#16
|
|||
|
|||
Î ìåõàíèçìàõ âîçíèêíîâåíèÿ è êëàññèôèêàöèÿõ òðàíçèòîðíûõ èììóíîäåôèöèòîâ íóæíî ñïðàøèâàòü âðà÷åé àëëåðãîëîãîâ-èììóíîëîãîâ. Òðàíçèòîðíûå èììóíîäåôèòû èëè ïðîõîäÿùèå õàðàêòåðèçóþòñÿ ñåçîííîñòüþ òå÷åíèÿ. Åñëè ýòî êàñàåòñÿ ãåðïåñà, òî âîçìîæíû ÷àñòûå ðåöèäèâû â ìåæñåçîíüå: îñåíü, âåñíà. Ïî äàííûì ó÷¸íûõ èç ÃÍÖ ÐÔ Èíñòèòóòà èììóíîëîãèè ÔÌÁÀ Ðîññèè ó ïàöèåíòîâ "èììóíîëîãè÷åñêè çäîðîâûõ" â îñòàëüíûå âðåìåíà ãîäà, â ìåæñåçîíüå âîçíèêàþò îïðåäåë¸ííûå íàðóøåíèÿ ðàáîòû èììóííîé ñèñòåìû, ÷òî ïðèâîäèò ê ðåöèäèâàì.
×òî êàñàåòñÿ äîêàçàòåëüíîé áàçû: áàçà ñóùåñòâóåò. Óðîâåíü äîêàçàòåëüíîñòè íèçêèé ïî ìèðîâûì ñòàíäàðòàì. |
#17
|
||||
|
||||
À âîò ìíåíèå èììóíîëîãà-àëëåðãîëîãà"
"...ðåáåíîê ìîæåò áîëåòü ÎÐÇ õîòü 10-15 ðàç â ãîä, íî åñëè îí êàæäûé ðàç ñàì è áåç îñîáûõ óñèëèé âðà÷åé âûçäîðàâëèâàåò, òî ó òàêîãî ðåáåíêà íåò ïðîáëåì ñ èììóíèòåòîì..." "Ìû ãîâîðèì î ÷àñòî áîëåþùèõ äåòÿõ. Êàêîé êðèòåðèé, ÷òî îíè áîëåþò ÷àñòî? Åñëè ðåáåíîê áîëååò ÎÐÂÈ 4-6 ðàç â ãîä, ýòî ìíîãî? Ìíå êàæåòñÿ, â òàêîì ñëó÷àå íàäî ðàçáèðàòüñÿ, ÷òî ñêðûâàåòñÿ ïîä ýòèì äèàãíîçîì, à ÎÐÂÈ ëè ýòî. Íàïðèìåð, èç ìîåãî îïûòà ðàáîòû ñ âçðîñëûìè ïàöèåíòàìè - ÷àñòî ïîä òàêèì äèàãíîçîì ñêðûâàåòñÿ àëëåðãè÷åñêàÿ ïàòîëîãèÿ è ïðè îáñëåäîâàíèè âûÿâëÿåò àëëåðãè÷åñêèé ðèíèò è/èëè áðîíõèàëüíàÿ àñòìà, ïðè÷åì ñ òèïè÷íîé êëèíè÷åñêîé êàðòèíîé. Òîãäà òàêèõ äåòåé äåéñòâèòåëüíî íàäî íàïðàâëÿòü ê àëëåðãîëîãó-èììóíîëîãó, íî èìåííî ñ ïîäîçðåíèåì íà àëëåðãè÷åñêóþ ïàòîëîãèþ, âîçìîæíû è äðóãèå âàðèàíòû, òóò óæ çàäà÷à ïåäèàòðà ðàçáèðàòüñÿ. Ìíå ïðîñòî õîòåëîñü âûñêàçàòü ñâîþ ëè÷íóþ òî÷êó çðåíèÿ. ß ïÿòü ëåò (îäèíàòóðà+àñïèðàíòóðà) ïðîðàáîòàëà â ýòîé ñôåðå è ñ÷èòàþ, ÷òî ó íàñ ñëèøêîì ïðåóâåëè÷èâàåòñÿ çíà÷èìîñòü êîíñóëüòàöèè ó èììóíîëîãà, ýòîò âðà÷ ðàñöåíèâàåòñÿ êàê ïîñëåäíÿÿ íàäåæäà ïàöèåíòà. Ìíîãèå âçðîñëûå ïàöèåíòû, íàïðàâëåííûå íà êîíñóëüòàöèþ àëëåðãîëîãà-èììóíîëîãà ïî ïîâîäó «âòîðè÷íîãî èììóíîäåôèöèòà» íóæäàþòñÿ ñêîðåå â êîíñóëüòàöèè ïñèõèàòðà, â âèäó íàëè÷èÿ ïîãðàíè÷íîé ïñèõè÷åñêîé ïàòîëîãèè èëè äàæå ýíäîãåííîãî çàáîëåâàíèÿ. Íåîïðàâäàííî ÷àñòî íàçíà÷àåòñÿ èññëåäîâàíèå èììóííîãî ñòàòóñà. Òîãäà êàê èññëåäîâàíèå òåõ èëè èíûõ ïîêàçàòåëåé èììóííîãî ñòàòóñà (èìåþ â âèäó îïðåäåëåíèå ñóáïîïóëÿöèé ëèìôîöèòîâ, ôàãîöèòîçà, óðîâíÿ ñûâîðîòî÷íûõ èììóíîãëîáóëèíîâ è íåêîòîðûå äðóãèå ïîêàçàòåëè) èìååò çíà÷åíèå äëÿ óñòàíîâêè äèàãíîçà è/èëè îïðåäåëåíèÿ ïðîãíîçà ïðåèìóùåñòâåííî â 3 ñèòóàöèÿõ - ïîäîçðåíèå íà ïåðâè÷íûé èììóíîäåôèöèò, ÂÈ×-èíôåêöèÿ íó è îíêîãåìàòîëîãèÿ. ×òî êàñàåòñÿ èììóíîìîäóëèðóþùèõ ïðåïàðàòîâ, òî, ê ñîæàëåíèþ, íàñêîëüêî ÿ ïîíèìàþ, ïîëíîöåííûõ äîêàçàòåëüíûõ ìóëüòèöåíòðîâûõ èññëåäîâàíèé ïî åäèíîìó ïðîòîêîëó äëÿ áîëüøèíñòâà øèðîêî ðåêëàìèðóåìûõ ñåé÷àñ ïðåïàðàòîâ íå áûëî. Ïðîáëåìà ìíå åùå âèäèòñÿ â òîì, ÷òî êîãäà ÷èòàåøü àííîòàöèþ ê ïðåïàðàòó èëè ñòàòüþ, òî âñå êàæåòñÿ çàìå÷àòåëüíûì, à âîò â ðåàëüíîñòè âñå íåìíîãî íå òàê. Âåäü åñëè, ê ïðèìåðó, ÿ íàçíà÷àþ ïàöèåíòó ñ áðîíõèàëüíîé àñòìîé èíãàëÿöèîííûå ÃÊÑ, òî â áîëüøèíñòâå ñëó÷àåâ ïîëó÷ó ïîëîæèòåëüíûé îòâåò, äðóãîé âîïðîñ, ÷òî ìîæåò áûòü íóæíà áóäåò êîððåêöèÿ äîçû è ò.ï., òîæå ìû ìîæåì ñêàçàòü îá àäåêâàòíîé àíòèáàêòåðèàëüíîé òåðàïèè, àíòèãèïåðòåíçèâíûõ ïðåïàðàòàõ è äð. À âîò ñ èììóíîìîäóëÿòîðàìè òàê íå ïîëó÷àåòñÿ. ÈÌÕÎ, â ïðèìåíåíèè èììóíîìîäóëèðóþùèõ ïðåïàðàòîâ áîëüøå âîïðîñîâ, ÷åì îòâåòîâ, ÷òîáû âîò òàê ïðîñòî èñïîëüçîâàòü èõ ó ÷àñòî áîëåþùèõ äåòåé. À îòäåëüíîé ñïåöèàëüíîñòè èììóíîëîãèÿ íåò, åñòü îäíà ñïåöèàëüíîñòü 14.00.36 «Àëëåðãîëîãèÿ è èììóíîëîãèÿ», íî åñòü îñîáåííîñòü, ÷òî ñïåöèàëüíîñòü îäíà è äëÿ âðà÷à ëå÷åáíèêà, îêîí÷èâøåãî îðäèíàòóðó, è äëÿ âðà÷à-èññëåäîâàòåëÿ èëè áèîëîãà. È íå ðåäêîñòü, êîãäà â êà÷åñòâå êîíñóëüòàíòà âûñòóïàåò èìåííî âðà÷-èññëåäîâàòåëü, îñîáåííî â êîììåð÷åñêèõ ñòðóêòóðàõ. " |
#18
|
|||
|
|||
Ðå÷ü âðîäå áû øëà î âçðîñëîé æåíùèíå. Ïðè÷¸ì çäåñü äåòè? Íå íóæíî ìåøàòü â îäíó êó÷ó ëþäåé è êîíåé.
|
#19
|
|||
|
|||
Öèòàòà:
|
#20
|
||||
|
||||
Êëèíè÷åñêèå ïîäõîäû â ýòîì ñëó÷àå îòëè÷àòüñÿ íå áóäóò. Ïðîñòî ýòà öèòàòà áûëà èìåííî î äåòÿõ.
"... Êñòàòè, ê èììóíîëîãó ïîñûëàþò íå òîëüêî äåòåé, íî è âçðîñëûõ. À âðà÷ó àëëåðãîëîãó-èììóíîëîãó ïîòîì ïðèõîäèòñÿ óáåæäàòü ïàöèåíòà, ÷òî ó íåãî âñå íîðìàëüíî ñ èììóíèòåòîì è åìó íå íóæíî ñäàâàòü àíàëèç íà èììóííûé ñòàòóñ, à ñëîæíåå âñåãî, êîãäà ïðèõîäèò ïàöèåíò óæå ñî ñäåëàííûì èììóííûì ñòàòóñîì, à òàì êàêèå-òî îòêëîíåíèÿ îò "íîðìû", âîò òóò ïðèõîäèòñÿ òóãî, ò.ê. ñåé÷àñ âñåì èçâåñòíî, ÷òî âñå áîëåçíè îò èììóíèòåòà." |
#21
|
|||
|
|||
Íó, íó. Âñû ¸ùå ñêàæèòå, ÷òî ïåäèàòðû íå íóæíû. Âåçäå îäèíàêîâûå êëèíè÷åñêèå ïîäõîäû.
Èíòåðåñíî, âñå ëè ðóññêèå ïåðåáðàâøèåñÿ â USA îáëàäàþò òàêèì èíòåëëåêòîì èëè îò ÷åëîâåêà çàâèñèò? |
#22
|
||||
|
||||
Ïðîñòèòå, Èâàí, ÿ íå ñîâñåì ïîíÿëà, ÷åé èíòåëëåêò Âû õîòåëè áû îáñóäèòü?
Ïåäèàòðû î÷åíü íóæíû, íî íå òå, êîòîðûå íàçíà÷àþò äåòÿì èììóíoìîäóëÿòîðû ïðè ïðîñòóäàõ. |
|
#23
|
||||
|
||||
Öèòàòà:
------------------ Evaluation of Suspected Immunodeficiency Children with recurrent infections are among the most frequent types of patients seen by primary care physicians. The number of pediatric patients suspected of having primary or secondary immunodeficiency far exceeds the actual number of cases despite the emergence of the human immunodeficiency virus (HIV) epidemic. Most patients with recurrent infections do not have an identifiable immunodeficiency disorder. A major reason for the apparent high rate of recurrent infections is excessive exposure of infants or children to infectious agents in out-of-home child care and other group settings. In addition, excessive use of antibiotics by physicians has masked the classic presentation of many of the primary immunodeficiency diseases. Primary care physicians must have a high index of suspicion if defects of the immune system are to be diagnosed early enough that appropriate treatment can be instituted before there is irreversible damage. This problem is made more difficult because none of these defects are screened for currently in the perinatal period or later in childhood, and there is widespread use of antibiotics for respiratory infections, which can mask genetic defects in the immune system. Evaluation of immune function should be initiated for children with clinical manifestations of a specific immune disorder or with unusual, chronic, or recurrent infections such as (1) two or more systemic or serious bacterial infections (e.g., sepsis, osteomyelitis, or meningitis); (2) three or more serious respiratory or documented bacterial soft tissue infections (e.g., cellulitis, draining otitis media, or lymphadenitis) within 1 yr; (3) infections occurring at unusual sites (e.g., liver or brain abscess); (4) infections with unusual pathogens (e.g., Aspergillus, Serratia marcescens, Nocardia, or Burkholderia cepacia); and (5) infections with common childhood pathogens but of unusual severity. The screening tests selected for immunologic evaluation should be broadly informative, reliable, and cost effective. Familiarity with certain clinical guidelines aids in the initial selection of tests. Patients with deficiencies of antibodies, phagocytic cells, or complement have recurrent infections with encapsulated bacteria. Thus, patients with only repeated viral infections (with the exception of persistent enterovirus infections) are not as likely to have any of these disorders. Children with defects in antibody production, phagocytic cells, or complement proteins may grow and develop normally despite their recurrent infections unless they develop bronchiectasis from repeated lower respiratory tract bacterial infections or have persistent enteroviral infections of the central nervous system. By contrast, patients with deficiencies in T-cell function usually develop opportunistic infections early in life and fail to thrive. ---------- È ò.ä. |
#24
|
|||
|
|||
Öèòàòà:
Íå ãîâîðÿ óæ î òîì, ÷òî áîëüøèíñòâî âòîðè÷íûõ èììóíîäåôèöèòîâ èìååò âðåìåííûé (èëè ïåðèîäè÷åñêèé) õàðàêòåð. |
#25
|
||||
|
||||
Öèòàòà:
|
#26
|
|||
|
|||
Alon!
È ïî «èììóíèòåòó» ýêçàìåíû ÿ â ñâîå âðåìÿ ñäàâàë (ñêîëüêî òàì ÷àñîâ íà íåãî îòïóùåíî â ìåä. èí-òàõ?). È íè îäèí ãîä â ýêñïåðèìåíòàëüíûõ è êëèíè÷åñêèõ ðàáîòàõ áûë ñâÿçàí ñ èññëåäîâàíèÿìè ðàçëè÷íûõ ôàêòîðîâ èììóíèòåòà. Îòêóäà òàêàÿ óâåðåííîñòü, ÷òî Âû èëè òà æå Ñòóäåíöîâà, êîòîðàÿ î ñåáå íàñòîëüêî âûñîêîãî ñàìîìíåíèÿ, ÷òî îöåíèâàåò («íå îäîáðÿåò») ìåíÿ çà âñå è çà âñÿ ïî òðè ðàçà íà äåíü, ëó÷øå ìåíÿ â íåì ðàçáèðàåòåñü? |
#27
|
|||
|
|||
Ïðîñòî äåâî÷êà òàê ïûòàåòñÿ ñàìîóòâåðäèòüñÿ.
|
#28
|
||||
|
||||
Ãîñïîäèí Çàéöåâ!
Âû õîòü è ëþáîçíàòåëüíûé, íî âñå æå äèëåòàíò, ïîýòîìó óæå â ñîòûé ðàç ñîâåòóþ âàì ïðèñëóøèâàòüñÿ ê òîìó, ÷òî ãîâîðÿò ñåðòèôèöèðîâàííûå ñïåöèàëèñòû, ê êîòîðûì îòíîñèòñÿ, â îòëè÷èå îò óâàæàåìîãî Èâàíà Êîêîòêèíà, è ñòîëü íåëþáèìàÿ âàìè ßíà. È åùå... íà ïðîòÿæåíèå äîëãèõ ëåò âû ó÷àñòâîâàëè â îïûòàõ íà ëþäÿõ, è, íåñìîòðÿ íà ýòî, âñå âðåìÿ ïûòàåòåñü ãîâîðèòü çäåñü î ïîðÿäî÷íîñòè è ñïðàâåäëèâîñòè.Óéìèòåñü. |
#29
|
||||
|
||||
×òî ñàìîå óæàñíîå, èììóíîìîäóëÿòîðû íàïðàâî è íàëåâî íàçíà÷àþò ïðîâèçîðû â àïòåêàõ. È áîëüíûå ïîêóïàþò. Êàê çàìàí÷èâî çâó÷èò "äëÿ ïîâûøåíèÿ èììóíèòåòà".
|
#30
|
||||
|
||||
Öèòàòà:
|