci.1998;87:1547-1553.4. Gurley BJ, Gardner SF, Hubbard MA. Content versus label claims in ephedra-containing dietarysupplements. Am J Health Syst Pharm. 2000;57:963-969.5. Samenuk D, Link MS, Homoud MK, et al. Adverse cardiovascular events tempor ally associated with mahuang, an herbal source of ephedrine. Mayo Clinic Proc. 2002;77:12-16.6. Haller CA, Benowitz NL. Adverse cardiovascular and central nervous system events associated withdietary supplements containing ephedra alkaloids. N Engl J Med. 2000;343:1833-1838.7. Zahn KA, Li RL, Purssell RA. Cardiovascular toxicity after ingestion of “herbal ecstasy.” J Emerg Med.1999;17:289-291.8. Theoharides TC. Sudden death of a healthy college student related to ephedrine toxicity from a ma-huangcontaining drink. J Clin Psychopharmacol. 1997;17:437-439.9. Onuigbo M, Alikhan M. Over-the-counter sympathomimetics: a risk factor for cardiac arrhythmias inpregnancy. South Med J. 1998;91:1153-1155.10. Shekelle PG, Hardy ML, Morton SC, et al. Efficacy and safety of ephedra for weight loss and athleticperformance: a meta-analysis. JAMA. 2003;289(12)1537-45.Coronary Dissection and Thrombosis After Ingestion of EphedraSrikanth Sola, M.D., Tarek Helmy, Andro Kacharava,Division of Cardiology, Emory University, Atlanta, GeorgiaOver the counter dietary supplements that contain ephedra alkaloids are widely used in the United States forweight loss, energy enhancement, and to boost athletic performance. Several adverse reactions have beenassociated with the use of these supplements, including hypertension, myocardial infarction, stroke,arrhythmias, seizures, and death. The deaths of several athletes who took dietary supplements containing34

ephedra alkaloids have brought media attention to the possib le risks of these compounds and have lead someto question their safety. Despite warnings from the Food and Drug Administration (FDA) regarding the useof these compounds, such supplements are still widely used and have become a multi-billion dollar a yearindustry. In this article we present a case report and a brief review of the literature of the adverse effects ofthese compounds.The case regards a 50 year-old female who developed a myocardial infarction after taking an over the countersupplement containing an ephedra alkaloid. This case is unusual in that the patient developed both aspontaneous LAD dissection (probably causing the initial episode of ischemia) as well as acute OM1thrombosis (causing the recurrent ischemic episode), and that she was in a hypercoaguable state duringcoronary intervention resulting in failure of intracoronary thrombolysis and acute thrombosis of the LAD,despite use of full anticoagulation and glycoprotein IIb/IIIa blockers. Although the patient had a history ofmild hypertension in the distant past, this had been well controlled without medications on a regimen of dietand exercise. She did not have any other risk factors for coronary artery disease, nor had she been taking anyother medications or supplements for several months prior. While it is not possible to prove causation basedon a single patient case, we feel that the occurrence of both an acute thrombus and an arterial dissection, aswell as the temporal relationship of the patient’s ephedra ingestion to her myocardial infarction, suggest anassociation between ephedra alkaloid ingestion and her acute coronary event.LMLADLCXsur. 1 marcxena koronaruli arteriis ganSreveba da Trombozi35

marcxena koronaruli arteriis koronaruli angiograma, romelzec aRiniSnebapirveli marginaluri arteriis totaluri okluzia (TeTri isari) da marcxenawina daRmavali arteriis ganSreveba (Savi isari).LAD - marcxena wina daRmavali arteriaLM - marcxena ZiriTadi arteriaLCX - marcxena Semomxvevi arteriauwyveti samedicino ganaTlebauwyveti samedicino ganaTlebis saWiroebaTa Sefasebis aucilebloba(usg)jefri r. normani, siuzan i. Senoni, maikl l. merinimakmasteris universiteti, hamiltoni (ontario, kanada)BMJ 2004, 328:999-1001 ©(moamzades n. demetraSvi lma da z. kirtavam)Sesavaliprofesiuli kompetenturobis SenarCuneba profesionalizmis kritikuladmniSvnelovan komponents warmoadgens. tradiciuli meTodebi, romlebic eyrdnobaindividualur TviTSefasebas, sadReisod araadekvaturia. amavdroulad, aranaklebrTulia kanonmdebrivi reserTifikaciis programebis individualizireba, romlebicxSirad aRiqmeba rogorc dromoWmuli. amitom saWiroa SemuSavdes standartizebulindividualur saWiroebaTa Sefasebis ukeTesi meTodebi. Cven gTavazobT ramdenimeSesaZlo strategias.winaistoriayvela profesiis msgavsad, medicinas sazogadoebis mier miniWebuli aqvsprofesiuli avtonomia, im daSvebiT, rom masSi momuSave praqtikosebi miCneulniiqnebian kompetenturebad praqtikuli saqmianobis dawyebisas da SeinarCuneben amkompetencias praqtikuli saqmianobis ganxorcielebis manZilze. tradiciulad, esaris individualuri pasuxismgebloba, rom praqtikosma akeTos yvelaferi, racsaWiroa imisTvis, raTa SeinarCunos kompetenturoba 1 .warsulSi kompetenturobis SenarCuneba ar iyo problematuri sakiTxi, vinaidansaTanado axali codnis akumulireba nela mimdinareobda. dResdReobiT ki eqimsar unda hqondes imedi, rom darCeba kompetenturi umaRlesi saswavleblisdamTavrebidan xuT welze meti xnis manZilze. am problemis erT-erTi pasuximoiZebneba uwyvet saganmanaTleblo programebSi, gansakuTrebiT – problemazeorientirebul midgomaSi. kerZod ki, unda fokusireba xdebodes TviTSefasebisunarisa da TviTSemswavleli unar-Cvevebis ganviTarebaze, raTa moxdes samedicino©- statiis gamoqveyneba SeTanxmebulia BMJ-s redaqciasTan1- amave dros qveynebis umravlesobas gaaCnia specialuri regulatoruli sistemebi amkompetenturobis periodulad gansasazRvravad, Tumca isini xSirad gansxvavebulia.36

kursdamTavrebulebSi kompetenturobis SenarCunebis moTxovnilebis Camoyalibebada maTi saTanado unariT aRWurva. sxvadasxva (Tumca aramravalricxvovani)monacemebis mixedviT, es iyo praqtikulad ganuxorcielebadi sakiTxi. ver vityviT,rom problemaze dafuZnebuli swavlagavlili medikosebi ukeT inarCuenebenkomptenecias wlebis ganmavlobaSi. metic, aSkaraa, rom TviTSefaseba aris imazeufro rTuli, vidre Cven vfiqrobdiT. da bolos, TviTSefaseba ar aRmocendaumaRlesi ganaTlebis damTavrebis Semdeg, rogorc cvalebadi praqtikis moTxovnisSedegi. siblisa da Tanaavt. dakvirvebebis mixedviT, praqtikosebs midrekileba aqvTmiiRon ganaTleba im sferoSi, romelSic isini isedac sakmaod kargad erkvevian,maSin roca Tavs arideben im sferoebs, sadac namdvilad ar arian srulyofilni.dakvirvebebis mixedviT, TviTmonitorirebis programebi, iseTebi, rogoric ariskompetenturobis SenarCunebis programa (kSTp), romelic tovebs praqtikosebs maTxelSive arsebul saSualebebTan, SesaZloa uimedod optimisturi iyos. norcinismixedviT, moxaliseobrivi reserTifikaciis strategiis yvela mcdeloba, romelicganxorcielda samedicino specialistebis amerikuli sabWos wevrebis iniciativiT,Cavarda da sabolood mainc Seicvala savaldebulo procedurebiT.aqedan gamodinare didi mcdeloba iqna Cadebuli kompetenturobis SenarCunebisufro formalizebul (standartul) midgomebze. amis ramodenime modeli arsebobs- magaliTad, formaluri dakvirvebiTi recenzia (formal peer review), da, sadacsaWiroa, remediacia (remediation - koreqtivebis Setana), anda - werilobiTireserTifikaciis gamocda. yvela maTgani Zviria. formaluri dakvirvebiTi recenzia,romelTa individualizireba aucilebelia, gansaxorcieleblad rTulia immasStabiT, romelic saWiroa adekvaturi monitoringis uzrunvelsayofad farToiurisdiqciis pirobebSi. rogorc norcini miuTiTebs, standartuli auditisgamoyeneba SesaZlebelia mxolod SedarebiT erTnair pirobebTan/mdgomareobebTanmimarTebaSi, maSin roca specialistTa umravlesobis praqtika mniSvnelovanwiladmimarTulia iSviaT, magram klinikurad mniSvnelovan mdgomareobaTa diagnostikasada mkurnalobisaken. gamocdebs aqvT masStabis ekonomia (rac metia monawile, miTnaklebia TiToeul maTganze danaxarjebi), magram maTi Sesabamisoba arsebulkompetenturobasTan an individualuri praqtikis saWiroebebTan saeWvoa, da Tanac,testebis Seqmna da ganaxleba ZviradRirebulia. da bolos, orive es strategiamowodebulia licenzirebis kanonis farglebSi operirebisaTvis, da amgvarad,naklebad savaraudoa maTi nebayoflobiTi miReba.ra aris sadReisod saWiro? iseTi midgomis gamoZebna, romelic oqros Sualediiqneba `TviTSefasebis anarqiasa~ da `ufrosi Zmis~ (cenzoris) midgomebs Soris;strategiebi, romlebic danaxuli iqnan rogorc mxardamWeri da individualuristrategiebi, kvlav miznobrivad rCebian. bolo drois fokusireba uwyvetisamedicino ganaTlebis (usg) swavlebis saWiroebebis Sefasebaze imedis momcemia.Semajamebeli Tezisebiuwyveti samedicino ganaTlebis tradiciuli midgomebi, romlebicdafuZnebulia praqtikosebis mier maTi codnis TviTSefasebasa daTviTSeswavlaze, savaraudod araefeqturni ariancentralizebuli meTodebi, iseTebi, rogoricaa regularulirelicenzireba an reserTifikaciis gamocdebi individualuripraqtikis maxasiaTeblebisadmi rTulad mosargebia da praqtikosi37

medikosebis mier aRiqmeba rogorc safrTxeaucilebelia saWiroebebis Sefasebis inovaciuri strategiebiganxilulia ramdenime strategia, maT Soris - praqtikuliauditisa da standartizebuli Sefasebebis strategiebi.ratom aris mniSvnelovani uwyveti samedicino ganaTlebis saWiroebaTa Sefasebausg saboloo mizani mdgomareobs imaSi, rom eqimebis praqtikuli qcevebis SecvliTgaumjobesdes Sedegi pacientisaTvis – daavadebis diagnostikisa da mkurnalobismaqsimalurad usafrTxo da efeqturi axali, dasabuTebuli meTodebis gamoyenebisada moZvelebuli meTodebis praqtikidan droulad amoRebis meSveobiT.literaturis sistematuri mimoxilvebidan Cans, rom uwyveti samedicinoganaTlebis programebi, romlebic momzadebulia saWiroebaTa kargad momzadebulSeswavlaze dayrdnobiT, efeqturni arian eqimebis qcevebis SecvlaSi. amaRmoCenebis Sesabamisad cvlileba moxda uwyvet samedicino ganaTlebaze, mismiznebsa da efeqturobaze SexedulebebSi. arasaganmanaTleblo miznebis mqonedawesebulebebis mier uwyveti samedicino ganaTlebis SemoTavazebebis pasiurmimRebad yofnis nacvlad, adgili aqvs eqimebis met iniciativas, rom maT aqtiuradmoaxdinon imis SerCeva, Tu ra unda iswavlon, rogor unda iswavlon da rommoxdes Seswavlilis Sedegze asaxva. TviTSeswavlis midgomis saWiroebebisdasakmayofileblad gafarTovda uwyveti samedicino ganaTlebis formati, raTamoicvas seminarebi, mcire praqtikaze dafuZnebuli saswavlo jgufebi, kompaqtdiskebismeSveobiT miwodebuli individualizirebuli programebi, veb-gverdebi,samuSao wignebi, Jurnalebi, praqtikuli gaidlainebi, sarecenzio konsultaciebida “akademiuri detalizireba”. kursis formatis aseTi gziT gavrceleba dRemdewarmoadgens codnis miwodebis meTodebis erT-erT nairsaxeobas. miuxedavadprezentaciis formatisa, SeTavazebebi SesaZlebelia iyos araefeqturi, Tuki armoxda maTi Sinaarsis safuZvliani Seswavla da gamarTleba specifiurisaWiroebebis Sefasebis meSveobiT.swavlis saWiroebebi gansxvavdeba saganmanaTleblo saWiroebebisagansadReisod Rrma naprali rCeba individualuri praqtikosis swavlebissaWiroebebsa da kursebis SemomTavazebeli usg uwyebebis mier gansazRvrulsaganmanaTleblo saWiroebebis prioritetebs Soris. es ori erTmaneTis sinonimiar aris. swavlebis saWiroebebi aris personaluri, specifiuri da ganisazRvrebaindividualuri Semswavlelis mier miRebuli praqtikuli gamocdilebiT, dasmulikiTxvebiT, praqtikuli auditiT, TviTSefasebis testebiTa da wyaroebiT. TumcaTeoriulad eqimebi unda iyenebdnen am meTodebs, raTa Seqmnan TviTswavlebisgegmebi, magram praqtikaSi eqimebis umravlesobisaTvis aseTi ram ar SeiniSneba.saganmanaTleblo saWiroebebi ki SesaZloa ganisazRvros rogorc mTelimiznobrivi auditoriis interesebis gamoxatuleba an aRqmuli saWiroebebi, daSiZleba dadgindes Semowmebebis, fokusuri jgufebis, regionaluri praqtikisnimuSebis analizisa da usg programebis Sefasebebis meSveobiT. isini ufro zogadxasiaTs atareben, vidre swavlebis saWiroebebi da SesaZloa mimarTuli iyonrogorc monawileTa cnobismoyvareobisa da akademiuri interesebis, aseve - kargadgansazRvruli individualuri swavlebis saWiroebebis dasakmayofileblad.saganmanaTleblo saWiroebebis Sefasebebis magaliTi aris gansxvavebaTa anu38

napralis analizi, romlis drosac adgili aqvs sadReiso (realurad moqmedi)praqtikuli qcevis Sedarebas praqtikis idealur an miRebul standartebTan. amissapirispirod, individualur SemTxvevaTa magaliTze im sakiTxebis Seswavlam,romlebmac Seqmnes es intervali, SesaZloa gansazRvros swavlebis saWiroebebi.romelia winmsvleli gza?Tu eqimebs ar SeuZliaT saimedod Seafason TavianTi sakuTari swavlebissaWiroebebi, xolo didi masStabis gamokiTxvebs ZaluZT Seafason mxolodsaganmanaTleblo saWiroebebi, ra iqneba winmsvleli gza? Cven gvWirdebagavzardoT swavlebis saWiroebebis Sefasebebis obieqturoba, imavdroulad adgiliunda hqondes usg procesis gamartivebas, raTa eqimebma regularulad gaiaron esprograma. mcirericxvovani kvlevebia Catarebuli, romlebic mimarTuli iqnebodasaWiroebebis Sefasebis teqnologiis gaumjobesebisaken.damtkicebuli strategiebierT-erTi midgoma xorcieldeba ufro metad struqturuli praqtikis auditismeSveobiT. perolma da Tanaavt. aCvenes, rom eqimebma, romlebic awarmoebdnenswavlebis sakiTxebis saofiso vizitebis dRiurs, SeZles SeeqmnaT swavlebis ufrospecifiuri miznebi, vinem imaT, vinc amas ar akeTebda. am dakvirvebebismniSvnelobas ukavSirdeba bergusis da Tanaavt. daskvna, rom klinikuri sakiTxebisstruqtura warmoadgens konsultantebisagan sasargeblo pasuxebis mopovebisgasaRebs. kifma da Tanaavt. aRmoaCines, rom praqtikuli auditis ukukavSirikombinirebuli samagaliTo recenzentebis SedarebasTan da “miRwevad”niSnulebTan, aumjobesebs zogadi praqtikis eqimTa, TerapevtTa da endkrinologTajgufis mzrunvelobis Sedegebs diabetian pacientebSi.alternatiulad, swavlebis saWiroebebis ukeTesi ganmsazRvrelebi SesaZloamiRebuli iqnas standartizirebuli Sefasebebis savarjiSoebidan. kohenma daTanavt. gamoigones savarjiSo, romelic Sedgeboda 10 nawilisagan da saWiroebda25 wuTs. is modelirebul iqna obieqtur struqturul klinikur gamocdaze. maTisamedicino praqtikis saeqimo Sefasebis (PAMP) savarjiSo dagegmili iyo faqtiurisazogadoebrivi klinikuri praqtikis sakiTxebis asaxvisaTvis, ramac aCvenamisaRebi fsiqometriuli Tvisebebi, Tumca amavdroulad Rirda daaxloebiT 250dolari erT eqimze. es midgoma uzrunvelyofs eqimTa efeqturobis mdidarukukavSirs, magram unda viwrod fokusirdes im masStabze, romelic SesaZlebeliada logikuria samarTavad. globaluri Sefasebebi, romlidanac eqimebs SeuZliaTCamoayalibon TavianTi swavlebis saWiroebebi, SesaZloa mopovebuli iqnas asewodebul 360 gradusiani SefasebebiT. masoni da Tanaavt. aRwerdnen am midgomispilotur swavlebas, maT Soris 20 eqims. monawileebis Sesaxeb komentarebis farTodiapazoni iqna mopovebuli, magram maRali fasi da dro - 5 saaTi erT eqimze,SesaZloa seriozuli winaRoba aRmoCndes am strategiis danergis gzaze, rocasaqme did saavadmyofos exeba.potenciuri strategiebisaWiroebebis Sefasebis es strategiebi Sefasebuli iqna rogorc sakmaod efeqturi.Cven gvjera, rom Rirs sxva strategiebis Seswavlac. eleqtronuli samedicino39

istoriebi praqtikis profilis analizis SesaZleblobis TvalsazrisiT sakmaodsaimedo Cans. saTanadod dagegmili sistemis dros, eqimebs SeuZliaT CaataronTavianTi diagnostikuri unar-Cvevebisa da Terapiuli spqtris sakuTari miznobrivianalizi. SesaZlebelia procesis ise avtomatizireba, rom SerCeul klinikurproblemebze profilebi iqmnebodes gansazRvruli intervalebiT. aseTi analiziSesaZlebelia wardgenili iqnas ganxilvaze uwyveti samedicino ganaTlebisadgilobriv akademiur erTeulebSi an maregulirebel uwyebaSi, rogorc SefasebisniSani da gamoyenebuli iqnas uwyveti ganaTlebis kreditebisaTvis. maSin, rodesacanalizi warmoSobs wminda informaciul sakiTxebs, praqtikis profilebi SesaZloaeleqtronulad emTxveodnen Sesabamis praqtikul gaidlainebs an mimoxilviTstatiebs da eqimTan gadagzavnil Sesabamis dokumentebs. swavlebis unikalursakiTxebSi uwyveti samedicino ganaTlebis adgilobrivma akademiurma erTeulebmaSesaZloa daxmareba gauwion TavianT eqimebs ganaviTaron personalizirebulisaganmanaTleblo gegmebi. aseTi analizis sawarmoeblad eleqtronul samedicinoCanawerebis gamoyenebas gaaCnia efeqturobis upiratesoba da obieqturoba,vinaidan analizi dafuZnebulia yvela Sesabamis pacientze.rogorc perolis praqtikis dRiuris meTodis gagrZeleba (gafarToeba), eqimebsSeuZliaT Seinaxon Canawerebi maTTvis saintereso da problematur `daraj~(sentinel) pacientebze. unda SemuSavdes kompiuteruli programebi (software), raTadaxmareba gaewios pacientebis Sesaxeb arsebiTi informaciis struqturuli gziT`daWeras~ da uzrunvelyofil iqnas Canawerebis kodirebis saSualebebi samomavloZiebisaTvis da informaciis amosaRebad.uwyveti samedicino ganaTlebis akademiur erTeulebs SeuZliaT Seqmnan mokle,TiToTemiani savarjiSoebi praqtikis auditis mizniT, rac eqimebs an maTi ofisisTanamSromlebs SeeZlebaT Seavson. Sevsebuli profili, romelic isev undaSedardes maRali xarisxis dasabuTebul mimoxilvebs an klinikuri praqtikisgaidlainebs, SeiZleba ukan daubrundes eqims gasacnobad. uwyveti ganaTlebiskreditebi SesaZloa mopovebul iqnas auditis nakrebis dasrulebiT andadamatebiTi kreditebiT, romelic miiReba savarjiSoebis dinamikaSi keTebiT. esmeTodi iZleva alternatiul meTods, im SemTxvevaSi, roca recenzirebismonacemebi xelmisawvdomi ar aris.es midgomebi warmoadgenen mcdelobas, rom swavlebis saWiroebebis Sefasebebigaxdes ufro obieqturi, SedarebiT martivi da gansaxorcileblad arc ise Zviri.rasakvirvelia, sxva midgomebic iarsebebs, romlebic Cven ar gangvixilavs.moiazreba uwyveti samedicino ganaTlebis akademiuri erTeulebis origansxvavebuli roli. tradiciuli kursebis momzadebis damatebiT, akademiurmaganyofilebebma SesaZloa Secvalon eqimebisadmi TavianTi daxmarebis mcdelobaswavlebis saWiroebebis Sefasebis vargisiani saSualebebis gamoyenebisa daswavlebis gegmebis ganviTarebis mimarTulebiT. amis dafinanseba SeiZlebaganxorcieldes calke anda erToblivad eqimebis, maTi maregulirebeli uwyebebis,specialobaTa sazogadoebebis da mTavrobis mier. zogierTi iurisdiqciiT,maregulirebel uwyebebs (mag. jandacvis saministroebs) SesaZloa surdeTSeinarCunon mxolod maregulirebeli roli, xolo saganmanaTleblo rolidatovon uwyveti samedicino ganaTlebis akademiuri erTeulebis kompetenciaSi.sxvagan ki, maregulirebel uwyebebs SeiZleba surdeT daitovon orivezemoTaRniSnuli funqcia. saboloo jamSi nebismier qveyanaSi unda gamomuSavdes40

iseTi midgoma, romelic gaiTvaliswinebs adgilobriv Taviseburebebs, eqimTaraodenobas, da sakanonmdeblo bazas.swavlebis saWiroebaTa gansazRvris potenciuri strategiebi:1. perioduli Sida auditi eleqtronuli ofisis CanawerebisgamoyenebiT,2. individualizirebuli auditis Sedegebis Sedareba mimdinareliteraturasTan an klinikuri praqtikis gaidlainebTan,3. individualizirebuli auditis Sedegebis SedarebasamagaliTo recenziebTan (`niSnulebis~ meTodi),4. TiTo sakiTxiani auditis savarjiSo, momzadebuli uwyvetisamedicino ganaTlebis adgilobrivi akademiuriganyofilebis mier,5. “guSagi” pacientebis Sesaxeb Canawerebis warmoeba da gansja.literatura:1. Sibley JC, Sackett DL, Neufeld V at al., A randomized trial of Continuing Medical Education. N Eng JMed, 1982;306:511-5.2. Norcini JJ. Recertification in the United States. BMJ, 1999; 319:1183-5.3. Perol D, Boissel J-P, Broussole C, et al. A simple tool to evoke physicians’ real training needs. AcadMed. 2002, 77:407-10.4. Berguss GR, Randall CS, Sinift SD, Rosenthal DM, . Does the structure of clinical questions affect theoutcome of curbside consultations with speacility colleagues? Arch Fam Med.2000; 9:541-7.5. Kiefe CI, Allison JJ, Williams OD et al. Improving quality improvement using achievable benchmarksfor physician feedback. A randomized controlled trial. JAMA, 2001;285:2871-9.6. Cohen R, Amiel GE, Tann M et al. Performance assessment of community-based physicians evaluatingthe relaibility and validity of a toll for determining CME needs. Acad Med. 2002; 77:1247-54.The Need for Need Assesment in Continuing Medical EducationG.R Norman, S.I. Shannon, M.L. MarrinBMJ 2004, 328: 999-1001Maintenance of professional competence is a critical component of professionalism. Traditional approachesto continuing education that reply on self assessment and self training are likely to be ineffective. Centralisedmethods, such as regular relicensure or resertification examinations, are difficult to tailor to thecharacteristics of individual practices and are perceived as threatening by physicians. Innovative strategiesfor needs assessment are needed. Several strategies are reviewed, including: periodic internal audits by usingelectronic office records, individualised audit results compared with current literature or practice guidelines,individualised audit results compared with exemplary peers (benchmarking), single issue aud it toolsdeveloped by local academic units for continuing medical education, and facilitated notekeeping andreflection around sentinel patients.41

ioinformatikadargis mimoxilvanino demetraSvili,erovnuli sainformacio saswavlo centrinino_demetrashvili@nilc.org.geram ganapiroba bioinformatikis disciplinis Camoyalibeba?Tanamedrove biologiisa da genuri teqnologiis ganviTarebam warmoqmnainformaciis siuxve. ramdenime samodelo organizmis STamomavlobiTi informaciiskvleva sistematurad mimdinareobs rodesac maTi genomis sruli nukleotidurimwkrivi aris gansazRvruli. udaoa, rom yvela am eqsperimentalur monacemebs damisgan warmoqmnil informacias udidesi zegavlena eqneba biologiis yveladisciplinaze, maT Soris medicinaze. am sferoSi monacemebis marTvisa daanalizisaTvis gaCnda maTematikis, statistikisa da kompiuteruli mecnierebisgamoyenebis mzardi moTxovnileba. dasaxelebuli disciplinebis kopleqsuricodnis moTxovnilebam ganapiroba bioinformatikis Camoyalibeba.rogor exmareba bioinformatika biologebs?biologia 21 saukuneSi ganicdis transformacias wminda laboratoriazedayrdnobili mecnierebidan informaciuli mecnierebisaken. molekuluribiologiis mZlavrma winsvlam bolo ramdenime wlis ganmavlobaSi, maT Sorisgenomis kvlevis mudmivad mzardma monacemebma migviyvana didi moculobisbiologiur informaciis dagrovebamde, rac rTuli gasaSifria samecnierosazogadoebis mier. bioinformatika moicavs monacemebis miRebas, organizebas,analizsa da Senaxvas, rac moiTxovs kompiuteruli meTodebis daxmarebas.sxvadasxva meTodebis meSveobiT is advilad xelmisawvdoms xdis informaciisswored im eqstraqtis amoRebas, romelic biologs sWirdeba. amgvarad,bioinformatikis umTavresi amocana mdgomareobs sxvadasxva tipis monacemebisanalizsa da interpretaciaSi, maT Soris-nukleotiduri da aminomJavurimwkrivebis, cilebis sferosa da cilebis struqturebis amocnobaSi. es saboloodexmareba biologebs ujreduli moqmedebebis Sesaxeb amomwuravi suraTis miRebaSi.vin SeiZleba gaxdes bioinformatikosi?nebismieri biologiis mtkice codniT, umjobesia sabunebismetyvelo mecnierebismagistri, romelsac gaaCnia am sferosaTvis saTanado kompiuteruli codna daunar-Cvevebi. bioinformatika aseve moiTxovs logikur msjelobasa dagadawyvetilebis miRebis karg unars.42

a aris bioinformatikis kvlevis are?kvleva bioinformatikaSi moicavs iseTi unar-Cvevebis ganviTarebasa daganxorcielebas, romelic iZleva sxvadasxva tipis informaciisadmi efeqturadxelmisawvdomobis saSualebas. kvlevis meore are moicavs iseTi algoriTmebisSeqmnas, romelic prognozirebas gaukeTebs sxvadasxva biologiur monacemebsrogoric aris genebi, cilis funqcia, cilis struqtura da sfero, aseve SeafasebsfarTo monacemebs Soris arsebul damokidebulebas. dResdReobiT Zalian xSiradmecnierebi axorcieleben Ziebebs monacemTa bazebSi, imisaTvis rom ganaxorcielonhipoTezebis formulireba da farTo masStabis eqsperimentebis dizaini. genomis,proteomikis sferom gaiara grZeli gza, rac bioinformatikuli analizisxelSewyobiT xdeboda.ra aris SedarebiTi genomi?SedarebiTi genomi moicavs sxvadasxva organizmebis genomis Sedarebas, genetikurdoneze maTi konservaciis Seswavlasa da nimuSebis mopovebas, ramac SesaZloamoamzados axali genebis aRmoCena da evoluciuri damokidebulebebis dadgena.adamianis genomis proeqti mimdinareobda 1990-2003 wlebSi, romelsackoordinirebas uwevda energiisa da janmrTelobis erovnuli institutisdepartamenti. adamianis dnm-is Tanmimdevrobis dadgenis proeqtis dasrulebadaemTxva vatsonisa da krikis mier dnm-is fundamentaluri struqturis aRweris50 wlisTavs. adamianis genomis proeqti moicavda iseT sakiTxebs, rogoric arisgenetikuri da fizikuri rukebis Sedgena, dnm-is Tanmimdevrobis dadgena,dasrulebuli Tanmimdevrobis simZlavrisa da Rirebulebis garkveva, genebisidentifikacia, samodelo organizmebis genomis Tanmimdevrobis dasruleba,genebis funqcionaluri analizi.bioteqnologiis informaciis erovnuli centris (biec, National Centre forBiotechnology Information (NCBI) Sesaxebsenatorma klaudi peperma Seicno kompiutizirebuli informaciis damuSavebismeTodebis aucilebloba biosamedicino kvlevebis CatarebisaTvis, ramac ganapirobabioteqnologiis informaciis erovnuli centris daarseba 1988 wlis 4 noembers. esdawesebuleba warmoadgens janmrTelobis erovnuli institutis (NIH) mediciniserovnuli biblioTekis (NLM) danayofs. medicinis erovnuli biblioTeka iyoSerCeuli imis gamo, rom mas gamocdileba hqonda biosamedicino monacemTa bazebisSeqmnasa da SenaxvaSi. Bbiec-is misia aris axali sainformacio teqnologiebisganviTareba, rac xels Seuwyobs iseTi fundamentaluri molekuluri dagenetikuri procesebis codnas, romlebic akontroleben janmrTel da daavadebulorganizmebs. ufro zustad ki, biec xelmZRvanelobas uwevs molekuluribiologiis, bioqimiisa da genetikis Sesaxeb arsebuli codnis Senaxvasa daanalizisaTvis avtomaturi sistemebis Seqmnas; samecniero sazogadoebis mier ammonacemTa bazebis gamoyenebis xelSewyobas; bioteqnologiis informaciis erovnulda saerTaSoriso doneze Segrovebis koordinirebul mcdelobas; da kvlevisCatarebas kompiuterze dayrdnobili informaciis damuSavebis mowinave meTodebiT,raTa dadgindes biologiurad mniSvnelovani molekulebis struqtura da funqcia.43

sad gamoiyeneba bioinformatika da rogor?bioinformatikis saSualebebi gamoiyeneba evoluciur biologiaSi, cilebismodelirebaSi, genomis rukis Sedgenasa da funqcionalur genomSi.evoluciuri biologiidan Tu daviwyebT, sakmaod saintereso iqneboda sxvadasxvaorganizmebs Soris arsebuli nimuSebisa da evoluciuri damokidebulebebisdadgena, risTvisac saWiroa dnm-sa da cilebis Tanmimdevrobis dadgena. cilebs,romlebic gviCveneben mniSvnelovnad dakonservebul Tanmimdevrobas, ganekuTvnebianerTsa da imave ojaxs. cilebis nakecebisa (protein folds) da ojaxebis SeswavliT,mecnierTaTvis SesaZlebeli gaxdeba aRadginon or saxeobas Soris arsebulidamokidebuleba, aagon evoluciuri xeebi.dResdReobiT cilebis struqturebis dadgenis sami ZiriTadi gza arsebobs:rentgenis sxivebiT kristalografia, birTvul-magnituri rezonansi dakompiteruli modelireba. es bolo meTodi iyenebs eqsperimentalurad dadgenilicilebis struqturebs (Sablons), raTa prognozi gaukeTos axali cilisstruqturas, romelic Sedgeba msgavsi amonomJavebis Tanmimdevrobisagan (samizne).kristalografiis meTodi sakmaod ZviradRirebuli da metad zusti saSualebaacilis struqturis dasadgenad, Tumca is ver gamoiyeneba yvela cilis SemTxvevaSi,vinaidan yvela cila ar kristaldeba. kompiuteruli modelireba aris naklebadzusti danarCen or meTodTan SedarebiT, Tumca imavdroulad bevrad iafi dagamoyenebadi yvela cilis SemTxvevaSi. maTematikuri statistikis elementebi kigvexmareba imis dadgenaSi, Tu ramdenad zustad moxda cilis struqturiswinaswarmetyveleba (modelis Sesafaseblad).genomis rukis dadgenis sakiTxi SeiZleba iTqvas amowurulia, vinaidan gaSifruliaiseTi rTuli organizmis genetikuri kodi, rogoric aris adamiani. magram rasiZleva kodis gaSifrva (nukleotidebis Tanmimdevrobis codna), Tu ar dadgindaromeli geni an genebis jgufi ra funqciazea pasuxismgebeli? amaze pasuxs scemsfunqcionaluri genomi. genebis funqciebis amocnobis mravali gza arsebobs.genebis gamoxatuleba (eqspresia) Seiswavleba sxvadasxva qsovilebsa daSemTxvevebSi. bioqimiisa da kompiuteruli biologiis meSveobiT xdeba cilebisstruqturisa da urTierTqmedebis dadgena. bunebrivad an eqsperimentaluradmomxdari genis mutaciis Seswavla metad mniSvnelovania funqciebis dasadgenad.komplementaluri dnm-is (kdnm) mikroCifsi (complementary DNA microarray - cDNA),rogorc genebis funqciebis dadgenis erT-erTi farTod gavrcelebuliteqnologia:ujredi Seicavs genebis srul kompleqts. biologiis centraluri dogmidancnobilia, rom cilis warmoqmnis procesi Semdeg elementebs moicavs:genitranskripcia (transcription)mrnmmesinjeri rnm (messenger RNA)44

translacia (translation)cilatranskripciis procesi aris uaRresad regulirebuli da genebis is kompleqti,romelic eqspresirdeba ujredis sxvadasxva tipis mier da sxvadasxvafiziologiuri zewolis dros varirebs. TiToeuli genisaTvis, mrnm-is odenoba,romelic transkripcirdeba am genis mier, ganisazRvreba rogorc misi eqspresiisdone. eqspresiis donis Seswavlis mniSvneloba mdgomareobs imaSi, rom swored misicvalebadoba da sxvaoba asaxavs ujredebis funqciebis sxvaobas.kdnm mikroCifsis analizi aris erT-erTi im meTodTagani, romelic iZlevasaSualebas winaswargansazRvruli genebis kompleqtisaTvis ganisazRvroseqspresirebis done, e.w. transkripciis profili. am meTodis upiratesobamdgomareobs imaSi, rom is SesaZleblobas iZleva ganisazRvros eqspresirebis donegenebis farTo kompleqtisaTvis zomier fasSi. genebis kompleqtis “mTeli suraTi”warmodgenilia erT Cifsze, am teqnologias gaaCnia maRali mwarmoebluroba.Bioinformatics – reviewN. Demetrashvili, National Information Learning Centrenino_demetrashvili@nilc.org.geThe development in modern biology and gene technology has generated a wealth of information.The hereditary information of several model organisms are systematically examined as thecomplete nucleotide sequences of their genomes are being determined. There is no doubt that allthis experimental data and the information derived from it will have a tremendous impact on alldisciplines of biology, including medicine. For the management and analysis of data in this fieldthere is a growing demand for tools provided by mathematics, statistics and computer science.Bioinformatics was established as a discipline to meet the growing demand of complex knowledgeof aforementioned disciplines.How does bioinformatics help biologists?Biology in the 21st century is being transformed from a purely lab-based science to an informationscience as well. Major advances in the field of molecular biology over the past few years includingthe evergrowing genomic data have led to a large amount biological information which is difficult todecipher by the scientific community. Bioinformatics is all about retrieving, organizing, analyzingand storing data which will require the help of computational methods. It delivers easy access ofinformation and projects a method for extracting only that information that is specifically asked bythe biologists. Therefore, the field of bioinformatics has evolved such that the most pressing taskinvolves the analysis and interpretation of various types of data, including nucleotide and aminoacid sequences, protein domains, and protein structures. This ultimately helps the biologist toobtain a comprehensive picture of the cellular activities.[1] http://www.math.chalmers.se/Stat/Bioinfo/Master/[2] http://inbios.hprd.org/faqs[3] http://www.ncbi.nlm.nih.gov/About/primer/bioinformatics.html45

[4] Bondjers C. (2003) A functional genomics approach to PDGF and pericyte biology. PhDDissertation[5] Demetrashvili N. (2004) Statistical and Bioinformatics Aspects on the Detection of PericytespecificGenes by cDNA Microarray. Master Thesis.konferenciebiamerikis telemedicinis asociaciis me-9 yovelwliuri konferencia(tampa, florida, 2-5 maisi, 2004 w)zviad kirtava, erovnuli sainformacio saswavlo centris direqtorizkirtava@nilc.org.ge28 aprilidan 9 maisamde vimyofebodi mivlinebiT aSS-Si – vaSingtonsa da tampaSi -prezentaciebiT telemedicinis da distanciuri swavlebis sferoSi. aRniSnulimivlineba dafinansda Sveicaruli organizaciis `saerTaSoriso urTierTobaTa dausafrTxoebis qselis~ (International Relations and Security Network – ISN) mier, romelTanacerovnuli sainformacio saswavlo centri TanamSromlobs 2000 wlidandistanciuri swavlebis programuli platformis ganviTarebis sferoSi.29 aprils vaSingtonSi, aSS-Si Sveicariis saelCoSi Catarda prezentacia, sadacCems mier warmodgenili iqna jandacvis telematikis (telemedicinis dadistanciuri swavlebis) sferoSi saqarTveloSi ganxorcielebuli proeqtebi dasamuSaoebi. amave seminarze Cveni meore partniori organizaciis - aSS-is`partnioroba mSvidobisaTvis sainformacio marTvis sistemis~ (Partnership for PeaceInformation Management System – PIMS) warmomadgenlis q-n meripat moleris mierwarmodgenili iqna telemedicinis piloturi proeqti uzbekeTSi, xolo rumineTisarmiis telemedicinis koordinatoris aurelian morarus mier – telemedicinissferoSi rumineTis gamocdileba. seminars, garda Sveicariis saelCoswarmomadgenlebisa, daeswrnen italiis da rumineTis saelCoebis, aseve -vaSingtonSi arsebuli telemedicinis organizaciebis warmomadgenlebi.2-5 maiss tampaSi (floridis Stati) Catarda amerikis telemedicinis asociaciis(ata) yovelwliuri konferencia, romelsac 1200-ze meti delegati eswreboda. 1maiss aqve Catarda erTdRiani winasakonferencio seminari, romelic organizebuliiyo aSS armiis telemedicinis da uaxlesi teqnologiebis kvlevebis centris(Telemedicine and Advanced Technology Research Centre – TATRC) mier. swored am seminarze,romelic wels aRmosavleT evropas mieZRvna deviziT – `SevxvdeT samedicinoproblemebs cvalebad samyaroSi!~ - warmodgenil 8 Tematur moxsenebas Soris erTerTiiyo Cemi moxsenebac – `distanciuri swavlebis meTodebi saqarTvelosaTvis~,romelic sakmao interesiT iqna miRebuli auditoriis mier. prezentaciis Semdeggadmomeca armiis telemedicinis da uaxlesi teqnologiebis kvlevebis centrisdireqtoris, aSS armiis general-leitenant lester martines-lopesis prizi dasamaxsovro medali.ata-s konferencia oficialurad 2 maiss gaixsna tampas SexvedraTa (konvenciebis)centris SenobaSi asociaciis prezidentis, tusonis universitetis profesoris46

onald vainSteinis mier. konferenciis msvlelobaSi Catarda 4 plenaruli da 60paraleluri seqcia, romelic ZiriTadad Semdeg specialur interesis jgufebsmoicavda: telejanmrTeloba binaze (telemonitoringi), teqnologiebi,teledermatologia, mentaluri telejanmrTeloba, telepaTologia, teleeqTnoba,telerabilitacia, biznesi da finansebi, adamianuri faqtori/treiningi,saerTaSoriso TanamSromloba.warmodgenili iyo 200-mde gamosvliTi da 100-ze meti posteruli prezentacia.konferencias eswrebodnen 50-ze meti qveynis warmomadgenlebi. Sexvedrissponsorebs Soris iyvnen telemedicinis aparaturisa da teqnologiebis msxvilimwarmoeblebi: AMD Telemedicine, Apollo Telemedicine, American Telecare, Polycom, GE MedicalSystems, Health Care Vision, Phone DoctorX, Nortel Networks, Verizon, ViTelNet, Viterion, MedWeb,IBM Life Sciences, HomMed, Samsung, Siemens Medical, SHL Telemedicine, TeleDoc, Tandberg, da sxv.konferenciaze warmodgenili iqna uamravi saintereso proeqti. veteranTa binazemonitoringis qseli mraval qronikul daavadebaTa gamwvavebis prevenciis mizniT(aSS veteranTa administracia da Health Hero Network); telepaTologiis erTianisistema didi tbebis 12 hospitals Soris, romelic saSualebas iZlevamorfologiuri daskvnebis konsultacias wamyvan eqspertebTan, rac droisa daxarjebis ekonomiisa (25 da 67%-iT) da maRali xarisxis miRwevis saSualebasiZleva (apolo telemedicine da didi tbebis regionis veteranTa saavaadmyofoebisqseli); teleradiologiis sistema retgenis suraTebis konsultaciis mizniTkaribis kunZul antiguas saavadmyofoebTan (Med Web da antiguas mTavroba);diabeturi retinopaTiis teleskriningi saSiS garTulebaTa droulad prevenciismizniT (Canon da `kaizer permanente~), videokonferenciebis sistema 130 daSorebulidawesebulebebis klivlendis universitetis hispitalTa gaerTianebidankonsultaciis mizniT (Polycom da klivlendis universiteti), telesonografiagarTulebul orsulobaTa bolo trimestris telemonitoringis mizniT (HealthCareVision da CrdiloeT texasis jandacvis dawesebulebaTa qseli); pediatriuligadaudebeli daxmarebis ukeT warmasarTavad telemedicinis gamoyeneba(kaliforniis universitetis da saavadmyofoebis qseli), sasoflo regionebSitravmatizmis msxverplTa swrafi mobilizaciis da konsultaciis sistema(vermontis samedicino koleji, texasis universiteti da aSS samxedro qirurgiulikvlevebis instituti); eqstremalur garemoebebSi (kunZuli diego garsia, kunZulioahu, havaize, da monRoleTis udabnoebSi) telemedicinis saSualebaTa gadatanisada aRWurvis gamocdileba (totaluri miRwevis centri, fort gordoni, jorjia davirjiniis Tanamegobrobis universitetis telemedicinis centri) da sxv.konferenciis sagamofeno darbazSi gansakuTrebuli yuradRebiT sargeblobdnenmobiluri komunikaciis sistemebi – gasaSleli mcire zomis satelituri antenebida am antenebiT aRWurvili saswrafo daxmarebis manqanebi telemedicinis sruliSesaZleblobebiT, robotuli qirurgiis mowyobiloba manZilze rTulioperaciebis Catarebis SesaZleblobiT, aSS samxedro Zalebis qveiTTa sabrZolomanqanis `straikeris~ brZolis velze da eqstremalur pirobebSi samedicinodaxmarebis varianti, mobiluri sameTauro punqti, romelsac telemedicinis dauaxlesi telekomunikaciebis aparaturis garda meti mimzidvelobisaTvis mcirezomis samwvade mayalic hqonda damontaJebuli (amerikelebi qarTvelebze naklebyuradRebas ar uTmoben mwvadis momzadebas!). amas Tan erTvoda Tavad qalaq tampasda misi zRapruli yuris silamaze, romlis srulad daTvalierebis saSualeba,saintereso da datvirTuli programis gamo, samwuxarod, ar momeca.47

gansakuTrebiT dasamaxsovrebeli iyo ori leqcia: Sraineris bavSvTasaavadmyofoebis qselis Sesaxeb (piter armstrongi) da kenet berdis xsovnisadmimiZRvnili rCeuli leqcia, romelic misTvis Cveuli brwyinvale iumoriT da natifstilSi waikiTxa amerikis telemedicinis asociaciis sapatio prezidentma, prof.jei sandersma (globaluri telemedicinis jgufi).konferenciis mimdinareobisas mqonda Sexvedrebi telemedicinis sxvadasxvacentrebis (virjiniis, arizonis, karolinis) da organizaciebis – armiistelemedicinis centris, telemedicinis saerTaSoriso sazogadoebis, luqsemburgisevropis telemedicinis qselis tel-e-med-is warmomadgenlebTan, amerikistelemedicinis asociaciis sapatio prezident jei sandersTan, prof. ronaldmerelTan (virjiniis Tanamegobrobis universiteti), dr. ron poropatiCTan(uolter ridis samxedro saavadmyofo), prof. maikl akermanTan (nacionalurisamedicino biblioTeka), dr. devid lemTan (nato), prof. maikl nerlixTan(telemedicinis saerTaSoriso sazogadoebis prezidenti, germaniis telemedicinisasociacia), dr. frenk liuvensTan (luqsemburgis telemedicinis saerTaSorisogamofena), dr. Carlz dornTan (cincinatis universiteti), prof. butC roserTan(kaliforniis universiteti), dr. rifat latifisTan (arizonis telemediciniscentri), dr. ivica klapanTan (xorvatiis telemedicinis asociaciis prezidenti) dasxva cnobil eqspertebTan.konferenciis daxurvisadmi miZRvnili sadili moewyo amerikuli fexburTiadgilobrivi gundis ` tampa beis mekobreTa~ reimond jeimsis saxelobisstadionze.American Telemedicine Association 9 th Annual Meeting, Tampa, FL, May 2-5, 2004Z. Kirtava, Director, National Information Learning Center, Tbilisi, GeorgiaAn observation of ATA recent meeting in Tampa. Dr. Z. Kirtava made presentation at concurrent workshoporganized by Telemedicine and Advanced Training Research Center. Dr. Kirtava’s trip was sponsored byInternational Relations and Security Network (ISN, Switzerland) and American International Health Alliance(AIHA).www.atmeda.org48

internetis samedicino Internet MedicaldaijestiDigest#1-2 (95-96)31.03.2004 *• did britaneTSi daibada bavSvi, romelsac guli sxeulis gareT aqvs• kardiologebi swavloben gulis daavadebis skriningis axal meTods• sisxlSi qolesterinis donis saganmanaTleblo erovnulma programam ganaaxlamozrdilTa mkurnalobis panelis III gaidlainebi• gulis ukmarobiT avadmyofebSi beta-blokerebi kargi efeqturobiT da sakmarisiamtanobiT xasiaTdebian• meoradi insultis ganviTarebis maRali riski aspirinTan SedarebiT gacilebiTefeqturad mcirdeba varfarinis Sesaferisi doziT mkurnalobis Sedegad• tvinis infarqtis zoma ufro mcirea da gamosavalic ufro ukeTesi, rodesac iSemiurinsults win uswrebs xanmokle iSemiuri Setevebi• arasteroiduli anTebis sawinaaRmdego wamlebis gamoyeneba amcirebs miokardiumisinfarqtis risks im pacientebSi, romlebic profilaqtikur aspirins ar iReben. Tumca,isini damatebiT damcvel rols ar asruleben aspirinis momxmareblebSi• acetaminofenis kavSiri asTmasTan• axali gaidlaini asTmis mqone orsuli qalebis mkurnalobis Sesaxeb• zogierTi gamoTvlis Tanaxmad, ruseTSi 1 milioni adamiania inficirebuli aivvirusiT, an daavadebulia SidsiT• aSS-s SidsTan brZolis saerTaSoriso sazogadoebam ganaaxla antiretrovirusulimkurnalobis rekomendaciebi• Baby born with heart outside body• Cardiologist Studying New Method of Screening for Heart Disease• The National Cholesterol Education Program (NCEP) has updated their Adult Treatment Panel (ATP) IIIguidelines• Beta-blockers are effective and tolerated well enough in patinets with heart failure• High risk of a secondary stroke is reduced more effectively by treatment with adjusted-dose warfarin than withaspirin• Brain infarct size is smaller and outcomes are better when ischemic strokes are preceded by transient ischemicattacks• NSAIDs appear to reduce the risk of myocardial infarction (MI) in patients not taking prophylactic aspirin.However, they do not seem to provide any extra protection to aspirin users• Acetaminophen relation with Asthma• New guidelines have been issued for treating asthmatic women during pregnancy• Researchers estimate over one million Russians to be having HIV/AIDS* - teqnikuri mizezebis gamo Jurnali da daijesti daibeWda 2004 wlis ivnisSi49

• International AIDS Society–USA has updated their recommendations for antiretroviral managementdid britaneTSi daibada bavSvi, romelsac guli sxeulis gareT aqvsdid britaneTSi daibada gogona Zalze iSviaTi paTologiiT – misi guli mdebareobsara gulmkerdis RruSi, aramed mis gareT, ityobineba BBC. miuxedavad amisa, axalSobiliCarli sauzerni (Charli Southern) gadarCa da is kvlavac eqimTa meTvalyureobis qveS imyofeba.bavSvi daibada vadamde 7 kviriT adre mdgomareobiT, romelsac medicinaSi guliseqtopia (Ectopia cordis) ewodeba. gulis eqtopia Cveulebriv aris mkerdis Zvlisa daperikardiumis ganuviTareblobis Sedegi, romlis drosac gulis midamoSi arsebulinaoWebi ver ixureba saTanadod da guli rCeba gulmkerdis gareT. Cveulebriv, aseTiaxalSobilebi maSinve iRupebian sisxlSi Jangbadis ukmarisobisa da ganviTarebuliinfeqciebis gamo.eqimebma Carlis gadarCenis Sansebi Seafases rogorc erTi milionTan, Tumca man kargadgadaitana ori urTulesi operacia da saqme iqamde midis, rom momavalSi gaxdebaCveulebrivi bavSvi yovelgvari problemebis gareSe.gulis kedlis defeqtis Canacvleba moxda kaniT da specialuri sinTetikurimasalisagan damzadebuli firfitiT (Gore-tex). ufro mozrdil asakSi, Carlis kidev erTioperacia elodeba, romlis drosac moxdeba mkerdis Zvlis rekonstruqcia. amJamad, 6kviris gogonas damoukideblad sunTqvac ki SeuZlia.`roial brisbenisa da qalTa hospitalis” eqimebi Carlis `patara saocrebas” uwodeben.kardiologebi swavloben gulis daavadebis skriningis axal meTodsmulticentruli kvlevis Tanaxmad, romelsac veiq forestis universitetis baptistTasamedicino centris kardiologi, medicinis mecnierebaTa doqtori, devid heringtoni(David M. Herrington) xelmZRvanelobs, adreuli stadiis aTerosklerozis skriningisaTvisarteriebis gasqelebis xarisxis gazomva SesaZloa warmoadgendes gulis daavadebisa dainsultis maRali riskis mqone adamianebis identificirebis erT-erT axal gzas.heringtonis kvleva daibeWda amerikis gulis asociaciis samedicino Jurnalis`serquleiSen” eleqtronul versiaSi.`es kvleva gvTavazobs im adamianTa identificirebis axal gzas, romlebic dganangulis koronaruli daavadebis riskis winaSe”, Tqva heringtonma. `mamakacebis 50, xoloqalebis 64%-Si, romlebic uecrad gardaicvalnen gulis koronaruli daavadebiT,daavadebis aranairi klinikuri simptomi adre ar SeimCneoda”.im adamianebSi, romlebSic aTerosklerozi ganviTarebis adreul stadiaze imyofeba,gulmkerdis SigniTa kedlis sisxlZarRvebze folaqebis warmoqmnis Sedegad,TandaTanobiT xdeba sisxlZarRvTa gasqeleba. am daavadebis dasadgeni arainvaziuritestis gamoyenebiT, SesaZlebeli gaxdeba mkurnalobis gacilebiT adre dawyeba da,Sesabamisad, kardiovaskularuli daavadebis da garTulebebis ganviTarebis riskisSemcireba.kvlevam, romelSic monawileobas iRebda 267 adamiani, aCvena, rom iseTi zomebismiRebiT, rogoricaa sisxlis wnevis gasazomi aparatis msgavsi testi damagniturbirTvuli rezonansi, kargad ganisazRvreboda aortis aTerosklerozis xarisxi.mowyobiloba zomavda sisxlis moculobas fexSi, afasebda ra arteriis gasqelebisxarisxs.50

`veiq forest”-is universitetis garda, kvleva Catarda atlantis veteranTa samedicinocentrSi, kolumbiis universitetis samedicino centrSi da maiamis samedicino centrTanarsebul jeksonis memorialur hospitalSi.`bevrma adamianma ar icis, rom mas aqvs gulis daavadebis adreuli stadia da misimkurnaloba SesaZlebelia”, Tqva heringtonma. `Cven yvelafers vakeTebT imisaTvis, romvipovoT aseTi adamianebis identificirebis axali gzebi, ise rom maT CautardeTpreventuli mkurnaloba rac SeiZleba male da amiT Tavidan acilebul iqnas miokardiumisinfarqti an insulti”.rogorc heringtonma aRniSna, testi kvlavac ganviTarebis qveS imyofeba da is jer araris mzad klinikuri gamoyenebisaTvis. magram rogorc man Tqva, saWiro iqneba testisdamatebiTi Seswavla. heringtonis xelmZRvanelobiT Catarebul kvlevaSi asevemonawileobas iRebdnen: medicinis mecnierebaTa doqtori atlantis veteranTa samedicinocentridan, virjil brauni ( W. Virgil Brown), kolumbiis universitetis samedicino centrismedicinis mecnierebaTa doqtori, lori moska (Lori Mosca), atlantis veteranTa samedicinocentris medicinis mecnierebaTa doqtori, uoren devisi (Warren Davis) da medicinismecnierebaTa doqtori maiamis samedicino centridan, gregori handli (W. Gregory Hundle y).amerikis gulis asociaciis Tanaxmad, am qveyanaSi mcxovreb adamianebSi, sikvdilobasyvelaze metad gulis koronaruli daavadeba iwvevs. daaxloebiT yovel 26 wamSi, aSS-SierT adamians mainc aqvs koronaruli Seteva, xolo yovel wuTSi, erTi adamiani mainciRupeba am daavadebiT.sisxlSi qolesterinis donis saganmanaTleblo erovnulma programam ganaaxlamozrdilTa mkurnalobis panelis III gaidlainebi axlaxans Catarebuli statinebiskvlevis SedegebiT da gamoaqveyna isini Jurnalis `serquleiSen” 12 ivlisis nomerSi.2001 wlis gaidlainebSi, maRali riskis mqone adamianebSi, dabali simkvrivislipoproteinebis qolesterinis doniT – sul mcire 130mg/dl, rekomendirebuli iyo misidaweva 100 mg/dl-mde.ganaxlebul gaidlainebSi igive rekomendaciaa mocemuli. Tumca, dabali simkvrivislipoproteinebis qolesterinis donis daweva 100 mg/dl-ze qvemoT, warmoadgensmkurnalobis mizans miokardiumis infarqtis an sikvdilobis Zalze maRali riskis mqonepacientebSi. am jgufSi Sedian kardiovaskularul daavadebasTan erTad diabetis mqoneadamianebi, mudmivi mwevelebi, is adamianebi, romlebSic hipertenzia faqtiurad araakontrolirebuli, metaboluri sindromis xelSemwyob sxvadasxva risk-faqtorTaerToblioba (trigliceridebis maRali koncentracia, maRali simkvrivis lipoproteinebisqolesterinis dabali done, simsuqne) da agreTve is adamianebi, romlebmac axlowarsulSi gadaitanes miokardiumis infarqti.saSualoze maRali riskis mqone adamianebs miekuTvnebian mravali risk-faqtoris mqoneadamianebi, romlebSic miokardiumis infarqtis riskisa da gulis daavadebis Sedegadgamowveuli sikvdilobis albaToba 10-20%-ia 10 wlis manZilze. am pacientTa mkurnalobaunda moxdes maSin, Tu dabali simkvrivis lipoproteinebis qolesterinis done 130 mg/dlia,an ufro maRalia; maSin, roca medikamentozuri mkurnaloba alternatiulia, rocadabali simkvrivis lipoproteinebis qolesterinis done 100-129mg/dl farglebSi meryeobs.maRali da saSualoze maRali riskis mqone pacientebSi Catarebuli mkurnalobis mizaniadabali simkvrivis lipoproteinebis qolesterinis donis 30-40%-iT Semcireba. dabali dasaSualo riskis mqone adamianebis mkurnalobis rekomendaciebi ar Secvlila da igivea,rac mocemulia 2001 wlis gaidlainebSi. statinebis axlaxans Catarebuli kvlevisSedegebidan gamomdinare, arsebobs myari safuZveli imisa, rom asakis miuxedavad moxdesmkurnalobis Catareba, vinaidan qolesterinis dasaqveiTebeli intervencia xSiradefeqturia da gamarTlebulia asakovan adamianebSic.51

andomizebuli klinikuri kvlevebis axlaxans Catarebuli gadasinjvis Tanaxmad,aRmoCnda, rom miuxedavad beta-blokatorebis gverdiTi efeqtebisa, gulis ukmarisobismqone pacientebi mTlianobaSi am wamlebs kargad itanen.Jurnalis `anals ov internal medisin” 12 ivlisis nomerSi, multicentruli jgufi,torontos universitetis profesor, denis kos xelmZRvanelobiT (Dennis T. Ko), aqveynebs1966-2002 wlebSi Catarebuli klinikuri kvlevebis analizs, sadac gulis ukmarisobismqone pacientebs randomizebulad dauniSnes beta-blokatorebiT an placeboTimkurnaloba.mkvlevarTa jgufma aRmoaCina, rom beta-blokatorebiT mkurnaloba namdvilad iyodakavSirebuli hipotenziis, Tavbrusxvevisa da bradikardiis riskis wliuri maCveneblismniSvnelovan zrdasTan, Tumca, maT aseve aRmoaCines, rom am medikamentebiT mkurnalobadakavSirebuli iyo nebismieri mizeziT gamowveuli sikvdilobis, gulis ukmarisobisSedegad hospitalizaciis da gulis ukmarisobis gauaresebis SemTxvevaTa ricxvisSemcirebasTan.winagulovani fibrilaciis, xanmokle iSemiuri Setevisa da msubuqi xarisxis insultismqone pacientebSi meoradi insultis ganviTarebis maRali riski aspirinTan SedarebiTgacilebiT efeqturad mcirdeba varfarinis Sesaferisi doziT mkurnalobis Sedegad ,Tanaxmad Jurnalis “sTrouq” aprilis nomerSi gamoqveynebuli statiisa.iSemiur insultTan SedarebiT, xanmokle iSemiuri Setevebi ufro iSviaTad arisdakavSirebuli winagulovan fibrilaciasTan, ramac SeiZleba gvafiqrebinos, romwinagulovani fibrilaciis dros antiTrombolizur Terapiaze pasuxi gansxvavebuliiqneba xanmokle iSemiuri Setevebis mqone da iSemiuri insultis mqone pacientebSi,ganmartaven prof. robert harti (Dr. Robert G. Hart) da misi kolegebi. am Teoriis ukeTgamosakvlevad, maT gamoiyenes winagulovani fibrilaciis evropuli kvlevisa da insultisprevenciis kvlevis monacemebi.prof. hartma da misma kolegebma aRmoaCines, rom xanmokle iSemiuri Setevebis mqonepacientebSi iSemiuri insultis sixSire aspiriniT mkurnalobisas wliurad saSualod 7%-s udrida, xolo im pacientebSi, romlebsac adre msubuqi xarisxis insulti hqondaTgadatanili - 11%-s. varfariniT mkurnalobisas es maCvenebeli Sesabamisad 3%-s da 4%-sSeadgenda. “ori didi randomizebuli klinikuri kvlevis monawileTa analizma vergamoavlina imis damamtkicebeli sabuTi, rom xanmokle iSemiuri Setevebis SemdegganviTarebuli winagulovani fibrilaciis mqone pacientebsa da iSemiuri insultis SemdegganviTarebuli winagulovani fibrilaciis mqone pacientebSi mkurnaloba sxvadasxvanairadunda Catardes. 2tvinis infarqtis zoma ufro mcirea da gamosavalic ufro ukeTesi, rodesac iSemiurinsults win uswrebs xanmokle iSemiuri Setevebi, aqveyneben germaneli mkvlevarebiJurnalis “sTrouq”-is martis nomerSi. birTvul-magnituri rezonansis Sedegebidangamomdinare, warmatebuli efeqti mosdevs endogenur neiroproteqcias. wina kvlevebismixedviT, xanmokle iSemiurma Setevebma SesaZloa uzrunvelyon neiroproteqcia iSemiuritolerantobis xelSewyobiT. Tumca dacvis es meqanizmi dRemde ucnobi iyo.2 - es kidev erTxel adasturebs Cvens wina mimoxilvaSi gamoTqmul mosazrebas (ix. `internetis samedicinodaijesti~ #3(94-95), 2003), rom xanmokle iSemiuri Setevis iSemiuri insultisagan calke nozologiuradgamoyofas mcire praqtikuli sargebeli Tu moaqvs, albaT umjobesia igi iSemiuri insultis mimdinareobisvariantad ganvixiloT (ix Semdegi referensi).52

amis gamo, prof. siuzen vegenerma (Dr. Susanne Wegener) da misma kolegebma gansazRvresperfuzia da qsovilebis dazianeba insultis mqone pacientebSi. 10 pacients wina 4 kvirismanZilze hqonda gadatanili xanmokle iSemiuri Seteva, 6 maTgans – 5 kviriT adre, xolo49 pacients arasodes ar hqonia gadatanili xanmokle iSemiuri Seteva. birTvul -magniturirezonansi Catarda simptomebis dawyebidan 12 saaTis ganmavlobaSi da Semdgom – 3-7 dReSi.perfuziis SezRudvis, rekanalizaciisa da okluziis tipebis xarisxi da simwvave argansxvavdeboda jgufebs Soris, rac mkvlevarebis azriT imas miuTiTebs, romdamcvelobiTi efeqti ar mosdevs xanmokle iSemiuri Setevebis mier gamowveul ukeTesvaskularul momaragebas da kolateralur cirkulacias.bolo birTvul-magniturma rezonansma aCvena, rom infarqtis moculoba saSualod 9.1ml iyo xanmokle iSemiuri Setevebis anamnezis mqone pacientebSi, xolo 36.5 ml - amSetevebis armqone pacientebSi. im 10 pacients Soris, romlebSic xanmokle iSemiuriSetevis ganviTarebidan 4 kviraze naklebi dro iyo gasuli, infarqtis moculobaSeadgenda 5.6 ml. erTaderTi faqtori mravlobiTi xazovani regresiis analizSi, romelicgansazRvravda infarqtis saboloo zomas, iyo prodromaluri xanmokle iSemiuri Seteva.insultis maCvenebelic gacilebiT dabali iyo im xanmokle iSemiuri Setevebis mqonepacientTa jgufSi, romlebic droulad moaTavses saavadmyofoSi. “Tumca xanmokleiSemiuri Seteva sagangaSo niSania, bunebrivad SeZenili iSemiuri tolerantobisdamatebiTma gamokvlevam SesaZloa momavalSi axal perspeqtiul neiroproteqciamde damwvave insultis Terapiamde migviyvanos”, dasZenen mkvlevarebi.aspirinis arSemcveli arasteroiduli anTebis sawinaaRmdego wamlebis gamoyeneba, rogorcCans, amcirebs miokardiumis infarqtis ganviTarebis risks im pacientebSi, romlebicprofilaqtikur aspirins ar iReben. Tumca, isini damatebiT damcvel rols ar asrulebenaspirinis momxmareblebSi, aqveyneben mkvlevarebi “jornel ov de ameriqen kolej ovkardioloji”-s 17 martis nomerSi. pensilvaniis universitetis profesorma da kvlevismTavarma avtorma filadelfiaSi, prof. stiven kimelma (Dr. Stephen Kimmel) Reuters Health-TaninterviuSi ganacxada, rom “arasteroiduli anTebis sawinaaRmdego wamlebi SesaZloaamcirebdnen miokardiumis infarqtis risks, magram isini ar unda iqnan gamoyenebuli ammizniT. miokardiumis infarqtis prevenciisaTvis mxolod aspirinis gamoyeneba SeiZleba”.prof. kimelma da misma kolegebma gamoikvlies zogierTi agentis, gansakuTrebiTibuprofenis gavlena miokardiumis infarqtis riskze, aspiriniT mkurnalobis dros da misgareSe. mkvlevarebma Caatares SemTxveva-kontrolirebuli kvleva. masSi monawileoba miiRo1000-ze metma adamianma, romlebsac gadatanili hqondaT arafataluri miokardiumisinfarqti, sakontrolo jgufSi ki 4-jer meti adamiani iRebda monawileobas. impacientebSi, romlebic ar iRebdnen aspirins, arasteroiduli anTebis sawinaaRmdegowamlebis gamoyenebam mniSvnelovnad Seamcira miokardiumis infarqtis riski (riskisfardoba udrida 0,53). Sedegebi msgavsi iyo ibuprofenisa da naproqsenis gamoyenebis dros.amave dros im pacientebSi, romlebic iRebdnen aspirins, magram ara aspirinis arSemcvelarasteroidul anTebis sawinaaRmdego wamlebs, Sesabamisi riskis fardoba udrida 0,79.Tumca, aspirinis Semcveli da misi arSemcveli arasteroiduli anTebis sawinaaRmdegowamlebis erTdroulma gamoyenebam ar ganapiroba miokardiumis infarqtisagan ufro metidacva.Tanmxleb saredaqcio statiaSi, prof. jefta kertisi (Dr. Jeptha P. Curtis) da harlankrumholci (Dr. Harlan Krumholz) ielis universitetis medicinis skolidan, eTanxmebian immosazrebas, rom sakiTxi jerjerobiT ar aris srulad gadaWrili. Tumca isini miuTiTebenimaze, rom “pacientebs, romlebic ibuprofens aniWeben upiratesobas, xolo saWiroebenaspirins, eqimebma unda auxsnan, rom kvlevis Sedegebi srulad ar adastureben immosazrebas, TiTqos es kombinacia sazianoa”.53

adre Catarebuli ramodenime kvlevis Tanaxmad, acetaminofenis gamoyeneba dakavSirebuliaasTmasTan, xolo axla prospeqtuli kvlevis Sedegebi ufro metad amtkiceben amasociaciis arsebobas.asTmis riskze acetaminofenis gavlenis Sesafaseblad prof. grem barma (Dr. R. GrahamBarr) da misma kolegebma gaaanalizes eqTanTa janmrTelobis kvlevis Sedegebi,prospeqtuli kvleva, romelSic monawileobda 120,000-ze meti qali. acetaminofenisgamoyenebis sixSire uSualod iyo dakavSirebuli asTmis riskTan (p=0,006), naTqvamiastatiaSi. im pacientebSi, romlebic TveSi 14 an ufro meti dRis ganmavlobaSi iRebdnenpreparats, 63%-iT ufro maRali iyo asTmis ganviTarebis riski im qalebTan SedarebiT,romlebic ar iRebdnen acetaminofens.“jerjerobiT naadrevia imis rekomendacia, rom asTmis mqone pacientebma ar miiRonacetaminofeni, magram saWiroa damatebiTi kvlevis Catareba filtvebze acetaminofeniszegavlenis dasadgenad, raTa damtkicdes an uaryofil iqnas es aRmoCena da moxdespacientTa im qvejgufis identificireba, romlebSic asTma modificirebulia[ganpirobebulia] acetaminofeniT”, acxadebs prof. baris jgufi.gamoica axali gaidlaini asTmis mqone orsuli qalebis mkurnalobis Sesaxeb,romlebic gansxvavdeba 2 wlis win gamocemuli gaidlainisagan. asTma orsuli qalebisdaaxloebiT 7%-s emarTeba da, zogierTi kvlevis Tanaxmad, es qalebi dganan preeklampsiismomatebuli riskis winaSe, anda arsebobs naadrevi mSobiarobis, axalSobilis dabaliwoniT dabadebisa da misi perinataluri sikvdilis safrTxe.axali gaidlaini ZiriTadad xazs usvams asTmis mqone orsuli qalebis intensiurmonitorings TveSi erTxel da pacientTaTvis asTmis kontrolis mniSvnelobis axsnas.aseve yuradReba unda mieqces asTmis dozis damaqveiTebel Terapias, Cveulebrivze ufrometad unda moxdes gamwvavebebis prevencia, an mkurnalobaSi dozis daqveiTebaze Tavi undaiqnas Sekavebuli orsulobis dasrulebamde.axali rekomendaciebis Tanaxmad:• msubuqi simZimis intermisiuli asTmis dros orsul qalebs unda daeniSnosxanmokle moqmedebis mqone SesunTqvadi beta 2 –agonistebi, upiratesadalbuteroli. adre rekomendebuli wamali iyo terbutalini.• susti xarisxis mudmivi asTmis dros, orsul qalebs unda umkurnalon dabalidozis SesunTqvadi kortikosteroidebiT, upiratesad budezonidiT.Tavdapirvelad am saxis asTmis samkurnalod kromolins (intals) iyenebdnen.amJamad, kromolini, iseve rogorc leikotrienis receptoris antagon istebi daTeofilini, mkurnalobis alternatiul saSualebebad aris miCneuli.• saSualo simZimis asTmis samkurnalod ori erTmaneTis msgavsi rekomendaciaarsebobs. esenia:1. SesunTqvadi kortikosteroidebis dabali doza + xangrZlivi moqmedebismqone SesunTqvadi beta 2 –agonistebi, kerZod salmeteroli.2. saSualo doziT SesunTqvadi kortikosteroidebi. adre rekomendebulikromolini da oraluri beta 2 –agonistebi aRar gamoiyeneba.• mudmivi mwvave asTmis dros orsul qalebs unda daeniSnos SesunTqvadikortikosteroidebis maRali doza, upiratesad budezonidi da oraluriprednizoni maqsimum 60mg doziT. Tumca arsebobs imis safrTxe, rom orsulobispirvel trimestrSi mwvave asTmis mkurnaloba oraluri kortikosteroidebiTSesaZloa dakavSirebuli iyos axalSobilTa “mglis xaxiT” dabadebis, naadrevimSobiarobis da axalSobilTa dabali woniT dabadebis riskis zrdasTan.zogierTi gamoTvlis Tanaxmad, ruseTSi 1 milioni adamiania inficirebuli aiv virusiT, andaavadebulia SidsiT (oficialuri monacemebiT, maTi raodenoba 300 000-s aRwevs). 2004wels, gaerTianebuli erebis ganviTarebis programis egidiT Catarda gamokvleva, romlisSedegebis Tanaxmad, qveyana `katastrofis zRvarze” imyofeba. gaeros ganviTarebis54

programis specialistTa prognoziT, 2045 wlisaTvis ruseTSi aiv-iT inficirebuli iqnebamosaxleobis 8%. Sedegad, am droisaTvis 20,7 milioni adamiani daiRupeba. epidemia ruseTsmisi Sida saerTo produqtis 14% daujdeba. miuxedavad imisa, rom qveyana aSkarad axlosimyofeba momakvdinebeli daavadebis epidemiasTan, qveynis prezidenti mxolod gakvriTexeba am problemas da arasodes gaukeTebia raime seriozuli gancxadeba daavadebisTaobaze.aiv da SidsTan brZolisaTvis federalur biujetSi mxolod 5.3 milioni dolariagamoyofili, amgvarad, momakvdinebeli virusiT inficirebul, yovel registrirebuladamianze wliurad mxolod 17 dolari modis. amasTan, SidsTan brZolisaTvis gamoyofilTanxebs ganagebs ara jandacvis saministro, aramed - momxmarebelTa uflebebis dacvissaagento.Tumca, sinaTle mainc Cans gvirabis bolos. gaeros ganviTarebis programis msofliofondma ruseTisTvis 157 milioni dolari gamoyo, rac Sidsis krizisTan brZolis 5 wlianperiods moxmardeba. magram is adamianebi, romlebic uSualod am sferoSi muSaoben,amtkiceben, rom Tu kremli Sidsis problemas prioritetulad ar miiCnevs, fondis miergamoyofili Tanxebic albaT uazrod daikargeba.aSS-is SidsTan brZolis saerTaSoriso sazogadoebam ganaaxla antiretrovirusulimkurnalobis rekomendaciebi da gamoaqveyna isini `amerikis samedicino asociaciisJurnalis~ - `jama~-s nomerSi. axal gaidlainebSi, romelTa ganaxleba moxda 2001 wlidan,saubaria imaze, Tu rodis unda moxdes antiretrovirusuli mkurnalobis dawyeba, rawamlebis gamoyenebaa mizanSewonili, rodis unda moxdes mkurnalobis reJimis Secvla daromeli wamali unda CaerTos im SemTxvevaSi, Tu erTi wamliT mkurnaloba uSedegoaRmoCndeba.iseTma axalma antiretrovirusulma wamlebma, rogoricaa: atazanaviri, emtricitabini,enfuvirtidi da fozamprenaviri, ufro mravalferovani gaxades mkurnalobisTavdapirveli da Semdgomi reJimebis arCevani. arsebobs ufro gansazRvrulirekomendaciebi im specifiur wamlebsa Tu mkurnalobis reJimebze, romelTa gamoyenebamizanSewonilia, sxvebis ki _ ara, gansakuTrebiT mkurnalobis sawyis etapze.im SemTxvevaSi, Tu romelime konkretul agentTan dakavSirebuli simptomebi ar moixsneba,an adgili eqneba toqsiurobis ganviTarebas, paneli eqimebs urCevs ama Tu im medikamentismxolod erTi wamliT Senacvlebas. magaliTad, zidovudinTan dakavSirebuli anemiisdros, misi Secvla SesaZlebelia stavudiniT. Tu konkretulad erT wamalze araa eWvimitanili da toqsiuroba imdenad Zlieria, rom saWiroa mkurnalobis kursis droebiTiSewyveta, pacients unda moexsnas kombinirebul mkurnalobaSi CarTuli yvela wamali.Baby born with heart outside bodyCharli Southern has defied the odds by surviving despite being born with her heart outside her chest, it is reported.She was born seven weeks premature with a very rare condition called ectopia cordis where the chest fails to closeproperly over part of the heart.Doctors rated Charli's chances of survival at one to million, but so far she has confounded medical opinion.But she is making a good recovery following two major operations, and it is hoped she will lead a normal life.Not only did Charli have to endure major surgery to put her heart back in the right place, she also had to overcomekidney failure and a potentially fatal chest infection.Doctors at Royal Brisbane and Women's Hospital had to close the gap in Charli's chest following surgery with amixture of existing skin and protective Gore-tex. This was then covered in clingfilm to keep the infection at bay.Now, at six weeks old, she is able to breathe on her own. She has also begun breast feeding and is gaining weightrapidly.55

Charli will need further surgery to reconstruct part of her breast bone when older.Cardiologist Studying New Method of Screening for Heart DiseaseA multi-center study led by Wake Forest University Baptist Medical Center cardiologist David M. Herrington, M.D.,M.H.S., suggests that measuring the stiffness of arteries to screen for early atherosclerosis may be another way toidentify people at risk for heart disease or stroke.Herrington’s study was published on-line in Circulation, a medical journal of the American Heart Association.“The study suggests another way to identify people who are at risk for coronary heart disease,” said Herrington. “50%of men and 64% of women who die suddenly of coronary heart disease had no previous symptoms of the disease.”The blood vessels of individuals who are in the early stages of atherosclerosis begin to stiffen due to the buildup ofplaque on the interior walls of the vessels. Using a non-invasive test to detect this disease would allow treatment tobegin much earlier in an effort to reduce the odds of further cardiovascular disease.The study, which involved 267 participants, showed that measurements taken with a blood-pressure-like test, andconfirmed with magnetic resonance imaging (MRI), were “strongly predictive of extent of aortic atherosclerosis.” Thedevice measured blood volume in the leg as a way to gauge artery stiffness.In addition to Wake Forest Baptist, the study was conducted at the Atlanta V. A. Medical Center, Columbia UniversityMedical Center, and Jackson Memorial Hospital at the University of Miami Medical Center.“Many people are unaware that they have early stages of heart disease that could be treated,” said Herrington. “We areworking hard at Wake Forest Baptist to develop new ways to identify these people so they can begin preventivetreatment sooner and avoid having a heart attack or stroke.”Herrington said the test is still under development and not yet ready for clinical use. But he said that a further study ofthe test was warranted. The research team led by Herrington included W. Virgil Brown, M.D., Atlanta V. A. MedicalCenter, Ga., Lori Mosca, M.D., Ph.D., Columbia University Medical Center, N.Y., Warren Davis, M.D., Atlanta V. A.Medical Center, Ga., W. Gregory Hundley, M.D., Wake Forest Baptist and Jeffrey Raines, Ph.D., University of MiamiMedical Center, Fla.According to the American Heart Association, coronary heart disease is the single largest killer of men and womenAmerica. Approximately every 26 seconds someone will suffer from a coronary event in the United States and aboutevery minute someone will die from one.The National Cholesterol Education Program (NCEP) has updated their Adult Treatment Panel (ATP) IIIguidelines with evidence derived from recent statin trials and published them in the July 12 issue of Circulation.The 2001 guidelines recommended for high-risk individuals with LDL-cholesterol levels of at least 130 mg/dL toreduce LDL cholesterol to target levels of less than 100 mg/dL.The updated guidelines preserve the same general goal of cholesterol-lowering treatment for high-risk individuals as inthe 2001 guidelines. However, to reduce LDL-cholesterol levels to less than 100 mg/dL is a therapeutic option forpeople at very high risk of MI or death. Very high risk individuals are those with cardiovascular disease plus diabetes,persistent cigarette smoking, poorly controlled hypertension, or multiple risk factors of the metabolic syndrome (hightriglycerides, low levels of high density lipoprotein [HDL] cholesterol, obesity), and those who recently had an MI.Moderately high risk individuals are defined as those with multiple risk factors and an estimated 10% to 20% risk ofMI or cardiac death within 10 years. These individuals should be treated if LDL-cholesterol levels are 130 mg/dL orhigher, whereas drug therapy is optional if levels are between 100 to 129 mg/dL.Goals for drug therapy in individuals at high or moderately high risk should be a 30% to 40% reduction in LDLcholesterollevels. Recommendations for treating individuals at low or moderate risk are unchanged from the 200156

guidelines. Evidence from the recent statin trials supp orts treatment, when indicated, regardless of age, as interventionsto lower cholesterol levels are often effective and justified even in older individuals.Despite concerns about side effects of beta-blockers, a recent overview of randomized trials has found that thesedrugs are generally well tolerated by patients with heart failure .In the July 12th issue of the Annals of Internal Medicine, a multicenter team led by Dr. Dennis T. Ko of the Universityof Toronto in Canada reports its analysis of trials conducted between 1966 and 2002 in which patients with heartfailure were randomized to treatment with beta-blockers or placebo.The team found that beta-blocker therapy was indeed associated with significant absolute annual increases in risks ofhypotension, dizziness, and bradycardia. They also found, however, that beta-blocker therapy was associated withreductions in all-cause mortality, heart-failure associated hospitalizations, and worsening heart failure.In patients with atrial fibrillation (AF) and a history of transient ischemic attack (TIA) or nondisabling stroke,the high risk of a secondary stroke is reduced more effectively by treatment with adjusted-dose warfarin thanwith aspirin, according to a report in the April issue of Stroke.TIAs are less commonly associated with AF than is ischemic stroke, hinting that the response to antithrombotic therapymay differ for AF patients with TIA than for those with prior ischemic stroke, Dr. Robert G. Hart and colleaguesexplain. To further explore this theory, they pooled the data from the European Atrial Fibrillation Trial (EAFT) and theStroke Prevention in Atrial Fibrillation III (SPAF) trial.Dr. Hart and his team found that the frequency of ischemic stroke during treatment with aspirin averaged 7% per yearin patients with a TIA and 11% per year for those with a prior nondisabling stroke. These rates dropped to 3% and 4%per year, respectively, during treatment with warfarin. "These analyses of participants from 2 large randomized clinicaltrials revealed no evidence that atrial fibrillation patients with prior TIA should be managed differently from those withprior ischemic stroke regarding long-term secondary prevention," the authors conclude.Brain infarct size is smaller and outcomes are better when ischemic strokes are preceded by transient ischemicattacks (TIAs), German researchers report in the March issue of Stroke. Results of MRI imaging suggest that thebeneficial effect is due to endogenous neuroprotection. Previous reports have suggested that TIA may offerneuroprotection by promoting ischemic tolerance. However, objective measures were lacking and the mechanism ofprotection was unclear.Dr. Susanne Wegener and her associates therefore assessed perfusion and tissue damage in stroke patie nts. Ten patientshad experienced a TIA within the previous 4 weeks, six had had one more than 4 weeks previously, and 49 had neverhad a TIA. MRIs were performed within 12 hours of symptom onset and again after 3 to 7 days. The extent andseverity of perfusion restriction, recanalization and occlusion types did not differ between groups, suggesting, say theinvestigators, that the protective effect is not due to a better vascular supply or collateral circulation induced by TIA.A final MRI showed that the infarct volume averaged 9.1 mL in patients with a history of TIA and 36.5 mL in thosewith no such history. Among the 10 whose TIA had occurred less than 4 weeks previously, the volume was 5.6 mL.The only factor in multiple linear regression analysis that was predictive of final infarct size was prodromal TIA.Stroke scale scores were also significantly lower at hospital discharge in the TIA group. "Although a TIA is analarming sign," the researchers conclude, "further delineation and exploration of naturally occurring ischemictolerance," may offer "a new perspective in future neuroprotection and acute stroke therapy."The use of non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) appears to reduce the risk ofmyocardial infarction (MI) in patients not taking prophylactic aspirin. However, they do not seem to provide anyextra protection to aspirin users, researchers report in the March 17th issue of the Journal of the American College ofCardiology. In fact, lead investigator Dr. Stephen Kimmel of the University of Pennsylvania, Philadelphia told Reuters57

Health that "NSAIDs may reduce the risk of MI, but they should not be used for this purpose. Only aspirin should beused to specifically prevent MI."Dr. Kimmel and colleagues examined the effects of such agents, particularly ibuprofen, on MI risk, in the presence orabsence of aspirin. The researchers conducted a case-control study. This involved more than 1000 subjects who hadhad a first nonfatal MI and about four times as many controls. In nonusers of aspirin, NSAIDs led to a significantreduction in MI risk (adjusted odds ratio 0.53). Results were similar with both ibuprofen and naproxen. For those usingaspirin, but not non-aspirin NSAIDs, the corresponding odds ratio was 0.79. However, using both aspirin and nonaspirinNSAIDs did not appear to provide increased protection.In an accompanying editorial, Drs. Jeptha P. Curtis and Harlan M. Krumholz of Yale University School of Medicine,New Haven, Connecticut, agree that the issue is not resolved. They point out however that in "patients who have astrong preference for ibuprofen and a need for aspirin, it is reasonable to reassure them that the preponderance of theevidence does not clearly demonstrate that this combination is harmful."Acetaminophen use has been linked to asthma in several studies, but now findings from a prospective studyprovide further evidence to support this association. To evaluate the effect of acetaminophen use on asthma risk,Dr. R. Graham Barr and colleagues analyzed data from the Nurses Health Study, a prospective study involving morethan 120,000 women. The frequency of acetaminophen use was directly related to the risk of asthma (p for trend =0.006), the report indicates. Compared with nonusers, women who took the drug for more than 14 days per month were63% more likely to develop asthma."It would be premature to recommend acetaminophen avoidance for patients with asthma, but further research onpulmonary responses to acetaminophen is necessary to confirm or refute these findings and to identify subgroupswhose asthma may be modified by acetaminophen," Dr. Barr's team states.New guidelines have been issued for treating asthmatic women during pregnancy that depart from guidelinesreleased only two years ago. Asthma reportedly affects about 7% of pregnant women, and some research has suggestedthat these women are at an increased risk of preeclampsia or having a child suffer perinatal mortality, preterm birth, orlow birth weight.The new guidelines discuss the need to intensely monitor women with asthma once a month during pregnancy andeducate patients on the importance of asthma control. Caution must also be taken in step-down therapy, with more caretaken than usual in preventing flare-ups, or even postponing step-down therapy until the pregnancy is completed.The new recommendations are as follows:• For mild intermittent asthma, pregnant women should be prescribed short-acting inhaled beta2-agonists,preferably albuterol. Previously, the recommended drug was terbutaline.• For mild persistent asthma, pregnant women should be prescribed low-dose inhaled corticosteroids (ICS),preferably budesonide. Previously, cromolyn was the initial preferred treatment; now that is an alternativerecommended treatment, as well as leukotriene receptor antagonists or theophylline.• For moderate asthma, there are two equal recommendations: either a low dose of an ICS plus a long-actinginhaled beta 2-agonist such as salmeterol, or a medium-dose ICS. Previous recommendations of cromolyn andoral beta 2 -agonists are no longer recommended.• For persistent severe asthma, pregnant women should be prescribed a high dose of an ICS, preferablybudesonide, and oral prednisone as a last resort at a maximum of 60 mg. The risks of not treating severeasthma need to be weighed against the indication that oral corticosteroid use during the first trimester wasassociated with an increased risk in cleft palate and with preterm birth and low birth weight.58

According to several estimations, approximately one million people are HIV-infected in Russia, or having AIDSalready (official data accounts 300,000 cases). By the recent study carried out in the framework of the United NationsDevelopment Program, country stands “at the edge of a disaster”. UN specialists suggest that Russia might follow ascenario according to which around 8% of country’s population could be HIV-positive for 2045. As a result of suchdevelopment, over 20.7 Russians would die due to AIDS, and the epidemy would cost 14% of GDP to Russia. Despiteof the grave situation, Russian President Vladimer Putin never made programmatic statements about the issue, andrarely mentions the problem in passing only. In recent report to State Federal Council President Putin never mentionedHIV-AIDS, and he also has declined direct invitation to the AIDS International Conference in Bangkok this summer.Russian state budget has only 5.3 million USD on HIV/AIDS annually, which equals $17 per every registered patie nt.Besides, these sums are under the Customers Rights Agency, not of the Ministry of Health of Russia.Still there is a light at the end of the tunnel. UN Global Fund has aloted 157 million USD for next 5 years to fight theforthcoming health crisis, but those who work in this sector, warn, that if Kremlin doesn’t provide clear priorities infighting HIV, the money still may vanish in nowhere.The International AIDS Society–USA has updated their recommendations for antiretroviral management andpublished them in JAMA. The new guidelines, updated from 2001, discuss when to start antiretroviral therapy, whatdrugs to start with, when to change drug regimens, and what drug regimens to switch to after therapy fails.New antiretroviral drugs, such as atazanavir, emtricitabine, enfuvirtide, and fosamprenavir, have broadened therapeuticoptions for initial and subsequent regimens. New evidence allows more definitive recommendations for specific drugsor regimens to include or avoid, especially for initial therapy.The panel suggests single-drug substitutions when symptoms associated with a particular agent do not resolve, or whentoxicity develops. For example, for zidovudine-related anemia, zidovudine could be changed to stavudine. If a singledrug is not the clear culprit and toxicity is severe enough to require temporary discontinuation of therapy, all agents inthe combination should be stopped.59

iumori samedicino Temazemkurnalobis meTodijoni mivida fsiqiatrTan Tavisi fobiis Taobaze.`eqimo, - uTxra man, - raRac jandaba mWirs. rodesac vwvebi, mgonia, rom sawolsqveviT viRacaa. sawolis qveS vZvrebi, rom Sevamowmo, da maSin meCveneba, rom axlasawolze wevs viRac... isev zeviT avZvrebi, da kvlav mgonia, rom sawols qveSviRacaa... mokled mTel Rames zeviT-qveviT ZromialSi vatareb da lamisaa gavgiJde!miSveleT rame!”`gasagebia. ori weli damWirdeba, kviraSi samjer unda moxvide da pirobas gaZlev,mag SiSs mogixsni~ - ganucxada eqimma.`eg ra damijdeba?~`yoveli seansi – 100 dolari.~`mosula~ - uTxra jonma.eqvsi Tvis mere fsiqiatri jons SemTxveviT Sexvda quCaSi.`ratom aRar gamoCndi?~ - hkiTxa eqimma, - `xom giTxari, mogarCen-meTqi?~`TiTo seansi 100 dolarad? xom gaviyidebodi 2 weliwadSi!.. me ukve barmenmamomarCina, Tanac Zalian iafad – sul raRac 10 dolarad!~`eg rogor?~ – gancvifrda eqimi.`ubralod mirCia sawolisTvis fexebi momeWra!~Effective treatmentJohn went to a psychiatrist for his phobia."Doc," he said, "I've got trouble. Every time I get into bed, I think there's somebody under it. I get under thebed, I think there's somebody on top of it. Top, under, top, under. You gotta help me, I'm going crazy!""Just put yourself in my hands for two years," said the shrink, "Come to me three times a week, and I'll cureyour fears.""How much do you charge?""A hundred dollars per visit.""I'll sleep on it," said John.Six months later the doctor met John on the street."Why didn't you ever come to see me again?" asked the psychiatrist."For a hundred buck's a visit? A bartender cured me for ten dollars.""Is that so! How?""He told me to cut the legs off the bed!"60

nacnobobabarSi ori kaci zis. erTma maTganma gverdiT msxdoms Sexeda da eubneba – `raRacmecnobi, aqauri xom ara xar?~ kacma gamoxeda da Tavi dauqnia - `ki, am quCazevcxovrob.~`ar xumrob? – gaioca pirvelma – mec xom am quCaze vcxovrob... Tanac Cemi xnisunda iyo. skolaSi sad dadiodi?~`frensis luisSi, 1966-Si davamTavre. Sen?~`daikarge!! mec xom eg skola davamTavre, Tanac swored 66-Si... kolejSi sadRaiyavi?~`beloitSi, viskonsinis StatSi~.`vaa! mec xom beloitSi vswavlobdi. romel sacxovrebelSi iyavi?~`kevin salivanSi...~`ara, amis dajereba...kaci barmenisken mitrialda da gatacebiT elaparakeba: `jo, gagigia egeTi rame?milionSi erTxel Tu moxdeba. am kacma, romelic Turme Cemsave quCaze cxovrobs,Cemi skola daamTavra imave wels, roca mec. mere erTsadaimave kolejSivswavlobdiT da Turme erT sacxovrebelSic ki vcxovrobdiT... gasagiJebeliapirdapir...~barmenma orives gamoxeda da Tavi daiqnia – `naRdad gasagiJebelia!~bars mesame kaci miuaxlovda da barmens hkiTxa – `jo, ra xdeba axali?~ `bevriaraferi, ager, jonsonis tyupebi isev gamoileSnen da axalgazrdobas ixseneben~.ClassmatesThere was a man sitting at a bar, and he looks over at the gentleman sitting next to him and says, "Hey, youlook familiar.Are you from around here?" The man answers, "Yeah, I live down the street.""No kidding?" says the first man, "Well, so do I. And hey, you look about my age. Where did you go to highschool?""Oh I went to Francis Lewis. Graduated in '66.How 'bout you?""Get out. I went to Francis Lewis. And I graduated in '66, too.""Where'd you go to college?""Beloit, in Wisconsin.""No way! I went to Beloit too. What dorm?""Kevin Sullivan dorm.""Sullivan? You're not going to believe this . . ."Joe the bartender walks over, and the first guy says, "Joe, you won't believe it in a million years. This guywent to the same high school as me, graduated the same year I did, and went to the same college. We wereeven in the same dorm. Isn't that amazing?"61

Joe looks at them both and says, "Yeah, that's just plain amazing."A third man comes in and says, "Hey Joe. What's new?" Joe says,"Not much. The Johnson twins are drunk again."62

saqarTvelos jandacvis veb-gverdis saaplikacioformaerovnuli sainformaciosaswavlo centri (essc)iv. javaxiSvilis q. #51tel 94 13 88faqsi 94 13 91el-fosta: dmeskhi@nilc.org.geinterneti: www.nilc.org.gewww.health.net.geinternetis veb-gverdis monacemebis forma organizaciebisaTvis(SeiZleba mowodebul iqnas rogorc qarTul, aseve - inglisur enebze)1. organizaciis dasaxeleba:sruli dasaxeleba da abreviatura (rogorcqarTul, aseve - inglisur enebze)2. organizaciis misamarTi:qalaqi, kodi, quCa, nomeri, oTaxebis nomeri (rogorc qarTul, aseve - inglisur enebze)3. telefoni #1:4. telefoni #2:5. faqsi:+995-32-xx xx xx+995-32-xx xx xx+995-32-xx xx xx6. el-fosta:7. veg-gverdi:arsebuli URL anda sasurveli abreviatura inglisurad8. organizaciis struqtura:1. ganyofilebebis CamonaTvali2. TanamSromelTa raodenoba3. SeiZleba iyos organizaciuli gegma9. organizaciis xel-li piris mokle biografia:maqs. 300 sityva(sasurvelia qarTul da inglisur enebze)10. organizaciis miznebi:mokle aRweriloba (maqs 100 sityva)63

11. organizaciis proeqtebi:mimdinare:CamonaTvali da TiToeul proeqtze:1. dasaxeleba2. mokle aRweriloba (daaxlebiT 100 sityvaTiToeul proeqtze)3. dafinansebis wyaro4. ganxorcielebis periodi5. regioni, sadac mimdinareobda6. beneficiarTa raodenoba7. proeqtSi monawileTa raodenoba8. biujetiSesrulebuli:CamonaTvali da TiToeul proeqtze igive tipisinformacia12. organizaciis gegmebi:mokle informacia, anda Tu proeqtis zustimonaxazi arsebobs, maSin imave formiT, racmimdinare proeqtebzea miTiTebuli:13. organizaciis mier sxva iuridiul Tu fizikur pirebTan TanamSromlobissfero:gasaRebi sityvebi: Keywordsorganizacia sTavazobs: (eqspertiza /servisi)organizacias sWirdeba: (eqspertiza /servisi)14. organizaciis partniorebi:miuTiTeT is organizaciebi, romelTanacgindaT, rom Tq veni gverdidan iyos bmuli, mag.jandacvis saministros romelime departamenti,romelime saerTaSoriso organizacia (mag.damfinansebeli) da a.S.15. organizaciis simbolo (logo):.jpg, .gif anda romelime sxva grafikuli faili,sasurvelia mcire zomis (ara Corel)16. sakontaqto piris monacemebi (araa aucilebeli direqtoris, umjobesia - teqnikuripersonalis monacemebi)telefonifaqsiel-fostamobiluri telefoni64