tomo 6 - la mejora asistencial del diabético

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  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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    CN @FGDXN

    NRLR]FKBLNCMFC MLNH]LBDCn bnclmnm nrlr}fkblnc | cdr zxdexn`nrmf fgdxn fk mlnhf}fr

    HLHCLD]FBN MF CN

    Bddxmlknmdx

    @n}fv Rfev Mnw

    RDBLFMNM FRZNDCN MF MLNHF]FR

    Exvzd mf ]xnhngd mf Mlnhf}fr | N}fkblk Zxl`nxln 1

  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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    CN @FGDXN NRLR]FKBLNCMFC MLNH]LBD

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nrmf `fgdxn fk mlnhf}fr

    Bddxmlknmdx

    @n}fv Rfev Mnw

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    Bddxmlknblk Exvzd mf ]xnhngd mf Mlnhf}fr | N}fkblk Zxl`nxln mf cn RdblfmnmFrzndcn mf Mlnhf}fr+ XfmEFMNZR+

    Fml}n7

    8::< Rdblfmnm Frzndcn mf Mlnhf}fr /RFM,

    Zxfl`zxfrlk7 @dkdBd`z# R+ N+Mfzrl}d cfenc7 @->6:5

  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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    Rdblfmnm Frzndcn mf Mlnhf}fr

    Gvk}n Mlxfb}lqn

    @nkvfc Nevlcnx Mldrmnmd

    Zxfrlmfk}f

    Cvlr Bnr}nd Edkwcfw

    Qlbfzxfrlmfk}f >+

    Fmfc`lxd Cvlr @fkkmfw ]dxxf

    Qlbfzxfrlmfk}f 8+

    Cvbxfbln Ofxxnkw mf cn @dxfknRfbxf}nxln

    Nk}dkld Zxfw Zxfw

    Qlbfrfbxf}nxld

    Gdr @nkvfc Afxkkmfw-Xfnc Cf`dr

    ]frdxfxd

    Rnxn Nx}dcn @fkkmfw

    Qdbnc >+

    @nxlrdc Xvlw mf Nmnkn

    Qdbnc 8+

    Nchfx}d @dxfkd Bnxnwd

    Qdbnc 2+

    Abd+ Gnqlfx Enxbn Rdlmk

    Qdbnc =+

    Gnqlfx Cna}n ]fgfmdx

    Qdbnc 6+

  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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    @n}fv Rfev Mnw

    @mlbd mf An`lcln+ VHR Fr Bnr}fcc /@fkdxbn,+ L Hncfnxr+

    Axnkblrbd Gnqlfx Enxbn Rdlmk

    @mlbd mf An`lcln+ Bfk}xd mf Rncvm mf Zdxxld+ Zdk}fqfmxn+

    Gnqlfx Mfw Frzlkd

    @mlbd mf An`lcln FNZ mf ]nnccn+ Knqnxxn+

    Zxdfrdx Bcklbd Nrdblnmd mf cn Anbvc}nm mf @fmlblkn

    mf cn Vklqfxrlmnm mf Knqnxxn+

    Gdxef Knqnxxd Zxfw

    N}fkblk Zxl`nxln Mfznx}n`fk}d 6 Odrzl}nc Bcklbd

    Vklqfxrl}nxld Qncfkbln+

    Gdr Gvnk Ncf`k Rkbofw

    Frzfblnclr}n fk @fmlblkn An`lclnx | Bd`vkl}nxln+

    Bfk}xd mf Rncvm mf ]nbdxdk}f+ Bddxmlknmdx mf cn Vklmnm

    mf Bnclmnm mf cn Efxfkbln mf N}fkblk Zxl`nxln+ ]fkfxlf+

    Gdr Cvlr ]dxxfr Hnlcf

    Frzfblnclr}n fk @fmlblkn An`lclnx | Bd`vkl}nxln

    | fk @fmlblkn Zxfqfk}lqn | Rncvm Zhclbn+ Bfk}xd mf Rncvm

    Xdmxevfw Zn}fkn+ Cdexdd+

    Gdr @nkvfc @lccnxvfcd ]xlccd

    @mlbd mf An`lcln+ Bfk}xd mf Rncvm ]dxxfxd Cn Znw+ Wnxnedwn+

    XFMEFMNZR+

    Q

    kmlbf mf nv}dxfr

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    @nkfc @n}n Bnrfr

    Frzfblnclr}n fk @fmlblkn An`lclnx | Bd`vkl}nxln+

    Bfk}xd mf N}fkblk Zxl`nxln Cn @lkn+ Rnk} Nmxl mf Hfrr+Hnxbfcdkn+ Exvz mFr}vml mf cn Mlnhf}lr fk N}fkbl Zxl`xln

    /EFMNZR, mf cn BN@ALB+ Xfm EFMNZR+

    Zn}l Fwivxxn Cdldcn

    @mlbd mf An`lcln+ B+ R+ Wv`nln+ Bd`nxbn Elzvwidn Filncmf+

    Drnilmf}wn+

    Zfmxd @vdw Bnbod]bklbd mf Rncvm Zhclbn+ Vklmnm Mdbfk}f mf @fmlblkn

    An`lclnx | Bd`vkl}nxln mf Rnk}nkmfx+ Bnk}nhxln+

    Xnnfc Bdcr Bonbnx}fevl

    @mlbd mf An`lcln+ Bfk}xd mf Rncvm mf Rnk}dn+ Bnk}nhxln+

    Rfxqlbld Bk}nhxd mf Rncvm+

    Xnnfc Xd}nfbof mfc Bn`zd@mlbd mf An`lcln+ B+ R+ Ncwn+ Bd`nxbn Elzvwidn Filncmf+

    Drnilmf}wn+

    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    QL

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    QLL

    kmlbf mf bnz}vcdr

    Mf cn nrlr}fkbln nc mlnh}lbd n cdr zxdexn`nr

    mf `fgdxn mf cn bnclmnm

    Zxcded

    @n}fv Rfev Mnw

    >

    Cn dzdx}vklmnm mf `fgdxn fk cn nrlr}fkbln

    mlnhf}dcelbn

    Nrzfb}dr `f}dmdcelbdr

    Gdxef Knqnxxd# Zfmxd @vdw# Xnnfc Bdcr

    5

    Dhgf}lqdr mf cn `fgdxn bdk}lkvnmn

    fk fc mlnh}lbd

    Fr}kmnxfr f lkmlbnmdxfr

    @n}fv Rfev Mnw# Gdr Cvlr ]dxxfr Hnlcf# Gnqlfx Mfw Frzlkd

    25

    Mf cn qnxlnhlclmnm nrlr}fkblnc n cnr evnr

    mf zxb}lbn bcklbn fk mlnhf}fr

    Xnnfc Xd}nfbof mfc Bn`zd# Zn}l Fwivxxn Cdldcn

    12

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    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    QLLL

    Rlr}f`nr mf xfelr}xd mf cn lkadx`nblk

    mfc mlnh}lbd

    Cn dxenklwnblk nrlr}fkblnc

    Gdr Gvnk Ncf`k Rkbofw# Axnkblrbd Gnqlfx Enxbn Rdlmk

    86

    Mf cn fmvbnblk mlnhf}dcelbn

    nc f`zdufx`fk} mfc mlnh}lbd

    Cnr nrdblnbldkfr mf mlnh}lbdr

    @n}fv Rfev Mnw# Gdr @nkvfc @lccnxvfcd ]xlccd

    >=

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    @n}fv Rfev Mnw

    NVK^VFznxfwbn vkn dhqlfmnm }fkfx zxdfrldkncfr rnkl}nxldrhlfk dx`nmdr fk mlnhf}dcden kd fr enxnk}n mf fgdx n}fk-blk kl mf `n|dx rn}lrnbblk mfc mlnh}lbd+ Zvfr rl onhcn`dr mf

    bnclmnm mf cn n}fkblk mfc mlnh}lbd zvfmfk flr}lx d}xdr nb}dxfr#

    nc nxefk mf cn dx`nblk blfk}abd }bklbn mfc zxdfrldknc# ~vf#

    bd`d qncdxfr nnmlmdr# lkv|nk rl bnhf `r fk cdr fr}kmnxfr mfbnclmnm nm`l}lmdr | ~vf lkbcvrd rfnk bnznbfr mf `fgdxnx fk

    `n|dx exnmd cn bnclmnm mf qlmn | cn rn}lrnbblk mfc znblfk}f+

    Fr zdx fccd ~vf fc bdkbfz}d mf bnclmnm fk cn n}fkblk ~vf rf mn nc

    mlnh}lbd zvfmf vb}vnx mfrmf }f`nr dxenklwn}lqdr# n cnr evnr mf

    zxb}lbn bcklbn# mfrmf fc }lf`zd ~vf mfmlbn`dr n cn bdkrvc}n mfc

    mlnh}lbd n cnr md}fr bd`vklbn}lqnr mf cdr rnkl}nxldr+++ Nr# nrzfb-

    }dr bd`d cn bdk}lkvlmnm nrlr}fkblnc# fk}fkmlmn bd`d }xnrfxfkbln

    mf lkdx`nblk | cn bddxmlknblk fk}xf klqfcfr# d cn lk}fexnclmnm#

    bd`d qnxlfmnm mf rfxqlbldr ~vf rf dfx}nk# rfxnk vknr mf }nk}nr bn-

    xnb}fxr}lbnr ~vf mfaklxnk fr}f bdkbfz}d+ Zdx }nk}d# n zxldxl kdr

    mn`dr bvfk}n ~vf fc bdkbfz}d mf bnclmnm nzclbnmd n fkfx`fmn-

    mfr bxklbnr kd mfgn mf rfx vk nrvk}d xfnc`fk}f bd`zclbnmd+

    \ fr ~vf flr}fk exnk bnk}lmnm mf bdkbfz}dr fk bdk}lkvn fqd-

    cvblk ~vf bxfnk mlfxfkblnr fk fc mlr}lk}d nhdxmngf | `nkfgd mf

    >

    Mf cn nrlr}fkblnnc mlnh}lbdn cdr zxdexn`nr mf

    `fgdxn mf cn bnclmnmZxcded

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    cn fkfx`fmnm | ~vf mn bd`d xfrvc}nmd vkn exnk qnxlnhlclmnm fk

    cn n}fkblk mfc mlnh}lbd+ Qnxlnhlclmnm ~vf kd rf `nklafr}n rdcd

    fk cdr nrzfb}dr bcklbdr d `f}nhclbdr# rlkd ~vf zvfmf `nklfr-}nxrf fk fc mlr}lk}d }xn}d ~vf xfblhf fc znblfk}f# fk rv exnmd mf rn-

    }lrnbblk# | cn zdr}xf fk fc mlfxfk}f bdkrv`d mf xfbvxrdr ~vf rf

    onbf znxn fc `nkfgd | }xn}n`lfk}d mf cn fkfx`fmnm+

    ]nc qfw rfn zdx fccd ~vf }dmdr fr}n`dr mf nbvfxmd ~vf fc dhgf-

    }lqd mf cn bnclmnm mf cn n}fkblk kd mfhfxn rfx d}xd ~vf `fgdxnx

    cn n}fkblk mfc fkfx`d# | mf no ~vf }dmd cd ~vf xfmvkmf fk fr-

    }nkmnxlwnx nb}vnbldkfr# nbdx}nx zxdbfrdr nrlr}fkblncfr# `fgdxnxcdr blxbvl}dr+++ lxk fkbn`lknmd n fr}f zxdzrl}d+ Mfk}xd mf cn fr-

    }nkmnxlwnblk mf nb}vnbldkfr kd bnhf mvmn ~vf cn mlvrlk mf cn

    lkdx`nblk blfk}labd}bklbn fk dx`n mf evnr d zxd}dbdcdr# cn

    dx`nblk bdk}lkvnmn# mlr`lkvlx cn qnxlnhlclmnm fk cn zxb}lbn

    bcklbn9 | ~vf cn fqncvnblk mf cn nb}lqlmnm xfnclwnmn `fmlnk}f cn

    nzclbnblk mf lkmlbnmdxfr bdk rvr bdxxfrzdkmlfk}fr fr}kmnxfr

    }fkmfx n vkldx`lwnx cnr nb}vnbldkfr mf cdr rnkl}nxldr+ Zdx }nk}d#

    n`hdr rfxnk `}dmdr qclmdr znxn `fgdxnx cn bnclmnm nrlr}fk-blnc mfc mlnh}lbd+

    Fr mfblx# mfrmf vk nrzfb}d ecdhnc# zdmxn`dr mfblx ~vf fc bdk-

    bfz}d mf bnclmnm }d}nc fk cn n}fkblk nc mlnh}lbd lk}fk}nxn nrf-

    evxnx cn ffb}lqlmnm# cn fablfkbln mf cn n}fkblk nr bd`d cn

    rn}lrnbblk mf fr}f+ ]nc qfw rfn zdx fccd ~vf fk bnclmnm mfc mln-

    h}lbd }lzd 8 /M@8, cd r l`zdx}nk}f kd rfn cn cdkel}vmlknclmnm

    mf cn n}fkblk /`mlbd mf bnhfbfxn }dmn cn qlmn, rlkd cn bdk}l-

    kvlmnm mf cn n}fkblk ~vf zfx`l}n `nk}fkfx cn `lr`n n}fkblk

    lkmfzfkmlfk}f`fk}f mfc zfxrdknc ~vf cd n}lfkmf# nmfbvnkmd cdr

    xfelr}xdr bcklbdr# cn dxenklwnblk mf cdr bfk}xdr# cn mfaklblk mf

    bd`zf}fkblnr fk fc f~vlzd nrlr}fkblnc | cn bdxxfb}n xfevcnblk

    fk}xf klqfcfr nrlr}fkblncfr+ Fc fgf`zcd bcrlbd rfxnk cnr exnkmfr

    bnmfknr vc}lknbldkncfr zxlkblzld mf bdkrlr}fkbln d mf vkl-

    dx`lmnm ~vf bxfnk xnk~vlblnr ~vf dhclenk n vkn `lr`n l`n-

    efk# zxdmvb}dr bd`d @bMdkncm# Rofxn}dk+++

    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    8

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    Rf fk}lfkmf# zdx }nk}d# ~vf cn bnclmnm mf cn n}fkblk ~vf rf mn

    nc mlnh}lbd rfn vkn kfbfrlmnm mf cn f`zxfrn n cn qfw ~vf vkn kf-

    bfrlmnm mfc zxdfrldknc+ Vkn kfbfrlmnm mfc zxdfrldknc ~vf cdrlfk}f vkmn`fk}nc`fk}f fk cn nc}n mf nb}vnclwnblk mf rvr bd-

    kdbl`lfk}dr mlnhf}dcelbdr /dx`nblk bdk}lkvnmn,# fk cn dxen-

    klwnblk mf cn f`zxfrn rnkl}nxln | fk cdr xfbvxrdr bdk cdr ~vf

    bvfk}n /zdx fgf`zcd cn bnxfkbln mf zfxrdknc mf fkfx`fxn# mlf-

    }lr}n# zdmcded# xf}lkexnd+++,+ \ nmf`r vkn kfbfrlmnm ~vf fr}

    bdkmlbldknmn zdx cn exnk bnk}lmnm mf nrzfb}dr mf cn fkfx`fmnm

    n cdr ~vf rf }lfkfk ~vf onbfx xfk}f# }nc fr fc bnrd mf nrzfb}dr

    mlnekr}lbdr# zxfqfk}lqdr /zxl`nxln# rfbvkmnxln# }fxblnxln, bd`dmf }xn}n`lfk}d d mf zxd`dblk mf cn rncvm+ Nc `nxefk mf fr}d# fc

    bdkbfz}d mf kfbfrlmnm fr} k}l`n`fk}f clenmd nc mf cn mf-

    `nkmn ~vf rf efkfxn fk cn n}fkblk nc mlnh}lbd# | nc mf cn

    dfx}n ~vf fc rlr}f`n cf onbf | n znx}lx mf n~v mfc zxdmvb}d

    ~vf rf bdkrlevf# | fr}d rfxn hrlbn`fk}f fc bdkbfz}d mf bnclmnm

    fk fc `nkfgd mfc mlnh}lbd+

    Fr mfblx# n exnkmfr xnredr cn bnclmnm mf cn efr}lk mfc zxdbfrdnrlr}fkblnc qn k}l`n`fk}f xfcnbldknmd bdk fc exnmd mf bdk}xdc

    ~vf rf onbf mfc zxdbfrd# bdk cn bnclmnm mf cn n}fkblk xfblhlmn#

    bdk cn bnclmnm mf qlmn | n cn zdr}xf bdk fc exnmd mf xfrzdkrnhlcl-

    wnblk f`zdkmfxn`lfk}d ~vf onbf fc mlnh}lbd mf rv zxdzln

    fkfx`fmnm /nv}dbdk}xdc,+

    N znx}lx mf n~v# cnr lk}fxqfkbldkfr ~vf lmfk}la~vfk cdr zxd-

    hcf`nr mf bnclmnm fk cn zxb}lbn nrlr}fkblnc dhrfxqnmn# zdx vk

    cnmd /lkmlbnmdxfr,9 onenk vkn fqncvnblk bdk}lkvn fk fc }lf`zd

    | zxdzdkenk fmlmnr bdxxfb}dxnr rfek bxl}fxldr mf bnclmnm blfk-

    }abd }bklbn# zdx d}xn# rfxk cd ~vf mfkd`lkn`dr zxdexn`nr mf

    `fgdxn fk cn n}fkblk mlnh}lbd+

    Kd fr mf f}xnnx zdx fccd ~vf fk cn mfbcnxnblk mf Rnlk} Qlk-

    bfk} >

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    ~vf lk}fxqlfkfk fk fc `nkfgd mf cn mlnhf}fr /zxdfrldkncfr mf cn

    rncvm# znblfk}fr# lkmvr}xln | edhlfxkdr, fk zxdexn`nr mf nbblk

    bdkgvk}n bdk cdr ~vf nb}vnx rdhxf fr}n fkfx`fmnm+ N znx}lx mffr}f `d`fk}d# fk kvfr}xd znr# | bdlkblmfk}f bdk cn Xfdx`n mf

    N}fkblk Zxl`nxln /XNZ,# rf bxfnxdk zxdexn`nr | zxd}dbdcdr

    znxn cn n}fkblk mf fr}dr fkfx`dr# }nc fr fc bnrd mfc Exvz mFr-

    }vml mf cn Mlnhf}fr n cN}fkbl Zxl`xln mf Rncv} EFMNZR

    ~vf mfrmf >

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    ]dmd fr}f zxdbfrd on qfklmd l`zvcrnmd zdx cnr kvfqnr }fbkd-

    cdenr | cdr zxdexn`n lkr}l}vbldkncfr mf n}fkblk n klqfc mf bd-

    `vklmnmfr nv}kd`nr | `lklr}fxld mf rnklmnm | bdkrv`d+ Cnlkdx`n}lwnblk mf cn olr}dxln bcklbn# zdx rv znx}f# bdk cn bfk}xn-

    clwnblk mf cdr mn}dr bcklbdr# cn nexvznblk mf cdr nb}dr bcklbdr

    zdx zxdhcf`nr d fzlrdmldr# | cn lmfk}labnblk mf bn`zdr frzfb-

    abdr znxn lkmlbnmdxfr fk fr}nr# onk rvzvfr}d vk znrd bvnk}l}n-

    }lqd | bvncl}n}lqd n cn odxn mf lmfk}labnx cn xfnclmnm nrlr}fkblnc mfc

    mlnh}lbd+ Cdr zxdexn`nr lkr}l}vbldkncfr fk dx`n mf zcnkfr fr-

    }xn}elbdr onk rlmd vk frzncmnxnwd n }dmnr fr}nr lklbln}lqnr znx}l-

    bvcnxfr fk zdr mf `fgdxnx cn n}fkblk mf fr}nr zfxrdknr+

    Mf }dmd fccd rf onhcn f}fkrn`fk}f fk fr}n zf~vfn `dkdexnn

    rdhxf bnclmnm | mlnhf}fr fccl}vr+ Frzfxn`dr ~vf rfn mf rv nexnmd+

    Hlhcldexnan

    >+ D}fxd N# Rn}vxkd Z# @nx~vf} X+ Enxnk}n | `fgdxn mf cn bnclmnm+ Fk7 N}fkblk

    Zxl`nxln+ Bdkbfz}dr# dxenklwnblk | zxb}lbn bcklbn+ 2+ fm+ Fm+ @drh|$Md|`nClhxdr+ Hnxbfcdkn >+

    6+ Exvzd mf Fr}vmld mf cn Mlnhf}fr fk cn N}fkblk Zxl`nxln mf Rncvm+ Evn znxn

    fc }xn}n`lfk}d mf cn mlnhf}fr 8 fk cn N}fkblk Zxl`nxln+ Fm+ Onxbdvx}+ Hnxbf-

    cdkn >

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    5+ Ofxkkmfw F# Xdvxn Z# Hfxfkevfx @+ Lkmlbnmdxfr znxn cn fqncvnblk mf cn

    bnclmnm mf cn n}fkblk nc mlnh}lbd }lzd 8+ Fmvbnblk Mlnhf}dcelbn zxdf-

    rldknc >9 8?/5,7 =?=-=:+ Efxqr G# Zxfw Afxkkmfw @+ Cn olr}dxln bcklbn fcfb}xklbn fk n}fkblk zxl-

    `nxln+ Avkmn`fk}d bcklbd# }fxlbd | zxb}lbd+ RF@FXEFK 8:::9 817 >5-28+

    >>+ @nlkdvr NE# Iddz`nk XG# Elcc G@# Hnifx X# Zfxrdk UR+ Xfcn}ldkrolz hf}-

    uffk bdk}lkvl}| d bnxf nkm mlnhf}fr bdk}xdc7 fqlmfkbf xd` }of ]olxm Kn-}ldknc Ofnc}o nkm Kv}xl}ldk Rvxqf|+ N` G Zvhclb Ofnc}o 8::=9 8+ Edvmrunnxm NK# Cn` I# R}dci XZ# Xv}}fk VF@+ vncl}| d xfbdxmlke d mn}n

    xd` zn}lfk}r ul}o }|zf 8 mlnhf}fr lr kd} n qnclm lkmlbn}dx d ~vncl}| d bnxf+

    N bxdrr-rfb}ldknc r}vm|+ An` Zxnb} 8::29 8:7 >52-59 8::29 >127 >>?:-1+

    >2+ Bdkrfgfxn mf Rncvm mfc Rlr}f`n Rnkl}nxld Zhclbd mf Nkmncvbn+ Zcnk Lk}f-

    exnc mf Mlnhf}fr mf Nkmncvbn 8::2-8::5+ Gvk}n mf Nkmncvbn+ Rfqlccn 8::2+

    >=+ @lklr}fxld mf Rnklmnm | Bdkrv`d+ Fr}xn}feln fk Mlnhf}fr mfc Rlr}f`n Kn-

    bldknc mf Rncvm+ @nmxlm 8::5+ VXC7o}}z7$$uuu+`rb+fr$dxenklwnbldk$rkr$zcnkBnclmnmRKR$zm$fbfcfkbln$bvlmnm

    drzncln}lqdr-mlnhf}fr$MLNHF]FR$fr}xn}felnTmlnhf}frTrlr}f`nTknbldkncTrncvm+zm+

    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    1

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    Gdxef Knqnxxd# Zfmxd @vdw# Xnnfc Bdcr

    Fc blbcd mf `fgdxn7 mf cn lmfk}labnblk mf cdr

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  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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    Fc }fr} rnkevkfd xfbd`fkmnmd znxn fc mlnekr}lbd mf cn mlnhf-}fr fk kldr | nmvc}dr$nr /kd efr}nk}fr, fr cn ecvbf`ln zcnr`}lbn/EZN, fk n|vknr /n|vknr 0 zfxldmd mf nc `fkdr ? odxnr rlk lk-efr}n bncxlbn zxfqln n cn mf}fx`lknblk,+

    Fc }fr} mf Rdhxfbnxen dxnc mf Ecvbdrn bdk 56 e /RDE 56 e, nvkrlfkmd `r rfkrlhcf | nced `r frzfbabd ~vf cn EZN znxn fcmlnekr}lbd mf mlnhf}fr# zxfrfk}n vkn `fkdx xfzxdmvblhlclmnm |

    ncevkdr lkbdkqfklfk}fr znxn ccfqnxcd n cn zxb}lbn mfhlmd n cnr xl-evxdrnr bdkmlbldkfr mf zxfznxnblk znxn cn zxvfhn fk cdr zn-blfk}fr# cd bvnc vklmd n cn nblclmnm mf nbbfrd mf cn EZN# rv n|dxnbfz}nhlclmnm | vk fkdx bdr}f bdkqlfx}fk cn EZN fk fc }fr} mf xf-fxfkbln znxn fc mlnekr}lbd mf cn mlnhf}fr+

    Fk cn ]nhcn 2 aevxnk cdr bxl}fxldr zxdzvfr}dr zdx cn NrdblnblkN`fxlbnkn mf Mlnhf}fr /NMN, fk rv lkdx`f mf 8::< znxn fc mlne-kr}lbd mf Mlnhf}fr>

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    bd`d znxn cn zxfrfk}nblk v}vxn mf vkn mlnhf}fr bcklbn+ Fr}nr fk-}lmnmfr | rvr bxl}fxldr mlnekr}lbdr rf xfbdefk fk cn ]nhcn =+

    Kfbfrlmnm mf vkn fqncvnblk `mlbn# bdk}xdc

    ecvb`lbd# dxlfk}nblk fmvbn}lqn fk mlf}n | fr}lcdr

    mf qlmn# nzd|d zrlbdrdblnc | vk }xn}n`lfk}d fabnw

    | zfxrdknclwnmd

    Fqncvnblk lklblnc

    Cdr dhgf}lqdr n bdkrfevlx bdk fc znblfk}f mlnh}lbd }xnr vkn fqn-cvnblk `mlbn lklblnc rfxnk cdr rlevlfk}fr8:7

    >+ Bcnrlabnx fc }lzd mf mlnhf}fr | cdr nb}dxfr mf xlfred bnxmld-qnrbvcnx nrdblnmdr+

    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    8=

    ]nhcn 2+ Bxl}fxldr mlnekr}lbdr mf mlnhf}fr

    Bxl}fxldr Klqfc ecvb`lbd

    >+ Rk}d`nr mf olzfxecvbf ln /zdclvxln#zdclmlzrln,n, Ecvbf`ln nc nwnx fk zcnr`n qfkdrd

    8+ Ecvbf`ln fk n|vknr fk zcnr`n qfkdrd2+ Ecvbf`ln n cnr 8 odxnr fk zcnr`n

    qfkdrd }xnr rdhxfbnxen dxnc mf ecvbdrn/RDE 56 e mf ecvbdrn,

    8:: `e$mc />>#> ``dc$c, >81 `e$mc /5 ``dc$c,'

    8:: `e$mc />>#> ``dc$c,'

    ' Vk qncdx nc}fxnmd rf on mf bdkax`nx fk mdr mnr mlr}lk}dr+

    ]nhcn =+ Bxl}fxldr mlnekr}lbdr mf zxfmlnhf}fr

    Fk}lmnm Klqfc Ecvb`lbd

    >+ Ecvbf`ln hnrnc nc}fxnmn /EHN,

    8+ Lk}dcfxnkbln n cn Ecvbdrn /L]E,EZ 8 odxnr fk zcnr`n qfkdrd/RDE 56 e mf ecvbdrn,

    >::->86 `e$mc/6#1 `dc$c-1#< `dc$c,

    >=:->> ``dc$c,

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    8+ Mf}fb}nx cn zxfrfkbln mf bd`zclbnbldkfr frzfbabnr mf cnmlnhf}fr+

    2+ Qncdxnx fc exnmd mf bdk}xdc ecvb lbd | fc xfrvc}nmd mf }xn-}n`lfk}dr zxfqldr+

    =+ Adx`vcnx | nbdxmnx vk zcnk efkfxnc mf }xn}n`lfk}d | nblcl-}nx cnr hnrfr znxn nrfevxnx vk rfevl`lfk}d zdr}fxldx+

    Fk ]nhcn 6 rf vfr}xnk cdr bd`zdkfk}fr xfbd`fkmnmdr zdx cn

    NMN 8::< ~vf mfhf bdk}fkfx cn fqncvnblk `mlbn lklblnc mf }dmdznblfk}f mlnh}lbd+

    Cn dzdx}vklmnm mf fgdxn fk cn nrlr}fkbln mlnhf}dcelbn

    86

    ]nhcn 6+ Bdk}fklmdr mf cn fqncvnblk `mlbn lklblnc nc znblfk}f

    mlnh}lbd

    >+ Olr}dxln zxfqln /nkn`kfrlr,7 Fmnm | bnxnb}fxr}lbn mf bd lfkwd+ Ohl}dr ncl`fk}nxldr# zn}xk mf bd`lmnr# rl}vnblk kv}xlbldknc+

    Fmvbnblk mlnh}lbn zxfqln+ Mlf}nr zxfqlnr xfnclwnmnr | xfrvc}nmdr+ Zn}xk mf nb}lqlmnm rlbn# x`nbdr v}lclwnmdr | xfrvc}nmdr fk cdr

    nv}d-bdk}xdcfr mfc znblfk}f+ Fzlrdmldr mf bf}dnblmdrlr f olzdecvbf`lnr zxfqlnr# lk}fkrlmnm |

    bnvrnr+ Olr}dxln mf bd`zclbnbldkfr mf cn mlnhf}fr7

    n, @lbxdqnrbvcnx7 xf}lkdzn}n# kfxdzn}n# kfvxdzn}n /rfkrdxlnc7cfrldkfr fk zlfr9 nv}dk`lbn7 mlrvkblk rfvnc# enr}xdznxfrln,+

    h, @nbxdqnrbvcnx7 bnxmldqnrbvcnx# bfxfhxdqnrbvcnx# nx}fxlnc zfxlxlbn+b, D}xdr7 zxdhcf`nr zrlbd-rdblncfr# mfk}ncfr+8+ Fn`fk rlbd7

    Zfrd# }nccn# L@B+ ]N rfk}nmd | fk dx}dr}n}lr`d+ Adkmd mf dgd+ Zncznblk mfc }lxdlmfr+ Zlfc /nbnk}drlr klexlbnkr | wdknr mf lk|fbblk mf lkrvclkn,+ Fonvr}lqn fzcdxnblk mf f}xf`lmnmfr lkfxldxfr7

    n, Lkrzfbblk+

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  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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    h, Bdk}xdc mf cn OhN>B

    Rf xfnclwnx bd`d `kl`d mdr qfbfr nc nd fk znblfk}fr ~vfzxfrfk}nk vk bdk}xdc ecvb`lbd fr}nhcf+ Bnmn }xfr `frfr fk cdrznblfk}fr n ~vlfkfr rf cfr on dmlabnmd fc }xn}n`lfk}d d kd bdk-rlevfk vk hvfk bdk}xdc ecvb`lbd+ Fr l`zdx}nk}f cn nbbfrlhlcl-mnm nc `mlbd znxn ngvr}nx fc }xn}n`lfk}d fk vk }lf`zd xnwdknhcf}xnr cn mf}fx`lknblk mf cn N>b+

    b, Dhgf}lqdr mf bdk}xdc ecvb`lbd

    Cn OhN>b bdkr}l}v|f fc zxl`fx dhgf}lqd mf bdk}xdc ecvb`lbd+Fk efkfxnc rf bdkrlmfxn hvfk bdk}xdc ecvb`lbd vk klqfc mf

    N>b 35 & nvk~vf fk rl}vnbldkfr lkmlqlmvncfr | mfk}xd mf cdzdrlhcf# cd lmfnc rfxn zxfrfk}nx qncdxfr fk fc xnked mf kdx-`nclmnm N>b 31 & /=-1 &, | ~vf kd dbnrldknxnk olzdecvbf-`lnr fk fc znblfk}f+

    Zdx fc bdk}xnxld ncbnkwnx cdr klqfcfr mf N>b rfxn `fkdr fr-}xlb}d fk znblfk}f bdk nk}fbfmfk}fr mf olzdecvbf`lnr lk}fk-rnr# cl`l}nblk fk cn fzfb}n}lqn mf qlmn# kldr# f`hnxnwnmnr#

    znblfk}fr bdk bd`dxhlclmnm nrdblnmn | n~vfccdr bdk cnxenfqdcvblk mf cn mlnhf}fr rlk bd`zclbnbldkfr qnrbvcnxfr+

    Xfrzfb}d n cdr klqfcfr mf ecvbf`ln bnzlcnx rf bdkrlmfxn vkhvfk bdk}xdc ecvb`lbd blxnr mf ecvbf`ln bnzlcnx zxfzxnk-mlnc mf 5:->2: `e$mc | ecvbf`ln bnzlcnx zdr}zxnkmlnc /8-2odxnr }xnr cn bd`lmn, 3>?: `e$mc+ Vk xfrv`fk mf cdr dhgf}l-

    qdr mf bdk}xdc ecvb`lbd rf zvfmf nzxfblnx fk cn ]nhcn 1+

    Cn dzdx}vklmnm mf fgdxn fk cn nrlr}fkbln mlnhf}dcelbn

    85

    ]nhcn 1+ Dhgf}lqdr mf bdk}xdc ecvb`lbd znxn nmvc}dr bdk mlnhf}fr

    N>bEcvbf`ln bnzlcnx zxfzxnkmlncEcvbf`ln bnzlcnx zdr}zxnkmlnc

    35#: & /xnked kdx`nc =-1 &,5:-2: `e$mc /2#?: `e$mc /3>: ``dc$c,

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    Dxlfk}nblk mlf}}lbn-kv}xlbldknc | mf fgfxblbld rlbd

    fk cn mlnhf}fr

    >+ Bd`d kdx`n efkfxnc }dmd znblfk}f mlnh}lbd mfhfxn xfbl-hlx mf `nkfxn lkmlqlmvnclwnmn lkr}xvbbldkfr mlf}}lbnr zdx znx}fmf vk zxdfrldknc bvnclabnmd fk kv}xlblk n`lclnxlwnmd bdk cnmlnhf}fr | hngd cn bdhfx}vxn mfc rlr}f`n rnkl}nxld+

    Fr zxfblrd nbdkrfgnx xfmvbblk mf zfrd fk znblfk}fr dhfrdr#nvk~vf rfn `dmfr}n |n ~vf fr nqdxnhcf znxn mlr`lkvlx fc bd`-

    zdkfk}f mf lkrvck xfrlr}fkbln+

    Cn xfmvbblk mf bnxhdolmxn}dr# cnr mlf}nr hngnr exnrnr d cnr mlf-}nr olzdbncxlbnr zvfmfk rfx ffb}lqnr n bdx}d zcnwd rlk f`hnxedcn nb}lqlmnm rlbn xfevcnx | zxdexn`nmn fr `r fabnw znxn `nk-}fkfx vkn xfmvbblk mfc zfrd+

    Cnr exnrnr rn}vxnmnr mfhfxk bdkr}l}vlx fkdr mfc 5 & mfc }d}ncmf bncdxnr fk cn mlf}n mlnxln `lkl`lwnkmd nc l`d cn lkefr}n mf

    exnrnr }xnkr fk cn ncl`fk}nblk+

    Rf mfhfx cl`l}nx cn lkefr}n mlnxln mf hfhlmnr ncbdoclbnr n vknvklmnm mf hfhlmn zdx mn fk fc bnrd mf cn `vgfx | n mdr vklmnmfrmf hfhlmn zdx mn fk fc bnrd mfc od`hxf+

    8+ Xfrzfb}d nc fgfxblbld rf xfbd`fkmnx xfnclwnx fgfxblbld rlbdnfxhlbd `dmfxnmd /6:-5: & mf xfbvfkbln bnxmlnbn `l`n fr-}l`nmn zdx cn fmnm, mvxnk}f nc `fkdr >6: `lk$rf`nkn | xfnclwnxfgfxblbldr mf xfrlr}fkbln `vrbvcnx }xfr qfbfr zdx rf`nkn rl kdflr}f bdk}xnlkmlbnblk+

    2+Nzd|d zrlbd-rdblnc+

    Cn zxdhcf`}lbn zrlbd-rdblnc mfc znblfk}f bdk mlnhf}fr mfhfrfx nhdxmnmn bd`d vkn znx}f `r mfc zxdbfrd nrlr}fkblnc fk cdxffxfk}f n nb}l}vmfr | fzfb}n}lqnr xfk}f n rv fkfx`fmnm# nfb-

    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    8?

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    }lqlmnm | fr}nmd mf kl`d# nrzfb}dr mf bnclmnm mf qlmn# xfbvxrdrfbdk`lbdr# rdblncfr | f`dbldkncfr f}b+ nblcl}nkmd fc nbbfrd mf

    cdr znblfk}fr n zxdfrldkncfr bvnclabnmdr+

    ]xn}n`lfk}d fabnw | zfxrdknclwnmd

    Xfblfk}f`fk}f rf on zvhclbnmd vk bdkrfkrd fk}xf cnr rdblfmn-mfr n`fxlbnkn | fvxdzfn mf mlnhf}fr NMN | FNRM xfrzfb}d nc}xn}n`lfk}d r nzxdzlnmd rfek cn fqlmfkbln mlrzdklhcf znxn fc

    znblfk}f bdk Mlnhf}fr }lzd 8 ~vf rf fzdkf fk cn Alevxn >+ Fk ef-kfxnc cd `r mfr}nbnhcf mf fr}f lkdx`f xfrzfb}d n ncedxl}`dr

    nk}fxldxfr fr cd rlevlfk}f7

    Rf mfhf lklblnx }xn}n`lfk}d nx`nbdcelbd mfrmf fc mlne-kr}lbd bdk `f}dx`lkn gvk}d n bn`hldr fk cdr fr}lcdr mf

    qlmn d`fk}nkmd cn mlf}n | fc fgfxblbld rlbd+ Rf lxk nn-mlfkmd dzdx}vkn`fk}f d}xdr nk}lmlnh}lbdr /rfek bxl}f-xldr mf ffb}lqlmnm fk xfmvbblk mf N>b# rlkfxeln fk `fbn-klr`d mf nbblk d bdr}f, d lkrvclkn# bd`d `fmlmn znxn

    ncbnkwnx | `nk}fkfx bvnk}d nk}fr cdr klqfcfr mf N>b zdxmfhngd mf 5 & fk cn `n|dxn mf znblfk}fr+ Fk xfcnblk n cdr zdrlhcfr ffb}dr nmqfxrdr mf cnr ecl}nwdknr xfrzfb}d ncxlfred mf nznxlblk mf fkfx`fmnmfr bnxmldqnrbvcnxfr /lk-nx}dr# lkrvlblfkbln bnxmlnbn, rf xfbd`lfkmn v}lclwnxcdrbdk zxfbnvblk+ D}xdr x`nbdr nk}lmlnh}lbdr bd`d n-ecv-bdrlmnmnr# eclklmnr# zxn`clk}lmf# ffkn}lmf f lkolhlmdxfr mfcn MZZ-LQ kd lkbcvlmdr fk ncedxl}`dr nk}fxldxfr zdx nced`fkdx flbnbln# mn}dr bcklbdr cl`l}nmdr d zxfbld fcfqnmd

    zvfmfk rfx fcfbbldkfr nmfbvnmnr fk znblfk}fr lkmlqlmvn-cfr znxn cdexnx vk hvfk bdk}xdc ecvb`lbd+ Fc lklbld bdk lk-rvclkn fk fc `d`fk}d mfc mlnekr}lbd rf xfbd`lfkmn znxnlkmlqlmvdr kd dhfrdr bdk rk}d`nr olzfxecvb`lbdr lk}fk-rdr+

    Cn dzdx}vklmnm mf fgdxn fk cn nrlr}fkbln mlnhf}dcelbn

    8

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    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    2:

    ]nhcn5+Bdk}xdcmfbd`zclbnbldkfr`nbxdqnrbvcnxfrfkmlnh}lbdr}lzd8

    Anb}dxmfxlfred

    D

    hgf}lqd

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    3

    >2:$?:``Oe

    >2:->26:`e$mc

    Mlf}nL

    fkexnrn+

    Fgfxblb

    ld+

    Xfmvbblkzfrd+

    ]xn}n`lfk}dbdkFR]N]LKN7

    n,BdkFBQ7nc}nrmdrlronr

    }ndhgf}lqd+

    h,;=:ndrbdk>d`rAXBQ+

    b,CMC;>::`e$mcbdk`

    c}lzcfrAXBQ+

    m,Zvfmfkbdkrlmfxnxrfbd`hlknbldkfrmfolzdclzf`ln

    k}fr+

    NK]LNEXFENBLK

    Rfeklkmlbnblk

    NNR/56->18`e$m,7

    n,RlFBQzxfqlnd;=:ndr|>AXBQ+

    h,NNR)BcdzlmdexfcrlzxdexfrlkmfFBQ+

    Bcdzlmdexfcrlbdk}xnlkm

    lbnblkNNR+

    ]NHN^VLR@D

    B

    frnblkbdkrv`d

    Bdkrfgdnznblfk}frbfrn

    blkmfcbdkrv`d+

    Dfx}nxd}xdr}xn}n`lfk}d

    r+

    FKAFX@FMNM

    BDXDKNXLN

    N

    vrfkbln

    LFBN)FR]N]LKN)N

    NR7

    n,BdkFBQzxfqln+

    h,RlL@

    zxfqld7nnmlx-hcd~vfnk}fr+

    b,;=:ndr)>AXBQ+

    m,Lkrvablfkblnbnxmnbnbd

    k}xnlkmlbnmn7

    @f}dx`lkn|Ecl}nwdknr

    +

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    Cn dzdx}vklmnm mf fgdxn fk cn nrlr}fkbln mlnhf}dcelbn

    2>

    ]nhcn?+Bdk}xdcmfbd`zclbnbldkfr`lbxdqnrbvcn

    xfrfkmlnh}lbdr}lzd8

    Fk}lmnm

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    ]xn

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    ::

    /mn,+

    Kfaxdzn}lnmlnh}lbn;

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    avkblkxfknc+

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    zxdexfrlkdz}l`lwnkmdbdk}xdc

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    @d`fk}dmfcmlnekr}lbd|

    nkvnc`fk}fx

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    n,]fr}mffbxfblkvxlknxlnmf

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    LF

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    n,M

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    h,M

    @}

    lzd87LFBN|NXNLL+

    b,M

    @}

    lzd8)kfxdzn}n7NXN

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    Xfmvbblkmflkefr}nzxd}fk

    nrn

    :#?->ex$Ie$mn+

    Bdk}xdcxfevcnxmfI|bxfn}lklkn+

    Xf`l}lxnkfxdcdenrl

    lk

    rvablfkblnxfkncnqnkwnmn

    XF]LKDZN]NMLNH]

    LBN

    Rl`zcf+

    Kdzxdclafxn}lqn/XMK

    Z,+

    Zxdclafxn}lqn/XMZ,+

    Fmf`n`nbvcnx+

    Xfmvblxxlfredmfnznxlblk|

    zxdexfrlkdz}l`lwnkmdbdk}xdc

    ecvb`lbd|]N+

    @d`fk}dmfcmlnekr}lbdn

    nkvnc`fk}fx

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    +

    h,@rxfbvfk

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    b,Bnmn8-2nd

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    Xf`l}lxnD}nc`cdedrlrf

    mf}fb}nzn}dcden+

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    mlbnmnAd}dbdnevcnblkfk

    7

    n,N

    c}dxlfredmfXMZ+

    h,R

    leklabn}lqdfmf`n`nbvcnx+

    b,B

    nrdrexnqfrmfXMKZ+

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    ncn

    zxfqfkblkmfFBQbdkNNR+

  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    28

    ]nhcn?+Bdk}xdcmfbd`zclbnbldkfr`lbxdqnrbvcn

    xfrfkmlnh}lbdr}lzd8/bdk}lkvnblk,

    Fk}lmnm

    Bxlhnmd

    ]xn

    }n`lfk}d

    KFVXDZN]NMLNH]L

    BN

    Zdclkfvxdzn}nmlr}nc

    rl`}xlbn/ZMR,+

    Kfvxdzn}nnv}dk`lb

    n/KN,+

    @d`fk}dmfcmlnekr}lbd|

    nkvnc`fk}fx

    fnclwnx7

    n,Fn`fkbd`

    zcf}dmfcdrzlfr|

    nzclbnx}fr}b

    cklbdr+

    rfkblccdrznx

    nmf}fb}nxZMR+

    h,Fr}vmldfcfb

    }xdarldcelbdxnxn

    qfwlkmlbnmd

    +

    b,Fmvbnblkn

    }dmdrcdrznblfk}fr

    fkfcnv}dbvlmnmdmfcdrzlfr+

    m,Zxfevk}nxzdxrk}d`nr|rlekdr

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    f,V}lclwnx`fmlbnblklkmlbnmnfk

    fc}xn}n`lfk}dmfcnZMR|KN

    znxn`fgdxnxcnbnclmnmmfqlmn

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    ]xn}n`lfk}drfkZMR7

    n,N

    `l}xlz}lclkn>:-56`enbdr}

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    dx}xlz}lclkn86-56`enbdr}nxrf

    L`lzxn`lkn86-56`enbdr}n

    xrf

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    nhnzfk}lkn2::->8::$?o+

    B

    nxhn`nwfzlkn8::-=::$?o+

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    vcdf}lkn1:->8:`e$8=o+

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    n,R

    lk}d`}lbdmfbnmnfk}lmnm

    +

  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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    Kfbfrlmnm mf mf}fb}nx zxfbdw`fk}f

    cn zxfrfkbln mf bd`zclbnbldkfr `nbxd

    | `lbxdqnrbvcnxfr dbnrldknmnr zdx cn mlnhf}fr`fmlnk}f vk rfevl`lfk}d ~vf zdrlhlcl}f

    vkn lk}fxqfkblk fabnw

    Bd`zclbnbldkfr @NBXDQNRBVCNXFR

    Cn fkfx`fmnm bnxmldqnrbvcnx /FBQ,7 bdkr}l}v|f cn `n|dx bnvrnmf `dxhl`dx}nclmnm fk fc znblfk}f mlnh}lbd# nmf`r fc bdk}xdcfr}xlb}d mf cdr nb}dxfr mf xlfred bnxmldqnrbvcnx /AXBQ, zdmxn

    xfmvblx onr}n vk 6: & cnr bd`zclbnbldkfr `nbxd-`lbxdqnrbvcn-xfr mf cn mlnhf}fr+ Fk cn ]nhcn 5 rf fzdkfk fr~vf`}lbn`fk}fcdr dhgf}lqdr n bdkrfevlx | cnr lkmlbnbldkfr mf }xn}n`lfk}d znxnlk}fxqfklx rdhxf cdr AXBQ /O]N# mlrclzf`ln# nk}lnexfenblk# }n-hn~vlr`d | fkfx`fmnm bdxdknxln fr}nhcfblmn, xfbd`fkmnmdr

    zdx cn NMN 8::+ @nx~vf} X# Nqfccnkn F# Mnqlkr G+ Cn bnclmnm fk n}fkblk zxl`nxln mf rncvm7

    kvfqnr zfxrzfb}lqnr+ A@B+ >?+8+ Rn}vxkd Ofxkkmfw ZG# Enrbk Bkdqnr GG# Znxxn Olmnced Z /fmr+,+ ]xn}nmd mf

    bnclmnm nrlr}fkblnc fk n}fkblk zxl`nxln+ @nmxlm7 Mv Zdk} Zonx`n RN+ >

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    6+ Ixlroknk R# Knro A# Hnifx K# Aducfx M# Xn|`nk E+ Xfmvb}ldk lk mlnhf}lbn`zv}n}ldkr dqfx >> |fnxr lk n mfakfm V+I+ zdzvcn}ldk7 hfkfa}r d `vc}l-

    mlrblzclknx| }fn` udxi nkm bdk}lkvdvr zxdrzfb}lqf nvml}+ Mlnhf}fr Bnxf+8::?9 2>/>,7 +

    1+ Vklqfxrl}| Odrzl}ncr Hxlr}dc KOR Advkmn}ldk ]xvr}+ Ylk}fxkf}P+ Hxlr}dc+ Zxlk-blzcfr dx hfr} zxnb}lbf lk bclklbnc nvml}+ Ybl}nmd >6 fkfxd 8::6 fkfxd 8::8=>-6+

    6 fkfxd8:::+ Exnk`d 6+8 ULK Yrd}unxfP /@nxxven} G# Qlcn G# Znqfrl @# Rnkw A+ Fr}l`n-blk mfc }n`nd mf cn `vfr}xn fk cn lkqfr}lenblk bcklbn | fzlmf`ldcelbn+@fm Bclk /Hnxbfcdkn,+ >

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    >1+ Anhfx @# Hdrbo @# Udccfxrofl` O# Cfn}ofx`nk R# Exdc X+ Zvhclb xfzdx}lkelk ofnc}o bnxf7 odu md bdkrv`fxr vrf ~vncl}|-d-bnxf lkdx`n}ldk4 N r|r}f-

    `n}lb xfqlfu+ @fm Bnxf+ 8::,7 >-?+>5+ KLQFC7 Kf}ofxcnkmr Lkr}l}v}f dx Ofnc}o Rfxqlbfr o}}z Xfrfnxbo Ylk}fxkf}P+

    V}xfbo}7 VD]F ~vfr}ldkknlxf dx zn}lfk}r ul}o mlnhf}fr /=6 l}f` qfxrldk,+YBl}nmd >6 fkfxd 8::?P+ Mlrzdklhcf fk7 $$uuu+klqfc+kc$+

    >?+ ]nhxlwl GR# DXdvxif ZI# Ulcrdk NG# Bd|kf F]+ Rfxqlbf ~vncl}| dx ]|zf 8 mln-hf}fr lk Nvr}xncln7 }of zn}lfk} zfxrzfb}lqf+ Mlnhf} @fm+ 8::?9 86/6,7 1>8-5+

    >+

    8:+ @lklr}fxld mf Rnklmnm | Bdkrv`d7 Fr}xn}feln fk Mlnhf}fr mfc Rlr}f`n Kn-bldknc mf Rncvm+ Ylk}fxkf}P+ @nmxlm Ybl}nmd >6 fkfxd 8::

  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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    @n}fv Rfev Mnw# Gdr Cvlr ]dxxfr Hnlcf#

    Gnqlfx Mfw Frzlkd

    CN mlnhf}fr `fccl}vr fr vk }xnr}dxkd `f}nhclbd mf nc}n zxfqn-cfkbln nrdblnmn n vk fcfqnmd xlfred bnxmldqnrbvcnx# `d}lqdzdx fc ~vf rf cn bdkrlmfxn bd`d vkd mf cdr zxlkblzncfr zxdhcf-

    `nr mf rncvm fk cdr znlrfr mfrnxxdccnmdr+ Cdr znblfk}fr mlnh}l-

    bdr# nmf`r mf cnr bd`zclbnbldkfr `lbxdqnrbvcnxfr# zxfrfk}nkvk lkbxf`fk}d mf xlfred fk cn `dxhl`dx}nclmnm bnxmldqnrbvcnx

    mf 8 n = qfbfr rvzfxldx n cn zdhcnblk efkfxnc# rlfkmd fr}f xlfred

    `n|dx fk cnr `vgfxfr+

    Fr}nr bd`zclbnbldkfr mlr`lkv|fk cn frzfxnkwn | cn bnclmnm mf

    qlmn mfc mlnh}lbd | fr}k xfcnbldknmnr bdk cn fmnm# bdk cdr ndr

    mf fqdcvblk mf cn mlnhf}fr# bdk fc exnmd mf bdk}xdc `f}nhclbd

    | bdk cn bnclmnm nrlr}fkblnc mf cn n}fkblk ~vf rf zxfr}n n fr}dr

    znblfk}fr+

    Exnk znx}f mf cnr bd`zclbnbldkfr nrdblnmnr n cn mlnhf}fr rf

    zvfmfk zxfqfklx | od| rnhf`dr ~vf cnr `fmlmnr fkbn`lknmnr nc

    bdk}xdc `f}nhclbd rdk }lcfr znxn xfmvblx fc mnd `lbxdqnrbvcnx

    | ~vf fc nhdxmngf `vc}lnb}dxlnc mf }dmdr cdr nb}dxfr mf xlfred

    bnxmldqnrbvcnx rdk ffb}lqdr znxn xfmvblx cnr bd`zclbnbldkfr n-

    bxdqnrbvcnxfr+

    25

    Dhgf}lqdr mf cn `fgdxnbdk}lkvnmnfk fc mlnh}lbd

    Fr}kmnxfr f lkmlbnmdxfr

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    Cn mlnhf}fr fr vkn fkfx`fmnm bxklbn ~vf zxfblrn nb}vnbldkfr

    mfrmf nk}fr mf ~vf rfn mf}fb}nmn# `fmlnk}f nb}lqlmnmfr zxfqfk-

    }lqnr | mf zxd`dblk mf cn rncvm# onr}n mfrzvr mf ~vf rvxgnk cnrbd`zclbnbldkfr znxn fql}nx ~vf nbnhfk fk cfrldkfr lxxfqfxrlhcfr

    bd`d cn bfevfxn d cnr n`zv}nbldkfr+ Znxn fccd# mfhf`dr bdkrf-

    evlx cn l`zclbnblk mf cdr znblfk}fr# onhlmn bvfk}n ~vf cdr xfrvc-

    }nmdr fr}k k}l`n`fk}f xfcnbldknmdr bdk fc exnmd mf lkdx`n-

    blk$fmvbnblk mfc mlnh}lbd+

    Bvnkmd onhcn`dr mf fkfx`fmnmfr bxklbnr# rnhf`dr ~vf fc

    l`znb}d mf cn nrlr}fkbln rnkl}nxln zvfmf }nxmnx ndr fk xfafgnxrffk }x`lkdr mf `dxhlclmnm | `dx}nclmnm | ~vf# cdr xfrvc}nmdr mf-

    zfkmfk fk blfx}n `fmlmn mf nb}dxfr f}fxkdr n cdr zxdfrldkncfr

    rnkl}nxldr# bd`d cnr bnxnb}fxr}lbnr mf cdr znblfk}fr d mf cn zxd-

    zln fkfx`fmnm+ Fr}nr rdk ncevknr mf cnr bnvrnr ~vf onbfk ~vf

    cn `fgdxn bdk}lkvn mf cn bnclmnm rf bfk}xf zxlkblznc`fk}f fk cn

    fqncvnblk mfc zxdbfrd nrlr}fkblnc | mf cdr xfrvc}nmdr lk}fx`f-

    mldr+

    Cn hnrf mf vk zxdexn`n mf `fgdxn mf cn bnclmnm nrlr}fkblnc rf

    hnrn fk cn `dkl}dxlwnblk mf nrzfb}dr l`zdx}nk}fr mf cn n}fkblk

    rnkl}nxln znxn mf}fb}nx zxdhcf`nr v dzdx}vklmnmfr mf `fgdxn+

    Znxn fccd# fr kfbfrnxld mfklx vkdr dhgf}lqdr# vkdr lkmlbnmdxfr |

    vkdr fr}kmnxfr bdk cdr ~vf fqncvnx | }xnr fccd nbdkrfgnx | `f-

    gdxnx cn n}fkblk nc mlnh}lbd>#8#2#=#6+

    Cdr dhgf}lqdr

    Cdr zxdexn`nr mf bnclmnm nrlr}fkblnc }lfkfk bd`d knclmnm `f-

    gdxnx cn nrlr}fkbln zxfr}nmn n cd cnxed mf }dmn cn fkfx`fmnm+ Fk

    fc zfxdmd zxfzn}deklbd# fc zn}deklbd | fc mf xfrvc}nmdr /bd`-

    zclbnbldkfr# `dx}nclmnm,+ Fk hnrf n fccd# rf mfkfk cnr mlfxfk-

    }fr nb}vnbldkfr zxfqfk}lqnr7 Zxfqfkblk zxl`nxln# rfbvkmnxln |

    }fxblnxln+

    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    2?

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    Zxfqfkblk zxl`nxln

    Fc dhgf}lqd mf cn zxfqfkblk zxl`nxln fk mlnhf}fr fr xf}xnrnx d

    zxfqfklx cn fkfx`fmnm fk fc lkmlqlmvd nrlk}d`}lbd+ Fk fr}f nznx-}nmd rvxef fc bdkbfz}d mf n znx}lx mf bvkmd vk znblfk}f fr bdk-

    rlmfxnmd mlnh}lbd+ Cn bnznblmnm zxfmlb}lqn mf blfx}dr zvk}dr mf

    bdx}f mf cn ecvbf`ln fk fc fr}nhcfbl`lfk}d mf mf}fx`lknmnr bd`-

    zclbnbldkfr olwd qnxlnx cdr bxl}fxldr mlnekr}lbdr zdx cn Nrdbln-

    blk N`fxlbnkn mf Mlnhf}fr /NMN, fk >

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    nznxlblk mf cn mlnhf}fr d mf rvr bd`zclbnbldkfr fk rv f}nzn nrlk-

    }d`}lbn# rf fkbvnmxnk mfk}xd mf cn zxfqfkblk rfbvkmnxln+ Nr#

    fr bdkdblmd ~vf fk fc `d`fk}d mfc mlnekr}lbd# vk 2:-6: & mfcdr mlnh}lbdr |n zxfrfk}nk bd`zclbnbldkfr+ Fr}d fr mfhlmd n ~vf

    flr}f vk zfxdmd fk}xf = | 5 ndr fk fc ~vf# nvk~vf flr}fk nc}f-

    xnbldkfr ecvb`lbnr kd rf on mlnekdr}lbnmd cn mlnhf}fr+ Cn mf-

    }fbblk zxfbdw mf cn mlnhf}fr znxfbf celbn fk }x`lkdr mf `lkl-

    `lwnx cnr bd`zclbnbldkfr# zfxd kd flr}fk fqlmfkblnr mlxfb}nr

    ~vf nqncfk fc bxlhnmd zdhcnbldknc+ Fk bn`hld cn `n|dxn mf cnr

    rdblfmnmfr blfk}bnr xfbd`lfkmnk cn mf}fbblk dzdx}vklr}n zdx

    fc `mlbd mf n`lcln fk exvzdr mf xlfred+ Cnr xfbd`fkmnbldkfrmf bxlhnmd rdk cnr rlevlfk}fr7

    >+ Zfxrdknr `n|dxfr mf =6 ndr# bnmn 2 ndr+

    8+ Nkvnc`fk}f# fk zfxrdknr bdk ncek nb}dx mf xlfred AX mf

    mlnhf}fr7

    Nk}fbfmfk}fr mf mlnhf}fr fk n`lclnxfr mf >+

    fx

    exnmd+ Dhfrlmnm+

    @nbxdrd`n |$d mlnhf}fr efr}nbldknc zxfqln+

    Bdcfr}fxdc OMC 26 |$d }xleclbxlmdr 86: `e$mc+

    Olzfx}fkrlk nx}fxlnc+

    Mlnekr}lbd zxfqld mf L]E d EHN+

    F}klnr mf nc}d xlfred+

    Vk lkmlbnmdx mf bnclmnm fk zxfqfkblk rfbvkmnxln fr cn zxfqn-

    cfkbln mf mlnhf}fr bdkdblmn# ~vf nmf`r vfr}xn fc exnmd mf l`-

    zclbnblk mfc f~vlzd fk cn bnz}nblk zxfbdw mfc znblfk}f mlnh-

    }lbd>:#>>#>8+

    Rv bd`zcf`fk}nxld fr ncbnkwnx klqfcfr kl`dr mf mlnhf}fr

    lekdxnmn# d n~vfccn ~vf mf}fb}nmn d bdkdblmn# vf dcqlmnmn zdx

    fc f~vlzd ~vf n}lfkmf nc znblfk}f# | ~vf zdkf n zxvfhn }nk}d n

    cn dxenklwnblk rnkl}nxln | rv zxfr}nblk mf bvlmnmdr bd`d fc

    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    =:

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    rlr}f`n mf xfelr}xd# fc `lbxdf~vlzd# cn bd`vklbnblk fk}xf cdr

    fkbnxenmdr mf rv n}fkblk d cn dxenklwnblk mfc bfk}xd+ Rfxn

    zdx }nk}d# vk `nxbnmdx mf bnclmnm fk cn n}fkblk mf nc}n rfkrl-hlclmnm+

    Cn zn}dcden zfxlkn}nc

    Fc dhgf}lqd rf hnrn fk fql}nx cnr bd`zclbnbldkfr zfxlkn}ncfr fk

    kldr mf nmxfr mlnh}lbnr+ Mfrmf >+

    Zxfqfkblk }fxblnxln

    ]lfkf bd`d knclmnm fql}nx |$d xf}xnrnx cnr bd`zclbnbldkfr ~vfrf zxdmvbfk fk cn fqdcvblk mf cn mlnhf}fr# | }lfkf ~vf qfx bdk

    }dmnr cnr nb}lqlmnmfr fkbn`lknmnr nc }xn}n`lfk}d /bdk}xdc, | xf-

    onhlcl}nblk mf r}nr+

    Cn mlnhf}fr fr vk nb}dx lkmfzfkmlfk}f mf fkfx`fmnm nx}f-

    xldrbcfxdrn+ Cn xfmvbblk mf cdr nb}dxfr mf xlfred bnxmldqnrbv-

    cnx ~vf rf nrdblnk n cn mlnhf}fr /}nhnbd# olzfx}fkrlk# mlrclzf-

    `ln+++,# mlr`lkv|fk fc xlfred mf znmfbfx cn fkfx`fmnm }nk}d

    `nbxdqnrbvcnx /fkfx`fmnm bdxdknxln# nbblmfk}f bfxfhxdqnrbv-

    cnx# nx}fxldzn}n zfxlxlbn, bd`d lbxdqnrbvcnx /xf}lkdzn}n# kf-

    xdzn}n | kfvxdzn}n, ~vf nfb}nk kd}nhcf`fk}f n cn bnclmnm mf

    qlmn | bd`zdx}nk vk fcfqnmd bdr}f>2#>=#>6#>1#>5 /]nhcn >,+

    Zxfqfkblk bvn}fxknxln>?#>

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    rnxln`fk}f+ Kd dhr}nk}f# bv`zclfkmd cdr zxfbfz}dr mf cnr }xfrnk}fxldxfr r}n kd mfhfxn flr}lx+ Mf `dmd ~vf kd fr mf f}xnnx

    ~vf kd rfn bdkrlmfxnmn bd`d }nc zdx `vbodr nv}dxfr+

    Nk nr# }fkfx fk bvfk}n fr}f bdkbfz}d fql}n `nk}fkfx cn l`-

    zxfrlk mf ~vf bvnk}d `r `fgdx fk fc znblfk}f mlnh}lbd |

    zxfqlfkf cn rdhxflk}fxqfkblk | bdk fccd fc fxxdx `mlbd zdx nb-

    blk+ Fc dhgf}lqd mf bdkrfevlx fc bdk}xdc mf cn mlnhf}fr zdx fc

    zxdzld lkmlqlmvd# fql}nkmd cn nb}vnblk rnkl}nxln# lxn fk fr}f

    rfk}lmd+

    Cdr lkmlbnmdxfr

    Vk lkmlbnmdx mf bnclmnm fr vkn fmlmn bvnk}l}n}lqn ~vf rf v}lclwn

    znxn `dkl}dxlwnx | fqncvnx cn bnclmnm mf nrzfb}dr mf cn zxb}lbn

    rnkl}nxln ~vf bxff`dr xfcfqnk}fr+

    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    =8

    ]nhcn >+ Dhgf}lqdr mf hvfk bdk}xdc fk fc znblfk}f mlnh}lbd

    /`dmlabnmd mfc NMN 8::?,>>+ Dhgf}lqdr lk}fx`fmldr

    Dhgf}lqd ncbnkwnmd Lkrvablfk}f

    OhN>b /&, 35 ;?

    Ecvbf`ln hnrnc$zxfzxnkmlnc

    /`e$mc,5:->2: ;>2:

    Ecvbf`ln zdr}zxnkmlnc /`e$mc, 3>?: ;>?:

    Bdcfr}fxdc-CMC /`e$mc, 3>:: ;>2:

    Bdcfr}fxdc-OMC /`e$mc, ;6: 3=:

    ]xleclbxlmdr /`e$mc, 3>6: ;8::

    ]N /`` Oe, 3>2:$:?: ;>=:$:

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    Cdr lkmlbnmdxfr kd rdk vkn `fmlmn mlxfb}n mf cn bnclmnm zfxd

    zfx`l}fk mf}fb}nx zxdhcf`nr znxn nknclwnxcdr# fr}l`vcnkmd cn bn-

    clmnm mf cn n}fkblk zxfr}nmn | fgdxnkmd n cn qfw cn fblfkbln mfcrlr}f`n+

    Cn nb}vnc l`zcnk}nblk mf rlr}f`nr mf lkdx`nblk fk cn zxb-

    }lbn }d}nclmnm mf cdr rfxqlbldr mf rncvm mf cnr mlfxfk}fr bd`vkl-

    mnmfr nv}kd`nr nblcl}n cn zdrlhlclmnm mf v}lclwnx lkmlbnmdxfr mf

    rncvm | dh}fkfx lkdx`nblk mf `nkfxn `r fblfk}f }nk}d mf cn

    nb}lqlmnm nrlr}fkblnc bd`d mf rncvm zhclbn8>#88+

    Cdr lkmlbnmdxfr zdx xfecn efkfxnc fk kvfr}xd `fmld fqncnk fc

    exnmd mf bdk}xdc mfc znblfk}f mlnh}lbd /zdx fgf`zcd# zdxbfk}ngf

    mf znblfk}fr mlnh}lbdr }lzd 8 bdk OhN>b35,8= `fmlnk}f lkmlbn-

    mdxfr mf zxdbfrd d mf xfrvc}nmdr# zfxd }n`hlk cd onbfk rdhxf fc

    }lzd mf zxfrbxlzblk ~vf rf onbf n fr}dr znblfk}fr /fgf`zcdr7 zdx-

    bfk}ngf mf `f}dx`lkn$nk}lmlnh}lbdr dxncfr,82+

    Cdr lkmlbnmdxfr zvfmfk rfx mf mdr }lzdr Lkmlbnmdxfr hnrnmdr fk zxdzdxbldkfr7 Vrnmdr onhl}vnc-

    `fk}f fk cdr zxdexn`nr mf fgdxn bdk}lkvn mf cn bnclmnm | ~vf

    `lmfk nrzfb}dr mf cn nrlr}fkbln ~vf rf frbdefk bd`d `r xf-

    cfqnk}fr | bv|n zxfrfkbln d nvrfkbln onbf`dr f~vlqncfk}f n

    zxfrfkbln d mffb}d mf bnclmnm | ~vf# zdx cd }nk}d# zvfmf nfb-

    }nx nc xfrvc}nmd mf cn n}fkblk nc znblfk}f+ @lmfk nrzfb}dr mf

    cn nrlr}fkbln rnkl}nxln ~vf rdcn`fk}f xf~vlfxfk vkn xfqlrlk

    zdr}fxldx znxn fqncvnxcdr+

    Fgf`zcd7 k`fxd mf mlnh}lbdr bdk OhN>b xfnclwnmn$}d}nc

    mlnh}lbdr fr}vmlnmdr+

    Lkmlbnmdxfr bfk}lkfcn7 @lmfk vk ofbod exnqf# zdbd xf-

    bvfk}f | n `fkvmd fql}nhcf+ Xf~vlfxfk rlf`zxf vk nkclrlr

    lk`fmln}d znxn bdkdbfx cnr bnvrnr ~vf cd on|nk zxdqdbnmd |

    `fgdxnxcnr+ Fk fc bnrd mf cn mlnhf}fr vk lkmlbnmdx bfk}lkfcn

    Dhgf}lqdr mf cn `fgdxn bdk}lkvnmn fk fc mlnh}lbd

    =2

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    kfcn zdmxn rfx vk lkmlbnmdx aknc# }nc bd`d vkn n`zv}nblk

    d vk bd`n mlnh}lbd ~vf zdx rv exnqfmnm mfhfk nknclwnxrf

    cnr bnvrnr ~vf onk zxdmvblmd fr}n rl}vnblk lk`fmln}n-`fk}f+

    Bnxnb}fxr}lbnr mf cdr lkmlbnmdxfr

    Cdr lkmlbnmdxfr mfhfk bv`zclx vkn rfxlf mf xf~vlrl}dr znxn ~vf

    rfnk }lcfr+ Mfhfk mf rfx7

    Bdkbxf}dr+ ]lfkfk ~vf fr}nx hlfk mfaklmdr | mfrbxl}dr mf vkn

    dx`n bcnxn+

    Dhgf}lqdr+ Znxn nblcl}nx cn xfbdelmn mf mn}dr+

    Zdbdr | xfnclr}nr bdk cnr bdkmlbldkfr mf cn dxenklwnblk+

    Hnrnmdr fk cnr fqlmfkblnr blfk}abnr nb}vnclwnmnr | nzd|n-

    mdr fk zxd}dbdcdr d evnr mf zxb}lbn bcklbn+

    Xfcfqnk}fr znxn cdr nrzfb}dr mf cn n}fkblk bcklbn ~vf rf

    zxf}fkmf fqncvnx+

    Rfkrlhcfr+ Mfhfk xffgnx cdr bn`hldr dxlelknmdr zdx vkn lk-

    }fxqfkblk mf}fx`lknmn+

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    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

    ==

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    kl}nxlnr fk Frznn /EFMNZR,8= /]nhcn 2, n rlr}f`nr rnkl}nxldr

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    bvncl}n}lqn mf cdr xfbvxrdr mlrzdklhcfr znxn ncbnkwnx cdr dhgf-

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    ~vf vk rfxqlbld fr mf bnclmnm+ N fkvmd rf mlbf ~vf cn bnclmnm

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    rvfcfk rfx dxenklwn}lqdr+ Mf}xr mf vkn hvfkn dxenklwnblk

    on| vk nv`fk}d mf cn ffb}lqlmnm# mf cn rn}lrnbblk mfc zxdf-

    Dhgf}lqdr mf cn `fgdxn bdk}lkvnmn fk fc mlnh}lbd

    =6

    ]nhcn 8+ Zxlkblzncfr Evnr mf Zxb}lbn Bcklbn

    Evn mf Zxb}lbn Bcklbn fkMlnhf}fr ]lzd LL mfc Rlr}f`n

    Knbldknc mf Rncvm /RKR,

    8::? o}}z7$$uuu+evlnrncvm+fr$kfuBn}ncded+nrz

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    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

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  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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    Dhgf}lqdr mf cn `fgdxn bdk}lkvnmn fk fc mlnh}lbd

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  • 8/3/2019 Tomo 6 - La Mejora Asistencial Del Diabtico

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    Xnanfc Xd}nfbof mfc Bn`zd# Zn}l Fwivxxn Cdldcn

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    12

    Mf cn qnxlnhlclmnmnrlr}fkblnc n cnr evnrmf zxb}lbn bcklbn

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    1=

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    Mfk}xd mf cn Fr}xn}feln fk mlnhf}fr mfc Rlr}f`n Knbldknc mfRncvm /RKR, aevxn bd`d vkd mf rvr dhgf}lqdr Fcnhdxnx# nmnz}nx

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    Xledx fk cn fcnhdxnblk7 zxdbfrd v}lclwnmd znxn xfvklx | rlk-}f}lwnx cn fqlmfkbln9 `}dmdr znxn dx`vcnx cnr xfbd`fkmn-

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    11

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    ]dmn cn lkdx`nblk blfk}abn rfn cdbnclwnmn | fqncvnmn nmf-bvnmn`fk}f+

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    Bcklbdr7zxdfrldkncfr nrlr}fkblncfr bdk fzfxlfkbln fk fc}f`n dhgf}d mf cn EZB | bdk bnznblmnm znxn }xnhngnx fkf~vlzd+

    Fzfx}dr fk `f}dmdcden /F@,7 rdk frzfblnc`fk}f kfbfrn-xldr rvr bdkdbl`lfk}dr rdhxf cfb}vxn bx}lbn | rk}frlr mf cn lk-dx`nblk+ Fzfxlfkbln fk cn fcnhdxnblk mf vkn EZB+

    Mdbv`fk}nclr}n7 bdcnhdxn fr}xfbon`fk}f bdk fc EFE fk fcmlrfd mf cnr fr}xn}felnr mf hr~vfmn | fk cn zxdqlrlk mf cnhlhcldexnn kfbfrnxln+

    Cn `fgdxn nrlr}fkblnc mfc mlnh}lbd

    Cn bnclmnm nrlr}fkblnc | cdr zxdexn`nr mf `fgdxn fk mlnhf}fr

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    Znblfk}fr$bvlmnmdxfr7 rv zxfrfkbln bdk}xlhv|f n ~vf rf }fkenfk bvfk}n cn qlrlk mf cdr | cnr znblfk}fr f l`zdx}nk}f znxn cn

    fcnhdxnblk mfc `n}fxlnc frbxl}d znxn cdr znblfk}fr+

    Bdcnhdxnmdx fzfx}d7zxdfrldknc bcklbd bdk zxfr}leld fk fc`hl}d mf cn evn+ Rv vkblk fr mfcl`l}nx cnr zxfevk}nr bc-klbnr lklblncfr | xfqlrnx cnr xfbd`fkmnbldkfr+

    Fk cn fcfbblk mf cdr `lf`hxdr mfc Exvzd fcnhdxnmdx mf cnEvn /EFE, fr kfbfrnxld }fkfx fk bvfk}n fk}xf d}xdr fc k`fxd

    mf zxdfrldkncfr kfbfrnxld /xfbd`fkmnhcf fk}xf rflr | mdbf,+ Cnbd`zdrlblk bvncl}n}lqn mfhf xfvklx cnr mlfxfk}fr qlrldkfr mfc}f`n# zdx fgf`zcd fk vkn EZB rdhxf mlnhf}fr mfhfxn mf lkbcvlxbd`d `kl`d `mlbdr mf n`lcln# fkmdbxlkcdedr# fmvbnmdxfrfk mlnhf}fr# fkfx`fxnr# mfhfxnk }fkfx fzfxlfkbln fk fc }f`n |rfx xfzxfrfk}n}lqdr mf cdr zxlkblzncfr exvzdr mf lk}fxr+ Fc EFEmfhf bdk}nx bdk fzfx}dr fk onhlclmnmfr mf hr~vfmn# cfb}vxnbx}lbn | rk}frlr mf cn fqlmfkbln blfk}abn# cd lmfnc rfxn ~vf cdr

    bcklbdr }vqlfxnk fzfxlfkbln fk fr}dr }f`nr | bnznblmnm mf }xn-hngnx fk f~vlzd# nr bd`d mlrzdklhlclmnm mf }lf`zd znxn fcnhd-xnblk mf cn evn | bdkdbl`lfk}d mfc `fmld mdkmf cn `lr`n qn nrfx l`zcf`fk}nmn+ ]dmd mfzfkmfx mfc `hl}d mdkmf rf mfr-nxxdccn cn EZB | mf rv zdr}fxldx mlvrlk+

    Fc vkbldkn`lfk}d mfc f~vlzd mfhf hvrbnx fc exnmd r nc}d mfxledx | fablfkbln+ Cn bdkr}l}vblk mfc f~vlzd | zcnklabnblk mfc}xnhngd rvfcfk rfx dhgf}d mf cn zxl`fxn xfvklk mfc exvzd+

    Kd flr}fk x`vcnr `elbnr xfrzfb}d nc k`fxd mf xfvkld-kfr efkfxncfr+ Cn fzfxlfkbln kdr mlbf ~vf cnr xfvkldkfr efkf-xncfr kvkbn mfhfk rfx mf`nrlnmnr /nbdkrfgnhcf ncxfmfmdx mf}xfr,+

    Vkn qfw cnr zxfevk}nr bcklbnr fr}k mfaklmnr rf rvfcf }xnhngnxfk exvzdr r xfmvblmdr /8-2 zfxrdknr, onr}n cn xfmnbblk mf vk

    Mf cn qnxlnhlclmnm nrlr}fkblnc n cnr evnr

    mf zxb}lbn bcklbn fk mlnhf}fr

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    hdxxnmdx bdk cnr xfbd`fkmnbldkfr ~vf xfrzdkmfk n cnr zxfevk-}nr dx`vcnmnr+

    Cdr bcklbdr ~vf znx}lblznk fk cn fcnhdxnblk mf vkn evn rvf-cfk kfbfrl}nx dx`nblk rdhxf fc mfrnxxdccd mf cnr EZB hnrnmnrfk cn fqlmfkbln | rdhxf cnr ofxxn`lfk}nr ~vf rf kfbfrl}nk znxn rvfcnhdxnblk+ Cn dx`nblk hrlbn mfhlfxn }xn}nx nc `fkdr fr}drnrzfb}dr7 mlrfd | fcnhdxnblk mf cn EZB# dx`vcnblk mf cnr zxf-evk}nr bcklbnr# hr~vfmn | rfcfbblk mf cn cl}fxn}vxn# fqncvnblk| rk}frlr mf cn fqlmfkbln blfk}abn# dx`vcnblk mf cnr xfbd`fk-

    mnbldkfr# mlvrlk f l`zcf`fk}nblk+ Cd `r nzxdzlnmd fr xfncl-wnx cn dx`nblk zdx `mvcdr rvbfrlqdr mf dx`n ~vf cdr `lf`-hxdr mfc exvzd nbbfmnk n fccdr rfek rvr kfbfrlmnmfr+

    Cn }xnkrznxfkbln fk cn mfbcnxnblk mf fr}nr evnr flef ~vf}dmdr cdr `lf`hxdr mfc EFE# bdcnhdxnmdxfr# fzfx}dr | xfqlrd-xfr# xfnclbfk vkn bvlmnmdrn mfbcnxnblk mf lk}fxfrfr+ Rf bdkrl-mfxnk cdr rlevlfk}fr }lzdr mf lk}fxfrfr7 cdr zfxrdkncfr# ~vf l`-

    zclbnk odkdxnxldr d hfkfabldr zfxrdkncfr mf vk `lf`hxd mfcf~vlzd | cdr kd zfxrdkncfr# l`zclbnk vkn aknkblnblk ~vf hfkf-abln nc mfznx}n`fk}d d vklmnm hngd xfrzdkrnhlclmnm mlxfb}lqn mfvk lf`hxd mfc f~vlzd# rlk ~vf r}f cd xfblhn zfxrdknc`fk}f+ Fkkvfr}xd `fmld# rf xfbd`lfkmn mfbcnxnx cdr lk}fxfrfr mf cdr c}l-`dr }xfr ndr | onhl}vnc`fk}f cd ~vf rf mfbcnxn fr fc }lzd mf nb-}lqlmnm | fc kd`hxf mf cn bd`znn# kd cn bvnk}n+ Cnr fqncvn-bldkfr mf fr}f nznx}nmd fk cnr EZB knbldkncfr `nklafr}nk ~vf}dmnqn fr vkn zxb}lbn bdk vk n`zcld `nxefk mf `fgdxn>2+

    Cnr mfbcnxnbldkfr mfhfk xfnclwnxrf nk}fr mf cn bdkr}l}vblk mf-akl}lqn mfc EFE+

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    58

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    fxfk}fr mfblrldkfr ~vf rf zcnk}fnk nc lk}fk}nx }xn}nx fc zxdhcf`ndhgf}d mf cn evn+

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