#1
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áèëèðóáèí 170 ìêì/ë -> ôîòîòåðàïèÿ?
Óâàæàåìûå êîëëåãè!
Êîãäà ïîêàçàíà ôîòîòåðàïèÿ?  íàøåì ðîääîìå, íàïðèìåð, çäîðîâîìó äîíîøåííîìó ðåáåíêó â âîçðàñòå 3õ – 4õ ñóòîê íà÷èíàþò ñâåòîëå÷åíèå, êîãäà óðîâåíü íåïðÿìîãî áèëèðóáèíà â åãî êðîâè 170_ ìêì/ë è âûøå. Ýòè ïîêàçàíèÿ íå ÿâëÿþòñÿ ðåçóëüòàòîì êàêîãî-ëèáî íàó÷íîãî èññëåäîâàíèÿ, à âûðàáîòàíû â ðåçóëüòàòå ñîãëàøåíèÿ ñïåöèàëèñòîâ íàøåãî ãîðîäà ñ ó÷åòîì èõ îïûòà, êâàëèôèêàöèè, à òàê æå ñ ó÷åòîì ìíåíèÿ âûøåñòîÿùèõ ýêñïåðòîâ. Ïðè òàêîì ïîäõîäå òðåáóþò ëå÷åíèÿ äî 30% âñåõ ðîäèâøèõñÿ äåòåé. Ìåíÿ áåñïîêîèò íèçêèé äîêàçàòåëüíûé óðîâåíü òàêîãî ïîäõîäà ê ðàçðàáîòêå ïîêàçàíèé ê ëå÷åíèþ, ïðîùå ãîâîðÿ, íå çðÿ ëè ìû ëå÷èì ÷àñòü èç äåòåé? Òàê óæ ëè áåçâðåäíà ôîòîòåðàïèÿ, è òàê ëè óæ îïàñíû æåëòóõè? Íóæíî ó÷åñòü åùå ìîìåíò ïñèõîëîãè÷åñêîé òðàâìû ãîñïèòàëèçèðîâàííûõ ðåáåíêà è ìàìû, ìîìåíòû èõ ðàçëóêè, ðèñê ÂÁÈ, è ò.ï. Õîòåëîñü áû çíàòü, êàêèå ïîäõîäû ê ôèçèîëîãè÷åñêèì æåëòóõàì ó âàñ? |
#2
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Íîðìû îáù.áèë.: 1 äåíü <86 ìêìîëü/ë; 2 äåíü <154 ìêìîëü/ë; 3-5 äíè <205 ìêìîëü/ë; (èç íåãî ñâÿç.áèë.<5,1ìêìîëü/ë).
Àìåðèêàíñêèå êðèòåðèè èíèöèàöèè ôîòîòåðàïèè íîðì. íîâîðîæäåííûõ: 2å ñóòêè >/= 257 ìêìîëü/ë; 3è ñóòêè >/= 308 ìêìîëü/ë; 4å ñóòêè è ñòàðøå >/= 342 ìêìîëü/ë (ïî îáùåìó áèëèðóáèíó). Èñòî÷íèê çíàíèé: Am Fam Physician 2002 Feb 15;65(4):599-606 Hyperbilirubinemia in the term newborn. Porter ML, Dennis BL. Dewitt Army Community Hospital, Fort Belvoir, Virginia, USA. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Hyperbilirubinemia is one of the most common problems encountered in term newborns. Historically, management guidelines were derived from studies on bilirubin toxicity in infants with hemolytic disease. More recent recommendations support the use of less intensive therapy in healthy term newborns with jaundice. Phototherapy should be instituted when the total serum bilirubin level is at or above 15 mg per dL (257 micromol per L) in infants 25 to 48 hours old, 18 mg per dL (308 micromol per L) in infants 49 to 72 hours old, and 20 mg per dL (342 micromol per L) in infants older than 72 hours. Few term newborns with hyperbilirubinemia have serious underlying pathology. Jaundice is considered pathologic if it presents within the first 24 hours after birth, the total serum bilirubin level rises by more than 5 mg per dL (86 micromol per L) per day or is higher than 17 mg per dL (290 micromol per L), or an infant has signs and symptoms suggestive of serious illness. The management goals are to exclude pathologic causes of hyperbilirubinemia and initiate treatment to prevent bilirubin neurotoxicity. |
#3
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Who are you, Dr. Vad?
Îãðîìíîå ñïàñèáî çà èñ÷åðïûâàþùóþ èíôîðìàöèþ!
Âû î÷åíü ïîìîãëè ìíå, Dr. Vad! Áûë áû ðàä óçíàòü î Âàñ áîëüøå. |
#4
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Íåáîëüøîå äîïîëíåíèå:
Age,h Total serum bilirubin level, mg/dL (pmol/L) ------------A ------B---------C ---------D 25-48 >12 (210) >15 (260) >20 (340) >25 (430) 49-72 >15 (260) >18 (310) >25 (430) >30 (510) >72 _ >17 (290) >20 (340) >25 (430) >30 (510) A- Consider Phototherapy† B-Phototherapy C-Exchange Transfusion if Intensive Photo therapy Fails‡ D-Exchange Transfusion and Intensive Phototherapy † Phototherapy at these TSB levels is a clinical option, meaning that the intervention is available and may be used on the basis of individual clinical judgment. ‡ Intensive phototherapy (Appendix) should produce a decline of TSB of 1 to 2 mg/dL within 4 to 6 hours and the TSB level should continue to fall and remain below the threshold level for exchange transfusion. If this does not occur, it is considered a failure of phototherapy. Èñòî÷íèê: Practice Guideline. Management of Hyperbilirubinemia in the Healthy Term Newborn. AMERICAN ACADEMY OF PEDIATRICS - 1994 Ýòèìè ðåêîìåíäàöèÿìè ÀÀÐ ïîëüçóþòñÿ íà ñåãîäíÿøíèé äåíü âî âñåì ìèðå. Îáðàòè âíèìàíèå - äëÿ íåäîíîøåííûõ è äëÿ ðàííåé ãèïåðáèëèðóáèíåìèè åñòü äðóãèå ïðîòîêîëû. Ñîâåòóþ îçíàêîìèòü ýêñïåðòîâ. Óäà÷è! |
#5
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ß áû åùå äîáàâèë, ÷òî íà ïðàêòèêå ÿ ïðîøó ìàìó ïðèéòè â ëàáîðàòîðèþ ÷åðåç 24 ÷àñà ïîñëå ïåðâîãî çàáîðà. Äâå öèôðû äàþò ìíå êàðòèíó êóäà áèëëèðóáèí äâèæåòñÿ.
 êàêîì ñâåòîâîì äèàïàçîíå Âû ïðèìåíÿåòå ôîòîòåðàïèþ? |
#6
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Óâàæàåìûé Vladlen, Dr. Vad, Ó÷àñòêîâûé!
Óâàæàåìûå êîëëåãè, âñå êòî ÷èòàåò ýòó äèñêóññèþ! Áîëüøîå ñïàñèáî çà ïðîÿâëåííîå ó÷àñòèå ê íàøèì ïðîáëåìàì! Îòëè÷íàÿ èäåÿ - ïîçíàêîìèòü ýêñïåðòîâ ñ ïðîòîêîëàìè ÀÀÏ! Òîëüêî, ÿ íå äóìàþ, ÷òî îíè ñ íèìè íå çíàêîìû. Åñòü íåêèå ñäåðæèâàþùèå ôàêòîðû, ìåøàþùèå èõ âíåäðåíèþ â ïðàêòèêó, è îíè ïðèìåðíî ñëåäóþùèå (ÿ íå çíàþ, ÷òî èç ýòîãî ñîîòâåòñòâóåò äåéñòâèòåëüíîñòè): - Ó àìåðèêàíöåâ, âåðîÿòíî, äðóãàÿ ìåòîäèêà îïðåäåëåíèÿ áèëèðóáèíà. - Àìåðèêàíñêèå äåòè, âåðîÿòíî, íå èìåþò âîçìîæíîñòè ïðîõîäèòü äèñïàíñåðíîå íàáëþäåíèå ó íåâðîïàòîëîãà. -  Àìåðèêå íåò äåòñêèõ íåâðîëîãîâ. - Òàì íå ñóùåñòâóåò äèàãíîçà ìèíèìàëüíàÿ öåðåáðàëüíàÿ äèñôóíêöèÿ. - Ó íàñ è òàê ïåðåïîëíåíû øêîëû äëÿ óìñòâåííî îòñòàëûõ… Åñëè åùå íå ëå÷èòü æåëòóõè! Ìîæåò, êòî-òî íàçîâåò åùå? ß, âñå æå, äóìàþ áîðîòüñÿ çà èçìåíåíèå ñóùåñòâóþùåé ïðàêòèêè.  òîì ÷èñëå, è ñ âàøåé ïîääåðæêîé, äîðîãèå äðóçüÿ! Ìîæåò áûòü, êòî – íèáóäü óæå ñòàëêèâàëñÿ ñ ïîäîáíûìè òðóäíîñòÿìè? – âàø îïûò áûë áû áåñöåíåí! Ñåé÷àñ ÿ, áóäó÷è «÷àéíèêîì» â èíòåðíåòå, èùó èíôîðìàöèþ î ïðîâåäåííûõ èññëåäîâàíèÿõ ïî äëèòåëüíîìó (íåñêîëüêî ìåñÿöåâ) âëèÿíèè îòíîñèòåëüíî íåâûñîêîé (100-200 ìêì/ë) ãèïåðáèëèðóáèíåìèè íà ÖÍÑ. Áóäó ðàä ëþáîìó ñîäåéñòâèþ! |
#7
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Äëÿ ó÷àñòêîâîãî
Äëÿ ôîòîòåðàïèè ïðèìåíÿåòñÿ áåëûé, ñèíèé è çåëåíûé (ðåæå) ñâåò (áèëèðóáèí àáñîðáèðóåò ñâåò ñ äëèíîé âîëíû 450 íì).
Âàæíî ïîìíèòü î ðàññòîÿíèè (50ñì), ñèëå èçëó÷åíèÿ (îò 6 äî 30-40 mW/cm2/nm), ðàçìåðå îáëó÷àåìîé ïëîùàäè òåëà (ìàêñèìàëüíî âîçìîæíàÿ) è íåêîòîðûõ äðóãèõ ïîäðîáíîñòÿõ. Óäà÷è. |
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#8
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Ìíå íå ñîâñåì ïîíÿòíî, vlg_asb, ÷òî Âû èìåëè ââèäó, êîãäà ïîÿñíÿëè ïðè÷èíû ñäåðæèâàþùèõ ôàêòîðîâ, ìåøàþùèõ âíåäðåíèþ â ïðàêòèêó ïðîòîêîëîâ âåäåíèÿ ãèïåðáèëèðóáèíåìèè:
- Àìåðèêàíñêèå äåòè, âåðîÿòíî, íå èìåþò âîçìîæíîñòè ïðîõîäèòü äèñïàíñåðíîå íàáëþäåíèå ó íåâðîïàòîëîãà. -  Àìåðèêå íåò äåòñêèõ íåâðîëîãîâ. Ýòî Âàì îòêóäà èçâåñòíî? Êàê ýòî ìåøàåò ñëåäîâàíèþ ïðîòîêîëó âðà÷àìè â Ðîññèè? |
#9
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Óâàæàåìûé Ó÷àñòêîâûé!
... Ýòî âñåãî ëèøü íåñêîëüêî íåñåðüåçíûõ àðãóìåíòîâ â ñåðüåçíîì ñïîðå. Òàêèå âåùè òðóäíî îïðîâåðãíóòü è òðóäíî äîêàçàòü. Ñêîðåå âñåãî, ÿ ñëûøàë íà îäíîì èç ñåìèíàðîâ, è ãäå - ýòî íå âàæíî. Çäåñü èìååòñÿ â âèäó íåêèå âîçìîæíûå ïîâðåæäåíèÿ íåðâíîé ñèñòåìû ïðè äëèòåëüíîé ãèïåðáèëèðóáèíåìèè (÷òî-òî âðîäå ìèíèìàëüíîé öåðåáðàëüíîé äèñôóíêöèè), êîòîðûå ìîãóò áûòü âûÿâëåíû òîëüêî ðîññèéñêèìè íåâðîëîãàìè êàê ðàç â ñèëó çàèíòåðåñîâàâøèõ Âàñ ãèïîòåòè÷åñêèõ ïðè÷èí. Ýòî ñ÷èòàåòñÿ ñåðüåçíûì àðãóìåíòîì ê òîìó, ÷òîáû óâåëè÷èòü ÷èñëî äåòåé, ïîäëåæàùèõ ëå÷åíèþ, ñíèçèâ ïîðîãîâûé óðîâåíü áèëèðóáèíà ïî ñðàâíåíèþ ñî ñòàíäàðòíûìè ïðîòîêîëàìè AAP. |
#10
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--Ãèïåðáèëèðóáèíåìèÿ âûçûâàåò "ìèíèìàëüíóþ öåðåáðàëüíóþ äèñôóíêöèþ"
--Â àìåðèêå î íåé íå çíàþò, ïîòîìó ÷òî: --Òàì íåò äåòñêèõ íåâðîïàòîëîãîâ |
#11
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Àìåðèêàíñêèå íåâðîïàòîëîãè äåéñòâèòåëüíî íå çíàþò, ÷òî òàêîå "ìèíèìàëüíàÿ öåðåáðàëüíàÿ äèñôóíêöèÿ". Âïðî÷åì, ýòîãî íå çíàåò íèêòî, êðîìå îòå÷åñòâåííûõ äåòñêèõ íåâðîïàòîëîãîâ.
Åñëè ÿ ïðàâèëüíî ïîíÿëà, îòå÷åñòâåííûå íåîíàòîëîãè ñòàðàþòñÿ ñåáÿ ïî âîçìîæíîñòè çàñòðàõîâàòü, ò.ê. ýòîò äèàãíîç ñòàâèòñÿ â îñíîâíîì çäîðîâûì äåòÿì. Ñ óâàæåíèåì |
#12
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Íåñêîëüêî àáñòðàêòîâ êàñàþùèõñÿ âëèÿíèÿ ãèïåðáèëèðóáèíåìèè íà ÖÍÑ. Ìîæåò ïðèãîäÿòñÿ.
Pediatrics 1993 Nov;92(5):651-7 Comment in: Pediatrics. 1994 Aug;94(2 Pt 1):246. Neonatal hyperbilirubinemia and long-term outcome: another look at the Collaborative Perinatal Project. Newman TB, Klebanoff MA. Department of Laboratory Medicine, School of Medicine, University of California, San Francisco 94143-0626. OBJECTIVE. To examine the association between neonatal bilirubin levels and subsequent neurodevelopmental outcome. DESIGN. Prospective cohort study. SETTING. 12 US medical centers from 1959 (first births) to 1974 (last follow-up). PARTICIPANTS. 41,324 singleton white or black infants with birth weight > or = 2500 g who had neonatal bilirubin measurements recorded and survived at least 1 year. MAIN OUTCOME MEASURES. Wechsler Intelligence Scale for Children Intelligence Quotient (IQ) at age 7 years, blinded neurologic examination at age 7 years, and sensorineural hearing loss at age 8 years. RESULTS. There was no association between IQ and bilirubin. For example, comparing children who had maximum bilirubin levels > or = 342 mumol/L (20 mg/dL) with those who had lower bilirubin levels, adjusted mean IQs were 105.0 and 103.4 in whites (difference + 1.6; 95% confidence interval [CI]: -0.4 to +3.5) and 91.0 and 93.3 in blacks (difference -2.3; 95% CI: -4.8 to +0.2). Abnormal neurologic examination results were reported in 12 of 268 children (4.5%) with bilirubin > or = 342 mumol/L (20 mg/dL) compared with 1249 of 33,004 children (3.8%) with lower levels (relative risk [RR] = 1.2; 95% CI: 0.7 to 2.1). The frequency of abnormal or suspicious neurologic examination results increased in a stepwise fashion with increasing bilirubin level (P < .001), from 4346/29,258 (14.9%) of those with bilirubin levels < 171 mumol/L (10 mg/dL) to 60/268 (22.4%) of those with bilirubin levels. > or = 342 mumol/L (20 mg/dL), apparently due to increasing minor motor abnormalities at higher bilirubin levels. Sensorineural hearing loss was not associated with high bilirubin levels (RR = 1.0; 95% CI: 0.3 to 3.0). CONCLUSIONS. Neonatal bilirubin levels seem to have little effect on IQ, definite neurologic abnormalities, or hearing loss. Higher bilirubin levels are associated with minor motor abnormalities, but the clinical importance of this finding is limited by the weakness of the association, the mild nature of the abnormalities, and the lack of evidence that they are prevented by treatment. Clin Perinatol 1990 Jun;17(2):331-58 Does hyperbilirubinemia damage the brain of healthy full-term infants? Newman TB, Maisels MJ. Department of Pediatrics, University of California, San Francisco. In the 1950s, exchange transfusion to keep the total serum bilirubin below 20 mg/dl was shown to be an effective way of preventing kernicterus in babies with erythroblastosis fetalis. For the last 15 to 20 years this level has also been used to determine the need for intervention in healthy full-term infants who do not have hemolytic disease. A critical review of all the available data including six studies from the collaborative perinatal project (more than 30,000 infants) and several smaller studies of term infants without hemolysis reveals essentially no evidence of adverse effects of bilirubin on IQ, neurologic examination, or hearing. The investigation and treatment of normal infants with jaundice is expensive and potentially harmful. We need to reassess our approach to hyperbilirubinemia in healthy full-term infants. Pediatrics 1991 Jun;87(6):797-805 Intelligence at six years in relation to neonatal bilirubin levels: follow-up of the National Institute of Child Health and Human Development Clinical Trial of Phototherapy. Scheidt PC, Graubard BI, Nelson KB, Hirtz DG, Hoffman HJ, Gartner LM, Bryla DA. Human Learning and Behavior Branch, National Institute of Child Health and Human Development, Bethesda, Maryland 20892. Results of the National Institute of Child Health and Human Development Randomized Controlled Trial of Phototherapy were examined for the relationship of neonatal bilirubin level to neurological and developmental outcome at 6-year follow-up. This analysis focused on 224 control children with birth weight of less than 2000 g. Bilirubin levels were maintained below previously specified levels by the use of exchange transfusion only (24%). Rates of cerebral palsy were not significantly higher for children with elevated maximum bilirubin level than for those whose level remained low. No association was evident between maximum bilirubin level and IQ (Full Scale, Verbal, or Performance) by simple correlation analysis (r = -.087, P = .2 for Full Scale) or by multiple linear regression adjusting for factors that covary with IQ (beta = -.15, P = .58). IQ was not associated with mean bilirubin level, time and duration of exposure to bilirubin, or measures of bilirubin-albumin binding. Thus, over the range of bilirubin levels permitted in this clinical trial, there was no evidence of bilirubin toxicity to the central nervous system. Measures used to control the level of bilirubin in low birth weight neonates appear to prevent effectively the risk of bilirubin-induced neurotoxicity. Pediatrics 1985 Sep;76(3):351-4 Relationship of serum bilirubin levels to ototoxicity and deafness in high-risk low-birth-weight infants. de Vries LS, Lary S, Dubowitz LM. During a 4-year period, 12 premature infants, all less than 34 weeks of gestation and all with a bilirubin level above 240 mumol/L (14 mg/dL) were determined to have bilateral sensorineural deafness. In order to to investigate how far the hyperbilirubinemia or any a associated factor might have been a causative factor, all infants of 34 weeks of gestation or less who had a serum bilirubin level above 240 mumol/L were investigated. For a period of 4 years, 99 infants meeting these criteria were classified as high risk or low risk on the basis of perinatal risk factors. Eight of the 22 high-risk infants with birth weight less than 1,500 g, but only two of 43 high-risk infants with birth weight greater than 1,500 g were deaf (P less than .05). The deaf infants were also matched with infants of normal hearing who had similar bilirubin levels and the same number of adverse perinatal factors. The mean duration of hyperbilirubinemia was significantly longer in the deaf infants (P less than .02), and they appeared to have a greater number of acidotic episodes while they were hyperbilirubinemic. These findings suggest that in healthy preterm infants with birth weight greater than 1,500 g, high bilirubin levels carry little risk, whereas a serum bilirubin level greater than 240 mumol/L in high-risk preterm infants with birth weight of 1,500 g or less is associated with a high risk of deafness. |
#13
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Äëÿ vlg_asb
"Ýòî âñåãî ëèøü íåñêîëüêî íåñåðüåçíûõ àðãóìåíòîâ â ñåðüåçíîì ñïîðå"
Òóò ñïîðèòü íå î ÷åì. Íàäî ïðîñòî ó÷èòüñÿ. |
#14
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Íå â áðîâü à â ãëàç, yananshs. Ñïàñèáî.
Ñòàëî áûòü áèëèðóáèí 180-200 ó äîíîøåííûõ íå âûçûâàåò òóìàííûõ "íàðóøåíèé â ìîçãàõ"? Êàê Âû íàøëè ýòè ññûëêè? Åñëè Âàñ íå çàòðóäíèò, íå ìîãëè áû îïèñàòü êàê Âû ïîëó÷èëè ýòè ññûëêè? Ìîæåò êòî-òî ñìîæåò çàãëÿíóòü â èññëåäîâàíèÿ ñî âñåãî ìèðà è íàéòè äîêàçàòåëüñòâà "ìèíèìàëüíîé öåðåáðàëüíîé äèñôóíêöèè"? Ñêîëüêî âðåìåíè Âû çàòðàòèëè íà ïîèñê? Ìû æå âðà÷è. Íàøå ëå÷åíèå âñåãäà äîëæíî áûòü îñíîâàíî íà ôàêòàõ. Íå ïðàâäà ëè? |
#15
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Dear Ó÷àñòêîâûé
ß ÷àùå âñåãî èñïîëüçóþ ïîèñêîâóþ ñèñòåìó National Library of Medicine [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Åñëè íàáðàòü â ýòîé ñèñòåìå minimal cerebral dysfunction, òî ñèñòåìà âûäà¸ò ðóññêóþ ñòàòüþ: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] è ñòàòüþ èç êàêîãî-òî ëàòèíîàìåðèêàíñêîãî æóðíàëà 75 ãîäà. Îñòàëüíûå ïóáëèêàöèè áóäóò îá ADHD. Òåðìèí "minimal cerebral dysfunction" ñóùåñòâîâàë êîãäà-òî â àíãëîÿçû÷íîé ëèòåðàòóðå (íà ÷òî ìíå óæå óêàçàëè íà ýòîì ôîðóìå) äëÿ îáîçíà÷åíèÿ "attention deficit hyperactivity disorder" (ADHD), íî ñåé÷àñ, íàñêîëüêî ÿ çíàþ, íå èñïîëüçóåòñÿ. Ïóáëèêàöèé, ñâÿçûâàþùèõ ðàçâèòèå ADHD ñ ãèïåðáèëèðóáèíåìèåé ÿ íå íàøëà. Ñ óâàæåíèåì ßíà |