ประชุมวิชาการ ศิริราช 52
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ประชุมวิชาการ ศิริราช 52 ประชุมวิชาการ ศิริราช 52 Document Transcript

  • (i) àǪÈÒʵÏÃÇÁÊÁÑÂ: ‹ ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â Œ Ô ºÃóҸԡÒà Á³Õ Ãѵ¹äªÂÒ¹¹·, ¾.º. ¸ÕÃо§É µÑ³±ÇÔàªÕÂÃ, ¾.º. ºÃóҸԡÒÃËÇÁ ¹Ô¸¾²¹ à¨ÕÂáØÅ, ¾.º. Ô Ñ ¡ÁŠᡌǡԵ³Ã§¤, ¾.º. Ô ´ÒÃÒÇÃó ǹЪÕǹÒÇÔ¹, ¾.º. ªØÉ³Ò Êǹ¡Ãе‹ÒÂ, ¾.º. ÇÒ³Õ ÇÔÊ·¸ÔàÊÃÕǧȏ, ¾.º. Ø â¤Ã§¡ÒõíÒÃÒËÇÁ ÃÐËNjҧ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å áÅÐ ¤³Ðá¾·ÂÈÒʵÏ ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑ ÔÔ
  • (ii)àǪÈÒʵÏÃÇÁÊÁÑÂ: ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ ÔISBN 978-974-11-1145-9ʧǹÅÔ¢ÊÔ·¸Ôìâ¤Ã§¡ÒõíÒÃÒËÇÁ ÃÐËNjҧ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å áÅÐ ÔÔ¤³Ðá¾·ÂÈÒʵÏ ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅѾÔÁ¾¤Ãѧ·Õè 1 ¾.È. 2552 é ¨íҹǹ 1,500 àŋÁ¾ÔÁ¾·ÕèºÃÔÉ· ¾Õ.àÍ.ÅÕ¿ÇÔ§ ¨íÒ¡Ñ´ Ñ è4 «ÍÂÊÔù¸Ã 7 ºÒ§¾ÅÑ´ ¡Ãا෾ÁËÒ¹¤Ã 10700 Ôâ·ÃÈѾ· 0 2881 9890
  • (iii) ¤íÒ¹íÒ ¤³º´Õ¢Í§âçàÃÕ¹ᾷÊͧáˋ§·ÕࡋÒᡋ·Ê´ã¹»ÃÐà·Èä·Â ¤×Í ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª è Õè Ø ÔÔ¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å áÅÐ ¤³Ðá¾·ÂÈÒʵÏ ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑ 䴌µ¡Å§¡Ñ¹·Õ¨ÐÁÕ è¡Ô¨¡ÃÃÁÍѹ໚¹¤ÇÒÁËÇÁÁ×Í·Ò§ÇÔªÒ¡ÒÃÃÐËNjҧâçàÃÕ¹ᾷ·§Êͧáˋ§¹Õµ§áµ‹»‚ ¾.È. 2551 áÅÐ Ñé é Ñé¼Å¼ÅԵ˹Ö觢ͧ¤ÇÒÁËÇÁÁ×͹Õé 䴌ᡋ ˹ѧÊ×Í “àǪÈÒʵÏËÇÁÊÁÑÂ: ÇÔªÒ¡ÒÃᾷ¡ŒÒÇ˹ŒÒ»ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â” Íѹ໚¹Ë¹Ñ§Ê×ÍàŋÁáá¢Í§ â¤Ã§¡ÒõíÒÃÒËÇÁ ÃÐËNjҧ¤³Ðᾷ ԷѧÊͧ â´Â䴌ú¤ÇÒÁ͹Øà¤ÃÒÐˏº·¤ÇÒÁ·Ò§ÇÔªÒ¡Òèҡ¤³Ð¼Ù¹¾¹¸«§à»š¹¼ÙàªÕÂǪҭ੾Òзҧ é Ñ Œ Ô Öè Œ èã¹ÃдѺ»ÃÐà·È䴌ËÇÁÁ×͡ѹÃǺÃÇÁ¤ÇÒÁÃٌ·Õè·Ñ¹ÊÁÑÂáÅФÃͺ¤ÅØÁËÑÇ¢ŒÍ·Ò§¡ÒÃᾷ·Ñ駷Õè໚¹¤ÇÒÁÃٌ´ŒÒ¹ÇÔ·ÂÒÈÒʵϾé×¹°Ò¹áÅдŒÒ¹¤ÅÔ¹Ô¡·ÕèÊÒÁÒö¹íÒä»»ÃÐÂØ¡µãªŒä´Œ¨ÃÔ§ã¹àǪ»¯ÔºÑµÔ·Õè¡íÒÅѧ䴌ÃѺ¤ÇÒÁʹã¨ã¹»˜¨¨ØºÑ¹ à¹×èͧ¨Ò¡à¹×éÍËÒÇÔªÒã¹Ë¹Ñ§Ê×ÍàŋÁ¹ÕéÁÕ¤ÇÒÁËÅÒ¡ËÅÒÂÁÒ¡¡Í§ºÃóҸԡÒè֧䴌¨Ñ´ËÑÇ¢ŒÍµ‹Ò§æ ໚¹¡Å؋Á ´Ñ§¹Õé (1) ¡ÒÃʋ§àÊÃÔÁÊØ¢ÀÒ¾áÅСÒû‡Í§¡Ñ¹âä(2) ËÑÇ¢ŒÍµÒÁÃкº (3) ËÑÇ¢ŒÍ੾ÒÐÊÒ¢ÒÇÔªÒ (4) State of the Art (5) ¡¯ËÁÒ·ҧ¡ÒÃᾷáÅÐÃкº¤Çº¤ØÁ (6) ¡ÒÃÇԨ·ҧÇÔ·ÂÒÈÒʵÏ¡ÒÃᾷ áÅÐ (7) ¡ÒþÂÒºÒÅ Ñ ¡Í§ºÃóҸԡÒÃáÅФ³Ð¼ÙŒ¹Ô¾¹¸ÁÕ¤ÇÒÁÁ؋§ÁÑè¹·Õè¨Ð¹íÒ¤ÇÒÁÃٌ·Õè䴌ÃǺÃÇÁÁÒà¾×èÍÁͺ໚¹ÇÔ·ÂҷҹᡋºØ¤Åҡ÷ҧ¡ÒÃᾷ·Ø¡·‹Ò¹ãˌÊÒÁÒö¹íÒä»ãªŒ»ÃСͺã¹àǪ»¯ÔºÑµÔ à¾×èÍãˌà¡Ô´»ÃÐ⪹ÊÙ§ÊØ´µ‹Í¤Ø³ÀÒ¾ªÕÇÔµ·Õè´Õ¢Í§»Ç§ª¹ªÒÇä·Â ãˌÊÁ¡Ñº»ÃÐà´ç¹ËÅÑ¡ (main theme)¢Í§Ë¹Ñ§Ê×ÍàǪÈÒʵÏÃÇÁÊÁÑÂàŋÁ¹Õé ¤×Í “ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â” ‹ Œ Ô ¡Í§ºÃóҸԡÒÃ
  • (iv) ¤íÒ¹ÔÂÁ “àǪÈÒʵÏÃÇÁÊÁÑÂ: ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â” ໚¹Ë¹Ñ§Ê×Í ‹ Œ ÔàŋÁáá¢Í§ â¤Ã§¡ÒõíÒÃÒËÇÁ ÃÐËNjҧ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å áÅÐ ÔÔ¤³Ðá¾·ÂÈÒʵÏ ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑ «Ö§à»š¹Ë¹Ö§ã¹â¤Ã§¡ÒäÇÒÁËÇÁÁ×Í·Ò§ÇÔªÒ¡ÒÃÃÐËNjҧ è èâçàÃÕ¹ᾷÊͧáˋ§·ÕࡋÒᡋ·Ê´¢Í§»ÃÐà·Èä·Â ˹ѧÊ×ÍàŋÁ¹Õ䴌ÃǺÃÇÁ¤ÇÒÁÃÙáÅмŧҹÇԨ è Õè Ø é Œ Ñ·ÕÁ¤³¤‹ÒµÅÍ´¨¹¤ÇÒÁ¡ŒÒÇ˹ŒÒ·Ò§¡ÒÃᾷáÅÐÊÒ¸ÒóÊØ¢ â´Â䴌ú¤ÇÒÁËÇÁÁ×Í໚¹Í‹ҧ´Õ§ è Õ Ø Ñ Ôè¨Ò¡¤³Ð¼Ù¹¾¹¸«§à»š¹¼ÙàªÕÂǪҭ੾Òзҧã¹ÃдѺ»ÃÐà·È¡Ç‹Ò 100 ·‹Ò¹ ˹ѧÊ×ÍàŋÁ¹ÕÁ§à¹Œ¹¡Òà Œ Ô Öè Œ è é ؋¹íÒͧ¤¤ÇÒÁÃٌ ÇÔ·ÂÒ¡ÒÃáÅÐà·¤â¹âÅÂÕ·Ò§¡ÒÃᾷ··¹ÊÁÑÂáÅÐ໚¹àÅÔÈÁÒ»ÃÐÂØ¡µãªŒÍ‹ҧàËÁÒÐ Õè ÑÊÁÊíÒËÃѺ¡ÒôÙáÅÊØ¢ÀÒ¾¢Í§¤¹ä·Â ã¹¹ÒÁ¢Í§¤³Ðá¾·ÂÈÒʵÏ·Ñé§ÊͧʶҺѹ ¤³º´ÕÁÕ¤ÇÒÁÂÔ¹´Õ໚¹Í‹ҧÂÔ觷ÕèËÇÁÁ×Í·Ò§ÇÔªÒ¡ÒÃÃÐËNjҧâçàÃÕ¹ᾷÊͧáˋ§¹Õ¨Ð໚¹»ÃÐ⪹µÍ ᾷ ¾ÂÒºÒÅ ºØ¤Åҡ÷ҧ¡ÒÃᾷ é ‹·Ø¡ÊÒ¢Ò «Ö§¨Ð¡‹Íãˌà¡Ô´»ÃÐ⪹Ê§ÊØ´µ‹Í¤Ø³ÀÒ¾ªÕǵ¢Í§ÁËÒª¹ªÒÇä·Â ãˌÊÁ¡Ñº»ÃÐà´ç¹ËÅÑ¡ è Ù Ô(main theme) ¢Í§Ë¹Ñ§Ê×ÍàǪÈÒʵÏÃÇÁÊÁÑÂàŋÁ¹Õé ¤×Í “ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò ‹ Œ¤Ø³ÀÒ¾ªÕǵä·Â” ÔÈÒʵÃÒ¨ÒϤÅÔ¹¡¹ÒÂᾷ¸ÃÇѲ¹ ¡ØÅ·¹Ñ¹·¹ Ô Õ ÈÒʵÃÒ¨ÒϹÒÂᾷʹÔÈà ÀÑ·ÃÒ´Ùŏ ¤³º´Õ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÔÔ ¤³º´Õ ¤³Ðá¾·ÂÈÒʵÏ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ
  • (v) ¡Í§ºÃóҸԡÒê×Í-Ê¡ØÅ è ¡ÁŠᡌǡԵ³Ã§¤ ÔÇز¡ÒÃÈÖ¡ÉÒ Ô ¾.º., Ç.Ç.ÍÒÂØÃÈÒʵϵíÒá˹‹§·Ò§ÇÔªÒ¡Òà ¼ÙªÇÂÈÒʵÃÒ¨ÒÏ Œ ‹Ë¹‹Ç§ҹ ÀÒ¤ÇÔªÒÍÒÂØÃÈÒʵÏʶҺѹ ¤³Ðá¾·ÂÈÒʵÏ ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅѪ×Í-Ê¡ØÅ è ªØÉ³Ò Êǹ¡Ãе‹ÒÂÇز¡ÒÃÈÖ¡ÉÒ Ô ¾.º., Ç.Ç.ÍÒÂØÃÈÒʵÏ, Í.Ç. ÍÒÂØÃÈÒʵÏâäµÔ´àª×Í, é Ph.D. Immunology/MicrobiologyµíÒá˹‹§·Ò§ÇÔªÒ¡Òà ÃͧÈÒʵÃÒ¨ÒÏ˹‹Ç§ҹ ÊÒ¢ÒÇÔªÒâäµÔ´àª×Í ÀÒ¤ÇÔªÒÍÒÂØÃÈÒʵÏ éʶҺѹ ¤³Ðá¾·ÂÈÒʵÏ ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅѪ×Í-Ê¡ØÅ è ´ÒÃÒÇÃó ǹЪÔǹÒÇÔ¹Çز¡ÒÃÈÖ¡ÉÒ Ô ¾.º., ».ªÑ¹ÊÙ§ (ÍÒÂØÃÈÒʵÏ), Ç.Ç. µ¨ÇÔ·ÂÒ, Í.Ç. ¾ÂÒ¸ÔÇ·ÂÒ¤ÅÔ¹¡ é Ô ÔµíÒá˹‹§·Ò§ÇÔªÒ¡Òà ÃͧÈÒʵÃÒ¨ÒÏ˹‹Ç§ҹ ÊÒ¢ÒÇÔªÒâ»Ã⵫ÑÇ ÀÒ¤ÇÔªÒ»ÃÊÔµÇÔ·ÂÒʶҺѹ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å ÔÔª×Í-Ê¡ØÅ è ¸ÕÃо§É µÑ³±ÇÔàªÕÂÃÇز¡ÒÃÈÖ¡ÉÒ Ô ¾.º., Ç.Ç.ÍÒÂØÃÈÒʵÏ, Í.Ç. ÍÒÂØÃÈÒʵÏâäµÔ´àª×Í éµíÒá˹‹§·Ò§ÇÔªÒ¡Òà ÈÒʵÃÒ¨ÒÏ˹‹Ç§ҹ ÊÒ¢ÒÇÔªÒâäµÔ´àª×Í ÀÒ¤ÇÔªÒÍÒÂØÃÈÒʵÏ éʶҺѹ ¤³Ðá¾·ÂÈÒʵÏ ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ
  • (vi)ª×Í-Ê¡ØÅ è ¹Ô¸¾²¹ à¨ÕÂáØÅ Ô ÑÇز¡ÒÃÈÖ¡ÉÒ Ô ¾.º.,Ç.Ç. ÍÒÂØÃÈÒʵÏ, Í.Ç. ÍÒÂØÃÈÒʵÏâäÃкº¡ÒÃËÒÂã¨áÅÐàǪºíҺѴÇԡĵµíÒá˹‹§·Ò§ÇÔªÒ¡Òà ÃͧÈÒʵÃÒ¨ÒÏ˹‹Ç§ҹ ÊÒ¢ÒÇÔªÒâäÃкº¡ÒÃËÒÂã¨áÅÐÇѳâä ÀÒ¤ÇÔªÒÍÒÂØÃÈÒʵÏʶҺѹ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å ÔÔª×Í-Ê¡ØÅ è Á³Õ Ãѵ¹äªÂÒ¹¹·Çز¡ÒÃÈÖ¡ÉÒ Ô ¾.º., ».ªÑ¹ÊÙ§ (ÊÙµÈÒʵÏ-¹ÃÕàǪÇÔ·ÂÒ), Ç.Ç. ÊÙµÈÒʵÏ-¹ÃÕàǪÇÔ·ÂÒ, é Ô Ô Certificate .ellow in Reproductive Biology, Ç.Ç. àǪÈÒʵÏ¡ÒÃà¨ÃÔ­¾Ñ¹¸Ø, Í.Ç. àǪÈÒʵϤÃͺ¤ÃÑÇ, Ç·.Á. (¡ÒþѲ¹ÒÊØ¢ÀÒ¾)µíÒá˹‹§·Ò§ÇÔªÒ¡Òà ÈÒʵÃÒ¨ÒÏ˹‹Ç§ҹ ˹‹Çµ‹ÍÁäÌ·Í·Ò§¹ÃÕàǪ ÊÒ¢ÒÇÔªÒàǪÈÒʵÏ¡ÒÃà¨ÃÔ­¾Ñ¹¸Ø ‹ ÀÒ¤ÇÔªÒÊÙµÈÒʵÏ-¹ÃÕàǪÇÔ·ÂÒ ÔʶҺѹ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å ÔÔª×Í-Ê¡ØÅ è ÇÒ³Õ ÇÔÊ·¸ÔàÊÃÕǧȏ Ø ìÇز¡ÒÃÈÖ¡ÉÒ Ô ¾.º., ».ªÑ¹ÊÙ§ (¡ØÁÒÃàǪÈÒʵÏ), Ç.Ç. ¡ØÁÒÃàǪÈÒʵÏ, é Dip. of Dermatology, Cert. in Ped. Dermatology, Í.Ç. (àǪÈÒʵϤÃͺ¤ÃÑÇ), Í.Ç. (¡ØÁÒÃàǪÈÒʵÏ µ¨ÇÔ·ÂÒ)µíÒá˹‹§·Ò§ÇÔªÒ¡Òà ÃͧÈÒʵÃÒ¨ÒÏ˹‹Ç§ҹ ˹‹ÇÂâä¼ÔÇ˹ѧ ÀÒ¤ÇÔªÒ¡ØÁÒÃàǪÈÒʵÏʶҺѹ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å ÔÔ
  • (vii) ÊÒúѭº··Õè ˹ŒÒ ¤íÒ¹íÒ ¤íÒ¹ÔÂÁ ¡Í§ºÃóҸԡÒà ¡ÒÃʋ§àÊÃÔÁÊØ¢ÀÒ¾áÅСÒû‡Í§¡Ñ¹âä 1 Pediatric, Adolescent & Adult Vaccines 1 ¾­.ÍØÉÒ ·ÔÊÂÒ¡Ã 2 ¡ÒÃãˌǤ«Õ¹ã¹à´ç¡ä·Â»¡µÔ Ñ 5 ¾­.¡ØÅ¡Ñ­­Ò ⪤侺Ùŏ¡¨ Ô 3 ÇѤ«Õ¹»‡Í§¡Ñ¹âä㹼ÙãË­‹ áÅмÙʧÍÒÂØ Œ Œ Ù 9 ¹¾.¸ÕÃо§É µÑ³±ÇÔàªÕÂà 4 ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ 21 ¹¾.Á§¤Å ອ¨ÒÀÔºÒÅ, ¹¾.ÊØ¸Õ Êѧ¢Ãѵ¹ 5 ¡ÒõÃǨ¤Ñ´¡ÃͧÁÐàÃç§àµŒÒ¹Á 37 ´Ã.¹¾.Ê׺ǧȏ ¨Ø±ÒÀÔÊ·¸Ôì Ô 6 Applied physiology for quality of life 43 ´Ã.¹¾. ÀÒÊ¡Ã ÇѸ¹¸Ò´Ò 7 Unrecognized Medical Problems in Elderly: Geriatric Depression 49 Sookjaroen Tangwongchai, M.D. 8 Delirium: An Unrecognized Medical Problem in Older Patients 51 ¹¾.Ãا¹Ôù´Ã »ÃдÔÉ°ÊØÇÃó ‹ Ñ 9 ¡ÒÃŌÁã¹¼ÙʧÇÑ Œ Ù 61 ¾­.ÍÒÃÕõ¹ Êؾ·¸Ô¸Ò´Ò Ñ Ø 10 .acial Rejuvenation 73 ¹¾.¨ÃÑ­ ÁËÒ·ØÁÐÃѵ¹ 11 Novel Sunscreen and Photoprotective Methods 75 ¹¾.»ÃÐÇԵà ÍÑÈÇÒ¹¹·, ¾­.ª¹ÔÉ®Ò Ç§É»ÃÐÀÒÃѵ¹ 12 The Cosmetic Use of Botulinum Toxin 81 ¾­.ÃѧÊÔÁÒ Ç³ÔªÀÑ¡´Õà´ªÒ, ¹¾.Çþ§É Á¹ÑÊà¡ÕÂõÔ, ¾­.ÃѪµ¸Ã ËÁ͹¨Ñ¹·Ã
  • (viii) 13 Anti-aging Pharmacology: Theory and Research Model 91 Sirikul Chotewuttakorn, M.Sc. 14 Clinical and Laboratory Evidence of Antioxidants Activity on the Skin 97 Nopadon Noppakun, M.D. 15 Anti-aging Pharmacology: Antioxidants and Longevity 99 Uraiwan Panich, M.D. ËÑÇ¢ŒÍµÒÁÃкº¨Ñ¡ÉØ âʵ ÈÍ ¹ÒÊÔ¡ 16 The Glaucoma Myths & .acts 101 Prin Rojanapongpun,M.D., Visanee Tantisevi,M.D., Naris Kitnarong, M.D. 17 ¡ÒÃÃÑ¡ÉÒâä·Ò§¨Ñ¡ÉØÇ·ÂÒ´ŒÇ¡Òéմ ⺷ÙŹÁ ·çÍ¡«Ô¹ Ô Ô Ñ 109 ¾­.¾ÃÔÁÒ ËÔíÇÔDz¹¡Å Ñ Ñ Ø 18 Current Trend in Chronic Rhinitis 117 ¹¾.»ÒÃÂÐ ÍÒȹÐàʹ, ¾­.©ÇÕÇÃó ºØ¹¹Ò¤, ¹¾.΁âÃªÔ ¨Ñ¹·ÒÀÒ¡ØÅ, ¾­.Êؾ¹´Ò ªÙÊ¡ØÅ Ô 19 Surgical Management of Chronic Rhinitis 129 ¾­.Êؾ¹´Ò ªÙÊ¡ØÅ Ô 20 ¡ÒÃÃÑ¡ÉÒ䫹ÑÊ´ŒÇÂÂÒ 133 ¹¾.͹ѭ­ ྱdzԪ 21 ¡ÒÃÃÑ¡ÉÒ䫹ÑÊ´ŒÇ¡Òü‹ÒµÑ´ 135 ¹¾.ÁÅ.¡Ãà¡ÕÂÃµÔ Ê¹Ô·Ç§ÈÃкºËÑÇã¨áÅÐËÅÍ´àÅ×Í´ 22 ÃкҴÇÔ·ÂҢͧâä¤ÇÒÁ´Ñ¹âÅËÔµÊ٧㹻ÃÐà·Èä·Â 137 ¹¾.¾ÕÃÐ ºÙóСԨà¨ÃÔ­ 23 Recent Clinical Trials in Hypertension 143 ¹¾.¾ÕÃÐ ºÙóСԨà¨ÃÔ­ 24 á¹Ç¤Ô´ãËÁ‹ã¹¡ÒÃÃÑ¡ÉÒâä¤ÇÒÁ´Ñ¹âÅËÔµÊÙ§ 149 ¾­.ÇÕùت ÃͺÊѹµÔ梯 25 Update Management of Hypertension in Renal Disease 155 ¾­.»ÇÕ³Ò ÊØʳ°µ¾§É, ¹¾.ÊÁªÒ àÍÕÂÁ͋ͧ Ñ è 26 Controversy in Ischemic Heart Disease 163 ¹¾.ªÅÔµ àªÕÂÃÇԪ Ñ
  • (ix)Ãкº·Ò§à´Ô¹ËÒÂ㨠27 ¡ÒÃÃÑ¡ÉһʹÍÑ¡àʺã¹âç¾ÂÒºÒÅáÅлʹÍÑ¡àʺ·Õà¡ÕÂÇ¢ŒÍ§¡Ñº è è 165 à¤Ã×ͧª‹ÇÂËÒÂã¨ã¹¼ÙãË­‹ è Œ ¹¾.ªØÉ³Ò Êǹ¡Ãе‹Ò 28 Obstructive Sleep Apnea: Pathophysiology and Its Consequences 183 ¾­.¾ÔÁÅ Ãѵ¹ÒÍÑÁ¾ÇÑŏ 29 Management of Obstructive Sleep Apnea in Thai Adults 189 Prakobkiat Hirunwiwatkul, M.D. 30 Alternative Treatment for Snoring and Obstructive Sleep Apnea 191 ¹¾.ÇÔª­ ºÃóËÔíÑÃкº·Ò§à´Ô¹ÍÒËÒà 31 ¡ÒÃÃÑ¡ÉҼٻǷյ´àª×ÍäÇÃÑʵѺÍÑ¡àʺºÕẺàÃ×ÍÃѧ Œ † è Ô é é 197 ¹¾.¾ÔÊ° µÑ§¡Ô¨ÇÒ¹Ôª¹ Ô éÃкº·Ò§à´Ô¹»˜ÊÊÒÇÐ 32 Emergency in Management of Potassium Disorders 207 ¹¾.³Ñ°ÇØ²Ô âµÇ¹íÒªÑÂ, ¹¾.ÊÁªÒ àÍÕÂÁ͋ͧ èÃкº¡ÅŒÒÁà¹×ÍáÅСÃд١ é 33 âä¡Ãд١¾Ãع: ÀÑÂà§Õº¢Í§ÊØ¢ÀÒ¾ Rehabilitating & 217 Revitalizing after the Tragedy ¾­.ÇÔäÅ ¤Ø»µ¹ÃµÈ¡ØÅ ÔÑ Ô Ñ 34 High Tibial Osteotomy 227 ¹¾.·ÈÈÒʵÏ ËÒ­Ãاâ蹏 ‹ 35 Update in the Management of Rheumatoid Arthritis 229 ¾­.Á¹Ò¸Ô» âÍÈÔÃÔÃкº»ÃÐÊÒ· 36 ªÕÇÇÔ·ÂҢͧÀÒÇлǴÈÕÃÉÐ 239 ¹¾.͹ѹµ ÈÃÕà¡ÕÂõԢ¨Ã 37 Management of Acute Ischemic Stroke 253 ¾­.¹Ô¨ÈÃÕ ªÒ­³Ã§¤, ¾­.ÍÃÍØÁÒ ªØµà¹µÃ Ô 38 ¡Òÿ„¹¿Ù¼»ÇÂâäËÅÍ´àÅ×Í´ÊÁͧ œ ٌ † 263 ¾­.¡ÄÉ³Ò ¾ÔÃàǪ
  • (x) 39 Interventional Management of Acute Stroke 275 ¾­.ÍÑ­ªÅÕ ªÙâ蹏 40 ¡ÅØÁâä¤ÇÒÁà¤Å×͹äËǼԴ»¡µÔáÅСÒÃŧ·ÐºÕ¹¼Ù»Ç¾ÒÏ¡¹Êѹ ‹ è Œ † Ô 287 ¹¾.Ãاâ蹏 ¾Ô·ÂÈÔÃ,Ô ¹Ê.³Ñ°¹ÔÀÒ ÇÃóªÑÂ, ‹ ¹¾.¸Ò¹Ô¹·Ã ÍÑÈÇÇÔàªÕÂèԹ´ÒâÅËÔµÇÔ·ÂÒ 41 Practical Uses of Heparins 295 ¹¾.¾ÅÀÑ·Ã â蹏¹¤ÃÔ¹·Ã 42 Thalassemia: Prevention and Control 303 ¾­.¾Ã¾ÔÁÅ àÃ×ͧÇزàÅÔÈ ÔÃкºµ‹ÍÁäÌ·ÍáÅÐàÁµÒºÍÅÔ«Á ‹ Ö 43 Metabolic Syndrome: The Predictor of Type 2 Diabetes 309 ¾­.ÍÀÔÃ´Õ ÈÃÕǨµÃ¡ÁÅ ÔÔ 44 ໇ÒËÁÒ¡ÒäǺ¤ØÁÃдѺ¹éÒµÒÅã¹¼Ù»ÇÂàºÒËÇÒ¹ í Œ † 317 ¹¾.»¯Ô³° ºÙóзÃѾ¢¨Ã Ñ 45 Update Management in Diabetes Mellitus 323 ¾­.¹Ñ¹·¡Ã ·Í§áµ§ 46 âä䵨ҡàºÒËÇÒ¹ 331 ¹¾.¾ÔÊ·¸Ôì ¡µàÇ·Ô¹ Ø 47 ෌ÒàºÒËÇÒ¹: ¡ÒõÃǨ»ÃÐàÁÔ¹áÅÐá¹Ç·Ò§¡ÒÃÃÑ¡ÉÒ 339 ¾­.¡ØÅÀÒ ÈÃÕÊÇÑÊ´ÔìâäµÔ´àª×Í é 48 An Overview on Dengue Diagnosis 345 ´Ã.ÍØäÃÇÃó â¦ÉÔµÒ¹¹· 49 Update on Dengue 2009 351 ¾­.ÍØÉÒ ·ÔÊÂÒ¡Ã 50 䢌ധ¡ÕáÅÐ䢌àÅ×Í´ÍÍ¡ã¹¼ÙãË­‹ Œ 361 ¹¾.¸ÕÃо§É µÑ³±ÇÔàªÕÂà 51 WHO Clinical Assay Guidelines: Just for Your Information 379 ´Ã.ÍØäÃÇÃó â¦ÉÔµÒ¹¹·, ¹¾.»ÃÐàÊÃÔ° ·Í§à¨ÃÔ­ 52 Prevention of the Spread of Drug-Resistant Bacteria in Thailand 383 ¹¾.ÊØʳˏ ÍÒȹÐàʹ Ñ
  • (xi) 53 Beta-lactam Resistance among Common Bacterial Pathogens 389 ¹¾.ªØÉ³Ò Êǹ¡Ãе‹Ò 54 Emerging Infectious Agents: .ungi 407 ´Ã.ÍÃÔÂÒ ¨Ô¹´ÒÁ¾Ã, ´Ã.·Ã§ÈÑ¡´Ôì ·Í§ªÙÈ¡´Ôì Ñ 55 Nipah Virus: Evidence for Seasonal Preference in Disease Transmission 411 ´Ã.ÊØÀÒÀó ÇѪþÄÉÒ´Õ, ¹¾.¸ÕÃÐÇѲ¹ àËÁÐ¨Ø±Ò 56 Surviving Sepsis: ¡ÒÃÅ´ÍѵÃÒµÒÂáÅСÒÃ㪌ÂÒµŒÒ¹¨ØŪվÍ‹ҧàËÁÒÐÊÁ 419 ¾­.³ÊÔ¡Ò­¨¹ Íѧ¤àÈ¡ÇÔ¹Â Ñ 57 AIDS: Mom and Kid 427 ÃÈ.¹¾.ªÔÉ³Ø ¾Ñ¹¸Øà¨ÃÔ­  ËÑÇ¢ŒÍ੾ÒÐÊÒ¢ÒÇÔªÒ¡ØÁÒÃàǪÈÒʵÏ 58 âäË×´·ÕÁÍÒ¡ÒÃÃعáç è Õ 431 ¾­.¾Ãó·Ô¾Ò ©ÑµÃªÒµÃÕ 59 ÀÒÇÐᾌùáç Ø 437 ¾­.Í÷Ñ ¾ÔºÅâÀ¤Ò¹Ñ¹· Ù 60 ·Òáà¡Ô´¡‹Í¹¡íÒ˹´ÃÐÂзŒÒ 445 ¾­.ÃѪ®Ò ¡Ô¨ÊÁÁÒö 61 »˜­ËÒ·Õ¾ºä´ŒºÍ¢ͧ·Òáà¡Ô´¡‹Í¹¡íÒ˹´ÃÐÂзŒÒÂ è ‹ 451 ¹¾.ÊѹµÔ »Ø³³ÐËÔµÒ¹¹· 62 Cancer in Thai Children 459 ¹¾.»˜­­Ò àÊ¡ÊÃä, ¾­.¡ÇÔdz³ ÇÕáØÅ Ñ 63 ¡ÒÃÃÑ¡ÉÒâäÁÐàÃç§ã¹à´ç¡â´Â¡ÒûÅÙ¡¶‹ÒÂà«Åŏµ¹¡íÒà¹Ô´àÁç´àÅ×Í´ Œ 467 ¾­.¡ÅÕºÊäº ÊÃþÊÔµ 64 Acute Respiratory .ailure Update 471 ¹¾.ÃبÀѵµ ÊíÒÃÒ­ÊíÒÃǨ¡Ô¨ Ô 65 How to Ventilate Pediatric Patients with Respiratory .ailure/ARDS 485 ¹¾.¡ÇÕÇÃó ÅÔÁ»ÃÐÂÙà é 66 Severe ARI: What’s New? 495 ¾­.ǹѷ»ÃÕÂÒ ¾§ÉÊÒÁÒö 67 Hospital–acquire Pneumonia in Children 503 ¾­.ÈÈԸà ÅÔ¢µ¹Ø¡Å Ô Ù 68 What’s Pediatricians Should Know about Genetics 509 ´Ã.¾­.¡Ñ­­Ò ÈØÀ»‚µ¾ÃÔ
  • (xii) 69 ¾Ñ¹¸ØÈÒʵÏã¹àǪ»¯Ôºµ¢Í§¡ØÁÒÃᾷ Ñ Ô 517 ¹¾.ÇÃÈÑ¡´Ôì ⪵ÔàÅÍÈÑ¡´Ôì 70 âä¾Ñ¹¸Ø¡ÃÃÁàÁµÒºÍÅÔ¡ÊíÒËÃѺᾷàǪ»¯Ôºµ·Çä» áÅÐ ¡ØÁÒÃᾷ Ñ Ô Ñè 523 ¹¾.¹Ô¸ÇªÃ ÇѲ¹ÇÔ¨Òó ÔÑ 71 âä¡Ãд١¾Ñ¹¸Ø¡ÃÃÁ 531 ¾­.¾ÃÊÇÃä ÇÊѹµ 72 Endothelial Cell Activation and Hemostatic Defects in Dengue Infection 549 ¾­.´ÒÃÔ¹·Ã «Íâʵ¶Ô¡Å Ø 73 Update on Inherited Bone Marrow Syndromes in Children 557 ¹¾.ºØ­ªÙ ¾§È¸¹Ò¡ØÅ 74 Drug Abuse in Teenagers 567 ¾­.ºØ­ÂÔ§ ÁҹкÃԺó è Ù 75 Drug Abuse in Teenagers: Preventive Approach 573 ¾­.¨Ñ¹·±µÒ ¾Ä¡ÉÒ¹Ò¹¹· Ô 76 ¼Å¡Ãзº¢Í§¡ÒÃ㪌ÊÒÃàʾµÔ´¢³ÐµÑ§¤ÃÃÀµÍ¡ÒÃà¨ÃÔ­àµÔºâµ ¾Ñ²¹Ò¡ÒÃ é ‹ 581 áÅоĵԡÃÃÁ¢Í§à´ç¡ ¾­.ÊØÚɳ ÊبÃÔµ¾§È Õ Ñ 77 Treatment Strategies in Childhood Epilepsy 589 ¹¾.ÊØêÑ ÅÔ¢ÊÔ·¸ÔDz¹¡ØÅ ìѨԵàǪÇÔ·ÂÒ 78 ¨Ò¡ÊÒà˵طҧÊѧ¤ÁÊÙ¡Òû‡Í§¡Ñ¹áÅСÒôÙáÅÃÑ¡ÉÒâä«ÖÁàÈÃŒÒ ‹ 601 ¹¾.¾Õþ¹¸ Å×ͺح¸ÇѪªÑ 79 âä«ÖÁàÈÌÒáÅСÒõѧ¤ÃÃÀ é 609 ¹¾.ʹ·ÃÃÈ ºØÉÃÒ·Ô¨ÃѧÊÕÇ·ÂÒ Ô 80 Update in Radiology 615 ¹¾.¨ÒµØùµ µÑ¹µÔǵ¹Ð Ñ 81 Update in Nuclear Medicine 619 ¾­.ÀÒÇ¹Ò ÀÙÊÇÃó ØÇÔÊ­­ÕÇ·ÂÒ Ñ Ô 82 Anesthesia Patient Safety: Where Are We? 629 ¹¾.ÊÁÃѵ¹ ¨ÒÃØšɳҹѹ· Ñ
  • (xiii) 83 Patient Safety in Anesthesia: Where Are We? 637 ¾­.ÈÔþà »µÁÒ¹ÐÍÒÃÕ Ô Ô 84 Health Law Update for Anesthesia Personnel 645 ¾­.Íѧ¤³Ò àËÅ×ͧ¹·Õà·¾ 85 Health Law Update for Healthcare Professional 649 ¹¾.¾Ô·Ã ¸ÃÃÁ¸ÃÒ¹¹· Ù 86 ÂÒÃЧѺ»Ç´: ¡ÒÃàÅ×͡㪌µÒÁ¾ÂÒ¸Ô¡Òà¹Ô´¢Í§¤ÇÒÁ»Ç´ í 655 ¹¾.»¹ ÈÃÕ»ÃШԵµÔªÂ › Ñ 87 ¡ÒúíҺѴ¤ÇÒÁ»Ç´à©Õº¾Åѹ㹼ٻÇÂÊÙ§ÍÒÂØ Œ † 659 ¾­.ÍÃÅѡɳ Ãʹ͹ѹµ 88 Current Issue in Acute Pain Management: “SIMPLE” Concepts 665 in Postoperative Pain Management ¾­.ÇÔÁÅÅѡɳ ʹѹÈÔÅ»Š è 89 Postoperative Pain Management in the .irst Year of Life 669 ¾­.ÊØÇÃÃ³Õ ÊØÃàÈóÕǧȏÈÑÅÂÈÒʵÏ 90 Update in Breast Cancer 677 ¹¾.ÁÒÇÔ¹ ǧȏÊÒÂÊØÇÃó 91 Strategy to Save Time Bomb 689 ÃÈ.¹¾.¡ÔµµÔªÂ àËÅ×ͧ·ÇÕº­ Ñ Ø 92 Hospital Awareness in Mass Casualty and Natural Disaster 693 ¹¾.»ÃÕªÒ ÈÔ÷ͧ¶ÒÇÃ Ô State of the Art 93 ÍÑŵÌҫÒÇ´ 4 ÁÔµÔ ÁÕ´ÁÒ¡¡Ç‹Ò¤ÇÒÁºÑ¹à·Ô§ Õ 697 ¹¾.¸ÕÃо§È à¨ÃÔ­ÇԷ 94 Minimally Invasive Surgery - How Minimal Can They Be?: 707 General Surgeon’s View ¹¾.¾Ñ²¹¾§È ¹ÒÇÕà¨ÃÔ­ 95 Minimally Invasive Surgery in Rhinologic/Allergic Disease 711 ¹¾.¾§È¡Ã µÑ¹µÔÅ»¡Ã Õ  96 Advanced Wound Care Technology 717 ¹¾.ÍÀԪ Íѧʾѷ¸ Ñ
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  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 3àÍ¡ÊÒÃ͌ҧÍÔ§1. Ãѵ⹷Ñ ¾ÅѺÃÙ¡ÒÃ, ÍØÉÒ ·ÔÊÂÒ¡Ã. á¹Ç·Ò§¡ÒÃãˌǤ«Õ¹ã¹à´ç¡ä·Â. ã¹: á¹Ç·Ò§àǪ»¯Ôºµ¡ÁÒÃàǪä·Â. ¡Ãا෾Ï: Œ Ñ Ñ Ô Ø ºÃÔɷΘǹéÒ ¾ÃÔ¹µÔ§ ¨íÒ¡Ñ´, 2542: 19-20. Ñ › í é é2. ÍØÉÒ ·ÔÊÂÒ¡Ã. ÇѤ«Õ¹ã¹à´ç¡. ã¹: ¡ØÊÒÇ´Õ àÁÅ×ͧ¹¹·, ·Ô¾ÂÊª¹ àÍÕÂÁÊÍÒ´, ºÃóҸԡÒÃ. ÂҡѺâä·Õ¾ºº‹ÍÂã¹à´ç¡. Ø è è ¡Ãا෾Ï: ºÃÔÉ· ¹ÔÇä·ÂÁԵáÒþÔÁ¾ (1996) ¨íÒ¡Ñ´, 2552: I3-I8. Ñ3. ÍØÉÒ ·ÔÊÂÒ¡Ã. Optional Vaccines.ã¹: ¹ÇŨѹ·Ã »ÃÒº¾ÒÅ, ÈÔÃÇÃó ǹҹءÅ, ÊØªÒ´Ò ÈÃÕ·¾ÂÇÃó, ÊتÅÒ ©ÑµÃ Ô Ù Ô Õ à¾ÃÔ´¾ÃÒÂ, ºÃóҸԡÒÃ. Optimizing Health Care in Pediatrics. ¡Ãا෾Ï: ºÃÔÉ· ºÕÂ͹´ àÍç¹à·ÍÏä¾Ã« ¨íÒ¡Ñ´, Ñ 2551: 164-6.4. American Academy of Pediatrics. Active and Passive Immunization. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL. American Academy of Pediatrics; 2006: 1-103.5. Thisyakorn U, Pancharoen C, Chuenkitmongkol S, Ortiz E. Immunogenicity and safety of a DTaP-IPV//PRP-T vaccine (PentaximTM) booster during the second year of life in Thai children primed with an acellular pertussis combined vaccine. Southeast Asian J Trop Med Public Health 2009; 40: 1-13.6. Vaccine Concerns. Available at: http://www.immunize.org/catg.d/4038myth.htm. Accessed November 26, 2007.7. Centers for Disease Control and Prevention. Some Common Misconceptions about vaccination and how to respond to them. Available at: http://www.cdc.gov/vaccines/vac-gen/6mishome.htm. Accessed November 26, 2007.8. MMWR The facts. Available at: http://www.mmrthefacts.nhs.uk/. Accessed November 26, 2007.9. ¸ÕÃо§É µÑ³±ÇÔàªÕÂÃ, ÍØÉÒ ·ÔÊÂÒ¡Ã. Vaccines: from birth to adulthood. ã¹: ªØÉ³Ò Êǹ¡Ãе‹ÒÂ, ¡ÁŠᡌǡԵ³Ã§¤, Ô ºÃóҸԡÒÃ. Leadership in Medicine. ¡Ãا෾Ï: âç¾ÔÁ¾áˋ§¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ, 2551: 186-203.
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  • 20 ÇѤ«Õ¹»‡Í§¡Ñ¹âä㹼ÙãË­‹ áÅмÙʧÍÒÂØ Œ ŒÙ12. Halperin S, Smith B, Russell M, et al. Adult formulation of a five component acellular pertussis vaccine combined with diphtheria and tetanus toxoids and inactivated poliovirus vaccine is safe and immunogenic in adolescents and adults. Pediatr Infect Dis J2000;19:276-83.13. Barreto L, Guasparini R, Meekison W, Noyad .,3,Young L, Mills E. Humoral immunity 5 years after booster immunization with an adolescent and adult formulation combined tetanus, diphtheria, and 5-component acellular pertussis vaccine. Vaccine 2007;25:8172–9.14. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants. Recommendations of The Advisory Committee on Immunization Practices (ACIP). MMWR 2008;57(RR-4):1-51.15. Prevention of pneumococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(RR-8):1-24.16. WHO position paper. 23-valent pneumococcal polysaccharide vaccine. Wky Epidemiol Rep 2008; 83:373-84.17. Whitney CG, Schaffner W, Butler JC. Rethinking recommendations for use of pneumococcal vaccines in adults. Clin Infect Dis 2001;33:662-75.18. Mangtani P, Cutts ., Hall AJ. Efficacy of polysaccharide pneumococcal vaccine in adults in more developed countries: the state of the evidence. Lancet2003;3:71-8.19. Jackson LA, Neuzil KM, Yu O, et al. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N Engl J Med2003;348:1747-55.20. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP),2008. MMWR 2008;57(RR-7);1-64..21. Mandelman PM, Cordova J, Cho I. Safety,efficacy and effectiveness of the influenza virus vaccine,trivalent,type A and B,live,cold-adapted ( CAIV-T ) in healthy children and healthy adults. Vaccine 2001;19:2221-6.22. Holland D, Booy R, Looze D., Eizenberg P, McDonald J, Karrasch J,et al. Intradermal influenza vaccine administered using a new microinjection system produces superior immunogenicity in elderly adults: A randomized controlled trial. J Infect Dis 2008;198:650-8.23. Nichol KL, Margolis KL, Wuorenema J, Sternberg T. The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community. N Engl J Med 1994;331:778-84.24. Christenson B, Lundbergh P, Hedlund J, Ortgvist A. Effects of a large-scale intervention with influenza and 23- valent pneumococcal vaccines in adults aged 65 years and older. Lancet 2001;357:1008-11.25. Jefferson T, Rivetti D, Rivetti A, Rudin M, Di Pietrantonj C, Demicheli V. Efficacy and effectiveness of influenza vaccines in elderly people: a systematic review. Lancet 2005;366:1165-74.26. Katz J, Cooper EM, Walther RR, Sweeney EW, Dworkin RH. Acute pain in Herpes zoster and its impact on health-related quality of life. Clin Infect Dis 2004:39:342-8.27. Levin MJ,1 M. N. Oxman MN, Zhang H, Johnson,5 GR, Stanley H. Varicella-zoster virus–specific immune responses in elderly recipients of a herpes zoster vaccine. J Infect Dis 2008;197: 825-37.28. 114c M.N. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent Herpes Zoster and postherpetic neuralgia in older adults. N Engl J Med 2005;352:2271-84.29. Michael N. Oxman MN, Levin MJ,the Shingles Prevention Study Group. Vaccination against herpes zoster and postherpetic neuralgia. J Infect Dis 2008; 97: S 228-36.30. Homberger J, Robertus K. Cost-effectiveness of a vaccine to prevent Herpes zoster and postherpetic neuralgia in older adults. Ann Intern Med 2006:145;317-25.
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 21 4 ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ ÃͧÈÒʵÃÒ¨ÒϹÒÂᾷÁ§¤Å ອ¨ÒÀÔºÒÅ ¼ÙŒª‹ÇÂÈÒʵÃÒ¨ÒϹÒÂᾷÊØ¸Õ Êѧ¢Ãѵ¹ ÀÒ¤ÇÔªÒÊÙµÈÒʵÏ-¹ÃÕàǪÇÔ·ÂÒ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å Ô ÔÔ ÁÐàÃ移ҡÁ´Å١໚¹ÁÐàÃ秢ͧÍÇÑÂÇÐÊ׺¾Ñ¹¸ØÊµÃÕ·Õ辺º‹ÍÂ໚¹Íѹ´ÑºÊͧÃͧ¨Ò¡ÁÐàÃç§àµŒÒ¹Á Íغµ¡Òó¢Í§ÁÐàÃ移ҡÁ´ÅÙ¡·ÑÇâÅ¡ ¾ºÊÙ§¶Ö§à¡×ͺ 500,000 ÃÒµ‹Í»‚ áÅÐÁÕ¼»ÇÂàÊÕÂ Ñ Ô è ٌ †ªÕǵÁÒ¡¡Ç‹Ò 270,000 ÃÒµ‹Í»‚(1) ã¹»ÃÐà·È·Õ¾²¹ÒáÅŒÇ Íغµ¡Òó¢Í§ÁÐàÃ移ҡÁ´Å١Ŵŧ Ô è Ñ Ñ ÔÍ‹ҧÁÒ¡ã¹ÃÐÂÐËÅÒÂÊÔº»‚·¼Ò¹ÁÒ ·Ñ§¹Õ໚¹¼ÅÁÒ¨Ò¡¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡à¾×Í Õè ‹ é é èËÒʵÃÕ·Á¤ÇÒÁàÊÕ§µ‹Íâä¹Õé µÅÍ´¨¹¤ÇÒÁ¼Ô´»¡µÔ¢Í§»Ò¡Á´ÅÙ¡¡‹Í¹·Õ¨Ð¡ÅÒÂ໚¹ÁÐàÃç§ áÅÐãˌ Õè Õ è è¡ÒôÙáÅÃÑ¡ÉÒᵋà¹Ô¹æ ·íÒãˌÊÒÁÒöŴ¡ÒÃà¡Ô´ÁÐàÃ移ҡÁ´Å١ŧ䴌ÁÒ¡(2) ÊíÒËÃѺ»ÃÐà·Èä·Â èÁÐàÃ移ҡÁ´Å١໚¹ÁÐàÃ秷Õ辺ÁÒ¡·ÕèÊØ´¢Í§ÊµÃÕ â´ÂÁÕÍغѵԡÒó»ÃѺÁҵðҹµÒÁÍÒÂØ (agestandardized rate) 19.8 µ‹Í»ÃЪҡà 100,000 ¤¹µ‹Í»‚ The International Agency for Researchon Cancer (IARC) ÃÒ§ҹNjһÃÐà·Èä·ÂÁÕ¼»ÇÂÁÐàÃ移ҡÁ´ÅÙ¡ãËÁ‹»ÅÐ 6,243 ÃÒ áÅÐàÊÕ ٌ † ‚ªÕǵ 2,620 ÃÒ âä¹Õ¨§Âѧ໚¹»˜­ËÒÊíҤѭ·Ò§ÊÒ¸ÒóÊØ¢¢Í§»ÃÐà·Èä·Â¨¹¶Ö§»˜¨¨Øº¹ Ô (1) éÖ Ñ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡´ŒÇÂà«ÅŏÇÔ·ÂÒ ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡´ŒÇÂà«ÅŏǷÂÒÇÔ¸´§à´ÔÁ (conventional Pap smear) Ô Õ éÑ䴌ú¡ÒÃÂÍÁÃѺNjÒ໚¹ÇÔ¸·»ÃÐʺ¤ÇÒÁÊíÒàÃç¨ÁÒ¡·Õʴ㹡ÒÃÅ´Íغµ¡Òó¢Í§ÁÐàÃ移ҡÁ´ÅÙ¡ã¹ Ñ Õ Õè èØ Ñ Ôª‹Ç§ÃÐÂÐàÇÅÒ¡Ç‹Ò 50 »‚·¼Ò¹ÁÒ ã¹»‚ ¤.È. 1988 American Cancer Society (ACS) 䴌ÇÒ§ Õè ‹á¹Ç·Ò§¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡änjÇÒ ÊµÃÕ·¡¤¹¤ÇÃ䴌ú¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃç§ ‹ Ø Ñ»Ò¡Á´ÅÙ¡àÁ×ÍàÃÔÁÁÕà¾ÈÊÑÁ¾Ñ¹¸ ËÃ×ÍÁÕÍÒÂؤú 18 »‚ â´ÂµÃǨ´ŒÇ¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸´§à´ÔÁ è è Ô Õ ÑéËÇÁ¡Ñº¡ÒõÃǨÀÒÂã¹·Ø¡»‚ áÅжŒÒ¼Å¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´Å١໚¹»¡µÔµ´µ‹Í¡Ñ¹ 3 ¤Ãѧ Ô é¢Ö¹ä» ÍÒ¨ànj¹ÃÐÂÐàÇÅҢͧ¡ÒõÃǨ ·Ñ§¹Õ¢¹ÍÂÙ¡º´ØžԹ¨¢Í§á¾·Â¼ãˌ¡ÒôÙáÅ á¹Ç·Ò§¹Õé é é é Öé ‹ Ñ Ô ÙŒ (3)䴌 ÃÑ º ¡ÒÃÂÍÁÃÑ º áÅÐ¶× Í »¯Ô ºÑ µÔ Í Â‹ Ò §¡ÇŒ Ò §¢ÇÒ§ã¹·Ø ¡ ͧ¤ ¡ ÷Õè ´Ù á Å´Œ Ò ¹ÊØ ¢ ÀÒ¾¢Í§»ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡Ò ä´Œá¡‹ ʶҺѹÁÐàÃç§áˋ§ªÒµÔ (National Cancer Institute), American College of
  • 22 ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ (Cervical Cancer Screening)Obstetricians and Gynecologists, American Medical Association ໚¹µŒ¹ Í‹ҧäáçµÒÁ ã¹ÃÐÂÐËÅÒ»‚·¼Ò¹ÁÒ ÁÕÃÒ§ҹÁÒ¡ÁÒ·ջÃÐàÁÔ¹»ÃÐÊÔ·¸ÔÀÒ¾¢Í§¡ÒõÃǨ´ŒÇÂÇÔ¸¹áÅоºÇ‹Ò ¤ÇÒÁäÇ Õè ‹ è Õ éÕ(sensitivity) ¢Í§¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸´§à´ÔÁ¤‹Í¹¢ŒÒ§µèÒ (µÒÃÒ§·Õè 1) ¨Ò¡ÃÒ§ҹẺ meta-analysis Ô Õ Ñé íà¾×ÍËÒ¤ÇÒÁ¶Ù¡µŒÍ§áÁ‹¹ÂíҢͧ conventional Pap smear 㹡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ èâ´ÂÇÔà¤ÃÒÐˏ¨Ò¡¡ÒÃÈÖ¡ÉÒ·Ñé§ËÁ´ 28 ÃÒ§ҹ¾ºÇ‹Ò ¤‹Òà©ÅÕè¢ͧ¤ÇÒÁäÇ áÅФÇÒÁ¨íÒà¾ÒÐ(specificity) ¢Í§¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸´§à´ÔÁ෋ҡѺÌÍÂÅÐ 58 áÅÐÌÍÂÅÐ 69 µÒÁÅíҴѺ(4) ¨Ò¡ Ô Õ ÑéÃÒ§ҹ¢Í§ U. S. Agency for Health Care Policy and Research (AHCPR) ¾ºÇ‹Ò ¡ÒÃÈÖ¡ÉÒã¹ÅѡɳйÕÊǹãË­‹Á¤ÇÒÁÅíÒàÍÕ§ (biased study) ¤‹Í¹¢ŒÒ§ÁÒ¡áÅÐÊÃØ»Ç‹Ò ¤ÇÒÁäǢͧ¡ÒõÃǨà«Åŏ é‹ ÕÇÔ·ÂÒÇÔ¸´§à´ÔÁ㹡ÒÃÇÔ¹¨©ÑÂÁÐàÃ移ҡÁ´ÅÙ¡ áÅФÇÒÁ¼Ô´»¡µÔ¢Í§»Ò¡Á´ÅÙ¡¡‹Í¹·Õ¨Ð¡ÅÒÂ໚¹ Õ éÑ Ô èÁÐàÃç§ÁÕà¾Õ§ÌÍÂÅÐ 51 ËÃ×ÍÍÕ¡¹ÑÂ˹֧¡ç¤Í ¡ÒõÃǨ´ŒÇÂÇÔ¸¹Á¼ÅźÅǧ·Õ¤Í¹¢ŒÒ§ÊÙ§ (ÁÕ¤ÇÒÁ (5) è × Õ Õé Õ è ‹¼Ô´»¡µÔ·»Ò¡Á´ÅÙ¡ ᵋ¡ÒõÃǨãˌ¼Å»¡µÔ) Õè ¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸¢Í§àËÅÇ (liquid-based cytology) ໚¹¡ÒõÃǨ·Ò§à«ÅŏǷÂÒÍÕ¡ Ô Õ ÔÇԸ˹֧ «Ö§ä´ŒÁ¡ÒùíÒÁÒ㪌᷹¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸´§à´ÔÁ ¾ºÇ‹ÒÊÒÁÒöª‹ÇÂᡌ»­ËÒàÃ×ͧ¡ÒÃ Õ è è Õ Ô Õ Ñé ˜ èà¡çºµÑÇÍ‹ҧ·ÕäÁ‹à¾Õ§¾Í (inadequate specimen) ¢Í§¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸´§à´ÔÁ (µÒÃÒ§·Õè 2) è Ô Õ Ñé¹Í¡¨Ò¡¹Õé ¡ÒÃÈÖ¡ÉÒʋǹãË­‹ÃÒÂ§Ò¹Ç‹Ò ¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸ãËÁ‹¹Á¤ÇÒÁäǴաNjҡÒõÃǨà«Åŏ Ô Õ éÕ ÕÇÔ·ÂÒÇÔ¸´§à´ÔÁ ·íÒãˌµÃǨ¾ºÃÍÂâä¢Ñ¹ÊÙ§ (high grade lesion) ·Õ»Ò¡Á´Å١䴌ÁÒ¡¢Ö¹ (µÒÃÒ§·Õè Õ Ñé é è é3) ÃÇÁ·Ñ§ÊÒÁÒöŴ¼ÅźÅǧ¢Í§¡ÒõÃǨŧÍ‹ҧÁÕ¹ÂÊíҤѭ·Ò§Ê¶ÔµÔ µÑ§áµ‹»‚ ¤.È. 1996 ໚¹ é Ñ (6) 鵌¹ÁÒ ¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸¢Í§àËÅÇ´ŒÇÂÇÔ¸Õ ThinPrep 䴌ú¡ÒÃÂÍÁÃѺâ´Âͧ¤¡ÒÃÍÒËÒÃáÅÐ Ô Õ ÑÂҢͧ»ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡Ò㹡ÒùíÒÁÒ㪌µÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ ËÅѧ¨Ò¡¹Ñ¹ ÁÕ¡ÒùíÒ éÇÔ¸¹ÁÒ㪌᷹¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸´§à´ÔÁÍ‹ҧá¾Ã‹ËÅÒ â´Âã¹ÃÐÂÐ 5 »‚·¼Ò¹ÁÒ ÁÒ¡¡Ç‹ÒÌÍÂÅÐ Õ éÕ Ô Õ Ñé Õè ‹60 ¢Í§¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ã¹»ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡Ò䴌㪌¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸¢Í§ Ô ÕàËÅÇ ¹Í¡¨Ò¡¹Õé ËÅÒ»ÃÐà·Èã¹·ÇÕ»ÂØâû ઋ¹ ÊËÃÒªÍҳҨѡà 㪌¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸¢Í§ (7) Ô ÕàËÅÇÁÒµÃǨ¤Ñ´¡Ãͧâä᷹¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸´§à´ÔÁ ã¹»‚ ¤.È. 1999 U.S. Agency for Ô Õ Ñé (8,9)Health Care Policy and Research 䴌»ÃÐàÁÔ¹»ÃÐÊÔ·¸ÔÀÒ¾ áÅФÇÒÁ¤ØÁ·Ø¹ (cost-effectiveness) Œ¢Í§¡ÒÃ㪌¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸¢Í§àËÅÇ㹡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ â´ÂÇÔà¤ÃÒÐˏ Ô Õ¨Ò¡ÃÒ§ҹẺ meta-analysis ¢Í§¡ÒÃÈÖ¡ÉÒµ‹Ò§æ áÅÐÊÃØ»Ç‹Ò ¡ÒõÃǨ´ŒÇ¡ÒõÃǨà«ÅŏǷÂÒ ÔÇÔ¸¢Í§àËÅÇÁÕ¤ÇÒÁ¤ØÁ·Ø¹·Õʴ㹡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ ã¹»‚ ¤.È. 2002 American Õ Œ èØ (5)Cancer Society 䴌¨´»ÃЪØÁËÇÁ¡ÑºÍ§¤¡Ãµ‹Ò§ æ ·Õ´áÅ´ŒÒ¹ÊØ¢ÀҾ㹻ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡Ò ä´Œá¡‹ Ñ è ÙAmerican College of Obstetricians and Gynecologists, American Society of Colposcopy andCervical Pathology (ASCCP), American Social Health Association ໚¹µŒ¹ à¾×Í·º·Ç¹á¹Ç·Ò§ è㹡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ áÅÐ䴌¢ÍÊÃØ» ´Ñ§¹Õé Œ (10) 1. ¤ÇÃàÃÔÁ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ã¹ÊµÃÕÀÒÂËÅѧàÃÔÁÁÕà¾ÈÊÑÁ¾Ñ¹¸»ÃÐÁÒ³ è è3 »‚ ËÃ×ÍàÁ×ÍÁÕÍÒÂؤú 21 »‚ è
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  • 24 ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ (Cervical Cancer Screening) 1. ¡ÅØÁÊÒ¾ѹ¸Ø·Á¤ÇÒÁàÊÕ§µèÒ (low risk HPV) ¤×Í àª×Í HPV·Õ·Òãˌà¡Ô´ condyloma ‹  Õè Õ è í é è íáÅÐÃÍÂâä¢Ñ¹µèÒ (low grade squamous intraepithelial lesion ËÃ×ÍLSIL) Áըҹǹ 12 ÊÒ¾ѹ¸Ø é í í䴌ᡋ 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81 áÅÐÊÒ¾ѹ¸Ø CP 6108 2. ¡ÅØÁÊÒ¾ѹ¸Ø·Á¤ÇÒÁàÊÕ§ÊÙ§ (high risk ËÃ×Í oncogenic HPV) ¤×Í àª×Í HPV ·Õ·Òãˌ ‹  Õè Õ è é è íà¡Ô´ÃÍÂâä¢Ñ¹ÊÙ§ (high grade squamous intraepithelial lesion ËÃ×Í HSIL) áÅÐÁÐàÃ移ҡÁ´ÅÙ¡ é«Ö§ÁÕ 15 ÊÒ¾ѹ¸Ø 䴌ᡋ 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73 áÅÐ 82 è¡ÒõÃǨËÒàª×éÍ HPV à¹×ͧ¨Ò¡àª×Í HPV äÁ‹ÊÒÁÒöà¾ÒÐàÅÕ§ãˌàµÔºâµáÅÐẋ§µÑÇã¹à«Åŏà¾ÒÐàÅÕ§·ÑÇä» (cell è é é é èculture) »ÃСͺ¡Ñº¡ÒõÃǨËÒÀÙÁµÒ¹·Ò¹µ‹Íàª×Í HPV (serological assay) ¡ç§äÁ‹Á¤ÇÒÁ¶Ù¡µŒÍ§ Ô Œ é Ñ ÕáÁ‹¹ÂíÒà¾Õ§¾Í ´Ñ§¹Ñ¹ÇÔ¸·´·Ê´ã¹¡ÒõÃǨËÒàª×Í HPV ¤×Í ¡ÒõÃǨËÒ DNA ¢Í§àª×Í HPV (17) é Õ Õè Õ Õè Ø é éã¹»˜¨¨Øº¹ ÁÕǸ¡ÒõÃǨËÒ HPV DNA ã¹µÑÇÍ‹ҧʋ§µÃǨ·Õ¹ÂÁ㪌 2 ÇÔ¸Õ ¤×Í Ñ ÔÕ è Ô (18 - 20) 1. Hybrid Capture II ໚¹ÇÔ¸Õ non-radioactive signal amplification â´Â·íÒ¡Òà hybridizationDNA ¢Í§àª×Í HPV ã¹µÑÇÍ‹ҧ·ÕµÍ§¡ÒõÃǨ´ŒÇ RNA probe «Ö§áº‹§à»š¹ low risk probe à¾×Í é è Œ è èµÃǨËÒàª×Í HPV ÊÒ¾ѹ¸Ø·Á¤ÇÒÁàÊÕ§µèÒ áÅÐ high risk probe à¾×͵ÃǨËÒ àª×Í HPV ÊÒ¾ѹ¸Ø é  Õè Õ è í è é·ÕÁ¤ÇÒÁàÊÕ§ÊÙ§ RNA-DNA hybrids ·Õà¡Ô´¢Ö¹¨Ð¶Ù¡¨Ñºänjã¹ËÅØÁ microtiter ËÅѧ¨Ò¡¹Ñ¹¨Ð㪌 è Õ è è é émonoclonal antibody ·Õµ´¡ÑºÊÒÃà¤ÁÕàÃ×ͧáʧࢌÒÁҨѺ¡Ñº RNA-DNA hybrids áŌÇŌҧʋǹà¡Ô¹ÍÍ¡ è Ô㪌 luminometer ÇÑ´»ÃÔÁÒ³áʧÍÍ¡ÁÒ໚¹ relative light units «Ö§ÁÕ¤ÇÒÁÊÑÁ¾Ñ¹¸¡º»ÃÔÁÒ³¢Í§ è ÑHPV DNA ·ÕµÍ§¡ÒõÃǨ (semi-quantitative measurement) ÇÔ¸¡ÒõÃǨ HPV DNA ´ŒÇ Hybrid è Œ ÕCapture II 䴌ú¤ÇÒÁ¹ÔÂÁÍ‹ҧá¾Ã‹ËÅÒÂã¹ËÅÒ»ÃÐà·È áÅÐ䴌ú¡ÒÃÃѺÃͧâ´Âͧ¤¡ÒÃÍÒËÒÃ Ñ ÑáÅÐÂÒ »ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡Ò à¾×͹íÒÁÒ㪌㹷ҧ¤ÅÔ¹¡ Í‹ҧäáçµÒÁ Hybrid Capture II ¡çÁ¢Í è Ô Õ Œ¨íÒ¡Ñ´ºÒ§»ÃСÒà ¡Å‹ÒǤ×Í ¡ÒõÃǨÇÔ¸¹äÁ‹ÊÒÁÒöºÍ¡ª¹Ô´ËÃ×ÍÊÒ¾ѹ¸Ø¢Í§ HPV 䴌 áÅÐ¨Ð Õ éÕ µŒÍ§ÁÕàª×Í HPV Í‹ҧ¹ŒÍ 5,000 viral copies/ml ËÃ×Í 1 pg/ml ¨Ö§¨ÐµÃǨ¾ºä´Œ ·íÒãˌäÁ‹ÊÒÁÒö éµÃǨËÒàª×Í HPV »ÃÔÁÒ³¹ŒÍ æ 㹺ҧµÑÇÍ‹ҧ䴌 ¹Í¡¨Ò¡¹ÕǸ¹Â§ÁÕ cross-reactivity ÃÐËNjҧ é é Ô Õ Õé Ñlow risk áÅÐ high risk probe ·íÒãˌà¡Ô´¼ÅºÇ¡Åǧ«Ö§à»š¹¼ÅàÊÕµ‹Í¡ÒôÙáÅÃÑ¡ÉҼٻǠ·íÒãˌµÍ§ è Œ † Œ¶Ù¡Ê‹§µÃǨÍ×¹æ à¾ÔÁàµÔÁâ´ÂäÁ‹¨Ò໚¹ ઋ¹ colposcopic examination ÃÇÁ·Ñ§ÍÒ¨¶Ù¡ÃÑ¡ÉÒâ´Â¡Òà è è í éµÑ´»Ò¡Á´ÅÙ¡Í͡໚¹ÃÙ»¡ÃÇ (conization) ໚¹µŒ¹ 2. Polymerase Chain Reaction ໚¹ÇÔ¸Õ target amplification â´ÂàÃÔÁ¨Ò¡¢ÂÒ¨íҹǹ èDNA ¢Í§àª×Í HPV ¡‹Í¹áŌǨ֧·íÒ¡ÒõÃǨËÒ ÁÕ¤ÇÒÁäÇÊÙ§Áҡ㹡ÒõÃǨËÒàª×Í HPV à¹×ͧ¨Ò¡ é é èÊÒÁÒöµÃǨËÒàª×Í HPV áÁŒ¨ÐÁըҹǹà¾Õ§àÅ硹ŒÍÂã¹µÑÇÍ‹ҧʋ§µÃǨ¡çµÒÁ (10-100 viral copies/ é íml) ¹Í¡¨Ò¡¹Õé polymerase chain reaction ºÒ§ÇÔ¸Õ àª‹¹ linear array HPV genotyping test ÂѧÊÒÁÒöá¡ÊÒ¾ѹ¸Ø¢Í§àª×Í HPV ã¹µÑÇÍ‹ҧʋ§µÃǨÍ͡໚¹ª¹Ô´µ‹Ò§æ 䴌 ·íÒãˌ·ÃÒºÇ‹Ò àª×Í  é éHPV ÊÒ¾ѹ¸Ø¹¹à»š¹ persistent infection ËÃ×ÍäÁ‹ ËÃ×Í໚¹àª×Í HPV ÊÒ¾ѹ¸Ø·ä´ŒÃºà¢ŒÒÁÒãËÁ‹  Ñé é  Õè ÑÍ‹ҧäáçµÒÁ ¤ÇÒÁäÇ·ÕʧÁÒ¡¢Í§ÇÔ¸Õ PCR ·íÒãˌà¡Ô´¼ÅºÇ¡Åǧ¨Ò¡ cross-contamination 䴌§Ò èÙ ‹¡ÒõÃǨ´ŒÇÂÇÔ¸¹¨§µŒÍ§ÁÕ¡ÒäǺ¤ØÁ¤Ø³ÀҾ͋ҧã¡ÅŒª´ Õ Õé Ö Ô
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 25 ¨Ò¡¢ŒÍÁÙÅ·Ò§´ŒÒ¹ÃкҴÇÔ·ÂÒ áÅиÃÃÁªÒµÔ¢Í§àª×éÍ HPV 㹡Òá‹ÍÁÐàÃ移ҡÁ´ÅÙ¡µÅÍ´¨¹¡ÒõÃǨ¾ºàª×Í HPV 㹪Թà¹×ͻҡÁ´ÅÙ¡¢Í§¼Ù»Ç·Õ໚¹âäÁÐàÃ移ҡÁ´ÅÙ¡ ·íÒãˌ䴌 é é é Œ † 袌ÍÊÃØ»´Ñ§µ‹Í仹Õé (13,14,21-24) 1. ¾ºàª×Í HPV ª¹Ô´·ÕÁ¤ÇÒÁàÊÕ§ÊÙ§ÁÒ¡¡Ç‹ÒÌÍÂÅÐ 99 ¢Í§¼Ù»ÇÂÁÐàÃ移ҡÁ´ÅÙ¡ é è Õ è Œ † 2. Persistent infection ¢Í§àª×Í HPV ª¹Ô´·ÕÁ¤ÇÒÁàÊÕ§ÊÙ§ÁÕ¤ÇÒÁ¨íÒ໚¹µ‹Í¡ÒþѲ¹Òä» é è Õ è໚¹ÁÐàÃ移ҡÁ´ÅÙ¡ 3. ¤Ø³¤‹Ò㹡Ò÷íÒ¹Ò¼Åź (negative predictive value) ¢Í§¡ÒõÃǨàª×Í HPV ª¹Ô´·ÕÁÕ é è¤ÇÒÁàÊÕ§ÊÙ§ÊÙ§ÁÒ¡â´Â੾ÒÐÍ‹ҧÂÔ§àÁ×Í㪌ÃÇÁ¡Ñº¡ÒõÃǨ·Ò§à«ÅŏǷÂÒ â´ÂÁÕ¤³¤‹Ò㹡Òà è è è ‹ Ô Ø·íÒ¹Ò¼Åź¢Í§¡ÒÃ㪌¡ÒõÃǨ·Ñ§ 2 ÇÔ¸Õ ÁÒ¡¡Ç‹ÒÌÍÂÅÐ 99 (µÒÃÒ§·Õè 4) é 4. ¡ÒõÃǨËÒàª×éÍ HPV ª¹Ô´·ÕèÁÕ¤ÇÒÁàÊÕè§ÊÙ§ÁÕ¤ÇÒÁäÇ㹡ÒÃÇÔ¹Ô¨©ÑÂÁÐàÃ移ҡÁ´ÅÙ¡ÃÇÁ·Ñ§¤ÇÒÁ¼Ô´»¡µÔ¢Í§»Ò¡Á´ÅÙ¡·Õà¡ÕÂÇ¢ŒÍ§ÊÙ§¡Ç‹Ò¡ÒõÃǨ´ŒÇÂà«ÅŏǷÂÒ é è è Ôº·ºÒ·¢Í§¡ÒõÃǨ HPV DNA 㹡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ ´Ñ§·Õè¡Å‹ÒÇ¢ŒÒ§µŒ¹ ¡ÒõԴàª×éÍ HPV ໚¹ÊÒà˵ØÊíҤѭ¢Í§¡ÒÃà¡Ô´ÁÐàÃ移ҡÁ´ÅÙ¡(13,14)¡ÒõÃǨ HPV ª¹Ô´¤ÇÒÁàÊÕ§ÊÙ§ÁÕ¤ÇÒÁäÇ㹡ÒõÃǨ¾º¤ÇÒÁ¼Ô´»¡µÔ¢Í§»Ò¡Á´ÅÙ¡·Õ໚¹ CIN è è2/3 ÊÙ§¶Ö§ÃŒÍÂÅÐ 95-100 áÅÐÁÕ¤³¤‹Ò㹡Ò÷íÒ¹Ò¼ÅźÊíÒËÃѺ CIN 2/3 ÊÙ§¶Ö§ÃŒÍÂÅÐ 99-100 â´Â Ø੾ÒÐàÁ×Í㪌ÃÇÁ¡Ñº¡ÒõÃǨ·Ò§à«ÅŏǷÂÒ ¶ŒÒ¡ÒõÃǨ·Ñ§ 2 Í‹ҧãˌ¼Åź¨ÐÁÕäÇ áÅФس¤‹Òã¹ è ‹ Ô é¡Ò÷íÒ¹Ò¼ÅźÊÙ§¶Ö§ÃŒÍÂÅÐ 100 (21 - 24) ¡ÒõÃǨ HPV ª¹Ô´¤ÇÒÁàÊÕ§ÊÙ§¨Ö§ä´ŒÃº¤ÇÒÁʹ㨠áÅÐ è ѹíÒÁÒ㪌㹡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ 1. ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡´ŒÇ¡ÒõÃǨ HPV à¾Õ§Í‹ҧà´ÕÂÇ ¨Ò¡¡ÒÃÈÖ¡ÉÒ¤ÇÒÁ¶Ù¡µŒÍ§áÁ‹¹ÂíҢͧ¡ÒõÃǨ HPV DNA 㹡ÒõÃǨËÒÃÍÂâä¢Ñ¹ÊÙ§·Õè é»Ò¡Á´ÅÙ¡ ÁÕËÅÒÂÃÒ§ҹ·ÕáÊ´§Ç‹Ò ¡ÒõÃǨ HPV DNA ÁÕ¤ÇÒÁäÇ㹡ÒõÃǨËÒÃÍÂâä¢Ñ¹ÊÙ§ è é¢Í§»Ò¡Á´ÅÙ¡ÊÙ§¡Ç‹Ò¡ÒõÃǨ´ŒÇÂà«ÅŏǷÂÒ Ô (25,26) Clavel áÅФ³Ð (2001) 䴌·Ò¡ÒõÃǨËÒ (21) íHPV DNA ã¹ÊµÃÕ»ÃÐÁÒ³ 8,000 ÃÒ·ÕÁÒÃѺ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ áÅоºÇ‹Ò¡Òà èµÃǨ HPV DNA ÁÕ¤ÇÒÁäÇÌÍÂÅÐ 100 㹡ÒõÃǨ¾º¤ÇÒÁ¼Ô´»¡µÔ¢Í§»Ò¡Á´ÅÙ¡·Õ໚¹ CIN 2/3 èàÁ×Íà·Õº¡Ñº¡ÒõÃǨà«ÅŏǷÂÒÇÔ¸´§à´ÔÁ áÅÐÇÔ¸¢Í§àËÅÇ«Ö§ÁÕ¤ÇÒÁäÇà¾Õ§ÌÍÂÅÐ 58 áÅÐÌÍÂÅÐ è Ô Õ éÑ Õ è84 µÒÁÅíҴѺ Í‹ҧäáçµÒÁ¤ÇÒÁ¨íÒà¾ÒТͧ¡ÒõÃǨ HPV DNA ¨ÐµèҡNjҡÒõÃǨ´ŒÇÂà«Åŏ íÇÔ·ÂÒ ·Ñ§¹Õà¹×ͧ¨Ò¡ Íغµ¡Òó¢Í§¡ÒõԴàª×Í HPV ¨ÐÊÙ§ÁÒ¡ã¹ÊµÃÕ·ÁÍÒÂعÍ â´Â¾ºÊÙ§ÊØ´ã¹ é é è Ñ Ô é Õè Õ ŒÊµÃÕÍÒÂØ»ÃÐÁÒ³ 20 »‚«§ÊµÃÕ¡ÅØÁ¹Õ¨Ð¾º¤ÇÒÁ¼Ô´»¡µÔ ËÃ×ÍÃÍÂâä¢Ñ¹ÊÙ§·Õ»Ò¡Á´ÅÙ¡ ÃÇÁ·Ñ§ÁÐàÃç§ Öè ‹ é é è é»Ò¡Á´ÅÙ¡¹ŒÍÂÁÒ¡ Íغµ¡Òó¡ÒõԴàª×Í HPV ¨ÐŴŧàÁ×ÍÍÒÂØÁÒ¡¢Ö¹«Ö§ÊÑÁ¾Ñ¹¸¡º¡ÒÃÁÕà¾È (27) Ñ Ô é è é è ÑÊÑÁ¾Ñ¹¸áÅШíҹǹ¤Ù¹Í¹·ÕŴŧ ¨Ò¡¡ÒÃÈÖ¡ÉÒã¹ÊËÃÒªÍҳҨѡþºÇ‹ÒÁÒ¡¡Ç‹ÒÌÍÂÅÐ 30 ¢Í§ÊµÃÕ ‹ èÍÒÂØÃÐËNjҧ 20-29 »‚·ÁÒÃѺ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡¨ÐµÃǨ¾º¡ÒõԴàª×Í HPV ª¹Ô´·Õè Õè éÁÕ¤ÇÒÁàÊÕ§ÊÙ§ è (28,29) ¹Í¡¨Ò¡¹Õé Peyton áÅФ³Ð 䴌·Ò¡ÒÃÈÖ¡ÉÒã¹»ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡ÒáÅоº (30) íÍغµ¡Òó¢Í§¡ÒõԴàª×Í HPV ´Ñ§¡Å‹ÒÇÊ٧ઋ¹¡Ñ¹ â´Â¾ºÊÙ§¶Ö§ÃŒÍÂÅÐ 39.2 ¢Í§ÊµÃÕÍÒÂØÃÐËNjҧ Ñ Ô é18-40 »‚·ÁÒÃѺ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ Õè
  • 26 ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ (Cervical Cancer Screening) ¡ÒõԴàª×Í HPV ʋǹãË­‹¨ÐËÒÂ䴌àͧâ´ÂäÁ‹¡Íãˌà¡Ô´¾ÂÒ¸ÔÊÀÒ¾ËÃ×ÍÃÍÂâäã´æ ·Õ»Ò¡ é ‹ èÁ´ÅÙ¡ â´Â੾ÒÐÍ‹ҧÂÔ§ã¹ÊµÃÕ·ÁÍÒÂعÍ Moscicki áÅФ³Ð (2003) ¾ºÇ‹ÒÌÍÂÅÐ 70-90 è Õè Õ Œ (31) (32)¢Í§¡ÒõԴàª×Í HPV ã¹ÊµÃÕ·ÁÍÒÂعͨÐËÒÂ䴌àͧÀÒÂã¹ 12-24 à´×͹ ¹Í¡¨Ò¡¹Õé ¾ºÇ‹ÒÃÍÂâä é Õè Õ Œ¢Ñ¹µèÒ·Õ»Ò¡Á´ÅÙ¡ (low grade lesions) ÁÑ¡¨ÐËÒÂä»ä´Œàͧâ´Â੾ÒÐÍ‹ҧÂÔ§ã¹ÃÒ·յÃǨäÁ‹¾º é í è è è¡ÒõԴàª×Í HPV ª¹Ô´¤ÇÒÁàÊÕ§Ê٧ËÇÁ´ŒÇ Nobbenhuis áÅФ³Ð 䴌µÃǨµÔ´µÒÁʵÃÕ·ÁÃÍ é è (33) Õè Õâä¢Ñ¹µèÒ·Õ»Ò¡Á´ÅÙ¡ÁÒ¡¡Ç‹Ò 4 »‚ ¾ºÇ‹ÒÃÍÂâä´Ñ§¡Å‹ÒǨÐËÒÂ䴌àͧÌÍÂÅÐ 100 ã¹ÊµÃÕ·äÁ‹ÁÕ é í è Õè¡ÒõԴàª×Í HPV ª¹Ô´¤ÇÒÁàÊÕ§ÊÙ§ áÅÐàÁ×Íà·Õº¡ÑºÊµÃÕ·Á¡ÒõԴàª×ʹѧ¡Å‹ÒÇÃÍÂâä¨ÐËÒÂàͧ é è è Õè Õ éà¾Õ§ÌÍÂÅÐ 70 à¹×ͧ¨Ò¡ ¤ÇÒÁªØ¡¢Í§¡ÒõԴàª×Í HPV ÊÙ§ÁÒ¡ â´Â੾ÒÐʵÃÕ·ÁÍÒÂعÍ áÅÐ è é Õè Õ Œ¡ÒõԴàª×ÍʋǹãË­‹ÊÒÁÒöËÒÂä»ä´ŒàͧàÁ×ÍàÇÅÒ¼‹Ò¹ä» â´ÂäÁ‹¡Íãˌà¡Ô´¤ÇÒÁ¼Ô´»¡µÔã´æ ·Õ»Ò¡ é è ‹ èÁ´ÅÙ¡ áÅÐã¹»˜¨¨Øº¹ÂѧäÁ‹ÁǸ·Á»ÃÐÊÔ·¸ÔÀҾ㹡ÒÃá¡¡ÒõԴàª×Í HPV NjÒ໚¹ transient infection Ñ Õ Ô Õ Õè Õ éËÃ×Í persistent infection ´Ñ§¹Ñ¹ ͧ¤¡Ã·Õ´áÅ´ŒÒ¹ÊØ¢ÀÒ¾ËÅÒÂáˋ§¨Ö§ÂѧÁÕ¤ÇÒÁÅѧàŷըйíÒ¡Òà é è Ù èµÃǨ HPV DNA à¾Õ§Í‹ҧà´ÕÂÇÁÒ㪌㹡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡â´Â੾ÒÐÍ‹ҧÂÔ§ èã¹»ÃÐà·È·ÕÁá¹Ç·Ò§¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡´ŒÇÂà«ÅŏǷÂÒ·ÕÁ»ÃÐÊÔ·¸ÔÀÒ¾ÍÂÙáÅŒÇ è Õ Ô è Õ ‹ 2. ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡â´Â¡ÒõÃǨ HPV DNA ËÇÁ¡Ñº¡ÒõÃǨà«ÅŏÇÔ·ÂÒ ¤‹Ò㪌¨ÒÂ㹡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡¢Ö¹ÍÂÙ¡º¤ÇÒÁ¶Õ㹡ÒõÃǨ ´Ñ§¹Ñ¹¶ŒÒÁÕ ‹ é ‹ Ñ è éá¹Ç·Ò§ã¹¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡·ÕÊÒÁÒöŴ¤ÇÒÁ¶Õ㹡ÒõÃǨŧ ᵋ§¤§änj«§ è è Ñ Öè»ÃÐÊÔ·¸ÔÀÒ¾¢Í§¡ÒõÃǨ‹ÍÁ¨Ðª‹Ç»ÃÐËÂÑ´¤‹Ò㪌¨ÒÂŧ䴌Í‹ҧÁËÒÈÒÅ áÅÐ໚¹·Õ·ÃÒº¡Ñ¹´ÕáÅŒÇ ‹ èÇ‹Ò ÊµÃÕ¤¹Ë¹Ö§ÍҨ㪌ÃÐÂÐàÇÅÒ¹Ò¹¶Ö§ 20 »‚ËÅѧ¡ÒõԴàª×Í HPV 㹡ÒþѲ¹Òä»à»š¹ÁÐàÃ移ҡ è éÁ´ÅÙ¡ (34) Van den Akker-van Marie áÅФ³Ð(35) 䴌·Ò¡ÒÃÈÖ¡ÉÒã¹»ÃÐà·Èà¹à¸ÍÏᏴ â´Âà»ÃÕº íà·ÕºÍغµ¡Òó¡ÒÃà¡Ô´ CIN 3 ·ÕÃÐÂÐàÇÅÒ 5 »‚ËÅѧ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡´ŒÇÂà«Åŏ Ñ Ô èÇÔ·ÂÒ«Ö§ãˌ¼Å»¡µÔ ¡ÑºÍغµ¡Òó¡ÒÃà¡Ô´ CIN 3 ·ÕÃÐÂÐàÇÅÒ 10 »‚ËÅѧ¡ÒõÃǨ´ŒÇÂà«ÅŏǷÂÒãˌ è Ñ Ô è ԼŻ¡µÔ áÅСÒõÃǨ HPV DNA ãˌ¼Åź áÅÐÊÃØ»Ç‹Ò ¡ÒÃà¾ÔÁ¡ÒõÃǨ HPV DNA ࢌÒä»ã¹¡Òà èµÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ÊÒÁÒöÂ×´ÃÐÂÐàÇÅҢͧ¡ÒõÃǨᵋÅФÃÑé§ (¡íÒ˹´änj 5 »‚)ÍÍ¡ä»ä´ŒÍ¡ 2-5 »‚ ¡Å‹ÒǤ×Í ÊÒÁÒöµÃǨ¤Ñ´¡Ãͧâä䴌·¡ 7-10 »‚ ¹Í¡¨Ò¡¹Õé Bulkmans áÅÐ Õ Ø¤³Ð ¡íÒÅѧ·íÒ¡ÒÃÈÖ¡ÉÒẺ randomized controlled trial ·ÕÁªÍÇ‹Ò POBSCAM RCT ã¹ÊµÃÕ (36) è Õ ×è44,000 ÃÒ·ÕÁÒµÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ áÅÐÁÕÍÒÂØÃÐËÇèÒ§ 30-60 »Õ â´Âà»ÃÕºà·ÕºÃÐËÇèÒ§- è¡ÒõÃǨ´ŒÇÂà«ÅŏǷÂÒà¾Õ§Í‹ҧà´ÕÂÇ ¡Ñº¡ÒõÃǨ´ŒÇÂà«ÅŏǷÂÒ Ã‹ÇÁ¡Ñº¡ÒõÃǨ HPV DNA Ô Ôà¾×͵ÃǨËÒÃÍÂâäµÑ§áµ‹ CIN 3 ·ÕÃÐÂÐàÇÅÒ 5 »‚ â´ÂÁÕ໇ÒËÁÒ·ըТÂÒÂàÇÅÒ¡ÒõÃǨ¤Ñ´¡Ãͧ è é è èâäÁÐàÃ移ҡÁ´ÅÙ¡ÍÍ¡ä»ãˌÁÒ¡¡Ç‹Ò 5 »‚ ¼Å·Õ䴌¨Ò¡¡ÒÃÈÖ¡ÉÒ¹Õé ÍÒ¨·íÒãˌà¡Ô´¤ÇÒÁà»ÅÕ¹á»Å§ è èã¹á¹Ç·Ò§¡ÒõÃǨ¤Ñ´¡ÃͧÁÐàÃ移ҡÁ´ÅÙ¡ â´Âà¾ÔÁÃÐÂÐˋҧ¢Í§¡ÒõÃǨᵋÅФÃѧÍÍ¡ä» è é ã¹»ÃÐà·ÈÊËÃÒªÍҳҨѡà ÁÕ¡ÒÃÈÖ¡ÉÒ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´Å١Ẻrandomized controlled trial â´Â㪌¡ÒõÃǨ HPV DNA ËÇÁ¡Ñº¡ÒõÃǨ´ŒÇÂà«ÅŏǷÂÒ ä´Œá¡‹ Ô
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  • 28 ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ (Cervical Cancer Screening) »˜¨¨Øº¹ àÃÔÁÁÕ¤ÇÒÁà»ÅÕ¹á»Å§ã¹á¹Ç·Ò§¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ â´ÂÁÕ¡ÒÃ Ñ è è¹íÒ¡ÒõÃǨ HPV DNA ÁÒ㪌ÃÇÁ¡Ñº¡ÒõÃǨ´ŒÇÂà«ÅŏǷÂÒÁÒ¡¢Ö¹ à¾×Íà¾ÔÁ¤ÇÒÁäÇ áÅÐÅ´¼Å ‹ Ô é è èźÅǧ¢Í§¡ÒõÃǨŧ Í‹ҧäáçµÒÁ ᾷ¼´áŤÇÃÁÕ¤ÇÒÁÃٌ áÅзÃÒº¶Ö§¢ŒÍ¨íÒ¡Ñ´¢Í§¡ÒõÃǨ ٌ ÙHPV DNA (¤ÇÒÁ¨íÒà¾ÒÐ·ÕµÒ â´Â੾ÒÐÍ‹ҧÂÔ§ ¡ÒùíÒÁÒ㪌µÃǨã¹ÊµÃÕ·ÁÍÒÂعÍ à¹×ͧ¨Ò¡ è èí è Õè Õ Œ èʵÃÕ¡ÅØÁ¹ÕÁͺµ¡Òó¡ÒõԴàª×Í HPV ÊÙ§ÍÂÙáÅŒÇ áµ‹âÍ¡ÒÊà¡Ô´¤ÇÒÁ¼Ô´»¡µÔ¢Í§»Ò¡Á´ÅÙ¡·Õ໚¹ ‹ é ÕØ Ñ Ô é ‹ èÃÍÂâä¢Ñ¹ÊÙ§ áÅÐÁÐàÃ移ҡÁ´ÅÙ¡ÁÕ¹ÍÂÁÒ¡) áÅÐÊÒÁÒöãˌ¤Òá¹Ð¹íÒᡋʵÃÕ·ÁÒ¢ÍÃѺ¡ÒõÃǨ é Œ í Õè¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ µÅÍ´¨¹àÅ×͡㪌㹡ÅØÁ»ÃЪҡ÷ÕàËÁÒÐÊÁ à¹×ͧ¨Ò¡ ¡ÒÃ㪌¡Òà ‹ è èµÃǨ HPV DNA ÁÒ¡à¡Ô¹ä» ¹Í¡¨Ò¡¨ÐÊÌҧ¤ÇÒÁ¡Ñ§ÇÅã¨á¡‹ÊµÃշ䴌ú¡ÒõÃǨáÅŒÇ Âѧ·íÒãˌ Õè Ñà¡Ô´¡ÒÃʋ§µÃǨÍ×¹æ ·ÕäÁ‹¨Ò໚¹ ÃÇÁ¶Ö§¡ÒÃÃÑ¡ÉÒ·ÕÁÒ¡à¡Ô¹ä»´ŒÇ «Ö§Ê‹§¼Åãˌà¡Ô´¤ÇÒÁÊÔ¹à»Å×ͧ è è í è è éáÅÐÍÒ¨à¡Ô´¢ŒÍá·Ã¡«ŒÍ¹¨Ò¡¡ÒõÃǨ áÅСÒÃÃÑ¡ÉÒ·ÕäÁ‹¨Ò໚¹´ŒÇ è íº·ºÒ·¢Í§¡ÒõÃǨ HPV Genotyping 㹡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ ¡ÒõԴàª×Í HPV ᵋÅÐÊÒ¾ѹ¸ØÁ¤ÇÒÁàÊÕ§·Õ¨Ðà¡Ô´ÁÐàÃ移ҡÁ´Å١䴌äÁ‹à·‹Ò¡Ñ¹ Mu?oz é  Õ è èáÅФ³Ð (39) ¾ºÇ‹Ò¤ÇÒÁàÊÕ§¢Í§¡ÒÃà¡Ô´ÁÐàÃ移ҡÁ´ÅÙ¡¨ÐÊÙ§ÁÒ¡ã¹¼Ù·µ´àª×Í HPV16 (Odds è Œ Õè Ô éRatio ËÃ×Í OR = 282) ËÃ×Í HPV 18 (OR = 223) ËÃ×ͤÇÒÁàÊÕ§¤‹Í¹¢ŒÒ§µèÒã¹¼Ùµ´àª×Í HPV 35 è í Œ Ô é(OR = 62) ËÃ×Í HPV 68 (OR = 44) â´Â·Õè HPV ÊÒ¾ѹ¸ØµÒ§æ ·Õ¡Å‹ÒÇÁÒ¹Õ¨´ÍÂÙ㹡ÅØÁÊÒ¾ѹ¸Ø  ‹ è éÑ ‹ ‹·ÕÁ¤ÇÒÁàÊÕ§ÊÙ§·Ñ§ÊÔ¹ (high risk HPV ËÃ×Í oncogenic HPV) Petry áÅФ³Ð(40) ÃÒ§ҹNjÒʵÃÕ·Õè è Õ è é éµÃǨ¾ºÃÍÂâä¢Ñ¹µèÒ·Õ»Ò¡Á´ÅÙ¡ áÅÐÁÕ¡ÒõԴàª×Í HPV16 ÁÕá¹Ç⹌Á·Õ¤ÇÒÁ¼Ô´»¡µÔ¹¹Âѧ¤§ÍÂً é í è é è Ñé(stable) ËÃ×Í໚¹ÁÒ¡¢Öé¹ (pregression) ÊÙ§¡Ç‹ÒʵÃÕ·ÕèµÃǨäÁ‹¾ºàª×éÍ HPV16 ᵋ¾ºàª×éÍ HPV¡ÅØÁàÊÕ§ÊÙ§ÊÒ¾ѹ¸Ø͹æ (non-HPV16) Khan áÅФ³Ð(41) µÔ´µÒÁʵÃÕ·ÁÒµÃǨ¤Ñ´¡ÃͧÁÐàÃç§ ‹ è  ×è Õè»Ò¡Á´ÅÙ¡¹Ò¹¶Ö§ 10 »‚ ¾ºÇ‹ÒÍغµ¡ÒóÊÐÊÁ¢Í§¡ÒÃà¡Ô´ÃÍÂâä CIN 3 ËÃ×ÍÁÒ¡¡Ç‹Òã¹ÊµÃÕ·µÃǨ Ñ Ô èÕ¾ºàª×Í HPV16 áÅÐ HPV18 ෋ҡѺÌÍÂÅÐ 17 áÅÐ 14 µÒÁÅíҴѺ ᵋã¹ÊµÃÕ·µÃǨ¾ºàª×Í HPV é Õè é¡ÅØÁàÊÕ§ÊÙ§ÊÒ¾ѹ¸Ø͹æ (non-HPV 16/18) ¾ºÍغµ¡ÒóÊÐÊÁà¾Õ§ÌÍÂÅÐ 3 áÅÐŴŧàËÅ×Í ‹ è  ×è Ñ ÔÌÍÂÅÐ 0.8 ã¹ÊµÃÕ·µÃǨ¾ºàª×Í HPV ¡ÅØÁÊÒ¾ѹ¸·Á¤ÇÒÁàÊÕ§µèÒ ¹Í¡¨Ò¡¹Õé ÂѧÁÕ¡ÒÃÈÖ¡ÉÒ Õè é ‹ Õè Õ è íÍ×¹æ ·ÕÃÒ§ҹ¶Ö§¡ÒõԴàª×Í HPV ¡ÅØÁàÊÕ§Ê٧ᵋÅÐÊÒ¾ѹ¸Ø¡º¤ÇÒÁàÊÕ§¢Í§¡Òá‹Íãˌà¡Ô´ÃÍÂâä è è é ‹ è  Ñ è¢Ñ¹ÊÙ§·Õ»Ò¡Á´ÅÙ¡ áÅоºÇ‹ÒʵÃÕ·µ´àª×Í HPV16 áÅÐ HPV18 ÁÕ¤ÇÒÁàÊÕ§·Õ¨Ðà¡Ô´ÃÍÂâä¢Ñ¹ÊÙ§·Õè é è Õè Ô é è è é»Ò¡Á´ÅÙ¡ÊÙ§¡Ç‹ÒʵÃÕ·µ´àª×Í HPV ¡ÅØÁàÊÕ§ÊÙ§ÊÒ¾ѹ¸Ø͹æ(42,43) ´Ñ§¹Ñ¹ ¡ÒõÃǨËÒàª×Í HPV Õè Ô é ‹ è  ×è é é¡ÅØÁÊÒ¾ѹ¸Ø·Á¤ÇÒÁàÊÕ§ÊÙ§ÃÇÁ 13 ÊÒ¾ѹ¸Ø·ãªŒã¹»˜¨¨Øº¹ â´ÂäÁ‹á¡Í͡໚¹ÊÒ¾ѹ¸Øª¹Ô´µ‹Ò§æ ‹  Õè Õ è  Õè Ñ ä´Œ ·íÒãˌäÁ‹ÊÒÁÒöºÍ¡¤ÇÒÁàÊÕ§¢Í§¡Òá‹ÍâäÁÐàÃ移ҡÁ´ÅÙ¡ã¹Í¹Ò¤µä´ŒÍ‹ҧªÑ´à¨¹ è »˜¨¨Øº¹ ´ŒÇÂÇÔDz¹Ò¡Ò÷ҧ෤â¹âÅÂբͧ polymerase chain reaction (PCR) àÃÒÊÒÁÒö Ñ ÑµÃǨ¨íÒṡ HPV Í͡໚¹ÊÒ¾ѹ¸ØµÒ§æ 䴌·§ËÁ´ 37 ÊÒ¾ѹ¸Øâ´Â㪌¡ÒõÃǨ linear array HPV  ‹ Ñé genotyping ·íÒãˌ¡Ò÷íÒ¹Ò¤ÇÒÁàÊÕ§µ‹Í¡Òá‹ÍâäÁÐàÃç§ ËÃ×ͤÇÒÁ¼Ô´»¡µÔ¢Í§»Ò¡Á´Å١䴌áÁ‹¹ èÂíÒ¢Ö¹ «Ö§¨ÐÁÕ»ÃÐ⪹ã¹¡ÒõÃǨµÔ´µÒÁ áÅÐཇÒÃÐÇѧâäʵÃÕ·µ´àª×Í HPV 䴌Í‹ҧÁÕ»ÃÐÊÔ·¸Ô é è Õè Ô é
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 29ÀÒ¾ÁÒ¡¢Ö¹ ã¹Í¹Ò¤µ ÍÒ¨¨ÐÁÕ¡ÒùíÒ¡ÒõÃǨ HPV genotyping ÁÒ㪌㹡ÒõÃǨ¤Ñ´¡Ãͧâä éÁÐàÃ移ҡÁ´ÅÙ¡ â´ÂʵÃÕ·¾ºÇ‹ÒÁÕ¡ÒõԴàª×Í HPV16 ËÃ×Í HPV18 ¤ÇÃ䴌ú¡ÒõÃǨÊ׺¤Œ¹à¾ÔÁ Õè é Ñ èàµÔÁ´ŒÇ¡ÒõÃǨ colposcopy ᵋʵÃÕ·µ´àª×Í HPV ¡ÅØÁàÊÕ§ÊÙ§ÊÒ¾ѹ¸Ø͹æ ÍҨ䴌ú¡ÒõÃǨ Õè Ô é ‹ è  ×è ѵԴµÒÁ à¹×ͧ¨Ò¡¤ÇÒÁàÊÕ§¢Í§ÊµÃÕ¡ÅØÁ¹ÕµÍ¡ÒÃà¡Ô´ÃÍÂâä¢Ñ¹ÊÙ§·Õ»Ò¡Á´ÅÙ¡Áչ͡NjҡÅØÁ·Õµ´ è è ‹ é ‹ é è Œ ‹ è Ôàª×Í HPV16 ËÃ×Í HPV18 ÁÒ¡ (á¼¹¼Ñ§·Õè 2) éàÍ¡ÊÒÃ͌ҧÍÔ§1. .erlay J, Bray ., Pisani P, Parkin DM: Cancer incidence, mortality and prevalence worldwide. In: GLOBOCAN 2002, Version 2.0. IARC Cancer Base No. 5. Lyon: IARC Press; 2004, http://www.dep.iarc.fr/globocan/ globocan.htm.2. Nieminen P, Kallio M, Hakama M. The effect of mass screening on incidence and mortality of squamous and adenocarcinoma of cervix uteri. Obstet Gynecol 1995;85:1017-1021.3. .ink DJ. Change in American Cancer Society Checkup Guidelines for detection of cervical cancer. CA Cancer J Clin 1988;38:127-8.4. .ahey MT, Irwig L, Macaskill P. Meta-analysis of Pap-test accuracy. Am J Epidemiol 1995;141:680-9.5. Agency for Health Care Policy and Research. Evaluation of cervical cytology: evidence report/technology assessment (no. 5) Rockville, MD: AHCPR, January 1999. Online monograph: http://www.ahcpr.gov/clinic/ epcsums/cervsumm.htm.6. Bernstein SJ, Sanchez-Ramos L, Ndubisi B. Liquid-based cervical cytologic smear study and conventional Papanicolaou smears: a meta-analysis of prospective studies comparing cytologic sample diagnosis, sample adequacy. Am J Obstet Gynecol 2001;185:308-17.7. Guidos BJ, Selvaggi SM. Use of the ThinPrep test in clinical practice. Diagn Cytopathol 1999;20:70-3.8. Scottish Cervical Screening Programme. Steering group report on the feasibility of introducing liquid-based cytology (monograph online) Edinburgh: Scottish Cervical Screening Programme, 2002. Available online at http://www.omni.ac.uk/browse/mesh/detail/C0010818L0010818.html.9. National Institute for Clinical Excellence. .inal appraisal consultation document: guidance on the use of liquid- based cytology for cervical screening (review of existing guidance Number 5) (monograph online). London: NICE, 2003. Available online at http://www.nice.org.uk/Docref.asp?d=82877.10. Saslow D, Runowicz CD, Solomon D, Moscicki A, Smith RA, Eyre HJ, et al. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin 2002;52:342-62.11. Laiwejpithaya S, Rattanachaiyanont M, Benjapibal M, Khuakoonratt N, Boriboonhirunsarn D, Laiwejpithaya S, et al. Comparison between Siriraj liquid-based and conventional cytology for detection of abnormal cervicovaginal smears: A split-sample study. Asian Pacific J Cancer Prev 2008;9:575-80.12. Davey E, Barratt A, Irwig L, Chan S., Macaskill P, Mannes P, et al. Effect of study design and quality on unsatisfactory rates, cytology classifications, and accuracy in liquid-based versus conventional cervical cytology: a systematic review. Lancet 2006;367:122-32.13. Walboomers JM, Jacobs MV, Manos MM, Bosch .X, Kummer JA, Shah KV, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999;189:12-9.14. Bosch .X, Lorincz A, Munoz N, Meijer CJ, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol 2002;55:244-65.
  • 30 ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ (Cervical Cancer Screening)15. de Villiers EM, .auquet C, Broker TR, Bernard HU, zur Hausen H. Classification of papillomaviruses. Virology 2004;324:17-27.16. Mu?oz N, Bosch .X, de Sanjose S, Herrero R, Castellsague X, Shah KV, et al. Epidemiologic classification of human papilloma virus types associated with cervical cancer. N Engl J Med 2003;348:518-27.17. Dillner J. The serological response to papillomavirus. Semin Cancer Biol 1999;9:423-30.18. Molijn A, Kleter B, Quint W, van Doorn L. Molecular diagnosis of human papillomavirus (HPV) infections. J Clin Virology 2005;32S:S43-S51.19. Lorincz AT. Hybrid Capture method for detection of human papillomavirus DNA in clinical specimens: a tool for clinical management of equivocal Pap smears and for population screening. J Obstet Gynaecol Res 1996;22:629- 36.20. Bozzetti M, Nonnenmacher B, Mielzinska I, Villa L, Lorincz A, Breitenbach V, et al. Comparison between Hybrid Capture II and polymerase chain reaction results among women at low-risk for cervical cancer. Ann Epidemiol 2000;10:466.21. Clavel C, Masue M, Bory JP, Putaud I, Mageonjean C, Lorenzato ., et al. Human papillomavirus in primary screening for the detection of high-grade cervical lesions: a study of 7932 women. Br J Cancer 2001;89:1616-23.22. Petry KU, Menton S, Menton M, van Loenen-.rosch ., de Carvalho Gomes H, Holz B, et al. Inclusion of HPV testing in routine cervical cancer screening for women above 29 years in Germany: results for 8466 patients. Br J Cancer 2003;88:1570-7.23. Kulasingam SL, Hughes JP, Kinat NB, Mao C, Weiss NS, Kuypers JM, et al. Evaluation of HPV testing in primary screening for cervical abnormalities: comparison of sensitivity, specificity, and frequency of referral. JAMA 2002;288:1749-55.24. Meijer CLM, Rozendaal L, vander Linden JC. Human papillomavirus testing for primary cervical screening. In: .ranco E, Monsonego J, eds. New developments in cervical cancer screening and prevention. Oxford: Blackwell Science, 1997:338-47.25. Cuzick J, Sasieni P, Davies P, Adams J, Normand C, .rater A, et al. A systemic review of the role of human papillomavirus testing within a cervical screening programme. Health Technol Assess 1999;3:1-196.26. Schneider A, Hoyer H, Lota B, Leistritza S, Kuhne-Heid R, Nindl I, et al. Screening for high-grade cervical intraepithelial neoplasia and cancer by testing for high-risk HPV, routine cytology or colposcopy. Int J Cancer 2000;89:529-34.27. Burk RD, Ho GY, Beardsley L, Lempa M, Peters M, et al. Sexual behavior and partner characteristics are predominant risk factors for genital human papillomavirus infection in young women. J Infect Dis 1996;174:679- 89.28. Kitchener HC, Wheeler P, Desai M, Corbitt G, Roberts C, Maguire P, et al. The ARTISTIC trial – a randomized trial in screening to improve cytology. In: 21st International Papillomavirus Conference; 2004. p.219 (Abs.268)29. Cuschieri KS, Cubie HA, Whitley MW, Seagar AL, Arends MJ, Moore C, et al. Multiple high risk HPV infections are common in cervical neoplasia and young women in a cervical screening population. J Clin Pathol 2004;57:68- 72.30. Peyton CL Gravitt PE, Hunt W, Hundley RS, Zhoa M, Apple RJ, et al. Determinants of genital human papillomavirus detection in a US population. J Infect Dis 2001;183:1554-64.31. Ho GY, Bierman R, Beardsley L, Chang CJ, Burk RD. Natural history of cervicovaginal papillomavirus infection in young women. N Engl J Med 1998;338:423-8.32. Moscicki AB. Cervical cytology screening in teens. Curr Womens Health Rep 2003;3:433-7.
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 3133. Nobbenhuis MA, Helmerhorst TJ, van den Brule AJ, Rozendaal L, Vaarhorst .J, Bezemer PD, et al. Cytological regression and clearance of high-risk human papillomavirus in women with an abnormal cervical smear. Lancet 2001;358:1782-3.34. Ostor AG. Natural history of cervical intraepithelial neoplasia: a critical review. Int J Gynaecol Pathol1993;12:186- 92.35. Van den Akker-van Marie ME, van Ballegooijen, Rozendaal L, Meijer CJLM, Habbema JD.. Extended duration of the detectable stage by adding HPV test in cervical cancer screening. Br J Cancer 2003;89:1830-3.36. Bulkmans NWJ, Rozendaal L, Snijders PJ., Voorhorst .J, Boeke AJP, Zandwijken GRJ, et al. POBSCAM, a population-based randomized controlled trial for implementation. Int J Cancer 2004;110:94-101.37. Cuzick J, Szarewski A, Cubie H, Hulman G, Kitchener H, Luesley D, et al. Management of women who test positive for high-risk types of human papillomavirus: the HART study. Lancet 2003;362:1871-6.38. Wright TC, Schiffman M, Solomon D, Cox JT, Garcia ., Goldie S, et al. Interim guidance for the use of human papillomavirus DNA testing as an adjunct to cervical cytology for screening. Obstet Gynecol 2004;103:304-9.39. Mu?oz N, Bosch .X, Castellsague X, Diaz M, de Sanjose S, Hammouda D, et al. Against which human papillomavirus types shall we vaccinate and screen? The international perspective. Int J Cancer 2004;111:278– 85.40. Petry KU, B?hmer G, Iftner T, Davies P, Brummer O, K?hnle H. .actors associated with an increased risk of prevalent and incident grade III cervical intraepithelial neoplasia and invasive cervical cancer among women with Papanicolaou tests classified as grades I or II cervical intraepithelial neoplasia. Am J Obstet Gynecol 2002;186: 28-34.41. Khan MJ, Castle PE, Lorincz AT, Wacholder S, Sherman M, Scott DR, et al. The elevated 10-year risk of cervical precancer and cancer in women with human papillomavirus (HPV) type 16 or 18 and the possible utility of type-specific HPV testing in clinical practice. J Natl Cancer Inst 2005;97:1072-9.42. Castle PE, Solomon D, Schiffman M, Wheeler CM. Human papillomavirus type 16 infections and 2-year absolute risk of cervical precancer in women with equivocal and mild cytologic abnormalities. J Natl Cancer Inst 2005;97:1066-71.43. Brummer O, Hollwitz B, B?hmer G, K?hnle H, Petry KU. Human papillomavirus-type persistence patterns predict the clinical outcome of cervical intraepithelial neoplasia. Gynecol Oncol 2006;102:517-22.
  • 32 ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ (Cervical Cancer Screening)µÒÃÒ§·Õè 1 Performance of conventional cytology in various large research studies Authors Country Ages Study size Sensitivity Specificity Histological cut-offCuzick (1999) United Kingdom 34+ 2988 88 98 CIN 2+Hutchinson (1999) Costa Rica 18+ 8636 55 98 CIN 2+Ratnam (2000) Canada 18 - 69 2098 56 62 CIN 2+Denny (2000) South Africa 35 - 65 2944 70 85 CIN 2+Denny (2002) South Africa 35 - 65 2754 40 96 CIN 1+Cuzick (2003) United Kingdom 30 - 60 11085 77 96 CIN 1+Petry (2003) Germany 30+ 8466 44 98 CIN 2+Salmeron (2003) Mexico 15 - 85 7868 59 98 CIN 1+Sankaranarayan (2004) India 25 - 65 10591 65 92 CIN 2+CIN = cervical intraepithelial neoplasia·ÕèÁÒ: Screening test. In: IARC Handbooks of Cancer Prevention, Vol 10. Cervix Cancer Screening. Lyon: IARC Press; 2005.µÒÃÒ§·Õè 2 Comparison of specimen adequacy in conventional cytology with liquid-based cytology Authors Conventional Liquid-based cytology No. Limited (%) Unstatisf (%) No. Limited (%) Unstatisf (%)Bolick (1998) 39408 17.8 1.0 10694 11.6 0.3Dupree (1998) 22323 - 2.0 19351 - 3.8Diaz-Rosario (1999) 74756 22.0 0.2 56339 18.7 0.7Carpenter (1999) 5000 19.4 0.6 2727 10.5 0.3Guidos (1999) 5423 21.4 1.2 9583 0.7 0.5Vassilakol (1999) 88569 4.7 1.5 111358 1.2 0.2Tench (2000) 10367 31.0 2.9 2231 15.8 0.4Weintraub (2000) 130050 27.8 0.3 39790 8.1 0.2Obwegeser (2001) 1002 2.5 0 997 5.5 1.4Baker (2002) 4872 18.2 0.7 3286 9.1 0.8Cheung (2003) 191581 2.6 0.48 190667 0.5 0.3Moss (2003) 74584 - 9.7 34813 - 2.0·ÕèÁÒ: Screening test. In: IARC Handbooks of Cancer Prevention, Vol 10. Cervix Cancer Screening. Lyon: IARC Press; 2005.
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 33µÒÃÒ§·Õè 3 Comparison of identification of SIL using conventional cytology with liquid- based cytology Authors Conventional Liquid-based cytology Increase in No. LSIL HSIL No. LSIL HSIL HSILBolick (1998) 39408 0.8% 0.3% 10694 2.3% 0.8 173%Dupree (1998) 22323 0.9% 0.2% 19351 1.4% 0.3 50%Papillo (1998) 18569 0.9% 0.5% 8541 1.6% 0.7 55%Carpenter (1999) 5000 4.4% 1.9% 2727 6.9% 2.4 26%Diaz-Rosario (1999) 74756 1.6% 0.26% 56339 2.7% 0.52 102%Guidos (1999) 5423 1.0% 0.3% 9583 3.6% 1.0 233%Vassilakol (1999) 88569 1.6% 0.4% 111358 2.5% 0.7 79%Hatch (2000) 16260 2.9% 1.5% 7934 6.1% 3.2 116%Tench (2000) 10367 0.6% 0.5% 2231 1.0% 0.7 46%Weintraub (2000) 126619 0.5% 0.1% 39455 1.8% 0.5 400%Obwegeser (2001) 1002 3.7% 1.8% 997 4.7% 1.6 -11%Baker (2002) 4872 2.8% 0.7% 3286 4.1% 1.0 43%Cheung (2003) 191581 1.0% 0.25% 190667 1.7% 0.24 -4%Moss (2003) 67856 2.3% 1.4% 34128 2.6% 1.7 21%Colgan (2004) 445225 1.4% 0.4% 445011 1.8% 0.35 -LSIL = low grade squamous intraepithelial lesion, HSIL = high grade squamous intraepithelial lesion·ÕèÁÒ: Screening test. In: IARC Handbooks of Cancer Prevention, Vol 10. Cervix Cancer Screening. Lyon: IARC Press; 2005.
  • 34 ¡ÒõÃǨ¤Ñ´¡ÃͧâäÁÐàÃ移ҡÁ´ÅÙ¡ (Cervical Cancer Screening)µÒÃÒ§·Õè 4 Performance of HPV DNA testing and cervical cytology for screening in women aged 30 years or more in cross-sectional studies Population N CIN 2+ Sensitivity (%) Specificity (%) NPV (%) Pap HPV Combination Pap HPV Combination CombinationGermany 7592 1.01 33.8 85.7 93.5 98.7 96.7 95.7 0.999United Kingdom 10358 0.90 72.2 96.9 100.0 98.7 93.4 93.2 1.000Mexico 6115 1.41 57.0 94.2 97.7 98.8 94.0 93.5 1.000Costa Rica 6176 1.75 80.4 86.3 92.2 94.5 94.4 90.3 0.998South Africa 2925 3.56 74.0 84.9 87.0 87.9 81.8 78.1 0.988China 1936 4.34 94.0 97.6 100.0 77.8 84.8 69.5 1.000Baltimore 1040 0.48 60.0 100.0 100.0 97.8 96.5 95.8 1.000CIN = cervical intraepithelial neoplasia, HPV = human papillomavirus, NPV = negative predictive value·ÕèÁÒ: Wright TC, Schiffman M, Solomon D, Cox JT, Garcia ., Goldie S, et al. Interim guidance for the use of human papillomavirus DNA testing as an adjunct to cervical cytology for screening. Obstet Gynecol 2004;103:304-9.á¼¹¼Ñ§·Õè 1 Algorithm for the management of women using a combination of cervical cytology and HPV DNA testing for primary cervical cancer screening. HPV = human papillomavirus; ASCUS = atypical squamous cells of undetermined significance.·ÕèÁÒ: Wright TC, Schiffman M, Solomon D, Cox JT, Garcia ., Goldie S, et al. Interim guidance for the use of human papillomavirus DNA testing as an adjunct to cervical cytology for screening. Obstet Gynecol 2004;103:304-9.
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 35á¼¹¼Ñ§·Õè 2 Algorithm for the management of women using a combination of cervical cytology, HPV DNA testing and gynotyping for cervical cancer screening. HPV = human papillomavirus; ASCUS = atypical squamous cells of undetermined significance.·ÕèÁÒ: Khan MJ, Castle PE, Lorincz AT, Wacholder S, Sherman M, Scott DR, et al. The elevated 10-year risk of cervical precancer and cancer in women with human papillomavirus (HPV) type 16 or 18 and the possible utility of type-specific HPV testing in clinical practice. J Natl Cancer Inst 2005;97:1072-9.
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 37 5 ¡ÒõÃǨ¤Ñ´¡ÃͧÁÐàÃç§àµŒÒ¹Á ÍÒ¨ÒϹÒÂᾷ´Í¡àµÍÏÊ׺ǧȏ ¨Ø±ÒÀÔÊÔ·¸Ôì ÀÒ¤ÇÔªÒÈÑÅÂÈÒʵÏ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å ÔÔ ÁÐàÃç§àµŒÒ¹Á໚¹ÁÐàÃ秷ÕÁͺµ¡ÒóÊ§·ÕÊ´ã¹¼ÙË­Ô§·ÑÇâÅ¡ ã¹»ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡Ò áÅÐ è ÕØ Ñ Ô Ù èØ Œ èã¹ÂØâû ÁÕ¡Òäíҹdz¾ºÇ‹Ò life time risk ¢Í§¼Ù˭ԧ㹡ÒÃà¡Ô´ÁÐàÃç§àµŒÒ¹Á ෋ҡѺ 1 µ‹Í 8 áÅÐ ŒÁÕÃÒÂ§Ò¹Ç‹Ò ã¹»‚ ¤È. 2001 ·ÑèÇâÅ¡Áռٌ»†ÇÂãËÁ‹·Õè䴌ÃѺ¡ÒÃÇÔ¹Ô¨©ÑÂNjÒ໚¹ÁÐàÃç§àµŒÒ¹Á ÁÒ¡¡Ç‹Ò1 ŌҹÃÒµ‹Í»‚ áÅÐÁÕ¼·àÊÕªÕǵ¨Ò¡ÁÐàÃç§àµŒÒ¹Á»ÃÐÁÒ³ 375,000 ¤¹ 1 ÊíÒËÃѺ㹻ÃÐà·Èä·Â ٌ Õè ԨҡʶԵ¢Í§Ê¶ÒºÑ¹ÁÐàÃç§áˋ§ªÒµÔ ÁÕ¡ÒäҴ¡ÒóÇÒ ã¹»‚¤È. 2008 ÁÕ¼»ÇÂãËÁ‹·ä´ŒÃº¡ÒÃÇÔ¹¨©ÑÂÇ‹Ò Ô ‹ ٌ † Õè Ñ Ô໚¹ÁÐàÃç§àµŒÒ¹Á 12,700 ÃÒ 2 «Ö§¶ŒÒ໚¹´Ñ§·Õ¤Ò´¡Òó¨ÃÔ§ ÁÐàÃç§àµŒÒ¹Á¡ç¨Ð¡ÅÒÂ໚¹ÁÐàÃ秷վº è è 躋Í·ÕÊ´ã¹»ÃÐà·Èä·ÂàËÁ×͹¡Ñº»ÃÐà·È·Ò§ÂØâû áÅÐÊËÃÑ°ÍàÁÃÔ¡Ò èØ à¹×ͧ¨Ò¡»˜­ËҴѧ¡Å‹ÒÇ¢ŒÒ§µŒ¹ ·íÒãˌ¡ÒõÃǨ¤Ñ´¡Ãͧà¾×ͤŒ¹ËÒÁÐàÃç§àµŒÒ¹Á (breast cancer è èscreening) ¡ÅÒÂ໚¹»˜­ËÒÃдѺ»ÃÐà·È·Õè¨ÐµŒÍ§ËѹÁÒãˌ¤ÇÒÁʹã¨Áҡ໚¹¾ÔàÈÉ â´ÂÁÕÇѵ¶Ø»ÃÐʧ¤à¾×ͷըФŒ¹ËÒÁÐàÃç§àµŒÒ¹Áã¹ÃÐÂÐàÃÔÁµŒ¹ â´Â੾ÒСÒ䌹ËÒÁÐàÃç§àµŒÒ¹Áãˌ䴌¡Í¹·Õ¨ÐàÃÔÁ è è è ‹ è èÁÕÍÒ¡ÒÃáÊ´§ â´Â㪌Ǹ¡Ò÷ÕàËÁÒÐÊÁ·ÕÊ´¡ÑºÊÀÒÇзҧàÈÃÉ°¡Ô¨áÅÐÊѧ¤Áã¹»ÃÐà·È Í‹ҧäáç ÔÕ è èصÒÁ ã¹»˜¨¨Øº¹à¹×ͧ¨Ò¡¡ÒÃÈÖ¡ÉÒÇÔ¨Âà¡ÕÂǡѺ¡Ò÷íÒ¡ÒäѴ¡ÃͧÁÐàÃç§àµŒÒ¹Áã¹»ÃÐà·Èä·ÂàͧÂѧ Ñ è Ñ èÁչ͠´Ñ§¹Ñ¹á¹Ç·Ò§¡Òû¯Ôºµã¹¡ÒÃÈÖ¡ÉҤѴ¡ÃͧÁÐàÃç§àµŒÒ¹Áã¹»ÃÐà·Èä·Â¨Ö§Âѧ¤‹Í¹¢ŒÒ§ÍÔ§ä» Œ é Ñ Ô¡Ñºá¹Ç·Ò§»¯Ôºµ¢Í§µ‹Ò§»ÃÐà·È໚¹Ê‹Ç¹ãË­‹ Ñ ÔÇÔ¸Õ¡ÒõÃǨ¤Ñ´¡ÃͧÁÐàÃç§àµŒÒ¹Á ÇÔ¸¡ÒõÃǨ¤Ñ´¡ÃͧÁÐàÃç§àµŒÒ¹Á·Õ㪌㹷ҧ¤ÅÔ¹¡ ã¹»˜¨¨Øº¹ÁÕËÅÒÂÇÔ¸Õ ·ÕÊҤѭ 䴌ᡋ Õ è Ô Ñ èí 1. ¡ÒõÃǨËҧ¡Ò´ŒÇµ¹àͧ (Brest self exam, BSE) 2. ¡ÒõÃǨËҧ¡ÒÂâ´ÂᾷËÃ×ͺؤÅҡ÷ҧ¡ÒÃᾷ (Clinical breast exam, CBE) 3. ¡ÒõÃǨ´ŒÇÂà¤Ã×ͧáÁÁâÁá¡ÃÁ è 4. ¡ÒõÃǨ´ŒÇ¤Å×¹àÊÕ§¤ÇÒÁ¶Õʧ ËÃ×Í ÍÑŵÃÒ«Òǹ´ è èÙ 5. ¡ÒõÃǨ´ŒÇÂÇÔ¸¡Ò÷ҧÃѧÊÕ͹æ ÊíÒËÃѺ¼Ù·Á¤ÇÒÁàÊÕ§Ê٧㹡ÒÃà¡Ô´ÁÐàÃç§àµŒÒ¹Á ઋ¹ Õ ×è Œ Õè Õ è¡ÒõÃǨ MRI
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  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 41ÊÃØ» ¡ÒõÃǨ¤Ñ´¡ÃͧÁÐàÃç§àµŒÒ¹Á໚¹àÃ×ͧ·Õ¨ÐµŒÍ§ãˌ¤ÇÒÁÊíҤѭ à¾ÃÒÐÍغµ¡Òó¢Í§ÁÐàÃç§ è è Ñ ÔൌҹÁà¾ÔÁÊÙ§¢Ö¹Áҡ㹪‹Ç§·ÈÇÃÃÉËÅѧ ¡ÒõÃǨ¾ºÁÐàÃç§àµŒÒ¹ÁµÑ§áµ‹ÃÐÂÐàÃÔÁµŒ¹ ·íÒãˌÊÒÁÒö è é é èÅ´¤‹Ò㪌¨ÒÂ㹡ÒÃÃÑ¡ÉÒâäÁÐàÃç§àµŒÒ¹Á䴌Í‹ҧªÑ´à¨¹ áÅÐÂѧÊÒÁÒöà¾ÔÁÍѵÃÒ¡ÒÃÍÂÙÃÍ´¢Í§¼Ù»Ç ‹ è ‹ Œ †ä´ŒÁÒ¡¢Ö¹´ŒÇ Í‹ҧäáçµÒÁ ã¹·Ò§»¯ÔºµÔ ¡ÒèÐàÅ×͡㪌¡ÒõÃǨÇÔ¸ã´ã¹¡ÒõÃǨ¤Ñ´¡ÃͧÁÐàÃç§ é Ñ ÕൌҹÁ ໚¹ÊÔ§·ÕµÍ§¾Ô¨ÒóÒÍ‹ҧÃͺ¤Íº à¾×Í·Õ¨Ðãˌ䴌»ÃÐ⪹Ê§Êش㹡Ò䌹ËÒÁÐàÃç§àµŒÒ¹Á è è Œ è è Ùã¹ÃÐÂÐàÃÔÁµŒ¹ áÅС‹Íãˌà¡Ô´¤ÇÒÁ¤ØÁ¤‹ÒãˌÁÒ¡·ÕÊ´ è Œ èØàÍ¡ÊÒÃ͌ҧÍÔ§1. Bray ., McCarron P, Parkin DM. The changing global patterns of female breast cancer incidence and mortality. Breast Cancer Res 2004; 6:229-239.2. Chaiwerawatana A. Cancer in Thailand Vol IV. Page 48-50. 2007.3. US Preventive Services Task .orce. Screening for breast cancer: recommendations and rationale. Ann Intern Med 2002; 137:344-346.4. Teh W, Wilson AR. The role of ultrasound in breast cancer screening. A consensus statement by the European Group for Breast Cancer Screening. Eur J Cancer 1998; 34:449-450.5. Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, Morris E, Pisano E, Schnall M, Sener S, Smith RA, Warner E, Yaffe M, Andrews KS, Russell CA. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007; 57:75-89.6. Smith RA, Saslow D, Sawyer KA, Burke W, Costanza ME, Evans WP, III, .oster RS, Jr., Hendrick E, Eyre HJ, Sener S. American Cancer Society guidelines for breast cancer screening: update 2003. CA Cancer J Clin 2003; 53:141-169.
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 43 6 Applied Physiology for Quality of Life ¼ÙŒª‹ÇÂÈÒʵÃÒ¨ÒϹÒÂᾷÀÒÊ¡Ã ÇѸ¹¸Ò´Ò ÀÒ¤ÇÔªÒÊÃÕÃÇÔ·ÂÒ ¤³Ðá¾·ÂÈÒʵÏ ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑ¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂà¾×èͤسÀÒ¾¢Í§ªÕÇÔµ »˜¨¨ØºÑ¹á¹Ç·Ò§ã¹¡ÒÃʋ§àÊÃÔÁÊØ¢ÀÒ¾·Ò§¡Ò ·ÕèÊíҤѭ ¤×ÍàÃ×èͧ¢Í§âÀª¹Ò¡ÒÃáÅСÒÃÍÍ¡¡íÒÅѧ¡Ò «Ö§»˜¨¨Øº¹Í§¤¡Ò÷ҧÇÔªÒ¡Òõ‹Ò§æ ઋ¹ American College of Sports Medicine è Ñ(ACSM), American Medical Association (AMA) ÏÅÏ ¶×ÍÇ‹Ò ¡Ô¨¡ÃÃÁ·Ò§¡Ò (physical activity)áÅСÒÃÍÍ¡¡íÒÅѧ¡Ò (exercise) ¹Ñé¹à»š¹¾×é¹°Ò¹·ÕèÊíҤѭ㹡Òû‡Í§¡Ñ¹âäáÅСÒÃÃÑ¡ÉÒ·Ò§¡ÒÃᾷÊÁÑÂãËÁ‹ Í‹ҧäáçµÒÁ 㹡ÒÃÊíÒÃǨ¢Í§ ACSM ¾ºÇ‹Ò¼ÙŒ»†Ç»ÃÐÁÒ³ 65% ʹ㨷Õè¨ÐÍÍ¡¡íÒÅѧ¡ÒÂà¾×ÍãˌʢÀÒ¾´ÕËҡᾷ໚¹¼Ùá¹Ð¹íÒáÅÐÁÕ¡ÒÃãˌ¢ÍÁÙÅ㹡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂà¾ÔÁàµÔÁ è Ø Œ Œ èᵋ¾ºÇ‹ÒÁÕᾷà¾Õ§ 41% ෋ҹѹ·Õ͸ԺÒÂãˌ¼»ÇÂàË繤ÇÒÁÊíҤѭ¢Í§¡ÒÃÍÍ¡¡íÒÅѧ¡Ò áÅÐ é è ٌ †äÁ‹ãª‹á¾·Â·Ø¡¤¹ã¹¡Å؋Á¹Õé·Õè¨Ðãˌ¤íÒá¹Ð¹íҡѺ¼ÙŒ»†ÇÂNjҡÒÃÍÍ¡¡íÒÅѧ¡ÒÂã´àËÁÒÐÊÁËÃ×Í´Õ·ÕèÊØ´ÊíÒËÃѺ¼Ù»Ç ¼Ù»Ç¨֧äÁ‹Á¢ÍÁÙÅ´Õà¾×ÍàÅ×Í¡¡ÒÃÍÍ¡¡íÒÅѧ¡Ò·ÕàËÁÒÐÊÁãˌ¡ºµ¹àͧ(1) Œ † Œ † Õ Œ è è Ñ ¾×¹°Ò¹¡ÒÃãˌ¤ÇÒÁÃÙ·Ò§¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂâ´Â·ÑÇ仵ŒÍ§ãˌͧ¤»ÃСͺãˌ¤Ãº´Ñ§µ‹Í仹Õé ¤×Í é Œ èÇÔ¸¡ÒÃÍÍ¡¡íÒÅѧ¡Ò (mode of exercise) ¤ÇÒÁ˹ѡ¢Í§¡ÒÃÍÍ¡¡íÒÅѧ¡Ò (intensity) ÃÐÂÐàÇÅÒ Õ¢Í§¡ÒÃÍÍ¡¡íÒÅѧ¡Ò (duration) áÅÐ ¤ÇÒÁ¶Õ¢Í§¡ÒÃÍÍ¡¡íÒÅѧ¡Ò (frequency) «Ö§¢ŒÍÁÙÅ·ÕËÒ䴌 è è è¨Ò¡µíÒÃÒ àÍ¡ÊÒà ¤íÒá¹Ð¹íÒ·ÑÇ仨Ðá¹Ð¹íÒ¤¹·ÑÇä»ËÃ×ͼٻÇÂäÁ‹ª´à¨¹ã¹á§‹¢Í§ÇÔ¸¡ÒÃÍÍ¡¡íÒÅѧ è è Œ † Ñ Õ¡Ò ઋ¹ á¹Ç·Ò§¡ÒÃÍÍ¡¡íÒÅѧ¡Ò·ÑÇä» ACSM áÅÐ American Heart Association (AHA) à¾×Íʋ§ è èàÊÃÔÁÊØ¢ÀÒ¾¢Ñ¹µèÒ ¤×Í ÍÍ¡¡íÒÅѧ¡ÒÂà¾×ÍËÑÇ㨠(cardio) ÃдѺ»Ò¹¡ÅÒ§ 30 ¹Ò·ÕµÍÇѹ 5 Çѹµ‹Í é í è ‹ÊÑ»´Òˏ ËÃ×ÍÍÍ¡¡íÒÅѧ¡ÒÂà¾×ÍËÑÇã¨ÃдѺ˹ѡ 20 ¹Ò·ÕµÍÇѹ 3 Çѹµ‹ÍÊÑ»´Òˏ ËÇÁ¡Ñº¡ÒÃÍÍ¡¡íÒÅѧ è ‹¡ÒÃà¾×ÍàÊÃÔÁÊÌҧ¤ÇÒÁá¢ç§áç¢Í§¡ÅŒÒÁà¹×Í (strength-training exercises) 8-12 ¤Ãѧµ‹Í·‹Ò 10 ·‹Ò è é é2 ¤Ãѧµ‹ÍÊÑ»´Òˏ â´Âãˌ¤Ò¹ÔÂÒÁ¢Í§¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂÃдѺ»Ò¹¡ÅÒ§Ç‹Ò Ë¹Ñ¡à¾Õ§¾Í·Õ¨Ðà¾ÔÁÍѵÃÒ é í è è¡ÒÃൌ¹¢Í§ËÑÇ㨠ÁÕà˧×ÍÍÍ¡ ᵋ§ÊÒÁÒöʹ·¹Ò䴌ÃÐËNjҧ¡ÒÃÍÍ¡¡íÒÅѧ¡Ò Í‹ҧäáçµÒÁ¨Ð è Ñ (1)àËç¹ä´ŒÇÒÃÒÂÅÐàÍÕ´à¡ÕÂǡѺÇÔ¸¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂແ´¡ÇŒÒ§Ç‹Ò¨Ð·íÒÍÐäáç䴌«§ÊÒÁÒö㪌䴌㹤¹ ‹ è Õ Öè·ÑÇä»·Õá¢ç§áçáÅÐÁÕÊ¢ÀÒ¾´Õ ᵋ㹼ٷÁâäËÃ×Í¡ÒúҴà¨çººÒ§Í‹ҧ ¡ÒÃÍÍ¡¡íÒÅѧ¡ÒºҧÇÔ¸ÂÍÁ è è Ø Œ Õè Õ Õ ‹¨ÐÁÕ¤ÇÒÁàÊÕ§µ‹Í¡ÒúҴà¨çºÊÙ§¡Ç‹Ò¤¹·ÑÇä» áÅмŴշ䴌ÍÒ¨äÁ‹¤Á¡Ñº¤ÇÒÁàÊÕ§¹Ñ¹ è è Õè ، è é ËÒ¡¡Å‹ÒǶ֧¡ÒÃÍÍ¡¡íÒÅѧ¡Ò ¤íÒ¾Ù´·ÕÂÍ´àÂÕÂÁ 2 »ÃÐ⤷դÇáŋÒǶ֧ ¡ç¤Í “The best è è è ×exercise for you is the exercise that is best to you” áÅÐ “the hard part of regular exercise is the
  • 44 Applied Physiology for Quality of Liferegular, not the exercise” (1) «Ö§¤ÇÒÁËÁÒÂâ´ÂÃÇÁ¤×Í¡ÒÃÍÍ¡¡íÒÅѧ¡Ò·մ·Ê´ ¤×Í µŒÍ§àËÁÒÐã¹ è è Õ Õè طء´ŒÒ¹·Ñ§ÃٻËҧ ÍØ»¡Ã³·ãªŒ ʶҹ·Õè ÃÐÂÐàÇÅÒ·ÕËÒ䴌 ÃÇÁ·Ñ§¤ÇÒÁ¾Ö§¾Í㨢ͧ¼ÙÍÍ¡¡íÒÅѧ¡Ò é Õè è é Œà¾ÃÒШзíÒãˌ¤¹¼Ù¹¹ÊÒÁÒöÍÍ¡¡íÒÅѧ¡ÒÂ䴌Í‹ҧÊÁèÒàÊÁÍ «Ö§à»š¹àÃ×ͧ·ÕÂÒ¡ÁÒ¡·Õ¨Ð·íÒ䴌 áÅÐ Œ Ñé í è è è è¨Ö§à»š¹àÃ×ͧÂÒ¡¢Ö¹ä»ÍÕ¡·Õᾷ¨ÐÊÒÁÒöá¹Ð¹íÒ¡ÒÃÍÍ¡¡íÒÅѧ¡Ò·ÕàËÁÒÐÊÁãˌ¡º¼Ù·ãˌ¤Ò»ÃÖ¡ÉÒ è é è è Ñ Œ Õè íâ´Â੾ÒÐÍ‹ҧÂÔ§ã¹ÃÐÂÐàÇÅÒ»ÃÖ¡ÉÒᾷÁ¨Ò¡Ñ´ è Õí ã¹´ŒÒ¹¢Í§¡ÒÃÇҧἹ¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂãˌÊÁèÒàÊÁ͹ѹ ¾ºÇ‹Ò ¡ÒÃàÅÔ¡ÍÍ¡¡íÒÅѧ¡ÒÂã¹ í é¼ÙàÃÔÁµŒ¹ÍÍ¡¡íÒÅѧ¡ÒÂà¡Ô´¢Ö¹ÁÒ¡ã¹ 6-8 ÊÑ»´Òˏáá¨Ö§á¹Ð¹íÒãˌµ§·Ñ§à»‡ÒËÁÒÂÃÐÂÐÊѹáÅÐ໇ÒËÁÒ Œ è é Ñé é éÃÐÂÐÂÒÇ µÑÇÍ‹ҧઋ¹ ໇ÒËÁÒÂÃÐÂÐÊѹ ઋ¹ ¡ÒÃÅ´¹éÒ˹ѡ ¡ÒÃà¾ÔÁ¤ÇÒÁ¿µ â´ÂÁյǪÕÇ´·Õè (2) é í è Ñ éÑÊÒÁÒöàË繤ÇÒÁ¡ŒÒÇ˹ŒÒ䴌 ઋ¹ ¹éÒ˹ѡ·ÕŴŧ àÇÅÒ㹡ÒÃÇÔ§·Õʹŧ ໚¹µŒ¹ Ëҡ໚¹ä»ä´Œ¤Çà í è è è éÑÁÕ໇ÒËÁÒ·ժ´à¨¹Ç‹Ò¨Ø´ÁاËÁÒÂãˌ¶§µÑǪÕǴઋ¹äà à·Õº¡Ñº¤¹ã¹¡ÅØÁà´ÕÂǡѹ ÍÂÙã¹ÃдѺ¤ÇÒÁ è Ñ ‹ Ö éÑ ‹ ‹¿µã´ ʋǹ໇ÒËÁÒÂÃÐÂÐÂÒÇ ÍҨ໚¹ÃдѺ¹éÒµÒÅáÅÐä¢Áѹã¹àÅ×Í´ ໚¹µŒ¹ «Ö§áÊ´§ãˌàËç¹ä´Œ¶§ í è Ö¤ÇÒÁàÊÕ§µ‹ÍâäàÃ×ÍÃѧ·ÕŴŧ ã¹·Ò§»¯ÔºµÔ ¡ç¤Í ãˌÍÍ¡¡íÒÅѧ¡ÒÂã´¡ç䴌·¤¹æ¹Ñ¹ÊÒÁÒö·íÒ䴌 è é è Ñ × Õè éÊÁèÒàÊÁÍ â´Â੾ÒÐÍ‹ҧÂÔ§ËÒ¡ÁÕ¤ÊÁÃÊ ËÃ×Íà¾×͹½Ù§ÍÍ¡¡íÒÅѧ¡ÒÂËÇÁ¡Ñ¹ ઋ¹ àŋ¹¡Íŏ¿ àŋ¹ í è ً èà·¹¹ÔÊ ÏÅÏ à»š¹µŒ¹ à¾ÃÒоºÇ‹Ò¡ÒÃÍÍ¡¡íÒÅѧ¡Ò´ŒÇ¡ѹ¡Ñº¡ÅØÁ¤¹·Õè¡ ¾ºÇ‹Ò¨Ð·íÒãˌÁ¡Òà ‹ è ٌ Ñ ÕÍÍ¡¡íÒÅѧ¡ÒÂ䴌µÍà¹×ͧÂÒǹҹ¡Ç‹Ò¡ÒÃÍÍ¡¡íÒÅѧ¡Ò¤¹à´ÕÂÇ ‹ è (2) Í‹ҧäáçµÒÁ ËҡᾷµŒÍ§¡Ò÷Õè¨Ðá¹Ð¹íÒ¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂãˌ໚¹Ê‹Ç¹Ë¹Ö觢ͧ¡ÒÃʋ§àÊÃÔÁÊØ¢ÀÒ¾ËÃ×Í¡ÒÃÃÑ¡ÉÒ á¾·Â¤ÇÃÁÕ¤ÇÒÁÃÙà¡ÕÂǡѺÇÔ¸¡ÒÃÍÍ¡¡íÒÅѧ¡Ò·ÕÊÒÁÒö·íÒ䴌§ÒÂã¹ Œ è Õ è ‹¤¹·ÑÇä» ÃÇÁ·Ñ§ÃÒÂÅÐàÍÕ´·Õ¨Ò໚¹à¾×Í»‡Í§¡Ñ¹¤ÇÒÁàÊÕ§µ‹Í¡ÒúҴà¨çºËÃ×ÍÍѹµÃÒ¨ҡ¡ÒÃÍÍ¡ è é èí è è¡íÒÅѧ¡ÒÂ¹Ñ¹æ «Ö§áÁŒÇÒ Jonas 䴌á¹Ð¹íÒÃÒÂÅÐàÍÕ´¢Í§ÇÔ¸¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂänj¾ÍÊѧࢻ 4 ÇÔ¸Õ ä´Œá¡‹ é è ‹ Õ¡ÒÃà´Ô¹ ¡ÒÃÇÔ§ ¡Òû˜¹¨Ñ¡ÃÂÒ¹ áÅСÒÃNjÒ¹éÒ ¨Ð¾ºÇ‹ÒµíÒÃÒàŋÁ¹Õ«§¶×Í䴌ÇÒ໚¹µíÒÃÒ¾×¹°Ò¹ è › í (3) é Öè ‹ é·Ò§á¾·Âã¹á§‹¢Í§¤íÒá¹Ð¹íÒ㹡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂãˌ¡Ñº¼ÙŒ»†Ç·Õè·Ñ¹ÊÁÑ ᵋÂѧ¢Ò´¢ŒÍÁÙÅ·Õè¨íÒ໚¹ÍÕ¡ËÅÒ»ÃСÒë֧ªÕãˌàËç¹Ç‹ÒàÃ×ͧ¡Ò÷ըÐãˌᾷ·Çä»á¹Ð¹íÒ¡ÒÃÍÍ¡¡íÒÅѧ¡Ò·ÕàËÁÒÐÊÁãˌ¡º è é è è Ñè è ѼٻÇ Âѧ¤§µŒÍ§ÁÕ¡ÒÃÃǺÃÇÁͧ¤¤ÇÒÁÃÙ·¨Ò໚¹ ÊíÒËÃѺµíÒÃÒ¾×¹°Ò¹à¡ÕÂǡѺ¡ÒÃÍÍ¡¡íÒÅѧ¡Ò Œ † Œ Õè í é èÊíÒËÃѺᾷà¾ÔÁàµÔÁ ·ÕÊҤѭÂÔ§¡Ç‹Ò¹Ñ¹¤Ç÷ըÐÁÕµÒÃÒ«Ö§ÃǺÃÇÁÃÒÂÅÐàÍÕ´·ÕàËÁÒÐÊÁà¡ÕÂǡѺ¡Òà è èí è é è í è è èÍÍ¡¡íÒÅѧ¡ÒÂÊíÒËÃѺ¤¹·ÑÇä»·ÕÊÒÁÒö͋ҹáÅйíÒ¤ÇÒÁÃÙ¹¹ä»ãªŒ»¯Ôºµä´Œ â´Â»ÃÖ¡ÉҡѺᾷ è è Œ Ñé Ñ Ôà¾Õ§»˜­ËÒ·Õ«º«ŒÍ¹à·‹Ò¹Ñ¹ è Ñ é ã¹àÃ×ͧ¢Í§ÇÔ¸¡ÒÃÍÍ¡¡íÒÅѧ¡Ò ¡ÒÃÇԧ໚¹ÇÔ¸¾¹°Ò¹·Õ·¡¤¹¤Ç÷ըÐÁÕ¤ÇÒÁÃÙà¾ÃÒÐÊÒÁÒö è Õ è Õ ×é è Ø è Œ»¯Ôºµä´Œ§ÒÂà¹×ͧ¨Ò¡ãªŒÍ»¡Ã³à¾Õ§Ãͧ෌ÒÇÔ§ ÊÒÁÒöËÒʶҹ·ÕÍÍ¡¡íÒÅѧ¡ÒÂ䴌ÁÒ¡ÁÒ ÁÕ¤ÇÒÁ Ñ Ô ‹ è Ø è è˹ѡ·Õ¨Ð㪌àÇÅÒÍÍ¡¡íÒÅѧ¡ÒÂäÁ‹¹Ò¹¹Ñ¡¡ç¨Ð䴌»ÃÐ⪹¡ºÊØ¢ÀÒ¾ ¡ÒÃÇÔ§ÁÕ¢Í䴌à»ÃÕºàÁ×Íà·Õº è Ñ è Œ è¡Ñº¡ÒÃà´Ô¹ ¤×Í ÊÒÁÒö㪌¾Åѧ§Ò¹ä´ŒÁÒ¡¡Ç‹Òã¹àÇÅÒ·Õè෋ҡѹ à·Õº¡Ñº¡Òû˜›¹¨Ñ¡ÃÂÒ¹áÅСÒÃNjÒ¹éÒ ¤×Í ÁÕáç¡ÃÐá·¡«Ö§ª‹ÇÂàÊÃÔÁÊÌҧÁÇÅ¡Ãд١ »‡Í§¡Ñ¹¡Ãд١¾Ãع ÃÇÁ·Ñ§ã¹·Ò§ÊÃÕÃÇÔ·ÂÒ í è é»ÃÐÊÔ·¸ÔÀÒ¾¢Í§¡ÒÃÇԧ㹤¹·Ø¡¤¹ã¡ÅŒà¤Õ§¡Ñ¹ ᵋ»ÃÐÊÔ·¸ÔÀҾ㹡ÒÃNjÒ¹éÒµ‹Ò§¡Ñ¹ÁÒ¡ ËÁÒ¤ÇÒÁ è íÇ‹Ò ¡ÒÃNjÒ¹éÒ·Õ㪌¾Åѧ§Ò¹à·‹Ò¡Ñ¹ÍҨ䴌ÃÐÂзҧ·ÕµÒ§¡Ñ¹ÁÒ¡ à¹×ͧ¨Ò¡¤¹·ÕÇÒ¹éÒâ´Âà·¤¹Ô¤¡Òà í è è ‹ (4) è è‹ íNjÒ¹éíÒ·ÕèäÁ‹´Õ ઋ¹ ÈÕÃÉоŒ¹¹éíÒÁÒ¡à¡Ô¹ä» ËÃ×ÍNjÒ¹éíÒáŌǵÑÇʋÒÂä»ÁÒ¨Ðà˹×èÍÂàÃçÇ ·íÒãˌ
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  • 46 Applied Physiology for Quality of Life500 äÁŏ(8) â´Â·ÑèÇä»ã¹¹Ñ¡ÇÔ觷ÕèÍÍ¡¡íÒÅѧ¡Ò´ŒÇ¡ÒÃÇÔè§ ¢Ñé¹µèíÒ·Õè 30 ¹Ò·Õµ‹ÍÇѹ ÊÑ»´ÒˏÅÐ3 ¤ÃÑé§ Ëҡ㪌Ãͧ෌ÒÇÔè§à¾Õ§¤Ù‹à´ÕÂÇ ¤ÇÃà»ÅÕè¹Ãͧ෌ÒÍ‹ҧ¹ŒÍ»‚ÅÐ 1 ¤ÃÑé§ ËÒ¡ÇÔè§ÁÒ¡¡Ç‹Ò¹Õé¡çµŒÍ§à»ÅÕè¹Ãͧ෌ÒÇÔè§àÃçÇ¢Öé¹µÒÁÊѴʋǹ´Ñ§¡Å‹ÒÇ ËÒ¡´ÙÃÒÂÅÐàÍÕ´à¡ÕÂǡѺʶҹ·Õǧ ¾×¹¼ÔÇ·Õǧ ·Õ¹ÂÁã¹·Ò§»¯Ôºµ¢Í§¤¹·ÑÇ令§ÁÕ àª‹¹ è è Ôè é è Ôè è Ô Ñ Ô èµÒÁÊǹÊÒ¸ÒóÐËÃ×Ͷ¹¹Ë¹·Ò§µ‹Ò§æ ¡ÑºÇÔ§º¹ÅÙǧÊÒ¾ҹã¹Ê¶Ò¹·ÕÍÍ¡¡íÒÅѧ¡Ò ¹‹Òʹã¨Ç‹Ò è ‹ Ôè è¡ÒÃÇÔ§·Ñ§ÊͧÃٻẺÁÕ¼Åᵡµ‹Ò§¡Ñ¹ºŒÒ§Í‹ҧäà ËÒ¡Áͧã¹á§‹¢Í§¤ÇÒÁ»ÅÍ´ÀÑÂáÅФÇÒÁàÊÕ§µÑÇ è é è¡ÒúҴà¨çº ¡ÒÃÇÔ§º¹ÅÙǧÊÒ¾ҹ¹Ñ¹¤§¨Ð»ÅÍ´ÀÑÂ¡Ç‹Ò áµ‹¡Á¢Í¨íҡѴ㹡Ò÷ըÐËÒÅÙǧ㪌㹡ÒÃ è ‹ Ôè é ç Õ Œ è ‹ èÔÍÍ¡¡íÒÅѧ¡Ò·ÕÂÒ¡¡Ç‹Ò ã¹·Ò§ÊÃÕÃÇÔ·ÂÒ ÁÕ¤ÇÒÁᵡµ‹Ò§¡Ñ¹ã¹¡Ã³Õ¢Í§¡ÒÃà¾ÔÁ»ÃÐÊÔ·¸ÔÀÒ¾¡íÒÅѧ è è¢Òà¾×Í㪌㹡ÒÃàŋ¹¡ÕÌÒ â´Â»¡µÔ¹¡¡ÕÌÒËÅÒ»ÃÐàÀ··ÕµÍ§¡ÒÃà¾ÔÁ¡íÒÅѧ¢Ò㹡ÒÃÇÔ§àÃçÇËÃ×Í¡ÃÐâ´´ è Ñ è Œ è è¨ÐÍÒÈÑ¡Òýƒ¡«ŒÍÁâ´Â¡ÒÃÇÔ§¢Ö¹à¢Ò «Ö§äÁ‹Á¼ÅàÊÕµ‹ÍËҧ¡ÒÂà¹×ͧ¨Ò¡¡Ò÷íÒ§Ò¹¢Í§¡ÅŒÒÁà¹×Í໚¹ è é è Õ è é¡ÒÃË´µÑÇẺ concentric contraction ᵋËÒ¡µŒÍ§ÁÕ¡ÒÃÇԧŧà¢Ò´ŒÇ 㹪‹Ç§¹Õ¡Ò÷íÒ§Ò¹¢Í§¡ÅŒÒÁ è éà¹×éÍ໚¹¡ÒÃË´µÑÇẺ eccentric contraction «Ö觡‹Íãˌà¡Ô´¤ÇÒÁàÊÕ觵‹Í¡ÒúҴà¨çº(9) ᵋËÒ¡»ÃÐÂØ¡µ¡Òýƒ¡¡ÅŒÒÁà¹×Í¢Òâ´ÂÇÔ¸Õ¡ÒÃÇÔ觺¹ÅًÇÔè§ã¹ÅѡɳлÃѺ¤ÇÒÁªÑ¹¢Í§ÅًÇÔè§ãˌàËÁ×͹¡Ñº é¡ÒÃÇÔ§¢Ö¹à¢Ò ᵋäÁ‹ÁšɳСÒÃÇԧŧà¢Ò ÊÒÁÒö㪌໚¹½ƒ¡à¾ÔÁ¾Åѧ¢Í§¡ÅŒÒÁà¹×Í¢Ò䴌Í‹ҧ è é Õ Ñ è è éÁÒ¡ â´Â»ÃÒȨҡ¤ÇÒÁàÊÕ§µ‹Í¡ÒúҴà¨çº¨Ò¡¡ÒÃÇԧŧà¢Ò«Ö§à»š¹¡ÒÃË´µÑǡŌÒÁà¹×ÍẺ (10) è è è éeccentric contraction ·Õ¡µÑÇÍ‹ҧÁÒ¤‹Í¹¢ŒÒ§ÂÒǷѧËÁ´à»š¹àÃ×ͧ¤ÇÒÁÃÙ¾¹°Ò¹ã¹¡ÒÃãˌ¤Òá¹Ð¹íÒ¡ÒÃÇÔ§ ËÒ¡ è é è Œ ×é í 軘¨¨ÑÂã¹´ŒÒ¹·Ø¹·ÃѾäÁ‹à»š¹·Õ¨Ò¡Ñ´áÅŒÇ ¼Ùà¢Õ¹ÍÂÒ¡¨Ðá¹Ð¹íÒàÃ×ͧ¡ÒÃàŋ¹¡Íŏ¿ãˌ·¡¤¹ä´Œ·ÃÒº èí Œ è ض֧»ÃÐ⪹änjàÅ硹ŒÍ à¾ÃÒÐ໚¹¡ÕÌÒ·ÕÊÒÁÒöàŋ¹ä´Œ¨¹¶Ö§ÇÑ 70 »‚໚¹Í‹ҧ¹ŒÍ ·ÕÊҤѭ㪌¡Òà è èíà´Ô¹«Ö§äÁ‹ãªŒ¾Åѧ§Ò¹ÁÒ¡ã¹àÇÅÒÍѹÊѹᵋ¡ãˌà¡Ô´»ÃÐ⪹¡ºÊØ¢ÀÒ¾äÁ‹¹Í¡NjҡÒÃÍÍ¡¡íÒÅѧ¡Ò è é ç Ñ ŒÍ×¹æ ËÃ×ͨÐÁÒ¡¡Ç‹Ò´ŒÇ«éÒä»à¹×ͧ¨Ò¡¡ÒÃà´Ô¹ÍÍ¡Ãͺ¡Íŏ¿ 18 ËÅØÁ㪌àÇÅÒ»ÃÐÁÒ³ 4 ªÑÇâÁ§ è í è èᵋµÍ§à´Ô¹äÁ‹ãª‹¹§Ã¶¡Íŏ¿¨Ö§¨Ð䴌»ÃÐ⪹ ·ÕÊҤѭ㪌໚¹¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂ䴌ÊÒËÃѺ·Ø¡¤¹ ã¹ Œ Ñè èí í¹Ñ¡¡Íŏ¿ÊÙ§ÍÒÂØ·ÍÒÂØà¡Ô¹ 60 »‚·§¡ÅØÁ·ÕÊ¢ÀÒ¾´ÕáÅСÅØÁ·Õà¤ÂÁÕ»ÃÐÇÑµÔ myocardial infarction ·ÕÁÕ Õè Ñé ‹ è Ø ‹ è èÍÒ¡Ò䧵ÑÇáŌÇà¡Ô¹ 3 à´×͹àÁ×ÍãˌÍÍ¡¡íÒÅѧ¡ÒÂâ´Â¡ÒõաÍŏ¿áŌÇà¡çº¼Å¤Å׹俿‡ÒËÑÇ㨠µ‹Íà¹×ͧ è è èÍÕ¡ 24 ªÑÇâÁ§ ¨Ð¤Å׹俿‡ÒËÑÇ㨷ռ´»¡µÔ㹪‹Ç§µÕ¡Íŏ¿ ¹ŒÍ¡NjҪ‹Ç§·Õ·Ò¡Ô¨¡ÃÃÁÍ׹梳е׹¹Í¹ è è è Ô è í è è«Öè§Í¸ÔºÒÂä´ŒÇ‹Ò ¡ÒõաÍŏ¿ãªŒ¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂâ´Â¡ÒÃà´Ô¹à»š¹ËÅÑ¡¨ÐÁÕ¡ÒÃ㪌¾Åѧ§Ò¹µèíÒÃÒÇ3 METs (metabolic equivalent) ᵋ㹢³Ð·íÒ¡Ô¨¡ÃÃÁÍ×¹ºÒ§¤ÃѧÍÒ¨µŒÍ§ãªŒ¾Åѧ§Ò¹ÁÒ¡¡Ç‹Ò¹Õ¨§ è é éÖ¾º¤Å׹俿‡ÒËÑÇ㨷ռ´»¡µÔÁÒ¡¡Ç‹Ò ¨ÐàËç¹ä´ŒÇÒ¡ÒÃàŋ¹¡Íŏ¿¹Ñ¹ÁÕ¤ÇÒÁàÊÕ§µ‹ÍâäËÑÇ㨵èÒ¡Ç‹Ò è è Ô ‹ é è í¡Ò÷íÒ¡Ô¨¡ÃÃÁÍ×¹æáÅÐ໚¹¡Ô¨¡ÃÃÁ¡ÒÃÍÍ¡¡íÒÅѧ¡Ò·շÒ䴌㹼ÙʧÍÒÂØÁÒ¡æ è è í ŒÙ ¨Ò¡µÑÇÍ‹ҧ·Õ¡Å‹ÒÇÁÒã¹µÑÇÍ‹ҧ¢ŒÒ§µŒ¹ ¨ÐàËç¹ä´ŒÇÒ¡ÒûÃÐÂØ¡µ¤ÇÒÁÃÙ·Ò§ÊÃÕÃÇÔ·ÂÒà¾×Í è ‹ Œ è㪌͸ԺÒ¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂãˌàËÁÒÐÊÁÁÕÁÒ¡ÁÒ ᵋ¤ÇÒÁÃÙàªÔ§»ÃÐÂØ¡µÊǹ·ÕÊҤѭ·ÕÁÍÂÙÁҡ໚¹ Œ ‹ èí è Õ ‹·Õ蹋ÒàÊÕ´ÒÂNjÒÍÂًà¾Õ§ã¹ÃдѺ¢Í§§Ò¹ÇԨѠâ´ÂäÁ‹ä´ŒÁռٌ·Õè¨ÐÊ×èÍͧ¤¤ÇÒÁÃٌàËŋҹÕéÁÒ¶‹Ò·ʹãˌ»ÃЪҪ¹·ÑÇä»ä´Œ·ÃÒºáÅÐã¹ä»»¯Ôºµä´Œ «Ö§áÁŒáµ‹¢ÍÁÙŵÑÇÍ‹ҧ·Õ¡ÁҷѧËÁ´ ˹ѧÊ×Í·ÕÍÒ¨¶×Í è Ñ Ô è Œ è é è䴌NjÒ໚¹µíÒÃÒÊíÒËÃѺᾷ·Õè¨Ðá¹Ð¹íÒ¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂãˌ¡Ñº»ÃЪҪ¹ÂѧäÁ‹ÁÕà¹×éÍËÒàËŋҹÕéÍÂً
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 47¤§¨ÐµŒÍ§Ã͡ѹÍÕ¡µ‹Íä»Ç‹ÒàÁ×ÍäèÐÁÕͧ¤¡Ã·Õ¨Ð·íÒ˹ŒÒ·ÕÃǺÃÇÁ¤ÇÒÁÃÙàËŋҹÕà¼Âá¾Ã‹Ê»ÃЪҪ¹ è è è Œ é ًà¾×èÍ¡Ãе،¹ãˌ»ÃЪҪ¹Ê¹ã¨¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂâ´Â¶ŒÇ¹Ë¹ŒÒ áÅÐÁÕÊØ¢ÀÒ¾·Õè´Õ¢Ö鹨ҡ¼Å¢Í§¡ÒÃÍÍ¡¡íÒÅѧ¡Ò·ÕàËÁÒÐÊÁ èàÍ¡ÊÒÃ͌ҧÍÔ§1. Jonas S. Introduction: What this book is about. In: Jonas S, Phillips EM, editors. ACSM’s exercise is medicineTM A Clinician’s guide to exercise prescription. Philadelphia (PA): Lippincott Williams & Wilkins; 2009. p. 1-122. Skinner JS. In: Exercise adherence and prescription for special populations. In: Skinner JS, editor. Exercise testing and exercise prescription for special cases. theoretical basis and clinical application. (3rd ed.) Philadelphia (PA): Lippincott Williams & Wilkins; 2005. p. 124-1333. Jonas S. Technique and equipment. In: Jonas S, Phillips EM, editors. ACSM’s exercise is medicineTM A Clinician’s guide to exercise prescription. Philadelphia (PA): Lippincott Williams & Wilkins; 2009. p. 181-1944. McArdle WD, Katch .I, Katch VL. In: Energy expenditure during walking, jogging, running, and swimming. In: McArdle WD, Katch .I, Katch VL., editors. Exercise physiology. energy, nutrition, & human performance. (6th ed.) Baltimore (MD): Lippincott Williams & Wilkins; 2007. p. 209-228.5. Miller DI. Ground Reaction .orce in Distance Running. In Cavanagh PR, editor. Biomechanics of Distance Running. Champaign (IL): Human Kinetics; 1990. p. 203-224.6. Anderson DD, Adams DJ, Hale JE. Mechanical effects of force acting on bone, cartilage, ligaments, and tendons. In Nigg BM, Macintosh BR, Mester J, editors. Biomechanics and Biology of movement. Champaign (IL): Human Kinetics; 2000. p. 283-306.7. Lafortune MA, Valient GA, McLean, B. In: Biomechanics of running. In: Hawley JA, editor. Running. Oxford: Blackwell Science; 2000. p. 28-43.8. Verdejo R, Mills NJ. Heel-shoe interactions and the durability of EVA foam running-shoe midsoles. J Biomech 2004;37:1379-1386.9. McArdle WD, Katch .I, Katch VL. In: Muscle strength: training muscles to become stronger. In: McArdle WD, Katch .I, Katch VL., editors. Exercise physiology. energy, nutrition, & human performance. (6th ed.) Baltimore (MD): Lippincott Williams & Wilkins; 2007. p. 509-553.10. Swanson SC, Caldwell GE. An integrated biomechanical analysis of high speed incline and level treadmill running. Med Sci Sports Exerc 2000;32:1146-1155.11. Underdorben M, Kolb M, Bauer I, Baurer U, Brune M, Bener K, et al. Cardiovascular load of competitive golf in cardiac patient and healthy controls. Med Sci Sports Exerc 2000;32:1674-1678.
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 49 7Unrecognized Medical Problems in Elderly : Geriatric Depression Sookjaroen Tangwongchai Department of Psychiatry , .aculty of Medicine, Chulalongkorn University Geriatric Depression is common and can have serious consequences; includingdisability,diminished quality of life, burden for caregiver, increased mortality and health serviceutility. Due to the physical comorbidity and atypical feature of depressive symptoms, half of thedepressed elderly were unrecognized and undertreated. Objective: Review the epidemiology of geriatric depression, clinical feature and diagnosis and treatment available from evidence-based data. Materials and methods: Literature review was performed to obtained for evidence-based information for geriatric depression and management. Results: Clinically significant geriatric depression was present in 11-30% of elderlyreported from western countries, and 12.78-31.6% from Thailand. The prevalence increasedwith age and was more frequent in female. Depression of late onset (age above 65 years old)usually occurred in the context of medical illness and had higher rate of cognitive impairment,and was associated with cerebrovascular abnormalities. Loss and humiliation were foundto be critical precipitating stressful life events. Anxiety, somatic complaints, memory loss,insomnia may be the most prominent presenting symptoms. Psychosis and suicide was frequentlyreported in geriatric depression. Diagnosis required careful psychiatric and medical historytaking, physical and mental status evaluation; including neurologic and cognitive assessmentto differentiate with normal and complicated grief, MCI and dementia. Depressed elderly often overused health services. The management should focus onnonpharmacological intervention, counseling, psychotherapy and support group, and prescriptionof antidepressants. SSRIs were the first-line agents for better tolerability and less drug interaction.
  • 50 Unrecognized medical problems in elderly : Geriatric depression Conclusion: Geriatric depression is highly prevalent and unrecognized. Somaticcomplaints medical comorbidity and cognitive impairment may mark depressive symptoms.Management should include biopsychosocial intervention for resolution of symptoms, preventionfor relapse and recurrent, and improvement of functional capacity.
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 51 8 Delirium: An Unrecognized Medical Problem in Older Patients ¼ÙŒª‹ÇÂÈÒʵÃÒ¨ÒϹÒÂᾷÃ؋§¹ÔÃѹ´Ã »ÃдÔÉ°ÊØÇÃó ÀÒ¤ÇÔªÒÍÒÂØÃÈÒʵÏ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÔÔ ÀÒÇЫÖÁ ÊѺʹà©Õº¾Åѹ (delirium) ໚¹»˜­ËÒ·Õ辺º‹ÍÂã¹àǪ»¯ÔºÑµÔà¡ÕèÂǡѺ¼ÙŒÊÙ§ÍÒÂØâ´Â¾ºÇ‹Ò ÌÍÂÅÐ 10-15 ¢Í§¼ÙʧÍÒÂØ ¶Ù¡ÃѺänjáÉÒã¹ËͼٻÇÂÍÒÂØáÃÃÁà¹×ͧ¨Ò¡ÁÕÀÒÇйÕé áÅÐ ŒÙ Ñ Œ † è¼Ù»ÇÂÊÙ§ÍÒÂاÁÕâÍ¡ÒÊà¡Ô´ delirium ã¹¢³Ð·ÕÍÂÙã¹âç¾ÂÒºÒÅÍաÌÍÂÅÐ 15-25 (1,2) ¼Ù»Ç·ÕÁÕ delirium Œ † Ñ è ‹ Œ † èÁÕ͵ÃÒµÒÂÊÙ§¢Ö¹ÁÒ¡ µŒÍ§ÃÑ¡ÉÒµÑÇã¹âç¾ÂÒºÒŹҹ¢Ö¹ áÅÐÊÔ¹à»Å×ͧ¤‹ÒÃÑ¡ÉÒ¾ÂÒºÒÅÁÒ¡¢Ö¹ Ñ é é é é¹Í¡¨Ò¡¹Ñ¹Âѧ·íÒãˌà¡Ô´¤ÇÒÁ¾Ô¡ÒÃáÅЪ‹Çµ¹àͧ䴌¹ÍÂŧ (functional decline) (3-4) áÅÐáÁŒ¨Ò˹‹ÒÂ é Œ íÍÍ¡¨Ò¡âç¾ÂÒºÒÅä»áÅŒÇ ¼Ù»ÇÂàËŋҹÕ§ÁÕ¡ÒÃàÊ×ÍÁÊÁÃöÀÒ¾¢Í§ÊÁͧ (cognitive impairment) Œ † é Ñ èÁÕ¤ÇÒÁ¾Ô¡Òà áÅÐÁÕ͵ÃÒ¡ÒÃàÊÕªÕǵ㹠1 »‚ááÊÙ§¡Ç‹Ò¼Ù»ÇÂÊÙ§ÍÒÂØ·Çä» (5-6 Í‹ҧäáçµÒÁÂѧÁÕᾷ Ñ Ô Œ † Ñè¨íҹǹäÁ‹¹Í·վÅÒ´¡ÒÃÇÔ¹¨©ÑÂÀÒÇйÕé ´Ñ§¹Ñ¹ º·¤ÇÒÁ¹Õ¨Ð์¹àÃ×ͧ¡ÒÃÇÔ¹¨©Ñ ¡ÒÃÃÑ¡ÉÒÀÒÇÐ Œ è Ô (1) é é è Ôdelirium ãˌ¶¡µŒÍ§ÃÇ´àÃçÇ ÃÇÁ·Ñ§á¹Ç·Ò§¡Òû‡Í§¡Ñ¹ÁÔãˌ¼»ÇÂÊÙ§ÍÒÂطúänjã¹âç¾ÂÒºÒÅà¡Ô´ÀÒÇйÕé Ù é ٌ † Õè ѤíÒ¨íÒ¡Ñ´¤ÇÒÁ ÀÒÇЫÖÁ ÊѺʹà©Õº¾Åѹ ËÃ×Í delirium ¤×ͤÇÒÁ¼Ô´»¡µÔ¢Í§Ë¹ŒÒ·ÕÊÁͧËÅÒ´ŒÒ¹ (global ècognitive impairment) «Ö§ÁÑ¡à¡Ô´¨Ò¡ÊÒà˵طҧ¡Ò (organic cause) ÍÒ¡ÒÃà¡Ô´¢Ö¹Í‹ҧÃÇ´àÃçÇ è é(acute onset) áÅÐ໚¹ÍÂÙã¹ÃÐÂÐàÇÅÒÊѹ (short duration) â´ÂÁÕÍÒ¡ÒÃഋ¹ ¤×Í ¢Ò´¤ÇÒÁãʋ㨠‹ é(inattention), ¤ÇÒÁ¤Ô´äÁ‹»ÐµÔ´»Ðµ‹Í (disorganized thinking) áÅÐÃдѺ¤ÇÒÁÃÙÊ¡µÑÇŴŧ (alteration ŒÖof consciousness level) (7)ÍÒ¡ÒÃáÅÐÍÒ¡ÒÃáÊ´§ ¼ÙŒ»†Ç·ÕèÁÕ delirium ¨Ðà¡Ô´ÍÒ¡ÒüԴ»¡µÔ¢Í§ÊÁÃöÀÒ¾ÊÁͧã¹ÃÐÂÐàÇÅÒÃÇ´àÃçÇ â´Â·ÑÇ仨ÐÁÕ»ÃÐÇѵʹ¡Ç‹Ò 2 ÊÑ»´Òˏ (8) áÅФÇÒÁÃعáç¢Í§ÍÒ¡ÒèÐᵡµ‹Ò§¡Ñ¹ä´Œã¹Ãͺ 24 ªÑÇâÁ§ è Ô Ñé è(fluctuation of symptoms) â´Â¼Ù»ÇÂÁÑ¡ÁÕÍÒ¡ÒÃÁÒ¡ã¹àÇÅÒ¡ÅÒ§¤×¹ ᵋÍÒ¨´Õ¢¹ã¹ª‹Ç§¡ÅÒ§Çѹ Œ † ÖéÍÒ¡ÒÃÊíҤѭ·ÕªÇÂÇÔ¹¨©ÑÂÀÒÇйÕé ¤×Í ¤ÇÒÁãʋ㨠(attention) ¢Í§¼Ù»ÇÂŴŧ ¶Ù¡Ãº¡Ç¹ÊÁÒ¸Ô䴌§ÒÂ è ‹ Ô Œ † ‹äÁ‹ÊÒÁÒöʹ·¹Òµ‹Íà¹×ͧ áÅФÇÒÁ¤Ô´ÊѺʹ äÁ‹»ÐµÔ´»Ðµ‹Í (disorganized thinking) ¼Ù»ÇÂÊÙ§ÍÒÂØ è Œ †ÃÒÇ˹֧ã¹ÊÕ¨ÐÁÕÃдѺ¤ÇÒÁÃÙÊ¡µÑÇŴŧ ËÃ×Í«ÖÁËÅѺ «Ö§àÃÕÂ¡Ç‹Ò hypoalert-hypoactive delirium è è ŒÖ è
  • 52 Delirium: An Unrecognized Medical Problem in Older Patients·íÒãˌǹ¨©ÑÂÀÒÇйÕ䴌ÂÒ¡ ã¹¢³Ð·Õ¼»ÇÂÊÙ§ÍÒÂØ͡˹֧ã¹ÊÕÍÒ¨àÍÐÍСŒÒÇÌÒÇ ¡ÃÐǹ¡ÃÐÇÒ ´Ö§ÊÒÂ Ô Ô é è ٌ † Õ è è¹éÒà¡Å×Í »‚¹Å§¨Ò¡àµÕ§ «Ö§àÃÕÂ¡Ç‹Ò hyperalert-hyperactive delirium ʋǹ¼Ù»Ç·ÕàËÅ×ÍÍÒ¨ÁÕšɳзѧ í è Œ † è Ñ é2 Í‹ҧËÇÁ¡Ñ¹ (mixed type) (9,10) ¹Í¡¨Ò¡¹Ñ¹¼Ù»ÇÂÍÒ¨ÁÕÍÒ¡ÒüԴ»¡µÔ¢Í§ÊÁÃöÀÒ¾ÊÁͧ´ŒÒ¹ é Œ †Í×¹ ઋ¹ ¡ÒÃ㪌ÀÒÉÒ ¡ÒÃÃѺÃٌ áÅФÇÒÁ¨íÒ ·íÒãˌʺʹ äÁ‹ÃàÇÅÒ Ê¶Ò¹·ÕáÅкؤ¤Å (disorientation) è Ñ ÙŒ è¼ÙŒ»†ÇºҧÃÒÂÍÒ¨ÁÕ»ÃÐÊÒ·ËÅ͹ (hallucination) «Öè§Áѡ໚¹ª¹Ô´àËç¹ÀÒ¾ËÅ͹ ÁÒ¡¡Ç‹ÒËÙáNjÇËÃ×ͺҧÃÒÂÍÒ¨ÁÕÍÒ¡ÒÃËÇÒ´ÃÐáǧ ¹Í¡¨Ò¡¹Ñ¹¼Ù»ÇÂÁÑ¡ÁÕ¤ÇÒÁ¼Ô´»Ã¡µÔ¢Í§¡ÒÃËÅѺ-µ×¹ (sleep- é Œ † èwake cycle) â´Â«ÖÁËÅѺ㹪‹Ç§¡ÅÒ§Çѹ ᵋÁÍÒ¡Òù͹äÁ‹ËÅѺ ¡ÃÐǹ¡ÃÐÇÒ ÊѺʹ µÍ¹¡ÅÒ§¤×¹ Õ¡ÒÃÇÔ¹Ô¨©Ñ ÊÁÒ¤Á¨Ôµá¾·ÂÍàÁÃÔ¡¹ä´Œ¡Ò˹´à¡³±¡ÒÃÇÔ¹¨©ÑÂÀÒÇÐ delirium ·Ò§¤ÅÔ¹¡ (diagnostic Ñ í Ô Ôcriteria for delirium ËÃ×Í DSM-IV) ã¹ ¤È. 1994 ´Ñ§µÒÃÒ§·Õè 1 (11)µÒÃÒ§·Õè 1 Diagnostic criteria for delirium (DSM-IV criteria)1. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) withreduced ability to focus, sustain, or shift attention.2. A change in cognition (such as memory deficit, disorientation, language disturbance) or thedevelopment of a perceptual disturbance that is not better accounted for by a preexisting,established, or evolving dementia.3. The disturbance develops over a short period of time (usually hours to days) and tends tofluctuate during the course of the day.4. There is evidence form the history, physical examination, or laboratory findings that thedisturbance is caused by the direct physiologic consequences of a general medical condition.´Ñ´á»Å§¨Ò¡ American Psychiatric Association (11) Inouye áÅФ³Ð 䴌ȡÉÒÍÒ¡Ò÷ҧ¤ÅÔ¹¡¢Í§¼Ù»Ç delirium áÅÐàʹÍࡳ±¡ÒÃÇÔ¹¨©ÑÂ Ö Ô Œ † Ô·ÕàÃÕÂ¡Ç‹Ò Confusion Assessment Method (CAM) «Ö§´Ñ´á»Å§¨Ò¡à¡³±¡ÒÃÇÔ¹¨©Ñ¢ͧÊÁÒ¤Á¨Ôµ è è ÔᾷÍàÁÃÔ¡¹ à¾×Íᾷ·Çä»ÇÔ¹¨©ÑÂÀÒÇйÕ䴌§Ò¢ֹ áÅÐ䴌·´ÊͺáŌÇNjÒÁÕ¤ÇÒÁäÇ (sensitivity) Ñ è Ñè Ô é ‹ éáÅФÇÒÁ¨íÒà¾ÒÐ (specificity) ÊÙ§ ¤×Í ÃŒÍÂÅÐ 94-100 áÅРÌÍÂÅÐ 90-95 µÒÁÅíҴѺ (12) ´Ñ§áÊ´§ã¹µÒÃÒ§·Õè 2
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 53µÒÃÒ§·Õè 2 Confusion Assessment Method (CAM) diagnostic algorithm*1. Acute onset and fluctuating course2. Inattention3. Disorganized thinking4. Altered level of consciousness*The diagnosis of delirium by CAM requires the presence of 1 and 2 and either 3 or 4.´Ñ´á»Å§¨Ò¡ Inouye SK, et al (12)ÊÒà˵ØáÅл˜¨¨ÑÂàÊÕè§ Delirium ໚¹¡ÅØÁÍÒ¡Ò÷ÕÁ»¨¨ÑÂàÊÕ§ËÅÒ»ÃСÒÃËÇÁ¡Ñ¹ (multifactorial syndrome) ઋ¹ ‹ è Õ ˜ èà´ÕÂǡѺ»˜­ËҢͧ¼ÙŒ»†ÇÂÊÙ§ÍÒÂØ (geriatric syndromes) Í×è¹æ ·Ñ駨ҡ»˜¨¨Ñ·Õè໚¹ÊÒà˵Øà´ÔÁ«Öè§Ê‹§àÊÃÔÁãˌà¡Ô´ delirium 䴌§Ò (predisposing factors) ઋ¹ ÀÒÇÐÊÁͧàÊ×ÍÁ ¤ÇÒÁà¨çº»†Ç·ҧ¡Ò ‹ è·ÕèÃعáç ÀÒÇЫÖÁàÈÃŒÒ à»š¹µŒ¹ áÅл˜¨¨ÑÂàÊÕ觷Õè໚¹ÊÒà˵ءÃе،¹ãˌ¼ÙŒ»†ÇÂà¡Ô´ÍÒ¡Òà delirium(precipitating factors) ઋ¹ ¡Òü‹ÒµÑ´ãË­‹ ¡Òû†ÇÂ˹ѡ¨¹µŒÍ§à¢ŒÒÃÑ¡ÉÒã¹ËÍÍÀÔºÒÅ ¡ÒÃ䴌úÂÒ Ñ«Ö§ÍÍ¡Ä·¸ÔµÍÊÁͧ ËÃ×Í ¡ÒÃÍ´¹Í¹ ໚¹µŒ¹ «Ö§¤ÇÒÁàÊÕ§¢Í§¡ÒÃà¡Ô´ delirium ã¹¼Ù»ÇÂÊÙ§ÍÒÂØ è ì ‹ è è Œ †¢Ö¹¡Ñº ¤ÇÒÁÊÑÁ¾Ñ¹¸¢Í§¤ÇÒÁÃعáç¢Í§»˜¨¨ÑÂàÊÕ§·Ñ§ 2 ª¹Ô´´Ñ§¡Å‹ÒÇËÇÁ¡Ñ¹ (9) µÑÇÍ‹ҧઋ¹¼Ùʧ é è é ŒÙÍÒÂØ«§äÁ‹ÁÕ predisposing factor µŒÍ§ä´ŒÃº precipitating factor ·Õùáç ઋ¹ µÔ´àª×ÍÃعáç ËÃ×Í èÖ Ñ èØ é»†ÇÂ˹ѡ¨¹µŒÍ§ÃÑ¡ÉÒµÑÇã¹ËÍÍÀÔºÒÅ ¨Ö§¨Ðà¡Ô´ delirium ã¹·Ò§µÃ§¡Ñ¹¢ŒÒÁ ËÒ¡¼ÙŒÊÙ§ÍÒÂØÁÕpredisposing factor ÁÒ¡ÍÂÙáÅŒÇ àª‹¹ ÊÙ§ÍÒÂØÁÒ¡ ÁÕÊÁͧàÊ×ÍÁ ËÃ×ÍÁÕâä»ÃШíÒµÑÇÍÂÙËÅÒÂâä ÍÒ¨ ‹ è ‹à¡Ô´ delirium 䴌§Ò áÁŒ¨Ð䴌ú precipitating factor ·ÕäÁ‹¤ÍÂÃعáç áÅÐà¹×ͧ¨Ò¡¤ÇÒÁËÅÒ¡ËÅÒ ‹ Ñ è ‹ è¢Í§»˜¨¨ÑÂàÊÕ§àËŋҹÕé ᾷ¨§¨íÒ໚¹µŒÍ§¤Ô´¶Ö§»˜¨¨Ñµ‹Ò§ æ ·ÕÍÒ¨ÁÕÊǹà¡ÕÂÇ¢ŒÍ§ áÅФŒ¹ËÒá¡Œä¢ è Ö è ‹ è·Ø¡ÊÒà˵ط໚¹ä»ä´Œã¹¼Ù»ÇÂÃÒ¹ѹ Õè Œ † 默¨¨ÑÂà´ÔÁ·Õèʋ§àÊÃÔÁãˌà¡Ô´ delirium 䴌§‹Ò (Predisposing factors) ¨Ò¡¡ÒÃÈÖ¡ÉÒÃǺÃÇÁ¢ŒÍÁÙÅâ´Â Inouye (2,9,13) »˜¨¨ÑÂàÊÕ觫Öè§Ê‹§àÊÃÔÁãˌ¼ÙŒ»†ÇÂÊÙ§ÍÒÂØà¡Ô´delirium 䴌§ÒÂÁÕÁÒ¡ÁÒ 䴌ᡋÀÒÇÐ cognitive impairment ËÃ×ÍÊÁͧàÊ×ÍÁ (dementia) âäÊÁͧ ‹ èÍ×¹æ ઋ¹ âäËÅÍ´àÅ×Í´ÊÁͧ âä¾ÒÏ¡¹Êѹ »ÃÐÇѵà¤Â໚¹ delirium ÁÕâä»ÃШíÒµÑÇËÃ×Íâä·Ò§ è Ô Ô¡Ò«֧Ãعáç ઋ¹ âäµÔ´àª×Í, âäËÑÇã¨, âä»Í´, âäÁÐàÃç§, âäàÁµÒºÍÅÔ¤áÅе‹ÍÁäÌ·Í ໚¹µŒ¹ è é ‹¡ÒâҴ¤ÇÒÁÊÒÁÒö㹡ÒôÙáŵ¹àͧ (functional impairment) ÊÙ§ÍÒÂØÁÒ¡ (ÍÒÂØÁÒ¡¡Ç‹Ò 75 »‚)âääµÇÒÂàÃ×ÍÃѧ ÀÒÇТҴ¹éÒ ÀÒÇзØâÀª¹Ò¡Òà ÃÇÁ·Ñ§ÀÒÇТҴ¡ÒÃÃѺÃٌ (sensory deprivation) é í éઋ¹ ¼ÙʧÍÒÂØ·µÒÁÑÇËÃ×ÍËÙµ§ÁÒ¡ ¨Ðà¡Ô´ delirium 䴌§ÒÂàÁ×Ͷ١ÃѺänjã¹âç¾ÂÒºÒÅ à¹×ͧ¨Ò¡à»ÅÕ¹ ŒÙ Õè Ö ‹ è è èÊÔ§áǴŌÍÁÍ‹ҧ¡ÃзѹËѹ è
  • 54 Delirium: An Unrecognized Medical Problem in Older Patients»˜¨¨Ñ«Ö觡Ãе،¹ãˌà¡Ô´ delirium (precipitating factors) ¨Ò¡¡ÒÃÈÖ¡ÉÒÃǺÃÇÁ¢Í§ Inouye ઋ¹à´ÕÂǡѹ (2,9,14) ¾ºÇ‹Ò»˜¨¨ÑÂàÊÕ§´Ñ§¡Å‹ÒÇÁÕÁÒ¡ÁÒ èµÑÇÍ‹ҧઋ¹ ¡ÒÃ㪌ÂÒËÅÒª¹Ô´ã¹àÇÅÒà´ÕÂǡѹ ¡ÒÃÈÖ¡ÉÒ¾ºÇ‹Ò ¡ÒÃÊѧÂÒãËÁ‹ÁÒ¡¡Ç‹Ò 3 ª¹Ô´à»š¹ 軘¨¨Ñ¡Ãеعãˌà¡Ô´ delirium ¹Í¡¨Ò¡¹Ñ¹¾ºÇ‹Ò ÀÒÇÐäÁ‹à¤Å×͹·Õè (immobility) ËÃ×Í ¡ÒÃ㪌ͻ¡Ã³ Œ (14) é è غҧ»ÃÐàÀ·«Ö§·íÒãˌ¼»ÇÂà¤Å×͹·Õ䴌¹Í 䴌ᡋ ÊÒÂÊǹ»˜ÊÊÒÇÐ ËÃ×Í ¡Òü١ÁÑ´¼Ù»Ç ÀÒÇТҴ è ٌ † è è Œ Œ †¹éÒ ÀÒÇзØâÀª¹Ò¡Òà âä·Õà¡Ô´¨Ò¡ºØ¤Åҡ÷ҧ¡ÒÃᾷ (iatrogenic events) âä·Ò§Ãкº ઋ¹ í èâäµÑº âääµÇÒ âäËÑÇ㨠âäµÔ´àª×éÍ ÀÒÇмԴ»¡µÔ·Ò§àÁµÐºÍÅÔ¤ ÃÇÁ·Ñ駤ÇÒÁ¼Ô´»¡µÔ¢Í§´Øŏ¡Ã´-´‹Ò§ ¡ÒÃËÂØ´ÂÒ benzodiazepine ËÃ×ÍËÂØ´´×Á alcohol ¡Ð·Ñ¹Ëѹ ¡ÒÃà»ÅÕ¹á»Å§¢Í§ è èÊÔ§áǴŌÍÁ ઋ¹ ¡Òö١ÃѺänjã¹âç¾ÂÒºÒÅ ¡ÒÃÍ´¹Í¹ ÃÇÁ·Ñ§»˜¨¨Ñ·ҧ¨Ôµã¨ ઋ¹ ¡ÒÃÊÙ­àÊÕ è éºØ¤¤ÅÍѹ໚¹·Õá ÀÒÇЫÖÁàÈÃŒÒ ¤ÇÒÁà¨çº»Ç´ ໚¹»˜¨¨ÑÂàÊÕ§«Ö§¡Ãеعãˌ¼Ê§ÍÒÂØà¡Ô´ delirium 䴌 èÑ è è Œ ٌ ٠໚¹·ÕÂÍÁÃѺ¡Ñ¹·ÑÇä»Ç‹Ò 㹺Ãôһ˜¨¨ÑÂàÊÕ§«Ö§¡Ãеعãˌà¡Ô´ delirium ·Õ¡Å‹ÒÇÁÒáŌǷѧËÁ´ è è è è Œ è é¹Ñ¹ ¡ÒÃ㪌ÂÒ«Ö§äÁ‹àËÁÒÐÊÁÊíÒËÃѺ¼ÙʧÍÒÂØ à»š¹ÊÒà˵آͧ delirium ·Õ¾ºº‹Í·ÕÊ´ â´Â੾ÒÐ é è ŒÙ è èØ (15)ÂÒ·ÕÍÍ¡Ä·¸ÔµÍ¨Ôµ»ÃÐÊÒ· (psychoactive agents) áÅÐÂÒ·ÕÁÄ·¸Ôì anticholinergics ÊíÒËÃѺÃÒª×Í è ì ‹ è Õ èÂÒ«Ö§·íÒãˌ¼»ÇÂÊÙ§ÍÒÂØà¡Ô´ delirium 䴌 áÊ´§ã¹µÒÃÒ§·Õè 3 è ٌ †µÒÃÒ§·Õè 3 Drugs associated with deliriumSedative/hypnotics: Benzodiazepines (especially flurazepam, diazepam) BarbituratesNarcotics (especially meperidine)Anticholinergics: Antihistamines (diphenhydramine, hydroxyzine) Antiparkinsonians (benztropine, trihexyphenidyl) Antispasmodics (belladonna, loperamide) Atropine/scopolamine Heterocyclic antidepressants (amitriptyline, imipramine, doxepin) Neuroleptics (chlorpromazine, haloperidol, thioridazine)Cardiac medications: Antiarrhythmics (quindine, procainamide, lidocaine) Antihypertensives (!-blockers, methyldopa) Digitalis glycosidesGastrointestinal medications: H2 –antagonists (cimetidine, ranitidine, famotidine, nizatidine) Metoclopramide
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 55Miscellaneous Anticonvulsants Corticosteroids Levodopa Lithium Nonsteroidal anti-inflammatory drugs ¨Ò¡»˜¨¨ÑÂàÊÕ§¢Í§¡ÒÃà¡Ô´ delirium ã¹¼Ù»ÇÂÊÙ§ÍÒÂØ´§¡Å‹ÒÇ¢ŒÒ§µŒ¹ ÁÕ¼ÃǺÃÇÁÊÃػ໚¹ÊÙµÃ è Œ † Ñ ÙŒ(16) ª‹ÇÂãˌ¨Ò§‹Ò ¤×Í “DELIRIUM” ´Ñ§¹Õé í D Dementia E Electrolyte imbalance L Lungs, liver, heart, kidney, brain failure I Infection R Rx (medications) I Injury, pain, stress U Unfamiliar environment M Metabolic causes¡ÒûÃÐàÁÔ¹¼ÙŒ»†Ç ¡ÒÃÇÔ¹¨©Ñ delirium ໚¹ clinical diagnosis «Ö§¢Ñ¹µÍ¹ã¹¡ÒûÃÐàÁÔ¹¼Ù»ÇÂÊÙ§ÍÒÂØ·ÁÕ delirium Ô è é Œ † Õè·íÒ䴌â´Â «Ñ¡»ÃÐÇѵԨҡ­ÒµÔËÃ×;ÂÒºÒÅ·Õè´Ùáżٌ»†Ç à¾×èÍãˌ·ÃÒº¶Ö§ÊÁÃöÀÒ¾à´ÔÁ¢Í§ÊÁͧ(baseline mental function) áÅСÒÃà»ÅÕ¹á»Å§¢Í§ÍÒ¡Ò÷ҧÊÁͧ ·Ñ§ onset áÅÐ ÃÐÂÐàÇÅÒ·ÕÁÕ è é èÍÒ¡Òà ¨Ò¡¹Ñé¹¾ÂÒÂÒÁ«Ñ¡»ÃÐÇÑµÔ ·º·Ç¹àǪÃÐàºÕ¹ áÅеÃǨËҧ¡Ò¼ٌ»†ÇÂà¾×èͤŒ¹ËÒÊÒà˵ØËÃ×Í»˜¨¨ÑÂàÊÕ§·Õà¡ÕÂÇ¢ŒÍ§µ‹Ò§ æ´Ñ§¡Å‹ÒÇ¢ŒÒ§µŒ¹ ¡ÒõÃǨËҧ¡Ò¼ٻÇ ์¹¡ÒõÃǨËҧ¡Ò·ÑÇä» è è è Œ † èáÅСÒõÃǨ·Ò§Ãкº»ÃÐÊÒ·â´ÂÅÐàÍÕ´à¾×ÍËÒÍÒ¡ÒÃáÊ´§à©¾ÒзÕè (localizing sign) ¡ÒõÃǨ èmental status ¢Í§¼Ù»ÇÂ䴌ᡋ ÃдѺ¤ÇÒÁÃÙÊ¡µÑÇ ¤ÇÒÁ¨íÒ orientation áÅСÒõÃǨ¤ÇÒÁãʋ㨠Œ † Œ Ö(attention) «Ö§·íÒâ´Â µÃǨ forward digit span «Ö§à»š¹¡ÒÃãˌ¼»Ç¹ѺàÅ¢µÒÁ¼ÙµÃǨà¾ÔÁ¢Ö¹·ÕÅÐ è è ٌ † Œ è éËÅÑ¡ (¼ÙʧÍÒÂØ»¡µÔ¤ÇùѺµÒÁ䴌Í‹ҧ¹ŒÍ 5 ËÅÑ¡) ËÃ×Íãˌ¼»Çº͡Çѹ㹠1 ÊÑ»´ÒˏÂ͹ËÅѧ Œ ٠ٌ † ŒËÃ×͵ÃǨ serial 7’s ¤×Íãˌź 7 ¨Ò¡ 100 áÅÐź 7 ¨Ò¡¤íҵͺ·Õ䴌ä»ÍÕ¡ 3-5 ¤Ãѧ ໚¹µŒ¹ è é (8) àÁ×ÍÇÔ¹¨©ÑÂÀÒÇÐ delirium 䴌áÅŒÇ ¤ÇÃÊ׺¤Œ¹ËÒÊÒà˵آͧÀÒÇÐ delirium ·Ò§ËŒÍ§»¯ÔºµÔ è Ô Ñ¡Òà â´Â¤íÒ¹Ö§¶Ö§¤ÇÒÁ໚¹ä»ä´Œ¢Í§¤ÇÒÁ¼Ô´»¡µÔ¹¹ã¹¼Ù»ÇÂᵋÅÐÃÒ ¡ÒÃÊ׺¤Œ¹àº×ͧµŒ¹·Õ¤Ç÷íÒ éÑ Œ † é è䴌ᡋ µÃǨ CBC, serum electrolytes, BUN, creatinine, glucose, calcium áÅÐ urinalysis ʋǹ¡ÒõÃǨ chest x-ray áÅÐ cultures µ‹Ò§ æ ¤ÇÃÊѧ੾ÒÐ㹡óշʧÊÑ¡ÒõԴàª×Í ¡ÒõÃǨ brain imaging è Õè é(ઋ¹ CT scan, MRI) ÁÕ»ÃÐ⪹¹ÍÂÁÒ¡ ¤Ç÷íÒ੾ÒÐàÁ×ÍʧÊÑÂNjҨÐÁÕ¾ÂÒ¸ÔÊÀÒ¾ã¹ÊÁͧ Œ (17) è
  • 56 Delirium: An Unrecognized Medical Problem in Older Patientsઋ¹ µÃǨ¾º localizing sign «Ö§à¡Ô´ãËÁ‹ ÁÕ»ÃÐÇѵͺµà˵طÈÃÉÐ ËÃ×ÍÊ׺¤Œ¹àº×ͧµŒ¹áŌÇÂѧäÁ‹¾º è ÔØ Ñ Ô Õè Õ éÊÒà˵آͧ delirium ෋ҹѹ é (18)¡Òû¯ÔºÑµÔÃÑ¡ÉÒ ËÅÑ¡¡Òû¯ÔºµÃ¡ÉҼٻǠdelirium ÁÕ´§¹Õé Ñ ÔÑ Œ † Ñ 1. ãˌ¡ÒÃÃÑ¡ÉÒᡌä¢ÊÒà赯 áÅл˜¨¨ÑÂàÊÕ§µ‹Ò§ æ ¢Í§ÀÒÇйշ¤¹¾º´Ñ§¡Å‹ÒÇáŌǢŒÒ§µŒ¹ è é Õè Œ 2. ·º·Ç¹ÃÒ¡ÒÃÂÒ«Ö觼ٌ»†ÇÂ䴌ÃѺ â´Â੾ÒÐÂÒ«Öè§ÍÍ¡Ä·¸Ô쵋ÍÊÁͧáÅÐÂÒ·ÕèÍÍ¡Ä·¸Ôìanticholinergic ¤ÇÃÅ´ËÃ×ÍËÂØ´ÂҴѧ¡Å‹ÒÇãˌÁÒ¡·Õʴ෋ҷըÐ໚¹ä´Œ â´ÂÂÖ´ËÅÑ¡Ç‹Ò ãªŒÂÒ¹ŒÍª¹Ô´ èØ è·ÕÊ´ã¹¢³Ð·Õ¼»ÇÂÁÕ delirium èØ è ٌ † 3. ãˌ¡ÒôÙáÅ·ÑÇä» (supportive care) ઋ¹ ´ÙáÅÀÒÇÐ fluid-electrolyte balance ÀÒÇÐ èâÀª¹Ò¡Òà áÅл‡Í§¡Ñ¹¡ÒÃà¡Ô´¼Åá·Ã¡«ŒÍ¹¨Ò¡ÀÒÇÐäÁ‹à¤Å×͹äËÇ (immobility) áÅСÒÃäÁ‹ÍÂÙ¹§ è ‹ èÔ(agitation) 4. ¡ÒÃÃÑ¡ÉÒâ´ÂäÁ‹ãªŒÂÒ (nonpharmacologic approaches) 䴌ᡋ¡ÒèѴ¡ÒÃà¡ÕÂǡѺÊÔ§áÇ´ è èŌÍÁ áÅСÒþÂÒºÒżٻÇ «Ö§¾ºÇ‹Ò໚¹»ÃÐ⪹ÊÒËÃѺ¼Ù»Ç delirium ·Ø¡ÃÒ Œ † è í Œ † (9,19) ÇÔ¸¡ÒÃàËÅ‹Ò Õ¹Õ䴌ᡋ é ¡. ¨Ñ´ãˌÍÂÙã¹ÊÔ§áǴŌÍÁ·ÕÁáʧÊNjҧ¾Í¤Çà áÅÐà§Õºʧº ‹ è è Õ ¢. ´ÙáÅàÃ×ͧ orientation ¢Í§¼Ù»Ç ઋ¹ ¨Ñ´ãˌÁ¹Ò́¡Ò »¯Ô·¹ÍÂÙã¹ËŒÍ§ ãˌ­ÒµÔËÃ×ͼٌ è Œ † Õ Ô ‹´ÙáŤÍº͡¼Ù»ÇÂà¡ÕÂǡѺÇѹ àÇÅÒ Ê¶Ò¹·Õè ¨Ñ´áNj¹µÒËÃ×Íà¤Ã×ͧª‹Ç¿˜§ (¶ŒÒÁÕ) ÁÒãˌ¼»Ç Œ † è è ٌ † ¤. ¨Ñ´ãˌÁà¤Ã×ͧª‹Ç¡Ãеع¤ÇÒÁ¨íҢͧ¼Ù»Ç 䴌ᡋ ÊÔ§¢Í§¤Ø¹à¤Â·Õ㪌໚¹»ÃШíÒ·ÕºÒ¹ Õ è Œ Œ † è Œ è è Œ­ÒµÔ ¼Ù´áÅ ÃÇÁ·Ñ§¾ÂÒºÒŤÇÃ໚¹¤¹à´ÔÁµÅÍ´àÇÅÒ Œ Ù é §. ¾Ù´¤Ø»Åͺ㨼ٻÇÂãˌʧº áÅÐãˌ¼»ÇÂ䴌à´Ô¹ËÃ×ͪ‹ÇÂàËÅ×͵¹àͧ㹡ԨÇѵûÃÐ Œ † ٌ †¨íÒÇѹµ‹Ò§ æ ෋ҷշÒ䴌 è í ¨. ËÅÕ¡àÅÕ§¡Òü١ÁÑ´¼Ù»Ç à¹×ͧ¨Ò¡¨Ð·íÒãˌ¼»Ç¡ÃÐǹ¡ÃÐÇÒ ´Ô¹Ã¹ÁÒ¡¢Ö¹ áÅÐ è Œ † è ٌ † é éà¡Ô´ÍѹµÃÒÂ䴌 ©. ¾ÂÒÂÒÁãˌ¼»ÇÂ䴌¹Í¹ËÅѺ¾Ñ¡¼‹Í¹µÍ¹¡ÅÒ§¤×¹Í‹ҧàµçÁ·Õè â´ÂäÁ‹Áʧú¡Ç¹ ٌ † Õ Ôè 5. ¡ÒÃÃÑ¡ÉÒ´ŒÇÂÂÒ (pharmacologic approaches) â´Â੾ÒÐà¾×èͤǺ¤ØÁÍÒ¡ÒÃÊѺʹÇعÇÒ ËÃ×Í¡ŒÒÇÌÒÇÃعáç ÍѹÍҨ໚¹ÍØ»ÊÃ䵋͡ÒÃÃÑ¡ÉÒ¾ÂÒºÒÅ ËÃ×Í໚¹ÍѹµÃÒµ‹ÍµÑǼٻÇ ‹ Œ †àͧ ÂÒ·Õá¹Ð¹íÒãˌ㪌໚¹Íѹ´Ñºáá䴌ᡋ haloperidol à¾ÃÒÐÁռŢŒÒ§à¤Õ§ anticholinergic áÅÐ è (9)hypotension ¹ŒÍ¡NjÒÂÒ antipsychotic ª¹Ô´Í×¹ â´ÂãˌÂÒ haloperidol ¢¹Ò´ 0.5-1 Á¡. ·Ò§»Ò¡ èáÅÐÍÒ¨ãˌ«Ò䴌¤ÃѧÅÐ 0.5 Á¡. ·Ø¡¤ÃÖ§¶Ö§Ë¹Ö§ªÑÇâÁ§¨¹¼Ù»ÇÂʧºÅ§ (ÂÒ¹ÕÁ¡äÁ‹·Òãˌ¼»ÇÂËÅѺ) íé é è è è Œ † é Ñ í ٌ †ã¹¡Ã³Õ·¼»ÇÂÇعÇÒÂÁÒ¡ áÅÐäÁ‹ÂÍÁ¡Ô¹ÂÒ ÍÒ¨µŒÍ§©Õ´ haloperidol ¢¹Ò´ 2.5 mg ࢌҡŌÒÁ áÅÐ Õè ٌ † ‹«éÒ¢¹Ò´à´ÔÁ䴌·¡¤ÃÖ§¶Ö§Ë¹Ö§ªÑÇâÁ§¨¹¼Ù»ÇÂʧºàª‹¹¡Ñ¹â´Â·ÑÇ仼ٻÇÂÊÙ§ÍÒÂØÁ¡äÁ‹µÍ§¡Òâ¹Ò´ í Ø è è è Œ † è Œ † Ñ ŒÂÒà¡Ô¹ 3-5 Á¡. ËÅѧ¨Ò¡¹Ñ¹ãˌÂÒ¹Õã¹¢¹Ò´»ÃÐÁÒ³¤Ã֧˹֧¢Í§ loading dose ·Õãˌä»áÅŒÇ à¾×Í (8) é é è è è è໚¹ maintenance dose ã¹Çѹ¶Ñ´ä» (ÍҨẋ§ãˌǹÅÐ 1-2 ¤Ãѧ) ¤ÇÃ㪌ÂÒã¹¢¹Ò´µèÒ·ÕÊ´·Õ¨Ð·íÒãˌ Ñ é í èØ è
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 57¼Ù»ÇÂʧºä´Œ áÅÐàÃÔÁÅ´ÂÒŧ㹠2-3 Çѹ «Ö§â´Â·ÑÇä»ÁÑ¡äÁ‹¨Ò໚¹µŒÍ§ãªŒÂÒ haloperidol à¡Ô¹ 1 ÊÑ»´Òˏ (8) Œ † è è è í ÂÒ antipsychotic ÍÕ¡¡ÅØÁ˹֧·ÕÍҨ㪌䴌 ¤×Í ÂÒ atypical neuroleptics 䴌ᡋ risperidone, ‹ è èolanzapine, áÅÐ quetiapine à¹×ͧ¨Ò¡ÁռŢŒÒ§à¤Õ§·Õ¨Ð·íÒãˌà¡Ô´ÍÒ¡Òà extrapyramidal ¹ŒÍ (9) è è¡Ç‹ÒÂÒ haloperidol áÅÐÁռšÒÃÈÖ¡ÉÒÊ¹ÑºÊ¹Ø¹Ç‹Ò ¡ÒÃ㪌ÂÒ¡ÅØÁ¹Õã¹¼ÙʧÍÒÂØÁ¤ÇÒÁàÊÕ§µ‹Í¡ÒÃàÊÕ ‹ é ŒÙ Õ èªÕǵ¹ŒÍ¡NjÒÂÒ conventional antipsychotics Í‹ҧäáçµÒÁ ÂѧäÁ‹Á¢ÍÁÙÅ·Õª´à¨¹Ç‹ÒÂÒ atypical Ô (20) Õ Œ è Ñneuroleptics ÁÕ»ÃÐÊÔ·¸Ô¼Å㹡ÒäǺ¤ØÁÍÒ¡Òà delirium ´Õ¡Ç‹ÒÂÒ haloperidol ¢¹Ò´¢Í§ÂÒ atypicalneuroleptics ·Õá¹Ð¹íÒ¤×Í risperidone 0.5 Á¡.·Ò§»Ò¡ ÇѹÅÐ 1-2 ¤Ãѧ, ÂÒ olanzapine 2.5-5 Á¡.·Ò§ è é»Ò¡ ¡‹Í¹¹Í¹ ÇѹÅФÃѧ áÅÐÂÒ quetiapine 25 Á¡.·Ò§»Ò¡ ÇѹÅÐ 1-2 ¤Ãѧ (9) ÊíÒËÃѺÂÒÍ×¹·ÕÍÒ¨ é é è èàÅ×͡㪌䴌໚¹Íѹ´ÑºÃͧŧÁÒ ä´Œá¡‹ trazodone «Ö§à»š¹ÂÒµŒÒ¹àÈÃŒÒ (antidepressant) «Ö§ÁÕÄ·¸Ô·Ò è è ì íãˌ§Ç§ ¢¹Ò´ÂÒ·Õ㪌¤Í 25-100 Á¡.·Ò§»Ò¡ ¡‹Í¹¹Í¹ ‹ è × (9) â´Â·ÑÇä» äÁ‹¤ÇÃ㪌ÂÒ benzodiazepine à¾×Í·íÒãˌ¼»Ç delirium ʧº à¹×ͧ¨Ò¡ÁÕ¡ÒÃÈÖ¡ÉÒ è è ٌ † è·Õ¾ºÇ‹Ò ÂÒ¹ÕÍÒ¨·íÒãˌÍÒ¡Òâͧ¼Ù»ÇÂàÅÇŧ ´Ñ§¹Ñ¹ ¨Ö§¤ÇÃ㪌ÂÒ¡ÅØÁ¹Õ੾ÒÐ㹡óշ¼»ÇÂà¡Ô´ è é Œ † é ‹ é Õè ٌ †delirium ¨Ò¡¡ÒâҴÂÒ benzodiazepines ËÃ×͵ԴÊØÃÒàÃ×ÍÃѧáŌÇËÂØ´´×Á¡ÃзѹËѹ (delirium tremens) é èÍ‹ҧäáçµÒÁ à¹×ͧ¨Ò¡ÂÒ haloperidol ËÃ×Í atypical neuroleptics ÁÑ¡äÁ‹·Òãˌ¼»ÇÂËÅѺ ¨Ö§ÍÒ¨ãˌ è í ٌ †ÂÒ lorazepam ¢¹Ò´ 0.5-1 Á¡.·Ò§»Ò¡ ¤Ù¡ºÂÒ haloperidol ËÃ×Í atypical neuroleptics 䴌 à¾×Í ‹ Ñ èËÇѧ¼Åãˌ¼»ÇÂ䴌¹Í¹ËÅѺ¾Ñ¡¼‹Í¹ºŒÒ§ ٌ †¡Òû‡Í§¡Ñ¹ ¼Å¡ÒÃÈÖ¡ÉÒàÃ×ͧ¡Òû‡Í§¡Ñ¹ delirium ã¹¼Ù»ÇÂÊÙ§ÍÒÂطúänjáÉÒã¹á¼¹¡ÍÒÂØáÃÃÁ¢Í§ è Œ † Õè Ñ Ñâç¾ÂÒºÒÅÂѧÁբ͢Ѵጧ â´Â¡ÒÃÈÖ¡ÉÒ·Õ໚¹ landmark study ã¹àÃ×ͧ¹Õ¤Í ¡ÒÃÈÖ¡ÉÒ Hospital Œ è è é ×Elder Life Program (HELP) «Ö§à»š¹¡ÒÃÈÖ¡ÉÒª¹Ô´ randomized controlled trial â´Â Inouye áÅР褳Р(21,22) ¾ºÇ‹Ò ¡Òû¯ÔºµµÍ¼Ù»ÇÂÊÙ§ÍÒÂØËÅÒÂÇÔ¸ÃÇÁ¡Ñ¹ (multicomponent intervention) 䴌ᡋ Ñ Ô ‹ Œ † Ջ¡ÒôÙáÅàÃ×ͧ cognition ¢Í§¼Ù»Ç ¡ÒÃᡌä¢ÍÒ¡Òù͹äÁ‹ËÅѺâ´ÂäÁ‹ãªŒÂÒ ¡Òû‡Í§¡Ñ¹áÅÐá¡Œä¢ è Œ †ÀÒÇÐ immobility ¡ÒÃᡌ䢻˜­ËÒ visual áÅÐ hearing impairment áÅСÒÃᡌä¢ÀÒÇТҴ¹éÒ ª‹ÇÂÅ´ íÍغµ¡Òó¢Í§ delirium ã¹¼Ù»ÇÂÊÙ§ÍÒÂØ«§ÃѺänjã¹ã¹á¼¹¡ÍÒÂØáÃÃÁ¢Í§âç¾ÂÒºÒÅ䴌ÃÒÇÌÍÂÅÐ Ñ Ô Œ † èÖ40 ᵋäÁ‹ÊÒÁÒöŴ¤ÇÒÁÃعáç ËÃ×ÍÃÐÂÐàÇÅҢͧÀÒÇÐ delirium 䴌 ÍÕ¡¡ÒÃÈÖ¡ÉÒ˹֧·Õ໚¹ randomized controlled trial ·íÒã¹¼Ù»ÇÂÊÙ§ÍÒÂØ«§ÃѺänjã¹ã¹á¼¹¡ è è Œ † èÖÍÒÂØáÃÃÁઋ¹à´ÕÂǡѹ ¡ÅѺ¾ºÇ‹Ò¡ÒÃࢌÒä»Ã‹ÇÁÃÑ¡ÉÒ áÅеԴµÒÁ´Ùáżٌ»†ÇÂ㹪‹Ç§·ÕèÍÂًã¹âç¾ÂÒºÒÅâ´ÂᾷàǪÈÒʵϼʧÍÒÂØ äÁ‹ªÇÂÅ´¤ÇÒÁÃعáçáÅÐÃÐÂÐàÇÅҢͧ¡ÒÃà¡Ô´ delirium (23) ٌ Ù ‹ ¹Í¡¨Ò¡¹Ñ¹ ÂѧÁÕÍ¡ 2 ¡ÒÃÈÖ¡ÉÒ·Õ¾ºÇ‹Ò â»Ãá¡ÃÁ¡ÒôÙáżٻÇÂẺÊËÊÒ¢ÒàªÔ§ÃØ¡¹íÒâ´Â é Õ è Œ †¾ÂÒºÒÅ (nurse-led interdisciplinary intervention program) «Ö§»ÃѺÊÔ§áǴŌÍÁ¢Í§âç¾ÂÒºÒÅãˌ è èàËÁÒСѺ¼ÙʧÍÒÂØ ª‹ÇÂÅ´¤ÇÒÁÃعáç¢Í§ÀÒÇÐ delirium Å´ÃÐÂÐàÇÅҢͧÀÒÇйÕé áÅÐÅ´ÃÐÂÐàÇÅÒ ŒÙ¡ÒäÃͧàµÕ§¢Í§¼Ù»ÇÂÊÙ§ÍÒÂØ䴌 áÁŒ¨ÐäÁ‹ÊÒÁÒöŴÍغµ¡Òó¢Í§ÀÒÇйաµÒÁ (24, 25) Œ † Ñ Ô é ç
  • 58 Delirium: An Unrecognized Medical Problem in Older Patients â´ÂÊÃØ» ÀÒÇЫÖÁ ÊѺʹà©Õº¾ÅѹËÃ×Í delirium ໚¹»˜­ËÒ·Õ¾ºº‹ÍÂã¹¼Ù»ÇÂÊÙ§ÍÒÂØ áÅÐ è Œ †ÁÕÊǹÊíҤѭ·Õ·Òãˌ¼Å¡ÒÃÃÑ¡ÉÒ¼Ù»ÇÂäÁ‹´Õ ·Ñ§ã¹á§‹ÍµÃÒµÒÂáÅФسÀÒ¾ªÕǵ ÀÒÇйÕÍÒ¨ÇÔ¹¨©ÑÂÂÒ¡ ‹ è í Œ † é Ñ Ô é ÔÊíÒËÃѺ¼Ù»ÇÂÊÙ§ÍÒÂØ â´Â੾ÒÐàÁ×Í໚¹áºº hypoactive delirium ¼Å¡ÒÃÃÑ¡ÉҼٻǢֹ¡Ñº¡ÒÃÇÔ¹¨©Ñ Œ † è Œ † é ÔÀÒÇйÕãˌ䴌ÃÇ´àÃçÇ ¤Œ¹ËÒ»˜¨¨ÑÂàÊÕ§ËÃ×ÍÊÒà˵آͧÀÒÇйÕé áÅÐᡌä¢Í‹ҧ·Ñ¹·‹Ç§·Õ ¹Í¡¨Ò¡¹Ñ¹ é è é¡Òû‡Í§¡Ñ¹ÁÔãˌ¼»Ç·ÕáÉÒµÑÇÍÂÙã¹âç¾ÂÒºÒÅà¡Ô´ delirium ໚¹ÊÔ§·Õᾷ·¡¤¹·Õ´áżٻÇÂÊÙ§ ٌ † è Ñ ‹ è è Ø è Ù Œ †ÍÒÂؤÇû¯ÔºµÔÑàÍ¡ÊÒÃ͌ҧÍÔ§1. Inouye SK. The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994 ; 97 : 278-882. Inouye SK. Delirium in hospitalized older patients. Clin Geriatr Med 1998 ; 14 : 745-643. Cole MG, Primeau .J. Prognosis of delirium in elderly hospital patients. Can Med Assoc J 1993 ; 149 : 41-64. Murray AM, Levkoff SE, Wetle TT, et al. Acute delirium and functional decline in the hospitalized elderly patients. J Gerontol: Med Sci 1993 ; 48 : M181-M1865. Levkoff SE, Evans DA, Liptzin B, et al. Delirium: the occurrence and persistence of symptoms among elderly hospitalized patients. Arch Intern Med 1992 ; 152 : 334-406. Rockwood K. The occurrence and duration of symptoms in elderly patients with delirium. J Gerontol : Med Sci 1993 ; 48 : M162-M1667. Lipowski ZJ. Delirium in the elderly patient. N Engl J Med 1989: 320: 578-828. .rancis J. Delirium in older patients. J Am Geriatr Soc 1992; 40: 829-379. Inouye SK. Delirium in older persons. N Engl J Med 2006; 354: 1157-6510. Meagher DJ, O’Hanlon D, O’Mahony E, et al. Relationship between symptoms and motoric subtype of delirium. J Neuropsychiatry Clin Neurosci 2000; 12: 51–611. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, 4th edition. Washington, DC: American Psychiatric Association, 1994: 123-3312. Inouye SK, vanDyck CH, Alesi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med 1990; 133: 941-4813. Inouye SK. Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med 1993; 119: 474-8114. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275: 852-715. Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: A symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med 1999; 106: 565-7316. Inouye SK. Delirium in hospitalized elderly patients: Recognition, evaluation and management. Connecticut Med 1993; 57: 309-1517. Koponen H, Hurri L, Stenback U, et al. Computed tomography findings in delirium. J Nerv Ment Dis 1989; 177: 226-3118. .rancis J, Hilko EM, Kapoor WN. Acute mental change: When are head scans needed (abstract). Clin Res 1991; 39:10319. Beresin EV. Delirium in the elderly. J Geriatr Psychiatry Neurol 1988; 1: 127-43
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 5920. Wang PS, Schneeweiss S, Avorn J, et al. Risk of death in elderly users of conventional versus atypical antipsychotic medications. N Engl J Med 2005; 353: 2335-4121. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340: 669-7622. Inouye S.K., Bogardus S.T., Baker D.I., et al:  The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients.  J Am Geriatr Soc 2000; 48: 1679-170623. Cole MG, McCusker J, Bellavance ., et al. Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ 2002; 167: 753-924. Milisen K, .oreman MD, Abraham IL, et al. A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. J Am Geriatr Soc 2001; 49: 523–3225. Lundstrom M, Edlund A, Karlsson S, et al. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc 2005; 53: 622–28
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 61 9 ¡ÒÃŌÁ㹼ٌÊÙ§ÇÑ ÈÒʵÃÒ¨ÒÏᾷ˭ԧÍÒÃÕÃѵ¹ Êؾط¸Ô¸Ò´Ò ÀÒ¤ÇÔªÒàǪÈÒʵÏ¿¹¿Ù ¤³Ðá¾·ÂÈÒʵÏ ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑ „œ ÁÒ¡¡Ç‹Ò˹֧ã¹ÊÒÁ¢Í§¼ÙʧÇÑ·ÕÁÕ ÍÒÂØÁÒ¡¡Ç‹Ò 65 »‚¨ÐŌÁã¹áµ‹Åл‚ àÁ×ÍŌÁáŌǾºÇ‹Ò 20-30% è ŒÙ è è¨ÐÁÕ»­ËÒ¡ÒúҴà¨çºËÅÒÂÍ‹ҧ ઋ¹ ¡Ãд١ÊÐ⾡ËÑ¡ ºÒ´à¨çºÊÁͧ ·íÒãˌà¤Å×͹äËÇŴŧ µŒÍ§ ˜ è¾Ö§¾Ò áÅÐàÊÕªÕǵ¡‹Í¹ÇÑÂÍѹ¤Çà ¤ÇÒÁàÊÕ§㹡ÒÃŌÁÁÒ¡¢Ö¹ã¹¼ÙʧÇÑ·ÕÍÒÂØÁÒ¡ ÁÕâäËÇÁ ઋ¹âä è Ô è é ŒÙ èËÅÍ´àÅ×Í´ÊÁͧ ¾ÒÏ¡¹Êѹ âä¢ŒÍ ãʋ¢Òà·ÕÂÁ ໚¹µŒ¹ ¡ÒÃŌÁ·íÒãˌ»Ç´ ·Ø¾¾ÅÀÒ¾áÅСÅÑÇ¡Òà Ôà´Ô¹ äÁ‹Á¹ã¨ã¹¡ÒÃà¤Å×͹äËÇËÃ×Í»ÃСͺ¡Ô¨ÇѵûÃШíÒÇѹ ¡ÒÃŌÁ໚¹»˜­ËÒ·ÕÁ¡¶Ù¡ÁͧNjÒ໚¹ Ñè è è ѸÃÃÁ´Òã¹¼ÙʧÇÑ «Ö§·íÒãˌ¡Òû‡Í§¡Ñ¹ÀÒÇйÕ§»¯ÔºµäÁ‹¨ÃÔ§¨Ñ§¹Ñ¡ ŒÙ è é Ñ Ñ Ô 1, 2 ¡Ò֍µÑÇ (balance) ËÁÒ¶֧ ¤ÇÒÁÊÒÁÒö㹡Ò÷íÒãˌ¨´Èٹ¶Ç§¢Í§Ã‹Ò§¡Ò (center Ø ‹of gravity) ÍÂÙÀÒÂã¹ base of support ÁÕ¡ÒÃ㪌ÃкºÃѺ¤ÇÒÁÃÙÊ¡áÅÐÃкºÊѧ¡ÒÃ㹡Ò÷íÒãˌ·Ã§ ‹ ŒÖ èµÑÇÍÂÙ䴌㹷‹Ò upright ÃÐËNjҧ¡Ò÷íÒ¡Ô¨¡ÃÃÁµ‹Ò§æ ºÒ§¤ÃѧàÃÕ¡ postural control1, 2 ‹ 默¨¨ÑÂÀÒÂã¹ (Internal factors) ·Õè·íÒãˌà¡Ô´¡ÒÃŌÁ 2 - 7 1) ¡ÅŒÒÁà¹×Í͋͹áçã¹ÇѪÃÒ (Age-related sarcopenia) é 2) ÁͧàËç¹äÁ‹ª´ ઋ¹ µŒÍ¡ÃШ¡ µŒÍËÔ¹ ¡ÒÃàÊ×ÍÁ·Ò§¨ÍÃѺÀÒ¾ Ñ è 3) ·‹Òà´Ô¹áÅСÒ֍µÑǼԴ»¡µÔ ઋ¹ âäËÅÍ´àÅ×Í´ÊÁͧ âä¢Í§ä¢ÊѹËÅѧ ¼Ù»Ç·ÕÁ¤ÇÒÁ Œ † è Õ¼Ô´»¡µÔ/¤ÇÒÁàÊ×ÍÁ¢Í§ÊÁͧʋǹ·Õ¤Çº¤ØÁ¡Ò֍µÑÇ ¢ŒÍÍÑ¡àʺ »ÅÒ»ÃÐÊÒ·ÍÑ¡àʺªÒ è è 4) âä¢Í§Ãкº¡ÒÃäËÅàÇÕ¹âÅËÔµáÅÐËÑÇ㨠ઋ¹ âä¤ÇÒÁ´Ñ¹âÅËÔµÊÙ§ ˹ŒÒÁ×´àÇÕ¹ÈÕÃÉÐËÑÇã¨àµŒ¹¼Ô´¨Ñ§ËÇÐ 5) ¤ÇÒÁº¡¾Ã‹Í§¢Í§ÊµÔ»­­ÒáÅСÒÃÃѺÃٌ ÀÒÇÐÊÁͧàÊ×ÍÁ «ÖÁàÈÃŒÒ ÇÔµ¡¡Ñ§ÇÅ ˜ è 6) ¡ÃÐà¾Òл˜ÊÊÒÇзíÒ§Ò¹¼Ô´»¡µÔ à¡Ô´»˜ÊÊÒÇк‹ÍÂ/àÅç´ÃÒ´ ·íÒãˌ¼Ê§ÇѵŒÍ§à˧ÃÕº·Õ¨Ðä» ÙŒ Ù èࢌÒˌͧ¹éÒí 7) ¡ÒÃ䴌úÂÒËÅÒª¹Ô´¾ÃŒÍÁ¡Ñ¹ (Polypharmacy) ·íÒãˌà¡Ô´¼Å¢ŒÒ§à¤Õ§ ઋ¹ àÇÕ¹ÈÕÃÉÐ Ñ¡Ò֍µÑÇäÁ‹´·ÒãˌÅÁ䴌§Ò ઋ¹ ÂÒÅ´¤ÇÒÁ´Ñ¹ Âҹ͹ËÅѺÃЧѺ»ÃÐÊÒ· ÂÒÅ´»Ç´ ÂÒ¤ÅÒÂ Õ í Œ ‹¡ÅŒÒÁà¹×Í é
  • 62 ¡ÒÃŌÁã¹¼ÙʧÍÒÂØ ŒÙ»˜¨¨ÑÂÀÒ¹͡ (External factors) ·Õè·íÒãˌà¡Ô´¡ÒÃŌÁ 2 - 7 1) áʧÊNjҧäÁ‹¾Íà¾Õ§ 2) ¾×¹Å×¹ËÃ×Íàŋ¹ÃдѺ ¾×¹ËŒÍ§¹éÒÅ×¹ é è é í è 3) ¢Ñ¹ºÑ¹ä´á¤ºà¡Ô¹ä»áÅÐäÁ‹ÁÃÒÇºÑ¹ä´ é Õ 4) ÍØ»¡Ã³µ¡áµ‹§ºŒÒ¹áÅÐà¤Ã×ͧ㪌·äÁ‹àËÁÒÐÊÁã¹àÃ×ͧ¢Í§¢¹Ò´áÅФÇÒÁÊÙ§ è Õè è 5) ÇÒ§¢Í§à¡Ð¡ÐµÒÁ¾×¹ é 6) àÅÕ§ÊѵǏàÅÕ§«Ö§ÍÒ¨ÇÔ§ª¹·íÒãˌˡŌÁ é é è è¡Å䡢ͧ¡ÒÃŌÁáÅСÃд١ËÑ¡¨Ò¡¡ÒÃŌÁ 2 - 7 ¾ºÇ‹ÒàÁ×ÍŌÁáŌÇÁÕâÍ¡ÒÊà¡Ô´¡Ãд١ËÑ¡ â´Â¾º·Õ¢ÍÁ×Íã¹ÇÑ¡ÅÒ§¤¹ÍÒÂØ 40-60 »‚ ·Õ¡Ãд١ è è Œ èÊѹËÅѧ㹼ÙʧÇÑÂÍÒÂØ 60 – 75 »‚ ·Õ¡Ãд١ femur ¢Í§¢ŒÍÊÐ⾡㹼ÙʧÇÑÂÍÒÂØÁÒ¡¡Ç‹Ò 75 »‚¢¹»‚ ŒÙ è ŒÙ éÖâ´ÂÁÕ¡Å䡢ͧ¡ÒÃŌÁ´Ñ§ÃÙ»·Õè 1    ÃÙ»·Õè 1 áÊ´§¡Å䡢ͧ¡ÒÃŌÁ㹼ٌÊÙ§ÇÑÂ
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  • 64 ¡ÒÃŌÁã¹¼ÙʧÍÒÂØ ŒÙ 5) áÊ´§¡ÒõÃǨËҧ¡Ò·ըÒ໚¹ã¹¡Ò䌹ËÒÊÒà˵ØáÅл˜¨¨ÑÂàÊÕ§㹡ÒÃŌÁ èí èµÒÃÒ§·Õè 1 ¡ÒõÃǨËҧ¡Ò·ÑÇ仵ÒÁÃкºÍÇÑÂÇÐ à¾×ͤŒ¹ËÒÊÒà˵ØáÅл˜¨¨ÑÂàÊÕ§¢Í§¡ÒÃŌÁ6 -11 è è è¡ÒõÃǨËҧ¡Ò¨íÒṡÃкº ÍÒ¡ÒÃáÊ´§·Õ辺NjÒ໚¹¤ÇÒÁàÊÕ觡ÒõÃǨ·ÑÇä» è ¢Ò´¡ÒôÙáÅ෌Ò/Ãͧ෌ҷÕÊÇÁãʋäÁ‹àËÁÒÐÊÁ è µÒÁÑÇ/ÁͧäÁ‹ª´ Ñ ãªŒÍ»¡Ã³ªÇÂà´Ô¹äÁ‹àËÁÒÐÊÁ Ø ‹ µŒÍ§ËÂØ´ªÐ§Ñ¡¡ÒÃà´Ô¹ àÁ×Ͷ١ªÇ¹¾Ù´¤Ø¢³Ðà´Ô¹ è ÀÒÇзØâÀª¹Ò¡Òà ÅØ¡Â×¹¨Ò¡à¡ŒÒÍÕ䴌ÂÒ¡ éÃкº»ÃÐÊÒ· ¡ÒÃà´Ô¹¼Ô´»¡µÔ ÅÒ¹ÊÒµҼԴ»¡µÔ ÁÕ¡ÒÃà»ÅÕ¹á»Å§¢Í§¤ÇÒÁµÖ§µÑǡŌÒÁà¹×͡ŌÒÁà¹×Í͋͹áç è é é ᢹ¢ÒªÒÃкºËÑÇã¨áÅÐËÅÍ´àÅ×Í´ ªÕ¾¨Ãൌ¹àÃçÇ/ªŒÒ¼Ô´»¡µÔ ËÑÇã¨àµŒ¹¼Ô´»¡µÔ ¤ÇÒÁ´Ñ¹âÅËÔµµèÒàÁ×Íà»ÅÕ¹·‹Ò·Ò§ í è è ÁÕ Carotid bruitsÃкº¡Ãд١áÅСŌÒÁà¹×Í é ¢ŒÍµÔ´ÂÖ´ ¢ŒÍࢋÒËÅÇÁäÁ‹Á¹¤§ Ñè »Ç´¢ŒÍʵԻ­­ÒáÅШԵ㨠˜ ¤ÇÒÁ¨íÒàÊ×ÍÁè «ÖÁàÈÌҡÒûÃÐàÁÔ¹¡Ò֍µÑÇáÅСÒÃŌÁ´ŒÇ Special test6 - 13 1) Timed single leg stance 2) Berg balance scale 3) Tinetti balance scale 4) .unctional reach test 5) Timed up-and-go test 6) Dynamic Gait Index
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  • 66 ¡ÒÃŌÁã¹¼ÙʧÍÒÂØ ŒÙ ! ᵋÅСԨ¡ÃÃÁ¨ÐÁÕ¡ÒÃãˌ¤Ðá¹¹ 5 ÃдѺ µÑ§áµ‹ 0-4 ¤Ðá¹¹ ¢Ö¹ÍÂÙ¡º¤ÇÒÁÊÒÁÒö㹠é é ‹ Ñ ¡Ò÷íÒ¡Ô¨¡ÃÃÁ ËÃ×Í ÃÐÂÐàÇÅÒ·Õ㪌㹡Ò÷íÒ¡Ô¨¡ÃÃÁ è ! ¤Ðá¹¹ÃÇÁÊÙ§ÊØ´ÁÕ¤Ò෋ҡѺ 56 ¤Ðá¹¹ ‹ ! < 45 ¤Ðá¹¹ ¶×ÍNjÒÁÕ¤ÇÒÁ¼Ô´»¡µÔã¹´ŒÒ¹¡Ò֍µÑÇ áÅÐÁÕ¤ÇÒÁàÊÕ§µ‹Í¡ÒÃŌÁÊÙ§ è ! ¡Ò÷´Êͺ¹ÕÁ¤ÇÒÁäÇ ( sensitivity ) 㹡Ò÷íÒ¹Ò¤‹Ò¤ÇÒÁàÊÕ§¢Í§¡ÒÃˡŌÁÊÙ§¶Ö§ é Õ è 53 % àÁ×Í·íÒ¡Ò÷´Êͺ㹤¹»¡µÔ è ! ÁÕ¤ÇÒÁäÇÊÙ§¶Ö§ 91 % àÁ×Í·íÒ¡Ò÷´Êͺ㹼ٷÁ»ÃÐÇѵà¤ÂˡŌÁÁÒ¡‹Í¹ è Œ Õè Õ ÔTinetti balance scale ! ·íÒ 24¡Ô¨¡ÃÃÁ 䴌ᡋ ¡Ò֍µÑÇ ¡ÒÃà´Ô¹ 1. ÊÁ´ØÅ㹡Òùѧè 1. ¡ÒõѴÊԹ㨢ͧ¼ÙʧÇÑÂàÁ×Í䴌ú¤íÒÊѧãˌ ŒÙ è Ñ è 2. ÅØ¡¢Ö¹¨Ò¡à¡ŒÒÍÕé é ÍÍ¡à´Ô¹ 3. ¤ÇÒÁ¾ÂÒÂÒÁ㹡ÒÃÅØ¡¢Ö¹¨Ò¡à¡ŒÒÍÕé 2. ÃÐÂСŒÒÇáÅФÇÒÁÊ٧෌ҷÕ¡㹢³Ð¡ŒÒÇà´Ô¹ é è 4. ÊÁ´ØÅã¹·‹ÒÂ×¹ËÅѧ¨Ò¡ÅØ¡¢Ö¹¨Ò¡à¡ŒÒÍÕé ã¹áµ‹ÅСŒÒÇ é 5. ÊÁ´ØÅã¹·‹ÒÂ×¹ 3. ¤ÇÒÁÊÁÁÒµÃã¹ÃÐÂСŒÒÇã¹à·ŒÒ·Ñ§Êͧ¢ŒÒ§ é 6. ¡Ò÷´ÊͺÊÁ´ØÅã¹·‹ÒÂ×¹ 4. ¤ÇÒÁµ‹Íà¹×ͧ¢Í§¡ÒáŒÒÇ෌Òã¹áµ‹ÅСŒÒÇ è 7. Â×¹ËÅѺµÒ 5. ÇÔ¶¡ÒÃà´Ô¹ Õ 8. ËÁعµÑÇ 360 ͧÈÒ 6. ÅѡɳТͧËҧ¡Ò¢³Ðà´Ô¹ (¾Ô¨Òóҵѧᵋé 9. ¡Òùѧŧ è ÈÕÃÉШô»ÅÒÂ෌Ò) 7. ·‹Òà´Ô¹â´Â¾Ô¨ÒóҨҡ¤ÇÒÁ¡ÇŒÒ§¢Í§à·ŒÒ ·Ñ§Êͧ¢³Ðà´Ô¹ é ! 㪌àÇÅÒ㹡Ò÷´Êͺ»ÃÐÁÒ³ 10-15 ¹Ò·Õ ! ʋǹ·Õè 1 Balance Assessment ÁÕ¤Ðá¹¹àµçÁ෋ҡѺ 16 ¤Ðá¹¹ ! ʋǹ·Õè 2 Gait Assessment ÁÕ¤Ðá¹¹àµçÁ 12 ¤Ðá¹¹ ! ᵋÅСԨ¡ÃÃÁÁÕ¤Ðá¹¹ 3 ÃдѺ µÑ§áµ‹ 0-2 ¤Ðá¹¹ ‹ é ! 0 ¤Ðá¹¹ ÁÕ¤ÇÒÁº¡¾Ã‹Í§à¡ÕÂǡѺ¡ÒÃÃÑ¡ÉÒÊÁ´ØÅã¹Ã‹Ò§¡Ò è ! 2 ¤Ðá¹¹ ÊÒÁÒö·íÒ¡Ô¨¡ÃÃÁ¹Ñ¹æ 䴌´Çµ¹àͧÍ‹ҧÍÔÊÃÐáÅÐÁѹ¤§ é Œ è ! ¼ÅÃÇÁ¤Ðá¹¹¢Í§·Ñ§ 2 ʋǹ«Ö§ÁÕ¤Ðá¹¹ÊÙ§Êش෋ҡѺ 28 ¤Ðá¹¹ é è ! < 19 ¤Ðá¹¹ ÁÕ¤ÇÒÁàÊÕ§ÊÙ§µ‹Í¡ÒÃà¡Ô´¡ÒÃˡŌÁ è ! 19-24 ¤Ðá¹¹ ÁÕ¤ÇÒÁàÊÕ§µ‹Í¡ÒÃˡŌÁ䴌 è ! > 24 ¤Ðá¹¹ ¶×ÍNjÒÁÕ¤ÇÒÁ»ÅÍ´ÀÑÂ㹡ÒÃà¤Å×͹äËÇ㹪Õǵ»ÃШíÒÇѹ è Ô ! Sensitivity 70% áÅÐ Specificity 52%
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  • 72 ¡ÒÃŌÁã¹¼ÙʧÍÒÂØ ŒÙ 10. ¡ÒÃᡌ䢻˜¨¨ÑÂÀÒ¹͡·Õ·Òãˌà¡Ô´¡ÒÃŌÁ è íÊÃØ» ã¹»˜¨¨Øº¹ÁÕËÅÑ¡°Ò¹·Ò§§Ò¹ÇÔ¨ÂáÅзҧ¤ÅÔ¹¡ªÑ´à¨¹áŌÇNjҡÒáÒõÃǨ¤Ñ´¡Ãͧâä/¤ÇÒÁ Ñ Ñ ÔàÊÕ§¢Í§¡ÒÃŌÁã¹¼ÙʧÇÑ ¡ÒÃÍÍ¡¡íÒÅѧ¡Ò ÁÕÊǹª‹ÇÂãˌ¼»ÇÂà´Ô¹áÅÐà¤Å×͹äËÇ´Õ¢¹ ¡Ò֍µÑÇ è ŒÙ ‹ ٌ † è Öé´Õ¢Öé¹ Å´¤ÇÒÁàÊÕè§㹡ÒÃŌÁ »ÃСͺ¡Ô¨ÇѵûÃШíÒÇѹ䴌ÁÒ¡¢Öé¹ µÅÍ´¨¹ª‹Ç´ŒÒ¹¨Ôµã¨ ·íÒãˌ¤Ø³ÀÒ¾ªÕǵ´Õ¢¹ Ô ÖéàÍ¡ÊÒÃ͌ҧÍÔ§1. National center for injury prevention and control:.all and hip fractures among older adults,August 5,2004.2. Rose DJ,.allproof.A comprehensive balance and mobility training program.Champaign III,2003,Human Kinetic.3. Maki BE, Holliday PJ, Topper AK..ear of falling and postural performance in the elderly. J Gerontol. 1991 ;46(4):M123-31.4. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH.Interventions for preventing falls in elderly people. Cochrane Database Syst Rev.2009 ;15 (2):CD000340. Review.5. Sherrington C, Lord SR, Vogler CM, Close JC, Howard K, Dean CM, Clemson L,Barraclough E, Ramsay E, O’Rourke SD, Cumming RG. Minimising disability and falls in older people through a post-hospital exercise program: a protocol for a randomised controlled trial and economic evaluation. BMC Geriatr. 2009 26;9:8.6. Costello E, Edelstein JE. Update on falls prevention for community-dwelling older adults: review of single and multifactorial intervention programs. J Rehabil Res Dev. 2008;45(8):1135-52.7. Onen ., Higgins S, Onen SH. .alling-asleep-related injured falls in the elderly. J Am Med Dir Assoc. 2009 ;10(3):207-10.8. Perell KL, Nelson A, Goldman RL, et al. .all risk assessment measures: an analytic review. J Gerontol A Biol Sci Med Sci. 2001;56:M761–M766.9. Scott V, Votova K, Scanlan A, Close J. Multifactorial and functional mobility assessment tool for fall risk among older adults in community, home-support, long-term and acute care settings. Age Ageing. 2007;36:130–9.10. National Institute of Clinical Excellence. Clinical guideline 21: the assessment and prevention of falls in older people, 2004. Available at: http://www.nice.org.uk. Accessed July 11,2005.11. Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev. 2003;(4):CD000340.12. Wall C 3rd, Wrisley DM, Statler KD. Vibrotactile tilt feedback improves dynamic gait index: A fall risk indicator in older adults. Gait Posture. 2009 Apr [Epub ahead of print] PubMed PMID: 19345107.13. Donoghue D.How much change is true change? The minimum detectable change of the Berg Balance Scale in elderly people. Rehabil Med. 2009 ;41(5):343-6.14. Begg R, Kamruzzaman J. A machine learning approach for automated recognition of movement patterns using basic, kinetic and kinematic gait data. J Biomech. 2005 ;38(3):401-8.
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  • 74 .acial Rejuvenation - ¡ÒÃ㪌áʧ LASER 㹡Ò÷íÒ .acial Resurfacing ¡Ò÷íÒÈÑÅ¡ÃÃÁµ¡áµ‹§à¾×ÍãˌãºË¹ŒÒ´ÙàÂÒǏÇ »ÃÐàÀ··Õ¨Ò໚¹µŒÍ§ãªŒ¡Òü‹ÒµÑ´à¢ŒÒª‹Ç è Ñ èí«Öè § ¨Ð·í Ò â´ÂÈÑ Å Âᾷ µ ¡áµ‹ § ·Õè ¨ Ð㪌 ¤ ÇÒÁÃٌ · Ò§´Œ Ò ¹ÈÑ Å Â¡ÃÃÁµ¡áµ‹ § à¾×è Í ¡ÒÃàÊÃÔ Á ÊÌ Ò §(Reconstructive Plastic Surgery) ÁÒ»ÃÐÂØ¡µãªŒà¾×Í¡ÒÃàÊÃÔÁÊÇ (Aesthetic Plastic Surgery) èà¾×Íãˌ¡Òü‹ÒµÑ´ä´Œ¼Å´Õ, âäá·Ã¡«ŒÍ¹áÅмŢŒÒ§à¤Õ§¹ŒÍ ઋ¹ è ¡Òü‹ÒµÑ´´Ö§Ë¹ŒÒ¼Ò¡ (.orehead or Brow lift) ¡Òü‹ÒµÑ´´Ö§¢ÁѺ (Temple lift) ¡Òü‹ÒµÑ´´Ö§Ë¹ŒÒ (.ace lift) ¡Òü‹ÒµÑ´´Ö§¤Í (Neck lift) ¡Òü‹ÒµÑ´µ¡áµ‹§¤Ò§ (Mentoplasty) àËŋҹÕ໚¹µŒ¹ «Ö§ÃÒÂÅÐàÍÕ´¨Ð䴌ºÃÃÂÒµ‹Íä» ¼Åá·Ã¡«ŒÍ¹ÍѹÍÒ¨¨Ðà¡Ô´¢Ö¹ä´Œ ઋ¹ ÁÕ é è éàÅ×Í´¤Ñ§ãµŒ¼Ç˹ѧ, ¡ÒõԴàª×Í, ¡Òü‹ÒµÑ´ä»â´¹ÍÇÑÂÇÐÊíҤѭæ ઋ¹àʌ¹»ÃÐÊÒ·, ¡ÅŒÒÁà¹×Í ·íÒãˌ è Ô é éãºË¹ŒÒºÔ´àºÕÂÇ, ¡Òü‹ÒµÑ´àÅÒÐà¹×ÍàÂ×Íãˌ¶¡µŒÍ§ÁÔãˌà¹×ÍàÂ×ÍáÅмÔÇ˹ѧµÒÂã¹ÃÐÂе‹ÍÁÒ ÏÅÏ àËÅ‹Ò é é è Ù é è¹ÕÈÅÂᾷ¨ÐµŒÍ§·íÒ´ŒÇ¤ÇÒÁÃÐÁÑ´ÃÐÇѧ áÅеŒÍ§·íÒâ´ÂÈÑÅÂᾷµ¡áµ‹§·ÕÁ¤ÇÒÁÃÙ¤ÇÒÁªíÒ¹Ò­ é Ñ è Õ Œâ´Â੾ÒÐ ÃÇÁ·Ñ§¡ÒÃàµÃÕÂÁµÑǼٻÇ¡‹Í¹¼‹ÒµÑ´, ÃÐËNjҧ¼‹ÒµÑ´ áÅÐËÅѧ¼‹ÒµÑ´ à¾×Íãˌ䴌¼Å´Õ·Ê´ é Œ † è Õè ØÊíÒËÃѺ¼Ù»ÇŒ †
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 75 11 Novel Sunscreen and Photoprotective Methods ÃͧÈÒʵÃÒ¨ÒϹÒÂᾷ»ÃÐÇԵà ÍÑÈÇÒ¹¹· ÀÒ¤ÇÔªÒÍÒÂØÃÈÒʵÏ ¤³Ðá¾·ÂÈÒʵÏ ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑ ¼ÙŒª‹ÇÂÈÒʵÃÒ¨ÒÏ ᾷ˭ԧª¹ÔÉ®Ò Ç§É»ÃÐÀÒÃѵ¹ ÀÒ¤ÇÔªÒµ¨ÇÔ·ÂÒ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å ÔÔ áʧᴴÁÕ»ÃÐ⪹µÍÁÕʧ·ÕÁªÇµº¹âÅ¡ ઋ¹ ãˌ¤ÇÒÁͺÍع, »ÃÐ⪹ã¹¡ÒÃÁͧàËç¹, ‹ Ôè è Õ Õ Ô ‹Áռŵ‹ÍÍÒÃÁ³áÅШíÒ໚¹ã¹¡ÒÃÊѧà¤ÃÒÐˏ vitamin D ¢Í§Ã‹Ò§¡ÒÂÁ¹Øɏ Í‹ҧäáç´ËÒ¡àÃÒ䴌ú Õ Ñ»ÃÔÁÒ³áʧᴴ·ÕÁÒ¡à¡Ô¹ä»¨Ðà¡Ô´â·É䴌 µÑÇÍ‹ҧ ઋ¹ ¼ÔÇ˹ѧáʺäËÁŒ, ¡ÃÐ, ½‡Ò, ¼ÔÇ˹ѧᡋ 衋͹ÇÑÂ, ÁÐàÃ秼ÔÇ˹ѧ áÅеŒÍ¡ÃШ¡ ໚¹µŒ¹ áʧᴴ·Õ¼Ò¹ÁÒÂѧ¾×¹¼ÔÇâÅ¡»ÃСͺ´ŒÇ ÃѧÊÕ infrared (700 -106 ¹Òâ¹àÁµÃ) áʧ㹡ÒÃ è ‹ éÁͧàËç¹ ËÃ×Í áʧÊNjҧ (visible light; 400-700 ¹Òâ¹àÁµÃ), ÃѧÊÕ ultraviolet A (UVA; 320-400 ¹Òâ¹àÁµÃ)áÅÐÃѧÊÕ ultraviolet B (UVB; 290-320 ¹Òâ¹àÁµÃ) ÊíÒËÃѺ UVA ¹Ñ¹áº‹§Í͡໚¹ ÃѧÊÕ ultraviolet A1 é(UVA1; 340-400 ¹Òâ¹àÁµÃ) áÅÐÃѧÊÕ ultraviolet A2 (UVA2; 320-340 ¹Òâ¹àÁµÃ) ʋǹÃѧÊÕ ultravioletC ¹Ñ¹¶Ù¡âÍ⫹㹺ÃÃÂÒ¡ÒÈ¡Ãͧänj ¨Ö§äÁ‹ÊÒÁÒö¼‹Ò¹ÁÒÂѧ¾×¹¼ÔÇâÅ¡ ¡ànj¹ã¹ºÒ§ºÃÔàdz·ÕÁ¡Òà é é è Õ·ÐÅآͧªÑé¹âÍ⫹ â´Â ÃѧÊÕ UVA áÅÐ UVB ¹Õé໚¹µÑÇ¡Ò÷íÒà¡Ô´ÍѹµÃÒµ‹Í¼ÔÇ˹ѧ¢Í§¤¹àÃÒà¹×ͧ¨Ò¡Íغµ¡Òó·Ê§¢Ö¹¢Í§ÁÐàÃ秼ÔÇ˹ѧâ´Â੾ÒÐÍ‹ҧÂÔ§ melanoma »˜¨¨Øº¹¨Ö§ÁÕ¡ÒÃó礏 è Ñ Ô Õè Ù é è Ñ»‡Í§¡Ñ¹¼ÔÇ˹ѧ¨Ò¡áʧᴴ â´Â์¹¡Òû‡Í§¡Ñ¹¼ÔÇ˹ѧ¨Ò¡ÃѧÊÕ ultraviolet «Ö觷íÒ䴌ËÅÒÂÇԸմѧµ‹Í仹Õé1. ¡ÒÃ㪌ÊÒáѹᴴ (Sunscreening agents) 1.1 ª¹Ô´¢Í§ÊÒáѹᴴ ËÃ×Í ÊÒáÃͧÃѧÊÕÂÙÇÕ (UV filters) ÊÒáѹᴴẋ§Í͡໚¹ 3 ¡ÅØÁ¢Ö¹¡Ñº¡Åä¡¡ÒÃÍÍ¡Ä·¸Ôì (1) ‹ é 1.1.1 Organic filters (Chemical filters) ÍÍ¡Ä·¸Ôâ´Â¡Òôٴ«ÑºÃѧÊÕultraviolet áŌÇà¡Ô´ ì¡ÒÃà»ÅÕ¹á»Å§â¤Ã§ÊÌҧ·Ò§à¤ÁբͧÊÒùѹ µÑÇÍ‹ҧ organic filters ઋ¹ avobenzone, cinnamates, è éoctocrylenes, benzophenones, para-aminobenzoic acid (PABA), padimate-O, salicylates à¹×ͧ¨Ò¡¡Åä¡¡Ò÷íÒ§Ò¹¢Í§ÊÒáѹᴴ㹡ÅØÁ¹Õé ¤×Í ¡Òôٴ«ÑºÃѧÊÕÂÇ໚¹ËÅÑ¡ ´Ñ§¹Ñ¹ è ‹ ÙÕ éÊÒÃËÅÒµÑǨ֧ÁÕ¡ÒÃà»ÅÕè¹á»Å§â¤Ã§ÊÌҧáÅÐÊÙ­àÊÕ¤ÇÒÁÊÒÁÒö㹡ÒÃ໚¹ÊÒáѹᴴä»(photolabile) ઋ¹ avobenzone ¡ÒÃ㪌ÊÒÃ㹡ÅØÁ¹Õâ´ÂµŒÍ§ä´ŒÃºá´´ÍÂÙ໚¹àÇÅÒ¹Ò¹ ¨Ö§ÁÕâÍ¡ÒÊ ‹ é Ñ ‹
  • 76 Novel Sunscreen and Photoprotective Methodsà¡Ô´¡ÒÃäËÁŒá´§áÅÐ䴌ú¼Å¡Ãзº¨Ò¡ÃѧÊÕÂÇ͹æ䴌 ᾷ¨§ÁÑ¡á¹Ð¹íÒãˌ¼»ÇÂáÅмٺÃÔâÀ¤·Ò Ñ Ù Õ ×è Ö ÙŒ † Œ¤ÃÕÁ¡Ñ¹á´´«éÒÍ‹ҧ¹ŒÍ·ء 2 ªÑÇâÁ§ ËÒ¡µŒÍ§ä´ŒÃºáʧᴴµ‹Íà¹×ͧ¹Ò¹æ â´Â੾ÒÐËҡNjÒ¹éÒ í è Ñ è íËÃ×Íàŋ¹¹éÒ ÂÔ§ÍÒ¨µŒÍ§·Ò¤ÃÕÁ¡Ñ¹á´´«éÒº‹Í¢ֹ à¾ÃÒй͡¨Ò¡ÊÒáѹᴴ¨ÐÊÅÒµÑǨҡ¡ÒÃ䴌 í è í éÃѺÂÙÇáŌÇÂѧ¶Ù¡ªÐÍÍ¡ä»ÍÕ¡´ŒÇÂ Õ ¾Ñ²¹Ò¡ÒÃã¹Âؤ»˜¨¨Øº¹·íÒãˌÁÊÒáѹᴴ·ÕÁ¤ÇÒÁ “¤§µÑǔ àÁ×ÍÊÑÁ¼ÑÊÃѧÊÕÂÇÕ (photostable) Ñ Õ è Õ è Ù·ÕÊҤѭ ¤×Í àÁ×ͼÊÁÊÒáѹᴴàËŋҹաºÊÒáѹᴴÍ×¹·Õè photolabile ¡ç¨ÐÊÒÁÒöà¾ÔÁ¤ÇÒÁ¤§µÑÇ èí è é Ñ è èãˌ¡ºÊÒáѹᴴàËŋҹѹ䴌´Ç 㹻˜¨¨Øº¹àÃÒ¨Ö§¾ºàË繤ÃÕÁ¡Ñ¹á´´·ÕÁÊǹ¼ÊÁ¢Í§ÊÒáÃͧÃѧÊÕ Ñ é Œ Ñ è ՋÂÙÇËÅÒÂæ µÑǼÊÁ¡Ñ¹ Õ 1.1.2 Inorganic filters (Physical filters) ÊÒáѹᴴ㹡ÅØÁ inorganic filters «Ö§ÁÕšɳÐ໚¹ “particles” àËŋҹÕÍÍ¡Ä·¸Ôâ´Â ‹ è Ñ é ì¡ÒÃÊзŒÍ¹ÃѧÊÕ ultraviolet ໚¹ËÅÑ¡ ¤Ø³ÊÁºÑµ¢Í§ particles »ÃСÒÃ˹֧¡ç¤ÍÂÔ§ÁÕ¢¹Ò´ãË­‹¡¨Ð Ô è × è çÊзŒÍ¹ÃѧÊժǧ¤Å×¹ÂÒÇ䴌ÁÒ¡ ´Ñ§¹Ñ¹¨Ö§äÁ‹à»š¹·Õ¹Ò»ÃÐËÅÒ´ã¨Ç‹ÒàÁ×Í·ÒÊÒáѹᴴ㹡ÅØÁ¹Õé ¨Ö§àËç¹ ‹ è é è ‹ è ‹¼ÔÇ˹ѧÁÕÊ¢ÒÇ «Ö§¡ç໚¹à¾ÃÒÐÁÕ¡ÒÃÊзŒÍ¹áʧª‹Ç§¤Å×¹ÂÒÇ㹪‹Ç§áʧÊNjҧ ËÃ×Í visible light ໚¹ Õ è èÍ‹ҧÁÒ¡ ã¹àÇÅÒµ‹ÍÁÒàÁ×ÍÁÕ¾²¹Ò¡ÒüÅÔµ inorganic filters ·ÕÁ¢¹Ò´ particles àÅç¡Å§¨Ö§·íÒãˌÊÒà è Ñ è աѹᴴÂؤãËÁ‹ÊзŒÍ¹ÃѧÊժǧ¤Å×¹Êѹ ¤×Í ÃѧÊÕÂÇ䴌ÁÒ¡¢Ö¹áÅÐáʧÊNjҧ¹ŒÍÂŧ ·íÒãˌ䴌ÊÒáѹᴴ ‹ è é ÙÕ é·ÕÁ¤³ÊÁºÑµµÒÁ·ÕᾷµÍ§¡ÒÃáÅÐÁÕšɳÐäÁ‹¾§»ÃÐʧ¤¹ÍÂŧ è Õ Ø Ô è Œ Ñ Ö Œ ¡ÒÃÈÖ¡ÉÒÀÒÂËÅѧ¾ºÇ‹Ò inorganic filters ·ÕÁ¢¹Ò´ particle àÅç¡ (micronized form) ÂѧÁÕ è ÕÄ·¸Ô´´«ÑºÃѧÊÕ ultraviolet 䴌¤ÅŒÒ¡Ѻ organic filters ઋ¹¡Ñ¹ â´Â·ÑÇä» inorganic filters ¨ÐäÁ‹¡Í ì Ù è ‹ãˌà¡Ô´ÍÒ¡ÒÃᾌ ÊÒÁÒö㪌䴌»ÅÍ´ÀÑÂã¹à´ç¡ Í‹ҧäáç´ã¹à´ç¡àÅç¡·ÕÍÒÂعÍÂ¡Ç‹Ò 6 à´×͹ äÁ‹ Õ è Œá¹Ð¹íÒãˌ㪌ÊÒáѹᴴà¹×èͧ¨Ò¡àÁµÒºÍÅÔÊÁáÅÐÃкº¡ÒâѺ¶‹ÒÂÊÒõ‹Ò§æã¹à´ç¡àÅç¡ÍÒ¨ÂѧäÁ‹¾Ñ²¹ÒàµçÁ·Õè µÑÇÍ‹ҧÊÒáѹᴴ㹡ÅØÁ¹Õ䴌ᡋ titanium dioxide (TiO2), zinc oxide (ZnO), iron ‹ éoxide, kaolin, talc áÅÐcalamine 1.1.3 Organic particulates ÊÒÃ㹡ÅØÁ¹ÕÍÍ¡Ä·¸Ô·§â´Â¡Òôٴ«ÑºáÅÐÊзŒÍ¹ÃѧÊÕ ultraviolet µÑÇÍ‹ҧÊÒáѹᴴ㹠‹ é ì Ñé¡ÅØÁ¹Õ䴌ᡋ Methylene bis- benzotriazolyl tetramethylbutylphenol (MBBT; Tinosorb®M) ‹ é
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 77µÒÃÒ§·Õè 1 ¤Ø³ÊÁºÑµÔ¢Í§ÊÒáѹᴴ㹡Òû‡Í§¡Ñ¹ÃѧÊÕÍÑŵÃÒäÇâÍàŵ(2,3)ª¹Ô´ÊÒáѹᴴ ¤ÇÒÁÊÒÁÒö㹡Òû‡Í§¡Ñ¹ ÃѧÊÕ ultravioletOctinoxate (octyl methoxycinnamate) UVBOctisalate (octyl salicylate) UVBOctocrylene UVBEnzacamene (4-Methylbenzylidene camphor) UVBOxybenzone UVB, UVA2Sulisobenzone UVB, UVA2Avobenzone UVA1Terephthalydene dicamphor sulfonic acid (TDSA; Mexoryl®SX) UVA1Drometrizole trisiloxane (DTS; Mexoryl®XL) UVB, UVA2, UVA1Methylene bis- benzotriazolyl tetramethylbutylphenol(MBBT; Tinosorb®M) UVB, UVA2, UVA1Bis-ethylhexyloxyphenol methoxyphenol triazine(BEMT; Tinosorb®S) UVB, UVA2, UVA1Titanium dioxide ¢Ö¹¡Ñº¢¹Ò´¢Í§ particle éZinc oxide ¢Ö¹¡Ñº¢¹Ò´¢Í§ particle é 1.2 Sun (ËÃ×Í sunburn) Protection .actor (SP.) SP. ໚¹¤‹Ò·ÕºÍ¡»ÃÐÊÔ·¸ÔÀÒ¾¢Í§Âҡѹᴴ㹡ÒáѹÃѧÊÕ ultraviolet â´Â੾ÒÐÍ‹ҧÂÔ§ è èUVB â´Â¤íҹdz¨Ò¡ SP. = MED of skin with sunscreen MED of skin without sunscreen â´Â sunscreen ·Õ㪌¤Ò¹Ç³ËÒSP. ¨ÐµŒÍ§·Ò»ÃÔÁÒ³ 2 mg/cm2 è í MED = minimal erythema dose, ËÁÒ¶֧»ÃÔÁÒ³ÃѧÊÕ ultraviolet ¹ŒÍ·ÕÊ´·Õ·Òãˌ è Ø è í¼ÔÇ˹ѧ·Õ·Ò·´ÊͺÁÕÍÒ¡ÒÃá´§ â´Â͋ҹ¼Å·Õè 24 ªÑÇâÁ§ËÅѧ䴌úÃѧÊÕ ultraviolet è í è Ñ ¨Ð¢Í¡µÑÇÍ‹ҧà¾×ÍãˌࢌÒã¨ä´Œ§Ò à¡ÕÂǡѺ¤‹Ò SP. ´Ñ§¹Õé è ‹ è ÊÁÁصàÃÒÂ×¹µÒ¡á´´¹Ò¹ 10 ¹Ò·Õ áŌǷíÒãˌ¼Ç˹ѧàÃÒÁÕÍÒ¡ÒÃá´§ ËÒ¡àÃÒ·ÒÂҡѹᴴ Ô ÔSP. 10 ¨Ò¡¹Ñ¹ä»Â×¹µÒ¡á´´ àÃÒÊÒÁÒöÂ×¹µÒ¡Í͡䴌¹Ò¹ 10 X 10 =100 ¹Ò·Õ ¼ÔÇ˹ѧ¢Í§àÃÒ é¨Ö§¨ÐÁÕÍÒ¡ÒÃá´§ (ËÁÒÂà赯 ÍÒ¡ÒÃá´§¢Í§¼ÔÇ˹ѧµÒÁËÅѧ¡ÒÃ䴌ú ultraviolet ¨ÐÁÕ¤ÇÒÁá´§ªÑ´·ÕÊ´·Õè Ñ è Ø24 ªÁ.)
  • 78 Novel Sunscreen and Photoprotective Methods ¤¹Ê‹Ç¹ãË­‹à¢ŒÒã¨Ç‹ÒÂҡѹᴴ·Õ´¤ÍÂҡѹᴴ·ÕÁÕ SP.ÊÙ§ ᷌·¨ÃÔ§áŌÇ໚¹¤ÇÒÁࢌÒ㨷Õè è Õ × è ÕèäÁ‹¶¡µŒÍ§ Âҡѹᴴ·ÕÁÕ SP. ÊÙ§ÍÒ¨ÁÕ¡ÒÃãʋÊÒáѹᴴŧä»ËÅÒµÑÇÍÒ¨ÁÕâÍ¡ÒÊᾌ䴌 áÅзÕè Ù èÊíҤѭ¤‹Ò SP. ໚¹¤‹Ò·ÕºÍ¡»ÃÐÊÔ·¸ÔÀҾ㹡Òû‡Í§¡Ñ¹ÍÒ¡ÒÃäËÁŒá´§¢Í§¼ÔÇ˹ѧ «Ö§ÍÒ¡ÒÃäËÁŒ è èá´§¢Í§¼ÔÇ˹ѧ¹Ñ¹à¡Ô´¨Ò¡ÃѧÊÕ UVB ໚¹ËÅÑ¡ (à¡Ô´¨Ò¡ UVA ໚¹Ê‹Ç¹¹ŒÍÂ) ´Ñ§¹Ñ¹Âҡѹᴴ·ÕÁÕ é é èSP. ÊÙ§¨Ö§à»š¹Âҡѹᴴ·Õ»Í§¡Ñ¹ÃѧÊÕ UVB 䴌´Õ ᵋÍÒ¨äÁ‹ãª‹Âҡѹᴴ·Õ´·Ê´ à¾ÃÒÐÂҡѹᴴ è ‡ è Õ Õè Ø·Õ´¤Çû‡Í§¡Ñ¹ä´Œ·§ÃѧÊÕ UVAáÅÐ UVB ¨Ò¡¢ŒÍÁÙÅ·Ò§¡ÒÃᾷ㹻˜¨¨Øº¹¾ºÇ‹Ò·Ñ§ UVA áÅÐ UVB è Õ Ñé Ñ éÁÕÊǹÊíҤѭ·íÒãˌà¡Ô´ÍѹµÃÒµ‹Í¼ÔÇ˹ѧ ·íÒãˌà¡Ô´ÀÒÇмÔÇ˹ѧᡋ¡Í¹ÇÑ ÃÇÁ¶Ö§ÁÐàÃ秼ÔÇ˹ѧ´ŒÇ ‹ ‹ÊíÒËÃѺ»˜¨¨Øº¹ÂѧäÁ‹Á¡ÒáíÒ˹´Áҵðҹ㹡Òú͡»ÃÐÊÔ·¸ÔÀÒ¾¡Òû‡Í§¡Ñ¹ÃѧÊÕ UVA¢Í§Âҡѹ Ñ Õá´´·ÕÂÍÁÃѺ¡Ñ¹·ÑÇâÅ¡ ᵋÅлÃÐà·È¨Ð㪌Áҵðҹ·Õᵡµ‹Ò§¡Ñ¹ ઋ¹ »ÃÐà·ÈÍѧ¡ÄÉ㪌 Boots star è è èrating »ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡Ò㪌 star rating »ÃÐà·È­Õ»¹ãªŒ¤Ò PA ໚¹µŒ¹ «Ö§ÊÒáѹᴴ·ÕÁ¤³ÊÁºÑµÔ è ؆ ‹ è è Õ Ø㹡Òû‡Í§¡Ñ¹ÃѧÊÕ UVA 䴌¹¹áÊ´§´Ñ§µÒÃÒ§·Õè 2 Ñé µÒÃÒ§·Õè 2 ÊÒáѹᴴ·ÕÁ¤³ÊÁºÑµã¹¡Òû‡Í§¡Ñ¹ÃѧÊÕ UVA(2,3) è Õ Ø Ô UVA filters Avobenzone (»‡Í§¡Ñ¹ UVA1 ᵋäÁ‹¤§·¹µ‹Íáʧ) Oxybenzone (»‡Í§¡Ñ¹ UVA 2) Sulisobenzone (»‡Í§¡Ñ¹ UVA 2) Terephthalydene dicamphor sulfonic acid (TDSA; Mexoryl®SX) Drometrizole trisiloxane (DTS; Mexoryl®XL) Methylene bis- benzotriazolyl tetramethylbutylphenol (MBBT; Tinosorb®M) Bis-ethylhexyloxyphenol methoxyphenol triazine (BEMT; Tinosorb®S) Titanium dioxide (¢Ö¹¡Ñº¢¹Ò´¢Í§ particle) é Zinc oxide (¢Ö¹¡Ñº¢¹Ò´¢Í§ particle) é 1.3 ¡ÒÃàÅ×͡㪌Âҡѹᴴ ¡ÒÃàÅ×Í¡ÂҡѹᴴäÁ‹¨Ò໚¹µŒÍ§àÅ×Í¡ª¹Ô´·ÕÁÕ SP. ÊÙ§ ᵋ¤ÇÃàÅ×͡㪌ÂҡѹᴴãˌÊÍ´ í è¤ÅŒÍ§¡Ñº¡Ô¨¡ÃÃÁ㹪Õǵ»ÃШíÒÇѹ¢Í§àÃÒNjÒã¹áµ‹ÅÐÇѹàÃÒµŒÍ§ÍÍ¡á´´ÁÒ¡¹ŒÍÂà¾Õ§㴠àÇÅÒàÅ×Í¡ Ô«×ÍÂҡѹᴴ¤ÇÃàÅ×Í¡ª¹Ô´·ÕÊÒÁÒö»‡Í§¡Ñ¹ UVA 䴌´Ç (Êѧࡵ䴌¨Ò¡¤‹Ò PA·ÕÃкآҧËÅÍ´) é è Œ è Œ¡Ò÷ÒÂҡѹᴴµŒÍ§·Ò˹ҾÍÊÁ¤Çà (2mg/cm ) ¨Ö§¨Ð䴌 “protection factor” ã¡ÅŒà¤Õ§·Õ¡Ò˹´ 2 è íänj ઋ¹ ·Ò»ÃÔÁÒ³ 1 ¡ÃÑÁ (ËÃ×Í 2 ¢ŒÍ¹ÔÇÁ×Í) ÊíÒËÃѺ¡Ò÷ҷÑÇ˹ŒÒ 1 ¤Ãѧ ËÃ×ÍËÒ¡µŒÍ§¡Ò÷ÒÂÒ é è é¡Ñ¹á´´·Ñ§µÑÇ ¤Ç÷һÃÔÁÒ³ 35 ¡ÃÑÁ ËÃ×Í 35 ÁÔÅÅÔŵõ‹Í¡ÒÃ·Ò 1 ¤Ãѧ áÅФÇ÷ҫéÒ ËÅѧNjÒ¹éÒ é Ô é í íËÃ×Íàŋ¹¡ÕÌÒ à¹×ͧ¨Ò¡¹éÒáÅÐà˧×ͨÐÅÐÅÒÂÂҡѹᴴÍÍ¡ä»ä´Œ è í è
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 79 1.4 ¼Å¢ŒÒ§à¤Õ§¢Í§¡ÒÃ㪌ÊÒáѹᴴ â´Â·ÑÇ仡ÒÃ㪌ÊÒáѹᴴ¹Ñºä´ŒÇÒ໚¹ÊÔ§·Õ»ÅÍ´ÀÑ ¡ÒÃᾌ·§ã¹ÅѡɳРcontact è ‹ è è Ñéallergy ¤×Í ¡ÒÃᾌµÑÇÊÒÃàͧ áÅÐ photocontact allergy ¤×Í ¡ÒÃᾌÊÒÃàÁ×èÍ䴌ÃѺáʧËÇÁ´ŒÇ¾ºä´Œ¹ÍÂàÁ×Íà·Õº¡Ñº¨íҹǹ¤ÃѧáÅлÃÔÁÒ³¡ÒÃ㪌·ÇâÅ¡ Œ è é Ñè ¤ÇÒÁ¡Ñ§ÇÅ»ÃСÒÃ˹֧¢Í§¼ÙºÃÔâÀ¤ ¤×Í ¡Ò÷ÕÊÒáѹᴴ¶Ù¡´Ù´«ÖÁࢌÒÊÙ¡ÃÐáÊâÅËԵ䴌 è Œ è ‹·Ñ§¹ÕÁÃÒ§ҹ·Õ¾ºÇ‹ÒÊÒáѹᴴºÒ§µÑÇÁÕÄ·¸Ôì “estrogenic” ¨Ö§¡‹Íãˌà¡Ô´¤ÇÒÁ¡Ñ§ÇÅNjҡÒÃ䴌úÊÒà é é Õ è ѡѹᴴµ‹Íà¹×ͧ¡Ñ¹¹Ò¹æ ¨Ð·íÒãˌ¼ãªŒÁâÍ¡ÒÊ໚¹ÁÐàÃç§àµŒÒ¹Á ÏÅÏ à¾ÔÁ¢Ö¹ËÃ×ÍäÁ‹ è ٌ Õ è é ¾Ñ²¹Ò¡Ò÷ÕÊҤѭÍÕ¡»ÃСÒÃ˹֧ ¤×Í ¡ÒÃÂÖ´ ËÃ×Í “µÃÖ§” ÊÒáѹᴴ¡Ñº “polymer” «Ö§ èí è è·íÒãˌÊÒÃàËŋҹÕà¡ÒеԴ¡Ñº¼ÔÇ˹ѧ䴌´¢¹ ¡ÃШÒµÑÇ´Õ¢¹ áÅж١´Ù´«ÖÁࢌÒÊÙ¡ÃÐáÊâÅËÔµ¹ŒÍÂŧ é Õ Öé Öé ‹´Ñ§¹Ñ¹¼Åâ´ÂÃÇÁ·Ñ§Ãкº¨Ö§¹‹Ò¨ÐŴŧ é é2. ¡Òû‡Í§¡Ñ¹áʧᴴâ´ÂàÊ×éͼŒÒ áÅÐËÁÇ¡ (Physical photoprotection) àÊ×ͼŒÒª‹Ç»‡Í§¡Ñ¹¼ÔÇ˹ѧ¨Ò¡ÍѹµÃÒ¢ͧáʧᴴ䴌´Õ â´Âª¹Ô´áÅФسÊÁºÑµ¢Í§¼ŒÒ¹Ñ¹ é Ô éÊÒÁÒö¡Ñ¹áʧᴴ䴌µÒ§¡Ñ¹ ઋ¹ ¼ŒÒ wool, jeans, polyester ¡Ñ¹ÃѧÊÕ ultraviolet䴌´¡Ç‹Ò¼ŒÒ cotton, ‹ Õranyon áÅÐlinen. ¼ŒÒÊÕࢌÁ¡Ñ¹ÃѧÊÕ ultraviolet䴌´¡Ç‹Ò¼ŒÒÊÕÍ͹ ËÁÇ¡ª‹Ç»‡Í§¡Ñ¹áʧᴴºÃÔàdz Õ ‹ (4)ÈÕÃÉÐ, ˹ŒÒ áÅÐ¤Í â´Â¨Ð»‡Í§¡Ñ¹áʧᴴ䴌´ËÃ×ÍäÁ‹¹¹¢Ö¹¡ÑºÇÑʴط㪌·ÒËÁÇ¡ ÃÙ»·Ã§¢Í§ËÁÇ¡ Õ Ñé é Õè íáÅТ¹Ò´¢Í§»‚¡ËÁÇ¡ ¨Ò¡¡ÒÃÈÖ¡ÉÒà»ÃÕºà·ÕºËÁÇ¡»‚¡¡ÇŒÒ§ áÅÐËÁÇ¡»‚¡á¤º ¾ºÇ‹ÒËÁÇ¡»‚¡¡ÇŒÒ§ ( > 7.5 cm.) ÊÒÁÒö»‡Í§¡Ñ¹áʧᴴ䴌´Õ ã¹¢³Ð·ÕËÁÇ¡»‚¡á¤º (<2.5 cm.) ¨Ð»‡Í§¡Ñ¹ èáʧᴴºÃÔàdz¨ÁÙ¡, ¤ÍáÅФҧ䴌¹ÍÂÁÒ¡ Œ (5)3. ¡Òû‡Í§¡Ñ¹áʧᴴâ´ÂÇÔ¸ÕÍ×è¹æ 㹪Õǵ»ÃШíÒÇѹ àÃÒÊÒÁÒöàÅÕ§áʧᴴâ´ÂËźᴴ㵌à§Ò¢Í§ÍÒ¤Òà ÍÂÙ㵌ÃÁäÁŒ ËÃ×Í㪌 Ô è ‹ ‹Ã‹Áà¾×Í»‡Í§¡Ñ¹áʧᴴ ¶Ö§áÁŒÍÂÙã¹ÍÒ¤ÒÃàÃÒ¡çÁâÍ¡ÒÊÃѺÃѧÊÕ UV à¹×ͧ¨Ò¡ÃѧÊÕ UVAÂѧÊÒÁÒö¼‹Ò¹ è ‹ Õ è¡ÃШ¡ä´Œ »˜¨¨ØºÑ¹ºŒÒ¹·ÕèÍÂًÍÒÈÑÂÃÇÁ¶Ö§ÍÒ¤ÒÃÊíҹѡ§Ò¹¹ÔÂÁ㪌¡ÃШ¡à»š¹Ê‹Ç¹»ÃСͺÊíҤѭà¹×ͧ¨Ò¡ãˌ¤ÇÒÁÊǧÒÁᡋÍÒ¤Òà ¤Ø³ÊÁºÑµ¢Í§¡ÃШ¡â´Â·ÑÇ仹ѹÊÒÁÒö»‡Í§¡Ñ¹¡Òü‹Ò¹¢Í§ è Ô è éÃѧÊÕ UVB ᵋÃѧÊÕ UVAÊÒÁÒö¼‹Ò¹¡ÃШ¡à¢ŒÒÁÒ䴌 ´Ñ§¹Ñ鹼ٌ·Õè¹Ñ觷íÒ§Ò¹ã¡ÅŒ¡ÃШ¡¨Ö§ÁÕâÍ¡ÒÊÃѺÃѧÊÕ UVA䴌 »˜¨¨Øº¹ÁÕ¡ÒüÅÔµ¡ÃШ¡·ÕÁ¤³ÊÁºÑµ»Í§¡Ñ¹ÃѧÊÕ UVA, ã¹¢³Ð·Õáʧvisible Âѧ¼‹Ò¹ Ñ è Õ Ø Ô ‡ èࢌҵÒÁ»¡µÔ ¨Ö§à»š¹ÍÕ¡·Ò§àÅ×Í¡ÊíÒËÃѺ¼Ù·µÍ§¡ÒÃÅ´ÍѹµÃÒ¨ҡáʧᴴ Œ Õè Œ ã¹·Ø¡Çѹ¤¹Ê‹Ç¹ãË­‹ µŒÍ§à´Ô¹·Ò§â´Âö¹µà¾×ÍÁÒ·íÒ§Ò¹ à¹×ͧ¨Ò¡¡ÒèÃҨ÷յ´¢Ñ´·íÒ è è è ÔãˌᵋÅÐÇѹµŒÍ§ãªŒàÇÅÒ¹Ò¹ÍÂÙã¹Ã¶Â¹µ ¡ÃШ¡Ë¹ŒÒö¹µ (windshield) ·íÒ¨Ò¡ laminated glass ‹ÁÕ¤³ÊÁºÑµã¹¡ÒáѹUVA䴌´ÁÒ¡ ã¹¢³Ð·Õ¡ÃШ¡´ŒÒ¹¢ŒÒ§¤¹¢ÑºáÅСÃШ¡´ŒÒ¹¢ŒÒ§¼Ùâ´ÂÊÒÃʋǹ Ø Ô Õ è ŒãË­‹à»š¹ tempered glass¨Ð»‡Í§¡Ñ¹ UVA䴌à¾Õ§ºÒ§Ê‹Ç¹ (µÒÃÒ§·Õè 3) ´Ñ§¹Ñ¹ËÒ¡µŒÍ§¡ÒÃàÅÕ§¡Òà é è䴌úÃѧÊÕ ultraviolet ¢³ÐÍÂÙã¹Ã¶Â¹µ ¤ÇõԴ¿ÅÁ¡Ãͧáʧö¹µà¾ÔÁ(6) Ñ ‹  è
  • 80 Novel Sunscreen and Photoprotective MethodsµÒÃÒ§·Õè 3 áÊ´§ÃŒÍÂÅТͧÃѧÊÕ UVA·Õ輋ҹ¡ÃШ¡Ã¶Â¹µ(6) ¡ÃШ¡Ã¶Â¹µ ª¹Ô´¢Í§¡ÃШ¡ ÌÍÂÅТͧÃѧÊÕ UVA ·Õ輋ҹ¡ÃШ¡¡ÃШ¡Ë¹ŒÒ¢Í§Ã¶Â¹µ (Windshield) Laminated glass 3%¡ÃШ¡´ŒÒ¹¢ŒÒ§ Tempered glass 48%¡ÃШ¡ËÅѧ¢Í§Ã¶Â¹µ Tempered glass 48%ÊÃØ» ¡Òû‡Í§¡Ñ¹ÍѹµÃÒ¨ҡáʧᴴ·íÒ䴌â´ÂàÅÕ§¡ÒÃÍ͡ᴴ㹪‹Ç§àÇÅÒ·ÕÁ»ÃÔÁÒ³ ultraviolet è è ÕÊÙ§ ¤×ͪ‹Ç§àÇÅҵѧᵋ 10.00-16.00 ¹. 㪌àÊ×ͼŒÒ·ÕàËÁÒÐÊÁ ÊÇÁËÁÇ¡»‚¡¡ÇŒÒ§ ËÃ×͡ҧËÁàÁ×Í é é è èÍÍ¡á´´ áNj¹¡Ñ¹á´´¨Ðª‹Ç»‡Í§¡Ñ¹¡ÒÃà¡Ô´µŒÍ¡ÃШ¡¨Ò¡áʧᴴ䴌 àÃÒ¤ÇÃ㪌Âҡѹᴴ໚¹»ÃШíÒàÁ×èÍÍÍ¡á´´áÅФÇÃàÅ×͡㪌Âҡѹᴴ·ÕèÁդسÊÁºÑµÔ»‡Í§¡Ñ¹ä´Œ·Ñé§UVA áÅÐUVB áÅÐÊÒÁÒö¡Ñ¹¹éÒ䴌 ¡Ò÷ÒÂҡѹᴴ¤ÇÃãˌ˹ҾÍÊÁ¤ÇÃáÅзҫéÒËÅѧNjÒ¹éÒËÃ×Íàŋ¹¡ÕÌÒ ¡ÒÃà´Ô¹·Ò§â´Â í í íö¹µÁâÍ¡ÒÊ䴌úáʧ UVA ¼‹Ò¹à¢ŒÒÁÒ·Ò§¡ÃШ¡´ŒÒ¹¢ŒÒ§ ¨Ö§¤ÇõԴ¿ÅÁ¡Ãͧáʧö¹µà¾ÔÁ Õ Ñ  èàÍ¡ÊÒÃ͌ҧÍÔ§1. ³Ñ¯°Ò ÃѪµÐ¹ÒÇÔ¹ Âҡѹᴴ ã¹: ÇÔªµ ÅÕ¹µ¾§É, ºÃóҸԡÒÃ. áʧᴴáÅмÔÇ˹ѧ ¾ÔÁ¾¤Ãѧ·Õè 1 áÍÅ ·Õ à¾ÃÊ; 2547 Ô Ø é ˹ŒÒ 378-4202. Tuchinda C, Lim HW, Osterwalder U, Rougier A. Novel emerging sunscreen technologies. Dermatol Clin 2006; 24: 105-17.3. Kullavanijaya P, Lim HW. Photoprotection. J Am Acad Dermatol 2005;52:937-58.4. Hoffmann K, Laperre J, Avermaete A, Altmeyer P, Gambichler T. Defined UV protection by apparel textiles. Arch Dermatol 2001;137:1089-94.5. Diffey BL, Cheeseman J. Sun protection with hats. Br J Dermatol 1992;127:10-2.6. Tuchinda C, Srivannaboon S, Lim HW. Photoprotection by windowglass, automobile glass and sunglasses. J Am Acad Dermatol 2006; 54: 845-54.
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 81 12 The Cosmetic Use of Botulinum Toxin ÃͧÈÒʵÃÒ¨ÒÏ ¹ÒÂᾷÇþ§É Á¹ÑÊà¡ÕÂÃµÔ ÀÒ¤ÇÔªÒµ¨ÇÔ·ÂÒ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÔÔ ÍÒ¨ÒÏ ᾷ˭ԧÃѧÊÔÁÒ Ç³ÔªÀÑ¡´Õà´ªÒ ÀÒ¤ÇÔªÒµ¨ÇÔ·ÂÒ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÔÔ ÍÒ¨ÒÏ ᾷ˭ԧÃѪµ¸Ã ËÁ͹¨Ñ¹·Ã ÀÒ¤ÇÔªÒÍÒÂØÃÈÒʵÏ ¤³Ðá¾·ÂÈÒʵÏ ¨ØÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑÂÊÒÃ⺷ÙÅÔ¹ØÁ ·çÍ¡«Ô¹¤×ÍÍÐäà ⺷ÙŹÁ ·çÍ¡«Ô¹ (Botulinum Toxin, BNT) ໚¹â»ÃµÕ¹·ÕÊÌҧÁÒ¨Ò¡àª×ÍẤ·ÕàÃÕª¹Ô´Ë¹Ö§ Ô Ø è é èª×Í ¤ÅÍʵÃÔà´ÕÂÁ ⺷ÙŹÁ (Clostridium botulinum) «Ö§à»š¹àª×ͪ¹Ô´¡ÃÑÁºÇ¡ spore-forming bacilli è Ô Ñè è é·ÕäÁ‹µÍ§¡ÒÃÍÍ¡«Ôਹ㹡ÒÃà¨ÃÔ­àµÔºâµ ¨¹¶Ö§»˜¨¨Øº¹ÁÕÊÒà BNT ·Ñ§ËÁ´ 8 ª¹Ô´ (subtypes) ¤×Í è Œ Ñ éA, B, C1, C2, D, E, F áÅÐ G «Ö§ÁÕ¢¹Ò´âÁàÅ¡ØÅᵡµ‹Ò§¡Ñ¹ä» µÑ§áµ‹ 300 to 900 kDa ᵋÊÒà è ébotulinun toxin ·ÕÁ㪌¡¹Í‹ҧá¾Ã‹ËÅÒÂÁÕ 2 ª¹Ô´¤×Í botulinun toxin type A áÅÐ B è Õ Ñ Botulinun toxin type A ¼ÅÔµ¨Ò¡ Clostridium botulinum, Hall strain â¤Ã§ÊÌҧ botulinuntoxin µŒ¹áººã¹ÃÐÂÐáá໚¹ polypeptides ÊÒÂà´ÕÂÇ¢¹Ò´ÂÒÇÁÕ¹Ò˹ѡ 150 kDa ¤Ø³ÊÁºÑµ¢Í§ éí Ô¾ÔÉäÁ‹Ã¹áç ᵋàÁ×Í polypeptides ¶Ù¡á¡ÊÅÒÂ䴌໚¹ 2 ÊÒ ¤×Í heavy chain (100 kDa) áÅÐÊÒÂ Ø èlight chain (50 kDa)â´ÂÁÕʧ¡ÐÊÕà¡ÒÐÍÂÙã¹ light chain ¡ÒÃà»ÅÕ¹á»Å§ÀÒÂã¹ÊÒ·çÍ¡«Ô¹·íÒãˌ Ñ ‹ è¾ÔÉÁÕÄ·¸Ôáç¢Ö¹ ´Ñ§áÊ´§ã¹ÃÙ»·Õè 1 ì é ÃÙ»·Õè 1 áÊ´§â¤Ã§ÊÌҧâÁàÅ¡ØÅ 3 ÁÔµÔ ¢Í§ 150 kDa Botulinum toxin A complex »ÃСͺ´ŒÇ 2 ÊÒ àª×èÍÁ¡Ñ¹´ŒÇ¾ѹ¸Ð disulfide 1) ÊÒ 100 kDa heavy chain (´ŒÒ¹«ŒÒÂÁ×Í) ໚¹Ê‹Ç¹¢Í§ binding domain ·ÕÁ˹ŒÒ·Õ仨Ѻ¡Ñº presynaptic nerve membrane Ẻ è Õ è high affinity áÅÐirreversible »ÃСͺ´ŒÇ ·ÕÁÕ N-terminus áÅÐC- è terminus 2) ÊÒ 50 kDa light chain ໚¹Ê‹Ç¹¢Í§ Catalytic domain ·Õ¶¡ è Ù »Å‹ÍÂÍÍ¡ä»ÍÂÙ㹫ÑÂâµ¾ÅÒÊ«ÖÁ ä»á¡â»ÃµÕ¹ã¹ synaptic ‹ fusion complex
  • 82 The Cosmentic Use of Botulinum Toxin¡Åä¡¡ÒÃÍÍ¡Ä·¸Ôì ÊÒà botulinun toxin ·Ø¡ª¹Ô´ÁÕÄ·¸Ô·Òãˌà¡Ô´¡ÒäÅÒµÑǢͧ¡ÅŒÒÁà¹×ͪÑǤÃÒÇ â´Â·íÒ˹ŒÒ·Õè ì í é èÂѺÂѧäÁ‹ãˌà¡Ô´¡ÒÃËÅѧ¢Í§ÊÒà Acetylcholine (ACh) ࢌÒä»ã¹ª‹Í§Ç‹Ò§ synaptic cleft ºÃÔàdz»ÅÒ é è»ÃÐÊÒ·¢Í§¡ÅŒÒÁà¹×Í áÅÐÂѧÁÕÄ·¸ÔµÍ»ÅÒ»ÃÐÊÒ·¢Í§ autonomic cholinergic «Ö§ÁÕ˹ŒÒ·Õ㹡Òà é ì ‹ è èÊÌҧà˧×Í´ŒÇ ᵋ¨ÐäÁ‹Á¼Å·íÒÅÒÂàʌ¹»ÃÐÊÒ· áÅÐäÁ‹Á¼Åµ‹Í¡ÒÃÊÌҧËÃ×Í¡ÒÃÊÐÊÁ¢Í§ÊÒà ACh è Õ Õ ã¹ÀÒÇл¡µÔ¨ÐÁÕ¡ÒÃÊÌҧÊÒà ACh ºÃèØÍÂÙ㹶ا (vesicles) ÃÍÍÂ٨ҹǹÁÒ¡ à¡ÅŒÒÁà¹×Í ‹ ‹í é¨Ðà¡Ô´¡ÒÃË´à¡Ã秢ֹ¡çµÍàÁ×Í ACh ¨Ñº¡ÑºµÑÇÃѺ (receptors) º¹ peripheral cholinergic motor neuron é ‹ èend plate (docking step) áÅж١»Å‹ÍÂä»Âѧ neuromuscular junction áÅÐÁÕ¢ºÇ¹¡Òà depolarizationà¡Ô´¢Ö¹ ËÅѧ¡Òéմ BNT ¡ÒÃ͋͹áç¢Í§¡ÅŒÒÁà¹×ͨÐäÁ‹à¡Ô´¢Ö¹ã¹·Ñ¹·Õà¾ÃÒШеŒÍ§ÁÕ¢¹µÍ¹¡Òà é é é Ñéà»ÅÕè¹á»Å§¢Í§ÂÒ¡‹Í¹ â´Â¢ºÇ¹¡Ò÷Õè⺷ÙÅÔ¹ØÁ ·çÍ¡«Ô¹à¢ŒÒÊً»ÅÒ»ÃÐÊÒ·ÁÕ 4 ¢Ñ鹵͹´Ñ§áÊ´§ã¹ÃÙ»·Õè 2 ʋǹ¡ÒÃà»ÅÕ¹¢Í§»ÅÒ»ÃÐÊÒ·¡ÅѺÊÙÊÀÒ¾»¡µÔ ÂѧäÁ‹·ÃÒº¡Åä¡á¹‹ª´ ᵋ è ‹ ÑÊѳ¹ÔɰҹNjÒà¡Ô´¨Ò¡¡ÒÃÊÌҧãËÁ‹¢Í§»ÅÒ»ÃÐÊÒ· (collateral axonal sprouting) «Ö§»ÃСͺ´ŒÇ è2 ¢Ñ¹µÍ¹ é ¢Ñ¹µÍ¹·Õè 1. Binding step: Botulinun toxin à¡ÒÐ cholinergic receptor (receptor- émediated endocytosis) â´Âʋǹ C-terminal ¢Í§ÊÒ heavy chain ¨Ðà¡ÒСѺµÑÇÃѺ cholinergic receptor «Ö§ÍÂÙº¹ è ‹¼¹Ñ§ËØÁ (cell membrane) ¢Í§ presynaptic cholinergic motor nerve terminal à¡Ô´à»š¹ “toxin-receptor Œcomplex” ¢Ñ鹵͹·Õè 2. Internalization step: Botulinum toxin à¤Å×è͹ࢌÒÀÒÂã¹à«Åŏ ¼¹Ñ§ËØÁà«Åŏ»ÃÐÊÒ·ºÃÔàdz»ÅÒ»ÃÐÊÒ·¨ÐâͺŌÍÁ botulinun toxin «Ö§à¡ÒÐÍÂÙ¡ºµÑÇÃѺ Œ è ‹ Ñ(toxin-receptor complex) áŌÇËÅشࢌÒä»ÀÒÂã¹à«Åŏ¡ÅÒÂ໚¹ toxin-containing vesicle ã¹ cytoplasm¢Í§à«Åŏ»ÃÐÊÒ· ÃÙ»·Õè 2 áÊ´§¡Åä¡¡ÒÃÍÍ¡Ä·¸Ôì¢Í§ÊÒÃ⺠·ÙÅÔ¹ØÁ ·çÍ¡«Ô¹ 2 (1) àÁ×ÍÊÒ heavy chain ¢Í§ botulinun toxin ä»à¡ÒСѺ è µÑÇÃѺ plasma membrane receptor ·Õè»ÅÒ»ÃÐÊÒ· (neuromuscular junction) (2) ¨Ò¡¹Ñé ¹ ¼¹Ñ § à«Åŏ »ÃÐÊÒ·ºÃÔ à dz´Ñ § ¡Å‹ Ò Ç¨ÐâͺŌ Í Á botulinun toxin complex ࢌÒ仡ÅÒÂ໚¹ vesicle ÅÍÂÀÒÂã¹à«Åŏ (3) ÊÒ¢ͧ botulinun toxin ·Õèà¡ÒСѹ¨ÐËÅØ´ÍÍ¡ºÃÔàdz disulfide bond ʋǹ¢Í§ light chain ¨Ðà¤Å×͹ÍÍ¡ÁÒã¹ è cytoplasm áÅÐ仨Ѻ¡Ñº SNARE complex (soluble N-ethylmaleimide-sensitive factor attachment protein receptor) º¹µÑÇÃѺ·Õ¨Òà¾Òе‹Íª¹Ô´¢Í§ botulinun toxin (4) ·íÒãˌ èícomplex á¡ÍÍ¡¨Ò¡¡Ñ¹ ʋ§¼ÅãˌäÁ‹à¡Ô´¡Òà exocytosis ¢Í§ Acetylcholine ä»Âѧ synaptic space of NMJ (LC = lightchain; HC = heavy chain C-terminus; HN = heavy chain N-terminus; SNAP-25 synaptosome-associated protein of 25 kd;VAMP = vesicle-associated membrane protein)
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 83 ¢Ñ鹵͹·Õè 3. Translocation step: ¡ÒÃà¤Å×è͹ŒÒ¢ͧ BNT ÀÒÂã¹à«Åŏ Botulinun toxin «Ö§»ÃСͺ´ŒÇÂÊÒ heavy chain à¡ÒСѺÊÒ light chain ÀÒÂã¹ vesicle è¨ÐÁÕ¡ÒÃà»ÅÕ¹á»Å§â´ÂÊÒ·ѧÊͧËÅØ´ÍÍ¡¨Ò¡¡Ñ¹µÃ§ disulfide bond á¡໚¹ 2 ÊÒ áÅоºÇ‹Ò è é੾ÒÐ light chain (ÁÕ highly specific zinc-dependent protease) ¨ÐËÅØ´ÍÍ¡¹Í¡ vesicle ࢌÒÁÒã¹cytoplasm ¢Í§à«Åŏ»ÃÐÊÒ· ¢ºÇ¹¡ÒùյͧÍÒÈÑ N-terminal ¢Í§ heavy chain ໚¹µÑǪ‹ÇÂãˌ é Œlight chain ¼‹Ò¹ÍÍ¡¨Ò¡ vesicle 䴌 ¢Ñ鹵͹·Õè 4. Blocking step: ¡ÒÃÂѺÂÑ駡ÒÃËÅÑ觢ͧ acetylcholine ¡ÒÃÂѺÂѧ¡ÒÃËÅѧ¢Í§ acetylcholine «Ö§à»š¹ neurotransmitter â´Â light chain ¨Ðà¡ÒСѺ é èµÑÇÃѺ (receptor) ¨Ò¡¡ÒÃÈÖ¡ÉÒ·Õè nerve ending ¾ºÇ‹ÒÁÕµÇÃѺ (receptor) ¢Í§ light chain ËÅÒ Ѫ¹Ô´«Ö§áµ‹ÅЪ¹Ô´¨ÐÁÕ¤ÇÒÁ¨íÒà¾Òе‹Í light chain ¢Í§ botulinun toxin ᵋÅЪ¹Ô´ ´Ñ§µÒÃÒ§·Õ1 ઋ¹ è èC-terminus ¢Í§ light chain ¢Í§ BNT-A ÁÕ¤ÇÒÁ¨íÒà¾ÒСѺµÑÇÃѺ SNAP-25A (25 kDa synaptosomeassociated protein) â´ÂàÁ×Í botulinun toxin type A à¡ÒСѺ SNAP-25 ¡ç¨ÐÂѺÂѧ¡ÒÃËÅѧ¢Í§ è é èacetylcholine ·Õè neuromuscular junction ʋǹ Gin70-Phe77 «Ö§à»š¹¡Ã´ÍÐÁÔâ¹ã¹ botulinun toxin ètype B ¨ÐÁÕ¤ÇÒÁ¨íÒà¾ÒСѺµÑÇÃѺ VAMP (vesicle-associated membrane protein) áÅÐ synaptobrevin·ÕÍÂÙºÃÔàdzàÂ×ÍËØÁ»ÅÒ»ÃÐÊÒ· è ‹ è ŒµÒÃÒ§·Õè 1 áÊ´§ Binding sites º¹ SNARE Protein Complex ¢Í§ botulinun toxin ª¹Ô´µ‹Ò§ 檹Դ¢Í§ Botulinun toxin ª¹Ô´¢ÍºµÑÇÃѺ µíÒá˹‹§·Õ¾ºµÑÇÃѺ èBotulinun toxin -A SNAP-25 Presynaptic plasma membraneBotulinun toxin -B VAMP/synaptobrevin Synaptic vesicleBotulinun toxin -C1, C2 SYNTAXIN, SNAP-25, Syntaxin Presynaptic plasma membraneBotulinun toxin -D VAMP, synaptobrevin, Synaptic vesicle, Cellubrevin Vesicles of endocytosing/ recycling systemBotulinun toxin -E SNAP-25 Presynaptic plasma membraneBotulinun toxin -F VAMP, synaptobrevin, Synaptic vesicle, Cellubrevin Vesicles of endocytosing/ recycling systemBotulinun toxin -G VAMP, synaptobrevin, Syntaxin ¢Ñ鹵͹·Õè 5: Resprouting ¡ÒÃÊÌҧãËÁ‹¢Í§ axon ¾ºÇ‹ÒËÅѧ¨Ò¡©Õ´ botulinun toxin à¾Õ§ 2 Çѹ ¨ÐÁÕᢹ§¢Í§ axon à¡Ô´¢Ö¹ãËÁ‹ ã¡ÅŒ¡ººÃÔàdzà´ÔÁ é Ñ ¢Ñ¹µÍ¹·Õè 6 Re-establishing motor end-plate é
  • 84 The Cosmentic Use of Botulinum Toxin ÁÕ¡ÒÃÊÌҧ Motor end-plate ãËÁ‹ã¹áµ‹ÅÐᢹ§ axon ·ÕᵡãËÁ‹ ·íÒãˌ¡ÒÃËÅѧ¢Í§ ACh è èàÁ×ÍÁÕ¡ÒÃᵡᢹ§ axon à¾ÔÁÁÒ¡¢Ö¹ ¡ÒÃËÅѧ¢Í§ ACh ¡ç¨Ðà¾ÔÁ¢Ö¹µÒÁÅíҴѺ·íÒãˌ¡ÅŒÒÁà¹×Íà¡Ô´ è è é è è é é¡ÒÃÃÑ´µÑÇ䴌áÅÐàÁ×Í Motor end-plate à´ÔÁ¡ÅѺÊÙÀÒÇл¡µÔ ᢹ§ axon «Ö§à¡Ô´ãËÁ‹¡¨Ð¤‹ÍÂÊÅÒÂ è ‹ è çËÒÂä»ÃÙ»·Õè 3, 4 áÊ´§¡ÒÃà¡Ô´ãËÁ‹¢Í§á¢¹§»ÅÒ»ÃÐÊÒ·ËÅѧ©Õ´ botulinun toxin áÅÐÁÕ¡ÒÃÊÌҧ motor end plate ãËÁ‹¢Öé¹ã¹ºÃÔàdz¢ŒÒ§à¤Õ§ 㹺ÃÃ´Ò botulinun toxin ·Ø¡ª¹Ô´ botulinun toxin type A ໚¹ª¹Ô´·ÕÁÄ·¸ÔáçÊØ´ áÅйÔÂÁ è Õ ì㪌¡¹Í‹ҧá¾Ã‹ËÅÒ·ҧ¡ÒÃᾷ ËÅѧ¡Òéմ botulinun toxin ¾ºÇ‹Ò¡ÅŒÒÁà¹×ͨÐàÃÔÁ͋͹áçÀÒÂ Ñ é èã¹ 6 ªÑèÇâÁ§ áÅÐàËç¹¼ÅÊÙ§ÊØ´ã¹àÇÅÒ»ÃÐÁÒ³ 7 Çѹ ¼Å¹Õé¨Ð໚¹ÍÂًà¾Õ§ªÑèǤÃÒǤ×Í»ÃÐÁÒ³ 3-6 à´×͹ àÁ×͡ŌÒÁà¹×Ͷ١¤ÅÒµÑÇ´ŒÇ botulinun toxin µ‹Íà¹×ͧ¡Ñ¹ ¨Ðà¡Ô´ÀÒÇСŌÒÁà¹×ÍÅÕººÒ§ è é è éʋǹ¨Ò¡¡ÒÃäÁ‹ä´ŒãªŒ§Ò¹ (disuse muscular atrophy) »ÃÔÁÒ³Âҷյͧ¡ÒÃ㪌㹡Òéմ¤Ãѧµ‹Íä»¨Ð è Œ 鹌ÍÂŧ áÅÐÊÒÁÒö©Õ´ã¹ÃÐÂÐàÇÅÒ·ÕËÒ§ÍÍ¡ä»ä´Œ è ‹ ¡ÒÃ㪌ÊÒà botulinun toxin à¾×Í»ÃÐ⪹ã¹´ŒÒ¹¤ÇÒÁÊǧÒÁ (aesthetic medicine) àÃÔÁ è è¢Ö¹ã¹»‚ ¤.È.1987 â´Â Dr.Jean Carruthers ¨Ñ¡ÉØᾷªÒÇ᤹ҴÒ䴌 ÊѧࡵàËç¹Ç‹ÒÃÍ‹¹ËÑǤÔÇ é é¨ÐËÒÂä»àÁ×Í©Õ´ botulinun toxin ÃÑ¡ÉÒâä blepharospasm áÅдŒÇÂÊÒÁբͧà¸Í ¤×Í Dr.Alastair èCarruthers ໚¹á¾·Â¼Ç˹ѧᾷ·§Êͧ·‹Ò¹¨Ö§ä´ŒÃÇÁ¡Ñ¹¹íÒ botulinun toxin type A ÁÒÃÑ¡ÉÒ Ô Ñé ‹ÃÍ‹¹º¹ãºË¹ŒÒ ઋ¹ ÃÍ‹¹ºÃÔàdzËÑǤÔÇ (glabellar frown lines) ÃÍ‹¹º¹Ë¹ŒÒ¼Ò¡ (horizontal éforehead lines) áÅÐÃ͵չ¡Ò (lateral canthal lines) ¾ºÇ‹Ò䴌¼Å´Õ áÅÐÃÒ§ҹ¼Å¡Òà ÃÑ¡ÉÒ¤Ãѧ éáá㹻‚ ¤.È.1990 ¨Ö§à¡Ô´¡ÃÐáʹÔÂÁ㪌 botulinun toxin 㹡ÅØÁᾷÊÒ¢Òâä¼ÔÇ˹ѧà¾ÔÁ¢Ö¹ÁÒ¡ ‹ è éáÅÐÁÕÃÒ§ҹ·´Åͧ©Õ´ botulinun toxin ÃÔÇÃͺÃÔàdz˹ŒÒ¼Ò¡ áÅкÃÔàdzÍ×¹æ ¢Í§¼ÔÇ˹ѧ·ÕÁÃÇ é è è Õ ÔéÃ͵ÒÁÍÒÂآ ¨¹¤³Ð¡ÃÃÁ¡ÒÃÍÒËÒÃáÅÐÂÒ »ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡Ò (US-FDA) 䴌͹حҵãˌ㪌 ÑBotulinum toxin A (Botox®) 㹡ÒÃÃÑ¡ÉÒÃÍ‹¹ºÃÔàdzËÑǤÔÇ (glabellar hyperdynamic lines) ã¹»‚ é¤.È.2002
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 85µíÒÃѺÂÒ (The Different Products) ¨¹¶Ö§»˜¨¨Øº¹ÁÕ botulinun toxin 3 µíÒÃѺ·ÕÁ¨Ò˹‹ÒÂáÅÐ㪌¡¹Í‹ҧá¾Ã‹ËÅÒ 䴌ᡋ botulinun Ñ è Õí Ñtoxin type A 2 ª¹Ô´ ¤×Í (a) Botox /Vistabel (Allergan, Irvine, Calif.) áÅÐ (b) Dysport/ Reloxin(Speywood Pharmaceuticals, Maidenhead, England; Inamed, Santa Barbara, Calif.) áÅÐ botulinuntoxin type B 1 ª¹Ô´ ¤×Í Myobloc (Elan Pharmaceuticals, South San Francisco, Calif.) ã¹»ÃÐà·Èä·ÂÁÕà¾Õ§ botulinun toxin type A 2 µíÒÃѺ·ÕÁ¨Ò˹‹Ò ¤×Í Botox® ¢Í§ºÃÔÉ· è Õí ÑAllergan ÁÕ¢¹Ò´ÂÒ 100 ˹‹Ç µ‹Í˹֧¢Ç´ «Ö§ä´ŒÃº¤ÇÒÁ¹ÔÂÁã¹»ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡Ò áÅлÃÐà·È è è Ñä·Â ÁÒ¡¡Ç‹ÒÂÒ Dysport ¢Í§ºÃÔÉ· Ipsen Ltd. ÁÕ¢¹Ò´ÂÒ 500 ˹‹Ç µ‹Í˹֧¢Ç´ «Ö§à»š¹·Õ¹ÂÁ ® Ñ è è è Ôã¹»ÃÐà·ÈÍѧ¡ÄÉ áÅСÅØÁ·ÇÕ»ÂØâû à¹×ͧ¨Ò¡Âҷѧ 2 ª¹Ô´ä´ŒÁÒ¨Ò¡¢ºÇ¹¡ÒüÅԵᵡµ‹Ò§¡Ñ¹ ¨Ö§ÁÕ ‹ è é¤ÇÒÁáç¢Í§ÂÒᵡµ‹Ò§¡Ñ¹â´Â¾ºÇ‹ÒÂÒ BotoxÍÍ¡Ä·¸Ôáç¡Ç‹Ò Dysport 2-4 à·‹Ò áµ‹Í‹ҧäáç ìµÒÁÃÒ¤Òµ‹Í˹‹Ç¢ͧ Dysport ¨Ð¶Ù¡¡Ç‹Ò ¨Ö§·íÒãˌ Dysport 䴌ú¤ÇÒÁ¹ÔÂÁá¾Ã‹ËÅÒÂÁÒ¡¢Ö¹ Ñ é¡ÒÃà¡çºÂÒ ¡ÒÃàµÃÕÂÁÂÒ áÅСÒÃà¨×ͨҧ 㹢ǴÂÒ ·Ñ§ Botox áÅÐ Dysport »ÃСͺ´ŒÇ albumin áÅÐ exotoxin ·Õ¶¡·íÒãˌ໚¹ é è Ùlyophilized form ã¹ÃÙ»¼§á»‡§ (powder) ºÃèØ㹢ǴÊÙ­­Ò¡ÒÈ «Ö§·íÒãˌ¤³ÀÒ¾¢Í§ÂÒ¤§µÑÇÊÙ§¶Ö§ è Ø4 »‚ ¡‹Í¹¶Ö§àÇÅÒ㪌§Ò¹ ÂÒ·Õ§äÁ‹¼ÊÁ¤ÇÃà¡çºáª‹á¢ç§änjã¹ÍسËÀÙÁµÒ¡Ç‹Ò -5 °C à¹×ͧ¨Ò¡ÊÒà BNT è Ñ Ô íè è¶Ù¡·íÒÅÒÂ䴌§ÒÂàÁ×Í䴌ú¤ÇÒÁÌ͹ ÁÕ¡ÒÃà»ÅÕ¹á»Å§¤ÇÒÁ໚¹¡Ã´´‹Ò§ (pH) ËÃ×ÍáÁŒáµ‹¶¡¡Ãзº ‹ è Ñ è Ù¡ÃÐá·¡ (mechanical stress) ´Ñ§¹Ñ¹¡Òâ¹Ê‹§áÅСÒÃà¡çºÃÑ¡ÉÒÂҨеŒÍ§ÃÐÇѧãˌÍÂÙã¹ÀÒÇÐÊÙ­­Ò¡Ò é ‹È áÅÐÁÕ¤ÇÒÁª×¹·Õ¾ÍàËÁÒÐ é è ÇÔ¸¡ÒüÊÁ botulinun toxin ºÃÔÉ· Allergan á¹Ð¹íÒãˌ㪌¹Òà¡Å×͹ÍÏÁÍÅ«Ö§»ÃÒȨҡÊÒÃ Õ Ñ éí è¡Ñ¹ºÙ´à¾ÃÒÐÊÒáѹºÙ´ benzyl alcohol ¨Ð·íÒÅÒ botulinun toxin ¡ÒüÊÁ¤ÇÃãˌ¹Òà¡Å×ÍäËÅà¢ŒÒ éí㹢ǴàͧÍ‹ҧªŒÒæ Í‹Ò㪌áç´Ñ¹¹éÒà¡Å×ÍࢌÒ㹢Ǵ äÁ‹¤ÇÃà¢Â‹Ò¢Ç´ áÅÐÃÐÇѧÍ‹Òãˌà¡Ô´¿Í§ÍÒ¡ÒÈ íã¹¢³Ð¼ÊÁÂÒ àÁ×ͼÊÁáŌÇãˌà¡çºÃÑ¡ÉÒänjã¹ÍسËÀÙÁÔ 2-8 °C ¡ÒÃà¨×ͨҧÂÒᾷᵋÅз‹Ò¹¨Ð㪌 èᵡµ‹Ò§¡Ñ¹ ã¹àÍ¡ÊÒáíҡѺ¢Í§ Botox ãˌ¢ÍÁÙÅãˌÊÒÁÒöà¨×ͨҧ¹éÒà¡Å×͹ÍÏÁÍÅ䴌 1, 2, ËÃ×Í 4 Œ íÁÔÅÅÔŵà à¾×Íãˌ䴌¤ÇÒÁࢌÁ¢Œ¹¢Í§ BNT 10, 5, ËÃ×Í 2.5 ˹‹Çµ‹Í 0.1 ÁÔÅÅÔŵõÒÁÅíҴѺ Ô è Ô à¾×ÍãˌÂÒ botulinun toxin ¤§»ÃÐÊÔ·¸ÔÀÒ¾·Õ´Õ àÁ×Íà¨×ͨҧÂÒáŌǤÇÃ㪌ÀÒÂã¹ 4 ªÑÇâÁ§ è è è èâ´Â»ÃÐÊÔ·¸ÔÀÒ¾¢Í§ÂÒ¨ÐŴŧàÃ×ÍÂæ ËÅѧ¨Ò¡¼ÊÁÂÒ áµ‹¨Ò¡¡ÒÃÈÖ¡ÉÒ¾ºÇ‹Ò¼Å¢Í§ÂÒÂѧ¤§ÍÂً è»ÃÐÁҳÌÍÂÅÐ 50 àÁ×ÍàÇÅÒ¼‹Ò¹ä» 1 ÊÑ»´Òˏ Í‹ҧäáçµÒÁà¹×ͧ¨Ò¡ÂÒÁÕÃÒ¤Òᾧ áÅШҡ¡Òà è èÈÖ¡ÉÒ¾ºÇ‹Ò»ÃÐÊÔ·¸ÔÀÒ¾¢Í§ÂÒËÅѧà¨×ͨҧ¨Ð¤§µÑÇ䴌¹Ò¹¶Ö§ 6 ÊÑ»´Òˏ ¶ŒÒà¡çºänj㹵ÙàÂç¹ÍسËÀÙÁÔ Œ2-8 °C ã¹»˜¨¨Øº¹á¾·ÂËÅÒ·‹Ò¹¨Ð㪌ÂÒ·Õ¼ÊÁáŌÇÀÒÂã¹ 2 ÊÑ»´Òˏâ´Â¾ºÇ‹Ò»ÃÐÊÔ·¸ÔÀÒ¾¢Í§ Ñ èÂҨж١·íÒÅÒ¶ŒÒ¹íÒ¡ÅѺä»áª‹á¢ç§ÍÕ¡¤Ãѧé
  • 86 The Cosmentic Use of Botulinum Toxinà·¤¹Ô¡¡ÒéմÊÒÃ⺷ÙÅÔ¹ØÁ ·çÍ¡«Ô¹Í ÇÔ¸¡Òéմ¹ÔÂÁºÃèØÂÒã¹ËÅÍ´ÂÒ (syringe) ¢¹Ò´ 1 ÁÔÅÅÔŵà áÅÐ㪌à¢çÁ¢¹Ò´àÅç¡àºÍÏ Õ Ô30-gauge à¾×ÍÅ´¤ÇÒÁà¨çº ᾷºÒ§·‹Ò¹¹ÔÂÁ㪌ËÅÍ´ÂÒª¹Ô´ hubless needles à¹×ͧ¨Ò¡äÁ‹µÍ§¡Òà è è Œ·Ô§ÂÒ»ÃÐÁÒ³ 0.2 ÁÔÅÅÔŵà ·Õµ´ÍÂÙã¹ËÑÇà¢çÁ (hub) é Ô è Ô ‹ ÃÔÇÃÍÂʋǹãË­‹º¹ãºË¹ŒÒ (Facial wrinkles) à¡Ô´ÁÒ¨Ò¡¡ÒÃË´à¡Ã秢ͧ¡ÅŒÒÁà¹×Í«éÒæ â´Â é é íà¡Ô´ã¹·ÔÈ·Ò§µÑ§©Ò¡¡Ñºá¹Ç¡ÒÃË´à¡Ã秡ŌÒÁà¹×Í (muscular contraction) ·ÕÍÂٴҹŋҧ àÁ×Í¡ÒÅàÇÅÒ é é è ‹ Œ 輋ҹ仼ÔÇ˹ѧÊÙ­àÊÕ¤ÇÒÁÂ×´ËÂعáÅÐà¡Ô´¡ÒÃà»ÅÕ¹á»Å§¨Ò¡áʧᴴ (photoaging) ·íÒãˌà¡Ô´ ‹ èÃÔÇÃÍ¢ֹ ã¹ÇÔªÒâä¼ÔÇ˹ѧÁÕ¡ÒùíÒÊÒà Botulinum toxin A ÁÒ㪌à¾×Íãˌ¡ÅŒÒÁà¹×ͤÅÒµÑÇ ËÃ×Í é é è éËÂØ´¡ÒÃË´µÑǪÑèǤÃÒÇ à¾×èÍÅ´ÃÔéÇÃÍÂàËÕèÂÇ‹¹Íѹà¡Ô´¨Ò¡¡ÒÃáÊ´§ÊÕ˹ŒÒ໚¹»ÃШíÒ àª‹¹ÃÍ‹¹Ë¹ŒÒ¼Ò¡ (forehead lines), ÃÍ‹¹ËÑǤÔÇ (glabellar lines), Ã͵չ¡Ò (crow’s feet), ÃÍ‹¹¨ÁÙ¡ é(bunny lines), ÃÍ‹¹Ãͺ»Ò¡ (perioral wrinkles), ÃÍ‹¹ºÃÔàdzÅíÒ¤Í (platysmal bands) ໚¹µŒ¹ 㹡Òéմ botulinun toxin à¾×Í»ÃÐ⪹ã¹´ŒÒ¹¤ÇÒÁÊǧÒÁ à¹×ͧ¨Ò¡¡ÅŒÒÁà¹×ͺÃÔàdz㺠è è é˹ŒÒÍÂÙµ¹ ¨Ö§ÊÒÁÒö©Õ´ä´Œâ´ÂµÃ§ äÁ‹µÍ§ÍÒÈÑ electromyography àËÁ×͹ઋ¹¡ÒÃÃÑ¡ÉÒÀÒÇСŌÒÁ ‹ ×é Œà¹×ÍË´à¡Ãç§ ¡ÒáíÒ˹´¨Ø´©Õ´ãˌ¼»ÇÂà¡Ã秡ŌÒÁà¹×ÍÁÑ´·Õ¨Ð©Õ´ áÅЩմ¨Ø´·Õ¡ÅŒÒÁà¹×ÍÃÑ´µÑÇ·íÒãˌà¡Ô´ é ٌ † é è è éÃÍ‹¹ÁÒ¡·ÕÊ´â´Â¤ÇéմÂÒã¹¢³Ð¡ÅŒÒÁà¹×ͤÅÒµÑÇ »ÃÔÁÒ³ÂÒ·Õ㪌¨Ðá»Ã¼Ñ¹µÃ§¡Ñº¾×¹·Õ·µÍ§ èØ é è é è Õè Œ¡ÒÃÃÑ¡ÉÒ, ¢¹Ò´ (muscle mass) áÅФÇÒÁá¢ç§áç¢Í§¡ÅŒÒÁà¹×Í (tone) â´Â·ÑÇä»à¾ÈªÒµŒÍ§¡Òà é è㪌»ÃÔÁÒ³ÂÒÁÒ¡¡Ç‹Òà¾ÈË­Ô§ ´Ñ§µÒÃÒ§·Õè 2µÒÃÒ§·Õè 2 áÊ´§¢ŒÍ¤ÇþԨÒÃ³Ò (Variables influencing treatment plan) 㹡Òéմ Botulinun toxin µÑÇá»Ã (Influencing Variables) ¼Å·Õèà¡Ô´ (Effects)¾×¹·Õ·µÍ§¡ÒÃÃÑ¡ÉÒ (Regions) é è Õè Œ Áռŵ‹Í»ÃÔÁÒ³ÂÒ µíÒá˹‹§·Õ©´ ÃÐÂÐˋҧÃÐËNjҧ¡ÒéմᵋÅФÃѧ è Õ éà¾È ʋǹãË­‹à¾ÈªÒµŒÍ§¡ÒÃ㪌»ÃÔÁÒ³ÂÒÁÒ¡¡Ç‹Òà¾ÈË­Ô§¢¹Ò´¢Í§¡ÅŒÒÁà¹×Í (Muscle mass) µŒÍ§ãªŒÂÒ»ÃÔÁÒ³Áҡ㹡ŌÒÁà¹×Í¢¹Ò´ãË­‹ áÅÐá¢ç§áç é é ẋ§Í͡໚¹ 3 ª¹Ô´ - Kinetic: ÃÔÇÃÍÂÁÒ¡¢Ö¹àÁ×ÍÁÕ¡ÒÃáÊ´§ÍÍ¡¢Í§¡ÅŒÒÁà¹×Í ÃÐÂÐ é é è é àÇÅÒÍÍ¡Ä·¸Ô¢Í§ÂÒ botulinun toxin ÂÒǹҹ·ÕÊ´ ì èؤÇÒÁá¢ç§áç¢Í§¡ÅŒÒÁà¹×Í é - Hyperkinetic: ÃÔÇÃÍÂà¡Ô´¨Ò¡¡Ò÷աŌÒÁà¹×ÍË´µÑǵ‹Íà¹×ͧ é è é è(Muscle tonus) ÁÒÂÒǹҹ ¼Ù»ÇÂÁÑ¡©Õ´«éÒ¡‹Í¹äÁ‹ÃÍãˌ¡Ò÷íÒ§Ò¹¢Í§¡ÅŒÒÁà¹×Í Œ † í é ¡ÅѺ¤×¹ÁÒËÁ´ - Hypertonic: ÃÔÇÃÍÂà¡Ô´¨Ò¡¡ÅŒÒÁà¹×Í·ÕÁ¡ÒÃË´à¡Ãç§ÍÂÙµÅÍ´àÇÅÒ é é è Õ ‹ ¡Òéմ botulinun toxin䴌¼ÅäÁ‹´Õ¹Ñ¡äÁ‹ÊÒÁÒö¡íҨѴÃÔéÇÃÍ 䴌ËÁ´ ¼Å¢Í§ÂÒÍÒ¨ÍÂÙäÁ‹¹Ò¹à¾Õ§ 1-2 à´×͹ ‹
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 87 µÑÇá»Ã (Influencing Variables) ¼Å·Õèà¡Ô´ (Effects)àª×ÍªÒµÔ é Áռŵ‹Í¤ÇÒÁ˹Ңͧ¼ÔÇ˹ѧ (thickness) áÅеíÒá˹‹§¢Í§¡ÅŒÒÁà¹×Í é (anatomy)¤ÇÒÁ˹ҢͧªÑ¹¼ÔÇ˹ѧ é ªÑ¹¼ÔÇ˹ѧ·Õ˹ҡNjҵŒÍ§ãªŒÂÒ»ÃÔÁÒ³ÁÒ¡¡Ç‹Ò é 誹Դ¢Í§ÃÔÇÃÍ é Botulinun toxin ¨Ð䴌¼Å´Õã¹ÃÔÇÃͪ¹Ô´ Dynamics ÁÒ¡¡Ç‹Òª¹Ô´ é Static Rhytides¼Å¢ŒÒ§à¤Õ§¢Í§¡ÒéմÊÒÃ⺷ÙÅÔ¹ØÁ ·çÍ¡«Ô¹ à¹×ͧ¨Ò¡¼Å¢Í§¡Òéմ botulinun toxin ໚¹ÍÂÙà¾Õ§ªÑǤÃÒÇ ÍѵÃÒ¡ÒÃà¡Ô´¼Å¢ŒÒ§à¤Õ§¡ç¾º è ‹ 蹌͵ÒÁä»´ŒÇ à¾×ÍÅ´¤ÇÒÁàÊÕ§·Õ¨Ðà¡Ô´¼Å¢ŒÒ§à¤Õ§¨Ò¡¡Òéմ botulinun toxin ᾷ¤ÇþԨÒÃ³Ò è è è¶Ö§¢ŒÍˌÒÁ ¢ŒÍ¤ÇÃÃÐÇѧ㹡Òéմ BNT áÅФÇÃÈÖ¡ÉÒ¡ÒÂÇÔÀÒ¤¢Í§¡ÅŒÒÁà¹×Í áÅÐÁÕ¤ÇÒÁࢌÒ㨶֧ é¼ÅÃÇÁ¡ÒÃáÊ´§ÍÍ¡¢Í§ãºË¹ŒÒàÁ×͡ŌÒÁà¹×ͷѧËÁ´·íҧҹËÇÁ¡Ñ¹ ¡ÒéմÂÒÃͺ´Ç§µÒµŒÍ§©Õ´ãˌ è é éˋҧ¨Ò¡¢ÍºàºŒÒ¡Ãд١µÒÍ‹ҧ¹ŒÍ 1 ૹµÔàÁµÃ áÅЪջÅÒÂà¢çÁÍÍ¡¨Ò¡¡ÃÐ´Ù¡àºŒÒµÒ áÅоÂÒÂÒÁ éËÅÕ¡àÅÕ§àʌ¹àÅ×Í´½Í â´Â¡ÒéմÂÒã¹»ÃÔÁÒ³µèҨлÅÍ´ÀÑ¡NjÒáÅÐÊÒÁÒö©Õ´à¾ÔÁàµÔÁ䴌ÀÒÂËÅѧ è í èËÅѧ¡ÒéմÂÒ¤ÇÃá¹Ð¹íÒãˌ¼»ÇÂÍÂٷҹѧ¹Ò¹»ÃÐÁÒ³ 4 ªÑÇâÁ§ à¾×ÍäÁ‹ãˌÂÒäËŨҡ¨Ø´©Õ´ áÅРٌ † ‹ ‹ è è è¤ÇâÂѺãªé¡ÅéÒÁà¹×ʹѧ¡ÅèÒǺèÍÂæ ËÅѧ©Õ´ÂÒ àªè¹ ÂÔÁ ¢ÁÇ´¤ÔÇËÃ×ÍàÅÔ¡¤ÔÇ (10 ¤ÃѧµèͪÑÇâÁ§ à»ç¹- é é é é é èàÇÅÒ 4 ªÑÇâÁ§) à¾×ͪ‹ÇÂãˌÂÒà¡ÒСѺµÑÇÃѺ䴌´¢¹ è è Õ Öé ¼Å¢ŒÒ§à¤Õ§¢Í§¡Òéմ botulinun toxin à¾×Í»ÃÐ⪹ã¹´ŒÒ¹¤ÇÒÁÊǧÒÁ¹Ñ¹¾º¹ŒÍ ¼Å¢ŒÒ§ è éà¤Õ§੾ÒзÕè (local complications) ·ÕÍÒ¨à¡Ô´ä´Œ ઋ¹ ÍÒ¡ÒÃà¨çººÃÔàdz©Õ´ ¼ÔÇ˹ѧºÇÁ á´§ ªéÒºÃÔàdz è í·Õ©´ ÍÒ¨ÁÕÍÒ¡ÒûǴÈÕÃÉÐ ÁÖ¹ÈÕÃÉÐ ¤Å×¹äʌ ËÃ×ÍÁÕÍÒ¡ÒäÇÒÁÃÙÊ¡á»Å纺ÃÔàdz·Õ©´ªÑǤÃÒÇ (short- è Õ è ŒÖ è Õ èterm hypesthesia) â´Â¼Å¢ŒÒ§à¤Õ§੾Òзշ¾ºº‹Í·ÕÊ´¤×Íà¡Ô´ÃͪéÒ¨Ò¡¡Òéմ (ecchymosis) è Õè èØ í«Ö§¾ºä´ŒºÍºÃÔàdz¼ÔÇ˹ѧÃͺ´Ç§µÒ ᵋ¶ÒàÅ×͡㪌à¢çÁ¢¹Ò´àÅç¡ ¡´ËÂØ´àÅ×Í´·Ñ¹·ÕËÅѧ¶Í¹à¢çÁ è ‹ ŒÍÍ¡¨Ò¡¼ÔÇ ËÃ×Í©Õ´Í‹ҧÃÐÁÑ´ÃÐÇѧÁÑ¡äÁ‹à¡Ô´»˜­ËҴѧ¡Å‹ÒÇ áµ‹äÁ‹¤ÇâÂÕéºÃÔàdz©Õ´à¾ÃÒÐÂÒÍÒ¨¡ÃШÒÂÍÍ¡¹Í¡ÃÍ©մ ¹Í¡¨Ò¡¹Õ¤ÇöÒÁ»ÃÐÇѵ¡ÒÃÃѺ»ÃзҹÂÒ¡ÅØÁáÍÊä¾ÃÔ¹ (aspirin), é Ô ‹aspirin-containing drugs, drugs that inhibit platelet function ËÃ×ÍÂÒ non-steroidal antiinflammatorydrug «Ö§¨Ð·íÒãˌà¡Ô´ÃͪéÒ§‹Ò ãˌËÂØÂҴѧ¡Å‹ÒÇ 7-10 Çѹ¡‹Í¹©Õ´ è í à¾×ÍÅ´¤ÇÒÁà¨çº»Ç´ºÃÔàdz·Õ©´ ¤ÇÃ㪌Áͺպ¨Ñº¼ÔÇ˹ѧáÅСŌÒÁà¹×Í¡¢Ö¹ (Pinching) è è Õ × é 颳Щմãˌà´Ô¹ÂÒªŒÒæ ËÃ×Í©Õ´ÂÒÊÍ´à¢çÁ (needle bevel up) ¼‹Ò¹à¢ŒÒ·Ò§ÃÙ¢Á¢¹ (opening of a Øpilosebaceous unit) ᾷºÒ§·‹Ò¹¹ÔÂÁãˌ»ÃФº´ŒÇ¤ÇÒÁàÂ繷ѹ·ÕËÅѧ©Õ´ à¾×ÍÅ´¤ÇÒÁà¨çº Å´ èÍÒ¡ÒúÇÁ áÅÐá´§ªéÒ í ¡ÒÃà¡Ô´ÀÒÇд×é͵‹ÍÂÒ botulinun toxin ¨Ò¡¡ÒÃÊÌҧá͹µÔºÍ´Õé (Immunogenicity andneutralizing antibodies) ¾ºä´Œ¹Í (ã¹Í´Õµ¾ºÃŒÍÂÅÐ 3- 5 %) áÅÐäÁ‹¾ºÁÕÃÒ§ҹ¨Ò¡¡Òéմ Œbotulinun toxin ã¹·Ò§¼ÔÇ˹ѧà¾×ÍàÊÃÔÁ¤ÇÒÁ§ÒÁ â´Â¾ºÇ‹Ò¡ÒÃÊÌҧá͹µÔºÍ´Õ¨Ðá»Ã¼Ñ¹µÃ§¡Ñº·Ñ§ è é é
  • 88 The Cosmentic Use of Botulinum Toxin¢¹Ò´¢Í§ÂÒ (dose per session) áÅФÇÒÁ¶Õè (interval between the dose) â´Â੾ÒÐã¹ÃÒ·ÕÁ¡Òà è Õ©Õ´ÂÒ»ÃÔÁÒ³ÊÙ§ÁÒ¡¡Ç‹Ò 300 ˹‹Ç 㹤Ãѧà´ÕÂÇ áÅЩմÂÒˋҧ¡Ñ¹µèÒ¡Ç‹Ò 3 à´×͹ é í ã¹»˜¨¨Øº¹â´Â¡ÒÃÊÌҧÀÙÁ¤Á¡Ñ¹µ‹ÍµŒÒ¹¹Õ䴌¹ÍÂŧÍÕ¡ Íѹà¹×ͧÁÒ¨Ò¡ÁÕ¤ÇÒÁ¾ÂÒÂÒÁàµÃÕÂÁ Ñ Ô ØŒ é Œ èbotulinun toxin ãˌºÃÔÊ·¸Ô¢¹ â´Â¡ÒÃÅ´»ÃÔÁÒ³â»ÃµÕ¹Å§ ºÃÔÉ· Allergan àÃÔÁµŒ¹¼ÅÔµ¨Ò¡ÂÒ Botox Ø ì Öé Ñ èÃعáá batch No.79-11 ÁÕ»ÃÔÁÒ³â»ÃµÕ¹ÊÙ§ (25ng/vial) áÅе‹ÍÁÒã¹»‚ ¤.È.1997 ¾Ñ²¹ÒÁÒ໚¹Ãع ‹ ‹No.BCB 20-24 ·ÕÁâ»ÃµÕ¹Å´Å§¶Ö§ 80% àËÅ×Í 5ng/vial ã¹»˜¨¨Øº¹ áÅÐÁÕ¼»Ç¨íҹǹ¹ŒÍÂÁÒ¡·ÕäÁ‹ è Õ Ñ ÙŒ † èµÍºÊ¹Í§µ‹Í¡Òéմ BNT à¾ÃÒмٻÇ·Õà¡Ô´á͹µÔºÍ´Õ¢¹Ê‹Ç¹ãË­‹¡Â§ÁÕ¡Òõͺʹͧ·Õ´Õ Œ † è é Öé ç Ñ è ˹‹Ç¢ͧÂÒ©Õ´ botulinun toxin 㪌»ÃÔÁҳ໚¹¹Ò⹡ÃÑÁ (nanogram = 10 ) â´Â¹íÒÁÒËÒ 9 -¤‹Ò standard â´Âà»ÃÕºà·Õº໚¹Ë¹‹Ç (unit) â´ÂÂÒ 1 ˹‹Ç ËÁÒ¶֧»ÃÔÁÒ³ÂÒ©Õ´ (intra-peritonealinjection) ·ÕÊÒÁÒö¦‹Ò˹٠Swiss-Webster à¾ÈàÁÕ¢¹Ò´¹éÒ˹ѡ 18-20 ¡ÃÑÁ µÒÂ䴌ÃÍÂÅÐ 50 è í Œ¢Í§¨íҹǹ˹ٷ§ËÁ´ (LD50) áÅÐ 1 ¹Ò⹡ÃÑÁ¢Í§ÂÒ©Õ´¨ÐÁÕ¤ÇÒÁáç෋ҡѺ 2.5 ˹‹Ç â´Â¢¹Ò´ ÑéÂÒ·Õ¡Íãˌà¡Ô´¾ÔÉ㹤¹ (LD50) »ÃÐÁÒ³ 40 ˹‹Çµ‹Í¹éÒ˹ѡµÑÇ 1 ¡ÔâÅ¡ÃÑÁ ËÃ×ÍÁÒ¡¡Ç‹Ò 2,800 è ‹ íÂÙ¹Ôµ 㹤¹·ÕèÁÕ¹éíÒ˹ѡµÑÇ 70 ¡ÔâÅ¡ÃÑÁ «Ö觢¹Ò´ÂÒ·Õè·´Åͧ¹Õé໚¹»ÃÔÁÒ³·ÕèÊÙ§¡Ç‹Ò·Õè㪌ÃÑ¡ÉÒÁÒ¡»ÃÔÁÒ³¢Í§Âҩմ㹡ÒÃÃÑ¡ÉÒ·Ò§¼ÔÇ˹ѧà¾×ÍàÊÃÔÁ¤ÇÒÁ§ÒÁ (cosmetic therapeutic dose) »ÃÐÁÒ³ è25-75 ˹‹ÇÂÊÃØ» µÑé§áµ‹ÁÕ¡ÒùíÒÊÒÃ⺷ÙÅÔ¹ØÁ ·çÍ¡«Ô¹ (Botulinum toxin) ÁÒ㪌㹷ҧ¡ÒÃᾷÁÒ¡¡Ç‹Ò25 »‚ ¨¹¶Ö§»˜¨¨Øº¹ä´ŒÁ¡ÒÃ㪌à¾×Í»ÃÐ⪹ã¹´ŒÒ¹¤ÇÒÁÊǧÒÁ (cosmetics treatments) ËÃ×Íá¡Œä¢ Ñ Õ è¤ÇÒÁº¡¾Ã‹Í§¢Í§ãºË¹ŒÒµÒÁÁÒÍ‹ҧá¾Ã‹ËÅÒ áÅÐÁÕà·¤¹Ô¤ÇÔ¸¡Ò÷յҧ¡Ñ¹ÍÍ¡ä» ÁÕ¡ÒùíÒÁÒ©Õ´ Õ è ‹à¾×Í·íÒãˌ˹ŒÒàÃÕÂÇŧ ¡¡ÃЪѺ¼ÔÇ˹ѧ Å´à˧×ͺÃÔàdzÃÑ¡áÌ ½†ÒÁ×Í µÅÍ´¨¹ÃÑ¡ÉÒÍÒ¡ÒûǴ è èÈÕÃÉÐáÅлǴà¡Ã秵Œ¹¤Í ÏÅÏ à¹×ͧ¨Ò¡ÁÕÃÒ§ҹÇÒÃÊÒ÷ҧ¡ÒÃᾷ·áÊ´§¶Ö§¤ÇÒÁ»ÅÍ´ÀÑ áÅÐ è Õè»ÃÐÊÔ·¸ÔÀÒ¾¢Í§âº·ÙŹÁ ·çÍ¡«Ô¹ÁÒÍ‹ҧµ‹Íà¹×ͧ ÃÇÁ件֧¤ÇÒÁ¾Ö§¾Í㨢ͧ¤¹ä¢Œ ·íÒãˌ¡Òéմ Ô Ø èÊÒÃ⺷ÙŹÁ ·çÍ¡«Ô¹à»š¹Ëѵ¶¡ÒÃà¾×ͤÇÒÁÊǧÒÁ (minimal invasive aesthetic procedures) ·Õ䴌 Ô Ø è èÃѺ¤ÇÒÁ¹ÔÂÁÁÒ¡·ÕÊ´ ¨Ò¡¡ÒÃÊíÒÃǨ¢Í§ÊÁÒ¤Á The American Society for Aesthetic Plastic èØSurgery (ASAPS) ã¹»‚ ¤.È.2008 ¾ºÇ‹Òã¹»ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡Ò»ÃÐà·Èà´ÕÂÇÁÕ¡Òéմ¡Ñ¹¶Ö§3.8 Ōҹ¤Ãѧµ‹Í»‚ áÅÐÁÕá¹Ç⹌Á·Õ¨Ðà¾ÔÁÁÒ¡¢Ö¹àÃ×ÍÂæ ·Ñ§ã¹¼ÙË­Ô§áÅм٪Ò â´Â㪌໚¹¡ÒÃÃÑ¡ÉÒ é è è é è é Œ Œà´ÕÂÇ ËÃ×ÍËÇÁ¡ÑºàÅà«ÍÏ ËÃ×ÍÊÒÃàµÔÁàµçÁ (fillers) è
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 89àÍ¡ÊÒÃ͌ҧÍÔ§1. Hexsel D, Dal’forno T. Type A botulinum toxin in the upper aspect of the face. Clin Dermatol 2003;21(6):488-97.2. Mandeville JT, Rubin PA. Injectable agents for facial rejuvenation: botulinum toxin and dermal filling agents. Int Ophthalmol Clin 2004;44(1):189-212.3. Rohrich RJ, Janis JE, Fagien S, Stuzin JM. The cosmetic use of botulinum toxin. Plast Reconstr Surg 2003;112(5 Suppl):177S-88S; quiz 188S, 192S; discussion 189S-191S.4. Sommer B. How to avoid complications when treating hyperdynamic folds and wrinkles. Clin Dermatol 2003;21(6):521-3.5. Karsai S, Raulin C. Current Evidence on the Unit Equivalence of Different Botulinum Neurotoxin A Formulations and Recommendations for Clinical Practice in Dermatology. Dermatol Surg 2009; 35:1-8.6. Flynn TC. Update on Botulinum Toxin. Semin Cutan Med Surg 2006;25:115-121.7. Shetty MK. Guidelines on he Use in Botulinum Toxin Type A. Indian J Dermatol Venereal Leprol 2008;74:S13-22.
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 91 13 Anti-aging Pharmacology: Theory and Research Model Sirikul Chotewuttakorn, MSc. Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University Aging is a complex biological process caused by intrinsic or genetic programs. It isassociated with a paradox of immunodeficiency and inflammation(1). Many theories are establishedto explain the processes involved in aging, however different theories of aging should not beconsidered as mutually exclusive, but complementary of others in the explanation of some orall features of the normal aging process. Accordingly, several mechanisms are found to beinvolved in the aging process such as inflammatory modulation(2, 3),oxidative stress (4),immunomodulation (5, 6) genetic regulation (7, 8), calorie restriction (9), hormonal regulation,(10, 11)ect. The field of aging research is rapidly becoming the niche of thousands of laboratoriesworldwide. The encompassed expertise ranged from genetics and evolution to molecular andcellular biology, biochemistry and behavior. Almost studies were performed in the hope ofdeveloping the practical and effective anti-aging strategies based on rational approaches. Forthe scientific community, anti-aging research refers exclusively to slowing, preventing, or reversingthe aging process while, in the medical and business community, anti-aging medicine meansearly detection, prevention, and reversal of age-related diseases. Anti-aging pharmacology is one of many anti-aging research fields that exclusively aimto investigate the anti-aging activity of any interesting compounds. Several theories on whatprocess of aging are targeted for the best anti aging results. Among these theories are: The free radical theory of aging The glycation theory of aging Telomeres DNA and DNA damage Longevity genes Gene silencing Hormones Accumulation of toxins and chemical garbage
  • 92 Anti-aging Pharmacology: Theory and Research Model Although no convincing evidence is available for the administration of existing “anti-aging” remedies capable of slowing aging or increasing longevity in humans, several studieson animal models have shown that aging rates and life expectancy can be modified. Longevityis commonly measured in many research models to prove changes in both cellular levels andorganism levels through genetic and pharmacological means. The most extensively organismsused are the nematode, Caenorhabditis elegans, the fruit fly, Drosophila melanogaster, androdents from the mammalian species. These organisms possess many advantages for agingstudies including their very well understood biology, relatively short life cycles, inexpensiveand ease of genetic manipulability. The most widely used mammalian aging model is thelaboratory mouse due to the close evolutionary relationship between men and mice that givesmouse aging studies obvious relevance to human aging.(12, 13) The other long-lived animalsoccasionally used in some models are reptiles, crocodiles, amphibians and birds. Surprisingly,from the research literature review on interventions in aging, a commonly encountered problemis the conflicting results from studies using the same intervention but from different laboratories.There are many factors contributing to the variability, including the model organism chosen asthe test subject, the design of the intervention study and the location of the testing laboratories.Many reports might be compromised by one or more design flaws including a lack of resourcesor the expertise to design a scientifically study. Nevertheless, several supplements andinterventions for anti aging purpose were easily found in the market in spite of lacking thestrong evidences extrapolated from the appropriate model to validate such claims. In 2000,there was an Interventions Testing Program (ITP), established by the National Institute onAging (NIA) to evaluate agents that are considered plausible candidates for delaying aging orpreventing late-life disease in laboratory mice. ITP was developed by a meeting of experts fromdiverse fields of aging research. (14-16) Several model systems were discussed in this meetingand the genetically heterogeneous (HET) mouse was finally considered to be the best fit. Thetest compounds chosen previously provided preliminary data showing beneficial effects onaging in mice or strong theoretically backed up by evidence of increased life span in short-livedmodels such as nematodes or fruit flies or both.(15, 16) Nine compounds were selected in testingas of May 2007,(15) including the aspirin, nitroflurbiprofen (NFP), 4-OH-?-phenyl-N-tert-butyl nitrone(4-OH-PBN), ordihydroguiaretic acid (NDGA), caffeic acid phenethyl ester (CAPE), enalaprilmaleate, rapamycin , simvastatin and resveratrol.
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 93Table Summary of current compounds tested in an aging intervention program by NIA 11 Compounds Mechanism of action Possible effect on agingAspirin inhibit COX-1 & COX-2, suppresses anti-inflammation, anti-oxidant, production of TNFa through NF- kB anti-thrombotic, slow chronic diseases of agingNFP inhibit COX-1 & COX-2, donate NO anti-inflammation in CNS, protect against GI toxicity&CVSNDGA suppress proinflammatory gene anti-oxidant, anti-inflammatory expression & PGE2 production slow disease progression4-OH-PBN stabilize free radicals protects against age-related diseases including stroke &CACaffeic cidphenethyl inhibit oxidant production and antioxidant, anti-inflammation,ester (CAPE) formation of oxidized bases, suppress immunomodulation, anti- TPA-induced tumour carcinogenEnalapril maleate inhibit angiotensin converting enzyme modulate hypertension, obesity diabetes & CHF; regulate metabolic function and decrease oxidative stressRapamycin inhibit protein kinase TOR antifungal, immunosuppressive, (target of rapamycin) inhibit helper T anticancer, cell proliferation reminiscent of dietary restrictionSimvastatin inhibits HMG-CoA reductase reduce cholesterol, anti-oxidant, (3-hydroxy-3-methylglutaryl coenzyme A) anti-inflammation, stimulate NO bioavailability, reduce CVDResveratrol stimulate sirtuin protein deacetylase anti-inflammation, anti-oxidant, and effect the estrogen receptor, COX, anti-carcinogen toll receptor, cytochrome P450 enzyme
  • 94 Anti-aging Pharmacology: Theory and Research Model The primary endpoint was increased longevity. The experimental design was plannedusing genetically heterogeneous mice, bred as the four-way cross. The design comparedmultiple experimental agents to two control groups. Tests were conducted simultaneously atthree sites. Mice also were tested for several age-sensitive traits, such as T-cell subsets,cataract development, humoral immunity, cognitive abilities, and spontaneous activity. Agentsshowing promise in the initial screen were tested in a follow-up protocol, including multiple age-sensitive traits and detailed pathology. Group size was sufficient to detect 11 percent changein longevity at 80 percent power and 13 percent change at 90 percent power. An interimanalysis was planed to conduct using survival data available on the date at which at least 50%of the male control mice had died at each test site. In the first cohort, mice were exposed toone of four agents: aspirin, NFP, 4-OH-PBN or NDGA. The interim data showed that NDGAreduced early life mortality risks in genetically heterogeneous mice at multiple test sites.(15)These results did not address the central goal of the ITP, which was to determine if any of thetest agents slowed aging to an extent sufficient to increase maximum lifespan. However, ayear later, the full lifespan analysis of survival data was presented from pooling data of allthree sites showed that both NDGA (p= 0.0006) and aspirin (p= 0.01) led to increased lifespanof male mice, although no effect on lifespan was observed in females.(17) The study was thenplanned to further investigate whether NDGA or aspirin, over a range of doses, could beproved to postpone death and various age-related outcomes reproducibly in mice. As interestin antiaging therapies is still growing, the information obtained from such well-developed modelmight ultimately lead to the development of effective interventions to prevent, delay, or evenreverse age-related pathology. Application or modification of this program is also promising inorder to investigate other putative compounds that might yield pharmacological effects inextending human lifespan.àÍ¡ÊÒÃ͌ҧÍÔ§1. Gupta S, Agrawal A, Agrawal S, Su H, Gollapudi S. A paradox of immunodeficiency and inflammation in human aging: lessons learned from apoptosis. Immun Ageing. 2006;3:5.2. Yoshizaki T, Milne JC, Imamura T, Schenk S, Sonoda N, Babendure JL, et al. SIRT1 exerts anti-inflammatory effects and improves insulin sensitivity in adipocytes. Mol Cell Biol. 2009 ;29:1363-1374.3. Franceschi C, Bonafe M, Valensin S, Olivieri F. Inflamm-aging: an evolutionary perspective of Immunosenescence. Ann NY Acad Sci. 2000;908:244-254.4. Biesalski HK. Free radical theory of aging. Current Opinion in Clinical Nutrition & Metabolic Care. 2002;5:5-10.5. Horan MA, Fox RA. Ageing and the immune response—a unifying hypothesis? Mech Ageing Dev. 1984;26:165- 1681.
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 956. Horvathova K, Novotny L, Tothova D, Vachalkova A. Determination of free radical scavenging activity of quercetin, rutin, luteolin and apigenin in H2O2-treated human ML cells K562. Neoplasma. 2004;51:395-399.7. Kenyon C. Ponce d’elegans: Genetic Quest for the Fountain of Youth. Cell. 1996;84:501-504.8. Guarente L, Kenyon C. Genetic pathways that regulate ageing in model organisms. Nature. 2000;408:255-262.9. Smith DL, Jr., McClure JM, Matecic M, Smith JS. Calorie restriction extends the chronological lifespan of Saccharomyces cerevisiae independently of the Sirtuins. Aging Cell. 2007;6:649-662.10. Wiebke Arlt MH. Hormones and immune function: implications of aging. Aging Cell. 2004;3:209-216.11. Buffenstein R, Pinto M. Endocrine function in naturally long-living small mammals. Molecular and Cellular Endocrinology. 2009;299:101-111.12. Svenson KL, Von Smith R, Magnani PA, Suetin HR, Paigen B, Naggert JK, et al. Multiple trait measurements in 43 inbred mouse strains capture the phenotypic diversity characteristic of human populations. J Appl Physiol. 2007 June 1, 2007;102:2369-2378.13. Peters LL, Robledo RF, Bult CJ, Churchill GA, Paigen BJ, Svenson KL. The mouse as a model for human biology: a resource guide for complex trait analysis. Nat Rev Genet. 2007;8:58-69.14. Warner HR, Ingram D, Miller RA, Nadon NL, Richardson AG. Program for testing biological interventions to promote healthy aging. Mechanisms of Ageing and Development. 2000;115:199-207.15. Miller RA, Harrison DE, Astle CM, Floyd RA, Flurkey K, Hensley KL, et al. An aging Interventions Testing Program: study design and interim report. Aging Cell. 2007;6:565-575.16. Nadon Nl, Strong R, Miller RA, Nelson J, Javors M, ZD S, et al. Design of aging intervention studies: the NIA interventions testing program. AGE. 2008.17. Strong R, Miller RA, Astle CN, Floyd RA, Flurkey K, Hensley KL, et al. Nordihydroguaiaretic acid and aspirin increase lifespan of genetically heterogeneous male mice. Aging Cell. 2008;7:641-650.
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 97 14Clinical and Laboratory Evidence of Antioxidants Activity on the Skin Nopadon Noppakun, M.D. Department of Medicine, Faculty of Medicine,Chulalongkorn University Skin is equipped with endogenous antioxidants which are enzymatic and nonenzyamaticcutaneous antioxidants. Enzymatic antioxidants are superoxide dismutase, gutathioneperoxidase. Nonenzymatic are antioxidants; vitamin E, coenzyme Q10 , ascorbate. Endogenousantioxidants can protect skin damage by reactive oxygen species (ROS) that produced bynormal cellular metabolism only. Excessive UV exposure will overwhelm and deplete endogenousantioxidants and produce oxidative stress that lead to skin aging and skin cancer. Thus thereis the requirement for exogenous antioxidants to treat skin aging and prevent cancer. Numerous topical antioxidants have been analyzed for their ability to prevent or reverseclinical signs associated with photoaging secondary to ROS. They are L-ascorbic acid (vitaminC), – tocopherol (Vitamin E), Coenzyme Q10 , Flavanoides ( e.g. Camellia sinensis leaf),Pantothenic acids . Most of the studies to evaluate the efficacy of these antioxidants weredone in animals and extrapolated to use in human. Requirements for these antioxidants towork effectively as the antiaging agents are sufficient concentration in the skin, stable in thecosmetic formulation and readily absorbed into the skin.Other topical antioxidants such asQ10, -lipoic acid, GTPP in green tea, Niacinamide had been studied in the laboratories, andanimals. But few studies were done in human with only fair scientific evidences. Systemic approach to treat photoaging had also been studied. A combination of l-proline, l-lysine, manganese, copper, zinc, quercetin, grape seed extract, N-acetyl D-glucosamineand glucosamine sulfate , was shown to improve wrinkles by 34% in a pilot study. A combinationof vitamin E, vitamin C, carotenoid, selenium, and proanthocyanidin led to a significant decreasein induction of MMP after UV exposure in human skin. It also showed reduction in UV-inducederythema, but no statistic significant.
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 99 15 Anti-aging Pharmacology: Antioxidants and Longevity Uraiwan Panich, M.D., Ph.D. Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University The free radical or oxidative stress theory of aging has attracted considerable interestin aging-related research. Such theory conceived by Denham Harman in 1956 postulated theassociation between progressive oxidative damage caused by reactive oxygen species (ROS)accumulation and the aging process(1). Although the mechanisms by which ROS mediatesaging remain unclear, a number of evidence shows that oxidative insults can contribute to age-related degenerative diseases and shortened life span. It is clear that an imbalance betweenROS production and removal is defined as oxidative stress leading to potential damage tovarious biomolecules and disturbance of cellular responses. Additional theories containingROS concept, which have been proposed in recent years, include the mitochondria theory ofaging, the cellular senescence theory of aging and the molecular inflammatory theory ofaging(2). Mitochondrial respiration is responsible as the major intracellular source of ROS,continuously produced as byproducts of aerobic metabolism. There are also other intracellularsources of ROS generation such as peroxisomal fatty acid metabolism, cytochome P-450 andxanthine-xanthine oxidase reactions and NADPH oxidase produced during phagocytosis. ROScan also be generated by the exogenous sources or stress from environment such as radiation,infection, pollutants, chemical oxidants, xenobiotics and cigarette smoke(3). Excess ROS leadingto oxidative damage causes a wide range of genetic, metabolic and cellular responses implicatedin the cell injury and death by direct damage of biomolecules including protein, lipid and DNAand by modulation of cell signaling. Redox modulation of crucial transcription factors can affectcell viability and function and also contribute to inflammatory process associated with a widerange of age-related pathologies such as cardiovascular diseases, neurodegenerative diseasesand cancer(4). Since ROS constantly generated in vivo are involved in cell growth, differentiation anddeath leading to a number of pathologies including aging, in order to limit biomolecule damage
  • 100 Anti-aging Pharmacology: Antioxdants and Longevitycaused by ROS accumulation, a wide range of enzymatic and non-enzymatic antioxidant defenseshave been developed in human body. Endogenous antioxidant defenses comprise of enzymaticand non-enzymatic antioxidants working in a complex network to maintain intracellular redoxbalance and inhibit cellular damage. Primary antioxidant enzymes such as superoxide dismutase(SOD), catalase (CAT) and different types of peroxidases (e.g., glutathione peroxidase) andnon-enzymatic or small molecular-weight antioxidants such as glutathione (GSH), thioredoxin,vitamin E and C, and trace elements (e.g., zinc and selenium) function as ROS scavengers(5). There is substantial evidence indicating a link between oxidative damage and aging,therefore pharmacological properties of antioxidants have been widely studied in order todevelop antioxidant invention or therapy for age-related degenerative diseases that may promotelongevity. The studies to investigate the beneficial effects of antioxidant intervention in delayingaging is to increase antioxidant defense, either by antioxidant supplementation aspharmacological approach or by overexpression of antioxidant enzyme genes as geneticapproaches(6). Antioxidant enzyme mimetics with SOD and CAT activity and overexpression ofSOD provided longer life spans in nonmammalian models using C. elegans and Drosophila,respectively, although there have been conflicting and disappointing results in mammalianmodels(7). Hence, substantial variation in the life span and effects of antioxidant enzymemanipulation using different models needs to be taken into account. In addition, aging processis complex and cannot be explained by a single theory. Further research using long-livedanimal model is needed in order to explore common mechanisms contributed to the agingprocess that will yield crucial insight into effective approaches for retarding age-related diseasesand promoting longevity.References1. Harman D. Free radical theory of aging: an update: increasing the functional life span. Ann NY Acad Sci 2006;1067:10-21.2. Muller FL, Lustgarten MS, Jang Y, Richardson A, Van Remmen H.Trends in oxidative aging therories. Free Rad Biol Med 2007;43:477-503.3. Speakman JR. Body size, energy metabolism and lifespan. J Exp Biol 2005; 208-1717-30.4. Kregel KC, Zhang HJ. An integrated view of oxidative stress in aging: basic mechanisms, functional effects, and pathological considerations. Am J Physiol Regul Integr Comp Physiol 2007; 292:18–36.5. Gutteridge JM, Halliwell B. Free radicals and antioxidants in the year 2000. A historical look to the future. Ann NY Acad Sci 2000; 899:136-47.6. Melov S, Ravenscroft J, Malik S, Gill MS, Walker DW, Clayton PE, et al. Extension of life-span with superoxide dismutase/catalase mimetics. Science 2000; 289: 1567-9.7. Brzozowska A, Kaluza J, Knoops KT, de Groot LC. Supplement use and mortality: the SENECA study. Eur J Nutr 2008;47:131-7.
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 101 16 The Glaucoma Myths & Facts Prin Rojanapongpun, MD., Visanee Tantisevi, MD. Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University Naris Kitnarong, MD., MBA. Department of Ophthalmology, Siriraj Hospital, Mahidol University Glaucoma is a disease that is known for over a century, yet the understanding of thedisease is still quite limited in the public. General practitioners may face the same problem butat a different level. But as a practitioner, it is imperative that physician must have an adequateknowledge to answer some of the frequently asked questions to their patients. The price of notknowing the correct answers is high as glaucoma is a second leading cause of blindnessworldwide. Most people think there are warning signs for glaucoma, such as blurred vision andhalo, but this is a myth in most of the cases. The fact is most of the early glaucoma cases willnever have any symptom. Based on recent study, at least 25% to 35% of retinal ganglion cellmust be lost before it is detectable by automated visual field testing.1 One of the most common myth is that only older people get glaucoma. But glaucomacan start at a very beginning decade of life based on how many risk factors the person have.The risk factors include family history, high refractive error, Asian as well as Afro-American,hypertension, diabetes, low diastolic blood pressure, migraine, sleep apnea and thin corneaare all known to be associated with glaucoma. The list of ‘myth and fact’ in glaucoma isendless. Jogging can reduce eye pressure2 seems like a myth but in fact this has been provenas a fact including that wearing tight neckties can increase eye pressure and glaucoma risk3 . Since glaucoma is the leading cause of preventable blindness, we should all know thefacts and myths of the disease. In this article, we select some of the most common glaucomamyths.
  • 102 The Glaucoma Myths & FactsMyth I see 20/20 and need no glasses. I can’t have glaucoma. Fact Glaucoma usually leave people with perfect central vision by damaging the peripheralvision first. The central vision is only affected at a late stage of the disease.Myth Glaucoma have elevated intraocular pressure (IOP). Fact Glaucoma has a strong link with high IOP and the disease is characterized but notdefined by elevated IOP. Elevated IOP should be regarded as a risk factor for glaucoma andis not the disease itself. The actual pathology is the damage of the optic nerve head and notthe elevated IOP. Not all types of glaucoma have high IOP. In fact, some forms of glaucomaare strongly related to hemodynamic changes and impaired perfusion at the optic nerve.Myth People with high IOP will get definitely glaucoma in the future. Fact High intra-ocular pressure (IOP) will cause glaucoma, but not everyone. Number cannottell the whole story. IOP is a major risk factor and the only factor, nowadays, can be manipulatedwith glaucoma treatment. That is reason why we have heard about it a lot. High IOP can beonly ocular hypertension4 , a group of higher- than-usual IOP people yet no sign of glaucomaoptic neuropathy. A big study followed them for five years and found less than 10% of thesepeople developed glaucoma, though they pointed out hypotensive eye drops can lower thischance for 50%(3). Moreover, in Japan, high prevalence of normo-tension glaucoma wasfound. This term refers to group of people who develop glaucoma despite their IOP are withinnormal range (< 21 mmHg, according to baseline data from western studies)5 . Rather, thereare many factors involved in IOP reading as well as many factors for glaucoma for those areat risk.
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 103Myth Only old people get glaucoma. Fact The prevalence and incidence of glaucoma increases with age, but it can be found atany age. In fact, glaucoma diagnosed in an adult may began from the teenager’s years.Congenital and developmental glaucoma also found sporadically in newborns. Individuals withglaucoma risk factors may develop disease earlier in life. For instance, African Americans aresix times as likely to develop glaucoma as compared to Caucasian Americans at a youngerage.Myth Glaucoma is inherited. The family member will get it. Fact Family history is an important risk factor for glaucoma. Though there are specificgenes that have been identified to have some links with glaucoma, the practical aspect ofgenetic diagnosis and implication is still limited. An individual must be assessed to find otherrisk factors of glaucoma such as age, elevated IOP, African and Asian descent, refractiveerrors, However, if there is a family history of glaucoma, the other members should be screenedfor glaucoma.Myth Computer use leads to glaucoma. Fact There was a report on the link between heavy computer use and glaucoma.6 However,it seems like the study was performed in a cohort of Japanese worker that included mainlymen and with high refractive errors or were not measured comprehensively. It is known thatJapanese has high incidence of normal tension glaucoma and also high degree of myopia isalready known to be risk factor of glaucoma. So, this statement does need more evidence andnot necessary true.
  • 104 The Glaucoma Myths & FactsMyth Glaucoma usually presents with eye pain. Pain, redness and blurred vision are most common signs and symptoms of glaucoma. Fact Chronic glaucoma, both open and close angle, is usually insidious in onset, slowlyprogressive and painless. Many patients discover glaucoma from general eye examinationwithout any signs or symptoms. Visual field defect may be observed before visual acuity lossbecause central visual acuity is relatively unaffected until late in the disease. Acute angleclosure is typically manifested by ocular pain, headache, blurred vision, rainbow-color aroundlight (halos), nausea, and vomiting. Rapid rising of intraocular pressure causes corneal edema,which accounts for visual symptoms. Because incidence of acute glaucoma is by far less thanthose of both chronic angle-closure and open angle glaucoma, most glaucoma shows nopresenting sign and symptoms7 .Myth One with high blood pressure has high eye pressure. Fact Blood pressure and eye pressure vary independently. Controlling blood pressure doesnot mean IOP is controlled. However, high blood pressure is often-but not always- associatedwith elevated intraocular pressure. Interestingly, low blood pressure is strongly associated withsome forms of glaucoma, such as normal-tension glaucoma (NTG).Myth Glaucoma is not curable Once you have got glaucoma, your disease will not stop, your vision will deteriorateand eventually blind. Medication can help but surgery is of no good. Fact It is true that glaucoma destroys nerve fiber layers of the eye and the dead nerve fiberswill not resurrect. Other two groups of nerve fibers are the dying and the living can be rescuedand preserved. That is when the disease stage has gone moderate to severe. It could not becured back to normal especially central vision was involved. In fact, if detected at very early stage, no sign of definite optic nerve head damage orvisual field defect, patients prone to angle closure glaucoma can be successfully intervened
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 105with laser or surgery for modifying anterior chamber angle width. This will prevent glaucomadevelopment for years or even cure it from progressing. The so-called curative treatment wasalso shown in post-acute angle closure attack eyes.8Myth One can tell if one is developing glaucoma by having blurred vision. Fact Unfortunately, this is not true in majority of glaucoma cases. Most early glaucoma hasno symptom or any change in the vision until late in the course. But once vision has been lostdue to glaucoma, it is permanent since the basic pathology is at the ganglion cell in the retina,which is not replaceable. There is no effective treatment to restore the neurone and thedamaged axon.Myth Asians have less glaucoma Fact Blacks and Asians are at higher risk for developing glaucoma. Based on recent studies,glaucoma is nearly 3 times more common in Asians than the Caucasians. However, thedetection is less efficient among many Asian countries as of limited resources. Glaucoma alsomanifests itself differently in various ethnic groups. Afro-American develop glaucoma ten yearsearlier than Caucasians.Myth Nutrition and lifestyle have no effect on glaucoma. Fact We now know that nutrition, exercise, stress management, and other aspects of yourlifestyle can affect glaucoma. Certain vitamin and mineral supplements, as well as herbs mayhelp preserve the health and integrity of the optic nerve in glaucoma. Aerobic exercise such as brisk walking, jogging, bicycling, or swimming, does helpreduce IOP by as much as 20 percent if performed for at least thirty minutes, at least threetimes per week.9 However, weight lifting, scuba diving, certain yoga positions (head stand),Valsalva and high resistance wind instruments10 shall be avoided in glaucoma patients as theycan raise IOP.
  • 106 The Glaucoma Myths & FactsMyth Exercise worsens glaucoma. Fact There were several studies demonstrated the effects of exercise on intraocular pressure(IOP). The effects may be to increase or decrease depend upon duration and type of exerciseand physical fitness of subjects. Some reports showed the evidences of exercise-related visualloss in patients with glaucoma.11 The hypothesis to explain the deterioration of visual functionrelated to exercise includes pupil dilatation leading to acute angle closure, ocular hypoperfusionand pigment dispersion. However, light exercise is encouraged in glaucoma patients.Myth People with advanced glaucoma will go blind. We cannot do anything to stop diseaseprogression Fact Glaucoma is the most common cause of irreversible blindness all around the world.The visual loss could not be restored but effective treatment can prevent further visual damage.Aggressive treatment could be considered in advanced glaucoma such as laser, surgery;glaucoma drainage device. Several modalities can prevent blindness in such cases. (4)Myth Cataract, if left untreated, can become glaucoma. People usually believe these two disorders are related or both diseases are thecontinuum. Cataract, when get harder or brownish or turns white, it is looks through pupils likea rock in the eye. Treatable disease becomes incurable if left it for so long. Fact This belief is partly wrong, partly true. Thai term of glaucoma may mislead theunderstanding that there is something like a rock in the eye causing disease. As a matter offact, cataract is aging process. Lens grows old and opaque every minute until able to disturbdaily vision. Glaucoma is a spectrum of optic neuropathy with clinical characteristics andspecific risk factors. Report of glaucoma prevalence is 1-2% in many studies. Not all of peoplewith simple cataract will turn glaucoma unless they do have risks. Therefore, it is possible thatthese two disorders can coincidentally occur at the same time.
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 107 However, secondary glaucoma from cataract can happen. In mature or hypermaturecataract, they can be complicated by phacomorphic glaucoma which is secondary angle typeor phacolytic / phacoanaphylactic glaucoma which are secondary open angle. Definite treatmentcertainly is lens extraction once diagnosis is made.12Myth If I have both the cataract and glaucoma, I will need two separate surgeries. Fact Both cataract and glaucoma surgery can be performed in the same setting. There arecases that two separate surgeries may be more appropriate. If a glaucoma patient is in needof cataract surgery, the doctor has three options: cataract surgery alone; two staged surgeries(either cataract surgery first or later performed at different times); and combined cataract-glaucoma surgery.Reference1 Kerrigan–Baumrind LA, Quigley HA, Pease ME, Kerrigan DF, and Mitchell RS. Number of Ganglion Cells in Glaucoma Eyes Compared with Threshold Visual Field Tests in the Same Persons. Invest. Ophthalmol. Vis. Sci. 2000. 41: 741-7482 Qureshi IA. Effects of exercise on intraocular pressure in physically fit subjects. Clin Exp Pharmacol Physiol. 1996 Aug;23(8):648-52.3 Teng, C, Gurses-Ozden, R, Liebmann, J M, Tello, C, Ritch, R. Effect of a tight necktie on intraocular pressure. Br J Ophthalmol 2003 87: 946-9484 Kass MA, Heuer DK, Higginbotham EJ, Johnson CA, Keltner JL, Miller JP, Parrish RK 2nd, Wilson MR, Gordon MO. The Ocular Hypertension Treatment Study: a randomized trial determines that topical hypotensive medication delays or prevents the onset of primary open angle glaucoma. Arch Ophthalmol. 2002 Jun;120(7):701-13;discussion 829-30.5 Iwase A, Suzuki Y, Araei M, Yamamoto T, Abe H, Shirato S, Kawayama Y, Mishima HK, Shimizu H, Tomita G, Inoue Y, KitazawaY: the Tajimi Study Group. Japan Glaucoma Society. The Prevalence of primary open angle glaucoma in Japanese; the Tajimi study. Ophthalmology 2004 Sep;111(9):1641-8.6 Tatemichi M, Nakano T, Tanaka K, Hayashi T, Nawa T, Miyamoto T, Hiro H, Sugita M. Possible association between heavy computer users and glaucomatous visual field abnormalities: a cross sectional study in Japanese workers. J Epidemiol Community Health 2004 58: 1021-10277 Kitnarong N, Libratanasakul S, Metheetrairut A, Ruangvaravate N. Acute primary angle-closure in Thailand. Asian J Ophthalmol. 2007;9:197-2028 Teekhasaenee C, Ritch R. Combined phacoemulsification and goniosynechialysis for uncontrolled chronic angle- closure glaucoma after acute angle closure attack. Ophthalmology 1999 Apr;106(4):669-74.9 Passo MS, Goldberg L, Elliot DL, Van Buskirk EM. Exercise Training Reduces Intraocular Pressure Among Subjects Suspected of Having Glaucoma. Arch Ophthalmol. 1991;109(8):1096-1098.
  • 108 The Glaucoma Myths & Facts10 Schuman JS. Increased intraocular pressure and visual field defects in high resistance wind instrument players. Ophthalmology, Volume 107, Issue 1, Pages 127-13311 Shah P, Whittaker KW, Wells AP, Khaw PT. Exercise induced visual loss associated with advanced glaucoma in young adults. Eye 2001; 15: 616–620.12 Liesegang TJ, Skuta GL, Cantor LB eds. Basic and Clinical Science Course. Section 10 2005-2006. San Francisco: American Academy of Ophthalmology; 2005.1 Kerrigan–Baumrind LA, Quigley HA, Pease ME, Kerrigan DF, and Mitchell RS. Number of Ganglion Cells in Glaucoma Eyes Compared with Threshold Visual Field Tests in the Same Persons. Invest. Ophthalmol. Vis. Sci. 2000. 41: 741-7482 Qureshi IA. Effects of exercise on intraocular pressure in physically fit subjects. Clin Exp Pharmacol Physiol. 1996 Aug;23(8):648-52.3 Teng, C, Gurses-Ozden, R, Liebmann, J M, Tello, C, Ritch, R. Effect of a tight necktie on intraocular pressure. Br J Ophthalmol 2003 87: 946-9484 Kass MA, Heuer DK, Higginbotham EJ, Johnson CA, Keltner JL, Miller JP, Parrish RK 2nd, Wilson MR, Gordon MO. The Ocular Hypertension Treatment Study: a randomized trial determines that topical hypotensive medication delays or prevents the onset of primary open angle glaucoma. Arch Ophthalmol. 2002 Jun;120(7):701-13;discussion 829-30.5 Iwase A, Suzuki Y, Araei M, Yamamoto T, Abe H, Shirato S, Kawayama Y, Mishima HK, Shimizu H, Tomita G, Inoue Y, KitazawaY: the Tajimi Study Group. Japan Glaucoma Society. The Prevalence of primary open angle glaucoma in Japanese; the Tajimi study. Ophthalmology 2004 Sep;111(9):1641-8.6 Tatemichi M, Nakano T, Tanaka K, Hayashi T, Nawa T, Miyamoto T, Hiro H, Sugita M. Possible association between heavy computer users and glaucomatous visual field abnormalities: a cross sectional study in Japanese workers. J Epidemiol Community Health 2004 58: 1021-10277 Kitnarong N, Libratanasakul S, Metheetrairut A, Ruangvaravate N. Acute primary angle-closure in Thailand. Asian J Ophthalmol. 2007;9:197-2028 Teekhasaenee C, Ritch R. Combined phacoemulsification and goniosynechialysis for uncontrolled chronic angle- closure glaucoma after acute angle closure attack. Ophthalmology 1999 Apr;106(4):669-74.9 Passo MS, Goldberg L, Elliot DL, Van Buskirk EM. Exercise Training Reduces Intraocular Pressure Among Subjects Suspected of Having Glaucoma. Arch Ophthalmol. 1991;109(8):1096-1098.10 Schuman JS. Increased intraocular pressure and visual field defects in high resistance wind instrument players. Ophthalmology, Volume 107, Issue 1, Pages 127-13311 Shah P, Whittaker KW, Wells AP, Khaw PT. Exercise induced visual loss associated with advanced glaucoma in young adults. Eye 2001; 15: 616–620.12 Liesegang TJ, Skuta GL, Cantor LB eds. Basic and Clinical Science Course. Section 10 2005-2006. San Francisco: American Academy of Ophthalmology; 2005.
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  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 113 ¡ÒÃÍÑÁ¾ÒµàÃ×ÍÃѧ (chronic CN VI palsy) BTX ໚¹¡ÒÃÃÑ¡ÉÒàÊÃÔÁËÇÁ¡Ñº¡Òü‹Ò é µÑ´¡ÅŒÒÁà¹×͵ҌҡŌÒÁà¹×Í (muscle transposition) â´Â©Õ´ BTX ÃÐËNjҧ¡Òà é é ·íÒ¼‹ÒµÑ´ËÃ×ÍËÅѧ¼‹ÒµÑ´ÀÒÂã¹ 15 Çѹ «Ö§ª‹ÇÂÅ´âÍ¡ÒÊ¡ÒÃà¡Ô´ anterior segment è ischemia áÅкÃÔàdzÅÒ¹ÊÒµҷÕäÁ‹ÁÀÒ¾«ŒÍ¹à¾ÔÁ¢Ö¹ è Õ è é 4.2.àʌ¹»ÃÐÊÒ·ÊÁͧ¤Ù·Õè 3 ËÃ×Í 4 ÍÑÁ¾Òµ (CN III or IV palsy) ‹ ¡Òéմ BTX ãˌ¼ÅäÁ‹´¹¡ã¹¡Ã³Õ¹Õé ᵋ㹪‹Ç§áá¢Í§¡ÒÃÍÑÁ¾Òµâ´Â੾ÒÐËÅѧ¨Ò¡ Õ Ñ¡ÒÃà¡Ô´Íغµà赯 ËÒ¡¨ÐÃÍ¡Òÿ„¹µÑǢͧàʌ¹»ÃÐÊÒ·ÍÒ¨©Õ´ BTX ª‹ÇÂÅ´ÍÒ¡ÒÃÀÒ¾«ŒÍ¹ªÑǤÃÒÇ Ñ Ô œ è䴌 (6) 5. µÒࢷÕ§ÁÕÍÂÙËÅѧ¨Ò¡¡Òü‹ÒµÑ´¡ÅŒÒÁà¹×ÍµÒ ã¹»ÃÔÁÒ³ÁØÁࢷÕäÁ‹ÁÒ¡¹Ñ¡ BTX ¨ÐÊÒÁÒö èÑ ‹ é èᡌä¢ä´Œ ËÒ¡äÁ‹µÍ§¡Ò÷íÒ¼‹ÒµÑ´«éÒ Œ í 6. µÒà¢ËÅѧ¨Ò¡¡Ò÷íÒ¼‹ÒµÑ´ÃÑ¡ÉҨͻÃÐÊÒ·µÒÅÍ¡ (retinal detachment surgery) ¨Ò¡¡ÒÃ㪌ᶺ«ÔÅ⤹ÃÑ´ÅÙ¡µÒ ËÃ×Í¡Òü‹ÒµÑ´ÃÑ¡ÉÒµŒÍËÔ¹·Õãʋ·Í«ÔÅ⤹ª‹ÇÂ㹡ÒÃÃкÒ¹éÒÀÒÂã¹ÅÙ¡µÒÍÍ¡ Ô è ‹ Ô íÊÙ¾¹·Õ㵌àÂ×ÍºØµÒ à¹×ͧ¨Ò¡µÒࢡóÕàËŋҹÕäÁ‹ÊÒÁÒö¹íÒᶺÃÑ´ËÃ×Í·‹Í·Õ໚¹ÊÒà˵ØÍ͡䴌 ¡Òü‹Ò ‹ ×é è è è é èµÑ´¡ÅŒÒÁà¹×ͨÐÁÕâÍ¡ÒÊàÊÕ§·Õ¨Ð·íÒãˌᶺÃÑ´ËÃ×Í·‹ÍËÅش䴌 ¡Òéմ BTX ¨Ö§à»š¹ÇÔ¸·»ÅÍ´ÀÑÂáÅÐ é è è Õ ÕèÊÒÁÒöª‹ÇÂÅ´ÍÒ¡ÒÃÀÒ¾«ŒÍ¹Å§ ÊíÒËÃѺâäµÒࢷÕäÁ‹¤ÇÃ㪌 ⺷ÙŹÁ ·çÍ¡«Ô¹ 㹡ÒÃÃÑ¡ÉÒà¹×ͧ¨Ò¡¼Å¡ÒÃÃÑ¡ÉÒäÁ‹´¹¡ 䴌ᡋ è Ô Ñ è Õ ÑµÒà¢ËÅѧ¡Òü‹ÒµÑ´·Õà¡Ô´¨Ò¡¶Í¡ŌÒÁà¹×Íä»´ŒÒ¹ËÅѧÁÒ¡à¡Ô¹ä»ËÃ×͡ŌÒÁà¹×ÍËÅØ´ËÒÂä» µÒࢪ¹Ô´ è é éÁÕ¡ÒÃÂÖ´µÔ´ ઋ¹ µÒࢨҡä·ÃÍ´ã¹ÃÐÂÐàÃ×ÍÃѧ µÒࢷÕÁÁÁࢠ> 40 PD áÅмٻǵÒࢷÕÁ¤ÇÒÁ é è Õ Ø Œ † è Õ¼Ô´»¡µÔ¢Í§¡ÅŒÒÁà¹×Í antagonist ËÇÁ´ŒÇ ઋ¹ Duane’s retraction syndrome é¡ÒÃ㪌 BTX ã¹ÀÒÇеÒÊÑè¹ (Nystagmus) 㹡óռ»ÇÂÁÕ»­ËÒàÃ×ͧÀÒ¾ÊѹËÅѧ¨Ò¡à¡Ô´ÍÒ¡ÒõÒÊѹ (acquired nystagmus) ¾ºä´Œã¹ ٌ † ˜ è è èmultiple sclerosis ËÃ×ÍÍÒ¡ÒõÒÊѹᵋ¡Òà¹Ô´ ¼Ù»Ç¨ÐÁÕ»­ËÒàÃ×ͧÀÒ¾ÊѹáÅСÒÃÁͧàËç¹Å´Å§ è í Œ † ˜ è è¡Òéմ BTX ࢌÒËÅѧÅÙ¡µÒ (retrobulbar) 25-30 U ¨Ðª‹ÇÂãˌµÒÊѹŴŧáÅСÒÃÁͧàË繡ç¨Ð´Õ¢¹ è Öéᵋ¾ºÇ‹ÒÁռŢŒÒ§à¤Õ§â´Â੾ÒÐã¹àÃ×ͧ¢Í§ÀÒ¾«ŒÍ¹áÅÐ˹ѧµÒµ¡¤‹Í¹¢ŒÒ§ÁÒ¡ µ‹ÍÁÒ¾ºÇ‹Ò¡Òà è (7)©Õ´ÂÒࢌҡŌÒÁà¹×Í rectus ᵋÅÐÁÑ´¨Ð䴌¼Å´Õ¡Ç‹Ò¡ÒéմࢌÒËÅѧÅÙ¡µÒ(8) é¡ÒÃ㪌 BTX ã¹âäµÒ¨Ò¡âää·ÃÍ´ (Thyroid related ophthalmopathy) º·ºÒ·¢Í§ BTX ã¹âä¹ÕÁÕ 3 ¡Ã³Õ ¤×Í é 1. ¡ÒÃᡌä¢ÀÒÇÐÀÒ¾«ŒÍ¹¨Ò¡¡ÅŒÒÁà¹×éͼԴ»¡µÔã¹ÃÐÂÐà©Õº¾Åѹ (acute restrictivestrabismus) «Ö§Âѧãˌ¼ÅäÁ‹´¹¡ ᵋÊÒÁÒö㪌áÉÒªÑǤÃÒÇà¾×ͪÐÅÍ¡Òü‹ÒµÑ´ã¹ÃÒ·ռ»ÇÂÂѧäÁ‹ è Õ Ñ Ñ è è è ٌ †¾ÃŒÍÁËÃ×ÍäÁ‹àËÁÒÐÊÁ·Õ¨ÐÃѺ¡Òü‹ÒµÑ´ ʋǹã¹ÃÐÂÐàÃ×ÍÃѧ ¡ÅŒÒÁà¹×͵‹Ò§æ¨ÐÁÕ¡ÒÃà»ÅÕ¹á»Å§à»š¹ è é é è¾Ñ§¼×´·íÒãˌ BTX äÁ‹ÊÒÁÒö㪌áÉÒã¹ÃÐÂйÕ䴌 Ñ é
  • 114 ¡ÒÃÃÑ¡ÉÒâä·Ò§¨Ñ¡ÉØÇ·ÂÒ´ŒÇ¡Òéմ ⺷ÙŹÁ ·çÍ¡«Ô¹ Ô Ô Ñ 2. ¡ÒÃᡌä¢à»Å×Í¡µÒ·ÕÍÂÙʧ¡Ç‹Ò»¡µÔã¹¼Ù»ÇÂâää·ÃÍ´ (Lid retraction) ⺷ÙŹÁ ·Í¡«Ô¹ è ‹Ù Œ † Ô ÑÁÕº·ºÒ·ã¹¡ÒÃÃÑ¡ÉҼٻǷÕÁà»Å×Í¡µÒÃѧÊÙ§¡Ç‹Ò»¡µÔ·à¡Ô´¨Ò¡âää·ÃÍ´ â´Â੾ÒÐä·ÃÍ´à»š¹ Œ † è Õ é Õè¾ÔÉ à¹×ͧ¨Ò¡µíÒá˹‹§¢Í§à»Å×Í¡µÒº¹¨Ð¶Ù¡¡ÅŒÒÁà¹×ÍàÅç¡æ´ŒÒ¹ã¹¢Í§à»Å×Í¡µÒ´Ö§ãˌÍÂÙã¹µíÒá˹‹§ è é ‹·ÕèÊÙ§¢Ö鹡Njһ¡µÔ ¡Òéմ BTX ÍÒ¨·íÒâ´Â¾ÅÔ¡à»Å×Í¡µÒº¹¢Öé¹ áŌǩմÂÒä»·Õè㵌àÂ×èͺصҴŒÒ¹ã¹¢Í§à»Å×Í¡µÒº¹(9)ËÃ×ͨЩմ¼‹Ò¹¼ÔÇ˹ѧºÃÔàdz´ŒÒ¹¹Í¡¢Í§à»Å×Í¡µÒº¹(10,11) «Ö§¨Ð䴌¼Å´Õã¹ÃÒ·Õè èÁÕà»Å×Í¡µÒÍÂÙʧäÁ‹ÁÒ¡¹Ñ¡áÅÐäÁ‹ÁµÒ⻹ÍÍ¡ÁÒÁÒ¡ ‹Ù Õ 3. ¡ÒÃÃÑ¡ÉÒÀÒÇФÇÒÁ´Ñ¹ã¹ÅÙ¡µÒÊÙ§àÁ×Í¡ÅÍ¡µÒ¢Ö¹º¹ à¹×ͧ¨Ò¡¡ÅŒÒÁà¹×Í inferior rectus è é è éã¹¼Ù»ÇÂä·ÃÍ´¨ÐâµáÅкÇÁ¢Ö¹ ʋǹ˹֧໚¹¨Ò¡¡ÒÃÍÑ¡àʺáÅÐàÅ×Í´¤Ñ§ÍÂÙÀÒÂ㹡ŌÒÁà¹×Í·íÒãˌ Œ † é è è ‹ é¡ÅŒÒÁà¹×Í´Ö§áÅÐÂÖ´µÔ´ÅÙ¡µÒänj ·íÒãˌ¼»ÇÂäÁ‹ÊÒÁÒöÁͧ¢Ö¹º¹ä´Œ áÅШзíÒãˌà¡Ô´¡Òô֧¡´¼¹Ñ§ é ٌ † éÅÙ¡µÒ ¤ÇÒÁ´Ñ¹ÀÒÂã¹ÅÙ¡µÒ¨ÐÊÙ§¢Ö¹ ¡Òéմ BTX ࢌÒÊ١ŌÒÁà¹×Í inferior rectus ¨Ð·íÒãˌ¤ÇÒÁ´Ñ¹ é ‹ éµÒŴŧ䴌 (12)¡ÒÃ㪌 ⺷ÙÅÔ¹ÑÁ ·çÍ¡«Ô¹ 㹡Å؋Áâä¡ÒÃà¤Å×è͹äËǼԴ»¡µÔ¢Í§¡ÅŒÒÁà¹×éÍãºË¹ŒÒ (facial movement disorders) ¡ÒÃà¤Å×͹äËǼԴ»¡µÔ ¢Í§¡ÅŒÒÁà¹×ÍãºË¹ŒÒ·ÕÊÒÁö㪌⺷ÙŹÁ ·çÍ¡«Ô¹ 㹡ÒÃÃÑ¡ÉÒ·Õ¾º è é è Ô Ñ èº‹ÍÂáÅÐ㪌¡¹Í‹ҧá¾Ã‹ËÅÒ 䴌ᡋ à»Å×Í¡µÒáÅÐ˹ѧµÒ¡Ãеء ¡ÅŒÒÁà¹×ÍãºË¹ŒÒ¡Ãеء¤ÃÖ§«Õ¡ Ñ é è 1. à»Å×Í¡µÒáÅÐ˹ѧµÒ¡Ãеء (essential blephalospasm) ¾ºä´ŒºÍÂã¹¼ÙË­Ô§ ÍÒ¡Òâͧà»Å×Í¡µÒáÅÐ˹ѧµÒ¡Ãеء¨Ð¾ºä´Œã¹ÃдѺµ‹Ò§æ¡Ñ¹ ઋ¹ ‹ ŒÃÙÊ¡äÁ‹ÊºÒÂµÒ ¡ÃоÃÔºµÒº‹Í ¶ŒÒ¡ÅŒÒÁà¹×Íà¡Ãç§ÁÒ¡¨ÐÅ×ÁµÒäÁ‹¢¹·Ñ§Êͧ¢ŒÒ§ ¡Òéմ BTX ໚¹ ŒÖ é Öé é¡ÒÃÃÑ¡ÉÒ·Õ´·Ê´áÅÐ໚¹Áҵðҹ㹡ÒÃÃÑ¡ÉÒâä¹Õ(13) ᵋ¤ÇÃÃÐÇѧËÅÕ¡àÅÕ§¡Òéմ·ÕÊǹ¡ÅÒ§¢Í§ è Õ Õè Ø é è è‹à»Å×Í¡µÒ´ŒÒ¹º¹à¾ÃÒШж١¡ÅŒÒÁà¹×Í Levator ·íÒãˌà»Å×Í¡µÒº¹µ¡ä´Œ é 2. ¡ÅŒÒÁà¹×ÍãºË¹ŒÒ¡Ãеء¤ÃÖ§«Õ¡ (hemifacial spasm) é è ¡Òéմ BTX ¨ÐÊÒÁÒöãˌ¡ÒÃÃÑ¡ÉÒ䴌àÁ×ÍäÁ‹¾º¾ÂÒ¸ÔÊÀÒ¾·Õ໚¹ÊÒà˵آͧ¡ÒᴷѺ è èàʌ¹»ÃÐÊÒ·ÊÁͧ¤Ù·Õè 7 (facial nerve) ËÃ×ÍËÅѧ¨Ò¡ä´Œ·Ò¡ÒÃÃÑ¡ÉÒ¾ÂÒ¸ÔÊÀÒ¾·Õ¡´·Ñºàʌ¹»ÃÐÊÒ· ‹ í èᵋ§ÁÕ¡ÒáÃеء¢Í§¡ÅŒÒÁà¹×ÍÍÂً Ñ é¡ÒÃ㪌 ⺷ÙÅÔ¹ÑÁ ·çÍ¡«Ô¹ã¹¡ÒÃÃÑ¡ÉÒâä¹éíÒµÒäËżԴ»¡µÔàÇÅÒà¤ÕéÂÇÍÒËÒèҡàʌ¹»ÃÐÊÒ·§Í¡¼Ô´·Õè (Crocodile tear) ã¹âä¹Õ¼»Ç¨ÐÁÕ¤ÇÒÁÃíÒ¤Ò­Í‹ҧÁÒ¡ à¹×ͧ¨Ò¡¹éÒµÒ¨ÐäËŵÅÍ´àÇÅÒ·Õà¤ÕÂÇÍÒËÒÃËÃ×Í é ٌ † è í è é¾Ù´ «Ö§à¡Ô´¨Ò¡¡Òç͡¢Í§àʌ¹»ÃÐÊÒ·ä»ã¹·Õ¼´»¡µÔ ¡Òéմ BTX ࢌÒä»ã¹µ‹ÍÁ¹éÒµÒʋǹ·ÕÍÂÙ㵌 è è Ô í è ‹à»Å×Í¡µÒ¨Ð·íÒãˌÊÒÁÒöŴ»ÃÔÁÒ³¹éÒµÒ·ÕäËÅ䴌 ãˌ¼Å¤‹Í¹¢ŒÒ§´Õ ᵋµÍ§©Õ´«éÒઋ¹à´ÕÂǡѺ¡Òéմ í è Œ íࢌҡŌÒÁà¹×ÍµÒ é (14)
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 115¡ÒÃ㪌 ⺷ÙÅÔ¹ÑÁ ·çÍ¡«Ô¹ã¹¡ÒÃÃÑ¡ÉÒâäµÒáˌ§ (Dry eye syndrome) ¡ÒÃÃÑ¡ÉÒÀÒÇеÒáˌ§ÍÒÈÑÂËÅÑ¡¡ÒÃÅ´¡ÒúպµÑǢͧ¡ÅŒÒÁà¹×Í orbicularis oculi «Ö§¨Ð·íÒ é èÁռŷíÒãˌ¡ÒÃÃкÒ¹éÒµÒÍÍ¡¨Ò¡µÒŴŧ â´Â㪌 BTX ©Õ´·Õ´Ò¹ã¹¢Í§à»Å×Í¡µÒŋҧã¡ÅŒ¡ºÃ٢ͧ í è Œ Ñ·‹ÍÃкÒ¹éÒµÒ í (15)¡ÒÃ㪌 ⺷ÙŹÁ ·çÍ¡«Ô¹ ·íÒãˌà¡Ô´ÀÒÇÐà»Å×Í¡µÒº¹µ¡à¾×Í¡ÒÃÃÑ¡ÉÒ (ptosis Ô Ñ èinduction) ÊÒÁÒö㪌⺷ÙŹÁ ·çÍ¡«Ô¹ ·íÒãˌà¡Ô´Ë¹Ñ§µÒµ¡á·¹¡ÒÃàÂçºà»Å×Í¡µÒ 㹼ٻǷءÃÒ·Õè Ô Ñ Œ †¨íÒ໚¹µŒÍ§·íÒãˌà»Å×Í¡µÒº¹áÅÐŋҧµÔ´¡Ñ¹ªÑǤÃÒÇ (temporary tarsorrhaphy) â´ÂäÁ‹µÍ§·íÒ¡ÒÃ è Œ¼‹ÒµÑ´ ઋ¹ 㹼ٻǷÕËÅѺµÒäÁ‹Ê¹Ô·¨Ò¡àʌ¹»ÃÐÊÒ·ÊÁͧ¤Ù·Õè 7 ÍÑÁ¾Òµ ËÃ×ÍÊÒà˵Ø͹·Õ·Òãˌ¡ÃШ¡ Œ † è ‹ ×è è íµÒáˌ§¨Ò¡¡ÒÃËÅѺµÒäÁ‹Ê¹Ô· â´Â੾ÒÐã¹ÃÒ·ÕÁ¤ÇÒÁÃÙÊ¡¢Í§¡ÃШ¡µÒŴŧ (corneal anesthesia) è Õ ŒÖáÅÐäÁ‹ÁÕ Bell’s phenomenon ÊíÒËÃѺ¢ŒÍ´Õ¢Í§ BTX ¤×Í ÊÒÁÒö·íÒ䴌㹷ءÃÒÂâ´ÂäÁ‹Á¢ÍˌÒÁ Õ Œ·íÒ䴌ÃÇ´àÃçÇ ãªŒÍ»¡Ã³¹Í äÁ‹·ÒãˌûËҧ¢Í§¢Íºà»Å×Í¡µÒàÊÕÂä» áµ‹¡Ò÷íÒãˌà»Å×Í¡µÒ»´Å§ Ø Œ í ÙÁҹѹäÁ‹ä´Œà¡Ô´¢Ö¹·Ñ¹·Õ µŒÍ§ãªŒàÇÅÒ»ÃÐÁÒ³ 1-2 ÇѹËÅѧ©Õ´ÂÒà»Å×Í¡µÒ¨Ö§¨ÐŧÁÒ»´ä´ŒÊ¹Ô· é é¡ÒÃ㪌 ⺷ÙŹÁ ·çÍ¡«Ô¹ ã¹¼Ù»ÇÂ˹ѧµÒŋҧÁŒÇ¹à¢ŒÒã¹ (lower lid entropion) Ô Ñ Œ † BTX ÊÒÁÒö㪌ÃÑ¡ÉÒ䴌ã¹ÃÒ·Õè˹ѧµÒÁŒÇ¹à¢ŒÒã¹·Õèà¡Ô´¨Ò¡¡ÒÃà¡Ã秵ÑǢͧ¡ÅŒÒÁà¹×éÍorbicularis oculi «Ö§ã¹ºÒ§ÃÒ¢¹µÒ·ÕÁǹࢌÒä»ÍÒ¨·íÒãˌà¡Ô´á¼Å·Õ¡ÃШ¡µÒ«Ö§¨Ð¡Ãеعãˌ¡ÅŒÒÁ è è Œ è è Œà¹×ÍÃͺµÒà¡Ã秵ÑÇÁÒ¡¢Ö¹ ´Ñ§¹Ñ¹¡Òéմ BTX ¨Ð·íÒãˌ¡ÅŒÒÁà¹×ͤÅÒµÑÇ¢¹µÒ·ÕÁǹࢌÒ仨СÅѺ é é (16) é é è ŒÁÒÍÂÙ·à´ÔÁ Å´ºÒ´á¼ÅáÅСÒáÃеع¨Ò¡¡ÃШ¡µÒ·íÒãˌÍÒ¡Ò÷ѧËÁ´´Õ¢¹ËÃ×ÍËÒÂä»ä´Œ ‹ èÕ Œ é Öé¡ÒÃ㪌 ⺷ÙÅÔ¹ÑÁ ·çÍ¡«Ô¹ à¾×èÍÅ´ÃÍ‹¹Ãͺ´Ç§µÒ ãºË¹ŒÒ áÅÐÅíÒ¤Í ÃÍ‹¹·Õ»ÃÒ¡¯¢Ö¹à¡Ô´¨Ò¡¡ÒÃà¡Ã秵ÑǢͧ¡ÅŒÒÁà¹×ͺÃÔàdz¹Ñ¹ ¡ÒÃ㪌 BTX ©Õ´ºÃÔàdzÃÍ è é é 鋹¨Ðª‹ÇÂãˌÃÍ‹¹¹Ñ¹ËÒÂä»ä´Œ ᵋµÍ§ÃÐÇѧ»˜­ËÒ¡ÒÃá¾Ã‹¡ÃШÒ¢ͧÂÒ·íÒãˌà»Å×Í¡µÒµ¡ËÃ×Í é Œ¡ÅŒÒÁà¹×ÍÍ×¹½†Íä»ä´Œ ´Ñ§¹Ñ¹¤ÇüÊÁ BTX ãˌÁ¤ÇÒÁࢌÁ¢Œ¹ÊÙ§¾Í¤ÇÃà¾×Íãˌ»ÃÔÁÒ³ÂÒ·Õ©´Å´Å§ é è é Õ è è ÕËÅѧ©Õ´¤Çá´àºÒæà¾×ÍäÁ‹ãˌàÅ×Í´ÍÍ¡ è
  • 116 ¡ÒÃÃÑ¡ÉÒâä·Ò§¨Ñ¡ÉØÇ·ÂÒ´ŒÇ¡Òéմ ⺷ÙŹÁ ·çÍ¡«Ô¹ Ô Ô ÑàÍ¡ÊÒÃ͌ҧÍÔ§1. American Academy of Ophthalmology. Botulinum toxin therapy of eye muscle disorders. Safety and effectiveness. Ophthalmology 1989 Sep;Pt 2: 37 - 412. Dutton JJ, Fowler AM. Botulinum toxin in ophthalmology. Surv Ophthalmol. 2007 Jan-Feb;52(1):13-31.3. Rowe FJ, Noonan CP. Botulinum toxin for the treatment of strabismus. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD006499.4. Han SH, Lew H, Jeong CW, Lee JB. Effect of botulinum toxin A chemodenervation in sensory strabismus. J Pediatr Ophthalmol Strabismus. 2001 Mar-Apr;38(2):68-71.5. McNeer KW. Botulinum toxin injection into the superior rectus muscle of the non-dominant eye for dissociated vertical deviation. J Pediatr Ophthalmol Strabismus 1989 Jul-Aug;26(4):162 - 46. Talebnejad MR, Sharifi M, Nowroozzadeh MH. The role of Botulinum toxin in management of acute traumatic third-nerve palsy. J AAPOS. 2008 Oct;12(5):510-3.7. Tomsak RL, Remler BF, Averbuch-Heller L, et al: Unsatisfactory treatment of acquired nystagmus with retrobulbar injection of botulinum toxin. Am J Ophthalmol 119:489—96, 19958. Carruthers J, et al: The treatment of congenital nystagmus with Botox. J Pediatr Ophthalmol Strabismus 32:306— 8, 19959. Uddin JM, Davies PD. Treatment of upper eyelid retraction associated with thyroid eye disease with subconjunctival botulinum toxin injection. Ophthalmology. 2002 Jun;109(6):1183-710. Shih MJ, Liao SL, Lu HY. A single transcutaneous injection with Botox for dysthyroid lid retraction. Eye. 2004 May;18(5):466-9.11. Chuenkongkaew W. Botulinum toxin treatment for upper lid retraction of dysthyroidism. J Med Assoc Thai. 2003 Nov;86(11):1051-4.12. Kikkawa DO, Cruz RC Jr, Christian WK, Rikkers S, Weinreb RN, Levi L, et al. Botulinum A toxin injection for restrictive myopathy of thyroid-related orbitopathy: effects on intraocular pressure. Am J Ophthalmol. 2003 Apr;135(4):427-31.13. Hallett M, Evinger C, Jankovic J, Stacy M; BEBRF International Workshop. Update on blepharospasm: report from the BEBRF International Workshop. Neurology. 2008 Oct 14;71(16):1275-82.14. Nava-Casta?eda A, Tovilla-Canales JL, Boullosa V, Tovilla-y-Pomar JL, Monroy-Serrano MH, Tapia-Guerra V, et al. Duration of botulinum toxin effect in the treatment of crocodile tears. Ophthal Plast Reconstr Surg. 2006 Nov- Dec;22(6):453-615. Sahlin S, Chen E, Kaugesaar T, Almqvist H, Kjellberg K, Lennerstrand G. Effect of eyelid botulinum toxin injection on lacrimal drainage. Am J Ophthalmol. 2000 Apr;129(4):481-6.16. Christiansen G, Mohney BG, Baratz KH, Bradley EA. Botulinum toxin for the treatment of congenital entropion. Am J Ophthalmol. 2004 Jul;138(1):153-5.
  • º··ÕèàǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 117 18 Current Trend in Chronic Rhinitis ¼ÙŒª‹ÇÂÈÒʵÃÒ¨ÒϹÒÂᾷ »ÒÃÂÐ ÍÒȹÐàʹ1, ÈÒʵÃÒ¨ÒÏà¡ÕÂõԤسᾷ˭ԧ ©ÇÕÇÃó ºØ¹¹Ò¤1, ¼ÙŒª‹ÇÂÈÒʵÃÒ¨ÒϹÒÂᾷ ΁âÃªÔ ¨Ñ¹·ÒÀÒ¡ØÅ2, ÃͧÈÒʵÃÒ¨ÒÏᾷ˭ԧ ÊؾԹ´Ò ªÙÊ¡ØÅ3 1 ÀÒ¤ÇÔªÒâʵ ¹ÒÊÔ¡ ÅÒÃÔ§«Ç·ÂÒ ¤³Ðá¾·ÂÈÒʵÏÈÃÃÒª¾ÂÒºÒÅ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å Ô ÔÔ2 ÊÒ¢ÒÇÔªÒâäÀÙÁᾌáÅÐÀÙÁ¤Á¡Ñ¹·Ò§¤ÅÔ¹¡ ÀÒ¤ÇÔªÒÍÒÂØÃÈÒʵÏ ¤³Ðá¾·ÂÈÒʵϨÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ Ô Ô ØŒ Ô Ø 3 ÀÒ¤ÇÔªÒâʵ ÈÍ ¹ÒÊÔ¡ÇÔ·ÂÒ ¤³Ðá¾·ÂÈÒʵϨÌÒŧ¡Ã³ÁËÒÇÔ·ÂÒÅÑÂ Ø ¤§äÁ‹Áã¤Ã»¯Ôàʸ䴌ÇÒ “䢌ËÇÑ´” ËÃ×Í âä¨ÁÙ¡ÍÑ¡àʺà©Õº¾Åѹ (acute rhinitis) ·Õà¡Ô´¨Ò¡ Õ ‹ èäÇÃÑÊ໚¹âä·Õ辺º‹Í·ÕèÊØ´ ᵋ໚¹âä·ÕèäÁ‹¤‹ÍÂÁÕ»˜­ËÒ㹡ÒÃÇÔ¹Ô¨©Ñ áÅÐÁÑ¡ËÒÂ䴌àͧÀÒÂã¹7-10 Çѹ ã¹¢³Ð·Õâä¨ÁÙ¡ÍÑ¡àʺàÃ×ÍÃѧ (chronic rhinitis) ໚¹âä·Õ¾ºä´Œ¹ÍÂ¡Ç‹Ò ¤×Í ¾º»ÃÐÁÒ³ è é è ŒÃŒÍÂÅÐ 20 ã¹»ÃЪҡ÷ÑÇä»(1) ᵋ໚¹âä·ÕÁ»­ËÒ㹡ÒÃÇÔ¹¨©ÑÂáÅÐÃÑ¡ÉÒÁÒ¡¡Ç‹Ò à¹×ͧ¨Ò¡ÊÒà赯 è è Õ ˜ Ô è¢Í§âä¨ÁÙ¡ÍÑ¡àʺàÃ×ÍÃѧÁÕÁÒ¡ÁÒ áÅкҧÃÒ¡çÁËÅÒÂÊÒà˵ØÃÇÁ¡Ñ¹ ´Ñ§¹Ñ¹ã¹¡ÒôÙáÅÃÑ¡ÉҼٻǠé Õ ‹ é Œ †àËŋҹը§¤ÇÃÇÔ¹¨©ÑÂËÒÊÒà˵Øãˌṋ¡Í¹ à¾×ͨÐ䴌·ÃÒº¾ÂÒ¸Ô¡Òà¹Ô´ áÅÐãˌ¡ÒÃÃÑ¡ÉÒ䴌µÃ§¨Ø´ éÖ Ô ‹ è í ã¹·Ò§»¯Ôºµ¹ÂÁẋ§âä¨ÁÙ¡ÍÑ¡àʺàÃ×ÍÃѧÍ͡໚¹ 2 ¡ÅØÁ¡‹Í¹ ¤×Í ¡ÅØÁ·Õà¡Ô´¨Ò¡¡ÒõԴ Ñ Ô Ô é ‹ ‹ èàª×Í (infectious rhinitis) äÁ‹ÇÒ¨Ð໚¹äÇÃÑÊ áº¤·ÕàÃÕ ËÃ×ÍÃÒ áÅСÅØÁ·ÕäÁ‹ä´Œà¡Ô´¨Ò¡¡ÒõԴàª×Í (non- é ‹ ‹ è éinfectious rhinitis) «Ö§ã¹¡ÅØÁ¹Õ§ẋ§Í͡໚¹ÍÕ¡ 2 ¡ÅØÁ ¤×Í ¡ÅØÁ·Õà¡Ô´¨Ò¡ÀÙÁᾌ (allergic rhinitis) è ‹ é Ñ ‹ ‹ è ÔáÅСÅØÁ·ÕäÁ‹ä´Œà¡Ô´¨Ò¡ÀÙÁᾌ (non-allergic rhinitis) ¡ÅØÁËÅѧ¹ÕºÒ§áˋ§àÃÕ¡NjҡÅØÁ non-allergic, non- ‹ è Ô ‹ é ‹infectious rhinitis «Ö§ÂѧÊÒÁÒöá¡‹ÍÂ䴌͡ËÅÒÂÊÒà赯 ÃÇÁ·Ñ§ª¹Ô´·ÕäÁ‹¾ºÊÒà赯 (idiopathic)(2,3) è Õ é èÃÒÂÅÐàÍÕ´¢Í§¡ÒèíÒṡª¹Ô´¢Í§âä¨ÁÙ¡ÍÑ¡àʺ áÊ´§änj㹠ÃÙ»·Õè 1
  • 118 Current Trend in Chronic Rhinitis ÃÙ»·Õè 1. ¡ÒÃẋ§ª¹Ô´¢Í§âä¨ÁÙ¡ÍÑ¡àʺ㹷չ¨Ð¡Å‹ÒǶ֧âä¨ÁÙ¡ÍÑ¡àʺàÃ×ÍÃѧ 2 ¡ÅØÁãË­‹¤Í âä¨ÁÙ¡ÍÑ¡àʺ¨Ò¡ÀÙÁᾌ (allergic rhinitis) áÅÐâä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹ è Õé é ‹ × Ôᾌ (non-allergic rhinitis) âä¨ÁÙ¡ÍÑ¡àʺ¨Ò¡ÀÙÁᾌ ໚¹âä·ÕÁ¤ÇÒÁ¼Ô´»¡µÔ¢Í§ÃкºÀÙÁ¤Á¡Ñ¹¢Í§Ã‹Ò§¡Òª¹Ô´·Õè Ô è Õ Ô ŒØÁÕÍÒ¡ÒÃáÊ´§·Ò§¨ÁÙ¡ à¡Ô´ËÅѧ¨Ò¡ä´ŒÃºÊÒá‹ÍÀÙÁᾌࢌÒä»·íÒ»¯Ô¡ÃÂҡѺ IgE (IgE mediated type Ñ Ô ÔÔI hypersensitivity reaction) à¡Ô´¡ÒÃÍÑ¡àʺ¢Í§àÂ×ͺبÁÙ¡ ·íÒãˌà¡Ô´ÍÒ¡Òäѹ ¹éÒÁÙ¡äËÅ ¨ÒÁ è íáÅФѴ¨ÁÙ¡ µÑ§áµ‹¹Í ¨¹¶Ö§à»š¹ÁÒ¡ ¨¹·íÒãˌ¤³ÀÒ¾ªÕǵ·Ñ§·Ò§´ŒÒ¹Ã‹Ò§¡ÒÂ, ¨Ôµã¨ áÅСÒÃ é Œ Ø Ô éࢌÒÊѧ¤Áá‹ŧ àÁ×Íà·Õº¡Ñº¤¹»¡µÔ·Çä» è Ñè (4) âä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾Œ ¤×Íâä·Õ·Òãˌ¼»ÇÂÁÕÍÒ¡Òà ¤Ñ´¨ÁÙ¡ ¹éÒÁÙ¡äËÅ ·ÕäÁ‹ä´ŒÁÊÒà赯 è í ٌ † í è ÕÁÒ¨Ò¡¡ÒõԴàª×Í ËÃ×ÍâäÀÙÁᾌ «Ö§ÍÒ¨ÁÕÊÒà˵طª´à¨¹ ·ÕÊÒÁÒöÃÑ¡ÉÒ䴌 仨¹¶Ö§äÁ‹ÁÊÒà赯 é Ô è Õè Ñ è Õ·Õª´à¨¹ áÅÐÂÒ¡µ‹Í¡ÒÃÃÑ¡ÉÒ âä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾Œ ÍÒ¨·íÒãˌ¼»ÇÂÁÕÍÒ¡ÒäŌÒ¡Ѻâä¨ÁÙ¡ è Ñ ÙŒ †ÍÑ¡àʺ¨Ò¡ÀÙÁᾌ䴌 ᵋàÁ×Í·íÒ¡ÒõÃǨ¾ÔàÈÉâ´Â¡Ò÷íÒ allergic work up áÅÐ infectious work up Ô èáŌǾºÇ‹Ò ÍÒ¡Òôѧ¡Å‹ÒÇäÁ‹ä´ŒÁÊÒà˵ØÁÒ¨Ò¡ ¡ÒõԴàª×Í ËÃ×ÍÀÙÁᾌ ã¹ÊÁÑ¡‹Í¹ ÁÑ¡¨Ð㪌¤ÒÇ‹Ò Õ é Ô í“vasomotor rhinitis” ÊíÒËÃѺâä¹Õé â´ÂËÁÒ¶֧âä·ÕÁ¤ÇÒÁ¼Ô´»¡µÔ·ÁÊÒà˵ØÁÒ¨Ò¡¤ÇÒÁ¼Ô´»¡µÔ è Õ Õè բͧàʌ¹àÅ×Í´ ËÃ×Íàʌ¹»ÃÐÊÒ·ã¹àÂ×èͺبÁÙ¡ «Öè§äÁ‹ÁÕ¢ŒÍÁÙžÔÊÙ¨¹Ç‹Ò ÁÕ¤ÇÒÁ¼Ô´»¡µÔ´Ñ§¡Å‹ÒǨÃÔ§ËÃ×ÍäÁ‹ â´ÂÁÒ¡¼Ù»Ç¨ÐÁÕÍÒ¡ÒäѴ¨ÁÙ¡ ËÃ×ÍÁÕ¹ÒÁÙ¡äËÅŧ¤Í ËÃ×ͨÒÁ â´ÂäÁ‹ÁÊÒà˵بÒà¾ÒзÕè Œ † éí Õ íªÑ´à¨¹ ¼Ù»ÇÂÁÑ¡¤Ô´Ç‹Òà¡Ô´¨Ò¡ÊÒÃÃФÒÂà¤×ͧµ‹Ò§æ ã¹ÊÔ§áǴŌÍÁ â´ÂÍÒ¡ÒÃÁÑ¡¨ÐÁÒ¡¢Ö¹ àÁ×ÍËÒÂ㨠Œ † è é èàÍÒ¡ÅÔ¹¹éÒËÍÁ ËÃ×ͤÇѹºØËÃÕࢌÒä» ÃѺ»ÃзҹÍÒËÒÃÃʨѴ ËÃ×ÍÁÕ¡ÒÃà»ÅÕ¹á»Å§¢Í§ÍÒÃÁ³ è í è èËÃ×ÍÍÒ¡ÒÈÃͺ¢ŒÒ§ µ‹Ò§¨Ò¡¼Ù»ÇÂâä¨ÁÙ¡ÍÑ¡àʺ¨Ò¡ÀÙÁᾌ ·ÕÊÒÁÒöºÍ¡ÊÒà˵ط·Òãˌà¡Ô´ÍÒ¡Òà Œ † Ô è Õè í
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 119䴌ª´à¨¹ ᾷ¤ÇþÂÒÂÒÁËÒÊÒà˵ط¡Í‹ҧ ·Õ໚¹ä»ä´Œ¢Í§¡ÒÃÍÑ¡àʺã¹â¾Ã§¨ÁÙ¡ ¡‹Í¹·Õ¨Ð Ñ Ø è èãˌ¡ÒÃÇÔ¹¨©ÑÂNjÒ໚¹ non-allergic rhinitis of unknown etiology ÔÍغѵԡÒó âä¨ÁÙ¡ÍÑ¡àʺ¨Ò¡ÀÙÁᾌ໚¹âä·Õ¾ºä´ŒºÍÂã¹»ÃÐà·Èä·Â áÅлÃÐà·ÈÍ×¹æ·ÑÇâÅ¡ ÍغµÔ Ô è ‹ è è Ñ¡Òó¢Í§âä¹Õ¾ºä´Œ»ÃÐÁҳÌÍÂÅÐ 10-25 ¢Í§»ÃЪҡ÷ÑÇä» Ê‹Ç¹Íغµ¡Òó¢Í§âä¨ÁÙ¡ÍÑ¡àʺ é è (5,6) Ñ Ôª¹Ô´äÁ‹á¾Œ ã¹µ‹Ò§»ÃÐà·ÈÁÕµ§áµ‹ÃÍÂÅÐ 28 ¶Ö§ 60 «Ö§¤ÇÒÁᵡµ‹Ò§¹ÕÍÒ¨áÊ´§¶Ö§ ¤íÒ¨íÒ¡Ñ´¤ÇÒÁ Ñé Œ (7,8) è é¢Í§âä áÅÐÇÔ¸·ãªŒã¹¡ÒÃÇÔ¹¨©ÑÂâä·Õᵡµ‹Ò§¡Ñ¹ Íغµ¡Òó¢Í§âä¨ÁÙ¡ÍÑ¡àʺàÃ×ÍÃѧ·Ñ§Êͧ¹ÕÁÕ Õ Õè Ô è Ñ Ô é é éá¹Ç⹌ÁÊÙ§¢Ö¹àÃ×ÍÂæ â´Â੾ÒÐã¹àÁ×ͧãË­‹ ·ÕÁÁžÔÉ·Ò§ÍÒ¡ÒÈà¾ÔÁ¢Ö¹ àª×ÍNjҡÒ÷ÕÁ»ÃÔÁÒ³ é è è Õ è é è è բͧÊÒá‹ÍÀÙÁᾌ áÅÐÊÒÃÃФÒÂà¤×ͧã¹ÍÒ¡ÒÈÁÒ¡¢Ö¹ áÅлÃЪҡÃÊÑÁ¼ÑʡѺÊÒôѧ¡Å‹ÒÇã¹ÍÒ¡ÒÈ Ô éÁÒ¡¢Ö¹ ·íÒãˌ¾º¼Ù»ÇÂà¾ÔÁ¢Ö¹ é Œ † è é ÊíÒËÃѺâäÁÙ¡ÍÑ¡àʺ¨Ò¡ÀÙÁᾌ ¨Ð¾ºã¹à´ç¡ªÒº‹Í¡NjÒà´ç¡Ë­Ô§ ᵋ㹼ÙãË­‹¨Ð¾ºã¹ Ô Œ¼ÙŒË­Ô§ä´Œº‹Í¡NjҼٌªÒ âäÁÙ¡ÍÑ¡àʺ¨Ò¡ÀÙÁÔᾌ¹ÕéÁÑ¡¨ÐàÃÔèÁáÊ´§ÍÒ¡ÒÃã¹ÇÑÂàÃÕ¹ËÃ×ÍÇÑÂÃ؋¹µ‹Ò§¨Ò¡âä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾Œ «Öè§Ê‹Ç¹ãË­‹ ÁÑ¡àÃÔèÁÁÕÍÒ¡Òà àÁ×èÍÍÒÂØÁÒ¡ â´Â»ÃÐÁҳÌÍÂÅÐ 70 ¢Í§¼Ù»ÇÂâä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾Œ ÁÕÍÒÂØà¡Ô¹ 20 »‚(9) áÊ´§Ç‹Ò¡ÒÃà»ÅÕ¹á»Å§ºÒ§Í‹ҧ Œ † è«Ö§à¡ÕÂÇ¢ŒÍ§¡ÑºÍÒÂØ ÍÒ¨ÁÕÊǹËÇÁ㹡Ò÷íÒãˌà¡Ô´âä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾Œ¹Õé è è ‹ÊÒà赯 âä¨ÁÙ¡ÍÑ¡àʺ¨Ò¡ÀÙÁᾌ ໚¹âä·Õà¡Ô´¨Ò¡ËÅÒÂÊÒà赯 (multifactorial disease) ¾Íẋ§ Ô èÊÒà˵ØËÅѡ䴌 3 »ÃСÒà ¤×Í 1. Predisposing factor »˜¨¨Ñ·Õè໚¹ÊÒà˵ØËÅÑ¡ 䴌ᡋ àÃ×èͧ¢Í§¾Ñ¹¸Ø¡ÃÃÁ (heredity)â´Â¼Ù»Ç·Õ໚¹âäÀÙÁᾌ (atopic disease) ÁÕ¤ÇÒÁ¼Ô´»¡µÔ¢Í§ immune response gene (IR - Œ † è Ôgene) «Ö§·íÒ˹ŒÒ·Õ¤Çº¤ØÁ¡ÒÃÊÌҧÀÙÁ¤Á¡Ñ¹¢Í§Ã‹Ò§¡Ò áÅÐ gene ·Õ¼´»¡µÔ¹ÊÒÁÒö¶‹Ò·ʹ è è Ô ØŒ è Ô éÕä»ÂѧÅÙ¡ áÅÐËÅҹ䴌 (10) 2. Primary or specific factor »˜¨¨Ñ·Õ໚¹ÊÒà˵Øâ´ÂµÃ§ 䴌ᡋ ÊÔ§·Õ¼»ÇÂᾌ ËÃ×ÍÊÒà è è è ٌ †¡‹ÍÀÙÁᾌ (antigen, allergen) ª¹Ô´·Õ·Òãˌà¡Ô´ÍÒ¡ÒÃ䴌ºÍ¤×Í ÊÒ÷ÕÍÂÙã¹ÍÒ¡ÒÈ (aeroallergen) Ô è í ‹ è ‹áÅÐࢌÒÊÙÃÒ§¡ÒÂâ´Â¡ÒÃËÒÂ㨠(inhalant) ઋ¹ ½Ø¹ºŒÒ¹ (house dust), µÑÇäÃ㹽عºŒÒ¹ (house-dust ‹‹ † †mite), à¡Êþת (pollen), ªÔ¹Ê‹Ç¹ ËÃ×ÍÊÔ§¢Ñº¶‹Ò¢ͧáÁŧ·ÕÍÒÈÑÂÍÂÙ㹺ŒÒ¹ ઋ¹ áÁŧÊÒº, Âا, é è è ‹áÁŧÇѹ, Á´ ÊÒá‹ÍÀÙÁᾌ·ÊҤѭ·Õʴ㹽ع ¤×Í µÑÇäýع «Ö§ÊÒá‹ÍÀÙÁᾌ¹¹ ÁÕÍÂÙ·§ã¹µÑÇäÃ Ô Õè í èØ † † è Ô Ñé ‹ ÑéáÅÐã¹ÊÔ§¢Ñº¶‹Ò¢ͧÁѹ è 3. Secondary or precipitating factors 䴌ᡋ à˵ØàÊÃÔÁ·Õ·ÒãˌÍÒ¡ÒÃáÊ´§ÍÍ¡ÁÒ è íËÃ×ÍÁÕÍÒ¡ÒÃÁÒ¡¢Ö¹ä´Œ ઋ¹ âäµÔ´àª×Í, ÊÒÃÃФÒÂà¤×ͧµ‹Ò§æ (direct irritants) ઋ¹ ¡ÅÔ¹©Ø¹, ¤Çѹ é é 赋ҧæ, ½Ø†¹ÅÐÍͧ·Ø¡»ÃÐàÀ·, physical factors ઋ¹ ¡ÒÃÍÍ¡¡íÒÅѧ¡ÒÂ, ¡ÒÃà»ÅÕè¹á»Å§Í‹ҧ
  • ÃÇ´àÃçǢͧÍسËÀÙÁ,Ô psychic factor ઋ¹ à¤ÃÕ´, ÇÔµ¡¡Ñ§ÇÅ, ¤ÇÒÁ¼Ô´»¡µÔ·Ò§¡ÒÂÇÔÀҤ㹨ÁÙ¡ ઋ¹¼¹Ñ§¡Ñ¹ª‹Í§¨ÁÙ¡¤´ (deviated nasal septum), septal spur ໚¹µŒ¹ é âä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾Œ ÍÒ¨à¡Ô´¨Ò¡ÊÒà˵صҧæ䴌ËÅÒÂÊÒà赯 (µÒÃÒ§·Õè 1) ‹µÒÃÒ§·Õè 1: ÊÒà˵آͧâä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾Œ (non - allergic rhinitis)1. Syndromes of known etiology 1.1 Drug – induced (rhinitis medicamentosa) - Nasal decongestants - Antihypertensive (e.g. reserpine, -blockers, prazosin, methyldopa, phentolamine, guanethidine) - Oral contraceptive pills / estrogen - Aspirin / NSAIDS - Antidepressants - Ophthalmic – adrenergic blockers - Bromocriptine 1.2 Metabolic conditions - Pregnancy (rhinitis of pregnancy), menstrual cycle - Hypothyroidism, hyperthyroidism - Diabetes mellitus 1.3 Anatomic abnormalities - Septal deviations / spurs - Nasal polyps - Tumor of nose and / or paranasal sinus 1.4 Systemic autoimmune diseases - SLE - Sjögren’s syndrome - Churg – Strauss 1.5 Granulomatous disease - Sarcoidosis - Wegener’s granulomatosis2. Condition related to physical and chemical exposures - Occupational rhinitis - Cold, dry air–induced rhinitis
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 121 - Gustatory rhinitis - Pollutant–induced rhinitis - Hot food–induced rhinitis - Bright–light exposure3. Syndromes of unknown etiology - Non-allergic rhinitis with eosinophilia syndrome (NARES) - Hypertrophic, inflammatory rhinitis - Vasomotor rhinitis¾ÂÒ¸ÔÊÃÕÃÇÔ·ÂҢͧâä¨ÁÙ¡ÍÑ¡àʺàÃ×éÍÃѧ (chronic inflammation) ÃÙ»·Õè 2. á¼¹ÀÙÁÔáÊ´§¾ÂÒ¸ÔÊÃÕÃÇÔ·ÂҢͧ¡ÒÃÍÑ¡àʺ¨Ò¡ÀÙÁÔᾌ(11) ÊíÒËÃѺâä¨ÁÙ¡ÍÑ¡àʺ¨Ò¡ÀÙÁᾌ ¡ÒÃÍÑ¡àʺ¨Ò¡ÀÙÁᾌ»ÃСͺ´ŒÇ sensitization phase Ô Ô(ÃÙ»·Õè 2) «Ö§ÁÕ¡ÒÃÊÌҧ IgE ËÅѧ¨Ò¡ÊÑÁ¼ÑʡѺÊÒá‹ÍÀÙÁᾌ áÅÐ clinical phase «Ö§·íÒãˌÁÍÒ¡Òà è Ô è Õµ‹Ò§æ ÃÐËNjҧÊÑÁ¼ÑʡѺÊÒá‹ÍÀÙÁÔᾌ¹Ñé¹ «Ö觪‹Ç§¹ÕéÂѧẋ§Í͡໚¹ early-phase response «Öè§
  • 122 Current Trend in Chronic Rhinitisà¡ÕÂÇ¢ŒÍ§¡Ñº degranulation ¢Í§ mast cell áÅÐ late-phase response «Ö§à¡ÕÂÇ¢ŒÍ§¡Ñº ¡ÒÃà¾ÔÁ¢Ö¹ è è è è é¢Í§ inflammatory cells ã¹àÂ×ͺبÁÙ¡ áÅÐÁÕ¡ÒÃËÅѧ cytokines ÁÒ¡¢Ö¹ cytokines áÅÐ mediators è è éàËŋҹշÒãˌà¡Ô´ expression ¢Í§ adhesion molecules áÅСÒÃÊÌҧ chemoattractants à¾×Í é í è´Ö§´Ù´à«ÅŏµÒ§æ ࢌÒÁÒã¹àÂ×ͺبÁÙ¡à¡Ô´ late-phase response ÁÕ¡ÒÃÊÌҧ inflammatory mediators ‹ èÁÒ¡¢Ö¹ áÅÐä»à¾ÔÁ¡Òõͺʹͧ¢Í§ end organ ·íÒãˌàÂ×ͺبÁÙ¡äÇ (hyperresponsiveness ) µ‹ÍÊÒà é è 衋ÍÀÙÁᾌ໚¹¾ÔàÈÉ·ÕàÃÕÂ¡Ç‹Ò priming effect ¹Í¡¨Ò¡¹Ñ¹¼Ù»ÇÂÂѧÁÕ¤ÇÒÁäǵ‹ÍÊÒÃÍ×¹æ ·ÕäÁ‹ãª‹ÊÒÃ Ô è é Œ † è 衋ÍÀÙÁᾌ´Ç ઋ¹ ÍÒ¡ÒÈàÂç¹, histamine, methacholine «Ö§¼Å¢Í§¡Ãкǹ¡Òôѧ¡Å‹ÒÇ ÍÒ¨ËÒÂ Ô Œ èàͧ䴌 ËÃ×Í·íÒãˌà¡Ô´ÀÒÇÐá·Ã¡«ŒÍ¹µÒÁÁÒ䴌 (11) ¾ÂÒ¸ÔÊÃÕÃÇÔ·ÂÒ㹡ÒÃà¡Ô´âä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾ŒÂ§äÁ‹ª´à¨¹ ã¹ÃÒ·ÕäÁ‹ÃÊÒà赯 (non- Ñ Ñ è ŒÙallergic rhinitis of unknown etiology) ¹Ñ¹ àª×ÍNjÒÍÒ¨¨Ðà¡Ô´¨Ò¡¡Òõͺʹͧ·ÕÁÒ¡¼Ô´»¡µÔ¢Í§ é è èàÂ×ͺبÁÙ¡µ‹ÍÊÒÃÃФÒÂà¤×ͧµ‹Ò§æã¹ÊÔ§áǴŌÍÁ (nasal hyperreactivity) «Ö§ÁÕ afferent sensory è è èpathway ä»ÂѧÃкº»ÃÐÊҷʋǹ¡ÅÒ§ áÅÐãˌ efferent limb ÁÒ·Ò§ parasympathetic fiber ¡Òõͺʹͧ·ÕèÁÒ¡¼Ô´»¡µÔ¹Õé ÍÒ¨·ÓãËéÁÕ¡ÒÃËÅÑ觹éÓÁÙ¡ÁÒ¡¼Ô´»¡µÔ ËÃ×ͤѴ¨ÁÙ¡ÁÒ¡¼Ô´»¡µÔ ¨Ò¡parasympathetic activity ·Õèà¾ÔèÁ¢Öé¹(12) Í‹ҧäáçµÒÁ ÊÒà˵ØáÅСÅ䡢ͧ¡ÒÃà¾ÔèÁ¢Ö鹢ͧparasympathetic activity ¹ÕäÁ‹ª´à¨¹ ÍҨ໚¹à¾Õ§ variation ¢Í§¡Òõͺʹͧ·Õ»¡µÔ¢Í§ é Ñ èàÂ×ͺبÁÙ¡ ¡ç໚¹ä´Œ ¹Í¡¨Ò¡¹ÕÁ¡ÒÃÈÖ¡ÉÒ«Ö§áÊ´§Ç‹Ò¼Ù»ÇÂâä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾Œª¹Ô´·ÕäÁ‹Ãٌ è é Õ è Œ † èÊÒà˵عéÕ ÍÒ¨ÁÕ¤ÇÒÁ¼Ô´»¡µÔ㹡Ò÷íÒ§Ò¹¢Í§Ãкº»ÃÐÊÒ·Íѵâ¹ÁÑµÔ ·Õ¤Çº¤ØÁàʌ¹àÅ×Í´ã¹àÂ×ͺبÁÙ¡ è èâ´ÂµÍºÊ¹Í§µ‹Í¡ÒÃà»ÅÕ¹á»Å§·‹Ò·Ò§¢Í§Ã‹Ò§¡Ò (¨Ò¡¹Ñ§ä»¹Í¹) ËÃ×Í¡ÒáÃеع´ŒÇ¤ÇÒÁàÂç¹ è è ŒºÃÔàdzãºË¹ŒÒ ·íÒãˌ nasal airway resistance ÊÙ§¡Ç‹Ò¤¹»¡µÔ (13)¡ÒÃÇÔ¹Ô¨©ÑÂâä ÁÕ¨´»ÃÐʧ¤à¾×ÍÂ×¹Âѹ¡ÒÃÇÔ¹¨©ÑÂâä ÃÇÁ·Ñ§ÇÔ¹¨©ÑÂâäÍ×¹ ·ÕÍÒ¨à¡Ô´Ã‹ÇÁ¡Ñºâä¨ÁÙ¡ÍÑ¡àʺ Ø è Ô é Ô è èàÃ×ÍÃѧ áÅмÅá·Ã¡«ŒÍ¹·ÕÍÒ¨¨Ðà¡Ô´¢Ö¹¨Ò¡âä¹Õé à¾×Í·Õ¨Ð䴌ãˌ¡ÒÃÃÑ¡ÉÒ仾ÌÍÁ¡Ñ¹ ¡Òëѡ»ÃÐÇÑµÔ é è é è è¡ÒõÃǨËҧ¡Ò áÅÐ ¡ÒõÃǨ¾ÔàÈÉ ¨Ðª‹ÇÂÇÔ¹¨©ÑÂá¡âä¨ÁÙ¡ÍÑ¡àʺàÃ×ÍÃѧ ¨Ò¡ÊÒà˵صҧæ Ô é ‹(µÒÃÒ§·Õè 2)
  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 123µÒÃÒ§·Õè 2: ÅѡɳзÕè㪌ª‹ÇÂÇÔ¹Ô¨©ÑÂá¡âä¨ÁÙ¡ÍÑ¡àʺ¨Ò¡ÊÒà˵ص‹Ò§æ (14) Allergic Rhinitis Non-Allergic Rhinitis Infectious Rhinitis1. »ÃÐÇÑµÔ Íغµ¡ÒóµÒÁ ÁÕÍÒ¡ÒÃã¹ÃÒ seasonalÁÑ¡ÁÕÍÒ¡ÒõÅÍ´»‚ ËÃ×Í Ñ Ô Áѡ໚¹ÁÒ¡ã¹Ä´Ù½¹ Ä´Ù¡ÒÅ type ໚¹ÁÒ¡ ËÃ×ͪ‹Ç§·ÕÁ¡Òà è Õ àÁ×ÍÍÒ¡ÒÈà»ÅÕ¹ è è µÔ´àª×ÍÃкҴ é ÍÒÂØ·àÃÔÁÁÕÍÒ¡Òà ÁÑ¡àÃÔÁã¹ÇÑÂà´ç¡ ËÃ×ÍÇÑÂÃع Õè è è ‹ ÇѼÙãË­‹ Œ äÁ‹¨Ò¡Ñ´ÍÒÂØ í (ÌÍÂÅÐ 70 àÃÔÁàÁ×Í (ÌÍÂÅÐ 70 àÃÔÁàÁ×Í è è è è ÍÒÂØ < 20 »‚) ÍÒÂØ > 20 »‚) »˜¨¨Ñªѡ¹íÒ ÊÒá‹ÍÀÙÁᾌ áÅÐ Nonspecific irritants Ô ÊÒá‹ÍÀÙÁᾌ áÅÐ Ô (Precipitating non-specific irritants non - specific irritants factors) âäÀÙÁᾌ͹æ·Õè ¾ºä´ŒºÍ ઋ¹ asthma, Ô ×è ‹ äÁ‹¤Í¾º ‹ ¾ºä´ŒºÒ§â´Â໚¹ Œ ¾ºÃ‹ÇÁ´ŒÇ atopic dermatitis, coincidence allergic conjunctivitis »ÃÐÇѵâäÀÙÁᾌ Ô Ô ¾ºä´ŒºÍ ‹ äÁ‹¤Í¾º ‹ ¾ºä´ŒºÒ§ â´Â໚¹ Œ 㹤Ãͺ¤ÃÑÇ coincidence ÍÒ¡ÒÃÊíҤѭ ¤Ñ¹ ¨ÒÁ ¹éÒÁÙ¡äËÅ ¤Ñ´¨ÁÙ¡ ¹éÒÁÙ¡äËÅ í í ¤Ñ´¨ÁÙ¡ ¹éÒÁÙ¡¢Œ¹ í ¹éÒÁÙ¡äËÅŧ¤Í ÁÑ¡ÁÕÍÒ¡Òà ¹éÒÁÙ¡äËÅŧ¤Í í í ÁÕ䢌 à¨çº¤Í ·Ò§µÒâ´Â੾ÒÐã¹ ÁÕÍÒ¡Ò÷ҧµÒ¹ŒÍ µ‹ÍÁ¹éÒàËÅ×ͧ·Õ¤Íâµ í è seasonal type2. µÃǨËҧ¡Ò ÅѡɳÐàÂ×ͺبÁÙ¡ ºÇÁ ÊÕ«´ ¹éÒÁÙ¡ãÊ ºÇÁ ÊÕ«´ ËÃ×ͪÁ¾Ù è Õ í Õ ºÇÁ á´§ ¹éÒÁÙ¡¢Œ¹ í áÅйéÒÁÙ¡ í ÍÒ¨¾º polypoid ¹éÒÁÙ¡ãÊ ÍÒ¨¾º í äÁ‹¤Í¾ºÅѡɳР‹ change 䴌 polypoid change 䴌 polypoid change3. ¡ÒõÃǨ¾ÔàÈÉ Eosinophils ã¹àÅ×Í´ ÁÑ¡ÊÙ§ ÁÑ¡äÁ‹Ê§ ¡ànj¹ NARES Ù ÁÑ¡»¡µÔ Eosinophils ã¹ ÁÑ¡ÊÙ§ ÁÑ¡äÁ‹Ê§ ¡ànj¹ NARES Ù ÁÑ¡¾º neutrophils nasal smear ÁÒ¡¡Ç‹Ò Skin test Positive Negative Negative Specific IgE ã¹ ÁÑ¡ÊÙ§ »¡µÔ »¡µÔ serum
  • 124 Current Trend in Chronic Rhinitis¡ÒÃÃÑ¡ÉÒ ¡ÒÃÃÑ¡ÉÒâä¨ÁÙ¡ÍÑ¡àʺàÃ×ÍÃѧ ¤ÇÃàÃÔÁµÑ§áµ‹Í¸ÔºÒÂãˌ¼»Ç áÅФ¹ã¹¤Ãͺ¤ÃÑǼٻÇÂ à¢ŒÒ é è é ٌ † Œ †ã¨âä¹ÕéÍ‹ҧ¶Ù¡µŒÍ§ áÅÐá¹Ð¹íÒãˌ¼ÙŒ»†Ç´Ùáŵ¹àͧãˌàËÁÒÐÊÁ ઋ¹ ÃÑ¡ÉÒÊØ¢ÀÒ¾ãˌá¢ç§áçâ´ÂÍÍ¡¡íÒÅѧ¡ÒÂÊÁèÒàÊÁÍ, ÃѺ»ÃзҹÍÒËÒ÷ÕÁ»ÃÐ⪹ãˌ¤Ãº 5 ËÁÙ,‹ ¹Í¹ËÅѺ¾Ñ¡¼‹Í¹ãˌà¾Õ§ í è Õ¾Í áÅÐ ÃÑ¡ÉÒÊØ¢ÀÒ¾¨Ôµãˌʴª×¹ ᨋÁãÊ à¾ÃÒжŒÒÁÕ¤ÇÒÁà¤ÃÕ´ ÇÔµ¡¡Ñ§ÇÅ ÍÒ¨·íÒãˌÍÒ¡Òâͧ èâä໚¹ÁÒ¡¢Ö¹ ¶ŒÒ¼Ù»ÇÂÁÕÍÒ¡ÒâͧâäË×´ ËÃ×Íâä·Ò§à´Ô¹ËÒÂã¨Ê‹Ç¹Å‹Ò§ ¡ç¤ÇÃãˌ¡ÒÃÃÑ¡ÉÒËÇÁ é Œ †´ŒÇ ÊíÒËÃѺâä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾Œ àÁ×;ºÊÒà˵ط·Òãˌà¡Ô´ÍÒ¡Òà ¤ÇÃÃÑ¡ÉÒµÒÁÊÒà赯 è Õè íʋǹã¹ÃÒ·ÕäÁ‹¾ºÊÒà˵ت´à¨¹ ¤ÇÃãˌ¡ÒÃÃÑ¡ÉÒઋ¹à´ÕÂǡѺ âä¨ÁÙ¡ÍÑ¡àʺ¨Ò¡ÀÙÁᾌ´§¹Õé è Ñ Ô Ñ ËÅÑ¡¡ÒÃÃÑ¡ÉÒÁÕÍÂً 4 ¢Ñ¹µÍ¹ ¤×Í é 1. ¡ÒÃËÅÕ¡àÅÕè§ ËÃ×Í¡íҨѴÊÔ觷Õèᾌ ËÃ×ÍÊÔ觷Õè·íÒãˌà¡Ô´ÍÒ¡Òà (allergen or irritantavoidance) ໚¹¡ÒÃÃÑ¡ÉÒ·ÕÊҤѭ·ÕÊ´ â´ÂËÅÕ¡àÅÕ§ÊÔ§·Õᾌ ÊÒÃÃФÒÂà¤×ͧ ËÃ×Í¡íҨѴ ËÃ×ÍÅ´»ÃÔÁÒ³ èí èØ è è è¢Í§ÊÒá‹ÍÀÙÁᾌ áÅÐÊÒÃÃФÒÂà¤×ͧ ·ÕÁÍÂÙã¹ÊÔ§áǴŌÍÁÃͺµÑÇãˌàËÅ×͹ŒÍ·ÕÊ´ â´Â੾ÒÐ Ô è Õ ‹ è èØã¹ËŒÍ§¹Í¹«Ö§¼Ù»ÇµŒÍ§ãªŒàÇÅÒÍÂÙã¹ËŒÍ§¹Õé 6–8 ªÑÇâÁ§ µ‹ÍÇѹ è Œ † ‹ è á¹Ð¹íÒãˌ¼»ÇÂÊÑ§à¡µÇ‹Ò ÊÒà ٌ †ËÃ×ÍÀÒÇÐáǴŌÍÁÍÐäà ·Õ·ÒãˌÍÒ¡ÒÃ໚¹ÁÒ¡¢Ö¹ à¾×Í·Õ¨Ð䴌ËÅÕ¡àÅÕ§ Í‹ҧäáçµÒÁ ºÒ§¤Ãѧ è í é è è è é¡ÒÃËÅÕ¡àÅÕ§ ໚¹ÊÔ§·Õ»¯Ôºµä´ŒÂҡ㹪Õǵ»ÃШíÒÇѹ è è è Ñ Ô Ô 2. ¡ÒÃ㪌ÂÒºÃÃà·ÒÍÒ¡Òà (pharmacological treatment) ઋ¹ - Antihistamine (H1-receptor antagonist) «Ö§¨Ðä»á‹§¨Ñº histamine receptor ·íÒãˌ 軇ͧ¡Ñ¹¡ÒÃÍÍ¡Ä·¸Ô¢Í§ histamine ·Õ¶¡ËÅѧÍÍ¡ÁÒ «Ö§¨Ð䴌¼Å´Õ¡µÍàÁ×ÍãˌÂÒ ¡‹Í¹·Õ¨ÐÊÑÁ¼ÑÊ ì è Ù è è ç ‹ è è¡ÑºÊÒá‹ÍÀÙÁᾌ Ô ¡ÒÃ㪌ÂÒ¡ÅØÁ antihistamine ¹Õé á¹Ð¹íÒãˌ㪌㹼ٻÇÂâä¨ÁÙ¡ÍÑ¡àʺ¨Ò¡ÀÙÁÔ ‹ Œ †á¾Œ·ÁÍÒ¡ÒÃäÁ‹ÁÒ¡ áÅÐÁÕÍÒ¡ÒÃà¾Õ§¤Ãѧ¤ÃÒÇ (intermittent allergic rhinitis) áÅмٻÇÂâä¨ÁÙ¡ Õè Õ é Œ †ÍÑ¡àʺª¹Ô´äÁ‹á¾Œ¡ÅØÁ·ÕÁÍÒ¡ÒùéÒÁÙ¡äËÅ (runners) ËÃ×ÍÁÕÍÒ¡ÒèÒÁ (sneezers) ໚¹ÍÒ¡ÒÃËÅÑ¡ ‹ è Õ í - Decongestant ÁÕ·§ã¹ÃÙ» systemic 䴌ᡋ pseudoephedrine áÅÐ topical 䴌ᡋ Ñéephedrine, oxymetazoline â´Â¨Ð仡Ãеع - adrenergic receptor 㹨ÁÙ¡·íÒãˌËÅÍ´àÅ×Í´Ë´ ŒµÑÇ áÅÐà¹×ÍàÂ×Í㹨ÁÙ¡ÂغºÇÁ ·íÒãˌÍÒ¡ÒäѴ¨ÁÙ¡¹ŒÍÂŧ á¹Ð¹íÒãˌ㪌㹼ٻÇÂâä¨ÁÙ¡ÍÑ¡àʺ é è Œ †¨Ò¡ÀÙÁᾌ áÅмٻÇÂâä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾Œ·ÁÍÒ¡ÒäѴ¨ÁÙ¡ (blocker) ໚¹ÍÒ¡ÒÃËÅÑ¡ Ô Œ † Õè Õ - Corticosteroids ÊÒÁÒöãˌ䴌ã¹ÃÙ» systemic 䴌ᡋ oral prednisolone ËÃ×Í topical(intranasal)䴌ᡋ beclomethasone, budesonide, triamcinolone, fluticasone, mometasone â´Âoral corticosteroids Áբͺ‹§ªÕ㹡ÒÃ㪌áÉÒâä¨ÁÙ¡ÍÑ¡àʺàÃ×ÍÃѧ ¤×Í Œ é Ñ é 1. ã¹ÃÒ·ÕÁÍÒ¡ÒäѴ¨ÁÙ¡ÁÒ¡ «Ö§·íÒãˌ¡ÒÃ㪌 topical steroids 䴌¼ÅäÁ‹´Õ à¹×ͧ¨Ò¡ÂÒäÁ‹ è Õ è èÊÒÁÒöࢌÒä»ã¹¨Á١䴌·Ç¶Ö§ Ñè 2. ã¹ÃÒ·ÕÁÕ anosmia ËÇÁ´ŒÇ è 3. ã¹ÃÒ·ÕÁôÊմǧ¨ÁÙ¡àÅç¡æ ËÇÁ´ŒÇ áÅÐãˌ oral steroids à¾×Í·íÒ medical polypectomy è ÕÔ è 4. ã¹ÃÒ·ÕÁÕ rhinitis medicamentosa ËÇÁ´ŒÇ à¹×ͧ¨Ò¡¡ÒÃ㪌 topical decongestant è è¹Ò¹à¡Ô¹ä»
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  • àǪÈÒʵÏÃÇÁÊÁÑ : ÇÔªÒ¡ÒÃᾷ¡ÒÇ˹ŒÒ »ÃÐÊҹ㨾Ѳ¹Ò¤Ø³ÀÒ¾ªÕǵä·Â ‹ Œ Ô 127area ᤺ «Ö§ÍÒ¨à¡Ô´¨Ò¡ sagging ¢Í§ lower lateral cartilage ËÃ×Í ¡ÒÃÊÙ­àÊÕ cartilaginous èsupport ¡Òü‹ÒµÑ´á¡Œä¢¤ÇÒÁ¼Ô´»¡µÔàËŋҹըзíÒãˌÍÒ¡ÒäѴ¨ÁÙ¡´Õ¢¹ä´Œ é Öé 4.2) ¡Òü‹ÒµÑ´à¾×èÍÃÑ¡ÉÒÍÒ¡ÒùéíÒÁÙ¡äËŠ䴌ᡋ ¡Ò÷íÒ vidian neurectomy «Ö§ ໚¹¡ÒõѴàÍÒ vidian nerve «Ö§ãˌ parasympathetic è ènerve ÁÒàÅÕ§àÂ×ͺبÁÙ¡ ·íÒãˌÍÒ¡ÒùéÒÁÙ¡äËÅÅ´¹ŒÍÂŧ «Ö§¨Ò¡¡ÒõԴµÒÁ¼Ù»ÇÂã¹ÃÐÂÐÂÒÇ é è í è Œ †¾ºÇ‹ÒÁÕÍÒ¡ÒùéÒÁÙ¡äËÅ¢Ö¹ÁÒ䴌͡ ËÅѧ¼‹ÒµÑ´ «Ö§à¡Ô´¨Ò¡ vidian nerve regeneration ¡Òü‹ÒµÑ´ í é Õ è¹ÕÁ¼¹ÂÁ·íÒ¹ŒÍÂŧà¾ÃÒСÒÃ㪌 ipratropium bromide ÁÑ¡ãˌ¼Å¡ÒÃÃÑ¡ÉÒ·Õ´Õ ã¹¡ÅØÁ¼Ù»Ç´ѧ¡Å‹ÒÇ é Õ ÙŒ Ô è ‹ Œ †àÍ¡ÊÒÃ͌ҧÍÔ§1. Bousquet J, van Cauwenberge P, Khaltaev N. Allergic Rhinitis and its Impact on Asthma (ARIA). J Allergy Clin Immunol 2001;108 (5 Pt 2): S147-334.2. van Rijswijk JB, Blom HM, Fokkens WJ. Idiopathic rhinitis, the ongoing quest. Allergy 2005; 60: 1471-81.3. Bousquet J, Khaltaev N, Cruz AA, Denberg J, Fokkens WJ, Togias A, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 Update (in collaboration with the World Health Organization, GA2LEN and AllerGen). Allergy 2008; 63 (Suppl. 86): 8-160.4. Juniper EF, Guyatt GH. Development and testing of a new measure of health status for clinical trials in rhinoconjunctivitis. Clin Exp Allergy 1991; 21: 77-83.5. International Rhinitis Management Working Group. International Consensus Report on Diagnosis and Management of Rhinitis. Allergy 1994;49 (19 Suppl):1-34.6. Strachan D, Sibbald B, Weiland S, et al. Worldwide variations in prevalence of symptoms of allergic rhinoconjunctivitis in children: the International Study of Asthma and Allergies in Childhood (ISAAC). Pediatr Allergy Immunol 1997; 8: 161-176.7. Mullarkey MF, Hill JS, Webb DR. Allergic and non-allergic rhinitis: their characterization with attention to the meaning of nasal eosinophilia. J Allergy Clin Immunol 1980; 65: 122-126.8. Wittig HJ, McLaughlin ET, Leifer KL, Bellott JD. Risk factors for the development of allergic disease: analysis of 2,190 patient records. Ann Allergy 1978; 41: 84-88.9. Togias A. Age relationships and clinical features of non-allergic rhinitis. J Allergy Clin Immunol 1990; 85: 182 (abstract).10. Mc Devitt HO, Benacerraf B. Genetic control of specific immune responses. Adv Immunol 1969; 11: 31-74.11. Naclerio RM. Pathophysiology of perennial allergic rhinitis. Allergy 1997;52 (Suppl. 36):7-13.12. Rouadi PW, Naclerio RM. Vasomotor rhinitis. In: Gates GA, ed. Current therapy in otolaryngology-head and neck surgery. St. Louis: Mosby, 1998: 505-513.13. Altissimi G, Gallucci L, Rossetti M, Simoncelli C. Diagnosing nasal hyperreactivity with positional rhinomanometry. Ann Oto Rhino Laryngol 1996; 105: 901-904.14. ¾Õþѹ¸ à¨ÃÔ­ªÒÈÃÕ, ©ÇÕÇÃó ºØ¹¹Ò¤. âä¨ÁÙ¡ÍÑ¡àʺª¹Ô´äÁ‹á¾Œ. ã¹ »¡Ôµ ÇÔªÂÒ¹¹·, ÊØ¡­­Ò ⾸ԡҨÃ, à¡ÕÂÃµÔ Ñ í Ãѡɏç¸ÃÃÁ, ºÃóҸԡÒÃ. Allergy 2000’s: µíÒÃÒâäÀÙÁᾌ. ¡Ãا෾Ï: âç¾ÔÁ¾ªÇ¹¾ÔÁ¾, 2541: 355-365. ؋ Ô15. Malm L, Wihl JA. Intra-nasal beclomethasone dipropionate in vasomotor rhinitis. Acta Allergol 1976; 31: 245-253.16. Ebner C, Siemann U, Bohle B, Willheim M, Wiedermann U, Schenk S, et al. Immunological changes during specific immunotherapy of grass pollen allergy: reduced lymphoproliferative responses to allergen and shift from TH2 to TH1 in T-cell clones specific for Phl p 1, a major grass pollen allergen. Clin Exp Allergy 1997;27:1007- 1015.
  • 128 Current Trend in Chronic Rhinitis17. Klimek L, Dormann D, Jarman ER, Cromwell O, Riechelmann H, Reske-Kunz AB. Short-term preseasonal birch pollen allergoid immunotherapy influences symptoms, specific nasal provocation and cytokine levels in nasal secretions, but not peripheral T-cell responses, in patients with allergic rhinitis. Clin Exp Allergy 1999;29:1326- 1335.18. Andri L, Senna G, Betteli C, Givanni S, Andri G, Falagiani P. Local nasal immunotherapy for Dermatophagoides- induced rhinitis: efficacy of a powder extract. J Allergy Clin Immunol 1993;91:987-996.19. Mungan D, Misirligil Z, Gurbuz L. Comparison of the efficacy of subcutaneous and sublingual immunotherapy in mite-sensitive patients with rhinitis and asthma-a placebo controlled study. Ann Allergy Asthma Immunol 1999;82:485- 490.
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