Redaktoriaus žodis

Redaktoriaus žodis

Arvydas AmbrozaitisVis labiau skubėdami ir nuolatos stengdamiesi išmėginti naujus dalykus, bandome užmaskuoti savo tuštumą. Per trumpą laiką planuojame atlikti kiek įmanoma daugiau darbų. Tai panašu į atviras lenktynes, nors mes nežinome, kodėl ir su kuo lenktyniaujame.

  Darbas niekada neteikia džiaugsmo, jei atliekamas skubant, esant spaudimui iš išorės. Tai prieštarauja mūsų prigimčiai. Nuolatinė skuba temdo nuovokumą. Kad sutaupytų laiko, žmogus pradeda naudoti iš anksto parengtus atsakymus, renkasi trumpiausią kelią, dirba be įkvėpimo.

  Dažnai sakoma, kad šiais laikais gyvenimas yra toks sudėtingas, toks įtemptas ir perkrautas, kad esame priversti skubėti, kad išgyventume. Bet aš galvoju kitaip: mes dar turime galimybę rinktis. Galime primygtinai siekti tokių darbo sąlygų, kurios neverčia skubėti. Kai savo darbą ir pareigas atliksime neskubėdami, rečiau klysime, išvengsime įtampos, gerės mūsų gyvenimo kokybė.

   Eknathas Easwaranas (1910–1999)

Mieli kolegos,

 

nelabai karštą vasarą pakeitė vėsokas ruduo. Rudenį įprasta įvertinti ne tik gamtos padovanotas gėrybes ir vaisius, bet ir pasidžiaugti per metus atliktų darbų rezultatais. Po ilgo ir įtempto darbo – jūsų dėmesiui pirmasis šių metų žurnalo Internistas priedo Infekcinės ligos numeris.  Nors žurnalas oficialiai įvardytas kaip Lietuvos infektologų draugijos (LID) leidinys, tačiau jis yra skirtas ne vien infekcinių ligų gydytojams, epidemiologams, mikrobiologams, visuomenės sveikatos specialistams, bet ir bendrosios praktikos gydytojams.

Šie metai prasidėjo skaudžiomis netektimis. Mūsų bendruomenė neteko dviejų iškilių LID narių, ryškių asmenybių, patyrusių gydytojų. Gegužės 11-ąją mirė ilgametė Respublikinės Šiaulių ligoninės Suaugusiųjų infekcinių ligų skyriaus vedėja gyd. Irena Ruškuvienė, o gegužės 29-ąją netekome ilgametės Kauno medicinos instituto Infekcinių ligų katedros vedėjos prof. Jūratės Dievaitienės.

Birželio 2 dieną Klaipėdoje vyko 22-oji LID organizuota mokslinė praktinė konferencija Infektologija 2017, skirta aktualiems infekcinių ligų klausimams. Nors registracijos mokestis buvo nemažas, konferencijoje dalyvavo daugiau nei 100 dalyvių, tarp jų net 30 gydytojų iš Latvijos grupė, vadovaujama doc. Ievos Tolmanės. Galime sakyti, kad tai buvo tarptautinė konferencija, nes pranešimus skaitė lektoriai iš Londono (Sanjai Bhaganis), Rygos (Paulas Aldinšas), Helsinkio (Kirsi Auro), Malmės (Leo Flamholcas), Ženevos (Giedrius Likatavičius). Taip pat buvo pateikti įdomūs klinikiniai atvejai iš realaus gyvenimo (Judita Minickaitė-Katinienė, Liucijus Ambraška, Audronė Marcinkutė). Ši konferencija nebūtų įvykusi, jei ne mūsų ištikimų rėmėjų parama, už ką jiems labai dėkojame. Šių metų naujiena – sinchroninis vertimas iš anglų į lietuvių ir iš lietuvių į anglų kalbą.

Kalbant apie aktualias Lietuvai infekcines ligas, galima pasidžiaugti, kad Lietuvos Respublikos sveikatos apsaugos ministro 2016 metų lapkričio 15 dienos įsakymu V-1258 sudaryta darbo grupė 2017 metais gegužės mėnesį parengė Žmogaus imunodeficito viruso ligos diagnostikos ir gydymo, kompensuojamo iš Privalomojo sveikatos draudimo fondo (PSDF) biudžeto lėšų, tvarkos aprašo projektą, kurio galutinę redakciją po pastabų ir pasiūlymų pateikimo ministerijai planuojama svarstyti artimiausiame PSDF posėdyje 2017 metų spalio mėnesį. Darbo grupės veikloje aktyviai dalyvavo ir LID nariai – Raimonda Matulionytė, Ligita Jančorienė, Arvydas Ambrozaitis, Auksė Mickienė ir Daiva Vėlyvytė. Šiuo metu galiojantis 2010 metų Lietuvos respublikos sveikatos apsaugos ministerijos įsakymu patvirtintas Aprašas leidžia pradėti gydymą antiretrovirusiniais vaistais (ARV), kai CD4 skaičius yra <350 ląst./mm3. Lietuva kartu su Latvija lieka vienintelės Europos Sąjungos šalys, kur gydymą ARV galima pradėti taip toli pažengus infekcijai. Europos AIDS klinikinė draugija (angl. European AIDS Clinical Society – EACS) gydymą ARV rekomenduoja visiems žmogaus imunodeficito virusi (ŽIV) infekuotiems asmenims, nepriklausomai nuo CD4 skaičiaus. 2017 metais atliktas išsamus ŽIV / AIDS priežiūros ir gydymo Lietuvoje įvertinimo tyrimas parodė, kad tik 32 proc. sergančiųjų yra gydomi. Lietuvoje tik 16 proc. yra saugūs ir negali užkrėsti aplinkinių, o visi kiti – beveik 80 proc. – gali platinti infekciją. Lietuvoje yra nemažai užsikrėtusiųjų ŽIV, kurie nė karto nesilankė pas gydytoją ir negavo sveikatos priežiūros paslaugų. Taigi visų mūsų siekis, kad kuo daugiau žmonių sužinotų savo ŽIV statusą, kad jiems kaip galima anksčiau būtų pasiekiamas efektyvus gydymas, kad užsikrėtusieji neplatintų viruso.

Patvirtinus Aprašą, iš esmės jis taps pagaliau suderintu su Europos AIDS klinikinės draugijos rekomendacijomis. Pagrindiniai naujojo Aprašo pokyčiai:

  • terapija ARV skiriama visiems ŽIV užsikrėtusiems pacientams siekiant stabdyti ŽIV perdavimą;
  • ŽIV užsikrėtusiam pacientui diagnozavus tuberkuliozę, gydymas ARV skiriamas jau po 2–4 savaičių nuo tuberkuliozės gydymo pradžios;
  • tarp pradiniam gydymui rekomenduojamų pirmo pasirinkimo ARV derinių yra integrazių inhibitoriai, skiriami derinant su 2 nukleozidų atvirkštinės transkriptazės inhibitoriais (NATI);
  • efavirenzas rekomenduojamas tik kaip alternatyvaus pasirinkimo vaistas kartu su NATI;
  • ŽIV užsikrėtusiai ir ARV negydytai nėščiajai profilaktinis gydymas ARV pradedamas kaip galima anksčiau (buvo – nuo 28 nėštumo savaitės);
  • gimdymas natūraliu būdu siūlomas moterims, kurioms nėštumo metu buvo skirti ARV ir ŽIV RNR <50 kop./ml (anksčiau cezario pjūvis buvo rekomenduojamas visoms infekuotoms moterims 38 nėštumo savaitę) ir kt.

Kalbant apie integrazės inhibitorius, svarbu pažymėti, kad integrazės inhibitorius dolutegraviras buvo skiriamas vadovaujantis vaistinio preparato charakteristikų santrauka, o kitas integrazės inhibitorius raltegraviras – tik konsiliumo sprendimu, kai yra nustatomos gretutinės patologijos ir būklės arba esant koinfekcijai su hepatito B virusu (HBV) ar hepatito C virusu (HCV), nustačius netoleravimą pirmojo pasirinkimo vaistams. Šis raltegraviro skyrimo apribojimas buvo nepagrįstas, nes abu vaistai tos pačios klasės, yra kompensuojami tai pačiai ligai gydyti, gydymo išlaidos beveik yra identiški, tačiau skyrimo sąlygos buvo skirtingos. Čia įvyko teigiamos permainos: remiantis 2017 metų rugsėjo mėnesio 18 dienos Lietuvos Respublikos sveikatos apsaugos ministro įsakymu Nr. V-1094, raltegraviro skyrimui ankstesni apribojimai nėra taikomi nuo spalio 1 dienos, taip pat apie 30 proc. sumažėjo šio svarbaus ARV kaina.

Dolutegraviras ir raltegraviras greičiau sumažina viremiją esant dideliam pradiniam ŽIV RNR lygiui, ypač tinka esant vėlyvai diagnostikai. Jei nėščiosios gydymas dėl ŽIV infekcijos pradedamas po 28 nėštumo savaitės, pirmaeilis derinys gydymui iki gimdymo yra su raltegraviru.

Raltegraviras saugus nėštumo metu (dolutegraviras nėštumo metu neskiriamas), saugus esant gretutinėms lėtinėms inkstų ligoms. Praktiškai nėra kliniškai reikšmingų tarpusavio sąveikų su kitais vaistais, tarp jų ir su lėtinio hepatito C gydymui vartojamais tiesiogiai virusą veikiančiais antivirusiniais vaistais, todėl raltegraviras ypač tinka HCV ir ŽIV koinfekcijai gydyti.

2017 metais liepos 20 dieną Europos vaistų agentūra (angl. European Medicines Agency – EMA) įregistravo naują sudėtinį įvairių ARV grupių derinį: darunaviras / kobicistatas / emtricitabinas / tenofoviro alafenamido fumaratas. Rekomenduojamos vaistų vartojimo dozės: 800 mg / 150 mg / 200 mg / 10 mg 1 k./p. valgio metu.

Naujienos ir kitos aktualios Lietuvai infekcinės ligos gydymo srityje. Lietuvos Respublikos sveikatos apsaugos ministro 2017 metų rugsėjo 18 dienos įsakymu V-1094 į Ligų ir kompensuojamųjų vaistų joms gydyti sąrašą įtrauktas 2016 metais liepos 29 dieną registruotas Europos Sąjungoje tiesiogiai veikiantis HCV kombinuotas antivirusinis preparatas. Jį sudaro elbasviras – NS5A inhibitorius, grazopreviras – NS3/4A proteazės inhibitorius. Kaip ir Viekirax® (ombitasviras + paritapreviras + ritonaviras) + Exviera® (dasabuviras), jis yra skirtas 1 ir 4 HCV genotipu užsikrėtusiems ligoniams gydyti. Gydymo trukmė – 12–16 savaičių, priklausomai nuo HCV genotipo potipio ir viremijos lygio. Užsikrėtus 1a HCV genotipu, vaistinis preparatas skiriamas 16 savaičių kartu su ribavirinu pacientams, kurių pradinė HCV RNR koncentracija viršija 800 000 TV/ml ir (arba) yra specifinių NS5A polimorfizmų. Tai sumažina gydymo nesėkmės riziką iki minimumo.

Kokie gi šio antivirusinio vaisto privalumai? Kadangi vaistas nėra metabolizuojamas inkstuose, jis tinka visiems pacientams, net ir HCV užsikrėtusiems hemodializuojamiems ligoniams gydyti, taip pat prieš inksto transplantaciją. Nedaug nepageidaujamų reiškinių, labai mažai tarpusavio sąveikų su kitais vaistais. Esant HCV ir ŽIV koinfekcijai, šis antivirusinis vaistinis preparatas gali būti skiriamas ir tiems ligoniams, kurie prieš tai dar nebuvo gydyti ARV, nes jo sudėtyje nėra ritonaviro. Labai patogus vartoti – rekomenduojama dozė yra 1 tabletė 1 k./p. nepriklausomai nuo valgio.

Šių metų naujiena – tai keturvalentė gripo vakcina. Europos užkrečiamųjų ligų centro rekomenduojama jau nuo 2014 metų, dabar atsirado ir Lietuvoje, ir ją jau galima įsigyti. Kaip žinoma, yra dvi B tipo gripo viruso padermės, ir ne visada pavyksta nuspėti, kuri padermė cirkuliuos gripo sezono metu. Nustatyta, kad vidutiniškai 1 iš 4 gripo sezonų vyraujanti B gripo viruso padermė, deja, neatitinka trivalentėje vakcinoje esančio B viruso antigeno, todėl gali būti mažesnis gripo vakcinos efektyvumas susirgus B viruso sukelta gripo infekcija. To galima išvengti pasiskiepijus naująja keturvalente gripo vakcina, skirta skiepyti vaikus nuo 3 metų ir suaugusiuosius. Keturvalentė vakcina apsaugos nuo bet kurios B gripo viruso padermės sukeltos infekcijos, nes jos sudėtyje yra abiejų B gripo viruso padermių antigenų.

Lietuvoje didinant skiepijimo nuo sezoninio gripo mastą ir įgyvendinant Lietuvos Respublikos sveikatos apsaugos ministro 2014 metų sausio 3 dieną įsakymą Nr. V-8 Dėl Nacionalinės imunoprofilaktikos 2014–2018 metais programos patvirtinimo, Valstybinė ligonių kasa (VLK) kiekvienam gripo sezonui kasmet skiria nemažai lėšų, už kurias perkama sezoninio gripo vakcina, kuria nemokamai skiepijami rizikos grupių asmenys:

  • vyresni nei 65 metų;
  • sergantys lėtinėmis širdies ir kraujagyslių, kvėpavimo takų, inkstų ligomis, lėtinėmis ligomis, susijusiomis su imuniniais mechanizmais, piktybiniais navikais;
  • gyvenantys socialinės globos ir slaugos įstaigose;
  • nėščiosios;
  • sveikatos priežiūros įstaigų darbuotojai.

Šiemet VLK 20172018 metų gripo sezonui nupirko daugiau nei 123 tūkst. gripo trivalentės vakcinos Influvac® dozių. Reikėtų pabrėžti, kad Lietuvoje yra apie 700 tūkst. rizikos grupėms priklausančių žmonių…

Yra naujienų ir žmogaus papilomos viruso (ŽPV) vakcinacijos srityje.

Šių metų rugsėjo 1 dieną sukako lygiai metai, kai vykdant nacionalinę imunizacijos programą buvo pradėtos skiepyti nuo ŽPV sukeliamos infekcijos 11 metų mergaitės. Rezultatai džiuginantys – paskiepyta apie 55 proc. visų vienuolikamečių mergaičių, apsaugant jas nuo didelės dalies ŽPV sukeliamų ligų. Tai viršija Europos šalių vidurkį, vertinant vakcinaciją nuo ŽPV.  Visos valstybės užsakytos vakcinos sunaudotos, kitiems metams jų tikimasi gauti daugiau.

Dėl pastaruoju metu matomų demografinių pokyčių visuomenėje, pailgėjusio žmonių išgyvenamumo ir medicinos mokslų laimėjimų įvairių rizikos grupių suaugusiųjų skiepijimas, siekiant juos apsaugoti nuo užkrečiamųjų ligų, kurios gali būti kontroliuojamos vakcinomis, tampa labai reikšmingas. Deja, kol kas trūksta mokslo pagrįstų įrodymų dėl suaugusiųjų rizikos grupių skiepijimo veiksmingumo ir saugumo. Esant dideliam suaugusiųjų rizikos grupių asmenų skiepijimo rekomendacijų poreikiui, vadovaujantis prieinama moksline literatūra, kitų šalių ar atskirų sveikatos priežiūros įstaigų patirtimi, užsienio ir Lietuvos skiepijimo ekspertų nuomone, LID kartu su kitų specialybių gydytojų draugijų atstovais jau 2015 metais parengė ir išleido pirmąjį suaugusiųjų rizikos grupių skiepijimo Lietuvoje metodinių rekomendacijų leidinį. Jo tiražas dėl aktualumo ir svarbos gana greitai išseko, greitai buvo išplatintas po visą šalį. Šiemet, 2017-aisiais, šios rekomendacijos buvo atnaujintos ir dar labiau adaptuotos Lietuvai.

2016 metais, nutraukus pneumokokinės polisacharidinės 23-valentės vakcinos (PPSV 23) gamybą ir tiekimą į Lietuvą, atitinkamai buvo pakoreguoti rekomendacijų skyreliai, susiję su pneumokokine infekcijos profilaktika. Pneumokokinės vakcinos gali būti įskiepijamos kartu su sezoninio gripo vakcina. Į rekomendacijas, be Bexsero® vakcinos, bus įtraukta ir kita meningokokinė vakcina nuo B sukeliamos meningokokinės infekcijos – Trumenba®.

Metodines rekomendacijas rengė prof. A. Ambrozaitis, prof. L. Jančorienė, prof. A. Mickienė, doc. D. Vėlyvytė kartu su įvairių medicinos specialybių konsultantais. Rekomendacijos skirtos visų kvalifikacijų medicinos gydytojams ir visuomenės sveikatos specialistams.

Taigi jūsų rankose pirmasis šių metų žurnalo Internistas priedo Infekcinės ligos numeris.

Šiame numeryje rasite aktualius medicinos visuomenei apžvalginius straipsnius apie Clostridium difficile sukeltą enterokolitą, erkinį encefalitą, virusinį hepatitą A, taip pat apie tymus, vakcina valdomą infekciją, bet iki šiol sukeliančią nemažai ligų visoje Europoje.

Pristatomas įdomus klinikinis atvejis apie erkinio encefalito diagnostikos sunkumus skiepytam nuo erkinio encefalito asmeniui (gyd. L. Ambraška).

Jūsų dėmesiui – įspūdžiai ir vertinga informacija iš dviejų šiemet vykusių tarptautinių konferencijų. Šių metų balandžio 22–25 dienomis Vienoje vyko 27-asis Europos klinikinės mikrobiologijos ir infekcinių ligų kongresas (angl. European Congress of Clinical Microbiology and Infectious Diseases – ECCMID), kuriame dalyvavo nemažai dalyvių iš Lietuvos. Apžvalginę informaciją apie naujienas infektologijos srityje parengė šio kongreso dalyviai Vilniaus universiteto ligoninės Santaros klinikų Infekcinių ligų centro infekcinių ligų gyd. Mindaugas Paulauskas ir gyd. rez. Elžbieta Matulytė. Šių metų liepos 23–27 dienomis Paryžiuje vyko kitas infekcinių ligų gydytojams labai svarbus Tarptautinės AIDS draugijos kongresas. Jį apžvelgė šio kongreso dalyvės gyd. Gabrielė Gaižutytė ir gyd. rez. E. Matulytė.

Skaitytojai šiame Infekcinių ligų žurnalo numeryje ras ir kitos aktualios informacijos.

 

  Dėkoju visiems autoriams, žurnalo rėmėjams ir linkiu malonaus skaitymo!

Vyriausiasis redaktorius

prof. Arvydas Ambrozaitis


284 mintys apie “Redaktoriaus žodis

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