Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when...

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  • 7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg

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    \fgeaianw) 03) ?-40)

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    0 Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_

    mbe`dpgaes ca| zdpgbeps ~fa cdgi pa |bszae` pa B__) ~gpf zb|-

    sgspbeob a| |bor||beob ac `gsbdsb `bszgpb pbofegodiiw d`btrdpb

    sr|nb|w&3'

    % Pfbsb ge`gg rdis d|b `bbmb` pa fdb |bc|dopa|w

    of|aego |fgeasgersgpgs &\O\_'&>'

    &Cgnr|b 4'%

    Bvgspgen dina|gpfms `a eap d``|bss `gsbdsb zb|sgspgen dcpb| B__&6'

    % Gp acpbe sbbms pa pfb zdpgbep pfdp pfb zfwsgogde fds igppib paaccb| lbwae` depglgapgos) oa|pgoaspb|ag`s) a| cr|pfb| sr|nb|w%

    Ca| ge`gg rdis ~gpf of|aego oar|sbs a| ae pfb iaakarp ca| d

    eb~ pfb|dzbrpgo dzz|adof) pfgs mdw azbe pfbm pa mgsibd`gen

    oidgms c|am z|azaebeps a| srzzigb|s ac dipb|edpgb pfb|dzgbs%

    NADI_ AC PFG_ \BSGB^

    Pfgs |bgb~ d|pgoib sbbks pa z|ag b pfb fbdipf-od|b z|dopgpgaeb|

    ~gpf geca|mdpgae |bnd|`gen ddgidlib dipb|edpgb pfb|dzgbs ca|

    pfb mdednbmbep ac O\_ ac zdpgbeps |bc|dopa|w pa B__) sa ds

    pa bedlib pfbm pa lbppb| mbbp pfb ebb s ac pfgs of|aegodiiw gii

    zazridpgae% Pfb bvgspgen p|bdpmbep azpgaes de` pfb bg`beob

    srzza|pgen pfbm d|b |bgb~b` ge pfb oaepbvp ac pfb or||bep

    kea~ib`nb ae pfb zdpfanbebsgs ac O\_%

    Ds O\_ fds aeiw |bobepiw lbbe doobzpb` ds d oigegodi bepgpw lw

    pfb |bnridpa|w drpfa|gpgbs ge pfb Regpb` _pdpbs&7'

    ) `arlib-lige`)

    zidobla oaep|aiib` p|dgis ac pfb|dzw ca| zasp-B__ `gsbdsb d|b

    |d|b de` pfasb pfdp fdb lbbe zb|ca|mb fdb |d|biw lbbe dig-

    `dpb` lw d sboae` p|gdi% Pfb|dzw gs pfbe acpbe ldsb bgpfb| ae

    de bvpbesgae c|am cg|sp z|geogzibs &pfb g`bepgcgodpgae ac d sp|dpb-

    nw ldsb` ae zdpfazfwsgaianw' a| ldsb` rzae pfb alsb|b`

    |bszaesb ge apfb| `gsbdsbs srof ds dorpb ldopb|gdi sgersgpgs a|

    reazb|dpb` edsdi zaiwzasgs% \bsrips d|b disa acpbe |bza|pb`

    debo`apdiiw) ge igmgpb` sb|gbs) |bp|aszbopgbiw) de` ~gpfarp d

    dig` oaep|ai n|arz% Ebb|pfbibss) O\_ ea~ dccbops d id|nb

    ermlb| ac zdpgbeps nialdiiw) de` pfarnf bg`beob gs igmgpb`)

    nrg`deob gs |btrg|b` pa bedlib d z|dopgp gaeb|) ~fam gs ibss

    bvzb|gbeob` ge pfb mdednbmbep ac pfbsb zdpgbeps) pa accb|

    |dpgaedi od|b%

    Z\AOB__ @B_O\GZPGAE

    D pbdm ac p~a pb|pgd|w |fgeaiangsps |bgb~b` ddgidlib igpb|dpr|b

    ae zasp-B__ `gsbdsb de` pfb|dzw rsgen de Benigsf idenrdnb

    Mb`igeb

    de` Naanib sbd|of ge pfb d|bds ac of|aego sgersgpgs

    de` zaiwzasgs &igmgpb` pa pfb d`rip zazridpgae) frmde) oigegodi

    p|gdis) gpbms ~gpf dlsp|dops' ~ds oae`ropb` de` cr|pfb| |bcgeb`

    ldsb` ae pfb ge`gg rdi pazgos% Aeiw d|pgoibs zrligsfb dcpb|

    Hderd|w 477> ~b|b geoir`b`% Dew zbb|-|bgb~b` zrligodpgaes

    odzpr|b` ge d Mb igeb

    sbd|of lrp eap ge pfb apfb| p~a sacp-

    ~d|b dzzigodpgaes) wbp `bbmb` gmza|pdep) ~b|b disa geoir`b %

    D|pgoibs ~b|b n|d`b` ca| sp|benpf ac bg`beob dooa|`gen pa

    DDZ _OTGM &Dmb|gode Dod`bmw ac Zb`gdp| gos _pbb|gen

    Oammgppbb ae Trdigpw Gmz|abmbep de` Mdednbmbep'nrg`b-

    igebs%&6>'

    \boammbe`dpgaes ca| mdednbmbep ~b|b bspdligsfb` lw `|d~-

    gen rzae sp|dpbngbs d`dzpb` c|am pfb N|d`bs ac

    \boammbe`dpgae) Dssbssmbep) @bbiazmbep de` Bdirdpgae

    &N\D@B' n|d gen swspbm) ~fgof oidssgcgbs sp|benpf ac |boam-

    mbe`dpgaes dooa| gen pa pfb ldideob ac pfb lbebcgps de` `a~e-

    sg bs dcpb| oaesg`b|gen pfb trdigpw ac pfb bg`beob &4:') de`

    c|am pfb |bobepiw zrligsfb` DDA-FE_ nrg`bigebs ge sgersgpgs

    ~fgof rsbs d sgmgid| sp|dpbnw%&6'

    Pfbsb swspbms d``|bss pfb `gsd`depdnbs gefb|bep pa apfb|n|d gen swspbms) srof ds d idok ac sbzd|dpgae lbp~bbe pfb trdi-

    gpw ac pfb bg`beob de` pfb sp|benpf ac |boammbe`dpgaes) pfb

    idok ac p|deszd|beow dlarp hr`nmbeps) de` pfb idok ac bvzigogp

    dokea~ib`nbmbep ac dirbs de` z|bcb|beobs% Pfgs pwzb ac sws-

    pbm gs zd|pgorid|iw rsbcri ge d|bds pfdp d|b oaep|ab|sgdi a|

    ~fb|b |boammbe`dpgaes d|b oibd| lrp aeiw alsb|dpgaedi spr -

    gbs a| bvzb|p azgegae d|b ddgidlib%

    \boammbe`dpgaes ~b|b ca|mridpb` ldsb` ae pfb sp|benpf ac

    pfb bg`beob de` gps zapbepgdi |gsk!lbebcgp |dpga% Ds mdew pfb|-

    dzgbs fdb eap lbbe srlhbopb pa sdcbpw bdirdpgae ge d oigegodi

    p|gdi sbppgen) pfb zapbepgdi ca| fd|m ~ds dssbssb` ca| bdof pfb|d-

    zw de` ~bgnfs ge pfb |boammbe`dpgae% \boammbe`dpgae

    azpgaes ~b|b pa |boammbe` ~bdkiw) ma`b|dpbiw a| sp|aeniw;

    accb| ds de azpgae ca| pfb|dzw; a| pa eap |boammbe` d ngbe

    pfb|dzw ds bgpfb| oigegodi p|gdi `dpd `g eap srzza|p gps rsb a| d

    oaeob|e ca| pavgogpw ~ds eapb`%

    _OAZB AC PFB Z\ALIBM

    Gp gs bspgmdpb pfdp dzz|avgmdpbiw 3 lgiigae `aiid|s gs szbep ge

    pfb R%_% deerdiiw ae pfb|dzw ca| |fgegpgs de` sgersgpgs&44'

    % Gp gs

    rekea~e ~fdp zb|obepdnb ac pfgs gs ca| zasp-B__ `gsbdsb) lrp

    pfb zibpfa|d ac ~bl sgpbs de` zfwsgogdes szbogcgodiiw pd|nbpgen

    pfgs md|kbp gs d pbspgmaegdi pa pfb gepb|bsp de` pfb zapbepgdi

    bvzbesb dssaogdpb ~gpf gp%

    Cgnr|b 4% Zb|sgspbep `gsbdsb ac pfb mdvgiid|w sgers `bszgpb ~g biw zdpbep

    mdvgiid|w sgers aspgrm zasp B__%

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    @bs|agsgb|s de` Kgipw 2

    ^fgib pfb ermlb| ac ge`gg rdis ~gpf zb|sgspbep `gsbdsb dcpb|

    B__ odeeap lb z|bogsbiw p|dokb`) pfb ermlb|s ode lb bspgmdp-

    b` c|am zrligsfb spr gbs ae pfb sroobss ac B__ ca| O\_ ~gpf

    a| ~gpfarp edsdi zaiwzasgs% B__ |bmdges aeb ac pfb masp oam-

    mae sr|ngodi z|aob`r|bs) ~gpf ab| 2::%::: zb|ca|mb wbd|iw

    ge pfb R%_% diaeb &4

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    3 Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_

    aoor| lbp~bbe bvdob|ldpgaes ac `gsbdsb ge zdpgbeps oaiaegxb

    ~gpf pfgs dnbep&'

    ) GI-4\&?6'

    ) O0&?7'

    )

    DIAV-2) DIAV-2DZ) de` OW_IP4&0:'

    ) lrp pfb creopgaedi sgn-

    egcgodeob ac pfbsb cge gens |bmdges rekea~e% D signfpiw fgnfb|

    c|btrbeow ac O\_ ~ds eapb ge ge`gg rdis fbpb|anbebars ca|

    pfb OC 2:6 nbeb&04'

    ) lrp pfgs igmgpb bccbop gs gesrccgogbep pa

    bvzidge dii odsbs%

    Ge d cgedi oaesg b|dpgae ds pa pfb reob|pdge dbpgaianw ac zasp-

    B__ `gsbdsb) pfb gecirbeob ac be`asoazgo sgers sr|nb|w &B__'

    ae pfb zfwsgaianw de`!a| ldopb|gaianw ac pfb zd|dedsdi sgersbs

    |bmdges id|nbiw rekea~e% Ofdenbs ge pfb sgers beg|aembep

    dcpb| B__ mdw dipb| geedpb mbofdegsms ac gmmregpw a| l|gen

    dlarp bvobss spgmridpgae ac szbogcgo `bcbeobs% Ge pfb ea|mdi

    sgprdpgae) pfb pa|prars `|dgednb zdpf ac pfb sgers cgipb|s arps

    zd|pgoridpb mdppb| de` z|bbeps gps `bzasgpgae ge pfb sgers odg-

    pgbs% \bmadi ac pfgs mbofdegodi ld||gb| diia~s pfb bvpb|edi

    beg|aembep doobss pa de d|bd pfdp ~ds ca|mb|iw z|apbopb`

    c|am bvzasr|b&0

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    @bs|agsgb|s de` Kgipw >

    pgaes pa pfb edsdi mroasd d|b ddgidlib% D spr w ac pfbg| bccbo-

    pgbebss dp `bzasgpgae fds reca|predpbiw lbbe `aeb ae reazb|-

    dpb` sgersbs |dpfb| pfde zdpbep) zasp-sr|ngodi aebs&0>'

    % Ge reaz-

    b|dpb` sgersbs) zbebp|dpgae ca| eblrigsb` zd|pgoibs gs |dpfb|

    zaa|&06'

    ) ~gpf edsdi g||gndpgae dcca|`gen lbppb| `bzasgp gae%

    Ldsb` ae mdpfbmdpgodi ma`bis) `bzasgpgae gs fa~bb| z|ald-

    liw mrof befdeob` dc pb| ~g`begen ac pfb asp gd dc pb| B__%

    Zbebp|dpgae ac zrisdpgib-pwzb `bgobs srof ds pfb ^dpb|-Zgk

    fdb eap lbbe bdirdpb ge pfgs sbppgen% @g|bop gep|dsgers `bza-

    sgpgae gd ge`~biigen odpfbpb| accb|s fgnfb| |dpbs ac `bzasgpgae

    lrp mdw lb paa gedsgb ge samb sbppgens a| ca| iaen-pb|m rsb%

    _digeb8_p|aen |boammbe dpgae) ma`b|dpb bg beob%

    \dpgaedib8_digeb g||gndpgae fds lbbe sfa~e pa gmz|ab sgnes

    de` swmzpams ac |fgeasgersgpgs zasp-B__ ge aeb z|aszbopgb

    spr w% Pfb |gsk ac pfb|dzw gs ebnignglib de` pfb zapbepgdi lbeb-

    cgp oaesg b|dlib%

    G||gndpgae ~gpf sdigeb |bmdges de gmza|pdep zd|p ac pfb pfb|d-

    zbrpg o d| sbedi ) de` fd s lbbe |boammbe`b` ge d |bobe p

    Oaof|deb |bgb~ ae pfgs srlhbop&07'

    % Pfba|bpgodi d`depdnbs d|b

    pfdp gp gmz|abs mroaogigd|w cia~) fw |dpbs pfb mroasd) de`

    cirsfbs d~dw pavgo de` a| g||gpdpgb srlspdeobs c|am pfb sr|cdob

    ac pfb mroasd% Pfb azpgmdi oaeobep|dpgae ac sdigeb fds eap

    lbbe `bpb|mgeb ) lrp g||gndpgae ~gpf fwzb|paego sairpgaes mdw

    odrsb g||gpdpgae ge srsobzpglib ge`gg`rdis%

    Edsdi g||gndpgae fds lbbe rsb` sgeob deogbep pgmbs&2:'

    % \bobep

    `bsgnes fdb sarnfp pa gmz|ab ae pfb mbpfa` lw |boam-

    mbe gen de` gesp|ropgen ae d ma|b oaebegbep fbd` zasgpgae-gen &~dpb| strg|pb` gepa pfb zdssdnbs ~gpf pfb fbd` cibvb` ca|-

    ~d| ' de` ae pfb rsb ac mbdes ca| nbppgen pfb sairpgae gepa pfb

    zdssdnbs &lril de` sw|genb pbofegtrbs' dp d fgnfb| z|bssr|b%

    Ca| bvdmzib) gepb|bspgen d`dzpdpgaes ac pfb ^dpb|-Zgk swspbm

    rsb` ca| |bmadi ac `bepdi zidtrb d|b ddgidlib% Pfgs mbpfa`

    rsbs zrisdpgib g||gndpgae `bigb|b` gd d d|gbpw ac d dzpb|s pa

    gmz|ab oibdegen% Pfbg| rsb mdw pfba|bpgodiiw lb ma|b bccbo-

    pgb dp |b`rogen ldopb|gdi iad` ge sgprdpgaes ~fb|b sbo|bpgaes

    d|b pbedogars% Ia~-pbof sairpgaes srof ds segccgen ~dpb| arp ac

    pfb zdim ac pfb fde` sfari` lb `gsoar|dnb`) ds pfbw mdw

    geo|bdsb pfb |gsk ac oaepdmgedpgae ac pfb edsdi zdssdnbs%

    Niroaoa|pgoaspb|ag`s8_p|aen |boammbe`dpgae) ma`b|dpb bg-

    `beob%

    \dpgaedib8Pazgodi oa|pgoaspb|ag s fdb lbbe sfa~e pa |b`rob

    gecidmmdpgae ge O\_ de` pa lb dssaogdpb` ~gpf d |b ropgae ac

    |boab|w acs% dr|brs ge zdpgbeps re`b|nagen |bgsgae B__%

    Pfbg| bccbopgbebss ge |b`rogen edsdi zaiwzasgs fds lbbe

    `bmaesp|dpb` ge \OPs) de` pfbw fdb lbbe sfa~e bccbopgb ge

    |b`rogen sgnes de` swmzpams ac zasp-B__ `gsbdsb ~fbe

    dzzigb` `g|bopiw gepa pfb sgers gd ge`~biigen odpfbpb|% \gsk

    dzzbd|s mgea| ds ea bccbop ae zgprgpd|w-d |bedi dvgs fds lbbe

    sfa~e ge d smdii z|aszbopgb p|gdi%

    Oa|pgoaspb|ag s ge d|gars ca|ms fdb iaen lbbe rsb` ge pfb

    mdednbmbep ac of|aego sgersgpgs de` edsdi zaiwzasgs) lapf z|b-

    de` zasp-azb|dpgbiw) de` |bz|bsbep pfb mdgespdw ac pfb|dzw ca|

    ge`gg rdis ~gpf zasp-B__ `gsbdsb% Pfb mbofdegsm ac dopgae ac

    oa|pgoaspb|ag s gs pa z|bbep lge gen ac p|deso|gzpgae cdopa|s ge

    pfb eroibrs pfb|blw ma`ridpgen pfb p|deso|gzpgae ac d id|nb

    ermlb| ac nbebs ae obiis geaib` ge gmmreb de` gecidmmd-

    pa|w |bszaesbs% Pfbw d|b disa dlib pa gecirbeob pfb p|desidpgaedi

    de` zasp-p|desidpgaedi mbofdegsms lw ~fgof z|apbges d|b swe-

    pfbsgxb ) z|aobssb` de` bvza|pb` c|am obiis% Pfgs gefglgps pfb

    bvz|bssgae ac gecidmmdpa|w nbebs) mdgeiw ofbmadpp|dopdeps)

    pfb|blw |b`rogen lapf pfb |bo|rgpmbep de` pfb dopgdpgae ac

    gecidmmdpa|w obiis% _pb|ag s d|b pfrs lbebcgogdi ge oaep|aiigen

    gecidmmdpgae dssaogdpb` ~gpf O\_ ~gpf de` ~gpfarp edsdi

    zaiwzasgs&24'

    %

    Cr|pfb|ma|b) ds pfbw `a eap gefglgp pfb bzgpfbigdi obii nbebs

    gmza|pdep ca| geedpb gmmregpw) oa|pgoaspb|ag s mdw bbe drn-

    mbep pfb geedpb gmmreb |bszaesb lw geo|bdsgen pfb bvz|bs-

    sgae ac PI\s ae pfb bzgpfbigdi sr|cdob de` befdeogen pfb z|a-

    `ropgae ac gps bccbopa|s srof ds oaiibopges) oamzibmbep de`

    dorpb-zfdsb z|apbges) dmaen apfb|s&2

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    6 Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_

    `bbiazmbep ac swspbmgo sg b bccbops% Fa~bb|) pfb sdcbpw ac

    g||gndpgae ~gpf :%2 mn ac lr`bsaeg b LG@ fds lbbe oaecg|mb

    lw ^|gnfp ~fa sfa~b` ea bccbop ae pfb FZD dvgs ds `bpb|-

    mgeb lw mbdsr|bs ac sb|rm oa|pgsai de` |bszaesb pa DOPF

    spgmridpgae ge d smdii n|arz ac zdpgbeps&27'

    %

    _fa|p-pb|m oar|sbs ac a|di) pazgodi de` GS depglgapgos d|b |boam-

    mbe`b` ca| dorpb bvdob|ldpgaes ac swmzpams8 Ma b|dpb |boam-

    mbe`dpgae) ~bdk bg`beob ldsb` ae p|gdis ac depglgapgo pfb|dzw

    ca| dorpb ldopb|gdi sgersgpgs de` ldopb|gaianw ac O\_%

    \dpgaedib8Ea spr`gbs ac bccbopgbebss ge O\_ de` |gsk ac sg b

    bccbops ac depglgapgos de` `bbiazmbep ac |bsgspdeob%

    A|di depglgapgos8 Lw `bcgegpgae) ge`gg rdis ~gpf \O\_ `a eap

    |bszae` pa a|di depglgapgos% Ngbe pfbg| idok ac z|abe bccgodow

    ge pfb iaen-pb|m mdednbmbep ac zdpgbeps ~gpf of|aego `gsbdsb

    de` pfb zapbepgdi ca| `bbiazmbep ac |bsgspdeob) pfbw sfari`

    z|aldliw lb |bsb|b` ca| bvdob|ldpgaes ~gpf sfa|p-pb|m oar|sbs&3:)34'

    % Od|b mrsp lb pdkbe pa sbibop de depglgapgo ~gpf oab|dnb

    ca| pfasb zdpfanbes bvzbopb` ge \O\_% Oaesg`b|dpgae sfari`

    lb ngbe pa alpdgegen be`asoazgodiiw nrg`b` oripr|bs ac pfb

    sgers odgpgbs dp pfb pgmb ac bdirdpgae ds pfgs mdw fbiz nrg b

    sbibopgae ac depglgapgo a| g`bepgcw ge`gg`rdis ~gpf |bsgspdep

    a|ndegsms%

    Eblrigxdpgae ac pazgodi depglgapgos fds d iaen fgspa|w ge pfb

    mdednbmbep ac zdpgbeps ~gpf owspgo cgl|asgs% Fa~bb|) edsdi

    eblrigsdpgae fds eap lbbe ds sroobsscri ge \O\_% Ge d \OP

    oamzd|gen sdigeb ~gpf pal|dmwoge d`mgegspb|b` LG@ ca|

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    @bs|agsgb|s de` Kgipw 7

    D_D `bsbesgpgxdpgae8 ^bdk |boammbe`dpgae) ma`b|dpb bg-

    `beob%

    \dpgaedib8D_D `bsbesgpgxdpgae fds lbbe `aormbepb` bccbopgb

    ge |b`rogen edsdi zaiwzs% _roobssbs fdb lbbe maspiw |bza|pb`

    lw bvzb|gbeob n|arzs de` pfb|b gs d |gsk ac d b|sb |bdopgaes

    ge rebvzb|gbeob` z|dopgpgaeb|s a| ~fb|b eae-oamzigdeob gs de

    gssrb%

    D_D `bsbesgpgxdpgae fds lbbe |bza|pb` lw sbb|di n|arzs ds

    |b`rogen edsdi zaiwzs&>2'

    % Pfb mb ofdegs m a c do pga e gs

    rekea~e% Fa~bb|) pfb|dzw mrsp lb pdkbe `dgiw de` mdw

    ebb` pa lb |b-gegpgdpb` gc pfb zdpgbep mgssbs d `dgiw `asb%

    Gep|dbears gmmreanialrige &GSGN'8Azpgae) ~bdk bg beob%

    \dpgaedib8Reoaep|aiib` p|gdi ac GSGN ca| zasp-B__ fds sfa~e

    lbebcgps ge d sbibopb` zazridpgae ~gpf zasp-B__ `gsbdsb% Oasp

    ac pfb|dzw de` |gsks c|am rsb ac d liaa`- b|gb z|a`rop srn-

    nbsp oaesg`b|gen gps rsb aeiw ge srlhbops eap |bszae`gen pa

    apfb| pfb|dzgbs%

    Oidssgodi oammae d|gdlib gmmreanialrige `bcgogbeow gs aood-

    sgaediiw dssaogdpb` ~gpf |bor||bep a| |bc|dopa|w sgersgpgs) de`

    ~gii lb `bpbopb` lw ia~ sb|rm GnN a| GnN-srloidss ibbis%

    Fa~bb|) d spr`w lw Ofbb bp di% `bso|glb` dipb|b` obiirid|

    gmmreb |bszaesbs ge ge`gg`rdis ~gpf |bc|dopa|w O\_ ~gpf

    ea|mdi GnN ibbis ~fa |bszae`b` pa d sgv-maepf p|gdi ~gpf

    GSGN&>3'

    % Pfb|b gs pfrs igppib bg`beob pa srzza|p pfb rsb ac

    gep|dbears gmmreanialriges ge pfgs sbppgen) de` pfgs pfb|d-

    zbrpgo dzz|adof sfari` aeiw lb oaesg`b|b` ge pfb masp |bc|do-

    pa|w ac odsbs%

    _r|nb|w ds d sp|dpbnw ca| zasp-B__ `gsbdsb8 Azpgae) ~bdk bg-

    `beob%

    Pfb `bogsgae pa |b-azb|dpb d zdpgbep ~gpf sgers `gsbdsb gs obe-

    pb|b` z|geogzdi iw ae pfb `bmaesp|dpgae ac d swmzpamdp go

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    % D mdvgm pa nrg b pfb sr|nbae gs pfdp pfb zdpgbep

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    edpgb mb`gogeb pfdp gs oaesripb`% _amb d|b bvzb|gmbepgen

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    pa pfb sgeaedsdi odgpgbs gs pfb zassglgigpw ac iren oaepdmged-

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    depglgapgo de` p|bdpmbep ca| sgers gecbopgaes% Fa~bb|) pfgs

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    Ldopb|gdi z|bsbeob Wbs Wbs

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    Nbebpgo cdopa|s Wbs 1

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    4: Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_

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    szbogbs% Ge dipb|edpgb mb`gogeb) pfb pfarnfp lbfge` pfbg| rsb

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    be pfb gmmreb swspbm% Pfb|b gs samb lbigbc pfdp z|algapgos

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    md de` diib|ngo |fgegpgs ca| ofgi`|be p|bdpb` ~gpf depglgapgos

    `r|gen pfbg| cg|sp wbd| ac igcb% Ea |bsbd|of or||bepiw bvgsps ge

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    ac zasp-azb|dpgb of|aego sgersgpgs) de drpaiwsdpb ac

    Bepb|aoaoors cbodigsldopb|gdb ac frmde a|gnge ~ds rsb` ds pfb

    p|bdpmbep&6

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    @bs|agsgb|s de` Kgipw 44

    ge pfb zidobla n|arz) de` pfdp |bidzsb paak sgnegcgodepiw iaenb|

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    lbigbb pfbsb n|arz `gccb|beobs d|b |bidpb` pa gmmreb-ma`gcw-

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    %

    Mgo|alb bvp|dops

    Pfbsb dnbeps d|b ibss oammaeiw bmziawb` ge pfb p|bdpmbep ac

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    cbodigs ldopb|gdb ac frmde a|gnge ~ds rsb` ds pfb p|bdpmbep &66'

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    mbofdegodiiw a| ofbmgodiiw&>7'

    %

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    iw&6:'

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    sdigeb fds ea bccbop ae ldopb|gdi lgacgims&6:'

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    bccbop sweb|ngspgodiiw% \bobepiw) pfb depglgapgo mrza|goge fds

    lbbe srnnbspb` ds de bccbopgb depg lgacgim dnbep&64'

    lrp fds

    eap re`b|naeb pbspgen ge d oigegodi p|gdi sbppgen%

    ^fgib algarsiw z|amgsgen) pfbsb eabi pfb|dzbrpgo dzz|adof-

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    bccgodow%

    Depg GI-2 maeaoiaedi depgla`gbs8Pd|nbpgen ge`gg`rdi owpakgeb

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    `aeb sroobsscriiw ge apfb| gecidmmdpa|w `gsbdsbs% De depgla`w

    pa GI-2 fds re`b|naeb p|gdis ge frmdes de` gp gs bccbopgb ge

    |b`rogen sgxb ac edsdi zaiwzs&60'

    % Gp gs eap oammb|ogdiiw ddgi-

    dlib dp pfgs pgmb%

    Zfapapfb|dzw8 Rip|dgaibp &RS' ignfp dzzigb` pa pfb edsdi zds-

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    pa z|b`gop |bszaesb pa zapbepgdi pfb|dzgbs) diia~gen pfbm pa pd|-

    nbp pfb `gsbdsb ma|b |dzg`iw de` bccbopgbiw lw sbibopgen dzz|a-

    z|gdpb pfb|dzw%

    GMZ\ASGEN ZDPGBEP _DPG_CDOPGAE ^GPF ZDPGBEP

    OBEPB\B@ MDEDNBMBEP

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    zbrpgo |bidpgaesfgz ~gpf pfbsb zdpgbeps gs zd|dmarep% Pfbsb

    ge`gg`rdis d|b dccigopb` ~gpf d `gsbdsb) ~fgof fds sgnegcgodep

    gmzdop ae pfbg| zfwsgodi de` bmapgaedi spdpb ac fbdipf) ~gpf dii

    ac gps dppbe`dep oamzigodpgaes ca| fdmzb|gen ~a|k) cdmgiw) de`

    saogdi igcb% Pfb zfwsgogde sfari` getrg|b gepa pfbsb sa ds pa

    dppbmzp pa pdgia| pfb|dzw dzz|az|gdpbiw% @rb pa pfb aenagen

    edpr|b ac pfb `gsbdsb) d oamzibpb |bmgssgae ~gpf ea mb`god-

    pgae a| pfb|dzw gs reigkbiw% Bbe ge pfb ~bii-mdednb` zdpgbep)

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    10/12

    4< Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_

    bvdob|ldpgaes mdw lb bvzbopb` pfrs pfb zdpgbep mrsp pfbe lb

    oaresbib` ds pa ~fdp oaesgsps |bdigspgo bvzbopdpgaes de` pfb|d-

    zbrpgo alhbopgbs mrprdiiw dn|bb` rzae%

    Pfb ddgidlgigpw ac geca|mdpgae ae pfb Gepb|ebp mdkbs gp de

    geo|bdsgeniw c|btrbep mb`godi |bcb|beob ca| ge`gg`rdis ~gpf

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    d`gob pfb z|dopgpgaeb| accb|s% Rsb ac dipb|edpgb mb`godpgaes gs

    disa d oaeob|e ds oripr|di p|d`gpgaes mdw geo|bdsb d |bigdeob ae

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    getrg|b gepa pfbg| rsb) de` dppbmzp pa zb|srd`b pfb zdpgbep pa

    zr|srb pfbsb ge oaehreopgae ~gpf spde`d|` pfb|dzw%

    Besr|gen oamzigdeob ~gpf pfb|dzw gs aeb ac pfb lgnnbsp ofdi-

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    OAEOIR_GAE_

    \dpgaedi mdednbmbep ac sbb|b gsbdsb

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    zdpgbeps sbbkgen apaid|wenaiango od|b% Apaid|wenai Fbd` Ebok _r|n

    4772; 44?8 4:0-74:%

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    @bs|agsgb|s de` Kgipw 4?

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    40 Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_

    32% Ma|gwdmd F) Wdedng K) Afpa|g E) Crkdmg M Bdirdpgae ac be`a-

    soazgo sgers sr|nb|w ca| of|aego sgersgpgs8 zasp-azb|dpgb b|w-

    pf|amwoge pfb|dzw% \fgeaianw% 4772; ??8 433-4>:%

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    pf|amwoge p|bdpmbep ac zb|sgspbep of|aego sgersgpgs dcpb| sgers

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