A tshuaj psychotropic, lub hom phiaj ntawm kev kho mob puas siab puas ntsws, hu ua antipsychotic (tseem yog tshuaj tiv thaiv kev puas siab puas ntsws lossis tshuaj tiv thaiv kev puas siab ntsws). Nws yog dab tsi thiab nws ua haujlwm li cas? Cia peb kawm.
Neuroleptic. Nws yog dab tsi? Keeb kwm thiab yam ntxwv
Neuroleptics hauv tshuaj tau tshwm sim tsis ntev los no. Ua ntej lawv qhov kev tshawb pom, cov tshuaj feem ntau siv los kho kev puas siab puas ntsws yog tshuaj ntsuab (xws li, henbane, belladonna, opiates), cov tshuaj calcium hauv cov hlab ntsha, bromides, thiab narcotic pw tsaug zog.
Nyob rau thaum ntxov 50s ntawm lub xyoo pua 20th, antihistamines los yog lithium ntsev tau pib siv rau lub hom phiaj no.
Ib qho ntawm thawj zaug neuroleptics yog chlorpromazine (lossis chlorpromazine), uas txog thaum ntawd tau suav tias yog ib qho tshuaj tiv thaiv kab mob. Nws tau siv dav txij li xyoo 1953, feem ntau yog tshuaj sedative lossis ua tshuaj tiv thaiv kab mob (rau tus mob schizophrenia).
Cov alkaloid reserpine tau dhau los ua cov tshuaj tiv thaiv kev puas siab puas ntsws, tab sis tsis ntev tau muab txoj hauv kev rau lwm cov tshuaj, zoo dua, vim nws tsis muaj txiaj ntsig.
Early 1958Lwm cov tshuaj tiv thaiv kev puas siab puas ntsws tshwm sim: trifluoperazine (triftazine), haloperidol, thioproperazine thiab lwm yam.
Lo lus "neuroleptic" tau npaj rau xyoo 1967 (thaum kev faib tawm ntawm cov tshuaj psychotropic ntawm thawj tiam tau tsim) thiab nws tau xa mus rau cov tshuaj tsis yog tsuas yog muaj cov nyhuv antipsychotic, tab sis kuj muaj peev xwm ua rau muaj kev puas siab puas ntsws (akatasia, neuroleptic parkinsonism, ntau yam tshuaj tiv thaiv dystonic thiab lwm yam). Feem ntau, cov teeb meem no tshwm sim los ntawm cov tshuaj xws li chlorpromazine, haloperidol thiab triftazin. Ntxiv mus, lawv txoj kev kho mob yuav luag ib txwm nrog los ntawm cov kev mob tshwm sim tsis zoo: kev nyuaj siab, kev ntxhov siab, ntshai heev, kev xav tsis zoo.
Yav dhau los, cov tshuaj tiv thaiv kab mob kuj tseem tuaj yeem hu ua "cov tshuaj tiv thaiv zoo", yog li cov tshuaj tiv thaiv kev puas siab puas ntsws thiab tranquilizers yog ib qho thiab tib yam. Vim li cas? Vim hais tias lawv kuj ua rau cov lus hais sedative, hypnotic thiab tranquilizing-tiv thaiv kev ntxhov siab vim, nrog rau lub xeev tshwj xeeb ntawm indifference (ataraxia). Tam sim no lub npe no tsis siv rau tshuaj tiv thaiv kab mob.
Txhua cov tshuaj tiv thaiv kev puas siab puas ntsws tuaj yeem muab faib ua qhov raug thiab atypical. Peb tau piav qhia ib feem ntawm cov tshuaj tiv thaiv kev puas siab puas ntsws, tam sim no peb yuav xav txog cov tshuaj atypical antipsychotic. Nws yog dab tsi? Qhov no yog ib pawg ntawm cov tshuaj softer. Lawv tsis ua kom muaj zog ntawm lub cev raws li cov qauv. Lawv nyob rau tiam tshiab ntawm neuroleptics. Qhov kom zoo dua ntawm atypical antipsychotics yog tias lawv muaj tsawg dua ntawm dopamine receptors.
Neuroleptics: indications
Txhua cov tshuaj tiv thaiv kev puas siab puas ntsws muaj ib qho khoom tseem ceeb - muaj txiaj ntsig zoo rau cov tsos mob tshwm sim (hallucinations, delusions, pseudohallucinations, illusions, cwj pwm tsis zoo, mania, aggressiveness thiab arousal). Tsis tas li ntawd, cov tshuaj tiv thaiv kev puas siab puas ntsws (feem ntau atypical) yuav raug tshuaj los kho cov tsos mob ntawm kev nyuaj siab lossis tsis txaus (autism, kev xav flattening, desocialization, thiab lwm yam). Txawm li cas los xij, lawv cov txiaj ntsig cuam tshuam nrog kev kho cov tsos mob tsis txaus yog ib lo lus nug loj. Cov kws tshaj lij qhia tias cov tshuaj tiv thaiv kab mob tsuas tuaj yeem tshem tawm cov tsos mob thib ob.
Atypical neuroleptics, uas muaj lub zog tsis muaj zog ntawm kev ua haujlwm dua li ib txwm muaj, kuj tau siv los kho kev puas siab puas ntsws bipolar.
Lub koom haum American Psychiatric txwv tsis pub siv cov neuroleptics los kho cov tsos mob ntawm kev puas siab puas ntsws thiab kev coj tus cwj pwm ntawm dementia. Tsis tas li ntawd, lawv yuav tsum tsis txhob siv rau insomnia.
Nws tsis tuaj yeem raug kho nrog ob lossis ntau dua tshuaj tiv thaiv tib lub sijhawm. Thiab nco ntsoov tias cov tshuaj tiv thaiv kab mob yog siv los kho cov kab mob loj, nws tsis pom zoo kom coj lawv li ntawd.
Cov teebmeem tseem ceeb thiab cov txheej txheem ntawm kev ua haujlwm
Niaj hnub nimno neuroleptics muaj ib qho kev ua haujlwm ntawm cov tshuaj tiv thaiv kev puas siab puas ntsws, vim tias lawv muaj peev xwm txo qis kev sib kis ntawm cov paj hlwb tsuas yog hauv cov hlab hlwb uas dopamine xa cov impulses. Cia peb saib ze dua ntawm cov kab ke no thiab cov txiaj ntsig ntawm cov tshuaj tiv thaiv kab mob rau lawv.
- Mesolimbic txoj kev. Ib qho kev txo qis hauv kev xa cov paj hlwb impulses hauv txoj kev no tshwm sim thaum noj ib yamtshuaj antipsychotic, raws li nws txhais tau tias tshem tawm cov tsos mob tshwm sim (piv txwv li, hallucinations, delusions, thiab lwm yam)
- Mesocortical txoj kev. Ntawm no, kev txo qis hauv kev sib kis ntawm impulses ua rau muaj qhov tshwm sim ntawm cov tsos mob ntawm tus mob schizophrenia (muaj xws li kev tsis zoo xws li kev tsis txaus siab, kev xav tsis zoo, kev txom nyem ntawm kev hais lus, smoothing ntawm kev cuam tshuam, anhedonia) thiab kev paub tsis meej (kev saib tsis taus, kev ua haujlwm tsis zoo, thiab lwm yam)..). Kev siv cov neuroleptics ib txwm, tshwj xeeb tshaj yog siv mus ntev, ua rau muaj kev cuam tshuam tsis zoo, nrog rau kev ua haujlwm tsis zoo ntawm lub hlwb. Kev tshem tawm cov tshuaj tiv thaiv kab mob hauv qhov no yuav tsis pab.
- Nigrostriatal path. Blockade ntawm dopamine receptors nyob rau hauv cov ntaub ntawv no feem ntau ua rau muaj kev phiv los ntawm antipsychotics (akathisia, parkinsonism, dystonia, salivation, dyskinesia, trismus ntawm lub puab tsaig, thiab lwm yam). Cov kev mob tshwm sim no tau pom hauv 60% ntawm cov neeg mob.
- Tuberoinfundibular txoj hauv kev (kev sib kis ntawm impulses ntawm limbic system thiab pituitary caj pas). Thaiv cov receptors ua rau muaj kev nce hauv cov tshuaj hormone prolactin. Tawm tsam qhov keeb kwm yav dhau los no, muaj ntau yam tshwm sim tshwm sim, xws li gynecomastia, galactorrhea, kev sib deev tsis ua haujlwm, infertility pathology thiab txawm mob qog pituitary.
Nyob zoo neuroleptics muaj kev cuam tshuam ntau dua ntawm dopamine receptors; atypical sawv daws cuam tshuam serotonin nrog rau lwm cov neurotransmitters (cov tshuaj uas xa cov hlab ntsha impulses). Vim li no, atypical antipsychotics tsawg dua yuav ua rau hyperprolactinemia,Cov kab mob extrapyramidal, kev nyuaj siab neuroleptic, nrog rau cov kev tsis txaus siab ntawm cov paj hlwb thiab cov tsos mob tsis zoo.
Cov cim qhia ntawm kev thaiv ntawm α 1 -adrenergic receptors yog qhov txo qis hauv cov ntshav siab, orthostatic hypotension, kev loj hlob ntawm kiv taub hau, pom kev qaug zog.
Nrog blockade ntawm H1-histamine receptors, hypotension tshwm sim, qhov xav tau ntawm carbohydrates nce thiab hnyav nce, nrog rau kev tso siab.
Yog tias blockade ntawm acetylcholine receptors tshwm sim, cov kev mob tshwm sim hauv qab no tshwm sim: cem quav, qhov ncauj qhuav, tachycardia, tso zis tso quav, nce intraocular siab thiab cuam tshuam ntawm kev pab. Tsis meej pem thiab tsaug zog kuj tuaj yeem tshwm sim.
Cov kws tshawb fawb sab hnub poob tau ua pov thawj tias muaj kev sib txuas ntawm cov tshuaj tiv thaiv kab mob (cov tshuaj tiv thaiv kab mob tshiab lossis cov laus, raug lossis atypical, tsis muaj teeb meem) thiab mob plawv tuag sai.
Tsis tas li, kev kho mob nrog cov tshuaj tiv thaiv kab mob ua rau muaj kev pheej hmoo mob stroke thiab myocardial infarction. Qhov no yog vim lub fact tias cov tshuaj psychotic cuam tshuam rau lipid metabolism. Kev noj tshuaj tiv thaiv kab mob kuj tuaj yeem ua rau mob ntshav qab zib hom 2. Qhov muaj feem yuav tau txais cov teeb meem loj ntxiv nrog kev kho mob ua ke nrog cov tshuaj tiv thaiv kab mob thiab atypical.
Cov tshuaj tiv thaiv kab mob tuaj yeem ua rau qaug dab peg los ntawm kev txo qis qhov qaug dab peg.
Feem ntau cov tshuaj tiv thaiv kab mob (feem ntau yog phenothiazine antipsychotics) muaj cov nyhuv hepatotoxic loj, thiab tuaj yeem ua rau muaj kev loj hlob ntawm cholestatic.jaundice.
Kev kho mob ntshav qab zib hauv cov neeg laus tuaj yeem ua rau muaj kev pheej hmoo mob ntsws los ntawm 60%.
Kev txawj ntse ntawm cov tshuaj tiv thaiv kab mob
Kev tshawb fawb qhib-daim ntawv qhia tau pom tias atypical antipsychotics yog qhov ua tau zoo dua li cov tshuaj tiv thaiv kev puas siab puas ntsws hauv kev kho mob neurocognitive impairment. Txawm li cas los xij, tsis muaj pov thawj ntseeg tias muaj kev cuam tshuam rau kev puas hlwb neurocognitive. Atypical antipsychotics, uas muaj qhov sib txawv me ntsis ntawm kev ua ntau dua li cov neeg raug, raug sim ntau zaus.
Hauv ib qho ntawm cov kev tshawb fawb soj ntsuam, cov kws kho mob piv cov teebmeem ntawm risperidone thiab haloperidol ntawm cov koob tshuaj tsawg. Thaum kawm, tsis muaj qhov sib txawv tseem ceeb hauv kev nyeem ntawv. Haloperidol ntawm koob tshuaj tsawg kuj tau pom tias muaj cov txiaj ntsig zoo ntawm kev ua haujlwm neurocognitive.
Yog li, lo lus nug ntawm qhov cuam tshuam ntawm thawj lossis thib ob tiam tshuaj tiv thaiv kev puas siab puas ntsws ntawm kev txawj ntse tseem muaj teeb meem.
Kev faib tawm ntawm cov tshuaj tiv thaiv kab mob
Nws twb tau hais los saum toj no tias cov tshuaj tiv thaiv kab mob tau muab faib ua qhov raug thiab atypical.
Ntawm cov kab mob neuroleptics yog:
- Sedative antipsychotics (uas muaj cov nyhuv inhibitory tom qab siv): promazine, levomepromazine, chlorpromazine, alimemazine, chlorprothixene, periciazine thiab lwm yam.
- Incisive antipsychotics (muaj cov tshuaj tiv thaiv kev puas siab puas ntsws thoob ntiaj teb): fluphenazine, trifluoperazine, thioproperazine, pipothiazine, zuclopenthixol, thiab haloperidol.
- Disinhibiting (muaj qhib,disinhibitory kev txiav txim): carbidine, sulfiride thiab lwm yam.
Atypical antipsychotics suav nrog cov tshuaj xws li aripiprazole, sertindole, ziprasidone, amisulpride, quetiapine, risperidone, olanzapine thiab clozapine.
Muaj lwm qhov kev faib tawm ntawm cov tshuaj tiv thaiv kab mob, raws li lawv qhov txawv:
-
Phenotiazines, nrog rau lwm yam tricyclic derivatives. Ntawm lawv yog: ● antipsychotics nrog ib tug piperidine core (thioridazine, pipotiazine, periciazine), uas muaj ib tug nruab nrab antipsychotic nyhuv thiab me me neudocrine thiab extrapyramidal phiv;
muaj peev xwm thaiv dopamine receptors, thiab kuj muaj me ntsis cuam tshuam rau. Acetylcholine thiab adrenoreceptors.
- Txhua thioxanthene derivatives (chlorprothixene, flupentixol, zuclopenthixol) uas ua zoo ib yam li phenothiazine.
- Substituted benzamides (tiapride, sultopride, sulpiride, amisulpride), uas nws ua kuj zoo ib yam li phenothiazine antipsychotics.
- Txhua yam butyrophenone derivatives (trifluperidol, droperidol, haloperiodol, benperidol).
- Dibenzodiazapine thiab nws cov derivatives (olanzapine, clozapine, quetiapine).
- Benzisoxazole thiab nws cov derivatives(risperidone).
- Benzisothiazolylpiperazine thiab nws cov derivatives (ziprasidone).
- Indole thiab nws cov derivatives (sertindole, dicarbine).
- YPiperazinylquinolinone (aripiprazole).
Los ntawm tag nrho cov saum toj no, peb tuaj yeem paub qhov txawv ntawm cov tshuaj tiv thaiv kab mob pheej yig - tshuaj muag yam tsis muaj tshuaj hauv khw muag tshuaj, thiab pab pawg tshuaj tiv thaiv kab mob uas tau muag nruj me ntsis raws li tshuaj.
Kev sib cuam tshuam ntawm neuroleptics nrog lwm yam tshuaj
Zoo li lwm yam tshuaj, cov tshuaj tiv thaiv kev puas siab puas ntsws niaj hnub cuam tshuam nrog lwm cov tshuaj yog tias noj tib lub sijhawm. Qee qhov kev sib cuam tshuam yog qhov txaus ntshai heev rau tib neeg lub cev, yog li nws yog ib qho tseem ceeb kom paub tias cov tshuaj tiv thaiv kev puas siab puas ntsws txaus ntshai rau noj nrog. Nco ntsoov tias kev lom neeg neuroleptic feem ntau tshwm sim meej vim tias lawv cuam tshuam nrog lwm yam tshuaj.
Kev sib tham nrog cov tshuaj tiv thaiv kev ntxhov siab ua rau muaj kev nce ntxiv ntawm kev ua ntawm ob leeg neuroleptics thiab cov tshuaj tiv thaiv kev ntxhov siab lawv tus kheej. Lawv kev sib xyaw ua ke tuaj yeem ua rau cem quav, tuag tes tuag taw ileus, arterial hypertension.
Tsis pom zoo kom muab ua ke:
- Kev sib xyaw ntawm cov tshuaj tiv thaiv kab mob thiab benzodiazepines ua rau muaj kev nyuaj siab ua pa, sedative phiv.
- Thaum noj ib txhij nrog lithium npaj, kev txhim kho ntawm hyperglycemia, qhov tsos ntawm kev tsis meej pem, tsaug zog yog ua tau. Lawv kev sib xyaw ua ke tuaj yeem tso cai, tab sis tsuas yog nyob rau hauv kev saib xyuas kev kho mob xwb.
- Siv nrog adrenomimetics (ephedrine, metasone, norepinephrine, epinephrine) ua rau txo qis ntawm ob qho tib sitshuaj.
- Antihistamines, thaum noj ua ke nrog cov tshuaj tiv thaiv kev puas siab puas ntsws, ua rau lawv cov nyhuv inhibitory ntawm lub hauv nruab nrab paj hlwb.
- Cawv, tshuaj loog, tshuaj tsaug zog, lossis tshuaj tiv thaiv kab mob ua ke nrog cov tshuaj tiv thaiv kev puas siab puas ntsws muaj txiaj ntsig zoo ib yam.
- Noj tshuaj tiv thaiv kab mob nrog tshuaj tua kab mob thiab tshuaj loog ua rau muaj kev nce ntxiv hauv lawv cov txiaj ntsig. Qhov kev sib xyaw ua ke no muaj kev nyuaj siab rau lub hauv nruab nrab lub paj hlwb.
- Neuroleptics noj nrog insulin thiab tshuaj tiv thaiv ntshav qab zib ua rau txo qis hauv lawv cov txiaj ntsig.
- Noj tshuaj tiv thaiv kab mob nrog tetracyclines ua rau muaj kev pheej hmoo ntawm daim siab puas tsuaj los ntawm co toxins.
YContraindications
Ob qho tib si atypical thiab raug tshuaj tiv thaiv kab mob muaj cov npe ntawm cov contraindications:
- tus neeg mob tsis kam noj tshuaj;
- muaj lub ntsej muag kaw glaucoma, prostate adenoma, porphyria, parkinsonism, pheochromocytoma;
- ua xua rau cov tshuaj tiv thaiv kab mob hauv tib neeg keeb kwm;
- daim siab thiab raum tsis zoo;
- cev xeeb tub thiab pub niam mis;
- kab mob ntawm cov hlab plawv;
- mob febrile mob;
- coma.
Cov teebmeem ntawm cov tshuaj tiv thaiv kab mob
Nrog kev kho mob mus sij hawm ntev, txawm tias qhov zoo tshaj plaws antipsychotic muaj kev phiv.
Txhua cov tshuaj tiv thaiv kab mob tuaj yeem ua rau muaj kev pheej hmoo ntawm kev tsim dopamine hypersensitivity, uas ua rauCov tsos mob ntawm psychosis thiab tardive dyskinesia.
Feem ntau, cov tsos mob no tshwm sim thaum cov neuroleptic tshem tawm (qhov no tseem hu ua "kev tshem tawm syndrome"). Cov tsos mob tshem tawm muaj ntau ntau yam: hypersensitivity psychoses, unmasked dyskinesia (los yog recoil dyskinesia), cholinergic "recoil" syndrome, thiab lwm yam.
Txhawm rau tiv thaiv tus mob no, kev kho mob nrog tshuaj tua kab mob yuav tsum ua kom tiav maj mam, maj mam txo cov koob tshuaj.
Thaum noj tshuaj tiv thaiv kab mob hauv cov koob tshuaj ntau, cov kev mob tshwm sim xws li neuroleptic deficient syndrome tau sau tseg. Raws li cov ntaub ntawv pov thawj, qhov tshwm sim no tshwm sim hauv 80% ntawm cov neeg mob noj tshuaj tiv thaiv kab mob.
Kev hloov pauv hauv lub hlwb nrog kev siv sijhawm ntev
Raws li cov placebo-tswj cov kev tshawb fawb ntawm macaques muab cov koob tshuaj ib txwm ntawm olanzapine lossis haloperidol rau ob xyoos, neuroleptics txo lub hlwb ntim thiab qhov hnyav los ntawm qhov nruab nrab ntawm 8-11%. Qhov no yog vim qhov txo qis ntawm qhov ntim ntawm cov xim dawb thiab grey. Kev rov qab los ntawm cov tshuaj tiv thaiv kab mob yog tsis yooj yim sua.
Tom qab tshaj tawm cov txiaj ntsig, cov kws tshawb fawb raug liam tias tsis kuaj cov tshuaj tiv thaiv kab mob rau cov tsiaj ua ntej nkag mus rau hauv khw muag tshuaj, thiab ua rau muaj kev phom sij rau tib neeg.
Ib tus kws tshawb fawb, Nancy Andreasen, paub tseeb tias qhov txo qis ntawm cov teeb meem grey thiab kev siv tshuaj tiv thaiv kab mob feem ntau cuam tshuam rau tib neeg lub cev thiab ua rau atrophy ntawm prefrontal cortex. Ntawm qhov tod tes, nws kuj tau sau tseg tias cov tshuaj tiv thaiv kev puas siab puas ntsws yog cov tshuaj tseem ceeb,muaj peev xwm kho tau ntau yam mob, tab sis tsuas yog yuav tsum tau noj tsawg heev.
Hauv xyoo 2010, cov kws tshawb fawb J. Leo thiab J. Moncrieff tau luam tawm kev tshuaj xyuas kev tshawb fawb raws li kev sib nqus resonance ntawm lub hlwb. Txoj kev tshawb no tau ua los sib piv lub hlwb hloov pauv ntawm cov neeg mob noj tshuaj tiv thaiv kab mob thiab cov uas tsis noj lawv.
Nyob rau hauv 14 ntawm 26 tus neeg mob (hauv cov neeg mob noj tshuaj tiv thaiv kab mob), qhov txo qis hauv lub hlwb, cov teeb grey thiab dawb tau pom.
Ntawm 21 tus neeg mob (hauv cov neeg mob uas tsis tau noj tshuaj tiv thaiv kab mob, lossis tau noj, tab sis noj me me), tsis muaj qhov hloov pauv.
Hauv xyoo 2011, tib tus kws tshawb fawb Nancy Andreasen tau luam tawm cov txiaj ntsig ntawm kev tshawb fawb uas nws pom muaj kev hloov pauv hauv lub hlwb hauv 211 tus neeg mob uas tau noj tshuaj tiv thaiv kab mob ntev heev (ntau dua 7 xyoo). Nyob rau tib lub sijhawm, qhov koob tshuaj loj dua, qhov ntim ntawm lub hlwb txo qis dua.
Drug Development
Tam sim no, cov tshuaj tiv thaiv kev puas siab puas ntsws tshiab tau tsim tawm uas yuav tsis cuam tshuam rau cov neeg txais khoom. Ib pawg ntawm cov kws tshawb fawb tau thov tias cannabidiol, ib feem ntawm cannabis, muaj cov nyhuv antipsychotic. Yog li nws muaj peev xwm sai sai no peb yuav pom cov tshuaj no nyob rau ntawm lub rhawv ntawm cov khw muag tshuaj.
Zoo kawg
Peb cia siab tias tsis muaj leej twg muaj lus nug ntxiv txog qhov neuroleptic yog dab tsi. Nws yog dab tsi, dab tsi yog nws mechanism ntawm kev txiav txim thiab qhov tshwm sim ntawm kev noj nws, peb tau tham saum toj no. Nws tseem tsuas yog ntxiv tias txawm li cas los xij ntawm cov tshuaj hauv lub ntiaj teb niaj hnub no, tsis yog ib yam khoomtuaj yeem tshawb xyuas tag nrho. Thiab qhov ua kom yuam kev tuaj yeem xav tau los ntawm txhua yam, thiab ntau ntxiv los ntawm cov tshuaj nyuaj xws li tshuaj tiv thaiv kab mob.
Tsis ntev los no tau muaj qhov nce ntxiv ntawm cov neeg mob kev nyuaj siab raug kho nrog tshuaj tiv thaiv kab mob. Tawm ntawm qhov tsis paub txog qhov txaus ntshai ntawm cov tshuaj no, tib neeg ua rau lawv tus kheej tsis zoo. Antipsychotics yuav tsum tsis txhob siv rau lwm lub hom phiaj tshaj li qhov lawv xav siv. Thiab dab tsi cuam tshuam cov tshuaj no rau lub hlwb yog tawm ntawm lo lus nug.
Qhov no yog vim li cas cov tshuaj tiv thaiv kev puas siab puas ntsws, muaj nyob rau hauv cov tshuaj tiv thaiv, yuav tsum tau siv nrog ceev faj (thiab tsuas yog koj 100% tseeb tias koj xav tau), thiab tseem zoo dua tsis txhob siv txhua yam tsis muaj kws kho mob tshuaj.
