CPG Management of Transfusion Dependent Thalassaemia
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Transcript of CPG Management of Transfusion Dependent Thalassaemia
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2
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
:( JA\HZLGGBHN KHM ZJSLLHBHN
:(; NLHL]BJ JA\HZLGGBHN
:(;(; Bh}sam|j}bah
E Nlhl}bj ja|hzlggbhn bz }el psajlzz bh ~ebje pk}blh}z as slgk}bvlz
k} sbzd af k mbzasmls }ek} okr cl elslmb}ksr ksl kmvbzlm af }el
jahzl{|lhjlz af }el mbzasmls' }el psackcbgb}r af mlvlgapbhn as
}skhzob}}bhn b}' khm af }el ~krz bh ~ebje }ebz okr cl pslvlh}lm!
kvabmlm as kolgbask}lm(36 Glvlg BBB
E Nlhl}bj ja|hzlggbhn bz lzzlh}bkg }a psa}lj} }el k|}ahaor af
kh bhmbvbm|kg as ja|pgl khm }a f|gg }elbs sbne}z }a okubo|o
bhfasok}bah kca|} }el mbzasmls khm }a elgp }elo }a |hmlsz}khm
khm }a jeaazl koahn }el ap}bahz kvkbgkcgl(:0Glvlg BBB
E Jahmlh}bkgb}r af nlhl}bj bhfasok}bah hllmz }a cl slzplj}lm(:0 Glvlg BBB
E ]el z|jjlzz af nlhl}bj ja|hzlggbhn mlplhmz js|jbkggr ah b}z
lm|jk}bahkg' vag|h}ksr khm hahpslzjsbp}bvl!hahmbslj}bvlhk}|sl(32Glvlg BBB
E Pzrjeaganbjkg z|ppas} khm lopek}bj slgk}bahzebp cl}~llh }el
ja|hzlggas khm }el ja|hzlgll ksl bopas}kh} lglolh}z af nlhl}bj
ja|hzlggbhn(:0Glvlg BBB
:(;(3 ^ea zea|gm psavbml nlhl}bj ja|hzlggbhn1
E Nlhl}bj ja|hzlggbhn zea|gm cl psavbmlm cr Jgbhbjkg Nlhl}bjbz}z'
nlhl}bj ja|hzlggasz as kml{|k}lgr }skbhlm olmbjkg!h|szbhn z}kff
~ea ksl jahmlh} k} psavbmbhn bhfasok}bah slnksmbhn kgg kzplj}z
af }ekgkzzklobk(:0/:=Glvlg BB/:
E Nlhl}bj ja|hzlggbhn af k} sbzd ja|pglz khm fkobgblz ~b}e kfflj}lm
bhmbvbm|kgz' khm fas plapgl ~b}e |h|z|kg jkssbls z}k}lz as
pks}bj|gks psacglo!bzz|l' zea|gm cl psavbmlm cr nlhl}bjbz}z!}skbhlm maj}asz(32Glvlg BBB
E Elkg}e ~asdlsz bhvagvlm bh psavbmbhn bhb}bkg zjsllhbhn }lz}z hllm
}a cl kcgl }a psavbml zbopgl khm jglks bhfasok}bah kca|} }el
slkzahz khm acilj}bvlz af }el }lz}z( Gkr ja|hzlggasz zea|gm
cl kvabmlm(32':=Glvlg BBB
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Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
:(;(: ^elh }a psavbml }el nlhl}bj ja|hzlggbhn1
E Ja|hzlggbhn zea|gm cl afflslm clfasl jkssbls zjsllhbhn bzjahm|j}lm khm kf}ls }el slz|g} cljaolz kvkbgkcgl(:Glvlg BBB TSlfls }a Kpplhmbu : khm =_
E Z|b}kcgl bhfasok}bah zea|gm cl okml kvkbgkcgl(:
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;;
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
SLJAOOLHMK]BAH
Nlhl}bj ja|hzlggbhn zea|gm cl psavbmlm cr kh kppsapsbk}lgr }skbhlmpsaflzzbahkg( %Nskml J"
Nlhl}bj ja|hzlggbhn zea|gm cl jahm|j}lm bh kjjasmkhjl }a }el
fagga~bhn psbhjbpglz9
E Psavbzbah af slglvkh} khm acilj}bvl bhfasok}bah4
E Psavbzbah af pzrjeazajbkg z|ppas}4
E Jahzbmlsk}bah af fkobgbkg bopgbjk}bahz4
E Ac}kbhbhn bhfasolm jahzlh} fas nlhl}bj }lz}bhn4
E Lhz|sbhn jahmlh}bkgb}r af nlhl}bj bhfasok}bah4
E Kppsapsbk}l ekhmgbhn af pa}lh}bkg mbzjsbobhk}bah kz k slz|g} af
}lz}bhn4
E Kzz|sbhn k|}ahaoa|z mljbzbah/okdbhn cr }el ja|hzlgll %Nskml J"
:(;(6 Zea|gm pslhk}kg mbknhazbz cl mbzj|zzlm1
E Bh oaz} jkzlz' kfflj}lm cbs}ez z}lo fsao fkbg|sl }a bhfaso pkslh}z
af }el pazzbcbgb}r af sbzd khm pslvlh}bah kml{|k}lgr sk}els }ekh
}elbs slilj}bah af fal}kg }lz}bhn(32Glvlg BBB
E Mljbzbahz fas pslhk}kg mbknhazbz ksl bh|lhjlm cr okhr fkj}asz'
ha} slgbnba|z as j|g}|skg fkj}asz kgahl(:5 Glvlg BB/:
E Slgbnbah khm fkb}e ksl bopas}kh} fkj}asz bh }el mljbzbah okdbhn
psajlzz c|} }el plsjlbvlm zlvlsb}r af }el jahmb}bahz ~bgg pgkr k
oasl bopas}kh} sagl(:6':5/=; Glvlg BBB
E Slpsam|j}bvl ap}bahz fas fkobgblz kfflj}lm ~b}e k }skhzf|zbah/
mlplhmlh} }ekgkzzklobk okias pk}blh} zea|gm cl mljbmlm cr
}el fkobgblz }elozlgvlz kf}ls nlhl}bj ja|hzlggbhn(=3/=: Glvlg BBB
SLJAOOLHMK]BAH
Pslhk}kg mbknhazbz zea|gm cl mbzj|zzlm slnksmglzz af slgbnba|z khmj|g}|skg ckjdnsa|hm( %Nskml J"
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;3
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
:(3 JKZJKML ZJSLLHBHN
:(3(; Bh}sam|j}bah
E Nlhl}bj zjsllhbhn' mlhlm cr }el L|saplkh Zajbl}r af E|okh
Nlhl}bjz %LZEN" kz khr dbhm af }lz} plsfasolm fas }elzrz}lok}bj lksgr ml}lj}bah as lujg|zbah af k nlhl}bj mbzlkzl' }el
pslmbzpazb}bah as slzbz}khjl }a z|je k mbzlkzl' as }a ml}lsobhl~el}els k plszah jkssblz k nlhl vksbkh} ~ebje okr psam|jl
mbzlkzl bh affzpsbhn( Jkzjkml zjsllhbhn bz k nlhl}bj/zjsllhbhnz}sk}lnr }ek} }ksnl}z slgk}bvlz af jkssblsz!kfflj}lm bhmbvbm|kgz af
nlhl}bj mbzasmlsz }esa|ne }el }lz}bhn af }elbs pelha}rplz asnlha}rplz(== Glvlg BBB
:(3(3 ^ek} bz }el sagl af jkzjkml zjsllhbhn bh }el okhknlolh} af}ekgkzzklobk pk}blh}z1
E Pslvlh}bhn }ekgkzzklobk cbs}ez bz ckzlm ah bmlh}bfrbhn bhmbvbm|kgz
k} sbzd' psavbmbhn kml{|k}l bhfasok}bah ah sbzd khm pazzbcbgb}blz}a slm|jl }ek} sbzd(32Glvlg BBB
E Zjsllhbhn fkobgr oloclsz af kh bhmlu jkzl %}ekgkzzklobk okias
as jkssblsz" zea|gm cl plsfasolm(=
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;:
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
=( CGAAM ]SKHZF\ZBAH ]ELSKPR
]el kbo af cgaam }skhzf|zbah bh }ekgkzzklobk bz }a z|ppslzz
lu}skolm|ggksr ekloapablzbz ~ebgl obhbobzbhn jaopgbjk}bahz af |hmls
}skhzf|zbah khm okbh}kbhbhn hasokg ~lgg clbhn(
]el mljbzbah }a z}ks} cgaam }skhzf|zbah ~bgg sl{|bsl psapls kzzlzzolh}
af lkje bhmbvbm|kg }ekgkzzklobk pk}blh}( ]skhzf|zbah zea|gm cl
z}ks}lm psaop}gr ~elh }elsl bz jgbhbjkg lvbmlhjl af zlvlsl khklobk
~b}e zrop}aoz as zbnhz af jksmbkj fkbg|sl' fkbg|sl }a }esbvl' khm!as
}ekgkzzklobk cahl mlfasob}r(
=(; OKHKNLOLH]
=(;(; Psl/]skhzf|zbah Bhvlz}bnk}bahz
E Pk}blh} zea|gm cl pelha}rplm fas KCA' Se' Dlgg'=>/=2 Glvlg BB/: Dbmm'
M|ffr khm OHZz
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;=
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
Vag|ol af }skhzf|zbah9 cl}~llh ;< / 30 og!dn mlplhmbhn ah }el psl/}skhzf|zbah Ec khm eklok}ajsb} af pkjdlm jlggz psavbmlm cr }el cgaamckhd %Slfls }a ]kcgl 3"( ^elhlvls pazzbcgl' }el ~eagl ckn af cgaamzea|gm cl |zlm }a pslvlh} ~kz}knl(
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;
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
Perzbjbkhz zea|gm ekvl ebne glvlg af k~kslhlzz af }el bhflj}bah khm bfckj}lsklobk bz z|zplj}lm' pkslh}lskg kh}bcba}bjz knkbhz} Phl|oajajj|zkhm Ekloapebg|z zea|gm cl z}ks}lm(6=/66 Glvlg B
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;5
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
E BO Clhyk}ebhl plhbjbggbh : / = ~lldgr jkh cl |zlm kz kh kg}lshk}bvl(
E Fas pk}blh}z kgglsnbj }a plhbjbggbh' kg}lshk}bvlz bhjg|ml
lsr}esaorjbh' ja}sboaukyagl khm oaubaukjbh(62 Glvlg BBB
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;2
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
6( KZZLZZOLH] AF BSAH C\SMLH
Oah}egr pkjdlm slm cgaam jlgg %PSCJ" }skhzf|zbahz ~bgg slz|g} bh kh bsah
bh}kdl af 0(: / 0(< on!dn!mkr( Kf}ls kca|} ;0 / 30 }skhzf|zbahz' oaz}pk}blh}z ~bgg ekvl k zls|o flssb}bh %ZF" glvlg lujllmbhn ;000 n!G ' kh bsah
gakm jahzbmlslm ebne lha|ne }a ~ksskh} bsah jelgk}bah }elskpr(5
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30
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
6(: OKNHL]BJ SLZAHKHJL BOKNBHN %OSB"
OSB bz k |zlf|g khm hah bhvkzbvl }aag fas lz}bok}bhn }bzz|l bsah avlsgakm(]~a ckzbj kppsakjelz ekvl cllh mlvlgaplm9
;( Bhmbslj} {|kh}b}k}bvl ol}eamz }ek} |zl zbnhkg bh}lhzb}r sk}ba %ZBS"
3( Mbslj} {|kh}b}k}bvl ol}eamz }ek} |zl ]3' ]3) as S3' S3) pkskol}lsz
6(:(; Jksmbkj khm Gbvls ]3
Jksmbkj khm gbvls ]3 jkh cl olkz|slm mbslj}gr( Ea~lvls' }el}ljehb{|lz ksl gbob}lm m|l }a b}z zlhzb}bvb}r }a jksmbkj khm slzpbsk}asroa}bahz(23/2: Glvlg BB/:
6(:(3 OSB ]3)
OSB ]3) bz fkz} khm lkzr }a kj{|bsl' sac|z} }a oa}bah' oasl zlhzb}bvl}a bsah glvlgz khm slpsam|jbcgl avls }bol bh mbfflslh} jlh}slz ~b}embfflslh} zjkhhlsz( Ea~lvls b} sl{|bslz k pk}blh}z jaaplsk}bahkhm kcbgb}r }a ma k cslk}e/eagm m|sbhn }el psajlm|sl( Z}|mblz ekvlmloahz}sk}lm }el |}bgb}r af }ebz pkskol}ls bh pslmbj}bhn lksgr jksmbkjzbmlsazbz vlsz|z jahvlh}bahkg ljeajksmbanskper( Vkg|lz af 7 30 oz
bhmbjk}l jksmbkj bsah avlsgakm(2=/2< Glvlg BB/:]el vkg|lz ksl kgza jaopkskcgl}a gbvls bsah jahjlh}sk}bah cr cbapzr(>3 Glvlg BB/: Ahnabhn z}|mblz ksl clbhnmahl }a kzzlzz }bzz|l bsah bh a}els asnkhz cr ]3) olkz|slolh}z(
6(:(: OSB S3
OSB S3 ekz cllh zea~h }a jasslgk}l ~b}e GBJ( Olkz|slolh} af S3 crOSB ekz ha~ cllh vkgbmk}lm kz k slgbkcgl khm slpsam|jbcgl olkz|slolh}
af GBJ(
26/2> Glvlg BB/3
Ea~lvls' khkgrzbz af OSB S3 bz zaglgr plsfasolm cr kjaoolsjbkg lh}b}r khm }elslfasl luplhzbvl(
6(= ]EL HLLM ]A MA CA]E GBVLS KHM JKSMBKJ BSAHKZZLZZOLH]Z
Z}|mblz ekvl fkbglm }a zea~ khr zbnhbjkh} jasslgk}bah cl}~llh gbvlskhm jksmbkj bsah avlsgakm cr OSB( ]elslfasl' b} bz hljlzzksr }a olkz|slca}e gbvls khm jksmbkj bsah zlpksk}lgr(52'2='25 Glvlg BB/:
SLJAOOLHMK]BAH
Zls|o flssb}bh glvlgz zea|gm cl oahb}aslm lvlsr : / 6 oah}ez( %Nskml J"
OSB ]3) zea|gm cl |zlm }a kzzlzz jksmbkj bsah z}k}|z bh agmls jebgmslh(
%Nskml J"
OSB S3 jkh cl |zlm }a kzzlzz gbvls bsah( %Nskml J"
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3;
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
>( BSAH JELGK]BAH ]ELSKPR
]el }slk}olh} fas bsah avlsgakm bh cgaam }skhzf|zbah mlplhmlh}}ekgkzzklobk pk}blh}z bz bsah jelgk}bah( Luplsblhjl ~b}e }el lksgblz}
jelgk}as mlzflssbaukobhl zea~lm }ek} naam jaopgbkhjl khm kcbgb}r }adllp }el zls|o flssb}bh glvlgz jahzbz}lh}gr 7 3000 }a 3
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33
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
]ebz }lmba|z khm |hpglkzkh} z|cj|}khla|z ms|n slnbol ekz slz|g}lm bhpaas jaopgbkhjl khm elhjl jaopsaobzlz }el lfflj}bvlhlzz af MFA( Bhjgbhbjkg pskj}bjl' }el jaopgbkhjl }a MFA oaha}elskpr ~kz slpas}lm }askhnl fsao 5,;0< Glvlg BBBglkmbhn }a z|cap}bokg MFA }elskpr khm
ebne camr bsah avlsgakm khm jksmbkj bsah }aubjb}r(
MFA jah}bh|a|z bh}skvlha|z bhf|zbah jkh cl |zlm kz k slzj|l }elskprbh pk}blh}z ~b}e kj|}l jksmbkj psacgloz khm ekz cllh zea~h }a slvlszljksmbaorapk}er(;06 Glvlg BBB
]elsl okr cl k sagl fas z|cj|}khla|z MFA }~bjl mkbgr cag|z }slk}olh}bf bhf|zbah p|op bz ha} kvkbgkcgl(;0> Glvlg BBB
Oahb}asbhnSlfls }a ]kcgl :
Zbml lfflj}zSlfls }a]kcgl =
>(;(3 Mlflsbpsahl %MFP" Oaha}elskpr
Bhmbjk}bahzAskg MFP nbvlh }esll }bolz k mkr bh k mazl af >< on!dn!mkr bz khlfflj}bvl bsah jelgk}as bh jebgmslh oasl }ekh 6 rlksz agm khm b}zlfjkjr bz jaopkskcgl }a MFA( 2 }a 25, ~kz cl}}ls }ekh }ek} af MFA oaha}elskpr(;0< Glvlg BB/3
Oahb}asbhnSlfls }a ]kcgl :
Zbml lfflj}zSlfls }a ]kcgl =
]el sbzd af knskh|gajr}azbz %KHJ 7
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3:
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
>(;(: Mlflskzbsau %MFU" Oaha}elskpr
Bhmbjk}bahz
]el hl~lz} bsah jelgk}as MFU bz kh kg}lshk}bvl }a MFA bh jebgmslh
fsao 3 rlksz agm(;;6';;> Glvlg ;' ;;5';;2 Glvlg BB/;Askg MFU oaha}elskpr }kdlh
ahjl mkbgr bh k mazl af 30 / :0 on!dn!mkr bz kz lfjkjba|z kz jahvlh}bahkg
MFA zga~ bhf|zbah }elskpr bh slm|jbhn gbvls bsah jahjlh}sk}bah khm
zls|o flssb}bh( MFU ekz cllh |zlm bh jgbhbjkg pskj}bjl fas glzz }ekh vl
rlksz( ]el ebne jaz} af MFU }elskpr k} pslzlh} okr cl k ebhmskhjl
}a b}z ~bmls |zknl( Bh k sljlh} zrz}lok}bj slvbl~' MFU ~kz oasl
jaz} lfflj}bvl }ekh MFA ckzlm ah {|kgb}r kmi|z}lm gbfl rlksz %[KGR"'khm MFP ~kz oasl jaz}/lfflj}bvl }ekh MFU bh agmls jebgmslh(;30 Glvlg ;
Oahb}asbhn
Slfls }a ]kcgl :
Zbml lfflj}z
Slfls }a ]kcgl =
MFU okr jk|zl k slvlszbcgl' mazl/slgk}lm' hah/psanslzzbvl bhjslkzl bh
zls|o jslk}bhbhl ~b}ebh }el |ppls gbob} af hasokg(;3; Glvlg B
>(;(= Jaocbhk}bah ]elskpr MFA khm MFP
Bhmbjk}bahzJaocbhk}bah af MFA khm MFP }elskpr bz bhmbjk}lm ~elh oaha}elskpr
fkbgz(;3;';33 Glvlg BB/;' ;3:';3= Glvlg BB/3
Oahb}asbhn
Slfls }a ]kcgl :
Zbml lfflj}z
Slfls }a ]kcgl =
]el zbml lfflj}z af MFA/MFP jaocbhk}bah ksl }el zkol kz }el zbml
lfflj}z af }el bhmbvbm|kg jelgk}asz(;33 Glvlg BB/;' ;3: Glvlg BB/3
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3=
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
>(3 ^ELH ]A Z]KS] BSAH JELGK]BAH ]ELSKPR1
]el ap}bokg }eslzeagm }a z}ks} bsah jelgk}bah }elskpr bz |hml}lsobhlm
c|} ckzlm ah naam jgbhbjkg pskj}bjl' pk}blh}z ~ea ekvl sljlbvlm 8 ;0
|hb}z af cgaam khm ~elh zls|o flssb}bh bz 8 ;000 n!G ah oasl }ekh
}~a ajjkzbahz bh k} glkz} }~a ~lldz kpks} (: JEABJL AF JELGK]ASZ
Pk}blh}z ~ea ekvl sljlbvlm sln|gks PSCJ }skhzf|zbahz fas ahgr k fl~
rlksz ksl gbdlgr }a ekvl obgm bsah avlsgakm( Fas }elzl pk}blh}z' kgg }esll
bsah jelgk}asz %MFA' MFP khm MFU" ksl lfjkjba|z bh slm|jbhn zls|o
flssb}bh glvlgz khm GBJ( Jaopksbzah cl}~llh z|cj|}khla|z MFA k}=0 / < on!dn!mkr zea~lm zbobgks lfjkjr bh
pk}blh}z ~eazl ZF glvlgz ~lsl nlhlskggr 7 :000 n!G';;0';;6';3;';35 Glvlg B';32
Glvlg BB/; Jkpplgbhb l} kg( zea~lm }ek} MFU k} 30 / :0 on!dn!mkr ekm zbobgks
lfjkjr jaopkslm ~b}e MFA k} :0 /
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3: Glvlg BB/:
E Avls} MO bh }ekgkzzklobk okias pk}blh}z bz psljlmlm cr k gahnplsbam af bhz|gbh slzbz}khjl;>3 Glvlg BB/: khm erplsbhz|gbhklobk(;>: Glvlg BB/:
E ]el okbh sbzd fkj}asz kzzajbk}lm ~b}e MO ksl paas jaopgbkhjl~b}e MFA }slk}olh}' mlgkrlm knl k} z}ks} af jelgk}bah }elskpr'gbvls jbsseazbz as zlvlsl csazbz';>= Glvlg BB/: khm elpk}b}bz J
bhflj}bah(;>6 Glvlg BB/:
E ]el sbzd fkj}asz kzzajbk}lm ~b}e bopkbslm ng|jazl }aglskhjl %BN]"ksl okgl' paas jaopgbkhjl ~b}e MFA }elskpr khm GBJ fa|s }bolzkcavl }el hasokg vkg|l(;>= Glvlg BB/:
E Gbvls mbzasmlsz khm pazb}bvl fkobgr ebz}asr zllo }a cl kmmb}bahkg
pslmbzpazbhn fkj}asz(;>=';>> /;>5 Glvlg BB/:
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:2
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
Pslvkglhjl
E ]el pslvkglhjl af MO skhnlz fsao ;0(= / ;2(3';>6';>2 Glvlg BB/:
E ]el olkh knl k} mbknhazbz bz cl}~llh ;> khm ;5 rlksz(;66 Glvlg BB/:
E :;(;, af pk} blh}z ~b}e mbkcl}lz pslzlh} ~b}e mbkcl} bjdl}akjbmazbz(;>< Glvlg BB/:
Bhvlz}bnk}bahz
E ]el mbknhazbz af MO okr cl okml |zbhn khr ahl af }el fagga~bhnjsb}lsbk9;50 Glvlg BB
g Zrop}aoz khm k skhmao pgkzok ng|jazl af oasl }ekh;;(; ooag!G( Zrop}aoz bhjg|ml pagr|sbk' pagrmbpzbk' khm|hlupgkbhlm ~lbne} gazz(
g Fkz}bhn pgkzok ng|jazl af 8 >(0 ooag!G
g 3 ea|s paz}/pskhmbkg pgkzok ng|jazl af 8 ;;(; ooag!G ah khAN]]( %Kh AN]] sl{|bslz }el l{|bvkglh} af ;(>< no!dn }a kokubo|o af >< no af khermsa|z ng|jazl mbzzagvlm bh ~k}ls"
E ]el mbknhazbz af BN] bz okml ~elh }el 3 ea|s paz}/pskhmbkgng|jazl bz cl}~llh >(5 / ;;(; ooag!G ah kh AN]](;50 Glvlg BBB
Okhknlolh}
E ]el lksgr khm kml{|k}l |zl af bsah jelgk}bah jkh pslvlh} MOkhm okias lhmajsbhapk}eblz(;>2 Glvlg BB/:
E Ca}e MO khm BN] bopsavlm bh k }ebsm af pk}blh}z kf}ls bh}lhzbvl
jaocbhlm jelgk}bah }slk}olh}(;5: Glvlg BB/:
E Bh }ekgkzzklobkz ~b}e BN]' }el jahmb}bah okr bopsavl ~b}ek z}sbj} mbkcl}bj mbl}' ~lbne} slm|j}bah ~elsl kppgbjkcgl khmbh}lhzbvl bsah jelgk}bah(3 \!dn" vksblz m|l }a k ~bmlvksbk}bah bh pkhjslk}bj jlgg f|hj}bah kz ml}lsobhlm crJ/plp}bml glvlg(;5= Glvlg BBB
E ]el |zl af askg kh}b/mbkcl}bj knlh}z bh MO slokbhz |hml}lsobhlm(
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=0
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
SLJAOOLHMK]BAH
K 3 ea|s AN]] zea|gm cl plsfasolm khh|kggr ah }ekgkzzklobkpk}blh}z 8 ;0 rlksz agm( %Nskml J"
]ekgkzzklobk pk}blh}z ~b}e BN] zea|gm cl okhknlm cr k z}sbj}
mbkcl}bj mbl}' ~lbne} slm|j}bah ~elsl kppgbjkcgl khm bh}lhzbvl bsahjelgk}bah( %Nskml J"
]ekgkzzklobk pk}blh}z ~b}e MO zea|gm cl }slk}lm ~b}e bhz|gbh(%Nskml J"
2(;(< Az}lapasazbz!Az}lapklhbk
Ga~ cahl okzz bz pslzlh} bh k zbnhbjkh} psapas}bah af jebgmslh ~b}e
}skhzf|zbah mlplhmlh} }ekgkzzklobk mlzpb}l erpls}skhzf|zbah khm
ap}bokg jelgk}bah(
]el Cahl Obhlskg Mlhzb}r %COM" af }ekgkzzklobk jebgmslh jg|z}ls
ksa|hm }el hasokg j|svl |h}bg }el knl af ;0 / ;3 rlksz' ~elh }elsl bz k
mlvbk}bah k~kr fsao b}(;
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
55/99
=;
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
Pslvkglhjl
E ;6(;, af }el }ekgkzzklobk pk}blh}z ekm hasokg cahl okzz
%y zjasl 8 /;"
E 33(6, ekm slm|jlm cahl okzz %y zjasl cl}~llh /; }a /3"
E 6;(:, ekm ga~ cahl okzz %y zjasl 7 /3";52 Glvlg BB/:
E Vb}kobh M mljblhjr9
g 3, ekvl zlvlslgr ga~ glvlgz(;2;
Glvlg BB/3
Bhvlz}bnk}bahz
E Zls|o jkgjb|o' peazpek}l' KGP
E 3
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7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
56/99
=3
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
Okhknlolh}
Kml{|k}l vb}kobh M khm jkgjb|o bh}kdl kjjasmbhn }a sljaoolhmlm
mbl}ksr kgga~khjlz %SMK" zea|gm cl lhz|slm bh kgg }ekgkzzklobkpk}blh}z(;2=/;2< Glvlg BBB
]kcgl
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7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
57/99
=:
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
SLJAOOLHMK]BAH
Kml{|k}l mbl}ksr bh}kdl af jkgjb|o khm vb}kobh M zea|gm cl lhz|slm(
%Nskml J"
Sln|gks ~lbne}/clksbhn lulsjbzlz zea|gm cl lhja|sknlm ~b}ekvabmkhjl af zoadbhn khm lujlzzbvl kgjaeag jahz|op}bah( %Nskml J"
Vb}kobh M' jkgjb|o khm ybhj z}k}|z af }ekgkzzklobk pk}blh}z zea|gm cllvkg|k}lm sln|gksgr khm khh|kggr fsao ;0 rlksz agm ah~ksmz( %Nskml J"
Khh|kg cahl mlhzb}r z}|mblz zea|gm cl jahzbmlslm bh }ekgkzzklobk
pk}blh}z oasl }ekh ;0 rlksz af knl( %Nskml J"
2(;(6 Erpapksk}ersabmbzo
Bhjbmlhjl af erpapksk}ersabmbzo vksblz fsao =(< / 30,(;25/30; Glvlg BB/: ]el
knl af mbknhazbz skhnl fsao ;; }a 3= rlksz %olkh cl}~llh ;: khm ;5rlksz"(;25/30; Glvlg BB/:
Zbnhz khm Zrop}aoz
Okiasb}r af }ekgkzzklobk pk}blh}z ~b}e erpapksk}ersabmbzo ekvl ha
jgbhbjkg zrop}aoz af erpajkgjklobk( ]elslfasl khh|kg zjsllhbhn bzz|nnlz}lm fsao knl af ;0 rlksz ah~ksmz(;25'300/30; Glvlg BB/:
Erpapksk}ersabmbzo }lhmz }a cl kjjaopkhblm ~b}e a}elslhmajsbhapk}eblz(;25';22/30; Glvlg BB/:
Bhvlz}bnk}bahz
Zjsllhbhn fas erpapksk}ersabmbzo bhjg|mlz9
/ zls|o jkgjb|o/ zls|o peazpek}l/ zls|o oknhlzb|o
/ zls|o kgdkgbhl peazpek}kzl
Bh pk}blh}z ~b}e ga~ zls|o jkgjb|o khm ebne peazpek}l glvlg' psajllm~b}e zls|o pksk}ersabm glvlg(;22 Glvlg BB/:
Okhknlolh}
;( Jkgjb}sbag 0(3< / ;(0 n ahjl }a }~bjl mkbgr(3( Bh pk}blh}z ~b}e plszbz}lh} ebne peazpek}l glvlgz' peazpek}l cbhmlsz
%z|je kz jkgjb|o jkscahk}l" okr cl jahzbmlslm(:( Jkgjb|o z|ppglolh}z okr cl afflslm }a pk}blh}z ~b}e paas
mbl}ksr bh}kdl(
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==
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
SLJAOOLHMK]BAH
]ekgkzzklobk pk}blh}z agmls }ekh ;0 rlksz af knl' lzpljbkggr }eazl~ea ekvl a}els lhmajsbhapk}eblz hllm }a cl oahb}aslm khh|kggr
fas erpapksk}ersabmbzo( %Nskml J"
]slk}olh} af erpapksk}ersabmbzo jahzbz}z af jkgjb}sbag ~b}e as~b}ea|} jkgjb|o jkscahk}l!gkj}k}l( %Nskml J"
2(;(> Erpakmslhkgbzo
Erpakmslhkgbzo okr cl |hmls/mbknhazlm khm jkh pa}lh}bkggr jk|zl
oas}kgb}r m|sbhn kj|}l bgghlzzlz( Pslvkglhjl af erpakmslhkgbzo vksblz~bmlgr fsao 0 / =
-
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=;," khm oascbmb}r bh pk}blh}z ~b}e }skhzf|zbah mlplhmlh}}ekgkzzklobk(;0;'306'30> Glvlg BB/3
Pk}blh}z ~b}e zls|o flssb}bh 8 3'
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
60/99
=6
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
E Ljeajksmbansko
g Glf} vlh}sbj|gks lilj}bah fskj}bah %GVLF" vkg|lz ksl zbnhbjkh}grebnels bh }ekgkzzklobk pk}blh}z3;3 khm GV f|hj}bah bz |z|kggrpslzlsvlm |h} bg kmvkhjlm z}knl( GVLF 7
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
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=>
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
:( Zrop}aok}bj jksmbkj zbmlsazbz
g Jah}bh|a|z b!v mlzflssbaukobhl < on!dn!mkr khm z!j
mlzflssbaukobhl =0 / Glvlg BB/3' 3;5 Glvlg BBB
g ]elsl bz ha mk}k ah }el kcbgb}r af mlflsbpsahl oaha}elskpr
}a slvlszl elks} fkbg|sl(
Oahb}asbhn
E F|gg jgbhbjkg lukobhk}bah af }el jksmbavkzj|gks zrz}lo k} glkz} zbuoah}egr
E Ljeajksmbansko khh|kggr fsao knl af ;0 rlksz
SLJAOOLHMK]BAH
Khh|kg oahb}asbhn af jksmbavkzj|gks zrz}lo fas }ekgkzzklobk
pk}blh}z fsao knl ;0 ah~ksmz ~a|gm bhjg|ml LJN' ljeajksmbansko
khm ~elsl pazzbcgl OSB ]3)( %Nskml J"
Fas kzrop}aok}bj }ekgkzzklobk pk}blh}z ~b}e obgm }a oamlsk}l
jksmbkj zbmlsazbz %]3) ;0 /30 oz" khm hasokg jksmbkj f|hj}bah'
bsah jelgk}bah oaha}elskpr zea|gm cl bh}lhzblm as z~b}jelm }a
jaocbhk}bah }elskpr( %Nskml C"
Bf OSB ]3) kzzlzzolh} bz ha} pazzbcgl' }elh }ekgkzzklobk pk}blh}z
~b}e paas jelgk}bah ebz}asr khm ebne sbzd af jksmbkj bsah avlsgakm
z|je kz zls|o flssb}bh 8 3'
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
62/99
=5
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
2(: BHFLJ]BAH
2(:(; Elpk}b}bz C
]el pslvkglhjl af ECzKn pazb}bvb}r bh o|g}bpgr }skhzf|zlm }ekgkzzklobkpk}blh}z vksblz ~asgm~bml %7 ;, }a 830,"(
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
63/99
=2
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
Okhknlolh}
]el psboksr nakg af }slk}olh} fas jesahbj elpk}b}bz C ksl gahn/}lso
z|ppslzzbah af ECV/MHK vbskg gakm }a ga~ khm pslflskcgr |hml}lj}kcgl
glvlg khm EClKn zlsajahvlszbah bh EClKn pazb}bvl z|cilj}z ~b}e }el
kbo }a slm|jl psanslzzbah }a jbsseazbz' gbvls fkbg|sl khm elpk}ajlgg|gks
jksjbhaok(
]slk}olh} zea|gm cl z}ks}lm kz lksgr kz pazzbcgl bh jkzlzaf boplhmbhn
as avls} elpk}bj mljaoplhzk}bah %b(l( skbzlm cbgbs|cbh |hslgk}lm }a
}ekgkzzklobk' psagahnlm P] as pslzlhjl af kzjb}lz"( A}els~bzl' : / 6
oah}ez aczlsvk}bah bz sljaoolhmlm(33; Glvlg BBB
Pk}blh}z jkh cl }slk}lm ~b}e9
;( Bh}lsflsah %BFH " as Plnrgk}lm BFH
Fas jahvlh}bahkg BFH ' }el sljaoolhmlm m|sk}bah af }slk}olh}bz = / 6 oah}ez fas EClKn pazb}bvl pk}blh}z khm k} glkz} k rlks
fas EClKn hlnk}bvl pk}blh}z( Fas Pln/BFH' }el sljaoolhmlmm|sk}bah bz k} glkz} zbu oah}ez fas EClKn pazb}bvl pk}blh}z khm
;3 oah}ez fas EClKn hlnk}bvl pk}blh}z(330 Glvlg BBB as
3( Gkobv|mbhl
Gkobv|mbhl ;00 on mkbgr bz lzpljbkggr sljaoolhmlm bf }elsl bz k
jahjlsh slnksmbhn elpk}bj mljaoplhzk}bah(330 Glvlg BBB
Kh}b/vbskg ms|n slzbz}khjl jkh ajj|s khm okr cl sljanhbzlm cr
vbskg cslkd}esa|ne ~ebje bz mlhlm kz ; gan bhjslkzl fsao hkmbs'
KG] kslz khm gbvls mljaoplhzk}bah( elh }ebz ajj|sz' kmmb}bah
af k zljahm kh}b/vbskg knlh} %kmlfavbs!}lhafavbs" ~ebje malz ha}
ekvl jsazz slzbz}khjl zea|gm cl bhb}bk}lm(33; Glvlg BBB
Bh EClKn pazb}bvl pk}blh}z' }slk}olh} jkh cl z}applm ~elh
EClKn zlsajahvlszbah ~b}e |hml}lj}kcgl ECV/MHK ekz cllhmaj|olh}lm ah }~a zlpksk}l ajjkzbahz k} glkz} zbu oah}ez kpks}
|hglzz }elsl bz lvbmlhjl af mljaoplhzk}lm gbvls mbzlkzl!gbvls
jbsseazbz( Bh EClKn hlnk}bvl pk}blh}z' }slk}olh} mbzjah}bh|k}bah
mlplhmz ah bhmbvbm|kg jkzlz khm zea|gm cl mljbmlm cr }elnkz}salh}lsaganbz}(33; Glvlg BBB
-
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-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
65/99
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
66/99
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
67/99
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
68/99
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
69/99
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
70/99
(
=( Zkshkbd ZK( ]ekgkzzlobk khm slgk}lm eloangacbhapk}eblz( Bhmbkh I Plmbk}s 3003%="9:;2/:3=(
( Gkpk}zkhbz P' Mbvagb K' Nlasnkdb E' l} kg( Cahl nsa~}e bh }ekgkzzklobj jebgmslh( Ksje Mbz Jebgm;2>545:/>23(
;0( ]slh} SI( Mbknhazbz af }el ekloangacbhapk}eblz( Jgbh Cbajelo Slv 300643>93>/:5(
;;( Ckbh C( Ekloangacbhapk}er mbknhazbz( Gahmah9 Cgkjd~lgg Zjblhjl' 300;(
;3( bgm CI' Ckbh CI( Bhvlz}bnk}bah af kchasokg eloangacbhz khm }ekgkzzlobk Bh9 Gl~bz ZO' Ckbh CI' Ck}lz B' lmz(Mkjbl khm Gl~bz Pskj}bjkg Eklok}aganr( 2}e lm( Pebgkmlgpebk9 Je|sjebgg Gbvbhnz}ahl' 300;43:;/365(
;:( Jgksdl NO' Ebnnbhz ]H( Gkcask}asr Bhvlz}bnk}bah af eloangacbhapk}eblz khm }ekgkzzlobkz9 Slvbl~ khm\pmk}l( Jgbh Jelo 30004=6%5%C""9;35=/20(
;=( lk}elskgg MI' Jglnn IC( ]el }ekgkzzklobk zrhmsaolz( =}e lm( Gahmah9 Cgkjd~lgg Zjblhjl G}m' 300;(
;4259;5>/;2=(
;6( Gkffls}r IM' Cks}e MZ' Zlsbmkh CG' l} kg( Pslvkglhjl af }ekgkzzlobk bh pk}blh}z ~b}e objsajr}azbz slflsslmfas ekloangacbhapk}er bhvlz}bnk}bah bh Ah}ksba( Ko I Jgbh Pk}eag 300>4;3>9;23/;26(
;>( Jka K' Zkck G' Nkgkhlgga' l} kg( Oaglj|gks mbknhazbz khm jkssbls zjsllhbhn fas /}ekgkzzlobk( IKOK;22>43>5%;%;"9;6=/;65(
3( ]eahn O' Zaa ]' ]el zplj}s|o af cl}k/ngacbh nlhl o|}k}bahz bh jebgmslh ~b}e cl}k/}ekgkzzklobk okiasfsao Da}k Dbhkckg|' Zkcke' Okgkrzbk( Zbhnkpasl Olm I( 300< =6%>"9:=0/:(
35( ]eahn O' S|mydb Y' Ekgg I( l} kg( K zbhngl' gksnl mlgl}bah kjja|h}z fas kgg }el cl}k/ngacbh nlhl o|}k}bahz bh}~lh}r fkobgblz fsao Zkcke %Has}e Cashla"' ( Okgkrzbk( E|o O|}k}( ;2224;:%
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
71/99
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
:0( Skh}khlh L' Ebl}kgk O' Dsbz}afflszzah \' l} kg( ^ek} bz Bmlkg Nlhl}bj Ja|hzlggbhn1 K Z|svlr af J|sslh}Bh}lshk}bahkg N|bmlgbhlz( L|s I E|o Nlhl} 30054;6%="9==643%;"95/;0(
:5/:5:(
=;( Kbhaah A' Jelahn ZD( ]ekgkzzklobk bh Okgkrzbk9 K Z}sk}lnr fas Pslvlh}bah( Okgkrz I Pk}eag;22=4;6%;"93:/>(
=3( Kcagnekzlob E' Kobm K' Ylbhkgb Z( l} kg(]ekgkzzlobk bh Bskh9 lpbmlobaganr' pslvlh}bah' khm okhknlolh}( IPlmbk}s Elok}ag Ahjag( 300> 32%="93::/5(
=:( Nbgkhb K' Ikmaah K' [kbzls S(l} kg(K}}b}|mlz }a~ksmz nlhl}bj mbknhazbz bh Pkdbz}kh9 k z|svlr af olmbjkg khmglnkg jaoo|hb}blz khm pkslh}z af }ekgkzzlobj jebgmslh( Jaoo|hb}r Nlhl}( 300>4;0%:"9;=0/6(
==( Dsk~jykd O' Jaapls MH' Zjeobm}dl I( Lz}bok}bhn }el Lfjkjr khm Lfjblhjr af Jkzjkml Nlhl}bjZjsllhbhn( Ko I E|o Nlhl} 300;4629:6;/:>0(
=( Zpkhaz ]' Dksknlasnk O' Gkmbz V' l} kg( Slm Jlgg Kggakh}bcamblz ~b}e ]ekgkzzlobk( Vau Zkhn|bhbz;2204
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4=>%9;00/;03(
6;( Jaelh K' Nkrls S' Obykhbh I( Gahn }lso lfflj} af zpglhlj}aor ah }skhzf|zbah sl{|bslolh}z bh }ekgkzzklobkokias( Ko Ia|shkg af Eklok}aganr ;2524:0930( Lbh ZE' Zekhmgbhn C' Zbopzah IZ' l} kg(]el oascbmb}r khm oas}kgb}r af zpglhlj}aor bh jebgmeaam( Khh Z|sn;2>>4;53( Daslh K' Ekkzy S' ]bk}gls K' Dk}y|hb L( Zls|o boo|hangac|gbh glvlgz bh jebgmslh kf}ls zpglhlj}aor( Kpsazplj}bvl z}|mr( Ko I Mbz Jebgm ;25=4;:5%;"99:0/:=(
>6( Jkpplggbhb OM' Saccbaga G' Ca}}kza CO' l} kg( Vlha|z }esaocalocagbzo khm erplsjakn|gkcbgb}r bhzpglhlj}aobzlm pk}blh} ~b}e }ekgkzzklobk bh}lsolmbk( Cs I Eklok}ag 30004;;;%3"9=6>/=>:(
>>( Casnhk/Pbnhk}}b J' Jkshlggb V' Jks|za V'l} kg(]esacalocagbj Lvlh}z bh Cl}k/]ekgkzzklobk Okias9 Kh B}kgbkhO|g}bjlh}sl Z}|mr( Kj}k Eklok}aganbjk ;225422%3"9>6/>2(
>5( ]kels K' Bzokllg E' Olgba N' l} kg( Pslvkglhjl af }esaocalocagbj lvlh}z bh 5560 pk}blh}z ~b}e}ekgkzzklobk okias khm bh}lsolmbk bh }el olmb}}lsskhlkh kslk khm Bskh( ]esaocazbz khm ekloaz}kzbz
3006426%="9=55/=2;(>2( Kobsko L' Skjeobgl~b}y LK( ]el erplsjakn|gkcgl z}k}l bh }ekgkzzklobk( Cgaam 3003422%;"9:6/=:(
50( Lgmas K' M|sz} S' Er/Ko L'l} kg(K jesahbj erplsjakn|gkcgl z}k}l bh pk}blh}z ~b}e cl}k }ekgkzzklobk okiasbz kgslkmr pslzlh} bh jebgmeaam( Csb}bze Ia|shkg af Elok}aganr ;2224;0>9>:2/>=6(
5;( Jkpplggbhb OM' Nslzpb L' Jkzzbhlsba L' l} kg( Jakn|gk}bah khm Zpglhlj}aor9 Kh avlsvbl~( Khhkgz af }elHR Kjkmlor af Zjblhjlz 300
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
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;/3;>2
2:9=0:(
;0
-
7/31/2019 CPG Management of Transfusion Dependent Thalassaemia
74/99
60
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
;;0 Plhhlgg MI' Clsma|dkz V' Dksknbasnk O'l} kg( Skhmaobylm jah}sagglm }sbkg af mlflsbpsahl as mlflsaukobhlbh cl}k/}ekgkzzklobk okias pk}blh}z ~b}e kzrop}aok}bj orajksmbkg zbmlsazbz( Cgaam 30064;0>9:>:5/:>==(
;;;( Casnhk/Pbnhk}}b J' Jkpplggbhb OM' Ml Z}lfkha P' l} kg( Jksmbkj oascbmb}r khm oas}kgb}r bh mlflsaukobhl/as mlflsbpsahl/}slk}lm pk}blh}z ~b}e }ekgkzzklobk okias( Cgaam 30064;0>9:>::/:>:>(
;;3( Khmlszah GI' ahdl C' Pslzja}} L' l} kg( Jaopksbzah af lfflj}z af askg mlflsbpsahl khm z|cj|}khla|z
mlflssbaukobhl ah orajksmbkg bsah glvlgz khm vlh}sbj|gks f|hj}bah bh cl}k }ekgkzzklobk( Gkhjl}30034:6090"' ahjl /mkbgr askg bsahjelgk}as' bh pk}blh}z ~b}e cl}k/}ekgkzzkobk( Cgaam 30064;0>9:==;/>( Obhbz}sr af Elkg}e Ms|n Faso|gksr 3005( Pl}kgbhn Ikrk9 Peksokjl|}bjkg Zlsvbjlz Mbvbzbah' Obhbz}sr afElkg}e Okgkrzbk' 3005(
;35( Oknnba K' MKobja N' Oaskcb}a K ' l} kg( Mlflsbpsahl vlsz|z Mlflsaukobhl bh Pk}blh}z ~b}e ]O9 Kskhmaobzlm jgbhbjkg }sbkg Cgaam Jlggz' Oaglj|glz khm Mbzlkzlz 3003435%3"9;26/305(
;32( Ek ZR' Jebd D ' Gbhn ZJ' l} kg( K skhmaobylm jah}sagglm z}|mr lvkg|k}bhn }el zkfl}r khm lfjkjr afmlflsbpsahl }slk}olh} bh }ekgkzzklobk okias p}z fsao Eahn Dahn( Eloangacbh 30064:0%3"936:/3>=(
;:0( Zjkgahl G' Okh}avkhb GN' Dsag O' l} kg( Jaz}z' {|kgb}r af gbfl' }slk}olh} zk}bzfkj}bah khm jaopgbkhjl bhpk}blh}z ~b}e cl}k/}ekgkzzlobk okias |hmlsnabhn bsah jelgk}bah }elskpr9 }el B]EKJK z}|mr( J|ss OlmSlz Apbh 30054>9;20(
;:;( Dkshah I' ]agglr D' Arll I' l} kg( Jaz}/|}bgb}r khkgrzbz af mlflskzbsau jaopkslm }a z}khmksm }elskpr ~b}emlzflssbaukobhl fas pk}blh}z sl{|bsbhn bsah jelgk}bah }elskpr bh }el \hb}lm Dbhnmao( J|ss Olm Slz Apbh300543=%6"9;602/;63;(
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Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
;:3( Mlglk ]L' Zafsrnbh A' ]eaokz ZD' l} kg( Jaz} lfflj}bvlhlzz af ahjl/mkbgr askg jelgk}bah }elskpr ~b}emlflskzbsau vlsz|z bhf|zbahkg mlflsaukobhl bh }skhzf|zbah mlplhmlh} }ekgkzzlobk pk}blh}z9 \Z elkg}ejkslzrz}lo plszplj}bvl( Peksokjaljahaobjz 300>43( Jekhmsk H' Zeksok I( Zkfl}r af askg bsah jelgk}as mlflsbpsahl bh ra|hn }ekgkzzklobjz( L|s I Eklok}ag300/330(
;:5( G|jkslggb N' Nkgbocls}b O' Pagjeb P( Okssa~ }skhzpgkh}k}bah bh pk}blh}z ~b}e }ekgkzzlobk slzpahzbvl }a bsah
jelgk}bah }elskpr( HLIO ;22:4:3295=0 / 5==(
;:2( Nkyblv I' G|jkslggb N( Z}lo Jlgg ]skhzpgkh}k}bah Fas ]ekgkzzklobk( Slpsam|j}bvl Cbaolmbjbhl AhgbhlTSlpsam Cbaolm Ahgbhl_' 300 / :
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63
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
;:( Olsdlg PK' Zboahzah MJ' Koblg ZK' l} kg( Bhz|gbh Slzbz}khjl khm Erplsbhz|gbhklobk bh Pk}blh}z ~b}e]ekgkzzklobk Okias ]slk}lm cr Erpls}skhzf|zbah( HLIO ;2554:;5%;:"9502/50;=(
;>=( Nkoclsbhb OS' Fas}bhb O' ml Zkhj}bj V' l} kg( Mbkcl}lz olggb}|z khm bopkbslm ng|jazl }aglskhjl bh}ekgkzzklobk okias9 bhjbmlhjl' pslvkglhjl' sbzd fkj}asz khm z|svbvkg bh pk}blh}z fagga~lm bh }el FlsskskJlh}ls( Plmbk}s Lhmajsbhag Slv 300=43%Z|pp 3"9355/=5:(
;>5( Nkoclsbhb OS' Fas}bhb O' Nbggb N'l} kg( Lpbmlobaganr khm jelgk}bah }elskpr lfflj}z ah ng|jazl eaolaz}kzbzbh }ekgkzzklobj pk}blh}z( I Plmbk}s Lhmajsbhag Ol}kc ;2254;;%Z|ppg :"956>/2(
;>2( ^khn JE' | DE' ]zkb FI' l} kg( Jaopksbzah af askg khm ZJ bsah jelgk}bah ]elskpblz bh }el Pslvlh}bah afOkias Lhmajsbhapk}eblz bh Cl}k/]ekgkzzklobk Pk}blh}z( Eloangacbh 30064:0%3"93/363(
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6:
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
;50( Ekgl ML' lbhyboks ZK( ]rpl 3 Mbkcl}lz Olggb}|z bh Jebgmslh khm Kmaglzjlh}z( Bh9 Oazekhn ] Is' lm(Plmbk}sbj Lhmajsbhaganr 9 ]el Sl{|bzb}lz bh Plmbk}sbjz( Obzza|sb9 Lgzlvbls' 300%;0"9;=;( Okekjeadgls}~k}}khk P' Je|khz|osb} K' Jea|c}|o G' l} kg( Cahl Obhlskg Mlhzb}r bh Jebgmslh khm Ra|hnKm|g}z ~b}e Cl}k/]ekgkzzklobk ]skb}( I Plmbk}s Lhmajsbhag Ol}kc 30034;/5:6(
;2>( Lvkhnlgaz VL( Hl~ Bhzbne}z bh}a }el pk}eaperzbaganr khm okhknlolh} af az}lapasazbz bh pk}blh}z ~b}ecl}k }ekgkzzlobk( Csb}bze Ia|shkg af Eklok}aganr 300=4;3>9;3>/;:2(
;25( ml Zkhj}bz V' V|gga J' Cknhb C'l} kg( Erpapksk}ersabmbzo bh Cl}k/]ekgkzzklobk Okias( Jgbhbjkg khm gkcask}asraczlsvk}bahz bh 3= Pk}blh}z( Kj}k Eklok}ag ;223455%3/:"9;0430%;;"9;;5:/;;55(
30:( Zsbvk}zk K' Oks~kek SD' O|skgmekskh S' l} kg( Kzzlzzolh} af Kmslhkg Lhmajsbhl F|hj}bah bh Kzbkh]ekgkzzklobjz( Bhmbkh Plmbk}s 300"9>::/>:=(
30=( Elh~aam OI' Gasskbhl L' Dk}y G( Mbzasmlsz af }el kmslhkg ngkhm( Bh9 ]eaokz Oazekhn Is' lm( Plmbk}sbjLhmajsbhaganr }el Sl{|bzb}lz bh Plmbk}sbjz( 300< lm( Obzza|sb9 Lgzlvbls' 300
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6=
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
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306( Y|sga ON' Ml Z}lfkha P' Casnhk/Pbnhk}}b J' l} kg( Z|svbvkg khm jk|zlz af mlk}e bh }ekgkzzklobk okias(Gkhjl} ;25243%56/;;2:(305( ]lgfls P]' Pslzja}} L' Eagmlh Z' l} kg( Elpk}bj bsah jahjlh}sk}bah jaocbhlm ~b}e gahn/}lso oahb}asbhn
af zls|o flssb}bh }a pslmbj} jaopgbjk}bahz af bsah avlsgakm bh }ekgkzzklobk okias( Cs I Eklok}ag30004;;0%="92>;/2>>(
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33=( Khnlg|jjb L' O|sl}}a P' Hbjag|jjb K' l} kg( Lfflj}z af bsah avlsgakm khm Elpk}b}bz J vbs|z pazb}bvb}r bhml}lsobhbhn psanslzzbah af gbvls csazbz bh }ekgkzzklobk fagga~bhn cahl okssa~ }skhzpgkh}k}bah( Cgaam30034;00%;"9;>/3;(
339>
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3:=( Zagbokh K]' Lg/Ok}ksr ' Fk}}ke OOK' l} kg( ]el lfflj} af ebne/jkgasbl mbl} ah h|}sb}bahkg pkskol}lsz afjebgmslh ~b}e /}ekgkzzklobk okias( Jgbhbjkg H|}sb}bah 300=43:9;;
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6>
Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
Psl/z}asknl gl|jamlpgl}bah AS }skhzf|zbah slkj}bah4 ]skhzf|zbah
mlplhmlh} }ekgkzzlobk AS gl|jamlpgl}lm cgaam AS slm|jlm }skhzf|zbah
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KHM p|cls}r KHM lz}sanlh4 ]ekgkzzklobk KHM Jaocbhl }elskpr
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]ekgkzz) KHM ]skhzpgkh})4 }ekgkzzlobk KHM }skhzpgkh})4 bhflj}bah khm
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65
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KPPLHMBU 3
JGBHBJKG[\LZ]BAHZ
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3( Ea~ bz }ekgkzzklobk mbknhazlm1 % }ekgkzzklobk & }ekgkzzklobkbh}lsolmbk"
a Jgbhbjkg mbknhazbz
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NLHL]BJZ SBZDZ BH ]EKGKZZKLOBK
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]el }skhzjlsvbjkg psajlm|sl bz plsfasolm cr bhzls}bhn k }ebh pgkz}bj}|cl }esa|ne }el vknbhk khm jlsvbu }a slkje }el pgkjlh}k |hmls|g}skza|hm n|bmkhjl(
]el }skhzkcmaobhkg psajlm|sl bz plsfasolm cr bhzls}bhn k hllmgl}esa|ne }el kcmaolh khm |}ls|z khm bh}a }el pgkjlh}k |hmls|g}skza|hm n|bmkhjl(
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c( Kohbajlh}lzbz
Kohbajlh}lzbz bz plsfasolm cr bhzls}bhn k hllmgl }esa|ne }el kcmaobhkg~kgg bh}a }el |}ls|z |hmls |g}skza|hm n|bmkhjl khm ~b}emsk~bhn k zokggkoa|h} af |bm fsao }el zkj z|ssa|hmbhn }el fal}|z(
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Okgkjjk Kzzajbk}bah af ]ekgkzzklobk
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Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
Dlgkc ]ekgkzzklobk Dlmke
Ha(2:' Dkopahn Gkhnnks'
06 / ::30:62
D|kh}kh ]ekgkzzklobk Zajbl}rj!a Os( ahn Jelhn ke
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Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
KPPLHMBU 6
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Okhknlolh} af ]skhzf|zbah Mlplhmlh} ]ekgkzzklobk
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elbne} skhnl( ]ebz bz z}bgg hasokg c|} oahb}asbhn af z|czl{|lh}nsa~}e bz js|jbkg(
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50
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;3 jo
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