LIGASI ARTERI ARTERI HAEMORRHOIDAL DIBANDINGKAN LIGASI PITA KARET UNTUK PENGELOLAAN GEJALA TINGKAT DUA DAN HEMOROID(WASIR) DERAJAT TIGA: SEBUAH MULTISENTER, OPEN-LABEL, PERCOBAAN TERKONTROL SECARA ACAK RINGKASAN Latar belakang: interen!i "e#$% &$n' ti*$+ nt .$!ir e+$! ren#$% ti#$ #iet$%i/ +i'$!i $rteri H$e*rr%i#$+ (HAL) te+$% #i!+$n !e"$'$i ter$i $*$n !e*e !e*ent nt$r $r$$ +i'$ +i'$!i !i it$ it$ $re $rett (RBL (RBL)) $#$+ $#$+$% $% en' en'" "$t $t$n $n r$.$ r$.$tt 0$+$ 0$+$n n ** ** #i'n$$n/ K$*i *e*"$n#in'$n e$*"%$n !ete+$% HAL #i"$n#in'$n RBL $#$ $!ien #en'$n %e*ri# #er$0$t II-III/ Metode : *+ti!enter ini, en-+$"e+, e+* $r$+e+, er1"$$n terntr+ $1$ ter*$! $!ien #$ri 23 $t tr!t UK NHS/ K$*i #i!$rin' $!ien "er!i$ 24 t$%n $t$ +e"i% t$ &$n' *en'$+$*i *en'$+$*i .$!ir 'r$#e II-III/ K$*i *n'e!+!i $!ien &$n' !e"e+*n&$ te+$% *eneri*$ er$!i $*"eien, +e"i% #$ri !$t en'"$t$n in0e!i nt .$!ir, $t$ r!e#r +e"i% #$ri !$t RBL #$+$* .$t 5 t$%n !e"e+* !e"e+* erert$n/ $!ien &$n' *e*en%i *e*en%i !&$r$t !e1$r$ $1$ (#$+$* r$!i 2: 2) "$i RBL $t$ HAL #en'$n D+er/ Pen'$1$$n it #i%$!i+$n *ter #$n !tr$ti6i e# +e% !$t #en'$n "+ r$n $1$/ A+$!i en&e*"n&i$n #i1$$i #en'$n *en''n$$n !i!te* "er"$!i! .e"/ Pene+iti$n ini $#$+$% en-+$"e+ t$n$ *$!in' e!ert$, #ter, $t$ !t$6 ene+iti$n/ H$!i+ ri*er $#$+$% e$*"%$n $#$ 2 t$%n, "er$!$+ #$ri eni+$i$n &$n' #i+$r$n $!ien #$+$* *"in$!i #en'$n en''n$$n !*"er #$&$ #$ri ** r$ti!i #$n r*$% !$it 1$t$t$n *ere$/ *ere$/ Ke$*" Ke$*"%$ %$n n #i$n$+i #i$n$+i!i! !i! $#$ $#$ $!ien $!ien &$n' &$n' te+$% te+$% *en0$+$ *en0$+$ni ni !$+$% !$+$% !$t inter interen! en!ii #$n te+$% te+$% #itin# #itin#$+ $+$n0 $n0ti ti !e+$*$ !e+$*$ *ini*$+ *ini*$+ 2 t$%n/ t$%n/ Pene+it Pene+iti$n i$n ini ter#$6t$r #en'$n re'i!tr& re'i!tr & ISRCTN, ISRCTN72587329 ISRCTN72587329 Hasil: D$ri 8 Sete*"er ;2, 9 Mei, ;27, #$ri 898 $!ien &$n' #i!rinin', 24< !e1$r$ $1$ #it'$!$n nt e+* HAL #$n 243 nt e+* RBL/ D$ri e!ert$, 553 *e*i+ii #$t$ %$!i+ ri*er (239 $#$ e+* RBL #$n 292 $#$ e+* HAL)/ P$#$ 2 t$%n $!1$-r!e#r, 43 (78=) #$ri 239 $!ien #$+$* e+* RBL #$n 74 (5;=) #$ri 292 $!ien #$+$* e+* HAL *e*i+ii e$*"%$n $*"eien ($#0!te# ##! r$ti >AOR? @ 5, 8<= CI 2 @ 7-5 @ <2 ; @ ;;;<)/ A+$!$n t$*$ nt !e+i!i% ini $#$+$% 0*+$% r!e#r t$*"$%$n &$n' #ier+$n nt *en1$$i er"$i$n (<3 >5=? e!ert$ #$+$* e+* RBL #$n 5 >27=? e!ert$ #$+$* e+* HAL *e*i+ii r!e#r "eritn&$ nt %e*ri#)/ Me$n n&eri 2 %$ri !ete+$% r!e#r it 5 @ 7 (SD @ 4) $#$ e+* RBL #$n 7 @ 9 ( @ 4) $#$ e+* HAL (!e+i!i% -2 @ , 8<= CI -2 @ 4 nt -; @ < ; @ ;;;) $#$ %$ri e 3 !r &$n' 2 @ 9 ( @ 5) $#$ e+* RBL #$n 5 @ 2 ( @ 7) $#$ e+* HAL (!e+i!i% -2 @ <, - @ ; -2 @ ; ; @ ;;;2)/ !r n&eri $nt$r$ e+*-e+* #i 2 %$ri #$n 9 *in''/ 2< r$n' #i+$r$n e6e !$*in' &$n' !eri! &$n' *e*er+$n er$.$t$n #i r*$% !$it/ S$t $!ien #$+$* #$+$* e+* e+* RBL *e*i+i *e*i+iii t*r t*r #"r #"r &$n' &$n' !#$% !#$% $#$/ $#$/ D$ri D$ri 27 e6e
!$*in' &$n' ter!i!$ !eri!, 2 (3=) "er$#$ #i $nt$r$ e!ert$ &$n' #i"$ti #en'$n HAL #$n #$ (2=) "er$#$ #i *ere$ &$n' #ir$.$t #en'$n RBL/ En$* $!ien *en'$+$*i n&eri (!$t #i"$ti #en'$n RBL, +i*$ #i"$ti #en'$n HAL), ti'$ te+$% er#$r$%$n &$n' ti#$ *e*er+$n tr$n!6!i (!$t #i"$ti #en'$n RBL, #$ #i"$ti #en'$n HAL), #$ #i e+* HAL *e*i+ii reten!i rin, #$ #i e+* HAL *e*i+ii $!$'$+ *$r$%, #$n !$t #i e+* HAL *e*i+ii e*n'in$n !e!i! (#i"$ti #en'$n $nti"iti) Interpretasi: Me!in e$*"%$n !ete+$% HAL +e"i% ren#$% #$ri$#$ RBL tn''$+, HAL it +e"i% *en&$it$n #$ri$#$ RBL/ Per"e#$$n #i e$*"%$n $ren$ e"t%$n nt "$n#in'! "er+$n' $#$ e+* RBL/ P$!ien (#$n *i!$ri! e!e%$t$n) *n'in +e"i% !$ !eerti r!! RBL e HAL &$n' +e"i% in$!i6/
PENGANTAR He*ri# %$!i+ #$ri e*"e!$r$n +e!! %$e*rr%i#$+ #$n er"$%$n $t+'i! #i "$nt$+ $n$+, *nen nr*$+ #$ri !$+r$n $n!/ Ke0$#i$n ini ter0$#i !eit$r !eerti'$ #$ri +$!i/ Seit$r 5 ;;;, er$!i %$e*rr%i# &$n' #i+$$n #i In''ri! $#$ ;;7-;;
METODE Met#e ini #iter"it$n $#$ t$%n ;2 er"$i$n *et#e "eritn&$ #i*+$in&$ ene+iti$n &$n' ter!e#i$ #$+$* +$*ir$n/ St#i #e!$in #$n e!ert$ M+ti!enter ini, e+* $r$+e+ terntr+ $1$/ Si#$n' "er+$n'!n' #i 23 r*$% !$it #i In''ri! NHS $t/ Di#e+e'$!i$n Pene+iti$n #i 23 r*$% !$it ini #ii#enti6i$!i #$n *e*int$ er!et0$ni 1$+n e!ert$/ Pe!ert$ &$n' *e*en%i !&$r$t &$n' "er!i$ 24 t$%n $t$ +e"i% t$ #en'$n 'e0$+$ #er$0$t #$ $t$ .$!ir #er$0$t ti'$/ K$*i *en&in'ir$n $!ien &$n' !e"e+*n&$ *eneri*$ er$!i %e*ri#, +e"i% #$ri !$t en'"$t$n in0e!i nt %e*ri#, $t$ +e"i% #$ri !$t r!e#r RBL #$+$* .$t 5 t$%n !e"e+* erert$n/ K$*i 0'$ *en&in'ir$n $!ien #en'$n !e!i! eri$n$+, er$#$n'$n en&$it !!, e'$n$!$n +ret$+, !#$% $#$ 1e#er$ !6in'ter, #$n i**n #e6i!ien!i, '$n''$n %ier$'+$"i+it$!, #$n $!ien &$n' ti#$ *$* nt $n$!te!i ** $t$ $ne!te!i !in$+/ Pe!ert$ !e1$r$ in#ii#$+ $1$ (#$+$* 2: 2 r$!i) nt *eneri*$ HAL $t$ RBL/ Pen'$1$$n it #i%$!i+$n *ter #$n #i e+*$n #en'$n !$t *en''n$$n "+ er*t$!i #$ri r$n $1$ #$, e*$t, #$n en$*/ A+$!i en&e*"n&i$n #i1$$i *en''n$$n ter!$t Penelitian dala konteks Bti !e"e+* ene+iti$n ini H$e*rr%i#$+ Arter& +i'$!i (HAL) $#$+$% r!e#r &$n' re+$ti6 "$r &$n' te+$% *en0$#i !e*$in "$i !e"$'$i en'"$t$n nt %e*ri#/ Se"$% '$*"$r$n "$i $#$ ;2; #$n e*$t +$!$n !i!te*$ti! #iter"it$n $nt$r$ ;;8 #$n ;2< *en&rti r$n'n&$ $+it$! #$t$ &$n' "$i !e"$'$i "ti entn'$n #$ri teni HAL/ Reie. ter*$! +i*$ 0i $1$, #$ er1"$$n %rt er"$n#in'$n, #$n 2 ene+iti$n %rt/ D$ri er1"$$n %rt ter!e"t, +$!$n tin'$t e$*"%$n &$n' #i*+$n nt HAL "eri!$r #$ri 22= !$*$i 23 <=/ Se"$% teni &$n' "i$!$ #i'n$$n nt en'"$t$n #ini %e*ri# #en'$n +i'$!i it$ $ret (RBL)/ Teni ini !e#er%$n$ #$n *#$% nt *e+$!$n$$n, ti#$ *e*er+$n $ne!te!i #$n #en'$n e*+i%$n &$n' 1e$t/ Ini $#$+$% e*"$n#in' &$n' 0e+$! nt en'"$t$n $.$+ %e*ri#/ S$*$i !$$t ini, ti#$ $#$ er1"$$n $1$ &$n' te+$% *e*"$n#in'$n HAL #en'$n RBL/ Ni+$i t$*"$% ene+iti$n ini, ene+iti$n ini $#$+$% !e"$% *+ti!enter, e+* $r$+e+ $1$ terntr+ #$ri 53; $!ien *e*"$n#in'$n HAL #en'$n RBL/ Tin'$t e$*"%$n nt HAL it !e1$r$ !i'ni6i$n +e"i% ren#$% #i"$n#in'$n RBL (5;= ! 78=, ; ;;2) $#$ 2 "+$n/ Per$.$t$n +e"i% +$n0t #ier+$n #i 52= e+* RBL #$n 2<= #$ri e+* HAL (r$!i ##! &$n' #i!e!$i$n >AOR? nt +e"i% +$n0t r!e#r 49, 8<= CI 2 9<-7 85 ; ;;;)/ 24= #$ri e+* RBL #ier+$n !e!i "$n#in' e#$ #$+$* t$%n/ Ti#$ ter*$! $!ien ini !e"$'$i e$*"%$n 0i$ *ere$ *e+$r$n er"$i$n $t$ en&e*"%$n $#$ 2 t$%n *en'%$!i+$n en'r$n'$n &$n' +e"i% "e!$r #$ri tin'$t e$*"%$n nt RBL #$n ti#$ $#$ #i !t$ti!ti !e+i!i% $nt$r$ e+* (HAL 5;= ! RBL 53 <=, $OR 2 5<, ; 4<- 2< ; ;)/ K$+it$! %i#, !r e$r$%$n 'e0$+$, ntinen!i$ !r, #$n *+i$!i &$n' ter0$#i $#$
6reen!i &$n' !$*$/ R$!$ !$it +e"i% "e!$r #$n "er+$n'!n' +e"i% +$*$ !ete+$% r!e#r HAL/ P$#$ $n$+i!i! "i$&$ er$.$t$n e!e%$t$n $#$+$% tin''i/ P$#$ %$!i+ $!! e1i+, HAL $#$+$% !eit$r F 2/;;; +e"i% *$%$+ #$n !$n'$t ti#$ *n'in nt "i$&$ e6eti6 #i $*"$n' F ; ;;;-5; ;;;/ Tin'$t e$*"%$n #$ri &$n' #i+$r$n !e"e+*n&$, *e!in $*"% #i 2 t$%n +e"i% ren#$% nt HAL #i"$n#in'$n #en'$n RBL tn''$+, "$n&$ #ter $$n *e*erti*"$n'$n RBL !e"$'$i en'"$t$n/ Ji$ *ere$ #en'$n RBL "er+$n' #$+$* t$%n ini #ie1$+i$n !e"$'$i e$*"%$n 0i$ *ere$ *e+$r$n e!e*"%$n $#$ 2 t$%n/ H$!i+ +$inn&$ 0'$ !er$ $t$ +e"i% "r (#$+$* %$+ n&eri) !ete+$% HAL/ HAL +e"i% *$%$+ #$n ti#$ *r$% #$+$* !i!te* en'$1$$n e6eti6/ Ber"$!i! .e" #i *$n$ e!ert$ i#enti6i$!i #i*$!$n !e"e+* $+$!i tern'$/ Pene+iti$n ini $#$+$% en-+$"e+/
PROSED!R Pr$-en'$1$$n #$n #$!$r e!iner ter*$! E-
#$n ert$n&$$n tent$n' er$.$t$n +e"i% +$n0t/ Bent eni+$i$n +ini! !e+e!$i $#$ 9 *in'' n0n'$n n!+t$n $t$ #$ri 1$t$t$n $!ien/ Ji$ !e"$% r1t!i !e+e!$i, in6r*$!i ini #i1$t$t #i !ini, "er!$*$ #en'$n !e"$% ert$n&$$n e$*"%$n (!$*$ !eerti ri*er ert$n&$$n %$!i+) #$t$ $#$ !eti$ *+i$!i, er$.$t$n +e"i% +$n0t #$n en'"$t$n &$n' #iren1$n$$n/ Unt *en'i#enti6i$!i rr!i $!ien #en'$n %e*ri# "er+$n' $#$ 2 "+$n !ete+$% interen!i, $ren$ ti#$ $#$ #i$+i#$!i $!ien &$n' #i+$r$n !r 'e0$+$ $#$, $*i *e*int$ e!ert$ ert$n&$$n, 2 "+$n $!1$-interen!i: P$#$ !$$t ini, $$$% An#$ *er$!$ 'e0$+$ #$ri An#$ .$!ir $#$+$%: (2) !e*"% $t$ *e*"$i #i"$n#in'$n #en'$n !e"e+* er$.$t$n $t$ () ti#$ "er"$% $t$ +e"i% "r #i"$n#in'$n #en'$n en'"$t$n !e"e+*n&$ P$!ien #i$n''$ *e*i+ii .$!ir "er+$n' eti$ !$+$% !$t #$ri "erit #i1$t$t: ti#$ "er"$% $t$ "r #i"$n#in'$n #en'$n !e"e+* *e*+$i en'"$t$n #i 2 "+$n, $!ien #i+$r$n Pr!e#r "eritn&$ (RBL, HAL, %$e*rr%i#e1t*&, %$e*rr%i#e&, in0e!i %$e*rr%i#$+ $t$ r!e#r +$in &$n' re+e$n) +e"i% 2 "+$n (#ter ** >GP? #$n $t$ 1$t$t$n r*$% !$it) $t$ $#$n&$ 'e0$+$ $t$ eri!ti.$ &$n' !$n'$t *enn0$n e$*"%$n ($nt$r$ $!ien ti#$ *e*en%i #$ riteri$ !e"e+*n&$), !eerti &$n' #it!$n +e% #$ #i"t$$n tri$+ ene+iti (JPT, BPRS $en#i)/ D$t$ +$in &$n' #i*+$n #$ri e!iner $#$ 2 "+$n $#$+$%: E-
HASIL H$!i+ t$*$ $#$+$% rr!i $!ien #en'$n .$!ir "er+$n' $#$ 2 "+$n !ete+$% r!e#r, "er$!$+ #$ri eni+$i$n &$n' #i+$r$n $!ien #i *"in$!i #en'$n en''n$$n !*"er #$&$ #$ri GP #$n 1$t$t$n r*$% !$it/ En#int !en#er #ini+$i $#$ 9 *in'' #$n 2 "+$n $#$+$%: e$r$%$n 'e0$+$ (#ini+$i #en'$n HSS #i$#$t$!i #$ri N&!tr* #$n re$n), er!e#i$$n inntinen!i$ (#ini+$i *en''n$$n #i$+i#$!i $ie& 6e!e! !r inntinen!i$), n&eri (#ini+$i *en''n$$n AS 2; 1*), *+i$!i "e#$%, er+ nt +e"i% +$n0t en'"$t$n, 'e0$+$ er!i!ten $#$ 9 *in'', #$n ti+it$! %e$+t%!t$te "er#$!$r$n E-
*en'$n''$ it *n'in "$%.$ !eti$ !it! $$n *e*i+ii *ini*$+ #$ $%+i "e#$%, #$+$* %$+ e$t$n nt *en#ete!i ini !e+i!i% $#$+$% 4<= D$&$ 8;= 0i$ $#$ ti#$ $#$ $nt$r$-#ter "e#$% $ri$!i/ K$ren$ r!e#r "e#$% ini #ie*"$n'$n #en'$n "$i #$n !t$n#$r, ICC $#$+$% %$r$$n *en0$#i %$*ir n+ #$n #i%$r$$n r$n !$*e+ &$n' #i!+$n nt *e*i+ii +e"i% #e$t #en'$n ten$'$ 8;=/ An$+i!i! ri*er $#$ in#ii# &$n' *en'$+$*i !$+$% !$t interen!i #$n #iiti nt *ini*$+ 2 t$%n (#i#e6ini!i$n !e"$'$i +$!i ene+iti$n #i te!)/ K$*i *e+$$n $n$+i!i! t$*"$%$n #i er-rt1+ (PP) +$!i, ter"$t$! $#$ r$n'-r$n' &$n' *e*en%i #en'$n rt+/ Pen&i*$n'$n #$ri *et#e &$n' ti#$ #i$n''$ #$+$* $it$nn&$ #en'$n $n$+i!i! PP ter$it #en'$n r!e! er!et0$n, ter0$.$" 0en#e+$ nt eni+$i$n, e+$&$$n (#$ *en'$r$% e riteri$ e!+!i #$n #$ e!ert$ ti#$ *e*en%i !&$r$t &$n' #it$ri), #$n !$t e!ert$ #i"eri $ne!te!i ** nt r!e#r RBL/ Di+$$n $n$+i!i! e$*"%$n *en''n$$n r$n#* *#e+ re're!i +'i!ti *en1e'$t #i *$n$ $ri$t &$n' *e*i+ii $+$!i en'"$t$n, 0eni! e+$*in, !i$ !$$t er$!i, #$n !e0$r$% interen!i !e"e+*n&$ !e"$'$i &$n' tet$ $%+i "e#$% ter*$! !e"$'$i 6$tr $1$ / An$+i!i! !en!itiit$! +e"i% +$n0t *eni+$i $$$% $r$teri!ti #$!$r +$inn&$ ('e0$+$ !r, E-
HASIL Ant$r$ 8 Sete*"er ;2, #$n 9 Mei ;27, 53 e!ert$ (#$ri 898 #i!$rin') !e1$r$ $1$ #it'$!$n nt *eneri*$ RBL $t$ HAL 243 e!ert$ #i$+$!i$n nt *eneri*$ RBL, #$n 24< #i$+$!i$n nt *eneri*$ HAL (i'r 2)/ D$ #$ri e!ert$ ter!e"t ("$i !e1$r$ $1$ #it'$!$n nt RBL) te+$% #i%$! #$ri ene+iti$n "en$r-"en$r $ren$ $#$n&$ eti#$+$&$$n: !$t !e"e+* r!e#r, #$n &$n' e#$ !ete+$% r!e#r/ D$ri 53; e!ert$ !e1$r$ $1$ &$n' #itin#$+$n0ti, 57; *eneri*$ en'"$t$n (i'r 2) K$r$teri!ti #$!$r *ere$ #itn0$n #$+$* t$"e+ 2/ 57; e!ert$ *eneri*$ en'"$t$n (i'r 2)/ D$t$ %$!i+ &$n' ter!e#i$ nt 553 e!ert$ (292 #i e+* HAL #$n 239 $#$ e+* RBL)/ P$#$ 2 "+$n, <9 e!iner $!ien !een%n&$ !e+e!$i, 59 "ent GP, #$n 553 "ent n!+t$n #ie*"$+i$n/ ++.- !e+e!$i $#$ !it! $#$ 4 A'!t! ;2AOR? 5, 8<= CI 2 7-5 <2, ICC ; ;;; ; ;;;<)/ Rin1i$ne$*"%$n, !e1$r$ e!e+r%$n #$n #en'$n riteri$ #i!$0i$n #$+$* T$"e+ / Prr!i e!ert$ &$n' *e+$r$n e$*"%$n $#$+$% !$*$ $nt$r$ e+*, #en'$n 8= #$ri re!n#en $#$ e#$ e+* &$n' *en&$t$$n *ere$ er1$&$ 'e0$+$ #$ri %e*ri# *ere$ ti#$ "er"$% $t$ +e"i% "r (AOR nt #i+$r$n !en#iri e$*"%$n 2 ;9, ; 9;-2 4< ; 4<)/ It *enin'$t e$*"%$n ter$it #en'$n RBL tert$*$ #i!e"$"$n tin''in&$ tin'$t r!e#r t$*"$%$n #i+$$n !ete+$% interen!i $.$+ (5=), #i"$n#in'$n #en'$n 27= $#$ e+* HAL 2 t$%n 6++.- (AOR nt +$n0t r!e#r 49, 2 9<-7 85 ; ;;;)/ Le"i% +$n0t ti'$ (=) e!ert$ #$+$* e+* RBL #i$n''$ *e*i+ii 'e0$+$ &$n' n!i!ten #en'$n .$!ir "er+$n'/ Berit +$!$n #$ri nt$ *e#i! #$n r!e#r +e"i% 2 "+$n 6++.-, &$n' #i+$$n "t$ e+* er+$$n: #$+$* #$ $!! e!ert$ #i1$t$t *n'in *e*"t%$n er$.$t$n +e"i% +$n0t #i *ere$ 9-*in'' n0n'$n tet$i e*#i$n %i+$n' nt *enin#$+$n0ti eti'$ te+$% #ir$.$t #i r*$% !$it #$ $+i nt er#$r$%$n &$n' "er+e"i%$n t$i ti#$ *en0$+$ni en'"$t$n/ P$#$ 9 *in'', #$t$ &$n' ter!e#i$ nt 85 $!ien (i'r)/ 75 (8=) #$ri 2<; e!ert$ #$+$* e+* RBL #i+$r$n %e*ri# *ere$ !e"$'$i ti#$ "er"$% $t$ +e"i% "r, #i"$n#in'$n #en'$n 2 (4=) #$ri 275 e!ert$ #$+$* e+* HAL !e+$in it, !$+$% !$t e!ert$ #i *$!in'-*$!in' e+* *e*i+ii e*#i$n RBL *en0$+$ni/ Den'$n #e*ii$n 0*+$% e!e+r%$n $!ien #en'$n
'e0$+$ er!i!ten $#$+$% 77 (8=) #i"$n#in'$n 25 (8=) #i!e!$i$n r$!i ##! 7 5< (8<= CI 28-4 9< ; ;;;2)/ P$#$ 9 *in'', !r HSS +e"i% tin''i $#$ e+* RBL, *enn0$n 'e0$+$ 0$n'$ en#e r$n' n&$t$ "erit HAL (+$*ir$n)/ Ni+$i r$t$-r$t$ $#$+$% 7 ; (SD 5 <) $#$ e+* RBL #$n 5 ; (5 2) #i HAL e+*, #en'$n !e+i!i% #i!e!$i$n #$+$* 1$r$ 2 ; (8<= CI ; 52 4 ; ;2;)/ Ti#$ $#$ !e+i!i% 0e+$! $#$ 2 "+$n, #en'$n r$t$-r$t$ *en0$#i 5 9 (5 ) nt RBL #$n 5 9 (5 5) nt HAL ($#0!te# #i 66 !e+i!i% ; ;, 8<= CI -; 4-; 4 ; 84) Se"e+* interen!i, ti+it$! e!e%$t$n *e$n (E ;? $#$ e+* RBL ! 2 7 >2 8? #$+$* e+* HAL !e+i!i% -; 2, -; 9-; 5 ; 77) #$n 9 *in'' (2 > 2? $#$ e+* RBL ! 2 ; >2 4? #$+$* e+* HAL !e+i!i% ; , -; -; 3 ; 5)/ 2< r$n' #i+$r$n e6e !$*in' &$n' !eri! &$n' *e*"t%$n er$.$t$n #i r*$% !$it (t$"e+ 5)/ S$t $!ien *en'$+$*i "e"er$$ ei!#e er#$r$%$n !ete+$% RBL en&e+i#i$n +e"i% +$n0t *en'n'$$n t*r ret*/ E6e !$*in' &$n' !eri! ini #i+$!i6i$!i$n !e"$'$i r$-$#$ #$n ti#$ ter*$!/ D$ri !i!$ 27 e6e !$*in' &$n' !eri!, 2 (3=) "er$#$ #i $nt$r$ e!ert$ &$n' #i"$ti #en'$n HAL (!$+$% !$t #i $nt$r$n&$ te+$% "er$+i% #$ri e+* RBL) #$n #$ (2=) "er$#$ #i *ere$ #i"$ti #en'$n RBL/ En$* $!ien *en'$+$*i n&eri e"e"$!$nn&$ nt "ere$n0$n'$n tin''$+ #i r*$% !$it (6i e #i"$ti #en'$n HAL, !$t #ier+$$n #en'$n RBL), ti'$ *e*i+ii er#$r$%$n (ti#$ *e*er+$n tr$n!6!i, #$ #ier+$$n #en'$n HAL, !$t #ier+$$n #en'$n RBL), #$ *e*i+ii reten!i rin, #$ *e*i+ii enin'$t$n $!$'$+, #$n !$+$% !$t *e*i+ii e*n'in$n !e!i! (#i"$ti #en'$n $nti"iti) e-27 eri!ti.$ &$n' #i%$r$$n !e"$'$i rt+ ene+iti$n/
Te*$n-te*$n t$*$ #$+$* $n$+i!i! er1"$$n *r$% ti+it$! *enn0$n "$%.$ r!e#r HAL t$*$n&$ ti#$ *en0$#i ni+$i &$n' e6eti6 #i"$n#in'$n #en'$n RBL #en'$n "i$&$ $*"$n' e6eti6it$! F ; ;;;-5; ;;; er AL/ D$+$* $!! #$!$r %$!i+, !e+i!i% tt$+ "i$&$ r$t$-r$t$ $#$+$% F 2;3 +e"i% tin''i nt HAL #$ri$#$ RBL (t$"e+ 7)/ AL! &$n' +e"i% tin''i nt HAL #$ri$#$ RBL N$*n, !e+i!i% !$n'$t e1i+ (; ;2;), !e%in''$ r$!i e6eti6it$! t$*"$%$n C!te (ICER) !e"e!$r F 2;7 73 er t$*"$%$n AL/ P$#$ F ; ;;; er $*"$n' "$t$! AL, HAL *e*i+ii n+r"$"i+it$! *en0$#i e6eti6 "i$&$-e 66 $#$ F 5; ;;; $*"$n' "$t$!, it *e*i+ii ; ;< e*n'in$n *en0$#i "i$&$-e 66 e6eti6/ Me$n tt$+ "i$&$ er $!ien nt HAL $#$+$% F 23<; (8<= CI 2/555-/293) #i"$n#in'$n #en'$n F 35 (<<2-489) nt RBL (t$"e+ 5)/ Di $nt$r$ 4; e!ert$ &$n' #ier+$n +e"i% +$n0t r!e#r, *$&rit$! (2< #$ri 5 $#$ e+* HAL #$n 7< #$ri <3 $#$ e+* RBL) *en0$+$ni r!e#r tn''$+ #$n #$+$* e"$n&$$n $!! ini $#$+$% RBL, *e!in "e"er$$ $ri$!i ter1$t$t #i !$t: "i$&$ !e"$% RBL t$*"$%$n r!e#r #$+$* er1"$$n ini $#$+$% F <5 29/ Se"$'$i RBL $#$+$% !in'$t r!e#r r$.$t 0$+$n #en'$n (re+$ti6) *ini*$+ eti#$n&$*$n$n e$#$ $!ien, #$$t #i$t$$n "$%.$ Di $nt$r$ 4; e!ert$ &$n' #ier+$n +e"i% +$n0t r!e#r, *$&rit$! (2< #$ri 5 $#$ e+* HAL #$n 7< #$ri <3 $#$ e+* RBL) *en0$+$ni r!e#r tn''$+ #$n #$+$* e"$n&$$n $!! ini $#$+$% RBL, *e!in "e"er$$ $ri$!i ter1$t$t #i !$t: "i$&$ !e"$% RBL t$*"$%$n r!e#r #$+$* er1"$$n ini $#$+$% F <5 29/ Se"$'$i RBL $#$+$% !in'$t r!e#r r$.$t 0$+$n #en'$n (re+$ti6) *ini*$+ eti#$n&$*$n$n e$#$ $!ien, #$$t #i$t$$n "$%.$ RBL ti#$ !en#iri *enn0$n e$*"%$n/ Ai"$tn&$, $*i *e+$$n $n$+i!i! !t-%1 t$*"$%$n nt *en&e+i#ii !e0$% *$n$ e$*"%$n $nt$r$ r$.$t 0$+$n en'"$t$n RBL #$n HAL (&$it, ti#$ ter*$! "$n#in'! e#$ #i e+* RBL)/ D$ri 52 $!ien #$+$* e+* RBL &$n' *en0$+$ni *en'+$n' RBL,2 &$n' #i+$!i6i$!i$n e*"$+i !e"$'$i nne$*"%$n $ren$ *ere$ #i+$r$n !e#$n' #i!e*"%$n $t$ #ier"$ii $#$ 2 t$%n/ $n$+i!i! ini *en'"$% 0*+$% reren!i e 99 (53 <=) #i Ke+* RBL, #$n 74 (5;=) $#$ e+* HAL (#i!e!$i$n ##! r$!i 2 5<, 8<= CI ; 4<- 2< ; ;)/ Se"$% (!t-%1) $n$+i!i! +e"i% +$n0t *e+i%$t rr!i e!ert$ &$n' !r 'e0$+$ it "$i n+ $t$ !$t, $ren$ n*r ini !e!$i #en'$n #e6ini!i en&e*"%$n #i'n$$n +e% N&!tr*/ Prr!i *enn0$n "$%.$ *e!in $#$ +e"i% #i!e*"%$n $!ien #$+$* e+* HAL #i 9 *in'' (52= RBL ! 54= HAL) #$n 2 t$%n (3= RBL ! 52= HAL), ti#$ $#$ !t$ti!ti #i 66 !e+i!i% $nt$r$ e+* (#i!e!$i$n OR ; 35, ; 77-2 ; 5 $#$ 9 *in'' #$n OR ; 38, ; 79-2 54 ; 7 $#$ 2 t$%n)/ De!$in tri$+ "er$rti "$%.$ $#$ !e+i!i% #i $nt$r$ interen!i #$+$* %$+ t$n''$+ en'$1$$n #$n er$!i (RBL !erin' #i+$$n !e'er$ !e#$n'$n $!ien HAL er'i e #$6t$r tn'' Li%$t T$"e+ 2)/ K$ren$ it, #$t$ #$!$r #i1$t$t "$i #i en'$1$$n #$n $#$ !$$t er$!i/
DISK!SI
Ke$*"%$n 2 "+$n !ete+$% HAL it !e1$r$ !i'ni6i$n +e"i% ren#$% #$ri$#$ !ete+$% RBL/ Pen&$it H$e*rr%i#$+ $#$+$% 0in$, n#i!i #en'$n en'"$t$n tert$*$ #it0$n nt *en'$t$!i 'e0$+$/ Den'$n ti#$ $#$n&$ !e"$% '+ 'e0$+$ #i$+i#$!i !i!te*, $*i *er$!$ enent $+in' entin' #$ri e"er%$!i+$n en'"$t$n $!ien &$n' #i+$r$n %$!i+ er"$i$n #$n e"t%$n nt *en'%in#$ri r!e#r t$*"$%$n/Di *$n$ $!ien te+$% *en0$+$ni interen!i +e"i% +$n0t nt .$!ir, *ere$ #i$n''$ te+$% ter+$n'/ Ber#$!$r$n re*i! ini, HAL *n1+ !erir/ Seririt$! 0e+$! %$r! #i+et$$n #$+$* nte! r$ti!/ 24= #$ri e!ert$ #$+$* e+* RBL *en0$+$ni "$n#in' "er+$n'/ Ini $#$+$% r$te &$n' ** #$n $!ien *n'in i+i%$n &$n' +e"i% "$i #$ri$#$ *en0$+$ni er$!i 0i$ *e*i+ii ten!i &$n' !$*$ nt er"$i$n/ Me*$n' "e"er$$ #ter $n''$ RBL !e"$'$i en'"$t$n/ Ter*$! $!ien ini !e"$'$i !$t e"er%$!i+$n (0i$ *ere$ *e+$r$n er"$i$n $#$ 2 "+$n) *en'%$!i+$n en'r$n'$n e$*"%$n #$n ti#$ $#$ #i !t$ti!ti !e+i!i% $nt$r$ e+*/ Be"er$$ !t#i !e"e+*n&$ te+$% *en'$n#$+$n +ini! &$ni e*eri!$$n #$n 'e0$+$ $!ien &$n' #i+$r$n, r$n' +$in %$n&$ $#$ !i*t*$t+'i/ eti$ *e*erti*"$n'$n 'e0$+$ !$0$, "e"er$$ ene+iti *en'$n''$ $!ien &$n' "e"$! #$rie$*"%$n 0i$ *ere$ ti#$ *e*i+ii 'e0$+$ eri$n$+ !$*$ !e$+i &$n' +$in %$n&$ er"$i$n/ Cnt% $ri$!i ter'$ntn' $#$ #e6ini!i ini #i!e#i$$n +e% !$t !t#i *e+$r$n tin'$t e$*"%$n 9;=, 5; "+$n !ete+$% HAL Pr!e#r, n$*n 49= #$ri $!ien !e1$r$ "er!$*$$n *en''$*"$r$ enin'$t$n er"$i$n 'e0$+$/ 6$tr-6$tr +$in &$n' *e*en'$r%i e$*"%$n ter*$! #r$!i tin#$ +$n0t/ K$*i *e*i+i% nt *eni+$i e$*"%$n $#$ 2 "+$n $ren$ #$t$ &$n' #i"+i$!i$n *enn0$n !e"$'i$n e$*"%$n ter0$#i #$+$* .$t r$n' #$ri 2 t$%n/ N$*n, #$t$ $*i *enn0$n "$%.$ 'e0$+$ er!i!ten &$n' +e"i% ren#$% nt e#$ e+* $#$ 9 *in'' (HAL 8= ! RBL 8=) #en'$n er!$$n "e!$r !e$n0$n' t$%n #$n ti#$ 0e+$! $$$% $t$ $$n er!$$n #$t$r$n tin''i ini/ R$t$- R$t$ !r e$r$%$n 'e0$+$ *e*"$i !ete+$% e#$ interen!i +e% !$*$i 5 in $#$ !$+$ 2< titi #i 9 *in''/ Pen'%itn'$n nt $ri$"e+ +$in #$+$* *#e+ (!i$, 0eni! e+$*in, en'"$t$n !e"e+*n&$, #$n !r $.$+), *ere$ &$n' *en0$+$ni RBL *e*i+ii !r HSS &$n' tin''i #i ti*eint ini tet$i ti#$ $#$ !e+i!i% 0e+$! $#$ 2 t$%n/ Penin'$t$n !ete+$% e#$ interen!i it ti#$ "e'it "e!$r !eerti &$n' #i+i%$t +e% N&!tr* #$n re$n-re$n &$n' *en'$*$ti !e+i!i% #$ri !eit$r 9 in !ete+$% interen!i/N$*n, #$+$* !t#i &$n' r$ er$!i &$n' *e*i+ii !r +e"i% tin''i #$ri$#$ #$t$, *en1er*in$n e+$! &$n' +e"i% tin''i #$ri .$!ir r$-er$.$t$n/ N&!tr* *ener$$n #e6ini!i #$ri "$t !e"$'$i ;-2 titi $#$ !i!te* eni+$i$n ini, ti#$ $#$ !e+i!i% $nt$r$ #$ interen!i #i ti*eint $$n/ Me*$n', it $#$+$% %$+ &$n' *en1+ "$'$i*$n$ "e"er$$ $!ien *e+$r$n !r ter!e"t *e!in *e*erti*"$n'$n #iri nt #i!e*"%$n $t$ #ier"$ii/ H$+ ini *enn0$n "$%.$ "$n&$ $!ien &$n' ti#$ e#+i #en'$n tin'$t tertent 'e0$+$ er!i!ten &$n' "er%"n'$n #en'$n .$!ir/ Interen!i nt .$!ir $#$ #$!$rn&$ "ert0$n *enin'$t$n $+it$! %i#, &$n' $ren$n&$ *en0$#i in#i$tr entin' #$ri e"er%$!i+$n/ H$!i+ $*i *enn0$n "$%.$ !e"$'i$n "e!$r $!ien #i e#$ e+* *e*i+ii enin'$t$n #$!$r $+it$! %i# !ete+$% interen!i #$ri %$ri
2 #$n !eter!n&$/ Se"e+* t$n''$+ ini $#$ !e+i!i% &$n' *en#n' #$ri RBL, *n'in "er$it$n #en'$n 6$t$ "$%.$ r!e#r HAL +e"i% *en&$it$n #$n n&eri "er+$n'!n' +e"i% +$*$/ Me!in ti#$ $#$ 0$n'$ $n0$n' !e+i!i% $$n ter+i%$t $nt$r$ e#$ e+*, e#$ interen!i ti#$ *en'%$!i+$n er"$i$n e1i+ !r #i $+it$! %i#/ O+e% $ren$ it, e#$ interen!i *n1+ "er%$r'$ #$ri er!eti6 ini/ A+tern$tie i+i%$n en'e++$$n 0$*in$n "erit *e*i+ii en'e1$+i$n en&e"$" nt 'e0$+$ #$n *e*"eri$n '$*"$r$n ** !$r$n '$&$ %i# *n'in ti#$ !e!$i/ Men'i!tir$%$t$n !6in'ter $n$+ *e*ert$%$n$n ntinen!i$ #$n 0$rin'$n %$e*rr%i#$+ ntri"!i ter%$#$ e*"ent$n !e'e+ e#$ #$r$/ O+e% $ren$ it '$n''$n 0$rin'$n ini $ren$ $#$n&$ r+$! "erten!i *en&e"$"$n e"1r$n $n$+/ H$!i+ ini n!i!ten #en'$n ini: $#$ $.$+ *$&rit$! e!ert$ #$ri e#$ e+* ti#$ $t$ !$n'$t rin'$n *en'$+$*i inntinen!i$/ Kre!i r+$! &$n' *en'$i"$t$n en'r$n'$n e1i+ #i r$t$ !r en$%$n$n !ete+$% e#$ interen!i t$n$ !e+i!i% $nt$r$ interen!i/ Ke"$n&$$n $!ien *e+$r$n n&eri "eritn&$ e$#$ e#$ r!e#r/ Unt RBL ini "i$!$n&$ inten!it$! ren#$%, #$n #i!e+e!$i$n 1e$t !eit$r !eten'$% #$ri $!ien &$n' *e*"t%$n $n$+'e!i !e+$*$ "e"er$$ %$ri/ Unt HAL, !$it !e1$r$ !i'ni6i$n +e"i% "e!$r !$*$i 2 *in'' tet$i %$r! #i!e+e!$i$n #i %$*ir !e*$ $!ien #en'$n 5 *in''/ $n$+'e!i$ %$ri$n #ier+$n +e% !e"$'i$n "e!$r nt ert$*$ *in'', !eerti "$%.$ $#$ 5 *in'' ti'$ ere*$t #$ri $!ien te+$% "er%enti *in* "$t/ A#$ "e"er$$ er1"$$n $1$/ Sr AS te+$% #i'n$$n ,*erin'$! te*$n ini *enn0$n !e"$'i$n "e!$r $!ien *e*i+ii n&eri !e#$n' #i "e"er$$ %$ri !ete+$% HAL, t$i it r$!$ !$it ini *en0$#i *ini*$+ $t$ ti#$ $#$ r$!$ !$it #en'$n 2-5 *in'', %$+ ini *er$$n n!i!ten!i #en'$n %$!i+ te*$n/ In!i#en e6e !$*in' ren#$% nt e#$ e+* er+$$n/ D$ $!ien #$ri e+* RBL #ier+$n r$.$t in$/ H$+ ini re+e$n !e"$'$i r!e#r "i$!$n&$ #i+$$n #i #e$rte*en r$.$t 0$+$n, !erin' #en'$n er!et0$n *ini*$+/ A#$ e$#$$n nt "e"er$$ r*$% !$it nt *en'$tr r!e#r RBL %$r! #i+$$n #$+$* +in'n'$n, *e*n'in$n 6r*$+ r!e! er!et0$n/ H$ri #i*$n$ $!! *$!, #en'$n .$t !in'$t en'$*$t$n, *n'in te+$% #i%in#$ri e"t%$n nt r*$% !$it *$! %$n&$ !$t $!ien #$+$* 0i 1"$ $*i &$n' *e*i+ii !$it &$n' ter$!$ $r$% $!1$-r!e#r/ An$+i!i! "i$&$ er$.$t$n e!e%$t$n tin''i/ D$+$* $!! $n$+i!i! #$!$r, HAL $#$+$% !eit$r F 2/;;; +e"i% *$%$+ #$ri RBL/ K$ren$ $#$ !e#iit !e+i!i% !e1$r$ e!e+r%$n e!e%$t$n ter$it $+it$! %i# $nt$r$ #$ r!e#r, ICER er t$*"$%$n AL !$n'$t tin''i #$n !e1$r$ !i'ni6i$n *e+e"i%i "i$&$ $*"$n' e6eti6it$! #$ri F ; ;;;-5; ;;; er AL/ B$%$n 0i$ !e+i!i% #i e$*"%$n &$n' #i$!*!i$n (&$it, !$t RBL r!e#r ! HAL) "i$&$ r$!i e6eti6it$! $#$+$% !eit$r F <;;;/ P$#$ #$!$rn&$, HAL !$n'$t ti#$ *n'in nt "i$&$ e6eti6 $#$ F ; ;;;-5; ;;; er $*"$n' "$t$! AL/ D$t$ *en'en$i "i$&$ er$.$t$n e!e%$t$n #$ri ene+iti$n +$in $#$+$% 0$r$n'/ $n$+i!i! "i$&$ te+$% #i+$$n #$+$* !$t er1"$$n *e*"$n#in'$n %$e*rr%i#e& #i0eit #en'$n RBL, #en'$n "i$&$ %$e*rr%i#e& #i0eit *en0$#i !"!t$n!i$+ +e"i% tin''i #$n ti#$ *n'in #i$n''$ "i$&$ e6eti6 #i 2 t$%n/ N$*n, en+i! #i$!*!i$n "$%.$ "i$&$ $ren$ *enin'$t e$*"%$n #en'$n RBL $$n "er$rti "$%.$ ini !e+i!i% $$n 0$t% #$ri .$t e
.$t/ A!*!i ini *n'in "er+$ nt HAL, *e!in "i$&$ &$n' re+$ti6 ren#$% RBL *e*"$t it ti#$ *n'in/ H$+ ini *n'in +e"i% *r$%, e6eti6 "$'i $!ien nt e*"$+i nt RBL +e"i% +$n0t 0i$ e$*"%$n ter0$#i !eti$ !$$t/ K$*i *en1$t$t +e"i% "$n&$ $!ien &$n' *en$ri #iri #i HAL e+* #i"$n#in'$n $#$ e+* RBL/ A+$!$n t$*$ nt !e+i!i% #$+$* en$ri$n "er%"n'$n #en'$n $!ien &$n' *en$ri #iri #$ri er!et0$n/ 2< $!ien #$ri e+* HAL *en$ri !et0 #i"$n#in'$n #en'$n #$ #$ri e+* RBL/ Ini *er$$n !e+i!i% $!ti &$n' "er$it$n #en'$n .$t *enn'' interen!i/ RBL !erin' #i+$$n !e'er$ !ete+$% en'$1$$n !e#$n'$n nt $!ien HAL #ite*$t$n $#$ #$6t$r tn''/ D$+$* "e"er$$ $!! #$6t$r tn'' !$n'$t $n0$n' (%in''$ 3; %$ri)/ A#$ &$n' #in&$t$$n $#$ er"e#$$n-er"e#$$n #$+$* $r$teri!ti $.$+ "$'i *ere$ &$n' *en'n#r$n #iri/ Pr$'*$ti!, #e!$in *+ti!enter, *en''n$$n 1$*r$n $"$ten ** #$n en'$0$r$n r*$% !$it NHS #i !e+r% UK, *e*$!ti$n "$%.$ %$!i+ &$n' #i'ener$+i!$!i$n nt !e*$ $!ien *en1$ri en'"$t$n nt .$!ir e+$! II-III/ N$*n, $#$ ten!i eter"$t$!$n/ Pert$*$, .$t #$ri tin#$ +$n0t ti#$ *n'in *e*$#$i #ier$n0$n' tin#$ +$n0t *n'in *enn0$n er!$$n +e"i% +$n0t #$+$* 'e0$+$, *en'"$% "i$&$ er$.$t$n e!e%$t$n/ Ke#$, $*i *en''n$$n G+i'%er &$n' !i!te* eni+$i$n nt .$!ir, &$n' te+$% #iriti $ren$ #e6ini!i %e*ri# e+$! I $#$ !e#iit $*"i'it$! "er$it$n #en'$n ni+$i &$n' +e"i% ren#$% tet$i !$+$% $$n +$!i6i$!i $#$+$% **/ Keti'$, *e!in HAL *n1+ !e#er%$n$ #$n *#$% #ie+$0$ri, *n'in $#$ r$ "e+$0$r &$n' "ere$n0$n'$n/ Be"er$$ ene+iti$n *en''$*"$r$n %$!i+ &$n' +e"i% "r $#$ $!ien $.$+/ er1"$$n $*i #ier+$n "$%.$ $%+i "e#$% %$r! te+$% #i+$$n !eti#$n&$ +i*$ $!! #i"i*"in' #$n t$*"$%$n +i*$ r!e#r !e"e+* erert$n ("er#$!$r$n r#!en re*en#$!i), tet$i ti#$ $#$ #$t$ &$n' $#$ nt *en#e6ini!i$n eti$ *eten!i ter1$$i/ Keter"$t$!$n $%ir $#$+$% r$n'n&$ !1rin' #i$+i#$!i !i!te* nt .$!ir/ P$#$ !$$t #e!$in ini er1"$$n ti#$ $#$ !i!te* !eerti &$n' ter!e#i$/ Sete+$% $.$+ ene+iti$n $*i, !i!te* eni+$i$n te+$% #ie*"$n'$n/ Ke!i*+$nn&$, HAL +e"i% e6eti6 #$ri$#$ RBL tn''$+/ N$*n, 0i$ RBL #i$n''$ !e"$'$i en'"$t$n *e+i"$t$n "$n#in' *en'+$n'i, r!e#r !$*$-!$*$ e6eti6/ De*ii$n +$, !r e$r$%$n 'e0$+$, *+i$!i, $+it$! %i#, #$n !r en$%$n$n $nt$r$ HAL #$n RBL, #$n $!ien *en'$+$*i n&eri +e"i% "$n&$ #i $.$+ eri#e $!1$ er$!i !ete+$% HAL/ HAL ini !e1$r$ !i'ni6i$n +e"i% *$%$+ #$n ti#$ *n'in "i$&$-e 66 e6eti6/ K$ren$ ini, $!ien (#$n *i!$ri!) *n'in +e"i% !$ Tent !$0$ #$ri RBL nt en'"$t$n .$!ir/
