Tehran Univ Med J (TUMJ), Vol.70, No.5, August 2012 LQ by TUMJ TUMJ

‫داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬ ‫دوره ‪70‬‬

‫ﺷﻤﺎره ‪5‬‬

‫ﻣﺮداد ‪1391‬‬

‫ﺻﺎﺣﺐ اﻣﺘﻴﺎز‪ :‬داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬ ‫ﻣﺪﻳﺮ ﻣﺴﺆول‪ :‬دﻛﺘﺮ ﺳﻴﺪ ﺣﺴﻦ اﻣﺎﻣﻲرﺿﻮي‬ ‫ﺳﺮدﺑﻴﺮ‪ :‬دﻛﺘﺮ ﻧﺎدره ﺑﻬﺘﺎش‬ ‫ﻣﺪﻳﺮ اﺟﺮاﻳﻲ‪ :‬دﻛﺘﺮ ﻣﺤﻤﺪ ﻋﻠﻲ ﻧﻮﻳﺎن اﺷﺮف‬ ‫ﺷﻮراي دﺑﻴﺮان‬

‫دﻛﺘﺮ ﺷﺎﻫﻴﻦ آﺧﻮﻧﺪزاده‪ ،‬دﻛﺘﺮ ﺻﺪﻳﻘﻪ ﺑﺮﻧﺎ‪ ،‬دﻛﺘﺮ ﺟﻤﺸﻴﺪ ﺣﺎﺟﺘﻲ‪ ،‬دﻛﺘﺮ ﻋﻠﻴﺮﺿﺎ ﺧﻮﺷﻨﻮﻳﺴﺎن‪ ،‬دﻛﺘﺮ ﻧﻴﻤﺎ رﺿﺎﻳﻲ‪ ،‬دﻛﺘﺮ ﻧﮕﺎر ﺳﺠﺎدﻳﺎن‪،‬‬ ‫دﻛﺘﺮ ﻋﻠﻲ ﻋﺮبﺧﺮدﻣﻨﺪ‪ ،‬دﻛﺘﺮ ﻧﻌﻤﺖاﷲ ﻋﻄﺎﻳﻲ‪ ،‬دﻛﺘﺮ راﻣﺶ ﻋﻤﺮاﻧﻲﭘﻮر‪ ،‬دﻛﺘﺮ ﻣﺤﻤﻮد ﻗﺎﺿﻲ ﺧﻮاﻧﺴﺎري‪ ،‬دﻛﺘﺮ ﺳﻴﺪﺟﻮاد ﻗﺎﺿﻲ ﻣﻴﺮ ﺳﻌﻴﺪ‪،‬‬ ‫دﻛﺘﺮ ﻣﻬﺮي ﻛﺪﺧﺪاﻳﻲ‪ ،‬دﻛﺘﺮ ﺳﻴﻨﺎ ﻣﺮادﻣﻨﺪ‪ ،‬دﻛﺘﺮ زﻳﻨﺖ ﻧﺎدﻳﺎﺣﺘﻤﻲ‪ ،‬دﻛﺘﺮ ﻣﺤﻤﺪ ﻋﻠﻲ ﻧﻮﻳﺎن اﺷﺮف‬ ‫ﻫﻴﺄت ﺗﺤﺮﻳﺮﻳﻪ‬

‫دﻛﺘﺮ ﻧﺎﺻﺮ اﺑﺮاﻫﻴﻤﻲ درﻳﺎﻧﻲ‪ ،‬دﻛﺘﺮ ﻣﺤﻤﻮد اﻛﺒﺮﻳﺎن‪ ،‬دﻛﺘﺮ ﻓﺮﻧﺎز آﻣﻮزﮔﺎر ﻫﺎﺷﻤﻲ‪ ،‬دﻛﺘﺮ ﺑﺎﺑﻚ ﺑﻬﺎر‪ ،‬دﻛﺘﺮ ﭘﺮوﻳﻦ ﭘﺎﺳﺎﻻر‪ ،‬دﻛﺘﺮ ﭘﺮﻳﭽﻬﺮ ﭘﺎﺳﺒﺨﺶ‪،‬‬ ‫دﻛﺘﺮ زاﻫﺪ ﺣﺴﻴﻦ ﺧﺎن‪ ،‬دﻛﺘﺮ زﻫﺮا ﺣﻼﺟﻲ‪ ،‬دﻛﺘﺮ ﻓﺎﻃﻤﻪ داوري ﺗﻨﻬﺎ‪ ،‬دﻛﺘﺮ ﻣﻬﺮﻧﺎز رﺳﻮﻟﻲﻧﮋاد‪ ،‬دﻛﺘﺮ ﻣﺴﻌﻮد ﺳﺘﻮده‪ ،‬دﻛﺘﺮ ﻋﻠﻴﺮﺿﺎ ﺷﻌﺒﺎﻧﻲ‪،‬‬ ‫دﻛﺘﺮ اﺣﻤﺪرﺿﺎ ﻃﻼﺋﻲﭘﻮر‪ ،‬دﻛﺘﺮ ﻣﺤﻤﺪرﺿﺎ ﻇﻔﺮﻗﻨﺪي‪ ،‬دﻛﺘﺮ ﻣﺤﻤﺪ ﻛﺠﺒﺎفزاده‪ ،‬دﻛﺘﺮ ﺳﻴﺪ ﻣﺤﻤﺪﺟﻮاد ﻣﺮﺗﻀﻮي‪ ،‬دﻛﺘﺮ اﻋﻈﻢاﻟﺴﺎدات ﻣﻮﺳﻮي‪،‬‬ ‫دﻛﺘﺮ ﻣﺤﻤﺪﺟﻮاد ﻣﻴﻜﺎﺋﻴﻠﻲ‪ ،‬دﻛﺘﺮ ﺑﻬﺮوز ﻧﺒﺌﻲ‪ ،‬دﻛﺘﺮ ﻣﺮﺿﻴﻪ وﺣﻴﺪ دﺳﺘﺠﺮدي‪ ،‬دﻛﺘﺮ ﻣﺤﻤﺪرﺿﺎ ﻫﺎدﻳﺎن‬ ‫ﻫﻴﺄت ﺗﺤﺮﻳﺮﻳﻪ ﺑﻴﻦ اﻟﻤﻠﻠﻲ‬

‫دﻛﺘﺮ ﻓﺮﻫﻨﺎك اﺳﺪي )ﺷﻴﻜﺎﮔﻮ(‪ ،‬دﻛﺘﺮ ﺟﻮاد ﭘﺮوﻳﺰي )ﻓﻴﻼدﻟﻔﻴﺎ(‪ ،‬دﻛﺘﺮ ﻣﺤﻤﺪرﺿﺎ ﻛﺸﺘﮕﺮ )ﻟﻨﺪن(‪ ،‬دﻛﺘﺮ اﻓﺸﻴﻦ ﮔﻨﺠﻲ )اﺳﺘﺮاﺳﺒﻮرگ(‪،‬‬ ‫دﻛﺘﺮ ﺷﻬﻼ ﻣﺴﻌﻮد )ﻓﻠﻮرﻳﺪا(‪ ،‬دﻛﺘﺮ ﭘﺮوﻳﺰ ﻫﻨﺠﻨﻲ )ﭘﻨﺴﻴﻠﻮاﻧﻴﺎ(‬ ‫وﻳﺮاﺳﺘﺎران‬

‫دﻛﺘﺮ ﻧﺎدره ﺑﻬﺘﺎش‪ ،‬دﻛﺘﺮ ﻣﺤﻤﺪ ﻋﻠﻲ ﻧﻮﻳﺎن اﺷﺮف‪ ،‬دﻛﺘﺮ وﺣﻴﺪ ﻧﻴﻜﻮﻳﻲ‪ ،‬دﻛﺘﺮ ﺳﻴﺪ ﺑﻬﻨﺎم ﻫﺎﺷﻤﻲ‬ ‫ﻫﻤﻜﺎران دﻓﺘﺮ ﻣﺠﻠﻪ‬

‫ﺣﺴﻴﻦ ﭼﺎﻳﭽﻲ‪ ،‬راﺣﻠﻪ رﻣﻀﺎﻧﻲ‪ ،‬ﺳﺤﺮ ﺻﺪﻳﻖ‪ ،‬ﻣﻌﺼﻮﻣﻪ ﻋﺴﮕﺮي‪ ،‬آرزو ﻛﻤﻴﺰاﻧﻲ‬ ‫ﻧﺸﺎﻧﻲ‪ :‬ﺗﻬﺮان‪ ،‬ﺧﻴﺎﺑﺎن ﻗﺪس‪ ،‬ﺧﻴﺎﺑﺎن ﭘﻮرﺳﻴﻨﺎ‪ ،‬داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬ﺳﺎﺧﺘﻤﺎن آﻣﻮزش‪ ،‬ﻃﺒﻘﻪ اول‪ ،‬ﺷﻤﺎره ‪ ،202‬دﻓﺘﺮ ﻣﺠﻠﻪ‬ ‫آدرس اﻟﻜﺘﺮوﻧﻴﻚ‪ http://tumj.tums.ac.ir :‬ﭘﺴﺖ اﻟﻜﺘﺮوﻧﻴﻚ‪medjournal@tums.ac.ir :‬‬ ‫ﺻﻨﺪوق ﭘﺴﺘﻲ ‪ ،14155/6447‬ﺗﻠﻔﻜﺲ‪Online submission: http://journals.tums.ac.ir/login ، 88962510 :‬‬ ‫ﺑﺮاﺳﺎس ﻣﺼﻮﺑﻪ ﻛﻤﻴﺴﻴﻮن ﻧﺸﺮﻳﺎت ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻛﺸﻮر‪ ،‬ﺑﻪ ﻧﻮﻳﺴﻨﺪﮔﺎن ﻣﻘﺎﻻت اﻳﻦ ﻣﺠﻠﻪ اﻣﺘﻴﺎز ارﺗﻘﺎي ﻋﻠﻤﻲ ﭘﮋوﻫﺸﻲ ﺗﻌﻠﻖ ﻣﻲﮔﻴﺮد‪.‬‬ ‫ﺗﻴﺮاژ‪ 1000 :‬ﻧﺴﺨﻪ‬

‫ﻟﻴﺘﻮﮔﺮاﻓﻲ‪ ،‬ﭼﺎپ و ﺻﺤﺎﻓﻲ‪ :‬ﺑﻬﺮﻧﮓ‬

‫)راﻳﮕﺎن(‬

‫ﻧﻤﺎﻳﻪ ﺷﺪه در‪:‬‬

‫‪SCOPUS, EMBASE, Cambridge Scientific Abstracts (CSA), CAB Abstracts (CABI), Chemical Abstract Service (CAS),‬‬ ‫‪DOAJ, Psych Info, ULRICH΄S, Index Copernicus, IMEMR, EMR Beta, SID, Magiran, Iran Medex‬‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬ ‫دوره ‪70‬‬

‫ﺷﻤﺎره ‪5‬‬

‫ﻣﺮداد ‪1391‬‬

‫ﻓﻬﺮﺳﺖ‬ ‫ﺗﻌﻴﻴﻦ اﺛﺮ اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺮ ﺑﻴﺎن ژن ‪ PPARγ‬در رده ﺳﻠﻮﻟﻲ ﻣﺎﻛﺮوﻓﺎژي ‪275...........................................................................................RAW 264.7‬‬ ‫ﺣﺴﻴﻦ ﻣﻨﺘﺨﺐ ﻳﮕﺎﻧﻪ‪ ،‬ﺣﺴﻴﻦ ﺑﺎﺑﺎ اﺣﻤﺪي رﺿﺎﻳﻲ‪ ،‬ﻣﺤﻤﻮد دوﺳﺘﻲ‬

‫ﺗﺎﺛﻴﺮ وزن ﻧﻮزاد و دﻣﺎي ﻣﺤﻴﻂ ﺑﺮ ﻣﻴﺰان اﻧﺘﻘﺎل ﺑﻴﻦ وﺿﻌﻴﺖﻫﺎي ﻫﻴﭙﻮﺗﺮﻣﻲ در ﻧﻮزادان ﺑﺴﺘﺮي در ‪ ،NICU‬ﺑﺎ اﺳﺘﻔﺎده از ﻣﺪل ﻣﺎرﻛﻮف‪282..............................‬‬ ‫ﻋﻠﻴﺮﺿﺎ اﻛﺒﺮزاده ﺑﺎﻏﺒﺎن‪ ،‬ﺳﺎرا ﺟﺎم ﺑﺮﺳﻨﮓ‪ ،‬ﺣﻤﻴﺪ ﭘﺰﺷﻚ‪ ،‬ﻓﺎﻃﻤﻪ ﻧﻴﺮي‬

‫ﻣﻘﺎﻳﺴﻪ ﻛﺎرﺑﺮد ‪ Ligasure‬ﺑﺎ ‪ Stapler‬ﺧﻄﻲ در رزﻛﺴﻴﻮن و ﺗﺮﻣﻴﻢ روده‪289................................................................................................................‬‬ ‫ﻋﻠﻴﺮﺿﺎ ﺗﻮﺳﻠﻲ‪ ،‬ﻋﺒﺎس ﻋﺒﺪاﻟﻠﻬﻲ‪ ،‬ﺣﺎﻣﺪ ﮔﻞ ﻣﺤﻤﺪ زاده‬

‫ﻣﻴﺰان ﺗﻮاﻓﻖ ﻃﻴﻒﺳﻨﺠﻲ ﺗﺸﺪﻳﺪ ﻣﻐﻨﺎﻃﻴﺴﻲ ﺑﺎ آﻧﺘﻲژن اﺧﺘﺼﺎﺻﻲ ﭘﺮوﺳﺘﺎت ﺳﺮم در ﺗﺸﺨﻴﺺ ﻋﻮد ﻣﻮﺿﻌﻲ ﺳﺮﻃﺎن ﭘﺮوﺳﺘﺎت ﺑﻪدﻧﺒﺎل رادﻳﻜﺎل‬

‫ﭘﺮوﺳﺘﺎﺗﻜﺘﻮﻣﻲ‪295..........................................................................................................................................................................................‬‬ ‫ﻣﻬﻴﺎر ﻏﻔﻮري‪ ،‬ﻋﻠﻲ وﻓﺎﻳﻲﺷﺎﻫﻲ‬

‫ﻣﻘﺎﻳﺴﻪ ﺳﺮﻋﺖ ﺣﺪاﻛﺜﺮ ﺳﻴﺴﺘﻮﻟﻲ ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﭘﻨﻴﺲ ﻗﺒﻞ و ﺑﻌﺪ از ﺗﺰرﻳﻖ ﭘﺎﭘﺎورﻳﻦ در اﺧﺘﻼل ﻧﻌﻮظ‪301.....................................................................‬‬ ‫ﺳﻴﺪ ﻣﺮﺗﻀﻲ ﺑﺎﻗﺮي‪ ،‬ﻣﺤﻤﻮدرﺿﺎ ﻃﺎﻫﺮي‬

‫ﺑﻠﻮك ﻋﺼﺐ اﻛﺴﻲﭘﻴﺘﺎل ﺑﺰرگ ﺑﺎ ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ‪/‬ﻣﺘﻴﻞ ﭘﺮدﻧﻴﺰوﻟﻮن و ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ‪/‬ﺳﺎﻟﻴﻦ در ﺳﺮدرد ﻧﺎﺷﻲ از ﻣﺼﺮف ﺑﻴﺶ از ﺣﺪ دارو‪308.......................‬‬ ‫ﻋﻠﻲ ﻋﻠﻴﺰاده ﺧﻄﻴﺮ‪ ،‬ﻣﻬﺪي ﭘﻨﺎﻫﺨﻮاﻫﻲ‪ ،‬ﻋﻠﻴﺮﺿﺎ ﺧﻮاﺟﻪ ﻧﺼﻴﺮي‪ ،‬ﻃﻴﺐ رﻣﻴﻢ‪ ،‬ﻣﻨﺼﻮره ﺗﻘﺎء‬

‫ﻧﺘﺎﻳﺞ درﻣﺎن دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧﻮ در ‪ 29‬ﺑﻴﻤﺎر ﻣﺮاﺟﻌﻪﻛﻨﻨﺪه ﺑﻪ ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻔﺎﻳﺤﻴﺎﻳﻴﺎن ﺗﻬﺮان در ﻣﺪت ‪ 40‬ﺳﺎل‪314.....................................................‬‬ ‫ﻣﺤﻤﺪ رﻫﺒﺮ‪ ،‬ﻣﺤﻤﻮد ﺟﺒﻞ ﻋﺎﻣﻠﻲ‪ ،‬ﻧﺎدﻳﺎ آﻗﺎﺟﺎﻧﻲ‪ ،‬رﺿﺎ ﺷﻔﻴﻊﭘﻮر‬

‫ارﺗﺒﺎط ‪ ،Chemerin‬ﻫﻮرﻣﻮن ﺑﺎﻓﺖ ﭼﺮﺑﻲ‪ ،‬ﺑﺎ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ‪320....................................................................... ...................................‬‬ ‫ﺳﭙﻴﺪه ﺣﻘﻴﻘﻲ‪ ،‬ﭘﺮﻳﭽﻬﺮ ﻳﻐﻤﺎﻳﻲ‪ ،‬ﻓﺎﻃﻤﻪ ﻫﺎﺷﻤﻲ‪ ،‬ﻧﻐﻤﻪ ﺳﻌﺎدﺗﻲ‪ ،‬ﻓﻬﻴﻤﻪ رﻣﻀﺎﻧﻲ ﺗﻬﺮاﻧﻲ‪ ،‬ﻣﻬﺪي ﻫﺪاﻳﺘﻲ‬

‫ﻋﻮاﻣﻞ ﻣﻮﺛﺮ در ﻋﻮارض رﻳﻮي و ﺷﻜﺴﺖ اﻛﺴﺘﻮﺑﺎﺳﻴﻮن در ﺟﺮاﺣﻲﻫﺎي داﺧﻞ ﺟﻤﺠﻤﻪاي ‪ 254‬ﺑﻴﻤﺎر ‪ :‬ﮔﺰارش ﻛﻮﺗﺎه‪325........................................................‬‬ ‫ﺳﻴﺪ وﺣﻴﺪ ﺣﻴﺪري‪ ،‬ﺳﻴﺪ ﻣﺤﻤﻮد رﻣﻚ ﻫﺎﺷﻤﻲ‪ ،‬ﻋﻨﺎﻳﺖاﷲ ﻋﺒﺎسﻧﮋاد‪ ،‬ﻓﺎﻃﻤﻪ ﻋﺒﺎﺳﻲ ﮔﺮاوﻧﺪ‪ ،‬ﺑﺘﻮل ﻗﺮﺑﺎﻧﻲ ﻳﻜﺘﺎ‬

‫رﻳﺴﻚ ﻓﺎﻛﺘﻮرﻫﺎي اﺑﺘﻼ ﺑﻪ ﺑﻴﻤﺎري ﺳﻞ ‪ :‬ﮔﺰارش ﻛﻮﺗﺎه‪330.......................................................................................................................................‬‬ ‫اﻟﻬﺎم ﺑﻴﺮاﻧﻮﻧﺪ‪ ،‬ﺳﻌﻴﺪ ﻋﺎﺑﺪﻳﺎن ﻛﻨﺎري‪ ،‬ﻋﻠﻲرﺿﺎ ﺧﻠﻴﻠﻴﺎن‪ ،‬ﺑﻬﻨﻮش ﺑﻴﺮاﻧﻮﻧﺪ‬

‫)‪Tehran Univ Med J (TUMJ) 2012 August;70(5‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫راﻫﻨﻤﺎي ﻧﻮﻳﺴﻨﺪﮔﺎن‬ ‫‪ -1‬اﺻﻮل ﻛﻠﻲ‪ -1 :‬آﻳﻴﻦ ﻧﮕﺎرش زﺑﺎن ﻓﺎرﺳﻲ رﻋﺎﻳﺖ ﺷﺪه و از ﺑﻪﻛﺎر ﺑـﺮدن ﻛﻠﻤـﺎت‬

‫ﺑﺎﺷﺪ و ﻋﻨﻮان ﺟﺪول‪ ،‬ﺑﺎﻻي آن و در ﻧﻤﻮدار‪ ،‬زﻳﺮ آن ﻗﺮار ﮔﻴﺮد )ﺑﺎ ذﻛـﺮ ﺷـﻤﺎره(‪ .‬ﺑـﺎ‬

‫ﺧــﺎرﺟﻲ ﻛــﻪ ﻣﻌــﺎدل رﺳــﺎ در ﻓﺎرﺳــﻲ دارﻧــﺪ‪ ،‬ﺧــﻮدداري ﺷــﻮد‪ -2 .‬ﻣﻘــﺎﻻت ﺑــﻪ‬

‫ﺗﻮﺟﻪ ﺑﻪ ﻣﺤﺪودﻳﺖ ﺻﻔﺤﺎت ﻣﺠﻠﻪ‪ ،‬ﺑﺪﻳﻬﻲ اﺳﺖ از ﺗﻜﺮار اراﻳﻪ ﻣﻄـﺎﻟﺒﻲ ﻛـﻪ در ﻣـﺘﻦ‬

‫آدرس اﻟﻜﺘﺮوﻧﻴﻚ ﻣﺠﻠﻪ "‪ "http://journals.tums.ac.ir/login.aspx‬ارﺳـﺎل ﮔـﺮدد‬

‫آورده ﺷﺪهاﻧﺪ در ﺟﺪاول و ﺑﺎﻟﻌﻜﺲ ﺑﺎﻳﺪ اﺟﺘﻨﺎب ﻧﻤﻮد‪ ،‬ﺟـﺪاول و ﻧﻤﻮدارﻫـﺎ ﻓﺎرﺳـﻲ‬

‫)‪ Microsoft word 2003‬ﻳـﺎ ﺑﺎﻻﺗﺮ(‪ -3 .‬ﻣﻘﺎﻟﻪ ﺑﻪﻃﻮر ﻫﻢزﻣـﺎن ﺑـﺮاي ﺳـﺎﻳﺮ ﻣﺠـﻼت‬

‫ﺑﺎﺷﻨﺪ‪ .‬ﻋﻜﺲﻫﺎ‪ ،‬ﻧﻤﻮدارﻫﺎ و ﺟﺪاول ﻣﺮﺑﻮط ﺑﻪ ﻣﻘﺎﻟﻪ ﺑﻪﻫﻤﺮاه ﺗﻮﺿﻴﺤﺎت آنﻫﺎ ﺑﺎﻳﺴﺘﻲ‬

‫ارﺳﺎل ﻧﮕﺮدد و در ﺳﺎﻳﺮ ﻣﺠﻼت )ﺣﺘﻲ ﺑﻪ زﺑﺎن اﻧﮕﻠﻴﺴﻲ و ﻏﻴﺮه( ﺑﻪ ﭼﺎپ ﻧﺮﺳﻴﺪه‬

‫ﺟﺪاﮔﺎﻧﻪ و در دﻧﺒﺎﻟﻪ ﻣﺘﻦ اﺻﻠﻲ ﻣﻘﺎﻟﻪ آورده و ﺷﻤﺎرهﮔـﺬاري ﮔـﺮدد‪ .‬ﻛﻴﻔﻴـﺖ ﺗـﺼﺎوﻳﺮ‬

‫ﺑﺎﺷﺪ‪ -4 .‬ﻣﻘﺎﻻت ﭘﺬﻳﺮﻓﺘﻪ ﺷﺪه ﺷﺎﻣﻞ ﻣﻘـﺎﻻت ﺗﺤﻘﻴﻘـﻲ‪ ،‬ﻣـﺮوري‪ ،‬ﮔـﺰارش ﻛﻮﺗـﺎه و‬

‫ارﺳﺎﻟﻲ ﻣﻄﻠﻮب ﺑﺎﺷﺪ‪.‬‬

‫ﮔﺰارش ﻣﻮردي ﻣﻲﺑﺎﺷﺪ‪ -5 .‬در اﻧﺠﺎم ﭘـﮋوﻫﺶ‪ ،‬اﺻـﻮل ﺑﻴﺎﻧﻴـﻪ ﻫﻠـﺴﻴﻨﻜﻲ )‪ (2008‬و‬

‫ﺑﺤﺚ‪ -1 :‬آﺛﺎر و اﻫﻤﻴﺖ ﻳﺎﻓﺘﻪﻫﺎي ﺑﻪدﺳﺖ آﻣﺪه و ﻣﺤﺪودﻳﺖ آنﻫﺎ‪ -2 .‬ذﻛﺮ ﻧﺘـﺎﻳﺞ‬

‫ﺿﻮاﺑﻂ اﺧﻼق ﭘﺰﺷﻜﻲ رﻋﺎﻳﺖ ﮔﺮدد‪.‬‬

‫ﺗﺤﻘﻴﻖ ﻣﺸﺎﺑﻪ دﻳﮕﺮان و ذﻛﺮ ﻣﻐﺎﻳﺮات و ﻣﻮارد ﻧﻘﺾﻛﻨﻨﺪه‪ -3 .‬ﺗﻮﺿﻴﺢ ﻋﻠـﺖ ﺗﻔـﺎوت‬

‫‪ -2‬ﻧﺤﻮه ﺗﻨﻈﻴﻢ ﻣﻘﺎﻻت ﺗﺤﻘﻴﻘﻲ‪ -1 :‬ﺻﻔﺤﻪ اول )ﻋﻨﻮان( ﺷﺎﻣﻞ ﻋﻨﻮان ﻣﻘﺎﻟـﻪ‪ ،‬ﻧـﺎم و‬

‫ﺑﻴﻦ ﻧﺘﺎﻳﺞ اﻳﻦ ﺗﺤﻘﻴﻖ ﺑﺎ ﻣﻘﺎﻻت ﻗﺒﻠـﻲ‪ -4 .‬ﺗﻮﺿـﻴﺢ ﻣـﻮارد ﻛـﺎرﺑﺮد ﻋﻤﻠـﻲ و ﻗﺎﺑﻠﻴـﺖ‬

‫ﻧﺎمﺧﺎﻧﻮادﮔﻲ ﻧﻮﻳﺴﻨﺪﮔﺎن‪ ،‬درﺟﻪ ﻋﻠﻤـﻲ و آدرس دﻗﻴـﻖ ﻛﻠﻴـﻪ ﻧﻮﻳـﺴﻨﺪﮔﺎن )از ﺟﻤﻠـﻪ‬

‫ﺗﻌﻤﻴﻢﭘﺬﻳﺮي ﻧﺘﺎﻳﺞ‪ -5 .‬راﻫﻨﻤﺎﻳﻲ ﺑﺮاي اداﻣﻪ ﺗﺤﻘﻴﻖ ﺧﻮد ﻳﺎ دﻳﮕﺮان‪ ،‬در ﻣﺠﻤﻮع اراﻳـﻪ‬

‫ﻛﺪﭘﺴﺘﻲ‪ ،‬ﺗﻠﻔﻦ‪ ،‬دورﻧﮕﺎر و ﭘﺴﺖ اﻟﻜﺘﺮوﻧﻴﻚ( ﻣﺤﻞ اﻧﺠﺎم ﭘـﮋوﻫﺶ‪ ،‬ﻣـﺴﺌﻮل ﻣﻘﺎﻟـﻪ و‬ ‫ﺗﺎرﻳﺦ ارﺳﺎل ﻣﻘﺎﻟﻪ ﺑﺎﺷﺪ‪ -2 .‬ﺻﻔﺤﻪ دوم و ﺳﻮم ﺷﺎﻣﻞ ﺧﻼﺻﺔ ﻓﺎرﺳـﻲ و اﻧﮕﻠﻴـﺴﻲ و‬ ‫ﻛﻠﻤﺎت ﻛﻠﻴﺪي ﻓﺎرﺳﻲ و اﻧﮕﻠﻴﺴﻲ ﺑﺎﺷﺪ‪.‬‬ ‫ﭼﻜﻴﺪه ﻓﺎرﺳﻲ‪ 240-250 :‬ﻛﻠﻤﻪ و در ﭼﻬﺎر ﭘﺎراﮔﺮاف ﺑﺎ ﻋﻨﺎوﻳﻦ زﻣﻴﻨـﻪ و ﻫـﺪف‪،‬‬

‫آنﭼﻪ ﻛﻪ از اﻳﻦ ﺗﺤﻘﻴﻖ ﺑﻪ ﻋﻠﻢ اﺿﺎﻓﻪ ﺷﺪه اﺳﺖ‪.‬‬ ‫ﻣﻨﺎﺑﻊ‪ :‬ﺷﻤﺎره ﻣﻨﺎﺑﻊ در ﻣﺘﻦ ﻗﻴﺪ ﺷﻮد و از ﻋﺪد ﻳﻚ ﺷﺮوع و ﺑﻪﺗﺮﺗﻴﺐ اﺿﺎﻓﻪ ﮔـﺮدد‪.‬‬ ‫ﺿﻤﻦ اﻧﻄﺒﺎق ﺗﻌﺪاد رﻓﺮاﻧﺲﻫﺎي ﻣﺤﺘﻮاي ﻣﻘﺎﻟﻪ و ﻟﻴﺴﺖ اﻧﺘﻬﺎﻳﻲ آن‪ ،‬ﻣﺘﻦ رﻓـﺮاﻧﺲﻫـﺎ‬ ‫ﺑﻪﺗﺮﺗﻴﺐ ﻇﻬﻮر‪ ،‬در ﻓﻬﺮﺳﺖ ﻣﻨﺎﺑﻊ آورده ﺷﻮﻧﺪ‪ .‬ﻣﻨﺎﺑﻊ ﻓﺎرﺳـﻲ ﺑـﻪ اﻧﮕﻠﻴـﺴﻲ ﺑﺮﮔـﺮدان‬

‫روشﺑﺮرﺳﻲ‪ ،‬ﻳﺎﻓﺘﻪﻫﺎ‪ ،‬ﻧﺘﻴﺠﻪﮔﻴﺮي و ﻛﻠﻤـﺎت ﻛﻠﻴـﺪي )ﺣـﺪاﻗﻞ ‪ 3‬و ﺣـﺪاﻛﺜﺮ ‪ 7‬واژه(‬

‫ﺷﻮد‪ .‬ﻧﺤﻮه ﺗﻨﻈﻴﻢ ﻣﻨﺎﺑﻊ در ﻣﺜﺎلﻫﺎي زﻳﺮ آورده ﺷﺪه اﺳﺖ‪:‬‬

‫ﺗﻨﻈﻴﻢ ﺷﻮد‪ .‬ﺗﻮﺻﻴﻪ ﻣﻲﺷﻮد ﻧﺴﺒﺖ ‪ 1-2-2-1‬در ﺗﻬﻴﻪ ﭼﻜﻴﺪه ﺑـﺎ ﭼﻬـﺎر ﻋﻨـﻮان ﻓـﻮق‬

‫‪1. Qazi F, McGuire WP. The treatment of epithelial ovarian cancer. CA Cancer‬‬ ‫‪J Clin 1995;45(2):88-101.‬‬ ‫‪2. Piazza AJ, Stoll BJ. Jaundice and hyperbilirobinemia in the newborn. In:‬‬ ‫‪Kliegman RM, Behrman RE, Jenson HB, Stanton BF, editors. Nelson‬‬ ‫‪Textbook of Pediatrics. 18th ed. Philadelphia, PA: Saunders Elsevier; 2007. p.‬‬ ‫‪756-65.‬‬ ‫‪3. O'Callaghan C, Stephenson T. Pocket Paediatrics. 2nd ed. Edinburgh:‬‬ ‫‪Churchill Livingstone; 2004.‬‬ ‫‪4. Williams FM, Cherkas LF, Spector TD, MacGregor AJ. A common genetic‬‬ ‫‪factor underlies hypertension and other cardiovascular disorders. BMC‬‬ ‫‪Cardiovasc Disord [Internet]. 2004 Apr 20 [cited 2009 Mar 23]; Available‬‬ ‫‪from: http://www.biomedcentral.com/1471-2261/4/20‬‬ ‫‪5. Ghofranipour F, Shojaee zade D. Use of health belief model in prevention of‬‬ ‫]‪brucelosis in Shahr-e-cord City in Iran. Daneshvar J 1997;15:23-8. [Persian‬‬

‫ﻟﺤﺎظ ﺷﻮد‪ .‬ﭼﻜﻴﺪه اﻧﮕﻠﻴﺴﻲ ﺑﺎﻳﺪ ﻣﻨﻄﺒﻖ ﺑﺎ ﭼﻜﻴـﺪه ﻓﺎرﺳـﻲ ﺑﺎﺷـﺪ و در ﺑﺨـﺶﻫـﺎي‬ ‫‪ Conclusion ،Results ،Methods ،Background‬و ‪ Keywords‬ﺗﻨﻈـــﻴﻢ و در ﺣـــﺪود‬ ‫‪ 240-250‬ﻛﻠﻤﻪ ﺑﺎﺷﺪ‪ -3 .‬اﺻﻞ ﻣﻘﺎﻟﻪ ﺷﺎﻣﻞ ﻣﻮارد زﻳﺮ اﺳﺖ‪:‬‬ ‫ﻣﻘﺪﻣﻪ‪ :‬ﻳﻚ ﺻﻔﺤﻪ ﺷﺎﻣﻞ‪ -1 :‬اﻃﻼﻋﺎت ﻗﺒﻠﻲ و زﻣﻴﻨﻪاي اﻧﺠﺎم ﺷﺪه و ﺳﺎﺑﻘﻪ ﺑﺎ ذﻛﺮ‬ ‫رﻓﺮاﻧﺲ‪ -2 .‬ﺿﺮورت اﻧﺠﺎم ﺗﺤﻘﻴﻖ‪ -3 .‬ﺳﺆاﻻت ﺑﺪون ﭘﺎﺳﺨﻲ ﻛﻪ اﻳﻦ ﺗﺤﻘﻴﻖ ﺑﻪ آنﻫﺎ‬ ‫ﭘﺎﺳﺦ ﻣﻲﮔﻮﻳﺪ و ﺑﻴﺎن اﻳﻦ ﻣﻮﺿﻮع ﻛﻪ ﭼﮕﻮﻧﻪ ﻧﺘﺎﻳﺞ اﻳـﻦ ﺗﺤﻘﻴـﻖ ﻣـﻲﺗﻮاﻧـﺪ ﺑـﻪ رﻓـﻊ‬ ‫اﺑﻬﺎﻣﺎت ﻛﻤﻚ ﻛﻨﺪ‪ -4 .‬ﺗﻌﺮﻳﻒ اﺻﻄﻼﺣﺎت ﺗﺨﺼﺼﻲ ﻳﺎ اﺧﺘﺼﺎرات ﻋﻠﻤﻲ‪ -5 .‬ﻫﺪف‬ ‫ﺗﺤﻘﻴﻖ ﺑﻪ ﻧﺤﻮ روﺷﻦ‪.‬‬ ‫روش ﺑﺮرﺳﻲ‪ :‬ﺑﻪﻧﺤﻮي ﺑﺎﻳﺪ ﻧﻮﺷﺘﻪ ﺷﻮد ﻛﻪ ﻫﺮ ﺧﻮاﻧﻨـﺪهاي ﺑﺘﻮاﻧـﺪ ﺑـﺎ آن‪ ،‬ﺗﺠﺮﺑـﻪ‬

‫‪ -3‬ﻧﺤﻮه ﺗﻨﻈﻴﻢ ﻣﻘﺎﻻت ﮔﺰارش ﻣﻮارد‪ -1 :‬ﺻﻔﺤﻪ اول ﻣﺸﺎﺑﻪ ﻣﻘـﺎﻻت ﺗﺤﻘﻴﻘـﻲ‪-2 .‬‬

‫ﻧﻮﻳﺴﻨﺪه ﻣﻘﺎﻟﻪ را ﺗﻜﺮار ﻛﻨﺪ‪ ،‬ﺷﺎﻣﻞ ﻃﺮاﺣﻲ ﺗﺤﻘﻴـﻖ‪ :‬ﺟﺰﻳﻴـﺎت روش ﻣﻄﺎﻟﻌـﻪ و ﻋﻠـﺖ‬

‫ﺻﻔﺤﻪ دوم و ﺳﻮم ﺷﺎﻣﻞ ﺧﻼﺻﻪ ﻓﺎرﺳـﻲ و اﻧﮕﻠﻴـﺴﻲ و ﻛﻠﻤـﺎت ﻛﻠﻴـﺪي ﻓﺎرﺳـﻲ و‬

‫اﻧﺘﺨﺎب آن )ﻣﺜﻼ ﻛﻮﻫﻮرت(‪ -‬ﻣﺪت زﻣﺎن اﺟﺮاي ﻃﺮح و ﭘﻲﮔﻴﺮي‪ -1 .‬زﻣـﺎن و ﻣﻜـﺎن‬

‫اﻧﮕﻠﻴﺴﻲ ﻣﻲ ﺑﺎﺷﺪ‪ .‬ﺧﻼﺻﻪ ﮔﺰارش ﻣﻮردي ﺣﺪاﻛﺜﺮ ‪ 130-150‬ﻛﻠﻤﻪ ﺑﺎﺷـﺪ‪ -3 .‬اﺻـﻞ‬

‫اﺟﺮاي ﭘﮋوﻫﺶ‪ -2 .‬ﺳﻮژهﻫـﺎ و ﻧﻤﻮﻧـﻪﻫـﺎي ﻣـﻮرد آزﻣـﻮن و ﻣـﻼك اﻧﺘﺨـﺎب‪ .‬روش‬

‫ﻣﻘﺎﻟﻪ ﺷﺎﻣﻞ ﻣﻮارد زﻳﺮ اﺳﺖ‪ :‬ﻣﻘﺪﻣﻪ‪ :‬ﺷﺮح ﺣﺎل ﺑﻴﻤﺎر‪ ،‬ﺑﺤﺚ‪ :‬ﮔـﺰارش ﻣـﻮرد و ﺑﺤـﺚ‬

‫ﻧﻤﻮﻧﻪﮔﻴﺮي و ﻣﻨﻄﻖ ﺗﻌﺪاد ﻧﻤﻮﻧﻪ )اﻳﻦ ﻗﺴﻤﺖ ﺑﺴﻴﺎر ﻣﻬﻢ اﺳﺖ و در اﺑﺘﺪاي اﻣﺮ ﻣـﻮرد‬

‫ﻣﺠﻤﻮﻋﺎً از ‪ 1500‬ﻛﻠﻤﻪ ﺑﻴﺶﺗﺮ ﻧﺒﻮده و ﺣﺪاﻛﺜﺮ دو ﺟﺪول ﻳﺎ ﺗـﺼﻮﻳﺮ اراﻳـﻪ ﺷـﻮد‪-4 .‬‬

‫ﻛﺎرﺷﻨﺎﺳﻲ ﻗﺮار ﻣﻲﮔﻴﺮد(‪ -‬ﻣﻼكﻫﺎي ورود و ﺧﺮوج ﺑﻪ ﻣﻄﺎﻟﻌﻪ‪ -3 .‬ﻧﺤﻮه ﺟﻤـﻊآوري‬

‫ﻣﻨﺎﺑﻊ ﻣﺸﺎﺑﻪ ﻣﻘﺎﻻت ﺗﺤﻘﻴﻘﻲ اﺳﺖ‪.‬‬

‫اﻃﻼﻋــﺎت‪ -4 .‬رﻋﺎﻳــﺖ ﻣــﻮازﻳﻦ اﺧــﻼق در ﭘــﮋوﻫﺶ‪ -5 .‬اﺑﺰارﻫــﺎي اﻧــﺪازهﮔﻴــﺮي‪.‬‬

‫‪ -4‬ﻧﺤﻮه ﺗﻨﻈﻴﻢ ﻣﻘﺎﻻت ﻣﺮوري‪ -1 :‬اﻳﻦ ﻣﻘﺎﻻت ﺑﺮاي اراﻳﻪ آﺧﺮﻳﻦ ﻳﺎﻓﺘﻪﻫﺎي ﻋﻠﻤـﻲ‬

‫‪ -6‬آزﻣﻮنﻫﺎي آﻣﺎري‪ -7 .‬ﻧﺎم ﻛﺸﻮر و ﺷﺮﻛﺖ ﺳﺎزﻧﺪه ﻣﻮاد و دﺳﺘﮕﺎهﻫﺎ )ﺑﻪ اﻧﮕﻠﻴـﺴﻲ‬

‫درﺑﺎره ﻳﻚ ﻣﻮﺿﻮع ﺧﺎص ﺑﺎﺷﺪ‪ -2 .‬ﻧﻮﻳﺴﻨﺪه در زﻣﻴﻨﻪ ﻣﻮﺿﻮع ﻣﻘﺎﻟﻪ ﺻـﺎﺣﺐ ﻧﻈـﺮ و‬

‫ﻧﻮﺷﺘﻪ ﺷﻮﻧﺪ(‪.‬‬

‫داراي ﻣﻘﺎﻟﻪ ﺑﺎﺷﻨﺪ‪ -3 .‬از رﻓﺮﻧﺲﻫﺎي ﻧﻮﻳﺴﻨﺪه در ﻣﻘﺎﻟﻪ اﺳﺘﻔﺎده ﺷﺪه ﺑﺎﺷﺪ‪.‬‬

‫ﻳﺎﻓﺘﻪﻫﺎ‪ :‬اراﻳﻪ ﻧﺘﺎﻳﺞ دﻗﻴﻖ‪ -1 :‬رﻋﺎﻳـﺖ اﺻـﻮل ﻋﻠﻤـﻲ )ﮔـﺰارش ﻋـﺪد ﺑـﺎ درﺻـﺪ‪-‬‬

‫‪ -5‬ﻫﻴﺄت ﺗﺤﺮﻳﺮﻳﻪ ﻣﺠﻠﻪ در ﻗﺒﻮل ﻳﺎ رد‪ ،‬ﻳﺎ اﺻﻼح ﻣﻘﺎﻟﻪ )ﺑـﺎ ﺗﺄﻳﻴـﺪ ﻣﺆﻟـﻒ( آزاد‬

‫ﮔﺰارش ﻣﻴﺎﻧﮕﻴﻦ ﺑﺎ ﺣﺪود اﻃﻤﻴﻨﺎن‪ -‬ﻣﻴﺎﻧﻪ ﺑـﺎ ‪ -2 .(Range‬ﭘﺮﻫﻴـﺰ از ﻧـﺸﺎن دادن ﻫﻤـﻪ‬

‫اﺳﺖ و از ﭘﺲ دادن ﻣﻘﺎﻟﻪ و ﻣﻠﺤﻘﺎت آن ﻣﻌﺬور ﻣﻲﺑﺎﺷﺪ‪.‬‬

‫ﻳـﺎﻓﺘﻪﻫﺎي ﺑﻪدﺳﺖ آﻣﺪه ﺑﻪﺟﺰ ﻳـﺎﻓﺘﻪﻫﺎي ﻣﻬﻢ و ﺗﻌﻴـﻴﻦﻛﻨﻨـﺪه‪ -3 .‬اﺳﺘــﻔﺎده ﻣﻨــﺎﺳﺐ‬

‫‪ -6‬ﻧﻮﻳﺴﻨﺪﮔﺎن ﻣﻘﺎﻻت ﻣﺴﺌﻮل ﻧﻮﺷﺘﻪﻫﺎ و ﻣﺪاﻓﻊ ﻣﻄﺎﻟﺐ ﭼﺎپ ﺷﺪه از ﻣﻘﺎﻟﻪ ﺧـﻮد در‬

‫از ﺟﺪول و ﻧﻤﻮدار ﺑﺎ ﺣﺪاﻗﻞ ﺗﻌﺪاد ﻣﻤﻜﻦ ﺑﻪﻃﻮريﻛﻪ ﺑﻪ ازاي ﻫﺮ ﺳـﻪ ﺻـﻔﺤﻪ ﺗـﺎﻳﭙﻲ‬

‫ﻣﺠﻠﻪ ﺧﻮاﻫﻨﺪ ﺑﻮد‪.‬‬

‫ﻳﻚ ﺟﺪول ﻳﺎ ﻧﻤﻮدار اﺳﺘﻔﺎده ﺷﻮد‪ ،‬ﺿﻤﻦ اﻳﻦﻛﻪ ﻧﻤﻮدار ﺑﺎﻳﺪ ﺳﻴﺎه و ﺳﻔﻴﺪ و دو ﺑﻌﺪي‬

‫‪ -7‬اﺳﺘﻔﺎده از ﻣﻨﺪرﺟﺎت ﻣﺠﻠﻪ ﺑﺎ ذﻛﺮ ﻛﺎﻣﻞ ﻣﺄﺧﺬ آزاد اﺳﺖ‪.‬‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪5‬‬

‫ﺗﻌﻴﻴﻦ اﺛﺮ اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺮ ﺑﻴﺎن ژن ‪ PPARγ‬در رده ﺳﻠﻮﻟﻲ ﻣﺎﻛﺮوﻓﺎژي ‪RAW 264.7‬‬

‫‪275‬‬

‫ﻣﻘﺎﻟﻪ اﺻﻴﻞ‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ ،5‬ﺻﻔﺤﻪﻫﺎي ‪ 275‬ﺗﺎ ‪281‬‬

‫ﺗﻌﻴﻴﻦ اﺛﺮ اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺮ ﺑﻴﺎن ژن ‪ PPARγ‬در رده ﺳﻠﻮﻟﻲ ﻣﺎﻛﺮوﻓﺎژي ‪RAW 264.7‬‬

‫ﺣﺴﻴﻦ ﻣﻨﺘﺨﺐ ﻳﮕﺎﻧﻪ‬

‫ﭼﻜﻴﺪه‬

‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ﻣﻘﺎﻟﻪ‪1390/10/13 :‬‬

‫ﺗﺎرﻳﺦ ﭘﺬﻳﺮش‪1391/03/17 :‬‬

‫ﺣﺴﻴﻦ ﺑﺎﺑﺎ اﺣﻤﺪي رﺿﺎﻳﻲ‬

‫زﻣﻴﻨﻪ و ﻫﺪف‪ :‬ﻋﻮاﻣﻞ ﻣﺘﻌﺪدي در اﻳﺠﺎد ﺑﻴﻤﺎريﻫﺎي ﻗﻠﺒﻲ‪ -‬ﻋﺮوﻗﻲ دﺧﻴﻞاﻧﺪ‪ ،‬از ﺟﻤﻠـﻪ اﺳـﻴﺪﻫﺎي ﭼـﺮب ﺗـﺮاﻧﺲ‪ ،‬ﻛـﻪ‬

‫ﻣﺤﻤﻮد دوﺳﺘﻲ‬

‫ﺑﻪﻃﻮر ﻋﻤﺪه ﻃﻲ ﻓﺮآﻳﻨﺪﻫﺎي اﺷﺒﺎعﺳﺎزي روﻏﻦﻫﺎي ﮔﻴﺎﻫﻲ ﺑﻪوﺟﻮد ﻣﻲآﻳﻨﺪ‪ .‬اﻳﻦ ﻓﺮآﻳﻨﺪﻫﺎ ﻣﻮﺟﺐ ﺗـﺸﻜﻴﻞ روﻏـﻦﻫـﺎي‬

‫*‬

‫ﮔﺮوه ﺑﻴﻮﺷﻴﻤﻲ ﺑﺎﻟﻴﻨﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ‬ ‫ﺗﻬﺮان‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬

‫ﻧﻴﻤﻪﺟﺎﻣﺪ ﻣﻲﺷﻮد‪ ،‬اﻣﺮوزه ﻣﺸﺨﺺ ﺷﺪه اﺳﺖ ﻛﻪ اﻳﻦ ﻣﺎده ﻏﺬاﻳﻲ ﻋﺎﻣﻞ ﺧﻄﺮ ﻣﻬﻤﻲ در ﺑﺮوز و ﭘﻴـﺸﺮﻓﺖ آﺗﺮوﺳـﻜﻠﺮوز‬ ‫اﺳﺖ؛ از ﻃﺮف دﻳﮕﺮ ﻣﺸﺨﺺ ﺷـﺪه اﺳـﺖ ﻛـﻪ‪ ،‬ﺗﻌـﺪادي از ﮔﻴﺮﻧـﺪهﻫـﺎي ﻫـﺴﺘﻪاي از ﺟﻤﻠـﻪ ‪PPAR‬ﻫـﺎ‬ ‫)‪Activated Receptor‬‬

‫‪(Peroxisome‬‬

‫‪ Proliferator‬در ﻫﻤﻮﺳﺘﺎز ﻟﻴﭙﻴﺪ و ﭘﺎﺗﻮژﻧﺰ ﺑﻴﻤﺎريﻫﺎي ﻗﻠﺒﻲ‪ -‬ﻋﺮوﻗﻲ دﺧﺎﻟﺖ داﺷـﺘﻪ و ﻧﻘـﺶﻫـﺎي‬

‫ﺑﻪﺳﺰاﻳﻲ اﻳﻔﺎ ﻣﻲﻛﻨﻨﺪ؛ از اﻳﻦ رو در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺗﺎﺛﻴﺮ اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺮ ﺑﻴﺎن ژن ‪ PPARγ‬ﻣﻮرد ﺑﺮرﺳﻲ ﻗﺮار ﮔﺮﻓﺘﻪ ﺷﺪ‪.‬‬ ‫روش ﺑﺮرﺳﻲ‪ :‬ﺳﻠﻮلﻫﺎي ﻣﺎﻛﺮوﻓﺎژي ‪ RAW264.7‬ﺑﺎ ﻏﻠﻈﺖﻫﺎي ‪ ،0/5mM‬ﻳﻚ و دو اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﻪﻣﺪت ﺷﺶ ﺳﺎﻋﺖ‬ ‫ﺗﻴﻤﺎر ﮔﺮدﻳﺪﻧﺪ‪ .‬ﮔﺮوه ﻛﻨﺘﺮل ﻧﻴﺰ ﺣﺎوي اﺗﺎﻧﻮل ‪) %50‬ﺑﻪﻋﻨﻮان ﺣﻼل( ﻣﻌﺎدل ﻣﻘـﺪار اﺗـﺎﻧﻮل اﺳـﺘﻔﺎده ﺷـﺪه در ﻏﻠﻈـﺖ دو‬ ‫ﻣﻴﻠﻲﻣﻮﻻر ﻟﺤﺎظ ﮔﺮدﻳﺪ‪ .‬ﺑﻌﺪ از اﺳﺘﺨﺮاج ‪ RNA‬و ﺳﻨﺘﺰ ‪ cDNA‬ﻣﻴـﺰان ﺑﻴـﺎن ژن ‪ PPARγ‬ﺑـﺎ روش‬

‫‪PCR‬‬

‫‪ Real-Time‬ﻣـﻮرد‬

‫ﺳﻨﺠﺶ ﻗﺮار ﮔﺮﻓﺖ‪.‬‬ ‫ﻳﺎﻓﺘﻪﻫﺎ‪ :‬اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﻌﺪ از ﺗﻴﻤﺎر ﺷﺶ ﺳﺎﻋﺘﻪ در ﻫﺮ ﺳﻪ ﻏﻠﻈﺖ ‪ ،0/5mM‬ﻳﻚ و دو ﻣﻴﺰان ﺑﻴـﺎن ژن ‪ PPARγ‬را در رده‬ ‫ﺳﻠﻮﻟﻲ ﻣﺎﻛﺮوﻓﺎژي ‪ RAW264.7‬در ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﮔﺮوه ﻛﻨﺘﺮل‪ ،‬ﺑﻪﺗﺮﺗﻴﺐ ‪ 1/68 ،1/36‬و ‪ 3/24‬ﺑﺮاﺑﺮ ﻛﺎﻫﺶ داد )‪.(P<0/05‬‬ ‫ﻧﺘﻴﺠﻪﮔﻴﺮي‪ :‬اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ‪ ،‬از ﻃﺮﻳـﻖ ﻛـﺎﻫﺶ ﺑﻴـﺎن ژن ﮔﻴﺮﻧـﺪه ﻫـﺴﺘﻪاي ‪ PPARγ‬ﺑﺎﻋـﺚ ﺑـﺮوز‪ ،‬ﺗـﺸﺪﻳﺪ و ﻳـﺎ ﺗـﺴﺮﻳﻊ‬ ‫*‬

‫ﺑﻴﻤﺎريﻫﺎي ﻗﻠﺒﻲ و ﻋﺮوﻗﻲ ﺑﻪﺧﺼﻮص آﺗﺮوﺳﻜﻠﺮوز ﻣﻲﺷﻮد و اﻳﻦ ﻳﺎﻓﺘﻪ اﻫﻤﻴﺖ ﻛـﺎﻫﺶ ﻣـﺼﺮف اﻳـﻦ ﻣـﺎده ﻏـﺬاﻳﻲ را‬ ‫ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪ :‬ﺗﻬﺮان‪ ،‬ﺑﻠﻮار ﻛﺸﺎورز‪ ،‬ﺧﻴﺎﺑﺎن ﻗﺪس‪،‬‬

‫ﺧﻴﺎﺑﺎن ﭘﻮرﺳﻴﻨﺎ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬داﻧﺸﻜﺪه‬

‫ﻧﺸﺎن ﻣﻲدﻫﺪ‪.‬‬

‫ﭘﺰﺷﻜﻲ‪ ،‬ﮔﺮوه ﺑﻴﻮﺷﻴﻤﻲ ﺑﺎﻟﻴﻨﻲ ﺗﻠﻔﻦ‪021-64053265 :‬‬ ‫‪E-mail: doostimd@sina.tums.ac.ir‬‬

‫ﻛﻠﻤﺎت ﻛﻠﻴﺪي‪ :‬ﻛﺸﺖ ﺳﻠﻮل‪ ،‬اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ‪ ،‬آﺗﺮوﺳﻜﻠﺮوز‪ ،‬ﺑﻴﺎن ژن‪ ،‬اﺳﻴﺪ ﭼﺮب ﺗﺮاﻧﺲ‪.PPARγ ،‬‬

‫ﻣﻘﺪﻣﻪ‬

‫اﺳﻴﺪﻫﺎي ﭼﺮب در ﭘﺎﺗﻮژﻧﺰ ﺑﻴﻤﺎريﻫﺎي ﻗﻠﺒـﻲ‪ -‬ﻋﺮوﻗـﻲ ﺑـﻪﺧـﺼﻮص‬ ‫آﺗﺮواﺳﻜﻠﺮوز داراي اﻫﻤﻴﺖ ﺑﺮﺟﺴﺘﻪاي ﻫﺴﺘﻨﺪ‪ .‬اﻣﺮوزه ﻣـﺸﺨﺺ ﺷـﺪه‬

‫اﺳﻴﺪﻫﺎي ﭼﺮب )‪ (Fatty acids‬از اﺻﻠﻲﺗﺮﻳﻦ اﺟﺰاي ﺗﺸﻜﻴﻞدﻫﻨﺪه‬

‫اﺳﺖ اﺳﻴﺪﻫﺎي ﭼﺮب ﻋﻼوه ﺑﺮ ﻧﻘﺶﻫﺎي ﻣﺘﻌﺪدي ﻛﻪ دارﻧﺪ‪ ،‬ﻣﻲﺗﻮاﻧﻨـﺪ‬

‫ﻟﻴﭙﻴﺪﻫﺎ ﻣﺤﺴﻮب ﻣﻲﺷﻮﻧﺪ‪ ،‬ﻛﻪ ﺑﻪﻋﻨﻮان ﻳﻜﻲ از ﻣﻮاد ﺳﻪﮔﺎﻧﻪ ﺑﺨﺶ ﻗﺎﺑﻞ‬

‫ﺑﻪﻋﻨﻮان ﻟﻴﮕﺎﻧﺪي ﺑﺮاي ﮔﻴﺮﻧﺪهﻫﺎي ﻫﺴﺘﻪاي ﻣﻬﻤـﻲ از ﺟﻤﻠـﻪ ‪PPAR‬ﻫـﺎ‬

‫ﺗﻮﺟﻬﻲ از ﺳﺒﺪ ﻏﺬاﻳﻲ ﺧﺎﻧﻮار را ﺷﺎﻣﻞ ﻣﻲﺷﻮﻧﺪ؛ از آﻧﺠﺎﻳﻲ ﻛﻪ ﻟﻴﭙﻴـﺪﻫﺎ‬

‫ﻋﻤﻞ ﻛﻨﻨـﺪ‪.‬‬

‫‪Peroxisome Proliferator Activated Receptor gamma‬‬

‫ﻧــﺴﺒﺖ ﺑــﻪ ﺳــﺎﻳﺮ ﻣــﻮاد ﺳــﻪﮔﺎﻧــﻪ از ﭘﺘﺎﻧــﺴﻴﻞ اﻧــﺮژيزاﻳــﻲ ﺑــﺎﻻﺗﺮي‬

‫)‪ (PPARγ‬از ﻣﻬﻢﺗﺮﻳﻦ ﮔﻴﺮﻧﺪهﻫﺎي ﻫﺴﺘﻪاي اﺳﺖ ﻛﻪ ﻧﻘﺶ ﺑﻪﺳـﺰاﻳﻲ در‬

‫ﺑﺮﺧﻮردارﻧﺪ‪ ،‬ﻟﺬا ﺗﻮﺟﻪ ﺑـﻪ ﻛﻤﻴـﺖ‪ ،‬ﻛﻴﻔﻴـﺖ و ﻧﻴـﺰ ﻧـﻮع اﺳـﻴﺪ ﭼـﺮب‬

‫ﻣﺘﺎﺑﻮﻟﻴﺴﻢ ﻟﻴﭙﻴﺪ ﺑﻪﻋﻬﺪه دارد‪ ،‬اﻳﻦ ﮔﻴﺮﻧﺪه ﻫﺴﺘﻪاي ﻗﺎدر اﺳـﺖ ژنﻫـﺎي‬

‫ﺗﺸﻜﻴـﻞدﻫﻨﺪه آن اﻣـﺮي ﺿـﺮوري و ﺣﺎﻳـﺰ اﻫﻤﻴـﺖ اﺳﺖ‪ 1.‬از ﻃـﺮﻓﻲ‬

‫ﻫـﺪف ﺑـﺴﻴﺎري از ﺟﻤﻠـﻪ‬

‫‪ATP-Binding Cassette, sub-family A1‬‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):275-81‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﺣﺴﻴﻦ ﻣﻨﺘﺨﺐ ﻳﮕﺎﻧﻪ و ﻫﻤﻜﺎران‬

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‫‪،ATP-Binding‬‬

‫اﺛﺮات ﺧﻮد را اﻋﻤﺎل ﻣﻲﻛﻨﻨﺪ‪ ،‬ﺑﻪﻃﻮر ﻗﻄﻊ ﻣﻲﺗﻮاﻧـﺪ ﻛﻤـﻚ ﻣـﻮﺛﺮي در‬

‫‪ Interleukin‬و ﻏﻴــﺮه را ﻓﻌــﺎل ﻧﻤﺎﻳــﺪ‪ .‬ژنﻫــﺎي ﻣــﺬﻛﻮر از‬

‫ﻛﻨﺘﺮل اﻳﻦ ﺑﻴﻤﺎريﻫﺎ داﺷﺘﻪ ﺑﺎﺷﺪ‪ .‬از اﻳﻦرو اﺣﺘﻤﺎﻻ ﻣﻲﺗﻮاﻧﺪ در ﻃﺮاﺣﻲ‬

‫ﻓﺎﻛﺘﻮرﻫﺎي دﺧﻴﻞ ﺑﺴﻴﺎر ﻣﻬﻢ در ﻣﺘﺎﺑﻮﻟﻴﺴﻢ ﻟﻴﭙﻴﺪ ﻣﺤﺴﻮب ﻣـﻲﺷـﻮﻧﺪ و‬

‫راهﻛﺎرﻫﺎي ﻋﻤﻠﻲ در ﺟﻬﺖ ﭘﻴﺸﮕﻴﺮي و ﻳﺎ ﺟﻠﻮﮔﻴﺮي از وﺧﻴﻢﺗﺮ ﺷـﺪن‬

‫ﻟﺬا اﺧﺘﻼل در ﻓﻌﺎﻟﻴﺖ ﻫﺮ ﻛﺪام از اﻳﻦ ژنﻫﺎ ﻣـﻲﺗﻮاﻧـﺪ ﺧﻄـﺮ اﺑـﺘﻼ ﺑـﻪ‬

‫آن ﻣﻮرد اﺳﺘﻔﺎده ﻗﺮار ﮔﻴﺮد‪.‬‬

‫)‪(ABCG1) ،(ABCA1‬‬ ‫)‪6 (IL6‬‬

‫‪Cassette, sub-family G1‬‬

‫‪2‬‬

‫آﺗﺮوﺳﻜﻠﺮوز را اﻓﺰاﻳﺶ دﻫﺪ‪.‬‬

‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ اﻋﻤﺎل ﻣﺘﻔﺎوﺗﻲ ﻛﻪ ﻣﺘﻌﺎﻗﺐ ﻓﻌـﺎل ﻳـﺎ ﻏﻴـﺮ ﻓﻌـﺎل ﺷـﺪن‬ ‫‪PPAR‬ﻫﺎ ﺑﺮوز ﻣﻲﻛﻨﺪ‪ ،‬ﻣﺸﺨﺺ ﺷﺪه اﺳﺖ ﻛـﻪ ﻧـﻮع اﺳـﻴﺪ ﭼـﺮب در‬

‫روش ﺑﺮرﺳﻲ‬

‫‪3‬‬

‫ﻣﻄﺎﻟﻌﻪ ﻛﻨﻮﻧﻲ از ﻧﻮع ﺗﺠﺮﺑﻲ‪ -‬ﺑﻨﻴـﺎدي ﺑـﻮده و در ﺳـﺎل ‪ 1390‬در‬

‫ﺑﻪﻃﻮر ﻣﺜﺎل در ﻣﻄﺎﻟﻌﺎت ﺑﺴﻴﺎري ﻧﺸﺎن داده ﺷﺪه اﺳـﺖ ﻛـﻪ اﺳـﻴﺪﻫﺎي‬

‫ﮔﺮوه ﺑﻴﻮﺷﻴﻤﻲ ﭘﺰﺷﻜﻲ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬـﺮان‬

‫)‪Polyunsaturated Fatty Acids (PUFA‬‬

‫اﻧﺠﺎم ﺷﺪه اﺳﺖ‪ .‬ﻣﻮاد ﻣﻮرد اﺳﺘﻔﺎده ﻋﺒﺎرﺗﻨﺪ از‪ :‬رده ﺳﻠﻮﻟﻲ ﻣﺎﻛﺮوﻓﺎژي‬

‫داراي آراﻳﺶ ﻓﻀﺎﻳﻲ ﺳﻴﺲ و ﺑﻪﺧﺼﻮص اﺳﻴﺪﻫﺎي ﭼﺮب ‪ ω3‬ﺑﻴﺎن ژن‬

‫‪ RAW264.7‬از ﻣﺮﻛﺰ ذﺧﺎﻳﺮ ژﻧﺘﻴـﻚ ﺧﺮﻳﺪاري ﺷﺪ‪ .‬ﻣﺤﻴﻂ ﻛﺸﺖ ﺳﻠﻮﻟﻲ‬

‫‪ PPARγ‬را اﻓﺰاﻳﺶ ﻣﻲدﻫﻨﺪ‪ .‬در ﻣﻄﺎﻟﻌﻪ دﻳﮕﺮي ﻧـﺸﺎن داده ﺷـﺪه اﺳـﺖ‬

‫ﺟﻨﻴﻦ ﮔﺎوي ‪(Fetal Bovine Serum,‬‬

‫ﻓﻌﺎﻟﻴﺖ و ﻫﻢﭼﻨﻴﻦ ﺑﻴﺎن اﻳﻦ ﮔﻴﺮﻧﺪه ﻫﺴﺘﻪاي ﻧﻘﺶ ﺗﻌﻴﻴﻦﻛﻨﻨﺪهاي دارد‪.‬‬ ‫ﭼﺮب ﺑﺎ ﭼﻨﺪ ﭘﻴﻮﻧـﺪ دوﮔﺎﻧـﻪ‬

‫ﻛﻪ اﺳﻴﺪﻫﺎي ﭼﺮب ﻏﻴﺮاﺷﺒﺎع ﺗﺮاﻧﺲ ﻣﻮﺟـﻮد در روﻏـﻦﻫـﺎي ﺻـﻨﻌﺘﻲ‬

‫‪ ،(Cat. No. E15-883) DMEM‬ﺳﺮم‬ ‫)‪No.) FBS‬‬

‫‪ ،(F1051Cat.‬آﻧﺘــﻲﺑﻴﻮﺗﻴــﻚ ﭘﻨﻲﺳﻴﻠﻴﻦ‪ /‬اﺳﺘﺮﭘﺘﻮﻣﺎﻳــﺴﻴﻦ‬

‫‪ (Cat. No.‬و ﮔﻠﻮﺗﺎﻣﻴﻦ‬

‫داراي اﺛﺮ ﻣﺨﺎﻟﻒ اﺳﻴﺪﻫﺎي ﭼﺮب ﻧﻮع ﺳﻴﺲ ﻣﻲﺑﺎﺷﺪ و ﺑﻪﻋﻨـﻮان ﻳـﻚ‬

‫)‪15140‬‬

‫ﻓﺎﻛﺘﻮر ﺧﻄﺮ ﺑﻴﻤﺎريﻫﺎي ﻗﻠﺒﻲ‪ -‬ﻋﺮوﻗﻲ ﺷﻨﺎﺧﺘﻪ ﺷﺪه اﺳﺖ‪ .‬ﻟﺬا ﺑﺎ ﺗﻮﺟﻪ‬

‫)‪ USA‬ﺗﻬﻴﻪ ﮔﺮدﻳﺪ‪ .‬ﻛﻴﺖﻫـﺎي اﺳﺘﺨﺮاج ‪ ،RNA‬ﻳـﺎ‬

‫ﺑﻪ اﺛﺮات ﻣﻀﺮ و ﻧﺎﻣﻄﻠﻮب اﺳﻴﺪﻫﺎي ﭼﺮب ﺗﺮاﻧﺲ اﻧﺘﻈﺎر ﻣـﻲرود اﻳـﻦ‬ ‫اﺳﻴﺪﻫﺎي ﭼﺮب ﺑﺮﺧﻼف اﺳﻴﺪﻫﺎي ﭼـﺮب ﺳـﻴﺲ ﺑﻴـﺎن ژن ‪ PPARγ‬را‬

‫‪ (Cat. No. 205311) Transcription‬و ﻫﻢﭼﻨﻴﻦ ﭘﺮاﻳﻤﺮ ژنﻫـﺎي‬ ‫)‪QT00100296‬‬

‫ﻛﺎﻫﺶ دﻫﻨﺪ‪.‬‬

‫اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ‪ C18:9;1‬ﻛﻪ ﻓﺮاوانﺗﺮﻳﻦ اﺳﻴﺪ ﭼﺮب ﺗﺮاﻧﺴﻲ اﺳـﺖ‬

‫)‪Germany‬‬

‫‪ (Cat.‬و ﺳـــﻨﺘﺰ ‪ cDNA‬ﻳـــﺎ‬

‫‪plus Mini RNeasy‬‬

‫)‪74134‬‬

‫‪4‬‬

‫‪No.‬‬

‫)‪G7513‬‬

‫‪ (Cat. No.‬از‬

‫‪(GIBCO Co.,‬‬

‫‪No.‬‬

‫‪ (Cat.‬و‬

‫‪Reverse‬‬

‫‪QuantiTect‬‬

‫‪No. QT01136772) β-Actin‬‬

‫‪ ،(QIAGEN Co.,‬ﻫــﻢﭼﻨــﻴﻦ ﻛﻴــﺖ‬

‫‪PPARγ‬‬

‫‪ (Cat.‬از‬

‫‪green Real Time‬‬

‫‪ (Cat.‬از )‪ (TAKARA Co., Japan‬ﺗﻬﻴــﻪ‬

‫ﻛﻪ ﺑﻪﻃﺮق ﺻﻨﻌﺘﻲ ﺗﺸﻜﻴﻞ ﻣﻲﮔﺮدد‪ ،‬ﺑـﻪﻋﻨـﻮان ﻋﺎﻣـﻞ ﺧﻄـﺮ ﻣﻬﻤـﻲ در‬

‫‪No. PR081A) PCRSYBER‬‬

‫اﻳﺠــﺎد ﺑــﺴﻴﺎري از ﺑﻴﻤــﺎريﻫــﺎ از ﻗﺒﻴــﻞ ﺑﻴﻤــﺎريﻫــﺎي ﻗﻠﺒــﻲ‪ -‬ﻋﺮوﻗــﻲ‬

‫ﮔﺮدﻳﺪ‪ .‬ﺗﺠﻬﻴﺰات ﻣﺼﺮﻓﻲ ﻧﻴﺰ از )‪ (JETBIOFIL Co., Canada‬ﺧﺮﻳﺪاري‬

‫)ﺑﻪﺧﺼﻮص آﺗﺮوﺳﻜﻠﺮوز( ﺷﻨﺎﺧﺘﻪ ﺷﺪه اﺳﺖ‪ .‬ﻋﻠﻲرﻗﻢ اﻳـﻦﻛـﻪ ﻧـﺸﺎن‬

‫ﮔﺮدﻳﺪ‪ .‬ﻣﺮاﺣﻞ اﻧﺠﺎم ﺑﺮرﺳﻲ ﺑﻪﺗﺮﺗﻴﺐ در ذﻳﻞ آورده ﺷﺪه اﺳﺖ‪.‬‬

‫داده ﺷﺪه ﻛﻪ اﻳﺰوﻣﺮﻫﺎي دﻳﮕﺮ اﺳـﻴﺪﻫﺎي ﭼـﺮب ﺗـﺮاﻧﺲ ﻛـﻪ ﺑـﻪﻃـﻮر‬

‫اﻟﻒ‪ -‬ﻛﺸﺖ رده ﺳﻠﻮﻟﻲ ﻣﺎﻛﺮوﻓﺎژي ‪ :RAW264.7‬اﻳﻦ ﺳﻠﻮلﻫـﺎ در‬

‫ﻃﺒﻴﻌﻲ در ﻓﺮآوردهﻫﺎي ﻟﺒﻨﻲ وﺟﻮد دارﻧﺪ‪ ،‬اﺛـﺮي ﺑـﺮ ﻟﻴﭙـﻮﭘﺮوﺗﻴﻴﻦﻫـﺎي‬

‫ﻣﺤﻴﻂ ﻛـﺸﺖ )‪ Dulbecco’s Modified Eagle's Medium (DMEM‬ﻛـﻪ‬

‫ﺧﻮن ﻧﻤﻲﮔﺬارﻧﺪ‪ 5،‬اﻣﺎ در ﻣﻄﺎﻟﻌﺎت اﻧﺠﺎم ﺷﺪه ﺑﺮ روي اﺳﻴﺪ اﻻﻳﻴـﺪﻳﻚ‬

‫داراي ‪ %10‬ﺳــﺮم ﺟﻨــﻴﻦ ﮔــﺎوي‪ %1/25 ،‬ﮔﻠﻮﺗــﺎﻣﻴﻦ و ﻫــﻢﭼﻨــﻴﻦ ‪%1‬‬

‫ﻣﺸﺨﺺ ﺷﺪه اﺳﺖ ﻛﻪ اﻳﻦ ﻧﻮع از اﺳﻴﺪﻫﺎي ﭼﺮب ﺑـﺎ ﺗﻐﻴﻴـﺮ ﭘﺮوﻓﺎﻳـﻞ‬

‫آﻧﺘﻲﺑﻴﻮﺗﻴﻚ ﭘﻨـﻲﺳـﻴﻠﻴﻦ‪ /‬اﺳﺘﺮﭘﺘﻮﻣﺎﻳـﺴﻴﻦ ﺑـﻮد‪ ،‬ﻛـﺸﺖ داده ﺷـﺪ و در‬

‫ﻟﻴﭙﻴﺪي ﺑﻪﻃﻮر ﻣﺜﺎل ﺑﺎ اﻓﺰاﻳﺶ ﻟﻴﭙﻮﭘﺮوﺗﻴﻴﻦ ﺑﺎ ﭼﮕﺎﻟﻲ ﭘـﺎﻳﻴﻦ )‪ (LDL‬و از‬

‫اﻧﻜﻮﺑــﺎﺗﻮر ‪ 37 C‬و ‪ CO2 %5‬ﻗــﺮار داده ﺷــﺪ‪ .‬ﺑﻌــﺪ از رﺷــﺪ و ﺗﻜﺜﻴــﺮ‬

‫ﻃــﺮف دﻳﮕــﺮ ﺑــﺎ ﻛــﺎﻫﺶ ﻟﻴﭙــﻮﭘﺮوﺗﻴﻴﻦ ﺑــﺎ ﭼﮕــﺎﻟﻲ ﺑــﺎﻻ )‪ (HDL‬ﻋﺎﻣــﻞ‬

‫ﺳﻠﻮلﻫﺎ و اﻧﺠﺎم ﭘﺎﺳﺎژ‪ ،‬ﺳﻠﻮلﻫﺎي ﭘﺎﺳﺎژ دﻫﻢ ﺑﺮاي اﻧﺠﺎم ﻣﺮاﺣﻞ ﺑﻌﺪي‬

‫‪6‬‬

‫ﻣﺴﺘﻌﺪﻛﻨﻨﺪه ﻣﻬﻤﻲ در ﺑﺮوز آﺗﺮوﺳﻜﻠﺮوز اﺳﺖ‪.‬‬

‫اﻧﺘﺨــﺎب ﮔﺮدﻳــﺪ‪ .‬ب‪ -‬ﺗﻌﻴــﻴﻦ دوز ﺳــﻤﻲ و ﻛــﺸﻨﺪه )آزﻣــﻮن ‪(MTT‬‬

‫از ﻃﺮﻓﻲ ﻫﻤﺎنﻃﻮر ﻛﻪ ﮔﻔﺘﻪ ﺷﺪ‪ ،‬ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻧﻘﺶ ﺑﺮﺟـﺴﺘﻪاي ﻛـﻪ‬

‫‪:3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide‬‬

‫ﮔﻴﺮﻧﺪهﻫﺎي ﻫﺴﺘﻪاي ﻣـﺬﻛﻮر و ﺑـﻪﺧـﺼﻮص ‪ PPARγ‬در ﺑﻴﻤـﺎريﻫـﺎي‬

‫اﻳﻦ آزﻣﻮن ﺑﺮاي ﻣﺸﺨﺺ ﻧﻤﻮدن ﻏﻠﻈـﺖ ﻛـﺸﻨﺪه اﺳـﻴﺪ اﻻﻳﻴـﺪﻳﻚ ﺑـﺮ‬

‫ﻗﻠﺒﻲ‪ -‬ﻋﺮوﻗﻲ و در راس آن آﺗﺮوﺳﻜﻠﺮوز دارﻧﺪ‪ ،‬ﻟﺬا وﺟﻮد ارﺗﺒﺎط ﺑﻴﻦ‬

‫روي ﺳﻠﻮل ﺻﻮرت ﻣﻲﮔﻴﺮد ﻛﻪ ﻃﻲ ﻣﺮاﺣﻞ زﻳﺮ ﺻﻮرت ﭘـﺬﻳﺮﻓﺖ‪ :‬در‬

‫اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ و ‪ PPARγ‬ﺑـﺴﻴﺎر ﻣﻨﻄﻘـﻲ ﺑـﻪﻧﻈـﺮ ﻣـﻲرﺳـﺪ‪ .‬در واﻗـﻊ‬

‫ﻫﺮ ﻣﻴﻜﺮوﭘﻠﻴﺖ ‪ 96‬ﺧﺎﻧﻪاي ﺗﻌـﺪاد ‪ 20‬ﻫـﺰار ﺳـﻠﻮل ﺗﻮزﻳـﻊ ﮔﺮدﻳـﺪ و‬

‫ﻣﺸﺨﺺ ﺷﺪن ﻣﻜﺎﻧﻴﺴﻢﻫﺎﻳﻲ ﻛﻪ از ﻃﺮﻳﻖ آن اﺳﻴﺪﻫﺎي ﭼـﺮب ﺗـﺮاﻧﺲ‬

‫ﺑﻪﻣﺪت دو ﺳﺎﻋﺖ اﻧﻜﻮﺑﻪ ﺷـﺪ‪ .‬ﺑﻌـﺪ از ﺗﻬﻴـﻪ ﻣﺤﻠـﻮل ﻛـﺎري ‪ MTT‬ﺑـﺎ‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ 275 ،5‬ﺗﺎ ‪281‬‬

‫ﺗﻌﻴﻴﻦ اﺛﺮ اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺮ ﺑﻴﺎن ژن ‪ PPARγ‬در رده ﺳﻠﻮﻟﻲ ﻣﺎﻛﺮوﻓﺎژي ‪RAW 264.7‬‬

‫‪277‬‬

‫ﻏﻠﻈﺖ ‪ ،0/5mg/ml‬اﻳﻦ ﻣﺤﻴﻂ ﺟﺎﻳﮕﺰﻳﻦ ﻣﺤﻴﻂ ‪ RPMI‬ﮔﺮدﻳـﺪ‪ ،‬ﺳـﭙﺲ‬

‫آن ﺑــﺮاي اﻧﺠــﺎم‬

‫ﺳﻠﻮلﻫﺎ ﺑﻪﻣـﺪت ﺳـﻪ ﺳـﺎﻋﺖ در دﻣـﺎي ‪ 37 C‬اﻧﻜﻮﺑـﻪ ﮔﺮدﻳﺪﻧـﺪ‪ .‬در‬

‫)‪ scientific Co., USA‬در ﻃﻮل ﻣﻮج ‪ 540nm‬ﻗﺮاﺋﺖ ﮔﺮدﻳﺪ‪.‬‬

‫ﻣﺮﺣﻠــﻪ ﺑﻌــﺪ ﻣﺤــﻴﻂ ﻛــﺎري ‪ MTT‬ﺑــﺎ‬

‫)‪Dimethyl Sulfoxide (DMSO‬‬

‫‪PCR‬‬

‫‪ Real Time‬ﺑــﺎ دﺳــﺘﮕﺎه ﻧــﺎﻧﻮدراپ‬

‫ي‪ -‬ﺑﺮرﺳﻲ ﺑﻴﺎن ژن ‪ :PPARγ‬ﺑﺎ اﺳﺘﻔﺎده از دﺳـﺘﮕﺎه‬

‫‪(Thermo‬‬

‫‪(Rotor-Gene‬‬

‫ﺟﺎﻳﮕﺰﻳﻦ و ﻣﺠﺪداً ﺑﻪﻣﺪت ‪ 15‬دﻗﻴﻘﻪ اﻧﻜﻮﺑﻪ ﺷﺪﻧﺪ و در ﻧﻬﺎﻳـﺖ ﻣﻴـﺰان‬

‫‪ 6000) Real Time PCR‬و ﺑﺎ ﺑﻪﻛﺎرﮔﻴﺮي دﺳـﺘﻮراﻟﻌﻤـﻞ ﻣﺮﺑﻮﻃـﻪ ﻛﻴـﺖ‬

‫ﺟﺬب ﻧﻮري اﻳﺠﺎد ﺷﺪه در ﻃﻮل ﻣﻮج ‪ 540‬ﻧﺎﻧﻮﻣﺘﺮ ﺗﻮﺳﻂ اﻻﻳﺰا رﻳـﺪر‬

‫‪ SYBER green‬ﺷــﺮﻛﺖ ﺗﺎﻛــﺎرا )‪ ،(Japan‬ژن ‪ PPARγ‬و ﻫــﻢﭼﻨــﻴﻦ ژن‬

‫ﻗﺮاﺋﺖ ﮔﺮدﻳﺪ‪.‬‬

‫‪ β-Actin‬ﺑــﻪﻋﻨــﻮان ژن ﻣﺮﺟــﻊ‪ ،‬ﺗﻜﺜﻴــﺮ ﮔﺮدﻳــﺪ‪ ،‬و ﻣﻴــﺰان ﺑﻴــﺎن ژن در‬ ‫‪(Bovine‬‬

‫ﮔﺮوهﻫـﺎي ﺗﻴﻤـﺎر ﺷـﺪه و ﻛﻨﺘـﺮل‪ ،‬ﻣـﻮرد اﻧـﺪازهﮔﻴـﺮي ﻗـﺮار ﮔﺮﻓـﺖ‪.‬‬

‫‪ .Serum‬ﻻزﻣــﻪ ورود اﺳــﻴﺪ اﻻﻳﻴــﺪﻳﻚ ﺑــﻪ درون‬

‫‪ Real Time PCR‬ﺑﻪﺻﻮرت دو ﻣﺮﺣﻠﻪاي )‪ (Two step‬اﺟﺮا ﮔﺮدﻳﺪ؛ ﻛـﻪ‬

‫ﺳﻠﻮلﻫﺎي ﻛﺸﺖ داده ﺷﺪه‪ ،‬اﻳـﻦ اﺳـﺖ ﻛـﻪ ﺑـﻪﺻـﻮرت ﻳـﻚ ﺗﺮﻛﻴـﺐ‬

‫ﭼﮕﻮﻧﮕﻲ ﺑﺮﻧﺎﻣﻪ اﺟﺮاﻳﻲ آن در ﺟﺪول‪ 1 -‬آورده ﺷﺪه اﺳﺖ‪ .‬در ﻧﻬﺎﻳﺖ‬

‫ﻣﺤﻠﻮل ﺑﺎﺷﺪ‪ ،‬ﻣﺤﻠﻮلﺳﺎزي اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺎ اﺗﺼﺎل ﺑـﻪ آﻟﺒـﻮﻣﻴﻦ ﺳـﺮم‬

‫دادهﻫﺎ ﺑﺎ ﻧﺮماﻓﺰار ‪ SPSS‬وﻳﺮاﺳﺖ ‪ 11/5‬و آزﻣﻮن آﻣﺎري ‪ ANOVA‬آﻧﺎﻟﻴﺰ‬

‫ﮔﺎوي )‪ (BSA‬ﺣﺎﺻﻞ ﮔﺮدﻳﺪ‪ ،‬ﺑﺪﻳﻦﺻﻮرت ﻛﻪ در اﺑﺘﺪا ﻣﻘﺪار ﻣﻮرد ﻧﻈﺮ‬

‫و ﺗﻔﺴﻴﺮ ﺷﺪﻧﺪ )ﻣﻌﻨﻲدار ﺑﻮدن اﺧﺘﻼف در ﺻﻮرﺗﻲ ﻗﺎﺑﻞ ﻗﺒﻮل ﺧﻮاﻫـﺪ‬

‫از اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ‪ ،‬در ﺣﺪاﻗﻞ ﻣﻘﺪار ﻣﻤﻜﻦ اﺗﺎﻧﻮل ‪ %50‬ﺣﻞ ﮔﺮدﻳـﺪه و‬

‫ﺑﻮد ﻛﻪ ‪ P<0/05‬ﺑاﺷﺪ(‪.‬‬

‫ج‪ -‬ﻛﻮﻧﮋوﮔﺎﺳﻴﻮن اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺎ آﻟﺒﻮﻣﻴﻦ ﺳﺮم ﮔﺎوي‬ ‫)‪Albumin, BSA‬‬

‫ﺳﭙﺲ ﺑﺎ ﻣﺤﻴﻂ ﺣﺎوي ﻳﻚ درﺻﺪ وزن ﺣﺠﻤﻲ آﻟﺒﻮﻣﻴﻦ ﻋﺎري از اﺳـﻴﺪ‬ ‫ﭼﺮب ﺑﻪ ﺣﺠﻢ ﻣﻄﻠﻮب رﺳﺎﻧﻴﺪه ﺷﺪ و ﺳﭙﺲ ﻏﻠﻈﺖﻫﺎي ‪ ،0/5mM‬ﻳﻚ‬

‫ﻳﺎﻓﺘﻪﻫﺎ‬

‫و دو اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺗﻬﻴﻪ ﮔﺮدﻳﺪ‪ .‬در اﻧﺘﻬﺎ ﻣﺤﻴﻂ ﺣﺎﺻﻠﻪ ﺑـﻪﻣـﺪت ‪2-3‬‬ ‫ﺳﺎﻋﺖ در اﻧﻜﻮﺑﺎﺗﻮر ﺷﻴﻜﺮدار‪ ،‬در دﻣﺎي ‪ 37 C‬ﻗـﺮار ﮔﺮﻓـﺖ و ﺟﻬـﺖ‬ ‫اﺳﺘﺮﻳﻞ ﻛﺮدن آن از ﻓﻴﻠﺘﺮ ﺑﺎ ﻗﻄﺮ ‪ 0/2‬ﻣﻴﻜﺮون اﺳﺘﻔﺎده ﮔﺮدﻳﺪ‪.‬‬

‫ﻧﺘﺎﻳﺞ آزﻣﻮن ‪ :MTT‬ﺑـﺎ ﺗﻮﺟـﻪ ﺑـﻪ ﻧﺘـﺎﻳﺞ ﺣﺎﺻـﻞ از آزﻣـﻮن ‪،MTT‬‬ ‫ﻏﻠﻈﺖ ﻛﺸﻨﺪه اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺮ روي ﺳﻠﻮلﻫﺎ )ﻏﻠﻈﺘﻲ ﻛﻪ در آن ﺑﻴﺶ‬

‫د‪ -‬ﺗﻴﻤﺎر ﺳﻠﻮلﻫﺎ ﺑﺎ اﺳﻴﺪ اﻻﻳﻴـﺪﻳﻚ‪ :‬ﺑﻌـﺪ از دور رﻳﺨـﺘﻦ ﻣﺤـﻴﻂ‬

‫از ‪ %50‬ﺳﻠﻮلﻫﺎ ﻛﺸﺘﻪ ﺷﻮﻧﺪ(‪ ،‬ﻏﻠﻈﺖ ‪ 4mM‬و ﺑﺎﻻﺗﺮ را ﻧﺸﺎن ﻣﻲدﻫـﺪ‪.‬‬

‫ﻛﺸﺖ‪ ،‬ﺳﻠﻮلﻫﺎ ﺑﺎ ﻣﺤﻴﻂ ﻛﺸﺖ ﺗﺎزه ﻛﻪ ﺣـﺎوي ﻏﻠﻈـﺖﻫـﺎي ‪،0/5mM‬‬

‫ﺑﻌﺪ از ﺗﻴﻤﺎر ﺳﻠﻮلﻫﺎي ﻣﺎﻛﺮوﻓﺎژي ‪ RAW264.7‬ﺑﺎ ﭘﻨﺞ ﻏﻠﻈﺖ ﻣﺨﺘﻠـﻒ‬

‫ﻳﻚ و دو اﺳـﻴﺪ اﻻﻳﻴـﺪﻳﻚ ﻛﻮﻧﮋوﮔـﻪ اﺳـﺖ‪ ،‬ﺗﻴﻤـﺎر ﮔﺮدﻳـﺪ و ﺳـﭙﺲ‬

‫اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ و ﮔﺬﺷﺖ ﻣﺪت زﻣـﺎﻧﻲ ‪ 24‬ﺳـﺎﻋﺖ ﺑـﻪ ﻛﻤـﻚ آزﻣـﻮن‬

‫ﺳﻠﻮلﻫﺎي ﺗﻴﻤﺎر ﺷﺪه ﺑﻪﻣﺪت ﺷﺶ ﺳـﺎﻋﺖ در ‪ 37 C‬اﻧﻜﻮﺑـﻪ ﮔﺮدﻳـﺪ‪.‬‬

‫‪ ،MTT‬ﻣﻴﺰان زﻧﺪه ﻣﺎﻧـﺪن ﺳـﻠﻮلﻫـﺎ ﺗﻮﺳـﻂ دﺳـﺘﮕﺎه ﻧـﺎﻧﻮدراپ ﻣـﻮرد‬

‫ﮔﺮوه ﻛﻨﺘﺮل ﻧﻴﺰ ﻃﻮري ﻟﺤﺎظ ﮔﺮدﻳﺪ ﻛﻪ ﺣﺎوي ﺗﻤﺎم ﺗﺮﻛﻴﺒـﺎت ﻣﻮﺟـﻮد‬

‫ارزﻳﺎﺑﻲ ﻗﺮار ﮔﺮﻓﺖ )ﻧﻤﻮدار‪.(1 -‬‬

‫در ﮔﺮوهﻫﺎي ﺗﻴﻤﺎر ﺷﺪه ﺑﻪﺟﺰ اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺎﺷﺪ؛ ﻫﻢﭼﻨﻴﻦ ﺑﻪﻣﻨﻈـﻮر‬

‫ﺗﻌﻴﻴﻦ ﻏﻠﻈﺖ ‪ :RNA‬ﻫﻤـﺎنﻃـﻮر ﻛـﻪ ﮔﻔﺘـﻪ ﺷـﺪ ﻏﻠﻈـﺖ ‪ RNA‬ﺑـﺎ‬

‫ﺟﻠﻮﮔﻴﺮي از اﻳﺠﺎد ﺗﺪاﺧﻞ در ﻧﺘﺎﻳﺞ‪ ،‬ﺑﻪ ﮔﺮوه ﻛﻨﺘﺮل اﺗﺎﻧﻮل ‪ %50‬ﻣﻌﺎدل‬

‫اﺳﺘﻔﺎده از ﻧﺎﻧﻮدراپ اﻧﺪازهﮔﻴﺮي و ﺳﭙﺲ ﺑﻪﻣﻴـﺰان ‪ 1µg‬از ‪ RNA‬ﻣـﻮرد‬

‫ﻣﻘﺪار ﻣﻮﺟﻮد در ﮔﺮوه ﺗﻴﻤﺎر ﺷﺪه ﺑـﺎ ﻏﻠﻈـﺖ دو ﻣﻴﻠـﻲﻣـﻮﻻر اﻓـﺰوده‬

‫ﻧﻈﺮ ﺑﺮاي ﺳﻨﺘﺰ ‪ cDNA‬اﺳﺘﻔﺎده ﮔﺮدﻳﺪ‪ .‬ﺳـﭙﺲ ﺑﻴـﺎن ژن ‪ PPARγ‬ﺗﻮﺳـﻂ‬

‫ﮔﺮدﻳﺪ‪.‬‬

‫روش ‪ Real Time PCR‬ﻣﻮرد ارزﻳـﺎﺑﻲ ﻗﺮار ﮔﺮﻓﺖ؛ و ﻫﻤﺎنﮔﻮﻧﻪ ﻛﻪ در‬

‫ه‪ -‬اﺳﺘﺨﺮاج ‪ RNA‬و ارزﻳﺎﺑﻲ آن از ﻧﻈﺮ ﻛﻴﻔﻴﺖ و ﻛﻤﻴﺖ‪ :‬ﺑﺎ اﺳﺘﻔﺎده‬ ‫از ﻛﻴﺖ ﺧﺮﻳﺪاري ﺷﺪه از ﺷﺮﻛﺖ ﻛﻴﺎژن و ﻃﺒﻖ دﺳﺘﻮراﻟﻌﻤﻞ ﻣﺮﺑﻮﻃـﻪ‪،‬‬ ‫‪ RNA‬ﺳﻠﻮلﻫﺎ اﺳﺘﺨﺮاج ﺷﺪ‪ .‬ﺳﭙﺲ ﻏﻠﻈﺖ ‪ RNA‬از ﻃﺮﻳﻖ ﺟﺬب ﻧﻮري‬ ‫آن در ﻃــﻮل ﻣــﻮج ‪ 540nm‬ﺗﻮﺳــﻂ ﻧــﺎﻧﻮدراپ ﺗﻌﻴــﻴﻦ و ﻛﻴﻔﻴــﺖ‬

‫‪RNA‬‬

‫ﻣﺮﺣﻠﻪ‬

‫ﺑﻪوﺳﻴﻠﻪ ژل آﮔﺎرز ﻣﻮرد ﺗﺎﻳﻴﺪ ﻗﺮار ﮔﺮﻓﺖ‪.‬‬ ‫و‪ -‬ﺳــﻨﺘﺰ ‪ :cDNA‬ﺑــﺎ اﺳــﺘﻔﺎده از ﻛﻴــﺖ ﺷــﺮﻛﺖ ﻛﻴــﺎژن و ﻃﺒــﻖ‬ ‫دﺳــﺘﻮراﻟﻌﻤﻞ ﺷــﺮﻛﺖ ﺳــﺎزﻧﺪه ﻛﻴــﺖ‪ ،‬از روي ‪ RNA‬ﺣﺎﺻــﻠﻪ‬

‫ﺟﺪول‪ :1 -‬ﺑﺮﻧﺎﻣﻪ اﺟﺮاﻳﻲ ‪ Real Time PCR‬ﺑﻪﺻﻮرت دو ﻣﺮﺣﻠﻪاي )‪(two step‬‬

‫‪cDNA‬‬

‫ﺳﺎﺧﺘﻪ ﺷﺪ‪ .‬ﻏﻠﻈﺖ ‪ cDNA‬ﻧﻴـﺰ ﺑﻪﻣﻨﻈﻮر اﻃﻤﻴـﻨﺎن از ﻛﺎﻓﻲ ﺑﻮدن ﻏﻠﻈﺖ‬

‫دﻣﺎ )ﺳﺎﻧﺘﻲﮔﺮاد(‬

‫زﻣﺎن )ﺛﺎﻧﻴﻪ(‬

‫درﻳﺎﻓﺖ ﺳﻴﮕﻨﺎل‬

‫وﻗﻔﻪ اﺑﺘﺪاﻳﻲ‬

‫‪95‬‬

‫‪15‬‬

‫‪-‬‬

‫دور اول‬

‫‪95‬‬

‫‪5‬‬

‫‪-‬‬

‫دور دوم‬

‫‪60‬‬

‫‪45‬‬

‫‪+‬‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):275-81‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﺣﺴﻴﻦ ﻣﻨﺘﺨﺐ ﻳﮕﺎﻧﻪ و ﻫﻤﻜﺎران‬

‫‪278‬‬

‫ﻣﻴﺰان ﺑﻴﺎن ‪PPAR  mRNA‬‬

‫ﻧﻤﻮدار‪ :1 -‬ﻧﺘﺎﻳﺞ آزﻣﻮن ‪ .MTT‬ﻏﻠﻈﺖﻫﺎي ‪ ،1mM‬دو‪ ،‬ﺳﻪ‪ ،‬ﭼﻬﺎر‪ ،‬و ﭘـﻨﺞ اﺳـﻴﺪ اﻻﻳﻴـﺪﻳﻚ‬

‫ﻧﻤﻮدار‪ :2 -‬ﻧﺘﺎﻳﺞ آزﻣﻮن‬

‫ﺑﻪﻣﺪت ‪ 24‬ﺳﺎﻋﺖ ﺑﺮ روي ﺳﻠﻮلﻫﺎي ‪ RAW264.7‬ﺗﻴﻤﺎر ﺷﺪه و درﺻﺪ زﻧﺪه ﻣﺎﻧﺪن ﺳـﻠﻮلﻫـﺎ ﺑـﺎ‬

‫‪.RAW264.7‬‬

‫‪PCR‬‬

‫‪ Real Time‬ﺑﻴﺎن ‪ PPARγ mRNA‬در رده ﺳـﻠﻮﻟﻲ‬

‫آزﻣﻮن ‪ MTT‬ﺑﺮ اﺳﺎس ﻣﻴﺰان ﺟﺬب ﺗﻮﺳﻂ دﺳﺘﮕﺎه ﻧﺎﻧﻮدراپ ﻣﻮرد ارزﻳﺎﺑﻲ ﻗﺮار ﮔﺮﻓﺖ‪.‬‬

‫ﻣﺼﺮف اﺳﻴﺪﻫﺎي ﭼﺮب ﺗﺮاﻧﺲ و ﺑﻴﻤﺎريﻫﺎي ﻗﻠﺒﻲ‪ -‬ﻋﺮوﻗﻲ را اﺛﺒـﺎت‬ ‫ﻧﻤﻮدار‪ 2 -‬ﻣﺸﻬﻮد اﺳﺖ‪ ،‬اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ در ﻏﻠﻈﺖﻫﺎي ‪ ،0/5mM‬ﻳـﻚ‬ ‫و دو‪ ،‬ﻣﻴﺰان ﺑﻴﺎن ‪ PPARγ‬را در ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﮔﺮوه ﻛﻨﺘﺮل‪ ،‬ﺑﻪﺗﺮﺗﻴـﺐ ‪،1/36‬‬

‫ﻣﻄﺎﻟﻌﺎت اﺧﻴـﺮ ﺗﺤﻘﻴﻘـﺎت ﺧـﻮد را ﺑـﻪ روي ﻧﻘـﺶﻫـﺎي ﺗﻨﻈﻴﻤـﻲ‬ ‫اﺳﻴﺪﻫﺎي ﭼﺮب ﺑﻪﻋﻨﻮان ﻟﻴﮕﺎﻧـﺪ‪ ،‬و ﺗﻨﻈـﻴﻢﻛﻨﻨـﺪه ﺑﻴـﺎن ژنﻫـﺎ ﻣﺘﻤﺮﻛـﺰ‬

‫‪ 1/68‬و ‪ 3/24‬ﺑﺮاﺑﺮ ﻛﺎﻫﺶ داده اﺳﺖ )‪.(P<0/05‬‬ ‫‪ RNA‬ﺣﺎﺻﻠﻪ از رده ﺳﻠﻮﻟﻲ ‪ RAW264.7‬ﺗﺤﺖ ﺗﻴﻤﺎر ﺑﺎ ﻏﻠﻈﺖﻫﺎي‬ ‫‪ ،0/5mM‬ﻳﻚ و دو‪ ،‬اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺎ ﺗﻜﻨﻴﻚ‬

‫ﻧﻤﻮدهاﻧﺪ‪.‬‬

‫ﻧﻤﻮدهاﻧﺪ‪ .‬اﻣﺎ ﺑﺤﺚﻫﺎي ﺿﺪ و ﻧﻘﻴﻀﻲ در ﻣﻮرد اﺛﺮات‪ ،‬ﭘﻴﺎﻣﺪ و ﻣﻜﺎﻧﻴﺴﻢ‬ ‫‪7‬‬

‫‪ Real Time‬ﺗﻜﺜﻴـﺮ‬

‫دﻗﻴﻖ ﻣﺘﻌﺎﻗﺐ ﻣﺼﺮف اﺳﻴﺪ ﭼﺮب ﺗﺮاﻧﺲ وﺟﻮد دارد‪ .‬در اﻳـﻦ ﻣﻄﺎﻟﻌـﻪ‬

‫ﮔﺮدﻳﺪ‪ .‬ﻣﻴﺰان ﺑﻴﺎن ‪ PPARγ mRNA‬ﺑﺮاي ﺳﻪ ﻏﻠﻈﺖ ﻣﺬﻛﻮر در ﻣﻘﺎﻳـﺴﻪ‬

‫اﺛﺮ ﻏﻠﻈﺖﻫﺎي ‪ ،0/5mM‬ﻳﻚ و دو اﺳـﻴﺪ اﻻﻳﻴـﺪﻳﻚ ﺑـﺮ روي ﺑﻴـﺎن ژن‬

‫ﺑﺎ ﮔﺮوه ﻛﻨﺘـﺮل‪ ،‬ﺑـﻪﺗﺮﺗﻴـﺐ ‪ 1/68 ،1/36‬و ‪ 3/24‬ﺑﺮاﺑـﺮ ﻛـﺎﻫﺶ ﻳﺎﻓـﺖ‬

‫‪ PPARγ‬ﻣﻮرد ﺑﺮرﺳﻲ ﻗﺮار ﮔﺮﻓﺖ‪ .‬ﻣﺪت زﻣـﺎن ﺗﻴﻤـﺎر ﺳـﻠﻮل ﺑـﺎ اﺳـﻴﺪ‬

‫)‪) (P<0/05‬ﻫﺮ آزﻣﻮن ﺑﺮاي ﻫﺮ ﺳﻪ ﻏﻠﻈﺖ ﺳﻪ ﺑﺎر ﺗﻜﺮار ﮔﺮدﻳﺪ(‪.‬‬

‫اﻻﻳﻴﺪﻳﻚ ﺷﺶ ﺳﺎﻋﺖ در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪ‪ .‬اﺳﻴﺪﻫﺎي ﭼﺮب ﺟﺮﻳﺎن ﺧﻮن‬

‫‪PCR‬‬

‫در ﻏﻠﻈﺖﻫﺎي ﺑﺎﻻ‪ ،‬ﻳﻜﻲ از ﻋﻮاﻣﻞ ﺗﺸﺪﻳﺪﻛﻨﻨﺪه و ﻣﻬﻢ در اﻳﺠـﺎد ﻓـﺸﺎر‬

‫ﺑﺤﺚ‬

‫ﺧﻮن ﺑﺎﻻ )‪ (0/5-1mM‬و اﻓﺰاﻳﺶ ﻟﻴﭙـﻮﭘـﺮوﺗﻴﻴﻦﻫـﺎي ﻣـﻀﺮ ﻣﺜـﻞ‬

‫‪LDL‬‬

‫)‪ (1-2mM‬ﻣﺤﺴﻮب ﻣﻲﺷﻮﻧﺪ‪ .‬ﻟﺬا در ﻃﺮح ﺣﺎﺿﺮ ﻏﻠﻈﺖﻫﺎي ﻣـﺬﻛﻮر‬

‫اﻣﺮوزه ﺑﻴﻤﺎريﻫﺎي ﻗﻠﺒﻲ‪ -‬ﻋﺮوﻗﻲ و در راس آنﻫﺎ آﺗﺮوﺳﻜﻠﺮوز از‬

‫اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺮاي ﺗﻴﻤﺎر ﺑﺮ روي ﺳﻠﻮلﻫﺎ اﻧﺘﺨﺎب ﮔﺮدﻳـﺪ ﺗـﺎ ﺑﺘﻮاﻧـﺪ‬

‫ﻣﻬﻢﺗﺮﻳﻦ ﻋﻠﻞ ﻣﺮگ و ﻣﻴﺮ در دﻧﻴﺎ و ﺑﻪﺧﺼﻮص در ﺟﻮاﻣـﻊ ﭘﻴـﺸﺮﻓﺘﻪ و‬

‫ﻣﻜﺎﻧﻴﺴﻢ اﺣﺘﻤﺎﻟﻲ و ﻧﻘﺶ اﻳﻦ اﻳﺰوﻣﺮي از اﺳـﻴﺪ ﭼـﺮب در ﭘﻴﺎﻣـﺪﻫﺎي‬

‫در ﺣﺎل ﭘﻴﺸﺮﻓﺖ ﺑﻪﺷﻤﺎر ﻣﻲآﻳﺪ‪.‬‬

‫ﻣﻨﺠﺮ ﺑﻪ اﺧﺘﻼﻻت ﻣﺬﻛﻮر را روﺷﻦ ﻧﻤﺎﻳﺪ‪ .‬ﻧﺘﺎﻳﺞ ﺣﺎﺻﻞ از اﻳﻦ ﺑﺮرﺳﻲ‬

‫از ﻣﻬﻢﺗﺮﻳﻦ ﻋﻮاﻣﻞ ﻣﺴﺘﻌﺪﻛﻨﻨﺪه اﻳﻦ ﺑﻴﻤﺎريﻫﺎ ﻣﻲﺗـﻮان ﺑـﻪ ﺳـﺎﺑﻘﻪ‬

‫ﻧﺸﺎن دادﻧﺪ ﻛﻪ اﺳـﻴﺪ اﻻﻳﻴـﺪﻳﻚ در ﻫـﺮ ﺳـﻪ ﻏﻠﻈـﺖ ﻣـﺬﻛﻮر ﺑﻴـﺎن ژن‬

‫ﻓﺎﻣﻴﻠﻲ‪ ،‬ﻧﻮع رژﻳﻢ ﻏﺬاﻳﻲ‪ ،‬ﺟﻨﺴﻴﺖ‪ ،‬ﺳـﻦ‪ ،‬اﺳـﺘﺮس‪ ،‬ﺷـﺮاﻳﻂ روﺣـﻲ و‬

‫‪ PPARγ‬را در ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﮔﺮوه ﻛﻨﺘـﺮل‪ ،‬ﺑـﻪﺗﺮﺗﻴـﺐ ‪ 1/68 ،1/36‬و ‪3/24‬‬

‫رژﻳﻢ ﻏﺬاﻳﻲ اﺷﺎره ﻧﻤﻮد‪ .‬از اﻳﻦ ﻣﻴﺎن رژﻳﻢ ﻏﺬاﻳﻲ ﺑﻪﻋﻨﻮان ﻳـﻚ ﻋﺎﻣـﻞ‬

‫ﺑﺮاﺑﺮ ﻛﺎﻫﺶ ﻣﻲدﻫﺪ )‪.(P<0/05‬‬

‫ﻣﻬــﻢ و از ﻃﺮﻓــﻲ ﻗﺎﺑــﻞ ﻛﻨﺘــﺮل از ﻧﻈــﺮ ﻛﻤــﻲ و ﻛﻴﻔــﻲ ﻋﺎﻣــﻞ ﺑــﺴﻴﺎر‬ ‫ﺗﻌﻴـﻴﻦﻛﻨﻨﺪهاي اﺳﺖ‪ .‬ﻣﻄﺎﻟـﻌﺎت ﮔﺴﺘﺮده اﭘﻴﺪﻣﻴـﻮﻟﻮژﻳـﻜﻲ ارﺗﺒﺎط ﺑﻴـﻦ‬

‫ﻧﺘﺎﻳﺞ اﻳﻦ ﺑﺮرﺳﻲ ﻛﻪ ﺑﻪﺻﻮرت ‪ In vitro‬اﻧﺠﺎم ﺷﺪ‪ ،‬ﻧﺘـﺎﻳﺞ ﻣﻄﺎﻟﻌـﻪ‬ ‫دﻳﮕﺮي ﻛﻪ در آن اﺛﺮ اﺳﻴﺪﻫﺎي ﭼﺮب ﺗﺮاﻧﺲ ﺑﻪ روي ﺑﻴـﺎن ژن‬

‫‪PPARγ‬‬

‫ﺗﻌﻴﻴﻦ اﺛﺮ اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﺮ ﺑﻴﺎن ژن ‪ PPARγ‬در رده ﺳﻠﻮﻟﻲ ﻣﺎﻛﺮوﻓﺎژي ‪RAW 264.7‬‬

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‫‪In‬‬

‫در ﻧﻬﺎﻳﺖ ﺑﻪﻣﻨﻈﻮر ﺟﻤﻊﺑﻨﺪي ﻣﻄﻠﺐ‪ ،‬ﻫﻤﺎنﮔﻮﻧﻪ ﻛﻪ ﭘﻴﺶﺗﺮ ﻣﻄﺮح‬

‫‪ vivo‬ﻛﻪ ﺑﺮ روي ﭼﻨﺪ ﮔﺮوه از ﻣﻮشﻫﺎي ﺻﺤﺮاﻳﻲ ﺻـﻮرت ﭘـﺬﻳﺮﻓﺖ‪،‬‬

‫ﺷﺪ ‪ PPARγ‬ﺑﻴﺎن ژنﻫﺎي ﻣﺨﺘﻠﻔﻲ ﻛﻪ در ﻫﻤﻮﺳﺘﺎز ﻟﻴﭙﻴﺪﻫﺎ ﺑـﻪﺧـﺼﻮص‬

‫ﻧﺸﺎن داده ﺷﺪ ﻛﻪ اﺳﻴﺪ ﭼﺮب ﺗﺮاﻧﺲ ﺑﺎﻋـﺚ ﻛـﺎﻫﺶ ﻣﻌﻨـﻲدار و ﻗﺎﺑـﻞ‬

‫ﻛﻠﺴﺘﺮول ﻧﻘـﺶ دارﻧـﺪ را ﻛﻨﺘـﺮل و ﺗﻨﻈـﻴﻢ ﻣـﻲﻛﻨـﺪ‪ .‬از ﻃـﺮف دﻳﮕـﺮ‬

‫ﺗﻮﺟﻬﻲ )در ﺣﺪود ‪ (%40‬در ﺑﻴﺎن ژن ‪ PPARγ‬ﻣﻲﺷﻮد‪ 8.‬از ﻃﺮف دﻳﮕـﺮ‬

‫اﺳﻴﺪﻫﺎي ﭼﺮب )ﺑﻪﺧﺼﻮص اﺳﻴﺪﻫﺎي ﭼﺮب ﻏﻴﺮاﺷـﺒﺎع ﺗـﺮاﻧﺲ و ﻳـﺎ‬

‫در ﺗﺤﻘﻴﻖ دﻳﮕﺮي ﻛﻪ ﺑﻪ روي ‪ 24‬ﻓﺮد داوﻃﻠﺐ اﻧﺠـﺎم ﮔﺮدﻳـﺪ‪ ،‬ﺑﻌـﺪ از‬

‫ﺳﻴﺲ( ﺑﻪﻋﻨﻮان ﻟﻴﮕﺎﻧﺪي ﺑـﺮاي ‪PPAR‬ﻫـﺎ ﻋﻤـﻞ ﻣـﻲﻛﻨﻨـﺪ؛‪ 15‬در واﻗـﻊ‬

‫ﻳﻚ دوره ﺷﺶ ﻫﻔﺘﻪاي ﺑﺎ ﻳﻚ رژﻳﻢ ﻏﺬاﻳﻲ از اﺳﻴﺪﻫﺎي ﭼﺮب ﺗﺮاﻧﺲ‪،‬‬

‫ﻣﺘﻌﺎﻗﺐ اﺗﺼﺎل ﻟﻴﮕﺎﻧﺪ ﺑﻪ ‪ PPARγ‬ﻛﻤﭙﻠﻜﺴﻲ ﺗـﺸﻜﻴﻞ ﻣـﻲﮔـﺮدد ﻛـﻪ ﺑـﺎ‬

‫ﻧﺘﺎﻳﺠﻲ ﻣﺘﻨﺎﻗﺾ ﺑﺎ ﻧﺘﺎﻳﺞ اﻳﻦ ﻣﻘﺎﻟﻪ ﺑﻪدﺳﺖ آﻣﺪ‪ ،‬ﭼﺮا ﻛﻪ ﻣﺸﺨﺺ ﺷـﺪ‪،‬‬

‫‪16‬‬

‫اﺗﺼﺎل ﺑﻪ ﭘﺮوﻣﻮﺗﻮر ژنﻫﺎي ﻫﺪف ﻣﻮﺟﺐ ﻓﻌﺎل ﺷﺪن آنﻫﺎ ﻣﻲﺷـﻮد‪.‬‬

‫اﺳﻴﺪﻫﺎي ﭼﺮب ﺗﺮاﻧﺲ ﺑﺎﻋـﺚ اﻓـﺰاﻳﺶ ﺑﻴـﺎن ‪ PPARγ‬ﻣـﻲﺷـﻮد‪ .‬ﻧﻜﺘـﻪ‬

‫ﭼﺮﺑﻲﻫﺎي ﺟﺎﻣﺪ ﻋﻼوه ﺑﺮ اﺳﻴﺪﻫﺎي ﭼﺮب اﺷﺒﺎع ﺣﺎوي ﻣﻘﺎدﻳﺮ ﺑـﺎﻻﻳﻲ‬

‫ﺟﺎﻟﺐ در اﻳﻦ ﻣﻄﺎﻟﻌﻪ اﻳﻦ ﺑﻮد ﻛﻪ ﻣﻴﺰان اﻓﺰاﻳﺶ ﺑﻴﺎن ‪ PPARγ‬در ﻣـﺮدان‬

‫اﺳﻴﺪﻫﺎي ﭼﺮب ﺗﺮاﻧﺲ ﺑﻮده‪ ،‬و اﻳﻦ ﻣﺎده ﻏﺬاﻳﻲ ﺑﺨﺶ ﻗﺎﺑﻞ ﺗـﻮﺟﻬﻲ از‬

‫ﻣﻮرد ﺑﺮرﺳﻲ ﻗﺮار ﮔﺮﻓﺘﻪ را ﺗﺎﻳﻴﺪ ﻣﻲﻛﻨﺪ؛ ﺑﻪﻃﻮري ﻛﻪ در اﻳﻦ ﻣﻄﺎﻟﻌﻪ‬

‫‪9‬‬

‫ﻧﺴﺒﺖ ﺑﻪ زﻧﺎن ﺑﻪﻃﻮر ﻣﻌﻨﻲداري ﺑﻴﺶﺗﺮ اﺳﺖ‪.‬‬

‫رژﻳﻢ ﻏﺬاﻳﻲ ﺑﻪﺧﺼﻮص در ﻛﺸﻮرﻫﺎي ﺻﻨﻌﺘﻲ را ﺷـﺎﻣﻞ ﻣـﻲﺷـﻮﻧﺪ‪ .‬از‬

‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ اﻳﻦ دﺳﺖآوردﻫﺎ‪ ،‬از ﻃﺮﻓﻲ ﻣﻲﺗﻮان ﺗﻔﺎوتﻫﺎي ﻣﺮﺑـﻮط‬

‫ﻃﺮف دﻳﮕﺮ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﭘﻴﺸﺮوي ﺑـﻪﺳـﻤﺖ ﺻـﻨﻌﺘﻲﺗـﺮ ﺷـﺪن زﻧـﺪﮔﻲ‪،‬‬

‫ﺑﻪ ﺑﻴﺎن ‪ PPARγ‬را ﺑﻪ ﻧﻮع اﺳﻴﺪﻫﺎي ﭼﺮب رژﻳﻢ ﻏﺬاﻳﻲ ﻧـﺴﺒﺖ داد و از‬

‫اﻓﺰاﻳﺶ روز اﻓﺰوﻧﻲ در ﻣﺼﺮف ﻏﺬاﻫﺎي آﻣﺎده )ﺑﻪﻋﻨﻮان ﻣﻨﺒﻊ ﺳﺮﺷـﺎري‬

‫ﻃﺮﻓﻲ ﻣﻲﺗﻮان ﺗﻔﺎوتﻫﺎي ﺟﻨﺴﻴﺘﻲ ﻣﺜـﻞ ﺷـﺮاﻳﻂ ﻫﻮرﻣـﻮﻧﻲ را دﺧﻴـﻞ‬

‫از اﺳــﻴﺪﻫﺎي ﭼــﺮب ﺗــﺮاﻧﺲ( ﻣﻮاﺟــﻪ ﻫــﺴﺘﻴﻢ‪ .‬ﻟــﺬا ﺑﺮرﺳــﻲ ﺗــﺎﺛﻴﺮات‬

‫داﻧﺴﺖ‪ .‬اﻟﺒﺘﻪ در ﺑﺮﺧـﻲ ﺑﺮرﺳـﻲﻫـﺎ‪ ،‬ﺗﻔـﺎوتﻫـﺎي ﻣﻼﺣﻈـﻪ ﺷـﺪه ﺑـﻪ‬

‫اﺳﻴﺪﻫﺎي ﭼﺮب ﺗﺮاﻧﺲ و روﺷﻦ ﺷﺪن ﻣﻜﺎﻧﻴﺴﻢ و اﻋﻤـﺎل ﻣﺘﻔـﺎوت آن‬

‫ﭘﻠﻲﻣﻮرﻓﻴﺴﻢ ژن ‪ PPARγ‬ﻧﻴﺰ ﻧﺴﺒﺖ داده ﺷـﺪه اﺳـﺖ‪ 10.‬در ﻣﺠﻤـﻮع از‬

‫ﻣﻲﺗﻮاﻧﺪ ﻛﻤﻚ ﻣﻮﺛﺮي در ﺟﻬﺖ ﻛﺎﻫﺶ ﺑﺮوز ﺳﻜﺘﻪﻫﺎي ﻗﻠﺒﻲ و ﻋﺮوﻗﻲ‬

‫آﻧﺠﺎﻳﻲ ﻛﻪ ﺗﺎﻛﻨﻮن در ﻫﻴﭻ ﻣﻄﺎﻟﻌﻪي ﻣﻨﺘﺸﺮ ﺷﺪهاي‪ ،‬ﺑﺮرﺳـﻲ اﺛـﺮ اﺳـﻴﺪ‬

‫و ﻣﺮگﻫﺎي ﻧﺎﮔﻬﺎﻧﻲ اراﻳﻪ ﻧﻤﺎﻳﺪ‪.‬‬

‫اﻻﻳﻴﺪﻳﻚ ﺑﺮ روي ﺑﻴﺎن ژن ‪ PPARγ‬ﺑـﻪﺻـﻮرت ‪ In vivo‬اﻧﺠـﺎم ﻧﮕﺮﻓﺘـﻪ‬

‫ﻧﺘﺎﻳﺞ اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺗﺎﻳﻴﺪ دﻳﮕﺮي ﺑﺮ اﻳﻦ اﻣﺮ اﺳﺖ ﻛﻪ‪ ،‬ﻣﺼﺮف ﻛﻢﺗـﺮ‬

‫اﺳﺖ‪ ،‬اﻧﺠﺎم ﻣﻄﺎﻟﻌﻪاي در اﻳﻦ زﻣﻴﻨﻪ ﺿﺮوري و ﺣـﺎﻳﺰ اﻫﻤﻴـﺖ ﺑـﻪﻧﻈـﺮ‬

‫و ﻳﺎ ﺑﻴﺶﺗﺮ ﻳﻚ ﻣﺎده ﻏﺬاﻳﻲ ﻣﻤﻜﻦ اﺳـﺖ ﺑـﺮ ﻣﻘـﺪار اﻧـﺮژي ﻣـﺼﺮﻓﻲ‬

‫ﻣﻲرﺳﺪ‪ .‬اﮔﺮ ﭼﻪ در ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ اﺳﻴﺪ اﻻﻳﻴـﺪﻳﻚ ﺑﻴـﺎن ژن ‪ PPARγ‬را‬

‫ﺗﺎﺛﻴﺮﮔﺬار ﺑﺎﺷﺪ‪ ،‬اﻣﺎ ﻧﻮع و در واﻗﻊ ﻛﻴﻔﻴـﺖ ﻣـﻮاد ﻏـﺬاﻳﻲ ﻧﻘـﺶ ﺑـﺴﻴﺎر‬

‫ﻛﺎﻫﺶ داد وﻟﻲ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻣﻐﺎﻳﺮتﻫﺎي دﻳﺪه ﺷﺪه ﺑـﺎ دﻳﮕـﺮ ﻣﻄﺎﻟﻌـﺎت‬

‫‪17‬‬

‫ﺗﻌﻴﻴﻦﻛﻨﻨﺪهﺗﺮي ﺑﺮ روي ﭘﻴﺎﻣﺪﻫﺎي ﻣﺘﻌﺎﻗﺐ ﻣﺼﺮف ﻣﻮاد ﻏـﺬاﻳﻲ دارد‪.‬‬

‫ﺑﻪﻧﻈﺮ ﻣﻲرﺳﺪ ﻧﻪ ﺗﻨﻬﺎ اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﺑﻠﻜﻪ ﻋﻮاﻣﻞ دﻳﮕـﺮي در ﺑﻴـﺎن ژن‬

‫ﻫﻢﭼﻨﻴﻦ ﺑﺮاي دﺳﺖﻳﺎﺑﻲ ﺑـﻪ اﻳـﻦ ﻫـﺪف‪ ،‬ﭘﻴـﺸﻨﻬﺎد ﻣـﻲﮔـﺮدد ﻛـﻪ در‬

‫‪ PPARγ‬ﻧﻘﺶ ﺗﻌﻴﻴﻦﻛﻨﻨﺪه داﺷﺘﻪ ﺑﺎﺷﻨﺪ‪.‬‬

‫ﻣﻄﺎﻟﻌﺎت آﻳﻨﺪه‪ ،‬ﺑﺮرﺳـﻲ اﺛـﺮ اﺳـﻴﺪﻫﺎي ﭼـﺮب ﺗـﺮاﻧﺲ ﺑـﻪ روي ﺑﻴـﺎن‬

‫از ﻃﺮف دﻳﮕﺮ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ اﻳﻦ ﻳﺎﻓﺘﻪﻫﺎ و ﻫﻢﭼﻨﻴﻦ ﻣﻄﺎﻟﻌـﺎت ﺑـﺴﻴﺎر‬

‫ژنﻫﺎي ﻫﺪف ‪ PPARγ‬ﺑﻪﺧﺼﻮص‬

‫‪CETP‬‬

‫‪ ABCA1, ABCG1, apoAI,‬و‬

‫ﮔﺴﺘﺮده دﻳﮕﺮي ﻛﻪ در اﻳﻦ زﻣﻴﻨﻪ اﻧﺠﺎم ﺷﺪه اﺳﺖ‪ ،‬ﻣـﻲﺗـﻮان اﺳـﺘﺪﻻل‬

‫)‪ Lipoprotein Lipase (LPL‬و ﻫﻢﭼﻨـﻴﻦ ﮔﻴﺮﻧـﺪهﻫـﺎي ﻫـﺴﺘﻪاي دﻳﮕـﺮ‬

‫ﻧﻤﻮد ﻛﻪ اﺳﻴﺪ اﻻﻳﻴﺪﻳﻚ ﻋﻼوه ﺑـﺮ ﻛـﺎﻫﺶ ﺑﻴـﺎن ژن ‪ PPARγ‬از ﻃﺮﻳـﻖ‬

‫ﻣـﺮﺗﺒﻂ ﻣﺜـﻞ )‪Liver X Receptor (LXR‬ﻫـﺎ و‬

‫‪Farnesoid X Receptor‬‬

‫دﺧﺎﻟﺖ در ﻣﺴﻴﺮﻫﺎي دﻳﮕﺮ ﻧﻴﺰ ﺑﺎ ﺗﻐﻴﻴﺮ در ﭘﺮوﻓﺎﻳـﻞ ﻟﻴﭙﻴـﺪي ﻣﻨﺠـﺮ ﺑـﻪ‬

‫)‪(FXR‬ﻫﺎ ﻛﻪ از ﺟﻤﻠﻪ ﻣﻬﻢﺗﺮﻳﻦ ﭘﺮوﺗﻴﻴﻦﻫﺎ و ﻋﻮاﻣﻞ ﺷﻨﺎﺧﺘﻪ ﺷﺪه دﺧﻴﻞ‬

‫اﻳﺠــﺎد اﺧــﺘﻼل در ﻣﺘﺎﺑﻮﻟﻴــﺴﻢ ﻟﻴﭙﻴــﺪﻫﺎ و ﻣﺘﻌﺎﻗﺒــﺎً ﺑــﺮوز و ﭘﻴــﺸﺮﻓﺖ‬

‫در ﻫﻤﻮﺳﺘﺎز ﻟﻴﭙﻴﺪﻫﺎ ﻫﺴﺘﻨﺪ اﻧﺠﺎم ﭘﺬﻳﺮد‪ 18،‬ﭼﺮا ﻛﻪ اﺧﺘﻼل در ﺑﻴﺎن و ﻳﺎ‬

‫ﺑﻴﻤﺎريﻫﺎﻳﻲ ﻣﺜﻞ آﺗﺮوﺳﻜﻠﺮوز ﻣﻲﺷﻮد‪ .‬ﺑﻪﻃﻮر ﻣﺜﺎل در ﻣﻮارد ﺑـﺴﻴﺎري‬

‫ﻓﻌﺎﻟﻴﺖ ﻫـﺮ ﻛـﺪام از اﻳـﻦ ﭘـﺮوﺗﻴﻴﻦﻫـﺎ ﻣـﻲﺗﻮاﻧـﺪ ﺗـﺴﺮﻳﻊ و ﻳـﺎ ﺑـﺮوز‬

‫ﭘﻴﺎﻣﺪﻫﺎي اﺳﻴﺪﻫﺎي ﭼﺮب ﺗﺮاﻧﺲ را ﺑﻪ اﻓﺰاﻳﺶ ﺑﻴﺎن ﻓﺎﻛﺘﻮرﻫﺎي اﻟﺘﻬﺎﺑﻲ‬

‫آﺗﺮوﺳﻜﻠﺮوز را ﻣﻮﺟﺐ ﺷﻮد‪.‬‬

‫ﻣﺜﻞ ‪ TNFα ،CRP‬و ‪ IL6‬ﻣﺮﺗﺒﻂ ﻧﻤـﻮدهاﻧـﺪ‪12.‬و‪ 11‬در ﻣﻄﺎﻟﻌـﺎت دﻳﮕـﺮي‬

‫ﺳﭙﺎﺳﮕﺰاري‪ :‬اﻳﻦ ﻣﻘﺎﻟﻪ ﺑﺨﺸﻲ از ﭘﺎﻳﺎنﻧﺎﻣﻪ ﺗﺤﺖ ﻋﻨـﻮان "ﺑﺮرﺳـﻲ‬

‫ﻋﻨﻮان ﺷﺪه اﺳﺖ ﻛﻪ اﺳﻴﺪﻫﺎي ﭼﺮب ﺗﺮاﻧﺲ ﻣﻲﺗﻮاﻧﺪ ﺑﺎ ﺟﺎيﮔﻴـﺮي در‬

‫اﺛــﺮ اﺳــﻴﺪ اﻻﻳﻴــﺪﻳﻚ ﺑــﺮ ﺑﻴــﺎن ژن ‪ ABCA1‬و ‪ PPARγ‬در رده ﺳــﻠﻮﻟﻲ‬

‫ﺳﺎﺧﺘﻤﺎن ﻏﺸﺎﻫﺎي ﺳﻠﻮلﻫﺎي ﻣﺎﻛﺮوﻓﺎژي‪ ،‬اﻧﺪوﺗﻠﻴﻮم و ﭼﺮﺑﻲ ﻣﺴﻴﺮﻫﺎي‬

‫ﻣﺎﻛﺮوﻓﺎژي‬

‫‪ "RAW‬در ﻣﻘﻄﻊ ﻛﺎرﺷﻨﺎﺳﻲ ارﺷﺪ در ﺳـﺎل ‪ 1389‬و‬

‫ﭘﻴﺎمرﺳﺎﻧﻲ واﺑﺴﺘﻪ ﺑﻪ ﻏﺸﺎ را ﻣﺨﺘﻞ ﻧﻤﻮده و ﭘﻴﺎﻣﺪﻫﺎي ﻗﻠﺒﻲ‪ -‬ﻋﺮوﻗـﻲ و‬

‫ﻛﺪ ‪ 142‬ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑـﺎ ﺣﻤﺎﻳـﺖ داﻧـﺸﮕﺎه ﻋﻠـﻮم ﭘﺰﺷـﻜﻲ و ﺧـﺪﻣﺎت‬

‫‪14‬و‪13‬‬

‫اﻟﺘﻬﺎﺑﻲ را ﻣﻮﺟﺐ ﺷﻮد‪.‬‬

‫‪264.7‬‬

‫ﺑﻬﺪاﺷﺘﻲ درﻣﺎﻧﻲ ﺗﻬﺮان اﺟﺮا ﺷﺪه اﺳﺖ‪.‬‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):275-81‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻳﮕﺎﻧﻪ و ﻫﻤﻜﺎران‬ ‫ﻣﻨﺘﺨﺐ‬ Montakhab Yegane H.‫ﺣﺴﻴﻦ‬ et al.

280

References 1. Murphy MG. Dietary fatty acids and membrane protein function. J Nutr Biochem 1990;1(2):68-79. 2. Takano H, Komuro I. Peroxisome proliferator-activated receptor gamma and cardiovascular diseases. Circ J 2009;73(2):214-20. 3. Krey G, Braissant O, L'Horset F, Kalkhoven E, Perroud M, Parker MG, et al. Fatty acids, eicosanoids, and hypolipidemic agents identified as ligands of peroxisome proliferator-activated receptors by coactivator-dependent receptor ligand assay. Mol Endocrinol 1997;11(6):779-91. 4. Deckelbaum RJ, Worgall TS, Seo T. n-3 fatty acids and gene expression. Am J Clin Nutr 2006;83(6 Suppl):1520S-1525S. 5. Lacroix E, Charest A, Cyr A, Baril-Gravel L, Lebeuf Y, Paquin P, et al. Randomized controlled study of the effect of a butter naturally enriched in trans fatty acids on blood lipids in healthy women. Am J Clin Nutr 2012;95(2):318-25. 6. Mozaffarian D, Katan MB, Ascherio A, Stampfer MJ, Willett WC. Trans fatty acids and cardiovascular disease. N Engl J Med 2006;354(15):1601-13. 7. Attia-Skhiri N, Fournier N, Pourci ML, Paul JL. Trans fatty acids: effects on lipoprotein metabolism and cardiovascular risk. Ann Biol Clin (Paris) 2009;67(5):517-23. 8. Saravanan N, Haseeb A, Ehtesham NZ, Ghafoorunissa. Differential effects of dietary saturated and trans-fatty acids on expression of genes associated with insulin sensitivity in rat adipose tissue. Eur J Endocrinol 2005;153(1):159-65. 9. Kuhnt K, Flotho S, Benjamin S, Boerchers T, Schubert R, Jahreis G, Spener F. Gene expression after dietary intervention with trans fatty acids (trans-11/trans-12 18:1) in humans. Eur J Lipid Sci Technol 2009;111(5):442-50. 10. Paradis AM, Fontaine-Bisson B, Bossé Y, Robitaille J, Lemieux S, Jacques H, et al. The peroxisome proliferator-activated

receptor alpha Leu162Val polymorphism influences the metabolic response to a dietary intervention altering fatty acid proportions in healthy men. Am J Clin Nutr 2005;81(2):523-30. 11. Han SN, Leka LS, Lichtenstein AH, Ausman LM, Schaefer EJ, Meydani SN. Effect of hydrogenated and saturated, relative to polyunsaturated, fat on immune and inflammatory responses of adults with moderate hypercholesterolemia. J Lipid Res 2002;43(3):445-52. 12. Baer DJ, Judd JT, Clevidence BA, Tracy RP. Dietary fatty acids affect plasma markers of inflammation in healthy men fed controlled diets: a randomized crossover study. Am J Clin Nutr 2004;79(6):96973. 13. Ruth MR, Wang Y, Yu HM, Goruk S, Reaney MJ, Proctor SD, et al. Vaccenic and elaidic acid modify plasma and splenocyte membrane and mitogen-stimulated cytokine production in obese insulin resistant JCR: LA-cp rats. Nutrients 2010;2:181-97. 14. Mozaffarian D. Trans fatty acids-effects on systemic inflammation and endothelial function. Atheroscler Suppl 2006;7(2):29-32. 15. Keller H, Dreyer C, Medin J, Mahfoudi A, Ozato K, Wahli W. Fatty acids and retinoids control lipid metabolism through activation of peroxisome proliferator-activated receptor-retinoid X receptor heterodimers. Proc Natl Acad Sci U S A 1993;90(6):2160-4. 16. Sampath H, Ntambi JM. Polyunsaturated fatty acid regulation of genes of lipid metabolism. Annu Rev Nutr 2005;25:317-40. 17. Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med 2011;364(25):2392-404. 18. Li AC, Glass CK. PPAR- and LXR-dependent pathways controlling lipid metabolism and the development of atherosclerosis. J Lipid Res 2004;45(12):2161-73.

281 ‫ ﺗﺎ‬275 ،5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

281

‫ﻛﺎراﻳﻲ دو روش ﭘﺎﻳﺶ ﺑﺮاي ﺗﺸﺨﻴﺺ ﻋﻔﻮﻧﺖ ﻣﺤﻞ ﺟﺮاﺣﻲ در ﺑﺨﺸﻬﺎي ﺟﺮاﺣﻲ ﻋﻤﻮﻣﻲ‬

Tehran University Medical Journal, August 2012; Vol. 70, No. 5: 275-281

Original Article

Determining effects of elaidic acid on PPAR- gamma expression in RAW 264.7 macrophage cell line Abstract Hossein Montakhab Yegane M.Sc. Hossein Babaahmadi Rezaiy Ph.D. Mahmood Doosti Ph.D.* Department of Biochemistry, School of Medicine Tehran University of Medical Sciences, Tehran, Iran.

Received: January 03, 2012

Accepted: June 06, 2012

Background: Several dietary factors are involved in cardiovascular coronary heart diseases, including trans fatty acids, which are generally formed during hydrogenation of vegetable oils, a process that causes conversion of liquid oils into semisolid fats. Nowadays, it is well-known that trans fatty acids form a major risk factor in the occurrence and progression of atherosclerosis. On the other hand, it has been identified that some nuclear receptors, such as PPARs, are involved and play important roles in lipid homeostasis and pathogenesis of cardiovascular diseases. Therefore, we studied the effect of elaidic acid on gene expression of peroxisome proliferator activated receptor gamma (PPARγ). Methods: Murine macrophage RAW264.7 cells were treated by 0.5, 1, and 2 mM concentrations of elaidic acid for 6 h. The control group was treated by 50% ethanol (as solvent), equivalent to the amount of ethanol used in 2 mM concentration of elaidic acid. Later, the total RNA was extracted and its cDNA was synthesized. Finally, the quantity of PPARγ gene expression was measured by real-time PCR. Results: Overall, 0.5, 1, and 2 mM concentrations of elaidic acid decreased PPARγ gene expression in RAW264.7 macrophage cell line by -1.36, -1.68, and -3.24 folds compared with the control group, respectively. Conclusion: By decreasing the expression of nuclear receptor PPARγ, elaidic acid causes, intensifies or accelerates the occurrence of cardiovascular diseases, especially atherosclerosis. This finding shows the importance of reducing the consumption of

Corresponding author: Dept. of Clinical Biochemistry, Keshavarz Blvd., Ghods St., Poorsina St., Tehran University of Medical Sciences, School of Medicine, Tehran, Iran. Tel: +98-21-64053265 E-mail: doostimd@Sina.tums.ac.ir

elaidic acid containing foods. Keywords: atherosclerosis, cell culture, elaidic acid, gene expression, trans fatty acids, PPARγ.

Tehran Univ Med J (TUMJ) 2012 August;70(5):275-81

http://tumj.tums.ac.ir

‫ﻋﻠﻴﺮﺿﺎ اﻛﺒﺮزاده ﺑﺎﻏﺒﺎن و ﻫﻤﻜﺎران‬

‫‪282‬‬

‫ﻣﻘﺎﻟﻪ اﺻﻴﻞ‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ ،5‬ﺻﻔﺤﻪﻫﺎي ‪ 282‬ﺗﺎ ‪288‬‬

‫ﺗﺎﺛﻴﺮ وزن ﻧﻮزاد و دﻣﺎي ﻣﺤﻴﻂ ﺑﺮ ﻣﻴﺰان اﻧﺘﻘﺎل ﺑﻴﻦ وﺿﻌﻴﺖﻫﺎي ﻫﻴﭙﻮﺗﺮﻣﻲ در ﻧﻮزادان ﺑﺴﺘﺮي در ‪،NICU‬‬ ‫ﺑﺎ اﺳﺘﻔﺎده از ﻣﺪل ﻣﺎرﻛﻮف‬

‫ﻋﻠﻴﺮﺿﺎ اﻛﺒﺮزاده ﺑﺎﻏﺒﺎن‬

‫‪*1‬‬

‫‪2‬‬

‫ﺳﺎرا ﺟﺎم ﺑﺮﺳﻨﮓ‬

‫ﭼﻜﻴﺪه‬

‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ﻣﻘﺎﻟﻪ‪1390/12/23 :‬‬

‫ﺗﺎرﻳﺦ ﭘﺬﻳﺮش‪1391/03/06 :‬‬

‫زﻣﻴﻨﻪ و ﻫﺪف‪ :‬ﻫﻴﭙﻮﺗﺮﻣﻲ ﻳﻜﻲ از ﻋﻮاﻣﻞ ﻣﻬﻢ در ﺑﻘﺎي ﻧﻮزادان‪ ،‬ﺑﻪﺧﺼﻮص در ﻣﻴﺎن ﻧﻮزادان ﻛﻢ وزن اﺳﺖ‪ .‬ﻣﺎﻧﺪﮔﺎري‬

‫‪3‬‬

‫ﺣﻤﻴﺪ ﭘﺰﺷﻚ‬

‫ﻃﻮﻻﻧﻲﻣﺪت در وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﻣﻨﺠﺮ ﺑﻪ ورم‪ ،‬ﺧﻮنرﻳﺰي‪ ،‬ﻳﺮﻗﺎن و ﻣﺮگ ﻣﻲﺷﻮد‪ .‬از اﻳﻦ ﺟﻬﺖ ﭘﮋوﻫﺶ ﺣﺎﺿﺮ‬

‫ﻓﺎﻃﻤﻪ ﻧﻴﺮي‬

‫ﺗﻼﺷﻲ در ﺟﻬﺖ ﺑﺮرﺳﻲ ﻋﻮاﻣﻞ ﻣﻮﺛﺮ ﺑﺮ ﮔﺬار از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ در ﻧﻮزادان اﺳﺖ‪.‬‬

‫‪4‬‬

‫‪ -1‬ﮔﺮوه ﻋﻠﻮم ﭘﺎﻳﻪ‪ ،‬داﻧﺸﻜﺪه ﻋﻠﻮم ﺗﻮانﺑﺨﺸﻲ‪،‬‬ ‫ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﻓﻴﺰﻳﻮﺗﺮاﭘﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم‬ ‫ﭘﺰﺷﻜﻲ ﺷﻬﻴﺪ ﺑﻬﺸﺘﻲ‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬ ‫‪ -2‬ﮔﺮوه آﻣﺎر زﻳﺴﺘﻲ‪ ،‬داﻧﺸﺠﻮي دﻛﺘﺮي‪،‬‬ ‫داﻧﺸﻜﺪه ﭘﻴﺮاﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ‬ ‫ﺷﻬﻴﺪ ﺑﻬﺸﺘﻲ‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬ ‫‪ -3‬ﮔﺮوه آﻣﺎر‪ ،‬داﻧﺸﻜﺪه رﻳﺎﺿﻲ‪ ،‬آﻣﺎر و ﻋﻠﻮم‬ ‫ﻛﺎﻣﭙﻴﻮﺗﺮ‪ ،‬ﭘﺮدﻳﺲ ﻋﻠﻮم‪ ،‬داﻧﺸﮕﺎه ﺗﻬﺮان‪ ،‬ﺗﻬﺮان‪،‬‬ ‫اﻳﺮان‪.‬‬ ‫‪ -4‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﻣﺎدر‪ ،‬ﺟﻨﻴﻦ و ﻧﻮزاد‪ ،‬داﻧﺸﮕﺎه‬ ‫ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬

‫روش ﺑﺮرﺳﻲ‪ :‬ﻧﻤﻮﻧﻪي ﺑﻪﻛﺎر ﮔﺮﻓﺘﻪ ﺷﺪه در اﻳﻦ ﭘﮋوﻫﺶ ﺷﺎﻣﻞ ‪ 439‬ﻧﻮزاد ﺑﺴﺘﺮي در ﺑﺨﺶ‬

‫‪NICU‬‬

‫در ﺑﻴﻤﺎرﺳﺘﺎن اﻣﺎم‬

‫ﺧﻤﻴﻨﻲ )ره( ﺷﻬﺮ ﺗﻬﺮان ﺑﻮد‪ .‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ‪ ،‬درﺟﻪ ﺣﺮارت رﻛﺘﺎل ﻧﻮزادان در ﺑﺪو ﺗﻮﻟﺪ و ﺳﭙﺲ در اداﻣﻪ ﺑﻪ ﻓﺎﺻﻠﻪﻫﺎي‬ ‫‪ 30‬دﻗﻴﻘﻪاي‪ ،‬ﺗﺎ رﺳﻴﺪن ﺑﻪ دﻣﺎي ﻧﺮﻣﺎل اﻧﺪازهﮔﻴﺮي ﺷﺪ‪ .‬در ﺗﺤﻠﻴﻞ دادهﻫﺎ و ﺑﺮآورد ﻧﺮخ اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ از‬ ‫ﻣﺪل ﭼﻨﺪ وﺿﻌﻴﺘﻲ ﻣﺎرﻛﻮف )‪ (Markov models‬ﺑﺎ دو ﻣﺘﻐﻴﺮ ﻫﻤﺮاه وزن و دﻣﺎي ﻣﺤﻴﻂ ﺗﻮﻟﺪ اﺳﺘﻔﺎده و ﻧﺮماﻓﺰار ‪ R‬ﺑﺮاي‬ ‫ﺑﺮازش ﺑﻪﻛﺎر ﮔﺮﻓﺘﻪ ﺷﺪ‪.‬‬ ‫ﻳﺎﻓﺘﻪﻫﺎ‪ :‬ﻧﺮخ اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺷﺪﻳﺪ ﺑﻪ وﺿﻌﻴﺖ ﺧﻔﻴﻒ آن ‪ 0/1192‬در دﻗﻴﻘﻪ و ﺑﺮاي اﻧﺘﻘﺎل از وﺿﻌﻴﺖ‬ ‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺑﻪ وﺿﻌﻴﺖ ﻧﺮﻣﺎل‪ 0/0549 ،‬در دﻗﻴﻘﻪ ﺑﺮآورد ﺷﺪ‪ .‬ﻣﺘﻐﻴﺮ وزن اﺛﺮ ﻣﻌﻨﻲداري ﺑﺮ اﻧﺘﻘﺎل از وﺿﻌﻴﺖ‬ ‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﺑﻪ ﺣﺎﻟﺖ ﻧﺮﻣﺎل داﺷﺖ‪ ،‬ﻓﺎﺻﻠﻪ اﻃﻤﻴﻨﺎن ‪0/4165) %95‬و ‪ .(P<0/001) ،(0/1364‬دﻣﺎي ﻣﺤﻴﻂ ﺗﻮﻟﺪ ﻧﻴﺰ اﺛﺮ‬ ‫ﻣﻌﻨﻲداري ﺑﺮ ﺗﻐﻴﻴﺮ وﺿﻌﻴﺖ ﻧﻮزاد از ﺣﺎﻟﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺑﻪ وﺿﻌﻴﺖ ﻧﺮﻣﺎل داﺷﺖ‪ ،‬ﻓﺎﺻﻠﻪ اﻃﻤﻴﻨﺎن ‪ %95‬ﺑﺮاي ﭘﺎراﻣﺘﺮ اﺛﺮ‬ ‫دﻣﺎي ﻣﺤﻴﻂ ﺑﺮ ﻧﺮخ اﻧﺘﻘﺎل )‪ 0/4963‬و ‪ (0/0439‬و )‪ (P<0/001‬ﺑﺮآورد ﺷﺪ‪.‬‬ ‫ﻧﺘﻴﺠﻪﮔﻴﺮي‪ :‬ﻣﻄﺎﻟﻌﻪ ﻧﺸﺎن داد‪ ،‬ﻧﻮزادان ﺑﺎ وزن ﻧﺮﻣﺎل و ﻣﺘﻮﻟﺪ ﺷﺪه در دﻣﺎي ﺑﺎﻻي ‪ 28 C‬ﺳﺮﻳﻊﺗﺮ از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ‬

‫*‬

‫ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪ :‬ﺗﻬﺮان‪ ،‬ﻣﻴﺪان اﻣﺎم ﺣﺴﻴﻦ )ع(‪ ،‬اﺑﺘﺪاي‬

‫ﺧﻴﺎﺑﺎن دﻣﺎوﻧﺪ‪ ،‬روﺑﺮوي ﺑﻴﻤﺎرﺳﺘﺎن ﺑﻮﻋﻠﻲ‪ ،‬داﻧﺸﻜﺪه‬ ‫ﻋﻠﻮم ﺗﻮانﺑﺨﺸﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺷﻬﻴﺪ ﺑﻬﺸﺘﻲ‬

‫ﻣﻨﺘﻘﻞ ﻣﻲﺷﻮﻧﺪ‪ .‬ﭼﻮن وزن ﻧﻮزاد در زﻣﺎن ﺗﻮﻟﺪ در اﺧﺘﻴﺎر ﻛﺎدر ﭘﺰﺷﻜﻲ ﻧﻴﺴﺖ‪ ،‬ﻛﻨﺘﺮل دﻣﺎي ﻣﺤﻴﻂ ﺗﻮﻟﺪ ﻣﻲﺗﻮاﻧﺪ ﺑﻬﺒﻮدي‬ ‫را ﺗﺴﺮﻳﻊ ﻛﻨﺪ‪.‬‬

‫ﺗﻠﻔﻦ‪021-77561722 :‬‬ ‫‪E-mail: akbarzad@sbmu.ac.ir‬‬

‫ﻛﻠﻤﺎت ﻛﻠﻴﺪي‪ :‬ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي‪ ،‬وزن ﻧﻮزاد‪ ،‬دﻣﺎي ﻣﺤﻴﻂ ﺗﻮﻟﺪ‪ ،‬ﻣﺪل ﭼﻨﺪ وﺿﻌﻴﺘﻲ ﻣﺎرﻛﻮف‪ ،‬ﻧﺮخ اﻧﺘﻘﺎل‪.‬‬

‫ﻣﻘﺪﻣﻪ‬

‫ﺧﺸﻚ ﻣﻮاﺟﻪ ﻣﻲﺷﻮد و ﺑﺎ اﻓﺰاﻳﺶ ﺗﻮﻟﻴﺪ ﺣﺮارت و ﺗﻼش ﺑﺮاي ﺣﻔﻆ‬ ‫ﺣﺮارت ﻣﻮﺟﻮد ﺑﻪوﺳﻴﻠﻪ اﻧﻘﺒﺎض ﻋﺮوق ﺟﻠﺪي ﺑﻪ اﻳﻦ ﻣﺴﺎﻟﻪ ﭘﺎﺳﺦ‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي )‪ (Neonatal hypothermia‬را ﻣﻲﺗﻮان ﺑﻪﻋﻨﻮان‬

‫ﻣﻲدﻫﺪ‪ .‬ﭘﺎﺳﺦدﻫﻲ در ﻟﺤﻈﻪاي از زﻣﺎن ﺻﻮرت ﻣﻲﮔﻴﺮد و ﻣﻲﺗﻮاﻧﺪ‬ ‫‪2‬‬

‫ﺣﺎﻟﺖ ﻏﻴﺮﻧﺮﻣﺎل دﻣﺎﻳﻲ ﻛﻪ در آن دﻣﺎي ﺑﺪن ﻧﻮزاد زﻳﺮ ‪ 36/5 C‬اﻓﺖ‬

‫ﺳﺎﻋﺖﻫﺎ اداﻣﻪ ﭘﻴﺪا ﻛﻨﺪ‪ .‬در ﻓﻘﺪان ﻣﺤﺎﻓﻈﺖ ﺣﺮارﺗﻲ‪ ،‬ﻧﻮزاد ﻣﻤﻜﻦ‬

‫ﻣﻲﻛﻨﺪ‪ ،‬ﺗﻌﺮﻳﻒ ﻛﺮد‪ 1.‬اداﻣﻪ روﻧﺪ ﻛﺎﻫﺶ دﻣﺎي ﺑﺪن ﻣﻲﺗﻮاﻧﺪ ﻣﻨﺠﺮ ﺑﻪ‬

‫اﺳﺖ ﻣﻘﺪار ﻗﺎﺑﻞ ﺗﻮﺟﻬﻲ از ﺣﺮارت ﺑﺪن را از دﺳﺖ ﺑﺪﻫﺪ‪ .‬ﮔﺎه در‬

‫اﺛﺮات ﻧﺎﻣﻄﻠﻮب ﺑﺎﻟﻴﻨﻲ‪ ،‬ﺷﺎﻣﻞ ﻣﺸﻜﻼت ﻣﺘﺎﺑﻮﻟﻴﻚ ﺗﺎ ﻣﺮگ ﮔﺮدد‪ .‬در‬

‫اوﻟﻴﻦ دﻗﺎﻳﻖ ﺗﻮﻟﺪ‪ ،‬دﻣﺎي ﭘﻮﺳﺖ ‪ 2-4 C‬اﻓﺖ ﻣﻲﻛﻨﺪ‪4.‬و‪ 3‬در واﻗﻊ‪ ،‬ﻧﺮخ‬

‫ﻫﻨﮕﺎم ﺗﻮﻟﺪ‪ ،‬ﻧﻮزاد ﺗﺎزه ﻣﺘﻮﻟﺪ ﺷﺪهي ﺧﻴـﺲ ﻧﺎﮔﻬﺎن ﺑﺎ ﻣﺤﻴـﻄﻲ ﺳـﺮد و‬

‫از دﺳﺖ دادن ﺣﺮارت وﻗﺘﻲ ﻛﻪ ﻧﻮزاد ﻋﺮﻳﺎن در دﻣﺎي ‪ 23 C‬ﻗﺮار‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ 282 ،5‬ﺗﺎ ‪288‬‬

‫ﺑﺮآورد ﻣﻴﺰان اﻧﺘﻘﺎل ﺑﻴﻦ وﺿﻌﻴﺖ ﻫﺎي ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي ﻣﺎرﻛﻮف‬

‫‪283‬‬

‫‪19‬و‪18‬‬

‫ﻣﻲﮔﻴﺮد‪ ،‬ﻫﻤﺎﻧﻨﺪ ﻧﺮخ ﺣﺮارﺗﻲ اﺳﺖ ﻛﻪ ﻳﻚ ﻓﺮد ﺑﺎﻟﻎ در دﻣﺎي ‪ 0 C‬از‬

‫ﺷﺒﻜﻴﻪ ﻧﺎﺷﻲ از دﻳﺎﺑﺖ‪.‬‬

‫دﺳﺖ ﻣﻲدﻫﺪ‪ 5.‬اﻋﻤﺎﻟﻲ ﻣﺜﻞ‪ ،‬رﻫﺎ ﻛﺮدن ﻧﻮزاد ﺑﺪون ﻣﺤﺎﻓﻈﺖ ﺣﺮارﺗﻲ‪،‬‬

‫اﺳﺘﻔﺎده از روشﻫﺎي ﺗﻮﺻﻴﻔﻲ و رﮔﺮﺳﻴﻮن ﻟﺠﺴﺘﻴﻚ ﺷﻴﻮع ﻫﻴﭙﻮﺗﺮﻣﻲ‬

‫ﺑﻪ ﺗﺎﺧﻴﺮ اﻧﺪاﺧﺘﻦ ﺧﺸﻚ ﻛﺮدن و ﻗﻨﺪاق ﻛﺮدن‪ ،‬ﺣﻤﺎم دادن ﻧﻮزاد‬

‫ﺑﺮآورد و ﻋﻮاﻣﻞ ﻣﺨﺎﻃﺮه آن ﻣﻮرد آزﻣﻮن ﻗﺮار ﮔﺮﻓﺘﻪ و ﺗﻌﻴﻴﻦ‬

‫ﺑﻼﻓﺎﺻﻠﻪ ﺑﻌﺪ از ﺗﻮﻟﺪ از ﻣﻮاردي اﺳﺖ ﻛﻪ ﻣﻲﺗﻮاﻧﺪ اﺣﺘﻤﺎل ﻫﻴﭙﻮﺗﺮم‬

‫ﺷﺪهاﻧﺪ‪21.‬و‪ 20‬ﺑﺎ اﻳﻦ ﺣﺎل ﺗﺎﻛﻨﻮن ﻧﺮخ اﻧﺘﻘﺎل ﺑﻴﻦ وﺿﻌﻴﺖﻫﺎي ﻫﻴﭙﻮﺗﺮﻣﻲ‬

‫‪1‬‬

‫در ﻣﻄﺎﻟﻌﺎﺗﻲ ﻛﻪ در ﮔﺬﺷﺘﻪ اﻧﺠﺎم ﺷﺪه‪ ،‬ﺑﺎ‬

‫و ﻫﻢﭼﻨﻴﻦ ﮔﺬار از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ و ﻋﻮاﻣﻞ ﻣﻮﺛﺮ ﺑﺮ اﻳﻦ اﻧﺘﻘﺎل‬

‫ﺷﺪن ﻧﻮزاد را اﻓﺰاﻳﺶ دﻫﺪ‪.‬‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ در ﺳﺎﻋﺎت اوﻟﻴﻪ ﺗﻮﻟﺪ ﻳﻜﻲ از دﻻﻳﻞ ﻣﻬﻢ اﻳﺠﺎد ﺑﻴﻤﺎري‬

‫ﻣﻮرد ﻣﻄﺎﻟﻌﻪ ﻗﺮار ﻧﮕﺮﻓﺘﻪ اﺳﺖ‪ ،‬ﻟﺬا در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺳﻌﻲ ﺷﺪه اﺳﺖ ﺗﺎ‬

‫و در ﻧﻬﺎﻳﺖ ﻣﺮگ ﻧﻮزادان در ﻛﺸﻮرﻫﺎي در ﺣﺎل ﺗﻮﺳﻌﻪ اﺳﺖ‪ .‬ﺷﻴﻮع‬

‫ﺑﺎ اﺳﺘﻔﺎده از ﻣﺪل ﻣﺎرﻛﻮف‪ ،‬ﻧﺮخ اﻧﺘﻘﺎل ﺑﻴﻦ وﺿﻌﻴﺖﻫﺎي ﻣﺨﺘﻠﻒ‬

‫ﺑﺎﻻي ﻫﻴﭙﻮﺗﺮﻣﻲ در ﻛﺸﻮرﻫﺎﻳﻲ ﺑﺎ ﺑﻴﺶﺗﺮﻳﻦ ﺑﺎر ﻣﺮگ ﻧﻮزادان ﮔﺰارش‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي ﺑﺮآورد و اﺛﺮ وزن ﻧﻮزاد و دﻣﺎي ﻣﺤﻴﻂ ﺗﻮﻟﺪ ﺑﺮ اﻳﻦ‬

‫ﺷﺪه اﺳﺖ‪ 6.‬ﺳﺎزﻣﺎن ﺑﻬﺪاﺷﺖ ﺟﻬﺎﻧﻲ‬

‫)‪(WHO‬‬

‫ﻗﻮاﻧﻴﻦ ﻛﻨﺘﺮل دﻣﺎي ﺑﺪن‬

‫ﻧﺮخ ﺗﻌﻴﻴﻦ ﺷﻮد‪.‬‬

‫را در ﻣﻴﺎن ﻗﻮاﻧﻴﻦ ﻣﺮاﻗﺒﺖﻫﺎي ﻧﻮزادي ﺑﺮاي ﻛﺸﻮرﻫﺎي در ﺣﺎل ﺗﻮﺳﻌﻪ‬ ‫ﮔﻨﺠﺎﻧﺪه اﺳﺖ‪ 5.‬ﻫﻴﭙﻮﺗﺮﻣﻲ ﺣﺘﻲ در ﻛﺸﻮرﻫﺎﻳﻲ ﻛﻪ داراي آب و ﻫﻮاي‬

‫روش ﺑﺮرﺳﻲ‬

‫ﮔﺮﻣﺴﻴﺮي ﻫﺴﺘﻨﺪ ﻧﻴﺰ ﺷﻴﻮع دارد‪ .‬ﺑﻪﻋﻨﻮان ﻣﺜﺎل در ﻧﭙﺎل ‪ %85‬از ﻧﻮزادان‬ ‫ﺗﺎزه ﻣﺘﻮﻟﺪ ﺷﺪه در دو ﺳﺎﻋﺖ اوﻟﻴﻪ زﻧﺪﮔﻲ دﻣﺎﻳﻲ ﻛﻢﺗﺮ از ‪36 C‬‬

‫ﻧﻤﻮﻧﻪ ﺑﻪﻛﺎر ﮔﺮﻓﺘﻪ ﺷﺪه در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑﺨﺸﻲ از ﻣﻄﺎﻟﻌﻪ ﻃﻮﻟﻲ‬

‫دارﻧﺪ‪ 7.‬در اﺗﻴﻮﭘﻲ‪ 8،‬زاﻣﺒﻴﺎ‪ 9‬و زﻳﻤﺒﺎﺑﻮه‪ 10‬از ﻳﻚ دوم ﺗﺎ دو ﺳﻮم ﻧﻮزادان‬

‫ﻣﺸﺎﻫﺪهاي ﺑﺰرگﺗﺮي ﻛﻪ ﺗﻮﺳﻂ ‪ Nayeri‬و ‪ Nili‬ﺑﺮ روي ﻧﻮزادان‬

‫ﺑﻌﺪ از ﺗﻮﻟﺪ ﻫﻴﭙﻮﺗﺮم ﻫﺴﺘﻨﺪ‪.‬‬

‫ﺑﺴﺘﺮي در ﺑﺨﺶ ﻣﺮاﻗﺒﺖﻫﺎي وﻳﮋه ﻧﻮزادان‬

‫)‪(NICU‬‬

‫در ﺑﻴﻤﺎرﺳﺘﺎن‬

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‫در ﻣﻄﺎﻟﻌﻪاي ﻛﻪ در اﻳﺮان ﺑﺮ روي ‪ 940‬ﻧﻮزاد اﻧﺠﺎم ﺷﺪ ﺷﻴﻮع‬

‫وﻟﻴﻌﺼﺮ )ﻋﺞ( ﺷﻬﺮ ﺗﻬﺮان اﻧﺠﺎم ﺷﺪه اﺳﺖ‪ ،‬ﻣﻲﺑﺎﺷﺪ‪ .‬ﻣﻌﻴﺎرﻫﺎي ورود‬

‫در ﻣﻄﺎﻟﻌﺎت ﭘﺰﺷﻜﻲ وﺿﻌﻴﺖ‬

‫ﻋﺒﺎرت ﻫﺴﺘﻨﺪ از ﻫﻴﭙﻮﺗﺮم ﺑﻮدن ﻧﻮزاد در ﺑﺪو ﺗﻮﻟﺪ و ﻣﺎﻧﺪﮔﺎري در اﻳﻦ‬

‫ﺳﻼﻣﺖ اﻓﺮاد ﻳﺎ ﭘﺎﺳﺦ ﺑﻪ ﻳﻚ درﻣﺎن ﻳﺎ ﻣﺤﺮك ﺧﺎص اﻏﻠﺐ ﺑﻪﺻﻮرت‬

‫وﺿﻌﻴﺖ ﺣﺪاﻗﻞ ﺗﺎ دوﻣﻴﻦ زﻣﺎن اﻧﺪازهﮔﻴﺮي درﺟﻪ ﺣﺮارت و ﻣﻌﻴﺎر‬

‫وﺿﻌﻴﺖﻫﺎي ﻣﺨﺘﻠﻒ ﺛﺒﺖ ﻣﻲﺷﻮد‪ ،‬ﮔﺎﻫﻲ اﻳﻦ ﻣﺸﺎﻫﺪه وﺿﻌﻴﺖ در‬

‫ﺧﺮوج ﻋﺒﺎرت اﺳﺖ از رﺳﻴﺪن ﻧﻮزاد ﺑﻪ وﺿﻌﻴﺖ ﻧﺮﻣﺎل‪ .‬ﺑﺎ ﻣﻨﻈﻮر‬

‫ﻃﻮل زﻣﺎن ﺗﻜﺮار ﻣﻲﺷﻮد‪ .‬ﻣﺪلﻫﺎي ﭼﻨﺪ وﺿﻌﻴﺘﻲ ﭘﻴﻮﺳﺘﻪ زﻣﺎن ﺑﻪ‬

‫ﻧﻤﻮدن اﻳﻦ ﻣﻼكﻫﺎ‪ 439 ،‬ﻧﻮزاد در اﻳﻦ ﺗﺤﻘﻴﻖ ﺑﺮرﺳﻲ ﺷﺪﻧﺪ‪.‬‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ‪ %53/3‬ﻋﻨﻮان ﮔﺮدﻳﺪ‪.‬‬

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‫ﺷﻜﻞ ﮔﺴﺘﺮدهاي در ﻣﺪلﺑﻨﺪي ﻣﺘﻐﻴﺮﻫﺎي ﻃﺒﻘﻪﺑﻨﺪي ﺷﺪه و ﺟﻤﻊآوري‬

‫در اﻳﻦ ﻣﺠﻤﻮﻋﻪ داده درﺟﻪ ﺣﺮارت رﻛﺘﺎل ﻧﻮزادان اﺑﺘﺪا در ﺑﺪو‬

‫ﺷﺪه در ﻃﻮل زﻣﺎن ﺑﻪﻛﺎر ﻣﻲروﻧﺪ‪ .‬در ﻛﺎرﺑﺮدﻫﺎي ﭘﺰﺷﻜﻲ‪ ،‬ﻣﺘﻐﻴﺮ ﭘﺎﺳﺦ‬

‫ﺗﻮﻟﺪ اﻧﺪازهﮔﻴﺮي ﺷﺪ و در ﺻﻮرﺗﻲ ﻛﻪ درﺟﻪ ﺣﺮارت رﻛﺘﺎل ﻛﻢﺗﺮ از‬

‫ﻣﻤﻜﻦ اﺳﺖ ﻣﺮﺑﻮط ﺑﻪ وﺿﻌﻴﺖﻫﺎي ﺑﻴﻤﺎري ﺑﺎﺷﺪ و اﻳﻦ وﺿﻌﻴﺖﻫﺎ‬

‫‪ 36/5‬ﺑﻮد اﻧﺪازهﮔﻴﺮيﻫﺎ ﺑﻪ ﻓﺎﺻﻠﻪﻫﺎي ‪ 30‬دﻗﻴﻘﻪ ﺗﺎ ﺧﺎرج ﺷﺪن ﻧﻮزاد از‬

‫ﻣﻤﻜﻦ اﺳﺖ در ﻓﻮاﺻﻞ زﻣﺎﻧﻲ ﻧﺎﻣﻨﻈﻤﻲ ﻣﺸﺎﻫﺪه ﺷﺪه ﺑﺎﺷﻨﺪ‪ .‬ﭼﻨﻴﻦ‬

‫وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ اداﻣﻪ ﻳﺎﻓﺖ‪ .‬ﭘﺎﺳﺦ در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪه ﺷﺪت‬

‫ﺑﺮﻧﺎﻣﻪ ﻣﺸﺎﻫﺪهاي را ﻣﺸﺎﻫﺪه ﭘﺎﻧﻠﻲ ﮔﻮﻳﻨﺪ‪ 12.‬در اﻳﻦ ﺷﺮاﻳﻂ زﻣﺎنﻫﺎي‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﺑﻮد ﻛﻪ ﺑﻪﺻﻮرت‪ ،‬درﺟﻪ ﺣﺮارت ﻧﺮﻣﺎل )دﻣﺎي رﻛﺘﺎل‬

‫اﻧﺘﻘﺎل اﻏﻠﺐ ﺑﺎ ﺳﺎﻧﺴﻮر ﻓﺎﺻﻠﻪاي ﻫﻤﺮاه اﺳﺖ‪ ،‬ﺑﺪﻳﻦﻣﻌﻨﻲ ﻛﻪ زﻣﺎن دﻗﻴﻖ‬

‫‪ ،(36/5-38C‬ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ )درﺟﻪ ﺣﺮارت رﻛﺘﺎل ‪،(35-36/5 C‬‬

‫اﻧﺘﻘﺎلﻫﺎ از ﻳﻚ وﺿﻌﻴﺖ ﺑﻪ وﺿﻌﻴﺖ دﻳﮕﺮ ﺑﻴﻤﺎري ﻣﻌﻠﻮم ﻧﻴﺴﺖ‪ .‬وﺟﻮد‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﻣﺘﻮﺳﻂ )درﺟﻪ ﺣﺮارت رﻛﺘﺎل ‪ (32-35 C‬و ﻫﻴﭙﻮﺗﺮﻣﻲ‬

‫اﻳﻦ ﻧﻮع از ﺳﺎﻧﺴﻮر‪ ،‬ﻛﺎر ﺑﺮآورد ﭘﺎراﻣﺘﺮﻫﺎي ﻣﺪل را در ﺣﺎﻟﺖ ﻛﻠﻲ‬

‫ﺷﺪﻳﺪ )درﺟﻪ ﺣﺮارت زﻳﺮ ‪ (32 C‬درﺟﻪﺑﻨﺪي ﺷﺪ‪.‬‬

‫ﻣﺸﻜﻞ ﻣﻲﺳﺎزد‪ .‬از اﻳﻦ رو ﻓﺮآﻳﻨﺪﻫﺎي ﭼﻨﺪ وﺿﻌﻴﺘﻲ ﮔﺎﻫﻲ اوﻗﺎت ﺑﻪ‬

‫در اﻳﻦ ﻣﻄﺎﻟﻌﻪ‪ ،‬دو ﮔﺮوه آﺧﺮ ﺗﺮﻛﻴﺐ ﺷﺪه و ﺑﻪﻋﻨﻮان وﺿﻌﻴﺖ‬

‫ﮔﻮﻧﻪاي ﻓﺮض ﻣﻲﺷﻮﻧﺪ ﻛﻪ داراي وﻳﮋﮔﻲ ﻣﺎرﻛﻮف ﺑﺎﺷﻨﺪ‪ 13.‬اﻳﻦ ﻓﺮض‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﺷﺪﻳﺪ در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪ‪ .‬در ﻣﻄﺎﻟﻌﻪ ﻣﺬﻛﻮر درﺟﻪ ﺣﺮارت‬

‫ﻣﻮﺟﺐ ﻣﻲﺷﻮد ﻣﺤﺎﺳﺒﻪ ﺗﺎﺑﻊ درﺳﺖﻧﻤﺎﻳﻲ و در ﻧﺘﻴﺠﻪ ﺑﺮآورد‬

‫ﻧﻮزادان ﺑﻨﺎﺑﺮ ﺗﻮﺻﻴﻪ ﺳﺎزﻣﺎن ﺑﻬﺪاﺷﺖ ﺟﻬﺎﻧﻲ ﺗﺎ رﺳﻴﺪن ﺑﻪ وﺿﻌﻴﺖ‬

‫ﭘﺎراﻣﺘﺮﻫﺎي ﻣﺪل ﺳﺎدهﺗﺮ ﺷﻮد‪.‬‬

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‫ﻧﺮﻣﺎل اﻧﺪازهﮔﻴﺮي ﺷﺪ‪ 22،‬در ﻧﺘﻴﺠﻪ ﻫﺮ ﻧﻮزاد ﺑﻪ ﺗﻌﺪاد دﻓﻌﺎت ﻣﺨﺘﺺ‬

‫اﻳﻦ ﻧﻮع از ﻣﺪلﻫﺎ در ﺳﻄﺢ وﺳﻴﻌﻲ از ﻛﺎرﺑﺮدﻫﺎي ﭘﺰﺷﻜﻲ ﺑﻪﻛﺎر‬ ‫‪16‬و‪15‬‬

‫رﻓﺘﻪاﻧﺪ‪ ،‬ﺑﺮاي ﻣﺜﺎل در ‪،HIV/AIDS‬‬

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‫ﺳﺮﻃﺎن ﭘﺴﺘﺎن‬

‫و آﺳﻴﺐ‬

‫ﺧﻮد ﻣﻌﺎﻳﻨﻪ ﮔﺮدﻳﺪ‪ .‬در ﻣﺪلﻫﺎي ﭼﻨﺪ وﺿﻌﻴﺘﻲ دادهﻫﺎ ﺑﻪﺻﻮرت ﺳﺮي‬ ‫ﻣﺸﺎﻫﺪات ‪ xi 0 , xi1 ,..., xin‬در‬

‫زﻣﺎنﻫﺎي ‪ti 0 ,..., tin‬‬

‫در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﻣﻲﺷﻮﻧﺪ ﻛﻪ‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):282-8‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻋﻠﻴﺮﺿﺎ اﻛﺒﺮزاده ﺑﺎﻏﺒﺎن و ﻫﻤﻜﺎران‬

‫‪284‬‬

‫ﺣﺎﺻﻞ از ﻓﺮآﻳﻨﺪ ) ‪ X (t‬اﺳﺖ‪ ،‬اﻳﻦ ﻓﺮآﻳﻨﺪ ﻣﻘﺎدﻳﺮ ‪ 1,..., R‬وﺿﻌﻴﺖ را ﺑﺮاي‬

‫ﺗﻮﻟﺪ در دو ﻃﺒﻘﻪ‪ ،‬دﻣﺎي ﻣﺤﻴﻂ ﺗﻮﻟﺪ زﻳﺮ ‪ 28 C‬و دﻣﺎي ﻣﺤﻴﻂ ﺑﺎﻻي‬

‫ﻫﺮ ﺑﻴﻤﺎر ‪ i  1,..., N‬اﺧﺘﻴﺎر ﻣﻲﻛﻨﺪ‪ .‬در اﻳﻦ ﺻﻮرت ﻟﮕﺎرﻳﺘﻢ ﺗﺎﺑﻊ درﺳﺖ‪-‬‬

‫‪ ،28 C‬ﺑﻪﻋﻨﻮان ﻣﺘﻐﻴﺮﻫﺎي ﻫﻤﺮاه ﺑﻪ ﻣﺪل وارد ﺷﺪ‪.‬‬

‫ﻧﻤﺎﻳﻲ ﺑﻪ ﺷﻜﻞ زﻳﺮ ﺑﻴﺎن ﻣﻲﺷﻮد‪.‬‬ ‫‪ni‬‬

‫‪23‬‬

‫‪N‬‬

‫)) ‪l ( )   log( p xi ( j1) xij (ti ( j 1) , tij ;‬‬

‫ﻳﺎﻓﺘﻪﻫﺎ‬

‫‪i 1 j 1‬‬

‫ﻛﻪ در آن‬ ‫ﻣﺎﺗﺮﻳﺲ‬

‫) ‪prs (t 0 , t1 ,  )  p ( x (t1 )  s | x (t 0 )  r ; ‬‬ ‫‪R R‬‬

‫دراﻳﻪ‬

‫)‪(r , s‬‬

‫از‬ ‫ﺗﻤﺎم ‪ 439‬ﻧﻮزاد وارد ﺷﺪه ﺑﻪ ﻣﻄﺎﻟﻌﻪ در ﺑﺪو ﺗﻮﻟﺪ ﻫﻴﭙﻮﺗﺮم ﺑﻮدهاﻧﺪ‪،‬‬

‫اﺣﺘﻤﺎل اﻧﺘﻘﺎل اﺳﺖ ﻛﻪ ﺑﻪوﺳﻴﻠﻪ ﺣﻞ ﻣﻌﺎدﻟﻪ ﭘﻴﺸﺮو‬ ‫‪24‬‬

‫از ﻣﻴﺎن آنﻫﺎ ‪ 11‬ﻧﻔﺮ )‪ (%2/5‬در وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﻣﺘﻮﺳﻂ ﺗﺎ ﺷﺪﻳﺪ و‬

‫ﻛﻮﻟﻤﻮﮔﺮوف زﻳﺮ ﻗﺎﺑﻞ دﺳﺖﻳﺎﺑﻲ اﺳﺖ‪.‬‬ ‫) ‪dP(t0 , t‬‬ ‫) ‪ p(t0 , t )Q (t‬‬ ‫‪dt‬‬

‫در اﻳﻦ ﺗﺴﺎوي ‪ Q‬ﻣﺎﺗﺮﻳﺲ ﺷﺪت اﻧﺘﻘﺎل اﺳﺖ ﻛﻪ‬

‫‪ 428‬ﻧﻔﺮ )‪ (%97/5‬در وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﻗﺮار داﺷﺘﻨﺪ‪ .‬ﺗﻮزﻳﻊ‬

‫ﺗﻌﺮﻳﻒ‬

‫ﻓﺮاواﻧﻲ وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادان در زﻣﺎنﻫﺎي ﻣﻮرد ﻣﻄﺎﻟﻌﻪ در‬

‫ﻣﻲﺷﻮد‪ .‬ﺑﺎ ﺑﻪدﺳﺖ آوردن ﻣﺎﺗﺮﻳﺲ ﺷﺪت اﻧﺘﻘﺎل در اﻳﻦ ﻣﺪل ﻣﻲﺗﻮاﻧﻴﻢ‬

‫ﺟﺪول‪ 1 -‬آﻣﺪه اﺳﺖ‪ .‬ﺑﺎ ﺑﺮازش ﻣﺪل ﭼﻨﺪ وﺿﻌﻴﺘﻲ ﻣﺎرﻛﻮف ﺑﺎ دو‬

‫ﻣﻴﺎﻧﮕﻴﻦ زﻣﺎن ﻣﺎﻧﺪﮔﺎري در ﻫﺮ وﺿﻌﻴﺖ ﺑﻴﻤﺎري را ﻣﺤﺎﺳﺒﻪ ﻛﻨﻴﻢ‪ ،‬اﻳﻦ‬

‫ﻣﺘﻐﻴﺮ ﻫﻤﺮاه‪ ،‬ﻧﺮخ اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺷﺪﻳﺪ ﺑﻪ ﺧﻔﻴﻒ و از‬

‫ﻣﻌﻴﺎر ﺑﺎ ﻋﻜﺲ دراﻳﻪﻫﺎي ﻗﻄﺮ اﺻﻠﻲ ﻣﺎﺗﺮﻳﺲ ﺷﺪت اﻧﺘﻘﺎل ﺑﺮاﺑﺮ اﺳﺖ‪.‬‬

‫وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺑﻪ ﻧﺮﻣﺎل ﺑﻪﺗﺮﺗﻴﺐ‪ 0/1192 ،‬و ‪ 0/0549‬در‬

‫اﻟﮕﻮرﻳﺘﻢ ﻋﺪدي‪ ،‬در ﺳﺎل ‪ 1985‬ﺑﺮاي ﻣﺤﺎﺳﺒﻪ ﺑﺮآوردﻫﺎي ﻣﺎﻛﺰﻳﻤﻢ‬

‫دﻗﻴﻘﻪ ﺑﺮآورد ﺷﺪ‪ .‬ﺑﻪ اﻳﻦ ﻣﻌﻨﻲ ﻛﻪ اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺷﺪﻳﺪ‬

‫درﺳﺖﻧﻤﺎﻳﻲ ﻣﺪل ﻓﻮق اراﻳﻪ ﺷﺪه اﺳﺖ‪ 25.‬ﺑﺎ ﺑﺮازش اﻳﻦ ﻣﺪل ﻫﻢﭼﻨﻴﻦ‬

‫ﺑﻪ ﺣﺎﻟﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺳﺮﻳﻊﺗﺮ از اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ‬

‫اﻣﻜﺎن ﺑﺮآورد ﻧﺴﺒﺖ ﻣﺨﺎﻃﺮه ﺑﺮاي ﻫﺮ دو ﺳﻄﺢ از ﺳﻄﻮح ﺑﻴﻤﺎري را‬

‫ﺧﻔﻴﻒ ﺑﻪ ﻧﺮﻣﺎل اﺗﻔﺎق ﻣﻲاﻓﺘﺪ‪ .‬ﻣﺘﻐﻴﺮ وزن ﻧﻮزاد اﺛﺮ ﻣﻌﻨﻲداري ﺑﺮ ﻧﺮخ‬

‫در ﺳﻄﻮح ﻣﺘﻐﻴﺮﻫﺎي ﻣﺴﺘﻘﻞ را دارﻳﻢ‪ .‬در ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﻣﺪل ﭼﻨﺪ‬

‫اﻧﺘﻘﺎل از ﻫﻴﭙﻮﺗﺮﻣﻲ ﺷﺪﻳﺪ ﺑﻪ ﺣﺎﻟﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﻧﺪاﺷﺖ‪ .‬ﻓﺎﺻﻠﻪ‬

‫وﺿﻌﻴﺘﻲ ﻣﺎرﻛﻮﻓﻲ ﺑﺎ دو ﻣﺘﻐﻴﺮ ﻫﻤﺮاه وزن ﻧﻮزاد و دﻣﺎي ﻣﺤﻴﻂ ﺗﻮﻟﺪ‪،‬‬

‫اﻃﻤﻴﻨﺎن ‪ %95‬ﺑﺮاي ﭘﺎراﻣﺘﺮ اﺛﺮ وزن ﻧﻮزاد ﺑﺮ ﻧﺮخ اﻧﺘﻘﺎل )‪ 2/276‬و‬

‫ﺑﻪ دادهﻫﺎ ﺑﺮازش داده ﺷﺪ‪ .‬اﺛﺮ اﻳﻦ ﻣﺘﻐﻴﺮﻫﺎ ﺑﻪﻋﻨﻮان ﻋﻮاﻣﻞ ﻣﻮﺛﺮ ﺑﺮ ﻧﺮخ‬

‫‪ (-1/619‬ﺑﻪدﺳﺖ آﻣﺪ‪ ،‬اﻣﺎ اﺛﺮ وزن ﻧﻮزاد ﺑﺮ اﻧﺘﻘﺎل از وﺿﻌﻴﺖ‬

‫اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺷﺪﻳﺪ ﺑﻪ ﺧﻔﻴﻒ و ﺧﻔﻴﻒ ﺑﻪ ﻧﺮﻣﺎل‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺑﻪ وﺿﻌﻴﺖ ﻧﺮﻣﺎل ﻣﻌﻨﻲدار ﺑﻮد )‪ (P<0/001‬و ﻓﺎﺻﻠﻪ‬

‫ﺑﺮرﺳﻲ ﺷﺪ‪ .‬وزن ﻧﻮزاد در ﺳﻪ ﻃﺒﻘﻪ‪ ،‬ﺑﺴﻴﺎر ﻛﻢ وزن )زﻳﺮ ‪ ،(1500gr‬ﻛﻢ‬

‫اﻃﻤﻴﻨﺎن ‪ %95‬ﺑﺮاي اﻳﻦ ﭘﺎراﻣﺘﺮ )‪ 0/4165‬و ‪ (0/1364‬ﺑﺮآورد ﺷﺪ‪ .‬ﺗﺎﺛﻴﺮ‬

‫وزن )‪ (1500-2500gr‬و ﻧﺮﻣـﺎل وزن )ﺑﺎﻻي ‪ (2500gr‬و دﻣﺎي ﻣﺤﻴـﻂ‬

‫وزن ﺑﺮ ﻧﺮخ اﻧﺘﻘﺎل از وﺿﻌﻴـﺖ ﻫﻴـﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺑﻪ ﻧﺮﻣﺎل ﺑﻪ ﺗﻔﻜﻴـﻚ‬

‫دراﻳﻪﻫﺎي آن ﺑﻪ ﺷﻜﻞ زﻳﺮ ﺑﺎ ﺷﺮط‬

‫‪   qrs‬‬ ‫‪rs‬‬

‫‪rr‬‬

‫‪ q‬ﺑﺮاي‬

‫‪r  1,..., R‬‬

‫ﺟﺪول‪ :1 -‬ﺗﻮزﻳﻊ ﻓﺮاواﻧﻲ وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادان در زﻣﺎنﻫﺎي ﻣﺸﺎﻫﺪه ﺷﺪه و درﺻﺪ آن‬ ‫وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﺷﺪﻳﺪ‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ‬

‫ﻧﺮﻣﺎل‬

‫ﻣﺠﻤﻮع‬

‫زﻣﺎن ﺑﻪ دﻗﻴﻘﻪ‬ ‫‪1‬‬

‫‪30‬‬

‫*‪60‬‬

‫*‪90‬‬

‫*‪120‬‬

‫ﺗﻌﺪاد‬

‫‪11‬‬

‫‪0‬‬

‫درﺻﺪ در زﻣﺎن‬

‫‪%2/5‬‬

‫‪%0‬‬

‫ﺗﻌﺪاد‬

‫‪428‬‬

‫‪100‬‬

‫‪16‬‬

‫‪2‬‬

‫‪0‬‬

‫درﺻﺪ در زﻣﺎن‬

‫‪%97/5‬‬

‫‪%22/8‬‬

‫‪%16/0‬‬

‫‪%12/5‬‬

‫‪%0‬‬

‫ﺗﻌﺪاد‬

‫‪0‬‬

‫‪339‬‬

‫‪84‬‬

‫‪14‬‬

‫‪2‬‬

‫درﺻﺪ در زﻣﺎن‬

‫‪%0‬‬

‫‪%77/2‬‬

‫‪%84/0‬‬

‫‪%87/5‬‬

‫‪%100/0‬‬

‫ﺗﻌﺪاد‬

‫‪439‬‬

‫‪100‬‬

‫‪16‬‬

‫‪2‬‬

‫درﺻﺪ در زﻣﺎن‬

‫‪%100/0‬‬

‫* در اﻳﻦ زﻣﺎنﻫﺎ ﺗﻮزﻳﻊ ﻓﺮاواﻧﻲ وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﻓﻘﻂ ﺑﺮاي ﻧﻮزاداﻧﻲ اراﻳﻪ ﺷﺪه اﺳﺖ ﻛﻪ در زﻣﺎن ﻗﺒﻞ در وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺑﻮدهاﻧﺪ‬

‫ﺑﺮآورد ﻣﻴﺰان اﻧﺘﻘﺎل ﺑﻴﻦ وﺿﻌﻴﺖ ﻫﺎي ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي ﻣﺎرﻛﻮف‬

‫‪285‬‬

‫ﺟﺪول‪ :2 -‬ﺑﺮآورد ﻣﻴﺎﻧﮕﻴﻦ زﻣﺎن ﻣﺎﻧﺪﮔﺎري در وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺑﻪ ﺗﻔﻜﻴﻚ ﮔﺮوهﻫﺎي وزﻧﻲ و دﻣﺎي ﻣﺤﻴﻂ ﺗﻮﻟﺪ در ﻧﻮزادان ﻫﻴﭙﻮﺗﺮﻣﻲ ﻣﻮرد ﻣﻄﺎﻟﻌﻪ‬ ‫ﻧﺎم ﻣﺘﻐﻴﺮ ﻛﻤﻜﻲ‬ ‫وزن ﻧﻮزاد در زﻣﺎن ﺗﻮﻟﺪ‬

‫دﻣﺎي ﻣﺤﻴﻂ ﺗﻮﻟﺪ‬

‫ﺳﻄﻮح ﻣﺘﻐﻴﺮ ﻛﻤﻜﻲ‬

‫ﺑﺮآورد ﻣﻴﺎﻧﮕﻴﻦ )دﻗﻴﻘﻪ(‬

‫ﺑﺴﻴﺎر ﻛﻢ وزن )‪(<1500‬‬

‫‪38/049‬‬

‫ﻛﻢ وزن )‪(1500-2500‬‬

‫‪28/858‬‬

‫ﻧﺮﻣﺎل )‪(>2500‬‬

‫‪21/887‬‬

‫زﻳﺮ ‪ 28‬درﺟﻪ ﺳﺎﻧﺘﻲﮔﺮاد‬

‫‪38/292‬‬

‫ﺑﺎﻻي ‪ 28‬درﺟﻪ ﺳﺎﻧﺘﻲﮔﺮاد‬

‫‪29/228‬‬

‫ﮔﺮوهﻫﺎي وزﻧﻲ در ﻏﺎﻟﺐ ﺑﺮآورد زﻣﺎن ﻣﺎﻧﺪﮔﺎري در وﺿﻌﻴﺖ‬

‫ﺑﺤﺚ‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ در ﺟﺪول‪ 2 -‬ﻧﺸﺎن داده ﺷﺪه اﺳﺖ‪ .‬اﺛﺮ دﻣﺎي ﻣﺤﻴﻂ‬ ‫ﺗﻮﻟﺪ ﺑﺮ ﻧﺮخ اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺑﻪ وﺿﻌﻴﺖ ﻧﺮﻣﺎل‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي ﻳﻜﻲ از ﻋﻮاﻣﻞ ﺗﺎﺛﻴﺮﮔﺬار در ﺑﻘﺎي ﻧﻮزادان‬

‫ﻣﻌﻨﻲدار ﺑﻮد )‪ ،(P<0/001‬ﻓﺎﺻﻠﻪ اﻃﻤﻴﻨﺎن ‪ %95‬ﺑﺮاي ﭘﺎراﻣﺘﺮ اﺛﺮ دﻣﺎي‬

‫ﺑﻪﺧﺼﻮص ﻧﻮزادان ﻛﻢ وزن اﺳﺖ‪ .‬ﻋﺪم ﺗﻮﺟﻪ ﭘﺮﺳﻨﻞ ﺑﻬﺪاﺷﺘﻲ و‬

‫ﻣﺤﻴﻂ ﺑﺮ ﻧﺮخ اﻧﺘﻘﺎل‪ 0/4963) ،‬و ‪ (0/0439‬ﺑﻪدﺳﺖ آﻣﺪ‪ .‬اﺛﺮ اﻳﻦ ﻣﺘﻐﻴﺮ‬

‫درﻣﺎﻧﻲ ﺑﻪ اﻗﺪاﻣﺎت اوﻟﻴﻪ ﺳﺎدهاي ﭼﻮن‪ ،‬ﻓﺮاﻫﻢ آوردن ﻣﺤﻴﻄﻲ ﮔﺮم‪،‬‬

‫ﺑﺮ اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺷﺪﻳﺪ ﺑﻪ ﺧﻔﻴﻒ ﻣﻌﻨﻲدار ﻧﺒﻮد‪ .‬ﻓﺎﺻﻠﻪ‬

‫ﺑﺪون ﺟﺮﻳﺎن ﻫﻮا و ﺗﻤﻴﺰ در ﻫﻨﮕﺎم ﺗﻮﻟﺪ ﻧﻮزاد‪ ،‬از ﻋﻮاﻣﻞ اﺻﻠﻲ ﺑﺮوز‬

‫اﻃﻤﻴﻨﺎن ‪ %95‬ﺑﺮاي ﭘﺎراﻣﺘﺮ اﺛﺮ اﻳﻦ ﻣﺘﻐﻴﺮ در اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ‬

‫اﻳﻦ ﻋﺎرﺿﻪ اﺳﺖ‪.‬‬

‫‪1‬‬

‫ﺷﺪﻳﺪ ﺑﻪ ﺧﻔﻴﻒ )‪ 2/448‬و ‪ (-1/915‬ﺑﻪدﺳﺖ آﻣﺪ‪ .‬زﻣﺎن ﻣﺎﻧﺪﮔﺎري در‬

‫ﻫﻤﺎنﻃﻮر ﻛﻪ در ﻣﻘﺪﻣﻪ ذﻛﺮ ﻛﺮدﻳﻢ ﻃﺒﻖ ﺗﺤﻘﻴﻘﺎت‪ ،‬ﺑﺎ ﺑﺎﻗﻲ ﻣﺎﻧﺪن‬

‫وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺑﻪ ﺗﻔﻜﻴﻚ دو ﻃﺒﻘﻪ دﻣﺎﻳﻲ‪ ،‬در ﺟﺪول‪2 -‬‬

‫ﻧﻮزاد در ﺣﺎﻟﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺻﺪﻣﺎت ﺟﺒﺮانﻧﺎﭘﺬﻳﺮي از ﻟﺤﺎظ ﺑﺎﻟﻴﻨﻲ‪ ،‬از‬

‫آﻣﺪه اﺳﺖ‪ .‬ﺑﺮ اﺳﺎس اﻳﻦ ﺟﺪول ﻧﻮزادان ﺑﺴﻴﺎر ﻛﻢ وزن‪ ،‬ﺗﻘﺮﻳﺒﺎً ﺑﻪﻃﻮر‬

‫ﻣﺸﻜﻼت ﻣﺘﺎﺑﻮﻟﻴﻜﻲ ﮔﺮﻓﺘﻪ ﺗﺎ ﻣﺮگ‪ ،‬ﺑﻪ وي وارد ﺧﻮاﻫﺪ ﺷﺪ‪ ،‬ﺑﻨﺎﺑﺮاﻳﻦ‬

‫ﻣﻴﺎﻧﮕﻴﻦ ‪ 38‬دﻗﻴﻘﻪ زﻣﺎن ﻣﻲﺑﺮد ﺗﺎ از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺑﻪ‬

‫اﻧﺘﻘﺎل ﻫﺮ ﭼﻪ ﺳﺮﻳﻊﺗﺮ ﻧﻮزاد از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺑﺴﻴﺎر ﺣﺎﻳﺰ‬

‫وﺿﻌﻴﺖ ﻧﺮﻣﺎل ﺑﺮﺳﻨﺪ در ﺣﺎﻟﻲ ﻛﻪ ﻧﻮزادان ﺑﺎ وزن ﻛﻢ ﺗﻘﺮﻳﺒﺎً‪ ،‬ﺑﻪﻃﻮر‬

‫اﻫﻤﻴﺖ اﺳﺖ و در ﻫﻤﻴﻦ ﺟﻬﺖ آﮔﺎﻫﻲ از ﻋﻮاﻣﻠﻲ ﻛﻪ اﻳﻦ اﻧﺘﻘﺎل‬

‫ﻣﺘﻮﺳﻂ ‪ 29‬دﻗﻴﻘﻪ در وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺑﺎﻗﻲ ﻣﻲﻣﺎﻧﻨﺪ‪ .‬ﻣﺘﻮﺳﻂ‬

‫را ﺗﺴﺮﻳﻊ ﻣﻲﻛﻨﻨﺪ ﻣﻲﺗﻮاﻧﺪ ﮔﺎم ﻣﻮﺛﺮي در ﺟﻠﻮﮔﻴﺮي از وﻗﻮع‬

‫زﻣﺎﻧﻲ ﻛﻪ ﻧﻮزاد در وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﺑﻪ ﺳﺮ ﻣﻲﺑﺮد ﺗﺎ ﺑﻪ ﺣﺎﻟﺖ‬

‫ﻣﺸﻜﻼت ﭘﺲ از ﺑﺮوز ﻫﻴﭙﻮﺗﺮﻣﻲ ﺑﺎﺷﺪ‪ ،‬ﺑﻪ ﻫﻤﻴﻦ دﻟﻴﻞ اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑﻪ‬

‫ﻧﺮﻣﺎل ﺑﺮﺳﺪ در دﻣﺎي ﺑﺎﻻي ‪ 28 C‬ﻛﻢﺗﺮ از زﻣﺎﻧﻲ اﺳﺖ ﻛﻪ دﻣﺎي‬

‫ﻣﻨﻈﻮر ﺑﺮآورد زﻣﺎن ﻣﺎﻧﺪﮔﺎري ﻣﻮﻗﺖ ﻧﻮزاد در وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ و‬

‫ﻣﺤﻴﻂ زﻳﺮ ‪ 28 C‬اﺳﺖ‪ ،‬اﻳﻦ زﻣﺎن در دﻣﺎي زﻳﺮ ‪ 28 C‬ﺑﻪﻃﻮر ﻣﺘﻮﺳﻂ‬

‫ﺗﻌﻴﻴﻦ ﻋﻮاﻣﻞ ﻣﻮﺛﺮ ﺑﺮ اﻧﺘﻘﺎل ﻧﻮزاد از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺑﻪ ﺣﺎﻟﺖ‬

‫‪ 38‬دﻗﻴﻘﻪ در ﻣﻘﺎﺑﻞ ‪ 29‬دﻗﻴﻘﻪ ﺑﺮاي دﻣﺎي ﺑﺎﻻي ‪ 28 C‬اﺳﺖ‪.‬‬

‫ﻧﺮﻣﺎل اﻧﺠﺎم ﮔﺮﻓﺖ‪.‬‬

‫ﻧﺴﺒﺖ ﻣﺨﺎﻃﺮه ﺑﺮاي وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﻧﺴﺒﺖ ﺑﻪ ﺷﺪﻳﺪ‬

‫در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺳﻪ ﺳﻄﺢ ﺑﺮاي وزن ﻧﻮزادان در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪ‪،‬‬

‫‪ 1/388‬ﺑﺎ ﻓﺎﺻﻠﻪ اﻃﻤﻴﻨﺎن ‪ 9/740) ،%95‬و ‪ (0/1980‬و ﺑﺮاي وﺿﻌﻴﺖ‬

‫ﻧﻮزادان ﺑﺴﻴﺎر ﻛﻢ وزن )زﻳﺮ ‪ 1500‬ﮔﺮم(‪ ،‬ﻧﻮزادان ﻛﻢ وزن‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﺮﻣﺎل ﻧﺴﺒﺖ ﺑﻪ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ‪ 1/318‬ﺑﺎ ﻓﺎﺻﻠﻪ اﻃﻤﻴﻨﺎن‬

‫)‪ 1500-2500‬ﮔﺮم( و ﻧﻮزادان ﺑﺎ وزن ﻧﺮﻣﺎل )ﺑﺎﻻي ‪ 2500‬ﮔﺮم(‪ .‬اﺛﺮ‬

‫‪ 1/5167) ،%95‬و ‪ (1/1461‬در ﺳﻄﻮح ﻣﺘﻐﻴﺮ وزن ﺑﺮآورد ﺷﺪ‪ .‬ﻧﺴﺒﺖ‬

‫وزن ﻧﻮزاد در اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺑﻪ وﺿﻌﻴﺖ ﻧﺮﻣﺎل ﻣﻌﻨﻲدار‬

‫ﻣﺨﺎﻃﺮه ﺑﺮاي وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ ﻧﺴﺒﺖ ﺑﻪ ﺷﺪﻳﺪ ‪ 1/3058‬ﺑﺎ‬

‫ﺑﻮد ﺑﻪ اﻳﻦ ﺷﻜﻞ ﻛﻪ ﻧﻮزادان ﺑﺴﻴﺎر ﻛﻢ وزن ﺑﺎ ﻧﺮخ ﻛﻢﺗﺮ و ﻧﻮزادان‬

‫ﻓﺎﺻﻠﻪ اﻃﻤﻴﻨﺎن ‪ 11/5692) %95‬و ‪ (0/147‬و ‪ 1/3101‬ﺑﺎ ﻓﺎﺻﻠﻪ اﻃﻤﻴﻨﺎن‬

‫ﻧﺮﻣﺎل وزن ﺑﺎ ﻧﺮخ ﺑﻴﺶﺗﺮي از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﺎرج ﺷﺪﻧﺪ‪ .‬اﻳﻦ‬

‫‪ 1/6426) ،%95‬و ‪ (1/0448‬ﺑﺮاي وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﺮﻣﺎل ﻧﺴﺒﺖ ﺑﻪ‬

‫ﻧﺘﻴﺠﻪ ﻣﻮﻳﺪ ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﺎﺗﻲ اﺳﺖ ﻛﻪ ﺷﻴﻮع ﻫﻴﭙﻮﺗﺮﻣﻲ را در ﻧﻮزادان‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ در ﺳﻄﻮح ﻣﺘﻐﻴﺮ دﻣﺎي ﻣﺤﻴﻂ ﺑﺮآورد ﺷﺪ‪.‬‬

‫ﻣﻮرد ﺑﺮرﺳﻲ ﻗﺮار دادهاﻧﺪ‪.‬‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):282-8‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻋﻠﻴﺮﺿﺎ اﻛﺒﺮزاده ﺑﺎﻏﺒﺎن و ﻫﻤﻜﺎران‬

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‫اﻛﺜﺮ ﻣﻄﺎﻟﻌﺎت اﻧﺠﺎم ﺷﺪه در ﺑﺮرﺳﻲ ﺷﻴﻮع ﻫﻴﭙﻮﺗﺮﻣﻲ وزن را ﺑﻪ‬

‫وﺟﻮد‪ ،‬از ﻣﻄﺎﻟﺐ ﻣﻮرد ﺗﻮﺟﻪ در ﺑﺮازش اﻳﻦ ﻣﺪلﻫﺎ ﻫﺴﺘﻨﺪ‪ .‬در‬

‫ﻋﻨﻮان ﻳﻜﻲ از ﻋﻮاﻣﻞ ﻣﺨﺎﻃﺮه در ﺑﺮوز ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي ﻣﻌﺮﻓﻲ‬

‫ﻣﻄﺎﻟﻌﺎت ﭘﺰﺷﻜﻲ دادهﻫﺎ در اﻏﻠﺐ ﻣﻮارد‪ ،‬ﺷﺎﻣﻞ ﻳﻚ ﺳﺮي از‬

‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻧﺘﻴﺠﻪ ﺑﻪدﺳﺖ آﻣﺪه در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻣﻲﺗﻮان‬

‫ﺗﺸﺨﻴﺺﻫﺎي ﺳﻄﻮح ﺑﻴﻤﺎري در زﻣﺎنﻫﺎي ﻣﻨﺤﺼﺮ ﺑﻪ ﻓﺮد ﺑﺮاي ﻫﺮ‬

‫ﮔﻔﺖ ﻧﻪ ﺗﻨﻬﺎ وزن ﻋﺎﻣﻞ ﻣﻮﺛﺮ ﺑﺮ ﺷﻴﻮع ﻫﻴﭙﻮﺗﺮﻣﻲ اﺳﺖ‪ ،‬ﺑﻠﻜﻪ ﻋﺎﻣﻞ‬

‫ﺑﻴﻤﺎر اﺳﺖ‪ .‬ﺑﻪ دﻟﻴﻞ اﻳﻦﻛﻪ ﺗﻐﻴﻴﺮ وﺿﻌﻴﺖ ﺑﻴﻤﺎر در ﺑﺎزهﻫﺎي ﭘﻴﻮﺳﺘﻪاي‬

‫ﻣﻬﻤﻲ در ﮔﺬار از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻴﺰ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻫﻢﭼﻨﻴﻦ اﺛﺮ دﻣﺎي‬

‫از زﻣﺎن رخ ﻣﻲدﻫﺪ و ﻣﺸﺎﻫﺪه وﺿﻌﻴﺖ ﺑﻴﻤﺎر در ﻧﻘﺎط زﻣﺎﻧﻲ ﮔﺴﺴﺘﻪ‬

‫ﻣﺤﻴﻂ ﺗﻮﻟﺪ ﻧﻮزاد ﺑﺮ ﻧﺮخ اﻧﺘﻘﺎل از وﺿﻌﻴﺖﻫﺎي ﻫﻴﭙﻮﺗﺮﻣﻲ ﻣﻮرد‬

‫ﺻﻮرت ﻣﻲﮔﻴﺮد‪ ،‬اﻣﻜﺎن از دﺳﺖ دادن زﻣﺎن دﻗﻴﻖ ﺗﻐﻴﻴﺮ وﺿﻌﻴﺖ وﺟﻮد‬

‫ﺑﺮرﺳﻲ ﻗﺮار ﮔﺮﻓﺖ‪ .‬دﻣﺎي ﻣﺤﻴﻂ ﺗﻮﻟﺪ در دو ﺳﻄﺢ دﻣﺎي زﻳﺮ ‪ 28 C‬و‬

‫دارد‪ .‬ﻣﺪلﻫﺎي ﺑﺴﻴﺎري ﺑﺮاي ﺑﺮازش ﺑﻪ دادهﻫﺎي ﻃﻮﻟﻲ ﭘﺰﺷﻜﻲ و‬

‫ﺑﺎﻻي ‪ 28 C‬ﺑﻪ ﻣﺪل وارد ﺷﺪ‪ .‬ﻧﺘﺎﻳﺞ ﻧﺸﺎن داد ﻧﻮزادان ﻣﺘﻮﻟﺪ ﺷﺪه در‬

‫ﺗﺤﻠﻴﻞ آنﻫﺎ در دﺳﺖ اﺳﺖ‪ .‬در اﻳﻦ ﻣﻴﺎن‪ ،‬ﻣﺪلﻫﺎي ﭼﻨﺪ وﺿﻌﻴﺘﻲ اﻳﻦ‬

‫دﻣﺎي ﺑﺎﻻي ‪ 28 C‬زﻣﺎن ﻛﻢﺗﺮي را در وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﻣﻲﮔﺬراﻧﻨﺪ‪،‬‬

‫ﻗﺎﺑﻠﻴﺖ را دارﻧﺪ ﻛﻪ ﺑﺮآورد ﻧﺮخﻫﺎي اﻧﺘﻘﺎل را ﺑﺎ ﻟﺤﺎظ ﻛﺮدن اﻳﻦ‬

‫‪11‬و‪2‬‬

‫ﻛﺮدهاﻧﺪ‪،‬‬

‫اﻳﻦ ﻣﻄﻠﺐ ﻧﻴﺰ ﻣﻮﻳﺪ ﺗﻮﺻﻴﻪﻫﺎي ﺳﺎزﻣﺎنﻫﺎي ﺑﻴﻦاﻟﻤﻠﻠﻲ ﻣﺒﻨﻲ ﺑﺮ ﮔﺮم‬ ‫ﻧﮕﻪ داﺷﺘﻦ ﻧﻮزاد ﻫﻨﮕﺎم ﺗﻮﻟﺪ اﺳﺖ‪.‬‬

‫‪5‬‬

‫‪27‬‬

‫ﺳﺎﻧﺴﻮر ﻓﺎﺻﻠﻪاي ﺑﻪدﺳﺖ دﻫﻨﺪ‪.‬‬

‫ﺑﻪ دﻟﻴﻞ وﺟﻮد اﻳﻦ وﻳﮋﮔﻲ در دادهﻫﺎي ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ‪ ،‬از اﻳﻦ ﻣﺪل‬

‫ﻣﻄﺎﻟﻌﺎﺗﻲ ﻛﻪ در ﺳﺎلﻫﺎي ﮔﺬﺷﺘﻪ در زﻣﻴﻨﻪ ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي‬

‫ﺑﺮاي ﺑﺮآورد ﻧﺮخﻫﺎي اﻧﺘﻘﺎل اﺳﺘﻔﺎده ﺷﺪ‪ .‬ﻻزم ﺑﻪ ذﻛﺮ اﺳﺖ در اﻛﺜﺮ‬

‫ﺻﻮرت ﮔﺮﻓﺘﻪ اﺳﺖ اﻏﻠﺐ ﺑﻪ ﺑﺮرﺳﻲ ﺷﻴﻮع ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي و ﻋﻮاﻣﻞ‬

‫ﻣﻄﺎﻟﻌﺎت در زﻣﻴﻨﻪ ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي ﺑﻪ ﺑﺮرﺳﻲ ﻋﻮاﻣﻞ ﻣﻮﺛﺮ ﺑﺮ ﺷﻴﻮع‬ ‫‪28‬‬

‫‪Bhatt‬‬

‫ﻛﻪ ﺷﻴﻮع‬

‫ﻣﻮﺛﺮ ﺑﺮ ﺷﻴﻮع ﺑﻪﺻﻮرت ﻣﻘﻄﻌﻲ ﭘﺮداﺧﺘﻪاﻧﺪ و ﻣﻄﺎﻟﻌﻪ آن ﺑﻪ ﺷﻜﻞ‬

‫آن ﭘﺮداﺧﺘﻪ ﺷﺪه اﺳﺖ‪ ،‬ﺑﻪﻋﻨﻮان ﻣﺜﺎل ﻣﻄﺎﻟﻌﻪ‬

‫ﻃﻮﻟﻲ و ﺑﺮرﺳﻲ روﻧﺪ اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﻛﻢﺗﺮ ﻣﺪ ﻧﻈﺮ ﺑﻮده‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ را در ﻧﻮزادان ﻧﺎرس در وزنﻫﺎي ﻣﺨﺘﻠﻒ ﻣﻮرد ﻣﻄﺎﻟﻌﻪ ﻗﺮار‬

‫اﺳﺖ‪ .‬ﻫﻤﺎنﻃﻮر ﻛﻪ ذﻛﺮ ﮔﺮدﻳﺪ‪ ،‬ﻣﺎﻧﺪن ﻧﻮزاد در وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ‬

‫داده اﺳﺖ و ﺑﺮرﺳﻲ ﺑﻪﺻﻮرت ﺗﻌﻴﻴﻦ ﻋﻮاﻣﻞ ﻣﻮﺛﺮ ﺑﺮ اﻧﺘﻘﺎل ﺑﻪ وﺿﻌﻴﺖ‬

‫ﻣﻨﺠﺮ ﺑﻪ ﺻﺪﻣﺎت ﺑﺎﻟﻴﻨﻲ ﺑﺴﻴﺎري ﺧﻮاﻫﺪ ﺷﺪ‪ .‬در اﻳﻦ ﭘﮋوﻫﺶ ﺑﺎ اﺳﺘﻔﺎده‬

‫ﻧﺮﻣﺎل ﻛﻢﺗﺮ ﺻﻮرت ﮔﺮﻓﺘﻪ اﺳﺖ‪ .‬ﻫﺮ ﭼﻨﺪ در اﻳﻦ ﻣﻄﺎﻟﻌﻪ اﺛﺮ وزن زﻣﺎن‬

‫از ﻣﺪلﻫﺎي ﭼﻨﺪ وﺿﻌﻴﺘﻲ ﻣﺎرﻛﻮف ﺑﻪ ﺑﺮرﺳﻲ ﻧﺮخ اﻧﺘﻘﺎل و ﺑﻪوﻳﮋه‬

‫ﺗﻮﻟﺪ ﻧﻮزاد و دﻣﺎي ﻣﺤﻴﻂ ﺗﻮﻟﺪ ﺑﺮ اﻧﺘﻘﺎل از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺷﺪﻳﺪ‬

‫ﺑﺮرﺳﻲ و ﺗﻌﻴﻴﻦ ﻋﻮاﻣﻞ ﻣﻮﺛﺮ ﺑﺮ اﻳﻦ ﻧﺮخ ﭘﺮداﺧﺘﻪ ﺷﺪ‪ .‬از اﻳﻦ رو ﻧﻘﻄﻪ‬

‫ﺑﻪ وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺧﻔﻴﻒ از دﻳﺪﮔﺎه آﻣﺎري ﻣﻌﻨﻲدار ﻧﺒﻮد‪ ،‬ﺑﺎ اﻳﻦ‬

‫ﻗﻮت و ﻧﻴﺰ ﻋﻠﺖ ﺗﻤﺎﻳﺰ اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑﺎ ﻣﻄﺎﻟﻌﺎت ﭘﻴﺸﻴﻦ‪ ،‬ﺑﺮرﺳﻲ ﻧﺮخ‬

‫ﺣﺎل ﻣﻲﺗﻮاﻧﺪ ﻧﺎﺷﻲ از ﺣﺠﻢ ﻛﻢ ﻧﻮزادان در ﮔﺮوه ﻫﻴﭙﻮﺗﺮﻣﻲ ﺷﺪﻳﺪ‬

‫اﻧﺘﻘﺎل و ﻋﻮاﻣﻞ ﻣﻮﺛﺮ ﺑﺮ آن اﺳﺖ ﻛﻪ ﻣﻲﺗﻮاﻧﺪ ﻛﻤﻚ ﺷﺎﻳﺎﻧﻲ در ﻛﺎﻫﺶ‬

‫ﺑﺎﺷﺪ‪ .‬اﻳﻦ ﻣﻄﻠﺐ را ﻣﻲﺗﻮان ﺑﺎ اﻧﺠﺎم ﻣﻄﺎﻟﻌﺎﺗﻲ ﺑﺎ ﺣﺠﻢ ﻧﻤﻮﻧﻪ ﺑﺎﻻﺗﺮ در‬

‫ﺻﺪﻣﺎت ﻧﺎﺷﻲ از ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي ﺷﻮد‪.‬‬

‫اﻳﻦ ﮔﺮوه ﺑﺮرﺳﻲ ﻧﻤﻮد‪ .‬ﺿﻤﻦ اﻳﻦﻛﻪ ﺑﺮرﺳﻲ ﻧﺮخ اﻧﺘﻘﺎل ﺑﺎ در ﻧﻈﺮ‬

‫ﻣﺪلﻫﺎي ﭼﻨﺪ وﺿﻌﻴﺘﻲ ﻣﺎرﻛﻮف ﺑﻪﻃﻮر ﻣﻌﻤﻮل در ﻣﻄﺎﻟﻌﻪ‬

‫ﮔﺮﻓﺘﻦ ﻧﻤﺮه آﭘﮕﺎر ﻧﻮزادان ﻣﻲﺗﻮاﻧﺪ ﻧﺘﺎﻳﺞ ﻛﺎﻣﻞﺗﺮي ﺑﻪدﺳﺖ دﻫﺪ‪.‬‬

‫ﺑﻴﻤﺎريﻫﺎي ﻣﺰﻣﻦ ﺑﻪﻛﺎر رﻓﺘﻪ اﺳﺖ ﻛﻪ در آن‪ ،‬وﺿﻌﻴﺖ ﺑﻴﻤﺎر ﺑﻴﻦ‬

‫از آﻧﺠﺎﻳﻲ ﻛﻪ وزن ﻧﻮزاد در ﻫﻨﮕﺎم ﺗﻮﻟﺪ در اﺧﺘﻴﺎر ﻛﺎدر ﭘﺰﺷﻜﻲ‬

‫وﺿﻌﻴﺖﻫﺎي ﮔﺴﺴﺘﻪ ﺑﻴﻤﺎري در ﻃﻮل زﻣﺎن ﺗﻐﻴﻴﺮ ﻣﻲﻛﻨﺪ‪ ،‬ﺑﻪﻋﻨﻮان ﻣﺜﺎل‬

‫ﻧﻴﺴﺖ‪ ،‬ﻧﮕﻪ داﺷﺘﻦ درﺟﻪ ﺣﺮارت ﻣﺤﻴﻂ ﺗﻮﻟﺪ ﻧﻮزاد در دﻣﺎي ﻣﻨﺎﺳﺐ‬

‫ﺑﺮاي ﺑﺮرﺳﻲ ﻣﺸﻜﻼت ﭘﺲ از ﭘﻴﻮﻧﺪ رگ در ﺑﻴﻤﺎران ﻗﻠﺒﻲ ﻣﺪﻟﻲ ﺑﺎ‬

‫ﻣﻲﺗﻮاﻧﺪ ﻣﻨﺠﺮ ﺑﻪ ﺗﻐﻴﻴﺮ وﺿﻌﻴﺖ ﺳﺮﻳﻊﺗﺮ ﻧﻮزاد از وﺿﻌﻴﺖ ﻫﻴﭙﻮﺗﺮﻣﻲ ﺑﻪ‬

‫ﭼﻬﺎر وﺿﻌﻴﺖ ﺑﺮازش داده ﺷﺪ و در آن اﺛﺮ ﺳﻦ ﻓﺮد ﮔﻴﺮﻧﺪه‪ ،‬ﺳﻦ ﻓﺮد‬

‫ﺣﺎﻟﺖ ﻧﺮﻣﺎل ﺷﻮد‪ .‬از اﻳﻦ ﺟﻬﺖ آﻣﻮزش در اﻳﻦ زﻣﻴﻨﻪ ﻣﻲﺗﻮاﻧﺪ ﺑﺴﻴﺎر‬

‫اﻫﺪا ﻛﻨﻨﺪه و ﺟﻨﺲ ﻓﺮد ﮔﻴﺮﻧﺪه را ﺑﺮ ﻣﻮﻓﻖ ﺑﻮدن ﭘﻴﻮﻧﺪ را در ﻃﺒﻘﺎت‬

‫ﺣﺎﻳﺰ اﻫﻤﻴﺖ ﺑﺎﺷﺪ‪.‬‬

‫ﻣﺨﺘﻠﻒ و ﺗﺮﻛﻴﺒﻲ از ﻣﺘﻐﻴﺮﻫﺎي ﻫﻤﺮاه ﺑﺮرﺳﻲ ﻛﺮدﻧﺪ‪ ،‬در آن ﻣﻄﺎﻟﻌﻪ‬

‫ﺳﭙﺎﺳﮕﺰاري‪ :‬اﻳﻦ ﻣﻘﺎﻟﻪ ﺣﺎﺻﻞ ﻃﺮح ﺗﺤﻘﻴﻘﺎﺗﻲ ﺗﺤﺖ ﻋﻨﻮان‬

‫ﻧﻮﻳﺴﻨﺪﮔﺎن ﺑﺎ اﺳﺘﻔﺎده از اﻳﻦ ﻣﺪل ﭼﻬﺎر وﺿﻌﻴﺘﻲ ﻧﺸﺎن دادﻧﺪ اﻓﺮاد در‬

‫"ﻣﺪلﻫﺎي ﭼﻨﺪ وﺿﻌﻴﺘﻲ ﻣﺎرﻛﻮف و ﻛﺎرﺑﺮد آنﻫﺎ در ﺗﺤﻠﻴﻞ دادهﻫﺎي‬

‫ﺑﺮﺧﻲ از اﻳﻦ ﺗﺮﻛﻴﺐﻫﺎي ﻣﺘﻐﻴﺮﻫﺎي ﻫﻤﺮاه ﺑﺎ ﻧﺮخ ﺑﻴﺶﺗﺮي ﺑﻪ وﺿﻌﻴﺖ‬

‫ﻫﻴﭙﻮﺗﺮﻣﻲ ﻧﻮزادي" ﻣﺼﻮب داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ و ﺧﺪﻣﺎت ﺑﻬﺪاﺷﺘﻲ‬

‫‪26‬‬

‫ﭼﻬﺎرم ﺑﻴﻤﺎري ﻣﻲرﺳﻨﺪ‪.‬‬

‫ﺑﺮآورد ﻧﺮخ اﻧﺘﻘﺎل ﺑﻴﻦ وﺿﻌﻴﺖﻫﺎي ﺑﻴﻤﺎري‪ ،‬ﻣﻄﺎﻟﻌﻪ اﺛﺮ ﻋﻮاﻣﻞ‬ ‫ﻣﺨﺎﻃﺮه ﺑﺮ اﻳﻦ اﻧﺘﻘﺎلﻫﺎ و ﺑﺮرﺳﻲ اﺛﺮ ﻣﺪاﺧﻠﻪﻫﺎي ﭘﺰﺷﻜﻲ در ﺻﻮرت‬

‫درﻣﺎﻧﻲ ﺷﻬﻴﺪ ﺑﻬﺸﺘﻲ در ﺳﺎل ‪ 1390‬ﺑﻪ ﻛﺪ ‪ 7528‬ﻣﻲﺑﺎﺷﺪ‪ ،‬ﻛﻪ ﺑﺎ‬ ‫ﺣﻤﺎﻳﺖ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ و ﺧﺪﻣﺎت ﺑﻬﺪاﺷﺘﻲ درﻣﺎﻧﻲ ﺷﻬﻴﺪ‬ ‫ﺑﻬﺸﺘﻲ اﻧﺠﺎم ﺷﺪه اﺳﺖ‪.‬‬

287

‫ي ﻣﺎرﻛﻮف‬Akbarzadeh ‫ﭙﻮﺗﺮﻣﻲ ﻧﻮزاد‬Baghban ‫وﺿﻌﻴﺖ ﻫﺎي ﻫﻴ‬ ‫ﺑﺮآورد ﻣﻴﺰان اﻧﺘﻘﺎل ﺑﻴ‬ A. et‫ﻦ‬al.

References 1. Kumar V, Shearer JC, Kumar A, Darmstadt GL. Neonatal hypothermia in low resource settings: a review. J Perinatol 2009;29(6):401-12. 2. Alexander G, Williams D. Shivering and non-shivering therogenesis during summit metabolism in young lambs. J Physiol 1968;198(2):251-76. 3. Dahm LS, James LS. Newborn temperature and calculated heat loss in the delivery room. Pediatrics 1972;49(4):504-13. 4. Adamson KJ Jr, Towell ME. Thermal homeostasis in the fetus and newborn. Anesthesiology 1965;26:531-48.. 5. World Health Organization (WHO). Thermal Protection of the Newborn: A Practical Guide. Maternal and Newborn Health. [Internet] 1997 [cited 2012 Jun 15]; Available from: http://whqlibdoc.who.int/hq/1997/WHO_RHT_MSM_97.2.pdf 6. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L; Lancet Neonatal Survival Steering Team. Evidencebased, cost-effective interventions: how many newborn babies can we save? Lancet 2005;365(9463):977-88. 7. Johanson RB, Malla DS, Tuladhar C, Amatya M, Spencer SA, Rolfe P. A survey of technology and temperature control on a neonatal unit in Kathmandu, Nepal. J Trop Pediatr 1993;39(1):410. 8. Tafari N, Olsson EE. Neonatal cold injury in the tropics. Ethiop Med J 1973;11(1):57-65. 9. Christensson K, Ransjö-Arvidson AB, Kakoma C, Lungu F, Darkwah G, Chikamata D, et al. Midwifery care routines and prevention of heat loss in the newborn: a study in Zambia. J Trop Pediatr 1988;34(5):208-12. 10. Kambarami RA, Mutambirwa J, Maramba PP. Caregivers' perceptions and experiences of 'kangaroo care' in a developing country. Trop Doct 2002;32(3):131-3. 11. Nayeri F, Nili F. Hypothermia at birth and its associated complications in newborns: a follow up study. Iranian J Publ Health 2006;35(1):48-52. 12. Jackson CH. Multi-state modelling with R: the msm package. [internet] 2007 Oct 1 [cited 2012 Jun 15]; Available from: http://rss.acs.unt.edu/Rdoc/library/msm/doc/msm-manual.pdf 13. Hung-Wen Yeh. Estimating parameters in Markov models for longitudinal studies with missing data or surrogate outcomes. [Internet] 2007 Jan 1 [cited 2012 Jun 15]; Texas Medical Center Dissertations (via ProQuest). Available from: http://digitalcommons.library.tmc.edu/dissertations/AAI3290040 14. Titman AC, Sharples LD. A general goodness-of-fit test for Markov and hidden Markov models. Stat Med 2008;27(12):217795.

Tehran Univ Med J (TUMJ) 2012 August;70(5):282-8 http://tumj.tums.ac.ir

15. Aalen OO, Farewell VT, De Angelis D, Day NE, Gill ON. A Markov model for HIV disease progression including the effect of HIV diagnosis and treatment: application to AIDS prediction in England and Wales. Stat Med 1997;16(19):2191-210. 16. Gentleman RC, Lawless JF, Lindsey JC, Yan P. Multi-state Markov models for analysing incomplete disease history data with illustrations for HIV disease. Stat Med 1994;13(8):805-21. 17. Duffy SW, Chen HH, Tabar L, Day NE. Estimation of mean sojourn time in breast cancer screening using a Markov chain model of both entry to and exit from the preclinical detectable phase. Stat Med 1995;14(14):1531-43. 18. Marshall G, Jones RH. Multi-state models and diabetic retinopathy. Stat Med 1995;14(18):1975-83. 19. Kosorok M, Chao WH. The analysis of longitudinal ordinal response data in continuous time. J Am Stat Assoc 1996;91(434):807-17. 20. Zayeri F, Kazemnejad A, Ganjali M, Babaei G, Nayeri F. Incidence and risk factors of neonatal hypothermia at referral hospitals in Tehran, Islamic Republic of Iran. East Mediterr Health J 2007;13(6):1308-18. 21. Gluckman PD, Wyatt JS, Azzopardi D, Ballard R, Edwards AD, Ferriero DM, et al. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet 2005;365(9460):663-70. 22. Maternal Health and Safe Motherhood Programme. Thermal control of the newborn: a practical guide. Pennsylvania State University: Maternal Health and Safe Motherhood Programme, Division of Family Health, World Health Organization, 1993. 23. Titman AC. Computation of the asymptotic null distribution of goodness-of-fit tests for multi-state models. Lifetime Data Analysis 2009;15(4):519-33. 24. Cox DR, Miller HD. The Theory of Stochastic Processes. London: Chapman and Hall; 1965. 25. Kalbfleisch JD Lawlwss JF. The analysis of panel data under a Markov assumption. J Am Stat Assoc 1985;80(392):863-71. 26. Jackson CH, Sharples LD, Thompson SG, Duffy SW, Couto E. Multi-state Markov models for disease progression with classification error. Statistician 2003;52(2):193-209. 27. Jackson CH. Multi-state models for panel data: the msm package for R. J Statistic Software 2011;38(8):11-24. 28. Bhatt DR, White R, Martin G, Van Marter LJ, Finer N, Goldsmith JP, et al. Transitional hypothermia in preterm newborns. J Perinatol 2007;27 Suppl 2:S45-7.

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Tehran University Medical Journal, August 2012; Vol. 70, No. 5: 282-288

Original Article

The effects of temperature and birth weight on the transition rate of hypothermia in hospitalized neonates using Markov models Abstract Alireza Akbarzadeh Baghban Ph.D.1* Sara Jambarsang M.Sc.2 Hamid Pezeshk Ph.D.3 Fatemeh Nayeri M.D.4 1- Department of Basic Sciences, School of Rehabilitation Sciences, Physiotherapy Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2- Department of Biostatistics, Ph.D. Student, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3- School of Mathematics, Statistics and Computer Science, College of Science, University of Tehran, Tehran, Iran. 4- Maternal, Fetal & Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Received: March 13, 2012 Accepted: May 26, 2012

Background: Hypothermia is an important determinant of survival in newborns, especially among low-birth-weight ones. Prolonged hypothermia leads to edema, generalized hemorrhage, jaundice and ultimately death. This study was undertaken to examine the factors affecting transition from hypothermic state in neonates. Methods: The study consisted of 439 neonates hospitalized in NICU of Valiasr in Tehran, Iran in 2005. The neonates’ rectal temperature was measured immediately after birth and every 30 minutes afterwards, until neonates passed hypothermia stages. In order to estimate the rate of transition from neonatal hypothermic state, we used multistate Markov models with two covariates, birth weight and environmental temperature. We also used R package to fit the model. Results: Estimated transition rates from severe hypothermia and mild hypothermia were 0.1192 and 0.0549 per minute, respectively. Weight had a significant effect on transition from hypothermia to normal condition (95% CI: 0.1364–0.4165, P<0.001). Environmental temperature significantly affected the transition from hypothermia to normal stage (95% CI: 0.0439–0.4963, P<0.001). Conclusion: The results of this study showed that neonates with normal weight and neonates in an environmental temperature greater than 28 C had a higher transition rate from hypothermia stages. Since birth weight at the time of delivery is not under the control of medical staff, keeping the environmental temperature in an optimum level could help neonates to pass through the hypothermia stages faster.

Corresponding author: Emam Hossein Sq., Damavand St., Opposite Boali Hospital, School of Rehabilitation Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: +98-21-77561722 E-mail: akbarzad@sbmu.ac.ir

Keywords: birth weight, environmental, hypothermia, multi-state Markov models, neonatal, temperature, transition rate.

288 ‫ ﺗﺎ‬282 ،5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

‫ﻣﻘﺎﻳﺴﻪ ﻛﺎرﺑﺮد ‪ Ligasure‬ﺑﺎ ‪ Stapler‬ﺧﻄﻲ در رزﻛﺸﻦ و ﺗﺮﻣﻴﻢ روده‬

‫‪289‬‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ ،5‬ﺻﻔﺤﻪﻫﺎي ‪ 289‬ﺗﺎ ‪294‬‬

‫ﻣﻘﺎﻟﻪ اﺻﻴﻞ‬

‫ﻣﻘﺎﻳﺴﻪ ﻛﺎرﺑﺮد ‪ Ligasure‬ﺑﺎ ‪ Stapler‬ﺧﻄﻲ در رزﻛﺴﻴﻮن و ﺗﺮﻣﻴﻢ روده‬

‫ﭼﻜﻴﺪه‬

‫‪1‬‬

‫ﻋﻠﻴﺮﺿﺎ ﺗﻮﺳﻠﻲ‬

‫‪*2‬‬

‫ﻋﺒﺎس ﻋﺒﺪاﻟﻠﻬﻲ‬

‫ﺣﺎﻣﺪ ﮔﻞ ﻣﺤﻤﺪ زاده‬

‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ﻣﻘﺎﻟﻪ‪1390/10/19 :‬‬

‫ﺗﺎرﻳﺦ ﭘﺬﻳﺮش‪1391/02/26 :‬‬

‫زﻣﻴﻨﻪ و ﻫﺪف‪ :‬ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ اﻫﻤﻴﺖ رزﻛﺸﻦ و ﺗﺮﻣﻴﻢ روده ﺑﺎرﻳﻚ و ﻓﻘﺪان ﻣﻄﺎﻟﻌﺎت ﻛﺎﻓﻲ در اﻳﻦ زﻣﻴﻨﻪ‪ ،‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺟﻬﺖ‬

‫‪3‬‬

‫ﻣﻘﺎﻳﺴﻪ ﻋﻮارض و ﻫﺰﻳﻨﻪ ﻧﺎﺷﻲ از ﻛﺎرﺑﺮد ﻟﻴﮕﺎﺷﻮر و اﺳﺘﺎﭘﻠﺮ ﺧﻄﻲ در رزﻛﺸﻦ و ﺗﺮﻣﻴﻢ روده ﺑﺎرﻳﻚ ﻃﺮاﺣﻲ ﺷﺪ‪.‬‬

‫‪ -1‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﺟﺮاﺣﻲ آﻧﺪوﺳﻜﻮﭘﻴﻚ و‬ ‫روشﻫﺎي ﻛﻢﺗﻬﺎﺟﻤﻲ‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﻗﺎﺋﻢ )ﻋﺞ(‪،‬‬ ‫داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻣﺸﻬﺪ‪،‬‬ ‫ﻣﺸﻬﺪ‪ ،‬اﻳﺮان‪.‬‬ ‫‪ -2‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﺟﺮاﺣﻲ ﺳﺮﻃﺎن‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن‬ ‫اﻣﺎم رﺿﺎ )ع(‪ ،‬داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم‬

‫روش ﺑﺮرﺳﻲ‪ :‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻳﻚ ﻛﺎرآزﻣﺎﻳﻲ ﺑﺎﻟﻴﻨﻲ ﻓﺎز ﻳﻚ ﺑﻮد ﻛﻪ در ﺳﺎل ‪ 1389‬ﺗﺎ ‪ 1390‬در ﺑﻴﻤﺎرﺳﺘﺎن ﻗﺎﺋﻢ ﺷﻬﺮ ﻣـﺸﻬﺪ‬ ‫اﻧﺠﺎم ﮔﺮﻓﺖ‪ .‬ﺣﺠﻢ ﻧﻤﻮﻧﻪ ‪ 9‬ﻧﻔـﺮ در ﻫـﺮ ﮔـﺮوه ﺗﻌﻴـﻴﻦ ﺷـﺪ‪ .‬روش ﻛـﺎر ﺑـﻪاﻳـﻦ ﺻـﻮرت ﺑـﻮد ﻛـﻪ در ﻋﻤـﻞ ﺟﺮاﺣـﻲ‬ ‫ﻻﭘﺎروﺳﻜﻮﭘﻴﻚ ﮔﺎﺳﺘﺮﻳﻚ ﺑﺎيﭘﺲ‬

‫)‪gastric bypass‬‬

‫‪ (Laparoscopic‬ﺑﺮاي درﻣﺎن ﭼﺎﻗﻲ ﻣﺮﺿﻲ ﺑﻴﻤﺎران ﻧﻴﺎز ﺑﻪ ﻗﻄﻊ ﻛﺮدن‬

‫ﻗﺴﻤﺘﻲ از روده ﺑﺎرﻳﻚ و ﺳﭙﺲ ﺑﺴﺘﻦ دو اﻧﺘﻬﺎي آن در ﻳﻜﻲ از ﻣﺮاﺣﻞ ﻋﻤﻞ دارﻧﺪ‪ .‬اﻳـﻦ ﺑﻴﻤـﺎران اﻧﺘﺨـﺎب ﻣـﻲﺷـﺪﻧﺪ و‬ ‫ﺑﻪﺻﻮرت ﺗﺼﺎدﻓﻲ ﺑﻪ دو ﮔﺮوه اﺳﺘﻔﺎده از روش اﺳﺘﺎﭘﻠﺮ ﻳﺎ ﻟﻴﮕﺎﺷـﻮر ﺗﻘـﺴﻴﻢ ﺷـﺪﻧﺪ‪ .‬ﻋـﻮارض ﻋﻤـﻞ ﺟﺮاﺣـﻲ و ﻫﺰﻳﻨـﻪ‬

‫ﭘﺰﺷﻜﻲ ﻣﺸﻬﺪ‪ ،‬ﻣﺸﻬﺪ‪ ،‬اﻳﺮان‪.‬‬

‫ﻣﺼﺮﻓﻲ در اﺗﺎق ﻋﻤﻞ ﺑﺮرﺳﻲ ﺷﺪ‪.‬‬

‫‪ -3‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﺟﺮاﺣﻲ آﻧﺪوﺳﻜﻮﭘﻴﻚ و‬

‫ﻳﺎﻓﺘﻪﻫﺎ‪ :‬ﻫﺰﻳﻨﻪ ﺟﺮاﺣﻲ و وﺳﺎﻳﻞ در ﮔﺮوه اﺳﺘﺎﭘﻠﺮ ﺑﻴﻦ ‪ 29/5‬ﺗﺎ ‪ 40‬ﻣﻴﻠﻴﻮن رﻳﺎل و ﺑﺎ ﻣﻴﺎﻧﮕﻴﻦ ‪ 31/83±3/5‬ﻣﻴﻠﻴﻮن رﻳﺎل و‬

‫روشﻫﺎي ﻛﻢﺗﻬﺎﺟﻤﻲ‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﻗﺎﺋﻢ )ﻋﺞ(‪،‬‬ ‫داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻣﺸﻬﺪ‪،‬‬ ‫ﻣﺸﻬﺪ‪ ،‬اﻳﺮان‪.‬‬

‫در ﮔﺮوه ﻟﻴﮕﺎﺷﻮر ﺑﻴﻦ ‪ 24‬ﺗﺎ ‪ 35‬و ﺑﺎ ﻣﻴﺎﻧﮕﻴﻦ ‪ 26/72±3/92‬ﻣﻴﻠﻴﻮن رﻳﺎل ﺑﻮد و ﺗﻔﺎوت ﻣﻌﻨﻲداري ﺑﻴﻦ دو ﮔﺮوه وﺟﻮد‬ ‫داﺷﺖ )‪ .(P=0/004‬ﻃﻮل ﻣﺪت ﺟﺮاﺣﻲ در ﮔﺮوه اﺳﺘﺎﭘﻠﺮ ‪ 200±3/4‬دﻗﻴﻘﻪ و در ﮔﺮوه ﻟﻴﮕﺎﺷﻮر ‪ 240±10‬دﻗﻴﻘﻪ ﺑﻮد و‬ ‫ﺗﻔﺎوت ﻣﻌﻨﻲداري ﺑﻴﻦ دو ﮔﺮوه وﺟﻮد داﺷﺖ )‪.(P=0/043‬‬ ‫ﻧﺘﻴﺠﻪﮔﻴﺮي‪ :‬ﻛﺎرﺑﺮد ﻟﻴﮕﺎﺷﻮر در رزﻛﺸﻦ و ﺗﺮﻣﻴﻢ روده ﺑﺎرﻳﻚ‪ ،‬از روش اﺳﺘﺎﭘﻠﺮ ﺧﻄﻲ ﻣﻘﺮون ﺑﻪ ﺻﺮﻓﻪﺗﺮ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺑﻪﻧﻈﺮ‬

‫*‬

‫ﻣﻲرﺳﺪ اﻳﻦ روش‪ ،‬ﻋﻮارض ﺧﺎﺻﻲ ﺑﻪدﻧﺒﺎل ﻧﺪاﺷﺘﻪ و اﻳﻤﻦ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻣﺪت زﻣﺎن ﺟﺮاﺣﻲ ﺑﺎ ﻟﻴﮕﺎﺷﻮر ﺑﻴﺶﺗﺮ از ﺟﺮاﺣﻲ ﺑﺎ‬ ‫ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪ :‬ﻣﺸﻬﺪ‪ ،‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﺟﺮاﺣﻲ‬

‫ﺳﺮﻃﺎن‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن اﻣﺎم رﺿﺎ )ع(‪ ،‬داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪،‬‬ ‫داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﻣﺸﻬﺪ‬

‫اﺳﺘﺎﭘﻠﺮ ﻣﻲﺑﺎﺷﺪ‪.‬‬

‫ﺗﻠﻔﻦ‪0511-8022677 :‬‬

‫‪E-mail: abdollahia@mums.ac.ir‬‬

‫ﻛﻠﻤﺎت ﻛﻠﻴﺪي‪ :‬اﺳﺘﺎﭘﻠﺮ‪ ،‬ﻟﻴﮕﺎﺷﻮر‪ ،‬روده ﺑﺎرﻳﻚ‪ ،‬ﻛﺎﻫﺶ ﻫﺰﻳﻨﻪ‪ ،‬ﻃﻮل ﻣﺪت ﻋﻤﻞ‪.‬‬

‫ﻣﻘﺪﻣﻪ‬

‫ﻣﻨﻌﻄﻒ ﻛﺮدهاﻧﺪ ﻳﻜﻲ از اﻳﻦ روشﻫﺎ ﻟﻴﮕﺎﺷﻮر ﻣﻲﺑﺎﺷﺪ‪ 2.‬ﻟﻴﮕﺎﺷﻮر‪ ،‬ﻳﻚ‬ ‫دﺳﺘﮕﺎه اﻟﻜﺘﺮوﺗﺮﻣﺎل ﺟﻬﺖ ﻛﻨﺘﺮل ﻋﺮوق ﺑﺎ ﻣﻜﺎﻧﻴﺴﻢ اﻧﻌﻘﺎدﻛﻨﻨﺪه‬

‫اﺳﺘﺎﭘﻠﺮ )‪ ،(Stapler‬دﺳﺘﮕﺎه ﻣﻜﺎﻧﻴﻜﻲ ﺟﻬﺖ دوﺧﺖ و ﺗﺮﻣﻴﻢ‬

‫ﻣﻲﺑﺎﺷﺪ‪ ،‬ﻛﻪ ﺑﺎ اﺳﺘﻔﺎده از اﻧﺮژي ﮔﺮﻣﺎﻳﻲ و ﻓﺸﺎر ﻋﻤﻞ ﻣﻲﻛﻨﺪ‬

‫‪3-5‬و‪1‬‬

‫و‬

‫ﻗﺴﻤﺘﻲ از دﺳﺘﮕﺎه ﮔﻮارش ﻣﻲﺑﺎﺷﺪ‪ 1.‬در روش ﺟﺮاﺣﻲ ﻻﭘﺎروﺳﻜﻮﭘﻴﻚ‬

‫ﺑﺎﻋﺚ ﺗﺸﻜﻴﻞ ﻣﺠﺪد اﻻﺳﺘﻴﻦ و ﻛﻼژن و ﺗﺮﻣﻴﻢ ﻋﺮوق ﺣﺪاﻛﺜﺮ ﺗﺎ ﻫﻔﺖ‬

‫ﺟﻬﺖ ﺑﺮﻳﺪن و ﺑﺴﺘﻦ روده ﺑﺎرﻳﻚ و ﻳﺎ ﻣﻌﺪه از اﺳﺘﺎﭘﻠﺮ ﺧﻄﻲ اﺳﺘﻔﺎده‬

‫ﻣﻴﻠﻲﻣﺘﺮ ﻣﻲﺷﻮد‪ 6‬ﺑﺎزﺳﺎزي و آﻧﺎﺳﺘﻮﻣﻮز روده ﺑﺎرﻳﻚ ﻧﻴﺎزﻣﻨﺪ ﻗﺮارﮔﻴﺮي‬

‫ﻣﻲﺷﻮد‪ 1.‬ﺑﻪدﻟﻴﻞ ﻫﺰﻳﻨﻪ ﺑﺎﻻي اﻳﻦ روش و ﻣﺪت زﻣﺎن ﻃﻮﻻﻧﻲ ﻋﻤﻞ‬

‫ﻛﻼژن زﻳﺮ ﻣﺨﺎط دو ﺳﺮ روده در ﻛﻨﺎر ﻫﻢ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﻪﺻﻮرت ﺳﻨﺘﻲ‬

‫ﺟﺮاﺣﻲ و ﻋﺪم اﻣﻜﺎن اﺳﺘﻔﺎده از آﻧﺎﺳﺘﻮﻣﻮزﻫﺎي دﺳﺘﻲ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ‬

‫ﺑﺎ اﺳﺘﻔﺎده از ﺑﺨﻴﻪ ﻳﺎ اﺳﺘﺎﭘﻠﺮ اﻧﺠﺎم ﺷﺪه اﺳﺖ‪.‬‬

‫وﻗﺖﮔﻴـﺮ ﺑﻮدن آن اﺧﻴـﺮاً ﻣﺤﻘﻘﺎن ﺗـﻮﺟﻪ ﺧـﻮد را ﺑﻪ روشﻫﺎي دﻳـﮕﺮ‬

‫از زﻣـﺎﻧﻲ ﻛﻪ دﺳﺘﮕﺎه ﻟﻴﮕﺎﺷﻮر در ﺑﺴـﺘﻦ و ﻗﻄـﻊ ﻛـﺮدن ﻋﺮوق ﺑﺎ‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):289-94‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻋﻠﻴﺮﺿﺎ ﺗﻮﺳﻠﻲ و ﻫﻤﻜﺎران‬

‫‪290‬‬

‫ﻫﻤﻴﻦ ﻣﻜﺎﻧﻴﺴﻢ ﻳﻌﻨﻲ ﻗﺮار دادن ﻛﻼژن دو ﺳﺮ ﻋﺮوق ﺧﻮﻧﻲ ﻛﻨﺎر ﻫﻢ‬

‫‪ 1390‬در ﺑﻴﻤﺎرﺳﺘﺎن ﻗﺎﺋﻢ ﺷﻬﺮ ﻣﺸﻬﺪ اﻧﺠﺎم ﮔﺮﻓﺖ‪ .‬ﺣﺠﻢ ﻧﻤﻮﻧﻪ ‪ 9‬ﻧﻔـﺮ‬

‫ﻣﻮﻓﻖ ﻋﻤﻞ ﻛﺮده اﺳﺖ و ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ اﻳﻦﻛﻪ ﻫﻤﻴﻦ ﻣﻜﺎﻧﻴﺴﻢ ﻳﻌﻨﻲ ﻛﻨﺎر‬

‫در ﻫﺮ ﮔﺮوه ﺗﻌﻴﻴﻦ ﺷﺪ‪ .‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﭘﺲ از ﮔﺮﻓﺘﻦ رﺿﺎﻳﺖﻧﺎﻣﻪ ﻛﺘﺒﻲ‬

‫ﻫﻢ ﻗﺮارﮔﻴﺮي ﻛﻼژن در ﺑﺎﻓﺖ روده ﺑﺎرﻳﻚ ﻋﺎﻣﻞ ﻣﻮﻓﻘﻴﺖ در اﻳﺠﺎد‬

‫آﮔﺎﻫﺎﻧﻪ از ﺑﻴﻤﺎران و ﺑﺎ ﻣﺠﻮز ﻛﻤﻴﺘـﻪ اﺧـﻼق داﻧـﺸﮕﺎه ﻋﻠـﻮم ﭘﺰﺷـﻜﻲ‬

‫آﻧﺎﺳﺘﻮﻣﻮز ﻣﻲﺑﺎﺷﺪ‪ ،‬اﻣﻜﺎن اﺳﺘﻔﺎده از دﺳﺘﮕﺎه ﻟﻴﮕﺎﺷﻮر ﻧﻴﺰ ﺟﻬﺖ اﻧﺠﺎم‬

‫ﻣﺸﻬﺪ ﻧﻤﻮﻧﻪﮔﻴﺮي ﺑﻪروش در دﺳﺘﺮس اﻧﺠﺎم ﺷـﺪ‪ ،‬ﺳـﭙﺲ ﺑـﻪﺻـﻮرت‬

‫‪1‬‬

‫آﻧﺎﺳﺘﻮﻣﻮز روده ﺑﺎرﻳﻚ ﺑﻪﻧﻈﺮ اﻣﻜﺎنﭘﺬﻳﺮ ﻣﻲآﻳﺪ‪.‬‬

‫ﺗﺼﺎدﻓﻲ ﺑﻪ دو ﮔﺮوه ﺗﻘﺴﻴﻢ ﺷـﺪﻧﺪ ﻛﻠﻴـﻪ ﺑﻴﻤـﺎراﻧﻲ ﻛـﻪ ﻛﺎﻧﺪﻳـﺪ ﻋﻤـﻞ‬

‫در ﻣﻄﺎﻟﻌﺎت اﺧﻴﺮ از ﻟﻴﮕﺎﺷﻮر ﺑﻪﻃﻮر ﻣﻮﻓﻘﻴـﺖآﻣﻴـﺰي در ﺟﺮاﺣـﻲ‬ ‫ﻛﻮدﻛﺎن و ﺑﺰرگﺳﺎﻻن اﺳﺘﻔﺎده ﺷﺪه اﺳﺖ‪8.‬و‪ 7‬ﻫﻢﭼﻨـﻴﻦ ﭘـﮋوﻫﺶﻫـﺎي‬

‫ﺟﺮاﺣﻲ ﮔﺎﺳﺘﺮﻳﻚ ﺑﺎيﭘﺲ ﺑﻮدﻧـﺪ‪ ،‬ﺑـﺎ ‪ ،40<BMI<50kg/m2‬در ﮔـﺮوه‬ ‫ﺳﻨﻲ ‪ 20-65‬ﺳﺎل وارد ﻣﻄﺎﻟﻌﻪ ﺷﺪﻧﺪ‪.‬‬

‫اﺧﻴــﺮ ﻣﻮﻓﻘﻴــﺖ اﻳــﻦ روش را در ﭼﻨــﺪﻳﻦ ﺟﺮاﺣــﻲ ﻧﻈﻴــﺮ ﺟﺮاﺣــﻲ‬ ‫‪13‬‬

‫ﺗﻴﺮوﻳﻴﺪ‪ 9-11،‬زﻧﺎن‪ 12،‬اوروﻟﻮژي‪ 13‬و ﻫﻤﻮروﻳﻴﺪ ﻧﺸﺎن داده اﺳﺖ‪.‬‬

‫ﻣﻌﻴﺎرﻫـﺎي ﺧـﺮوج از ﻣﻄﺎﻟﻌـﻪ ﻋﺒـﺎرت ﺑـﻮد از‪ :‬ﺑﻴﻤـﺎران ﻣﺒـﺘﻼ ﺑــﻪ‬ ‫ﺑﻴﻤﺎريﻫﺎي زﻣﻴﻨـﻪاي از ﺟﻤﻠـﻪ دﻳﺎﺑـﺖ‪ ،‬ﻫﻴﭙﻮﺗﻴﺮوﻳﻴـﺪي‪ ،‬ﺑﻴﻤـﺎريﻫـﺎي‬

‫در ﻣﻄﺎﻟﻌﺎت ﻓﻮاﻳﺪ زﻳﺎدي ﺑﺮاي اﻳﻦ روش ذﻛﺮ ﺷﺪه اﺳﺖ از ﺟﻤﻠﻪ‬

‫آدرﻧﺎل و ﻣﺼﺮف ﻛﻮرﺗﻴﻜﻮاﺳﺘﺮوﻳﻴﺪ‪ .‬دادهﻫﺎ ﺗﻮﺳﻂ ﭼـﻚﻟﻴـﺴﺘﻲ ﻛـﻪ از‬

‫اﻳﻦ ﻓﻮاﻳﺪ‪ ،‬ﻛﺎﻫﺶ ﺧﻮنرﻳﺰي‪16‬و‪ 15‬و ﻧﻴﺎز ﻛﻢﺗﺮ ﺑﻪ ﺗﺮاﻧـﺴﻔﻮزﻳﻮن ﺧـﻮن‬

‫روي ﭘﺮوﻧﺪه ﺗﻜﻤﻴﻞ ﻣﻲﺷـﺪ ﺟﻤـﻊآوري ﮔﺮدﻳـﺪ و ﺷـﺎﻣﻞ ﻣﺸﺨـﺼﺎت‬

‫در ﺣﻴﻦ ﺟﺮاﺣﻲ ﻣﻲﺑﺎﺷﺪ‪18.‬و‪ 17‬در ﺑﺮﺧﻲ ﻣﻄﺎﻟﻌﺎت ﻧﻴـﺰ ﻛـﺎﻫﺶ ﻣـﺪت‬

‫دﻣﻮﮔﺮاﻓﻴﻚ‪ ،‬اﻧـﺪﻛﺲ ﺷـﺎﺧﺺ ﺗـﻮده ﺑـﺪﻧﻲ‪ ،‬ﻫﺰﻳﻨـﻪ ﺟﺮاﺣـﻲ‪ ،‬ﺗﻌـﺪاد‬

‫‪18‬و‪17‬‬

‫روزﻫﺎي ﺑﺴﺘﺮي در ﺑﻴﻤﺎرﺳﺘﺎن‪ ،‬زﻣﺎن ﻋﻤﻞ ﺟﺮاﺣـﻲ و ﻋـﻮارض ﻋﻤـﻞ‬

‫زﻣﺎن و ﻫﺰﻳﻨﻪ ﻋﻤﻞ ﺟﺮاﺣﻲ‪ ،‬از ﻓﻮاﻳﺪ اﻳﻦ روش ذﻛﺮ ﺷـﺪه اﺳـﺖ‪.‬‬

‫ﻣﻄﺎﻟﻌﺎﺗﻲ ﭼﻨﺪ در ﻣﻮرد اﺳﺘﻔﺎده از ﻟﻴﮕﺎﺷـﻮر ﺟﻬـﺖ ﺑـﺴﺘﻦ و اﺳـﺘﺎﻣﭗ‬

‫ﺟﺮاﺣﻲ ﺑﻮد‪.‬‬

‫ﻛﺮدن دﺳﺘﮕﺎه ﮔﻮارش ﭼﻪ در اﻧـﺴﺎن ﺑـﻪﺻـﻮرت ﻣﺤـﺪودﺗﺮ و ﭼـﻪ در‬

‫روش ﻛﺎر ﺑﻪ اﻳﻦ ﺻﻮرت ﺑﻮد ﻛﻪ ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﻧﻴﺎز ﺑـﻪ ﻗﻄـﻊ ﻛـﺮدن‬

‫ﺣﻴﻮان ﺑﻪﺻﻮرت ﮔﺴﺘﺮدهﺗﺮ اﻧﺠﺎم ﺷﺪه اﺳﺖ و ﻧﺘـﺎﻳﺞ ﻣﻮﻓﻘﻴـﺖآﻣﻴـﺰي‬

‫ﻗﺴﻤﺘﻲ از روده ﺑﺎرﻳﻚ و ﺳﭙﺲ ﺑﺴﺘﻦ دو اﻧﺘﻬـﺎي آن داﺷـﺘﻨﺪ اﻧﺘﺨـﺎب‬

‫ﺑﻪدﺳﺖ آﻣﺪه اﺳﺖ‪.‬‬

‫ﺷﺪﻧﺪ‪ .‬ﺑﺮاي ﻳﻜﺴﺎنﺳﺎزي ﺑﻴﻤﺎران‪ ،‬از ﺧﺎﻧﻢﻫﺎي ﻣﺒﺘﻼ ﺑﻪ ﭼـﺎﻗﻲ ﻣﺮﺿـﻲ‬

‫ﻣﻄﺎﻟﻌﺎﺗﻲ ﻧﻴﺰ در راﺑﻄﻪ ﺑﺎ ﻛﻨﺘﺮل ﭘﺎراﻧﺸﻴﻢ رﻳﻪ ﺑﺎ ﻟﻴﮕﺎﺷﻮر اﻧﺠﺎم ﺷﺪه‬

‫ﻛﻪ ﺗﺤﺖ ﻋﻤﻞ ﺟﺮاﺣﻲ‬

‫‪Laparoscopic Roux-En-Y Gastric Bypass‬‬

‫‪Roux-en-y gastric bypss‬‬

‫ﻗﺮار ﻣﻲﮔﺮﻓﺘﻨﺪ اﺳﺘﻔﺎده ﺷﺪ‪ .‬در اﻳﻦ روش‪ ،‬در ﭼﻨﺪ ﻣﺮﺣﻠـﻪ از ﻣﺮاﺣـﻞ‬

‫ﺟﻬﺖ ﻛﺎت ﻛﺮدن و ﺑﺴﺘﻦ روده ﺑﺎرﻳـﻚ و ﻣﻌـﺪه ﺑـﻪﺟـﺎي اﺳـﺘﻔﺎده از‬

‫ﻋﻤﻞ ﺟﺮاﺣﻲ ﻧﻴﺎز ﺑﻪ ﻗﻄﻊ ﻛﺮدن روده ﺑﺎرﻳﻚ و ﻣﻌﺪه و ﺑـﺴﺘﻦ ﻗـﺴﻤﺖ‬

‫اﺳﺘﺎﭘﻠﺮ از ﻟﻴﮕﺎﺷﻮر اﺳﺘﻔﺎده ﺷﺪه ﺑﻮد و ﻧﺘـﺎﻳﺞ ﻣﻮﻓﻘﻴـﺖآﻣﻴـﺰي ﺣﺎﺻـﻞ‬

‫ﻗﻄﻊ ﺷﺪه ﺑﺎ اﺳﺘﺎﭘﻠﺮ وﺟﻮد داﺷﺖ‪ .‬در اﻳـﻦ ﻋﻤـﻞ در روش ﻣﻌﻤـﻮل در‬

‫ﺷﺪه ﺑﻮد‪ 19.‬در ﻣﻄﺎﻟﻌﻪ ذﻛﺮ ﺷﺪه ﻣﺰاﻳﺎي اﺳﺘﻔﺎده از ﻟﻴﮕﺎﺷﻮر در ﻣﻘﺎﻳـﺴﻪ‬

‫ﻓﺎﺻﻠﻪ ‪ 40-50‬ﺳﺎﻧﺘﻲﻣﺘﺮي ﻟﻴﮕﺎﻣﺎن اﺑﺘﺪاي ژوژﻧﻮم ﺟﻬﺖ اﻳﺠﺎد ﺑـﺎزوي‬

‫ﺑﺎ اﺳﺘﺎﭘﻠﺮ ﺑﻪ اﻳﻦ ﺷﻜﻞ ﻋﻨﻮان ﺷﺪه ﺑـﻮد‪ :‬ﭘﺮﻫﻴـﺰ از ﺧـﻮنرﻳـﺰي‪ ،‬ﻟﻴـﻚ‬

‫‪ ،Roux‬روده ﺑﺎرﻳﻚ ﺗﻮﺳـﻂ اﺳـﺘﺎﭘﻠﺮ ﺧﻄـﻲ‬

‫‪(Ethicon: endosurgery‬‬

‫آﻧﺎﺳﺘﻮﻣﻮز‪ ،‬ﺑﺎز ﺷﺪن ﻣﺤﻞ اﺳﺘﺎﭘﻠﺮ ﺷﺪه و ﻓﻴﺴﺘﻮل ﻧﺎﺷﻲ از اﺳﺘﺎﭘﻠﺮ‪ 19.‬ﺑﺎ‬

‫)‪USA‬‬

‫ﺗﻮﺟﻪ ﺑﻪ ﻣﺤﺪود ﺑﻮدن ﺗﻌـﺪاد ﻣﻄﺎﻟﻌـﺎت و ﺑـﺎ ﺗﻮﺟـﻪ ﺑـﻪ ﻋﻤﻠـﻲ ﺑـﻮدن‬

‫ﻣﻲﺷﺪ‪ .‬در روش ﻣـﻮرد ﻣﻄﺎﻟﻌـﻪ‪ ،‬در اﻳـﻦ ﻣﺮﺣﻠـﻪ ﺑـﻪﺟـﺎي اﺳـﺘﻔﺎده از‬

‫اﺳﺘﻔﺎده از ﻟﻴﮕﺎﺷﻮر در رزﻛﺸﻦ و ﺗﺮﻣﻴﻢ روده ﺑﺎرﻳﻚ ﺑﺎ در ﻧﻈﺮ ﮔـﺮﻓﺘﻦ‬

‫اﺳﺘﺎﭘﻠﺮ ﺧﻄﻲ از ﻟﻴﮕﺎﺷـﻮر‬

‫‪(Coviden: Ligasure atlas Tissue fusion‬‬

‫ﺻﺮﻓﻪﺟﻮﻳﻲ ﻫﺰﻳﻨﻪ ﭼـﺸﻢﮔﻴـﺮ در اﺳـﺘﻔﺎده از ﻟﻴﮕﺎﺷـﻮر در ﻣﻘﺎﻳـﺴﻪ ﺑـﺎ‬

‫)‪ open instrument, USA‬اﺳﺘﻔﺎده ﻣﻲﺷﺪ )ﺷﻜﻞ‪ .(1 -‬از ﺑﻴﻦ ‪ 18‬ﺑﻴﻤـﺎر‬

‫اﺳﺘﺎﭘﻠﺮ‪ ،‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻫﺰﻳﻨﻪ ﺗـﺮﻣﻴﻢ روده ﺑﺎرﻳـﻚ ﺗﻮﺳـﻂ رزﻛـﺸﻦ ﺑـﺎ‬

‫در ﻳﻚ ﮔﺮوه روده ﺑﺎرﻳﻚ در ﻣﺮﺣﻠﻪ اﻳﺠـﺎد ﺑـﺎزوي ‪ Roux‬ﺑـﺎ اﺳـﺘﺎﭘﻠﺮ‬

‫ﻟﻴﮕﺎﺷﻮر ﺑﻪﻫﻤﺮاه ﺗﻘﻮﻳﺖ اﺳﺘﺎﻣﭗ ﺑﺎ ﺑﺨﻴﻪ روي آن‪ ،‬ﺑـﺎ وﺳـﻴﻠﻪ دﻳﮕـﺮي‬

‫ﺧﻄﻲ و در ﮔﺮوه دﻳﮕﺮ ﺑﺎ ﻟﻴﮕﺎﺷﻮر ﻛﺎت ﺷﺪ و ﺳـﭙﺲ ﺗـﺮﻣﻴﻢ ﺑـﺎ ﺑﺨﻴـﻪ‬

‫اﺳﺖ‪ .‬در ﻳـﻚ ﻣﻄﺎﻟﻌـﻪ در ﻋﻤـﻞ ﺟﺮاﺣـﻲ‬

‫ﺑﻪﻧﺎم اﺳﺘﺎﭘﻠﺮ ﺧﻄﻲ )‪ (Linear stapler‬ﻣﻮرد ﻣﻘﺎﻳﺴﻪ ﻗﺮار ﮔﺮﻓﺖ‪.‬‬

‫‪2-0‬‬

‫‪ stapler,‬ﻗﻄﻊ ﺷﺪه و دو ﺳﺮ ﻗﻄﻊ ﺷﺪه آن ﺗﻮﺳﻂ اﺳـﺘﺎﭘﻠﺮ ﺑـﺴﺘﻪ‬

‫‪NJ, USA) PDS‬‬

‫‪ (Ethicon Inc., Somerville,‬در ﻳــﻚ ﻻﻳــﻪ‬

‫ﺑﻪﺻﻮرت ﭘﻴﻮﺳﺘﻪ در ﺑﻴﻤﺎراﻧﻲ ﻛﻪ روده ﺑﺎرﻳﻚ ﺑﺎ ﻟﻴﮕﺎﺷـﻮر ﻗﻄـﻊ ﺷـﺪه‬

‫روش ﺑﺮرﺳﻲ‬

‫ﺑﻮد‪ ،‬روي ﻣﻨﻄﻘﻪ ﻟﻴﮕﺎﺷﻮر ﺷﺪه ﻛﻪ ﻣﻮﻗﺘﺎً ﺑﺴﺘﻪ ﺷﺪه ﺑﻮد‪ ،‬ﺟﻬﺖ ﺗﻘﻮﻳـﺖ‬ ‫اﻧﺠﺎم ﺷﺪ )ﺷﻜﻞ‪.(2 -‬‬

‫اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻳﻚ ﻛﺎرآزﻣﺎﻳﻲ ﺑﺎﻟﻴﻨﻲ ﻓﺎز ﻳﻚ ﺑﻮد ﻛﻪ در ﺳﺎل ‪ 1389‬ﺗﺎ‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ 289 ،5‬ﺗﺎ ‪294‬‬

‫اﻳﻦ اﻧﺘﺨﺎب ﺑﻴـﻦ ﺑﻴـﻤﺎران ﻛﺎﻣﻼ ﺑﻪﺻﻮرت ﺗﺼﺎدﻓﻲ اﻧﺠﺎم ﺷﺪ‪ .‬ﺗﻨﻬﺎ‬

‫ﻣﻘﺎﻳﺴﻪ ﻛﺎرﺑﺮد ‪ Ligasure‬ﺑﺎ ‪ Stapler‬ﺧﻄﻲ در رزﻛﺸﻦ و ﺗﺮﻣﻴﻢ روده‬

‫‪291‬‬

‫ﺷﻜﻞ‪ :1 -‬روده ﺑﺎرﻳﻚ در ﺣﺎل ﻗﻄﻊ ﺷﺪن ﺑﺎ ﻟﻴﮕﺎﺷﻮر‬

‫ﺷﻜﻞ‪ :2 -‬ﺳﻮﭼﻮر ﺗﻘﻮﻳﺘﻲ ﺑﺎ ﻧﺦ ‪ PDS 2-0‬ﺑﺮ روي ﻣﺤﻞ ﻟﻴﮕﺎﺷﻮر ﺷﺪه‬

‫در اﻳﻦ ﻳﻚ ﻣﺮﺣﻠﻪ از ﻣﺮاﺣـﻞ ﺟﺮاﺣـﻲ از ﻟﻴﮕﺎﺷـﻮر ﺑـﻪﺟـﺎي اﺳـﺘﺎﭘﻠﺮ‬

‫داﺷﺘﻨﺪ‪ .‬ﺳﻦ ﺑﻴﻤﺎران در ﮔﺮوه اﺳﺘﺎﭘﻠﺮ ﺑﻴﻦ ‪ 20‬ﺗﺎ ‪ 65‬ﺳﺎل و ﺑـﺎ ﻣﻴـﺎﻧﮕﻴﻦ‬

‫اﺳﺘﻔﺎده ﺷـﺪ و در ﺳـﺎﻳﺮ ﻣﺮاﺣـﻞ ﺟﺮاﺣـﻲ در ﻫـﺮ دو ﮔـﺮوه از روش‬

‫‪ 34/66±3/3‬و در ﮔﺮوه ﻟﻴﮕﺎﺷﻮر ﺑـﻴﻦ ‪ 29‬ﺗـﺎ ‪ 57‬ﺳـﺎل و ﺑـﺎ ﻣﻴـﺎﻧﮕﻴﻦ‬

‫ﻣﻌﻤﻮل ﻳﻌﻨﻲ اﺳﺘﻔﺎده از اﺳﺘﺎﭘﻠﺮ ﺟﻬﺖ ﺑﺮﻳـﺪن و ﺑـﺴﺘﻦ ﻗـﺴﻤﺖ ﺑﺮﻳـﺪه‬

‫‪ 38/36±6/05‬ﺑﻮد‪ .‬ﺗﻔﺎوت ﻣﻌﻨـﻲداري ﺑـﻴﻦ دو ﮔـﺮوه وﺟـﻮد ﻧﺪاﺷـﺖ‬

‫ﺷﺪه اﺳﺘﻔﺎده ﺷﺪ‪ .‬ﺳﭙﺲ در اﻧﺘﻬﺎي ﻋﻤﻞ ﺑﺎ ﺗﺴﺖ ﺑﻠﻮدوﻣﺘﻴﻠﻦ ﺑﺴﺘﻪ ﺷﺪن‬

‫)‪ ،(P>0/050‬وزن ﺑﻴﻤﺎران در ﮔﺮوه اﺳﺘﺎﭘﻠﺮ ﺑﻴﻦ ‪ 87‬ﺗﺎ ‪ 147‬و ﺑﺎ ﻣﻴﺎﻧﮕﻴﻦ‬

‫آﻧﺎﺳﺘﻮﻣﻮز ﺑﺮرﺳﻲ ﺷﺪ و در روز ﭼﻬﺎرم ﺑﻌﺪ از ﻋﻤﻞ ﻧﻴﺰ ﻗﺒﻞ از ﺷـﺮوع‬

‫‪ 97/61±10/30‬و در ﮔــﺮوه ﻟﻴﮕﺎﺷــﻮر ﺑــﻴﻦ ‪ 98‬ﺗــﺎ ‪ 140‬و ﺑــﺎ ﻣﻴــﺎﻧﮕﻴﻦ‬

‫رژﻳﻢ ﻏﺬاﻳﻲ ﺑـﺮاي ﺑﻴﻤـﺎران ﮔﺮاﻓـﻲ ﺑـﺎ ﻣـﺎده ﺣﺎﺟـﺐ ﺟﻬـﺖ ﺑﺮرﺳـﻲ‬

‫‪ 113/22±6/08‬ﺑﻮد و ﺗﻔﺎوت ﻣﻌﻨﻲداري ﺑﻴﻦ دو ﮔﺮوه وﺟـﻮد ﻧﺪاﺷـﺖ‬

‫آﻧﺎﺳﺘﻮﻣﻮزﻫﺎ و اﺳﺘﺎﻣﭗﻫﺎ ﮔﺮﻓﺘﻪ ﺷﺪ‪.‬‬

‫)‪ BMI .(P>0/050‬ﺑﻴﻤﺎران‪ ،‬در ﮔﺮوه اﺳﺘﺎﭘﻠﺮ ﺑﻴﻦ ‪ 40‬ﺗﺎ ‪ 46‬و ﺑﺎ ﻣﻴﺎﻧﮕﻴﻦ‬

‫ﺗﻤﺎم اﻋﻤﺎل ﺟﺮاﺣﻲ ﺗﻮﺳﻂ ﻳـﻚ ﺟـﺮاح اﻧﺠـﺎم ﺷـﺪ‪ ،‬در روزﻫـﺎي‬

‫‪ 40/25±3/77‬و در ﮔــﺮوه ﻟﻴﮕﺎﺷــﻮر ﺑــﻴﻦ ‪ 42‬ﺗــﺎ ‪ 50‬و ﺑــﺎ ﻣﻴــﺎﻧﮕﻴﻦ‬

‫ﺑﺴﺘﺮي ﺑﻌﺪ از ﻋﻤﻞ ﺑﻴﻤﺎران ﺗﻮﺳﻂ ﺟﺮاح دﻳﮕﺮي ﻛـﻪ از ﺗﻘـﺴﻴﻢﺑﻨـﺪي‬

‫‪ 44/72±3/29‬ﺑﻮد و ﺗﻔﺎوت ﻣﻌﻨﻲداري ﺑﻴﻦ دو ﮔـﺮوه وﺟـﻮد ﻧﺪاﺷـﺖ‬

‫ﺑﻴﻤﺎران اﻃﻼع ﻧﺪاﺷﺖ از ﻧﻈﺮ اﻳﺠـﺎد ﻋـﻮارض وﻳﺰﻳـﺖ ﺷـﺪﻧﺪ‪ .‬ﺳـﭙﺲ‬

‫)‪ .(P=0/066‬ﻣﻴﺎﻧﮕﻴﻦ روزﻫﺎي ﺑﺴﺘﺮي در ﮔﺮوه اﺳـﺘﺎﭘﻠﺮ ‪ 5/55±3/43‬و‬

‫‪‬‬

‫در ﮔﺮوه ﻟﻴﮕﺎﺷﻮر ‪ 4/66±3/90‬ﺑﻮد و ﺗﻔﺎوت ﻣﻌﻨﻲداري ﺑـﻴﻦ دو ﮔـﺮوه‬

‫دادهﻫﺎ ﺑﺎ ﻧﺮماﻓـﺰار ‪ SPSS‬وﻳﺮاﺳـﺖ ‪ 16‬و ‪ Mann-Whitney U-test‬و‬

‫‪2‬‬

‫ﻣﻮرد ﺗﺠﺰﻳﻪ و ﺗﺤﻠﻴﻞ ﻗﺮار ﮔﺮﻓﺘﻨﺪ‪.‬‬

‫وﺟﻮد ﻧﺪاﺷﺖ )‪.(P=0/603‬‬ ‫ﻫﺰﻳﻨﻪ ﺟﺮاﺣﻲ و وﺳﺎﻳﻞ در ﮔﺮوه اﺳﺘﺎﭘﻠﺮ ﺑﻴﻦ ‪ 29/5‬ﺗﺎ ‪ 4/0‬ﻣﻴﻠﻴـﻮن‬

‫ﻳﺎﻓﺘﻪﻫﺎ‬ ‫در اﻳـﻦ ﻣﻄﺎﻟﻌﻪ ﻛﻠﻴﻪ ﺑﻴـﻤﺎران زن ﺑﻮدﻧﺪ و ﺳﻦ ﺑﻴـﻦ ‪ 20‬ﺗﺎ ‪ 65‬ﺳﺎل‬

‫رﻳﺎل و ﺑﺎ ﻣﻴﺎﻧﮕﻴﻦ ‪ 31/83±3/5‬ﻣﻴﻠﻴﻮن رﻳﺎل و در ﮔﺮوه ﻟﻴﮕﺎﺷـﻮر ﺑـﻴﻦ‬ ‫‪ 24‬ﺗﺎ ‪ 35‬ﻣﻴﻠﻴﻮن رﻳﺎل و ﺑﺎ ﻣﻴﺎﻧﮕﻴﻦ ‪ 26/72±3/92‬ﻣﻴﻠﻴﻮن رﻳـﺎل ﺑـﻮد و‬ ‫ﺗﻔﺎوت ﻣﻌﻨﻲداري ﺑﻴـﻦ دو ﮔﺮوه وﺟﻮد داﺷﺖ )‪ .(P=0/004‬ﻣﺪت زﻣﺎن‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):289-94‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻋﻠﻴﺮﺿﺎ ﺗﻮﺳﻠﻲ و ﻫﻤﻜﺎران‬

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‫ﺻﺮﻓﻪﺟﻮﻳﻲ ﺷﺪ‪ 19.‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻧﻴﺰ ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ را ﺗﺎﻳﻴﺪ ﻣﻲﻛﻨﺪ‪.‬‬

‫ﺟﺪول‪ :1 -‬ﻣﻘﺎﻳﺴﻪ ﻋﻮارض ﺑﻌﺪ از ﻋﻤﻞ در دو ﮔﺮوه‬ ‫اﺳﺘﺎﭘﻠﺮ‬

‫ﻟﻴﮕﺎﺷﻮر‬

‫ﻓﻴﺴﺘﻮل‬

‫‪-‬‬

‫ﺗﺐ‬

‫‪-‬‬

‫‪1‬‬

‫در ﻣﻄﺎﻟﻌــﻪ ‪ Moreno-Sanz‬در ﻋﻤــﻞ ﻛﻮﻟﻜﺘــﻮﻣﻲ راﺳــﺖ ﺑــﻪروش‬ ‫ﻻﭘﺎروﺳﻜﻮﭘﻴﻚ ﺟﻬﺖ ﺑﺴﺘﻦ اﺳﺘﺎﻣﭗ اﻳﻠﺌﻮم‪ ،‬ﺑﻪﺟﺎي اﺳﺘﻔﺎده از اﺳـﺘﺎﭘﻠﺮ‬ ‫از ﻟﻴﮕﺎﺷﻮر ‪ Atlas‬اﺳﺘﻔﺎده ﺷﺪ و ﻫﻴﭻﮔﻮﻧﻪ ﻣﺸﻜﻠﻲ از ﺟﻤﻠﻪ ﻧﺸﺖ و ﻳـﺎ‬

‫آﺑﺴﻪ ﺑﻌﺪ از ﺟﺮاﺣﻲ‬

‫‪1‬‬

‫‪-‬‬

‫ﭘﻨﻮﻣﻮﻧﻲ‬

‫‪-‬‬

‫ﺑﺎز ﺷﺪن ﻣﺤﻞ اﺳﺘﺎﻣﭗ در ﺑﻴﻤﺎران ﺑﻪوﺟﻮد ﻧﻴﺎﻣﺪ‪ 20.‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻧﻴـﺰ ﺑـﺎ‬

‫ﭘﺮﻳﺘﻮﻧﻴﺖ‬

‫‪-‬‬

‫ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﻫﻢﺧﻮاﻧﻲ دارد‪.‬‬

‫‪-‬‬

‫آﻣﺒﻮﻟﻲ‬ ‫)‪(P=0/086‬‬

‫در ﻣﻄﺎﻟﻌﻪ ‪ Smulders‬اﺳﺘﻔﺎده از ﻟﻴﮕﺎﺷﻮر در ﺑﺴﺘﻦ روده ﺑﺎرﻳﻚ در‬ ‫ﺧﻮك‪ ،‬ﺗﺤﺖ ﻣﻄﺎﻟﻌﻪ ﻗـﺮار ﮔﺮﻓـﺖ و ﻧﺘﻴﺠـﻪ از ﻧﻈـﺮ ﻣﻴﻜﺮوﺳـﻜﻮﭘﻲ و‬ ‫ﻫﻴﺴﺘﻮﻟﻮژﻳﻚ آزﻣﺎﻳﺶ ﺷﺪ و ﺑﻪ اﻳﻦ ﻧﺘﻴﺠﻪ رﺳﻴﺪ ﻛﻪ اﺳﺘﻔﺎده از ﻟﻴﮕﺎﺷﻮر‬ ‫‪21‬‬

‫ﺟﻬﺖ ﺑﺴﺘﻦ و آﻧﺎﺳﺘﻮﻣﻮز روده ﺑﺎرﻳﻚ اﻣﻜﺎنﭘﺬﻳﺮ و ﺑﻲﺧﻄـﺮ اﺳـﺖ‪،‬‬ ‫ﺟﺮاﺣﻲ در ﮔﺮوه ﻟﻴﮕﺎﺷﻮر ﺑﻴﻦ ‪ 210‬ﺗﺎ ‪ 250‬دﻗﻴﻘﻪ و ﺑﺎ ﻣﻴﺎﻧﮕﻴﻦ‬

‫ﻫﻢﭼﻨﻴﻦ در ﻣﻄﺎﻟﻌﻪ ‪ Sorgato‬ﺑﺮ روي ﮔﺮوﻫﻲ از ﺧﺮﮔﻮشﻫـﺎ ﺑـﺴﺘﻦ و‬

‫‪ 240±10‬دﻗﻴﻘﻪ و در ﮔﺮوه اﺳﺘﺎﭘﻠﺮ ﺑﻴﻦ ‪ 180‬ﺗﺎ ‪ 210‬و ﺑﺎ ﻣﻴﺎﻧﮕﻴﻦ‬

‫اﺳﺘﺎﻣﭗ ﻛﺮدن روده ﺑﺎرﻳﻚ و ﺳﻜﻮم ﺗﻮﺳﻂ ﻟﻴﮕﺎﺷﻮر آزﻣـﺎﻳﺶ ﺷـﺪ‪ .‬در‬

‫‪ 200±3/4‬دﻗﻴﻘﻪ ﺑﻮد و ﺗﻔﺎوت ﻣﻌﻨﻲداري ﺑﻴﻦ دو ﮔﺮوه وﺟﻮد داﺷﺖ‬

‫اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻗﺪرت و اﺳﺘﺤﻜﺎم اﺳﺘﺎﻣﭗ ﺑﻼﻓﺎﺻﻠﻪ ﺑﻌﺪ از ﻟﻴﮕﺎﺷﻮر ﺷـﺪن‬

‫)‪ .(P=0/040‬ﻫﻴﭻ ﻣﻮردي ﻧﺸﺖ ﺑﻠﻮدوﻣﺘﻴﻠﻦ در ﺣﻴﻦ ﻋﻤﻞ ﺟﺮاﺣﻲ‪،‬‬

‫و ﭘﺮوﺳﻪ ﺗﺮﻣﻴﻢ اﺳﺘﺎﻣﭗ ﺑﻪ روشﻫﺎي ﻫﻴﺴﺘﻮﭘﺎﺗﻮﻟﻮژﻳﻚ ﺑﺮرﺳﻲ ﺷـﺪ و‬

‫ﻧﺸﺖ ﻣﺎده ﺣﺎﺟﺐ در روز ﭼﻬﺎر ﭘﺲ از ﻋﻤﻞ ﺟﺮاﺣﻲ در ﮔﺮاﻓﻲ و ﻧﻴﺰ‬

‫اﻳﻦ ﻧﺘﻴﺠﻪ ﺣﺎﺻﻞ ﺷﺪ ﻛﻪ اﺳﺘﻔﺎده از ﻟﻴﮕﺎﺷﻮر ﺟﻬﺖ ﺑﺴﺘﻦ روده ﺑﺎرﻳﻚ‬

‫ﻣﺮگ در دو ﮔﺮوه ﻣﺸﺎﻫﺪه ﻧﺸﺪ و ﺗﻨﻬﺎ ﻳﻚ ﻣﻮرد ﻋﺎرﺿﻪ ﺟﺮاﺣﻲ در‬ ‫ﮔﺮوه درﻣﺎن ﺑﺎ اﺳﺘﺎﭘﻠﺮ دﻳﺪه ﺷﺪ )ﺟﺪول‪.(1 -‬‬

‫‪22‬‬

‫ﻣﻲﺗﻮاﻧﺪ ﻣﻄﻤﺌﻦ و اﻳﻤﻦ ﺑﺎﺷﺪ‪.‬‬

‫در ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﻧﻴﺰ ﻫﻴﭻﮔﻮﻧﻪ ﻧﺸﺖ ﺑﻠﻮدوﻣﺘﻴﻠﻦ ﻳﺎ ﻣـﺎده ﺣﺎﺟـﺐ‬ ‫دﻳﺪه ﻧﺸﺪ و ﻫﻴﭻ ﻋﺎرﺿﻪ در اﺳـﺘﻔﺎده از اﻳـﻦ روش ﻣـﺸﺎﻫﺪه ﻧﮕﺮدﻳـﺪ‪.‬‬ ‫‪ ،Gehrig‬در ﻳﻚ ﻣﻄﺎﻟﻌﻪ ﻣﻘﺪﻣﺎﺗﻲ درﻳﺎﻓﺖ ﻛﻪ در روش ﻟﻴﮕﺎﺷﻮر ﻣـﺪت‬

‫ﺑﺤﺚ‬

‫زﻣﺎن ﺟﺮاﺣﻲ ﻛﻮﺗﺎهﺗﺮ‪ ،‬ﻣﻴﺰان ﺧﻮنرﻳـﺰي ﻛـﻢﺗـﺮ و ﻫﺰﻳﻨـﻪﻫـﺎ ﺑـﻪﻃـﻮر‬

‫در ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﻫﻴﭻﮔﻮﻧﻪ ﻋﺎرﺿﻪاي در ﮔﺮوه ﻟﻴﮕﺎﺷـﻮر ﻣـﺸﺎﻫﺪه‬

‫ﻣﻌﻨﻲداري در اﻳﻦ ﮔﺮوه ﻛﻢﺗﺮ اﺳﺖ‪ 23.‬در ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿـﺮ ﻣـﺪت زﻣـﺎن‬

‫ﻧﺸﺪ ﺗﻨﻬﺎ ﻳﻚ ﻣﻮرد آﺑﺴﻪ در ﮔﺮوه اﺳﺘﺎﭘﻠﺮ ﻣﺸﺎﻫﺪه ﺷﺪ ﻛﻪ ﭘﺲ از درﻧﺎژ‬

‫ﺑﺴﺘﺮي در ﺑﻴﻦ دو ﮔﺮوه ﺗﻔﺎوت ﻣﻌﻨﻲداري ﻧﺪاﺷﺖ‪ ،‬ﻣﻴﺰان ﺧـﻮنرﻳـﺰي‬

‫و ﺷﺴﺘﺸﻮ و ﺗﻌﺒﻴﻪ درن ﺑﺪون ﻣﺸﺎﻫﺪه ﻟﻴﻚ واﺿﺢ از ﻣﺤﻞ آﻧﺎﺳﺘﻮﻣﻮزﻫﺎ‬

‫ﻧﻴﺰ ﺑﺮرﺳﻲ ﻧﺸﺪ وﻟﻲ ﻫﺰﻳﻨﻪ ﺟﺮاﺣﻲ ﺑـﻪﻃـﻮر ﻣﻌﻨـﻲداري ﻛـﻢﺗـﺮ ﺑـﻮد‪.‬‬

‫و ﻧﻴﺰ ﺑﺪون اﻳﺠـﺎد ﻓﻴـﺴﺘﻮل ﺑﻬﺒـﻮد ﻳﺎﻓـﺖ‪ .‬ﻫﺰﻳﻨـﻪ اﻳـﻦ روش ﺗﻔـﺎوت‬

‫ﻛﺎرﺑﺮد ﻟﻴﮕﺎﺷﻮر در رزﻛـﺸﻦ و ﺗـﺮﻣﻴﻢ روده ﺑﺎرﻳـﻚ‪ ،‬از روش اﺳـﺘﺎﭘﻠﺮ‬

‫ﻣﻌﻨﻲداري ﺑﺎ روش اﺳﺘﺎﭘﻠﺮ داﺷﺖ‪ .‬ﻣﻴﺎﻧﮕﻴﻦ ﻃﻮل ﻣﺪت ﺟﺮاﺣﻲ ﺑﻪﻃـﻮر‬

‫ﺧﻄﻲ ﻣﻘﺮون ﺑﻪ ﺻﺮﻓﻪﺗﺮ ﺑﻪﻧﻈﺮ ﻣﻲرﺳﺪ و ﺑﻪﻧﻈﺮ ﻣﻲرﺳﺪ ﻛـﻪ ﻋـﻮارض‬

‫ﻣﻌﻨﻲداري در ﮔﺮوه ﻟﻴﮕﺎﺷﻮر از اﺳﺘﺎﭘﻠﺮ ﺑﻴﺶﺗﺮ ﺑﻮد‪.‬‬

‫ﺧﺎﺻﻲ ﺑﻪدﻧﺒﺎل ﻧﺪاﺷﺘﻪ و اﻳﻤﻦ ﺑﺎﺷﺪ‪ ،‬ﻫﺮﭼﻨﺪ ﻣـﺪت زﻣـﺎن ﺟﺮاﺣـﻲ در‬

‫در ﻣﻄﺎﻟﻌﻪ ‪ Ettinger‬در ﻋﻤﻞ ﺟﺮاﺣـﻲ‬

‫‪Roux-en-y gastric bypss‬‬

‫از روش ﺑﺪون اﺳﺘﺎﭘﻠﺮ اﺳﺘﻔﺎده ﺷـﺪ‪ .‬ﺑـﺪﻳﻦﻣﻨﻈـﻮر آنﻫـﺎ در ‪ 10‬ﺑﻴﻤـﺎر‬ ‫ﺟﻬﺖ ﺑﺮﻳـﺪن و ﺑـﺴﺘﻦ روده ﺑﺎرﻳـﻚ و ﻗـﺴﻤﺖ ﻣﻌـﺪه در ﻃـﻲ ﻋﻤـﻞ‬

‫اﻳﻦ روش‪ ،‬ﺑﻴﺶﺗﺮ اﺳﺖ‪.‬‬ ‫اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺟﻬـﺖ ﺗﻌﻤـﻴﻢ ﺑـﻪ ﺟﺎﻣﻌـﻪ ﻛـﺎﻓﻲ ﻧﻤـﻲﺑﺎﺷـﺪ و اﻧﺠـﺎم‬ ‫ﻣﻄﺎﻟﻌﺎت آﺗﻲ ﺑﺎ ﺣﺠﻢ ﻧﻤﻮﻧﻪ ﻛﺎﻓﻲ ﺿﺮوري ﺑﻪﻧﻈﺮ ﻣﻲرﺳﺪ‪.‬‬

‫ﺟﺮاﺣﻲ از ﻟﻴﮕﺎﺷﻮر ‪ Atlas‬اﺳﺘﻔﺎده ﻛﺮدﻧﺪ و ﺑﻌﺪ ﺑـﻪ روي ﻣﺤـﻞ ﺑـﺴﺘﻪ‬

‫ﺳﭙﺎﺳﮕﺰاري‪ :‬اﻳﻦ ﻣﻘﺎﻟﻪ‪ ،‬ﺣﺎﺻﻞ ﺑﺨـﺸﻲ از ﭘﺎﻳـﺎنﻧﺎﻣـﻪ آﻗـﺎي دﻛﺘـﺮ‬

‫ﺷﺪن ﺳﻮﭼﻮرﻫﺎي ﭘﻴﻮﺳﺘﻪ ﺑﻪﻣﻨﻈﻮر ﺗﻘﻮﻳـﺖ و اﻃﻤﻴﻨـﺎن از ﺑـﺴﺘﻪ ﺑـﻮدن‬

‫ﺣﺎﻣﺪ ﮔﻞﻣﺤﻤﺪزاده ﺗﺤﺖ ﻋﻨﻮان "ﻣﻘﺎﻳﺴﻪ ﻛﺎرﺑﺮد ﻟﻴﮕﺎﺷـﻮر ﺑـﺎ اﺳـﺘﺎﭘﻠﺮ‬

‫اﺳﺘﺎﻣﭗ روده و ﺑﺮ روي ﻣﻌﺪه ﻟﻴﮕﺎﺷﻮر ﺷﺪه اﺳﺘﻔﺎده ﻛﺮدﻧﺪ‪ .‬ﻣﺰاﻳﺎي اﻳﻦ‬

‫ﺧﻄﻲ در رزﻛﺸﻦ و ﺗﺮﻣﻴﻢ روده" در ﻣﻘﻄﻊ دﻛﺘﺮاي ﺗﺨﺼﺼﻲ در ﺳـﺎل‬

‫روش ﭘﺮﻫﻴﺰ از ﺧﻮنرﻳﺰي‪ ،‬ﻟﻴﻚ آﻧﺎﺳﺘﻮﻣﻮز‪ ،‬ﺑـﺎز ﺷـﺪن ﻣﺤـﻞ اﺳـﺘﺎﭘﻠﺮ‬

‫‪ 1390‬ﺑﻪ ﻛﺪ ‪ 1805‬ﻛﻪ ﺑﺎ ﺣﻤﺎﻳﺖ داﻧـﺸﮕﺎه ﻋﻠـﻮم ﭘﺰﺷـﻜﻲ و ﺧـﺪﻣﺎت‬

‫ﺷــﺪه و ﻓﻴــﺴﺘﻮل ﻧﺎﺷــﻲ از اﺳــﺘﺎﭘﻠﺮ ﺑــﻮد‪ .‬ﻫــﻢﭼﻨــﻴﻦ در ﻫﺰﻳﻨــﻪ ﻧﻴــﺰ‬

‫ﺑﻬﺪاﺷﺘﻲ درﻣﺎﻧﻲ ﻣﺸﻬﺪ اﺟﺮا ﺷﺪه اﺳﺖ‪.‬‬

293

‫رزﻛﺸﻦ و ﺗﺮﻣﻴﻢ روده‬Tavassoli ‫ ﺧﻄﻲ در‬Stapler ‫ ﺑﺎ‬Ligasure ‫ﻣﻘﺎﻳﺴﻪ ﻛﺎرﺑﺮد‬ A. et al.

References 1. Lee WJ, Chen TC, Lai IR, Wang W, Huang MT. Randomized clinical trial of Ligasure versus conventional surgery for extended gastric cancer resection. Br J Surg 2003;90(12):1493-6. 2. Diener MK, Heukaufer C, Schwarzer G, Seiler CM, Antes G, Buchler MW, et al. Pancreaticoduodenectomy (classic Whipple) versus pylorus-preserving pancreaticoduodenectomy (pp Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2008;(2):CD006053. 3. Gelmini R, Romano F, Quaranta N, Caprotti R, Tazzioli G, Colombo G, et al. Sutureless and stapleless laparoscopic splenectomy using radiofrequency: LigaSure device. Surg Endosc 2006;20(6):991-4. 4. Romano F, Franciosi C, Caprotti R, Uggeri F, Uggeri F. Hepatic surgery using the Ligasure vessel sealing system. World J Surg 2005;29(1):110-2. 5. Marcello PW, Roberts PL, Rusin LC, Holubkov R, Schoetz DJ. Vascular pedicle ligation techniques during laparoscopic colectomy. A prospective randomized trial. Surg Endosc 2006;20(2):263-9. Epub 2005 Dec 9. 6. Kennedy JS, Stranahan PL, Taylor KD, Chandler JG. High-burststrength, feedback-controlled bipolar vessel sealing. Surg Endosc 1998;12(6):876-8. 7. Shigemura N, Akashi A, Nakagiri T, Ohta M, Matsuda H. A new tissue-sealing technique using the Ligasure system for nonanatomical pulmonary resection: preliminary results of sutureless and stapleless thoracoscopic surgery. Ann Thorac Surg 2004;77(4):1415-8; discussion 1419. 8. Shigemura N, Akashi A, Nakagiri T. New operative method for a giant bulla: sutureless and stapleless thoracoscopic surgery using the Ligasure system. Eur J Cardiothorac Surg 2002;22(4):646-8. 9. Albanese CT, Sydorak RM, Tsao K, Lee H. Thoracoscopic lobectomy for prenatally diagnosed lung lesions. J Pediatr Surg 2003;38(4):553-5. 10. Tirabassi MV, Banever GT, Tashjian DB, Moriarty KP. Quantitation of lung sealing in the survival swine model. J Pediatr Surg 2004;39(3):387-90. 11. Youssef T, Mahdy T, Farid M, Latif AA. Thyroid surgery: use of the LigaSure Vessel Sealing System versus conventional knot tying. Int J Surg 2008;6(4):323-7.

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12. Slomovitz BM, Ramirez PT, Frumovitz M, Soliman PT, Bevers M, Coleman RL, et al. Electrothermal bipolar coagulation for pelvic exenterations. Gynecol Oncol 2006;102(3):534-6. 13. Sengupta S, Webb DR. Use of a computer-controlled bipolar diathermy system in radical prostatectomies and other open urological surgery. ANZ J Surg 2001;71(9):538-40. 14. Muzi MG, Milito G, Nigro C, Cadeddu F, Andreoli F, Amabile D, et al. Randomized clinical trial of LigaSure and conventional diathermy haemorrhoidectomy. Br J Surg 2007;94(8):937-42. 15. Slomovitz BM, Ramirez PT, Frumovitz M, Soliman PT, Bevers M, Coleman RL, et al. Electrothermal bipolar coagulation for pelvic exenterations. Gynecol Oncol 2006;102(3):534-6. 16. Eroglu A, Turkyilmaz A, Aydin Y, Erdem AF, Tokur M, Karaoglanoglu N. The use of the LigaSure Vessel Sealing System in esophageal cancer surgery. Ann Thorac Surg 2007;84(6):2076-9. 17. Cheang T, Hanna SS, Wright FC, Law CH. Use of a collagen-sealing device in hepatic resection: a comparative analysis to standard resection technique. HPB (Oxford) 2006;8(3):194-9. 18. Sengupta S, Webb DR. Use of a computer-controlled bipolar diathermy system in radical prostatectomies and other open urological surgery. ANZ J Surg 2001;71(9):538-40. 19. Ettinger JE, Ramos AC, Azaro E, Galvão-Neto MP, Mello CA, Galvão MS, et al. Staplerless laparoscopic gastric bypass: a new option in bariatric surgery. Obes Surg 2006;16(5):638-45. 20. Moreno-Sanz C, Picazo-Yeste J, Seoane-Gonzáles J, Manzanera-Díaz M, Tadeo-Ruiz G. Division of the small bowel with the LigaSure Atlas device during the right laparoscopic colectomy. J Laparoendosc Adv Surg Tech A 2008;18(1):99-101. 21. Smulders JF, de Hingh IH, Stavast J, Jackimowicz JJ. Exploring new technologies to facilitate laparoscopic surgery: creating intestinal anastomoses without sutures or staples, using a radio-frequencyenergy-driven bipolar fusion device. Surg Endosc 2007;21(11):21059. 22. Sorgato N, Bernante P, Pelizzo MR. Application of the LigaSure tissue sealing system to intestinal resection. Experimental and clinical trial. Ann Ital Chir 2008;79(5):383-8. 23. Gehrig T, Müller-Stich BP, Kenngott H, Fischer L, Mehrabi A, Büchler MW, et al. LigaSure versus conventional dissection technique in pancreatoduodenectomy: a pilot study. Am J Surg 2011;201(2):166-70.

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Tehran University Medical Journal, August 2012; Vol. 70, No. 5: 289-294

Original Article

Resection and reconstruction of small intestine with ligasure and linear stapler: a comparative study Abstract Alireza Tavassoli M.D.1 Abbas Abdollahi M.D.2* Hamed Golmohammadzadeh M.D.3 1- Endoscopic & Minimally Invasive Surgery Research Center, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. 2- Surgical Oncology Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. 3- Endoscopic & Minimally Invasive Surgery Research Center, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

Received: January 09, 2012

Accepted: May 15, 2012

Background: Regarding the limited number of studies on the feasibility of resection and repair of the small intestine by ligasure, we performed this study to compare ligasure with linear stapler for the previously mentioned operation. Methods: This phase 1 clinical trial study was performed in Ghaem Hospital, an educational hospital affiliated to Mashhad University of Medical Sciences, from 2010 to 2011. After obtaining permission from the University’s ethics committee and a written

informed consent from each patient, we recruited 18 patients. The participants who had morbid obesity and were candidates for laparoscopic gastric bypass surgery were randomly allocated to two stapler and ligasure groups. The data were collected and analyzed by three statistical tests, including Mann-Whitney U test, by SPSS 16. Results: All patients were female with the age range of 20-65 years. Cost in the stapler group ranged between 29,500,000 to 40,000,000 Rial (mean 31,830,000± 3,500,000 Rials) and in ligasure group it was between 24,000,000 to 35,000,000 Rials (mean 26,720,000± 3,290,000 Rials). There was a significant difference between the two groups in cost (P=0.004). Duration of the operations were 200±3.4 and 240±10 minutes in the stapler and

ligasure groups, respectively. The difference in duration was significant between the two groups (P=0.043). No significant differences were observed in complications. Conclusion: Application of ligasure in resection and reconstruction of small intestine is more cost-effective than stapler, although duration of surgery is longer. *

Corresponding author: Surgical Oncology Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Tel: +98-511-8022677 E-mail: abdollahia@mums.ac.ir

Keywords: cost-effectiveness, duration, ligasure, operation, small intestine, stapler.

294 ‫ ﺗﺎ‬289 ،5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

‫ﺗﻮاﻓﻖ ‪ MRS‬و ‪ PSA‬در ﺗﺸﺨﻴﺺ ﻋﻮد ﺳﺮﻃﺎن ﭘﺮوﺳﺘﺎت‬

‫‪295‬‬

‫ﻣﻘﺎﻟﻪ اﺻﻴﻞ‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ ،5‬ﺻﻔﺤﻪﻫﺎي ‪ 295‬ﺗﺎ ‪300‬‬

‫ﻣﻴﺰان ﺗﻮاﻓﻖ ﻃﻴﻒﺳﻨﺠﻲ ﺗﺸﺪﻳﺪ ﻣﻐﻨﺎﻃﻴﺴﻲ ﺑﺎ آﻧﺘﻲژن اﺧﺘﺼﺎﺻﻲ ﭘﺮوﺳﺘﺎت ﺳﺮم در ﺗﺸﺨﻴﺺ ﻋﻮد‬ ‫ﻣﻮﺿﻌﻲ ﺳﺮﻃﺎن ﭘﺮوﺳﺘﺎت ﺑﻪدﻧﺒﺎل رادﻳﻜﺎل ﭘﺮوﺳﺘﺎﺗﻜﺘﻮﻣﻲ‬

‫ﭼﻜﻴﺪه‬

‫ﻣﻬﻴﺎر ﻏﻔﻮري‬

‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ﻣﻘﺎﻟﻪ‪1391/01/29 :‬‬

‫ﺗﺎرﻳﺦ ﭘﺬﻳﺮش‪1391/02/17 :‬‬

‫*‬

‫ﻋﻠﻲ وﻓﺎﻳﻲﺷﺎﻫﻲ‬

‫زﻣﻴﻨﻪ و ﻫﺪف‪ :‬ﻳﻜﻲ از وﻳﮋﮔﻲﻫﺎي آدﻧﻮﻛﺎرﺳﻴﻨﻮم ﭘﺮوﺳﺘﺎت ﭼﻨﺪ ﻛﺎﻧﻮﻧﻪ ﺑﻮدن آن ﻣﻲﺑﺎﺷﺪ‪ .‬ﺑﻪ ﮔﻮﻧﻪاي ﻛﻪ اﻳـﻦ ﻛـﺎﻧﻮنﻫـﺎ‬

‫ﮔﺮوه رادﻳﻮﻟﻮژي‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﺣﻀﺮت رﺳﻮل اﻛﺮم‬ ‫)ص(‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬

‫ﻣﻤﻜﻦ اﺳﺖ ﺑﺎ اﺳﺘﻔﺎده از ﺳﻲﺗﻲاﺳﻜﻦ ﻳﺎ‬

‫)‪Resonance Imaging (MRI‬‬

‫‪ Magnetic‬ﻗﺎﺑﻞ ﺗﺸﺨﻴﺺ ﻧﺒﺎﺷﻨﺪ‪ .‬در اﻳﻦ ﻣﻄﺎﻟﻌـﻪ‬

‫ﺳﻌﻲ ﺷﺪه اﺳـﺖ ﺗـﺎ ارزش ‪ MRS‬و ﺗﻮاﻓـﻖ آن ﺑـﺎ )‪) Prostatic Specific Antigen (PSA‬ﺑـﻪﻋﻨـﻮان روش ﻗـﺪﻳﻤﻲ( ﺑـﺮاي‬ ‫ﺗﺸﺨﻴﺺ ﻋﻮد ﺑﺎﻓﺖ ﺗﻮﻣﻮرال در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺳﺮﻃﺎن ﭘﺮوﺳﺘﺎت ﻣﻮرد ﺑﺮرﺳﻲ ﻗﺮار ﮔﻴﺮد‪.‬‬ ‫روش ﺑﺮرﺳﻲ‪ :‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ در ﻗﺎﻟﺐ ﻳﻚ ﻣﻄﺎﻟﻌﻪ ﻣﻘﻄﻌﻲ اﻧﺠﺎم ﺷﺪ‪ .‬ﻧﻤﻮﻧﻪي ﻣﻮرد ﭘﮋوﻫﺶ ﻋﺒـﺎرت ﺑـﻮد از ﺑﻴﻤـﺎراﻧﻲ ﻛـﻪ‬ ‫ﺑﻪﻣﻨﻈﻮر ﺗﺸﺨﻴﺺ و درﻣﺎن ﻋﻮد ﻟﻮﻛﺎل ﺳﺮﻃﺎن ﭘﺮوﺳﺘﺎت‪ ،‬ﭘﺲ از رادﻳﻜﺎل ﭘﺮوﺳﺘﺎﺗﻜﺘﻮﻣﻲ ﻣﺮاﺟﻌﻪ ﻛﺮده ﺑﻮدﻧﺪ‪ .‬ﺑﻪﺻﻮرت‬ ‫ﺳﻨﺘﻲ ﻣﻘﺎدﻳﺮ ‪ PSA‬ﺑﻴﺶ از ‪ 0/2‬ﻧﺎﻧﻮﮔﺮم در دﺳﻲﻟﻴﺘﺮ ﺑﻪﻣﻨﺰﻟﻪ ﻋﻮد ﻟﻮﻛﺎل ﺗﻮﻣﻮر در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪ‪ .‬ﻧﺘﺎﻳﺞ ‪ MRS‬ﺑـﺮ ﺣـﺴﺐ‬ ‫ﻧﺴﺒﺖ ﻣﺠﻤﻮع ﻛﺮاﺗﻴﻦ و ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات و ﺣﺪ ﺗﻤﺎﻳﺰﻫﺎي ﻣﺨﺘﻠﻒ ﺑﺎ ‪ PSA‬ﻣﻘﺎﻳﺴﻪ ﺷﺪ‪.‬‬ ‫ﻳﺎﻓﺘﻪﻫﺎ‪ :‬ﺗﻌﺪاد ‪ 139‬ﺑﻴﻤﺎر وارد ﻣﻄﺎﻟﻌﻪ ﺷﺪﻧﺪ‪ .‬ﻋﻮد ﺗﻮﻣﻮر در ‪ 107‬ﺑﻴﻤﺎر )‪ (%77‬ﺑﺮ اﺳﺎس ‪ PSA‬ﺳﺮم ﺗـﺸﺨﻴﺺ داده ﺷـﺪ‪.‬‬ ‫ﻣﻴﺎﻧﮕﻴﻦ ‪ PSA‬و ﻣﺠﻤﻮع ﻣﻴﺰان ﻛﺮاﺗﻴﻦ و ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات در ﺑﻴﻤﺎران دارا و ﻓﺎﻗﺪ ﻋﻮد ﺗﻔﺎوت آﻣﺎري ﻣﻌﻨﻲداري داﺷـﺖ‪.‬‬ ‫ﺗﻮاﻓﻖ ‪ PSA‬ﺑﺎ ‪ MRS‬در ﺣﺪ ﺗﻤﺎﻳﺰ ‪ 100 ،50‬و ‪ 150‬ﺑﻪﺗﺮﺗﻴﺐ ‪ %94/4 ،%94/1‬و ‪ %85/1‬ﺑﻮد‪ .‬ﺿﺮﻳﺐ ﻫﻤﺒﺴﺘﮕﻲ ﺑﻴﻦ اﻳﻦ دو‬ ‫روش ﺗﺸﺨﻴﺼﻲ ‪ 0/481‬ﺑﻪدﺳﺖ آﻣﺪ‪.‬‬ ‫ﻧﺘﻴﺠﻪﮔﻴﺮي‪ :‬ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻧﺸﺎن داد ﻛﻪ ‪ MRS‬ﺑﻪﻋﻨﻮان ﻳﻜﻲ از اﺑﺰارﻫﺎي دﻗﻴﻖ ﺗﺸﺨﻴﺺ ﺳـﺮﻃﺎن ﭘﺮوﺳـﺘﺎت و ﻋـﻮد آن‬

‫*‬

‫ﻣﻄﺮح ﻣﻲﺑﺎﺷﺪ‪ .‬ﺑﻪﺧﺼﻮص در ﺣﺪ ﺗﻤﺎﻳﺰ ‪ 100‬ﺑﺮاي ﻧﺴﺒﺖ ﻣﺠﻤﻮع ﻛﺮاﺗﻴﻦ و ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات ﺗﻮاﻓﻘﻲ در ﺣﺪود ‪ %95‬ﺑﺎ‬ ‫ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪ :‬ﺗﻬﺮان‪ ،‬ﺧﻴﺎﺑﺎن ﺳﺘﺎرﺧﺎن‪ ،‬ﺧﻴﺎﺑﺎن‬

‫ﻧﻴﺎﻳﺶ‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﺣﻀﺮت رﺳﻮل اﻛﺮم )ص(‪ ،‬ﺑﺨﺶ‬ ‫رادﻳﻮﻟﻮژي‬

‫‪ PSA‬را ﺷﺎﻫﺪ ﺑﻮدﻳﻢ‪.‬‬

‫ﺗﻠﻔﻦ‪021-66033785 :‬‬ ‫‪E-mail: vafaeea@yahoo.ca‬‬

‫ﻛﻠﻤﺎت ﻛﻠﻴﺪي‪ ،PSA ،MRS :‬ﺳﺮﻃﺎن ﭘﺮوﺳﺘﺎت‪ ،‬ﻋﻮد ﺗﻮﻣﻮر‪.‬‬

‫ﭘﺮوﺳﺘﺎت ﺑﺮاي ﺗـﺸﺨﻴﺺ ﺑﻴﻤـﺎريﻫـﺎ و ﺳـﺮﻃﺎن ﭘﺮوﺳـﺘﺎت و ﺗﻌﻴـﻴﻦ‬

‫ﻣﻘﺪﻣﻪ‬

‫ﻣﺮﺣﻠﻪ آن اﺳﺘﺎﻧﺪارد ﻃﻼﻳﻲ اﺳﺖ‪ ،‬ﻟﻴﻜﻦ ﺑﻪﺟﻬﺖ ﺗﻬﺎﺟﻤﻲ ﺑﻮدن ﺑﻴﻮﭘﺴﻲ‬ ‫‪Prostatic Specific‬‬

‫‪6‬و‪5‬‬

‫)‪ Antigen (PSA‬ﻣـﻮارد ﻣـﺸﻜﻮك ﺑـﻪ ﺳـﺮﻃﺎن ﭘﺮوﺳـﺘﺎت ﻛـﻪ در ﻃـﻲ‬

‫ﺑﺪﻳﻦﻋﻠﺖ روشﻫﺎي ﺗﺼﻮﻳﺮﺑﺮداري ﻛﻢﺗﺮ ﺗﻬﺎﺟﻤﻲ در ﺳﺎلﻫـﺎي اﺧﻴـﺮ‬

‫ﻏﺮﺑﺎلﮔﺮي ﻛﺸﻒ ﻣﻲﺷﻮﻧﺪ رو ﺑﻪ اﻓﺰاﻳﺶ ﺑﻮده و ﺑﺮاي رد ﻳﺎ ﺗـﺸﺨﻴﺺ‬

‫ﻣﻮرد ﺗﻮﺟﻪ و اﺳﺘﻘﺒﺎل ﻗﺮار ﮔﺮﻓﺘﻪ اﺳﺖ‪.‬‬

‫در ﻃﻲ ﺳﺎلﻫﺎي اﺧﻴﺮ و ﺑﺎ ﮔﺴﺘﺮش آزﻣـﺎﻳﺶ‬

‫ﺳﺮﻃﺎن ﭘﺮوﺳﺘﺎت ﻧﻴﺎز ﺑﻪ اﻧﺠﺎم ﺑﻴﻮﭘﺴﻲ از ﭘﺮوﺳﺘﺎت اﺳﺖ‪2.‬و‪ 1‬ﻫﻢﭼﻨﻴﻦ‬

‫از ﭘﺮوﺳﺘﺎت ﺗﻤﺎﻳﻞ ﺑﻪ اﻧﺠﺎم روشﻫﺎي ﻛﻢﺗﺮ ﺗﻬﺎﺟﻤﻲ ﺑﻴﺶﺗﺮ اﺳـﺖ‪.‬‬

‫از ﺟﻤﻠﻪ اﻳﻦ روشﻫﺎ اﺳﺘﻔﺎده از‬

‫‪Magnetic Resonance Imaging‬‬

‫از ‪ PSA‬ﺑﻪﻣﻨﻈﻮر ارزﻳﺎﺑﻲ وﺿـﻌﻴﺖ ﭘـﺲ از درﻣـﺎن ﺑﻴﻤـﺎران ﻣﺒـﺘﻼ ﺑـﻪ‬

‫)‪ (MRI‬اﺳﺖ‪ .‬ﺗﺼﻮﻳﺮﺑﺮداري ﺑﺎ رزوﻧﺎﻧﺲ ﻣﻐﻨﺎﻃﻴﺴﻲ ﻗﺪرت ﺗﻤﺎﻳﺰ ﺑﺎﻻﻳﻲ‬

‫ﺳﺮﻃﺎن ﭘﺮوﺳﺘﺎت اﺳﺘﻔﺎده ﻣﻲﺷﻮد‪4.‬و‪ 3‬اﮔﺮﭼﻪ ﺑﺮرﺳﻲ ﻫﻴـﺴﺘﻮﭘﺎﺗﻮﻟﻮژﻳﻚ‬

‫از ﻛﻨﺘﺮاﺳﺖ ﺑﺎﻓﺖ ﻧﺮم را ﻧﺴﺒﺖ ﺑﻪ رادﻳﻮﮔﺮاﻓﻲ ﻣﺮﺳﻮم اﻳﺠﺎد ﻣﻲﻛﻨـﺪ و‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):295-300‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻣﻬﻴﺎر ﻏﻔﻮري و ﻫﻤﻜﺎران‬

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‫ﭘﻴﺸﺮﻓﺖ ﺑﺎرزي در ﺗﻤﺎم ﺳﻄﻮح اﻳﻦ رﺷﺘﻪ ﺗﺨﺼﺼﻲ ﻣﺤﺴﻮب ﻣﻲﺷﻮد‪.‬‬

‫ﺷﺮاﻳﻂ ورود ﺑﻪ ﻣﻄﺎﻟﻌـﻪ ﺑـﻪﺗﺮﺗﻴـﺐ وارد ﻣﻄﺎﻟﻌـﻪ ﺷـﺪﻧﺪ و از روش در‬

‫از ﺟﻤﻠﻪ روشﻫـﺎي ﻧـﻮﻳﻦ ﺗـﺼﻮﻳﺮﺑﺮداري ﻣﺒﺘﻨـﻲ ﺑـﺮ ‪ MRI‬اﺳـﺘﻔﺎده از‬

‫دﺳﺘﺮس )‪ (Available‬ﺑﺮاي اﻧﺘﺨﺎب ﺑﻴﻤﺎران اﺳﺘﻔﺎده ﮔﺮدﻳـﺪ ﺗـﺎ ﺣﺠـﻢ‬

‫‪Magnetic Resonance Spectroscopy‬‬

‫ﻧﻤﻮﻧﻪ ﻣﺤﺎﺳﺒﻪ ﺷﺪه ﻛﺎﻣﻞ ﺷﻮد‪ .‬ﺑﺎ در ﻧﻈﺮ ﮔﺮﻓﺘﻦ ﺧﻄﺎي ﻧﻮع اول ﺑﺮاﺑـﺮ‬

‫ﻃﻴﻒﺳﻨﺠﻲ ﺗﺸﺪﻳﺪ ﻣﻐﻨﺎﻃﻴﺴﻲ‬

‫ﺑﺎ ‪ ،%5‬دﻗﺖ ﻣﻄﺎﻟﻌﻪ ﺑﺮاﺑﺮ ﺑﺎ ‪ 0/06‬و اﻋﻼم ﺣﺴﺎﺳﻴﺖ ‪ MRS‬در ﺗﺸﺨﻴﺺ‬

‫)‪ (MRS‬اﺳﺖ‪.‬‬ ‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ اﻳﻦﻛﻪ ﻋﻤﻠﻜـﺮد ﺑﻴﻮﺷـﻴﻤﻴﺎﻳﻲ ﺑﺎﻓـﺖﻫـﺎي ﺗﻮﻣـﻮرال ﺑـﺎ‬ ‫ﺑﺎﻓﺖﻫﺎي ﻧﺮﻣﺎل ﻣﺘﻔﺎوت اﺳـﺖ‪ ،‬در اﻳـﻦ روش اﻃﻼﻋـﺎت ﺑﻴﻮﺷـﻴﻤﻴﺎﻳﻲ‬

‫ﺗﻮﻣﻮرﻫﺎي ﭘﺮوﺳﺘﺎت ﺑﺮاﺑﺮ ﺑﺎ ‪ %85‬ﺑﺮ اﺳﺎس ﻣﻄﺎﻟﻌﺎت ﻗﺒﻠﻲ ﺣﺠﻢ ﻧﻤﻮﻧﻪ‬ ‫‪10‬‬

‫ﻣﻌﺎدل ‪ 140‬ﻧﻔﺮ ﻣﺤﺎﺳﺒﻪ ﺷﺪ‪.‬‬

‫ﺑﺎﻓﺖﻫﺎي ﺗﻮﻣﻮرال ﺑﺮرﺳﻲ ﺷـﺪه و از ﺑﺎﻓـﺖﻫـﺎي ﻃﺒﻴﻌـﻲ اﻓﺘـﺮاق داده‬

‫ﭘﺲ از اﺧﺬ رﺿﺎﻳﺖ آﮔﺎﻫﺎﻧﻪ‪ ،‬در ﺗﻤﺎم ﺑﻴﻤﺎران ‪ MRS‬اﻧﺠـﺎم ﺷـﺪ و‬

‫ﻣﻲﺷﻮد‪ MRS .‬ﭘﺘﺎﻧﺴﻴﻞ ﺧﺎﺻﻲ ﺟﻬﺖ ﺗﺸﺨﻴﺺ ﺗﻮﻣﻮرﻫـﺎﻳﻲ ﻛـﻪ داراي‬

‫ﻫﻢزﻣﺎن ‪ PSA‬ﺳﺮم آنﻫﺎ ﻧﻴﺰ ﭼﻚ ﻣﻲﮔﺮدﻳﺪ‪ .‬ﺑﺮ اﺳـﺎس ‪) PSA‬ﺑـﻴﺶ از‬

‫ﻛﻨﺘﺮاﺳــﺖ ﻛــﺎﻓﻲ در ﺗــﺼﺎوﻳﺮ ﻧﻴــﺴﺘﻨﺪ دارد‪ 7‬و ﺑﺎﻋــﺚ ﻓــﺮاﻫﻢ آوردن‬

‫‪ 0/2‬ﻧﺎﻧﻮﮔﺮم در دﺳﻲﻟﻴﺘﺮ( ﻋﻮد در ﺑﻴﻤﺎران ﺗﻌﺮﻳـﻒ ﻣـﻲﺷـﺪ‪ .‬از ﻟﺤـﺎظ‬

‫اﻃﻼﻋﺎﺗﻲ راﺟﻊ ﺑﻪ ﻣﺘﺎﺑﻮﻟﻴﺖﻫﺎي ﺑﺎﻓﺘﻲ ﻣﻲﺷـﻮد‪ 8.‬ﺗـﺼﺎوﻳﺮ ﺑﻴﻮﻣـﺪﻳﻜﺎل‬

‫ﻳﺎﻓﺘﻪﻫﺎي ﺗﺼﻮﻳﺮﺑﺮداري ﺑﻪ ﺳﻪ ﮔﺮوه زﻳﺮ ﺗﻘﺴﻴﻢ ﺷﺪﻧﺪ‪:‬‬

‫اﻳﺠــﺎد ﺷــﺪه ﺗﻮﺳــﻂ ‪ MRS‬ﻧﺘﻴﺠــﻪ واﻛ ـﻨﺶ ﺑــﻴﻦ ﻫــﺴﺘﻪ اﺗــﻢ و ﻣﻴــﺪان‬

‫ﺑﻴﻤﺎراﻧﻲ ﻛـﻪ در ﺗـﺼﺎوﻳﺮ ﻣﻌﻤـﻮل‬

‫‪MRI‬‬

‫)‪ (T2W,T1W‬آنﻫـﺎ‪ ،‬ﻳﺎﻓﺘـﻪ‬

‫ﻣﻐﻨﺎﻃﻴﺴﻲ ﻣﻲﺑﺎﺷﺪ‪ .‬از آﻧﺠـﺎ ﻛـﻪ اﺗـﻢﻫـﺎي ﻣﺨﺘﻠـﻒ در ﻓﺮﻛـﺎﻧﺲﻫـﺎي‬

‫ﭘﺎﺗﻮﻟﻮژﻳﻚ روﻳﺖ ﻧﺸﺪ و ﺗﺤﺖ ﺑﺮرﺳﻲ ‪ MRS‬ﻗﺮار ﮔﺮﻓﺘﻨﺪ‪ .‬ﺑﻴﻤﺎراﻧﻲ ﻛﻪ‬

‫ﻣﺨﺘﻠﻒ رزوﻧﺎﻧﺲ دارﻧﺪ‪ ،‬ﻓﺮﻛﺎﻧﺲ رزوﻧﺎﻧﺲ آنﻫﺎ ﻧﺸﺎندﻫﻨﺪه اﻃﻼﻋﺎت‬

‫در ﺗﺼﺎوﻳﺮ ﻣﻌﻤﻮل ‪ (T2W,T1W) MRI‬آنﻫﺎ‪ ،‬ﺗﻮده دﻳﺪه ﺷـﺪ ﻧﻴـﺰ ﺗﺤـﺖ‬

‫ﺳﺎﺧﺘﺎري در ﻣﻮرد ﻣﺤﺘﻮاي ﺷﻴﻤﻴﺎﻳﻲ آنﻫﺎﺳﺖ‪ .‬اﻣﺮوزه ﭘﻴﺸﺮﻓﺖﻫـﺎ در‬

‫ﺑﺮرﺳﻲ ‪ MRS‬ﻗﺮار ﮔﺮﻓﺘﻨﺪ‪ .‬ﺑﻴﻤﺎراﻧﻲ ﻛﻪ در ﺗﺼﺎوﻳﺮ ﻣﻌﻤﻮل‬

‫)‪(T2W,T1W‬‬

‫‪ MRS‬ﺑﻪﺳﻤﺖ روشﻫﺎي ﺗـﺸﺨﻴﺺ در ﺑﻴﻤـﺎران ﻣـﺸﻜﻮك ﺑـﻪ ﻛﺎﻧـﺴﺮ‬

‫‪ MRI‬آنﻫﺎ ﺑﺎﻗﻲﻣﺎﻧﺪه ﺑﺎﻓﺖ ﭘﺮوﺳﺘﺎت در ﻣﺤﻞ ﺟﺮاﺣﻲ دﻳـﺪه ﻣـﻲﺷـﻮد‬

‫‪9‬‬

‫ﻧﻴــﺰ ﺗﺤــﺖ ﺑﺮرﺳــﻲ ‪ MRS‬ﻗــﺮار ﮔﺮﻓﺘﻨــﺪ‪ MRI .‬و ‪ MRS‬ﺑــﺎ دﺳــﺘﮕﺎه‬

‫ﭘﺮوﺳﺘﺎت ﮔﺴﺘﺮش ﻳﺎﻓﺘﻪ اﺳﺖ‪.‬‬

‫ﻳﻜﻲ از وﻳﮋﮔﻲﻫﺎي آدﻧﻮﻛﺎرﺳﻴﻨﻮم ﭘﺮوﺳﺘﺎت‪ ،‬ﭼﻨﺪ ﻛﺎﻧﻮﻧﻪ ﺑﻮدن و‬

‫)‪MAGNETOM Avanto 1.5 Tesla MRI system (Siemens, Germany‬‬

‫وﺟﻮد ﻫﻢزﻣﺎن آن در ﭼﻨﺪ ﻧﻘﻄﻪ از ﭘﺮوﺳﺘﺎت و ﮔﺴﺘﺮش آن ﺑﻪ ﺧﺎرج‬

‫و ﺑﺎ ﻛﻮﻳﻞ اﻧﺪورﻛﺘﺎل اﻧﺠـﺎم ﮔﺮدﻳـﺪ‪ .‬اﻧـﺪازهﮔﻴـﺮي ﻛـﻮﻟﻴﻦ‪ ،‬ﻛـﺮاﺗﻴﻦ و‬

‫از ﻛﭙﺴﻮل اﺳﺖ‪ ،‬ﺑﻪ ﮔﻮﻧﻪاي ﻛﻪ اﻳﻦ ﻛﺎﻧﻮنﻫﺎ ﻣﻤﻜﻦ اﺳﺖ ﺑﺎ اﺳﺘﻔﺎده از‬

‫ﺳـــﻴﺘﺮات ﺗﻮﺳـــﻂ روش ‪ Multi sample‬اﻧﺠـــﺎم ﺷـــﺪ و ﺗﻮﺳـــﻂ‬

‫ﻗﺎﺑﻞ ﺗﺸﺨﻴﺺ ﻧﺒﺎﺷﺪ‪ 8.‬ﺑﻪﻫﻤﻴﻦ دﻟﻴﻞ اﺳﺘﻔﺎده از‬

‫ارورادﻳﻮﻟﻮژﻳﺴﺖ ﻣﺠﺮب ﺗﻔﺴﻴﺮ ﮔﺮدﻳﺪ‪ .‬ﻧﺘﺎﻳﺞ ‪ MRS‬ﺑﺮ ﺣـﺴﺐ ﻧـﺴﺒﺖ‬

‫ﺟﻬﺖ ﺑﺮرﺳﻲ ﺗﻮدهﻫﺎي ﺗﻮﻣﻮرال و ﻳﺎ ﺑﺎﻓﺖ ﺑﺎﻗﻲﻣﺎﻧﺪه ﻣﻮرد‬

‫ﻛﺮاﺗﻴﻦ‪ +‬ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات و ﺣﺪ ﺗﻤﺎﻳﺰﻫﺎي ﻣﺨﺘﻠﻔﻲ ﻛﻪ در اﻳﻦ ﻣﻄﺎﻟﻌـﻪ‬

‫ﺗﻮﺟﻪ ﻗﺮار ﮔﺮﻓﺘﻪ اﺳﺖ و در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺳﻌﻲ ﺷﺪه اﺳﺖ ﺗﺎ ارزش‬

‫ﻣﺸﺨﺺ ﺷﺪه اﺳﺖ ﺑﺎ ‪ PSA‬ﻣﻘﺎﻳﺴﻪ ﺷـﺪه و ﻣﻨﺎﺳـﺐﺗـﺮﻳﻦ ﺣـﺪ ﺗﻤـﺎﻳﺰ‬

‫ﺑﺮاي ﺗﺸﺨﻴﺺ ﻋﻮد ﺑﺎﻓﺖ ﺗﻮﻣﻮرال در‬

‫ﻧﺴﺒﺖ ﻛﺮاﺗﻴﻦ‪ +‬ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات ﺑﺮاي ﺗﺸﺨﻴﺺ ﻋـﻮد ﻣـﺸﺨﺺ ﺷـﺪ‪.‬‬

‫ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺳﺮﻃﺎن ﭘﺮوﺳﺘﺎت ﺑﺮرﺳﻲ ﺷﻮد‪ .‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑﻪ ﻟﺤﺎظ‬

‫ﻣﻼك ﺗـﺸﺨﻴﺺ ﻋـﻮد ﺗﻮﻣـﻮر ﻣﻘـﺎدﻳﺮ ‪ PSA‬ﺑـﻴﺶ از ‪ 0/2‬ﻧـﺎﻧﻮﮔﺮم در‬

‫اﺟﺮاﻳﻲ‪ ،‬وﺟﻮد ﺑﻴﻤﺎران و ﻫﺰﻳﻨﻪ ﻗﺎﺑﻞ ﻗﺒﻮل آن ﻣﻮرد ﺗﻮﺟﻪ ﻗﺮار ﮔﺮﻓﺘﻪ و‬

‫دﺳﻲﻟﻴﺘﺮ ﺑﻮد‪.‬‬

‫ﺳﻲﺗﻲاﺳﻜﻦ ﻳﺎ‬ ‫‪MRS‬‬

‫‪MRS‬‬

‫‪MRI‬‬

‫و ﺗﻮاﻓﻖ آن ﺑﺎ‬

‫‪PSA‬‬

‫ﺑﻪﻋﻨﻮان ﭘﺎﻳﺎنﻧﺎﻣﻪ ﺗﺨﺼﺼﻲ رﺷﺘﻪ رادﻳﻮﻟﻮژي اﺟﺮا ﺷﺪه اﺳﺖ‪.‬‬

‫ﻳﺎﻓﺘﻪﻫﺎ‬ ‫روش ﺑﺮرﺳﻲ‬ ‫ﺗﻌﺪاد ‪ 139‬ﺑﻴﻤﺎر وارد ﻣﻄﺎﻟﻌﻪ ﺷﺪﻧﺪ‪ .‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻣﺸﺨﺺ ﺷﺪ‬ ‫اﻳﻦ ﻣﻄﺎﻟﻌﻪ در ﺳﺎل ‪ 1389‬در ﺑﻴﻤﺎرﺳﺘﺎن ﺣﻀﺮت رﺳـﻮل داﻧـﺸﮕﺎه‬

‫ﻛﻪ در ‪ 107‬ﺑﻴﻤﺎر )‪ (%77‬ﺑﺮ اﺳﺎس ‪ PSA‬ﺳﺮم )ﺑﻴﺶ از ‪ 0/2‬ﻧﺎﻧﻮﮔﺮم در‬

‫)‪(Cross sectional‬‬

‫دﺳﻲﻟﻴﺘﺮ( ﺗﻮﻣﻮر ﻋﻮد ﻛﺮده ﺑﻮد و در ‪ 32‬ﺑﻴﻤﺎر )‪ (%23‬ﻋﻮد ﺗﻮﻣﻮر ﻣﻨﻔﻲ‬

‫اﻧﺠﺎم ﺷﺪه اﺳﺖ‪ .‬ﻧﻤﻮﻧﻪ ﻣﻮرد ﭘﮋوﻫﺶ ﻋﺒﺎرﺗﻨﺪ از ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﺑﻪﻣﻨﻈـﻮر‬

‫ﺑﻮد‪ .‬در ‪ 103‬ﺑﻴﻤﺎر )‪ (%74‬ﻳﺎﻓﺘﻪﻫﺎي ﺗﺼﻮﻳﺮﺑﺮداري ﺑﻪﻧﻔﻊ ﻋﻮد ﻟﻮﻛﺎل‬

‫ﺗﺸﺨﻴﺺ و درﻣﺎن ﻋـﻮد ﻟﻮﻛـﺎل ﺳـﺮﻃﺎن ﭘﺮوﺳـﺘﺎت‪ ،‬ﭘـﺲ از رادﻳﻜـﺎل‬

‫ﺗﻮﻣﻮر ﻣﺸﺎﻫﺪه ﺷﺪ و در ‪ 36‬ﺑﻴﻤﺎر )‪ (%26‬ﻋﻮد ﻟﻮﻛﺎل ﺗﻮﻣﻮر ﻣﻨﻔﻲ ﺑﻮد‪.‬‬

‫ﭘﺮوﺳﺘﺎﺗﻜﺘﻮﻣﻲ ﻣﺮاﺟﻌﻪ ﻛﺮده ﺑﻮدﻧﺪ‪ .‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻛﻠﻴﻪ ﺑﻴﻤﺎران واﺟـﺪ‬

‫ﻣﻴﺎﻧﮕﻴﻦ ﺳﻨﻲ ﺑﻴﻤﺎران در ﮔﺮوه ﻋﻮد ﻛﺮده ‪ 68/7±9/1‬ﺳﺎل و در ﮔﺮوه‬

‫ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان در ﻗﺎﻟﺐ ﻳﻚ ﻣﻄﺎﻟﻌـﻪ ﻣﻘﻄﻌـﻲ‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ 295 ،5‬ﺗﺎ ‪300‬‬

‫ﺗﻮاﻓﻖ ‪ MRS‬و ‪ PSA‬در ﺗﺸﺨﻴﺺ ﻋﻮد ﺳﺮﻃﺎن ﭘﺮوﺳﺘﺎت‬

‫ﻋﻮد ﻣﻨﻔﻲ ‪ 68/8±9/2‬ﺳﺎل ﺑﻮد‪ .‬ﻣﻘﺎﻳﺴﻪ اﻳﻦ ﻣﻘﺎدﻳﺮ ﺗﻔﺎوت آﻣﺎري‬

‫‪297‬‬

‫در ﻧﻤﻮدار‪ 1 -‬ﻣﻨﺤﻨﻲ‬

‫)‪Receiver Operating Characteristic (ROC‬‬

‫ﻣﻌﻨﻲداري را ﻧﺸﺎن ﻧﻤﻲدﻫﺪ )‪ .(P=0/924‬در ﺑﻴﻤﺎران داراي ﻋﻮد ﺗﻮﻣﻮر‬

‫ﺗﺸﺨﻴﺺ ﻋﻮد ﺗﻮﻣﻮر در ﺣﺪ ﺗﻤﺎﻳﺰﻫﺎي ﻣﺨﺘﻠﻒ ﻣﺠﻤﻮع ﻛﺮاﺗﻴﻦ و‬

‫ﺑﺮاﺳﺎس ‪ PSA‬در ﭘﻨﺞ )‪ (%3/6‬ﺑﻴﻤﺎر ﺑﺎﻓﺖ ﭘﺮوﺳﺘﺎت ﺑﺎﻗﻲﻣﺎﻧﺪه و در دو‬

‫ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات ﻧﺸﺎن داده ﺷﺪه اﺳﺖ‪ .‬ﺑﻪﻣﻨﻈﻮر ﺑﺮرﺳﻲ راﺑﻄﻪ ‪ PSA‬و‬

‫ﺑﻴﻤﺎر )‪ (%1/9‬ﻧﻴﺰ ﻣﺘﺎﺳﺘﺎز اﺳﺘﺨﻮاﻧﻲ وﺟﻮد داﺷﺖ‪ .‬در ‪ 14‬ﺑﻴﻤﺎر‬

‫ﻧﺴﺒﺖ ﻛﻮﻟﻴﻦ‪ ،‬ﻛﺮاﺗﻴﻦ ﺑﻪ ﺳﻴﺘﺮات ﻫﻤﺒﺴﺘﮕﻲ ﻣﻴﺎن اﻳﻦ دو ﻣﺘﻐﻴﺮ ﻛﻤ‪‬ﻲ‬

‫)‪ (%13/1‬ﻧﻴﺰ ﺗﻮﻣﻮر ﻋﻮد ﻛﺮده ﺑﺎ روشﻫﺎي ﻣﻌﻤﻮل ‪ MRI‬ﻗﺎﺑﻞ ﻣﺸﺎﻫﺪه‬

‫ﺑﺮرﺳﻲ ﺷﺪ ﻛﻪ ﺿﺮﻳﺐ ﻫﻤﺒﺴﺘﮕﻲ آنﻫﺎ ‪ 0/481‬ﺑﻮد و ﺣﺎﻛﻲ از راﺑﻄﻪ‬

‫ﺑﻮد‪ .‬در دو ﺑﻴﻤﺎر از ﭘﻨﺞ ﺑﻴﻤﺎري ﻛﻪ ﺑﺎﻓﺖ ﭘﺮوﺳﺘﺎت ﺑﺎﻗﻲﻣﺎﻧﺪه داﺷﺘﻨﺪ و‬

‫ﻣﻴﺎن اﻳﻦ دو اﺳﺖ )‪ .(P<0/001‬ﺟﻬﺖ ﻣﺤﺎﺳﺒﻪ ﺿﺮﻳﺐ ﻫﻤﺒﺴﺘﮕﻲ از‬

‫ﻫﻢﭼﻨﻴﻦ در ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﻣﺘﺎﺳﺘﺎز اﺳﺘﺨﻮاﻧﻲ داﺷﺘﻨﺪ‪ ،‬ﻳﺎﻓﺘﻪ ﺗﺼﻮﻳﺮﺑﺮداري‬

‫آزﻣﻮن ﻛﺎﭘﺎ اﺳﺘﻔﺎده ﺷﺪه اﺳﺖ و ‪ P<0/05‬ﻣﻌﻨﻲدار ﺗﻠﻘﻲ ﻣﻲﺷﻮد‪.‬‬

‫ﻣﺜﺒﺖ ﺑﺮاي ﻋﻮد ﻟﻮﻛﺎل دﻳﺪه ﻧﺸﺪ‪.‬‬ ‫در ﺟﺪول‪ ،1 -‬ﻣﻴﺎﻧﮕﻴﻦ ‪ PSA‬و ﻧﺴﺒﺖ ﻣﺠﻤﻮع ﻛﺮاﺗﻴﻦ و ﻛﻮﻟﻴﻦ ﺑﻪ‬ ‫ﺳﻴﺘﺮات در‬

‫‪MRS‬‬

‫در دو ﮔﺮوه ﻋﻮد ﻣﺜﺒﺖ و ﻋﻮد ﻣﻨﻔﻲ ﻣﺸﺨﺺ ﺷﺪه‬

‫اﺳﺖ‪ .‬ﻣﻨﺪرﺟﺎت اﻳﻦ ﺟﺪول ﻧﺸﺎن ﻣﻲدﻫﺪ ﻛﻪ ﻣﻴﺎﻧﮕﻴﻦ ‪ PSA‬و ﻣﺠﻤﻮع‬ ‫ﻛﺮاﺗﻴﻨﻴﻦ و ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات در ﺑﻴﻤﺎران دارا و ﻓﺎﻗﺪ ﻋﻮد ﺗﻔﺎوت آﻣﺎري‬ ‫ﻣﻌﻨﻲداري داﺷﺘﻪ اﺳﺖ‪.‬‬

‫ﺟﺪول‪ :1 -‬ﻣﻴﺎﻧﮕﻴﻦ ﻣﻘﺎدﻳﺮ ‪ PSA‬و ﻛﺮاﺗﻴﻦ‪ +‬ﻛﻮﻟﻴﻦ ﺑﻪ ﺳـﻴﺘﺮات در ﺑﻴﻤـﺎران دﭼـﺎر‬ ‫ﻋﻮد ﺗﻮﻣﻮر ﭘﺮوﺳﺘﺎت و ﺑﻴﻤﺎران ﻏﻴﺮ ﻋﻮد‬ ‫ﻣﺘﻐﻴﺮ ﻣﻮرد ﺑﺮرﺳﻲ‬ ‫‪PSA‬‬

‫در ﺟﺪول‪ ،2 -‬راﺑﻄﻪ ﻧﺴﺒﺖ ﻣﺠﻤﻮع ﻛﺮاﺗﻴﻦ و ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات‬ ‫در ﺣﺪ ﺗﻤﺎﻳﺰ ‪ 100 ،50‬و ‪ 150‬ﺑﺎ ﻋﻮد ﺗﻮﻣﻮر )ﺑﺮاﺳﺎس ﺣﺪ ﺗﻤﺎﻳﺰ‬

‫‪PSA‬‬

‫ﻛﺮاﺗﻴﻦ‪ +‬ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات‬

‫ﻋﻮد ﺗﻮﻣﻮر‬

‫ﻣﻴﺎﻧﮕﻴﻦ‬

‫‪P‬‬

‫ﻋﻮد ﻧﺪارد‬

‫‪0/084±0/048‬‬

‫‪*<0/001‬‬

‫ﻋﻮد دارد‬

‫‪3/7±2/5‬‬

‫ﻋﻮد ﻧﺪارد‬

‫‪17/8±12/3‬‬

‫‪*<0/001‬‬

‫ﻋﻮد دارد‬

‫‪307/5±148‬‬

‫* ﺗﻔﺎوت ﻣﻌﻨﻲدار اﺳﺖ‬

‫‪ 0/2‬و ﺑﻴﺶﺗﺮ ﺑﻪﻋﻨﻮان ﻋﻮد ﺗﻮﻣﻮر( ﻧﺸﺎن داده ﺷﺪه اﺳﺖ‪.‬‬

‫ﺟﺪول‪ :2 -‬راﺑﻄﻪ ﻧﺴﺒﺖ ﻛﺮاﺗﻴﻦ‪ +‬ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات ﺑﺎ ﻋﻮد ﺗﻮﻣﻮر‬ ‫ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات‬

‫‪150‬‬

‫>‬

‫‪0‬‬

‫‪97‬‬

‫ﻣﺠﻤﻮع‬

‫‪32‬‬

‫‪107‬‬

‫‪139‬‬

‫ﺣﺪ ﺗﻤﺎﻳﺰ ﻛﺮاﺗﻴﻦ‪+‬‬

‫ﺑﺪون ﻋﻮد‬

‫ﻋﻮد‬

‫ﻣﺠﻤﻮع‬

‫‪150‬‬

‫‪‬‬

‫‪32‬‬

‫‪10‬‬

‫‪42‬‬

‫‪150‬‬

‫ﺣﺴﺎﺳﻴﺖ‬

‫ﻣﺠﻤﻮع‬

‫‪32‬‬

‫‪107‬‬

‫‪139‬‬

‫وﻳﮋﮔﻲ‬

‫‪100‬‬

‫ارزش اﺧﺒﺎري ﻣﺜﺒﺖ‬

‫‪100‬‬

‫>‬

‫‪0‬‬

‫‪102‬‬

‫ارزش اﺧﺒﺎري ﻣﻨﻔﻲ‬

‫‪100‬‬

‫‪‬‬

‫‪32‬‬

‫‪5‬‬

‫‪37‬‬

‫ﻣﻴﺰان ﺗﻮاﻓﻖ‬

‫ﻣﺠﻤﻮع‬

‫‪32‬‬

‫‪107‬‬

‫‪139‬‬

‫ﺳﻄﺢ زﻳﺮ ﻣﻨﺤﻨﻲ‬

‫‪50‬‬

‫‪ROC‬‬

‫‪50‬‬

‫>‬

‫‪0‬‬

‫‪104‬‬

‫‪Odds ratio‬‬ ‫)‪(CI95%‬‬

‫‪50‬‬

‫‪‬‬

‫‪32‬‬

‫‪3‬‬

‫‪35‬‬

‫‪35/7‬‬ ‫‪%97/1‬‬

‫‪%100‬‬

‫‪%91/4‬‬

‫‪%94/1‬‬

‫‪%98/6‬‬

‫)‪(11/7-108/8‬‬

‫‪21/4‬‬ ‫‪%95/3‬‬

‫‪%100‬‬

‫‪%86/5‬‬

‫‪%94/4‬‬

‫‪%97/7‬‬

‫)‪(9/1-50/4‬‬

‫‪13/3‬‬ ‫‪%90/6‬‬

‫‪%100‬‬

‫‪%76/2‬‬

‫‪%85/1‬‬

‫‪%96/3‬‬

‫)‪(6/8-26/1‬‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):295-300‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻫﻤﻜﺎران‬ ‫ﻏﻔﻮري و‬ ‫ﻣﻬﻴﺎر‬ ‫‪Ghafuri‬‬ ‫‪M. et al.‬‬

‫‪298‬‬

‫ﺳﻪ ﺣﺪود ﺗﻤﺎﻳﺰ ‪ 20‬ﺗﺎ ‪ 50 ،50‬ﺗﺎ ‪ 100‬و ﺑﻴﺶﺗﺮ از ‪ 100‬ﺑﻪﺗﺮﺗﻴﺐ ﺑﺮاي‬ ‫ﻋﺪم ﻋﻮد‪ ،‬ﻣﺸﻜﻮك ﺑﻪ ﻋﻮد و ﻋﻮد ﻗﻄﻌﻲ اﺳﺘﻔﺎده ﺷﺪه ﺑﻮد ﻻزم ﺑﻪ ذﻛـﺮ‬ ‫اﺳﺖ ﻛﻪ ﺑﻪﺟﺰ ﻣﻄﺎﻟﻌﻪ ﻣﺬﻛﻮر ﺣﺪ ﺗﻤـﺎﻳﺰ ﻣﺸﺨـﺼﻲ در ﻣﻨـﺎﺑﻊ ﭘﺰﺷـﻜﻲ‬ ‫ﺑﺮاي ﻧﺴﺒﺖ ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات در ‪ MRS‬ﺟﻬﺖ ﺗـﺸﺨﻴﺺ ﻋـﻮد ﺗﻮﻣـﻮر‬ ‫ﭘﺮوﺳﺘﺎت اراﻳﻪ ﻧﺸﺪه اﺳﺖ‪ 10.‬در ﻣﻄﺎﻟﻌـﻪ اﻳـﺸﺎن ﺣـﺴﺎﺳﻴﺖ‪ ،‬وﻳﮋﮔـﻲ‪،‬‬ ‫ارزش اﺧﺒﺎري ﻣﺜﺒﺖ و ارزش اﺧﺒﺎري ﻣﻨﻔﻲ ‪ MRS‬ﺑﺮاي ﺗﺸﺨﻴﺺ ﻋﻮد‬ ‫ﺗﻮﻣﻮر ﭘﺮوﺳﺘﺎت ﺑﻪﺗﺮﺗﻴﺐ ‪ %93 ،%88 ،%84‬و ‪ %74‬ﮔﺰارش ﺷـﺪه ﺑـﻮد‪.‬‬ ‫ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻧﺸﺎن داد ﻛﻪ در ﺣﺪ ﺗﻤﺎﻳﺰ ‪ 50‬داراي ﺣﺴﺎﺳﻴﺖ ‪%97/1‬‬ ‫و وﻳﮋﮔﻲ ‪ %100‬ﺑﻮده اﺳﺖ‪ .‬ﻫﺮ ﭼﻪ ﺣﺪ ﺗﻤﺎﻳﺰ اﻓﺰاﻳﺶ ﻳﺎﺑﺪ‪ ،‬ﺣـﺴﺎﺳﻴﺖ‬ ‫ﻛﻢﺗـﺮ ﺷـﺪه و وﻳﮋﮔـﻲ ﻫـﻢﭼﻨـﺎن ‪ %100‬ﺑـﻮده اﺳـﺖ‪ .‬ﻟـﻴﻜﻦ ﻛـﺎﻫﺶ‬ ‫ﺣﺴﺎﺳﻴﺖ ﭼﻨﺪان ﻗﺎﺑﻞ ﺗﻮﺟﻪ ﻧﺒﻮده اﺳﺖ‪.‬‬ ‫ﻧﻤﻮدار‪ :1 -‬ﻣﻨﺤﻨﻲ‬

‫‪ROC‬‬

‫ﺗﺸﺨﻴﺺ ﻋﻮد ﺗﻮﻣﻮر در ﺣﺪ ﺗﻤﺎﻳﺰﻫﺎي ﻣﺨﺘﻠﻒ ﻣﺠﻤـﻮع‬

‫در ﺧﺼﻮص ﻣﻄﺎﻟﻌﺎﺗﻲ ﺑﺎ ﻣﻮﺿﻮع اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑﺎﻳﺪ ﺗﻮﺟﻪ ﻧﻤـﻮد ﻛـﻪ‬ ‫ﻧﺘﺎﻳﺞ اﻳﻦ ﮔﻮﻧﻪ ﻣﻄﺎﻟﻌﺎت ﺑﻪﻃﻮر ﻣﺸﺨﺼﻲ ﺑﺎ ﺗﻜﻨﻮﻟﻮژي ﺗـﺼﻮﻳﺮﺑﺮداري‬

‫ﻛﺮاﺗﻴﻦ و ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات‬

‫ارﺗﺒﺎط دارد‪ .‬ﻟﺬا ﻗﺎﺑﻞ اﻧﺘﻈﺎر اﺳﺖ ﻛﻪ ﻣﻄﺎﻟﻌﺎت ﻗﺒﻠﻲ ﻛﻪ ﺑﺎ دﺳﺘﮕﺎهﻫـﺎﻳﻲ‬ ‫ﺑﺎ ﺗﻜﻨﻮﻟﻮژي ﻗﺪﻳﻤﻲﺗﺮ اﻧﺠﺎم ﺷﺪه اﺳﺖ‪ ،‬دﻗﺖ ﻛـﻢﺗـﺮي را ﺑـﺮاي‬

‫ﺑﺤﺚ‬

‫‪MRS‬‬

‫ﻗﺎﻳﻞ ﺑﺎﺷﻨﺪ و ﻣﻄﺎﻟﻌﺎت ﺑﻌﺪي ﺑﺎ دﻗﺖ ﺑﻴﺶﺗﺮي ﻫﻤﺮاه ﺧﻮاﻫﻨﺪ ﺑـﻮد‪ .‬ﺑـﺎ‬

‫ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻧﺸﺎن داده اﺳﺖ ﻛﻪ در ﺑﻴﻤﺎران داراي ﻋـﻮد ﺗﻮﻣـﻮر‬

‫اﻳﻦ وﺟﻮد ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻧﺸﺎن داده اﺳﺖ ﻛﻪ ‪ MRS‬ﻣﻲﺗﻮاﻧﺪ ﺑﻪﻋﻨـﻮان‬

‫ﻣﻘﺪار ﻣﺠﻤﻮع ﻛﺮاﺗﻴﻦ و ﻛﻮﻟﻴﻦ ﺑﻪ ﺳﻴﺘﺮات ﺑﻪﻃﻮر ﻣﻌﻨﻲداري ﺑﻴﺶﺗـﺮ از‬

‫ﻳﻜﻲ از اﺑﺰارﻫﺎي دﻗﻴﻖ ﺗﺸﺨﻴﺺ ﺳﺮﻃﺎن ﭘﺮوﺳـﺘﺎت و ﻋـﻮد آن ﻣﻄـﺮح‬

‫ﺑﻴﻤﺎران ﻓﺎﻗﺪ ﻋﻮد ﺑﻮده اﺳﺖ‪ .‬ﻫﻤـﻴﻦ ﻣﻮﺿـﻮع در ﺧـﺼﻮص ‪ PSA‬ﻫـﻢ‬

‫ﺑﺎﺷﺪ وﻟﻲ اﻧﺠﺎم ﻣﻄﺎﻟﻌﺎت ﺑﻴﺶﺗﺮ ﺑﺎ ﺣﺠﻢ ﻧﻤﻮﻧﻪ ﺑﺎﻻﺗﺮ ﺑﺮاي رﺳﻴﺪن ﺑـﻪ‬

‫دﻳﺪه ﺷﺪه اﺳﺖ‪ .‬ﻗﺎﺑﻞ ﺗﻮﺟﻪ آنﻛﻪ ﻣﻴﺎن ‪ PSA‬و ﻣﺠﻤﻮع ﻛﺮاﺗﻴﻦ و ﻛﻮﻟﻴﻦ‬

‫ﻧﺘﺎﻳﺞ ﻗﻄﻌﻲﺗﺮ ﺿﺮوري اﺳﺖ‪.‬‬

‫ﺑﻪ ﺳﻴﺘﺮات راﺑﻄﻪ ﻣﻌﻨﻲداري دﻳﺪه ﺷﺪه اﺳـﺖ و اﻓـﺰاﻳﺶ ﻫـﺮ ﻳـﻚ ﺑـﺎ‬

‫ﺳﭙﺎﺳﮕﺰاري‪ :‬اﻳﻦ ﻣﻘﺎﻟﻪ ﺣﺎﺻﻞ ﭘﺎﻳﺎنﻧﺎﻣـﻪ ﺗﺤـﺖ ﻋﻨـﻮان "ﺑﺮرﺳـﻲ‬

‫اﻓﺰاﻳﺶ ﻣﻘﺎﺑﻞ ﻣﻌﻨﻲدار و ﻗﺎﺑﻞ ﺗﻮﺟﻪ دﻳﮕﺮي ﻫﻤﺮاه ﺑﻮده اﺳـﺖ‪ .‬ﻣﻴـﺰان‬

‫ﻣﻴﺰان ﺗﻮاﻓﻖ ‪ MRS‬ﺑﺎ آﻧﺘﻲ ژن اﺧﺘﺼﺎﺻﻲ ﭘﺮوﺳﺘﺎت ﺳـﺮم در ﺗـﺸﺨﻴﺺ‬

‫ﺗﻮاﻓﻖ ﻣﻴﺎن ‪ PSA‬و ‪ MRS‬ﺑﺮاي ﺗﺸﺨﻴﺺ ﻋﻮد ﺗﻮﻣﻮر ﻧﻴـﺰ در ﺣـﺪ ﻗﺎﺑـﻞ‬

‫ﻋﻮد ﻣﻮﺿﻌﻲ ﺳﺮﻃﺎن ﭘﺮوﺳﺘﺎت ﺑﻪدﻧﺒـﺎل رادﻳﻜـﺎل ﭘﺮوﺳـﺘﺎﺗﻜﺘﻮﻣﻲ" در‬

‫ﻗﺒﻮﻟﻲ ﺑﻮده و در ﺣﺪ ﺗﻤﺎﻳﺰ ‪ 100‬ﺑﺮاي ﻧﺴﺒﺖ ﻣﺠﻤﻮع ﻛﺮاﺗﻴﻦ و ﻛـﻮﻟﻴﻦ‬

‫ﻣﻘﻄــﻊ دﻛﺘــﺮاي ﺗﺨﺼــﺼﻲ رادﻳﻮﻟــﻮژي در ﺳــﺎل ‪ 1389‬و ﻛ ـﺪ ‪1370‬‬

‫ﺑﻪ ﺳﻴﺘﺮات ﺗﻮاﻓﻘﻲ در ﺣﺪود ‪ %95‬را ﺷﺎﻫﺪ ﺑﻮدهاﻳﻢ‪ .‬ﺑﺮ اﺳـﺎس ﻣﻄﺎﻟﻌـﻪ‬

‫ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺎ ﺣﻤﺎﻳﺖ داﻧـﺸﮕﺎه ﻋﻠـﻮم ﭘﺰﺷـﻜﻲ و ﺧـﺪﻣﺎت ﺑﻬﺪاﺷـﺘﻲ‬

‫‪ Sciarra‬ﺑﺮاي ﻧﺴـﺒﺖ ﻣﺠﻤﻮع ﻛﺮاﺗﻴـﻦ و ﻛﻮﻟﻴـﻦ ﺑﻪ ﺳﻴـﺘﺮات در‬

‫‪MRS‬‬

‫درﻣﺎﻧﻲ ﺗﻬﺮان اﺟﺮا ﺷﺪه اﺳﺖ‪.‬‬

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Tehran University Medical Journal, August 2012; Vol. 70, No. 5: 295-300

Original Article

Correlation between MRS and serum PSA in the diagnosis of local recurrence after radical prostatectomy Abstract Mahyar Ghafuri M.D. Ali Vafaee Shahi M.D.* Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran.

Corresponding author: Dept. of Radiology, Hazrat-e-Rasul Hospital, Niayesh St., Sattar khan Blvd., Tehran, Iran. Tel: +98-21-66033785 E-mail: vafaeea@yahoo.ca

Received: April 17, 2012 Accepted: May 06, 2012

Background: Multifocality, multicentricity and extension beyond the prostate capsule are all characteristics of prostatic adenocarcinoma that may escape diagnosis by conventional CT scanning or MRI. This study was designed to assess the diagnostic value of magnetic resonance spectroscopy (MRS) in prostatic carcinoma and its compatibility with prostatic specific antigen (PSA) as the conventional method. Methods: In this cross-sectional study, we recruited 139 patients with previous radical prostatectomy referring to Radiology department of Hazrate-e-Rasul Hospital during the first half of 2011 for the evaluation of local recurrence. Traditionally, local recurrence is defined as serum PSA concentration >0.2 ng/dl. We used 1.5-tesla Siemens Avanto MRI unit with endorectal coil and measured creatine, choline and citrate levels before calculating choline-creatine/citrate ratio. Correlation between MRS findings with PSA concentration was evaluated in regards to the multiple levels of the previously mentioned ratio. Results: Local recurrence was found in 107 (77%) patients based on PSA levels. The mean values for serum PSA levels and creatine-choline/citrate ratio were significantly different in patients with and without local recurrence. Creatine-choline/citrate ratios greater than 50, 100 and 150 (as different cut-off points of recurrence) were respectively seen in 104, 102 and 97 patients and agreement ratio between MRS and PSA in these levels were 94.1%, 94.4% and 85.1%, respectively. Correlation coefficient between these two methods was 0.481. Conclusion: MRS is a valuable tool for evaluating recurrence inpatients with prostate cancer treated by radical prostatectomy and it is in good agreement with serum PSA levels. Keywords: magnetic resonance spectroscopy, prostate cancer, prostatic specific antigen, pecurrence.

300 ‫ ﺗﺎ‬295 ،5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

‫ﺳﺮﻋﺖ ﺣﺪاﻛﺜﺮ ﺳﻴﺴﺘﻮﻟﻲ ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﭘﻨﻴﺲ‬

‫‪301‬‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ ،5‬ﺻﻔﺤﻪﻫﺎي ‪ 301‬ﺗﺎ ‪307‬‬

‫ﻣﻘﺎﻟﻪ اﺻﻴﻞ‬

‫ﻣﻘﺎﻳﺴﻪ ﺳﺮﻋﺖ ﺣﺪاﻛﺜﺮ ﺳﻴﺴﺘﻮﻟﻲ ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﭘﻨﻴﺲ ﻗﺒﻞ و ﺑﻌﺪ از ﺗﺰرﻳﻖ ﭘﺎﭘﺎورﻳﻦ در اﺧﺘﻼل ﻧﻌﻮظ‬

‫ﭼﻜﻴﺪه‬

‫ﺳﻴﺪ ﻣﺮﺗﻀﻲ ﺑﺎﻗﺮي‬ ‫ﻣﺤﻤﻮدرﺿﺎ ﻃﺎﻫﺮي‬

‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ﻣﻘﺎﻟﻪ‪1390/11/24 :‬‬

‫ﺗﺎرﻳﺦ ﭘﺬﻳﺮش‪1391/02/02 :‬‬

‫*‬

‫زﻣﻴﻨﻪ و ﻫﺪف‪ :‬اﺧﺘﻼل ﻋﻤﻠﻜﺮد ﺟﻨﺴﻲ در ﻣﺮدان‪ ،‬ﻣﻤﻜﻦ اﺳﺖ ﻧﺎﺷﻲ از ﻧﺎﻛﺎﻓﻲ ﺑﻮدن ﻧﻌﻮظ ﺑﺎ ﻣﻨﺸﺎي ﻋﺮوﻗﻲ ﺑﺎﺷﺪ‪ .‬ﻳﻜﻲ‬

‫ﮔﺮوه رادﻳﻮﻟﻮژي‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻬﻴﺪ ﻫﺎﺷﻤﻲﻧﮋاد‪،‬‬ ‫داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬

‫از روشﻫﺎي ﺗﺸﺨﻴﺺ آن‪ ،‬ﺗﺰرﻳﻖ داﺧﻞ ﺳﻴﻨﻮزوﻳﻴﺪي ﭘﺎﭘﺎورﻳﻦ و ﺳﭙﺲ ﺑﺮرﺳﻲ ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﭘﻨـﻴﺲ ﺑـﺎ اﺳـﺘﻔﺎده از‬ ‫ﺳﻮﻧﻮﮔﺮاﻓﻲ داﭘﻠﺮ اﺳﺖ‪ .‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ راﺑﻄـﻪ ﻣﻴـﺎن )‪ Peak Systolic Velocity (PSV‬ﺷـﺮﻳﺎن ﻛـﺎورﻧﻮزال ﻗﺒـﻞ از ﺗﺰرﻳـﻖ‬ ‫ﭘﺎﭘﺎورﻳﻦ و ﻧﺎﺗﻮاﻧﻲ ﺟﻨﺴﻲ ﺑﺎ ﻋﻠﺖ ﻋﺮوﻗﻲ ﺑﺮرﺳﻲ ﮔﺮدﻳﺪه اﺳﺖ‪.‬‬ ‫روش ﺑﺮرﺳﻲ‪ :‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ در ﺳﺎلﻫﺎي ‪ 1389‬و ‪ 1390‬در ﺑﻴﻤﺎرﺳﺘﺎن ﻫﺎﺷﻤﻲﻧﮋاد ﺗﻬﺮان در ﻗﺎﻟﺐ ﻳﻚ ﻣﻄﺎﻟﻌﻪ ﻛﺎرآزﻣـﺎﻳﻲ‬ ‫ﺑﺎﻟﻴﻨﻲ ﺧﻮد ﺷﺎﻫﺪ ﺷﻮﻧﺪه )‪ (Self-controlled‬اﻧﺠﺎم ﺷﺪه اﺳﺖ‪ .‬ﺟﻤﻌﻴﺖ ﻣﻮرد ﻣﻄﺎﻟﻌـﻪ ﺑﻴﻤـﺎران ﻣﺒـﺘﻼ ﺑـﻪ اﺧـﺘﻼل ﻧﻌـﻮظ‬ ‫ﻣﻲﺑﺎﺷﺪ‪ .‬ﺑﺎ اﺳﺘﻔﺎده از دﺳﺘﮕﺎه ﺳﻮﻧﻮﮔﺮاﻓﻲ ‪ PSV‬ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﭘﻨﻴﺲ ﺛﺒﺖ ﺷﺪه و در ﻣﺮﺣﻠﻪ ﺑﻌـﺪ ﺑﻴﻤـﺎران ‪ 40‬ﺗـﺎ ‪80‬‬ ‫ﻣﻴﻠﻲﮔﺮم ﭘﺎﭘﺎورﻳﻦ درﻳﺎﻓﺖ ﻛﺮده و ﻣﺠﺪداً ‪ PSV‬ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﺛﺒﺖ ﮔﺮدﻳﺪ‪ .‬ﻧﺘﺎﻳﺞ ﺑﻪدﺳﺖآﻣﺪه در ﻗﺒﻞ و ﺑﻌﺪ از ﺗﺰرﻳﻖ‬ ‫ﺑﺎ ﻳﻚدﻳﮕﺮ ﻣﻘﺎﻳﺴﻪ ﺷﺪ‪.‬‬ ‫ﻳﺎﻓﺘﻪﻫﺎ‪ 90 :‬ﺑﻴﻤﺎر ﻣﺬﻛﺮ ﺑﺎ ﻣﻴﺎﻧﮕﻴﻦ ﺳﻨﻲ ‪ 47/713/7‬ﺳﺎل وارد ﻣﻄﺎﻟﻌـﻪ ﺷـﺪﻧﺪ‪ .‬ﭘﺎﺳـﺦ ﺑـﻪ ﺗﺰرﻳـﻖ ﭘﺎﭘـﺎورﻳﻦ در ‪%45/5‬‬ ‫)‪ 41‬ﺑﻴﻤﺎر( ﻣﺜﺒﺖ ﺑﻮد‪ .‬ﻣﻴﺎﻧﮕﻴﻦ ‪ PSV‬ﻗﺒﻞ از ﺗﺰرﻳﻖ ﺑﺮاﺑﺮ ﺑـﺎ ‪ 14/68±5/65cm/s‬و ﺑﻌـﺪ از ﺗﺰرﻳـﻖ ‪ 53/74±18/8cm/s‬ﺑـﻮد‬ ‫)‪ .(P<0/001‬در ﮔﺮوه ﺑﻴﻤﺎران ﺑﺎ اﺧﺘﻼل ﻧﻌﻮظ ﺷﺮﻳﺎﻧﻲ‪ PSV ،‬ﻗﺒﻞ از ﺗﺰرﻳﻖ ﺑﺎ ﺣﺪ ﺗﻤـﺎﻳﺰ ‪ PSV‬ﻣﻌـﺎدل ‪ 10cm/s‬ﻣﻘﺎﻳـﺴﻪ و‬ ‫ﺑﺮرﺳﻲ ﮔﺮدﻳﺪ‪ .‬ﺑﺮ اﻳﻦ اﺳﺎس ﻣﻘﺪار ﺣﺴﺎﺳﻴﺖ اﻳﻦ ﺣﺪ ﺗﻤﺎﻳﺰ ‪ %50‬و وﻳﮋﮔﻲ آن ‪ %100‬ﻣﻲﺑﺎﺷﺪ‪.‬‬ ‫ﻧﺘﻴﺠﻪﮔﻴﺮي‪ :‬ﻣﻴﺰان ‪ PSV‬ﻗﺒﻞ از ﺗﺰرﻳﻖ ﻣﻌﺎدل ‪ 10cm/s‬ﺑﻪﻋﻨﻮان ﺣﺪ ﺗﻤﺎﻳﺰ ﺟﻬﺖ اﻓﺘﺮاق ﻋﻠـﻞ ﺷـﺮﻳﺎﻧﻲ اﺧـﺘﻼل ﻧﻌـﻮظ از‬

‫*‬

‫ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪ :‬ﺗﻬﺮان‪ ،‬ﺷﻬﺮآرا‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن رﺳﻮل‬

‫اﻛﺮم‪ ،‬ﺑﺨﺶ رادﻳﻮﻟﻮژي‬

‫ﺣﺴﺎﺳﻴﺖ ﻻزم ﺑﺮﺧﻮردار ﻧﻴﺴﺖ وﻟﻲ وﻳﮋﮔﻲ ﺑﺎﻻﻳﻲ دارد‪.‬‬

‫ﺗﻠﻔﻦ‪021-64352578 :‬‬

‫‪E-mail: dmrt53@yahoo.com‬‬

‫ﻛﻠﻤﺎت ﻛﻠﻴﺪي‪ ،Peak systolic velocity :‬ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال‪ ،‬ﭘﺎﭘﺎورﻳﻦ‪ ،‬اﺧﺘﻼل ﻧﻌﻮظ‪.‬‬

‫‪ %10‬دﻳﮕﺮ ﺷﺪﻳﺪ اﺳﺖ‪ .‬ﺑﺎ اﻓﺰاﻳﺶ ﺳﻦ ﻣﻮارد ﻣﺘﻮﺳﻂ و ﺷﺪﻳﺪ ‪2-3‬‬

‫ﻣﻘﺪﻣﻪ‬

‫‪2-4‬‬

‫ﺑﺮاﺑﺮ ﺷﺎﻳﻊﺗﺮ ﻣﻲﺷﻮﻧﺪ‪.‬‬

‫اﺧﺘﻼل ﻋﻤﻠﻜﺮد ﺟﻨﺴﻲ )‪ (Sexual dysfunction‬در ﻣﺮدان‪ ،‬ﺑﻪﻣﻌﻨﻲ‬

‫اﺧﺘﻼل ﻧﻌﻮظ ﻳﻚ ﺑﻴﻤﺎري ﺷﺎﻳﻊ و ﻣﻬﻢ ﺑﺎ ﻋﻮارض ﻣﺘﻌﺪد ﻣﻲﺑﺎﺷﺪ‪.‬‬

‫ﻋﺪم ﺗﻮاﻧﺎﻳﻲ در رﺳﻴﺪن ﺑﻪ راﺑﻄﻪ رﺿﺎﻳﺖﺑﺨﺶ ﺟﻨﺴﻲ اﻃﻼق ﻣﻲﮔﺮدد‬

‫اﻣﺮوزه اﺧﺘﻼل ﻧﻌﻮظ را ﻋﺎﻣﻞ ﭘﻴﺸﮕﻮﻳﻲ ﻛﻨﻨﺪه در ﻋﺎرﺿﻪﻫﺎي ﻗﻠﺒﻲ‪-‬‬

‫‪1‬‬

‫ﻋﺮوﻗﻲ در ﺑﺮﺧﻲ ﻣﺮدان ﻣﻲداﻧﻨﺪ و رﻳﺴﻚ ﺑﻴﻤﺎريﻫﺎي ﻗﻠﺒﻲ‪ -‬ﻋﺮوﻗﻲ‬

‫ﻧﺎﺗﻮاﻧﻲ در ﻧﻌﻮظ آﻟﺖ )‪ (Penile erection‬اﺧﺘﻼل ﺷﺎﻳﻌﻲ اﺳﺖ ﻛﻪ در‬

‫در آنﻫﺎ را ﻣﺸﺎﺑﻪ اﻓﺮاد ﺳﻴﮕﺎري ﻳﺎ ﺑﺎ ﺳﺎﺑﻘﻪ ﻣﺜﺒﺖ ﻓﺎﻣﻴﻠﻲ ﺳﻜﺘﻪ ﻗﻠﺒﻲ‬

‫ﺣﺪود ‪ %52‬ﻣﺮدان از ‪ 40‬اﻟﻲ ‪ 70‬ﺳﺎﻟﻪ در ﻃﻮل ﻋﻤﺮ ﺧﻮد ﺑﻪ درﺟﺎﺗﻲ از‬

‫ﻣﻲداﻧﻨﺪ‪ 5.‬ﺑﻪﻣﻮازات ﭘﻴﺸﺮﻓﺖ در ﺷﻨﺎﺧﺖ ﻓﻴﺰﻳﻮﻟﻮژي ﻗﻠﺒﻲ‪ -‬ﻋﺮوﻗﻲ‪،‬‬

‫اﻳـﻦ اﺧﺘﻼﻻت ﻣﺒﺘﻼ ﻣﻲﺷﻮﻧﺪ‪ %17 :‬اﻳـﻦ ﻣﻮارد ﺧﻔﻴﻒ‪ %25 ،‬ﻣﺘﻮﺳﻂ و‬

‫ﻣﻄﺎﻟﻌﺎت زﻳﺎدي در زﻣﻴﻨﻪ ﻓﻴﺰﻳﻮﻟﻮژي ﻧﻌﻮظ ﺑﺎ ﻧﮕﺎه وﻳﮋه ﺑﻪ ﻓﺎﻛﺘﻮرﻫﺎي‬

‫و ﻣﻤﻜﻦ اﺳﺖ ﻧﺎﺷﻲ از ﻧﺎﻛﺎﻓﻲ ﺑﻮدن ﻧﻌﻮظ و ﻳﺎ اﺷﻜﺎل در اﻧﺰال ﺑﺎﺷﺪ‪.‬‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):301-7‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﺳﻴﺪ ﻣﺮﺗﻀﻲ ﺑﺎﻗﺮي و ﻫﻤﻜﺎران‬

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‫ﺗﻨﻈﻴﻢﻛﻨﻨﺪه اﻧﺪوﺗﻠﻴﻮم و ﻣﺎﻫﻴﭽﻪﻫﺎي ﺻﺎف اﺟﺴﺎم ﻛﺎورﻧﻮزال ﺑﻪﻋﻤﻞ‬

‫‪ (Flaccid‬و ﻧﺎﺗﻮاﻧﻲ ﺟﻨﺴﻲ ﺑﺎ ﻋﻠﺖ ﻋﺮوﻗﻲ ﻣﻮرد ارزﻳﺎﺑﻲ ﻗﺮار ﮔﻴﺮد ﺗـﺎ‬

‫آﻣﺪه اﺳﺖ و از اﻳﻦ دﻳﺪﮔﺎه ﺑﻴﻤﺎريﻫﺎي اﺻﻠﻲ ﻫﻢﭼﻮن آﺗﺮواﺳﻜﻠﺮوز‪،‬‬

‫ﺑﺘﻮان ﺑﻴﻤﺎران ﺑﺎ اﺧﺘﻼل ﻣـﺬﻛﻮر را ﺑـﺪون ﻧﻴـﺎز ﺑـﻪ ﺑﺮرﺳـﻲ ﺗﺸﺨﻴـﺼﻲ‬

‫دﻳﺎﺑﺖ ﻗﻨﺪي‪ ،‬ﻫﻴﭙﺮﺗﺎﻧﺴﻴﻮن‪ ،‬ﻫﻴﭙﺮﻟﻴﭙﻴﺪﻣﻲ و ﺳﻨﺪرم ﻣﺘﺎﺑﻮﻟﻴﻚ ﭘﺎﻳﻪﻫﺎي‬

‫ﺑﻪﻧﺴﺒﺖ ﺗﻬﺎﺟﻤﻲ و دردﻧـﺎك و ﻋﺎرﺿـﻪدار ﻧﺎﺷـﻲ از ﺗﺰرﻳـﻖ ﭘﺎﭘـﺎورﻳﻦ‬

‫ﺗﺤﻘﻴﻘﺎت درﺑﺎره اﺧﺘﻼل ﻧﻌﻮظ را ﺗﺸﻜﻴﻞ ﻣﻲدﻫﻨﺪ‪ 6.‬ﺑﻪﻟﺤﺎظ اﺗﻴﻮﻟﻮژﻳﻚ‬

‫ﺗﺸﺨﻴﺺ داد‪.‬‬

‫ﻋﻮاﻣﻞ رواﻧﻲ‪ ،‬ﻋﺼﺒﻲ‪ ،‬ﻫﻮرﻣﻮﻧﻲ‪ ،‬ﺷﺮﻳﺎﻧﻲ‪ -‬ورﻳﺪي و آﻧﺎﺗﻮﻣﻴﻚ در‬ ‫‪7-9‬‬

‫ﺑﺮوز اﺧﺘﻼل ﻧﻌﻮظ دﺧﺎﻟﺖ دارﻧﺪ‪.‬‬

‫روش ﺑﺮرﺳﻲ‬

‫ﺑﺎ وﺟﻮد آنﻛﻪ در ﻃﻲ ﺳـﻮﻧﻮﮔﺮاﻓﻲ و ﺑـﻪﺧـﺼﻮص ﺑـﺎ اﺳـﺘﻔﺎده از‬ ‫اﺑﺰارﻫﺎي ﺟﺪﻳﺪ ﺳﻮﻧﻮﮔﺮاﻓﻲ ﺗﺼﻮﻳﺮ ﻗﺎﺑﻞ ﻗﺒﻮﻟﻲ از ارﮔـﺎنﻫـﺎ ﺑـﻪدﺳـﺖ‬

‫اﻳﻦ ﻣﻄﺎﻟﻌﻪ در ﺷﺶ ﻣﺎﻫﻪ دوم ‪ 1389‬و ﺳﻪ ﻣﺎﻫـﻪ اول ﺳـﺎل ‪1390‬‬

‫ﻣﻲآﻳﺪ‪ ،‬ﻟﻴﻜﻦ ﺷﻨﺎﺳـﺎﻳﻲ روشﻫـﺎي ﺳـﻮﻧﻮﮔﺮاﻓﻲ ﺟﺪﻳـﺪ و ﻫـﻢﭼﻨـﻴﻦ‬

‫در ﺑﻴﻤﺎرﺳﺘﺎن ﻫﺎﺷﻤﻲﻧﮋاد داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬـﺮان در ﻗﺎﻟـﺐ ﻳـﻚ‬

‫ﺷﺎﺧﺺﻫﺎي ﺟﺪﻳﺪ ﺑﺮاي ﺑﺮرﺳﻲ ﺳﻼﻣﺖ و ﻋﻤﻠﻜﺮد ارﮔﺎنﻫﺎ ﻫﻢﭼﻨـﺎن‬

‫ﻣﻄﺎﻟﻌﻪ ﻛﺎرآزﻣﺎﻳﻲ ﺑﺎﻟﻴﻨﻲ ﺧﻮد ﺷﺎﻫﺪ ﺷـﻮﻧﺪه )‪ (Self controlled‬اﻧﺠـﺎم‬

‫ﻣﻮرد ﺗﻮﺟﻪ ﭘﺰﺷﻜﺎن و ﻣﺤﻘﻘـﺎن ﻗـﺮار دارد‪ 10.‬ورود ﺳـﻮﻧﻮﮔﺮاﻓﻲ داﭘﻠـﺮ‬

‫ﺷﺪه اﺳﺖ‪ .‬ﻣﻄﺎﻟﻌﻪ ﺗﻮﺳﻂ دﺳـﺘﻴﺎر رادﻳﻮﻟـﻮژي ﺳـﺎل ﭼﻬـﺎر و زﻳﺮﻧﻈـﺮ‬

‫رﻧﮕﻲ ﺑﺮاي ﺑﺮرﺳﻲ اﺧﺘﻼل ﻧﻌﻮظ ﺑﺎ ﻣﺤﺎﺳﺒﻪ ﺳﺮﻋﺖ ﺣﺪاﻛﺜﺮ ﺳﻴـﺴﺘﻮﻟﻲ‬

‫ﻣــﺴﺘﻘﻴﻢ اﺳــﺘﺎد رادﻳﻮﻟــﻮژي ﻣﺮﻛــﺰ ﻣــﺬﻛﻮر‪ ،‬ﺑــﺎ دﺳــﺘﮕﺎه ﺳــﻮﻧﻮﮔﺮاﻓﻲ‬

‫‪ Peak Systolic Velocity‬و ﺳـــﺮﻋﺖ اﻧﺘﻬـــﺎي دﻳﺎﺳـــﺘﻮﻟﻲ‬

‫)‪ESAOTE Technos (Linear probe LA 523, 5-10 MHz, Italy, 2002‬‬

‫)‪ (End Diastolic Velocity‬در ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﭘﻨﻴﺲ ﻗﺒـﻞ و ﺑﻌـﺪ از‬

‫اﻧﺠﺎم ﮔﺮدﻳﺪ‪ .‬ﺟﻤﻌﻴﺖ ﻣﻮرد ﻣﻄﺎﻟﻌﻪ در اﻳـﻦ ﺗﺤﻘﻴـﻖ ﻋﺒـﺎرت اﺳـﺖ از‬

‫ﺗﺰرﻳﻖ ﭘﺎﭘﺎورﻳﻦ ﻧﻘﺶ ﻋﻤﺪهاي در اﻧﺘﺨﺎب ﺑﻬﺘﺮﻳﻦ درﻣﺎن ﺑﺮاﺳﺎس ﻣﻴﺰان‬

‫ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﻧﺎرﺳﺎﻳﻲ در ﻧﻌﻮظ‪ .‬ﻣﻌﻴﺎرﻫﺎي ورود ﺑﻪ ﻣﻄﺎﻟﻌـﻪ ﻋﺒـﺎرت‬

‫اﻳﻦ اﻧﺪﻛﺲﻫﺎ ﺑﺮاي ﺑﻴﻤﺎران داﺷﺘﻪ اﺳﺖ‪ 11.‬ﻣﺮاﺣـﻞ ﻣﺨﺘﻠـﻒ ﻧﻌـﻮظ ﺑـﺎ‬

‫ﺑﻮد از اﺑﺘﻼ ﺑﻪ اﺧﺘﻼل ﻧﻌﻮظ‪ ،‬ﻛﺎﻧﺪﻳﺪ درﻣﺎن ﺑﺎ ﭘﺎﭘﺎورﻳﻦ‪ ،‬اﻋﻼم رﺿـﺎﻳﺖ‬

‫اﺳﺘﻔﺎده از ﺳﻮﻧﻮﮔﺮاﻓﻲ داﭘﻠﺮ ﺑﺮرﺳﻲ ﺷﺪه و ﺳﺮﻋﺖﻫﺎي ﻣﺨﺘﻠﻒ ﺟﺮﻳﺎن‬

‫ﻣﺒﻨﻲ ﺑﺮ ورود ﺑﻪ ﻣﻄﺎﻟﻌﻪ‪ ،‬ﻗﺎﺑﻠﻴﺖ اﻧﺠﺎم ﺳﻮﻧﻮﮔﺮاﻓﻲ داﭘﻠﺮ رﻧﮕﻲ‪ ،‬ﻗﺎﺑﻠﻴﺖ‬

‫ﺧﻮن در ﻓﺎزﻫﺎي ﻗﻠﻪ ﺳﻴـﺴﺘﻮﻟﻲ )‪ (Peak systolic‬و اﻧﺘﻬـﺎي دﻳﺎﺳـﺘﻮﻟﻲ‬

‫ﺗﺰرﻳﻖ ﭘﺎﭘﺎورﻳﻦ‪ .‬ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﻓﺎﻗﺪ اﻃﻼﻋﺎت ﺑﺎﻟﻴﻨﻲ ﻗﺎﺑﻞ اﻋﺘﻤﺎد ﺑﻮدﻧﺪ و‬

‫)‪ (End diastolic‬ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﺑﺎ ﻣﺮاﺣﻞ ﭼﻬﺎرﮔﺎﻧـﻪ ﻧﻌـﻮظ ﺷـﺎﻣﻞ‬

‫ﺑﻴﻤﺎراﻧﻲ ﻛﻪ اﻣﻜﺎن اﻧﺠﺎم ﺳﻮﻧﻮﮔﺮاﻓﻲ داﭘﻠﺮ رﻧﮕﻲ ﻳـﺎ ﺗﺰرﻳـﻖ ﭘﺎﭘـﺎورﻳﻦ‬

‫ﺷﻞ )‪ ،(Flaccid‬ﭘﺮ ﺷـﺪن )‪ ،(Filling‬اﺣﺘﻘـﺎن )‪ (Tumescence‬و ﻧﻌـﻮظ‬

‫ﺑﺮاي آنﻫﺎ وﺟﻮد ﻧﺪاﺷﺖ از ﻣﻄﺎﻟﻌﻪ ﺧﺎرج ﺷﺪﻧﺪ‪ .‬در اﻳﻦ ﻣﻄﺎﻟﻌـﻪ ﻛﻠﻴـﻪ‬

‫ﺳﻔﺖ )‪ (Rigid erection‬ﺗﻄﺒﻴﻖ داده ﺷﺪه اﺳـﺖ‪ .‬ﺑـﺮ اﻳـﻦ اﺳـﺎس ﻧـﻮع‬

‫ﺑﻴﻤﺎران واﺟﺪ ﺷﺮاﻳﻂ ورود ﺑﻪ ﻣﻄﺎﻟﻌﻪ ﺑﻪﺗﺮﺗﻴﺐ وارد ﻣﻄﺎﻟﻌﻪ ﺷـﺪﻧﺪ و از‬

‫ﻋﺮوﻗﻲ ﻧﺎﺗﻮاﻧﻲ ﺟﻨﺴﻲ در ﻣﺮدان ﻛﻪ ﺷـﺎﻳﻊﺗـﺮﻳﻦ ﻓـﺮم ﻧـﺎﺗﻮاﻧﻲ ﺟﻨـﺴﻲ‬

‫روش در دﺳﺘﺮس )‪ (Available‬ﺑﺮاي اﻧﺘﺨﺎب ﺑﻴﻤﺎران اﺳﺘﻔﺎده ﺗﺎ ﺣﺠـﻢ‬

‫اﺳــﺖ ﺑــﻪ اﻧــﻮاع ﻣﺨﺘﻠــﻒ ﺷــﺮﻳﺎﻧﻲ )‪ ،(Arterial‬ورﻳــﺪي )‪ (Venous‬و‬

‫ﻧﻤﻮﻧﻪ ﻣﺤﺎﺳﺒﻪ ﺷﺪه ﻛﺎﻣﻞ ﮔﺮدﻳﺪ‪ .‬ﺑﺎ در ﻧﻈـﺮ ﮔـﺮﻓﺘﻦ ﺧﻄـﺎي ﻧـﻮع اول‬

‫)‪(PSV‬‬

‫‪12‬‬

‫ﻣﺨﺘﻠﻂ )‪ (Mixed‬ﻃﺒﻘﻪﺑﻨﺪي ﺷﺪه اﺳﺖ‪.‬‬

‫ﻣﻌﺎدل ‪ ،%5‬ﺧﻄﺎي ﻧﻮع دوم ﻣﻌﺎدل ‪ %20‬و ﺑﺎ اﺳﺘﻔﺎده از راﺑﻄـﻪ ﻣﻘﺎﻳـﺴﻪ‬

‫از ﻣﻨﻈﺮ درﻣﺎﻧﻲ ﻧـﺎﺗﻮاﻧﻲﻫـﺎي ﺟﻨـﺴﻲ ﻋﺮوﻗـﻲ از ﻧـﻮع ورﻳـﺪي و‬

‫ﻣﻴﺎﻧﮕﻴﻦﻫﺎ در دو ﺟﺎﻣﻌﻪ ﺣﺠﻢ ﻧﻤﻮﻧﻪ ﻣﻌﺎدل ‪ 86‬ﻧﻔﺮ ﻣﺤﺎﺳـﺒﻪ ﺷـﺪ‪ ،‬ﻛـﻪ‬

‫‪ Mixed‬اﻏﻠﺐ ﻧﺎاﻣﻴﺪﻛﻨﻨﺪه ﺑﻮده اﺳﺖ اﻣﺎ روشﻫﺎي درﻣﺎﻧﻲ ﻣﺘﻌﺪد ﻃﺒـﻲ‬

‫ﻧﺘﺎﻳﺞ ﻗﺒـﻞ و ﺑﻌـﺪ از ﻣﻄﺎﻟﻌـﻪ ﺗﻌﻴـﻴﻦ و ﺑـﺎ ﻫـﻢ ﻣﻘﺎﻳـﺴﻪ ﺷـﺪ‪ .‬ﭘـﺲ از‬

‫ﺑﺮاي ﻧﻮع ﺷﺮﻳﺎﻧﻲ وﺟﻮد دارد‪ .‬ﻳﻜﻲ از اﻳﻦ روشﻫﺎ ﻛﻪ ﻫﻢ ﺗﺸﺨﻴﺼﻲ و‬

‫ﻫﻤﺎﻫﻨﮕﻲﻫﺎي ﻣﻌﻤﻮل اداري و اراﻳﻪ اﻃﻼﻋﺎت ﻛﺎﻣﻞ ﺑﻪ ﺑﻴﻤـﺎران و اﺧـﺬ‬

‫ﻫﻢ درﻣﺎﻧﻲ ﻣﺤﺴﻮب ﻣـﻲﺷـﻮد اﺳـﺘﻔﺎده از ﺗﺰرﻳـﻖ داﺧـﻞ ﻛـﺎورﻧﻮزال‬

‫رﺿﺎﻳﺖﻧﺎﻣـﻪ آﮔﺎﻫﺎﻧـﻪ از ﻫـﺮ ﺑﻴﻤـﺎر‪ ،‬اﻃﻼﻋـﺎت ﺑـﺎﻟﻴﻨﻲ ﺑـﻪﺷـﺮح ﻓـﺮم‬

‫ﭘﺎﭘﺎورﻳﻦ اﺳﺖ‪ 13.‬ﮔﺮ ﭼﻪ ﻋﻮارض ﺷﺪﻳﺪ ﻧﺎﺷـﻲ از اﻳـﻦ ﺗﺰرﻳـﻖ )ﻣﺎﻧﻨـﺪ‬

‫ﭘﺮﺳﺶﻧﺎﻣﻪ از ﺑﻴﻤـﺎران اﺧـﺬ ﺷـﺪ‪ .‬اﻃﻼﻋـﺎت ﺷﺨـﺼﻲ ﺑﻴﻤـﺎران ﻛـﺎﻣﻼً‬

‫ﭘﺮﻳﺎﭘﻴﺴﻢ( درﺻـﺪ ﺑـﺴﻴﺎر ﭘـﺎﻳﻴﻨﻲ )‪ (%2/6‬را ﺑـﻪ ﺧـﻮد اﺧﺘـﺼﺎص داده‬

‫ﻣﺤﺮﻣﺎﻧﻪ ﺑﻮد و ﺑﺎر ﻣﺎﻟﻲ اﺿﺎﻓﻪ ﺑﻪ آﻧﺎن ﺗﺤﻤﻴﻞ ﻧﺸﺪ‪ .‬ﻫﺮ ﺑﻴﻤﺎر ﺑﺎ اﺳﺘﻔﺎده‬

‫اﺳﺖ‪ 14،‬ﺑﺎ اﻳﻦ ﺣﺎل اﻳﻦ روش ﺗﺸﺨﻴﺼﻲ داراي ﻋﻮارﺿﻲ ﻧﻈﻴﺮ اﻛﻴﻤـﻮز‬

‫از دﺳﺘﮕﺎه ﺳﻮﻧﻮﮔﺮاﻓﻲ داﭘﻠﺮ رﻧﮕﻲ ﺗﺤﺖ ﺑﺮرﺳﻲ ﺳﺮﻋﺖ ﭘﻴـﻚ ﺟﺮﻳـﺎن‬

‫ﻣﺤــﻞ ﺗﺰرﻳــﻖ‪ ،‬ﮔﻴﺠــﻲ‪ ،‬ﻓﻴﺒــﺮوز و ﭘﺮﻳﺎﭘﻴــﺴﻢ اﺳــﺖ و روش دردﻧــﺎﻛﻲ‬

‫ﺧﻮن در ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﭘﻨﻴﺲ ﻗﺮار ﮔﺮﻓﺖ‪ .‬در ﻣﺮﺣﻠﻪ ﺑﻌـﺪ ﺑﻴﻤـﺎران‬

‫ﻣﺤﺴﻮب ﻣﻲﺷﻮد‪ 13.‬ﻟﺬا در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺳﻌﻲ ﺷﺪه اﺳﺖ ﺗﺎ وﺟﻮد راﺑﻄﻪ‬

‫ﺑﻪروش زﻳﺮ ﺗﺤﺖ ﺑﺮرﺳﻲ ﺑـﺎ ﭘﺎﭘـﺎورﻳﻦ ﻗـﺮار ﮔﺮﻓﺘﻨـﺪ‪ 40 :‬ﻣﻴﻠـﻲﮔـﺮم‬

‫ﻣﻴﺎن ﻣﻘﺎدﻳﺮ ‪ PSV‬ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﻗﺒﻞ از ﺗﺰرﻳـﻖ ﭘﺎﭘـﺎورﻳﻦ )در ﺣـﺎل‬

‫ﭘﺎﭘـﺎورﻳﻦ )‪ (Papaverine HCL 4%, 1ml= 40mg, OMINO, Czech‬ﺑـﻪ‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ 301 ،5‬ﺗﺎ ‪307‬‬

‫ﺳﺮﻋﺖ ﺣﺪاﻛﺜﺮ ﺳﻴﺴﺘﻮﻟﻲ ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﭘﻨﻴﺲ‬

‫‪303‬‬

‫اﺟــﺴﺎم ﻏــﺎري ﭘﻨــﻴﺲ ﺗﺰرﻳــﻖ ﺷــﺪه و در ﺻــﻮرت ﻋــﺪم ﭘﺎﺳــﺦدﻫــﻲ‬

‫ﻃﺒﻘﻪﺑﻨﺪي ﻧﺸﺪه ﺑﻮده اﺳﺖ‪ .‬ﻳﺎﻓﺘﻪﻫﺎي اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻧﺸﺎن داد ﻛﻪ ﻣﻴـﺎﻧﮕﻴﻦ‬

‫ﻧﻴﻢﺳﺎﻋﺖ ﺑﻌﺪ ﻳﻚ ﻧﻮﺑﺖ دﻳﮕﺮ اﻳﻦ ﺗﺰرﻳﻖ ﺻﻮرت ﻣـﻲﮔﺮﻓـﺖ‪ .‬ﻧﺘﻴﺠـﻪ‬

‫‪ PSV‬ﻗﺒﻞ از ﺗﺰرﻳﻖ ﺑﺮاﺑﺮ ﺑﺎ ‪ 14/68±5/65cm/s‬و ﺑﻌﺪ از ﺗﺰرﻳﻖ ﺑﺮاﺑﺮ ﺑـﺎ‬

‫ﺗﺰرﻳﻖ ﻳﻜﻲ از دو ﺣﺎﻟﺖ ﭘﺎﺳﺦ ﻳﺎ ﻋﺪم ﭘﺎﺳﺦ ﺑﺎﻟﻴﻨﻲ ﺑﻮد‪ .‬ﭘﺲ از ﺗﺰرﻳـﻖ‬

‫‪ 53/74±18/8cm/s‬ﺑﻮد )‪.(P<0/001‬‬

‫ﭘﺎﭘﺎورﻳﻦ ﻣﺠﺪدا ﺳﻮﻧﻮﮔﺮاﻓﻲ داﭘﻠﺮ ﺟﻬـﺖ اﻧـﺪازهﮔﻴـﺮي ﺳـﺮﻋﺖ ﭘﻴـﻚ‬

‫در ﺟﺪول‪ ،1 -‬ﻣﻴﺎﻧﮕﻴﻦ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﻗﺒـﻞ و ﺑﻌـﺪ از‬

‫ﺟﺮﻳﺎن ﺧﻮن در ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﭘﻨﻴﺲ اﻧﺠﺎم ﻣﻲﺷﺪ‪ .‬ﻧﺘﺎﻳﺞ ﺑـﻪدﺳـﺖ‬

‫ﺗﺰرﻳﻖ ﭘﺎﭘﺎورﻳﻦ ﺑﺮ ﺣﺴﺐ زﻳﺮ ﮔﺮوهﻫﺎي ﻣﺘﻐﻴﺮﻫﺎي ﻣﻮرد ﻣﻄﺎﻟﻌﻪ ﻧـﺸﺎن‬

‫آﻣﺪه در ﻗﺒﻞ و ﺑﻌﺪ از ﺗﺰرﻳﻖ ﺑﺎ ﻳﻚدﻳﮕﺮ ﻣﻘﺎﻳﺴﻪ ﺷﺪه و ﻫـﻢﭼﻨـﻴﻦ ﺑـﺮ‬

‫داده ﺷﺪه اﺳﺖ‪ .‬ﻣﻨﺪرﺟﺎت اﻳﻦ ﺟـﺪول ﻧـﺸﺎن ﻣـﻲدﻫـﺪ ﻛـﻪ ﻣﻴـﺎﻧﮕﻴﻦ‬

‫ﺣﺴﺐ ﺳﻦ‪ ،‬وﺟﻮد ﺑﻴﻤﺎري دﻳﺎﺑﺖ‪ ،‬وﺟﻮد ﺑﻴﻤﺎري ﻫﻴﭙﺮﺗﺎﻧﺴﻴﻮن‪ ،‬ﺳﻴﮕﺎر‪،‬‬

‫ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﻗﺒﻞ و ﺑﻌﺪ از ﺗﺰرﻳـﻖ ﭘﺎﭘـﺎورﻳﻦ ﺑـﺮ ﺣـﺴﺐ‬

‫وﺟﻮد اﺧـﺘﻼﻻت ﻧﺨـﺎﻋﻲ‪ ،‬وﺟـﻮد اﺧـﺘﻼﻻت آﻧﺎﺗﻮﻣﻴـﻚ و ﻫـﻢﭼﻨـﻴﻦ‬

‫ﺗﻤﺎﻣﻲ ﻣﺘﻐﻴﺮﻫﺎي ﻣﻮرد ﻣﻄﺎﻟﻌﻪ از ﺟﻤﻠﻪ ﺳﻦ‪ ،‬ﻣﺼﺮف ﺳﻴﮕﺎر‪ ،‬ﻣﺪت اﺑﺘﻼ‬

‫ﺑﺮﺣﺴﺐ ﻃﻮل ﻣﺪت اﺑﺘﻼ ﺑﻪ ﻧﺎرﺳﺎﻳﻲ در ﻧﻌﻮظ آﻧـﺎﻟﻴﺰ ﺷـﺪ‪ .‬ﻫـﻢﭼﻨـﻴﻦ‬

‫ﺑﻪ ﺑﻴﻤﺎري‪ ،‬اﺑﺘﻼ ﺑﻪ ﺑﻴﻤﺎريﻫﺎي زﻣﻴﻨﻪاي از ﺟﻤﻠﻪ دﻳﺎﺑﺖ‪ ،‬ﻓﺸﺎر ﺧـﻮن و‬

‫ﻣﻘﺎدﻳﺮ ‪ PSV‬ﻗﺒـﻞ از ﺗﺰرﻳـﻖ ﺑـﺮ ﺣـﺴﺐ ﺣـﺴﺎﺳﻴﺖ‪ ،‬وﻳﮋﮔـﻲ و ارزش‬

‫اﺧﺘﻼل آﻧﺎﺗﻮﻣﻴﻚ‪ ،‬اﺧﺘﻼف آﻣﺎري ﻣﻌﻨﻲداري را ﻗﺒﻞ و ﺑﻌـﺪ از ﻣﺪاﺧﻠـﻪ‬

‫اﺧﺒﺎري ﻣﺜﺒﺖ و ﻣﻨﻔﻲ ﻣﻮرد ﺗﺤﻠﻴﻞ ﻗﺮار ﮔﺮﻓـﺖ‪ PSV .‬ﻧﻬـﺎﻳﻲ ﻣﻴـﺎﻧﮕﻴﻦ‬

‫ﻧﺸﺎن ﻣـﻲدﻫـﺪ‪ ،‬ﻳﻌﻨـﻲ در ﺗﻤـﺎﻣﻲ ﻣﺘﻐﻴﺮﻫـﺎ ﻣﻴـﺎﻧﮕﻴﻦ ﺳـﺮﻋﺖ ﺟﺮﻳـﺎن‬

‫‪PSV‬ﻫﺎي اﻧﺪازهﮔﻴﺮيﺷﺪه دو ﺟﺴﻢ ﻏﺎري در ﻫﺮ ﺑﻴﻤﺎر ﺑـﻮد‪ .‬ﺑـﻪﻣﻨﻈـﻮر‬

‫ﺳﻴﺴﺘﻮﻟﻴﻚ ﺑﻌﺪ از ﺗﺰرﻳﻖ ﭘﺎﭘﺎورﻳﻦ اﻓﺰاﻳﺶ ﻣﻌﻨﻲداري داﺷﺘﻪ اﺳـﺖ اﻣـﺎ‬

‫آﻧﺎﻟﻴﺰ آﻣﺎري اﺑﺘﺪا ﺑـﺎ اﺳـﺘﻔﺎده از ‪ ،Kolmogorov-Smirnov Test‬ﺗﻮزﻳـﻊ‬

‫ﻣﻴﺎﻧﮕﻴﻦ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﻗﺒﻞ از ﺗﺰرﻳﻖ ﭘﺎﭘﺎورﻳﻦ ﺑـﺮ ﺣـﺴﺐ‬

‫دادهﻫﺎ ﺑﺮرﺳﻲ ﺷﺪ‪ .‬آزﻣﻮنﻫﺎي ﻣـﻮرد اﺳـﺘﻔﺎده در اﻳـﻦ ﻣﻄﺎﻟﻌـﻪ ﺷـﺎﻣﻞ‬

‫زﻳﺮ ﮔﺮوهﻫﺎي ﻣﺘﻐﻴﺮﻫﺎي ﻣﻮرد ﻣﻄﺎﻟﻌـﻪ اﺧـﺘﻼف آﻣـﺎري ﻣﻌﻨـﻲداري را‬

‫آزﻣــﻮنﻫــﺎي ﭘــﺎراﻣﺘﺮي اﺳــﺘﻘﻼل دو ﮔــﺮوه ‪ Independent t-test‬و‬

‫ﻧﺸﺎن ﻧﻤﻲدﻫﺪ‪.‬‬

‫‪ Paired t-test‬ﺑﻮد‪ .‬اﻣﺎ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻋﺪم ﺗﺒﻌﻴﺖ دادهﻫﺎي ﮔﺮوﻫﻲ ﻛـﻪ ﺑـﻪ‬

‫در ﺟﺪول‪ ،2 -‬ﻣﻴﺎﻧﮕﻴﻦ ﻣﺘﻐﻴﺮﻫﺎي ﻛﻤ‪‬ﻲ ﻣـﻮرد ﻣﻄﺎﻟﻌـﻪ ﺑـﺮ ﺣـﺴﺐ‬

‫درﻣﺎن ﭘﺎﺳﺦ ﻣﻨﻔﻲ داده ﺑﻮدﻧﺪ ﺑﻪﻣﻨﻈﻮر ﻣﻘﺎﻳﺴﻪ ﻣﺘﻐﻴﺮﻫﺎي ﻛﻤ‪‬ﻲ آنﻫـﺎ از‬

‫اﻳﺠﺎد ﻧﻌﻮظ ﻧﺸﺎن داده ﺷﺪه اﺳﺖ‪ .‬ﻧﺘﺎﻳﺞ اراﻳﻪﺷﺪه در اﻳﻦ ﺟﺪول ﻧـﺸﺎن‬

‫‪ Kruskal‬اﺳﺘﻔﺎده ﮔﺮدﻳﺪ‪ .‬ﻫﻢﭼﻨﻴﻦ ﺟﻬـﺖ ﻣﻘﺎﻳـﺴﻪ‬

‫ﻣﻲدﻫﺪ ﻛﻪ ﺗﻨﻬﺎ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﺑﻌﺪ از درﻳﺎﻓﺖ ﭘﺎﭘـﺎورﻳﻦ و‬

‫ﻣﺘﻐﻴﺮﻫــﺎي ﻛﻴﻔــﻲ آزﻣــﻮن ‪ Fisher’s exact test‬اﺳــﺘﻔﺎده ﺷــﺪ‪ .‬ﺳــﻄﺢ‬

‫ﻫﻢﭼﻨﻴﻦ ﻣﺪت زﻣﺎن اﺑﺘﻼ ﺑﻪ اﺧﺘﻼل ﻧﻌﻮظ در اﻓﺮادي ﻛﻪ ﭘﺎﺳـﺦ ﻣﺜﺒـﺖ‬

‫ﻣﻌﻨﻲداري آزﻣﻮنﻫﺎ ‪ 0/05‬در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪ و ﻧﺮماﻓـﺰار آﻣـﺎري ﻣـﻮرد‬

‫داﺷﺘﻨﺪ ﺑﻪﺷﻜﻞ ﻣﻌﻨﻲداري ﺑﺎ ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﭘﺎﺳﺦ ﻣﻨﻔﻲ داﺷـﺘﻨﺪ ﻣﺘﻔـﺎوت‬

‫اﺳﺘﻔﺎده ‪ SPSS‬وﻳﺮاﺳﺖ ‪ 16‬ﺑﻮد‪.‬‬

‫ﺑﻮد )‪ .(P<0/05‬ﻧﺘﺎﻳﺞ اﻳﻦ ﺟﺪول ﻧﺸﺎن ﻣﻲدﻫـﺪ ﻛـﻪ دو ﮔـﺮوه از ﻧﻈـﺮ‬

‫آزﻣﻮن‬

‫‪Wallis Test‬‬

‫ﻣﻴﺎﻧﮕﻴﻦ ﻣﺘﻐﻴﺮﻫﺎي ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﻗﺒﻞ از درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ‪،‬‬

‫ﻳﺎﻓﺘﻪﻫﺎ‬

‫ﻣﺼﺮف ﺳﻴﮕﺎر و ﺳﻦ ﺗﻔﺎوت آﻣﺎري ﻣﻌﻨﻲداري ﻧﺪاﺷﺘﻨﺪ )‪ .(P>0/05‬در‬ ‫ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻣﻴﺎﻧﮕﻴﻦ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﻗﺒﻞ از درﻳﺎﻓﺖ ﭘﺎﭘـﺎورﻳﻦ‬

‫‪ 90‬ﺑﻴﻤﺎر ﻣﺬﻛﺮ ﺑﺎ ﻣﻴـﺎﻧﮕﻴﻦ ﺳـﻨﻲ ‪ 47/7+13/7‬ﺳـﺎل وارد ﻣﻄﺎﻟﻌـﻪ‬

‫در ﺑﻴﻦ ﮔﺮوﻫﻲ از ﺑﻴﻤﺎران ﻛﻪ ﻣﺒﺘﻼ ﺑﻪ ﻧﻮع ﺷﺮﻳﺎﻧﻲ ﺑﻴﻤﺎري ﺑﻮدﻧﺪ ﺑﺮاﺑـﺮ‬

‫ﺷﺪﻧﺪ ﻛﻪ ‪ 11) %12/2‬ﺑﻴﻤﺎر( ﻣﺒﺘﻼ ﺑﻪ دﻳﺎﺑﺖ ﻣﻠﻴﺘﻮس‪) %5/6 ،‬ﭘﻨﺞ ﺑﻴﻤﺎر(‬

‫ﺑــﺎ ‪ 11±4/82cm/s‬ﻣﺤﺎﺳــﺒﻪ ﺷــﺪ‪ .‬ﺑــﻪﻫﻤــﻴﻦ ﻣﻨﻈــﻮر آزﻣــﻮن آﻣــﺎري‬

‫ﻣﺒﺘﻼ ﻫﻴﭙﺮﺗﺎﻧﺴﻴﻮن و ‪) %8/9‬ﻫﺸﺖ ﺑﻴﻤﺎر( ﻣﺒﺘﻼ ﺑﻪ ﻧﻘﺺ آﻧـﺎﺗﻮﻣﻴﻜﻲ در‬

‫ﺗﻚﻧﻤﻮﻧﻪاي اﻧﺠﺎم ﺷﺪ و ﻧﺸﺎن داد ﻛﻪ اﺧﺘﻼف ﻣﻌﻨﻲداري ﺑﺎ ﻣﻘﺪار ﺣـﺪ‬

‫آﻟﺖ ﺗﻨﺎﺳﻠﻲ ﺑﻮدﻧﺪ‪ .‬ﻫﻢﭼﻨﻴﻦ ﻳﻚ ﻧﻔـﺮ از ﺷـﺮﻛﺖﻛﻨﻨـﺪﮔﺎن در ﻣﻄﺎﻟﻌـﻪ‬

‫ﺗﻤﺎﻳﺰ ﻣﺘﻮن ﻣﺮﺟﻊ )‪ (10cm/s‬ﻧﺪارد )‪.(P=0/551‬‬

‫ﺣﺎﺿﺮ ﺑﻪ ﺑﻴﻤﺎري آﺳﻴﺐ ﻃﻨﺎب ﻧﺨﺎﻋﻲ )ﻓﻠﺞ اﻃﻔﺎل( دﭼﺎر ﺑﻮد‪.‬‬

‫‪T‬‬

‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ اﻳﻦﻛـﻪ ﺳـﺮﻋﺖ ﺟﺮﻳـﺎن ﺳﻴـﺴﺘﻮﻟﻴﻚ ﻗﺒـﻞ از درﻳﺎﻓـﺖ‬

‫در اﻧﺘﻬﺎي ﻣﻄﺎﻟﻌﻪ و درﻳﺎﻓﺖ دوز ﭘﺎﭘﺎورﻳﻦ‪ ،‬از ﻛﻞ ‪ 90‬ﺑﻴﻤـﺎر ﻣـﻮرد‬

‫ﭘﺎﭘﺎورﻳﻦ ﻣﻘﺪار ‪ 10cm/s‬و ﺑﺎﻻﺗﺮ و ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴـﺴﺘﻮﻟﻴﻚ ﺑﻌـﺪ از‬

‫ﺑﺮرﺳﻲ‪ ،‬در ‪ %54/4‬ﻣﻮارد )‪ 49‬ﺑﻴﻤﺎر( ﻧﻌﻮظ از ﻧﻈﺮ ﺑﺎﻟﻴﻨﻲ ﻣﺸﺎﻫﺪه ﻧـﺸﺪ‬

‫درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ ﻣﻘﺪار ‪ 30cm/s‬و ﺑـﺎﻻﺗﺮ ﺑـﻪﻋﻨـﻮان ﻣﺜﺒـﺖ واﻗﻌـﻲ در‬

‫و ‪ 41) %45/5‬ﺑﻴﻤﺎر( ﻧﻌﻮظ ﻧﺮﻣﺎل داﺷﺘﻨﺪ‪ .‬ﻗﺎﺑﻞ ذﻛﺮ اﺳﺖ در ﺑﻴﻦ اﻓـﺮاد‬

‫ﺗﺸﺨﻴﺺ ﻗﻠﻤﺪاد ﻣﻲﺷﻮﻧﺪ‪ ،‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻧﻴﺰ از اﻳﻦ ﻣﻌﻴﺎرﻫﺎ ﺑـﻪﻋﻨـﻮان‬

‫ﺑﺪون ﻧﻌﻮظ ﻧﻮع اﺧـﺘﻼل ﻧﻌـﻮﻇﻲ آنﻫـﺎ در ‪ 38) %77/6‬ﻧﻔـﺮ( از ﻧـﻮع‬

‫ﺗﺴﺖ ﻏﺮﺑﺎلﮔﺮي اﺳﺘﻔﺎده ﺷﺪ و ﺑـﺎ اﻳﺠـﺎد ﻧﻌـﻮظ ﺑـﻪﻋﻨـﻮان اﺳـﺘﺎﻧﺪارد‬

‫ورﻳﺪي‪ ،‬در ‪ 9) %18/4‬ﻧﻔﺮ( از ﻧﻮع ﺷﺮﻳﺎﻧﻲ و در ‪) %4/1‬دو ﻧﻔﺮ( از ﻧﻮع‬

‫ﻃﻼﻳﻲ ﻣﻘﺎﻳﺴﻪ ﺷﺪ‪ .‬اﻳﻦ ﻣﻘﺎﻳﺴﻪ در ﺟﺪول‪ 3 -‬اراﻳﻪ ﺷﺪه اﺳﺖ‪.‬‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):301-7‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﺳﻴﺪ ﻣﺮﺗﻀﻲ ﺑﺎﻗﺮي و ﻫﻤﻜﺎران‬

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‫در ﺗﻤﺎم ﺑﻴﻤﺎران ﻣﻘﺪار وﻳﮋﮔﻲ آزﻣـﻮن ﻗﺒـﻞ از درﻳﺎﻓـﺖ ﭘﺎﭘـﺎورﻳﻦ‬

‫)‪ (Gold standard‬و ﺳــﺮﻋﺖ ﺟﺮﻳــﺎن ﺳﻴــﺴﺘﻮﻟﻴﻚ ﻗﺒــﻞ از درﻳﺎﻓــﺖ‬

‫ﺑﺮاﺑﺮ ﺑﺎ ‪ %90/24‬و ﺣﺴﺎﺳﻴﺖ آزﻣﻮن ﺑﺮاﺑﺮ ﺑﺎ ‪ %20/41‬و ﻫﻢﭼﻨﻴﻦ ارزش‬

‫ﭘﺎﭘﺎورﻳﻦ )‪ 10cm/s‬و ﺑﺎﻻﺗﺮ( ﺑﻪﻋﻨﻮان ﺗﺴﺖ ﻏﺮﺑﺎلﮔﺮي )‪ (Cut off‬ﻣﻮرد‬

‫اﺧﺒﺎري ﻣﻨﻔﻲ و ﻣﺜﺒﺖ ﺑﻪﺗﺮﺗﻴﺐ ﺑﺮاﺑـﺮ ﺑـﺎ ‪ %71/42 ،%48/68‬ﻣـﻲﺑﺎﺷـﺪ‪.‬‬

‫ﺑﺮرﺳﻲ آﻣﺎري ﻗﺮار ﮔﺮﻓﺖ )ﺟﺪول‪ .(4 -‬ﺑﺮ اﻳﻦ اﺳﺎس ﻣﻘﺪار ﺣﺴﺎﺳﻴﺖ‬

‫ﻣﻘﺪار وﻳﮋﮔﻲ آزﻣـﻮن ﺑﻌـﺪ از درﻳﺎﻓـﺖ ﭘﺎﭘـﺎورﻳﻦ ‪ %100‬و ﺣـﺴﺎﺳﻴﺖ‬

‫آزﻣﻮن ﺑﺮاﺑﺮ ﺑﺎ ‪ %50‬و وﻳﮋﮔﻲ آزﻣﻮن ﺑﺮاﺑﺮ ﺑﺎ ‪ %100‬و ﻫـﻢﭼﻨـﻴﻦ ارزش‬

‫آزﻣﻮن ﺑﺮاﺑﺮ ﺑـﺎ ‪ %14/29‬و ﻫـﻢﭼﻨـﻴﻦ ارزش اﺧﺒـﺎري ﻣﻨﻔـﻲ و ﻣﺜﺒـﺖ‬

‫اﺧﺒﺎري ﻣﺜﺒﺖ و ﻣﻨﻔﻲ ﺑﻪﺗﺮﺗﻴﺐ ﺑﺮاﺑﺮ ﺑﺎ ‪ %100‬و ‪ %20‬ﻣﻲﺑﺎﺷﺪ‪.‬‬

‫ﺑﻪ ﺗﺮﺗﻴﺐ ﺑﺮاﺑﺮ ﺑﺎ ‪ 41/83×100=%49/3‬و ‪ 7/7×100=%100‬دﺳﺖ آﻣـﺪ‪.‬‬ ‫در ﮔﺮوه ﺑﻴﻤﺎران ﺑﺎ اﺧﺘﻼل ﻧﻌﻮظ ﺷﺮﻳﺎﻧﻲ‪ ،‬ﺳﺮﻋﺖ ﺟﺮﻳـﺎن ﺳﻴـﺴﺘﻮﻟﻴﻚ‬ ‫ﺑﻌﺪ از درﻳـﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ )‪ 30cm/s‬و ﺑﺎﻻﺗﺮ( ﺑﻪﻋﻨﻮان اﺳﺘﺎﻧﺪارد ﻃﻼﻳﻲ‬ ‫ﺟﺪول‪ :2 -‬ﻣﻘﺎﻳﺴﻪ ﻣﻴﺎﻧﮕﻴﻦ ﻣﺘﻐﻴﺮﻫﺎي ﻛﻤ‪‬ﻲ ﻣﻮرد ﻣﻄﺎﻟﻌﻪ ﺑﺮ ﺣﺴﺐ اﻳﺠﺎد ﻧﻌﻮظ‬ ‫اﻳﺠﺎد ﻧﻌﻮظ‬

‫ﻣﻨﻔﻲ‬

‫‪P‬‬

‫ﻣﺜﺒﺖ‬

‫ﻣﺘﻐﻴﺮ‬ ‫ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ‬

‫‪14/02±6‬‬

‫‪15/46±5/16‬‬

‫‪0/230‬‬

‫‪49/94±18/72‬‬

‫‪58/29±18/07‬‬

‫‪0/035‬‬

‫‪44/08±14/03‬‬

‫‪38/88±13‬‬

‫‪0/074‬‬

‫ﺳﻴﮕﺎر ﻣﺼﺮﻓﻲ‬

‫‪2/61±9/77‬‬

‫‪1/85±6/99‬‬

‫‪0/679‬‬

‫ﻃﻮل دوره اﺧﺘﻼل ﻧﻌﻮظ )ﺳﺎل(‬

‫‪5/5±6/06‬‬

‫‪2/84±3/32‬‬

‫‪0/015‬‬

‫ﺟﺪول‪ :1 -‬ﻣﻴﺎﻧﮕﻴﻦ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﻗﺒﻞ و ﺑﻌﺪ از ﺗﺰرﻳـﻖ ﭘﺎﭘـﺎورﻳﻦ ﺑـﺮ‬

‫ﻗﺒﻞ از درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ‬

‫ﺣﺴﺐ زﻳﺮ ﮔﺮوهﻫﺎي ﻣﺘﻐﻴﺮﻫﺎي ﻣﻮرد ﻣﻄﺎﻟﻌﻪ‬

‫ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ‬

‫ﻣﺘﻐﻴﺮﻫﺎ‬ ‫ﻣﺼﺮف‬ ‫ﺳﻴﮕﺎر‬

‫ﻗﺒﻞ‬

‫ﺑﻌﺪ‬

‫‪P‬‬

‫ﺳﻴﮕﺎريﻫﺎ‬

‫‪16/17±2/98‬‬

‫‪59/58±17/66‬‬

‫‪<0/001‬‬

‫ﻏﻴﺮﺳﻴﮕﺎريﻫﺎ‬

‫‪14/45±5/94‬‬

‫‪52/85±18/9‬‬

‫‪<0/001‬‬

‫‪P‬‬

‫‪0/330‬‬

‫‪0/250‬‬

‫‪‬‬

‫‪14/5±6/03‬‬

‫‪51/07±17/4‬‬

‫‪<0/001‬‬

‫‪ 1-5‬ﺳﺎل‬

‫‪14/45±4/63‬‬

‫‪54/11±19/18‬‬

‫‪<0/001‬‬

‫>‬

‫‪15/5±7/37‬‬

‫‪57±20/4‬‬

‫‪<0/001‬‬

‫‪0/791‬‬

‫‪0/576‬‬

‫‪14/23±4/74‬‬

‫‪54/71±15/01‬‬

‫‪<0/001‬‬

‫‪ 30-40‬ﺳﺎل‬

‫‪16/41±7/53‬‬

‫‪56/4±21/4‬‬

‫‪<0/001‬‬

‫‪ 40-50‬ﺳﺎل‬

‫‪14/1±4/46‬‬

‫‪56/95±19/1‬‬

‫‪<0/001‬‬

‫‪13/4±4/05‬‬

‫‪47/21±17/02‬‬

‫‪<0/001‬‬

‫‪P‬‬

‫‪0/230‬‬

‫‪0/253‬‬

‫دارد‬

‫‪15/27±5/74‬‬

‫‪48/64±20/12‬‬

‫‪<0/001‬‬

‫ﻧﺪارد‬

‫‪14/59±5/67‬‬

‫‪54/45±18/63‬‬

‫‪<0/001‬‬

‫‪P‬‬

‫‪0/712‬‬

‫‪0/339‬‬

‫دارد‬

‫‪13/6±4/4‬‬

‫‪41/6±13/16‬‬

‫‪<0/001‬‬

‫ﻧﺪارد‬

‫‪14/74±5/73‬‬

‫‪54/46±18/9‬‬

‫‪0/003‬‬

‫‪P‬‬

‫‪0/663‬‬

‫‪0/138‬‬

‫دارد‬

‫‪14/37±5/53‬‬

‫‪66±23/2‬‬

‫‪<0/001‬‬

‫ﻧﺪارد‬

‫‪14/71±5/7‬‬

‫‪52/55±18/04‬‬

‫‪<0/001‬‬

‫‪P‬‬

‫‪0/875‬‬

‫‪0/053‬‬

‫ﻳﻚﺳﺎل‬ ‫ﻣﺪت‬ ‫ﺑﻴﻤﺎري‬

‫‪ 5‬ﺳﺎل‬ ‫‪P‬‬

‫‪ 30‬ﺳﺎل‬

‫ﺳﻦ‬

‫‪ 50‬ﺳﺎل‬

‫دﻳﺎﺑﺖ‬

‫ﻫﻴﭙﺮﺗﺎﻧﺴﻴﻮن‬

‫اﺧﺘﻼل‬ ‫آﻧﺎﺗﻮﻣﻴﻚ‬

‫<‬

‫>‬

‫آزﻣﻮن آﻣﺎري‪ Paired t-test :‬و ﻣﻘﺎدﻳﺮ ﻣﻌﻨﻲدار‬

‫ﺑﻌﺪ از درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ‬

‫)‪(cm/s‬‬

‫ﺳﻦ )ﺳﺎل(‬

‫آزﻣﻮن آﻣﺎري‪ Independent t-test :‬و ﻣﻘﺎدﻳﺮ ﻣﻌﻨﻲدار‬

‫‪P<0/05‬‬

‫ﺟﺪول‪ :3 -‬ﻣﻘﺎﻳﺴﻪ ﭘﺎﺳﺦ ﺑﻪ ﭘﺎﭘﺎورﻳﻦ ﺑﺮ ﺣﺴﺐ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ در ﻗﺒـﻞ‬ ‫و ﺑﻌﺪ از درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ‬ ‫ﭘﺎﺳﺦ ﺑﻪ درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ‬

‫ﭘﺎﺳﺦ ﻣﺜﺒﺖ‬

‫ﭘﺎﺳﺦ ﻣﻨﻔﻲ‬

‫ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ‬ ‫ﻗﺒﻞ از درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ‬ ‫ﺑﻌﺪ از درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ‬

‫‪ 10‬و ﺑﺎﻻﺗﺮ‬

‫‪37‬‬

‫‪39‬‬

‫ﻛﻢﺗﺮ از ‪10‬‬

‫‪4‬‬

‫‪10‬‬

‫‪ 30‬و ﺑﺎﻻﺗﺮ‬

‫‪41‬‬

‫‪42‬‬

‫ﻛﻢﺗﺮ از ‪30‬‬

‫‪0‬‬

‫‪7‬‬

‫ﺟﺪول‪ :4 -‬راﺑﻄﻪ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﺑﻌﺪ از درﻳﺎﻓﺖ ﭘﺎﭘـﺎورﻳﻦ )‪ 30cm/s‬و‬ ‫ﺑﺎﻻﺗﺮ( ﺑﺎ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺧﻮن ﺳﻴﺴﺘﻮﻟﻴﻚ ﻗﺒﻞ از درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ‬

‫‪P<0/05‬‬

‫ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﺑﻌﺪ از درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ‬

‫ﻛﻢﺗﺮ از‬

‫‪30cm/s‬‬

‫ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﻗﺒﻞ درﻳﺎﻓﺖ از ﭘﺎﭘﺎورﻳﻦ‬

‫‪30cm/s‬‬

‫و ﺑﺎﻻﺗﺮ‬

‫ﻛﻢﺗﺮ از ‪10‬‬

‫‪4‬‬

‫‪0‬‬

‫‪ 10‬و ﺑﺎﻻﺗﺮ‬

‫‪4‬‬

‫‪1‬‬

‫ﺳﺮﻋﺖ ﺣﺪاﻛﺜﺮ ﺳﻴﺴﺘﻮﻟﻲ ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﭘﻨﻴﺲ‬

‫‪305‬‬

‫زﻣﻴﻨﻪاي دﻳﺎﺑﺖ داراي اﻫﻤﻴﺖ ﺑﺴﻴﺎري اﺳﺖ ﺑﻪ ﻧﺤﻮي ﻛﻪ ﻣﺒﺘﻼﻳﺎن ﺑﻪ‬

‫ﺑﺤﺚ‬

‫دﻳﺎﺑﺖ ﻧﺴﺒﺖ ﺑﻪ ﺳﺎﻳﺮ ﮔﺮوهﻫﺎ ﻛﻢﺗﺮﻳﻦ ﻣﻴﺰان ﻧﻌﻮظ ﻛﺎﻣﻞ را ﺑﺎ ﺗﺰرﻳﻖ‬ ‫ﻧﺘﺎﻳﺞ ﺣﺎﺻﻞ از دادهﻫﺎي اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻧﺸﺎن ﻣﻲدﻫﺪ ﻛﻪ اﻏﻠﺐ‬

‫ﭘﺎﭘﺎورﻳﻦ ﻛﺴﺐ ﻧﻤﻮدﻧﺪ‪.‬‬

‫ﺑﻴﻤﺎران ﺗﺤﺖ ﻣﻄﺎﻟﻌﻪ ﻣﺎ در ﺳﻨﻴﻦ ‪ 30‬ﺗﺎ ‪ 50‬ﺳﺎل ﻗﺮار داﺷﺘﻨﺪ و ﻧﻴﺎزﻣﻨﺪ‬

‫ﻫﺮ ﭼﻨﺪ ﻛﻪ در ﺑﻴﻤﺎران دﻳﺎﺑﺘﻲ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺧﻮن ﺳﻴﺴﺘﻮﻟﻴﻚ ﺑﻌﺪ‬

‫ﻣﺪاﺧﻼت درﻣﺎﻧﻲ ﺟﻬﺖ ﺑﻬﺒﻮد وﺿﻌﻴﺖ ﻧﻌﻮظ ﺑﻮدﻧﺪ‪ .‬در اﻏﻠﺐ ﺑﻴﻤﺎران‬

‫از ﺗﺰرﻳﻖ ﺑﺎ ﺑﻴﻤﺎران ﻏﻴﺮ دﻳﺎﺑﺘﻲ ﺗﻔﺎوﺗﻲ ﻧﺪاﺷﺖ‪ .‬ﻳﺎﻓﺘﻪﻫﺎي اﻳﻦ ﻣﻄﺎﻟﻌﻪ‬ ‫‪PSV‬‬

‫ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال )ﻗﺒﻞ و ﻳﺎ ﺑﻌﺪ از ﺗﺰرﻳﻖ‬

‫ﺑﻴﻤﺎري زﻣﻴﻨﻪاي وﺟﻮد ﻧﺪاﺷﺖ و ﺷﺎﻳﻊﺗﺮﻳﻦ ﺑﻴﻤﺎري زﻣﻴﻨﻪاي دﻳﺎﺑﺖ‬

‫ﻧﺸﺎن داده اﺳﺖ ﻛﻪ‬

‫ﻗﻨﺪي ﺑﻮد ﻛﻪ در ﺣﺪود ‪ %12‬ﺑﻴﻤﺎران ﺑﻪ آن ﻣﺒﺘﻼ ﺑﻮدﻧﺪ‪ .‬ﺷﺎﻳﻊﺗﺮﻳﻦ ﻧﻮع‬

‫ﭘﺎﭘﺎورﻳﻦ( از ﺣﺴﺎﺳﻴﺖ و ارزش ﭘﻴﺶﮔﻮﻳﻲ ﺑﺎﻻﻳﻲ ﺑﺮﺧﻮردار ﻧﻴﺴﺘﻨﺪ ﺗﺎ‬

‫اﺧﺘﻼل ﻧﻌﻮظ ﻧﻴﺰ از ﻧﻮع ورﻳﺪي ﺑﻮد‪ .‬از آﻧﺠﺎ ﻛﻪ در اﻳﻦ ﻣﻄﺎﻟﻌﻪ از‬

‫ﺑﺘﻮان از آنﻫﺎ ﺑﻪﻋﻨﻮان ﻣﻌﻴﺎر ﻣﺴﺘﻘﻞ ﺟﻬﺖ ﺗﺸﺨﻴﺺ ﺑﻴﻤﺎران از اﻓﺮاد‬

‫ﺷﺎﺧﺺ ﺣﺪاﻛﺜﺮ ﺳﺮﻋﺖ ﺳﻴﺴﺘﻮﻟﻴﻚ ﺑﻪﻋﻨﻮان ﺷﺎﺧﺺ ﺑﺮرﺳﻲ ﺗﺎﺛﻴﺮ‬

‫ﺳﺎﻟﻢ اﺳﺘﻔﺎده ﻧﻤﻮد ﺑﻠﻜﻪ ﺑﻪﻋﻨﻮان ﻣﻜﻤﻞ ﺑﻪﻫﻤﺮاه ﺳﺎﻳﺮ اﻃﻼﻋﺎت‬

‫ﭘﺎﭘﺎورﻳﻦ اﺳﺘﻔﺎده ﺷﺪه اﺳﺖ‪ ،‬ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻧﺸﺎن داده اﺳﺖ ﻛﻪ‬

‫ﺑﺮﮔﺮﻓﺘﻪ از ﺑﺮرﺳﻲﻫﺎي داﭘﻠﺮ رﻧﮕﻲ و اﻣﻮاج اﺳﭙﻜﺘﺮال ﺷﺮﻳﺎن‬

‫ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﭘﺲ از ﻣﺪاﺧﻠﻪ داراي ﻣﻴﺎﻧﮕﻴﻦ ﺑﻴﺶﺗﺮي‬

‫ﻛﺎورﻧﻮزال‪ ،‬در اﻓﺘﺮاق زﻳﺮ ﮔﺮوهﻫﺎي ﻋﻠﻞ ﻋﺮوﻗﻲ اﺧﺘﻼل ﻧﻌﻮظ ﻛﺎرﺑﺮد‬

‫ﺑﻮده اﺳﺖ‪ .‬اﻳﻦ ﻳﺎﻓﺘﻪ ﺣﺎﻛﻲ از ﺗﺎﺛﻴﺮ ﻣﺜﺒﺖ ﭘﺎﭘﺎورﻳﻦ در ﺑﻬﺒﻮد ﺟﺮﻳﺎن‬

‫دارد‪ .‬اﻟﺒﺘﻪ ﺑﻪدﻟﻴﻞ ﺑﺎﻻ ﺑﻮدن وﻳﮋﮔﻲ آنﻫﺎ‪ PSV ،‬ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال داراي‬

‫ﺧﻮن ﻣﻮرد ﻧﻴﺎز ﺟﻬﺖ ﻧﻌﻮظ دارد‪ .‬ﺑﺎ اﻳﻦ ﺣﺎل اﻳﺠﺎد ﻧﻌﻮظ ﺑﻪﺻﻮرت‬

‫ارزش ﻗﺎﺑﻞ ﻗﺒﻮﻟﻲ ﺑﻪﻣﻨﻈﻮر ﺷﻨﺎﺳﺎﻳﻲ اﻓﺮاد ﺳﺎﻟﻢ ﻣﻲﺑﺎﺷﺪ اﻣﺎ در‬

‫ﻋﻴﻨﻲ در ‪ %45‬ﺑﻴﻤﺎران دﻳﺪه ﺷﺪه اﺳﺖ‪.‬‬

‫ﻏﺮﺑﺎلﮔﺮي ﺑﻴﻤﺎران ارزش ﻛﺎﻓﻲ ﻧﺪارد‪.‬‬

‫ﻧﺘﺎﻳﺞ اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻧﺸﺎن ﻣﻲدﻫﺪ ﻛﻪ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﺑﻌﺪ‬

‫ﺣﺪ ﺗﻤﺎﻳﺰ‬

‫‪PSV‬‬

‫ﻛﻢﺗﺮ از ‪ 10cm/s‬در ‪) Flaccid penis‬ﻗﺒﻞ از‬

‫از درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ در اﻓﺮادي ﻛﻪ ﭘﺎﺳﺦ ﻧﻌﻮظ ﻣﺜﺒﺖ داﺷﺘﻨﺪ ﺑﻪﺷﻜﻞ‬

‫ﺗﺰرﻳﻖ( ﺟﻬﺖ اﻓﺘﺮاق ﺑﻴﻤﺎران ﺑﺎ ﻋﻠﻞ ﺷﺮﻳﺎﻧﻲ از ﺳﺎﻳﺮ ﻋﻠﻞ ﻋﺮوﻗﻲ‬

‫ﻣﻌﻨﻲداري ﺑﺎ ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﭘﺎﺳﺦ ﻣﻨﻔﻲ داﺷﺘﻨﺪ ﻣﺘﻔﺎوت ﺑﻮد‪ .‬ﺑﺪﻳﻦﺻﻮرت‬

‫اﺧﺘﻼل ﻧﻌﻮظ‪ ،‬در ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻣﻮرد ﺑﺮرﺳﻲ ﻗﺮار ﮔﺮﻓﺖ و ﻣﻴﺰان‬

‫ﻛﻪ ﻣﻴﺎﻧﮕﻴﻦ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﺑﻌﺪ از درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ در‬

‫ﺣﺴﺎﺳﻴﺖ آن ﺣﺪود ‪ %50‬و ارزش اﺧﺒﺎري آن ﺣﺪود ‪ %20‬ﻣﺤﺎﺳﺒﻪ‬

‫ﮔﺮوه ﭘﺎﺳﺦ ﻣﺜﺒﺖ ﺑﺎﻻﺗﺮ ﺑﻮده اﺳﺖ‪ .‬ﻧﻜﺘﻪ ﻣﻬﻢ دﻳﮕﺮ اﻳﻦ اﺳﺖ ﻛﻪ‬

‫ﮔﺮدﻳﺪ‪ .‬ﺑﺪﻳﻦﺗﺮﺗﻴﺐ ﻛﻪ از ‪ 9‬ﺑﻴﻤﺎر ﻣﺒﺘﻼ ﺑﻪ اﺧﺘﻼل ﺷﺮﻳﺎﻧﻲ ﭼﻬﺎر ﺑﻴﻤﺎر‬

‫ﻣﺪت زﻣﺎن اﺑﺘﻼ ﺑﻪ ﺑﻴﻤﺎري در ﮔﺮوه ﭘﺎﺳﺦ ﻣﻨﻔﻲ ﺑﺎﻻﺗﺮ از ﮔﺮوه ﻣﺜﺒﺖ‬

‫ﻣﻴﺰان‬

‫ﻗﺒﻞ از ﺗﺰرﻳﻖ در آنﻫﺎ ﻛﻢﺗﺮ از ‪ 10 cm/s‬ﺑﻮد و در ﭘﻨﺞ‬

‫ﺑﻮد‪ ،‬ﺑﻪﻋﺒﺎرت دﻳﮕﺮ ﻫﺮ ﭼﻪ ﻣﺪت اﺑﺘﻼ ﺑﻪ اﺧﺘﻼﻻت ﻧﻌﻮﻇﻲ ﺑﻴﺶﺗﺮ‬

‫ﺑﻴﻤﺎر ﺑﻴﺶﺗﺮ از ﺣﺪ ﻣﺬﻛﻮر ﺑﻮده اﺳﺖ‪ .‬ﺿﻤﻦ آنﻛﻪ در ﻳﻜﻲ از ﺑﻴﻤﺎران‬

‫ﺑﺎﺷﺪ ﻣﻴﺰان ﭘﺎﺳﺦ ﺑﻪ ﭘﺎﭘﺎورﻳﻦ ﻛﻢﺗﺮ ﺧﻮاﻫﺪ ﺑﻮد‪ .‬اﻳﻦ ﻳﺎﻓﺘﻪﻫﺎ ﻧﺸﺎن‬

‫اﻳﻦ ﻣﻴﺰان ‪ 20cm/s‬ﺑﻮد ﻛﻪ ﺑﻌﺪ از ﺗﺰرﻳﻖ ﺑﻪ ﺣﺪود ‪ 61cm/s‬رﺳﻴﺪ‪ .‬اﻣﺎ‬

‫ﻣﻲدﻫﻨﺪ ﻛﻪ درﻣﺎن ﺳﺮﻳﻊ ﺑﻴﻤﺎران ﺟﻬﺖ رﺳﻴﺪن ﺑﻪ ﻧﺘﺎﻳﺞ درﻣﺎﻧﻲ‬

‫ﻃﺒﻖ ﺳﺎﻳﺮ ﻣﻌﻴﺎرﻫﺎي ﺑﺮرﺳﻲ داﭘﻠﺮ ﺑﻪدﻟﻴﻞ ﭘﺮ ﻧﺸﺪن ﺑﺨﺶ ﭘﺮوﮔﺰﻳﻤﺎل‬

‫ﺿﺮوري اﺳﺖ و ﺑﺎ اﻗﺪام ﻋﺎﺟﻞ ﻣﻲﺗﻮان ﻧﺴﺒﺖ ﺑﻴﺶﺗﺮي از ﺑﻴﻤﺎران را‬

‫ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﭼﭗ و ﻋﺪم اﻓﺰاﻳﺶ ﻗﻄﺮ ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال در ﻣﺪت‬

‫ﺑﻪ ﻧﻌﻮظ ﻛﺎﻣﻞ رﺳﺎﻧﺪ‪.‬‬

‫ﺑﺮرﺳﻲ‪ ،‬ﻧﺎرﺳﺎﻳﻲ ﺷﺮﻳﺎﻧﻲ در وي ﻣﻄﺮح ﮔﺮدﻳﺪ‪.‬‬

‫‪PSV‬‬

‫ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﻧﺸﺎن ﻣﻲدﻫﺪ ﻛﻪ دو ﮔﺮوه از ﻧﻈﺮ ﻣﻴﺎﻧﮕﻴﻦ ﻣﺘﻐﻴﺮﻫﺎي‬

‫ﻣﻘﺎﻳﺴﻪ ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﺑﺎ ﻣﻄﺎﻟﻌﺎت دﻳﮕﺮان ﺷﺒﺎﻫﺖﻫﺎ و‬

‫ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺳﻴﺴﺘﻮﻟﻴﻚ ﻗﺒﻞ از درﻳﺎﻓﺖ ﭘﺎﭘﺎورﻳﻦ‪ ،‬ﻣﺼﺮف ﺳﻴﮕﺎر و‬

‫ﺗﻔﺎوتﻫﺎﻳﻲ را ﻧﺸﺎن داده اﺳﺖ‪ .‬در ﻣﻄﺎﻟﻌﻪ ‪ ،Golijanin‬ﻧﺘﺎﻳﺞ ﺑﺮرﺳﻲ‬ ‫‪PSV‬‬

‫ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﺑﻌﺪ از ﺗﺰرﻳﻖ داروﻫﺎي وازواﻛﺘﻴﻮ‪،‬‬

‫ﺳﻦ ﺗﻔﺎوت آﻣﺎري ﻣﻌﻨﻲداري ﻧﺪاﺷﺖ‪ .‬اﻳﻦ ﺑﺪان ﻣﻌﻨﻲ اﺳﺖ ﻛﻪ ﺑﻪﻧﻈﺮ‬

‫ﻧﺸﺎن داد‬

‫ﻧﻤﻲرﺳﺪ ﺳﻦ و ﺳﻴﮕﺎر ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ را ﺗﺤﺖ ﺗﺎﺛﻴﺮ ﻗﺮار داده ﺑﺎﺷﺪ‪.‬‬

‫ﺑﺎﻻﺗﺮ از ‪ 30-40cm/s‬ﻧﺮﻣﺎل و ﻣﻮارد ﻛﻢﺗﺮ از ‪ 25cm/s‬ﻣﻄﺮحﻛﻨﻨﺪه ﻧﻮع‬

‫ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻧﺸﺎن ﻣﻲدﻫﺪ ﻛﻪ ﻣﻴﺎﻧﮕﻴﻦ ﺳﺮﻋﺖ ﺟﺮﻳﺎن ﺧﻮن‬

‫ﺷﺮﻳﺎﻧﻲ اﺧﺘﻼل ﻧﻌﻮظ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺳﺎﻳﺮ ﻣﻌﻴﺎرﻫﺎي ﺗﺸﺨﻴﺼﻲ از ﺟﻤﻠﻪ ﻗﻄﺮ‬

‫ﺳﻴﺴﺘﻮﻟﻴﻚ ﻗﺒﻞ از ﺗﺰرﻳﻖ در اﺧﺘﻼل ﻧﻌﻮﻇﻲ ورﻳﺪي و ﺷﺮﻳﺎﻧﻲ ﺗﻔﺎوﺗﻲ‬

‫‪Acceleration time‬‬

‫ﺷﺮﻳﺎﻧﻲ ﻛﺎورﻧﻮزال‪ ،‬ﻣﻴﺰان دﻳﻼﺗﺎﺳﻴﻮن آن و ﻣﻴﺰان‬

‫ﻗﺒﻞ از ﺗﺰرﻳﻖ( ﻧﻤﻲﺗﻮان ﺑﻪﻋﻨﻮان ﻣﻌﻴﺎر‬

‫در آن‪ ،‬ﺗﻔﺎوت ‪ PSV‬ﺑﻴﻦ دو ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﺑﻴﺶ از ‪ 10cm/s‬و ﺗﻨﮕﻲ‬

‫ﻣﺴﺘﻘﻞ ﺟﻬﺖ ﺗﻔﻜﻴﻚ زﻳﺮ ﮔﺮوهﻫﺎي ﻋﻠﻞ ﻋﺮوﻗﻲ اﺧﺘﻼل ﻧﻌﻮظ اﺳﺘﻔﺎده‬

‫‪borderline‬‬

‫ﻧﺪارد‪ .‬ﻟﺬا از اﻳﻦ ﻣﻌﻴﺎر‬

‫)‪PSV‬‬

‫ﻧﻤﻮد‪ .‬ﻳﺎﻓﺘﻪﻫﺎي ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻧﺸﺎن داده اﺳﺖ ﻛﻪ در ﻣﻴﺎن ﺑﻴﻤﺎريﻫﺎي‬

‫ﻓﻮﻛﺎل در ﻣﺴﻴﺮ ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال در ﻣﻮارد )‪(25-30cm/s‬‬ ‫‪15‬‬

‫‪ PSV‬ﻛﺎرﺑﺮد دارد‪.‬‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):301-7‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻫﻤﻜﺎران‬ ‫ﺑﺎﻗﺮي و‬ Bagheri S.M.‫ﻣﺮﺗﻀﻲ‬ et al. ‫ﺳﻴﺪ‬

‫ ﺑﻪﻋﻨﻮان ﺣﺪ ﺗﻤﺎﻳﺰ ﺟﻬﺖ اﻓﺘﺮاق ﻋﻠﻞ ﺷﺮﻳﺎﻧﻲ اﺧﺘﻼل‬10cm/s ‫ﻣﻌﺎدل‬ ‫ﻗﺒﻞ از‬

PSV

306

‫در ﺷﺮﻳﺎن ﻛﺎورﻧﻮزال ﻗﺒﻞ و‬

PSV

‫ اﺳﺘﻔﺎده از‬Jyotsna ‫در ﻣﻄﺎﻟﻌﻪ‬

‫ﻧﻌﻮظ از ﺣﺴﺎﺳﻴﺖ ﻻزم ﺑﺮﺧﻮردار ﻧﻴﺴﺖ ﮔﺮﭼﻪ ﻣﻴﺎﻧﮕﻴﻦ‬

‫ﺑﻌﺪ از ﺗﺰرﻳﻖ دارو ﻣﺪﻧﻈﺮ ﻗﺮار ﮔﺮﻓﺖ و ﺑﺮرﺳﻲﻫﺎ ﺑﺎ ﺣﺪ ﺗﻤﺎﻳﺰﻫﺎي‬

‫( ﺗﻔﺎوت ﻣﻌﻨﻲداري‬11+4/8cm/s) ‫ﺗﺰرﻳﻖ در ﺑﻴﻤﺎران ﻣﻮرد ﻣﻄﺎﻟﻌﻪ ﻣﺎ‬

‫ در ﻧﻬﺎﻳﺖ ﺣﺪ ﺗﻤﺎﻳﺰ‬.‫ ﻣﻮرد آﻧﺎﻟﻴﺰ آﻣﺎري ﻗﺮار ﮔﺮﻓﺖ‬15 ‫ و‬10 ‫ و‬5cm/s

‫ ﺑﺎ اﻳﻦ ﺣﺎل ﺑﻪدﻟﻴﻞ ﻛﻢ ﺑﻮدن ﺣﺠﻢ‬.‫ ﻧﺪاﺷﺘﻪ اﺳﺖ‬10cm/s ‫ﺑﺎ ﺣﺪ ﺗﻤﺎﻳﺰ‬

%98 ‫ ارزش اﺧﺒﺎري ﻣﻨﻔﻲ‬،%93/6 ‫ وﻳﮋﮔﻲ‬،%94 ‫ ﺑﺎ ﺣﺴﺎﺳﻴﺖ‬10cm/s

‫ ﺑﻴﻤﺎر از ﻣﺠﻤﻮع‬9) ‫ﻧﻤﻮﻧﻪ ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﻧﻮع ﺷﺮﻳﺎﻧﻲ اﺧﺘﻼل ﻧﻌﻮظ‬

‫ ﺑﻪﻋﻨﻮان ﺣﺪ ﺗﻤﺎﻳﺰ دﻗﻴﻖ در اﻓﺘﺮاق ﻋﻠﻞ‬،%80 ‫و ارزش اﺧﺒﺎري ﻣﺜﺒﺖ‬

‫ﻣﻘﺪور‬

ROC

‫ ﺗﻌﻴﻴﻦ ﺣﺪ ﺗﻤﺎﻳﺰ ﺟﺪﻳﺪ ﺑﺎ اﺳﺘﻔﺎده از ﻣﻨﺤﻨﻲ‬،(‫ ﺑﻴﻤﺎر‬90

‫ در ﻣﻄﺎﻟﻌﻪ‬.‫ﺷﺮﻳﺎﻧﻲ از ﺳﺎﻳﺮ ﻋﻠﻞ ﻋﺮوﻗﻲ اﺧﺘﻼل ﻧﻌﻮظ ﻣﻄﺮح ﮔﺮدﻳﺪ‬

.‫ﻧﺒﻮد‬

‫ ﺑﻴﻤﺎر( ﻣﺒﺘﻼ ﺑﻪ ﻧﻮع ﺷﺮﻳﺎﻧﻲ اﺧﺘﻼل ﻧﻌﻮظ‬9) ‫ ﺑﻴﻤﺎران‬%22/5 ‫ﻓﻮق‬

‫ اﻳﻦ ﻣﻘﺎﻟﻪ ﺣﺎﺻﻞ ﭘﺎﻳﺎنﻧﺎﻣـﻪ ﺗﺤـﺖ ﻋﻨـﻮان "ﻣﻘﺎﻳـﺴﻪ‬:‫ﺳﭙﺎﺳﮕﺰاري‬

‫ در ﺣﺎﻟﺖ‬10cm/s ‫ ﻣﻌﺎدل‬PSV ‫ دﻗﺖ ﺣﺪ ﺗﻤﺎﻳﺰ‬16.‫ﺗﺸﺨﻴﺺ داده ﺷﺪﻧﺪ‬ 17‫و‬18

‫ ﺷــﺮﻳﺎن ﻛــﺎورﻧﻮزال ﭘﻨــﻴﺲ ﻗﺒــﻞ و ﺑﻌــﺪ از‬Peak systolic velocity

.‫ در ﭼﻨﺪ ﻣﻘﺎﻟﻪ دﻳﮕﺮ ﻧﻴﺰ ﺗﺎﻳﻴﺪ ﮔﺮدﻳﺪ‬Flaccid

‫ﺗﺰرﻳــﻖ ﭘﺎﭘــﺎورﻳﻦ در ﺑﻴﻤــﺎران ﻣﺒــﺘﻼ ﺑــﻪ اﺧــﺘﻼل ﻋﻤﻠﻜــﺮد ﻧﻌــﻮظ‬

‫ ﻏﻴﺮ دﻳﺎﺑﺘﻲ‬80) ‫ ﺑﻴﻤﺎر‬120 ‫ ﻛﻪ ﺑﺮ روي‬،Kahvecioğlu ‫در ﻣﻄﺎﻟﻌﻪ‬

‫( ﻣﺮاﺟﻌﻪﻛﻨﻨﺪه ﺑـﻪ ﺑﻴﻤﺎرﺳـﺘﺎن ﻫﺎﺷـﻤﻲﻧـﮋاد در‬Erectile dysfunction)

PSV

‫" در ﻣﻘﻄﻊ دﻛﺘﺮي‬1390 ‫ و ﺳﻪ ﻣﺎﻫﻪ اول ﺳﺎل‬1389 ‫ﺷﺶ ﻣﺎه دوم ﺳﺎل‬

‫ ﻣﻲﺗﻮاﻧﺪ ﭘﻴﺶﮔﻮﻳﻲﻛﻨﻨﺪه ﻧﻮع ﺷﺮﻳﺎﻧﻲ‬%85 ‫ ﺑﺎ دﻗﺖ‬Flaccid ‫در ﺣﺎﻟﺖ‬

1368 ‫ و ﻛـﺪ‬1390 ‫ و‬1389 ‫ﺗﺨﺼﺼﻲ در رﺷـﺘﻪ رادﻳﻮﻟـﻮژي در ﺳـﺎل‬

‫ در ﮔﺮوه ﺑﻴﻤﺎران دﻳﺎﺑﺘﻲ‬%51 ‫اﺧﺘﻼل ﻧﻌﻮظ ﺑﺎﺷﺪ ﺑﺮ ﺧﻼف دﻗﺖ ﭘﺎﻳﻴﻦ‬

‫ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺎ ﺣﻤﺎﻳﺖ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷـﻜﻲ و ﺧـﺪﻣﺎت ﺑﻬﺪاﺷـﺘﻲ و‬

.‫درﻣﺎﻧﻲ ﺗﻬﺮان اﺟﺮا ﺷﺪه اﺳﺖ‬

‫ دﻳﺎﺑﺘﻲ( اﻧﺠﺎم ﺷﺪ ﻧﺸﺎن داد ﻛﻪ در ﮔﺮوه ﺑﻴﻤﺎران ﻏﻴﺮ دﻳﺎﺑﺘﻲ‬40 ‫و‬

.‫ﻛﻪ ﻋﻠﺖ آن ﭼﻨﺪ ﻓﺎﻛﺘﻮري ﺑﻮدن اﺧﺘﻼل ﻧﻌﻮظ در اﻳﻦ ﺑﻴﻤﺎران اﺳﺖ‬

(‫ )ﻗﺒﻞ از ﺗﺰرﻳﻖ‬Flaccid ‫در ﺣﺎﻟﺖ‬

PSV

‫ﻧﺘﻴﺠﻪ ﻧﻬﺎﻳﻲ اﻳﻦﻛﻪ ﻣﻴﺰان‬

References 1. NIH Consensus Conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA 1993;270(1):83-90. 2. Johannes CB, Araujo AB, Feldman HA, Derby CA, Kleinman KP, McKinlay JB. Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts male aging study. J Urol 2000;163(2):460-3. 3. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994;151(1):5461. 4. Padma-Nathan H. Diagnostic and treatment strategies for erectile dysfunction: the 'Process of Care' model. Int J Impot Res 2000;12 Suppl 4:S119-21. 5. Miner MM. Men's health in primary care: an emerging paradigm of sexual function and cardiometabolic risk. Urol Clin North Am 2012;39(1):1-23. 6. Gratzke C, Angulo J, Chitaley K, Dai YT, Kim NN, Paick JS, et al. Anatomy, physiology, and pathophysiology of erectile dysfunction. J Sex Med 2010;7(1 Pt 2):445-75. 7. Andersson KE. Erectile physiological and pathophysiological pathways involved in erectile dysfunction. J Urol 2003;170(2 Pt 2):S6-13; discussion S13-4. 8. Aversa A, Isidori AM, De Martino MU, Caprio M, Fabbrini E, Rocchietti-March M, et al. Androgens and penile erection: evidence for a direct relationship between free testosterone and cavernous vasodilation in men with erectile dysfunction. Clin Endocrinol (Oxf) 2000;53(4):517-22. 9. Burchardt M, Burchardt T, Baer L, Kiss AJ, Pawar RV, Shabsigh A, et al. Hypertension is associated with severe erectile dysfunction. J Urol 2000;164(4):1188-91. 10. Andersson KE. Pharmacology of penile erection. Pharmacol Rev 2001;53(3):417-50.

11. Xuan XJ, Sun P, Teng JB, Liu HN, Mei H. Value of degree diagnosis with color Doppler flow imaging in the treatment of male erectile dysfunction. Zhonghua Yi Xue Za Zhi 2009;89(40):2835-8. 12. Rath PC, Agarwala MK, Dhar PK, Lakshmi C, Ahsan SA, Deb T, et al. Carotid artery involvement in patients of atherosclerotic coronary artery disease undergoing coronary artery bypass grafting. Indian Heart J 2001;53(6):761-5. 13. Brener BJ, Brief DK, Alpert J, Goldenkranz RJ, Parsonnet V, Feldman S, et al. A four-year experience with preoperative noninvasive carotid evaluation of two thousand twenty-six patients undergoing cardiac surgery. J Vasc Surg 1984;1(2):326-38. 14. Kilic M, Serefoglu EC, Ozdemir AT, Balbay MD. The actual incidence of papaverine-induced priapism in patients with erectile dysfunction following penile colour Doppler ultrasonography. Andrologia 2010;42(1):1-4. 15. Golijanin D, Singer E, Davis R, Bhatt S, Seftel A, Dogra V. Doppler evaluation of erectile dysfunction - part 2. Int J Impot Res 2007;19(1):43-8. 16. Sen J, Godara R, Singh R, Airon RK. Colour Doppler sonography of flaccid penis in evaluation of erectile dysfunction. Asian J Surg 2007;30(2):122-5. 17. Schwartz AN, Lowe M, Berger RE, Wang KY, Mack LA, Richardson ML. Assessment of normal and abnormal erectile function: color Doppler flow sonography versus conventional techniques. Radiology 1991;180(1):105-9. 18. Meuleman EJ, Bemelmans BL, van Asten WN, Doesburg WH, Skotnicki SH, Debruyne FM. Assessment of penile blood flow by duplex ultrasonography in 44 men with normal erectile potency in different phases of erection. J Urol 1992;147(1):51-6. 19. Kahvecioğlu N, Kurt A, Ipek A, Yazicioğlu KR, Akbulut Z. Predictive value of cavernosal peak systolic velocity in the flaccid penis. Adv Med Sci 2009;54(2):233-8.

307 ‫ ﺗﺎ‬301 ،5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

307

‫ﻛﺎراﻳﻲ دو روش ﭘﺎﻳﺶ ﺑﺮاي ﺗﺸﺨﻴﺺ ﻋﻔﻮﻧﺖ ﻣﺤﻞ ﺟﺮاﺣﻲ در ﺑﺨﺸﻬﺎي ﺟﺮاﺣﻲ ﻋﻤﻮﻣﻲ‬

Tehran University Medical Journal, August 2012; Vol. 70, No. 5: 301-307

Original Article

Peak systolic velocity of cavernosal artery of the penis before and after papaverine injection in erectile dysfunction Abstract Seyyed Morteza Bagheri Ph.D. Mahmoodreza Taheri M.D.* Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran.

Received: February 13, 2012

Accepted: April 21, 2012

Background: Sexual dysfunction in males is characterized by the inability to achieve or maintain an erection sufficient for a satisfactory sexual activity. Erectile dysfunction is a common disorder in males and intracavernosal injection of papaverine followed by color Doppler ultrasonography of the penis is used to diagnose and treat vascular impotence. In this study, we examined the relationship between changes in peak systolic velocity (PSV) and erectile dysfunction with vascular cause after a cavernosal injection of papaverin. Methods: We performed this self-controlled clinical trial in Shahid Hasheminejad Hospital in Tehran, Iran during 2010 and 2011. The study population consisted of 90 patients with erectile dysfunction. The peak systolic velocity (PSV) of cavernosal arteries was evaluated before and after injection of 40-80 mg papaverine and it was compared in the patients with and without response to injection. Results: The mean age of participants was 47.713.7 years. Response to papaverine injection was positive in 41(45.5%) patients. The mean PSV values were 14.68+5.65 and 53.74+18.8 cm/s before and after the injection, respectively (P<0.001). A PSV cut-off

point of 10 cm/s was determined for the condition before injection. The sensitivity and specificity of the value for diagnosis of arterial erectile dysfunction were calclulated as 50% and 100%, respectively.

Conclusion: A PSV cut-off point of 10 cm/s in flaccid status before papaverine injection has a low sensitivity but high specificity for the diagnosis of arterial erectile dysfunction. Future studies with sufficient cases of arterial erectile dysfunction are *

Corresponding author: Dept. of Radiology, Rasule-akram Hospital, Shahrara Blvd., Tehran, Iran. Tel: +98-21-64352578 E-mail: dmrt53@yahoo.com

necessary for final judgments and suggestion a new cut off point. Keywords: cavernosal artery, erectile dysfunction, papaverine, peak systolic velocity.

Tehran Univ Med J (TUMJ) 2012 August;70(5):301-7

http://tumj.tums.ac.ir

‫ﻋﻠﻲ ﻋﻠﻴﺰاده ﺧﻄﻴﺮ و ﻫﻤﻜﺎران‬

‫‪308‬‬

‫ﻣﻘﺎﻟﻪ اﺻﻴﻞ‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ ،5‬ﺻﻔﺤﻪﻫﺎي ‪ 308‬ﺗﺎ ‪313‬‬

‫ﺑﻠﻮك ﻋﺼﺐ اﻛﺴﻲﭘﻴﺘﺎل ﺑﺰرگ ﺑﺎ ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ‪/‬ﻣﺘﻴﻞ ﭘﺮدﻧﻴﺰوﻟﻮن و ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ‪/‬ﺳﺎﻟﻴﻦ در ﺳﺮدرد‬ ‫ﻧﺎﺷﻲ از ﻣﺼﺮف ﺑﻴﺶ از ﺣﺪ دارو‬

‫ﭼﻜﻴﺪه‬

‫‪1‬‬

‫ﻋﻠﻲ ﻋﻠﻴﺰاده ﺧﻄﻴﺮ‬

‫‪2‬‬

‫ﻣﻬﺪي ﭘﻨﺎﻫﺨﻮاﻫﻲ‬

‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ﻣﻘﺎﻟﻪ‪1391/01/27 :‬‬

‫ﺗﺎرﻳﺦ ﭘﺬﻳﺮش‪1391/02/27 :‬‬

‫زﻣﻴﻨﻪ و ﻫﺪف‪ :‬ﺳﺮدردﻫﺎي ﻧﺎﺷﻲ از ﻣﺼﺮف ﺑﻴﺶ از ﺣﺪ دارو ﺳﺮدردﻫﺎﻳﻲ ﻫﺴﺘﻨﺪ ﻛﻪ ﺑﻴﺶ از ‪ 15‬روز در ﻣﺎه ﻃﻮل ﻛﺸﻴﺪه‬

‫‪3‬‬

‫ﻋﻠﻴﺮﺿﺎ ﺧﻮاﺟﻪ ﻧﺼﻴﺮي‬

‫و در اﺛﺮ ﻫﺮ داروي ﻣﺴﻜﻨﻲ ﻛﻪ ﺑﺮاي ﻛﺎﻫﺶ درد ﻣﺼﺮف ﻣﻲﺷﻮد اﻳﺠﺎد ﻣﻲﮔﺮدد‪ .‬اﻏﻠﺐ درﻣﺎنﻫﺎي داروﻳﻲ اﺳـﺘﻔﺎدهﺷـﺪه‬

‫‪4‬‬

‫ﻃﻴﺐ رﻣﻴﻢ‬

‫در اﻳﻦ اﻓﺮاد ﺑﻲﻧﺘﻴﺠﻪ ﺑﻮده اﺳﺖ‪ .‬در ﺑﺮﺧﻲ ﻣﻮارد از ﺑﻠﻮك ﻋﺼﺐ اﻛﺴﻲﭘﻴﺘﺎل ﺑﺰرگ ﺑﺮاي درﻣﺎن اﻳـﻦ ﺳـﺮدردﻫﺎ اﺳـﺘﻔﺎده‬

‫‪5‬و‪*1‬‬

‫ﻣﻨﺼﻮره ﺗﻘﺎء‬

‫ﻣﻲﺷﻮد‪.‬‬ ‫روش ﺑﺮرﺳﻲ‪ :‬ﻣﻄﺎﻟﻌﻪ ﺑﻪﺻﻮرت ﺗﺠﺮﺑﻲ و دو ﺳﻮﻳﻪ ﻛﻮر در ﺑﻴﻤﺎران ﺑﺰرگﺳﺎل ﻣﺮاﺟﻌـﻪﻛﻨﻨـﺪه ﺑـﻪ درﻣﺎﻧﮕـﺎه ﻧﻮروﻟـﻮژي‬

‫‪ -1‬ﮔﺮوه ﻧﻮروﻟﻮژي‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﺳﻴﻨﺎ‬ ‫‪ -2‬ﮔﺮوه ﺑﻴﻬﻮﺷﻲ‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﺳﻴﻨﺎ‬

‫ﺑﻴﻤﺎرﺳﺘﺎن ﺳﻴﻨﺎ از ﺧﺮداد ﺳﺎل ‪ 1388‬اﻟﻲ ﺧﺮداد ‪ 1390‬اﻧﺠﺎم ﮔﺮدﻳﺪ‪ .‬ﺑﻠـﻮك ﻋـﺼﺐ ﭘـﺲ ﺳـﺮي در ﮔـﺮوه اول ﺑـﺎ ‪3ml‬‬

‫‪ -3‬ﮔﺮوه ﺑﻴﻬﻮﺷﻲ‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﺷﺮﻳﻌﺘﻲ‬

‫ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ ‪ %0/5‬و ‪ 2ml‬ﺳﺎﻟﻴﻦ و در ﮔﺮوه دوم ﺑﺎ ﺗﺮﻛﻴﺐ ‪ 3ml‬ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ ‪ %0/5‬ﺑﻪﻫﻤﺮاه ‪ 80‬ﻣﻴﻠﻲﮔﺮم ﻣﺘﻴﻞ ﭘﺮدﻧﻴﺰوﻟـﻮن‬

‫‪ -4‬ﻣﺤﻘﻖ‪ ،‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﺗﺮوﻣﺎ و ﺟﺮاﺣﻲ‬

‫اﻧﺠﺎم ﺷﺪ‪ .‬ﻛﺎﻫﺶ ﺷﺪت ﺳﺮدرد ﺑـﺮ اﺳـﺎس ﻣﻌﻴـﺎر ‪ Visual Analogue Scale‬و اﻓـﺰاﻳﺶ ﻣـﺪت روزﻫـﺎي ﺑـﺪون ﺳـﺮدرد‬

‫ﺑﻴﻤﺎرﺳﺘﺎن ﺳﻴﻨﺎ‬ ‫‪ -5‬ﮔﺮوه ﻧﻮروﻟﻮژي‪ ،‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﺑﻴﻤﺎريﻫﺎي‬

‫اﻧﺪازهﮔﻴﺮي ﺷﺪ‪ P<0/05 .‬ﻣﻌﻨﻲدار در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪ‪.‬‬ ‫ﻳﺎﻓﺘﻪﻫﺎ‪ 13 :‬ﻣﺮد و ‪ 19‬زن ﺑﺎ ﻣﻴﺎﻧﮕﻴﻦ ﺳﻨﻲ ‪ 39/88±8/76‬ﺳﺎل در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺷـﺮﻛﺖ ﻛﺮدﻧـﺪ‪ .‬ﻣﻴـﺎﻧﮕﻴﻦ ﻛـﺎﻫﺶ ﺷـﺪت‬

‫ﻣﻐﺰ و اﻋﺼﺎب اﻳﺮان‬

‫ﺳﺮدرد ﻳﻚ ﺳﺎﻋﺖ ﺑﻌﺪ از ﺗﺰرﻳﻖ در ﮔﺮوه اول ‪ 5/56±1/03‬و در ﮔﺮوه دوم ‪ 4/63±1/92‬ﺑﻮد‪ .‬ﻣﻴـﺎﻧﮕﻴﻦ روزﻫـﺎي ﺑـﺪون‬ ‫داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬

‫ﺳﺮدرد ﻳﻚﻣﺎه ﭘﺲ از ﺗﺰرﻳﻖ در ﮔﺮوه اول ‪ 8/75‬و در ﮔﺮوه دوم ‪ 4/75‬روز ﺑﻮد‪ .‬در ﻫﻴﭻ ﻣﻮرد اﺧﺘﻼف آﻣﺎري ﻣﻌﻨﻲداري‬ ‫ﻣﻴﺎن دو ﮔﺮوه وﺟﻮد ﻧﺪاﺷﺖ‪.‬‬

‫*‬

‫ﻧﺘﻴﺠﻪﮔﻴﺮي‪ :‬اﺳﺘﻔﺎده از ﻫﺮ دو روش ﻧﺘﺎﻳﺞ ﻳﻜﺴﺎن و ﻣﻮﺛﺮي در درﻣﺎن ﺑﻴﻤﺎري داﺷﺖ‪ .‬اﻳﻦ ﻧﻜﺘﻪ ﺑﻪﺧﺼﻮص در ﻣﻮرد اﻳﻦ‬ ‫ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪ :‬ﺗﻬﺮان‪ ،‬ﺧﻴﺎﺑﺎن اﻣﺎم ﺧﻤﻴﻨﻲ‪ ،‬ﻧﺮﺳﻴﺪه‬

‫ﺑﻪ ﻣﻴﺪان ﺣﺴﻦآﺑﺎد‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﺳﻴﻨﺎ‬

‫ﺳﺮدردﻫﺎ ﻛﻪ اﻏﻠﺐ ﻣﻘﺎوم ﺑﻪ درﻣﺎن ﺑﻮده و ﺑﺎﻋﺚ اﺧﺘﻼل در زﻧﺪﮔﻲ روزﻣﺮه ﺑﻴﻤﺎران ﻣﻲﮔﺮدد اﻫﻤﻴﺖ دارد‪.‬‬

‫ﺗﻠﻔﻦ‪021-66348529 :‬‬ ‫‪E-mail: toghae@sina.tums.ac.ir‬‬

‫ﻛﻠﻤﺎت ﻛﻠﻴﺪي‪ :‬ﻣﺼﺮف ﺑﻴﺶ از ﺣﺪ دارو‪ ،‬ﺑﻠﻮك ﻋﺼﺐ‪ ،‬ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ‪ ،‬ﻋﺼﺐ اﻛﺴﻲﭘﻴﺘﺎل ﺑﺰرگ‪.‬‬

‫ﺧــﻮدي داﺧــﻞ ﺟﻤﺠﻤــﻪاي‪ ،‬ﺿــﺎﻳﻌﺎت ﻓــﻀﺎﮔﻴﺮ داﺧــﻞ ﺟﻤﺠﻤــﻪاي(‪،‬‬

‫ﻣﻘﺪﻣﻪ‬

‫ﺑﻴﻤﺎريﻫﺎي اﻟﺘﻬﺎﺑﻲ ﻣﺎﻧﻨﺪ آرﺗﺮﻳﺖ ﺳـﻠﻮل ژآﻧـﺖ‬ ‫‪ Chronic‬ﺑــﻪ‬

‫)‪ ،(GCA‬ﺳﺮدرد ﺑﺎ ﻣﻨﺸﺎي ﮔﺮدﻧﻲ )ﺳﺮوﻳﻜﻮژﻧﻴﻚ(‪ ،‬ﻋﻔﻮﻧﺖﻫـﺎﻳﻲ ﻣﺎﻧﻨـﺪ‬

‫دﺳﺘﻪاي از ﺳﺮدردﻫﺎ ﻛﻪ ﺑﻴﺶ از ‪ 15‬روز در ﻣﺎه و ﺑﻪﻣﺪت ﺣـﺪاﻗﻞ ﺳـﻪ‬

‫‪2‬و‪1‬‬

‫ﻣﻨﻨﮋﻳــﺖ ﻣــﺰﻣﻦ و ﺳــﺮدردﻫﺎي ﻧﺎﺷــﻲ از اﻓــﺰاﻳﺶ ﻣــﺼﺮف دارو‪.‬‬

‫ﻣﺎه وﺟﻮد داﺷﺘﻪ اﺳﺖ ﮔﻔﺘﻪ ﻣﻲﺷﻮد‪ .‬اﺧﺘﻼﻻﺗـﻲ ﻛـﻪ ﻣـﻲﺗﻮاﻧـﺪ ﺑﺎﻋـﺚ‬

‫ﺷﺎﻳﻊﺗﺮﻳﻦ اﻧﻮاع ‪ ،CDH‬ﻣﻴﮕﺮن ﻣـﺰﻣﻦ و ﺳـﺮدردﻫﺎي ﻧﺎﺷـﻲ از ﻣـﺼﺮف‬

‫ﺳــﺮدرد ﻣ ـﺰﻣﻦ روزاﻧــﻪ‬

‫)‪Daily Headache (CDH‬‬

‫‪Giant Cell Arthritis‬‬

‫‪CDH‬ﻫﺎي ﺛﺎﻧﻮﻳﻪ ﮔﺮدد ﻣﺘﻌﺪد ﻣﻲﺑﺎﺷﻨﺪ ﻛﻪ از آن ﺟﻤﻠﻪ ﻣﻲﺗﻮان ﺑﻪ ﻣﻮارد‬ ‫زﻳﺮ اﺷﺎره ﻧﻤﻮد‪ :‬اﺧـﺘﻼﻻت اﻳﺠـﺎد ﺷـﺪه در ﻓـﺸﺎر داﺧـﻞ ﺟﻤﺠﻤـﻪاي‬ ‫)اﻓﺰاﻳـﺶ اﻳﺪﻳـﻮﭘﺎﺗﻴـﻚ ﻓﺸﺎر داﺧﻞ ﺟﻤﺠﻤﻪاي‪ ،‬ﻫﻴـﭙﻮﺗﺎﻧﺴﻴﻮن ﺧﻮدﺑﻪ‪-‬‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ 308 ،5‬ﺗﺎ ‪313‬‬

‫‪4‬و‪3‬‬

‫ﺑﻴﺶ از ﺣﺪ دارو ﻣﻲﺑﺎﺷﻨﺪ‪.‬‬

‫ﺳــﺮدردﻫﺎي ﻧﺎﺷــﻲ از ﻣــﺼﺮف ﺑــﻴﺶ از ﺣــﺪ دارو‬ ‫)‪(MOH‬‬

‫‪Medication‬‬

‫‪ Overuse Headache‬در ﮔﺬﺷﺘﻪ ﺗﺤﺖ ﻋﻨﻮان ﺳﺮدردﻫﺎي ﻧﺎﺷﻲ‬

‫ﺳﺮدرد ﻧﺎﺷﻲ از ﻣﺼﺮف ﺑﻴﺶ از ﺣﺪ دارو‬

‫از ﻣــﺼﺮف دارو ﻳــﺎ ﺳــﺮدردﻫﺎي راﺟﻌــﻪ ﺧﻮاﻧــﺪه ﻣــﻲﺷــﺪ‪.‬‬

‫‪MOH‬‬

‫‪309‬‬

‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻣﻴﺰان ﺑﻪﻧﺴﺒﺖ ﺑﺎﻻي ﻋـﻮد ‪ MOH‬ﺑـﺎ ﺗﻮﺟـﻪ ﺑـﻪ وﺟـﻮد‬

‫ﺳﺮدردﻫﺎﻳﻲ ﻫﺴﺘﻨﺪ ﻛﻪ ﺑﻴﺶ از ‪ 15‬روز در ﻣﺎه ﻃﻮل ﻛﺸﻴﺪه و در اﺛﺮ ﻫﺮ‬

‫درﻣﺎنﻫﺎي ﻣﺨﺘﻠﻒ در ﺑﺮﺧﻲ ﻣﻄﺎﻟﻌﺎت‪ ،‬از ﺑﻠـﻮك ﻋـﺼﺐ اﻛـﺴﻲﭘﻴﺘـﺎل‬

‫‪6‬و‪5‬‬

‫‪ Greater‬ﺑــﺮاي درﻣــﺎن اﻳــﻦ ﻧــﻮع‬

‫داروي ﻣﺴﻜﻦ ﻛﻪ ﺑﺮاي ﻛﺎﻫﺶ درد ﻣﺼﺮف ﻣﻲﺷﻮد اﻳﺠﺎد ﻣﻲﮔـﺮدد‪.‬‬

‫ﺑــﺰرگ‬

‫)‪Occipital Nerve (GON‬‬

‫ﻣﻴﺰان ﺷﻴﻮع ﺟﻤﻌﻴﺘﻲ ‪ CDH‬ﻛﻪ ﻫﻢزﻣﺎن دارو ﻣﺼﺮف ﻣـﻲﻛﻨﻨـﺪ ﺣـﺪود‬

‫ﺳﺮدردﻫﺎ ﻧﻴﺰ اﺳﺘﻔﺎده ﮔﺮدﻳﺪه اﺳﺖ ﻛﻪ ﻧﺘﻴﺠﻪ ﻣﺜﺒﺘﻲ داﺷﺘﻪ اﺳﺖ‪13.‬و‪ 12‬در‬

‫‪7‬‬

‫ﻣﻮاردي ﻛﻪ ﻓﺮد ﺳﺎﺑﻘﻪ ﺳﺮدردﻫﺎي ﻧﻮع ‪ MOH‬را دارد‪ ،‬ﻣﻴـﺰان ﺷﻜـﺴﺖ‬

‫ﻣﻌﻴﺎرﻫﺎي ﺗﺸﺨﻴﺼﻲ در ‪ MOH‬ﻋﺒﺎرﺗﻨﺪ از‪ -1 :‬وﺟﻮد ﺳﺮدرد ﺑـﻴﺶ‬

‫درﻣﺎن ﺑﻠﻮك ‪ GON‬ﺣﺪود ﺳﻪ ﺑﺮاﺑﺮ ﻣﻲﺑﺎﺷﺪ‪ 14.‬ﺑﻪﻃـﻮر ﺗﻘﺮﻳﺒـﻲ ‪2-3ml‬‬

‫از ‪ 15‬روز در ﻣﺎه ﻛـﻪ داراي ﻣﻌﻴﺎرﻫـﺎي ﺷـﻤﺎره )‪ (3‬و )‪ (4‬ﻧﻴـﺰ ﺑﺎﺷـﺪ‪،‬‬

‫ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ )‪ (Bupivacaine‬ﻳﺎ ﻟﻴﺪوﻛﺎﻳﻴﻦ و ﻳﺎ ﺗﺮﻛﻴﺒﻲ از ﻫـﺮ دو ﺑـﺮاي‬

‫‪ %1/4‬اﺳﺖ ﻛﻪ از آن ﻣﻴﺎن ‪ %18-33‬را ﺑﻴﻤﺎران ‪ MOH‬ﺗﺸﻜﻴﻞ ﻣﻲدﻫﻨﺪ‪.‬‬

‫‪15‬‬

‫‪ -2‬ﻣﺼﺮف ﻣﻨﻈﻢ و ﺑﻴﺶ از ﺣﺪ ﻳﻚ ﻳﺎ ﭼﻨﺪ دارو در ﺑـﻴﺶ از ﺳـﻪ ﻣـﺎه‬

‫ﺑﻠﻮك ‪ GON‬ﻛﻔﺎﻳﺖ ﻣﻲﻛﻨﺪ‪ .‬ﻋﻮارض ﺟﺎﻧﺒﻲ اﻧﺪﻛﻲ ﺑﺮاي ﺑﻠـﻮك‬

‫ﺑﺮاي درﻣﺎن و ﻛﺎﻫﺶ ﻋﻼﻳﻢ ﺳـﺮدرد‪ -3 ،‬ﺳـﺮدردﻫﺎﻳﻲ ﻛـﻪ ﻋﻠـﻲرﻏـﻢ‬

‫ﮔﺰارش ﺷﺪه اﺳﺖ‪ .‬در ﺻﻮرﺗﻲﻛﻪ ﺑﻠـﻮك و ﺗﺰرﻳـﻖ ﻛﻮرﺗﻴﻜﻮاﺳـﺘﺮوﻳﻴﺪ‬

‫ﻣﺼﺮف دارو اداﻣﻪ ﻳﺎﻓﺘﻪ ﻳﺎ ﺑﺪﺗﺮ ﻣﻲﺷﻮﻧﺪ‪ -4 ،‬ﺳـﺮدردﻫﺎﻳﻲ ﻛـﻪ دو ﻣـﺎه‬

‫ﺻﻮرت ﮔﻴﺮد‪ ،‬ﻋﻮارض ﺷﺎﻣﻞ آﻟﻮﭘـﺴﻲ ﻣﻮﺿـﻌﻲ و ﺑـﻪﻧـﺪرت ﺳـﻨﺪرم‬

‫ﭘﺲ از ﻗﻄﻊ ﻣﺼﺮف دارو ﺑﻬﺘﺮ ﺷﺪه ﻳﺎ ﻣﺎﻧﻨﺪ ﻗﺒﻞ ﻣﻲﮔﺮدﻧﺪ‪ .‬ﺑـﻴﺶﺗـﺮﻳﻦ‬

‫‪GON‬‬

‫‪17‬و‪16‬‬

‫ﻛﻮﺷﻴﻨﮓ ﻣﻲﺑﺎﺷﺪ‪.‬‬

‫داروي ﻣــﻮرد اﺳــﺘﻔﺎده در ‪ MOH‬ﻋﺒﺎرﺗﻨــﺪ از آﻧﺎﻟﮋزﻳــﻚﻫــﺎ‪ ،‬اﭘﻴﻮﻳﻴــﺪﻫﺎ‪،‬‬

‫دو ﺣﺎﻟﺖ اﺻﻠﻲ ﻛﻪ ﺑﺎ ﺑﻠﻮك ‪ GON‬درﻣـﺎن ﻣـﻲﺷـﻮﻧﺪ ﻋﺒﺎرﺗﻨـﺪ از‪:‬‬

‫ارﮔﻮﺗﺎﻣﻴﻦﻫﺎ و ﺗﺮﻳﭙﺘﺎنﻫﺎ ﺑﻪﺗﻨﻬﺎﻳﻲ ﻳﺎ ﻫﻤﺮاه ﺑﺎ ﺳﺎﻳﺮ داروﻫﺎ‪ .‬ﻓﺎﺻﻠﻪ ﺑـﻴﻦ‬

‫ﻧــﻮراﻟﮋي اﻛــﺴﻲﭘﻴﺘــﺎل )ﻳــﺎ ﻧﻮرﻳــﺖ( و ﺳــﺮدرد ﺳــﺮوﻳﻜﻮژﻧﻴﻚ‪ .‬در‬

‫ﻣﺼﺮف ﻣﻜﺮر اﻳﻦ داروﻫـﺎ و ﭘﻴـﺸﺮﻓﺖ ‪ CDH‬در ﻣـﻮرد ﺗﺮﻳﭙﺘـﺎنﻫـﺎ در‬

‫ﺳﺮدردﻫﺎي دﻳﮕﺮ ﺷﺎﻣﻞ ﺧﻮﺷﻪاي )‪ (Cluster‬و ﻣﻴﮕﺮن ﻣـﺰﻣﻦ ﻧﻴـﺰ اﻳـﻦ‬

‫ﻛﻮﺗﺎهﺗﺮﻳﻦ زﻣﺎن )‪ 1/7‬ﺳﺎل(‪ ،‬در ﻣﻮرد ارﮔﻮتﻫﺎ )‪ 2/7‬ﺳﺎل( و در ﻣﻮرد‬

‫درﻣﺎن ﭘﻴﺸﻨﻬﺎد ﺷﺪه اﺳﺖ‪ .‬در ﻣﻴﮕﺮن ﻣﺰﻣﻦ ﻧﻴﺰ ﻧﺘﺎﻳﺞ ﺑﻠﻮك ‪ GON‬ﻗﺎﺑـﻞ‬

‫‪8‬‬

‫ﻗﺒﻮل اﺳﺖ وﻟﻲ ﻧﺘﻴﺠﻪ ﺑﻠـﻮك ‪ GON‬در ﺳـﺮدرد ‪ MOH‬ﻫﻨـﻮز ﻣـﺸﺨﺺ‬

‫آﻧﺎﻟﮋزﻳﻚﻫﺎ )‪ 4/8‬ﺳﺎل( ﺑﻮد‪.‬‬

‫ﻣﺸﺨﺺ ﻧﻤـﻮدن اﻳـﻦﻛـﻪ آﻳـﺎ ﻣـﺼﺮف ﺑـﻴﺶ از ﺣـﺪ دارو ﻋﻠـﺖ‬

‫‪18‬و‪14‬‬

‫ﻧﻴﺴﺖ‪.‬‬

‫اﻳﺠﺎدﻛﻨﻨﺪه اﺧﺘﻼل ﺳﺮدرد روزاﻧﻪ )‪ (CDH‬ﻣﻲﺑﺎﺷﺪ ﻧﻴﺎزﻣﻨـﺪ اﻳـﻦ ﻣـﺴﺎﻟﻪ‬

‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻣﻮارد ذﻛﺮ ﺷﺪه اﺣﺘﻤﺎل اﻳﻦﻛﻪ ﺑﺘﻮان ﺑﺎ اﻧﺘﺨﺎب ﺻـﺤﻴﺢ‬

‫اﺳــﺖ ﻛ ـﻪ ﻣــﺼﺮف دارو ﻗﻄــﻊ ﮔــﺮدد‪ .‬در ﺻــﻮرﺗﻲﻛ ـﻪ ﺑﻴﻤــﺎر دﭼــﺎر‬

‫دوز درﻣﺎﻧﻲ دارو و ﻣﺤﻞ ﻣﻨﺎﺳﺐ ﺗﺰرﻳﻖ‪ ،‬ﻣﻴﺰان درد ﺑﻴﻤـﺎران ﻣﺒـﺘﻼ ﺑـﻪ‬

‫ﺳﺮدردﻫﺎﻳﻲ ﺑﺎ اﻟﮕﻮي ﻗﺒﻠﻲ )ﻛﻢﺗﺮ از ‪ 15‬روز در ﻣـﺎه( دو ﻣـﺎه ﭘـﺲ از‬

‫‪ MOH‬را ﺗﺎ ﺣﺪود زﻳﺎدي ﻛﺎﻫﺶ داد وﺟﻮد دارد‪ .‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑـﺎ ﻫـﺪف‬

‫ﻗﻄﻊ ﻣﺼﺮف دارو ﮔﺮدﻳﺪ‪ ،‬ﺗﺸﺨﻴﺺ ‪ MOH‬داده ﻣﻲﺷـﻮد‪ .‬ﺗـﺸﺨﻴﺺ در‬

‫ﺑﺮرﺳﻲ ﻛـﺎﻫﺶ درد ﺑﻴﻤـﺎران ﻣﺒـﺘﻼ ﺑـﻪ ‪ MOH‬ﭘـﺲ از اﻧﺠـﺎم ﺑﻠـﻮك و‬

‫ﺻﻮرت ﺗﺪاوم ﺳﺮدرد ﺑﻴﺶ از ‪ 15‬روز در ﻣﺎه ﻋﻠﻲرﻏـﻢ ﻗﻄـﻊ ﻣـﺼﺮف‬

‫ﭘﻲﮔﻴﺮي آنﻫﺎ اﻧﺠﺎم ﺷﺪه اﺳﺖ‪.‬‬

‫‪2‬‬

‫دارو‪ ،‬ﺑﻴﻤﺎري ‪ CDH‬اوﻟﻴﻪ ﺧﻮاﻫﺪ ﺑﻮد‪.‬‬

‫ﭘﺎﺗﻮژﻧﺰ ‪ MOH‬ﻧﺎﻣﺸﺨﺺ اﺳﺖ‪ .‬ﻓﺮﺿﻴﻪ اوﻟﻴﻪ ﻛﺎﻫﺶ آﺳﺘﺎﻧﻪ ﺗﺤﺮﻳﻚ‬

‫روش ﺑﺮرﺳﻲ‬

‫ﻋﺼﺐ ﺗﺮيژﻣﻴﻨﺎل اﺳﺖ ﻛﻪ ﺑﻪﻋﻠﺖ اﺧﺘﻼل ﻧﺎﺷـﻲ از ﻣـﺼﺮف دارو در‬ ‫ﻛﺎﻫﺶ ﻣﻬﺎر ﻋﺼﺒﻲ ﻣﻲﺑﺎﺷﺪ‪ 9.‬ﺑﺮرﺳﻲﻫﺎي اﺧﻴﺮ ﺑﺎ ﻓﻠﻮردياﻛﺴﻲ ﮔﻠﻮﻛﺰ‬

‫ﻣﻄﺎﻟﻌﻪ ﺑﻪﺻﻮرت ﺗﺠﺮﺑﻲ و دو ﺳﻮﻳﻪ ﻛﻮر در ﺑﻴﻤـﺎران ﺑـﺰرگﺳـﺎل‬

‫‪ (FDG‬در اﻳﻦ ﺑﻴﻤﺎران ﻧـﺸﺎن ﻣـﻲدﻫـﺪ ﻛـﻪ ﻧـﻮاﺣﻲ ﻣﻐـﺰي‬

‫ﻣﺒﺘﻼ ﺑﻪ ‪ MOH‬ﻣﺮاﺟﻌﻪﻛﻨﻨﺪه ﺑﻪ درﻣﺎﻧﮕﺎه ﻧﻮروﻟﻮژي ﺑﻴﻤﺎرﺳـﺘﺎن ﺳـﻴﻨﺎ از‬

‫ﻣﺮﺑﻮط ﺑﻪ ﺷﺒﻜﻪ درد ﻣﺮﻛﺰي دﭼﺎر ﻛـﺎﻫﺶ ﻣﺘﺎﺑﻮﻟﻴـﺴﻢ ﺷـﺪه و ﭘـﺲ از‬

‫ﺧﺮداد ﺳـﺎل ‪ 1388‬اﻟـﻲ ﺧـﺮداد ‪ 1390‬اﻧﺠـﺎم ﮔﺮدﻳـﺪ‪ .‬ﺑﻴﻤـﺎران داراي‬

‫)‪(Reactive‬‬

‫ﺗﺸﺨﻴﺺ ‪ MOH‬ﺑﺮ اﺳﺎس ﻣﻌﻴﺎرﻫﺎي ﺗﻌﻴﻴﻦﺷﺪه وارد ﻣﻄﺎﻟﻌﻪ ﺷﺪﻧﺪ‪ 1.‬در‬

‫ﻣﻲﺷﻮﻧﺪ‪ .‬از ﻃﺮف دﻳﮕﺮ در اﻳﻦ ﺑﻴﻤﺎران ﻛﻮرﺗﻜﺲ اورﺑﻴﺘﻮ‪-‬ﻓﺮوﻧﺘﺎل ﻧﻴـﺰ‬

‫ﺻﻮرﺗﻲﻛﻪ در ﻫﺮ ﻛﺪام از ﻣﺮاﺣﻞ درﻣﺎن و ﭘﻲﮔﻴـﺮي ﻣـﺸﺨﺺ ﮔﺮدﻳـﺪ‬

‫ﭘﺲ از ﻗﻄﻊ دارو دﭼﺎر ﻛﺎﻫﺶ ﻣﺘﺎﺑﻮﻟﻴﺴﻢ ﻣﻲﮔـﺮدد‪ .‬ﺑـﻪدﻟﻴـﻞ ﺗﻐﻴﻴـﺮات‬

‫ﻣﻨﺸﺎي ﺳﺮدردﻫﺎي ﺑﻴﻤﺎر ﻏﻴﺮ از ﻣﺼﺮف ﺑﻴﺶ از ﺣﺪ دارو اﺳﺖ‪ ،‬ﺑﻴﻤـﺎر‬

‫ﻣﺘﺎﺑﻮﻟﻴﻚ و ﻧﻘﺶ ﻛﻮرﺗﻜﺲ اورﺑﻴﺘـﻮ‪-‬ﻓﺮوﻧﺘـﺎل در ﺳـﻮءﻣـﺼﺮف ﻣـﻮاد‪،‬‬

‫از ﻣﻄﺎﻟﻌﻪ ﺧﺎرج ﺷﺪ‪.‬‬

‫‪PET) PET‬‬

‫ﻋــﺪم ﻣــﺼﺮف داروي ﻣــﺴﻜﻦ ﺑــﻪﺳــﺮﻋﺖ ﻣﺠــﺪداً ﻓﻌــﺎل‬

‫ﻣﺤﻘﻘﻴﻦ ﺑﻴﺎن ﻣﻲﻛﻨﻨﺪ ﻛﻪ ﻛﺎﻫﺶ ﻣﺘﺎﺑﻮﻟﻴﺴﻢ ﻛﻮرﺗﻜﺲ اورﺑﻴﺘـﻮ‪-‬ﻓﺮوﻧﺘـﺎل‬ ‫‪11‬و‪10‬‬

‫ﺑﺎﻋﺚ اﻓﺰاﻳﺶ اﺣﺘﻤﺎل ﻋﻮد ﺳﻮءﻣﺼﺮف ﻣﻲﮔﺮدد‪.‬‬

‫ﺑﻴﻤﺎران ﺑﺮ ﺣﺴﺐ داروي ﻣﻮرد اﺳﺘﻔﺎده ﺟﻬﺖ اﻧﺠﺎم ﺑﻠﻮك ﻋـﺼﺐ‬ ‫اﻛﺴﻲﭘﻴﺘﺎل ﺑﻪ دو ﮔﺮوه ﺗﻘﺴﻴﻢ ﺷـﺪﻧﺪ‪) :‬اﻧﺘﺨـﺎب ﺑﻴﻤـﺎران و ﻗـﺮار دادن‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):308-13‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻋﻠﻲ ﻋﻠﻴﺰاده ﺧﻄﻴﺮ و ﻫﻤﻜﺎران‬

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‫آنﻫــﺎ در ﻫــﺮ ﻛــﺪام از ﮔــﺮوهﻫــﺎ ﺑــﻪروش‬

‫‪Balanced Block‬‬

‫‪ Randomization‬ﺑﻮده اﺳﺖ( ﮔﺮوه اﻟﻒ‪ -‬ﺑﻴﻤـﺎراﻧﻲ ﺑﻮدﻧـﺪ ﻛـﻪ ﺑﻠـﻮك‬

‫اﺳﺘﻔﺎده ‪NSAID‬ﻫﺎ )‪ 29‬ﻧﻔﺮ در ﻫﺮ دو ﮔﺮوه( و ﻛـﻢﺗـﺮﻳﻦ داروي ﻣـﻮرد‬ ‫اﺳﺘﻔﺎده اﭘﻴﻮﻳﻴﺪ )ﭘﻨﺞ ﻧﻔﺮ در ﻫﺮ دو ﮔﺮوه( ﻣﻲﺑﺎﺷﺪ‪.‬‬

‫ﻋــﺼﺐ ﭘــﺲ ﺳــﺮي در آنﻫــﺎ ﺑــﺎ ﺗﺮﻛﻴــﺐ ‪ 3ml‬ﺑﻮﭘﻴﻮاﻛــﺎﻳﻴﻦ ‪%0/5‬‬

‫ﺷﺪت ﺳﺮدرد ﺑﻴﻤﺎر ﺑﺮ اﺳﺎس ‪ VAS‬از ﺻـﻔﺮ ﺗـﺎ ‪ 10‬ﻧﻤـﺮهﮔـﺬاري‬

‫‪ (Marcaine,‬و ‪2ml‬‬

‫ﮔﺮدﻳﺪ‪ .‬ﻣﻴﺎﻧﮕﻴﻦ ﺷﺪت ﺳـﺮدرد در ﺑﻴﻤـﺎران ﺷـﺮﻛﺖ ﻛﻨﻨـﺪه در ﻣﻄﺎﻟﻌـﻪ‬

‫)‪AstraZeneca Pharmaceutical Co., Sweden‬‬

‫‪ 7/84±0/88‬ﺑـﻮد‪ .‬ﺣـﺪاﻗﻞ ﺷـﺪت ﺳـﺮدرد ﺷـﺶ و ﺣـﺪاﻛﺜﺮ ‪ 10‬ﺑـﻮد‪.‬‬

‫ﺳﺎﻟﻴﻦ اﻧﺠﺎم ﮔﺮدﻳﺪ‪.‬‬ ‫ﮔﺮوه ب‪ -‬ﺑﻴﻤﺎراﻧﻲ ﺑﻮدﻧﺪ ﻛﻪ در آنﻫﺎ ﺑﻠﻮك ﻋﺼﺐ ﭘﺲ ﺳـﺮي ﺑـﺎ‬

‫ﻣﻴﺎﻧﮕﻴﻦ ﻛﻠﻲ روزﻫﺎي ﺑﺪون ﺳﺮدرد در ﻣﺎه در ﺑﻴﻤﺎران ﺷﺮﻛﺖﻛﻨﻨـﺪه در‬

‫ﺗﺮﻛﻴــﺐ ‪ 3ml‬ﺑﻮﭘﻴﻮاﻛــﺎﻳﻴﻦ ‪ %0/5‬ﺑــﻪﻫﻤــﺮاه ‪ 80mg‬ﻣﺘﻴــﻞ ﭘﺮدﻧﻴﺰوﻟــﻮن‬

‫ﻣﻄﺎﻟﻌﻪ ‪ 7/69±5/89‬روز ﺑﻮد‪ 9 .‬ﻧﻔﺮ از ﺑﻴﻤﺎران در ﺗﻤـﺎم روزﻫـﺎي ﻣـﺎه‬

‫)‪(Methylprednisolone, Caspian Tamin Pharmaceutical Co., Iran‬‬

‫ﺳﺮدرد داﺷﺘﻨﺪ و ﭼﻬﺎر ﻧﻔﺮ ﺣﺪاﻗﻞ ‪ 15‬روز در ﻣﺎه ﺳـﺮدرد داﺷـﺘﻨﺪ‪ .‬دو‬

‫اﻧﺠﺎم ﺷﺪ‪.‬‬

‫ﮔﺮوه از ﻧﻈﺮ ﺳﻦ و ﻣﺸﺨﺼﺎت ﺑﻴﻤﺎري ﻫﻤﮕﻮن ﺑﻮدﻧﺪ )ﺟﺪول‪.(1 -‬‬

‫در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﭘﻴﺎﻣﺪ )‪ (Outcome‬ﻣﺪ ﻧﻈﺮ ﻣﺎ ﻛﺎﻫﺶ ﺷﺪت ﺳـﺮدرد‬

‫ﻣﻴﺎﻧﮕﻴﻦ ﺷﺪت ﺳﺮدرد در زﻣﺎنﻫﺎي ﻣﺨﺘﻠﻒ ﭘﺲ از ﺗﺰرﻳﻖ ﺑﺎ ﻗﺒـﻞ‬

‫‪ Visual Analogue Score‬و اﻓـﺰاﻳﺶ ﻣـﺪت‬

‫از ﺗﺰرﻳﻖ در ﻧﻤﻮدار‪ 1 -‬ﻣﻘﺎﻳﺴﻪ ﺷﺪه اﺳﺖ‪ .‬ﻳﺎﻓﺘﻪﻫﺎي ﻣﻄﺎﻟﻌﻪ ﻧـﺸﺎن داد‬

‫روزﻫﺎي ﺑﺪون ﺳﺮدرد ﺑﻮد ﻟﺬا ﺷﺪت ﺳـﺮدرد در ﻫـﺮ ﮔـﺮوه ﺑـﻪﺷـﻜﻞ‬

‫ﻛﻪ ﻛﺎﻫﺶ ﺷﺪت ﺳﺮدرد ﭘﺲ از ﺗﺰرﻳﻖ در ﻫﺮ دو ﮔـﺮوه ﻣـﺸﻬﻮد ﺑـﻮد‪.‬‬

‫ﺟﺪاﮔﺎﻧﻪ ﻗﺒﻞ از ﺗﺰرﻳﻖ‪ ،‬ﺳﺎﻋﺖ اول ﺑﻌـﺪ از ﺗﺰرﻳـﻖ‪ 24 ،‬ﺳـﺎﻋﺖ‪ ،‬ﻫﻔﺘـﻪ‬

‫اﻟﺒﺘﻪ ﺑﻴﻦ دو ﮔﺮوه ﻣﻮرد ﻣﻄﺎﻟﻌﻪ در زﻣﺎنﻫـﺎي ﻣﺨﺘﻠـﻒ ﭘـﺲ از ﺗﺰرﻳـﻖ‬

‫اول‪ ،‬ﻣﺎه اول‪ ،‬ﻣﺎه دوم و ﻣﺎه ﺳﻮم ﺑﻌﺪ از ﺗﺰرﻳﻖ ارزﻳﺎﺑﻲ ﮔﺮدﻳـﺪ‪ .‬ﺳـﭙﺲ‬

‫اﺧﺘﻼف ﻣﻌﻨـﻲداري وﺟـﻮد ﻧﺪاﺷـﺖ‪ .‬در ﻧﻤـﻮدار‪ 2 -‬ﻣﻴـﺎﻧﮕﻴﻦ ﺗﻌـﺪاد‬

‫ﺗﻌﺪاد روزﻫﺎي ﺑﺪون ﺳﺮدرد در ﻣﺎه‪ ،‬ﻗﺒـﻞ از ﺗﺰرﻳـﻖ‪ ،‬اوﻟـﻴﻦ‪ ،‬دوﻣـﻴﻦ و‬

‫روزﻫﺎي ﺑﺪون ﺳﺮدرد ﺑﺮ ﺣﺴﺐ ﮔﺮوهﻫـﺎي ﻣـﻮرد ﻣﻄﺎﻟﻌـﻪ ﻧـﺸﺎن داده‬

‫ﺳﻮﻣﻴﻦ ﻣﺎه ﭘﺲ از ﺗﺰرﻳﻖ ﻧﻴﺰ در ﻫـﺮ ﮔـﺮوه ﺑـﻪﺷـﻜﻞ ﺟﺪاﮔﺎﻧـﻪ ﻣـﻮرد‬

‫ﺷﺪه اﺳﺖ‪ .‬در ﻫﻔﺘﻪ اول در ﻫﺮ دو ﮔـﺮوه ﺑـﻴﺶﺗـﺮﻳﻦ ﺗﻌـﺪاد روزﻫـﺎي‬

‫ارزﻳﺎﺑﻲ ﻗﺮار ﮔﺮﻓﺖ‪ .‬در ﺻﻮرﺗﻲﻛﻪ ﺑﻴﻤﺎران داروﻫﺎي ﭘﻴﺸﮕﻴﺮيﻛﻨﻨـﺪه از‬

‫ﺑﺪون ﺳﺮدرد ﻣﺸﺎﻫﺪه ﻣﻲﮔﺮدد و ﺳﭙﺲ ﺑﻌﺪ از ﻣﺎه اول اﻳﻦ ﺗﺎﺛﻴﺮ ﻛﻢﺗـﺮ‬

‫ﺳﺮدرد ﻣﺼﺮف ﻣﻲﻛﺮدﻧﺪ داروﻫﺎﻳﺸﺎن ﻗﺒﻞ و ﺑﻌـﺪ از ﺗﺰرﻳـﻖ ﺑـﻪﺷـﻜﻞ‬

‫ﻣﻲﺷﻮد‪ .‬اﺧﺘﻼف آﻣﺎري ﻣﻌﻨﻲداري در روزﻫـﺎي ﺑـﺪون ﺳـﺮدرد در دو‬

‫ﻗﺒﻠﻲ اداﻣﻪ داده ﺷﺪ‪.‬‬

‫ﮔﺮوه دﻳﺪه ﻧﺸﺪ‪.‬‬

‫ﺑـﺮ اﺳـﺎس ﻣﻌﻴـﺎر‬

‫)‪(VAS‬‬

‫ﺗﺎﻳﻴﺪﻳﻪ ﻛﻤﻴﺘﻪ اﺧﻼق داﻧﺸﮕﺎه ﺑـﺎ ﺷـﻤﺎره ‪/130/2163‬د‪ 90/‬ﺟﻬـﺖ‬ ‫اﻧﺠﺎم ﻣﻄﺎﻟﻌﻪ اﺧﺬ ﮔﺮدﻳﺪ‪ .‬ﺑﺮاي ﺗﺠﺰﻳـﻪ و ﺗﺤﻠﻴـﻞ دادهﻫـﺎ از ﻧـﺮماﻓـﺰار‬ ‫آﻣﺎري ‪ SPSS‬وﻳﺮاﺳﺖ ‪ 17‬آزﻣـﻮنﻫـﺎي آﻣـﺎري ﺗﻮﺻـﻴﻔﻲ )ﻣﻴـﺎﻧﮕﻴﻦ و‬ ‫اﻧﺤﺮافﻣﻌﻴﺎر( و ﺗﺤﻠﻴﻠﻲ ‪ Student’s t-test‬اﺳﺘﻔﺎده ﮔﺮدﻳﺪ‪.‬‬

‫ﺟﺪول‪ :1 -‬ﺳﻦ و ﻣﺸﺨﺼﺎت ﺑﻴﻤﺎري در اﻓﺮاد ﺷﺮﻛﺖﻛﻨﻨﺪه در ﻣﻄﺎﻟﻌﻪ ﺑـﺮ ﺣـﺴﺐ‬ ‫ﮔﺮوهﻫﺎي ﻣﻮرد ﻣﻄﺎﻟﻌﻪ‬ ‫ﮔﺮوه ﺳﺎﻟﻴﻦ‬ ‫)‪(Mean± SD‬‬

‫ﻳﺎﻓﺘﻪﻫﺎ‬ ‫در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ‪ 32‬ﺑﻴﻤﺎر ﺷﺮﻛﺖ داﺷﺘﻨﺪ ﻛﻪ ﺑﻪﺻﻮرت ﺗـﺼﺎدﻓﻲ ﺑـﻪ‬ ‫دو ﮔﺮوه ‪ 16‬ﻧﻔﺮي ﺗﻘـﺴﻴﻢ ﺷـﺪﻧﺪ‪ 13 .‬ﻣـﺮد و ‪ 19‬زن در اﻳـﻦ ﻣﻄﺎﻟﻌـﻪ‬ ‫ﺷﺮﻛﺖ داﺷﺘﻨﺪ )در ﮔﺮوه ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ و ﺳﺎﻟﻴﻦ ﺷﺶ ﻣﺮد و ‪ 10‬زن و در‬ ‫ﮔﺮوه ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ و ﻣﺘﻴﻞ ﭘﺮدﻧﻴﺰوﻟﻮن ﻫﻔﺖ ﻣﺮد و ‪ 9‬زن(‪ .‬ﻣﻴﺎﻧﮕﻴﻦ ﺳﻨﻲ‬ ‫ﺑﻴﻤﺎران ‪ 39/88±8/76‬ﺳﺎل ﺑﺎ ﺣـﺪاﻗﻞ ﺳـﻦ ‪ 26‬ﺳـﺎل و ﺣـﺪاﻛﺜﺮ ﺳـﻦ‬ ‫‪ 59‬ﺳــﺎل ﺑــﻮد‪ .‬ﻣﻴــﺎﻧﮕﻴﻦ ﻛﻠــﻲ زﻣــﺎن اﺑــﺘﻼ ﺑــﻪ ﺳــﺮدرد در ﺑﻴﻤــﺎران‬ ‫ﺷﺮﻛﺖﻛﻨﻨـﺪه در ﻣﻄﺎﻟﻌـﻪ ‪ 10/67±9/52‬ﺳـﺎل )ﺣـﺪاﻗﻞ زﻣـﺎن ﺳـﺮدرد‬ ‫ﻳﻚﺳﺎل و ﺣﺪاﻛﺜﺮ ‪ 38‬ﺳـﺎل( ﺑـﻮد‪ .‬ﺑـﻴﺶﺗـﺮﻳﻦ داروي ﻣـﺴﻜﻦ ﻣـﻮرد‬

‫ﮔﺮوه ﻣﺘﻴﻞ‬

‫*‪P‬‬

‫ﭘﺮدﻧﻴﺰوﻟﻮن‬ ‫)‪(Mean± SD‬‬

‫ﺳﻦ )ﺳﺎل(‬

‫زﻣﺎن ﻛﻠﻲ اﺑﺘﻼ ﺑﻪ ﺳﺮدرد‬

‫‪39/00±9/47‬‬ ‫‪10/28±10/25‬‬

‫‪40/75±8/20‬‬ ‫‪11/06±9/05‬‬

‫‪0/581‬‬ ‫‪0/821‬‬

‫)ﺳﺎل(‬ ‫زﻣﺎن اﺑﺘﻼ ﺑﻪ ‪) MOH‬ﺳﺎل(‬

‫‪4/65±5/63‬‬

‫‪5/36±5/45‬‬

‫‪0/719‬‬

‫ﺷﺪت ﺳﺮدرد )‪(0-10‬‬

‫‪7/94±0/77‬‬

‫‪7/75±1/00‬‬

‫‪0/557‬‬

‫روزﻫﺎي ﺑﺪون ﺳﺮدرد‬

‫‪7/94±6/27‬‬

‫‪7/44±5/69‬‬

‫‪0/815‬‬

‫)روز در ﻣﺎه(‬ ‫* آزﻣﻮن آﻣﺎري‪ Student’s t-test :‬و ‪ P<0/05‬ﻣﻌﻨﻲدار ﻣﻲﺑﺎﺷﺪ‬ ‫‪MOH: Medication Overuse Headache‬‬

‫ﺳﺮدرد ﻧﺎﺷﻲ از ﻣﺼﺮف ﺑﻴﺶ از ﺣﺪ دارو‬

‫‪311‬‬

‫ﻧﻤﻮدار‪ :1 -‬ﻣﻴﺎﻧﮕﻴﻦ ﺷﺪت ﺳﺮدرد در زﻣﺎنﻫﺎي ﻣﺨﺘﻠﻒ ﺑﺮ ﺣﺴﺐ ﮔﺮوهﻫﺎي‬

‫ﻧﻤﻮدار‪ :2 -‬ﻣﻴﺎﻧﮕﻴﻦ روزﻫﺎي ﺑﺪون ﺳﺮدرد در ﻃﻮل ﻳﻚﻣﺎه در زﻣﺎنﻫﺎي ﻣﺨﺘﻠﻒ‬

‫ﻣﻮرد ﻣﻄﺎﻟﻌﻪ‬

‫ﺑﺮ ﺣﺴﺐ ﮔﺮوهﻫﺎي ﻣﻮرد ﻣﻄﺎﻟﻌﻪ‬

‫ﺑﺤﺚ‬

‫ﻛﻪ ﭘﺲ از ﺗﺰرﻳﻖ‪ ،‬روزﻫﺎي ﺑﺪون ﺳﺮدرد در ﻫﺮ دو ﮔﺮوه اﻓﺰاﻳﺶ ﻧﺸﺎن‬ ‫داد و اﻳﻦ اﻓﺰاﻳﺶ ﺗﺎ ﭘﺎﻳﺎن ﻣﻄﺎﻟﻌﻪ ﺗﻘﺮﻳﺒﺎً ﺛﺎﺑﺖ ﺑﺎﻗﻲ ﻣﺎﻧﺪ‪ .‬ﻫﺮ ﭼﻨﺪ ﻛﻪ در‬

‫ﺗﻌﺪاد ﺑﻴﻤﺎران ﻣﻮرد ﺑﺮرﺳﻲ در اﻏﻠﺐ ﻣﻄﺎﻟﻌﺎت ﭘﺎﻳﻴﻦ ﻣﻲﺑﺎﺷـﺪ ﻛـﻪ‬

‫اﻏﻠﺐ ﻣﻮارد ﺑﻴﻦ دو ﮔﺮوه اﺧﺘﻼف آﻣﺎري ﻣﻌﻨﻲداري وﺟﻮد ﻧﺪاﺷﺖ اﻣﺎ‬

‫اﻳﻦ اﻣﺮ ﺑﻪدﻟﻴﻞ ﺗﺠﺮﺑﻪ ﻛﻢ اﺳـﺘﻔﺎده از اﻳـﻦ روش درﻣـﺎﻧﻲ اﺳـﺖ‪ .‬اﻟﺒﺘـﻪ‬

‫ﻫﺮ دو ﮔﺮوه اﺛﺮﺑﺨﺸﻲ ﻣﻨﺎﺳﺒﻲ از ﻧﻈﺮ ﻛﺎﻫﺶ ﺷﺪت ﺳﺮدرد و ﻫﻢﭼﻨﻴﻦ‬

‫ﻣﺎﻫﻴﺖ ﺑﻴﻤﺎري ﺑﻪ ﮔﻮﻧﻪاي اﺳﺖ ﻛﻪ درد و رﻧـﺞ ﻓﺮاواﻧـﻲ ﺑـﺮاي ﺑﻴﻤـﺎر‬

‫روزﻫﺎي ﺑﺪون ﺳﺮدرد ﻧﺸﺎن دادﻧﺪ‪.‬‬

‫اﻳﺠﺎد ﻛﺮده و در ﺑﺮﺧﻲ ﻣﻮارد ﻋﻤﻠﻜـﺮد ﻃﺒﻴﻌـﻲ زﻧـﺪﮔﻲ وي را ﻣﺨﺘـﻞ‬

‫در ﻣﻄﺎﻟﻌﻪ ‪ ،Tobin‬ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ اﻧـﻮاع ﻣﺨﺘﻠـﻒ ﺳـﺮدرد ﺗﺤـﺖ‬

‫ﻣﻲﻛﻨﺪ‪ .‬ﻳﺎﻓﺘﻦ راﻫﻲ ﺑﺮاي ﻛﺎﻫﺶ درد ﺑﻴﻤﺎر ﻣﻲﺗﻮاﻧﺪ ﺗـﺎ ﺣـﺪود زﻳـﺎدي‬

‫ﺑﻠﻮك ﻋﺼﺐ اﻛﺴﻲﭘﻴﺘﺎل ﻗﺮار ﮔﺮﻓﺘﻪ ﺑﻮدﻧـﺪ و اﺛﺮﺑﺨـﺸﻲ درﻣـﺎن ﻣـﻮرد‬

‫ﻛﻴﻔﻴﺖ زﻧﺪﮔﻲ وي را ﺑﻬﺒـﻮد ﺑﺨـﺸﺪ‪ .‬در ﻣﻄﺎﻟﻌـﻪ ﺣﺎﺿـﺮ ﺑﻠـﻮك‬

‫‪GON‬‬

‫ﺑﺮرﺳﻲ ﻗﺮار ﮔﺮﻓﺘﻪ ﺑـﻮد‪ 14.‬در اﻳـﻦ ﻣﻄﺎﻟﻌـﻪ ‪ 25‬ﺑﻴﻤـﺎر ﻣﺒـﺘﻼ ﺑـﻪ‬

‫‪MOH‬‬

‫ﺑﻪﻋﻨﻮان ﻳﻚ روش درﻣﺎﻧﻲ ﻣﻮرد ﺑﺮرﺳﻲ ﻗـﺮار ﮔﺮﻓﺘـﻪ اﺳـﺖ و ﺟﻬـﺖ‬

‫ﺷﺮﻛﺖ ﻛﺮدﻧﺪ‪ .‬ﺑﻴﺶﺗﺮﻳﻦ داروي ﻣﻮرد اﺳﺘﻔﺎده اﭘﻴﻮﻳﻴـﺪ و ‪ NSAID‬ﺑـﻮد‬

‫ﺑﺮرﺳﻲ دﻗﻴﻖﺗﺮ داروي ﻣﻮرد اﺳﺘﻔﺎده ﻧﻤﻮﻧﻪﻫـﺎي ﻣـﻮرد ﺑﺮرﺳـﻲ ﺑـﻪ دو‬

‫ﻛﻪ ﺣﺪود ‪ 16‬ﻧﻔﺮ از ‪ 25‬ﻧﻔﺮ از آن اﺳﺘﻔﺎده ﻛﺮدﻧﺪ‪ .‬در ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﻧﻴﺰ‬

‫ﮔﺮوه ﺗﻘﺴﻴﻢ ﺷﺪﻧﺪ‪ .‬اﻟﺒﺘﻪ ﻫـﺮ دو ﮔـﺮوه از داروي ﺑﻮﭘﻴﻮاﻛـﺎﻳﻴﻦ اﺳـﺘﻔﺎده‬

‫ﺑﻴﺶﺗﺮﻳﻦ داروي ﻣﻮرد ﻣﺼﺮف در ﺑﻴﻤﺎران در ﻫﺮ دو ﮔﺮوه ‪ NSAID‬ﺑﻮد‬

‫ﮔﺮدﻳﺪه اﺳﺖ ﺗﺎ ﺑﺘﻮان ﺳﻄﺢ ﻣﻨﺎﺳﺒﻲ از ﻛﺎﻫﺶ ﺳﺮدرد را ﺑﺮاي ﺑﻴﻤـﺎران‬

‫ﻛﻪ ﺑﺎ ﻣﻄﺎﻟﻌﻪ ‪ Tobin‬ﺗﺎ ﺣﺪودي زﻳـﺎدي ﻫـﻢﺧـﻮاﻧﻲ داﺷـﺖ‪ .‬ﻣﻴـﺎﻧﮕﻴﻦ‬

‫ﻓﺮاﻫﻢ ﻧﻤﻮد‪ .‬در ﺑﺮرﺳﻲ دادهﻫﺎ ﻣﺸﺨﺺ ﮔﺮدﻳـﺪ ﻛـﻪ در ﻫـﺮ دو ﮔـﺮوه‬

‫ﻛﺎﻫﺶ ﺳﺮدرد در اﻳﻦ ﺑﻴﻤﺎران ‪ %71‬و ﻣﻴﺎﻧﮕﻴﻦ زﻣﺎن اﺛﺮﺑﺨﺸﻲ ‪ 5/5‬ﻫﻔﺘﻪ‬

‫ﻛﺎﻫﺶ درد واﺿﺤﻲ ﻳﻚ ﺳﺎﻋﺖ ﭘﺲ از ﺗﺰرﻳﻖ اﻳﺠﺎد ﮔﺮدﻳﺪ ﺑﻪ ﮔﻮﻧﻪاي‬

‫ﺑﻮد ﻛﻪ ﺑﺎ ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ در ﮔﺮوه ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ‪ +‬ﺳﺎﻟﻴﻦ ﻛﻪ ﻛـﺎﻫﺶ‬

‫ﻛﻪ ﺷﺪت ﺳﺮدرد ﻳﻚﺳـﺎﻋﺖ ﭘـﺲ از ﺗﺰرﻳـﻖ در ﮔـﺮوه ﺑﻮﭘﻴﻮاﻛـﺎﻳﻴﻦ‪+‬‬

‫ﺷﺪت ﺳﺮدرد ﺣﺪود ‪ 70‬درﺻـﺪ در ﻳـﻚﺳـﺎﻋﺖ ﭘـﺲ از ﺗﺰرﻳـﻖ ﺑـﻮد‬

‫ﺳﺎﻟﻴﻦ ‪ 70‬درﺻﺪ و در ﮔﺮوه ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ‪ +‬ﭘﺮدﻧﻴﺰوﻟـﻮن ‪ 59/74‬درﺻـﺪ‬

‫ﻫﻢﺧﻮاﻧﻲ داﺷﺖ‪ .‬در ﻣﻄﺎﻟﻌﻪ ‪ ،Afridi‬ﺑﻴﻤﺎراﻧﻲ ﻛـﻪ ﺣـﺪاﻗﻞ ‪ 15‬روز در‬ ‫‪19‬‬

‫ﻧﺴﺒﺖ ﺑﻪ ﻗﺒﻞ از ﺗﺰرﻳﻖ ﻛﺎﻫﺶ ﻳﺎﻓﺖ‪ .‬ﺗﺎﺛﻴﺮ ﺗﺰرﻳﻖ روي ﺷﺪت ﺳـﺮدرد‬

‫ﻣﺎه دﭼﺎر ﺳﺮدرد ﺑﻮدﻧﺪ وارد ﻣﻄﺎﻟﻌـﻪ ﺷـﺪﻧﺪ‪ .‬اﻟﺒﺘـﻪ از ﻟﻴـﺪوﻛﺎﻳﻴﻦ ‪%2‬‬

‫در ﻫﻔﺘﻪ اول ﻣﺎﻛﺰﻳﻤﻢ ﺑﻮده و ﺳﭙﺲ ﺑﻪﺗﺪرﻳﺞ ﻛﻢﺗﺮ ﻣﻲﺷـﺪ‪ .‬ﭘـﺲ از آن‬

‫ﻫﻤﺮاه ﺑﺎ ﻣﺘﻴﻞ ﭘﺮدﻧﻴﺰوﻟﻮن اﺳﺘﻔﺎده ﺷﺪه ﺑﻮد ﻛﻪ ﻣﻴﺎﻧﮕﻴﻦ ﭘﺎﺳﺦدﻫﻲ ﻧﺴﺒﻲ‬

‫ﺷﺪت ﺳﺮدرد ﺑﻴﻤﺎر ﺑﻪﺗﺪرﻳﺞ ﺗﺎ ﭘﺎﻳﺎن ﻣﻄﺎﻟﻌﻪ )ﺳﻪ ﻣـﺎه ﭘـﺲ از ﺗﺰرﻳـﻖ(‬

‫ﺣﺪود ‪ 45‬روز را ﻧﺸﺎن داد‪ .‬در ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﻣﻴﺎﻧﮕﻴﻦ روزﻫـﺎي ﺑـﺪون‬

‫ﺑﻪﺻﻮرت ﺗﺪرﻳﺠﻲ اﻓﺰاﻳﺶ ﻳﺎﻓﺘﻪ ﺑﻪ ﮔﻮﻧﻪاي ﻛﻪ ﺷﺪت آن ﺑﻪ ‪ 85‬درﺻﺪ‬

‫ﺳﺮدرد ﺣﺘﻲ ﺳﻪ ﻣﺎه ﭘﺲ از درﻣﺎن در ﮔﺮوهﻫـﺎي ﻣـﻮرد ﻣﻄﺎﻟﻌـﻪ ﺑـﺎﻻي‬

‫)‪ 6/63‬در ﻣﻘﺎﺑﻞ ‪ (7/75‬در ﮔﺮوه ﻣﺘﻴﻞ ﭘﺮدﻧﻴﺰوﻟﻮن و ‪ 81‬درﺻـﺪ ﻣﻘـﺪار‬

‫‪ 10‬روز ﺑﻮد ﻛﻪ ﺗﻔﺎوت زﻳﺎدي ﺑﺎ ﻣﻄﺎﻟﻌـﺎت ﻣـﺸﺎﺑﻪ داﺷـﺖ‪ .‬در ﻣﻄﺎﻟﻌـﻪ‬

‫اوﻟﻴﻪ )‪ 6/44‬در ﻣﻘﺎﺑﻞ ‪ (7/94‬در ﮔﺮوه ﺳﺎﻟﻴﻦ رﺳﻴﺪ‪ .‬ﻳﺎﻓﺘﻪﻫـﺎ ﻧـﺸﺎن داد‬

‫‪ ،Ashkenazi‬ﻣﻴــﺎﻧﮕﻴﻦ زﻣــﺎن ﺑــﺪون ﺳــﺮدرد ‪ 2/7±3/8‬روز در ﮔــﺮوه‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):308-13‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫و ﻫﻤﻜﺎران‬Khatir ‫ﻋﻠﻴﺰاده ﺧﻄﻴﺮ‬ ‫ﻋﻠﻲ‬ Alizade A. et al.

312

‫ ﺑــﻪﺟــﺎي‬GON ‫ اﺳــﺘﻔﺎده از ﺑﻠــﻮك‬،‫ﺑــﺮاي درﻣــﺎن زودﻫﻨﮕــﺎم ﺑﻴﻤــﺎران‬

‫ در ﺣﺎﻟﻲﻛﻪ در اﻳﻦ ﻣﻄﺎﻟﻌﻪ اﻳـﻦ ﻣﻘـﺪار‬13.‫درﻳﺎﻓﺖﻛﻨﻨﺪه ﺑﻮﭘﻴﻮاﻛﺎﻳﻴﻦ ﺑﻮد‬

‫ )ﺑﻌـﺪ از ﻗﻄـﻊ‬MOH ‫ﻛﻮرﺗﻴﻜﻮاﺳﺘﺮوﻳﻴﺪ ﺧﻮراﻛﻲ در درﻣﺎن ﻣﺮﺣﻠﻪ ﺣﺎد‬

.‫ روز در ﻣﺎه ﺑﻮد‬15 ‫ﺑﻴﺶﺗﺮ از‬

‫ ﺑـﻪﻧﻈـﺮ‬.‫(( ﭘﻴﺸﻨﻬﺎد ﻣـﻲ ﺷـﻮد‬Overuse) ‫داروﻫﺎي ﻣﺼﺮف ﺑﻴﺶ از ﺣﺪ‬

%66 ‫ ﻛﺎﻫﺶ ﺷﺪت ﺳـﺮدرد ﺑـﺎ ﻫـﺮ ﻣﻴﺰاﻧـﻲ در‬،Tobin ‫در ﻣﻄﺎﻟﻌﻪ‬

‫ ﻧـﺴﺒﺖ ﺑـﻪ ﻣـﺼﺮف ﻛﻮرﺗﻴﻜﻮاﺳـﺘﺮوﻳﻴﺪ‬GON ‫ﻣﻲرﺳﺪ ﻋﻮارض ﺑﻠـﻮك‬

‫اﻓﺮاد دﻳﺪه ﺷﺪ وﻟﻲ در ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﺟﺰ ﻳـﻚ ﻣـﻮرد در ﺗﻤـﺎم ﻣـﻮارد‬

‫ﺧﻮراﻛﻲ )ﺑﻪﺧﺼﻮص در ﺑﻴﻤﺎران دﻳﺎﺑﺘﻲ و ﻓﺸﺎر ﺧﻮن( ﻛﻢﺗـﺮ اﺳـﺖ و‬

‫ ﻣﻴــﺰان‬،‫ در اﻳــﻦ ﻣﻄﺎﻟﻌــﻪ‬14.(%97) ‫ﻛ ـﺎﻫﺶ ﺳــﺮدرد ﻣــﺸﺎﻫﺪه ﮔﺮدﻳــﺪ‬

‫ﻣﻲﺗﻮان از اﻳﻦ روش ﺗﺎ زﻣـﺎﻧﻲ ﻛـﻪ اﺛـﺮ داروﻫـﺎي ﭘﺮوﻓﻴﻼﻛـﺴﻲ ﺑـﺮاي‬

‫ﭘﺎﺳﺦدﻫﻲ ﺑﺎﻻﻳﻲ در دو ﮔﺮوه ﻣﻮرد ﻣﻄﺎﻟﻌﻪ ﻣﺸﺎﻫﺪه ﮔﺮدﻳﺪ و اﻳﻦ ﭘﺎﺳﺦ‬

‫ ﭘﻴﺸﻨﻬﺎد ﻣﻲﮔﺮدد ﺑـﺎ ﻛـﺎﻫﺶ اﺛـﺮ‬.‫ آﻏﺎز ﮔﺮدد اﺳﺘﻔﺎده ﻧﻤﻮد‬MOH ‫درﻣﺎن‬

‫ در‬.‫ﺗﺎ ﭘﺎﻳﺎن زﻣﺎن ﭘﻲﮔﻴﺮي )ﺳﻪ ﻣﺎه( ﺗﺎ ﺣـﺪ ﻗﺎﺑـﻞ ﻗﺒـﻮﻟﻲ ﭘﺎﺑﺮﺟـﺎ ﺑـﻮد‬

‫ﺑﻠﻮك ﭘﺲ از ﭼﻨﺪ ﻫﻔﺘﻪ در ﺗﺤﻘﻴﻖ دﻳﮕﺮي اﺛﺮﺑﺨﺸﻲ ﺑﻠﻮك ﻣﺠﺪد را در‬

‫ ﭘﺎﺳﺦدﻫﻲ ﭘـﺎﻳﻴﻨﻲ‬MOH ‫ ﺑﻴﺎن ﮔﺮدﻳﺪه اﺳﺖ ﻛﻪ ﺑﻴﻤﺎران‬،Grazzi ‫ﻣﻄﺎﻟﻌﻪ‬

.‫ﻛﺎﻫﺶ ﻣﻴﺰان ﺳﺮدرد ﻣﻮرد ﺑﺮرﺳﻲ ﻗﺮار داد‬

.‫ دارﻧﺪ ﻛﻪ ﻧﺘﻴﺠﻪ ﺑﺎ ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﺗﻔﺎوت داﺷﺖ‬GON ‫ﻧﺴﺒﺖ ﺑﻪ ﺑﻠﻮك‬

‫ اﻳﻦ ﻣﻘﺎﻟﻪ ﺣﺎﺻﻞ ﭘﺎﻳﺎنﻧﺎﻣﻪ ﺗﺤﺖ ﻋﻨﻮان "ﺑﺮرﺳﻲ اﺛـﺮ‬:‫ﺳﭙﺎﺳﮕﺰاري‬

‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻧﺘﺎﻳﺞ ﺑﻪدﺳﺖآﻣﺪه از اﻳﻦ ﻣﻄﺎﻟﻌـﻪ و ﺳـﺎﻳﺮ ﻣﻄﺎﻟﻌـﺎت اﻧﺠـﺎم‬

‫ ﻣﺘﻴـﻞ ﭘﺮدﻧﻴﺰوﻟـﻮن در‬/‫ﺑﻠﻮك ﻋﺼﺐ ﭘﺲ ﺳﺮي ﺑﺰرگ ﺑـﺎ ﺑﻮﭘﻴﻮاﻛـﺎﻳﻴﻦ‬

‫ ﺑﻪﻧﻈﺮ ﻣﻲرﺳـﺪ اﺳـﺘﻔﺎده از ﻫـﺮ دو روش ﻧﺘـﺎﻳﺞ ﻳﻜـﺴﺎن و اﻟﺒﺘـﻪ‬،‫ﺷﺪه‬

"Medication Overuse Headache ‫ ﺳـﺎﻟﻴﻦ در‬/‫ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﺑﻮﭘﻴﻮاﻛـﺎﻳﻴﻦ‬

‫ اﻳﻦ ﻧﻜﺘﻪ ﺑـﻪﺧـﺼﻮص در ﻣـﻮرد‬.‫ دارد‬MOH ‫ﻣﻮﺛﺮي در درﻣﺎن ﺑﻴﻤﺎري‬

412 ‫ و ﻛـﺪ‬1390 ‫در ﻣﻘﻄﻊ دﻛﺘﺮاي ﺗﺨﺼﺼﻲ داﺧﻠﻲ اﻋﺼﺎب در ﺳﺎل‬

‫اﻳﻦ ﻧﻮع از ﺳﺮدردﻫﺎ ﻛﻪ ﻣﻘـﺎوم ﺑـﻪ درﻣـﺎن ﺑـﻮده و ﺑﺎﻋـﺚ اﺧـﺘﻼل در‬

‫ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺎ ﺣﻤﺎﻳﺖ داﻧـﺸﮕﺎه ﻋﻠـﻮم ﭘﺰﺷـﻜﻲ و ﺧـﺪﻣﺎت ﺑﻬﺪاﺷـﺘﻲ‬

‫ اﻧﺠـﺎم‬.‫زﻧﺪﮔﻲ روزﻣﺮه ﺑﻴﻤﺎران ﻣﻲﮔﺮدد ﺑﺴﻴﺎر ﺣﺎﻳﺰ اﻫﻤﻴـﺖ ﻣـﻲﺑﺎﺷـﺪ‬

.‫درﻣﺎﻧﻲ ﺗﻬﺮان اﺟﺮا ﺷﺪه اﺳﺖ‬

‫ اﺳﺘﻔﺎده از ﻧﺘﺎﻳـﺞ ﺗﺤﻘﻴﻖ‬،‫ﻣﻄﺎﻟﻌﺎت دﻗﻴـﻖﺗﺮ ﺑﺎ ﺗﻌﺪاد ﻧﻤﻮﻧﻪﻫﺎي ﺑﻴـﺶﺗﺮ‬

References 1. Silberstein SD, Olesen J, Bousser MG, Diener HC, Dodick D, First M, et al. The International Classification of Headache Disorders, 2nd Edition (ICHD-II): revision of criteria for 8.2 Medication-overuse headache. Cephalalgia 2005;25(6):460-5. 2. Bradley WG, Daroff RB, Fenichel GM, Jankovic J, editors. Bradley: Neurology in Clinical Practice. 5th ed. Philadlephia, Pa: Butterworth Heinemann Elsevier; 2010. p. 2011-63. 3. Leinisch-Dahlke E, Jürgens T, Bogdahn U, Jakob W, May A. Greater occipital nerve block is ineffective in chronic tension type headache. Cephalalgia 2005;25(9):704-8. 4. Katsarava Z, Fritsche G, Muessig M, Diener HC, Limmroth V. Clinical features of withdrawal headache following overuse of triptans and other headache drugs. Neurology 2001;57(9):16948. 5. Scher AI, Stewart WF, Ricci JA, Lipton RB. Factors associated with the onset and remission of chronic daily headache in a population-based study. Pain 2003;106(1-2):81-9. 6. Silberstein S, Lipton R, Dodick D, Freitag F, Mathew N, Brandes J, et al. Topiramate treatment of chronic migraine: a randomized, placebo-controlled trial of quality of life and other efficacy measures. Headache 2009;49(8):1153-62. 7. Colás R, Muñoz P, Temprano R, Gómez C, Pascual J. Chronic daily headache with analgesic overuse: epidemiology and impact on quality of life. Neurology 2004;62(8):1338-42. 8. Katsarava Z, Muessig M, Dzagnidze A, Fritsche G, Diener HC, Limmroth V. Medication overuse headache: rates and predictors for relapse in a 4-year prospective study. Cephalalgia 2005;25(1):12-5. 9. Fumal A, Laureys S, Di Clemente L, Boly M, Bohotin V, Vandenheede M, et al. Orbitofrontal cortex involvement in chronic analgesic-overuse headache evolving from episodic migraine. Brain 2006;129(Pt 2):543-50.

10. Pini LA, Cicero AF, Sandrini M. Long-term follow-up of patients treated for chronic headache with analgesic overuse. Cephalalgia 2001;21(9):878-83. 11. Pageler L, Katsarava Z, Diener HC, Limmroth V. Prednisone vs. placebo in withdrawal therapy following medication overuse headache. Cephalalgia 2008;28(2):152-6. 12. Mathew NT, Frishberg BM, Gawel M, Dimitrova R, Gibson J, Turkel C; BOTOX CDH Study Group. Botulinum toxin type A (BOTOX) for the prophylactic treatment of chronic daily headache: a randomized, double-blind, placebo-controlled trial. Headache 2005;45(4):293-307. 13. Ashkenazi A, Matro R, Shaw JW, Abbas MA, Silberstein SD. Greater occipital nerve block using local anaesthetics alone or with triamcinolone for transformed migraine: a randomised comparative study. J Neurol Neurosurg Psychiatry 2008;79(4):415-7. 14. Tobin JA, Flitman SS. Occipital nerve blocks: effect of symptomatic medication: overuse and headache type on failure rate. Headache 2009;49(10):1479-85. 15. Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics 2010;7(2):197-203. 16. Shields KG, Levy MJ, Goadsby PJ. Alopecia and cutaneous atrophy after greater occipital nerve infiltration with corticosteroid. Neurology 2004;63(11):2193-4. 17. Lavin PJ, Workman R. Cushing syndrome induced by serial occipital nerve blocks containing corticosteroids. Headache 2001;41(9):902-4. 18. Young WB, Marmura M, Ashkenazi A, Evans RW. Expert opinion: greater occipital nerve and other anesthetic injections for primary headache disorders. Headache 2008;48(7):1122-5. 19. Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection in primary headache syndromes: prolonged effects from a single injection. Pain 2006;122(1-2):126-9. 20. Grazzi L, Andrasik F, Usai S, Bussone G. Headache with medication overuse: treatment strategies and proposals of relapse prevention. Neurol Sci 2008;29(2):93-8.

313 ‫ ﺗﺎ‬308 ،5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

313

‫ﻛﺎراﻳﻲ دو روش ﭘﺎﻳﺶ ﺑﺮاي ﺗﺸﺨﻴﺺ ﻋﻔﻮﻧﺖ ﻣﺤﻞ ﺟﺮاﺣﻲ در ﺑﺨﺸﻬﺎي ﺟﺮاﺣﻲ ﻋﻤﻮﻣﻲ‬

Tehran University Medical Journal, August 2012; Vol. 70, No. 5: 308-313

Original Article

Greater occipital nerve block by bupivacaine/methyl prednisolone vs. bupivacaine/normal saline in medication overuse headache Abstract

Received: April 15, 2012 Accepted: May 16, 2012

Ali Alizade Khatir M.D. Mehdi Panahkhahi M.D.2 Alireza Khage Nasiri M.D.3 Tayeb Ramim M.D.4 Mansoureh Toghae M.D.1,5* 1- Department of Neurology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. 2- Department of Anesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. 3- Department of Anesthesiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. 4- Researcher, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran. 5- Department of Neurology, Iranian Center of Neurological Research, Tehran University of Medical Sciences, Tehran, Iran.

Background: Medication overuse headaches (MOH) include headaches that last more than 15 days a month and usually occur after long-term use of analgesic. Most methods of medical treatment are ineffective. In some studies, great occipital nerve block is used to treat the headaches. Methods: This double-blind experimental study was performed in adult patients with MOH who attended Sina Hospital in Tehran from June 2009 to June 2011. Greater

occipital nerve (GON) block was done in the two groups of patients by administering a combination of 3 ml of 0.5% bupivacaine and 2 ml of 5% saline or 3 ml of 0.5% bupivacaine and 80 mg of methyl prednisolone. We evaluated headache severity by Visual analog scale (VAS) and recorded days without headache. If patients were taking pain medications, preventive medications were given as usual before and after the injection. Student’s t-test was performed for statistical analysis and a P<0.05 was considered significant. Results: Overall, 13 male and 19 female patients with a mean age of 39.88±8.76 years participated in the study. The mean reduction in headache severity one hour after injection was 5.56±1.03 and 4.63±1.92 in the first and second groups, respectively. Average days without headache one month after injection were 8.75 and 4.75 days in the first and second groups, respectively. There were no significant differences between the two groups. Conclusion: Both methods seem to be effective in medication overuse headaches

Corresponding author: Dept. of Neurology, Sina Hospital, Imam Khomeini Ave., Hassan Abad Sq., Tehran, Iran. Tel: +98-21-66348529 E-mail: toghae@sina.tums.ac.ir

treatment. This finding is important as non-responders to conventional methods will otherwise have a decreased quality of life. Keywords: bupivacaine, greater occipital nerve, medication overuse headaches, nerve block.

Tehran Univ Med J (TUMJ) 2012 August;70(5):308-13

http://tumj.tums.ac.ir

‫ﻣﺤﻤﺪ رﻫﺒﺮ و ﻫﻤﻜﺎران‬

‫‪314‬‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ ،5‬ﺻﻔﺤﻪﻫﺎي ‪ 314‬ﺗﺎ ‪319‬‬

‫ﻣﻘﺎﻟﻪ اﺻﻴﻞ‬

‫ﻧﺘﺎﻳﺞ درﻣﺎن دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧﻮ در ‪ 29‬ﺑﻴﻤﺎر ﻣﺮاﺟﻌﻪﻛﻨﻨﺪه‬ ‫ﺑﻪ ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻔﺎﻳﺤﻴﺎﻳﻴﺎن ﺗﻬﺮان در ﻣﺪت ‪ 40‬ﺳﺎل‬

‫ﭼﻜﻴﺪه‬

‫‪1‬‬

‫ﻣﺤﻤﺪ رﻫﺒﺮ‬

‫‪1‬‬

‫ﻣﺤﻤﻮد ﺟﺒﻞ ﻋﺎﻣﻠﻲ‬ ‫ﻧﺎدﻳﺎ آﻗﺎﺟﺎﻧﻲ‬

‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ﻣﻘﺎﻟﻪ‪1390/03/15 :‬‬

‫ﺗﺎرﻳﺦ ﭘﺬﻳﺮش‪1391/03/03 :‬‬

‫زﻣﻴﻨﻪ و ﻫﺪف‪ :‬ﺑﻪﻋﻠﺖ ﻧﺎدر ﺑﻮدن دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧﻮ )‪ Congenital Dislocation of the Knee (CDK‬ﻋﻠﻲرﻏﻢ وﺟﻮد‬

‫‪*2‬‬

‫روشﻫﺎي درﻣﺎﻧﻲ ﻣﺘﻨﻮع‪ ،‬ﺗﻌﺪاد ﻣﻄﺎﻟﻌﺎت اﻧﺠﺎم ﺷﺪه در ﻣﻮرد درﻣﺎن ارﺟﺢ آن اﻧﺪك ﻣﻲﺑﺎﺷﺪ‪ .‬اﻳﻦ ﻣﻘﺎﻟﻪ در واﻗﻊ ﮔﺰارﺷﻲ‬

‫‪2‬‬

‫رﺿﺎ ﺷﻔﻴﻊﭘﻮر‬

‫از ﻧﺘﺎﻳﺞ ﺑﻪدﺳﺖآﻣﺪه ﺗﻮﺳﻂ اﻳﻦ ﻣﺮﻛﺰ در درﻣﺎن اﻳﻦ ﺑﻴﻤﺎري ﻃﻲ ﭼﻬﻞ ﺳﺎل اﺧﻴﺮ ﻣﻲﺑﺎﺷﺪ‪.‬‬

‫‪ -1‬ﮔﺮوه ارﺗﻮﭘﺪي‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪،‬‬

‫روش ﺑﺮرﺳﻲ‪ :‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺗﻮﺻﻴﻔﻲ‪ ،‬ﭘﺮوﻧﺪه ﭘﺰﺷـﻜﻲ ﻛﻠﻴـﻪ ﺑﻴﻤـﺎراﻧﻲ ﻛـﻪ ﻃـﻲ ﺳـﺎلﻫـﺎي ‪ 1349-89‬در ﺑﻴﻤﺎرﺳـﺘﺎن‬

‫ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬

‫ﺷﻔﺎﻳﺤﻴﺎﻳﻴﺎن ﭘﺬﻳﺮش ﺷﺪه ﺑﻮدﻧﺪ‪ ،‬ﻣﻮرد ﺑﺮرﺳﻲ ﻗﺮار ﮔﺮﻓﺖ‪ .‬در ﻧﻬﺎﻳﺖ ‪ 29‬ﺑﻴﻤﺎر ﺑﺎ ‪ 54‬دررﻓﺘﮕﻲ زاﻧﻮ ﺗﺤﺖ ﻣﻄﺎﻟﻌـﻪ ﻗـﺮار‬

‫‪ -2‬ﮔﺮوه ارﺗﻮﭘﺪي‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪،‬‬

‫ﮔﺮﻓﺘﻨﺪ‪ .‬ﻓﺮم ﺟﻤﻊآوري اﻃﻼﻋﺎت‪ ،‬ﺷﺎﻣﻞ دادهﻫﺎي ﻣﺮﺑﻮط ﺑﻪ ﻣﻴﺰان ﺧﻢ ﺷـﺪن )‪ ،(Flexion‬ﻛﻨﺘﺮاﻛﭽـﺮ‪ ،‬ﻟـﻨﮕﺶ‪ ،‬ﻧﺎﭘﺎﻳـﺪاري‬

‫ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻔﺎﻳﺤﻴﺎﻳﻴﺎن‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬

‫)‪ (Instability‬و ﻋﻮارض ﭘﺲ از ﻋﻤﻞ ﺟﺮاﺣﻲ و درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ‪ ،‬ﺑﺮاي ﻫﺮ ﺑﻴﻤﺎر ﻛﺎﻣﻞ ﺷﺪ‪.‬‬ ‫ﻳﺎﻓﺘﻪﻫﺎ‪ :‬از ‪ 54‬زاﻧﻮي ﻣﻄﺎﻟﻌﻪﺷﺪه ‪ %42‬ﺑﺎ درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ درﻣﺎن ﺷﺪﻧﺪ و ‪ %58‬ﺗﺤﺖ ﻋﻤﻞ ﺟﺮاﺣﻲ ﻗﺮار ﮔﺮﻓﺘﻨﺪ‪ .‬ﻣﺤﺪوده‬ ‫ﺣﺮﻛﺘﻲ ﺑﻪدﺳﺖآﻣﺪه در درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ و ﺟﺮاﺣﻲ ﺑـﺎ ﺳـﺎﻳﺮ ﻣﻄﺎﻟﻌـﺎت ﻗﺎﺑـﻞ ﻣﻘﺎﻳـﺴﻪ ﺑـﻮد‪ .‬ﺑﺮرﺳـﻲ ﻣﻴـﺰان ﺧـﻢ ﺷـﺪن‬ ‫)‪ ،(Flexion‬ﻛﻨﺘﺮاﻛﭽﺮ‪ ،‬ﻟﻨﮕﺶ‪ ،‬ﻧﺎﭘﺎﻳﺪاري )‪ (Instability‬و ﻋﻮارض ﭘﺲ از ﻋﻤﻞ ﺟﺮاﺣﻲ و درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ اﻧﺠﺎم ﺷـﺪه ﺑـﺎ‬ ‫ﻧﺘﺎﻳﺞ رﺿﺎﻳﺖﺑﺨﺶ ﻫﻤﺮاه ﺑﻮد‪ .‬ﻫﻢﭼﻨﻴﻦ در ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﺗﺤﺖ ﻋﻤﻞ ﺟﺮاﺣﻲ ﻃﻮﻳﻞﺳﺎزي ﺗﺎﻧﺪون ﭼﻬﺎر ﺳﺮ راﻧﻲ ﻫﻤﺮاه ﺑﺎ‬ ‫ﻓﻴﻜﺲ ﻛﺮدن ﻣﻔﺼﻞ زاﻧﻮ ﺑﺎ ﭘﻴﻦ ﺑﺮاي ‪ 2-3‬ﻫﻔﺘﻪ ﻗﺮار ﮔﺮﻓﺘﻪ ﺑﻮدﻧﺪ ﻧﺘﺎﻳﺞ اﻣﻴﺪوارﻛﻨﻨﺪه ﺑﻮد‪.‬‬ ‫ﻧﺘﻴﺠﻪﮔﻴﺮي‪ :‬ﻛﻠﻴﻪ ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧﻮ در ﻫﺮ ﺳﻨﻲ ﻛﻪ ﻣﺮاﺟﻌﻪ ﻛﻨﻨﺪ‪ ،‬اﺑﺘﺪا ﺗﺤﺖ درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ ﻗﺮار‬

‫*‬

‫ﮔﻴﺮﻧﺪ و در ﺻﻮرت ﻋﺪم ﭘﺎﺳﺦ درﻣﺎﻧﻲ‪ ،‬ﺟﺮاﺣﻲ ﺷﻮﻧﺪ‪ .‬ﻧﺘﺎﻳﺞ ﻋﻤﻠﻜﺮد زاﻧﻮ در درﻣﺎن ﻣﺤـﺎﻓﻈﺘﻲ ﻗﺎﺑـﻞ ﻗﺒـﻮل ﺑـﻮده و ﺑـﺎ‬ ‫ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪ :‬ﺗﻬﺮان‪ ،‬ﻣﻴﺪان ﺑﻬﺎرﺳﺘﺎن‪ ،‬ﺧﻴﺎﺑﺎن‬

‫ﻣﺠﺎﻫﺪﻳﻦ اﺳﻼم‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻔﺎ ﻳﺤﺎﻳﻴﺎن‬

‫ﻋﻮارض ﻛﻢﺗﺮي ﻫﻤﺮاه اﺳﺖ‪.‬‬

‫ﺗﻠﻔﻦ‪0911-1935709 :‬‬ ‫‪E-mail: nadiaaqajani@yahoo.com‬‬

‫ﻛﻠﻤﺎت ﻛﻠﻴﺪي‪ :‬دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧﻮ‪ ،‬دررﻓﺘﮕﻲ‪ ،‬زاﻧﻮ‪.CDK ،‬‬

‫ﺑﻴﻤﺎران دررﻓﺘﮕﻲ دوﻃﺮﻓﻪ دارﻧﺪ‪ 2.‬ﻋﻠﺖ آن ﻧﺎﺷﻨﺎﺧﺘﻪ اﺳﺖ‪ .‬ﺗﺌﻮريﻫـﺎي‬

‫ﻣﻘﺪﻣﻪ‬

‫ﻣﺨﺘﻠﻔﻲ ﺑﺮاي آن ﻋﻨﻮان ﺷـﺪه اﺳـﺖ ﻣﺜـﻞ آﺳـﻴﺐ زاﻳﻤـﺎﻧﻲ‪ ،‬ﻣﻮﻗﻌﻴـﺖ‬ ‫‪Congenital Dislocation of the Knee‬‬

‫ﻏﻴﺮﻃﺒﻴﻌﻲ ﺟﻨﻴﻦ در داﺧﻞ رﺣﻢ‪ ،‬اﻓـﺰاﻳﺶ ﻓـﺸﺎر داﺧـﻞ رﺣـﻢ واﻟﻴﮕـﻮ‬

‫)‪ (CDK‬ﺑﻴﻤﺎري ﻧﺎدري اﺳﺖ ﻛﻪ اوﻟﻴﻦﺑﺎر در ﺳﺎل ‪ 1822‬ﺗﻮﺳﻂ ﭘﺰﺷـﻚ‬

‫ﻫﻴﺪرآﻣﻨﻴﻮس‪ ،‬ﻋـﺪم وﺟـﻮد ﻳـﺎ ﺗﻜﺎﻣـﻞ ﻧﻴـﺎﻓﺘﻦ رﺑـﺎط ﺻـﻠﻴﺒﻲ ﻗـﺪاﻣﻲ‬

‫ﺳﻮﻳﻴﺴﻲ‪ ،‬آﻗﺎي ‪ Chatelaine‬ﺗﻮﺻﻴﻒ ﺷﺪ‪ .‬ﺑـﺮوز آن از ﺣـﺪود ‪ %17‬ﺗـﺎ‬

‫)‪ ،Anterior Cruciate Ligament (ACL‬ﺟﻤﻊﺷﺪﮔﻲ ﻋـﻀﻠﻪ ﭼﻬـﺎر ﺳـﺮ‬

‫‪ %7‬در ‪ 1000‬ﺗﻮﻟﺪ ﮔﺰارش ﺷﺪه اﺳﺖ‪ 1،‬در زﻧﺎن ‪ 2-3‬ﺑﺮاﺑﺮ ﻣﺮدان دﻳﺪه‬

‫راﻧــﻲ و وراﺛــﺖ‪4.‬و‪ 3‬ﺷــﺎﻳﻊﺗــﺮﻳﻦ ﻧﺎﻫﻨﺠــﺎري ﻫﻤــﺮاه ﺑــﺎ آن دررﻓﺘﮕــﻲ‬

‫ﻣﻲﺷﻮد‪ .‬در اﻧﺪام ﭼﭗ و راﺳﺖ ﺑﻪﺻﻮرت ﻣﺴﺎوي دﻳﺪه ﻣﻲﺷﻮد و ‪1/3‬‬

‫ﻣـﺎدرزادي ﻟﮕﻦ )‪ Developmental Dysplasia of the Hip (DDH‬اﺳﺖ‬

‫دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧـﻮ‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ 314 ،5‬ﺗﺎ ‪319‬‬

‫ﻧﺘﺎﻳﺞ درﻣﺎن دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧﻮ در ‪ 29‬ﺑﻴﻤﺎر‬

‫‪315‬‬

‫ﺷﻜﻞ‪ :1 -‬ﺗﻘﺴﻴﻢﺑﻨﺪي اﻧﻮاع دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧﻮ‬

‫ﻛﻪ در ‪ %45‬ﻣﻮارد دﻳﺪه ﻣﻲﺷﻮد‪ .‬ﻧﺎﻫﻨﺠﺎري ﻣﺎدرزادي ﭘﺎ ﻛﻪ ﺷـﺎﻳﻊﺗـﺮﻳﻦ‬

‫ﺷﻜﻞ‪ :2 -‬دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧﻮ‬

‫آن ﭘﺎي ﭼﻨﺒﺮي )‪ (Club foot‬اﺳﺖ در ‪ %31‬ﻣﻮارد و دررﻓﺘﮕﻲ ﻣﺎدرزادي‬ ‫آرﻧﺞ در ‪ %10‬ﻣﻮارد دﻳﺪه ﻣﻲﺷﻮد‪6.‬و‪ 5‬دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧـﻮ اﻏﻠـﺐ‬ ‫ﺑﺎ ﺳﻨﺪرمﻫﺎﻳﻲ ﻣﺜﻞ آرﺗﺮوﮔﺮﻳﭙﻮز و ﺳﻨﺪرم ﻻرﺳﻦ ﻫﻤﺮاﻫﻲ دارد و ﻧـﻮع‬ ‫‪8‬و‪7‬‬

‫دوﻃﺮﻓﻪ ﺑﻪﻃﻮر ﺗﻘﺮﻳﺒﻲ ﻫﻤﻴﺸﻪ ﺳﻨﺪرﻣﻴﻚ اﺳﺖ‪.‬‬

‫‪2‬‬

‫اﻳﻦ ﺑﻴﻤﺎري ﺑﻪ ﺳﻪ دﺳﺘﻪ )‪ (Grade‬ﺗﻘﺴﻴﻢ ﻣﻲﺷﻮد )ﺷﻜﻞ‪:(1 -‬‬ ‫‪I‬‬

‫‪ Grade‬ﻳــﺎ ‪ :Congenital hyperextension of the knee‬زاﻧــﻮ در‬

‫ﻫﻴﭙﺮاﻛﺴﺘﺎﻧﺴﻴﻮن ‪ 15-20‬ﻗﺮار دارد و ﻣﻲﺗﻮاﻧﺪ ﺑﻪﺻـﻮرت ﻏﻴـﺮ ﻓﻌـﺎل‬ ‫‪ 45-90‬ﺧﻢ ﺷﻮد‪.‬‬ ‫‪ Grade II‬ﻳﺎ ‪ :Congenital subluxation of the knee‬زاﻧﻮ در ‪25-45‬‬ ‫ﻫﻴﭙﺮاﻛﺴﺘﺎﻧﺴﻴﻮن ﻗﺮار دارد و ﻗﺎدر ﺑـﻪ ﺧـﻢ ﺷـﺪن ﺗـﺎ ﭘﻮزﻳـﺸﻦ ﻧـﻮﺗﺮال‬ ‫)ﺻﻔﺮ درﺟﻪ( ﻣﻲﺑﺎﺷﺪ‪ .‬ﻣﻘﺪاري ﺗﻤﺎس ﺑﻴﻦ ﺳﻄﺢ ﻣﻔﺼﻠﻲ ﺗﻴﺒﻴﺎ و ﻓﻤـﻮر‬ ‫وﺟﻮد دارد‪.‬‬

‫ﺷﻜﻞ‪ :3 -‬روش ﺟﺮاﺣﻲ ‪ Quadricepsplasty‬ﺑﺎ ﺗﻜﻨﻴﻚ ‪ Fisher‬و‬

‫‪Curtis‬‬

‫‪ Grade III‬ﻳـﺎ ‪ :Congenital dislocation of the knee‬دررﻓﺘﮕـﻲ ﻛﺎﻣـﻞ‬ ‫ﺳﻄﺢ ﻣﻔﺼﻠﻲ وﺟﻮد دارد و ﺑﻴﻦ ﺳﻄﺢ ﻣﻔـﺼﻠﻲ ﺗﻴﺒﻴـﺎ و ﻓﻤـﻮر ﺗﻤﺎﺳـﻲ‬ ‫وﺟﻮد ﻧﺪارد‪ ،‬ﺧﻢ ﻛﺮدن زاﻧﻮﻫﺎ ﻣﻤﻜﻦ ﻧﻤـﻲﺑﺎﺷـﺪ‪ 2.‬در ﺣﺎﻟـﺖ ﻇـﺎﻫﺮي‬ ‫زاﻧﻮﻫﺎ در وﺿﻌﻴﺖ ﻫﻴﭙﺮاﻛﺴﺘﺎﻧﺴﻴﻮن ﻗﺮار دارﻧﺪ و ﻣﺤﺪودﻳﺖ ﺧﻢ ﺷﺪن‬

‫ﭘﺎﺗﻼ ﺑﻪﺳﻤﺖ ﻟﺘﺮال وﺟﻮد داﺷـﺘﻪ ﺑﺎﺷـﺪ‪ .‬ﻣﺎﻫﻴﭽـﻪﻫـﺎي ﻫﻤـﺴﺘﺮﻳﻨﮓ و‬

‫زاﻧﻮﻫﺎ وﺟﻮد دارد )ﺷﻜﻞ‪ .(2 -‬ﭘـﺎﺗﻼ اﻏﻠـﺐ ﻛﻮﭼـﻚ و ﺗﻜﺎﻣـﻞ ﻧﻴﺎﻓﺘـﻪ‬

‫ﻟﻴﮕﺎﻣﺎنﻫﺎي ﻛﻮﻟﺘﺮال از ﭼﺴﺒﻨﺪﮔﻲ ﻓﻤﻮرال ﺧﻮد ﺑﻪﺳﻤﺖ ﺟﻠﻮ ﺣﺮﻛـﺖ‬

‫‪9‬و‪8‬‬

‫اﺳﺖ و ﺷﻜﻞ ﻛﻮﻧﺪﻳﻞﻫﺎي ﻓﻤﻮر ﺑﻪﺻﻮرت ﮔﺮد ﺷﺪه ﻣﻲﺑﺎﺷﺪ‪.‬‬

‫ﻣﻬﻢﺗﺮﻳﻦ ﻳﺎﻓﺘﻪ ﭘﺎﺗﻮﻟﻮژﻳﻚ در اﻳﻦ ﺑﻴﻤﺎري ﺟﻤـﻊﺷـﺪﮔﻲ ﻣﻜﺎﻧﻴـﺴﻢ‬

‫ﻛﺮدهاﻧﺪ و ﺑﻪﻋﻨﻮان اﻛﺴﺘﺎﻧـﺴﻮر زاﻧـﻮ در ﻣﻮﻗﻌﻴـﺖ ﺟﺪﻳـﺪ ﺧـﻮد ﻋﻤـﻞ‬ ‫ﻣﻲﻛﻨﻨـﺪ‪ .‬رﺑـﺎط ﺻـﻠﻴﺒﻲ ﺧﻠﻔـﻲ‬

‫)‪Posterior Cruciate Ligament (PCL‬‬

‫ﻛﻮآدري ﭘﺲ و ﻛﭙﺴﻮل ﻗﺪاﻣﻲ ﻣﻲﺑﺎﺷﺪ‪ .‬ﺟﻤﻊﺷﺪﮔﻲ اﻳﻠﻴﻮ‪-‬ﺗﻴﺒﻴﺎل ﺑﺎﻧﺪ و‬

‫ﻛﻮﺗﺎه و ﺳﻔﺖ و رﺑﺎط ﺻﻠﻴﺒﻲ ﻗـﺪاﻣﻲ )‪ (ACL‬ﺗﻜﺎﻣـﻞ ﻧﻴﺎﻓﺘـﻪ ﻳـﺎ ﻏﺎﻳـﺐ‬

‫ﺳﭙﺘﻮم ﺑﻴﻦ ﻋﻀﻼﻧﻲ ﻟﺘﺮال ﻫﻢ ﻣﻤﻜﻦ اﺳـﺖ وﺟـﻮد داﺷـﺘﻪ ﺑﺎﺷـﺪ‪ .‬ﭘـﺎچ‬

‫ﻣﻲﺑﺎﺷﺪ‪ .‬درﺟﺎت ﻣﺨﺘﻠﻒ ﺷﻠﻲ ﻟﻴﮕﺎﻣﺎﻧﻲ در اﻳﻦ ﺑﻴﻤﺎري وﺟـﻮد دارد و‬

‫ﺳﻮﭘﺮا ﭘﺎﺗﻼر در ‪ %50‬ﺑﻴـﻤﺎران ﻣﺤﻮ ﺷﺪه اﺳﺖ‪ .‬ﻣﻤﻜﻦ اﺳﺖ دررﻓﺘـﮕﻲ‬

‫ﻓﻴﺒﺮوز ﻋﻀﻠﻪ ﭼﻬﺎر ﺳﺮ راﻧﻲ در ﻫﻤﻪ ﺑﻴﻤﺎران وﺟﻮد دارد و ﭼـﺴﺒﻨﺪﮔﻲ‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):314-9‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻣﺤﻤﺪ رﻫﺒﺮ و ﻫﻤﻜﺎران‬

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‫‪11‬و‪10‬‬

‫‪ 1349-89‬ﺑﺎ ﺗﺸﺨﻴﺺ دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧﻮ در اﻳـﻦ ﻣﺮﻛـﺰ ﺗﺤـﺖ‬

‫ﺑﻬﺘﺮﻳﻦ روش ﺗﺸﺨﻴﺺ اﻳـﻦ ﺑﻴﻤـﺎري رادﻳـﻮﮔﺮاﻓﻲ ﻟﺘـﺮال زاﻧـﻮ اﺳـﺖ‪.‬‬

‫درﻣﺎن ﻗﺮار ﮔﺮﻓﺘﻨﺪ ﺑﺮرﺳﻲ ﺷﺪﻧﺪ ﻛﻪ ‪ 42‬ﺑﻴﻤﺎر ﺑﻮد‪ .‬ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﭘﺮوﻧـﺪه‬

‫ﺳﻮﻧﻮﮔﺮاﻓﻲ ﺣﺘﻲ در ﺳﻪ ﻣﺎﻫﻪ اول ﺑـﺎرداري ﺗﺸﺨﻴـﺼﻲ اﺳـﺖ و ﺑـﺴﺘﻪ‬

‫ﺑﻴﻤﺎرﺳﺘﺎﻧﻲ ﻛﺎﻣﻞ و ﭘﻲﮔﻴﺮي ﻣﻨﺎﺳﺐ داﺷﺘﻨﺪ ﻳـﺎ ﺑﻴﻤـﺎر ﻗﺎﺑـﻞ دﺳﺘﺮﺳـﻲ‬

‫ﺑﻮدن ﭘﺎچ ﺳﻮﭘﺮا ﭘﺎﺗﻼر را ﻧﺸﺎن ﻣﻲدﻫﺪ‪ .‬ﺳﻮﻧﻮﮔﺮاﻓﻲ در ﻧﻮزاد ﺗـﺎزه ﺑـﻪ‬

‫ﺟﻬﺖ ﻣﻌﺎﻳﻨﻪ و ﺟﻤﻊآوري اﻃﻼﻋـﺎت ﺑـﻮد اﻧﺘﺨـﺎب ﺷـﺪﻧﺪ ﻛـﻪ ﺷـﺎﻣﻞ‬

‫دﻧﻴﺎ آﻣﺪه‪ ،‬ﻣﻨﺎﻃﻖ ﻫﻴﭙﺮاﻛﻮ و ﺑﺎرﻳﻚﺷﺪﮔﻲ اﻧﺘﻬﺎي ﻋﻀﻠﻪ ﭼﻬﺎر ﺳﺮ راﻧـﻲ‬

‫‪ 29‬ﺑﻴﻤﺎر ﺑﻮد‪ .‬ﻓﺮم ﺟﻤﻊآوري اﻃﻼﻋﺎت ﺑﺮاي اﻳﻦ ﺑﻴﻤﺎران ﻛﺎﻣﻞ ﺷﺪ‪.‬‬

‫داﺧﻞ ﻣﻔﺼﻠﻲ ﺑﻪﻣﻴﺰان ﻣﺘﻔـﺎوت در اﻳـﻦ ﺑﻴﻤـﺎران دﻳـﺪه ﻣـﻲﺷـﻮد‪.‬‬

‫را ﻧﺸﺎن ﻣﻲدﻫﺪ‪ .‬آرﺗﺮوﮔﺮاﻓﻲ ﺟﻬﺖ ﺑﺮرﺳﻲ ﺑﻴﻤﺎران ﻣﻘـﺎوم ﺑـﻪ درﻣـﺎن‬ ‫ﻣﺤﺎﻓﻈﺘﻲ اﻧﺠﺎم ﻣﻲﺷﻮد و در ﺻﻮرت ﺑﺴﺘﻪ ﺑـﻮدن ﭘـﺎچ ﺳـﻮﭘﺮا ﭘـﺎﺗﻼر‬

‫ﻳﺎﻓﺘﻪﻫﺎ‬

‫ﺑﻴﻤﺎر ﺑﻪﻋﻨﻮان ﻣﻮرد ﻣﻘﺎوم ﺑﻪ درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ ﺗﺤﺖ ﻋﻤﻞ ﺟﺮاﺣﻲ ﻗﺮار‬ ‫ﻣﻲﮔﻴﺮد و در اﻳﻦ روش ﻟﻴﮕﺎﻣﺎنﻫﺎي ﻃﺒﻴﻌﻲ ﺑﻪ ﻫﻢ ﺑﺮرﺳـﻲ ﻣـﻲﺷـﻮد‪.‬‬

‫اﻳﻦ ﺑﻴﻤﺎري ﻧﺎدر ﻣﻲﺑﺎﺷﺪ ﺑـﻪﻃـﻮري ﻛـﻪ در ﻃـﻮل ‪ 40‬ﺳـﺎل ﺗﻨﻬـﺎ‬

‫‪ MRI‬ﺟﻬﺖ ﺑﺮرﺳﻲ اﻳﻦ ﺑﻴﻤﺎران اﺳﺘﻔﺎده ﻧﻤﻲﺷﻮد‪13.‬و‪ 12‬درﻣﺎن ﺑﺮ ﺣﺴﺐ‬

‫‪ 42‬ﻣﻮرد از اﻳﻦ ﺑﻴﻤﺎري در ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻔﺎﻳﺤﻴﺎﻳﻴﺎن ﭘﺬﻳﺮش ﺷﺪه اﺳﺖ‪.‬‬

‫ﺷﺪت ﺑﻴﻤﺎري و ﺳﻦ ﺑﻴﻤﺎر ﻣﺘﻔﺎوت اﺳﺖ‪ .‬در ﻧﻮزاد ﺗﺎزه ﺑـﻪ دﻧﻴـﺎ آﻣـﺪه‬

‫‪ 29‬ﺑﻴﻤﺎر ﺑﺎ ‪ 54‬زاﻧﻮ ﺗﺤﺖ ﻣﻄﺎﻟﻌﻪ ﻗﺮار ﮔﺮﻓﺘﻨﺪ‪ %65 .‬ﺑﻴﻤـﺎران ﻣﻮﻧـﺚ و‬

‫ﺑﺎ ﺑﻴﻤﺎري ﺧﻔﻴﻒ ﺗﺎ ﻣﺘﻮﺳﻂ درﻣﺎنﻫﺎي ﻣﺤـﺎﻓﻈﺘﻲ اﻧﺠـﺎم ﻣـﻲﺷـﻮد‪ .‬در‬

‫‪ Grade‬و ‪ %21‬ﻣﺒﺘﻼ ﺑﻪ‬

‫ﺷﻜﺴﺖ درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ و ﺑﻪﺧﺼﻮص ﺳﻦ ﺑﺎﻻﺗﺮ درﻣﺎن ﺟﺮاﺣﻲ اﻧﺠﺎم‬

‫‪ %35‬ﻣﺬﻛﺮ ﺑﻮدﻧﺪ‪ %33 .‬زاﻧﻮﻫﺎ ‪%46 ،Grade I‬‬ ‫‪III‬‬

‫‪II‬‬

‫‪ Grade‬ﺑﻮدﻧﺪ‪ .‬ﻣﺘﻮﺳﻂ زﻣﺎن ﭘﻲﮔﻴﺮي ‪ 8/5‬ﺳﺎل ﺑـﻮد )ﺷـﺶ ﻣـﺎه ﺗـﺎ‬

‫ﻣﻲﺷﻮد‪ .‬درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ ﺷﺎﻣﻞ ﻛﺸﺶ )‪ (Traction‬و ﭘﺎوﻟﻴـﻚ ﻫـﺎرﻧﺲ‬

‫‪ 28‬ﺳﺎل(‪ .‬ﻣﻴﺎﻧﮕﻴﻦ ﺳـﻦ ﺑﻴﻤـﺎران در ﭘـﻲﮔﻴـﺮي ﻧﻬـﺎﻳﻲ ‪ 18/1‬ﺳـﺎل )از‬

‫‪15‬و‪14‬‬

‫‪ 21‬ﻣﺎﻫﻪ ﺗﺎ ‪ 33‬ﺳﺎﻟﻪ( ﺑﻮد‪ %14 .‬ﺑﻴﻤﺎران دررﻓﺘﮕﻲ اﻳﺰوﻟﻪ ﻣﺎدرزادي زاﻧﻮ‬

‫)‪(Quadricepsplasty‬‬

‫و ﺑﻘﻴﻪ آرﺗﺮوﮔﺮﻳﭙﻮز و ﺳﻨﺪرﻣﻴﻚ ﺑﻮدﻧـﺪ‪ .‬در ‪ %83‬ﺑﻴﻤـﺎران دﻳـﺴﭙﻼزي‬

‫)‪ (Pavlic harness‬و ﮔﭻﮔﻴﺮي ﻣﻜـﺮر )‪ (Serial casting‬ﻣـﻲﺑﺎﺷـﺪ‪.‬‬ ‫ﺷﺎﻳﻊﺗﺮﻳﻦ روش ﺟﺮاﺣﻲ ﻛﻮادريﺳـﭙﺲﭘﻼﺳـﺘﻲ‬ ‫ﺗﻜﻨﻴﻚ ‪ Fisher‬و ‪ Curtis‬ﻣﻲﺑﺎﺷﺪ )ﺷﻜﻞ‪.(3 -‬‬

‫ﺳﺎﻳﺮ روشﻫﺎي ﺟﺮاﺣﻲ اﺳﺘﻔﺎده ﺷﺪه در درﻣﺎن اﻳﻦ ﺑﻴﻤﺎري ﺷـﺎﻣﻞ‬ ‫‪16‬و‪3‬‬

‫ﻣﻮارد زﻳﺮ ﻣﻲﺑﺎﺷﺪ‪.‬‬

‫ﻣﺎدرزادي ﻫﻴﭗ ﻫﻤﺮاه وﺟﻮد داﺷﺖ‪ .‬ﻧﺎﻫﻨﺠﺎري ﭘـﺎ در ‪ %65‬ﺑﻴﻤـﺎران و‬ ‫دررﻓﺘﮕﻲ ﻣﺎدرزادي آرﻧﺞ در ‪ %17‬ﺑﻴﻤﺎران وﺟﻮد داﺷﺖ‪ .‬ﻫﻤـﻪ ﺑﻴﻤـﺎران‬ ‫ﺗﺤﺖ درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ ﻗﺮار ﮔﺮﻓﺘﻨﺪ ﻛﻪ در ﻧﻬﺎﻳﺖ ‪ 23‬زاﻧﻮ ﺗﺤﺖ درﻣـﺎن‬

‫ﻛﻮﺗﺎه ﻛﺮدن ﻓﻤﻮر )‪ ،(Femural shortening‬اﻧﺘﻘﺎل ﻋﻀﻠﻪ ﺑﻪ دﻳﺴﺘﺎل‬ ‫ﺗــﺮ )‪ ،(Distal quadriceps muscle slide procedure‬اﻓــﺰاﻳﺶ ﻃــﻮل‬

‫ﻣﺤﺎﻓﻈﺘﻲ و ‪ 31‬زاﻧﻮ ﺗﺤـﺖ ﻋﻤـﻞ ﺟﺮاﺣـﻲ ﻛـﻮادريﺳـﭙﺲﭘﻼﺳـﺘﻲ و‬ ‫ﻛﻮﺗﺎهﺳﺎزي ﻓﻤﻮر ﻗﺮار ﮔﺮﻓﺘﻨﺪ‪.‬‬

‫‪(Percutaneous quadriceps‬‬

‫درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ ﺑﻴﻤﺎران ﮔﭻﮔﻴﺮي ﻣﻜﺮر و اﻗـﺪاﻣﺎت ﺗـﻮانﺑﺨـﺸﻲ‬

‫)‪ ،lengthening‬ﺑﺮﻳــﺪن ﺗﺎﻧــﺪون ﻛــﻮادريﺳــﭙﺲ ﺑــﺎ ﺣــﺪاﻗﻞ اﻧــﺴﺰﻳﻮن‬

‫ﺑﻮد‪ .‬ﺗﻤﺎﻣﻲ ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﺑﻪ درﻣﺎن ﻣﺤـﺎﻓﻈﺘﻲ ﭘﺎﺳـﺦ دادﻧـﺪ‬

‫‪Grade I, II‬‬

‫)‪ ،(Mini open quadriceps tenotomy‬ﺗﻐﻴﻴﺮ ﻣﺤﻞ اﺗﺼﺎل رﺑﺎط ﺻـﻠﻴﺒﻲ‬

‫ﺑﻴﻤﺎري ﺑﻮدﻧﺪ‪ .‬ﺳﻦ ﺷﺮوع آن در اﻛﺜﺮ ﺑﻴﻤﺎران ﺳﻪ ﻣﺎه ﺑـﻮد و درﻣـﺎن در‬

‫ﻗﺪاﻣﻲ )‪ ،(ACL advancement‬ﺧﺎرجﻛﺮدن ﻣﻴﻨﻴﺴﻚ )‪،(Meniscectomy‬‬

‫اﻳﻦ ﻣﺮﻛﺰ ﻳﺎ ﺳﺎﻳﺮ ﻣﺮاﻛﺰ ﺷﺮوع ﺷﺪه ﺑـﻮد‪ .‬در دو ﺑﻴﻤـﺎر در ﺳـﻦ ﺑـﺎﻻي‬

‫ﺑﺎزﺳﺎزي رﺑـﺎط ﺻـﻠﻴﺒﻲ ﻗـﺪاﻣﻲ )‪ ،(ACL reconstruction‬ﻛﭙـﺴﻮﻟﻮراﻓﻲ‬

‫ﻳﻚ ﺳﺎل درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ آﻏﺎز ﺷﺪ ﻛﻪ ﭘﺎﺳﺦ درﻣﺎﻧﻲ ﺧﻮب ﺑﻮد‪ .‬ﻃـﻮل‬

‫)‪ ،(Capsulorraphy‬اﺳﺘﺌﻮﺗﻮﻣﻲ )‪ ،(Osteotomy‬آرﺗﺮودز )‪،(Arthrodesis‬‬

‫دوره درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ از دو ﻫﻔﺘﻪ ﺗـﺎ ﻳـﻚﺳـﺎل ﻣﺘﻐﻴـﺮ ﺑـﻮد و ﺑـﻪﻃـﻮر‬

‫ﺗﻌﻮﻳﺾ ﻣﻔﺼﻞ )‪.(Arthroplasty‬‬

‫ﻣﺘﻮﺳﻂ ‪ 4/5‬ﻣﺎه ﻃﻮل ﻛﺸﻴﺪه اﺳﺖ‪.‬‬

‫ﺗﺎﻧــﺪون ﻛــﻮادريﺳــﭙﺲ از راه ﭘﻮﺳــﺖ‬

‫ﻣﺘﻮﺳﻂ ﻓﻠﻜﺸﻦ ﺑﻪدﺳﺖ آﻣﺪه ‪ 93/3°‬و ﻣﺘﻮﺳﻂ اﻛﺴﺘﻨﺸﻦ ﺑﻪدﺳـﺖ‬

‫روش ﺑﺮرﺳﻲ‬

‫آﻣﺪه در درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ ‪ -0/6°‬ﺑﻮد‪ .‬در ‪ %17‬زاﻧﻮﻫﺎ رﻛﻮرواﺗﻮم ﭘﺎﻳـﺪار‬ ‫وﺟــﻮد داﺷــﺖ و در ‪ %4‬اﻳــﻦ زاﻧﻮﻫــﺎ ﻓﻠﻜــﺸﻦ ﻛﻨﺘﺮاﻛﭽــﺮ‬

‫‪(Flexion‬‬

‫ﻣﻄﺎﻟﻌﻪ ﺑﻪﺻـﻮرت ﺗﻮﺻـﻴﻔﻲ و ‪ Case series‬اﻧﺠـﺎم ﺷـﺪ‪ .‬ﺑـﻪ اﻳـﻦ‬

‫)‪ contracture‬دﻳﺪه ﺷﺪ‪ .‬ﻫﻴﭻ ﺑﻴﻤﺎري از ﺑﺮﻳﺲ ﺑﺮاي راه رﻓـﺘﻦ اﺳـﺘﻔﺎده‬

‫ﺻﻮرت ﻛﻪ ﺑﺎ ﻣﺮاﺟﻌﻪ ﺑﻪ ﺑﺎﻳﮕﺎﻧﻲ ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻔﺎﻳﺤﻴﺎﻳﻴﺎن‪ ،‬از اول آذر ﺗـﺎ‬

‫ﻧﻤﻲﻛﺮد‪ .‬ﻟﻨﮕﺶ ﺑﻪﻋﻠﺖ ﻣﺸﻜﻼت زاﻧﻮ در ‪ %5‬ﺑﻴﻤـﺎران وﺟـﻮد داﺷـﺖ‪.‬‬

‫ﺑﻴﺴﺖ و ﭘﻨﺠﻢ اﺳﻔﻨﺪ ﺳﺎل ‪ 1389‬ﻛﻠﻴـﻪ ﺑﻴﻤـﺎراﻧﻲ ﻛـﻪ ﻃـﻲ ﺳـﺎلﻫـﺎي‬

‫درﻣﺎن ﺟﺮاﺣﻲ در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑـﻪ ‪ Grade II, III‬ﺑﻴﻤـﺎري اﻧﺠـﺎم ﺷـﺪ‪.‬‬

‫ﻧﺘﺎﻳﺞ درﻣﺎن دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧﻮ در ‪ 29‬ﺑﻴﻤﺎر‬

‫ﻳﻚ زاﻧﻮي ‪ Grade I‬ﻛﻪ در ﺳﻦ ﺳﻪ ﺳـﺎﻟﮕﻲ ﻣﺮاﺟﻌـﻪ ﻛـﺮده ﺑـﻮد و ﺑـﻪ‬

‫‪317‬‬

‫ﺑﺤﺚ‬

‫درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ ﭘﺎﺳﺦ ﻧﺪاد ﻫﻢ ﺗﺤﺖ ﻋﻤﻞ ﺟﺮاﺣﻲ ﻗﺮار ﮔﺮﻓـﺖ‪ .‬ﺳـﻦ‬ ‫ﻣﺘﻮﺳﻂ ﻋﻤﻞ ﺟﺮاﺣﻲ ‪ 24‬ﻣﺎه )ﭼﻬﺎر ﻣﺎه ﺗـﺎ ﭘـﻨﺞ ﺳـﺎل( ﺑـﻮد‪ .‬ﻣﺘﻮﺳـﻂ‬

‫در ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻫﻴﭻ ﺑﻴﻤﺎر‬

‫‪III‬‬

‫‪ Grade‬ﺑﻪ درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ ﭘﺎﺳﺦ ﻧـﺪاد‪.‬‬

‫ﻓﻠﻜﺸﻦ ﺑﻪدﺳﺖ آﻣﺪه ‪ 80°‬و ﻣﺘﻮﺳﻂ اﻛﺴﺘﻨﺸﻦ ﺑﻪدﺳﺖ آﻣﺪه ‪ 4/3°‬ﺑﻮد‪.‬‬

‫ﺑﻪ ﻫﺮ ﺣﺎل ﺑﻴﻤﺎران ﺑﺎ ﻫﺮ ‪ Grade‬و در ﻫﺮ ﺳﻨﻲ ﻛﻪ ﻣﺮاﺟﻌﻪ ﻛﻨﻨـﺪ اﺑﺘـﺪا‬

‫در ‪ %12‬زاﻧﻮﻫﺎي ﻋﻤﻞﺷﺪه رﻛﻮرواﺗﻮم ﭘﺎﻳﺪار وﺟـﻮد داﺷـﺖ و در‬

‫ﺗﺤﺖ درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ ﻗﺮار ﮔﻴﺮﻧﺪ در ﺻﻮرت ﻋـﺪم ﭘﺎﺳـﺦ ﺑـﻪ درﻣـﺎن‬

‫‪ %38‬اﻳﻦ زاﻧﻮﻫﺎ ﻓﻠﻜﺸﻦ ﻛﻨﺘﺮاﻛﭽﺮ دﻳﺪه ﺷﺪ‪ .‬دو ﺑﻴﻤﺎر ﺑﺮاي راه رﻓﺘﻦ از‬ ‫ﺑﺮﻳﺲ اﺳﺘﻔﺎده ﻣﻲﻛﺮدﻧﺪ‪ .‬ﻟﻨﮕﺶ ﺑﻪﻋﻠﺖ ﻣﺸﻜﻼت زاﻧﻮ در ‪ %14‬ﺑﻴﻤﺎران‬

‫ﻣﺤﺎﻓﻈﺘﻲ ﻋﻤﻞ ﺟﺮاﺣﻲ ﺑﺮاﻳﺸﺎن اﻧﺠﺎم ﺷﻮد‪.‬‬ ‫‪15‬و‪12‬‬

‫ﺑﺮ اﺳﺎس ﻧﻈﺮ اﻛﺜﺮ ﻣﻮﻟﻔﻴﻦ‬

‫درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ ﺗـﺎ ﺳـﻪ ﻣـﺎه اداﻣـﻪ‬

‫ﻳﺎﺑﺪ و در ﺻﻮرت ﻋـﺪم ﭘﺎﺳـﺦ درﻣـﺎﻧﻲ ﻋﻤـﻞ ﺟﺮاﺣـﻲ اﻧﺠـﺎم ﺷـﻮد‪.‬‬

‫وﺟﻮد داﺷﺖ‪.‬‬ ‫ﺳــﻪ درﺻــﺪ دﭼــﺎر ﻧﻜــﺮوز زﺧــﻢ ﭘــﺲ از ﺟﺮاﺣــﻲ ﺷــﺪﻧﺪ‪%16 ،‬‬

‫در ﻣﻄﺎﻟﻌﻪ ﻣﺎ در‬

‫‪II‬‬

‫‪ Grade I,‬ﺑﻴﻤﺎري ﻧﺘﺎﻳﺞ درﻣﺎﻧﻲ ﺧﻮﺑﻲ ﺑﺎ ‪ 6-12‬ﻣـﺎه‬

‫ﺷﻜﺴﺘﮕﻲ ﺑﻪدﻧﺒﺎل ﻓﻴﺰﻳﻮﺗﺮاﭘﻲ ﺑﻌﺪ از ﺟﺮاﺣﻲ ﭘﻴﺪا ﻛﺮدﻧﺪ‪ %19 ،‬اﻧﺤﻨـﺎي‬

‫درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ در ﭼﻨـﺪ ﺑﻴﻤـﺎر دﻳـﺪه ﺷـﺪ‪ .‬ﻧﺘـﺎﻳﺞ ﻣﺤـﺪوده ﺣﺮﻛـﺖ‬

‫ﻏﻴﺮﻃﺒﻴﻌــﻲ ﭘﺮوﮔﺰﻳﻤــﺎل ﺗﻴﺒﻴــﺎ )‪ (Tibial proximal bowing‬داﺷــﺘﻨﺪ‪،‬‬

‫‪Johnson‬‬

‫ﺣﺮﻛــﺖ زاﻧــﻮي ﻧــﺎﻣﻄﻠﻮب )‪ (<60‬در ‪ %26‬زاﻧﻮﻫــﺎ دﻳــﺪه ﺷــﺪ‪ .‬ﻋــﺪم‬

‫)‪ (ROM‬ﺑــﻪدﺳــﺖ آﻣــﺪه در درﻣــﺎن ﻣﺤــﺎﻓﻈﺘﻲ ﺑــﺎ ﻣﻄﺎﻟﻌــﻪ‬ ‫‪12‬‬

‫ﺑﺮاﺑﺮ اﺳﺖ‪.‬‬

‫ﺟﺎاﻧﺪازي ﻣﻨﺎﺳﺐ زاﻧﻮﻫﺎ ﭘﺲ از ﺟﺮاﺣـﻲ در ‪ %23‬زاﻧﻮﻫـﺎ دﻳـﺪه ﺷـﺪ‪.‬‬

‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻧﺘﺎﻳﺞ ﺑﻪدﺳﺖ آﻣـﺪه در درﻣـﺎن ﺟﺮاﺣـﻲ و ﻣﺤـﺎﻓﻈﺘﻲ‪،‬‬

‫در ﻣﻘﺎﻳﺴﻪ درﻣﺎن ﺟﺮاﺣﻲ و ﻣﺤـﺎﻓﻈﺘﻲ‪ ،‬در درﻣـﺎن ﺟﺮاﺣـﻲ ﻋـﻮارض‬

‫ﺣﺮﻛﺖ زاﻧﻮي ﺑﻬﺘﺮ و زاﻧﻮي ﺑﺎ ﺛﺒﺎتﺗﺮي در درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ ﺑـﻪدﺳـﺖ‬

‫ﺑﻴﺶﺗﺮ‪ ،‬ﻓﻠﻜﺸﻦ ﻛﻨﺘﺮاﻛﭽﺮ ﺑﻴﺶﺗﺮ‪ ،‬ﺣﺮﻛﺖ زاﻧﻮي ﻛﻢﺗـﺮ و رﻛﻮرواﺗـﻮم‬

‫آﻣﺪ‪ .‬ﺷﺮوع درﻣﺎن ﻣﺤﺎﻓﻈﺘﻲ زﻳﺮ ﺳﻪ ﻣﺎه و ﻧﺒـﻮدن ﺑﻴﻤـﺎري ﻫﻤـﺮاه اﺛـﺮ‬ ‫ﻣﻄﻠﻮﺑﻲ ﺑﺮ ﻋﻤﻠﻜﺮد زاﻧﻮ دارد‪ .‬در ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﺑﻴﺶﺗﺮ ﺑﻴﻤﺎران‬

‫ﻛﻢﺗﺮ دﻳﺪه ﺷﺪ‪.‬‬ ‫ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﺗﺤﺖ ﻋﻤـﻞ ﺟﺮاﺣـﻲ ﻛـﻮادريﺳـﭙﺲ ﭘﻼﺳـﺘﻲ ﻗـﺮار‬

‫‪Grade I, II‬‬

‫ﺑﻴﻤﺎري ﻛﻪ ﺗﺤﺖ ﻋﻤﻞ ﺟﺮاﺣﻲ ﻗﺮار ﮔﺮﻓﺘﻨﺪ‪ ،‬دﻳﺮ ﻣﺮاﺟﻌﻪ ﻛﺮده ﺑﻮدﻧﺪ‪.‬‬

‫ﮔﺮﻓﺘﻨﺪ دو ﮔﺮوه ﺑﻮدﻧﺪ‪ %34 .‬زاﻧﻮﻫﺎ ﭘﺲ از اﺗﻤﺎم ﻃﻮﻳـﻞﺳـﺎزي ﻋـﻀﻠﻪ‬

‫در ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﻣﺸﺨﺺ ﺷﺪ ﻛﻪ درﻣﺎن ﻫـﺮ ﭼـﻪ زودﺗـﺮ ﺷـﺮوع‬

‫‪(Trans articular‬‬

‫ﺷﻮد ﭘﺎﺳﺦ درﻣﺎﻧﻲ ﺑﻬﺘﺮ اﺳـﺖ و زﻣـﺎن رﺳـﻴﺪن ﺑـﻪ ﺣـﺪاﻛﺜﺮ ﻣﺤـﺪوده‬

‫ﭼﻬﺎر ﺳﺮ ﺑﻪﻣﺪت ‪ 2-3‬ﻫﻔﺘﻪ‪ ،‬ﻓﻴﻜﺴﺎﺳﻴﻮن زاﻧﻮ ﺑﺎ ﭘﻴﻦ‬ ‫)‪ pin‬اﻧﺠﺎم ﺷﺪ و در ‪ %66‬زاﻧﻮﻫﺎ اﻳﻦﻛﺎر اﻧﺠﺎم ﻧﺸﺪ‪.‬‬

‫ﺣﺮﻛﺘﻲ ﻛﻢﺗﺮ اﺳﺖ‪ .‬ﻣﺤـﺪوده ﺣﺮﻛﺘـﻲ ﺑـﻪدﺳـﺖ آﻣـﺪه در ﻋﻤـﻞﻫـﺎي‬ ‫‪12‬‬

‫از زاﻧﻮﻫﺎي ﺗﺤﺖ ﻋﻤﻞ ﺟﺮاﺣﻲ ﻗﺮار ﮔﺮﻓﺘﻪ در ﺣﺪود ‪ %80‬زاﻧﻮﻫـﺎ‬

‫ﺟﺮاﺣﻲ ﺑﺎ ﺳﺎﻳﺮ ﻣﻄﺎﻟﻌﺎت ﻣﻄﺎﺑﻖ اﺳﺖ‪ .‬ﻣﺘﻮﺳﻂ ﺣﺮﻛﺖ ﺑﻪدﺳﺖ آﻣـﺪه‬

‫ﻧﺎﭘﺎﻳﺪاري وﺟﻮد داﺷﺖ و از زاﻧﻮﻫﺎي دﭼﺎر ﻧﺎﭘﺎﻳﺪاري‪ %71 ،‬دﻓـﻮرﻣﻴﺘﻲ‬

‫زاﻧﻮ در ﺑﻴﻤﺎران ﻣﺎ ﻧﺴﺒﺖ ﺑﻪ ﻣﻄﺎﻟﻌﺎﺗﻲ ﻛﻪ ﺑﻴﻤﺎران ﻗﺒﻞ از ﺳﻦ ﺷﺮوع راه‬

‫واﻟﮕﻮس )‪ (Valgus deformity‬داﺷﺘﻨﺪ‪ .‬ﺷﻴﻮع ﻧﺎﭘﺎﻳﺪاري ﭘـﺲ از ﻋﻤـﻞ‬

‫رﻓﺘﻦ ﻋﻤﻞ ﺷﺪهاﻧـﺪ ﺑﺮاﺑـﺮ ﺑـﻮد‪ ،‬ﻋﺎﻣـﻞ ﺳـﻦ در زﻣـﺎن ﺟﺮاﺣـﻲ ﺗـﺄﺛﻴﺮ‬

‫ﺟﺮاﺣــﻲ در‬

‫‪II, III‬‬

‫‪ Grade‬ﺑﻴﻤــﺎري و ﻧﻴــﺰ در ﺳــﻨﺪرم ﻻرﺳــﻦ و‬

‫آرﺗﺮوﮔﺮﻳﭙﻮز ﺑﻪﺻﻮرت ﺗﻘﺮﻳﺒﺎً ﻣﺴﺎوي دﻳﺪه ﺷﺪ‪.‬‬ ‫ﻣﺤﺪوده ﺣﺮﻛﺘﻲ ﻣﻨﺎﺳﺐ زاﻧﻮ در اﻛﺜﺮ ﺑﻴﻤﺎران ﭘﺲ از ﻫـﺸﺖ ﻫﻔﺘـﻪ‬

‫ﻣﺸﺨﺼﻲ روي ﻋﻤﻠﻜﺮد ﻧﻬﺎﻳﻲ زاﻧﻮ ﻧﺪاﺷﺖ‪.‬‬ ‫ﻧﺘﺎﻳﺞ ﺑﻪدﺳﺖ آﻣﺪه در ﻛـﻮادريﺳـﭙﺲ ﭘﻼﺳـﺘﻲ ﺑـﺎ ﻓـﻴﻜﺲ ﻛـﺮدن‬ ‫ﻣﻮﻗـــﺖ زاﻧـــﻮ‬

‫‪Quadricepsplasty with transarticular fixation‬‬

‫از ﭘﺎﻳﺎن ﺑﻲﺣﺮﻛﺘﻲ ﺑﻌﺪ ﻋﻤﻞ ﺑﻪدﺳـﺖ آﻣـﺪه و اﻳـﻦ ﻣﺤـﺪوده ﺣﺮﻛﺘـﻲ‬

‫رﺿﺎﻳﺖﺑﺨﺶ ﺑﻮد و اﻳـﻦ روش ﻧـﺴﺒﺖ ﺑـﻪ روش ﺑـﺪون ﻓﻴﻜـﺴﺎﺳﻴﻮن‬

‫ﺑﻪدﺳﺖ آﻣﺪه در ﭼﻨﺪ ﺑﻴﻤﺎر در ﻃﻲ ﻣﺎهﻫﺎي آﻳﻨﺪه ﺑﺎ ﻗﻄـﻊ ﺗـﻮانﺑﺨـﺸﻲ‬

‫ﺗﻮﺻﻴﻪ ﻣﻲﺷﻮد‪ .‬در ﺑﻴﻤﺎران ﻣﺎ ﻛﻪ ﺗﺤﺖ ﻋﻤﻞ ﺟﺮاﺣـﻲ ﻗـﺮار ﮔﺮﻓﺘـﻪ در‬

‫ﺑﻪﻃﺮز ﭼﺸﻢﮔﻴﺮي ﻛﺎﻫﺶ ﻳﺎﻓﺖ‪ .‬در ﺑﻴﻤﺎران دﭼـﺎر ﻋﺎرﺿـﻪ ﺷﻜـﺴﺘﮕﻲ‬

‫‪ %80‬زاﻧﻮﻫﺎ ﻧﺎﭘﺎﻳﺪاري واﻟﮕـﻮس )‪ (Valgus instability‬دﻳـﺪه ﺷـﺪ‪ ،‬ﺑـﺎ‬

‫ﺣﻴﻦ ﻓﻴﺰﻳﻮﺗﺮاﭘﻲ‪ ،‬در ﻧﻬﺎﻳﺖ در ﻫﻤﻪ اﻳﻦ ﺑﻴﻤﺎران ﺣﺮﻛﺖ ﻣﻨﺎﺳـﺐ زاﻧـﻮ‬

‫ﺗﻮﺟﻪ ﺑﻪ اﺣﺘﻤﺎل ﺑﺎﻻي اﻳﺠﺎد آرﺗﺮوز زودرس ﺑﺎﻳﺪ ﺑﺮ ﻋﻤﻞﻫﺎي ﺟﺮاﺣﻲ‬

‫ﺑﻪدﺳﺖ آﻣﺪ‪ .‬در ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﺣﻴﻦ ﻋﻤﻞ ﺟﺮاﺣﻲ ﻓﻠﻜﺸﻦ زاﻧﻮي ﺑﻴﺶ از‬

‫اﺳــﺘﺌﻮﺗﻮﻣﻲ‪ ،‬ﺑﺎزﺳــﺎزي رﺑــﺎط ﺻــﻠﻴﺒﻲ ﻗــﺪاﻣﻲ و ﻛﭙــﺴﻮﻟﻮراﻓﻲ ﺗﺄﻛﻴــﺪ‬

‫‪ 90°‬ﺑﻪدﺳﺖ آﻣﺪ ﻟﺰوﻣﺎ ﺣﺮﻛﺖ ﻣﻨﺎﺳـﺐ زاﻧـﻮ ﭘـﺲ از ﻋﻤـﻞ ﺟﺮاﺣـﻲ‬

‫ﺑﻴﺶﺗﺮي ﺷﻮد‪ .‬ﻧﺘﺎﻳﺞ ﺑﻬﺘﺮ در ﺑﻴﻤﺎراﻧﻲ دﻳﺪه ﺷﺪ ﻛﻪ ﺗﺤﺖ ﺗـﻮانﺑﺨـﺸﻲ‬

‫ﺑﻪدﺳﺖ ﻧﻴﺎﻣﺪ‪ .‬دو زاﻧﻮ ﺗﺤﺖ ﻛﻮﺗﺎهﺳﺎزي ﻓﻤﻮر ﻗﺮار ﮔﺮﻓﺘﻨﺪ ﻛﻪ ﺑﻪﻋﻠـﺖ‬

‫ﻣﺪاوم ﻗﺮار داﺷﺘﻨﺪ و ﺑﻴﻤﺎر ﺑﻪﻃﻮر ﻣﺪاوم ﭘﻲﮔﻴﺮي ﻣﻲﺷﺪﻧﺪ‪.‬‬

‫ﺗﻌﺪاد ﻛﻢ ﻣﻮارد‪ ،‬ﻳﺎﻓﺘﻪﻫﺎ ﻗﺎﺑﻞ ﺑﺮرﺳﻲ ﻧﺒﻮدﻧﺪ‪.‬‬

‫ﺳﭙﺎﺳﮕﺰاري‪ :‬اﻳـﻦ ﻣﻘﺎﻟﻪ ﺣﺎﺻﻞ ﭘﺎﻳـﺎنﻧﺎﻣﻪ ﺗﺤﺖ ﻋﻨـﻮان "ﺑـﺮرﺳﻲ‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):314-9‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻫﻤﻜﺎران‬ Rahbar‫رﻫﺒﺮ و‬ M. et‫ﻣﺤﻤﺪ‬ al.

318

‫ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺎ ﺣﻤﺎﻳﺖ داﻧﺸﮕﺎه‬31210 ‫ و ﻛﺪ‬1390 ‫ﺗﺨﺼﺼﻲ در ﺳﺎل‬

‫ﻧﺘﺎﻳﺞ درﻣﺎن دررﻓﺘﮕﻲ ﻣﺎدرزادي زاﻧﻮ در ﺑﻴﻤﺎران ﻣﺮاﺟﻌﻪﻛﻨﻨﺪه ﺑﻪ‬

.‫ﻋﻠﻮم ﭘﺰﺷﻜﻲ و ﺧﺪﻣﺎت ﺑﻬﺪاﺷﺘﻲ درﻣﺎﻧﻲ ﺗﻬﺮان اﺟﺮا ﺷﺪه اﺳﺖ‬

‫" در ﻣﻘﻄﻊ دﻛﺘﺮاي‬1349-89 ‫ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻔﺎ ﻳﺤﻴﺎﻳﻴﺎن ﻃﻲ ﺳﺎلﻫﺎي‬

References 1. Kazemi SM, Abbasian MR, Hosseinzadeh HR, Zanganeh RF, Eajazi A, Besheli LD. Congenital dislocation of the knee in a 16year-old girl. Orthopedics 2010;33(5). 2. Insall JN, Scott WN, editors. Surgery of the Knee. 3rd ed. Philadelphia: Churchill-Livingstone; 2001. p. 1337. 3. Shattock SG. Genu recurvatum in a foetus at term. Trans Pathol Soc London 1891;(42):280-92. 4. Katz MP, Grogono JS, Soper KC. The etiology and treatment of congenital dislocation of the knee. J Bone Joint Surg (Br) 1967;49:112-20. 5. Carlson DH, O'Connor J. Congenital dislocation of the knee. AJR Am J Roentgenol 1976;127(3):465-8. 6. orincour G, Chotel F, Rudigoz RC, Guibal-Baggio AL, Berard J, Pracros JP, et al. Prenatal diagnosis of congenital genu recurvatum following amniocentesis complicated by leakage. Ultrasound Obstet Gynecol 2003;22(6):643-5. 7. Niebauer JJ, King DE. Congenital dislocation of the knee. J Bone Joint Surg Am 1960;42-A:207-25. 8. Herring JA, editor. Tachdjian's Pediatric Orthopaedics. 4th ed. Philadelphia, PA: WB Saunders; 2008. p. 919.

9. Kamata N, Takahashi T, Nakatani K, Yamamoto H. Ultrasonographic evaluation of congenital dislocation of the knee. Skeletal Radiol 2002;31(9):539-42. 10. Ko JY, Shih CH, Wenger DR. Congenital dislocation of the knee. J Pediatr Orthop 1999;19(2):252-9. 11. Shahla A. Congenital anterior tibiofemural subluxation. Acta Med Iran 2008;46(3):283-86. 12. Johnson E, Audell R, Oppenheim WL. Congenital dislocation of the knee. J Pediatr Orthop 1987;7(2):194-200. 13. Nogi J, MacEwen GD. Congenital dislocation of the knee. J Pediatr Orthop 1982;2(5):509-13. 14. Haga N, Nakamura S, Sakaguchi R, Yanagisako Y, Taniguchi K, Iwaya T. Congenital dislocation of the knee reduced spontaneously or with minimal treatment. J Pediatr Orthop 1997;17(1):59-62. 15. Canale ST, Beatty JH, editors. Campbell's Operative Orthopaedics. 11th ed. St. Louis: Mosby; 2008. p. 1113. 16. Shah NR, Limpaphayom N, Dobbs MB. A minimally invasive treatment protocol for the congenital dislocation of the knee. J Pediatr Orthop 2009;29(7):720-5.

319 ‫ ﺗﺎ‬314 ،5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

319

‫ﻛﺎراﻳﻲ دو روش ﭘﺎﻳﺶ ﺑﺮاي ﺗﺸﺨﻴﺺ ﻋﻔﻮﻧﺖ ﻣﺤﻞ ﺟﺮاﺣﻲ در ﺑﺨﺸﻬﺎي ﺟﺮاﺣﻲ ﻋﻤﻮﻣﻲ‬

Tehran University Medical Journal, August 2012; Vol. 70, No. 5: 314-319

Original Article

Congenital dislocation of knee: results of the treatment in 29 cases between 1970 and 2010 years at Shafa Yahyaian Hospital in Tehran Abstract Mohammad Rahbar M.D.1 Mahmud Jabalameli M.D.1 Nadia Aqajani M.D.2* Reza Shafipour M.D.2 1- Department of Orthopaedia, Tehran University of Medical Sciences, Tehran, Iran. 2- Department of Orthopaedia, Tehran University of Medical Sciences, The Shafa Hospital, Tehran, Iran.

Received: June 15, 2011 Accepted: May 23, 2012

Background: There are not many reports regarding the treatment approaches of congenital dislocation of the knee in the literature. Therefore, the preferred method of treatment of this rare congenital disease is still controversial. Hereby, we report the treatment outcome of 29 patients admitted in Shafa Yahyaian Hospital during 40 years. Methods: In this retrospective study done in Shafa Yahyaian Hospital in Tehran, Iran during 2010, we retrospectively reviewed the medical records of 29 patients treated conservatively or surgically for congenital dislocation of the knee. Patients had been evaluated for an average follow-up of 8.5 years. Results: Overall, 54 knee dislocations had been treated surgically (58%) or conservatively (42%). Range of knee motion, persistent recurvatum, instability, valgus deformity after treatment and limping were the more important factors reported in the two surgically or conservatively treated groups. Knee function was satisfactory in patients with conservative treatment. Despite 80% of instability in the operated knees, patients could ambulate with or without braces and had a range of motion equal to 80 degrees. Knee function was also good after quadricepsplasty with transarticular pins in selected cases. Conclusion: We recommend a conservative approach to the disease, regardless of the patient’s age at the time of treatment and subsequent surgery in patients with dissatisfactory recovery. Quadricepsplasty with transarticular fixation is recommended as a good option in treating these patients. Posterior capsulorrhaphy for patients with CDK and ligamentous laxity is also recommended.

Corresponding author: Shafa Hospital, Mojahedin-e-eslam St., Baharestan Sq., Tehran, Iran. Tel: +98-911-1935709 E-mail: nadiaaqajani@yahoo.com

Keywords: congenital dislocation of the knee, CDK, dislocation, knee.

Tehran Univ Med J (TUMJ) 2012 August;70(5):314-9

http://tumj.tums.ac.ir

‫ﺳﭙﻴﺪه ﺣﻘﻴﻘﻲ و ﻫﻤﻜﺎران‬

‫‪320‬‬

‫ﻣﻘﺎﻟﻪ اﺻﻴﻞ‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ ،5‬ﺻﻔﺤﻪﻫﺎي ‪ 320‬ﺗﺎ ‪324‬‬

‫ارﺗﺒﺎط ‪ ،Chemerin‬ﻫﻮرﻣﻮن ﺑﺎﻓﺖ ﭼﺮﺑﻲ‪ ،‬ﺑﺎ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ‬

‫‪1‬‬

‫ﺳﭙﻴﺪه ﺣﻘﻴﻘﻲ‪ ،1‬ﭘﺮﻳﭽﻬﺮ ﻳﻐﻤﺎﻳﻲ‬ ‫‪1‬‬

‫ﻓﺎﻃﻤﻪ ﻫﺎﺷﻤﻲ‪ ،1‬ﻧﻐﻤﻪ ﺳﻌﺎدﺗﻲ‬ ‫‪2‬‬

‫ﻓﻬﻴﻤﻪ رﻣﻀﺎﻧﻲ ﺗﻬﺮاﻧﻲ‬ ‫‪*3‬‬

‫ﻣﻬﺪي ﻫﺪاﻳﺘﻲ‬

‫ﭼﻜﻴﺪه‬

‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ﻣﻘﺎﻟﻪ‪1390/09/22 :‬‬

‫ﺗﺎرﻳﺦ ﭘﺬﻳﺮش‪1391/02/17 :‬‬

‫زﻣﻴﻨﻪ و ﻫﺪف‪ :‬آدﻳﭙﻮﻛﻴﻦﻫﺎ ﭘﺮوﺗﻴﻴﻦﻫﺎي ﻣﺘﺮﺷﺤﻪ از ﺑﺎﻓﺖ ﭼﺮﺑﻲ ﻫﺴﺘﻨﺪ ﻛﻪ در ﻛﻨﺘـﺮل ﻣﺘﺎﺑﻮﻟﻴـﺴﻢ ﺑـﺪن ﺷـﺮﻛﺖ دارﻧـﺪ‪.‬‬ ‫ﻛﻤﺮﻳﻦ )‪ (Chemerin‬از ﺟﻤﻠﻪ آدﻳﭙﻮﻛﻴﻦﻫﺎ ﺑﻮده و داراي ﻧﻘﺶﻫﺎي ﺑﻴﻮﻟﻮژﻳﻜﻲ ﮔﻮﻧﺎﮔﻮن اﺳـﺖ‪ .‬ﻃﺒـﻖ ﻣﻄﺎﻟﻌـﺎت ﻣﺨﺘﻠـﻒ‬ ‫ﺳﻄﺢ ﺳﺮﻣﻲ ﻛﻤﺮﻳﻦ ﺑﺎ ﺗﻐﻴﻴﺮ در ﺷﺎﺧﺺ ﺗﻮده ﺑﺪﻧﻲ )‪ ،(BMI‬ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ‪ ،‬ﺳﻨﺪرم ﻣﺘﺎﺑﻮﻟﻴﻚ‪ ،‬دﻳﺎﺑﺖ و ﺑﻴﻤﺎريﻫـﺎي‬

‫‪ -1‬ﮔﺮوه زﻳﺴﺖﺷﻨﺎﺳﻲ‪ ،‬واﺣﺪ ﻋﻠﻮم ﺗﺤﻘﻴﻘﺎت‬

‫ﻗﻠﺒﻲ‪ -‬ﻋﺮوﻗﻲ در ارﺗﺒﺎط ﺑﻮده اﺳﺖ‪ .‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑﺎ ﻫﺪف ﺑﺮرﺳﻲ ارﺗﺒﺎط ﺳﻄﺢ ﺳﺮﻣﻲ ﻫﻮرﻣﻮن ﻛﻤﺮﻳﻦ ﺑﺎ ﺳﻨﺪرم ﺗﺨﻤﺪان‬

‫ﺗﻬﺮان‪ ،‬داﻧﺸﮕﺎه آزاد اﺳﻼﻣﻲ‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬

‫ﭘﻠﻲﻛﻴﺴﺘﻴﻚ )‪ (PCOS‬در زﻧﺎن ﻣﺒﺘﻼ اﻧﺠﺎم ﺷﺪ‪.‬‬

‫‪ -2‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت آﻧﺪوﻛﺮﻳﻨﻮﻟﻮژي ﺗﻮﻟﻴﺪ ﻣﺜﻞ‪،‬‬

‫روش ﺑﺮرﺳﻲ‪ :‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻣﻮرد‪ -‬ﺷﺎﻫﺪي در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ‪ PCOS‬در ﺑﻴﻤﺎرﺳﺘﺎن ﻃﺎﻟﻘﺎﻧﻲ ﺗﻬﺮان در ﺳـﺎل ‪ 1390‬اﻧﺠـﺎم‬

‫ﭘﮋوﻫﺸﻜﺪه ﻋﻠﻮم ﻏﺪد درونرﻳﺰ و ﻣﺘﺎﺑﻮﻟﻴﺴﻢ‪،‬‬ ‫داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺷﻬﻴﺪ ﺑﻬﺸﺘﻲ‪ ،‬ﺗﻬﺮان‪،‬‬ ‫اﻳﺮان‪.‬‬

‫ﺷﺪ‪ .‬ﺗﻌﺪاد ‪ 45‬ﺑﻴﻤﺎر ‪ PCOS‬و ﻫﻢﭼﻨﻴﻦ ‪ 45‬ﻧﻔﺮ ﺑﻪﻋﻨﻮان ﮔﺮوه ﺷﺎﻫﺪ ﺑﻪروش ﻧﻤﻮﻧﻪﮔﻴﺮي آﺳﺎن اﻧﺘﺨﺎب ﺷﺪﻧﺪ‪ .‬ﻣﻴـﺰان‬

‫‪BMI‬‬

‫و ﺳﻄﺢ ﺳﺮﻣﻲ ﻫﻮرﻣﻮنﻫﺎي ﻛﻤﺮﻳﻦ و اﻧﺴﻮﻟﻴﻦ ﺑﻪروش اﻻﻳﺰا ﺳـﺎﻧﺪوﻳﭽﻲ و ﻫـﻢﭼﻨـﻴﻦ ﻣﻴـﺰان ﮔﻠـﻮﻛﺰ ﺳـﺮﻣﻲ ﺑـﻪروش‬

‫‪ -3‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﭘﻴﺸﮕﻴﺮي و درﻣﺎن ﭼﺎﻗﻲ‪،‬‬

‫رﻧﮓﺳﻨﺠﻲ آﻧﺰﻳﻤﻲ در ﺣﺎﻟﺖ ﻧﺎﺷﺘﺎ اﻧﺪازهﮔﻴﺮي ﺷﺪﻧﺪ‪ .‬ﺷﺎﺧﺺ ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ ﺑﺎ ﻣﺪل ‪ HOMA-IR‬ﻣﺤﺎﺳﺒﻪ ﮔﺮدﻳﺪ‪.‬‬

‫ﭘﮋوﻫﺸﻜﺪه ﻋﻠﻮم ﻏﺪد درون رﻳﺰ و ﻣﺘﺎﺑﻮﻟﻴﺴﻢ‪،‬‬

‫ﻳﺎﻓﺘﻪﻫﺎ‪ :‬ﻣﻴﺰان ﻫﻮرﻣﻮن ﻛﻤﺮﻳﻦ‪ ،‬ﮔﻠﻮﻛﺰ و ﻫﻮرﻣﻮن اﻧﺴﻮﻟﻴﻦ ﺳﺮم در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ‪ PCOS‬ﺑﻪﻃـﻮر ﻣﻌﻨـﻲداري از ﻟﺤـﺎظ‬

‫داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺷﻬﻴﺪ ﺑﻬﺸﺘﻲ‪ ،‬ﺗﻬﺮان‪،‬‬

‫آﻣﺎري از ﮔﺮوه ﺷﺎﻫﺪ ﺑﻴﺶﺗﺮ ﺑﻮد و اﻳﻦ اﻓﺮاد ﺑﺎ ﻣﺤﺎﺳﺒﻪ ‪ HOMA-IR‬ﻣﺸﺨﺺ ﺷﺪ ﻛﻪ ﻣﺒﺘﻼ ﺑﻪ ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧـﺴﻮﻟﻴﻦ ﺑﻮدﻧـﺪ‬

‫اﻳﺮان‪.‬‬

‫)‪ .(P<0/05‬اﻣﺎ ﻫﻤﺒﺴﺘﮕﻲ ﻣﻌﻨﻲداري ﺑﻴﻦ ﺳﻄﺢ ﻛﻤﺮﻳﻦ ﺳﺮم ﺑﺎ اﻧﺴﻮﻟﻴﻦ‪ ،‬ﮔﻠﻮﻛﺰ و ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ و ‪ BMI‬در ﺑﻴﻤـﺎران‬ ‫ﻣﺒﺘﻼ ﺑﻪ ‪ PCOS‬ﺑﺎ ﮔﺮوه ﺷﺎﻫﺪ وﺟﻮد ﻧﺪاﺷﺖ‪.‬‬ ‫ﻧﺘﻴﺠﻪﮔﻴﺮي‪ :‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻧﺸﺎن ﻣﻲدﻫﺪ ﻛﻪ ﻣﻴﺰان ﻫﻮرﻣﻮن ﻛﻤﺮﻳﻦ در ﺳﺮم ﺑﻴﻤﺎران ‪ PCOS‬ﻧﺴﺒﺖ ﺑﻪ ﮔﺮوه ﺷﺎﻫﺪ داراي‬

‫*‬

‫ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪ :‬ﺗﻬﺮان‪ ،‬ﺑﺰرﮔﺮاه ﭼﻤﺮان‪ ،‬ﺧﻴﺎﺑﺎن ﻳﻤﻦ‪،‬‬

‫اﺑﺘﺪاي وﻟﻨﺠﻚ‪ ،‬ﺧﻴﺎﺑﺎن ﭘﺮواﻧﻪ‪ ،‬ﭘﻼك ‪ ،24‬ﭘﮋوﻫﺸﻜﺪه‬ ‫ﻋﻠﻮم ﻏﺪد درونرﻳﺰ و ﻣﺘﺎﺑﻮﻟﻴﺴﻢ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ‬ ‫ﺷﻬﻴﺪ ﺑﻬﺸﺘﻲ‬

‫‪BMI‬‬

‫ﻣﺸﺎﺑﻪ‪ ،‬اﻓﺰاﻳﺶ ﻗﺎﺑﻞ ﺗﻮﺟﻬﻲ دارد‪ .‬ﺑﺮاﺳﺎس ﻳﺎﻓﺘﻪﻫﺎي اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺗﻐﻴﻴﺮات ﻛﻤﺮﻳﻦ ﻣﻲﺗﻮاﻧﺪ در ﺗﺸﺨﻴﺺ ﻣﻜﺎﻧﻴﺴﻢ اﺧﺘﻼل‬ ‫ﻣﺬﻛﻮر و ﻳﺎﻓﺘﻦ راﻫﻜﺎرﻫﺎي درﻣﺎﻧﻲ ﺟﺪﻳﺪ ﻣﻮﺛﺮ واﻗﻊ ﺷﻮد‪.‬‬

‫ﺗﻠﻔﻦ‪021-22432500 :‬‬

‫‪E-mail: hedayati@endocrine.ac.ir‬‬

‫ﻛﻠﻤﺎت ﻛﻠﻴﺪي‪ :‬ﻛﻤﺮﻳﻦ‪ ،‬ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ‪ ،‬ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ‪ ،‬اﻧﺴﻮﻟﻴﻦ‪ ،‬ﭼﺎﻗﻲ‪ ،‬ﺷﺎﺧﺺ ﺗﻮده ﺑﺪﻧﻲ‪.‬‬

‫دﻳﺎﺑﺖ ﻧﻮع دو‬

‫ﻣﻘﺪﻣﻪ‬

‫)‪2 Diabetes Mellitus (T2DM‬‬

‫‪ ،Type‬اﺧﺘﻼل در‬

‫‪2‬و‪1‬‬

‫ﺑﺎﻓﺖ ﭼﺮﺑﻲ ﺑﻪﻋﻨﻮان‬

‫ﭼﺮﺑﻲﻫﺎي ﺧﻮن و ﭼﺎﻗﻲ اﺣﺸﺎﻳﻲ ﻧﻴﺰ ﻣﻲﺑﺎﺷﻨﺪ‪.‬‬ ‫‪Polycystic Ovarian Syndrome‬‬

‫ﻳﻚ ﺳﻴﺴﺘﻢ ﻫﻮرﻣﻮﻧﻲ ﻓﻌﺎل ﻋﻼوه ﺑﺮ اﻳﻔﺎي ﻧﻘﺶ در ذﺧﻴﺮه اﻧﺮژي‪ ،‬در‬

‫از ﺟﻤﻠﻪ ﺑﻴﻤﺎريﻫﺎي ﺷﺎﻳﻊ ﻏﺪد درونرﻳﺰ ﺑﻮده ﻛﻪ از ﺟﻤﻠﻪ‬

‫ﻛﻨﺘﺮل ﻣﺘﺎﺑﻮﻟﻴﺴﻢ ﺑﺪن ﻧﻴﺰ ﺷﺮﻛﺖ ﻣﻲﻛﻨﺪ‪ .‬آدﻳﭙﻮﻛﻴﻦﻫﺎ‪ ،‬ﭘﺮوﺗﻴﻴﻦﻫﺎي‬

‫ﻋﻼﻳﻢ آن ازدﻳﺎد آﻧﺪروژنﻫﺎ و ﻋﺪم ﺗﺨﻤﻚﮔﺬاري ﻣﺰﻣﻦ اﺳﺖ‪ .‬ﺑﻴﻤﺎران‬

‫‪4‬و‪3‬‬

‫ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ‬ ‫)‪(PCOS‬‬

‫ﻣﺒﺘﻼ ﺑﻪ‬

‫‪PCOS‬‬

‫داراي اﺧﺘﻼﻻت ﻣﺘﺎﺑﻮﻟﻴﻜﻲ ﻣﺎﻧﻨﺪ ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ‪،‬‬

‫ﻧﻘﺺ ﻋﻤﻠﻜﺮدي ﺳﻠـﻮلﻫﺎي ﺑـﺘﺎ در ﻟـﻮزاﻟﻤﻌﺪه‪ ،‬ﻋـﺪم ﺗﺤـﻤﻞ ﮔﻠﻮﻛﺰ‪،‬‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ 320 ،5‬ﺗﺎ ‪324‬‬

‫ﺗﺮﺷﺢﺷﺪه از ﺑﺎﻓﺖ ﭼﺮﺑﻲ ﻫﺴﺘﻨﺪ ﻛﻪ اﻳﻦ ﻧﻘﺶ را ﺑﻪ ﻋﻬﺪه دارﻧﺪ‪.‬‬

‫ﻃﺒﻖ ﻣﻄﺎﻟﻌﺎت اﻧﺠﺎم ﮔﺮﻓﺘﻪ‪ ،‬آدﻳﭙﻮﻛﻴﻦﻫﺎ ﻧﻘﺶ ﻣﻬﻤﻲ در ﭘﻴﺪاﻳﺶ‬ ‫‪6‬و‪5‬‬

‫ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ اﻳﻔﺎ ﻣﻲﻛﻨﻨﺪ‪.‬‬

‫ﻛﻤﺮﻳﻦ )‪ (Chemerin‬از ﺟﻤﻠﻪ اﻳﻦ‬

‫ارﺗﺒﺎط ‪ ،Chemerin‬ﻫﻮرﻣﻮن ﺑﺎﻓﺖ ﭼﺮﺑﻲ‪ ،‬ﺑﺎ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ‬

‫آدﻳﭙﻮﻛﻴﻦﻫﺎﺳﺖ ﻛﻪ ﺑﻪﺻﻮرت ﭘﻠﻲﭘﭙﺘﻴﺪ ﻧﺎﺑﺎﻟﻎ ﺑﺎ وزن ﻣﻮﻟﻜﻮﻟﻲ ‪18‬‬

‫ﻣﻌﻴﺎرﻫﺎي ﺗﺨﺼﺼﻲ اﻧﺴﺘﻴﺘﻮ ﻣﻠﻲ ﺑﻬﺪاﺷﺖ‬

‫‪321‬‬

‫‪National Institutes of‬‬

‫‪15‬‬

‫‪ Health‬ﺗﻮﺳﻂ ﻣﺘﺨﺼﺺ زﻧﺎن در درﻣﺎﻧﮕﺎه زﻧﺎن ﺑﻴﻤﺎرﺳﺘﺎن‬

‫ﻛﻴﻠﻮداﻟﺘﻮن از ﺑﺎﻓﺖ ﭼﺮﺑﻲ اﺣﺸﺎﻳﻲ و ﻛﺒﺪ ﺗﺮﺷﺢ ﻣﻲﺷﻮد‪ .‬ﺳﭙﺲ‬

‫)‪(NIH‬‬

‫ﺑﻪﻛﻤﻚ آﻧﺰﻳﻢ ﺳﺮﻳﻦ ﭘﺮوﺗﺌﺎز ﺑﺎ ﺣﺬف ﺷﺶ اﺳﻴﺪ آﻣﻴﻨﻪ از اﻧﺘﻬﺎي‬

‫آﻳﺖاﷲ ﻃﺎﻟﻘﺎﻧﻲ اﻧﺠﺎم ﮔﺮﻓﺖ( و زﻧﺎن ﺳﺎﻟﻢ )اﻓﺮاد ﻏﻴﺮ ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم‬

‫ﻛﺮﺑﻮﻛﺴﻴﻞ ﭘﻠﻲﭘﭙﺘﻴﺪ ﻧﺸﺎﻧﻪ ﺑﻪ ﻛﻤﺮﻳﻦ ﺑﺎﻟﻎ ﺑﺎ وزن ﻣﻮﻟﻜﻮﻟﻲ ‪16‬‬

‫ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ( ﻣﻮرد ارزﻳﺎﺑﻲ ﻗﺮار ﮔﺮﻓﺘﻨﺪ‪ .‬اﻓﺮادي ﻛﻪ داروﻫﺎﻳﻲ‬

‫‪8‬و‪7‬‬

‫ﻛﻴﻠﻮداﻟﺘﻮن ﺗﺒﺪﻳﻞ ﻣﻲﮔﺮدد‪.‬‬

‫ﻧﻈﻴﺮ ﻣﺘﻔﻮرﻣﻴﻦ و داروﻫﺎﻳﻲ ﻛﻪ ﺑﺮ ﻫﻮرﻣﻮنﻫﺎ و ﻣﺘﺎﺑﻮﻟﻴﺴﻢ ﺑﺪن ﻣﻮﺛﺮ‬

‫ﻃﺒﻖ ﺗﺤﻘﻴﻘﺎت ‪ ،Bozaoglu‬ﺑﻪدﻟﻴﻞ ﻧﻘﺶ ﻛﻤﺮﻳﻦ در ﺗﻤﺎﻳﺰ‬

‫ﺑﺎﺷﺪ ﻣﺼﺮف ﻛﺮده ﺑﻮدﻧﺪ از ﻣﻄﺎﻟﻌﻪ ﺣﺬف ﺷﺪﻧﺪ‪.‬‬

‫ﺳﻠﻮلﻫﺎي ﭼﺮﺑﻲ و اﻓﺰاﻳﺶ ﺟﺬب ﮔﻠﻮﻛﺰ‪ ،‬اﻳﻦ ﭘﺮوﺗﻴﻴﻦ را در ﮔﺮوه‬

‫ﺣﺠﻢ ﻧﻤﻮﻧﻪ ﺑﺮ اﺳﺎس ﻣﻄﺎﻟﻌﺎت ﻣﺸﺎﺑﻪ ﺣﺪاﻗﻞ ‪ 45‬ﻧﻔﺮ در ﻫﺮ ﮔﺮوه‬

‫آدﻳﭙﻮﻛﻴﻦﻫﺎ ﻃﺒﻘﻪﺑﻨﺪي ﻛﺮدﻧﺪ‪ 9.‬ﻻزم ﺑﻪ ذﻛﺮ اﺳﺖ ﻛﻪ ﺗﻮﻟﻴﺪ ﻛﻤﺮﻳﻦ‬

‫ﺗﻌﻴﻴﻦ ﺷﺪ‪ .‬از ﻛﻠﻴﻪ ﻣﺮاﺟﻌﻴﻦ رﺿﺎﻳﺖﻧﺎﻣﻪ آﮔﺎﻫﺎﻧﻪ ﻛﺘﺒﻲ ﺟﻬﺖ اﺳﺘﻔﺎده از‬

‫ﺑﻪﻋﻨﻮان ﻳﻚ ﭘﺮوﺗﻴﻴﻦ ﻛﻤﻮﺗﺎﻛﺘﻴﻚ در ﻣﻨﺎﻃﻖ اﻟﺘﻬﺎﺑﻲ ﻧﻴﺰ ﮔﺰارش ﺷﺪه‬

‫ﻧﻤﻮﻧﻪ ﺧﻮن آنﻫﺎ در ﻃﺮح ﺗﺤﻘﻴﻘﺎﺗﻲ ﮔﺮﻓﺘﻪ ﺷﺪ‪ .‬ﻓﺮم ﺟﻤﻊآوري‬

‫اﺳﺖ‪ .‬اﻳﻦ ﻣﻮﻟﻜﻮل ﻧﻘﺶ ﻣﻬﻢ و ﺑﺎﻟﻘﻮهاي در ﻛﻨﺘﺮل ﭘﺎﺳﺦ اﻳﻤﻨﻲ در‬

‫دادهﻫﺎي دﻣﻮﮔﺮاﻓﻴﻚ ﺑﺮاي ﻫﺮ ﻳﻚ از اﻓﺮاد ﺷﺮﻛﺖﻛﻨﻨﺪه در ﻣﻄﺎﻟﻌﻪ‬

‫ﻧﻮاﺣﻲ ﻣﻠﺘﻬﺐ و ﺑﺎﻓﺖﻫﺎي ﻣﺠﺮوح اﻳﻔﺎ ﻣﻲﻛﻨﺪ و ﺑﻪﻋﻨﻮان ﻳﻚ ﻋﺎﻣﻞ‬

‫ﺗﻜﻤﻴﻞ ﺷﺪ‪ .‬ﻣﺸﺨﺼﺎت ﺗﻦﺳﻨﺠﻲ ﺷﺎﻣﻞ اﻧﺪازهﮔﻴﺮي وزن ﺑﺎ ﺣﺴﺎﺳﻴﺖ‬

‫ﻛﻤﺮﻳﻦ ﺑﻪﻋﻨﻮان ﻳﻚ ﻋﺎﻣﻞ‬

‫‪ 100‬ﮔﺮم و ﻗﺪ ﺑﺎ ﺣﺴﺎﺳﻴﺖ ‪ 0/5‬ﺳﺎﻧﺘﻲﻣﺘﺮ اﺧﺬ ﺷﺪ و ﺷﺎﺧﺺ ﺗﻮده‬

‫ﭘﺎراﻛﺮﻳﻦ‪ /‬اﺗﻮﻛﺮﻳﻦ اﺳﺖ ﻛﻪ ﻣﻨﺠﺮ ﺑﻪ ﺗﺤﺮﻳﻚ واﺑﺴﺘﮕﻲ ﺟﺬب ﮔﻠﻮﻛﺰ‬

‫ﺑﺪﻧﻲ از ﺗﻘﺴﻴﻢ وزن )ﻛﻴﻠﻮﮔﺮم( ﺑﺮ ﻣﺠﺬور ﻗﺪ )ﻣﺘﺮ ﻣﺮﺑﻊ( ﻣﺤﺎﺳﺒﻪ‬

‫ﺗﻮﺳﻂ اﻧﺴﻮﻟﻴﻦ و اﻓﺰاﻳﺶ ﭘﻴﺎمرﺳﺎﻧﻲ اﻧﺴﻮﻟﻴﻦ در آدﻳﭙﻮﺳﻴﺖﻫﺎ‬

‫ﮔﺮدﻳﺪ‪ .‬از اﻓﺮاد داوﻃﻠﺐ در وﺿﻌﻴﺖ ﻧﺎﺷﺘﺎ ﺳﻪ ﻣﻴﻠﻲﻟﻴﺘﺮ ﺧﻮن ورﻳﺪي‬

‫‪11‬و‪10‬‬

‫ﺿﺪ اﻟﺘﻬﺎﺑﻲ ﻧﻴﺰ ﺷﻨﺎﺧﺘﻪ ﺷﺪه اﺳﺖ‪.‬‬

‫‪12‬و‪11‬‬

‫در ﺣﺎﻟﺖ ﻧﺸﺴﺘﻪ از ورﻳﺪ آﻧﺘﻪ ﻛﻮﺑﻴﺘﺎل دﺳﺖ ﭼﭗ ﮔﺮﻓﺘﻪ ﺷﺪ‪ .‬ﭘﺲ از‬

‫ﻣﻲﺷﻮد‪.‬‬

‫ﻃﺒﻖ ﭘﮋوﻫﺶﻫﺎي اﺧﻴﺮ ﺳﻄﺢ ﺳﺮﻣﻲ ﻛﻤﺮﻳﻦ در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ‬ ‫ﭼﺎﻗﻲ و دﻳﺎﺑﺖ ﻧﻮع دو اﻓﺰاﻳﺶ ﻣﻲﻳﺎﺑﺪ‪ .‬ﻏﻠﻈﺖ ﭘﻼﺳﻤﺎﻳﻲ ﻛﻤﺮﻳﻦ ﻧﻴﺰ‬

‫ﭘﻨﺞ دﻗﻴﻘﻪ زﻣﺎن اﻧﻌﻘﺎد‪ ،‬ﻧﻤﻮﻧﻪﻫﺎي ﻣﺬﻛﻮر ﺑﻪﻣﺪت ‪ 10‬دﻗﻴﻘﻪ ﺑﺎ دور‬

‫‪rpm‬‬

‫‪ 3000‬ﺳﺎﻧﺘﺮﻳﻔﻴﻮژ ﺷﺪﻧﺪ‪.‬‬

‫ﻫﻤﺒﺴﺘﮕﻲ ﻣﺜﺒﺘﻲ ﺑﺎ ﺷﺎﺧﺺ ﺗﻮده ﺑﺪﻧﻲ )‪ ،(BMI‬ﮔﻠﻮﻛﺰ ﺧﻮن ﻧﺎﺷﺘﺎ‪،‬‬

‫آزﻣﺎﻳﺶﻫﺎي روﺗﻴﻦ ﺳﻨﺠﺶ ﮔﻠﻮﻛﺰ اﻧﺠﺎم ﮔﺮﻓﺖ و ﺑﻘﻴﻪ ﺳﺮمﻫﺎي‬

‫‪Tumor Necrosis ) TNF-α‬‬

‫ﺑﻪدﺳﺖآﻣﺪه در دﻣﺎي ‪ -80 C‬ﻓﺮﻳﺰ ﺷﺪﻧﺪ و ﺟﻬﺖ آزﻣﺎﻳﺶﻫﺎﻳﻲ ﻧﻈﻴﺮ‬

‫اﻧﺴﻮﻟﻴﻦ ﺳﺮم ﺧﻮن ﻧﺎﺷﺘﺎ‪ ،‬ﻟﭙﺘﻴﻦ‪ ،‬رزﻳﺴﺘﻴﻦ‪،‬‬

‫‪13‬و‪9‬‬

‫‪ (Factor-α‬و ‪ (Interleukin-6) IL-6‬دارد‪.‬‬

‫ﻛﻤﺮﻳﻦ و اﻧﺴﻮﻟﻴﻦ ﻣﻮرد اﺳﺘﻔﺎده ﻗﺮار ﮔﺮﻓﺘﻨﺪ‪ .‬ﺳﻄﺢ ﻛﻤﺮﻳﻦ ﺳﺮم ﺑﺎ‬

‫در ﭼﻨﺪ ﺳﺎل اﺧﻴﺮ ﻣﻄﺎﻟﻌﺎﺗﻲ ﺻﻮرت ﮔﺮﻓﺘﻪ اﺳﺖ ﻛﻪ ارﺗﺒﺎط‬

‫روش اﻻﻳﺰاي رﻗﺎﺑﺘﻲ ﺑﺎ اﺳﺘﻔﺎده از ﻛﻴﺖ اﻻﻳﺰاي ﻛﻤﺮﻳﻦ اﻧﺴﺎﻧﻲ‬

‫ﻧﺰدﻳﻚ ﭼﺎﻗﻲ و ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ را ﺑﺎ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ‬

‫‪ (Cusabio Biotech Co., Ltd Manufacturer‬ﺑﺎ‬

‫)‪(PCOS‬‬

‫‪14‬و‪6‬‬

‫در زﻧﺎن ﻧﺸﺎن ﻣﻲدﻫﺪ‪.‬‬

‫ﺑﻨﺎﺑﺮاﻳﻦ اﺣﺘﻤﺎﻻ ﻣﻴﺎن ﺳﻄﺢ ﺳﺮﻣﻲ‬

‫ﻛﻤﺮﻳﻦ‪ ،‬ﻫﻮرﻣﻮن ﻣﺘﺮﺷﺤﻪ ﺑﺎﻓﺖ ﭼﺮﺑﻲ‪ ،‬ﺑﺎ ‪ PCOS‬ارﺗﺒﺎط وﺟﻮد دارد‪.‬‬ ‫ﻟﺬا ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﺑﺎ ﻫﺪف ﺑﺮرﺳﻲ ارﺗﺒﺎط ﻛﻤﺮﻳﻦ ﺑﺎ ﺳﻨﺪرم‬ ‫ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ اﻧﺠﺎم ﮔﺮﻓﺖ‪.‬‬

‫)‪& Supplier, China‬‬

‫ﺣﺴﺎﺳﻴﺖ ﻫﺸﺖ ﭘﻴﻜﻮﮔﺮم ﺑﺮ ﻣﻴﻠﻲﻟﻴﺘﺮ ﺗﻌﻴﻴﻦ ﺷﺪ‪.‬‬ ‫اﻧﺪازهﮔﻴﺮي ﻫﻮرﻣﻮن اﻧﺴﻮﻟﻴﻦ ﺑﻪروش آﻧﺰﻳﻢ اﻳﻤﻮﻧﻮاﺳﻲ ﺑﺎ اﺳﺘﻔﺎده‬ ‫از ﻛﻴﺖ )‪ (Mercodia Co., Sweden‬اﻧﺠﺎم ﮔﺮﻓﺖ‪ .‬در ﻧﻬﺎﻳﺖ ﺟﺬب‬ ‫ﻧﻮري و ﻣﺤﺎﺳﺒﻪ ﻧﺘﺎﻳﺞ ﺗﻮﺳﻂ دﺳﺘﮕﺎه ﺧﻮاﻧﺶﮔﺮ اﻻﻳﺰا ﺧﻮاﻧﺪه ﺷﺪ‪.‬‬ ‫اﻧﺪازهﮔﻴﺮي ﺳﻄﺢ ﮔﻠﻮﻛﺰ ﺑﺎ روش ﻓﺘﻮﻣﺘﺮﻳﻚ اﻧﺠﺎم ﮔﺮﻓﺖ‪ .‬ﻣﻴﺰان‬

‫روش ﺑﺮرﺳﻲ‬ ‫ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﻳﻚ ﻣﻄﺎﻟﻌﻪ ﻣﻮرد‪ -‬ﺷﺎﻫﺪي اﺳﺖ ﻛﻪ روي ﺑﻴﻤﺎران‬ ‫ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ ﻣﺮاﺟﻌﻪﻛﻨﻨﺪه ﺑﻪ درﻣﺎﻧﮕﺎه زﻧﺎن‬

‫‪16‬‬

‫ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ ﻧﻴﺰ ﻃﺒﻖ ﻓﺮﻣﻮل زﻳﺮ ﻣﺤﺎﺳﺒﻪ ﮔﺮدﻳﺪ‪.‬‬

‫‪HOMA: Fasting Serum Insulin (μu⁄ml)× Insulin Fasting Plasma‬‬ ‫‪Glucose (mmol) /22.5‬‬

‫ﺗﺠﺰﻳﻪ و ﺗﺤﻠﻴﻞ دادهﻫﺎ ﺗﻮﺳﻂ ﻧﺮماﻓﺰار آﻣﺎري‬

‫‪SPSS‬‬

‫وﻳﺮاﺳﺖ ‪18‬‬ ‫ﻣﻴﺎﻧﮕﻴﻦ‪±‬‬

‫ﺑﻴﻤﺎرﺳﺘﺎن آﻳﺖاﷲ ﻃﺎﻟﻘﺎﻧﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺷﻬﻴﺪ ﺑﻬﺸﺘﻲ در‬

‫اﻧﺠﺎم ﮔﺮﻓﺖ‪ .‬ﺗﻤﺎﻣﻲ ﻧﺘﺎﻳﺞ ﺑﻪدﺳﺖآﻣﺪه ﺑﻪﺻﻮرت‬

‫ﺳﺎل ‪ 1390‬اﻧﺠﺎم ﮔﺮﻓﺖ‪ .‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ دو ﮔﺮوه ‪ 45‬ﻧﻔﺮي از زﻧﺎن‬

‫اﻧﺤﺮافﻣﻌﻴﺎر ﺑﻴﺎن ﺷﺪ‪ .‬ﺑﺎ اﺳﺘﻔﺎده از ‪،Kolmogorov-Smirnov Test‬‬

‫ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ )ﺗﺸﺨﻴﺺ آنﻫﺎ ﺑﺎ در ﻧﻈﺮ ﮔﺮﻓﺘﻦ‬

‫ﺗﻮزﻳﻊ ﻣﺘﻐﻴﺮﻫﺎ ﻣﻮرد ﺑﺮرﺳﻲ ﻗﺮار ﮔﺮﻓﺖ ﻛﻪ ﻛﻠﻴﻪ ﻣﺘﻐﻴﺮﻫﺎي ﻛﻤﻲ‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):320-4‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﺳﭙﻴﺪه ﺣﻘﻴﻘﻲ و ﻫﻤﻜﺎران‬

‫‪322‬‬

‫ﺑﻪاﺳﺘﺜﻨﺎي ﻣﺘﻐﻴﺮ اﻧﺴﻮﻟﻴﻦ داراي ﺗﻮزﻳﻊ ﻧﺮﻣﺎل ﺑﻮدﻧﺪ‪ .‬ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻧﺮﻣﺎل‬

‫ﮔﺮوه ﺑﻴﻤﺎر ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ ﺑﻪﺗﻔﻜﻴﻚ در‬

‫ﻧﺒﻮدن ﻣﺘﻐﻴﺮ اﻧﺴﻮﻟﻴﻦ از ﺗﺒﺪﻳﻞ ﻟﮕﺎرﻳﺘﻤﻲ ﺑﻪﻣﻨﻈﻮر ﻧﺮﻣﺎل ﻛﺮدن آن‬

‫ﺟﺪول‪ 1 -‬ﻧﺸﺎن داده ﺷﺪه اﺳﺖ‪ .‬در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان‬

‫اﺳﺘﻔﺎده ﺷﺪ‪ .‬ﺑﻪﻣﻨﻈﻮر ﻣﻘﺎﻳﺴﻪ ﻣﻴﺎﻧﮕﻴﻦ ﺑﻴﻦ ﮔﺮوهﻫﺎ از آزﻣﻮن‬

‫ﭘﻠﻲﻛﻴﺴﺘﻴﻚ ﺳﻄﺢ ﻫﻮرﻣﻮن ﻛﻤﺮﻳﻦ‪ ،‬اﻧﺴﻮﻟﻴﻦ‪ ،‬ﮔﻠﻮﻛﺰ و ﻣﻴﺰان ﻣﻘﺎوﻣﺖ‬

‫‪ Independent sample T-test‬و ﺑﺮاي ﺑﺮرﺳﻲ راﺑﻄﻪ ﺑﻴﻦ ﻣﺘﻐﻴﺮﻫﺎي‬

‫ﺑﻪ اﻧﺴﻮﻟﻴﻦ ﺑﻪﻃﻮر ﻣﻌﻨﻲداري ﺑﻴﺶﺗﺮ از ﮔﺮوه ﺷﺎﻫﺪ ﺑﻮد )‪P<0/05‬؛‬

‫ﻛﻤﻲ در ﮔﺮوهﻫﺎ از ﺿﺮﻳﺐ ﻫﻤﺒﺴﺘﮕﻲ ﭘﻴﺮﺳﻮن اﺳﺘﻔﺎده ﺷﺪ‪ .‬اﺧﺘﻼف‬

‫ﺟﺪول‪ .(1 -‬اﻣﺎ ﻣﻴﺰان ﺷﺎﺧﺺ ﺗﻮده ﺑﺪﻧﻲ در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم‬

‫ﻣﻌﻨﻲدار ﺑﻮدن در ﺳﻄﺢ ‪ α=0/05‬ﺑﺮرﺳﻲ ﺷﺪ‪.‬‬

‫ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ ﻧﺴﺒﺖ ﺑﻪ ﮔﺮوه ﺷﺎﻫﺪ اﺧﺘﻼف ﻣﻌﻨﻲداري را ﻧﺸﺎن‬ ‫ﻧﺪاد )‪P>0/05‬؛ ﺟﺪول‪ .(1 -‬ﻫﻢﭼﻨﻴﻦ ارﺗﺒﺎط آﻣﺎري ﻣﻌﻨﻲداري ﻣﻴﺎن‬ ‫ﺳﻄﺢ ﺳﺮﻣﻲ ﻫﻮرﻣﻮن ﻛﻤﺮﻳﻦ ﺑﺎ ﺷﺎﺧﺺ ﺗﻮده ﺑﺪﻧﻲ و ﻣﻘﺎدﻳﺮ ﺳﺮﻣﻲ‬

‫ﻳﺎﻓﺘﻪﻫﺎ‬

‫ﮔﻠﻮﻛﺰ و اﻧﺴﻮﻟﻴﻦ و ﺷﺎﺧﺺ ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ در ﮔﺮوه ﺑﻴﻤﺎران‬ ‫ﻣﻴﺎﻧﮕﻴﻦ ﻧﻤﺎﻳﻪ ﺗﻮده ﺑﺪﻧﻲ‪ ،‬ﺳﻄﺢ ﺳﺮﻣﻲ ﮔﻠﻮﻛﺰ و ﻫﻮرﻣﻮنﻫﺎي‬ ‫ﻛﻤﺮﻳﻦ و اﻧﺴﻮﻟﻴﻦ و ﻣﻴـﺰان ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴـﻦ ﺑﻴـﻦ ﮔـﺮوه ﺷـﺎﻫﺪ و‬

‫ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ و ﮔﺮوه ﺷﺎﻫﺪ وﺟﻮد ﻧﺪاﺷﺖ‬ ‫)‪P>0/05‬؛ ﺟﺪول‪.(2 -‬‬

‫ﺑﺤﺚ‬ ‫ﺟﺪول‪ :1 -‬ﻣﺸﺨﺼﺎت ﺑﻴﻮﺷﻴﻤﻴﺎﻳﻲ و آﻧﺘﺮوﭘﻮﻣﺘﺮﻳﻚ ﮔﺮوه ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺳـﻨﺪرم‬ ‫ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ و ﮔﺮوه ﺷﺎﻫﺪ‬ ‫ﮔﺮوه ﺷﺎﺧﺺ‬

‫ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ‪(n=45) PCOS‬‬

‫ﺷﺎﻫﺪ )‪(n=45‬‬

‫‪(kg/m2) BMI‬‬

‫‪26/8±4/3‬‬

‫‪25/7±4/1‬‬

‫ﻛﻤﺮﻳﻦ )‪(pg/dl‬‬

‫‪657/5±273/3‬‬

‫‪474±295/1‬‬

‫اﻧﺴﻮﻟﻴﻦ )‪(mU/l‬‬

‫‪10/8±5/2‬‬

‫‪7/6±4/4‬‬

‫ﮔﻠﻮﻛﺰ )‪(mg/dL‬‬

‫‪104/1±13/4‬‬

‫‪100/3±9/3‬‬

‫‪2/8±1/3‬‬

‫‪1/9±1/1‬‬

‫‪HOMA-IR‬‬

‫‪BMI: Body Mass Index‬‬ ‫‪HOMA-IR: Homeostatic Model Assessment-Insulin Resistance‬‬

‫ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﻧﺸﺎن داد ﻛﻪ ﺳﻄﺢ ﺳﺮﻣﻲ ﻛﻤﺮﻳﻦ در اﻓﺮاد‬ ‫ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ ﻧﺴﺒﺖ ﺑﻪ ﮔﺮوه ﺷﺎﻫﺪ ﺑﻴﺶﺗﺮ‬ ‫اﺳﺖ‪ .‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ارﺗﺒﺎط ﻣﻌﻨﻲداري ﻣﻴﺎن ﺳﻄﺢ ﺳﺮﻣﻲ ﻛﻤﺮﻳﻦ ﺑﺎ‬ ‫ﻣﻴﺰان اﻧﺴﻮﻟﻴﻦ‪ ،‬ﮔﻠﻮﻛﺰ و ﺷﺎﺧﺺ ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ ﻣﺸﺎﻫﺪه ﻧﺸﺪ‪ ،‬ﻛﻪ‬ ‫ﻣﻤﻜﻦ اﺳﺖ ﺑﻪﻋﻠﺖ ﻣﺤﺪودﻳﺖ ﺗﻌﺪاد ﻧﻤﻮﻧﻪﻫﺎي ﻣﻮرد ﺑﺮرﺳﻲ ﺑﺎﺷﺪ‪.‬‬ ‫ﺑﻪﻃﻮر ﻛﻠﻲ‪ ،‬ﺗﻌﺪاد ﻛﻤﻲ از ﻣﻄﺎﻟﻌﺎت اﺧﺘﻼف ﺳﻄﻮح ﺳﺮﻣﻲ‬ ‫ﻛﻤﺮﻳﻦ را در دو ﮔﺮوه اﻓﺮاد ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ و‬ ‫ﮔﺮوه ﺳﺎﻟﻢ ﮔﺰارش ﻛﺮدهاﻧﺪ‪ .‬ﺗﻘﺮﻳﺒﺎ ﺗﻤﺎﻣﻲ آنﻫﺎ ﻧﺘﺎﻳﺞ ﻫﻢﺳﻮﻳﻲ را ﺑﺎ‬ ‫ﻳﺎﻓﺘﻪﻫﺎي ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﮔﺰارش ﻛﺮدهاﻧﺪ‪.‬‬ ‫در ﻣﻄﺎﻟﻌﻪاي ﻛﻪ ﺑﺮ روي ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان‬ ‫ﭘﻠﻲﻛﻴﺴﺘﻴﻚ اﻧﺠﺎم ﺷﺪ‪ ،‬ﻧﺸﺎن داد ﻛﻪ ﺳﻄﻮح ‪ m-RNA‬و ﭘﺮوﺗﻴﻴﻦ‬

‫ﺟﺪول‪ :2 -‬ﻣﻘﺪار ﻫﻤﺒﺴﺘﮕﻲ ﭘﻴﺮﺳﻮن ﻣﻴﺎن ﻫﻮرﻣﻮن ﻛﻤﺮﻳﻦ ﺑﺎ ﻧﻤﺎﻳـﻪ ﺗـﻮده ﺑـﺪﻧﻲ‪،‬‬ ‫ﮔﻠﻮﻛﺰ‪ ،‬ﻟﮕﺎرﻳﺘﻢ اﻧﺴﻮﻟﻴﻦ و ﺷﺎﺧﺺ ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ در ﮔﺮوه ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑـﻪ‬ ‫ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ و ﮔﺮوه ﺷﺎﻫﺪ‬ ‫ﺷﺎﻫﺪ ‪ 45‬ﻧﻔﺮ‬

‫ﮔﺮوه‬

‫ﻣﻮرد ‪ 45‬ﻧﻔﺮ‬

‫ﻛﻤﺮﻳﻦ در ﻧﻤﻮﻧﻪ ﭼﺮﺑﻲ ﺷﻜﻤﻲ و ﭼﺮﺑﻲ زﻳﺮ ﭘﻮﺳﺘﻲ زﻧﺎن ﻣﺒﺘﻼ اﻓﺰاﻳﺶ‬ ‫دارد‪ 17.‬در ﻣﻄﺎﻟﻌﻪي دﻳﮕﺮي روي زﻧﺎن ﭼﺎق ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان‬ ‫ﭘﻠﻲﻛﻴﺴﺘﻴﻚ‪ ،‬در آزﻣﻮن اول ﺳﻄﺢ ﻛﻤﺮﻳﻦ ﺧﻮن و ﺑﺎﻓﺖ ﭼﺮﺑﻲ در زﻧﺎن‬

‫‪r‬‬

‫‪p‬‬

‫‪r‬‬

‫‪p‬‬

‫ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ ﻧﺴﺒﺖ ﺑﻪ ﮔﺮوه ﻛﻨﺘﺮل اﻓﺰاﻳﺶ‬

‫‪(kg/m2) BMI‬‬

‫‪0/22‬‬

‫‪0/13‬‬

‫‪0/004‬‬

‫‪0/98‬‬

‫ﭼﺸﻢﮔﻴﺮي داﺷﺖ‪ .‬در آزﻣﻮن دوم‪ ،‬اﻓﺰاﻳﺶ ﺷﺪﻳﺪ ﺳﻄﺢ ﻛﻤﺮﻳﻦ ﺗﻮﺳﻂ‬

‫ﮔﻠﻮﻛﺰ )‪(mg/dl‬‬

‫‪-0/11‬‬

‫‪0/45‬‬

‫‪0/1‬‬

‫‪0/5‬‬

‫اﻧﺴﻮﻟﻴﻦ در ﺑﺪن ﻣﻮﺟﻮد زﻧﺪه ﺑﻪدﺳﺖ آﻣﺪ‪ .‬در آزﻣﻮن ﺳﻮم ﻧﺸﺎن داده‬

‫ﻟﮕﺎرﻳﺘﻢ اﻧﺴﻮﻟﻴﻦ )‪(mU/L‬‬

‫‪0/07‬‬

‫‪0/64‬‬

‫‪0/09‬‬

‫‪0/54‬‬

‫ﺷﺪ داروي ﻣﺖ ﻓﻮرﻣﻴﻦ‪ ،‬ﺳﻄﺢ ﻛﻤﺮﻳﻦ ﺧﻮن را در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ‬

‫‪HOMA-IR‬‬

‫‪0/04‬‬

‫‪0/77‬‬

‫‪0/13‬‬

‫‪0/38‬‬

‫ﺷﺎﺧﺺ‬

‫در آزﻣﻮن ﻫﻤﺒﺴﺘﮕﻲ ﺳﻄﺢ ﻣﻌﻨﻲداري ‪ P<0/05‬در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪ‪.‬‬ ‫‪HOMA-IR: Homeostatic Model Assessment-Insulin Resistance‬‬

‫ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ ﻣﻘﺎوم ﺑﻪ اﻧﺴﻮﻟﻴﻦ ﺑﻪﺷﺪت ﻛﺎﻫﺶ ﻣﻲدﻫﺪ‬ ‫و اﻧﺴﻮﻟﻴﻦ ﻣﻨﺠﺮ ﺑﻪ ﺗﻨﻈﻴﻢ ﺑﺎﻟﻘﻮه ﻛﻤﺮﻳﻦ در ﺷﺮاﻳﻂ درون و ﺑﻴﺮون ﺑﺪن‬

‫ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ‬ ‫ ﺑﺎ‬،‫ﭼﺮﺑﻲ‬S.‫ﺑﺎﻓﺖ‬ ‫ ﻫﻮرﻣﻮن‬،Chemerin ‫ارﺗﺒﺎط‬ Haghighi et al.

323

‫( ﻛﻪ اﻳﻦ ﻧﺘﺎﻳﺞ ﻧﺸﺎن ﻣﻲدﻫﺪ ﻛﻪ ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ در‬P<0/05)

‫ ﻫﻢﭼﻨﻴﻦ در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻣﺸﺨﺺ ﮔﺮدﻳﺪ ﻛﻪ‬.‫ﻣﻮﺟﻮد زﻧﺪه ﻣﻲﺷﻮد‬

‫ اﻣﺎ ارﺗﺒﺎط ﻣﻌﻨﻲداري ﻣﻴﺎن‬،‫ ﺑﻴﺶﺗﺮ از ﮔﺮوه ﻛﻨﺘﺮل اﺳﺖ‬PCOS ‫ﺑﻴﻤﺎران‬

‫ﻫﻤﺒﺴﺘﮕﻲ ﻣﺜﺒﺖ ﭼﺸﻢﮔﻴﺮي ﻣﻴﺎن ﻛﻤﺮﻳﻦ ﺧﻮن و ﻛﻤﺮﻳﻦ ﻣﻮﺟﻮد در‬

.‫ﺳﻄﺢ ﻛﻤﺮﻳﻦ ﺳﺮم ﺑﺎ ﻣﻴﺰان ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ ﻣﺸﺎﻫﺪه ﻧﺸﺪ‬ ‫ ﺳﻄﺢ ﺳﺮﻣﻲ ﻛﻤﺮﻳﻦ در‬،‫ﻃﺒﻖ ﻧﺘﺎﻳﺞ اﻳﻦ ﭘﮋوﻫﺶ و ﺳﺎﻳﺮ ﻣﻄﺎﻟﻌﺎت‬

(Waist to Hip WHR ،BMI

‫ﺑﺎﻓﺖ ﭼﺮﺑﻲ زﻳﺮ ﭘﻮﺳﺘﻲ و ﺷﻜﻤﻲ ﺑﺎ‬

‫و ﺗﺮيﮔﻠﻴﺴﺮﻳﺪ ﺧﻮن وﺟﻮد‬

HOMA-IR

،‫ اﻧﺴﻮﻟﻴﻦ‬،‫ ﮔﻠﻮﻛﺰ‬،Ratio)

‫ اﻓﺰاﻳﺶ در‬.‫اﻓﺮاد ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ اﻓﺰاﻳﺶ ﻣﻲﻳﺎﺑﺪ‬

‫ ﻣﺴﺘﻘﻞ از ﺗﻐﻴﻴﺮات ﻧﻤﺎﻳﻪ ﺗﻮده ﺑﺪﻧﻲ در ﺑﻴﻤﺎران‬،‫ﻣﻴﺰان ﻛﻤﺮﻳﻦ ﺳﺮم‬

‫ ﺗﺤﻘﻴﻘﺎت ﻣﺸﺎﺑﻬﻲ در ﻫﻤﻴﻦ راﺳﺘﺎ اﻧﺠﺎم داد ﻛﻪ ﻣﺸﺎﻫﺪه ﻛﺮد‬Ernst

‫ ﺑﻨﺎﺑﺮاﻳﻦ ﺗﻐﻴﻴﺮات ﺳﻄﺢ‬.‫ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ اﺳﺖ‬

‫ﺳﻄﺢ ﻛﻤﺮﻳﻦ ﺧﻮن در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ دﻳﺎﺑﺖ ﻧﻮع دو و ﭼﺎﻗﻲ اﻓﺰاﻳﺶ‬

‫ﺳﺮﻣﻲ ﻛﻤﺮﻳﻦ را ﻣﻲﺗﻮان ﺑﻪﻋﻨﻮان ﻣﻌﻴﺎري ﺑﺮاي ﺗﺸﺨﻴﺺ و ﺗﺎﻳﻴﺪ‬

‫ﻣﻲﻳﺎﺑﺪ و در ﻧﻤﻮﻧﻪﻫﺎي ﻛﺸﺖﺷﺪه ﺑﺎﻓﺖ ﭼﺮﺑﻲ در ﺷﺮاﻳﻂ آزﻣﺎﻳﺸﮕﺎﻫﻲ‬

‫ ﺑﺪﻳﻦﺗﺮﺗﻴﺐ ﺳﻨﺠﺶ اﻳﻦ‬.‫ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ ﺑﻪﻛﺎر ﺑﺮد‬

‫اﻧﺴﻮﻟﻴﻦ ﺑﻪﺻﻮرت واﺑﺴﺘﻪ ﺑﻪ دوز و واﺑﺴﺘﻪ ﺑﻪ زﻣﺎن ﺑﺎﻋﺚ اﻓﺰاﻳﺶ‬

‫ﻫﻮرﻣﻮن ﻣﻲﺗﻮاﻧﺪ در ﺗﺸﺨﻴﺺ ﻣﻜﺎﻧﻴﺴﻢ اﺧﺘﻼل ﻣﺬﻛﻮر و ﻳﺎﻓﺘﻦ راﻫﻜﺎر‬

‫ ﻫﻢﭼﻨﻴﻦ ﻫﻤﺒﺴﺘﮕﻲ ﻣﺜﺒﺘﻲ ﻣﻴﺎن‬.‫ﺗﺮﺷﺢ ﻛﻤﺮﻳﻦ از ﺑﺎﻓﺖ ﭼﺮﺑﻲ ﻣﻲﺷﻮد‬

.‫درﻣﺎﻧﻲ ﻣﻮﺛﺮ واﻗﻊ ﺷﻮد‬ ‫ اﻳﻦ ﻣﻘﺎﻟﻪ ﺣﺎﺻﻞ ﺑﺨﺸﻲ از ﭘﺎﻳﺎنﻧﺎﻣﻪ ﺗﺤﺖ ﻋﻨﻮان‬:‫ﺳﭙﺎﺳﮕﺰاري‬

.‫دارد‬

‫ ﭘﺮوﺗﻴﻴﻦ واﻛﻨﺶدﻫﻨﺪه‬،‫ رزﻳﺴﺘﻴﻦ‬،‫ﺳﻄﺢ ﻛﻤﺮﻳﻦ ﺳﺮم ﺧﻮن ﺑﺎ ﻟﭙﺘﻴﻦ‬ 7

.‫ وﺟﻮد داﺷﺖ‬IL-6 ‫ و‬TNF-α ،(CRP)

‫"ﺑﺮرﺳﻲ ارﺗﺒﺎط ﺳﻄﺢ ﻛﻤﺮﻳﻦ ﻫﻮرﻣﻮن ﺑﺎﻓﺖ ﭼﺮﺑﻲ ﺑﺎ ﺳﻨﺪروم ﺗﺨﻤﺪان‬

‫ﻧﺘﺎﻳﺞ ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﻧﺸﺎن داد ﻛﻪ ﺳﻄﺢ ﺳﺮﻣﻲ ﻛﻤﺮﻳﻦ در اﻓﺮاد‬

1390 ‫(" در ﻣﻘﻄﻊ ﻛﺎرﺷﻨﺎﺳﻲ ارﺷﺪ در ﺳﺎل‬PCOS) ‫ﭘﻠﻲﻛﻴﺴﺘﻴﻚ‬

‫ﻣﺒﺘﻼ ﺑﻪ ﺳﻨﺪرم ﺗﺨﻤﺪان ﭘﻠﻲﻛﻴﺴﺘﻴﻚ ﻧﺴﺒﺖ ﺑﻪ ﮔﺮوه ﺷﺎﻫﺪ ﺑﻴﺶﺗﺮ‬

،‫ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺎ ﺣﻤﺎﻳﺖ ﭘﮋوﻫﺸﻜﺪه ﻋﻠﻮم ﻏﺪد درونرﻳﺰ و ﻣﺘﺎﺑﻮﻟﻴﺴﻢ‬

‫ ﻫﻢﭼﻨﻴﻦ در اﻳﻦ ﻣﻄﺎﻟﻌﻪ اﺧﺘﻼف ﻣﻌﻨﻲداري ﻣﻴﺎن‬.(P<0/05) ‫اﺳﺖ‬

.‫داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺷﻬﻴﺪ ﺑﻬﺸﺘﻲ اﺟﺮا ﺷﺪه اﺳﺖ‬

‫ﻣﻴﺰان ﻣﻘﺎوﻣﺖ ﺑﻪ اﻧﺴﻮﻟﻴﻦ در اﻓﺮاد ﻣﻮرد و ﮔﺮوه ﺷﺎﻫﺪ ﻣﺸﺎﻫﺪه ﺷﺪ‬

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plasmacytoid dendritic cells to lymphoid organs and inflamed skin. J Exp Med 2005;201(4):509-15. 11. Weigert J, Neumeier M, Wanninger J, Filarsky M, Bauer S, Wiest R, et al. Systemic chemerin is related to inflammation rather than obesity in type 2 diabetes. Clin Endocrinol (Oxf) 2010;72(3):342-8. 12. Tan BK, Chen J, Farhatullah S, Adya R, Kaur J, Heutling D, et al. Insulin and metformin regulate circulating and adipose tissue chemerin. Diabetes 2009;58(9):1971-7. 13. Parlee SD, Ernst MC, Muruganandan S, Sinal CJ, Goralski KB. Serum chemerin levels vary with time of day and are modified by obesity and tumor necrosis factor-{alpha}. Endocrinology 2010;151(6):2590-602. 14. Ernst MC, Sinal CJ. Chemerin: at the crossroads of inflammation and obesity. Trends Endocrinol Metab 2010;21(11):660-7. 15. Zawadski JK, Dunaif A. Diagnostic criteria for polycystic ovary syndrome: towards a rational approach. In: Dunaif A, Givens JR, Haseltine F, editors. Polycystic Ovary Syndrome. Boston, MA: Blackwell Scientific; 1992. p. 377–84. 16. Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia 1985;28(7):412-9. 17. Sell H, Laurencikiene J, Taube A, Eckardt K, Cramer A, Horrighs A, et al. Chemerin is a novel adipocyte-derived factor inducing insulin resistance in primary human skeletal muscle cells. Diabetes 2009;58(12):2731-40.

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Tehran University Medical Journal, August 2012; Vol. 70, No. 5: 320-324

Original Article

The association between serum chemerin concentration and polycystic ovarian syndrome Abstract

Received: December 13, 2011 Accepted: May 06, 2012

Sepideh Haghighi M.Sc. Parichehre Yaghmaei Ph.D.1 Fatemeh Hashemi M.Sc.1 Naghmeh Saadati M.Sc.1 Fahimeh Ramezani Tehrani M.D.2 Mehdi Hedayati Ph.D.3* 1- Department of Biology, Faculty of Basic Sciences, Science and Research Branch, Islamic Azad University, Tehran, Iran. 2- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3- Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Adipokines are proteins which are secreted from the adipose tissue. These groups of proteins are involved in the control of metabolism. Chemerin is one of these adipokines with different proposed biological roles. Serum levels of chemerin have been associated with increased body mass index, insulin resistance, metabolic syndrome, diabetes and cardiovascular diseases. The aim of this study was to assess the association between serum chemerin concentrations and polycystic ovarian syndrome. Methods: This case-control study was performed in Taleghani Hospital in Tehran, Iran during 2011. On 45 patients with polycystic ovarian syndrome and 45 normal individuals as the control group. The participants were selected by easy given sampling method. Body mass index, fasting chemerin and serum insulin concentrations were measured by Enzyme-Linked Immunosorbent Assay (ELIZA) method. Fasting serum glucose was measured by the enzyme-calorimetric method and insulin resistance index (HOMA-IR) was measured by the calculation of relevant equation. Data was analyzed

using independent t-test and Pearson’s correlation coefficient by SPSS version 18. Results: Serum chemerin, insulin, and glucose concentrations were significantly higher in patients with polycystic ovarian syndrome than the control group. There was no significant correlation between body mass index, serum levels of insulin, glucose, HOMA-IR, or chemerin in cases and controls.

Conclusion: This study showed that serum chemerin levels increase in polycystic *

Corresponding author: Chamran Highway, Velenjak St., Yaman St., Parvaneh St., No. 24, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: +98-21-22432500 E-mail: hedayati@endocrine.ac.ir

ovarian syndrome. The findings also suggest that changes in chemerin serum levels could be considered as a criterion for polycystic ovarian syndrome. Keywords: BMI, chemerin, HOMA-IR, insulin, obesity, polycystic ovarian syndrome.

324 ‫ ﺗﺎ‬320 ،5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

‫ﻋﻮاﻣﻞ ﻣﻮﺛﺮ در ﻋﻮارض رﻳﻮي و ﺷﻜﺴﺖ اﻛﺴﺘﻮﺑﺎﺳﻴﻮن در ﺟﺮاﺣﻲﻫﺎي داﺧﻞ ﺟﻤﺠﻤﻪاي‬ ‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ ،5‬ﺻﻔﺤﻪﻫﺎي ‪ 325‬ﺗﺎ ‪329‬‬

‫‪325‬‬

‫ﮔﺰارش ﻛﻮﺗﺎه‬

‫ﻋﻮاﻣﻞ ﻣﻮﺛﺮ در ﻋﻮارض رﻳﻮي و ﺷﻜﺴﺖ اﻛﺴﺘﻮﺑﺎﺳﻴﻮن در ﺟﺮاﺣﻲﻫﺎي داﺧﻞ ﺟﻤﺠﻤﻪاي ‪ 254‬ﺑﻴﻤﺎر‪:‬‬ ‫ﮔﺰارش ﻛﻮﺗﺎه‬

‫ﭼﻜﻴﺪه‬

‫‪1‬‬

‫ﺳﻴﺪ وﺣﻴﺪ ﺣﻴﺪري‬

‫ﺳﻴﺪ ﻣﺤﻤﻮد رﻣﻚ ﻫﺎﺷﻤﻲ‬

‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ﻣﻘﺎﻟﻪ‪1391/01/23 :‬‬

‫ﺗﺎرﻳﺦ ﭘﺬﻳﺮش‪1391/02/10 :‬‬

‫‪1‬‬

‫زﻣﻴﻨﻪ و ﻫﺪف‪ :‬داﻧﺴﺘﻦ ﻋﻮاﻣﻞ ﻣﺮﺗﺒﻂ ﺑﺎ ﻋﻮارض رﻳﻮي و ﺷﻜﺴﺖ در اﻛﺴﺘﻮﺑﺎﺳﻴﻮن در ﺟﺮاﺣﻲﻫﺎي ﻣﻐﺰي ﻣـﻲﺗﻮاﻧـﺪ در‬

‫‪1‬‬

‫ﻋﻨﺎﻳﺖاﷲ ﻋﺒﺎسﻧﮋاد‬

‫ﺟﻠﻮﮔﻴﺮي از اﺑﺘﻼ ﺑﻪ اﻳﻦ ﻋﻮارض ﻣﻮﺛﺮ ﺑﺎﺷﺪ ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﺑـﻪ ﺑﺮرﺳـﻲ رﻳـﺴﻚ ﻓﺎﻛﺘﻮرﻫـﺎ و ﺷـﻴﻮع ﻋـﻮارض رﻳـﻮي و‬

‫‪2‬‬

‫ﻓﺎﻃﻤﻪ ﻋﺒﺎﺳﻲ ﮔﺮاوﻧﺪ‬

‫ﺷﻜﺴﺖ اﻛﺴﺘﻮﺑﺎﺳﻴﻮن در ﺟﺮاﺣﻲﻫﺎي داﺧﻞ ﺟﻤﺠﻤﻪاي ﻣﻲﭘﺮدازد‪.‬‬

‫‪*3‬‬

‫ﺑﺘﻮل ﻗﺮﺑﺎﻧﻲ ﻳﻜﺘﺎ‬

‫روش ﺑﺮرﺳﻲ‪ :‬ﺗﻌﺪاد ‪ 254‬ﺑﻴﻤﺎر ﺗﺤﺖ اﻋﻤﺎل ﺟﺮاﺣﻲ اﻳﻨﺘﺮاﻛﺮاﻧﻴﺎل را در ﺑﻴﻤﺎرﺳﺘﺎن ﻓﻴﺮوزﮔﺮ‪ ،‬در ﺳﺎل ‪ ،1387-89‬ﺑﻪﻃﻮر‬ ‫‪ -1‬ﮔﺮوه ﺟﺮاﺣﻲ اﻋﺼﺎب‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﻓﻴﺮوزﮔﺮ‪،‬‬ ‫داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬ ‫‪ -2‬ﭘﺰﺷﻚ ﻋﻤﻮﻣﻲ‪ ،‬داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه‬ ‫ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬ ‫‪ -3‬ﻣﺮﻛﺰ ﺗﺤﻘﻴﻘﺎت ﻋﻠﻮم ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﻜﺪه‬ ‫ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه آزاد اﺳﻼﻣﻲ واﺣﺪ ﭘﺰﺷﻜﻲ‬ ‫ﺗﻬﺮان‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‪.‬‬

‫*‬

‫ﮔﺬﺷﺘﻪﻧﮕﺮ ﻣﻄﺎﻟﻌﻪ ﻧﻤﻮدﻳﻢ‪.‬‬ ‫ﻳﺎﻓﺘﻪﻫﺎ‪ :‬ﻋﻮارض رﻳﻮي در ﺑﻴﻤﺎران ﺑﺎ ﺷﻜﺴﺖ اﻳﻨﺘﻮﺑﺎﺳﻴﻮن )‪ ،(P=0/002‬ﺗﻬﻮﻳﻪ ﻣﻜـﺎﻧﻴﻜﻲ ﺑـﻪﻣـﺪت ﺑـﻴﺶ از ‪ 24‬ﺳـﺎﻋﺖ‬ ‫)‪ ،(P=0/001‬ﻓﺸﺎر ﺧﻮن )‪ ،(P=0/001‬ﻣـﺼﺮف ﺳـﻴﮕﺎر )‪ ،(P=0/040‬ﻧﻴـﺎز دوﺑـﺎره ﺑـﻪ ﺟﺮاﺣـﻲ )‪ (P=0/003‬و ﻣﻮرﺗـﺎﻟﻴﺘﻲ‬ ‫)‪ (P=0/001‬ﺑﻴﺶﺗﺮ ﺑﻮد‪.‬‬ ‫ﻧﺘﻴﺠﻪﮔﻴﺮي‪ :‬ﻣﺪت زﻣﺎن ﺑﻴﻬﻮﺷﻲ‪ ،‬ﻣﺪت زﻣﺎن ﺟﺮاﺣﻲ‪ ،‬ﻧﻴﺎز ﺑﻪ اﻳﻨﺘﻮﺑﺎﺳﻴﻮن و ﻣﺪت زﻣﺎن آن و ﻧﻴﺰ ﻣﺪت زﻣـﺎن اﻗﺎﻣـﺖ در‬ ‫‪ ICU‬از رﻳﺴﻚ ﻋﻮاﻣﻞ ﻣﺮﺗﺒﻂ ﺑﺎ ﻋﻮارض رﻳﻮي ﺑﻮده و ﻫﻮﺷﻴﺎري ﻗﺒﻞ از ﺟﺮاﺣﻲ و ﺷﻜﺴﺖ اﻳﻨﺘﻮﺑﺎﺳﻴﻮن ﺑﻪﻃﻮر ﻣﺴﺘﻘﻞ از‬

‫ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪ :‬ﺗﻬﺮان‪ ،‬ﺧﻴﺎﺑﺎن دﻛﺘﺮ ﺷﺮﻳﻌﺘﻲ‪ ،‬زرﮔﻨﺪه‪،‬‬

‫داﻧﺸﮕﺎه آزاد اﺳﻼﻣﻲ‪ ،‬واﺣﺪ ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻛﺪ ﭘﺴﺘﻲ‬ ‫‪191689313‬‬

‫ﺳﺎﻳﺮ ﻣﺘﻐﻴﺮﻫﺎ ﺑﺎ ﻋﻮارض رﻳﻮي ﻫﻤﺮاه ﻫﺴﺘﻨﺪ‪.‬‬

‫ﺗﻠﻔﻦ‪021-22006660 :‬‬

‫‪E-mail: bahareh59gh@yahoo.com‬‬

‫ﻛﻠﻤﺎت ﻛﻠﻴﺪي‪ :‬ﺟﺮاﺣﻲﻫﺎي داﺧﻞ ﺟﻤﺠﻤﻪاي‪ ،‬ﻋﻮارض رﻳﻮي‪ ،‬ﺷﻜﺴﺖ در اﻛﺴﺘﻮﺑﺎﺳﻴﻮن‪.‬‬

‫داﻧﺴﺘﻦ ﻋﻮاﻣﻞ ﻣﺮﺗﺒﻂ ﺑﺎ ﻋـﻮارض رﻳـﻮي و ﻧﻴـﺎز ﺑـﻪ اﻛـﺴﺘﻮﺑﺎﺳﻴﻮن در‬

‫ﻣﻘﺪﻣﻪ‬

‫ﺟﺮاﺣﻲﻫﺎي ﻣﻐﺰي ﻣﻲﺗﻮاﻧﺪ در ﺟﻠﻮﮔﻴﺮي از اﺑﺘﻼ ﺑﻪ اﻳﻦ ﻋﻮارض ﻣﻮﺛﺮ‬

‫ﻋﻮارض رﻳـﻮي )‪ (Pulmonary complications‬از ﻋﻮاﻣـﻞ اﺻـﻠﻲ‬

‫ﺑﺎﺷﺪ ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ را ﻃﺮاﺣﻲ ﻧﻤﻮدﻳﻢ ﺗﺎ ﺑﻪ ﺑﺮرﺳﻲ رﻳﺴﻚ ﻓﺎﻛﺘﻮرﻫﺎ و‬

‫ﻣﻮرﺑﻴﺪﻳﺘﻲ ﭘـﺲ از اﻋﻤـﺎل ﺟﺮاﺣـﻲ ﻣـﻲﺑﺎﺷـﺪ‪ .‬ﺷـﺎﻳﻊﺗـﺮﻳﻦ ﻋـﻮارض‬

‫ﺷﻴﻮع ﻋﻮارض رﻳﻮي و ﻧﻴﺎز ﺑـﻪ اﻳﻨﺘﻮﺑﺎﺳـﻴﻮن در ﺟﺮاﺣـﻲﻫـﺎي داﺧـﻞ‬

‫آﺗﻠﻜﺘﺎزي‪ ،‬ﭘﻨﻮﻣﻮﻧﻲ و ﻧﺎرﺳﺎﻳﻲﻫﺎي ﺗﻨﻔﺴﻲ ﻣﻲ ﺑﺎﺷﻨﺪ‪ 1.‬ﻋـﻮارض رﻳـﻮي‬

‫ﺟﻤﺠﻤﻪاي ﺑﭙﺮدازﻳﻢ‪.‬‬

‫در ﺟﺮاﺣﻲﻫﺎي ﻣﻐﺰي ﺑﺎ ﺗﻮﺟﻪ ﺑـﻪ ﻧـﻮع ﻋﻤـﻞ‪ ،‬ﻣـﺪت ﻃـﻮﻻﻧﻲ ﻋﻤـﻞ‪،‬‬ ‫درﮔﻴﺮي ﻣﺮاﻛﺰ ﻣﺨﺘﻠـﻒ ﻣﻐـﺰي و ﺳـﻄﻮح ﻣﺘﻔـﺎوت ﻫﻮﺷـﻴﺎري داراي‬

‫روش ﺑﺮرﺳﻲ‬

‫اﻫﻤﻴﺖ وﻳﮋهاي ﻣﻲﺑﺎﺷﻨﺪ و در ﺑﻌﻀﻲ ﻣﻮارد ﻧﻴﺎز ﺑﻪ ﺗﻬﻮﻳـﻪ ﻣﻜـﺎﻧﻴﻜﻲ را‬ ‫‪3‬و‪2‬‬

‫ﺑﺮاي ﺑﻴﻤﺎران اﻳﺠﺎد ﻣﻲﻧﻤﺎﻳﺪ‪.‬‬

‫در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﮔﺬﺷﺘﻪﻧﮕﺮ ﺑﺎ ﻣﺮاﺟﻌﻪ ﺑﻪ ﺑﺎﻳﮕﺎﻧﻲ ﺑﻴﻤﺎرﺳﺘﺎن ﻓﻴﺮوزﮔﺮ‬

‫ﺗﺎ آﻧﺠﺎ ﻛﻪ ﻣﺎ ﻣﻲداﻧﻴﻢ ﺗـﺎﻛﻨﻮن ﻣﻄﺎﻟﻌـﻪاي در اﻳـﻦ زﻣﻴﻨـﻪ در اﻳـﺮان‬

‫ﭘﺮوﻧﺪه ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﻃﻲ ﺳﺎلﻫـﺎي ‪ 1387‬ﻟﻐﺎﻳـﺖ ‪ 1389‬ﺗﺤـﺖ اﻋﻤـﺎل‬

‫اﻧﺠﺎم ﻧﺸﺪه اﺳﺖ و ﮔﺰارﺷﺎت دﻳـﮕﺮ ﻧﻴـﺰ ﻣﺤﺪود ﻣﻲﺑـﺎﺷﺪ‪ .‬از آﻧﺠﺎ ﻛﻪ‬

‫ﺟﺮاﺣﻲ اﻳﻨﺘﺮاﻛﺮاﻧﻴﺎل ﻗﺮار ﮔﺮﻓﺘﻨﺪ ﺟﻬﺖ ﻣﻄﺎﻟﻌـﻪ اﻧﺘﺨـﺎب و اﻃﻼﻋـﺎت‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):325-9‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﺳﻴﺪ وﺣﻴﺪ ﺣﻴﺪري و ﻫﻤﻜﺎران‬

‫‪326‬‬

‫آن ﻫﺎ ﺛﺒﺖ ﺷﺪ‪ .‬در اﻧﺘﻬﺎ ﺗﻤﺎﻣﻲ اﻃﻼﻋﺎت ﮔـﺮدآوريﺷـﺪه در ﻧـﺮماﻓـﺰار‬

‫ﺑﻮدﻧﺪ ﻛﻪ ﺷﺎﻳﻊﺗﺮﻳﻦ ﻧﻮع ﻋﺎرﺿﻪ رﻳﻮي ﭘﻨﻮﻣﻮﻧﻲ )‪ (%60‬در ‪ 24‬ﺑﻴﻤﺎر‬

‫‪ANOVA‬‬

‫ﺑﻮد‪ .‬در رﺗﺒﻪ ﺑﻌﺪ آﻣﺒﻮﻟﻲ رﻳﻮي )‪ (%25‬در ‪ 10‬ﺑﻴﻤﺎر و ﺳﭙﺲ ادم رﻳﻮي‬

‫ﺟﻬﺖ آﻧﺎﻟﻴﺰ دادهﻫﺎ اﺳﺘﻔﺎده ﺷﺪه و ‪ P<0/05‬ﻣﻌﻨﻲدار در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪ‪.‬‬

‫)‪ (%7/5‬در ﺳﻪ ﺑﻴﻤﺎر و ﺑﻌﺪ ﭘﻠﻮرال اﻓﻴﻮژن )‪ (%5‬در دو ﺑﻴﻤﺎر و ﻳﻚ‬

‫‪ SPSS‬وﻳﺮاﺳــﺖ ‪ 18‬آﻧــﺎﻟﻴﺰ ﺷــﺪ‪ .‬از ﺗــﺴﺖﻫــﺎي آﻣــﺎري ‪ χ2‬و‬

‫ﻣﻮرد آﺗﻠﻜﺘﺎزي ﻫﻤﺮاه ﭘﻨﻮﻣﻮﻧﻲ )‪ (%2/5‬داﺷﺘﻴﻢ‪ .‬ﻧﻴﺎز ﺑﻪ وﻧﺘﻴﻼﺳﻴﻮن در‬ ‫ﻣﻄﺎﻟﻌﻪ ﻣﺎ )‪ 77‬ﺑﻴﻤﺎر( ‪ %30/31‬ﺑﻮد ﻛﻪ از اﻳﻦ ﻣﻴﺎن ‪) %7/8‬ﺷﺶ ﺑﻴﻤﺎر(‬

‫ﻳﺎﻓﺘﻪﻫﺎ‬

‫ﻣﺪت زﻣﺎن ﺑﻴﺶﺗﺮ از ‪ 48‬ﺳﺎﻋﺖ اﻳﻨﺘﻮﺑﻪ ﺑﻮدﻧﺪ و ‪ 14‬ﺑﻴﻤﺎر از ‪ 77‬ﺑﻴﻤﺎر‬ ‫در اﻳـﻦ ﻣﻄﺎﻟﻌﻪ ‪ 40‬ﺑﻴـﻤﺎر )‪ (%16‬ﻣﺒﺘﻼ ﺑﻪ ﻋﺎرﺿﻪ رﻳـﻮي ﺑﻌﺪ ﻋﻤﻞ‬

‫)‪ (%18‬دﭼﺎر ﺷﻜﺴﺖ در اﻛﺴﺘﻮﺑﺎﺳﻴﻮن ﺷﺪﻧﺪ‪.‬‬

‫ﺟﺪول‪ :1 -‬ﻣﻘﺎﻳﺴﻪ ﻣﺘﻐﻴﺮﻫﺎ و رﻳﺴﻚ ﻓﺎﻛﺘﻮرﻫﺎي ﺷﻜﺴﺖ اﻛﺴﺘﻮﺑﺎﺳﻴﻮن در ﺑﻴﻤﺎران داراي ﺟﺮاﺣﻲ درون ﺟﻤﺠﻤﻪاي‬ ‫ﻓﺮاواﻧﻲ‬

‫ﻣﺘﻐﻴﺮ‬

‫ﺑﺎﻻي ﭼﺎدرﻳﻨﻪ ﻣﺨﭽﻪ‬ ‫ﻣﺤﻞ ﺟﺮاﺣﻲ‬ ‫ﭘﺎﻳﻴﻦ ﭼﺎدرﻳﻨﻪ ﻣﺨﭽﻪ‬ ‫‪+‬‬ ‫ﺗﻜﺮار ﻋﻤﻞ‬ ‫‬‫‪+‬‬ ‫ﻣﺮگ و ﻣﻴﺮ‬ ‫‬‫‪+‬‬ ‫ﺳﻴﮕﺎر‬ ‫‬‫‪+‬‬ ‫ﻓﺸﺎر ﺧﻮن‬ ‫‬‫‬‫ﻧﻴﺎز ﺑﻪ ﺗﻬﻮﻳﻪ ﻣﻜﺎﻧﻴﻜﻲ‬ ‫‪+‬‬ ‫‬‫ﻋﻮارض رﻳﻮي‬ ‫‪+‬‬

‫*‪P‬‬

‫ﺷﻜﺴﺖ اﻳﻨﺘﻮﺑﺎﺳﻴﻮن‬

‫ﺗﻌﺪاد‬

‫‪+‬‬ ‫‪9‬‬

‫‬‫‪220‬‬

‫‪%‬‬

‫‪%64/30‬‬

‫‪%91/70‬‬

‫ﺗﻌﺪاد‬

‫‪5‬‬

‫‪20‬‬

‫‪%‬‬

‫‪%35/70‬‬

‫‪%8/30‬‬

‫ﺗﻌﺪاد‬

‫‪5‬‬

‫‪49‬‬

‫‪%‬‬

‫‪%35/70‬‬

‫‪%20/40‬‬

‫ﺗﻌﺪاد‬

‫‪9‬‬

‫‪191‬‬

‫‪%‬‬

‫‪%64/30‬‬

‫‪%79/60‬‬

‫ﺗﻌﺪاد‬

‫‪11‬‬

‫‪35‬‬

‫‪%‬‬

‫‪%78/60‬‬

‫‪%14/60‬‬

‫ﺗﻌﺪاد‬

‫‪3‬‬

‫‪205‬‬

‫‪%‬‬

‫‪%21/40‬‬

‫‪%85/40‬‬

‫ﺗﻌﺪاد‬

‫‪5‬‬

‫‪49‬‬

‫‪%‬‬

‫‪%35/70‬‬

‫‪%20/40‬‬

‫ﺗﻌﺪاد‬

‫‪9‬‬

‫‪191‬‬

‫‪%‬‬

‫‪%64/30‬‬

‫‪%79/60‬‬

‫ﺗﻌﺪاد‬

‫‪9‬‬

‫‪55‬‬

‫‪%‬‬

‫‪%64/30‬‬

‫‪%22/90‬‬

‫ﺗﻌﺪاد‬

‫‪5‬‬

‫‪185‬‬

‫‪%‬‬

‫‪%35/70‬‬

‫‪%77/10‬‬

‫ﺗﻌﺪاد‬

‫‪0‬‬

‫‪177‬‬

‫‪%‬‬

‫‪%0/00‬‬

‫‪%73/80‬‬

‫ﺗﻌﺪاد‬

‫‪14‬‬

‫‪63‬‬

‫‪%‬‬

‫‪%100/00‬‬

‫‪%26/30‬‬

‫ﺗﻌﺪاد‬

‫‪7‬‬

‫‪207‬‬

‫‪%‬‬

‫‪%50/00‬‬

‫‪%86/30‬‬

‫ﺗﻌﺪاد‬

‫‪7‬‬

‫‪33‬‬

‫‪%‬‬

‫‪%50/00‬‬

‫‪%13/80‬‬

‫* آزﻣﻮن آﻣﺎري ﻣﻮرد اﺳﺘﻔﺎده ‪ 2‬ﺑﻮد‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ 325 ،5‬ﺗﺎ ‪329‬‬

‫‪0/007‬‬

‫‪0/184‬‬

‫‪0/001‬‬

‫‪0/184‬‬

‫‪0/002‬‬

‫‪0/001‬‬

‫‪0/002‬‬

‫ﻋﻮاﻣﻞ ﻣﻮﺛﺮ در ﻋﻮارض رﻳﻮي و ﺷﻜﺴﺖ اﻛﺴﺘﻮﺑﺎﺳﻴﻮن در ﺟﺮاﺣﻲﻫﺎي داﺧﻞ ﺟﻤﺠﻤﻪاي‬

‫ﻣﻘﺎﻳﺴﻪ ﻣﺘﻐﻴﺮﻫﺎ و رﻳﺴﻚ ﻓﺎﻛﺘﻮرﻫﺎي ﺷﻜﺴﺖ اﻛﺴﺘﻮﺑﺎﺳﻴﻮن در‬

‫‪327‬‬

‫‪ 48‬ﺳﺎﻋﺖ اﻳﻨﺘﻮﺑﻪ ﺷﺪه ﺑﻮدﻧﺪ ﻫﻤﮕﻲ ﻋﺎرﺿﻪ رﻳﻮي ﺛﺒﺖ ﻛﺮدﻧﺪ‪.‬‬

‫‪Celis‬‬

‫ﺑﻴﻤﺎران داراي ﺟﺮاﺣﻲ درون ﺟﻤﺠﻤﻪاي در ﺟﺪول ‪ 1‬آﻣﺪه اﺳﺖ‪.‬‬

‫و ‪ Croce‬ﻧﺸﺎن داد ﻛﻪ اﻓﺰاﻳﺶ زﻣﺎن وﻧﺘﻴﻼﺳﻴﻮن ﺑﺎﻋﺚ اﻳﺠﺎد ﻣﻘﺎوﻣﺖ‬

‫ﻣﻴﺎﻧﮕﻴﻦ ﺳﻦ در اﻓﺮاد داراي ﻋﺎرﺿﻪ رﻳﻮي ﺑﻪﻃﻮر ﻣﻌﻨﻲداري ﺑﻴﺶﺗﺮ‬

‫ﺑﺎﻛﺘﺮﻳﺎﻳﻲ ﻣﺎﻧﻨﺪ ﻣﻘﺎوﻣﺖ ﺑﻪ ‪ Acinetobacter baunail‬ﺷﺪه ﻛﻪ ﺑﺎﻋﺚ‬ ‫‪5‬و‪4‬‬

‫ﺑﻮد )‪ 64/02±14‬در ﺑﺮاﺑﺮ ‪ .P=0/001 ،41/6±17‬اﻓﺮاد داراي ﻋﺎرﺿﻪ‬

‫ﭘﻨﻮﻣﻮﻧﻲ ﻣﻲﮔﺮدد‪.‬‬

‫رﻳﻮي ﺑﻪﻃﻮر ﻣﻌﻨﻲداري ﻧﻴﺎز ﺑﻴﺶﺗﺮ ﺑﻪ وﻧﺘﻴﻼﺳﻴﻮن ﺑﻪﻣﺪت ﺑﻴﺶ از ‪48‬‬

‫ﺣﺎﺿﺮ ﻛﻪ ﺑﻴﺶﺗﺮ از ‪ 48‬ﺳﺎﻋﺖ ﺗﺤﺖ اﻳﻨﺘﻮﺑﺎﺳﻴﻮن ﻗﺮار داﺷﺘﻨﺪ‪،‬‬

‫ﺳﺎﻋﺖ داﺷﺘﻨﺪ )‪.(P=0/001‬‬

‫ﭘﻨﻮﻣﻮﻧﻲ ﺛﺒﺖ ﺷﺪ ﻛﻪ ﺑﻪ ﻧﻮﻋﻲ ﻳﺎﻓﺘﻪﻫﺎي ﺑﺎﻻ را ﺗﺎﻳﻴﺪ ﻣﻲﻛﻨﺪ‪ ،‬ﺑﻨﺎﺑﺮاﻳﻦ‬

‫ﻣﻴﺎﻧﮕﻴﻦ ﻣﺪت زﻣﺎن وﻧﺘﻴﻼﺳﻴﻮن در اﻓﺮاد داراي ﻋﺎرﺿﻪ رﻳﻮي‬

‫در ﭼﻬﺎر ﻧﻔﺮ از ﺷﺶ ﻧﻔﺮ ﺑﻴﻤﺎر )‪ (%66‬ﻣﻄﺎﻟﻌﻪ‬

‫ﺑﺎﻳﺴﺘﻲ ﺑﻪﻣﺪت اﻗﺎﻣﺖ‬

‫‪ICU‬‬

‫ﺑﻪﻃﻮر ﻣﻌﻨﻲداري ﺑﻴﺶﺗﺮ ﺑﻮد )‪ 16/8±10‬در ﺑﺮاﺑﺮ ‪ 5/09±4‬ﺳﺎﻋﺖ و‬

‫ﺑﻪﺧﺼﻮص ﻛﻪ ﺗﺨﺖﻫﺎي‬

‫‪ .(P=0/001‬ﻣﻴﺎﻧﮕﻴﻦ ﻫﻮﺷﻴﺎري ﺑﻌﺪ ﻋﻤﻞ در اﻓﺮاد داراي ﻋﺎرﺿﻪ رﻳﻮي‬

‫ﺑﻪﻫﻤﺮاه دارد‪.‬‬

‫در اﻳﻦ ﺑﻴﻤﺎران ﺗﻮﺟﻪ وﻳﮋهاي داﺷﺖ‪.‬‬

‫‪ICU‬‬

‫ﻣﺤﺪود ﺑﻮده و ﻫﺰﻳﻨﻪﻫﺎي ﺑﺎﻻﻳﻲ‬

‫ﺑﻪﻃﻮر ﻣﻌﻨﻲداري ﻛﻢﺗﺮ ﺑﻮد )‪ 11±4‬در ﺑﺮاﺑﺮ ‪ 13/2±3‬و ‪.(P=0/001‬‬

‫در ﻣﻘﺎﻟﻪﻫﺎي ‪ Drakulovic‬و ‪ Eberhardt‬از اﺻﻄﻼح ﭘﻨﻮﻣﻮﻧﻲ‬

‫ﻣﻴﺎﻧﮕﻴﻦ ﻫﻮﺷﻴﺎري ﻗﺒﻞ ﻋﻤﻞ در اﻓﺮاد داراي ﻋﺎرﺿﻪ رﻳﻮي ﺑﻪﻃﻮر‬

‫واﺑﺴﺘﻪ ﺑﻪ وﻧﺘﻴﻼﺗﻮر ﻧﺎم ﺑﺮده ﺷﺪه و ﻋﻨﻮان ﺷﺪه اﺳﺖ ﻛﻪ ﭼﻬﺎر روز‬

‫ﻣﻌﻨﻲداري ﻛﻢﺗﺮ ﺑﻮد )‪ 10/7±4‬در ﺑﺮاﺑﺮ ‪ 13/2±3‬و ‪ .(P=0/001‬ﻣﻴﺎﻧﮕﻴﻦ‬ ‫ﻣﺪت زﻣﺎن اﻗﺎﻣﺖ در‬

‫‪ICU‬‬

‫در اﻓﺮاد داراي ﻋﺎرﺿﻪ رﻳﻮي ﺑﻴﺶﺗﺮ ﺑﻮد‬

‫)‪ 22/4±27‬در ﺑﺮاﺑﺮ ‪ 5/1±3‬روز و ‪.(P=0/001‬‬ ‫ﻣﻴﺎﻧﮕﻴﻦ ﻣﺪت زﻣﺎن اﻗﺎﻣﺖ در ﺑﻴﻤﺎرﺳﺘﺎن در اﻓﺮاد داراي ﻋﺎرﺿﻪ‬

‫‪7‬و‪6‬‬

‫ﭘﺲ از اﻳﻨﺘﻮﺑﻪ ﺷﺪن ﭘﻨﻮﻣﻮﻧﻲ ﺗﻮﺳﻌﻪ ﭘﻴﺪا ﻣﻲﻛﻨﺪ‪.‬‬ ‫ﺣﺎﺿﺮ ﻣﻴﺰان اﻗﺎﻣﺖ در‬

‫‪ICU‬‬

‫در ﻧﺘﺎﻳﺞ ﭘﮋوﻫﺶ‬

‫ﺑﺎﻋﺚ اﻓﺰاﻳﺶ ﺷﻜﺴﺖ اﻛﺴﺘﻮﺑﺎﺳﻴﻮن‬

‫ﻣﻲﺷﺪ اﻳﻦ ﻗﺴﻤﺖ از ﻧﺘﺎﻳﺞ ﻫﻤﮕﺎم ﺑﺎ ﻣﻄﺎﻟﻌﺎت ‪ Torres‬و ‪ Arozullah‬و‬ ‫‪8-10‬‬

‫‪ Pereira‬ﺑﻮد‪.‬‬

‫آنﻫﺎ ﻧﻴﺰ ﺷﻜﺴﺖ اﻛﺴﺘﻮﺑﺎﺳﻴﻮن را در رﻳﺴﻚ اﺑﺘﻼ ﺑﻪ‬

‫رﻳﻮي ﺑﻪﻃﻮر ﻣﻌﻨﻲداري ﺑﻴﺶﺗﺮ ﺑﻮد )‪ 24±27‬روز در ﺑﺮاﺑﺮ ‪ 8/7±5‬و‬

‫ﻋﻮارض رﻳﻮي و ﻣﺪت زﻣﺎن اﻗﺎﻣﺖ در‬

‫‪ .(P=0/001‬ﻋﻮارض رﻳﻮي در ﺑﻴﻤﺎران ﻛﻪ رﻳﺴﻚ ﻓﺎﻛﺘﻮرﻫﺎي زﻳﺮ را‬

‫ﻣﻴﺰان ﺳﻄﺢ ﻫﻮﺷﻴﺎري ﭘﺲ از ﻋﻤﻞ در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﻋﻮارض رﻳﻮي‬

‫داﺷﺘﻨﺪ ﺑﻪﻃﻮر ﻣﻌﻨﻲداري ﺑﻴﺶﺗﺮ دﻳﺪه ﺷﺪ‪ :‬ﺷﻜﺴﺖ اﻛﺴﺘﻮﺑﺎﺳﻴﻮن‬

‫ﭘﺎﻳﻴﻦﺗﺮ ﺑﻮد‪ .‬ﺑﻪﻋﻼوه ﻣﻴﺰان ﺳﻄﺢ ﻫﻮﺷﻴﺎري در ﺑﻴﻤﺎران ﺑﺎ ﺷﻜﺴﺖ‬

‫)‪ ،(P=0/002‬ﺗﻬﻮﻳﻪ ﻣﻜﺎﻧﻴﻜﻲ ﺑﻪﻣﺪت ﺑﻴﺶ از ‪ 24‬ﺳﺎﻋﺖ )‪،(P=0/001‬‬

‫اﻛﺴﺘﻮﺑﺎﺳﻴﻮن ﭘﺎﻳﻴﻦﺗﺮ ﺑﻮد اﻳﻦﻛﻪ ﺷﻜﺴﺖ اﻛﺴﺘﻮﺑﺎﺳﻴﻮن ﺑﺎﻋﺚ ﺗﻐﻴﻴﺮات‬

‫ﻧﻴﺎز دوﺑﺎره ﺑﻪ ﻋﻤﻞ ﺟﺮاﺣﻲ )‪ .(P=0/003‬از ﻋﻮاﻣﻞ زﻣﻴﻨﻪاي ﺑﻴﻤﺎران‬

‫ﺳﻄﺢ ﻫﻮﺷﻴﺎري ﻣﻲﺷﻮد و ﻳﺎ ﺗﻐﻴﻴﺮات ﺳﻄﺢ ﻫﻮﺷﻴﺎري در ﺷﻜﺴﺖ‬

‫داراي ﻫﻴﭙﺮﺗﺎﻧﺴﻴﻮن )‪ (P=0/0001‬و ﺑﻴﻤﺎران ﺳﻴﮕﺎري )‪ (P=0/04‬داراي‬

‫اﻛﺴﺘﻮﺑﺎﺳﻴﻮن ﻣﻮﺛﺮ اﺳﺖ از ﻣﺤﺪودﻳﺖ ﻣﻄﺎﻟﻌﻪ ﺑﻮده ﻛﻪ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻧﻮع‬

‫ﻋﻮارض رﻳﻮي ﺑﻴﺶﺗﺮي ﺑﻮدﻧﺪ‪ .‬ﻣﻴﺰان ﻣﻮرﺗﺎﻟﻴﺘﻪ در ﺑﻴﻤﺎران ﺑﺎ ﻋﻮارض‬

‫ﻣﻄﺎﻟﻌﻪ ﻧﻤﻲﺗﻮان ﺑﻪ آن ﭘﺎﺳﺦ ﮔﻔﺖ‪ .‬در ﻣﻄﺎﻟﻌﻪ ‪ Ebrenhardt‬ﻧﺸﺎن داده‬

‫رﻳﻮي ﺑﻪﻃﻮر ﻣﻌﻨﻲداري )‪ (P=0/0001‬ﺑﻴﺶﺗﺮ ﺑﻮد‪ .‬ﺑﻪﻋﻼوه ﻃﻮل ﻣﺪت‬

‫ﺷﺪه اﺳﺖ ﻛﻪ ﺑﺮوز ﭘﻨﻮﻣﻮﻧﻲ ﺑﺎ دوز ﺑﺎرﺑﻴﺘﻮرات و درﺻﺪ ﻣﻮاد ﻣﺴﻜﻦ‬

‫ﺟﺮاﺣﻲ )‪ 4/3±2‬در ﺑﺮاﺑﺮ ‪ 3/04±1‬و ‪ (P=0/001‬و ﻃﻮل ﻣﺪت ﺑﻴﻬﻮﺷﻲ‬

‫واﺑﺴﺘﻪ اﺳﺖ‪ ،‬اﻳﻦ ﻋﻮاﻣﻞ ﺑﺎﻋﺚ ﻛﻠﻮﻧﻴﺰه ﺷﺪن ﺑﺎﻛﺘﺮيﻫﺎ در ﻣﺠﺎري‬

‫‪ICU‬‬

‫ﻣﻮﺛﺮ داﻧﺴﺘﻪاﻧﺪ‪ .‬راﺑﻄﻪ‬

‫‪7‬‬

‫)‪ 4/9±2‬در ﺑﺮاﺑﺮ ‪ 3/8±2‬و ‪ (P=0/03‬در ﺑﻴﻤﺎران داراي ﺷﻜﺴﺖ‬

‫ﻫﻮاﻳﻲ ﻣﻲﺷﻮﻧﺪ‪ .‬ﺑﻨﺎﺑﺮ ﻧﺘﺎﻳﺞ اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻣﺪت زﻣﺎن ﺑﻴﻬﻮﺷﻲ‪ ،‬ﻣﺪت‬

‫اﻛﺴﺘﻮﺑﺎﺳﻴﻮن ﺑﻪﻃﻮر ﻣﻌﻨﻲداري ﺑﻴﺶﺗﺮ ﺑﻮد‪ ،‬در اﺳﺘﻔﺎده از آﻧﺎﻟﻴﺰ‬

‫زﻣﺎن ﺟﺮاﺣﻲ‪ ،‬ﻧﻴﺎز ﺑﻪ اﻳﻨﺘﻮﺑﺎﺳﻴﻮن و ﻣﺪت زﻣﺎن آن و ﻧﻴﺰ ﻣﺪت زﻣﺎن‬ ‫‪ICU‬‬

‫ﻟﺠﺴﺘﻴﻚ‪ ،‬ﻫﻮﺷﻴﺎري ﻗﺒﻞ از ﺟﺮاﺣﻲ )‪ (P=0/03‬و ﺷﻜﺴﺖ‬

‫اﻗﺎﻣﺖ در‬

‫اﻛﺴﺘﻮﺑﺎﺳﻴﻮن )‪ (P=0/001‬ﺑﻪﻃﻮر ﻣﺴﺘﻘﻞ از ﺳﺎﻳﺮ ﻣﺘﻐﻴﺮﻫﺎ ﺑﺎ ﻋﻮارض‬

‫ﻫﻮﺷﻴﺎري ﻗﺒﻞ از ﺟﺮاﺣﻲ و ﺷﻜﺴﺖ اﻳﻨﺘﻮﺑﺎﺳﻴﻮن ﺑﻪﻃﻮر ﻣﺴﺘﻘﻞ از‬

‫رﻳﻮي ﻫﻤﺮاﻫﻲ ﻣﻌﻨﻲدار داﺷﺘﻨﺪ‪.‬‬

‫ﺳﺎﻳﺮ ﻣﺘﻐﻴﺮﻫﺎ ﺑﺎ ﻋﻮارض رﻳﻮي ﻫﻤﺮاه ﻫﺴﺘﻨﺪ‪.‬‬

‫از رﻳﺴﻚ ﻋﻮاﻣﻞ ﻣﺮﺗﺒﻂ ﺑﺎ ﻋﻮارض رﻳﻮي ﺑﻮده و‬

‫ﺳﭙﺎﺳﮕﺰاري‪ :‬اﻳﻦ ﻣﻘﺎﻟﻪ ﺣﺎﺻﻞ ﺑﺨﺸﻲ از ﭘﺎﻳـﺎنﻧﺎﻣـﻪ ﺗﺤـﺖ ﻋﻨـﻮان‬

‫ﺑﺤﺚ‬

‫"ﺑﺮرﺳﻲ ﻋﻮاﻣﻞ ﺧﻄﺮﺳﺎز ﻋﻮارض رﻳﻮي و ﺷﻜﺴﺖ در اﻳﻨﺘﻮﺑﺎﺳﻴﻮن در‬ ‫ﺟﺮاﺣﻲﻫﺎي اﻟﻜﺘﻴﻮ داﺧﻞ ﺟﻤﺠﻤـﻪاي‪ ،‬ﻣـﺮوري ﺑـﺮ ‪ 254‬ﺑﻴﻤـﺎر در دو‬

‫در ﻣﻄﺎﻟﻌﻪ ﻣﺎ ﻣﻴﺎﻧﮕﻴﻦ ﻣﺪت زﻣﺎن ﺗﻬﻮﻳﻪ ﻣﻜﺎﻧﻴﻜﻲ ﻧﻴﺰ در ﺑﻴﻤﺎران‬ ‫ﺑﺎ ﻋﻮارض رﻳﻮي ﺑﻴﺶﺗﺮ ﺑﻮد‪ .‬ﺑﻪﻃﻮري ﻛﻪ ﻫﻤﻪ ﺑﻴﻤﺎراﻧﻲ ﻛﻪ ﺑﻴﺶﺗﺮ از‬

‫ﺳﺎل" ﻣﻲﺑﺎﺷﺪ ﻛﻪ در ﺳـﺎل ‪ 1391‬در داﻧـﺸﮕﺎه ﻋﻠـﻮم ﭘﺰﺷـﻜﻲ ﺗﻬـﺮان‬ ‫اﺟﺮا ﺷﺪه اﺳﺖ‪.‬‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):325-9‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻫﻤﻜﺎران‬ ‫ﺣﻴﺪري و‬ Heydari S.V. et‫وﺣﻴﺪ‬ al. ‫ﺳﻴﺪ‬

328

References 1. Beauregard CL, Friedman WA. Routine use of postoperative ICU care for elective craniotomy: a cost-benefit analysis. Surg Neurol 2003;60(6):483-9; dicussion 489. 2. Holland MC, Mackersie RC, Morabito D, Campbell AR, Kivett VA, Patel R, et al. The development of acute lung injury is associated with worse neurologic outcome in patients with severe traumatic brain injury. J Trauma 2003;55(1):106-11. 3. Rincón-Ferrari MD, Flores-Cordero JM, Leal-Noval SR, MurilloCabezas F, Cayuelas A, Muñoz-Sánchez MA, et al. Impact of ventilator-associated pneumonia in patients with severe head injury. J Trauma 2004;57(6):1234-40. 4. Celis R, Torres A, Gatell JM, Almela M, Rodríguez-Roisin R, Agustí-Vidal A. Nosocomial pneumonia. A multivariate analysis of risk and prognosis. Chest 1988;93(2):318-24. 5. Croce MA. Postoperative pneumonia. Am Surg 2000;66(2):1337. 6. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S, Ferrer M. Supine body position as a risk factor for nosocomial

pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999;354(9193):1851-8. 7. Eberhardt KE, Thimm BM, Spring A, Maskos WR. Dose-dependent rate of nosocomial pulmonary infection in mechanically ventilated patients with brain oedema receiving barbiturates: a prospective case study. Infection 1992;20(1):12-8. 8. Epstein SK. Decision to extubate. Intensive Care Med 2002;28(5):535-46. 9. Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg 2000;232(2):24253. 10. Pereira ED, Fernandes AL, da Silva Anção M, de Araúja Pereres C, Atallah AN, Faresin SM. Prospective assessment of the risk of postoperative pulmonary complications in patients submitted to upper abdominal surgery. Sao Paulo Med J 1999;117(4):151-60.

329 ‫ ﺗﺎ‬325 ،5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

329

‫ﻛﺎراﻳﻲ دو روش ﭘﺎﻳﺶ ﺑﺮاي ﺗﺸﺨﻴﺺ ﻋﻔﻮﻧﺖ ﻣﺤﻞ ﺟﺮاﺣﻲ در ﺑﺨﺸﻬﺎي ﺟﺮاﺣﻲ ﻋﻤﻮﻣﻲ‬

Tehran University Medical Journal, August 2012; Vol. 70, No. 5: 325-329

Brief Report

Factors related to extubation failure and post pulmonary complications in intracranial surgery in 254 patients: a brief report Abstract Seyed Vahid Heydari M.D.1 Seyyed Mahmoud Ramak Hashemi M.D.1 Enayat A. Abasnejad M.D.1 Fatemeh Abbasi Gravnd M.D.2 Batool Ghorbani Yekta Ph.D.3* 1- Department of Neurosurgery, Firoozgar Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran. 2- General Practitioner, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran. 3- Medical Sciences Research Center, Islamic Azad University, Tehran Medical Branch, Tehran, Iran.

Received: April 11, 2012

Accepted: April 29, 2012

Background: The purpose of this study was to determine the prevalence and associated factors for postoperative pulmonary complications (PPCs) and extubation failure in patients having undergone intracranial surgery. Methods: In this retrospective study done in Firozgar Hospital during 2008-2010, we followed up 254 patients through a clinical questionnaire and observation of the clinical course of participants in pre- and post-operative periods. Results: Overall, 40 (15.74%) patients had postoperative pulmonary complications. The most common PPC was pneumonia, which was seen in 24 patients (60% of complications). The average duration of ventilation in patients with PPC was significantly higher (16.8.±10 vs. 5.09±4.5 days; P=0.001) than patients without the complication. The mean Glasgow coma scale (GCS) after surgery in patients with PPC was significantly lower (11.±4 vs. 13.2±3; P=0.001) than the rest of the patients. Moreover, the mean age of patients with PPC was significantly higher (64.02±14 vs. 41.6.±17 years; P=0.001). Average duration of stay in ICU in patients with PPC was also

higher (24.±27 vs. 8.7±0.5; P=0.001). Conclusion: GCS before surgery and failed extubation independently of other variables were significantly associated with pulmonary complications independent of other variables. Keywords: extubation, failure, intracranial, postoperative complications, pulmonary, surgery. *

Corresponding author: Medical Branch, Islamic Azad University, khagani St., Zargandeh, Tehran, Iran. Tel: +98-21-22006660 E-mail: bahareh59gh@yahoo.com

Tehran Univ Med J (TUMJ) 2012 August;70(5):325-9

http://tumj.tums.ac.ir

‫اﻟﻬﺎم ﺑﻴﺮاﻧﻮﻧﺪ و ﻫﻤﻜﺎران‬

‫‪330‬‬

‫ﮔﺰارش ﻛﻮﺗﺎه‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ ،5‬ﺻﻔﺤﻪﻫﺎي ‪ 330‬ﺗﺎ ‪333‬‬

‫رﻳﺴﻚ ﻓﺎﻛﺘﻮرﻫﺎي اﺑﺘﻼ ﺑﻪ ﺑﻴﻤﺎري ﺳﻞ‪ :‬ﮔﺰارش ﻛﻮﺗﺎه‬

‫‪*2‬‬

‫اﻟﻬﺎم ﺑﻴﺮاﻧﻮﻧﺪ‪ ،1‬ﺳﻌﻴﺪ ﻋﺎﺑﺪﻳﺎن ﻛﻨﺎري‬ ‫‪4‬‬

‫ﻋﻠﻲرﺿﺎ ﺧﻠﻴﻠﻴﺎن‪ ،3‬ﺑﻬﻨﻮش ﺑﻴﺮاﻧﻮﻧﺪ‬

‫‪ -1‬ﻛﻤﻴﺘﻪ ﺗﺤﻘﻴﻘﺎت داﻧﺸﺠﻮﻳﻲ‪ ،‬ﻛﺎرﺷﻨﺎس ارﺷﺪ‬ ‫ﻣﻴﻜﺮوبﺷﻨﺎﺳﻲ‪ ،‬داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم‬ ‫ﭘﺰﺷﻜﻲ ﻣﺎزﻧﺪران‪ ،‬ﺳﺎري‪ ،‬اﻳﺮان‪.‬‬ ‫‪ -2‬ﮔﺮوه اﻳﻤﻨﻲﺷﻨﺎﺳﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ‬ ‫ﻣﺎزﻧﺪران‪ ،‬ﺳﺎري‪ ،‬اﻳﺮان‪.‬‬ ‫‪ -3‬ﮔﺮوه آﻣﺎر زﻳﺴﺘﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ‬ ‫ﻣﺎزﻧﺪران‪ ،‬ﺳﺎري‪ ،‬اﻳﺮان‪.‬‬

‫ﭼﻜﻴﺪه‬

‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ﻣﻘﺎﻟﻪ‪1390/11/26 :‬‬

‫ﺗﺎرﻳﺦ ﭘﺬﻳﺮش‪1391/02/17 :‬‬

‫زﻣﻴﻨﻪ و ﻫﺪف‪ :‬ﺳﻞ ﻣﻬﻢﺗﺮﻳﻦ ﺑﻴﻤﺎري ﻋﻔﻮﻧﻲ اﺳﺖ ﻛﻪ ﺳﺎﻟﻴﺎﻧﻪ ﻣﻮﺟﺐ آﻟﻮدﮔﻲ ﺣﺪود ﻫﺸﺖ ﻣﻴﻠﻴﻮن ﻧﻔﺮ در ﺟﻬﺎن ﻣﻲﺷﻮد‪.‬‬ ‫ﻫﺪف از اﻳﻦ ﭘﮋوﻫﺶ ﺑﺮرﺳﻲ رﻳﺴﻚ ﻓﺎﻛﺘﻮرﻫﺎي اﺑﺘﻼ ﺑﻪ ﺑﻴﻤﺎري ﺳﻞ ﺑﻮد‪.‬‬ ‫روش ﺑﺮرﺳﻲ‪ :‬در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺗﻮﺻﻴﻔﻲ ‪ 183‬ﻓﺮد ﻣﺴﻠﻮل ﻣﺮاﺟﻌﻪﻛﻨﻨﺪه ﺑﻪ ﻣﺮﻛﺰ ﺑﻬﺪاﺷﺖ اﺳﺘﺎن ﻣﺎزﻧﺪران در ﻃﻲ ﺳﺎلﻫﺎي‬ ‫‪ 1388-90‬ﺑﺮرﺳﻲ ﺷﺪﻧﺪ‪ .‬ﭘﺲ از اﻧﺪازهﮔﻴﺮي ﺳﻄﺢ ﻗﻨﺪ ﺧﻮن ﻧﺎﺷﺘﺎ و ﭘﺎدﺗﻦﻫـﺎي ‪ ،HIV‬اﻃﻼﻋـﺎت ﻣﺮﺑـﻮط ﺑـﻪ اﺳـﺘﻌﻤﺎل‬ ‫دﺧﺎﻧﻴﺎت ﺑﺎ اﺳﺘﻔﺎده از ﭘﺮﺳﺶﻧﺎﻣﻪ و ﺑﻪﺻﻮرت ﺣﻀﻮري ﻛﺴﺐ ﺷﺪ‪.‬‬ ‫ﻳﺎﻓﺘﻪﻫﺎ‪ :‬ﻣﻴﺎﻧﮕﻴﻦ ﺳﻨﻲ ﺑﻴﻤﺎران ‪ 46/8±19/8‬ﺳﺎل ﺑﻮد‪ .‬ﺷﺎﻳﻊﺗﺮﻳﻦ ﻋﺎﻣﻞ ﺧﻄﺮزا دﻳﺎﺑﺖ و ﻛﻢﺗﺮﻳﻦ ﺷﻴﻮع ﻣﺮﺑﻮط ﺑﻪ ‪ HIV‬ﺑﻮد‪.‬‬ ‫ﻫﻢﭼﻨﻴﻦ ﺑﻴﻦ ﺷﻴﻮع دﻳﺎﺑﺖ در زﻧﺎن در ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﻣﺮدان )‪ (OR=0/19 ،%95 CI=0/07±0/46‬و ﻣﺼﺮف ﺳﻴﮕﺎر در ﻣﺮدان در‬

‫‪ -4‬داﻧﺸﺠﻮي ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪،‬‬ ‫داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺟﻨﺪيﺷﺎﭘﻮر‪ ،‬اﻫﻮاز‪ ،‬اﻳﺮان‪.‬‬

‫ﻣﻘﺎﻳﺴﻪ ﺑﺎ زﻧﺎن )‪ (OR=12/4 ،%95 CI=2/8±54/4‬اﺧﺘﻼف آﻣﺎري ﻣﻌﻨﻲداري وﺟﻮد داﺷﺖ )‪.(P<0/05‬‬ ‫ﻧﺘﻴﺠﻪﮔﻴﺮي‪ :‬ﻧﺘﺎﻳﺞ ﺣﺎﺻﻞ از اﻳﻦ ﭘﮋوﻫﺶ‪ ،‬ﻧﺸﺎن ﻣﻲدﻫﺪ ﻛﻪ دﻳﺎﺑﺖ و ﺳﻴﮕﺎر ﻣﻲﺗﻮاﻧﻨﺪ ﺑﻪﻋﻨﻮان رﻳﺴﻚ ﻓﺎﻛﺘﻮرﻫﺎي ﻣﻬﻤﻲ‬

‫*‬

‫ﺑﺮاي اﺑﺘﻼ ﺑﻪ ﺳﻞ ﻣﺤﺴﻮب ﺷﻮﻧﺪ‪ ،‬ﻟﺬا در ﺻﻮرت ﺑﺮوز ﻋﻼﻳﻢ ﺗﻨﻔﺴﻲ در اﻳﻦ اﻓﺮاد‪ ،‬ﺳﻞ ﻣﻲﺗﻮاﻧﺪ ﻳﻜﻲ از ﺗـﺸﺨﻴﺺﻫـﺎي‬ ‫ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪ :‬ﺳﺎري‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ‬

‫ﻣﺎزﻧﺪران‪ ،‬داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬ﮔﺮوه اﻳﻤﻨﻲﺷﻨﺎﺳﻲ‬

‫اﻓﺘﺮاﻗﻲ ﻣﻬﻢ در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﻮد‪.‬‬

‫ﺗﻠﻔﻦ‪0151-3543081 :‬‬ ‫‪E-mail: abedianks@razi.tums.ac.ir‬‬

‫ﻛﻠﻤﺎت ﻛﻠﻴﺪي‪ :‬ﺳﻞ‪ ،‬دﻳﺎﺑﺖ‪.HIV ،‬‬

‫ﻣﻘﺪﻣﻪ‬

‫ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ اﺧﺘﻼﻻت ﻏﺪد اﻧﺪوﻛﺮﻳﻦ ﺑﻪﺧﺼﻮص دﻳﺎﺑﺖ‪ ،‬در‬ ‫‪2‬‬

‫ﻣﻌﺮض اﺑﺘﻼ ﺑﻪ ﻓﺮمﻫﺎي ﭘﻴﺸﺮﻓﺘﻪ ﺑﻴﻤﺎري ﺳﻞ ﻣﻲﺑﺎﺷﻨﺪ‪ .‬ﻫﻢﭼﻨﻴﻦ‬ ‫ﺳﻞ )‪ (Tuberculosis‬ﻳﻜﻲ از ﻣﻬﻢﺗﺮﻳﻦ ﺑﻴﻤﺎريﻫﺎي ﻋﻔﻮﻧﻲ اﺳﺖ‬

‫ﻣﺼﺮف ﺳﻴﮕﺎر ﻛﻪ از ﻣﻌﻀﻼت ﻣﻬﻢ ﺑﻬﺪاﺷﺘﻲ ﺑﻪﺷﻤﺎر ﻣﻲآﻳﺪ‪ ،‬در ﺑﻴﻦ‬

‫ﻛﻪ ﺳﺎﻟﻴﺎﻧﻪ ﻣﻮﺟﺐ ﻣﺮگ و ﻣﻴﺮ ﺣﺪود دو ﻣﻴﻠﻴﻮن ﻧﻔﺮ در ﺟﻬﺎن ﻣﻲﺷﻮد‪.‬‬

‫ﺑﻴﻤﺎران ﻣﺴﻠﻮل ﺑﻪﺧﺼﻮص اﻓﺮاد داراي ﺳﻞ رﻳﻮي از ﺷﻴﻮع ﺑﺎﻻﻳﻲ‬

‫ﻫﺮ ﺳﺎﻟﻪ ‪ 8-10‬ﻣﻴﻠﻴﻮن ﻣﻮرد ﺟﺪﻳﺪ ﺳﻠﻲ در ﺟﻬﺎن ﮔﺰارش ﻣﻲﺷﻮد‪.‬‬

‫ﺑﺮﺧﻮردار اﺳﺖ‪.‬‬

‫ﺑﻴﺶﺗﺮﻳﻦ ﺑﺮوز ﻣﻮارد اﻳﻦ ﺑﻴﻤﺎري در ﻛﺸﻮرﻫﺎي آﺳﻴﺎﻳﻲ و آﻓﺮﻳﻘﺎﻳﻲ‬

‫اﺳﺘﻌﻤﺎل دﺧﺎﻧﻴﺎت ﻣﻲﺗﻮاﻧﺪ ﻋﻤﻠﻜﺮد ﺳﻴﺴﺘﻢ اﻳﻤﻨﻲ ﻫﻤﻮرال‪،‬‬

‫دﻳﺪه ﻣﻲﺷﻮد ﻛﻪ اﻳﺮان ﻧﻴﺰ از ﺟﻤﻠﻪ اﻳﻦ ﻛﺸﻮرﻫﺎ ﺑﻪﺷﻤﺎر ﻣﻲآﻳﺪ‪ 1.‬از‬

‫ﻣﮋكﻫﺎي ﺗﻨﻔﺴﻲ ﻣﺎﻛﺮوﻓﺎژﻫﺎي آﻟﻮﺋﻮﻻر را ﻣﺨﺘﻞ ﻛﻨﺪ و ﻣﻨﺠﺮ ﺑﻪ‬

‫ﻋﻮاﻣﻞ ﻣﻮﺛﺮ در ﺑﺮوز و ﭘﻴﺸﺮﻓﺖ اﻳﻦ ﺑﻴﻤﺎري‪ ،‬ﻫﻤﺮاﻫﻲ ﻋﻮاﻣﻞ ﺧﻄﺮزا‬

‫ﻛﺎﻫﺶ ﺗﻌﺪاد ﻟﻨﻔﻮﺳﻴﺖﻫﺎي‬

‫‪3‬‬

‫ﻣﺎﻧﻨﺪ دﻳﺎﺑﺖ‪ ،‬ﻣﺼﺮف ﺳﻴﮕﺎر‪ ،HIV ،‬ﻧﺎرﺳﺎﻳﻲ ﻣﺰﻣﻦ ﻛﻠﻴﻪ و ﻏﻴﺮه‬

‫ﻫﻢﭼﻨﻴﻦ در ﻛﺸﻮرﻫﺎي ﺟﻬﺎن ﺳﻮم ﻫﻤﺮاﻫﻲ ﺑﻴﻤﺎري ﺳﻞ ﺑﺎ اﻳﺪز‬

‫ﻣﻲﺑﺎﺷﺪ‪ .‬در ﺗﻤﺎﻣﻲ اﻳﻦ ﻣﻮارد ﻧﻘﺺ ﺳﻴﺴﺘﻢ اﻳﻤﻨﻲ ﻣﺸﻬﻮد اﺳﺖ ﻛﻪ‬

‫)‪(HIV/TB‬‬

‫‪HIV‬‬

‫ﻣﻲﺗﻮاﻧﺪ در روﻧﺪ ﺑﻴﻤﺎريزاﻳﻲ ﺳﻞ ﻧﻘﺶ ﻣﻮﺛﺮي داﺷﺘﻪ ﺑﺎﺷﺪ‪ .‬ﻣﻄﺎﻟﻌﺎت‬

‫ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﻣﻴﺰان ﻣﺮگ و ﻣﻴﺮ در اﻳﻦ اﻓﺮاد ﭼﻬﺎر ﺑﺮاﺑﺮ اﻓﺮادي اﺳﺖ ﻛﻪ‬

‫ﻣﺘﻌﺪدي ﻧﺸﺎندﻫﻨﺪه اﻓﺰاﻳﺶ ﺷﻴﻮع ﺳﻞ در ﺑﻴﻤﺎران دﻳﺎﺑﺘﻲ ﻣﻲﺑﺎﺷﺪ‪.‬‬

‫ﻓﺎﻗﺪ اﻳﻦ ﻋﻔﻮﻧﺖ ﻫﻢزﻣﺎن ﻫﺴﺘﻨﺪ‪ 4.‬ﺑﺮاﺳﺎس ﮔﺰارش ﺳﺎزﻣﺎن ﺟﻬﺎﻧﻲ‬

‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‪ ،‬ﻣﺮداد ‪ ،1391‬دوره ‪ ،70‬ﺷﻤﺎره ‪ 330 ،5‬ﺗﺎ ‪333‬‬

‫‪CD4‬‬

‫و ﺗﻀﻌﻴﻒ ﺳﻴﺴﺘﻢ اﻳﻤﻨﻲ ﺑﺪن ﺷﻮد‪.‬‬

‫از ﻋﻠﻞ اﺻﻠﻲ ﻣﺮگ و ﻣﻴﺮ اﻓﺮاد آﻟﻮده ﺑﻪ ﻋﻔﻮﻧﺖ‬

‫رﻳﺴﻚ ﻓﺎﻛﺘﻮرﻫﺎي اﺑﺘﻼ ﺑﻪ ﺑﻴﻤﺎري ﺳﻞ‬

‫‪331‬‬

‫ﺑﻬﺪاﺷﺖ در ژوﺋﻦ ﺳﺎل ‪ 2004‬ﻣﻴﻼدي‪ ،‬ﺷﻴﻮع ﺳﻞ ﺗﻮﺑﺮﻛﻠﻮزﻳﺲ در‬

‫ﺑﻴﻦ ﻣﺮدان و زﻧﺎن از ﻧﻈﺮ آﻣﺎري اﺧﺘﻼف ﻣﻌﻨﻲداري وﺟﻮد ﻧﺪاﺷﺖ‬

‫اﻳﺮان ‪ 13‬ﻣﻮرد در ﻫﺮ ﺻﺪ ﻫﺰار ﻧﻔﺮ ﺟﻤﻌﻴﺖ ﻣﻲﺑﺎﺷﺪ‪ 5.‬ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﺑﺮوز‬

‫)‪.(OR=2/5 ،%95 CI=0/26±25/4 ،P=0/3‬‬

‫ﻣﻘﺎوﻣﺖﻫﺎﻳﻲ داروﻳﻲ و ﻋﺪم ﻣﻮﻓﻘﻴﺖ در ﻛﻨﺘﺮل ﺳﻞ و ﻫﻢﭼﻨﻴﻦ ﺷﻴﻮع‬

‫ﺑﻴﻦ ﺷﻴﻮع دﻳﺎﺑﺖ در زﻧﺎن ﺑﺎ ﻓﺮاواﻧﻲ ‪ %28/5‬در ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﻣﺮدان ﺑﺎ‬

‫ﺑﻪﻧﺴﺒﺖ ﺑﺎﻻي ﺳﻞ در اﻳﺮان‪ ،‬اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑﺎ ﻫﺪف ﺑﺮرﺳﻲ ﻋﻮاﻣﻞ ﺧﻄﺮزا‬

‫ﻓﺮاواﻧﻲ ‪ %7/07‬ﺗﻔﺎوت آﻣﺎري ﻣﻌﻨﻲداري وﺟﻮد داﺷﺖ )‪،P<0/05‬‬

‫در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺳﻞ ﺳﺎﻛﻦ در ﺷﻤﺎل اﻳﺮان ﻃﺮاﺣﻲ ﺷﺪ‪.‬‬

‫‪CI=0/07±0/46‬‬

‫‪ .(OR=0/19 ،%95‬ﻫﻢﭼﻨﻴﻦ ﺷﻴﻮع ﻣﺼﺮف ﺳﻴﮕﺎر در‬

‫اﻳﻦ ﺑﻴﻤﺎران ‪ %13/7‬ﺑﻮد ﻛﻪ ﺑﻴﻦ ﻣﺮدان ﺑﺎ ﻓﺮاواﻧﻲ ‪ %23/2‬و زﻧﺎن ﺑﺎ‬ ‫ﻓﺮاواﻧﻲ ‪ %2/3‬اﺧﺘﻼف ﻣﻌﻨﻲداري وﺟﻮد داﺷﺖ )‪،P<0/05‬‬

‫روش ﺑﺮرﺳﻲ‬

‫‪.(OR=12/4 ،%95 CI=2/8±54/4‬‬

‫در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺗﻮﺻﻴﻔﻲ‪ 183 ،‬ﺑﻴﻤﺎر ﻣﺒﺘﻼ ﺑﻪ ﺳﻞ )‪ 99‬ﻣﺮد و ‪84‬‬ ‫زن( ﻣﺮاﺟﻌﻪﻛﻨﻨﺪه ﺑﻪ ﻣﺮﻛﺰ ﺑﻬﺪاﺷﺖ اﺳﺘﺎن ﻣﺎزﻧﺪران در ﻃﻲ ﺳﺎلﻫﺎي‬

‫ﺑﺤﺚ‬

‫‪ 1388-90‬ﭘﺲ از ﻛﺴﺐ رﺿﺎﻳﺖ آﮔﺎﻫﺎﻧﻪ اﻧﺘﺨﺎب ﺷﺪﻧﺪ‪ .‬اﻧﺘﺨﺎب‬ ‫)‪(WHO‬‬

‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ اﻳﻦﻛﻪ در ﺑﺮوز و ﭘﻴﺸﺮﻓﺖ ﺑﻴﻤﺎري ﺳﻞ ﻋﻮاﻣﻞ‬

‫ﺻﻮرت ﮔﺮﻓﺘﻪ ﺑﻮد ﻛﻪ ﺷﺎﻣﻞ ﻣﺸﺎﻫﺪه آدﻧﻮﭘﺎﺗﻲ ﻧﺎف رﻳﻪ‪ ،‬ﻣﺜﺒﺖ ﺷﺪن‬

‫ﺑﻲﺷﻤﺎري دﺧﻴﻞ ﻫﺴﺘﻨﺪ‪ ،‬ﻧﻘﺶ ﻋﻮاﻣﻠﻲ ﻣﺎﻧﻨﺪ دﻳﺎﺑﺖ‪ ،‬ﻣﺼﺮف ﺳﻴﮕﺎر و‬

‫‪6‬‬

‫در اﺑﺘﻼ ﺑﻪ اﻳﻦ ﺑﻴﻤﺎري ﺣﺎﻳﺰ اﻫﻤﻴﺖ اﺳﺖ‪ 1.‬ﻫﻢﭼﻨﻴﻦ در ﺗﺒﺪﻳﻞ‬

‫ﺑﻴﻤﺎران اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺑﺮ ﻃﺒﻖ ﭘﺮوﺗﻜﻞ ﺳﺎزﻣﺎن ﺑﻬﺪاﺷﺖ ﺟﻬﺎﻧﻲ‬

‫ﻧﺘﻴﺠﻪ ﻛﺸﺖ ﻳﺎ اﺳﻤﻴﺮ ﻣﺴﺘﻘﻴﻢ‪ ،‬داﺷﺘﻦ ﻋﻼﻳﻢ ﻛﻠﻴﻨﻴﻜﻲ ﺑﻮده اﺳﺖ‪.‬‬

‫‪HIV‬‬

‫اﻃﻼﻋﺎت ﻣﺮﺑﻮط ﺑﻪ اﺳﺘﻌﻤﺎل دﺧﺎﻧﻴﺎت ﺑﺎ اﺳﺘﻔﺎده از ﭘﺮﺳﺶﻧﺎﻣﻪ و‬

‫ﻓﺮم ﻏﻴﺮﻓﻌﺎل‪ ،‬ﺑﻪ ﻓﺮم ﻓﻌﺎل و ﭘﻴﺸﺮﻓﺘﻪ اﻳﻦ ﺑﻴﻤﺎري‪ ،‬وﺿﻌﻴﺖ ﺳﻴﺴﺘﻢ‬

‫ﺑﻪﺻﻮرت ﺣﻀﻮري ﻛﺴﺐ ﺷﺪ‪.‬‬

‫اﻳﻤﻨﻲ ﻓﺮد ﻧﻘﺶ ﺧﻴﻠﻲ ﻣﻬﻤﻲ اﻳﻔﺎ ﻣﻲﻛﻨﺪ‪ .‬ﻣﺼﺮف ﺳﻴﮕﺎر ﻣﻲﺗﻮاﻧﺪ در‬

‫ﻫﻢﭼﻨﻴﻦ از ﻫﺮ ﻳﻚ از اﻓﺮاد ﻣﻮرد ﺑﺮرﺳﻲ ‪ 5ml‬ﺧﻮن ﻣﺤﻴﻄﻲ‬

‫ﻋﻤﻠﻜﺮد ﻣﺎﻛﺮوﻓﺎژﻫﺎي آﻟﻮﺋﻮﻻر و ﻋﺮﺿﻪ آﻧﺘﻲژن اﺧﺘﻼل اﻳﺠﺎد ﻛﻨﺪ در‬ ‫‪3‬‬

‫ﮔﺮﻓﺘﻪ ﺷﺪ و ﭘﺲ از ﺟﺪاﺳﺎزي ﺳﺮم ﻫﺮ ﻧﻤﻮﻧﻪ‪ ،‬ﺑﺎ اﺳﺘﻔﺎده از ﻛﻴﺖ‬

‫ﻧﺘﻴﺠﻪ ﻛﺎراﻳﻲ ﺳﻴﺴﺘﻢ اﻳﻤﻨﻲ اﺧﺘﺼﺎﺻﻲ ﻛﺎﻫﺶ ﻣﻲﻳﺎﺑﺪ‪ .‬ﻫﻢﭼﻨﻴﻦ ﺑﺎ‬

‫ﺑﻪﻣﻨﻈﻮر ﺑﺮرﺳﻲ‬

‫ﺗﺎﺛﻴﺮي ﻛﻪ ﻧﻴﻜﻮﺗﻴﻦ در اﻳﺠﺎد آﻧﺮژي در ﺳﻠﻮلﻫﺎي ‪ T10‬و اﻳﺠﺎد اﺧﺘﻼل‬

‫)‪ (Daio plost, Italy‬و ﺗﻜﻨﻴﻚ اﻻﻳﺰا آﻧﺘﻲﺑﺎدي‬

‫‪HIV‬‬

‫اﺑﺘﻼ ﺑﻪ ﻋﻔﻮﻧﺖ‪ ،‬ﻧﻤﻮﻧﻪﻫﺎ ﻣﻮرد ارزﻳﺎﺑﻲ ﻗﺮار ﮔﺮﻓﺘﻨﺪ‪.‬‬ ‫ﻗﻨﺪ ﺧﻮن ﺑﻴﻤﺎران ﺑﺎ اﺳﺘﻔﺎده از ﻛﻴﺖ ﺷﺮﻛﺖ ﭘﺎرسآزﻣﺎ و روش‬ ‫آﻧﺰﻳﻤﻲ‪ -‬ﻛﺎﻟﺮي ﻣﺘﺮي و دﺳﺘﮕﺎه آﺗﻮآﻧﺎﻟﻴﺰور ﺑﻴﻮﺷﻴﻤﻲ اﻧﺪازهﮔﻴﺮي ﺷﺪ‪.‬‬ ‫ﻫﻢﭼﻨﻴﻦ‪ ،‬ﻗﻨﺪ ﺧﻮن ﻧﺎﺷﺘﺎ‬

‫)‪(FBS‬‬

‫ﺑﻴﺶ از ‪ 110‬و ﻗﻨﺪ دو ﺳﺎﻋﺘﻪ ﺑﺎﻻي‬

‫در ﻋﻤﻠﻜﺮد اﻳﻤﻨﻲ ﺳﻠﻮﻟﻲ دارد‪ ،‬ﻓﺮد‪ ،‬ﻣﺴﺘﻌﺪ ﻋﻔﻮﻧﺖﻫﺎي داﺧﻞ ﺳﻠﻮﻟﻲ‬ ‫ﻣﺎﻧﻨﺪ ﻣﺎﻳﻜﻮﺑﺎﻛﺘﺮﻳﻮم ﺗﻮﺑﺮﻛﻠﻮزﻳﺲ ﻣﻲﺷﻮد‪ .‬در ﻣﻄﺎﻟﻌﻪاي ﻛﻪ‬

‫‪Mauryra‬‬

‫اﻧﺠﺎم دادﻧﺪ ﻣﺸﺎﻫﺪه ﻛﺮد ﻛﻪ ﺑﻴﻦ ﻣﺼﺮف ﺳﻴﮕﺎر و ﺑﻴﻤﺎري ﺳﻞ ارﺗﺒﺎط‬ ‫‪7‬‬

‫ﻣﻌﻨﻲداري وﺟﻮد دارد‪.‬‬

‫‪ ،140‬ﺑﻪﻋﻨﻮان ﺑﻴﻤﺎر دﻳﺎﺑﺘﻲ در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪ‪ .‬ﺗﺠﺰﻳﻪ و ﺗﺤﻠﻴﻞ دادهﻫﺎ ﺑﺎ‬

‫در ﭘﮋوﻫﺶ ﺣﺎﺿﺮ‪ ،‬ﺷﻴﻮع ﻣﺼﺮف ﺳﻴﮕﺎر در ‪ 183‬ﻓﺮد ﻣﺴﻠﻮل‬

‫وﻳﺮاﺳﺖ ‪ 18‬و آﻣﺎر ﺗﻮﺻﻴﻔﻲ ﺗﻮزﻳﻊ ﻓﺮاواﻧﻲ‬

‫‪ %13/7‬ﺑﻮد ﻛﻪ در ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﻣﻄﺎﻟﻌﻪي ‪ Rezaiitalab‬ﻛﻪ ﺑﺮ روي ‪ 64‬ﻓﺮد‬

‫اﺳﺘﻔﺎده از ﻧﺮماﻓﺰار‬

‫‪SPSS‬‬

‫و ‪ 2‬ﻣﺤﺎﺳﺒﻪ ﺷﺪ‪.‬‬

‫ﻣﺴﻠﻮل ﺑﺎ ﻓﺮاواﻧﻲ ‪ %59/4‬اﻧﺠﺎم داد از ﺷﻴﻮع ﻛﻢﺗﺮي ﺑﺮﺧﻮردار اﺳﺖ‪.‬‬

‫‪8‬‬

‫دﻳﺎﺑﺖ از دﻳﮕﺮ رﻳﺴﻚ ﻓﺎﻛﺘﻮرﻫﺎي ﻣﻬﻢ اﺳﺖ ﻛﻪ ﻫﻤﺮاﻫﻲ ﺳﻞ ﺑﺎ اﻳﻦ‬

‫ﻳﺎﻓﺘﻪﻫﺎ‬

‫ﺑﻴﻤﺎري ﻣﻨﺠﺮ ﺑﻪ ﻛﺎﻫﺶ‬

‫‪CR3‬‬

‫ﻣﻮﻧﻮﺳﻴﺖﻫﺎ و‬

‫‪IL-2‬‬

‫ﻣﻮﺟﻮد ﺑﺮ ﺳﻄﺢ‬

‫ﻟﻨﻔﻮﺳﻴﺖﻫﺎ ﻣﻲﺷﻮد‪ ،‬در ﻧﺘﻴﺠﻪ ﻣﻨﺠﺮ ﺑﻪ ﻛﺎﻫﺶ اﻳﻤﻨﻲ ﺳﻠﻮﻟﻲ ﻓﺮد‪ 9‬و‬

‫در اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺗﻮﺻﻴﻔﻲ ﻣﻘﻄﻌﻲ ‪ 183‬ﺑﻴﻤﺎر ﻣﺒﺘﻼ ﺑﻪ ﺳﻞ ﺷﺎﻣﻞ‬

‫اﺳﺘﻌﺪاد اﺑﺘﻼ ﺑﻪ ﺳﻞ ﻣﻲﺷﻮد‪ 2.‬در ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﺷﺎﻳﻊﺗﺮﻳﻦ رﻳﺴﻚ‬

‫‪ 99‬ﻣﺮد و ‪ 84‬زن ﺑﺮرﺳﻲ ﺷﺪﻧﺪ ﻛﻪ داراي ﻣﻴﺎﻧﮕﻴﻦ ﺳﻨﻲ ‪ 46/8‬و‬

‫ﻓﺎﻛﺘﻮر در ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺳﻞ‪ ،‬دﻳﺎﺑﺖ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺷﻴﻮع آن در زﻧﺎن‬

‫اﻧﺤﺮافﻣﻌﻴﺎر ‪ 19/8‬ﺳﺎل ﺑﻮدﻧﺪ‪ .‬ﺷﺎﻳﻊﺗﺮﻳﻦ ﻋﺎﻣﻞ ﺧﻄﺮزا در اﻳﻦ ﺑﻴﻤﺎران‬

‫ﺣﺪود ﭼﻬﺎر ﺑﺮاﺑﺮ ﻣﺮدان اﺳﺖ ﻛﻪ اﻳﻦ ﺗﻔﺎوت از ﻧﻈﺮ آﻣﺎري ﻣﻌﻨﻲدار‬

‫دﻳﺎﺑﺖ ﺑﺎ ﻓﺮاواﻧﻲ ‪ %16/9‬و ﻛﻢﺗﺮﻳﻦ ﺷﻴﻮع ﻣﺮﺑﻮط ﺑﻪ ‪ HIV‬ﺑﺎ ﻓﺮاواﻧﻲ ‪%2‬‬

‫در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﻣﻲﺷﻮد )‪ (P<0/05‬و ﺑﺎ آﻣﺎري ﻛﻪ در ﺳﺎل ‪ 2006‬اﻋﻼم‬

‫ﺑﻮد‪ .‬ﻓﺮاواﻧﻲ ﻋﻔﻮﻧﺖ ‪ TB/HIV‬در ﻣﺮدان ‪ %3/03‬و در زﻧﺎن ‪ %1/2‬ﺑﻮد ﻛﻪ‬

‫ﺷﺪ )از ﻧﻈﺮ ﺷﻴﻮع ﺑﺎﻻﺗﺮ دﻳﺎﺑﺖ در زﻧﺎن در ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﻣﺮدان( ﻫﻢﺧﻮاﻧﻲ‬

‫‪Tehran Univ Med J (TUMJ) 2012 August;70(5):330-3‬‬ ‫‪http://tumj.tums.ac.ir‬‬

‫ﻫﻤﻜﺎران‬ ‫ﺑﻴﺮاﻧﻮﻧﺪ و‬ Biranvand E. ‫اﻟﻬﺎم‬ et al.

332

‫ ﻧﺸﺎن ﻣﻲدﻫﺪ ﻛﻪ دﻳﺎﺑﺖ و ﺳﻴﮕﺎر ﻣﻲﺗﻮاﻧﻨﺪ ﺑﻪﻋﻨﻮان‬،‫اﻳﻦ ﭘﮋوﻫﺶ‬

‫ ﺑﻨﺎﺑﺮاﻳﻦ‬،‫رﻳﺴﻚ ﻓﺎﻛﺘﻮرﻫﺎي ﻣﻬﻤﻲ ﺑﺮاي اﺑﺘﻼ ﺑﻪ ﺳﻞ ﻣﺤﺴﻮب ﺷﻮﻧﺪ‬

‫ اﻧﺠﺎم دادﻧﺪ ﺷﻴﻮع دﻳﺎﺑﺖ‬Walker ‫ اﻣﺎ در ﺑﺮرﺳﻲ ﻛﻪ‬.‫ﻫﻢﺧﻮاﻧﻲ داﺷﺖ‬

‫ﻳﻜﻲ از ﺗﺸﺨﻴﺺﻫﺎي اﻓﺘﺮاﻗﻲ ﻛﻪ در ﺻﻮرت ﺑﺮوز ﻋﻼﻳﻢ ﺗﻨﻔﺴﻲ در‬

‫ ﺑﻪﻋﻼوه در‬13.‫را در ﻣﺮدان ﻣﺴﻠﻮل ﻳﻚ و ﻧﻴﻢ ﺑﺮاﺑﺮ زﻧﺎن اﻋﻼم ﻛﺮدﻧﺪ‬

‫ ﻟﺬا‬.‫ اﺣﺘﻤﺎل وﺟﻮد ﺑﻴﻤﺎري ﺳﻞ اﺳﺖ‬،‫اﻳﻦ اﻓﺮاد ﻣﻲﺗﻮان در ﻧﻈﺮ ﮔﺮﻓﺖ‬

.‫ ﺧﻄﺮ ﻓﻌﺎل ﺷﺪن ﻋﻔﻮﻧﺖ ﺳﻞ ﺑﺴﻴﺎر ﺑﺎﻻﺳﺖ‬HIV ‫ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ‬

Prez-Guzman

،Nissapathorn ‫ﻫﻢﭼﻨﻴﻦ ﺑﺎ ﻣﻄﺎﻟﻌﻪي‬

.‫دارد‬

‫ﺑﺎ ﻃﺮاﺣﻲ ﺑﺮﻧﺎﻣﻪﻫﺎي ﻣﺪون در ﺟﻬﺖ ﺗﺮك ﺳﻴﮕﺎر در ﺟﺎﻣﻌﻪ و ﻧﻴﺰ ﺑﺎ‬

‫اﻳﻦ دو ﺑﻴﻤﺎري ﺑﺮ ﻫﻤﺪﻳﮕﺮ اﺛﺮ ﻣﺘﻘﺎﺑﻞ دارﻧﺪ زﻳﺮا ﺑﺎ ﺗﺮﺷﺢ‬

‫ﻏﺮﺑﺎلﮔﺮي ﺑﻴﻤﺎران دﻳﺎﺑﺘﻲ ﻣﻲﺗﻮان اﻓﻖ ﺗﺎزهاي در ﺟﻬﺖ ﻛﻨﺘﺮل و‬

‫ ﺗﻮاﻧﺎﻳﻲ ﺗﻜﺜﻴﺮ وﻳﺮوس‬،‫ﺳﺎﻳﺘﻮﻛﻴﻦﻫﺎي ﭘﻴﺶاﻟﺘﻬﺎﺑﻲ از ﮔﺮاﻧﻮﻟﻮم ﺳﻠﻲ‬

.‫ﭘﻴﺸﮕﻴﺮي ﺑﻴﻤﺎري ﺑﺎزﭘﺪﻳﺪ ﺳﻞ ﺗﺮﺳﻴﻢ ﻧﻤﻮد‬

‫ و ﻣﺎﻛﺮوﻓﺎژ ﻛﻪ ﻧﻘﺶ‬CD4 ‫ ﺑﻴﺶﺗﺮ ﺷﺪه و ﺑﺎ ﻛﺎﻫﺶ ﻟﻨﻔﻮﺳﻴﺖﻫﺎي‬HIV

‫ اﻳﻦ ﻣﻘﺎﻟﻪ ﺣﺎﺻﻞ ﺑﺨﺸﻲ از ﭘﺎﻳـﺎنﻧﺎﻣـﻪ ﺗﺤـﺖ ﻋﻨـﻮان‬:‫ﺳﭙﺎﺳﮕﺰاري‬

‫ﻣﻬﻤﻲ در ﺣﺬف ﻣﺎﻳﻜﻮﺑﺎﻛﺘﺮومﻫﺎ دارﻧﺪ ﺧﻄﺮ ﻓﻌﺎل ﺷﺪن ﻋﻔﻮﻧﺖ ﺳﻠﻲ‬

‫ و رﺳــﭙﺘﻮر‬HLA-H ‫"ﺑﺮرﺳــﻲ ارﺗﺒــﺎط ﺑﻴــﺎن و ﭘﻠــﻲﻣﻮرﻓﻴــﺴﻢ ژنﻫــﺎي‬

‫ ﻧﺘﺎﻳﺞ ﺣﺎﺻﻞ از اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺗﻮﺻﻴﻔﻲ ﻧﺸﺎن داد ﻛﻪ‬14.‫ﻧﻴﺰ اﻓﺰاﻳﺶ ﻣﻲﻳﺎﺑﺪ‬

‫اﻳﻨﺘﺮﻓﺮون ﮔﺎﻣﺎ ﺑﺎ ﺑﻴﻤﺎري ﺳـﻞ" در ﻣﻘﻄـﻊ ﻛﺎرﺷﻨﺎﺳـﻲ ارﺷـﺪ در ﺳـﺎل‬

‫ اﺑﺘﻼ ﺑﻪ ﻋﻔﻮﻧﺖ‬،‫ﻛﻢﺗﺮﻳﻦ رﻳﺴﻚ ﻓﺎﻛﺘﻮر در ﺑﻴﻦ ﺑﻴﻤﺎران ﻣﻮرد ﺑﺮرﺳﻲ‬

‫ ﻣﻲﺑﺎﺷﺪ ﻛﻪ ﺑﺎ ﺣﻤﺎﻳـﺖ داﻧـﺸﮕﺎه ﻋﻠـﻮم ﭘﺰﺷـﻜﻲ و‬1298 ‫ و ﻛﺪ‬1390

‫ ﺷﻴﻮع ﻋﻔﻮﻧﺖ‬،‫ در آﻓﺮﻳﻘﺎ‬Mukadi ‫ درﺣﺎﻟﻲ ﻛﻪ در ﺑﺮرﺳﻲ‬،‫اﺳﺖ‬

.‫ﺧﺪﻣﺎت ﺑﻬﺪاﺷﺘﻲ درﻣﺎﻧﻲ ﻣﺎزﻧﺪران اﺟﺮا ﺷﺪه اﺳﺖ‬

HIV

‫ ﻧﺘﺎﻳﺞ ﺣﺎﺻﻞ از‬.‫ ﮔﺰارش ﺷﺪ‬%26/9 ،%35، %31/3 ‫ ﺑﻪﺗﺮﺗﻴﺐ‬TB/HIV

References 1. Wise J. WHO identifies 16 countries struggling to control tuberculosis. BMJ 1998;316(7136):957. 2. Edsall J, Collins JG, Gray JA. The reactivation of tuberculosis in New York City in 1967. Am Rev Respir Dis 1970;102(5):725-36. 3. Hocking WG, Golde DW. The pulmonary-alveolar macrophage (first of two parts). N Engl J Med 1979;301(11):580-7. 4. Pape JW. Tuberculosis and HIV in the Caribbean: approaches to diagnosis, treatment, and prophylaxis. Top HIV Med 2004;12(5):144-9. 5. Tubercolusis. Center for Diseases Control (CDC), Iranian Ministry of Health and Medical Education, 2004. 6. World Health Organisation (WHO). Tuberculosis (TB). Global Tuberculosis Control Surveillance, Planning, Financing, Who Report. 2008. [Internet] 2008 [cited 2012 May 15]; Available from: http://www.who.int/tb/publications/global_report/2008/en/ 7. Maurya V, Vijayan VK, Shah A. Smoking and tuberculosis: an association overlooked. Int J Tuberc Lung Dis 2002;6(11):94251. 8. Rezaei-talab F, Akbari H, Rezaei-talab GH. Smooking associated with pulmonary TB. Med J Mashhad Univ Med Sci 2007;50(95):75-80. [Persian] 9. Tsukaguchi K, Yoneda T, Yoshikawa M, Tokuyama T, Fu A, Tomoda K, et al. Case study of interleukin-1 beta, tumor necrosis

factor alpha and interleukin-6 production peripheral blood monocytes in patients with diabetes mellitus complicated by pulmonary tuberculosis. Kekkaku 1992;67(12):755-60. 10. Guya MM. Diabetes and hypothyroidism. Annual Conference of Diabetes and Hypothyroidism Screening. Center for Diseases Control (CDC), Iranian Ministry of Health and Medical Education, 2006. 11. Nissapathorn V, Kuppusamy I, Josephine FP. Tuberculosis. A resurgent disease in immunosuppressed patients. Southeast Asian J Trop Med Public Health 2006;37:153-60. 12. Pérez-Guzmán C, Vargas MH, Torres-Cruz A, Pérez-Padilla JR, Furuya ME, Villarreal-Velarde H. Diabetes modifies the male:female ratio in pulmonary tuberculosis. Int J Tuberc Lung Dis 2003;7(4):354-8. 13. Walker C, Unwin N. Estimates of the impact of diabetes on the incidence of pulmonary tuberculosis in different ethnic groups in England. Thorax 2010;65(7):578-81. 14. Liberato IR, de Albuquerque Mde F, Campelo AR, de Melo HR. Characteristics of pulmonary tuberculosis in HIV seropositive and seronegative patients in a Northeastern region of Brazil. Rev Soc Bras Med Trop 2004;37(1):46-50 15. Mukadi YD, Maher D, Harries A. Tuberculosis case fatality rates in high HIV prevalence populations in sub-Saharan Africa. AIDS 2001;15(2):143-52.

333 ‫ ﺗﺎ‬330 ،5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

333

‫ﻛﺎراﻳﻲ دو روش ﭘﺎﻳﺶ ﺑﺮاي ﺗﺸﺨﻴﺺ ﻋﻔﻮﻧﺖ ﻣﺤﻞ ﺟﺮاﺣﻲ در ﺑﺨﺸﻬﺎي ﺟﺮاﺣﻲ ﻋﻤﻮﻣﻲ‬

Tehran University Medical Journal, August 2012; Vol. 70, No. 5: 330-333

Brief Report

Risk factors for tuberculosis infection: a brief report

Abstract

Received: February 15, 2012

Accepted: May 06, 2012

Elham Biranvand M.Sc. Saeid Abediankenari Ph.D.2* Alireza Khalilian Ph.D.3 Behnoush Biranvand4 1- M.Sc. Microbiology, Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran. 2- Department of Immunology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. 3- Bio Statistics, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. 4- Medical Student, Jondishapour University of Medical Sciences, Ahvaz, Iran.

Background: Tuberculosis is one of the most important diseases with annually 8 million new cases worldwide. The purpose of this study was to investigate the risk factors for tuberculosis (TB) infection. Methods: In this descriptive study performed in Health center of Maznadaran province during 2010-2011, 183 patients with pulmonary and extrapulmonary TB infection were recruited. After measuring fasting blood sugar, and human immunodeficiency virus (HIV) antibodies, history of smoking was taken by using a questionnaire.

Results: The mean age of the participants was 46.8±19.8 years. The most common risk factor was diabetes and the lowest was HIV infection. Moreover, the prevalence of diabetes in women compared with that of men (OR=0.19, 95% CI=0.07±0.46) and smoking in men compared with women (OR=12.4, 95% CI=2.8±54.4, P<0.05) had statistically significant differences (P<0.05). Conclusion: The results of this research show that diabetes and smoking could be risk factors for tuberculosis infection. It is concluded that, in case of respiratory symptoms in patients with diabetes and smoking, tuberculosis can be considered as an important differential diagnosis. Keywords: diabetes mellitus, HIV, tuberculosis.

Corresponding author: Dept. of Immunology, Mazandaran University of Medical Sciences, Sari, Iran. Tel: +98-151-3243081 E-mail: abedianks@razi.tums.ac.ir

Tehran Univ Med J (TUMJ) 2012 August;70(5):330-3

http://tumj.tums.ac.ir

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5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

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Tehran Univ Med J (TUMJ) 2012 August;70(5) http://tumj.tums.ac.ir

Tehran University Medical Journal Volume 70

Number 5

August 2012

Contents Determining effects of elaidic acid on PPAR- gamma expression in RAW 264.7 macrophage cell line......................................................................................................................................................275 Montakhab Yegane H, Babaahmadi Rezaiy H, Doosti M.

The effects of temperature and birth weight on the transition rate of hypothermia in hospitalized neonates using Markov models...........................................................................................................282 Akbarzadeh Baghban A, Jambarsang S, Pezeshk H, Nayeri F.

Resection and reconstruction of small intestine with ligasure and linear stapler: a comparative study...................................................................................................................................................289 Tavassoli A, Abdollahi A, Golmohammadzadeh H.

Correlation between MRS and serum PSA in the diagnosis of local recurrence after radical prostatectomy.....................................................................................................................................295 Ghafuri M, Vafaee Shahi A.

Peak systolic velocity of cavernosal artery of the penis before and after papaverine injection in erectile dysfunction.............................................................................................................................301 Bagheri S.M, Taheri M.

Greater occipital nerve block by bupivacaine/methyl prednisolone vs. bupivacaine/normal saline in medication overuse headache..........................................................................................................308 Alizade Khatir A, Panahkhahi M, Khage Nasiri A, Ramim T, Toghae M.

Congenital dislocation of knee: results of the treatment in 29 cases between 1970 and 2010 years at Shafa Yahyaian Hospital in Tehran................................................................................................314 Rahbar M, Jabalameli M, Aqajani N, Shafipour R.

The association between serum chemerin concentration and polycystic ovarian syndrome................320 Haghighi S, Yaghmaei P, Hashemi F, Saadati N, Ramezani Tehrani F, Hedayati M.

Factors related to extubation failure and post pulmonary complications in intracranial surgery in 254 patients: a brief report................................................................................................................325 Heydari S.V, Ramak Hashemi S.M, Abasnejad E.A, Abbasi Gravnd F, Ghorbani Yekta B.

Risk factors for tuberculosis infection: a brief report...........................................................................330 Biranvand E, Abediankenari S, Khalilian A, Biranvand B.

5 ‫ ﺷﻤﺎره‬،70 ‫ دوره‬،1391 ‫ ﻣﺮداد‬،‫ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ ﺗﻬﺮان‬،‫ﻣﺠﻠﻪ داﻧﺸﻜﺪه ﭘﺰﺷﻜﻲ‬

TUMJ

TEHRAN UNIVERSITY MEDICAL JOURNAL The Official Publication of Medical School, Tehran University of Medical Sciences Volume 70

Number 5

August 2012

Chairman: S.H. Emami Razavi Editor in Chief: N. Behtash Executive Editor: M.A. Noyan Ashraf Associate Editors: SH. Akhondzadeh, A. Arab Kheradmand, N. Ataei, S. Borna, M. Ghazi Khansari, S.J. Ghazi Mirsaeed, J. Hajati, M. Kadkhodaei, A. Khoshnevisan, S. Moradmand, Z. Nadiya Hatmi, M.A. Noyan Ashraf, R. Omranipoor, N. Rezaei, N. Sajjadian Editorial Board: M. Akbarian, F. AmoozegarHashemi, B. Bahar, F. Davari Tanha, N. Ebrahimi Daryani, M.R. Hadiyan, Z. Hallaji, Z. Hussain Khan, M. Kajbaf Zadeh, M.J Mikaeli, A. Mousavi, S.M.J. Mortazavi, B. Nabaei, P. Pasalar , P. Pasbakhsh, M. Rasooli Negad, A. Shaabani, M. Sotoodeh, A.R. Talaeipoor, M. Vahid Dasjerdi, M.R. Zafarghandi International Board: F. Assadi (Chicago), J. Parvizi (Philadelphia), A. Gangi (Strasbourg), M.R. Keshtgar (London), Sh. Masood (Florida), P. Hanjani (Pennsylvania) Editors: N. Behtash, S.B. Hashemi, V. Nikoui, M.A. Noyan Ashraf Office staff: M. Asgari, H. Chaychi, A. Kamizani, R. Ramezani, S. Sadigh Publisher: Tehran University of Medical Sciences Office: Tehran University Medical Journal, Medical School, 202 Amouzesh building, Poursina Ave., Ghods St., Keshavarz Blvd., Tehran, Iran, P.o. Box: 14155-6447, Tel: +98(21)88962510, Fax: +98(21)88962510, Online submission: http://journals.tums.ac.ir/login, and http://tumj.tums.ac.ir, Email: medjournal@tums.ac.ir

TUMJ is indexed/ abstracted in: SCOPUS, EMBASE, Cambridge Scientific Abstracts (CSA), CAB Abstracts (CABI), Chemical Abstract Service (CAS), DOAJ, Psych Info, ULRICHÎ&#x201E;S, Index Copernicus, IMEMR, EMR Beta, SID, Magiran and Iran Medex