E•øº.¶AI¢IATP.TEL
30-05-03
13:07
™ÂÏ›‰·1
E§§HNIKH ¶AI¢IATPIKH ETAIPEIA AºIEPøMA: ÀÁ›· ÙÔ˘ ·È‰ÈÔ‡ 2000 265 H ÓÂÔÁÓÔÏÔÁ›· ÛÙËÓ ·Ó·ÙÔÏ‹ Ù˘ ÙÚ›Ù˘ ¯ÈÏÈÂÙ›·˜
319 BPAXEIA ¢HMO™IEY™H EÌÂÈÚ›· ·fi ÂÚÈÙÒÛÂȘ ÌÂÛÔÎÔÈÏȷ΋˜ ÂÈÎÔÈÓˆÓ›·˜ Û ‚Ú¤ÊË
M. •¿ÓıÔ˘
A. TÛÈÏÈÌÈÁοÎË, A. M·ÓÔ˘Ú¿, £. TÛÂÎÔ˘Ú¿, B. AÁÁÂÏ¿ÎÔ˘, A. ™¯ÔÈÓ¿ÎË, ¶. ™Ù·ÛÈÓfi˜, §. ¶ÏÔ˘Ì›‰Ë˜
268 H Ïԛ̈ÍË ·fi ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ˘ÏˆÚÔ‡ ÛÙ· ·È‰È¿ 322 EN¢IAºEPOY™E™ ¶EPI¶Tø™EI™ IÓ҉˘ ÎÔÏÔÓÔ¿ıÂÈ· Û ·ÛıÂÓ‹ Ì ΢ÛÙÈ΋ ›ÓˆÛË
E. PÒÌ·-°È·ÓÓ›ÎÔ˘
272 H ÔÈÎÔÁ¤ÓÂÈ· Î·È Ë ÊÚÔÓÙ›‰· ÙˆÓ ·È‰ÈÒÓ Ì ·Ó·Ëڛ˜
TOMO™ 63 ●
¶AI¢IATPIKH
™. NÙÔ˘ÓÙÔ˘Ó¿Î˘, A. ZËÛÔ‡ÏË, A. §Ô˘Ú›‰·, E. PÒÌ·-°È·ÓÓ›ÎÔ˘, N. M·ÓˆÏ¿ÎË
°. KÔÙÙ·Ú›‰Ë
326 Ÿ„ÈÌË ÂÓ‰ÔÌ‹ÙÚÈ· Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi: ÎÏÈÓÈο Î·È ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù·
●
TEYXO™ 4
●
ETO™ 2000
ISSN 0377-2551
275 AP£PO ™YNTA•H™ H ¯Ú‹ÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙÔ Û‡Ó‰ÚÔÌÔ Turner: ™‡Á¯ÚÔÓ˜ ·fi„ÂȘ Î·È ÚÔ‚ÏËÌ·ÙÈÛÌÔ›
O. ¶··‰¿ÎË-¶··Ó‰Ú¤Ô˘, M. Z·Ú›ÊË, I. OÈÎÔÓÔÌ›‰Ë˜, A. •˘ÔÏ˘Ù¿-Z·¯·ÚÈ¿‰Ë
M.A. M·ÁÈ¿ÎÔ˘, °.¶. XÚÔ‡ÛÛÔ˜
278 ANA™KO¶H™H ™‡Ó‰ÚÔÌÔ Turner Î·È ·˘ÍËÙÈ΋ ÔÚÌfiÓË: ¢ÈηÈÔÏÔÁÂ›Ù·È ·ÎfiÌË Ô ·Ú¯ÈÎfi˜ ÂÓıÔ˘ÛÈ·ÛÌfi˜;
330 ™YNEXIZOMENH EK¶AI¢EY™H AÎÙÈÓÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ÛÙ· ·È‰È¿ M.°. ¶··‰¿ÎË, I. ™. K·ÛηڤÏ˘
X. K·Ó·Î¿-Gantenbein
337 ¶PAKTIKE™ O¢H°IE™ TOY ¶AI¢IATPOY TÚÔ¯·›· ·Ù˘¯‹Ì·Ù· - O‰ËÁ›Â˜ ÚfiÏ˄˘ 287 EPEYNHTIKE™ EP°A™IE™ E›Â‰· ·Ú·ÁfivÙˆv ·ÈÌfiÛÙ·Û˘ Û ·ÛıÂv›˜ Ì Á·Ï·ÎÙo˙·ÈÌ›· ˘fi ‰›·ÈÙ· Ì "Á¿Ï· ÛfiÁÈ·˜" K. ™o‡ÏË, E. ¶Ï·ÙoÎo‡ÎË, E. ¶··ÎˆvÛÙ·vÙ›vo˘, E. MȯÂϷοÎË, ™. AÚÒvË
K.£. TÛÔ˘Ì¿Î·˜
339 I™TOPIA TH™ E§§HNIKH™ ¶AI¢IATPIKH™ ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ- ¶ÔÚ›· 39 ÂÙÒÓ X. TÛÂÁ΋
292 ¶ÚˆÙfiÎÔÏÏÔ ¤ÁηÈÚ˘ ÂÏÂÁ¯fiÌÂÓ˘ ÚÈÓÔÁ·ÛÙÚÈ΋˜ Û›ÙÈÛ˘ Û ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ· ·È‰È¿ °. MÚÈ·ÛÔ‡Ï˘, N. Z¿‚Ú·˜, M. N·ÚÏ›ÔÁÏÔ˘, A. X·Ù˙‹˜
342 E¶π™∆O§Œ˜ ¢. ∫·Ú·ÌÂÚfiÔ˘ÏÔ˜ £. ¶ÂÚÚ¿Î˘ ¶.¢. §··ÙÛ¿Ó˘ ¡. ª·ÙÛ·ÓÈÒÙ˘
302 ¢È·ÔÈÛÔÊ¿ÁÂÈ· ÎÔÏÈ΋ ‚ËÌ·ÙÔ‰fiÙËÛË ÛÙ· ÓÂÔÁÓ¿: ÂÎÙ›ÌËÛË Ù˘ ı¤Û˘ ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ A.E. M·ÚÁÂÙ¿Î˘, X. TÚ¿·ÏË, ¢. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜, °. °ÚËÁÔÚÈ¿‰Ô˘, N. I·Îˆ‚›‰Ô˘, °. KÔ˘Ú¿Î˘, H. ¢ÂÏÏ·ÁÚ·ÌÌ¿ÙÈη˜
347 ¶AI¢IATPIKH ENHMEPø™∏ ∂. µ·Ï¿ÛÛË-∞‰¿Ì
309 E›Â‰· ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ Û ‰‡Ô ÓÂÔÁÓ¿ ÌÂ Ì˘ÎËÙÈ·ÛÈ΋ Ïԛ̈ÍË ·fi Candida albicans ¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·
I. §·Ì·‰·Ú›‰Ë˜, E. ¢ËÌËÙÚ›Ô˘, M. £ÂÔ‰ˆÚ¿ÎË, A. X›˙·, M. ™·‚‚¿Ï·, E. MȯÂϷοÎË
314 §ÔÈÌÒÍÂȘ ·fi ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È· Û ·È‰È¿
™˘ÓÙÔÌÔÁڷʛ˜
¶. ™˘Ú›‰Ë˜, E. M·ÏÙ¤˙Ô˘, ¢. K·ÊÂÙ˙‹˜
PAEDIATRIKI
Hellenic Paediatric Society
πOÀ§πO™-∞À°OÀ™∆O™ 2000
●
TOMO™ 63
●
TEYXO™ 4O
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·5
E§§HNIKH ¶AI¢IATPIKH ETAIPEIA
¶AI¢IATPIKH TfiÌÔ˜ 63, T‡¯Ô˜ 4Ô Io˘Ï-∞˘Á. 2000
HELLENIC PAEDIATRIC SOCIETY
¢ÈÌËÓÈ·›· ¤Î‰ÔÛË E›ÛËÌÔ ¶ÂÚÈÔ‰ÈÎfi Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜
Bimonthly Publication The Official Journal of the Hellenic Paediatric Society
EΉfiÙ˘ K. °ÚÈ‚¤·˜
Publisher K. Griveas
I‰ÈÔÎÙ‹Ù˘© EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 Aı‹Ó·È 115 28
Owner© Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28
TËÏ:. (01) 7771 140 / 7771 663, Fax: 7758 354
Tel. (01) 7771 140 / 7771 663, Fax: 7758 354
EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ¶Úfi‰ÚÔ˜ : A. KˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ ¢È¢ı˘ÓÙ‹˜ : E. B·Ï¿ÛÛË-A‰¿Ì M¤ÏË : º. Aı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘ : M. Aı·Ó·Û›Ô˘-MÂÙ·Í¿ : ™. AÓ‰ÚÔÓ›ÎÔ˘ : ™. K›ÙÛÈÔ˘-T˙¤ÏË : ™. N¿ÎÔ˘ : T. ¶·Ó·ÁȈÙfiÔ˘ÏÔ˜ : A. ™˘Ú›ÁÔ˘-¶··‚·ÛÈÏ›Ԣ : K. ¶Ú›ÊÙ˘ : °. ™˘ÚÔÁÈ·ÓÓfiÔ˘ÏÔ˜ : ™. TÛ›ÙÔ˘Ú·
Scientific President Editor Members
™‡Ì‚Ô˘ÏÔÈ ∂Ù·ÈÚÂÈÒÓ ¶·È‰È·ÙÚÈÎÒÓ ÀÔÂȉÈÎÔÙ‹ÙˆÓ ™. °Ú·Ê¿ÎÔ˜ ∞ÈÌ·ÙÔÏÔÁ›·-OÁÎÔÏÔÁ›· ∂. ƒÒÌ· °·ÛÙÚÂÓÙÂÚÔÏÔÁ›· µ. ™ËÏÈÒÙË ∂Ó‰ÔÎÚÈÓÔÏÔÁ›· µ. £·ÓfiÔ˘ÏÔ˜ ∫·Ú‰ÈÔÏÔÁ›· ∂. ¶ÂÙÚ›‰Ô˘ ∫ÔÈÓˆÓÈ΋ ¶·È‰È·ÙÚÈ΋ ª. •¿ÓıÔ˘ ¡ÂÔÁÓÔÏÔÁ›· ∫. ™ÙÂÊ·Ó›‰Ë˜ ¡ÂÊÚÔÏÔÁ›· §. ¶··ÁÈ·ÓÓÔ‡ÏË ¶·È‰Ô‰ÔÓÙÈ·ÙÚÈ΋ ∞. ¶··‚·ÛÈÏ›Ԣ ¶·È‰ÔÓ¢ÚÔÏÔÁ›· π. ∆۷ӿη˜ ¶·È‰ÔÓ¢ÌÔÓÔÏÔÁ›·
Consultants, Paediatric Subspecialty Societies S. Grafacos Haematology-Oncology E. Roma Gastroenterology V. Spilioti Endocrinology V. Thanopoulos Cardiology E. Petridou Social Paediatrics M. Xanthou Neonatology K. Stefanidis Nephrology L. Papagianouli Paedodontics A. Papavassiliou Neurology J. Tsanakas Pneumonology
ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· º. ª·˘ÚÔÂȉ‹
English Editing S. Nakou
™‡Ì‚Ô˘ÏÔ˜ ™Ù·ÙÈÛÙÈ΋˜ ∂. ™·Ú·Ê›‰Ô˘
Statistics Consultant E. Sarafidou
™˘ÓÙÔÓÈÛÙ‹˜ ∂ΉfiÛˆ˜
Publishing Coordinator
E¶I™THMONIKE™ EK¢O™EI™ E.¶.E. ¶. T۷ω¿ÚË 3, 151 22 M·ÚÔ‡ÛÈ TËÏ.: 61 43 501-4-5 Fax: 61 41 365
SCIENTIFIC PUBLICATIONS Ltd P. Tsaldari 3, Marousi 151 22 Tel.: 61 43 501-4-5, Fax: 61 31 365
EÙ‹ÛÈ· ™˘Ó‰ÚÔÌ‹ EȉÈ΢fiÌÂÓÔÈ, ºÔÈÙËÙ¤˜:
10000 ‰Ú¯. 5000 ‰Ú¯.
Editorial Board : A. Konstadopoulos : E. Valassi-Adam : F. Athanassiadou-Piperopoulou : M. Athanassiou-Metaxa : S. Andronikou : S. Kitsiou-Tzeli : S. Nakou : T. Panagiotopoulos : A. Syrigou-Papavassiliou : K. Priftis : G. Syrogiannopoulos : S. Tsitoura
Annual Subscription All foreign countries: US $ 30
πSSN 0377-2551 i
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·7
E§§HNIKH ¶AI¢IATPIKH ETAIPEIA
HELLENIC PAEDIATRIC SOCIETY
¶AI¢IATPIKH
PAEDIATRIKI
TfiÌÔ˜ 63, T‡¯Ô˜ 4Ô πÔ‡Ï.-∞˘Á. 2000
Volume 63, No. 4, Jul-Aug. 2000
¶EPIEÃOMENA
CONTENTS ™ÂÏ.
AºIEPøMA: YÁ›· ÙÔ˘ ·È‰ÈÔ‡ 2000
Page
SPECIAL SERIES: Children's Health 2000
H ÓÂÔÁÓÔÏÔÁ›· ÛÙËÓ ·Ó·ÙÔÏ‹ Ù˘ ÙÚ›Ù˘ ¯ÈÏÈÂÙ›·˜ M. •¿ÓıÔ˘
Neonatology at the dawn of the third millenium 265
H Ïԛ̈ÍË ·fi ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ˘ÏˆÚÔ‡ ÛÙ· ·È‰È¿ E. PÒÌ·-°È·ÓÓ›ÎÔ˘
M. Xanthou
265
Helicobacter pylori infection in children E. Roma-Yiannikou
268
268
H ÔÈÎÔÁ¤ÓÂÈ· Î·È Ë ÊÚÔÓÙ›‰· ÙˆÓ ·È‰ÈÒÓ Ì ·Ó·Ëڛ˜
The family and care of the child with disability
°. KÔÙÙ·Ú›‰Ë
Y. Kottaridi
272
272
AP£PO ™YNTA•H™
EDITORIAL
H ¯Ú‹ÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙÔ Û‡Ó‰ÚÔÌÔ Turner: ™‡Á¯ÚÔÓ˜ ·fi„ÂȘ Î·È ÚÔ‚ÏËÌ·ÙÈÛÌÔ›
The use of growth hormone in the treatment of short stature in Turner syndrome
M.A. M·ÁÈ¿ÎÔ˘, °.¶. XÚÔ‡ÛÛÔ˜
M.A. Magiakou, G.P. Chroussos
275
275
ANA™KO¶H™H
REVIEW ARTICLE
™‡Ó‰ÚÔÌÔ Turner Î·È ·˘ÍËÙÈ΋ ÔÚÌfiÓË: ¢ÈηÈÔÏÔÁÂ›Ù·È ·ÎfiÌË Ô ·Ú¯ÈÎfi˜ ÂÓıÔ˘ÛÈ·ÛÌfi˜;
Turner syndrome and growth hormone: Is the initial enthusiasm justified?
X. K·Ó·Î¿-Gantenbein
C. Kanaka-Gantenbein
278
EPEYNHTIKE™ EP°A™IE™
ORIGINAL PAPERS
E›Â‰· ·Ú·ÁfivÙˆv ·ÈÌfiÛÙ·Û˘ Û ·ÛıÂv›˜ Ì Á·Ï·ÎÙo˙·ÈÌ›· ˘fi ‰›·ÈÙ· Ì "Á¿Ï· ÛfiÁÈ·˜"
Haemostatic factors in patients with galactosaemia on soybean diet
K. ™o‡ÏË, E. ¶Ï·ÙoÎo‡ÎË, E. ¶··ÎˆvÛÙ·vÙ›vo˘, E. MȯÂϷοÎË, ™. AÚÒvË
K. Schulpis, E. Platokouki, E. Papakonstantinou, E. Michelakakis, S. Aroni
287
278
287
¶ÚˆÙfiÎÔÏÏÔ ¤ÁηÈÚ˘ ÂÏÂÁ¯fiÌÂÓ˘ ÚÈÓÔÁ·ÛÙÚÈ΋˜ Û›ÙÈÛ˘ Û ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ· ·È‰È¿
Optimized enteral feeding in critically ill children; a prospective study in a paediatric intensive care unit
°. MÚÈ·ÛÔ‡Ï˘, N. Z¿‚Ú·˜, M. N·ÚÏ›ÔÁÏÔ˘, A. X·Ù˙‹˜
G. Briassoulis, N. Zavras, M. Narlioglou, T. Hatzis
292
¢È·ÔÈÛÔÊ¿ÁÂÈ· ÎÔÏÈ΋ ‚ËÌ·ÙÔ‰fiÙËÛË ÛÙ· ÓÂÔÁÓ¿: ÂÎÙ›ÌËÛË Ù˘ ı¤Û˘ ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ A.E. M·ÚÁÂÙ¿Î˘, X. TÚ¿·ÏË, ¢. °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜, °. °ÚËÁÔÚÈ¿‰Ô˘, N. I·Îˆ‚›‰Ô˘, °. KÔ˘Ú¿Î˘, H. ¢ÂÏÏ·ÁÚ·ÌÌ¿ÙÈη˜
A. Margetakis, C.Trapali, D. Georgakopoulos, G. Grigoriadou, N. Iakovidou, G. Kourakis, H Dellagrammaticas
302
Chitotriosidase levels in Candida albicans infection J. Labadaridis, E. Dimitriou, M. Theodoraki, A. Hiza, M. Savala, H. Michelakakis
309
309
§ÔÈÌÒÍÂȘ ·fi ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È· Û ·È‰È¿ ¶. ™˘Ú›‰Ë˜, E. M·ÏÙ¤˙Ô˘, ¢. K·ÊÂÙ˙‹˜
Transoesophageal pacing in neonates: Estimation of the appropriate site of minimum pacing threshold
302
E›Â‰· ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ Û ‰‡Ô ÓÂÔÁÓ¿ ÌÂ Ì˘ÎËÙÈ·ÛÈ΋ Ïԛ̈ÍË ·fi Candida albicans I. §·Ì·‰·Ú›‰Ë˜, E. ¢ËÌËÙÚ›Ô˘, M. £ÂÔ‰ˆÚ¿ÎË, A. X›˙·, M. ™·‚‚¿Ï·, E. MȯÂϷοÎË
292
Non-tuberculous mycobacterial lymphadenitis in children 314
™˘Ó¯›˙ÔÓÙ·È
P. Spyridis, H. Maltezou, D. Kafetzis
314
Continued
iii
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·8
E§§HNIKH ¶AI¢IATPIKH ETAIPEIA
HELLENIC PAEDIATRIC SOCIETY
¶AI¢IATPIKH
PAEDIATRIKI
TfiÌÔ˜ 63, T‡¯Ô˜ 4Ô πÔ‡Ï.-∞˘Á. 2000
Volume 63, No. 4, Jul-Aug 2000
™ÂÏ.
Page
BPAXEIA ¢HMO™IEY™H
SHORT REPORT
EÌÂÈÚ›· ·fi ÂÚÈÙÒÛÂȘ ÌÂÛÔÎÔÈÏȷ΋˜ ÂÈÎÔÈÓˆÓ›·˜ Û ‚Ú¤ÊË
A study of ventricular septal defects in the first year of life
A. TÛÈÏÈÌÈÁοÎË, A. M·ÓÔ˘Ú¿, £. TÛÂÎÔ˘Ú¿, B. AÁÁÂÏ¿ÎÔ˘, A. ™¯ÔÈÓ¿ÎË, ¶. ™Ù·ÛÈÓfi˜, §. ¶ÏÔ˘Ì›‰Ë˜ 319
A. Tsilimingaki, A. Manoura, T. Tsekoura, V. Agelakou, A. Schoinaki, P. Stasinos, L. Ploumidis
EN¢IAºEPOY™E™ ¶EPI¶Tø™EI™
CASE REPORTS
IÓ҉˘ ÎÔÏÔÓÔ¿ıÂÈ· Û ·ÛıÂÓ‹ Ì ΢ÛÙÈ΋ ›ÓˆÛË
Fibrosing colonopathy in cystic fibrosis
™. NÙÔ˘ÓÙÔ˘Ó¿Î˘, A. ZËÛÔ‡ÏË, A. §Ô˘Ú›‰·, E. PÒÌ·-°È·ÓÓ›ÎÔ˘, N. M·ÓˆÏ¿ÎË
322
Ÿ„ÈÌË ÂÓ‰ÔÌ‹ÙÚÈ· Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi: ÎÏÈÓÈο Î·È ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· O. ¶··‰¿ÎË-¶··Ó‰Ú¤Ô˘, M. Z·Ú›ÊË, I. OÈÎÔÓÔÌ›‰Ë˜, A. •˘ÔÏ˘Ù¿-Z·¯·ÚÈ¿‰Ë
S. Doudounakis, A. Zissouli, A. Lourida, E. Roma-Giannicou, N. Manolaki
326
O. Papadaki-Papandreou, M. Zarifi, I. Oikonomidis, A. Xypolyta-Zachariadi
CONTINUING MEDICAL EDUCATION
AÎÙÈÓÔÏÔÁÈ΋ ¢ÈÂÚ‡ÓËÛË Ù˘ °·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ¶·ÏÈÓ‰ÚfiÌËÛ˘ ÛÙ· ¶·È‰È¿
GastroÔesophageal reflux in children: methods of radiological evaluation 330
¶PAKTIKE™ O¢H°IE™ TOY ¶AI¢IATPOY
M. Papadaki, I. Kaskarelis
326
330
PAEDIATRICIAN'S PRACTICAL ADVICE TO PARENTS
TÚÔ¯·›· ·Ù˘¯‹Ì·Ù· - O‰ËÁ›Â˜ ¶ÚfiÏ˄˘ K.£. TÛÔ˘Ì¿Î·˜
322
Late intrauterine cytomegalovirus infection: clinical and imaging findings
™YNEXIZOMENH EK¶AI¢EY™H M.°. ¶··‰¿ÎË, I. ™. K·ÛηڤÏ˘
319
337
I™TOPIA TH™ E§§HNIKH™ ¶AI¢IATPIKH™
K.T. Tsoumakas
337
HISTORY OF HELLENIC PAEDIATRICS C. Tsegi
339
342
LETTERS
342
347
PAEDIATRIC NEWS
347
¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ- ¶ÔÚ›· 39 ÂÙÒÓ X. TÛÂÁ΋
339
E¶π™∆O§E™ ¢. ∫·Ú·ÌÂÚfiÔ˘ÏÔ˜ £. ¶ÂÚÚ¿Î˘ ¶.¢. §··ÙÛ¿Ó˘ ¡. ª·ÙÛ·ÓÈÒÙ˘
¶∞π¢π∞∆ƒπ∫∏ E¡∏ª∂ƒø™∏ ∂. µ·Ï¿ÛÛË-∞‰¿Ì
¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·
Forthcoming meetings
™˘ÓÙÔÌÔÁڷʛ˜
Abbreviations
iv
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·9
O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜ H ¶AI¢IATPIKH Â›Ó·È Ë Â›ÛËÌË ÂÈÛÙËÌÔÓÈ΋ ¤Î‰ÔÛË Î·È È‰ÈÔÎÙËÛ›· Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜ (E ¶ E ). Œ¯ÂÈ ˆ˜ ‚·ÛÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ·) ÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ¤ÚÁÔ˘ ‚) ÙËÓ ÂÓË̤ڈÛË ÙˆÓ ·È‰È¿ÙÚˆÓ Û ı¤Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡ Î·È Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ηıÒ˜ Î·È Ù˘ ‰ËÌfiÛÈ·˜ ˘Á›·˜ Á) ÙË ‰È¢ÎfiÏ˘ÓÛË Ù˘ ‰È·Î›ÓËÛ˘ ÙˆÓ È‰ÂÒÓ Î·È Ù˘ ·Ó¿Ù˘Í˘ Ù˘ ¤Ú¢ӷ˜ ÛÙÔ Â‰›Ô Ù˘ ˘Á›·˜ ÙÔ˘ ·È‰ÈÔ‡ ‰) ÙËÓ ÚfiÔ‰Ô Ù˘ ÂÏÏËÓÈ΋˜ ·È‰È·ÙÚÈ΋˜ ̤ۈ Ù˘ ÎÚÈÙÈ΋˜ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ÎÂÈÌ¤ÓˆÓ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË Â) ÙËÓ ÂÓı¿ÚÚ˘ÓÛË Î·È Î·ÏÏȤÚÁÂÈ· Ù˘ ÂÈÛÙËÌÔÓÈ΋˜ ÂÈÎÔÈÓˆÓ›·˜ ÛÙËÓ ÂÏÏËÓÈ΋ ÁÏÒÛÛ· °È· ÙÔÓ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË: ¿ÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ EÈÛÙËÌÔÓÈ΋˜ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜), ·Ó·ÛÎÔ‹ÛÂȘ,›ηÈÚ· ı¤Ì·Ù·, ¿ÚıÚ· ÂȉÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜, ÂÚ¢ÓËÙÈΤ˜ ÌÂϤÙ˜, ÎÏÈÓÈΤ˜ ·Ú·ÙËÚ‹ÛÂȘ, Ú·ÎÙÈο ı¤Ì·Ù·, ÁÂÓÈο ı¤Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÙÔÓ ÚÔÁÚ·ÌÌ·ÙÈÛÌfi Î·È ÙËÓ ÔÚÁ¿ÓˆÛË Ù˘ È·ÙÚÈ΋˜ Âη›‰Â˘Û˘ Î·È ˘Á›·˜, Û˘˙ËÙ‹ÛÂȘ ÛÙÚÔÁÁ˘ÏÔ‡ ÙÚ·Â˙ÈÔ‡, ÎÏÈÓÈÎÔ·ıÔÏÔÁÈΤ˜ Û˘˙ËÙ‹ÛÂȘ, ÛÂÌÈÓ¿ÚÈ·, Û˘ÌfiÛÈ·, ÂӉȷʤÚÔ˘Û˜ ÎÏÈÓÈΤ˜ Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ, ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ, ¿ÚıÚ· Û˘Ó¯È˙fiÌÂÓ˘ È·ÙÚÈ΋˜ Âη›‰Â˘Û˘, ÂÈÛÙÔϤ˜ ÚÔ˜ ÙË Û‡ÓÙ·ÍË, ‚È‚ÏÈÔÎÚÈۛ˜, ÂÈÛÙËÌÔÓÈ΋ ÂȉËÛÂÔÁÚ·Ê›· fiˆ˜ ÂÓË̤ڈÛË ÁÈ· ÙË ‰ÈÂÍ·ÁˆÁ‹ Û˘Ó‰ڛˆÓ, Û˘ÌÔÛ›ˆÓ Î·È ÁÈ· ‰Ú·ÛÙËÚÈfiÙËÙ˜ Û¯ÂÙÈΤ˜ Ì ÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡. OÈ ÂÚÁ·Û›Â˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È ÚÔ˜ ÎÚ›ÛË ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÛÙÔ ÂÚÈÔ‰ÈÎfi ¶AI¢IATPIKH ·ÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó ÛÙË ‰È‡ı˘ÓÛË: EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 11528 Aı‹Ó· H ¶AI¢IATPIKH ·ÎÔÏÔ˘ı› ÙȘ KÔÈÓ¤˜ ¶ÚԉȷÁڷʤ˜ ÁÈ· XÂÈÚfiÁÚ·Ê· Ô˘ YÔ‚¿ÏÏÔÓÙ·È Û BÈÔ˚·ÙÚÈο ¶ÂÚÈÔ‰Èο Ô˘ ‰È·ÌÔÚÊÒıËÎ·Ó ·fi ÙËÓ ICMJE (International Committee of Medical Journal Editors. Uniform Requirements for Manuscripts Submitted to Biomedical Journals. N Eng J Med 1997;337:309315,http://jama.ama-assn.org/info/auinst-req.htlm) ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÂÈÛÙÔÏ‹, Ô˘ Û˘Ó˘ÔÁÚ¿ÊÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜, ÛÙËÓ ÔÔ›·: ·) ÂÚÈÁÚ¿ÊÂÙ·È ·Ó·Ï˘ÙÈο Ë Û˘Ì‚ÔÏ‹ ÂοÛÙÔ˘ ÙˆÓ Û˘ÁÁڷʤˆÓ (ۯ‰ȷÛÌfi˜, ·Ó¿Ï˘ÛË, ÂÚÌËÓ›· ¢ÚËÌ¿ÙˆÓ,Û˘ÏÏÔÁ‹ ‰Â‰Ô̤ӈÓ, Û˘ÁÁÚ·Ê‹ ÂÚÁ·Û›·˜, ·Ó·ÌfiÚʈÛË ÎÂÈ̤ÓÔ˘), ‚) ‰ËÏÒÓÂÙ·È fiÙÈ fiÏÔÈ ÔÈ Û˘ÁÁÚ·Ê›˜ ÂÁÎÚ›ÓÔ˘Ó Î·È ÌÔÚÔ‡Ó Ó· ˘ÔÛÙËÚ›ÍÔ˘Ó ÙÔ ÚÔ˜ ‰ËÌÔÛ›Â˘ÛË Î›ÌÂÓÔ ‹ ÙÌ‹Ì· ÙÔ˘, Á) ‰ËÏÒÓÂÙ·È Ë ÚԤϢÛË Ù˘ ¯ÚËÌ·ÙÔ‰fiÙËÛ˘ ÁÈ· ÙË
Û˘ÁÎÂÎÚÈ̤ÓË ÂÚÁ·Û›· (£· ·Ó·Ê¤ÚÂÙ·È ÛÙÔ Ù¤ÏÔ˜ Ù˘ ÂÚÁ·Û›·˜), ‰) ‰ËÏÒÓÂÙ·È ·Ó ÔÈ Û˘ÁÁÚ·Ê›˜ ¤¯Ô˘Ó οÔÈ· ÔÈÎÔÓÔÌÈ΋ Û¯¤ÛË Ì ÂÙ·ÈÚ›· ‹ ÔÚÁ·ÓÈÛÌfi Ô˘ ¤¯ÂÈ ÔÈÎÔÓÔÌÈÎfi ÂӉȷʤÚÔÓ ÁÈ· Ù· Â˘Ú‹Ì·Ù· ‹ ÙȘ ·fi„ÂȘ ÙÔ˘ Û˘ÁÁڷʤ· (·˘Ùfi ‰ÂÓ ÂËÚ¿˙ÂÈ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÓÙ·ÎÙÒÓ ·ÏÏ¿ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÁÓˆÛÙfi ÛÙÔ˘˜ ·Ó·ÁÓÒÛÙ˜), Â) ‰ËÏÒÓÂÙ·È fiÙÈ Ë ÂÚÁ·Û›· ‰ÂÓ ¤¯ÂÈ ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢Ù› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ EÏÏËÓÈÎfi ÂÚÈÔ‰ÈÎfi. H ¶AI¢IATPIKH ÂÓı·ÚÚ‡ÓÂÈ ÙËÓ ˘Ô‚ÔÏ‹ ÂÚÁ·ÛÈÒÓ Ô˘ ¤¯Ô˘Ó ‹‰Ë ‰ËÌÔÛÈ¢Ù› ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ Û ÍÂÓfiÁψÛÛ· ÂÚÈÔ‰Èο Ì ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ÔÈ Û˘ÁÁÚ·Ê›˜ Û˘Ó˘Ô‚¿ÏÏÔ˘Ó ÊˆÙÔ·ÓÙ›ÁÚ·ÊÔ Ù˘ ÍÂÓfiÁψÛÛ˘ ‰ËÌÔÛ›Â˘Û˘ Î·È ÙËÓ ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙÔ˘ ‰È¢ı˘ÓÙ‹ Û‡ÓÙ·Í˘ ÙÔ˘ ÍÂÓfiÁψÛÛÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ŸÏ˜ ÔÈ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ıˆÚÔ‡ÓÙ·È È‰ÈÔÎÙËÛ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ ¶AI¢IATPIKH Î·È Ë ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘Û‹ ÙÔ˘˜ ÂÈÙÚ¤ÂÙ·È ÌfiÓÔ ÌÂÙ¿ ·fi ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙÔ˘ ¢È¢ı˘ÓÙ‹ Ù˘ E.™.E. ŸÏ˜ ÔÈ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÁÚ·Ù‹ ‰‹ÏˆÛË ÙˆÓ Û˘ÁÁڷʤˆÓ fiÙÈ ¤ÁÈÓ·Ó Û‡Ìʈӷ Ì ÙË ‰È·Î‹Ú˘ÍË ÙÔ˘ EÏÛ›ÓÎÈ ÙÔ˘ 1975 fiˆ˜ ·Ó·ıˆڋıËΠÙÔ 1983, Î·È Û‡Ìʈӷ Ì ÙË ™‡Ì‚·ÛË ÁÈ· Ù· ¢ÈηÈÒÌ·Ù· ÙÔ˘ ¶·È‰ÈÔ‡. H ηٷ¯ÒÚËÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙËÓ ¶AI¢IATPIKH ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙÔ˘ ÂÚȯÔ̤ÓÔ˘ ÙÔ˘˜ ·fi ÙËÓ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›·, ÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‹ ·fi ÙÔÓ EΉfiÙË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. EÊfiÛÔÓ Ë ÂÚÁ·Û›· Á›ÓÂÈ ·Ô‰ÂÎÙ‹, ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Û‡Ìʈӷ Ì ÙȘ ˘Ô‰Â›ÍÂȘ ÙˆÓ ÎÚÈÙÒÓ Î·È ÂÎ Ó¤Ô˘ ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ˘Ô‚¿ÏÂÙ·È ÛÙËÓ EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ Û˘Óԉ¢fiÌÂÓÔ ·fi ‰ÈÛΤٷ Î·È ÂÈÛÙÔÏ‹ fiÔ˘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο, ÛËÌÂ›Ô ÚÔ˜ ÛËÌ›Ô, ÔÈ ÙÚÔÔÔÈ‹ÛÂȘ ‹ ÔÈ ·ÓÙÈÚÚ‹ÛÂȘ ÛÙȘ ÚÔÙ¿ÛÂȘ ÙˆÓ ÎÚÈÙÒÓ. H ηı˘ÛÙ¤ÚËÛË Ù˘ ·ӢԂÔÏ‹˜ ÙÔ˘ ÙÚÔÔÔÈË̤ÓÔ˘ ÎÂÈ̤ÓÔ˘ ¤Ú·Ó ÙˆÓ 4 ÌËÓÒÓ Û˘Ó¿ÁÂÙ·È Ó¤· ˘Ô‚ÔÏ‹. T· ΛÌÂÓ· ÙˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ÂÓ Á›ÓÔÓÙ·È ·Ô‰ÂÎÙ¤˜ ÁÈ· ‰ËÌÔÛ›Â˘ÛË ‰ÂÓ ÂÈÛÙÚ¤ÊÔÓÙ·È. MÔÚ› Ó· ÂÈÛÙÚ·ÊÔ‡Ó, ÂÊfiÛÔÓ ˙ËÙËı›, Ù· Û¯‹Ì·Ù· Î·È ÔÈ ÊˆÙÔÁڷʛ˜ Ô˘ Ù· Û˘Óԉ‡ԢÓ. T· ¤ÍÔ‰· ÙˆÓ ÊÈÏ̘ Î·È ÙˆÓ ·Ó·Ù‡ˆÓ ‚·Ú‡ÓÔ˘Ó ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Î·È Ú¤ÂÈ Ó· ÏËÚÒÓÔÓÙ·È Ì ÙËÓ ·ÔÛÙÔÏ‹ ÙÔ˘ ÚÒÙÔ˘ ‰ÔÎÈÌ›Ô˘ ηÙ¢ı›·Ó ÛÙÔÓ Ù˘ÔÁÚ¿ÊÔ.
vii
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·10
™‡ÓÙ·ÍË ÙˆÓ ÂÚÁ·ÛÈÒÓ TÔ Û‡ÓÔÏÔ Ù˘ ÂÚÁ·Û›·˜ (Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ÈÓ¿ÎˆÓ Î·È ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÈÎfiÓˆÓ) Ú¤ÂÈ Ó· Â›Ó·È ‰·ÎÙ˘ÏÔÁÚ·ÊË̤ÓÔ ÛÙË ÌÈ· fi„Ë Ï¢ÎÔ‡ ¯·ÚÙÈÔ‡ ÌÂÁ¤ıÔ˘˜ A4 (22X28 cm) Ì ‰ÈÏfi ‰È¿ÛÙËÌ· ÌÂٷ͇ ÙˆÓ ÁÚ·ÌÌÒÓ Î·È Ê·Ú‰È¿ ÂÚÈıÒÚÈ· (2,5 cm) ÛÙȘ ‰‡Ô Ï¢ڤ˜. TÔ Î›ÌÂÓÔ Ú¤ÂÈ Ó· ¤¯ÂÈ ÙËÓ ·ÎfiÏÔ˘ıË ‰È¿Ù·ÍË: ÛÂÏ›‰· Ù›ÙÏÔ˘, ÂÚ›ÏË„Ë ÛÙ· ÂÏÏËÓÈο Î·È Ù· ·ÁÁÏÈο, ΛÌÂÓÔ, ¢¯·ÚÈÛٛ˜ ηıÒ˜ Î·È ·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢, ‚È‚ÏÈÔÁÚ·Ê›·, ›Ó·Î˜, ÂÈÎfiÓ˜, Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ, ηٿÏÔÁÔ˜ Û˘ÓÙÌ‹ÛˆÓ. K¿ı ¤Ó· ·fi Ù· ·Ú·¿Óˆ ÛÙÔȯ›· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ Û ¯ˆÚÈÛÙfi ʇÏÏÔ Î·È ÔÈ ÛÂÏ›‰Â˜ Ó· ·ÚÈıÌÔ‡ÓÙ·È ‰È·‰Ô¯Èο ·Ú¯›˙ÔÓÙ·˜ Ì ÙË ÛÂÏ›‰· Ù›ÙÏÔ˘. H ¤ÎÙ·ÛË ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ÁÈ· ÙȘ ·Ó·ÛÎÔ‹ÛÂȘ Û 15-25, ÁÈ· ÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ Û 12-15 Î·È ÁÈ· Ù· ›ηÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÎÏÈÓÈΤ˜ Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ Û 3-5 ‰·ÎÙ˘ÏÔÁÚ·ÊË̤Ó˜ ÛÂÏ›‰Â˜, ÂÓÒ ÁÈ· ÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ Û 1000 ϤÍÂȘ Î·È ÁÈ· ÙȘ ÂÈÛÙÔϤ˜ Û 250-300 ϤÍÂȘ. ™ÂÏ›‰· Ù›ÙÏÔ˘ ¶Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÙÔÓ Ù›ÙÏÔ (<14 ϤÍÂȘ) Î·È ÙÔ ‚Ú·¯‡ Ù›ÙÏÔ (<5 ϤÍÂȘ) ÙÔ˘ ¿ÚıÚÔ˘, - ÙÔ fiÓÔÌ· Î·È ÙÔ ÂÒÓ˘ÌÔ Î¿ıÂ Û˘ÁÁڷʤ· ÛÙËÓ ÔÓÔÌ·ÛÙÈ΋, - ÙÔ ÂÈÛÙËÌÔÓÈÎfi ΤÓÙÚÔ (›‰Ú˘Ì·, ÎÏÈÓÈ΋, ÂÚÁ·ÛÙ‹ÚÈÔ) ·fi fiÔ˘ ÚÔ¤Ú¯ÂÙ·È Ë ÂÚÁ·Û›·. ™Â ÂÚ›ÙˆÛË ¤ÏÏÂȄ˘ Û˘ÓÂÚÁ·Û›·˜ ÌÂ Û˘ÁÎÂÎÚÈ̤ӷ ΤÓÙÚ·, Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÂÙ·È Ë È‰ÈfiÙËÙ· ÙÔ˘/ÙˆÓ Û˘ÁÁڷʤˆÓ (.¯. ȉÈÒÙ˘ ·È‰›·ÙÚÔ˜) Î·È Ô ÙfiÔ˜ ‰È·ÌÔÓ‹˜ ÙÔ˘/ÙˆÓ, - ÙËÓ Ï‹ÚË ‰È‡ı˘ÓÛË Î·È ÙÔ ÙËϤʈÓÔ ÙÔ˘ Û˘ÁÁڷʤ· Ì ÙÔÓ ÔÔ›Ô Á›ÓÂÙ·È Ë ·ÏÏËÏÔÁÚ·Ê›·. ¶ÂÚÈÏ‹„ÂȘ H ÂÚ›ÏË„Ë ÙˆÓ ÂÚ¢ÓËÙÈÎÒÓ ÂÚÁ·ÛÈÒÓ Ú¤ÂÈ Ó· Â›Ó·È ‰ÔÌË̤ÓË. N· ·Ó·ÎÂÊ·Ï·ÈÒÓÂÈ ·) ÙÔ˘˜ ÛÙfi¯Ô˘˜, ‚) ÙË ÌÂıÔ‰ÔÏÔÁ›·, Á) Ù· ΢ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Î·È ‰) Û¯fiÏÈ· ‹ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ù˘ ÌÂϤÙ˘. ¢ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÂÈ ÙȘ 250 ϤÍÂȘ. ™ÙËÓ ÂÚ›ÏË„Ë ÛÙ· ·ÁÁÏÈο Ú¤ÂÈ Ó· ·Ó·ÁÚ¿ÊÔÓÙ·È ÛÙËÓ ·Ú¯‹ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ô Ù›ÙÏÔ˜ Ù˘ ÂÚÁ·Û›·˜ Î·È Ù· ÔÓfiÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ ÛÙ· ·ÁÁÏÈο. TÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ·ÁÁÏÈÎÔ‡ ÎÂÈ̤ÓÔ˘ ‰ÂÓ Ú¤ÂÈ Ó· ‰È·Ê¤ÚÂÈ ·fi ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÂÏÏËÓÈÎfi. ¶ÂÚ›ÏË„Ë ‰ÂÓ ¤¯Ô˘Ó ÔÈ Ô‰ËÁ›Â˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÚÔ˜ ÙÔ˘˜ ÁÔÓ›˜. T· ¿ÚıÚ· Û‡ÓÙ·Í˘ Î·È ÔÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ¤¯Ô˘Ó ÌfiÓÔ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë. K¿Ùˆ ·fi ÙËÓ ÂÏÏËÓÈ΋ Î·È ÙËÓ ·ÁÁÏÈ΋ ÂÚ›ÏË„Ë ÛËÌÂÈÒÓÔÓÙ·È ÙÚÂȘ ¤ˆ˜ ¤ÓÙ ϤÍÂȘ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙÔ ıÂÌ·ÙÈÎfi ¢ÚÂÙ‹ÚÈÔ. K›ÌÂÓÔ OÈ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ÂÈÛ·ÁˆÁ‹, ˘ÏÈÎfi Î·È ÌÂıfi‰Ô˘˜, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘˙‹ÙËÛË. H ÂÈÛ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· ‰Â‰Ô̤ӷ Ù˘
viii
¤Ú¢ӷ˜ ÛÙÔ Û˘ÁÎÂÎÚÈ̤ÓÔ ı¤Ì· Ì ÙȘ ΢ÚÈfiÙÂÚ˜ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ Î·È ÙÔ ÛÎÔfi Ù˘ ÂÚÁ·Û›·˜. H ÂÚÈÁÚ·Ê‹ ÙÔ˘ ˘ÏÈÎÔ‡ Î·È ÙˆÓ ÌÂıfi‰ˆÓ Ú¤ÂÈ Ó· Â›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÚÎÂÙ¿ ÏÂÙÔÌÂÚ‹˜ ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙËÓ ·Ó··Ú·ÁˆÁ‹ ÙÔ˘˜ ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜. T· ·ÔÙÂϤÛÌ·Ù· Ú¤ÂÈ Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ì ۷ʋÓÂÈ· Î·È Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÙËÓ ··Ú·›ÙËÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. H Û˘˙‹ÙËÛË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ÚÔ·ÙÔ˘Ó ·fi ÙËÓ ÂÚÁ·Û›·, ÙË ÛËÌ·Û›· Ô˘ ÌÔÚ› Ó· ¤¯Ô˘Ó Î·È ÙËÓ Èı·Ó‹ Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ Ì ·Ú·ÙËÚ‹ÛÂȘ ¿ÏÏˆÓ ÂÚ¢ÓËÙÒÓ. OÈ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÈÛ·ÁˆÁ‹, ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË. OÈ ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó Û‡ÓÙÔÌË ÂÚÈÁÚ·Ê‹ Ù˘ ÂÚ›ÙˆÛ˘ Î·È ‚Ú·¯Â›· Û˘˙‹ÙËÛË Ì ¤ÌÊ·ÛË ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. TÈ̤˜ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ OÈ ÙÈ̤˜ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Ú¤ÂÈ Ó· ÂÎÊÚ¿˙ÔÓÙ·È ÛÙÔ ¢ÈÂıÓ¤˜ ™‡ÛÙËÌ· MÔÓ¿‰ˆÓ (SI Units) Î·È ÛÙÔ MÂÙÚÈÎfi (Conventional - ™˘Ì‚·ÙÈÎfi) ™‡ÛÙËÌ· ̤۷ Û ·Ú¤ÓıÂÛË. ¶›Ó·Î˜ ÌÂÙ·ÙÚÔ‹˜ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÛÙÔ JAMA ÙÔ˘ 1986 (255:23292339). ™˘ÓÙÔÌÔÁڷʛ˜ OÈ Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ¤¯Ô˘Ó ÂÈ‚ÏËı› ‰ÈÂıÓÒ˜ ‰ËÌÔÛȇÔÓÙ·È Û οı Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ™‡ÓıÂÙÔÈ Î·È Ì·ÎÚÔÛÎÂÏ›˜ fiÚÔÈ Ô˘ ·ӷϷ̂¿ÓÔÓÙ·È Û˘¯Ó¿ ÛÙÔ Î›ÌÂÓÔ ÌÔÚÔ‡Ó Ó· ·ÓÙÈηı›ÛÙ·ÓÙ·È ·fi Û˘ÓÙÔÌÔÁڷʛ˜ Ô˘ ÂÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ Û ÂȉÈÎfi ηٿÏÔÁÔ Ô ÔÔ›Ô˜ ˘Ô‚¿ÏÏÂÙ·È Ì·˙› Ì ÙËÓ ÂÚÁ·Û›·. OÈ Û˘ÓÙÔÌÔÁڷʛ˜ ·Ó·Ê¤ÚÔÓÙ·È Û ·Ú¤ÓıÂÛË ÌfiÓÔ ÛÙȘ ÂÚÈÏ‹„ÂȘ. BÈ‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ™ÙÔ ÙÌ‹Ì· Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ηٷ¯ˆÚÔ‡ÓÙ·È fiϘ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ™ÙÔ Î›ÌÂÓÔ ÔÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ·Ó·Ê¤ÚÔÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Û ·Ú¤ÓıÂÛË. OÈ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜ ‰ÂÓ Ú¤ÂÈ Ó· ˘ÂÚ‚·›ÓÔ˘Ó ÙȘ 70 ÛÙȘ ·Ó·ÛÎÔ‹ÛÂȘ, ÙȘ 30 ÛÙȘ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜, ÙȘ 12 ÛÙ· ›ηÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ ÂÚÈÙÒÛÂȘ, ÙȘ 5 ÛÙȘ ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ. H ·Ó·ÊÔÚ¿ ÂÏÏËÓÈÎÒÓ ‰ËÌÔÛȇÛÂˆÓ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË. H Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙȘ ÚԉȷÁڷʤ˜ Ù˘ National Library of Medicine (H¶A) Î·È Ù˘ International Committee of Medical Journal Editors (N Eng J Med 1997;337:309315,http://jama.ama-assn.org/info/auinst-req.htlm). OÈ Û˘ÓÙÌ‹ÛÂȘ ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ Á›ÓÔÓÙ·È Ì ‚¿ÛË ÙÔ Index Medicus (List of Journals Indexed in Index Medicus http://www.nlm.nih.gov).
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·11
¶·Ú·‰Â›ÁÌ·Ù· ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ I. ¶ÂÚÈÔ‰Èο AÓ ÔÈ Û˘ÁÁÚ·Ê›˜ Â›Ó·È ¤ˆ˜ ¤ÍÈ ·Ó·ÁÚ¿ÊÔÓÙ·È fiÏÔÈ, ·Ó Â›Ó·È ÂÙ¿ ‹ ÂÚÈÛÛfiÙÂÚÔÈ ·Ó·ÁÚ¿ÊÔÓÙ·È ÔÈ ÚÒÙÔÈ ¤ÍÈ Î·È ÚÔÛÙ›ıÂÙ·È “et al” ‹ “Î·È Û˘Ó”. T·ÎÙÈ΋ ¤Î‰ÔÛË ÂÚÈÔ‰ÈÎÔ‡: ™ÙÂÊ·Ó›‰Ë˜ A, KÔÚÈÙÛÈ¿‰Ë˜ ™, Mȯ·‹Ï B, AÓ‰ÚÔ˘Ï·Î¿Î˘ ºA. O˘ÚÔ‰˘Ó·ÌÈο Â˘Ú‹Ì·Ù· Û ·ÛıÂÓ›˜ Ì ·ÏȤ˜ ‚·Ï‚›‰Â˜ Ù˘ ÔÈÛı›·˜ Ô˘Ú‹ıÚ·˜. AÚ¯ EÏÏ I·ÙÚ 1988;15:448-455. Vega KJ, Pina I, Krevsky B. Heart transplantation is associated with an increased risk for pancreatobiliary disease. Ann Intern Med 1996;124:980-983. ™˘ÌÏËڈ̷ÙÈÎfi Ù‡¯Ô˜ ÂÚÈÔ‰ÈÎÔ‡: Llach F. Parathyroidectomy in chronic renal failure: Indications, surgical approach and the use of calcitriol. Kidney Int 1990; 38 (29 suppl):S62-S68. XˆÚ›˜ Û˘ÁÁڷʤ·: Coffee drinking and cancer of the pancreas [editorial]. BMJ 1981;283:628. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù‡Ô˘ ¿ÚıÚÔ˘: §ÂΤ· B, M·ÎԇϷ X, M·ÙÛ·ÓÈÒÙ˘ N. ¢È·ÓÔÛÔÎÔÌÂȷΤ˜ ‰È·ÊÔÚ¤˜ ÛÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ıÓËÛÈÌfiÙËÙ·. TÈ ˘Ô‰ÂÈÎÓ‡Ô˘Ó; ¶ÂÚÈÏ. 78, 26Ô ¶·ÓÂÏ. ¶·È‰. ™˘Ó. Iˆ¿ÓÓÈÓ· 28-29 M·˚Ô˘ 1988. Spargo PM, Manners JM. DDAVP and open heart surgery [letter]. Anaesthesia 1989;44:363-364. II. BÈ‚Ï›· KÂÊ¿Ï·ÈÔ Û ‚È‚Ï›Ô: Schuster V. Renal clearance. In: Seldin DW, Giebich G, eds. The kidney: physiology and pathophysiology. 2nd ed. New York: Raven Press, 1992:943-978. ™‡ÁÁÚ·ÌÌ· ‹ ÌÔÓÔÁÚ·Ê›·: M·Ú¿ÙÔ˘-AÏÈÚ¿ÓÙË §. OÈÎÔÁ¤ÓÂÈ· ÛÙËÓ Aı‹Ó·: OÈÎÔÁÂÓÂȷο ÚfiÙ˘· Î·È Û˘˙˘ÁÈΤ˜ Ú·ÎÙÈΤ˜. Aı‹Ó·: EıÓÈÎfi K¤ÓÙÚÔ KÔÈÓˆÓÈÎÒÓ EÚ¢ÓÒÓ 1995. ¢ËÌÔÛ›Â˘ÛË Û ÙfiÌÔ Ú·ÎÙÈÎÒÓ: Bauer AW. The two definitions of bacterial resistance. In: Smith AJ, Rogers CA, eds. Proceedings of the Third International Congress of Chemotherapy; 1962 May 2931; New York: International Society of Chemotherapy, 1963:484-500. ¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: MÂÓ¤ÙÔ˘-M·Ú·ÓÙ›‰Ô˘ A. XÚËÛÈÌÔÔ›ËÛË ÔÏÏ·ÏÒÓ ÂȉÈÎÒÓ ‰ÔÎÈÌ·ÛÈÒÓ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô ÙˆÓ ÂÈÙÒÛÂˆÓ Ù˘ ÌÔÏ˘‚‰È¿Ûˆ˜ ÛÙÔ K.N.™. ·È‰ÈÒÓ (¢È‰·ÎÙ. ¢È·ÙÚ.). Aı‹Ó·: IÓÛÙÈÙÔ‡ÙÔ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ 1988.
ÕÚıÚ· Û ËÏÂÎÙÚÔÓÈ΋ ÌÔÚÊ‹: Morse SS. Factors in the emergence of infectious diseases.Emerg Infect Dis [serial online]1995 JanMar[cited 1996 June 5];1(1):[24 screens]. Available from: URL: http://www.cdc.gov/ncidod/EID/eid.htm ¶›Ó·Î˜ Î·È ÂÈÎfiÓ˜ AÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó (¤Ó· ÚˆÙfiÙ˘Ô+‰‡Ô ʈÙÔ·ÓÙ›ÁÚ·Ê·). ¶Ú¤ÂÈ Ó· ¤¯Ô˘Ó Ï¿ÙÔ˜ ›ÛÔ Ì ÙÔ Ï¿ÙÔ˜ ÙÔ˘ ÌÔÓfiÛÙËÏÔ˘ (8 cm) ‹ Ì ÙÔ Ï¿ÙÔ˜ fiÏ˘ Ù˘ ÛÂÏ›‰·˜ (16,8 cm). TÔ Ì¤ÁÈÛÙÔ Ì‹ÎÔ˜ ÙÔ˘˜, Ì·˙› Ì ÙÔ˘˜ Ù›ÙÏÔ˘˜ ‰ÂÓ Ú¤ÂÈ Ó· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ·fi 22 cm. OÈ ›Ó·Î˜ ·ÚÈıÌÔ‡ÓÙ·È Ì ·Ú·‚ÈÎÔ‡˜ ·ÚÈıÌÔ‡˜ Ì ÙË ÛÂÈÚ¿ Ô˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÛÙÔ Î›ÌÂÓÔ. ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‚Ú·¯‡ Ù›ÙÏÔ Î·È ÂÂÍ‹ÁËÛË ÙˆÓ Û˘ÓÙÌ‹ÛÂˆÓ ÛÙÔ Î¿Ùˆ ̤ÚÔ˜. ™ÙÔ˘˜ ›Ó·Î˜ Ú¤ÂÈ Ó· ·ÔʇÁÔÓÙ·È ÔÈ Î¿ıÂÙ˜ ÁÚ·Ì̤˜. ŸÏÔ ÙÔ ·ÂÈÎÔÓÈÛÙÈÎfi ˘ÏÈÎfi (Û¯‹Ì·Ù·, ‰È·ÁÚ¿ÌÌ·Ù·, ʈÙÔÁڷʛ˜, ÎÏ.) ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÂÈÎfiÓ˜. £· Ú¤ÂÈ Ó· Â›Ó·È ¿ÚÈÛÙ˘ ÔÈfiÙËÙ·˜ Ì ÌÔÚÊ‹ ʈÙÔÁÚ·ÊÈÒÓ ‹ Î·È ÚˆÙÔÙ‡ˆÓ. ™˘ÛÙ‹ÓÂÙ·È ÛÙ· Û¯‹Ì·Ù· Ó· ·ÔʇÁÔÓÙ·È ÔÈ ÛÎÈ¿ÛÂȘ ÛÙÔ ÊfiÓÙÔ Î·È ÙÔ Î›ÌÂÓÔ Ì¤Û· ÛÙËÓ ÂÈÎfiÓ·. ™ÙÔ ›Ûˆ ̤ÚÔ˜ ÙˆÓ ÂÈÎfiÓˆÓ Ú¤ÂÈ Ó· ÛËÌÂÈÒÓÂÙ·È Ì ÌÔχ‚È Ô ·ÚÈıÌfi˜ Ù˘ ÂÈÎfiÓ·˜ Î·È ÙÔ fiÓÔÌ· ÙÔ˘ ÚÒÙÔ˘ Û˘ÁÁڷʤ·, ηıÒ˜ Î·È ¤Ó· ‚¤ÏÔ˜ ÙÔ ÔÔ›Ô Ó· ‰Â›¯ÓÂÈ ÙÔ ¿Óˆ ̤ÚÔ˜ Ù˘ ÂÈÎfiÓ·˜. ™ÙȘ ʈÙÔÁڷʛ˜ ·ÛıÂÓÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·ÁÓˆÚ›˙ÂÙ·È Ë Ù·˘ÙfiÙËÙ¿ ÙÔ˘˜. OÈ ·ÛıÂÓ›˜ ‰ÂÓ Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÔÓÔÌ·ÛÙÈο. ¶ÚÈÓ ·ÔÛÙ›ÏÂÙ ÙËÓ ÂÚÁ·Û›· Û·˜ ‚‚·Èˆı›Ù fiÙÈ ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÂÈÛÙÔÏ‹ ˘Ô‚ÔÏ‹˜ - ‰‹ÏˆÛË fiÙÈ ‰ÂÓ ¤¯ÂÈ ˘Ô‚ÏËı› Û˘Á¯ÚfiÓˆ˜ Û ¿ÏÏÔ EÏÏËÓÈÎfi ÂÚÈÔ‰ÈÎfi Î·È ‰ÂÓ ¤¯ÂÈ ‹‰Ë ‰ËÌÔÛÈ¢Ù›. - ·Ó¿Ù˘Ô Î·È ÂÈÛÙÔÏ‹ ¤ÁÎÚÈÛ˘ ÙÔ˘ ‰È¢ı˘ÓÙ‹ Û‡ÓÙ·Í˘ Û ÂÚ›ÙˆÛË Ô˘ ¤¯ÂÈ ‰ËÌÔÛÈ¢Ù› Û ÍÂÓfiÁψÛÛÔ ÂÚÈÔ‰ÈÎfi - 3 ·ÓÙ›ÁÚ·Ê· ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ù˘ ÂÚÁ·Û›·˜ - ÛÂÏ›‰· Ù›ÙÏÔ˘ (¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - Ù›ÙÏÔ Î·È ‚Ú·¯‡ Ù›ÙÏÔ ÂÚÁ·Û›·˜ - fiÓÔÌ· Î·È ÂÒÓ˘ÌÔ Û˘ÁÁڷʤˆÓ (ÔÏÔÁڿʈ˜), ÂÈÛÙËÌÔÓÈÎfi/¿ ΤÓÙÚÔ/· fiÔ˘ ¤ÁÈÓÂ Ë ÂÚÁ·Û›· - fiÓÔÌ·, ‰È‡ı˘ÓÛË Î·È ÙËϤʈÓÔ Û˘ÁÁڷʤ· ÁÈ· ·ÏÏËÏÔÁÚ·Ê›· - ÂÚ›ÏË„Ë ÂÏÏËÓÈ΋-·ÁÁÏÈ΋, ϤÍÂȘ ÎÏÂȉȿ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ηٿÏÔÁÔ Û˘ÓÙÔÌÔÁÚ·ÊÈÒÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ΛÌÂÓÔ (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ‚È‚ÏÈÔÁÚ·Ê›· (‰ÈÏfi ‰È¿ÛÙËÌ· - ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) - ›Ó·Î˜ (Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó - ÂÈÎfiÓ˜, Ì ‚¤ÏÔ˜ ÛÙÔ ›Ûˆ ̤ÚÔ˜ Ó· ‰Â›¯ÓÂÈ ÚÔ˜ Ù· ¿ӈ, ·ÚÈıÌË̤Ó˜, ÂȘ ÙÚÈÏÔ‡Ó - Ù›ÙÏÔÈ ÂÈÎfiÓˆÓ (‰ÈÏfi ‰È¿ÛÙËÌ· - Ô Î·ı¤Ó·˜ Û ¯ˆÚÈÛÙ‹ ÛÂÏ›‰·) ÂȘ ÙÚÈÏÔ‡Ó.
ix
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·265
¶∞π¢π∞∆ƒπ∫∏ 2000;63:265-267
AºIEPøMA: YÁ›· ÙÔ˘ ·È‰ÈÔ‡ 2000
H ÓÂoÁÓÔÏÔÁ›· ÛÙËÓ ·Ó·ÙÔÏ‹ Ù˘ ÙÚ›Ù˘ ¯ÈÏÈÂÙ›·˜ M·ÚȤÙÙ· •¿ÓıÔ˘ M. Xanthou. Neonatology at the dawn of the third millenium. Paediatriki 2000;63:265-267. ● Abstract: During the second half of the 20th century impressive progress was made in neonatology based on knowledge that was gained from research on the fetus and the newborn. With the help of the technological revolution which occurred at the same time, the first neonatal intensive care units were created. The neonatal morbidity and mortality rates fell dramatically during the following years and today 80% of the babies of BW<1000g survive, and only 8-15% of them develop major handicaps. The reduction of neonatal morbidity and mortality was due in part to the new methods of treatment and prophylaxis which were applied, including the administration of surfactant and high frequency ventilation to babies suffering from respiratory distress syndrome, the administration of i.v. lg and growth factors to increase neonatal host defense mechanisms against infections, and total parenteral nutrition. A second factor in improved survival comprises the improved methods of diagnosis. Today with the new methods of imaging and with the help of molecular biology, congenital illness can be diagnosed very early and even at the beginning of intrauterine life. Thirdly there has been improvement in the quality and organization of perinatal care. In Greece perinatal mortality has decreased considerably during the last 20 years, and this is of added importance as the birth rate during the same time period has been decreasing. Key words: neonatology, intensive care, morbidity, mortality.
H ÚfiÔ‰Ô˜ ÛÙËÓ ÓÔÛËÏ›· ÙˆÓ ÓÂÔÁÓÒÓ ·ÔÙÂÏ› ¤Ó· ·fi Ù· ÈÔ ÛËÌ·ÓÙÈο ÂÈÙ‡ÁÌ·Ù· ÙÔ˘ 20Ô‡ ·ÈÒÓ·. M¤¯ÚÈ ÙÔ Ù¤ÏÔ˜ ÙÔ˘ 19Ô˘ ·ÈÒÓ· ÚfiˆÚ· ÌÈÎÚÔ‡ ‚¿ÚÔ˘˜ ıˆÚÔ‡ÓÙ·Ó ·˘Ù¿ Ì B°<2500ÁÚ.Î·È ·fi ·˘Ù¿ ÙÔ 70% ¤ı·ÈÓ·Ó. TÔ 1900 Ô Pierre Budin ÛÙÔ ¶·Ú›ÛÈ Î·Ù·Û··Û ÙËÓ ÚÒÙË ıÂÚÌÔÎÔÈÙ›‰· Î·È ÂÈÛ‹Á·Á ÙÔ Ï‡ÛÈÌÔ ÙˆÓ ¯ÂÚÈÒÓ ÚÈÓ ·fi ÙËÓ Â·Ê‹ Ì ÙÔ ÓÂÔÁ¤ÓÓËÙÔ. M ·˘Ù¿ Î·È ÌfiÓÔ Ù· ̤ÙÚ· ÌÂÈÒıËÎÂ Ë ıÓËÛÈÌfiÙËÙ· ÙˆÓ ÓÂÔÁÓÒÓ Ì B°<2500 ÁÚ. ÂÚ›Ô˘ ÛÙÔ 20%. K·Ù¿ ÙÔ ÚÒÙÔ ‹ÌÈÛ˘ ÙÔ˘ 20Ô‡ ·ÈÒÓ·, Ù›ÔÙ ÛËÌ·ÓÙÈÎfi ‰ÂÓ Û˘Ó¤‚Ë. K·Ù¿ ÙÔ ‰Â‡ÙÂÚÔ ‹ÌÈÛ˘ ÛËÌÂÈÒÓÂÙ·È ÌÈ· Ú·ÁÌ·ÙÈ΋ ·ӿÛÙ·ÛË ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÚÔÒÚˆÓ Î·È ‚·ÚÈ¿ ¿ÚÚˆÛÙˆÓ ÓÂÔÁÓÒÓ. TÔ ÌÂÁ¿ÏÔ ÂӉȷʤÚÔÓ ¿Ú¯ÈÛ Á‡Úˆ ÛÙ· 1950, fiÙ·Ó ÔÈ ÂÚ¢ÓËÙ¤˜ ÛÙÚ¿ÊËÎ·Ó ÛÙË ÌÂϤÙË Ù˘ Ê˘ÛÈÔÏÔÁ›·˜ Î·È Ê˘ÛÈÔ·ıÔÏÔÁ›·˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È ÙÔ˘ ÓÂÔÁÓÔ‡. OÈ ÁÓÒÛÂȘ ·˘Ù¤˜, Ì·˙› Ì ÙËÓ ÌÂÁ¿ÏË Ù¯ÓÔÏÔÁÈ΋ ÚfiÔ‰Ô Ô˘ ¿ÓıÈ˙ ›Û˘ ÂΛÓË ÙËÓ ÂÔ¯‹, Ô‰‹ÁËÛ ÛÙËÓ ‰ËÌÈÔ˘ÚÁ›· ÙˆÓ ÚÒÙˆÓ MÔÓ¿‰ˆÓ EÓÙ·ÙÈ΋˜ NÔÛËÏ›·˜ NÂÔÁÓÒÓ ÛÙËÓ ‰ÂηÂÙ›· 1960-1970. ŒÙÛÈ, ÂÓÒ Ë ıÓËÛÈÌfiÙËÙ· ÙˆÓ Ôχ ÌÈÎÚÒÓ ÚÔÒÚˆÓ Ì B°<1200 ÁÚ. ÚÈÓ ·fi ÙÔ 1970 ‹Ù·Ó Á‡Úˆ ÛÙÔ 80% ÌÂÙ¿ ÙÔ 1980 ¤ÂÛ ÛÙÔ 20%. ™Â ·˘Ùfi, ÂÎÙfi˜ ·fi ÙȘ MÔÓ¿‰Â˜ EÓÙ·ÙÈ΋˜ NÔÛËÏ›·˜ Û˘Ó¤‚·Ï·Ó ÛËÌ·ÓÙÈο Î·È Ó¤Â˜ ıÂڷ¢ÙÈΤ˜ ̤ıÔ‰ÔÈ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ÓÂÔÁÓÒÓ. ¶ÚÈÓ ·fi ÙÔ 1970 ÙÔ I‰ÈÔ·ı¤˜ ™‡Ó‰ÚÔÌÔ AÓ·Ó¢ÛÙÈ΋˜ ¢˘Û¯¤ÚÂÈ·˜ (I™A¢) ·ÔÙÂÏÔ‡Û ÙËÓ Î˘ÚÈfiÙÂÚË ·ÈÙ›· ı·Ó¿ÙÔ˘ Ù˘ ÓÂÔÁÓÈ΋˜ ÂÚÈfi‰Ô˘. H ·Ó·Î¿Ï˘„Ë Î·È ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (Surfactant) ÂÏ¿ÙÙˆÛ ÙËÓ ıÓËÛÈÌfiÙËÙ· ÙÔ˘ I™A¢ ηٿ 40% Î·È ÙȘ ÂÈÏÔΤ˜ ÙÔ˘ ηٿ 60% (1). TÂÏÂ˘Ù·›· Û˘ÓÈÛÙ¿Ù·È Ô ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁˆÓ Ó· ‰›‰ÂÙ·È fi¯È ÌfiÓÔ ıÂڷ¢ÙÈο, ·ÏÏ¿ Î·È ÚÔÊ˘Ï·ÎÙÈο Û ÓÂÔÁ¤ÓÓËÙ· Ì ËÏÈΛ· ΢‹Ûˆ˜ <32 ‚‰ÔÌ¿‰ˆÓ Ù· ÔÔ›· ηٿ ÙËÓ ·Ó¿ÓË„Ë ¯ÚÂÈ¿˙ÔÓÙ·È ‰È·ÛˆÏ‹ÓˆÛË (2). O Û˘Ó‰˘·ÛÌfi˜ ¯ÔÚ‹ÁËÛ˘ ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÛÙË ÌËÙ¤Ú· ÚÔ ÙÔ˘ ÙÔÎÂÙÔ‡ Î·È ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙ· ÓÂÔÁÓ¿ ʤÚÓÂÈ Ù· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· (3). OÈ Î·ÈÓÔ‡ÚÁȘ ̤ıÔ‰ÔÈ Ù¯ÓËÙÔ‡ ·ÂÚÈÛÌÔ‡, fiˆ˜ ·˘Ù¤˜ Ô˘ ·Ú¤¯ÔÓÙ·È Ì ·Ó·Ó¢ÛÙ‹Ú˜ ˘„ËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ Ì ٷϷÓÙÒÛÂȘ ‹ ·ÂÚÈÒıËÛË Î·È ‰›‰Ô˘Ó 200-1200 ·Ó·ÓÔ¤˜/ÏÂÙfi, ‰ÂÓ ˘¿Ú¯ÂÈ ·ÌÊÈ‚ÔÏ›· fiÙÈ
265
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·266
¶∞π¢π∞∆ƒπ∫∏ 2000;63:265-267
M. •¿ÓıÔ˘
ÛÒ˙Ô˘Ó ÓÂÔÁÓ¿ Ù· ÔÔ›· ‰ÂÓ ·ÓÙ·ÔÎÚ›ÓÔÓÙ·È ÛÙÔÓ Û˘Ó‹ıË ·ÂÚÈÛÌfi(4). H ¯Ú‹ÛË ÙÔ˘ ÌÔÓÔÍÂȉ›Ô˘ ÙÔ˘ ·˙ÒÙÔ˘ (NO) Ì·˜ ÚÔÛʤÚÂÈ ¿ÌÂÛË Î·È ÂÈÙ˘¯‹ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ˘¤ÚÙ·Û˘. H ıÂڷ›· Ì ˘„›Û˘¯ÓÔ Ù·Ï·ÓÙˆÛÈÎfi ·ÂÚÈÛÌfi Î·È Û˘Á¯ÚfiÓˆ˜ ÂÈÛÓÔ‹ NO, ‰›‰ÂÈ Ù· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Û ‚·ÚȤ˜ Ó¢ÌÔÓÈΤ˜ ˘ÂÚÙ¿ÛÂȘ (5). T¤ÏÔ˜, Ë Â͈ۈ̷ÙÈ΋ Ô͢ÁfiÓˆÛË Ì¤Ûˆ ÌÂÌ‚Ú¿Ó˘ (ECMO) Â›Ó·È Ë ÙÂÏÂ˘Ù·›· ̤ıÔ‰Ô˜ Ë ÔÔ›· ¯ÚËÛÈÌÔÔÈÂ›Ù·È fiÙ·Ó ¤¯Ô˘Ó ·ÔÙ‡¯ÂÈ fiϘ ÔÈ ÚÔ·Ó·ÊÂÚı›Û˜ ̤ıÔ‰ÔÈ, Ì ηϿ ·ÔÙÂϤÛÌ·Ù· ΢ڛˆ˜ fiÙ·Ó ·ÊÔÚ¿ ÓÂÔÁ¤ÓÓËÙ· Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 2000 ÁÚ. (6). ™ËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË Ì›ˆÛË Ù˘ ˘„ËÏ‹˜ ÓÂÔÁÓÈ΋˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ Ô˘ ÔÊ›ÏÔÓÙ·È Û ÛÔ‚·Ú¤˜ ÓÂÔÁÓÈΤ˜ ÏÔÈÌÒÍÂȘ ¤¯Ô˘Ó ·›ÍÂÈ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÔÈ ÓÂÒÙÂÚ˜ ̤ıÔ‰ÔÈ ÂÓ›Û¯˘Û˘ ÙˆÓ ·ÓÔÛÔ‚ÈÔÏÔÁÈÎÒÓ ·Ì˘ÓÙÈÎÒÓ Ì˯·ÓÈÛÌÒÓ ÙÔ˘ ÓÂÔÁÓÔ‡. OÈ ÏÔÈÌÒÍÂȘ ·ÎfiÌË Î·È Û‹ÌÂÚ· ·ÔÙÂÏÔ‡Ó Ì›· ·fi ÙȘ ·ÚȘ ·Èٛ˜ ÓÂÔÁÓÈ΋˜ ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ Î·È È‰È·›ÙÂÚ· ÛÙȘ ˘fi ·Ó¿Ù˘ÍË ¯ÒÚ˜ Î·È ÛÙȘ MÔÓ¿‰Â˜ EÓÙ·ÙÈ΋˜ NÔÛËÏ›·˜ NÂÔÁÓÒÓ. T· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¯ÔÚËÁÔ‡ÓÙ·È Û ÓÂÔÁ¤ÓÓËÙ· ÂÓ‰ÔÊϤ‚Ș ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ Î·È ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔÈ ·ÈÌÔÔÈËÙÈÎÔ› ·˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ì ÛÎÔfi ÙËÓ ÂÓ›Û¯˘ÛË ÙˆÓ ·Ì˘ÓÙÈÎÒÓ ÙÔ˘˜ Ì˯·ÓÈÛÌÒÓ. OÈ ÂÓ‰ÔÊϤ‚Ș ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ (IVIG) ÚÔÛʤÚÔ˘Ó ·ÓÙÈÛÒÌ·Ù· ÛÙ· ÌÈÎÚÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ ÙˆÓ ÔÔ›ˆÓ Ù· ›‰· Â›Ó·È Ôχ ¯·ÌËÏ¿. £· Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÔÈ IV ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ ÂÎÙfi˜ ·fi ÙËÓ ·ÓÙÈÏÔÈÌÔÁfiÓÔ ‰Ú¿ÛË ÙÔ˘˜ ¤¯Ô˘Ó Î·È ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ‰Ú¿ÛË (7). OÈ ·˘ÍËÙÈÎÔ› ·ÈÌÔÔÈËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ (G-CSF Î·È GM-CSF) ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·Ú·ÁˆÁ‹ ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ ·ÏÏ¿ Î·È ÛÙËÓ ‚ÂÏÙ›ˆÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘˜ (8). ŒÙÛÈ ÔÈ ÂÓ‰ÔÊϤ‚Ș ·ÓÔÛÔÛÊ·ÈÚ›Ó˜ ηıÒ˜ Î·È ÔÈ ·ÈÌÔÔÈËÙÈÎÔ› ·˘ÍËÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ fiÙ·Ó ‰›‰ÔÓÙ·È ıÂڷ¢ÙÈο Û ÓÂÔÁÓÈΤ˜ ÛË„·È̛˜ ‹ ÚÔÊ˘Ï·ÎÙÈο ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ÏÔÈÌÒÍÂˆÓ ¤¯Ô˘Ó ‰ÒÛÂÈ Ôχ ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· (7,8). T¤ÏÔ˜, ı· Ú¤ÂÈ Ó· ·Ó·ÊÂÚı› Ë ÌÂÁ¿ÏË Û˘Ì‚ÔÏ‹ Ù˘ ÔÏÈ΋˜ ·ÚÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜ ȉȷ›ÙÂÚ· ÛÙ· ÌÈÎÚÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÚfiˆÚ· ÓÂÔÁÓ¿. M ÙË ¯ÔÚ‹ÁËÛË ·ÌÈÓÔͤˆÓ Î·È ÏÈÒÓ ÂÓ‰ÔÊÏ‚›ˆ˜ ·fi ÙËÓ ÚÒÙË ÎÈfiÏ·˜ ̤ڷ Ù˘ ˙ˆ‹˜, ÂÈÙ‡¯ıËΠfi¯È ÌfiÓÔ Ë Ì›ˆÛË Ù˘ ıÓËÛÈÌfiÙËÙ·˜, ·ÏÏ¿ ·˘Í‹ıËÎÂ Î·È Ë ÌÂÙ¤ÂÈÙ· Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ ÓÂÔÁÓÒÓ ·˘ÙÒÓ (9). Afi ÙÔ 1990 Î·È ÌÂÙ¿, ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ÓÂÔÁÓÒÓ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ <1000 ÁÚ. Î·È ‰È¿ÚÎÂÈ· ΢‹Ûˆ˜ ÛÙ· fiÚÈ· Ù˘ ‚ȈÛÈÌfiÙËÙ·˜ (23 Ì 24 ‚‰ÔÌ¿‰Â˜), ÂÈ˙Ô‡Ó. EÓÒ ÙÔ ÔÛÔÛÙfi ÂÈ‚›ˆÛ˘ ÙˆÓ ÓÂÔÁÓÒÓ ·˘ÙÒÓ Û‹ÌÂÚ· ‰ÈÏ·ÛÈ¿ÛÙËΠÊÙ¿ÓÔÓÙ·˜ ÙÔ 80%, ÙÔ ÔÛÔÛÙfi ÙˆÓ ÛÔ‚·ÚÒÓ ·Ó·ËÚÈÒÓ ‰ÂÓ ·˘Í‹ıËΠÛËÌ·ÓÙÈο ÛÙ· ÂÈ˙‹Û·ÓÙ· ÓÂÔÁÓ¿ Î·È Î˘Ì·›ÓÂÙ·È ÌÂٷ͇ 8-15% (10-12). TÂÏÂ˘Ù·›Â˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ì ÙËÓ ÂÈ‚›ˆÛË ÙˆÓ Ôχ ÌÈÎÚÒÓ ·˘ÙÒÓ ÓÂÔÁÓÒÓ ‰ÂÓ ·˘Í‹ıËÎÂ Ë ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË ·ÏÏ¿ ·˘Í‹ıËÎ·Ó Ë ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ· Ù˘ ÚÔˆÚfiÙËÙ·˜, Ë Ì˘ˆ›· Î·È Ô ÛÙÚ·‚ÈÛÌfi˜. ¢È·ÈÛÙÒıËΠ›Û˘, fiÙÈ ÔÏÏ¿ ·fi Ù· Ôχ ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÓÂÔÁÓ¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜ ÛÙÔ Û¯ÔÏÂ›Ô Î·È ¯ÚÂÈ¿˙ÔÓÙ·È È‰È·›ÙÂÚË ˘ÔÛÙ‹ÚÈÍË ÁÈ· Ó· ÌËÓ ·ÚÔ˘ÛÈ¿ÛÔ˘Ó Úfi‚ÏËÌ· ÛÙË Û¯ÔÏÈ΋ ÙÔ˘˜ ›‰ÔÛË. H ÌË ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË ÙˆÓ ÌÂÙ¤ÂÈÙ· ·Ó·ËÚÈÒÓ ÔÊ›ÏÂÙ·È, ÂÎÙfi˜ ·fi ÙË ¯Ú‹ÛË ÙˆÓ Ó¤ˆÓ ıÂڷ¢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ, ÛÙËÓ ÔÚÁ¿ÓˆÛË Î·È ‚ÂÏÙ›ˆÛË Ù˘ ÂÚÈÁÂÓÓËÙÈ΋˜ ÊÚÔÓÙ›‰·˜. ™ÙË ¯ÒÚ· Ì·˜ ηٿ ÙËÓ 15ÂÙ›· 19831998 Ë ÂÚÈÁÂÓÓËÙÈ΋ ıÓËÛÈÌfiÙËÙ· ˘Ô‰ÈÏ·ÛÈ¿ÛÙËÎÂ Î·È ¤ÊÙ·Û ÛÙÔ 10,5% (13). TÔ ÂӉȷʤÚÔÓ Î·È Ë ÂÓ·Û¯fiÏËÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ÎfiÛÌÔ˘ ·ÓÙÈηÙÔÙÚ›˙ÂÙ·È ÙfiÛÔ ÛÙÔ Ï‹ıÔ˜ ÙˆÓ ÂÏÏËÓÈÎÒÓ ‰ËÌÔÛȇÛÂˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÓÂÔÁÓ¿ ÛÙÔÓ ‰ÈÂıÓ‹ Î·È ÂÏÏËÓÈÎfi È·ÙÚÈÎfi Ù‡Ô (ÌfiÓÔ ÛÙ· ·È‰È·ÙÚÈο ÂÚÈÔ‰Èο, ÛÙË B¿ÛË EÏÏËÓÈ΋˜ BÈ‚ÏÈÔÁÚ·Ê›·˜ "YÁ›· ÙÔ˘ ¶·È‰ÈÔ‡" ·Ó·Ê¤ÚÔÓÙ·È 80 ‰ËÌÔÛȇÛÂȘ) fiÛÔ Î·È ·fi ÙÔ ÁÂÁÔÓfi˜ Ù˘ ·Ó·ÁÓÒÚÈÛ˘ ·fi ÙËÓ ¶ÔÏÈÙ›· ÂÍÂȉ›Î¢Û˘ ÙˆÓ ·È‰È¿ÙÚˆÓ Â› ‰ÈÂÙ›· ÛÙËÓ ÂÓÙ·ÙÈ΋ ÓÔÛËÏ›· ÓÂÔÁÓÒÓ. T¤ÏÔ˜, Ë Ì›ˆÛË ÙˆÓ ·Ó·ËÚÈÒÓ ÔÊ›ÏÂÙ·È ·ÎfiÌË ÛÙËÓ ¤ÁηÈÚË, Û˘¯Ó¿ ÂÓ‰ÔÌ‹ÙÚÈ·, ‰È¿ÁÓˆÛË ÓfiÛˆÓ, Ì ÙËÓ ‚Ô‹ıÂÈ· ÙˆÓ Ó¤ˆÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ ÌÂıfi‰ˆÓ Î·È Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ ηıÒ˜ Î·È ÛÙËÓ ÂÊ·ÚÌÔÁ‹ ÌÂıfi‰ˆÓ ÚfiÏ˄˘ ÓÔÛËÚÒÓ Î·Ù·ÛÙ¿ÛˆÓ, fiˆ˜ ÂÁÎÂÊ·ÏÈÎÒÓ ‚Ï·‚ÒÓ, ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ·˜ Ù˘ ÚÔˆÚfiÙËÙ·˜, ·Ó·ÈÌÈÒÓ ÎÏ. ŒÙÛÈ, Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ˘ÔÍÈ΋˜ ÈÛ¯·ÈÌÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜, ¤¯Ô˘Ó ‰Ôı› Û ÓÂÔÁÓ¿ Ì ·ÛÊ˘Í›· Ê·ÈÓÔ‚·Ú‚ÈÙ¿ÏË, ıÂÈÈÎfi Ì·ÁÓ‹ÛÈÔ, ‚ÈÙ·Ì›ÓË E Î·È ÙÒÚ· ÙÂÏÂ˘Ù·›· ·ÏÏÔÔ˘ÚÈÓfiÏË Î·È ÈÓ‰ÔÌÂı·Î›ÓË (14). OÈ ¤Ú¢Ó˜ ÛÙÔÓ ÙÔ̤· ·˘Ùfi Û˘Ó¯›˙ÔÓÙ·È. °È· ÙËÓ ÚÔʇϷÍË Ù˘ ·ÌÊÈ‚ÏËÛÙÚÔÂȉԿıÂÈ·˜ Ù˘ ÚÔˆÚfiÙËÙ·˜ Û ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ ÓÂÔÁ¤ÓÓËÙ· ‰›‰ÔÓÙ·È ÚÔÊ˘Ï·ÎÙÈο ÔÈ ‚Èٷ̛Ә A Î·È E (15). H ¯ÔÚ‹ÁËÛË ÙˆÓ ‚ÈÙ·ÌÈÓÒÓ ·˘ÙÒÓ Ì·˙› Ì ÙËÓ ÎÚ˘ÔıÂڷ›· Î·È ÙËÓ ÂÊ·ÚÌÔÁ‹ ·ÎÙ›ÓˆÓ Laser ¤¯Ô˘Ó ÂÏ·ÙÙÒÛÂÈ ÙËÓ Ù‡ÊψÛË. T¤ÏÔ˜, ÁÈ· ÙËÓ ÚfiÏË„Ë Ù˘ ·Ó·ÈÌ›·˜ Ù˘ ÚÔˆÚfiÙËÙ·˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Û‹ÌÂÚ· Ë ·Ó·Û˘Ó‰˘·Ṳ̂ÓË ÂÚ˘ıÚÔÔÈËÙ›ÓË Ë ÔÔ›· ¤¯ÂÈ ÂÏ·ÙÙÒÛÂÈ ÛËÌ·ÓÙÈο ÙȘ ÌÂÙ·ÁÁ›ÛÂȘ ·›Ì·ÙÔ˜ ·ÎfiÌË Î·È Û ‚·ÚÈ¿ ¿Û¯ÔÓÙ· ÚfiˆÚ· (16).
266
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·267
¶∞π¢π∞∆ƒπ∫∏ 2000;63:265-267
∞ÊȤڈ̷: ÀÁ›· ÙÔ˘ ·È‰ÈÔ‡ 2000
E›Ó·È ÂÌÊ·Ó¤˜ fiÙÈ Ì ÙËÓ ÂͤÏÈÍË Ù˘ ÂÈÛÙ‹Ì˘ fiÏÔ Î·È ÌÈÎÚfiÙÂÚÔ˘ ‚¿ÚÔ˘˜ Î·È ËÏÈΛ·˜ ΢‹Ûˆ˜ ÓÂÔÁÓ¿ ÂÈ˙Ô‡Ó. K·È ÙÔ ÛËÌ·ÓÙÈÎfi ÂÚÒÙËÌ· Ô˘ ·Ó·Î‡ÙÂÈ Â›Ó·È: Ô‡ ı· Ú¤ÂÈ Ó· ÛÙ·Ì·Ù‹ÛÔ˘Ì ÒÛÙ ӷ ÌËÓ ¤¯Ô˘Ì ÌÂÁ¿ÏË ·‡ÍËÛË ·Ó·ËÚÈÒÓ; ¶·ÏÈ¿ ϤÁ·Ì fiÙÈ ı· Ú¤ÂÈ Ó· ÛÙ·Ì·Ù‹ÛÔ˘Ì ÛÙ· 1500 ÁÚ. ‚¿ÚÔ˜ Á¤ÓÓËÛ˘, ·ÚÁfiÙÂÚ· ÛÙ· 1000 ÁÚ., Û‹ÌÂÚ· ıˆÚÂ›Ù·È ‚ÈÒÛÈÌÔ ¤Ó· ÓÂÔÁÓfi 500ÁÚ. Î·È ˘ÔÏÔÁ›˙ÂÙ·È ÛÙÔ˘˜ ÂÚÈÁÂÓÓËÙÈÎÔ‡˜ ı·Ó¿ÙÔ˘˜, ‰ËÏ·‰‹ ·ÎfiÌË ÎÈ ·Ó Âı¿ÓÂÈ ÂÓ‰ÔÌËÙÚ›ˆ˜. H ÁÂÓÈ΋ ÙÔÔı¤ÙËÛË Â›Ó·È fiÙÈ ·Ó ¤Ó· Ôχ ÌÈÎÚfi ̈Úfi "ı¤ÏÂÈ Ó· ˙‹ÛÂÈ" ¯ˆÚ›˜ Ó· ¤¯ÂÈ ‚·ÚȤ˜ ‚Ï¿‚˜, fiˆ˜ .¯. 4Ô˘ ‚·ıÌÔ‡ ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·, ÙfiÙ ڤÂÈ Ó· ÙÔ ‚ÔËı‹ÛÔ˘Ì fiÛÔ ÌÔÚԇ̠ÁÈ·Ù› ¤¯ÂÈ ÔÏϤ˜ Èı·ÓfiÙËÙ˜ Ó· ÂÍÂÏȯı› Ê˘ÛÈÔÏÔÁÈο. E›ÏÔÁÔ˜ H Ì¿¯Ë ÁÈ· ÙËÓ ÂÈ‚›ˆÛË Î·È Ê˘ÛÈÔÏÔÁÈ΋ ÂͤÏÈÍË ÙˆÓ ÚÔÒÚˆÓ ÓÂÔÁÓÒÓ Û˘Ó¯›˙ÂÙ·È Î·È Î·Ù¿ ÙËÓ ÙÚ›ÙË ¯ÈÏÈÂÙ›· Î·È ·ÔÎÙ¿ ·ÎfiÌË ÈÔ ÌÂÁ¿ÏË ÛËÌ·Û›· ·Ó Ï¿‚Ô˘Ì ˘fi„Ë Ì·˜ fiÙÈ ÔÈ ÁÂÓÓ‹ÛÂȘ ÛÙËÓ ¯ÒÚ· Ì·˜ ·fi 150.000 ÚÈÓ 20 ¯ÚfiÓÈ·, ¤¯Ô˘Ó η٤ÏıÂÈ Û‹ÌÂÚ· ÛÙȘ 98.000. TÂÏÂÈÒÓÔÓÙ·˜, ı· ‹ıÂÏ· Ó· ·Ó·ÊÂÚıÒ ÛÙÔ fiÙÈ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ë Ù¯ÓËÙ‹ ÁÔÓÈÌÔÔ›ËÛË ÂÊ·ÚÌfi˙ÂÙ·È Â˘Ú¤ˆ˜ Ì ÌÂÁ¿Ï˜ ÂÈÙ˘¯›Â˜ ·ÏÏ¿ Î·È Ì ·‡ÍËÛË ÙˆÓ ÚÔÒÚˆÓ ÙÔÎÂÙÒÓ ÏfiÁˆ Ôχ‰˘ÌˆÓ ΢‹ÛˆÓ. O 20fi˜ ·ÈÒÓ·˜ ʇÁÂÈ Î·È ·Ó·Ù¤ÏÏÂÈ Ô 21Ô˜, Ô ÔÔ›Ô˜ Ì ÙȘ ÂÈÙ‡ÍÂȘ Ù˘ ÌÔÚȷ΋˜ ‚ÈÔÙ¯ÓÔÏÔÁ›·˜, Ì·˜ ˘fiÛ¯ÂÙ·È ı·‡Ì·Ù· Ô˘ Â›Ó·È ‰‡ÛÎÔÏÔ ·ÎfiÌË Î·È Ó· Ù· Û˘ÏÏ¿‚Ô˘ÌÂ, fiˆ˜ ÙË ıÂڷ›· ·ÓÈ¿ÙˆÓ ÓfiÛˆÓ Ì ÙËÓ ·ÓÙÈηٿÛÙ·ÛË ·ıÔÏÔÁÈÎÒÓ ÁÔÓȉ›ˆÓ, ÙË ‰ËÌÈÔ˘ÚÁ›· ·ÓıÚˆ›ÓˆÓ ÔÚÁ¿ÓˆÓ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·È... ‰È·ÎÔ¤˜ ÛÙÔÓ ÕÚË! ÕÚ·Á ÙÈ ı·‡Ì·Ù· Ó· Ì·˜ ÂÈÊ˘Ï¿ÛÛÂÈ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÙfiÛÔ ÌÈÎÚÒÓ Î·È Â˘·›ÛıËÙˆÓ ÓÂÔÁÓÒÓ; BÈ‚ÏÈÔÁÚ·Ê›· 1. Morley CJ. Systematic review of prophylactic versus rescue surfactant. Arch Dis Child 1997;77:F70-F4. 2. Renie JM, Bokhari SA. Recent advances in neonatology. Arch Dis Child Fetal Neonatal 1990;81:F1-F4. 3. Jobe AH, Mitchell BR, Gunkel JH. Beneficial effects of the combined use of prenatal corticosteroids and postnatal surfactant on preterm infants. Am J Obstet Gynecol 1993;168:508-513. 4. Clark RH, Yoder BA, Sell MS. Prospective randomized comparison of high frequency oscillation and conventional ventilation in candidates for extra-corporeal membrane oxygenation. J Ped 1994;124:447-454. 5. Kinsella JP, Truog WE, Walsh WF. Randomized, multicenter trial of inhaled nitric oxide and high frequency oscillatory ventilation in severe persistent pulmonary hypertension of the newborn. J Ped 1997;131:55-62. 6. Collaborative ECMO Trial Group. UK Collaborative randomized trial of neonatal extracorporeal membrane oxygenation. Lancet 1996; 348: 75-82. 7. Seth T, Cairo MS. The role of cytokines in the prevention and treatment of neonatal sepsis. In: Neonatal hematology and Immunology III. Bellanti JA, Bracci R, Prindull G, Xanthou M, eds. Excepta Medica, International Congress Series 1131. Amsterdam: Elsevier 1997:49-53. 8. Haque KN. Does intravenous immunoglobulin therapy have a role in the treatment of neonatal sepsis? Bellanti JA, Bracci R, Prindull G, Xanthou M, eds. Excepta Medica, International Congress Series 1131. Amsterdam: Elsevier 1997:55-61. 9. Fletcher A, ed. Neonatology: Pathophysiology and Management of the Newborn. 4rth ed. Nutrition 1994;24:343-348. 10. The Victorian infant collaborative study group. Improved outcome in the 1990s for infants weighing 500-999gr at birth. Arch Dis Child 1997;77:91-94. 11. Battin M, Ling E, Whitfield MF, Mackinnon M, Effer SB. Has the outcome for extremely low gestational age (ELGA) infants improved following recent advances in neonatal intensive care? Amer J Perinat 1998;8:469-477. 12. O'Shea TM, Klinepeter KL, Goldstein DJ. Survival and developmental disability in infants with B.W. of 501 to 800gr born between 1979 and 1994. Ped 1997;100:982-986. 13. M·ÎԇϷ X. ¶ÚÔÛˆÈ΋ ÂÈÎÔÈÓˆÓ›·, 2000. 14. Vannucci RC, Perlman JM. Interventions for perinatal hypoxic-ischemic encephalopathy. Ped 1997;100:1004-1014. 15. Papagaroufalis C, Spyropoulos G, Stamocosta E, Megreli C, Xanthou M. A trial of Vitamin A supplementation for the prevention of retinopathy of prematurity in very low birth weight infants. In: Koppe JG, Eskes TKAB, van Geijn HP, Wiesenhaan PF, Ruys JH, eds. Care, Concern and Cure in Perinatal Medicine: Proceedings of the XIIIth European Congress of Perinatal Medicine, Amsterdam, The Netherlands, May 1992. Lancs, England: The Parthenon Publishing Group 1993:187-193. 16. Obladen M, Maier RF. Recombinant human erythropoietin: A therapeutic option in anemia of prematurity. Xanthou M, Bracci L, Prindull G, eds. In: Neonatal Haematology and Immunology II. Excepta Medica International Congress Series 1038. Amsterdam: Elsevier, 1993: 99-110.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: M·Ú›· •¿ÓıÔ˘ ¢È¢ı‡ÓÙÚÈ· B' M.E.N. NÂÔÁÓÒÓ, NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ "∏ AÁ›· ™ÔÊ›·", ∞ı‹Ó·
267
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·268
¶∞π¢π∞∆ƒπ∫∏ 2000;63:268-271
H Ïԛ̈ÍË ·fi ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ˘ÏˆÚÔ‡ ÛÙ· ·È‰È¿ EÏ¢ıÂÚ›· PÒÌ·-°È·ÓÓ›ÎÔ˘ E. Roma-Yiannikou. Helicobacter pylori infection in children. Paediatriki 2000;63:268-271. ● Abstract: Helicobacter pylori infection is common among the adult population and its incidence in the paediatric population increases with age ranging between 5 and 80% in the developed and the developing world respectively. It is responsible for human diseases such as gastritis and peptic ulcer and there is evidence that early infection in childhood predisposes to atrophic gastritis and gastric cancer in adulthood. Symptomatic children should be investigated by gastroscopy for the isolation of H. pylori, and H. pylori positive children treated with effective short regimes for 7-10 days consisting of proton pump inhibitors, combined with two antibiotics such as amoxicillin, clarithromycin or metronidazole, according to the sensitivity test of the gastric culture. Large-scale screening of all asymptomatic children is impossible due to the large numbers of infected children, increased antibiotic resistance and high rates of treatment failure. Prevention of H. pylori infection by improving hygienic status and probably by the use of the appropriate vaccine will diminish infection and its consequent morbidity in children and adults. Key words: Helicobacter pylori, therapeutic regimes, cancer.
TÔ ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÙÔ˘ ˘ÏˆÚÔ‡ (H. pylori) ·Ó·Î·Ï‡ÊıËÎÂ Ù˘¯·›· Û ηÏÏȤÚÁÂÈ· ÈÛÙÔ‡ ·fi ÙÔ ˘ÏˆÚÈÎfi ¿ÓÙÚÔ ÚÈÓ 18 ¯ÚfiÓÈ·. ŒÎÙÔÙÂ, ·ÎÔÏÔ‡ıËÛ·Ó ¯ÈÏÈ¿‰Â˜ ÌÂϤÙ˜ Ô˘ ·Ô‰ÂÈÎÓ‡Ô˘Ó ·Ê' ÂÓfi˜ ÙËÓ ·ÁÎfiÛÌÈ· ηٷÓÔÌ‹ Ù˘ Ïԛ̈͢ Î·È ·Ê' ÂÙ¤ÚÔ˘ ÙËÓ ·ıÔÁfiÓÔ ‰Ú¿ÛË ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ ÛÙÔÓ ¿ÓıÚˆÔ.(1) EȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë Û˘¯ÓfiÙËÙ· Ù˘ Ïԛ̈͢ Â›Ó·È ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁË ÙˆÓ Û˘ÓıËÎÒÓ ˘ÁÈÂÈÓ‹˜ Î·È ·˘Í¿ÓÂÙ·È ·Ú¿ÏÏËÏ· Ì ÙËÓ ËÏÈΛ· (1-3). EӉȷʤÚÔÓ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Û ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙÔ˘ ÏËı˘ÛÌÔ‡ Ù˘ Á˘ Ë Ïԛ̈ÍË ·Ú¯›˙ÂÈ ·fi ÙËÓ ·È‰È΋ ËÏÈΛ· Î·È Ê·›ÓÂÙ·È fiÙÈ ·˘Ùfi Û˘Ì‚¿ÏÏÂÈ fi¯È ÌfiÓÔ ÛÙË ÓÔÛËÚfiÙËÙ· ÛÙ· ·È‰È¿ ·ÏÏ¿ Î·È Èı·ÓfiÓ Ó· ¢ı‡ÓÂÙ·È ÁÈ· ÛÔ‚·ÚfiÙÂÚ˜ ÂÈÙÒÛÂȘ ÌÂÙ¿ ·fi Ì·ÎÚÔ¯ÚfiÓÈ· ·Ú·ÌÔÓ‹ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ ÛÙÔ ÛÙÔÌ¿¯È, ηٿ ÙËÓ ÂÓ‹ÏÈÎÔ ‰ËÏ·‰‹ ˙ˆ‹. H Û˘¯ÓfiÙËÙ· Ù˘ Ïԛ̈͢ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ÛÙȘ ·ÓÂÙ˘Á̤Ó˜ ¯ÒÚ˜ Î˘Ì·›ÓÂÙ·È ·fi 6 ¤ˆ˜ 15%, ÂÓÒ ÛÙȘ ˘fi ·Ó¿Ù˘ÍË ÂÚ›Ô˘ ÙÔ 80% ÙÔ˘ ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡ ̤¯ÚÈ Ù· 15 ¯ÚfiÓÈ· ¤¯ÂÈ ÌÔÏ˘Óı›. ™ÙËÓ EÏÏ¿‰· ÔÈ ÌÂϤÙ˜ Â›Ó·È Ï›Á˜. H Û˘¯ÓfiÙËÙ· ÛÙ· ·Û˘Ìو̷ÙÈο ·È‰È¿ Î˘Ì·›ÓÂÙ·È ·fi 15 ¤ˆ˜ 40%, ÂÓÒ ÙÔ ÔÛÔÛÙfi Â›Ó·È ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚÔ ÛÙ· Û˘Ìو̷ÙÈο ·È‰È¿. TÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ô˘ ‰È·ÁÓÒÛıËÎ·Ó ÈÛÙÔÏÔÁÈο ÛÙËÓ A' ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ Ì Ïԛ̈ÍË ·fi H. pylori ˘ÂÚ‚·›ÓÂÈ Ù· 400. H Û˘¯ÓfiÙËÙ· ÛÙËÓ ÂÊ˂›· ·Ó¤Ú¯ÂÙ·È ÛÙÔ 60% ÙˆÓ ·È‰ÈÒÓ Ô˘ Á·ÛÙÚÔÛÎÔÔ‡ÓÙ·È.(3) AÓ Î·È ·ÎfiÌ· Û˘˙ËÙÂ›Ù·È Ô ÙÚfiÔ˜ ÌÂÙ¿‰ÔÛ˘ ÙÔ˘ H. pylori- ÈÔ Èı·Ó‹ Ê·›ÓÂÙ·È Ë ÌÂÙ¿‰ÔÛË Ì ÙË ÛÙÔÌ·ÙÈ΋ Î·È ÛÙÔÌ·ÙÔÚˆÎÙÈ΋ Ô‰fi - ÂÓÙÔ‡ÙÔȘ, Â›Ó·È Û·Ê¤˜ fiÙÈ Ë Â·Ê‹ Ì ÌÔÏ˘Ṳ̂ӷ ¿ÙÔÌ· Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È Ô Û˘Á¯ÚˆÙÈÛÌfi˜ Û ȉڇ̷ٷ ¢ÓÔÔ‡Ó ÙËÓ ÌÂÙ¿‰ÔÛ‹ ÙÔ˘. ¶Ú¿ÁÌ·ÙÈ, ÛÙËÓ A' ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ ÌÂÏÂÙ‹ıËÎ·Ó Ì Á·ÛÙÚÔÛÎfiËÛË Ù· ̤ÏË ÔÈÎÔÁÂÓÂÈÒÓ 41 ·È‰ÈÒÓ Ì Á·ÛÙÚ›Ùȉ· ·fi H. pylori Î·È ‚Ú¤ıËÎ·Ó ÌÔÏ˘Ṳ̂ӷ Û ÔÛÔÛÙfi 90%, ÂÓÒ Û οı ÔÈÎÔÁ¤ÓÂÈ· ˘‹Ú¯Â ¤Ó· ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì¤ÏÔ˜ ÌÔÏ˘Ṳ̂ÓÔ(4). ™¯ÂÙÈο Ì ÙË Ê˘ÛÈ΋ ÔÚ›· Ù˘ Ïԛ̈͢ Ê·›ÓÂÙ·È fiÙÈ ÌÔÚ› Ó· Á›ÓÂÈ ·˘ÙfiÌ·ÙË ›·ÛË Î·È ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ ‚Ú¤ÊË Ô˘ ÌÔχÓıËÎ·Ó ·fi H. pylori Û˘¯Ó¿ ··ÏÏ¿ÛÛÔÓÙ·È ·ÚÁfiÙÂÚ· ·fi ·˘Ùfi.(5) ™ÙËÓ ÏÂÈÔÓfiÙËÙ· fï˜ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·fi ÙË ÛÙÈÁÌ‹ Ô˘ ı· ÂÁηٷÛÙ·ı› ÙÔ ÌÈÎÚfi‚ÈÔ ÛÙÔ ÛÙÔÌ¿¯È, ·Ó ‰ÂÓ ˘¿ÚÍÂÈ ·Ú¤Ì‚·ÛË, ı· Ì›ÓÂÈ ‰È· ‚›Ô˘. H Ïԛ̈ÍË ÚÔηÏ› ÈÛÙÔÏÔÁÈ΋ ‚Ï¿‚Ë Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÔÍ›· Á·ÛÙÚ›Ùȉ· Î·È Û˘Óԉ‡ÂÙ·È ·fi ·¯ÏˆÚ˘‰Ú›·, Î·È ÌÂÙ·›ÙÂÈ Û ¯ÚfiÓÈ· ÂÓÂÚÁfi Á·ÛÙÚ›Ùȉ·. H ¯ÚfiÓÈ· ÊÏÂÁÌÔÓ‹ ÚÔηÏ› ÛÙË Û˘Ó¤¯ÂÈ· ‚Ï¿‚Ë ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Ì ·ÔÙ¤ÏÂÛÌ· ·ÙÚÔÊ›· Î·È ˘Ô¯ÏˆÚ˘‰Ú›·, ÂÓÒ ¿ÏÏÔÙÂ Ë Ïԛ̈ÍË ÚÔηÏ› ÂÈÏÔΤ˜ fiˆ˜ ÂÙÈÎfi ¤ÏÎÔ˜ Î·È Î·ÚΛÓÔ ÛÙÔÌ¿¯Ô˘.
268
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·269
¶∞π¢π∞∆ƒπ∫∏ 2000;63:268-271
∞ÊȤڈ̷: ÀÁ›· ÙÔ˘ ·È‰ÈÔ‡ 2000
¶›Ó·Î·˜ 1.
¶›Ó·Î·˜ 2.
™˘ÌÙÒÌ·Ù·
EΉËÏÒÛÂȘ Ù˘ Ïԛ̈͢ ·fi H. pylori ÂÎÙfi˜
* ÎÔÈÏȷο ¿ÏÁË
ÂÙÈÎÔ‡
* ·ÈÌ·Ù¤ÌÂÛË
* ηډȷÁÁÂȷ΋ ÓfiÛÔ˜
* ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›·
* Ê·ÈÓfiÌÂÓÔ Raynaud
* ˘ÔÚˆÙÂ˚Ó·ÈÌ›·
* ËÌÈÎÚ·Ó›·
* ηı˘ÛÙ¤ÚËÛË ÛˆÌ·ÙÈ΋˜ ·Ó¿Ù˘Í˘
* ·˘ÙÔ·ÓÔÛ›· * ‰ÂÚÌ·ÙÔÏÔÁÈο ÓÔÛ‹Ì·Ù· * ·ı‹ÛÂȘ ÙÔ˘ ‹·ÙÔ˜
™Â ¤Ó· ÌÂÁ¿ÏÔ ÔÛÔÛÙfi ÙÔ˘ ÏËı˘ÛÌÔ‡ Ë Ïԛ̈ÍË Â›Ó·È ·Û˘Ìو̷ÙÈ΋.(1) EÚ¢ÓËÙ¤˜ Ô˘ ÂÈÚ·Ì·ÙÈο ÌfiÏ˘Ó·Ó ÙÔ˘˜ ·˘ÙÔ‡˜ ÙÔ˘˜ ¤‰ÂÈÍ·Ó fiÙÈ ÙÔ ÂÏÈÎÔ‚·ÎÙËÚ›‰ÈÔ ÚÔηÏ› ÔÍ›· Ïԛ̈ÍË Ì ¯ÚfiÓÔ ÂÒ·Û˘ 1 ¤ˆ˜ 7 Ë̤Ú˜, Ô˘ ÂΉËÏÒÓÂÙ·È Ì ÂÈÁ·ÛÙÚ·ÏÁ›·, Ó·˘Ù›·, ηÎÔ˘¯›· Î·È ÌÂÚÈΤ˜ ÊÔÚ¤˜ Â̤ÙÔ˘˜. T· Û˘ÌÙÒÌ·Ù· ÂΉËÏÒÓÔÓÙ·È Û ÔÛÔÛÙfi 50% ÙˆÓ ÂÓËÏ›ÎˆÓ Ô˘ ÌÔχÓıËηÓ, ÂÓÒ ‰ÂÓ Â›Ó·È ÁÓˆÛÙ‹ Ë Û˘¯ÓfiÙËÙ· Ù˘ ÎÏÈÓÈ΋˜ ÂΉ‹ÏˆÛ˘ Ù˘ Ïԛ̈͢ ÛÙ· ·È‰È¿. ™Ù· ·È‰È¿ ÙÔ H. pylori ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ·ÈÙ›· Á·ÛÙÚ›Ùȉ·˜ Ô˘ ÌÔÚ› Ó· ÚÔ‚¿ÏÂÈ Ì ¯ÚfiÓÈ· ÎÔÈÏȷο ¿ÏÁË, Â›Ó·È ˘Â‡ı˘ÓÔ ÁÈ· ÙÔ ÂÙÈÎfi ¤ÏÎÔ˜ (ÛÙ· ÌÈÛ¿ ÂÚ›Ô˘ ·È‰È¿ Ì ¤ÏÎÔ˜ Û˘Ó˘¿Ú¯ÂÈ H. pylori) (1,3,6,7), Û¿ÓÈ· ÁÈ· ˘ÂÚÙÚÔÊÈ΋ Á·ÛÙÚÂÓÙÂÚÔ¿ıÂÈ· Î·È ˘ÔÚˆÙÂ˚Ó·ÈÌ›·, ·ÈÌ·Ù¤ÌÂÛË, ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›· Î·È Á·ÛÙÚÈÎfi ϤÌʈ̷ (›Ó·Î·˜ 1). ŸÛÔÓ ·ÊÔÚ¿ Ù· ÎÔÈÏȷο ¿ÏÁË Â›Ó·È ·ÌÊÈÏÂÁfiÌÂÓÔ Î·Ù¿ fiÛÔÓ Â˘ı‡ÓÂÙ·È ÙÔ H. pylori, ÂÓÒ ÌÔÏ˘Ṳ̂ӷ ·È‰È¿ ‰ÂÓ ·Ó¤ÊÂÚ·Ó ÎÔÈÏȷο ¿ÏÁË Û˘¯ÓfiÙÂÚ· ·fi ¿ÏÏ· Ô˘ ‰ÂÓ Â›¯·Ó ÌÔÏ˘Óı›. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË Ì·˜, ·fi Ù· 396 ·È‰È¿ Ì ¯ÚfiÓÈ· ÎÔÈÏȷο ¿ÏÁË Ô˘ Á·ÛÙÚÔÛÎÔ‹ıËηÓ, ÌfiÓÔ 28,5% ›¯·Ó Ïԛ̈ÍË ·fi H. pylori.(6) Y¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ÙÔ H. pylori ¢ı‡ÓÂÙ·È ÁÈ· Â͈ÂÓÙÂÚÈΤ˜ ÂΉËÏÒÛÂȘ, ‰ËÏ·‰‹ Û˘ÌÌÂÙÔ¯‹ ·fi ÙÔ Î·Ú‰È·ÁÁÂÈ·Îfi Û‡ÛÙËÌ· Ì ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÈÛ¯·ÈÌÈ΋˜ ÓfiÛÔ˘, Ê·ÈÓfiÌÂÓÔ Raynaud, ËÌÈÎÚ·Ó›·, ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· fiˆ˜ ȉÈÔ·ı‹ ıÚÔÌ‚ÔÂÓÈ΋ ÔÚʇڷ, ·˘ÙÔ¿ÓÔÛÔ ı˘ÚÂÔÂȉԿıÂÈ· (ı˘ÚÂÔÂȉ›Ùȉ·, ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi), ‰ÂÚÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ fiˆ˜ ¯ÚfiÓÈ· ÎÓ›‰ˆÛË Î·È ·ÎÌ‹ roseaca Î·È Ù¤ÏÔ˜ Ë·ÙÈ΋ Û˘ÌÌÂÙÔ¯‹ Ì Èı·Ó‹ ·‡ÍËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ˘ÂÚ·Ì̈ÓÈ·ÈÌ›·˜ Û ÎÈÚÚˆÙÈÎÔ‡˜ ·ÛıÂÓ›˜, ηıÒ˜ ›Û˘ Î·È ¯ÚfiÓÈ· ¯ÔÏÔ΢ÛÙ›Ùȉ· 1 (›Ó·Î·˜ 2). H ÛȉËÚÔÂÓÈ΋ ·Ó·ÈÌ›· ·ÔÙÂÏ› Û¿ÓÈ· ÂÈÏÔ΋ Ù˘ Ïԛ̈͢, ÂÓÒ Ë Î·ı˘ÛÙ¤ÚËÛË ÛÙË ÛˆÌ·ÙÈ΋ ·Ó¿Ù˘ÍË Ì¿ÏÏÔÓ Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ¯·ÌËÏfi ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎfi Â›Â‰Ô ÙˆÓ ·È‰ÈÒÓ ·Ú¿ Ì ÙËÓ ¿ÌÂÛË Â›‰Ú·ÛË ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ ÛÙËÓ ÛˆÌ·ÙÈ΋ ·‡ÍËÛË ÙÔ˘ ·È‰ÈÔ‡. °È· ÙȘ ÂΉËÏÒÛÂȘ ÂÎÙfi˜ ÂÙÈÎÔ‡ ̤ÓÂÈ Ó· ‰È¢ÎÚÈÓÈÛı› ·Ó Ë Ïԛ̈ÍË Â›Ó·È Ë ·ÈÙ›· ‹ Û˘Ì‚¿ÏÏÔ˘Ó ÎÈ ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜. ŸÛÔÓ ·ÊÔÚ¿ ÙË ‰È¿ÁÓˆÛË, Û‹ÌÂÚ· ˘¿Ú¯Ô˘Ó ÔÈΛϘ ̤ıÔ‰ÔÈ (›Ó·Î·˜ 3). H ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË ·Ú·Ì¤ÓÂÈ ·ÍÈfiÈÛÙË Ì¤ıÔ‰Ô˜ Î·È ÙÔ CLO test ¤¯ÂÈ Â˘·ÈÛıËÛ›· ÂÚ›Ô˘ 90%.(1,3,7) H ηÏÏȤÚÁÂÈ· ÈÛÙÔ‡ ·ÔÙÂÏ› ÙËÓ ÈÔ ÂȉÈ΋ ̤ıÔ‰Ô ·ÏÏ¿ Ë Â˘·ÈÛıËÛ›· Ù˘ ‰È·Ê¤ÚÂÈ ÛÙ· ‰È¿ÊÔÚ· ÂÚÁ·ÛÙ‹ÚÈ·. TÔ ÌÂÁ¿ÏÔ Ù˘ ÏÂÔÓ¤ÎÙËÌ· Â›Ó·È fiÙÈ ÂϤÁ¯ÂÙ·È Ë Â˘·ÈÛıËÛ›· ÛÙ· ·ÓÙÈ‚ÈÔÙÈο Î·È ¤ÙÛÈ Á›ÓÂÙ·È Ë ÛˆÛÙ‹ ÂÈÏÔÁ‹ ÙÔ˘˜ ÁÈ· ÙËÓ ÂÎÚ›˙ˆÛË ÙÔ˘ ÌÈÎÚÔ‚›Ô˘. H PCR ‰ÂÓ ¤¯ÂÈ ·ÎfiÌË ÙÂÎÌËÚȈı› Û·Ó Ì¤ıÔ‰Ô˜ ÚÔ˘Ù›Ó·˜, ·ÏÏ¿ ÚÔÛʤÚÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ÂϤÁ¯Ô˘ ÙˆÓ ÛÙÂϯÒÓ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ Î·È ÙˆÓ ÌÂÙ·ÏÏ¿ÍÂÒÓ ÙÔ˘. ŸÛÔÓ ·ÊÔÚ¿ Ù· ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ H. pylori Ù· IgG ¶›Ó·Î·˜ 3.
¶›Ó·Î·˜ 4.
¢È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ·fi H. pylori
NÔÛ‹Ì·Ù· ÙÔ˘ ÂÙÈÎÔ‡ ·fi Ïԛ̈ÍË Ì H.pylori
* * * * * * * *
* * * *
BÈÔ„›· ηÏÏȤÚÁÂÈ· ÈÛÙÔ‡ CLO test PCR ÈÛÙÔ‡ ·ÓÙÈÛÒÌ·Ù· ·ÓÙÈÁfiÓÔ ÙÔ˘ HP ÛÙ· ÎfiÚ·Ó· ·ÓÙÈÁfiÓÔ ÙÔ˘ HP ÛÙ· Ô‡Ú· test ·Ó·ÓÔ‹˜ Ì 13C- Ô˘Ú›·
Á·ÛÙÚ›Ùȉ· ¤ÏÎÔ˜ ηÚΛÓÔ˜ ÛÙÔÌ¿¯Ô˘ ϤÌʈ̷ ÛÙÔÌ¿¯Ô˘
269
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·270
¶∞π¢π∞∆ƒπ∫∏ 2000;63:268-271
∂. PÒÌ·-°È·ÓÓ›ÎÔ˘
Â›Ó·È ÈÔ ·ÍÈfiÈÛÙ· Û˘ÁÎÚÈÙÈο Ì ٷ IgA Î·È Ù· IgM, ·ÏÏ¿ Ë Â˘·ÈÛıËÛ›· ÙÔ˘˜, ȉȷ›ÙÂÚ· ÛÙ· ·È‰È¿, Â›Ó·È ÌÈÎÚ‹ (̤¯ÚÈ 60%) Î·È ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ¿ÓÙÔÙ ÙËÓ ÂÓÂÚÁfi Ïԛ̈ÍË, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÌÔÚ› Ó· ·Ú·Ì›ÓÔ˘Ó ÛÙÔÓ ÔÚfi ̤¯ÚÈ ¤Ó· ¯ÚfiÓÔ ÌÂÙ¿ ·fi ÙËÓ ÂÎÚ›˙ˆÛË ÙÔ˘ ÌÈÎÚÔ‚›Ô˘.(1,7) EÔ̤ӈ˜, ‰ÂÓ ÂӉ›ÎÓ˘Ù·È Ë ¤Ó·ÚÍË ıÂڷ›·˜ ÌfiÓÔ Ì ÙËÓ ·Ó‡ÚÂÛË ıÂÙÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÛÙÔÓ ÔÚfi. ™ÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜ Ë ‰ÔÎÈÌ·Û›· ÂÎÓÔ‹˜ Ù˘ Ô˘Ú›·˜ ¤¯ÂÈ ÙÂÎÌËÚȈı› Û·Ó ·ÍÈfiÈÛÙË ÌË ÂÂÌ‚·ÙÈ΋ ̤ıÔ‰Ô˜ ÂϤÁ¯Ô˘ Ù˘ ·ÚÔ˘Û›·˜ ÙÔ˘ ÂÏÈÎÔ‚·ÎÙËÚȉ›Ô˘ ÛÙÔÓ Á·ÛÙÚÈÎfi ‚ÏÂÓÓÔÁfiÓÔ ·ÏÏ¿ ÛÙ· ·È‰È¿ ¯ÚÂÈ¿˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ ·ÍÈÔÈÛÙ›·˜ Ù˘ ÌÂıfi‰Ô˘.(8,9) MÈ· ·Ï‹, ÌË ÂÂÌ‚·ÙÈ΋ ̤ıÔ‰Ô˜ Ì ÈηÓÔÔÈËÙÈ΋ ¢·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· Â›Ó·È Ë ·Ó·˙‹ÙËÛË ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ H. pylori ÛÙ· ÎfiÚ·Ó·. OÈ ÌÂϤÙ˜ Â›Ó·È Ï›Á˜ ·ÎfiÌË Î·È Ù· ·ÔÙÂϤÛÌ·Ù· ·fi ÙËÓ ¤Ú¢ӷ Ô˘ Á›ÓÂÙ·È ÛÙÔ ÌÈÎÚÔ‚ÈÔÏÔÁÈÎfi ÙÌ‹Ì· ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ ·›‰ˆÓ "AÁ›· ™ÔÊ›·" Û ۇÁÎÚÈÛË Ì ÙËÓ ÈÛÙÔÏÔÁÈ΋ ‰È¿ÁÓˆÛË Â›Ó·È ÂÓı·ÚÚ˘ÓÙÈο. AÎfiÌË ÈÔ ÚfiÛÊ·ÙË Â›Ó·È ·Ó·˙‹ÙËÛË ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ ÛÙ· Ô‡Ú·, ·ÏÏ¿ ‰ÂÓ ˘¿Ú¯Ô˘Ó ·ÎfiÌË ÙÂÎÌËÚȈ̤Ó˜ ÌÂϤÙ˜. H Â˘Úˆ·˚΋ ÔÌ¿‰· ÌÂϤÙ˘ ÙÔ˘ ÂÏÈÎÔ‚·ÎÙËÚȉ›Ô˘, ÛÙËÓ ÔÔ›· Û˘ÌÌÂÙ¤¯ÂÈ Î·È Ë A' ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ, ·˘Ù‹ ÙËÓ ÂÔ¯‹ ‰ÈÂÍ¿ÁÂÈ ÌÈ· ÔÏ˘ÎÂÓÙÚÈ΋ Û˘ÁÎÚÈÙÈ΋ ÌÂϤÙË fiÏˆÓ ÙˆÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÌÂıfi‰ˆÓ ÁÈ· Ó· ‰ÒÛÂÈ ·¿ÓÙËÛË ÛÙÔ ı¤Ì· ·˘Ùfi. AÓ ˘¿Ú¯Ô˘Ó Û‹ÌÂÚ· ÚÔ‚ÏËÌ·ÙÈÛÌÔ› ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ïԛ̈͢ ÛÙÔÓ ÂÓ‹ÏÈη, ·˘ÙÔ› Á›ÓÔÓÙ·È Ôχ ÂÚÈÛÛfiÙÂÚÔÈ fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· ÙÔ ·È‰›. K·È ·˘Ùfi Â›Ó·È Â‡ÏÔÁÔ ·Ó ·Ó·ÏÔÁÈÛı› ηÓ›˜ fiÙÈ Ë ıÂڷ›· ÛÙÔ ·È‰› ¤¯ÂÈ ¿ÌÂÛÔ ÛÙfi¯Ô ÙËÓ ÂÎÚ›˙ˆÛË Î·È ÙËÓ ‡ÊÂÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ·ÒÙÂÚÔ ÛÙfi¯Ô ÙËÓ ÚfiÏË„Ë ÙˆÓ ÂÈÏÔÎÒÓ ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹(1) (›Ó·Î·˜ 4) ¶ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÓÙÈÌÂÙˆÈÛı› ÙÔ ·È‰› Ì Ïԛ̈ÍË ·fi H. pylori ı· Ú¤ÂÈ Ó· ÏËÊıÔ‡Ó ˘fi„Ë ÔÈ È‰È·ÈÙÂÚfiÙËÙ˜ ÙÔ˘ ·È‰ÈÔ‡, ‰ËÏ·‰‹ ÙÔ fiÙÈ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È -ȉȷ›ÙÂÚ· ÛÙË ‚ÚÂÊÈ΋- ˘¿Ú¯ÂÈ Û ·ÚÎÂÙfi ÔÛÔÛÙfi ·˘ÙfiÌ·ÙË ›·ÛË, Ë ·Ó·ÍÈÔÈÛÙ›· ÙˆÓ ÌË ÂÂÌ‚·ÙÈÎÒÓ ‰È·ÁÓˆÛÙÈÎÒÓ ÌÂıfi‰ˆÓ Î·È Ë ÌË Î·Ï‹ -ÚÔ˜ ÙÔ ·ÚfiÓ- ÙÂÎÌËÚ›ˆÛ‹ ÙÔ˘˜, Î·È Ù¤ÏÔ˜ ÙÔ ÌÈÎÚfiÙÂÚÔ ÔÛÔÛÙfi ÂÎÚ›˙ˆÛ˘ ÙÔ˘ ÌÈÎÚÔ‚›Ô˘ Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ ÂÓ‹ÏÈΘ.(10-12) EÚˆÙ‹Ì·Ù· ÏÔÈfiÓ Ô˘ ··Û¯ÔÏÔ‡Ó ÚÈÓ Û˘ÛÙËı› ıÂڷ›· Û ¤Ó· ·È‰› ›ӷÈ: ·) ·Ó ˘¿Ú¯Ô˘Ó Û˘Ì-ÙÒÌ·Ù·, ‚) ·Ó ı· ÎÈÓ‰˘Ó‡ÛÂÈ Ú·ÁÌ·ÙÈο ·fi ηÚΛÓÔ ÛÙÔÌ¿¯Ô˘ ÛÙËÓ ÂÓ‹ÏÈÎÔ ˙ˆ‹ ÂÊfiÛÔÓ ‰ÂÓ ÂÈÙ¢¯ı› ÂÎÚ›˙ˆÛË, Á) Ì‹ˆ˜ ·Ó·Ù˘¯ıÔ‡Ó ·ÓıÂÎÙÈο ÛÙÂϤ¯Ë, ‰) Ì‹ˆ˜ Ë ÂÎÚ›˙ˆÛË ‰È·Ù·Ú¿ÍÂÈ ÙÔ ÔÈÎÔÛ‡ÛÙËÌ· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ ÚÔηÏÒÓÙ·˜ ¤ÙÛÈ ¿ÏÏ· ÓÔÛ‹Ì·Ù· fiˆ˜ ·ÏÈÓ‰ÚÔÌÈ΋ ÓfiÛÔ. E›Ó·È ȉȷ›ÙÂÚ· ‰‡ÛÎÔÏÔ Ó· ··ÓÙ‹ÛÂÈ Î·Ó›˜ ÛÙ· ÈÔ ¿Óˆ ÂÚˆÙ‹Ì·Ù·. H E˘Úˆ·˚΋ ÔÌ¿‰· ÂÚÁ·Û›·˜ ÁÈ· ÙË Ïԛ̈ÍË Ì H. pylori ÛÙ· ·È‰È¿ η٤ÏËÍ fiÙÈ Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È ÁÈ· Ïԛ̈ÍË ·fi H. pylori οı ·È‰› Ô˘ ¤¯ÂÈ Û˘ÌÙÒÌ·Ù·.(7) EΛÓÔ fï˜, Ô˘ ÚÔηÏ› ‰˘ÛÎÔÏ›· Â›Ó·È fiÙÈ ÛÙ· ·È‰È¿ Â›Ó·È ··Ú·›ÙËÙË Ë Á·ÛÙÚÔÛÎfiËÛË ÁÈ·Ù› ‰ÂÓ ˘¿Ú¯ÂÈ ·ÍÈfiÈÛÙË ÌË ÂÂÌ‚·ÙÈ΋ ‰È·ÁÓˆÛÙÈ΋ ÂͤٷÛË. ŸÛÔÓ ·ÊÔÚ¿ Ù· ıÂڷ¢ÙÈο Û¯‹Ì·Ù·, ˘¿Ú¯ÂÈ ÔÌÔÈfiÙËÙ· Ì ·˘Ù¿ ÙˆÓ ÂÓËϛΈÓ. ¢ËÏ·‰‹, ·Ó·˙ËÙÔ‡ÓÙ·È ·Ï¿, ¢¤ÏÈÎÙ·, ·ÔÙÂÏÂÛÌ·ÙÈο Î·È ¯ˆÚ›˜ ·ÚÂÓ¤ÚÁÂȘ ıÂڷ¢ÙÈο Û¯‹Ì·Ù·, ¤ÙÛÈ ÒÛÙ ÙÔ ÔÛÔÛÙfi ÂÎÚ›˙ˆÛ˘ Ó· Êı¿ÛÂÈ 90%.(12,13) ¢˘ÛÙ˘¯Ò˜, ÛÙ· ·È‰È¿ ‰ÂÓ ˘¿Ú¯ÂÈ ¿ÓÙ· ηϋ Û˘ÌÌfiÚʈÛË, ˘¿Ú¯Ô˘Ó ·ÓıÂÎÙÈο ÛÙÂϤ¯Ë Î·È ÙÔ ÔÛÔÛÙfi ÂÎÚ›˙ˆÛ˘ Û˘¯Ó¿ Â›Ó·È ¯·ÌËÏfi ·ÎfiÌË Î·È Ì ٷ ›‰È· Û¯‹Ì·Ù· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡Ó ÔÈ ÂÓ‹ÏÈΘ. £· Ú¤ÂÈ Ó· ÙÔÓÈÛı› fiÙÈ ÔÙ¤ ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ¤Ó· ÌfiÓÔ ·ÓÙÈ‚ÈÔÙÈÎfi, ÁÈ·Ù› ·Ó·Ù‡ÛÛÂÙ·È ·ÓıÂÎÙÈÎfiÙËÙ·. ™Ù· ·È‰È¿ ‰ÔÎÈÌ¿ÛıËÎ·Ó Ì·ÎÚ¿˜ ‰È¿ÚÎÂÈ·˜ ıÂڷ¢ÙÈο Û¯‹Ì·Ù· ̤¯ÚÈ 6 ‚‰ÔÌ¿‰Â˜. TÔ ÔÛÔÛÙfi ÂÎÚ›˙ˆÛ˘ ÛÙÔÓ Â·Ó¤ÏÂÁ¯Ô Ì Á·ÛÙÚÔÛÎfiËÛË ·Ó¿ÏÔÁ· Ì ٷ ıÂڷ¢ÙÈο Û¯‹Ì·Ù· Î˘Ì¿ÓıËΠ·fi 70 ¤ˆ˜ 80%. T· ‰‡Ô ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¯ÔÚËÁÔ‡ÓÙ·È Ù· ‚Ú·¯¤· Û¯‹Ì·Ù·, ‰È¿ÚÎÂÈ·˜ 7 ¤ˆ˜ 10 ËÌÂÚÒÓ(13,14). T· ÚÔÙÂÈÓfiÌÂÓ· ıÂڷ¢ÙÈο Û¯‹Ì·Ù· Â›Ó·È ·Ó·ÛÙÔÏ›˜ Ù˘ ·ÓÙÏ›·˜ ÚˆÙÔÓ›Ô˘ (omeprazole, lanzoprazole ÎÙÏ.) Î·È Û˘Ó‰˘·ÛÌfi˜ ‰‡Ô ·ÓÙÈ‚ÈÔÙÈÎÒÓ (ÎÏ·Ú˘ıÚÔÌ˘Î›ÓË, ·ÌÔ͢ÎÈÏÏ›ÓË, ÌÂÙÚÔÓȉ·˙fiÏË). E¿Ó ‰ÂÓ ÂÈÙ¢¯ı› ÂÎÚ›˙ˆÛË ÚÔÛÙ›ıÂÙ·È ÛÙÔ ÚÔËÁÔ‡ÌÂÓÔ Û¯‹Ì· Î·È ‚ÈÛÌÔ‡ıÈÔ (Denol). ŸÌˆ˜, ÙÔ ˘„ËÏfi ÔÛÔÛÙfi ·ÔÙ˘¯›·˜ ÂÎÚ›˙ˆÛ˘ ÙÔ˘ H. pylori ÛÙ· ·È‰È¿, Ë ·Ó¿Ù˘ÍË ·ÓÙÔ¯‹˜, Î·È Ô ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ÌÔÏ˘ÛÌ¤ÓˆÓ ·È‰ÈÒÓ ÛÙÔÓ Ï·Ó‹ÙË Î·ıÈÛÙÔ‡Ó ·Ó¤ÊÈÎÙË ÙË Ì·˙È΋ ıÂڷ›· ÂÎÚ›˙ˆÛ˘ ÙÔ˘ H. pylori ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi. ŒÓ· ÂÌ‚fiÏÈÔ ·ÔÙÂÏ› ÙË ÌÔÓ·‰È΋ ÂÏ›‰· ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ÂÍ·Ê¿ÓÈÛË Ù˘ Ïԛ̈͢, Ú·ÎÙÈ΋ Ô˘ ÂÊ·ÚÌfiÛıËÎÂ Î·È ¤Ù˘¯Â ÙËÓ ÂÍ·Ê¿ÓÈÛË ÔÏÏÒÓ ¿ÏÏˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ(15). A’ fi,ÙÈ Ê·›ÓÂÙ·È ˘¿Ú¯Ô˘Ó ÔÏÏ¿ ·Ó·¿ÓÙËÙ· ÂÚˆÙ‹Ì·Ù· fiÛÔÓ ·ÊÔÚ¿ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ Ïԛ̈͢ Ì H. pylori ÛÙ· ·È‰È¿ Î·È ¿ÓÙ· ˘¿Ú¯ÂÈ Ô ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ Ì‹ˆ˜ ˘¿Ú¯Ô˘Ó ·Ú·Ï‹„ÂȘ, ·ÏÏ¿ ›Ûˆ˜ Î·È ˘ÂÚ‚ÔϤ˜. ™‡Ìʈӷ Ì ÙÔ ÙÂÏÂ˘Ù·›Ô consensus ¯ÔÚËÁÂ›Ù·È ıÂڷ›· ÂÎÚ›˙ˆÛ˘ Û οı ·È‰› Ì ıÂÙÈ΋ ‚ÈÔ„›·, Î·È 6 ‚‰ÔÌ¿‰Â˜ ·ÚÁfiÙÂÚ· Á›ÓÂÙ·È screening ·Ó·ÓÔ‹˜ Ì 13C- Ô˘Ú›· ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ıÂڷ›·˜. ¢ÂÓ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ¤ÏÂÁ¯Ô˜ ·Ó ‰ÂÓ ˘¿Ú¯Ô˘Ó Û˘ÌÙÒÌ·Ù·, Ô‡Ù ıÂڷ›· ¯ˆÚ›˜ ıÂÙÈ΋ ‚ÈÔ„›·. AÓ ‰ÂÓ ÛÎÔ‡ԢÌ ӷ ıÂڷ‡ÛÔ˘Ì ‰ÂÓ ¤¯ÂÈ ÓfiËÌ· Ó· ÂϤÁ¯ÂÙ·È ÙÔ ·È‰› ÁÈ· ÙËÓ ·ÚÔ˘Û›· Ïԛ̈͢ ·fi H. pylori. §fiÁˆ ÙÔ˘ ˘„ËÏÔ‡ ÔÛÔÛÙÔ‡ ·Ó¿Ù˘Í˘ ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ ÚÔÙÈÌ¿Ù·È Ó· Á›ÓÂÙ·È Î·ÏÏȤÚÁÂÈ· Î·È ÙÂÛÙ Â˘·ÈÛıËÛ›·˜. ™ÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ, ÔÈ MÂÓÙ‹˜ Î·È Û˘Ó. ‰È·›ÛÙˆÛ·Ó ·ÓıÂÎÙÈÎfiÙËÙ· 28% ÛÙË ÌÂÙÚÔÓȉ·˙fiÏË Î·È 5,5% ÛÙËÓ ÎÏ·ÚÈıÚÔÌ˘Î›ÓË ÛÙ· ·È‰È¿.(16)
270
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·271
¶∞π¢π∞∆ƒπ∫∏ 2000;63:268-271
∞ÊȤڈ̷: ÀÁ›· ÙÔ˘ ·È‰ÈÔ‡ 2000
™Â ·ÓÙ›ıÂÛË Ì ÙÔ˘˜ ÂÓËÏ›ÎÔ˘˜, ÛÙ· ·È‰È¿ ›̷ÛÙ ÈÔ ÂÏ·ÛÙÈÎÔ› fiÛÔÓ ·ÊÔÚ¿ ÙȘ ÂӉ›ÍÂȘ ıÂڷ›·˜ ÂÎÚ›˙ˆÛ˘ ÙÔ˘ H. pylori, ›Ûˆ˜ ÁÈ·Ù› ‰ÂÓ ˘¿Ú¯Ô˘Ó ÙÂÎÌËÚȈ̤Ó˜ Û˘ÁÎÚÈÙÈΤ˜ ÌÂϤÙ˜ ÁÈ· ÙȘ ·ÒÙÂÚ˜ ÂÈÙÒÛÂȘ ÛÙËÓ ˘Á›·. E›Ì·ÛÙ ÂÈÊ˘Ï·ÎÙÈÎÔ› ÁÈ· ÙË Ì·˙È΋ ÂÎÚ›˙ˆÛË ÛÙ· ·Û˘Ìو̷ÙÈο ·È‰È¿, ÏfiÁˆ ÙÔ˘ ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ·Ó¿Ù˘Í˘ ·ÓıÂÎÙÈÎÒÓ ÛÙÂϯÒÓ. EÍ¿ÏÏÔ˘, ‰ÂÓ ˘¿Ú¯ÂÈ ÙÂÎÌËÚ›ˆÛË fiÙÈ Ë ÂÎÚ›˙ˆÛË Ù˘ Ïԛ̈͢ ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ· ı· ÌÂÈÒÛÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÁÈ· ÌÂÏÏÔÓÙÈÎfi ηÚΛÓÔ ÛÙÔÓ ÂÓ‹ÏÈη. E›ÏÔÁÔ˜ MÂÙ¿ ÙÔÓ ˘ÂÚ‚¿ÏÏÔÓÙ· ˙‹ÏÔ ÁÈ· ÙËÓ ÂÍ·Ê¿ÓÈÛË ÙÔ˘ ÂÏÈÎÔ‚·ÎÙËÚȉ›Ô˘ ·fi ÙÔ Á·ÛÙÚÈÎfi ‚ÏÂÓÓÔÁfiÓÔ Û ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ ÂÈÎÚ·Ù› ÛÎÂÙÈÎÈÛÌfi˜ ·Ó ÙÂÏÈο ¤¯ÂÈ ¤Ó‰ÂÈÍË Ë ÂÎÚ›˙ˆÛË. ¶·Ú·Ù‹ÚËÛ·Ó ‰ËÏ·‰‹, fiÙÈ ÂÓ‹ÏÈΘ ÌÂÙ¿ ÙËÓ ÂÎÚ›˙ˆÛË ÙÔ˘ H. pylori ·ÚÔ˘Û›·Û·Ó Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ÂÓÒ ÙÂÏÂ˘Ù·›· ·˘Í‹ıËÎÂ Ô Î·ÚΛÓÔ˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘. TÔ ÁÂÁÔÓfi˜ ·˘Ùfi ÂÓÈÛ¯‡ÂÈ ÙËÓ ¿Ô„Ë fiÙÈ ›Ûˆ˜ ÙÔ H. pylori ÚÔÛٷهÂÈ ·fi ÙËÓ ÂÌÊ¿ÓÈÛË Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘. AÎfiÌË ÂÚÈÛÛfiÙÂÚÔ ÚÔ‚ÏËÌ·ÙÈÛÌfi ÚÔηÏ› Ù· ÙÂÏÂ˘Ù·›· 2 ¯ÚfiÓÈ· Ë ¿Ô„Ë ÌÂÚÈÎÒÓ ÂÚ¢ÓËÙÒÓ Ô˘ ı¤ÙÔ˘Ó ÛÔ‚·Ú¿ ÙËÓ Èı·ÓfiÙËÙ· fiÙÈ ÙÔ H. pylori ›Ûˆ˜ ·ÔÙÂÏ› Ê˘ÛÈÔÏÔÁÈ΋ ¯ÏˆÚ›‰· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È ·ÎfiÌ· ÂÚÈÛÛfiÙÂÚÔ fiÙÈ ›Ûˆ˜ Â›Ó·È ¯Ú‹ÛÈÌÔ ÛÙÔÓ ÍÂÓÈÛÙ‹. O Ó¤Ô˜ ·˘Ùfi˜ ÛÎÂÙÈÎÈÛÌfi˜ ¤Ú¯ÂÙ·È ·ÎÚÈ‚Ò˜ ÙË ÛÙÈÁÌ‹ Ô˘ ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙÔ ı¤Ì· ÙÂÏÈο ¤¯Ô˘Ó ÂÈÛı› ÁÈ· ÙȘ ÛÔ‚·Ú¤˜ ÂÈÙÒÛÂȘ ÛÙËÓ ˘Á›· ·fi ÙË Ïԛ̈ÍË ·˘Ù‹. ŸÌˆ˜, ·fi fiÏÔ˘˜ ÔÌÔÏÔÁÂ›Ù·È fiÙÈ Ë ·Ó·Î¿Ï˘„Ë ÙÔ˘ H. pylori Î·È Ë Û˘Û¯¤ÙÈÛ‹ ÙÔ˘ Ì ÙË Á·ÛÙÚ›Ùȉ·, ÙÔ ¤ÏÎÔ˜, ÙÔ Á·ÛÙÚÈÎfi ηÚΛÓÔ Î·È ÙÔ MALT-ϤÌʈ̷ ·ÔÙÂÏÔ‡Ó ÙË ÌÂÁ·Ï‡ÙÂÚË ÚfiÔ‰Ô Ù˘ Á·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜ Ù· ÙÂÏÂ˘Ù·›· 50 ¯ÚfiÓÈ·. H ÁÓÒÛË ·˘Ù‹ ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· Ó· ÂÍ·Ê·ÓÈÛıÔ‡Ó ÓfiÛÔÈ Ô˘ ¢ı‡ÓÂÙ·È ÁÈ· ¯ÈÏÈ¿‰Â˜ ı·Ó¿ÙÔ˘˜ οı ¯ÚfiÓÔ.(1,7) TÂÏÈο, ‰ÂÓ Â›Ó·È ·ÎfiÌË ‚¤‚·ÈÔ ·Ó Ë ‰È·Ù·Ú·¯‹ ·˘Ù‹ Ù˘ Û˘Ì‚›ˆÛ˘ ÙÔ˘ ÂÏÈÎÔ‚·ÎÙËÚȉ›Ô˘ ÙÔ˘ ˘ÏˆÚÔ‡ Ì ÙÔÓ ÍÂÓÈÛÙ‹, Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙË ıÂڷ›· ÂÎÚ›˙ˆÛ˘ ÙÔ˘, ¤¯ÂÈ ·ÚÓËÙÈΤ˜ ÂÈÙÒÛÂȘ. ¶ÚÔ˜ ÙÔ ·ÚfiÓ fï˜, ÂÈÎÚ·Ù› Ë ¿Ô„Ë ˘¤Ú Ù˘ ¯ÚËÛÈÌÔÔ›ËÛ˘ ÚÔÏËÙÈÎÒÓ Ì¤ÛˆÓ ÁÈ· ÙË Ì›ˆÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ Ïԛ̈͢ ·fi ÙÔ ÌÈÎÚfi‚ÈÔ ·˘Ùfi. BÈ‚ÏÈÔÁÚ·Ê›· 1. Koletzko S, Ashorn M. The year in Helicobacter pylori. Paediatrics. Current opinion in Gastroenterology (Supplement 1) 1998;14:S 57-S63. 2. Barden PK. Epidemiological features of Helicobacter pylori infection in developing countries. Clin Infect Dis 1997;25:973-978. 3. Roma-Giannikou, Panayiotou J, Vanvliet C, Charissiadou A, Anasi H, Pangali A, Matsaniotis N. Helicobacter pylori in Greek children with upper gastrointestinal symptoms. Hellenic J Gastroenterol 1993;6:251-259. 4. Roma-Giannikou E, Balatsos B, Panayiotou J, Van-Vliet C, Papaliodi J, Charissiadou A, Siahanidou T, Skandalis N. Intrafamilial spread of Helicobacter pylori. Hellenic J Gastroenter 1999;12:96-100. 5. Xia HH, Talley NJ. Natural acquisition and spontaneous elimination of Helicobacter pylori infection: clinical implications. Am J Gastroenterol 1997;92:1780-1787. 6. Roma E, Panayiotou J, Kafritsa P, Vanvliet C, Giannoulia A, Constantopoulos A. Upper gastrointestinal disease, Helicobacter Pylori and recurrent abdominal pain. Acta Paediatr 1999;88:1-4. 7. Drum B, Koletzko S, Oderda G. Helicobacter pylori Infection in Children: A concensus statement. J P Gastr Nutr 2000;30:207-213. 8. Kindermann A, Demmelmair H, Koletzko B, Wiebecke B, Koletzko S. Diagnostic value and errors of the 13C- urea breath test in children. Gut 1997;41(Suppl.):A67. 9. Jones NL, Bourke B, Sherman PM. Breath testing for Helicobacter pylori infection in children: a breath of fresh air? (editorial, comment) J Pediatr 1997;131:791-793. 10. Abdel RS, Nahata MC. Guidelines for the treatment of Helicobacter pylori in the pediatric population. Ann Pharmacother 1997;32-1247-1249. 11. Oderda G. Cure of Helicobacter pylori in children. Helicobacter 1997;2(Suppl1):S73-76. 12. Walsh D, Goggin N, Rowland M, Durnin M, Moriatri S, Drumm B. One week treatment for Helicobacter pylori infection. Arch Dis Child 1997;76:352-355. 13. Blecker U, Gold Bd. Treatment of Helicobacter pylori infection; a review. Pediatr Infect Dis J 1997;16:391-399. 14. Berquist W. New, Improved Helicobacter pylori eradication therapy in children. J Ped Gastroent Nutr 1998;26:360-362. 15. Czinn S. What is the role for vaccination in Helicobacter pylori? Gastroenterol 1997;113:S149-S153. 16. Mentis A, Roma E, Pangalis A, Katsigiannakis E. Susceptibilities of Helicobacter pylori strains isolated from children with gastritis to selected antibiotics. J Antimicrob Chemother 1999;44:720-22.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: E. ƒÒÌ·-°È·ÓÓ›ÎÔ˘ ∞Ó·ÏËÚÒÙÚÈ· ∫·ıËÁ‹ÙÚÈ· ¶·È‰È·ÙÚÈ΋˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∏ ∞Á›· ™ÔÊ›·”, Aı‹Ó· 115 27
271
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·272
¶∞π¢π∞∆ƒπ∫∏ 2000;63:272-274
H ÔÈÎÔÁ¤ÓÂÈ· Î·È Ë ÊÚÔÓÙ›‰· ÙˆÓ ·È‰ÈÒÓ Ì ·Ó·Ëڛ˜ °›ÙÛ· KÔÙÙ·Ú›‰Ë Y. Kottaridi. The family and care of the child with disability. Paediatriki 2000;63:272-274. ● Abstract: In the Greek context, the care of the child with disability is undertaken mainly by the family with inadequate information and support from the community and the state. Parents complain about negative attitudes on the part of society, social and physical barriers and problems of communication and relationships with health professionals, as well as about delays in detection and intervention. They meet the needs of the child to the best of their ability, but they are very concerned about the future of the child when they are gone, as the family unit is gradually loosening its bonds and its traditional function is changing. Key words: disability, special needs.
T· ÚÔ‚Ï‹Ì·Ù· Î·È Ù· ˙ËÙ‹Ì·Ù· Ô˘ ·ÊÔÚÔ‡Ó ÙÔ ·Ó¿ËÚÔ ·È‰› ·ÔÎÙÔ‡Ó Û˘ÓÔ¯‹, fi¯È ̤ۈ οÔÈ·˜ ÔÚÁ·ÓˆÌ¤Ó˘ ÔÚıÔÏÔÁÈ΋˜ ÂÓfiÙËÙ·˜, ·ÏÏ¿ ΢ڛˆ˜ ‰ÈfiÙÈ ¤¯Ô˘Ó ÌÈ· ÎÔÈÓ‹ Û˘Ó·ÈÛıËÌ·ÙÈ΋ ‚¿ÛË: ÙËÓ ·ÓËÛ˘¯›· Ô˘ fiÏÔÈ ÓÔÈÒıÔ˘Ì ÁÈ· ÙË ÌÔ›Ú· ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ ÛÙÔÓ ÎfiÛÌÔ ÙÔ˘ ·‡ÚÈÔ. AÓËÛ˘¯Ô‡Ì ÁÈ· ÙË Ê˘ÛÈ΋ Î·È ÙËÓ ÓÂ˘Ì·ÙÈ΋ ÙÔ˘˜ ˘Á›·, ÁÈ· ÙËÓ ÚÔÛ·ÚÌÔÁ‹ ÙÔ˘˜ ÛÙÔÓ Ú˘ıÌfi Ù˘ Û‡Á¯ÚÔÓ˘ ˙ˆ‹˜, ÁÈ· ÙË Û¯¤ÛË ÙÔ˘˜ Ì ÙÔ ¿ÌÂÛÔ ÔÈÎÔÁÂÓÂÈ·Îfi Î·È ÙÔ ÎÔÈÓˆÓÈÎfi ÂÚÈ‚¿ÏÏÔÓ. Aӷʤڈ ÔÚÈṲ̂Ó˜ ‰È·ÈÛÙÒÛÂȘ Î·È ·Ú·ÙËÚ‹ÛÂȘ ·fi ÂÎ ‚·ı¤ˆÓ Û˘ÓÂÓÙ‡ÍÂȘ Ì ÔÈÎÔÁ¤ÓÂȘ ·È‰ÈÒÓ Ì ÎÈÓËÙÈ΋, ·ÈÛıËÙËÚȷ΋, ÓÔËÙÈ΋ ·Ó·ËÚ›·. OÈ Û˘ÓÂÓÙ‡ÍÂȘ ·˘Ù¤˜ ·ÔÙÂÏÔ‡Ó Ì¤ÚÔ˜ ÌÈ·˜ ¢ڇÙÂÚ˘ ÌÂϤÙ˘ Ô˘ ¤ÁÈÓ ÛÙÔ Ï·›ÛÈÔ ÂÓfi˜ ‰È·ÎÚ·ÙÈÎÔ‡ ÂÚ¢ÓËÙÈÎÔ‡ ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂٷ͇ ÌÂÛÔÁÂÈ·ÎÒÓ ¯ˆÚÒÓ Ì ΤÓÙÚÔ Û˘ÓÙÔÓÈÛÌÔ‡ ÙÔ EıÓÈÎfi IÓÛÙÈÙÔ‡ÙÔ YÁ›·˜ Î·È I·ÙÚÈ΋˜ ŒÚ¢ӷ˜ ÛÙÔ ¶·Ú›ÛÈ (INSERM). ŒÓ· ·fi Ù· ÚÒÙ· ÛËÌ·ÓÙÈο Û˘ÌÂÚ¿ÛÌ·Ù· Ô˘ ·Ó·‰‡ıËΠ·fi ÙȘ Û˘ÓÂÓÙ‡ÍÂȘ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ,ÛÙË ¯ÒÚ· Ì·˜, ›Ûˆ˜ Î·È ÂÏÏ›„ÂÈ ÔÚÁ·ÓˆÌ¤ÓˆÓ ˘Ô‰ÔÌÒÓ, Â›Ó·È Ô ÔÈÎÔÁÂÓÂÈ·Îfi˜ ıÂÛÌfi˜ ·˘Ùfi˜ Ô˘ ۯ‰fiÓ ·ÔÎÏÂÈÛÙÈο ¤¯ÂÈ ÂÈÊÔÚÙÈÛı› Ì ÙË ÊÚÔÓÙ›‰· ÙˆÓ ·È‰ÈÒÓ Ì ·Ó·Ëڛ˜. °È· ÙȘ ÔÈÎÔÁ¤ÓÂȘ ·˘Ù¤˜ Ë ÂÌÂÈÚ›· Ì ÙËÓ ·Ó·ËÚ›· Â›Ó·È ¤Ó· ‚·Ú‡ ÊÔÚÙ›Ô Ô˘ ÛËÎÒÓÂÈ Ë ÔÈÎÔÁ¤ÓÂÈ·, ΢ڛˆ˜ Ë ÌËÙ¤Ú·, ¯ˆÚ›˜ ÏËÚÔÊfiÚËÛË, ηıÔ‰‹ÁËÛË ‹ ÛÙ‹ÚÈÍË ·fi ÙÔ ÎÚ¿ÙÔ˜ ‹ ÙËÓ ÎÔÈÓˆÓ›·. EÂȉ‹ Ë ÎÔÈÓˆÓ›· Â›Ó·È ‰ÔÌË̤ÓË ¤ÙÛÈ ÒÛÙ ӷ ÈηÓÔÔÈ› ÚˆÙ·Ú¯Èο ÙȘ ·Ó¿ÁΘ ÙˆÓ ˘ÁÈÒÓ ·ÙfïÓ, Ë ·Ó·ËÚ›· Â›Ó·È ‰··ÓËÚ‹. TÔ ÌÂÁ·Ï‡ÙÂÚÔ Ì¤ÚÔ˜ ÙÔ˘ ÎfiÛÙÔ˘˜ - ÔÈÎÔÓÔÌÈÎÔ‡ Î·È „˘¯ÔÎÔÈÓˆÓÈÎÔ‡ - Ô˘ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÔÈ ÔÈÎÔÁ¤ÓÂȘ ÂÈ‚¿ÏÏÂÙ·È ÎÔÈÓˆÓÈο Î·È ‰ÂÓ Â›Ó·È ÂÁÁÂÓ¤˜ ÛÙË Ê‡ÛË Ù˘ ·Ó·ËÚ›·˜. TÔ ÔÈÎÔÓÔÌÈÎfi ‚¿ÚÔ˜ ÚÔ·ÙÂÈ ·fi ÙÔ fiÙÈ ÁÂÓÈο, ÔÈ ÁÔÓ›˜ Î·È fi¯È Ë ÎÔÈÓˆÓ›· ·Ó·Ì¤ÓÂÙ·È Ó· ÏËÚÒÛÔ˘Ó ÙȘ ˘¤ÚÔÁΘ ‰·¿Ó˜ Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi ÙȘ ÂȉÈΤ˜ ·Ó¿ÁΘ ÙÔ˘ ·È‰ÈÔ‡. ¶·ÚÔÌÔ›ˆ˜, ÌÂÁ¿ÏÔ Ì¤ÚÔ˜ ÙÔ˘ „˘¯ÔÎÔÈÓˆÓÈÎÔ‡ ÊÔÚÙ›Ô˘ Ô˘ ˆ̛˙ÔÓÙ·È ÔÈ ÁÔÓ›˜ ÙÔ‡˜ ÂÈ‚¿ÏÏÂÙ·È ÂÂȉ‹ ‰ÂÓ ˘¿Ú¯Ô˘Ó ÔÈ Î·Ù¿ÏÏËϘ ˘ÔÛÙËÚÈÎÙÈΤ˜ ˘ËÚÂۛ˜ fiˆ˜ ηÙ' Ô›ÎÔÓ ÊÚÔÓÙ›‰·, ÏËÚÔÊfiÚËÛË Û¯ÂÙÈο Ì ÙË ‰È¿ÁÓˆÛË, ÙËÓ ·ÁˆÁ‹ Î·È ÙË ıÂڷ›·, ηıÒ˜ Î·È ÂÎ·È‰Â˘ÙÈο Î·È ÌÔÚʈÙÈο ÚÔÁÚ¿ÌÌ·Ù· ÁÈ· ÙÔ ·È‰›. O ÛÙÈÁÌ·ÙÈÛÌfi˜ Ù˘ ·Ó·ËÚ›·˜ ·fi ÙËÓ ÎÔÈÓˆÓ›· Î·È Ù· ÚfiÙ˘· Û˘ÌÂÚÈÊÔÚ¿˜ Ô˘ ÚÔ·ÙÔ˘Ó ·fi ·˘ÙfiÓ ÙÔÓ ÛÙÈÁÌ·ÙÈÛÌfi ›Û˘ ÂÌÔ‰›˙Ô˘Ó ÙȘ ÔÈÎÔÁ¤ÓÂȘ Ó· ¤¯Ô˘Ó ¤Ó· Ê˘ÛÈÔÏÔÁÈÎfi ÙÚfiÔ ˙ˆ‹˜. ŸÌˆ˜, Î·È ÙÔ ÔÈÎÔÓÔÌÈÎfi Î·È ÙÔ „˘¯ÔÎÔÈÓˆÓÈÎfi ÎfiÛÙÔ˜ ·ÓÙÈÛÙ·ıÌ›˙ÔÓÙ·È, ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÂÚÈÎÒ˜, Ì ÔʤÏË Ô˘ ·ÔÚÚ¤Ô˘Ó ·fi ·˘ÍË̤ÓË Û˘ÓÂȉËÙÔÔ›ËÛË, ·fi ‚ÂÏÙȈ̤Ó˜ ÈηÓfiÙËÙ˜ ·ÓÙÈÌÂÙÒÈÛ˘ Î·È ·fi ÙËÓ ·Ó¿ÁÎË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÁÈ· ÂÓۈ̿وÛË Î·È ÎÔÈÓˆÓÈ΋ ¤ÓÙ·ÍË Ô˘ ÚÔ·ÙÂÈ ·fi ÙËÓ ÂÌÂÈÚ›· Ù˘ ·Ó·ËÚ›·˜. ¶ÔÏÏ¿ ·fi Ù· ¤ÍÔ‰· Ù˘ ·Ó·ËÚ›·˜ Ô˘ ʤÚÂÈ Ë ÔÈÎÔÁ¤ÓÂÈ· ı· ÌÔÚÔ‡Û·Ó Ó· ÌÂȈıÔ‡Ó Ì ÌÈ· ÂÓÙÔÓfiÙÂÚË ˘ÔÛÙËÚÈÎÙÈ΋ ·ÓÙ·fiÎÚÈÛË ÂΠ̤ÚÔ˘˜ Ù˘ ÎÔÈÓˆÓ›·˜. H ·Ó·ËÚ›· Û' ¤Ó· ·È‰› Â›Ó·È ÌÈ· ·fi ÙȘ ÈÔ Ô‰˘ÓËÚ¤˜ ÂÌÂÈڛ˜ Ó· ·Ô‰Â¯ı› ηÓ›˜. TÔ ‚·ı‡ Î·È Û˘¯Ó¿ ÎÚ˘Êfi Û˘Ó·›ÛıËÌ· Ù˘ ·ÒÏÂÈ·˜ Î·È Ù˘ ·‰ÈΛ·˜, ÂÁÁÂÓ¤˜ Û ·˘Ù‹ ÙËÓ ÂÌÂÈÚ›·, ÙËÓ Î·ıÈÛÙÔ‡Ó ÚfiÎÏËÛË ÁÈ·
272
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·273
¶∞π¢π∞∆ƒπ∫∏ 2000;63:272-274
∞ÊȤڈ̷: ÀÁ›· ÙÔ˘ ·È‰ÈÔ‡ 2000
ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Î·È ÙË ‰˘ÛÎÔÏÂ‡Ô˘Ó Ó· ΢ÚÈ·Ú¯‹ÛÂÈ ¿Óˆ Û ·˘Ù‹Ó Î·È Ó· ÙËÓ ÂϤÁÍÂÈ. M ÙËÓ ÚfiÔ‰Ô ÛÙËÓ È·ÙÚÈ΋ Ù¯ÓÔÏÔÁ›·, Ù· ·Ó¿ËÚ· ·È‰È¿ ˙Ô˘Ó ˆ˜ ÙËÓ ÂÊ˂›· ·ÏÏ¿ Î·È Ôχ ÂÚÈÛÛfiÙÂÚÔ, ˆ˜ ÂÓ‹ÏÈΘ. A˘Ùfi ÙÔ ıÂÙÈÎfi ÁÂÁÔÓfi˜ ‰ËÌÈÔ˘ÚÁ› ÚfiÛıÂÙ· „˘¯ÔÎÔÈÓˆÓÈο ‚¿ÚË Ô˘ ˆ̛˙ÔÓÙ·È Î˘Ú›ˆ˜ ÔÈ ÔÈÎÔÁ¤ÓÂȘ. ŒÓ· ‰Â‡ÙÂÚÔ ÛËÌ·ÓÙÈÎfi Û˘Ì¤Ú·ÛÌ· Â›Ó·È fiÙÈ Ë ÎÔÈÓ‹ ÁÓÒÌË ÙÔÔıÂÙÂ›Ù·È ˘¤Ú Ù˘ ‡·Ú͢ Î·È ÂÓ›Û¯˘Û˘ ÙÔ˘ KÚ¿ÙÔ˘˜ ¶ÚfiÓÔÈ·˜, Ì ÛÔ‚·ÚfiÙÂÚË Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË ·Ú¤Ì‚·ÛË Û fiÏ· Ù· ›‰·. OÈ ÁÔÓ›˜ ·Â˘ı‡ÓÔ˘Ó "ÛÎÏËÚ‹" ÎÚÈÙÈ΋ ÛÙËÓ ˘Ô‚¿ıÌÈÛË ÙˆÓ ÚÔÓÔÈ·ÎÒÓ Ï¢ÚÒÓ ÙÔ˘ ÎÚ¿ÙÔ˘˜, ·ÈÛı·ÓfiÌÂÓÔÈ ¤ÓÙÔÓ· ÙËÓ ·Ó·ÛÊ¿ÏÂÈ· Ù˘ ·ÁÔÚ¿˜ Î·È Ù˘ ·ıÂÛÌÔÔ›ËÙ˘ ÎÔÈÓˆÓ›·˜. ŒÓ· ÙÚ›ÙÔ Â‡ÚËÌ· Â›Ó·È fiÙÈ Ô ‚·ıÌfi˜ ÂÓË̤ڈÛ˘ Ù˘ ÂÏÏËÓÈ΋˜ ÎÔÈÓˆÓ›·˜ ÁÈ· Ù· ˙ËÙ‹Ì·Ù· Ù˘ ·Ó·ËÚ›·˜ ÂÌÊ·Ó›˙ÂÙ·È ¯·ÌËÏfi˜. EÍ·ÈÙ›·˜ Ù˘ ¿ÁÓÔÈ·˜ Î·È Ù˘ ÂÏÏÈÔ‡˜ ÏËÚÔÊfiÚËÛ˘, ·Ó·Ù‡ÛÛÔÓÙ·È ÚÔηٷϋ„ÂȘ, ·ÚÓËÙÈΤ˜ ÛÙ¿ÛÂȘ Î·È ‰È·ı¤ÛÂȘ ÌÂ Û˘Ó¤ÂÈ· ÙË ‰È¿ÎÚÈÛË, ÙË ÌË ·Ô‰Ô¯‹, ÙËÓ ÂÚÈıˆÚÈÔÔ›ËÛË Î·È ÙÔÓ ÛÙÈÁÌ·ÙÈÛÌfi Ô˘ ‰˘ÛÎÔÏÂ‡Ô˘Ó ÙËÓ ÔÚı‹ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ·Ó·ËÚ›·˜, ·ÎfiÌË Î·È ·fi ÙËÓ ›‰È· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·. ™ËÌ·ÓÙÈÎfi Â›Ó·È Ó· ·Ó·ÊÂÚı› fiÙÈ Ë ÎÔÈÓˆÓÈ΋ ·Ô‰Ô¯‹ ÂËÚ¿˙ÂÙ·È Î·È ·fi ÙËÓ ÙÔÔı¤ÙËÛË ÙˆÓ ÁÔÓÈÒÓ ·¤Ó·ÓÙÈ ÛÙÔ Úfi‚ÏËÌ·. ™˘¯Ó¿ ÔÈ ÁÔÓ›˜ ÚÔ‚¿ÏÏÔ˘Ó ÛÙËÓ ÎÔÈÓˆÓ›· ·˘Ùfi Ô˘ ÊÔ‚Ô‡ÓÙ·È, fiÙÈ ‰ËÏ·‰‹ ÙÔ˘˜ Ï˘Ô‡ÓÙ·È, ÂÂȉ‹ ·˘ÙÔ› ÔÈ ›‰ÈÔÈ Ï˘Ô‡ÓÙ·È ÙÔÓ Â·˘Ùfi ÙÔ˘˜. ÕÚ·, Ë ÌË ·Ô‰Ô¯‹ Û˘¯Ó¿ ÍÂÎÈÓ¿ ·fi ÙÔ˘˜ ›‰ÈÔ˘˜ ÙÔ˘˜ ÁÔÓ›˜. ŒÙÛÈ, ηٷϋÁÔ˘Ì ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë ·Ó·ËÚ›· Â›Ó·È ¤Ó· ÁÂÁÔÓfi˜, ÂÓÒ Ë ÌÂÈÔÓÂÍ›· ÁÈ· ÙËÓ ·Ó·ËÚ›· ηٷÛ΢¿˙ÂÙ·È ·Ú¯Èο ·fi ÙËÓ ›‰È· ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·. H ¢¿ÊÓË OÈÎÔÓfiÌÔ˘, Ô˘ ¤¯ÂÈ ·Ó·ÏÒÛÂÈ ÙË ˙ˆ‹ Ù˘ ÛÙË ÊÚÔÓÙ›‰· ÙˆÓ ·Ó¿ËÚˆÓ ·È‰ÈÒÓ, ϤÂÈ Û οÔÈ· ÔÌÈÏ›· Ù˘: "E›Ó·È ‚¤‚·ÈÔ fiÙÈ ÌÚÔ˜ ÛÙÔÓ ı¿Ó·ÙÔ ‹ ÛÙËÓ ·Ó·ËÚ›· ÂÓfi˜ ·È‰ÈÔ‡, ÔÈ ÁÔÓ›˜ ‰ÂÓ ‰È·ı¤ÙÔ˘Ó Ô‡Ù ·ÓÙÈÛÒÌ·Ù· Ô‡Ù ηÌÈ¿ ¿ÏÏË ÌÔÚÊ‹ Ê˘ÛÈÔÏÔÁÈ΋˜ ·Ó·ÎÔ‡ÊÈÛ˘.(...) OÈ ·ÓÙȉڿÛÂȘ ÙÔ˘˜ Â›Ó·È ÚˆÙfiÁÔÓ˜ Î·È ÔÏϤ˜ ÊÔÚ¤˜ ·›ÚÓÔ˘Ó ÙË ÌÔÚÊ‹ ηı·Ú‹˜ ·ÓÙ›ÛÙ·Û˘. A˘Ùfi ÌÔÚ› Ó· Ê·›ÓÂÙ·È ·Ú¿ÏÔÁÔ ÛÙÔ˘˜ ¿ÏÏÔ˘˜, ·ÏÏ¿ Ë ÂÍ‹ÁËÛË ›Ûˆ˜ Â›Ó·È fiÙÈ ÔÈ ÁÔÓ›˜, ÂÓÙÂÏÒ˜ ·ÚÔÂȉÔÔ›ËÙÔÈ Î·È ·Ó¤ÙÔÈÌÔÈ, ÚÔÛ·ıÔ‡Ó Ó· ηٷϿ‚Ô˘Ó Î·È Ó· ‰Â¯ıÔ‡Ó ÙË Ó¤· ·˘Ù‹ Ú·ÁÌ·ÙÈÎfiÙËÙ·.(...) ŒÙÛÈ, ·Ú¯›˙ÂÈ Ë ·Ó·˙‹ÙËÛË. OÈ ÁÔÓ›˜ ÍÂÎÈÓÔ‡Ó ÁÈ· Ó· ·Ó·Î·Ï‡„Ô˘Ó ÙÈ Û˘Ì‚·›ÓÂÈ Ì ÙÔ ·È‰› ÙÔ˘˜. ZËÙÔ‡Ó ÏËÚÔÊÔڛ˜ Î·È ¿ÌÂÛ˜ χÛÂȘ.(...) ZËÙÔ‡Ó ‚Ô‹ıÂÈ· Î·È ·ÓÙ› ÁÈ' ·˘Ù‹Ó ÙÔ˘˜ ÚÔÛʤÚÂÙ·È Û˘Ó‹ıˆ˜ ¤Ó· ·fi Ù· ÙÚ›· ηο: ›Ù ÌÂÚ‰Â̤Ó˜ Î·È ·Î·Ù·ÓfiËÙ˜ ÁÓÒ̘, ¤ÙÔÈ̘ ÊÚ¿ÛÂȘ, ˘ÂÎÊ˘Á¤˜, ›Ù ÂÈÛÙËÌÔÓÈο ‰Â‰Ô̤ӷ Ô˘ ÂÈ‚¿ÏÏÔÓÙ·È ˆ˜ ‰fiÁÌ·Ù·, ›ÙÂ, ÙÔ ¯ÂÈÚfiÙÂÚÔ, ·ÏÏËÏÔÛ˘ÁÎÚÔ˘fiÌÂÓ˜ ·fi„ÂȘ.(...) AÓ ÌÔÚÔ‡Û·Ó Ó· ¤¯Ô˘Ó fiÏÔÈ ÔÈ ÁÔÓ›˜ ÙȘ ȉÂÒ‰ÂȘ Û˘Óı‹Î˜ ÁÈ· ‰È¿ÁÓˆÛË, ıÂڷ›·, ÏËÚÔÊfiÚËÛË Î·È ÛÙ‹ÚÈÍË Ô˘ ˘¿Ú¯Ô˘Ó Û ÔÚÈṲ̂ӷ K¤ÓÙÚ· ÙÔ˘ Â͈ÙÂÚÈÎÔ‡, ı· ÏÈÁfiÛÙ¢ ÛËÌ·ÓÙÈο Ë ·›ÛıËÛË ÙÔ˘ ¯¿Ô˘˜ Î·È Ù˘ ηٷÛÙÚÔÊ‹˜". H ÂÌÂÈÚ›· Ì·˜ ·fi ÙȘ ·ʤ˜ Ì·˜ Ì ÔÈÎÔÁ¤ÓÂȘ Ô˘ ¤¯Ô˘Ó ·Ó¿ËÚÔ ·È‰› ›ӷÈ: M·Ó¿‰Â˜ Ô˘ ‰ÂÓ ¿ÓÙÂÍ·Ó ÙÔ ‚·Ú‡ ÊÔÚÙ›Ô Ù˘ ÊÚÔÓÙ›‰·˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È ÙÔ "¤ÎÏÂÈÛ·Ó" Û ›‰Ú˘Ì· ‹ ¿Û˘ÏÔ. ¶·Ù¤Ú˜ ÔÈ ÔÔ›ÔÈ ÂÁη٤ÏÂÈ„·Ó ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÌË ÌÔÚÒÓÙ·˜ Ó· ·ÓÙ¤ÍÔ˘Ó ÙÔ ÁÂÁÔÓfi˜ Ù˘ ·Ó·ËÚ›·˜ ÙÔ˘ ·È‰ÈÔ‡ ÙÔ˘˜. OÈÎÔÁ¤ÓÂȘ Ô˘ Ífi‰Â„·Ó ÂÚÈÔ˘Û›Â˜ ÛÙËÓ ÚÔÛ¿ıÂÈ¿ ÙÔ˘˜ Ó· ηχ„Ô˘Ó ÔÈÎÔÓÔÌÈο ÙȘ ÙÂÚ¿ÛÙȘ ··ÈÙ‹ÛÂȘ ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ Î·ıÒ˜ Î·È ÔÈÎÔÁ¤ÓÂȘ Ô˘, ¯ˆÚ›˜ ηӤӷ ÔÈÎÔÓÔÌÈÎfi ÂÊfi‰ÈÔ, ÍÂÎÈÓÔ‡Ó ÙÔÓ ·ÁÒÓ· ÌËÓ Í¤ÚÔÓÙ·˜ Ò˜ Î·È ·fi Ô‡ Ó· ˙ËÙ‹ÛÔ˘Ó ‚Ô‹ıÂÈ·. OÈÎÔÁ¤ÓÂȘ Ô˘ ÂÎÌÂÙ·ÏχÔÓÙ·È ÙȘ ·Ó·Ëڛ˜ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜ Ì ‰È¿ÊÔÚÔ˘˜ ÙÚfiÔ˘˜ Î·È ÁÈ· ‰È¿ÊÔÚÔ˘˜ ÏfiÁÔ˘˜. OÈÎÔÁ¤ÓÂȘ Ô˘ ·ÚÓÔ‡ÓÙ·È Ó· ‰Ô˘Ó ÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ·, ÚÔÛÎÔÏÏË̤ÓÔÈ Û ÚÔηٷϋ„ÂȘ Ô˘ ı¤ÏÔ˘Ó Ù· ¿ÙÔÌ· Ì ·Ó·Ëڛ˜ ¿ÙÔÌ· ÎÏÂÈṲ̂ӷ ÛÙÔ Û›ÙÈ Î·È Ù¤ÏÔ˜, ÔÈÎÔÁ¤ÓÂȘ Ô˘ ÍÂÂÚÓÔ‡Ó Ù· ·‰È¤ÍÔ‰· Ì ‰‡Ó·ÌË Î·È ı¤ÏËÛË. Y¿Ú¯Ô˘Ó Û›ÁÔ˘Ú·, Î·È ÔÏϤ˜ ¿ÏϘ ÂÚÈÙÒÛÂȘ ·ÓÙÈÌÂÙÒÈÛ˘ Ù˘ ·Ó·ËÚ›·˜ ·fi ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, ·ÊÔ‡ οı ·È‰› Â›Ó·È ÌÔÓ·‰ÈÎfi Î·È Î¿ı ÁÔÓÈfi˜ ¤¯ÂÈ ÙÔ ‰ÈÎfi ÙÔ˘ ÙÚfiÔ Ó· ÛΤÊÙÂÙ·È Î·È Ó· ÂÓÂÚÁ›. OÈ ÁÔÓ›˜ ÙˆÓ ·È‰ÈÒÓ Ì ·Ó·Ëڛ˜ ¤¯Ô˘Ó ÌÂÚÈΤ˜ ÎÔÈÓ¤˜ ·Ó¿ÁΘ: - TËÓ ·Ó¿ÁÎË Ó· ¤¯Ô˘Ó ·ÎÚÈ‚‹ ÏËÚÔÊfiÚËÛË Á‡Úˆ ·fi ÙË Ê‡ÛË ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙÔ˘ ·È‰ÈÔ‡. - TËÓ ·Ó¿ÁÎË Ó· ‰Â¯ÙÔ‡Ó ˘ÔÛÙ‹ÚÈÍË, Û˘Ì‚Ô˘Ï‹ Î·È Âη›‰Â˘ÛË Ì ÛÎÔfi Ó· ÈηÓÔÔÈÔ‡Ó ÙȘ ··ÈÙ‹ÛÂȘ ÙÔ˘ ·È‰ÈÔ‡ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ˙ˆ‹. - TËÓ ·Ó¿ÁÎË ˘ËÚÂÛÈÒÓ Ô˘ Ó· ·ÚÌfi˙Ô˘Ó ÛÙÔ ·È‰› ÙÔ˘˜, Î·È Ù¤ÏÔ˜, - TËÓ ·Ó¿ÁÎË Ó· ÛÎÂÊıÔ‡Ó ÙËÓ Â˘‰ÔΛÌËÛË fiÏˆÓ ÙˆÓ ÌÂÏÒÓ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ŸÌˆ˜, fiˆ˜ Ê¿ÓËΠ·fi ÙËÓ ¤Ú¢ӷ ·˘Ù‹, ÔÈ ÔÈÎÔÁ¤ÓÂȘ Ì ·Ó¿ËÚÔ ·È‰› ÛÙË ¯ÒÚ· Ì·˜ ÓÔÈÒıÔ˘Ó ÌfiÓ˜ Î·È ·‚Ô‹ıËÙ˜ ÛÙÔÓ ·ÁÒÓ· ÙÔ˘˜. OÈ ÁÔÓ›˜ ‰È·Ù˘ÒÓÔ˘Ó Ù· ·Ú¿ÔÓ¿ ÙÔ˘˜ ¤ÌÌÂÛ· ‹ ¿ÌÂÛ· Î·È Ì ‰È·ÊÔÚÂÙÈ΋ ¤ÓÙ·ÛË Î·È Û˘¯ÓfiÙËÙ·. ¶·Ú·ÔÓÔ‡ÓÙ·È: - ÁÈ· ·ÚÓËÙÈ΋ ÛÙ¿ÛË ·fi ÙËÓ ÏÂ˘Ú¿ Ù˘ ÎÔÈÓˆÓ›·˜, - ÁÈ· ÎÔÈÓˆÓÈο Î·È Ê˘ÛÈο ÂÌfi‰È·, - ÁÈ· ·Ó·Ú΋ ÏËÚÔÊfiÚËÛË, - ÁÈ· ·Ó·Ú΋ ÂÈÛÙËÌÔÓÈ΋ ηıÔ‰‹ÁËÛË Î·È ˘ÔÛÙ‹ÚÈÍË, - ÁÈ· ÚÔ‚Ï‹Ì·Ù· ÂÈÎÔÈÓˆÓ›·˜ Î·È Û¯¤ÛÂˆÓ Ì ÙÔ˘˜ ÁÈ·ÙÚÔ‡˜ Î·È ÙÔ˘˜ ¿ÏÏÔ˘˜ ·ÁÁÂÏ̷ٛ˜ ˘Á›·˜, - ÁÈ· ÌË ¤ÁηÈÚË ‰È¿ÁÓˆÛË Î·È ·Ú¤Ì‚·ÛË,
273
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·274
¶∞π¢π∞∆ƒπ∫∏ 2000;63:272-274
°. KÔÙÙ·Ú›‰Ë
- ÁÈ· ·Ó·Ú΋ ÂÍÂȉÈÎÂ˘Ì¤ÓË ÊÚÔÓÙ›‰·, - ÁÈ· ¤ÏÏÂÈ„Ë ÚÔÛˆÈÎÔ‡ ηٿÏÏËÏÔ˘ ÁÈ· ÔÏÈÛÙÈ΋ ÊÚÔÓÙ›‰· Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ·ÓÙÈÌÂÙÒÈÛË „˘¯ÔÏÔÁÈÎÒÓ, ÎÔÈÓˆÓÈÎÒÓ, ·Ó·Ù˘ÍÈ·ÎÒÓ ·Ó·ÁÎÒÓ, „˘¯·ÁˆÁ›·˜ Î·È ·È‰Â›·˜, - ÁÈ· ¤ÏÏÂÈ„Ë ˘ËÚÂÛÈÒÓ ÊÚÔÓÙ›‰·˜ ÛÙÔ Û›ÙÈ. ŒÓ· ·fi Ù· ÌÂÁ·Ï‡ÙÂÚ· ÚÔ‚Ï‹Ì·Ù· Ô˘ ·Ó·Ê¤ÚÔ˘Ó Â›Ó·È ÙÔ ÎÚ¿ÙÔ˜ ÁÚ·ÊÂÈÔÎÚ·Ù›·˜ Ô˘ ¤¯Ô˘Ó Ó· ·ÓÙÈÌÂÙˆ›ÛÔ˘Ó, ÙÔ ÔÔ›Ô ÔÚÈṲ̂Ó˜ ÊÔÚ¤˜ ·ÔÙÂÏ› ÌÈ· ÂÓÙÂÏÒ˜ ·Ú·ÓÔ˚΋ ηٿÛÙ·ÛË. TÔ˘˜ ··Û¯ÔÏ› Ôχ ÙÔ Ì¤ÏÏÔÓ ÙÔ˘ ·È‰ÈÔ‡ fiÙ·Ó ÔÈ ›‰ÈÔÈ Ï›„Ô˘Ó, ηıÒ˜ ÔÈ ÔÈÎÔÁÂÓÂÈ·ÎÔ› ‰ÂÛÌÔ› ¯·Ï·ÚÒÓÔ˘Ó Î·È Ë ·Ú·‰ÔÛȷ΋ ÏÂÈÙÔ˘ÚÁ›· Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ·ÏÏ¿˙ÂÈ. ZËÙÔ‡Ó ÙË ‰Ú·ÛÙËÚÈÔÔ›ËÛË ÙÔ˘ ÎÚ¿ÙÔ˘˜ ÁÈ· Ó· ηχ„ÂÈ ÙȘ ·˘Í·ÓfiÌÂÓ˜ ·Ó¿ÁΘ Ô˘ Û‹ÌÂÚ· ˆ̛˙ÂÙ·È Ë ›‰È· Ë ÔÈÎÔÁ¤ÓÂÈ·. E›ÏÔÁÔ˜ H ‰˘Ó·ÙfiÙËÙ· Ó· ÂÈÙ‡¯ÂÈ Î·Ó›˜ ÈηÓÔÔÈËÙÈ΋ ÔÈfiÙËÙ· ˙ˆ‹˜ οو ·fi ÙȘ ȤÛÂȘ Î·È ÙȘ ·‚‚·ÈfiÙËÙ˜ Ô˘ ÚÔηÏ› Ë ·Ó·ËÚ›· Â›Ó·È ÌÈ· ÙÂÚ¿ÛÙÈ· ÚfiÎÏËÛË. H ÂÌÂÈÚ›· οı ÔÈÎÔÁ¤ÓÂÈ·˜ Â›Ó·È ÌÔÓ·‰È΋ Î·È ‰ÂÓ ÌÔÚ› Ó· ÂÚÈÔÚÈÛÙ› Û ¤Ó·Ó ÎÏÈÓÈÎfi Ù‡Ô. ŸÌˆ˜, ˘¿Ú¯Ô˘Ó ˙ËÙ‹Ì·Ù· Ô˘ ÌÔÚ› Ó· ÚÔ‚ÏÂÊıÔ‡Ó Î·È Ô˘ Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔÓÙ·È ˘fi„Ë ÁÈ· ÙËÓ ˘ÔÛÙ‹ÚÈÍË Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È ÙˆÓ Â·ÁÁÂÏÌ·ÙÈÒÓ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙË ÊÚÔÓÙ›‰· Ù˘ ·Ó·ËÚ›·˜. °È' ·˘ÙfiÓ ÙÔ ÛÎÔfi, ‰ÂÓ ·ÚÎÔ‡Ó ÔÈ ÁÓÒÛÂȘ Î·È ÔÈ Î·Ï¤˜ ‰È·ı¤ÛÂȘ. XÚÂÈ¿˙ÔÓÙ·È ÔÏÈÙÈΤ˜ ˘Á›·˜ Î·È ÚfiÓÔÈ·˜ Î·È ÚˆÙÔ‚Ô˘Ï›Â˜ ÁÈ· ÚÔÁÚ¿ÌÌ·Ù· Ô˘ Ó· ¤¯Ô˘Ó ˆ˜ ›ÎÂÓÙÚÔ ÙËÓ ÔÈÎÔÁ¤ÓÂÈ·.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °. KÔÙÙ·Ú›‰Ë, KÔÈÓˆÓÈÔÏfiÁÔ˜, IÓÛÙÈÙÔ‡ÙÔ KÔÈÓˆÓÈ΋˜ ¶ÔÏÈÙÈ΋˜, E.K.K.E MÂÛÔÁ›ˆÓ 14-18, Aı‹Ó·
274
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·275
¶∞π¢π∞∆ƒπ∫∏ 2000;63:275-277
Aƒ£ƒO ™À¡∆∞•∏™
H ¯Ú‹ÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙÔ Û‡Ó‰ÚÔÌÔ Turner: ™‡Á¯ÚÔÓ˜ ·fi„ÂȘ Î·È ÚÔ‚ÏËÌ·ÙÈÛÌÔ› M·Ú›·-AÏÂÍ¿Ó‰Ú· M·ÁÈ¿ÎÔ˘1, °ÂÒÚÁÈÔ˜ ¶. XÚÔ‡ÛÔ˜2
M. Magiakou, G. Chroussos. The use of growth hormone in the treatment of short stature in Turner syndrome. Paediatriki 2000;63:275-277. ● Abstract: Girls with Turner syndrome are short and the great majority of them achieve a suboptimal final height. Although these patients do not have growth hormone (GH) deficiency, those with the worst final height prognosis may benefit from treatment with GH. Their gain in final height varies from 0 to 10 cm, with
a modest average gain of between 4 and 7 cm. Since GH treatment is parenteral, of long duration and expensive, considerable thought and commitment on the part of the physician, the patient and her parents is required.
TÔ Û‡Ó‰ÚÔÌÔ Turner, Ô˘ Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ¯ÚˆÌÔÛˆÌÈ΋ ·ÓˆÌ·Ï›· ÛÙ· ÎÔÚ›ÙÛÈ·, ·ÚÈıÌ› Û‹ÌÂÚ· ÂηÙÔÓÙ¿‰Â˜ ¯ÈÏÈ¿‰Â˜ ¿Û¯Ô˘Û˜ Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ. YÔÏÔÁ›˙ÂÙ·È fiÙÈ Ô ÛËÌÂÚÈÓfi˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ Ì ÙÔ Û‡Ó‰ÚÔÌÔ ÛÙȘ Hӈ̤Ó˜ ¶ÔÏÈÙ›˜ Ù˘ AÌÂÚÈ΋˜ Â›Ó·È 75.000. TȘ ÚÒÙ˜ ‰ÂηÂٛ˜ ÌÂÙ¿ ÙËÓ ÂÚÈÁÚ·Ê‹ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ (1938), fiˆ˜ ‹Ù·Ó Ê˘ÛÈÎfi, ÔÈ ÂÈÛÙ‹ÌÔÓ˜ ÚÔÛ¿ıËÛ·Ó Ó· ··ÓÙ‹ÛÔ˘Ó ‚·ÛÈο ÂÚˆÙËÌ·ÙÈο Û¯ÂÙÈο Ì ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ·, ÙËÓ ÁÂÓÂÙÈ΋ Î·È ÙË ıÂڷ›· ÙÔ˘. TȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, ÙÔ Û. Turner ¤¯ÂÈ ·ÔÙÂϤÛÂÈ ·ÓÙÈΛÌÂÓÔ ÂÎÙÂٷ̤Ó˘ ¤Ú¢ӷ˜ ‰È·ÊfiÚˆÓ È·ÙÚÈÎÒÓ ÔÌ¿‰ˆÓ (¶·È‰È¿ÙÚˆÓ EÓ‰ÔÎÚÈÓÔÏfiÁˆÓ - ¶·ıÔÏfiÁˆÓ - æ˘¯È¿ÙÚˆÓ - M·ÈÂ˘Ù‹ÚˆÓ), Ì ·ÔÙ¤ÏÂÛÌ· Ó· ¤¯Ô˘Ó ÛËÌÂȈı› ÙÂÚ¿ÛÙȘ ÚfiÔ‰ÔÈ ÛÙËÓ Î·Ù·ÓfiËÛË Î·È ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘. ™‹ÌÂÚ·, ·ÛıÂÓ›˜ Ì ÙÔ Û‡Ó‰ÚÔÌÔ ·˘Ùfi ÌÔÚÔ‡Ó Ó· Â›Ó·È ˘ÁÈ‹, Â˘Ù˘¯‹ Î·È ·Ú·ÁˆÁÈο ̤ÏË Ù˘ ÎÔÈÓˆÓ›·˜, Î·È ÛÙfi¯Ô˜ Â›Ó·È Ó· Ï˘ı› ηٿ ÙÔ ‰˘Ó·ÙfiÓ Î·È ÙÔ ·Ú·ÌÈÎÚfi Úfi‚ÏËÌ· Ô˘ ÙȘ ··Û¯ÔÏ›. A˜ ÌË Í¯Óԇ̠fiÙÈ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ‰È¿ÊÔÚ· ΤÓÙÚ· Â͈ۈ̷ÙÈ΋˜ ÁÔÓÈÌÔÔ›ËÛ˘ ·Ó·Ê¤ÚÔ˘Ó ÂÈÙ˘¯Â›˜ ΢‹ÛÂȘ ÌÂÙ¿ ÂÌʇÙ¢ÛË ˆ·Ú›ˆÓ Û ÔÛÔÛÙfi 50-60% Û Á˘Ó·›Î˜ Ì Û. Turner (1,2). H ¤ÁηÈÚË Î·È ÛˆÛÙ‹ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÎÔÓÙÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜, Ô˘ ··ÓÙ¿ Û ÔÛÔÛÙfi 95-100%, Â›Ó·È ÂȂ‚ÏË̤ÓË ÛÙÔ Ï·›ÛÈÔ Ù˘ ÚÔÛ¿ıÂÈ·˜ Ù˘
‚ÂÏÙ›ˆÛ˘ Ù˘ ÔÈfiÙËÙ·˜ ˙ˆ‹˜ ÙˆÓ ·ÛıÂÓÒÓ. H ÚÔÛ¿ıÂÈ· ·˘Ù‹ ı· Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ Û˘Ó¯‹ ˘ÔÛÙËÚÈÎÙÈ΋ ·ʋ ÙˆÓ ıÂÚ·fiÓÙˆÓ ·È‰›·ÙÚˆÓ-ÂÓ‰ÔÎÚÈÓÔÏfiÁˆÓ Ì ÙÔ˘˜ ÁÔÓ›˜ Î·È ÙȘ ·ÛıÂÓ›˜ ·fi ÙËÓ ·È‰È΋ ËÏÈΛ· ̤¯ÚÈ ÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹, ÛˆÛÙ‹ ÏËÚÔÊfiÚËÛË Î·È Âη›‰Â˘ÛË ·ÌÊÔÙ¤ÚˆÓ, ‰È·ÎÚÈÙÈÎfi ¯ÂÈÚÈÛÌfi ÙˆÓ ÚÔ‚ÏËÌ¿ÙˆÓ Ù˘ ÂÊË‚È΋˜ ËÏÈΛ·˜, Î·È ‚·ıÌÈ·›· ηıÔ‰‹ÁËÛË Î·È ‰È·Û‡Ó‰ÂÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ÔÌ¿‰· I·ÙÚÒÓ EÓËϛΈÓ. H ·Ó·Û˘Ó‰˘·Ṳ̂ÓË ·˘ÍËÙÈ΋ ÔÚÌfiÓË (GH), Ô˘ ·ÔÙÂÏ› ÙËÓ ÌfiÓË Ô˘ÛÈ·ÛÙÈ΋ ıÂڷ¢ÙÈ΋ ÂÈÏÔÁ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÎÔÓÙÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜, ¿Ú¯ÈÛ ӷ ÂÊ·ÚÌfi˙ÂÙ·È Û ·È‰È¿ Ì Û. Turner ·fi ÙÔ 1985. T· ÚÒÙ· ·ÔÙ¤ÏÂÛÌ· Ù˘ ıÂڷ›·˜ ‹Ù·Ó ÂÏȉÔÊfiÚ· (3). EÓÙÔ‡ÙÔȘ, Û˘Ó Ùˆ ¯ÚfiÓˆ, ·ÚÎÂÙ¿ ΤÓÙÚ· ·Ó¤ÊÂÚ·Ó ÌË ı·̷ÙÈ΋ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜, Î·È ¤ÙÛÈ, ¿Ú¯ÈÛ·Ó Ó· ÂÁ›ÚÔÓÙ·È ÂÚˆÙËÌ·ÙÈο Û¯ÂÙÈο Ì ÙË Û¯¤ÛË ÎfiÛÙÔ˘˜-ÔʤÏÔ˘˜ Ù˘ ÂÓ ÏfiÁˆ ıÂڷ›·˜, ‰Â‰Ô̤Ó˘ Ù˘ Ì·ÎÚÔ¯ÚÔÓÈfiÙËÙ¿˜ Ù˘ Î·È ÙÔ˘ ˘„ËÏfiÙ·ÙÔ˘ ÎfiÛÙÔ˘˜ Ù˘. OÈ ÂÈÛÙ‹ÌÔÓ˜ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙÔ ı¤Ì· ‰È·¯ˆÚ›˙ÔÓÙ·È Û‹ÌÂÚ· ÛÙÔ˘˜ ÂÓıÔ˘ÛÈÒ‰ÂȘ ˘ÔÛÙËÚÈÎÙ¤˜ Ù˘ ıÂڷ›·˜ Ì GH Î·È ÛÙÔ˘˜ ÛÎÂÙÈÎÈÛÙ¤˜, Î·È ÙÔ ¯¿ÛÌ· ÌÂٷ͇ ÙÔ˘˜ Ê·›ÓÂÙ·È Û˘Ó¯Ҙ Ó· ÌÂÁ·ÏÒÓÂÈ. OÈ ÌÂÓ ÚÒÙÔÈ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ ‰ÂÓ ı· Ú¤ÂÈ Ó· ÛÙÂÚËıÔ‡Ó ÔÈ ·ÛıÂÓ›˜ ÌÈ· ıÂڷ›· Ì ÔÏÏ¿ ÔʤÏË Î·È ¯ˆÚ›˜
1 2
∫ey words: Turner syndrome, GH treatment, final height.
B' ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ A' ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ
275
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·276
¶∞π¢π∞∆ƒπ∫∏ 2000;63:275-277
ÎÈÓ‰‡ÓÔ˘˜, ÔÈ ‰Â ‰Â‡ÙÂÚÔÈ fiÙÈ ÛÔ‚·Úfi fiÊÂÏÔ˜ (ˆ˜ ÚÔ˜ ÙËÓ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜) ‰ÂÓ ¤¯ÂÈ Ì¤¯ÚÈ ÛÙÈÁÌ‹˜ ·Ô‰Âȯı› (2,4-6). H ‰ËÌÔÛ›Â˘ÛË ·Ó·ÛÎfiËÛ˘ Ù˘ Û¯ÂÙÈ΋˜ Ì ÙÔ ı¤Ì· ‚È‚ÏÈÔÁÚ·Ê›·˜ Û ·˘Ùfi ÙÔ Ù‡¯Ô˜ Ù˘ "¶·È‰È·ÙÚÈ΋˜" (X.K·Ó·Î¿ -Gantenbein, ÛÂÏ. ) Ì·˜ ‰›‰ÂÈ fiϘ ÙȘ ÏÂÙÔ̤ÚÂȘ ÙˆÓ Ì¤¯ÚÈ ÙÒÚ· ‰ËÌÔÛÈÂ˘Ì¤ÓˆÓ ÂÚ¢ÓÒÓ. Afi ÙËÓ Ôχ ÂÌÂÚÈÛٷو̤ÓË ·˘Ù‹ ·Ó·ÛÎfiËÛË, Ë /Ô ¶·È‰›·ÙÚÔ˜ ÌÔÚ› Ó· ·ÓÙÏ‹ÛÂÈ Ù· ÂÍ‹˜ ‚·ÛÈο Û˘ÌÂÚ¿ÛÌ·Ù·: 1. ™Â ·ÁÎfiÛÌÈÔ Â›Â‰Ô, ‰ÂÓ ıˆÚÔ‡ÓÙ·È ÈηÓÔÔÈËÙÈο Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ıÂڷ›·˜ Ì GH ÛÙË ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ·ÛıÂÓÒÓ Ì Û. Turner (·Ó·ÊÂÚfiÌÂÓÔ Ì¤ÛÔ Î¤Ú‰Ô˜ ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Ù˘ ٿ͈˜ ÙˆÓ 4-7 ÂηÙÔÛÙÒÓ, ‰È·Î˘Ì¿ÓÛÂȘ ÌÂٷ͇ ÙˆÓ ÌÂÏÂÙÒÓ ·fi 0-10 ÂηÙÔÛÙ¿). 2. ¶·Ú¿ ÙÔÓ ÌÂÁ¿ÏÔ ÚÔ‚ÏËÌ·ÙÈÛÌfi Î·È ÙË Ì›ˆÛË ÙÔ˘ ·Ú¯ÈÎÔ‡ ÂÓıÔ˘ÛÈ·ÛÌÔ‡, ·Ú·Ì¤ÓÂÈ ·Ó·ÌÊÈÛ‚‹ÙËÙÔ ÁÂÁÔÓfi˜ fiÙÈ ıÂڷ›· Ì GH ‚ÂÏÙÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ ÔÛÙÈ΋ ˘ÎÓfiÙËÙ·, Î·È ¤¯ÂÈ Â˘ÓÔ˚ο ·ÔÙÂϤÛÌ·Ù· ÛÙÔ ÏÈȉ·ÈÌÈÎfi profile Î·È ÛÙËÓ „˘¯ÔÏÔÁ›· ÙˆÓ ·ÛıÂÓÒÓ (7-9). 3. Afi ÙȘ ̤¯ÚÈ ÙÒÚ· ˘¿Ú¯Ô˘Û˜ ÌÂϤÙ˜ Î·È ÙÔÓ ÌÂÁ¿ÏÔ ·ÚÈıÌfi ÌÂÏÂÙÒÓ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ÂͤÏÈÍË ‰È·ÈÛÙÒÓÂÙ·È, Ôχ ÛˆÛÙ¿ ηٿ ÙË ÁÓÒÌË Ì·˜, fiÙÈ ÔÈ ·Ó¿ ÙÔÓ ÎfiÛÌÔ ÂÚ¢ÓËÙ¤˜ ‰ÂÓ Ê·›ÓÔÓÙ·È ‰È·ÙÂıÂÈ̤ÓÔÈ Ó· "·ÔÚÚ›„Ô˘Ó" ÙËÓ ¯Ú‹ÛË Ù˘ GH ÛÙÔ Û. Turner, ·Ú¿ ÌfiÓÔÓ ·Ó ·Ô‰Âȯı› fiÙÈ Ë Û¯¤ÛË ÎfiÛÙÔ˘˜-ÔʤÏÔ˘˜ Â›Ó·È ·ÚÓËÙÈ΋. ŒÙÛÈ, Û‹ÌÂÚ· ÂÚ¢ÓÒÓÙ·È fiÏÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ı· ÌÔÚÔ‡Û·Ó Ó· ÂËÚ¿ÛÔ˘Ó ÙËÓ ¤Î‚·ÛË Ù˘ ıÂڷ›·˜ Ì GH, fiˆ˜ .¯. ·) ÙÔ ‰˘Ó·ÌÈÎfi ·Ó¿Ù˘Í˘ ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ (·Ó ‰ËÏ·‰‹ ˆÊÂÏÔ‡ÓÙ·È ·fi ÙË ıÂڷ›· ÂÚÈÛÛfiÙÂÚÔ ÔÈ ÎÔÓÙfiÙÂÚ˜ ‹ ÔÈ „ËÏfiÙÂÚ˜ ·ÛıÂÓ›˜ ‹ ÙÈ ÚfiÏÔ ·›˙ÂÈ ÙÔ ÎÏËÚÔÓÔÌÈÎfi ‰˘Ó·ÌÈÎfi ÁÈ· ÙÔ ‡„Ô˜), ‚) Ë ÂӉ‰ÂÈÁ̤ÓË ¯ÚÔÓÔÏÔÁÈ΋ Î·È ÔÛÙÈ΋ ËÏÈΛ· ÂÓ¿Ú͈˜ Ù˘ ıÂڷ›·˜, Á) Ë ÌÔÚÊ‹ ηڢÔÙ‡Ô˘, ‰) Ù· ›‰· Ù˘ ÂÓ‰ÔÁÂÓÔ‡˜ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, Â) Ë ÂӉ‰ÂÈÁ̤ÓË ‰fiÛË, Û˘¯ÓfiÙËÙ· Î·È ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜, ÛÙ) Ô Û˘Ó‰˘·ÛÌfi˜ Ì ¿ÏÏ· Ê¿Ú̷η (ÔÍ·Ó‰ÚÔÏfiÓË), ˙) Ë ÂӉ‰ÂÈÁ̤ÓË ËÏÈΛ· ÔÈÛÙÚÔÁÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘. Afi Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÂÓ ÏfiÁˆ ÂÚ¢ÓÒÓ ÂÏ›˙Ô˘Ì fiÙÈ Û‡ÓÙÔÌ· ı· ˘¿ÚÍÔ˘Ó ÙÂÏÈο Û˘ÌÂÚ¿ÛÌ·Ù· ÁÈ· ÙËÓ "¿ÚÈÛÙË" Â›Ï˘ÛË ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ÙÔ˘ ÎÔÓÙÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÛÙȘ ·ÛıÂÓ›˜ Ì Û. Turner. ¶ÚÈÓ Û·˜ ηٷı¤ÛÔ˘Ì ÙËÓ ÚÔÛˆÈ΋ Ì·˜ ¿Ô„Ë ÛÙÔ ÂÚÒÙËÌ· "E›ÛÙ ˘¤Ú Ù˘ ıÂڷ›·˜ Ì GH ÛÙÔ Û. Turner;", ÂÈÙÚ¤„Ù ̷˜ Ó· ÂÍËÁ‹ÛÔ˘Ì ÙÔ ÁÈ·Ù› Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ıÂڷ›·˜ Ì GH ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ‰ÂÓ Â›Ó·È Â‡ÎÔÏÔ Ó· Á›ÓÔ˘Ó ÈηÓÔÔÈËÙÈο. ¶ÚÒÙÔÓ, ‰ÈfiÙÈ ÛÙÔ Û. Turner ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ·Ó¿ÚÎÂÈ· Ù˘ GH Ì ÙËÓ "ÎÏ·ÛÈ΋" ¤ÓÓÔÈ· ÙÔ˘ fiÚÔ˘, ·ÏÏ¿ Ë ·ÈÙ›· ÙÔ˘ ÎÔÓÙÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Â›Ó·È ÔÏ˘·Ú·ÁÔÓÙÈ΋ (X. K·Ó·Î¿-Gantenbein, ÛÂÏ. 278-286). §fiÁˆ ·ÎÚÈ‚Ò˜ Ù˘ ·ÈÙ›·˜ ·˘Ù‹˜, ÙÔ Ì¤ÛÔ ·Ó¿ÛÙËÌ· ·ÛıÂÓÒÓ Ì Û. Turner Ô˘ ‰ÂÓ ¤Ï·‚·Ó ÔÚÌÔÓÈ΋ ıÂڷ›· Â›Ó·È 3,1 ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ οو ·fi ÙÔÓ
276
M. A. M·ÁÈ¿ÎÔ˘, °. ÃÚÔ‡ÛÔ˜
̤ÛÔ fiÚÔ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÂÓËÏ›ÎˆÓ (10). H "·ÒÏÂÈ·" ·˘ÙÒÓ ÙˆÓ ÛÙ·ıÂÚÒÓ ·ÔÎÏ›ÛÂˆÓ ÙÔ˘ ‡„Ô˘˜ Á›ÓÂÙ·È ÂÓ Ì¤ÚÂÈ Î·Ù¿ ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ˙ˆ‹ (ÏfiÁˆ ÌÈÎÚ‹˜ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ηı˘ÛÙ¤ÚËÛ˘ ·‡ÍËÛ˘ Ù· ·È‰È¿ Ì Û. Turner ÁÂÓÓÈÔ‡ÓÙ·È Ì ̋ÎÔ˜ ÌÂȈ̤ÓÔ Î·Ù¿ 0,6 ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ), ÂÚ›Ô˘ 1,4 ÛÙ·ıÂÚ¤˜ ·ÔÎÏ›ÛÂȘ ¯¿ÓÔÓÙ·È Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÌËÓÒÓ, ÂÓÒ Ô ÌÂȈ̤ÓÔ˜ ÂÙ‹ÛÈÔ˜ Ú˘ıÌfi˜ ·‡ÍËÛ˘ ÌÂÙ¿ ·˘Ù‹ ÙËÓ ËÏÈΛ· Î·È Ë ¤ÏÏÂÈ„Ë ÙÔ˘ "growth spurt" ηٿ ÙËÓ ÂÊ˂›· Ô‰ËÁÔ‡Ó ÛÙËÓ ÂÚ·ÈÙ¤Úˆ Ì›ˆÛË ÙÔ˘ ‡„Ô˘˜. H ¯ÔÚ‹ÁËÛË GH (Û ‰fiÛË ÙÔ˘Ï¿¯ÈÛÙÔÓ Î·Ù¿ 25% ·Ú·¿Óˆ ·fi ÙË ‰fiÛË ˘ÔηٿÛÙ·Û˘ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙËÓ ˘ÔÊ˘Ûȷ΋ ·Ó¿ÚÎÂÈ·) ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ ÂÓ Ì¤ÚÂÈ ÛÙËÓ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜, ·ÏÏ¿ Û›ÁÔ˘Ú·, ‰ÂÓ ÌÔÚ› Ó· "·Ú¤Ì‚ÂÈ" ÛÙËÓ ·ÒÏÂÈ· ÙˆÓ 2 ÛÙ·ıÂÚÒÓ ·ÔÎÏ›ÛÂˆÓ ÙÔ˘ ‡„Ô˘˜, Ô˘ ¯¿ıËÎ·Ó Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 18 ÌËÓÒÓ. M fiϘ ÙȘ ÂÈÊ˘Ï¿ÍÂȘ Ô˘ ÚԷӷʤÚıËηÓ, Î·È ÂÓ ·Ó·ÌÔÓ‹ ÙˆÓ ÙÂÏÈÎÒÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ Ù˘ ·ÁÎfiÛÌÈ·˜ ¤Ú¢ӷ˜, ÈÛÙ‡ԢÌ fiÙÈ Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıËıÔ‡Ó ÔÈ ÙÂÏÂ˘Ù·›Â˜ ›ÛË̘ Ô‰ËÁ›Â˜ Ù˘ AÌÂÚÈηÓÈ΋˜ Aη‰ËÌ›·˜ ¶·È‰È¿ÙÚˆÓ (1997), Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ Û. Turner ÛÙȘ ÂӉ›ÍÂȘ ¯ÔÚËÁ‹Ûˆ˜ GH (11). H ıÂڷ›· Ì GH ‰ÂÓ Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ, Ë ÂӉ‰ÂÈÁ̤ÓË ‰fiÛË Â›Ó·È 0,7-0,9 IU/kg/‚‰ÔÌ¿‰· (20-30 IU/m2/‚‰ÔÌ¿‰·) › 6 Ë̤Ú˜/‚‰ÔÌ¿‰·, Î·È Ë ÛˆÛÙfiÙÂÚË ËÏÈΛ· ÔÈÛÙÚÔÁÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘ Â›Ó·È Ù· 13 ¤ÙË (2). H ¿Ô„‹ Ì·˜ Â›Ó·È fiÙÈ Ë ¯Ú‹ÛË Ù˘ GH ÛÙÔ Û. Turner ı· Ú¤ÂÈ Ó· Û˘˙ËÙÂ›Ù·È ‰ÈÂÍÔ‰Èο Û·Ó ıÂڷ¢ÙÈ΋ ÂÈÏÔÁ‹ Ì ÙÔ˘˜ ÁÔÓ›˜ Î·È ÙȘ ·ÛıÂÓ›˜, Ë ‰Â ·fiÊ·ÛË ÁÈ· ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜ ‰ÂÓ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ÂÛ¢Ṳ̂ӷ Î·È ˘fi Û˘Óı‹Î˜ "¿Á¯Ô˘˜" ·fi ÙËÓ ÏÂ˘Ú¿ ÙˆÓ ÁÔÓ¤ˆÓ, ÂÊfiÛÔÓ Â›Ó·È ÁÓˆÛÙfi fiÙÈ Î·ı˘ÛÙ¤ÚËÛË ¤Ó·Ú͢ Ù˘ ıÂڷ›·˜ ÁÈ· ÌÂÚÈÎÔ‡˜ Ì‹Ó˜ ‰ÂÓ ·ÏÏ¿˙ÂÈ Ù· ·ÔÙÂϤÛÌ·Ù·. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÁÔÓ›˜ ·ÔÊ·Û›˙Ô˘Ó, ÌÂÙ¿ ÛˆÛÙ‹ ÂÓË̤ڈÛË, Ó· ˘Ô‚¿ÏÔ˘Ó Ù· ·È‰È¿ ÙÔ˘˜ ÛÙË ıÂڷ›· Ì ÙÔ ÛÎÂÙÈÎfi fiÙÈ Ì ·˘Ùfi ÙÔÓ ÙÚfiÔ “οÓÔ˘Ó fi,ÙÈ Á›ÓÂÙ·È Î·Ï‡ÙÂÚÔ ÁÈ· ÙÔ ·È‰› ÙÔ˘˜”. £ÂˆÚԇ̠·ÎfiÌË, fiÙÈ ·ÛıÂÓ›˜ Ì ÈηÓÔÔÈËÙÈÎfi ·Ó¿ÛÙËÌ· ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È Ó· ˘Ô‚ÏËıÔ‡Ó Û ıÂڷ›· Ì GH. BÈ‚ÏÈÔÁÚ·Ê›· 1. Turner HH. A syndrome of infantilism, congenital webbed neck and cubitus valgus. Endocrinology 1938;28:566-574. 2. Saenger P. Turner's syndrome: Current concepts. NEJM 1996;335(23):1749-1754. 3. Rosenfeld RG, Frane J, Attie KM, Brasel JA, Burstein S, Cara JF et al. Six year results of a randomized, prospective trial of human growth hormone and oxandrolone in Turner syndrome. J Pediatr 1992;121:49-55. 4. Donaldson MD. Growth hormone therapy in Turner syndrome: Current uncertainties and future strategies. Horm Res 1997;48 (Suppl 5):35-44.
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·277
¶∞π¢π∞∆ƒπ∫∏ 2000;63:275-277
5. Haeusler G. Growth hormone therapy in patients with Turner syndrome. Horm Res 1998;49 (suppl 2):62-66. 6. Donaldson MDC. Unresolved problems in the treatment of short stature for Turner syndrome. International Growth Monitor 1998;8:2-9. 7. Sylven L, Hagenfeldt K, Ringertz H. Impact of hormonal replacement therapy on bone mineral density in women with Turner syndrome. In: Albertsson-Wikland K, Ranke MB, eds. Turner syndrome in a life span perspective: Research and clinical aspects. Amsterdam: Elsevier Science BV, 1995:241-248. 8. Lanes R, Gunczler P, Palacios A, Villaroel O. Serum lipids, lipoprotein lp(a) and plasminogen activator inhibitor-1 in patients with Turner's syndrome before and during growth hormone and estrogen therapy. Fertil Steril 1997;68:473-477.
™‡Ó‰ÚÔÌÔ Turner Î·È ·˘ÍËÙÈ΋ ÔÚÌfiÓË
9. Lagrou K, Xhrouet-Heinrichs D, Heinrichs C, Graen M, Chanoine JP, Malvaux P et al. Age-related perception of stature, acceptance of therapy and psychosocial functioning in human growth hormone-treated girls with Turner's syndrome. J Clin Endocrinol Metab 1998;83:1494-1501. 10. Ranke MB, Pfluger H, Rosendahl W, Stubbe P, Enders H, Bierich JR et al. Turner syndrome: spontaneous growth in 150 cases and review of the literature. Eur J Pediatr 1983;141:81-88. 11. American Academy of Pediatrics. Committee on Bioethics and Committee on Drugs: Considerations related to the use of recombinant human growth hormone in children. Pediatrics 1997;99:122-129.
¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: M·Ú›·-AÏÂÍ¿Ó‰Ú· M·ÁÈ¿ÎÔ˘ B' ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”, ∞ı‹Ó·
277
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·278
¶∞π¢π∞∆ƒπ∫∏ 2000;63:278-286
ANA™KO¶∏™∏
™‡Ó‰ÚÔÌÔ Turner Î·È ·˘ÍËÙÈ΋ ÔÚÌfiÓË: ¢ÈηÈÔÏÔÁÂ›Ù·È ·ÎfiÌË Ô ·Ú¯ÈÎfi˜ ÂÓıÔ˘ÛÈ·ÛÌfi˜; XÚÈÛÙ›Ó· K·Ó·Î¿ - Gantenbein
● ¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜ Â›Ó·È Ë ÎÚÈÙÈ΋ ·Ó·ÛÎfiËÛË Î·È ÌÂÙ·-·Ó¿Ï˘ÛË ÙˆÓ ‰ËÌÔÛÈÂ˘Ì¤ÓˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÎÔÚÈÙÛÈÒÓ Ì ۇӉÚÔÌÔ Turner Ô˘ ¤Ï·‚·Ó ·˘ÍËÙÈ΋ ÔÚÌfiÓË. TÔ Û‡Ó‰ÚÔÌÔ Turner Â›Ó·È ¤Ó· ·fi Ù· Û˘¯ÓfiÙÂÚ· ÁÂÓÂÙÈο Û‡Ó‰ÚÔÌ·, ‰Â‰Ô̤ÓÔ˘ fiÙÈ ·ÊÔÚ¿ 1 ÂÚÈÛÙ·ÙÈÎfi /2000-2500 ÁÂÓÓ‹ÛÂȘ ıËϤˆÓ ÓÂÔÁÓÒÓ Î·È ÙÔ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ·Ó¢ڛÛÎÂÙ·È ÛÙÔ 95-100% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Ì ÙÔ ™‡Ó‰ÚÔÌÔ. Y¿Ú¯ÂÈ ÏËıÒÚ· ÚÔÛÊ¿ÙˆÓ ‰ËÌÔÛȇÛÂˆÓ Ì ‰Â‰Ô̤ӷ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÛÙ· ÎÔÚ›ÙÛÈ· Ô˘ ¤Ï·‚·Ó ·˘ÍËÙÈ΋ ÔÚÌfiÓË. ¶·Ú¿ ÙÔÓ ‰È·ÊÔÚÂÙÈÎfi ۯ‰ȷÛÌfi ÙˆÓ ‰È·ÊfiÚˆÓ ÌÂÏÂÙÒÓ Î·È Ù· ÌÂıÔ‰ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· Û‡ÁÎÚÈÛ˘ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÙˆÓ ÂÚÁ·ÛÈÒÓ, Ë ¯ÔÚ‹ÁËÛË Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ê·›ÓÂÙ·È Ó· ÂÈʤÚÂÈ ¤Ó· ̤ÛÔ Î¤Ú‰Ô˜ ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Ù˘ ٿ͈˜ ÙˆÓ 6 ÂηÙÔÛÙÒÓ (Ì ‰È·Î˘Ì¿ÓÛÂȘ ·fi 0-10 ÂηÙÔÛÙ¿) Î·È ‚ÂÏÙ›ˆÛË Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÙˆÓ ÎÔÚÈÙÛÈÒÓ Ì ÙÔ ™‡Ó‰ÚÔÌÔ, ¤ÙÛÈ ÒÛÙ ӷ ÂӉ›ÎÓ˘Ù·È Ë ¯ÔÚ‹ÁËÛË Ù˘ ÛÙÔ ™‡Ó‰ÚÔÌÔ Turner ÛÙȘ ̤¯ÚÈ Û‹ÌÂÚ· ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓ˜ ‰fiÛÂȘ ÙˆÓ 0,7-0,9 IU/kg/‚‰ÔÌ¿‰·. ¶·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· Ê·›ÓÂÙ·È Ó· Â›Ó·È Ë ËÏÈΛ· ¤Ó·Ú͢ Ù˘ ıÂڷ›·˜, Ô ‚·ıÌfi˜ ηı˘ÛÙ¤ÚËÛ˘ Ù˘ ÔÛÙÈ΋˜ ËÏÈΛ·˜, Ô Î·Ú˘fiÙ˘Ô˜ Î·È ÙÔ ÁÔÓÂ˚Îfi ‡„Ô˜, ÂÓÒ ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜, .¯. Ë ‰fiÛË, Û˘¯ÓfiÙËÙ· Î·È ‰È¿ÚÎÂÈ· Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ηıÒ˜ Î·È Ë ¤ÎÎÚÈÛË ÂÓ‰ÔÁÂÓÔ‡˜ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ‰ÂÓ Ê·›ÓÔÓÙ·È Ó· ÂËÚ¿˙Ô˘Ó ÙÔ ·ÔÙ¤ÏÂÛÌ·. ™˘ÌÏËڈ̷ÙÈΤ˜ ÌÂϤÙ˜ ··ÈÙÔ‡ÓÙ·È ÁÈ· ÙË ‰È·Ï‡ηÓÛË Ù˘ ȉ·ÓÈ΋˜ ËÏÈΛ·˜ ¯ÔÚ‹ÁËÛ˘ ÔÈÛÙÚÔÁfiÓˆÓ Î·È ÚÔÛı‹Î˘ ÔÍ·Ó‰ÚÔÏfiÓ˘. ¶·È‰È·ÙÚÈ΋ 2000;63:278-286. §¤ÍÂȘ ÎÏÂȉȿ: Û‡Ó‰ÚÔÌÔ Turner, ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. C. Kanaka-Gantenbein. Turner syndrome and growth hormone: Is the initial enthusiasm justified? Paediatriki 2000;63:278-286. ● Abstract: This paper summarizes data published on the final height of growth hormone (GH) treated girls with Turner syndrome, with emphasis on meta-analysis of the published data. Turner syndrome is a common genetic disorder, with a frequency of 1 case in 2,000-2,500 live newborn females. Extremely severe short stature, with a final height of 20 cm shorter than the average for the female population is observed in 95-100% of girls with Turner syndrome. Human growth hormone (hGH) is used worldwide for the treatment of these girls. Recent data on final height with hGH therapy reveal an average benefit of about 6 cm over the projected adult height, with a wide variation within studies, ranging from 0 to 10 cm, along with improvement in the bone density. Prognostic factors influencing the outcome are the chronological age and bone age delay at initiation of treatment, the karyotype and the parental height, while other factors such as dose, frequency and duration of hGH administration or levels of endogenous GH secretion do not seem to play a major role. Prospective studies are under way which aim to elucidate the ideal age for oestrogen substitution and oxandrolone therapy. Key words: Turner syndrome, growth hormone treatment, final height.
TÔ Û‡Ó‰ÚÔÌÔ Turner ·ÔÙÂÏ› ¤Ó· ·fi Ù· Û˘¯ÓfiÙÂÚ· ÁÂÓÂÙÈο Û‡Ó‰ÚÔÌ· ÌÂ Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ 1/2000-2500 ÁÂÓÓ‹ÛÂȘ ı‹ÏÂˆÓ ÓÂÔÁÓÒÓ (1,2). H Û˘¯ÓfiÙËÙ· Â›Ó·È Ôχ ÌÂÁ·Ï‡ÙÂÚË ÌÂٷ͇ ÙˆÓ ıËϤˆÓ
278
ÂÌ‚Ú‡ˆÓ 1Ô˘ ÙÚÈÌ‹ÓÔ˘, ‰Â‰Ô̤ÓÔ˘ fiÙÈ 99,9% ÙˆÓ Î˘ËÌ¿ÙˆÓ Ì ÙÔ Û‡Ó‰ÚÔÌÔ ‰ÂÓ Î·Ù·Ï‹ÁÂÈ Û Á¤ÓÓËÛË ÏfiÁˆ ·˘ÙfiÌ·ÙˆÓ ·Ô‚ÔÏÒÓ (1). H ˘ÔΛÌÂÓË ¯ÚˆÌÔÛˆÌȷ΋ ·ÓˆÌ·Ï›· ›ӷÈ
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·279
¶∞π¢π∞∆ƒπ∫∏ 2000;63:278-286
·Ô˘Û›· ÙÔ˘ ÂÓfi˜ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ X, ‰ËÏ. ηڢfiÙ˘Ô˜ 45,XO ÛÙfi 55%-60% ÙˆÓ ÂÚÈÙÒÛˆÓ, ‰·ÎÙ˘ÏÈÔÂȉ¤˜ ¯ÚˆÌfiۈ̷ X Û 3,5%, ÈÛÔ¯ÚˆÌfiۈ̷ X Û 8,5%, ̈۷˚ÎÈÛÌfi˜ 45,XO/46,XY Û 6,5%, ÂÓÒ ¿ÏϘ ‰ÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜ ·Ó¢ڛÛÎÔÓÙ·È Û ÌÈÎÚfiÙÂÚ· ÔÛÔÛÙ¿ (2). K‡ÚÈ· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο TÔ ™‡Ó‰ÚÔÌÔ Turner ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¯·ÌËÏfi ·Ó¿ÛÙËÌ·, ˘ÔÁÔÓ·‰ÈÛÌfi, ·˘¯ÂÓÈÎfi ÙÂÚ‡ÁÈÔ, ‚Ï·ÈÛÔ‡˜ ·ÁÎÒÓ˜, ÏÂÌÊÔ›‰ËÌ· ¯ÂÈÚÒÓ Î·È Ô‰ÒÓ Î·Ù¿ ÙË Á¤ÓÓËÛË, Ï·Ù‡ ıÒڷη Ì ÌÂÁ¿ÏË ·fiÛÙ·ÛË ıËÏÒÓ Î·È ÂÈÛ¤¯Ô˘Û˜ ıËϤ˜, ¯·ÌËÏ‹ ÚfiÛÊ˘ÛË Ì·ÏÏÈÒÓ, Ó‡¯È· "‰›ÎËÓ ÛÊ˘Úfi˜" (ongles en marteau), ÌÏ ÛÎÏËÚÔ‡˜ (blue sclera), ÎÏ (2-4). EÈϤÔÓ, ··ÓÙÒÓÙ·È Û˘¯ÓfiÙÂÚ· ¿ÏϘ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ .¯. ÛÙ¤ÓˆÛË ÙÔ˘ ÈÛıÌÔ‡ Ù˘ ·ÔÚÙ‹˜, ·ÓˆÌ·Ï›Â˜ ÙÔ˘ Ô˘ÚÔÔÈËÙÈÎÔ‡ (ÂÙ·ÏÔÂȉ‹˜ ÓÂÊÚfi˜, ‰ÈÏfi ·Ô¯ÂÙ¢ÙÈÎfi Û‡ÛÙËÌ·), ‚·ÚËÎÔ˝· (2,5,6) Î·È ·˘ÙÔ¿ÓÔÛ· ÓÔÛ‹Ì·Ù· (7,8). ¶Úfi‚ÏËÌ· ·Ó¿Ù˘Í˘ TÔ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ·Ó¢ڛÛÎÂÙ·È Û ¿Óˆ ÙˆÓ 90% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ÙÔ˘ ™˘Ó‰ÚfiÌÔ˘ (9), Ì ·ÔÙ¤ÏÂÛÌ· Ù· ÎÔÚ›ÙÛÈ· ·˘Ù¿ Ó· ηٷϋÁÔ˘Ó, ¯ˆÚ›˜ ıÂڷ›·, Û fiÏ· Ù· ̤ÚË ÙÔ˘ ÎfiÛÌÔ˘, ηٿ ̤ÛÔÓ fiÚÔ 20 ÂηÙÔÛÙ¿ ÎÔÓÙ‡ÙÂÚ· ÙÔ˘ ̤ÛÔ˘ fiÚÔ˘ Á˘Ó·ÈÎÒÓ ÙÔ˘ ÂοÛÙÔÙ ÏËı˘ÛÌÔ‡ (10-12). Afi ÓˆÚ›˜ ·Ó·˙ËÙ‹ıËÎ·Ó ·Ú¿ÁÔÓÙ˜ Ô˘ Ó· ÂËÚ¿˙Ô˘Ó ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, .¯. Ô Î·Ú˘fiÙ˘Ô˜, Ë ¤Ó·ÚÍË ÂÊ˂›·˜ ‹ fi¯È, ÙÔ Ì¤ÛÔ ÁÔÓÂ˚Îfi ‡„Ô˜ ÎÏ. (10-12). NÂfiÙÂÚ˜ ÌÂϤÙ˜ η٤‰ÂÈÍ·Ó ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ηڢÔÙ‡Ô˘ ÛÙÔ ·Ó¿ÛÙËÌ· (13). AÛıÂÓ›˜ Ì ηڢfiÙ˘Ô 46,X,I(Xq) ηٷϋÁÔ˘Ó Û ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÂÓÒ ·ÛıÂÓ›˜ Ì ηڢfiÙ˘Ô 45,XO/46,XY ‹ Ì ηڢfiÙ˘Ô 46,X, del (Xq) ·ÚÔ˘ÛÈ¿˙Ô˘Ó Î·Ï‡ÙÂÚÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. EÈϤÔÓ, ·ÛıÂÓ›˜ Ì ‰Èۈ̛· ÙÔ˘ ‚Ú·¯¤Ô˜ ÛΤÏÔ˘˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ X (Xp) ηٷϋÁÔ˘Ó ÛËÌ·ÓÙÈο „ËÏfiÙÂÚ˜ ·fi ·ÛıÂÓ›˜ Ì ÌÔÓÔۈ̛· ÙÔ˘ Xp. TÔ Ì¤ÛÔ ÁÔÓÂ˚Îfi ‡„Ô˜ ÂËÚ¿˙ÂÈ Â›Û˘ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÙˆÓ ÎÔÚÈÙÛÈÒÓ ·˘ÙÒÓ, fiˆ˜ Î·È ÛÙËÓ ÂÚ›ÙˆÛË ˘ÁÈÒÓ ·È‰ÈÒÓ (12,14,15). EÈϤÔÓ ÓÔÛÔÏÔÁÈΤ˜ ÔÓÙfiÙËÙ˜, .¯. ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ÛÙ· Ï·›ÛÈ· ı˘ÚÂÔÂȉ›Ùȉ·˜ Hashimoto ‹ ÊÏÂÁÌÔÓ҉˘ ÓfiÛÔ˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘, ηٷÛÙ¿ÛÂȘ Ô˘ ··ÓÙÒÓÙ·È Û¯ÂÙÈο Û˘¯Ó¿ ÛÙÔ ™‡Ó‰ÚÔÌÔ, ÌÔÚÔ‡Ó Ó· ÂËÚ¿ÛÔ˘Ó ·ÚÓËÙÈο ÙËÓ ·Ó¿Ù˘ÍË (8), ÂÓÒ ·˘ÙfiÌ·ÙË ÂÌÊ¿ÓÈÛË ÂÊ˂›·˜ Û¯ÂÙ›˙ÂÙ·È Ì ηχÙÂÚÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· (14). T· ·›ÙÈ· ÙÔ˘ ¯·ÌËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ‰ÂÓ ¤¯Ô˘Ó Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈÛÙ›, Ê·›ÓÂÙ·È ¿ÓÙˆ˜ fiÙÈ Ë ·Ô˘Û›· ÙÔ˘ ÁÔÓȉ›Ô˘ SHOX (16), Ô˘ ηıÔÚ›˙ÂÈ ÙÔ ·Ó¿-
™‡Ó‰ÚÔÌÔ Turner Î·È ·˘ÍËÙÈ΋ ÔÚÌfiÓË
™˘ÓÙÔÌÔÁڷʛ˜ hGH = human Growth Hormone = ·ÓıÚÒÈÓË A˘ÍËÙÈ΋ OÚÌfiÓË IGF I = Insulin-like Growth factor I = ™ˆÌ·ÙỔ›ÓË C
ÛÙËÌ· Î·È ‚Ú›ÛÎÂÙ·È ÛÙÔ ‚Ú·¯‡ ÛΤÏÔ˜ ÙÔ˘ ¯ÚˆÌÔÛÒÌ·ÙÔ˜ X, ·›˙ÂÈ ÚˆÙ·Ú¯ÈÎfi ÚfiÏÔ, ÂÓÒ ÂÈϤÔÓ ·Ú¿ÁÔÓÙ˜ fiˆ˜ ‡·ÚÍË ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ¿ÍÔÓ· GH-IGFI Î·È ÛÎÂÏÂÙÈ΋˜ ‰˘ÛÏ·Û›·˜ Û˘Ì‚¿ÏÏÔ˘Ó Â›Û˘ ÛÙËÓ ·ıÔÁ¤ÓÂÈ· (17). §fiÁˆ ÙÔ˘ ¯·ÌËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜, ηٷÛ΢¿ÛÙËÎ·Ó ÂȉÈΤ˜ η̇Ϙ ·Ó¿Ù˘Í˘ ÙˆÓ ÎÔÚÈÙÛÈÒÓ Ì ÙÔ ™‡Ó‰ÚÔÌÔ Û ‰È¿ÊÔÚ˜ ÏËı˘ÛÌȷΤ˜ ÔÌ¿‰Â˜ (10). ŸÛÔÓ ·ÊÔÚ¿ ÙȘ ÚԂϤ„ÂȘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÙˆÓ ÎÔÚÈÙÛÈÒÓ ·˘ÙÒÓ, ¤ÁÈÓ ÂÌÊ·Ó‹˜ Ë ‰˘ÛÎÔÏ›· ÂÊ·ÚÌÔÁ‹˜ ÚԂϤ„ÂˆÓ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙȘ ÚԂϤ„ÂȘ Ô˘ ÂÊ·ÚÌfi˙ÔÓÙ·È ÛÙÔÓ ˘ÁÈ‹ ÏËı˘ÛÌfi (18). ŒÙÛÈ, ÔÈ Lyon et al. (19) ÚfiÙÂÈÓ·Ó fiÙÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÙˆÓ ÎÔÚÈÙÛÈÒÓ ·˘ÙÒÓ ÌÔÚ› Ó· ÚÔ‚ÏÂÊı› ·fi ÙÔ ‡„Ô˜ ÙÔ˘ ·È‰ÈÔ‡ Û ÌÈ· ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹ ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ·, ÌÂÙ¿ ·fi ÚÔ¤ÎÙ·ÛË ÙÔ˘ ‰Â‰Ô̤ÓÔ˘ ‡„Ô˘˜ ÛÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹, ¿Óˆ ÛÙȘ ·ÓÙ›ÛÙÔȯ˜ η̇Ϙ ‡„Ô˘˜ ÙÔ˘ ÂοÛÙÔÙ ÏËı˘ÛÌÔ‡ ÁÈ· ÙÔ Û‡Ó‰ÚÔÌÔ, ‚·ÛÈ˙fiÌÂÓÔÈ ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ù· ÎÔÚ›ÙÛÈ· ·˘Ù¿ ‰ÂÓ ı· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ÙÔ ¿ÏÌ· Û ‡„Ô˜ Ô˘ Ê˘ÛÈÔÏÔÁÈο ÂÈÙ˘Á¯¿ÓÂÙ·È Î·Ù¿ ÙËÓ ÂÊ˂›· (pubertal growth spurt). ŒÙÛÈ ÚԤ΢„Â Ô fiÚÔ˜ ÙÔ˘ "ÚÔ‚·ÏÏfiÌÂÓÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜"= projected adult height: PAH) Ô ÔÔ›Ô˜ ıˆÚÂ›Ù·È Ë ÈÔ ¤Á΢ÚË Ì¤ıÔ‰Ô˜ Úfi‚Ï„˘ ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÛÙÔ ™‡Ó‰ÚÔÌÔ Turner (20-22). TÔ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ¤ÛÙÚ„ ·fi ÓˆÚ›˜ ÙÔ ÂӉȷʤÚÔÓ ÙˆÓ ÂÓ‰ÔÎÚÈÓÔÏfiÁˆÓ Û ‰˘Ó·ÙfiÙËÙ˜ ıÂڷ¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘. AÚ¯Èο ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ıÂڷ›˜ Ì ‚¿ÛË ·Ó·‚ÔÏÈο Û΢¿ÛÌ·Ù·, Ì ·ÚÈÔ ÂÎÚfiÛˆÔ ÙËÓ ÔÍ·Ó‰ÚÔÏfiÓË Î·ıÒ˜ Î·È ¯ÔÚ‹ÁËÛË ·Èı˘Ó˘Ï-ÔÈÛÙÚ·‰ÈfiÏ˘, Ù· ÔÔ›· ¤ÊÂÚ·Ó ÌfiÓÔ ÌÈÎÚ‹ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ (23). AÈÛÈfi‰ÔÍ· ·ÔÙÂϤÛÌ·Ù· ·Ú·ÙËÚ‹ıËÎ·Ó ·ÓÙÈı¤Ùˆ˜ ÌÂÙ¿ ·fi ‚Ú·¯‡¯ÚÔÓË ¯ÔÚ‹ÁËÛË ·ÓıÚÒÈÓ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (hGH) Û ÎÔÚ›ÙÛÈ· Ì ÙÔ ™‡Ó‰ÚÔÌÔ (24), ¤ÙÛÈ ÒÛÙÂ Ë ¯ÔÚ‹ÁËÛË hGH ÛÙÔ ™‡Ó‰ÚÔÌÔ Turner ηıÈÂÚÒıËΠ‰ÈÂıÓÒ˜. TÂÏÈÎfi AÓ¿ÛÙËÌ· ÙˆÓ ·È‰ÈÒÓ Ô˘ ‹Ú·Ó ·˘ÍËÙÈ΋ ÔÚÌfiÓË MfiÏȘ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ˘‹ÚÍ·Ó Ï¤ÔÓ ‰Â‰Ô̤ӷ, fi¯È ÙˆÓ ÚÔÁÓˆÛÙÈÎÒÓ ÙÂÏÈÎÔ‡ ‡„Ô˘˜, ·ÏÏ¿ ÙÔ˘ Ú·ÁÌ·ÙÈÎÔ‡ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ ÎÔÚÈÙÛÈÒÓ Ì ÙÔ ™‡Ó‰ÚÔÌÔ Ô˘ ‹Ú·Ó ·˘ÍËÙÈ΋ ÔÚÌfiÓË, Î·È Ô ·Ú¯ÈÎfi˜ ÂÓıÔ˘ÛÈ·ÛÌfi˜ ¿Ú¯ÈÛ ϤÔÓ Ó· ÌÂÙÚÈ¿˙ÂÙ·È. Y¿Ú¯ÂÈ ÌÂÁ¿ÏÔ˜ ·ÚÈıÌfi˜ ÂÚÁ·ÛÈÒÓ Ô˘ ·Ô‰ÂÈÎÓ‡ÂÈ ÙÔ fiÊÂÏÔ˜ ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ·fi ÙË
279
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·280
¶∞π¢π∞∆ƒπ∫∏ 2000;63:278-286
X. K·Ó·Î¿ - Gantenbein
¶›Ó·Î·˜ 1·. ™˘ÓÔÙÈ΋ ·Ú¿ıÂÛË ÙˆÓ ‰ËÌÔÛÈÂ˘Ì¤ÓˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ‰ÂÓ Î·Ù·‰ÂÈÎÓ‡Ô˘Ó Î¤Ú‰Ô˜ ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÎÔÚÈÙÛÈÒÓ Ì ™‡Ó‰ÚÔÌÔ Turner Ô˘ ¤Ï·‚·Ó ·˘ÍËÙÈ΋ ÔÚÌfiÓË. ∞ӷʤÚÔÓÙ·È ÔÈ Ì¤Û˜ ÙÈ̤˜ ± ™Ù·ıÂÚ¤˜ ∞ÔÎÏ›ÛÂȘ (SD=standard deviation). ™Â ·Ú¤ÓıÂÛË ·Ó·Ê¤ÚÂÙ·È ÙÔ Â‡ÚÔ˜ ‰È·Î‡Ì·ÓÛ˘ ÙˆÓ ÙÈÌÒÓ. EÚÁ·Û›·
AÛıÂÓ›˜ (n)
XH ¤Ó·Ú͢ (ŒÙË)
¢fiÛË hGH OÍ·Ó‰ÚÔÏfiÓË EE ng/kg/d, IU/Kg/week mg/Kg/day XH
TA cm
PAH Lyon cm
ŸÊÂÏÔ˜ cm
Werther A˘ÛÙÚ·Ï›·, 1995
n=18 n=15
11(7-14) 11(7-14)
1,2 +EE 1,2+ placebo (2yrs), + EE
5Ì/d, XH:11 5Ì/d, XH:13
147,3 ± 5,6 148,1 ± 4,5
143,6 ± 4,2 142,6 ± 4,7
3,7 5,4
Takano, I·ˆÓ›·, 1995
n=12 n=16
10,3 ± 2,4 9,3 ± 2,6
0,5 1,0
XH>13
145,1 ± 4,7 144,0 ± 2,2
137 137
8,1 7,0
0,5, then 1,0
100→200 XH= 15,7
147,6
142,2
5,0
147,7
141-142
5,0-6,0
Pasquino, IÙ·Ï›·, 1996
n=18 Ctrl=18
Rochiccioli, °·ÏÏ›·, 1995
n=117
12,9 ± 2,0
0,7- 0,9
0,05-0,1 n=24
Nilsson, ™Ô˘Ë‰›·, 1996
I(n=13) II(n=17) III(n=15)
12,3 ±1,7 12,1 ±1,7 12,3 ±2,1
Ox(1yr), II or III Ox+GH 0,7 Ox+GH0,7+EE
0,05-0,1
100
151,0 ± 6,7 154,2 ± 6,6 151,1 ± 4,6
143,6 ± 4,9 145,7 ± 5,1 148,1 ± 6,2
7,4 8,5 3,0
Haeusler, A˘ÛÙÚ›·, 1996
n=20
11,8±2,4 (7,3-16,4)
0,4-0,6
0,0625
50 16,3±1,7
152,9±3,5
143,7±4,0
9,2
V. den Broeck 5 ¯ÒÚ˜, 1995
n=56
12,9
0,5-1,2
50-125 XH=14,5
150,7±4,9
147,8
2,9
Massa OÏÏ·Ó‰›·, 1995
n=45
0,85
100 XH>12
152,3±5,3
147-149,7
2,6-5,3
Ranke, KIGS, 1995
n=82
12,0 (10,3-14,7)
0,7 (0,5-0,9)
n=31 XH=13,8
149,6 (141-155,4)
142,4
7,2
Plotnick H¶A, 1998
n=622
10,1±3,6
1,0
148,3±5,6
141,9±6,2
6,4
Rosenfeld, H¶A,1998
n=17 n=43 Ctrl=25(R)
9,1±2,1 9,7±2,5 9,1±1,7
0,8 0,8+Ox -
XH:15,2±0,9 XH:14,9±0,9 XH:15,8±1,8
150,4±5,5 152,1±5,9 144,2±6,0
142,0±5,9 141,8±5,9 144,2±5,6
8,4 10,3 -
Hochberg, IÛÚ·‹Ï,1998
n=25 Ctrl=24(M)
10,7±1,4 10,7±1,4
0,8 -
XH:13,2±1,0 XH:13,2±1,0
147,3±4,9 142,9±5,1
142,6±5,2 143,5±4,2
4,7±2,9
Stephure, K·Ó·‰¿˜,1998
n=41 Ctrl=29(M)
11,1±1,5 11,3±1,4
1,0
XH:13 XH:13
146,1±6,5 141,4±4,7
Quigley, H¶A, 1998
n=83
11,5±2,2
0,9
™˘ÓÔÏÈο
¯ÔÚ‹ÁËÛË hGH Û ‰È·ÊÔÚÂÙÈÎÔ‡˜ ÏËı˘ÛÌÔ‡˜ (17,21,22,25-33), ÂÓÒ ÌÈÎÚfiÙÂÚÔ˜ ·ÚÈıÌfi˜ ‰ËÌÔÛȇÛÂˆÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÈÎÚ‹ ¤ˆ˜ ·Û‹Ì·ÓÙË ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ (34-37). OÈ ›Ó·Î˜ 1·, 1‚ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘ÓÔÏÈο Ù· ·ÔÙÂϤÛÌ·Ù· fiÏˆÓ ÙˆÓ Ì¤¯ÚÈ Û‹ÌÂÚ· ‰ËÌÔÛÈÂ˘Ì¤ÓˆÓ ÂÚÁ·ÛÈÒÓ (¶›Ó·Î˜ 1·, 1‚). AӷχÔÓÙ·È ÂȉÈÎfiÙÂÚ· ‰‡Ô ΢ڛˆ˜ ·Ó·ÛÎÔ‹ÛÂȘ, Ô˘ Û˘ÓÔ„›˙Ô˘Ó Ù· ‰Â‰Ô̤ӷ ‰È·ÊfiÚˆÓ ÂÚ-
280
XH=13,6 n=31
0,0625
148,9±6,7
6,3±1,1 vs.controls 143,6±5,8
5,4 ±2,2
6,07 cm
Á·ÛÈÒÓ Î·È ‰ËÌÔÛȇÙËÎ·Ó ÛÙÔ Hormone Research, ›ÛËÌÔ ÂÈÛÙËÌÔÓÈÎfi ÂÚÈÔ‰ÈÎfi Ù˘ E˘Úˆ·˚΋˜ EÙ·ÈÚ›·˜ ¶·È‰ÔÂÓ‰ÔÎÚÈÓÔÏÔÁ›·˜, Ë Ì›· ÙÔ 1997 ·fi ÙÔÓ Donaldson (27) Î·È Ë ‰Â‡ÙÂÚË ÙÔ 1998 ·fi ÙÔÓ Haeusler (17). O Donaldson (27) ·Ó¤Ï˘Û ٷ ‰Â‰Ô̤ӷ 10 ÂÚÁ·ÛÈÒÓ ·fi AÌÂÚÈ΋, A˘ÛÙÚ·Ï›·, E˘ÚÒË, Î·È ¤‰ÂÈÍ fiÙÈ ÛÙȘ 8 ·fi ÙȘ 10 ÂÚÁ·Û›Â˜ ˘¿Ú¯ÂÈ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Ì ¯ÔÚ‹ÁËÛË A˘ÍËÙÈ΋˜
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·281
¶∞π¢π∞∆ƒπ∫∏ 2000;63:278-286
™‡Ó‰ÚÔÌÔ Turner Î·È ·˘ÍËÙÈ΋ ÔÚÌfiÓË
¶›Ó·Î·˜ 1‚. ™˘ÓÔÏÈ΋ ·Ú¿ıÂÛË ÙˆÓ ‰ËÌÔÛÈÂ˘Ì¤ÓˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ηٷ‰ÂÈÎÓ‡Ô˘Ó Î¤Ú‰Ô˜ ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÎÔÚÈÙÛÈÒÓ Ì ™‡Ó‰ÚÔÌÔ Turner Ô˘ ¤Ï·‚·Ó ·˘ÍËÙÈ΋ ÔÚÌfiÓË. ∞ӷʤÚÔÓÙ·È ÔÈ Ì¤Û˜ ÙÈ̤˜ ± ™Ù·ıÂÚ¤˜ ∞ÔÎÏ›ÛÂȘ (SD=standard deviation). EÚÁ·Û›·
AÛıÂÓ›˜ (n)
XH ¤Ó·Ú͢ (ŒÙË)
Taback, K·Ó·‰¿˜, 1996
n=17
12,4
Chu, ™ÎˆÙ›·, 1997
n=26
Dacou, EÏÏ¿‰·, 1998
¢fiÛË hGH OÍ·Ó‰ÚÔÏfiÓË IU/Kg/week mg/Kg/day
EE ng/kg/d, XH
TA cm
PAH Lyon cm
ŸÊÂÏÔ˜ cm
0,9
125-500 XH:13,3
148,0
148,2
0,2 N.S.
12,5
0,9
50 XH:12,8
142,6
142,0
0,6 N.S.
n=35
12,0±1,8
0,7± 0,2
XH:15,6±1,3 146,1 ± 6,6
Ctrl=27(M)
12,4±3,3
-
XH:14,2±1,8 144,0 ± 6,1
ÔÚÌfiÓ˘, ÙÔ Â‡ÚÔ˜ fï˜ ÙÔ˘ ÔʤÏÔ˘˜ Û ÂηÙÔÛÙ¿ (cm) ·fi ÙË ıÂڷ›· ‹Ù·Ó Ôχ ÌÂÁ¿ÏÔ, ÙfiÛÔ ·fi ÂÚÁ·Û›· Û ÂÚÁ·Û›· (Î˘Ì·ÈÓfiÌÂÓÔ ·fi 2,6 ¤ˆ˜ 10 cm), fiÛÔ Î·È ÌÂٷ͇ ÙˆÓ ‰È·ÊfiÚˆÓ ·ÛıÂÓÒÓ Ù˘ ÂοÛÙÔÙ ÂÚÁ·Û›·˜. H ̤ÛË ËÏÈΛ· ¤Ó·Ú͢ Ù˘ ıÂڷ›·˜ Ì hGH ‹Ù·Ó Û¯ÂÙÈο ÚÔ¯ˆÚË̤ÓË (9,113,1 ÂÙÒÓ) Î·È ÌÔÚ› Ó· ¢ı‡ÓÂÙ·È ÁÈ· Ù· ̤ÙÚÈ· ·ÔÙÂϤÛÌ·Ù· Ù˘ ıÂڷ›·˜, ÏfiÁˆ ·Ú·ÌÔÓ‹˜ ÌÈÎÚÔ‡ ‰˘Ó·ÌÈÎÔ‡ ‡„Ô˘˜. ™Â ·Ó¿ÏÔÁ· Û˘ÌÂÚ¿ÛÌ·Ù· η٤ÏËÍÂ Î·È Ë ·Ó·ÛÎfiËÛË ÙÔ˘ Haeusler (17), Ô˘ ·Ó¤Ï˘Û ٷ ‰ÈÂıÓ‹ ‰Â‰Ô̤ӷ ¯ÔÚ‹ÁËÛ˘ hGH Û ‰fiÛÂȘ 0.5-1.2 IU/Kg/‚‰ÔÌ¿‰· Ì ‹ ¯ˆÚ›˜ ÔÍ·Ó‰ÚÔÏfiÓË. M›· ÚfiÛÊ·ÙË ÌÂϤÙË ·fi ÙËÓ AÌÂÚÈ΋ (21) Ô˘ ·Ó¤Ï˘Û ٷ ‰Â‰Ô̤ӷ ÎÔÚÈÙÛÈÒÓ Ì ÙÔ ™‡Ó‰ÚÔÌÔ Ô˘ ÂÚÈÏ‹ÊıËÎ·Ó ÛÙËÓ EıÓÈ΋ MÂϤÙË ·Ó¿Ù˘Í˘ ÌÂÙ¿ ¯ÔÚ‹ÁËÛË A˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ù˘ Genentech, η٤‰ÂÈÍ fiÙÈ Ë ¯ÔÚ‹ÁËÛË hGH ¤ÊÂÚ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ ÙˆÓ ÎÔÚÈÙÛÈÒÓ Ù˘ ٿ͈˜ ÙˆÓ 6,4±4,9 cm. EÈÚÔÛı¤Ùˆ˜, Ë Ì·ÎÚÔ¯ÚfiÓÈ·, ÔÏ˘ÎÂÓÙÚÈ΋, ÚÔ‰ÚÔÌÈ΋, Ù˘¯·ÈÔÔÈË̤ÓË ÌÂϤÙË Ù˘ AÌÂÚÈ΋˜ ÙˆÓ Rosenfeld Î·È Û˘Ó. Ô˘ ‰ËÌÔÛȇıËΠÚfiÛÊ·Ù· (22) ‰Â›¯ÓÂÈ ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÌÂÙ¿ ¯ÔÚ‹ÁËÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÌfiÓ˘ ‹ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÔÍ·Ó‰ÚÔÏfiÓË. H ÂÚÁ·Û›· ·˘Ù‹ ¤¯ÂÈ ÙÔ ÏÂÔÓ¤ÎÙËÌ· fiÙÈ Â›Ó·È ÚÔ‰ÚÔÌÈ΋ ÌÂÙ¿ ·fi Û˘ÓÔÏÈÎfi ¯ÚfiÓÔ ·Ú·ÎÔÏÔ‡ıËÛ˘ 12 ÂÙÒÓ Î·È ÂÚÈÏ·Ì‚¿ÓÂÈ ‰Â‰Ô̤ӷ ÎÔÚÈÙÛÈÒÓ Ô˘ ¤Ï·‚·Ó ıÂڷ›· Û ÌÈÎÚfiÙÂÚ˜ ËÏÈ˘ (4,7-12,4 ÂÙÒÓ, ̤ÛË ËÏÈΛ· 9,3 ÂÙÒÓ) ·' fi,ÙÈ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜. M ‚¿ÛË ÙËÓ ÌÂϤÙË ·˘Ù‹, Ù· ÎÔÚ›ÙÛÈ· Ô˘ ¤Ï·‚·Ó ÌfiÓÔ ·˘ÍËÙÈ΋ ÔÚÌfiÓË ¤Êı·Û·Ó ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· 8,4±4,5 cm ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ˘ ÚÔ‚·ÏÏfiÌÂÓÔ˘, ·˘Ù¿ Ô˘ ¤Ï·‚·Ó Û˘Ó‰˘·ÛÌfi A˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Î·È ÔÍ·Ó‰ÚÔÏfiÓ˘ ¤Êı·Û·Ó ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· 10,3± 4,7 cm ·ÓÒÙÂÚÔ ÙÔ˘ ·Ó·ÌÂÓfiÌÂÓÔ˘, ÂÓÒ ÈÛÙÔÚÈ΋ ÔÌ¿‰· Û˘ÁÎÚ›Ûˆ˜, fiÌÔÈ· ·fi ÏÂ˘Ú¿˜ ËÏÈΛ·˜, ̤ÛÔ˘ ÁÔÓÂ˚ÎÔ‡ ‡„Ô˘˜, ‡„Ô˘˜
N.S.
EÂÍËÁ‹ÛÂȘ Û˘ÓÙÌ‹ÛÂˆÓ ÈÓ¿ÎˆÓ n= AÚÈıÌfi˜ ·ÛıÂÓÒÓ XH ¤Ó·Ú͢= XÚÔÓÔÏÔÁÈ΋ ËÏÈΛ· ¤Ó·Ú͢ ¢fiÛË hGH= ¢fiÛË A˘ÍËÙÈ΋˜ OÚÌfiÓ˘ IU/Kg/wk=¢ÈÂıÓ›˜ MÔÓ¿‰Â˜/ XÈÏÈfiÁÚ·ÌÌÔ ‚¿ÚÔ˘˜/ ‚‰ÔÌ¿‰· Ctrl= Controls: ÔÌ¿‰· ÂϤÁ¯Ô˘ R= restrospective: ·Ó·‰ÚÔÌÈ΋ ÔÌ¿‰· ÂϤÁ¯Ô˘ M= matched: ÔÌ¿‰· ÂϤÁ¯Ô˘, fiÌÔÈ· Ì ÙÔ˘˜ ·ÛıÂÓ›˜ EE= Ethinyl-estradiol= AÈı˘Ó˘Ï/ÔÈÛÙÚ·‰ÈfiÏË TA= TÂÏÈÎfi AÓ¿ÛÙËÌ· PAH= Projected adult height: ÚÔ‚·ÏfiÌÂÓÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· NS= ÌË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi
¤Ó·Ú͢ Î·È Î·Ú˘ÔÙ‡Ô˘ η٤ÏËÁ Û ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· fiÌÔÈÔ Ì ÙÔ ·Ó·ÌÂÓfiÌÂÓÔ. ¢‡Ô ÂÚÁ·Û›Â˜ Ô˘ ‰ÂÓ ¤‰ÂÈÍ·Ó ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ›ӷÈ, Ë ÂÚÁ·Û›· ÙˆÓ Taback Î·È Û˘Ó. ·fi ÙÔÓ K·Ó·‰¿ (34), Î·È Ë ÙˆÓ Chu Î·È Û˘Ó. ·fi ÙË ™ÎÔÙ›· (35). ™‡Ìʈӷ Ì ÙËÓ ÚÒÙË, ÙÔ ÚÔ‚·ÏÏfiÌÂÓÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ›¯Â ˘ÔÏÔÁÈÛÙ› ·ÚÎÂÙ¿ „ËÏ¿, 148 cm, ÒÛÙÂ Ë ¯ÔÚ‹ÁËÛË hGH Ó· ÌËÓ Ê·›ÓÂÙ·È Ó· ÂÈʤÚÂÈ ÂÈϤÔÓ fiÊÂÏÔ˜ (34). ™ÙËÓ ÂÚÁ·Û›· ÙˆÓ Chu Î·È Û˘Ó. (35), ·ÓÙÈı¤Ùˆ˜, ·ÛıÂÓ›˜ Ô˘ ¤Ï·‚·Ó A˘ÍËÙÈ΋ ÔÚÌfiÓË Ì ̤ÛË ËÏÈΛ· ¤Ó·Ú͢ Ù˘ ıÂڷ›·˜ 12,5 ¤ÙË (‡ÚÔ˜ 9,7-16,8 ¤ÙË), ¤Êı·Û·Ó ̤ÛÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· 142,6 cm, fiÌÔÈÔ Ì ÙÔ ·Ó·ÌÂÓfiÌÂÓÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÙˆÓ 142,0 cm. TÔ ÁÂÁÔÓfi˜ fï˜ fiÙÈ ÛÙËÓ ÂÚÁ·Û›· ·˘Ù‹ Ë ¯ÔÚ‹ÁËÛË hGH ¿Ú¯ÈÛ Û ÚÔ¯ˆÚË̤ÓË ËÏÈΛ·, ›Ûˆ˜ ÌÔÚ› Ó· ÂÍËÁ‹ÛÂÈ ÙËÓ ·Ô˘Û›· ΤډԢ˜ ·fi ÙË ıÂڷ›·. M›· ·ÎfiÌË ÂÚÁ·Û›· Ô‡ ‰Â›¯ÓÂÈ ·Ô˘Û›· ‚ÂÏÙ›ˆÛ˘ ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙËÓ ¯ÒÚ· Ì·˜ (36). H ÂÚÁ·Û›· ·˘Ù‹ ¤¯ÂÈ ÙÔ ÏÂÔÓ¤ÎÙËÌ· fiÙÈ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù·˘Ùfi¯ÚÔÓË ÔÌ¿‰· ÂϤÁ¯Ô˘, Ë ÔÔ›· ‰ÂÓ ¤Ï·‚ hGH ÁÈ· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ·ÔʇÁÂÈ Ù· ÌÂÈÔÓÂÎÙ‹Ì·Ù· ÂÎÙ›ÌËÛ˘ ÙÔ˘
281
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·282
¶∞π¢π∞∆ƒπ∫∏ 2000;63:278-286
ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Ì ‚¿ÛË ÚԂϤ„ÂȘ ‹ Ì ‚¿ÛË ÈÛÙÔÚÈο ‰Â‰Ô̤ӷ Ô˘ ›Ûˆ˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó Ï¤ÔÓ Ù· ‰Â‰Ô̤ӷ ·Ó¿Ù˘Í˘ ÙÔ˘ ÏËı˘ÛÌÔ‡. M ‚¿ÛË ÙË ÌÂϤÙË ·˘Ù‹, 35 ÎÔÚ›ÙÛÈ· Ô‡ ¤Ï·‚·Ó hGH ¤Êı·Û·Ó Û ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· 146,1±6,6 cm, ÛÙ·ÙÈÛÙÈο ÌË ‰È·ÊÔÚÂÙÈÎfi ·fi ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÙˆÓ 27 ÎÔÚÈÙÛÈÒÓ Ô˘ ‰ÂÓ ¤Ï·‚·Ó hGH Î·È ·ÔÙ¤ÏÂÛ·Ó ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘ (144,0±6,1 cm). H ·Ô˘Û›· ÔʤÏÔ˘˜ Û ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·, ÌÔÚ› ›Û˘ Ó· ÔÊ›ÏÂÙ·È ÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ıÂڷ›· ¿Ú¯ÈÛ Û ÚÔ¯ˆÚË̤ÓË Û¯ÂÙÈο ¯ÚÔÓÔÏÔÁÈ΋ ËÏÈΛ· (12,0 ±1,8 ÂÙÒÓ) ‹ ÛÙËÓ ÌÈÎÚ‹ Ù˘ Û¯ÂÙÈο ‰È¿ÚÎÂÈ· (2,7 ±1,2 ¤ÙË) ‹ ·ÎfiÌË ÛÙËÓ Î·ı˘ÛÙ¤ÚËÛË ÚÔÛı‹Î˘ ÔÈÛÙÚÔÁfiÓˆÓ ÛÙË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ (15,6±1,3 ÂÙÒÓ). ŒÙÛÈ, Ô‡ÙÂ Ë ÂÚÁ·Û›· ·˘Ù‹ ÌÔÚ› Ó· ·Ó·ÈÚ¤ÛÂÈ ·Ú¿ ÌfiÓÔ Ó· ÌÂÙÚÈ¿ÛÂÈ ›Ûˆ˜ Ù· ÂÓı·ÚÚ˘ÓÙÈο ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÔÏ˘¿ÚÈıÌˆÓ ÌÂÏÂÙÒÓ Ô˘ ‰Â›¯ÓÔ˘Ó Î¤Ú‰Ô˜ Ì ÙË ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË. MÂıÔ‰ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· H ÌÂÁ¿ÏË ÏËıÒÚ· ÙˆÓ ‰ËÌÔÛȇÛÂˆÓ Î·È Ù· ·ÓÙÈÎÚÔ˘fiÌÂÓ· ÔÏϤ˜ ÊÔÚ¤˜ ·ÔÙÂϤÛÌ·Ù· ¤Î·Ó·Ó ÂÌÊ·Ó‹ Ù· ÌÂıÔ‰ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· οı ÂÚÁ·Û›·˜ Î·È ÙË ‰˘ÛÎÔÏ›· Û‡ÁÎÚÈÛ˘ ÙˆÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ ÙÔ˘˜. AÚ¯Èο ¤ÁÈÓ ۷ʋ˜ Ë ‰˘ÛÎÔÏ›· Û‡ÁÎÚÈÛ˘ ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÙˆÓ ·È‰ÈÒÓ Ô˘ ‹Ú·Ó ·˘ÍËÙÈ΋ ÔÚÌfiÓË Ì ÈÛÙÔÚÈο ‰Â‰Ô̤ӷ ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ì ÙËÓ ¿ÚÔ‰Ô ÙˆÓ ÂÙÒÓ ˘¿Ú¯ÂÈ ÁÂÓÈο Ì›· ‚ÂÏÙ›ˆÛË ÙÔ˘ ‚ÈÔÙÈÎÔ‡ ÂȤ‰Ô˘ Ô˘ Ì ÙË ÛÂÈÚ¿ ÙÔ˘ ¢ÓÔ› ÙË ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÂÚÈϤÎÔÓÙ·˜ ÏÔÈfiÓ ÙË ‰˘Ó·ÙfiÙËÙ· Û‡ÁÎÚÈÛ˘ ‰Â‰ÔÌ¤ÓˆÓ Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ Î·È Û‡Á¯ÚÔÓˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ. E›Û˘ Ë Û‡ÁÎÚÈÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Ì ÙÔ ÚÔ‚·ÏÏfiÌÂÓÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ηٿ Lyon, Â›Ó·È ÌÂÓ Ë Ì¤ıÔ‰Ô˜ Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÁ·Û›Â˜, ·ÏÏ¿ Â›Ó·È ÁÓˆÛÙ‹ Ë ·Ó·ÎÚ›‚ÂÈ· ÚԂϤ„ÂˆÓ Î·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ô ˘ÔÏÔÁÈÛÌfi˜ ·˘Ùfi˜ ‰ÂÓ Ï·Ì‚¿ÓÂÈ ˘fi„Ë ÙËÓ ÂοÛÙÔÙ ηı˘ÛÙ¤ÚËÛË Ù˘ ÔÛÙÈ΋˜ ËÏÈΛ·˜. T¤ÏÔ˜, Ì ٷ ·Ú¯Èο ÂÓı·ÚÚ˘ÓÙÈο ‰Â‰Ô̤ӷ Ù˘ ‚Ú·¯˘ÚfiıÂÛÌ˘ ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘, Â›Ó·È ‰‡ÛÎÔÏÔ ÁÈ· ËıÈÎÔ‡˜ ÏfiÁÔ˘˜ Ó· ÂÈÏÂÁ› ÌÈ· ÔÌ¿‰· ÎÔÚÈÙÛÈÒÓ Ì ÙÔ Û‡Ó‰ÚÔÌÔ Ô˘ ‰ÂÓ ı· ¿ÚÂÈ ·˘ÍËÙÈ΋ ÔÚÌfiÓË, ÁÈ· Ó· ·ÔÙÂϤÛÂÈ Û˘ÁÎÚ›ÛÈÌË ÔÌ¿‰· ÂϤÁ¯Ô˘. ÕÏψÛÙÂ Ë ‰˘Ó·ÙfiÙËÙ· placebo, ‰ËÏ. ηıËÌÂÚÈÓ‹˜ ¤ÓÂÛ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ ÔÚÔ‡ Û ÔÌ¿‰· ÂϤÁ¯Ô˘ ı· ÚÔÛ¤ÎÚÔ˘Â Î·È ¿ÏÈ Û ËıÈο ÂÌfi‰È·. AÎfiÌË, ·Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ÌÂÁ¿ÏË ÏÂÈÔÓfiÙËÙ· ÙˆÓ ÂÚÁ·ÛÈÒÓ ·ÊÔÚ¿ ·Ó·‰ÚÔÌÈΤ˜ ÌÂϤÙ˜, ÔÈ Ôԛ˜ ÂÎ ÙÔ˘ ۯ‰ȷÛÌÔ‡ ÙÔ˘˜ ‰ÂÓ Â›Ó·È Ù˘¯·ÈÔÔÈË̤Ó˜ Î·È ÂÌÂÚȤ¯Ô˘Ó Ù· ÌÂÈÔÓÂÎÙ‹Ì·Ù· ÌÈ·˜ ·Ó·‰ÚÔÌÈ΋˜ ·Ó¿Ï˘Û˘ ·ÔÙÂÏÂÛÌ¿ÙˆÓ. EÈϤÔÓ, ˘¿Ú¯ÂÈ ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÙfiÛÔ Ù˘
282
X. K·Ó·Î¿ - Gantenbein
‰fiÛˆ˜ fiÛÔ Î·È Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ‚‰ÔÌ·‰È·›·˜ ¯ÔÚËÁ‹Ûˆ˜ Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙȘ ‰È¿ÊÔÚ˜ ÔÌ¿‰Â˜ Ô˘ ¤Ï·‚·Ó ıÂڷ›·. M›· ÚfiÛıÂÙË ÔÈÎÈÏÔÌÔÚÊ›· ÛÙË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ¯·ÌËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÏϤ˜ ÔÌ¿‰Â˜ ¯ÚËÛÈÌÔÔ›ËÛ·Ó ÔÍ·Ó‰ÚÔÏfiÓË ·Ú¿ÏÏËÏ· ‹ fi¯È Ì ÙË ¯ÔÚ‹ÁËÛË A·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘. E›Û˘, Ô ¯ÚfiÓÔ˜ ¤Ó·Ú͢ Ù˘ ¯ÔÚ‹ÁËÛ˘ hGH Ì ‹ ¯ˆÚ›˜ ÔÍ·Ó‰ÚÔÏfiÓË ‰È·Ê¤ÚÂÈ ÛËÌ·ÓÙÈο ÛÙȘ ‰È¿ÊÔÚ˜ ÂÚÁ·Û›Â˜. OÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÁ·Û›Â˜ ·Ó·Ï‡Ô˘Ó ‰Â‰Ô̤ӷ ÎÔÚÈÙÛÈÒÓ Ì ¤Ó·ÚÍË ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Û ۯÂÙÈο ÚÔ¯ˆÚË̤ÓË ËÏÈΛ· (12 ÂÙÒÓ), Ì ·ÔÙ¤ÏÂÛÌ· Ù· ÂÚÈıÒÚÈ· ÁÈ· ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ Ó· Â›Ó·È Ï¤ÔÓ ÂÚÈÔÚÈṲ̂ӷ Î·È Ó· ¢ı‡ÓÔÓÙ·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ÁÈ¿ ÙËÓ ·‰˘Ó·Ì›· ηٿ‰ÂÈ͢ ÔʤÏÔ˘˜ ·fi ÙË ıÂڷ›· (27,35,36). ŒÓ· ÂÈÚfiÛıÂÙÔ Úfi‚ÏËÌ· ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙˆÓ ‰È·ÊfiÚˆÓ ÂÚÁ·ÛÈÒÓ Â›Ó·È ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÚÔÛı‹ÎË ÙˆÓ ÔÈÛÙÚÔÁfiÓˆÓ (·Èı˘Ó˘Ï-ÔÈÛÙÚ·‰ÈfiÏ˘) Á›ÓÂÙ·È Û ‰È·ÊÔÚÂÙÈΤ˜ ËÏÈ˘ ÛÙȘ ‰È¿ÊÔÚ˜ ÂÚÁ·Û›Â˜ (22,27,35,36,38). ¶·Ú¿ Ù· ÌÂıÔ‰ÔÏÔÁÈο ·˘Ù¿ ÚÔ‚Ï‹Ì·Ù·, Ë ÌÂÙ·-·Ó¿Ï˘ÛË ÙˆÓ ‰ËÌÔÛÈÂ˘Ì¤ÓˆÓ ‰Â‰ÔÌ¤ÓˆÓ ÛÎÔfi ¤¯ÂÈ Ó· ··ÓÙ‹ÛÂÈ ÛÙ· η›ÚÈ· ÂÚˆÙ‹Ì·Ù·: XÔÚ‹ÁËÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘: - ¶fiÙÂ Â›Ó·È Ë È‰·ÓÈ΋ ËÏÈΛ· ¤Ó·Ú͢; - ¶ÔÈ· Â›Ó·È Ë È‰·ÓÈ΋ Î·È ·ÛÊ·Ï‹˜ ‰fiÛË Î·È Û˘¯ÓfiÙËÙ· ¯ÔÚ‹ÁËÛ˘; - M ‹ ¯ˆÚ›˜ ÚÔÛı‹ÎË ÔÍ·Ó‰ÚÔÏfiÓ˘; - ¶ÔÈ· Â›Ó·È Ë Â›ÙˆÛË ÛÙËÓ ÔÛÙÈ΋ ËÏÈΛ·; - Y¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË Ù˘ ·¿ÓÙËÛ˘ Ù˘ ÂÓ‰ÔÁÂÓÔ‡˜ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙȘ ‰˘Ó·ÌÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÚfiÎÏËÛ˘ Ù˘ Î·È ÙÔ˘ ·ÔÙÂϤÛÌ·ÙÔ˜ ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘; - Y¿Ú¯ÂÈ Â›‰Ú·ÛË ÙÔ˘ ηڢÔÙ‡Ô˘ ÛÙËÓ ·ÓÙ·fiÎÚÈÛË ıÂڷ›·˜ Ì ·˘ÍËÙÈ΋ ÔÚÌfiÓË; ¢È¿ÊÔÚÔÈ ÂÚ¢ÓËÙ¤˜ ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ‰ÂÓ ‚Ú‹Î·Ó Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ËÏÈΛ·˜ ¤Ó·Ú͢ Ù˘ ıÂڷ›·˜ Î·È ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ (17,27,29,32,36). AÍ›˙ÂÈ fï˜ Ó· ÛËÌÂȈı› fiÙÈ fiϘ ÔÈ ·ÛıÂÓ›˜ Ô‡ ¤Êı·Û·Ó ÙÔ ÙÂÏÈÎfi ÙÔ˘˜ ·Ó¿ÛÙËÌ· ¿Ú¯ÈÛ·Ó ıÂڷ›· Û¯ÂÙÈο ·ÚÁ¿ (9 -12 ¤ÙË), ÔÏϤ˜ ÊÔÚ¤˜ Ì¿ÏÈÛÙ· Û ËÏÈΛ· 16 ÂÙÒÓ, Ì ·ÔÙ¤ÏÂÛÌ· ·ÚÎÂÙfi ‰˘Ó·ÌÈÎfi ‡„Ô˘˜ Ó· ¤¯ÂÈ ‹‰Ë ¯·ı›, ÒÛÙ ٷ Û˘ÌÂÚ¿ÛÌ·Ù· Ó· ÌËÓ ÌÔÚÔ‡Ó Ó· ÁÂÓÈ΢ıÔ‡Ó ÁÈ· ÙË ¯ÔÚ‹ÁËÛË Û ÈÔ ÌÈÎÚ¤˜ ËÏÈ˘. ™ÙËÓ ÂÚÁ·Û›· ÙÔ˘ Plotnick Î·È Û˘Ó. (21) Ê·›ÓÂÙ·È fiÙÈ ÎÔÚ›ÙÛÈ· Ô˘ ¿Ú¯ÈÛ·Ó ıÂڷ›· Ì hGH Û Ó·ÚfiÙÂÚË ËÏÈΛ· ›¯·Ó ηχÙÂÚË ‚ÂÏÙ›ˆÛË ÙÔ˘ ·Ó·ÛÙ‹Ì·ÙÔ˜ ÙÔ˘˜ (21). E›Û˘, ÔÈ Rosenfeld Î·È Û˘Ó. (22) Î·È Ranke Î·È Û˘Ó. (38) ÂȂ‚·ÈÒÓÔ˘Ó Ù· ηχÙÂÚ· ·ÔÙÂϤÛÌ·Ù·, fiÙ·Ó Ë ıÂڷ›· ·Ú¯›˙ÂÈ
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·283
¶∞π¢π∞∆ƒπ∫∏ 2000;63:278-286
Û ÌÈÎÚfiÙÂÚË ËÏÈΛ·, ÂÓÒ ÔÈ Haeusler Î·È Û˘Ó. (17,29) Î·È Joss Î·È Û˘Ó. (26) ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÙÔ fiÊÂÏÔ˜ ¤Ó·Ú͢ Û Ó·ÚfiÙÂÚË ËÏÈΛ· ¤¯ÂÈ Û·Ó ·ÚÓËÙÈÎfi ·ÓÙ›Ô‰· ÙËÓ ÂÈÙ¿¯˘ÓÛË ˆÚ›Ì·ÓÛ˘ Ù˘ ÔÛÙÈ΋˜ ËÏÈΛ·˜, Ì ·ÔÙ¤ÏÂÛÌ· ÙÔ Î·ı·Úfi ΤډԘ ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· Ó· Â›Ó·È Ìˉ·ÌÈÓfi. H ‰fiÛË Ù˘ ¯ÔÚËÁËı›۷˜ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ‰ÂÓ Ê·›ÓÂÙ·È Ó· Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· (15,17,21,29,32,36), ÂÓÒ ÔÈ Ranke Î·È Û˘Ó. (38) ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë ‰fiÛË Ù˘ hGH Û¯ÂÙ›˙ÂÙ·È ıÂÙÈο Ì ÙÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ·. ™Â Ì›· ÚfiÛÊ·ÙË ÂÚÁ·Û›· (28), ÚÔÙ›ÓÂÙ·È ‰˘Ó·ÙfiÙËÙ· ‚ÂÏÙ›ˆÛ˘ ÙÔ˘ ıÂڷ¢ÙÈÎÔ‡ ·ÔÙÂϤÛÌ·ÙÔ˜, Ì ·‡ÍËÛË Ù˘ ‰fiÛ˘ Ù˘ hGH ̤¯ÚÈ Î·È 2,1 IU/Kg/‚‰ÔÌ¿‰· fiÙ·Ó Ô Ú˘ıÌfi˜ ·Ó¿Ù˘Í˘ ÂÈ‚Ú·‰‡ÓÂÙ·È. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÂÚ¢ÓËÙ¤˜ ˘ÔÛÙËÚ›˙Ô˘Ó fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÓ¤ÛÂˆÓ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ‰ÂÓ ÂËÚ¿˙ÂÈ ÙÔ ÙÂÏÈÎfi ·ÔÙ¤ÏÂÛÌ· (27,36) ÂÓÒ ·ÓÙÈı¤Ùˆ˜. ÔÈ Plotnick Î·È Û˘Ó. (21) ˘ÔÛÙËÚ›˙Ô˘Ó ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË. H ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜ Ì ·˘ÍËÙÈ΋ ÔÚÌfiÓË ÂËÚ¿˙ÂÈ ıÂÙÈο ÙËÓ ¤Î‚·ÛË Î·Ù¿ ÔÚÈṲ̂ÓÔ˘˜ ÂÚ¢ÓËÙ¤˜ (21), ÂÓÒ Î·Ù¿ ¿ÏÏÔ˘˜ ‰ÂÓ ÙËÓ ÂËÚ¿˙ÂÈ (32,36,37). ŒÓ·˜ ÂÚ·ÈÙ¤Úˆ ÚÔÁÓˆÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÌÂÏÂÙ‹ıËÎÂ Â›Ó·È Ë Â›‰Ú·ÛË ÙÔ˘ ‚·ıÌÔ‡ ÙÔ˘ ¯·ÌËÏÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜ ηٿ ÙËÓ ¤Ó·ÚÍË ÛÙÔ Î¤Ú‰Ô˜ ·fi ÙË ıÂڷ›·. ŸÛÔ ÂÓÙÔÓfiÙÂÚÔ ÙÔ ¯·ÌËÏfi ·Ó¿ÛÙËÌ· ηٿ ÙËÓ ¤Ó·ÚÍË ıÂڷ›·˜, ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ Î¤Ú‰Ô˜ Ù˘ ¯ÔÚ‹ÁËÛ˘ hGH (21,25) Î·È fiÛÔ „ËÏfiÙÂÚÔ ÙÔ ÎÔÚ›ÙÛÈ Î·Ù¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜, ÙfiÛÔ Î·Ï‡ÙÂÚÔ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· (38). H ›وÛË Ù˘ ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙËÓ ˆÚ›Ì·ÓÛË Ù˘ ÔÛÙÈ΋˜ ËÏÈΛ·˜ ·ÔÙ¤ÏÂÛ ı¤Ì· ·ÌÊÈÏÂÁoÌ¤ÓˆÓ Û˘ÌÂÚ·ÛÌ¿ÙˆÓ. OÈ Joss et al. (26) ÂͤÊÚ·Û·Ó ·ÓËÛ˘¯›Â˜ fiÙÈ ÂÓˆÚ›˜ ¤Ó·ÚÍË ¯ÔÚ‹ÁËÛ˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ì ‹ ¯ˆÚ›˜ ÔÍ·Ó‰ÚÔÏfiÓË ÂÈÙ·¯‡ÓÂÈ ‰˘Û·Ó¿ÏÔÁ· ÙËÓ ÔÛÙÈ΋ ËÏÈΛ·, Ì ·ÔÙ¤ÏÂÛÌ· ·ÒÏÂÈ· ‰˘Ó·ÌÈÎÔ‡ ÙÂÏÈÎÔ‡ ‡„Ô˘˜, ¤ÙÛÈ ÒÛÙ ÚfiÙÂÈÓ·Ó Ë ¤Ó·ÚÍË ¯ÔÚ‹ÁËÛ˘ hGH Ó· ÌËÓ Á›ÓÂÙ·È ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 9 ÂÙÒÓ, ÂÓÒ ¿ÏÏÔÈ ÂÚ¢ÓËÙ¤˜ (17,22,27) ‰ÂÓ ÂȂ‚·›ˆÛ·Ó ÙÔ˘˜ Êfi‚Ô˘˜ ·˘ÙÔ‡˜. ¶¿ÓÙˆ˜, fiÛÔ ÌÂÁ·Ï‡ÙÂÚÔ˜ Ô ‚·ıÌfi˜ ηı˘ÛÙ¤ÚËÛ˘ Ù˘ ÔÛÙÈ΋˜ ËÏÈΛ·˜ ηٿ ÙËÓ ¤Ó·ÚÍË hGH, ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ Î¤Ú‰Ô˜ ·fi ÙËÓ ıÂڷ›· (21,25). E›Ó·È ÁÓˆÛÙfi, fiÙÈ ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ÎÔÚÈÙÛÈÒÓ Ì ™‡Ó‰ÚÔÌÔ Turner ·ÚÔ˘ÛÈ¿˙ÂÈ ·Ó·Ú΋ (GHmax<11ng/ml Û 22%) ‹ ÂÏÏÈ‹ ¤ÎÎÚÈÛË (GHmax<7ng/ml Û 9,7%) ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙȘ ‰˘Ó·ÌÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÚfiÎÏËÛ˘ Ù˘ (25). º·›ÓÂÙ·È fiÙÈ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË hGH ‰ÂÓ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ·¿ÓÙËÛË Ù˘ ÂÓ‰ÔÁÂÓÔ‡˜ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙȘ ‰˘Ó·ÌÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÚfiÎÏËÛ‹˜ Ù˘ (21,25,36)
™‡Ó‰ÚÔÌÔ Turner Î·È A˘ÍËÙÈ΋ ÔÚÌfiÓË
ŒÓ·˜ ÂÈϤÔÓ ·Ú¿ÁÔÓÙ·˜ Ô˘ ÌÂÏÂÙ‹ıËÎÂ Â›Ó·È Ô Î·Ú˘fiÙ˘Ô˜. KÔÚ›ÙÛÈ· Ì ηڢfiÙ˘Ô ÈÛÔ¯ÚˆÌÔÛÒÌ·ÙÔ˜ Â›Ó·È ÈÔ ÎÔÓÙ¿ Î·È ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ ‚·ıÌfi ηı˘ÛÙ¤ÚËÛ˘ Ù˘ ÔÛÙÈ΋˜ ËÏÈΛ·˜ Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ¤¯Ô˘Ó ÌÂÁ·Ï‡ÙÂÚÔ fiÊÂÏÔ˜ ·fi ÙËÓ ¯ÔÚ‹ÁËÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ (25). Ÿˆ˜ ·Ó·Ê¤ÚıËÎÂ, ÙÔ Ì¤ÛÔ ÁÔÓÂ˚Îfi ‡„Ô˜ ·ÔÙÂÏ› ¤Ó· ·fi ÙÔ˘˜ ·ÚÈÔ˘˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ηıÔÚ›˙Ô˘Ó ÙÔ ·Ó¿ÛÙËÌ· ÎÔÚÈÙÛÈÔ‡ Ì ÙÔ ™‡Ó‰ÚÔÌÔ Î·È Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ Î·È ÙËÓ ¤Î‚·ÛË Ù˘ ıÂڷ›·˜ (15,36,38). K·Ù¿ ÔÚÈṲ̂ÓÔ˘˜ Ì¿ÏÈÛÙ· ÂÚ¢ÓËÙ¤˜, ÙÔ ‡„Ô˜ Ù˘ ÌËÙ¤Ú·˜ ·ÔÙÂÏ› ÈÛ¯˘ÚfiÙÂÚÔ ÚÔÁÓˆÛÙÈÎfi ·Ú¿ÁÔÓÙ· ·fi ÙÔ ‡„Ô˜ ÙÔ˘ ·Ù¤Ú· (36). AÛÊ¿ÏÂÈ·/ ¶·ÚÂÓ¤ÚÁÂȘ, ÂÈϤÔÓ ÔʤÏË Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ¢ÂÓ ·Ú·ÙËÚ‹ıËΠ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ۷ί·ÚÒ‰Ô˘˜ ‰È·‚‹ÙË, Ô‡Ù ηÏÔ‹ıÔ˘˜ ÂÓ‰ÔÎÚ¿ÓÈ·˜ ˘¤ÚÙ·Û˘, Ô‡Ù ÂÍ¿ÚıÚËÌ· Ù˘ ÎÂÊ·Ï‹˜ ÙÔ˘ ÌËÚÈ·›Ô˘ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ÛÙȘ ¯ÚËÛÈÌÔÔÈËı›Û˜ ‰fiÛÂȘ (21,22,27). ŒÙÛÈ, ‰fiÛÂȘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ Ù˘ ٿ͈˜ ÙˆÓ 0,7-0,9 IU/Kg/‚‰ÔÌ¿‰· (20-30 IU/m2/ ‚‰ÔÌ¿‰·) Â›Ó·È ÁÂÓÈÎÒ˜ ·Ô‰ÂÎÙ¤˜ Î·È ·ÛÊ·Ï›˜ (21,22,27). AÍ›˙ÂÈ Ó· ÙÔÓÈÛÙ› fiÙÈ ¤Ó· ÂÈϤÔÓ fiÊÂÏÔ˜ ·fi ÙËÓ ¯ÔÚ‹ÁËÛË hGH ÛÙ· ÎÔÚ›ÙÛÈ· Ì ™‡Ó‰ÚÔÌÔ Turner Â›Ó·È Ë ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ÔÛÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ (39). KÔÚ›ÙÛÈ· Ô˘ ¤Ï·‚·Ó ·˘ÍËÙÈ΋ ÔÚÌfiÓË ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÙÔ ‚·ıÌfi ÔÛÙÂÔÂÓ›·˜ Ô˘ ¤¯Ô˘Ó ÎÔÚ›ÙÛÈ· Ì ÙÔ ™‡Ó‰ÚÔÌÔ Ô˘ ‰ÂÓ ‹Ú·Ó ·˘ÍËÙÈ΋ ÔÚÌfiÓË (39-41). M ‹ ¯ˆÚ›˜ ÚÔÛı‹ÎË ÔÍ·Ó‰ÚÔÏfiÓ˘ Afi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ÂÚÁ·ÛÈÒÓ ˘¿Ú¯Ô˘Ó ÈÛ¯˘Ú¤˜ ÂӉ›ÍÂȘ fiÙÈ Ë ÚÔÛı‹ÎË ÔÍ·Ó‰ÚÔÏfiÓ˘ ÛÙË ıÂڷ›· Ì hGH ÂÈʤÚÂÈ ÂÈϤÔÓ fiÊÂÏÔ˜ ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· (17,22,26), ¤ÙÛÈ ÒÛÙ ӷ ÚÔÙ›ÓÂÙ·È Ô Û˘Ó‰˘·ÛÌfi˜ ·˘Ùfi˜ Û·Ó Î·Ï‡ÙÂÚË ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÚÔÛʤÚÂÈ ÂÈϤÔÓ ÙÔ ÏÂÔÓ¤ÎÙËÌ· ÂÓfi˜ ηχÙÂÚÔ˘ ·Ó·ÛÙ‹Ì·ÙÔ˜ ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ· Ô‡ ÌÔÚ› Ó· ‚ÔËı‹ÛÂÈ „˘¯ÔÏÔÁÈο Ù· ÎÔÚ›ÙÛÈ· ·˘Ù¿ Î·È Ó· ÂÈÙÚ¤„ÂÈ ÙËÓ ÚÔÛı‹ÎË ÔÈÛÙÚÔÁfiÓˆÓ Û ÌÈÎÚfiÙÂÚË ËÏÈΛ·, Ô˘ Ì ÙË ÛÂÈÚ¿ ÙÔ˘˜ ı· ‰Ú¿ÛÔ˘Ó Â˘ÓÔ˚ο ÛÙË „˘¯ÔÏÔÁÈ΋ ηٿÛÙ·ÛË ÙˆÓ ÎÔÚÈÙÛÈÒÓ ·˘ÙÒÓ Î·È ÛÙËÓ ÂÏ¿ÙÙˆÛË Î·Ù¿ ÙÔ ‰˘Ó·Ùfi ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Ù˘ ÔÛÙÂÔfiÚˆÛ˘ (22,27,39-42). Y¿Ú¯Ô˘Ó οÔÈÔÈ ÂÓ‰ÔÈ·ÛÌÔ› ÛÙË ¯ÔÚ‹ÁËÛË Ù˘ Û Ó·ڋ ËÏÈΛ·, ÏfiÁˆ Ù˘ Èı·ÓfiÙËÙ·˜ ÛËÌ·ÓÙÈ΋˜ ÚÔfi‰Ô˘ Ù˘ ÔÛÙÈ΋˜ ËÏÈΛ·˜ Ô˘ ı· ÂÈʤÚÂÈ ÂÏ¿ÙÙˆÛË ÙÔ˘ ‰˘Ó·ÌÈÎÔ‡ ÙÂÏÈÎÔ‡ ‡„Ô˘˜ (26), ÔÈ ÔÔ›ÔÈ fï˜ ‰ÂÓ ÂȂ‚·ÈÒÓÔÓÙ·È ·fi ¿ÏÏÔ˘˜ ÂÚ¢ÓËÙ¤˜ (22). AÓÂÈı‡ÌËÙ˜ ‰Ú¿ÛÂȘ Ù˘ ÔÍ·Ó‰ÚÔÏfiÓ˘ fiˆ˜, ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ Ù˘ ÎÏÂÈÙÔÚ›‰·˜ ‹ Î·È ‚¿ı˘ÓÛË Ù˘ ʈӋ˜, Ô˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ·fi ÙË
283
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·284
¶∞π¢π∞∆ƒπ∫∏ 2000;63:278-286
¯Ú‹ÛË „ËÏÒÓ ‰fiÛˆÓ, ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂÌÊ·Ó›˙ÔÓÙ·È Û ‰fiÛË 0,05-0,0625 mg/kg/Ë̤ڷ (22,27,38). £ÂˆÚÂ›Ù·È Û·Ó ·ÛÊ·Ï‹˜ ËÏÈΛ· ¤Ó·Ú͢ Ù˘ ıÂڷ›·˜ Ì ÔÍ·Ó‰ÚÔÏfiÓË Ë ËÏÈΛ· ÙˆÓ 8-9 ÂÙÒÓ, fiÙ·Ó Ê˘ÛÈÔÏÔÁÈο ·Ó·Ì¤ÓÂÙ·È ¤Ó·ÚÍË ·‰ÚÂÓ·Ú¯‹˜ (26,27). ¶fiÙ ڤÂÈ Ó· ÚÔÛÙÂı› ÌÈÎÚ‹ ‰fiÛË ÔÈÛÙÚÔÁfiÓˆÓ ÁÈ· ÂÌÊ¿ÓÈÛË ‰Â˘ÙÂÚÔÁÂÓÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘ ʇÏÔ˘; Y¿Ú¯ÂÈ ÁÂÓÈο Ô Êfi‚Ô˜ fiÙÈ ÂÓˆÚ›˜ ÚÔÛı‹ÎË ÔÈÛÙÚÔÁfiÓˆÓ ı· ÂÈʤÚÂÈ ÂÈÙ¿¯˘ÓÛË Ù˘ ÔÛÙÈ΋˜ ËÏÈΛ·˜ Ì ‰˘ÛÌÂÓ›˜ Û˘Ó¤ÂȘ ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· (14,17,27,36) ÂÓÒ Î·ı˘ÛÙ¤ÚËÛË ˘ÔηٿÛÙ·Û˘ Ì ÔÈÛÙÚÔÁfiÓ· Û ¤Ó· ™‡Ó‰ÚÔÌÔ Ô‡ Û˘Óԉ‡ÂÙ·È ·fi ÙÔ ÛËÌ·ÓÙÈÎfi Úfi‚ÏËÌ· Ù˘ ÔÛÙÂÔfiÚˆÛ˘ ÚÔ‚ÏËÌ·Ù›˙ÂÈ (22,27,32,39-42). E›Û˘, ηı˘ÛÙ¤ÚËÛË ÚfiÎÏËÛ˘ ÂÊ˂›·˜ ηٷϋÁÂÈ Û ·ÒÏÂÈ· ÙÔ˘ ΤډԢ˜ Û ‡„Ô˜ (loss of pubertal growth spurt) fiˆ˜ ¤‰ÂÈÍÂ Ë ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË ÙˆÓ Shah Î·È Û˘Ó. (37) Î·È Ù· ‰Â‰Ô̤ӷ Ù˘ ÂÚÁ·Û›·˜ ÙˆÓ Hochberg Î·È Û˘Ó. (32) ηٷ‰ÂÈÎÓ‡Ô˘Ó fiÙÈ Ë ËÏÈΛ· ÚÔÛı‹Î˘ ÙˆÓ ÔÈÛÙÚÔÁfiÓˆÓ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ ÛËÌ·ÓÙÈο ÙËÓ ¤Î‚·ÛË Ù˘ ıÂڷ›·˜ Ì hGH, ˘ÔÛÙËÚ›˙ÔÓÙ·˜ fiÙÈ ˘ÔηٿÛÙ·ÛË Ì ÔÈÛÙÚÔÁfiÓ· ‰ÂÓ Ú¤ÂÈ Ó· ηı˘ÛÙÂÚ› ¤Ú·Ó Ù˘ ËÏÈΛ·˜ ÙˆÓ 13-14 ÂÙÒÓ (27,32). ŒÙÛÈ, Â›Ó·È Ì¿ÏÏÔÓ ·Ô‰ÂÎÙfi fiÙÈ ÚÔÛı‹ÎË ÔÈÛÙÚÔÁfiÓˆÓ ‰ÂÓ ı· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 12 ÂÙÒÓ Î·È ‰ÂÓ ı· Ú¤ÂÈ Ó· ηı˘ÛÙÂÚ› Ôχ ÌÂÙ¿ Ù· 13-14 ¤ÙË Î·È fiÙÈ ·ÛÊ·Ï‹˜ ‰fiÛË ¤Ó·Ú͢ ıˆÚÔ‡ÓÙ·È Ù· 50ng/Kg/Ë̤ڷ ·Èı˘Ó˘Ï-ÔÈÛÙÚ·‰ÈfiÏ˘ (27,32,42). MÈ· ÂıÓÈ΋ ÚÔ‰ÚÔÌÈ΋ ÌÂϤÙË Ô˘ ¿Ú¯ÈÛ ‹‰Ë ÛÙÔ Hӈ̤ÓÔ B·Û›ÏÂÈÔ ÌÂ Ù˘¯·ÈÔÔ›ËÛË ÙˆÓ ÎÔÚÈÙÛÈÒÓ Ì ÙÔ ™‡Ó‰ÚÔÌÔ ˘fi hGH ÁÈ· Ó· Ï¿‚Ô˘Ó ÔÈÛÙÚÔÁfiÓ· Û ËÏÈ˘ 12 ‹ 14 ÂÙÒÓ, ÛÎÔfi ¤¯ÂÈ ·ÎÚÈ‚Ò˜ Ó· ‰ÒÛÂÈ ·¿ÓÙËÛË ÛÙËÓ È‰·ÓÈ΋ ËÏÈΛ· ¤Ó·Ú͢ ÔÈÛÙÚÔÁÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘ (27). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ıÂڷ›· Ì ·˘ÍËÙÈ΋ ÔÚÌfiÓË ÎÔÚÈÙÛÈÒÓ Ì ™‡Ó‰ÚÔÌÔ Turner, Û ‰fiÛÂȘ 0,7-0,9 IU/Kg/week Â›Ó·È ·ÛÊ·Ï‹˜ Î·È ÂÈʤÚÂÈ Î·Ù¿ ̤ÛÔ fiÚÔ, ¤Ó· Û˘ÓÔÏÈÎfi ΤډԘ Ù˘ ٿ͈˜ ÙˆÓ 6,07 ÂηÙÔÛÙÒÓ ÛÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. ø˜ ·ÛÊ·Ï‹˜ Î·È Î·Ù¿ÏÏËÏË ËÏÈΛ· ¤Ó·Ú͢ Ù˘ ıÂڷ›·˜ ıˆÚÂ›Ù·È Ë ËÏÈΛ· ÙˆÓ 6 -8 ÂÙÒÓ, ÂÓÒ ¯ÔÚ‹ÁËÛË Û ÌÈÎÚfiÙÂÚ˜ ËÏÈ˘ ¯Ú‹˙ÂÈ ÂÚ·ÈÙ¤Úˆ ÌÂϤÙ˘. OÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂËÚ¿˙Ô˘Ó ÙËÓ ¤Î‚·ÛË Ù˘ ıÂڷ›·˜ ›ӷÈ: - TÔ ‡„Ô˜ ηٿ ÙËÓ ¤Ó·ÚÍË - H ÔÛÙÈ΋ ËÏÈΛ· ηٿ ÙËÓ ¤Ó·ÚÍË - O ηڢfiÙ˘Ô˜ - TÔ ÁÔÓÂ˚Îfi ‡„Ô˜
284
X. K·Ó·Î¿ - Gantenbein
H ‰fiÛË Ù˘ ·˘ÍËÙÈ΋˜ ÔÚÌfiÓ˘ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ¤Î‚·ÛË, ÂÓÒ ÚÔÛ·ÚÌÔÁ‹, ‰ËÏ. ·‡ÍËÛË Ù˘ ‰fiÛ˘ ̤¯ÚÈ Î·È 2,1 IU/Kg/‚‰ÔÌ¿‰· fiÙ·Ó Ô Ú˘ıÌfi˜ ·Ó¿Ù˘Í˘ ÂÈ‚Ú·‰‡ÓÂÙ·È, ›Ûˆ˜ ‚ÂÏÙÈÒÓÂÈ ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. ¶ÚÔÛı‹ÎË ÔÍ·Ó‰ÚÔÏfiÓ˘ ÛÙË ıÂڷ›· Ì hGH, Û ËÏÈΛ· 8-9 ÂÙÒÓ Û˘Ì‚¿ÏÏÂÈ ÛÙËÓ ÂÚ·ÈÙ¤Úˆ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ·Ó·ÛÙ‹Ì·ÙÔ˜. T¤ÏÔ˜, Ë ıÂڷ›· ˘ÔηٷÛÙ¿Ûˆ˜ Ì ÌÈÎÚ¤˜ ‰fiÛÂȘ ÔÈÛÙÚÔÁfiÓˆÓ ı· Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ÂÚ›Ô˘ ÛÙË ËÏÈΛ· ÙˆÓ 13 ÂÙÒÓ, ·ÊÂÓfi˜ ÌÂÓ ÁÈ· Ó· ÌËÓ ÂȉÂÈÓÒÓÂÙ·È ÙÔ Úfi‚ÏËÌ· Ù˘ ÔÛÙÂÔfiÚˆÛ˘ Ì ηı˘ÛÙ¤ÚËÛË Ù˘ ÔÚÌÔÓÈ΋˜ ˘ÔηٿÛÙ·Û˘ Î·È ·ÊÂÙ¤ÚÔ˘, ÁÈ· ‚ÂÏÙ›ˆÛË Ù˘ „˘¯ÔÏÔÁÈ΋˜ ηٿÛÙ·Û˘ ÙˆÓ ÎÔÚÈÙÛÈÒÓ ·˘ÙÒÓ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ˘ÂÚ‚ÔÏÈ΋ ηı˘ÛÙ¤ÚËÛË ÚÔÛı‹Î˘ ÔÈÛÙÚÔÁfiÓˆÓ ‰ÂÓ Ê·›ÓÂÙ·È Ó· ÂËÚ¿˙ÂÈ Â˘ÓÔ˚ο ÙÔ ÙÂÏÈÎfi ·Ó¿ÛÙËÌ·. BÈ‚ÏÈÔÁÚ·Ê›· 1. Lippe B. Turner syndrome. Endocrinol Metab Clin N Am 1991;20:121-152. 2. Chatelain P, Berlier P, Francois R. Pathology of the ovary: Gonadal dysgenesis. In: Bertrand J, Rappaport R, Sizonenko PC, eds. Pediatric Endocrinology: Physiology, Pathophysiology and Clinical Aspects, 2nd ed. New York: Williams and Wilkins, 1993:420-428. 3. Ullrich O. Ueber typische Kombinationsbilder multipler Abartungen. Z Kinderheilk 1930; 49:271-276. 4. Turner HH. A syndrome of infantilism, congenital webbed neck and cubitus valgus. Endocrinology 1938; 23: 566574. 5. Lippe B, Gefner ME, Dietrich RB, Boechatmi, Kangarloo H. Renal malformation in patients with Turner's Syndrome: imaging in 141 patients. Pediatrics 1988;82:852-856. 6. Ranier-Pope CR, Cunningham RD, Nadas AS, Crigler JF Jr. Cardiovascular malformations in Turner's syndrome. Pediatrics 1964; 33: 919-925. 7. Williams ED, Engel F, Forbes AP.Thyroiditis and gonadal dysgenesis. N Engl J Med 1964;270:805-810. 8. Vanderschueren-Lodeweyckx M. Autoimmunity problems in Turner syndrome. In: Albertsson-Wikland K, Ranke MB, eds. Turner syndrome in a life span perspective:Research and clinical aspects. Amsterdam: Elsevier Science BV, 1995: 267-273. 9. Park E, Bailey JD, Ciwell CA. Growth and maturation of patients with Turner's syndrome. Pediatr res. 1983;17:1-7. 10. Ranke MB, Pfluger H, Rosendahl W, Stubbe P, Enders H, Bierich JR et al. Turner syndrome: spontaneous growth in 150 cases and review of the literature. Eur J Pediatr 1983; 141:81-88. 11. Ranke MB, Grauer ML. Adult height in Turner syndrome: results of a multinational survey. Horm Res 1994;42:90-94. 12. Karlberg J, Albertsson-Wikland K. Natural Growth ·nd aspects of growth standards in Turner syndrome. In: Albertsson-Wikland K, Ranke MB, eds. Turner syndrome
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·285
¶∞π¢π∞∆ƒπ∫∏ 2000;63:278-286
13.
14.
15.
16.
17. 18.
19. 20.
21.
22.
23.
24.
25.
26.
in a life span perspective:Research and clinical aspects. Amsterdam: Elsevier Science BV, 1995: 75-86. Low LC, Sham C, Kwan E, Karlberg J, Tang G, Cheung PT et al. Spontaneous growth in Chinese patients with Turner’s syndrome and influence of karyotype. Acta Paediatr 1997 Jan 86(1):18-21. Massa G, Vanderschueren-Lodeweyckx M, Malvaux M. Linear growth in patients with Turner syndrome:influence of spontaneous puberty and parental height. Eur J Pediatr 1990; 149: 246-250. Rochiccioli P, David M, Malpeuch G, Colle M, Limal JM, Barrin J, et al. Study of final height in Turner's syndrome: ethnic and genetic influences. Acta Paediatr 1994;83:305308. Rao E, Weiss B, Fukami M, Rump A, Niesler B, Mertz A et al. Pseudoautosomal deletions encompassing a novel homeobox gene cause growth failure in idiopathic short stature and Turner syndrome. Nat Genet 1997;16:54-63. Haeusler G. Growth hormone therapy in patients with Turner Syndrome.Horm Res 1998; 49 (suppl 2):62-66. Naeraa RW, Eiken M, Legarth EG, Nieben J. Spontaneous growth, final height and prediction of final height in Turner syndrome. In: Ranke MB, Rosenfeld RG (eds) Turner syndrome: Growth promoting therapies. Amsterdam: Elsevier Science BV,1991:113-116. Lyon AJ, Preece MA, Grant DB. Growth curve for girls with Turner syndrome. Arch Dis Child 1985;60:932-935. Attie KM, Frane JW. Accuracy of adult height prediction methods for Turner syndrome using US untreated control data. Horm Res 1997;48(suppl. 2):60. Plotnick L, Attie KM, Blethen SL, Sy JP. Growth hormone treatment of girls with Turner syndrome: The National Cooperative Growth Study experience. Pediatrics 1998;102:479-481. Rosenfeld RG, Attie KM, Frane J, Brasel JA, Burstein S, Cara JF, et al. Growth Hormone therapy of Turner's Syndrome: Beneficial effect on adult height. J Pediatr 1998;132:319-324. Bareille P, Massarano AA, Stanhope R. Final height outcome in girls with Turner syndrome treated with a combination of low dose oestrogen and oxandrolone. Eur J Pediatr 1997;156:358-362. Rosenfeld RG, Frane J, Attie KM, Brasel JA, Burstein S, Cara JF et al. Six-year results of a randomized, prospective trial of human growth hormone and oxandrolone in Turner syndrome. J Pediatr 1992;121:4955. Schmitt K, Haeusler G, Blümel P, Plöchl E, Frisch H. Short and long-term (final height) growth responses to growth hormone (GH) therapy in patients with Turner syndrome: Correlation of growth response to stimulated GH levels, spontaneous GH secretion and karyotype Horm Res 1997;47:67-72. Joss E, Mullis PE, Werder EA, Partsch CJ, Sippell WG. Growth promotion and Turner-specific bone age after
™‡Ó‰ÚÔÌÔ Turner Î·È A˘ÍËÙÈ΋ ÔÚÌfiÓË
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39. 40.
therapy with Growth hormone and in combination with Oxandrolone: When should therapy be started in Turner syndrome? Horm Res 1997; 47:102-109. Donaldson MD. Growth hormone therapy in Turner syndrome - Current uncertainties and future strategies. Horm Res 1997;48 (Suppl 5):35-44. Carel JC, Mathivon L, Gendrel C, Ducret JP, Chaussain JL. Near normalization of final height with adapted doses of GH in Turner’s syndrome. J Clin Endocrinol Metab 1998;83:1462-1466. Haeusler G, Schmitt K, Blümel P, Plöschl E, Waldhör T. Growth hormone in combination with anabolic steroids in patients with Turner syndrome: effect on bone maturation and adult height. Acta Paediatr 1996;85:1408-1414. Canadian Growth Hormone Advisory Committee. Growth hormone treatment to final height in Turner syndrome: a randomized controlled trial. Horm Res 1998; 50 Suppl.3:25 (P7). Quigley CA, Anglin G, Whittaker N, Chipman JJ and the Lilly US Turner Syndrome Study Group. Growth hormone increases final height of patients with Turner syndrome. Horm Res 1998; 50 Suppl.3:26 (P13). Hochberg Z, Zadik Z. Final height in Turner syndrome on Growth hormone therapy: a controlled study. Horm Res 1998; 50 Suppl.3:28 (P18). Rouwe CW, Drayer NM. Increased final height in girls with Turner syndrome after treatment with recombinant human growth hormone. Horm Res 1998; 50 Suppl.3:53 (P121). Taback SP, Collu R, Deal CL, Guyda HJ, Salisbury S, Dean HJ et al. Does growth hormone supplementation affect adult height in Turner’s syndrome? Lancet 1996; 348:25-26. Chu CE, Paterson WF, Kelnar CJH, Smail PJ, Greene SA, Donaldson MDC. Variable effect of growth hormone on growth and final adult height in Scottish patients with Turner’s syndrome. Acta Paediatr 1997;86:160-164. Dacou-Voutetakis C, Karavanaki-Karanassiou K, Petrou V, Georgopoulos N, Maniati-Christidi M, Mavrou A. The growth pattern and final height of girls with Turner syndrome with and without human growth hormone treatment. Pediatrics, 1998;101:663-668. Shah NS, Spoudeas HA, Preece MA, on behalf of British Society for Paediatric Endocrinology and Diabetes. Does treatment usefully increase final height in Turner girls? Horm Res 1998; 50 Suppl.3:25 (P8). Ranke MB, Price DA, Maes M, Albertsson-Wikland K, Lindberg A. Factors influencing final height in Turner syndrome following GH treatment: results of the Kabi International Growth Study (KIGS). In: Albertsson-Wikland K, Ranke MB, eds. Turner syndrome in a life span perspective: Research and clinical aspects. Amsterdam: Elsevier Science BV, 1995:161-165. Rubin K. Turner syndrome and osteoporosis: mechanisms and prognosis. Pediatrics 1998;102:481-485. Bachrach LK. Osteopenia in Turner girls. In: AlbertssonWikland K, Ranke MB, eds. Turner syndrome in a life span
285
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·286
¶∞π¢π∞∆ƒπ∫∏ 2000;63:278-286
perspective:Research and clinical aspects. Amsterdam: Elsevier Science BV, 1995: 233-239. 41. Sylven L, Hagenfeldt K, Ringertz H. Impact of hormonal replacement therapy on bone mineral density in women with Turner syndrome. In: Albertsson-Wikland K, Ranke MB, eds. Turner syndrome in a life span perspective: Research and clinical aspects. Amsterdam: Elsevier Science BV, 1995:241-248.
X. K·Ó·Î¿ - Gantenbein
42. Ross JL, McCauley E, Roeltgen D, Long L, Kushner H, Feuillan P et al. Self-Concept and behavior in adolescent girls with Turner syndrome: Potential estrogen effects. J Clin Endocrinol Metab 1996;81:926-931.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 16-04-1999 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-06-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¢Ú. XÚÈÛÙ›Ó· K·Ó·Î¿ - Gantenbein ¶·È‰›·ÙÚÔ˜- ¶·È‰ÔÂÓ‰ÔÎÚÈÓÔÏfiÁÔ˜ - §¤ÎÙÔÚ·˜ ¶·È‰ÔÂÓ‰ÔÎÚÈÓÔÏÔÁ›·˜ T˘ÌÊÚËÛÙÔ‡ 52 - 15234 X·Ï¿Ó‰ÚÈ, Aı‹Ó·
286
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·287
¶∞π¢π∞∆ƒπ∫∏ 2000;63:287-291
∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™
E›Â‰· ·Ú·ÁfiÓÙˆÓ ·ÈÌfiÛÙ·Û˘ Û ·ÛıÂÓ›˜ Ì Á·Ï·ÎÙo˙·ÈÌ›· ˘fi ‰›·ÈÙ· Ì "Á¿Ï· ÛfiÁÈ·˜" KÏÂo¿ÙÚ· ™o‡ÏË1, EϤÓË ¶Ï·ÙoÎo‡ÎË2, E˘¿ÁÁÂÏo˜ ¶··ÎˆÓÛÙ·ÓÙ›Óo˘1, EϤÓË MȯÂϷοÎË1, ™oÊ›· AÚÒÓË2 ● ¶ÂÚ›ÏË„Ë: TÚÂȘ Ù‡oÈ ‰È·Ù·Ú·¯ÒÓ Ù˘ Á·Ï·ÎÙo˙·ÈÌ›·˜ ¤¯o˘Ó ÂÚÈÁÚ·Ê› oÈ oo›oÈ ·ÓÙ·oÎÚ›ÓoÓÙ·È ÛÙË ıÂڷ¢ÙÈ΋ ‰È·ÈÙËÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ì Úo˚fiÓÙ· ÂχıÂÚ· Ï·ÎÙfi˙˘/Á·Ï·ÎÙfi˙˘ Ì ·ÚÈo ·ÓÙÈÚfiÛˆfi Ùo˘˜ Ù· Úo˚fiÓÙ· ÛfiÁÈ·˜ ηٿ ÙË ÓÂoÁÓÈ΋ Î·È ‚ÚÂÊÈ΋ ËÏÈΛ·. E›Ó·È ÁÓˆÛÙfi fiÙÈ oÈ Ê˘ÙÈΤ˜ ÚˆÙ½Ó˜, fiˆ˜ oÈ ÚoÂÚ¯fiÌÂÓ˜ ·fi ÛfiÁÈ· o˘ ÂÌÂÚȤ¯ÂÈ ÈÛoÊÏ·‚oÓoÂȉ‹, ‚oËıo‡Ó ÛÙËÓ Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ¯oÏËÛÙÂÚfiÏ˘. AÎfiÌË ¤¯o˘Ó ·Ú·ÙËÚËı› ÌÂȈ̤Ó˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙˆÓ ·Ú·ÁfiÓÙˆÓ VII, Ù˘ ÈÓˆ‰oÁoÓoÏ˘ÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜, Ù˘ ÚˆÙ½Ó˘ C (PC) Î·È Ù˘ AÓÙÈıÚoÌ‚›Ó˘ III (ATIII) ÛÂ Ê˘ÙoÊ¿Áo˘˜. MÂÏÂÙ‹Û·Ì ÙfiÛo ÙȘ ·Ú·Ì¤ÙÚo˘˜ Ù˘ ‹Íˆ˜ fiÛo Î·È Ù· ÏÈ›‰È· Û oÚfi 18 ·ÛıÂÓÒÓ (ËÏÈΛ· ‰È¿ÁÓˆÛ˘ 8,5±3,5 Ë̤Ú˜), oÈ 15 ¤·Û¯·Ó ·fi ÎÏ·ÛÛÈ΋ Á·Ï·ÎÙo˙·ÈÌ›· Î·È oÈ 3 ·fi ·Ó¿ÚÎÂÈ· ÂÈÌÂÚ¿Û˘, ËÏÈΛ·˜ 3,2+0,2 ÌËÓÒÓ. H ¯oÚ‹ÁËÛË Ùo˘ Û΢¿ÛÌ·Ùo˜ Ù˘ ÛfiÁÈ·˜ ¿Ú¯ÈÛ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ‰È¿ÁÓˆÛË Î·È Ùo˘˜ Û˘ÁÎÚ›Ó·Ì Ì ÂΛÓo˘˜ ÙˆÓ Ì·ÚÙ‡ÚˆÓ ·ÚfiÌoÈ·˜ ËÏÈΛ·˜. H ¯oÏËÛÙÂÚfiÏË, Ë ¯·ÌËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÏÈoÚˆÙ½Ó˘ (LDL) Î·È Ë ·oÏÈoÚˆÙ½ÓË B ‚Ú¤ıËÎ·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚ˜ Û˘ÁÎÚÈÓfiÌÂÓ˜ Ì Ùo˘˜ Ì¿ÚÙ˘Ú˜. E›Û˘ ¯·ÌËÏfiÙÂÚ· ‚Ú¤ıËÎ·Ó Ù· ›‰· ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜ II, VII, IX, X Î·È PC. £ÂˆÚo‡Ì fiÙÈ Ù· ¯·ÌËÏ¿ ›‰· ÏÈȉ›ˆÓ ÙˆÓ Á·Ï·ÎÙo˙·ÈÌÈÎÒÓ ·ÛıÂÓÒÓ Ì·˜ Â›Ó·È ˘Â‡ı˘Ó· ÙfiÛo ÁÈ· ÙËÓ ·oÚÚfiÊËÛË, fiÛo Î·È ÁÈ· ÙË ÌÂÙ·ÊoÚ¿ Ù˘ BÈÙ·Ì›Ó˘ K ÛÙoÓ Ùfio Û‡ÓıÂÛ˘ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, oÈ Á·Ï·ÎÙo˙·ÈÌÈÎo› ·ÛıÂÓ›˜ ˘fi ‰›·ÈÙ· Ì Úo˚fiÓÙ· ÛfiÁÈ·˜ ·Úo˘ÛÈ¿˙o˘Ó ÌÂÙ·‚oϤ˜ ÙˆÓ ÏÈȉ›ˆÓ Ùo˘˜ Î·È ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜ ·ÚfiÌoȘ Ì ÂΛӘ ÙˆÓ Ê˘ÙoÊ¿ÁˆÓ. ¶·È‰È·ÙÚÈ΋ 2000;63:287-291. §¤ÍÂȘ ÎÏÂȉȿ: Á·Ï·ÎÙo˙·ÈÌ›·, ·Ú¿ÁoÓÙ˜ ‹Íˆ˜, ‰›·ÈÙ· Ì ÛfiÁÈ·. K. Schulpis, E. Platokouki, E. Papakonstantinou, E. Michelakakis, S. Aroni. Haemostatic factors in patients with galactosaemia on soybean diet. Paediatriki 2000;63:287-291. ● Abstract: Three major disorders associated with galactose metabolism which respond to dietary treatment have been described. A nutritionally adequate galactose/lactose free soybean formula is the basis of this diet, which is one of the main means of management of the disease during infancy. Intake of vegetable protein, such as soybean protein, results in low plasma cholesterol levels. Lower concentrations of Factor VII, fibrinolytic activity and Antithrombin III (AT III) have been observed in vegetarians. Of 18 patients with galactosaemia at a mean diagnosed age of 8.5±3.5 days, on soybean diet, 15 suffered from classic galactosaemia and 3 from epimerase deficiency. From these children, at a mean age of 3.2±0.8 months, and from 38 healthy children of comparable age on a commercial formula a 5.0 ml blood sample was drawn, after 8 hours' fasting, for estimation of lipid and haemostatic variables. Cholesterol, LDL and Apo B concentrations were found significantly lower in the galactosaemic infants than in the control group. Factors II, VII, IX, X and PC were found to be decreased. It has been suggested that the low levels of haemostatic factors in galactosaemic patients are due to reduced absorption or delivery of vitamin K to the site of synthesis of haemostatic factors. The galactosaemic patients in this study on a soybean diet demonstrated changes in their haemostatic and lipid profile similar to those seen in vegetarians. Key words: galactosaemia, haemostatic factors, soybean diet.
1 2
IÓÛÙÈÙo‡Ùo YÁ›·˜ Ùo˘ ¶·È‰Èo‡ NoÛoÎoÌ›o ¶·›‰ˆÓ "AÁ›· ™oÊ›·" 11527 Aı‹Ó· MoÓ¿‰· AÈÌfiÛÙ·Û˘, AÈÌoÚÚoÊÈÏ›·˜ NoÛoÎoÌ›o ¶·›‰ˆÓ "AÁ›· ™oÊ›·" 11527 Aı‹Ó·
287
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·288
¶∞π¢π∞∆ƒπ∫∏ 2000;63:287-291
EÈÛ·ÁˆÁ‹ H Á·Ï·ÎÙo˙·ÈÌ›· Â›Ó·È Ì›· ÎÏËÚoÓoÌÈ΋ ‰È·Ù·Ú·¯‹ Ùo˘ ÌÂÙ·‚oÏÈÛÌo‡ Ùo˘ ˘‰·Ù¿ÓıÚ·Îo˜ Á·Ï·ÎÙfi˙Ë. TÚÂȘ Â›Ó·È oÈ Ù‡oÈ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ o˘ ÂÚÈÁÚ¿ÊoÓÙ·È ·Ó¿ÏoÁ· Ì ÙËÓ ·ÈÙÈoÏoÁ›· Ùo˘˜: ·) H ÚoÂÚ¯fiÌÂÓË ·fi ·Ó¿ÚÎÂÈ· Ùo˘ ÂÓ˙‡Ìo˘ ÂÈÌÂÚ¿ÛË Ù˘ o˘Úȉ˘ÏÈ΋˜ ‰ÈʈÛÊoÚÈ΋˜ Á·Ï·ÎÙfi˙˘, o˘ ¤¯ÂÈ ˆ˜ ·oÙ¤ÏÂÛÌ· ÙË ÌÂȈ̤ÓË ÌÂÙ·ÙÚo‹ Ù˘ Á·Ï·ÎÙfi˙˘ Û ÁÏ˘Îfi˙Ë, ‚) H ·Ó¿ÚÎÂÈ· Ù˘ o˘Úȉ˘ÏÈ΋˜ ÙÚ·ÓÛÊÂÚ¿Û˘ Ù˘ ʈÛÊoÚÈ΋˜-1Á·Ï·ÎÙfi˙˘ (ÎÏ·ÛÈ΋ Á·Ï·ÎÙo˙·ÈÌ›·) Î·È Á) H ·Ó¿ÚÎÂÈ· Ù˘ Á·Ï·ÎÙoÎÈÓ¿Û˘ o˘ ηٷχÂÈ ÙËÓ ·ÓÙ›‰Ú·ÛË ·Ú·ÁˆÁ‹˜ ʈÛÊoÚÈ΋˜-1-Á·Ï·ÎÙfi˙˘ ·fi Á·Ï·ÎÙfi˙Ë. H ÌÂÁ·Ï‡ÙÂÚË oÛfiÙËÙ· Ù˘ ÚoÂÚ¯fiÌÂÓ˘ ·fi ÙȘ ÙÚoʤ˜ Á·Ï·ÎÙfi˙˘ Úo¤Ú¯ÂÙ·È ·fi ÙoÓ ˘‰·Ù¿Óıڷη Ï·ÎÙfi˙Ë, ¤Ó· ‰˘Û·Î¯·Ú›ÙË o˘ ÂÌÂÚȤ¯ÂÙ·È Î˘Ú›ˆ˜ ÛÙo Á¿Ï· Î·È ˘‰ÚoχÂÙ·È Û Á·Ï·ÎÙfi˙Ë Î·È ÁÏ˘Îfi˙Ë Ì ÙËÓ ‰Ú¿ÛË Ù˘ ÂÓÙÂÚÈ΋˜ Ï·ÎÙ¿Û˘, Ë oo›· ¤¯ÂÈ Ê˘ÛÈoÏoÁÈ΋ ‰Ú·ÛÙÈÎfiÙËÙ· ÛÙo˘˜ ·ÛıÂÓ›˜ Ì Á·Ï·ÎÙo˙·ÈÌ›· (1-3). MoÓ·‰È΋ ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛo˘ Â›Ó·È Ë ‰È·ÈÙËÙÈ΋ ·ÁˆÁ‹ ·fi ÙËÓ oo›· ·o˘ÛÈ¿˙o˘Ó oÈ ˘‰·Ù¿ÓıڷΘ Ï·ÎÙfi˙Ë/Á·Ï·ÎÙfi˙Ë. ™˘ÓÂÒ˜ Ùo ÚoÛÊÂÚfiÌÂÓo Ïo‡ÛÈo ÛÙo˘˜ Úo·Ó·ÊÂÚfiÌÂÓo˘˜ ˘‰·Ù¿ÓıڷΘ Á¿Ï·, ·ÓÙÈηı›ÛÙ·Ù·È ÛÙo˘˜ ¿Û¯oÓÙ˜ ·fi ¿ÏÏo ÚoÂÚ¯fiÌÂÓo ·fi ÚˆÙ½ÓË ÛfiÁÈ·˜ Î·È Ùo oo›o ‰ÂÓ ÂÚȤ¯ÂÈ Á·Ï·ÎÙfi˙Ë/Ï·ÎÙfi˙Ë. Œ¯ÂÈ ·o‰Âȯı›, ·fi oÏÏÒÓ ÂÙÒÓ, fiÙÈ Ë ÚfiÛÏË„Ë ÚˆÙ½Ó˘ Â›Ó·È ·fi Ùo˘˜ ϤoÓ ÛËÌ·ÓÙÈÎo‡˜ ‰È·ÈÙËÙÈÎo‡˜ ·Ú¿ÁoÓÙ˜ o˘ ÂËÚ¿˙o˘Ó Ùo ÌÂÙ·‚oÏÈÛÌfi Ù˘ XoÏËÛÙÂÚfiÏ˘ (XoÏ). EȉÈÎfiÙÂÚ·, fiÛoÓ ·ÊoÚ¿ ÛÙo ›‰o˜ ÙˆÓ ÚˆÙÂ˚ÓÒÓ, Ë ¯oÚ‹ÁËÛË ÚˆÙ½Ó˘ Ê˘ÙÈ΋˜ Úo¤Ï¢Û˘ Û ۇÁÎÚÈÛË Ì ÂΛÓË Ù˘ ˙ˆÈ΋˜ Úo¤Ï¢Û˘ ¤¯ÂÈ ˆ˜ ·oÙ¤ÏÂÛÌ· ÙË Ì›ˆÛË ÙˆÓ ˘„ËÏÒÓ ÂȤ‰ˆÓ Ù˘ XoÏ. OÈ Ï¤oÓ ÁÓˆÛÙ¤˜ ÌÂϤÙ˜ ·ÊoÚo‡Ó ÛÙËÓ Î·˙½ÓË Î·È ÙË ÛfiÁÈ·. H ‰Ú¿ÛË Ù˘ ÙÂÏÂ˘Ù·›·˜ Â›Ó·È ÁÓˆÛÙfi fiÙÈ ¤¯ÂÈ ·ÍÈfiÏoÁo ˘o¯oÏËÛÙÂÚÈÓ·ÈÌÈÎfi ·oÙ¤ÏÂÛÌ· (4,5). H ›‰Ú·ÛË ·˘Ùo‡ Ùo˘ ›‰o˘˜ ‰È·ÙÚoÊ‹˜ ÛÙo˘˜ ·Ú¿ÁoÓÙ˜ Ù˘ ‹Íˆ˜ o˘ ÂÍ·ÚÙÒÓÙ·È ·fi ÙË ÏÈo‰È·Ï˘Ù‹ ‚ÈÙ·Ì›ÓË K ÂÓ‰¤¯ÂÙ·È Ó· Â›Ó·È ÛËÌ·ÓÙÈ΋. O Haines Î·È Û˘Ó. (6) ·Ó¤ÊÂÚ·Ó fiÙÈ oÈ BÚÂÙÙ·Óo› Ê˘ÙoÊ¿ÁoÈ Â›¯·Ó ¯·ÌËÏfiÙÂÚ· ›‰· fi¯È ÌfiÓoÓ Ùo˘ ·Ú¿ÁoÓÙ· ‹Íˆ˜ VII Û˘ÁÎÚÈÓfiÌÂÓoÈ Ì ÂΛÓo˘˜ o˘ ‰ÂÓ ‹Ù·Ó Ê˘ÙoÊ¿ÁoÈ, ·ÏÏ¿ Î·È Ù˘ ·ÓÙÈıÚoÌ‚›Ó˘ III (AT III) Î·È Ù˘ ÈÓˆ‰oÁoÓÔÏ˘ÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜. £ÂÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ·Ú·ÙËÚ‹ıËÎ·Ó Â›Û˘, fiÛoÓ ·ÊoÚ¿ ÛÙËÓ ÚfiÛÏË„Ë Ê˘ÙÈÎÒÓ ÈÓÒÓ Î·È oÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ oͤˆÓ Ì ÙËÓ AT III. ™Â ·ÓÙ›ıÂÛË Ì ٷ Â˘Ú‹Ì·Ù· ÙˆÓ Haines ηÈ
288
K. ™o‡ÏË Î·È Û˘Ó.
Û˘Ó. (6), oÈ Miller Î·È Û˘Ó. (7) ·¤‰ÂÈÍ·Ó Û ÌÈ· Û‡ÓÙoÌË ÌÂϤÙË Ùo˘˜ fiÙÈ Â¿Ó Ùo ηıËÌÂÚÈÓfi ‰È·ÈÙoÏfiÁÈo ÂÌÂÚȤ¯ÂÈ 80% Ï›o˜ ·˘Í¿ÓoÓÙ·È Ù· ›‰· Ùo˘ ·Ú¿ÁoÓÙ· ‹Íˆ˜ VII ÛÙo ·›Ì·, ÂÓÒ Ù· Ïo‡ÛÈ· Û ˘‰·Ù¿ÓıڷΘ ‰È·ÈÙoÏfiÁÈ· ¤¯o˘Ó ·oÙ¤ÏÂÛÌ· ÙËÓ Ì›ˆÛË ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜ VII, VIII Î·È X ·ÏÏ¿ ·˘Í¿Óo˘Ó ÙËÓ ÈÓˆ‰oÁÔÓÔÏ˘ÙÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· (8). ¶ÚoÛ¿ıÂÈ· Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ‹Ù·Ó Ó· ÂÎÙÈÌËıo‡Ó Ù· ›‰· ·Ú·Ì¤ÙÚˆÓ Ù˘ ·ÈÌfiÛÙ·Û˘ Û Á·Ï·ÎÙo˙·ÈÌÈÎo‡˜ ·ÛıÂÓ›˜ o˘ ‰È·ÙÚ¤ÊoÓÙ·È ·oÎÏÂÈÛÙÈο Ì "Á¿Ï·" ÛfiÁÈ·˜.
¶›Ó·Î·˜ 1. E›Â‰· ·Ú·ÁfiÓÙˆÓ ·ÈÌfiÛÙ·Û˘ Û ·ÛıÂÓ›˜ Ì Á·Ï·ÎÙo˙·ÈÌ›· Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ¶·Ú¿ÁÔÓÙ˜
∞ÛıÂÓ›˜ N=15
ª¿ÚÙ˘Ú˜ (N=38)
P
TT (%)
16,15 ±3,43
15,4 ±1,04
NS
PT (%)
11,98 ±0,66
11,43 ±0,45
NS
APTT (%)
30,42 ±7,86
27,96 ±3,15
(NS)
I (%)
248,3 ±63,6
278,1 ±12,4
NS
II (%)
85,7 ±9,1
94,8 ±10,2
0.012
VII (U/dl)
81,7 ±16,6
95,4 ±15,2
0.006
VIII (%)
106,0 ±28,7
109,2 25,8
(NS)
X (%)
81,3 ±16,2
98,4 ±12,8
0.01
IX (U/dl)
74,1 ±20,7
84,0 ±22,67
0.016
33,25 ±3,85
NS
ATIII (%)
36,82 ±2,01
Plg (%)
96,9 ±15,3
92,8 ± 20,5
NS
PC (%)
72,9 ±28,1
92,0 ±11,5
0.0001
NS: MË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÙÈÌ‹ OÈ ÙÈ̤˜ ÂÎÊÚ¿˙oÓÙ·È: ̤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·289
¶∞π¢π∞∆ƒπ∫∏ 2000;63:287-291
¶·Ú¿ÁÔÓÙ˜ ·ÈÌfiÛÙ·Û˘ ÛÙË Á·Ï·ÎÙÔ˙·ÈÌ›·
¶›Ó·Î·˜ 2. E›Â‰· ÏÈȉ›ˆÓ ÛÙo˘˜ ·ÛıÂÓ›˜ Ì Á·Ï·ÎÙo˙·ÈÌ›· Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ ÙˆÓ Ì·ÚÙ‡ÚˆÓ. §È›‰È· AÛıÂÓ›˜ M¿ÚÙ˘Ú˜ P (mg/dl) (N=12) (N=38) XoÏ
143,8 ±28,4
181,0 ±12,1
0,0001
TÚÈÁÏ
126,6 ±49,7
100,1 ±10,6
0,001
HDL
42,0 ±12,9
45,0 ±5,6
0,079 (NS)
LDL
80,8 ±27,1
118,0 ±6,7
0,0001
24,9 ±9,6
15,6 ±5,6
0,0001
Ao A1
130,6 ±27,7
101,1 ±21,3
0,0001
Ao B
50,5 ±13,0
71,3 ±4,1
0,0001
VLDL
NS: MË ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ÙÈÌ‹ OÈ ÙÈ̤˜ ÂÎÊÚ¿˙oÓÙ·È: ̤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË
YÏÈÎfi Î·È M¤ıÔ‰ÔÈ ¢ÂηoÎÙÒ (18) ·ÛıÂÓ›˜ Ì Á·Ï·ÎÙo˙·ÈÌ›·, ̤Û˘ ËÏÈΛ·˜ ‰È¿ÁÓˆÛ˘ 8,5±3,5 ËÌÂÚÒÓ, o˘ Ù¤ıËÎ·Ó Û ‰›·ÈÙ· ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙËÓ ‰È¿ÁÓˆÛ‹ Ùo˘˜, ·fi Ùo˘˜ oo›o˘˜ oÈ 15 ¤·Û¯·Ó ·fi ÙËÓ ÎÏ·ÛÈ΋ ÌoÚÊ‹ Ù˘ ÓfiÛo˘ Î·È oÈ ˘fiÏoÈoÈ 3 ·fi ·Ó¿ÚÎÂÈ· Ù˘ ÂÈÌÂÚ¿Û˘, Ì ̤ÛË ËÏÈΛ· 3,2+0,8 ÌËÓÒÓ, ¤Ï·‚·Ó ̤Úo˜ ÛÙË ÌÂϤÙË Ì·˜. TÚÈ¿ÓÙ· oÎÙÒ (38) ˘ÁÈ‹ ‚Ú¤ÊË ·ÚfiÌoÈ·˜ ËÏÈΛ·˜, Ù· oo›· ‰È·ÙÚ¤ÊoÓÙo Ì ÎoÓÈooÈË̤Óo Á¿Ï·, ·oÙ¤ÏÂÛ·Ó ÙËÓ oÌ¿‰· Ì·ÚÙ‡ÚˆÓ. OÈ ·ÛıÂÓ›˜ ÙÚ¤ÊoÓÙ·È Ì ÂȉÈÎfi "Á¿Ï·" ·fi ÛfiÁÈ· (Izomil), ÂχıÂÚo Á·Ï·ÎÙfi˙˘/Ï·ÎÙfi˙˘. To "Á¿Ï·" ·˘Ùfi ÂÚȤ¯ÂÈ 2,1g/100ml ÚˆÙ½ÓË, 6,9 gr/100 ml ˘‰·Ù¿ÓıڷΘ Î·È 2,69g/100ml Ï›o˜. OÈ Ì¿ÚÙ˘Ú˜ ‰È·ÙÚ¤ÊoÓÙ·Ó Ì Á¿Ï· ÎoÓÈooÈË̤Óo Ùo oo›o ÂÚÈ›¯Â 3,4 g/100ml ÚˆÙ½ÓË, 4,8g/100ml ˘‰·Ù¿ÓıڷΘ Î·È 4,7g/100ml Ï›o˜. H ‚ÈÙ·Ì›ÓË K ÂÌÂÚȤ¯ÂÙo Û ˘ÎÓfiÙËÙ· 10Ìg/100ml Î·È ÛÙ· ‰‡o Á¿Ï·Ù·. TfiÛo oÈ ·ÛıÂÓ›˜ fiÛo Î·È oÈ Ì¿ÚÙ˘Ú˜ ·Ú¤ÌÂÈÓ·Ó ÓËÛÙÈÎo› › 5 ÒÚ˜ ÚÈÓ ÙËÓ ·ÈÌoÏË„›· (5,0 ml) ÁÈ· ÙË Ì¤ÙÚËÛË ÙˆÓ Ë·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜ Î·È ÙˆÓ ÂȤ‰ˆÓ ÏÈȉ›ˆÓ ÛÙoÓ oÚfi Ùo˘˜.
·) ¶·Ú¿ÁoÓÙ˜ ‹Íˆ˜ O ¯ÚfiÓo˜ ÚoıÚoÌ‚›Ó˘ (PT), o ¯ÚfiÓo˜ ÂÓÂÚÁoo›ËÛ˘ ıÚoÌ‚oÏ·ÛÙ›Ó˘ (APTT), o ¯ÚfiÓo˜ ıÚoÌ‚›Ó˘ (TT), Ùo ÈÓˆ‰oÁfiÓo (I), oÈ ·Ú¿ÁoÓÙ˜ II, VII, VIII, IX, X, Î·È Ùo Ï·ÛÌÈÓoÁfiÓo (Plg) ÌÂÙÚ‹ıËÎ·Ó ÛÙo Ï¿ÛÌ· ÌÂÙ¿ ·fi ÚoÛı‹ÎË ÎÈÙÚÈÎo‡ Ó·ÙÚ›o˘, ¯ÚËÛÈÌooÈÒÓÙ·˜ ÂȉÈÎfi Ì˯¿ÓËÌ· (RA, Organon Teknika) Ì ·ÓÙȉڷÛÙ‹ÚÈ· Ù˘ AKZO. H ·ÓoÛo‰È¿¯˘ÛË (Berling Hoechst) Î·È Ë Ì¤ıo‰o˜ Elisa ¯ÚËÛÈÌooÈ‹ıËÎ·Ó ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ATIII (·ÓÙÈıÚoÌ‚›ÓË πππ) Î·È PC (ÚˆÙ½ÓË C). ‚) §ÈȉÈoÁÚ¿ÌÌ·Ù· ŸÏoÈ oÈ oÚo› Ê˘Ï¿¯ÙËÎ·Ó Û ‚·ıÈ¿ ηٿ„˘ÍË ¤ˆ˜ fiÙo˘ ÌÂÙÚËıo‡Ó Ì ÂȉÈÎfi Kit-test Î·È ·Ó·Ï˘Ù‹ BA-500. OÈ ÛÙ·ÙÈÛÙÈΤ˜ ·Ó·Ï‡ÛÂȘ o˘ ·ÊoÚo‡Û·Ó ÙfiÛo ÛÙ· ›‰· ÙˆÓ ÏÈȉ›ˆÓ fiÛo Î·È ÛÙo˘˜ ·Ú¿ÁoÓÙ˜ ‹Íˆ˜ ÌÂٷ͇ ÙˆÓ oÌ¿‰ˆÓ ¤ÁÈÓ·Ó Ì Ùo Student's ttest. TÈ̤˜ p<0,05 ıˆڋıËÎ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜. H ÁÚ·ÌÌÈ΋ Û˘Û¯¤ÙÈÛË ¯ÚËÛÈÌooÈ‹ıËΠÁÈ· ÙËÓ ·Ó‡ÚÂÛË Û˘Û¯ÂÙ›ÛÂˆÓ ÌÂٷ͇ ÙˆÓ ÏÈȉ›ˆÓ Î·È ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜ ÛÙo˘˜ ·ÛıÂÓ›˜ Ì·˜, Ë ÙÈÌ‹ r>±0,60 ıˆڋıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋. ∞ÔÙÂϤÛÌ·Ù· T· Ë·ÙÈο ¤Ó˙˘Ì· ¢ڤıËÛ·Ó ÛÂ Ê˘ÛÈoÏoÁÈο ›‰· ÙfiÛo ÛÙo˘˜ ·ÛıÂÓ›˜ fiÛo Î·È ÛÙo˘˜ Ì¿ÚÙ˘Ú˜. ¶·Ú¿ÁoÓÙ˜ ‹Íˆ˜: OÈ ·Ú¿ÁoÓÙ˜ ‹Íˆ˜ ·Úo˘ÛÈ¿˙oÓÙ·È ÛÙoÓ ¶›Ó·Î· 1. ¶·ÚfiÏo o˘ oÈ ·Ú¿ÁoÓÙ˜ ‹Û·Ó ̤۷ ÛÙ· Ê˘ÛÈoÏoÁÈο fiÚÈ·, oÈ ·Ú¿ÁoÓÙ˜ II, VII, IX, X Î·È PC ¢ڤıËÎ·Ó ÌÂȈ̤ÓoÈ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο Û˘ÁÎÚÈÓfiÌÂÓoÈ, Ì ÂΛÓo˘˜ ÙˆÓ Ì·ÚÙ‡ÚˆÓ. §È›‰È·: ™ÙoÓ ¶›Ó·Î· 2 ·Úo˘Û›·˙oÓÙ·È Ë Ì¤ÛË ÙÈÌ‹ Î·È Ë ÛÙ·ıÂÚ¿ ·fiÎÏÈÛË ÙˆÓ ÏÈȉ›ˆÓ ÛÙoÓ oÚfi ÙˆÓ ·ÛıÂÓÒÓ Ì·˜. OÈ ÙÈ̤˜ ÙˆÓ XoÏ, Ë LDL Î·È Ë AoB ‹Û·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚ˜ Û˘ÁÎÚÈÓfiÌÂÓ˜ Ì ÂΛӘ ÙˆÓ Ì·ÚÙ‡ÚˆÓ. AÓÙ›ıÂÙ·, Ù· ÙÚÈÁÏ˘ÎÂÚ›‰È· ÛÙo˘˜ ·ÛıÂÓ›˜ Ì·˜ ‹Û·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚ· ÂÓÒ ÛÙ· ›‰· Ù˘ HDL ‰ÂÓ ·Ú·ÙËÚ‹ıËΠ‰È·ÊoÚ¿ ÌÂٷ͇ ÙˆÓ ‰‡o oÌ¿‰ˆÓ. ™ÙoÓ ¶›Ó·Î· 3 ÂÌÊ·Ó›˙oÓÙ·È oÈ Û˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ÙˆÓ ·ÈÌoÛÙ·ÙÈÎÒÓ ·Ú·ÁfiÓÙˆÓ Î·È ÙˆÓ ÏÈȉ›ˆÓ. ™˘˙‹ÙËÛË ¶oÏϤ˜ ÂÚÁ·Û›Â˜ ¤¯o˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ÚfiÛÏË„Ë ÚˆÙÂ˚ÓÒÓ ÚoÂÚ¯oÌ¤ÓˆÓ ·fi ÛfiÁÈ· ¤¯ÂÈ Â˘ÂÚÁÂÙÈο ·oÙÂϤÛÌ·Ù· ˆ˜ Úo˜ ÙËÓ ÚfiÏË„Ë Ù˘ ·ÚÙËÚÈoÛÎÏ‹Ú˘ÓÛ˘ ÌÂÈÒÓoÓÙ·˜ ÙfiÛo Ù· ›‰· Ù˘
289
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·290
¶∞π¢π∞∆ƒπ∫∏ 2000;63:287-291
K. ™o‡ÏË Î·È Û˘Ó.
¶›Ó·Î·˜ 3. ™˘Û¯¤ÙÈÛË ÌÂٷ͇ ·Ú·ÁfiÓÙˆÓ ·ÈÌfiÛÙ·Û˘ Î·È ÏÈȉ›ˆÓ Û ·ÛıÂÓ›˜ Ì Á·Ï·ÎÙo˙·ÈÌ›·. ¶·Ú¿ÁoÓÙ˜ §È›‰È· XoÏ
TÚÈÁÏ
HDL
LDL
VLDL
Ao B
Ao A
II
+0,71
*
*
*
*
*
*
VII
+0,70
+0,81
*
+0,72
*
+0,76
*
IX
*
*
*
0,68
*
*
*
X
*
+0,80
*
*
+0,80
*
*
PC
+0,61
*
*
*
*
+0,61
*
XoÏ fiÛo Î·È Ù˘ LDL ηıfiÙÈ ÂÌÂÚȤ¯ÂÈ ÈÛoÊÏ·‚oÓoÂȉ‹ (genistein) (9,10). OÈ Á·Ï·ÎÙo˙·ÈÌÈÎo› ·ÛıÂÓ›˜ Ì·˜ ˘fi ‰›·ÈÙ· Ì ÛfiÁÈ· ›Û˘ ÂÌÊ¿ÓÈÛ·Ó ¯·ÌËϤ˜ XoÏ, LDL Î·È AoB ‰Â›¯ÓoÓÙ·˜ ÌÈ· ·ÓÙÈ-·ıËÚoÁÂÓÂÙÈ΋ ÂÈÎfiÓ· (9,10). ∂›Û˘, ÂÂȉ‹ Ë Á‡ÛË ÙˆÓ Úo˚fiÓÙˆÓ ÛfiÁÈ·˜ Â›Ó·È ·ÚÎÂÙ¿ ‰˘Û¿ÚÂÛÙË, Ë ÚoÛı‹ÎË ˙¿¯·Ú˘ ›¯Â ˆ˜ ·oÙ¤ÏÂÛÌ· ÙËÓ Â˘¯¿ÚÈÛÙË ÚfiÛÏË„‹ Ùo˘˜ ·ÏÏ¿ Î·È ÙËÓ ·‡ÍËÛË ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ÛÙoÓ oÚfi, o˘ ·Ú·ÙËÚ‹ıËÎÂ Î·È ÛÙo˘˜ ·ÛıÂÓ›˜ Ì·˜. ŸÌˆ˜, Ù· ·˘ÍË̤ӷ ›‰· ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ ›¯·Ó ›Û˘ Û·Ó ·oÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË ÙˆÓ VLDL ÛÙo˘˜ ·ÛıÂÓ›˜ Ì·˜ (11). OÈ ·Ú¿ÁoÓÙ˜ ‹Íˆ˜ II Î·È VII ¢ڤıËÛ·Ó ¯·ÌËÏo› ÛÙo˘˜ ·ÛıÂÓ›˜ Ì·˜ Û˘ÁÎÚÈÓfiÌÂÓoÈ Ì ÂΛÓo˘˜ ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ¶Èı·ÓfiÓ Ùo ‡ÚËÌ· ·˘Ùfi Ó· oÊ›ÏÂÙ·È ÛÙ· ¯·ÌËÏ¿ ›‰· Ù˘ XoÏ. E›Ó·È ¿ÏψÛÙ ÁÓˆÛÙfi, fiÙÈ Ù· ˘„ËÏ¿ ›‰· Ù˘ XoÏ Û˘Û¯ÂÙ›˙oÓÙ·È Ì ÛËÌ·ÓÙÈ΋ ·‡ÍËÛË Ùo˘ ·Ú¿ÁoÓÙ· VII Ù˘ ‹Íˆ˜ (11,12). O Úo·Ó·ÊÂÚfiÌÂÓo˜ ·Ú¿ÁoÓÙ·˜ ‹Íˆ˜ ·Ú·ÙËÚ‹ıËΠ·ÚÎÂÙ¿ ÌÂȈ̤Óo˜ Û oÌ¿‰Â˜ ÏËı˘ÛÌo‡ fiˆ˜ ·˘Ù‹ Ù˘ Ê˘Ï‹˜ Bantu (13) Î·È ÙˆÓ Ê˘ÙoÊ¿ÁˆÓ (12). ¶·Ú¿ÏÏËÏ·, Ë ˘‰·Ù·ÓıÚ·Îo‡¯o˜ ‰›·ÈÙ· o˘ ·ÎoÏo˘ıo‡Ó oÈ Á·Ï·ÎÙo˙·ÈÌÈÎo› ·ÛıÂÓ›˜ ı· ÌoÚo‡Û ÎÈ ·˘Ù‹, Ó· ÌÂÈÒÛÂÈ ÙoÓ ·Ú¿ÁoÓÙ· VII (10), fiˆ˜ ‚Ú¤ıËÎ·Ó Â›Û˘ ÌÂȈ̤ÓoÈ oÈ ·Ú¿ÁoÓÙ˜ II, VII Î·È PC Û oÌ¿‰Â˜ Ê˘ÙoÊ¿ÁˆÓ (8,12). AÎfiÌË, oÈ Úo·Ó·ÊÂÚfiÌÂÓoÈ ·Ú¿ÁoÓÙ˜ ‹Íˆ˜ ·Ú¿ÁoÓÙ·È ÛÙo ‹·Ú Î·È Ë Û‡ÓıÂÛ‹ Ùo˘˜ ÂÍ·ÚÙ¿Ù·È ·fi Ù· ›‰· Ù˘ ‚ÈÙ·Ì›Ó˘ K, ÌÈ·˜ ÏÈo‰È·Ï˘ÙÈ΋˜ ‚ÈÙ·Ì›Ó˘. ¶·ÚfiÏo o˘ Ë ‰›·ÈÙ· ÙˆÓ Ê˘ÙoÊ¿ÁˆÓ Â›Ó·È Ïo‡ÛÈ· Û ‚ÈÙ·Ì›ÓË K, ÂÓÙo‡ÙoȘ, Ë ÌÂȈ̤ÓË ÚfiÛÏË„Ë Ï›o˘˜ Ì Ùo Á¿Ï· (2,69 g/100ml Á·Ï·ÎÙo˙·ÈÌÈÎo› Î·È 4,7 g/100 ml Ì¿ÚÙ˘Ú˜) ·fi ÙÔ˘˜ Á·Ï·ÎÙo˙·ÈÌÈÎÔ‡˜ ı· ÌoÚo‡Û ӷ ÂËÚ¿ÛÂÈ ÙËÓ ·oÚÚfiÊËÛË Ù˘ ‚ÈÙ·Ì›Ó˘ K ÛÙo ¤ÓÙÂÚo, Ì ·oÙ¤ÏÂÛÌ· ÙËÓ ÌÂȈ̤ÓË ·ÍÈoo›ËÛ‹ Ù˘ ·fi ̤Úo˘˜ Ùo˘ ‹·Ùo˜ ÁÈ· ÙËÓ ·Ú·ÁˆÁ‹ ÙˆÓ ÂÍ·ÚÙˆÌ¤ÓˆÓ ·fi ·˘Ù‹Ó ·Ú·ÁfiÓÙˆÓ. A˘Ù‹ Ë ˘fiıÂÛË ˘oÛÙËÚ›˙ÂÙ·È Î·È ·fi ÙË ÛÙÂÓ‹ Û˘Û¯¤ÙÈÛË o˘ ¢ڤıË ÌÂٷ͇ ÙˆÓ
290
ÂÍ·ÚÙˆÌ¤ÓˆÓ ·fi ÙËÓ ‚ÈÙ·Ì›ÓË K ·Ú·ÁfiÓÙˆÓ ·ÈÌfiÛÙ·Û˘ (II, VII, IX, X, PC) Î·È ÙˆÓ ÏÈȉ›ˆÓ (XoÏ, TÚÈÁÏ, LDL Î·È AoB) o˘ ·Ú·ÙËÚ‹ıËΠÛÙo˘˜ Á·Ï·ÎÙo˙·ÈÌÈÎo‡˜ ·ÛıÂÓ›˜ Ì·˜ ˘fi ‰›·ÈÙ· (14,15). ™˘ÌÂÚ·ÛÌ·ÙÈο, oÈ Á·Ï·ÎÙo˙·ÈÌÈÎo› ·ÛıÂÓ›˜ ˘fi ‰›·ÈÙ· Ì ÛfiÁÈ· ÂÌÊ·Ó›˙o˘Ó ÌÂÙ·‚oϤ˜ ÛÙȘ Û˘ÁÎÂÓÙÚÒÛÂȘ ÙfiÛo ÙˆÓ ÏÈȉ›ˆÓ fiÛo Î·È ÙˆÓ ·Ú·ÁfiÓÙˆÓ ‹Íˆ˜, ·ÚfiÌoȘ Ì ÙȘ ·Ú·ÙËÚo‡ÌÂÓ˜ ÛÙo˘˜ Ê˘ÙoÊ¿Áo˘˜. BÈ‚ÏÈÔÁÚ·Ê›· 1. Segal S. Disorders of galactose metabolism. In: Scriver CR, Beadet AI, Sly W, eds. The metabolic and molecular basis of inherited disease: London: MTP, 1995:967-990. 2. Schweitzer S, Shin NS, Jacobs C, Broedehl J. Longterm outcome in 134 patients with galactosemia. Eur J Pediatr 1993;152:36-43. 3. Francis D. Galactosemia. In: Diets for sick children. London: Blackwell Scientific Publications, 1986:386-396. 4. Karasawa T, Tanaka M, Uemura T, Osanai T. Antiatherogenicity of soybean protein. Ann NY Acad Sci 1992;676:202-214. 5. Dwyer JT. Health aspects of vegetarian diet. Am J Clin Nutr 1988;48:712-738. 6. Haines AP, Chakrabarti R, Fisher D, Meade TW, North WRS. Haemostatic and other variables in vegetarians and non vegetarians. Thromb Res 1980;19:139-148. 7. Miller FJ, Martin JC, Webster J. Association between dietary fat intake and plasma factor VII coagulant activity. Atherosclerosis 1986;60:269-277. 8. Masarei J, Rouse J, Lynch W, Robertson K. Effects of a lacto-ovo vegetarian diet on serum concentrations of cholesterol, triglyceride, HDL, apoprotein B, and Lp (a). Am J Clin Nutr 1984;40:468-479. 9. Schulpis KH, Papakonstantinou EP, Michelakakis H, Shin Y. The antiatherogenic profile of galactosemic children on soybean diet. J Inher Metab Dis 1996;19:91-92. 10. Fehily AM, Millbank JE, Yarnell JWG, Hayes TM. Dietary determinants of lipoproteins, total cholesterol, viscosity, fibrinogen and blood pressure. Am J Clin Nutr 1982;36:890-918. 11. Durrington D. Triglyceride levels in children. In: Hyperlipidaemia Diagnosis and treatment. London: Wright Ed, 1989:42-43.
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·291
¶∞π¢π∞∆ƒπ∫∏ 2000;63:287-291
12. Pan Wen Harn, Chia Jung Chin, Chin-Tou Shew. Hemostatic factors and blood lipids in young Buddhist vegetarians and omnivores. Am J Clin Nutr 1993;58: 354-359. 13. Merskey C, Nossel HL. Blood coagulation after the ingestion of saturated and unsaturated fats. Lancet 1997;i:806-810.
¶·Ú¿ÁÔÓÙ˜ ·ÈÌfiÛÙ·Û˘ ÛÙË Á·Ï·ÎÙÔ˙·ÈÌ›·
14. Meade TW, North WRS, Chakrabarti R. Haemostatic function and cardiovascular death, early results of a prospective study. Lancet 1980;17:1050-1053. 15. Nahouny GN. Dietary fiber, lipid metabolism and atherosclerosis. Feb Proc 1982;41:2801-2806.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 24-08-1999 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 14-04-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ÏÂÔ¿ÙÚ· ™Ô‡ÏË πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, °Ô˘‰›, ∞ı‹Ó·
291
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·292
¶∞π¢π∞∆ƒπ∫∏ 2000;63:292-301
¶ÚˆÙfiÎÔÏÏÔ ¤ÁηÈÚ˘ ÂÏÂÁ¯fiÌÂÓ˘ ÚÈÓÔÁ·ÛÙÚÈ΋˜ Û›ÙÈÛ˘ Û ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ· ·È‰È¿ °ÂÒÚÁÈÔ˜ MÚÈ·ÛÔ‡Ï˘, NÈÎfiÏ·Ô˜ Z¿‚Ú·˜, M·Ú›· N·ÚÏ›ÔÁÏÔ˘, AÓ·ÛÙ¿ÛÈÔ˜ X·Ù˙‹˜ ● ¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ηٷÁÚ¿„ÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ÂÊ·ÚÌÔÁ‹˜ ÂÓfi˜ ÚˆÙÔÎfiÏÏÔ˘ ¤ÁηÈÚ˘ ÚÈÓÔÁ·ÛÙÚÈ΋˜ Û›ÙÈÛ˘ (E°™) ÛÙËÓ ÔÍ›· Ê¿ÛË ÎÚ›ÛÈÌ˘ ÓfiÛÔ˘ Û ·È‰È¿ Ô˘ ÂÈÛ¿ÁÔÓÙ·È Û ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ (ME£). ™ÙË ÌÂϤÙË Û˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó 36 ·ÛıÂÓ›˜, ËÏÈΛ·˜ 2 ¤ˆ˜ 204 ÌËÓÒÓ Ì ÛÔ‚·Ú¤˜ ·ı‹ÛÂȘ, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ÛË„·ÈÌ›·˜, ·Ó·Ó¢ÛÙÈ΋˜ ·Ó¿ÚÎÂÈ·˜, ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈÎÒÓ Î·ÎÒÛÂˆÓ Î·È ÂÁη˘Ì¿ÙˆÓ. H ËÌÂÚ‹ÛÈ· ıÂÚÌȉÈ΋ ÚfiÛÏË„Ë (¶) Û˘Û¯ÂÙ›ÛıËΠ̠ÙÔÓ ÚÔ‚ÏÂfiÌÂÓÔ ‚·ÛÈÎfi ÌÂÙ·‚ÔÏÈÛÌfi (¶BM), ÙËÓ ÚÔ‚ÏÂfiÌÂÓË Î·Ù·Ó¿ÏˆÛË ÂÓ¤ÚÁÂÈ·˜ (¶KE) Î·È ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘, Û‡Ìʈӷ Ì ٷ Û˘ÛÙ‹Ì·Ù· ·ÍÈÔÏfiÁËÛ˘ PRISM Î·È TISS. H £¶ ÚÔÛ¤ÁÁÈÛ ÛËÌ·ÓÙÈο ÙÔÓ ¶BM ÙÔ 2Ô 24-ˆÚÔ ÓÔÛËÏ›·˜ (46,4±3 vs 45±1,4 kcal/kg/day) Î·È ÙËÓ ¶KE ÙÔ 5Ô 24-ˆÚÔ (71±4,7 vs 74,8±12,7 kcal/kg/day). TÔ Û‡ÓÔÏÔ ÙˆÓ ˆÚÒÓ ¯ˆÚ›˜ Û›ÙÈÛË (1,4% ÙÔ˘ Û˘ÓfiÏÔ˘ ˆÚÒÓ Û›ÙÈÛ˘) Û¯ÂÙ›ÛıËΠÛËÌ·ÓÙÈο Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ (p<0,001) Î·È ‰ÂÓ Û¯ÂÙÈ˙fiÙ·Ó Ì ‰È·Ù·Ú·Á̤ÓË ·ÓÔ¯‹ Ù˘ Û›ÙÈÛ˘ ·ÏÏ¿ Ì ·ÓÂÍ¿ÚÙËÙÔ ·Ú¿ÁÔÓÙ· (ÚÔÛ¿ıÂÈ· ·ÔۈϋӈÛ˘). ™Â ÁÚ·ÌÌÈ΋ ·Ó¿Ï˘ÛË ÔÏÏ·Ï‹˜ ·ÏÈÓ‰ÚfiÌËÛ˘, ·ÚÓËÙÈο ÛÙË ÂÊ·ÚÌÔÁ‹ Ù˘ E°™ Û˘Ó¤‚·Ï·Ó ·ÓÂÍ¿ÚÙËÙ· Ë Î·Î‹ ÙÂÏÈ΋ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘ (p<0,0001) Î·È ˘„ËÏ‹ ‚·ıÌÔÏÔÁ›· TISS. Y„ËÏ¿ Ì˘Ôηډȷο ÎÏ¿ÛÌ·Ù· (EF 66% vs 32%, p<0,0001 ‹ SF 35% vs 19%, p=0,001) ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙˆÓ ·ÛıÂÓÒÓ Û¯ÂÙ›ÛıËÎ·Ó Ì ÂÈÙ˘¯›· Ù˘ E°™. MfiÓÔ ¤Ó· 5,6% ÙˆÓ ·ÛıÂÓÒÓ ·ÚÔ˘Û›·Û ÓÔÛÔÎÔÌÂȷ΋ Ó¢ÌÔÓ›·, ‰È¿ÚÚÔȘ ‹ ¯ÚÂÈ¿ÛıËΠ·ÁˆÁ‹ Ì ÛÈÛ·Ú›‰Ë ÏfiÁˆ ÌË ÚÔÒıËÛ˘ ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘. H ıÓËÛÈÌfiÙËÙ· ‹Ù·Ó 5,6%. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ¤ÁηÈÚË ÂÓÙÂÚÈ΋ Û›ÙÈÛË ÌÂ Î¿Ï˘„Ë ÙˆÓ ‚·ÛÈÎÒÓ ÌÂÙ·‚ÔÏÈÎÒÓ ·Ó·ÁÎÒÓ Ì ÂȉÈ΋ Ï‹ÚË ˘ÁÚ‹ ÙÚÔÊ‹ Â›Ó·È ÂÊÈÎÙ‹, ·ÛÊ·Ï‹˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÛÙËÓ ¿ÌÂÛË ÌÂÙ·ÎÚÈÙÈ΋ (post-stress) ηٿÛÙ·ÛË Û ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙ· ·È‰È¿ Ô˘ ÓÔÛËχÔÓÙ·È Û ME£. H ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ E°™ Ì ÙË Ì˘Ôηډȷ΋ Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÂÚÈÁÚ¿ÊÂÙ·È ÁÈ· ÚÒÙË ÊÔÚ¿. ¶·È‰È·ÙÚÈ΋ 2000;63:292-301. §¤ÍÂȘ ÎÏÂȉȿ: ¤ÁηÈÚË ÂÓÙÂÚÈ΋ Û›ÙÈÛË, ÚÈÓÔÁ·ÛÙÚÈ΋ Û›ÙÈÛË, ηٷӿψÛË ÂÓ¤ÚÁÂÈ·˜, ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜, Á·ÛÙÚÈÎfi ˘fiÏÂÈÌÌ·, ÎÚ›ÛÈÌË ÓfiÛÔ˜. G. Briassoulis, N. Zavras, M. Narlioglou, T. Hatzis. Optimized enteral feeding in critically ill children; a prospective study in a paediatric intensive care unit. Paediatriki 2000;63:292-301. ● Abstract: The aim of this study was to investigate the feasibility, adequacy and efficacy of early intragastric feeding (EGF) in critically ill children. In the study 36 critically ill children received EGF through a naso-gastric tube from day 1 (energy intake equal to 1/2, 1, 5/4, 6/4 and 6/4 of the predicted basal metabolic rate (PBMR) on days 1 to 5, respectively). Severity of illness was assessed by the PRISM Score, the TISS and indices of organ failure. Predicted energy expenditure (PEE), PBMR, and caloric intake (CI) were calculated using recommended formulae. EF and SF were measured by echocardiography on day 1. The early success rate was 94.4% and predicted late enteral feeding success accurately (p=0.005). CI approached PBMR on the 2nd day (46.4±3 vs 45±1.4 kcal/kg/day) and PEE on the 5th day (71±4.7 vs 74.8±12.7 kcal/kg/day). Non-feeding hours (1.4% of the total feeding hours) correlated to the PRISM (p<0.001), while transient withholding EGF was not primarily due to feeding intolerance (extubation). Multivariate stepwise regression analysis showed that poor outcome and high TISS correlated with failure of EGF (p<0.0001). Patients who succeeded EGF had significantly higher EF (66% vs 32%, p<0.0001) or SF (35% vs 19%, p=0.001) than those who failed. Most patients tolerated EGF well; only 5.6%
MÔÓ¿‰· EÓÙ·ÙÈ΋˜ £Âڷ›·˜, NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ "AÁ›· ™ÔÊ›·", Aı‹Ó·
292
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·293
¶∞π¢π∞∆ƒπ∫∏ 2000;63:292-301
EÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Û ·È‰È¿ Û ME£
developed nosocomial pneumonia or diarrhoea, and 8.3% needed treatment with cisapride because of delay gastric emptying. The mortality rate (5.6%) was different in the final success and failure groups (p<0.002) and was lower than predicted by the admission severity scores (12±0.03%). In conclusion, this study showed that escalated increases of CI during the acute phase of a critical illness are very well tolerated and are not clinically detrimental. Key words: early enteral feeding, nasogastric feeding, energy expenditure, residual, critical illness.
EÈÛ·ÁˆÁ‹ H ·ÔÙ˘¯›· ÛÙËÓ ¿ÌÂÛË ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜ Û ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ· ·È‰È¿ Ô‰ËÁ› Û˘¯Ó¿ ÛÙËÓ ¯ÔÚ‹ÁËÛË O¶¢ Ì ·ÔÙ¤ÏÂÛÌ· ÙÔÓ Î›Ó‰˘ÓÔ Ù˘ ·˘ÍË̤Ó˘ ÓÔÛËÚfiÙËÙ·˜, ıÓËÛÈÌfiÙËÙ·˜, ÙË ÌË ÈÛfiÚÚÔË Û›ÙÈÛË Î·È ·ÎfiÌË ÙÔ ·˘ÍË̤ÓÔ ÎfiÛÙÔ˜ (1). §fiÁˆ Ù˘ Û˘¯Ó¿ ÂËÚ·Ṳ̂Ó˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙÔ˘ ÛÙÔÌ¿¯Ô˘, ÛÙËÓ ÚÔÛ¿ıÂÈ· ÂÚÈÔÚÈÛÌÔ‡ Ù˘ O¶¢, ÙÂÏÂ˘Ù·›· Û ÔÏϤ˜ ME£ ÂÊ·ÚÌfi˙ÂÙ·È Ë ‰È·˘ÏˆÚÈ΋ ‹ ÓËÛÙȉÈ΋ ̤ıÔ‰Ô˜ Û›ÙÈÛ˘. ŒÙÛÈ ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜ Ô˘ ·ÊÔÚÔ‡Ó ÛÙËÓ ¤ÁηÈÚË ¤Ó·ÚÍË Ù˘ ÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜ Û ÂÓ‹ÏÈΘ ·Ó·Ê¤ÚÔÓÙ·È ÛÙË ¯Ú‹ÛË Á·ÛÙÚÔÛÙÔÌ›·˜ ‹ ÓËÛÙȉÔÛÙÔÌ›·˜ (2). Ÿˆ˜ fï˜, Î·È Ë ÂÊ·ÚÌÔÁ‹ Ù˘ O¶¢ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÂËÚ·Ṳ̂ÓË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ ÊÚ·ÁÌÔ‡, ¤ÙÛÈ Î·È Ë ÓËÛÙȉÈ΋ Û›ÙÈÛË Û˘Ó‰¤ÂÙ·È Ì ÙË ÌË Ê˘ÛÈÔÏÔÁÈ΋ Ú·ÎÙÈ΋ Ù˘ ·Ú¿Î·Ì„˘ ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ‚ÏÂÓÔÁfiÓÔ˘, ÙÔ˘ Ù˘ ‰È¤ÁÂÚÛ˘ ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÔÚÌÔÓÒÓ Î·È Ù˘ ÔÛ̈ڇıÌÈÛ˘ Ô˘ ÚÔÛʤÚÂÈ. BÈÔÏÔÁÈΤ˜ ·ÏÏËÏÂȉڿÛÂȘ, ›Û˘ ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ¿Ô„Ë Ù˘ ÂÈÏÔÁ‹˜ Ù˘ ‰È·Á·ÛÙÚÈ΋˜ Ô‰Ô‡ Û›ÙÈÛ˘ ÙˆÓ ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙˆÓ ·È‰ÈÒÓ. E›Ó·È ÁÓˆÛÙfi fiÙÈ ÔÈ Á·ÛÙÚÈΤ˜ ÂÎÎÚ›ÛÂȘ, Ô˘ ·ÔÙÂÏÔ‡Ó ÙÔÓ Î˘ÚÈfiÙÂÚÔ ·ÓÙÈ‚·ÎÙËÚȉȷÎfi Ì˯·ÓÈÛÌfi ÙÔ˘ ÂÓÙ¤ÚÔ˘, ÌÂÈÒÓÔÓÙ·È fiÙ·Ó Ë ÙÚÔÊ‹ ·ÂÏ¢ıÂÚÒÓÂÙ·È ÛÙÔ ‰ˆ‰Âη‰¿ÎÙ˘ÏÔ (3). EÈÚfiÛıÂÙ·, Ë Û›ÙÈÛË Ì¤Ûˆ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ηıÂÙ‹Ú· Â›Ó·È Â‡ÎÔÏË, ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ÂȉÈ΋ Ù¯ÓÈ΋ ÁÈ· ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ ηıÂÙ‹Ú· Î·È Û˘ÁÎÚÈÙÈο, ¤¯ÂÈ ÙÔ ¯·ÌËÏfiÙÂÚÔ ÎfiÛÙÔ˜. H ¤ÁηÈÚË ÂÓÙÂÚÈ΋ Û›ÙÈÛË ·Ô‰Â›¯ıËΠ¢ÂÚÁÂÙÈ΋ Û ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜ Ì ÂÁη‡Ì·Ù· (4), ‹ ÌÂÙÂÁ¯ÂÈÚËÙÈο (5). EÓÙÔ‡ÙÔȘ, Ë ·ÛÊ¿ÏÂÈ· Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ¤ÓÔ˜ ¤ÁηÈÚÔ˘ ÂÈıÂÙÈÎÔ‡ Û¯‹Ì·ÙÔ˜ ÚÈÓÔÁ·ÛÙÚÈ΋˜ Û›ÙÈÛ˘ ‰ÂÓ ¤¯ÂÈ ÌÂÏÂÙËı› Û ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ· ·È‰È¿ (¤Ú¢ӷ ÛÙÔ MEDLINE). ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÍÂÙ¿ÛË ÙËÓ ˘fiıÂÛË fiÙÈ Ë E°™ ηٿ ÙË ‰¿ÚÎÂÈ· ÛÔ‚·Ú‹˜ ¿ıËÛ˘ Â›Ó·È ÂÊÈÎÙ‹ Î·È ·ÛÊ·Ï‹˜ Û ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙ· ·È‰È¿. YÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ AÛıÂÓ›˜ ™ÙË ÌÂϤÙË ÂÚÈÂÏ‹ÊıËÛ·Ó 36 ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙ· ·È‰È¿ Ô˘ ˘ÔÛÙËÚ›˙ÔÓÙ·Ó Ì Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi. °È· Ó· ÂÚÈÏËÊıÔ‡Ó ÛÙË ÌÂϤÙË, ÔÈ ·ÛıÂÓ›˜
™˘ÓÙÔÌÔÁڷʛ˜ O¶¢
OÏÈ΋ ·ÚÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹
ME£
MÔÓ¿‰· EÓÙ·ÙÈ΋˜ £Âڷ›·˜
¶BM
¶ÚÔ‚ÏÂfiÌÂÓÔ˜ ‚·ÛÈÎfi˜ ÌÂÙ·‚ÔÏÈÛÌfi˜
E°™
ŒÁηÈÚË ÚÈÓÔÁ·ÛÙÚÈ΋ Û›ÙÈÛË
SIRS
™‡Ó‰ÚÔÌÔ Û˘ÛÙËÌ·ÙÈ΋˜ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ·¿ÓÙËÛ˘
PRISM
Pediatric Risk of Mortality
TISS
Therapeutic Intervention Scoring System
MOSF
¶ÔÏ˘ÔÚÁ·ÓÈ΋ ·Ó¿ÚÎÂÈ·
¶KE
¶ÚÔ‚ÏÂfiÌÂÓË Î·Ù·Ó¿ÏˆÛË ÂÓ¤ÚÁÂÈ·˜
£¶
£ÂÚÌȉÈ΋ ÚfiÛÏË„Ë
™HA
™˘ÓÈÛÙÒÌÂÓ˜ ËÌÂÚ‹ÛȘ ·Ó¿ÁΘ
A£¶
AÓ·ÌÂÓfiÌÂÓË ıÂÚÌȉÈ΋ ÚfiÛÏË„Ë
EF
KÏ¿ÛÌ· ÂÍÒıËÛ˘
SF
KÏ¿ÛÌ· ‚Ú¿¯˘ÓÛ˘
¤Ú ӷ ÏËÚÔ‡Ó Ù· ·ÎfiÏÔ˘ı· ÎÚÈÙ‹ÚÈ·: ·) ·Ó·ÌÂÓfiÌÂÓË ‰È¿ÚÎÂÈ· ·Ú·ÌÔÓ‹˜ ÛÙË ME£>5 Ë̤Ú˜, ‚) ·Ó·ÌÂÓfiÌÂÓË ‰È¿ÚÎÂÈ· Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ >3 Ë̤Ú˜, Á) ·Ô˘Û›· ÓÂÊÚÈ΋˜ ‹ Ë·ÙÈ΋˜ ÓfiÛÔ˘, ‰) ÈÛÙÔÚÈÎfi ÂχıÂÚÔ ¯ÚfiÓÈ·˜ Á·ÛÙÚÂÓÙÂÚÈ΋˜ ÓfiÛÔ˘, Â) ¤Ó·ÚÍË ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ ÙȘ ÚÒÙ˜ 12 ÒÚ˜ ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹. ¶ÚˆÙfiÎÔÏÏÔ Û›ÙÈÛ˘ ¶Ï‹Ú˘ ˘ÁÚ‹ ÙÚÔÊ‹ (Nutrison Pediatric ÁÈ· ·È‰È¿ οو ÙˆÓ 10 ÂÙÒÓ, Nutrison Standard ÁÈ· ·È‰È¿ ¿Óˆ ÙˆÓ 10 ÂÙÒÓ) ¯ÔÚËÁ›ÙÔ Ì¤Ûˆ ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ۈϋӷ ̤۷ ÛÙȘ 12 ÚÒÙ˜ ÒÚ˜ ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙË ME£. TÔ ˆÚÈ·›Ô ÔÛfi ˘ÔÏÔÁÔ˙fiÙ·Ó Û‡Ìʈӷ Ì ÙÔ ÚˆÙfiÎÔÏÏÔ, Ì ÛÙfi¯Ô Ó· Êı¿ÛÂÈ ÙÔÓ ¶BM ÛÙÔ 2Ô 24ˆÚÔ Ù˘ ÓÔÛËÏ›·˜ Î·È Ó· ÙÔÓ ˘Âڂ› ηٿ 50% ÙȘ ÂfiÌÂÓ˜ Ë̤Ú˜, Î·È ÂÓÒ Ô ·ÛıÂÓ‹˜ ·Ú¤ÌÂÓ Û ηٿÛÙ·ÛË stress (ÚfiÛÏË„Ë ÂÓ¤ÚÁÂÈ·˜ ›ÛË Ì ÙÔ 1/2, 1, 5/4, 6/4 Î·È 6/4 ÙÔ˘ ¶BM ‰È·‰Ô¯Èο ÙȘ Ë̤Ú˜ 1-5). K·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ E°™, ÔÈ ·ÛıÂÓ›˜ Ì ÚÔ‚Ï‹Ì·Ù· ÛÙËÓ ÚÔÒıËÛË Ù˘ ‰È·ÙÚÔÊ‹˜ ÂÎÙÈÌÒÓÙ·Ó ÁÈ· ÙÔ Â›Â‰Ô Ù˘ ηٷÛÙÔÏ‹˜ Î·È Ù˘ ·Ú¿Ï˘Û˘, Î·È ·Ó ˘‹Ú¯Â Úfi‚ÏËÌ·, ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·Ó Ì ¯ÔÚ‹ÁËÛË ÛÈÛ·Ú›‰Ë˜ (2 mg/kg/8ˆÚÔ) ÁÈ· 48 ÒÚ˜.
293
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·294
¶∞π¢π∞∆ƒπ∫∏ 2000;63:292-301
°. MÚÈ·ÛÔ‡Ï˘ Î·È Û˘Ó.
™˘ÏÏÔÁ‹ ‰Â‰ÔÌ¤ÓˆÓ OÈ ·ÛıÂÓ›˜ Ù·ÍÈÓÔÌÔ‡ÓÙ·Ó a priori ÛÙȘ ·ÎfiÏÔ˘ı˜ ‰È·ÁÓˆÛÙÈΤ˜ ηÙËÁÔڛ˜: ÛË„·ÈÌ›· / ÌËÓÈÁÁ›Ùȉ·, ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË, ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ·, Ó¢ÚÔÌ˘˚΋ ¿ıËÛË Î·È ÂÁη‡Ì·Ù·. ™Ë„·ÈÌ›·, ÛËÙÈ΋ ηٷÏËÍ›· Î·È SIRS ÔÚ›ÛıËÎ·Ó Ì ‚¿ÛË Ù· ÎÚÈÙ‹ÚÈ· ÔÌÔʈӛ·˜ Ù˘ AÌÂÚÈοÓÈ΢ EÙ·ÈÚ›·˜ £ˆÚ·ÎÔ¯ÂÈÚÔ˘ÚÁÒÓ Î·È Ù˘ EÙ·ÈÚ›·˜ EÓÙ·ÙÈ΋˜ £Âڷ›·˜ (6). H ÂÎÙ›ÌËÛË Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ Ù˘ ¿ıËÛ˘ ÁÈÓfiÙ·Ó Ì ‚¿ÛË ÙÔ PRISM score (7), ÙÔ TISS ÙÚÔÔÔÈË̤ÓÔ ÁÈ· Ù· ·È‰È¿ (8), Î·È ÙÔ˘˜ ‰Â›ÎÙ˜ ÔÚÁ·ÓÈ΋˜ ·Ó¿ÚÎÂÈ·˜. H MOSF ÔÚ›ÛıËΠ̠ٷ ÎÚÈÙ‹ÚÈ· ÙˆÓ Wilkinson Î·È Û˘Ó (9). O ¶BM ˘ÔÏÔÁÈ˙fiÙ·Ó Ì ‚¿ÛË ÙȘ ÂÍÈÛÒÛÂȘ ÙˆÓ Schofield (10) Î·È Harris-Benedict (11). AÎÔÏÔ‡ıˆ˜, ÔÏÏ·Ï·ÛÈ·˙fiÙ·Ó Ì ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‰ÈfiÚıˆÛ˘ fiˆ˜ ÚÔÙ¿ıËÎ·Ó ·fi ÙÔÓ Seashore (12) ÁÈ· Ó· ÂÎÙÈÌËı› Ë ¶KE. H £¶ ˘ÔÏÔÁÈ˙fiÙ·Ó Î·ıËÌÂÚÈÓ¿ ·fi ÙȘ οÚÙ˜ ÓÔÛËÏ›·˜ ÙˆÓ ·ÛıÂÓÒÓ. OÈ ™HA ˘ÔÏÔÁ›˙ÔÓÙ·Ó ·fi ÙÔ˘˜ ›Ó·Î˜ ÙÔ˘ ÂıÓÈÎÔ‡ Û˘Ì‚Ô˘Ï›Ô˘ ¤Ú¢ӷ˜ Û ı¤Ì·Ù· ÙÚÔÊ›ÌˆÓ Î·È Û›ÙÈÛ˘ ÙˆÓ H¶A (13). T· ÎÏ¿ÛÌ·Ù· Ì˘Ôηډȷ΋˜ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ SF Î·È EF ˘ÔÏÔÁ›˙ÔÓÙ·Ó Ì ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډȿ˜ ÛÙË ME£ ·ÓÂÈÏËÌ̤ӷ ηٿ ÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ÎÚ›ÛÈÌ˘ ÓfiÛÔ˘. TÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÁÈÓfiÙ·Ó ‰›Ï· ÛÙËÓ ÎÏ›ÓË ÙÔ˘ ·ÛıÂÓÔ‡˜ Ì ÙÔ Ultramark 8 Ultrasound System, Advanced Technology Laboratory, Squibb, Washington, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ˯ԂÔÏ›˜ 3 Î·È 5 MHz, Î·È ÔÈ Î·Ù·Áڷʛۘ ÙÈ̤˜ ÙÔ˘ ÚÒÙÔ˘ 24ˆÚÔ˘ ÂÚÈÂÏ‹ÊıËÛ·Ó ÛÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË Ù˘ ÌÂϤÙ˘. H ÔÛfiÙËÙ· ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ˘ÔÏ›ÌÌ·ÙÔ˜, ÔÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Á·ÛÙÚÈÎÔ‡ ˘ÁÚÔ‡, Ë Û˘¯ÓfiÙËÙ· Ù˘ ÓÔÛÔÎÔÌÂȷ΋˜ Ó¢ÌÔÓ›·˜ Î·È ÔÈ ÂÈÏÔΤ˜ ·fi ÙÔ Á·ÛÙÚÂÓÙÂÚÈÎfi (¤ÌÂÙÔÈ, ‰È¿ÚÚÔȘ) ÛËÌÂÈÒÓÔÓÙ·Ó Î·ı' fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂϤÙ˘. EÈÙ˘¯‹˜ ıˆڋıËÎÂ Ë Û›ÙÈÛË Ô˘ ÔÏÔÎÏËÚÒıËΠۇÌʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘ ¤ÛÙˆ Ì ÌÈÎÚ¤˜ ·ÚÔ‰ÈΤ˜ ·ÔÎÏ›ÛÂȘ ÙˆÓ Î·Ï˘ÙfiÌÂÓˆÓ ¤Ó·ÓÙÈ ÙˆÓ Û˘ÓÙ·ÁÔÁÚ·ÊÔ‡ÌÂÓˆÓ ıÂÚÌ›‰ˆÓ. AÔÙ˘¯›· Ù˘ Û›ÙÈÛ˘ ıˆڋıËÎÂ Ë ‰È·ÎÔ‹ ÂÊ·ÚÌÔÁ‹˜
ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘ Î·È Ë ÁÈ· ÔÔÈÔ‰‹ÔÙ ÏfiÁÔ ÌË Û˘ÓÙ·ÁÔÁÚ¿ÊËÛË ÙˆÓ ˘ÔÏÔÁÈÛıÂÈÛÒÓ ıÂÚÌ›‰ˆÓ ‚¿ÛÂÈ ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘. E›Û˘, Ô ÙÚfiÔ˜ Û›ÙÈÛ˘ Î·È Ë £¶ ηٿ ÙËÓ ¤ÍÔ‰Ô Î·Ù·ÁÚ¿ÊÔÓÙ·Ó Î·È Û˘Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙȘ ·ÓÙ›ÛÙÔȯ˜ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË T· Ê˘ÛÈÔÏÔÁÈÎÒ˜ ηٷÓÂÌË̤ӷ ‰Â‰Ô̤ӷ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Û·Ó Ì¤ÛË ÙÈÌ‹±sem, ÂÓÒ Ù· ÌË Ê˘ÛÈÔÏÔÁÈÎÒ˜ ηٷÓÂÌË̤ӷ ‰Â‰Ô̤ӷ ‰›ÓÔÓÙ·È Û·Ó ‰È¿ÌÂÛË ÙÈÌ‹ Î·È Â‡ÚÔ˜ ÙÈÌÒÓ. H ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÙÔ two-tailed t-test ÁÈ· Ù· Ê˘ÛÈÔÏÔÁÈÎÒ˜ ηٷÓÂÌË̤ӷ ÌÂÙ¿ ·fi ‰ÈfiÚıˆÛË Î·Ù¿ Levene ÁÈ· ÙËÓ ÈÛfiÙËÙ· ÙˆÓ ·ÓÙÈı¤ÙˆÓ ‹ Ì ÙË Mann-Whitney U Wilcoxon ηٿٷÍË sum W test ÁÈ· Ù· ÌË Ê˘ÛÈÔÏÔÁÈο ηٷÓÂÌË̤ӷ ‰Â‰Ô̤ӷ. TÈ̤˜ Èı·ÓfiÙËÙ·˜ <0,05 Ì ٷ two-tailed tests ıˆڋıËÎ·Ó ÛËÌ·ÓÙÈΤ˜. ŸÙ·Ó ˘ÔÏÔÁÈ˙fiÙ·Ó Ë ÁÚ·ÌÌÈ΋ Û˘Û¯¤ÙÈÛË ÙfiÙ ¯ÚËÛÈÌÔÔÈ›ÙÔ Ë Î·Ù¿ Pearson ·Ó¿Ï˘ÛË. H ‰ÔÎÈÌ·Û›· ηٿ Fisher ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ‰Â‰Ô̤ӈÓ. H ÔÏ˘·Ú·ÁÔÓÙȷ΋ ·Ó¿Ï˘ÛË ·ÏÈÓ‰ÚfiÌËÛ˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· Ó· ·Ó·Ï‡ÛÂÈ ÙËÓ Û˘Ì‚ÔÏ‹ ÙˆÓ ‰È·ÊfiÚˆÓ ÎÏÈÓÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, Ù˘ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ ÙÔ˘ Ì˘Ôηډ›Ô˘, ÙËÓ ·ÓıÚˆÔÌÂÙÚ›· Î·È ÙËÓ ÛÔ‚·ÚfiÙËÙ· ÙˆÓ ÙÈÌÒÓ Ù˘ ¿ıËÛ˘ Û ۯ¤ÛË Ì ÙË ÌÂÙ·‚ÔÏ‹ ÛÙË ÚfiÛÏË„Ë ıÂÚÌ›‰ˆÓ. ŸÏ˜ ÔÈ ·Ó·Ï‡ÛÂȘ ¤ÁÈÓ·Ó Ì ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ™Ù·ÙÈÛÙÈÎÔ‡ ¶ÚÔÁÚ¿ÌÌ·ÙÔ˜ ÁÈ· ÙȘ KÔÈÓˆÓÈΤ˜ EÈÛً̘ (SPSS) ÁÈ· Windows, ¤Î‰ÔÛË 8.0. AÔÙÂϤÛÌ·Ù· KÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ™˘ÓÔÏÈο 4320 ÒÚ˜ Û›ÙÈÛ˘ ÂÚÈÏ‹ÊıËÎ·Ó ÛÙÔ ÚˆÙfiÎÔÏÏÔ E°™ ÙˆÓ 36 ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ›¯·Ó Ê˘ÛÈÔÏÔÁÈ΋ Ë·ÙÈ΋ Î·È ÓÂÊÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È Î·Ì›· ·ÓÙ¤Ó‰ÂÈÍË ÁÈ· ÂÓÙÂÚÈ΋ Û›ÙÈÛË. T· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·È‰ÈÒÓ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ¢¤Î· ·È‰È¿ (27,8%)
¶›Ó·Î·˜ 1. KÏÈÓÈο ‰Â‰Ô̤ӷ ÙˆÓ ·ÛıÂÓÒÓ ÙÔ ÚÒÙÔ 24ˆÚÔ (n=36). MÂÙ·‚ÏËÙ¤˜ HÏÈΛ· (Ì‹Ó˜) B¿ÚÔ˜ (kg) PRISM TISS ¶Èı·ÓfiÙËÙ· ı·Ó¿ÙÔ˘ Ì ÙËÓ Îϛ̷η PRISM (%) EF (%) SF (%)
M¤Û˱SEM M
¢È¿ÌÂÛË ÙÈÌ‹ ÙÈÌ‹
EÏ¿¯ÈÛÙË Ë
54,8±9,1 21±1,9 11,1±1,4 27±1,8
42 18 9,0 25,0
2,0 3,6 2,0 9,0
11±0,09 65±1,8 34±1,2
4,0 68 35
0,00 33 16 -
M¤ÁÈÛÙË Ë
-
SEM= ™Ù·ıÂÚfi ÛÊ¿ÏÌ·; PRISM=Pediatric Risk of Mortality; TISS=Therapeutic Intervention Scoring System, EF=Ejection Fraction, SF=Shortening Fraction.
294
204 50 47,0 56,0 99 77 46
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·295
¶∞π¢π∞∆ƒπ∫∏ 2000;63:292-301
EÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Û ·È‰È¿ Û ME£
›¯·Ó ÛË„·ÈÌ›·,12 (33,3%) ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË, 6 (16,7%) ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ·, 3 (8,3%) Ó¢ÚÔÌ˘˚΋ ÓfiÛÔ Î·È 5 (13,9%) ÂÁη‡Ì·Ù·. H ‰È¿ÚÎÂÈ· ÙÔ˘ Ì˯·ÓÈÎÔ‡ ·ÂÚÈÛÌÔ‡ ‹Ù·Ó 5±0,7 Ë̤Ú˜ (‡ÚÔ˜ 1-16 Ë̤Ú˜), ÂÓÒ Ë Ì¤ÛË ·Ú·ÌÔÓ‹ ÛÙË ME£ ‹Ù·Ó 9,8±1,3 Ë̤Ú˜ (‡ÚÔ˜ 1-46 Ë̤Ú˜). H Û¯¤ÛË ·ÁÔÚÈÒÓ/ÎÔÚÈÙÛÈÒÓ ‹Ù·Ó 1,3:1. ¢‡Ô ·ÛıÂÓ›˜ (5,6%) η٤ÏËÍ·Ó (ÌË ·Ó·ÛÙÚ¤„ÈÌË ÛËÙÈ΋ ηٷÏËÍ›·). K·Ù¿ ÙË 1Ë Ì¤Ú· Ù˘ ÌÂϤÙ˘ 30,6% ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó Û ΛӉ˘ÓÔ ÁÈ· Ì›ˆÛË ÙˆÓ ·ÔıÂÌ¿ÙˆÓ Ï›Ô˘˜ Î·È 25% ÁÈ· Ì›ˆÛË ÙˆÓ ·ÔıÂÌ¿ÙˆÓ ÚˆÙ›Ó˘ Û‡Ìʈӷ Ì ÙÔ˘˜ Frisancho (14), Ryan Î·È Martinez (15). EÈϤÔÓ, 16,7% ‹Ù·Ó Û ΛӉ˘ÓÔ ÁÈ· ¯ÚfiÓÈ· Î·È 22,2% ÁÈ· ÔÍ›· ÚˆÙÂ˚ÓÈ΋ ÂÓÂÚÁÂȷ΋ ˘ÔıÚ„›· Û‡Ìʈӷ Ì ÙË ÛÙ·‰ÈÔÔ›ËÛË Î·Ù¿ Waterlow ( ). ™˘ÓÔÏÈο, ÙÔ 16,7% ›¯Â ‹‰Ë ÌÂȈ̤ӷ ·Ôı¤Ì·Ù· Ï›Ô˘˜ ‹ ÚˆÙ›Ó˘ Î·È 5,5% ‹Ù·Ó ‹‰Ë Û ¯ÚfiÓÈ· ‹ ÔÍ›· ÚˆÙÂ˚ÓÈ΋ ÂÓÂÚÁÂȷ΋ ˘ÔıÚ„›·. ™¯¤ÛË ÌÂٷ͇ ıÂÚÌȉÈ΋˜ ÚfiÛÏ˄˘ Î·È ·Ó·ÌÂÓfiÌÂÓ˘ ÂÓÂÚÁÂȷ΋˜ ηٷӿψÛ˘ K·Ù¿ ÙËÓ 1Ë Ì¤Ú·, Ë £¶ ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË ·fi ÙÔÓ ¶BM, ¶KE Î·È ™HA. H £¶ ÏËÛ›·Û ÙËÓ ¶BM ηٿ ÙË ‰Â‡ÙÂÚË Ì¤Ú· (46,4±3 vs 45±1,4 kcal/kg/Ë̤ڷ) Î·È ÙËÓ ¶KE ÙËÓ 5Ë Ì¤Ú· (71±4,7 vs 74,8±12,7 kcal/kg/Ë̤ڷ). K·Ù¿ ÙËÓ 5Ë Ì¤Ú·, Ë £¶ ͤڷÛ ÙÔÓ ¶BM ÛËÌ·ÓÙÈο (71±4,7 vs 45±1,4 kcal/kg/Ë̤ڷ, p<0,0001), ˘ÂÚ‚·›ÓÔÓÙ·˜ ÙËÓ ·Ó·ÌÂÓfiÌÂÓË (expected) £¶ (A£¶) ηٿ ÙËÓ 5Ë Ì¤Ú· (71±4,7 vs 67,9±2,1 kcal/kg/Ë̤ڷ) (EÈÎfiÓ· 1). ¢È·ÊÔÚ¤˜ ÌÂٷ͇ £¶ (·Ú·ÙËÚËı›۷) Î·È A£¶ (·Ó·ÌÂÓfiÌÂÓË), ÙˆÓ ÚÔ‚ÏÂfiÌÂÓˆÓ ÙÈÌÒÓ ıÂÚÌȉÈ΋˜ ηٷӿψÛ˘, ηıÒ˜ Î·È ÙˆÓ Û˘ÓÈÛÙÒÌÂÓˆÓ ÂÓÂÚÁÂÈ·ÎÒÓ ‰··ÓÒÓ Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 2. MfiÓÔ ÔÈ Î·Ù¿ ˙‡ÁË ‰È·ÊÔÚ¤˜ ÌÂٷ͇ £¶ Î·È ™HA ‰È¤ÊÂÚ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο Ì ·ÚÓËÙÈ΋ Û¯¤ÛË Î·Ù¿ ÙÔ Ù¤-
EÈÎfiÓ· 1. ™˘Û¯¤ÙÈÛË Ù˘ ıÂÚÌȉÈ΋˜ ÚfiÛÏ˄˘ (£¶) Ì ÙȘ ÚÔ‚ÏÂÊı›Û˜ ÙÈ̤˜ ‚·ÛÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ (¶BM), ηٷӷψı›۷˜ ÂÓ¤ÚÁÂÈ·˜ (¶KE), Û˘ÓÈÛÙÒÌÂÓˆÓ ËÌÂÚ‹ÛÈˆÓ ·Ó·ÁÎÒÓ (™HA) Î·È ·Ó·ÌÂÓfiÌÂÓ˘ ıÂÚÌȉÈ΋˜ ÚfiÛÏ˄˘ (A£¶) ÙËÓ 5Ë Ë̤ڷ ÂÓfi˜ ÚˆÙÔÎfiÏÏÔ˘ ¤ÁηÈÚ˘ ÚÈÓÔÁ·ÛÙÚÈ΋˜ Û›ÙÈÛ˘ (E°™) Û ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙ· ·È‰È¿. ÏÔ˜ ÙÔ˘ E°™ ÚˆÙÔÎfiÏÏÔ˘. TË 2Ë Ì¤Ú· Ë ‰È·ÊÔÚ¿ ¶£-¶BM ‹Ù·Ó ·ÚÓËÙÈ΋ Û ÂÚÈÛÛfiÙÂÚÔ˘˜ ·fi ÙÔ˘˜ ÌÈÛÔ‡˜ ·ÛıÂÓ›˜ (58%), ÂÓÒ Î·Ù¿ ÙËÓ 5Ë Ì¤Ú· Ë ‰È·ÊÔÚ¿ ÌÂٷ͇ ¶£-¶BM ‹Ù·Ó <0 ÌfiÓÔ Û ÔÛÔÛÙfi 8,3% Î·È >0 Û ÔÛÔÛÙfi 91,7% ÙˆÓ ·ÛıÂÓÒÓ. ™˘Û¯¤ÙÈÛË ÌÂٷ͇ £¶ Î·È ÎÏÈÓÈÎÒÓ ÌÂÙ·‚ÏËÙÒÓ M¤¯ÚÈ ÙË Û˘ÌÏ‹ÚˆÛË ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘ E°™, Ë £¶ ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÌÂٷ͇ ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Î·È ·ıÔÏÔÁÈÎÒÓ ·ÛıÂÓÒÓ (69,9±5,0 vs 79,2±5,3 kcal/kg/Ë̤ڷ, p=0,5) ‹ Û ·ÛıÂÓ›˜ Ì ‹ ¯ˆÚ›˜ ıÂÙÈÎfi ÚÔËÁÔ‡ÌÂÓÔ ÈÛÙÔÚÈÎfi (66±5,3 vs 72±5,3
¶›Ó·Î·˜ 2. ¢È·ÊÔÚ¤˜ ηٿ ˙‡ÁË ÌÂٷ͇ ÙˆÓ ·Ú·ÙËÚÔ‡ÌÂÓ˘, ·Ó·ÌÂÓfiÌÂÓ˘, Û˘ÓÈÛÙÒÌÂÓ˘ Î·È ÚÔ‚ÏÂfiÌÂÓ˘ ıÂÚÌȉÈ΋˜ ÚfiÛÏ˄˘ ηٿ ÙËÓ 5Ë Ë̤ڷ ÂÓfi˜ ÚˆÙÔÎfiÏÏÔ˘ ¤ÁηÈÚ˘ ‰È·Á·ÛÙÚÈ΋˜ Û›ÙÈÛ˘ ÛÙËÓ ÔÍ›· Ê¿ÛË ÎÚ›ÛÈÌ˘ ÓfiÛÔ˘ (n=36). Paired Samples Test
¢È·ÊÔÚ¤˜ ηٿ ˙‡ÁË M¤ÛË ÙÈÌ‹ ± SEM
™HA - £¶ (kcal/kg/Ë̤ڷ) ¶KE - £¶ (kcal/kg/Ë̤ڷ) ¶BM - £¶ (kcal/kg/Ë̤ڷ) A£¶ - £¶ (kcal/kg/Ë̤ڷ)
17,8 ± 4,4 * 3,8 ± 11,7 -25,9 ± 4,1 * -3,3 ± 3,9
95% ŸÚÈ· ·ÍÈÔÈÛÙ›·˜ X·ÌËÏfiÙÂÚ·
Y„ËÏfiÙÂÚ·
8,8 -19,8 -34,4 -11,4
26,8 27,5 -17,4 4,8
* p <0,0001 SEM= ™Ù·ıÂÚfi ÛÊ¿ÏÌ·, £¶= ıÂÚÌȉÈ΋ ÚfiÛÏË„Ë (·Ú·ÙËÚËı›۷), A£¶= ·Ó·ÌÂÓfiÌÂÓË ıÂÚÌȉÈ΋ ÚfiÛÏË„Ë, ™HA= Û˘ÓÈÛÙÒÌÂÓ˜ ËÌÂÚ‹ÛȘ ·Ó¿ÁΘ, ¶KE= ÚÔ‚ÏÂfiÌÂÓË Î·Ù·Ó¿ÏˆÛË ÂÓ¤ÚÁÂÈ·˜, ¶BM= ÚÔ‚ÏÂfiÌÂÓÔ˜ ‚·ÛÈÎfi˜ ÌÂÙ·‚ÔÏÈÛÌfi˜
295
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·296
¶∞π¢π∞∆ƒπ∫∏ 2000;63:292-301
°. MÚÈ·ÛÔ‡Ï˘ Î·È Û˘Ó.
EÈÎfiÓ· 2. ™˘Û¯¤ÙÈÛË Ì˘Ôηډȷ΋˜ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ Î·È Û˘ÓÔÏÈÎÔ‡ ÚÔÛÏ·Ì‚·ÓfiÌÂÓÔ˘ ÔÛÔ‡ Û›ÙÈÛ˘. kcal/kg/Ë̤ڷ, p=0,7). EÈÚfiÛıÂÙ·, Ù· ÔÛ¿ Á·ÛÙÚÈÎÔ‡ ˘ÔÏ›ÌÌ·ÙÔ˜ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÌÂٷ͇ ÙˆÓ ‰È·ÊÔÚÂÙÈÎÒÓ ÔÌ¿‰ˆÓ ·ÛıÂÓÂÈÒÓ. AÓÙ›ıÂÙ·, ÛËÌ·ÓÙÈ΋ ‹Ù·Ó Ë Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ÙÔ˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓÔ˘ ÔÛÔ‡ Û›ÙÈÛ˘ Î·È ÙˆÓ Ì˘ÔηډȷÎÒÓ ÎÏ·ÛÌ¿ÙˆÓ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ EF (r=0,40, p=0,002) Î·È SF (r=0,34, p=0,004) (EÈÎfiÓ· 2). E·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ ÌÂÙÚ‹ÛÂȘ ÂÓÂÚÁÂȷ΋˜ ÚfiÛÏ˄˘ E·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ ÌÂÙÚ‹ÛÂȘ ÙˆÓ ÌÂÙ·‚ÔÏÒÓ A£¶-£¶ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ Ì ‹ ¯ˆÚ›˜ MOSF (p<0,0001) ‹ ÛËÙÈ΋ ηٷÏËÍ›· (p<0,0001) ηٿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· Ù˘ ÌÂϤÙ˘ (EÈÎfiÓ· 3). AÓÙ›ıÂÙ·, ·ÓÂÈÏËÌ̤Ó˜ ÌÂÙÚ‹ÛÂȘ ÙˆÓ ‰È·ÊÔÚÒÓ A£¶-£¶ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ Ì ‹ ¯ˆÚ›˜ SIRS (p=0,6). ™¯¤ÛË ÌÂٷ͇ £¶ Î·È Ê·ÚÌ¿ÎˆÓ H £¶ ‰ÂÓ ‰È¤ÊÂÚ ÛËÌ·ÓÙÈο ÌÂٷ͇ ·ÛıÂÓÒÓ Ô˘ ÂÏ¿Ì‚·Ó·Ó ‹ fi¯È ÔÈÔÂȉ‹ (67,9±5,9 vs 78±6,9 kcal/kg/Ë̤ڷ, p=0,3) ‹ ·ÁÁÂÈÔ‰Ú·ÛÙÈο Ê¿Ú̷η (63,2±10,8 vs 73,5±5,0 kcal/kg/Ë̤ڷ, p=0,4). AÓÙ›ıÂÙ·, ·ÛıÂÓ›˜ Ô˘ ÂÏ¿Ì‚·Ó·Ó Ó¢ÚÔÌ˘˚ÎÔ‡˜ ·ÔÎÏÂÈÛÙ¤˜ ›¯·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË £¶ Û ۯ¤ÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ‰ÂÓ ÂÏ¿Ì‚·Ó·Ó ·Ú¿Ï˘ÛË (65,8±4,9 vs 93,8±7,9 kcal/kg/Ë̤ڷ, p<0,02). H ‰È·ÊÔÚ¿ ·˘Ù‹ ·ÓÙ·Ó·ÎÏÔ‡Û ·ÓÙ›ÛÙÔÈ¯Ë ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ fiÛÔÓ ·ÊÔÚ¿ ÙÔ Á·ÛÙÚÈÎfi ˘fiÏÂÈÌÌ· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ E°™ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ (6±2,3 vs 0±0 ml/ÒÚ·, p=0,015). ¶·ÚfiÌÔÈ·, ·ÛıÂÓ›˜ Ô˘ ÂÏ¿Ì‚·Ó·Ó ÔÈÔÂȉ‹ ¿ÊËÓ·Ó ÌÂÁ·Ï‡ÙÂÚË ÔÛfiÙËÙ· Á·ÛÙÚÈÎÔ‡ ˘ÔÏ›ÌÌ·ÙÔ˜ Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ‰ÂÓ ¤·ÈÚÓ·Ó ÔÈÔÂȉ‹ (7,2±2,7 vs 0,2±0,1 ml/ÒÚ·, p=0,018). AÛıÂÓ›˜ Ô˘ ¤·ÈÚÓ·Ó ‹ fi¯È ·Á-
296
EÈÎfiÓ· 3. E·Ó·Ï·Ì‚·ÓfiÌÂÓ˜ ÌÂÙÚ‹ÛÂȘ ÙˆÓ ‰È·ÊÔÚÒÓ A£¶-£¶ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ Ì ‹ ¯ˆÚ›˜ MOSF (¿Óˆ) ‹ ÛËÙÈ΋ ηٷÏËÍ›· (οو) ηٿ ÙËÓ ÚÒÙË Â‚‰ÔÌ¿‰· ÂÊ·ÚÌÔÁ‹˜ ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘ ¤ÁηÈÚ˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘. ÁÂÈÔ‰Ú·ÛÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ‰ÂÓ ‰È¤ÊÂÚ·Ó ˆ˜ ÚÔ˜ ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ ˘ÔÏ›ÌÌ·ÙÔ˜ (6,9 vs 4,3 ml/ÒÚ·, p=0,6). E°™: ÂÈÙ˘¯›·-·ÔÙ˘¯›· H ¿ÌÂÛË ÂÈÙ˘¯›· ¤Êı·Û ÙÔ ÔÛÔÛÙfi 94,4%, ÚԂϤÔÓÙ·˜ ÙËÓ ÂÈÙ˘¯‹ ÙÂÏÈ΋ (¤ˆ˜ Î·È ÙËÓ ¤ÍÔ‰Ô) ÂÓÙÂÚÈ΋ Û›ÙÈÛË Û ÔÛÔÛÙfi 97,1% (p-=0,005). H ÚfiÛÏË„Ë ÂÓ¤ÚÁÂÈ·˜ ÙˆÓ ·ÛıÂÓÒÓ Î·Ù¿ ÙËÓ ¤ÍÔ‰Ô Ô˘ ¤ÊÂÚ·Ó Û ¤Ú·˜ ÙÔ ÚˆÙfiÎÔÏÏÔ E°™ ‹Ù·Ó 84 (45-130) kcal/kg/Ë̤ڷ. H ÙÂÏÈ΋ ‰È·ÊÔÚ¿ ÂÓ¤ÚÁÂÈ·˜ ÌÂٷ͇ Ù˘ 5˘ Ë̤ڷ˜ Î·È ·˘Ù‹˜ ηٿ ÙËÓ ¤ÍÔ‰Ô ‹Ù·Ó -9,6 kcal/kg/Ë̤ڷ (-73-+18). AÔÙ˘¯›· Ù˘ E°™ ·Ú·ÙËÚ‹ıËΠ΢ڛˆ˜ Û ÌË ·Ó·ÛÙÚ¤„ÈÌË ÛËÙÈ΋ ηٷÏËÍ›·. OÈ ·ÛıÂÓ›˜ Ô˘ ·¤Ù˘¯·Ó ηٿ ÙËÓ E°™ ›¯·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚÔ ÎÏ¿ÛÌ· ‚Ú¿¯˘ÓÛ˘ ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ (19% vs 35%, p=0,001) ‹ ÎÏ¿ÛÌ· ÂÍÒıËÛ˘ (32% vs 66%, p<0,0001) ÛÂ
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·297
¶∞π¢π∞∆ƒπ∫∏ 2000;63:292-301
Û‡ÁÎÚÈÛË Ì ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ¤ÊÂÚ·Ó Û ¤Ú·˜ ÙÔ ÚˆÙfiÎÔÏÏÔ (EÈÎfiÓ· 4). TÔ ¿ıÚÔÈÛÌ· ÙˆÓ ˆÚÒÓ ¯ˆÚ›˜ Û›ÙÈÛË ·ÓÙÈÛÙÔȯԇÛ ÛÙÔ 1,4% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ˆÚÒÓ Û›ÙÈÛ˘, ·ÓÙÈÛÙÔȯÒÓÙ·˜ Û 3,6±1,7 ÒÚ˜ (0-60) ÁÈ· οı ·ÛıÂÓ‹ Û fiÏË ÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ÌÂϤÙ˘. OÈ ÒÚ˜ ·˘Ù¤˜ ‰È·ÎÔ‹˜ Ù˘ Û›ÙÈÛ˘ Û¯ÂÙ›˙ÔÓÙ·Ó ıÂÙÈο ÚÔ˜ ÙȘ ÙÈ̤˜ ÙˆÓ PRISM, TISS, Î·È ·ÚÓËÙÈο Ì ÙÔ EF (r=-0,32, p=0,007) ‹ SF (r=0,37, p=0,002). ™Â ÔÏ˘·Ú·ÁÔÓÙȷ΋ ·Ó¿Ï˘ÛË ·ÏÈÓ‰ÚfiÌËÛ˘, ÌfiÓÔ Ë ÂÈ‚›ˆÛË (r2=0,62, p<0,0001) Î·È ÙÔ TISS (r2=-3, p<0,02) Û˘Û¯ÂÙ›˙ÔÓÙ·Ó ·ÓÂÍ¿ÚÙËÙ· Ì ÙË ‰È·ÊÔÚ¿ £¶-¶BM. E°™ -ÂÈÏÔΤ˜ OÈ ·ÛıÂÓ›˜ ·Ó¤¯ıËÎ·Ó ÙËÓ E°™ Ôχ ηϿ. H Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÈÏÔÎÒÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·Ó Ì ÙË Û›ÙÈÛË Ì ÚÈÓÔÁ·ÛÙÚÈÎfi ηıÂÙ‹Ú· ‹Ù·Ó ÌÈÎÚ‹ (13,9%). ¢È¿ÚÚÔÈ· (5,6%) Î·È ÂËÚ·Ṳ̂ÓË Á·ÛÙÚÈ΋ ΤӈÛË (8,3%) ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó Ì ‚Ú·¯‡¯ÚÔÓË Ì›ˆÛË Ù˘ Û›ÙÈÛ˘. H ·ÚÔ‰È΋ ‰È·ÎÔ‹ Ù˘ E°™ ‰ÂÓ ÔÊÂÈÏfiÙ·Ó ÛÙË ÌË ·ÓÔ¯‹ Ù˘ Û›ÙÈÛ˘ ΢ڛˆ˜, ·ÏÏ¿ ÛÙËÓ ÚÔ·ÈÚÂÙÈ΋ ‰È·ÎÔ‹ Ù˘ ÁÈ· ÙËÓ ·ÔۈϋӈÛË. MfiÓÔ ¤Ó·˜ ·ÛıÂÓ‹˜ ›¯Â ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· Á·ÛÙÚÈÎÔ‡ ηٿ ÙËÓ 5Ë Ì¤Ú· (Klebsiella) Î·È ‰‡Ô ·Ó¤Ù˘Í·Ó ÓÔÛÔÎÔÌÂȷ΋ Ó¢ÌÔÓ›·, ÂÓÒ 12 ·ÛıÂÓ›˜ (33.3%) ›¯·Ó ıÂÙÈ΋ ηÏÏȤÚÁÂÈ· ·›Ì·ÙÔ˜. TÚÂȘ ·ÛıÂÓ›˜ ıÂڷ‡ıËÎ·Ó Ì ÂÈÙ˘¯›· Ì ¯ÔÚ‹ÁËÛË ÛÈÛ·Ú›‰Ë˜ ÏfiÁˆ ηı˘ÛÙÂÚË̤Ó˘ Á·ÛÙÚÈ΋˜ ΤӈÛ˘. Ÿ„ÈÌ· ÚÔ‚Ï‹Ì·Ù· Û¯ÂÙÈ˙fiÌÂÓ· Ì ÙË Û›ÙÈÛË, Ì ‰È·ÎÔ‹ Ù˘ Û›ÙÈÛ˘ ÁÈ· ÏÈÁfiÙÂÚÔ ·fi 1 Ë̤ڷ, ÂÚÈÂÏ¿Ì‚·Ó·Ó ÙȘ ‰È¿ÚÚÔȘ (5,6%) Î·È ÙË Á·ÛÙÚÔ¿ÚÂÛË
EÈÎfiÓ· 4. ™‡ÁÎÚÈÛË ÙˆÓ ÎÏ·ÛÌ¿ÙˆÓ ÂÍÒıËÛ˘ (EF) Î·È ‚Ú¿¯˘ÓÛ˘ (SF), ÂÓ‰ÂÈÎÙÈÎÒÓ Ù˘ Ì˘Ôηډȷ΋˜ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜, ÌÂٷ͇ ·ÛıÂÓÒÓ Ô˘ ÔÏÔÎÏ‹ÚˆÛ·Ó ‹ ·¤Ù˘¯·Ó Ó· ·Ó¯ıÔ‡Ó ÙÔ ÚˆÙfiÎÔÏÏÔ ¤ÁηÈÚ˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ (p=0,001).
EÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Û ·È‰È¿ Û ME£
(5,6%) Û 4 ·ÛıÂÓ›˜ Ì ÛËÙÈ΋ ηٷÏËÍ›·. MfiÓÔ 2 ·ÛıÂÓ›˜ ¯ÚÂÈ¿ÛıËÎ·Ó O¶¢ ÌÂÙ¿ ·fi ÙË Û˘ÌÏ‹ÚˆÛË Ù˘ E°™ ÂÓÒ 21 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ (58,3%) ÂÍ‹Ïı·Ó Û˘Ó¯›˙ÔÓÙ·˜ ÙË Û›ÙÈÛË Ì ÚÈÓÔÁ·ÛÙÚÈÎfi ηıÂÙ‹Ú·. H ıÓËÙfiÙËÙ· ÛÙË ME£ (5,6%) ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË ÁÈ· ÙËÓ ÔÌ¿‰· Ì ÂÈÙ˘¯Ë̤ÓË ÙÂÏÈ΋ Û›ÙÈÛË Û ۇÁÎÚÈÛË Ì ÂΛÓË Ù˘ ÔÌ¿‰·˜ Ô˘ ·¤Ù˘¯Â Ó· ÔÏÔÎÏËÚÒÛÂÈ ÙÔ ÚˆÙfiÎÔÏÏÔ (p<0,002), Î·È ‹Ù·Ó ¯·ÌËÏfiÙÂÚË ·fi ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ·fi ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘ (PRISM) ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹ (12±0,3). ™˘˙‹ÙËÛË EÏ¿¯ÈÛÙ˜ ÌÂϤÙ˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· ·Ó·Ê¤ÚÔÓÙ·È ÛÙȘ ıÂÚÌȉÈΤ˜ ·Ó¿ÁΘ ÙˆÓ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ ÛÙË ‰È¿ÚÎÂÈ· ÌÈ·˜ ÎÚ›ÛÈÌ˘ ÓfiÛÔ˘. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ‰Â›¯ıËΠfiÙÈ ÔÈ ÂÓÂÚÁÂȷΤ˜ ·Ó¿ÁΘ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÚԂϤÔÓÙ·È ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÙȘ ™HA ‹ ÂȉÈΤ˜ ÂÍÈÛÒÛÂȘ ˘ÂÚÂÎÙÈÌÔ‡Ó ÙËÓ Ú·ÁÌ·ÙÈο ‰··ÓfiÌÂÓË ÂÓ¤ÚÁÂÈ· ÛÙË Ê¿ÛË ÙÔ˘ stress. H ÌÂÙÚËı›۷ ÂÓ¤ÚÁÂÈ· ÛÙË Ê¿ÛË ÙÔ˘ stress ‚Ú¤ıËΠӷ ÚÔÛÂÁÁ›˙ÂÈ ÙÔÓ ¶BM (17) ÂÓÒ ÔÈ ˘ÔÏÔÁÈÛÌÔ› ¶KE ¤¯Ô˘Ó ‰Âȯı› ÙÂÏ›ˆ˜ ·Î·Ù¿ÏÏËÏÔÈ ÁÈ· ˘ÔÏÔÁÈÛÌfi Ù˘ ıÂÚÌȉÈ΋˜ Î¿Ï˘„˘ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ (18). AÙ˘¯Ò˜, ÔÈ ÚÔÙÂÈÓfiÌÂÓ˜ ËÌÂÚ‹ÛȘ ·Ó¿ÁΘ Û ·È‰È¿ Û stress ¤¯Ô˘Ó ‚·ÛÈÛı› Û ÌÂϤÙ˜ Ô˘ ¤¯Ô˘Ó Á›ÓÂÈ Û ˘ÁÈ‹, ¯ˆÚ›˜ stress ¿ÙÔÌ· (19,20), Ô‰ËÁÒÓÙ·˜ ÔÏϤ˜ ÊÔÚ¤˜ Û ˘ÂÚÛ›ÙÈÛË (21). H ˘ÂÚÛ›ÙÈÛË, fï˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÚÂÓ¤ÚÁÂȘ, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ÚÔηÏÔ‡ÌÂÓ˘ ·fi ÙË Û›ÙÈÛË ıÂÚÌÔÁ¤ÓÂÛË, Ù˘ ·˘ÍË̤Ó˘ ·Ú·ÁˆÁ‹˜ CO2, Î·È ÙË ÏÈÒ‰Ë ÂÓ·fiıÂÛË ÛÙÔ ‹·Ú (22). T·˘Ùfi¯ÚÔÓ·, ÌÂϤÙ˜ ‚Ú·¯‡¯ÚÔÓ˘ ‹ ·Ó·ÚÎÔ‡˜ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ (23) ·¤Ù˘¯·Ó Ó· ‰Â›ÍÔ˘Ó ÔÔÈÔ‰‹ÔÙ ¢ÓÔ˚Îfi ·ÔÙ¤ÏÂÛÌ· Û ‚·Ú¤ˆ˜ ¿Û¯ÔÓÙ˜ ·ÛıÂÓ›˜. AÓÙ›ıÂÙ·, ¤Ú¢ӷ Û ·ÛıÂÓ›˜ Ì ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋ οΈÛË ¤‰ÂÈÍ·Ó fiÙÈ Ë ·Ó·Ú΋˜ ıÂÚÌȉÈ΋ Î¿Ï˘„Ë Û˘Ó‰¤ÂÙ·È Ì ·˘ÍË̤ÓË ıÓËÛÈÌfiÙËÙ· Î·È ıÓËÙfiÙËÙ·. ™ÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ·, ÔÈ ÂÓÂÚÁÂȷΤ˜ ·Ó¿ÁΘ ÙˆÓ ·ÛıÂÓÒÓ ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ Ê¿ÛË Ù˘ ÓfiÛÔ˘. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË, ÛÙËÓ ÔÔ›· Ë Î·Ù·Ó¿ÏˆÛË ÂÓ¤ÚÁÂÈ·˜ ÚÔÔÛ‰ÈÔÚ›ÛıËΠ۠‰È¿ÊÔÚ· ÛÙ¿‰È· ÔÍ›·˜ ÓfiÛÔ˘, Ë ÌÂÙÚËı›۷ ÂÓ¤ÚÁÂÈ· ÌÂÈÒıËΠÛËÌ·ÓÙÈο ÛÙË Ê¿ÛË Ù˘ ÛËÙÈ΋˜ ηٷÏËÍ›·˜, ÂÓÒ ¤Êı·Û ÛÙȘ ˘„ËÏfiÙÂÚ˜ ÙÈ̤˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ó¿Î·Ì„˘ ·fi ÙË ÛË„·ÈÌ›· (24). ¶ÚfiÛıÂÙ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô ˘ÂÚÌÂÙ·‚ÔÏÈÛÌfi˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ê¿Û˘ Ù˘ ÓfiÛÔ˘ ‰ÂÓ Â›Ó·È ÙfiÛÔ Û˘¯Ófi˜ Û ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙ· ·È‰È¿ (25-26) Î·È ÓÂÔÁÓ¿ (27) fiˆ˜ ›¯Â ÚÔËÁÔ‡ÌÂÓ· ˘ÔÙÂı›. EÔ̤ӈ˜, Ô Î›Ó‰˘ÓÔ˜ ·fi ˘ÂÚÛ›ÙÈÛË Î·È ÌÂÙ·‚ÔÏÈ΋ ÂÈ‚¿Ú˘ÓÛË ÙÔ˘ ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙÔ˘ ·È‰ÈÔ‡ Â›Ó·È ÛËÌ·ÓÙÈÎfi˜ (28). ŒÙÛÈ, Û‡Ìʈӷ Ì ÙÔ Û¯Â‰È·ÛÌfi ÙÔ˘ ·ÚfiÓÙÔ˜
297
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·298
¶∞π¢π∞∆ƒπ∫∏ 2000;63:292-301
ÚˆÙÔÎfiÏÏÔ˘, Ë E°™ ‚Ô‹ıËÛ ӷ Î·Ï˘Êı› Ô ¶BM ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÍ›·˜ Ê¿Û˘ Ù˘ ÓfiÛÔ˘ Î·È Ë ¶KE ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·Ó¿ÚÚˆÛ˘, fiˆ˜ ·˘Ù‹ ÚÔÛ‰ÈÔÚÈ˙fiÙ·Ó ·fi ÙËÓ ÚÔÛ¿ıÂÈ· ·Ô‰¤ÛÌ¢Û˘ ·fi ÙÔÓ Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi. H ¿ÌÂÛË ÂÈÙ˘¯›· ‹Ù·Ó 94,4%, ÚԂϤÔÓÙ·˜ Ù·˘Ùfi¯ÚÔÓ· ÙËÓ fi„ÈÌË ÂÓÙÂÚÈ΋ Û›ÙÈÛË Ì ·ÛÊ¿ÏÂÈ· (97,1%). AÔÙÂϤÛÌ·Ù· Ô˘ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë Á·ÛÙÚÈ΋ Ô‰fi˜ Â›Ó·È Ì›· ÂÊÈÎÙ‹ ÂÓ·ÏÏ·ÎÙÈ΋ χÛË ÛÙËÓ ·ÚÂÓÙÂÚÈ΋ Î·È ÂÓÙÂÚÈ΋ Û›ÙÈÛË ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ‚·ÚÈ¿˜ ÓfiÛÔ˘. T· Â˘Ú‹Ì·Ù· ·˘Ù¿ Â›Ó·È Â˘ÓÔ˚ÎfiÙÂÚ· ·fi ÂΛӷ ÌÂÏÂÙÒÓ Û ME£ ÂÓËÏ›ÎˆÓ fiÔ˘ Ê·›ÓÂÙ·È fiÙÈ ÌfiÓÔ Û 75% ÂÈÙ˘Á¯¿ÓÂÙ·È ÈηÓÔÔÈËÙÈ΋ Û›ÙÈÛË (29). ¶·ÚfiÌÔÈ·, Û ÌÂϤÙË Ì ÚÒÈÌË Û›ÙÈÛË Û ÂÓ‹ÏÈΘ, ÌfiÓÔ ÙÔ 42% ¤Ù˘¯Â ÈηÓÔÔÈËÙÈ΋ Û›ÙÈÛË ÙËÓ 5Ë Ì¤Ú· (30). H ÚÒÈÌË Û›ÙÈÛË fï˜, Â›Ó·È Ôχ ÛËÌ·ÓÙÈ΋, ηıÒ˜ ÌÂÈÒÓÂÈ ÙËÓ ˘ÂÚηٷ‚ÔÏÈ΋ ·¿ÓÙËÛË ÛÙÔ stress, Ë ‰Â ¯Ú‹ÛË ÛÈÙÈÛÙÈÎÒÓ ÚˆÙÔÎfiÏÏˆÓ Â˘ÓÔ› ȉȷ›ÙÂÚ· ÙËÓ ÂÊ·ÚÌÔÁ‹ Ù˘. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÙÔ 94% ÙˆÓ ·È‰ÈÒÓ Ì stress ¤Ù˘¯Â Ï‹ÚË Û›ÙÈÛË Ì¤Û· Û 4 Ë̤Ú˜ ÌÂÙ¿ ÙÔ stress. To ‡ÚËÌ· ·˘Ùfi Â›Ó·È ·ÚfiÌÔÈÔ Ì ÙȘ ·Ú·ÙËÚ‹ÛÂȘ Û ÂÓ‹ÏÈΘ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û Ì›˙ÔÓ· ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË Î·È ÛÈÙ›ÛÙËÎ·Ó ÚÔÁÚ·ÌÌ·ÙÈṲ̂ӷ ÂÓÙÂÚÈο ¤ˆ˜ ÙËÓ 4Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ë̤ڷ. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ‰Â›¯ıËΠ̛· ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ·ÔÙ˘¯›·˜ ÛÙËÓ ·ÓÔ¯‹ Ù˘ E°™ Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘, fiˆ˜ ÂÎÙÈÌ‹ıËΠ̠ٷ Û˘ÛÙ‹Ì·Ù· PRISM Î·È TISS, Î·È Î˘Ú›ˆ˜ Ì ٷ ÎÏ¿ÛÌ·Ù· ‚Ú¿¯˘ÓÛ˘ Î·È ÂÍÒıËÛ˘ Ù˘ ηډȷ΋˜ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜. ™Â ÚÔËÁÔ‡ÌÂÓË ÌÂϤÙË, Ë ÌÂÙÚËı›۷ ηٷӿψÛË ÂÓ¤ÚÁÂÈ·˜ ‚Ú¤ıËΠÛËÌ·ÓÙÈο ÌÂȈ̤ÓË Û ·ÛıÂÓ›˜ Ì ÛË„·ÈÌ›·, Î·È ·ÎfiÌË ÂÚÈÛÛfiÙÂÚÔ Û ·ÛıÂÓ›˜ Ì ÛËÙÈÎfi shock, ÂÓÒ ·ÓÙ›ıÂÙ· Ë Î·Ù·Ó¿ÏˆÛË ÂÓ¤ÚÁÂÈ·˜ ·˘Í‹ıËΠÌfiÓÔ ÌÂÙ¿ ÙËÓ ·Ó¿ÚÚˆÛË ·fi ÙË ÛË„·ÈÌ›·. ŒÙÛÈ, ‰Â›¯ıËΠÌÈ· ·Ó·ÏÔÁÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ÛË„·ÈÌ›·˜ Î·È Ù˘ ηٷӿψÛ˘ ÂÓ¤ÚÁÂÈ·˜ (24). ŸÌˆ˜, ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Â›Ó·È Ë ÚÒÙË ÊÔÚ¿ Ô˘ ‰Â›¯ÓÂÙ·È Ì›· ·ÚfiÌÔÈ· Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ‰˘Ó·ÙfiÙËÙ·˜ ÚÒÈÌ˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Î·È ÌÂȈ̤Ó˘ ηډȷ΋˜ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ Û ÎÚ›ÛÈÌ· ¿ÚÚˆÛÙÔ˘˜ ·ÛıÂÓ›˜ ‚·Ú¤ˆ˜ (MEDLINE). H ·Ú΋˜ ÚÔ‹ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙË ÛÏ·¯ÓÈ΋ ΢ÎÏÔÊÔÚ›· ‰È·ÛÊ·Ï›˙ÂÙ·È fi¯È ÌfiÓÔ ·fi ÙËÓ ÈηÓÔÔÈËÙÈ΋ Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ Ì˘Ôηډ›Ô˘, ·ÏÏ¿ Î·È ·fi ÙËÓ Û˘Ó¯‹ ‰È¤ÁÂÚÛË ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ·fi ÙËÓ E°™. ø˜ ÂÎ ÙÔ‡ÙÔ˘, Ë E°™ ‰ÈÂÁ›ÚÂÈ ÙËÓ ›‰È· ÙË ıÚÂÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘, ·ÔÙÚ¤ÔÓÙ·˜ ηÙ' ¤ÎÙ·ÛË ÙËÓ ·ÙÚÔÊ›· ÙÔ˘ Î·È Â˘ÓÔÒÓÙ·˜ ÙËÓ ·Ó¿ÎÙËÛË Ù˘ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ¿˜ ÙÔ˘ (31). B¤‚·È·, Û ηٷÛÙ¿ÛÂȘ ÌÂȈ̤ÓÔ˘ fiÁÎÔ˘ ·ÏÌÔ‡, fiˆ˜ Û ηٷÛÙ¿ÛÂȘ ‚·ÚÈ¿˜ ÛËÙÈ΋˜ ηٷÏËÍ›·˜ Ô˘ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÛËÌ·ÓÙÈο ÌÂȈ̤ÓË Û˘ÛÙ·ÏÙÈÎfiÙËÙ· ÙÔ˘ Ì˘Ô-
298
°. MÚÈ·ÛÔ‡Ï˘ Î·È Û˘Ó.
ηډ›Ô˘, Ë ÛÏ·¯ÓÈ΋ ·ÈÌ¿ÙˆÛË ·Ú·Ì¤ÓÂÈ Û Ôχ ¯·ÌËÏ¿ ›‰·. K·È ·˘Ùfi ·Ú¿ ÙËÓ ·Ó·ÌÊÈÛ‚‹ÙËÙË ‰È¤ÁÂÚÛË Ù˘ ÂÓÙÂÚÈ΋˜ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ̤ۈ Ù˘ Û˘Ó¯ԇ˜ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘. EȂ‚·›ˆÛË Ù˘ ˘fiıÂÛ˘ ·˘Ù‹˜ ·ÔÙÂÏ› ÙÔ Â‡ÚËÌ· fiÙÈ ÛÙËÓ ·ÚÔ‡Û· ¤Ú¢ӷ Ë ·ÔÙ˘¯›· Ù˘ E°™ ÔÊÂÈÏfiÙ·Ó Î˘Ú›ˆ˜ ÛÙË ÌË ·ÓÙÈÛÙÚÂÙ‹ ÛËÙÈ΋ ηٷÏËÍ›·. A˘Ùfi Û˘ÌʈÓ› Ì ٷ ·ÔÙÂϤÛÌ·Ù· ÌÂϤÙ˘ Ô˘ ¤ÁÈÓ Û ·È‰È¿ Ì ÛÔ‚·Ú¿ ÂÁη‡Ì·Ù·, ÛÙ· ÔÔ›· Ë ÌË ·ÓÔ¯‹ Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙËÓ ÂΉ‹ÏˆÛË ÛË„·ÈÌ›·˜ Î·È ·‡ÍËÛË Ù˘ ıÓËÛÈÌfiÙËÙ·˜ (32). H ÛÔ‚·Ú‹ ÓfiÛËÛË Û˘Ó‰¤ÂÙ·È Ì ·ÙÚÔÊ›· ÙÔ˘ ÂÓÙ¤ÚÔ˘ Î·È ·˘ÍË̤ÓË ‰È·‚·ÙfiÙËÙ· ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Û ‚·ÎÙËÚ›‰È· Î·È Ì·ÎÚÔÌfiÚÈ· fiˆ˜ ÔÈ ÂÓ‰ÔÙÔ͛Ә (33). H ·ÚÔ˘Û›· ÙÚÔÊ‹˜ ÛÙÔÓ ÂÓÙÂÚÈÎfi ۈϋӷ ·ÔÙÂÏ› ÛËÌ·ÓÙÈÎfi ÂÚ¤ıÈÛÌ· ÁÈ· ÙË ‰È·Ù‹ÚËÛË Ù˘ ÛÏ·Á¯ÓÈ΋˜ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ·›Ì·ÙÔ˜ (34) Î·È Ù˘ ·ÎÂÚ·ÈfiÙËÙ·˜ ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘. ŒÓ·˜ ·ÚÈıÌfi˜ ÌÂÏÂÙÒÓ Û ÂÓ‹ÏÈΘ ‰È·Ù˘ÒÓÂÈ ÙËÓ ˆÊ¤ÏÂÈ· ·fi ÙËÓ ¿ÌÂÛË ÂÓÙÂÚÈ΋ Û›ÙÈÛË Û ‚·ÚÈ¿ ¿Û¯ÔÓÙ˜ ·ÛıÂÓ›˜ (35). ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, Ë ıÓËÛÈÌfiÙËÙ· ÛÙË ME£ ‹Ù·Ó ÌÈÎÚfiÙÂÚË ·fi ÙËÓ ·Ó·ÌÂÓfiÌÂÓË Û ۯ¤ÛË Ì ÙËÓ Îϛ̷η ‚·Ú‡ÙËÙ·˜ Ù˘ ÓfiÛÔ˘ (5.6% vs 12%). H ıÓËÛÈÌfiÙËÙ· ›Û˘ ‹Ù·Ó ÌÈÎÚfiÙÂÚË ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ô˘ ÛÈÙ›ÛıËÎ·Ó ÂÈÙ˘¯Ò˜ Û ۯ¤ÛË Ì ·˘ÙÔ‡˜ Ô˘ ·¤Ù˘¯·Ó Ó· ÛÈÙÈÛıÔ‡Ó ¿ÌÂÛ· ‰È·Á·ÛÙÚÈο. T· Â˘Ú‹Ì·Ù· ·˘Ù¿ Û˘ÌʈÓÔ‡Ó Ì ÌÂϤÙ˜ Ô˘ ‰Â›¯ÓÔ˘Ó Ó· ˘¿Ú¯ÂÈ ·˘ÍË̤ÓË ÂÈ‚›ˆÛË Î·È Ì›ˆÛË Ù˘ ıÓËÛÈÌfiÙËÙ·˜ Û ·ÛıÂÓ›˜ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ¤ÁηÈÚË ÂÓÙÂÚÈ΋ Û›ÙÈÛË (36). T· ‚·ÚÈ¿ ¿Û¯ÔÓÙ· ·È‰È¿ Û’ ·˘Ù‹ ÙË ÌÂϤÙË ·Ó¤¯ÙËÎ·Ó Î·Ï¿ ÙËÓ E°™, ηıÒ˜ ÙÔ 86% ÙˆÓ ·ÛıÂÓÒÓ ‰ÂÓ Â›¯Â ‰˘ÛÎÔÏ›· ÛÙËÓ ÚÔÒıËÛË Ù˘ Û›ÙÈÛ˘. TÔ Â‡Ú‹Ì· ·˘Ùfi Â›Ó·È ·ÚfiÌÔÈÔ Ì ÚÔËÁÔ‡ÌÂÓË ÂÌÂÈÚ›· Ô˘ ›¯Â ‰Â›ÍÂÈ fiÙÈ ÙÔ 80-90% ÙˆÓ ‚·ÚÈ¿ ·Û¯fiÓÙˆÓ ÂÓËÏ›ÎˆÓ ·Ó¤¯ÔÓÙ·È ÙËÓ ÂÓÙÂÚÈ΋ Û›ÙÈÛË ÙȘ ÚÒÙ˜ ̤Ú˜ Ù˘ ÂÈÛ·ÁˆÁ‹˜ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÚÔ˘Û›· ‹ fi¯È ÂÓÙÂÚÈÎÒÓ ‹¯ˆÓ. T· Úfi‰ÚÔÌ· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ¤ÁηÈÚË Á·ÛÙÚÈ΋ Û›ÙÈÛË Â›Ó·È ÂÊÈÎÙ‹ Û ‰È¿ÊÔÚ˜ ·ı‹ÛÂȘ fiÔ˘ ··ÈÙÂ›Ù·È Ì˯·ÓÈÎfi˜ ·ÂÚÈÛÌfi˜. ™Â ÚfiÛÊ·ÙË ÌÂϤÙË ‰Â›¯ıËΠ›Û˘, fiÙÈ Ë ¤ÁηÈÚË ÂÓÙÂÚÈ΋ Û›ÙÈÛË Â›Ó·È ‰˘Ó·Ù‹ ·ÎfiÌË Î·È Û ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜ Ì ÔÍ›· ·ÁÎÚ·ٛÙȉ· (37). ™Â ÌÂϤÙ˜ Û ·È‰È¿, ÚfiÛÊ·ÙË ¤Ú¢ӷ ÂȂ‚·›ˆÛ ÙËÓ ·ÛÊ·Ï‹ ¯ÔÚ‹ÁËÛË ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ Û ·È‰È¿ Û Â͈ۈ̷ÙÈ΋ Ô͢ÁfiÓˆÛË (38). B¤‚·È·, Ë ÛÔ‚·Ú‹ ÓfiÛËÛË ÌÔÚ› Ó· ÂËÚ¿ÛÂÈ ·ÚÓËÙÈο ÙË Á·ÛÙÚÂÓÙÂÚÈ΋ ÏÂÈÙÔ˘ÚÁ›· (39). AÓ Î·È ÔÈ ÙÚ¤¯Ô˘Û˜ ·fi„ÂȘ ÁÈ· ÙÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ÙÔ˘˜ ˘Â‡ı˘ÓÔ˘˜ ÁÈ· ÙËÓ Á·ÛÙÚÈ΋ ΤӈÛË Â›Ó·È ÂÚÈÔÚÈṲ̂Ó˜, Â›Ó·È Ê·ÓÂÚfi fiÙÈ Ë Á·ÛÙÚÔ¿ÚÂÛË ÍÂÎÈÓ¿ ·fi ¤Ó· Ê¿ÛÌ· ÎÈÓËÙÈÎÒÓ ‰˘ÛÏÂÈÙÔ˘ÚÁÈÒÓ (40). H ·˘ÍË̤ÓË ÂÓ‰ÔÎÚ¿ÓÈ· ›ÂÛË, ÔÈ Î˘ÙÔΛÓ˜ Ô ·Ú¿ÁˆÓ ·ÂÏ¢ı¤ÚˆÛ˘ Ù˘ ÎÔÚÙÈÎÔÙÚÔ›Ó˘, Ù· ÔÈÔ-
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·299
¶∞π¢π∞∆ƒπ∫∏ 2000;63:292-301
Âȉ‹ Î·È ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜ Â›Ó·È ‰˘Ó·Ùfi Ó· ·ÛÎÔ‡Ó Î¿ÔÈ· ›‰Ú·ÛË. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË, ÔÈ ·ÛıÂÓ›˜ Ô˘ ÂÏ¿Ì‚·Ó·Ó Ó¢ÚÔÌ˘˚ÎÔ‡˜ ·ÔÎÏÂÈÛÙ¤˜ ˘ÔÏ›ÔÓÙ·Ó Ù˘ ÚÔ‚ÏÂfiÌÂÓ˘ £¶ ÏfiÁˆ ÙÔ˘ ÌÂÁ·Ï‡ÙÂÚÔ˘ ÔÛÔ‡ Á·ÛÙÚÈÎÔ‡ ˘ÔÏ›ÌÌ·ÙÔ˜. T· ÔÈÔÂȉ‹ Ê·›ÓÂÙ·È Â›Û˘ Ó· ·ÛÎÔ‡Ó ·ÚÓËÙÈ΋ ›‰Ú·ÛË ÛÙËÓ Á·ÛÙÚÈ΋ ΤӈÛË. ™Â ¿ÏÏË ÌÂϤÙË, Ë Û˘¯ÓfiÙËÙ· ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÂÈÏÔÎÒÓ ‹Ù·Ó ›Û˘ ¯·ÌËÏ‹ ÌÂٷ͇ ÙˆÓ ÌÈÎÚÒÓ ·È‰ÈÒÓ Ì ÂÁη‡Ì·Ù· Ô˘ ÛÈÙ›˙ÔÓÙ·Ó Ì ÚÈÓÔÁ·ÛÙÚÈÎfi ηıÂÙ‹Ú· (41). AÚÔÛ‰fiÎËÙ·, ÌÂÁ·Ï‡ÙÂÚË ‹Ù·Ó Ë Û˘¯ÓfiÙËÙ· ÙˆÓ Á·ÛÙÚÂÓÙÂÚÈÎÒÓ ÂÈÏÔÎÒÓ ÌÂٷ͇ ‚·Ú¤ˆ˜ ·Û¯fiÓÙˆÓ ·È‰ÈÒÓ Ô˘ ÛÈÙ›˙ÔÓÙ·Ó Ì ÂÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ ‰È·˘ÏˆÚÈο (42). KÔÈÏȷ΋ ‰È¿Ù·ÛË, ÌÂÁ¿ÏÔ Á·ÛÙÚÈÎfi ˘fiÏÂÈÌÌ· (17%), Î·È ‰È¿ÚÚÔÈ· (9,7%) ‹Ù·Ó ÔÈ Î˘ÚÈfiÙÂÚ˜ ÂÈÏÔΤ˜, Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ÚÔÛˆÚÈÓ‹ ‰È·ÎÔ‹. ™ÙÔ˘˜ ·ÛıÂÓ›˜ Ì·˜, Ë ‰È¿ÚÚÔÈ· ·ÓÙÈÌÂÙˆÈ˙fiÙ·Ó Ì ÚÔÛˆÚÈÓ‹ ÌfiÓÔ Ì›ˆÛË Ù˘ Û›ÙÈÛ˘, ÂÓÒ Ë ¯ÔÚ‹ÁËÛË ÛÈÛ·Ú›‰Ë˜ ‚ÂÏÙ›ˆÓ ·ÔÙÂÏÂÛÌ·ÙÈο ÙË Á·ÛÙÚÈ΋ ÎÈÓËÙÈÎfiÙËÙ·. H ÛÈÛ·Ú›‰Ë ¤¯ÂÈ ‰Âȯı› fiÙÈ ‚ÂÏÙÈÒÓÂÈ ÙËÓ Á·ÛÙÚÈ΋ ΤӈÛË Ú˘ıÌ›˙ÔÓÙ·˜ ÙË Û¯¤ÛË ÌÂٷ͇ ÙˆÓ Û˘Û¿ÛÂˆÓ ÙÔ˘ ‰ˆ‰Âη‰¿ÎÙ˘ÏÔ˘ Î·È ÙÔ˘ ¿ÓÙÚÔ˘ ÙÔ˘ ÛÙÔÌ¿¯Ô˘, Î·È ·˘Í¿ÓÔÓÙ·˜ ÙÔÓ ·ÚÈıÌfi ÙˆÓ Û˘ÛÙÔÏÒÓ ÙÔ˘ ¿ÓÙÚÔ˘ (43). EÍ¿ÏÏÔ˘, Ë ÓËÛÙ›· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ‰È¿ÚÚÔÈ·˜ ·Ú·Ù›ÓÂÈ ÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ·˘ÍË̤Ó˘ ‰È·ÂÚ·ÙfiÙËÙ·˜ ÛÙ· ÌÂÁ¿Ï· ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ ÌfiÚÈ· ÁÏ˘Îfi˙˘, ÂÓÒ Ë Û˘Ó¤¯ÈÛË Ù˘ ÂÓÙÂÚÈ΋˜ ‰È·ÙÚÔÊ‹˜ ¢ÓÔ› ÙË ÁÚËÁÔÚfiÙÂÚË ·Ó¿Ï·ÛË ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ (60). A˘Ù‹ Î·È ¿ÏϘ ÌÂϤÙ˜ ‰›ÓÔ˘Ó ¤ÌÊ·ÛË ÛÙËÓ ÂÍ¿ÚÙËÛË Ù˘ Á·ÛÙÚÂÓÙÂÚÈ΋˜ Ô‰Ô‡ ·fi ÙȘ ÂÓ‰Ô·˘ÏÈΤ˜ ıÚÂÙÈΤ˜ Ô˘Û›Â˜ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·È ÙËÓ ·Ó·Î·Ù·Û΢‹ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘. EÈÚfiÛıÂÙ·, ÔÏϷϤ˜ ÎÏÈÓÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ÂȂ‚·ÈÒÛÂÈ fiÙÈ Ë ¿ÌÂÛË Û›ÙÈÛË, Û ‰È¿ÊÔÚ· ‰È·ÚÚÔ˚ο Û‡Ó‰ÚÔÌ·, Û˘Ó‰¤ÂÙ·È Ì ηχÙÂÚË ¤Î‚·ÛË, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ‰È¿ÚÎÂÈ·˜ Ù˘ ÓfiÛÔ˘ (44), Ù˘ ·Ó¿ÎÙËÛ˘ ‚¿ÚÔ˘˜ Î·È ‚ÂÏÙ›ˆÛ˘ Ù˘ ηٿÛÙ·Û˘ ıÚ¤„˘ (45). A˘Ùfi ÂÓÈÛ¯‡ÂÙ·È Î·È ·fi ÙȘ ÙÂÏÂ˘Ù·›Â˜ Ô‰ËÁ›Â˜ Ù˘ AÌÂÚÈοÓÈ΢ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜ ÁÈ· ÙÔ ·È‰› ¯ˆÚ›˜ stress, Ë ÔÔ›· ÂȉÔÎÈÌ¿˙ÂÈ ÙËÓ ¿ÌÂÛË Û›ÙÈÛË Ì ·Ó¿ÏÔÁË ÁÈ· ÙËÓ ËÏÈΛ· ‰È·ÙÚÔÊ‹, ÛËÌÂÈÒÓÔÓÙ·˜ fiÙÈ ·˘Ù‹ Ë Ú·ÎÙÈ΋ ‰ÂÓ ¯ÂÈÚÔÙÂÚ‡ÂÈ ÙË ‰È¿ÚÚÔÈ·, ÌÔÚ› Ó· ÌÂÈÒÛÂÈ ÙȘ ÎÂÓÒÛÂȘ, Ó· ‚Ú·¯‡ÓÂÈ ÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ÓfiÛÔ˘ Î·È Ó· ‚ÂÏÙÈÒÛÂÈ ÙË ıÚ¤„Ë (46). E˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ ‰Â›¯ÓÔ˘Ó Â›Û˘, fiÙÈ Î·È Û ηٿÛÙ·ÛË ‚·ÚÈ¿˜ ÓfiÛÔ˘, ÙÔ ·È‰› Ì ÙË ‰È¿ÚÚÔÈ· ‹ ÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ Á·ÛÙÚÈ΋˜ ΤӈÛ˘ ı· Ú¤ÂÈ Ó· Û˘Ó¯›˙ÂÈ Ó· ÛÈÙ›˙ÂÙ·È, ·Ó Î·È Û ÌÈÎÚfiÙÂÚÔ Ú˘ıÌfi ·ÚÔ‰Èο. MfiÓÔ 2 ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ ·¤Ù˘¯·Ó ÛÙËÓ ÔÏÔÎÏ‹ÚˆÛË ÙÔ˘ ÚˆÙÔÎfiÏÏÔ˘, Î·È ˘ÔÛÙËÚ›¯ıËÎ·Ó Ì O¶¢. A˘Ùfi ÙÔ ÔÛÔÛÙfi Â›Ó·È ÌÈÎÚfiÙÂÚÔ ·fi ÙÔ 9,7% ÌÈ·˜ ÌÂϤÙ˘ Ì ÂÓÙÂÚÈ΋ Û›ÙÈÛË, ÛÙËÓ ÔÔ›· Ë ÂÓÙÂÚÈ΋ Û›ÙÈÛË ‰ÈÂÎfiË. ¶ÚÔÛˆÚÈÓ‹ ‰È·ÎÔ‹ Ù˘
EÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Û ·È‰È¿ Û ME£
Û›ÙÈÛ˘ ÛÙËÓ ÏÂÈÔ„ËÊ›· ÙˆÓ ·ÛıÂÓÒÓ Ì·˜ ‰ÂÓ ÔÊÂÈÏfiÙ·Ó ÛÙË ÌË ·ÓÔ¯‹ Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘, ·ÏÏ¿ ÛÙËÓ ÂÎÏÂÎÙÈ΋ ÚÔÛˆÚÈÓ‹ ‰È·ÎÔ‹ ÏfiÁˆ ·ÔۈϋӈÛ˘. ¶·ÚfiÏÔ Ô˘ ÙÔ ÚˆÙfiÎÔÏÏÔ Ù˘ E°™ ηıfiÚÈ˙Â Û˘ÁÎÂÎÚÈ̤ÓÔ ıÂÚÌȉÈÎfi ÛÙfi¯Ô, ÔÈ ÒÚ˜ ¯ˆÚ›˜ Û›ÙÈÛË Ù˘ ÚÔÛˆÚÈÓ‹˜ ‰È·ÎÔ‹˜ ‰ÂÓ ·Ó·ÏËÚÒÓÔÓÙ·Ó ¿ÓÙÔÙ (81,8 %). TÔ Â‡ÚËÌ· ·˘Ùfi ÙÔÓ›˙ÂÈ ÙËÓ ·Ó·ÁηÈfiÙËÙ· Ù˘ ¯Ú‹Û˘ ÂÓfi˜ ηٿÏÏËÏ· ۯ‰ȷṲ̂ÓÔ˘ ÚˆÙÔÎfiÏÏÔ˘, Ì ηٿÏÏËÏ· ÂÎ·È‰Â˘Ì¤ÓÔ ÚÔÛˆÈÎfi, ÁÈ· ÙÔÓ ÂÚÈÔÚÈÛÌfi ÙˆÓ ¯ÂÈÚÈÛÌÒÓ Î·Ù¿ ÙË Û›ÙÈÛË. M ÂÈÌÔÓ‹ (‰È·ÎÔ‹ Ù˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘ ÌfiÓÔ fiÙ·Ó Ë ÔÛfiÙËÙ· ÙÔ˘ ˘ÔÏ›ÌÌ·ÙÔ˜ ÍÂÂÚÓÔ‡Û ÙËÓ Û›ÙÈÛË ÙÔ˘ ÙÂÏÂ˘Ù·›Ô˘ 12ÒÚÔ˘) Î·È ÏÔÁÈ΋ ¯ÔÚ‹ÁËÛË ÚÔÎÈÓËÙÈÎÒÓ Ô˘ÛÈÒÓ, Ë ·Ó·ÏÔÁ›· ÂÓËÏ›ÎˆÓ ·ÛıÂÓÒÓ Ô˘ ÂÏ¿Ì‚·Ó·Ó ÌfiÓÔ ÂÓÙÂÚÈ΋ Û›ÙÈÛË ·˘Í‹ıËΠÛËÌ·ÓÙÈο ·fi 48,5 Û 91% (47). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Û˘Ó¯‹˜ 24-ˆÚË ÚÈÓÔÁ·ÛÙÚÈ΋ Û›ÙÈÛË ·ÔÙÂÏ› ·ÛÊ·Ï‹ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ̤ıÔ‰Ô ÁÈ· ÙËÓ ÂÈÙ˘¯‹ Î¿Ï˘„Ë ÙˆÓ ıÂÚÌȉÈÎÒÓ ·Ó·ÁÎÒÓ Î·È ÙË ‚ÂÏÙ›ˆÛË Ù˘ ıÚÂÙÈ΋˜ ηٿÛÙ·Û˘ ·È‰ÈÒÓ ÛÙËÓ ÔÍ›· Ê¿ÛË ÎÚ›ÛÈÌ˘ ÓfiÛÔ˘. H ¤ÁηÈÚË ÚÈÓÔÁ·ÛÙÚÈ΋ Û›ÙÈÛË ·Ô‰Â›¯ıËΠÂÊ·ÚÌfiÛÈÌË Û ‰È¿ÊÔÚ˜ ·ı‹ÛÂȘ, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ÛË„·ÈÌ›·˜ Î·È Ù˘ ÎÚ·ÓÈÔÂÁÎÂÊ·ÏÈ΋˜ οΈÛ˘, Î·È Î·Ï¿ ·ÓÂÎÙ‹ ÛÙ· ÂÚÈÛÛfiÙÂÚ· ‚·ÚÈ¿ ¿Û¯ÔÓÙ· ·È‰È¿. H Û˘Û¯¤ÙÈÛË Ù˘ ›ÌÔÓ˘ ¯·ÌËÏ‹˜ Ì˘Ôηډȷ΋˜ Û˘ÛÙ·ÏÙÈÎfiÙËÙ·˜ (ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓË Î·Ù·ÏËÍ›·) Ì ÙËÓ ·ÓÂÈÙ˘¯‹ ¤Î‚·ÛË ÂÓfi˜ ÂÈıÂÙÈÎÔ‡ ÚˆÙÔÎfiÏÏÔ˘ ÂÓÙÂÚÈ΋˜ Û›ÙÈÛ˘, ÂÚÈÁÚ¿ÊÂÙ·È ÁÈ· ÚÒÙË ÊÔÚ¿. BÈ‚ÏÈÔÁÚ·Ê›· 1. McClave SA, Lowen CC, Snider HL. Immunonutrition and enteral hyperalimentation of critically ill patients. Dig Dis Sci 1992;37:1153-1161. 2. Braga M, Gianotti L, Vignali A, Cestari A, Bisagi P, Carlo VD. Artificial nutrition after major abdominal surgery: Impact of route of administration and composition of the diet. Crit Care Med 1998;26:24-30. 3. Layan AJ, Orlando FG, Day AL, Kilroy RA, James PB, McGuigan JE. The effect of duodenojejunal alimentation on gastric pH and hormones in intensive care unit patients. Chest 1991;99:695. 4. Chiarelli A, Enzi G, Casadei A, Baggio B, Valerio A, Mazzoleni F. Very early nutritional supplementation in burned patients. Am J Clin Nutr 1990;51:1035-1039. 5. Moore MEE, Jones TH. Benefits of immediate jejunostomy feeding after major abdominal trauma. A prospective randomized study. J Trauma 1986;26:874-881. 6. Members of the American College of Chest Physicians / Society of Critical Care Medicine Consensus Conference Committee. American College of Chest Physicians / Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992;20:864-874. 7. Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of
299
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·300
¶∞π¢π∞∆ƒπ∫∏ 2000;63:292-301
8. 9.
10.
11.
12. 13.
14.
15.
16. 17.
18.
19.
20. 21.
22.
23.
24.
25.
mortality (PRISM) score. Crit Care Med 1988;16:11101116. Keene AR, Cullen DJ. Therapeutic Intervention Scoring System: Update 1983. Crit Care Med 1983;11:1-3. Wilkinson JD, Pollack MM, Glass NL, Kanter RK, Katz RW, Steihart CM. Mortality associated with multiple organ system failure and sepsis in pediatric intensive care unit. J Pediatr 1987;111:324-328. Schofield WN. Predicting basal metabolic rate, new standards and review of previous work. Human Nutrition: Clinical Nutrition 1985;39C (I Suppl):S5-S41. Harris JA, Benedict FG. Biometric studies of basal metabolism in man. Washington, DC: Carnegie Institute. 1919, publication 2793. Seashore JH. Nutritional support of children in the intensive care unit. Yale J Biol Med 1984;57:111-134. Subcommittee on the tenth edition of the RDAs, Food and Nutritional Research Council. Recommended Dietary Allowances. 10th ed. Washington, DC: National Academy Press;1989: 25-77. Friscancho AR. Triceps skinfold and upper arm muscle size norms for assessment of nutritional status. Am J Clinic Nutr 1974;27:1052-1058. Ryan A, Martinez GA. Physical growth of infants 7 to 13 months of age: Results from a national survey. Am J Phys Anthopol 1987;73:449-457. Waterlow JC. Classification and definition of protein calorie malnutrition. BMJ 1972;3:566. Briassoulis G, Shekhar Venkataraman S, Thompson A. Energy expenditure in critically ill children. Crit Care Med. 2000 Apr;28(4):1166-1172. Verhoeven JJ, Hazelzet Verhoeven JJ, Hazelzet JA, van der Voort E, Joosten KF. Comparison of measured and predicted energy expenditure in mechanically ventilated children. Intensive Care Med 1998;24:464-468. Beaton GH. Nutritional needs during the first year of life: Some concepts and perspectives. Pediatr Clin North Amer 1985:32:275-288. Talbot FB. Basal metabolism standards for children. Amer J Dis Child 1938;55:455-459. Weissman C, Kemper M. Assessing hypermetabolism and hypometabolism in the postoperative critically ill patient. Chest 1992;102:1566-1571. Bursztein S, Elwyn DH, Askanazi J. Energy metabolism and indirect calorimetry in critically ill and injured patients. Acute Care 1989;15:91-110. de Ledinghen V, Beau P, Mannant PR, Borderie C, Ripault MP, Silvain C et al. Early feeding or enteral nutrition in patients with cirrhosis after bleeding from esophageal varices? A randomized controlled study. Dig Dis Sci 1997;42:536-541. Kreymann G, Grosser S, Buggisch P, Gottschall C, Matthaei S, Greten H. Oxygen consumption and resting metabolic rate in sepsis, sepsis syndrome, and septic shock. Crit Care Med 1993;21:1012-1019. Winthrop AL, Wesson DE, Penchars PB, Jacobs DG, Tibor H, Filler RM. Injury severity, whole-body protein turnover and energy expenditure in pediatric trauma. J Pediatr Surg 1987;22:534-537.
300
°. MÚÈ·ÛÔ‡Ï˘ Î·È Û˘Ó.
26. Cebara BM, Gelmini M, Sarnik A. Oxygen consumption, energy expenditure, and substrate utilization after cardiac surgery in children. Crit Care Med 1992;20:1550-1554. 27. Forsyth JS, Crighton A. Low birthweight infants and total parenteral nutrition immediately after birth. I. Energy expenditure and respiratory quotient of ventilated and non-ventilated infants. Arch Dis Child 1995;73:F4-F7. 28. Joosten KF, Verhoeven JJ, Hazelzet JA. Energy expenditure and substrate utilization in mechanically ventilated children. Nutrition 1999;15:444-448. 29. Adam S, Batson S.A study of problems with the delivery of enteral feed in critically ill patients in 5 ICUs in the UK. Intensive Care Med 1997;23:261-266. 30. Heyland DK, Cook DJ, Winder B, Guyatt GH. Do critically ill patients tolerate early intragastric enteral nutrition? Clin Intensive Care 1996;7:68-73. 31. Gianotti L, Alexander JW, Nelson JL, Fukushima R, Pyles T, Chalk CL. Role of early enteral feeding and acute starvation on postburn bacterial translocation and host defense: prospective, randomized trials. Crit Care Med 1994;22:265-272. 32. Wolf SE, Jeschke MG, Rose JK, Desai MH, Herndon DN. Enteral feeding intolerance: an indicator of sepsisassociated mortality in burned children. Arch Surg 1997;132:1310-1314. 33. Alexander JW. Nutrition and translocation. JPEN 1990;14 (suppl):S170-S174. 34. Purcell PN, Danis K, Branson RD, Johnson DJ. Continuous duodenal feeding restores gut blood flow and increases gut blood flow and increases gut oxygen utilization during PEEP ventilation for lung injury. Am J Surg 1993;165:188-194. 35. Kudsk KA, Kudsk MD, Minard G. Enteral versus parenteral nutrition in the critically ill and injured. Curr Opin Crit Care 1995;1:255-260. 36. Moore MEE, Jones TN. Benefits of immediate jejunostomy feeding after major abdominal trauma. A prospective, randomised study. J Trauma 1986;26:874-881. 37. Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos CA. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg 1997;84:1665-1669. 38. Pettignano R, Heard M, Davis R, Labuz M, Hart M. Total enteral nutrition versus total parenteral nutrition during pediatric extracorporeal membrane oxygenation. Crit Care Med 1998;26:358-363. 39. Zaloga GP. Bedside method for placing small bowel feeding tubes in critically ill patients. Chest 1991;100:1643-1646. 40. Horowitz M, Fraser RJ. Gastroparesis: diagnosis and management. Scand J Gastroenterol Suppl 1995;213:716. 41. Trocki O, Michelini JA, Robbins ST, Eichelberger MR Evaluation of early enteral feeding in children less than 3 years old with smaller burns (8-25 per cent TBSA). Burns 1995;21(1):17-23. 42. Panadero E, Lopez-Herce J, Caro L, Sac\nchez A, Cueto E, Bustinza A. Transpyloric enteral feeding in critically ill children. J Pediatr Gastroenterol 1998;26:43-48.
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·301
¶∞π¢π∞∆ƒπ∫∏ 2000;63:292-301
43. Fraser RJ, Horowitz M, Maddox AF, Deut J. Postprandial antropyloroduodenal motility and gastric emptying in gastroparesis - effects of cisapride. Gut 1994;35:172-178. 44. Black R, Brown K, Becker S. Effects of diarrhea associated with specific enteropathogens on the growth of children in rural Bangladesh. Pediatrics 1984;73:799-805. 45. Brown KH, Gastanaduy AS, Saavedra JM, Lembcke J, Rivas D, Robertson AD, et al. Effect of continued oral feeding on clinical and nutritional outcomes of acute diarrhea in children. J Pediatr 1988;112:191-200.
EÓÙÂÚÈ΋ ‰È·ÙÚÔÊ‹ Û ·È‰È¿ Û ME£
46. Duggan C, Nurko S. “Feeding the gut”: The scientific basis for continued enteral nutrition during acute diarrhea. J Pediatr 1997;131:801-808. 47. Beale RJ, Maynard N, Smithies MN. Changing nutritional therapy in a general ICU. Intensive Care Med 1992;18 (2 suppl):S104.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 10-01-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-06-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °. ªÚÈ·ÛÔ‡Ï˘ ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ”∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
301
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·302
¶∞π¢π∞∆ƒπ∫∏ 2000;63:302-308
¢ÈÔÈÛÔÊ¿ÁÂÈ· ÎÔÏÈ΋ ‚ËÌ·ÙÔ‰fiÙËÛË ÛÙ· ÓÂÔÁÓ¿: EÎÙ›ÌËÛË Ù˘ ı¤Û˘ ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ AÓ‰Ú¤·˜ E. M·ÚÁÂÙ¿Î˘1, XÚÈÛÙ›Ó· TÚ¿·ÏË1, ¢ËÌ‹ÙÚ˘ °ÂˆÚÁ·ÎfiÔ˘ÏÔ˜1, °ÂˆÚÁ›· °ÚËÁÔÚÈ¿‰Ô˘1, NÈÎÔϤٷ I·Îˆ‚›‰Ô˘2, °ÂÒÚÁÈÔ˜ KÔ˘Ú¿Î˘2, HÚ·ÎÏ‹˜ ¢ÂÏÏ·ÁÚ·ÌÌ¿ÙÈη˜2 ● ¶ÂÚ›ÏË„Ë: H ‰ÈÔÈÛÔÊ¿ÁÂÈ· ‚ËÌ·ÙÔ‰fiÙËÛË Î·È ËÏÂÎÙÚÔηډÈÔÁÚ·Ê›· ¤¯ÂÈ ÛÔ˘‰·›· ‰È·ÁÓˆÛÙÈ΋ Î·È ıÂڷ¢ÙÈ΋ ÛËÌ·Û›· ÛÙ· ÓÂÔÁÓ¿. H ÌÂϤÙË ·˘Ù‹ ÂÎÙÈÌ¿ ÙÔ ‚¿ıÔ˜ ÂÈÛfi‰Ô˘ ÙÔ˘ ηıÂÙ‹Ú· ÛÙË ı¤ÛË ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ Û 26 ÓÂÔÁÓ¿ ËÏÈΛ·˜ ·fi 2 ̤¯ÚÈ 16 ËÌÂÚÒÓ, ÌÂ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· (15 ÓÂÔÁÓ¿) ‹ Ê˘ÛÈÔÏÔÁÈ΋ ηډȿ (11 ÓÂÔÁÓ¿) Î·È ·ÚÚ˘ı̛˜. XÚËÛÈÌÔÔÈ‹ıËΠ‰ÈÔÏÈÎfi ÔÈÛÔÊ¿ÁÂÈÔ ËÏÂÎÙÚfi‰ÈÔ 6 Fr Ì ‰È·ÔÏÈÎfi ‰È¿ÛÙËÌ· 20 mm Î·È Ë ‰È¤ÁÂÚÛË ¤ÁÈÓ ηٿ ÙË ‰È¿ÚÎÂÈ· ÊÏ‚ÔÎÔÌ‚ÈÎÔ‡ Ú˘ıÌÔ‡ Ì ÚÔÁÚ·ÌÌ·ÙÈ˙fiÌÂÓÔ ‰ÈÂÁ¤ÚÙË, Ì ‰È¿ÚÎÂÈ· ÂÚÂı›ÛÌ·ÙÔ˜ 10 msec Î·È Ì ‰˘Ó·ÙfiÙËÙ· ÌÂÙ·ÊÔÚ¿˜ ÛÙ·ıÂÚÔ‡, ÙÂÙÚ¿ÁˆÓÔ˘ Ú‡̷ÙÔ˜ Ì ¤ÓÙ·ÛË ·fi 020 mA. O ̤ÛÔ˜ ÂÏ¿¯ÈÛÙÔ˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜ ‹Ù·Ó 8,39 mA (‰È·Î‡Ì·ÓÛË 7-10 mA), ÙÔ Ì¤ÛÔ ‡„Ô˜ ÙÔ˘ ‰ÈÔÏÈÎÔ‡ ÎÔÏÈÎÔ‡ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜ ‹Ù·Ó 0,57 mV (‰È·Î‡Ì·ÓÛË 0,45-0,65 mV). TÔ Ì¤ÛÔ ‚¿ıÔ˜ ÛÙË ı¤ÛË ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ ‹Ù·Ó 12,93 cm (‰È·Î‡Ì·ÓÛË 11-14,5 cm), Ô ÂÏ¿¯ÈÛÙÔ˜ Ô˘‰fi˜ ·ÓȯÓ¢fiÙ·Ó 0,5 cm Âη٤ڈıÂÓ ÙÔ˘ ̤ÛÔ˘ ‚¿ıÔ˘˜ ÂÈÛfi‰Ô˘ ÙÔ˘ ηıÂÙ‹Ú· (ÚÈÓÔÁ·ÛÙÚÈο) Î·È Û˘Û¯ÂÙÈ˙fiÙ·Ó Ì ÙÔ Ì‹ÎÔ˜ ÙÔ˘ ÓÂÔÁÓÔ‡ (r=0,59). TÔ Ì¤ÁÈÛÙÔ ÎÔÏÈÎfi ËÏÂÎÙÚfiÁÚ·ÌÌ· ›¯Â Ôχ ÈÛ¯˘Ú‹ ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙÔÓ ÂÏ¿¯ÈÛÙÔ Ô˘‰fi (r=-0,95) ÛÙË ı¤ÛË ·Ó›¯Ó¢Û˘ ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ Ô˘‰Ô‡. ¢ÂÓ ‰È·ÈÛÙÒıËΠ‰È·ÊÔÚ¿ Û η̛· ·Ú¿ÌÂÙÚÔ ÌÂٷ͇ ÙˆÓ ÓÂÔÁÓÒÓ ÌÂ Û˘ÁÁÂÓ‹ Î·È ÂÎÂ›ÓˆÓ ¯ˆÚ›˜ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·. ™Ù· ÓÂÔÁÓ¿, Ô ˘ÔÏÔÁÈÛÌfi˜ ÙÔ˘ ‚¿ıÔ˘˜ ÂÈÛfi‰Ô˘ ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ηıÂÙ‹Ú· Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË Ù˘ ı¤Û˘ Ô˘ ηٷÁÚ¿ÊÂÙ·È ÙÔ Ì¤ÁÈÛÙÔ ÎÔÏÈÎfi ËÏÂÎÙÚfiÁÚ·ÌÌ· Â›Ó·È ÚÔÙÈÌfiÙÂÚÔ˜ ·fi ÙÔÓ ˘ÔÏÔÁÈÛÌfi Ì ‚¿ÛË ÙÔ Ì‹ÎÔ˜ ÙÔ˘ ÓÂÔÁÓÔ‡. ¶·È‰È·ÙÚÈ΋ 2000;63:302-308. §¤ÍÂȘ ÎÏÂȉȿ: ‰ÈÔÈÛÔÊ¿ÁÂÈ· ÎÔÏÈ΋ ‚ËÌ·ÙÔ‰fiÙËÛË, ÓÂÔÁÓfi, ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜. A. Margetakis, C. Trapali, D. Georgakopoulos, G. Grigoriadou, N. Iakovidou, G. Kourakis, H. Dellagrammaticas. Transoesophageal pacing in neonates: Estimation of the appropriate site of minimum pacing threshold. Paediatriki 2000;63:302-308. ● Abstract: Transoesophageal pacing and electrocardiography have important diagnostic and therapeutic uses in the neonate. This study evaluated the depth of esophageal insertion in minimizing transoesophageal atrial pacing threshold in 26 neonates aged 2 to 16 days with congenital heart disease (15) or normal heart (11) and arrhythmias. A 6 Fr oesophageal electrode with interelectrode spacing of 20 mm was used. Stimulation was performed during sinus rhythm with a programmable stimulator capable of delivering a constant-current, square-wave of 0-20 mA, with pulse width of 10 msec. The average minimal pacing threshold was 8.39 mA (range 7 to 10). The average maximum bipolar atrial electrogram amplitude was 0.57 mA (range 0.45 to 0.65). The average depth of catheter insertion in the site of minimal pacing threshold was 12.93 cm (range 11 to 14.5), it occurred within 0.5 cm bilaterally, and was correlated with patient height (r=0.59). The maximum bipolar atrial electrogram was highly negatively correlated with the minimum pacing threshold (r=-0.95) in the site of minimal threshold. There was no difference between neonates with and without congenital heart disease. In neonates, the estimation of catheter insertion depth using the maximum atrial electrogram amplitude is preferable to that for using the patient's height, and is critical for minimizing pacing threshold. Key words: transoesophageal atrial pacing, neonate, threshold.
NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ AıËÓÒÓ "¶.& A. K˘ÚÈ·ÎÔ‡" 1 K·Ú‰ÈÔÏÔÁÈÎfi TÌ‹Ì· 2 ME£ ÓÂÔÁÓÒÓ
302
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·303
¶∞π¢π∞∆ƒπ∫∏ 2000;63:302-308
EÈÛ·ÁˆÁ‹ T· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Á›ÓÔÓÙ·È ÚÔÛ¿ıÂȘ ÁÈ· Ó· ÙÂÎÌËÚȈıÔ‡Ó ÔÈ ÂȉÈΤ˜ ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈΤ˜ ‰È·ÁÓÒÛÂȘ Û ÓÂÔÁÓ¿ Ì ‰È·Ù·Ú·¯¤˜ ÙÔ˘ Ú˘ıÌÔ‡. TÔ ¤Ó·˘ÛÌ·, ηٿ ¤Ó· ÌÂÁ¿ÏÔ Ì¤ÚÔ˜, ÔÊ›ÏÂÙ·È ÛÙËÓ ‚ÂÏÙ›ˆÛË Ù˘ ηٷÓfiËÛ˘ ÙˆÓ ‰È·Ù·Ú·¯ÒÓ ÙÔ˘ Ú˘ıÌÔ‡ Î·È ÛÙË ‰È¿ıÂÛË ÏËıÒÚ·˜ Ê·Ú̿ΈÓ, ‚ËÌ·ÙÔ‰ÔÙÒÓ Î·È ¯ÂÈÚÔ˘ÚÁÈÎÒÓ Ù¯ÓÈÎÒÓ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘˜. A˘Ù¤˜ ÔÈ ıÂڷ¢ÙÈΤ˜ Î·È ‰È·ÁÓˆÛÙÈΤ˜ Ù¯ÓÈΤ˜ ÌÔÚÔ‡Ó Ó· ÂÊ·ÚÌÔÛÙÔ‡Ó Â‡ÎÔÏ· Î·È Â·ÚÎÒ˜ Û ÓÂÔÁÓ¿ Ì ‰È·Ù·Ú·¯¤˜ ÙÔ˘ Ú˘ıÌÔ‡, fiÙ·Ó ‰Ôı› ÚÔÛÔ¯‹ Û ÌÂÚÈΤ˜ ÏÂÙÔ̤ÚÂȘ. H ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ ·ÔÙÂÏ› Ì›· ·fi ÙȘ ·ÚȘ Û˘ÓÈÛÙÒÛ˜ ÂÈÙ˘¯Ô‡˜ ‚ËÌ·ÙÔ‰fiÙËÛ˘, ·ÊÔ‡ Ì ÙÔÓ Î·ıÔÚÈÛÌfi ÙÔ˘ ÌÔÚ› Ó· ÂÈÙ¢¯ı› ·ÔÙÂÏÂÛÌ·ÙÈ΋ ‚ËÌ·ÙÔ‰fiÙËÛË ·ÊÂÓfi˜, Î·È ·ÊÂÙ¤ÚÔ˘ Ó· ·ÔÊ¢¯ı› ÙÔ ·›ÛıËÌ· η‡ÛÔ˘ ‹ ÂÏ·ÊÚÔ‡ fiÓÔ˘ Ô˘ ÚÔηÏ›ٷÈ, fiÙ·Ó Ë ¤ÓÙ·ÛË ÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ú‡̷ÙÔ˜ ÍÂÂÚ¿ÛÂÈ Ù· 15 mA(1). ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ‹Ù·Ó Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘ ÌÂÁ¤ıÔ˘˜ Î·È Ù˘ ı¤Û˘ ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‰ÈÔÈÛÔÊ¿ÁÂÈÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ ÛÙ· ÓÂÔÁÓ¿ Î·È Ë Û¯¤ÛË ÙÔ˘ Ì‹ÎÔ˘˜ ÛÒÌ·ÙÔ˜ ÚÔ˜ ÙÔ ‚¿ıÔ˜ ÙÔÔı¤ÙËÛ˘ ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ ËÏÂÎÙÚÔ‰›Ô˘. ¶·ÚfiÌÔÈ· ÌÂϤÙË ‰ÂÓ ¤¯ÂÈ Ì¤¯ÚÈ Û‹ÌÂÚ· ‰ËÌÔÛÈ¢Ù› ÛÙËÓ ÂÏÏËÓÈ΋ ‚È‚ÏÈÔÁÚ·Ê›·, ÂÓÒ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, ·' fi,ÙÈ ÁÓˆÚ›˙Ô˘ÌÂ, ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÙ›ÛÙÔÈ¯Ë ÌÂϤÙË Ô˘ Ó· ·Ó·Ê¤ÚÂÙ·È ·ÔÎÏÂÈÛÙÈο Û ÓÂÔÁÓ¿. YÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ TÔ ˘ÏÈÎfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó 26 ÓÂÔÁÓ¿ (12 ¿ÚÚÂÓ·, 14 ı‹Ï·), ËÏÈΛ·˜ ·ËÛ˘ 32-41 ‚‰ÔÌ¿‰ˆÓ (38±1,42), ËÏÈΛ·˜ 2-16 ËÌÂÚÒÓ (6,96±4,27 ËÌ), ‚¿ÚÔ˘˜ 1750-4200 g (2858±754 g) Î·È Ì‹ÎÔ˘˜ 37-50 cm (43,04±4,08), ÛÙ· Ï·›ÛÈ· Ù˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ‰È¿ÊÔÚˆÓ ·ÚÚ˘ıÌÈÒÓ ÙÔ˘˜ Ì ‰ÈÔÈÛÔÊ¿ÁÂÈ· ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈ΋ ÌÂϤÙË. ¢Âη¤ÓÙ ·fi Ù· ÓÂÔÁÓ¿ ·˘Ù¿ ›¯·Ó Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· Î·È 11 ›¯·Ó Ê˘ÛÈÔÏÔÁÈ΋ ηډȿ.
OÈÛÔÊ¿ÁÂÈÔ˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜
BËÌ·ÙÔ‰fiÙ˘/Stimulator ™Â fiϘ ÙȘ ÌÂϤÙ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠÔÏ˘ÚÔÁÚ·ÌÌ·ÙÈ˙fiÌÂÓÔ˜ ‰ÈÂÁ¤ÚÙ˘ (FIAB programmable stimulator model 8817). H ‰ÈÔÈÛÔÊ¿ÁÂÈ· ‰È¤ÁÂÚÛË ÁÈÓfiÙ·Ó Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÛÙ·ıÂÚÔ‡ Î·È ÙÂÙÚ¿ÁˆÓ˘ ÌÔÚÊ‹˜ Ú‡̷ÙÔ˜, ‰È¿ÚÎÂÈ·˜ 10 msec (Pulse width). T¯ÓÈ΋ ÔÈÛÔÊ¿ÁÂÈ·˜ ηٷÁÚ·Ê‹˜ Î·È ‰È¤ÁÂÚÛ˘: ™Â fiϘ ÙȘ ÌÂϤÙ˜ ¯ÚËÛÈÌÔÔÈ‹ıËΠ¢ΛÓËÙÔ, Ì·Ï·Îfi Î·È ·ÚÈıÌË̤ÓÔ ‰ÈÔÏÈÎfi ‚ËÌ·ÙÔ‰ÔÙÈÎfi ËÏÂÎÙÚfi‰ÈÔ ÛÈÏÈÎfiÓ˘ 6 Fr (FIAB mod. 25125E ESOKID 2) Ì ‰È·ÔÏÈÎfi ‰È¿ÛÙËÌ· 20 mm. TÔ ËÏÂÎÙÚfi‰ÈÔ ÂÈÛ‹¯ıË ·fi ÙÔ ÚÒıˆÓ· ηٿ ÙÔÓ ›‰ÈÔ ÙÚfiÔ Ô˘ ÂÈÛ¿ÁÂÙ·È ¤Ó·˜ ÚÈÓÔÁ·ÛÙÚÈÎfi˜ ηıÂÙ‹Ú·˜ Ì ·Ú¯ÈÎfi ‚¿ıÔ˜ Ù· 16 ÂηÙÔÛÙ¿. H ·fiÛÙ·ÛË ·˘Ù‹ ÛËÌÂÈÒıËΠ¿Óˆ ÛÙÔ ËÏÂÎÙÚfi‰ÈÔ Î·È ·ÓÙÈÛÙÔȯԇÛ ÛÙËÓ ·fiÛÙ·ÛË ÚÒıˆÓ·˜-¿ˆ ¿ÎÚÔ ÙÔ˘ ËÏÂÎÙÚÔ‰›Ô˘ (distal). ™ÙË ı¤ÛË ·˘Ù‹ ηٷÁÚ¿ÊÔÓÙ·Ó Î·È ÊÈÏÙÚ¿ÚÔÓÙ·Ó ÛÙ· 40 Hz Ù· ‰ÈÔÏÈο ËÏÂÎÙÚÔÁÚ¿ÌÌ·Ù·. MÂÙÚÔ‡Û·Ì ÙÔ peak-to-peak ‡„Ô˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ÎÔÏÈÎÔ‡ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜ Ô˘ ÚÔÂÚ¯fiÙ·Ó ·fi ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÊÏ‚ÔÎÔÌ‚È΋ ÂÓÂÚÁÔÔ›ËÛË (EÈÎfiÓ· 1). ™ÙË ı¤ÛË ·˘Ù‹ ¯ÔÚËÁÔ‡Û·Ì ̛· ÛÂÈÚ¿ ÂÚÂıÈÛÌ¿ÙˆÓ Ì ̋ÎÔ˜ ·ÎÏÔ˘ 80% ·˘ÙÔ‡ ÙÔ˘ ÊÏ‚ÔÎÔÌ‚ÈÎÔ‡ Ú˘ıÌÔ‡, ·Ú¯›˙ÔÓÙ·˜ ·fi Ù· 16 mA Î·È ÌÂÈÒÓÔÓÙ·˜ Û˘Ó¯Ҙ ÙËÓ ¤ÓÙ·ÛË ÙÔ˘ Ú‡̷ÙÔ˜ (amplitude) ηٿ 1 mA ̤¯ÚȘ fiÙÔ˘ Ó· ÌË "Û˘ÏÏ·Ì‚¿ÓÂÙ·È" Ô ÎfiÏÔ˜ (EÈÎfiÓ· 1). H ÂÏ¿¯ÈÛÙË ··ÈÙÔ‡ÌÂÓË ¤ÓÙ·ÛË Ë ÔÔ›· ‰È¤ÁÂÈÚ ÙÔÓ ÎfiÏÔ ÔÚ›ÛÙËÎÂ Û·Ó "Ô ÙÔÈÎfi˜ ‰ÈÔÈÛÔÊ¿ÁÂÈÔ˜ Ô˘‰fi˜". K¿ı ‚ËÌ·ÙÔ‰ÔÙÈ΋ ÚÔÛ¿ıÂÈ· ηٷÁÚ·ÊfiÙ·Ó ÛÙÔÓ ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊÔ.
AÓ·ÈÛıËÛ›·-ηٷÛÙÔÏ‹ H ÌÂϤÙË Û fiÏ· Ù· ÓÂÔÁÓ¿ ¤ÁÈÓ ÛÙËÓ ÎÏ›ÓË ÙÔ˘˜. ™Â ηӤӷ ‰ÂÓ ¯ÚËÛÈÌÔÔÈ‹ıËΠ·Ó·ÈÛıËÛ›·. ™Â ‰‡Ô ÏfiÁˆ ¤ÓÙÔÓ˘ ·ÓËÛ˘¯›·˜ ¯ÔÚËÁ‹ıËΠ¯ÏˆÚ¿ÏË (50 mg /Kg POs). HÏÂÎÙÚÔηډÈÔÁÚ·ÊÈΤ˜ ηٷÁڷʤ˜ XÚËÛÈÌÔÔÈ‹ıËΠÎÔÈÓfi˜ ÙÚÈηӷÏÈÎfi˜ ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊÔ˜ (Mac PC Marquet) ÁÈ· ÙËÓ Ù·˘Ùfi¯ÚÔÓË Î·Ù·ÁÚ·Ê‹ ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜ Î·È ÙˆÓ V1, V2 ‹ D2, Ì ʛÏÙÚÔ ÛÙ· 40 Hz. H ηٷÁÚ·Ê‹ ÁÈÓfiÙ·Ó Ì ٷ¯‡ÙËÙ· ¯·ÚÙÈÔ‡ 25 Î·È 50 mm/sec Î·È Â˘·ÈÛıËÛ›· 20mm/mV.
EÈÎfiÓ· 1: (A) ‚ËÌ·ÙÔ‰fiÙËÛË (s) ·Ú¯Èο Ì ¤ÓÙ·ÛË 8 mA ÛÙËÓ ÔÔ›· ·Ú·ÙËÚÂ›Ù·È "Û‡ÏÏË„Ë" ÙÔ˘ ÎfiÏÔ˘ ·ÏÏ¿ Ë ‚ËÌ·ÙÔ‰fiÙËÛË Ì 7mA ·ÔÙ˘Á¯¿ÓÂÈ Ó· Û˘ÏÏ¿‚ÂÈ ÙÔÓ ÎfiÏÔ. K·Ù¿ Û˘Ó¤ÂÈ· Ô ÂÏ¿¯ÈÛÙÔ˜ Ô˘‰fi˜ Â›Ó·È 8 mA. (B) ÔÈÛÔÊ¿ÁÂÈÔ HK° ÛÙÔ ÔÔ›Ô ÌÂÙÚ¿Ù·È ÙÔ ‡„Ô˜ ÙÔ˘ ÎÔÏÈÎÔ‡ ¿ÚÌ·ÙÔ˜.
303
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·304
¶∞π¢π∞∆ƒπ∫∏ 2000;63:302-308
A. M·ÚÁÂÙ¿Î˘ Î·È Û˘Ó.
™ÙË Û˘Ó¤¯ÂÈ· ÌÂÙ·ÎÈÓÔ‡Û·Ì ÙÔÓ Î·ıÂÙ‹Ú· Ì ¤ÏÍË (Û·Ó "„¿ÚÂÌ·") ηٿ 0,5 cm Î·È Â·Ó·Ï·Ì‚¿Ó·Ì ÙȘ ηٷÁڷʤ˜, ÙȘ ÌÂÙÚ‹ÛÂȘ Î·È ÙȘ ‚ËÌ·ÙÔ‰ÔÙ‹ÛÂȘ ηٿ ÙÔÓ ›‰ÈÔ ÙÚfiÔ, fiˆ˜ ·Ú¯Èο ·Ó·Ê¤ÚıËÎÂ, ÁÈ· οı Ӥ· ı¤ÛË Î·È Ë ÌÂϤÙË ÙÂÚÌ·ÙÈ˙fiÙ·Ó ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË ÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ ÚˆÙÔÎfiÏÏÔ˘ ÛÙÔ ‚¿ıÔ˜ ÙˆÓ 9 ÂηÙÔÛÙÒÓ. ™Â ÂÚ›ÙˆÛË Ô˘ ··ÈÙ›ÙÔ ¤ÓÙ·ÛË Ú‡̷ÙÔ˜ ÌÂÁ·Ï‡ÙÂÚË ÙˆÓ 16 mA, ıˆڋıËΠfiÙÈ Ô Ô˘‰fi˜ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ ÙˆÓ 16 mA. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ·) XÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÁÚ·ÌÌÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (linear regression), ÁÈ· Ó· ÂÎÙÈÌËı› 1) Ë Û¯¤ÛË ÌÂٷ͇ ÙÔ˘ Ì‹ÎÔ˘˜ ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙÔ˘ Ì‹ÎÔ˘˜ ÙÔ˘ ËÏÂÎÙÚÔ‰›Ô˘ ÛÙË ı¤ÛË ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ Ô˘‰Ô‡ ‰È¤ÁÂÚÛ˘ Î·È 2) Ë Û¯¤ÛË ÌÂٷ͇ ÙˆÓ Ì¤ÛˆÓ ÙÔÈÎÒÓ ‚ËÌ·ÙÔ‰ÔÙÈÎÒÓ Ô˘‰ÒÓ Ì ÙÔ Ì¤ÛÔ ÂÏ¿¯ÈÛÙÔ ÙÔÈÎfi voltage. ‚) XÚËÛÈÌÔÔÈ‹ıËÎÂ Ô Û˘ÓÙÂÏÂÛÙ‹˜ Û˘Û¯¤ÙÈÛ˘ (correlation coefficients) ÁÈ· Ó· ÂÎÙÈÌËı› Ë Û¯¤ÛË ÌÂٷ͇ ÙÔ˘ Ì‹ÎÔ˘˜ Î·È ÙÔ˘ ‚¿ÚÔ˘˜ ÙˆÓ ·ÛıÂÓÒÓ ¤Ó·ÓÙÈ
ÙÔ˘ ̤ÁÈÛÙÔ˘ ‡„Ô˘˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ÎÔÏÈÎÔ‡ ¿ÚÌ·ÙÔ˜ Î·È ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡. Á) XÚËÛÈÌÔÔÈ‹ıËΠÙÔ Student t-test ÁÈ· Ó· ÂÏÂÁ¯ı› Â¿Ó ÙÔ ‡„Ô˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ÎÔÏÈÎÔ‡ ¿ÚÌ·ÙÔ˜ Î·È Ô ÂÏ¿¯ÈÛÙÔ˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜, ‰È·Ê¤ÚÔ˘Ó ·Ó¿ÏÔÁ· Ì ÙË ı¤ÛË (‚¿ıÔ˜ ÙÔÔı¤ÙËÛ˘) ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ËÏÂÎÙÚÔ‰›Ô˘ . AÔÙÂϤÛÌ·Ù· T· ۈ̷ÙÔÌÂÙÚÈο ÛÙÔȯ›·, ÙÔ ‚¿ıÔ˜ ÙÔÔı¤ÙËÛ˘ ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ËÏÂÎÙÚÔ‰›Ô˘, Ô ÂÏ¿¯ÈÛÙÔ˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜ Î·È ÙÔ Ì¤ÁÈÛÙÔ ‡„Ô˜ ÙÔ˘ ÊÏ‚ÔÎÔÌ‚ÈÎÔ‡ ÎÔÏÈÎÔ‡ ¿ÚÌ·ÙÔ˜ Ê·›ÓÔÓÙ·È ÛÙÔÓ ›Ó·Î· 1. ¶·ÚÔ˘Û›· ‹ fi¯È ·Ó·ÙÔÌÈ΋˜ ·ÓˆÌ·Ï›·˜ Ù˘ ηډȿ˜ H ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË (Student t-test) ‰ÂÓ ¤‰ÂÈÍ η̛· ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙÔ Ì‹ÎÔ˜, ÛÙÔ ‚¿ÚÔ˜, ÛÙÔ ‚¿ıÔ˜ ÙÔÔı¤ÙËÛ˘ ÙÔ˘ ËÏÂÎÙÚÔ‰›Ô˘ ÛÙË ı¤ÛË ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ Ô˘‰Ô‡, ÛÙÔ Ì¤ÁÈÛÙÔ ‡„Ô˜ ÙÔ˘ ÔÈÛÔ-
¶›Ó·Î·˜ 1. ™ˆÌ·ÙÔÌÂÙÚÈο ÛÙÔȯ›·, ‚¿ıÔ˜ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ ηıÂÙ‹Ú· ÛÙË ı¤ÛË ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ Ô˘‰Ô‡ (mA), Î·È ÙÔ˘ ̤ÁÈÛÙÔ˘ ÎÔÏÈÎÔ‡ ÔÈÛÔÊ¿ÁÂÈÔ˘ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜ (‡„Ô˜ A) NÂÔÁÓfi
HÏÈΛ· (Ë̤Ú˜)
µ¿ÚÔ˜ (g )
M‹ÎÔ˜ (cm)
B·ı-K·ı
O˘‰fi˜ (mA)
⁄„Ô˜ A (mV)
1 2 3 4 5
2 5 10 8 3
2350 3000 3100 2200 2150
42 48 46 39 39
13 14 14 11 12
7 8 8 7 9
0,55 0,6 0,6 0,5 0,55
6 7 8 9 10
4 2 16 11 14
4150 3000 2860 3200 2680
46 45 41 46 41
14 13 12,5 13,5 14
10 7 8 8 10
0,6 0,6 0,6 0,5 0,6
11 12 13 14 15
5 9 3 5 7
3010 2800 2700 1900 4200
44 39 39 39 48
14,5 12,5 13 13,5 14
10 9 10 9 7
0,5 0,6 0,6 0,65 0,6
16 17 18 19 20
2 6 8 10 4
2680 4100 2200 3100 1800
44 50 43 43 37
13 13,5 12 13 11,5
8 8 9 8 8
0,6 0,55 0,6 0,6 0,6
21 22 23 24 25 26
3 5 4 9 15 7
2000 1750 3400 2650 4100 3000
37 38 46 42 49 47
12 11,5 13 12,5 12 14
9 10 8 7 8 8
0,5 0,45 0,5 0,5 0,6 0,6
Min Max Mean SD Median
2 16 6,96 4,27 5,5
1750 4200 2858,21 754,90 2829,107
37 50 43,04 4,08 43
11 14,5 12,93 1,01 13
7 10 8,39 1,05 8
0,45 0,65 0,57 0,06 0,6
304
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·305
¶∞π¢π∞∆ƒπ∫∏ 2000;63:302-308
OÈÛÔÊ¿ÁÂÈÔ˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜
Ê¿ÁÂÈÔ˘ ÎÔÏÈÎÔ‡ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜ Î·È ÛÙÔÓ ÂÏ¿¯ÈÛÙÔ Ô˘‰fi, ÌÂٷ͇ ÙˆÓ ÓÂÔÁÓÒÓ ÌÂ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· Î·È ÂÎÂ›ÓˆÓ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ηډȿ (p>0,05). B¿ıÔ˜ ÙÔÔı¤ÙËÛ˘ ÙÔ˘ ηıÂÙ‹Ú· ™Â οı ·ÛıÂÓ‹ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó ÔÈ ÙÔÈÎÔ› ÂÏ¿¯ÈÛÙÔÈ Ô˘‰Ô› Î·È ÙÔ ‡„Ô˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ÎÔÏÈÎÔ‡ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜ ÁÈ· οı ı¤ÛË ÙÔ˘ ËÏÂÎÙÚÔ‰›Ô˘. ™Â ¤Ó· ·ÛıÂÓ‹ Ù˘ ÌÂϤÙ˘ Ì·˜ (ÓÂÔÁÓfi 16), Ì ÙË ‚ËÌ·ÙÔ‰fiÙËÛË ÚÔÎÏ‹ıËΠۇ۷ÛË ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ‚Ú·¯›ÔÓ·, Èı·ÓÒ˜ ÏfiÁˆ ‰È¤ÁÂÚÛ˘ ÙÔ˘ ‚Ú·¯ÈÔÓ›Ô˘ ϤÁÌ·ÙÔ˜, Û ¤Ó· ¿ÏÏÔ ÚÔÎÏ‹ıËΠ(ÓÂÔÁÓfi 14) Û‡Û·ÛË ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜. ™ÙÔ ›‰ÈÔ ÓÂÔÁÓfi ÚÔÎÏ‹ıËΠÎÔÈÏȷ΋ ‰È¤ÁÂÚÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ‚ËÌ·ÙÔ‰fiÙËÛ˘ Ì ÌÔÓ‹ÚË ÚÒÈÌË ‚ËÌ·ÙÔ‰ÔÙÈ΋ Û˘ÛÙÔÏ‹ (EÈÎfiÓ· 2). TÔ Ì¤ÛÔ Ì¤ÁÈÛÙÔ ‡„Ô˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ÎÔÏÈÎÔ‡ ¿ÚÌ·ÙÔ˜ Î˘Ì¿ÓıËΠ·fi 0,45 mV ̤¯ÚÈ 0,65 mV (Mean ±SD: 0,57±0,06 mV), ÂÓÒ Ô Ì¤ÛÔ˜ ÂÏ¿¯ÈÛÙÔ˜ Ô˘‰fi˜ Î˘Ì¿ÓıËΠÌÂٷ͇ 7 mA Î·È 10 mA (Mean ±SD: 8,39±1,05 mA). ¢È·ÈÛÙÒıËΠıÂÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ۈ̷ÙÈÎÔ‡ Ì‹ÎÔ˘˜ -‚¿ÚÔ˘˜ Î·È ‚¿ıÔ˘˜ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ ηıÂÙ‹Ú· (r=0,59 p=0,0006 (EÈÎfiÓ· 3) Î·È r=0,84 p=0,004 ·ÓÙ›ÛÙÔȯ·) ÂÓÒ ‰ÂÓ ‰È·ÈÛÙÒıËÎÂ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ۈ̷ÙÈÎÔ‡ Ì‹ÎÔ˘˜-‚¿ÚÔ˘˜ Î·È ÂÏ¿¯ÈÛÙÔ˘ Ô˘‰Ô‡ ‚ËÌ·ÙÔ‰fiÙËÛ˘ (r=0,33 p=0,099 Î·È r=0,17 p=0,386 ·ÓÙ›ÛÙÔȯ·). H Û¯¤ÛË ÌÂٷ͇ ÙÔ˘ ̤ÁÈÛÙÔ˘ ÎÔÏÈÎÔ‡ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜ Î·È ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡, ·Ó¿ÏÔÁ· ÚÔ˜ ÙË ı¤ÛË ÙÔ˘ ηıÂÙ‹Ú· ÛÙ· ÓÂÔÁÓ¿ Ù˘ ÌÂϤÙ˘ Ì·˜, Ê·›ÓÂÙ·È ÛÙËÓ ÂÈÎfiÓ· 4. ™ÙËÓ ÂÈÎfiÓ· 5 ·ÚÔ˘ÛÈ¿˙ÂÙ·È Ë Û¯¤ÛË ·˘Ù‹ ÁÈ· ÙÔ ÓÂÔÁÓfi 8, Ù· ۈ̷ÙÔÌÂÙÚÈο ÛÙÔȯ›· ÙÔ˘ ÔÔ›Ô˘ ÚÔÛÂÁÁ›˙Ô˘Ó ÙÔÓ Ì¤ÛÔ fiÚÔ. Y‹Ú¯Â Ì›· ÈÛ¯˘Ú‹ ·ÌÔÈ‚·›· Û¯¤ÛË ÌÂٷ͇ ÙÔ˘ ̤ÁÈÛÙÔ˘ ÎÔÏÈÎÔ‡ ¿ÚÌ·ÙÔ˜ Î·È ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ ÛÙȘ ‰È¿ÊÔÚ˜ ı¤ÛÂȘ ÂϤÁ¯Ô˘ ÁÈ· οı ·ÛıÂÓ‹, ¤ÙÛÈ ÒÛÙ fiÙ·Ó ÙÔ ÎÔÏÈÎfi ¤·ÚÌ· ÌÂÁ¿ÏˆÓÂ, Ô ÂÏ¿¯ÈÛÙÔ˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜ ÂÏ·ÙÙˆÓfiÙ·Ó.
EÈÎfiÓ· 2. ¢È¤ÁÂÚÛË Ù˘ ÎÔÈÏ›·˜ Ì ÌÔÓ‹ÚË ‰ÈÔÈÛÔÊ¿ÁÂÈ· ‚ËÌ·ÙÔ‰ÔÙÈ΋ Û˘ÛÙÔÏ‹.
∂ÈÎfiÓ· 3. B¿ıÔ˜ ÂÈÛfi‰Ô˘ ÙÔ˘ ηıÂÙ‹Ú· ÛÙË ı¤ÛË ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ Ô˘‰Ô‡ Û ۯ¤ÛË Ì ÙÔ Ì‹ÎÔ˜ ÙˆÓ ÓÂÔÁÓÒÓ. H ÁÚ·ÌÌ‹ ·˘Ù‹ ˘ÔÏÔÁ›ÛÙËΠ̠‚¿ÛË ÙËÓ Â͛ۈÛË ÁÚ·ÌÌÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ (linear regression) y=11,17+2,45x, fiÔ˘ y=ÙÔ Ì‹ÎÔ˜ ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È x=ÙÔ ‚¿ıÔ˜ ÂÈÛfi‰Ô˘ ÙÔ˘ ηıÂÙ‹Ú· ÌÂÙÚË̤ÓÔ ·fi ÙÔ ÚÒıˆÓ·.
∂ÈÎfiÓ· 4. O ̤ÛÔ˜ ÙÔÈÎfi˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜ (·ÎÏÔÈ) Î·È ÙÔ Ì¤ÛÔ Ì¤ÁÈÛÙÔ ÔÈÛÔÊ¿ÁÂÈÔ ÎÔÏÈÎfi ¤·ÚÌ· (ÙÚ›ÁˆÓ·) Û ۯ¤ÛË Ì ÙÔ ‚¿ıÔ˜ ÂÈÛfi‰Ô˘ ÙÔ˘ ηıÂÙ‹Ú· Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ Ì·˜. H ı¤ÛË ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ ۯ‰fiÓ Û˘Ì›ÙÂÈ Ì ÙË ı¤ÛË ÙÔ˘ ̤ÁÈÛÙÔ˘ ÎÔÏÈÎÔ‡ ¿ÚÌ·ÙÔ˜.
∂ÈÎfiÓ· 5. O ÙÔÈÎfi˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜ (·ÎÏÔÈ) Î·È ÙÔ Ì¤ÁÈÛÙÔ ÔÈÛÔÊ¿ÁÂÈÔ ÎÔÏÈÎfi ¤·ÚÌ· (ÙÚ›ÁˆÓ·) Û ۯ¤ÛË Ì ÙÔ ‚¿ıÔ˜ ÂÈÛfi‰Ô˘ ÙÔ˘ ηıÂÙ‹Ú· Û ÓÂÔÁÓfi 16-ËÌÂÚÒÓ (No 8 Ù˘ ÌÂϤÙ˘ Ì·˜). H ı¤ÛË ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ ۯ‰fiÓ Û˘Ì›ÙÂÈ Ì ÙË ı¤ÛË ÙÔ˘ ̤ÁÈÛÙÔ˘ ÎÔÏÈÎÔ‡ ¿ÚÌ·ÙÔ˜.
305
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·306
¶∞π¢π∞∆ƒπ∫∏ 2000;63:302-308
™˘ÁÎÂÎÚÈ̤ӷ, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÌÂϤÙ˘ Ì·˜, ˘‹Ú¯Â ۯ‰fiÓ ·fiÏ˘ÙË ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË (linear regression) (r=-0,95065 p=0,000) ÙÔ˘ ̤ÁÈÛÙÔ˘ ÊÏ‚ÔÎÔÌ‚ÈÎÔ‡ ¿ÚÌ·ÙÔ˜ Ì ÙÔÓ ÂÏ¿¯ÈÛÙÔ ‚ËÌ·ÙÔ‰ÔÙÈÎfi Ô˘‰fi ÛÙȘ ı¤ÛÂȘ ·fi 11 ¤ˆ˜ 15 ÂηÙÔÛÙ¿. K·Ù¿ ̤ÛÔÓ fiÚÔ, Ë ı¤ÛË ÛÙËÓ ÔÔ›· ηٷÁÚ·ÊfiÙ·Ó ÙÔ Ì¤ÁÈÛÙÔ ÎÔÏÈÎfi ¤·ÚÌ· (mean 0,57±0,06 mV) ·Â›¯Â 0,5 cm Âη٤ڈıÂÓ ÙÔ˘ ̤ÛÔ˘ ‚¿ıÔ˘˜ (12,94±0,94 cm) ÛÙÔ ÔÔ›Ô ‰È·ÈÛÙˆÓfiÙ·Ó Ô ÂÏ¿¯ÈÛÙÔ˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜ (8,38±1,02 mA). ŸÙ·Ó Ë Û˘Û¯¤ÙÈÛË Ô˘‰Ô‡/ÎÔÏÈÎÔ‡ ¿ÚÌ·ÙÔ˜ ¤ÁÈÓ ÛÙȘ ‰‡Ô ÈÔ ÂӉȷʤÚÔ˘Û˜ ˘ÔÔÌ¿‰Â˜ ‚¿ıÔ˘˜ ÙÔ˘ ηıÂÙ‹Ú· (11-13cm Î·È 13-15cm), ‰È·ÈÛÙÒıËΠfiÙÈ Ë Û˘Û¯¤ÙÈÛË ÛÙËÓ ÚÒÙË ÔÌ¿‰· ‹Ù·Ó Û¯ÂÙÈο ÌÈÎÚfiÙÂÚË (r=-0,93189 p=0,000) Û˘ÁÎÚÈÙÈο Ì ÙËÓ ‰Â‡ÙÂÚË (r=-0,99624 p=0,000). H Û‡ÁÎÚÈÛË ÙÔ˘ ÙÔÈÎÔ‡ ‡„Ô˘˜ ÙÔ˘ ÎÔÏÈÎÔ‡ ËÏÂÎÙÚÔÁÚ¿Ì·ÙÔ˜ Ì ÙÔ Ì¤ÁÈÛÙÔ ‡„Ô˜ ÙÔ˘ (Student t-test) ¤‰ÂÈÍ fiÙÈ: ·) ¢ÂÓ ˘‹Ú¯Â ‰È·ÊÔÚ¿ ÌÂٷ͇ 12,5 cm Î·È 13 cm ‚¿ıÔ˘˜ (t-value=-1,48 p=0,153), 13cm Î·È 13,5 cm (t-value=1,36 p=0,185), Î·È 12,5 cm Î·È 13,5 cm (t-value=-0,09 p=0,927). ‚) Y‹Ú¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ Û fiϘ ÙȘ ˘fiÏÔȘ ı¤ÛÂȘ ÂϤÁ¯Ô˘ (p<0,01). Á) ¢ÂÓ ˘‹Ú¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙ· Û˘ÌÌÂÙÚÈο, ˆ˜ ÚÔ˜ ÙÔ Ì¤ÛÔ ‚¿ıÔ˜ (13 cm), ˙‡ÁË ÂϤÁ¯Ô˘ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: Z‡ÁÔ˜ 12-14 cm (t-value=0,05 p=0,957) 11,5-14,5 cm (t-value=1,14 p=0,264) 11-15 cm (t-value=2,17 p=0,04) H Û‡ÁÎÚÈÛË ÙˆÓ ÙÔÈÎÒÓ Ô˘‰ÒÓ Ì ÙÔÓ ÂÏ¿¯ÈÛÙÔ Ô˘‰fi (Student t-test) ¤‰ÂÈÍ fiÙÈ: ·) ‰ÂÓ ˘‹Ú¯Â ‰È·ÊÔÚ¿ ÌÂٷ͇ 12,5 cm Î·È 13 cm ‚¿ıÔ˘˜ (t-value=-1,94 p=0,064), 13 cm Î·È 13,5 cm (t-value=-0,8 p=0,430), Î·È 12,5 cm Î·È 13,5 cm (t-value=0,62 p=0,538). EÔ̤ӈ˜, ÙÔ "·Ú¿ı˘ÚÔ" ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ Â›Ó·È 1 ÂηÙÔÛÙfi. ‚) Y‹Ú¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ Û fiϘ ÙȘ ˘fiÏÔȘ ı¤ÛÂȘ ÂϤÁ¯Ô˘ (p<0,05) Á) ¢ÂÓ ˘‹Ú¯Â ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ ‰È·ÊÔÚ¿ ÛÙ· Û˘ÌÌÂÙÚÈο, ˆ˜ ÚÔ˜ ÙÔ Ì¤ÛÔ ‚¿ıÔ˜ (13 cm), ˙‡ÁË ÂϤÁ¯Ô˘ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: Z‡ÁÔ˜ 12-14 cm (t-value=0,04 p=0,970) 11,5-14,5 cm (t-value=0 p=1,000) 11-15 cm (t-value=-0,44 p=0,662) ™˘˙‹ÙËÛË Œ¯ÂÈ ˘¿ÚÍÂÈ ·fi Ôχ ·Ï·È¿ ÌÂÁ¿ÏÔ ÂӉȷʤÚÔÓ ÁÈ· ÙÔÓ ÔÈÛÔÊ¿ÁÔ Û·Ó Ì›· Â͈ηډȷ΋ ı¤ÛË Î·Ù·ÁÚ·Ê‹˜ ÙÔ˘ HK°, ·ÏÏ¿ Ë ‚ËÌ·ÙÔ‰fiÙËÛË Ù˘ ηډȿ˜ ·fi ÙË ı¤ÛË ·˘Ù‹ ¤¯ÂÈ ·ÔÎÙ‹ÛÂÈ ÂӉȷʤÚÔÓ
306
A. M·ÚÁÂÙ¿Î˘ Î·È Û˘Ó.
ÌfiÓÔ Î·Ù¿ ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ·ÊÔ‡ ÔÈ ‰È·ÁÓˆÛÙÈΤ˜ Î·È ıÂڷ¢ÙÈΤ˜ ¯Ú‹ÛÂȘ Ù˘ ηډȷ΋˜ ‚ËÌ·ÙÔ‰fiÙËÛ˘ ¤¯Ô˘Ó ·˘ÍËı› ÛËÌ·ÓÙÈο (2-8). H ÎÏÈÓÈ΋ ¤Ú¢ӷ Î·È ·Ô‰Ô¯‹ Ù˘ ÔÈÛÔÊ¿ÁÂÈ·˜ ‚ËÌ·ÙÔ‰fiÙËÛ˘ ‹Ù·Ó ‚Ú·‰Â›· ÂÍ·ÈÙ›·˜ Ù˘ ÂÚÈÔÚÈṲ̂Ó˘ ·Ô‰Ô¯‹˜ ÙˆÓ ·Ú¯ÈÎÒÓ ÌÂÏÂÙÒÓ. O Benson (9) ÙÔÓ›˙ÂÈ fiÙÈ Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ ÂÚÂı›ÛÌ·ÙÔ˜ ·ÔÙÂÏÔ‡Ó ÎÚ›ÛÈÌÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ‚ËÌ·ÙÔ‰fiÙËÛË. T· ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ Ô˘‰Ô‡ ‰È¤ÁÂÚÛ˘ ·Ó·Ï‡ÔÓÙ·È Ì ÙËÓ Î·Ì‡ÏË ¤ÓÙ·Û˘-‰È¿ÚÎÂÈ·˜ (strength-duration curve). H ÌÔÚÊ‹ Ù˘ η̇Ï˘ ¤¯ÂÈ ÌÂÏÂÙËı› Û ‚·ÛÈÎfi Â›Â‰Ô Î·È ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÌÈ· ÁÚ·ÌÌÈ΋ ÌÂÌ‚Ú¿ÓË Û ¤Ó·Ó ÈÛÙfi Ì ·Ï‹ ÁˆÌÂÙÚ›·, ··ÈÙÂ›Ù·È Ì›· ÛÙ·ıÂÚ‹ ÌÂÙ·‚ÔÏ‹ Û ¤Ó· ÛÙ·ıÂÚfi ÛËÌÂ›Ô Ù˘ ÌÂÌ‚Ú¿Ó˘ ÒÛÙ ӷ Á›ÓÂÈ ·ÔÙÂÏÂÛÌ·ÙÈ΋ ‰È¤ÁÂÚÛË. M ÙËÓ ÔÈÛÔÊ¿ÁÂÈ· ‚ËÌ·ÙÔ‰fiÙËÛË ÂÊ·ÚÌfi˙ÂÙ·È ¤Ó· ‰›Ô ÂÚÂıÈÛÌ¿ÙˆÓ Û ÌÈ· ÁÚ·ÌÌÈ΋ ÌÂÌ‚Ú¿ÓË Î·È ·fi ıˆÚËÙÈ΋ ¿Ô„Ë, Ô ÈÔ ·ÔÙÂÏÂÛÌ·ÙÈÎfi˜ ı· ‹Ù·Ó ¤Ó·˜ ‚Ú·¯‡˜ ·ÏÏ¿ Ì ÌÂÁ¿ÏÔ ‡„Ô˜ (¤ÓÙ·ÛË), ÂÚÂıÈÛÌfi˜. ŸÌˆ˜, Ë ÂÈÏÔÁ‹ ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ¤ÓÙ·Û˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙË ‰˘ÛÊÔÚ›· Ô˘ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛÙÔÓ ·ÛıÂÓ‹. TÔ Ì¤ÁÂıÔ˜ Ù˘ ηډȿ˜ (Ë ·ÚÔ˘Û›· ‹ fi¯È Ì˘Ôηډȷ΋˜ ˘ÂÚÙÚÔÊ›·˜) ÌÔÚ› Ó· Â›Ó·È ¤Ó·˜ ÛËÌ·ÓÙÈÎfi˜ ·Ú¿ÁˆÓ Ô˘ ÂËÚ¿˙ÂÈ ÙËÓ ÂÈÙ˘¯›· Ù˘ ‚ËÌ·ÙÔ‰fiÙËÛ˘. T· ÔÈÛÔÊ¿ÁÂÈ· ÎÔÏÈο ËÏÂÎÙÚÔÁÚ¿ÌÌ·Ù· ηٷÁÚ¿ÊÔÓÙ·È Û οÔÈ· ·fiÛÙ·ÛË ·fi ÙËÓ Î·Ú‰È¿ Î·È ÂÔ̤ӈ˜ ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó Ì›· Û‡ÓıÂÛË ÔÏÏÒÓ ‰ÈÂÁÂÚÙÈÎÒÓ Î˘Ì¿ÙˆÓ. OÈ ·Ó·ÙÔÌÈÎÔ› Î·È ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ù˘ ÎÔÏÈ΋˜ Ì¿˙·˜ (̤ÁÂıÔ˜) Î·È Ë ÂÁÁ‡ÙËÙ· ÚÔ˜ ÙÔ ÎÔÏÈÎfi Ì˘ÔοډÈÔ Ô˘ ÚÔÛ‰ÈÔÚ›˙Ô˘Ó Ù· ËÏÂÎÙÚÔηډÈÔÁÚ·ÊÈο ¯·Ú·ÎÙËÚÈÛÙÈο Û ‰È·ÊÔÚÂÙÈΤ˜ ı¤ÛÂȘ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ‰ÂÓ ¤¯Ô˘Ó ÙÂÎÌËÚȈı› Ï‹Úˆ˜. AÓ Î·È Ë ÂÁÁ‡ÙËÙ· ÙˆÓ ÔÈÛÔÊ¿ÁÂÈˆÓ ËÏÂÎÙÚÔ‰›ˆÓ ¤¯ÂÈ ·Ô‰Âȯı› ·ÎÙÈÓÔÁÚ·ÊÈο, Ë ¤ÎÙ·ÛË ÛÙËÓ ÔÔ›· Ù· ÔÈÛÔÊ¿ÁÂÈ· ËÏÂÎÙÚÔÁÚ¿ÌÌ·Ù· ·ÓÙ·Ó·ÎÏÔ‡Ó ÙËÓ "·ÚÈÛÙÂÚ‹ ÎÔÏÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ·" ·Ú·Ì¤ÓÂÈ ·ÌÊÈÏÂÁfiÌÂÓË. ™ÙȘ ı¤ÛÂȘ Ô˘ ÂÍÂÙ¿Û·ÌÂ, ÂÓÒ Ë ÁˆÌÂÙÚÈ΋ Û¯¤ÛË ÌÂٷ͇ Ù˘ ηډȿ˜ Î·È ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ Â›Ó·È ÔχÏÔÎË, ÂÓÙÔ‡ÙÔȘ, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ ‰Â›¯ÓÔ˘Ó fiÙÈ Ë ÔÏ˘ÏÔÎfiÙËÙ· ÙˆÓ ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈÎÒÓ ÂȉڿÛÂˆÓ ÙˆÓ ‰È·ÛÙ¿ÛÂˆÓ ÙÔ˘ ÎfiÏÔ˘ Î·È Ë ÂÁÁ‡ÙËÙ· ÚÔ˜ ÙÔÓ ÔÈÛÔÊ¿ÁÔ, ÔÌ·ÏÔÔÈÔ‡ÓÙ·È ·fi ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜, ·ÊÔ‡ ÙÔ Ì¤ÁÈÛÙÔ ‡„Ô˜ ÙÔ˘ ÎÔÏÈÎÔ‡ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜, ÙÔ ‚ËÌ·ÙÔ‰ÔÙÈÎfi ·Ú¿ı˘ÚÔ Î·È Ô ÂÏ¿¯ÈÛÙÔ˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜, ‰ÂÓ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ Ì‹ÎÔ˜ Î·È ÙÔ ‚¿ÚÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜. TÔ ‚¿ıÔ˜ ÛÙÔ ÔÔ›Ô ÂÈÛ¿ÁÂÙ·È ÙÔ ÔÈÛÔÊ¿ÁÂÈÔ ËÏÂÎÙÚfi‰ÈÔ, Û‡Ìʈӷ Ì ÚÔËÁÔ‡ÌÂÓ˜ ÌÂϤÙ˜ (4,9), ·ÔÙÂÏ› ÙÔÓ ÛËÌ·ÓÙÈÎfiÙÂÚÔ ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡.
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·307
¶∞π¢π∞∆ƒπ∫∏ 2000;63:302-308
™Â ÌÂϤÙË ÙÔ˘ Benson et al (9), Ô˘ ·ÊÔÚÔ‡Û 30 ·ÛıÂÓ›˜ ËÏÈΛ·˜ ·fi 1 Ë̤ڷ˜ ̤¯ÚÈ 77 ÂÙÒÓ (ÙÚ›· ÓÂÔÁÓ¿) ‰È·ÈÛÙÒÓÂÙ·È ˘„ËÏ‹ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË (r=0,987 p<0,001) ÌÂٷ͇ ÙÔ˘ ‡„Ô˘˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ Î·È ÙÔ˘ ‚¿ıÔ˘˜ ÂÈÛfi‰Ô˘ ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ËÏÂÎÙÚÔ‰›Ô˘. ™ÙË ‰È΋ Ì·˜ ÌÂϤÙË Ô˘ ·ÊÔÚÔ‡Û ·ÔÎÏÂÈÛÙÈο ÓÂÔÁÓ¿, Ë Û˘Û¯¤ÙÈÛË ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÌÂÙ·‚ÏËÙÒÓ ‹Ù·Ó ÌÂÓ ıÂÙÈ΋, ·ÏÏ¿ fi¯È ÙfiÛÔ ÈÛ¯˘Ú‹ (r=0,594 p<0,001) fï˜, ‰È·ÈÛÙÒÓÂÙ·È ÈÛ¯˘ÚfiÙ·ÙË ·ÚÓËÙÈ΋ Û˘Û¯¤ÙÈÛË (r=-0,95065 p=0,000) ÌÂٷ͇ ÂÏ¿¯ÈÛÙÔ˘ Ô˘‰Ô‡ Î·È Ì¤ÁÈÛÙÔ˘ ‡„Ô˘˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ÊÏ‚ÔÎÔÌ‚ÈÎÔ‡ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜. £ÂˆÚԇ̠ÂÔ̤ӈ˜, fiÙÈ ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÓÂÔÁÓ¿, Ë ı¤ÛË ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ ·ÓÙÈÛÙÔȯ› Ôχ ηχÙÂÚ· ÛÙË ı¤ÛË Ô˘ ηٷÁÚ¿ÊÂÙ·È ÙÔ Ì¤ÁÈÛÙÔ ‡„Ô˜ ÙÔ˘ ÎÔÏÈÎÔ‡ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜ ·Ú¿ ÛÙË ı¤ÛË Ô˘ ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ·fi ÙÔ ‡„Ô˜ ÙÔ˘ ·ÛıÂÓÔ‡˜. EÓÙÔ‡ÙÔȘ, Ë ¯ÚËÛÈÌÔÔ›ËÛË ÙÔ˘ ‡„Ô˘˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ı¤Û˘ ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ ı· ÌÔÚÔ‡Û ӷ Â›Ó·È ÔχÙÈÌË ÁÈ· ÙËÓ Â›ÁÔ˘Û· ÔÈÛÔÊ¿ÁÂÈ· ËÏÂÎÙÚÈ΋ ·Ó¿Ù·ÍË, ÂÂȉ‹ Ë ÂÓÙfiÈÛË Ù˘ ı¤Û˘ ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ Ô˘‰Ô‡ Ì ‚¿ÛË ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÔÚ› Ó· Â›Ó·È ‰‡ÛÎÔÏË ÂÍ·ÈÙ›·˜ Ù˘ "ÌËÊÏ‚ÔÎÔÌ‚È΋˜" ÂÈÎfiÓ·˜ Ù˘ ÎÔÏÈ΋˜ ‰È¤ÁÂÚÛ˘ Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙËÓ Ù·¯˘Î·Ú‰›· (4,9). ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜ Î·È ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· Ù· ÓÂÔÁÓ¿, ÚÔÙ›ÓÔ˘Ì ÙË ¯ÚËÛÈÌÔÔ›ËÛË Ù˘ η̇Ï˘ Ô˘ Ê·›ÓÂÙ·È ÛÙËÓ ÂÈÎfiÓ· 3, ·ÓÂÍ¿ÚÙËÙ· ·Ó ÙÔ ÓÂÔÁÓfi ¿Û¯ÂÈ ‹ fi¯È ·fi Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·. ¶Ú·ÎÙÈο, ÚÔÙ›ÓÔ˘Ì ÙËÓ ·Ú¯È΋ ÚÈÓÔÁ·ÛÙÚÈ΋ ›ÛÔ‰Ô ÙÔ˘ ηıÂÙ‹Ú· Û ‚¿ıÔ˜ 13 ÂηÙÔÛÙÒÓ (mean±SD - 12,94±0,94 ÂηÙÔÛÙ¿) Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÌÂٷΛÓËÛË ÙÔ˘ ηıÂÙ‹Ú· ηٿ 0,5 ÂηÙÔÛÙfi ¿Óˆ ‹ οو ·fi ÙË ı¤ÛË ·˘Ù‹ (‚ËÌ·ÙÔ‰ÔÙÈÎfi ·Ú¿ı˘ÚÔ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡) ̤¯ÚȘ fiÙÔ˘ ηٷÁÚ·Ê› ÙÔ Ì¤ÁÈÛÙÔ ÎÔÏÈÎfi ËÏÂÎÙÚfiÁÚ·ÌÌ·. EȉÈÎfiÙÂÚ·, Ì ‚¿ÛË Ù· ÛÙÔȯ›· Ù˘ ÌÂϤÙ˘ Ì·˜, ıˆÚԇ̠fiÙÈ Ë ÚÔÒıËÛË Î·Ù¿ 0,5 ÂÎ. ÙÔ˘ ηıÂÙ‹Ú· ¤¯ÂÈ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· "Û˘Ó·ÓÙ‹ÛÂÈ" ÙÔÓ ÂÏ¿¯ÈÛÙÔ Ô˘‰fi (r=-0,99624 p=0,000) ·' fi,ÙÈ ¤¯ÂÈ Ë ·fiÛ˘ÚÛË ÙÔ˘ ηٿ ÙËÓ ›‰È· ·fiÛÙ·ÛË (r=-0,93189 p=0,000). M ÙÔÓ ¯ÂÈÚÈÛÌfi ·˘Ùfi ÈÛÙ‡ԢÌ fiÙÈ ı· ÂÚÈÔÚÈÛÙ› ‰Ú·ÛÙÈο Ô ¯ÚfiÓÔ˜ ÚÔÛ‰ÈÔÚÈÛÌÔ‡ Ù˘ ı¤Û˘ ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ Î·È Î·Ù¿ Û˘Ó¤ÂÈ· ı· ÂÏ·¯ÈÛÙÔÔÈËı› Ô ¯ÚfiÓÔ˜ Ù˘ ÔÈÛÔÊ¿ÁÂÈ·˜ ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈ΋˜ ÌÂϤÙ˘. T¤ÏÔ˜, ÂÂȉ‹ ˘¿Ú¯ÂÈ ÂÏ¿¯ÈÛÙË ˆÊ¤ÏÂÈ· ·fi ÙË ¯Ú‹ÛË Ú‡̷ÙÔ˜ Ì ‰È¿ÚÎÂÈ· >10 ms(9) (pulse width), ıˆÚԇ̠fiÙÈ ·˘Ùfi ı· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÌfiÓÔ Û ÂÚÈÙÒÛÂȘ Ô˘ Ô Ô˘‰fi˜ ÍÂÂÚÓ¿ Ù· 14 mA, fiÚÈÔ ¤Ú·Ó ÙÔ˘ ÔÔ›Ô˘ ÚÔηÏÂ›Ù·È ·›ÛıËÌ· ÂÏ·ÊÚÔ‡ ÔÈÛıÔÛÙÂÚÓÈÎÔ‡ η‡ÛÔ˘ ‹ fiÓÔ˘.
OÈÛÔÊ¿ÁÂÈÔ˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜
AÓ·ÊÔÚÈο Ì ÙËÓ ·ÛÊ¿ÏÂÈ· Ù˘ ÌÂıfi‰Ô˘, ‰ÂÓ ¤¯ÂÈ ‰ËÌÔÛÈ¢Ù› η̛· ÛÔ‚·Ú‹ fi„ÈÌË ÂÈÏÔ΋. O McNally (10) ¤‰ˆÛ 20 shocks ÙˆÓ 200 J ¤Î·ÛÙÔ ÛÙÔÓ ÔÈÛÔÊ¿ÁÔ 6 ÛÎ‡ÏˆÓ Î·È 15 shocks ÙˆÓ 60 J Û 8 ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜ Î·È ‰ÂÓ ·Ú·ÙËÚ‹ıËΠη̛· ‚Ï¿‚Ë. A˘Ù¿ Ù· ÂÓÂÚÁÂȷο ›‰· Â›Ó·È ÛËÌ·ÓÙÈο ÌÂÁ·Ï‡ÙÂÚ· ·fi ÂΛӷ Ô˘ ‰›ÓÔÓÙ·È ÁÈ· ÙËÓ ÔÈÛÔÊ¿ÁÂÈ· ‚ËÌ·ÙÔ‰fiÙËÛË. O Montoyo (2) ˘¤‚·Ï Û ÔÈÛÔÊ·ÁÔÛÎfiËÛË 6 ÂÓ‹ÏÈΘ ·ÛıÂÓ›˜ ÌÂÙ¿ ·fi ÔÈÛÔÊ¿ÁÂÈ· ‚ËÌ·ÙÔ‰fiÙËÛË Î·È ‰ÂÓ ‚ڋΠη̛· ·ÓˆÌ·Ï›·. ™Â Ì›· ÂÚ›ÙˆÛË, Ë ·˘ÙÔ„›· ÌÂÙ¿ ·fi Û˘Ó¯‹ ÔÈÛÔÊ¿ÁÂÈ· ‚ËÌ·ÙÔ‰fiÙËÛË 60 ˆÚÒÓ, ·ÔÎ¿Ï˘„ ÌÂÚÈΤ˜ ÂÚÈÔ¯¤˜ ‹È·˜ Ó¤ÎÚˆÛ˘ ÂΠȤÛˆ˜, fiˆ˜ ·˘Ù¤˜ Ô˘ ·Ú·ÙËÚÔ‡ÓÙ·È ÌÂÙ¿ ÙËÓ ÙÔÔı¤ÙËÛË ÚÈÓÔÁ·ÛÙÚÈÎÒÓ Î·ıÂÙ‹ÚˆÓ ÚÔ˘Ù›Ó·˜. OÌÔ›ˆ˜, ‰ÂÓ ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÛÔ‚·Ú¤˜ ¿ÌÂÛ˜ ÂÈÏÔΤ˜ Ù˘ ÔÈÛÔÊ¿ÁÂÈ·˜ ‚ËÌ·ÙÔ‰fiÙËÛ˘. ™ÙȘ ·Ú·¿Óˆ ÌÂϤÙ˜, Ë ÎÔÏÈ΋ ‚ËÌ·ÙÔ‰fiÙËÛË ˘ÚÔ‰fiÙËÛ ·Ô‰Â‰ÂÈÁ̤ӷ ÚÔ¸¿Ú¯Ô˘Û· ÎÔÈÏȷ΋ Ù·¯˘Î·Ú‰›· Û ‰‡Ô ·ÛıÂÓ›˜ Î·È ‰È¤ÁÂÚÛË ÙÔ˘ ÊÚÂÓÈÎÔ‡ Û ¤Ó· ·fi 65 ·ÛıÂÓ›˜. ™Â 4/38 ·ÛıÂÓ›˜ Ì ˘ÂÚÎÔÈÏȷ΋ Ù·¯˘Î·Ú‰›·, ÚÔÎÏ‹ıËΠÎÔÏÈ΋ Ì·ÚÌ·Ú˘Á‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÚÔÛ¿ıÂÈ·˜ ·Ó¿Ù·Í˘ Ù˘ Û ÊÏ‚ÔÎÔÌ‚ÈÎfi Ú˘ıÌfi. ¢È¤ÁÂÚÛË ÙÔ˘ ‚Ú·¯ÈÔÓ›Ô˘ ϤÁÌ·ÙÔ˜ Û˘Ó¤‚Ë Û ¤Ó· ‚Ú¤ÊÔ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ‚ËÌ·ÙÔ‰fiÙËÛ˘ ÛÙËÓ ÂÁÁ‡˜ ÂÚÈÔ¯‹ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘. AÓÙ›ıÂÙ· ÚÔ˜ ÙËÓ ‰È·ÊϤ‚È· ‚ËÌ·ÙÔ‰fiÙËÛË, Ë ÔÈÛÔÊ¿ÁÂÈ· ‚ËÌ·ÙÔ‰fiÙËÛË ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ·ÎÙÈÓÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ·ÔʇÁÔÓÙ·È fiϘ ÔÈ ÂÈÏÔΤ˜ Ô˘ ·ÊÔÚÔ‡Ó Ù· ·ÁÁ›·. ™˘ÌÂÚ¿ÛÌ·Ù· T· ·ÚÈ· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ Â›Ó·È fiÙÈ ÛÙ· ÓÂÔÁÓ¿: 1) ‰ÂÓ ‰È·ÈÛÙÒıËΠη̛· ‰È·ÊÔÚ¿ ÛÙÔ ‚¿ıÔ˜ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ ËÏÂÎÙÚÔ‰›Ô˘, ÛÙÔÓ ÂÏ¿¯ÈÛÙÔ ‚ËÌ·ÙÔ‰ÔÙÈÎfi Ô˘‰fi Î·È ÛÙÔ ‡„Ô˜ ÙÔ˘ ÊÏ‚ÔÎÔÌ‚ÈÎÔ‡ ÔÈÛÔÊ¿ÁÂÈÔ˘ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜ ÌÂٷ͇ ÙˆÓ ÓÂÔÁÓÒÓ ÌÂ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· Î·È ·˘ÙÒÓ Ì ·Ó·ÙÔÌÈο Ê˘ÛÈÔÏÔÁÈ΋ ηډȿ, 2) ÙÔ È‰·ÓÈÎfi ‚¿ıÔ˜ ÂÈÛ·ÁˆÁ‹˜ ÙÔ˘ ηıÂÙ‹Ú· ÌÔÚ› Ó· ÂÎÙÈÌËı› ηٿ ·ÚÈÔ ÏfiÁÔ ·fi ÙË ı¤ÛË ÛÙËÓ ÔÔ›· ηٷÁÚ¿ÊÂÙ·È ÙÔ Ì¤ÁÈÛÙÔ ‡„Ô˜ ÙÔ˘ ÎÔÏÈÎÔ‡ ËÏÂÎÙÚÔÁÚ¿ÌÌ·ÙÔ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÊÏ‚ÔÎÔÌ‚ÈÎÔ‡ Ú˘ıÌÔ‡ Î·È ÏÈÁfiÙÂÚÔ ·fi ÙÔ Ì‹ÎÔ˜ ÙÔ˘ ·ÛıÂÓÔ‡˜, 3) Ô ÂÏ¿¯ÈÛÙÔ˜ ‰ÈÔÈÛÔÊ¿ÁÂÈÔ˜ ‚ËÌ·ÙÔ‰ÔÙÈÎfi˜ Ô˘‰fi˜ ·Ú·ÙËÚÂ›Ù·È Û ·fiÛÙ·ÛË 0,5 ÂηÙÔÛÙ¿ Âη٤ڈıÂÓ Ù˘ ı¤Û˘ ÙÔ˘ ̤ÁÈÛÙÔ˘ ÔÈÛÔÊ¿ÁÂÈÔ˘ ÎÔÏÈÎÔ‡ ¿ÚÌ·ÙÔ˜ (mean ±SD: 12,93±1,01 cm) Î·È 4) Ô Ù·¯‡˜ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù˘ ı¤Û˘ Î·È ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ÂÏ¿¯ÈÛÙÔ˘ ‚ËÌ·ÙÔ‰ÔÙÈÎÔ‡ Ô˘‰Ô‡ ı· ÂÏ·ÙÙÒÛÂÈ ‰Ú·ÛÙÈο ÙÔ ¯ÚfiÓÔ Ù˘ ÌÂϤÙ˘, ı· ‚ÂÏÙÈÒÛÂÈ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· Ù˘ ‚ËÌ·ÙÔ‰fiÙËÛ˘ Î·È ı· ÂÚÈÔÚ›ÛÂÈ ÙȘ fiÔȘ Èı·Ó¤˜ ·ÓÂÈı‡ÌËÙ˜ ÂÓ¤ÚÁÂȘ (ÔÈÛıÔÛÙÂÚÓÈÎfi˜ fiÓÔ˜-η‡ÛÔ˜).
307
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·308
¶∞π¢π∞∆ƒπ∫∏ 2000;63:302-308
BÈ‚ÏÈÔÁÚ·Ê›· 1. Benson W Jr: Transesophageal electrocardiography and cardiac pacing:state of art. Circulation 1987;75(Suppl III):86-90. 2. Montoyo JV, Angel J, Valle V, Gausl C. Conversion of tachycardias by transesophageal atrial pacing. Am J Cardiol 1973;32:85-90. 3. Sterz H, Prager H, Koller H. Transesophageal rapid stimulation of the left atrium in atrial tachycardia. Z Kardiol 1978:67:136-138. 4. Gallagher JJ, SmIth WM, Kerr CR, Kasell J, Cook L, Relter M, Sterba R, Harte M. Esophageal pacing: a diagnostic and therapeutic tool. Circulation 1982;65:336-341. 5. Kerr C, Gallagher JJ, SmIth WM, Sterba R, German LD, Cook L, Kasell JH. The induction of atrial flutter and fibrillation and the termination of atrial flutter by esophageal pacing. PACE 1983:6:60-72.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 18-02-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-06-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: AÓ‰Ú¤·˜ EÌÌ. M·ÚÁÂÙ¿Î˘ NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ "¶.& A. K˘ÚÈ·ÎÔ‡" £Ë‚ÒÓ & §Â‚·‰Â›·˜ 115 27 °Ô˘‰›, Aı‹Ó·
308
A. M·ÚÁÂÙ¿Î˘ Î·È Û˘Ó.
6. Benson DW Jr, Dunnlgan A, Sterba R, Bend}U DG. Atrial pacing from the esophagus in diagnosis and management of tachycardia and palpitations. J Pediatr 1983;102:40-46. 7. Lucet V. Esophageal pacing in children. 38 consecutive cases. Arch Fr Pediatr.1990;47(3):185-9. 8. Moquet B, et al. Value of the esophageal approach in the diagnosis, treatment and therapeutic surveillance of arrhythmia in children. Arch Fr Pediatr.1 1989;46(1):1 1-7. Review. 9. Benson DW Jr, Sanford M, Dunnigan A, Bendit DG: Transesophageal atrial pacing threshold: role of interelectrode spacing, pulse width, and catheter insertion depth. Am J Cardiol 53:63;1984. 10. McNally EM, Meyer EC, Langendorf R. Elective countershock in unanesthetized patients with use of an esophageal electrode. Circulation 33:124, 1966.
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·309
¶∞π¢π∞∆ƒπ∫∏ 2000;63:309-313
E›Â‰· ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ Û ‰‡Ô ÓÂÔÁÓ¿ ÌÂ Ì˘ÎËÙÈ·ÛÈ΋ Ïԛ̈ÍË ·fi Candida albicans Iˆ¿ÓÓ˘ §·Ì·‰·Ú›‰Ë˜1, E˘·ÁÁÂÏ›· ¢ËÌËÙÚ›Ô˘2, M¿Úı· £ÂÔ‰ˆÚ¿ÎË1, AÛÛÂÌ X›˙·1, M·ÚÈ¿ÓÓ· ™·‚‚¿Ï·3, EϤÓË MȯÂϷοÎË2
● ¶ÂÚ›ÏË„Ë: OÈ Ì˘ÎËÙÈ·ÛÈΤ˜ ÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó ÛÔ‚·Úfi ·Ú¿ÁÔÓÙ· ıÓËÙfiÙËÙ·˜ Î·È ÓÔÛËÚfiÙËÙ·˜ ÛÙȘ EÓÙ·ÙÈΤ˜ MÔÓ¿‰Â˜ NÔÛËÏ›·˜ NÂÔÁÓÒÓ (MENN). H ¤ÁηÈÚË ‰È¿ÁÓˆÛ‹ ÙÔ˘˜ Î·È Ë ·ÍÈÔÏfiÁËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ ÙˆÓ ÂÊ·ÚÌÔ˙ÔÌ¤ÓˆÓ ıÂڷ¢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ Â›Ó·È È‰È·›ÙÂÚ· ÛËÌ·ÓÙÈΤ˜. H ¯ÈÙÔÙÚÈÔ˙ȉ¿ÛË ÙÔ˘ ·ÓıÚÒÔ˘ Â›Ó·È ¤Ó· ÚfiÛÊ·Ù· ·Ó·ÁÓˆÚÈṲ̂ÓÔ ¤Ó˙˘ÌÔ, ÙÔ ÌÔÓ·‰ÈÎfi Ì ·Ô‰Â‰ÂÈÁ̤ÓË ¯ÈÙÈÓÔÏ˘ÙÈ΋ ‰Ú¿ÛË. ™ÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ÌÂÏÂÙ‹Û·Ì ٷ ›‰· Ù˘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ Û ‰‡Ô ÓÂÔÁÓ¿ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ Ì˘ÎËÙÈ·ÛÈ΋ Ïԛ̈ÍË ÔÊÂÈÏfiÌÂÓË Û Candida albicans. MÂÙÚ‹ÛÂȘ ÙÔ˘ ÂÓ˙‡ÌÔ˘ Û ‰È·‰Ô¯Èο ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ¤‰ÂÈÍ·Ó ˆ˜ Ù· ›‰· ÙÔ˘ ÌÂÈÒıËÎ·Ó ‹ ·˘Í‹ıËÎ·Ó ·Ó¿ÏÔÁ· Ì ÙËÓ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘. T· Â˘Ú‹Ì·Ù¿ Ì·˜ ‰Â›¯ÓÔ˘Ó ˆ˜ ‰È·‰Ô¯ÈΤ˜ ÌÂÙÚ‹ÛÂȘ Ù˘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ ÌÔÚÔ‡Ó Ó· ·ÔÙÂϤÛÔ˘Ó ÚÒÈÌÔ ‰Â›ÎÙË Ì˘ÎËÙÈ·ÛÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ·ÏÏ¿ Î·È ÎÚÈÙ‹ÚÈÔ ·ÓÙ·fiÎÚÈÛ˘ ÛÙËÓ ÂÊ·ÚÌÔ˙fiÌÂÓË ıÂڷ›·. ¶·È‰È·ÙÚÈ΋ 2000;63:309-313. §¤ÍÂȘ ÎÏÂȉȿ: Candida albicans, ¯ÈÙÔÙÚÈÔ˙ȉ¿ÛË. J. Labadaridis, E. Dimitriou, M. Theodoraki, A. Hiza, M. Savala, H. Michelakakis. Chitotriosidase levels in Candida albicans infection. Paediatriki 2000;63:309-313. ● Abstract: Fungal infections have become an important factor in neonatal morbidity and mortality in neonatal intensive care units. Early diagnosis and proper assessment of the efficacy of the antifungal treatment are of the outmost importance. Human chitotriosidase is a recently identified enzyme and is the only one known so far to have proven chitinolytic activity. The levels of chitotriosidase were studied in two neonates with systemic Candida albicans infection. Assays of the enzymic activity in sequential urine and plasma samples showed that the enzyme levels increased or decreased in relation to the outcome of the infection. The data indicate that serial chitotriosidase assays can be used as an early indicator of fungal infection as well as for evaluating the efficacy of the applied therapy. Key words: Candida albicans, chitotriosidase.
EÈÛ·ÁˆÁ‹ H Û˘¯ÓfiÙËÙ· ÙˆÓ Ì˘ÎËÙÈ·ÛÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ÛÙȘ MÔÓ¿‰Â˜ EÓÙ·ÙÈ΋˜ NÔÛËÏ›·˜ NÂÔÁÓÒÓ (MENN) ¤¯ÂÈ ·˘ÍËı› ÛËÌ·ÓÙÈο Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÌÂ Û˘¯ÓfiÙÂÚ˜ ÙȘ ÏÔÈÌÒÍÂȘ ·fi Candida albicans (1,2). T· ˘„ËÏ¿ ÔÛÔÛÙ¿ ıÓËÙfiÙËÙ·˜ Î·È ÓÔÛËÚfiÙËÙ·˜ Ù˘ Û˘ÛÙËÌ·ÙÈ΋˜ ηÓÙÈÓÙ›·Û˘ ÛÙ· ÓÂÔÁÓ¿ ¤¯Ô˘Ó ·Ô‰Ôı› ÛÙËÓ Î·ı˘ÛÙ¤ÚËÛË Ù˘ ‰È¿ÁÓˆÛ˘ ·ÏÏ¿
1 2 3
Î·È ÛÙËÓ ·Ó·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ· ÙˆÓ ÂÊ·ÚÌÔ˙ÔÌ¤ÓˆÓ ıÂڷ¢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ (3). H ‡ÚÂÛË ÏÔÈfiÓ, ‰ÂÈÎÙÒÓ ÁÈ· ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË ÙˆÓ Ì˘ÎËÙÈ·ÛÈÎÒÓ ÏÔÈÌÒÍÂˆÓ ·ÏÏ¿ Î·È ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ÛÙË ¯ÔÚËÁÔ‡ÌÂÓË ıÂڷ›· Â›Ó·È È‰È·›ÙÂÚ˘ ÛËÌ·Û›·˜. H ¯ÈÙÔÙÚÈÔ˙ȉ¿ÛË ÙÔ˘ ·ÓıÚÒÔ˘ Â›Ó·È ¤Ó· ÚfiÛÊ·Ù· ·Ó·ÁÓˆÚÈṲ̂ÓÔ ¤Ó˙˘ÌÔ Ô˘ ·Ó‹ÎÂÈ, Ì ‚¿ÛË
NÂÔÁÓÔÏÔÁÈÎfi TÌ‹Ì· ¶°N N›Î·È·˜, ¶ÂÈÚ·È¿˜ ¢/ÓÛË EÓ˙˘ÌÔÏÔÁ›·˜ Î·È K˘ÙÙ·ÚÈ΋˜ §ÂÈÙÔ˘ÚÁ›·˜, IÓÛÙÈÙÔ‡ÙÔ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡, Aı‹Ó· MÈÎÚÔ‚ÈÔÏÔÁÈÎfi TÌ‹Ì· ¶°N N›Î·È·˜, ¶ÂÈÚ·È¿˜
309
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·310
¶∞π¢π∞∆ƒπ∫∏ 2000;63:309-313
ÙËÓ ÔÌÔÏÔÁ›· ÛÙËÓ ·ÏÏËÏÔ˘¯›· ·ÌÈÓÔͤˆÓ, ÛÙË ÌÂÁ¿ÏË ÔÈÎÔÁ¤ÓÂÈ· 18 ÙˆÓ ÁÏ˘ÎÔ˙˘ÏÔ-˘‰ÚÔÏ·ÛÒÓ (4). ™ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ·˘Ù‹ ·Ó‹ÎÔ˘Ó ÔÏϤ˜ ÔÌÔÂȉ›˜ ˆ˜ ÚÔ˜ ÙË ‰ÔÌ‹ ÙÔ˘˜ ÚˆÙ½Ó˜ Ô˘ ·Ó¢ڛÛÎÔÓÙ·È Û ¤Ó· Â˘Ú‡Ù·ÙÔ Ê¿ÛÌ· ÔÚÁ·ÓÈÛÌÒÓ (.¯. ‚·ÎÙ‹ÚÈ·, ̇ÎËÙ˜, Ê˘Ù¿, ¤ÓÙÔÌ·, ıËÏ·ÛÙÈο Î.·.) Î·È Ô˘ ‰È·Ê¤ÚÔ˘Ó ˆ˜ ÚÔ˜ ÙËÓ ÈηÓfiÙËÙ¿ ÙÔ˘˜ Ó· Î·Ù·Ï‡Ô˘Ó ÙË ‰È¿Û·ÛË Ù˘ ¯ÈÙ›Ó˘ (5,6). H ·ÓıÚÒÈÓË ¯ÈÙÔÙÚÈÔ˙ȉ¿ÛË Â›Ó·È Ë ÌÔÓ·‰È΋ ̤¯ÚÈ ÙÒÚ· ÚˆÙÂ˚ÓË ÙˆÓ ıËÏ·ÛÙÈÎÒÓ ·˘Ù‹˜ Ù˘ ÔÌ¿‰·˜ Ì ·Ô‰Â‰ÂÈÁ̤ÓË ¯ÈÙÈÓÔÏ˘ÙÈ΋ ‰Ú¿ÛË, Â›Ó·È ‰ËÏ·‰‹ Ì›· ¯ÈÙÈÓ¿ÛË (7,8). ¢Â‰Ô̤ÓÔ˘ fiÙÈ ÛÙȘ ‚ÈÔÏÔÁÈΤ˜ ÏÂÈÙÔ˘ÚÁ›Â˜ ÙˆÓ ¯ÈÙÈÓ·ÛÒÓ Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È Î·È Ë ¿Ì˘Ó· ¤Ó·ÓÙÈ ·ıÔÁfiÓˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ Ô˘ ÂÚȤ¯Ô˘Ó ¯ÈÙ›ÓË, fiˆ˜ Â›Ó·È ÔÈ Ì‡ÎËÙ˜ (9), ÛÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ÌÂÏÂÙ‹Û·Ì ÙË Û˘ÌÂÚÈÊÔÚ¿ Ù˘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ Û ÓÂÔÁÓ¿ ÌÂ Û˘ÛÙËÌ·ÙÈ΋ Ì˘ÎËÙÈ·ÛÈ΋ Ïԛ̈ÍË ÔÊÂÈÏfiÌÂÓË Û Candida albicans. M¤ÚÔ˜ Ù˘ ÂÚÁ·Û›·˜, Ô˘ ·ÔÙÂÏ› ÙËÓ ÚÒÙË ‰ÈÂıÓÒ˜ ÌÂϤÙË Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ Ù˘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ ÛÂ Ì˘ÎËÙÈ·ÛÈΤ˜ ÏÔÈÌÒÍÂȘ ÛÙÔÓ ¿ÓıÚˆÔ, ‰ËÌÔÛȇıËΠÛÙÔÓ ‰ÈÂıÓ‹ Ù‡Ô (10). ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ AÛıÂÓ‹˜ A: ¶ÚfiÎÂÈÙ·È ÁÈ· ¿ÚÚÂÓ ÓÂÔÁÓfi Ô˘ ÁÂÓÓ‹ıËΠÙÂÏÂÈfiÌËÓÔ Ì ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 3870 g ÌÂÙ¿ ·fi ÂÚÁÒ‰Ë ÙÔÎÂÙfi. NÔÛËχıËΠÛÙË MENN, ÏfiÁˆ ÂÚÈÁÂÓÓËÙÈ΋˜ ·ÛÊ˘Í›·˜ - ÂÈÛÚfiÊËÛ˘ Ì˘ÎˆÓ›Ô˘, Î·È ¯ÚÂÈ¿ÛıËΠÌ˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜. TÔ ÓÂÔÁÓfi Û ËÏÈΛ· 24 ËÌÂÚÒÓ ÂÍ‹Ïı ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË. ¢¤Î· Ë̤Ú˜ ·fi ÙËÓ ¤ÍÔ‰fi ÙÔ˘ ÂÈÛ‹¯ıË ÂÎ Ó¤Ô˘ ÏfiÁˆ ¿ÚÓËÛ˘ Ï‹„˘ ÙÚÔÊ‹˜, ˘ÚÂÙÔ‡ Î·È Â˘ÂÚÂıÈÛÙfiÙËÙ·˜. §ÂÙÔÌÂÚ‹˜ ÂÚÈÁÚ·Ê‹ ÙÔ˘ ÎÏÈÓÈÎÔ‡ ÈÛÙÔÚÈÎÔ‡ ¤ÁÈÓ ÛÙÔ ¢ÂÏÙ›Ô Ù˘ A' ¶·È‰È·ÙÚÈ΋˜ KÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ (11). H ¯ÈÙÔÙÚÈÔ˙ȉ¿ÛË ÌÂÙÚ‹ıËΠÁÈ· ÚÒÙË ÊÔÚ¿ Û ‰Â›ÁÌ· Ï¿ÛÌ·ÙÔ˜ ÙË 15Ë Ë̤ڷ Ù˘ ‰Â‡ÙÂÚ˘ ÓÔÛËÏ›·˜ fiÙ·Ó ÔÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ ‹Ù·Ó ıÂÙÈΤ˜ ÁÈ· Candida albicans. MÂÙÚ‹ÛÂȘ ¤ÁÈÓ·Ó Â›Û˘ Û ‰È·‰Ô¯Èο ‰Â›ÁÌ·Ù· Ï¿ÛÌ·ÙÔ˜ Î·È Ô‡ÚˆÓ (II-V) (¶›Ó·Î·˜ 1) Ô˘ ÂÏ‹ÊıËÛ·Ó ÛÙË Û˘Ó¤¯ÂÈ· ·Ó¿ ‚‰ÔÌ¿‰· ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜. ™ÙÔ Ù¤ÏÔ˜ Ù˘ ·Ú·¿Óˆ ¯ÚÔÓÈ΋˜ ÂÚÈfi‰Ô˘ ÔÈ Î·ÏÏȤÚÁÂȘ ÙÚÈÒÓ ‰È·‰Ô¯ÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ Ô‡ÚˆÓ ‹Ù·Ó ÛÙ›Ú˜. AÛıÂÓ‹˜ B: ¶ÚfiÎÂÈÙ·È ÁÈ· ¤Ó· ÚfiˆÚÔ ¿ÚÚÂÓ ÓÂÔÁÓfi 900 g Ô˘ ÁÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi ‡ÛÙÂÚ· ·fi ·ËÛË 28 ‚‰ÔÌ¿‰ˆÓ. H ÌËÙ¤Ú· ‰ÂÓ Â›¯Â Ì·È¢ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË, ‹Ù·Ó Ë 7Ë ÂÁ΢ÌÔÛ‡ÓË Ù˘ Î·È ÙÔ 4Ô ÛÙË ˙ˆ‹ Ù¤ÎÓÔ Ù˘. H ¤Ó·ÚÍË ÙˆÓ Ô‰˘ÓÒÓ ‹Ù·Ó ·˘ÙfiÌ·ÙË Î·È Ë Ú‹ÍË ÙˆÓ ˘Ì¤ÓˆÓ Û˘Ó¤‚Ë 2 ÒÚ˜ ÚÔ ÙÔ˘ ÙÔÎÂÙÔ‡. Apgar score ‰ÂÓ ·Ó·Ê¤ÚÂÙ·È. A̤ۈ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ‰È·ÛˆÏËÓÒ-
310
π. §·Ì·‰·Ú›‰Ë˜ Î·È Û˘Ó.
ıËÎÂ, ÛÙ·ıÂÚÔÔÈ‹ıËÎÂ Î·È ÌÂٷʤÚıËΠÛÙË MÔÓ¿‰· Ì·˜ ÙË 2Ë ÒÚ· ˙ˆ‹˜. AÚ¯Èο ÙÔ ÓÂÔÁÓfi ·ÚÔ˘Û›·Û ¤ÓÙÔÓÔ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, ̋Π۠Ì˯·ÓÈ΋ ·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË, ÙÔ˘ ¯ÔÚËÁ‹ıËÎ·Ó ÙÚÂȘ ‰fiÛÂȘ Â͈ÁÂÓÔ‡˜ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (surfactant), ÓÙÔ·Ì›ÓË ÂÓÒ ·Ú¿ÏÏËÏ· ¯ÔÚËÁ‹ıËΠ·ÌÈÎÈÏÏ›ÓË Î·È ÓÂÙÈÏÌÈΛÓË. TÔÔıÂÙ‹ıËΠ·ÚÙËÚÈ·Îfi˜ ÔÌÊ·ÏÈÎfi˜ ηıÂÙ‹Ú·˜ Î·È ÂÚÈÊÂÚÈ΋ ÁÚ·ÌÌ‹. EÌÊ¿ÓÈÛ ÛËÌ·ÓÙÈÎfi ·ÈÌÔ‰˘Ó·ÌÈÎfi ‚ÔÙ¿ÏÂÈÔ Î·È ÙÔ˘ ¯ÔÚËÁ‹ıËÎ·Ó ·Ú¯Èο ÊÔ˘ÚÔÛÂÌ›‰Ë Î·È ‰ÈÁÔÍ›ÓË Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÈÓ‰ÔÌÂı·Î›ÓË. TËÓ 11Ë Ë̤ڷ ˙ˆ‹˜ ÂÓÒ ‹Ù·Ó ·ÎfiÌË Û Ì˯·ÓÈ΋ ·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË, ·ÚÔ˘Û›·Û Âȉ›ӈÛË Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ïԛ̈͢ (§Â˘Î¿=5140 mm3, AÈÌÔÂÙ¿ÏÈ·=6000 mm3, CRP=314 mg/L) Î·È ÙÚÔÔÔÈ‹ıËΠÙÔ Û¯‹Ì· Ù˘ ·ÓÙÈ‚›ˆÛ˘ Û ·ÌÈηۛÓË Î·È ÙÂ˚ÎÔÏ·Ó›ÓË ÁÈ· ÙËÓ Î¿Ï˘„Ë ÙˆÓ gram (-) Î·È ÁÈ· ÙÔ ÂӉ¯fiÌÂÓÔ Ïԛ̈͢ ·fi ÂȉÂÚÌÈÎfi ÛÙ·Ê˘ÏfiÎÔÎÎÔ ·ÓÙ›ÛÙÔȯ·. YÔÛÙËÚ›¯ıËΠ·ÎfiÌË Ì ¯ÔÚ‹ÁËÛË ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ (Sandaglobulin) Î·È ÊÚ¤ÛÎÔ˘ ηÙ„˘Á̤ÓÔ˘ Ï¿ÛÌ·ÙÔ˜. ¶·Ú¿ ÙËÓ ·ÁˆÁ‹ ÙÔ ÓÂÔÁÓfi η٤ÏËÍ Ì ÂÈÎfiÓ· ÛËÙÈÎÔ‡ shock ÙË 13Ë Ë̤ڷ ˙ˆ‹˜. ™ÙȘ ηÏÏȤÚÁÂȘ (Ï‹„Ë 11Ë Ë̤ڷ) ·›Ì·ÙÔ˜, ÙÚ·¯ÂÈÔۈϋӷ Î·È ÔÌÊ·ÏÈÎÔ‡ ηıÂÙ‹Ú· ·Ó·Ù‡¯ıËΠCandida albicans. T· ·ÔÙÂϤÛÌ·Ù· ·˘Ù¿ ‚¤‚·È· Ù· Ï¿‚·Ì ÌÂÙ¿ ÙÔÓ ı¿Ó·ÙÔ ÙÔ˘ ÓÂÔÁÓÔ‡, ÁÈ' ·˘Ùfi Î·È ‰ÂÓ ¯ÔÚËÁ‹ıËΠ·ÓÙÈÌ˘ÎËÙÈ·ÛÈ΋ ·ÁˆÁ‹. MÂÙÚ‹ÛÂȘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ ¤ÁÈÓ·Ó Û ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ Ô˘ ÂÏ‹ÊıËÛ·Ó ÙËÓ 1Ë, 7Ë Î·È ÙË 13Ë Ë̤ڷ ˙ˆ‹˜. H ¯ÈÙÔÙÚÈÔ˙ȉ¿ÛË ÌÂÙÚ‹ıËΠ̠ÙÔ ÊıÔÚ›˙ÔÓ ˘fiÛÙڈ̷ ÌÂı˘ÏÔ˘ÌÂÏÏÈÊÂÚ‡Ï-‚-D-NN’N’’-ÙÚÈ·ÎÂÙ˘ÏÔÙÚÈfi˙Ë ÛÙÔ Ï¿ÛÌ· Î·È Ù· Ô‡Ú· ÙˆÓ ·ÛıÂÓÒÓ Û‡Ìʈӷ Ì ÙË Ì¤ıÔ‰Ô ÙˆÓ Hollak Î·È Û˘Ó. (12). TËÓ ·Ó¿ ‚‰ÔÌ¿‰· Ï‹„Ë ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ ÙËÓ ÂÈϤͷÌÂ Û·Ó ¤Ó· ÏÔÁÈÎfi ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ ÔÚ›·˜ Ù˘ Ïԛ̈͢ Î·È Ù˘ ·ÓÙ·fiÎÚÈÛ˘ ÛÙË ıÂڷ›· ÌÈ· Î·È Â›Ó·È Ë ÚÒÙË ÌÂϤÙË Ô˘ Á›ÓÂÙ·È ‰ÈÂıÓÒ˜ ¿Óˆ ÛÙÔ ı¤Ì· ·˘Ùfi. ¢Â‰Ô̤ÓÔ˘ fiÙÈ ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ‰ÂÓ ˘¿Ú¯Ô˘Ó ÙÈ̤˜ ·Ó·ÊÔÚ¿˜ ÁÈ· Ù· ›‰· Ù˘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ Û ÓÂÔÁÓ¿ ÌÂÏÂÙ‹ıËÎ·Ó 10 ÓÂÔÁÓ¿ ·ÓÙ›ÛÙÔȯ˘ ËÏÈΛ·˜ ˆ˜ Ì¿ÚÙ˘Ú˜. AÔÙÂϤÛÌ·Ù· ™‡Ìʈӷ Ì ٷ ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ·˘ÍË̤ӷ ›‰· ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘, Û ۇÁÎÚÈÛË ÌÂ Ê˘ÛÈÔÏÔÁÈο ÓÂÔÁÓ¿ Ù˘ ›‰È·˜ ËÏÈΛ·˜, ‚Ú¤ıËÎ·Ó ÛÙ· ·Ú¯Èο ‰Â›ÁÌ·Ù· Î·È È‰È·›ÙÂÚ· ÛÙ· Ô‡Ú· ÙÔ˘ ·ÛıÂÓÔ‡˜ A. ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ıÂڷ›·˜ Ù· ›‰· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÌÂÈÒıËÎ·Ó ÙfiÛÔ ÛÙÔ Ï¿ÛÌ· fiÛ· Î·È ÛÙ· Ô‡Ú·.
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·311
¶∞π¢π∞∆ƒπ∫∏ 2000;63:309-313
∏ ¯ÈÙÔÙÚÈÔ˙ȉ¿ÛË Û Ïԛ̈ÍË Candida albicans
¶›Ó·Î·˜ 1: E›Â‰· XÈÙÔÙÚÈÔ˙ȉ¿Û˘ Û ‰È·‰Ô¯Èο ‰Â›ÁÌ·Ù· Ô‡ÚˆÓ Î·È ·›Ì·ÙÔ˜ ÙˆÓ ÓÂÔÁÓÒÓ A,B. XÈÙÚÔÙÚÈÔ˙ȉ¿ÛË
AÛıÂÓ‹˜ A
AÛıÂÓ‹˜ B
º˘ÛÈÔÏÔÁÈΤ˜ TÈ̤˜
H̤ڷ NÔÛËÏ›·˜
¢Â›ÁÌ·
¶Ï¿ÛÌ· (nmoles/ml/hr)
O‡Ú· (nmoles/mg ÎÚ·ÙÈÓ./hr)
§Â˘Î¿ /mm3
TKE (mm/1h)
CRP (mg/L)
15Ë 22Ë 29Ë 36Ë 43Ë
I II III IV V
88 105 80 57 53
440 67 4 0
22670 13430 11000 9200 -
84 60 -
++ ++
1Ë 7Ë 13Ë
π ππ πππ
40 123 -
34 808 3275
21610 20200 5140
25-52 n=10
0-30 n=10
ŒÙÛÈ, ÛÙÔ Ù¤ÏÔ˜ ÙˆÓ 5 ‚‰ÔÌ¿‰ˆÓ, fiÙ·Ó ÔÈ Î·ÏÏȤÚÁÂȘ ÙÚÈÒÓ ‰È·‰Ô¯ÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ ‹Ù·Ó ÛÙ›Ú˜, Ù· ›‰· Ù˘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο ÛÙ· Ô‡Ú· Î·È ÂÏ·ÊÚÒ˜ ·˘ÍË̤ӷ ÛÙÔ Ï¿ÛÌ·. H Ì›ˆÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ ÂÍÂÏ›¯ıËΠ·Ú¿ÏÏËÏ· Ì ÙË ‚ÂÏÙ›ˆÛË ÙfiÛÔ Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜ fiÛÔ Î·È ÙˆÓ ¿ÏÏˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ·Ú·Ì¤ÙÚˆÓ (¶›Ó·Î·˜ 1). AÓÙ›ıÂÙ· ÛÙÔÓ ·ÛıÂÓ‹ B, ÛÙ· ·Ú¯Èο ‰Â›ÁÌ·Ù·, Ù· ›‰· ÙÔ˘ ÂÓ˙‡ÌÔ˘ ‹Ù·Ó ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· (¶›Ó·Î·˜ 1). A‡ÍËÛË ·Ú·ÙËÚ‹ıËΠÛÙÔ 2Ô ‰Â›ÁÌ·, Ì ÙË Ï‹„Ë ÙÔ˘ ÔÔ›Ô˘ ÙÔ ÓÂÔÁÓfi ·Ó¤Ù˘Í ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ‰Â›ÎÙ˜ Ïԛ̈͢, Ô˘ fiˆ˜ ·Ô‰Â›¯ıËΠ۠ηÏÏȤÚÁÂȘ Ô˘ ÂÏ‹ÊıËÛ·Ó ÙËÓ ›‰È· ¯ÚÔÓÈ΋ ÛÙÈÁÌ‹, ÔÊ›ÏÂÙÔ Û Candida albicans. ¶ÂÚ·ÈÙ¤Úˆ ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ ·Ú·ÙËÚ‹ıËΠÛÙÔ 3Ô ‰Â›ÁÌ· Ô˘ ÂÏ‹ÊıË ÙË 13Ë Ë̤ڷ ˙ˆ‹˜. ™˘˙‹ÙËÛË H ¯ÈÙ›ÓË Â›Ó·È ¤Ó· ÁÚ·ÌÌÈÎfi ÔÏ˘ÌÂÚ¤˜, ·ÔÙÂÏÔ‡ÌÂÓÔ ·fi ÌÔÓ¿‰Â˜ N-·ÎÂÙ˘ÏÔ-ÁÏ˘ÎÔ˙·Ì›Ó˘ Û˘Ó‰Â‰Â̤Ó˜ Ì ‚-1,4 ‰ÂÛÌÔ‡˜. E›Ó·È ·fi Ù· ϤÔÓ ‰È·‰Â‰Ô̤ӷ ÔÏ˘ÌÂÚ‹ ÛÙË Ê‡ÛË Î·È ·ÔÙÂÏ› ‰ÔÌÈÎfi ˘ÏÈÎfi ÙˆÓ Î˘ÙÙ·ÚÈÎÒÓ ÙÔȯˆÌ¿ÙˆÓ ÔÏÏÒÓ ÔÚÁ·ÓÈÛÌÒÓ Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Î·È ÙˆÓ Ì˘Î‹ÙˆÓ (13). H ·ÔÈÎÔ‰fiÌËÛ‹ Ù˘ Á›ÓÂÙ·È Ì ÙË ‰Ú¿ÛË ˘‰ÚÔÏ·ÛÒÓ ÛÙȘ Ôԛ˜ Û˘ÁηٷϤÁÂÙ·È Î·È Ë ÔÌ¿‰· ÙˆÓ ¯ÈÙÈÓ·ÛÒÓ, ÂÓ˙‡ÌˆÓ Ô˘ ¤¯Ô˘Ó ·Ó¢ÚÂı› ÙfiÛÔ Û ÔÚÁ·ÓÈÛÌÔ‡˜ Î·È Â›‰Ë Ô˘ ÂÚȤ¯Ô˘Ó ¯ÈÙ›ÓË fiÛÔ Î·È Û ¿ÏÏÔ˘˜ Ô˘ ‰ÂÓ ÙËÓ ÂÚȤ¯Ô˘Ó (9,14,15). ™Â ·˘Ù‹ ÙËÓ ÔÌ¿‰· ·Ó‹ÎÂÈ Î·È Ë ÚfiÛÊ·Ù· ·Ó·ÁÓˆÚÈṲ̂ÓË ¯ÈÙÔÙÚÈÔ˙ȉ¿ÛË ÙÔ˘ ·ÓıÚÒÔ˘. OÈ ‚ÈÔÏÔÁÈΤ˜ ‰Ú¿ÛÂȘ Ô˘ ¤¯Ô˘Ó ·Ô‰Ôı› ÛÙȘ ¯ÈÙÈÓ¿Û˜ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙË ÌÔÚÊÔÁ¤ÓÂÛË, ÙË ıÚ¤„Ë ÙˆÓ ÔÚ-
-
<2 <2 314 3-9
Á·ÓÈÛÌÒÓ Ô˘ ÙȘ ·Ú¿ÁÔ˘Ó, ÙËÓ ·ÏÏËÏ›‰Ú·ÛË ÔÈÎÈÛÙÔ‡- ·Ú·Û›ÙˆÓ, ÙËÓ ·ıÔÁ¤ÓÂÛË Ù˘ ÌfiÏ˘ÓÛ˘ ·ÏÏ¿ Î·È ÙËÓ ¿Ì˘Ó· ¤Ó·ÓÙÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ Ô˘ ÂÚȤ¯Ô˘Ó ¯ÈÙ›ÓË Î·È È‰È·›ÙÂÚ· ÙˆÓ Ì˘Î‹ÙˆÓ Î·È ÙˆÓ ÂÓÙfiÌˆÓ (15-18). O ‚ÈÔÏÔÁÈÎfi˜ ÚfiÏÔ˜ Ù˘ ·ÓıÚÒÈÓ˘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ ‰ÈÂÚÂ˘Ó¿Ù·È. Y¿Ú¯Ô˘Ó fï˜ ÔÏÏ¿ ÛÙÔȯ›· Ô˘ ÂÓÈÛ¯‡Ô˘Ó ÙËÓ ¿Ô„Ë ˆ˜ ı· Ú¤ÂÈ Ó· Û˘ÌÌÂÙ¤¯ÂÈ ÛÙËÓ ¿Ì˘Ó· ¤Ó·ÓÙÈ ·ıÔÁfiÓˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ, fiˆ˜ ÔÈ Ì‡ÎËÙ˜, Ô˘ ÂÚȤ¯Ô˘Ó ¯ÈÙ›ÓË. T· Ì·ÎÚÔÊ¿Á· Ô˘ ·ÔÙÂÏÔ‡Ó ¤Ó·Ó ·fi ÙÔ˘˜ ÚÒÙÔ˘˜ Î·È Î˘ÚÈfiÙÂÚÔ˘˜ Ì˯·ÓÈÛÌÔ‡˜ ¿Ì˘Ó·˜ ¤Ó·ÓÙÈ ÙˆÓ Ì˘Î‹ÙˆÓ (19), Â›Ó·È Û˘Á¯ÚfiÓˆ˜ Ë Î‡ÚÈ· ËÁ‹ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘, Ë ÔÔ›· ›Ù ·ÂÎÎÚ›ÓÂÙ·È ÂÍˆÎ˘ÙÙ·ÚÈο ›Ù ԉËÁÂ›Ù·È ÛÙ· Ï˘ÛÈۈ̿ÙÈ· ÙÔ˘ ΢ÙÙ¿ÚÔ˘. XÈÙÈÓÔÏ˘ÙÈ΋ ‰Ú¿ÛË ¤¯Ô˘Ó Î·È ÔÈ ‰‡Ô ÌÔÚʤ˜ ÙÔ˘ ÂÓ˙‡ÌÔ˘ Ô˘ ‰È·Ê¤ÚÔ˘Ó fï˜ ˆ˜ ÚÔ˜ ÙÔ ÌÔÚÈ·Îfi ‚¿ÚÔ˜ ÙÔ˘˜ Î·È ÙËÓ ÈηÓfiÙËÙ· ÚfiÛ‰ÂÛ˘ ¯ÈÙ›Ó˘. ŒÙÛÈ ÌfiÓÔ Ë ÂÍˆÎ˘ÙÙ·ÚÈο ¢ÚÈÛÎfiÌÂÓË ¯ÈÙÔÙÚÈÔ˙ȉ¿ÛË Ì ÌÔÚÈ·Îfi ‚¿ÚÔ˜ 50kDa, ¤Ó·ÓÙÈ 39kDa ÙÔ˘ ÂÓ‰ÔÏ˘ÛÈÛˆÌÈ·ÎÔ‡ ÂÓ˙‡ÌÔ˘, ÂÚȤ¯ÂÈ Ì›· ·ÏÏËÏÔ˘¯›· ÙÔ˘Ï¿¯ÈÛÙÔÓ 49 ·ÌÈÓÔͤˆÓ ÛÙÔ ·ÓıÚ·ÎÈÎfi ¿ÎÚÔ Ù˘ Ô˘ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÚfiÛ‰ÂÛË Ù˘ ¯ÈÙ›Ó˘ (12,20). A˘ÍË̤ÓË ·Ú·ÁˆÁ‹ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ ·fi Ù· Ì·ÎÚÔÊ¿Á· ¤¯ÂÈ ·Ú·ÙËÚËı› ÛÙË ÓfiÛÔ Gaucher (11), ÛÙȘ ·ıËÚÔÌ·ÙÈΤ˜ ϿΘ (21) Î·È ÈÔ ÚfiÛÊ·Ù· Û ÈÓ‰Èο ¯ÔÈÚ›‰È· Ô˘ ›¯·Ó ÌÔÏ˘Óı› Ì AÛ¤ÚÁÈÏÏÔ (Aspergillus fumigatus) (22). EÈϤÔÓ, ÂÒ·ÛË ÌÔÓÔ·ÙÙ·ÚˆÓ ÌÔÚÊÒÓ Candida albicans Ì ·Ó·Û˘Ó‰˘·Ṳ̂ÓÔ 50kDa ¤Ó˙˘ÌÔ Â›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË Ï‡ÛË ÙˆÓ Ì˘Î‹ÙˆÓ Î·È Ë ÂÓ‰ÔÂÚÈÙÔÓ·˚΋ ¯ÔÚ‹ÁËÛ‹ ÙÔ˘ Û ÔÓÙ›ÎÈ· ÌÂ Û˘ÛÙËÌ·ÙÈ΋ ÌfiÏ˘ÓÛË ·fi Candida albicans ‹ Aspergillus ›¯Â ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙË ı·̷ÙÈ΋ ·Ó¿ÚÚˆÛ‹ ÙÔ˘˜ (23).
311
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·312
¶∞π¢π∞∆ƒπ∫∏ 2000;63:309-313
ŸÏ˜ ÔÈ ·Ú·¿Óˆ ·Ú·ÙËÚ‹ÛÂȘ Û˘ÓËÁÔÚÔ‡Ó ÁÈ· ÙÔ fiÙÈ Ë ¯ÈÙÔÙÚÈÔ˙ȉ¿ÛË ·ÔÙÂÏ› ¤Ó· ÛËÌ·ÓÙÈÎfi ·Ú¿ÁÔÓÙ· ÙÔ˘ Ì˯·ÓÈÛÌÔ‡ ¿Ì˘Ó·˜ ¤Ó·ÓÙÈ ÙˆÓ Ì˘Î‹ÙˆÓ. T· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ÂÓÈÛ¯‡Ô˘Ó ·˘Ù‹ ÙËÓ Èı·ÓfiÙËÙ·, Û˘Á¯ÚfiÓˆ˜ fï˜ ‰Â›¯ÓÔ˘Ó ˆ˜ Ë ·‡ÍËÛË Ù˘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ ‰ÂÓ Â›Ó·È ·ÚÎÂÙ‹ ÁÈ· ÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ì˘ÎËÙÈ·ÛÈÎÒÓ ÏÔÈÌÒ͈Ó, οÙÈ Ô˘ Â›Ó·È ·Ó·ÌÂÓfiÌÂÓÔ, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ¿Ì˘Ó· ¤Ó·ÓÙÈ ÙˆÓ Ì˘Î‹ÙˆÓ ÛÙËÚ›˙ÂÙ·È ÛÙË Û˘Ó‰˘·Ṳ̂ÓË ‰Ú¿ÛË ÔÏÏÒÓ ·Ú·ÁfiÓÙˆÓ (19). OÈ Ì˘ÎËÙÈ·ÛÈΤ˜ ÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó ¤Ó· ÛËÌ·ÓÙÈο ·˘Í·ÓfiÌÂÓÔ Úfi‚ÏËÌ· ÛÙȘ MÔÓ¿‰Â˜ EÓÙ·ÙÈ΋˜ NÔÛËÏ›·˜ NÂÔÁÓÒÓ. T· ÓÂÔÁÓ¿ Î·È È‰È·›ÙÂÚ· Ù· ÌÈÎÚÔ‡ ‚¿ÚÔ˘˜ ÚfiˆÚ·, ¤¯Ô˘Ó ·ÓÒÚÈÌÔ ·ÓÔÛÔÏÔÁÈÎfi Û‡ÛÙËÌ· Ô˘ Ù· Úԉȷı¤ÙÂÈ Û ٤ÙÔȘ ÏÔÈÌÒÍÂȘ. EÈϤÔÓ Ë Ì·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ÈÛ¯˘ÚÒÓ ·ÓÙÈ‚ÈÔÙÈÎÒÓ Â˘Ú¤ˆ˜ Ê¿ÛÌ·ÙÔ˜, ÎÔÚÙÈ˙fiÓ˘, ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ‰ËÌÈÔ˘ÚÁ› ȉ·ÓÈÎfi ÂÚÈ‚¿ÏÏÔÓ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Ì˘ÎËÙÈ·ÛÈÎÒÓ ÏÔÈÌÒÍÂˆÓ (2,3). H ‰È¿ÁÓˆÛ‹ ÙÔ˘˜ Â›Ó·È Û˘¯Ó¿ ‰‡ÛÎÔÏË, ÂÓÒ ˘ÔÏÔÁ›˙ÂÙ·È ˆ˜ ÙÔ ÔÛÔÛÙfi „¢‰Ò˜ ·ÚÓËÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Û ηÏÏȤÚÁÂȘ Êı¿ÓÂÈ ÙÔ 20-50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (2). H ·Ú·Ù‹ÚËÛ‹ Ì·˜ ˆ˜ ÔÈ Ì˘ÎËÙÈ·ÛÈΤ˜ ÏÔÈÌÒÍÂȘ Ô‰ËÁÔ‡Ó Û ·‡ÍËÛË ÙˆÓ ÂȤ‰ˆÓ Ù˘ ¯ÈÙÔÙÚÈÔ˙ȉ¿Û˘ ÙˆÓ ·ÛıÂÓÒÓ, Ù· ÔÔ›· ÌÂÈÒÓÔÓÙ·È ‹ ·˘Í¿ÓÔÓÙ·È ·Ó¿ÏÔÁ· Ì ÙËÓ ¤Î‚·ÛË Ù˘ ÓfiÛÔ˘, ‰Â›¯ÓÂÈ ˆ˜ ÔÈ ‰È·‰Ô¯ÈΤ˜ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ ÂÓ˙‡ÌÔ˘ ÌÔÚÔ‡Ó Ó· ·ÔÙÂϤÛÔ˘Ó ÎÚÈÙ‹ÚÈÔ ·ÓÙ·fiÎÚÈÛ˘ ÛÙËÓ ÂÊ·ÚÌÔ˙fiÌÂÓË ıÂڷ›· ·ÏÏ¿ Î·È ÚÒÈÌÔ ‰Â›ÎÙË Ì˘ÎËÙÈ·ÛÈÎÒÓ ÏÔÈÌÒ͈Ó. OÈ Èı·Ó¤˜ ·˘Ù¤˜ ÂÊ·ÚÌÔÁ¤˜ ÛÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË Â›Ó·È ˘fi ‰ÈÂÚ‡ÓËÛË, ÛÙ· Ï·›ÛÈ· ÂÓfi˜ ¢ڇÙÂÚÔ˘ ÚÔÁÚ¿ÌÌ·ÙÔ˜ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ÌÂϤÙË ÌÂÁ·Ï‡ÙÂÚÔ˘ ·ÚÈıÌÔ‡ ÓÂÔÁÓÒÓ ·ÏÏ¿ Î·È ¿ÏÏˆÓ ÔÌ¿‰ˆÓ fiˆ˜ ÔÈ ·ÓÔÛÔηٷÛÙ·Ï̤ÓÔÈ ·ÛıÂÓ›˜.
π. §·Ì·‰·Ú›‰Ë˜ Î·È Û˘Ó.
7.
8.
9.
10.
11.
12.
13. 14. 15.
16.
17.
18.
BÈ‚ÏÈÔÁÚ·Ê›· 1. Baley J.E. Neonatal candidiasis. The current challenge. Clin Perinatol. 1991;18:263-280. 2. Nichols JM, Yuen KY, Tan AYC: Systemic fungal infections in neonates. Br J Hosp Med 1993;49:420-424. 3. Leibovitz E, Luster-Reicher A, Amitai M, Moligner S. Systemic candidal infections associated with the use of peripheral venous catheters in neonates: A 9 year experience. Clin Infec Dis 1992;14:485-491. 4. Henrissat B, Bairoch A. New families in the classification of glycosyl hydrolases based on amino acid sequence similarities. Biochem J 1993;293:781-788. 5. Hakala BE, White C, Recklies AD. Human cartilage gp-39, a major secretory product of articular chondrocyte and synovial cell, is a mammalian member of a chitinase protein family. J Biol Chem 1993;268:25803-25810. 6. Malette B, Merlen Y, Bleau G, Paquette Y. Oviductins posses chitinase- and mucin - like domains: a lead to the
312
19. 20.
21.
22.
search for the biological function of these oviduct-specific ZP-associated glycoproteins. Mol Reprod Dev 1995; 41:384-397. Den Tandt WR, Scharp S, Overdijk B. Evaluation of the hydrolysis of methylumbelliferyl-tetra-N-acetyl chiototetraoside by various glucosidases. A comparative study. Int J Biochem 1993;25:113-119. Overdijk B, van Steijn GJ. Human serum contains a chitinase: identification of an enzyme, formerly described as 4-methylumbelliferyl-tetra-N-acetylchitotetraoside hydrolase (MU-TCACT). Glycobiology 1994;4:797-803. Sahai AS, Manocha RW. Chitinases of fungi and plants: their involvement in morphogenesis and host-parasite interaction FEMS Microbiology Reviews 1993;11:317-338. Labadaridis J, Dimitriou E, Costalos C, et al. Serial chitotriosidase activity estimations in neonatal systemic candidiasis. Acta Paediatrica 1998;87:605-606. AÓ·ÁÓˆÛÙ¿Î˘ ¢, §·Ì·‰·Ú›‰Ë˜ I, AÓÙˆÓÔÔ‡ÏÔ˘ N. OÍ›· ÓÂÊÚÈ΋ ·Ó¿ÚÎÂÈ· Û ‚Ú¤ÊÔ˜ 2 ÌËÓÒÓ. ¢ÂÏÙ. A' ¶·È‰È·ÙÚ. KÏÈÓ. ¶·ÓÂ. AıËÓÒÓ 1998;45:180-186. Hollak CEM, van Weely S, van Oers MHJ and Aerts JMFG. Marked elevation of plasma chitotriosidase activity. J Clin Invest 1994;93:1288-1292. Mulisch M. Chitin in protistan organisms. Eur J Protistol 1993;29:1-18. Flach J, Pilet PE, Jolles P. What's new in chitinase research? Experientia 1992;48:701-716. Gooday GW. Diversity of roles for chitinases in nature. In: Zakaria MB, Nudna WMW, Abdullah MP eds. Chitin and chitosan - the versatile environmentally friendly modern materials. Pangi, Penerbit University Kebangsaan Malaysia 1995:191-202. Shahabudin M, Kaslow DC. Chitinase: a novel target for blocking parasite transmission? Parasitol Today 1993;9:252-258. Schlein Y, Jacobson RL, Shlomai J. Chitinase secreted by Leishmania functions in the sandfly vector. Proc R Soc B 1991;245:121-26. Broekaert WF, van Parijs J. Allen AK, Peumans WJ. Comparison of some molecular, enzymatic and antifungal properties of Chitinases from thorn-apple, tobacco and wheat. Physiol Mol Pl Pathol 1988;33:319-33. Vazquez-Torres A, Balish E. Macrophages in Resistance to Candidiasis. Microbiol Molec Biol Rev 1997;61:170-192. Renkema GH, Boot RG, Strijland A, Donker-Koopman WE, van den Berg M, Muijsers AO et al. Synthesis, sorting, and processing into distinct isoforms of human macrophage chitotriosidase. Eur J Biochem 1997;244: 279-285. Boot RG, van Archterberg TA, van Aken BE, Renkema GH, Jacobs MJ, Aerts JM et al. Strong induction of members of the chitinase family of proteins in atherosclerosis: Chitotriosidase and human cartilage hp-39 expressed in lesion macrophages. Arterioscler Thromb Vasc Biol 1999;19:687-694. Overdijk B, Van Steijn GJ, Odds FC. Distribution of chitinase in guinea pig tissues and increases in levels of
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·313
¶∞π¢π∞∆ƒπ∫∏ 2000;63:309-313
this enzyme after systemic infection with Aspergillus fumigatus. Microbiology 1999; 145:259-269. 23. Blommaart E, van Weely S, Boot R, Aerts JM, Friedman
∏ ¯ÈÙÔÙÚÈÔ˙ȉ¿ÛË Û Ïԛ̈ÍË Candida albicans
BA. Chitotriosidase: A natural antifungal agent? (Abstract) 3rd Workshop European Working Group on Gaucher Disease, Lemnos 1999.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 16-03-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-06-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¢Ú. EϤÓË MȯÂϷοÎË IÓÛÙÈÙÔ‡ÙÔ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ NÔÛ/ÌÂ›Ô ¶·›‰ˆÓ "H AÁ›· ™ÔÊ›·", Aı‹Ó· 11527
313
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·314
¶∞π¢π∞∆ƒπ∫∏ 2000;63:314-318
§ÔÈÌÒÍÂȘ ·fi ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È· Û ·È‰È¿ ¶·Ó·ÁÈÒÙ˘ ™˘Ú›‰Ë˜, EϤÓË M·ÏÙ¤˙Ô˘, ¢ËÌ‹ÙÚÈÔ˜ K·ÊÂÙ˙‹˜
● ¶ÂÚ›ÏË„Ë: ™ÙËÓ ·Ó·‰ÚÔÌÈ΋ ·˘Ù‹ ÌÂϤÙË ÂÍÂÙ¿ÛıËÎ·Ó Ù· ÎÏÈÓÈο Î·È ÂȉËÌÈÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο, ηıÒ˜ Î·È Ë ·ÓÙÈÌÂÙÒÈÛË Î·È Ë ¤Î‚·ÛË ·È‰ÈÒÓ Ì Ïԛ̈ÍË ·fi ÕÙ˘· M˘ÎÔ‚·ÎÙËÚ›‰È· (A.M.). MÂÏÂÙ‹ıËÎ·Ó Ù· ÈÛÙÔÚÈο 52 ·È‰ÈÒÓ ËÏÈΛ·˜ 0-14 ÂÙÒÓ Ù· ÔÔ›· ÓÔÛËχıËÎ·Ó ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ "¶. & A. K˘ÚÈ·ÎÔ‡" ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 19821997 Ì Ïԛ̈ÍË ·fi AM ηٿ ÙÔ ‰Â‡ÙÂÚÔ ‹ÌÈÛ˘ Ù˘ ÌÂϤÙ˘ ‰È·ÁÓÒÛıËÎ·Ó 40 ·ÛıÂÓ›˜ (76,5%). Afi ÙÔ˘˜ 52 ·ÛıÂÓ›˜ ÔÈ 47 ›¯·Ó ÂÈÔÏ‹˜ ÏÂÌÊ·‰ÂÓ›Ùȉ·, ÙÚÂȘ Ó¢ÌÔÓÈ΋ Î·È ‰‡Ô ÁÂÓÈÎÂ˘Ì¤ÓË ÓfiÛÔ. TÔ M. Avium ‹Ù·Ó ÙÔ Î·ÙÂÍÔ¯‹Ó A.M. ÌÂٷ͇ ·ÔÌÔÓˆı¤ÓÙˆÓ ÛÙÂϯÒÓ. H ÔÚ›· ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ ηıÒ˜ Î·È ÙÔ ÙÂÏÈÎfi ·ÈÛıËÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ‹Ù·Ó ÛÙÂÓ¿ Û˘Ó‰Â‰Â̤ÓÔ Ì ÙÔ ¯ÚfiÓÔ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·ÔηٿÛÙ·Û˘. OÈ ·ÛıÂÓ›˜ Ì Ó¢ÌÔÓÈ΋ ÓfiÛÔ Â›¯·Ó Ôχ ηϋ ÔÚ›· Ì ÙË ¯ÔÚ‹ÁËÛË 3-4 ·ÓÙÈÊ˘Ì·ÙÈÎÒÓ Ê·Ú̿ΈÓ, ÂÓÒ ÔÈ ‰‡Ô ·ÛıÂÓ›˜ Ì ÁÂÓÈÎÂ˘Ì¤ÓË ÓfiÛÔ Î·Ù¤ÏËÍ·Ó Ì¤Û· ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ·Ú¿ ÙË ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹. ¶·È‰È·ÙÚÈ΋ 2000;63:314-318. §¤ÍÂȘ ÎÏÂȉȿ: ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È·, ÏÂÌÊ·‰ÂÓ›Ùȉ·, M. Avium. P. Spyridis, H. Maltezou, D. Kafetzis. Non-tuberculous mycobacterial lymphadenitis in children. Paediatriki 2000;63:314-318. ● Abstract: A study was made to review the clinical and epidemiological features, management and outcome associated with the development of non-tuberculous mycobacterial (NTM) infection in children. The medical records of all children aged 0-14 years with NTM infection diagnosed at the P. and A. Kyriakou Children's Hospital between January 1982 and December 1997 were reviewed. During the study period 52 such children were identified, in 76.5% of whom the diagnosis was made during the second half of the period studied. Of the 52 patients, 47 had lymphadenitis, 3 pulmonary and 2 disseminated disease. Mycobacterium avium complex was the predominant isolate in these cases. Satisfactory aesthetic results were achieved when total excision of the affected lymph nodes was perfomed within one month of the onset of NTM lymphadenitis. The outcome was good for the 3 patients with pulmonary disease, but the 2 patients with the disseminated form died. In conclusion NTM infection in children is being diagnosed in increasing frequency during the last decade. Prompt total excision of the involved lymph nodes is indicated for an optimal outcome. Key words: non-tuberculous mycobacteria, lymphadenitis, M. Avium.
EÈÛ·ÁˆÁ‹ T· ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È· (A.M.) Â›Ó·È ıÂÙÈÎÔ› ηٿ gram ÔÍÂfiÊÈÏÔÈ ‚¿ÎÈÏÏÔÈ ÔÈ ÔÔ›ÔÈ ·Ó¢ڛÛÎÔÓÙ·È ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ È‰È·›ÙÂÚ· ÛÙÔ ÓÂÚfi Î·È ÙË ÛÎfiÓË. T· Ì˘ÎÔ‚·ÎÙËÚ›‰È· ·˘Ù¿ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÚÈÓ ·fi ¤Ó·Ó ·ÈÒÓ·, ÂÓÙÔ‡ÙÔȘ ÌfiÓÔ ÌÂÙ¿ ÙÔ 1950 ¿Ú¯ÈÛ·Ó Ó· ·Ó·ÁÓˆÚ›˙ÔÓÙ·È ˆ˜ ÛÔ‚·ÚÔ› ·ıÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙÔÓ ¿ÓıÚˆÔ. Œ¯ÂÈ ÂÚÈÁÚ·Ê› ηٿ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· Â˘Ú‡Ù·ÙÔ Ê¿ÛÌ· ÏÔÈÌÒÍÂˆÓ ·fi A.M.
ÛÙÔÓ ¿ÓıÚˆÔ, ·fi ÙËÓ ÚÔÛ‚ÔÏ‹ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ (΢ڛˆ˜ ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ ÙÔ˘ ÙÚ·¯‹ÏÔ˘), ̤¯ÚÈ ÙËÓ ·ÂÈÏËÙÈ΋ ÁÈ· ÙË ˙ˆ‹ ‰È·ÛÔÚ¿ Û ÔÏÏ¿ fiÚÁ·Ó·, Û ¿ÙÔÌ· Ì ·ÓÔÛÔηٷÛÙÔÏ‹. H ÙÂÏÂ˘Ù·›· ‰È·ÈÛÙÒÓÂÙ·È Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÚfiÛÊ·Ù·, ÂÍ·ÈÙ›·˜ ÙÔ˘ ÚfiÛÊÔÚÔ˘ ˘ÔÛÙÚÒÌ·ÙÔ˜ ÙÔ ÔÔ›Ô ·Ó·Ù‡ÛÛÂÙ·È Û ¿ÙÔÌ· Ì AIDS ‹ Û ÂÚÈÙÒÛÂȘ ηٷÛÙÔÏ‹˜ ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ·fi ηÎÔ‹ıË ÓÔÛ‹Ì·Ù· (1,2).
B' ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ, π·ÙÚÂ›Ô º˘Ì·ÙÈÒÛˆ˜ NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ "¶. Î·È A. K˘ÚÈ·ÎÔ‡", °Ô˘‰›
314
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·315
¶∞π¢π∞∆ƒπ∫∏ 2000;63:314-318
§ÔÈÌÒÍÂȘ ·fi ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È·
™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ÂÚÈÁÚ·ÊÔ‡Ó Ù· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο, Ù· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù·, Ë ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË Î·ıÒ˜ Î·È Ë ¤Î‚·ÛË ·È‰ÈÒÓ Ì Ïԛ̈ÍË ·fi A.M. YÏÈÎfi Î·È Ì¤ıÔ‰Ô˜ TÔ ˘ÏÈÎfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó ·ÛıÂÓ›˜ ÙÔ˘ NÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ "¶. & A. K˘ÚÈ·ÎÔ‡", ËÏÈΛ·˜ 014 ÂÙÒÓ, ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‰È·ÁÓÒÛıËΠÏԛ̈ÍË ·fi A.M. ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1982-1997. ™ÙË ÌÂϤÙË ÂÚÈÂÏ‹ÊıËÛ·Ó ·ÛıÂÓ›˜ Ì ·ÔÌfiÓˆÛË A.M. Û ηٿÏÏËÏÔ ‰Â›ÁÌ· ·fi ÙÔ ÓÔÛÔ‡Ó Û‡ÛÙËÌ· ÌÂÙ¿ ·fi ηÏÏȤÚÁÂÈ· Û ˘ÏÈÎfi LowensteinJensen ‹ Ì ÙË Ú·‰ÈÔÌÂÙÚÈ΋ ̤ıÔ‰Ô BACTEC. ™ÙȘ ÂÚÈÙÒÛÂȘ fiÔ˘ ‰ÂÓ ·ÔÌÔÓÒıËΠA.M., Ë ‰È¿ÁÓˆÛË Ù˘ Ïԛ̈͢ ·fi A.M. ÛÙËÚ›¯ıËΠÛÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· Ë ÔÔ›· ‹Ù·Ó Û˘Ì‚·Ù‹ Ì Ïԛ̈ÍË ·fi Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ì ٷ˘Ùfi¯ÚÔÓË ¤ÏÏÂÈ„Ë Â·Ê‹˜ Ì ÂÓ‹ÏÈη Ê˘Ì·ÙÈÎfi, ·ÚÓËÙÈ΋ ‹ ·ÌÊ›‚ÔÏË Ê˘Ì·ÙÈÓÔ·ÓÙ›‰Ú·ÛË Mantoux, ·Ô˘Û›· ÚfiÛÊ·ÙÔ˘ ÂÌ‚ÔÏÈ·ÛÌÔ‡ Ì BCG, Î·È Ê˘ÛÈÔÏÔÁÈ΋ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη. T· ·ÓˆÙ¤Úˆ Ô‰ËÁÔ‡Ó Ì ·ÚÎÂÙ‹ ·ÛÊ¿ÏÂÈ· ÛÙË ‰È¿ÁÓˆÛË Ïԛ̈͢ ·fi A.M. 7 6 5 4 3 2
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
0
1982
1
∂ÈÎfiÓ· 1. K·Ù·ÓÔÌ‹ ÙˆÓ ·ÛıÂÓÒÓ Ì ÏÂÌÊ·‰ÂÓ›Ùȉ· ·fi ÕÙ˘· M˘ÎÔ‚·ÎÙËÚ›‰È· ηٿ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Ù˘ ÌÂϤÙ˘.
AÔÙÂϤÛÌ·Ù· K·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÌÂϤÙ˘ ηٷÁÚ¿ÊËÎ·Ó Û˘ÓÔÏÈο 52 ·È‰È¿ (26 ·ÁfiÚÈ·) Ì Ïԛ̈ÍË ·fi A.M. OÈ ÂÈ̤ÚÔ˘˜ ‰È·ÁÓÒÛÂȘ ÂÚÈÂÏ¿Ì‚·Ó·Ó: ÂÈÔÏ‹˜ ÏÂÌÊ·‰ÂÓ›Ùȉ· (47 ·È‰È¿), Ó¢ÌÔÓÈ΋ ÓfiÛÔ˜ (3 ·È‰È¿), Î·È ‰È¿¯˘ÙË Ïԛ̈ÍË (2 ·È‰È¿). ™˘ÓÔÏÈο, 12 ·È‰È¿ (23%) ‰È·ÁÓÒÛıËÎ·Ó ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 198289 Î·È Ù· ˘fiÏÔÈ· 40 (77%) ÛÙÔ ‰Â‡ÙÂÚÔ ‹ÌÈÛ˘ Ù˘ ÌÂϤÙ˘, 1991-1997 (∂ÈÎfiÓ· 1). ™Â fi,ÙÈ ·ÊÔÚ¿ ÙËÓ Âԯȷ΋ ηٷÓÔÌ‹, ÙÔ 41% ÙˆÓ ·ÛıÂÓÒÓ ÂÌÊ¿ÓÈÛ ٷ ÚÒÙ· ÛËÌ›· ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ ηٿ ÙËÓ ÕÓÔÈÍË. Afi ÙÔ ÈÛÙÔÚÈÎfi ÙˆÓ ·ÛıÂÓÒÓ ‰ÂÓ ÚÔ·ÙÔ˘Ó ·ÛÊ·Ï‹ ÛÙÔȯ›· ÁÈ· ÙËÓ ËÁ‹ ÌfiÏ˘ÓÛ˘ ÛÂ
¶›Ó·Î·˜ 1. KÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ ÏÂÌÊ·‰¤ÓˆÓ (NÔ, %). ™ÎÏËÚfi˜ - ÎÈÓËÙfi˜ K·ıËψ̤ÓÔ˜ M·Ï·Îfi˜ (Z˘Ì҉˘) EÚ˘ıÚfiÙËÙ· KÏ˘‰·ÛÌfi˜ £ÂÚÌfi˜ ™˘Ú›ÁÁÈÔ ¶ÔÏÏ·Ï‹ ·˘ÙfiÌ·ÙË Ú‹ÍË
21 (45) 13 (28) 12 (26) 11 (23) 5 (11) 2 (4) 3 (6) 1 (2)
¶›Ó·Î·˜ 2. AÓ·ÙÔÌÈ΋ ı¤ÛË ÙˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ ÏÂÌÊ·‰¤ÓˆÓ (No, %). YÔÁÓ¿ıÈÔÈ ¶ÚfiÛıÈÔÈ ÙÚ·¯ËÏÈÎÔ› ¶ÚÔˆÙÈ·›ÔÈ BÔ˘‚ˆÓÈÎÔ› O›ÛıÈÔÈ ÙÚ·¯ËÏÈÎÔ› M·Û¯·ÏÈ·›ÔÈ
24 (51) 15 (32) 4 (9) 2 (4) 1 (2) 1 (2)
Â›Â‰Ô ÔÈÎÔÁ¤ÓÂÈ·˜, ¤ÎıÂÛË Û ˙Ò·, ‰È·ÈÙËÙÈΤ˜ Û˘Ó‹ıÂȘ ‹ Ù·Í›‰È· Û ÂÚÈÔ¯¤˜ ÂÓ‰ËÌÈΤ˜ ÁÈ· A.M. H ̤ÛË ËÏÈΛ· ÙˆÓ 47 ·ÛıÂÓÒÓ Ì ÂÈÔÏ‹˜ ÏÂÌÊ·‰ÂÓ›Ùȉ· ·fi A.M. ‹Ù·Ó Ù· 3 ¤ÙË (4 Ì‹Ó˜ - 10 ¤ÙË). H ‰ÈfiÁΈÛË ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ ‰È·ÈÛÙÒıËΠηٿ ̤ÛÔÓ fiÚÔ 30 Ë̤Ú˜ ÚÈÓ ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô (1 Ë̤ڷ - 2 ¯ÚfiÓÈ·). £ÂÚÌÔÎÚ·Û›· 38o38,5oC ‰È·ÈÛÙÒıËΠ۠٤ÛÛÂÚȘ ·ÛıÂÓ›˜ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÚÔÛ‚ÔÏ‹˜ ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ ‹ Ï›ÁÔ ·ÚÁfiÙÂÚ· (1Ë-12Ë Ë̤ڷ). EÌÂÈÚÈ΋ ıÂڷ›·, ΢ڛˆ˜ Ì ·ÓÙÈÛÙ·Ê˘ÏÔÎÔÎÎÈο ·ÓÙÈ‚ÈÔÙÈο, ¤Ï·‚·Ó 20/47 ·ÛıÂÓ›˜ (43%), ¯ˆÚ›˜ ÎÏÈÓÈ΋ ·ÓÙ·fiÎÚÈÛË, ÂÓÒ Ì ÙËÓ ˘Ô„›· Ïԛ̈͢ ·fi M. Ê˘Ì·Ù›ˆÛ˘ 9/47 ·ÛıÂÓ›˜ (19%) ¤Ï·‚·Ó ·fi ÙÔ˘˜ ıÂÚ¿ÔÓÙ˜ È·ÙÚÔ‡˜ ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹. ∏ ·ÁˆÁ‹ ÂÚÈÂÏ¿Ì‚·Ó ÈÛÔÓÈ·˙›‰Ë Î·È ÚÈÊ·ÌÈΛÓË, ¯ˆÚ›˜ ˘Ô¯ÒÚËÛË Ù˘ ÏÂÌÊ·‰ÂÓÈ΋˜ ‰ÈfiÁΈÛ˘. H ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹ ¯ÔÚËÁ‹ıËΠÛÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ·fi 12 Ë̤Ú˜ ¤ˆ˜ 12 Ì‹Ó˜ Ì ̤ÛË ‰È¿ÚÎÂÈ· 60 Ë̤Ú˜ ÚÈÓ ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌ›Ô. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì ÏÂÌÊ·‰ÂÓ›Ùȉ· ·fi A.M. ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË, ¯ˆÚ›˜ Û˘ÌÙÒÌ·Ù· ‹ ÎÏÈÓÈο Â˘Ú‹Ì·Ù·. T· ÎÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ ηٿ ÙËÓ ÚÔۤϢÛË ÛÙÔ ÓÔÛÔÎÔÌ›Ô, ÂÚȤ¯ÔÓÙ·È ÛÙÔÓ ›Ó·Î· 1, ÂÓÒ Ë ·Ó·ÙÔÌÈ΋ ı¤ÛË ÛÙÔÓ ›Ó·Î· 2. TÔ Ì¤ÛÔ Ì¤ÁÂıÔ˜ ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ ‹Ù·Ó 3x3 cm (1,5x1,5 ¤ˆ˜ 5x8 cm). ¢ÂÓ ‰È·ÈÛÙÒıËΠ‰ÈfiÁΈÛË ÏÂÌÊ·‰¤ÓˆÓ Û ¿ÏÏË ı¤ÛË ÏËÓ Ù˘ ·Ú¯È΋˜ ÚÔÛ‚ÔÏ‹˜. O ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÂÚÈÂÏ¿Ì‚·Ó ÁÂÓÈ΋ ÂͤٷÛË ·›Ì·ÙÔ˜, C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË, TKE, ¤ÏÂÁ¯Ô Ë·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÔÚÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÁÈ· ÈÔ‡˜, Bartonella henselae
315
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·316
¶∞π¢π∞∆ƒπ∫∏ 2000;63:314-318
EÈÎfiÓ· 2. A˘ÙfiÌ·ÙË Ú‹ÍË Î·È ·Ó¿Ù˘ÍË ¯ËÏÔÂȉԇ˜. Î·È Toxoplasma gondii Î·È ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì ÏÂÌÊ·‰ÂÓ›Ùȉ· ·fi A.M. ˘Ô‚Ï‹ıËÎ·Ó ÛÂ Ê˘Ì·ÙÈÓÔ·ÓÙ›‰Ú·ÛË ÌÂ Ê˘Ì·Ù›ÓË Lot 5180A πÓÛÙÈÙÔ‡ÙÔ˘ Pasteur-Merieux. TÔ Ì¤ÁÂıÔ˜ Ù˘ Ê˘Ì·ÙÈÓÔ·ÓÙ›‰Ú·Û˘ Î˘Ì¿ÓıËΠ·fi 0-15 ¯ÈÏ. Ì ̤ÛË ÙÈÌ‹ Ù· 7 ¯ÈÏ. H ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÛıÂÓÒÓ. OÈ ·ÛıÂÓ›˜ Ì ÏÂÌÊ·‰ÂÓ›Ùȉ· ˘Ô‚Ï‹ıËÎ·Ó Û ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË Ë ÔÔ›· ÂÚÈÂÏ¿Ì‚·Ó ÔÏÈ΋ ·Ê·›ÚÂÛË ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ Û 40 ·ÛıÂÓ›˜, ·ÚÔ¯¤Ù¢ÛË ·ÔÛÙËÌ·ÙÔÔÈËı¤ÓÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ Û ¤ÓÙ ·ÛıÂÓ›˜ Î·È Î·ı·ÚÈÛÌfi Î·È Ó·ÚÔÔ›ËÛË Â› ·˘ÙfiÌ·Ù˘ ڋ͢ ‹ ·Ó¿Ù˘Í˘ Û˘ÚÈÁÁ›Ô˘, Û ‰‡Ô. H ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË Ú·ÁÌ·ÙÔÔÈ‹ıËΠηٿ ̤ÛÔ fiÚÔ Û 36 Ë̤Ú˜ ·fi ÙËÓ ·Ú¯È΋ ÂÌÊ¿ÓÈÛË Ù˘ ‰ÈfiÁΈÛ˘ (6 Ë̤Ú˜ - 2 ¯ÚfiÓÈ·). IÛÙÔÏÔÁÈ΋ ÂͤٷÛË ˘ÏÈÎÔ‡ ÏÂÌÊ·‰¤ÓÔ˜ ¤ÁÈÓ Û 42 ·fi ÙÔ˘˜ 47 ¯ÂÈÚÔ˘ÚÁËı¤ÓÙ˜ ·ÛıÂÓ›˜, fiÔ˘ ¢ڤıËÛ·Ó ·ÏÏÔÈÒÛÂȘ ¯ÚfiÓÈ·˜ ÎÔÎÎȈ̷ÙÒ‰Ô˘˜ ÊÏÂÁÌÔÓ‹˜ Î·È ÓÂÎÚÒÛÂȘ Û˘Ì‚·Ù¤˜ Ì Ïԛ̈ÍË ·fi Ì˘ÎÔ‚·ÎÙËÚ›-
EÈÎfiÓ· 3. ¶·ÚÔ¯¤Ù¢ÛË ·ÔÛÙ‹Ì·ÙÔ˜ Î·È ÂԇψÛË Î·Ù¿ ‰Â‡ÙÂÚÔ ÛÎÔfi.
316
¶. ™˘Ú›‰Ë˜ Î·È Û˘Ó.
‰È·. K·ÏÏȤÚÁÂÈ· ÁÈ· Ì˘ÎÔ‚·ÎÙËÚ›‰È· ¤ÁÈÓ Û 45 ·ÛıÂÓ›˜ Î·È ·¤‚Ë ıÂÙÈ΋ Û 40. AÔÌÔÓÒıËΠM. Avium complex Û 33 ·ÛıÂÓ›˜ Î·È M. Kansasii Û ÙÚÂȘ. ™ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ 4 ·ÛıÂÓ›˜ ‰ÂÓ Ù˘ÔÔÈ‹ıËΠÙÔ ¿Ù˘Ô Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ. H ‰È¿ÁÓˆÛË Ù˘ ÏÂÌÊ·‰ÂÓ›Ùȉ·˜ ·fi ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È· ·Ô‰Â›¯ıËΠÌÈÎÚÔ‚ÈÔÏÔÁÈο Û 40 ·ÛıÂÓ›˜ ÂÓÒ ÛÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ÂÙ¿ ÛÙËÚ›¯ıËΠÛÙË Û˘Ì‚·Ù‹ ÌÂ Ì˘ÎÔ‚·ÎÙËÚȉȷ΋ Ïԛ̈ÍË ÈÛÙÔÏÔÁÈ΋ ÂÈÎfiÓ· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ÌÈÎÚfiÙÂÚË ·fi 10 ¯ÈÏ. Ê˘Ì·ÙÈÓÔ·ÓÙ›‰Ú·ÛË, ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜, ÙËÓ ¤ÏÏÂÈ„Ë Â·Ê‹˜ Ì ÂÓ‹ÏÈη Ê˘Ì·ÙÈÎfi Î·È Ù¤ÏÔ˜, ÙËÓ ·ÔηٿÛÙ·ÛË ¯ˆÚ›˜ ÙË ¯ÔÚ‹ÁËÛË ·ÓÙÈÊ˘Ì·ÙÈÎÒÓ Ê·Ú̿ΈÓ. ™ÙÔ˘˜ 13 ·ÛıÂÓ›˜ Ô˘ ·ÚÔ˘Û›·Û·Ó Ê˘Ì·ÙÈÓÔ·ÓÙ›‰Ú·ÛË ¿Óˆ ÙˆÓ 10 ¯ÈÏ. Ë ‰È¿ÁÓˆÛË Ù˘ ÏÂÌÊ·‰ÂÓ›Ùȉ·˜ ·fi A.M. ÂȂ‚·ÈÒıËΠÌÈÎÚÔ‚ÈÔÏÔÁÈο. EÓ ·Ó·ÌÔÓ‹ ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Ù˘ ηÏÏȤÚÁÂÈ·˜ ÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ, ¯ÔÚËÁ‹ıËΠ·ÓÙÈÊ˘Ì·ÙÈ΋ ·ÁˆÁ‹ Ë ÔÔ›· ÂÚÈÂÏ¿Ì‚·Ó IÛÔÓÈ·˙›‰Ë Î·È PÈÊ·ÌÈΛÓË, Û 14 ·ÛıÂÓ›˜. ¢‡Ô ·ÛıÂÓ›˜ Ì M. Avium complex Î·È ¤Ó·˜ ·ÛıÂÓ‹˜ Ì M. Kansasii ¤Ï·‚·Ó ÙËÓ ·ÓˆÙ¤Úˆ ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ ÁÈ· 9 Ì‹Ó˜ Î·È 12 Ì‹Ó˜ ·ÓÙ›ÛÙÔȯ· ¯ˆÚ›˜ ·ÔÙ¤ÏÂÛÌ·, ÚÈÓ ÚÔÛ¤ÏıÔ˘Ó ÛÙÔ ÓÔÛÔÎÔÌ›Ô. H ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Ì ÏÂÌÊ·‰ÂÓ›Ùȉ· ·fi A.M. ‰È‹ÚÎÂÛ ·fi 6 Ì‹Ó˜ ¤ˆ˜ 2 ¤ÙË ÌÂÙ¿ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË. K·Ó›˜ ‰ÂÓ ÂÌÊ¿ÓÈÛ ÏÂÌÊ·‰ÂÓ›Ùȉ· Û ı¤ÛË ¿ÏÏË ÂÎÙfi˜ Ù˘ ·Ú¯È΋˜, Û ¤ÓÙ fï˜ ·ÛıÂÓ›˜ ¯ÚÂÈ¿ÛÙËΠӷ Á›ÓÂÈ Î·È ‰Â‡ÙÂÚË ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË Â›Ù ‰ÈfiÙÈ ‰ÂÓ Â›¯Â Á›ÓÂÈ ·Ê·›ÚÂÛË fiÏˆÓ ÙˆÓ ÚÔÛ‚ÏËı¤ÓÙˆÓ ÏÂÌÊ·‰¤ÓˆÓ (4 ·ÛıÂÓ›˜) ›Ù ÁÈ·Ù› ·Ó·Ù‡¯ıËΠÏÂÌÊ·‰ÂÓ›Ùȉ· ÛÙË ÁÂÈÙÓÈ¿˙Ô˘Û· ÂÚÈÔ¯‹ ÚÔ˜ ÙËÓ ·Ú¯È΋ (1 ·ÛıÂÓ‹˜). H ‰Â‡ÙÂÚË Â¤Ì‚·ÛË ¤ÁÈÓ 3-4 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ÚÒÙË. ™Â 43/47 ·ÛıÂÓ›˜ ÙÔ ·ÈÛıËÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÛÙË ı¤ÛË Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ¤̂·Û˘ ‹Ù·Ó Ôχ ηÏfi, ÂÓÒ Ù¤ÛÛÂÚȘ ·ÛıÂÓ›˜ ·Ó¤Ù˘Í·Ó ‰‡ÛÌÔÚÊË Ô˘Ï‹ (¯ËÏÔÂȉ¤˜) Î·È ÔÈ ÙÚÂȘ ·fi ·˘ÙÔ‡˜ ¯ÚÂÈ¿ÛıËΠӷ ·ÔηٷÛÙ·ıÔ‡Ó Ì ·ÈÛıËÙÈ΋ ¤̂·ÛË. O ̤ÛÔ˜ ¯ÚfiÓÔ˜ Ù˘ ·ÈÛıËÙÈ΋˜ ·˘Ù‹˜ ·ÔηٿÛÙ·Û˘ ‹Ù·Ó 5 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË. OÈ 3 ·ÛıÂÓ›˜ (ËÏÈΛ·˜ 7, 10 Î·È 11 ÂÙÒÓ) Ì Ó¢ÌÔÓÈ΋ ÓfiÛÔ ·fi A.M. ¤·Û¯·Ó ·fi ˘ÔΛÌÂÓÔ ÓfiÛËÌ·: ϤÌʈ̷ Hodgkin (1 ·ÛıÂÓ‹˜), ‚·ÚÂÈ¿ Û˘Ó‰˘·Ṳ̂ÓË ·ÓÔÛÔ·Ó¿ÚÎÂÈ· (1) Î·È ·ÏÏÂÚÁÈÎfi ¿ÛıÌ· (1). ŒÓ·˜ ·ÛıÂÓ‹˜ ÂÏ¿Ì‚·ÓÂ Û˘ÛÙËÌ·ÙÈ΋ ·ÁˆÁ‹ Ì ÛÙÂÚÔÂȉ‹. K·È ÔÈ 3 ·ÛıÂÓ›˜ ›¯·Ó ÈÛÙÔÚÈÎfi ˘ÚÂÙÈ΋˜ ΛÓËÛ˘ ¤ˆ˜ 38,5oC Î·È ‚‹¯· ÙÔÓ ÙÂÏÂ˘Ù·›Ô Ì‹Ó·. H Ê˘Ì·ÙÈÓÔ·ÓÙ›‰Ú·Û‹ ÙÔ˘˜ ‹Ù·Ó οو ÙˆÓ 10 ¯ÈÏÈÔÛÙÒÓ. OÈ 3 ·ÛıÂÓ›˜ ˘Ô‚Ï‹ıËÎ·Ó Û ˘ÔÏÔÁÈÛÙÈ΋ ÙÔÌÔÁÚ·Ê›· ıÒڷη Ë ÔÔ›· ¤‰ÂÈÍ Ô˙Ò‰ÂȘ ÛÎÈ¿ÛÂȘ, ‰È¿ÌÂÛ˜ ‰ÈËı‹ÛÂȘ Î·È ·ÙÂÏÂÎٷۛ˜ Û fiÏÔ˘˜. H ηÏÏȤÚÁÂÈ· Á·ÛÙÚÈÎÔ‡ ˘ÁÚÔ‡ ¤‰ÂÈÍ M. Avium
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·317
¶∞π¢π∞∆ƒπ∫∏ 2000;63:314-318
complex Î·È ÛÙÔ˘˜ 3 ·ÛıÂÓ›˜. K·Ó¤Ó·˜ ‰ÂÓ ¤Ï·‚ ÂȉÈ΋ ·ÁˆÁ‹ ηٿ A.M. ŒÓ·˜ ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ ·˘ÙÔ‡˜ ‰ÂÓ Â·Ó‹Ïı ÁÈ· ·Ú·ÎÔÏÔ‡ıËÛË. OÈ ¿ÏÏÔÈ 2 ·ÛıÂÓ›˜ ·ÚÔ˘Û›·Û·Ó ·˘ÙfiÌ·ÙË ÎÏÈÓÈ΋ Î·È ·ÎÙÈÓÔÏÔÁÈ΋ ›·ÛË. MÂÙ¿ ·fi 2 Î·È 8 ¤ÙË ·Ú·ÎÔÏÔ‡ıËÛ˘ Â›Ó·È ˘ÁÈ›˜ Î·È ÂχıÂÚÔÈ Û˘ÌÙˆÌ¿ÙˆÓ Î·È ·ÎÙÈÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Û˘Ì‚·ÙÒÓ Ì Ïԛ̈ÍË ·fi A.M. T· 2 ·È‰È¿ Ì ‰È¿¯˘ÙË Ïԛ̈ÍË ·fi A.M. (ËÏÈΛ·˜ 7 Î·È 11 ÂÙÒÓ) ¤·Û¯·Ó ·fi Û‡Ó‰ÚÔÌÔ Evans Î·È AIDS, ·ÓÙ›ÛÙÔȯ·. E›¯·Ó ˘ÚÂÙÈ΋ ΛÓËÛË ¤ˆ˜ 39,0oC ÁÈ· ¤Ó· Ì‹Ó·, ÂÓÒ ¤Ó·˜ ·fi ·˘ÙÔ‡˜ ÂÌÊ¿ÓÈ˙ ‰È¿¯˘Ù· ÎÔÈÏȷο ¿ÏÁË. K·È ÔÈ 2 ·ÛıÂÓ›˜ ›¯·Ó Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·. ŒÓ·˜ ·fi ·˘ÙÔ‡˜ ˘Ô‚Ï‹ıËΠ۠Á·ÛÙÚÔÛÎfiËÛË Ë ÔÔ›· ¤‰ÂÈÍ ‰È¿¯˘Ù˜ ‚Ï¿‚˜ ηٿ Ì‹ÎÔ˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘, ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È ÙÔ˘ ‰ˆ‰Âη‰·ÎÙ‡ÏÔ˘. OÈ Î·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜ ¤‰ÂÈÍ·Ó M. Avium complex Î·È ÛÙÔ˘˜ 2 ·ÛıÂÓ›˜. E›Û˘, ·ÔÌÔÓÒıËΠ۠˘ÏÈÎfi ·fi ÙÔÓ ÔÈÛÔÊ¿ÁÔ (1 ·ÛıÂÓ‹˜), ÙÔ ÛÏ‹Ó· (1), Î·È ÙÔ Ì˘ÂÏfi ÙˆÓ ÔÛÙÒÓ (1). K·È ÔÈ 2 ·ÛıÂÓ›˜ ¤Ï·‚·Ó ÔχÌËÓË ·ÁˆÁ‹ Ì 3 ‹ 4 Ê¿Ú̷η Ì ‰Ú¿ÛË Î·Ù¿ ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘ ·˘ÙÔ‡, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ Ù˘ ÎÏ·ÚÈıÚÔÌ˘Î›Ó˘, fï˜ ‰ÂÓ ·ÚÔ˘Û›·Û·Ó ‚ÂÏÙ›ˆÛË. K·È ÔÈ 2 ·ÛıÂÓ›˜ Ì ‰È¿¯˘ÙË Ïԛ̈ÍË ·fi A.M. η٤ÏËÍ·Ó Ì¤Û· Û 1 ¤ÙÔ˜ ·fi ÙË ‰È¿ÁÓˆÛ‹ Ù˘. ™˘˙‹ÙËÛË T· A.M. ‰È·‚ÈÔ‡Ó ÛÙÔ Ê˘ÛÈÎfi ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘ ·ÓıÚÒÔ˘. H ÌfiÏ˘ÓÛË ÙÔ˘ ·ÓıÚÒÔ˘ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙËÓ ¤ÎıÂÛË Û ÛÎfiÓË Ë ÔÔ›· ÂÚȤ¯ÂÈ A.M. ‹ Ì ηٿÔÛË ‹ Î·È ¿ÌÂÛÔ ÂÌ‚ÔÏÈ·ÛÌfi ÛÙÔ ‰¤ÚÌ· (1,3). H ÂÌÊ¿ÓÈÛË ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ fï˜ ÂÍ·ÚÙ¿Ù·È Û ÌÂÁ¿ÏÔ ‚·ıÌfi ·fi ÙË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ÍÂÓÈÛÙ‹ ¤Ó·ÓÙÈ Ù˘ ÌfiÏ˘ÓÛ˘ ·fi A.M. ™Ù· ·È‰È¿, Ë ÏÂÌÊ·‰ÂÓ›Ùȉ· ÙˆÓ ÂÈÔÏ‹˜ ÏÂÌÊ·‰¤ÓˆÓ ·ÔÙÂÏ› ÙËÓ Î‡ÚÈ· ÂΉ‹ÏˆÛË, ȉȷ›ÙÂÚ· ÛÙȘ ËÏÈ˘ οو ÙˆÓ 5 ÂÙÒÓ (5). H Û˘¯ÓfiÙÂÚË ÂÌÊ¿ÓÈÛË Ù˘ ÏÂÌÊ·‰ÂÓ›Ùȉ·˜ ÙËÓ ÕÓÔÈÍË Ë ÔÔ›· ‰È·ÈÛÙÒıËΠÛÙË ÌÂϤÙË Ì·˜,
EÈÎfiÓ· 4. ¢ËÌÈÔ˘ÚÁ›· „˘¯ÚÔ‡ ·ÔÛÙ‹Ì·ÙÔ˜ Ì ۇÁ¯ÚÔÓË ÚÔÛ‚ÔÏ‹ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜.
§ÔÈÌÒÍÂȘ ·fi ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È·
·ÔÙÂÏ› ‡ÚËÌ· ÙÔ ÔÔ›Ô ¤¯ÂÈ ·Ó·ÊÂÚı› Î·È Û ¿ÏÏË ÌÂϤÙË (6). O ¯ÚfiÓÔ˜ Ô ÔÔ›Ô˜ ÌÂÛÔÏ·‚› ÌÂٷ͇ Ù˘ ÌfiÏ˘ÓÛ˘ Î·È Ù˘ ÂÌÊ¿ÓÈÛ˘ ÎÏÈÓÈÎÒÓ ÂΉËÏÒÛÂˆÓ ‰ÂÓ Â›Ó·È ÁÓˆÛÙfi˜, Â›Ó·È ÏÔÁÈÎfi fï˜ Ó· ˘Ôı¤ÛÂÈ Î·Ó›˜ fiÙÈ Ô ÌÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ÙˆÓ ÌÔχÓÛÂˆÓ Û˘Ì‚·›ÓÂÈ ÙÔ˘˜ ıÂÚÈÓÔ‡˜ Ì‹Ó˜, fiÔ˘ Ù· ·È‰È¿ ¤Ú¯ÔÓÙ·È Û ÛÙÂÓfiÙÂÚË Â·Ê‹ Ì ÙÔ Ê˘ÛÈÎfi ÂÚÈ‚¿ÏÏÔÓ (¯ÒÌ·, ÓÂÚfi). H ÊÏÂÁÌÔÓ‹ ÙˆÓ ÂÈÔÏ‹˜ ÏÂÌÊ·‰¤ÓˆÓ ¤¯ÂÈ ˘ÔÍ›· ‹ ¯ÚfiÓÈ· ÔÚ›· Î·È ÚfiÁÓˆÛË Î·Ï‹, Ë ÔÔ›· fï˜ ÌÔÚ› Ó· ηٷϋÍÂÈ ÛÙË ‰ËÌÈÔ˘ÚÁ›· Û˘ÚÈÁÁ›Ô˘ Â¿Ó ‰ÂÓ Á›ÓÂÈ ¤ÁηÈÚ· ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË (5). ™ÙË ÌÂϤÙË Ì·˜, ÙÔ Û‡ÓÔÏÔ ÙˆÓ ·È‰ÈÒÓ Ì ·ÈÛıËÙÈο ηÎfi ·ÔÙ¤ÏÂÛÌ· ·ÊÔÚÔ‡Û·Ó ÂÚÈÙÒÛÂȘ fiÔ˘ Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË Î·ı˘ÛÙ¤ÚËÛ ¤ÓÙ ̋Ó˜ ηٿ ̤ÛÔ fiÚÔ ·fi ÙËÓ ·Ú¯È΋ ÂÌÊ¿ÓÈÛË Ù˘ ÏÂÌÊ·‰ÂÓÈ΋˜ ‰ÈfiÁΈÛ˘. AÓÙ›ıÂÙ·, ÙÔ ·ÈÛıËÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ‹Ù·Ó Ôχ ηÏfi fiÙ·Ó Ë ·ÓÙÈÌÂÙÒÈÛË ‹Ù·Ó ¿ÌÂÛË Î·È ¿ÓÙˆ˜ fi¯È ¤Ú·Ó ÙÔ˘ ÂÓfi˜ ÌËÓfi˜. Afi ÙË ÌÂϤÙË Ì·˜ Â›Ó·È ÂÌÊ·Ó¤˜ fiÙÈ fiÙ·Ó ˘¿Ú¯Ô˘Ó ÛÔ‚·Ú¤˜ ˘Ô„›Â˜ fiÙÈ ÙÔ ·›ÙÈÔ Ù˘ ÏÂÌÊ·‰ÂÓ›Ùȉ·˜ Â›Ó·È Ù· A.M., Â›Ó·È ÂÈÙ·ÎÙÈ΋ Ë ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË ÙfiÛÔ ÙˆÓ ÂÌÊ·ÓÒ˜ ÚÔۂ‚ÏËÌ¤ÓˆÓ ÏÂÌÊ·‰¤ÓˆÓ, fiÛÔ Î·È ÙˆÓ ‡ÔÙˆÓ ¤ÚÈÍ Ù˘ ‚Ï¿‚˘. H ÚfiÛÊ·ÙË ÂÈÛ·ÁˆÁ‹ ÙˆÓ ÓÂÒÙÂÚˆÓ Ì·ÎÚÔÏȉÒÓ ˆ˜ ÂÓ·ÏÏ·ÎÙÈ΋ ıÂڷ›· ¤Ó·ÓÙÈ Ù˘ ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·Ê·›ÚÂÛ˘ Â›Ó·È ÂÏȉÔÊfiÚÔ˜, ‰ÂÓ ˘¿Ú¯ÂÈ fï˜ ·Ú΋˜ ÂÌÂÈÚ›· (7,8). E›Ó·È ÁÂÁÔÓfi˜ fiÙÈ Ù· Û˘Ó‹ıË ·ÓÙÈÊ˘Ì·ÙÈο Ê¿Ú̷η, fiˆ˜ Ê·›ÓÂÙ·È Î·È ·fi ÙË ÌÂϤÙË Ì·˜, ‰ÂÓ ÂËÚ¿˙Ô˘Ó ÙËÓ ÔÚ›· ÙˆÓ ÏÂÌÊ·‰ÂÓ›ÙȉˆÓ ·fi A.M. ™ÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ÂÚÈÂÏ‹ÊıËÛ·Ó ÌfiÓÔ ÔÈ ÏÂÌÊ·‰ÂÓ›Ùȉ˜ ÔÈ Ôԛ˜ ÌÈÎÚÔ‚ÈÔÏÔÁÈο ‹ ÈÛÙÔÏÔÁÈο ·Ô‰Â›¯ıËΠfiÙÈ ÔÊ›ÏÔÓÙ·È Û A.M., Ê·›ÓÂÙ·È fï˜ fiÙÈ Ë Û˘¯ÓfiÙËÙ¿ ÙÔ˘˜ Â›Ó·È ·ÎfiÌË ÌÂÁ·Ï‡ÙÂÚË. E›Ó·È ÂӉȷʤÚÔÓ fiÙÈ Ù· ÙÚ›· ٤ٷÚÙ· ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î·ÙÂÁÚ¿ÊËÛ·Ó Î·Ù¿ ÙÔ ‰Â‡ÙÂÚÔ ¯ÚÔÓÈÎfi ‹ÌÈÛ˘ Ù˘ ÌÂϤÙ˘ Ì·˜. AÍÈÔÛËÌ›ˆÙË ·‡ÍËÛË ÏÔÈÌÒÍÂˆÓ ·fi A.M. ‰È·ÈÛÙÒÓÂÙ·È Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, fiˆ˜ Ê·›ÓÂÙ·È Î·È ·fi ÌÂϤÙ˜ Û ¿ÏϘ ¯ÒÚ˜. A˘Ù‹ Ë ·‡ÍËÛË ÌÔÚ› Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ·È‰È¿ÙÚˆÓ ÛÙËÓ ·Ó·˙‹ÙËÛË ÏÔÈÌÒÍÂˆÓ Ô˘ ÔÊ›ÏÔÓÙ·È Û A.M., fï˜ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ Ú¤ÂÈ Ó· ·›˙ÂÈ Â›Û˘ Ë ·˘ÍË̤ÓË ÏÔÈÌÔÁfiÓÔ˜ ÈηÓfiÙËÙ· ÙˆÓ A.M. Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ηıÒ˜ Î·È ÂÚÈ‚·ÏÏÔÓÙÈΤ˜ ÌÂÙ·‚ÔϤ˜ (5,9,10). O ·˘ÍË̤ÓÔ˜ ·ÚÈıÌfi˜ ÂÚÈÙÒÛÂˆÓ Ô˘ ÔÊ›ÏÔÓÙ·È Û M. Avium complex ¤Ó·ÓÙÈ ÙˆÓ ¿ÏÏˆÓ Ì˘ÎÔ‚·ÎÙËÚȉ›ˆÓ Î·È Î˘Ú›ˆ˜ ÙÔ˘ M. Scrufolaceum ÙfiÛÔ ÛÙË ‰È΋ Ì·˜ fiÛÔ Î·È Û ¿ÏϘ ÌÂϤÙ˜, ÙÔÓ›˙ÂÈ ÙȘ ÔÈÎÔÏÔÁÈΤ˜ ·˘Ù¤˜ ÌÂÙ·‚ÔϤ˜ (4,6). ™Ù· ·È‰È¿ Ë Ó¢ÌÔÓÈ΋ ÂÓÙfiÈÛË Ïԛ̈͢ ·fi A.M. Â›Ó·È Û¿ÓÈ· ÂÎÙfi˜ ·fi ·È‰È¿ Ô˘ ¿Û¯Ô˘Ó ·fi ÈÓÒ‰Ë Î˘ÛÙÈ΋ ÓfiÛÔ. TÔ M. Avium complex Î·È ÙÔ M.
317
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·318
¶∞π¢π∞∆ƒπ∫∏ 2000;63:314-318
Kansasii Â›Ó·È Ù· ϤÔÓ ˘Â‡ı˘Ó· ÁÈ· ÙËÓ ÚfiÎÏËÛË Ó¢ÌÔÓÈ΋˜ ÓfiÛÔ˘. ¶Ú¿ÁÌ·ÙÈ, ÛÙË ‰È΋ Ì·˜ ÌÂϤÙË ÌfiÓÔ 3 ·fi Ù· 52 ·È‰È¿ ›¯·Ó Ó¢ÌÔÓÈ΋ ÂÓÙfiÈÛË Ù˘ Ïԛ̈͢ ·fi A.M. (1). ™Ù· ·È‰È¿ ·˘Ù¿ Û˘Ó‹ıˆ˜ ÚÔ¸¿Ú¯ÂÈ Ó¢ÌÔÓÈ΋ ÓfiÛÔ˜ ÙÔ˘ Ù‡Ô˘ Ù˘ ¯ÚfiÓÈ·˜ ·ÔÊÚ·ÎÙÈ΋˜ Ó¢ÌÔÓÔ¿ıÂÈ·˜, ‚ÚÔÁ¯ÈÂÎÙ·ÛÈÒÓ Î·È ÈÓÒ‰Ô˘˜ ΢ÛÙÈ΋˜ ÓfiÛÔ˘. T· ·È‰È¿ ·˘Ù¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ¯ÚfiÓÈÔ ‚‹¯·, ¯·ÌËÏ‹ ˘ÚÂÙÈ΋ ΛÓËÛË, ·ÓÔÚÂÍ›· Î·È ·ÒÏÂÈ· ‚¿ÚÔ˘˜. T· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· Û ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ Û˘Ó›ÛÙ·ÓÙ·È Û ·ÚÂÁ¯˘Ì·ÙÈΤ˜ ‰ÈËı‹ÛÂȘ, Ï¢ڛÙȉ·, ‡ÎÓˆÛË, Î·È fi˙Ô˘˜ ¯ˆÚ›˜ ÂÈÎfiÓ· ÛËÏ·›Ô˘ (11). ™ÙË ·ÚÔ‡Û· ÌÂϤÙË, fiÏ· Ù· ·È‰È¿ Ì Ó¢ÌÔÓÈ΋ ÓfiÛÔ ·fi A.M. ›¯·Ó ˘ÔΛÌÂÓÔ ÓfiÛËÌ· Î·È ·Ó¿ÏÔÁ· ÎÏÈÓÈο Î·È ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù·. H ‰È¿¯˘ÙË Ïԛ̈ÍË ·fi A.M. Û˘Ó·ÓÙ¿Ù·È Ôχ Û¿ÓÈ· ηٿ ÙËÓ ·È‰È΋ ËÏÈΛ·, ·ÎfiÌË Î·È Û ·È‰È¿ Ì ‚·ÚÈ¿ ·ÓÔÛÔηٷÛÙÔÏ‹, fiˆ˜ Ë ‚·ÚÈ¿ Û˘Ó‰˘·Ṳ̂ÓË ·ÓÔÛÔ·Ó¿ÚÎÂÈ· Î·È Î·ÎÔ‹ıÂȘ ˘fi ¯ËÌÂÈÔıÂڷ›·. TÔÓ›˙ÂÙ·È ¿ÓÙˆ˜, fiÙÈ Ë ·ÔÌfiÓˆÛË ÙÔ˘ Ì˘ÎÔ‚·ÎÙËÚȉ›Ô˘ ·fi ÛÙ›Ú˜ ÂÚÈÔ¯¤˜, fiˆ˜ Ô Ì˘ÂÏfi˜ ÙˆÓ ÔÛÙÒÓ Î·È ÙÔ ·›Ì·, Â›Ó·È ‰È·ÁÓˆÛÙÈΤ˜ (12). ¶·Ú¿ ÙË ¯ÔÚ‹ÁËÛË ÔÏÏ·ÏÒÓ Î·È Ì·ÎÚÔ¯ÚfiÓÈˆÓ ıÂڷ¢ÙÈÎÒÓ Û¯ËÌ¿ÙˆÓ, Ë ÚfiÁÓˆÛË Â›Ó·È ‰˘ÛÌÂÓ¤ÛÙ·ÙË Î·È Î·Ù¿ ·ÚÈÔ ÏfiÁÔ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ·ÚÈıÌËÙÈ΋ Î·È ÏÂÈÙÔ˘ÚÁÈ΋ ·ÓÔÛÔÏÔÁÈ΋ ¿ÚÎÂÈ· ÙˆÓ ·ÛıÂÓÒÓ (2,12). OÈ ‰˘Ô ÂÚÈÙÒÛÂȘ ‰È¿¯˘Ù˘ ÓfiÛÔ˘ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË ·ÊÔÚÔ‡Û·Ó ‚·ÚÈ¿ ·ÓÔÛÔηÙÂÛÙ·Ï̤ӷ ·È‰È¿ Ù· ÔÔ›· η٤ÏËÍ·Ó Ì¤Û· Û ¤Ó· ¤ÙÔ˜ ·fi ÙË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÔÈ ÏÔÈÌÒÍÂȘ ·È‰ÈÒÓ ·fi A.M. ·Ó·ÁÓˆÚ›˙ÔÓÙ·È Ì ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·, ÌÂ Û˘ÓËı¤ÛÙÂÚË ÂÓÙfiÈÛË ÙÔ˘˜ ÂÈÔÏ‹˜ ÏÂÌÊ·‰¤Ó˜. OÚÈÛÙÈ΋ χÛË ÛÙÔ Úfi‚ÏËÌ· ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ¤ÁηÈÚË ÔÏÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ·Ê·›ÚÂÛË ÙˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ ÏÂÌÊ·‰¤ÓˆÓ, Ë ÔÔ›· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÂÓÙfi˜ ÙÔ˘ ÚÒÙÔ˘ ÌËÓfi˜ ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ÏÂÌÊ·‰ÂÓÈ΋˜ ÚÔÛ‚ÔÏ‹˜. H ηı˘ÛÙ¤ÚËÛË ÛÙË ‰È¿ÁÓˆÛË Î·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ô‰ËÁ› ÛÙË ‰ËÌÈÔ˘ÚÁ›· „˘¯ÚÒÓ ·ÔÛÙËÌ¿ÙˆÓ, ·˘ÙÔÌ¿ÙˆÓ Ú‹ÍÂˆÓ ‰È·Ì¤ÛÔ˘ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È Ù¤ÏÔ˜ ÛÙË ‰ËÌÈÔ˘ÚÁ›· ›ÌÔÓˆÓ Û˘ÚÈÁÁ›ˆÓ Î·È ‰‡ÛÌÔÚÊˆÓ Ô˘ÏÒÓ. ™Â ·È‰È¿ Ì Ó¢ÌÔÓÈ΋ ÂÓÙfiÈÛË Ù· ÔÔ›· Â›Ó·È Û ηϋ ÎÏÈÓÈ΋ ηٿÛÙ·ÛË, Ë ÎÏÈÓÈ΋ Î·È ·ÎÙÈÓÔÏÔÁÈ΋ ·Ú·ÎÔÏÔ‡ıËÛ‹ ÙÔ˘˜ Ê·›ÓÂÙ·È Ó· ·ÔÙÂÏ› ÙË Ï‡ÛË. ÿÛˆ˜ ·Ô‰Âȯı› fiÙÈ ÔÈ ÓÂfiÙÂÚ˜ Ì·ÎÚÔÏ›‰Â˜ Â›Ó·È ¯Ú‹ÛÈ̘. H ÂÌÊ¿ÓÈÛË ‰È¿¯˘Ù˘ ÓfiÛÔ˘ Û ·È‰È¿ Ì ·ÓÔÛÔηٷÛÙÔÏ‹ ¤¯ÂÈ ‰˘ÛÌÂÓ‹ ÚfiÁÓˆÛË.
¶. ™˘Ú›‰Ë˜ Î·È Û˘Ó.
µÈ‚ÏÈÔÁÚ·Ê›· 1. Wolinsky E. Nontuberculous mycobacteria and associated diseases. Am Rev Resp Dis 1979;119:107-59. 2. Lincoln EM, Gilbert LA. Disease in children due to mycobacteria other than Mycobacterium tuberculosis. Am Rev Resp Dis 1972;105:683-714. 3. Pattz EF, Swensen SJ, Erasmus J. Pulmonary manifestations of nontuberculous mycobacterium. Radiol Clin North Am 1995;33:719-29. 4. O’ Brienn RJ, Geiter LJ, Snider DE. The epidemiology of nontuberculous mycobacterial diseases in the United States. Am Rev Respir Dis 1987;135:1007-14. 5. Starke JR, Correa AG. Management of mycobacterial infection and disease in children. Pediatr Infect Dis J 1995;14:455-70. 6. Wolinsky E. Mycobacterial lymphadenitis in children: a prospective study of 105 nontuberculous cases with longterm follow-up. Clinic Infect Dis 1995;20:954-63. 7. Tessier MH, Amoric JC, Mechinaud F, Dubesset D, Litoux P, Stalder JF. Clarithromycin for atypical mycobacterial lymphadenitis in non-immunocompromised children. Lancet 1994;344:1778. 8. Berger C, Pfyffer GE, Nadal D. Treatment of nontuberculous mycobacterial lymphadenitis with clarithromycin plus rifabutin. J Pediatr 1996;128:383-6. 9. Iseman MD. Mycobacterium avium complex and the normal host. N Engl Med J 1989;321:869-8. 10. Romanus V, Hallander HO, Wahlen P, Olinder - Nielsen AM, Magnusson PH, Juhlin I. Atypical mycobacteria in extrapulmonary disease among children. Incidence in Sweden from 1969 through 1990, related to changing BCG - vaccination coverage. Tubercle Lung Dis 1995;76:300-10. 11. American Thoracic Society: Diagnosis and treatment of disease caused by non-tuberculous mycobacteria. Am J Respir Crit Care Med 1997;156:1-25. 12. Stone A, Schelonka R, Drehner D, Ascher D. Disseminated M. avium complex in non-human immunodeficiency virus-infected pediatric patients. Pediatr Infect Dis J 1992;11:960-964.
™ËÌ›ˆÛË: M¤ÚÔ˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ¤¯ÂÈ ‰ËÌÔÛÈ¢ı› ÛÙÔ ÂÚÈÔ‰ÈÎfi Pediatr Infect Dis J 1999;18:968-70.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 25-10-1999 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-06-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¶·Ó·ÁÈÒÙ˘ ™˘Ú›‰Ë˜, E›ÎÔ˘ÚÔ˜ K·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ B’ ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ AıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ "¶. Î·È A. K˘ÚÈ·ÎÔ‡" £Ë‚ÒÓ Î·È §Â‚·‰Â›·˜, 115 27, Aı‹Ó·
318
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·319
¶∞π¢π∞∆ƒπ∫∏ 2000;63:319-321
µP∞XEIA ¢HMO™π∂À™H
EÌÂÈÚ›· ·fi ÂÚÈÙÒÛÂȘ ÌÂÛÔÎÔÈÏȷ΋˜ ÂÈÎÔÈÓˆÓ›·˜ Û ‚Ú¤ÊË AÌ·Ï›· TÛÈÏÈÌÈÁοÎË, AÓÙˆÓ›· M·ÓÔ˘Ú¿, £ÂÔÊ·Ó‹ TÛÂÎÔ˘Ú¿, B·ÛÈÏÈ΋ AÁÁÂÏ¿ÎÔ˘, AıËÓ¿ ™¯ÔÈÓ¿ÎË, ¶·Ó·ÁÈÒÙ˘ ™Ù·ÛÈÓfi˜, §¿ÌÚÔ˜ ¶ÏÔ˘Ì›‰Ë˜ ● ¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ ‹Ù·Ó Ë Î·Ù·ÁÚ·Ê‹ ÙˆÓ ‰È·ÊfiÚˆÓ Ù‡ˆÓ ÌÂÛÔÎÔÈÏȷ΋˜ ÂÈÎÔÈÓˆÓ›·˜, Ë ÌÂϤÙË Ù˘ ÂͤÏÈ͢ ÙÔ˘˜ Î·È Ë ıÂڷ¢ÙÈ΋ ÙÔ˘˜ ·ÓÙÈÌÂÙÒÈÛË ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ¯ÚfiÓÔ˘ ˙ˆ‹˜. YÏÈÎfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó 48 ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË ÌÈÎÚfiÙÂÚ· ÙÔ˘ ¤ÙÔ˘˜, Ô˘ ÂÍÂÙ¿ÛÙËÎ·Ó ÛÙÔ ·È‰ÔηډÈÔÏÔÁÈÎfi È·ÙÚÂ›Ô Û ÌÈ· ‰ÈÂÙ›·, Î·È ÛÙ· ÔÔ›· ‰È·ÈÛÙÒıËΠÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· Û·Ó ÌÔÓ‹Ú˘ ηډȷ΋ ‚Ï¿‚Ë. H ‰È¿ÁÓˆÛË ¤ÁÈÓ Ì ˯ÔηډÈÔÁÚ¿ÊËÌ· M-mode, ‰‡Ô ‰È·ÛÙ¿ÛÂˆÓ Î·È ¤Á¯ÚˆÌÔ Doppler. ¢È·ÈÛÙÒıËΠfiÙÈ 41 ‚Ú¤ÊË (85,5%) ›¯·Ó ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· Ì˘˚ÎÔ‡ Ù‡Ô˘, 6 ‚Ú¤ÊË (12,5%) ›¯·Ó ÂÚÈÌÂÌ‚Ú·ÓÒ‰Ë Î·È 1 ‚Ú¤ÊÔ˜ (2%) ›¯Â ˘ÔÓ¢ÌÔÓÈ΋ ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·. ™ÙË ‰È¿ÚÎÂÈ· Ù˘ ·Ú·ÎÔÏÔ‡ıËÛ˘ ·Ú·ÙËÚ‹ıËΠ·˘ÙfiÌ·ÙË Û‡ÁÎÏÂÈÛË Û 20 ‚Ú¤ÊË (41,6%) Ì ÌÈÎÚ‹ Ì˘˚΋ ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·. K·Ú‰È·Î‹ ·Ó¿ÚÎÂÈ· ·ÚÔ˘Û›·Û·Ó 5 ‚Ú¤ÊË (10,4%) Î·È 3 ‚Ú¤ÊË (6,2%) Ì ÂÚÈÌÂÌ‚Ú·ÓÒ‰Ë ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· ¯ÚÂÈ¿ÛÙËÎ·Ó ¯ÂÈÚÔ˘ÚÁÈ΋ Û‡ÁÎÏÂÈÛË. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Ì˘˚΋ ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· Â›Ó·È Ôχ Û˘¯ÓfiÙÂÚË ·fi ÙËÓ ÂÚÈÌÂÌ‚Ú·ÓÒ‰Ë. A˘Ùfi Â›Ó·È ÙÔ ·ÔÙ¤ÏÂÛÌ· Ù˘ ÂÓÙfiÈÛ˘ ÙˆÓ ÌÈÎÚÒÓ Ì˘˚ÎÒÓ ÌÂÛÔÎÔÈÏÈ·ÎÒÓ ÂÈÎÔÈÓˆÓÈÒÓ Ì ÙËÓ Â˘Ú›· ¯Ú‹ÛË Ù˘ ˘ÂÚ˯ÔηډÈÔÁÚ·Ê›·˜ ÛÙÔÓ ¤ÏÂÁ¯Ô ‚ÚÂÊÒÓ Ì Èı·Ó‹ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ·. ¶·È‰È·ÙÚÈ΋ 2000;63:319-321. §¤ÍÂȘ ÎÏÂȉȿ: ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·, ˘ÂÚ˯ÔηډÈÔÁÚ·Ê›·, ‚ÚÂÊÈ΋ ËÏÈΛ·. A. Tsilimingaki, A. Manoura, T. Tsekoura, V. Angelakou, A. Schinaki, P. Stasinos, L. Ploumidis. A study of ventricular septal defects in the first year of life. Paediatriki 2000;63:319-321. ● Abstract: A ventricular septal defect (VSD) as a single cardiac lesion was detected in 48 infants aged less than one year between January 1995 and February 1997. The diagnosis was made by two-dimensional echocardiography and Doppler colour flow mapping. Forty-one infants (85.5%) had a muscular septal defect, six (12.5%) a perimembranous defect and one (2%) a subpulmonary defect. Within the observation period spontaneous closure occurred in 20 small muscular septal defects (41.6%) while infants with a perimembranous VSD needed surgical closure of the defect. Congestive heart failure developed in five infants (10.4%). Muscular VSD seems to be a much more common than finding perimembranous VSD. This is probably a consequence of the detection of small muscular VSDs following the introduction of echocardiography as a standard method for investigating suspected congenital heart defects. Key words: ventricular septal defect, echocardiography, infants.
H ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· ·ÓÙÈÚÔۈ‡ÂÈ ÙÔ 20-30% ÙˆÓ Û˘ÁÁÂÓÒÓ Î·Ú‰ÈÔ·ıÂÈÒÓ Î·È, Ì ÂÍ·›ÚÂÛË ÙË ‰ÈÁÏÒ¯ÈÓ·-·ÔÚÙÈ΋ ‚·Ï‚›‰·, Â›Ó·È Ë ÈÔ Û˘¯Ó‹ Û˘ÁÁÂÓ‹˜ ηډÈÔ¿ıÂÈ·.(1-6) AӷʤÚÔÓÙ·È 1,53,5 ÂÚÈÙÒÛÂȘ ÛÙ· 1000 ˙ÒÓÙ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Î·È 4,5-7 ÛÙ· 1000 ÚfiˆÚ·.(1,7) øÛÙfiÛÔ, Ë Û˘¯ÓfiÙËÙ¿ Ù˘ ÌÂÈÒÓÂÙ·È Û 1 ÛÙ· 1000 ·È‰È¿ Û¯ÔÏÈ΋˜ ËÏÈΛ·˜ Î·È 0,5 Û 1000 ÂÓ‹ÏÈΘ.(2) H ÚÔԉ¢ÙÈ΋ ·˘Ù‹ Ì›ˆÛË ·ÓÙ·Ó·ÎÏ¿ ÙË Ê˘ÛÈ΋ ÔÚ›· Ù˘ ¿ıË-
Û˘ ·ÊÔ‡ ·Ú·ÙËÚÂ›Ù·È ·˘ÙfiÌ·ÙË Û‡ÁÎÏÂÈÛË Ù˘ ÂÈÎÔÈÓˆÓ›·˜ ÛÙÔ 25-50%, ÂÓÒ ÔÈ ÌÈÎÚ¤˜ ÌÂÛÔÎÔÈÏȷΤ˜ ÂÈÎÔÈӈӛ˜ Û˘ÁÎÏ›ÓÔ˘Ó ·˘ÙfiÌ·Ù· Û ÔÛÔÛÙfi Ô˘ ÚÔÛÂÁÁ›˙ÂÈ ÙÔ 80%. (1,3,4,7-11) H ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·˘ÙfiÌ·ÙˆÓ Û˘ÁÎÏ›ÛÂˆÓ Û˘Ì‚·›ÓÂÈ ÛÙ· ‰‡Ô ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ Î·È Ì¤¯ÚÈ ÙËÓ ËÏÈΛ· ÙˆÓ 8 ¯ÚfiÓˆÓ, ¤¯ÂÈ ÂÈÙÂÏÂÛÙ› ÙÔ 90% ÙˆÓ Û˘ÁÎϛۈÓ.(1,2,8) H ˯ÔηډÈÔÁÚ·Ê›· ‰‡Ô ‰È·ÛÙ¿ÛÂˆÓ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔ ·ÏÌÈÎfi Î·È Û˘Ó¯¤˜ Doppler ˯Ô-
B' ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ BÂÓÈ˙ÂÏ›Ԣ NÔÛÔÎÔÌ›Ԣ HÚ·ÎÏ›Ԣ KÚ‹Ù˘
319
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·320
¶∞π¢π∞∆ƒπ∫∏ 2000;63:319-321
ηډÈÔÁÚ¿ÊËÌ· Î·È ÙÔ ¤Á¯ÚˆÌÔ Doppler ¤¯Ô˘Ó ηıÈÂÚˆı› ˆ˜ ̤ıÔ‰Ô˜ ‰È¿ÁÓˆÛ˘ Î·È ÂÓÙfiÈÛ˘ Ù˘ ÌÂÛÔÎÔÈÏȷ΋˜ ÂÈÎÔÈÓˆÓ›·˜, ·ÏÏ¿ Î·È ˆ˜ ̤ÛÔ ÂÎÙ›ÌËÛ˘ ÙˆÓ ·ÈÌÔ‰˘Ó·ÌÈÎÒÓ Û˘ÓÂÂÈÒÓ, ÌÂÙÂÁ¯ÂÈÚËÙÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙˆÓ ·ÛıÂÓÒÓ Î·ıÒ˜ Î·È ÂÓÙfiÈÛ˘ Ù˘¯fiÓ ÂÈÏÔÎÒÓ Ù˘ ÌÂÛÔÎÔÈÏȷ΋˜ ÂÈÎÔÈÓˆÓ›·˜. (3,12,13) ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÌÂÈÚ›· ‰˘Ô ÂÙÒÓ ·fi 48 ÂÚÈÙÒÛÂȘ ‚ÚÂÊÒÓ Ô˘ ‰È·ÁÓÒÛÙËÎ·Ó Î·È ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÛÙÔ ¶·È‰ÔηډÈÔÏÔÁÈÎfi È·ÙÚÂ›Ô ÙÔ˘ BÂÓÈ˙¤ÏÂÈÔ˘ °ÂÓÈÎÔ‡ NÔÛÔÎÔÌ›Ԣ KÚ‹Ù˘. YÏÈÎfi Î·È Ì¤ıÔ‰Ô˜ YÏÈÎfi Ù˘ ÌÂϤÙ˘ ·ÔÙ¤ÏÂÛ·Ó Ù· 48 ÓÂÔÁÓ¿ Î·È ‚Ú¤ÊË ÌÈÎÚfiÙÂÚ· ÙÔ˘ ¤ÙÔ˘˜, 19 ·ÁfiÚÈ· Î·È 29 ÎÔÚ›ÙÛÈ·, Ô˘ ·Ú·¤ÌÊıËÎ·Ó ·fi ·È‰›·ÙÚÔ˘˜ ÛÙÔ ·È‰ÔηډÈÔÏÔÁÈÎfi È·ÙÚ›Ô, Û ‰È¿ÛÙËÌ· 2 ÂÙÒÓ, ÁÈ· ¤ÏÂÁ¯Ô ηډȷÎÔ‡ Ê˘Û‹Ì·ÙÔ˜ Î·È ÛÙ· ÔÔ›· ‰È·ÁÓÒÛÙËΠÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·, Û·Ó ÌÔÓ‹Ú˘ ηډȷ΋ ‚Ï¿‚Ë. H ‰È¿ÁÓˆÛË ¤ÁÈÓ Ì ˯ÔηډÈÔÁÚ¿ÊËÌ· M-mode, ‰‡Ô ‰È·ÛÙ¿ÛÂˆÓ Î·È ¤Á¯ÚˆÌÔ Doppler Ì Ì˯¿ÓËÌ· Hewlett-Packard Sonos 1000. °È· ÙË Ï‹„Ë ÙˆÓ Ë¯ÔηډÈÔÁÚ·ÊËÌ¿ÙˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËΠ˯ԂfiÏÔ˜ ÎÂÊ·Ï‹ 5 MHz. OÈ Ï‹„ÂȘ ¤ÁÈÓ·Ó ·fi ÙËÓ ˘ÔÍÈÊÔÂȉ‹, ÙËÓ ÎÔÚ˘Ê·›·, ÙËÓ ·Ú·ÛÙÂÚÓÈ΋ Î·È ÙËÓ ˘ÂÚÛÙÂÚÓÈ΋ ı¤ÛË. MÈ· Ù˘È΋ Û˘ÛÙÔÏÈ΋ ÚÔ‹ ‰È·Ì¤ÛÔ˘ ÙÔ˘ ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Ì ÙÔ ¤Á¯ÚˆÌÔ Î·È ÙÔ ·ÏÌÈÎfi Doppler ¤ıÂÙ ÙË ‰È¿ÁÓˆÛË Ù˘ ÌÂÛÔÎÔÈÏȷ΋˜ ÂÈÎÔÈÓˆÓ›·˜. K·ıÔÚ›ÛÙËÎ·Ó Ë ı¤ÛË Î·È ÙÔ Ì¤ÁÂıÔ˜ ÙˆÓ ÂÏÏÂÈÌÌ¿ÙˆÓ Ô˘ Ù·ÍÈÓÔÌ‹ıËÎ·Ó Û ÂÚÈÌÂÌ‚Ú·ÓÒ‰Ë, Ì˘˚ο, ˘Ô·ÚÙËÚȷο Î·È ÂÏÏ›ÌÌ·Ù· ÂÈÛfi‰Ô˘. TÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÂÏÏ›ÌÌ·ÙÔ˜ ηıÔÚ›ÛÙËΠ·Ó¿ÏÔÁ· Ì ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ·ÔÚÙÈ΋˜ Ú›˙·˜. MÂÁ¿Ï· ıˆڋıËÎ·Ó Ù· ÂÏÏ›ÌÌ·Ù· fiÙ·Ó ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘˜ ÏËÛ›·˙ ÙË ‰È¿ÌÂÙÚÔ Ù˘ ·ÔÚÙÈ΋˜ Ú›˙·˜, ̤ÙÚÈ·, fiÙ·Ó ‹Ù·Ó ·fi ÙÔ 1/3 ¤ˆ˜ Ù· 2/3 Ù˘ ·ÔÚÙÈ΋˜ Ú›˙·˜ Î·È ÌÈÎÚ¿, ·˘Ù¿ Ô˘ ‹Ù·Ó ÌÈÎÚfiÙÂÚ· ·fi ÙÔ 1/3 Ù˘ ‰È·Ì¤ÙÚÔ˘. H ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ‚ÚÂÊÒÓ Û˘Ó¯›ÛÙËΠ̤¯ÚÈ Ó· Û˘ÌÏËÚÒÛÔ˘Ó ÙÔ˘Ï¿¯ÈÛÙÔÓ ÙÔÓ 1Ô ¯ÚfiÓÔ ˙ˆ‹˜. ŸÏ· Ù· ‚Ú¤ÊË Â·ÓÂÍÂÙ¿ÛÙËÎ·Ó ÛÙÔ ·È‰ÔηډÈÔÏÔÁÈÎfi È·ÙÚ›Ô, Ì›· ‹ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· Î·È ÙË ÛÔ‚·ÚfiÙËÙ· Ù˘ ¿ıËÛ‹˜ ÙÔ˘˜. £ÂˆÚ‹ıËΠfiÙÈ Â‹Ïı ·˘ÙfiÌ·ÙË Û‡ÁÎÏÂÈÛË Ù˘ ÂÈÎÔÈÓˆÓ›·˜ fiÙ·Ó ÙÔ Ê‡ÛËÌ· ‰ÂÓ ‹Ù·Ó È· ·ÎÔ˘ÛÙfi. H Û‡ÁÎÏÂÈÛË ÂȂ‚·ÈÒıËΠ˘ÂÚ˯ÔÁÚ·ÊÈο. MfiÓÔ Ù¤ÛÛÂÚ· ·fi Ù· 48 ‚Ú¤ÊË, ¯ÚÂÈ¿ÛÙËΠӷ ·Ú·ÂÌÊıÔ‡Ó Û ·È‰ÔηډÈÔÏÔÁÈÎfi ΤÓÙÚÔ Ù˘ Aı‹Ó·˜, fiÔ˘ Ù· 3 ˘Ô‚Ï‹ıËÎ·Ó Û ηډÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË. AÔÙÂϤÛÌ·Ù· Afi Ù· 48 ‚Ú¤ÊË Ì ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·, ÛÙ· 24 (50%) Ë ‰È¿ÁÓˆÛË ¤ÁÈÓ Û ËÏÈΛ· ÌÈÎÚfiÙÂÚË
320
A. TÛÈÏÈÌÈÁοÎË Î·È Û˘Ó.
ÙˆÓ 4 ‚‰ÔÌ¿‰ˆÓ, Ì ̤ÛË ËÏÈΛ· 9 Ë̤Ú˜. ™Ù· ˘fiÏÔÈ· 24, ¤ÁÈÓ Û ËÏÈΛ· ·fi 1 ¤ˆ˜ 12 ÌËÓÒÓ, Ì ̤ÛË ËÏÈΛ· 4,5 Ì‹Ó˜. ¢È·ÈÛÙÒıËΠfiÙÈ 41 ‚Ú¤ÊË (85,5%) ›¯·Ó ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· Ì˘˚ÎÔ‡ Ù‡Ô˘, 6 ‚Ú¤ÊË (12,5%) ÂÚÈÌÂÌ‚Ú·ÓÒ‰Ë ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· Î·È 1 ‚Ú¤ÊÔ˜ (2%) ˘Ô·ÚÙËÚȷ΋ (˘ÔÓ¢ÌÔÓÈ΋). ŒÏÏÂÈÌÌ· ÂÈÛfi‰Ô˘ ‰ÂÓ ‰È·ÈÛÙÒıËΠ۠ηӤӷ ·fi Ù· ‚Ú¤ÊË. Afi Ù· 41 ‚Ú¤ÊË Ì ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· Ì˘˚ÎÔ‡ Ù‡Ô˘, Ù· 40 ›¯·Ó ÌÈÎÚ¿ Î·È Ôχ ÌÈÎÚ¿ ÂÏÏ›ÌÌ·Ù· Î·È 1 ›¯Â ̤ÙÚÈÔ˘ ÌÂÁ¤ıÔ˘˜ ¤ÏÏÂÈÌÌ·. T· 6 ‚Ú¤ÊË Ì ÙȘ ÂÚÈÌÂÌ‚Ú·ÓÒ‰ÂȘ ÌÂÛÔÎÔÈÏȷΤ˜ ÂÈÎÔÈӈӛ˜ Î·È ÙÔ 1 ‚Ú¤ÊÔ˜ Ì ÙËÓ ˘Ô·ÚÙËÚȷ΋ ÂÈÎÔÈÓˆÓ›· ›¯·Ó ̤ÙÚÈÔ˘ Î·È ÌÂÁ¿ÏÔ˘ ÌÂÁ¤ıÔ˘˜ ÂÏÏ›ÌÌ·Ù·. A˘ÙfiÌ·ÙË Û‡ÁÎÏÂÈÛË ·Ú·ÙËÚ‹ıËΠ۠20 ·È‰È¿ (41,6%), fiÏ· Ì ÌÈÎÚ‹ ‹ Ôχ ÌÈÎÚ‹ Ì˘˚ÎÔ‡ Ù‡Ô˘ ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·. K·Ú‰È·Î‹ ·Ó¿ÚÎÂÈ· ·ÚÔ˘Û›·Û·Ó 5 ‚Ú¤ÊË (10,4%), ·fi Ù· ÔÔ›· 1 ›¯Â Ì˘˚ÎÔ‡ Ù‡Ô˘ ¤ÏÏÂÈÌÌ· Î·È 4 ÂÚÈÌÂÌ‚Ú·Ó҉˜. T· ‚Ú¤ÊË ·˘Ù¿ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ¯ÔÚ‹ÁËÛË ‰ÈÁÔ͛Ӣ, ÊÔ˘ÚÔÛÂÌ›‰Ë˜ Î·È Î·ÙÔÚ›Ï˘ ηٿ ÂÚ›ÙˆÛË. TÚ›· ·fi Ù· ‚Ú¤ÊË ·˘Ù¿ (6,2%) ÙÔ˘ Û˘ÓfiÏÔ˘) Ì ÂÚÈÌÂÌ‚Ú·ÓÒ‰Ë ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· ¯ÚÂÈ¿ÛÙËÎ·Ó ¯ÂÈÚÔ˘ÚÁÈ΋ Û‡ÁÎÏÂÈÛË, Ù· 2 ÏfiÁˆ ÌË ·ÓÙÈÚÚÔÔ‡ÌÂÓ˘ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ Î·È ÙÔ 1 ÏfiÁˆ ÛÔ‚·Ú‹˜ ˘ÔÓ¢ÌÔÓÈ΋˜ ÛÙ¤ÓˆÛ˘. ™˘˙‹ÙËÛË TÔ ÌÂÛÔÎÔÈÏÈ·Îfi ‰È¿ÊÚ·ÁÌ· ÌÔÚ› Ó· ¯ˆÚÈÛÙ› Û ÌÂÌ‚Ú·Ó҉˜ Î·È ÛÂ Ì˘˚Îfi, Ì ÙÚÂȘ Û˘ÓÈÛÙÒÛ˜: ÙÔ Ì˘˚Îfi ‰È¿ÊÚ·ÁÌ· ÂÈÛfi‰Ô˘, ÙÔ ‰ÔÎȉ҉˜ ‰È¿ÊÚ·ÁÌ· Î·È ÙÔ ‰È¿ÊÚ·ÁÌ· ÂÍfi‰Ô˘.(2,11) OÈ ÌÂÛÔÎÔÈÏȷΤ˜ ÂÈÎÔÈӈӛ˜ (MKE) Ô˘ ÂÓÙÔ›˙ÔÓÙ·È ÎÔÓÙ¿ ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ ÌÂÌ‚Ú·ÓÒ‰Ô˘˜ ‰È·ÊÚ¿ÁÌ·ÙÔ˜, οو ·fi ÙËÓ ·ÔÚÙÈ΋ ‚·Ï‚›‰·, ÔÓÔÌ¿˙ÔÓÙ·È ÂÚÈÌÂÌ‚Ú·ÓÒ‰ÂȘ Î·È Â›Ó·È Û˘Ó‹ıˆ˜ ÌÔÓ‹ÚÂȘ. ŸÙ·Ó ÙÔ ¤ÏÏÂÈÌÌ· ÂÚÈ‚¿ÏÏÂÙ·È ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ·fi Ù· Ì˘˚ο Û˘ÛÙ·ÙÈο ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜, ÚfiÎÂÈÙ·È ÁÈ· ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· Ì˘˚ÎÔ‡ Ù‡Ô˘. ŸÙ·Ó Ï›ÂÈ ÙÂÏ›ˆ˜ ÙÔ ‰È¿ÊÚ·ÁÌ· ÂÍfi‰Ô˘ Î·È ÙÔ ¤ÏÏÂÈÌÌ· ‚Ú›ÛÎÂÙ·È ·ÎÚÈ‚Ò˜ οو ·fi ÙËÓ Ó¢ÌÔÓÈ΋ Î·È ÙËÓ ·ÔÚÙÈ΋ ‚·Ï‚›‰·, Ë ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· ÔÓÔÌ¿˙ÂÙ·È ˘Ô·ÚÙËÚȷ΋. TÔ ¤ÏÏÂÈÌÌ· Ô˘ ‚Ú›ÛÎÂÙ·È Î¿Ùˆ ·fi ÙË ‰È·ÊÚ·ÁÌ·ÙÈ΋ Áψ¯›Ó· Ù˘ ÙÚÈÁÏÒ¯ÈÓ·˜ ‚·Ï‚›‰·˜ Î·È ›Ûˆ Î·È Î¿Ùˆ ·fi Ù· ÂÚÈÌÂÌ‚Ú·ÓÒ‰Ë ÂÏÏ›ÌÌ·Ù·, ÔÓÔÌ¿˙ÂÙ·È ¤ÏÏÂÈÌÌ· ÂÈÛfi‰Ô˘.(1,2,11,12) ™ÙË ÌÂϤÙË Ì·˜, ÔÈ ÂÚÈÌÂÌ‚Ú·ÓÒ‰ÂȘ MKE ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó ÌfiÓÔ ÙÔ 12,5%, ÂÓÒ ÙÔ 85,5% ·ÔÙÂÏÔ‡Ó ÔÈ Ì˘˚ÎÔ‡ Ù‡Ô˘ MKE. T· ÔÛÔÛÙ¿ ·˘Ù¿ Û˘ÌʈÓÔ‡Ó Ì ÚfiÛÊ·Ù˜ ÌÂϤÙ˜, fiÔ˘ Û˘¯ÓfiÙÂÚ˜ Â›Ó·È ÔÈ Ì˘˚ÎÔ‡ Ù‡Ô˘ MKE ÌÂ Û˘¯ÓfiÙËÙ· 51-85%.(35,14) K·Ó¤Ó· ·fi Ù· ‚Ú¤ÊË ÌÂ Ì˘˚ÎÔ‡ Ù‡Ô˘ ¤ÏÏÂÈÌÌ· ‰ÂÓ ¯ÚÂÈ¿ÛÙËΠ¯ÂÈÚÔ˘ÚÁÈ΋ Û‡ÁÎÏÂÈÛË Î·È ÌfiÓÔ 1
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·321
¶∞π¢π∞∆ƒπ∫∏ 2000;63:319-321
·fi Ù· 41 ·ÚÔ˘Û›·Û ÛËÌ›· ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜. AÓÙ›ıÂÙ·, ·fi Ù· 6 ·È‰È¿ Ì ÂÚÈÌÂÌ‚Ú·ÓÒ‰Ë MKE, Ù· 4 ·ÚÔ˘Û›·Û·Ó ÛËÌ›· ÌË ·Ó·Ù·ÛÛfiÌÂÓ˘ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ Î·È Ù· 3 ·fi ·˘Ù¿ ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ¯ÂÈÚÔ˘ÚÁÈο. ™ÙÔ ‰È¿ÛÙËÌ· ·Ú·ÎÔÏÔ‡ıËÛ˘, ·Ú·ÙËÚ‹ıËΠ·˘ÙfiÌ·ÙË Û‡ÁÎÏÂÈÛË Û 20 ‚Ú¤ÊË Ì ÌÈÎÚ¤˜, Ì˘˚ÎÔ‡ Ù‡Ô˘ MKE (48,8% ÙˆÓ Ì˘˚ÎÒÓ ÂÏÏÂÈÌÌ¿ÙˆÓ), ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÚÒÙÔ˘ ¯ÚfiÓÔ˘ ˙ˆ‹˜. ™Â ·Ó¿ÏÔÁ˜ ÂÚÁ·Û›Â˜ ÙÔ ÔÛÔÛÙfi Î˘Ì·›ÓÂÙ·È ·fi 43% ̤¯ÚÈ 84%.(3-5,7,15) Afi ÙȘ ÂÚÈÌÂÌ‚Ú·ÓÒ‰ÂȘ ÌÂÛÔÎÔÈÏȷΤ˜ ÂÈÎÔÈӈӛ˜, Û η̛· ‰ÂÓ ·Ú·ÙËÚ‹ıËΠ·˘ÙfiÌ·ÙË Û‡ÁÎÏÂÈÛË. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Ì˘˚ÎÔ‡ Ù‡Ô˘ ÌÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· ¤¯ÂÈ ÛËÌ·ÓÙÈ΋ Èı·ÓfiÙËÙ· ·˘ÙfiÌ·Ù˘ Û‡ÁÎÏÂÈÛ˘ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ˙ˆ‹˜ Î·È Â›Ó·È Ôχ Û˘¯ÓfiÙÂÚË Ù˘ ÂÚÈÌÂÌ‚Ú·ÓÒ‰Ô˘˜. H ÚfiÁÓˆÛË ÁÈ· ÙËÓ Ì˘˚ÎÔ‡ Ù‡Ô˘ ÂÈÎÔÈÓˆÓ›· Â›Ó·È Î·Ï‡ÙÂÚË, fi¯È ÌfiÓÔ ˆ˜ ÚÔ˜ ÙËÓ Èı·ÓfiÙËÙ· ·˘ÙfiÌ·Ù˘ Û‡ÁÎÏÂÈÛ˘ ·ÏÏ¿ Î·È ÙË Û·ÓÈfiÙËÙ· ·Ó¿Ù˘Í˘ ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜. BÈ‚ÏÈÔÁÚ·Ê›· 1. Graham T, Gutgesell H. Ventricular Septal Defects In: Emmanouilidis GC, Allen HD, Riemenschneider TA, Gutgesell HP eds. Heart disease in infants, children and adolescents. 5th ed. Baltimore: Williams & Wilkins 1995:724-726. 2. ¢·ÛηÏfiÔ˘ÏÔ˜ ¢. MÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›·. ™ÙÔ: TÔ‡ÙÔ˘˙· ¶, MÔ˘ÓÙԇϷ X. K·Ú‰È·Î¤˜ ·ı‹ÛÂȘ, Aı‹Ó·: EΉ. °. ¶·ÚÈ˙È¿ÓÔ˜ 1992:941-965. 3. Trowitzsch E, Braun W, Stute M, Pielemeier W. Diagnosis, therapy and outcome of ventricular septal defect in the 1st year of life: a two-dimensional colour Doppler echocardiography study. Eur J Pediatr 1990;149:758-761. 4. Mehta A, Chidambaram B. Ventricular septal defect in the
MÂÛÔÎÔÈÏȷ΋ ÂÈÎÔÈÓˆÓ›· ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·
first year of life. Am J Cardiol 1992;70:364-366. 5. Meberg A, Otterstad JE, Froland G, Sorland S, NitterHauge S. Increasing incidence of ventricular septal defect caused by improved detection rate. Acta Paediatr 1994, 83(6):653-657. 6. Backer C, Winters R, Zales V, Takami H, Muster A, Benson W, Mavroudis C. Restrictive ventricular septal defect: how small is too small to close? Ann Thorac Surg 1993;56:1014-1019. 7. Moe D, Guntheroth W. Spontaneous closure of uncomplicated ventricular septal defect. Am J Cardiol 1987;60:674-678. 8. Shirali G, O'Brian Smith, Geva T. Quantitation of echocardiographic predictors of outcome in infants with isolated ventricular septal defect. Am Heart J 1995;130:1228-1235. 9. Byard R. Ventricular septal defect and sudden death in early childhood. J Paediatr Child Health 1994;30:439-44. 10. Frontera-Izquierdo P, Cabezuelo-Huerta G. Natural and modified history of isolated ventricular septal defect: a 17year study. Pediatr Cardiol 1992;13:193-197. 11. Perloff GK. The clinical recognition of congenital heart disease. 4th ed. Philadelphia: W.B. Saunders Company, 1994. 12. Silverman NH. Pediatric echocardiography. Baltimore: Williams & Wilkins, 1993. 13. Sutherland GR, Godman MJ, Smallhorn JF. Ventricular septal defects: two-dimensional echocardiographic and morphologic correlations. Br Heart J 1982;47:316-328. 14. Ruangritnamchai C, Khowsathit P, Pongpanich B. Spontaneous closure of small ventricular septal defect first six months of life. J Med Assoc Thai 1993;76 Suppl 2:63-71. 15. Hiraishi S, Agata Y, Nowatari M, Oguchi K, Misawa H, Hirota H et al. Incidence and natural course of trabecular ventricular septal defect: Two-dimensional echocardiography and color Doppler flow imaging study. J Pediatr 1992;120:409-415.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 19-10-1999 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 14-04-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: AÌ·Ï›· TÛÈÏÈÌÈÁοÎË HÚÔ‰fiÙÔ˘ 214, N¤· AÏÈηÚÓ·ÛÛfi˜ HÚ¿ÎÏÂÈÔ KÚ‹Ù˘, 71 601
321
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·322
¶∞π¢π∞∆ƒπ∫∏ 2000;63:322-325
E¡¢π∞º∂ƒOÀ™∂™ ¶∂ƒπ¶∆ø™∂π™
IÓ҉˘ ÎÔÏÔÓÔ¿ıÂÈ· Û ·ÛıÂÓ‹ Ì ΢ÛÙÈ΋ ›ÓˆÛË ™Ù·‡ÚÔ˜ NÙÔ˘ÓÙÔ˘Ó¿Î˘1, AÓ·ÛÙ·Û›· ZËÛÔ‡ÏË1, Aı·Ó·Û›· §Ô˘Ú›‰·2, EÏ¢ıÂÚ›· PÒÌ·-°È·ÓÓ›ÎÔ˘2, N›Ó· M·ÓˆÏ¿ÎË2
● ¶ÂÚ›ÏË„Ë: H ÈÓ҉˘ ÎÔÏÔÓÔ¿ıÂÈ· ·ÔÙÂÏ› ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ·, Ë ÔÔ›· ·Ó·ÁÓˆÚ›ÛıËΠÚfiÛÊ·Ù· Û ¿Û¯ÔÓÙ˜ ·fi ΢ÛÙÈ΋ ›ÓˆÛË Î·È Û¯ÂÙ›ÛıËΠ̠ÙË Ï‹„Ë ÌÂÁ¿ÏˆÓ ÔÛÔÙ‹ÙˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÛıÂÓÔ‡˜, ËÏÈΛ·˜ 9 ¯ÚfiÓˆÓ, Ì ΢ÛÙÈ΋ ›ÓˆÛË Î·È ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢ ·fi ËÏÈΛ·˜ 17 ÌËÓÒÓ. °È· ÌÂÁ¿ÏÔ ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· Ë ·ÛıÂÓ‹˜ ÂÏ¿Ì‚·Ó >35.000 UI ÏÈ¿Û˘/Kg/Ë̤ڷ. H ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒıËΠ̠ٷ Â˘Ú‹Ì·Ù· ÙÔ˘ ‚·ÚÈÔ‡¯Ô˘ ˘ÔÎÏ˘ÛÌÔ‡ (ÛËÌ·ÓÙÈ΋ ÛÙ¤ÓˆÛË Î·È ÚÔÛÙÂÓˆÙÈ΋ ‰È¿Ù·ÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ÂÈÏÂÔ‡, Ú›ÎÓˆÛË Î·È ·Ú·ÌfiÚʈÛË ÙÔ˘ ÎfiÏÔ˘), ÙË Ì·ÎÚÔÛÎÔÈ΋ ÂÈÎfiÓ· ηٿ ÙË Ï··ÚÔÙÔÌ›· Î·È ÙËÓ ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË, Ô˘ ·¤ÎÏÂÈÛ ¿ÏϘ ·ı‹ÛÂȘ ÙÔ˘ ÂÓÙ¤ÚÔ˘. M ÙËÓ ·Ó·ÚÔÛ·ÚÌÔÁ‹ Ù˘ ‰ÔÛÔÏÔÁ›·˜ ÙˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ, ‚ÂÏÙÈÒıËÎ·Ó Ù· ·ÎÙÈÓÔÏÔÁÈο, ÎÔÏÔÓÔÛÎÔÈο Î·È ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ¯ˆÚ›˜ fï˜ Ó· ·ÔÙڷ› Ë ÂÌÊ¿ÓÈÛË Ó¤ˆÓ ÂÂÈÛÔ‰›ˆÓ, ·Ó Î·È ·˘Ù¿ ‹Ù·Ó, ÁÂÓÈο, ÈÔ ‹È·. AÓ·ÛÎÔÂ›Ù·È Ë ÙÚ¤¯Ô˘Û· ‚È‚ÏÈÔÁÚ·Ê›· Û¯ÂÙÈο Ì ÙËÓ ·ıÔÁ¤ÓÂÈ·, ÙȘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ, ÙË ‰È¿ÁÓˆÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÓfiÛÔ˘. ¶·È‰È·ÙÚÈ΋ 2000;63:322-325. §¤ÍÂȘ ÎÏÂȉȿ: ΢ÛÙÈ΋ ›ÓˆÛË, ÈÓ҉˘ ÎÔÏÔÓÔ¿ıÂÈ·, ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì·. S. Doudounakis, A. Zissouli, A. Lourida, E. Roma-Giannicou, N. Manolaki. Fibrosing colonopathy in cystic fibrosis. Paediatriki 2000;63:322-325. ● Abstract: Colonopathy has recently been recognized as a complication of cystic fibrosis, and is related to the consumption of high doses of pancreatic enzymes. The case of a 9 year-old girl with cystic fibrosis and colonopathy is described. She presented with recurrent episodes of intestinal obstruction starting at the age of 17 months. In an attempt to control the number of bowel motions, the daily intake of lipase, over extended periods, was maintained at >35,000 UI/Kg. Diagnosis was based on the radiologic findings on barium enema (significant stenosis with prestenotic dilatation of the ileus and abnormal appearance of the colon), laparotomy findings and the histological picture which excluded other forms of intestinal disease. With appropriate changes in the amounts of pancreatic enzymes given daily, the endoscopic and radiologic findings improved significantly, but the patient suffered further episodes, although much less severe. Current literature on the pathogenesis, clinical presentation, diagnosis and treatment of the condition is reviewed. Key words: cystic fibrosis, fibrosing colonopathy, pancreatic enzymes.
EÈÛ·ÁˆÁ‹ H ÈÓ҉˘ ÎÔÏÔÓÔ¿ıÂÈ· ÂÚÈÁÚ¿ÊËΠˆ˜ ÓÔÛÔÏÔÁÈ΋ ÔÓÙfiÙËÙ· ÙÔ 1994 Û ·ÛıÂÓ›˜ Ì ΢ÛÙÈ΋ ›ÓˆÛË, Ô˘ ¤·ÈÚÓ·Ó ÌÂÁ¿Ï˜ ÔÛfiÙËÙ˜ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÁÈ· ‰È¿ÛÙËÌ· ϤÔÓ ÙˆÓ 12-15 ÌËÓÒÓ (1). H ÎÔÏÔÓÔ¿ıÂÈ· ÂÌÊ·Ó›ÛıËΠÌÂÙ¿ ÙËÓ Î˘ÎÏÔÊÔÚ›· Î·È ¯Ú‹ÛË Û΢·ÛÌ¿ÙˆÓ Ì ÌÂÁ¿ÏË ÂÚÈÂÎÙÈÎfiÙËÙ·
1 2
·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Û ÌÈ· ÚÔÛ¿ıÂÈ· ηχÙÂÚ˘ Î·È Â˘¯ÂÚ¤ÛÙÂÚ˘ ·ÓÙÈÌÂÙÒÈÛ˘ ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ (2). ¢ÂÓ Â›Ó·È ÁÓˆÛÙ‹ Ë ·ÎÚÈ‚‹˜ Û˘¯ÓfiÙËÙ· Ù˘ ÂÈÏÔ΋˜ Î·È ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜, ÂÂȉ‹ Ë ıÂڷ¢ÙÈ΋ ·ÁˆÁ‹ Ô˘ ÂÊ·ÚÌfi˙ÂÙ·È ·fi Ù· ‰È¿ÊÔÚ· K¤ÓÙÚ· ‰ÂÓ Â›Ó·È ÔÌÔÈfiÌÔÚÊË Î·È ˘¿Ú¯Ô˘Ó ‰È¿ÊÔÚ· Û΢¿ÛÌ·Ù· Ì ‰È·ÊÔÚÂÙÈο ¤Î‰Ô¯· ηÈ
TÌ‹Ì· IÓÔ΢ÛÙÈ΋˜, NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ "AÁ›· ™ÔÊ›·" ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ, NÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ "AÁ›· ™ÔÊ›·"
322
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·323
¶∞π¢π∞∆ƒπ∫∏ 2000;63:322-325
‰È·ÊÔÚÂÙÈ΋ ÂÚÈÂÎÙÈÎfiÙËÙ· Û ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì· (3). H ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ Û˘Ó›ÛٷٷÈ, ΢ڛˆ˜, Û ÂÂÈÛfi‰È· ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢ Ô˘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· Ù˘ ¿¯˘ÓÛ˘ Î·È ÛÙ¤ÓˆÛ˘ ÙÔ˘ ·˘ÏÔ‡ ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘. X·Ú·ÎÙËÚÈÛÙÈ΋ Â›Ó·È Ë ·ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· Î·È Ù· ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· (4,5). °È· ÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘, ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ, ··ÈÙ‹ıËΠ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË (ÂÓÙÂÚÂÎÙÔÌ‹) (6). ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ÎÔÚÈÙÛÈÔ‡ Ì ΢ÛÙÈ΋ ›ÓˆÛË Î·È ÈÓÒ‰Ë ÎÔÏÔÓÔ¿ıÂÈ· Ô˘ ÔÊ›ÏÂÙ·È ÛÙË Ï‹„Ë ÌÂÁ¿ÏˆÓ ÔÛÔÙ‹ÙˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ H ·ÛıÂÓ‹˜, ËÏÈΛ·˜ Û‹ÌÂÚ· 9 ¯ÚfiÓˆÓ, ÁÂÓÓ‹ıËΠÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi Î·È ‚¿ÚÔ˜ 3.200 gr. ¶·ÚÔ˘Û›·Û ÓÂÔÁÓÈÎfi ›ÎÙÂÚÔ Î·È ı‹Ï·Û ÁÈ· 1 Ì‹Ó·. ™Â ËÏÈΛ· 1ó ÌËÓfi˜ ÂÙ¤ıË Ë ÎÏÈÓÈ΋ ˘Ô„›· Ù˘ ΢ÛÙÈ΋˜ ›ÓˆÛ˘ ÏfiÁˆ ÔÏÏÒÓ, ÌÂÁ¿ÏˆÓ, ‰‡ÛÔÛ̈Ó, ÏÈ·ÚÒÓ ÎÂÓÒÛˆÓ, ÏËÌÌÂÏÔ‡˜ ÚfiÛÏ˄˘ ‚¿ÚÔ˘˜ Î·È Â›ÌÔÓÔ˘ ‚‹¯· ·fi ÙË Á¤ÓÓËÛË. H ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒıËΠ̠ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ¯ÏˆÚÈÔ‡¯ˆÓ ÛÙÔÓ È‰ÚÒÙ· Ì ÙË Ì¤ıÔ‰Ô Gibson - Cooke (95 mEq/L) Û ‰‡Ô ͯˆÚÈÛÙ¤˜ ÌÂÙÚ‹ÛÂȘ. MÂÙ¿ ÙË ‰È¿ÁÓˆÛË ¿Ú¯ÈÛ ıÂڷ›· ˘ÔηٿÛÙ·Û˘ Ì ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì· Î·È ‚Èٷ̛Ә, Ë ÁÂÓÈ΋ ηٿÛÙ·ÛË Ù˘ ·ÛıÂÓÔ‡˜ ‚ÂÏÙÈÒıËÎÂ Î·È Ë ÂͤÏÈÍ‹ Ù˘, ·fi ÏÂ˘Ú¿˜ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘, ‹Ù·Ó ÈηÓÔÔÈËÙÈ΋. ™Â ËÏÈΛ· 13 ÌËÓÒÓ Î·È 4ó ¯ÚfiÓˆÓ ÓÔÛËχıËΠÁÈ· Á·ÛÙÚÂÓÙÂÚ›Ùȉ·. ™Â ËÏÈΛ· 3 ¯ÚfiÓˆÓ Ô ·Ó·Ó¢ÛÙÈÎfi˜ ‚ÏÂÓÓÔÁfiÓÔ˜ ·ÔÈΛÛıËΠ·fi „¢‰ÔÌÔÓ¿‰·. Afi ÙËÓ ËÏÈΛ· ÙˆÓ 17 ÌËÓÒÓ Ì¤¯ÚÈ 5ó ¯ÚfiÓˆÓ, ·ÚÔ˘Û›·Û 6 ÂÂÈÛfi‰È· ·ÔÊÚ·ÎÙÈÎÔ‡ ÂÈÏÂÔ‡, Ô˘ ¯·Ú·ÎÙËÚ›ÛıËÎ·Ó ˆ˜ ÈÛÔ‰‡Ó·ÌÔ ÂÈÏÂÔ‡ ·fi ÌËÎÒÓÈÔ (Distal intestinal obstruction syndrome - DIOS). ŸÏ· ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó Û˘ÓÙËÚËÙÈο. T· ¤ÓÙ ÙÂÏÂ˘Ù·›· Û˘Ó¤‚ËÛ·Ó ÙÔ ÙÂÏÂ˘Ù·›Ô ÂÍ¿ÌËÓÔ. K·Ù¿ ÙÔ ÙÂÏÂ˘Ù·›Ô ÂÂÈÛfi‰ÈÔ ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢, ˘‹Ú¯Â ›ÌÔÓÔ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ÌÂÙˆÚÈÛÌfi˜ ÎÔÈÏ›·˜, ·˘ÍË̤ÓÔÈ ÂÓÙÂÚÈÎÔ› ‹¯ÔÈ Î·È, ÂÈϤÔÓ, ÚÔÛÙ¤ıËΠÂÈÛÎÔÈο ÂÌÊ·Ó‹˜ ÂÚÈÛÙ·ÏÙÈÛÌfi˜ ÙÔ˘ ÂÓÙ¤ÚÔ˘. ŒÙÛÈ, ‚¿ÛÂÈ ÙˆÓ Û˘¯ÓÒÓ ÂÂÈÛÔ‰›ˆÓ Î·È ÙˆÓ ¤ÓÙÔÓˆÓ Î·È Â›ÌÔÓˆÓ Û˘Ìو̿وÓ, ÂÙ¤ıË Ë ˘Ô„›· Ù˘ ÈÓÒ‰Ô˘˜ ÎÔÏÔÓÔ¿ıÂÈ·˜. ™Â ‚·ÚÈÔ‡¯Ô ˘ÔÎÏ˘ÛÌfi Ì Á·ÛÙÚÔÁÚ·Ê›ÓË ·ÂÈÎÔÓ›ÛıËΠÓËÌ·ÙÔÂȉ‹˜ ÛÙ¤ÓˆÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ÂÈÏÂÔ‡ Ì ÚÔÛÙÂÓˆÙÈ΋ ‰È¿Ù·ÛË, ÂÓÒ ÙÔ ‰ÂÍÈfi ÎfiÏÔÓ, ·fi ÙËÓ ÎÔÏÈ΋ η̋ ̤¯ÚÈ ÙÔ Ù˘ÊÏfi, ‹Ù·Ó ÚÈÎÓfi Î·È ·Ú·ÌÔÚʈ̤ÓÔ (EÈÎfiÓ· 1). AÎÔÏÔ‡ıËÛ ÂÚ¢ÓËÙÈ΋ Ï··ÚÔÙÔÌ›· ηٿ ÙËÓ ÔÔ›· ‰È·ÈÛÙÒıËΠ¤ÓÙÔÓË ÂÚ˘ıÚfiÙËÙ· Ì ÂÈÎfiÓ· ÊÏÂÁÌÔÓ‹˜ Î·È ¿¯˘ÓÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ ÙÂÏÈÎÔ‡ ÂÈÏÂÔ‡, ÙÔ˘ Ù˘ÊÏÔ‡ Î·È ÙÔ˘ ·ÓÈfiÓÙÔ˜ ÎfiÏÔ˘, Ô˘ ¤‰ÈÓ ÙËÓ ÂÓÙ‡ˆÛË ÓfiÛÔ˘ Crohn, ÏfiÁˆ Ù˘ ÔÔ›·˜ Ë Ï‹„Ë ‚ÈÔ„›·˜ ÂÁ΢ÌÔÓÔ‡Û ÙÔÓ Î›Ó‰˘ÓÔ
EÈÎfiÓ· 1. ¡ËÌ·ÙÔÂȉ‹˜ ÛÙ¤ÓˆÛË ÙÔ˘ ÂÈÏÂÔ‡ Ì ÚÔÛÙÂÓˆÙÈ΋ ‰È¿Ù·ÛË. ‰ËÌÈÔ˘ÚÁ›·˜ Û˘ÚÈÁÁ›ˆÓ. °È· ÙÔ ÏfiÁÔ ·˘Ùfi ‰ÂÓ ÂÏ‹ÊıËÛ·Ó ‚ÈÔ„›Â˜ ·fi ÙÔ ¤ÓÙÂÚÔ. TȘ ›‰È˜ Ì·ÎÚÔÛÎÔÈο ·ÏÏÔÈÒÛÂȘ ·ÚÔ˘Û›·˙Â Ë ÛΈÏËÎÔÂȉ‹˜ ·fiÊ˘ÛË, Ë ÔÔ›· Î·È ·Ê·ÈÚ¤ıËÎÂ. TÔ ‹·Ú ›¯Â Ô˙Ò‰Ë ÂÌÊ¿ÓÈÛË Î·È ÂÏ‹ÊıË ‰Â›ÁÌ· ÁÈ· ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË. ¶·ıÔÏÔÁÔ·Ó·ÙÔÌÈο, Ë ÛΈÏËÎÔÂȉ‹˜ ‰ÂÓ ·ÚÔ˘Û›·˙ ·ÍÈfiÏÔÁ˜ ÊÏÂÁÌÔÓÒ‰ÂȘ ·ÏÏÔÈÒÛÂȘ ÂÎÙfi˜ ·fi ÙËÓ ·ÚÔ˘Û›· ˘ÎÓ‹˜ ‚ϤÓÓ˘ Î·È ¿ÊıÔÓˆÓ ËˆÛÈÓÔÊ›ÏˆÓ ÛÙÔ ‚ÏÂÓÓÔÁfiÓÔ. T· Á·ÁÁÏȷο ·ÙÙ·Ú· ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. H ÈÛÙÔÏÔÁÈ΋ ·˘Ù‹ ÂÈÎfiÓ· ·¤ÎÏÂÈ ÙË ÊÏÂÁÌÔÓÒ‰Ë ÓfiÛÔ ÙÔ˘ ÂÓÙ¤ÚÔ˘. TÔ ‹·Ú ·ÚÔ˘Û›·˙ ‰È‡ڢÓÛË ÙˆÓ ˘Ï·›ˆÓ ‰È·ÛÙËÌ¿ÙˆÓ Î·È ÂÚȯÔÏ·ÁÁÂÈ›Ùȉ·, ÂÈÎfiÓ· Û˘Ì‚·Ù‹ Ì ·ÓÙ›‰Ú·ÛË ·fi Ù· ¯ÔÏËÊfiÚ· ÛÙ· Ï·›ÛÈ· Ù˘ ΢ÛÙÈ΋˜ ›ÓˆÛ˘. T· Â˘Ú‹Ì·Ù· ·˘Ù¿, ‰ËÏ·‰‹ Ë ÛÙ¤ÓˆÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙÔÓ ·ÔÎÏÂÈÛÌfi ÙÔ˘ ÊÏÂÁÌÔÓÒ‰Ô˘˜ ÂÓÙ¤ÚÔ˘, ¤ıÂÛ·Ó ÙË ‰È¿ÁÓˆÛË Ù˘ ÈÓÒ‰Ô˘˜ ÎÔÏÔÓÔ¿ıÂÈ·˜. ¢È·ÎfiËÎÂ Ë ¯ÔÚ‹ÁËÛË ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Î·È ¯ÔÚËÁ‹ıËΠÛÙÔȯÂÈ·Îfi Á¿Ï·. H ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÔÚ›· ‹Ù·Ó ÔÌ·Ï‹ Î·È ÛÙÔ˘˜ ÂfiÌÂÓÔ˘˜ 2 Ì‹Ó˜ ÙÔ ·È‰› ›¯Â ¿ÚÂÈ 3 ÎÈÏ¿. ™Â ·ӤÏÂÁ¯Ô Ì ÎÔÏÔÓÔÛÎfiËÛË / ‚ÈÔ„›· ÂÓÙ¤ÚÔ˘ 6 Ì‹Ó˜
323
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·324
¶∞π¢π∞∆ƒπ∫∏ 2000;63:322-325
™. NÙÔ˘ÓÙÔ˘Ó¿Î˘ Î·È Û˘Ó.
¯ÓÒÓ ·ÚÔ͇ÓÛÂˆÓ Ù˘ ¯ÚfiÓÈ·˜ ÂÓ‰Ô‚ÚÔÁ¯È΋˜ Ïԛ̈͢ ·fi „¢‰ÔÌÔÓ¿‰·, ÔÈ Ôԛ˜ ·ÓÙÈÌÂÙˆ›˙ÔÓÙ·È Ì ÂÓ‰ÔÊϤ‚È· ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Î·È ÔÛÙÂÔÂÓ›·, ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î·È ·Ú¯fiÌÂÓË ¯ÔÏÈ΋ ΛÚÚˆÛË, Ô˘ ÂÈ‚·Ú‡ÓÔ˘Ó Û˘ÓÔÏÈο ÙËÓ ÚfiÁÓˆÛË.
EÈÎfiÓ· 2. ∞ÂÈÎfiÓÈÛË 12 Ì‹Ó˜ ÌÂÙ¿ ÙË Ï··ÚÔÙÔÌ›·. ·ÚÁfiÙÂÚ·, Ô ‚ÏÂÓÓÔÁfiÓÔ˜ ÙÔ˘ ÙÂÏÈÎÔ‡ ÂÈÏÂÔ‡ Î·È ÙÔ˘ ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘ ·ÚÔ˘Û›·˙ ̤ÙÚÈÔ Ô›‰ËÌ· Ì ÂÛÙȷ΋ ·‡ÍËÛË ÙˆÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ·‡ÍËÛË ÙˆÓ ËˆÛÈÓÔʛψÓ. ™Â ‚·ÚÈÔ‡¯Ô ˘ÔÎÏ˘ÛÌfi (12 Ì‹Ó˜ ÌÂÙ¿ ÙË Ï··ÚÔÙÔÌ›·), Ë ÚÔ¸¿Ú¯Ô˘Û· ÛÙ¤ÓˆÛË Î·È Ë ‰È¿Ù·ÛË ÙÔ˘ ÂÈÏÂÔ‡ ‹Ù·Ó ÏÈÁfiÙÂÚÔ ÂÎÛÂÛËÌ·Ṳ̂Ó˜ (EÈÎfiÓ· 2). EÎÙfi˜ ·fi ‰‡Ô ·ÎfiÌË ÏÈÁfiÙÂÚÔ ÛÔ‚·Ú¿ ÂÂÈÛfi‰È· ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢, Û ËÏÈΛ· 7ó Î·È 8 ¯ÚfiÓˆÓ, Ô˘ ·ÓÙÈÌÂÙˆ›ÛıËÎ·Ó Û˘ÓÙËÚËÙÈο, ÙÔ ·È‰› ›¯Â ÂÚÈÔ‰Èο ‹È· ÂÓԯϋ̷ٷ ·fi ÙÔ ÂÙÈÎfi, ·ÔÙ¤ÏÂÛÌ· Ù˘ ÂÓÙÂÚÈ΋˜ ÛÙ¤ÓˆÛ˘. E·Ó·¯ÔÚËÁ‹ıËηÓ, ÛÙ·‰È·Î¿, ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì· Û ÌÈÎÚ¤˜ ‰fiÛÂȘ, ÒÛÙ ӷ ÂÍ·ÛÊ·Ï›˙ÂÙ·È ÈηÓÔÔÈËÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÎÂÓÒÛÂˆÓ Î·È Ó· ÂÈÙ¢¯ı› ηϋ ıÚ¤„Ë. H ÚfiÁÓˆÛË Ù˘ ·ÛıÂÓÔ‡˜, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ ÔÚ›· Ù˘ ÈÓÒ‰Ô˘˜ ÎÔÏÔÓÔ¿ıÂÈ·˜, Â›Ó·È ¿ÁÓˆÛÙË. H ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË (ÂÓÙÂÚÂÎÙÔÌ‹), ‰ÂÓ ıˆڋıËΠÂȂ‚ÏË̤ÓË ÂÍ·ÈÙ›·˜ Ù˘ ¤ÎÙ·Û˘ Ù˘ ‚Ï¿‚˘ Î·È Ù˘ Û˘ÌÌÂÙÔ¯‹˜ ÙÔ˘ ÂÈÏÂÔ‡ ÛÙË ÓfiÛÔ. ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚ›ÙˆÛË Ì›· Ì›˙ˆÓ ¤̂·ÛË ÂÎÙÈÌ‹ıËΠˆ˜ ȉȷ›ÙÂÚ· ·ÎÚˆÙËÚÈ·ÛÙÈ΋ Î·È ÂÈ‚·Ú˘ÓÙÈ΋ ÁÈ· ÙËÓ ·ÛıÂÓ‹, Ë ÔÔ›· ÂÎÙfi˜ ·fi Ù· ÚÔ‚Ï‹Ì·Ù· ÙÔ˘ ÂÙÈÎÔ‡, ·ÚÔ˘ÛÈ¿˙ÂÈ ÛÔ‚·Ú‹ Ì›ˆÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ (FVC: 44, FEV1: 41), ·ÔÙ¤ÏÂÛÌ· ÙˆÓ Û˘-
324
™˘˙‹ÙËÛË O fiÚÔ˜ ÈÓ҉˘ ÎÔÏÔÓÔ¿ıÂÈ· ·Ô‰›‰ÂÈ ÙÔÓ Ù‡Ô Ù˘ ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ÎfiÏÔ˘, Ô˘ ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ Û ·È‰È¿ Ì ΢ÛÙÈ΋ ›ÓˆÛË ÙÔ 1994 (1). ŒÎÙÔÙÂ, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÂÚ›Ô˘ 80 ÂÚÈÙÒÛÂȘ, Û ËÏÈ˘ Ô˘ Î˘Ì·›ÓÔÓÙ·È ·fi 9 ÌËÓÒÓ Ì¤¯ÚÈ 13 ¯ÚfiÓˆÓ, ÔÏϤ˜ ·fi ÙȘ Ôԛ˜ ‰ÂÓ ¤¯Ô˘Ó ÂȂ‚·Èˆı› ÈÛÙÔÏÔÁÈο, ·ÏÏ¿ ÌfiÓÔ ‚¿ÛÂÈ Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜ Î·È ÙÔ˘ ·ÎÙÈÓÔÏÔÁÈÎÔ‡ ÂϤÁ¯Ô˘ (2,3). ™Ù¤ÓˆÛË ÙÔ˘ ÂÓÙ¤ÚÔ˘ ¤¯ÂÈ ·Ú·ÙËÚËı› Î·È ÛÙÔ ·ÚÂÏıfiÓ Û ÂÓ‹ÏÈΘ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË Î·È ¿ÏÏˆÓ Ê·Ú̿ΈÓ, fiˆ˜ Â›Ó·È Ù· ‰ÈÔ˘ÚËÙÈο , Î·È Ù· ÌË ÛÙÂÚÔÂȉ‹ ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë Ê¿Ú̷η. H ·Ú¯È΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Û˘Ó›ÛÙ·ÙÔ ÛÂ Û˘Ìو̷ÙÔÏÔÁ›· ÂÓÙÂÚÈ΋˜ ·fiÊڷ͢ Ô˘ Û˘Ó‰˘·˙fiÙ·Ó Ì ¿¯˘ÓÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ÙÔ˘ ·ÓÈfiÓÙÔ˜ Î·È ÂÁοÚÛÈÔ˘ ÎfiÏÔ˘ Î·È ÛÙ¤ÓˆÛË ÙÔ˘ ·˘ÏÔ‡. Afi ÙȘ ÂÚÈÙÒÛÂȘ Ô˘ ¤¯Ô˘Ó ÌÂÏÂÙËı›, ÙÔ ÎÏÈÓÈÎfi Ê¿ÛÌ· Ù˘ ÈÓÒ‰Ô˘˜ ÎÔÏÔÓÔ¿ıÂÈ·˜ ÂÚÈÏ·Ì‚¿ÓÂÈ: ·) ÏËÌÌÂÏ‹ ·‡ÍËÛË Î·È Â›ÌÔÓË ‰˘Û·ÔÚÚfiÊËÛË ·Ú¿ ÙËÓ Î·ÓÔÓÈ΋ ¯ÔÚ‹ÁËÛË ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ, ‚) ›ÌÔÓÔ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜ Ì ÌÂÙˆÚÈÛÌfi ‹ ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË, Á) ·ÈÌ·ÙËÚ¤˜ ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ, ‰) Û·Ó›ˆ˜, ¯˘ÏÒ‰Ë ·ÛΛÙË. ¶·Ú¿ÏÏËÏ·, Û ·ÎÙÈÓԉȷÁÓˆÛÙÈÎfi ¤ÏÂÁ¯Ô ·ÂÈÎÔÓ›˙ÂÙ·È ¿¯˘ÓÛË ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜ Ì ÌÂȈ̤ÓË ÂÚ›ÛÙ·ÏÛË, ‚Ú¿¯˘ÓÛË ÙÔ˘ ÎfiÏÔ˘, ·Î·Ì„›· ÙÔ˘ ÂÓÙ¤ÚÔ˘, ‰È¿Ù·ÛË ÙÔ˘ ÙÂÏÈÎÔ‡ ÂÈÏÂÔ‡ (2,3). T· ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· Ù˘ ÈÓÒ‰Ô˘˜ ÎÔÏÔÓÔ¿ıÂÈ·˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÔÌÔÈfiÙËÙ˜ Ì ۇӉÚÔÌÔ ÈÛÔ‰‡Ó·ÌÔ ÂÈÏÂÔ‡ ·fi ÌËÎÒÓÈÔ Ô˘ Û˘Ó·ÓÙ¿Ù·È ÛÙÔ 1030% ÙˆÓ ·ÛıÂÓÒÓ Ì ΢ÛÙÈ΋ ›ÓˆÛË Î·È ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÚÔ˘Û›· ·¯‡ÚÚ¢ÛÙ˘ ÂÓÙÂÚÈ΋˜ ‚ϤÓÓ˘ Î·È ÂÓÛÊ‹ÓˆÛË ÎÔÚ¿ÓˆÓ, ·ÏÏ¿ ‰ÂÓ Û˘Óԉ‡ÂÙ·È Ì ¿¯˘ÓÛË ÙÔ˘ ÙÔȯÒÌ·ÙÔ˜ ‹ ÛÙ¤ÓˆÛË ÙÔ˘ ·˘ÏÔ‡ ÙÔ˘ ÂÓÙ¤ÚÔ˘. E›Ó·È ÁÓˆÛÙfi fiÙÈ Ë ÂÓÙÂÚÈ΋ ·fiÊÚ·ÍË (distal intestinal obstruction syndrome, DIOS) ÚÔ‚¿ÏÏÂÈ ÌÂ Û˘ÌÙÒÌ·Ù· fiˆ˜ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ÌÂÙˆÚÈÛÌfi, ‰˘ÛÎÔÈÏÈfiÙËÙ·, ÛÙ·ÛÈÌfiÙËÙ· ‹ ·ÒÏÂÈ· ‚¿ÚÔ˘˜. H ÈÓ҉˘ ÎÔÏÔÓÔ¿ıÂÈ· ÚÔÛ‚¿ÏÏÂÈ ÙÔ ÎfiÏÔÓ Î·È, ȉȷ›ÙÂÚ·, ÙÔ Ù˘ÊÏfi Î·È ÙÔ ·ÓÈfiÓ, ÂÓÒ Û ϛÁ˜ ÂÚÈÙÒÛÂȘ Ë ÚÔÛ‚ÔÏ‹ ·ÊÔÚ¿ Î·È ÛÙÔÓ ÙÂÏÈÎfi ÂÈÏÂfi (5). ¶·ıÔÁÓˆÌÔÓÈο ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· ·ÔÙÂÏÔ‡Ó Ë ˘Ô‚ÏÂÓÓÔÁfiÓÈ· ›ÓˆÛË Ì ¤ÎÙ·ÛË Î·È ÛÙÔ Ì˘˚Îfi ¯ÈÙÒÓ·, ÙÔ Ô›‰ËÌ· ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ Î·È Ë ‰È‹ıËÛË ·fi ˈÛÈÓfiÊÈÏ· Î·È Ì·ÛÙÔ·ÙÙ·Ú· (5). Afi ÙȘ ÚÒÙ˜ ·Ú·ÙËÚ‹ÛÂȘ Èı·ÓÔÏÔÁ‹ıËΠοÔÈ· Û˘Û¯¤ÙÈÛË ÌÂٷ͇ Ù˘ ÎÔÏÔÓÔ¿ıÂÈ·˜ Î·È Ù˘ ¯ÔÚ‹ÁËÛ˘ ÌÂÁ¿ÏˆÓ ‰fiÛÂˆÓ ·ÁÎÚ·ÙÈÎÒÓ
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·325
¶∞π¢π∞∆ƒπ∫∏ 2000;63:322-325
ÂÓ˙‡ÌˆÓ (1,7). K·È ·˘Ùfi Û˘Ì‚·›ÓÂÈ Â˘ÎÔÏfiÙÂÚ· Ì ÙË ¯Ú‹ÛË Û΢·ÛÌ¿ÙˆÓ ÌÂÁ¿Ï˘ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ Û ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì·. OÈ Smyth Î·È Û˘Ó. (1995) ‚Ú‹Î·Ó fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ÎÔÏÔÓÔ¿ıÂÈ· ¤·ÈÚÓ·Ó, ηٿ ̤ÛÔ fiÚÔ, ¿Óˆ ·fi 46.000 UI ÏÈ¿Û˘/Kg/Ë̤ڷ, Û ·ÓÙ›ıÂÛË Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜, ÛÙÔ˘˜ ÔÔ›Ô˘˜ Ë Ì¤ÛË ÚfiÛÏË„Ë ÏÈ¿Û˘ ‰ÂÓ ÍÂÂÚÓÔ‡Û ÙȘ 21.000 UI ÏÈ¿Û˘/Kg/Ë̤ڷ. T· Â˘Ú‹Ì·Ù¿ ÙÔ˘˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë Û˘Û¯¤ÙÈÛË Ù˘ ÎÔÏÔÓÔ¿ıÂÈ·˜ Ì ÙËÓ ÔÛfiÙËÙ· ÙˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ‹Ù·Ó ‰ÔÛÔÂÍ·ÚÙÒÌÂÓË Ì ۯÂÙÈÎfi ΛӉ˘ÓÔ 8,0 Û ۇÁÎÚÈÛË Ì ÙË ¯Ú‹ÛË ˘·ÎÙÈÎÒÓ, ÁÈ· ÙËÓ ÔÔ›· Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ‹Ù·Ó ÌfiÓÔ 2,4 (7). ™Â ¿ÏÏË ÌÂϤÙË, Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ˘ÔÏÔÁ›ÛıËΠ۠8,4 ÁÈ· ÔÛfiÙËÙ˜ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ >25.000 UI ÏÈ¿Û˘/Kg/Ë̤ڷ Î·È 64 ÁÈ· ÔÛfiÙËÙ˜ >50.000 UI ÏÈ¿Û˘/Kg/Ë̤ڷ (8). O ·ÎÚÈ‚‹˜ Ì˯·ÓÈÛÌfi˜ ÚfiÎÏËÛ˘ Ù˘ ‚Ï¿‚˘ ‰ÂÓ Â›Ó·È Ï‹Úˆ˜ ‰È¢ÎÚÈÓÈṲ̂ÓÔ˜. EÓÔ¯ÔÔÈÂ›Ù·È Ë ÙÔÍÈ΋ ‰Ú¿ÛË ÙˆÓ ÌÂÁ¿ÏˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÛÙÔ ‚ÏÂÓÓÔÁfiÓÔ ÙÔ˘ ÂÓÙ¤ÚÔ˘ ηıÒ˜ Î·È ÙˆÓ ¯ËÌÈÎÒÓ Ô˘ÛÈÒÓ (ÔÏ˘ÌÂÚ‹) ÙÔ˘ ÂÚÈ‚Ï‹Ì·ÙÔ˜ ÙˆÓ ÌÈÎÚÔ‰ÈÛΛˆÓ Î·È ÙˆÓ ÌÈÎÚÔÛÊ·ÈÚȉ›ˆÓ Ô˘ ÂÚȤ¯ÔÓÙ·È ÛÙËÓ Î¿„Ô˘Ï·. EÂȉ‹ Ù· ·È‰È¿ Ì ΢ÛÙÈ΋ ›ÓˆÛË ¤¯Ô˘Ó ÈÔ ¯·ÌËÏfi PH ÛÙÔ ÏÂÙfi ¤ÓÙÂÚÔ ÏfiÁˆ Ù˘ ÌÂȈ̤Ó˘ ·Ú·ÁˆÁ‹˜ ·ÁÎÚ·ÙÈÎÒÓ ˘ÁÚÒÓ, ηı˘ÛÙÂÚ› Ë ‰È¿Ï˘ÛË ÙÔ˘ ÂÚÈ‚Ï‹Ì·ÙÔ˜ Î·È ¤ÙÛÈ ·ÂÏ¢ıÂÚÒÓÔÓÙ·È ÌÂÁ¿Ï˜ ÔÛfiÙËÙ˜ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ÛÙÔ ÂÚÈÊÂÚÈÎfi ÙÌ‹Ì· ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘, ‹ ·ÎfiÌË Î·È ÙÔ ·¯‡, ÂÚÈÔ¯¤˜, ‰ËÏ·‰‹, Ô˘ ‰ÂÓ Â›Ó·È ·Ó·ÙÔÌÈο ÚÔÂÙÔÈÌ·Ṳ̂Ó˜ Ó· ÙȘ ‰Â¯ıÔ‡Ó Î·È Ó· ÙȘ ·Ó¯ıÔ‡Ó. ™ÙËÓ ÚfiÎÏËÛË Ù˘ ÂÓÙÂÚÈ΋˜ ‚Ï¿‚˘ Èı·ÓfiÓ Ó· Û˘Ì‚¿ÏÏÔ˘Ó Î·È ¿ÏÏÔÈ ·Ú¿ÁÔÓÙ˜, fiˆ˜ Ë Î·ı˘ÛÙÂÚË̤ÓË ‰›Ô‰Ô˜ ÙÔ˘ ÂÓÙÂÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘, Ô˘ ¤¯ÂÈ ˆ˜ Û˘Ó¤ÂÈ· ÙËÓ ·Ú·ÙÂٷ̤ÓË Â·Ê‹ Ì ÙÔ ‚ÏÂÓÓÔÁfiÓÔ, ‹ Ù· ÂÂÈÛfi‰È· ÂÓÙÂÚÈ΋˜ ÛÙ¿Û˘ ‹ ·fiÊڷ͢ Ô˘ ÂÈϤÎÔ˘Ó ÙËÓ Î˘ÛÙÈ΋ ›ÓˆÛË. ™Â ÂÈÚ·Ì·ÙÈο ÚfiÙ˘·, ¤¯ÂÈ ‰È·ÈÛÙˆı› ÙÔÍÈ΋ ‰Ú¿ÛË ÛÙÔ ¤ÓÙÂÚÔ ÙˆÓ ¯ËÌÈÎÒÓ Ô˘ÛÈÒÓ Ô˘ ÂÚÈ‚¿ÏÏÔ˘Ó Ù· ·ÁÎÚ·ÙÈο ¤Ó˙˘Ì·, fiˆ˜ ÙÔ Âı˘Ï-·ÎÚ‡ÏÈÔ (Panzytrat, Pancrease HL, Nutrizyme 22), ‰ÂÓ Â›Ó·È, fï˜ ·ÓÙ›ÛÙÔÈ¯Ë Ì ·˘Ù‹ Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙÔÓ ¿ÓıÚˆÔ (3). AÓÙ›ıÂÙ·, ÙÔ Êı·ÏÈÎfi (Creon) ıˆÚÂ›Ù·È ÈÔ ·ÛʷϤ˜, ÂÂȉ‹, Èı·ÓÒ˜, ‰È·Ï‡ÂÙ·È Û ¯·ÌËÏfiÙÂÚÔ PH Î·È ÂÏ¢ıÂÚÒÓÂÙ·È Ù·¯‡ÙÂÚ· Û ·ÓÒÙÂÚÔ ÙÌ‹Ì· ÙÔ˘ ÏÂÙÔ‡ ÂÓÙ¤ÚÔ˘ (3,10). H ˘fiıÂÛË Ó· ÂÌϤÎÂÙ·È Î·È ·˘ÙÔ¿ÓÔÛÔ˜ Ì˯·ÓÈÛÌfi˜ ‹ Ó· Â›Ó·È ·ıÔÏÔÁÈÎfi˜ Ô Ì˯·ÓÈÛÌfi˜ Ô˘ Ú˘ıÌ›˙ÂÈ ÙË Û‡ÓıÂÛË ÎÔÏÏ·ÁfiÓÔ˘ ·fi ÙÔ ÂÓÙÂÚÈÎfi ÙÔ›¯ˆÌ· ‰ÂÓ Ê·›ÓÂÙ·È Ó· Û˘ÁÎÂÓÙÚÒÓÂÈ ÔÏϤ˜ Èı·ÓfiÙËÙ˜ (9). H ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÈÓÒ‰Ô˘˜ ÎÔÏÔÓÔ¿ıÂÈ·˜, ÛÙËÚ›˙ÂÙ·È Î˘Ú›ˆ˜ ÛÙËÓ ·Ó·ÚÔÛ·ÚÌÔÁ‹ Ù˘ ‰fiÛ˘ ÙˆÓ ÂÓ˙‡ÌˆÓ. H ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË ÂÓÙÂÚÂÎÙÔÌ‹ Û˘ÓÈÛÙ¿Ù·È ÛÙȘ ÂÚÈÙÒÛÂȘ ÂÈÌÔÓ‹˜ Ù˘ ÎÏÈÓÈ΋˜ Û˘Ìو̷ÙÔÏÔÁ›·˜ Î·È ‡·Ú͢ ÛÔ‚·Ú‹˜ ÛÙ¤ÓˆÛ˘
ÙÔ˘ ÂÓÙ¤ÚÔ˘ ÛÙÔÓ ·ÎÙÈÓÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô Î·È ı· Ú¤ÂÈ Ó· ÂÚÈÔÚ›˙ÂÙ·È, fiÛÔÓ Â›Ó·È ‰˘Ó·ÙfiÓ, ÛÙÔ ÚÔۂ‚ÏË̤ÓÔ ÙÌ‹Ì· ÙÔ˘ ÂÓÙ¤ÚÔ˘ (4,6). H ÚfiÏË„Ë Ù˘ ÓfiÛÔ˘ ÂÈÙ˘Á¯¿ÓÂÙ·È Û‡Ìʈӷ Ì ÙËÓ EÈÙÚÔ‹ I·ÙÚÈ΋˜ AÛÊ¿ÏÂÈ·˜ - Committee on the Safety of Medicine (NԤ̂ÚÈÔ˜ 1995) - Ì ÙËÓ ·ÔÊ˘Á‹ ¯ÔÚ‹ÁËÛ˘ Û΢·ÛÌ¿ÙˆÓ Ù· ÔÔ›· ÂÚȤ¯Ô˘Ó ÌÂÁ¿Ï˜ ‰fiÛÂȘ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ Û ·ÛıÂÓ›˜ Ì ΢ÛÙÈ΋ ›ÓˆÛË ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 15 ¯ÚfiÓˆÓ. H ËÌÂÚ‹ÛÈ· ‰fiÛË ‰ÂÓ ı· Ú¤ÂÈ Ó· ÍÂÂÚÓ¿ ÙȘ 10.000 UI/Kg/Ë̤ڷ Î·È Ù· ¤Ó˙˘Ì· ı· Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Ì ȷÙÚÈ΋ Û˘ÓÙ·Á‹ (10). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ÈÓ҉˘ ÎÔÏÔÓÔ¿ıÂÈ· ·ÔÙÂÏ› Ì›· Û¿ÓÈ· ÂÈÏÔ΋ Ù˘ ıÂڷ›·˜ Ù˘ ΢ÛÙÈ΋˜ ›ÓˆÛ˘ ·fi ÌÂÁ¿Ï˜ ‰fiÛÂȘ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ, Ë ÔÔ›· ¤¯ÂÈ ·ÌÊ›‚ÔÏË ÚfiÁÓˆÛË. H ÙÚÔÔÔ›ËÛË Ù˘ ‰ÔÛÔÏÔÁ›·˜ ÙˆÓ ·ÁÎÚ·ÙÈÎÒÓ ÂÓ˙‡ÌˆÓ ıˆÚÂ›Ù·È Ô ÌfiÓÔ˜ ÙÚfiÔ˜ ÚfiÏ˄˘. BÈ‚ÏÈÔÁÚ·Ê›· 1. Smyth RL, Van Velzen D, Smyth AR, Lloyd DA, Heaf DP. Strictures of ascending colon in cystic fibrosis and high strength pancreatic enzymes. Lancet 1994;343:85-86. 2. Powel CJ. Colonic toxicity from pancreatins: a contemporary safety issue. Lancet 1999;353:911-915. 3. Littlewood JM. Update on intestinal strictures. JR Soc Med 1999;92 (suppl 37): S41-S49. 4. Borowitz DS, Grand RJ, Durie PR and the CF Consensus Committee. Use of pancreatic enzyme supplements for patients with cystic fibrosis in the context of fibrosing colonopathy. J Pediatr 1995;127:681-684. 5. Hasler WL. Pancreatic enzymes and colonic strictures with cystic fibrosis: A case- control study. Selected summaries. Gastroenterology 1998;114:609-612. 6. Reichard KW, Vinocour CD, Franco M, Crisci KL, Flick JA, Billmire DF et al. Fibrosing colonopathy in children with cystic fibrosis. J Pediatr Surg 1997;32:237-242. 7. Smyth RL, Ashby D, O’ Hea U, Burrows E, Lewis P, van Velzen D, et al. Fibrosing colonopathy in cystic fibrosis: results of a case control study. Lancet 1995; 346:1247-1251. 8. Fitzsimmons SC, Burkhart GA, Borowitz D, Grand RJ, Hammer strom T, Durie PR et al. High dose pancreatic enzyme supplements and fibrosing colonopathy in children with cystic fibrosis. N Engl J Med 1997;336:1283-1289. 9. Lee J, Ip W, Durie P. Is fibrosing colonopathy an immune mediated disease? Arch Dis Child 1997;77:66-70. 10. Current problems in Pharmacovigilance, Committee on Safety of Medicines Nov 1995;21:11.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 01-12-1999 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 14-04-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ™Ù·‡ÚÔ˜ ¡ÙÔ˘ÓÙÔ˘Ó¿Î˘ ∆Ì‹Ì· πÓÔ΢ÛÙÈ΋˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó· 115 27
325
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·326
¶∞π¢π∞∆ƒπ∫∏ 2000;63:326-329
Ÿ„ÈÌË ÂÓ‰ÔÌ‹ÙÚÈ· Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi: ÎÏÈÓÈο Î·È ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· O˘Ú·Ó›· ¶··‰¿ÎË-¶··Ó‰Ú¤Ô˘1, ª·Ú›· ∑·Ú›ÊË2, πˆ¿ÓÓ˘ OÈÎÔÓÔÌ›‰Ë˜3, ∞ÛË̛ӷ •˘ÔÏ˘Ù¿-∑·¯·ÚÈ¿‰Ë1 ● ¶ÂÚ›ÏË„Ë: H ÚÒÈÌË ÂÓ‰ÔÌ‹ÙÚÈ· Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi Û˘Ó‹ıˆ˜ Ô‰ËÁ› Û ‚·ÚÈ¿ Ó¢ÚÔÏÔÁÈο ÂÏÏ›ÌÌ·Ù· Ì Ó¢ÚÔ·ÈÛıËÙ‹ÚÈ· ‚·ÚËÎÔ˝· Î·È Ù˘Èο Ó¢ÚÔ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù·: ÂÓ‰ÔÂÁÎÂÊ·ÏÈΤ˜ ·ÚÂÁ¯˘Ì·ÙÈΤ˜ ·ÔÙÈÙ·ÓÒÛÂȘ, ·ÓˆÌ·Ï›Â˜ ÛÙË ÌÂÙ·Ó¿ÛÙ¢ÛË ÙˆÓ Ó¢ÚÒÓˆÓ (·Á˘Ú›· - ·¯˘Á˘Ú›· - ÔÏ˘ÌÈÎÚÔÁ˘Ú›·), ‰È·Ù·Ú·¯¤˜ ÛÙËÓ Ì˘ÂϛӈÛË, ·Ú·ÎÔÈÏȷΤ˜ ·ÛÙÂȘ, ‰È¿Ù·ÛË ÙˆÓ Ï·Á›ˆÓ ÎÔÈÏÈÒÓ Î·È ˘ÔÏ·Û›· Ù˘ ·ÚÂÁÎÂÊ·Ï›‰Ô˜. AÓÙ›ıÂÙ·, Ë fi„ÈÌË Ïԛ̈ÍË Û ÚÔ¯ˆÚË̤ÓË ÂÁ΢ÌÔÛ‡ÓË ¤¯ÂÈ ËÈfiÙÂÚ˜ ÂΉËÏÒÛÂȘ Ì ÌÈÎÚÔÎÂÊ·Ï›·, ‚·ÚËÎÔ˝· Î·È ÂÏ·ÊÚ¿ Ó¢ÚÔÏÔÁÈ΋ Û˘Ó‰ÚÔÌ‹. ¶ÂÚÈÁÚ¿ÊÔ˘Ì ÙËÓ ÂÚ›ÙˆÛË ÎÔÚÈÙÛÈÔ‡, 3 ÂÙÒÓ Ì Ó¢ÚÔ·ÈÛıËÙ‹ÚÈ· ‚·ÚËÎÔ˝· ÁÈ· ÙËÓ ÔÔ›· ÙÔÔıÂÙ‹ıËΠÎÔ¯ÏÈ·Îfi ÂÌʇÙÂ˘Ì·, ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·, ηϋ „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË Î·È ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ ÛÙ· ηÙÒÙÂÚ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· (47 ÂÎ., 5Ë ÂηÙÔÛÙÈ·›· ı¤ÛË). ™Ù· Ï·›ÛÈ· ÙÔ˘ ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÚÈÓ ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ ÎÔ¯ÏÈ·ÎÔ‡ ÂÌÊ˘Ù‡̷ÙÔ˜ ˘Ô‚Ï‹ıËΠ۠·ÍÔÓÈ΋ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ Î·È ÏÈıÔÂȉÒÓ ÔÛÙÒÓ. ™ÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ·Ú·ÙËÚ‹ıËÎÂ Û˘ÌÌÂÙÚÈο ˘fi˘ÎÓË ·ÂÈÎfiÓÈÛË Ù˘ Ï¢΋˜ Ô˘Û›·˜ ΢ڛˆ˜ ÛÙ· Ô›ÛıÈ· ÙÌ‹Ì·Ù· ÙˆÓ ËÌȈԉÒÓ Î¤ÓÙÚˆÓ ·ÌÊÔÙÂÚfiÏ¢ڷ, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ·ÂÈÎfiÓÈÛË ÙÔ˘ ˘ÔÏÔ›Ô˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜, Ù˘ ·ÚÂÁÎÂÊ·Ï›‰Ô˜ Î·È ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ™ÙËÓ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ·Ó·‰Â›¯ıËÎ·Ó Û˘ÌÌÂÙÚÈΤ˜ ÂÛٛ˜ ·˘ÍË̤ÓÔ˘ Û‹Ì·ÙÔ˜ Ì ·Û·Ê‹ fiÚÈ· ÛÙËÓ ÂÓ Ùˆ ‚¿ıÂÈ Ï¢΋ Ô˘Û›· ÙˆÓ ‚ÚÂÁÌ·ÙÈÎÒÓ, ÌÂوȷ›ˆÓ Î·È ÎÚÔÙ·ÊÈÎÒÓ ÏÔ‚ÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì ÌË ÂȉÈ΋ Ï¢ÎÔÂÁÎÂÊ·ÏÔ¿ıÂÈ·. K·È Ì ÙȘ ‰‡Ô ÌÂıfi‰Ô˘˜ Ë ·ÂÈÎfiÓÈÛË ÙˆÓ ·Ó·ÙÔÌÈÎÒÓ ÌÔÚ›ˆÓ ÙˆÓ ÏÈıÔÂȉÒÓ ÔÛÙÒÓ Î·È ÙˆÓ ·ÎÔ˘ÛÙÈÎÒÓ ÓÂ‡ÚˆÓ ˘‹ÚÍÂ Ê˘ÛÈÔÏÔÁÈ΋. H ·ÛıÂÓ‹˜ ·˘Ù‹ Ô˘ ÓÔÛËχÙËΠÁÈ· Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi ÛÙËÓ ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô, Èı·ÓÔÏÔÁԇ̠fiÙÈ ÓfiÛËÛ ÛÙÔ 3Ô ÙÚ›ÌËÓÔ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ Ì ·ÔÙ¤ÏÂÛÌ· ‹È· ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË Î·È ÂÚÈÔÚÈṲ̂ӷ ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù·. ¶·È‰È·ÙÚÈ΋ 2000;63:326-329. §¤ÍÂȘ ÎÏÂȉȿ: ÂÓ‰ÔÌ‹ÙÚÈ· Ïԛ̈ÍË, ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜, ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ·, ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·, Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·. O. Papadaki-Papandreou, M. Zarifi, I. Oikonomidis, A. Xypolyta-Zachariadou. Late intrauterine cylomegalovirus infection: clinical and imaging findings. Paediatriki 2000;63:326-329. ● Abstract: Early intrauaterine cylomegalovirus (CMV) infection typically leads to severe neurological deficits in the child, with sensorineural hearing loss and typical neuroradiological findings: cerebral calcifications, migrational anomalies (lissencephaly, polymicrogyria), myelination disorders, paraventricular cysts, dilatation of the lateral ventricles and cerebellar hypoplasia. By contrast CMV infection at a later stage of pregnancy causes milder clinical symptoms: microcephaly, hearing loss and less severe neurological findings. The case is presented of a 3-year old girl with sensorineural hearing loss, mild behavioural problems with hyperactivity, good psychomotor evolution and head circumference at the lower normal limits. Before the installation of a cochlear implant the girl underwent brain and petrous bone CT and MRI. The CT revealed irregular hypodense areas symmetrically in the posterior parts of the corona radiata. The MRI showed patchy areas of increased signal on T2-weighted images in the deep white matter of the frontal, parietal and temporal lobes bilaterally. It is believed that the CMV infection in this child, who had been hospitalised for CMV infection in the perinatal period, occurred in the third trimester of pregnancy and therefore the disease presented with a mild clinical picture and limited neuroradiological findings. Key words: intrauterine cytomegalovirus infection, central nervous system, CT, MRI. 1 2 3
∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ∆Ì‹Ì· ∞ÍÔÓÈÎÒÓ ∆ÔÌÔÁÚ¿ÊˆÓ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” ∞ÈÌ·ÙÔÏÔÁÈÎfi ÙÌ‹Ì·, ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
326
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·327
¶∞π¢π∞∆ƒπ∫∏ 2000;63:326-329
EÈÛ·ÁˆÁ‹ H Û˘ÁÁÂÓ‹˜ Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi (CMV) Â›Ó·È Ë Ï¤ÔÓ Û˘¯Ó‹ ÂÓ‰ÔÌ‹ÙÚÈ· Ïԛ̈ÍË ÙˆÓ ÓÂÔÁÓÒÓ Î·È Û˘Ì‚·›ÓÂÈ Û ÔÛÔÛÙfi ÂÚ›Ô˘ 1%.(1-3) MfiÓÔ 10% ÙˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ ·È‰ÈÒÓ Â›Ó·È Û˘Ìو̷ÙÈο ηٿ ÙË Á¤ÓÓËÛË.(1) T· ϤÔÓ ¤Î‰ËÏ· ÛËÌ›· Â›Ó·È Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›· Î·È ·Ù¤¯ÂȘ(50%).(1) B·ÚÈ¿ Ó¢ÚÔÏÔÁÈο Â˘Ú‹Ì·Ù· ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ 55% ÙˆÓ ·ÛıÂÓÒÓ, ËÈfiÙÂÚ˜ Ó¢ÚÔÏÔÁÈΤ˜ ·ÓˆÌ·Ï›Â˜ ÙÔ 31%, ÂÓÒ ‚·ÚËÎÔ˝· ·Ú·ÙËÚÂ›Ù·È Û 27% ÂÚ›Ô˘ (1,2). H ‰È¿ÁÓˆÛË ÂȂ‚·ÈÒÓÂÙ·È Ì ÙËÓ Î·ÏÏȤÚÁÂÈ· ÙÔ˘ ÈÔ‡ ÛÙ· Ô‡Ú· ‹ ÙÔÓ Û›ÂÏÔ Î·Ù¿ ÙȘ 4 ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ Ù˘ ˙ˆ‹˜, Ì ٷ ÂȉÈο IgM ·ÓÙÈÛÒÌ·Ù· ÛÙÔÓ ÔÚfi Î·È ÙÂÏÂ˘Ù·›· Ì ÙË Ì¤ıÔ‰Ô PCR. MÂÙ¿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô Ë ‰È¿ÁÓˆÛË Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ Ïԛ̈͢ Â›Ó·È ‰˘ÛÎÔÏfiÙÂÚË Î·È ‚·Û›˙ÂÙ·È ÛÙËÓ Ù˘È΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ·. M ÙËÓ Î·ÏÏȤÚÁÂÈ· ÙÔ˘ ÈÔ‡ Î·È ÙÔÓ ÔÚÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ηıÔÚÈÛÙ› Ô ·ÎÚÈ‚‹˜ ¯ÚfiÓÔ˜ ÚÔÛ‚ÔÏ‹˜ ·fi ÙÔÓ Èfi ηٿ ÙËÓ ÂÓ‰ÔÌ‹ÙÚÈ· ‹ ÙËÓ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô. T· Ù˘Èο ÎÏÈÓÈο Î·È ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· Ô˘ ÂÈÙÚ¤Ô˘Ó ÙË ‰È¿ÁÓˆÛË Ù˘ ÚÒÈÌ˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ Ïԛ̈͢ ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi ÌÂÙ¿ ÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Û ۯÂÙÈ΋ ‚È‚ÏÈÔÁÚ·Ê›·(2,3). ŒÙÛÈ, Û˘Ìو̷ÙÈ΋ Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi ÛÙ· ÚÒÙ· ÛÙ¿‰È· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ Û˘Ó‹ıˆ˜ Ô‰ËÁ› Û ÛÔ‚·Ú¿ Ó¢ÚÔÏÔÁÈο ÂÏÏ›ÌÌ·Ù· Ì ÌÈÎÚÔÎÂÊ·Ï›·, Ó¢ÚÔ·ÈÛıËÙ‹ÚÈ· ‚·ÚËÎÔ˝· Î·È ‚·ÚÂÈ¿ „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË. OÊı·ÏÌÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· ÔÊÂÈÏfiÌÂÓ· Û ¯ÔÚÈÔ·ÌÊÈ‚ÏËÛÙÚÔÂȉ›Ùȉ·, ηıÒ˜ Î·È ÂÈÏËÙÈΤ˜ ÎÚ›ÛÂȘ ¤¯Ô˘Ó ›Û˘ ·Ó·ÊÂÚı›(3). AÓÙ›ıÂÙ· Ë fi„ÈÌË Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi ηٿ Ù· ÙÂÏÂ˘Ù·›· ÛÙ¿‰È· Ù˘ ΢‹Ûˆ˜ ·ÚÔ˘ÛÈ¿˙ÂÈ ËÈfiÙÂÚË ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË, ÁÈ’ ·˘Ùfi Î·È Ù· ÎÚÈÙ‹ÚÈ· ÁÈ· ÙË ‰È¿ÁÓˆÛË ‰ÂÓ Â›Ó·È Û·Ê‹ Î·È Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Ùˆ¯¿(5). ¶ÂÚÈÁÚ¿ÊÔ˘Ì ÙËÓ ÂÚ›ÙˆÛË ÎÔÚÈÙÛÈÔ‡ Ì ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È Ó¢ÚÔ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· Û˘Ì‚·Ù¿ Ì Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi ηٿ ÙÔ ÙÂÏÂ˘Ù·›Ô ÙÚ›ÌËÓÔ Ù˘ ÂÁ΢ÌÔÛ‡Ó˘. ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛˆ˜ KÔÚ›ÙÛÈ ËÏÈΛ·˜ 3 ÂÙÒÓ ÚÔÛ‹Ïı ÁÈ· Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ÚÔÎÂÈ̤ÓÔ˘ Ó· ˘Ô‚ÏËı› Û ¤̂·ÛË ÙÔÔı¤ÙËÛ˘ ÎÔ¯ÏÈ·ÎÔ‡ ÂÌÊ˘Ù‡̷ÙÔ˜ ÏfiÁˆ ‚·ÚÂÈ¿˜ Ó¢ÚÔ·ÈÛıËÙ‹ÚÈ·˜ ‚·ÚËÎÔ˝·˜ ÁÓˆÛÙ‹˜ ·fi ËÏÈΛ·˜ 4 ÌËÓÒÓ. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ ÚÒÙÔ ·È‰› ˘ÁÈÒÓ ÌË Û˘ÁÁÂÓÒÓ ÁÔÓ¤ˆÓ ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÂÁ΢ÌÔÛ‡ÓË Î·È ÙÔÎÂÙfi Î·È ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 2.850 Kg. NÔÛËχÙËΠ۠ÓÂÔÁÓÔÏÔÁÈÎfi ÙÌ‹Ì· ÏfiÁˆ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, fiÔ˘ ‰È·ÁÓÒÛıËΠÏԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi Ì ıÂÙÈο IgM ·ÓÙÈÛÒÌ·Ù·. ™Â ËÏÈΛ· 4 ÌËÓÒÓ ‰È·ÈÛÙÒıËÎÂ
‚·ÚËÎÔ˝·, Ë ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛıËΠ·Ú¯Èο Ì ·ÎÔ˘ÛÙÈο Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÚÔÛÙ¤ıËÎÂ Î·È ·ÁˆÁ‹ ÏfiÁÔ˘, ¯ˆÚ›˜ fï˜ Ô˘ÛÈ·ÛÙÈ΋ ‚ÂÏÙ›ˆÛË ÙÔ˘ ÏfiÁÔ˘, ·Ó Î·È Ë „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË ÙÔ˘ ·È‰ÈÔ‡ ˘‹ÚÍ ÔÌ·Ï‹. ŒÙÛÈ, Û ËÏÈΛ· 3 ÂÙÒÓ ·ÔÊ·Û›ÛÙËÎÂ Ë ÙÔÔı¤ÙËÛË ÎÔ¯ÏÈ·ÎÔ‡ ÂÌÊ˘Ù‡̷ÙÔ˜ ÁÈ· ÚÈ˙ÈÎfiÙÂÚË ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‚·ÚËÎÔ˝·˜ ÛÙÔ ·ÎÔÔÏÔÁÈÎfi ÙÌ‹Ì· ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ Ì·˜. Afi ÙËÓ ÏÂÙÔÌÂÚ‹ Ó¢ÚÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË ‰ÂÓ ÚԤ΢„ ·ıÔÏÔÁÈÎfi ‡ÚËÌ·. TÔ ·È‰› ›¯Â ηϋ ÂÈÎÔÈÓˆÓ›· ‹Ù·Ó fï˜ ȉȷ›ÙÂÚ· ˘ÂÚÎÈÓËÙÈÎfi Î·È Ë ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ ÙÔ˘ (47 ÂÎ.) ·ÓÙÈÛÙÔȯԇÛ ÛÙËÓ 5Ë ÂηÙÔÛÙÈ·›· ı¤ÛË. ™Ù· Ï·›ÛÈ· ÙÔ˘ ÚÔÂÁ¯ÂÈÚËÙÈÎÔ‡ ÂϤÁ¯Ô˘ ÁÈ· ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ ÂÌÊ˘Ù‡̷ÙÔ˜, ÙÔ ·È‰› ˘Ô‚Ï‹ıËΠ›Û˘ Û ·ÍÔÓÈ΋ Î·È Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ Î·È ÏÈıÔÂȉÒÓ ÔÛÙÒÓ. ™ÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ·Ú·ÙËÚ‹ıËÎÂ Û˘ÌÌÂÙÚÈο ˘fi˘ÎÓË ·ÂÈÎfiÓÈÛË Ù˘ Ï¢΋˜ Ô˘Û›·˜ ΢ڛˆ˜ ÛÙ· Ô›ÛıÈ· ÙÌ‹Ì·Ù· ÙˆÓ ËÌȈÔÂȉÒÓ Î¤ÓÙÚˆÓ ·ÌÊÔÙÂÚfiÏ¢ڷ, ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ·ÂÈÎfiÓÈÛË ÙÔ˘ ˘ÔÏÔ›Ô˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜, Ù˘ ·ÚÂÁÎÂÊ·Ï›‰Ô˜ Î·È ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘. ™ÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ·Ó·‰Â›¯ıËÎ·Ó Û˘ÌÌÂÙÚÈΤ˜ ÂÛٛ˜ ·˘ÍË̤ÓÔ˘ Û‹Ì·ÙÔ˜ Ì ·Û·Ê‹ fiÚÈ· ÛÙËÓ ÂÓ Ùˆ ‚¿ıÂÈ Ï¢΋ Ô˘Û›· ÙˆÓ ‚ÚÂÁÌ·ÙÈÎÒÓ, ÌÂوȷ›ˆÓ Î·È ÎÚÔÙ·ÊÈÎÒÓ ÏÔ‚ÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ‡ÚËÌ· Û˘Ì‚·Ùfi Ì ÌË ÂȉÈ΋ Ï¢ÎÔÂÁÎÂÊ·ÏÔ¿ıÂÈ·.
EÈÎfiÓ· 1. ™˘ÌÌÂÙÚÈο ˘fi˘ÎÓË ·ÂÈÎfiÓÈÛË Ù˘ Ï¢΋˜ Ô˘Û›·˜ ÛÙ· Ô›ÛıÈ· ÙÌ‹Ì·Ù· ÙˆÓ ËÌȈÔÂȉÒÓ Î¤ÓÙÚˆÓ ·ÌÊÔÙÂÚfiÏ¢ڷ. ¢ÂÓ ·Ú·ÙËÚ‹ıËΠÂÓ›Û¯˘ÛË ÙˆÓ ·ÏÏÔÈÒÛÂˆÓ ·˘ÙÒÓ ÌÂÙ¿ ÙËÓ ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ÛÎÈ·ÁÚ·ÊÈÎÔ‡ ̤ÛÔ˘.
327
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·328
¶∞π¢π∞∆ƒπ∫∏ 2000;63:326-329
K·È Ì ÙȘ ‰‡Ô ÌÂıfi‰Ô˘˜ Ë ·ÂÈÎfiÓÈÛË ÙˆÓ ‰ÔÌÒÓ ÙˆÓ ÏÈıÔÂȉÒÓ ÔÛÙÒÓ Î·È ÙˆÓ ·ÎÔ˘ÛÙÈÎÒÓ ÓÂ‡ÚˆÓ ˘‹ÚÍÂ Ê˘ÛÈÔÏÔÁÈ΋. T· ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· ‰ÂÓ ‹Ù·Ó ÂȉÈο Î·È Ô ¤ÏÂÁ¯Ô˜ ÔÏÔÎÏËÚÒıËΠÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Ó¢ÚÔÂÎÊ˘ÏÈÛÙÈÎÔ‡ ÓÔÛ‹Ì·ÙÔ˜. Afi ÙÔÓ ÂÚ·ÈÙ¤Úˆ ¤ÏÂÁ¯Ô: ‚˘ıfi˜ Ê˘ÛÈÔÏÔÁÈÎfi˜, Ï˘ÛÔÛˆÌȷο ¤Ó˙˘Ì· Ê˘ÛÈÔÏÔÁÈο, ÏÈ·Ú¿ Ôͤ· Ì·ÎÚ¿˜ ·Ï‡ÛÔ˘ Î·È Ê˘Ù·ÓÈÎfi Ô͇ Ê˘ÛÈÔÏÔÁÈο. E›Û˘, ÙÔ ·ÌÈÓfiÁÚ·ÌÌ· ·›Ì·ÙÔ˜ Î·È Ô‡ÚˆÓ Î·È Ù· ÔÚÁ·ÓÈο Ôͤ· Ô‡ÚˆÓ ‚Ú¤ıËÎ·Ó Ê˘ÛÈÔÏÔÁÈο. ™˘˙‹ÙËÛË H Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi Â›Ó·È Ë Û˘¯ÓfiÙÂÚË ·fi ÙȘ Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ. TfiÛÔ Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· fiÛÔ Î·È Ù· ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· ÔÈΛÏÏÔ˘Ó ·Ó·ÏfiÁˆ˜ ÙÔ˘ ‚·ıÌÔ‡ Î·È ÙÔ˘ ¯ÚfiÓÔ˘ ÚÔÛ‚ÔÏ‹˜ ·fi ÙÔÓ Èfi. ŸÙ·Ó Ë Ïԛ̈ÍË Û˘Ì‚Â› ÛÙÔ ÚÒÙÔ ‹ ÛÙÔ ‰Â‡ÙÂÚÔ ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘ ÔÈ ‚Ï¿‚˜ ·fi ÙÔ KN™ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Â›Ó·È ÛÔ‚·Ú¤˜ Î·È ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÌÈÎÚÔÎÂÊ·Ï›·, ‰È·Ù·Ú·¯¤˜ ÌÂÙ·Ó¿ÛÙ¢Û˘ ÙˆÓ Ó¢ÚÒÓˆÓ (·Á˘Ú›·, ·¯˘Á˘Ú›·, ÔÏ˘ÌÈÎÚÔÁ˘Ú›·, ÂÙÂÚÔÙԛ˜), ÂÚÈÎÔÈÏȷΤ˜ ·ÔÙÈÙ·ÓÒÛÂȘ, ˘‰Ú·ÓÂ-
EÈÎfiÓ· 2. ™˘ÌÌÂÙÚÈΤ˜ ÂÛٛ˜ ·˘ÍË̤ÓÔ˘ Û‹Ì·ÙÔ˜ Ì ·Û·Ê‹ fiÚÈ· ÛÙËÓ ÂÓ Ùˆ ‚¿ıÂÈ Ï¢΋ Ô˘Û›· ÙˆÓ ‚ÚÂÁÌ·ÙÈÎÒÓ ÏÔ‚ÒÓ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ·Ú¿ Ù· ÈÓȷο Τڷٷ. ¶·ÚfiÌÔȘ ·ÏÏÔÈÒÛÂȘ ·ÂÈÎÔÓ›ÛıËÎ·Ó Î·È ÛÙËÓ ÂÓ Ùˆ ‚¿ıÂÈ Ô˘Û›· ÙˆÓ ÌÂوȷ›ˆÓ Î·È ÎÚÔÙ·ÊÈÎÒÓ ÏÔ‚ÒÓ ¿Ìʈ.
328
O. ¶··‰¿ÎË-¶··Ó‰Ú¤Ô˘ Î·È Û˘Ó.
ÁÎÂÊ·Ï›· ‹ ÔÚÂÁÎÂÊ·Ï›· Î·È Û·ÓÈfiÙÂÚ· ‰È¿Ù·ÛË ÙÔ˘ Ï·Á›Ô˘ ÎÔÈÏÈ·ÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ì ·ÚÔ˘Û›· ‰È·ÊÚ·ÁÌ·Ù›ˆÓ ÂÓÙfi˜ ·˘ÙÔ‡. E›Û˘, Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Û˘Ó˘¿Ú¯Ô˘Ó ·ÙÚÔÊ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, ˘ÔÏ·Û›· Ù˘ ·ÚÂÁÎÂÊ·Ï›‰Ô˜, ˘ÔÂÂÓ‰˘Ì·ÙÈΤ˜ ·ÛÂȘ ÙËÓ Ï¢΋ Ô˘Û›·, ΢ڛˆ˜ ·Ú¿ Ù· ÈÓȷο Τڷٷ, ‰È·Ù·Ú·¯¤˜ Ù˘ Ì˘ÂϛӈÛ˘, Ï¢ÎÔ̷ϷΛ· Î·È Î˘ÛÙÈ΋ ÂÁÎÂÊ·ÏÔ̷ϷΛ·. T· Â˘Ú‹Ì·Ù· ·˘Ù¿ ÂÎÙfi˜ ÙˆÓ ·ÔÙÈÙ·ÓÒÛÂˆÓ ·ÂÈÎÔÓ›˙ÔÓÙ·È Î˘Ú›ˆ˜ Ì ÙËÓ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·. H ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ·Ó·‰ÂÈÎÓ‡ÂÈ ÙȘ ·ÔÙÈÙ·ÓÒÛÂȘ, ·ÏÏ¿ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÈÎÚfiÙÂÚË Â˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ·fi ÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÛÙËÓ ·Ó¿‰ÂÈÍË ÙˆÓ ˘ÔÏÔ›ˆÓ ·ÏÏÔÈÒÛˆÓ. TÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÌÔÚ› ›Û˘ Ó· ·Ôηχ„ÂÈ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·, ·Ó Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ ¯·ÌËÏfiÙÂÚË Â˘·ÈÛıËÛ›· Î·È ÂȉÈÎfiÙËÙ· ·fi ÙË Ì·ÁÓËÙÈ΋ Î·È ÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·.(4,6) OÈ ·ÚÂÁ¯˘Ì·ÙÈΤ˜ ·ÔÙÈÙ·ÓÒÛÂȘ ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Â›Ó·È Â‡ÚËÌ· Ù˘ÈÎfi Ïԛ̈͢ ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi, ·ÏÏ¿ fi¯È ·ıÔÁÓˆÌÔÓÈÎfi. Œ¯Ô˘Ó ·Ó·ÊÂÚı› ÛÙÔ 40% ÂÚ›Ô˘ ÙˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ ·È‰ÈÒÓ Î·È ·Ó·‰ÂÈÎÓ‡ÔÓÙ·È ÛÙËÓ ·Ï‹ ·ÎÙÈÓÔÁÚ·Ê›· ÎÚ·Ó›Ô˘ Î·È ÛÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·. H ÂÁÁÂÓ‹˜ ·‰˘Ó·Ì›· Ù˘ Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ Ó· ·Ó·‰Â›ÍÂÈ ÙȘ ·ÔÙÈÙ·ÓÒÛÂȘ Â›Ó·È ÁÓˆÛÙ‹. OÈ ·ÔÙÈÙ·ÓÒÛÂȘ ¯·Ú·ÎÙËÚÈÛÙÈο ÂÓÙÔ›˙ÔÓÙ·È ÂÚÈÎÔÈÏȷο, ·ÏÏ¿ ÌÔÚ› ›Û˘ Ó· ˘¿Ú¯Ô˘Ó ÙfiÛÔ ÛÙÔÓ ÊÏÔÈfi Î·È ÛÙËÓ ˘ÔÊÏÔÈÒ‰Ë ÌÔ›Ú· Ù˘ Ï¢΋˜ Ô˘Û›·˜ fiÛÔ Î·È ÛÙ· ‚·ÛÈο Á¿ÁÁÏÈ·. OÈ ·Ú·ÎÔÈÏȷΤ˜ ·ÛÙÂȘ ÔÊ›ÏÔÓÙ·È Û ӤÎÚˆÛË, ÁÏÔ›ˆÛË ÙÔ˘ ·ÚÂÁ¯‡Ì·ÙÔ˜ Î·È ·ÂÈÎÔÓ›˙ÔÓÙ·È Â˘¯ÂÚ¤ÛÙÂÚ· Ì ÙËÓ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·.(4) ™ÙËÓ ·ÛıÂÓ‹ Ì·˜ ·Ú·ÙËÚ‹ıËÎ·Ó ‰È·Ù·Ú·¯¤˜ Ù˘ Ì˘ÂϛӈÛ˘, Ô˘ ·ÂÈÎÔÓ›ÛıËÎ·Ó ÛÙËÓ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ˆ˜ ÂÛٛ˜ ·ıÔÏÔÁÈÎÔ‡ Û‹Ì·ÙÔ˜ ÛÙËÓ Ï¢΋ Ô˘Û›·, ÂÓÒ Ë ·ÂÈÎfiÓÈÛË ÙÔ˘ ÊÏÔÈÔ‡ ˘‹ÚÍÂ Ê˘ÛÈÔÏÔÁÈ΋. ™˘ÓÂÒ˜, ÙÔ ·ıÔÏÔÁÈÎfi ·›ÙÈÔ Ú¤ÂÈ Ó· ¤‰Ú·Û ÌÂÙ¿ ÙËÓ 26Ë-28Ë Â‚‰ÔÌ¿‰· ·ËÛ˘ ‰ËÏ·‰‹ ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ‰È·‰Èηۛ·˜ ÌÂÙ·Ó¿ÛÙ¢Û˘ ÙˆÓ Ó¢ÚÒÓˆÓ. H ÌÈÎÚ‹ ·ÛıÂÓ‹˜ Ì·˜ ÚÔÛ‹Ïı ·ÚÈ· Ì Ó¢ÚÔ·ÈÛıËÙ‹ÚÈ· ‚·ÚËÎÔ˝· Î·È ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·, ÂÓÒ Ë ÂÚ›ÌÂÙÚÔ˜ ÎÂÊ·Ï‹˜ Ù˘ ÚÔÛ‰ÈÔÚ›˙ÂÙ·È ÛÙ· ηÙÒÙÂÚ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ·. ÕÏÏ· ÚÔ‚Ï‹Ì·Ù· ÏËÓ Ù˘ ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·˜ fiˆ˜ ÌÂȈ̤ÓË ·›ÛıËÛË ÛÙÔÓ fiÓÔ, ·Ù·Í›·, ˘ÔÙÔÓ›· ‹ ·‰ÂÍÈfiÙËÙ·, Ô˘ ÂÚÈÁÚ¿ÊÔÓÙ·È ÛÙËÓ ‚È‚ÏÈÔÁÚ·Ê›· Û ·È‰È¿ Ì fi„ÈÌË Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi(6) ‰ÂÓ ·Ú·ÙËÚ‹ıËÎ·Ó ÛÙËÓ ·ÛıÂÓ‹ Ì·˜. T· ÎÏÈÓÈο Â˘Ú‹Ì·Ù· Ù˘ Ó¢ÚÔ·ÈÛıËÙ‹ÚÈ·˜ ‚·ÚËÎÔ˝·˜, ÌÈÎÚÔÎÂÊ·Ï›·˜ Î·È ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·˜ ıˆÚÔ‡ÓÙ·È ÂÓ‰ÂÈÎÙÈο fi„ÈÌ˘ Ïԛ̈͢ ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi ηٿ ÙÔ ÙÂÏÂ˘Ù·›Ô ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘(6).
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·329
¶∞π¢π∞∆ƒπ∫∏ 2000;63:326-329
K·Ù¿ ÙfiÔ˘˜ ÔÈ Û˘ÚÚ¤Ô˘Û˜ ·ÔÌ˘ÂÏÈÓˆÙÈΤ˜, ÌË ÂÍÂÏÈÛÛfiÌÂÓ˜ ÂÛٛ˜ ÛÙË Ï¢΋ Ô˘Û›·, Ô˘ ·Ô‰›‰ÔÓÙ·È ÛÂ Ô˘Ï¤˜ ÁÏÔ›ˆÛ˘, fiˆ˜ ·Ó·‰ÂÈÎÓ‡ÔÓÙ·È Ì ÙË Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›·, ηıÒ˜ Î·È ¿ÏÏ· ¿Ù˘· ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Û ÂÚÈÙÒÛÂȘ Ïԛ̈͢ Ì ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi, ·fi ÙÔ˘˜ Sugita et al(9) Î·È Alonso et al(10) ·ÓÙ›ÛÙÔȯ·. OÈ Steinlin et al (6) ÂÚȤÁÚ·Ê·Ó ÙÔ 1966 ÂÙ¿ ·È‰È¿ Ì ÎÏÈÓÈο Î·È ·ÂÈÎÔÓÈÛÙÈο Â˘Ú‹Ì·Ù· ·Ó¿ÏÔÁ· Ì ·˘Ù¿ Ù˘ ÌÈÎÚ‹˜ ·ÛıÂÓÔ‡˜ Ì·˜, Èı·ÓÔÏÔÁÒÓÙ·˜ fi„ÈÌË Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi. M·ÎÚÔ¯ÚfiÓÈÔÈ Â·Ó¤ÏÂÁ¯ÔÈ ¯ÚÂÈ¿˙ÔÓÙ·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ·ÔÎÏÂÈÛı› Ù˘¯fiÓ ÂÍÂÏÈÎÙÈÎfiÙËÙ· ÙˆÓ ÎÏÈÓÈÎÒÓ Î·È ÂÂÈÎÔÓÈÛÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ. Œ¯ÂÈ ¿ÓÙˆ˜ ·Ó·ÊÂÚı› ÚÔԉ¢ÙÈ΋ ‚·ÚËÎÔ˝· Û ·È‰È¿ Ì ·Û˘Ìو̷ÙÈ΋ Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi(11), ÚÔԉ¢ÙÈ΋ ˘ÔÂÂÓ‰˘Ì·ÙÈ΋ Ó¤ÎÚˆÛË ÌÂÙ¿ ÙË Á¤ÓÓËÛË(12) ÛÂ Û˘ÁÁÂÓ‹ Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi Î·È Ù¤ÏÔ˜ ¤¯ÂÈ ÂÚÈÁÚ·Ê› ‚·ÚÂÈ¿ ÂÍÂÏÈÎÙÈ΋ ÂÁÎÂÊ·ÏÈ΋ ·ÙÚÔÊ›· Û ·È‰› Ì ÂÚÈÁÂÓÓËÙÈ΋ Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi(13). ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜ Ë ·ıÔÏÔÁÈ΋ ·ÂÈÎfiÓÈÛË Ù˘ Ï¢΋˜ Ô˘Û›·˜, Ô˘ Â›Ó·È Â‡ÚËÌ· ÌË ÂȉÈÎfi, Î·È Ë ·Ô˘Û›· ¿ÏÏˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ·ÂÈÎÔÓÈÛÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ, Û˘Ì‚·ÙÒÓ Ì ÚÒÈÌË Ïԛ̈ÍË ·fi ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi fiˆ˜ ÚԷӷʤÚıËÎ·Ó ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ‹È·, ·ÏÏ¿ ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÎÏÈÓÈ΋ ÂÈÎfiÓ· Ù˘ Ó¢ÚÔ·ÈÛıËÙ‹ÚÈ·˜ ‚·ÚËÎÔ˝·˜, Ù˘ ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·˜ Î·È Ù˘ ÌÈÎÚ‹˜ ÂÚÈ̤ÙÚÔ˘ Ù˘ ÎÂÊ·Ï‹˜ Ô˘ Ô‰ËÁÔ‡Ó ÛÙÔ Û˘Ì¤Ú·ÛÌ· fiÙÈ Ë ÚÔÛ‚ÔÏ‹ ·fi ÙÔ Î˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi Û˘Ó¤‚Ë fi„ÈÌ· Î·È Ì¿ÏÈÛÙ· ηٿ ÙÔ ÙÂÏÂ˘Ù·›Ô ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘ Î·È Ë ÂÈÙ˘¯‹˜ ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‚·ÚËÎÔ˝·˜ Ì ÎÔ¯ÏÈ·Îfi ÂÌʇÙÂ˘Ì· ÛÙÔ ·ÎÔÔÏÔÁÈÎfi ÙÌ‹Ì· ÙÔ˘ NÔÛÔÎÔÌ›Ԣ Ì·˜ ·ÔÙÂÏÔ‡Ó ÙÔ˘˜ ÏfiÁÔ˘˜ ·ÚÔ˘Û›·Û˘ Ù˘ ÂÚÁ·Û›·˜ Ì·˜.
BÈ‚ÏÈÔÁÚ·Ê›· 1. Dobbins JG, Stewart JA, Demmler GJ. Surveillance of congenital cytomegalovirus disease, 1990-1991. Collaborating Registry Group MMWR CDC Surveill Summ 1992;41:35-39. 2. Alford CA, Stagnos S. Pass RF, Britt WJ. Congenital and perinatal cytomegalovirus infection. Res Intet Dis 1990;12: 5745-5753. 3. Yair D, Gull I, Peyser MR, Lessing JB. Congenital cytomegalovirus infection. Eur J Obstet Gynecol Reprod Biol 1995;63:7-16. 4. Barkovich AJ, Lindau CE. Congenital cytomegalovirus infection of the brain: Imaging analysis and embryological considerations. AJNR 1994;15:703-704. 5. Boech C, Issakainen J, Kewitz G, Kikinis R, Martin E, Boltshause E. Magnetic resonance imaging of the brain in congenital cytomegalocirus infection. Pediatr Radiol 1989;19:91-93. 6. Steinlin MI, Nadal D, Eich GF, Martin E, Boltshauser EJ. Late intrauterine cytomegalovirus infection: clinical and neuroimaging findings. Pediatr Neurol 1996;15:249-253. 7. Barnes PD, Poussaint TY, Burrows PE. Imaging of pediatric central nervous system infections. Pediatric Neuroradiology 1994;4:367-391. 8. Hayward JC, Titelbaum DS, Clancy RR, Zimmerman RA. Lissesncephaly-pachygyria associeted with congenital cytomegalovirus infection. J Child Neurol 1991;6:109-114. 9. Sugita K, Ando M, Makino M, Takanashi J, Fujimoto N, Miimi H. Magnetic resonance imaging of the brain in congenital rubella virus and cytomegalovirus infection. ¡euroradiology 1996;3:315-319. 10. Alonso A, Alvarez A, Seara MJ, Lipares M, Villalon J. Unusual manifestations of postnatally acquired cytomegalovirus infection: findings on CT and MR. Pediatr Radiol 1997;2:217-221. 11. Williamson WD, Demmler GJ, Percy AK, Catlin FI. Progressice hearing loss in infants with asymptomatic congenital cytomegalovirus infection. Pediatrics 1992;90:862-866. 12. Bale JF, Sato Y, Eisert D. Progressive postnatal subependymal necrosis in an infant with congenital cytomegalovirus infection. Pediatr Neurol 1986;2:367. 13. Nabetani M, Tsuneishi S, Kugo M, Konishi H, Yamazaki T. A case of perinatal cytomegalovirus infection with severe progressive brain atrophy. No To Hattatsu 1993;25:76-80.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 19-04-1999 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-06-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: O. ¶··‰¿ÎË-¶··Ó‰Ú¤Ô˘ ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·Ó/Ì›Ô˘ ∞ıËÓÒÓ, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, °Ô˘‰› 115 27
329
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·330
¶∞π¢π∞∆ƒπ∫∏ 2000;63:330-336
™À¡∂Ãπ∑Oª∂¡∏ ∂∫¶∞π¢∂À™∏
AÎÙÈÓÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ·ÏÈÓ‰ÚfiÌËÛ˘ ÛÙ· ·È‰È¿ M·Ú›Ó· °. ¶··‰¿ÎË1, Iˆ¿ÓÓ˘ ™. K·ÛηڤÏ˘2
● ¶ÂÚ›ÏË„Ë: O fiÚÔ˜ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶) Â›Ó·È ÂÚÈÁÚ·ÊÈÎfi˜ Î·È ·Ó·Ê¤ÚÂÙ·È Û οı "¯ˆÚ›˜ ÚÔÛ¿ıÂÈ·" ·Ï›Ó‰ÚÔÌË Î›ÓËÛË ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ ÂÓÙfi˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘. H ÂÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË Ù˘ °O¶ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ‰ÔÎÈÌ·Û›· Bernstein, ÙËÓ ‰ÔÎÈÌ·Û›· Tuttle, ÙËÓ pH/ÌÂÙÚ›·, ÙÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ·, ÙËÓ Ì·ÓÔÌÂÙÚ›·, ÙËÓ ÂÓ‰ÔÛÎfiËÛË, ÙÔ ‚·ÚÈÔ‡¯Ô Á‡̷ (B°) Î·È ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· (U/S). H ·ÚÔ‡Û· ÌÂϤÙË Â›Ó·È ÂÎÙÂÓ‹˜ ·Ó·ÛÎfiËÛË Ù˘ ‚È‚ÏÈÔÁÚ·Ê›·˜ ÛÙÔ ı¤Ì· Ù˘ °O¶ ÛÙ· ·È‰È¿, Û¯ÂÙÈο Ì ÙÔ˘˜ ÙÚfiÔ˘˜ ·ÂÈÎÔÓÈÛÙÈ΋˜ ‰ÈÂÚ‡ÓËÛ‹˜ Ù˘. K‡ÚÈÔ˜ ÛÎÔfi˜ Ù˘ ÌÂϤÙ˘ Ì B° Â›Ó·È Ë ‰È·›ÛÙˆÛË ‹ Ô ·ÔÎÏÂÈÛÌfi˜ ·Ó¿ÚÎÂÈ·˜ ÙÔ˘ ·ÓÙÈ·Ó·ÁˆÁÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ Î·È ÙˆÓ ·‰ÚÒÓ ÌÔÚÊÒÓ ÔÈÛÔÊ·Á›Ùȉ·˜, ÂÓÒ Û˘Ó‹ıˆ˜ ÌÂÏÂÙ¿Ù·È ÙÔ Û‡ÓÔÏÔ ÙÔ˘ ·ÓÒÙÂÚÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜. H ¢·ÈÛıËÛ›· Î˘Ì·›ÓÂÙ·È ·fi 20-73% (Ì.Ô. 35%) Î·È Ë ÂȉÈÎfiÙËÙ· ÂÚ› ÙÔ 30% ÙˆÓ Û˘Ìو̷ÙÈÎÒÓ ·ÛıÂÓÒÓ. TÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì Tc99m ıˆÚÂ›Ù·È Ì¤ıÔ‰Ô˜ ÏÈÁfiÙÂÚÔ Â˘·›ÛıËÙË ÙÔ˘ B°, ¯Ú‹ÛÈÌË fï˜ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ·˘ÙÔηı¿ÚÛˆ˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘. TÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· ¤¯ÂÈ Î·ÙÂÍÔ¯‹Ó ¤Ó‰ÂÈÍË fiÔ˘ Ë °O¶ ÂΉËÏÒÓÂÙ·È ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi ÁÈ· ÙÔÓ ÂÓÙÔÈÛÌfi Èı·Ó‹˜ ÂÈÛÚÔÊ‹Ûˆ˜ ÛÙÔ˘˜ Ó‡ÌÔÓ˜, Û ÂÚÈÙÒÛÂȘ ηı˘ÛÙÂÚË̤Ó˘ Á·ÛÙÚÈ΋˜ ΤӈÛ˘ Î·È ·Ó·ÁˆÁ‹˜ ÌË ÔÍ›ÓÔ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘. TÔ U/S ‰ÂÓ ÂÈÙÚ¤ÂÈ ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ °O¶ Î·È Ù˘ ÔÈÛÔÊ·Á›Ùȉ·˜ ˆÛÙfiÛÔ, ÌÔÚ› Ó· ÌÂÏÂÙËıÔ‡Ó ÏÂÙÔÌÂÚÒ˜ Ë ·Ó·ÙÔÌ›· Î·È ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ Û˘Ì‚ÔÏ‹˜. £· ÌÔÚÔ‡Û ӷ Û˘ÛÙËı› ˆ˜ screening test Û ÎÏÈÓÈο ˘fiÙÔ˘˜ ÁÈ· °O¶ ·ÛıÂÓ›˜ Î·È Ì¿ÏÈÛÙ· ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ, Ì ‹ ¯ˆÚ›˜ Ù·˘Ùfi¯ÚÔÓË ÂÊ·ÚÌÔÁ‹ pH/ÌÂÙÚ›·˜. TÔ U/S ˆ˜ ÌfiÓË Ì¤ıÔ‰Ô˜ ˘ÔÏ›ÂÙ·È Û ·ÎÚ›‚ÂÈ· Ù˘ pH/ÌÂÙÚ›·˜ Î·È ¤¯ÂÈ ÙËÓ ›‰È· Ì ÙÔ B° ÂȉÈÎfiÙËÙ· (30%). ¶·È‰È·ÙÚÈ΋ 2000;63:330-336. §¤ÍÂȘ ÎÏÂȉȿ: Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, ·È‰È΋ ËÏÈΛ·, ·ÎÙÈÓÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË. M. Papadaki, I. Kaskarelis. GastroÔesophageal reflux in children: methods of radiological evaluation. Paediatriki 2000;63:330-336. ● Abstract: GastroÔesophageal reflux (GER) is the passage of gastric contents into the lower oesophagus and the term usually refers to symptomatic GER with or without histological oesophageal abnormalities. Various diagnostic tests are available for the assessment of the patient with suspected GER; the Bernstein test, the Tuttle test, intraoesophageal pH monitoring, gastric scintigraphy, oesophageal manometry, endoscopy, upper gastrointestinal (GI) barium studies and ultrasonography. The main aims of upper GI barium studies in examining children with suspected GER are to assess the adequacy of the antireflux mechanism and to detect gross morphological changes of reflux oesophagitis and possible upper gastrointestinal tract anatomical abnormalities. The sensitivity of barium studies varies between 20% and 73% and the specificity is estimated at 30% of symptomatic patients. Gastric scintigraphy is probably less sensitive than upper GI barium studies, although it is useful for evaluating oesophageal function and clearance. and is indicated primarily for evaluating infants with suspected aspiration, delayed gastric emptying and nonacid reflux. Ultrasonography (US) permits only poor assessment of the severity of GER and oesophagitis but it provides unique morphological information about the gastrooesophageal junction. US evaluation is almost as specific as upper GI barium studies for demonstrating GER in children but less accurate than oesophageal pH monitoring. It could be used as a screening test, coupled or not to pH analysis, in patients at risk, especially those under the age of 5 years. Key words: gastroÔesophageal reflux, childhood, radiological evaluation.
1 2
AÎÙÈÓԉȷÁÓˆÛÙÈÎfi TÌ‹Ì· °.¶.N. ¶·›‰ˆÓ AıËÓÒÓ "AÁ›· ™ÔÊ›·" AÎÙÈÓԉȷÁÓˆÛÙÈÎfi TÌ‹Ì· ¶.°.N.A. "O E˘·ÁÁÂÏÈÛÌfi˜”
330
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·331
¶∞π¢π∞∆ƒπ∫∏ 2000;63:330-336
EÈÛ·ÁˆÁ‹ O fiÚÔ˜ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË (°O¶) Â›Ó·È ÂÚÈÁÚ·ÊÈÎfi˜ Î·È ·Ó·Ê¤ÚÂÙ·È Û οı "¯ˆÚ›˜ ÚÔÛ¿ıÂÈ·" ·Ï›Ó‰ÚÔÌË Î›ÓËÛË ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ ÂÓÙfi˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘.(1) O ÂÈÔÏ·ÛÌfi˜ (fï˜ ÛÙËÓ ·ıÔÏÔÁ›· ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ·Ó¤Ú¯ÂÙ·È ÛÙÔ 75% Ì prevalence) Ù˘ °O¶ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi ÂÎÙÈÌ¿Ù·È ÛÙÔ 2-5% (2), Ë Û˘Ì‚ÔÏ‹ Ù˘ Û˘¯Ó¤˜, ·Ù˘¯Ò˜, ηٷ¯Ú‹ÛÂȘ Î·È ÛÙË ‰È¿ÁÓˆÛË Î·È ÛÙË ıÂڷ›· Ù˘. AÓ Î·È Ë ·ÓÙ›ÏË„Ë ÁÈ· ÙË °O¶ ¿Ú¯ÈÛ ӷ ·Ó·Ù‡ÛÛÂÙ·È ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1930, Û˘¯ÓfiÙÂÚË ·Ó·ÊÔÚ¿ Û ·˘Ù‹Ó ·Ú·ÙËÚÂ›Ù·È ÌfiÓÔ Î·Ù¿ Ù· ÙÂÏÂ˘Ù·›· 15-20 ¯ÚfiÓÈ·(3). A˘Ùfi, ÚÔÊ·ÓÒ˜, Û¯ÂÙ›˙ÂÙ·È Î·È Ì ÙȘ Û‡Á¯ÚÔÓ˜ ηÏÏ›ÙÂÚ˜ ‰È·ÁÓˆÛÙÈΤ˜ Ù¯ÓÈΤ˜ ·ÏÏ¿ Î·È Ì ÙËÓ ·˘ÍË̤ÓË ÂÓË̤ڈÛË - ÂÙÔÈÌfiÙËÙ· ÙˆÓ ÎÏÈÓÈÎÒÓ ÁÈ·ÙÚÒÓ. ¶·ıÔÊ˘ÛÈÔÏÔÁ›· ◊‰Ë ·fi ÙË ‰ÂηÂÙ›· ÙÔ˘ 1950 Ë ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ °O¶ ›¯Â Û˘Û¯ÂÙÈÛı› Ì ÙÔ ÌÂȈ̤ÓÔ ÙfiÓÔ (¯·Ï·ÚfiÙËÙ·) ÙÔ˘ ηÙÒÙÂÚÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ ÛÊÈÁÎÙ‹Ú· (KO™) Ô ÔÔ›Ô˜ ıˆÚÂ›Ù·È ˆ˜ Ô Î˘ÚÈfiÙÂÚÔ˜ ÊÚ·ÁÌfi˜ ÚÔÛÙ·Û›·˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ·fi ÙÔ fiÍÈÓÔ ÂÚȯfiÌÂÓÔ ÙÔ˘ ÛÙÔÌ¿¯Ô˘.(3,4) ™ÙÔ ÚÔÙÂÈÓfiÌÂÓÔ ÌÔÓÙ¤ÏÔ Ô ÔÈÛÔÊ¿ÁÔ˜ ÛÙÔ Û‡ÓÔÏfi ÙÔ˘ ÏÂÈÙÔ˘ÚÁ› ˆ˜ ÚÔˆıËÙÈ΋ ·ÓÙÏ›·, Ô ÛÙfiÌ·¯Ô˜ ˆ˜ ·Ôı‹ÎË ÂÓÒ Ô KO™ ˆ˜ ‚·Ï‚›‰· ÌÔÓ‹˜ ηÙ¢ı‡ÓÛˆ˜. ¶ÏËÌÌÂÏ‹˜ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ KO™, Û˘ÓÂÈÎÔ˘ÚÔ‡ÌÂÓË ÂӉ¯Ô̤ӈ˜ ·fi ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ (·ÚÔ˘Û›· ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘, ·˘ÍË̤ÓË ÔÛfiÙËÙ· Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘, ·˘ÍË̤ÓË ÂÓ‰ÔÎÔÈÏȷ΋ ›ÂÛË, ηı˘ÛÙÂÚË̤ÓË Î¤ÓˆÛË ÛÙÔÌ¿¯Ô˘, ÌÂȈ̤ÓË ·ÓÙÔ¯‹ ÔÈÛÔÊ·ÁÈÎÔ‡ ÂÈıËÏ›Ô˘, ÌË Ê˘ÛÈÔÏÔÁÈ΋ ÎÈÓËÙÈÎfiÙËÙ· - ·˘ÙÔοı·ÚÛË ÔÈÛÔÊ¿ÁÔ˘ Î.¿.) Ô‰ËÁ› ÛÙËÓ ·Ó·ÁˆÁ‹ Î·È Ù· ·ÎfiÏÔ˘ı¿ Ù˘ (3-5). O KO™ ‰È·ÙËÚÂ›Ù·È Û ÙÔÓÈ΋ Û‡Û·ÛË Û ÂÚ›Ô‰Ô ËÚÂÌ›·˜ Î·È ¯·Ï·ÚÔ‡Ù·È ÚÔ˜ ÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ ÂÚÈÛÙ·ÏÙÈÎÔ‡ ·̷ÙÔ˜ ÒÛÙ ӷ ÂÈÙÚ¤ÂÈ ÙË ‰›Ô‰Ô ÙÔ˘ ‚ψÌÔ‡(6). O Û˘ÓÙÔÓÈÛÌfi˜ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÙËÓ Î·Ù¿ÏÏËÏË Ó‡ڈÛË Ù˘ ÂÚÈÔ¯‹˜ ÂÎ ÙˆÓ ˆÓ ԢΠ¿Ó¢ ÁÈ· ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Û˘ÛÙ‹Ì·ÙÔ˜. TÔ ÁÂÁÔÓfi˜ fiÙÈ Ë °O¶ Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙÔ˘˜ 2 ÚÒÙÔ˘˜ Ì‹Ó˜ ˙ˆ‹˜ (1:300 ¤ˆ˜ 1:1000)(4) ηıÒ˜ Î·È ÛÙÔ 10% ÂÚ›Ô˘ ÙˆÓ ·È‰ÈÒÓ Ì Ó¢ÚÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· (ÓÔËÙÈ΋ ˘ÛÙ¤ÚËÛË, Ù¤ÙÚ·- ‹ ËÌÈ·ÚÂÙÈ΋ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË ÎÏ)(5,7) ·Ô‰›‰ÂÙ·È Û ·Ó·ÙÔÌÈ΋ Î·È ÏÂÈÙÔ˘ÚÁÈ΋ ·ÓˆÚÈÌfiÙËÙ· ÙÔ˘ Ó¢ÚÔÌ˯·ÓÈÛÌÔ‡ ÚÔÛÙ·Û›·˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘. (1) EÈϤÔÓ, Ë ÔÛfiÙËÙ· ÔÍ›ÓÔ˘ ÂÎÎÚ›Ûˆ˜ › ÎÂÓÔ‡ ÛÙÔÌ¿¯Ô˘ Â›Ó·È Ë ›‰È· Ì ÙÔ˘ ÂÓËÏ›ÎÔ˘ (30Mmol/Kgr/ÒÚ·), Ë ¯ˆÚËÙÈÎfiÙËÙ· ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ÌÈÎÚfiÙÂÚË(4) ÂÓÒ Î·È ÙÔ ÂÓ‰ÔÎÔÈÏÈ·Îfi ÙÌ‹Ì· (ÌÂÁ¿Ï˘ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ·ÚÂ-
∞ÎÙÈÓÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË
Ìfi‰ÈÛË ·ÏÈÓ‰ÚÔÌ‹Ûˆ˜) Â›Ó·È Û˘ÁÎÚÈÙÈο ‚Ú·¯‡ÙÂÚÔ ·fi ·˘Ùfi ÙÔ˘ ÂÓËÏ›ÎÔ˘.(1) TÔ Ì‹ÎÔ˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ·˘Í¿ÓÂÈ Ì ÙËÓ ·‡ÍËÛË Î·È ‰È¿Ï·ÛË ÙÔ˘ ·È‰ÈÔ‡ Î·È ·˘Ùfi Èı·ÓÒ˜ ÂÍËÁ› ÙËÓ ·˘ÙfiÌ·ÙË ‡ÊÂÛË ÙˆÓ ·Ó·ÁˆÁÒÓ ÌÂÙ¿ ÙÔ 18Ô Ì‹Ó·.(8) T¤ÏÔ˜, ¤¯ÂÈ ÂÚÈÁÚ·Ê› °O¶ Ì ·˘ÍË̤ÓÔ ÙfiÓÔ KO™ ËÈfiÙÂÚ˘ ¿ÓÙˆ˜ ‰È·‰ÚÔÌ‹˜(9) ÂÓÒ ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ Û˘Ó‰˘¿˙Ô˘Ó ·ÈÙÈÔÏÔÁÈο ÙË °O¶ Ì ·ÏÏÂÚÁ›· ÛÙÔ Á¿Ï· ·ÁÂÏ¿‰·˜.(10) KÏÈÓÈ΋ ÂÈÎfiÓ· T· ΢ÚÈfiÙÂÚ· Û˘ÌÙÒÌ·Ù· Ù˘ °O¶ Û˘ÓÔ„›˙ÔÓÙ·È ÛÙÔÓ ›Ó·Î· 1. H °O¶ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó¿Ù˘Í˘, ÂÈÏÔΤ˜ ·fi ÙÔ ÂÙÈÎfi Û‡ÛÙËÌ· (ÙÂÚˉfiÓ·, ÔÈÛÔÊ·Á›Ùȉ·, Ô˘ÏÒ‰Ë ÛÙ¤ÓˆÛË ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘, ÔÈÛÔÊ¿ÁÔ Barrett, ÂÓ‰ÔÔÈÛÔÊ·ÁÈÎÔ‡˜ Ôχԉ˜), ·fi ÙÔ Î·Ú‰ÈÔ·Ó·Ó¢ÛÙÈÎfi Û‡ÛÙËÌ· (˘ÔÙÚÔÈ¿˙Ô˘Û˜ ÏÔÈÌÒÍÂȘ, ·ÓÙȉڷÛÙÈ΋ ÓfiÛÔ ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ, ·ÛıÌ·ÙÈ΋ ‚ÚÔÁ¯›Ùȉ·, ¿ÓÔÈ·, ‚Ú·‰˘Î·Ú‰›·, ÛÈÁÌfi, Ï·Ú˘ÁÁÈÎfi ÎÔÎΛˆÌ· Î.¿.) ÂÓÒ Ë Û¯¤ÛË Ù˘ Ì ÙÔ Û‡Ó‰ÚÔÌÔ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ ÙˆÓ ‚ÚÂÊÒÓ (SIDS) ·Ú·Ì¤ÓÂÈ ·ÌÊÈÏÂÁfiÌÂÓË(4,7). ¶›Ó·Î·˜ 1. T· ΢ÚÈfiÙÂÚ· Û˘ÌÙÒÌ·Ù· Ù˘ °O¶. 1. ŒÌÂÙÔÈ - ·Ó·ÁˆÁ¤˜ 2. ¢˘ÛÊ·Á›· 3. EÈÁ¿ÛÙÚÈÔ ‹ ÔÈÛıÔÛÙÂÚÓÈÎfi ¿ÏÁÔ˜ Ù‡Ô˘ ÛÙËı¿Á¯Ë˜ 4. OÈÛıÔÛÙÂÚÓÈÎfi˜ η‡ÛÔ˜ 5. EÚ˘Á¤˜, ÌÂÙ·ÁÂ˘Ì·ÙÈÎfi ·›ÛıËÌ· ÏËÚÒÛˆ˜ 6. AÓÔÚÂÍ›· Èı·ÓÒ˜ ÏfiÁˆ ¿ÏÁÔ˘˜ ηٿ ÙËÓ Î·Ù¿ÔÛË (odynophagia) 7. MËڢηÛÌfi˜ 8. AÓ·ÈÌ›· ÛȉËÚÔÂÓÈ΋ 9. AÈÌ·Ù¤ÌÂÛË - ̤ϷÈÓ· 10. AÒÏÂÈ· ‚¿ÚÔ˘˜ - η΋ ıÚ¤„Ë 11. E˘ÂÚÂıÈÛÙfiÙËÙ· - ¿Ù˘ÔÈ ÎÔÏÈÎÔ› 12. ¢È·Ù·Ú·¯¤˜ ‡ÓÔ˘ 13. XÚfiÓÈ· ·Ó·Ó¢ÛÙÈο ÚÔ‚Ï‹Ì·Ù· 14. ™‡Ó‰ÚÔÌÔ Sandifer (ÔÈÛıfiÙÔÓÔ˜, ÌË Ê˘ÛÈÔÏÔÁÈ΋ ı¤ÛË ÎÂÊ·Ï‹˜)
¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË Ù˘ °O¶ H ÏÂÙÔÌÂÚ‹˜ Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ Î·È Ë ÚÔÛÂÎÙÈ΋ ÎÏÈÓÈ΋ ÂͤٷÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ ·ÔÙÂÏÔ‡Ó, ÛÙ· ¯¤ÚÈ· ÙÔ˘ ¤ÌÂÈÚÔ˘ ÁÈ·ÙÚÔ‡, ÙÔ ÚÒÙÔ Î·È Î·Ï‡ÙÂÚÔ ‰È·ÁÓˆÛÙÈÎfi ÂÚÁ·Ï›Ô. ∂ÓÙÔ‡ÙÔȘ, ÁÈ· ÙË ‰È¿ÁÓˆÛË, Â›Ó·È ··Ú·›ÙËÙË Ë ÂÚÁ·ÛÙËÚȷ΋ Û˘Ó‰ÚÔÌ‹ ÔÈ Î˘ÚÈfiÙÂÚÔÈ ÂÎÚfiÛˆÔÈ Ù˘ ÔÔ›·˜ ηٷÁÚ¿ÊÔÓÙ·È ÛÙÔÓ ›Ó·Î· 2.
331
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·332
¶∞π¢π∞∆ƒπ∫∏ 2000;63:330-336
¶›Ó·Î·˜ 2. EÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ÁÈ· ÙËÓ ‰È¿ÁÓˆÛË Ù˘ °O¶. EÚÁ·ÛÙËÚȷ΋ ‰ÈÂÚ‡ÓËÛË 1. 2. 3. 4. 5. 6. 7. 8.
¢ÔÎÈÌ·Û›· Bernstein ¢ÔÎÈÌ·Û›· Tuttle 24-ˆÚË ÂÓ‰ÔÔÈÛÔÊ·ÁÈ΋ PH/ÌÂÙÚ›· OÈÛÔÊ·ÁÔÁ·ÛÙÚÈÎfi ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì Ó¢ÌÔÓÈÎfi monitoring OÈÛÔÊ·ÁÔÁ·ÛÙÚÈ΋ Ì·ÓÔÌÂÙÚ›· EÓ‰ÔÛÎfiËÛË - ‚ÈÔ„›· ÔÈÛÔÊ¿ÁÔ˘ B·ÚÈÔ‡¯Ô ÔÈÛÔÊ·ÁÔÁÚ¿ÊËÌ· (‚·ÚÈÔ‡¯Ô Á‡̷ - B°) YÂÚ˯ÔÁÚ¿ÊËÌ· (UltraSound - U/S)
£· ·Ó·ÊÂÚıÔ‡ÌÂ Û˘ÓÔÙÈÎÒ˜, Û fiÛ˜ ·fi ÙȘ ·Ú·¿Óˆ ÌÂıfi‰Ô˘˜ ‰ÂÓ Â›Ó·È ·ÌÈÁÒ˜ ·ÎÙÈÓÔÏÔÁÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜, ÂÓÒ ¤ÌÊ·ÛË ı· ‰Ôı› ÛÙȘ ΢ڛˆ˜ ·ÎÙÈÓÔÏÔÁÈΤ˜ (‚·ÚÈÔ‡¯Ô Á‡̷ Î·È ˘ÂÚ˯ÔÁÚ¿ÊËÌ·) Î·È ÛÙË ÌÂٷ͇ ÙÔ˘˜ Û˘ÁÎÚÈÙÈ΋ ·ÍÈÔÏfiÁËÛË. H ‰ÔÎÈÌ·Û›· Bernstein ™˘Ó›ÛÙ·Ù·È Û ÙÔÔı¤ÙËÛË Î·ıÂÙ‹Ú· ̤¯ÚÈ ÙÔ˘ ̤ÛÔ˘ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ Î·È ÂÓ·ÏÏ·ÛÛfiÌÂÓ˜ ÂÁ¯‡ÛÂȘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ - ÔÍ›ÓÔ˘ ‰È·Ï‡Ì·ÙÔ˜ Ì ٷ˘Ùfi¯ÚÔÓË ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ Ë ‰Â ÂÌÂÈÚ›· ÛÙ· ·È‰È¿ Â›Ó·È Ìˉ·ÌÈÓ‹ (7). ™‹ÌÂÚ· ϤÔÓ Ë ‰ÔÎÈÌ·Û›· Bernstein ‰ÂÓ ¯ÚËÛÈÌÔÔÈ›ٷÈ. H ‰ÔÎÈÌ·Û›· Tuttle E›Ó·È Ë ÂÏÂÁ¯fiÌÂÓË, ÌÂÙ¿ ¯ÔÚ‹ÁËÛË ¯˘ÌÔ‡ Ì‹ÏÔ˘, pH/ÌÂÙÚ›· Ì ÌÂÁ·Ï‡ÙÂÚË ›Ûˆ˜ ¢·ÈÛıËÛ›· Î·È Ôχ ÌÈÎÚfiÙÂÚÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ˘ı‹Ûˆ˜ ·fi fiÙÈ Ë ‰ÔÎÈÌ·Û›· Berstein (7). T· ·ÔÙÂϤÛÌ·Ù· ·˘Ù‹˜ Ù˘ ‰ÔÎÈÌ·Û›·˜ Â›Ó·È Û˘¯Ó¿ ‰‡ÛÎÔÏÔ Ó· ÂÚÌËÓ¢ıÔ‡Ó Î·È ‰ÂÓ Â›Ó·È ·ÍÈfiÈÛÙ·. H pH/ÌÂÙÚ›· °ÂÓÈο ıˆÚÂ›Ù·È ˆ˜ Ë Î·Ï‡ÙÂÚË ÂÚÁ·ÛÙËÚȷ΋ ̤ıÔ‰Ô˜ ÚÔÛÂÁÁ›Ûˆ˜ Ù˘ °O¶ Î·È Ì¿ÏÈÛÙ· ÛȈËÏÒÓ ÌÔÚÊÒÓ Ù˘, ÂÊfiÛÔÓ ‰Â ÂÎÙÂÏÂ›Ù·È Lege artis, ÚÔÙ›ÓÂÙ·È ˆ˜ ·Ú¯ÈÎfi˜ ¤ÏÂÁ¯Ô˜ › ˘fiÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ.(1,3) ¶ÚÔÛ‰ÈÔÚ›˙ÂÈ ÙÔ ¯ÚfiÓÔ ÂÎı¤Ûˆ˜ ÙÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ ÛÙÔ fiÍÈÓÔ Á·ÛÙÚÈÎfi ÂÚȯfiÌÂÓÔ, Ë Â˘·ÈÛıËÛ›· Ù˘ ·˘Í¿ÓÂÈ Ì ÙÔ ¯ÚfiÓÔ ·Ú·ÎÔÏÔ˘ı‹Ûˆ˜ (monitoring) Â›Ó·È fï˜ ‰··ÓËÚ‹ Î·È fi¯È ‰È·ı¤ÛÈÌË Û fiÏ· Ù· ΤÓÙÚ·.(11) ™Ù· ‚Ú¤ÊË ıˆÚÂ›Ù·È ıÂÙÈ΋ ·Ó ÙÔ pH ÛÙÔÓ ÎÔÈÏÈ·Îfi ÔÈÛÔÊ¿ÁÔ Â›Ó·È Î¿Ùˆ ÙÔ˘ 4 ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 5% ÙÔ˘ ¯ÚfiÓÔ˘ ·Ú·ÎÔÏÔ˘ı‹Ûˆ˜ (Û˘Ó‹ıˆ˜ ¤Ó· 24/ˆÚÔ) (12). EÓÒ ‰ÂÓ ÚÔÛ‰ÈÔÚ›˙ÂÈ ÙÔÓ fiÁÎÔ ·Ó·ÁˆÁ‹˜, ÚÔÛ‰ÈÔÚ›˙ÂÈ fï˜ ÙË Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÂÈÛÔ‰›ˆÓ Î·È ÙÔ ¯ÚfiÓÔ ·ÔηٷÛÙ¿Ûˆ˜ ηÓÔÓÈÎÔ‡ pH ÛÙÔÓ ÔÈÛÔÊ¿ÁÔ. ™Ù· ÌÂÈÔÓÂÎÙ‹Ì·Ù· Ù˘ PH/ÌÂÙÚ›·˜ ηٷÁÚ¿-
332
M. ¶··‰¿ÎË, π. ™. ∫·ÛηڤÏ˘
ÊÂÙ·È Ë ·‰˘Ó·Ì›· Ù˘ Ó· Û˘ÏÏ¿‚ÂÈ ·Ó·ÁˆÁ¤˜ ÛÙË ÌÂÙ·ÁÂ˘Ì·ÙÈ΋ Ê¿ÛË ÏfiÁˆ ÂÍÔ˘‰ÂÙÂÚÒÛˆ˜ Ù˘ Á·ÛÙÚÈ΋˜ Ô͇ÙËÙ·˜ ·fi ÙËÓ ÙÚÔÊ‹ (6). ™‹ÌÂÚ· Â›Ó·È ‰˘Ó·ÙfiÓ Ë ÂͤٷÛË Ó· Á›ÓÂÈ Ì ÊÔÚËÙfi fiÚÁ·ÓÔ ·ÎfiÌË Î·È Û Â͈ÙÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜. TÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· TÔ ÛÈÓıËÚÔÁÚ¿ÊËÌ· Ì Tc99m ıˆÚÂ›Ù·È Ì¤ıÔ‰Ô˜ ÏÈÁfiÙÂÚÔ Â˘·›ÛıËÙË, ¯Ú‹ÛÈÌË fï˜ ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ·˘ÙÔηı¿ÚÛˆ˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ (13) ηıÒ˜ Î·È Û ÂÚÈÙÒÛÂȘ ·Ó·ÁˆÁ‹˜ ¯ÔÏ‹˜ ‹ ·¯ÏˆÚ˘‰Ú›·˜ fiÔ˘ Ë PH/ÌÂÙÚ›· ÌÔÚ› Ó· ‰ÒÛÂÈ „¢‰Ò˜ ·ÚÓËÙÈÎfi ·ÔÙ¤ÏÂÛÌ·.(12) EÈÙÚ¤ÂÈ Â›Û˘ ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ Ú˘ıÌÔ‡ Á·ÛÙÚÈ΋˜ ÎÂÓÒÛˆ˜, ÛËÌ·ÓÙÈ΋˜ ·Ú·Ì¤ÙÚÔ˘ ÛÙË ÌÂϤÙË Ù˘ °O¶, ÙÔÓ ÂÓÙÔÈÛÌfi Ó¢ÌÔÓÈÎÒÓ ÂÈÛÚÔÊ‹ÛˆÓ(6) ηÈ, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÔÈÛÔÊ·ÁÈ΋ Ì·ÓÔÌÂÙÚ›·, ÙËÓ ·Ó›¯Ó¢ÛË ÂÚÈÙÒÛÂˆÓ °O¶ Ì ‰È·Ù·Ú·¯‹ Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙÔ˘ ·ÓˆÙ¤ÚÔ˘ ÂÙÈÎÔ‡.(1) ø˜ ·Ú·Ù‹ÚËÛË fï˜, ÂÎÙ›ÓÂÙ·È Û ÂÚÈÔÚÈṲ̂ÓÔ ¯ÚfiÓÔ, ·Ó··Ú¿ÁÂÙ·È ‰‡ÛÎÔÏ·, ‰ÂÓ ÚÔÛ‰ÈÔÚ›˙ÂÈ Ì ·ÎÚ›‚ÂÈ· ÙËÓ ÔÛfiÙËÙ· ·Ó·ÁˆÁ‹˜ Î·È Î·ıfiÏÔ˘ ÙȘ Ù˘¯fiÓ ·Ó·ÙÔÌÈΤ˜ ·ÓˆÌ·Ï›Â˜.(6) E›Ó·È ̤ıÔ‰Ô˜ ¿ÓÂÙË ÁÈ· ÙÔÓ ¿ÚÚˆÛÙÔ Î·È ¯·ÌËÏ‹˜ ÂÈÎÈÓ‰˘ÓfiÙËÙ·˜ (¯·ÌËÏfiÙÂÚ˘ ·fi ÂΛӢ ÙÔ˘ B°)(6,14) Î·È ¤¯ÂÈ Î·ÙÂÍÔ¯‹Ó ¤Ó‰ÂÈÍË fiÔ˘ Ë °O¶ ÂΉËÏÒÓÂÙ·È ÌÂ Û˘ÌÙÒÌ·Ù· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi ÁÈ· ÙÔÓ ÂÓÙÔÈÛÌfi Èı·Ó‹˜ ÂÈÛÚÔÊ‹Ûˆ˜ ÛÙÔ˘˜ Ó‡ÌÔÓ˜. H ¢·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘ ÔÈΛÏÂÈ Â˘Ú¤ˆ˜ ·Ó¿ÌÂÛ· ÛÙȘ ‰È¿ÊÔÚ˜ ÌÂϤÙ˜ Î·È Î˘Ì·›ÓÂÙ·È ·fi 14-90% (Ì.Ô. 65%).(13) H Ì·ÓÔÌÂÙÚ›· H Ì·ÓÔÌÂÙÚ›· ·Ú¿ ÙÔ fiÙÈ ıˆڋıËΠ̤ıÔ‰Ô˜ "ÔÏÏ¿ ˘ÔÛ¯fiÌÂÓË" Ì ‰˘Ó·ÙfiÙËÙ˜ ηٷÁÚ·Ê‹˜ ÌÂÙ·‚ÔÏÒÓ ÛÙÔ ‚·ÛÈÎfi ÙfiÓÔ ÙÔ˘ KO™, ·Â‰Â›¯ıË ÙÂÏÈÎÒ˜ ÌÈÎÚ‹˜ ÎÏÈÓÈ΋˜ ÛËÌ·Û›·˜, Û˘Ó‰˘·˙fiÌÂÓË Û·ÓÈfiÙÂÚ· Ì ¿ÏϘ ‰ÔÎÈ̷ۛ˜ Î·È ·Ú·Ì¤ÓÔ˘Û·, ΢ڛˆ˜, ˆ˜ ÂÚÁ·ÏÂ›Ô ¤Ú¢ӷ˜.(6) H ÂÓ‰ÔÛÎfiËÛË H ÂÓ‰ÔÛÎfiËÛË, Ì ٷ˘Ùfi¯ÚÔÓË Î·Ù¿ ηÓfiÓ· ‚ÈÔ„›·,(15) ÏËÚÔÊÔÚ› ÁÈ· ÙËÓ ‡·ÚÍË ‹ fi¯È ÔÈÛÔÊ·Á›Ùȉ·˜ Î·È ÙË ÛÔ‚·ÚfiÙËÙ¿ Ù˘ ηıÒ˜ Î·È ÁÈ· ÙË ÁÚ·ÌÌ‹ ÌÂÙ·ÙÒÛˆ˜ ÙÔ˘ Ï·ÎÒ‰Ô˘˜ ÂÈıËÏ›Ô˘ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ÛÙÔ Î˘ÏÈÓ‰ÚÈÎfi ÙÔ˘ ÛÙÔÌ¿¯Ô˘ (ÔÈÛÔÊ¿ÁÔ˜ Barrett).(8) MÔÚ› Ó· Û˘Ì‚¿ÏÂÈ ÛÙË ‰È¿ÁÓˆÛË ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ Î·È ÁÂÓÈÎÒ˜ ıˆÚÂ›Ù·È ··Ú·›ÙËÙË Û ÛÔ‚·Ú¤˜, ÂÈÏÂÁ̤Ó˜ ÂÚÈÙÒÛÂȘ. H ÌÂϤÙË Ì ‚·ÚÈÔ‡¯Ô Á‡̷ H ÌÂϤÙË Ì ‚·ÚÈÔ‡¯Ô Á‡̷ (B°) ıˆÚÂ›Ù·È Ì¤ıÔ‰Ô˜ ·ÔÙÂÏÂÛÌ·ÙÈ΋, ÚÔÛÈÙ‹ Î·È ÊıËÓ‹. ™˘Ó‹ıˆ˜ ‰ÂÓ ÂÚÈÔÚ›˙ÂÙ·È ÛÙÔÓ ÔÈÛÔÊ¿ÁÔ ·ÏÏ¿ ·ÊÔÚ¿ ÙÔ Û‡ÓÔÏÔ ÙÔ˘ ·ÓˆÙ¤ÚÔ˘ Á·ÛÙÚÂÓÙÂÚÈÎÔ‡ (¤ˆ˜ ÙÔ Û‡Ó‰ÂÛÌÔ ÙÔ˘
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·333
¶∞π¢π∞∆ƒπ∫∏ 2000;63:330-336
Treitz ‹ ̤¯ÚÈ ÙÔÓ ÙÂÏÈÎfi ÂÈÏÂfi). EϤÁ¯ÂÙ·È ¤ÙÛÈ ÙÔ ÂӉ¯fiÌÂÓÔ ˘ÏˆÚÈ΋˜ ‹ 12/‰·ÎÙ˘ÏÈ΋˜ ÛÙÂÓÒÛˆ˜, Û˘ÁÁÂÓÒÓ 12/‰·ÎÙ˘ÏÈÎÒÓ Û˘ÌʇÛˆÓ, ‰È·ÊÚ·ÁÌ¿ÙˆÓ, ÌÂÌ‚Ú·ÓÒÓ, ‰˘ÛÎÈÓËÛÈÒÓ, malrotation, ÛÙÂÓÒÛˆ˜ ‹ ·ÙÚËÛ›·˜ ÂÓÙ¤ÚÔ˘ Î.¿.(6) ™Â ·ÛıÂÓ›˜ Ì ÎÏÈÓÈ΋ ˘Ô„›· °O¶ ·ÚÈÔ˜ ÛÎÔfi˜ Ê˘ÛÈο ·Ú·Ì¤ÓÂÈ Ë ‰È·›ÛÙˆÛË ‹ Ô ·ÔÎÏÂÈÛÌfi˜ ·Ó·ÚΛ·˜ ÙÔ˘ ·ÓÙÈ·Ó·ÁˆÁÈÎÔ‡ Ì˯·ÓÈÛÌÔ‡ (antireflux) Î·È ÙˆÓ ·‰ÚÒÓ ÌÔÚÊÒÓ ÔÈÛÔÊ·Á›Ùȉ·˜. ™ÙË ‰È¿ÁÓˆÛË ¿ÓÙˆ˜ Ù˘ ÔÈÛÔÊ·Á›Ùȉ·˜ Ë ÂÓ‰ÔÛÎfiËÛË ˘ÂÚ¤¯ÂÈ Ì ¢·ÈÛıËÛ›· ÂÚ›Ô˘ 70% ¤Ó·ÓÙÈ 35% ÙÔ˘ B°(1). K·Ù¿ ÙËÓ ÌÂϤÙË Ì ‚·ÚÈÔ‡¯Ô Á‡̷ ·Ú¤¯ÔÓÙ·È Â›Û˘ ÏËÚÔÊÔڛ˜ ˆ˜ ÚÔ˜ ÙËÓ ‡·ÚÍË ‹ fi¯È ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ (ÂÈÎfiÓ· 1), ÙÔ Ì¤ÁÂıÔ˜ ˘¿Ú¯Ô˘Û·˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘, ÙËÓ ‡·ÚÍË ÔÈÛÔÊ·ÁÈ΋˜ ÛÙÂÓÒÛˆ˜ (‚·ıÌfi˜-¤ÎÙ·ÛË), ‰È·Ù·Ú·¯ÒÓ Ù˘ ÎÈÓËÙÈÎfiÙËÙ·˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘, ηı˘ÛÙÂÚË̤Ó˘ Á·ÛÙÚÈ΋˜ ÎÂÓÒÛˆ˜ (antral dyskinesia) Î·È ÂÈÛÚÔÊ‹Ûˆ˜ ÛÙÔ ·Ó·Ó¢ÛÙÈÎfi. ¶Ú¤ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë Û˘Ì‚ÔÏ‹ ÙÔ˘ B° ÛÙËÓ ÂÎÙ›ÌËÛË Ù˘ Á·ÛÙÚÈ΋˜ ÎÂÓÒÛˆ˜ Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË Î·ıÒ˜ ÙÔ ‚¿ÚÈÔ Â›Ó·È Ô˘Û›· ·‰Ú·Ó‹˜ ηÈ, ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, ‰ÂÓ ÂÓÂÚÁÔÔÈ› ÙÔ˘˜ ‰ˆ‰Âη‰·ÎÙ˘ÏÈÎÔ‡˜ ˘Ô‰Ô¯Â›˜ Ô˘ ÙË Ú˘ıÌ›˙Ô˘Ó (8). Œ¯ÂÈ ÚÔÙ·ı› Ù·ÍÈÓfiÌËÛË ÛÙË ÌÂϤÙË Ù˘ °O¶ Ì B° ·Ó·ÏfiÁˆ˜ ÙÔ˘ ÂȤ‰Ô˘ ·Ó·ÁˆÁ‹˜, ·fi 1 (·Ó·ÁˆÁ‹ ÛÙÔ ÂÓ‰ÔÎÔÈÏÈ·Îfi ÙÌ‹Ì· ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘) ̤¯ÚÈ 5 (·Ó·ÁˆÁ‹ Ì ÂÈÛÚfiÊËÛË)(16), ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ fï˜ ÎÏÈÓÈÎÔ› ‰ÂÓ ıˆÚÔ‡Ó ·Ó·Áη›· ÌÈ· Ù¤ÙÔÈ· ÔÛÔÙÈ΋ ‰È·‚¿ıÌÈÛË ·ÊÔ‡ ÙÔ ‡„Ô˜ Ù˘ ·Ó·ÁˆÁ‹˜ ‰ÂÓ Û˘Û¯ÂÙ›˙ÂÙ·È Ô‡Ù Ì ÙË ‚·Ú‡ÙËÙ· Ù˘ ÓfiÛÔ˘, Ô‡Ù Ì ٷ PH/ÌÂÙÚÈο Â˘Ú‹Ì·Ù·, Ô‡Ù Ì ÙË ıÂڷ¢ÙÈ΋ ·¿ÓÙËÛË.(12,16) H ÌÂϤÙË Ì B° Û˘Ó¿ÁÂÙ·È ¤ÎıÂÛË ÙÔ˘ ·ÛıÂÓÔ‡˜ Û ÈÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›·. K·ıÒ˜ Ô ·Ô‰ÂÎÙfi˜ ¯ÚfiÓÔ˜ ·ÎÙÈÓÔÛÎÔ‹Ûˆ˜ ‰ÂÓ ÂÈÙÚ¤ÂÈ ÙˆÓ ÂÓÙÔÈÛÌfi ÂÚÈÛÙ·ÛÈ·ÎÒÓ °O¶ ‹ ¿ÏÏˆÓ Ô˘ Û˘Ì‚·›ÓÔ˘Ó ÌfiÓÔ ˘fi ÔÚÈṲ̂Ó˜ Û˘Óı‹Î˜ (.¯. ÌfiÓÔ Û fiÚıÈ· ÛÙ¿ÛË, ÌfiÓÔ ÙË Ó‡¯Ù· ‹ ÌfiÓÔ Û ηٿÛÙ·ÛË ÓËÛÙ›·˜) Ë Â˘·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘ ÌÂÈÒÓÂÙ·È Î·È Ë ·Í›· Ù˘, ȉ›ˆ˜ ÌÂÙ¿ ÙËÓ ÂÌÊ¿ÓÈÛË Ó¤ˆÓ Ù¯ÓÈÎÒÓ, Û˘˙ËÙ›ٷÈ.(15,17) ™Â ‰È¿ÊÔÚ˜ ÂÚÁ·Û›Â˜ Ë Â˘·ÈÛıËÛ›· Î˘Ì·›ÓÂÙ·È ·fi 20-73% (Ì.fi. 35%) Î·È Ë ÂȉÈÎfiÙËÙ· ÂÚ› ÙÔ 30% ÙˆÓ Û˘Ìو̷ÙÈÎÒÓ ·ÛıÂÓÒÓ.(12,15) ™ÙÔ „¢‰Ò˜ ·ÚÓËÙÈÎfi ·ÔÙ¤ÏÂÛÌ· Û˘Ì‚¿ÏÏÂÈ Ë ¯ÔÚ‹ÁËÛË ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜ ‚·Ú›Ô˘ ÛÙÔ ‰Â „¢‰Ò˜ ıÂÙÈÎfi ÔÈ ÎÚ·˘Á¤˜, Ë ¿ÛÎËÛË È¤Ûˆ˜ ÛÙÔ ÎÔÈÏÈ·Îfi ÙÔ›¯ˆÌ·, Ë ¯·ÌËÏfiÙÂÚË ı¤ÛË Ù˘ ÎÂÊ·Ï‹˜ Î·È Ô ˘ÂÚ‚¿ÏÏˆÓ ˙‹ÏÔ˜ ÛÙËÓ ·ÍÈÔÏfiÁËÛË ÌÈÎÚÔ·Ó·ÁˆÁÒÓ (12). TÔ B° ÏÔÈfiÓ Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È Û ÔÛfiÙËÙ· Û˘Ó‹ıÔ˘˜ Á‡̷ÙÔ˜ Î·È Ì ÙÔÓ ·ÛıÂÓ‹, ηٿ ÙÔ ‰˘Ó·ÙfiÓ, ‹ÚÂÌÔ. TÔ ÔÈÛÔÊ·ÁÔÁÚ¿ÊËÌ· ıˆÚÂ›Ù·È ıÂÙÈÎfi fiÙ·Ó ·Ú·ÙËÚËıÔ‡Ó ‹ 2 ·Ó·ÁˆÁ¤˜ ÛÙÔ Û‡ÓÙÔÌÔ ¯ÚfiÓÔ ÂÍÂÙ¿Ûˆ˜ ‹ 1 ·Ó·ÁˆÁ‹ Ì ۷ʋ fï˜ ηı˘ÛÙ¤ÚËÛË ÛÙËÓ Î¿ı·ÚÛË ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ·fi ÙÔ ÛÎÈ·ÁÚ·ÊÈÎfi(12). ¶ÚÒÈÌË ÎÚÈÎÔÊ·Ú˘ÁÁÈ΋ Û‡Û·ÛË ÌÂÙ¿ ÙȘ ÚÒÙ˜ ηٷ-
∞ÎÙÈÓÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË
EÈÎfiÓ· 1. MÂϤÙË Ì ‚·ÚÈÔ‡¯Ô Á‡̷ Û ·È‰› ËÏÈΛ·˜ 2 ÂÙÒÓ: ÔÏÈÛı·›ÓÔ˘Û· ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË. ¢È‡ڢÓÛË ÙÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ ÙÚ‹Ì·ÙÔ˜ ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ (‚¤ÏÔ˜) ‰È·Ì¤ÛÔ˘ ÙÔ˘ ÔÔ›Ô˘ ·ÂÈÎÔÓ›˙ÔÓÙ·È ÂÚÈÛÛfiÙÂÚ˜ ·fi ÙÚÂȘ Á·ÛÙÚÈΤ˜ Ù˘¯¤˜ Ó· ·Ó¤Ú¯ÔÓÙ·È ÚÔ˜ ÙÔÓ ıˆÚ·ÎÈÎfi ÔÈÛÔÊ¿ÁÔ. fiÛÂȘ ‚·Ú›Ô˘, ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· °O¶.(18) XÂÈÚÈÛÌÔ› ÚfiÎÏËÛ˘ (provocative maneuvers), fiÙ·Ó Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ÂÊ·ÚÌÔÛıÔ‡Ó, ÂÈÙÚ¤Ô˘Ó ÌÂÓ ÙË Û‡ÏÏË„Ë ÂÚÈÛÛÔÙ¤ÚˆÓ ·Ó·ÁˆÁÒÓ, ·˘Í¿ÓÔ˘Ó ‰ËÏ·‰‹ ÙËÓ Â˘·ÈÛıËÛ›· Ù˘ ÌÂıfi‰Ô˘, ÌÂÈÒÓÔ˘Ó fï˜ ÙËÓ ÂȉÈÎfiÙËÙ¿ Ù˘.(15) ¶ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔ ‚‹¯·, ÙË ‰ÔÎÈÌ·Û›· Valsava, ÙË ÌÂÙ·‚ÔÏ‹ ı¤Ûˆ˜ ·fi ‡ÙÈ· Û ‰ÂÍÈ¿ Ï¿ÁÈ· Î·È ÙË ‰ÔÎÈÌ·Û›· water siphon. ™Â ÌÂϤÙË ÙˆÓ J Keith-Thompson et al.(11) ÂÓÒ Ë ·˘ÙfiÌ·ÙË ·Ó·ÁˆÁ‹ Ì B° ·Â‰Â›¯ıË ıÂÙÈ΋ ÛÙÔ 26% ÙˆÓ Â›Û˘ ıÂÙÈÎÒÓ ÛÙËÓ PH/ÌÂÙÚ›·, ÂÚÈÙÒÛˆÓ, Ì ÙËÓ ÂÊ·ÚÌÔÁ‹ ÙˆÓ ·Ú·¿Óˆ ¯ÂÈÚÈÛÌÒÓ ÙÔ ÔÛÔÛÙfi ·˘Í‹ıËΠÛÙÔ 70% ·ÎfiÌË Î·È Û ÂÚÈÙÒÛÂȘ (Û·ÓÈfiÙÂÚ·) ·ÚÓËÙÈΤ˜ ÛÙËÓ PH/ÌÂÙÚ›· (11). ¶Ú¤ÂÈ Ó· ·Ó·ÊÂÚı› fiÙÈ ÙÔ B°, ·ÚfiÙÈ ıˆÚÂ›Ù·È Ì¤ıÔ‰Ô˜ ·ÛÊ·Ï‹˜, ÌÔÚ› Ó· ÚÔηϤÛÂÈ ·ÓÙȉڿÛÂȘ ˘ÂÚ¢·ÈÛıËÛ›·˜ Û ¿ÙÔÌ· Ì ÛÔ‚·Ú‹ ÙÚÔÊÈ΋ ·ÏÏÂÚÁ›· ÛÙ· ÔÔ›· Ú¤ÂÈ Ó· ÚÔÙÈÌ¿Ù·È ÙÔ Î·ı·Úfi ıÂÈÈÎfi ‚¿ÚÈÔ(18). TÔ B° ¤¯ÂÈ Î·ÙÂÍÔ¯‹Ó ¤Ó‰ÂÈÍË ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ·, fiÙ·Ó Ë °O¶ Â›Ó·È ÌÂÁ¿ÏË ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi Û˘ÁÁÂÓÔ‡˜ ·Ó·ÙÔÌÈ΋˜ ·ÓˆÌ·Ï›·˜.
333
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·334
¶∞π¢π∞∆ƒπ∫∏ 2000;63:330-336
O ˘ÂÚ˯ÔÙÔÌÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ O ˘ÂÚ˯ÔÙÔÌÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ (UltraSoundUS) ¿Ú¯ÈÛ ӷ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÁÈ· ÙË ‰È¿ÁÓˆÛË Ù˘ °O¶ ÙË ‰ÂηÂÙ›· ÙÔ˘ 1980. E›Ó·È ̤ıÔ‰Ô˜ ¿ÓÂÙË ÁÈ· ÙÔÓ ·ÛıÂÓ‹, ¯ˆÚ›˜ ÈÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›·, ÂÈÙÚ¤ÂÈ ‰Â Ì·ÎÚ‡ÙÂÚË ÂÚ›Ô‰Ô ·Ú·ÎÔÏÔ˘ı‹Ûˆ˜ Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ ÂÚÈÔ¯‹˜. E›Ó·È ·ÎÚÈ‚‹˜ Î·È ·ÍÈfiÈÛÙË ÁÈ· ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË ÙˆÓ ÂÌ¤ÙˆÓ Ù˘ ‚ÚÂÊÈ΋˜ ËÏÈΛ·˜ Î·È ı· ÌÔÚÔ‡Û ӷ Û˘ÛÙËı› ˆ˜ screening test Û ÎÏÈÓÈÎÒ˜ ‡ÔÙÔ˘˜ ÁÈ· °O¶ Î·È Ì¿ÏÈÛÙ· ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ (3,17,19-21). YÔÏ›ÂÙ·È Û ·ÎÚ›‚ÂÈ· Ù˘ PH/ÌÂÙÚ›·˜ Î·È ¤¯ÂÈ ÙËÓ ›‰È· Ì ÙÔ B° ÂȉÈÎfiÙËÙ· (ÂÚ› ÙÔ 30%) (3). K·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ 10ÏÂÙ˘ (Û˘Ó‹ıˆ˜) ·Ú·ÎÔÏÔ‡ıËÛ˘ ÛËÌÂÈÒÓÂÙ·È Ô ·ÚÈıÌfi˜ Î·È Ë ‰È¿ÚÎÂÈ· ÙˆÓ ÂÂÈÛÔ‰›ˆÓ °O¶, Ù· ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ·˘ÙÒÓ Î·ıÒ˜ Î·È ÔÈ Ù˘¯fiÓ ˘¿Ú¯Ô˘Û˜ ÌÔÚÊÔÏÔÁÈΤ˜ ·ÓˆÌ·Ï›Â˜ Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ Û˘Ì‚ÔÏ‹˜ (22). YÂÚ˯ÔÙÔÌÔÁÚ·ÊÈο, ¤Ó· ÂÂÈÛfi‰ÈÔ °O¶ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi (22): ·) ‰È¿ÓÔÈÍË ÙÔ˘ ηÙÒÙÂÚÔ˘ ÔÈÛÔÊ·ÁÈÎÔ‡ ÛÊÈÁÎÙ‹Ú· ‚) ·Ï›Ó‰ÚÔÌË Î›ÓËÛË ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ ÛÙÔÓ "¿ˆ" ÔÈÛÔÊ¿ÁÔ (∂ÈÎfiÓ· 2) Á) οı·ÚÛË ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ Ì ÂÚÈÛÙ·ÏÙÈΤ˜ ÎÈÓ‹ÛÂȘ ‰) ÎÏ›ÛÈÌÔ ÙÔ˘ ÛÊÈÁÎÙ‹Ú·. ™ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÂÂÈÛÔ‰›ˆÓ ‰ÂÓ Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÂÂÈÛfi‰È· ·Ï›Ó‰ÚÔÌ˘ ΛÓËÛ˘ ·¤Ú·, Ù· ÔÔ›· ıˆÚÔ‡ÓÙ·È Ê˘ÛÈÔÏÔÁÈο (22). TÔ U/S Û monitor ÌÔÚ› Ó· ÂÊ·ÚÌÔÛı› Ù·˘Ùfi¯ÚÔÓ· Ì ÙËÓ PH/ÌÂÙÚ›·, ÂÈÙ˘Á¯¿ÓÂÙ·È ¤ÙÛÈ Ë ÂÚÌËÓ›· ÙˆÓ ‰È·ÊfiÚˆÓ Ê¿ÛÂˆÓ Ù˘ pH/ÌÂÙÚÈ΋˜ η̇Ï˘ ·Ó·ÏfiÁˆ˜ Ù˘ ËÏÈΛ·˜, Ï‹„ˆ˜ ÙÚÔÊ‹˜, ı¤Ûˆ˜ ·ÛıÂÓÔ‡˜, ·˘Í‹Ûˆ˜ Ù˘ ÂÓ‰ÔÎÔÈÏȷ΋˜ ȤÛˆ˜ ÎÏ (23).
EÈÎfiÓ· 2. YÂÚ˯ÔÁÚ¿ÊËÌ· ÁÈ· °O¶ Û ‚Ú¤ÊÔ˜ ËÏÈΛ·˜ 4 ÌËÓÒÓ, Ô‚ÂÏÈ·›·/ÏÔÍ‹ ÙÔÌ‹ ηٿ ÙÔÓ ÂÈÌ‹ÎË ¿ÍÔÓ· ÙÔ˘ ÂÓ‰ÔÎÔÈÏÈ·ÎÔ‡ ÔÈÛÔÊ¿ÁÔ˘: ·Ï›Ó‰ÚÔÌË Î›ÓËÛË ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘ ÛÙÔÓ "¿ˆ" ÔÈÛÔÊ¿ÁÔ. H ÂÚÈÔ¯‹ ·Ó¿ÌÂÛ· ÛÙ· ‰‡Ô ‚¤ÏË ·ÓÙÈÛÙÔȯ› ÛÙÔ ÔÈÛÔÊ·ÁÈÎfi ÙÚ‹Ì· ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜.
334
M. ¶··‰¿ÎË, π. ™. ∫·ÛηڤÏ˘
TÔ ¤Á¯ÚˆÌÔ Doppler ·‡ÍËÛ ÙËÓ Â˘·ÈÛıËÛ›· ÙÔ˘ U/S ·fi 87 Û 94% ÙˆÓ ıÂÙÈÎÒÓ ÛÙËÓ PH/ÌÂÙÚ›· ÂÚÈÙÒÛˆÓ, Â›Ó·È ÈÔ Â˘·›ÛıËÙÔ Û ÁÚ‹ÁÔÚ˜, ÌÈÎÚ¤˜ ·Ó·ÁˆÁ¤˜ Î·È Î·Ù¿ÏÏËÏÔ Â›Û˘ ˆ˜ screening test (24,25). ŒÁ¯ÚˆÌÔ ·ÏÏfiÌÂÓÔ Doppler ÌÔÚ› Ó· ‰È·ÁÓÒÛÂÈ ·ÎfiÌË Î·È ÚÔÁÂÓÓËÙÈο ÙËÓ ‡·ÚÍË °O¶ Û˘Ó‰˘·˙fiÌÂÓ˘ Ì ˘ÏˆÚÈ΋ ·ÙÚËÛ›· (26). TÔ U/S ‰ÂÓ ÂÈÙÚ¤ÂÈ ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ °O¶ Î·È Ù˘ ÔÈÛÔÊ·Á›Ùȉ·˜ (27). ¢ÂÓ ÏËÚÔÊÔÚ› ›Û˘ ÁÈ· ÙËÓ ·˘ÙÔοı·ÚÛË ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ·fi ÙÔ ·Ó·¯ı¤Ó ÛÙÔÌ·¯ÈÎfi ÂÚȯfiÌÂÓÔ Ë ÔÔ›· ηٿ 90% ÂÈÙ˘Á¯¿ÓÂÙ·È ÌÂÙ¿ 2 ÌfiÏȘ ÂÚÈÛÙ·ÏÙÈο ·̷ٷ(4), Ô‡Ù ÁÈ· ÙÔ Ê·Ú˘ÁÁÔ-Ï·Ú˘ÁÁÈÎfi Û˘ÓÙÔÓÈÛÌfi (8). M ÙÔ U/S ÌÔÚÔ‡Ó Ó· ÌÂÏÂÙËıÔ‡Ó ÏÂÙÔÌÂÚÒ˜ Ë ·Ó·ÙÔÌ›· Î·È ·ıÔÊ˘ÛÈÔÏÔÁ›· Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ Û˘Ì‚ÔÏ‹˜ - ÂÚÈÔ¯‹˜ ÎÚ›ÛÈÌ˘ ÁÈ· ÙË °O¶ - Î·È Û˘ÁÎÂÎÚÈ̤ӷ: 1. O ÙfiÓÔ˜ ÙÔ˘ ÂÓ‰ÔÎÔÈÏÈ·ÎÔ‡ KO™, 2. TÔ Ì‹ÎÔ˜ ÙÔ˘ ÂÓ‰ÔÎÔÈÏÈ·ÎÔ‡ ÙÌ‹Ì·ÙÔ˜ Î·È Ë ÁˆÓ›· His Ô˘ ÂÓÂÚÁÔÔÈ› ÙÔ Ì˯·ÓÈÛÌfi Ù˘ ‚·Ï‚›‰·˜ ÂϤÁ¯Ô˘ (check valve) ηٿ ÙË ‰È¿Ù·ÛË ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ıfiÏÔ˘. E‰Ò Ë ÌÔÚÊÔÏÔÁÈ΋ Î·È ÏÂÈÙÔ˘ÚÁÈ΋ ÌÂϤÙË Ì U/S, fiÙ·Ó Á›ÓÂÙ·È ÚÔÛÂÎÙÈο Î·È Î¿Ùˆ ·fi ·˘ÛÙËÚ¿ ηıÔÚÈṲ̂Ó˜ ÎÏÈÓÈΤ˜ Û˘Óı‹Î˜, ˘ÂÚ¤¯ÂÈ. OÈ Û˘Óı‹Î˜ ·˘Ù¤˜ Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÔ˘Ó ˘fi„Ë ÙË Ê¿ÛË Ù˘ ·Ó·ÓÔ‹˜, ÙË Á·ÛÙÚÈ΋ ÏËÚfiÙËÙ· Î·È ÙËÓ ÂÓ‰ÔÎÔÈÏȷ΋ ›ÂÛË(8). ™˘ÓÈÛÙ¿Ù·È ÏÔÈfiÓ ÙÔ U/S Ó· Á›ÓÂÙ·È ÌÂÙ¿ ÙÔ Á‡̷, Ì ÙÔ ·È‰› ‹ÚÂÌÔ Î·È Ì ÚÔÛ‰ÈÔÚÈÛÌfi Ì¤ÛˆÓ ÙÈÌÒÓ ÌÂٷ͇ ÂÈÛÓÔ‹˜ Î·È ÂÎÓÔ‹˜(8). TÔ optimum ·Ó·ÙÔÌÈÎfi Ì‹ÎÔ˜ ÙÔ˘ ÛÊÈÁÎÙ‹Ú· Ô˘ ı· ÂÈÙÚ¤„ÂÈ ÂÈÙ˘¯‹ ·ÓÙÈÚÚfiËÛË ·˘ÍË̤Ó˘ ÂÓ‰ÔÎÔÈÏȷ΋˜ ȤÛˆ˜ ›ӷÈ, ηٿ ÙÔ˘˜ De Meester et al (28), ÌÂٷ͇ 20-25mm ÂÓÒ Ù· ·ÓÙ›ÛÙÔȯ· U/S-Ì‹ÎË, ÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Î·È Á·ÛÙÚÈÎÒÓ Ù˘¯ÒÓ, Â›Ó·È 25-30mm. ™ËÌÂȈ٤ÔÓ fiÙÈ Ë ÂÎÙ›ÌËÛË ÙÔ˘ Ì‹ÎÔ˘˜ ÙÔ˘ ÂÓ‰ÔÎÔÈÏÈ·ÎÔ‡ ÔÈÛÔÊ¿ÁÔ˘ Ì ¿ÏϘ Ù¯ÓÈΤ˜ (PH/ÌÂÙÚ›·, Ì·ÓÔÌÂÙÚ›·, ÛÈÓıËÚÔÁÚ¿ÊËÌ·) Â›Ó·È ÂÍ·ÈÚÂÙÈο ‰‡ÛÎÔÏË ‰Â‰Ô̤ÓÔ˘ fiÙÈ ·˘Ù¤˜ ·ÂÈÎÔÓ›˙Ô˘Ó ÌfiÓÔ ÙË ÏÂÈÙÔ˘ÚÁÈ΋ ¿Ô„Ë Ù˘ ·Ó·ÁˆÁ‹˜ (8). EÍ·ÈÙ›·˜ ·ÎÚÈ‚Ò˜ Ù˘ ¢·ÈÛıËÛ›·˜ ·˘Ù‹˜ ÙÔ˘ U/S, ÌÂÚÈÎÔ› Û˘ÓÈÛÙÔ‡Ó Ë ÌÂϤÙË Ì B° Ó· ÂÚÈÔÚ›˙ÂÙ·È ÛÙ· ·È‰È¿ ÂΛӷ Ô˘, ·Ú¿ ÙÔ ·ÚÓËÙÈÎfi U/S ÂÍ·ÎÔÏÔ˘ıÔ‡Ó Ó· ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘ÌÙÒÌ·Ù· (29,30). 3. H ÈηÓfiÙËÙ· ÙˆÓ ÛÎÂÏÒÓ ÙÔ˘ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Ó· Û˘ÁÎÚ·ÙÔ‡Ó ÛÙË ı¤ÛË ÙÔ˘ ÙÔÓ ÂÓ‰ÔÎÔÈÏÈ·Îfi ÔÈÛÔÊ¿ÁÔ ÂÌÔ‰›˙ÔÓÙ·˜ ÙË ‰ÈÔÏ›ÛıËÛ‹ ÙÔ˘ ÚÔ˜ ÙÔ ıÒڷη (17). TÔ U/S Â›Ó·È ÈÔ Â˘·›ÛıËÙÔ ·fi ÙÔ B° ÛÙË ‰È¿ÁÓˆÛË ÌÈÎÚÒÓ ‰È·ÊÚ·ÁÌ·ÙÔÎËÏÒÓ (8). AÔ˘Û›· ·ÂÈÎÔÓ›Ûˆ˜ Ù˘ Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋˜ Û˘Ì‚ÔÏ‹˜, ‚Ú·¯‡˜ ÂÓ‰ÔÎÔÈÏÈ·Îfi˜ ÔÈÛÔÊ¿ÁÔ˜, ·˘ÍË̤ÓË ‰È¿ÌÂÙÚÔ˜ ÙÔ˘ ÔÈÛÔÊ¿ÁÔ˘ ÛÙÔ Á·ÛÙÚÈÎfi ¿ÎÚÔ ÙÔ˘ Î·È ·ÓÒÌ·ÏË ÁˆÓ›· ÙÔ˘ His ıˆÚÔ‡ÓÙ·È ÛÙÔȯ›· ÂÓ‰ÂÈÎÙÈο ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ (∂ÈÎfiÓ· 3· & ∂ÈÎfiÓ· 3‚). H ·ÎÚÈ‚‹˜ ÂÎÙ›ÌËÛË ÙÔ˘ Á·ÛÙÚÈÎÔ‡ ¤Ú·ÙÔ˜ ÙÔ˘
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·335
¶∞π¢π∞∆ƒπ∫∏ 2000;63:330-336
ÔÈÛÔÊ·ÁÈÎÔ‡ ‚ÏÂÓÓÔÁfiÓÔ˘ Â›Ó·È ··Ú·›ÙËÙË ‰ÈfiÙÈ ÔÈ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ϙ Â›Ó·È Û˘¯Ó¿ Ìˉ·ÌÈÓ¤˜. ™Â ÓÂÔÁÓ¿ Î·È ÌÈÎÚ¿ ‚Ú¤ÊË Î‹Ï˜ ¤ˆ˜ Î·È 5 mm ‰ÂÓ Û·Ó›˙Ô˘Ó Î·È ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó ·ÒÏÂÈ· ÙÔ˘ 1/4 ÙÔ˘ ÎÔÈÏÈ·ÎÔ‡ ÔÈÛÔÊ¿ÁÔ˘. TÔ U/S ÂÈÙÚ¤ÂÈ ‰È·›ÛÙˆÛË ‚Ú·¯‡ÓÛˆ˜ ̤¯ÚÈ Î·È 2 mm ÁÂÁÔÓfi˜ Ô‡ ÂÍËÁ› ÙË ‰È·ÁÓˆÛÙÈ΋ ˘ÂÚÔ¯‹ ÙÔ˘ › ÙÔ˘ B° ÛÙȘ ÌÈÎÚ¤˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ϙ (8). ¢ÂÓ Ú¤ÂÈ, Ù¤ÏÔ˜, Ó· ·Ú·‚ϤÂÙ·È Ë ·Í›· ÙÔ˘ U/S ÛÙÔÓ ¤ÏÂÁ¯Ô Ù˘ Á·ÛÙÚÈ΋˜ ÂÍfi‰Ô˘ ÁÈ· ηٷÎÚ¿ÙËÛË ‹ ·fiÊÚ·ÍË. 5. ™˘ÁÎÚÈÙÈ΋ ·ÍÈÔÏfiÁËÛË ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÌÂıfi‰ˆÓ ÁÈ· ÙËÓ ‰È¿ÁÓˆÛË Ù˘ °O¶ EӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘ÁÎÚÈÙÈΤ˜ ÌÂϤÙ˜ ÌÂٷ͇ ÙˆÓ ‰È·ÊfiÚˆÓ Ù¯ÓÈÎÒÓ. M standard ÙËÓ pH/ÌÂÙÚ›·, Ë Â˘·ÈÛıËÛ›· ÙÔ˘ U/S Êı¿ÓÂÈ ÙÔ 95% Î·È Ë ÂȉÈÎfiÙËÙ¿ ÙÔ˘ ÙÔ 58%. OÙ·Ó ÛËÌ·ÓÙÈΤ˜ ·ÏÈÓ‰ÚÔÌ‹ÛÂȘ ıˆÚËıÔ‡Ó ·ıÔÏÔÁÈΤ˜ ¤ÛÙˆ Î·È ·Ó Â›Ó·È ·Û˘Ìو̷ÙÈΤ˜, ÙfiÙÂ Î·È Ë ÂȉÈÎfiÙËÙ· ÙÔ˘ U/S ‚ÂÏ-
EÈÎfiÓ· 3·, 3‚: YÂÚ˯ÔÁÚ¿ÊËÌ· ÁÈ· °O¶ Û ‚Ú¤ÊÔ˜ ËÏÈΛ·˜ 6 ÌËÓÒÓ, Ô‚ÂÏÈ·›·/ÏÔÍ‹ ÙÔÌ‹ ηٿ ÙÔÓ ÂÈÌ‹ÎË ¿ÍÔÓ· ÙÔ˘ ÂÓ‰ÔÎÔÈÏÈ·ÎÔ‡ ÔÈÛÔÊ¿ÁÔ˘: ÂÏ·Ùو̤ÓÔ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜ ÂϤÁ¯ÂÙ·È ÙÔ Ì‹ÎÔ˜ ÙÔ˘ ÂÓ‰ÔÎÔÈÏÈ·ÎÔ‡ ÔÈÛÔÊ¿ÁÔ˘ Ì ÙÈ̤˜ Ô˘ Î˘Ì·›ÓÔÓÙ·È ·fi 12 ¤ˆ˜ 16 ¯ÈÏ. (ÌÂÙÚ‹ÛÂȘ ·Ó¿ÌÂÛ· ÛÙ· ۇ̂ÔÏ· +). H ˘Ô„›· ÔÏÈÛı·›ÓÔ˘Û·˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ ÂȂ‚·ÈÒıËΠ̠B°.
∞ÎÙÈÓÔÏÔÁÈ΋ ‰ÈÂÚ‡ÓËÛË
ÙÈÒÓÂÙ·È (17). ™Â ÌÂϤÙË ÙˆÓ Hirsch et al › 84 ˘„ËÏ‹˜ Èı·ÓfiÙËÙ·˜ ÁÈ· °O¶ ·È‰ÈÒÓ, ÔÈ Â˘·ÈÛıËۛ˜ PH/ÌÂÙÚ›·˜, U/S Î·È ¤Á¯ÚˆÌÔ˘ Doppler ‹Û·Ó, ·ÓÙ›ÛÙÔȯ·, 60,71 - 51,20 - 59,50% (24). AÓ Î·È Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ Û˘ÁÎÚÈÙÈÎÒÓ ÌÂÏÂÙÒÓ Î·Ù·Ï‹ÁÂÈ ÛÙËÓ ·Ô‰Ô¯‹ Ù˘ PH/ÌÂÙÚ›·˜ ˆ˜ ÚÒÙ˘ ÌÂıfi‰Ô˘, ˘¿Ú¯Ô˘Ó Î·È ·Ó·ÊÔÚ¤˜ Ì ÚÔËÁÔ‡ÌÂÓÔ ÙÔ B° Î·È Ì¿ÏÈÛÙ· ÛÂ Û˘Ó‰˘·ÛÌfi Ì ¯ÂÈÚÈÛÌÔ‡˜ ÚÔÎÏ‹Ûˆ˜ (11). MÂÁ·Ï‡ÙÂÚÔ˜ ·ÚÈıÌfi˜ ·ÛıÂÓÒÓ Ì ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË ‹ ·˘ÙfiÌ·ÙË ·Ó·ÁˆÁ‹ ‰È·ÁÈÁÓÒÛÎÂÙ·È Ì B°, Ô‡Ù fï˜ Ë Â˘·ÈÛıËÛ›· Ô‡ÙÂ Ë ÂȉÈÎfiÙËÙ· Ù˘ ÌÂıfi‰Ô˘ ÙËÓ Î·ıÈÛÙÔ‡Ó Î·Ù¿ÏÏËÏË ÁÈ· ‰ÔÎÈÌ·Û›· ‰È·ÏÔÁ‹˜ (31). H Û‡ÁÎÚÈÛË U/S Î·È PH/ÌÂÙÚ›·˜ ·Ô‰ÂÈÎÓ‡ÂÈ Û‡ÌÙˆÛË ÛÙÔ 87% Ë ÔÔ›· Ì ¤Á¯ÚˆÌÔ Doppler Êı¿ÓÂÈ ÙÔ 94% (24). ™Â ·Ó¿ÏÔÁË ÌÂϤÙË ÙˆÓ S J Westra et al, U/S Î·È PH/ÌÂÙÚ›· Û˘Ì›ÙÔ˘Ó ÛÙË ıÂÙÈ΋ ‹ ·ÚÓËÙÈ΋ ‰È¿ÁÓˆÛË Û ÔÛÔÛÙfi 81-84% (17). EӉȷʤÚÔ˘Û· Â›Ó·È Î·È Ë Û‡ÁÎÚÈÛË ÌÂٷ͇ B° Î·È U/S Û ÌÂϤÙË ÙˆÓ DiMario et al: Û‡ÌÙˆÛË Î·Ù¿ 93% (5). H ¢·ÈÛıËÛ›· ÙÔ˘ U/S ıˆÚÂ›Ù·È ÌÂÁ·Ï‡ÙÂÚË ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ, ÏfiÁˆ ‰Â Î·È ÙˆÓ ¿ÏÏˆÓ ÚÔÛfiÓÙˆÓ ÙÔ˘, ÚÔÙ›ÓÂÙ·È ˆ˜ ÚÒÙË ÂÈÏÔÁ‹ fi¯È ÌfiÓÔ ÁÈ· ÙËÓ ·Ú¯È΋ ‰È¿ÁÓˆÛË ·ÏÏ¿ Î·È ÁÈ· ÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË (32). 6. ™˘ÌÂÚ¿ÛÌ·Ù· °ÂÓÈο, fiˆ˜ ÚÔ·ÙÂÈ ·fi ÙËÓ Û¯ÂÙÈ΋ ‚È‚ÏÈÔÁÚ·Ê›·: ● NÂÔÁÓ¿ Î·È ‚Ú¤ÊË Ì¤¯ÚÈ 2 ÌËÓÒÓ Ô˘ ÂÌÊ·Ó›˙Ô˘Ó Â̤ÙÔ˘˜ ¯Ú‹˙Ô˘Ó ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛ˘. ™ÙËÓ ËÏÈΛ· ·˘Ù‹ ÛËÌ·ÓÙÈ΋ Â›Ó·È Ë ÛˆÛÙ‹ Ï‹„Ë ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ Î·È Ë ÚÔÛÂÎÙÈ΋ ÎÏÈÓÈ΋ ÂͤٷÛË ÂÓÒ Ë ÂÚÁ·ÛÙËÚȷ΋ Û˘Ó‰ÚÔÌ‹, ÂÊfiÛÔÓ ÎÚÈı› ··Ú·›ÙËÙË, Û˘Ó‹ıˆ˜ ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÔ U/S, ÙËÓ PH/ÌÂÙÚ›· ηÈ, Û·ÓÈfiÙÂÚ· ÙÔ B°. ● ™ËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ‚ÚÂÊÒÓ ËÏÈΛ·˜ 2-12 ÌËÓÒÓ ÂÌÊ·Ó›˙ÂÈ Ê˘ÛÈÔÏÔÁÈ΋ ‹ ÏÂÈÙÔ˘ÚÁÈ΋ °O¶. E¿Ó Ë ·Ó¿Ù˘ÍË ÙÔ˘ ‚Ú¤ÊÔ˘˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋ ‰ÂÓ Û˘ÓÈÛÙ¿Ù·È Ë ÂÊ·ÚÌÔÁ‹ ÂÂÌ‚·ÙÈÎÒÓ Ù¯ÓÈÎÒÓ ‹ ‰ÔÎÈÌ·ÛÈÒÓ Ì ÈÔÓ›˙Ô˘Û· ·ÎÙÈÓÔ‚ÔÏ›·. TÔ U/S ı· ÌÔÚÔ‡Û ӷ Û˘ÛÙËı› Û·Ó screening test Û ÎÏÈÓÈο ‡ÔÙÔ˘˜ ÁÈ· °O¶ ·ÛıÂÓ›˜. E¿Ó ˘¿Ú¯ÂÈ ÎÏÈÓÈ΋ ˘Ô„›· fiÙÈ Ë °O¶ Â›Ó·È ‰Â˘ÙÂÚÔ·ı‹˜, Û˘ÓÈÛÙ¿Ù·È Ë ‰ÈÂÍ·ÁˆÁ‹ U/S ‹/Î·È B°. ● H °O¶ Ô˘ ·Ú·Ù›ÓÂÙ·È ¤Ú· ·fi ÙÔÓ 18Ô Ì‹Ó· Ù˘ ˙ˆ‹˜ Û˘¯Ó¿ ηٷϋÁÂÈ ¯ÚfiÓÈÔ Úfi‚ÏËÌ·, ·Ó¿ÏÔÁÔ Ì ÙË ÓfiÛÔ ÙˆÓ ÂÓËϛΈÓ. H °O¶ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜, ȉ›ˆ˜ Â¿Ó Ë ¤Ó·ÚÍË Ù˘ ÂÓÙÔ›˙ÂÙ·È ÌÂÙ¿ ÙÔÓ 12Ô Ì‹Ó· Ù˘ ˙ˆ‹˜, ¯Ú‹˙ÂÈ ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛ˘. H ÂÈÏÔÁ‹ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÂÍÂÙ¿ÛÂˆÓ ÂÍ·ÚÙ¿Ù·È ·fi Ù· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ·ÛıÂÓÔ‡˜. OÔÈ·‰‹ÔÙ ̤ıÔ‰Ô˜ ‹ Û˘Ó‰˘·ÛÌfi˜ ÌÂıfi‰ˆÓ Î·È ·Ó ÂÈÏÂÁ› ÁÈ· ÙËÓ ‰È¿ÁÓˆÛË Ù˘ °O¶ ÛÙ· ·È‰È¿ ‰ÂÓ Ú¤ÂÈ Ó· ÏËÛÌÔÓÂ›Ù·È fiÙÈ:
335
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·336
¶∞π¢π∞∆ƒπ∫∏ 2000;63:330-336
·) TÔ ·ÎÔÏÔ˘ıÔ‡ÌÂÓÔ ÚˆÙfiÎÔÏÏÔ ¤Ú¢ӷ˜ ¤¯ÂÈ ÌÂÁ¿ÏË ÛËÌ·Û›· ÁÈ· Ù· ·ÔÙÂϤÛÌ·Ù¿ Ù˘. ‚) H ÂÌÂÈÚ›· ÙÔ˘ ÂÍÂÙ¿˙ÔÓÙÔ˜ ÂËÚ¿˙ÂÈ Â˘ı¤ˆ˜ Î·È ÙËÓ Â˘·ÈÛıËÛ›· Î·È ÙËÓ ÂȉÈÎfiÙËÙ· fiÏˆÓ ÙˆÓ ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÌÂıfi‰ˆÓ Î·È ‰Ë ÙˆÓ Î˘ÚÈÔÙ¤ÚˆÓ (pH/ÌÂÙÚ›·˜, B°, U/S) Î·È Á) K·Ì›· ÂÚÁ·ÛÙËÚȷ΋ ‰È¿ÁÓˆÛË ‰ÂÓ Â‰Ú·ÈÒÓÂÙ·È ¯ˆÚ›˜ ÙË Û‡ÌÚ·ÍË ÙÔ˘ ¤ÌÂÈÚÔ˘ ÎÏÈÓÈÎÔ‡ ÁÈ·ÙÚÔ‡ Ô ÔÔ›Ô˜ ı· ÚÔÛʤÚÂÈ Î·È ÙËÓ ·ÍÈfiÈÛÙË ÎÏÈÓÈ΋ ÂÈÎfiÓ· Î·È ÙËÓ ex juventibus ÙÂÏÈ΋ ÙÂÎÌËÚ›ˆÛË. BÈ‚ÏÈÔÁÚ·Ê›· 1. Hyman PE. Gastroesophageal reflux: one reason why baby won't eat. J Pediatr 1994; 125:103-109. 2. Vandenplas Y. Gastroesophageal reflux in children. Scand J Gastroenterol 1995;30 (Suppl 213):s31-38. 3. Fonkalsrud EW, Ament ME. Gastroesophageal reflux in childhood. Curr Prob Surg 1996 ;33:1-70. 4. Gastroesophageal reflux. In: Behrman RE, Kliegmann RM, Alvin AM eds. Nelson Textbook of Pediatrics.15th ed. Philadelphia: W.B.Saunders Co. 1996:1055-1056. 5. Di Mario M, Bergami G, Fariello G et al. Diagnosis of gastroesophageal reflux in childhood. Comparison of ultrasonography and barium swallow. Radiol Med (Torino) 1995;89:76-81. 6. Hillemeier AC. Gastroesophageal reflux. Diagnostic and therapeutic approaches. Pediatr Clin N Am 1996;43:197-212. 7. Glassman M, Donald G, Grill B. Gastroesophageal reflux in children. Clinical manifestations, diagnosis, and therapy. Gastroenterol Clin N Am 1995;24:71-98. 8. Gomes H, Lallemand A, Lallemand P. Ultrasound of the gastroesophageal junction. Pediatr Radiol 1993;23:94-99. 9. Katzka DA, Sidhu M, Castell DO. Hypertensive lower esophageal sphincter pressures and gastroesophageal reflux: an apparent paradox that is not unusual. Am J Gastroenterol 1995;90:280-4. 10. Cavataio F, Iacono G, Montalto G et al. Gastroesophageal reflux associated with cow's milk allergy in infants: which diagnostic examinations are useful? Am J Gastroenterol 1996;91:1215-1220. 11. Thompson JK, Koehler RE, Richter JE. Detection of gastroesophageal reflux: value of barium studies compared with 24-hr pH monitoring. Am J Roentgenol 1994;162:621-626. 12. Sondheimer JM. Gastroesophageal reflux: update on pathogenesis and diagnosis. Pediatr Clin N Am 1988;35:103-116. 13. Ott DJ. Gastroesophageal reflux disease. Radiol Clin N Am 1994;32:1147-1166. 14. Laudizi L, Zaniol P, Venuta A et al. Gastroesophageal reflux in children. A combined radiologic and scintigraphic study. Radiol Med (Torino) 1990;79:381-383. 15. Ott DJ. Gastroesophageal reflux: what is the role of barium studies? Am J Roentgenol 1994;162:627-629. 16. McCauley RG, Darling DB, Leonidas JC. Et al. Gastroesophageal reflux in infants and children: a useful classification and reliable physiologic technique for its demonstration. Am J Roentgenol 1978;130:47-50.
336
M. ¶··‰¿ÎË, π. ™. ∫·ÛηڤÏ˘
17. Westra SJ, Wolf BH, Staalman CR. Ultrasound diagnosis of gastroesophageal reflux and hiatal hernia in infants and young children. J Clin Ultrasound 1990 ;18: 477-485. 18. Brady AP, Stevenson GW, Somers S et al. Premature contraction of the cricopharyngeus: a new sign of gastroesophageal reflux disease. Abdom Imaging 1995;20:225-229. 19. Stringer DA, Hassall E, Ferguson A. et al. Hypersensitivity reaction to single contrast barium meal studies in children. Pediatr Radiol 1993;23:587-588. 20. Naik DR, Bolia A, Moore DJ. Comparison of barium swallow and ultrasound in diagnosis of gastroesophageal reflux in children. BMJ 1985;290:1943-1945. 21. Wynchank S, Mann MD, Fisher R. et al. Ultrasound as a screening study for gastroesophageal reflux in children. Ann Trop Paediatr 1997;17:343-348. 22. Anvi EF, Rypens FR. Pediatric gastrointestinal tract. In: Dubbins PA, Joseph AEA, eds. Ultrasound in Gastroenterology. New York, Edinburgh, London: Churchill Livingstone, 1994:27-54. 23. Gomes H. Gastroesophageal reflux in infants: ultrasonographic reading of pHmetry. Arch Pediatrie 1994;7:639-645. 24. Hirsch W, Kedar R, Prei( U. Color doppler in the diagnosis of the gastroesophageal reflux in children: comparison with pH measurements and B-mode ultrasound. Pediatr Radiol 1996;26:232-235. 25. Hirsch W, Prei( U, Kedar R. Color coded Doppler ultrasound in diagnosis of gastroesophageal reflux. Clin Paediatr 1997;209:6-10. 26. Rizzo G, Capponi A, Arduini D et al. Prenatal diagnosis of gastroesophageal reflux by color and pulsed Doppler ultrasonography in a case of congenital pyloric atresia. Ultrasound Obst Gyn 1995;6:290-292. 27. Le Dosseur P, Moutounet L, Eurin D et al. Ultrasonography of the esophagus in children. Ann Radiol (Paris) 1994;37:494-499. 28. De Meester TR, Wernly GA, Bryant CH. Clinical and in vitro analysis of determinants of gastroesophageal competence: A study of principles of antireflux surgery. Am J Surg 1979;137:39-46. 29. Rollins MD, Shields MD, Quinn R et al. Value of ultrasound in differentiating causes of persisting vomiting in children. Gut 1991;32:612-614. 30. Aliotta A, Rapaccini GL, Pompili M et al. Ultrasonographic signs of sliding gastric hiatal hernia and their prospective evaluation. J Ultras Med 1995;14:457-461. 31. Johnston BT, Troshinsky MB, Castell JA et al. Comparison of barium radiology with esophageal pH monitoring in the diagnosis of gastroesophageal reflux disease. Am J Gastroenterol 1996;91:1181-1185. 32. Tani G, Sciutti R, Teglia F et al. Diagnosis of gastroesophageal reflux in children. Ultrasonography versus pH monitoring. Radiol Med (Torino) 1993;86:626-9. HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 17-01-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 07-06-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: M·Ú›Ó· °. ¶··‰¿ÎË KÚ›ÓˆÓ 6-8, 157 72 ZˆÁÚ¿ÊÔ˘
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·337
¶∞π¢π∞∆ƒπ∫∏ 2000;63:337-338
¶ƒ∞∫∆π∫∂™ O¢∏°π∂™ ∆OY ¶∞π¢π∞∆ƒOÀ
TÚÔ¯·›· ·Ù˘¯‹Ì·Ù· - O‰ËÁ›Â˜ ÚfiÏ˄˘ KˆÓÛÙ·ÓÙ›ÓÔ˜ £. TÛÔ˘Ì¿Î·˜ T· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ·ÔÙÂÏÔ‡Ó Û fiÏÔ ÙÔÓ ÎfiÛÌÔ ÛÔ‚·ÚfiÙ·ÙÔ Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜. ™ÙËÓ EÏÏ¿‰· ÔÈ ı¿Ó·ÙÔÈ ·fi ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· Â›Ó·È Û¯Â‰fiÓ ‰ÈÏ¿ÛÈÔÈ ·' fi,ÙÈ ·ÁÎÔÛÌ›ˆ˜. Œ¯Ô˘Ì 2.000 ı·Ó¿ÙÔ˘˜, 4.000 ‚·ÚÈ¿ Î·È 30.000 ÂÏ·ÊÚ¿ ÙÚ·˘Ì·Ù›Â˜ ηٿ ̤ÛÔ fiÚÔ ÙÔ ¯ÚfiÓÔ. Afi ÙÔ˘˜ ÓÂÎÚÔ‡˜ Î·È ÙÔ˘˜ ÙÚ·˘Ì·Ù›Â˜ ÙÔ 1/3 Â›Ó·È ·È‰È¿. TÔ ÙÚ·ÁÈÎfi ·˘Ùfi ÁÂÁÔÓfi˜ Á›ÓÂÙ·È ·ÎfiÌË ¯ÂÈÚfiÙÂÚÔ ·Ó ˘ÔÏÔÁ›ÛÂÈ Î·Ó¤Ó·˜ fiÙÈ ¤Ú· ·fi ÙÔ˘˜ ı·Ó¿ÙÔ˘˜, ÔÏÏÔ› ·fi ÙÔ˘˜ ÙÚ·˘Ì·Ù›Â˜ ̤ÓÔ˘Ó ·Ó¿ËÚÔÈ Î·È Ì¿ÏÈÛÙ· Û ÌÈÎÚ‹ ËÏÈΛ·. T· ÙÚÔ¯·›· ·Ù˘¯‹Ì·Ù· ‰ÂÓ Ù· ‰ËÌÈÔ˘ÚÁ› Ë Î·ÎÈ¿ ÒÚ· ‹ Ë Î·ÎÔÙ˘¯›·, Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÔÏÏÒÓ ·Ú·ÁfiÓÙˆÓ, fiˆ˜ ÙÔ ·ÓıÚÒÈÓÔ Ï¿ıÔ˜, Ë ·Ì¤ÏÂÈ·, Ë ·ÂÚÈÛ΄›·, Ë ÂÚÈÊÚfiÓËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘, Ë ¿ÁÓÔÈ· ÎÏ., Î·È ·˘ÙÔ‡˜ ¤¯Ô˘Ì ˘Ô¯Ú¤ˆÛË Ó· ÚÔÏ¿‚Ô˘ÌÂ. ™ÙËÓ EÏÏ¿‰· Ôχ Ï›Á· ̤ÙÚ· ÚfiÏ˄˘ Â›Ó·È ˘Ô¯ÚˆÙÈο Ì ÓfiÌÔ˘˜, ·ÏÏ¿ Î·È ÁÈ· fiÛ· ¤¯Ô˘Ó ıÂÛÈÛÙ› ÓfiÌÔÈ, ·˘ÙÔ› ‰ÂÓ ÙËÚÔ‡ÓÙ·È. OÈ ·È‰›·ÙÚÔÈ Î·Ù¤¯Ô˘Ó ȉȷ›ÙÂÚË ı¤ÛË Ô˘ ÙÔ˘˜ ‰›ÓÂÈ ÙË ‰˘Ó·ÙfiÙËÙ· ‰˘Ó·ÌÈ΋˜ ·Ú¤Ì‚·Û˘ ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ÙÚÔ¯·›ˆÓ ·Ù˘¯ËÌ¿ÙˆÓ ÛÙ· ·È‰È¿. TÔ ·È‰› ÌÔÚ› Ó· ‚ÚÂı› ˆ˜ ı‡Ì· ÙÚÔ¯·›Ô˘, ›Ù ˆ˜ Â˙fi˜ ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜, ›Ù ˆ˜ ÂÈ‚¿Ù˘ ÌÂÙ·ÊÔÚÈÎÔ‡ ̤ÛÔ˘ ‹ Î·È ·ÎfiÌ· ˆ˜ Ô‰ËÏ¿Ù˘ Î·È ÛÙËÓ ÂÊ˂›· ˆ˜ Ô‰ËÁfi˜. A. TÔ ·È‰› Â˙fi˜ ¶·È‰È¿ ÌÈÎÚfiÙÂÚ· ÙˆÓ 9 ÂÙÒÓ ‰ÂÓ Ú¤ÂÈ Ó· ΢ÎÏÔÊÔÚÔ‡Ó ÌfiÓ· ÙÔ˘˜, ¯ˆÚ›˜ ÂÈÙ‹ÚËÛË. MÂÙ¿ Ù· 9 ¯ÚfiÓÈ· ÌfiÓÔ ÌÂÙ¿ ·fi ηϋ Âη›‰Â˘ÛË ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜ Î·È ÂÍÔÈΛˆÛË Ì ÙË ‰È·‰ÚÔÌ‹ ÌÔÚÔ‡Ó Ó· ΢ÎÏÔÊÔÚÔ‡Ó ÌfiÓ· ÙÔ˘˜. ¶·È‰È¿ ¿Óˆ ÙˆÓ 12 ¯ÚfiÓˆÓ ÌÔÚÔ‡Ó Ó· Û˘ÌÂÚÈʤÚÔÓÙ·È ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜ ÛˆÛÙ¿ fiˆ˜ Î·È ÔÈ ÂÓ‹ÏÈÎÔÈ. B. TÔ ·È‰› ÂÈ‚¿Ù˘ - °È· ÙËÓ ·ÛÊ·Ï‹ ÌÂÙ·ÊÔÚ¿ ÙˆÓ ·È‰ÈÒÓ ˘¿Ú¯Ô˘Ó ÔÚÈṲ̂ÓÔÈ ‚·ÛÈÎÔ› ηÓfiÓ˜: - ¶ÔÙ¤ Ù· ·È‰È¿ ÛÙÔ ÌÚÔÛÙÈÓfi οıÈÛÌ· (ÂȉÈο ·Ó ˘¿Ú¯ÂÈ ·ÂÚfiÛ·ÎÔ˜), ¿ÓÙÔÙ ÛÙÔ ›Ûˆ. AÎfiÌ· Î·È Û ÂÏ·ÊÚÈ¿ Û‡ÁÎÚÔ˘ÛË ‹ Û ·fiÙÔÌÔ ÊÚÂÓ¿ÚÈÛÌ· ÙÔ ·È‰› ÎÈÓ‰˘Ó‡ÂÈ Ó· ÎÙ˘‹ÛÂÈ ÛÙÔ Ù·ÌÏfi ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘. ¶ÔÙ¤ ÛÙÔ ÔÚÙ-ÌÂ̤, ÛÙ· ÁfiÓ·Ù· ‹ ÛÙËÓ ·ÁηÏÈ¿ οÔÈÔ˘. Œ¯ÂÈ ‚ÚÂı› ˆ˜ ÙÔ 90% ÙˆÓ ·ÙfiÌˆÓ Ô˘ ÂÓÂÏ¿ÎËÛ·Ó Û ÙÚÔ¯·›Ô ·Ù‡¯ËÌ· Î·È ÎÚ·ÙÔ‡Û·Ó ·È‰È¿ ÛÙËÓ ·ÁηÏÈ¿ ÙÔ˘˜ Î·È ÛÒıËηÓ, ÛÒıËÎ·Ó ÂÂȉ‹ ÙÔ ·È‰› ÙÔ˘˜ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Û·Ó ·Û›‰·. - TÔ ·È‰› ¿ÓÙÔÙ ÛÙÔ ÂȉÈÎfi οıÈÛÌ· ·ÛÊ·Ï›·˜, Ì ÙËÓ ÂȉÈ΋ ˙ÒÓË ·ÛÊ·Ï›·˜, ÔÙ¤ 2 ·È‰È¿ Ì·˙› Û ÌÈ· ˙ÒÓË ·ÛÊ·Ï›·˜. M ÙËÓ ¯ÚËÛÈÌÔÔ›ËÛË ÙˆÓ ·È‰ÈÎÒÓ Î·ıÈÛÌ¿ÙˆÓ ÔÈ ı¿Ó·ÙÔÈ ·fi ÙÚÔ¯·›· ı· ÌÔÚÔ‡Û·Ó Ó· ÌÂȈıÔ‡Ó Î·Ù¿ 70% Î·È ÔÈ ÙÚ·˘Ì·ÙÈÛÌÔ› ηٿ 67%. ŸÌˆ˜, ·fi ÙÔ˘˜ ÁÔÓ›˜ Ô˘ ̤ÓÔ˘Ó ÛÙËÓ Aı‹Ó· Î·È ¤¯Ô˘Ó ·˘ÙÔΛÓËÙÔ, ÌfiÓÔ ÙÔ 58% ·ÁÔÚ¿˙Ô˘Ó ·È‰Èο ηı›ÛÌ·Ù· ·˘ÙÔÎÈÓ‹ÙÔ˘ Î·È ÛÙËÓ Â·Ú¯›· ÙÔ 32%, ÂÓÒ ‰˘ÛÙ˘¯Ò˜ ÌfiÓÔ ÙÔ 0,5-1% ·ÁÔÚ¿˙Ô˘Ó ÙÔ ÙÂÏÂ˘Ù·›ˆÓ ÚԉȷÁÚ·ÊÒÓ Î¿ıÈÛÌ· ·ÛÊ·Ï›·˜ Ô˘ Â›Ó·È ÂȉÈÎfi ÁÈ· ÙÔ ‚¿ÚÔ˜, ÙËÓ ËÏÈΛ·, ÙÔ Ì‹ÎÔ˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È ·Ú¤¯ÂÈ ÈηÓÔÔÈËÙÈ΋ ÚÔÛÙ·Û›·. T· ηı›ÛÌ·Ù· ·˘Ù¿ ʤÚÔ˘Ó ÙÔ Û‹Ì· ECE R 4403 ÛÙË Û˘Û΢·Û›·. Y¿Ú¯Ô˘Ó ·) ηı›ÛÌ·Ù· ÛÙÚ·Ì̤ӷ ÚÔ˜ Ù· ›Ûˆ ÁÈ· ·È‰È¿ Ì ‚¿ÚÔ˜ ˆ˜ 10 ÎÈÏ¿, ‚) ηı›ÛÌ·Ù· ‰ÈÏ‹˜ ηÙ‡ı˘ÓÛ˘ ÁÈ· ·È‰È¿ Ì ‚¿ÚÔ˜ ˆ˜ 20 ÎÈÏ¿, Á) ηı›ÛÌ·Ù· ÛÙÚ·Ì̤ӷ ÚÔ˜ Ù· ÂÌÚfi˜ ÁÈ· ·È‰È¿ ‚¿ÚÔ˘˜ 10-25 ÎÈÏ¿ Î·È ‰) ·Ó˘„ˆÙÈο ηı›ÛÌ·Ù· ÁÈ· ·È‰È¿ ‚¿ÚÔ˘˜ 15-35 ÎÈÏ¿. H ˙ÒÓË ·ÛÊ·Ï›·˜ Î·È ÛÙ· ›Ûˆ ηı›ÛÌ·Ù· ¤¯ÂÈ ‚ÚÂı› fiÙÈ ÌÂÈÒÓÂÈ ÙÔ˘˜ ı·Ó¿ÙÔ˘˜ ηٿ 22% Î·È ÙÔ˘˜ ÙÚ·˘Ì·ÙÈÛÌÔ‡˜ ηٿ 50%. H ˙ÒÓË ·ÛÊ·Ï›·˜ ıˆÚÂ›Ù·È Î·Ù¿ÏÏËÏË fiÙ·Ó ÙÔ ‰È·ÁÒÓÈÔ ÙÌ‹Ì· Ù˘ ÂÚÓ¿ ·fi ÙÔ Ì¤ÛÔ ÂÚ›Ô˘ Ù˘ ·fiÛÙ·Û˘ ÌÂٷ͇ ÙÔ˘ ¿ÎÚÔ˘ ÙÔ˘ ÒÌÔ˘ Î·È ÙÔ˘ Ï·ÈÌÔ‡. - ¶ÔÙ¤ Ù· ·È‰È¿ ÛÙÔ ·˘ÙÔΛÓËÙÔ Ì ÂÈΛӉ˘Ó· ·È¯Ó›‰È·. (EÈΛӉ˘ÓÔ Â›Ó·È Î¿ı ·È¯Ó›‰È Ô˘ Îfi‚ÂÈ, Û¯›˙ÂÈ ‹ ηٷ›ÓÂÙ·È). - OÈ fiÚÙ˜ ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘ Ú¤ÂÈ Ó· ·ÛÊ·Ï›˙ÔÓÙ·È ·' ¤Íˆ. ¶ÔÏÏ¿ ·È‰È¿ ÙÚ·˘Ì·Ù›˙ÔÓÙ·È ‹ Î·È ÛÎÔÙÒÓÔÓÙ·È ¤ÊÙÔÓÙ·˜ ¤Íˆ ·fi ÙËÓ fiÚÙ· ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘ Ô˘ ·ÓÔ›ÁÂÈ ·fiÙÔÌ· Û ÛÙÚÔÊ‹ ‹ fiÙ·Ó ·›˙Ô˘Ó Ì ÙËÓ fiÚÙ· ¯ˆÚ›˜ Ó· ÊÔÚÔ‡Ó ˙ÒÓË.
337
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·338
¶∞π¢π∞∆ƒπ∫∏ 2000;63:337-338
°. TÔ ·È‰› Ô‰ËÏ¿Ù˘ TÔ ·È‰› ˆ˜ Ô‰ËÏ¿Ù˘ Ú¤ÂÈ Ó· Û˘ÌÂÚÈʤÚÂÙ·È È· fiˆ˜ Ô Ô‰ËÁfi˜ Ô¯‹Ì·ÙÔ˜. T· ̤ÙÚ· Ô˘ ı· ÙÔ˘ ÂÍ·ÛÊ·Ï›ÛÔ˘Ó ÈηÓÔÔÈËÙÈ΋ ÚÔÛÙ·Û›· ›ӷÈ: - ηϋ Âη›‰Â˘ÛË, ˆÚÈÌfiÙËÙ·, ·˘ÍË̤ÓÔ ·›ÛıËÌ· ¢ı‡Ó˘. Ÿ¯È ·ÚÔÚÌËÙÈÎfiÙËÙ· Î·È ÂÚÈÊÚfiÓËÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘. - ¿ÚÈÛÙË ÁÓÒÛË ÙˆÓ ÂÓÓÔÈÒÓ ÙˆÓ ÛËÌ¿ÙˆÓ Î·È ÙˆÓ ‚·ÛÈÎÒÓ Î·ÓfiÓˆÓ Ô‰È΋˜ ΢ÎÏÔÊÔÚ›·˜. - ÊÚÔÓÙ›‰· ÁÈ· ÙËÓ Î·Ï‹ Û˘ÓÙ‹ÚËÛË ÙÔ˘ Ô‰ËÏ¿ÙÔ˘ Î·È Ù·ÎÙÈÎfi˜ ¤ÏÂÁ¯Ô˜. - ··ÁfiÚ¢ÛË ¯Ú‹Û˘ ·ÏÎÔÔÏÔ‡¯ˆÓ ÔÙÒÓ. - ·ÔÊ˘Á‹ ΢ÎÏÔÊÔÚ›·˜ Û ÔÏ˘Û‡¯Ó·ÛÙÔ˘˜ ‰ÚfiÌÔ˘˜ Î·È ¯ÚËÛÈÌÔÔ›ËÛË ¿ÓÙÔÙ Ù˘ ‰ÂÍÈ¿˜ "ψڛ‰·˜" ÙˆÓ ‰ÚfïÓ.
¶·È‰È·ÙÚÈÎfi TÌ‹Ì· NÔÛÔÎÔÌ›Ԣ KAT
338
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·339
¶∞π¢π∞∆ƒπ∫∏ 2000;63:339-341
I™∆Oƒπ∞ ∆∏™ ∂§§∏¡π∫∏™ ¶∞π¢π∞∆ƒπ∫∏™
¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ¶ÔÚ›· 39 ÂÙÒÓ XÚÈÛÙ›Ó· TÛÂÁ΋
TÔ 1961 ÙËÓ ¶·È‰È·ÙÚÈ΋ ÔÈÎÔÁ¤ÓÂÈ· ·ÔÙÂÏ› ÂÚÈÔÚÈṲ̂ÓÔ˜ ·ÏÏ¿ ÈηÓfi˜ ·ÚÈıÌfi˜ ·È‰È¿ÙÚˆÓ. OÈ ÂÚÈÛÛfiÙÂÚÔÈ ÛÙÂϤ¯ˆÓ·Ó Ù· NÔÛÔÎÔÌ›· ‹ ·ÛÎÔ‡Û·Ó ÙÔ Â¿ÁÁÂÏÌ· ÛÙËÓ ÚˆÙÂ‡Ô˘Û· ‹ ÛÙË £ÂÛÛ·ÏÔÓ›ÎË. §›ÁÔÈ ·È‰›·ÙÚÔÈ ·ÊÔ‡ ·¤ÎÙËÛ·Ó ÙËÓ ÂȉÈÎfiÙËÙ· ÛÙȘ ¶·È‰È·ÙÚÈΤ˜ KÏÈÓÈΤ˜ ‹Ú·Ó ÙÔ ‰ÚfiÌÔ ÁÈ· Ù· ¿ÙÚÈ· ‰¿ÊË ÁÈ· Ó· ÚÔÛʤÚÔ˘Ó ÙȘ ˘ËÚÂۛ˜ ÙÔ˘˜ ÛÙ· ·È‰È¿ ·ÔÌ·ÎÚ˘ÛÌ¤ÓˆÓ ÂÚÈÔ¯ÒÓ Ì ˘ÔÙ˘Ò‰Ë Ì¤Û·. ¶ÔÏϤ˜ ÊÔÚ¤˜ ÔÈ Û˘Ó¿‰ÂÏÊÔÈ ·fi ÙËÓ Â·Ú¯›· ÂÈÎÔÈÓˆÓÔ‡Û·Ó Ì·˙› Ì·˜ ÁÈ· Ó· ˙ËÙ‹ÛÔ˘Ó Ù· ÊÒÙ· Ì·˜ Û ‰‡ÛÎÔϘ ÂÚÈÙÒÛÂȘ ‹ ÁÈ· Ó· ÂȂ‚·ÈÒÛÔ˘Ó ÙË ‰È¿ÁÓˆÛ‹ ÙÔ˘˜. EΛÓË ÙË ¯ÚÔÓÈ¿ Û˘ÌÏËÚÒıËÎ·Ó 30 ¯ÚfiÓÈ· ·fi ÙËÓ ›‰Ú˘ÛË Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜ (E¶E) Î·È ÙÔ ¢.™. Ô˘ ÙÔ ·ÔÙÂÏÔ‡Û·Ó ÔÈ N›Î·˜ ZÂÚ‚fi˜ ¶Úfi‰ÚÔ˜, KˆÓ/ÓÔ˜ XˆÚ¤Ì˘ ∞ÓÙÈÚfi‰ÚÔ˜, ™ÔÊÔÎÏ‹˜ X·Ù˙ˉ¿Î˘ Î·È ¢ËÌ‹ÙÚ˘ §È·Î¿ÎÔ˜ °Ú·ÌÌ·Ù›˜, Iˆ¿ÓÓ˘ AÏ·Ì¿Ó˘ T·Ì›·˜, B·Û›ÏÂÈÔ˜ KˆÓÛÙ·ÓÙÈÓ›‰Ë˜, ™‡ÚÔ˜ ¢ÔÍÈ¿‰Ë˜ Î·È KˆÓ/ÓÔ˜ ¶·‰È·Ù¤Ï˘ M¤ÏË, Û ÌÈ· Û˘Ó‰ڛ·Û‹ ÙÔ˘ ¤Î·Ó ·ÔÏÔÁÈÛÌfi ÙˆÓ ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ Ù˘ E¶E ·˘Ù¿ Ù· 30 ¯ÚfiÓÈ· Ô˘ ¤Ú·Û·Ó ·fi ÙËÓ ›‰Ú˘Û‹ Ù˘. ™Â ·˘Ùfi ÙÔ ÛËÌÂ›Ô ·Í›˙ÂÈ Ó· ·Ó·Ê¤ÚÔ˘Ì ÙÔ ¯ÚÔÓÈÎfi ›‰Ú˘Û˘ Ù˘ E¶E.(1) H E¶E ȉڇıËΠÛÙȘ 25.2.1931 Ì ڈÙÔ‚Ô˘Ï›· ÙÔ˘ ·Â›ÌÓËÛÙÔ˘ ηıËÁËÙ‹ Ù˘ ¶·È‰È·ÙÚÈ΋˜ °ÂˆÚÁ›Ô˘ M·Îο, Ô ÔÔ›Ô˜ ˘‹ÚÍÂ Î·È Ô ÚÒÙÔ˜ ¶Úfi‰ÚÔ˜ ÙÔ˘ ¢.™. Ù˘. T· È‰Ú˘ÙÈο ̤ÏË ·ÔÙÂÏÔ‡Û·Ó Î·È ¿ÏÏÔÈ 25 ‰È·ÎÂÎÚÈ̤ÓÔÈ ·È‰›·ÙÚÔÈ Ù˘ ÂÔ¯‹˜ ÂΛӢ.(2) Ÿˆ˜ ·Ó·ÁÚ¿ÊÂÙ·È ÛÙÔ ÚÒÙÔ K·Ù·ÛÙ·ÙÈÎfi Ù˘ EÙ·ÈÚ›·˜ ÛÎÔfi˜ ‹Ù·Ó "Ë ÚÔ·ÁˆÁ‹ Ù˘ ·È‰È·ÙÚÈ΋˜ ηıfiÏÔ˘ Î·È Ë ÛÙÂÓˆÙ¤Ú· Û˘Ó·Ó·ÛÙÚÔÊ‹ ÙˆÓ ÂȉÈÎÒ˜ ÙÔÓ ÎÏ¿‰ÔÓ ÙÔ‡ÙÔÓ Ù˘ È·ÙÚÈ΋˜ ·ÛÎÔ‡ÓÙˆÓ È·ÙÚÒÓ".(3) T· ÚÒÙ· 30 ¯ÚfiÓÈ· ˙ˆ‹˜ Ù˘ E¶E ˘‹ÚÍ·Ó ·Ô‰ÔÙÈο Î·È ÙfiÛÔ Ù· ¢.™. Ì ÚÔ¤‰ÚÔ˘˜ Âͤ¯Ô˘Û˜ Î·È ‰È·ÎÂÎÚÈ̤Ó˜ ÌÔÚʤ˜ Ù˘ ¶·È‰È·ÙÚÈ΋˜ fiÛÔ Î·È ÔÈ ·È‰›·ÙÚÔÈ Ì¤ÏË ÂÍÂÙ¤ÏÂÛ·Ó Ï‹Úˆ˜ ÙËÓ ·ÔÛÙÔÏ‹ ÙÔ˘˜ ÒÛÙ "Ë ¶·È‰È·ÙÚÈ΋ Ó· ¤¯ÂÈ ÂÈ‚ÏËı› ˆ˜ ÂȉÈÎfiÙ˘, ˆ˜ ÎÏ¿‰Ô˜ ÂÚ‡Ó˘ ÔÏÏ¿ ÚÔÛÊ¤ÚˆÓ ÂȘ ÙËÓ EÏÏËÓÈÎ‹Ó ÂÈÛÙ‹ÌËÓ Î·È ˆ˜ ¿ÁÁÂÏÌ·, Ô‡ÙÈÓÔ˜ Ë ÎÔÈÓˆÓÈ΋ ·ÔÛÙÔÏ‹ Î·È Ë ÚÔÛÊÔÚ¿ ·fi È·ÙÚÔÎÔÈÓˆÓÈ΋˜ ÏÂ˘Ú¿˜, ÙfiÛÔÓ ‰È· ÙËÓ ÚÔÏËÙÈÎ‹Ó È·ÙÚÈÎ‹Ó fiÛÔÓ ‰È· ÙËÓ ÚÔÛÙ·Û›·Ó ÙÔ˘ ·È‰ÈÔ‡ ÁÂÓÈÎÒÙÂÚÔÓ, ·Ú' Ô˘‰ÂÓfi˜ Ó· ·ÌÊÈÛ‚ËًٷÈ". ™ÙË Û˘Ó‰ڛ·ÛË Ù˘ E¶E ÙÔ 1961 ÙÔ ¢.™. ·ÚfiÏÔ Ô˘ ¤ÌÂÈÓ ÈηÓÔÔÈË̤ÓÔ ·fi ÙȘ ‰Ú·ÛÙËÚÈfiÙËÙ˜ Ù˘ E¶E ηٿ Ù· 30 ¯ÚfiÓÈ· Ô˘ ¤Ú·Û·Ó, ‰È·›ÛÙˆÛ fiÙÈ ÔÈ ÂÈÛÙËÌÔÓÈΤ˜ ÂΉËÏÒÛÂȘ Ù˘ ·ÊÔÚÔ‡Û·Ó ÌfiÓÔ ÙÔ˘˜ ¶·È‰È¿ÙÚÔ˘˜ Ù˘ Aı‹Ó·˜ Î·È ı· ¤Ú ӷ ‚ÚÂı› ÙÚfiÔ˜ ÒÛÙ ӷ ·Â˘ı‡ÓÔÓÙ·È Î·È ÛÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ fiÏ˘ Ù˘ ¯ÒÚ·˜. ™ÙËÓ ÂfiÌÂÓË Û˘Ó‰ڛ·ÛË ÙÔ˘ ¢.™. ÌÂÙ¿ ·fi ÚfiÙ·ÛË ÙÔ˘ AÓÙÈÚÔ¤‰ÚÔ˘ Ù˘ E¶E, ÙÔ˘ ·Â›ÌÓËÛÙÔ˘ K·ıËÁËÙ‹ KˆÓÛÙ·ÓÙ›ÓÔ˘ XˆÚ¤ÌË, Ë ÔÔ›· ¤ÁÈÓ ÔÌfiʈӷ ·Ô‰ÂÎÙ‹ ·ÔÊ·Û›ÛÙËÎÂ: Ì›· ÊÔÚ¿ ÙÔ ¯ÚfiÓÔ Ó· Á›ÓÂÙ·È Ì›· ÂΉ‹ÏˆÛË Ù˘ EÙ·ÈÚ›·˜ Û ‰È¿ÊÔÚ˜ fiÏÂȘ Ù˘ EÏÏ¿‰·˜ Ô˘ ı· ‰›ÓÂÈ ·ÊÔÚÌ‹ ÛÙÔ˘˜ ÁÈ·ÙÚÔ‡˜ Ù˘ ÂÚÈʤÚÂÈ·˜ Ó· ‰Ú·ÛÙËÚÈÔÔÈËıÔ‡Ó, Ó· ·ÔÎÙ‹ÛÔ˘Ó Ó¤Â˜ ÁÓÒÛÂȘ, Ó· ·ÓÙ·ÏÏ¿ÍÔ˘Ó ·fi„ÂȘ, Ó· Û˘Ó·ÓÙËıÔ‡Ó Ì ʛÏÔ˘˜ Î·È Ó· Û˘ÛÊȯıÔ‡Ó ÔÈ ÌÂٷ͇ ÙÔ˘˜ Û¯¤ÛÂȘ.(4) ŒÙÛÈ Î·ıÈÂÚÒıËΠÙÔ ™¿‚‚·ÙÔ ·fiÁÂ˘Ì· Î·È Ë K˘Úȷ΋ Ù˘ ¶ÂÓÙËÎÔÛÙ‹˜ ˆ˜ ÂÙ‹ÛÈ· ÂÈÛÙËÌÔÓÈ΋ ÂΉ‹ÏˆÛË ÛÙËÓ ÂÚÈʤÚÂÈ·, ·Ú¯‹˜ ÁÂÓÔ̤Ó˘ ·fi ÙË £ÂÛÛ·ÏÔÓ›ÎË. ∫·È ÙÔ fiÓÔÌ· ·˘Ù‹˜ "¶·È‰È·ÙÚÈη› H̤ڷÈ". Ÿˆ˜ ·Ó·ÁÚ¿ÊÂÙ·È ÛÙÔ 1Ô ÚfiÁÚ·ÌÌ· "AÈ ¶·È‰È·ÙÚÈη› HÌ¤Ú·È ÔÚÁ·ÓÔ‡ÓÙ·È ÙÔ ÚÒÙÔÓ Î·Ù¿ ÙËÓ 27ËÓ Î·È 28ËÓ M·˝Ô˘ 1961 ÂÓ £ÂÛÛ·ÏÔÓ›ÎË ˘fi Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜ ÂÓ ÛÙÂÓ‹ Û˘ÓÂÚÁ·Û›· ÌÂÙ¿ Ù˘ EÓÒÛˆ˜ ¶·È‰È¿ÙÚˆÓ £ÂÛÛ·ÏÔӛ΢". H ÂΉ‹ÏˆÛË ÂÙ¤ıË ˘fi ÙËÓ ·ÈÁ›‰· ÙÈÌËÙÈ΋˜ ÂÈÙÚÔ‹˜ ÂÍ ÂÎÚÔÛÒˆÓ ¶ÓÂ˘Ì·ÙÈÎÒÓ I‰Ú˘Ì¿ÙˆÓ Ù˘ £ÂÛÛ·ÏÔӛ΢, ‰ËÏ. ÙÔ˘ ¶Ú˘Ù¿Óˆ˜ ÙÔ˘ AÚÈÛÙÔÙÂÏ›Ԣ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢ °ÂˆÚÁ›Ô˘ B¿Ú‚ÔÁÏË, ÙÔ˘ KÔÛÌ‹ÙÔÚÔ˜ Ù˘ I·ÙÚÈ΋˜ ™¯ÔÏ‹˜ NÈÎÔÏ¿Ô˘ K·‚·˙·Ú¿ÎË Î·È ÙÔ˘ ¶ÚÔ¤‰ÚÔ˘ Ù˘ I·ÙÚÈ΋˜ EÙ·ÈÚ›·˜ £ÂÛÛ·ÏÔӛ΢ E˘ÛÙ·ı›Ô˘ ¶·Ó·ÁȈÙfiÔ˘ÏÔ˘. ø˜ ¯ÒÚÔ˜ Û˘Ó‰ÚÈ¿ÛÂˆÓ ·Ú¯ˆÚ‹ıË ÙÔ ·ÌÊÈı¤·ÙÚÔ ÙÔ˘ XËÌ›Ԣ ÙÔ˘ AÚÈÛÙÔÙÂÏ›Ԣ ¶·ÓÂÈÛÙËÌ›Ô˘ £ÂÛÛ·ÏÔӛ΢.(5) "AÈ ¶·È‰È·ÙÚÈη› H̤ڷÈ" ¤Î·Ó·Ó ÙËÓ ¤Ó·ÚÍ‹ ÙÔ˘˜ ‰ÂÈÏ¿ - ‰ÂÈÏ¿ Î·È Ì ÛÎÂÙÈÎÈÛÌfi. ŒÁÈÓ·Ó 3 Û˘Ó‰ÚÈ¿ÛÂȘ Î·È ·Ó·ÎÔÈÓÒıËÎ·Ó 33 ÂÚÁ·Û›Â˜ ÔÈ Ôԛ˜ ·ÊÔÚÔ‡Û·Ó fiÏÔ˘˜ ÙÔ˘˜ ÙÔÌ›˜ Ù˘ ¶·È‰È·ÙÚÈ΋˜. ™Â ¿ÏÏË ·›ıÔ˘Û·
339
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·340
¶∞π¢π∞∆ƒπ∫∏ 2000;63:339-341
ÃÚÈÛÙ›Ó· ∆ÛÂÁ΋
˘‹Ú¯Â ¤ÎıÂÛË ‰È·ÊfiÚˆÓ ÂӉȷÊÂÚÔ˘ÛÒÓ ÂÚÈÙÒÛˆÓ. ¶·Ú¿ÏÏËÏ· Û οÔÈÔ ¯ÒÚÔ ÔÈ º·Ú̷΢ÙÈΤ˜ Î·È ÔÈ EÙ·ÈÚ›˜ °¿Ï·ÎÙÔ˜ ÂͤıÂÙ·Ó Ù· ÚÔ˚fiÓÙ· ÙÔ˘˜ Î·È ÂÓËÌ¤ÚˆÓ·Ó ÙÔ˘˜ È·ÙÚÔ‡˜ ÁÈ· Ù· Ó¤· ÚÔ˚fiÓÙ·. H Û˘ÌÌÂÙÔ¯‹ ÙÔ˘ ·ÎÚÔ·ÙËÚ›Ô˘ ‹Ù·Ó ÌÂÁ¿ÏË Ì ÂÚˆÙ‹ÛÂȘ, Û¯fiÏÈ· Î·È ÂÔÈÎÔ‰ÔÌËÙÈΤ˜ Û˘˙ËÙ‹ÛÂȘ Î·È fiÏÔÈ ‰È·›ÛÙˆÛ·Ó ˆ˜ ‹Ù·Ó Ì›· ÂΉ‹ÏˆÛË Ô˘ ı· ¤Ú ӷ ›¯Â Á›ÓÂÈ ·fi ηÈÚfi. TÔ ‚Ú¿‰˘ Ù˘ K˘Úȷ΋˜ Ë ÂΉ‹ÏˆÛË ¤ÎÏÂÈÓ Ì Á‡̷ ÛÙÔ ÔÔ›Ô Û˘ÌÌÂÙ›¯·Ó Î·È ÔÈ/·È Û˘ÓÔ‰Ô› ÙˆÓ Û˘Ó·‰¤ÏʈÓ. H ¢Â˘Ù¤Ú· ÙÔ˘ AÁ›Ô˘ ¶Ó‡̷ÙÔ˜ ‹Ù·Ó ·ÊÈÂڈ̤ÓË Û ÂΉÚÔÌ‹ ÛÙË Á‡Úˆ ÂÚÈÔ¯‹ Î·È ¤ÙÛÈ ‰ËÌÈÔ˘ÚÁ›ÙÔ Ì›· ÛÙÂÓ‹ Î·È ÂÁοډȷ ·ÙÌfiÛÊ·ÈÚ· Ì fiÏÔ˘˜ Ì·˜. O ·ÔÏÔÁÈÛÌfi˜ ·fi ÙȘ ¶ÚÒÙ˜ ¶·È‰È·ÙÚÈΤ˜ H̤Ú˜ ͤڷÛ ÙȘ ÚԂϤ„ÂȘ fiψÓ, Ë Û˘ÌÌÂÙÔ¯‹ ‹Ù·Ó ÌÂÁ¿ÏË Î·È ·fi fiÏË ÙËÓ EÏÏ¿‰· ·ÎfiÌË Î·È ·fi ÙËÓ KÚ‹ÙË. AÛÊ·ÏÒ˜ Ú¤ÂÈ Ó· ˘ÔÏÔÁ›ÛÔ˘ÌÂ Î·È ÙȘ ‰˘ÛÎÔϛ˜ Ô˘ ˘‹Ú¯·Ó ÛÙË ÌÂÙ·ÊÔÚ¿ ·fi ÙfiÛÔ Ì·ÎÚÈÓ¤˜ ÂÚÈÔ¯¤˜ Ù˘ ¯ÒÚ·˜. H ·ÙÌfiÛÊ·ÈÚ· Ô˘ ‰ËÌÈÔ˘ÚÁ‹ıËΠ‹Ù·Ó Ôχ ˙ÂÛÙ‹ Î·È ÊÈÏÈ΋ Ì ·ÔÙ¤ÏÂÛÌ· Ó· ηıÈÂÚˆıÔ‡Ó Î·È Ó· Á›ÓÔ˘Ó Ï¤ÔÓ ıÂÛÌfi˜.(6) AÎÔÏÔ‡ıËÛ·Ó Ë ¶¿ÙÚ·, ÙÔ HÚ¿ÎÏÂÈÔ KÚ‹Ù˘, Ù· Iˆ¿ÓÓÈÓ·, Ô BfiÏÔ˜. H Û˘ÌÌÂÙÔ¯‹ οı ¯ÚfiÓÔ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË Î·È ÙÔ Úfi‚ÏËÌ· Ô˘ ·ÓÙÈÌÂÙÒÈ˙·Ó ÔÈ ÔÚÁ·ÓˆÙ¤˜ ‹Ù·Ó Ó· ‚ÚÂıÔ‡Ó Î·Ù¿ÏÏËϘ ·›ıÔ˘Û˜ ÁÈ· ™˘Ó‰ÚÈ¿ÛÂȘ Î·È ÍÂÓԉԯ›· ÁÈ· ‰È·ÌÔÓ‹.(7) TËÓ ÂÔ¯‹ ÂΛÓË Ù· ÍÂÓԉԯ›· ‹Ù·Ó Ï›Á·, Ì ˘ÔÙ˘Ò‰ÂȘ ·Ó¤ÛÂȘ Î·È Ù· ÌÔÓ·‰Èο ηϿ ‹Ù·Ó ÁÈ· ÙÔÓ K·ıËÁËÙ‹, YÊËÁËÙ¤˜ Î·È ÁÂÓÈÎÒ˜ ÙÔ˘˜ ÌÂÁ·Ï‡ÙÂÚÔ˘˜. OÈ ÓÂÒÙÂÚÔÈ Û˘Ó‹ıˆ˜ ̤ӷÌ Û 3˘ ηÙËÁÔÚ›·˜ Î·È ·ÚÎÂÙ¤˜ ÊÔÚ¤˜ Ì·˜ ÊÈÏÔÍÂÓÔ‡Û·Ó Û˘Ó¿‰ÂÏÊÔÈ ÛÙ· Û›ÙÈ· ÙÔ˘˜. TÔ 1967 ÛÙËÓ K·‚¿Ï· ÔÈ ¤ÎÙ˜ "¶·È‰È·ÙÚÈΤ˜ H̤Ú˜" ‹Ù·Ó ͯˆÚÈÛÙ¤˜ ·ÊÔ‡ ÂÚfiÎÂÈÙÔ Ó· ·ÔÓÂÌËıÔ‡Ó ÁÈ· ÚÒÙË ÊÔÚ¿ Ù· "XˆÚ¤ÌÂÈ· Œ·ıÏ·" Ô˘ ·ıÏÔıÂÙ‹ıËÎ·Ó ·fi ÙËÓ E¶E ÛÙË ÌÓ‹ÌË ÙÔ˘ ‰·ÛοÏÔ˘ KˆÓÛÙ·ÓÙ›ÓÔ˘ XˆÚ¤ÌË Ô˘ ¤Ê˘Á ͷÊÓÈο ÙÔ ºÂ‚ÚÔ˘¿ÚÈÔ ÙÔ˘ 1966. TÔ ¤·ıÏÔ ·ÔÙÂÏÔ‡Û·Ó 3 ‚Ú·‚›· (A, B Î·È °) ÚˆÙfiÙ˘ˆÓ ÂÚÁ·ÛÈÒÓ Ô˘ ÂÎÚ›ÓÔÓÙÔ ·fi ÂÈÙÚÔ‹, ÛÙËÓ ÔÔ›· ÂÎÙfi˜ ÙˆÓ EÏÏ‹ÓˆÓ Û˘ÌÌÂÙ›¯·Ó Î·È 2 ‰È·ÎÂÎÚÈ̤ÓÔÈ Í¤ÓÔÈ Î·ıËÁËÙ¤˜ Ù˘ ¶·È‰È·ÙÚÈ΋˜. ™ÙË ÌÓ‹ÌË ÙÔ˘ ηıÈÂÚÒıËΠ›Û˘ Î·È Ì›· ÔÌÈÏ›· ·fi ͤÓÔ Î·ıËÁËÙ‹. H ÚÒÙË ¤ÁÈÓ ·fi ÙÔÓ K·ıËÁËÙ‹ Ù˘ 2˘ ¶·È‰È·ÙÚÈ΋˜ KÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ Ù˘ BÔ˘‰·¤ÛÙ˘ E. Körpel-Froni˘s. ŒÁÈÓ·Ó 8 Û˘Ó‰ÚÈ¿ÛÂȘ Ô˘ ÂÚÈÏ¿Ì‚·Ó·Ó 3 ÂÈÛËÁ‹ÛÂȘ ·Ó·ÎÔÈÓÒıËηÓ, 94 ÂÚÁ·Û›Â˜ › fiÏˆÓ ÙˆÓ ·È‰È·ÙÚÈÎÒÓ ıÂÌ¿ÙˆÓ Î·È ·ÚÔ˘ÛÈ¿ÛÙËÎ·Ó 17 ·Ó·ÚÙË̤Ó˜ ·Ó·ÎÔÈÓÒÛÂȘ TÔ 1971 ÔÈ "¶·È‰È·ÙÚÈΤ˜ H̤Ú˜" Û˘ÌÏ‹ÚˆÛ·Ó ÙËÓ ÚÒÙË 10ÂÙ›· ÙÔ˘˜ Î·È ÙÔ ¢.™. Ù˘ E.¶.E. Ì ¶Úfi‰ÚÔ ÙÔÓ K·ıËÁËÙ‹ NÈÎfiÏ·Ô M·ÙÛ·ÓÈÒÙË ·ÔÊ¿ÛÈÛ ӷ ÙÔ˘˜ ‰ÒÛÂÈ ·ÓËÁ˘ÚÈ΋ ÌÔÚÊ‹. K¿ÏÂÛ 14 ‰È·ÎÂÎÚÈ̤ÓÔ˘˜ ͤÓÔ˘˜ ÔÌÈÏËÙ¤˜ Ó· Û˘ÌÌÂÙ¿Û¯Ô˘Ó Ì ÂÈÛËÁ‹ÛÂȘ Î·È ÛÙÚÔÁÁ˘Ï¿ ÙÚ·¤˙È·. MÂٷ͇ ·˘ÙÒÓ ·Ó·Ê¤ÚÔ˘Ì ÙÔ˘˜ ηıËÁËÙ¤˜ J. Dogramaci K·ıËÁËÙ‹ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ Ù˘ ÕÁ΢ڷ˜ Î·È ¶Úfi‰ÚÔ Ù˘ ¢ÈÂıÓÔ‡˜ ¶·È‰È·ÙÚÈ΋˜ ŒÓˆÛ˘, ÙÔÓ S. Krugman ·fi ÙËÓ N.Y., ÙÔÓ A. Prader ·fi ÙË Z˘Ú›¯Ë, ÙÔÓ A. Sabin ·fi ÙÔ IÛÚ·‹Ï, ÙÔÓ G. Mathé ·fi ÙÔ ¶·Ú›ÛÈ Î·È ¿ÏÏÔ˘˜. TËÓ ÔÌÈÏ›· ÛÙË ÌÓ‹ÌË KˆÓ. XˆÚ¤ÌË ¤Î·ÓÂ Ô Nillo Halman, K·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ÛÙÔ ¶·Ó/ÌÈÔ ÙÔ˘ EÏÛ›ÓÎÈ Ì ı¤Ì· "Heredity of Kidney diseases". Œ‰Ú· Ù˘ ÂΉ‹ÏˆÛ˘ ‹Ù·Ó Ë Aı‹Ó· ÛÙËÓ ¶¿ÓÙÂÈÔ AÓˆÙ¿ÙË ™¯ÔÏ‹ ¶ÔÏÈÙÈÎÒÓ EÈÛÙËÌÒÓ. H ÂÈÙ˘¯›· ‹Ù·Ó ¿Ó¢ ÚÔËÁÔ˘Ì¤ÓÔ˘, Ë Û˘ÌÌÂÙÔ¯‹ ÙfiÛÔ ÙˆÓ ·È‰È¿ÙÚˆÓ fiÛÔ Î·È È·ÙÚÒÓ fiÏˆÓ ÙˆÓ ÂȉÈÎÔÙ‹ÙˆÓ Ô˘ ·Û¯ÔÏÔ‡ÓÙ·È Ì ÙÔ ·È‰› ‹Ù·Ó Ôχ ÌÂÁ¿ÏË. TÔ ÚfiÁÚ·ÌÌ· ÂÚÈÏ¿Ì‚·Ó 3 ÂÈÛËÁ‹ÛÂȘ, 2 ÛÙÚÔÁÁ˘Ï¿ ÙÚ·¤˙È·, 72 ·Ó·ÎÔÈÓÒÛÂȘ EÏÏ‹ÓˆÓ Î·È Í¤ÓˆÓ ÔÌËÏËÙÒÓ. ◊Ù·Ó Ï¤ÔÓ ÔÊı·ÏÌÔÊ·Ó‹˜ Ë ÂÈÙ˘¯›· ÙÔ˘ ıÂÛÌÔ‡ ·Ó ·Ó·ÏÔÁÈÛıԇ̠fiÙÈ ÛÙȘ ÚÒÙ˜ ¶·È‰È·ÙÚÈΤ˜ H̤Ú˜ ¤ÁÈÓ·Ó 3 Û˘Ó‰ÚÈ¿ÛÂȘ ÛÙȘ Ôԛ˜ ·Ó·ÎÔÈÓÒıËÎ·Ó 33 ÂÚÁ·Û›Â˜ Î·È ÌÂÙ¿ 10 ¯ÚfiÓÈ· 15 Û˘Ó‰ÚÈ¿ÛÂȘ Ì 3 ÂÈÛËÁ‹ÛÂȘ, 2 ÛÙÚÔÁÁ˘Ï¿ ÙÚ·¤˙È· Î·È 76 ·Ó·ÎÔÈÓÒÛÂȘ. K¿ı ¯ÚfiÓÔ "AÈ ¶·È‰È·ÙÚÈη› H̤ڷÈ" ›¯·Ó fiÏÔ Î·È ÌÂÁ·Ï‡ÙÂÚË Û˘ÌÌÂÙÔ¯‹. °È· ÙÔ ÏfiÁÔ ·˘Ùfi ÙÔ ¢.™. Ù˘ E¶E ÙÔ 1973 ·ÔÊ¿ÛÈÛ ˆ˜ ‹Ù·Ó ηÈÚfi˜ Ó· ıˆÚËı› È· ˆ˜ ™˘Ó¤‰ÚÈÔ Î·È ÌÂÙÔÓÔÌ¿ÛÙËÎ·Ó Û "¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ".(8) ŒÙÛÈ, ÙÔ 1973 ¤ÁÈÓ ÛÙË §Â˘ÎˆÛ›· ÛÙËÓ K‡ÚÔ ÙÔ 11Ô "¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ" ÌÂ Û˘ÌÌÂÙÔ¯‹ ÂÎÙfi˜ ÙˆÓ ·È‰È¿ÙÚˆÓ Î·È È·ÙÚÒÓ fiÏˆÓ ÙˆÓ ÂȉÈÎÔÙ‹ÙˆÓ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ·È‰›. H ÂÈÙ˘¯›· Ô˘ ͤڷÛ ÙȘ ÚԂϤ„ÂȘ fiÏˆÓ ‰Èη›ˆÛ ÙË ÌÂÙÔÓÔÌ·Û›· Û "¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ". AÎÔÏÔ˘ıÔ‡Ó Î·È ¿ÏÈ ‰È·‰Ô¯Èο ‰È¿ÊÔÚ˜ fiÏÂȘ Î·È ÓËÛÈ¿ Ù˘ ¯ÒÚ·˜ ÁÈ· Ó· Í·Ó·Á˘Ú›ÛÔ˘Ì ÛÙË £ÂÛÛ·ÏÔÓ›ÎË ÛÙÔ 28Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ÙÔ 1990 ÛÙÔ ÍÂÓÔ‰Ô¯Â›Ô "M·Î‰ÔÓ›· ¶·ÏÏ¿˜". H ÔÌÈÏ›· ÛÙË ÌÓ‹ÌË KˆÓ. XˆÚ¤ÌË ¤ÁÈÓ ·fi ÙÔÓ ŒÏÏËÓ· K·ıËÁËÙ‹ ÛÙÔ National Institute of Health ÛÙȘ H¶A Î. °ÂÒÚÁÈÔ XÚÔ‡ÛÔ, Ô ÔÔ›Ô˜ ÚfiÛÊ·Ù· ÂÍÂϤÁË K·ıËÁËÙ‹˜ Ù˘ ¶·È‰È·ÙÚÈ΋˜ ÛÙÔ ¶·Ó/ÌÈÔ AıËÓÒÓ. TÔ ı¤Ì· Ô˘ ·Ó¤Ù˘Í ‹Ù·Ó "KÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ·ÂÏ¢ıÂÚˆÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ù˘ ÎÔÚÙÈÎÔÙÚÔ›Ó˘ (CRH)". ™ÙÔ ÚfiÁÚ·ÌÌ· ÂÚÈÏ·Ì‚¿ÓÔÓÙ·Ó 2 EÈÛËÁ‹ÛÂȘ, 1 ™ÙÚÔÁÁ˘Ïfi TÚ·¤˙È, 168 AÓ·ÎÔÈÓÒÛÂȘ Î·È 53 ·Ó·ÚÙË̤Ó˜ ·Ó·ÎÔÈÓÒÛÂȘ. £· ‹ıÂÏ· Ó· ·Ó·Ê¤Úˆ fiÙÈ ÎÈ ¿ÏÏÔÈ ŒÏÏËÓ˜ È·ÙÚÔ› ÔÈ ÔÔ›ÔÈ ÛÔ‡‰·Û·Ó ÛÙË ¯ÒÚ· Ì·˜ ‹Ú·Ó ÙËÓ ÂȉÈÎfiÙËÙ· Ù˘ ¶·È‰È·ÙÚÈ΋˜ ÛÙËÓ ÎÏÈÓÈ΋ ÙÔ˘ K. XˆÚ¤ÌË Î·È ¤¯Ô˘Ó ‰È·Ú¤„ÂÈ ÛÙÔ Â͈ÙÂÚÈÎfi, ¤¯Ô˘Ó ÚÔÛÎÏËı› ÁÈ· ÙËÓ Î·ıÈÂڈ̤ÓË ÔÌÈÏ›· ÛÙË ÌÓ‹ÌË ÙÔ˘ ‰¿ÛηÏÔ˘ ÙÔ˘˜ fiˆ˜: TÔ 1982 ÛÙÔ 20Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ÛÙË X·ÏÎȉÈ΋, Ô Î. °È¿ÓÓ˘ §ÂˆÓ›‰·˜, K·ıËÁËÙ‹˜ Ù˘
340
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·341
¶∞π¢π∞∆ƒπ∫∏ 2000;63:339-341
¶·È‰È·ÙÚÈ΋˜ AÎÙÈÓÔÏÔÁ›·˜ ÛÙÔ ¶·ÓÂÈÛÙ‹ÌÈÔ Tufts ÙˆÓ H¶A Ì ı¤Ì·: O ·ÎÙÈÓÔÏfiÁÔ˜ Û·Ó Û‡Ì‚Ô˘ÏÔ˜ ÙÔ˘ ÎÏÈÓÈÎÔ‡ ¶·È‰È¿ÙÚÔ˘. TÔ 1983 ÛÙÔ 21Ô ÛÙËÓ Kˆ, Ë Î. E‡· ¶··Ì·Ùı·È¿ÎË-Lester, K·ıËÁ‹ÙÚÈ· Ù˘ ¶·È‰Ô„˘¯È·ÙÚÈ΋˜ ÛÙÔ ¶·ÓÂÈÛÙ‹ÌÈÔ McGill ÙÔ˘ K·Ó·‰¿, Ì ı¤Ì·: A˘ÙÔÎÙÔӛ˜ ÛÙ· ·È‰È¿ Î·È ÙÔ˘˜ ÂÊ‹‚Ô˘˜. TÔ 1985 ÛÙÔ 23Ô ÛÙËÓ EÚÌÈfiÓË, Ë Î. ™Ù¤ÏÏ· Z·¯·ÚÈÔ˘‰¿ÎË-Van Praagh, K·ıËÁ‹ÙÚÈ· Ù˘ ¶·È‰È΋˜ K·Ú‰ÈÔÏÔÁ›·˜ ÛÙÔ ¶·È‰È·ÙÚÈÎfi NÔÛÔÎÔÌÂ›Ô Ù˘ BÔÛÙÒÓ˘, Ì ı¤Ì·: º˘ÛÈÔÏÔÁÈ΋ Î·È ·ıÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ÌÂÛÔÎÔÏÈÎÔ‡ Î·È ÌÂÛÔÎÔÈÏÈ·ÎÔ‡ ‰È·ÊÚ¿ÁÌ·ÙÔ˜ Ù˘ ηډȿ˜ ÙÔ˘ ·ÓıÚÒÔ˘. TÔ 1998 ÛÙÔ 36Ô ÛÙËÓ ¶¿ÊÔ Ù˘ K‡ÚÔ˘, Ë Î. M·Ú›· ¢ÂÏË‚ÔÚÈ¿- ¶··‰ÔÔ‡ÏÔ˘ ∫·ıËÁ‹ÙÚÈ· ¶·È‰È·ÙÚÈ΋˜ Î·È º˘ÛÈÔÏÔÁ›·˜ ÛÙË ºÈÏ·‰¤ÏÊÈ· ÙˆÓ ∏.¶.∞. Afi ÙÔ 28Ô ™˘Ó¤‰ÚÈÔ Ô˘ ¤ÁÈÓ ÛÙË £ÂÛÛ·ÏÔÓ›ÎË, Ô ·ÚÈıÌfi˜ ÙˆÓ Û˘Ó¤‰ÚˆÓ ·˘Í‹ıËΠÙfiÛÔ ÒÛÙ ϤÔÓ ÌfiÓÔ Û fiÏÂȘ Ô˘ ‰È·ı¤ÙÔ˘Ó ÙË ÛˆÛÙ‹ ˘Ô‰ÔÌ‹ ÁÈ· Ó· ÊÈÏÔÍÂÓ‹ÛÔ˘Ó ¤Ó· ÙfiÛÔ ÌÂÁ¿ÏÔ Ï‹ıÔ˜ ÌÔÚ› Ó· Ú·ÁÌ·ÙÔÔÈËı› ÙÔ ™˘Ó¤‰ÚÈÔ Ì·˜. A˜ ÌËÓ Í¯ӿÌ fiÙÈ ÏfiÁˆ ÂÔ¯‹˜ Î·È ÙÔ˘ ÂÔÚÙ·ÛÙÈÎÔ‡ ÙÚÈË̤ÚÔ˘ Ë ÏÂÈÔÓfiÙ˘ ÙˆÓ Û˘Ó¤‰ÚˆÓ Û˘Óԉ‡ÔÓÙ·È Î·È ·fi ÙȘ ÔÈÎÔÁ¤ÓÂȤ˜ ÙÔ˘˜.(9) ŒÙÛÈ, ·ÎÔÏÔ˘ıËÛ·Ó ÙÔ HÚ¿ÎÏÂÈÔ KÚ‹Ù˘, Ë §ÂÌÂÛfi˜ K‡ÚÔ˘, Ë X·ÏÎȉÈ΋, Ë K¤Ú΢ڷ, Ë §‹ÌÓÔ˜, Ë Pfi‰Ô˜ Î·È ¿ÏÈ ÙÔ HÚ¿ÎÏÂÈÔ Î·È Ë ¶¿ÊÔ˜ K‡ÚÔ˘. TÔ ™˘Ó¤‰ÚÈÔ Â‰Ò Î·È ÌÂÚÈο ¯ÚfiÓÈ· ·Ú¯›˙ÂÈ ·fi ÙËÓ ¶·Ú·Û΢‹ ÙÔ ·fiÁÂ˘Ì· ̤¯ÚÈ ÙËÓ K˘Úȷ΋ ÙÔ ‚Ú¿‰˘. K·È ÊÙ¿ÓÔ˘Ì ÛÙÔ 37Ô Ì ÛÂÈÚ¿ Î·È ¿ÏÈ ·fi ÂΛ Ô˘ ·Ú¯›Û·ÌÂ, ÙË £ÂÛÛ·ÏÔÓ›ÎË, ÛÙÔ ÍÂÓÔ‰Ô¯Â›Ô "M·Î‰ÔÓ›· ¶·ÏÏ¿˜" Î·È Ì ·˘Ùfi ÎÏ›ÓÂÈ Ë ÙÂÏÂ˘Ù·›· ¯ÚÔÓÈ¿ ÙÔ˘ ·ÈÒÓ·. H ¤Ó·ÚÍË ÙÔ˘ ™˘Ó‰ڛԢ ¤ÁÈÓ Ì ÙËÓ ÔÌÈÏ›· ÙÔ˘ Aη‰ËÌ·˚ÎÔ‡ Î·È OÌfiÙÈÌÔ˘ K·ıËÁËÙ‹ Ù˘ ¶·È‰È·ÙÚÈ΋˜ NÈÎÔÏ¿Ô˘ M·ÙÛ·ÓÈÒÙË Ì ı¤Ì· "BÈÔ˚·ÙÚÈ΋ Î·È HıÈ΋". H ÔÌÈÏ›· ÛÙË ÌÓ‹ÌË KˆÓ. XˆÚ¤ÌË ¤ÁÈÓ ·fi ÙÔÓ K·ıËÁËÙ‹ Bush, Reader and Honorary Consultant in Pediatric Respiratory Medicine Ì ı¤Ì· "The child with very difficult asthma. ªechanisms and managment". Y‹Ú¯·Ó ¿ÏÏÔÈ ‰‡Ô ͤÓÔÈ ÚÔÛÎÂÎÏË̤ÓÔÈ ÔÌÈÏËÙ¤˜ Ô˘ ·Ó¤Ù˘Í·Ó ı¤Ì·Ù· Ù˘ ÂȉÈÎfiÙËÙ¿˜ ÙÔ˘˜. ŒÁÈÓ·Ó 2 ™ÙÚÔÁÁ˘Ï¿ TÚ·¤˙È·, 6 EÈÛËÁ‹ÛÂȘ, 3 ¢ÔÚ˘ÊÔÚÈο ™˘ÌfiÛÈ·, 98 ·Ó·ÎÔÈÓÒÛÂȘ Î·È Û˘˙ËÙ‹ıËÎ·Ó 286 ·Ó·ÚÙË̤Ó˜ ·Ó·ÎÔÈÓÒÛÂȘ. H Û˘ÌÌÂÙÔ¯‹ ‹Ù·Ó Ôχ ÌÂÁ¿ÏË, ÂÚ›Ô˘ 1500 Û‡Ó‰ÚÔÈ Ô˘ Û˘ÌÌÂÙ›¯·Ó Ô˘ÛÈ·ÛÙÈο Ì ÂÚˆÙ‹ÛÂȘ Î·È Û¯fiÏÈ· ÛÙȘ 30 Û˘Ó‰ÚÈ¿ÛÂȘ Î·È ¤‰ˆÛ·Ó Ì›· ·ÓËÁ˘ÚÈ΋ fi„Ë ÛÙÔ ™˘Ó¤‰ÚÈfi Ì·˜, ÙÔ ™˘Ó¤‰ÚÈÔ ÙÔ˘ 1999. TÂÏÂÈÒÓÔÓÙ·˜ ·˘Ù‹ ÙË Ì·ÎÚÔ¯ÚfiÓÈ· ·Ó·‰ÚÔÌ‹ ı· ‹ıÂÏ· Ó· ÙÔÓ›Ûˆ fiÙÈ fiÏÔÈ Ì·˜ ›̷ÛÙ ‚¤‚·ÈÔÈ fiÙÈ Ô ıÂÛÌfi˜ ·˘Ùfi˜ Ô˘ ¿Ú¯ÈÛ ‰ÂÈÏ¿ - ‰ÂÈÏ¿ ˆ˜ "¶·È‰È·ÙÚÈη› H̤ڷÈ" Î·È ÂÍÂÏ›¯ıËΠÛÈÁ¿ - ÛÈÁ¿ Û ¤Ó· ·fi Ù· ÌÂÁ·Ï‡ÙÂÚ·, ÔÏ˘ÏËı¤ÛÙÂÚ· Î·È ·ÍÈfiÏÔÁ· I·ÙÚÈο ™˘Ó¤‰ÚÈ· ı· Û˘Ó¯›ÛÂÈ ÙËÓ ›‰È· ÔÚ›· Î·È Û fiÏË ÙË ‰È·‰ÚÔÌ‹ ÙÔ˘ 21Ô˘ ·ÈÒÓ·. BÈ‚ÏÈÔÁÚ·Ê›· 1. ¶Ô˘Ï¿ÎÔ˘-PÂÌÂÏ¿ÎÔ˘ ŒÊË, ¶Ú›ÊÙ˘ K. ¶ÂÓ‹ÓÙ· ¯ÚfiÓÈ· "¶·È‰È·ÙÚÈ΋" (ÈÛÙÔÚÈÎÔ› ÛÙ·ıÌÔ› ÛÙËÓ ÔÚ›· ÌÈÛÔ‡ ·ÈÒÓ·) ¶·È‰È·ÙÚÈ΋ 1997;60:474-487. 2. M·ÚÙÛfiη˜ ™X. T· ÂÓ‹ÓÙ· ¯ÚfiÓÈ· Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜. ¶·È‰È·ÙÚÈ΋ 1981;44:377-378. 3. M·ÚÙÛfiη˜ ™X. Nˆ٤ڷ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋. Aگ›· E¶E, 1972;35:479-482. 4. ™¯fiÏÈ· Î·È ·fi„ÂȘ. AÈ ¶·È‰È·ÙÚÈη› HÌ¤Ú·È £ÂÛÛ·ÏÔӛ΢. Aگ›· E¶E 1961;24:53-54. 5. ¶·È‰È·ÙÚÈη› HÌ¤Ú·È £ÂÛÛ·ÏÔӛ΢. ¶ÚÔÛÊÒÓËÛË ¶ÚÔ¤‰ÚÔ˘ Ù˘ E¶E N›Î· ZÂÚ‚Ô‡ ηٿ ÙËÓ EÓ·ÚÎÙ‹ÚÈÔ TÂÏÂÙ‹, £ÂÛÛ·ÏÔÓ›ÎË 5-6 IÔ˘Ó›Ô˘ 1961. 6. ¶·È‰È·ÙÚÈη› Âȉ‹ÛÂȘ ·fi ÙËÓ EÏÏ¿‰· Î·È ÙÔ E͈ÙÂÚÈÎfi. Aگ›· E¶E 1961;24:107-108. 7. Z¿ÓÓÔ˘-M·ÚÈÔϤ· §. ™Î¤„ÂȘ Î·È ÂÓÙ˘ÒÛÂȘ. ¶·È‰È·ÙÚÈ΋ 1974;37:413-416. 8. ¶·È‰È·ÙÚÈη› Eȉ‹ÛÂȘ ·fi ÙËÓ EÏÏ¿‰· Î·È ÙÔ Â͈ÙÂÚÈÎfi. ¶ÂÚ·Á̤ӷ ¢.™. Ù˘ ¯ÚÔÓÈ΋˜ ÂÚÈfi‰Ô˘ 1964-1965. Aگ›· E¶E 1972;35:582-584. 9. ¶ÚÔÛÊÒÓËÛË ÙÔ˘ ¶ÚÔ¤‰ÚÔ˘ Ù˘ E¶E I. MÂÛÛ·ÚÈÙ¿ÎË. 28Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ. ¶·È‰È·ÙÚÈ΋ 1990;53:251-252.
341
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·342
¶∞π¢π∞∆ƒπ∫∏ 2000;63:342-346
∂¶π™∆O§∂™
AÙÂÏ›˜ ·Ó·ÊÔÚ¤˜ ÛÙÔ˘˜ ·Ú¯·›Ô˘˜ ÎÏ·ÛÈÎÔ‡˜ È·ÙÚÔ‡˜
™Â ÔÚÈṲ̂Ó˜ ÂÚÁ·Û›Â˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ ¶AI¢IATPIKH ÙfiÌÔ˜ 63, Ù‡¯Ô˜ 2, M·ÚÙ›Ô˘ - AÚÈÏ›Ô˘ 2000, ÂÓÒ Á›ÓÔÓÙ·È ·Ó·ÊÔÚ¤˜ Û ·Ú¯·›Ô˘˜ ŒÏÏËÓ˜ È·ÙÚÔ‡˜, ı· ‹ıÂÏ· Ó· ÂÈÛËÌ¿Óˆ fiÙÈ ‰ÂÓ ˘¿Ú¯ÂÈ Û¯ÂÙÈ΋ ·Ú·ÔÌ‹ ÛÙ· ÂÏÏËÓÈο ΛÌÂÓ¿ ÙÔ˘˜, ·ÏÏ¿ ·ÓÙ›ıÂÙ· ÔÈ ·Ú·Ô̤˜ Â›Ó·È Û ͤÓ˜ ÂÚÁ·Û›Â˜. ™˘ÁÎÂÎÚÈ̤ӷ, ÔÈ Û˘ÁÁÚ·Ê›˜ ÙÔ˘ ¿ÚıÚÔ˘ "¶ÂÚ›ÙˆÛË ·È‰ÈÔ‡ Ì ¯˘ÏÔ˘Ú›·", ÛÂÏ. 163-166, ‰›ÓÔ˘Ó ÙË ÛËÌ·ÓÙÈ΋ ÏËÚÔÊÔÚ›· ˆ˜ "ÁÈ· ÚÒÙË ÊÔÚ¿ Ô IÔÎÚ¿Ù˘ ·Ó·ÁÓÒÚÈÛÂ Î·È ÂÚȤÁÚ·„ ÙË ÓfiÛÔ". K·È ÂÓÒ ı· ÂÚ›ÌÂÓ ηÓ›˜ Ó· ‰ÂÈ ÙËÓ ·Ó·ÊÔÚ¿ ÛÙËÓ IÔÎÚ·ÙÈ΋ ™˘ÏÏÔÁ‹, ›Ûˆ˜ Î·È Ì ÙËÓ ·Ú¿ıÂÛË Û¯ÂÙÈÎÒÓ ÊÚ¿ÛˆÓ, ÔÈ Û˘ÁÁÚ·Ê›˜ ·Ú·¤ÌÔ˘Ó Û ‰‡Ô ͤÓ˜ ÂÚÁ·Û›Â˜. MÈ· Î·È ˘¿Ú¯Ô˘Ó Û¯ÂÙÈο ÏÂÍÈο-¢ÚÂÙ‹ÚÈ· Ù˘ IÔÎÚ·ÙÈ΋˜ ™˘ÏÏÔÁ‹˜, ÓÔÌ›˙ˆ fiÙÈ ÔÈ Û˘ÁÁÚ·Ê›˜ ‰ÂÓ ı· ‰˘ÛÎÔÏ¢fiÓÙÔ˘Û·Ó Ó· ¤‚ÚÈÛÎ·Ó ÙȘ ÊÚ¿ÛÂȘ "Ô‡ÚËÛ Ï›ÔÓ, ÂÏ·È҉˜ Ô˘Ï‡" Î·È "Ô‡ÚËÛÂÓ ÂÏ·È҉˜", ÔÈ Ôԛ˜ Â›Ó·È ·fi ÙÔ "EȉËÌÈÒÓ ÙÔ ÚÒÙÔÓ, 13, ¿ÚÚˆÛÙÔ˜ ‰ˆ‰¤Î·ÙÔ˜" Î·È ÙÔ "EȉËÌÈÒÓ ÙÔ ÙÚ›ÙÔÓ. ÕÚÚˆÛÙÔ˜ ÂÎηȉ¤Î·ÙÔ˜" ·ÓÙ›ÛÙÔȯ·. E›Û˘, ÔÈ Û˘ÁÁÚ·Ê›˜ ÙÔ˘ ¿ÚıÚÔ˘ "H ‚·ÛÈ΋ ÂÎÎÚÈÙÈ΋ Âʉڛ· ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ÛÙËÓ Ù·˘ÙÔÔ›ËÛË ÙÔ˘ ‰È·‚‹ÙË Ù‡Ô˘ 1", ÛÂÏ. 129-136, ÛËÌÂÈÒÓÔ˘Ó ÛÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ¿ÚıÚÔ˘ ÙÔ˘˜ fiÙÈ "...Ô Û·Î¯·Ú҉˘ ‰È·‚‹Ù˘ Â›Ó·È ÁÓˆÛÙfi˜ ÁÈ· ÂÚÈÛÛfiÙÂÚ· ·fi 2000 ¯ÚfiÓÈ·..." ·Ú·¤ÌÔÓÙ·˜ fï˜, Û ͤÓÔ ¿ÚıÚÔ. B‚·›ˆ˜, Î·È ·˘Ùfi ÙÔ ¿ÚıÚÔ ı· ÙÔ ÌÓËÌÔÓ‡ÛÔ˘Ó, ·ÏÏ¿ ηχÙÂÚ· ı· ‹Ù·Ó Ó· ›¯·Ó ÚÒÙ· ·Ó·Ê¤ÚÂÈ ÙÔ "¶ÂÚ› ‰È·‚ËÙ¤ˆ" ·fi ÙÔ ¤ÚÁÔ ÙÔ˘ AÚÂÙ·›Ô˘, "¶ÂÚ› ·ÈÙ›ˆÓ Î·È ÛËÌ›ˆÓ ¯ÚÔÓ›ˆÓ ·ıÒÓ" B, II. A˜ ÛËÌÂȈı› fiÙÈ Ù· ¿·ÓÙ· ÙÔ˘ AÚÂÙ·›Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó Û ‰‡Ô ÙfiÌÔ˘˜, Ì ÙÔ ·Ú¯·›Ô ΛÌÂÓÔ Î·È ·Ú¿ÏÏËÏ· Ì ÙË ÓÂÔÂÏÏËÓÈ΋ ÌÂÙ¿ÊÚ·ÛË, ·fi ÙȘ ÂΉfiÛÂȘ K¿ÎÙÔ˜. T¤ÏÔ˜, ÛÙÔ ¿ÚıÚÔ "H ÈÛÙÔÚ›· Ù˘ ·ÈÌÔÚÚÔÊÈÏ›·˜. EÈÙ‡ÁÌ·Ù· Î·È ÛÎȤ˜ ÙÔ˘ ¯ı˜ - ÚÔÛ‰Ô˘ Ù˘ ·‡ÚÈÔÓ", ÛÂÏ. 93-96, ÌÓËÌÔÓ‡ÂÙ·È ˆ˜ IÔÎÚ¿ÙÂÈÔ˜ ·Ú¯‹ ÙÔ "¶ÚÔÏ·Ì‚¿ÓÂÈÓ Î·È Ô˘¯› ıÂڷ‡ÂÈÓ", ¯ˆÚ›˜ ˆÛÙfiÛÔ Ó· ·Ó·Ê¤ÚÂÙ·È Ë ·Ú·ÔÌ‹ ÙÔ˘ ¤ÚÁÔ˘, ÛÙÔ ÔÔ›Ô Î·Ù·¯ˆÚ›˙ÂÙ·È ·˘Ù‹ Ë Ú‹ÛË. ™Ù· ¢ÚÂÙ‹ÚÈ· fï˜, Ù˘ IÔÎÚ·ÙÈ΋˜ ™˘ÏÏÔÁ‹˜, ·fi fiÛÔ ‰ÈÂÚ¢ӋıËÎ·Ó ‰ÂÓ ÂÓÙÔ›ÛÙËÎÂ Ë ·Ó·ÊÂÚfiÌÂÓË Ú‹ÛË. ¶Èı·ÓfiÓ, Ë Û˘ÁÁڷʇ˜ ı· ‹ıÂÏ ӷ ÌÓËÌÔÓ‡ÛÂÈ ÙË Ú‹ÛË "ˆÊÂϤÂÈÓ ‹ ÌË ‚Ï¿ÙÂÈÓ", Ô˘ Â›Ó·È ·fi ÙÔ "EȉËÌÈÒÓ ÙÔ ÚÒÙÔÓ" II, 5. ™˘ÓÔ„›˙ÔÓÙ·˜, ÓÔÌ›˙ˆ fiÙÈ Î·Ïfi ı· Â›Ó·È ÔÈ Û˘ÁÁÚ·Ê›˜ fiÙ·Ó ı· ı¤ÏÔ˘Ó Ó· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ˘˜ ·Ú¯·›Ô˘˜ ŒÏÏËÓ˜ È·ÙÚÔ‡˜, Ó· ÌÓËÌÔÓÂ‡Ô˘Ó ÚÒÙ· ÙËÓ ÂÏÏËÓÈ΋ ËÁ‹ ÙˆÓ ÎÂÈÌ¤ÓˆÓ ÙÔ˘˜, ÙËÓ ÔÔ›· ‡ÎÔÏ· ÌÔÚÔ‡Ó Ó· ·Ó·˙ËÙ‹ÛÔ˘Ó Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ó· ·Ú·ı¤ÙÔ˘Ó ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Í¤ÓË.
M ÙÈÌ‹ ¢ËÌ‹ÙÚÈÔ˜ K·Ú·ÌÂÚfiÔ˘ÏÔ˜, ¶·È‰›·ÙÚÔ˜ ¢È‰¿ÎÙˆÚ IÛÙÔÚ›·˜ Ù˘ I·ÙÚÈ΋˜
342
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·343
¶∞π¢π∞∆ƒπ∫∏ 2000;63:342-346
O˘Î Â’ ¿ÚÙˆ ÌfiÓÔÓ ˙‹ÛÂÙ·È ¿ÓıÚˆÔ˜...
Y¿Ú¯Ô˘Ó ÔÏÏÔ› Û˘Ó¿‰ÂÏÊÔÈ ÌÂٷ͇ Ì·˜, ÔÈ ÔÔ›ÔÈ ÂÎÙfi˜ ·fi ÙÔ ÌÂÚ¿ÎÈ Ù˘ I·ÙÚÈ΋˜ ÂȉÈÎfiÙËÙ·˜ ¤¯Ô˘Ó Î·È ÙÔ ÂӉȷʤÚÔÓ ÙÔ˘˜ ÛÙËÓ Ù¤¯ÓË, ÛÙË ÌÔ˘ÛÈ΋, ÛÙ· ÁÚ¿ÌÌ·Ù·, ÛÙÔÓ ·ıÏËÙÈÛÌfi. M ÙËÓ È‰ÈfiÙËÙ· ÙÔ˘ ·˘ÙÔ‰‡ÙË-ʈÙÔÁÚ¿ÊÔ˘, ı· ÌÔ˘ ÂÈÙÚ¤„ÂÙ ӷ ÌÔÈÚ·ÛÙÒ Ì·˙› Û·˜ (·Ó ÙÂÏÈο ‰ËÌÔÛȇÛÂÙ ¤Á¯ÚˆÌ˜ ÙȘ ʈÙÔÁڷʛ˜ Ô˘ ÙÚ¿‚ËÍ· ÙËÓ 25.05.2000 ÛÙÔÓ ¶·Á·ÛËÙÈÎfi) ÙË ı¤· ÂÓfi˜ ˘Ôı·Ï¿ÛÛÈÔ˘ Î·È ÂÓfi˜ ·Ú·ı·Ï¿ÛÛÈÔ˘ ÙÔ›Ô˘, ÚÈÓ ÍÂÛ¿ÛÂÈ ¤Ó· ÙÔÈÎfi ÌÔ˘Ú›ÓÈ. M·ÚÙ˘ÚÔ‡Ó fiÙÈ Ë ·ÙÚ›‰· Ì·˜, ·fi ·fi„ˆ˜ ÔÈÎÔÏÔÁ›·˜ ÙÔ˘Ï¿¯ÈÛÙÔÓ, ¤¯ÂÈ ·ÎfiÌË ÔÏÏ¿ Ó· ÚÔÛʤÚÂÈ Î·È ÛÙÔ Ì¤ÏÏÔÓ, ·ÚΛ Ó· ·Ó·ıÚ¤„Ô˘Ì ٷ ·È‰È¿ Î·È ˆ˜ ÔÈÎÔÏfiÁÔ˘˜. M ·ÊÔÚÌ‹ ·˘Ù‹ ÙË ‰ËÌÔÛ›Â˘ÛË, ›Ûˆ˜ ÎÚ›ÓÂÙ fiÙÈ ÁÈ· Ó· ÁÓˆÚÈÛÙԇ̠ηχÙÂÚ· ÌÂٷ͇ Ì·˜, Û οı Ù‡¯Ô˜ ·Ó·ÁÚ¿ÊÂÙÂ Î·È ¤Ó· Û¯fiÏÈÔ ÁÈ· Ù· ÂӉȷʤÚÔÓÙ· ÙˆÓ Û˘Ó·‰¤ÏÊˆÓ ÛÙËÓ Ù¤¯ÓË. Y¿Ú¯Ô˘Ó Î·È ÔÏÏÔ› Î·È Ì ÔÏÏ¿ ÂӉȷʤÚÔÓÙ·.
MÂ Û˘Ó·‰ÂÏÊÈÎÔ‡˜ ¯·ÈÚÂÙÈÛÌÔ‡˜ £Âfi‰ˆÚÔ˜ ¶ÂÚÚ¿Î˘
343
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·344
¶∞π¢π∞∆ƒπ∫∏ 2000;63:342-346
¶·È‰È¿ ∞Ï‚·ÓÈ΋˜ ηٷÁˆÁ‹˜ ÛÙ· ¡ÔÛÔÎÔÌ›· K˘Ú›Â˜ Î·È Î‡ÚÈÔÈ Ù˘ ™‡ÓÙ·Í˘, ™ÙÔ ÙÚ›ÙÔ Ù‡¯Ô˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ "¶AI¢IATPIKH" Î·È ÛÙÔ ÎÂÊ¿Ï·ÈÔ "¶AI¢IATPIKH ENHMEPø™H" ·Ó·Ê¤ÚÂÙ·È Ô ÏfiÁÔ˜ Ô˘ ‰ËÌÔÛȇıËΠÛÙÔ ÂÚÈÔ‰ÈÎfi Ë ÂȉËÌ›· ÈÏ·Ú¿˜ ÛÙËÓ AÏ‚·Ó›· ·fi ÙÔ˘˜ Û˘Ó·‰¤ÏÊÔ˘˜ ÙÔ˘ NÔÛÔÎÔÌ›Ԣ "MËÙ¤Ú· TÂÚ¤˙·" ÙˆÓ TÈÚ¿ÓˆÓ (1). EÈÛËÌ·›ÓÂÙ·È fiÙÈ "™ÙËÓ ·È‰È·ÙÚÈ΋ ÎÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ ‹‰Ë ·fi ÙËÓ ÂÓÙ·ÂÙ›· 1991-1994 Ù· ·È‰È¿ AÏ‚·ÓÈ΋˜ ηٷÁˆÁ‹˜ Î¿Ï˘Ù·Ó 16% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÂÈÛ·ÁˆÁÒÓ" (1). TÔ ÛÙÔÈ¯Â›Ô ·˘Ùfi Â›Ó·È ·Ôχو˜ ·Ó·ÎÚÈ‚¤˜, Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘, Â͈ڷÁÌ·ÙÈÎfi. §fiÁˆ Ù˘ Ì·ÎÚ¿˜ ÌÔ˘ ıËÙ›·˜ ˆ˜ ‰È¢ı˘ÓÙ‹ Ù˘ ¶·ÓÂÈÛÙËÌȷ΋˜ ¶·È‰È·ÙÚÈ΋˜ KÏÈÓÈ΋˜ ÙˆÓ Iˆ·ÓÓ›ÓˆÓ ·fi ÙÔ 1979 ̤¯ÚÈ ÙÔ 1997 ı· Ú¤ÂÈ Ó· Û·˜ ÂÓËÌÂÚÒÛˆ fiÙÈ ·fi Ù· ÛÙÔȯ›· Ù˘ ÎÏÈÓÈ΋˜ ÚÔ·ÙÂÈ fiÙÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ÓÔÛËÏ¢fiÌÂÓˆÓ ·È‰ÈÒÓ AÏ‚·ÓÈ΋˜ ηٷÁˆÁ‹˜ ηٿ ̤ÛÔ fiÚÔ ÌfiÏȘ ÏËÛ›·˙ ÙÔ 7% οı ¯ÚfiÓÔ. ¶ÚÔÙ¿ÛÛÔÓÙ·˜ ÙË ÏÔÁÈ΋ ÙˆÓ ·ÚÈıÌÒÓ ı· Ú¤ÂÈ Ó· Ï¿‚ÂÙ ˘fi„Ë Û·˜ fiÙÈ ·fi 1-1-1990 ̤¯ÚÈ 31-12-1995 ÓÔÛËχıËÎ·Ó ÛÙËÓ ÎÏÈÓÈ΋ 24.534 ·È‰È¿. EÏÏËÓÈ΋˜ ˘ËÎÔfiÙËÙ·˜ 22.823 (93,03%) Î·È AÏ‚·ÓÈ΋˜ ηٷÁˆÁ‹˜ 1.711 (6,97%) (2). T· ÛÙÔȯ›· ‚Ú›ÛÎÔÓÙ·È ÛÙË ‰È¿ıÂÛË fiÛˆÓ ÂÈı˘ÌÔ‡Ó Ó· Ù· ÌÂÏÂÙ‹ÛÔ˘Ó ‰Â‰Ô̤ÓÔ˘ fiÙÈ ÌÔÚÔ‡Ó Ó· Ù· ·Ó·˙ËÙ‹ÛÔ˘Ó ÛÙËÓ ·È‰È·ÙÚÈ΋ ‚È‚ÏÈÔÁÚ·Ê›· ÛÙË °Ú·ÌÌ·Ù›· Ù˘ ¶·ÓÂÈÛÙËÌȷ΋˜ ¶·È‰È·ÙÚÈ΋˜ KÏÈÓÈ΋˜, ÛÙ· ÂÚ·Á̤ӷ ÙÔ˘ ¶·ÓÂÈÛÙËÌÈ·ÎÔ‡ NÔÛÔÎÔÌ›Ԣ Iˆ·ÓÓ›ÓˆÓ ·ÏÏ¿ Î·È ÛÙÔÓ AıËÓ·˚Îfi Ù‡Ô (3) fiÔ˘ ‰ËÌÔÛȇÙËÎÂ Û˘ÁÎÚÔÙË̤ÓË ÂÈÎfiÓ· Ù˘ Èı·Á¤ÓÂÈ·˜ ÙˆÓ ÓÔÛËÏ¢fiÌÂÓˆÓ ·È‰ÈÒÓ ·fi ÙÔÓ ÁÚ¿ÊÔÓÙ·, ÏfiÁˆ ÙÔ˘ ÁÂÁÔÓfiÙÔ˜ fiÙÈ Ë ÏÔÁÈ΋ ÙˆÓ ·ÚÈıÌÒÓ Â›¯Â Î·È ÙfiÙ ηÎÔÔÈËı› ·fi ÂÚ¢ÓËÙÈ΋ ÔÌ¿‰· ÙˆÓ AıËÓÒÓ Ì ÙË ‰ËÌÔÛ›Â˘ÛË ¿ÚıÚÔ˘ ÛÙËÓ ¤ÁÎÚÈÙË ÂÊËÌÂÚ›‰· K·ıËÌÂÚÈÓ‹ (4) ˘fi ÙÔÓ Â͈ڷÁÌ·ÙÈÎfi fiÛÔ Î·È ÍÂÓfiÊÔ‚Ô Ù›ÙÏÔ "¶·ÓÂÈÛÙËÌȷ΋ KÏÈÓÈ΋ ÁÈ·... AÏ‚·Ó¿ÎÈ·"! TÔ ˆ˜ ¿Óˆ ¿ÚıÚÔ ÛÙËÓ K·ıËÌÂÚÈÓ‹ ÛÙËÚ›¯ıËΠ۠ÛÙÔȯ›· Ô˘ Û˘Ó¤Ù·Í ÂÚ¢ÓËÙÈ΋ ÔÌ¿‰· ÙˆÓ AıËÓÒÓ, Ë ÔÔ›· ‰ÂÓ ÂÚ‡ÓËÛ ÂÈÙfiÔ˘ ÙÔ ı¤Ì·, ‰ÂÓ Î·ÙfiÙ¢Û ÙÔ˘˜ ¯ÒÚÔ˘˜, ‰ÂÓ Â›‰Â ȉ›ÔȘ fiÌÌ·ÛÈ ÙËÓ Î·Ù¿ÛÙ·ÛË, fï˜ ›¯Â ÙËÓ ÙfiÏÌË Ó· ·ÔÊ·Óı› ÂÍ ·ÔÛÙ¿Ûˆ˜. ¢˘ÛÙ˘¯Ò˜ Ë ‰ËÌÔÛÈÔÁÚ¿ÊÔ˜ Î. N. K·Ú·ÌÔ‡˙Ë Ô˘ Û˘Ó¤Ù·Í ÙÔ ¿ÚıÚÔ ‰ÂÓ ˙‹ÙËÛ ÙË ÁÓÒÌË ÙˆÓ Â¯fiÓÙˆÓ ÙfiÙ ÙËÓ Â˘ı‡ÓË Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ¶·ÓÂÈÛÙËÌȷ΋˜ KÏÈÓÈ΋˜ ÙˆÓ Iˆ·ÓÓ›ÓˆÓ, ÒÛÙ ӷ ¤¯ÂÈ ÙË ¯·Ú¿ ÙÔ˘ ·ÓÙÈÏfiÁÔ˘, ·ÏÏ¿ ÂÏ·ÊÚ¿ ÙË Î·Ú‰›·, ·Ó·Î‹Ú˘Í ÙËÓ ÎÏÈÓÈ΋ domaine reservé ÙˆÓ ·Ï‚·ÓÔ·›‰ˆÓ (4). E˘Ù˘¯Ò˜, Ë Ú·ÁÌ·ÙÈÎfiÙËÙ· ‰È¤„¢Û ·ÌÊÔÙ¤ÚÔ˘˜ (2). T· ÛÙÔȯ›· Ô˘ ·Ó·Ê¤ÚÔ˘Ó Ù· ÂÈÛÙËÌÔÓÈο, ȉ›ˆ˜ Ù· È·ÙÚÈο ÂÚÈÔ‰Èο Î·È Î˘Ú›ˆ˜ ÙÔ ÓÔ‡ÌÂÚÔ Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È Â·ÚÎÒ˜ Î·È Â·ÓÂÈÏËÌ̤ӷ ÁÈ· Ó· ÏËÛÈ¿˙ÂÈ ÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜, ÒÛÙ ÔÈ ‰È·ÚıÚˆÙÈΤ˜ ·ÏÏ·Á¤˜ Ó· Â›Ó·È Â‡ÛÙԯ˜, ·ÔÙÂÏÂÛÌ·ÙÈΤ˜ Î·È Ó· ‰›ÓÔ˘Ó Ï‡ÛË ÛÙÔ Úfi‚ÏËÌ· Î·È fi¯È Ó· ‰ËÌÈÔ˘ÚÁÔ‡Ó ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ÎÏÈÓÈÎÒÓ, ȉ›ˆ˜ Ù˘ ·گ›·˜. °È· ÌÈ· ÊÔÚ¿ ·ÎfiÌË ·Ô‰Â›¯ıËΠfiÙÈ Ë ÌÂÙÚÈÔ¿ıÂÈ·, Ë Û‡ÓÂÛË Î·È Ô ÚÔÛÂÎÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÛÙÔȯ›ˆÓ ·ÔÙÂÏÔ‡Ó fiÏÔ ÛÙ· ¯¤ÚÈ· fiÛˆÓ ÂÈı˘ÌÔ‡Ó Ú·ÁÌ·ÙÈο Ó· Ï˘ıÔ‡Ó Ù· ÚÔ‚Ï‹Ì·Ù·. M ÙÈÌ‹ ¶¤ÙÚÔ˜ ¢. §··ÙÛ¿Ó˘ OÌ. K·ıËÁËÙ‹˜ - ¢È¢ı˘ÓÙ‹˜ ¶·Ó/΋˜ ¶·È‰È·ÙÚÈ΋˜ KÏÈÓÈ΋˜ ÙˆÓ Iˆ·ÓÓ›ÓˆÓ (1979-1997) BÈ‚ÏÈÔÁÚ·Ê›· 1. H ™‡ÓÙ·ÍË. ¶AI¢IATPIKH ENHMEPø™H. ¶·È‰È·ÙÚÈ΋ 2000;63:254-261. 2. °·Ï·Ó¿Î˘ E., KÚ¿ÏÏ˘ N., NÙÔ‡ÚÔ˜ £., E˘·ÁÁÂÏ›‰Ô˘ E., AÓ‰ÚÔÓ›ÎÔ˘ ™., ™È·ÌÔÔ‡ÏÔ˘ A. NÔÛËÏ›· ·È‰ÈÒÓ ·Ï‚·ÓÈ΋˜ ˘ËÎÔfiÙËÙ·˜: Ú·ÁÌ·ÙÈÎfiÙËÙ·, ÚÔ‚Ï‹Ì·Ù·, ÚÔÔÙÈΤ˜. ¶·È‰È·ÙÚÈ΋ 1998;61:276-286. 3. §··ÙÛ¿Ó˘ ¶. ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ Iˆ·ÓÓ›ÓˆÓ. KA£HMEPINH -°PAMMATA 20 I·ÓÔ˘·Ú›Ô˘ 1996. 4. K·Ú·ÌÔ‡˙Ë N. ¶·ÓÂÈÛÙËÌȷ΋ KÏÈÓÈ΋ ÁÈ·... AÏ‚·Ó¿ÎÈ·. KA£HMEPINH 4 I·ÓÔ˘·Ú›Ô˘ 1996.
344
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·345
¶∞π¢π∞∆ƒπ∫∏ 2000;63:342-346
¶·È‰È¿ ∞Ï‚·ÓÈ΋˜ ηٷÁˆÁ‹˜ ÛÙ· ¡ÔÛÔÎÔÌ›· A¿ÓÙËÛË ·fi ÙË ™‡ÓÙ·ÍË
E›Ó·È Ôχ ÎÔϷ΢ÙÈÎfi ÁÈ· ÙËÓ ¶AI¢IATPIKH Ó· ‰È·‚¿˙ÂÈ Ô ¶¤ÙÚÔ˜ §··ÙÛ¿Ó˘ ·ÎfiÌË Î·È ÙËÓ ¶·È‰È·ÙÚÈ΋ EÓË̤ڈÛË Î·È ·ÎfiÌË ÎÔϷ΢ÙÈÎfiÙÂÚÔ Ó· Ì·›ÓÂÈ ÛÙÔÓ ÎfiÔ Ó· ÛÙ›ÏÂÈ ÂÈÛÙÔÏ‹. E˘¯·ÚÈÛÙÔ‡ÌÂ. H ÏËÚÔÊÔÚ›· ÁÈ· ÙÔ 16% ÚÔ¤Ú¯ÂÙ·È ·fi ÙËÓ ÂÚÁ·Û›· ÙˆÓ ¶. §··ÙÛ¿ÓË, I. ¶··Â˘ÛÙ·ı›Ô˘, X. ¶ÂÙÛÔ‡ÎË, M. T˙Ô‡ÊË, E. °·Ï·Ó¿ÎË. "NÔÛÔÎÔÌÂȷ΋ ÂÚ›ı·Ï„Ë ·È‰ÈÒÓ AÏ‚·ÓÈ΋˜ ˘ËÎÔfiÙËÙ·˜" 33Ô ¶·ÓÂÏÏ. ¶·È‰ ™˘Ó 1995, AA257 fiÔ˘ ÁÚ¿ÊÂÙ·È: "™ÙËÓ ¶·ÓÂÈÛÙËÌȷ΋ ¶·È‰È·ÙÚÈ΋ KÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ Iˆ·ÓÓ›ÓˆÓ ÔÈ ÂÈÛ·ÁˆÁ¤˜ ÙˆÓ ·È‰ÈÒÓ AÏ‚·ÓÈ΋˜ ˘ËÎÔfiÙËÙ·˜ ¤ÊÙ·Û·Ó Î·Ù¿ ÙËÓ ÙÂÙÚ·ÂÙ›· 1991-1994 ÙȘ 1.516 (16% ÙÔ˘ Û˘ÓfiÏÔ˘ ÂÈÛ·ÁˆÁÒÓ Ù˘ KÏÈÓÈ΋˜)". OÈ ÂȉËÌÈÔÏÔÁÈΤ˜ Û¯¤ÛÂȘ Ì ÙÔÓ AÏ‚·ÓÈÎfi ÏËı˘ÛÌfi ÂȂ‚·ÈÒÓÔÓÙ·È ·fi Ù· ÛÙÔȯ›· Ô˘ ‰›ÓÂÈ Ô Î. §··ÙÛ¿Ó˘. ¢ÂÓ ·Ó·ÈÚÔ‡ÓÙ·È ·Ó ÙÔ ÔÛÔÛÙfi ÙˆÓ ÂÈÛ·ÁˆÁÒÓ ÛÙ· ÓÔÛÔÎÔÌ›· Â›Ó·È 6% ·ÓÙ› 16% Ô˘ ˘ÔÏfiÁÈ˙ ·Ï·ÈfiÙÂÚ·. AÏÏ¿, ÁÈ·Ù› ÔÈ ÚÔÛ‚ÏËÙÈΤ˜ ‰˘Ô ÙÂÏÂ˘Ù·›Â˜ ·Ú¿ÁÚ·ÊÔÈ; £· ‹Ù·Ó ¿‰ÈΘ ·ÎfiÌË ÎÈ ·Ó ›¯·Ì ·ÓÙÈÁÚ¿„ÂÈ Ï¿ıÔ˜ ÙÔ ÓÔ‡ÌÂÚÔ. H ˘ÔÁÚ¿ÊÔ˘Û· Â›Ó·È ‚·ı‡Ù·Ù· ¢ÁÓÒÌˆÓ ÁÈ· ÙȘ ÂÔÈÎÔ‰ÔÌËÙÈΤ˜ ηÙÛ¿‰Â˜ ÙÔ˘ ÂÈÛÙÔÏÔÁÚ¿ÊÔ˘ Ô˘ ‰È·ÌfiÚÊˆÛ·Ó ÙËÓ ÎÏÈÓÈ΋ Ù˘ ÛΤ„Ë ÛÙËÓ ·Ú¯‹ Ù˘ ÛÙ·‰ÈÔ‰ÚÔÌ›·˜ Ù˘. AÏÏ¿ Ó· ηÙËÁÔÚÂ›Ù·È ÁÈ· ¤ÏÏÂÈ„Ë ÛÔ‚·ÚfiÙËÙ·˜ Î·È ¤ÏÏÂÈ„Ë Â·ÚÎÔ‡˜ ÂϤÁ¯Ô˘ ÙˆÓ ÁÚ·ÙÒÓ Ù˘, ‰ÂÓ ÙÔ ·Í›˙ÂÈ. K·È ÙËÓ ·›ÚÓÂÈ ÙÔ ·Ú¿ÔÓÔ...
°È· ÙËÓ E.™.E. EϤÓË B·Ï¿ÛÛË-A‰¿Ì
345
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·346
¶∞π¢π∞∆ƒπ∫∏ 2000;63:342-346
X·ÚÙÔÁÚ¿ÊËÛË ÁÔÓȉÈÒÌ·ÙÔ˜ Î·È ˘Á›·
K¿ı ÛÙ·ıÌfi˜ ÂÈÛÙËÌÔÓÈ΋˜ ÚÔfi‰Ô˘ Â›Ó·È ¿ÍÈÔ˜ ÂÔÚÙ·ÛÌÔ‡. AÚΛ ÙÔ Â›Ù¢ÁÌ· Ó· ÂÚÌËÓ‡ÂÙ·È ÛˆÛÙ¿ Î·È Ó· ÌËÓ ‰ËÌÈÔ˘ÚÁ› Â͈ڷÁÌ·ÙÈΤ˜ ÚÔÛ‰Ô˘, fiˆ˜ ‰˘ÛÙ˘¯Ò˜ Û˘Ó¤‚Ë ÙËÓ Â‚‰ÔÌ¿‰· ·˘Ù‹ - NÈ΋ıËÎ·Ó ÔÈ ·ÚÚÒÛÙȘ, ÓÈ΋ıËΠÙÔ Á‹Ú·˜ - ÕÂÈÚ˜ Û˘ÓÂÓÙ‡ÍÂȘ Ì ÛÔ‚·ÚÔ‡˜ Î·È ÏÈÁfiÙÂÚÔ ÛÔ‚·ÚÔ‡˜ ÂÈÛÙ‹ÌÔÓ˜. £· ¤Ú fï˜, ÚˆÙ›ÛÙˆ˜ Ó· ÂÚˆÙËı› Ô Î·ıËÁËÙ‹˜ Î. ºÒÙ˘ K·Ê¿ÙÔ˜, °ÂÓÈÎfi˜ ¢È¢ı˘ÓÙ‹˜ ÙÔ˘ E˘Úˆ·˚ÎÔ‡ K¤ÓÙÚÔ˘ MÔÚȷ΋˜ BÈÔÏÔÁ›·˜ Ô˘ ‰Ú‡ÂÈ ÛÙË X·˚‰ÂÏ‚¤ÚÁË Î·È Û˘ÓÙÔÓ›˙ÂÈ Ù· ÈÔ ÛËÌ·ÓÙÈο ΤÓÙÚ· ÌÔÚȷ΋˜ ‚ÈÔÏÔÁ›·˜ ÙˆÓ ÎÚ·ÙÒÓ ÌÂÏÒÓ Ù˘ E˘Úˆ·˚΋˜ ŒÓˆÛ˘. TÔÓ ·ÚÂÏıfiÓÙ· M¿ÚÙÈÔ, fiÙ·Ó ÙÔ˘ ·ÔÓÂÌ‹ıËΠÙÔ AÚÈÛÙÂ›Ô Ù˘ Aη‰ËÌ›·˜, ÌÔ˘ › ¯·Ú·ÎÙËÚÈÛÙÈο: AÓ ¯ÚÂÈ¿ÛıËÎ·Ó 10 ÂÚ›Ô˘ ¯ÚfiÓÈ· ÁÈ· ÙË ¯·ÚÙÔÁÚ¿ÊËÛË ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÁÔÓȉÈÒÌ·ÙÔ˜ ı· ¯ÚÂÈ·Ûı› ÂӉ¯Ô̤ӈ˜ ¤Ó·˜ ·ÈÒÓ·˜ ÁÈ· ÙËÓ ·ÎÚÈ‚‹ ·ÔÎ¿Ï˘„Ë Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘. AÛÊ·ÏÒ˜ ı· ˆÊÂÏËı› - Û ÌÈÎÚ‹ Îϛ̷η - Ë È·ÙÚÈ΋ ·fi Ù· Û˘ÓÙÂÏÔ‡ÌÂÓ· ÂÚ¢ÓËÙÈο ÂÈÙ‡ÁÌ·Ù· ÌÂÙ¿ 10 ÂÚ›Ô˘ ¯ÚfiÓÈ·. OÈ Û˘¯ÓÔ› Î·È ˘ÂÚ‚ÔÏÈÎÔ› ÂÔÚÙ·ÛÌÔ› ÁÈ· ÙȘ ÂÈÙÂÏÔ‡ÌÂÓ˜ È·ÙÚÔ‚ÈÔÏÔÁÈΤ˜ ÚÔfi‰Ô˘˜ Ì·˜ ·Ú·Û‡ÚÔ˘Ó ¤Íˆ ·fi ÙË ˙¤Ô˘Û· Ú·ÁÌ·ÙÈÎfiÙËÙ· Ô˘ ‰È‰¿ÛÎÂÈ fiÙÈ Ô ÌÂÁ·Ï‡ÙÂÚÔ˜ Û‡ÌÌ·¯Ô˜ Ù˘ ˘Á›·˜ Ì·˜ Â›Ó·È Ë ·˘ÙÔÊÚÔÓÙ›‰·. ŸÏÔÈ ÁÓˆÚ›˙Ô˘Ì fiÙÈ ÔÈ ÌÂÁ¿ÏÔÈ Â¯ıÚÔ› Ù˘ ˘Á›·˜ Ì·˜ Â›Ó·È ÙÔ Î¿ÓÈÛÌ·, Ë ·¯˘Û·ÚΛ·, Ë Î·ıÈÛÙÈ΋ ˙ˆ‹, ÙÔ ¿Á¯Ô˜, Ë ·˘ÙÔηٷÛÙÚÔÊÈ΋ ÙÚÔ¯·›· Û˘ÌÂÚÈÊÔÚ¿ Î·È Ù· Û˘Ó·Ê‹. H ·ÔÊ˘Á‹ ÙÔ˘˜ Û˘ÓÂÈÛʤÚÂÈ ÛÙË Ì·ÎÚÔË̤Ú¢ÛË Î·È ÛÙËÓ ÔÈfiÙËÙ· ˙ˆ‹˜ Ì·˜ ‰ÂηϿÛÈ· ·fi ÙËÓ È·ÙÚÈ΋. °È· Ó· ˆÊÂÏËıԇ̠·fi Ù· ÌÂÏÏÔÓÙÈο È·ÙÚÈο ı·‡Ì·Ù· Ú¤ÂÈ ÚÒÙÔÓ Ó· ˘¿Ú¯Ô˘ÌÂ Î·È ‰Â‡ÙÂÚÔ Ó· ÌËÓ ¤¯Ô˘Ì ÂÈÙÚ¤„ÂÈ Ó· ˘ÔÛÙ› Ë ˘Á›· Ì·˜ ·Ó·ÓfiÚıˆÙ˜ ‚Ï¿‚˜. H ÌÂÁ·Ï‡ÙÂÚË ÚfiÔ‰Ô˜ Ù˘ Û‡Á¯ÚÔÓ˘ È·ÙÚÈ΋˜ Î·È Ë ÌÂÁ·Ï‡ÙÂÚË Û˘ÓÂÈÛÊÔÚ¿ Ù˘ ÛÙËÓ ˘Á›· Ì·˜ Â›Ó·È Ë Û˘ÓÂȉËÙÔÔ›ËÛË Ù˘ ·Í›·˜ Ù˘ ·˘ÙÔÊÚÔÓÙ›‰·˜.
K·ıËÁËÙ‹˜ N. M·ÙÛ·ÓÈÒÙ˘ °ÂÓÈÎfi˜ °Ú·ÌÌ·Ù‡˜ Ù˘ Aη‰ËÌ›·˜ AıËÓÒÓ
AÓ·‰ËÌÔÛ›Â˘ÛË ·fi ÙËÓ K·ıËÌÂÚÈÓ‹
346
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·347
¶∞π¢π∞∆ƒπ∫∏ 2000;63:347
¶AI¢IATPIK∏ ∂¡∏ª∂ƒø™∏
∞fi ÙËÓ ∂. µ·Ï¿ÛÛË-∞‰¿Ì AÏÏ·Á‹ ™‡ÓÙ·Í˘ H EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ Û˘ÌÏ‹ÚˆÛ ‰‡Ô ¯ÚfiÓÈ· ‰Ô˘ÏÂÈ¿˜ ÛÙËÓ ¶AI¢IATPIKH Î·È ı· ·Ú·‰ÒÛÂÈ Ù· ·Ú¯Â›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ ÛÙÔÓ Ó¤Ô ‰È¢ı˘ÓÙ‹ Û‡ÓÙ·Í˘ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔ ™˘Ó¤‰ÚÈÔ ÔfiÙ ·Ó·Ï·Ì‚¿ÓÂÈ Î·È ÙÔ Ó¤Ô ¢ÈÔÈÎËÙÈÎfi ™˘Ì‚Ô‡ÏÈÔ Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜. TÔ 5Ô Ù‡¯Ô˜ ÙÔ˘ 2000 ı· ‰ÈÂÎÂڷȈı› ·fi ÙËÓ ÂfiÌÂÓË E.™.E. ÂÓÒ Ë ÚÒËÓ... ı· οÓÂÈ ¿ÓÂÙ· ÙȘ ‰È·ÎÔ¤˜ Ù˘! H ¶AI¢IATPIKH ·Ó¤Î·ıÂÓ ÛÙËÚÈ˙fiÙ·Ó ÛÙÔÓ "·ÙÚȈÙÈÛÌfi ÙˆÓ Û˘ÓÙ·ÎÙÒÓ Ù˘" Î·È ‰ÂÓ Ù· ηٷʤÚÓÂÈ ÎÈ ¿ÛÎËÌ·, ·ÏÏ¿ ·˘Ùfi ‰ÂÓ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Û˘Ó¯›˙ÂÙ·È. ™ÙȘ ÚԉȷÁڷʤ˜ ÂÓfi˜ Û‡Á¯ÚÔÓÔ˘, ¤ÁÎÚÈÙÔ˘ ÂÈÛÙËÌÔÓÈÎÔ‡ ÂÚÈÔ‰ÈÎÔ‡ Î·È ÛÙ· ÎÚÈÙ‹ÚÈ· ·ÍÈÔÏfiÁËÛ‹˜ ÙÔ˘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Î·Ù·ÛÙ·ÙÈÎfi Î·È Î·ÓÔÓÈÛÌfi˜ ÏÂÈÙÔ˘ÚÁ›·˜. H ·ÚÔ‡Û· E.™.E. ¤¯ÂÈ Î·Ù·ı¤ÛÂÈ ¤Ó· Û¯¤‰ÈÔ Î·ÓÔÓÈÛÌÔ‡ ÏÂÈÙÔ˘ÚÁ›·˜ Ì·˙› Ì ÚÔÙ¿ÛÂȘ ÁÈ· ÙÚÔÔÔÈ‹ÛÂȘ Ô˘ ¤ÁÈÓ·Ó ·fi Ù· ̤ÏË Ù˘ Î·È ·fi ÙÔ˘˜ ÚÔËÁÔ‡ÌÂÓÔ˘˜ ‰È¢ı˘ÓÙ¤˜ Û‡ÓÙ·Í˘ (£. K·Ú¿ıÈÔ, N. M·ÓˆÏ¿ÎË, ™. X·˚‰¿, X. M·ÚÙÛfiη) ÙÔ˘˜ ÔÔ›Ô˘˜ Û˘Ì‚Ô˘Ï‡ÙËÎÂ. EÏ›˙Ô˘Ì ÙÔ ¢ÈÔÈÎËÙÈÎfi ™˘Ì‚Ô‡ÏÈÔ Ù˘ E.¶.E. Ó· ÙÔ ÂÂÍÂÚÁ·ÛÙ› fiÛÔ ÓÔÌ›˙ÂÈ fiÙÈ ¯ÚÂÈ¿˙ÂÙ·È Î·È Ó· ηϤÛÂÈ Û‡ÓÙÔÌ· ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ Û ηٷÛÙ·ÙÈ΋ ÁÂÓÈ΋ Û˘Ó¤Ï¢ÛË ÁÈ· Ó· Ù·ÎÙÔÔÈËı› ÙÔ ı¤Ì·.
*** N¤ÔÈ Î·ıËÁËÙ¤˜ ·È‰È·ÙÚÈ΋˜ Afi Ù· Ôχ ¢¯¿ÚÈÛÙ· ·È‰È·ÙÚÈο Ó¤·: ÂÍÂÏ›¯ÙËÎ·Ó Û ηıËÁËÙ¤˜ ÚÒÙ˘ ‚·ıÌ›‰·˜ ÔÈ Û˘Ó¿‰ÂÏÊÔÈ: A. KˆÛÙ·ÓÙfiÔ˘ÏÔ˜, A. ¢¿ÎÔ˘-BÔ˘ÙÂÙ¿ÎË, £. K·Ú¿ıÈÔ˜, º. K·Ó·ÎÔ‡‰Ë- T۷ηϛ‰Ô˘. E›Ó·È fiÏÔÈ ÁÓˆÛÙÔ› ÛÙÔ˘˜ ·Ó·ÁÓÒÛÙ˜ Ù˘ ¶AI¢IATPIKH™ ÎÈ Ô ÂÏÏËÓÈÎfi˜ ·È‰È·ÙÚÈÎfi˜ Ù‡Ô˜ ÙÔ˘˜ ÔÊ›ÏÂÈ ÔÏÏ¿. TÔÓ ¤¯Ô˘Ó ˘ÔÛÙËÚ›ÍÂÈ fi¯È ÌfiÓÔ ˆ˜ Û˘ÁÁÚ·Ê›˜ ·ÏÏ¿ Î·È ˆ˜ ‰È¢ı˘ÓÙ¤˜ Û‡ÓÙ·Í˘, Û˘ÓÙ¿ÎÙ˜ Î·È ÎÚÈÙ¤˜. £ÂÚÌfiٷٷ Û˘Á¯·ÚËÙ‹ÚÈ·! O ηıËÁËÙ‹˜ °. XÚÔ‡ÛÔ˜ Ô˘ ÂÍÂϤÁË ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ 1999 ¤¯ÂÈ Ï·ÌÂÚ‹ ·ÚÔ˘Û›· ÛÙÔÓ Í¤ÓÔ ÂÈÛÙËÌÔÓÈÎfi Ù‡Ô ·ÏÏ¿ fi¯È ÛÙÔÓ ÂÏÏËÓÈÎfi, ·È‰È·ÙÚÈÎfi. AÓÙ·ÔÎÚ›ıËΠÚfiı˘Ì· ÛÙËÓ ÚfiÛÎÏËÛË Ù˘ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜ Ó· ÁÚ¿„ÂÈ ¤Ó· ¿ÚıÚÔ Û‡ÓÙ·Í˘ ÁÈ· ÙËÓ ¶AI¢IATPIKH (ÛÂÏ. 275-277 ). K·Ï‹ ·Ú¯‹!
*** K¤ÓÙÚÔ ¢ËÏËÙËÚÈ¿ÛÂˆÓ Afi ÙÔ˘˜ ¢¯¿ÚÈÛÙÔ˘˜ ÛÙ·ıÌÔ‡˜ Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜: ÙÔ K¤ÓÙÚÔ ¢ËÏËÙËÚÈ¿ÛÂˆÓ Û˘ÌÏ‹ÚˆÛ 25 ¯ÚfiÓÈ· ÏÂÈÙÔ˘ÚÁ›·˜. T· ÁÈfiÚÙ·Û Û ÌÈ· Ôχ ÛÂÌÓ‹ ÂÔÚÙ·ÛÙÈ΋ ÂΉ‹ÏˆÛË fiÔ˘ ·ÚÎÂÙÔ› ÔÌÈÏËÙ¤˜ ·Ó·Ê¤ÚıËÎ·Ó ÛÙÔ Ò˜ ÍÂΛÓËÛ ÙÔ K¤ÓÙÚÔ. H ˘Ê˘Ô˘ÚÁfi˜ YÁ›·˜ ΢ڛ· XÚÈÛÙ¿ÎË ˘ÔÛ¯¤ıËΠÌÂÏÏÔÓÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙÔ˘ ¤ÚÁÔ˘ ÙÔ˘ K¤ÓÙÚÔ˘ (˘Ô˘ÚÁfi˜ ›ӷÈ, ÌÔÚ› Ú¿ÁÌ·ÙÈ Ó· ÙÔ ˘ÔÛÙËÚ›ÍÂÈ). AӷʤÚıËΠ›Û˘ ÛÙËÓ ˘ÔÛÙ‹ÚÈÍË Ô˘ ¤¯ÂÈ ‰Â¯ı› Ë ›‰È· ·fi ÙÔ K¤ÓÙÚÔ ¢ËÏËÙËÚÈ¿ÛÂˆÓ ˆ˜ ·ÁÁÂÏÌ·Ù›·˜ ˘Á›·˜ Î·È Â˘¯·Ú›ÛÙËÛ ÁÈ’ ·˘Ù‹Ó. ¶ÈÛÙ‡ˆ fiÙÈ ÔÈ Â˘¯·ÚÈÛٛ˜ Ù˘ ÂÎÊÚ¿˙Ô˘Ó fiÏÔ ÙÔÓ ·È‰È·ÙÚÈÎfi ÎfiÛÌÔ. E˘¯·ÚÈÛÙÔ‡ÌÂ, Û˘Ó¿‰ÂÏÊÔÈ ÙÔ˘ K¤ÓÙÚÔ˘ ¢ËÏËÙËÚÈ¿ÛˆÓ.
*** EÓËÌÂÚˆÙÈÎfi˜ ·ÔÏÔÁÈÛÌfi˜ H ˘ÔÁÚ¿ÊÔ˘Û· ¤Ï·‚ ¤Ó· ÂÓËÌÂÚˆÙÈÎfi ‰ÂÏÙ›Ô Ù˘ MÔÓ¿‰·˜ EÓÙ·ÙÈ΋˜ NÔÛËÏ›·˜ NÂÔÁÓÒÓ NÔÛÔÎÔÌ›Ԣ I·ÛÒ. EÓÙ˘ˆÛÈ¿˙ÂÈ ÙÔ fiÙÈ Ô ÚfiÏÔÁÔ˜ ‰ÂÓ ˘ÔÁÚ¿ÊÂÙ·È ÌfiÓÔ ·fi ÙÔÓ ‰È¢ı˘ÓÙ‹ ·ÏÏ¿ ·fi ÙÔ˘˜ 8 ÁÈ·ÙÚÔ‡˜ Ù˘ MÔÓ¿‰·˜ Î·È ÙȘ 2 ÚÔ˚ÛÙ¿ÌÂÓ˜. EÓÙ˘ˆÛÈ¿˙ÂÈ Â›Û˘, ÙÔ fiÙÈ Ë ÂÈ‚›ˆÛË ÙˆÓ ÌÈÎÚÒÓ ÚÔÒÚˆÓ (<1500 ÁÚ) ¤¯ÂÈ Êı¿ÛÂÈ ·ÈÛ›ˆ˜ ÛÙÔ 90%. OÈ ·ÔÏÔÁÈÛÌÔ› Û˘Ó‹ıˆ˜ ·Ô‚Ï¤Ô˘Ó ÛÙËÓ ÚÔ‚ÔÏ‹ ÙÔ˘ ¤ÚÁÔ˘ ÙˆÓ ÂÚÁ·˙fiÌÂÓˆÓ. ™ÙËÓ ÚÔÎÂÈ̤ÓË ÂÚ›ÙˆÛË, ÙÔ ˘ÏÈÎfi Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÙ·È Â›Ó·È ÏËÚÔÊÔÚÈ·Îfi Î·È ÂӉȷʤÚÔÓ. £· ‹Ù·Ó ηϋ ȉ¤· Ó· ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÛÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ ÛÙÔȯ›· ·fi ÙÔ˘˜ ·ÔÏÔÁÈÛÌÔ‡˜ Î·È ¿ÏÏˆÓ ÌÔÓ¿‰ˆÓ.
*** 347
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·348
¶∞π¢π∞∆ƒπ∫∏ 2000;63:348
BÈ‚ÏÈÔÁÚ·ÊÈ΋ ÂÓË̤ڈÛË K¿ı ‰Ú·ÛÙËÚÈfiÙËÙ· ·È‰È¿ÙÚˆÓ Ô˘ ÍÂʇÁÂÈ ·fi ÙÔÓ ‚ÈÔ˚·ÙÚÈÎfi ˘Ú‹Ó· Ù˘ ¶·È‰È·ÙÚÈ΋˜, ÂÎ ÙˆÓ Ú·ÁÌ¿ÙˆÓ ·ÁÓÔÂ›Ù·È ·fi ÙÔÓ ÂÚÈÔ‰ÈÎfi ·È‰È·ÙÚÈÎfi Ù‡Ô. EӉȷʤÚÔ˘Û· ‰Ô˘ÏÂÈ¿ Û˘Ó·‰¤ÏÊˆÓ ÁÈ· ÙÔ ÂÚÈ‚¿ÏÏÔÓ, ÁÈ· ÂÈÎÔÈÓˆÓ›·, ÁÈ· Ù· ‰ÈηÈÒÌ·Ù· ÙÔ˘ ·È‰ÈÔ‡, ÁÈ· ÓÔÌÔıÂÛ›·, ÁÈ· ÈÛÙÔÚ›· Ù˘ È·ÙÚÈ΋˜, ‰ËÌÔÛȇÂÙ·È Û˘Ó‹ıˆ˜ Û ÌË È·ÙÚÈÎfi Ù‡Ô ‹ ΢ÎÏÔÊÔÚ› ˆ˜ ÌÔÓÔÁÚ·Ê›·. ¢ÂÓ Î·Ù·ÏÔÁÔÁÚ·ÊÂ›Ù·È ·fi ÙËÓ IATPOTEK (www.mednet.gr) Ô‡Ù ·fi ÙËÓ IPI™ (www.ich.gr) ÎÈ ¤ÙÛÈ Î·Ó›˜ Ì·˜ ‰ÂÓ ¤¯ÂÈ ÚfiÛ‚·ÛË Û' ·˘Ù‹Ó. E›Ó·È Îڛ̷! Ÿ¯È ÌfiÓÔ ÁÈ·Ù› ·˘Ù¿ Ù· ‰›· ‰›ÓÔ˘Ó ÌÈ· ¿ÏÏË ıÂÒÚËÛË, ȉȷ›ÙÂÚ· ¯Ú‹ÛÈÌË ÛÙËÓ ¿ÛÎËÛË Ù˘ ·È‰È·ÙÚÈ΋˜ ·ÏÏ¿, Û˘¯Ó¿ Î·È ÁÈ· ÔÏÏÔ‡˜, Ë ·Ó¿ÁÓˆÛ‹ ÙÔ˘˜ Â›Ó·È Î·È ÌÈ· ¢¯·Ú›ÛÙËÛË. "T¤ÚÔ˘Ó ¿Ì· Î·È ‰È‰¿ÛÎÔ˘Ó"! TÔ IÓÛÙÈÙÔ‡ÙÔ YÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ÚÔÁÚ·ÌÌ·Ù›˙ÂÈ, ÂÎÙfi˜ ·fi ÙȘ ‰ËÌÔÛȇÛÂȘ ÛÙÔÓ È·ÙÚÈÎfi Ù‡Ô Î·È ÙȘ ·Ó·ÎÔÈÓÒÛÂȘ ÛÂ Û˘Ó¤‰ÚÈ· Ô˘ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙËÓ ˘Á›· ÙÔ˘ ·È‰ÈÔ‡, Ó· ηٷÏÔÁÔÁÚ·Ê› ›Û˘ Û¯ÂÙÈο ‚È‚Ï›· Î·È ÌÔÓÔÁڷʛ˜. H ·Ó·˙‹ÙËÛ‹ ÙÔ˘˜ ‰ÂÓ Â›Ó·È Î·ıfiÏÔ˘ ‡ÎÔÏË. °È’ ·˘Ùfi, Ôχ ı· ‚ÔËıÔ‡Û ·Ó οıÂ Û˘ÁÁڷʤ·˜ ¤ÛÙÂÏÓ ÛÙÔ I.Y.¶. ¤Ó· ·ÓÙ›Ù˘Ô Ù˘ ÂÚÁ·Û›·˜ ÙÔ˘ ÁÈ· ηٷÏÔÁÔÁÚ¿ÊËÛË. O Û˘Ó¿‰ÂÏÊÔ˜ ·È‰›·ÙÚÔ˜ ¢. K·Ú·ÌÂÚfiÔ˘ÏÔ˜, ‰È‰¿ÎÙˆÚ Ù˘ IÛÙÔÚ›·˜ Ù˘ I·ÙÚÈ΋˜ ›¯Â ÙËÓ Î·ÏÔÛ‡ÓË Ó· ÛÙ›ÏÂÈ ÛÙË ™‡ÓÙ·ÍË ÌÂÚÈΤ˜ ·fi ÙȘ ‰ËÌÔÛȇÛÂȘ ÙÔ˘. AӷʤÚÔ˘Ì ÙÔ˘˜ Ù›ÙÏÔ˘˜: 1. O È·ÙÚfi˜ M·ÓÔ˘‹Ï ™·Ú‹˜ TÂÓ¤‰ÈÔ˜ (1778-1802) Î·È ÙÔ ‰È·ÊˆÙÈÛÙÈÎfi ÙÔ˘ ¤ÚÁÔ, ™Ù·ÌÔ‡Ï˘, Aı‹Ó· 1999. 2. Iˆ¿ÓÓ˘ NÈÎÔÏ›‰Ë˜ Î·È Anton Stoerck Ù·‡ÙÈÛË ÙÔ˘ ÎÂÈ̤ÓÔ˘ ÙÔ˘ ‚È‚Ï›Ô˘ "EÚÌËÓ›· ÂÚ› ÙÔ˘ Ò˜ Ú¤ÂÈ Ó· ıÂڷ‡ÂÙ·È ÙÔ Á·ÏÏÈÎfiÓ ¿ıÔ˜, ‹ÁÔ˘Ó Ë Ì·Ï·ÊÚ¿ÓÙ˙·" BȤÓÓË 1794. Aı‹Ó· 1999. 3. H ·Ô‰Ô¯‹ Ù˘ Â˘Úˆ·˚΋˜ È·ÙÚÈ΋˜ ÂÈÛÙ‹Ì˘ ̤ۈ ÙˆÓ È·ÙÚÈÎÒÓ ‚È‚Ï›ˆÓ Ù˘ ÚÔÂÂÓ·ÛÙ·ÙÈ΋˜ ÂÚÈfi‰Ô˘. ¶Ú·ÎÙÈο "H ÂÈÛÙËÌÔÓÈ΋ ÛΤ„Ë ÛÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ 18Ô˜-19Ô˜ ·ÈÒÓ·˜" Aı‹Ó· 1998, 331-346. 4. H È·ÙÚÈ΋ ÛΤ„Ë Ì¤Û· ·fi Ù· ‚È‚Ï›· Ê˘ÛÈ΋˜ Ù˘ ÚÔ·ӷÛÙ·ÙÈ΋˜ ÂÚÈfi‰Ô˘. ¶Ú·ÎÙÈο "OÈ ÂÈÛً̘ ÛÙÔÓ EÏÏËÓÈÎfi ¯ÒÚÔ" K¤ÓÙÚÔ NÂÔÂÏÏËÓÈÎÒÓ ∂Ú¢ÓÒÓ E.I.E., Aı‹Ó· 1997,223-248. 5. ŒÓ· ·‚È‚ÏÈÔÁÚ¿ÊËÙÔ Î›ÌÂÓÔ ÙÔ˘ 1815 ÁÈ· ÙËÓ ÚÔÛÙ·Û›· ·fi ÙËÓ ·ÓÒÏË. °ÂˆÚÁ›Ô˘ KÔ˙¿ÎË T˘¿Ï‰Ô˘: "¶ÂÚ› ÙÔ˘ ηı·ÚÈÛÌÔ‡ ÙÔ˘ ·¤ÚÔ˜ ‰È· ÙÔ˘ ·ÏÈÎÔ‡ ÔͤԘ" EΉfiÛÂȘ ™Ù·ÌÔ‡Ï˘, Aı‹Ó· - ¶ÂÈÚ·È¿˜ 1994. 6. H ¶ÚÒÙË IÛÙÔÚ›· Ù˘ I·ÙÚÈ΋˜ ÛÙËÓ EÏÏËÓÈ΋ °ÏÒÛÛ·. ¶·Ú¿ÚÙËÌ·: KˆÛÙ·ÓÙ›ÓÔ˘ Mȯ·‹Ï, ™˘ÓÔÙÈ΋ IÛÙÔÚ›· Ù˘ I·ÙÚÈ΋˜, BȤÓÓË 1794. EΉfiÛÂȘ ™Ù·ÌÔ‡Ï˘, Aı‹Ó· - ¶ÂÈÚ·È¿˜,1994.
***
348
JULY-AUG.2000
30-05-03
13:24
™ÂÏ›‰·349
¶∞π¢π∞∆ƒπ∫∏ 2000;63:349-352
§Â‡ÎˆÌ· ˙ˆ‹˜ Aӷηχ„·Ì ÙË ı·˘Ì¿ÛÈ· ¤Î‰ÔÛË "§Â‡ÎˆÌ· ˙ˆ‹˜” ºˆÙÔÁÚ·ÊÈΤ˜ ·Ó·ÌÓ‹ÛÂȘ ·fi ÙÔ ¢ËÌÔÙÈÎfi BÚÂÊÔÎÔÌÂ›Ô AıËÓÒÓ 1947-1950, EΉfiÛÂȘ "ENTO™". E˘¯·ÚÈÛÙԇ̠ÙÔÓ ÂΉfiÙË Î. £.§. º·ÛÔ˘Ï¿ Ô˘ ¤ÙÚ„ ӷ ‰ËÌÔÛÈ¢ÙÔ‡Ó ÛÙËÓ ¶AI¢IATPIKH οÔȘ ʈÙÔÁڷʛ˜ Î·È ÙÔ ·Ú·Î¿Ùˆ ÂÓËÌÂÚˆÙÈÎfi ÛËÌ›ˆÌ·. TÔ ¢ËÌÔÙÈÎfi BÚÂÊÔÎÔÌÂ›Ô Ù˘ Aı‹Ó·˜ ȉڇıËΠÙÔ 1874, Ì ÛÎÔfi ÙËÓ ÂÚ›ı·Ï„Ë Î·È Û˘ÓÙ‹ÚËÛË ÙˆÓ ÂÁηٷÏÂÏÂÈÌÌ¤ÓˆÓ ‹ ÔÚÊ·ÓÒÓ ÓÂÔÁÓÒÓ. K·Ù¿ ̤ÛÔÓ fiÚÔ ‰‡Ô ‚Ú¤ÊË ÙËÓ Ë̤ڷ ÂÈÛ¿ÁÔÓÙ·Ó ÛÙÔ ÊÈÏ·ÓıÚˆÈÎfi ·˘Ùfi ›‰Ú˘Ì· ÙËÓ ÂÚ›Ô‰Ô 1947-1950. ŒÓ· Û‡ÓÔÏÔ 230 ·È‰ÈÒÓ, ÔÏÏ¿ ·fi Ù· ÔÔ›· ÍÂÂÚÓÔ‡Ó Ù· ‰‡Ô ¤ÙË Î·È ˘ÔÛÙËÚ›¯ıËÎ·Ó ÙËÓ ÎÚ›ÛÈÌË ·˘Ù‹ ÂÚ›Ô‰Ô ·fi ÙËÓ ÔÚÁ¿ÓˆÛË UNRRA ÙÔ˘ OHE Î·È ÙÔÓ ÂıÂÏÔÓÙÈÎfi ÂÏÏËÓÈÎfi ÔÚÁ·ÓÈÛÌfi ÿ‰Ú˘Ì· ÁÈ· ÙË ™ˆÙËÚ›· ÙÔ˘ ¶·È‰ÈÔ‡. H BԇϷ ¶··˚ˆ¿ÓÓÔ˘ (1898-1990), ÌÈ· ·fi ÙȘ ÎÔÚ˘Ê·›Â˜ EÏÏËÓ›‰Â˜ ʈÙÔÁÚ¿ÊÔ˘˜, ·Ó·Ï·Ì‚¿ÓÂÈ Ó· ··ı·Ó·Ù›ÛÂÈ Ì ÙÔ Ê·Îfi Ù˘ ÙÔ BÚÂÊÔÎÔÌÂ›Ô ÁÈ· ÏÔÁ·ÚÈ·ÛÌfi Ù˘ UNRRA. ™·Ú¿ÓÙ· ÔÎÙÒ ¯ÚfiÓÈ· ÌÂÙ¿, ÙÔ 1998, ȉڇÂÙ·È ÛÙËÓ Aı‹Ó· ÙÔ K¤ÓÙÚÔ EÚ¢ÓÒÓ "P›˙˜", ÌÈ· ÂÙ·ÈÚ›· ÌË ÎÂÚ‰ÔÛÎÔÈÎÔ‡ ¯·Ú·ÎÙ‹Ú· Ô˘ ¤¯ÂÈ ˆ˜ ÛÎÔfi ÙËÓ ·Ó·˙‹ÙËÛË ÙˆÓ Ê˘ÛÈÎÒÓ ÁÔÓÈÒÓ ÙˆÓ ˘ÈÔıÂÙËÌ¤ÓˆÓ ·È‰ÈÒÓ Ì¤Û· ·fi ÙË ‰ˆÚÂ¿Ó ÂÓË̤ڈÛË Î¿ı ÂӉȷÊÂÚfiÌÂÓÔ˘ Î·È ÙË Û˘ÛÙËÌ·ÙÈ΋ ·Ó·˙‹ÙËÛË ÛÙ· ·Ú¯Â›· ‚ÚÂÊÔÎÔÌ›ˆÓ, ÔÚÊ·ÓÔÙÚÔÊ›ˆÓ ‹ ¿ÏÏˆÓ È‰Ú˘Ì¿ÙˆÓ, ÛÙËÓ EÏÏ¿‰· Î·È ÙÔ Â͈ÙÂÚÈÎfi. TÔ K¤ÓÙÚÔ ·ÔÊ·Û›˙ÂÈ Ó· ÂΉÒÛÂÈ ÙÔÓ ·ÓÂÎÙ›ÌËÙÔ ÊˆÙÔÁÚ·ÊÈÎfi ıËÛ·˘Úfi Ù˘ B. ¶··˚ˆ¿ÓÓÔ˘ Ô˘ ·fi ÙÔ 1978 Ê˘Ï¿ÛÛÂÙ·È ÛÙÔ MÔ˘ÛÂ›Ô MÂÓ¿ÎË, Ì "ÛÎÔfi Ó· ʤÚÂÈ ÛÙÔ Êˆ˜ ͯ·Ṳ̂Ó˜ ÂÈÎfiÓ˜ ·fi ÙÔ ÛÎÏËÚfi ·ÚÂÏıfiÓ". TÔ ÔÏ˘ÙÂϤ˜ ¿ÏÌÔ˘Ì ÂÚÈÏ·Ì‚¿ÓÂÈ ÙÚÈ¿ÓÙ· ÔÎÙÒ ·ÛÚfiÌ·˘Ú˜ ʈÙÔÁڷʛ˜ Î·È Î˘ÎÏÔÊfiÚËÛ Û ÂÚÈÔÚÈṲ̂ÓÔ - Û˘ÏÏÂÎÙÈÎfi - ·ÚÈıÌfi ·ÓÙÈÙ‡ˆÓ, Ô˘ ʤÚÔ˘Ó ÙËÓ ˘ÔÁÚ·Ê‹ Î·È ÙË ÛÊÚ·Á›‰· ÙÔ˘ K¤ÓÙÚÔ˘ EÚ¢ÓÒÓ "P›˙˜". T· ¤ÛÔ‰· ·fi ÙËÓ ÒÏËÛË ÙÔ˘ Ï¢ÎÒÌ·ÙÔ˜ ı· Û˘Ì‚¿ÏÔ˘Ó ÛÙËÓ ·Ó·ÎÔ‡ÊÈÛË ÙÔ˘ ‰‡ÛÎÔÏÔ˘ Î·È ÔÏ˘‰¿·ÓÔ˘ ¤ÚÁÔ˘ ÙÔ˘ K¤ÓÙÚÔ˘. TÔ "§Â‡ÎˆÌ· ˙ˆ‹˜" Ô˘ ΢ÎÏÔÊfiÚËÛ Ì ÙËÓ Â˘ÁÂÓÈ΋ ÚÔÛÊÔÚ¿ ÙÔ˘ MÔ˘Û›Ԣ MÂÓ¿ÎË, ΢ÎÏÔÊÔÚ› Ì ·Ú¿ÏÏËÏË ÌÂÙ¿ÊÚ·ÛË ÛÙ· AÁÁÏÈο. ¢È·Ù›ıÂÙ·È ·fi ÙÔ K¤ÓÙÚÔ EÚ¢ÓÒÓ "P›˙˜" (0945-414493) Î·È ÙȘ ÂΉfiÛÂȘ "ENTO™".
349
JULY-AUG.2000
30-05-03
13:25
™ÂÏ›‰·350
¶∞π¢π∞∆ƒπ∫∏ 2000;63:349-352
ºˆÙÔÁÚ·ÊÈΤ˜ ·Ó·ÌÓ‹ÛÂȘ ·fi ÙÔ ¢ËÌÔÙÈÎfi µÚÂÊÔÎÔÌÂ›Ô ∞ıËÓÒÓ 1947-1950
"BÚÂÊÔ‰fi¯Ô˜. ∞fi ÙË “ªÂÁ¿ÏË ∂ÏÏËÓÈ΋ ∂Á΢ÎÏÔ·›‰ÂÈ·”. KÈ‚ÒÙÈÔÓ Â˘ÌÂÁ¤ı˜ ‰˘Ó¿ÌÂÓÔÓ Ó· ¯ˆÚ› ¤ˆ˜ ‰‡Ô ‚Ú¤ÊË ÂÍËψ̤ӷ. TÔ ÙÔÈÔ‡ÙÔÓ ÂÓÙÔȯ›˙ÂÙ·È ·Ú¿ ÙËÓ ÂÍÒı˘Ú·Ó ÙˆÓ ‚ÚÂÊÔÎÔÌ›ˆÓ ÚÔ˜ ÙÔÓ ÛÎÔfiÓ Ó· ÂÎÙ›ıÂÓÙ·È ÂÓ ·˘ÙÒ ÎÚ˘Ê¿ Ù· ‰È' ¤Ó· ÔÈÔÓ‰‹ÔÙ ÏfiÁÔÓ ·ÔÚÚÈÙfiÌÂÓ· ‹ ÂÁηٷÏÂÈfiÌÂÓ· ÓÂÔÁÓ¿ ‹ ‚Ú¤ÊË. ø˜ ‰Â ‹ıÂÏÂÓ ·ÔÙÂı› ÂΛ ÙÔ ·È‰›ÔÓ ·˘ÙfiÌ·ÙÔ˜ ËÏÂÎÙÚÈÎfi˜ ÎÒ‰ˆÓ ·ÁÁ¤ÏÏÂÈ ÙËÓ Ú¿ÍÈÓ Ù·‡ÙËÓ Ù˘ ÂÁηٷÏ›„ˆ˜".
ªˆÚfi ÛÙËÓ ÎÔ‡ÓÈ· ÎÔÈÌ¿Ù·È
350
JULY-AUG.2000
30-05-03
13:25
™ÂÏ›‰·351
¶∞π¢π∞∆ƒπ∫∏ 2000;63:349-352
π·ÙÚÈ΋ ÂͤٷÛË ÌˆÚÒÓ. ∂Î ÙÔ˘ π·ÙÚÈÎÔ‡ ÔÚ›ÛÌ·ÙÔ˜: £‹Ï˘, 25 ËÌÂÚÒÓ, 2700 ÁÚ·Ì. £¿Ó·ÙÔ˜ ·fi ·ÙÚÔÊ›· ‹·ÙÔ˜
ªˆÚfi ·ÊË̤ÓÔ ÛÙ· ÛηÏÈ¿
351
JULY-AUG.2000
30-05-03
13:25
™ÂÏ›‰·352
¶∞π¢π∞∆ƒπ∫∏ 2000;63:349-352
"¶·È‰È¿, ı‡Ì·Ù· ÙÔ˘ ÔϤÌÔ˘, ·fi οı ÁˆÓÈ¿ Ù˘ ∂ÏÏ¿‰·˜ ÌÂٷʤÚÔÓÙ·È Û π‰Ú‡Ì·Ù·
. °˘Ó·›Î· Ì ̈Úfi, ÙÔ ÎÚ·Ù¿ ÛÊÈÎÙ¿ ÎÈ fï˜ ı· ÙÔ ÂÁηٷÏ›„ÂÈ
352
JULY-AUG.2000
30-05-03
13:25
™ÂÏ›‰·353
¶PO™EXH ™YNE¢PIA ™Â٤̂ÚÈÔ˜ 2000 1-3 ™ÂÙÂÌ‚Ú›Ô˘ ™¿ÌÔ˜ 5Ë ∂ÈÛÙËÌÔÓÈ΋ ™˘Ó¿ÓÙËÛË ¶·È‰È¿ÙÚˆÓ ∞Ó·ÙÔÏÈ΋˜ ª·Î‰ÔÓ›·˜ & £Ú¿Î˘ ™˘Ó‰ÈÔÚÁ¿ÓˆÛË: ¢ËÌÔÎÚ›ÙÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £Ú¿Î˘ ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ÈÁ·›Ô˘ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ∫‡ÚÔ˘ •ÂÓÔ‰Ô¯Â›Ô Doryssa Bay, ¶˘ı·ÁfiÚÂÈÔ ™¿ÌÔ˘ OÚÁ¿ÓˆÛË-°Ú·ÌÌ·Ù›· Minerva Fairs & Congresses, TËÏ.: 01 3217 456 Fax: 01 3220 595 e-mail: minerva@mdnet.gr
OÎÙÒ‚ÚÈÔ˜ 2000 4-6 OÎÙˆ‚Ú›Ô˘ Portoroz, Slovenia 26th Annual Congress of the Union of Middle-Eastern & Mediterranean Paediatric Societies Information: Dr Ivan Vidmar Division for Paediatric Surgery & Intensive Care 1525 Ljubljana - Slovenia Fax: 0038661-1301714 OÚÁ¿ÓˆÛË-°Ú·ÌÌ·Ù›· C&C International A.E. TËÏ.: 01 68 89 100 Fax: 01 68 44 777 e-mail: congress@cnc.gr
30 ™ÂÙÂÌ‚Ú›Ô˘ 2000 ∞ı‹Ó· 14Ô ™ÂÌÈÓ¿ÚÈÔ E›ÁÔ˘Û·˜ Î·È EÓÙ·ÙÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ £¤Ì·: “AÓ·Ó¢ÛÙÈÎfi ™‡ÛÙËÌ· Î·È EÓÙ·ÙÈ΋ £Âڷ›·” OÚÁ¿ÓˆÛË: MÔÓ¿‰· EÓÙ·ÙÈ΋˜ £Âڷ›·˜ NÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ AıËÓÒÓ “¶. & A. K˘ÚÈ·ÎÔ‡” AÌÊÈı¤·ÙÚÔ NÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ AıËÓÒÓ “¶. & A. K˘ÚÈ·ÎÔ‡” ¶ÏËÚÔÊÔڛ˜: Î. °ÂˆÚÁ›· ™È‰ÂÚ‹ TËÏ. 77 98 033
xi
JULY-AUG.2000
30-05-03
13:25
™ÂÏ›‰·354
™YNTOMO°PAºIE™ - (Abbreviations) ™˘ÓÙÔÌÔÁڷʛ˜
EÏÏËÓÈÎÔ› fiÚÔÈ
AÁÁÏÈÎÔ› fiÚÔÈ
AIDS
Û‡Ó‰ÚÔÌÔ Â›ÎÙËÙ˘ ·ÓÔÛÔ·Ó¿ÚÎÂÈ·˜
AMP, ADP, ATP
ÌÔÓÔ-, ‰È-, ÙÚÈʈÛÊÔÚÈ΋ ·‰ÂÓÔÛ›ÓË
ATPase cal CSF ‹ ENY CNS ‹ ∫¡™ cm CoA cmÑ cm2 cAMP ÆC CRP DNA ECG ‹ ∏∫° EEG ‹ ∏∂° ELISA ESR ‹ ∆∫∂ EDTA g Hct Hb HLA
ÙÚÈʈÛÊ·Ù¿ÛË Ù˘ ·‰ÂÓÔÛ›Ó˘ ıÂÚÌ›‰· ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi ÎÂÓÙÚÈÎfi Ó¢ÚÈÎfi Û‡ÛÙËÌ· ÂηÙÔÛÙfi Û˘Ó¤Ó˙˘ÌÔ ∞ ΢‚ÈÎfi ÂηÙÔÛÙfi ÙÂÙÚ·ÁˆÓÈÎfi ÂηÙÔÛÙfi ·ÎÏÈÎfi AMP ‚·ıÌfi˜ KÂÏÛ›Ô˘ C-·ÓÙȉÚÒÛ· ÚˆÙ½ÓË ‰ÂÔ͢ÚÈ‚Ô˙ÔÓÔ˘ÎÏÂ˚ÓÈÎfi Ô͇ ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ· ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ· ¤Ó˙˘ÌÔ-Û˘Ó‰¤Ù˘ ·ÓÔÛÔÚÔÛÚfiÊËÛ˘ ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù·¯‡ÙËÙ· ηıÈ˙‹Ûˆ˜ ÂÚ˘ıÚÒÓ Âı˘ÏÂÓԉȷÌÈÓÔÙÂÙÚ·ÔÍÂ˚Îfi Ô͇ ÁÚ·ÌÌ¿ÚÈo ·ÈÌ·ÙÔÎÚ›Ù˘ ·ÈÌÔÛÊ·ÈÚ›ÓË ·ÓÙÈÁfiÓÔ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙ·˜
Ig ICU ‹ ª∂£ IU i.m. ‹ ∂.ª. i.p. ‹ ∂.¶. i.v. ‹ ∂.º. L log mol ªW ‹ MB MCH MCV mRNA m min n N NS ‹ ª™ Ôsm % PCR pH PCO2 PO2 p
·ÓÔÛÔÛÊ·ÈÚ›ÓË ÌÔÓ¿‰· ÂÓÙ·ÙÈ΋˜ ıÂڷ›·˜ ‰ÈÂıÓ‹˜ ÌÔÓ¿‰· ÂÓ‰ÔÌ˘˚ο ÂÓ‰ÔÂÚÈÙÔÓ·˚ο ÂÓ‰ÔÊϤ‚È· Ï›ÙÚÔ(·) ÏÔÁ¿ÚÈıÌÔ˜ ÁÚ·ÌÌÔÌfiÚÈÔ ÌÔÚÈ·Îfi ‚¿ÚÔ˜ ̤ÛË ·ÈÌÔÛÊ·ÈÚ›ÓË ÂÚ˘ıÚÒÓ Ì¤ÛÔ˜ fiÁÎÔ˜ ÂÚ˘ıÚÒÓ ·ÁÁÂÏÈÔÊfiÚÔ˜ RNA ̤ÙÚÔ ÏÂÙfi ·ÚÈıÌfi˜ Ó¢ÙÒÓÈÔ ÌË ÛËÌ·ÓÙÈÎfi ÔÛÌÒÏÈÔ Â› ÙÔȘ ÂηÙfi ·Ï˘ÛȉˆÙ‹ ·ÓÙ›‰Ú·ÛË ÔÏ˘ÌÂÚ¿Û˘ Û˘ÁΤÓÚˆÛË ÈfiÓÙˆÓ ˘‰ÚÔÁfiÓÔ˘ ÌÂÚÈ΋ Ù¿ÛË CO2 ÌÂÚÈ΋ Ù¿ÛË Ô͢ÁfiÓÔ˘ Èı·ÓfiÙËÙ·
acquired immunodeficiency syndrome adenosine 5mono-, di-, triphosphate adenosine triphosphatase calorie cerebrospinal fluid central nervous system centimeter coenzyme A cubic centimeter square centimeter cyclic AMP degree(s) Celsius C-reactive protein deoxyribonucleic acid electrocardiogram electroencephalogram enzyme-linked immunoabsorbent assay erythrocyte sedimentation rate ethylenediaminetetracetate gram haematocrit haemoglobin (human) histocompatibility leucocyte antigen immunoglobulin intensive care unit international Unit intramuscular intraperitoneal intravenous liter logarithm mole molecular weight mean corpuscular haemoglobin mean corpuscular volume messenger RNA meter minute number newton not significant osmole percent polymerase chain reaction potentia hydrogenii carbon dioxide pressure oxygen pressure probability
xii
JULY-AUG.2000
30-05-03
13:25
™ÂÏ›‰·355
™˘ÓÙÔÌÔÁڷʛ˜
EÏÏËÓÈÎÔ› fiÚÔÈ
AÁÁÏÈÎÔ› fiÚÔÈ
p.o. RIA RNA RDS sec s.c. ‹ À.¢. SD SE U
·fi ÙÔ ÛÙfiÌ· Ú·‰ÈÔ·ÓÔÛÔ·ÔÚÚÔÊËÙÈ΋ ‰ÔÎÈÌ·Û›· ÚÈ‚ÔÓÔ˘ÎÏÂ˚ÓÈÎfi Ô͇ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÈ·˜ ‰Â˘ÙÂÚfiÏÂÙÔ ˘Ô‰fiÚÈ· ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË ÛÙ·ıÂÚfi ÛÊ¿ÏÌ· ÌÔÓ¿‰·
by mouth radioimmunoassay ribonucleic acid respiratory distress syndrome second subcutaneous standard deviation standard error unit
™˘Ó‰˘·˙fiÌÂÓ· ÚÔı¤Ì·Ù· 12
tera- (10 ) 9 giga- (10 ) 6 mega-(10 ) 3 kilo- (10 ) 2 hecto(10 ) 1 deca (10 ) -1 deci (10 ) -2 centi- (10 ) -3 milli(10 ) -5 micro (10 ) -9 nano (10 ) -12 pico (10 ) -15 femto (10 ) -18 atto (10 )
Combining prefixes T G M k h da d c m Ì n p f a
xiii