E•øº.¶AI¢IATP.MAPT-A¶P
17-10-01 15:37
™ÂÏ›‰· 1
ISSN 0377-2551
M¿ÚÙÈÔ˜ - ∞Ú›ÏÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 2
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∫Ú˘„ÔÚ¯›· - ÙÚ¤¯Ô˘Û˜ ·fi„ÂȘ
GENERAL PAPER 93
°. ™·ÎÂÏÏ¿Ú˘, ∂. ∫fiÎÎÔÚË, ™. µÏ·˙¿Î˘, ∞. ∫Ú·ÛÔ˘‰¿Î˘, °. ÷ڛÛ˘
G. Sakellaris, H. Kokkori, S. Vlazakis, A. Krasoudakis, G. Charissis
ANA™KO¶H™∂π™ ™ËÌ·Û›· ÙÔ˘ Ȉ‰›Ô˘ Î·È Ù˘ ı˘ÚÔ͛Ӣ ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi
REVIEW ARTICLES 101
∫. ¶·ÓÙÛÈÒÙÔ˘
√ ıˆÚ·ÎÈÎfi˜ fiÓÔ˜ ÛÙ· ·È‰È¿. ∫ÏÈÓÈ΋ ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË
115
125
ORIGINAL PAPERS 132
∂. ¶··‚·ÛÈÏ›Ԣ, µ. ∫¿ÏÏÈÔ˘, ¡. ∫·Ì¿˜ 136
Infectious agents and low herd immunity in the etiology of childhood leukemia M. Dalamaga, E. Petridou, D. Trichopoulos, A. Mentis, A. Skalkidou, T. Karpathios, F. Athanasiadou-Piperopoulou, M. Kalmanti, D. Koliouskas, E. Kosmidou, J. Panagiotou, F. Tzortzatou-Stathopoulou
145
Comparative trial of natural and synthetic surfactants in the treatment of respiratory distress syndrome of prematurity E. Hatzidaki, E. Korakaki, M. Christodoulaki, K.M. Margari, D. Mamoulakis, A. Manoura, C. Giannakopoulou
∂. ÷Ù˙ˉ¿ÎË, ∂. ∫ÔڷοÎË, ª. ÃÚÈÛÙÔ‰Ô˘Ï¿ÎË, ∫.ª. ª·ÚÁ¿ÚË, ¢. ª·ÌÔ˘Ï¿Î˘, ∞. ª·ÓÔ˘Ú¿, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
√ÏÈ΋ ·ÓÙÈÔÍÂȉˆÙÈ΋ ÈηÓfiÙËÙ· Ï¿ÛÌ·ÙÔ˜ ·ÛıÂÓÒÓ Ì ÎÏ·ÛÈ΋ Ê·ÈÓ˘ÏÎÂÙÔÓÔ˘Ú›· ˘fi ‰›·ÈÙ·
The tubercular infection index among pre-school age children in the district of Korinthos ∂. ¶··‚·ÛÈÏ›Ԣ, µ. ∫¿ÏÏÈÔ˘, ¡. ∫·Ì¿˜
ª. ¡Ù·Ï·Ì¿Áη, ∂. ¶ÂÙÚ›‰Ô˘, ¢. ∆ÚȯfiÔ˘ÏÔ˜, ∞. ªÂÓÙ‹˜, Õ. ™Î·ÏΛ‰Ô˘, £. ∫·Ú¿ıÈÔ˜, º. ∞ı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘, ª. ∫·ÏÌ·ÓÙ‹, ¢. ∫ÔÏÈÔ‡Ûη˜, ∂. ∫ÔÛÌ›‰Ë, π. ¶·Ó·ÁÈÒÙÔ˘, º. ∆˙ˆÚÙ˙¿ÙÔ˘-™Ù·ıÔÔ‡ÏÔ˘
™˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ¯ÔÚ‹ÁËÛ˘ Ê˘ÛÈÎÔ‡ Î·È Û˘ÓıÂÙÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙÔ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ
Abuse of children by their peers D. Protagora-Lianou
∂ƒ∂À¡∏∆π∫∂™ ∂ƒ°∞™π∂™
§ÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ Î·È ¯·ÌËÏ‹ Û˘ÏÏÔÁÈ΋ ·ÓÔÛ›· ÛÙËÓ ÂӉ¯fiÌÂÓË ·ÈÙÈÔÏÔÁ›· Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜
Chest pain in children. A clinical diagnostic approach G.S. Varlamis
¡. ¶ÚˆÙ·ÁfiÚ·-§È·ÓÔ‡
¢Â›ÎÙ˘ ‰È·ÌfiÏ˘ÓÛ˘ Ì ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘ Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÛÙÔ ¡ÔÌfi ∫ÔÚÈÓı›·˜
The importance of iodine and thyroxine in the hyman organism K. Pantsiotou
°.™. µ·ÚÏ¿Ì˘
∏ ηÎÔÔ›ËÛË ·È‰ÈÒÓ ·fi ¿ÏÏ· ·È‰È¿
Current management of the undescended testis
154
Plasma total antioxidant status in phenylketonuria patients on diet
∫.∂. ™Ô‡ÏË, ™. ∆۷ΛÚ˘, °.∞. ∫·Ú›Î·˜, ª. ªÔ‡Î·˜, ¶. ªÂ¯Ú¿Î˘
K.H. Schulpis, S. Tsakiris, G.A. Karikas, M. Moukas, P. Behrakis
∏ Û˘Ó¤¯ÂÈ· ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ ÛÙËÓ ÚÒÙË ÂÛˆÙÂÚÈ΋ ÛÂÏ›‰·
Continuation of table of contents inside title page
March - April 2001 . Volume 64 . No 2
2001 MAPT- A¶PI§
17-10-01 15:34
™ÂÏ›‰· 5
ª¿ÚÙÈÔ˜ - ∞Ú›ÏÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 2
™˘Ó¤¯ÂÈ· ÂÚȯÔ̤ӈÓ
∂¡¢π∞º∂ƒ√À™∂™ ¶∂ƒπ¶∆ø™∂π™ ∏ ÔÍ›· ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ˆ˜ ÂΉ‹ÏˆÛË Û˘ÁÁÂÓÔ‡˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ Û ‚Ú¤ÊÔ˜
Continuation of table of contents
159
N. Baltogiannis, E. Papandreou, C. Chiotinis, V. Charisi, D. Keramidas
¡. ª·ÏÙÔÁÈ¿ÓÓ˘, ∂. ¶··Ó‰Ú¤Ô˘, Ã. ÃȈٛÓ˘, µ. ÷ڛÛË, ¢. ∫ÂÚ·Ì›‰·˜
¶·ÚÔ‰È΋ ÊÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË Î·È ˘ÂÚʈÛÊ·Ù·Û·ÈÌ›· ÌÂÙ¿ ·fi Ì·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ Û ÓÂÔÁÓfi
163
π. ∫·Ï¤ÁÈ·˜, ¡. π·Îˆ‚›‰Ô˘, ∂. ªÂÁ·ÏÔÁÈ¿ÓÓË, ™. ƒ¿ÌÌÔ˜, °. ∫Ô˘Ú¿Î˘, ∏. ¢ÂÏÏ·ÁÚ·ÌÌ¿ÙÈη˜
™˘ÁÁÂÓ‹˜ Û‡ÊÈÏË: Ì›· Û‡Á¯ÚÔÓË ·ÂÈÏ‹
168
172
177
181
188
Disorders of thyroid function in children with insulin dependent diabetes mellitus (IDDM) A. Kaimara-Papathanasiou, C. Hadjiathanasiou, C. Theodoridis
194
LETTERS ¶.¢. §··ÙÛ¿Ó˘, Õ. ÿÏÏ· Ã. ∫·Ú‹˜, ¢. ∫·Ú·Î·˚‰fi˜
¶.¢. §··ÙÛ¿Ó˘, Õ. ÿÏÏ· Ã. ∫·Ú‹˜, ¢. ∫·Ú·Î·˚‰fi˜
¶∞π¢π∞∆ƒπ∫∏ ∂¡∏ª∂ƒø™∏
Seizures after dermal exposure to DEET M. Narlioglou, G. Briassoulis, T. Hatzis
∞. ∫·˚Ì¿Ú·-¶··ı·Ó·Û›Ô˘, Ã. ÷Ù˙Ë·ı·Ó·Û›Ô˘, Ã. £ÂÔ‰ˆÚ›‰Ë˜
E¶π™∆√§∂™
Facial palsy caused by latent mastoiditis ∑. ∏ÏÈÔ‰ÚÔÌ›ÙË, º. æ‡¯Ô˘, π. ¡›Î·˜, •. ∫Ú›ÎÔ˜, ¶. ¡ÈÎÔÏ·˝‰Ô˘
ª. ¡·ÚÏ›ÔÁÏÔ˘, °. ªÚÈ·ÛÔ‡Ï˘, ∞. ÷Ù˙‹˜
¢È·Ù·Ú·¯¤˜ ı˘ÚÂÔÂȉÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û ·È‰È¿ Ì ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË
Kawasaki disease assosiated with primary Epstein-Barr virus infection G. Triantafyllidis, D. Karakaidos, P. Zosi, T. Vlachou, L. Kanaris, C. Karis
∑. ∏ÏÈÔ‰ÚÔÌ›ÙË, º. æ‡¯Ô˘, π. ¡›Î·˜, •. ∫Ú›ÎÔ˜, ¶. ¡ÈÎÔÏ·˝‰Ô˘
™·ÛÌÔ› ÌÂÙ¿ ·fi ¤ÎıÂÛË Û ÂÓÙÔÌÔ·ˆıËÙÈÎfi
Congenital syphilis: a current threat E. Korakaki, E. Hatzidaki, A. Manoura, P. Smirnaki, I. Papamastoraki, C. Giannakopoulou
°. ∆ÚÈ·ÓÙ·Ê˘ÏÏ›‰Ë˜, ¢. ∫·Ú·Î·˚‰fi˜, ¶. ∑ÒÛË, £. µÏ¿¯Ô˘, §. ∫·Ó¿Ú˘, Ã. ∫·Ú‹˜
¶¿ÚÂÛË ÚÔÛˆÈÎÔ‡ Û ·È‰› Ì ϷÓı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ·
Transient cortical hyperostosis and elevation of alkaline phosphatase following long-term administration of prostaglandin J. Kaleyias, N. Iakovidou, E. Megaloyianni, S. Rammos, G. Kourakis, H. Dellagrammaticas
∂. ∫ÔڷοÎË, ∂. ÷Ù˙ˉ¿ÎË, ∞. ª·ÓÔ˘Ú¿, ¶. ™Ì˘ÚÓ¿ÎË, π. ¶··Ì·ÛÙÔÚ¿ÎË, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
NfiÛÔ˜ Kawasaki Ì ·Û˘Ó‹ıË ÚˆÙÔ·ı‹ Ïԛ̈ÍË ·fi ÙÔÓ Èfi Epstein-Barr
CASE REPORTS Congenital diaphragmatic hernia presenting with acute respiratory distress in an infant
196
PAEDIATRIC NEWS
∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹
∑. Papadopoulou-Couloumbis
™˘Ó¯›˙ÔÓÙ·È
Continued
ªarch - April 2001 . Volume 64 . No 2
2001 MAPT- A¶PI§
17-10-01 15:34
™ÂÏ›‰· 6
ª¿ÚÙÈÔ˜ - ∞Ú›ÏÈÔ˜ 2001 . ∆fiÌÔ˜ 64 . ∆‡¯Ô˜ 2
™˘Ó¤¯ÂÈ· ÂÚȯÔÌ¤ÓˆÓ ¶∂ƒπ§∏æ∂π™ ∞ƒ£ƒø¡ ∞¶√ ∆∏ µπµ§π√°ƒ∞ºπ∞ ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ ̤ۈ Ù˘ PCR ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ÛÙ· ÙÚ·¯Âȷο ÂÎÎÚ›ÌÌ·Ù· ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ: Û˘Û¯¤ÙÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ ·fi ·‰ÂÓÔ˚Ô‡˜ Ì ÙË ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›·
Continuation of table of contents 100
Couroucli XI, Welty SE, Ramsay PL, Wearden ME Fuentes-Garcia FJ, Jiyuan NI, Jacobs TN Towbin JA, Bowles NE ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: ™. ºˆÙfiÔ˘ÏÔ˜
√ÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÙÔ›·˜ Î·È ÎÏÈÓÈ΋ ÔÚ›· Ïԛ̈͢ Ì RSV Û ÓÔÛËÏ¢fiÌÂÓ· Î·È ÌË ‚Ú¤ÊË
Couroucli XI, Welty SE, Ramsay PL, Wearden ME Fuentes-Garcia FJ, Jiyuan NI, Jacobs TN Towbin JA, Bowles NE Greek translation: S. Fotopoulos 124
Trefny P, Stricker T, Baerlocher C, Sennhauser FH ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: M. AÓıÚ·ÎfiÔ˘ÏÔ˜
¶·ÏÌÈ΋ Ô͢ÌÂÙÚ›·: ∆È Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi ÛÙÔ ∆Ì‹Ì· º˘ÛÈÔÏÔÁÈÎÒÓ ¡ÂÔÁÓÒÓ;
135
167
171
IL-8 and neutrophil elastase levels in the respiratory tract of infants with RSV bronchiolitis Abu-Harb M, Bell F, Finn A, Rao WH Nixon L, Shale D, Everard ML Greek translation: M. Anthrakopoulos
180
Shaw MP, Bath LE, Duff J, Kelnar CJ, Wallace WHB ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: º. ∞ı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘
¢È·Î‡Ì·ÓÛË ÙÔ˘ fiÓÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ıÂڷ›·˜ ÁÈ· ηÚΛÓÔ Û ·È‰È¿: ¶ÂÚÈÁÚ·ÊÈ΋ ÚÔÛ¤ÁÁÈÛË
Effect of seating position and restrained use on injuries to children in motor vehicle crashes Berg M, Cook L, Corneli H, Vernon D, Dean J Greek translation: ∆. Tsoumakas
Abu-Harb M, Bell F, Finn A, Rao WH Nixon L, Shale D, Everard ML ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: M. AÓıÚ·ÎfiÔ˘ÏÔ˜
¶·¯˘Û·ÚΛ· ÛÙÔ˘˜ ÂÈ‚ÈÒÛ·ÓÙ˜ ·fi Ï¢¯·ÈÌ›·. ∏ Û˘Ì‚ÔÏ‹ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜
Pulse oximetry: What’s normal in the newborn nursery? Levesque BM, Pollack P, Griffin BE, Nielsen HC Greek translation: M. Anthrakopoulos
Berg M, Cook L, Corneli H, Vernon D, Dean J ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: £. ∆ÛÔ˘Ì¿Î·˜
∂›Â‰· IL-8 Î·È Ô˘‰ÂÙÂÚÔÊÈÏÈ΋˜ ÂÏ·ÛÙ¿Û˘ ÛÙËÓ ·Ó·Ó¢ÛÙÈ΋ Ô‰fi ‚ÚÂÊÒÓ Ì ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ·fi RSV
Family history of atopy and clinical course of RSV infection in ambulatory and hospitalized infants Trefny P, Stricker T, Baerlocher C, Sennhauser FH Greek translation: M. Anthrakopoulos
Levesque BM, Pollack P, Griffin BE, Nielsen HC ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: M. AÓıÚ·ÎfiÔ˘ÏÔ˜
√È Û˘Ó¤ÂȘ Ù˘ ı¤Û˘ ÛÙÔ Î¿ıÈÛÌ· ·˘ÙÔÎÈÓ‹ÙÔ˘ Î·È Ù˘ ¯Ú‹Û˘ ˙ÒÓ˘ ·ÛÊ·Ï›·˜ ÛÙȘ ηÎÒÛÂȘ ÙˆÓ ·È‰ÈÒÓ Û ·˘ÙÔÎÈÓËÙÈÛÙÈο ·Ù˘¯‹Ì·Ù·
LITERATURE ABSTRACTS Detection of microorganisms in the tracheal aspirates of preterm infants by polymerase chain reaction: association of adenovirus infection with bronchopulmonary dysplasia
Obesity in leukemia survivors: The familial contribution Shaw MP, Bath LE, Duff J, Kelnar CJ, Wallace WHB Greek translation: F. Athanasiadou-Piperopoulou
187
Pain variations during cancer treatment in children: A descriptive survey Ljungman G, Gordh T, Sörensen S, Kreuger A Greek translation: F. Athanasiadou-Piperopoulou
Ljungman G, Gordh T, Sörensen S, Kreuger A ∞fi‰ÔÛË ÛÙ· ∂ÏÏËÓÈο: º. ∞ı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘
¶ÚÔÛ¯‹ ™˘Ó¤‰ÚÈ·
xv
Scheduled Medical Meetings
™˘ÓÙÔÌÔÁڷʛ˜
xix
Abbreviations
ªarch - April 2001 . Volume 64 . No 2
2001 MAPT- A¶PI§
17-10-01 15:34
™ÂÏ›‰· 7
M¿ÚÙÈÔ˜ - ∞Ú›ÏÈÔ˜ 2001
. ∆fiÌÔ˜
64
. ∆‡¯Ô˜
2
¢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·Ï·Î¿ ¢È¢ı˘ÓÙ‹˜ : ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹ M¤ÏË : ∂. ∞ÁÁÂÏ¿ÎË-°ÂˆÚÁ¿ÎË : º. Aı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘ : ª. ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ : °. µ·ÚÏ¿Ì˘ : ¶. ∫·ÊÚ›ÙÛ· : ∞. ∫ˆÓÛÙ·ÓÙfiÔ˘ÏÔ˜ : £. ∆ÛÈÏÈÁÈ¿ÓÓ˘ : ∫. ∆ÛÔ˘Ì¿Î·˜ : ™. ºˆÙfiÔ˘ÏÔ˜ : A. ÷Ù˙‹˜
Scientific President Editor Members
ºÈÏÔÏÔÁÈ΋ EÈ̤ÏÂÈ· ∂È̤ÏÂÈ· ÂÏÏËÓÈÎÒÓ ÎÂÈÌ¤ÓˆÓ º. ª·˘ÚÔÂȉ‹
Manuscript Editing
∂È̤ÏÂÈ· ·ÁÁÏÈÎÒÓ ÎÂÈÌ¤ÓˆÓ ∑. ¶··‰ÔÔ‡ÏÔ˘-∫Ô˘ÏÔ˘Ì‹
English Editing Z. Papadopoulou-Couloumbis
∞ÏÏËÏÔÁÚ·Ê›· ∂ÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∂Ù·ÈÚ›· ªÈ¯·Ï·ÎÔÔ‡ÏÔ˘ 92 ∞ı‹Ó·È 115 28 ∆ËÏ: (01) 7771 140, Fax: 7758 354
Correspondence Hellenic Paediatric Society Michalakopoulou 92 Athens 115 28 Tel: (01) 7771 140, Fax: 7758 354
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Editorial Board : K. Malaka : Z. Papadopoulou-Couloumbis : E. Agelaki-Georgaki : F. Athanassiadou-Piperopoulou : M. Anthrakopoulos : G. Varlamis : P. Kafritsa : A. Konstadopoulos : Th. Tsiligiannis : K. Tsoumakas : S. Fotopoulos : ∞. Hatzis
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March - April 2001
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Volume 64
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No 2
πSSN 0377-2551 i
2001 MAPT- A¶PI§
17-10-01 15:34
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O‰ËÁ›Â˜ ÚÔ˜ ÙÔ˘˜ ™˘ÁÁÚ·Ê›˜ A. °ÂÓÈΤ˜ ¶ÏËÚÔÊÔڛ˜ ∆Ô ÂÚÈÔ‰ÈÎfi "¶∞π¢π∞∆ƒπ∫∏" Â›Ó·È Ë Â›ÛËÌË ÂÈÛÙËÌÔÓÈ΋ ¤Î‰ÔÛË Î·È È‰ÈÔÎÙËÛ›· Ù˘ EÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ EÙ·ÈÚ›·˜. Œ¯ÂÈ ˆ˜ ‚·ÛÈÎÔ‡˜ ÛÙfi¯Ô˘˜ ÙËÓ ·ÔÙ‡ˆÛË ÙÔ˘ ·È‰È·ÙÚÈÎÔ‡ ¤ÚÁÔ˘ ÛÙËÓ ∂ÏÏ¿‰· Î·È ÙË Û˘Ó¯‹ È·ÙÚÈ΋ ÂÓË̤ڈÛË Î·È ÂÈÌfiÚʈÛË ÙˆÓ EÏÏ‹ÓˆÓ ¶·È‰È¿ÙÚˆÓ. °È· ÙÔ ÛÎÔfi ·˘Ùfi ‰¤¯ÂÙ·È ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÔÈÎÈÏ›· ¿ÚıÚˆÓ Î·È Û˘ÁÎÂÎÚÈ̤ӷ: ¿ÚıÚ· Û‡ÓÙ·Í˘ (ÌÂÙ¿ ·fi ÚfiÛÎÏËÛË Ù˘ EÈÛÙËÌÔÓÈ΋˜ ™˘ÓÙ·ÎÙÈ΋˜ EÈÙÚÔ‹˜), ·Ó·ÛÎÔ‹ÛÂȘ, ›ηÈÚ· ı¤Ì·Ù·, ÂÍÂÏ›ÍÂȘ ÛÙËÓ π·ÙÚÈ΋ ∂ÈÛÙ‹ÌË, ÚˆÙfiÙ˘Â˜ ÂÚ¢ÓËÙÈΤ˜ ÌÂϤÙ˜ Ì ·È‰È·ÙÚÈÎfi ‹ È·ÙÚÔÎÔÈÓˆÓÈÎfi ÂÚȯfiÌÂÓÔ, 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›·˜, ‚Ú·‚Â˘Ì¤Ó˜ ÂÚÁ·Û›Â˜, ÂÈÏÂÁ̤Ó˜ Û˘˙ËÙ‹ÛÂȘ ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ, ÂӉȷʤÚÔ˘Û˜ ÎÏÈÓÈΤ˜ Î·È ·ÂÈÎÔÓÈÛÙÈΤ˜ ÂÚÈÙÒÛÂȘ, ‚Ú·¯Â›Â˜ ‰ËÌÔÛȇÛÂȘ, ‚È‚ÏÈÔÎÚÈۛ˜, ÂÈÛÙÔϤ˜ ÚÔ˜ ÙË Û‡ÓÙ·ÍË, ÂÚÈÏ‹„ÂȘ Ù˘ ÂÏÏËÓÈ΋˜ Î·È Í¤Ó˘ ‚È‚ÏÈÔÁÚ·Ê›·˜, ·Ó·ÎÔÈÓÒÛÂȘ ÚÔÛ¯ÒÓ Û˘ÌÔÛ›ˆÓ Î·È Û˘Ó‰ڛˆÓ Û ı¤Ì·Ù· Û¯ÂÙÈο Ì ÙËÓ ¶·È‰È·ÙÚÈ΋ Î·È ·Ó·ÊÔÚ¤˜ Ó¤ˆÓ ÂΉfiÛˆÓ, ÂÏÏËÓÈÎÒÓ Î·È Í¤ÓˆÓ, ·È‰È·ÙÚÈÎÔ‡ ÂӉȷʤÚÔÓÙÔ˜. H EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ ‰È·ÙËÚ› ÙÔ ‰Èη›ˆÌ· Ó· ‰ËÌÔÛȇÂÈ ¿ÚıÚ· Ì ȉȷ›ÙÂÚÔ ÂÈÛÙËÌÔÓÈÎfi ÂӉȷʤÚÔÓ ¯ˆÚ›˜ Ó· ÙËÚÂ›Ù·È Ë ÛÂÈÚ¿ ˘Ô‚ÔÏ‹˜ Î·È Ó· ·ÔÊ·Û›˙ÂÈ ÁÈ· ÙË ‰ËÌÔÛ›Â˘ÛË ÂÚÁ·ÛÈÒÓ Ô˘ ¤¯Ô˘Ó ‚Ú·‚¢ı› ÛÙ· Ï·›ÛÈ· ÙÔ˘ ÂÙ‹ÛÈÔ˘ ¶·È‰È·ÙÚÈÎÔ‡ ™˘Ó‰ڛԢ, ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ÛÙÚÔÁÁ˘ÏÒÓ ÙÚ·Â˙ÒÓ È‰È·›ÙÂÚÔ˘ ÂӉȷʤÚÔÓÙÔ˜, Î·È ÙËÓ ÔÏÈ΋ ‹ ÌÂÚÈ΋ ‰ËÌÔÛ›Â˘ÛË ÂÈÛÙÔÏÒÓ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Û ‰ËÌÔÛÈÂ˘Ì¤Ó· ÂÈÛÙËÌÔÓÈο ¿ÚıÚ· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. µ. ÀÔ‚ÔÏ‹ Î·È ¢ËÌÔÛ›Â˘ÛË ÙˆÓ ∂ÚÁ·ÛÈÒÓ OÈ ÂÚÁ·Û›Â˜ Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È ÚÔ˜ ÎÚ›ÛË ÁÈ· ‰ËÌÔÛ›Â˘ÛË ÛÙÔ ÂÚÈÔ‰ÈÎfi "¶∞π¢π∞∆ƒπ∫∏" ·ÔÛÙ¤ÏÏÔÓÙ·È ÂȘ ÙÚÈÏÔ‡Ó ÛÙË ‰È‡ı˘ÓÛË: EÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ EÈÙÚÔ‹ EÏÏËÓÈ΋ ¶·È‰È·ÙÚÈ΋ EÙ·ÈÚ›· Mȯ·Ï·ÎÔÔ‡ÏÔ˘ 92 115 28 Aı‹Ó· ŸÏ˜ ÔÈ ÂÚÁ·Û›Â˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÂÈÛÙÔÏ‹, Ë ÔÔ›· ı· Û˘Ó˘ÔÁÚ¿ÊÂÙ·È ·fi fiÏÔ˘˜ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÛÙËÓ ÔÔ›· ı· ‰ËÏÒÓÂÙ·È fiÙÈ Ë ÂÚÁ·Û›· ‰ÂÓ ¤¯ÂÈ ÂÓ Ì¤ÚÂÈ ‹ ÂÍ ÔÏÔÎÏ‹ÚÔ˘ ‰ËÌÔÛÈ¢ı› ‹ ˘Ô‚ÏËı› ÁÈ· ÎÚ›ÛË Û ¿ÏÏÔ ÂÚÈÔ‰ÈÎfi Î·È fiÙÈ ÔÈ Û˘ÁÁÚ·Ê›˜ ÂÁÎÚ›ÓÔ˘Ó ÙË ‰ËÌÔÛ›Â˘Û‹ Ù˘ ÛÙÔ ÂÚÈÔ‰ÈÎfi "¶∞π¢π∞∆ƒπ∫∏". ∂ÈϤÔÓ, ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È Ù˘¯fiÓ ÂȉÔÙ‹ÛÂȘ - ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢. ŸÏ˜ ÔÈ ÎÏÈÓÈΤ˜ ¤Ú¢Ó˜ Ú¤ÂÈ Ó· Û˘Óԉ‡ÔÓÙ·È ·fi ÁÚ·Ù‹ ‰‹ÏˆÛË ÙˆÓ Û˘ÁÁڷʤˆÓ fiÙÈ ¤ÁÈÓ·Ó ÌÂÙ¿ ·fi ÏËÚÔÊÔÚË̤ÓË Û˘Ó·›ÓÂÛË ÙˆÓ ÌÂÙ¯fiÓÙˆÓ ‹ ÙˆÓ ÓÔÌ›ÌˆÓ ÂÎÚÔÛÒˆÓ ÙÔ˘˜ Û‡Ìʈӷ Ì ÙȘ ‰È·ÎËÚ‡ÍÂȘ ÙÔ˘ EÏÛ›ÓÎÈ Î·È ÙÔ˘ TfiÎÈÔ. ŸÏ˜ ÔÈ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ıˆÚÔ‡ÓÙ·È È‰ÈÔÎÙËÛ›· ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ "¶∞π¢π∞∆ƒπ∫∏" Î·È Ë ÔÏÈ΋ ‹ ÌÂ-
ÚÈ΋ ·Ó·‰ËÌÔÛ›Â˘Û‹ ÙÔ˘˜ ÂÈÙÚ¤ÂÙ·È ÌfiÓÔ ÌÂÙ¿ ·fi ¤ÁÁÚ·ÊË Û˘ÁηٿıÂÛË ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. ∏ ¶∞π¢π∞∆ƒπ∫∏ ÚÔÙ›ÓÂÈ Ó· ·ÎÔÏÔ˘ıÔ‡ÓÙ·È ÔÈ “∫ÔÈÓ¤˜ ¶ÚԉȷÁڷʤ˜ ÁÈ· ÃÂÈÚfiÁÚ·Ê· Ô˘ ˘Ô‚¿ÏÏÔÓÙ·È Û µÔ˚·ÙÚÈο ¶ÂÚÈÔ‰Èο” (Uniform Requirements for Manuscripts Submitted to Biomedical Journals) Ô˘ ‰ËÌÔÛȇÙËÎ·Ó ÛÙÔ JAMA 1997;277:927934, http://jama.ama-assn.org/info/auinst_req.html. OÈ ·fi„ÂȘ Î·È Ù· Û˘ÌÂÚ¿ÛÌ·Ù· ÙˆÓ Û˘ÁÁڷʤˆÓ Ô˘ ‰È·Ù˘ÒÓÔÓÙ·È ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ÂÚÁ·Û›Â˜ ‰ÂÓ ·ÓÙÈηÙÔÙÚ›˙Ô˘Ó ··Ú·›ÙËÙ· ·˘Ù¤˜ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡. H ηٷ¯ÒÚËÛË ‰È·ÊËÌ›ÛÂˆÓ ÛÙÔ ÂÚÈÔ‰ÈÎfi ‰ÂÓ ˘Ô‰ËÏÒÓÂÈ ÔˆÛ‰‹ÔÙ ¤ÁÎÚÈÛË ÙˆÓ ÂÚȯÔÌ¤ÓˆÓ 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 Ô˘ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÙËÓ ÂÚÁ·Û›· Û ÚfiÁÚ·ÌÌ· Word .doc ‹ MacWrite Î·È ÙÔ˘˜ ›Ó·Î˜, ·Ó Â›Ó·È ‰˘Ó·ÙfiÓ, Û ÚfiÁÚ·ÌÌ· Exel ηıÒ˜ Î·È ÂÈÛÙÔÏ‹ fiÔ˘ Ó· ·Ó·Ê¤ÚÔÓÙ·È ·Ó·Ï˘ÙÈο 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‹. °È· Ó· ÂÈÙ¢¯ı› Ë ¤ÁηÈÚË ‰ËÌÔÛ›Â˘ÛË Ù˘ ÂÚÁ·Û›·˜ Â›Ó·È ··Ú·›ÙËÙÔ Ó· ÂÈÛÙÚ¤ÊÂÙ·È ÙÔ ‰ÈÔÚıˆÌ¤ÓÔ Ù˘ÔÁÚ·ÊÈÎfi ‰ÔΛÌÈÔ ·fi ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ̤۷ Û ÂÙ¿ (7) Ë̤Ú˜. 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. 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. °. ™‡ÓÙ·ÍË ÙˆÓ ∂ÚÁ·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˘, ‚Ú·¯‡˜ 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˘.
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2001 MAPT- A¶PI§
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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 ÛÂÏ›‰Â˜, ÁÈ· Ù· ›ηÈÚ· ı¤Ì·Ù· Î·È ÙȘ ÂӉȷʤÚÔ˘Û˜ 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) ηıÒ˜ Î·È ÙÔÓ ‚Ú·¯‡ Ù›ÙÏÔ (<5 ϤÍÂȘ) ÙÔ˘ ¿ÚıÚÔ˘. ¢ÂÓ ÂÈÙÚ¤ÔÓÙ·È Û˘ÓÙÌ‹ÛÂȘ, - 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 Ú¤ÂÈ Ó· ·Ó·ÎÂÊ·Ï·ÈÒÓÂÈ ÙÔ˘˜ ÛÙfi¯Ô˘˜ Ù˘ ÂÚÁ·Û›·˜, ÙË ÌÂıÔ‰ÔÏÔÁ›·, Ù· ΢ÚÈfiÙÂÚ· ·ÔÙÂϤÛÌ·Ù· Î·È 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. 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 ÎÏÂȉȿ Ô˘ ı· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ÁÈ· ÙÔ ıÂÌ·ÙÈÎfi ¢ÚÂÙ‹ÚÈÔ. K›ÌÂÓÔ OÈ ÂÚ¢ÓËÙÈΤ˜ ÂÚÁ·Û›Â˜ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ÂÈÛ·ÁˆÁ‹, ÌÂıfi‰Ô˘˜, ·ÔÙÂϤÛÌ·Ù· Î·È Û˘˙‹ÙËÛË. H ∂ÈÛ·ÁˆÁ‹ ÂÚÈÏ·Ì‚¿ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· ‰Â‰Ô̤ӷ Ù˘ ¤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‹ ÙˆÓ ªÂıfi‰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 ™˘˙‹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¿ÁÓˆ-
vi
ÛË. T· ˘fiÏÔÈ· ı¤Ì·Ù· ¤¯Ô˘Ó ÂχıÂÚË ‰ÔÌ‹ ηٿ ÙËÓ ÎÚ›ÛË ÙˆÓ Û˘ÁÁڷʤˆÓ ÙÔ˘˜. ∂˘¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ - ¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) ı· Ú¤ÂÈ Ó· ·Ó·Ê¤ÚÔÓÙ·È ÛÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÎÂÈ̤ÓÔ˘ Î·È ÚÈÓ ·fi ÙȘ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ·Ú·Ô̤˜. 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 1986;255:2329-2339. ™˘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 Û‡ÓÙ·ÍË ÙˆÓ ‚È‚ÏÈÔÁÚ·ÊÈÎÒÓ ·Ú·ÔÌÒÓ Á›ÓÂÙ·È Û‡Ìʈӷ Ì ÙȘ ÚԉȷÁڷʤ˜ Ù˘ International Committee of Medical Journal Editors / Uniform Requirements for Manuscripts Submitted to Biomedical Journals (JAMA 1997;277:927-934), http://jama.amaassn.org/info/auinst_req.html. OÈ Û˘ÓÙÌ‹ÛÂȘ ÙˆÓ Ù›ÙÏˆÓ ÙˆÓ ÂÚÈÔ‰ÈÎÒÓ Á›ÓÔÓÙ·È Ì ‚¿ÛË ÙÔ Cumulated Index Medicus (List of Journals Indexed in Index Medicus, http://www.nlm.nih.gov). ¶·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‡: ∞ÏÂ͛Ԣ ¢, ª¿Ú· Ã, °È·ÓÓ·ÎÔÔ‡ÏÔ˘ Ã. ∂Ì‚fiÏÈ·, ·ÚfiÓ Î·È Ì¤ÏÏÔÓ: ›‰Ú·ÛË ÛÙËÓ ÂȉËÌÈÔÏÔÁ›· ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Î·È ÙËÓ ·È‰È·ÙÚÈ΋ Ú¿ÍË. ¶·È‰È·ÙÚÈ΋ 1996;59:272-279.
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™˘ÌÏËڈ̷ÙÈÎfi Ù‡¯Ô˜ ÂÚÈÔ‰ÈÎÔ‡: Flyvbjerg A. Role of growth hormone, insulin-like growth factors (IGFs) and IGF-binding proteins in the renal complications of diabetes. Kidney Int 1997;52 (60 Suppl):S12-S19.
¶›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. ™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.
Èڛ˜ Û˘ÁÁڷʤ·: National Institutes of Health Consensus Development Conference. Neurofibromatosis conference statement. Arch Neurol 1988;45:575-578. ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ Ù‡Ô˘ ¿ÚıÚÔ˘: ∫Ô˘Ú›‰Ë˜ Ã, ∫Ô˘Ú›‰Ë˜ °. ¶·¯˘Û·ÚΛ· Î·È ˘ÂÚÏÈȉ·ÈÌ›· Û ·È‰È¿ ‚ÔÚÂÈÔ‰˘ÙÈ΋˜ ∫‡ÚÔ˘ [¶ÂÚ›ÏË„Ë]. 36Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ; 1998 5-7 πÔ˘Ó›Ô˘; ¶¿ÊÔ˜, ∫‡ÚÔ˜;1998. ÛÂÏ. 172. Schreiner GF, Lange L. Ethanol modulation of macrophage influx in glomerulonephritis [abstract]. J Am Soc Nephrol 1991;2:562. Should antileukotriene therapies be used instead of inhaled corticosteroids in asthma? [Editorial]. Am J Respir Crit Care Med 1998;158:1697-1701. Laux-End R, Inaebnit D, Gerber HA, Bianchetti MG. Vasculitis associated with levamisole and circulating autoantibodies [letter]. Arch Dis Child 1996;75:355-356. II. µÈ‚Ï›· ∫ÂÊ¿Ï·ÈÔ Û ‚È‚Ï›Ô: Clark AG, Barratt TM. Steroid-responsive nephrotic syndrome. In: Barratt TM, Arner ED, Harmon WE, editors. Pediatric Nephrology. 4th ed. Baltimore: Lippincott William Wilkins; 1999. p. 742. ™‡ÁÁÚ·ÌÌ· ‹ ÌÔÓÔÁÚ·Ê›·: Gorlin RJ, Cohen MM, Levin LS. Syndromes of the head and neck. 3rd ed. New York: Oxford University Press; 1990. ¢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 29-31; New York: International Society of Chemotherapy; 1963. p. 484-500.
¶ÚÈÓ ·ÔÛÙ›ÏÂÙ ÙËÓ ÂÚÁ·Û›· Û·˜ ‚‚·Èˆı›Ù fiÙÈ ÂÚÈÏ·Ì‚¿ÓÂÈ: - ÂÈÛÙÔÏ‹ ˘Ô‚ÔÏ‹˜ - ‰‹ÏˆÛË ÌË ÚÔÁÂÓ¤ÛÙÂÚ˘ ‰ËÌÔÛ›Â˘Û˘ Ù˘ ÂÚÁ·Û›·˜ - 3 ·ÓÙ›ÁÚ·Ê· ÙÔ˘ ÎÂÈ̤ÓÔ˘ Ù˘ ÂÚÁ·Û›·˜ - ÛÂÏ›‰· Ù›ÙÏÔ˘ (¯ˆÚÈÛÙ‹ ÛÂÏ›‰·): ÂÚÈÏ·Ì‚¿ÓÂÈ - 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›‰·) - ¢¯·ÚÈÛٛ˜ ‹ ·Ó·ÁÓˆÚ›ÛÂȘ (·Ó·ÊÔÚ¿ Û ÂȉÔÙ‹ÛÂȘ-¯ÔÚËÁ›Â˜ ‹ ¿ÏϘ ËÁ¤˜ ˘ÔÛÙ‹ÚÈ͢) - ‚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.
¢È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹: ¡ÙÔ˘ÓÙÔ˘Ï¿Î˘ π. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ıÂڷ›· ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ÂÍ·ÚıÚ‹Ì·ÙÔ˜ ÙÔ˘ ÈÛ¯›Ô˘ Û ·È‰È¿ οو ÙÔ˘ ÂÓfi˜ ¤ÙÔ˘˜ [‰È‰·ÎÙÔÚÈ΋ ‰È·ÙÚÈ‚‹]. ∞ı‹Ó·: ¶·ÓÂÈÛÙ‹ÌÈÔ ∞ıËÓÒÓ; 1979. Kaplan SJ. Post hospital home health care: the
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°∂¡π∫√ £∂ª∞
Paediatriki 2001;64:93-100
GENERAL PAPER
∫Ú˘„ÔÚ¯›· - ÙÚ¤¯Ô˘Û˜ ·fi„ÂȘ °. ™·ÎÂÏÏ¿Ú˘1, ∂. ∫fiÎÎÔÚË2, ™. µÏ·˙¿Î˘1, ∞. ∫Ú·ÛÔ˘‰¿Î˘1, °. ÷ڛÛ˘1
Current management of the undescended testis G. Sakellaris1, H. Kokkori2, S. Vlazakis1, A. Krasoudakis1, G. Charissis1
¶ÂÚ›ÏË„Ë: ∏ ÎÚ˘„ÔÚ¯›· Â›Ó·È ÂÙÂÚfiÏ¢ÚÔ˜ Û ÔÛÔÛÙfi 80% ÂÚ›Ô˘ ÙˆÓ ÂÚÈÙÒÛˆÓ. £Âڷ‡ÂÙ·È Û¿ÓÈ· Ì ÙË ¯ÔÚ‹ÁËÛË ¯ÔÚÈÔÓÈ΋˜ ÁÔÓ·‰ÔÙÚÔ›Ó˘ (hCG) Î·È Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ¯ÂÈÚÔ˘ÚÁÈο ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ ÁÈ· Ó· ¤¯Ô˘ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙˆÓ ÛÂÚÌ·ÙÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ Î·È Î·Ï‹ ÛÂÚÌ·ÙÈ΋ ÏÂÈÙÔ˘ÚÁÈÎfiÙËÙ·. √ ÎÚ˘„fiگȘ ‰ÂÓ ˆÚÈÌ¿˙ÂÈ Ê˘ÛÈÔÏÔÁÈο ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ, ·Ú¿ÁÂÈ ‰Â ·ÓÙÈÛÒÌ·Ù· Ô˘ ‰ÚÔ˘Ó ‚Ï·ÙÈο Î·È ÛÙÔÓ ÔÚıfiÙÔÔ fiÚ¯È. ŸÛÔ ˘„ËÏfiÙÂÚ· ·fi ÙÔ fiÛ¯ÂÔ Â›Ó·È Ô fiگȘ, ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚ˜ ÈÛÙÔÌÔÚÊÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ·ÚÔ˘ÛÈ¿˙ÂÈ. √È ˘ÔÏ·ÛÙÈÎÔ› fiÚ¯ÂȘ Ú¤ÂÈ Ó· ·Ê·ÈÚÔ‡ÓÙ·È ¤ÁηÈÚ·. °ÂÓÈο, Ú¤ÂÈ Ó· ·Ê·ÈÚÔ‡ÓÙ·È ÔÈ ÎÚ˘„fiÚ¯ÂȘ Û ˘„ËÏ‹ ı¤ÛË, Ô˘ ‰ÂÓ ¤¯Ô˘Ó ηıËψı› ¯ÂÈÚÔ˘ÚÁÈο ÛÙÔ fiÛ¯ÂÔ ÚÈÓ ÙËÓ ÂÊ˂›·.
Abstract: The undescended testes are unilateral in approroximately 80% of cases, are rarely corrected by human chorionic gonadotropin (hCG), and should be treated by orchiopexy before the patient reaches the age of 3 years to permit optimal tubular development and sperm function. A cryptorchid testis does not mature normally after the age of 2 year and may produce antibodies which may have adverse effects on the normal contralateral descended testis. The higher a cryptorchid testis resides above the scrotum, the more dysgenetic the morphology is likely to be. Hypoplastic cryptorhid testis should be removed early. In general, high-positioned testes that have not been surgically placed into the scrotum before midadolescence should be removed.
§¤ÍÂȘ ÎÏÂȉȿ: ÎÚ˘„ÔÚ¯›·, ·ÓÙÈÌÂÙÒÈÛË.
Key words: undescended testis, management.
∂ÈÛ·ÁˆÁ‹ ∞fi Ù· ¿ÚÚÂÓ· ÓÂÔÁÓ¿, ¤Ó· ÔÛÔÛÙfi ÌÂٷ͇ 13% ¤¯ÂÈ ¿‰ÂÈÔ fiÛ¯ÂÔ, ηıÈÛÙÒÓÙ·˜ ÙËÓ ÎÚ˘„ÔÚ¯›· Ì›· ·fi ÙȘ ϤÔÓ Û˘¯Ó¤˜ ¯ÂÈÚÔ˘ÚÁÈΤ˜ ·ı‹ÛÂȘ ÛÙ· ·È‰È¿. ∂ÈÚfiÛıÂÙ·, ÂÎÙfi˜ Ù˘ ›‰Ú·Û˘ ÛÙË ÁÔÓÈÌfiÙËÙ·, Ë ÎÚ˘„ÔÚ¯›· Â›Ó·È ¤Ó·˜ ÁÓˆÛÙfi˜ ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·ÚΛÓÔ˘ ÛÙÔÓ fiÚ¯È. ∏ ·ÈÙÈÔÏÔÁ›· Ù˘ ÎÚ˘„ÔÚ¯›·˜ ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙË, ·Ú' fiÏ· ·˘Ù¿ Ù· ·Ó‰ÚÔÁfiÓ· Â›Ó·È ÁÓˆÛÙfi fiÙÈ ·›˙Ô˘Ó ¤Ó· ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÔÚÌÔÓÈ΋ Ú‡ıÌÈÛË Ù˘ ÔÚ¯È΋˜ ηıfi‰Ô˘. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ÙÔÔı¤ÙËÛË ÙÔ˘ fiگˆ˜ ÛÙÔ
ËÌÈfiÛ¯ÂÔ Â›Ó·È Ë ıÂڷ›· ÂÎÏÔÁ‹˜ ÁÈ· ÙÔ˘˜ ·ÏËı›˜ ÎÚ˘„fiÚ¯ÂȘ. ¶·ıÔÁ¤ÓÂÈ· ∂Ì‚Ú˘ÔÏÔÁ›· ∏ ÂÌ‚Ú˘˚΋ ·Ó¿Ù˘ÍË ÙÔ˘ fiگˆ˜ (1) ÌÔÚ› Ó· ‰È·ÈÚÂı› Û ÙÚÂȘ Ê¿ÛÂȘ: ñ ∂Ó‰ÔÎÔÈÏȷ΋ (·fi ÙÔÓ 1Ô ¤ˆ˜ ÙÔÓ 7Ô Ì‹Ó·). ñ ∂Ó‰ÔηӷÏÈ΋ (·fi ÙÔÓ 7Ô ˆ˜ ÙÔÓ 8Ô Ì‹Ó·). ñ √Û¯Â˚΋ (8Ô˜ Î·È 9Ô˜ Ì‹Ó·˜). √È fiÚ¯ÂȘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙȘ ÂÌ‚Ú˘˚Τ˜ ÌÂÛÔÓÂÊÚÈΤ˜ ·ÎÚÔÏÔʛ˜ Âη٤ڈıÂÓ Ù˘ ÛÔÓ‰˘ÏÈ΋˜ ÛÙ‹Ï˘.
1 ¶·È‰Ô¯ÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ¶.¡.∏. ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘ 2 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ µÂÓÈ˙¤ÏÂÈÔ˘-¶·Ó¿ÓÂÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘
1 ¶·È‰Ô¯ÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ¶.¡.∏. ¶·ÓÂÈÛÙ‹ÌÈÔ ∫Ú‹Ù˘ 2 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ µÂÓÈ˙¤ÏÂÈÔ˘-¶·Ó¿ÓÂÈÔ˘ ¡ÔÛÔÎÔÌ›Ԣ, ∏Ú¿ÎÏÂÈÔ ∫Ú‹Ù˘
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∫·ıÒ˜ ÙÔ ÚfiÛıÈÔ ÎÔÈÏÈ·Îfi ÙÔ›¯ˆÌ· ·Ó·Ù‡ÛÛÂÙ·È, ÔÈ fiÚ¯ÂȘ ÚÔÛʇÔÓÙ·È ÛÙÔ ‚Ô˘‚ˆÓÈÎfi fiÚÔ ·fi ›Ó˜ ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ Ô›·Î·. ªÂÙ·ÁÂÓ¤ÛÙÂÚË Û˘ÚÚ›ÎÓˆÛË ÙÔ˘ Ô›·Î· ÈÛÙ‡ÂÙ·È fiÙÈ ÚÔηÏ› ÙË ÌÂÙ·Ó¿ÛÙ¢ÛË ÙÔ˘ fiگˆ˜ ‰È·Ì¤ÛÔ˘ ÙÔ˘ ‚Ô˘‚ˆÓÈÎÔ‡ fiÚÔ˘ ηٿ ÙËÓ ÂÚ›Ô‰Ô ÙÔ˘ ¤‚‰ÔÌÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ Ì‹Ó·. ¶ÚÈÓ ÙËÓ Î¿ıÔ‰Ô, Ô fiگȘ ηχÙÂÙ·È ·fi ÂÚÈÙfiÓ·ÈÔ, ÙÔ ÔÔ›Ô ·ÎÔÏÔ‡ıˆ˜ ÌÂÙ·ÙÚ¤ÂÙ·È Û ÂÏ˘ÙÚÔÂȉ‹ ¯ÈÙÒÓ· ÛÙÔ fiÛ¯ÂÔ. √ Ô›·Î·˜ ÚÔÛʇÂÙ·È ¿ÓˆıÂÓ ÙÔ˘ ÂÁÁ‡˜ ¿ÎÚÔ˘ ÙÔ˘ ÛÂÚÌ·ÙÈÎÔ‡ fiÚÔ˘ Î·È ‰È·ÈÚÂ›Ù·È ÂÚÈÊÂÚÈο Û ·ÚÎÂÙ¤˜ Ù·Èӛ˜ Ô˘ Êı¿ÓÔ˘Ó Ì¤¯ÚÈ ÙÔ ‰·ÚÙfi ÛÙÔ fiÛ¯ÂÔ. ∂›Û˘, Ô fiگȘ Ê˘ÛÈÔÏÔÁÈο ·ÎÔÏÔ˘ı› ÙËÓ ¤ÎÙ·ÛË ÙÔ˘ ÔÛ¯¤Ô˘. ªÂÚÈΤ˜ ÊÔÚ¤˜, fï˜, ·ÎÔÏÔ˘ı› Î·È Ì›· ·fi ÙȘ Ù·Èӛ˜ ÙÔ˘ Ô›·Î· ÚÔ˜ ¤ÎÙÔË ı¤ÛË ÛÙÔ ÂÚ›ÓÂÔ, ˘ÂÚË‚Èο ‹ Û οÔÈ· ı¤ÛË ÙÔ˘ ÌËÚÔ‡. ŸÙ·Ó Ô fiگȘ Êı¿ÛÂÈ ÛÙÔ fiÛ¯ÂÔ Ô Ô›·Î·˜ Á›ÓÂÙ·È ‰˘Û‰È¿ÎÚÈÙÔ˜ Î·È ·ÙÚÔÊ›. ¶ÔÏϤ˜ Ï¢ڤ˜ Ô˘ ·ÊÔÚÔ‡Ó ÙËÓ ÂÌ‚Ú˘ÔÏÔÁÈ΋ Î·È ÌÔÚÊÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ fiگˆ˜ ·Ú·Ì¤ÓÔ˘Ó ·‰È¢ÎÚ›ÓÈÛÙ˜ ·ÎfiÌË. √ÚÌÔÓÈ΋ ›‰Ú·ÛË ∏ οıÔ‰Ô˜ ÙÔ˘ fiگˆ˜ ÛÙÔ fiÛ¯ÂÔ ÂËÚ¿˙ÂÙ·È ·fi ÙȘ ÌËÙÚÈΤ˜ ÁÔÓ·‰ÔÙÚÔ›Ó˜, ÔÈ Ôԛ˜ ÚÔηÏÔ‡Ó ÙËÓ ·Ú·ÁˆÁ‹ ·Ó‰ÚÔÁfiÓˆÓ ·fi ÙÔ˘˜ ÂÌ‚Ú˘˚ÎÔ‡˜ fiÚ¯ÂȘ (2). ∆· ·ÙÙ·Ú· Sertoli ÙÔ˘ fiگˆ˜ ·Ú¿ÁÔ˘Ó Ì›· ÂȉÈ΋ ÔÚÌfiÓË Ô˘ Â›Ó·È ÁÓˆÛÙ‹ ˆ˜ ·Ó·ÛÙÔϤ·˜ ÙÔ˘ Ì˘ÏÏÂÚ›Ԣ fiÚÔ˘ (MIF), ˘Â‡ı˘ÓË ÁÈ· ÙËÓ ˘ÔÛÙÚÔÊ‹ ÙˆÓ Ì˘ÏÏÂÚ›ˆÓ fiÚˆÓ. ∆· ·ÙÙ·Ú· Leyding ·Ú¿ÁÔ˘Ó ÙË ‰ÚÒÛ· ÙÔÈο ÙÂÛÙÔÛÙÂÚfiÓË, Ë ÔÔ›· Â›Ó·È ˘Â‡ı˘ÓË ÁÈ· ÙË ‰È·ÊÔÚÔÔ›ËÛË ÙÔ˘ ÌÂÛÔÓÂÊÚÈÎÔ‡ fiÚÔ˘ Û ÛÙÔȯ›· ÙÔ˘ Wolf. ∏ ¤ÎÎÚÈÛË ÙÂÛÙÔÛÙÂÚfiÓ˘ ̤۷ ÛÙËÓ ÂÌ‚Ú˘˚΋ ΢ÎÏÔÊÔÚ›· Î·È Ë ÂÚÈÊÂÚÈ΋ ÌÂÙ·ÙÚÔ‹ Ù˘ Û ‰È˘‰ÚÔÙÂÛÙÔÛÙÂÚfiÓË Â›Ó·È ˘Â‡ı˘ÓË ÁÈ· ÙËÓ ·ÚÚÂÓÔÔ›ËÛË ÙˆÓ ¤Íˆ ÁÂÓÓËÙÈÎÒÓ ÔÚÁ¿ÓˆÓ. ∂Ï¿Ùو̷ Û οÔÈÔ ÛÙ¿‰ÈÔ Ù˘ ÔÚ¯È΋˜ ÔÚÌÔÓÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ¿ÚÚÂÓ· „¢‰ÂÚÌ·ÊÚÔ‰ÈÙÈÛÌfi, Ì ‹ ¯ˆÚ›˜ ÎÚ˘„ÔÚ¯›·. À„ËϤ˜ ÙÈ̤˜ ÁÔÓ·‰ÔÙÚÔÈÓÒÓ Â›Ó·È ·ÚÔ‡Û˜ ÛÙËÓ Î˘ÎÏÔÊÔÚ›· ηٿ ÙËÓ ÂÚ›Ô‰Ô ÙˆÓ 8 ÙÂÏÂ˘Ù·›ˆÓ ‚‰ÔÌ¿‰ˆÓ Ù˘ ÂÌ‚Ú˘˚΋˜ ·Ó¿Ù˘Í˘ Î·È ·ÎÔÏÔ‡ıˆ˜ Â›Ó·È Û¯Â‰fiÓ ·Ó‡·ÚÎÙ˜ ·fi ÙË Á¤ÓÓËÛË ¤ˆ˜ ÙËÓ ËÏÈΛ· ÙˆÓ 10 - 12 ÂÙÒÓ, ÔfiÙ ٷ ›‰¿ ÙÔ˘˜ ·˘Í¿ÓÔ˘Ó ÂÎ Ó¤Ô˘. ∏ ·ÔÙ˘¯›· ÙÔ˘ fiگˆ˜ Ó· η٤ÏıÂÈ ÛÙÔ fiÛ¯ÂÔ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ÙÚ›ÙÔ˘ ÙÚÈÌ‹ÓÔ˘ Ù˘ ΢‹Ûˆ˜ ÌÔÚ› Ó· Û¯ÂÙ›˙ÂÙ·È Ì ·Ó¿ÚÎÂÈ· ÔÚÌÔÓÒÓ, Ì ·ÔÙ˘¯›· ÙÔ˘ fiگˆ˜ Ó· ··ÓÙ‹ÛÂÈ ÛÙȘ ÔÚÌfiÓ˜, Ì ·Ó·Ú΋ ¤ÏÍË ·fi ÙÔÓ Ô›·Î· ‹ Ì ¿ÏÏÔ˘˜ ÔÈΛÏÔ˘˜ ·Ú¿ÁÔÓÙ˜, ÁÈ·Ù› ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ·fi 80% Ù˘ ÎÚ˘„ÔÚ¯›·˜ Â›Ó·È ÂÙÂÚfiÏ¢ÚÔ˜.
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¶ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ˘Ôı¤ÙÔ˘Ó fiÙÈ Ë ÂÓ‰ÔÎÔÈÏȷ΋ οıÔ‰Ô˜ ÙÔ˘ fiگˆ˜ Â›Ó·È ·ÓÂÍ¿ÚÙËÙË ·fi ÙË ‰Ú¿ÛË ÙˆÓ ·Ó‰ÚÔÁfiÓˆÓ, ·ÏÏ¿ Ù· ·Ó‰ÚÔÁfiÓ· ÂϤÁ¯Ô˘Ó ÙËÓ Î¿ıÔ‰Ô ÙÔ˘ fiگˆ˜ ÛÙÔ fiÛ¯ÂÔ Ì¤Ûˆ ÙÔ˘ ‚Ô˘‚ˆÓÈÎÔ‡ fiÚÔ˘, Ú˘ıÌ›˙ÔÓÙ·˜ ÙË ÌÂÙ·Ó¿ÛÙ¢ÛË ÙÔ˘ Ô›·Î· ηıÒ˜ Î·È ÙËÓ ·‡ÍËÛË Ù˘ ÂÏ˘ÙÚÔÂÚÈÙÔÓ·˚΋˜ Ù˘¯‹˜ ‰È·Ì¤ÛÔ˘ ÙÔ˘ ÌËÚÔÁÂÓÓËÙÈÎÔ‡ Ó‡ÚÔ˘ (3,4). ¢ÂÓ Â›Ó·È ·Ô‰ÂÎÙfi fiÙÈ ÎÚ˘„fiÚ¯ÂȘ Ì Ì˯·ÓÈ΋ ·fiÊÚ·ÍË ÌÔÚÔ‡Ó Ó· η٤ÏıÔ˘Ó ÛÙÔ fiÛ¯ÂÔ ··ÓÙÒÓÙ·˜ Û Â͈ÁÂÓ›˜ ‹ ÂÓ‰ÔÁÂÓ›˜ ÔÚÌfiÓ˜ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÚÒÙˆÓ ÌËÓÒÓ. ∫ÂÓfi fiÛ¯ÂÔ ∆Ô fiÛ¯ÂÔ ÌÔÚ› Ó· Â›Ó·È ÎÂÓfi ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ Û ÔÛÔÛÙfi 20-30% Î·È ÛÙ· ÓÂÔÁÓ¿ ηٿ ÙË Á¤ÓÓËÛ‹ ÙÔ˘˜ Û ÔÛÔÛÙfi 1,8-4,0%. ∏ ‰È¿ÁÓˆÛË Ù˘ ·ÏËıÈÓ‹˜ ÎÚ˘„ÔÚ¯›·˜ Â›Ó·È ‰‡ÛÎÔÏÔ Ó· ÚÔÛ‰ÈÔÚÈÛÙ› ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ, ÂȉÈο ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ŒÂÈÙ·, Ô fiگȘ ÌÔÚ› Ó· Êı¿ÛÂÈ ÛÙÔ fiÛ¯ÂÔ Ì ̛· ‹È· ¤ÏÍË. ∆Ô ÎÂÓfi fiÛ¯ÂÔ ÌÔÚ› Ó· ÚÔ·ÙÂÈ ·fi ·Ó·ÛÒÌÂÓÔ˘˜ fiÚ¯ÂȘ, ·fi ·ÏËı›˜ ÎÚ˘„fiÚ¯ÂȘ (86%), ·fi ‰˘ÛÁÂÓÂÙÈÎÔ‡˜ ‹ ·ÙÚÔÊÈÎÔ‡˜ fiÚ¯ÂȘ (6%), ·fi ·Ô˘Û›· fiگˆ˜ (6%) ‹ ÂÎÙfiÔ˘ fiگˆ˜ (2%). ∫ÏÈÓÈΤ˜ ·Ú·ÏÏ·Á¤˜ Ù˘ ÎÚ˘„ÔÚ¯›·˜ ∞Ó·ÛÒÌÂÓÔÈ fiÚ¯ÂȘ Œ¯ÂÈ ˘ÔÏÔÁÈÛÙ› fiÙÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÔÈ ÌÈÛÔ› fiÚ¯ÂȘ, Ô˘ ‰ÂÓ Â˘Ú›ÛÎÔÓÙ·È ÛÙÔ Û‡ÛÙÔÈ¯Ô ËÌÈfiÛ¯ÂÔ Û ·ÁfiÚÈ· ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜, ‚Ú›ÛÎÔÓÙ·È Û ˘„ËÏfiÙÂÚË ı¤ÛË ÏfiÁˆ Û·ÛÌÔ‡ ÙÔ˘ ÎÚÂÌ·ÛÙ‹Ú· Ì˘fi˜ Î·È ·ÔÙ˘¯›·˜ Ï‹ÚÔ˘˜ ÚfiÛÊ˘Û˘ ÙÔ˘ οو fiÏÔ˘ ÙÔ˘ fiگˆ˜ ÛÙÔ fiÛ¯ÂÔ ‰È·Ì¤ÛÔ˘ ÙÔ˘ Ô›·Î·. ∆È ÛËÌ·›ÓÂÈ, fï˜, Ô fiÚÔ˜ Ù˘ ˘ÂÚ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙÔ˘ ÎÚÂÌ·ÛÙ‹Ú· Ì˘fi˜, ‰ÂÓ Â›Ó·È ÍÂοı·ÚÔ. ∂¿Ó ·˘Ùfi ÛËÌ·›ÓÂÈ ˘¤ÚÌÂÙÚË Â˘·ÈÛıËÛ›·, ·Ú·ÙÂٷ̤ÓË ‰È¿ÚÎÂÈ· ·¿ÓÙËÛ˘, ÌÈÎÚfi ‰È¿ÛÙËÌ· Ï·Óı¿ÓÔ˘Û·˜ ·¿ÓÙËÛ˘ ‹ ˘ÂÚ‚ÔÏÈ΋ Ì˘˚΋ ‰Ú·ÛÙËÚÈfiÙËÙ·, ·Ú·Ì¤ÓÂÈ ·‰È¢ÎÚ›ÓÈÛÙÔ. ¶Èı·Ó¿, ÏfiÁˆ ÙˆÓ ·ÌÊÈ‚ÔÏÈÒÓ ·˘ÙÒÓ, Ë ˘fiıÂÛË fiÙÈ Ë ˘ÂÚ‚ÔÏÈ΋ ‰Ú·ÛÙËÚÈfiÙËÙ· ÙÔ˘ ÎÚÂÌ·ÛÙ‹Ú· Û˘ÁÎÚ·Ù› ÙÔÓ fiÚ¯È Û ÚÔÔÛ¯Â˚΋ ı¤ÛË ‰ÂÓ ¤¯ÂÈ ‰ÔÎÈÌ·ÛÙ›. ™Â ÚfiÛÊ·Ù˜ ÌÂϤÙ˜ ÂÚÈÁÚ¿ÊËÎ·Ó Î·È Û˘ÁÎÚ›ıËÎ·Ó Ù· ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ÎÚÂÌ·ÛÙ‹Ú· Ì˘fi˜ Û ·ÁfiÚÈ· Ì ·Ó·ÛÒÌÂÓÔ˘˜ Î·È Ê˘ÛÈÔÏÔÁÈÎÔ‡˜ fiÚ¯ÂȘ, ηıÒ˜ Î·È Û ÎÚ˘„fiÚ¯ÂȘ. ∆· ·ÔÙÂϤÛÌ·Ù¿ ÙÔ˘˜ ‹Ù·Ó fiÙÈ ‰ÂÓ ÌÔÚÔ‡Û·Ó Ó· ˘ÔÛÙËÚ›ÍÔ˘Ó ‹ Ó· ÂÓ·ÓÙȈıÔ‡Ó ÛÙËÓ ˘fiıÂÛË Ù˘ Ì›˙ÔÓÔ˜ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙÔ˘ ÎÚÂÌ·ÛÙ‹Ú· Ì˘fi˜ ÛÙÔ˘˜ ·Ó·ÛÒÌÂÓÔ˘˜ fiÚ¯ÂȘ (5). √È ·Ó·ÛÒÌÂÓÔÈ fiÚ¯ÂȘ Û˘Ó‹ıˆ˜ η٤گÔÓÙ·È ÛÙÔ fiÛ¯ÂÔ ·˘ÙfiÌ·Ù·, fiÙ·Ó ÙÔ ·È‰› ÎÔÈÌ¿Ù·È ‹ Â›Ó·È ‹ÚÂÌÔ, fiˆ˜ Û ˙ÂÛÙfi Ì¿ÓÈÔ Î·È ÌÔÚ› Ó· η٤گÔÓÙ·È
2001 MAPT- A¶PI§
17-10-01 15:34
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¶·È‰È·ÙÚÈ΋ 2001;64:93-100
ÛÙÔ fiÛ¯ÂÔ Ì ÂÏ·ÊÚ¿ ¤ÏÍË. √È ·Ó·ÛÒÌÂÓÔÈ fiÚ¯ÂȘ Â›Ó·È Û˘Ó‹ıˆ˜ ·ÌÊÔÙÂÚfiÏ¢ÚÔÈ Î·È ·Ú·Ì¤ÓÔ˘Ó Û˘Ó‹ıˆ˜ ¿ÓˆıÂÓ ÙÔ˘ ÔÛ¯¤Ô˘ ̤¯ÚÈ Ù˘ ÂÊ˂›·˜, fiÙ·Ó ÔÈ fiÚ¯ÂȘ Á›ÓÔÓÙ·È ÌÂÁ·Ï‡ÙÂÚÔÈ Û fiÁÎÔ ·fi ÙÔ ¤Íˆ ‚Ô˘‚ˆÓÈÎfi ÛÙfiÌÈÔ Î·È Ô ÎÚÂÌ·ÛÙ‹Ú·˜ Ì˘˜ Á›ÓÂÙ·È ÏÈÁfiÙÂÚÔ ‰Ú·ÛÙÈÎfi˜. ∂¿Ó Û οÔÈ· ÛÙÈÁÌ‹ Ô fiگȘ Ê·›ÓÂÙ·È ÛÙÔ fiÛ¯ÂÔ ‹ η٤ÏıÂÈ Ì ‹È· ¤ÏÍË ÛÙÔ fiÛ¯ÂÔ, Ô ·ÛıÂÓ‹˜ ¤¯ÂÈ ·Ó·ÛÒÌÂÓÔ fiÚ¯È Î·È ÔÈ ÁÔÓ›˜ Ú¤ÂÈ Ó· ‰È·‚‚·ÈÒÓÔÓÙ·È fiÙÈ Ô fiگȘ ı· ·Ú·Ì›ÓÂÈ ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ ÔÛ¯Â˚΋ ı¤ÛË ÙÂÏÈο. √ fiÁÎÔ˜ ÙÔ˘ fiگˆ˜ Î·È Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÈÛÙ‡ÂÙ·È fiÙÈ Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ. ¢ÂÓ ¯ÚÂÈ¿˙ÔÓÙ·È ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË. ŒÎÙÔÔÈ fiÚ¯ÂȘ √ ¤ÎÙÔÔ˜ fiگȘ Û˘Ó‹ıˆ˜ ‚Ú›ÛÎÂÙ·È ÛÙÔ ÌËÚfi, ‚Ô˘‚ÒÓ· ‹ ˘ÂÚË‚Èο, ÏfiÁˆ ·ÓÒÌ·Ï˘ ÚfiÛÊ˘Û˘ ÙÔ˘ Ô›·Î·, Ì ÌÂÁ¿ÏË Èı·ÓfiÙËÙ· Ó· ˘ÔÛÙ› ÙÚ·˘Ì·ÙÈÛÌfi. ¶ÂÚ›Ô˘ 80% ·fi ÙÔ˘˜ ¤ÎÙÔÔ˘˜ fiÚ¯ÂȘ Â›Ó·È ÂÙÂÚfiÏ¢ÚÔÈ. ™˘Ó‹ıˆ˜ Â›Ó·È Î·ÓÔÓÈÎÔ› Û ̤ÁÂıÔ˜, Ì ηÓÔÓÈ΋ ÛÂÚÌ·ÙÔÁÂÓÂÙÈ΋ Î·È ÔÚÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ¶Ú¤ÂÈ Ó· ÙÔÔıÂÙËıÔ‡Ó ¯ÂÈÚÔ˘ÚÁÈο ÛÙÔ fiÛ¯ÂÔ Û Ó·ڋ ËÏÈΛ·. ÀÔÏ·ÛÙÈÎÔ› fiÚ¯ÂȘ ‹ ·Ô˘Û›· fiÚ¯ÂˆÓ ¶ÂÚ›Ô˘ ÙÔ 12% ÙˆÓ ·È‰ÈÒÓ Ì ÎÂÓfi fiÛ¯ÂÔ ı· ¤¯Ô˘Ó ·Ô˘Û›· ‹ ˘ÔÏ·Û›· fiگˆ˜. ∏ Û˘ÛÙÚÔÊ‹ ‹ ·fiÊÚ·ÍË Ù˘ ÔÚ¯È΋˜ ÚÔ‹˜ ·›Ì·ÙÔ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÌ‚Ú˘˚΋˜ ˙ˆ‹˜, ÈÛÙ‡ÂÙ·È fiÙÈ Â›Ó·È Ë ÌÂÁ·Ï‡ÙÂÚË ·ÈÙ›·, ηıÒ˜ Î·È ÔÚÌÔÓÈÎÔ› ·Ú¿ÁÔÓÙ˜. ªÂ ÙËÓ Ï‹ÚË ·Ô˘Û›· ÔÚ¯ÈÎÔ‡ ·ÚÂÁ¯‡Ì·ÙÔ˜, Ô fiÚÔ˜ ÙÔ˘ Müller ·Ó·Ù‡ÛÛÂÙ·È Î·È ‰È·ÊÔÚÔÔÈÂ›Ù·È Û ı‹ÏÂȘ ‰Ô̤˜. ™¿ÓÈ· ¤Ó·˜ fiگȘ ·ÔÙ˘Á¯¿ÓÂÈ Ó· ·Ó·Ù˘¯ı› Û˘ÓËı¤ÛÙÂÚ· ·fi ÙË ‰ÂÍÈ¿ ÏÂ˘Ú¿ Î·È ÂÚÈÛÙ·Ûȷο Û˘Ó˘¿Ú¯ÂÈ Û‡ÛÙÔȯԘ ·ÁÂÓÂÛ›· ÙÔ˘ ÓÂÊÚÔ‡ Î·È ÙÔ˘ Ô˘ÚËÙ‹Ú·. √ ÛÂÚÌ·ÙÈÎfi˜ fiÚÔ˜ Û ·˘ÙÔ‡˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Â›Ó·È Û˘Ó‹ıˆ˜ ˘ÔÏ·ÛÙÈÎfi˜ Î·È Î·Ù·Ï‹ÁÂÈ Ù˘ÊÏ¿ ÛÙÔ ‡„Ô˜ ÙÔ˘ ¤Ûˆ ‚Ô˘‚ˆÓÈÎÔ‡ ÛÙÔÌ›Ô˘. ∆Ô Û‡ÛÙÔÈ¯Ô ËÌÈfiÛ¯ÂÔ Û˘Ó‹ıˆ˜ Â›Ó·È ˘ÔÏ·ÛÙÈÎfi. ∞ÓÔÚ¯›· Û˘Ó‹ıˆ˜ ·Ú·ÙËÚÂ›Ù·È Û ¤Ó· ÔÛÔÛÙfi 6% Û ·ÁfiÚÈ· Ô˘ ¯ÂÈÚÔ˘ÚÁÔ‡ÓÙ·È ÁÈ· ÎÚ˘„ÔÚ¯›·. ∏ ·ÓÔÚ¯›· Û˘Ó‹ıˆ˜ Â›Ó·È ÂÙÂÚfiÏ¢ÚÔ˜ Û ÔÛÔÛÙfi 85% ÙˆÓ ÂÚÈÙÒÛˆÓ. ™Â Û¿ÓȘ ÂÚÈÙÒÛÂȘ, ·Ú·ÙËÚÂ›Ù·È ÌË ‚ÈÒÛÈÌÔ ÔÚ¯ÈÎfi ·Ú¤Á¯˘Ì· Î·È ÛÙȘ ‰‡Ô Ï¢ڤ˜. ∂›Û˘, Ù· ¤Íˆ ÁÂÓÓËÙÈο fiÚÁ·Ó· Â›Ó·È Ï‹Úˆ˜ ‰È·ÊÔÚÔÔÈË̤ӷ Û ¿ÚÚÂÓ˜ ‰Ô̤˜ ÛÙË Á¤ÓÓËÛË Î·È ¤Ó·˜ ˘ÔÙ˘Ò‰Ë˜ ÛÂÚÌ·ÙÈÎfi˜ fiÚÔ˜ ÙÂÏÂÈÒÓÂÈ Ù˘ÊÏ¿ ÛÙËÓ ÎÔÈÏÈ¿. ∏ Û˘ÛÙÚÔÊ‹ ‹ ·fiÊÚ·ÍË Ù˘ ÔÚ¯È΋˜ ·ÈÌ·ÙÈ΋˜ ÚÔ‹˜ ÈÛÙ‡ÂÙ·È fiÙÈ ·›˙ÂÈ ÚfiÏÔ ÛÙÔÓ “ÂÍ·Ê·ÓÈÛı¤ÓÙ· fiگȔ (vanishing testis) ‹ ÛÙÔ Û‡Ó‰ÚÔÌÔ Ù˘ ÔÚ¯È΋˜ ˘ÔÛÙÚÔÊ‹˜. ∏ ÂÊ˂›· ηı˘ÛÙÂÚ›, ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ˘„ËϤ˜ ÙÈ̤˜ FSH Î·È LH ÛÙÔ Ï¿-
Paediatriki 2001;64:93-100
ÛÌ· Î·È ¯·ÌËϤ˜ ÙÈ̤˜ ÙÂÛÙÔÛÙÂÚfiÓ˘. ÀÔÏ·ÛÙÈÎÔ› ‹ ‰˘ÛÁÂÓÂÙÈÎÔ› fiÚ¯ÂȘ ÔÙ¤ ‰ÂÓ ¤¯Ô˘Ó ÛÂÚÌ·ÙÔÁÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›· ·Ú¿ ÙËÓ ÔÔÈ·‰‹ÔÙ ıÂڷ›·. ∂ÓÙÔ‡ÙÔȘ, ÔÏÏÔ› ÎÚ˘„fiÚ¯ÂȘ Ì ‰È¿ÌÂÛÔ Û˘Ó‰ÂÙÈÎfi ÈÛÙfi Î·È Î‡ÙÙ·Ú· Leyding ı· ·Ú¿ÁÔ˘Ó ÙÂÛÙÔÛÙÂÚfiÓË ÁÈ· Ó· ÚÔηϤÛÂÈ ÁÔÓÈÌfiÙËÙ·. ∂›Û˘, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ÎÔÈÏ›·˜ ηıÒ˜ Î·È Ë ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÌÔÚÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó ÛÙÔÓ ÂÓÙÔÈÛÌfi ÂÓ‰ÔÎÔÈÏÈ·ÎÒÓ fiگˆÓ. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÈÂÚ‡ÓËÛË Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË ‰È¿ÁÓˆÛË, ‰ÈfiÙÈ ÔÈ ‰˘ÛÏ·ÛÙÈÎÔ› ‹ ÔÈ ÂÓ‰ÔÎÔÈÏÈ·ÎÔ› fiÚ¯ÂȘ ¤¯Ô˘Ó ˘„ËÏ‹ ÚԉȿıÂÛË ÚÔ˜ ηÎÔ‹ıË ÂÍ·ÏÏ·Á‹. √Ú¯È΋ ÚfiıÂÛË ÛÙËÓ ÂÊ˂›· ÌÔÚ› Ó· ÙÔÔıÂÙËı› ÛÙÔ fiÛ¯ÂÔ ÁÈ· ÎÔÛÌËÙÈÎÔ‡˜ ·ÏÏ¿ Î·È „˘¯ÔÏÔÁÈÎÔ‡˜ ÏfiÁÔ˘˜. ∂͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË ÙÂÛÙÔÛÙÂÚfiÓ˘ ÛÙËÓ ÂÊ˂›· ÚÔηÏ› ÈηÓÔÔÈËÙÈ΋ ·¿ÓÙËÛË ÛÙË ÛÂÍÔ˘·ÏÈ΋ ˆÚ›Ì·ÓÛË ÙÔ˘ ·Ó‰Úfi˜. ∞ÏËı‹˜ ÎÚ˘„oÚ¯›· √ fiگȘ, Ô ÔÔ›Ô˜ ‰ÂÓ Î·Ù¤Ú¯ÂÙ·È ÛÙÔ fiÛ¯ÂÔ ·˘ÙfiÌ·Ù·, Ì ÔÚÌÔÓÈ΋ ıÂڷ›· ‹ Ì ÂÁ¯Â›ÚËÛË Ì¤¯ÚÈ ÙÔ Ù¤Ù·ÚÙÔ ¤ÙÔ˜ Ù˘ ËÏÈΛ·˜, Èı·ÓfiÓ Ó· ÌËÓ ¤¯ÂÈ Î·ÓÔÓÈ΋ ÛÂÚÌ·ÙÔÁÂÓÂÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÛÙËÓ ÂÊ˂›·. √È ÂÚÈÛÛfiÙÂÚÔÈ ÎÚ˘„fiÚ¯ÂȘ ÂÌÔ‰›˙ÔÓÙ·È ÛÙÔ Ó· Êı¿ÛÔ˘Ó ÛÙÔ fiÛ¯ÂÔ, ÁÈ·Ù› Ë ÛÂÚÌ·ÙÈ΋ ·ÚÙËÚ›· Â›Ó·È ‚Ú·¯‡ÙÂÚË Ù˘ Ê˘ÛÈÔÏÔÁÈ΋˜. ¢ÂÓ Â›Ó·È ÁÓˆÛÙfi Â¿Ó Ë ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙË ÛÂÚÌ·ÙÈ΋ ·ÚÙËÚ›· ÂÓfi˜ ÌË ˘ÔÏ·ÛÙÈÎÔ‡ ÎÚ˘„fiگˆ˜ Â›Ó·È ÌÂȈ̤ÓË, Û˘ÁÎÚÈÙÈο Ì ÂÓfi˜ ÔÚıfiÙÔÔ˘ fiگˆ˜. ∫·ıÒ˜ ÂÚÈÛÛfiÙÂÚÔ ·fi 80% ÙˆÓ ·ÏËıÈÓÒÓ ÎÚ˘„fiÚ¯ÂˆÓ ·Ú·ÙËÚÔ‡ÓÙ·È ÂÙÂÚfiÏ¢ڷ, ÂȉÈ΋ ÔÚÌÔÓÈ΋ ·Ó¿ÚÎÂÈ· ı· ÌÔÚÔ‡Û ӷ ÂÓÔ¯ÔÔÈËı› ÁÈ· ÙËÓ ÎÚ˘„ÔÚ¯›·, Ë ÔÔ›· Â›Ó·È ‚¤‚·È· ‰‡ÛÎÔÏÔ Ó· ÚÔÛ‰ÈÔÚÈÛÙ›. ¶·È‰È¿ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ÎÚ˘„ÔÚ¯›· Â›Ó·È ÈÔ Èı·Ófi Ó· ¤¯Ô˘Ó ÂÓ‰ÔÎÚÈÓÈ΋ ·ÓˆÌ·Ï›· Ì ÔÚÌÔÓÈ΋ ·Ó¿ÚÎÂÈ·, ·Ú¿ ·È‰È¿ Ì ÂÙÂÚfiÏ¢ÚË. ∫¿ıÔ‰Ô˜ ÙÔ˘ fiگˆ˜ ̤۷ ÛÙÔ˘˜ 9 ÚÒÙÔ˘˜ Ì‹Ó˜ Ù˘ ˙ˆ‹˜ ·Ú·ÙËÚÂ›Ù·È ÛÙ· ÂÚÈÛÛfiÙÂÚ· ‚Ú¤ÊË Ì ¿‰ÂÈÔ fiÛ¯ÂÔ. ªÂÙ¿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜, Ë ·ÏËı‹˜ ÎÚ˘„ÔÚ¯›· Â›Ó·È ·ıÔÏÔÁÈ΋ ηٿÛÙ·ÛË Î·È ·Ú·ÙËÚÂ›Ù·È ÂÚ›Ô˘ Û ÔÛÔÛÙfi 1% Û ·˘Ù‹ ÙËÓ ËÏÈΛ·. ª¤ÙÚËÛË ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘ fiگˆ˜, Ù˘ ‰È·Ì¤ÙÚÔ˘, ÙˆÓ ÛÂÚÌ·ÙÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ Î·È ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ÛÂÚÌ·ÙÔÁÔÓ›ˆÓ, ‰Â›¯ÓÂÈ fiÙÈ Û Ó·ڿ ·È‰È¿ ÔÈ fiÚ¯ÂȘ ¤¯Ô˘Ó ÁÚ·ÌÌÈ΋ ·Ó¿Ù˘ÍË ÚÈÓ ÙËÓ ÂÊ˂›·. µÏ·ÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ÚÔηÏÔ‡Ó ÌÔÚÊÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ÛÙÔÓ ÎÚ˘„fiÚ¯È, ‰ÚÔ˘Ó ·fi ÙÔ Ù¤ÏÔ˜ ÙÔ˘ ‰Â‡ÙÂÚÔ˘ ¤ÙÔ˘˜ Ù˘ ˙ˆ‹˜. ¢È·ÊÔÚÂÙÈΤ˜ ·fi„ÂȘ ˘¿Ú¯Ô˘Ó fiÛÔÓ ·ÊÔÚ¿
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¶·È‰È·ÙÚÈ΋ 2001;64:93-100
ÙËÓ ËÏÈΛ· Ô˘ ·Ú¯›˙Ô˘Ó ÔÈ ‚Ï¿‚˜ ÛÙÔÓ ÎÚ˘„fiÚ¯È. ªÂÚÈÎÔ› ÂÚ¢ÓËÙ¤˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ Ì ÙÔÓ ·ÚÈıÌfi ÙˆÓ ÛÂÚÌ·ÙÔÁÔÓ›ˆÓ ηıÒ˜ Î·È Ì ÙËÓ ÔÛÔÙÈ΋ ÂͤٷÛË Ù˘ ‰ÔÌ‹˜ ÙÔ˘ ‰È¿ÌÂÛÔ˘ ÈÛÙÔ‡, fiÙÈ Ô ÎÚ˘„fiگȘ ‰ÂÓ ¤¯ÂÈ ÂÌÊ·Ó›˜ ÈÛÙÔÌÔÚÊÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰‡Ô ÚÒÙˆÓ ÂÙÒÓ Ù˘ ËÏÈΛ·˜ (6). ªÂÙ¿ Ù· ‰‡Ô ÚÒÙ· ¤ÙË, Ô ·ÚÈıÌfi˜ ÙˆÓ ÛÂÚÌ·ÙÔÁÔÓ›ˆÓ ÂÏ·ÙÙÒÓÂÙ·È ÛËÌ·ÓÙÈο. ∞Ú¯È΋ ÂÎʇÏÈÛË ‹ ·ÔÙ˘¯›· ·Ó¿Ù˘Í˘ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ˘˜ ÎÔÈÏÈ·ÎÔ‡˜ fiÚ¯ÂȘ, ÏfiÁˆ Ù˘ ˘„ËÏ‹˜ ıÂÚÌÔÎÚ·Û›·˜. ¶ÂÈÚ·Ì·ÙÈ΋ ÂÓ·fiıÂÛË fiگˆ˜ ·fi ÙÔ fiÛ¯ÂÔ Ì¤Û· ÛÙËÓ ÂÚÈÙÔÓ·˚΋ ÎÔÈÏfiÙËÙ· ÚÔηÏ› ÂÎʇÏÈÛË ÙÔ˘ ‚Ï·ÛÙÈÎÔ‡ ÂÈıËÏ›Ô˘. ∂›Û˘, Ë Â›‰Ú·ÛË ıÂÚÌfiÙËÙ·˜ Û ÔÛ¯Â˚Îfi fiÚ¯È ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÂÎÊ˘ÏÈÛÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ (7). √ ηÓÔÓÈÎfi˜ fiÁÎÔ˜ ÙÔ˘ fiگˆ˜ Â›Ó·È ÌÈÎÚfiÙÂÚÔ˜ ·fi 1,5 ml ηٿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ‰‡Ô ÚÒÙˆÓ ÂÙÒÓ Ù˘ ˙ˆ‹˜ Î·È ·Ú·Ì¤ÓÂÈ ÌÈÎÚfiÙÂÚÔ˜ ·fi 3 ml ̤¯ÚÈ Ù· 11 ¯ÚfiÓÈ·. ∞ÎÔÏÔ‡ıˆ˜ ·˘Í¿ÓÂÈ Ù·¯¤ˆ˜ ÁÈ· ¤Ó· ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 3-4 ÂÙÒÓ, ̤¯ÚȘ fiÙÔ˘ Êı¿ÛÂÈ ÙÔ Ì¤ÁÂıÔ˜ ÙÔ˘ ÂÓ‹ÏÈÎÔ˘ fiگˆ˜ (1215 ml). ªÂ ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜, Ô ÎÚ˘„fiگȘ ·Ó·Ù‡ÛÛÂÈ ÂӉȿÌÂÛË ›ÓˆÛË Ì ηı˘ÛÙÂÚË̤ÓË Î·È ·ÓÒÌ·ÏË ·Ó¿Ù˘ÍË ÛˆÏËÓ·Ú›ˆÓ. ∏ ÛÂÚÌ·ÙÔÁ¤ÓÂÛË Â›Ó·È ÂÏ·Ùو̤ÓË ÏfiÁˆ ·ÙÚÔÊ›·˜ ÙˆÓ ÛÂÚÌ·ÙÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ Ô˘ ÚÔηÏÂ›Ù·È Â›Ù ·fi Ì›ˆÛË Ù˘ ·ÁÁ›ˆÛ˘, ›Ù ·fi ÂͿψÛË Û˘Ó‰ÂÙÈÎÔ‡ ÈÛÙÔ‡. √ ÂÙÂÚfiÏ¢ÚÔ˜ ÎÚ˘„fiگȘ ÌÔÚ› Ó· ·Ú¿ÁÂÈ ·˘ÙÔ·ÓÙÈÛÒÌ·Ù·, Ù· ÔÔ›· ÂËÚ¿˙Ô˘Ó ‚Ï·ÙÈο ÙËÓ ·Ó¿Ù˘ÍË Î·È ÏÂÈÙÔ˘ÚÁ›· Î·È ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ Û ı¤ÛË fiگˆ˜ (8). ∆Ș ›‰È˜ ·ıÔÏÔÁÈΤ˜ ·ÏÏÔÈÒÛÂȘ ·Ú·ÙËÚԇ̠ÛÙ· ÛÂÚÌ·ÙÈο ÛˆÏËÓ¿ÚÈ· ÙÔ˘ ÂÙÂÚfiÏ¢ÚÔ˘ ÔÛ¯Â˚ÎÔ‡ fiگˆ˜ ÌÂÙ¿ ·fi Û˘ÛÙÚÔÊ‹ ÙÔ˘ ¿ÏÏÔ˘ fiگˆ˜ Ì ÛËÌ·ÓÙÈÎÔ‡ ‚·ıÌÔ‡ ÈÛ¯·ÈÌ›·, ¯ˆÚ›˜ Ë ÈÛ¯·ÈÌÈ΋ ÁÔÓ¿‰· Ó· ·Ê·ÈÚÂı›. ∫¿Ùˆ ·fi ·ıÔÏÔÁÈΤ˜ ηٷÛÙ¿ÛÂȘ, Ë ‚·ÛÈ΋ ÌÂÌ‚Ú¿ÓË ÙˆÓ ÛˆÏËÓ·Ú›ˆÓ Ô˘ ÏÂÈÙÔ˘ÚÁ› Ê˘ÛÈÔÏÔÁÈο Û·Ó ·ÓÔÛÔÏÔÁÈÎfi˜ ÊÚ·ÁÌfi˜ ÌÔÚ› Ó· Á›ÓÂÈ ÔÚ҉˘ Î·È Ó· ÂÎı¤ÛÂÈ Ù· ÛˆÏËÓ¿ÚÈ· Û ·ÓÙÈÛÒÌ·Ù·, ‰ËÌÈÔ˘ÚÁÒÓÙ·˜ ‰ËÏ·‰‹ ·ÓÙ›‰Ú·ÛË ·ÓÙÈÁfiÓÔ˘ - ·ÓÙÈÛÒÌ·ÙÔ˜. ∂¿Ó Ô ÎÚ˘„fiگȘ ‰ÂÓ ÙÔÔıÂÙËı› ÛÙÔ fiÛ¯ÂÔ, Ë ÁÔÓÈÌfiÙËÙ· ı· Â›Ó·È ÂÏ·Ùو̤ÓË. Œ¯ÂÈ Ê·Ó› ·fi ÔÏÏÔ‡˜ ÂÚ¢ÓËÙ¤˜ fiÙÈ Ó·ڿ ·È‰È¿ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ÔÚ¯ÂÔËÍ›· ı· ·Ó·Ù‡ÍÔ˘Ó ·ÎÔÏÔ‡ıˆ˜ ÌÂÁ·Ï‡ÙÂÚÔ ·ÚÈıÌfi ÛÂÚÌ·ÙÔÁÔÓ›ˆÓ. ¢È¿ÁÓˆÛË Ù˘ ÎÚ˘„ÔÚ¯›·˜ ™Â ÔÛÔÛÙfi ¿Óˆ ·fi 85% ÙˆÓ ·ÁÔÚÈÒÓ Ì ÎÂÓfi fiÛ¯ÂÔ, Ô fiگȘ ÌÔÚ› Ó· „ËÏ·Ê¿Ù·È ÛÙÔ ‚Ô˘‚ˆÓÈÎfi fiÚÔ ‹ Û ¤ÎÙÔË ı¤ÛË. ™¿ÓÈ· ·Ú·ÙËÚÂ›Ù·È ÌË Î·Ï¿ ·Ó·Ù˘Á̤ÓÔ fiÛ¯ÂÔ Î·È Û˘Ó‹ıˆ˜ Û˘Ó-
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‰˘¿˙ÂÙ·È Ì ˘„ËÏfi ‚Ô˘‚ˆÓÈÎfi ‹ ÎÔÈÏÈ·Îfi ‹ ·ÙÚÔÊÈÎfi fiÚ¯È ‹ ·Ô˘Û›· Ù˘ ÁÔÓ¿‰·˜. ¶ÚÔÛÂÎÙÈ΋ ÂͤٷÛË Ì ˙ÂÛÙ¿ ¯¤ÚÈ·, Ì ÙÔ ·È‰› ‹ÚÂÌÔ Î·È Û ‡ÙÈ· ı¤ÛË, Û˘Ó‹ıˆ˜ ÂÈÙÚ¤ÂÈ Â‡ÎÔÏË ·Ó·ÁÓÒÚÈÛË ÙÔ˘ ·Ó·ÛÒÌÂÓÔ˘ fiÚ¯È, Ô ÔÔ›Ô˜ ‰ÂÓ ¯ÚÂÈ¿˙ÂÙ·È ÂÚ·ÈÙ¤Úˆ ıÂڷ›·. ŸÙ·Ó Ô fiگȘ ¢ڛÛÎÂÙ·È Û ÚÔÔÛ¯Â˚΋ ı¤ÛË, Ú¤ÂÈ Ó· ÂϤÁ¯ÂÙ·È ÙÔ Ì¤ÁÂıfi˜ ÙÔ˘, Ë ÌÔÚÊ‹ ÙÔ˘, Ë ÛÊÚÈÁËÏfiÙËÙ¿ ÙÔ˘ Ì ÙÔÓ ·ÓÙ›ÛÙÔÈ¯Ô fiÚ¯È Î·È Ì fiÚ¯ÂȘ ·È‰ÈÒÓ Ù˘ ›‰È·˜ ËÏÈΛ·˜. ªÂÙ¿ ÙËÓ „ËÏ¿ÊËÛË, Ù· ‰¿ÎÙ˘Ï· ÙÔ˘ ÂÍÂÙ·ÛÙ‹ Ȥ˙Ô˘Ó Î¿ıÂÙ· ÙÔ Î¿Ùˆ ̤ÚÔ˜ Ù˘ ÎÔÈÏÈ¿˜ ·ÎÚÈ‚Ò˜ ¿Óˆ ·fi ÙË ı¤ÛË Ô˘ „ËÏ·Ê¿Ù·È Ô fiگȘ Î·È ·ÎÔÏÔ‡ıˆ˜ ÛÈÁ¿-ÛÈÁ¿ ÌÂÙ·ÎÈÓÔ‡ÓÙ·È ¿Óˆ ·fi ÙÔ ¤Íˆ ÛÙfiÌÈÔ ÙÔ˘ ‚Ô˘‚ˆÓÈÎÔ‡ fiÚÔ˘ Ì ÚfiıÂÛË Ó· “ÁÏÈÛÙÚ‹ÛÂÈ” Ô fiگȘ ̤۷ ÛÙÔ Û‡ÛÙÔÈ¯Ô ËÌÈfiÛ¯ÂÔ. ∆· ‰¿ÎÙ˘Ï· ÙÔ˘ ¿ÏÏÔ˘ ¯ÂÚÈÔ‡ ÌÔÚÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó È¿ÓÔÓÙ·˜ ÙÔÓ fiÚ¯È, fiÙ·Ó ·˘Ùfi˜ ÂÚ¿ÛÂÈ ÙÔÓ ·˘¯¤Ó· ÙÔ˘ ÔÛ¯¤Ô˘, ηÙ¢ı‡ÓÔÓÙ¿˜ ÙÔÓ Ì¤Û· ÛÙÔ ËÌÈfiÛ¯ÂÔ. ∞ÊÔ‡ ·ӷÏËÊı› ·˘Ù‹ Ë Î›ÓËÛË ·ÚÎÂÙ¤˜ ÊÔÚ¤˜, Ë ¯·ÌËÏfiÙÂÚË ‰˘Ó·Ù‹ ı¤ÛË ÙÔ˘ fiگˆ˜ ÌÔÚ› Ó· ÛËÌÂȈı›, fiˆ˜ .¯. ˘„ËÏfi˜ ‚Ô˘‚ˆÓÈÎfi˜, ¯·ÌËÏfi˜ ‚Ô˘‚ˆÓÈÎfi˜, ÚÔÔÛ¯Â˚Îfi˜, ¯·ÌËÏfi˜ ÔÛ¯Â˚Îfi˜ (ηÓÔÓÈÎfi˜). ∂¿Ó Ô fiگȘ ‰ÂÓ „ËÏ·Ê¿Ù·È, ÂÚ·ÈÙ¤Úˆ ÂͤٷÛË Â›Ó·È ··Ú·›ÙËÙË Û fiÚıÈ· ‹ ηıÈÛÙ‹ ı¤ÛË Ì ÛÙ·˘ÚˆÌ¤Ó· fi‰È·. ™¿ÓÈ· Â›Ó·È ··Ú·›ÙËÙË Ë ¯ÔÚ‹ÁËÛË ËÚÂÌÈÛÙÈÎÒÓ Û Ôχ ‰ÈÂÁÂÚÙÈο ·È‰È¿. ∂¿Ó ÌÂÙ¿ ·fi ·ÓÂÈÏËÌ̤Ó˜ ÂÍÂÙ¿ÛÂȘ Ô fiگȘ ‰ÂÓ „ËÏ·Ê¿Ù·È, ÙfiÙ Èı·Ó¿ Â›Ó·È ÎÔÈÏÈ·Îfi˜, ·ÙÚÔÊÈÎfi˜ ‹ ·Ô˘ÛÈ¿˙ÂÈ. ∂¿Ó Î·È ÔÈ ‰‡Ô fiÚ¯ÂȘ Â›Ó·È ·„ËÏ¿ÊËÙÔÈ, ÌÔÚ› Ó· ‰ÔÎÈÌ·Ûı› Ë Ì¤ÙÚËÛË Ù˘ ı˘Ï·ÎÈÔÙÚfiÔ˘ ÔÚÌfiÓ˘ (FSH), ˆ¯ÚÈÓÔÙÚfiÔ˘ ÔÚÌfiÓ˘ (LH) Î·È ÙÂÛÙÔÛÙÂÚfiÓ˘ ÛÙÔ ·›Ì· Î·È ÛÙË Û˘Ó¤¯ÂÈ· ‰È¤ÁÂÚÛË HCG. ∂¿Ó ·Ú·ÙËÚËı› ·‡ÍËÛË ÌfiÓÔ ÙˆÓ ÁÔÓ·‰ÔÙÚÔÈÓÒÓ (FSH), (LH), ÂÓÒ Ë ÙÂÛÙÔÛÙÂÚfiÓË ·Ú·Ì¤ÓÂÈ ÌÂȈ̤ÓË, Â›Ó·È Ê·ÓÂÚfi fiÙÈ fiÚ¯ÂȘ ‰ÂÓ ˘¿Ú¯Ô˘Ó (9-11). ∂¿Ó ·Ô˘ÛÈ¿˙ÂÈ ÌfiÓÔ Ô ¤Ó·˜ fiگȘ, ÎÏÈÓÈο Ë ¤Ú¢ӷ ÌÔÚ› Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ˘ÂÚ˯ÔÙÔÌÔÁÚ·Ê›·, ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·, ÊÏ‚ÔÁÚ·Ê›· Ù˘ Û‡ÛÙÔȯ˘ ¤Ûˆ ÛÂÚÌ·ÙÈ΋˜ ÊϤ‚·˜, Ï··ÚÔÛÎfiËÛË Î·È Ù¤ÏÔ˜ ÂÚ¢ÓËÙÈ΋ Ï··ÚÔÙÔÌ›· (12). £Âڷ›· Ù˘ ÎÚ˘„ÔÚ¯›·˜ ∞. ™˘ÓÙËÚËÙÈ΋ ıÂڷ›· ÎÚ˘„ÔÚ¯›·˜ ∆Ô ‚·ÛÈÎfi ÎÚÈÙ‹ÚÈÔ ÁÈ· Ó· ηıÔÚÈÛı› Ë ÂÈÙ˘¯›· Ù˘ ıÂڷ›·˜ Ù˘ ÎÚ˘„ÔÚ¯›·˜ Â›Ó·È Ë ÁÔÓÈÌfiÙËÙ·, fi¯È ·ÏÒ˜ Î·È ÌfiÓÔ Ë ·ÚÔ˘Û›· „ËÏ·ÊËÙÔ‡ fiگˆ˜ ÛÙÔ fiÛ¯ÂÔ. ∏ ıÂڷ›· Ì ¯ÔÚÈÔÓÈ΋ ÁÔÓ·‰ÔÙÚÔ›ÓË (hCG) ‚ÔËı¿ ÙËÓ Î¿ıÔ‰Ô ÙÔ˘ fiگˆ˜ ÌfiÓÔ ÛÙÔ˘˜ ·Ó·ÛÒÌÂÓÔ˘˜ ‹ ˘„ËÏÔ‡˜ ÔÛ¯Â˚ÎÔ‡˜ fiÚ¯ÂȘ Î·È ÂÚ›Ô˘
2001 MAPT- A¶PI§
17-10-01 15:34
™ÂÏ›‰· 97
¶·È‰È·ÙÚÈ΋ 2001;64:93-100
fiÏÔÈ Â·Ó¤Ú¯ÔÓÙ·È ÛÙËÓ ÚÔËÁÔ‡ÌÂÓË ı¤ÛË Ì¤Û· Û ¤Ó· Ì‹Ó· (13). ∏ ¯ÔÚ‹ÁËÛË hCG ‚ÔËı¿ ÛÙË ‰ÈÂÚ‡ÓËÛË ·È‰ÈÔ‡ Ì ÌË „ËÏ·ÊËÙfi fiÚ¯È Î·È ÌÔÚ› Ó· ‰È¢ÎÔχÓÂÈ ÙËÓ ÔÚ¯ÂÔËÍ›·. ¶ÔÏÏÔ› ¯ÂÈÚÔ˘ÚÁÔ› Û˘ÓÈÛÙÔ‡Ó Â¤Ì‚·ÛË Û ·È‰È¿ Ì ÎÚ˘„ÔÚ¯›· ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 2 ÂÙÒÓ, ÌfiÓÔ ÂÊfiÛÔÓ Ë ¯ÔÚ‹ÁËÛË hCG ›¯Â ·ÓÂÈÙ˘¯¤˜ ·ÔÙ¤ÏÂÛÌ·. º˘ÛÈο, ÔÏÏÔ› ÁÔÓ›˜ Â›Ó·È ·Úfiı˘ÌÔÈ ÛÙË ¯ÔÚ‹ÁËÛË ÂÓ‰ÔÌ˘˚ÎÒÓ ÂÓ¤ÛÂˆÓ hCG ÚÈÓ ÙËÓ Â¤Ì‚·ÛË, fiÙ·Ó Ë Èı·ÓfiÙËÙ· ηıfi‰Ô˘ Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi 10%. À„ËϤ˜ ‰fiÛÂȘ Î·È ÁÈ· ÌÂÁ¿ÏÔ ‰È¿ÛÙËÌ· ¯ÔÚËÁ‹ÛË hCG ÌÔÚ› Ó· ÚÔηϤÛÔ˘Ó ÂÎʇÏÈÛË ÙˆÓ ÛÂÚÌ·ÙÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ, ÚfiˆÚË ‹‚Ë Î·È ÚÒÈÌË Û‡ÁÎÏÈÛË ÂÈʇÛˆÓ. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ·Ú¿ÁÔÓÙÔ˜ ÙÔ˘ ‰ÈÂÁ›ÚÔÓÙÔ˜ ÙËÓ ˘fiÊ˘ÛË ÚÔ˜ ¤ÎÎÚÈÛË ˆ¯ÚÈÓÔÙÚfiÔ˘ ÔÚÌfiÓ˘ (LHRH) ¤¯ÂÈ ¯ÚËÛÈÌÔÔÈËı› ¢ڤˆ˜ ÛÙËÓ ∂˘ÚÒË, ·ÏÏ¿ ¯ˆÚ›˜ ȉȷ›ÙÂÚ· ·ÔÙÂϤÛÌ·Ù·, Û˘ÁÎÚÈÙÈο Ì ÙËÓ hCG. ∂Âȉ‹ ÌÂÙ·‚ÔÏ›˙ÂÙ·È Ù·¯‡Ù·Ù· Ô ·Ú¿ÁˆÓ LHRH, Û˘Ó‹ıˆ˜ ¯ÔÚËÁÂ›Ù·È Ì ÙË ÌÔÚÊ‹ ÙÔ˘ ÚÈÓÈÎÔ‡ spray. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ ·Ú¿ÁÔÓÙÔ˜ LH-RH Ú¤ÂÈ Ó· ·Ú¯›˙ÂÈ ÙÔ 10Ô Ì‹Ó· Ù˘ ˙ˆ‹˜ Î·È Ó· ‰›‰ÂÙ·È Û ‰fiÛË 400 mg x 3 ËÌÂÚËÛ›ˆ˜ ÁÈ· Ù¤ÛÛÂÚȘ ‚‰ÔÌ¿‰Â˜. ∞Ó ‰ÂÓ ÂÈÙ‡¯ÂÈ Ô Î‡ÎÏÔ˜ ·˘Ùfi˜, Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ¯ÔÚÈÔÓÈ΋ ÁÔÓ·‰ÔÙÚÔ›ÓË (∏CG) Û ‰fiÛË 1500 πU ‚‰ÔÌ·‰È·›ˆ˜ ÂÓ‰ÔÌ˘˚ο (̤ڷ ·Ú¿ ̤ڷ), ÁÈ· ÙÚÂȘ ‚‰ÔÌ¿‰Â˜. ∂› ˘ÔÙÚÔ‹˜, Ú¤ÂÈ Ó· ·ӷϷ̂¿ÓÂÙ·È ¤Ó·˜ Ï‹Ú˘ ·ÎÏÔ˜ LH-RH. ∞Ó ·ÔÙ‡¯ÂÈ Ë ÔÚÌÔÓÔıÂڷ›· Ú¤ÂÈ Ó· Á›ÓÂÈ ÔÚ¯ÂÔËÍ›· Û ϛÁ˜ ‚‰ÔÌ¿‰Â˜ Î·È ¿ÓÙˆ˜ ÚÔ Ù˘ ËÏÈΛ·˜ ÙˆÓ 2 ÂÙÒÓ. ∂› ·ÏËıÔ‡˜ ÂÎÙÔ›·˜ ‹ Û˘Ó‡·Ú͢ ‚Ô˘‚ˆÓÔ΋Ï˘, Ë ÔÚÌÔÓÔıÂÚ·›· ‰ÂÓ ¤¯ÂÈ Î·Ì›· ı¤ÛË. µ. ÃÂÈÚÔ˘ÚÁÈ΋ √È Î˘ÚÈfiÙÂÚ˜ ÂӉ›ÍÂȘ ÁÈ· ¯ÂÈÚÔ˘ÚÁÈ΋ ÙÔÔı¤ÙËÛË ÙÔ˘ ÎÚ˘„fiگˆ˜ ÛÙÔ fiÛ¯ÂÔ Â›Ó·È Ë ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ ÂӉ¯fiÌÂÓÔ˘ ÌÂÏÏÔÓÙÈ΋˜ ˘ÔÁÔÓÈÌfiÙËÙ·˜, Ë ‰ÈfiÚıˆÛË Ù˘ Û˘Ó˘¿Ú¯Ô˘Û·˜ ‚Ô˘‚ˆÓÔ΋Ï˘ Î·È Ë ÂÏ¿ÙÙˆÛË Ù˘ Èı·ÓfiÙËÙ·˜ ÙÚ·‡Ì·ÙÔ˜ ‹ Û˘ÛÙÚÔÊ‹˜ ÙÔ˘ fiگˆ˜. ∏ ÔÚ¯ÂÔËÍ›·, ›Û˘, ÚÔÏ·Ì‚¿ÓÂÈ „˘¯ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· ÁÈ· ÙÔÓ ¿Û¯ÔÓÙ· Î·È ÚÔÛʤÚÂÈ ¿ÚÈÛÙ· ÎÔÛÌËÙÈο ·ÔÙÂϤÛÌ·Ù·, ηıÒ˜ Î·È Â‡ÎÔÏË ÎÏÈÓÈ΋ ÂͤٷÛË ÁÈ· fiÁÎÔ ÙÔ˘ fiگˆ˜. ™‡Á¯ÚÔÓ˜ ıˆڋÛÂȘ Û˘ÓËÁÔÚÔ‡Ó ÛÙËÓ ¿Ô„Ë fiÙÈ Ô È‰·ÓÈÎfi˜ ¯ÚfiÓÔ˜ ÁÈ· ÙËÓ ÔÚ¯ÂÔËÍ›· Â›Ó·È ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 4 ÂÙÒÓ Î·È Èı·ÓfiÓ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ˙ˆ‹˜. √ ΛӉ˘ÓÔ˜ ‚Ï¿‚˘ ÛÙ· ÛÂÚÌ·ÙÈο ·ÁÁ›· Û ÓÂÔÁÓfi Ú¤ÂÈ Ó· ÏËÊı› Ôχ ÛÔ‚·Ú¿ ˘’fi„ÈÓ, Û ·ÓÙȉȷÛÙÔÏ‹ Ì ÙÔ fiÊÂÏÔ˜ Ù˘ Ôχ ÚfiˆÚ˘ ÙÔ-
Paediatriki 2001;64:93-100
Ôı¤ÙËÛ˘ ÙÔ˘ fiگˆ˜ ÛÙÔ fiÛ¯ÂÔ. ∂Ì›˜ ÚÔÙÈÌԇ̠ÙËÓ ËÏÈΛ· ÌÂٷ͇ 18 ÌËÓÒÓ Î·È 3 ÂÙÒÓ, ¿ÓÙ· Û ۯ¤ÛË Ì ٷ ۈ̷ÙÔÌÂÙÚÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙÔ˘ ·È‰ÈÔ‡ (14). √ ·ÓÙÈÎÂÈÌÂÓÈÎfi˜ ÛÙfi¯Ô˜ Ù˘ ÔÚ¯ÂÔËÍ›·˜ Â›Ó·È Ó· ÌÂÙ·‚¿ÏÏÂÈ ÙËÓ ÔÚ›· Ù˘ ÛÂÚÌ·ÙÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙÔ ÓÂÊÚÈÎfi Ì›Û¯Ô ‰È·Ì¤ÛÔ˘ ÙÔ˘ ¤Ûˆ ‚Ô˘‚ˆÓÈÎÔ‡ ÛÙÔÌ›Ô˘, ηıÒ˜ Î·È Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÂÈ Â˘ı›· ÔÚ›· Ù˘ ÛÂÚÌ·ÙÈ΋˜ ·ÚÙËÚ›·˜ ·fi ÙÔ ÓÂÊÚÈÎfi Ì›Û¯Ô ÛÙÔ fiÛ¯ÂÔ. ∏ ¯ÂÈÚÔ˘ÚÁÈ΋ ηı‹ÏˆÛË ÙÔ˘ fiگˆ˜ ÛÙÔ fiÛ¯ÂÔ, fiÙ·Ó ·˘Ùfi˜ Â›Ó·È „ËÏ·ÊËÙfi˜, Á›ÓÂÙ·È Ì ‚Ô˘‚ˆÓÈ΋ ÙÔÌ‹ Î·È Ë Ï¤ÔÓ ÚÔÛÊÈÏ‹˜ Ù¯ÓÈ΋ Â›Ó·È Ë Î·Ù¿ Lattimer-Benson-Lofti ÔÚ¯ÂÔËÍ›·, Ì ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ fiگˆ˜ ÌÂٷ͇ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÙÔ˘ ‰·ÚÙÔ‡ ¯ÈÙÒÓÔ˜ ÙÔ˘ ÔÛ¯¤Ô˘. ∫·Ù¿ ηÓfiÓ·, ‰È·ÓÔ›ÁÂÙ·È Ô ‚Ô˘‚ˆÓÈÎfi˜ fiÚÔ˜ ÁÈ· ÙËÓ ·Ú·Û΢‹ ÙÔ˘ ÂÚÈÙÔÓ·˚ÎÔ‡ Û¿ÎÎÔ˘ Ù˘ Û˘Ó˘¿Ú¯Ô˘Û·˜ ‚Ô˘‚ˆÓÔ΋Ï˘ Î·È ÙËÓ ˘„ËÏ‹ ·Ôϛӈۋ ÙÔ˘. °È· ÙÔ˘˜ ˘„ËÏÔ‡˜ fiÚ¯ÂȘ Ô˘ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ηıËψıÔ‡Ó ÛÙÔ fiÛ¯ÂÔ Ì ÙËÓ ÚÔ·Ó·ÊÂÚı›۷ Ù¯ÓÈ΋ (ÂÚ›Ô˘ 5%), Ë Ì¤ÛË ‰È·ÎÔÈÏȷ΋ ‹ Ë ÚÔÂÚÈÙÔÓ·˚΋ ÚÔۤϷÛË Â›Ó·È ÂȉÈο ¯Ú‹ÛÈ̘ ÁÈ· ·È‰È¿ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ˘„ËÏ‹ ÎÚ˘„ÔÚ¯›·, ηÙÔÚıÒÓÔÓÙ·˜ Ó· ηıËψıÔ‡Ó Î·È ÔÈ ‰‡Ô fiÚ¯ÂȘ ÛÙÔ fiÛ¯ÂÔ ‰È·Ì¤ÛÔ˘ Ì›·˜ ÙÔÌ‹˜. √È ÂÂÌ‚¿ÛÂȘ ·˘Ù¤˜ ÂӉ›ÎÓ˘ÓÙ·È ÁÈ· ·È‰È¿ ÛÙ· ÔÔ›· ¤¯Ô˘Ó ηٷÛÙÚ·Ê› ÔÈ ‚Ô˘‚ˆÓÈΤ˜ ·Ó·ÙÔÌÈΤ˜ Û¯¤ÛÂȘ ·fi ÚÔËÁÔ‡ÌÂÓ˜ ÂÂÌ‚¿ÛÂȘ, ηıÒ˜ Î·È ÁÈ· ·È‰È¿ Ì ˘Ô„›· ÔÚ¯È΋˜ ·ÁÂÓÂÛ›·˜ ‹ ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ʇÏÔ˘ (15). ∏ Ù¯ÓÈ΋ Fowler-Stephens ÚÔÛ‰›‰ÂÈ Ì‹ÎÔ˜ ÛÙÔÓ fiÚ¯È, ‰È·Ù¤ÌÓÔÓÙ·˜ Ù· ÛÂÚÌ·ÙÈο ·ÁÁ›· ÛÙÔÓ ÔÈÛıÔÂÚÈÙÔÓ·˚Îfi ¯ÒÚÔ, ηٿ ÙËÓ ÔÔ›· ÁÈ· ÙËÓ ·ÁÁ›ˆÛË ÙÔ˘ fiگˆ˜ ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ë ·ÚÙËÚ›· ÙÔ˘ ÛÂÚÌ·ÙÈÎÔ‡ fiÚÔ˘, ·ÁÁÂȷο ÙfiÍ· Ï¿ÁÈ· ·fi Ù· ÂÓ Ùˆ ‚¿ıÂÈ Î¿Ùˆ ÂÈÁ¿ÛÙÚÈ· ·ÁÁ›· ‰È·Ì¤ÛÔ˘ ÙÔ˘ Ô›ÛıÈÔ˘ ÙÔȯÒÌ·ÙÔ˜ Ù˘ ÂÏ˘ÙÚÔÂÚÈÙÔÓ·˚΋˜ Ù˘¯‹˜ ÂÈÛ¤Ú¯ÔÓÙ·È ÛÙËÓ ÂÚÈÔ¯‹ ÙÔ˘ Ô›·Î· (16). ∏ ÂÈÙ˘¯›· Ù˘ ¤̂·Û˘ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ fiÙÈ ‰ÂÓ ÂÎÙÂÏÔ‡ÓÙ·È ÂÎÙÂٷ̤Ó˜ ‰ÈÔÈÓ‹ÛÂȘ ÔÈÛıÔÂÚÈÙÔÓ·˚ο Î·È Ë ·ÔϛӈÛË ÙˆÓ ÛÂÚÌ·ÙÈÎÒÓ ·ÁÁ›ˆÓ Á›ÓÂÙ·È fiÛÔ „ËÏfiÙÂÚ· Â›Ó·È ‰˘Ó·ÙfiÓ. ∂Âȉ‹ Ë ·Ó¿Ù˘ÍË ·ÙÚÔÊÈÎÒÓ fiÚ¯ÂˆÓ ÌÂÙ¿ ÙË ‰È·ÙÔÌ‹ ÙˆÓ ÛÂÚÌ·ÙÈÎÒÓ ·ÁÁ›ˆÓ ‰ÂÓ Â›Ó·È Û¿ÓÈ· (ÂÚ›Ô˘ 30%), ·˘Ù‹ Ë Â¤Ì‚·ÛË Ú¤ÂÈ Ó· ¯ÚËÛÈÌÔÔÈÂ›Ù·È Ì ÂÈʇϷÍË Î·È ÌfiÓÔ fiÙ·Ó ¿ÏϘ ÂÂÌ‚¿ÛÂȘ ÏÈÁfiÙÂÚÔ ÂÈΛӉ˘Ó˜ ‰ÂÓ Ê·›ÓÔÓÙ·È ÂÊÈÎÙ¤˜. ∏ Ï··ÚÔÛÎÔÈ΋ ÂÎÙ¤ÏÂÛË Ù˘ Ù¯ÓÈ΋˜ ·˘Ù‹˜ Â›Ó·È ‰˘Ó·ÙfiÓ Ó· Á›ÓÂÈ. ∏ ·ÔηٿÛÙ·ÛË Ù˘ ÎÚ˘„ÔÚ¯›·˜ Û ‰‡Ô ÛÙ¿‰È· ÚÔÙÈÌ¿Ù·È ·fi ÔÏÏÔ‡˜ ¯ÂÈÚÔ˘ÚÁÔ‡˜, ·ÓÙ› Ù˘ ηı‹ÏˆÛ˘ ÙÔ˘ fiگˆ˜ Ì ٿÛË (17).
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√ fiگȘ, ηıÒ˜ Î·È Ô ÛÂÚÌ·ÙÈÎfi˜ ÙfiÓÔ˜, ÂÚÈÎÏ›ÔÓÙ·È Û ¤Ó· ÏÂÙfi Ê¿ÎÂÏÔ ·fi Silastic, ÂÏ·ÙÙÒÓÔÓÙ·˜ ¤ÙÛÈ ÙȘ Û˘ÌʇÛÂȘ Ì ÙÔ˘˜ ·Ú·Î›ÌÂÓÔ˘˜ ÈÛÙÔ‡˜, ‰È¢ÎÔχÓÔÓÙ·˜ ÙË ‰Â‡ÙÂÚË Â¤Ì‚·ÛË. ªÈÎÚÔ¯ÂÈÚÔ˘ÚÁÈΤ˜ Ù¯ÓÈΤ˜ (Silber Î·È Kelly) ·Ó·ÛÙÔÌÒÓÔÓÙ·˜ Ù· ÛÂÚÌ·ÙÈο ·ÁÁ›· Ì ·˘Ù¿ ÙÔ˘ ÌËÚÔ‡ ‹ ÙfiÍ· ·fi Ù· ÂÓ Ùˆ ‚¿ıÂÈ Î¿Ùˆ ÂÈÁ¿ÛÙÚÈ· ·ÁÁ›·, ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› Ì ÂÚÈÛÙ·Ûȷ΋ ÂÈÙ˘¯›· ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ˘„ËÏ‹˜ ÎÚ˘„ÔÚ¯›·˜. º˘ÛÈο ÔÈ Ù¯ÓÈΤ˜ ·˘Ù¤˜ ¤¯Ô˘Ó ÂÚÈÔÚÈṲ̂ÓË ÎÏÈÓÈ΋ ÂÊ·ÚÌÔÁ‹. ŸÙ·Ó Ô fiگȘ ‰ÂÓ ÌÔÚ› Ó· ·Ó¢ÚÂı› ÌÂÙ¿ ·fi ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ‚Ô˘‚ˆÓÈÎÔ‡ fiÚÔ˘, ÙÔ˘ ÔÈÛıÔÂÚÈÙÔÓ·˚ÎÔ‡ ¯ÒÚÔ˘, ‰È·ÂÚÈÙÔÓ·˚΋ ÚÔۤϷÛË ‰È·Ì¤ÛÔ˘ Ù˘ ›‰È·˜ ‚Ô˘‚ˆÓÈ΋˜ ÙÔÌ‹˜ (¯ÂÈÚÈÛÌfi˜ La Roque) Ú¤ÂÈ Ó· ÂÎÙÂÏÂ›Ù·È ÁÈ· ÙÔÓ ·ÔÎÏÂÈÛÌfi ·ÚÔ˘Û›·˜ ÂÓ‰ÔÎÔÈÏÈ·ÎÔ‡ fiگˆ˜. √ ÂÓ‰ÔÎÔÈÏÈ·Îfi˜ fiگȘ ÌÔÚ› ‡ÎÔÏ· Ó· Ì·˜ ‰È·Ê‡ÁÂÈ Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÔÈÛıÔÂÚÈÙÔÓ·˚΋˜ ‰ÈÂÚ‡ÓËÛ˘, ÁÈ·Ù› ÎÚ¤ÌÂÙ·È ÛÙËÓ ÂÚÈÙÔÓ·˚΋ ÎÔÈÏfiÙËÙ· ·fi ÙÔ ÌÂÛfiÚ¯ÈÔ. ∏ Ï··ÚÔÛÎfiËÛË ‚ÔËı¿ ¿Ú· Ôχ ÛÙËÓ ·Ó·ÁÓÒÚÈÛË ÂÓ‰ÔÎÔÈÏÈ·ÎÔ‡ fiگˆ˜ ‹ ÛÙËÓ ÂȂ‚·›ˆÛË Èı·Ó‹˜ ·ÓÔÚ¯›·˜ Û ·È‰È¿ Ì ÎÂÓfi fiÛ¯ÂÔ Î·È ÌË „ËÏ·ÊËÙÔ‡˜ fiÚ¯ÂȘ. ∏ Ï··ÚÔÛÎÔÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ·›˙ÂÈ ÂÓÂÚÁfi ÚfiÏÔ Î·È ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË Ù˘ ÎÚ˘„ÔÚ¯›·˜. ∏ Ù¯ÓÈ΋ Fowler-Stephen Ù˘ ÛÙ·‰È·Î‹˜ ÔÚ¯ÂfiÏ˘Û˘-ËÍ›·˜ ÙÔ˘ ÂÓ‰ÔÎÔÈÏÈ·ÎÔ‡ fiگˆ˜ ¤¯ÂÈ Á›ÓÂÈ ·Ô‰ÂÎÙ‹ ÙÂÏÂ˘Ù·›·, ¤ÙÛÈ ÒÛÙ ÙÔ ÚÒÙÔ ÛÙ¿‰ÈÔ Ù˘ Ù¯ÓÈ΋˜ Ó· Á›ÓÂÙ·È Ï··ÚÔÛÎÔÈο. ∏ ·Ú¯È΋ ·ÔϛӈÛË ÙˆÓ ÛÂÚÌ·ÙÈÎÒÓ ·ÁÁ›ˆÓ Ô‰ËÁ› Û ·‡ÍËÛË Ù˘ ·Ú¿Ï¢Ú˘ ·ÁÁ›ˆÛ˘ ÙÔ˘ fiگˆ˜ Î·È ÔÚ¯ÂÔËÍ›· ÌÔÚ› Ó· ÂÎÙÂÏÂÛÙ› ÂÈÙ˘¯Ò˜ 6 Ì‹Ó˜ ·ÚÁfiÙÂÚ·, Ì ·ÓÔÈÎÙ‹ ̤ıÔ‰Ô (18-20). ∆ÂÏÂ˘Ù·›·, Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Û ¤Ó· ¯ÚfiÓÔ Ï··ÚÔÛÎÔÈο Ó· ηıËψı› Ô fiگȘ ÛÙÔ Û‡ÛÙÔÈ¯Ô ËÌÈfiÛ¯ÂÔ (21-23). ¶ÂÚ›Ô˘ ÙÔ 15% ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ ı· ¤¯Ô˘Ó ·ÏËıÈÓ‹ ·Ô˘Û›· fiگˆ˜. °È· Ó· ÂȂ‚·Èˆı› Ë ‰È¿ÁÓˆÛË Ú¤ÂÈ ¯ÂÈÚÔ˘ÚÁÈο Ó· ·Ó·ÁÓˆÚÈÛıÔ‡Ó Ù· Ù˘ÊÏ¿ ¿ÎÚ· Î·È ÙˆÓ ÛÂÚÌ·ÙÈÎÒÓ ·ÁÁ›ˆÓ Î·È ÙÔ˘ fiÚÔ˘, ÁÈ·Ù› ÌfiÓÔ Ë ·Ó·ÁÓÒÚÈÛË ÙÔ˘ Ù˘ÊÏÔ‡ ¿ÎÚÔ˘ ÙÔ˘ ÛÂÚÌ·ÙÈÎÔ‡ fiÚÔ˘ ‰ÂÓ Â›Ó·È ‰È·ÁÓˆÛÙÈ΋. ªÂÚÈΤ˜ ÊÔÚ¤˜, ·ÙÚÔÊÈÎfi˜ fiگȘ ÌÔÚ› Ó· ÂÓÙÔÈÛı› ÛÙÔ ‚Ô˘‚ˆÓÈÎfi ηӿÏÈ ‹ ̤۷ ÛÙÔ fiÛ¯ÂÔ. ∂Âȉ‹ Ù¤ÙÔÈÔÈ fiÚ¯ÂȘ Â›Ó·È ·ÔÙ¤ÏÂÛÌ· ÚÔËÁÔ‡ÌÂÓ˘ Û˘ÛÙÚÔÊ‹˜, ÌÂÚÈÎÔ› ¯ÂÈÚÔ˘ÚÁÔ› Û˘ÓÈÛÙÔ‡Ó ÔÚ¯ÂÔËÍ›· ÛÙÔÓ ·ÓÙ›ıÂÙÔ fiÚ¯È. ∂¿Ó ¤Ó·˜ ·ÙÚÔÊÈÎfi˜ fiگȘ ·Ó¢ڛÛÎÂÙ·È Î·È Ô ·ÓٛϢÚÔ˜ Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi˜, Ú¤ÂÈ Ó· ÂÎÙÂÏÂ›Ù·È ÔÚ¯ÂÎÙÔÌ‹ Û‡ÛÙÔȯ·.
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™˘Ó‹ıˆ˜ Ú¤ÂÈ Ó· ÂÚÈ̤ÓÔ˘Ì ¤ˆ˜ ÙËÓ ÂÊ˂›· ÁÈ· Ó· ·Ê·ÈÚ¤ÛÔ˘Ì ÙÔ˘˜ ˘ÔÏ·ÛÙÈÎÔ‡˜ fiÚ¯ÂȘ. ŸÙ·Ó Ô fiگȘ ‰ÂÓ Â˘Ú›ÛÎÂÙ·È, Ë ÔÚ¯È΋ ÚfiıÂÛË ÛÙËÓ ·Ú¯‹ Ù˘ ÂÊ˂›·˜ Â›Ó·È ··Ú·›ÙËÙË. ∞ÔÙÂϤÛÌ·Ù· ¯ÂÈÚÔ˘ÚÁÈ΋˜ ıÂڷ›·˜ Î·È ÂÈÏÔΤ˜ ∏ ÁÔÓÈÌfiÙËÙ· Û ÌË ‰ÈÔÚıˆÌ¤ÓË ÂÙÂÚfiÏ¢ÚË ÎÚ˘„ÔÚ¯›· Â›Ó·È ÌÂٷ͇ 40-65%, ·ÏÏ¿ ÂÍ·ÚÙ¿Ù·È ·fi ÙÔ Ì¤ÁÂıÔ˜, ÙË ÌÔÚÊÔÏÔÁ›· Î·È ÙË ı¤ÛË ÙÔ˘ fiگˆ˜. ∏ ÁÔÓÈÌfiÙËÙ· Û ·ÛıÂÓ›˜ Ì ÂÙÂÚfiÏ¢ÚË ÎÚ˘„ÔÚ¯›· ‰ÈÔÚıˆÌ¤ÓË ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ Â›Ó·È ÂÚ›Ô˘ 92%. ™Â ÂΛÓÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ Ë ÔÚ¯ÂÔËÍ›· ÂÎÙÂϤÛıËΠ۠ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ·, Ë ¯·ÌËÏ‹ ÁÔÓÈÌfiÙËÙ· Î·È Ô ¯·ÌËÏfi˜ ·ÚÈıÌfi˜ ÛÂÚÌ·ÙÔ˙ˆ·Ú›ˆÓ ‰Â›¯ÓÔ˘Ó ÙË ÛÔ˘‰·ÈfiÙËÙ· Ù˘ ÁÚ‹ÁÔÚ˘ ηı‹ÏˆÛ˘ ÙÔ˘ fiگˆ˜ ÛÙÔ fiÛ¯ÂÔ. ŸÛÔ ˘„ËÏfiÙÂÚ· ·Ú·Ì¤ÓÂÈ Ô fiگȘ ¿Óˆ ·fi ÙÔ fiÛ¯ÂÔ, ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚ˜ ·ÓˆÌ·Ï›Â˜ ÛÙË ÌÔÚÊÔÏÔÁ›· ÙÔ˘ ·Ú·ÙËÚÔ‡ÓÙ·È, Ì ¯·ÌËÏ‹ ÁÔÓÈÌfiÙËÙ· Î·È ¯·ÌËÏfi ·ÚÈıÌfi ÛÂÚÌ·ÙÔ˙ˆ·Ú›ˆÓ (24). ¶·È‰È¿ Ì ÌË ‰ÈÔÚıˆÌ¤ÓË ·ÌÊÔÙÂÚfiÏ¢ÚË ÎÚ˘„ÔÚ¯›· Â›Ó·È 100% ÛÙ›ڷ. ∏ ·Ú·ÁˆÁ‹ ÙÂÛÙÔÛÙÂÚfiÓ˘ ›ӷÈ, Û˘¯Ó¿, ÂÚ›Ô˘ Ê˘ÛÈÔÏÔÁÈ΋. ∂¿Ó Ë ÔÚ¯ÂÔËÍ›· ÂÎÙÂÏÂ›Ù·È Û ·È‰È¿ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ÎÚ˘„ÔÚ¯›· ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÂÙÒÓ, ÂÚÈÛÛfiÙÂÚ· ·fi ÙÔ 50% Â›Ó·È ÁfiÓÈÌ· Î·È 30% ¤¯Ô˘Ó ÓÔÚÌÔÛÂÚÌ›·. ™Â ·È‰È¿ Ì ·ÌÊÔÙÂÚfiÏ¢ÚË ÎÚ˘„ÔÚ¯›· Ë ˆÚ›Ì·ÓÛË ÙˆÓ ÛÂÚÌ·ÙÈÎÒÓ ÛˆÏËÓ·Ú›ˆÓ Â›Ó·È ÙÔ˘ ›‰ÈÔ˘ ‚·ıÌÔ‡ Î·È ÛÙÔ˘˜ ‰‡Ô fiÚ¯ÂȘ, Û ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ˘ 40%. ∆· ›‰· Ù˘ FSH ·˘Í¿ÓÔ˘Ó ·ÓÙÈÛÙÚfiʈ˜ ·Ó¿ÏÔÁ· Ì ÙË ÛÂÚÌ·ÙÔÁ¤ÓÂÛË. À„ËÏ‹ LH ˘Ô‰ÂÈÎÓ‡ÂÈ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· ÙˆÓ Î˘ÙÙ¿ÚˆÓ Leydig Î·È ÁÔÓ·‰È΋ ·ÙÚÔÊ›·. ∞ÛıÂÓ›˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ·ÌÊÔÙÂÚfiÏ¢ÚË ÔÚ¯ÂÔËÍ›· ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 3 ÂÙÒÓ, ¤¯Ô˘Ó ÁÔÓÈÌfiÙËÙ· Á‡Úˆ ÛÙÔ 70%, ÂÓÒ ·ÛıÂÓ›˜ Ô˘ ˘Ô‚Ï‹ıËÎ·Ó Û ·ÌÊÔÙÂÚfiÏ¢ÚË ÔÚ¯ÂÔËÍ›· ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 13 ÂÙÒÓ, ¤¯Ô˘Ó ÁÔÓÈÌfiÙËÙ· Á‡Úˆ ÛÙÔ 15%. ªÂÙ¿ ·fi ÔÚ¯ÂÔËÍ›·, ÛÔ‚·Ú¤˜ ÂÈÏÔΤ˜ Ô˘ ÌÔÚ› Ó· ·Ú·ÎÈÓ‰˘Ó‡ÛÔ˘Ó ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ fiگˆ˜ ·Ú·ÙËÚÔ‡ÓÙ·È Û ÏÈÁfiÙÂÚÔ ·fi 5% ÙˆÓ ÂÂÌ‚¿ÛÂˆÓ Ô˘ ÂÎÙÂÏÔ‡ÓÙ·È ·fi ¤ÌÂÈÚÔ˘˜ ¯ÂÈÚÔ˘ÚÁÔ‡˜. ∏ ϤÔÓ ÛÔ‚·Ú‹ ÂÈÏÔ΋ Â›Ó·È Ë ·fiÊÚ·ÍË Ù˘ ·ÈÌ¿ÙˆÛ˘ ÙÔ˘ fiگˆ˜ ·fi ‚Ï¿‚Ë Î·Ù¿ ÙÔ˘˜ ¯ÂÈÚÈÛÌÔ‡˜, Ë Û˘ÛÙÚÔÊ‹ ÙÔ˘ ·ÁÁÂÈ·ÎÔ‡ Ì›Û¯Ô˘, Ë Û‡ÁÎÏÈÛË ÙˆÓ ÎÔÈÏÈ·ÎÒÓ Ì˘ÒÓ Ôχ ÛÊȯٿ, Ë ÛÙ¤ÓˆÛË ÙÔ˘ ·˘ÏÔ‡ ÙˆÓ ·ÁÁ›ˆÓ fiÙ·Ó Î·ıËψı› Ô fiگȘ ÛÙÔ fiÛ¯ÂÔ Ì ٿÛË. ∂Âȉ‹ Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÎÚ˘„fiگˆ˜ ‰ÂÓ Â›Ó·È Ë È‰·ÓÈ΋, Ë ÂÈÚfiÛıÂÙË ÚÔÛ‚ÔÏ‹ ÛÙÔÓ ·ÁÁÂÈ·Îfi
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Ì›Û¯Ô ¯ÂÈÚÔÙÂÚ‡ÂÈ ÙËÓ ÚfiÁÓˆÛË Û¯ÂÙÈο Ì ÙË ÏÂÈÙÔ˘ÚÁ›· ÌÂÙ¿ ÙËÓ ÙÔÔı¤ÙËÛ‹ ÙÔ˘ ÛÙÔ fiÛ¯ÂÔ. ¶·ÚÔ‰ÈÎfi Ô›‰ËÌ· ÙÔ˘ fiگˆ˜ ·fi ÌÂÚÈ΋ ·fiÊÚ·ÍË Ù˘ ÏÂÌÊÈ΋˜ Î·È ÊÏ‚È΋˜ ΢ÎÏÔÊÔÚ›·˜ Â›Ó·È Û˘¯Ófi Î·È Û˘Ó‹ıˆ˜ ˘Ô¯ˆÚ› Û 4 ‚‰ÔÌ¿‰Â˜. ÀÔ¯ÒÚËÛË ÙÔ˘ fiگˆ˜ Û ¤Ó· ÛËÌÂ›Ô ˘„ËÏfiÙÂÚ· ·fi ÙÔ ¤Íˆ ÛÙfiÌÈÔ ÙÔ˘ ‚Ô˘‚ˆÓÈÎÔ‡ fiÚÔ˘ Â›Ó·È ·Û‡ÓËı˜ Ì ÙËÓ ÙÔÔı¤ÙËÛË ÙÔ˘ fiگˆ˜ ÌÂٷ͇ ‰¤ÚÌ·ÙÔ˜ Î·È ‰·ÚÙÔ‡ ÙÔ˘ ÔÛ¯¤Ô˘. ∞Ó¿Ù˘ÍË ‚Ô˘‚ˆÓÔ΋Ï˘ ÌÂÙ¿ ·fi ÔÚ¯ÂÔËÍ›· Â›Ó·È Û¿ÓÈ·. ∫·ÎÔ‹ıÂÈ· Î·È ÎÚ˘„ÔÚ¯›· ¶ÂÚ›Ô˘ ÙÔ 12% ÙˆÓ fiÁÎˆÓ ÙÔ˘ fiگˆ˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÎÚ˘„fiÚ¯ÂȘ. √ ÎÚ˘„fiگȘ ¤¯ÂÈ 30-50 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· ·Ó·Ù‡ÍÂÈ Î·ÎÔ‹ıÂÈ· Û ۇÁÎÚÈÛË Ì ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi fiÚ¯È. ∞ÙÚÔÊÈÎÔ› Î·È ÂÓ‰ÔÎÔÈÏÈ·ÎÔ› fiÚ¯ÂȘ ¤¯Ô˘Ó 200 ÊÔÚ¤˜ ÌÂÁ·Ï‡ÙÂÚË Èı·ÓfiÙËÙ· Ó· ·Ó·Ù‡ÍÔ˘Ó Î·ÎÔ‹ıÂÈ· (25). ∏ ̤ÛË ËÏÈΛ· ÛÙËÓ ÔÔ›· ÌÔÚ› Ó· ·Ó·Ù˘¯ı› fiÁÎÔ˜ Û ÎÚ˘„fiÚ¯ÂȘ Â›Ó·È Ù· 26 ¤ÙË. √ ΛӉ˘ÓÔ˜ ·Ó¿Ù˘Í˘ ÓÂÔÏ¿ÛÌ·ÙÔ˜ Â›Ó·È ˘„ËÏfi˜ Û ·È‰È¿ Ì ¯ÚˆÌÔÛˆÌÈ΋ ·ÓˆÌ·Ï›· Î·È Û ·˘Ù¿ Ì ·ÓˆÌ·Ï›Â˜ ÛÙ· ¤Íˆ ÁÂÓÓËÙÈο fiÚÁ·Ó·. √È Û˘Ó‹ıÂȘ ηÎÔ‹ıÂȘ fiÁÎÔÈ Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙÔ˘˜ ÎÚ˘„fiÚ¯ÂȘ Â›Ó·È Ù· ÛÂÌÈÓÒÌ·Ù·, ÙÂÚ·ÙÔηÚÎÈÓÒÌ·Ù·, ÂÌ‚Ú˘˚ο ηÚÎÈÓÒÌ·Ù· Î·È ÙÂÚ·ÙÒÌ·Ù· ÂÓËϛΈÓ. ∏ Û˘¯ÓfiÙËÙ· ·Ó¿Ù˘Í˘ fiÁÎˆÓ fiگˆ˜ Û ÎÚ˘„fiÚ¯ÂȘ Ô˘ ηıËÏÒÓÔÓÙ·È ÛÙÔ fiÛ¯ÂÔ ÚÈÓ ÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ Â›Ó·È ÌÈÎÚfiÙÂÚË, Û˘ÁÎÚÈÙÈο Ì ÂΛÓÔ˘˜ Ô˘ ηıËÏÒÓÔÓÙ·È ÛÙËÓ ÂÊ˂›·. ™‡Á¯ÚÔÓ˜ ıˆڋÛÂȘ Û˘ÁÎÏ›ÓÔ˘Ó ÛÙËÓ ¿Ô„Ë fiÙÈ ·È‰È¿ ÌÂÁ·Ï‡ÙÂÚ· ÙˆÓ 14 ÂÙÒÓ Ì ÂÙÂÚfiÏ¢ÚË ÎÚ˘„ÔÚ¯›· Ú¤ÂÈ Ó· ˘Ô‚¿ÏÏÔÓÙ·È Û ‚ÈÔ„›·. ∂¿Ó Ô fiگȘ ‰Â›¯ÓÂÈ ˘ÔÏ·ÛÙÈÎfi˜ ‹ ‰˘ÛÏ·ÛÙÈÎfi˜ Ú¤ÂÈ Ó· ·Ê·ÈÚ›ٷÈ. ∂¿Ó ÛÙË ‚ÈÔ„›· ¤¯Ô˘ÌÂ Ê˘ÛÈÔÏÔÁÈο ÈÛÙÔÌÔÚÊÔÏÔÁÈο Â˘Ú‹Ì·Ù·, Ë ÔÚ¯ÂÔËÍ›· Â›Ó·È ··Ú·›ÙËÙË Ì ÙËÓ ÚÔ¸fiıÂÛË Ù˘ ÂÙ‹ÛÈ·˜ ·ÓÂͤٷÛ˘ ÁÈ· Ù˘¯fiÓ ·Ó¿Ù˘ÍË Î·ÎÔ‹ıÂÈ·˜. √ ΛӉ˘ÓÔ˜ ·Ó¿Ù˘Í˘ ÓÂÔÏ¿ÛÌ·ÙÔ˜ Ê·›ÓÂÙ·È Ó· ·˘Í¿ÓÂÈ ¿ÌÂÛ· Ì ÙËÓ ËÏÈΛ· ÛÙÔ ¯ÚfiÓÔ Ù˘ ÔÚ¯ÂÔËÍ›·˜. ¶·Ú·Ì¤ÓÂÈ, ‚¤‚·È·, ·‰È¢ÎÚ›ÓÈÛÙÔ Â¿Ó Ë ÔÚ¯ÂÔËÍ›· ÂÏ·ÙÙÒÓÂÈ ÛËÌ·ÓÙÈο ÙË Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ fiÁÎÔ˘. ∂›Û˘, Ê·›ÓÂÙ·È Ó· ˘¿Ú¯ÂÈ ÛÙÂÓ‹ Û¯¤ÛË ÌÂٷ͇ Ù˘ ·Ó¿Ù˘Í˘ ηÎÔ‹ıÂÈ·˜ ÛÙÔÓ fiÚ¯È Î·È ÙÔ˘ ‚·ıÌÔ‡ ˘ÔÏ·Û›·˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Fonkalsrud E. Undescended Testes. In: Welch K, Randolph J, Ravitch M, eds. Pediatric Surgery. 4th ed. 1986. p. 793-807. 2. Swenson’s Pediatric Surgery. 5th ed. 1990Undescended Testicle. p. 145-154.
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3. Fallat ME, Williams MPL, Farmer PJ, Galinaro RN, Stover BH , Winkersons. Histologic evaluation of inguinoscrotal migration of the gubernaculum in rodents during testicular descent and its relationship to the genitofemoral nerve. Pediatr Surg Intern 1992;7:265-270. 4. Hrabovszky Z, Farmer PJ, Hutson J. Does the sensory nucleus of the genitofemoral nerve have a role in testicular descent. J Pediatr Surg 2000;35:96-100. 5. Binqgol-Kologln M, Demirci M, BujuKpamuKcu M. Cremasteric reflexes of boys with descended, retractile, or undescended testes: An electrophysiological evaluation. J Pediatr Surg 1999;34:430-434. 6. °È·ÓÓfiÔ˘ÏÔ˜ °, ∞ÓÙ‡·˜ ™, ∫·ÎÏ·Ì¿Ó˘ ¶, µÂÚ‚ÂÚ›‰Ë˜ ª. ∫Ú˘„ÔÚ¯›·, KÏÈÓÈÎÔÂÚÁ·ÛÙËÚȷ΋ ·Ó·‰ÚÔÌÈ΋ ÌÂϤÙË. ∂ÏÏËÓ ÃÂÈÚÔ˘ÚÁ 1998;70:460-468. 7. Puri P, Nixon HH. Bilateral retractile testes: Subsequent effect on fertility. J Pediatr Surg 1997;12:563-567. 8. Murthy GG, Peress NS, Kahn SA. Demonstration of antibodies to testicular basement membrane by immunofluorescence in a patient with multiple primary endocrine deficiencies. J Clin Endocrinol Metabol 1976;42:637-640. 9. Mules LM, Holmes SJK. Human chorionic gonadotropin and laparoscopy in the treatment of impalpable testes. J Pediatr Surg 1994;29:551-552. 10. Turek PJ, Ewalt DH, Snyder HM, Stampfers D, Blyth B, Huff DS et al. The absent cryptorchid testis: Surgical findings and their implications for diagnosis and etiology. J Urol 1994;151:718-721. 11. ¶·È‰È·ÙÚÈ΋ O˘ÚoÏÔÁ›·, º. ∞Ó‰ÚÔ˘Ï·Î¿Î˘. ∫Ú˘„ÔÚ¯›·. EΉfiÛÂȘ µ∏∆∞; 1993. ÛÂÏ. 253-258. 12. Moore RG, Peters CA, Bauer SB, Maudell J, Retik AB. Laparoscopic evaluation of the nonpalpable testis: A prospective assessment of accuracy. J Urol 1994;151:728-731. 13. Rajfer J, Handelsman DJ, Swerdloff RS, Hurwitz R, Kaplan H, Vandergast T. Hormoral therapy of cryptorchidism: A randomized double-blind study comparing HCG and gonadotropin releasing hormone. N Engl J Med 1986;314:466-470. 14. Mengel W, Zimmerman FA, Hhecker WCh. Timing of repair for undescended testes. In: Fonkalsrud EW, Mengel W, eds. The Undescended Testis. Chicago, IL: Year Book Medical Publishers; 1981. p. 170. 15. Palacio M, Sferco A, Fenrandez A, Vilarrodona H. Inguinal Cordopexy: A simple and effective new technique for securing the testes in reoperative orchiopexy. J Pediatr Surg 1999;34:424-425. 16. ∫ÏÔÎοÚ˘ ∞, ∫ÒÙÛÈÔ˘ ª, ∑ÈÔ‡Ù˘ π, °ÂˆÚÁ¿Î˘ π, ∆ÛÈÛfiÔ˘ÏÔ˜ °, ™‚ÂÚÒÓ˘ ª Î·È Û˘Ó. ∞ÓÙÈÌÂÙÒÈÛË Ù˘ ˘„ËÏ‹˜ ÎÚ˘„ÔÚ¯›·˜ Ì ÙË Ì¤ıÔ‰Ô Stephens Fowler. ∂ÏÏËÓÈ΋ ÃÂÈÚÔ˘ÚÁÈ΋ 1995;67:626-629. 17. Corkery SJ. Staged orchiopexy: A new technique. J Pediatr Surg 1975;10:515-519. 18. Nassar AHM. Laparoscopic-assisted orchidopexy: A new aproach to the impalpable testis. J Pediatr Surg 1995;30:39-41.
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19. The Surgical Clinics of North America. Pediatr Surg; 1992. p. 1299-1313. 20. Bloom DA. Two-step orchiopexy with pelviscopic clip ligation of the spermatic vessels. J Urol 1991;145:1030-1033. 21. Jones PF, Youngson GG. Benefits of laparoscopy and Jones technique for nonpalpaple testis. J Urol 1999;162:169. 22. Eiquist EG, Stratakis CA, Rushton HG, Wather M. Laparoscopic diagnosis and clinical management of a solitary nonpalpable cryptorchid testicle in a postpubertal male. J Urol 2000;163:959-960. 23. Ng JW, Cheng D. Scroto-peritoneal port for laparoscopic orchidopexy. Pediatr Surg Int 1999;15:452. 24. Kieswetter WB, Shull WR, Fettermann GH. Histological changes in the testis following anatomically successful orchiopexy. J Pediatr Surg 1969;4:59-65.
25. ∞ÚÁÈ·Ó¿˜ ™, ∂ÌÌ·ÓÔ˘‹Ï °. ¢È·ÔÛ¯Â˚΋ ÔÚ¯ÂÔËÍ›·. ∂ÏÏËÓÈ΋ ÃÂÈÚÔ˘ÚÁÈ΋ 1995;67:623-625. 26. Cortes D, Thorup J, Frish M, Moller H, Jacobsen GK, Beck BL. Examination for intratubular germ cell neoplasia at operation for intratubular germ cell neoplasia at operation for undescended testis in boys. J Urol 1994;151:722-725.
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¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ¶ÚÔÛ‰ÈÔÚÈÛÌfi˜ ̤ۈ Ù˘ PCR ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ÛÙ· ÙÚ·¯Âȷο ÂÎÎÚ›ÌÌ·Ù· ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ: Û˘Û¯¤ÙÈÛË ÙˆÓ ÏÔÈÌÒÍÂˆÓ ·fi ·‰ÂÓÔ˚Ô‡˜ Ì ÙË ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›·1 ™ÎÔfi˜: ∏ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ‰˘ÛÏ·Û›· (µ¶¢) ıˆÚÂ›Ù·È fiÙÈ Â›Ó·È Ì›· ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÙfiÙËÙ·˜ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ‹Ù·Ó Ó· ÂÏÂÁ¯ı› Â¿Ó Ë ·ÚÔ˘Û›· ÏÔÈÌÔÁfiÓˆÓ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ Û ‰Â›ÁÌ·Ù· ÙÚ·¯ÂÈ·ÎÒÓ ÂÎÎÚÈÌÌ¿ÙˆÓ Â›¯Â Û¯¤ÛË Ì ÙËÓ ·Ó¿Ù˘ÍË µ¶¢. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ¢Â›ÁÌ·Ù· ÙÚ·¯ÂÈ·ÎÒÓ ÂÎÎÚÈÌÌ¿ÙˆÓ Ï·Ì‚¿ÓÔÓÙ·Ó ÛÙËÓ ‰È¿ÚÎÂÈ· Ù˘ ÚÒÙ˘ ‚‰ÔÌ¿‰·˜ Ù˘ ˙ˆ‹˜ Î·È ÂϤÁ¯ÔÓÙ·Ó Ì PCR ÁÈ· ·‰ÂÓÔ˚Ô‡˜, ÌÂÁ·ÏÔ΢ÙÙ·ÚÔ˚Ô‡˜, ·Ú‚Ô˚Ô‡˜, ·‰ÂÓÔ˚Ô‡˜, Ô˘ÚÂÔÏ¿ÛÌ·Ù·, Ì˘ÎÔÏ¿ÛÌ·Ù· Î·È ¯Ï·Ì‡‰È·. ŒÓ· ÓÂÔÁÓfi ÂıˆÚ›ÙÔ fiÙÈ Â›¯Â µ¶¢, fiÙ·Ó ‹Ù·Ó ÂÍ·ÚÙË̤ÓÔ ·fi ÙÔ Ô͢ÁfiÓÔ ÙËÓ 28Ë Ë̤ڷ ·fi ÙË Á¤ÓÓËÛË Î·È ÙËÓ 36Ë Â‚‰ÔÌ¿‰· ·fi ÙË Û‡ÏÏË„‹ ÙÔ˘. ∆· ̈ڿ Ô˘ η٤ÏËÍ·Ó ÚÈÓ ·fi ÙȘ ¯ÚÔÓÈΤ˜ ·˘Ù¤˜ ÂÚÈfi‰Ô˘˜ ·ÔÎÏ›ÔÓÙÔ ·fi ÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. ∞ÔÙÂϤÛÌ·Ù·: ∞fi Ù· 89 ‚Ú¤ÊË Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ÛÙËÓ ËÏÈΛ· ÙˆÓ 28 ËÌÂÚÒÓ, 13 η٤ÏËÍ·Ó, 45 ›¯·Ó µ¶¢ ÂÓÒ Ù· ˘fiÏÔÈ· 31 Ô˘ ‰ÂÓ Â›¯·Ó µ¶¢ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó Û·Ó Ì¿ÚÙ˘Ú˜. ™ÙËÓ ËÏÈΛ· ÙˆÓ 36 ‚‰ÔÌ¿‰ˆÓ ÌÂÙ¿ ÙË Û‡ÏÏË„‹ ÙÔ˘˜, 15 ‚Ú¤ÊË Î·Ù¤ÏËÍ·Ó, 39 ›¯·Ó ·ÎfiÌË µ¶¢, ÂÓÒ Ù· ˘fiÏÔÈ· 39 ‰ÂÓ Â›¯·Ó µ¶¢ (Ì¿ÚÙ˘Ú˜). ™ËÌ·ÓÙÈ΋ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ ÙÔ˘ DNA ÙˆÓ ·‰ÂÓÔ˚ÒÓ, ‰È·ÈÛÙÒıËΠÛÙ· ‚Ú¤ÊË Ì µ¶¢ Û˘ÁÎÚÈÙÈο Ì ÙÔ˘˜ Ì¿ÚÙ˘Ú˜, ÙfiÛÔ ÛÙËÓ ¯ÚÔÓÔÏÔÁÈ΋ ËÏÈΛ· ÙˆÓ 28 ËÌÂÚÒÓ (12/45=27% ¤Ó·ÓÙÈ 1/31=3%, p<0,01), fiÛÔ Î·È ÛÙËÓ ËÏÈΛ· ÙˆÓ 36 ‚‰ÔÌ¿‰ˆÓ
100
ÌÂÙ¿ ÙË Û‡ÏÏË„Ë (10/39=29% ¤Ó·ÓÙÈ 2/35=6%, p=0,01). √È ˘fiÏÔÈÔÈ ÌÈÎÚÔÔÚÁ·ÓÈÛÌÔ› ·ÔÌÔÓÒıËÎ·Ó Û ÌÈÎÚfi ÔÛÔÛÙfi Î·È ‰ÂÓ ‚Ú¤ıËΠӷ ˘¿Ú¯ÂÈ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ·˘ÙÒÓ Î·È Ù˘ ·Ó¿Ù˘Í˘ µ¶¢. ™˘ÌÂÚ¿ÛÌ·Ù·: ∏ ·ÚÔ‡Û· ÌÂϤÙË Â›Ó·È Ë ÚÒÙË Ô˘ ‰ËÌÔÛȇÂÈ ÙËÓ Û˘¯ÓfiÙËÙ· ·Ó‡ÚÂÛ˘ ÙÔ˘ DNA ÙˆÓ ·‰ÂÓÔ˚ÒÓ Û ‰Â›ÁÌ·Ù· ÙÚ·¯ÂÈ·ÎÒÓ ÂÎÎÚÈÌÌ¿ÙˆÓ Ù· ÔÔ›· ÂÏ‹ÊıËÛ·Ó Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÚÒÙ˘ ‚‰ÔÌ¿‰·˜ Ù˘ ˙ˆ‹˜ ·fi ‚Ú¤ÊË Ì µ¶¢ Î·È ÂÈÛËÌ·›ÓÂÈ fiÙÈ Ë ÚÔÁÂÓÓËÙÈ΋ ÚÔÛ‚ÔÏ‹ Ì ·‰ÂÓÔ˚Ô‡˜ ÌÔÚ› Ó· ·›˙ÂÈ ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ·Ó¿Ù˘ÍË µ¶¢.
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Couroucli XI, Welty SE, Ramsay PL, Wearden ME, Fuentes-Garcia FJ, Jiyuan NI, Jacobs TN, Towbin JA, Bowles NE Detection of microorganisms in the tracheal aspirates of preterm infants by polymerase chain reaction: association of adenovirus infection with bronchopulmonary dysplasia Pediatr Res 2000;47:225-232 ™‡ÚÔ˜ ºˆÙfiÔ˘ÏÔ˜
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A¡∞™∫√¶∏™H
Paediatriki 2001;64:101-114
REVIEW ARTICLE
™ËÌ·Û›· ÙÔ˘ Ȉ‰›Ô˘ Î·È Ù˘ ı˘ÚÔ͛Ӣ ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi ∫. ¶·ÓÙÛÈÒÙÔ˘
The importance of iodine and thyroxine in the human organism ∫. Pantsiotou
¶ÂÚ›ÏË„Ë: ∆Ô ÈÒ‰ÈÔ ˘¿Ú¯ÂÈ ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi Û ·ÂÈÚÔÂÏ¿¯ÈÛÙ˜ ÔÛfiÙËÙ˜ (15 mg). ∏ ËÌÂÚ‹ÛÈ· ηٷӿψÛË Èˆ‰›Ô˘ Â›Ó·È ÌÈÎÚ‹ (150-500 Ìg), ·ÏÏ¿ Û˘¯Ó¿ ·Ú·ÙËÚÂ›Ù·È Èˆ‰ÔÂÓ›·, ÁÈ·Ù› Î·È ÛÙÔ ÊÏÔÈfi Ù˘ Á˘ ÙÔ ÈÒ‰ÈÔ ˘¿Ú¯ÂÈ Û ÌÈÎÚ‹ ÔÛfiÙËÙ·. ŒÏÏÂÈ„Ë Èˆ‰›Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÊÙˆ¯¿ ¿ÙÔÌ·, Ô˘ ˙Ô˘Ó Û ÔÚÂÈÓ¤˜ ÂÚÈÔ¯¤˜, ¯ˆÚ›˜ Û˘ÁÎÔÈӈӛ˜, Ì·ÎÚÈ¿ ·fi ÙË ı¿Ï·ÛÛ· Î·È Î·Ù·Ó·Ï›ÛÎÔ˘Ó ÌfiÓÔ Ê˘ÙÈο ÚÔ˚fiÓÙ· Ô˘ ·Ú¿ÁÔÓÙ·È ÙÔÈο, ¯ˆÚ›˜ ηٷӿψÛË ˙ˆÈÎÒÓ Î·È Û˘ÓÙËÚËÌ¤ÓˆÓ ÙÚÔÊÒÓ Ô˘ ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ ÈÒ‰ÈÔ. ŸÙ·Ó ÙÔ 10% Î·È ¿Óˆ ÂÓfi˜ ÏËı˘ÛÌÔ‡ ¤¯ÂÈ ‰ÈÔÁΈ̤ÓÔ ı˘ÚÂÔÂȉ‹, ˘¿Ú¯ÂÈ Èˆ‰ÔÂÓ›· ÛÙËÓ ÂÚÈÔ¯‹ Î·È Ë Ì¤ÛË ÙÈÌ‹ ÙÔ˘ Ȉ‰›Ô˘ ÙˆÓ Ô‡ÚˆÓ 24ÒÚÔ˘, Â›Ó·È ÌÈÎÚfiÙÂÚË ·fi 100 Ìg. ∏ ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ ηٿ ÙËÓ ÂÌ‚Ú˘˚΋ ˙ˆ‹ Î·È Ù· ÙÚ›· ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜, ÚÔηÏ› ·Ó·ÓfiÚıˆÙ˜ ‚Ï¿‚˜, Ì ηı˘ÛÙ¤ÚËÛË ÛÙËÓ „˘¯ÔÎÈÓËÙÈ΋, ÓÔËÙÈ΋, ۈ̷ÙÈ΋ ·Ó¿Ù˘ÍË (¡Â˘ÚÔÏÔÁÈÎfi˜, ª˘ÍÔȉËÌ·ÙÈÎfi˜ ÎÚÂÙÈÓÈÛÌfi˜) Î·È ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ÚfiˆÚˆÓ ·Ô‚ÔÏÒÓ, ÂÓÒ Î·Ù¿ ÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· ÚÔηÏ› ‚ÚÔÁ¯Ô΋ÏË, ηı˘ÛÙ¤ÚËÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È ·˘Í¿ÓÂÈ ÙË Û˘¯ÓfiÙËÙ· ηÚΛÓÔ˘ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜, ÌÂÙ¿ ·fi ˘ÚËÓÈÎfi ·Ù‡¯ËÌ·, fiˆ˜ ÂΛÓÔ ÙÔ˘ Chernobyl. √ ÂÌÏÔ˘ÙÈÛÌfi˜ ÙˆÓ ÙÚÔÊÒÓ Ì ÈÒ‰ÈÔ (ÓÂÚfi, ·Ï¿ÙÈ, „ˆÌ›) ·ÔÙÂÏ› ÂıÓÈÎfi ηı‹ÎÔÓ. ™‹ÌÂÚ·, ¤Ó· ‰ÈÛÂηÙÔÌ̇ÚÈÔ ¿ÓıÚˆÔÈ (Û ÔÚÂÈÓ¤˜ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜), ۯ‰fiÓ ÙÔ 17% ÙÔ˘ Ï·Ó‹ÙË Ì·˜, ‚Ú›ÛÎÔÓÙ·È Û ¤ÏÏÂÈ„Ë. ∆Ô ÈÒ‰ÈÔ ‰Ú· ̤ۈ ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ Î·È ·ÔÙÂÏ› ÙÔ 64% ÙÔ˘ ‚¿ÚÔ˘˜ ÙÔ˘ ÌÔÚ›Ô˘ Ù˘ ı˘ÚÔ͛Ӣ. √È ı˘ÚÂÔÂȉÈΤ˜ ÔÚÌfiÓ˜ Ú˘ıÌ›˙Ô˘Ó ÙËÓ ˆÚ›Ì·ÓÛË ‰È·ÊfiÚˆÓ ÈÛÙÒÓ, ·˘Í¿ÓÔ˘Ó ÙȘ η‡ÛÂȘ Î·È ÂÈÙ·¯‡ÓÔ˘Ó ÂÓ˙˘ÌÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜. ¶ÂÚÈÔ¯¤˜ Ì ‰¿ÊË
Abstract: Iodine is an essential trace element in the human body and is present only in minute quantities (9 mg). The daily consumption of iodine is small (150-500 Ìg), but iodine deficiency is often observed, because there is small quantity of iodine on the earth. In developing countries iodine deficiency is observed among the poor, who live in mountainous areas, without public transportation and far away from the sea. Those people only consume locally produced vegetable foods, and are deprived of animal and of preserved foods which contain more iodine. When one finds goiters in more than 10% of the population, then there is iodine deficiency in that district and the concentration of iodine in 24 hour urine collection is less than 100 Ìg. Iodine deficiency during intrauterine life and during the first 3 years may cause unrepaired damage with developmental, psychokinetic and intellectual delay (Neurological cretinism and Myxedematous cretinism) and an increase in fetal loses. Iodine deficiency during childhood and adolescence may cause an increase in the incidence of bronchocele, developmental retardation and an increase in the incidence of thyroid cancer following nuclear accidents such as that of Chernobyl. In adulthood iodine deficiency may cause goitre, which causes difficulty in swallowing and breathing, and hypothyroidism as well as toxic goitre and cold nodules which can be cancerous. Today iodine deficiency has been reported to be present in about one billion people (17% of the earth’s population) who live in mountainous areas in developing countries. Enrichment of food with iodine (water, salt, bread) is
∂Ó‰ÔÎÚÈÓÔÏfiÁÔ˜
∂ndocrinologist
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ÊÙˆ¯¿ Û ÈÒ‰ÈÔ ‹ Î·È ÛÂÏ‹ÓÈÔ, ¤¯Ô˘Ó ¿ÙÔÌ· Ì ¯·ÌËÏfiÙÂÚÔ Ì¤ÛÔ ‰Â›ÎÙË ÓÔËÌÔÛ‡Ó˘, „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË Î·È ÂÏ·Ùو̤ÓË ·ÎÔ˘ÛÙÈ΋ Ô͇ÙËÙ·. √ Û˘ÁÁÂÓ‹˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ Â›Ó·È ·ÚfiÌÔÈ· ÌÔÚÊ‹ ÓÂ˘Ì·ÙÈ΋˜ ηı˘ÛÙ¤ÚËÛ˘, fiÙ·Ó ‰ÂÓ ·ÓÙÈÌÂÙˆÈÛı› ÂÁη›Úˆ˜. ∏ Û˘¯ÓfiÙËÙ¿ ÙÔ˘ Â›Ó·È 1:3500 ÁÂÓÓ‹ÛÂȘ. ∞˘Ù¿ Ù· ¿ÙÔÌ·, ηٿ ÙËÓ ÂÌ‚Ú˘˚΋ ˙ˆ‹ ·Ó·Ù‡ÛÛÔÓÙ·È Î·ÓÔÓÈο, ÁÈ·Ù› Ï·Ì‚¿ÓÔ˘Ó ı˘ÚÔÍ›ÓË ·fi ÙË ÌËÙ¤Ú·. ªÂÙ¿ ÙÔÓ ÙÔÎÂÙfi, ·Ó ‰Â Á›ÓÂÈ Ë ¤Ó·ÚÍË ·ÁˆÁ‹˜ Ì ı˘ÚÔÍ›ÓË, Ù· ·È‰È¿ ·Ó·Ù‡ÛÛÔ˘Ó ÌfiÓÈ̘ Ó¢ÚÔÏÔÁÈΤ˜ ‚Ï¿‚˜ Î·È „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË. ™ÙË ¯ÒÚ· Ì·˜, ·fi ÙÔ 1979, fiÏ· Ù· ÓÂÔÁ¤ÓÓËÙ· ÂϤÁ¯ÔÓÙ·È ÛÙ· Ì·ÈÂ˘Ù‹ÚÈ· ÁÈ· Û˘ÁÁÂÓ‹ ˘Ôı˘ÚÂÔÂȉÈÛÌfi Î·È Ï·Ì‚¿ÓÔ˘Ó ÂÓÙfi˜ ÌËÓfi˜ ıÂڷ›· Ì ı˘ÚÔÍ›ÓË.
a national priority in every country. Iodine acts through the action of thyroid hormones which regulate the maturation of various tissues, increase the metabolic rate and augment the enzymatic reactions. In areas with iodine deficiency the affected population has a low index of intelligence, growth retardation and decreased hearing ability. The incidence of congenital hypothyroidism is 1:3500 newborns in the first month of life and if untreated may cause mental retardation. During the prenatal period congenital hypothyroidism, have normal development because thyroxine is provided by their mother. Since 1979, all the newborns in our country undergo screening for congenital hypothyroidism and are treated with thyroxine within the first month of life (approximately 30 newborns are treated every year with thyroxine for hypothyroidism and have a regular follow up).
§¤ÍÂȘ ÎÏÂȉȿ: ÈÒ‰ÈÔ, Ȉ‰ÔÂÓ›·, ‚ÚÔÁ¯Ô΋ÏË, ÂÓ‰ËÌÈ΋ ‚ÚÔÁ¯Ô΋ÏË, Ó¢ÚÔÏÔÁÈÎfi˜ ÎÚÂÙÈÓÈÛÌfi˜, Ì˘ÍÔȉËÌ·ÙÈÎfi˜ ÎÚÂÙÈÓÈÛÌfi˜, ¤ÏÏÂÈ„Ë ÛÂÏËÓ›Ô˘, Û˘ÁÁÂÓ‹˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜.
Key words: iodine, iodine deficiency, goitre, endemic goitre, neurological cretinism, myxedematous cretinism, selenium deficiency, congenital hypothyroidism.
™˘ÓÙÔÌÔÁڷʛ˜ ∆4 £˘ÚÔÍ›ÓË FT4 ∂χıÂÚË £˘ÚÔÍ›ÓË ∆3 ∆ÚÈȈ‰Ôı˘ÚÔÓ›ÓË RT3 ∞Ó¿ÛÙÚÔÊË ∆ÚÈȈ‰Ôı˘ÚÔÓ›ÓË TSH £˘ÚÂÔÂȉÔÙÚfiÔ˜ √ÚÌfiÓË TBG √ÏÈ΋ ™Ê·ÈÚ›ÓË Ô˘ ‰ÂÛ̇ÂÈ ÙȘ ı˘ÚÂÔÂȉÈΤ˜ ÔÚÌfiÓ˜ WHO ¶·ÁÎfiÛÌÈÔ˜ √ÚÁ·ÓÈÛÌfi˜ ÀÁ›·˜ UNICEF ÿ‰Ú˘Ì· ∏ÓˆÌ¤ÓˆÓ ∂ıÓÒÓ ÁÈ· ÙÔ ·È‰› ICCIDD ¢ÈÂıÓ¤˜ ™˘Ì‚Ô‡ÏÈÔ ÁÈ· ÓÔÛ‹Ì·Ù· ÏfiÁˆ ¤ÏÏÂȄ˘ πˆ‰›Ô˘
∂ÈÛ·ÁˆÁ‹ ∆Ô ÈÒ‰ÈÔ ·Ó·Î·Ï‡ÊıËΠÙÔ 1811. º‡ÎË Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·Ó ˆ˜ ÚÒÙË ‡ÏË ÁÈ· ·Ú·ÁˆÁ‹ ÓÈÙÚÈÎÔ‡ Î·Ï›Ô˘ ÁÈ· ˘Ú›Ùȉ·, ηٿ ÙË ı¤ÚÌ·ÓÛË ·ÚÔ˘Û›·Û·Ó ·ÙÌÔ‡˜ Ì È҉˜ ¯ÚÒÌ· Î·È ÌÂÙ¿ ‰ËÌÈÔ˘ÚÁ‹ıËÎ·Ó ÎÚ‡ÛÙ·ÏÏÔÈ Èˆ‰›Ô˘. ∆Ô ÈÒ‰ÈÔ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ·fi ÙÔ 1820 ˆ˜ ·ÔÏ˘Ì·ÓÙÈÎfi Î·È ·ÓÙÈÛËÙÈÎfi ÛÙ· ÙÚ·‡Ì·Ù· Î·È ÙȘ ÏËÁ¤˜, fiÔ˘ ‰Ú· ̤ۈ Ù˘ Ì˘ÂÏÔÂÚÔÍÂȉ¿Û˘ Î·È ·ÂÓÂÚÁÔÔÈ› Ù· ‚·ÎÙËÚ›‰È·. ∂›Ó·È ‰Ú·ÛÙÈÎfiÙÂÚÔ ·ÔÏ˘Ì·ÓÙÈÎfi ·fi Ù· ¿ÏÏ· ·ÏÔÁfiÓ· ¯ÏÒÚÈÔ, ‚ÚÒÌÈÔ, ÊıfiÚÈÔ. ∆Ô ÈÒ‰ÈÔ, fï˜, Â›Ó·È Î·È ¤Ó· ·fi Ù· 22 ··Ú·›ÙËÙ· ÛÙÔȯ›· (ÙÔ ‰¤Î·ÙÔ ¤ÌÙÔ Î·Ù¿ ÂηÙÔÛÙÈ·›· ·Ó·ÏÔÁ›·) Ô˘ Û˘Óı¤ÙÔ˘Ó ÙÔ ·ÓıÚÒÈÓÔ ÛÒÌ· (1). ∆Ô ÈÒ‰ÈÔ ‚Ú›ÛÎÂÙ·È Û ÌÈÎÚ‹ ÔÛfiÙËÙ· ÛÙÔ ·ÓıÚÒÈÓÔ ÛÒÌ·, Â›Ó·È È¯ÓÔÛÙÔȯ›Ô, ‰ËÏ·‰‹ ÏÈÁfiÙÂÚÔ
102
·fi 100mg, ·ÏÏ¿ ‚Ú›ÛÎÂÙ·È Î·È ÛÙÔ ÊÏÔÈfi Ù˘ Á˘ Û ÌÈÎÚ‹ ÔÛfiÙËÙ·. °È· ÙËÓ ·ÎÚ›‚ÂÈ·, ¤Ó·˜ ÂÓ‹ÏÈη˜ ¤¯ÂÈ 15 mg Ȉ‰›Ô˘.∆Ô ÈÒ‰ÈÔ Ì ÙÔ ·ÌÈÓÔ͇ Ù˘ÚÔÛ›ÓË Û˘Óı¤ÙÔ˘Ó ÙȘ ı˘ÚÂÔÂȉÈΤ˜ ÔÚÌfiÓ˜ (∆3, ∆4) (∂ÈÎfiÓ· 1), Ô˘ Ú˘ıÌ›˙Ô˘Ó ÙËÓ ˆÚ›Ì·ÓÛË ‰È·ÊfiÚˆÓ ÈÛÙÒÓ, ·˘Í¿ÓÔ˘Ó ÙȘ η‡ÛÂȘ (ÌÂÙ·‚ÔÏÈÛÌfi) Î·È ÂÈÙ·¯‡ÓÔ˘Ó ‰È¿ÊÔÚÔ˘˜ ÂÓ˙˘ÌÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜. ∆Ô ÛÂÏ‹ÓÈÔ ·Ó·Î·Ï‡ÊıËΠÙÔ 1817 Î·È ıˆÚ›ÙÔ fiÙÈ ÚÔÂÚ¯fiÙ·Ó ·fi ÂÙÚÒÌ·Ù· (ÌÂÙˆڛÙ˜) Ù˘ ÛÂÏ‹Ó˘ (2). µÚ›ÛÎÂÙ·È Û ·ÂÈÚÔÂÏ¿¯ÈÛÙË ÔÛfiÙËÙ· ÛÙÔ ÊÏÔÈfi Ù˘ Á˘, ·ÏÏ¿ Â›Ó·È ··Ú·›ÙËÙÔ ÛÙËÓ Î·Ù·Û΢‹ ʈÙÔ΢ÙÙ¿ÚˆÓ ÁÈ· ÙÔ ·˘ÙfiÌ·ÙÔ ¿ÓÔÈÁÌ· Ù˘ fiÚÙ·˜. ∆Ô ÛÂÏ‹ÓÈÔ Â›Ó·È ÁÓˆÛÙfi ˆ˜ ··Ú·›ÙËÙÔ È¯ÓÔÛÙÔÈ¯Â›Ô ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡ ·fi ÙÔ 1957. ∆Ô ÛÂÏ‹ÓÈÔ Â›Ó·È ÙÔ 20fi ÛÙÔÈ¯Â›Ô Î·Ù¿ ÂηÙÔÛÙÈ·›· ·Ó·ÏÔÁ›· ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÛÒÌ·ÙÔ˜ Î·È ·ÔÙÂÏ› Û˘ÛÙ·ÙÈÎfi ÔÏÏÒÓ ÂÓ˙‡ÌˆÓ (¿Óˆ ·fi 10 ¤Ó˙˘Ì· ¤¯Ô˘Ó ÙËÓ ÂÓÂÚÁfi ÔÌ¿‰· ÛÂÏËÓÔ΢ÛÙ½ÓË), fiˆ˜ Ë ˘ÂÚÔÍÂȉ¿ÛË Ù˘ ÁÏÔ˘Ù·ıÂÈfiÓ˘, Ô˘ ‰ÂÛ̇ÂÈ ÙȘ ÂχıÂÚ˜ Ú›˙˜ Ô͢ÁfiÓÔ˘ Î·È Ù· ˘ÂÚÔÍ›‰È· Ô˘ Û¯ËÌ·Ù›˙ÔÓÙ·È ·fi ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈ·ÚÒÓ ÔͤˆÓ. ∆Ô ÛÂÏ‹ÓÈÔ Â›Ó·È ·ÓÙÈÔÍÂȉˆÙÈÎfi Î·È ‰Ú· ÛÂ Û˘ÓÂÚÁ·Û›· Ì ÙË ‚ÈÙ·Ì›ÓË ∂. ∆· ¤Ó˙˘Ì· Ô˘ ÌÂÙ·‚ÔÏ›˙Ô˘Ó ÙËÓ ÚÔÔÚÌfiÓË ∆4 ÛÙË ‰Ú·ÛÙÈ΋ ÔÚÌfiÓË ∆3 ‹ Û ·ÓÂÓÂÚÁfi rT3, ηıÒ˜ Î·È Ù· ¤Ó˙˘Ì· Ô˘ ÌÂÙ·‚ÔÏ›˙Ô˘Ó ÂÚ·ÈÙ¤Úˆ Ù·
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ªÔÓÔ˚ˆ‰ÔÙ˘ÚÔÛ›ÓË
¢˘˚ˆ‰ÔÙ˘ÚÔÛ›ÓË
D2,D1 -1 (5’) 3,5,3’ - ∆ÚÈȈ‰Ôı˘ÚÔÓ›ÓË (∆3)
£˘ÚÔÍ›ÓË (∆4) D3 -1 (5)
3,3’ ¢˘˚ˆ‰ÔÙ˘ÚÔÛ›ÓË (∆2)
3,3’,5’ - ∆ÚÈȈ‰Ôı˘ÚÔÓ›ÓË (∞ÓÙ›ÛÙÚÔÊË - ∆3)
∂ÈÎfiÓ· 1. √È ÌÔÓÔ- Î·È ‰˘- Ȉ‰ÔÙ˘ÚÔÛ›Ó˜ Â›Ó·È Úfi‰ÚÔ̘ ÔÚÌfiÓ˜. √È ∆4 Î·È ∆3 Â›Ó·È ÔÈ ‚ÈÔÏÔÁÈο ÂÓÂÚÁ¤˜ ı˘ÚÂÔÂȉÈΤ˜ ÔÚÌfiÓ˜. ∏ ∆3 ÂÎÎÚ›ÓÂÙ·È ·fi ÙÔ ı˘ÚÂÔÂȉ‹, ·ÏÏ¿ ΢ڛˆ˜ Û¯ËÌ·Ù›˙ÂÙ·È ÂÚÈÊÂÚÈο ·fi ÙË ı˘ÚÔÍ›ÓË Ì ÂÓ˙˘ÌÈ΋ ·Ô˚ˆ‰›ˆÛË. ∏ r∆3 Î·È Ë ∆2 Â›Ó·È ·ÓÂÓÂÚÁÔ› ÌÂÙ·‚Ôϛ٘ Ô˘ Û¯ËÌ·Ù›˙ÔÓÙ·È ·fi ÙËÓ ·Ô˚ˆ‰›ˆÛË ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ Û ÂÚÈÊÂÚÈÎÔ‡˜ ÈÛÙÔ‡˜. √È ·Ô˚ˆ‰ÈÓ¿Û˜ Ù˘ Ȉ‰Ôı˘ÚÔÓ›Ó˘ π,ππ,πππ, ÁÚ¿ÊÔÓÙ·È ˆ˜ D1, D2, D3, ·ÓÙ›ÛÙÔȯ·. ∏ D3 ·Ô˚ˆ‰ÈÒÓÂÈ ÙÔ ÈÒ‰ÈÔ 5 ÙÔ˘ ÂÛˆÙÂÚÈÎÔ‡ ‰·ÎÙ˘Ï›Ô˘ Î·È ÌÂÙ·‚¿ÏÏÂÈ ÙËÓ ∆4 Û ∆3.
ÚÔ˚fiÓÙ· Ù˘ ı˘ÚÔ͛Ӣ, ÂÚȤ¯Ô˘Ó ÛÂÏËÓÔ΢ÛÙ½ÓË (3). √ ı˘ÚÂÔÂȉ‹˜ Â›Ó·È Ô ÌÔÓ·‰ÈÎfi˜ ÂÓ‰ÔÎÚÈÓ‹˜ ·‰¤Ó·˜, Ô˘ ÂÓÒ Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙËÓ ÔÈfiÙËÙ· Ù˘ ˙ˆ‹˜, ÁÈ· Ó· ÏÂÈÙÔ˘ÚÁ‹ÛÂÈ ÛˆÛÙ¿ ÂÍ·ÚÙ¿Ù·È ·fi ȯÓÔÛÙÔȯ›· ÙˆÓ ÙÚÔÊÒÓ Ô˘ ÌÔÚ› Ó· ·Ó·ÚΛ ÛÙÔÓ ÙfiÔ Ô˘ ‰È·‚ÈÒÓÂÈ (¶›Ó·Î·˜ 1). ∆Ô ÈÒ‰ÈÔ Ô˘ Â›Ó·È ··Ú·›ÙËÙÔ ÁÈ· ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·Ú·ÁˆÁ‹ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ Î·È ÙÔ ÛÂÏ‹ÓÈÔ ÁÈ· ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ ÛÙË ‰Ú·ÛÙÈ΋ ÔÚÌfiÓË ∆3. ∏ ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi ∆Ô ÈÒ‰ÈÔ ÛÙ· ÛÔÓ‰˘ÏˆÙ¿ Û˘ÁÎÂÓÙÚÒÓÂÙ·È Î˘Ú›ˆ˜ ÛÙÔ ı˘ÚÂÔÂȉ‹ ÁÈ· Û‡ÓıÂÛË ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ, ·ÏÏ¿ ·˘ÍË̤ÓË Û˘ÁΤÓÙÚˆÛË ·Ú·ÙËÚÂ›Ù·È Î·È ÛÙÔ˘˜ ÛÈÂÏÔÁfiÓÔ˘˜ ·‰¤Ó˜, ÙÔ Á·ÛÙÚÈÎfi ‚ÏÂÓÓÔÁfiÓÔ, Ù· ¯ÔÚÈÔÂȉ‹ ϤÁÌ·Ù·, ÙȘ ˆÔı‹Î˜ Î·È ÙÔ Ì·ÛÙfi, ·ÏÏ¿ ‰ÂÓ ÁÓˆÚ›˙Ô˘Ì ·Ó ‰Ú· ˆ˜ ·ÓÙÈÛËÙÈÎfi. ŸÙ·Ó ˘¿Ú¯ÂÈ ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘, Ô ı˘ÚÂÔÂȉ‹˜ ‰ÈÔÁÎÒÓÂÙ·È ÁÈ· Ó· ÚÔÛÏ¿‚ÂÈ ÙÔ ÈÒ‰ÈÔ Ì ÌÂÁ·Ï‡ÙÂÚË ÂÈÊ¿ÓÂÈ· Î·È ‰ËÌÈÔ˘ÚÁÂ›Ù·È ‚ÚÔÁ¯Ô΋ÏË (5). ŸÙ·Ó Ë ‰ÈfiÁΈÛË ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ·Ú·ÙËÚÂ›Ù·È Û ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ˘ 10% ÂÓfi˜ ÏËı˘ÛÌÔ‡, ˘¿Ú¯ÂÈ ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ ÛÙË ÂÚÈÔ¯‹ (ÂÓ‰ËÌÈ΋
‚ÚÔÁ¯Ô΋ÏË). √ ı˘ÚÂÔÂȉ‹˜ ÛÙÔÓ ÂÓ‹ÏÈη ¤¯ÂÈ ‚¿ÚÔ˜ ÂÚ›Ô˘ 20 ÁÚ·ÌÌ¿ÚÈ· ÂÓÒ ÛÙË ‚ÚÔÁ¯Ô΋ÏË ÙÔ ‚¿ÚÔ˜ Â›Ó·È ÙÔ˘Ï¿¯ÈÛÙÔÓ ‰ÈÏ¿ÛÈÔ ÙÔ˘ Ê˘ÛÈÔÏÔÁÈÎÔ‡ Î·È ÌÔÚ› Ó· Êı¿ÛÂÈ Ù· 200-250 ÁÚ·ÌÌ¿ÚÈ· (6). ◊Ù·Ó ÁÓˆÛÙfi ·fi ÂÌÂÈÚÈΤ˜ ·Ú·ÙËÚ‹ÛÂȘ, fiÙÈ ¿ÙÔÌ· Ô˘ ˙Ô˘Ó Û „ËÏ¿ ‚Ô˘Ó¿ ¤¯Ô˘Ó Û˘¯Ó¿ ‰ÈÔÁΈ̤ÓÔ ı˘ÚÂÔÂȉ‹. √ ¿ÁÁÏÔ˜ È·ÙÚfi˜ Edward Browne (1644-1708), ηٿ ÙËÓ Â›Û΄‹ ÙÔ˘ ÛÙȘ ÕÏÂȘ ¤ÁÚ·„Â: “À¿Ú¯Ô˘Ó Â‰Ò ÔÏÏÔ› ¿ÓıÚˆÔÈ Ì ‚ÚÔÁ¯Ô΋ÏË. ªÂÚÈÎÔ› Â›Ó·È Ù˘ÊÏÔ›, ¿ÏÏÔÈ ÎˆÊ¿Ï·ÏÔÈ Î·È ¿ÏÏÔÈ ÓÂ˘Ì·ÙÈο ηı˘ÛÙÂÚË̤ÓÔÈ. √È ¿ÓıÚˆÔÈ Ù˘ ·ÓÒÙÂÚ˘ Ù¿Í˘, Ô˘ ˙Ô˘Ó Û ηχÙÂÚ˜ Û˘Óı‹Î˜ Î·È ›ÓÔ˘Ó ÎÚ·Û› Î·È Î·Ï‹˜ ÔÈfiÙËÙ·˜ ̇ڷ, ‰ÂÓ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘¯Ó¿ ·˘Ù¿ Ù· Â˘Ú‹Ì·Ù·” (7). ŒÓ· ‚È‚Ï›Ô ‰Â, Ô˘ ÁÚ¿ÊÙËΠÙÔ 1180 ·fi ÙÔ ƒÔÁ‹ÚÔ, ‰È¿ÛËÌÔ ¯ÂÈÚÔ˘ÚÁfi ÛÙÔ ¶·Ï¤ÚÌÔ Ù˘ πÙ·Ï›·˜, ·Ó·Ê¤ÚÂÈ ıÂڷ›· Ù˘ ‚ÚÔÁ¯Ô΋Ï˘ Ì ÛÙ¿¯ÙË Î·Ì̤ÓÔ˘ ÛfiÁÁÔ˘ ‹ ʇÎÈ· (8). ªÂ ÙËÓ ·Ó·Î¿Ï˘„Ë ÙÔ˘ Ȉ‰›Ô˘ ·Ú·Û΢¿˙ÂÙ·È ÛÙÔ ¶·Ú›ÛÈ ÙÔ ˘‰·ÙÈÎfi ‰È¿Ï˘Ì· Lugol ·fi ÙÔÓ ÔÌÒÓ˘ÌÔ ¯ËÌÈÎfi, Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËΠÛÙË ıÂڷ›· Ù˘ ‚ÚÔÁ¯Ô΋Ï˘, ·ÏÏ¿ ÂÁηٷÏ›ÊıËΠÛÙ· Ù¤ÏË ÙÔ˘ 19Ô˘ ·ÈÒÓ· ÏfiÁˆ ·ÚÂÓÂÚÁÂÈÒÓ (Ë Î·Ù¿¯ÚËÛË ÚÔηÏ› ˘Ôı˘ÚÂÔÂȉÈÛÌfi ·ÏÏ¿ Î·È ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi). ªfiÓÔ ÙÔ 1907 ·Ô‰Â›¯ıËΠfiÙÈ ÙÔ ÈÒ‰ÈÔ Â›Ó·È
103
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¶›Ó·Î·˜ 1. ™ÙÔȯ›· ·Ó¿ 100 gr ÙÚÔÊ‹˜ (4)
∞̇Á‰·Ï· ∞̇Á‰·Ï· µÚ·˙ÈÏ›·˜ ºÈÛÙ›ÎÈ· ∏ÏÈfiÛÔÚÔ˜ ™fiÁÈ· ™ÎfiÚ‰Ô ª·ÓÈÙ¿ÚÈ· ™¤ÏÈÓÔ ∫ÔÙfiÔ˘ÏÔ ˆÌfi ™ÔψÌfi˜ ÎÔÓÛ¤Ú‚· ™·Ú‰¤Ï˜ ÎÔÓÛ¤Ú‚· ¶¤ÛÙÚÔÊ· ‚Ú·Ṳ̂ÓË ∆fiÓÔ˜ °·Ú›‰Â˜ ª‡‰È· ∫˘‰ÒÓÈ· ı¿Ï·ÛÛ·˜ æˆÌ› ¿ÛÚÔ
∞Û‚¤ÛÙÈÔ mg 240 170 60 110 240 19 6 41 10 93 550 36 12 150 200 130 110
ª·ÁÓ‹ÛÈÔ mg 270 410 210 390 250 25 9 5 25 30 52 31 33 42 25 51 24
··Ú·›ÙËÙÔ ÁÈ· ÙË Ê˘ÛÈÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ı˘ÚÂÔÂȉ‹ ·fi ÙÔÓ ·ÌÂÚÈηÓfi David Marine, Ô ÔÔ›Ô˜ ¤Î·Ó ›Û˘, ÚÔÛ¿ıÂÈ· Ì·˙È΋˜ ÚfiÏ˄˘ Ù˘ ‚ÚÔÁ¯Ô΋Ï˘ Ì ÈÒ‰ÈÔ ÛÙÔ √¯¿ÈÔ Ù˘ ∞ÌÂÚÈ΋˜. ∏ ‹È· ¤ˆ˜ ̤ÙÚÈ· ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ ÚÔηÏ› (¶›Ó·Î·˜ 2) Ó¢ÚÔÏÔÁÈΤ˜ ‚Ï¿‚˜ (9,10) ÛÙË Û¯ÔÏÈ΋ ËÏÈΛ·, ηı˘ÛÙ¤ÚËÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘ Î·È ·˘ÍË̤ÓË Û˘¯ÓfiÙËÙ· ·ÚÔ‰ÈÎÔ‡ ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ (11,12). ∏ ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ ·˘Í¿ÓÂÈ ÙÔÓ Î›Ó‰˘ÓÔ ÂÌÊ¿ÓÈÛ˘ ηÚΛÓÔ˘ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ÛÙ· ·È‰È¿ (13) Û ÂÚ›ÙˆÛË ˘ÚËÓÈÎÔ‡ ·Ù˘¯‹Ì·ÙÔ˜, fiˆ˜ ÂΛÓÔ ÙÔ˘ Chernobyl Ô˘ Û˘Ó¤‚Ë ÙËÓ 26Ë ∞ÚÈÏ›Ô˘ ÙÔ˘ 1986. ∞˘Ùfi Û˘Ì‚·›ÓÂÈ, ÁÈ·Ù› ÙÔ Ú·‰ÈÂÓÂÚÁfi ÈÒ‰ÈÔ 131 Ô˘ ÚÔ¤Ú¯ÂÙ·È ·fi ÙÔ Ó¤ÊÔ˜ ÙÔ˘ ˘ÚËÓÈÎÔ‡ ·Ù˘¯‹Ì·ÙÔ˜ ηıÈ˙¿ÓÂÈ Î·È ‰È· ÙˆÓ ÙÚÔÊÒÓ Î·È ÙÔ˘ ·¤Ú· ÚÔÛÏ·Ì‚¿ÓÂÙ·È ·fi ÙÔ ı˘ÚÂÔÂȉ‹ Ȉ‰ÔÂÓÈÎÒÓ ·ÙfïÓ. ª·ÎÚÔ¯ÚfiÓÈ· ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ ‰ËÌÈÔ˘ÚÁ› ‰ÈfiÁΈÛË ı˘ÚÂÔÂȉԇ˜ (‚ÚÔÁ¯Ô΋ÏË ÌË ÙÔÍÈ΋), Ô˘ Â›Ó·È ÂÌÊ·Ó‹˜ ·fi ÙËÓ Â͈ÙÂÚÈ΋ ÂÌÊ¿ÓÈÛË ÙÔ˘ ·ÛıÂÓÔ‡˜, ÓÂ˘Ì·ÙÈ΋ Î·È „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË (14) Î·È ÂÏ·Ùو̤ÓË ÁÔÓÈÌfiÙËÙ·. ŒÏÏÂÈ„Ë ÛÂÏËÓ›Ô˘ ÛÙÔÓ ÔÚÁ·ÓÈÛÌfi ∏ ¤ÏÏÂÈ„Ë ÛÂÏËÓ›Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ¿ÙÔÌ· Ì ʷÈÓ˘ÏÎÂÙÔÓÔ˘Ú›· Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÙÚÔʤ˜ ÊÙˆ¯¤˜ Û ʷÈÓ˘Ï·Ï·Ó›ÓË, ÂÓÒ Ê˘ÛÈÔÏÔÁÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÂÈÙ˘Á¯¿ÓÂÙ·È ÌfiÓÔ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ ÛÂÏËÓ›Ô˘. ŒÏÏÂÈ„Ë ÛÂÏËÓ›Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙË ºÈÓÏ·Ó‰›· Î·È ÛÙË ¡. ∑ËÏ·Ó‰›·, fiÔ˘ Ë ËÌÂÚ‹ÛÈ· ÚfiÛÏË„Ë Â›Ó·È 30-50 Ìg, ÂÓÒ ÛÙËÓ ∞ÌÂÚÈ΋ Â›Ó·È 100-250 Ìg ËÌÂÚËÛ›ˆ˜. ∏ ¯ÔÚ‹ÁËÛË ÛÂÏËÓ›Ô˘ ÂÏ·ÙÙÒÓÂÈ ÙË
104
™›‰ËÚÔ˜ mg 3,0 2,5 2,5 6,4 9,7 1,9 0,6 0,4 0,7 1,4 2,9 1,0 1,6 1,1 7,7 26 1,6
™ÂÏ‹ÓÈÔ Ìg 4 1530 3 49 14 2 9 3 7 25 50 24 90 18 45 45 28
πÒ‰ÈÔ Ìg 2 20 20 (;) 6 3 3 (;) 10 59 23 16 14 28 120 160 6
ıÓËÙfiÙËÙ· ÙÔ˘ ηÚΛÓÔ˘ (ηÚΛÓÔ˜ ‰¤ÚÌ·ÙÔ˜ ·fi ·ÙÙ·Ú· squamous), ηıÒ˜ Î·È ÙË Û˘¯ÓfiÙËÙ· ÙÔ˘ ηÚΛÓÔ˘ Ó‡ÌÔÓÔ˜, ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘ Î·È ÚÔÛÙ¿ÙË. ªÂÌÔӈ̤ÓË ¤ÏÏÂÈ„Ë ÛÂÏËÓ›Ô˘ ·Ú·ÙËÚÂ›Ù·È Â›Û˘, Û ÂÚÈÔ¯¤˜ Ù˘ ∫›Ó·˜ (·fi ‚fiÚÂÈ· ·Ó·ÙÔÏÈο ¤ˆ˜ ÓfiÙÈ· ‰˘ÙÈο Î·È ÂÎÙ›ÓÂÙ·È Ì¤¯ÚÈ ÙÔ £È‚¤Ù), ÂÓÒ ¤ÏÏÂÈ„Ë ÛÂÏËÓ›Ô˘ Î·È Èˆ‰›Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ ÂÚÈÔ¯‹ ÙˆÓ πÌ·Ï·˝ˆÓ Î·È ÚÔηÏ› ηٷÛÙÚÔÊ‹ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ (Ì˘ÍÔȉËÌ·ÙÈÎfi˜ ÎÚÂÙÈÓÈÛÌfi˜) Î·È ÛÙËÓ ∫ÂÓÙÚÈ΋ ∞ÊÚÈ΋ (‚fiÚÂÈÔ Î·È ·Ó·ÙÔÏÈÎfi ∑·˝Ú) (15). ™ÙËÓ ∫›Ó·, Ë ¤ÏÏÂÈ„Ë ÛÂÏËÓ›Ô˘ Û ·È‰È¿ Î·È ¤ÁÎ˘Â˜ Á˘Ó·›Î˜ ·˘Í¿ÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÚÔÛ‚ÔÏ‹˜ ·fi ηډÈÔÌ˘Ô¿ıÂÈ· ÙÔ˘ Keshan (ÔÊ›ÏÂÙ·È Û Èfi) Î·È ÔÛÙÂÔ·ÚıÚÔ¿ıÂÈ· ÙÔ˘ Kashin-Beck Ô˘ ¶›Ó·Î·˜ 2. ∂›‰Ú·ÛË Ù˘ ¤ÏÏÂȄ˘ πˆ‰›Ô˘ ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi ∞. ∂Á΢ÌÔÛ‡ÓË 1. ∞˘ÙfiÌ·ÙË ¤ÎÙÚˆÛË 2. ¶ÚÒÈÌÔ˜ ÙÔÎÂÙfi˜ 3. ∂Ì‚Ú˘˚Îfi˜ ı¿Ó·ÙÔ˜ 4. ÀÔÏÂÈfiÌÂÓË ·Ó¿Ù˘ÍË ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ ÂÁÎÂÊ¿ÏÔ˘ µ. ¶·È‰È¿ 1. ¶ÓÂ˘Ì·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË 2. ∫·ı˘ÛÙ¤ÚËÛË „˘¯ÔÎÈÓËÙÈ΋˜ ·Ó¿Ù˘Í˘ 3. ÷ÌËÏfi ·Ó¿ÛÙËÌ· 4. ª˘˚΋ ·‰˘Ó·Ì›· 5. ¶·Ú¿Ï˘ÛË 6. ∂Ï·Ùو̤ÓË ·ÎÔ‹ Î·È ‰˘Û¯¤ÚÂÈ· ÛÙËÓ ÔÌÈÏ›· 7. ∫ÚÂÙÈÓÈÛÌfi˜ °. ∂Ó‹ÏÈΘ 1. µÚÔÁ¯Ô΋ÏË 2. ∞‰˘Ó·Ì›·, ∫·Ù·‚ÔÏ‹ 3. ∫ÚÂÙÈÓÈÛÌfi˜ 4. ∂Ï·Ùو̤ÓË ÁÔÓÈÌfiÙËÙ·
2001 MAPT- A¶PI§
17-10-01 15:34
™ÂÏ›‰· 105
¶·È‰È·ÙÚÈ΋ 2001;64:101-114
Paediatriki 2001;64:101-114
ÚÔԉ¢ÙÈο ÂȉÂÈÓÒÓÂÙ·È. ™Â ·˘Ù¤˜ ÙȘ ÂÚÈÔ¯¤˜ ÙÔ ÛÂÏ‹ÓÈÔ ÛÙÔ ·›Ì· Â›Ó·È 10 ng/ml, ÂÓÒ ÛÙÔ˘˜ ηÙÔ›ÎÔ˘˜ ‚ÈÔÌ˯·ÓÈÎÒÓ ÂÚÈÔ¯ÒÓ Î˘Ì·›ÓÂÙ·È ·fi 60110 ng/ml. ∏ ¤ÏÏÂÈ„Ë ÛÂÏËÓ›Ô˘ ÚÔηÏ› Ó¤ÎÚˆÛË ÙÔ˘ ‹·ÙÔ˜, Ô˘ ÂȉÂÈÓÒÓÂÙ·È fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ Î·È ¤ÏÏÂÈ„Ë ‚ÈÙ·Ì›Ó˘ ∂. ™ÙÔ ∑·˝Ú, ÙÔ 80% ÙˆÓ ·È‰ÈÒÓ Î¿Ùˆ ÙˆÓ 5 ÂÙÒÓ ¤¯Ô˘Ó ‚ÚÔÁ¯Ô΋ÏË. ∆Ô 10% ÙˆÓ ·ÙfiÌˆÓ Â›Ó·È Ì˘ÍÔȉËÌ·ÙÈÎÔ› ÎÚÂÙ›ÓÔÈ, ‰ËÏ·‰‹ ¿ÙÔÌ· Ì ÎÔÓÙfi ·Ó¿ÛÙËÌ·, ‰˘Û·Ó·ÏÔÁ›· ÛÒÌ·ÙÔ˜ (ÎÔÓÙ¿ ¿ÎÚ·), „˘¯ÔÎÈÓËÙÈ΋ Î·È ÓÂ˘Ì·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË, ·Ô˘Û›· ‰Â˘ÙÂÚÔÁÂÓÒÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘ ʇÏÔ˘, ˘Ôı˘ÚÂÔÂȉÈÛÌfi, ‚·ÚËÎÔ˝· Î·È ‰¤ÚÌ· Ú˘ÙȉˆÌ¤ÓÔ, ÁÂÚÔÓÙÈÎfi ‹ ÔȉËÌ·Ù҉˜ (∂ÈÎfiÓ· 2). ™ÙÔ £È‚¤Ù, Ë Û˘¯ÓfiÙËÙ· ·È‰ÈÒÓ Ì ÂÓ‰ËÌÈ΋ ‚ÚÔÁ¯Ô΋ÏË Â›Ó·È ÌÈÎÚfiÙÂÚË Û ۯ¤ÛË Ì ÙÔ ∑·˝Ú, ·Ú¿ ÙË ¯·ÌËÏfiÙÂÚË ·Ô‚ÔÏ‹ Ȉ‰›Ô˘ ·fi Ù· Ô‡Ú· ÙˆÓ ·È‰ÈÒÓ. ∆· ıÂÈÔ΢·ÓÈο Ù˘ ηÛÛ¿‚·, Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È ˆ˜ ÙÚÔÊ‹ ÛÙ· ·È‰È¿ ÙÔ˘ ∑·˝Ú, Â›Ó·È ¤Ó·˜ ÂÈϤÔÓ ‚ÚÔÁ¯ÔÎËÏÔÁfiÓÔ˜ ·Ú¿ÁˆÓ Ô˘ ÂȉÂÈÓÒÓÂÈ ÙËÓ ˘¿Ú¯Ô˘Û· Ȉ‰ÔÂÓ›· (16,17). ∏ ÔÛÙÂÔ·ÚıÚÔ¿ıÂÈ· Kashin-Beck ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ ∑·˝Ú, ·ÎfiÌË Î·È Û ‚·ÚȤ˜ ÌÔÚʤ˜ ¤ÏÏÂȄ˘ ÛÂÏËÓ›Ô˘. ∏ ·ÚÈ· ÙÚÔÊ‹ ÙˆÓ Î·ÙÔ›ÎˆÓ ÙÔ˘ £È‚¤Ù Â›Ó·È ÙÔ ÎÚÈı¿ÚÈ. ∫¿ÔÈ· ÙÔÍ›ÓË ·fi ̇ÎËÙ˜ Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ÛÙÔ ÎÚÈı¿ÚÈ, ÂȉÂÈÓÒÓÂÈ ÙËÓ ¤ÏÏÂÈ„Ë ÛÂÏËÓ›Ô˘ ÛÙÔ˘˜ ηÙÔ›ÎÔ˘˜ ÙÔ˘ £È‚¤Ù, ÒÛÙ ӷ ÂΉËÏÒÛÔ˘Ó ÛÙÂÚËÙÈÎfi ÓfiÛËÌ·. ™˘¯ÓfiÙËÙ· Ù˘ ¤ÏÏÂȄ˘ ÙÔ˘ Ȉ‰›Ô˘ ÛÙÔÓ Ï·Ó‹ÙË Ì·˜ ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ ¤Ó· ‰ÈÛÂηÙÔÌ̇ÚÈÔ ¿ÙÔÌ· (ÙÔ 17%) ·fi Ù· 6 ‰ÈÛÂηÙÔÌ̇ÚÈ· Ô˘ ηÙÔÈÎÔ‡Ó ÛÙÔÓ Ï·Ó‹ÙË Ì·˜, ÎÈÓ‰˘ÓÂ‡Ô˘Ó Ó· ·Ó·Ù‡ÍÔ˘Ó ÓÔÛ‹Ì·Ù· ÏfiÁˆ ¤ÏÏÂȄ˘ Ȉ‰›Ô˘ (18). ŒÏÏÂÈ„Ë Èˆ‰›Ô˘ ·Ú·ÙËÚÂ›Ù·È Û ÂÚÈÔ¯¤˜ Ô˘ ÙÔ ¤‰·ÊÔ˜ Â›Ó·È ÊÙˆ¯fi Û ÈÒ‰ÈÔ, ÂÂȉ‹ ¤ÁÈÓ ¤ÎÏ˘ÛË ÙÔ˘ ÂÈÊ·ÓÂÈ·ÎÔ‡ ‰¿ÊÔ˘˜, ›Ù ÏfiÁˆ ÌÂÙ·ÊÔÚ¿˜ ·fi ·ÁÂÙÒÓ˜ Û ÚÔËÁÔ‡ÌÂÓË ÁˆÏÔÁÈ΋ ÂÔ¯‹, ›Ù ÏfiÁˆ ˘„ËÏÒÓ ‚ÚÔ¯ÔÙÒÛÂˆÓ ‹ ÏË̶›Ó·Î·˜ 3. ∆È̤˜ ÂÏ¿¯ÈÛÙ˘ Û˘ÓÈÛÙÒÌÂÓ˘ ËÌÂÚ‹ÛÈ·˜ ηٷӿψÛ˘ πˆ‰›Ô˘ ηٿ WHO
∏ÏÈÎȷ΋ √Ì¿‰· ¶ÚfiˆÚ· –¡ÂÔÁÓ¿ µÚ¤ÊË ¶·È‰È¿
∂Ó‹ÏÈΘ ∫˘ÔÊÔÚÔ‡Û˜ £ËÏ¿˙Ô˘Û˜
0-5 ÌËÓÒÓ 5-12 ÌËÓÒÓ 1-3 ÂÙÒÓ 4-6 ÂÙÒÓ 7-10 ÂÙÒÓ
∏ÌÂÚ‹ÛÈ· ∫·Ù·Ó¿ÏˆÛË ·Ó¿ ¿ÙÔÌÔ >30 Ìg 90 Ìg 90 Ìg 90 Ìg 90 Ìg 120 Ìg 150 Ìg 200 Ìg 200 Ìg
∂ÈÎfiÓ· 2. §ÂÌÊ·‰ÂÓ›ÙȘ Î·È Ì˘ÍÔ›‰ËÌ·. ¶ÂÚÔ˘‚È·Ófi ·ÁÁ›Ô.
Ì‡ÚˆÓ (19). √È ÂÚÈÔ¯¤˜ Ì ÙË ÌÂÁ·Ï‡ÙÂÚË ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ ‚Ú›ÛÎÔÓÙ·È ÛÙ· „ËÏ¿ ‚Ô˘Ó¿ (ÕÏÂȘ, πÌ·Ï¿È·, ÕÓ‰ÂȘ) Î·È Û ÂÚÈÔ¯¤˜ Ì ¯·ÌËÏfi ˘„fiÌÂÙÚÔ ÔÈ Ôԛ˜, fï˜, Û˘¯Ó¿ ÏËÌÌ˘Ú›˙Ô˘Ó, fiˆ˜ ÙÔ ª·ÁÎÏ·ÓÙ¤˜ Î·È Ë ÓfiÙÈ· ∫›Ó·. √È ÂÚÈÛÛfiÙÂÚÔÈ ÏËı˘ÛÌÔ› Ì ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ ˙Ô˘Ó Û ÔÚÂÈÓ¤˜ ÂÚÈÔ¯¤˜ ·Ó·Ù˘ÛÛfiÌÂÓˆÓ ¯ˆÚÒÓ. ∞ÏÏ¿ ·ÎfiÌË Î·È ÛÙËÓ ∂˘ÚÒË 50-100 ÂηÙÔÌ̇ÚÈ· ¿ÙÔÌ· Â›Ó·È Û ΛӉ˘ÓÔ ÏfiÁˆ Ȉ‰ÔÂÓ›·˜ (∂ÈÎfiÓ· 3) (20). ™Â ÔÏϤ˜ ÂÚÈÔ¯¤˜ Ù˘ ∂˘ÚÒ˘, ȉ›ˆ˜ Û ̤ÚË Ù˘ ÎÂÓÙÚÈ΋˜, ÓfiÙÈ·˜ Î·È ·Ó·ÙÔÏÈ΋˜ ∂˘ÚÒ˘, Ë Ì¤ÛË ËÌÂÚ‹ÛÈ· ηٷӿψÛË Èˆ‰›Ô˘ Â›Ó·È Ôχ ¯·ÌËÏfiÙÂÚË Ù˘ ÂÏ¿¯ÈÛÙ˘ Û˘ÓÈÛÙÒÌÂÓ˘ ‰fiÛ˘ ÁÈ· ·È‰È¿ Î·È ÂÓ‹ÏÈΘ (¶›Ó·Î·˜ 3). ™‹ÌÂÚ·, Ë Ì¤ÛË ËÌÂÚ‹ÛÈ· ηٷӿψÛË ıˆÚÂ›Ù·È Â·Ú΋˜ ÌfiÓÔ Û ¤ÓÙ ¯ÒÚ˜ (∞˘ÛÙÚ›·, ºÈÓÏ·Ó‰›·, ¡ÔÚ‚ËÁ›·, ™Ô˘Ë‰›·, ∂Ï‚ÂÙ›·) (¶›Ó·Î·˜ 4) Î·È ·˘Ùfi ÂÈÙ‡¯ıËΠÌÂÙ¿ ·fi ÚÔÛ¿ıÂÈ· ÔÏÏÒÓ ÂÙÒÓ (21). §ÂÈÙÔ˘ÚÁ›Â˜ ÙÔ˘ Ȉ‰›Ô˘ Î·È ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ ÛÙÔÓ ·ÓıÚÒÈÓÔ ÔÚÁ·ÓÈÛÌfi ∆Ô ÈÒ‰ÈÔ Î˘ÎÏÔÊÔÚ› ÛÙÔ ·›Ì· Î·È ÚÔÛÏ·Ì‚¿ÓÂÙ·È ·fi ÙÔ Î‡ÙÙ·ÚÔ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ÂÓÂÚÁËÙÈο, ‰ËÏ·‰‹ Ì ηٷӿψÛË ÂÓ¤ÚÁÂÈ·˜ (22). ∆· ı˘Ï·ÎÈÒ‰Ë Î‡ÙÙ·Ú· ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ¤¯Ô˘Ó 30-250
105
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™ÂÏ›‰· 106
¶·È‰È·ÙÚÈ΋ 2001;64:101-114
Paediatriki 2001;64:101-114
ºÈÓÏ·Ó‰›· >300
¡ÔÚ‚ËÁ›· 150-250
µ√ƒ∂π∞ £∞§∞™™∞
πÚÏ·Ó‰›· 60-130
™Ô˘Ë‰›· 150-330
¢·Ó›· 40-90
√ÏÏ·Ó‰›·
µ∞§∆π∫∏
∏Ó. µ·Û›ÏÂÈÔ 70-130 µ¤ÏÁÈÔ 50-60
√˘ÎÚ·Ó›·
∆Û¯›· 30-80
∞∆§∞¡∆π∫√™ ø∫∂∞¡√™ °·ÏÏ›· 60-170
∂Ï‚ÂÙ›· 130-160
πÙ·Ï›· 10-130 ¶ÔÚÙÔÁ·Ï›· 10-130
¶Ôψӛ· 40-70
°ÂÚÌ·Ó›· 20-70
∞˘ÛÙÚ›· 150
√˘ÁÁ·Ú›·
∫ÚÔ·Ù›· 90
ƒÔ˘Ì·Ó›· 40-130
ª∞Àƒ∏ £∞§∞™™∞
™ÂÚ‚›·
πÛ·Ó›· 30-110
µÔ˘ÏÁ·Ú›· 20-60
∆Ô˘ÚΛ· ª∂™√°∂π√™ £∞§∞™™∞ ∂ÏÏ¿‰· 40-130
∂ÈÎfiÓ· 3. ∂ÎÙ›ÌËÛË ËÌÂÚ‹ÛÈ·˜ ÚfiÛÏ˄˘ Ȉ‰›Ô˘ ÛÙËÓ ∂˘ÚÒË (Ìg/ËÌÂÚËÛ›ˆ˜) ÙÔ 1992. ∏ ‰È·Î‡Ì·ÓÛË ÙˆÓ ÙÈÌÒÓ ÔÊ›ÏÂÙ·È Û ‰È·ÊÔÚÂÙÈΤ˜ ÂÚÈÔ¯¤˜ ̤ÙÚËÛ˘ ‹ Û ÂıÓÈΤ˜ ÌÂϤÙ˜. √È ÙÈ̤˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ ÔÛfiÙËÙ· Ù˘ ËÌÂÚ‹ÛÈ·˜ ·Ô‚ÔÏ‹˜ ÙÔ˘ Ȉ‰›Ô˘ ÛÙ· Ô‡Ú· 24ÒÚÔ˘ ‹ ÛÙË Û¯¤ÛË ÙÔ˘ Ȉ‰›Ô˘ ·Ó¿ ÁÚ·ÌÌ¿ÚÈÔ ÎÚ·ÙÈÓ›Ó˘ Î·È ·Ó·ÁˆÁ‹ Û Ìg/Ï›ÙÚÔ.
ÊÔÚ¤˜ ÂÚÈÛÛfiÙÂÚÔ ·ÓfiÚÁ·ÓÔ ÈÒ‰ÈÔ ·’fiÙÈ ÙÔ Ï¿ÛÌ·. ∆Ô ÈÒ‰ÈÔ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ·ÔÙÂÏ› ÙÔ 80% ÙÔ˘ Ȉ‰›Ô˘ ÙÔ˘ ÛÒÌ·ÙÔ˜. ∆Ô ÈÒ‰ÈÔ ÛÙÔ ·›Ì· Â›Ó·È 1 Ìg/Ï›ÙÚÔ. ∞̤ۈ˜ ÌfiÏȘ ÂÈÛ¤ÏıÂÈ ÙÔ ·ÓfiÚÁ·ÓÔ ÈÒ‰ÈÔ ÛÙÔ Î‡ÙÙ·ÚÔ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ÔÍÂÈ‰Ô‡Ù·È Î·È Û˘Ó‰¤ÂÙ·È Ì ÙÔ ·ÌÈÓÔ͇ Ù˘ÚÔÛ›ÓË, Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙÔ ÌfiÚÈÔ Ù˘ ı˘ÚÂÔÛÊ·ÈÚ›Ó˘ ÎÈ ¤ÙÛÈ ÌÂÙ·ÙÚ¤ÂÙ·È Û ÔÚÁ·ÓÈÎfi ÈÒ‰ÈÔ. ∏ ·ÓÙ›‰Ú·ÛË ·˘Ù‹ Á›ÓÂÙ·È Ì ÙË ‚Ô‹ıÂÈ· Ì›·˜ ·ÈÌÔÚˆÙ½Ó˘, Ù˘ ˘ÂÚÔÍÂȉ¿Û˘ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜, Ô˘ Â›Ó·È ÎÔÏÏË̤ÓË ÛÙË ÌÂÌ‚Ú¿ÓË ÙÔ˘ ΢ÙÙ¿ÚÔ˘. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ù· ·ÓÙÈÌÈÎÚÔÛˆÌȷο ·ÓÙÈÛÒÌ·Ù· ¤¯Ô˘Ó ˆ˜ ·ÓÙÈÁfiÓÔ ÙËÓ ˘ÂÚÔÍÂȉ¿ÛË ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ (23). ŒÓ· ÌfiÚÈÔ ∆4 ·ÔÙÂÏÂ›Ù·È ·fi Ù¤ÛÛÂÚ· ¿ÙÔÌ· Ȉ‰›Ô˘ Î·È ‰‡Ô ÌfiÚÈ· Ù˘ÚÔÛ›Ó˘. ∆Ô ÈÒ‰ÈÔ ·ÔÙÂÏ› ÙÔ 64% ÙÔ˘ ÌÔÚÈ·ÎÔ‡ ‚¿ÚÔ˘˜ Ù˘ ∆4.
106
∞Èٛ˜ Ù˘ ‚ÚÔÁ¯Ô΋Ï˘ ∏ ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ Â›Ó·È ÙÔ Û˘ÓËı¤ÛÙÂÚÔ ·›ÙÈÔ ‚ÚÔÁ¯Ô΋Ï˘ ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ¯ÒÚ˜ ÙÔ˘ ÎfiÛÌÔ˘ (24). ∆· ÙÚfiÊÈÌ· Ô˘ ·Ú¿ÁÔÓÙ·È Û ‰¿ÊË ÊÙˆ¯¿ Û ÈÒ‰ÈÔ, ‰ÂÓ ¤¯Ô˘Ó ÙËÓ ÔÛfiÙËÙ· Ȉ‰›Ô˘ ÙˆÓ ›‰ÈˆÓ ÙÚÔÊ›ÌˆÓ Ô˘ ·Ú¿ÁÔÓÙ·È Û ‰¿ÊË ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ÂÚÈÂÎÙÈÎfiÙËÙ· Û ÈÒ‰ÈÔ. ∆Ô fiÛÈÌÔ ÓÂÚfi ‰ÂÓ ÂÚȤ¯ÂÈ Ôχ ÈÒ‰ÈÔ (Û˘Ó‹ıˆ˜ 4-10 Ìg/Ï›ÙÚÔ) Î·È ¤ÙÛÈ ‰ÂÓ Û˘Ì‚¿ÏÏÂÈ Ôχ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ·Ó·ÁÎÒÓ ÙÔ˘ ·ÓıÚÒÔ˘. ∆Ô ÓÂÚfi, fï˜, ¯ÚËÛÈ̇ÂÈ ˆ˜ ‰Â›ÎÙ˘ ‡·Ú͢ ÌÈÎÚ‹˜ ‹ ηÓÔÓÈ΋˜ ÔÛfiÙËÙ·˜ Ȉ‰›Ô˘ ÛÙ· ÙÚfiÊÈÌ· Ô˘ ·Ú¿ÁÔÓÙ·È ÙÔÈο. ™Â ÂÚÈÔ¯¤˜ Ì Ȉ‰ÔÂÓ›·, ÙÔ ÈÒ‰ÈÔ ÛÙÔ ÓÂÚfi Â›Ó·È <2 Ìg/Ï›ÙÚÔ. ™Â ÂÚÈÔ¯¤˜ fiÔ˘ Ë ËÌÂÚ‹ÛÈ· ηٷӿψÛË Û ÈÒ‰ÈÔ Â›Ó·È Â·Ú΋˜, Ë Î‡ÚÈ· ·ÈÙ›· ‚ÚÔÁ¯Ô΋Ï˘ Î·È ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ Â›Ó·È Ë
2001 MAPT- A¶PI§
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¶›Ó·Î·˜ 4. ¶ÚfiÛÏË„Ë πˆ‰›Ô˘ Î·È ·Ô‚ÔÏ‹ ÛÙ· Ô‡Ú· ÛÙËÓ ∂Ï‚ÂÙ›·, ηٿ ÙËÓ ÂÚ›Ô‰Ô 1923-1990 ÃÚÔÓÔÏÔÁ›· ¶ÚÔÛı‹ÎË πˆ‰›Ô˘ ÛÙÔ ·Ï¿ÙÈ (ppm/kg NaCl) πÒ‰ÈÔ ÛÙ· Ô‡Ú· (Ìg/gr ÎÚ·ÙÈÓ›Ó˘) 24ˆÚË ÚfiÛÏË„Ë π-131 ·fi ÙÔ £˘ÚÂÔÂȉ‹ %
1923
1960
1974-78
1981-88
0 18 ± 8
3,75
7,5 90 ± 45 27 ± 5
15 150 ± 77 22 ± 6
52 ± 13
¯ÚfiÓÈ· ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ı˘ÚÂÔÂȉ›Ùȉ· (25). ∏ ÂÚÈÂÎÙÈÎfiÙËÙ· ÙˆÓ Ê˘ÙÈÎÒÓ Î·È ˙ˆÈÎÒÓ ÙÚÔÊÒÓ Û ÈÒ‰ÈÔ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ÔÛfiÙËÙ· ÙÔ˘ Ȉ‰›Ô˘ ÛÙ· ‰¿ÊË Ô˘ ·Ú¿ÁÔÓÙ·È. ∆Ô ÈÒ‰ÈÔ ÙÔ˘ ‰¿ÊÔ˘˜ Î·È ÙÔ˘ ı·Ï·ÛÛÈÓÔ‡ ÓÂÚÔ‡ ˘fi ÙËÓ Â›‰Ú·ÛË ÙÔ˘ ËÏÈ·ÎÔ‡ ʈÙfi˜ ÔÍÂÈ‰Ô‡Ù·È Û Ȉ‰ÈÔ‡¯· Ô˘ ÂÍ·ÙÌ›˙ÔÓÙ·È ÛÙÔÓ ·¤Ú·. ∏ Û˘ÁΤÓÙÚˆÛË ÙÔ˘ Ȉ‰›Ô˘ ÛÙÔ ı·Ï·ÛÛÈÓfi ÓÂÚfi Â›Ó·È 50-60 Ìg/Ï›ÙÚÔ Î·È ÛÙÔÓ ·¤Ú· 0,7 Ìg/΢‚ÈÎfi ̤ÙÚÔ. ∞ÚÎÂÙ‹ ÔÛfiÙËÙ· ·fi ·˘Ùfi ÙÔ ÈÒ‰ÈÔ ·Ó‚·›ÓÂÈ ÛÙË ÛÙÚ·ÙfiÛÊ·ÈÚ· (26), ·ÏÏ¿ Ì›· ÔÛfiÙËÙ· ¤ÊÙÂÈ ÛÙË ÁË Ì ÙË ‚ÚÔ¯‹ Î·È ÂÌÏÔ˘Ù›˙ÂÈ Ù· ·ÓÒÙÂÚ· ÛÙÚÒÌ·Ù· ÙÔ˘ ‰¿ÊÔ˘˜. °È· Ó· ÂÌÏÔ˘ÙÈÛÙ› ÙÔ ¤‰·ÊÔ˜ Ì ÈÒ‰ÈÔ Ú¤ÂÈ Ó· ÂÚ¿ÛÔ˘Ó ¯ÈÏÈ¿‰Â˜ ¯ÚfiÓÈ·. °È’ ·˘ÙfiÓ ÙÔ ÏfiÁÔ, ÚfiÛÊ·Ù· ‰¿ÊË Ô˘ ÚÔ¤Ú¯ÔÓÙ·È ·Ô ηÙÔÏ›ÛıËÛË Â›Ó·È ÊÙˆ¯¿ Û ÈÒ‰ÈÔ, ÂÓÒ ·Ï·È¿ ‰¿ÊË ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ. ∏ ÌÂÁ¿ÏË ·fiÛÙ·ÛË Ù˘ ÂÚÈÔ¯‹˜ ·fi ÙË ı¿Ï·ÛÛ·, Ë ¿Û¯ËÌË ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈ΋ ηٿÛÙ·ÛË, ηıÒ˜ Î·È ÔÈ ·Ú·È¤˜ Û˘ÁÎÔÈӈӛ˜ Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ ÂÏ·Ùو̤ÓË ÚfiÛÏË„Ë Èˆ‰›Ô˘ Ì ÙȘ ÙÚÔʤ˜. √È ÏÔ‡ÛÈÔÈ ÏËı˘ÛÌÔ› ηٷӷÏÒÓÔ˘Ó ÈÔ Ôχ ˙ˆÈΤ˜ ÙÚÔʤ˜ Ô˘ ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ ÈÒ‰ÈÔ ·fi ÙȘ Ê˘ÙÈΤ˜ Î·È ·ÁÔÚ¿˙Ô˘Ó „¿ÚÈ· Î·È ¿ÏÏ· ÚÔ˚fiÓÙ· ÏÔ‡ÛÈ· Û ÈÒ‰ÈÔ, Ù· ÔÔ›· ÌÂٷʤÚÔÓÙ·È ·fi ¿ÏϘ ÂÚÈÔ¯¤˜ Î·È ‰ÂÓ ÂÍ·ÚÙÒÓÙ·È ÌfiÓÔ ·fi ÙËÓ ÙÔÈ΋ ·Ú·ÁˆÁ‹. ∂Ó‰ËÌÈ΋ ‚ÚÔÁ¯Ô΋ÏË ÛÙËÓ ∂ÏÏ¿‰· ™ÙËÓ ∂ÏÏ¿‰· ˘‹Ú¯·Ó ·Ï·ÈfiÙÂÚ· ÂÚÈÔ¯¤˜ Ì ÂÓ‰ËÌÈ΋ ‚ÚÔÁ¯Ô΋ÏË (27). √È ÂÚÈÔ¯¤˜ ·˘Ù¤˜ ‹Ù·Ó Ë ‰˘ÙÈ΋ ∂ÏÏ¿‰· ÛÙËÓ ÔÚÔÛÂÈÚ¿ Ù˘ ¶›Ó‰Ô˘, ÔÚÂÈÓ¤˜ ÂÚÈÔ¯¤˜ Ù˘ £ÂÛÛ·Ï›·˜, Ù˘ ∂˘Ú˘Ù·Ó›·˜, Ù˘ ºıÈÒÙȉ·˜ Î·È Ù˘ ∫Ú‹Ù˘. ∏ ‚ÚÔÁ¯Ô΋ÏË ·Ú·ÙËÚÂ›Ù·È ÛÙ· ·È‰È¿, ÛÙÔ˘˜ ¤ÊË‚Ô˘˜ Î·È ÙȘ Á˘Ó·›Î˜. ™ÙÔ˘˜ ¿Ó‰Ú˜ ÌÂÙ¿ ÙËÓ ‹‚Ë, Ë Û˘¯ÓfiÙ˘ ÌÂÈÒÓÂÙ·È. ∫‡ÚÈÔ ·›ÙÈÔ ÂÓ‰ËÌÈ΋˜ ‚ÚÔÁ¯Ô΋Ï˘ ÛÙËÓ ∂ÏÏ¿‰· ‹Ù·Ó ·Ï·ÈfiÙÂÚ· Ë ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘,
¶›Ó·Î·˜ 5. K·Ù¿Ù·ÍË ¤ÏÏÂȄ˘ πˆ‰›Ô˘, Ù˘ ÂÎÎÚÈÓfiÌÂÓ˘ ÔÛfiÙËÙ·˜ ·fi Ù· Ô‡Ú· µ·ıÌfi˜ πˆ‰ÔÂÓ›·˜ πÒ‰ÈÔ √‡ÚˆÓ 24ÒÚÔ˘ (Ìg/L) º˘ÛÈÔÏÔÁÈ΋ ¶ÚfiÛÏË„Ë πˆ‰›Ô˘ ≥100 Ìg/L ∂Ï·ÊÚ¿ ¤ÏÏÂÈ„Ë πˆ‰›Ô˘ 50-100 Ìg/L ª¤ÙÚÈ· ¤ÏÏÂÈ„Ë πˆ‰›Ô˘ 25-50 Ìg/L µ·ÚÈ¿ ¤ÏÏÂÈ„Ë πˆ‰›Ô˘ ≤25 Ìg/L
·Ó·ÏfiÁˆ˜
ÂÓÒ Û‹ÌÂÚ· Ì ÙËÓ ·‡ÍËÛË ÙÔ˘ ‚ÈÔÎÔÈÓˆÓÈÎÔ‡ ÂȤ‰Ô˘ Î·È ÙȘ ·˘ÍË̤Ó˜ Û˘ÁÎÔÈӈӛ˜, ·ÚÈÔ ·›ÙÈÔ Â›Ó·È Ë ¯ÚfiÓÈ· ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ı˘ÚÂÔÂȉ›Ùȉ·. ∏ ‚ÚÔÁ¯Ô΋ÏË ÛÙËÓ ∂ÏÏ¿‰· ›¯Â ·Ô‰Âȯı› Ì ÙË Ì¤ÙÚËÛË ÙÔ˘ Ȉ‰›Ô˘ ÛÙÔ ÓÂÚfi, ÛÙÔ ¤‰·ÊÔ˜, ÛÙ· ÙÚfiÊÈÌ· ÂÓ‰ËÌÈÎÒÓ ÂÚÈÔ¯ÒÓ, ηıÒ˜ Î·È ÛÙÔ Ï¿ÛÌ· Î·È Ù· Ô‡Ú· ‚ÚÔÁ¯ÔÎËÏÔ·ıÒÓ ·ÚÚÒÛÙˆÓ (¶›Ó·Î·˜ 5). ∏ Ȉ‰ÔÂÓ›· ‹Ù·Ó ̤ÙÚÈ· ÎÈ ¤ÙÛÈ Ë ÂÓ‰ËÌÈ΋ ‚ÚÔÁ¯Ô΋ÏË ÛÙËÓ ∂ÏÏ¿‰· ‰ÂÓ Û˘Óԉ¢fiÙ·Ó Ì ÎÚÂÙÈÓÈÛÌfi ‹ ˘Ôı˘ÚÂÔÂȉÈÛÌfi. ∂ÓÒ fiÏÔÈ ÔÈ Î¿ÙÔÈÎÔÈ ¤¯Ô˘Ó Ȉ‰ÔÂÓ›· ÂÚ›Ô˘ ÛÙÔÓ ›‰ÈÔ ‚·ıÌfi ÛÙȘ ÂÓ‰ËÌÈΤ˜ ÂÚÈÔ¯¤˜, ˆÛÙfiÛÔ ÌfiÓÔ ¤Ó· ÔÛÔÛÙfi ·’ ·˘ÙÔ‡˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ‚ÚÔÁ¯Ô΋ÏË, ‰ËÏ·‰‹ ÌfiÓÔ fiÛÔÈ ¤¯Ô˘Ó οÔÈ· ÚԉȿıÂÛË (ÁÂÓÂÙÈÎfi ¤ÏÏÂÈÌÌ·) (28). ∞ÓÙÈÌÂÙÒÈÛË Ù˘ ÂÓ‰ËÌÈ΋˜ ‚ÚÔÁ¯Ô΋Ï˘ ∏ ÂÓ‰ËÌÈ΋ ‚ÚÔÁ¯Ô΋ÏË ÌÔÚ› Ó· ÂÍ·ÏÂÈÊı› ·fi ÙÔÓ Ï·Ó‹ÙË, ÁÈ·Ù› ÔÈ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÙÒÛÂȘ ÔÊ›ÏÔÓÙ·È ÛÙËÓ ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘. πÒ‰ÈÔ ÌÔÚ› Ó· ¯ÔÚËÁËı› Ì ÔÏÏÔ‡˜ ÙÚfiÔ˘˜. √ ηχÙÂÚÔ˜ Â›Ó·È Ë Èˆ‰›ˆÛË ÙÔ˘ ·Ï·ÙÈÔ‡, ÌÔÚ› fï˜ Ó· Á›ÓÂÈ Èˆ‰›ˆÛË ÙÔ˘ ÓÂÚÔ‡ ‹ ÙÔ˘ „ˆÌÈÔ‡. ∂ÓÒ ·fi ÙÔ 1924 ¿Ú¯ÈÛ·Ó Û ÔÏϤ˜ ¯ÒÚ˜ Ó· ÂÊ·ÚÌfi˙ÔÓÙ·È ÚÔÁÚ¿ÌÌ·Ù· ÂÌÏÔ˘ÙÈÛÌÔ‡ ÙˆÓ ÙÚÔÊÒÓ Ì ÈÒ‰ÈÔ, ÙÔ 1999 ÔÏÏÔ› ÏËı˘ÛÌÔ› ÓÔÛÔ‡Ó ‚·ÚÈ¿ ÏfiÁˆ ¤ÏÏÂȄ˘ Ȉ‰›Ô˘ (29). ∆Ô 1993, ÌÂÙ¿ ·fi ÎÔÈÓ‹ Û˘Ìʈӛ· ÙˆÓ ÔÚÁ·ÓÈÛÌÒÓ WHO, UNICEF Î·È ICCIDD, ÂÛÙ¿ÏË Û‡ÛÙ·ÛË Û fiÏ· Ù· ˘Ô˘ÚÁ›· ÀÁ›·˜ Ù˘ ∂˘ÚÒ˘, fiÔ˘ ·Ó·Ê¤ÚÂÙ·È Ë ‚·Ú‡ÙËÙ· ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ ·ÏÏ¿ Î·È Ë ·ÚfiÙÚ˘ÓÛË ÁÈ· ÂÓÂÚÁfi ‰Ú¿ÛË, ÒÛÙ ӷ ÂÍ·Ê·ÓÈÛıÔ‡Ó ÓÔÛ‹Ì·Ù· ÏfiÁˆ ¤ÏÏÂȄ˘ Ȉ‰›Ô˘ ·fi ÙËÓ ∂˘Úˆ·È΋ ∫ÔÈÓfiÙËÙ·. ∞˘Ùfi ÛËÌ·›ÓÂÈ ¯Ú‹ÛË Èˆ‰ÈˆÌ¤ÓÔ˘ ·Ï·ÙÈÔ‡ ÛÙȘ ÌÔÓ¿‰Â˜ ˙ˆÔÙÚÔÊ‹˜, ÛÙËÓ ·Ú·Û΢‹ Û˘ÓÙËÚËÌ¤ÓˆÓ ÙÚÔʛ̈Ó, ηıÒ˜ Î·È ÛÙÔ Ì·Á›ÚÂÌ· Ê·ÁËÙÒÓ ÁÈ· ¢Ú›· ηٷӿψÛË (catering) Î·È fi¯È ÌfiÓÔ Èˆ‰›ˆÛË ÙÔ˘ ÂÈÙÚ·¤˙ÈÔ˘ ·Ï·ÙÈÔ‡. ∏ ËÌÂÚ‹ÛÈ· ηٷӿψÛË ·Ï·ÙÈÔ‡, Û‹ÌÂÚ·, Â›Ó·È 8-12 ÁÚ·ÌÌ¿ÚÈ·. ™Ù· ‚ÈÔÌ˯·ÓÈο ÎÚ¿ÙË ·fi Ù· 10 ÁÚ·ÌÌ¿ÚÈ· ËÌÂÚ‹ÛÈ·˜ ηٷӿψÛ˘, ÌfiÓÔ Ù· 2 ÁÚ·ÌÌ¿ÚÈ· ÚÔ¤Ú¯ÔÓÙ·È ·fi ÙËÓ ÚÔÛı‹ÎË ÛÙÔ Ê·ÁËÙfi (ÂÈÙÚ·¤˙ÈÔ), ÂÓÒ ·fi ÙȘ ¤ÙÔÈ̘ ÙÚÔʤ˜ (Û¿ÏÙÛ˜, Ù˘ÚÈ¿, ·ÚÙÔÛ΢¿ÛÌ·Ù·) ÚÔÛÏ·Ì‚¿ÓÔÓÙ·È 8 ÁÚ·ÌÌ¿ÚÈ· ËÌÂÚËÛ›ˆ˜ (∂ÈÎfiÓ· 4) (30). πÒ‰ÈÔ ÌÔÚ› Ó· Ï·Ì‚¿ÓÂÙ·È ·fi ÙÔ Á¿Ï·, fiÙ·Ó ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÙÔ Èˆ‰ÔÊfiÚÌÈÔ
107
2001 MAPT- A¶PI§
17-10-01 15:34
™ÂÏ›‰· 108
¶·È‰È·ÙÚÈ΋ 2001;64:101-114
Paediatriki 2001;64:101-114
∞Ï¿ÙÈ ÁÈ· Ù¯ÓÈ΋ ¯Ú‹ÛË (fi¯È ¯Ú‹ÛË ÙÚÔÊ‹˜) ∞Ï¿ÙÈ ÁÈ· ηٷӿψÛË ·fi ˙Ò· √ÏÈÎfi ·Ï¿ÙÈ Ô˘ ·Ú¿ÁÂÙ·È ÁÈ· ηٷӿψÛË ·fi ÙÔÓ ¿ÓıÚˆÔ ∆ÚÔʤ˜
∫Ú˘Ì̤ÓÔ ·Ï¿ÙÈ
µÈÔÌ˯·Ó›· ∞Ï¿ÙÈ ÁÈ· ÔÈÎȷ΋ ¯Ú‹ÛË √ÈÎȷ΋ ¯Ú‹ÛË
∞ÒÏÂÈ· ¿Ï·ÙÔ˜ ηٿ ÙËÓ ·Ú·Û΢‹ ÙÔ˘ Ê·ÁËÙÔ‡
∞Ï¿ÙÈ Ô‡ÚˆÓ
∂ÈÎfiÓ· 4. ∏ ÚÔÛı‹ÎË Èˆ‰›Ô˘ ÛÙÔ ¿Ï·˜ Ù˘ ÙÚÔÊ‹˜. ∞: ∆Ô ÔÏÈÎfi ·Ï¿ÙÈ Ô˘ ηٷӷÏÒÓÂÙ·È ÌÔÚ› Ó· ˘ÔÏÔÁÈÛı› ·fi ÙÔ ÚÔÛÏ·Ì‚·ÓfiÌÂÓÔ ·Ï¿ÙÈ Ì ÙËÓ ÙÚÔÊ‹ ‹ ÙÔ ·Ô‚·ÏÏfiÌÂÓÔ ‰È· ÙˆÓ Ô‡ÚˆÓ. µ: ∞Ô‚ÔÏ‹ ¿Ï·ÙÔ˜ ‰È· ÙˆÓ Ô‡ÚˆÓ (ۯ‰fiÓ ›ÛË Ì ÙËÓ ÚfiÛÏË„Ë ∞). C: ∆Ô ÂÈÙÚ·¤˙ÈÔ ·Ï¿ÙÈ ÚÔÛÙ›ıÂÙ·È Î·Ù¿ ÙÔ Ì·Á›ÚÂÌ· ‹ ÛÙË ÌÂÚ›‰· ÙÔ˘ È¿ÙÔ˘. D: ∫Ú˘Ì̤ÓÔ ·Ï¿ÙÈ ˘¿Ú¯ÂÈ ÛÙ· ÂÌÔÚÈο ·Ú·ÁfiÌÂÓ· ÙÚfiÊÈÌ·. E: ∆Ô ·Ï¿ÙÈ ¯¿ÓÂÙ·È Î·Ù¿ ÙËÓ ·Ú·Û΢‹ Ù˘ ÙÚÔÊ‹˜. F: √ÏÈÎfi ·Ï¿ÙÈ Ô˘ ·Ú¿ÁÂÙ·È ÁÈ· ηٷӿψÛË ·fi ÙÔÓ ¿ÓıÚˆÔ.
ˆ˜ ·ÔÏ˘Ì·ÓÙÈÎfi ÛÙÔ ¿ÚÌÂÁÌ·, ‹ ·fi ÙÔ „ˆÌ›, fiÙ·Ó ÚÔÛÙ›ıÂÙ·È ˆ˜ Û˘ÓÙËÚËÙÈÎfi ·ÓÙ› ÙÔ˘ ‚ÚˆÌ›Ô˘ (ÂÊ·ÚÌfi˙ÂÙ·È ÛÙËÓ ∞˘ÛÙÚ·Ï›·). ™Â ¯ÒÚ˜ fiÔ˘ ÔÏÈÙÈÎÔ›, ÔÏÈÙÈÛÌÈÎÔ› Î·È ÁˆÁÚ·ÊÈÎÔ› ·Ú¿ÁÔÓÙ˜ οÓÔ˘Ó ‰‡ÛÎÔÏÔ ÙÔ ÚfiÁÚ·ÌÌ· ÂÌÏÔ˘ÙÈÛÌÔ‡ ÙˆÓ ÙÚÔÊÒÓ Ì ÈÒ‰ÈÔ, ÚÔʇϷÍË Î·È ıÂڷ›· Ù˘ ¤ÏÏÂȄ˘ Ȉ‰›Ô˘ ÂÈÙ˘Á¯¿ÓÂÙ·È Ì ÂÓ‰ÔÌ˘˚Τ˜ ÂÓ¤ÛÂȘ Ȉ‰›Ô˘, ˘fi ÌÔÚÊ‹Ó ‚Ú·‰¤ˆ˜ ·ÔÚÚÔÊÔ‡ÌÂÓÔ˘ Ï·‰ÈÔ‡. ™Â ¿ÙÔÌ· ¿Óˆ ÙˆÓ 45 ÂÙÒÓ ‰ÂÓ ¯ÔÚËÁÂ›Ù·È ÈÒ‰ÈÔ ÁÈ·Ù› ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÔ˘Ó ı˘ÚÂÔÙÔ͛ΈÛË ÏfiÁˆ ˘„ËÏ‹˜ Û˘¯ÓfiÙËÙ·˜ ÔÏ˘Ô˙Ò‰Ô˘˜ ‚ÚÔÁ¯Ô΋Ï˘ (31). πˆ‰ÈÔ̤ÓÔ Ï¿‰È ¯ÔÚËÁÂ›Ù·È Û‹ÌÂÚ· Û ÂÚÈÔ¯¤˜ Ù˘ ∫›Ó·˜, ÛÙȘ Á˘Ó·›Î˜ ÙËÓ Ë̤ڷ ÙÔ˘ Á¿ÌÔ˘ ÙÔ˘˜. ∞˘Ù¤˜ Û‡ÓÙÔÌ· ı· Ì›ÓÔ˘Ó ¤ÁÎ˘Â˜ Î·È ÙÔ ÈÒ‰ÈÔ ÙȘ ‚ÔËı¿ Ó· ¤¯Ô˘Ó ÙÂÏÂÈfiÌËÓË Î‡ËÛË Î·È ÁÂÚfi ·È‰›, ¯ˆÚ›˜ ÓÔÛ‹Ì·Ù· ÏfiÁˆ ¤ÏÏÂȄ˘ Ȉ‰›Ô˘. πˆ‰ÈÔ̤ÓÔ Ï¿‰È ÂÚȤ¯Ô˘Ó Î·È Ù· Ú·‰ÈÔÁÚ·ÊÈο ÛÎÈ·ÁÚ·ÊÈο Ô˘ ·ÔÙÂÏÔ‡ÓÙ·È ·fi ·Èı˘ÏÈÎÔ‡˜ ÂÛÙ¤Ú˜ Ù˘ ÌÔÓÔ- ‰È- Î·È ÙÚÈ- Ȉ‰ÔÙ˘ÚÔÛ›Ó˘ Ì ÏÈÓÔÏÂ˚Îfi, ÂÏ·˚Îfi, ·ÏÌÈÙÈÎfi Î·È ÛÙ·ÙÈÎfi Ô͇. ªÂ ÙÔÓ ÂÌÏÔ˘ÙÈÛÌfi ÙˆÓ ÙÚÔÊ›ÌˆÓ Û ÈÒ‰ÈÔ, ‰ÈÔÚıÒÓÂÙ·È Ë ı˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ÚÔԉ¢ÙÈο ÂÍ·Ê·Ó›˙ÂÙ·È Ë ‚ÚÔÁ¯Ô΋ÏË Î·È ‰ÂÓ ÂÌÊ·Ó›˙ÂÙ·È ÂÓ‰ËÌÈÎfi˜ ÎÚÂÙÈÓÈÛÌfi˜ Î·È ¤ÎÙˆÛË Ù˘ ÓÂ˘Ì·ÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∞˘Í¿ÓÂÈ ÌÂÙ¤ÂÈÙ·, fï˜, Ë Û˘¯ÓfiÙËÙ· ÙÔÍÈ΋˜ ÔÏ˘Ô˙Ò‰Ô˘˜ ‚ÚÔÁ¯Ô΋Ï˘ (32).
108
™ÙË ¯ÒÚ· Ì·˜ ΢ÎÏÔÊÔÚ› ÂÈÙÚ·¤˙ÈÔ ·Ï¿ÙÈ Ì ‰‡Ô ÌÔÚʤ˜, ·Ïfi Î·È Èˆ‰ÈˆÌ¤ÓÔ Î·È ÂÈϤÁÂÈ Ô Î·Ù·Ó·ÏˆÙ‹˜ ÂΛÓÔ Ô˘ ı· ¯ÚËÛÈÌÔÔÈ‹ÛÂÈ. ªÂ ÙËÓ Èˆ‰›ˆÛË ÙÔ˘ ·Ï·ÙÈÔ‡ ÚÔÛÙ›ıÂÙ·È ¤Ó· ̤ÚÔ˜ Ȉ‰ÈÔ‡¯Ô˘ Î·Ï›Ô˘ (∫π), ‹ ηχÙÂÚ· Ȉ‰ÈÎÔ‡ Î·Ï›Ô˘ (∫π√3), ÁÈ·Ù› ‰ÂÓ ÂÍ·ÙÌ›˙ÂÙ·È, ·Ó¿ 25-50 ¯ÈÏÈ¿‰Â˜ ̤ÚË (ppm) ¯ÏˆÚÈÔ‡¯Ô˘ Ó·ÙÚ›Ô˘ (33,34). ∂ÙÛÈ, Ì ËÌÂÚ‹ÛÈ· ÚfiÛÏË„Ë ·Ï·ÙÈÔ‡ 2,5-5 gr ÚÔÛÏ·Ì‚¿ÓÔÓÙ·È 100-200 Ìg Ȉ‰›Ô˘. ∏ ËÌÂÚ‹ÛÈ· ηٷӿψÛË Èˆ‰›Ô˘ ÛÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ Â›Ó·È 150-500 Ìg (0,15-0,5 mg). ™˘ÌÙÒÌ·Ù· ÏfiÁˆ ¤ÏÏÂȄ˘ ‹ ηٿ¯ÚËÛ˘ Ȉ‰›Ô˘ ŸÙ·Ó Ë ËÌÂÚ‹ÛÈ· ηٷӿψÛË Èˆ‰›Ô˘ Â›Ó·È 2550 Ìg, ·Ú·ÙËÚÂ›Ù·È Èˆ‰ÔÂÓÈ΋ ‚ÚÔÁ¯Ô΋ÏË. ŸÙ·Ó, fï˜, Ë ËÌÂÚ‹ÛÈ· ηٷӿψÛË Èˆ‰›Ô˘ Â›Ó·È ÏÈÁfiÙÂÚË ·fi 25 Ìg, ¤¯Ô˘Ì ÂÓ‰ËÌÈÎfi ÎÚÂÙÈÓÈÛÌfi. À¿Ú¯Ô˘Ó ‰‡Ô Ù‡ÔÈ ÂÓ‰ËÌÈÎÔ‡ ÎÚÂÙÈÓÈÛÌÔ‡: ·) Ô Ì˘ÍÔȉËÌ·ÙÈÎfi˜ (¯ˆÚ›˜ ‚ÚÔÁ¯Ô΋ÏË, ÁÈ·Ù› Ô ı˘ÚÂÔÂȉ‹˜ ¤¯ÂÈ Î·Ù·ÛÙÚ·Ê›), Ô˘ ÔÊ›ÏÂÙ·È Û ˘Ôı˘ÚÂÔÂȉÈÛÌfi ·Ô ‚·ÚÈ¿ Ȉ‰ÔÂÓ›·, ηıÒ˜ Î·È ¤ÏÏÂÈ„Ë ÛÂÏËÓ›Ô˘, ‚) Ô Ó¢ÚÔÏÔÁÈÎfi˜ (Ì ‚ÚÔÁ¯Ô΋ÏË ÏfiÁˆ ‰È¤ÁÂÚÛ˘ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ·fi ÙËÓ ·˘ÍË̤ÓË TSH), Ô˘ ÔÊ›ÏÂÙ·È Û ‚·ÚÈ¿ Ȉ‰ÔÂÓ›· ·fi ÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ Ù˘ ÂÓ‰ÔÌ‹ÙÚÈ·˜ ˙ˆ‹˜. ™ÙÔÓ ˘Ôı˘ÚÂÔÂȉÈÛÌfi ÏfiÁˆ Ȉ‰ÔÂÓ›·˜, Ë ·˘ÍË̤ÓË ‰È¤ÁÂÚÛË ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ·fi ÙËÓ TSH ÚÔηÏ› ·‡ÍËÛË ÙˆÓ ÂχıÂÚˆÓ ÚÈ˙ÒÓ Î·È ÙÔ˘ ˘ÂÚÔÍÂȉ›Ô˘ ÙÔ˘ ˘‰ÚÔÁfiÓÔ˘ (∏2√2) ÛÙ· ı˘ÚÂÔÂȉÈο ·ÙÙ·Ú·. §fiÁˆ ¤ÏÏÂȄ˘ ÛÂÏËÓ›Ô˘, ÙÔ ¤Ó˙˘ÌÔ ˘ÂÚÔÍÂȉ¿ÛË Ù˘ ÁÏÔ˘Ù·ıÂÈfiÓ˘ Â›Ó·È ·ÓÂÓÂÚÁfi Î·È ÔÈ ÂχıÂÚ˜ Ú›˙˜ Ô͢ÁfiÓÔ˘ ‰ÂÓ ÌÂÙ·‚ÔÏ›˙ÔÓÙ·È, ·ÏÏ¿ Û˘ÛÛˆÚ‡ÔÓÙ·È Î·È Î·Ù·ÛÙÚ¤ÊÔ˘Ó ÙÔ ı˘ÚÂÔÂȉÈÎfi ·ÙÙ·ÚÔ. ∏ Ì·ÎÚÔ¯ÚfiÓÈ· ηٿ¯ÚËÛË Èˆ‰›Ô˘ ÚÔηÏ› ·ÚÂÓ¤ÚÁÂȘ (.¯. ‰ÂηϿÛÈ· ÔÛfiÙËÙ· ·fi ÙȘ ËÌÂÚ‹ÛȘ ·Ó¿ÁΘ, 2 mg ËÌÂÚËÛ›ˆ˜). ∂˘ı˘ÚÂÔÂȉÈο ¿ÙÔÌ· Ì ¯ÚfiÓÈ· ÏÂÌÊÔ΢ÙÙ·ÚÈ΋ ı˘ÚÂÔÂȉ›Ùȉ· (ı˘ÚÂÔÂȉ›ÙȘ Hashimoto), ‹ Ì ÓfiÛÔ Graves Ô˘ ‚Ú›ÛÎÂÙ·È Û ‡ÊÂÛË, ‹ Á˘Ó·›Î˜ Ô˘ ·ÚÔ˘Û›·Û·Ó ı˘ÚÂÔÂȉ›Ùȉ· ÌÂÙ¿ ·fi ÙÔÎÂÙfi, ‹ ¤¯Ô˘Ó ÛÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘˜ ˘ÔÍ›· ı˘ÚÂÔÂȉ›Ùȉ·, ı· ·Ó·Ù‡ÍÔ˘Ó ˘Ôı˘ÚÂÔÂȉÈÛÌfi ÏfiÁˆ ηٿ¯ÚËÛ˘ Ȉ‰›Ô˘. ∞ÏÏ¿ Î·È ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi˜ ÏfiÁˆ ηٿ¯ÚËÛ˘ Ȉ‰›Ô˘ ÂÌÊ·Ó›˙ÂÙ·È, Û˘¯ÓfiÙÂÚ· Û ËÏÈÎȈ̤ӷ Ê˘ÛÈÔÏÔÁÈο ¿ÙÔÌ·, ·ÏÏ¿ Î·È Û ¿ÙÔÌ· Ì Ô˙Ò‰Ë ‚ÚÔÁ¯Ô΋ÏË, ȉ›ˆ˜ Û ÂÚÈÔ¯¤˜ Ì ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘. ∆· ¿ÙÔÌ·, fï˜, Ô˘ ‰ÂÓ ¤¯Ô˘Ó ÁÂÓÂÙÈο ‹ ÂÚÈ‚·ÏÏÔÓÙÈο ÚÔ‚Ï‹Ì·Ù· Ô˘ Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ ı˘ÚÂÔÂȉ‹, ı· ·Ú·Ì›ÓÔ˘Ó Â˘ı˘ÚÂÔÂȉÈο ·ÎfiÌË Î·È fiÙ·Ó ÂÎÙÂıÔ‡Ó Û ÌÂÁ¿ÏË ÔÛfiÙËÙ· Ȉ‰›Ô˘, Èı·ÓfiÓ ÏfiÁˆ ·˘ÙÔÚÚ‡ıÌÈÛ˘ Î·È ÂÏ¿ÙÙˆÛ˘ Ù˘ ÌÂÙ·ÊÔÚ¿˜ Ȉ‰›Ô˘ ÛÙÔ ı˘ÚÂÔÂȉ‹ (35). ∞˘ÍË̤ÓË ÚfiÛÏË„Ë Èˆ‰›Ô˘ ·fi ÙÔ ı˘ÚÂÔÂȉ‹ Ô‰ËÁ› Û ·Ó·-
2001 MAPT- A¶PI§
17-10-01 15:34
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¶·È‰È·ÙÚÈ΋ 2001;64:101-114
ÛÙÔÏ‹ Ù˘ Û‡ÓıÂÛ˘ ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ (Ê·ÈÓfiÌÂÓÔ Wolf-Chaikoff) Î·È ÙÂÏÈο Û ‚ÚÔÁ¯Ô΋ÏË Î·È Ì˘ÍÔ›‰ËÌ· (36,37). ™ËÌ·Û›· ÙÔ˘ Ȉ‰›Ô˘ Î·È Ù˘ ı˘ÚÔ͛Ӣ ηٿ ÙËÓ Î‡ËÛË ¶ÚÈÓ ·Ú¯›ÛÂÈ Ó· ÏÂÈÙÔ˘ÚÁ› Ô ı˘ÚÂÔÂȉ‹˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘, ÙÔÓ ÙÚ›ÙÔ ÂÚ›Ô˘ Ì‹Ó· Ù˘ ÂÌ‚Ú˘˚΋˜ ˙ˆ‹˜, Â›Ó·È ··Ú·›ÙËÙË Ë ·ÚÔ˘Û›· ¤ÛÙˆ Î·È ÌÈÎÚÒÓ ÔÛÔÙ‹ÙˆÓ Èˆ‰›Ô˘ Î·È ı˘ÚÔ͛Ӣ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË ÙˆÓ ‰È·ÎÏ·‰ÒÛÂˆÓ ÙˆÓ Ó¢ÚÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Î·È ÙË ÛˆÛÙ‹ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ Ó¢ÚÈÎÔ‡ ÈÛÙÔ‡ ÙÔ˘ ÂÌ‚Ú‡Ô˘ (38,39). ŸÙ·Ó ˘¿Ú¯ÂÈ ¤ÏÏÂÈ„Ë ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ ÛÙ· ·Ú¯Èο ÛÙ¿‰È· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, ·Ú·ÙËÚÔ‡ÓÙ·È ‚·ÚȤ˜ Ó¢ÚÔÏÔÁÈΤ˜ ÚÔÛ‚ÔϤ˜ (ÎÒʈÛË, Û·ÛÙÈ΋ ·Ú·ÏËÁ›·) (40). ∏ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ ·Ú¯›˙ÂÈ ·fi ÙȘ ÚÒÙ˜ ‚‰ÔÌ¿‰Â˜ Ù˘ ÂÌ‚Ú˘ÔÓÈ΋˜ ˙ˆ‹˜ Î·È Û¯Â‰fiÓ ÙÂÏÂÈÒÓÂÈ 3 ¯ÚfiÓÈ· ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Ì ·ÏÏËÏԉȷ‰Ô¯Èο ÛÙ¿‰È· ˆÚ›Ì·ÓÛ˘ Î·È ÔÚÁ·ÓÔÁ¤ÓÂÛ˘, ·‡ÍËÛË Ó¢ÚÔÏÔÁÈÎÒÓ Î˘Ù¿ÚˆÓ, ÌÂٷΛÓËÛË Î˘ÙÙ¿ÚˆÓ, ‰ËÌÈÔ˘ÚÁ›· Û˘Ó¿„ÂˆÓ Î·È Ì˘ÂϛӈÛ˘. √ Ï·ÎÔ‡ÓÙ·˜ Ú˘ıÌ›˙ÂÈ ÙÔ ÌÂÙ·‚ÔÏÈÛÌfi Ȉ‰›Ô˘ Î·È ı˘ÚÔ͛Ӣ ηı’ fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘, ̤ۈ ‰Ú¿Û˘ ÙˆÓ ·Ô˚ˆ‰ÈÓ·ÛÒÓ ππ Î·È πππ (41). ∏ ¤ÁÎ˘Ô˜ ¤¯ÂÈ ÌÂÁ·Ï‡ÙÂÚ˜ ·Ó¿ÁΘ Û ı˘ÚÂÔÂȉÈΤ˜ ÔÚÌfiÓ˜, ÏfiÁˆ ·˘ÍË̤Ó˘ ÓÂÊÚÈ΋˜ οı·ÚÛ˘ Î·È Ï‹„˘ Ûȉ‹ÚÔ˘ ˆ˜ Û˘Ìϋڈ̷ ÛÙËÓ ÙÚÔÊ‹ (42,43), ·ÏÏ¿ Î·È ÏfiÁˆ Èı·Ó‹˜ ‚ÚÒÛˆ˜ ÌÔÏ˘ÛÌ¤ÓˆÓ ÙÚÔÊÒÓ Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó ÛÙÔ ÂÌfiÚÈÔ ‹ Ï‹„ˆ˜ ·ÓÙÈÂÈÏËÙÈÎÒÓ Ê·ÚÌ¿ÎˆÓ (44,45). ∏ ∆4 ·˘Í¿ÓÂÈ Ê˘ÛÈÔÏÔÁÈο ÛÙËÓ ÂÁ΢ÌÔÛ‡ÓË Î·È Â›Ó·È ÂÚ›Ô˘ 14 Ìg/dl ÙÔ ÙÚ›ÙÔ ÙÚ›ÌËÓÔ (ÏfiÁˆ ·‡ÍËÛ˘ Ù˘ TBG), ·ÏÏ¿ ·˘Ùfi ‰ÂÓ Û˘Ì‚·›ÓÂÈ fiÙ·Ó Ë ÚfiÛÏË„Ë Èˆ‰›Ô˘ Â›Ó·È Ôχ ¯·ÌËÏ‹. ™Â ÂÚÈÔ¯¤˜ fiÔ˘ Ô Ó¢ÚÔÏÔÁÈÎfi˜ ÎÚÂÙÈÓÈÛÌfi˜ ˘ÂÚÈÛ¯‡ÂÈ, 50% ÙˆÓ ÂÁ·ˆÓ Á˘Ó·ÈÎÒÓ ¤¯Ô˘Ó ÙÈ̤˜ ∆4 ÌÈÎÚfiÙÂÚ˜ ÙÔ˘ 6 Ìg/dl. ∫ÏÈÓÈο Û˘ÌÙÒÌ·Ù· Î·È ÛËÌ›· ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ ‰ÂÓ Â›Ó·È ÂÌÊ·Ó‹ Û ·˘Ù¤˜ ÙȘ Á˘Ó·›Î˜. ∏ ‰Ú·ÛÙÈ΋ ÔÚÌfiÓË ∆3 Â›Ó·È Û˘¯Ó¿ Ê˘ÛÈÔÏÔÁÈ΋, ·Ó Î·È Â›Ó·È ·˘ÍË̤ÓË Ë ÙÈÌ‹ Ù˘ TSH. ŸÙ·Ó Ë ¤ÁÎ˘Ô˜ ¤¯ÂÈ ¯·ÌËÏ‹ ÂÎÙfi˜ ·fi ÙËÓ ∆4 Î·È ÙËÓ ∆3, ¤¯ÂÈ ‚·Ú‡ ˘Ôı˘ÚÂÔÂȉÈÛÌfi Î·È Â›Ó·È Èı·Ófi Ó· ·Ô‚¿ÏÏÂÈ ÙÔ ¤Ì‚Ú˘Ô. ª¤ÙÚËÛË Ù˘ TSH Î·È ÙˆÓ ·ÓÙÈı˘ÚÂÔÂȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ú¤ÂÈ Ó· Á›ÓÂÙ·È Û fiϘ ÙȘ Á˘Ó·›Î˜ Ô˘ ÂÈı˘ÌÔ‡Ó Ó· Û˘ÏÏ¿‚Ô˘Ó ·È‰› (46) Î·È ¤¯Ô˘Ó ÈÛÙÔÚÈÎfi Ì ·˘ÙfiÌ·Ù˜ ·Ô‚ÔϤ˜, ·ÏÏ¿ Î·È ÛÙȘ ¤ÁÎ˘Â˜, ÁÈ·Ù› Ô ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ Â›Ó·È Û˘¯Ófi˜, ÂÓÒ Ù· ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· ‰ÂÓ Â›Ó·È ¿ÓÙÔÙ ÂÌÊ·Ó‹ Î·È ÔÈ ÂÈÙÒÛÂȘ ÛÙÔ ¤Ì‚Ú˘Ô ÌÂÁ¿Ï˜ Î·È ÌË ·Ó·Ù¿ÍÈ̘ (47). ™ÙȘ ¤ÁÎ˘Â˜ Ì ÁÓˆÛÙfi ˘Ôı˘ÚÂÔÂȉÈÛÌfi Ú¤ÂÈ Ó· ·˘Í¿ÓÂÙ·È Ë ‰fiÛË Ù˘
Paediatriki 2001;64:101-114
ı˘ÚÔ͛Ӣ (48). ¶·È‰È¿ ·fi ÌËÙ¤Ú˜ Ì ˘Ôı˘ÚÂÔÂȉÈÛÌfi ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË, ¤¯Ô˘Ó ÌÈÎÚfiÙÂÚË ÓÂ˘Ì·ÙÈ΋ ÈηÓfiÙËÙ· (49). ∞ÏÏ¿ Î·È ·È‰È¿ Ô˘ ÔÈ ÌËÙ¤Ú˜ ›¯·Ó ˘„ËÏfi Ù›ÙÏÔ ·ÓÙÈÌÈÎÚÔÛˆÌÈ·ÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÙÔ ÙÂÏÂ˘Ù·›Ô ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘, ·ÏÏ¿ Ê˘ÛÈÔÏÔÁÈ΋ ı˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›·, ‚Ú¤ıËΠӷ ¤¯Ô˘Ó ‰Â›ÎÙË ÓÔËÌÔÛ‡Ó˘ ¯·ÌËÏfiÙÂÚÔ Î·Ù¿ 10 ‚·ıÌÔ‡˜ ·fi ·È‰È¿ ÌËÙ¤ÚˆÓ Ô˘ ‰ÂÓ Â›¯·Ó ·ÓÙÈÛÒÌ·Ù· (50). ∞ÎfiÌË Î·È fiÙ·Ó Ë Èˆ‰ÔÂÓ›· Â›Ó·È Ì¤ÙÚÈ·, ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÓÔËÙÈ΋ ηı˘ÛÙ¤ÚËÛË. ∞˘Ùfi ·Ô‰ÂÈÎÓ‡ÂÙ·È, Û˘ÁÎÚ›ÓÔÓÙ·˜ ÙÔ Ì¤ÛÔ fiÚÔ ÓÔËÌÔÛ‡Ó˘ ÏËı˘ÛÌÔ‡ ·fi Ȉ‰ÔÂÓÈΤ˜ ÂÚÈÔ¯¤˜ Ì ÙÔ Ì¤ÛÔ fiÚÔ ÓÔËÌÔÛ‡Ó˘ ÏËı˘ÛÌÒÓ ·fi ÌË Èˆ‰ÔÂÓÈΤ˜ ÂÚÈÔ¯¤˜ (51). °È’ ·˘Ùfi Ë Î·Ù·ÔϤÌËÛË ·ÎfiÌË Î·È Ì¤ÙÚÈ·˜ Ȉ‰ÔÂÓ›·˜ ·ÔÙÂÏ› ÂıÓÈÎfi ηı‹ÎÔÓ. §ÂÈÙÔ˘ÚÁ›Â˜ ÙÔ˘ Ȉ‰›Ô˘ Î·È ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ ÛÙÔ ¤Ì‚Ú˘Ô ¶ÂÈÚ¿Ì·Ù· Û ÔÓÙ›ÎÈ· ‰Â›¯ÓÔ˘Ó fiÙÈ ÔÈ ˘Ô‰Ô¯Â›˜ ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ ÂÎÊÚ¿˙ÔÓÙ·È ÛÙ· ·Ó·Ù˘ÛÛfiÌÂÓ· ¤Ì‚Ú˘· ÚÈÓ ÙËÓ ¤Ó·ÚÍË ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜. ∏ ∆3 Â›Ó·È ··Ú·›ÙËÙË ÁÈ· ÙË Ê˘ÛÈÔÏÔÁÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ ÂÁÎÂÊ¿ÏÔ˘ Î·È ·Ú¿ÁÂÙ·È Ì¤Ûˆ ÙÔ˘ ÂÓ˙‡ÌÔ˘ 5’ ·Ô˚ˆ‰ÈÓ¿Û˘ ππ, Ô˘ ˘¿Ú¯ÂÈ ÛÙÔ ÂÁÎÂÊ·ÏÈÎfi ·ÙÙ·ÚÔ Î·È ÌÂÙ·‚ÔÏ›˙ÂÈ ÙÔÈο ÙËÓ ∆4. ∏ ÂÌ‚Ú˘˚΋ ∆3 Â›Ó·È ¯·ÌËÏ‹ ÛÙÔ ·›Ì· ̤¯ÚÈ ÙÔ Ù¤ÏÔ˜ Ù˘ ·ËÛ˘, ÂÏ·ÊÚÒ˜ ·˘Í¿ÓÂÈ ÙÔ ÙÂÏÂ˘Ù·›Ô Ì‹Ó· Ù˘ ·ËÛ˘ Î·È Êı¿ÓÂÈ ÙȘ ÙÈ̤˜ ÂÓËÏ›ÎˆÓ ÌÂÙ¿ ÙË Á¤ÓÓËÛË. √È FT4, TBG Î·È TSH ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÚÔԉ¢ÙÈο ·‡ÍËÛË ·fi ÌfiÏȘ ·ÓȯÓ‡ÛÈ̘ ÙÈ̤˜, ÙË 12Ë Â‚‰ÔÌ¿‰· ·ËÛ˘, Û ÙÈ̤˜ ÂÓËÏ›ÎˆÓ ÙËÓ 36Ë Â‚‰ÔÌ¿‰·. √ ı˘ÚÂÔÂȉ‹˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ·Ú¯›˙ÂÈ Ó· ÏÂÈÙÔ˘ÚÁ› ÙÔ ‰Â‡ÙÂÚÔ ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘. ∆fiÙ ˘¿Ú¯ÂÈ Ù·¯Â›· ·‡ÍËÛË ¯Ú‹Û˘ Ù˘ ∆4 Û ‰È¿ÊÔÚÔ˘˜ ÈÛÙÔ‡˜, ·ÏÏ¿ Ë ÌÂÙ·ÊÔÚ¿ Ù˘ ∆4 ·fi ÙË ÌËÙ¤Ú· ÛÙÔ ¤Ì‚Ú˘Ô Û˘Ó¯›˙ÂÙ·È, ÒÛÙ ӷ Á›ÓÂÙ·È Ê˘ÛÈÔÏÔÁÈο Ë ·Ó¿Ù˘ÍË Î·È Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ ÂÁÎÂÊ¿ÏÔ˘ Û ÂÚ›ÙˆÛË ·ÁÂÓÂÛ›·˜ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ (52). ™Â ‚·ÚÈ¿ ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘, Ë ÌËÙ¤Ú· Î·È ÙÔ ¤Ì‚Ú˘Ô ¤¯Ô˘Ó ¤ÏÏÂÈ„Ë ∆4 Î·È Ô ÂÌ‚Ú˘˚Îfi˜ ÂÁΤʷÏÔ˜ ¤¯ÂÈ ¤ÏÏÂÈ„Ë ∆3. ∏ ÌËÙ¤Ú· Â›Ó·È Ë ÌfiÓË ËÁ‹ ∆4 ÁÈ· ÙÔ ·ÓıÚÒÈÓÔ ¤Ì‚Ú˘Ô Î·Ù¿ ÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ Î·È Ì¤ÚÔ˜ ÙÔ˘ ‰Â˘Ù¤ÚÔ˘ ÙÚÈÌ‹ÓÔ˘ (53). ™ÙÔ ÙÂÏÂ˘Ù·›Ô ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘, Ë FT4 ÛÙÔ ¤Ì‚Ú˘Ô ¤¯ÂÈ Û¯Â‰fiÓ ÙËÓ ›‰È· ÙÈÌ‹ Ì ÂΛÓË ÙˆÓ ÂÓËϛΈÓ. ∞ÏÏ¿ ·fi Ȉ‰ÔÂÓÈ΋ ΢ÔÊÔÚÔ‡Û·, Ë FT4 ÙÔ˘ ÓÂÔÁ¤ÓÓËÙÔ˘ Â›Ó·È ˘„ËÏfiÙÂÚË ·Ô ÂΛÓË Ù˘ ÌËÙ¤Ú·˜. ™Ù· ÓÂÔÁÓ¿, Ë FT4 Â›Ó·È ·Ó¿ÏÔÁË Ù˘ ËÏÈΛ·˜ ·ËÛ˘. ™Â ¤ÁÎ˘Ô ÌÂ Ê˘ÛÈÔÏÔÁÈ΋ ı˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›·, Ô˘ ʤÚÂÈ ¤Ì‚Ú˘Ô ÌÂ
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Paediatriki 2001;64:101-114
ŒÓ·ÚÍË ÌÂÁ¿ÏˆÓ ‚Ï·‚ÒÓ ÛÙÔ ∫ÂÓÙÚÈÎfi ¡Â˘ÚÈÎfi ™‡ÛÙËÌ· ∂Ó‰ËÌÈÎfi˜ ÎÚÂÙÈÓÈÛÌfi˜ ÏfiÁˆ ¤ÏÏÂȄ˘ Ȉ‰›Ô˘, ¤Ó·ÓÙÈ Û˘ÁÁÂÓÔ‡˜ ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ ªÈÎÙ¿ Ó¢ÚÔÏÔÁÈο Î·È ˘Ôı˘ÚÂÔÂȉÈο Â˘Ú‹Ì·Ù· ?
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∂ÈÎfiÓ· 5. ¢È¿ÁÚ·ÌÌ· ÌÔÚÊÔÏÔÁÈÎÒÓ Î·È ÏÂÈÙÔ˘ÚÁÈÎÒÓ ÂÍÂÏ›ÍÂˆÓ ÙÔ˘ ·ÓıÚÒÈÓÔ˘ ÂÁÎÂÊ¿ÏÔ˘, Ô˘ ÂËÚ¿˙ÔÓÙ·È ·fi ÙË ‰È·ıÂÛÈÌfiÙËÙ· ÙÔ˘ Ȉ‰›Ô˘ Î·È Ù˘ ı˘ÚÔ͛Ӣ.
Û˘ÁÁÂÓ‹ ˘Ôı˘ÚÂÔÂȉÈÛÌfi, Ô ÂÌ‚Ú˘˚Îfi˜ ÂÁΤʷÏÔ˜ ‰ÂÓ ¤¯ÂÈ ·ÍÈfiÏÔÁË ¤ÏÏÂÈ„Ë ∆3 ̤¯ÚÈ ÙÔÓ ÙÔÎÂÙfi. ªÂÙ¿, fï˜, Ë ÌËÙÚÈ΋ ÌÂÙ·ÊÔÚ¿ Ù˘ ∆4 ‰È·ÎfiÙÂÙ·È. ∏ ‚Ï¿‚Ë ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Á›ÓÂÙ·È ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi, fiÙ·Ó ÂÏ·ÙÙˆıÔ‡Ó ÔÈ ı˘ÚÂÔÂȉÈΤ˜ ÔÚÌfiÓ˜. ªÔÚ› Ó· ·ÔÊ¢¯ı› Ì ÚÒÈÌË ¤Ó·ÚÍË ıÂڷ›·˜ Ì ı˘ÚÔÍ›ÓË ‹ Ì ÌËÙÚÈÎfi ıËÏ·ÛÌfi, fiÔ˘ ÌÂٷʤÚÂÙ·È ¤Ó· ̤ÚÔ˜ Ù˘ ı˘ÚÔ͛Ӣ ·fi ÙË ÌËÙ¤Ú· ÛÙÔ ÓÂÔÁÓfi. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ ÔÈ ı˘ÚÂÔÂȉÈΤ˜ ÔÚÌfiÓ˜ ÌÂÙ·‚ÔÏ›˙ÔÓÙ·È Ì ‚Ú·‰‡ Ú˘ıÌfi Î·È Ë ∆4 ¤¯ÂÈ ËÌÈÂÚ›Ô‰Ô ˙ˆ‹˜ 6 Ë̤Ú˜. √È Ôχ ¯·ÌËϤ˜ ÙÈ̤˜ Ù˘ ÌËÙÚÈ΋˜ ∆4 ÏfiÁˆ Ȉ‰ÔÂÓ›·˜, ÌÔÚ› Ó· ÂËÚ¿ÛÔ˘Ó ÙËÓ ·Ó¿Ù˘ÍË ÙÔ˘ ÌÂÛÔÏÔ‚›Ô˘, ÙÔ˘ ˘·Ú·¯ÓÔÂȉԇ˜ ¯ÒÚÔ˘, ÙÔ˘ Îԯϛ·, ÙÔ˘ Ú·‚‰ˆÙÔ‡ ÛÒÌ·ÙÔ˜ Î·È ÙÔ˘ ÂÁÎÂÊ·ÏÈÎÔ‡ ÊÏÔÈÔ‡ ÛÙÔÓ ÂÁΤʷÏÔ ÙÔ˘ ÂÌ‚Ú‡Ô˘ (∂ÈÎfiÓ· 5) (54). °›ÓÂÙ·È ‰ÂÎÙfi Û‹ÌÂÚ·, fiÙÈ ÔÈ Ó¢ÚÔÏÔÁÈΤ˜ ‚Ï¿‚˜ ÙÔ˘ ÂÌ‚Ú‡Ô˘ ÔÊ›ÏÔÓÙ·È ÛÙË Û˘Ó‰˘·Ṳ̂ÓË ¯·ÌËÏ‹ ı˘ÚÔÍ›ÓË ÛÙË ÌËÙ¤Ú· Î·È ÙÔ ¤Ì‚Ú˘Ô, ·ÏÏ¿ Î·È ÛÙËÓ ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ Ô˘ ÂËÚ¿˙ÂÈ ÙË ·Ó¿Ù˘ÍË ÙÔ˘ ÂÌ‚Ú˘˚ÎÔ‡ ÂÁÎÂÊ¿ÏÔ˘ ÙÔ ÚÒÙÔ ÙÚ›ÌËÓÔ. ¶ÚÔˆÚfiÙËÙ· Î·È ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ∞̤ۈ˜ ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi, ÙÔ ·È‰› ·fi ÙÔ ˙ÂÛÙfi ÂÚÈ‚¿ÏÏÔÓ Ù˘ Ì‹ÙÚ·˜ ÂͤگÂÙ·È ÛÙÔ ÎÚ‡Ô Â͈ÙÂ-
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ÚÈÎfi ÂÚÈ‚¿ÏÏÔÓ Î·È Ú¤ÂÈ Ó· ·˘Í‹ÛÂÈ ÙȘ η‡ÛÂȘ. ∆Ô ÙÚ›ÙÔ ÙÚ›ÌËÓÔ Ù˘ ·ËÛ˘, Ë ÌÂÙ·ÊÔÚ¿ Ù˘ ∆4 ·fi ÙË ÌËÙ¤Ú· ÛÙÔ ¤Ì‚Ú˘Ô ‰È·ÎfiÙÂÙ·È ·fiÙÔÌ· ÙË ÛÙÈÁÌ‹ Ù˘ Á¤ÓÓËÛ˘. √ ı˘ÚÂÔÂȉ‹˜ ÂÓfi˜ ÙÂÏÂÈfiÌËÓÔ˘ ÓÂÔÁÓÔ‡ ÂÚȤ¯ÂÈ ÂÚ›Ô˘ 100 Ìg Ȉ‰›Ô˘. ∆· ÚfiˆÚ· ÓÂÔÁÓ¿ ·ÔÙÂÏÔ‡Ó ¤Ó· ÏËı˘ÛÌfi Ì ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ ·Ó·Ù˘ÍȷΤ˜ ·ÓˆÌ·Ï›Â˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ¤ÏÏÂÈ„Ë ÙÔ˘ Ȉ‰›Ô˘, ·ÎfiÌ· Î·È fiÙ·Ó Ë ÚfiÛÏË„Ë Èˆ‰›Ô˘ ·Ô ÙË ÌËÙ¤Ú· Â›Ó·È Â·Ú΋˜ ηٿ ÙËÓ ÂÁ΢ÌÔÛ‡ÓË (55,56),ȉ›ˆ˜ fiÙ·Ó ‰È·ÙÚ¤ÊÔÓÙ·È Ì ٷ Û˘Ó‹ıË ‰È·ÈÙÔÏfiÁÈ· ÙÔ˘ ÂÌÔÚ›Ô˘ Ô˘ ‰ÂÓ Â›Ó·È ÂÌÏÔ˘ÙÈṲ̂ӷ Ì ÈÒ‰ÈÔ (57). ™Ù· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ Ë FT4 ·˘Í¿ÓÂÈ, ·ÏÏ¿ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿ ÂÏ·ÙÙÒÓÂÙ·È. ∏ ÙÒÛË Î·È Ë ‰È¿ÚÎÂÈ¿ Ù˘ (·ÚÔ‰ÈÎfi˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜) Â›Ó·È ÙfiÛÔ ÌÂÁ·Ï‡ÙÂÚË, fiÛÔ ÌÈÎÚfiÙÂÚË Â›Ó·È Ë ËÏÈΛ· ·ËÛ˘. ∏ ÙÒÛË Ù˘ FT4 ·ÎÔÏÔ˘ı› ÌÂÙ¿ Ì›· ‚‰ÔÌ¿‰· ·‡ÍËÛ˘ Ù˘ TSH Î·È ·˘Ùfi ‰Â›¯ÓÂÈ fiÙÈ Ô ¿ÍÔÓ·˜ ˘Ôı¿Ï·ÌÔ˜-˘fiÊ˘ÛË-ı˘ÚÂÔÂȉ‹˜, ηıÒ˜ Î·È Ë ·ÚÓËÙÈ΋ ·Ï›Ó‰ÚÔÌË ·ÏÏËÏÔÚ‡ıÌÈÛË ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ Â›Ó·È ·Ó·Ú΋˜ Î·È Î·ı˘ÛÙÂÚË̤ÓË. ∫·Ù¿ ÙÔÓ ÚfiˆÚÔ ÙÔÎÂÙfi, Ë ÌËÙÚÈ΋ ÌÂÙ·ÊÔÚ¿ Ȉ‰›Ô˘ Î·È ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ ‰È·ÎfiÙÂÙ·È ÚÈÓ ÁÂÌ›ÛÂÈ Ô ı˘ÚÂÔÂȉ‹˜ ÁÈ· Ó· ηχ„ÂÈ ÙȘ ·˘ÍË̤Ó˜ ·Ó¿ÁΘ. ÃÚÂÈ¿˙ÂÙ·È Î¿ÔÈÔ˜ ¯ÚfiÓÔ˜ ÌÂÙ¿
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ÙÔÓ ÙÔÎÂÙfi, ÒÛÙÂ Ô ·ÓÒÚÈÌÔ˜ ı˘ÚÂÔÂȉ‹˜ Ó· ÚÔÛ·ÚÌÔÛÙ› ÛÙËÓ ·ÒÏÂÈ· Ù˘ ÌËÙÚÈ΋˜ ÚÔÛÊÔÚ¿˜. ™˘ÁÁÂÓ‹˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ª›· ¿ÏÏË ÌÔÚÊ‹ ÓÂ˘Ì·ÙÈ΋˜ - „˘¯ÔÎÈÓËÙÈ΋˜ ηı˘ÛÙ¤ÚËÛ˘ ÏfiÁˆ ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡, Â›Ó·È Ô Û˘ÁÁÂÓ‹˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜. ™ÙË ¯ÒÚ· Ì·˜ ·fi ÙÔ 1979 (Î·È ÛÙȘ ¿ÏϘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ ÙÔ˘ ÎfiÛÌÔ˘ ÓˆÚ›ÙÂÚ·), ÂÊ·ÚÌfi˙ÂÙ·È ·ÓȯÓ¢ÙÈÎfi ÚfiÁÚ·ÌÌ· ÁÈ· ÙËÓ ÚÒÈÌË ‰È¿ÁÓˆÛË ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ (58). ŸÏ· Ù· ·È‰È¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Û ¡ÔÛÔÎÔÌ›· ‹ π‰ÈˆÙÈΤ˜ ∫ÏÈÓÈΤ˜ ÂϤÁ¯ÔÓÙ·È, Ï·Ì‚¿ÓÔÓÙ·˜ ·fi ÙË ÊÙ¤ÚÓ· ÙËÓ 3Ë-7Ë Ë̤ڷ Ù˘ ˙ˆ‹˜ ÙÔ˘˜, Ì›· ÛÙ·ÁfiÓ· ·›Ì·ÙÔ˜ Ô˘ ÙÔÔıÂÙÂ›Ù·È Û ‰ÈËıËÙÈÎfi ¯·ÚÙ›. ∆Ô ¯·ÚÙ› ·˘Ùfi ·ÔÛÙ¤ÏÏÂÙ·È Ì ʿÎÂÏÔ Ù·¯˘‰ÚÔÌÈο ÛÙÔ πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ÛÙËÓ ∞ı‹Ó·. ∂Λ ÌÂÙÚ¿Ù·È Ú·‰ÈÔ·ÓÔÛÔÏÔÁÈο ·fi ÙËÓ ·ÔÍËڷ̤ÓË ÛÙ·ÁfiÓ· ·›Ì·ÙÔ˜ Ë TSH. ŸÙ·Ó Ë TSH >30 ÌI U/L, ÂȉÔÔÈÔ‡ÓÙ·È ÔÈ ÁÔÓ›˜ ÙÔ˘ ·È‰ÈÔ‡. ∞˘Ùfi Á›ÓÂÙ·È Û‡ÓÙÔÌ·, ÂÓÙfi˜ ‰¤Î· ¤ÓÙ ËÌÂÚÒÓ ·fi ÙËÓ Ë̤ڷ Ù˘ ·ÈÌÔÏË„›·˜, ÒÛÙ ӷ ·Ú¯›ÛÔ˘Ó ıÂڷ›· Ì ı˘ÚÔÍ›ÓË, ÚÈÓ Á›ÓÔ˘Ó ÌfiÓÈ̘ ‚Ï¿‚˜ ÛÙÔ Ó¢ÚÈÎfi Û‡ÛÙËÌ·. ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ ÛÙÔÓ ∂ÏÏËÓÈÎfi ÏËı˘ÛÌfi Â›Ó·È 1 ·Ó¿ 3427 ÁÂÓÓ‹ÛÂȘ. ª¤¯ÚÈ ÙÔ 1996 ¤¯Ô˘Ó ‰È·ÁÓˆÛı› ÛÙËÓ ∂ÏÏ¿‰· 545 ·È‰È¿ ÌÂ Û˘ÁÁÂÓ‹ ˘Ôı˘ÚÂÔÂȉÈÛÌfi (59). ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ, ·Ó Ô Û˘ÁÁÂÓ‹˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ‰È·ÁÓˆÛı› ÙÔÓ ÚÒÙÔ Ì‹Ó· Ù˘ ˙ˆ‹˜ Î·È ·Ú¯›ÛÂÈ ıÂڷ›· Ì ı˘ÚÔÍ›ÓË, ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË ÛÙÔ ·È‰›, ÂÓÒ ·Ó ηı˘ÛÙÂÚ‹ÛÂÈ Ë ‰È¿ÁÓˆÛË ÙÔ˘ ÂÌÊ·Ó›˙ÔÓÙ·È ÌfiÓÈ̘ „˘¯ÔÎÈÓËÙÈΤ˜ ‚Ï¿‚˜ Î·È Ë ÓÔËÙÈ΋ ÏÂÈÙÔ˘ÚÁ›· ÙˆÓ ·È‰ÈÒÓ Â›Ó·È ¯·ÌËÏ‹. ∆· ·È‰È¿ ·˘Ù¿ ‰ÂÓ ÌÔÚÔ‡Ó Ó· ·Ú·ÎÔÏÔ˘ı‹ÛÔ˘Ó Ù· Ì·ı‹Ì·Ù· Û ηÓÔÓÈÎfi Û¯ÔÏ›Ô, ·ÏÏ¿ Ú¤ÂÈ Ó· ÓÔÛËχÔÓÙ·È Û ÂȉÈο ȉڇ̷ٷ ÁÈ· ·Ó›·Ù· ·È‰È¿. ∆Ô ÎfiÛÙÔ˜ ÙÔ˘ ÂıÓÈÎÔ‡ ÚÔ¸ÔÏÔÁÈÛÌÔ‡ ÁÈ· ÙË Û˘ÓÙ‹ÚËÛË ·˘ÙÒÓ ÙˆÓ π‰Ú˘Ì¿ÙˆÓ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ ·fi ÙÔ ÎfiÛÙÔ˜ ÁÈ· ÙÔÓ ¤ÏÂÁ¯Ô fiÏˆÓ ÙˆÓ ·È‰ÈÒÓ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È Ì ÙÔ ·ÓȯÓ¢ÙÈÎfi ÚfiÁÚ·ÌÌ· ÁÈ· ÙË ‰È¿ÁÓˆÛË ·È‰ÈÒÓ ÌÂ Û˘ÁÁÂÓ‹ ˘Ôı˘ÚÂÔÂȉÈÛÌfi. ¶·Ú¿ ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÓÂ˘Ì·ÙÈ΋˜ ·Ó¿Ù˘Í˘ ÙˆÓ ·ÙfiÌˆÓ ÌÂ Û˘ÁÁÂÓ‹ ˘Ôı˘ÚÂÔÂȉÈÛÌfi, ¤Ó· ÔÛÔÛÙfi 10% ÙˆÓ ·È‰ÈÒÓ ·˘ÙÒÓ ˘ÔÏ›ÂÙ·È ÛÙËÓ „˘¯ÔÎÈÓËÙÈ΋ Î·È ÓÂ˘Ì·ÙÈ΋ ·Ó¿Ù˘ÍË. ∞Èٛ˜ Û˘ÁÁÂÓÔ‡˜ ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ √ Û˘ÁÁÂÓ‹˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ÔÊ›ÏÂÙ·È Î·Ù¿ 85% ÛÙËÓ ¤ÏÏÂÈ„Ë ÙÔ˘ ·‰¤Ó· (¤ÎÙÔÔ˜ 40%, ·ÁÂÓÂÛ›· 40%, ˘ÔÏ·ÛÙÈÎfi˜ 5%) Î·È Î·Ù¿ 15% Û ÁÂÓÂÙÈο ÂÏÏ›ÌÌ·Ù· ÁÈ· ÙË ‚ÈÔÛ‡ÓıÂÛË ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ. À¿Ú¯ÂÈ Î·È Ô ·ÚÔ‰ÈÎfi˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ÛÂ Û˘¯ÓfiÙËÙ· 1 ·Ó¿ 10.000 ÓÂÔÁ¤ÓÓË-
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Ù· Î·È ÔÊ›ÏÂÙ·È ÛÙË ÌÂÙ·ÊÔÚ¿ ‰È· ÙÔ˘ Ï·ÎÔ‡ÓÙ· ηٷÛÙ·ÏÙÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÙˆÓ ˘Ô‰Ô¯¤ˆÓ Ù˘ TSH ·fi ÙË ÌËÙ¤Ú· ÛÙÔ ¤Ì‚Ú˘Ô (60), ·ÏÏ¿ ΢ڛˆ˜ ÛÙËÓ ·˘ÍË̤ÓË ÔÛfiÙËÙ· Ȉ‰›Ô˘ ÛÙÔ ÓÂÔÁ¤ÓÓËÙÔ (·Ôχ̷ÓÛË ÔÌÊ¿ÏÈÔ˘ ÏÒÚÔ˘) Ô˘ ·ÚÂÌÔ‰›˙ÂÈ ·ÚÔ‰Èο ÙË ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ÛÙÔ ÓÂÔÁ¤ÓÓËÙÔ ‹ ÛÙËÓ Î·Ù¿¯ÚËÛË ¯Ú‹Û˘ Ȉ‰›Ô˘ ·fi ÙË ÌËÙ¤Ú· (61,62). ª¤¯ÚÈ ÚfiÛÊ·Ù· ıˆÚ›ÙÔ fiÙÈ Ô Û˘ÁÁÂÓ‹˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ Ì ·Ï·Û›· ‹ ·ÁÂÓÂÛ›· ·‰¤ÓÔ˜ ÔÊÂÈÏfiÙ·Ó ÛÂ Ù˘¯·›· ·›ÙÈ· (ÛÔÚ·‰ÈÎfi˜) Î·È ‰ÂÓ ÌÂÙ·‚È‚¿˙ÂÙ·È ÛÙÔ˘˜ ·ÔÁfiÓÔ˘˜. ŸÌˆ˜, ·Ó¢ڤıËÛ·Ó ÙÚ›· ÁÔÓ›‰È· Ô˘ Ú˘ıÌ›˙Ô˘Ó ÙË ÌÔÚÊÔÁ¤ÓÂÛË Î·È ÙËÓ Î¿ıÔ‰Ô ÙÔ˘ ı˘ÚÂÔÂȉԇ˜, ηıÒ˜ Î·È ÙË ‰È·ÊÔÚÔÔ›ËÛË ÙˆÓ ı˘Ï·ÎȈ‰ÒÓ ı˘ÚÂÔÂȉÈÎÒÓ Î˘ÙÙ¿ÚˆÓ Ô˘ Έ‰ÈÎÔÔÈÔ‡Ó ÙÚÂȘ ÌÂÙ·ÁÚ·ÊÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ (63). ∞˘ÙÔ› Â›Ó·È Ô ı˘ÚÂÔÂȉÈÎfi˜ ÌÂÙ·ÁÚ·ÊÈÎfi˜ ·Ú¿ÁˆÓ 1 (∆∆F-1), Ô ı˘ÚÂÔÂȉÈÎfi˜ ÌÂÙ·ÁÚ·ÊÈÎfi˜ ·Ú¿ÁˆÓ 2 (∆∆F-2) Î·È Ô Pax 8. ¶ÔÓÙ›ÎÈ· ÛÙ· ÔÔ›· ··Ï›ÊıËÎ·Ó (Knock out) ·˘Ù¿ Ù· ÁÔÓ›‰È·, ÁÂÓÓÈÔ‡ÓÙ·È Ì ϋÚË ·Ô˘Û›· ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ‹ Ì ¤ÎÙÔÔ ı˘ÚÂÔÂȉ‹. ∂ÙÂÚfi˙˘ÁÔ ¤ÏÏÂÈÌÌ· ·˘ÙÒÓ ÙˆÓ ÁÔÓȉ›ˆÓ ¤¯ÂÈ ÂÓÙÔÈÛÙ› Û ÓÂÔÁ¤ÓÓËÙ· ÌÂ Û˘ÁÁÂÓ‹ ˘Ôı˘ÚÂÔÂȉÈÛÌfi Î·È ‚·ÚÈ¿ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ‹ ·ÙÚËÛ›· ¯Ô¿Ó˘ ‹ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ ÙˆÓ ÓÂÊÚÒÓ. ªÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ PAX 8 ·Ó¢ڤıË Û ‰‡Ô ·È‰È¿ Ì ÛÔÚ·‰È΋ ·ÁÂÓÂÛ›· ÙÔ˘ ı˘ÚÂÔÂȉ‹ Î·È Û ÙÚ›· ̤ÏË Ì›·˜ ¿ÏÏ˘ ÚÔÛ‚·ÏÏfiÌÂÓ˘ ÔÈÎÔÁ¤ÓÂÈ·˜. ™ÙÔ 15% ÙÔ˘ Û˘ÁÁÂÓÔ‡˜ ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ Ô˘ ÔÊ›ÏÂÙ·È Û ‰˘ÛÔÚÌÔÓÔÁ¤ÓÂÛË, ˘¿Ú¯ÂÈ ÁÂ-
∂ÈÎfiÓ· 6. ¶Ï¿ÁÈ· ÙÔÌ‹ Ì·ÁÓËÙÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ Ô˘ ‰Â›¯ÓÂÈ ÙË Û¯¤ÛË ÙÔ˘ ı˘ÚÂÔÂȉ‹ Ì ÁÂÈÙÔÓÈο fiÚÁ·Ó· (ÙÚ·¯Â›·, ÔÈÛÔÊ¿ÁÔ˜, ÎÚÈÎÔÂȉ‹˜ ¯fiÓ‰ÚÔ˜).
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∂ÈÎfiÓ· 7. °˘Ó·›Î· ·fi ÔÚÂÈÓ‹ ÂÚÈÔ¯‹ Ù˘ ∫Ú‹Ù˘ Ì ¤ÓÙÔÓË ‰ÈfiÁΈÛË ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ (ÂÚÈÛÙ·ÙÈÎfi Û˘ÁÁڷʤˆ˜).
ÓÂÙÈÎfi ¤ÏÏÂÈÌÌ· ÛÙÔ˘˜ ‚ÈÔ¯ËÌÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ÁÈ· ÙË Û‡ÓıÂÛË ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ. ªÂÁ¿ÏÔ Â‡ÚÔ˜ ÌÂÙ·ÏÏ¿ÍÂˆÓ ¤¯ÂÈ ‚ÚÂı›, Ô˘ ΢ڛˆ˜ ÔÊ›ÏÂÙ·È Û ٤ÛÛÂÚ· ÁÔÓ›‰È·. ∞˘Ù¿ ›ӷÈ: 1) £˘ÚÂÔÛÊ·ÈÚ›Ó˘, 2) £˘ÚÂÔÂÚÔÍÂȉ¿Û˘ (64), 3) ¡¿ÙÚÈÔ – πÒ‰ÈÔ Û˘ÌÌÂÙ·ÊÔÚ¤·˜ (65), 4) Pendrel (66). µÚ¤ıËΠ·ÎfiÌË ÌÂÙ¿ÏÏ·ÍË ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ÚˆÙ½Ó˘ ÙÔ˘ ˘Ô‰Ô¯¤· Ù˘ TSH (67) Ô˘ ÚÔηÏ› ÎÏËÚÔÓÔÌÈÎfi Û˘ÁÁÂÓ‹ ˘Ôı˘ÚÂÔÂȉÈÛÌfi Ì ˘ÔÏ·ÛÙÈÎfi ·‰¤Ó·. ÕÏÏË ÌÂÙ¿ÏÏ·ÍË Ô˘ ·Ó¢ڤıË Â›Ó·È ÙÔ˘ ÁÔÓȉ›Ô˘ Ù˘ ‚-˘ÔÔÌ¿‰·˜ Ù˘ TSH Ô˘ ÚÔηÏ› ·Ï·Û›· ÙÔ˘ ·‰¤Ó· Î·È ˘Ôı˘ÚÂÔÂȉÈÛÌfi Î·È ‰ÂÓ ·ÓȯÓ‡ÂÙ·È ÛÙË ÛÙ·ÁfiÓ· ·›Ì·ÙÔ˜, fiÙ·Ó ÌÂÙÚ¿Ù·È ÌfiÓÔ Ë TSH Î·È fi¯È Ë ∆4 (68). ™˘ÌÂÚ¿ÛÌ·Ù· ∏ ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ ηٿ ÙËÓ ÂÌ‚Ú˘˚΋ ˙ˆ‹ ÚÔηÏ› ·Ó·ÓfiÚıˆÙ˜ ‚Ï¿‚˜ ÛÙËÓ ·Ó¿Ù˘ÍË Î·È ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘ Î·È Ù· ·È‰È¿ Ô˘ ı· ÁÂÓÓËıÔ‡Ó ÌÔÚ› Ó· Â›Ó·È ÎÚÂÙ›ÓÔÈ (69). ŒÏÏÂÈ„Ë Èˆ‰›Ô˘ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ÚÔηÏ› ˘Ôı˘ÚÂÔÂȉÈÛÌfi, ÓÂ˘Ì·ÙÈ΋ - „˘¯ÔÎÈÓËÙÈ΋ Î·È ÛˆÌ·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË. ŒÏÏÂÈ„Ë Èˆ‰›Ô˘ ÛÙËÓ ·È‰È΋ Î·È ÂÊË‚È΋ ËÏÈΛ· ÚÔηÏ› ˘Ôı˘ÚÂÔÂȉÈÛÌfi Î·È Î·ı˘ÛÙ¤ÚËÛË Ù˘ ۈ̷ÙÈ΋˜ ·Ó¿Ù˘Í˘, Ô˘ ·Ó·ÏËÚÒÓÂÙ·È ÌÂÙ¿ ÙË ıÂڷ›· Ì ı˘ÚÔÍ›ÓË. ∏ ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘ ÛÙ· ·È‰È¿ ·ÏÏ¿ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ ÚÔηÏ› ‚ÚÔÁ¯Ô΋ÏË, Ë ÔÔ›·, fiÙ·Ó Â›Ó·È ÌÂÁ¿ÏË, ÚÔηÏ› ÈÂÛÙÈο Ê·ÈÓfiÌÂÓ· ÛÙÔÓ ÔÈÛÔÊ¿ÁÔ Î·È ÛÙËÓ ÙÚ·¯Â›· Î·È ‰˘Û¯¤ÚÂÈ· ÛÙËÓ Î·Ù¿ÔÛË Î·È ÛÙËÓ ·Ó·ÓÔ‹ Û ‚·ÚȤ˜ ÂÚÈÙÒÛÂȘ (∂ÈÎfiÓ· 6). ªÔÚ› Ô ‰ÈÔÁΈ̤ÓÔ˜ ı˘ÚÂÔÂȉ‹˜, ·Ú¿ ÙÔ ÌÂÁ¿ÏÔ Ì¤ÁÂıÔ˜, Ó· ÌËÓ ·-
112
Ú¿ÁÂÈ Â·Ú΋ ÔÛfiÙËÙ· ı˘ÚÔ͛Ӣ Î·È Ó· ¤¯Ô˘Ì ˘Ôı˘ÚÂÔÂȉÈÛÌfi. ªÔÚ› fï˜ ÌÂÚÈÎÔ› fi˙ÔÈ ÙÔ˘ ‰ÈÔÁΈ̤ÓÔ˘ ı˘ÚÂÔÂȉԇ˜ Ó· ·ÔÎÙ‹ÛÔ˘Ó ·˘ÙÔÓÔÌ›·, Ó· ˘ÂÚÏÂÈÙÔ˘ÚÁÔ‡Ó Î·È Ó· ¤¯Ô˘Ì ÙÔÍÈ΋ ÔÏ˘Ô˙Ò‰Ë ‚ÚÔÁ¯Ô΋ÏË. ªÂÚÈÎÔ› „˘¯ÚÔ› fi˙ÔÈ ÛÙËÓ ÔÏ˘Ô˙Ò‰Ë ‚ÚÔÁ¯Ô΋ÏË ÌÔÚ› Ó· ÂÍ·ÏÏ·¯ıÔ‡Ó Û ηÚΛÓÔ. ŒÏÏÂÈ„Ë Èˆ‰›Ô˘, ‰˘ÛÙ˘¯Ò˜, ˘¿Ú¯ÂÈ ÛÙȘ Ë̤Ú˜ Ì·˜ (∂ÈÎfiÓ· 7) (70) Û ÔÏϤ˜ ÔÚÂÈÓ¤˜, ÊÙˆ¯¤˜, ·ÔÌÔӈ̤Ó˜ ·fi ÙÔÓ ˘fiÏÔÈÔ ÎfiÛÌÔ ÂÚÈÔ¯¤˜, Û ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜ ÙÔ˘ Ï·Ó‹ÙË Ì·˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È Ì·ÎÚÈ¿ ·fi ÙË ı¿Ï·ÛÛ· Î·È ÚÔηÏ› ÓÂ˘Ì·ÙÈ΋ ηı˘ÛÙ¤ÚËÛË Î·È ‚ÚÔÁ¯Ô΋ÏË. √ ÂÌÏÔ˘ÙÈÛÌfi˜ ÙÔ˘ ÓÂÚÔ‡, ÙÔ˘ „ˆÌÈÔ‡ ‹ ÙÔ˘ ·Ï·ÙÈÔ‡ Ì ÈÒ‰ÈÔ, ÁÈ· ˘ÁÈ›˜ ۈ̷ÙÈο Î·È ÓÂ˘Ì·ÙÈο ·ÓıÚÒÔ˘˜ Û ÂÚÈÔ¯¤˜ Ì ¤ÏÏÂÈ„Ë Èˆ‰›Ô˘, ·ÔÙÂÏ› ÂıÓÈÎfi ηı‹ÎÔÓ Î¿ı ¯ÒÚ·˜. µÈ‚ÏÈÔÁÚ·Ê›· 1. Martin ND. ¡ÂÚfi Î·È ·ÓfiÚÁ·Ó· ÛÙÔȯ›·. ™ÙÔ: Martin WD, Mayes AP, Rodwell WV ÂΉ. Harper’s µÈÔ¯ËÌ›· ∆fiÌÔ˜ µ. ∞ı‹Ó·, ÂÈÛÙ ÂΉ ¶·ÚÈÛÈ¿ÓÔ˜; 1985. ÛÂÏ. 597-610. 2. Asimov I. ∆Ô ¯ÚÔÓÈÎfi ÙˆÓ ÂÈÛÙËÌÔÓÈÎÒÓ ·Ó·Î·Ï‡„ˆÓ. ∏Ú¿ÎÏÂÈÔ, ¶·Ó ∂Ή ∫Ú‹Ù˘, 1993. 3. Goyens P, Golstein J, Nsombola B, Vis H, Dumont JE. Selenium deficiency as a possible factor in the pathogenesis of myxematous cretinism. Acta Endocrinol 1987;114:497-502. 4. McCance and Widdowson’s. The Composition of Foods. 5th ed. Cambridge: The Royal Society of Chemistry; 1993. 5. Gerber H. The transformation of normal thyroid cells to goiter: the role of iodine depletion and repletion. In: Nauman J, Glinoer D, Braverman LE, Hostalek U, eds. The Thyroid and Iodine, Merck European Thyroid
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√ ıˆÚ·ÎÈÎfi˜ fiÓÔ˜ ÛÙ· ·È‰È¿. KÏÈÓÈ΋ ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË °. ™. µ·ÚÏ¿Ì˘
Chest pain in children. A clinical diagnostic approach G. S. Varlamis
¶ÂÚ›ÏË„Ë: √ ıˆÚ·ÎÈÎfi˜ fiÓÔ˜, ÁÓˆÛÙfi˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›· Î·È ˆ˜ “ÚÔοډÈÔ˜ fiÓÔ˜”, Â›Ó·È ¤Ó· ·fi Ù· Û˘¯Ó¿ Û˘ÌÙÒÌ·Ù· Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ Î·È Ôχ Û˘¯Ó‹ ·ÈÙ›· ÚÔÛ¤Ï¢Û˘ ·È‰ÈÒÓ ÛÙÔ ¶·È‰ÔηډÈÔÏÔÁÈÎfi ∂͈ÙÂÚÈÎfi π·ÙÚ›Ô. ∏ ηډÈÔÊÔ‚›· ÙˆÓ ÁÔÓ¤ˆÓ Â›Ó·È ‚·ÛÈ΋ ·ÈÙ›· ÚfiÛıÂÙÔ˘ ¿Á¯Ô˘˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘, ·ÏÏ¿ Î·È Ô ›‰ÈÔ˜ Ô ıˆÚ·ÎÈÎfi˜ fiÓÔ˜ ·ÔÙÂÏ› Û˘¯Ó¿ ‰˘ÛÂ›Ï˘ÙÔ Úfi‚ÏËÌ·, ·Ó Ë ‰È¿ÁÓˆÛË ‚·Û›˙ÂÙ·È Û ÎÏÈÓÈο ÌfiÓÔ ÎÚÈÙ‹ÚÈ·. ™ÙËÓ ·Ó·ÛÎfiËÛË ·˘Ù‹ ‰ÈÂÚÂ˘Ó¿Ù·È ÙÔ ı¤Ì· ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÓÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Ì ÁÓÒÌÔÓ· ÙȘ ȉȷÈÙÂÚfiÙËÙ˜ Ù˘ ËÏÈΛ·˜ ·˘Ù‹˜, ηıÒ˜ Î·È Ù· ‰Â‰Ô̤ӷ ·fi ÙË ‰È·ÁÓˆÛÙÈ΋ ÙˆÓ ÂÓËϛΈÓ. ∂ÈϤÔÓ, ÌÂıԉ‡ÂÙ·È Ë ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ·È‰È¿ÙÚÔ˘ Î·È ÙÔ˘ ÁÂÓÈÎÔ‡ ÁÈ·ÙÚÔ‡, Ë ÔÔ›·, ÂÎÙfi˜ ÙˆÓ ¿ÏψÓ, ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ·ÈÙÈÔÏÔÁ›· Î·È ÛÙËÓ È‰È·›ÙÂÚË ÎÏÈÓÈ΋ ÛËÌÂÈÔÏÔÁ›·, ·ÏÏ¿ Î·È ÛÙ· ‰Â‰Ô̤ӷ ·fi ÙËÓ Î›ÓËÛË ÙÔ˘ ¶·È‰ÔηډÈÔÏÔÁÈÎÔ‡ ∂͈ÙÂÚÈÎÔ‡ π·ÙÚ›Ԣ Î·È ÙÔ˘ ¶·È‰ÔηډÈÔÏÔÁÈÎÔ‡ ¢È·ÁÓˆÛÙÈÎÔ‡ ∂ÚÁ·ÛÙËÚ›Ô˘ Ù˘ ∫ÏÈÓÈ΋˜ Ì·˜. π‰È·›ÙÂÚË ‚·Ú‡ÙËÙ· ‰›‰ÂÙ·È ÛÙËÓ ÂÚÈÁÚ·Ê‹ ÙˆÓ ÎÏÈÓÈÎÒÓ ÛËÌ›ˆÓ ÙˆÓ Î·Ú‰ÈÔÏÔÁÈÎÒÓ ·ÈÙ›ˆÓ ıˆÚ·ÎÈÎÔ‡ fiÓÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ·, ÒÛÙ ·˘Ù¿ Ó· ·Ó·ÁÓˆÚ›˙ÔÓÙ·È Î·È Ó· ÂȂ‚·ÈÒÓÔÓÙ·È ‹ Ó· ·ÔÎÏ›ÔÓÙ·È Ù·¯¤ˆ˜, ÏfiÁˆ Ù˘ ÁÂÓÈο ·Ô‰ÂÎÙ‹˜ Ì›˙ÔÓÔ˜ ÚÔÁÓˆÛÙÈ΋˜ ÛËÌ·Û›·˜ ÙÔ˘˜, ·Ú¿ ÙË ÛÙ·ÙÈÛÙÈο Û¯ÂÙÈο ¯·ÌËÏ‹ ·Ó·ÏÔÁ›· ÙÔ˘˜ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ·ÈÙ›ˆÓ ıˆÚ·ÎÈÎÔ‡ fiÓÔ˘ ÛÙ· ·È‰È¿. ∆¤ÏÔ˜, ‰›‰ÂÙ·È Ô ‰È·ÁÓˆÛÙÈÎfi˜ ·ÏÁfiÚÈıÌÔ˜, Ô˘ ¯ÚËÛÈÌÔÔÈÂ›Ù·È ÛÙÔ ¶·È‰È·ÙÚÈÎfi Î·È ÛÙÔ ¶·È‰ÔηډÈÔÏÔÁÈÎfi ∂͈ÙÂÚÈÎfi π·ÙÚÂ›Ô Ù˘ ∫ÏÈÓÈ΋˜ Ì·˜.
Abstract: Chest pain or precordial pain is a frequent symptom in childhood and a very frequent cause for seeking examination by a pediatric cardiologist. The fear of heart disease on the part of the parents is the main cause for an additional anxiety to the pediatrician, but also chest pain itself is often a difficult problem to solve if the diagnosis is based entirely on clinical criteria. This review analyzes chest pain in children with emphasis on the particularities pertinent to the young age group as well as on the available data accumulated from studies in adults. Moreover, the diagnostic approach on the part of the pediatrician is meticulously analyzed which, among others, is based on the etiology and the specific clinical signs, as well as on the data derived from our outpatient cardiology clinic. Specific emphasis is given on the description of the clinical signs, as well as on the various etiologic factors. Despite the low incidence of the cardiac causes of chest pain in childhood, their prompt recognition by the clinician is essential since it will contribute significantly to the overall prognosis. A diagnostic algorithm is finally presented which is used in our pediatric and pediatric cardiology clinics of our hospital.
§¤ÍÂȘ ÎÏÂȉȿ: ıˆÚ·ÎÈÎfi˜ fiÓÔ˜, ‰È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË.
Key words: chest pain, diagnostic approach.
¶·È‰›·ÙÚÔ˜ - ¶·È‰ÔηډÈÔÏfiÁÔ˜, ∞Ó. ∫·ıËÁËÙ‹˜ ∞.¶.£. ¢’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ∞.¶.£., ¡ÔÛÔÎÔÌÂ›Ô ∞.Ã.∂.¶.∞. £ÂÛÛ·ÏÔÓ›ÎË
Associate Professor of Pediatrics - Pediatric Cardiology 4th Pediatric Clinic, Aristotelion University of Thessaloniki A.H.E.P.A. Hospital, Thessaloniki
115
2001 MAPT- A¶PI§
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™ÂÏ›‰· 116
¶·È‰È·ÙÚÈ΋ 2001;64:115-124
Paediatriki 2001;64:115-124
∂ÈÛ·ÁˆÁ‹ √ ıˆÚ·ÎÈÎfi˜ fiÓÔ˜ (£¶) ÂÎÏ·Ì‚¿ÓÂÙ·È ·ÙÔÌÈο Î·È ÎÔÈÓˆÓÈο ˆ˜ ÚÔ¿ÁÁÂÏÔ˜ ÛËÌ·ÓÙÈÎÒÓ Î·È Î˘Ú›ˆ˜ ηډȷÎÒÓ ·ı‹ÛˆÓ, ÁÂÁÔÓfi˜ Ô˘ ÙÔ˘ ÚÔÛ‰›‰ÂÈ ÙËÓ È‰ÈfiÙËÙ· ÂÓfi˜ “Û˘ÌÙÒÌ·ÙÔ˜ Û˘Ó·ÁÂÚÌÔ‡”. ™Â ·˘Ùfi Û˘Ì‚¿ÏÏÂÈ Ë Ú·ÁÌ·ÙÈ΋ ·‡ÍËÛË Ù˘ ÛÙÂÊ·ÓÈ·›·˜ ÓfiÛÔ˘ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ Î·È Ë ÂÏÏÈ‹˜ ÏËÚÔÊfiÚËÛË ·fi Ù· ª¤Û· ª·˙È΋˜ ∂ÓË̤ڈÛ˘, Ô˘ Û˘Ó‰¤Ô˘Ó Û˘¯Ó¿ ÙÔÓ £¶ Ì ÙÔÓ ·ÈÊÓ›‰ÈÔ ı¿Ó·ÙÔ Ó¤ˆÓ Û˘Ó‹ıˆ˜ ·ÙfïÓ. √È ÈÔ ¿Óˆ ÏfiÁÔÈ Î·È Ë ÌÂÁ¿ÏË ÔÈÎÈÏ›· ·ÈÙ›ˆÓ ÙÔ˘ £¶ ÛÙ· ·È‰È¿, ηıÈÛÙÔ‡Ó ÙÔÓ £¶, Û˘¯Ó¿, ‰˘ÛÂ›Ï˘ÙÔ Úfi‚ÏËÌ· ÁÈ· ÙÔÓ ·È‰›·ÙÚÔ (1,2). ™ÎÔfi˜ Ù˘ ·Ó·ÛÎfiËÛ˘ ·˘Ù‹˜ Â›Ó·È Ë ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ı¤Ì·ÙÔ˜ ÙÔ˘ £¶ ÛÙËÓ ·È‰È΋ ËÏÈΛ· Î·È Ë ‰È·ÌfiÚʈÛË ÌÂıfi‰Â˘Û˘ ‰È·ÁÓˆÛÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ ·fi ÙÔÓ ›‰ÈÔ ÙÔÓ ÔÈÎÔÁÂÓÂÈ·Îfi ·È‰›·ÙÚÔ ‹ ÙÔ ÁÈ·ÙÚfi ÁÂÓÈ΋˜ π·ÙÚÈ΋˜, Ô˘ ‚·Û›˙ÂÙ·È ÛÙ· ‰Â‰Ô̤ӷ Ù˘ ‰ÈÂıÓÔ‡˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ ·ÏÏ¿ Î·È Ù˘ ΛÓËÛ˘ ÙÔ˘ ¶·È‰ÔηډÈÔÏÔÁÈÎÔ‡ ∂͈ÙÂÚÈÎÔ‡ π·ÙÚ›Ԣ Î·È ÙÔ˘ ¶·È‰ÔηډÈÔÏÔÁÈÎÔ‡ ¢È·ÁÓˆÛÙÈÎÔ‡ ∂ÚÁ·ÛÙËÚ›Ô˘ Ù˘ ∫ÏÈÓÈ΋˜ Ì·˜. ∏ ·ÓÙ›ÏË„Ë Î·È Ë ÂÎÙ›ÌËÛË ÙÔ˘ fiÓÔ˘ ÛÙËÓ ·È‰È΋ ËÏÈΛ· “¶fiÓÔ˜ Â›Ó·È ÙÔ ·›ÛıËÌ·, ηٿ ÙÔ ÔÔ›Ô ·Ú·ÙËÚÂ›Ù·È ˘„ËÏfi˜ Û˘Ó·ÈÛıËÌ·ÙÈÎfi˜ ÙfiÓÔ˜ ‰˘Û¿ÚÂÛÙ˘ ¯ÚÔÈ¿˜” (Houssay, 1963) (3). ∏ “¢ÈÂıÓ‹˜ ŒÓˆÛË ÁÈ· ÙË ªÂϤÙË ÙÔ˘ ¶fiÓÔ˘” ‰›ÓÂÈ 16 ¯ÚfiÓÈ· ·ÚÁfiÙÂÚ·, ÙÔÓ ·ÎfiÏÔ˘ıÔ ÔÚÈÛÌfi: “¶fiÓÔ˜ Â›Ó·È ‰˘Û¿ÚÂÛÙË ·ÈÛıËÛȷ΋ Î·È Û˘ÁÎÈÓËÛȷ΋ ÂÌÂÈÚ›·, Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ڷÁÌ·ÙÈ΋ ‰˘ÓËÙÈ΋ ÈÛÙÈ΋ ÚÔÛ‚ÔÏ‹” (4). ¶·Ú¿ ÙËÓ ¤ÎÙ·ÛË Ù˘ ¤Ú¢ӷ˜ ÙÔ˘ fiÓÔ˘, ÏËÚ¤ÛÙÂÚÔ˜ ÔÚÈÛÌfi˜ ‰ÂÓ ¤¯ÂÈ ‰Ôı› Î·È ·Ú·Ì¤ÓÔ˘Ó ·Ó·¿ÓÙËÙ· ÔÏÏ¿ ·ÎfiÌË ÂÚˆÙ‹Ì·Ù· (1,5,6). ∏ ÌÂÁ¿ÏË ÂͤÏÈÍË Ù˘ Ó¢ÚÔÊ˘ÛÈÔÏÔÁ›·˜ ·¤‰ÂÈÍ ÙËÓ ‡·ÚÍË Î·ÙÈÔ‡Û·˜ ·Ó·ÙÔÌÈ΋˜ Ô‰Ô‡, ÂÎÙfi˜ ·fi ÙË ÁÓˆÛÙ‹ ÎÂÓÙÚÔÌfiÏÔ Ô‰fi, ηıÒ˜ Î·È ÔÈÎÈÏ›· Ó¢ÚÔÌÂÙ·‚È‚·ÛÙÈÎÒÓ Î·È Ó¢ÚÔ·ÏÏÔȈÙÈÎÒÓ ‚ÈÔ¯ËÌÈÎÒÓ Ô˘ÛÈÒÓ, ¯ˆÚ›˜ ·fiÏ˘ÙË ‰È¢ÎÚ›ÓÈÛË Ù˘ ‰Ú¿Û˘ ÙÔ˘˜ (6,7). Œ¯ÂÈ, ›Û˘, ·Ô‰ÂȯÙ› fiÙÈ Ë ‡·ÚÍË ÙˆÓ ·Ó·ÙÔÌÈÎÒÓ Ô‰ÒÓ Î·È Ë ‰Ú¿ÛË ÙˆÓ Ó¢ÚÔÚ˘ıÌÈÛÙÈÎÒÓ Ô˘ÛÈÒÓ ÌÔÚ› Ó· ˘¿Ú¯ÂÈ ·fi ÙË Á¤ÓÓËÛË, ·ÎfiÌË Î·È Û ÚfiˆÚ· ÓÂ-
ÔÁÓ¿ Î·È Ù¤ÏÔ˜ fiÙÈ Ë ·ÓÙ›ÏË„Ë ÙÔ˘ fiÓÔ˘ ‰È·Ê¤ÚÂÈ ·fi ¿ÙÔÌÔ Û ¿ÙÔÌÔ, ÌÂٷ͇ ÙˆÓ Ê‡ÏˆÓ, ÛÙ· ›‰È· Ù· ¿ÙÔÌ· ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ·, ÂÓÒ ˘¿Ú¯Ô˘Ó Î·È ÂıÓÈΤ˜ ‰È·ÊÔÚ¤˜ ηıÒ˜ Î·È ‰È·ÊÔÚ¤˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ „˘¯ÔÏÔÁÈÎfi ÂÚÈ‚¿ÏÏÔÓ (2,8). ∏ ÂÎÙ›ÌËÛË ÙÔ˘ fiÓÔ˘ ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘ Â›Ó·È ¤Ó· ·fi Ù· ‰˘ÛÎÔÏfiÙÂÚ· ÚÔ‚Ï‹Ì·Ù·, ÂÂȉ‹ ‰ÂÓ ˘¿Ú¯ÂÈ ·ÓÙÈÎÂÈÌÂÓÈÎfi˜ Î·È ·ÏÔ˘ÛÙÂ˘Ì¤ÓÔ˜ ÎÏÈÓÈÎfi˜ ÙÚfiÔ˜. √ ¤ÏÂÁ¯Ô˜ ÙˆÓ Ì˯·ÓÈÛÌÒÓ Ê˘ÛÈÔÏÔÁÈ΋˜ ·¿ÓÙËÛ˘ ÛÙÔ stress ÌÔÚ› Ó· Á›ÓÂÈ ÂÈÚ·Ì·ÙÈο Ì ÔÏϤ˜ ÌÂıfi‰Ô˘˜, ÛÔ˘‰·ÈfiÙÂÚË ·fi ÙȘ Ôԛ˜ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Ë ÂÎÙ›ÌËÛË Ù˘ ¤ÎÊÚ·Û˘ ÙÔ˘ ÚÔÛÒÔ˘. ™ÙËÓ ÎÏÈÓÈ΋ Ú¿ÍË, η̛· ̤ıÔ‰Ô˜ ‰ÂÓ Â·ÚΛ, ‰ÈfiÙÈ ÛÙËÓ ·ÓÙ›ÏË„Ë Ù˘ ¤ÓÙ·Û˘ Î·È Ù˘ ÂÓÙfiÈÛ˘ ÙÔ˘ fiÓÔ˘ ÛÔ˘‰·ÈfiÙÂÚÔ˜ ·Ú¿ÁˆÓ Ê·›ÓÂÙ·È fiÙÈ Â›Ó·È Ë ËÏÈΛ·. ∏ ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ·È‰ÈÔ‡ ÛÙÔÓ ›‰ÈÔ ‚·ıÌfi ·ÏÁÂÈÓÔ‡ ÂÚÂı›ÛÌ·ÙÔ˜ Â›Ó·È ÙfiÛÔ ÈÔ ÛÙ·ıÂÚ‹ Î·È Û·Ê‹˜, fiÛÔ ÌÂÁ·Ï‡ÙÂÚË Â›Ó·È Ë ËÏÈΛ· ÙÔ˘ (¶›Ó·Î·˜ 1) (1,2,9-11). ø˜ ÚfiÛıÂÙÔÈ ·Ú¿ÁÔÓÙ˜ ÈηÓÔ› Ó· ÂËÚ¿ÛÔ˘Ó ÙËÓ ÂÎÙ›ÌËÛË Ù˘ ¤ÓÙ·Û˘ Î·È Ù˘ ÂÓÙfiÈÛ˘ ÙÔ˘ fiÓÔ˘ ·Ó·Ê¤ÚÔÓÙ·È: ·) Ë ÎÔÈÓˆÓÈ΋ ÂͤÏÈÍË ÙÔ˘ ·È‰ÈÔ‡, Ô˘ Â›Ó·È ˘Â‡ı˘ÓË ÁÈ· ÙÔÓ £¶ ·fi Ì›ÌËÛË, ηٿ ÙËÓ ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ· Î·È ÁÈ· ÙÔÓ £¶ - ÂΉ‹ÏˆÛË ÎÙËÙÈ΋˜ ‹ ·ÓÙȉڷÛÙÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ·¤Ó·ÓÙÈ ÛÙÔ˘˜ ÁÔÓ›˜, ηٿ ÙËÓ ÂÊË‚È΋ ËÏÈΛ· Î·È ‚) Ë ˘ÔÎÂÈÌÂÓÈ΋ ÙÔÔı¤ÙËÛË ÔÏÏÒÓ ÁÈ·ÙÚÒÓ, ÔÈ ÔÔ›ÔÈ Û˘¯Ó¿ ˘ÂÚÂÎÙÈÌÔ‡Ó ÙÔÓ fiÓÔ ÛÙȘ ÌÈÎÚ¤˜ ËÏÈ˘, ÂÓÒ ÙÔÓ ˘ÔÙÈÌÔ‡Ó ÛÙȘ ÌÂÁ·Ï‡ÙÂÚ˜ (1,5,11). ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë ·Ô˘Û›· ·ÓÙÈÎÂÈÌÂÓÈ΋˜ ÂÎÙ›ÌËÛ˘ ÙÔ˘ fiÓÔ˘, Ë Û˘ÓÂȉËÙÔÔ›ËÛ‹ ÙÔ˘, Ô˘ ¤¯ÂÈ ¿ÌÂÛË Û¯¤ÛË Ì ÙËÓ ËÏÈΛ·, Ë ·ÙÔÌÈ΋ ·ÓÔ¯‹ Û’ ·˘ÙfiÓ, Ë „˘¯ÔÎÔÈÓˆÓÈ΋ ˆÚ›Ì·ÓÛË ÙÔ˘ ·È‰ÈÔ‡ Î·È ÔÈ ÂÓ‰ÔÔÈÎÔÁÂÓÂȷΤ˜ Û¯¤ÛÂȘ Â›Ó·È ·Ú¿ÁÔÓÙ˜ Ô˘ Ù›ÓÔ˘Ó Ó· ‰ËÌÈÔ˘ÚÁ‹ÛÔ˘Ó ÂÈÎfiÓ· ·Û¿ÊÂÈ·˜ Á‡Úˆ ·fi ÙÔ Û‡Ìو̷ “fiÓÔ˜” Î·È ·˘Í¿ÓÔ˘Ó ·fiÙÔÌ· ÙË Û˘¯ÓfiÙËÙ· ÛÙËÓ ËÏÈΛ· ÙˆÓ 7-9 ¯ÚfiÓˆÓ. ªÔÚʤ˜ Î·È Û˘¯ÓfiÙËÙ· ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ fiÓÔ˘ ÛÙ· ·È‰È¿ √ £¶ ‰È·ÎÚ›ÓÂÙ·È Û Ô͇, ¯ÚfiÓÈÔ Î·È Â·Ó·Ï·Ì‚·ÓfiÌÂÓÔ ‹ ÂÚÈÔ‰ÈÎfi.
¶›Ó·Î·˜ 1. ∏ ÚfiÔ‰Ô˜ Ù˘ ·ÓÙ›Ï˄˘ ÙÔ˘ fiÓÔ˘ Ì ÙËÓ ËÏÈΛ· (1,10,11) ∏§π∫π∂™ °¤ÓÓËÛË-3ÌËÓÒÓ 6-18 ÌËÓÒÓ 18-36 ÌËÓÒÓ 3-7 ¯ÚfiÓˆÓ 7-9 ¯ÚfiÓˆÓ >9 ¯ÚfiÓˆÓ
116
∞¡∆π§∏æ∏ ¶√¡√À ªÓ‹ÌË ÂÒ‰˘ÓÔ˘ ÂÚÂı›ÛÌ·ÙÔ˜ ‹ ·˘ÙfiÌ·ÙÔ˘ fiÓÔ˘. ∞ÓÙ›‰Ú·ÛË ÔÚÁ‹˜ – Êfi‚Ô˘. ∫·Ï‡ÙÂÚË ¤ÓÓÔÈ·, ηχÙÂÚÔ˜ ÂÓÙÔÈÛÌfi˜. ŒÓ·ÚÍË ÏÂÎÙÈ΋˜ ÂÚÈÁÚ·Ê‹˜. ™˘Ó‹ı˘ Ë ˘ÂÚÂÎÙ›ÌËÛË Ù˘ ¤ÓÙ·Û˘. ™·Ê‹˜ Û˘ÓÂȉËÙÔÔ›ËÛË fiÓÔ˘ Î·È ·ÚÚÒÛÙÈ·˜. ŒÓ·ÚÍË Ì›ÌËÛ˘ fiÓÔ˘. ∂›‰Ú·ÛË ÂÚÈ‚¿ÏÏÔÓÙÔ˜. ¶Ï‹Ú˘ Û˘ÓÂȉËÙÔÔ›ËÛË Ù˘ ·ÚÚÒÛÙÈ·˜ ˆ˜ ·ÈÙ›·˜.
2001 MAPT- A¶PI§
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¶·È‰È·ÙÚÈ΋ 2001;64:115-124
™˘¯ÓfiÙÂÚÔ Úfi‚ÏËÌ· ÛÙ· ·È‰È¿ ıˆÚÂ›Ù·È Ô Â·Ó·Ï·Ì‚·ÓfiÌÂÓÔ˜ ‹ ÂÚÈÔ‰ÈÎfi˜ £¶, ·Ó ηÈ, ÛÙȘ ‰ËÌÔÛÈÂ˘Ì¤Ó˜ ηٷÁڷʤ˜ Û˘¯ÓfiÙËÙ·˜, ‰ÂÓ Á›ÓÂÙ·È ¿ÓÙÔÙÂ Ë ‰È¿ÎÚÈÛË ·˘Ù‹ (6,7,12). √È Selbst Î·È Û˘Ó (13) ·Ó·Ê¤ÚÔ˘Ó Û˘¯ÓfiÙËÙ· ÚÔÛ¤Ï¢Û˘ Û ·È‰È·ÙÚÈÎfi Â͈ÙÂÚÈÎfi È·ÙÚÂ›Ô ÁÈ· £¶, 6:1000. √ £¶ ·Ó·Ê¤ÚÂÙ·È ·fi ÙÔ˘˜ Brenner Î·È Û˘Ó (14) Î·È ·fi ÙÔÓ Fyfe (15) ˆ˜ Ë ‰Â‡ÙÂÚË ÌÂÙ¿ Ù· Ê˘Û‹Ì·Ù· ·ÈÙ›· ÚÔÛ¤Ï¢Û˘ Û ·È‰ÔηډÈÔÏÔÁÈÎfi Â͈ÙÂÚÈÎfi È·ÙÚ›Ô. ™ÙÔÓ ÂÏÏËÓÈÎfi ¯ÒÚÔ, Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ £¶ ÛÙÔ ·È‰È·ÙÚÈÎfi Â͈ÙÂÚÈÎfi È·ÙÚÂ›Ô ‹Ù·Ó, ÛÙË ÌÂϤÙË ÙˆÓ ∫Ô˘ÎÔ˘ÙÛ¿ÎË Î·È Û˘Ó (16), 0,18% ‹ ÂÚ›Ô˘ 2:1000. ™ÙË ‰È΋ Ì·˜ ∫ÏÈÓÈ΋, Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ £¶ ˆ˜ ·ÈÙ›· ÚÔÛ¤Ï¢Û˘ ÛÙÔ Â͈ÙÂÚÈÎfi È·ÙÚÂ›Ô ÂÂÈÁfiÓÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ‹Ù·Ó 77 Û 18570 ÂÚÈÙÒÛÂȘ (0,45%), ÂÓÒ ÛÙÔ ·È‰ÔηډÈÔÏÔÁÈÎfi Â͈ÙÂÚÈÎfi È·ÙÚ›Ô, ‹Ù·Ó 7 ÛÙ· 100 ·È‰È¿ ηٿ ̤ÛÔ fiÚÔ, ·ÔÙÂÏÒÓÙ·˜ ÙËÓ 3Ë ·ÈÙ›· ÚÔÛ¤Ï¢Û˘ (17). ∆¤ÏÔ˜, Ë ‰ÈÂÚ‡ÓËÛË Ù˘¯fiÓ Î·Ú‰È·Î‹˜ ·ÈÙÈÔÏÔÁ›·˜ Û ·È‰È¿ Ì £¶ ··Û¯fiÏËÛ ηٿ ÙËÓ ÚÔËÁÔ‡ÌÂÓË ÂÓÙ·ÂÙ›· ÙÔ ¶·È‰ÔηډÈÔÏÔÁÈÎfi ¢È·ÁÓˆÛÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈfi Ì·˜ Û ·Ó·ÏÔÁ›· 2,59% (58/2236 ÂÚÈÙÒÛÂȘ). ∏ Û˘¯ÓfiÙËÙ· ÙÔ˘ £¶ ·Ó¤Ú¯ÂÙ·È Ì ÙËÓ ËÏÈΛ·, Ì ÎÔڇʈÛË ÛÙËÓ ÚÔÂÊË‚È΋. ª¤ÛË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ Ì £¶ Â›Ó·È ·˘Ù‹ ÙˆÓ 13 ¯ÚfiÓˆÓ. ¢ÂÓ ˘¿Ú¯Ô˘Ó ‰È·ÊÔÚ¤˜ ˆ˜ ÚÔ˜ ÙÔ Ê‡ÏÔ (Û¯¤ÛË ·ÁÔÚÈÒÓ:ÎÔÚÈÙÛÈÒÓ = 1:1), ˘¿Ú¯Ô˘Ó fï˜ ‰È·ÊÔÚ¤˜ ˆ˜ ÚÔ˜ ÙȘ › ̤ÚÔ˘˜ Û˘¯ÓfiÙËÙ˜, ·Ó¿ÏÔÁ· Ì ÙËÓ ·ÈÙÈÔÏÔÁ›·. ÷ڷÎÙËÚÈÛÙÈÎfi ·Ú¿‰ÂÈÁÌ· ·ÔÙÂÏ› ÙÔ fiÙÈ Ë Û¯ÂÙÈο ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· ÙˆÓ
Paediatriki 2001;64:115-124
ηډÈÔ·Ó·Ó¢ÛÙÈÎÒÓ ·ÈÙ›ˆÓ ·Ó·Ì¤ÓÂÙ·È Û ËÏÈ˘ οو ÙˆÓ 12 ¯ÚfiÓˆÓ, ÂÓÒ ÙˆÓ „˘¯ÔÁÂÓÒÓ ·ÈÙ›ˆÓ Î·È Ù˘ ÔÛÙÂÔ¯ÔÓ‰Ú›Ùȉ·˜, Û ÎÔÚ›ÙÛÈ· ¿Óˆ ÙˆÓ 12 ¯ÚfiÓˆÓ. √ ¯ÚfiÓÈÔ˜ ·ӷϷ̂·ÓfiÌÂÓÔ˜ £¶ ‰È·ÚΛ ̤¯ÚÈ 3 ¯ÚfiÓÈ· Û ÔÛÔÛÙfi 45-69% Î·È ¿Óˆ ·fi 3 ¯ÚfiÓÈ· ÛÙÔ 19% ÙˆÓ ·È‰ÈÒÓ Ì £¶, ÂÓÒ Î·Ó¤Ó· ·fi Ù· ·È‰È¿ Ô˘ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÁÈ· ÂÚÈÛÛfiÙÂÚÔ ·fi 3 ¯ÚfiÓÈ·, ‰ÂÓ ·Ó¤Ù˘Í οÔÈ· ÛÔ‚·Ú‹ ¿ıËÛË (18-22). ∞fi ÙÔ˘˜ 103 ‰ÈÎÔ‡˜ Ì·˜ ·ÛıÂÓ›˜ Ì £¶, ¯ÚfiÓÈÔ˜ ·ӷϷ̂·ÓfiÌÂÓÔ˜ (ÂÚÈÔ‰ÈÎfi˜) £¶ ˘‹Ú¯Â ÛÙÔ 65%. ∞ÈÙÈÔÏÔÁ›· ÙÔ˘ £¶ ÛÙËÓ ·È‰È΋ ËÏÈΛ· ∫Ú›ÓÂÙ·È ÛÎfiÈÌË Ë ·Ú¿ıÂÛË ÙÔ˘ ›Ó·Î· 2, Ì ٷ ›‰Ë ÙÔ˘ £¶ ηډȷ΋˜ ·ÈÙÈÔÏÔÁ›·˜ ÙÔ˘ ÂÓ‹ÏÈÎÔ˘ (24,25), Ì ٷ ÔÔ›· ÌÔÚ› Ó· Á›ÓÂÙ·È ‰È·ÁÓˆÛÙÈ΋ Û‡Á¯˘ÛË Î·È Ù· ÔÔ›· ÌÔÚ› Ó· ÌÈÌÔ‡ÓÙ·È ÔÏÏ¿ ·È‰È¿ ÚÔÂÊË‚È΋˜ ËÏÈΛ·˜. ™ÙÔÓ ÂÓ‹ÏÈÎÔ, Ù· ηډȷÁÁÂȷο ·›ÙÈ· Â›Ó·È ·ÈÙ›· £¶ Û ÌÂÁ·Ï‡ÙÂÚË ·Ó·ÏÔÁ›· Û˘ÁÎÚÈÙÈο Ì ÙËÓ ·È‰È΋ ËÏÈΛ·. ™Â fiϘ fï˜ ÙȘ ËÏÈ˘, ۯ‰fiÓ Î¿ı ÛËÌÂ›Ô ÙÔ˘ ıÒڷη ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ÂÛÙ›· Á¤ÓÂÛ˘ £¶ (™¯‹Ì· 1) (24-26). ∏ ‰È¿ÎÚÈÛË ÙÔ˘ £¶ Û Ô͇ Î·È Â·Ó·Ï·Ì‚·ÓfiÌÂÓÔ ‹ ÂÚÈÔ‰ÈÎfi ‰È¢ÎÔχÓÂÈ Î·Ï‡ÙÂÚ· ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Î·È ÙË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË (27). ™ÙÔÓ ›Ó·Î· 3 ·Ó·ÁÚ¿ÊÔÓÙ·È Ù· ΢ÚÈfiÙÂÚ· ·›ÙÈ· ÙÔ˘ ÔͤԘ £¶ (10,13-15,20,21,28) Î·È ÛÙÔÓ ›Ó·Î· 4, ÙÔ˘ ·ӷϷ̂·ÓfiÌÂÓÔ˘ ‹ ÂÚÈÔ‰ÈÎÔ‡ £¶ ÙˆÓ ·È‰ÈÒÓ (7,13-15,19,20,22). ∂Ӊ›ÍÂȘ ÛÔ‚·ÚfiÙËÙ·˜ ÙÔ˘ ÔͤԘ £¶ ›ӷÈ: Ë ˆ¯ÚfiÙËÙ·, Ë
¶›Ó·Î·˜ 2. √ £¶ ηډȷÁÁÂȷ΋˜ ·ÈÙÈÔÏÔÁ›·˜ ÛÙÔÓ ÂÓ‹ÏÈη. √ÚÈÛÌÔ› Î·È ÎÏÈÓÈ΋ ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË (4,23-25) ™ÙÔ Ô͇ ¤ÌÊÚ·ÁÌ·, Ô £¶ Â›Ó·È Ô͇˜, ̤ÙÚÈ·˜ ‹ ÌÂÁ¿Ï˘ ¤ÓÙ·Û˘, ‰È¿ÚÎÂÈ·˜ >30 min, Ì ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÂÈÎfiÓ· Î·È ÂÓÙfiÈÛË ÛÙÔ ÚfiÛıÈÔ ıˆÚ·ÎÈÎfi ÙÔ›¯ˆÌ· Î·È ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÂÂÎÙ¿ÛÂȘ, fiˆ˜ ‚¿ÚÔ˜, ›ÂÛË, ο„ÈÌÔ ‹ ÛÊ›ÍÈÌÔ, Û˘¯Ó¿ ÂÂÎÙÂÈÓfiÌÂÓÔ ÛÙÔÓ ÙÚ¿¯ËÏÔ, ÙËÓ Î¿Ùˆ ÁÓ¿ıÔ, ÙË Ú¿¯Ë Î·È Ù· ¿Óˆ ¿ÎÚ·. √ fiÓÔ˜ ·˘Ùfi˜ ‰ÂÓ ˘Ê›ÂÙ·È Ì ÙË ¯Ú‹ÛË ÓÈÙÚˆ‰ÒÓ. ∏ ÛÙ·ıÂÚ‹ ‹ Ù˘È΋ ÛÙËı¿Á¯Ë ÚÔÛ¿ıÂÈ·˜ Â›Ó·È ÚÔοډÈÔ˜ fiÓÔ˜, Ô˘ ¤¯ÂÈ ÙÔ˘˜ ›‰ÈÔ˘˜, fiˆ˜ ÈÔ ¿Óˆ, ÎÏÈÓÈÎÔ‡˜ ¯·Ú·ÎÙ‹Ú˜, ·ÏÏ¿ ÂÌÊ·Ó›˙ÂÙ·È ÛÙË ‰È¿ÚÎÂÈ· ۈ̷ÙÈ΋˜ ¿ÛÎËÛ˘ ‹ „˘¯È΋˜ ¤ÓÙ·Û˘, ‰ËÏ. fiÙ·Ó ·˘Í¿ÓÔÓÙ·È ÔÈ ·Ó¿ÁΘ ÙÔ˘ Ì˘Ôηډ›Ô˘ Û Ô͢ÁfiÓÔ. ∆· ÈÔ ¿Óˆ Ê·ÈÓfiÌÂÓ· ˘Ô¯ˆÚÔ‡Ó ÌÂÙ¿ ·fi 5 min ÂÚ›Ô˘, Ì ÙË ‰È·ÎÔ‹ Ù˘ ÚÔÛ¿ıÂÈ·˜ ‹ ÙË Ï‹„Ë ˘ÔÁÏÒÛÛÈˆÓ ÓÈÙÚˆ‰ÒÓ ‰ÈÛΛˆÓ. ∏ ·ÛÙ·ı‹˜ ÛÙËı¿Á¯Ë ÔÊ›ÏÂÙ·È Û ÂÏ·Ùو̤ÓË ÚÔÛÊÔÚ¿ Ô͢ÁfiÓÔ˘ ÛÙÔ Ì˘ÔοډÈÔ ÏfiÁˆ ÂÏ¿ÙÙˆÛ˘ Ù˘ ÚÔ‹˜ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜ ·fi ıÚfiÌ‚Ô ‹ ·fi Û·ÛÌfi Î·È ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÛÙËı·Á¯È΋˜ Û˘Ìو̷ÙÔÏÔÁ›·˜ Û ÌÈÎÚ‹ ÎfiˆÛË ‹ Î·È Î·Ù¿ ÙËÓ ËÚÂÌ›·. ÷ڷÎÙËÚÈÛÙÈο, ¤گÂÙ·È Ì ÎÚ›ÛÂȘ Î·È ¤¯Ô˘Ó ÚÔÙ·ı› 3 ÛÙ¿‰È· ‚·Ú‡ÙËÙ·˜: 1) ¶ÚfiÛÊ·ÙË ÛÙËı¿Á¯Ë – ÂÚÈÛÛfiÙÂÚ˜ ·fi 3 ÎÚ›ÛÂȘ ÙËÓ Ë̤ڷ - fi¯È ÛÙËı¿Á¯Ë ·Ó¿·˘Û˘, 2) ÀÔÍ›· ÛÙËı¿Á¯Ë ·Ó¿·˘Û˘, .¯. › 1 Ì‹Ó· Î·È 3) ™ÙËı¿Á¯Ë ·Ó¿·˘Û˘ ÙȘ ÙÂÏÂ˘Ù·›Â˜ 48 ÒÚ˜. ∂ÎÙfi˜ ·fi ÙËÓ ·ıËÚÔÛÎÏËÚ˘ÓÙÈ΋ Ͽη, ¿ÏϘ ·Èٛ˜ ·ÛÙ·ıÔ‡˜ ÛÙËı¿Á¯Ë˜ Â›Ó·È ·˘Ù¤˜ Ô˘ ÂÏ·ÙÙÒÓÔ˘Ó ÙËÓ ÚÔÛÊÔÚ¿ Ô͢ÁfiÓÔ˘ ÛÙÔ Ì˘ÔοډÈÔ ‹ Ô˘ ·˘Í¿ÓÔ˘Ó ÙËÓ Î·Ù·Ó¿ÏˆÛË Ô͢ÁfiÓÔ˘ ÙÔ˘ Ì˘Ôηډ›Ô˘, fiˆ˜ Ë ·Ó·ÈÌ›·, Ë ˘fiÙ·ÛË, Ë ˘¤ÚÙ·ÛË, Ô ˘ÚÂÙfi˜, ÔÈ ·ÚÚ˘ı̛˜, Ë ˘ÔÍ›· Î·È Ë ı˘ÚÂÔÙÔ͛ΈÛË. ∏ ÌÈÎÚ·ÁÁÂȷ΋ ÛÙËı¿Á¯Ë (‹ Û‡Ó‰ÚÔÌÔ Ã), Û˘¯ÓfiÙÂÚË ÛÙȘ Á˘Ó·›Î˜, Â›Ó·È Ù˘È΋ ÛÙËı¿Á¯Ë, ¯ˆÚ›˜ Ó· ˘¿Ú¯ÂÈ ·fiÊÚ·ÍË, Ô‡Ù ۷ÛÌfi˜ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ ·ÏÏ¿ Ô‡Ù ÎÈ ÂÛÊ·Ï̤ÓË ·ÓÙ›ÏË„Ë ÙÔ˘ fiÓÔ˘. §¤ÁÂÙ·È ÌÈÎÚ·ÁÁÂȷ΋, ÂÂȉ‹ ‚Ï¿‚˜ ‚Ú›ÛÎÔÓÙ·È ÌfiÓÔ ÛÙȘ ÌÈÎÚ¤˜ ·ÚÙËڛ˜, Ù· ·ÚÙËÚ›‰È· Î·È Èı·ÓÒ˜ ÛÙÔ Ì˘ÔηډȷÎfi ·ÙÙ·ÚÔ. √ fiÓÔ˜ Ù˘ Ó¢ÌÔÓÈ΋˜ ÂÌ‚ÔÏ‹˜ ÌÔÈ¿˙ÂÈ Ì ÙË ÛÙËı¿Á¯Ë, ·ÏÏ¿ ÂÓÙÔ›˙ÂÙ·È ÛÙÔ Ï¿ÁÈÔ ıˆÚ·ÎÈÎfi ÙÔ›¯ˆÌ· ÎÈ ÂÌÊ·Ó›˙ÂÙ·È Û˘Ó‹ıˆ˜ Û ÎÏÈÓ‹ÚÂȘ ·ÚÚÒÛÙÔ˘˜. √ fiÓÔ˜ ÙÔ˘ ·ÔÚÙÈÎÔ‡ ‰È·¯ˆÚÈÛÌÔ‡ Â›Ó·È ·ÈÊÓ›‰ÈÔ˜ Û ·ÛıÂÓ›˜ Ì ÈÛÙÔÚÈÎfi ·ÚÙËÚȷ΋˜ ˘¤ÚÙ·Û˘, ·ÓÙ·Ó·ÎÏ¿ ¯·Ú·ÎÙËÚÈÛÙÈο ÛÙË Ú¿¯Ë Î·È ÂÈÙ›ÓÂÙ·È Ù·¯‡Ù·Ù·, ̤۷ Û 3 min, ÂÁηı›ÛÙ·Ù·È Î·È ÌÔÚ› Ó· ÂÈ̤ÓÂÈ ÁÈ· ÔÏϤ˜ ÒÚ˜, ·Ú¿ ÙȘ ÌÂÁ¿Ï˜ ‰fiÛÂȘ ·Ó·ÏÁËÙÈÎÒÓ Ê·Ú̿ΈÓ.
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¶·È‰È·ÙÚÈ΋ 2001;64:115-124
∂ÁΤʷÏÔ˜ √ÈÛÔÊ¿ÁÔ˜ ∆Ú·¯Â›· ∫Ï›‰Â˜ ∂Ï¿ÛÛˆÓ £ˆÚ·ÎÈÎfi˜ ª˘˜ ªÂ›˙ˆÓ £ˆÚ·ÎÈÎfi˜ ª˘˜ £ˆÚ·ÎÈÎfi ÙÔ›¯ˆÌ· µÚfiÁ¯ÔÈ ¶Ó‡ÌÔÓ˜ ∫·Ú‰È¿ ™ÙfiÌ·¯Ô˜ ¶¿ÁÎÚ·˜ - ¢ˆ‰Âη‰¿ÎÙ˘ÏÔ
Paediatriki 2001;64:115-124
™Ù¤ÚÓÔ ÃÔÓ‰ÚÔÏ¢ÚÈΤ˜ ·ÚıÚÒÛÂȘ
¶ÂÚÈοډÈÔ ∞ÚÈÛÙÂÚ‹ ÛÙÂÊ·ÓÈ·›· ·ÚÙËÚ›· ¢ÂÍÈ¿ ÛÙÂÊ·ÓÈ·›· ·ÚÙËÚ›·
™¯‹Ì· 1. ∂Ó‰ÂÈÎÙÈ΋ ÙÔÔÁÚ·ÊÈ΋ ·Ó·ÙÔÌÈ΋ ÂÓÙfiÈÛË ÙÔ˘ £¶.
·Ó·Ó¢ÛÙÈ΋ ‰‡ÛÓÔÈ·, Ë ·Ó·Ó¢ÛÙÈ΋ ÚÔÛ¿ıÂÈ· Î·È Ë Î˘¿ÓˆÛË. ø˜ ÚÔ˜ ÙË ÁÂÓÈ΋ Û˘¯ÓfiÙËÙ·, ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›·, Û¿ÓÈ· Á›ÓÂÙ·È Û·Ê‹˜ ‰È¿ÎÚÈÛË ÌÂٷ͇ ÔͤԘ Î·È Â·Ó·Ï·Ì‚·ÓfiÌÂÓÔ˘ £¶, ÂÓÒ ÔÈ Â› ̤ÚÔ˘˜ Û˘¯ÓfiÙËÙ˜ ÙˆÓ ·ÈÙ›ˆÓ ÙÔ˘ £¶ ÛÙ· ·È‰È¿ Î·È ÛÙÔ˘˜ ¤ÊË‚Ô˘˜ ‰È·Ê¤ÚÔ˘Ó ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ‰È·ÊfiÚˆÓ Û˘ÁÁڷʤˆÓ, ·Ó¿ÏÔÁ· Ì ÙËÓ ÚԤϢÛË ÙˆÓ ·ÚÚÒÛÙˆÓ (·È‰È·ÙÚÈÎfi, ·È‰ÔηډÈÔÏÔÁÈÎfi ÎÏ. Â͈ÙÂÚÈÎfi È·ÙÚ›Ô). √È ‚È‚ÏÈÔÁÚ·ÊÈο ·Ó·ÊÂÚfiÌÂÓ˜ ·ÈÙÈÔÏÔÁÈΤ˜ Û˘¯ÓfiÙËÙ˜ ÌÔÚÔ‡Ó Ó· Û˘ÓÔ„ÈÛÙÔ‡Ó ÛÙ· ·Ú·Î¿Ùˆ: ·) “ȉÈÔ·ı‹˜” ·ÈÙÈÔÏÔÁ›·: 12-85%, ‚) Ì˘ÔÛÎÂÏÂÙÈο ·›ÙÈ·: 15-31%, Á) Ó¢ÌÔÓÈο ·›ÙÈ·: 12-21%, ‰) „˘¯È·ÙÚÈο-„˘¯Ôۈ̷ÙÈο ·›ÙÈ·: 5-17%, Â) Á·ÛÙÚÂÓÙÂÚÈο ·›ÙÈ·: 4-7%, ÛÙ) ‰È¿ÊÔÚ· ·›ÙÈ·: 4-21% Î·È ˙) ηډÈÔÁÂÓ‹ ·›ÙÈ·: 1-6% (1,7,15-17,19-22,26-30). ∞fi ÔÚÈṲ̂ÓÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÈÛÙ‡ÂÙ·È fiÙÈ Ë Û˘¯ÓfiÙËÙ· Ù˘ ȉÈÔ·ıÔ‡˜ ·ÈÙÈÔÏÔÁ›·˜ ÛÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· Â›Ó·È ÌÈÎÚ‹, ‹ ÙÔ˘Ï¿¯ÈÛÙÔÓ ÌÈÎÚfiÙÂÚË ·’ fiÛÔ ıˆÚÔ‡ÓÙ·Ó Ì¤¯ÚÈ Û‹ÌÂÚ·. ™ÙÔÓ ›Ó·Î· 5 ηٷÁÚ¿ÊÔÓÙ·È ÏÂÙÔÌÂÚÒ˜ Ù· Â͈ηډȷο ·›ÙÈ· £¶ ÛÙ· ·È‰È¿ (7,13-15,19,21,22,26,31,32). ∞fi ÙÔ ¶·È‰È·ÙÚÈÎfi Â͈ÙÂÚÈÎfi È·ÙÚÂ›Ô Ù˘ ‰È΋˜ Ì·˜ ∫ÏÈÓÈ΋˜, ·Ú·¤ÌÊıËÎ·Ó Ì¤Û· Û 2,5 ¯ÚfiÓÈ· ÁÈ· ·È‰ÔηډÈÔÏÔÁÈ΋ ÂͤٷÛË 103 ·È‰È¿ Ì £¶, Ù· ÔÔ›· ÌÂÏÂÙ‹ıËÎ·Ó Î·Ú‰ÈÔÏÔÁÈο ¶›Ó·Î·˜ 3. ™˘Ó‹ıË ·›ÙÈ· ÙÔ˘ ÔͤԘ £¶ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (10,13-15,19,20,27) ∫∞ƒ¢π∞∫∞ ∞π∆π∞ ∂•ø∫∞ƒ¢π∞∫∞ ∞π∆π∞ 1. ¶ÂÚÈηډ›Ùȉ· 1. ¶Ó¢ÌÔÓÈο ·›ÙÈ·: 2. ∆Ú·‡Ì· - ·ÈÌÔÂÚÈοډÈÔ ·. ¶Ó¢ÌÔıÒڷη˜ 3. ∞ÚÚ˘ı̛˜ ‚. ¶Ó¢ÌÔÓ›· + Ï¢ڛÙȉ· 4. ÃÚ‹ÛË ÎÔη˝Ó˘ Á. ¶Ï¢ÚÔ‰˘Ó›· 2. √ÈÛÔÊ·ÁÈο ·›ÙÈ·: ·. √Í›· ÔÈÛÔÊ·Á›Ùȉ· ‚. ∫·Ù¿ÔÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜
118
(ÂÎÙfi˜ ·fi ‰ÔÎÈ̷ۛ˜ ÎfiˆÛ˘). ™Â 34 ·fi ·˘Ù¿ (33%) ˘‹Ú¯·Ó ηډÈÔÏÔÁÈο Â˘Ú‹Ì·Ù· Ô˘ ÌÔÚÔ‡Ó Ó· Û¯ÂÙÈÛıÔ‡Ó Ì ÙÔÓ ·Ó·ÊÂÚfiÌÂÓÔ ·fi Ù· ·È‰È¿ £¶. ∏ ‰ÈÂÚ‡ÓËÛË Ù˘ ·ÈÙÈÔÏÔÁ›·˜ ÙˆÓ ˘fiÏÔÈˆÓ ·¤‰ÂÈÍÂ Ì˘ÔÛÎÂÏÂÙÈ΋ ·ÈÙÈÔÏÔÁ›· Û 20 (19,4%), Ó¢ÌÔÓÈ΋ Û 4 (3,8%), „˘¯Ôۈ̷ÙÈ΋ Û 21 (20,3%), Á·ÛÙÚÂÓÙÂÚÈ΋ Û 8 (7,7%). ™Â 16 ·È‰È¿ (15,6%) ‰ÂÓ ·Ô‰Â›¯ÙËΠη̛· ·ÈÙ›·. ø˜ ÚÔ˜ Ù· ηډÈÔÏÔÁÈο ·›ÙÈ·, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ Û˘ÁÁÚ·Ê›˜ ÚÔÙÈÌÔ‡Ó ÙËÓ Ù·ÍÈÓfiÌËÛ‹ ÙÔ˘˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ·Ó·ÙÔÌÈ΋ ‚Ï¿‚Ë (14,16,26). ∏ › ̤ÚÔ˘˜ ·Ó·ÏÔÁ›· ÙˆÓ Î·Ú‰ÈÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ Û 34/103 ‰ÈÎÔ‡˜ Ì·˜ Â͈ÙÂÚÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì £¶ ‹Ù·Ó: ÚfiÙˆÛË Ù˘ ÌÈÙÚÔÂȉԇ˜ 47%, ·ÚÚ˘ı̛˜ 38,2%, ¿ÏϘ ‰È·Ù·Ú·¯¤˜ Ù˘ ÌÈÙÚÔÂȉԇ˜ (·Ï‹ ‰È¿Ù·ÛË ‰·ÎÙ˘Ï›Ô˘, ÌÂÌÔӈ̤ÓË ¿¯˘ÓÛË Áψ¯›Ó·˜ ÎÏ.) 8,8%, ÂÚÈηډ›Ùȉ· 2,9%, Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ 2,9% (™¯‹Ì· 2). √ £¶ ¤¯ÂÈ È‰È¿˙Ô˘Û· ÛËÌ·Û›· fiÙ·Ó ·ÔηχÙÂÙ·È Î·Ú‰ÈÔÏÔÁÈ΋ ·ÈÙ›·. ∂ȉÈ΋, fï˜, ÚÔÁÓˆÛÙÈ΋ ‚·Ú‡ÙËÙ· ¤¯ÂÈ ÛÙȘ ·ı‹ÛÂȘ Ù˘ ·ÔÚÙ‹˜ Î·È ÛÙȘ Ì˘ÔηډÈÔ¿ıÂȘ, fiÔ˘ Ë ÂÌÊ¿ÓÈÛË ÙÔ˘ fiÓÔ˘ ÛËÌ·›ÓÂÈ ÂÏ¿ÙÙˆÛË ·ÚÔ¯‹˜ Ô͢ÁfiÓÔ˘ ÛÙÔÓ Î·Ú‰È·Îfi Ì˘, ÔfiÙ ÌÔÚ› Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ Û˘ÁÎÔÈ΋ ÎÚ›ÛË, ·ÈÊÓ›‰È· ·ÚÚ˘ıÌ›· ‹ ·ÈÊÓ›‰ÈÔ˜ ı¿Ó·ÙÔ˜. ™ÙȘ ·ı‹ÛÂȘ ·˘Ù¤˜ Ô £¶ ÂÌÊ·Ó›˙ÂÙ·È Ì ÙËÓ ÂÈÎfiÓ· Ù˘ ÛÙËı¿Á¯Ë˜, fiˆ˜ ·˘Ù‹ Â›Ó·È ÁÓˆÛÙ‹ ·fi ÙÔ˘˜ ÂÓ‹ÏÈΘ, ÁÈ’·˘Ùfi Î·È ·ÔÎÙ¿ Ôχ ÌÂÁ¿ÏË ‰È·ÁÓˆÛÙÈ΋ Î·È ÚÔÁÓˆÛÙÈ΋ ÛËÌ·Û›· Ë Û˘Û¯¤ÙÈÛË Ù˘ ÂÌÊ¿ÓÈÛ˘ ÙÔ˘ £¶ Ì ÙË ÛˆÌ·ÙÈ΋ ÎfiˆÛË ‹ ÙÔ „˘¯ÈÎfi stress. ÕÏϘ ηډȷΤ˜ ·ı‹ÛÂȘ, fiˆ˜ .¯. Ë ÚfiÙˆÛË Ù˘ ÌÈÙÚÔÂȉԇ˜, ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ôχ Û˘¯Ó¿ (̤¯ÚÈ Î·È 30%) £¶, ·ÏÏ¿ ‰ÂÓ ˘¿Ú¯ÂÈ Î›Ó‰˘ÓÔ˜ ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ (29,31,32), ÙÔ˘Ï¿¯ÈÛÙÔÓ ÁÈ· ÙËÓ ·È‰È΋ ËÏÈΛ·. ∫ÏÈÓÈο Û‡Ó‰ÚÔÌ· Ì £¶ ȉȷ›ÙÂÚ˘ ÛËÌ·Û›·˜ ªË ηډȷ΋˜ ·ÈÙÈÔÏÔÁ›·˜ 1. ¶Ï¢ÚÔ¯ÔÓ‰Ú›Ùȉ·: ∂›Ó·È ·fi ÙȘ Û˘¯ÓfiÙÂÚ˜
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·Èٛ˜ £¶ Ì˘ÔÛÎÂÏÂÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜. ¶ÔÏÏÔ› ÛÙÔÓ ›‰ÈÔ fiÚÔ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ÙÔ “Ï¢ÚÔÛÙÂÚÓÈÎfi Û‡Ó‰ÚÔÌÔ”, ÙÔ “ıˆÚ·ÎÈÎfi Û‡Ó‰ÚÔÌÔ” Î·È ÙËÓ “Ï¢ÚÔÛÙÂÚÓÈ΋ ¯ÔÓ‰ÚÔ‰˘Ó›·”. ∏ Ï¢ÚÔ¯ÔÓ‰Ú›Ùȉ· Û˘Ó‰˘¿˙ÂÙ·È Ì Ïԛ̈ÍË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Î·È Ì ÎfiˆÛË. √ fiÓÔ˜ Â›Ó·È ·ÚÎÂÙ¿ ¯·Ú·ÎÙËÚÈÛÙÈÎfi˜: ÂÓÙÔ›˙ÂÙ·È Û˘Ó‹ıˆ˜ ÛÙÔ ‡„Ô˜ Ù˘ 4˘6˘ ÏÂ˘Ú¿˜, ‹ ÂÂÎÙ›ÓÂÙ·È ÛÙËÓ Ï¿ÙË ‹ ÛÙÔ ÂÈÁ¿ÛÙÚÈÔ (27). 2. ™‡Ó‰ÚÔÌÔ ÙÔ˘ ÚÔοډÈÔ˘ ȷ̷ۛÙÔ˜ (“precordial catch syndrome”): ∂›Ó·È Ô͇˜ fiÓÔ˜ ¿ÁÓˆÛÙ˘ ·ÈÙÈÔÏÔÁ›·˜, Ì ÂÈÎfiÓ· „¢‰ÔÛÙËı¿Á¯Ë˜, ‰È¿ÚÎÂÈ·˜ 0,5-5 min, Ì ÂÓÙfiÈÛË ÛÙËÓ ÎÔÚ˘Ê‹ Ù˘ ηډȿ˜. ∂·Ó·Ï·Ì‚¿ÓÂÙ·È ÔÏϤ˜ ÊÔÚ¤˜ ÙËÓ Ë̤ڷ Î·È Â¤Ú¯ÂÙ·È Î·Ù¿ ÎÚ›ÛÂȘ Ô˘ ‚·ıÌÈ·›· ·Ú·ÈÒÓÔ˘Ó (26,33). 3. ™‡Ó‰ÚÔÌÔ Tietze: Œ¯ÂÈ ÂÈÎfiÓ· ·ÚfiÌÔÈ· Ì ÙË Ï¢ÚÔ¯ÔÓ‰Ú›Ùȉ·, ·ÏÏ¿ ·fi ÙÔ ÈÛÙÔÚÈÎfi ·ÔηχÙÂÙ·È ÌÈÎÚfi˜ ‹ Î·È ·Ê·Ó‹˜ ÙÚ·˘Ì·ÙÈÛÌfi˜. ∏
Paediatriki 2001;64:115-124
ÎÏÈÓÈ΋ ‰È¿ÎÚÈÛ‹ ÙÔ˘ ÛÙËÚ›˙ÂÙ·È ÛÙËÓ ·Ó‡ÚÂÛË ÂÙÂÚfiÏ¢ÚÔ˘ ·ÙÚ·ÎÙfiÌÔÚÊÔ˘ Ôȉ‹Ì·ÙÔ˜, ÂÓÒ Ô fiÓÔ˜ Á›ÓÂÙ·È ÈÔ ¤ÓÙÔÓÔ˜ Ì ÙÔ ‚‹¯·, ÙÔ ÊÙ¿ÚÓÈÛÌ· Î·È ÙËÓ Î›ÓËÛË. ∂›Ó·È Û¿ÓÈÔ ÛÙ· ·È‰È¿ (26). √È ÈÔ ¿Óˆ ·ÚÎÂÙ¿ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ ÎÏÈÓÈΤ˜ ÂÈÎfiÓ˜ ʤÚÔÓÙ·È Î·È Ì ÙËÓ ÔÓÔÌ·Û›· “Û‡Ó‰ÚÔÌÔ ÙÔ˘ ıˆÚ·ÎÈÎÔ‡ ÙÔȯÒÌ·ÙÔ˜” (27). 4. æ˘¯ÔÁÂÓ‹ ·›ÙÈ·: ∆· „˘¯ÔÁÂÓ‹ ·›ÙÈ· ÛÙËÓ ·È‰È΋ ËÏÈΛ· ˆ˜ ·ÈÙ›· £¶ ÂÌÊ·Ó›˙ÔÓÙ·È ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 7-9 ¯ÚfiÓˆÓ. ∏ ÌÂÁ¿ÏË ‰È·ÊÔÚ¿ Û˘¯ÓfiÙËÙ·˜ ÌÂٷ͇ ÙˆÓ Û˘ÁÁڷʤˆÓ ÔÊ›ÏÂÙ·È Ì¿ÏÏÔÓ ÛÙÔ fiÙÈ Ù· „˘¯ÔÁÂÓ‹ ·›ÙÈ· Ù·˘Ù›˙ÔÓÙ·Ó Ì ٷ ȉÈÔ·ı‹ (5-17%). ™Ù· „˘¯ÔÁÂÓ‹ ·›ÙÈ· ηٷٿÛÛÔÓÙ·È ÔÈ „˘¯ÔÓÂ˘ÚˆÙÈΤ˜ ·ÓÙȉڿÛÂȘ ÙˆÓ ·È‰ÈÒÓ ÏfiÁˆ ·ÚÓËÙÈÛÌÔ‡ ‹ ÏfiÁˆ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÊÔÚÙÈṲ̂ÓÔ˘ Ì ¤ÓÙÔÓÔ „˘¯ÔÏÔÁÈÎfi stress, ÙÔ Û‡Ó‰ÚÔÌÔ ˘ÂÚ·ÂÚÈÛÌÔ‡, Ë „˘¯ÔÁÂÓ‹˜ ‚Ô˘ÏÈÌ›· (Ë ÔÔ›· ÚÔηÏ› ÔÈÛÔÊ·Á›Ùȉ·) Î·È ÙÚ·‡Ì·Ù· ÙÔ˘ ıÒڷη ·fi ηÎÔÌÂÙ·¯Â›ÚÈÛË ÙÔ˘ ·È‰ÈÔ‡
¶›Ó·Î·˜ 4. ™˘Ó‹ıË ·›ÙÈ· ÙÔ˘ ·ӷϷ̂·ÓfiÌÂÓÔ˘ (˘ÔÙÚÔÈ¿˙ÔÓÙÔ˜) £¶ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (7,13-15,19,20,22) ∫∞ƒ¢π∞∫∞ ∞π∆π∞ ∞. ªÂ ÈÛ¯·ÈÌ›· Ì˘Ôηډ›Ô˘ 1. ªÂÁ¿ÏË ˘ÂÚÙÚÔÊ›· ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜ ·. ∞ÔÊÚ·ÎÙÈΤ˜ ‚Ï¿‚˜ ‚. ¶Ó¢ÌÔÓÈ΋ ˘¤ÚÙ·ÛË 2. ¡fiÛÔ˜ Kawasaki µ. ªÂ ÂÚÈηډȷ΋ Û˘ÏÏÔÁ‹ 1. π‰ÈÔ·ı‹˜ (ÈÔÁÂÓ‹˜) ÂÚÈηډ›Ùȉ· 2. ™‡Ó‰ÚÔÌÔ ÌÂÙ¿ ÂÚÈηډÈÔÙÔÌ‹ °. ∞ÚÚ˘ı̛˜ ¢. ¶ÚfiÙˆÛË Ù˘ ÌÈÙÚÔÂȉԇ˜
∂•ø∫∞ƒ¢π∞∫∞ ∞π∆π∞ ∞. ªË ÔÚÁ·ÓÈο ·›ÙÈ· 1. π‰ÈÔ·ı‹˜ 2. æ˘¯ÔÁÂÓ‹˜ µ. ÕÏÏ· ·›ÙÈ· 1. ¶Ï¢ÚÔ¯ÔÓ‰Ú›Ùȉ· 2. √ÈÛÔÊ·Á›Ùȉ· 3. ÕÛıÌ· ÂÎÏ˘fiÌÂÓÔ Ì ¿ÛÎËÛË 4. ¢Ú·ÓÔ΢ÙÙ·ÚÈ΋ ÎÚ›ÛË
¶›Ó·Î·˜ 5. ∞Ó·Ï˘ÙÈ΋ ·ÈÙÈÔÏÔÁ›· ÙˆÓ Â͈ηډȷÎÒÓ ·ÈÙ›ˆÓ £¶ ÛÙ· ·È‰È¿ (7,13-15,19,21,22,26,31,32) ∞. ªÀ√™∫∂§∂∆π∫∞ – £øƒ∞∫π∫∞ ∞π∆π∞ ª˘˚΋ ˘ÂÚÎfiˆÛË, Ï¢ÚÔ¯ÔÓ‰Ú›Ùȉ·, Û‡Ó‰ÚÔÌÔ ÚÔοډÈÔ˘ ȷ̷ۛÙÔ˜ (catch), Û‡Ó‰ÚÔÌÔ Tietze, ÙÚ·‡Ì·, ηÎÔÌÂÙ·¯Â›ÚÈÛË ·È‰ÈÔ‡, οٷÁÌ·-Û‡ÓıÏÈ„Ë ÏÂ˘Ú¿˜ ‹ ÎÏÂȉÒÓ, ÍÈÊÔÂȉ·ÏÁ›·, ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·, Ú·‚‰ÔÌ˘ÔÛ¿ÚΈ̷, Ì˘ÔÛ›Ùȉ·, ·Á΢ÏÔÔÈËÙÈ΋ ÛÔÓ‰˘Ï›Ùȉ·, ÛÔÓ‰˘ÏÔÏ›ÛıËÛË, ÛÔÓ‰˘ÏfiÏ˘ÛË, ÂÁοÚÛÈ· Ì˘ÂÏ›Ùȉ·, ΋ÏË ÌÂÛÔÛÔÓ‰‡ÏÈÔ˘ ‰›ÛÎÔ˘, Á˘Ó·ÈÎÔÌ·ÛÙ›· (Û ·ÁfiÚÈ·), ıËÏ·Ú¯‹ (Û ÎÔÚ›ÙÛÈ·), ΢ÛÙÈ΋ Ì·ÛÙÔ¿ıÂÈ·. µ. ¶¡∂Àª√¡π∫∞ ∞π∆π∞ ¶Ó¢ÌÔıÒڷη˜, Ó¢ÌÔÌÂÛÔÓ¢ÌfiÓÈÔ, Ó¢ÌÔÓ›· (fiϘ ÔÈ ·ÈÙÈÔÏÔÁ›Â˜), ¯ÚfiÓÈÔ˜ ‚‹¯·˜, ˘Â˙ˆÎÔÙÈ΋ Û˘ÏÏÔÁ‹, Ï¢ÚÔ‰˘Ó›·, Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹, ÂÈÛÓÔ‹ ͤÓÔ˘ ÛÒÌ·ÙÔ˜, ÚˆÙÔ·ı¤˜ ‹ ‰Â˘ÙÂÚÔ·ı¤˜ ·‰¤ÓˆÌ· ‹ ηÚΛӈ̷, ‚ÚÔÁ¯ÈÎfi ¿ÛıÌ·. °. æÀÃ√™øª∞∆π∫∞ ∞π∆π∞ ∞ÌÈÁ›˜ „˘¯Ôۈ̷ÙÈΤ˜ ÂΉËÏÒÛÂȘ, stress, „˘¯ÔÏÔÁÈ΋ ›ÂÛË, Û‡Ó‰ÚÔÌÔ ˘ÂÚ·ÂÚÈÛÌÔ‡, ÎÚ›ÛÂȘ ·ÓÈÎÔ‡, Ó¢ÚÔÁÂÓ‹˜ ‚Ô˘ÏÈÌ›·, ηٷӷÁηÛÙÈ΋ „¢‰ÔÏÔÁ›·. ¢. °∞™∆ƒ∂¡∆∂ƒπ∫∞ ∞π∆π∞ √ÈÛÔÊ·Á›Ùȉ·, ·ÛÙÂȘ ÔÈÛÔÊ¿ÁÔ˘, Û·ÛÌfi˜ ÔÈÛÔÊ¿ÁÔ˘, Ú‹ÍË ÔÈÛÔÊ¿ÁÔ˘, ·¯·Ï·Û›·, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË, Á·ÛÙÚ›Ùȉ·, ÂÙÈÎfi ¤ÏÎÔ˜, Û‡Ó‰ÚÔÌÔ Zollinger-Elison, ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË, ηٿÔÛË Í¤ÓÔ˘ ÛÒÌ·ÙÔ˜, ¯ÔÏÔ΢ÛÙ›Ùȉ·, ·ÁÎÚ·ٛÙȉ·, ˘Ô‰È·ÊÚ·ÁÌ·ÙÈÎfi ·fiÛÙËÌ·. ∂. ∞§§∞ ∞π∆π∞ 1. ÃÚ‹ÛË: ÎÔη˝Ó˘, ηÓÔ‡, Û˘Ì·ıËÙÈÎÔÌÈÌËÙÈÎÒÓ Ô˘ÛÈÒÓ. 2. ŸÁÎÔÈ: ÓfiÛÔ˜ Hodgkin, ÏÂÌÊÒÌ·Ù·, ı˘ÌÒÌ·Ù·, ÙÂÚ·ÙÒÌ·Ù·, ÏÈÔÛ¿ÚΈ̷. 3. ¢È¿ÊÔÚ·: ۷ί·Ú҉˘ ‰È·‚‹Ù˘, ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi˜, ΢ÛÙÈ΋ ›ÓˆÛË, Ó¢ÚÔ˚ӈ̿وÛË, Û‡Ó‰ÚÔÌÔ Marfan, ‰Ú·ÓÔ΢ÙÙ·ÚÈ΋ ·Ó·ÈÌ›·, ÌÂÛÔÁÂÈ·Îfi˜ ˘ÚÂÙfi˜, ¯ÈÓÔÎÔÎΛ·ÛË.
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N=103
N=34 5 3% 4 3%
1 16%
1
3 9%
1
2
2 2 13%
3 2 38%
1 47%
4 5
6 66%
3 3 3% 4 1% 5 1%
4 5 6
™¯‹Ì· 2. ∞Ó·ÏÔÁ›· % ÙˆÓ Î·Ú‰ÈÔÏÔÁÈÎÒÓ ‰È·ÁÓÒÛÂˆÓ Û 34/103 ·È‰È¿ Ì £¶ ˆ˜ ·ÚÈÔ Û‡Ìو̷. ∞ÚÈÛÙÂÚ¿: ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ 34 ·È‰ÈÒÓ, Ì ηډÈÔÏÔÁÈÎfi ‡ÚËÌ·. ¢ÂÍÈ¿: ™ÙÔ Û‡ÓÔÏÔ ÙˆÓ 103 ·È‰ÈÒÓ Ì £¶. ∂Í‹ÁËÛË ˘ÔÌÓ‹Ì·ÙÔ˜: 1 = ¶ÚfiÙˆÛË ÌÈÙÚÔÂȉԇ˜, 2 = ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ηډȷÎÔ‡ Ú˘ıÌÔ‡, 3 = ¿ÏϘ ÏÂÈÙÔ˘ÚÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Ù˘ ÌÈÙÚÔÂȉԇ˜, 4 = ÂÚÈηډ›Ùȉ·, 5 = Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ.
·fi ÙÔ˘˜ ÁÔÓ›˜ ÙÔ˘ (21,34). ™ÙË ‰È΋ Ì·˜ ÔÌ¿‰· ÙˆÓ 103 ·È‰ÈÒÓ Ì £¶, ÂÓÒ Ù· ·ÌÈÁÒ˜ „˘¯ÔÁÂÓ‹ ·›ÙÈ· ÌfiÏȘ ˘ÂÚ¤‚·ÈÓ·Ó ÙÔ 20%, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙË ÁÂÓÂÛÈÔ˘ÚÁfi ·ÈÙ›·, ‚Ú¤ıËΠfiÙÈ ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÈÙ›·, ÙÔ 45,6% (47 ·È‰È¿) ›¯·Ó ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÁÈ· £¶. 5. ∏ ¯Ú‹ÛË ÎÔη˝Ó˘ Î·È ÓÈÎÔÙ›Ó˘ ·fi ¤ÊË‚Ô˘˜ Â›Ó·È Èı·Ó‹ ·ÈÙ›· £¶ Î·È Ì¿ÏÈÛÙ· Ì ηډÈÔÏÔÁÈ΋ ·ÈÙÈÔ·ıÔÁ¤ÓÂÈ·. ∏ ÎÔη˝ÓË ¤¯ÂÈ Û·Ó ·ÔÙ¤ÏÂÛÌ· ¤ÎÙ·ÎÙ˜ Û˘ÛÙÔϤ˜ Î·È ·›ÛıËÌ· ·ÏÌÒÓ, ·ÁÁÂÈÔÛ·ÛÌfi ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ, ·ÎfiÌË Î·È Ú·ÁÌ·ÙÈÎfi ¤ÌÊÚ·ÁÌ·. ∏ ¯Ú‹ÛË ÓÈÎÔÙ›Ó˘ ÂÈʤÚÂÈ ¯ÚfiÓÈÔ ‚‹¯·, ÂÓÒ Ë Î·Ù¿¯ÚËÛ‹ Ù˘ ÌÔÚ› Ó· ÂÈʤÚÂÈ ¤ÎÙ·ÎÙ˜ Û˘ÛÙÔϤ˜ Î·È ·ÁÁÂÈÔÛ·ÛÌfi ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ (35). ∫·Ú‰È·Î‹˜ ·ÈÙÈÔÏÔÁ›·˜ 1. ¶ÚfiÙˆÛË ÌÈÙÚÔÂȉԇ˜: ™ÙËÓ ÚfiÙˆÛË Ù˘ ÌÈÙÚÔÂȉԇ˜ Ô fiÓÔ˜ ÂÌÊ·Ó›˙ÂÙ·È ·ÚÎÂÙ¿ Û˘¯Ó¿ (̤¯ÚÈ Î·È ÛÙÔ 31% ÙˆÓ ÂÚÈÙÒÛˆÓ), ÛÙËÓ ·È‰È΋ ËÏÈΛ· ‰ÂÓ ¤¯ÂÈ ÚÔÁÓˆÛÙÈ΋ ÛËÌ·Û›· Î·È ÔÊ›ÏÂÙ·È Èı·ÓfiÓ (30-32) Û ÌË Ê˘ÛÈÔÏÔÁÈ΋ Û‡Û·ÛË ÙˆÓ ıËÏÔÂȉÒÓ Ì˘ÒÓ ‹ -Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ- Û Ì›ˆÛË ÙÔ˘ fiÁÎÔ˘ ·ÏÌÔ‡. ¶Ôχ Û˘¯Ó‹ Â›Ó·È fï˜ Î·È Ë ÂÌÊ¿ÓÈÛË ·ÚÚ˘ıÌÈÒÓ ÛÙËÓ ÚfiÙˆÛË Ù˘ ÌÈÙÚÔÂȉԇ˜ (18-25% Û ÂÓ‹ÏÈΘ), ÔfiÙÂ Â›Ó·È ÂӉ¯fiÌÂÓÔ Ô £¶ Ó· ÔÊ›ÏÂÙ·È ÛÙËÓ ·ÚÚ˘ıÌ›·, fiÙ·Ó ·˘Ù‹ ÂÈʤÚÂÈ ÂÏ¿ÙÙˆÛË Ù˘ ·ÚÔ¯‹˜ ÛÙȘ ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜. ∆fiÛÔ ÔÈ ·ÚÚ˘ı̛˜, fiÛÔ Î·È Ù· ÂÂÈÛfi‰È· £¶ Û ÚfiÙˆÛË, ˘Ô¯ˆÚÔ‡Ó ‹ ÂÍ·Ê·Ó›˙ÔÓÙ·È Ì ÙË ¯ÔÚ‹ÁËÛË ÁÈ· Ï›Á˜ ‚‰ÔÌ¿‰Â˜ ‚-·‰ÚÂÓÂÚÁÈÎÒÓ ·ÔÎÏÂÈÛÙÒÓ ·fi ÙÔ ÛÙfiÌ· (23,30-32,36). ªÂ ‚¿ÛË Ù· ‰Èο Ì·˜ ‰Â‰Ô̤ӷ ·fi ÙË ÌÂϤÙË ÙˆÓ 103 ·È‰ÈÒÓ Ì £¶ Ì›·˜ ‰ÈÂÙ›·˜, Ë ·Ó·ÏÔÁ›· 16 ·È‰ÈÒÓ Ì ÚfiÙˆÛË
120
ÌÈÙÚÔÂȉԇ˜ Û 103 ·È‰È¿ Ì £¶ (15,5%) Â›Ó·È Ê·ÈÓÔÌÂÓÈο ÌÂÁ¿ÏË. ∞Ó, fï˜, ‰Â¯ıԇ̠fiÙÈ ÂÚ›Ô˘ ÙÔ 5% ÙÔ˘ ·È‰ÈÎÔ‡ ÏËı˘ÛÌÔ‡ ¤¯ÂÈ ÚfiÙˆÛË ÌÈÙÚÔÂȉԇ˜, ÙfiÙÂ Ë Èı·ÓfiÙËÙ· £¶ ÛÙ· ·È‰È¿ Ì ÚfiÙˆÛË ˘ÔÏÔÁ›˙ÂÙ·È ÌfiÏȘ ÛÙÔ 1,7%. 2. ∏ ÓfiÛÔ˜ ÙÔ˘ Kawasaki: ™ÙË ÓfiÛÔ ÙÔ˘ Kawasaki, £¶ ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› ηٿ ÙÔ 1Ô ÛÙ¿‰ÈÔ Ù˘ ÓfiÛÔ˘, ηٿ ÙÔ ÔÔ›Ô Ë Î·Ú‰È¿ Û˘ÌÌÂÙ¤¯ÂÈ Ì ÂÚÈηډ›Ùȉ· ‹/Î·È Ì˘Ôηډ›Ùȉ· ̤¯ÚÈ ÙÔ 50% ÙˆÓ ÂÚÈÙÒÛÂˆÓ Î·È ÔÊ›ÏÂÙ·È Û˘Ó‹ıˆ˜ Û fiÓÔ ˘Â˙ˆÎÔÙÈ΋˜ ·ÈÙÈÔÏÔÁ›·˜. ™ÙÔ Ù¤ÏÔ˜, fï˜, ÙÔ˘ 2Ô˘ Ì ·Ú¯¤˜ 3Ô˘ ÛÙ·‰›Ô˘, ÂÌÊ·Ó›˙ÔÓÙ·È Ù· ·Ó¢ڇÛÌ·Ù· ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÚÙËÚÈÒÓ. √ £¶ ÏfiÁˆ ·Ó¢ڇÛÌ·ÙÔ˜ Û˘Ó‹ıˆ˜ ÔÊ›ÏÂÙ·È Û ¤ÌÊÚ·ÁÌ·, ÔfiÙÂ Û˘Ó˘¿Ú¯ÂÈ Ë ÎÏ·ÛÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· (¶›Ó·Î·˜ 2) Î·È Ù· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ÙÔ˘ ÂÌÊÚ¿ÁÌ·ÙÔ˜ (37). √ ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ¢È·ÁÓˆÛÙÈ΋ ÚÔÛ¤ÁÁÈÛË √È ‰˘ÛÎÔϛ˜ Ù˘ ‰È·ÁÓˆÛÙÈ΋˜ ÚÔÛ¤ÁÁÈÛ˘ ÙÔ˘ £¶ Û ·È‰› ÌÔÚÔ‡Ó Ó· Û˘ÓÔ„ÈÛÙÔ‡Ó ÛÙ· ÂÍ‹˜: ·) ∏ ÂÚÈÁÚ·Ê‹ Î·È Ë ·ÎÚÈ‚‹˜ ÂÓÙfiÈÛË ÙÔ˘ fiÓÔ˘ ÂÍ·ÚÙÒÓÙ·È ·fi ÙËÓ ËÏÈΛ· ÙÔ˘ ·È‰ÈÔ‡. ‚) ∏ ÂͤٷÛË Û˘¯Ó¿ Á›ÓÂÙ·È ˘fi ÙÔ ¿Á¯Ô˜ Ù˘ ηډÈÔÊÔ‚›·˜ ÙˆÓ ÁÔÓ¤ˆÓ Î·È ÌÂÚÈΤ˜ ÊÔÚ¤˜ Ì ·fiÎÚ˘„Ë Û˘ÓıËÎÒÓ Î·È Ì ÂÓÔ¯¤˜ ÙˆÓ ÁÔÓ¤ˆÓ. Á) √ fiÓÔ˜ ‰ÂÓ ÌÔÚ› Ó· ÌÂÙÚËı› ·ÓÙÈÎÂÈÌÂÓÈο. ‰) √È Èı·Ó¤˜ ·Èٛ˜ Â›Ó·È ¿Ú· ÔÏϤ˜, ÂÓÒ ÂÏ¿¯ÈÛÙ˜ ·fi ·˘Ù¤˜ ·ÔÙÂÏÔ‡Ó ·Èٛ˜ Ú·ÁÌ·ÙÈ΋˜ ·ÓËÛ˘¯›·˜. Œ¯ÔÓÙ·˜ ˘fi„Ë: ·) ÙËÓ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ £¶ ÛÙ·
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Û¿ÓÈÔ ÛÙ· ·È‰È¿ £¶ ·fi Ó¢ÌÔÓÈ΋ ÂÌ‚ÔÏ‹. 3. ™˘Ó‰˘·ÛÌfi˜ ÂÒ‰˘ÓÔ˘ Û·ÛÌÔ‡ + ˘ÚÂÙÔ‡ + ‹¯Ô˘ ÙÚÈ‚‹˜ Â›Ó·È ÂÓ‰ÂÈÎÙÈÎfi˜ ÚÔÛ‚ÔÏ‹˜ ·fi Èfi Coxsackie. 4. ∂ÈÛÎfiËÛË: ¢‡ÛÓÔÈ· Î·È Î˘¿ÓˆÛË + £¶ ·ÔÙÂÏÔ‡Ó ¤Ó‰ÂÈÍË Ó¢ÌÔÓÈ΋˜ ÂÌ‚ÔÏ‹˜. 5. ∞ÎÚfi·ÛË: ªÔÚÔ‡Ó Ó· ‰È·ÁÓˆÛıÔ‡Ó Ë Ó¢ÌÔÓ›· Î·È ÔÈ ·ÔÊÚ·ÎÙÈΤ˜ Ó¢ÌÔÓÈΤ˜ ·ı‹ÛÂȘ. 6. æËÏ¿ÊËÛË: ªÔÚÔ‡Ó Ó· ‰È·ÁÓˆÛıÔ‡Ó ÙÔ Ó¢ÌÔÌÂÛÔÓ¢ÌfiÓÈÔ, ÙÔ ˘Ô‰fiÚÈÔ ÂÌʇÛËÌ· Î·È ÔÈ Î·ÎÒÛÂȘ ÙˆÓ Ï¢ÚÒÓ. 7. ∂›ÎÚÔ˘ÛË Î·È ·ÎÚfi·ÛË: ªÔÚ› Ó· ‰È·ÁÓˆÛı› ˘Â˙ˆÎÔÙÈ΋ Û˘ÏÏÔÁ‹. √‰ËÁ¿ ÎÏÈÓÈο ÛËÌ›· Ì˘ÔÛÎÂÏÂÙÈÎÒÓ ·ÈÙ›ˆÓ ∆· Ì˘ÔÛÎÂÏÂÙÈο ·›ÙÈ· Â›Ó·È Î·Ù¿ ÁÂÓÈ΋ ·Ú·‰Ô¯‹ Ù· ÈÔ Û˘¯Ó¿ ÛÙ· ·È‰È¿. ∏ ·Ó·ÏÔÁ›· ÙÔ˘˜ Â›Ó·È ·fi 1:6 ̤¯ÚÈ 1:3 ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Ì £¶. √ ÎÏÈÓÈÎfi˜ ÁÈ·ÙÚfi˜ ÌÔÚ› Ó· ηıÔ‰ËÁËı› ·fi Ù· ·Ú·Î¿Ùˆ (1,7,13-15,19-22,26) (¶›Ó·Î·˜ 5): 1. ∏ÏÈΛ·: ∂›Ó·È Û˘¯ÓfiÙÂÚ· Û ËÏÈ˘ ¿Óˆ ·fi 12 ¯ÚfiÓˆÓ. 2. º‡ÏÔ: ∏ Ï¢ÚÔ¯ÔÓ‰Ú›Ùȉ· Â›Ó·È Û˘¯ÓfiÙÂÚË ÛÙ· ÎÔÚ›ÙÛÈ·. 3. πÛÙÔÚÈÎfi: √È ¤ÊË‚ÔÈ Ì £¶ ÛÙȘ ÈÔ Ù˘ÈΤ˜ ÂÚÈÙÒÛÂȘ, Û˘Ó‹ıˆ˜ ·ıÏÔ‡ÓÙ·È. 4. æËÏ¿ÊËÛË: ªÔÚ› Ó· ·Ôηχ„ÂÈ ÙÚ·‡Ì· Ì˘˚ÎÒÓ Ì·˙ÒÓ ‹ Ï¢ÚÒÓ. √‰ËÁ¿ ÎÏÈÓÈο ÛËÌ›· ηډÈÔÏÔÁÈÎÒÓ ·ÈÙ›ˆÓ √ ÎÏÈÓÈÎfi˜ ÁÈ·ÙÚfi˜ ÌÔÚ› Ó· ‚ÔËıËı› ·fi Ù· ·Ú·Î¿Ùˆ:
·È‰È¿, ‚) ÙÔ˘˜ ÎÏÈÓÈÎÔ‡˜ ¯·Ú·ÎÙ‹Ú˜ ÙÔ˘ fiÓÔ˘ ηډȷ΋˜ Î·È ¿ÏÏ˘ ›ÁÔ˘Û·˜ ·ÈÙÈÔÏÔÁ›·˜ ÛÙ· ·È‰È¿ Î·È ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ηıÒ˜ Î·È Á) ÙË ‚·ÛÈ΋ ‰È¿ÎÚÈÛË Û Ô͇ Î·È ¯ÚfiÓÈÔ £¶, ÛÙÔ ¶·È‰ÔηډÈÔÏÔÁÈÎfi ∂͈ÙÂÚÈÎfi π·ÙÚÂ›Ô Î·È ÛÙÔ ¶·È‰ÔηډÈÔÏÔÁÈÎfi ¢È·ÁÓˆÛÙÈÎfi ∂ÚÁ·ÛÙ‹ÚÈÔ Ù˘ ∫ÏÈÓÈ΋˜ Ì·˜ ÂÊ·ÚÌfi˙Ô˘Ì ÙÔÓ ·ÏÁfiÚÈıÌÔ ÙÔ˘ Û¯‹Ì·ÙÔ˜ 3. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ·È‰ÈÔ‡ Ì £¶ ‰ÂÓ Â›Ó·È ··Ú·›ÙËÙÔ˜ ÛÙËÓ Î·ıËÌÂÚÈÓ‹ ·È‰È·ÙÚÈ΋ Ú¿ÍË. √ ‚·ÛÈÎfi˜ ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ÂÚÈÔÚ›˙ÂÙ·È ÛÙËÓ ·Ó·ÁÓÒÚÈÛË ÙˆÓ ÔÏ›ÁˆÓ ÂÎÂ›ÓˆÓ ÂÚÈÙÒÛÂˆÓ Ô˘ ¯ÚÂÈ¿˙ÔÓÙ·È ÙË ‚Ô‹ıÂÈ· ÙÔ˘ ϤÔÓ ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ È·ÙÚÔ‡. ™ÙȘ ÂȉÈΤ˜ ·˘Ù¤˜ ÂÚÈÙÒÛÂȘ ı· ÌÔÚÔ‡Û·Ó Ó· Û˘ÛÙËıÔ‡Ó: ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη, ËÏÂÎÙÚÔηډÈÔÁÚ¿ÊËÌ·, ˘ÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ·, ·ÍÔÓÈ΋ ‹ Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ıÒڷη, ̤ÙÚËÛË ÙÔ˘ pH ÙÔ˘ ÛÙÔÌ¿¯Ô˘, ·ÎÙÈÓÔÁڷʛ˜ ÛÎÂÏÂÙÔ‡ ıÒڷη, ÁÂÓÈ΋ ÂͤٷÛË Ô‡ÚˆÓ, ÙÔÍÈÎÔÏÔÁÈ΋ ÂͤٷÛË Ô‡ÚˆÓ, ÂÍÂÙ¿ÛÂȘ ·›Ì·ÙÔ˜ ηْ ÂÈÏÔÁ‹ (19,26,27). √‰ËÁ¿ ÎÏÈÓÈο ÛËÌ›· Ó¢ÌÔÓÈÎÒÓ ·ÈÙ›ˆÓ √È Ó¢ÌÔÓÈΤ˜ ·Èٛ˜ £¶ ÛÙ· ·È‰È¿ Â›Ó·È Û˘¯Ó¤˜, ۯ‰fiÓ 1:5-6 ·È‰È¿ Ì £¶. √ ÎÏÈÓÈÎfi˜ ÁÈ·ÙÚfi˜ ÌÔÚ› Ó· ηıÔ‰ËÁËı› ·fi Ù· ·Ú·Î¿Ùˆ (19,22,26) (¶›Ó·Î·˜ 5 ): 1. ∏ÏÈΛ·: ∆· Ó¢ÌÔÓÈο ·›ÙÈ· ˆ˜ ·ÈÙ›· £¶ Â›Ó·È Û˘¯ÓfiÙÂÚ· Û ·È‰È¿ οو ÙˆÓ 12 ¯ÚfiÓˆÓ. 2. πÛÙÔÚÈÎfi Ï‹„˘ ·ÓÙÈÛ˘ÏÏËÙÈÎÒÓ Î·È ÓfiÛËÛ˘ ·fi ˘ÂÚËÎÙÈο Û‡Ó‰ÚÔÌ· Â›Ó·È ÂÓ‰ÂÈÎÙÈο ÁÈ· ÙÔÓ
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∞) √‰ËÁ¿ ÛËÌ›· Û˘ÁÁÂÓÒÓ Î·Ú‰ÈÔ·ıÂÈÒÓ (13-15,19,26,27,35-37) (¶›Ó·Î·˜ 6): 1. πÛÙÔÚÈÎfi Î·È ÎÏÈÓÈ΋ ·Ó›¯Ó¢ÛË ÛËÌ›ˆÓ ηډȷ΋˜ ÓfiÛÔ˘ (ηډȷ΋ ·Ó¿ÚÎÂÈ·, ΢¿ÓˆÛË, ·ÚÙËÚȷ΋ ˘¤ÚÙ·ÛË, ‡ÎÔÏË ÎfiˆÛË, ÌÂÁ·ÏÔηډ›·, ·ÚÚ˘ıÌ›·, ʇÛËÌ· Ì ÔÚÁ·ÓÈÎÔ‡˜ ¯·Ú·ÎÙ‹Ú˜). 2. √ÚÁ·ÓÈÎfi ʇÛËÌ·: ∆Ú·¯‡, Ì ‹ ¯ˆÚ›˜ ÚÔ›˙Ô, ¤ÓÙ·Û˘ 1-6/6, Ì ÛËÌ·ÓÙÈΤ˜ ÂÂÎÙ¿ÛÂȘ, Û˘¯Ó¿ ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ Ù˘ ¿ıËÛ˘ (.¯. ÛÙË ÌÂÛÔÏ¿ÙÈ· ¯ÒÚ· ÛÙË ÛÙ¤ÓˆÛË ÙÔ˘ ÈÛıÌÔ‡ Ù˘ ·ÔÚÙ‹˜). 3. ∞ÎÙÈÓÔÁÚ·Ê›· ıÒڷη: ∂ÍÂÙ¿˙ÔÓÙ·È: ·) ̤ÁÂıÔ˜ ηډȷ΋˜ ÛÎÈ¿˜ (ÌÂÁ·ÏÔηډ›· ‹/Î·È ¯·Ú·ÎÙËÚÈÛÙÈÎfi Û¯‹Ì· Â›Ó·È ÂӉ›ÍÂȘ Û˘ÁÁÂÓÔ‡˜ ηډÈÔ¿ıÂÈ·˜), ‚) ·ÁÁ›ˆÛË ÙˆÓ Ó¢ÌfiÓˆÓ (·˘ÍË̤ÓË Û ·ı‹ÛÂȘ Ì ‰È·Ê˘Á‹ ·fi ·ÚÈÛÙÂÚ¿ ÚÔ˜ Ù· ‰ÂÍÈ¿, ÂÏ·Ùو̤ÓË Û ·ı‹ÛÂȘ Ì ·Ï‹ ‹ Û˘Ó˘¿Ú¯Ô˘Û· ÛÙ¤ÓˆÛË Ù˘ Ó¢ÌÔÓÈ΋˜, Ê˘ÛÈÔÏÔÁÈ΋ Û ·ı‹ÛÂȘ Ì ÌÈÎÚ‹ ‰È·Ê˘Á‹, ÌÈÎÚ‹ ÛÙ¤ÓˆÛË Ó¢ÌÔÓÈ΋˜ Î·È Û ·ı‹ÛÂȘ Ù˘ ·ÚÈÛÙÂÚ‹˜ ÎÔÈÏ›·˜). 4. ∏∫°: ∞·Ú·›ÙËÙÔ Û fiÏÔ˘˜ ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ıˆÚ·ÎÈÎfi fiÓÔ Î·È ˘fiÓÔÈ· Û˘ÁÁÂÓÔ‡˜ ηډÈÔ¿ıÂÈ·˜, ·Ô‰ÂÈÎÓ‡ÂÈ Û˘Ó˘¿Ú¯Ô˘Û· ÈÛ¯·ÈÌ›· ‹ ·ÚÚ˘ıÌ›· Î·È ˘Ô‰ÂÈÎÓ‡ÂÈ ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘
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Ì˘Ôηډ›Ô˘. 5. ÀÂÚ˯ÔηډÈÔÁÚ¿ÊËÌ·: ∞·Ú·›ÙËÙÔ Û ÈÛ¯˘Ú‹ ˘fiÓÔÈ· Û˘ÁÁÂÓÔ‡˜ ηډÈÔ¿ıÂÈ·˜ Î·È ·ÔÙÂÏ› ¤Ó· ÈÛ¯˘Úfi, ˆ˜ Î·È ÙÔ ·fiÏ˘ÙÔ, ‰È·ÁÓˆÛÙÈÎfi ̤ÛÔ. µ) √‰ËÁ¿ ÛËÌ›· ›ÎÙËÙˆÓ Î·Ú‰ÈÔ·ıÂÈÒÓ (13-15,19,26,27,34-37) (¶›Ó·Î·˜ 7): √È Â›ÎÙËÙ˜ ηډÈÔ¿ıÂȘ ÂΉËÏÒÓÔÓÙ·È Ì ‰È·ÊÔÚÂÙÈ΋, Ë Î¿ı ̛·, ÎÏÈÓÈ΋ ÂÈÎfiÓ·. ∆Ô ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ ÙÔ˘ ÎÏÈÓÈÎÔ‡ ÁÈ·ÙÚÔ‡ Ú¤ÂÈ Ó· Â›Ó·È Î·Ù¿ÏÏËÏÔ Î·È Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ fiϘ ÙȘ Èı·Ó¤˜ ›ÎÙËÙ˜ ηډÈÔ¿ıÂȘ. ŒÙÛÈ: 1. ∏ ÂÚÈηډ›Ùȉ· ÂΉËÏÒÓÂÙ·È Ì £¶ Î·È ‰‡ÛÓÔÈ· (ȉ›ˆ˜ ÛÙËÓ Î·Ù¿ÎÏÈÛË) ÛÙË ‰È¿ÚÎÂÈ· ‹ ÌÂÙ¿ ·fi ÈÔÁÂÓ‹ ‹ ¿ÏÏË Ïԛ̈ÍË. 2. ∏ Ì˘Ôηډ›Ùȉ· ÂΉËÏÒÓÂÙ·È Ì ‡ÎÔÏË ÎfiˆÛË, ‰‡ÛÓÔÈ· Î·È ¿ÏÏ· ÛËÌ›· ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜, ̤¯ÚÈ Î·Ú‰È·Î‹ ηٷÏËÍ›· (collapsus). 3. ∏ ÂÓ‰Ôηډ›Ùȉ·, Ì ‚·ÚÈ¿ ÛËÙÈ΋ ÂÈÎfiÓ· Î·È ÂÌÊ¿ÓÈÛË Ê˘Û‹Ì·ÙÔ˜ Ô˘ ‰ÂÓ ÚÔ¸‹Ú¯Â ‹ ÙÚÔÔÔ›ËÛË Ê˘Û‹Ì·ÙÔ˜ Ô˘ ÚÔ¸‹Ú¯Â. 4. ∆Ô Û¿ÓÈÔ ÛÙ· ·È‰È¿ ¤ÌÊÚ·ÁÌ· Ì˘Ôηډ›Ô˘ ‰›ÓÂÈ £¶ Ì ηı·ÚÔ‡˜ ¯·Ú·ÎÙ‹Ú˜ ÛÙËı¿Á¯Ë˜, fiˆ˜ ·˘ÙÔ› Â›Ó·È ÁÓˆÛÙÔ› ·fi ÙÔ˘˜ ÂÓ‹ÏÈΘ, ·ÏÏ¿ ·ÚfiÌÔÈÔ £¶ ¤¯ÂÈ Î·È Ë ‚·ÚÈ¿ ‚·Ï‚ȉÈ΋ ηÈ
¶›Ó·Î·˜ 6. √‰ËÁ¿ ÎÏÈÓÈο ÛËÌ›· ÛÙȘ ΢ÚÈfiÙÂÚ˜ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ Ì Èı·ÓfiÙËÙ· £¶ ÛÙ· ·È‰È¿ (13-15,19,26,27,35-37) ™À°°∂¡∏™ ∫∞ƒ¢π√¶∞£∂π∞ 1. ™ÙÂÓÒÛÂȘ ‚·Ï‚›‰·˜ ·ÔÚÙ‹˜ 2. ™Ù¤ÓˆÛË ÈÛıÌÔ‡ ·ÔÚÙ‹˜ 3. ƒ‹ÍË ·Ó¢ڇÛÌ·ÙÔ˜ Valsalva 4. ∞ÓÒÌ·ÏË ¤ÎÊ˘ÛË ™∞ ·fi ÙËÓ Ó¢ÌÔÓÈ΋ 5. ™˘ÁÁÂÓ›˜ ÛÙÂÓÒÛÂȘ ™∞ 6. ™Ô‚·Ú‹ ÛÙ¤ÓˆÛË Ó¢ÌÔÓÈ΋˜ 7. ¶ÚfiÙˆÛË ÌÈÙÚÔÂȉԇ˜ 8. ∞ÚÚ˘ıÌÈÔÁfiÓÔ˜ ‰ÂÍÈ¿ ÎÔÈÏ›· º = ʇÛËÌ·, ™∞ = ÛÙÂÊ·ÓÈ·›·(˜) ·ÚÙËÚ›·(˜)
√¢∏°∞ ∫§π¡π∫∞ ™∏ª∂π∞ º, ¯·ÌËÏfi˜ ÛÊ˘ÁÌfi˜ º, ‰È·ÊÔÚ¿ ÛÊ˘ÁÌÔ‡ Î·È ∞¶ ÌÂٷ͇ ¿Óˆ Î·È Î¿Ùˆ ¿ÎÚˆÓ º ± º, ¯·Ú·ÎÙËÚÈÛÙÈÎfi ∏∫° ÷ڷÎÙËÚÈÛÙÈÎfi ∏∫° º, ∏∫°, ÂÏ·Ùو̤ÓË ·ÁÁ›ˆÛË Ó¢ÌfiÓˆÓ ∫ÏÈÎ ± º ± ‰˘ÛÏ·Û›· ıÒڷη ∞ÚÚ˘ıÌ›·, Û˘ÁÎÔÈ΋ ÚÔÛ‚ÔÏ‹
¶›Ó·Î·˜ 7. √‰ËÁ¿ ÎÏÈÓÈο ÛËÌ›· ÛÙȘ ΢ÚÈfiÙÂÚ˜ ›ÎÙËÙ˜ ηډÈÔ¿ıÂȘ Ì Èı·ÓfiÙËÙ· £¶ ÛÙ· ·È‰È¿ (13-15,20,27,28,36-38) ∂¶π∫∆∏∆∏ ∫∞ƒ¢π√¶∞£∂π∞ 1. ª˘ÔηډÈÔ¿ıÂȘ 2. ∂Ó‰Ô-Ì˘Ô-ηډ›Ùȉ· 3. ¡fiÛÔ˜ Kawasaki 4. ÀÂÚÎÔÈÏȷ΋ Ù·¯˘Î·Ú‰›· 5. ÕÏϘ ·ÚÚ˘ı̛˜ 6. ¶ÂÚÈηډ›Ùȉ·
√¢∏°∞ ∫§π¡π∫∞ ™∏ª∂π∞ ªÂÁ·ÏÔηډ›· ± º ± ∫∞ ™ËÙÈ΋ ÂÈÎfiÓ· ± º ± ÌÂÁ·ÏÔηډ›· ± ∫∞ ∫ÏÈÓÈ΋ ÂÈÎfiÓ· ∆·¯˘Î·Ú‰›· + ∫∞, ∏∫° ∞ÚÚ˘ıÌ›·, ÏÈÔı˘Ì›·, ∏∫° ¢‡ÛÓÔÈ·, ÌÂÁ·ÏÔηډ›· ± ‹¯Ô˜ ÙÚÈ‚‹˜ ± ·Ú¿‰ÔÍÔ˜ ÛÊ˘ÁÌfi˜ 7. ¶ÚÒÈÌË ÛÙÂÊ·ÓÈ·›· ÓfiÛÔ˜ - ¤ÌÊÚ·ÁÌ· ™·Î¯·Ú҉˘ ‰È·‚‹Ù˘, ‰˘ÛÏÈȉ·ÈÌ›·, ∏∫° 8. ∞ÁÁÂÈÔÛ·ÛÌfi˜ ™∞ ÃÚ‹ÛË Ô˘ÛÈÒÓ - Ê·Ú̿ΈÓ, ∏∫° º= ʇÛËÌ·, ∫∞= ηډȷ΋ ·Ó¿ÚÎÂÈ·, ™∞= ÛÙÂÊ·ÓÈ·›Â˜ ·ÚÙËڛ˜
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˘Ô‚·Ï‚ȉÈ΋ ÛÙ¤ÓˆÛË Ù˘ ·ÔÚÙ‹˜. 5. √È Ì˘ÔηډÈÔ¿ıÂȘ ÂΉËÏÒÓÔÓÙ·È: ∏ ‰È·Ù·ÙÈ΋ Ì ‡ÎÔÏË ÎfiˆÛË ‚·ıÌˉfiÓ ÂȉÂÈÓÔ‡ÌÂÓË, ·›ÛıËÌ· ·ÏÌÒÓ, ηϷÛÙÈÎfi Ú˘ıÌfi Î·È Ê‡ÛËÌ· ·Ó¿ÚÎÂÈ·˜ Ù˘ ÌÈÙÚÔÂȉԇ˜ Î·È Ë ˘ÂÚÙÚÔÊÈ΋ ÌÂ Û˘ÛÙÔÏÈÎfi Â͈ıËÙÈÎfi ʇÛËÌ·, Ô˘ Á›ÓÂÙ·È ÈÔ ÈÛ¯˘Úfi Ì ÙËÓ ¿ÛÎËÛË, ÂÓÒ Ô £¶ ÂÌÊ·Ó›˙ÂÙ·È Ì ÙËÓ ¿ÛÎËÛË (Ù‡Ô˘ ÛÙËı¿Á¯Ë˜) Î·È ·Ó·Î·Ï‡ÙÂÙ·È Û˘¯Ó¿ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· ÈÛÙÔÚÈÎfi ·ÈÊÓ›‰ÈÔ˘ ı·Ó¿ÙÔ˘ ÏfiÁˆ Ù˘ ÁÓˆÛÙ‹˜ ÌÂÁ¿Ï˘ Èı·ÓfiÙËÙ·˜ (ÂÚ›Ô˘ 50%) ·Ó‡ÚÂÛ˘ ÎÏËÚÔÓÔÌÈ΋˜ Û¯¤Û˘ ÛÙËÓ ¿ıËÛË ·˘Ù‹. °) √‰ËÁ¿ ÎÏÈÓÈο ÛËÌ›· ·ÚÚ˘ıÌÈÒÓ (1315,19,26,34-36): 1. √ Û˘Ó‰˘·ÛÌfi˜ “·›ÛıËÌ· ·ÏÌÒÓ” Î·È £¶ ‚¿˙ÂÈ ÙËÓ ˘fiÓÔÈ· οÔÈ·˜ ·ÚÚ˘ıÌ›·˜ ˆ˜ ·ÈÙ›·˜ ÙÔ˘ £¶. 2. √ Û˘Ó‰˘·ÛÌfi˜ “·›ÛıËÌ· ·ÏÌÒÓ” + £¶ + ÏÈÔı˘Ì›· ‹ Ù¿ÛË ÁÈ· ÏÈÔı˘Ì›· ± ÛËÌ›· ηډȷ΋˜ ·Ó¿ÚÎÂÈ·˜ ± shock, ı¤ÙÔ˘Ó ÙË ‰È¿ÁÓˆÛË ÛÔ‚·Ú‹˜ ·ÚÚ˘ıÌ›·˜ Ô˘ Ú¤ÂÈ Ó· ·ÓÙÈÌÂÙˆÈÛÙ› ¿ÌÂÛ·. 3. ™˘¯Ófi ·›ÙÈÔ ÚÔÎ¿Ú‰ÈˆÓ ·ÏÌÒÓ, Ù·¯˘Î·Ú‰›·˜ Î·È £¶ Â›Ó·È Ô ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi˜, ÁÂÁÔÓfi˜ Ô˘ ÂÈ‚¿ÏÏÂÈ ÙËÓ „ËÏ¿ÊËÛË ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ Û οı ·È‰› Ì £¶. µÈ‚ÏÈÔÁÚ·Ê›· 1. Beyer EJ, Wells N. The Assessment of Pain in Children. Pediatr Clin N Am 1989;36:837-854. 2. Anand KJS, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med 1987;317:1321-1329. 3. Houssay AB. º˘ÛÈÔÏÔÁ›· ÙÔ˘ ·ÓıÚÒÔ˘. ªÂÙ¿ÊÚ·ÛË: π. ÷Ù˙ËÌËÓ¿, ∞ı‹Ó·: ∂ΉfiÛÂȘ °. ¶·ÚÈÛÈ¿ÓÔ˜;1963. ÛÂÏ. 548,557. 4. IASP Subcommittee on Taxonomy. Pain Terms. A list with definitions and notes on usage. Pain 1979;6:249-252. 5. Mc Grath JP, Craig DK. Development and psychological factors in children’s pain. Pediatr Clin N Am 1989;36:823-836. 6. ∫·Ú·Ì¤Ú˘ ™. √ fiÓÔ˜. ¶·È‰È·ÙÚ µÔÚ ∂ÏÏ¿‰Ô˜ 1990;2 :186-189. 7. Schechter NL. Recurent pains in children. An overview and an approach. Pediatr Clin N Am 1984;31:949-968. 8. Beales JG, Kean JH, Lenox-Holt PJ. The child’s perception of the disease and the experience of pain in juvenile chronic arthritis. J Rheumatol 1983;10:61-65. 9. ∫·Û›ÌÔ˜ Ã, ∆Û›ÎÔ˘Ï·˜ π, µ·ÚÏ¿Ì˘ °, ¶··ÛÙ·‡ÚÔ˘ £, ∫ÔÚ›ÙÛÔÁÏÔ˘ ∞, πÂÚԉȷÎfiÓÔ˘ Ã. ∞ÓÙ›‰Ú·ÛȘ ÙÔ˘ Ó¢ÚÔÊ˘ÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È ‰È¿ÚÎÂÈ· ÙÔ˘ ÎÏ¿Ì·ÙÔ˜ ÌÂÙ¿ ÂÒ‰˘ÓÔÓ ÂÚ¤ıÈÛÌ· › ÌË ÂÁÎÂÊ·ÏÔ·ıÒÓ Î·È ÂÁÎÂÊ·ÏÔ·ıÒÓ ·È‰ÈÒÓ. ¶·È‰È·ÙÚÈ΋ 1977;40:414-424. 10. Grunau RVE, Craig KD. Pain expression in neonates: Facial action and cry. Pain 19 XX 28:395-410. 11. Craig KD, Mc Mahon RJ, Morison JD, Zaskow C. Development changes in infant pain expression during
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37. Burns JC, Shike H, Gordon JB, Malhotra A, Schoenwetter M, Kawasaki T. Sequelae of Kawasaki disease in adolescents and young adults. J Am Coll Cardiol 1996;281:253-257.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 12-07-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 05-12-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: °ÂÒÚÁÈÔ˜ ™. µ·ÚÏ¿Ì˘ µ·Û. ŸÏÁ·˜ 85, 546 43, £ÂÛÛ·ÏÔÓ›ÎË
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· √ÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÙÔ›·˜ Î·È ÎÏÈÓÈ΋ ÔÚ›· Ïԛ̈͢ Ì RSV Û ÓÔÛËÏ¢fiÌÂÓ· Î·È ÌË ‚Ú¤ÊË1 ™ÎÔfi˜: √ ·Ó·Ó¢ÛÙÈÎfi˜ Û˘Á΢ÙÈ·Îfi˜ Èfi˜ (RSV) ÌÔÚ› Ó· ÚÔηϤÛÂÈ ÛÔ‚·Ú‹ Ïԛ̈ÍË ÛÙ· ·È‰È¿. √È ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÛÔ‚·Ú‹˜ ÓfiÛÔ˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó: ËÏÈΛ· οو ÙˆÓ 6 ÌËÓÒÓ, ÚÔˆÚfiÙËÙ·, ÚÔ¸¿Ú¯Ô˘Û· ηډȷ΋ ‹ Ó¢ÌÔÓÈ΋ ÓfiÛÔ ‹ ‰˘ÛÏ·Û›·, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË Î·È ·ÓÔÛÔ·Ó¿ÚÎÂÈ·. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË Ù˘ ›‰Ú·Û˘ ÔÈÎÔÁÂÓÂÈ·ÎÔ‡ ÈÛÙÔÚÈÎÔ‡ ·ÏÏÂÚÁ›·˜ ÛÙËÓ ÎÏÈÓÈ΋ ÔÚ›· Ù˘ Ïԛ̈͢ Ì RSV ÓÔÛËÏ¢fiÌÂÓˆÓ Î·È ÌË ‚ÚÂÊÒÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó ·Ó·‰ÚÔÌÈο 172 ·ÛıÂÓ›˜ ËÏÈΛ·˜ οو ÙˆÓ 12 ÌËÓÒÓ (99 ÓÔÛËÏ¢fiÌÂÓÔÈ Î·È 73 ÌË ¯Ú‹˙ÔÓÙ˜ ÓÔÛËÏ›·˜). ∏ Û˘ÏÏÔÁ‹ ÙˆÓ ÏËÚÔÊÔÚÈÒÓ ¤ÁÈÓ ·fi ÙÔ˘˜ ʷΤÏÔ˘˜ ÙˆÓ ÓÔÛÔÎÔÌ›ˆÓ Î·È ·fi ÂÚˆÙËÌ·ÙÔÏfiÁÈ· Ô˘ ÛÙ¿ÏıËÎ·Ó Û ·È‰È¿ÙÚÔ˘˜. ∞ÔÙÂϤÛÌ·Ù·: ∆· ÓÔÛËÏ¢ı¤ÓÙ· ‚Ú¤ÊË Â›¯·Ó ÛËÌ·ÓÙÈο Û˘¯ÓfiÙÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÙÔ›·˜ ·fi Ù· ‚Ú¤ÊË Ô˘ ‰ÂÓ ¯ÚÂÈ¿ÛıËÎ·Ó ÓÔÛËÏ›·, 62% Î·È 29% ·ÓÙÈÛÙÔ›¯ˆ˜ (p<0,001). ∏ ‰È¿ÁÓˆÛË Ù˘ ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ ‹Ù·Ó Û˘¯ÓfiÙÂÚË ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ·ÙÔÈÎfi «ÊÔÚÙ›Ô» ·’ fiÙÈ Û ·ÛıÂÓ›˜ ¯ˆÚ›˜ ·Ó¿ÏÔÁÔ ÈÛÙÔÚÈÎfi, 89% ¤Ó·ÓÙÈ 74% ·ÓÙÈÛÙÔ›¯ˆ˜ (p<0,02). √È ÓÔÛËÏ¢ı¤ÓÙ˜ Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÙÔ›·˜ ·ÚÔ˘Û›·Û·Ó ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ ·fi ÂΛÓÔ˘˜ ¯ˆÚ›˜ ·ÚfiÌÔÈÔ ÈÛÙÔÚÈÎfi, 7,4±3,7 Ë̤Ú˜ ηÈ
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6,1±2,3 Ë̤Ú˜ ·ÓÙÈÛÙÔ›¯ˆ˜ (p<0,04). ÕÏÏÔÈ ·Ú¿ÁÔÓÙ˜, ÏËÓ Ù˘ ËÏÈΛ·˜, Ô˘ ıˆÚÔ‡ÓÙ·È ÚԉȷıÂÛÈÎÔ› ‚·ÚÈ¿˜ Ïԛ̈͢ Ì RSV (ÚÔˆÚfiÙËÙ·, ÚÔ¸¿Ú¯Ô˘Û· ηډȷ΋ ‹ Ó¢ÌÔÓÈ΋ ÓfiÛÔ˜ ‹ ‰˘ÛÏ·Û›·, Á·ÛÙÚÔÔÈÛÔÊ·ÁÈ΋ ·ÏÈÓ‰ÚfiÌËÛË), ‰ÂÓ ÂȂ‚·ÈÒıËÎ·Ó ˆ˜ Ù¤ÙÔÈÔÈ ÛÙËÓ ·ÚÔ‡Û· ÌÂϤÙË. ™˘ÌÂÚ¿ÛÌ·Ù·: ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ù· ‚Ú¤ÊË Ì ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ·ÙÔ›·˜ ‰È·ÙÚ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÛÔ‚·Ú‹˜ Ïԛ̈͢ Ì RSV, fiˆ˜ Ê·›ÓÂÙ·È ·fi Ù· ˘„ËÏfiÙÂÚ· ÔÛÔÛÙ¿, ÙË ÌÂÁ·Ï‡ÙÂÚË ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ Î·È ÙË Û˘¯ÓfiÙÂÚË ÚÔÛ‚ÔÏ‹ ·fi ‚ÚÔÁ¯ÈÔÏ›Ùȉ·.
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P, Stricker T, Baerlocher C, Sennhauser FH Family history of atopy and clinical course of RSV infection in ambulatory and hospitalized infants Pediatr Pulmonol 2000;30:302-306 ªÈ¯¿Ï˘ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ¶·È‰ÔÓ¢ÌÔÓÔÏfiÁÔ˜ ∂ÈÌÂÏËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ
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Paediatriki 2001;64:125-131
REVIEW ARTICLE
∏ ηÎÔÔ›ËÛË ·È‰ÈÒÓ ·fi ¿ÏÏ· ·È‰È¿ ¡. ¶ÚˆÙ·ÁfiÚ·-§È·ÓÔ‡
Abuse of children by their peers D. Protagora-Lianou
¶ÂÚ›ÏË„Ë: ∆· ÙÂÏÂ˘Ù·›· 20 ¯ÚfiÓÈ· ¤¯ÂÈ ÂÈÎÚ·Ù‹ÛÂÈ Ë ¿Ô„Ë fiÙÈ ÔÈ ÛˆÌ·ÙÈΤ˜ Î·È ÊÚ·ÛÙÈΤ˜ ÂÈı¤ÛÂȘ ·È‰ÈÒÓ ¤Ó·ÓÙÈ Û˘ÓÔÌ‹ÏÈΈÓ, ÔÈ ÔÔ›ÔÈ ·‰˘Ó·ÙÔ‡Ó Ó· ·Ì˘ÓıÔ‡Ó, ·ÔÙÂÏ› ÌÔÚÊ‹ ηÎÔÔ›ËÛ˘. Œ¯ÂÈ ‰È·ÈÛÙˆı› fiÙÈ ÔÚÈṲ̂ӷ ·È‰È¿ ÂÌϤÎÔÓÙ·È Î·Ù’ ·ӿÏË„Ë Û ٤ÙÔÈ· ÂÂÈÛfi‰È·, ˆ˜ ı‡Ì·Ù· ‹ ı‡Ù˜. √È ÂÌÂÈڛ˜ ·˘Ù¤˜ ¤¯Ô˘Ó ‰˘ÛÌÂÓ›˜ ÂÈÙÒÛÂȘ ÛÙËÓ „˘¯È΋ Î·È ÛˆÌ·ÙÈ΋ ÙÔ˘˜ ˘Á›·, ÙËÓ ÎÔÈÓˆÓÈ΋ ·Ó¿Ù˘ÍË Î·È ÙË Û¯ÔÏÈ΋ ÚfiÔ‰Ô. ∆· ·È‰È¿ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ ·ÔÙÂÏÔ‡Ó ÔÌ¿‰· ·˘ÍË̤ÓÔ˘ ÎÈÓ‰‡ÓÔ˘ ÁÈ· Ù¤ÙÔÈÔ˘ ›‰Ô˘˜ ηÎÔÔ›ËÛË ·fi Û˘ÓÔÌ‹ÏÈÎÔ˘˜. ∏ ·ÚÔ‡Û· ·Ó·ÛÎfiËÛË ¤¯ÂÈ ˆ˜ ÛÎÔfi ÙËÓ Â˘·ÈÛıËÙÔÔ›ËÛË ÙˆÓ ·È‰È¿ÙÚˆÓ Û’·˘Ùfi ÙÔ ı¤Ì·. ¶·ÚÔ˘ÛÈ¿˙ÔÓÙ·È ÂȉËÌÈÔÏÔÁÈο ÛÙÔȯ›·, Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÂÌÏÂÎfiÌÂÓˆÓ ·È‰ÈÒÓ, ÔÈ ÂÈÙÒÛÂȘ ÛÙËÓ ˘Á›· ηıÒ˜ Î·È Ì¤ÙÚ· ·ÓÙÈÌÂÙÒÈÛ˘.
Abstract: Over the past twenty years, in developed countries, there is a growing conviction that bullying constitutes a form of child abuse. It has been found that some children are repeatedly involved in such incidents, either as bullies or as victims. These experiences have adverse consequences on their mental and physical health, social development and academic progress. In particular, children with special needs are at increased risk for victimization. The purpose of this review is to heighten the pediatrician’s awareness of this problem. Epidemiological data, characteristics of bullies and victims, health consequences and intervention modalities are discussed.
§¤ÍÂȘ ÎÏÂȉȿ: ηÎÔÔ›ËÛË ·È‰ÈÒÓ, ÎÔÈÓˆÓÈΤ˜ Û¯¤ÛÂȘ ·È‰ÈÒÓ, ·È‰È¿ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ.
Key words: bullying, victimization, peer relationships, children with special needs.
∂ÈÛ·ÁˆÁ‹ √È Û˘ÁÎÚÔ‡ÛÂȘ ÌÂٷ͇ ·È‰ÈÒÓ ·ÔÙÂÏÔ‡Ó Ê˘ÛÈÔÏÔÁÈÎfi, ·Ô‰ÂÎÙfi Ê·ÈÓfiÌÂÓÔ fiÙ·Ó ÚfiÎÂÈÙ·È ÁÈ· “‰Ô‡Ó·È Î·È Ï·‚›Ӕ ÛÙ· Ï·›ÛÈ· ÈÛfiÙÈÌ˘ Û¯¤Û˘. ø˜ ηÎÔÔ›ËÛË ·fi Û˘ÓÔÌ‹ÏÈÎÔ˘˜, “peer abuse” ηٿ ÙËÓ ·ÁÁÏÈ΋ ÔÚÔÏÔÁ›·, ÔÚ›˙ÂÙ·È Ë Û˘ÛÙËÌ·ÙÈ΋, ÂÛÎÂÌ̤ÓË Î·È ·ÚÔÎ¿Ï˘ÙË ÂÈıÂÙÈÎfiÙËÙ· ·fi ̤ÚÔ˘˜ ÈÛ¯˘ÚfiÙÂÚÔ˘ ·ÙfiÌÔ˘ (‹ ÔÌ¿‰·˜ ·ÙfïÓ) ¤Ó·ÓÙÈ ·ÙfiÌÔ˘ Ô˘ ·‰˘Ó·Ù› Ó· ˘ÂÚ·ÛÈÛÙ› ÙÔÓ Â·˘Ùfi ÙÔ˘. ∏ ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ Û·Ó›ˆ˜ ÂÌϤÎÂÙ·È Û ٤ÙÔÈ· ÂÂÈÛfi‰È·. À¿Ú¯Ô˘Ó, fï˜, ¿ÙÔÌ· Ù· ÔÔ›· ηْ·ӿÏË„Ë ÂÈÙ›ıÂÓÙ·È Û ¿Ï-
ÏÔ˘˜ Î·È ¿ÙÔÌ· Ù· ÔÔ›· Û˘ÛÙËÌ·ÙÈο ‰¤¯ÔÓÙ·È Ù¤ÙÔȘ ÂÈı¤ÛÂȘ (1). ∏ ηÎÔÔ›ËÛË ·fi Û˘ÓÔÌ‹ÏÈÎÔ˘˜ ÌÔÚ› Ó· Ï¿‚ÂÈ ‰È¿ÊÔÚ˜ ÌÔÚʤ˜: ۈ̷ÙÈ΋ ‚›·, ÊÚ·ÛÙÈΤ˜ ÂÈı¤ÛÂȘ, ·ÔÎÏÂÈÛÌfi˜ ·fi ÎÔÈÓˆÓÈΤ˜ Û¯¤ÛÂȘ, ·Ê·›ÚÂÛË ‹ ηٷÛÙÚÔÊ‹ ÚÔÛˆÈÎÒÓ ·ÓÙÈÎÂÈ̤ӈÓ. ∆Ș ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, Ë Î·ÎÔÔ›ËÛË ·È‰ÈÒÓ ·fi ÂÓ‹ÏÈΘ ‚Ú›ÛÎÂÙ·È ÛÙÔ ÚÔÛ΋ÓÈÔ ÙÔ˘ ÂӉȷʤÚÔÓÙÔ˜. ∂›Ó·È ϤÔÓ ÁÓˆÛÙfi fiÙÈ Ù· ı‡Ì·Ù· Û˘Ó‹ıˆ˜ ‰ÂÓ ·Ó·˙ËÙÔ‡Ó ‚Ô‹ıÂÈ· Î·È ÁÈ’·˘ÙfiÓ ÙÔ ÏfiÁÔ Û˘ÓÈÛÙ¿Ù·È Â·ÁÚ‡ÓËÛË ·fi ̤ÚÔ˘˜ ÙˆÓ ·È‰È¿ÙÚˆÓ ÚÔÎÂÈ̤ÓÔ˘ Ó· Ú·ÁÌ·ÙÔÔÈËı› Ë
∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ ∞’ ¶·È‰È·ÙÚÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
∞Ó·ÏËÚˆÙ‹˜ ¢È¢ı˘ÓÙ‹˜ ∞’ ¶·È‰È·ÙÚÈÎÔ‡ ∆Ì‹Ì·ÙÔ˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
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ηٿÏÏËÏË ·Ú¤Ì‚·ÛË. ∂›Û˘, Â›Ó·È ÁÓˆÛÙfi fiÙÈ ·È‰È¿ Ô˘ ηÎÔÔÈÔ‡ÓÙ·È ·fi ¿ÏÏ· ·È‰È¿ ‰ÂÓ ·Ó·Ê¤ÚÔ˘Ó ÙÔ Úfi‚ÏËÌ· Û ÂÓ‹ÏÈΘ ÏfiÁˆ ÓÙÚÔ‹˜ Î·È Êfi‚Ô˘ ÁÈ· ·ÓÙ›ÔÈÓ· (2,3). ∂ȉËÌÈÔÏÔÁ›· ∆ÔÓ √ÎÙÒ‚ÚÈÔ Î·È ¡Ô¤Ì‚ÚÈÔ ÙÔ˘ 1999 Ú·ÁÌ·ÙÔÔÈ‹ıËΠÌÂϤÙË Û ‰Â›ÁÌ· 350 Ì·ıËÙÒÓ Ï˘Î›Ԣ Ù˘ ËÂÈÚˆÙÈ΋˜ ∂ÏÏ¿‰·˜. ∫·Ù¿ ÙË ‰‹ÏˆÛ‹ ÙÔ˘˜, ÙÔ 11,6% ÙˆÓ Ì·ıËÙÒÓ Â›¯Â ˘¿ÚÍÂÈ ı‡Ì· ۈ̷ÙÈ΋˜ ‹ ÏÂÎÙÈ΋˜ ‚›·˜. ∆Ô Ê·ÈÓfiÌÂÓÔ Â›Ó·È ÈÔ Û˘¯Ófi ÛÙȘ ËÌÈ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ (17,4%) Î·È ÏÈÁfiÙÂÚÔ ÛÙȘ ·ÁÚÔÙÈΤ˜ (8,5%). ¶ÈÔ Û˘¯Ó¿ Û˘Ì‚·›ÓÂÈ ÛÙ· ·ÁfiÚÈ· (16,8%) ·’ fiÙÈ ÛÙ· ÎÔÚ›ÙÛÈ· (6,6%). ∆Ô ÔÛÔÛÙfi ÙˆÓ Ì·ıËÙÒÓ Ô˘ ›¯·Ó ·Û΋ÛÂÈ ‚›· ¤Ó·ÓÙÈ ¿ÏÏˆÓ ‹Ù·Ó 23,2%, Ì ˘ÂÚÔ¯‹ ÙˆÓ ·ÁÔÚÈÒÓ (36,5%) ¤Ó·ÓÙÈ ÙˆÓ ÎÔÚÈÙÛÈÒÓ (10,4%). √È Ì·ıËÙ¤˜ Ì ¯·ÌËÏ‹ Û¯ÔÏÈ΋ ·fi‰ÔÛË Û˘ÌÌÂÙ¤¯Ô˘Ó ÈÔ Û˘¯Ó¿ Û ÂÂÈÛfi‰È· ‚›·˜, ˆ˜ ı‡Ì·Ù· (22,7% ¤Ó·ÓÙÈ 3,5% ÙˆÓ “·Ú›ÛÙˆÓ”) ‹ ˆ˜ ı‡Ù˜ (26,1% ¤Ó·ÓÙÈ 10,2% ÙˆÓ “·Ú›ÛÙˆÓ”). √È Èı·ÓfiÙËÙ˜ ÂÌÏÔ΋˜ ÌÂٷ͇ ∂ÏÏ‹ÓˆÓ Ì·ıËÙÒÓ Î·È ·ÓÙ›ÛÙÔȯˆÓ ·ÏÏÔ‰·ÒÓ Û ÂÂÈÛfi‰ÈÔ ‚›·˜, Â›Ó·È ·˘ÍË̤Ó˜ (29,4% ÙˆÓ Ì·ıËÙÒÓ) (6). ÕÏÏË ¤Ú¢ӷ, ÙÔ˘ ∂ıÓÈÎÔ‡ ∫¤ÓÙÚÔ˘ ∫ÔÈÓˆÓÈÎÒÓ ªÂÏÂÙÒÓ, ¤‰ÂÈÍ fiÙÈ Û ڿÍÂȘ ‚›·È˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÚÔ‚·›ÓÂÈ ÙÔ 29% ÙˆÓ Ì·ıËÙÒÓ ËÏÈΛ·˜ 12-15 ÂÙÒÓ Î·È ÙÔ 49% ÙˆÓ Ì·ıËÙÒÓ ËÏÈΛ·˜ 16-19 ÂÙÒÓ. ∏ Û˘¯ÓfiÙËÙ· Ù¤ÙÔÈˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ÔÈΛÏÏÂÈ ÛÙȘ ‰È¿ÊÔÚ˜ ÎÔÈÓˆÓÈΤ˜ Ù¿ÍÂȘ: ÙÔ 42% ÙˆÓ ·È‰ÈÒÓ ¿ÓÂÚÁˆÓ ÁÔÓÈÒÓ, ÙÔ 36% ·È‰ÈÒÓ ÂȯÂÈÚËÌ·ÙÈÒÓ Î·È Â·ÁÁÂÏÌ·ÙÈÒÓ Î·È ÙÔ 26% ·È‰ÈÒÓ ·ÁÚÔÙÒÓ Î·È ·ÓÂȉ›ÎÂ˘ÙˆÓ ÂÚÁ·ÙÒÓ (7). ŒÚ¢Ó˜ Û ‰È¿ÊÔÚ˜ ¯ÒÚ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë Î·ÎÔÔ›ËÛË ·È‰ÈÒÓ ·fi Û˘ÓÔÌ‹ÏÈÎÔ˘˜ ·ÔÙÂÏ› ‰ÈÂıÓ¤˜ Ê·ÈÓfiÌÂÓÔ. ™ÙËÓ ÚˆÙÔÔÚȷ΋ ¤Ú¢ӷ ÙÔ˘ Olweus ÙÔ 1977 ÛÙË ¡ÔÚ‚ËÁ›·, Ì ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ Ô˘ ‰È·ÓÂÌ‹ıËΠ۠13.000 Ì·ıËÙ¤˜ ËÏÈΛ·˜ 8-16 ÂÙÒÓ, ‚Ú¤ıËΠfiÙÈ ÙÔ 8% ·fi ·˘ÙÔ‡˜ ·ÓÂÈÏËÌ̤ӷ ηÎÔÔÈÔ‡Û ¿ÏÏÔ˘˜, ÂÓÒ ÙÔ 9% ‹Ù·Ó ı‡Ì·Ù· (1). ™ÙË ªÂÁ¿ÏË µÚÂÙ·Ó›·, Ù· ÔÛÔÛÙ¿ ÂÌÏÔ΋˜ Û ηÎÔÔ›ËÛË (ˆ˜ ı‡Ì·Ù· ‹ ı‡Ù˜) ‹Ù·Ó 27% ÛÙÔ ‰ËÌÔÙÈÎfi/Á˘ÌÓ¿ÛÈÔ Î·È 10% ÛÙÔ Ï‡ÎÂÈÔ (4), ÂÓÒ Û ¿ÏϘ ¯ÒÚ˜, fiˆ˜ ÛÙËÓ πÛ·Ó›·, Â›Ó·È 17%, ÛÙËÓ ∞˘ÛÙÚ·Ï›· 17% Î·È ÛÙȘ ∏¶∞ 15% (5). ø˜ ÚÔ˜ ÙËÓ ËÏÈΛ·, Ù· ÔÛÔÛÙ¿ ÙˆÓ ·È‰ÈÒÓ Ô˘ ηÎÔÔÈÔ‡ÓÙ·È ÂÏ·ÙÙÒÓÔÓÙ·È Ì ÙÔ ¤Ú·ÛÌ· ·fi ÙÔ ‰ËÌÔÙÈÎfi ÛÙÔ Á˘ÌÓ¿ÛÈÔ, ÂÓÒ Ù· ÔÛÔÛÙ¿ ÙˆÓ ÂÈıÂÙÈÎÒÓ ·È‰ÈÒÓ, ›Û˘ ÂÏ·ÙÙÒÓÔÓÙ·È ·ÏÏ¿ Û ÌÈÎÚfiÙÂÚÔ ‚·ıÌfi (ÌÂÚÈÎÔ› ÛÙÚ¤ÊÔÓÙ·È ÙfiÙ Û ÌÈÎÚfiÙÂÚ· ·È‰È¿) (1,4,8). ∆· ·ÁfiÚÈ· ηÎÔÔÈÔ‡Ó Î·È Î·ÎÔÔÈÔ‡ÓÙ·È ÈÔ Û˘¯Ó¿ ·fi Ù· ÎÔÚ›ÙÛÈ·. ∂›Û˘, Ù· ·ÁfiÚÈ· ÈÔ Û˘¯Ó¿ ·fi Ù· ÎÔÚ›ÙÛÈ· ·ÛÎÔ‡Ó ÛˆÌ·ÙÈ΋ ‚›·, ÂÓÒ ·ÓÙ›ıÂÙ· Ù· ÎÔÚ›ÙÛÈ· ¯ÚËÛÈÌÔÔÈÔ‡Ó Û˘¯ÓfiÙÂÚ· ÊÚ·ÛÙÈΤ˜ ÂÈı¤ÛÂȘ Î·È ÎÔÈÓˆÓÈÎfi ·Ô-
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ÎÏÂÈÛÌfi. ∆· ·ÁfiÚÈ· ÂÈÙ›ıÂÓÙ·È Û ·ÁfiÚÈ· Î·È ÎÔÚ›ÙÛÈ·, ÂÓÒ Ù· ÎÔÚ›ÙÛÈ· ÂÈÙ›ıÂÓÙ·È Û˘Ó‹ıˆ˜ Û ¿ÏÏ· ÎÔÚ›ÙÛÈ· (1,4,8). ø˜ ÚÔ˜ ÙËÓ ÎÔÈÓˆÓÈ΋ Ù¿ÍË, ÛÙË ªÂÁ¿ÏË µÚÂÙ·Ó›· Ë Û˘¯ÓfiÙËÙ· ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚË Û ˘Ô‚·ıÌÈṲ̂Ó˜ ÂÚÈÔ¯¤˜ (4,8). ∂›Û˘, Â›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ ÛÙË ªÂÁ¿ÏË µÚÂÙ·Ó›· ÔÈ Èı·ÓfiÙËÙ˜ ηÎÔÔ›ËÛ˘ Â›Ó·È ·˘ÍË̤Ó˜ ÁÈ· ·È‰È¿ ÂıÓÈÎÒÓ ÌÂÈÔÓÔÙ‹ÙˆÓ (3). ÷ڷÎÙËÚÈÛÙÈο ÙˆÓ ÂÌÏÂÎfiÌÂÓˆÓ ·È‰ÈÒÓ ¢È·ÎÚ›ÓÔÓÙ·È ÔÈ ·ÎfiÏÔ˘ı˜ ηÙËÁÔڛ˜ ·È‰ÈÒÓ Ô˘ ÂÌϤÎÔÓÙ·È Ù·ÎÙÈο Û ÂÂÈÛfi‰È· ηÎÔÔ›ËÛ˘: ÂÈıÂÙÈο ·È‰È¿, ηÎÔÔÈË̤ӷ ·È‰È¿ Î·È ÚÔÎÏËÙÈο ı‡Ì·Ù·, Ù· ÔÔ›· Î·È ÂÈÙ›ıÂÓÙ·È Î·È Î·ÎÔÔÈÔ‡ÓÙ·È: ∂ÈıÂÙÈο ·È‰È¿: ∏ ȉÈÔÛ˘ÁÎÚ·Û›· (temperament) Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ¢ÂÚÂıÈÛÙfiÙËÙ· ÎÈ Â‡ÎÔϘ ÂÎÚ‹ÍÂȘ ı˘ÌÔ‡, Úԉȷı¤ÙÂÈ ÁÈ· ÂÈıÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ Ô˘ ÌÔÚ› Ó· ÂΉËÏÒÓÂÙ·È ‹‰Ë ÛÙËÓ ÚÒÈÌË ÓËȷ΋ ËÏÈΛ· (9,10). ∆· ÂÈıÂÙÈο ·È‰È¿ ¤¯Ô˘Ó ıÂÙÈ΋ ÛÙ¿ÛË ·¤Ó·ÓÙÈ ÛÙË ‚›· (11). ∞ӷ̤ÓÔ˘Ó Ó· ·ÔÎÔÌ›ÛÔ˘Ó ÔʤÏË ·fi ‚›·È˜ Ú¿ÍÂȘ Î·È ÙÔ ıˆÚÔ‡Ó Î·ÙfiÚıˆÌ·. √ fiÓÔ˜ ÂÓfi˜ ı‡Ì·ÙÔ˜ Ô˘ ÚÔηÏ› Û˘ÌfiÓÈ· Î·È ‰˘ÛÊÔÚ›· ÛÙ· ÂÚÈÛÛfiÙÂÚ· ¿ÙÔÌ·, ÚÔÛʤÚÂÈ ÈηÓÔÔ›ËÛË Î·È ·›ÛıËÛË ‰‡Ó·Ì˘ Û’ ·˘Ù¿ Ù· ·È‰È¿ (12). ™˘Ó‹ıˆ˜ ¤¯Ô˘Ó ˘„ËÏ‹ ·˘ÙÔÂÎÙ›ÌËÛË Î·È ·ÓËÛ˘¯Ô‡Ó ÂÏ¿¯ÈÛÙ· ÁÈ· ·fiÚÚÈ„Ë ·fi Û˘ÌÌ·ıËÙ¤˜ ÎÈ ÂÈÏ‹ÍÂȘ ·fi ‰·ÛοÏÔ˘˜ (13). ∂›Ó·È ÏÈÁfiÙÂÚÔ ‰ËÌÔÊÈÏ‹ ·fi Ù· ÌË ÂÈıÂÙÈο ·È‰È¿ (·ÏÏ¿ ÈÔ ‰ËÌÔÊÈÏ‹ ·fi Ù· ı‡Ì·Ù·). ∞fi ÌÂϤÙ˜ Ì ÂÚˆÙËÌ·ÙÔÏfiÁÈ· ÚÔ·ÙÂÈ fï˜, fiÙÈ Û˘Ó‹ıˆ˜ ıˆÚÔ‡Ó ÙÔÓ Â·˘Ùfi ÙÔ˘˜ ÈÔ ‰ËÌÔÊÈÏ‹ ·’ fiÙÈ Â›Ó·È ÛÙËÓ Ú·ÁÌ·ÙÈÎfiÙËÙ· (Û ۇÁÎÚÈÛË Ì ÙȘ ÂÎÙÈÌ‹ÛÂȘ ÙˆÓ Û˘ÌÌ·ıËÙÒÓ ÙÔ˘˜) (14). ∆· ÂÈıÂÙÈο ·ÁfiÚÈ· ¤¯Ô˘Ó ηٿ ̤ÛÔ fiÚÔ ÌÂÁ·Ï‡ÙÂÚË ÛˆÌ·ÙÈ΋ ‰‡Ó·ÌË. ∏ Û¯ÔÏÈ΋ ÙÔ˘˜ ·fi‰ÔÛË Â›Ó·È Û˘Ó‹ıˆ˜ ̤ÙÚÈ· ‹ ·ÚÎÂÙ¿ οو ÙÔ˘ ÌÂÙÚ›Ô˘ (15). K·ÎÔÔÈË̤ӷ ·È‰È¿: ª¤Û· ÛÙ· Ê˘ÛÈÔÏÔÁÈο Ï·›ÛÈ·, ÔÈ È‰È·ÈÙÂÚfiÙËÙ˜ Ù˘ ÂÌÊ¿ÓÈÛ˘ (Á˘·ÏÈ¿, ·¯˘Û·ÚΛ· ÎÏ.) ‰ÂÓ ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ, ¿Ú· ÌfiÓÔ ˆ˜ ·ÊÔÚÌ‹. ªÂϤÙ˜ ÛÙȘ Ôԛ˜ Û˘ÁÎÚ›ıËÎ·Ó Ù· Ê˘ÛÈο ¯·Ú·ÎÙËÚÈÛÙÈο ηÎÔÔÈËÌ¤ÓˆÓ ·È‰ÈÒÓ Ì ¿ÏψÓ, ‰ÂÓ ‚Ú‹Î·Ó ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· “·ÚÂÎÎϛۈӔ. °È· Ù· ·ÁfiÚÈ·, Ë Ì˘˚΋ ‰‡Ó·ÌË Â›Ó·È ÛËÌ·ÓÙÈ΋ Î·È Ù· ·‰‡Ó·Ì· ¿ÙÔÌ· Û˘¯Ó¿ ¤ÊÙÔ˘Ó ı‡Ì·Ù· ÂÈı¤ÛˆÓ. ∂›Û˘, Ù· ·ÁfiÚÈ· Ì ÎÔÓÙfi ·Ó¿ÛÙËÌ· ηÎÔÔÈÔ‡ÓÙ·È ÈÔ Û˘¯Ó¿. ∆· ηÎÔÔÈË̤ӷ ÎÔÚ›ÙÛÈ· ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ÛÂ Ì˘˚΋ ‰‡Ó·ÌË ‹ ¿ÏÏ· ۈ̷ÙÈο ¯·Ú·ÎÙËÚÈÛÙÈο ·fi Ù· ˘fiÏÔÈ· (1,3). ∫·Ù¿ ̤ÛÔ fiÚÔ ¤¯Ô˘Ó οˆ˜ ¯·ÌËÏfiÙÂÚË Â›‰ÔÛË ÛÙÔ Û¯ÔÏÂ›Ô ·fi Ù· ¿ÏÏ· ·È‰È¿. ¶·È‰È¿ Ô˘ ηÎÔÔÈÔ‡ÓÙ·È Û˘ÛÙËÌ·ÙÈο
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·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙ·‰È·Î‹ ÙÒÛË Â›‰ÔÛ˘ ÛÙË ‰È¿ÚÎÂÈ· ÙÔ˘ Û¯ÔÏÈÎÔ‡ ¤ÙÔ˘˜. ŸÙ·Ó ηÎÔÔÈÔ‡ÓÙ·È ÌfiÓÔ ÁÈ· ¤Ó· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ·, ¤¯Ô˘Ó ¯·ÌËÏfiÙÂÚË ·fi‰ÔÛË Û’ ·˘Ùfi ÙÔ ‰È¿ÛÙËÌ· Î·È ·Ó·Î¿ÌÙÔ˘Ó fiÙ·Ó Ë Î·Ù¿ÛÙ·ÛË ‚ÂÏÙȈı› (16,17). ∆· ·È‰È¿ ·˘Ù¿ ·ÈÛı¿ÓÔÓÙ·È ÌÔÓ·ÍÈ¿ ÛÙÔ Û¯ÔÏ›Ô, ·ÓÙÈ¿ıÂÈ· ÚÔ˜ ·˘Ùfi Î·È ı¤ÏÔ˘Ó Ó· ÙÔ ·ÔʇÁÔ˘Ó. ™·Ó Û˘Ó¤ÂÈ·, ¤¯Ô˘Ó ÔÏϤ˜ ·Ô˘Û›Â˜, ̤ÓÔ˘Ó ›Ûˆ ÛÙË Û¯ÔÏÈ΋ ‰Ô˘ÏÂÈ¿ Î·È Ë ÂÈÛÙÚÔÊ‹ Á›ÓÂÙ·È fiÏÔ Î·È ÈÔ ‰‡ÛÎÔÏË. √È ÁÔÓ›˜ Î·È ÔÈ ‰¿ÛηÏÔÈ Ôχ Û˘¯Ó¿ ‰ÂÓ ÁÓˆÚ›˙Ô˘Ó ÙȘ ·Èٛ˜ ·˘Ù‹˜ Ù˘ ηٿÛÙ·Û˘ (18). ™Â ÎÔÈÓˆÓÈΤ˜ Û˘Ó·Ó·ÛÙÚÔʤ˜, ÔÈ ·ÓÙȉڿÛÂȘ ÙÔ˘˜ Â›Ó·È Û˘¯Ó¿ ·‰¤ÍȘ Î·È ·Î·Ù¿ÏÏËϘ ÁÈ· ÙËÓ ÂÚ›ÛÙ·ÛË (19,20). ŸÙ·Ó ‰¤¯ÔÓÙ·È ÂÈı¤ÛÂȘ ·ÓÙȉÚÔ‡Ó ·ıËÙÈο, ÎÏ·›Ó ‹ ·Ú·‰›‰Ô˘Ó Ù· Ú¿ÁÌ·Ù¿ ÙÔ˘˜ (21,22). ∞˘Ù‹ Ë Û˘ÌÂÚÈÊÔÚ¿ ‰›ÓÂÈ ÙÔ Ì‹Ó˘Ì· fiÙÈ ÔÈ ÂÈı¤ÛÂȘ fi¯È ÌfiÓÔ ‰ÂÓ ı· ÙÈ̈ÚËıÔ‡Ó ·ÏÏ¿ Î·È ı· ÂÈ‚Ú·‚¢ıÔ‡Ó (23). ∆›ÓÔ˘Ó Ó· ·›˙Ô˘Ó ÌfiÓ· ÙÔ˘˜ Î·È Û·Ó›ˆ˜ ·›ÚÓÔ˘Ó ÚˆÙÔ‚Ô˘Ï›Â˜ ÁÈ· ÎÔÈÓˆÓÈΤ˜ ·ʤ˜. Œ¯Ô˘Ó Ï›ÁÔ˘˜ Ê›ÏÔ˘˜ (‹ ηıfiÏÔ˘) Î·È ÔÈ ÊÈϛ˜ ÙÔ˘˜ ÚÔÛʤÚÔ˘Ó ÏÈÁfiÙÂÚË ÈηÓÔÔ›ËÛË Î·È ˘ÔÛÙ‹ÚÈÍË Û ۇÁÎÚÈÛË Ì ÂΛӘ ÙˆÓ ¿ÏÏˆÓ ·È‰ÈÒÓ (24,25). ∏ Û¯¤ÛË ·Ó¿ÌÂÛ· ÛÙËÓ ÚÔÛˆÈÎfiÙËÙ· ÙÔ˘ ·È‰ÈÔ‡ Î·È ÛÙËÓ ÈηÓfiÙËÙ¿ ÙÔ˘ Ó· ·ÓÙÈÌÂÙˆ›˙ÂÈ ÎÔÈÓˆÓÈΤ˜ ηٷÛÙ¿ÛÂȘ Â›Ó·È ÂÌÊ·Ó‹˜ ·fi Ôχ ÌÈÎÚ‹ ËÏÈΛ·. ™Â ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ Ì ·È‰È¿ ËÏÈΛ·˜ 15 Î·È 21 ÌËÓÒÓ, ÂΛӷ Ù· ÔÔ›· ‹Ù·Ó Ôχ ÚÔÛÎÔÏÏË̤ӷ ÛÙË ÌËÙ¤Ú· ÙÔ˘˜ Î·È ‰ÂÓ ÂÍÂÚ¢ÓÔ‡Û·Ó ÙÔ ÂÚÈ‚¿ÏÏÔÓ ‚Ú¤ıËÎ·Ó ·ÚÁfiÙÂÚ· (ÛÙÔ ÓËÈ·ÁˆÁ›Ô) Ó· Â›Ó·È Û˘ÓÂÛÙ·Ï̤ӷ ÎÔÈÓˆÓÈο Î·È Ó· ¤ÊÙÔ˘Ó, Û˘¯Ó¿, ı‡Ì·Ù· ÂÈı¤ÛˆÓ. ∞ÈÛı¿ÓÔÓÙ·È ¿Á¯Ô˜ Î·È ·Ó·ÛÊ¿ÏÂÈ· Û ÎÔÈÓˆÓÈΤ˜ ηٷÛÙ¿ÛÂȘ, ÙȘ Ôԛ˜ ¿ÏÏÔÈ ·ÓÙÈÌÂÙˆ›˙Ô˘Ó Ì ¿ÓÂÛË (26,27). ¶Èı·ÓÒ˜ ¤¯Ô˘Ó ÂÍ·Ú¯‹˜ ¯·ÌËÏ‹ ·˘ÙÔÂÎÙ›ÌËÛË Ô˘ Ù· ηıÈÛÙ¿ ÈÔ Â˘¿ÏˆÙ·, ·ÏÏ¿ Ù· ·ÓÂÈÏËÌ̤ӷ ·ÚÓËÙÈο ÌËӇ̷ٷ ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ Ù· ÂËÚ¿˙Ô˘Ó Â›Û˘. ™Â ÂÚˆÙËÌ·ÙÔÏfiÁÈ·, Ù· ı‡Ì·Ù· ηÎÔÔ›ËÛ˘ ‚·ıÌÔÏÔÁÔ‡Ó ÙÔÓ Â·˘Ùfi ÙÔ˘˜ ÈÔ ¯·ÌËÏ¿ Û ۇÁÎÚÈÛË Ì ¿ÏÏ· ·È‰È¿, ·fi ¿Ô„Ë ÂÌÊ¿ÓÈÛ˘, ÓÔËÌÔÛ‡Ó˘ Î·È ·ıÏËÙÈÎÒÓ ÈηÓÔًوÓ, ·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ·ÓÙÈÎÂÈÌÂÓÈο ‰ÂÓ ˘ÛÙÂÚÔ‡Ó (27,28). ¶ÚÔÎÏËÙÈο ı‡Ì·Ù·: ¶ÔÏÏ¿ ·fi ·˘Ù¿ Ù· ·È‰È¿ Â›Ó·È ˘ÂÚÎÈÓËÙÈο Î·È ·ÚÔÚÌËÙÈο. £˘ÌÒÓÔ˘Ó Â‡ÎÔÏ·, ·ÏÏ¿ Ë ÂÈıÂÙÈÎfiÙËÙ¿ ÙÔ˘˜ Â›Ó·È Û·Û̈‰È΋, ·Ó·ÔÙÂÏÂÛÌ·ÙÈ΋ Î·È Î·Ù·ÛÙ¤ÏÏÂÙ·È Â‡ÎÔÏ· (29). ªfiÓÔ Ì›· ÌÂÈÔÓfiÙËÙ· ı˘Ì¿ÙˆÓ Ê·›ÓÂÙ·È Ó· ÚÔηÏ› ·ÓÙ·ÁˆÓÈÛÌfi Ì ÙË Û˘ÌÂÚÈÊÔÚ¿ Ù˘. ∏ ηÎÔÔ›ËÛË ·È‰ÈÒÓ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ À¿Ú¯Ô˘Ó ·Ô‰Â›ÍÂȘ fiÙÈ Ù· ·È‰È¿ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ ‚Ú›ÛÎÔÓÙ·È Û ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· ηÎÔÔ›ËÛË ·fi Û˘ÓÔÌ‹ÏÈÎÔ˘˜. ∞˘Ù‹ Ë ·ÚÓËÙÈ΋ ÛÙ¿ÛË ÙÔ˘ ÂÚÈ‚¿ÏÏÔÓÙÔ˜ ÌÔÚ› Ó· ·ÔÙÂϤÛÂÈ ÂÌfi‰ÈÔ
Paediatriki 2001;64:125-131
ÁÈ· ÙËÓ ÂÈÙ˘¯‹ ¤ÓÙ·Í‹ ÙÔ˘˜ ÛÙÔ Û¯ÔÏÈÎfi Û‡ÛÙËÌ·. ™ˆÌ·ÙÈΤ˜ ·Ó·Ëڛ˜: ∏ Èı·ÓfiÙËÙ· Ó· ηÎÔÔÈËı› ¤Ó· ·È‰› Ì ÂÌÊ·Ó‹ ۈ̷ÙÈ΋ ·Ó·ËÚ›·, fiˆ˜ ÂÁÎÂÊ·ÏÈ΋ ·Ú¿Ï˘ÛË, Ì˘˚΋ ‰˘ÛÙÚÔÊ›·, ‰Èۯȉ‹ Ú¿¯Ë ‹ ·‰ÂÍÈfiÙËÙ·, Â›Ó·È ‰ÈÏ¿ÛÈ· ·˘Ù‹˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ·È‰ÈÒÓ, ·ÎfiÌË ÎÈ ·Ó ¤¯ÂÈ Ê˘ÛÈÔÏÔÁÈ΋ ÓÔËÌÔÛ‡ÓË. ™ÙË ªÂÁ¿ÏË µÚÂÙ·Ó›· ‰È·ÈÛÙÒıËΠfiÙÈ ÛÙÔ ‰ËÌÔÙÈÎfi Û¯ÔÏÂ›Ô ÌÔÚ› Ó· ηÎÔÔÈÂ›Ù·È ÙÔ 30% ·˘ÙÒÓ ÙˆÓ ·È‰ÈÒÓ. √È ÊÚ·ÛÙÈΤ˜ ÂÈı¤ÛÂȘ Û˘¯Ó¿ ·Ó·Ê¤ÚÔÓÙ·È ÛÙËÓ ·Ó·ËÚ›·. √È Èı·ÓfiÙËÙ˜ ηÎÔÔ›ËÛ˘ Â›Ó·È ·˘ÍË̤Ó˜ ·Ó ÙÔ ·È‰›, ·Ú¿ÏÏËÏ· Ì ÙËÓ ·Ó·ËÚ›·, ¤¯ÂÈ Î·È Ì·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜ ‹ Â›Ó·È ÎÔÈÓˆÓÈο ·ÔÌÔӈ̤ÓÔ Î·È ‰ÂÓ ¤¯ÂÈ Ê›ÏÔ˘˜ (30). ∞ÓÙÈı¤Ùˆ˜, fiÙ·Ó ÙÔ ·Ó¿ËÚÔ ·È‰› ¤¯ÂÈ ˘„ËÏ‹ ·˘ÙÔÂÎÙ›ÌËÛË, ÂÚÈÔÈË̤ÓË ÂÌÊ¿ÓÈÛË Î·È Â›Ó·È ÈηÓfi Ó· ÌÈÏ¿ÂÈ ·ÓÔȯٿ ÁÈ· ÙÔ Úfi‚ÏËÌ¿ ÙÔ˘, ÔÈ Èı·ÓfiÙËÙ˜ ηÎÔÔ›ËÛ˘ ÂÏ·ÙÙÒÓÔÓÙ·È (31). ª·ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜: ∏ Û˘¯ÓfiÙËÙ· ηÎÔÔ›ËÛ˘ ·È‰ÈÒÓ Ì ̷ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜ Â›Ó·È ‰ÈÏ¿ÛÈ· ·˘Ù‹˜ ÙˆÓ ¿ÏÏˆÓ ·È‰ÈÒÓ (32). ∏ ÈÔ ÚÔÊ·Ó‹˜ ÂÚÌËÓ›· ·˘ÙÔ‡ ÙÔ˘ Ê·ÈÓÔ̤ÓÔ˘ Â›Ó·È fiÙÈ ÙÔ ·È‰› ıˆÚÂ›Ù·È ·fi ÙÔ˘˜ Û˘ÌÌ·ıËÙ¤˜ ÙÔ˘ ÓÔËÙÈο ηÙÒÙÂÚÔ. ∂ÈϤÔÓ fï˜, ·È‰È¿ Ì ̷ıËÛȷΤ˜ ‰˘ÛÎÔϛ˜ Û˘¯Ó¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÚÔ‚Ï‹Ì·Ù· ÛÙÔÓ ÙÔ̤· Ù˘ ÎÔÈÓˆÓÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜, ÂȉÈο (·ÏÏ¿ fi¯È ÌfiÓÔ) fiÙ·Ó Â›Ó·È ˘ÂÚÎÈÓËÙÈο (33). ¢È·Ù·Ú·¯¤˜ ÙÔ˘ ÏfiÁÔ˘: ¶·È‰È¿ Ì ‰È·Ù·Ú·¯¤˜ ·ÓÙÈÏËÙÈÎÔ‡ ‹ ÂÎÊÚ·ÛÙÈÎÔ‡ ÏfiÁÔ˘ Î·È ÚÔ·ÓÙfi˜ Ù· ·È‰È¿ Ì ·ÒÏÂÈ· ·ÎÔ‹˜, Û˘¯Ó¿ ·ÔÚÚ›ÙÔÓÙ·È ·fi ¿ÏÏ· ·È‰È¿ (34). √ ÙÚ·˘ÏÈÛÌfi˜ Â›Ó·È Û¯ÂÙÈο ‹È· ‰È·Ù·Ú·¯‹, ·ÏÏ¿ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ÏÂÈÔÓfiÙËÙ· ÙˆÓ ·È‰ÈÒÓ Ì ·˘Ùfi ÙÔ Úfi‚ÏËÌ· ˘Ê›ÛÙ·Ù·È Î·Î‹ ÌÂÙ·¯Â›ÚÈÛË ·fi Û˘ÓÔÌ‹ÏÈÎÔ˘˜. √È ÌÈÛÔ› ÂÓ‹ÏÈΘ, ÔÈ ÔÔ›ÔÈ ÙÚ·‡ÏÈ˙·Ó ˆ˜ ·È‰È¿, ·Ó·Ê¤ÚÔ˘Ó fiÙÈ ÔÈ ·ÚÓËÙÈΤ˜ „˘¯ÔÏÔÁÈΤ˜ ÂÈÙÒÛÂȘ ·Ú·Ì¤ÓÔ˘Ó (35). ¢È·Ù·Ú·¯‹ ÚÔÛÔ¯‹˜: ¶·È‰È¿ Ì ‰È·Ù·Ú·¯‹ ÚÔÛÔ¯‹˜ ‰˘ÛÎÔχÔÓÙ·È Ó· ÂÈÎÂÓÙÚˆıÔ‡Ó Û ÛËÌ·ÓÙÈο ÂÚÂı›ÛÌ·Ù·, fi¯È ÌfiÓÔ Ì¤Û· ÛÙËÓ Ù¿ÍË ·ÏÏ¿ Î·È Û ÎÔÈÓˆÓÈΤ˜ ηٷÛÙ¿ÛÂȘ. ŒÙÛÈ, ÂÌÊ·Ó›˙ÔÓÙ·È ÂÁˆÎÂÓÙÚÈο Î·È ·‰È¿ÊÔÚ· Û ÎÔÈÓˆÓÈο ÌËӇ̷ٷ. §fiÁˆ ·ÚÔÚÌËÙÈÎfiÙËÙ·˜, ‰ÂÓ Â›Ó·È Èηӿ Ó· ÂϤÁÍÔ˘Ó Â·ÚÎÒ˜ ÙȘ ·ÓÙȉڿÛÂȘ ÙÔ˘˜ ÚÔ˜ ÙÔ˘˜ ¿ÏÏÔ˘˜. ∆· ¯·Ú·ÎÙËÚÈÛÙÈο ·˘Ù¿ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó Û ·fiÚÚÈ„Ë Î·È Î·ÎÔÔ›ËÛË (33). ¶·È‰È¿ Ì ‰È·Ù·Ú·¯‹ ÚÔÛÔ¯‹˜ Î·È ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· Û˘¯Ó¿ ÂΉËÏÒÓÔ˘Ó ·ÔÛ·ÛÌ·ÙÈ΋ Î·È ·Ó·ÔÙÂÏÂÛÌ·ÙÈ΋ ÂÈıÂÙÈÎfiÙËÙ·, Ë ÔÔ›· ÚÔηÏ› ·ÓÙȉڿÛÂȘ ·fi ÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘˜ (ÚÔÎÏËÙÈο ı‡Ì·Ù·) (29). √ÈÎÔÁÂÓÂȷ΋ ηٿÛÙ·ÛË √ÈÎÔÁ¤ÓÂȘ ÂÈıÂÙÈÎÒÓ ·È‰ÈÒÓ: ŸÙ·Ó ÙÔ ·È‰› Û˘ÛÙËÌ·ÙÈο ηÎÔÔÈ› Û˘ÓÔÌ‹ÏÈÎÔ˘˜, ÔÈ Èı·ÓfiÙËÙ˜
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¶·È‰È·ÙÚÈ΋ 2001;64:125-131
Ó· ˘¿Ú¯Ô˘Ó ÎÔÈÓˆÓÈο/ÔÈÎÔÓoÌÈο ÚÔ‚Ï‹Ì·Ù· ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Â›Ó·È ÙÚÈÏ¿ÛȘ Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi. ™ÙË ªÂÁ¿ÏË µÚÂÙ·Ó›·, ÙÔ 50% ÙˆÓ ÂÈıÂÙÈÎÒÓ ·ÁÔÚÈÒÓ ‰ÂÓ Â›¯Â ·Ù¤Ú· ÛÙÔ Û›ÙÈ (15% Û ÔÌ¿‰· ÂϤÁ¯Ô˘) (3). ™ÙȘ ÂÓ‰ÔÔÈÎÔÁÂÓÂȷΤ˜ Û¯¤ÛÂȘ, ÔÈ ·Ú¿ÁÔÓÙ˜ Ô˘ ÚÔ¿ÁÔ˘Ó ÙËÓ ÂÈıÂÙÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÛÙÔ ·È‰› ›ӷÈ: ·) Ë ¤ÏÏÂÈ„Ë ıÂÙÈÎÔ‡ Û˘Ó·ÈÛıËÌ·ÙÈÎÔ‡ ‰ÂÛÌÔ‡ ÙÔ˘ ÁÔÓ¤· Ì ÙÔ ·È‰›, ‚) ÔÈ ·˘Ù·Ú¯ÈΤ˜ ̤ıÔ‰ÔÈ ‰È··È‰·ÁÒÁËÛ˘ Ô˘ ÂÚÈÏ·Ì‚¿ÓÔ˘Ó ‡‚ÚÂȘ, ·ÂÈϤ˜ Î·È ÛˆÌ·ÙÈ΋ ‚›· Î·È Á) Ë ·ÓÂÎÙÈ΋ ÛÙ¿ÛË ·¤Ó·ÓÙÈ ÛÙË ‚›·ÈË Û˘ÌÂÚÈÊÔÚ¿ ÙÔ˘ ·È‰ÈÔ‡ (35). √ÈÎÔÁ¤ÓÂȘ ı˘Ì¿ÙˆÓ: √È ÔÈÎÔÁ¤ÓÂȘ ·˘Ù¤˜ ‰ÂÓ ‰È·Ê¤ÚÔ˘Ó ·fi ¿ÏϘ, ·fi ¿Ô„Ë ÎÔÈÓˆÓÈÎÔ‡/ÔÈÎÔÓÔÌÈÎÔ‡ ÂȤ‰Ô˘ (1). √È „˘¯ÔÏfiÁÔÈ ¤¯Ô˘Ó ·Ú·ÙËÚ‹ÛÂÈ fiÙÈ Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ Û˘ÓÔÌ‹ÏÈÎÔ˘˜, Ù· ηÎÔÔÈË̤ӷ ·È‰È¿ Â›Ó·È ÈÔ Û˘Ó‰Â‰Â̤ӷ Ì ÙȘ ÌËÙ¤Ú˜ ÙÔ˘˜. ¢ÂÓ ˘¿Ú¯Ô˘Ó ·Ô‰Â›ÍÂȘ fiÙÈ Ë ˘ÂÚÚÔÛÙ·Û›· ηıÈÛÙ¿ ÙÔ ·È‰› ÈÔ Â˘¿ÏˆÙÔ. ∂›Ó·È Èı·Ófi, Ô ÁÔÓ¤·˜ Ó· Û˘ÓÂȉËÙÔÔÈ› ÙȘ ‰˘ÛÎÔϛ˜ ÙÔ˘ ·È‰ÈÔ‡ Î·È Ó· ÚÔÛ·ı› Ó· ÙÔ ÚÔÛٷ٤„ÂÈ ·fi ÂÒ‰˘Ó˜ ÂÌÂÈڛ˜. ∂ÈϤÔÓ, ÙÔ ·È‰› Ô˘ ·ÔÚÚ›ÙÂÙ·È ·fi Û˘ÓÔÌ‹ÏÈÎÔ˘˜ ·Ú·Ì¤ÓÂÈ ·Ó·ÁηÛÙÈο ÂÚÈÛÛfiÙÂÚÔ ÛÙÔ Û›ÙÈ (1,3). √ÈÎÔÁ¤ÓÂȘ ÚÔÎÏËÙÈÎÒÓ ı˘Ì¿ÙˆÓ: √È ÔÈÎÔÁ¤ÓÂȘ ·˘Ù¤˜ ¯·Ú·ÎÙËÚ›˙ÔÓÙ·È ·fi ÂÍ·ÈÚÂÙÈο ˘„ËÏ‹ Û˘¯ÓfiÙËÙ· (38%) ¤ÎıÂÛ˘ ÙÔ˘ ·È‰ÈÔ‡ Û ‚›· ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ· (29). √È ÂÈÙÒÛÂȘ ÛÙËÓ ˘Á›· ∫·ÎÔÔÈË̤ӷ ·È‰È¿: ™Â Û‡ÁÎÚÈÛË Ì ÙÔ˘˜ Û˘ÌÌ·ıËÙ¤˜ ÙÔ˘˜, Ù· ηÎÔÔÈË̤ӷ ·È‰È¿ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÈÔ Û˘¯Ó¿ ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÎÔÈÏȷο ¿ÏÁË, ÎÂÊ·Ï·ÏÁ›Â˜, ·¸Ó›· Î·È ÂÓÔ‡ÚËÛË Û fiϘ ÙȘ Û¯ÔÏÈΤ˜ ËÏÈ˘ (37-40). ¡ÔÛÔ‡Ó ÈÔ Û˘¯Ó¿ ·fi ÈÒÛÂȘ Î·È ·ÊıÒ‰Ë ÛÙÔÌ·Ù›Ùȉ· Î·È ¤¯Ô˘Ó ÂÚÈÛÛfiÙÂÚ˜ ·Ô˘Û›Â˜ ÏfiÁˆ ·Ûı¤ÓÂÈ·˜ (38,40). ™ÙË ™ÎˆÙ›·, ·Ó·ÛÎfiËÛË ÙˆÓ ÈÛÙÔÚÈÎÒÓ Û Â͈ÙÂÚÈο È·ÙÚ›· ÓÔÛÔÎÔÌ›Ԣ ¤‰ÂÈÍ fiÙÈ, Û ‰È¿ÛÙËÌ· ÂÓfi˜ ¤ÙÔ˘˜, ÙÔ 8% ÙˆÓ ·È‰È·ÙÚÈÎÒÓ Î·ÎÒÛÂˆÓ ÔÊÂÈÏfiÙ·Ó Û ‚›· ·fi ̤ÚÔ˘˜ ¿ÏÏˆÓ ·È‰ÈÒÓ (41). ∆Ô ¿ÙÔÌÔ Ô˘ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi ÂÛˆÛÙÚ¤ÊÂÈ· Î·È ¿Á¯Ô˜ Â›Ó·È ·fi ÙËÓ ·Ú¯‹ ÈÔ Â˘¿ÏˆÙÔ Û ÂÈı¤ÛÂȘ, fï˜ Ë ÂÌÂÈÚ›· Ù˘ ηÎÔÔ›ËÛ˘ ÂÈʤÚÂÈ ÚfiÛıÂÙ˜ ÂÈÙÒÛÂȘ. ™Â ÌÂϤÙ˜ fiÔ˘ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ·È‰È¿ ÓËÈ·ÁˆÁ›Ԣ ·fi ÙËÓ ·Ú¯‹ ̤¯ÚÈ ÙÔ Ù¤ÏÔ˜ ÙÔ˘ Û¯ÔÏÈÎÔ‡ ¤ÙÔ˘˜, ÂΛӷ Ù· ÔÔ›· ÛÙËÓ ÔÚ›· ηÎÔÔÈ‹ıËÎ·Ó ‰ÂÓ Â›¯·Ó ‰ËÏÒÛÂÈ ÛÙÂÓÔ¯ÒÚÈ· Î·È ·ÚÔı˘Ì›· Ó· ¿Ó ۯÔÏÂ›Ô ÛÙËÓ ·Ú¯‹ ÙÔ˘ ¤ÙÔ˘˜, ·ÏÏ¿ ÌfiÓÔ ·ÚÁfiÙÂÚ· (16). ∞Ó¿Ï˘ÛË ÌÂÏÂÙÒÓ ·fi ÙËÓ ÙÂÏÂ˘Ù·›· 20ÂÙ›· ‰Â›¯ÓÂÈ fiÙÈ ·È‰È¿ ηÎÔÔÈË̤ӷ ·fi Û˘ÓÔÌ‹ÏÈÎÔ˘˜ ¤¯Ô˘Ó ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ÁÈ· „˘¯ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù·, Û ۇÁÎÚÈÛË Ì ¿ÏÏ· ·È‰È¿. ∆¤ÙÔÈ· ÚÔ‚Ï‹Ì·Ù·
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‰È·ÈÛÙÒÓÔÓÙ·È Î·È ÛÙ· ‰‡Ô ʇϷ, Û fiϘ ÙȘ ËÏÈ˘ Î·È Ì fiϘ ÙȘ ÌÔÚʤ˜ ηÎÔÔ›ËÛ˘ (38,44). √È ‰È·Ù·Ú·¯¤˜ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Â›Ó·È: ηٿıÏÈ„Ë, ·›ÛıËÌ· ÌÔÓ·ÍÈ¿˜, ¯·ÌËÏ‹ ·˘ÙoÂÎÙ›ÌËÛË Î·È ¿Á¯Ô˜ (18,27,39,40,45,46). ™ÙË ªÂÁ¿ÏË µÚÂÙ·Ó›·, Ô Êfi‚Ô˜ ÁÈ· ÂÈı¤ÛÂȘ ·fi Û˘ÌÌ·ıËÙ¤˜ Â›Ó·È Ì›· ·fi ÙȘ ΢ÚÈfiÙÂÚ˜ ·Èٛ˜ ·Ô˘ÛÈÒÓ ·fi ÙÔ Û¯ÔÏÂ›Ô (47). ∂ÈıÂÙÈο ·È‰È¿: ¶·ÚÔ˘ÛÈ¿˙Ô˘Ó ¯·ÌËÏfiÙÂÚË ÓÔÛËÚfiÙËÙ· ·fi Ù· ı‡Ì·Ù¿ ÙÔ˘˜, ·ÏÏ¿ ˘„ËÏfiÙÂÚË ·fi Ù· ˘fiÏÔÈ· ·È‰È¿ (38). ™Â ·˘Ù‹ ÙËÓ Î·ÙËÁÔÚ›· ÙˆÓ ·È‰ÈÒÓ, Ë Û˘¯ÓfiÙËÙ· ·Óı˘ÁÈÂÈÓ‹˜ Î·È ÚÈ„ÔΛӉ˘Ó˘ Û˘ÌÂÚÈÊÔÚ¿˜ Â›Ó·È ·˘ÍË̤ÓË: οÓÈÛÌ·, ηٷӿψÛË ÔÈÓÔÓ‡̷ÙÔ˜, ¿ÚÓËÛË ¯Ú‹Û˘ ÎÚ¿ÓÔ˘˜ ‹ ˙ÒÓ˘ ·ÛÊ·Ï›·˜ ÛÙ· Ô¯‹Ì·Ù· (40). ∂›Û˘, ·Ú·¤ÌÔÓÙ·È Û˘¯ÓfiÙÂÚ· ÁÈ· „˘¯È·ÙÚÈΤ˜ ÂÍÂÙ¿ÛÂȘ Û ۯ¤ÛË Ì ¿ÏÏ· ·È‰È¿ (44). ª·ÎÚÔÚfiıÂÛÌË ÚÔÔÙÈ΋ ™Â ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÂÈıÂÙÈο ·È‰È¿ Î·È ı‡Ì·Ù· ËÏÈΛ·˜ 8 ¤ˆ˜ 16 ÂÙÒÓ. ¢È·ÈÛÙÒıËΠfiÙÈ Ë ÏÂÈÔÓfiÙËÙ· ÂÍ·ÎÔÏÔ˘ıÔ‡Û ӷ ÂΉËÏÒÓÂÈ ·˘Ù‹ ÙË Û˘ÌÂÚÈÊÔÚ¿, ÚÔ·ÓÙfi˜ fiÛÔÓ ·ÊÔÚ¿ Ù· ηÎÔÔÈË̤ӷ ·ÁfiÚÈ·. ∏ ‡·ÚÍË „˘¯Ô·ıÔÏÔÁ›·˜ Û ËÏÈΛ· 8 ÂÙÒÓ Û¯ÂÙÈ˙fiÙ·Ó Ì ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÂÈıÂÙÈÎfiÙËÙ·˜ ‹ ηÎÔÔ›ËÛ˘ ·fi ¿ÏÏÔ˘˜ ÛÙËÓ ÂÊ˂›· (49,50). ™ÙËÓ ÂÓ‹ÏÈÎË ˙ˆ‹, Ù· ·È‰È¿ Ô˘ ·ÔÚÚ›ÙÔÓÙ·È ·fi ÙÔ˘˜ Û˘ÓÔÌ‹ÏÈÎÔ‡˜ ÙÔ˘˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÂÚÈÛÛfiÙÂÚ· „˘¯ÔÏÔÁÈο ÚÔ‚Ï‹Ì·Ù· (¿Á¯Ô˜, ηٿıÏÈ„Ë) Û ۇÁÎÚÈÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (51). ™Â ÚÔÔÙÈ΋ ÌÂϤÙË Ô˘ ¤ÁÈÓ ÛÙË ¡ÔÚ‚ËÁ›· Û ÔÌ¿‰· ·ÁÔÚÈÒÓ Ô˘ ηÎÔÔÈÔ‡ÓÙ·Ó Û˘ÛÙËÌ·ÙÈο ·fi ÙËÓ ¤ÎÙË Ì¤¯ÚÈ ÙËÓ ¤Ó·ÙË Ù¿ÍË Î·È Â·ÓÂÍÂÙ¿ÛÙËÎ·Ó Û ËÏÈΛ· 23 ÂÙÒÓ, ‰È·ÈÛÙÒıËΠfiÙÈ ÏÂÈÙÔ˘ÚÁÔ‡Û·Ó Ï¤ÔÓ ¯ˆÚ›˜ ȉȷ›ÙÂÚ· ÚÔ‚Ï‹Ì·Ù·, ·ÏÏ¿ ›¯·Ó ¯·ÌËÏfiÙÂÚË ·˘ÙÔÂÎÙ›ÌËÛË Î·È ˘„ËÏfiÙÂÚË Û˘¯ÓfiÙËÙ· ηٿıÏȄ˘ Û ۇÁÎÚÈÛË Ì ̿ÚÙ˘Ú˜ (49). ™Â ¿ÏÏË -·Ó·‰ÚÔÌÈ΋- ÌÂϤÙË Ì ÂÙÂÚfiÊ˘ÏÔ˘˜ ¿Ó‰Ú˜, ÔÈ ÔÔ›ÔÈ Â›¯·Ó ‰˘ÛÎÔϛ˜ ÛÙȘ ÂÚˆÙÈΤ˜ ÙÔ˘˜ Û¯¤ÛÂȘ, ·Ú·ÙËÚ‹ıËΠfiÙÈ Û˘¯Ó¿ ‰‹ÏˆÓ·Ó ı‡Ì·Ù· ηÎÔÔ›ËÛ˘ ·fi Û˘ÓÔÌ‹ÏÈÎÔ˘˜ ÛÙ· ·È‰Èο ÙÔ˘˜ ¯ÚfiÓÈ· (51). ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, ·È‰È¿ Ô˘ ηÎÔÔÈÔ‡Ó ¿ÏÏÔ˘˜ Ì·ı·›ÓÔ˘Ó fiÙÈ Ë ‚›· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ÁÈ· ÙËÓ Â›Ù¢ÍË ‰È¿ÊÔÚˆÓ ÛÙfi¯ˆÓ. ™Â ÚÔÔÙÈΤ˜ ÌÂϤÙ˜ ÛÙË ¡ÔÚ‚ËÁ›· Î·È ÛÙË ªÂÁ¿ÏË µÚÂÙ·Ó›·, fiÔ˘ ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó Ù¤ÙÔÈ· ·È‰È¿ ËÏÈΛ·˜ ̤¯ÚÈ 24 ÂÙÒÓ, ‚Ú¤ıËΠfiÙÈ Â›¯·Ó ÙÂÙÚ·Ï¿ÛÈ· Èı·ÓfiÙËÙ· ‰ÈηÛÙÈ΋˜ ηٷ‰›Î˘ ηıÒ˜ Î·È ·˘ÍË̤ÓË Èı·ÓfiÙËÙ· ÂÌÏÔ΋˜ Û ηÎÔ˘ÚÁ‹Ì·Ù· (4,15). √ ÚfiÏÔ˜ ÙˆÓ ÁÔÓ¤ˆÓ ŸÙ·Ó ÔÈ ÁÔÓ›˜ ‰È·ÈÛÙÒÛÔ˘Ó fiÙÈ ÙÔ ·È‰› ÙÔ˘˜ Ù˘¯·›ÓÂÈ Î·ÎÔÌÂÙ·¯Â›ÚÈÛ˘ ·fi ¿ÏÏ· ·È‰È¿, ˘¿Ú¯Ô˘Ó
2001 MAPT- A¶PI§
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̤ÙÚ· Ô˘ ÌÔÚÔ‡Ó Ó· ¿ÚÔ˘Ó ÁÈ· Ó· ÂÓÈÛ¯‡ÛÔ˘Ó ÙËÓ ·˘ÙÔÂÔ›ıËÛË Î·È ÙȘ ÎÔÈÓˆÓÈΤ˜ ‰ÂÍÈfiÙËÙ¤˜ ÙÔ˘. ∞Ó ÙÔ ÂÈÙ‡¯Ô˘Ó, ÙÔ ·È‰› ‰ÂÓ ı· ‰›ÓÂÈ ÙËÓ ÂÓÙ‡ˆÛË Â‡ÎÔÏ˘ Ï›·˜ ÛÙ· ÂÈıÂÙÈο ·È‰È¿. ª¤ÙÚ· Ô˘ ¤¯Ô˘Ó ·Ô‰Âȯı› ·ÔÙÂÏÂÛÌ·ÙÈο (1,25,53-56) ›ӷÈ: ·) Ë ·Ó¿Ù˘ÍË Ù˘ ۈ̷ÙÈ΋˜ ‰‡Ó·Ì˘ Î·È ‰ÂÍÈfiÙËÙ·˜ ̤ۈ ·ıÏËÙÈÛÌÔ‡, ‚) Ë Î·ÏÏȤÚÁÂÈ· ÂȉÈÎÒÓ Ù·Ï¤ÓÙˆÓ Î·È Ë ·Ó¿Ù˘ÍË ÂӉȷÊÂÚfiÓÙˆÓ Ô˘ ‚ÔËıÔ‡Ó ÙÔ ¿ÙÔÌÔ Ó· ‰È·ÎÚÈı›, Á) Ë ÚÔÒıËÛË ÎÔÈÓˆÓÈÎÒÓ Â·ÊÒÓ ÙÔ˘ ·È‰ÈÔ‡ (.¯. ÊÈÏÔÍÂÓ›· ÛÙÔ Û›ÙÈ, ‰ÈÔÚÁ¿ÓˆÛË ÂΉÚÔÌÒÓ Ì ʛÏÔ˘˜), ‰) Ë ·ÔÊ˘Á‹ ˘ÂÚÚÔÛÙ·Û›·˜, ‰›ÓÔÓÙ·˜ ÛÙÔ ·È‰› ÙËÓ Â˘Î·ÈÚ›· Ó· ·ÓÙÈÌÂÙˆ›ÛÂÈ Î·Ù·ÛÙ¿ÛÂȘ ÌfiÓÔ ÙÔ˘ fiÔÙ ÌÔÚ›, Â) Ë Û˘ÛÙËÌ·ÙÈ΋ ηıÔ‰‹ÁËÛË ÁÈ· ÙËÓ ·fiÎÙËÛË ÎÔÈÓˆÓÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ¯·Ú·ÎÙËÚÈ˙fiÌÂÓË ·fi ·˘ÙÔÂÔ›ıËÛË Î·È ÊÈÏÈÎfiÙËÙ· (Ì ÂÍ¿ÛÎËÛË ÛÙÔ ·ÛʷϤ˜ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ) Î·È ÛÙ) Ë Â·Ê‹ Ì ÙÔ Û¯ÔÏÂ›Ô (ÚÔÛ¤ÁÁÈÛË ÙÔ˘ ¢·›ÛıËÙÔ˘ Î·È ‰È·ÎÚÈÙÈÎÔ‡ ÂÎ·È‰Â˘ÙÈÎÔ‡ ÁÈ· ‚Ô‹ıÂÈ·). ™ÙËÓ ·È‰·ÁˆÁÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ÂÈıÂÙÈÎÒÓ ·È‰ÈÒÓ ¤¯ÂÈ ·ÊÈÂÚˆı› ¿ÊıÔÓË ‚È‚ÏÈÔÁÚ·Ê›·. √È ‚·ÛÈΤ˜ ·Ú¯¤˜ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È Â›Ó·È (1,3): ·) ·ÔÊ˘Á‹ Ù˘ ÊÚ·ÛÙÈ΋˜ Î·È ÛˆÌ·ÙÈ΋˜ ‚›·˜ ÛÙÔ Û›ÙÈ, ‚) ηÏÏȤÚÁÂÈ· Îϛ̷ÙÔ˜ ·Á¿Ë˜ Î·È ·Ô‰Ô¯‹˜ ÛÙËÓ ÔÈÎÔÁ¤ÓÂÈ·, Á) ı¤ÛÈÛË Û·ÊÒÓ ÔÚ›ˆÓ ·Ô‰ÂÎÙ‹˜ Û˘ÌÂÚÈÊÔÚ¿˜, ‰) ÂÓ›Û¯˘ÛË Ù˘ ÂÈı˘ÌËÙ‹˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÙÔ˘ ·È‰ÈÔ‡ Ì ·›ÓÔ˘˜ Î·È ÂÈ‚Ú¿‚¢ÛË Î·È Â) ·Ôı¿ÚÚ˘ÓÛË Ù˘ ‚›·È˘ Û˘ÌÂÚÈÊÔÚ¿˜, Ì ÙÈ̈ڛ˜ Ô˘ ÂÊ·ÚÌfi˙ÔÓÙ·È ÌÂ Û˘Ó¤ÂÈ·. ŸÏÔÈ ÔÈ ÂӉȷÊÂÚfiÌÂÓÔÈ ÁÔÓ›˜ ÔÊ›ÏÔ˘Ó Ó· ·Ó·˙ËÙÔ‡Ó ‚Ô‹ıÂÈ· ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÂӉ¯fiÌÂÓˆÓ Ì·ıËÛÈ·ÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ Î·È Û ÂȉÈΤ˜ ÂÚÈÙÒÛÂȘ Ó· ÚÔÛʇÁÔ˘Ó Î·È ÛÙȘ ˘ËÚÂۛ˜ „˘¯È΋˜ ˘Á›·˜. √ ÚfiÏÔ˜ ÙÔ˘ Û¯ÔÏ›Ԣ ¶ÚÈÓ ·fi 30 ¯ÚfiÓÈ·, Ô ¡ÔÚ‚ËÁfi˜ ηıËÁËÙ‹˜ „˘¯ÔÏÔÁ›·˜ Dan Olweus ˘ÔÛÙ‹ÚÈÍ ÙË ı¤ÛË fiÙÈ “Â›Ó·È ıÂÌÂÏÈ҉˜ ‰ËÌÔÎÚ·ÙÈÎfi ‰Èη›ˆÌ· ÙÔ˘ οı ·È‰ÈÔ‡ Ó· Û˘ÌÌÂÙ¤¯ÂÈ ÛÙË ˙ˆ‹ ÙÔ˘ Û¯ÔÏ›Ԣ ¯ˆÚ›˜ Ó· ·ÚÂÓԯϛٷȔ (1). ŒÎÙÔÙÂ, ¿Ú¯ÈÛ ӷ ÂÈÎÚ·Ù› Ë ¿Ô„Ë fiÙÈ ÔÈ ÂÓ‹ÏÈΘ ¤¯Ô˘Ó ¢ı‡ÓË ÁÈ· ÙËÓ ÂÈÙ‹ÚËÛË ÙˆÓ ÎÔÈÓˆÓÈÎÒÓ Û˘Ó·ÏÏ·ÁÒÓ ÌÂٷ͇ ·È‰ÈÒÓ. ∆· ÂÚÈÛÛfiÙÂÚ· ÂÂÈÛfi‰È· ηÎÔÔ›ËÛ˘ Û˘Ì‚·›ÓÔ˘Ó ÛÙÔ Û¯ÔÏÂ›Ô ‹ ÛÙË ‰È·‰ÚÔÌ‹ ÚÔ˜ ·˘Ùfi. ¢ÂÓ Ï·Ì‚¿ÓÔ˘Ó ¯ÒÚ· ̤۷ Û’ ¤Ó· ÎÂÓfi, ·ÏÏ¿ ¤¯Ô˘Ó Û¯¤ÛË Ì ÙË ÛÙ¿ÛË ÙÔ˘ ÚÔÛˆÈÎÔ‡ Î·È ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ Ì·ıËÙÒÓ. ™ÙË ªÂÁ¿ÏË µÚÂÙ·Ó›·, ·’ fiÏÔ˘˜ ÙÔ˘˜ Û¯ÔÏÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ Ô˘ ¤¯Ô˘Ó ÌÂÏÂÙËı› (ÎÔÈÓˆÓÈÎfi-ÔÈÎÔÓoÌÈÎfi Â›Â‰Ô ÙˆÓ Ì·ıËÙÒÓ, ̤ÁÂıÔ˜ ÙÔ˘ Û¯ÔÏ›Ԣ, ·ÚÈıÌfi˜ Ì·ıËÙÒÓ ÛÙËÓ Ù¿ÍË Î·È ¿ÏÏ·), ‚Ú¤ıËΠfiÙÈ Ë ÛÙ¿ÛË ÙÔ˘ Û¯ÔÏÈÎÔ‡ ÚÔÛˆÈÎÔ‡ ·ÔÙÂÏ› ÙÔÓ ÈÔ ÛËÌ·ÓÙÈÎfi. ™¯ÔÏ›·, ÙˆÓ ÔÔ›ˆÓ ÙÔ ÚÔÛˆÈÎfi ¤¯ÂÈ Û·Ê‹ ·ÚÓËÙÈ΋ ÛÙ¿ÛË ·¤Ó·-
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ÓÙÈ ÛÙË ‚›· ÌÂٷ͇ ÙˆÓ Ì·ıËÙÒÓ, ÂȂϤÂÈ Ù· ·È‰È¿ ÛÙ· ‰È·Ï›ÌÌ·Ù· Î·È ıˆÚ› fiÙÈ ¤¯ÂÈ Î·ı‹ÎÔÓ Ó· ·Ú¤Ì‚ÂÈ, Û¯ÔÏ›· ¤¯Ô˘Ó ÙË ¯·ÌËÏfiÙÂÚË Û˘¯ÓfiÙËÙ· ηÎÔÔ›ËÛ˘ (1,3,49). ∞·ÓÙÒÓÙ·˜ Û ÂÚˆÙËÌ·ÙÔÏfiÁÈ·, ÔÈ ÂÚÈÛÛfiÙÂÚÔÈ Ì·ıËÙ¤˜ ÂÎÊÚ¿˙Ô˘Ó ·ÚÓËÙÈο Û˘Ó·ÈÛı‹Ì·Ù· ÁÈ· ÙËÓ Î·ÎÔÔ›ËÛË ÌÂٷ͇ ·È‰ÈÒÓ, ·ÏÏ¿ ÔÌÔÏÔÁÔ‡Ó fiÙÈ ‰ÂÓ ÚÔÛ·ıÔ‡Ó Ó· ‚ÔËı‹ÛÔ˘Ó ÙÔ ı‡Ì· ‹ Ó· ·Ó·Ê¤ÚÔ˘Ó ÙÔ ÂÚÈÛÙ·ÙÈÎfi Û ÂÓ‹ÏÈΘ. ∆· ·È‰È¿ ı· ‹ıÂÏ·Ó Ó· ·ÚÂÌ‚·›ÓÔ˘Ó ÔÈ ÂÓ‹ÏÈΘ, ·ÏÏ¿ ‰ÂÓ ÈÛÙÂ‡Ô˘Ó fiÙÈ ÂΛÓÔÈ ÂӉȷʤÚÔÓÙ·È (57). ™ÙË ¡ÔÚ‚ËÁ›· ÂÊ·ÚÌfiÛÙËΠ·ÚÂÌ‚·ÙÈÎfi ÚfiÁÚ·ÌÌ· ÛÙ· Û¯ÔÏ›· fiÏ˘ Ù˘ ¯ÒÚ·˜ Ì ‚¿ÛË ÙËÓ ·Ú¯‹ fiÙÈ “ÙÔ Û¯ÔÏÂ›Ô ¤¯ÂÈ Â˘ı‡ÓË ÁÈ· ÙË Û˘ÓÔÏÈ΋ Û¯ÔÏÈ΋ ÂÌÂÈÚ›· ÙˆÓ Ì·ıËÙÒÓ”. ∏ Û˘¯ÓfiÙËÙ· ηÎÔÔ›ËÛ˘ ÌÂٷ͇ Ì·ıËÙÒÓ ÌÂÈÒıËΠηٿ 50% Û ‰‡Ô ¯ÚfiÓÈ· (48). ¶ÔÏÏ¿ ÚÔÁÚ¿ÌÌ·Ù· ¤¯Ô˘Ó ·ÎÔÏÔ˘ı‹ÛÂÈ Î·È Û ¿ÏϘ ¯ÒÚ˜, ΢ڛˆ˜ ÛÙË ªÂÁ¿ÏË µÚÂÙ·Ó›·, Ì ıÂÙÈο ·ÔÙÂϤÛÌ·Ù· (57,58). ∆Ô Û¯ÔÏ›Ô, ›Û˘, ÌÔÚ› Ó· ÚÔˆı‹ÛÂÈ ÙË ıÂÙÈ΋ ÛÙ¿ÛË ÙˆÓ ·È‰ÈÒÓ ·¤Ó·ÓÙÈ ÛÙÔ˘˜ Û˘ÌÌ·ıËÙ¤˜ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ Ú·ÁÌ·ÙÔÔÈÒÓÙ·˜: ·) ÂÓË̤ڈÛË ÁÈ· ÙËÓ Î·Ù¿ÛÙ·ÛË ÙˆÓ ·ÙfiÌˆÓ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ ̤ۈ Ù˘ Û¯ÔÏÈ΋˜ ‡Ï˘ Î·È ıÂÙÈÎÒÓ ·Ó·ÊÔÚÒÓ Û ٤ÙÔÈ· ¿ÙÔÌ· ÛÙË ÏÔÁÔÙ¯ӛ· Î·È ‚) ÚÔÒıËÛË ÙˆÓ Â·ÊÒÓ ÌÂٷ͇ “Ê˘ÛÈÔÏÔÁÈÎÒÓ” ·È‰ÈÒÓ Î·È ÂÎÂ›ÓˆÓ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ, fiÔ˘ fiÏÔÈ Û˘ÌÌÂÙ¤¯Ô˘Ó ÈÛfiÙÈÌ· Û ̛· ÔÈÎÈÏ›· ‰Ú·ÛÙËÚÈÔÙ‹ÙˆÓ (ÔÌ·‰ÈΤ˜ ÂÈÛÙËÌÔÓÈΤ˜ Î·È ÔÏÈÙÈÛÙÈΤ˜ ÚÔÛ¿ıÂȘ ·ÓÙ› ÙÔ˘ Û˘Ó·ÁˆÓÈÛÌÔ‡) (31,59,60). √ ÚfiÏÔ˜ ÙÔ˘ ·È‰È¿ÙÚÔ˘ ™ÙÔÓ È·ÙÚÈÎfi Ù‡Ô Ù˘ ªÂÁ¿Ï˘ µÚÂÙ·Ó›·˜ ÙÔÓ›˙ÂÙ·È Ù·ÎÙÈο fiÙÈ Ô ·È‰›·ÙÚÔ˜ ¤¯ÂÈ “ηı‹ÎÔÓ” Ó· ÂӉȷʤÚÂÙ·È ÁÈ· ÙȘ Û¯¤ÛÂȘ ÙˆÓ ·ÛıÂÓÒÓ ÙÔ˘ ÌÂ Û˘ÓÔÌ‹ÏÈÎÔ˘˜ ηıÒ˜ Î·È Ó· ˘Ô„È¿˙ÂÙ·È ÙËÓ Èı·Ó‹ ‡·ÚÍË ÚÔ‚ÏËÌ¿ÙˆÓ Û ·È‰È¿ Ì „˘¯Ôۈ̷ÙÈο Û˘ÌÙÒÌ·Ù· ‹ Û˘¯Ó¤˜ ηÎÒÛÂȘ (2,3,58). ToÓ π·ÓÔ˘¿ÚÈÔ ÙÔ˘ 1999, Ë ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ ‰ËÌÔÛ›Â˘Û ‰‹ÏˆÛË (Policy Statement), ÛÙËÓ ÔÔ›· ¤ÙÚ ÙÔ˘˜ ·È‰È¿ÙÚÔ˘˜ Ó· ·Ó·Ï¿‚Ô˘Ó Â˘ı‡ÓË ÁÈ· ÙËÓ ÚfiÏË„Ë, ·Ó›¯Ó¢ÛË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘ ‚›·È˘ Û˘ÌÂÚÈÊÔÚ¿˜ ÂΠ̤ÚÔ˘˜ ·È‰ÈÒÓ Î·È ÓÂÔÏ·›·˜ (61). ™ÙÔ “Pediatrics in Review” (Ù‡¯Ô˜ πÔ˘Ó›Ô˘ 2000), ·ÚÔ˘ÛÈ¿ÛÙËΠÁÈ· ÚÒÙË ÊÔÚ¿ ·Ó·ÛÎfiËÛË ÙÔ˘ ı¤Ì·ÙÔ˜ (62). √ ·È‰›·ÙÚÔ˜ ÌÔÚ› Ó· ·›ÍÂÈ ıÂÙÈÎfi ÚfiÏÔ ÛÙËÓ ÚÔ·ÁˆÁ‹ ˘ÁÈÔ‡˜ ÎÔÈÓˆÓÈ΋˜ Û˘ÌÂÚÈÊÔÚ¿˜ ÛÙ· ·È‰È¿ Ì ÔÈΛÏÔ˘˜ ÙÚfiÔ˘˜ Î·È Û fiÏ· Ù· ÛÙ¿‰È· Ù˘ ·Ó¿Ù˘Í‹˜ ÙÔ˘˜ (2,57,61): (·) ÛÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi Î·È ÎÔÈÓˆÓÈÎfi ÈÛÙÔÚÈÎfi ‰È·ÈÛÙÒÓÂÈ ·Ó ˘¿Ú¯Ô˘Ó ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·ÓÙÈÎÔÈÓˆÓÈ΋ Û˘ÌÂÚÈÊÔÚ¿ ÛÙÔ ·È‰› Î·È ‰›ÓÂÈ È‰È·›ÙÂÚË ÚÔÛÔ¯‹ ÛÙËÓ ·Ú·ÎÔÏÔ‡ıËÛË Î·È ÙË Û˘Ì‚Ô˘Ï¢ÙÈ΋, (‚) ·Ú·ÎÔÏÔ˘ı› ÛÙÂÓ¿ ÙËÓ
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ÎÔÈÓˆÓÈ΋ ·Ó¿Ù˘ÍË ÙÔ˘ ·È‰ÈÔ‡ Ì ÂȉÈΤ˜ ·Ó¿ÁΘ, (Á) ÛÙ· Ï·›ÛÈ· Ù·ÎÙÈ΋˜ ·È‰È·ÙÚÈ΋˜ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÌÔÚ› Ó· ·Ú·ÙËÚËıÔ‡Ó ÛÙÔ È·ÙÚÂ›Ô ÛËÌ›· ˘ÂÚ‚ÔÏÈο ÂÈıÂÙÈ΋˜ ‹ Û˘ÓÂÛÙ·Ï̤Ó˘ Û˘ÌÂÚÈÊÔÚ¿˜ Ô˘ ÂӉ¯Ô̤ӈ˜ Ó· Úԉȷı¤ÙÔ˘Ó ÁÈ· ÚÔ‚Ï‹Ì·Ù·, (‰) Ë ÂͤٷÛË ·È‰ÈÒÓ Ì ηÎÒÛÂȘ, ÚÔ·ÓÙfi˜ fiÙ·Ó ¤¯Ô˘Ó ÚÔÎÏËı› ÛÙÔ Û¯ÔÏ›Ô, Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÈ ÂÚˆÙ‹ÛÂȘ Ô˘ ·ÊÔÚÔ‡Ó ÙȘ ÂÚÈÛÙ¿ÛÂȘ Î·È fi¯È ÌfiÓÔ ÙÔ Ì˯·ÓÈÛÌfi Ù˘ οΈÛ˘, (Â) ·È‰È¿ Ì ˘ÔÙÚÔÈ¿˙ÔÓÙ· Û˘ÌÙÒÌ·Ù·, fiˆ˜ ÎÔÈÏȷο ¿ÏÁË, ÎÂÊ·Ï·ÏÁ›Â˜ Î·È ÂÓÔ‡ÚËÛË, ˘Ô‚¿ÏÏÔÓÙ·È Û ÂÍÂÙ¿ÛÂȘ ÁÈ· ÔÚÁ·ÓÈÎfi Úfi‚ÏËÌ·. ŸÙ·Ó Ô ¤ÏÂÁ¯Ô˜ ·Ô‚› ·ÚÓËÙÈÎfi˜ ‹ ‰ÂÓ ‰ÈηÈÔÏÔÁ› ÙËÓ ¤ÓÙ·ÛË ÙˆÓ Û˘Ìو̿وÓ, Ë ÚÔÛÔ¯‹ ÂÛÙÈ¿˙ÂÙ·È ÂÚÈÛÛfiÙÂÚÔ Û „˘¯ÔÎÔÈÓˆÓÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ∆Ô ·È‰› Ú¤ÂÈ Ó· ÂÚˆÙËı› ÁÈ· ÙȘ Û¯¤ÛÂȘ ÙÔ˘ ÌÂ Û˘ÓÔÌ‹ÏÈÎÔ˘˜ Î·È Ë Ù˘¯fiÓ ·Ó·ÊÂÚfiÌÂÓË ·fiÚÚÈ„Ë ‹ ηÎÔÔ›ËÛË Ó· ÏËÊı› ÛÔ‚·Ú¿ ˘fi„Ë, (ÛÙ) fiÙ·Ó ÙÔ ·È‰› ·ÚÔ˘ÛÈ¿˙ÂÈ Û˘ÌÙÒÌ·Ù· ¿Á¯Ô˘˜ ‹ ηٿıÏȄ˘ ·Ó·˙ËÙÔ‡ÓÙ·È ÔÈ ·Èٛ˜, (˙) fiÙ·Ó ÙÔ ·È‰› ·Ô˘ÛÈ¿˙ÂÈ Ôχ Û˘¯Ó¿ ·fi ÙÔ Û¯ÔÏÂ›Ô ‹ ·ÚÔ˘ÛÈ¿˙ÂÈ ‚·ıÌÈ·›· ÙÒÛË ÛÙËÓ ·fi‰ÔÛ‹ ÙÔ˘, Ï·Ì‚¿ÓÂÙ·È ˘fi„Ë Ë Èı·ÓfiÙËÙ· ηÎÔÔ›ËÛ˘ ·fi Û˘ÌÌ·ıËÙ¤˜ Î·È (Ë) fiÙ·Ó ÎÚ›ÓÂÙ·È ·Ó·Áη›· Ë ·Ú·ÔÌ‹ Û „˘¯ÔÏfiÁÔ ‹ ÎÔÈÓˆÓÈÎfi ÏÂÈÙÔ˘ÚÁfi, ÌÔÚ› Ó· ‰È¢ÎÔχÓÂÈ ÙË ‰È·‰Èηۛ· Î·È Ó· ‚ÔËı‹ÛÂÈ ÙËÓ ÔÈÎÔÁ¤ÓÂÈ· Ó· ÙÔ ·ÓÙÈÏËÊı› ˆ˜ Úfi‚ÏËÌ· ˘Á›·˜. ™˘Ì¤Ú·ÛÌ· ∏ ηÎÔÔ›ËÛË ·È‰ÈÒÓ ·fi ¿ÏÏ· ·È‰È¿ Â›Ó·È ¤Ó· ·ÚÓËÙÈÎfi ÎÔÈÓˆÓÈÎfi Ê·ÈÓfiÌÂÓÔ, ÛÙÔ ÔÔ›Ô ‰ÂÓ ¤¯ÂÈ ·ÎfiÌË ‰Ôı› Ë Ú¤Ô˘Û· ÚÔÛÔ¯‹. ™¯ÂÙ›˙ÂÙ·È Ì ‰˘ÛÌÂÓ›˜ ÂÈÙÒÛÂȘ ÁÈ· ÙË ÛˆÌ·ÙÈ΋ Î·È „˘¯È΋ ˘Á›· ÙˆÓ ÂÌÏÂÎfiÌÂÓˆÓ. ∂Âȉ‹ Ù· ı‡Ì·Ù· Û˘Ó‹ıˆ˜ ‰ÂÓ ·Ó·Ê¤ÚÔ˘Ó ÙÔ Úfi‚ÏËÌ·, ··ÈÙÂ›Ù·È Û˘Ó¯‹˜ ·ÁÚ‡ÓËÛË Î·È ÂÈÙ‹ÚËÛË ·fi ÙËÓ ÏÂ˘Ú¿ ÙˆÓ ÁÔÓ¤ˆÓ, ‰·ÛÎ¿ÏˆÓ Î·È ·È‰È¿ÙÚˆÓ. ∏ ·ÔÎ¿Ï˘„Ë ÙÔ˘ ÚÔ‚Ï‹Ì·ÙÔ˜ Â›Ó·È ÛÎfiÈÌË, ÁÈ·Ù› ÌÔÚ› Ó· Ô‰ËÁ‹ÛÂÈ Û ·ÔÙÂÏÂÛÌ·ÙÈ΋ ·Ú¤Ì‚·ÛË. ™ÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ ¤¯ÂÈ Á›ÓÂÈ Ï¤ÔÓ ·Ô‰ÂÎÙfi fiÙÈ Ë Î·ÎÔÔ›ËÛË ·È‰ÈÒÓ ·fi ¿ÏÏ· ·È‰È¿ ·ÔÙÂÏ› ·È‰È·ÙÚÈÎfi Úfi‚ÏËÌ·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Olweus D. Bullying at school. London: Blackwell Publishers, Ltd; 1993. p. 2. Dawkins J. Bullying in schools: doctors’ responsibilities [letter]. BMJ 1995;310:274-275. 3. Dawkins J, Hill P. Bullying: Another form of abuse? Recent Adv Pediatr 1995;13:103-121. 4. Whitney I, Smith PK. A survey of the nature and extent of bullying in junior/middle and secondary schools. Educ Res 1994;35:3-24. 5. Skinner A. Bullying: An annotated bibliography of literature and resources. Leicester: Youth Work Press; 1992. p. 22-28.
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 26-09-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 15-12-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¡ÙÔÏfiÚ˜ ¶ÚˆÙ·ÁfiÚ·-§È·ÓÔ‡ ¢ÈÔÓ‡ÛÔ˘ 15, ∫¿ÓÙ˙· ∞ÙÙÈ΋˜, 153 51 E-mail: Sophieirene53@hotmail.com
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∂ƒ∂À¡∏∆π∫∏ ∂ƒ°∞™π∞
Paediatriki 2001;64:132-135
ORIGINAL PAPER
¢Â›ÎÙ˘ ‰È·ÌfiÏ˘ÓÛ˘ Ì ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘ Û ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ ÛÙÔ ¡ÔÌfi ∫ÔÚÈÓı›·˜ ∂. ¶··‚·ÛÈÏ›Ԣ1, µ. ∫¿ÏÏÈÔ˘1, ¡. ∫·Ì¿˜2
The tubercular infection index among pre-school age children in the district of Korinthos ∂. ¶··‚·ÛÈÏ›Ԣ1, µ. ∫¿ÏÏÈÔ˘1, ¡. ∫·Ì¿˜2
¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ Ì·˜ ‹Ù·Ó Ë ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ‰Â›ÎÙË ‰È·ÌfiÏ˘ÓÛ˘ Ì ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘ ÛÙÔ ¡. ∫ÔÚÈÓı›·˜. ¶‹Ú·Ó ̤ÚÔ˜ 248 ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ (180 ŒÏÏËÓ˜, 68 ·ÏÏÔ‰·Ô›), ÛÙ· ÔÔ›· ¤ÁÈÓ ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux. §·Ì‚¿ÓÔÓÙ·˜ ˆ˜ ·ÚÓËÙÈ΋ ÙË ‰È‹ıËÛË 0-4 mm, ·ÌÊ›‚ÔÏË ÙË ‰È‹ıËÛË 5-9 mm Î·È ıÂÙÈ΋ ÂΛÓË Ô˘ Â›Ó·È ≥10 mm, ‰È·ÈÛÙÒÛ·Ì fiÙÈ Ô ‰Â›ÎÙ˘ ‰È·ÌfiÏ˘ÓÛ˘ Ì ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘ ÛÙÔ ¡. ∫ÔÚÈÓı›·˜ Â›Ó·È ¯·ÌËÏfi˜, ‰ËÏ. 1,2%. ∆Ô ÔÛÔÛÙfi ·˘Ùfi ÔÊ›ÏÂÙ·È ·ÔÎÏÂÈÛÙÈο ÛÙÔÓ ·ÏÏÔ‰·fi ÏËı˘ÛÌfi Ù˘ fiÏ˘ Ì·˜.
Abstract: The aim of this study was to determine the tubercular infection index in the district of Korinthos. We studied 248 children of pre-school age (180 Greeks, 68 immigrants) in whom we performed the Mantoux test. We considered as negative reaction a diameter of 0-4 mm, uncertain reaction a diameter of 5-9 mm, and positive reaction a diameter ≥10 mm. We conclude that the tubercular infection index in Korinthos is low (1,2%) and it is primarily due to the immigrant population of our town.
§¤ÍÂȘ ÎÏÂȉȿ: Ê˘Ì·Ù›ˆÛË, ‰Â›ÎÙ˘ ‰È·ÌfiÏ˘ÓÛ˘, ÚÔÛ¯ÔÏÈ΋ ËÏÈΛ·, ‰ÂÚÌÔ·ÓÙ›‰Ú·ÛË Mantoux.
Key words: tuberculosis, pre-school tubercular infection index, Mantoux test.
∂ÈÛ·ÁˆÁ‹ H Ê˘Ì·Ù›ˆÛË ÛÎÔÙÒÓÂÈ 2.000.000 ·ÓıÚÒÔ˘˜ οı ¯ÚfiÓÔ. ∏ Ù·¯‡ÙËÙ· ÂͿψÛ˘ ÙÔ˘ AIDS, Ë ·ÓıÈÛÙ¿ÌÂÓË ÛÙË Û˘Ó‰˘·Ṳ̂ÓË ıÂڷ›· Ê˘Ì·Ù›ˆÛË Î·È Ë ·‡ÍËÛË Ù˘ ÌÂٷΛÓËÛ˘ ÙÔ˘ ÏËı˘ÛÌÔ‡, Û˘Ì‚¿ÏÏÔ˘Ó ÛÙËÓ Âȉ›ӈÛË Ù˘ ›وÛ˘ Ù˘ ÓfiÛÔ˘. ªÂٷ͇ ÙˆÓ ÂÙÒÓ 2000 Î·È 2020, ÂÚ›Ô˘ 1 ‰ÈÛÂηÙÔÌ̇ÚÈÔ ¿ÓıÚˆÔÈ ı· ¤¯Ô˘Ó ÌÔÏ˘Óı›, 200 ÂηÙÔÌ̇ÚÈ· ¿ÓıÚˆÔÈ ı· ·ÚÚˆÛÙ‹ÛÔ˘Ó Î·È 35 ÂηÙÔÌ̇ÚÈ· ı· Âı¿ÓÔ˘Ó ·fi Ê˘Ì·Ù›ˆÛË, ·Ó Ô ¤ÏÂÁ¯Ô˜ ‰ÂÓ Á›ÓÂÈ ·˘ÛÙËÚfiÙÂÚÔ˜. ™‡Ìʈӷ Ì ÙÔÓ ¶·ÁÎfiÛÌÈÔ √ÚÁ·ÓÈÛÌfi ÀÁ›·˜, οı ¯ÚfiÓÔ ÂÚ›Ô˘ ÙÔ 1% ÙÔ˘ ·ÁÎfiÛÌÈÔ˘ ÏËı˘ÛÌÔ‡ ÌÔχÓÂÙ·È ·fi Ê˘Ì·Ù›ˆÛË, ÂÓÒ ÙÔ 5-10% ÙˆÓ ·Ó-
ıÚÒˆÓ Ô˘ ›¯·Ó ÌÔÏ˘Óı›, ı· ·ÚÚˆÛÙ‹ÛÔ˘Ó Î¿ÔÈ· ÛÙÈÁÌ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘˜ (1). ™ÙȘ ·Ó·Ù˘Á̤Ó˜ ¯ÒÚ˜ ·Ú·ÙËÚÂ›Ù·È Ì›· ÛËÌ·ÓÙÈ΋ ‡ÊÂÛË Î·È ÌÂٷΛÓËÛË Ù˘ Ê˘Ì·Ù›ˆÛ˘ ·fi ÙËÓ ·È‰È΋ Û ÌÂÁ·Ï‡ÙÂÚ˜ ËÏÈ˘ (2). ∏ Èı·ÓfiÙËÙ· ÂÍ¿ÏÂȄ˘ Ù˘ ÓfiÛÔ˘ Ê·ÈÓfiÙ·Ó Ú·ÁÌ·ÙÔÔÈ‹ÛÈÌË, Ë ·‡ÍËÛË, fï˜, ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ÙÔ˘ AIDS Î·È Ù˘ ÌÂٷΛÓËÛ˘ ÏËı˘ÛÌÒÓ ·fi ¯ÒÚ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ·Ó‚¿˙Ô˘Ó ÙÔ ÔÛÔÛÙfi ÙˆÓ Ó¤ˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ Î·Ù¿ 0-30%. ™ÙȘ ·Ó·Ù˘ÛÛfiÌÂÓ˜ ¯ÒÚ˜ Ë Î·Ù¿ÛÙ·ÛË Â›Ó·È ‰Ú·Ì·ÙÈ΋. √ Ê˘Ì·ÙÈÓÈÎfi˜ ‰Â›ÎÙ˘ ηχÙÂÈ ¿Óˆ ·fi Ù· 2/3 ÙÔ˘ ÏËı˘ÛÌÔ‡. π‰È·›ÙÂÚÔ Úfi‚ÏËÌ· ·ÓÙÈÌÂÙˆ›˙Ô˘Ó ÔÈ ¯ÒÚ˜ Ù˘ ∞ÊÚÈ΋˜ Ô˘
°ÂÓÈÎfi ¡Ô̷گȷÎfi ¡ÔÛÔÎÔÌÂ›Ô ∫ÔÚ›ÓıÔ˘ 1 ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ 2 °˘Ó·ÈÎÔÏÔÁÈ΋ - ª·È¢ÙÈ΋ ∫ÏÈÓÈ΋
132
General Prefecture Hospital of Korinthos 1 Pediatric Clinic 2 Obstetrics - Gynecology Clinic
age,
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‚Ú›ÛÎÔÓÙ·È Î¿Ùˆ ·fi ÙË ™·¯¿Ú·, fiÔ˘ 1.500.000 ÂÚÈÙÒÛÂȘ Ê˘Ì·Ù›ˆÛ˘ ·Ú·ÙËÚÔ‡ÓÙ·È Î¿ı ¯ÚfiÓÔ ˆ˜ ·ÔÙ¤ÏÂÛÌ· Ù˘ ÂȉËÌ›·˜ ÙÔ˘ AIDS (1,3-5). π‰È·›ÙÂÚÔ ÂӉȷʤÚÔÓ ÁÈ· ÙË ¯ÒÚ· Ì·˜ ·ÔÙÂÏÔ‡Ó Ù· Ó¤· ÂÚÈÛÙ·ÙÈο Î·È ÔÈ ı¿Ó·ÙÔÈ ·fi Ê˘Ì·Ù›ˆÛË ÛÙȘ ¯ÒÚ˜ Ù˘ ∞Ó·ÙÔÏÈ΋˜ ∂˘ÚÒ˘. ÀÔÏÔÁ›˙ÂÙ·È fiÙÈ ÛÙȘ ¯ÒÚ˜ ·˘Ù¤˜ ·Ú·ÙËÚÔ‡ÓÙ·È ÙÔ ¯ÚfiÓÔ 250.000 ÂÚÈÙÒÛÂȘ Ê˘Ì·Ù›ˆÛ˘ (1). ∆· ÛÙÔȯ›· ·˘Ù¿, ÛÂ Û˘Ó‰˘·ÛÌfi Ì ÙËÓ ·‡ÍËÛË Ù˘ ÌÂٷΛÓËÛ˘ ÙˆÓ Û˘ÁÎÂÎÚÈÌ¤ÓˆÓ ÏËı˘ÛÌÒÓ ÛÙËÓ ∂ÏÏ¿‰· Î·È È‰È·›ÙÂÚ· ÛÙËÓ fiÏË Ù˘ ∫ÔÚ›ÓıÔ˘, ·ÔÙ¤ÏÂÛ·Ó ÙËÓ ·ÊÔÚÌ‹ Ù˘ ÌÂϤÙ˘ Ì·˜ Ì ÛÎÔfi ÙËÓ Î·Ù·ÁÚ·Ê‹ Î·È ÙË ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ‰Â›ÎÙË ‰È·ÌfiÏ˘ÓÛ˘ Ì ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Ù˘ Ê˘Ì·Ù›ˆÛ˘, Ì ÙË Û˘ÌÌÂÙÔ¯‹ ÙˆÓ ·ÏÏÔ‰·ÒÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™ÙË ÌÂϤÙË Ì·˜, Ô˘ ‰ÈÂÓÂÚÁ‹ıËΠηٿ ÙËÓ ÂÚ›Ô‰Ô ÙÔ˘ ¤ÙÔ˘˜ 1999, ‹Ú·Ó ̤ÚÔ˜ 248 ·È‰È¿ ÚÔÛ¯ÔÏÈ΋˜ ËÏÈΛ·˜ 4-6 ¯ÚfiÓˆÓ (180 ∂ÏÏËÓfiÔ˘Ï·, 68 ·ÏÏÔ‰·Ô›) ·fi 6 ÎÚ·ÙÈÎÔ‡˜ Î·È 2 ȉȈÙÈÎÔ‡˜ ‚ÚÂÊÔÓËÈ·ÎÔ‡˜ ÛÙ·ıÌÔ‡˜. ∆· ·È‰È¿ Ù˘ ÌÂϤÙ˘ Ì·˜ ·ÓÙÈÚÔÛˆÂ‡Ô˘Ó ÙÔ 12% ÙÔ˘ Û˘ÓÔÏÈÎÔ‡ ·ÚÈıÌÔ‡ ÙˆÓ ·È‰ÈÒÓ Ô˘ ·Ó‹ÎÔ˘Ó ÛÙ· ÚÔ·Ó·ÊÂÚı¤ÓÙ· ËÏÈÎȷο Ï·›ÛÈ· ÙÔ˘ ¡ÔÌÔ‡ ∫ÔÚÈÓı›·˜ (ÌË Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ ÙˆÓ ·ı›ÁÁ·ÓˆÓ). ŒÁÈÓ ¤ÏÂÁ¯Ô˜ ÙˆÓ ·ÙÔÌÈÎÒÓ ‚È‚ÏÈ·Ú›ˆÓ ˘Á›·˜ Ì ÛÎÔfi Ó· ‰È·ÈÛÙˆı› Ô ÂÌ‚ÔÏÈ·ÛÌfi˜ ‹ fi¯È Ì BCG. ™ÙË Û˘Ó¤¯ÂÈ·, ¯ÔÚËÁ‹Û·Ì ÂÓ‰Ô‰ÂÚÌÈο ÛÙÔ Ì¤ÛÔ Ù˘ ηÌÙÈ΋˜ ÂÈÊ¿ÓÂÈ·˜ ÙÔ˘ ·ÓÙÈ‚Ú·¯›Ô˘ 0,1 ml ÎÂηı·Ṳ́Ó˘ Ê˘Ì·Ù›Ó˘ PPD ÙÔ˘ ÈÓÛÙÈÙÔ‡ÙÔ˘ Pasteur ÂÚÈÂÎÙÈÎfiÙËÙ·˜ 5 ÌÔÓ¿‰ˆÓ ·Ó¿ 0,1 ml. ¢ËÌÈÔ˘ÚÁ‹ıËΠÔÌÊfi˜ 6-10 mm. ∆· ·ÔÙÂϤÛÌ·Ù· ÂϤÁ¯ıËÛ·Ó ÌÂÙ¿ ·fi 48 ÒÚ˜. §¿‚·Ì ˆ˜ ·ÚÓËÙÈÎfi ·ÔÙ¤ÏÂÛÌ· ÙË ‰È‹ıËÛË 0-4 mm, ˆ˜ ·ÌÊ›‚ÔÏÔ ÙË ‰È‹ıËÛË 5-9 mm Î·È ˆ˜ ıÂÙÈÎfi ÙË ‰È‹ıËÛË Ô˘ ‹Ù·Ó ≥10 mm. ∏ ÛÙ·ÙÈÛÙÈ΋ ÂÂÍÂÚÁ·Û›· ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ¤ÁÈÓ Ì ÙË Ì¤ıÔ‰Ô ¯2.
∞ÔÙÂϤÛÌ·Ù· ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 248 ·È‰ÈÒÓ, Ù· 236 ›¯·Ó ·ÚÓËÙÈ΋ Mantoux, ÔÛÔÛÙfi 95,2%, ¤Ó·ÓÙÈ 12 ·È‰ÈÒÓ Ì ıÂÙÈ΋ Mantoux Î·È ÔÛÔÛÙfi 4,8% (∂ÈÎfiÓ· 1). √ ·ÚÈıÌfi˜ ÙˆÓ ·È‰ÈÒÓ ·Ó¿ ÂıÓÈÎfiÙËÙ· Ê·›ÓÂÙ·È ÛÙÔÓ ›Ó·Î· 2. ™˘ÁÎÂÎÚÈ̤ӷ, ·fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 180 ∂ÏÏËÓÔ·›‰ˆÓ Ù˘ ÌÂϤÙ˘ Ì·˜, Ù· 175 ›¯·Ó ·ÚÓËÙÈ΋ Mantoux (ÔÛÔÛÙfi 97,2%) Î·È 5 ·ÚÔ˘Û›·Û·Ó ıÂÙÈ΋ Mantoux (ÔÛÔÛÙfi 2,8%). ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ 68 ·ÏÏÔ‰·ÒÓ, Ù· 61 ›¯·Ó ·ÚÓËÙÈ΋ Mantoux (ÔÛÔÛÙfi 90%) Î·È 7 ·ÚÔ˘Û›·Û·Ó ıÂÙÈ΋ Mantoux (ÔÛÔÛÙfi 10%) (¶›Ó·Î·˜ 1). §·Ì‚¿ÓÔÓÙ·˜ ˘fi„Ë Ù· ‚È‚Ï›· ÙˆÓ Â͈ÙÂÚÈÎÒÓ È·ÙÚ›ˆÓ Ù˘ ¶·È‰È·ÙÚÈ΋˜ ÎÏÈÓÈ΋˜, ÙÔ 90% ÙˆÓ ÂÍÂÙ·˙fiÌÂÓˆÓ ·ÏÏÔ‰·ÒÓ Â›Ó·È ∞Ï‚·ÓÔ›.
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4,80%
95,20% ∞ÚÓËÙÈ΋
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∂ÈÎfiÓ· 1. ¶ÔÛÔÛÙ¿ ·ÔÙÂϤÛÌ·ÙÔ˜ ‰ÂÚÌÔ·ÓÙ›‰Ú·Û˘ Mantoux.
∞fi Ù· 12 ·È‰È¿ (ŒÏÏËÓ˜ Î·È ·ÏÏÔ‰·Ô›) Ô˘ ·ÚÔ˘Û›·Û·Ó ıÂÙÈ΋ Mantoux (¶›Ó·Î·˜ 1), Ù· 9 ›¯·Ó ÚÔËÁÔ˘Ì¤Óˆ˜ ÂÌ‚ÔÏÈ·ÛÙ› Ì ÂÌ‚fiÏÈÔ BCG (·ÚÔ˘Û›·Û·Ó Ê˘ÛÈÔÏÔÁÈÎÒ˜ ıÂÙÈ΋ Mantoux) Î·È ÔÛÔÛÙfi 3,6%, ÂÓÒ ·ıÔÏÔÁÈÎÒ˜ ıÂÙÈ΋ ·ÚÔ˘Û›·Û·Ó 3 ·È‰È¿ (·ÏÏÔ‰·Ô›), ÔÛÔÛÙfi 1,2%. ™˘˙‹ÙËÛË √ ‰Â›ÎÙ˘ ‰È·ÌfiÏ˘ÓÛ˘ ·ÔÙÂÏ› ÙÔÓ ÈÔ ·ÍÈfiÈÛÙÔ ‰Â›ÎÙË ·Ú·ÎÔÏÔ‡ıËÛ˘ Ù˘ Ê˘Ì·Ù›ˆÛ˘ ÎÈ ÂÎÊÚ¿˙ÂÈ ÙÔ ÔÛÔÛÙfi ÙˆÓ ıÂÙÈÎÒÓ ‰ÂÚÌÔ·ÓÙȉڿÛÂˆÓ ÙÔ˘ ÏËı˘ÛÌÔ‡ ÌÈ·˜ ÎÔÈÓˆÓ›·˜ (6). ™Ô‚·Úfi ‰È·ÁÓˆÛÙÈÎfi Úfi‚ÏËÌ·, fï˜, ·ÔÙÂÏ› Ë ·ÍÈÔÏfiÁËÛË Ù˘ ‰ÂÚÌÔ·ÓÙ›‰Ú·Û˘ Mantoux ÌÂÙ¿ ·fi Ê˘ÛÈ΋ ÌfiÏ˘ÓÛË ·fi ÂΛÓË, ÌÂÙ¿ ·fi ÂÌ‚ÔÏÈ·ÛÌfi Ì BCG. ªÂÙ¿ ·fi ÂÌ‚fiÏÈÔ BCG, ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ‰È‹ıËÛ˘ Êı¿ÓÂÈ ¤ˆ˜ 15 mm, ·ÏÏ¿ ÌÔÚ› Ó· ‰È·Î˘Ì·Óı› ·fi 3-30 mm (7). ™‡Ìʈӷ Ì ÙËÓ ∞ÌÂÚÈηÓÈ΋ ¶·È‰È·ÙÚÈ΋ ∞η‰ËÌ›·, Ì›· Mantoux >10 mm Û ·È‰› ÌÂÙ¿ BCG, Èı·ÓÒ˜ ˘Ô‰ËÏÒÓÂÈ ÌfiÏ˘ÓÛË (8). £· Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ı‹ÛÂÈ Ï‹„Ë Î·ÏÔ‡ Î·È ÏÂÙÔÌÂÚÔ‡˜ ÈÛÙÔÚÈÎÔ‡, Ì ¤ÌÊ·ÛË: 1) ÛÙË ¯ÒÚ· ÚÔ¤Ï¢Û˘ ÙÔ˘ ·È‰ÈÔ‡. ¶ÂÚÈÔ¯¤˜ fiˆ˜ Ë ∞Ó·ÙÔÏÈ΋ ∂˘ÚÒË, Ë ∞Û›·, Ë ¡∞ ∞ÌÂÚÈ΋, Ë ∞ÊÚÈ΋ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓÔ ÔÛÔÛÙfi ÂÚÈÛÙ·ÙÈÎÒÓ Ê˘Ì·Ù›ˆÛ˘, 2) ÛÙÔ ¯ÚfiÓÔ ÂÌ‚ÔÏÈ·ÛÌÔ˘ ÙÔ˘ ·È‰ÈÔ‡, 3) ÛÙÔ ·Ó ˘¿Ú¯ÂÈ Ô˘Ï‹ ÛÙË ı¤ÛË ÙÔ˘ ÂÌ‚ÔÏ›Ô˘, 4) ÛÙÔ ·Ó ÙÔ ·È‰› ¤¯ÂÈ ¤ÚıÂÈ Û ·ʋ Ì ÂÓ‹ÏÈÎÔ, ¿Û¯ÔÓÙ· ·fi ÂÓÂÚÁfi Ê˘Ì·Ù›ˆÛË (9). ™ÙËÓ ·ÍÈÔÏfiÁËÛË Ù˘ ‰ÂÚÌÔ·ÓÙ›‰Ú·Û˘ Mantoux Ú¤ÂÈ Ó· Ï¿‚Ô˘Ì ˘fi„Ë Ù˘ Ô‰ËÁ›Â˜ Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ∂Ù·ÈÚ›·˜ £ÒÚ·ÎÔ˜ (10), Û‡Ìʈӷ Ì ÙȘ Ôԛ˜: ñ Mantoux Ì ‰È¿ÌÂÙÚÔ >5 mm ıˆÚ›ٷÈ
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¶›Ó·Î·˜ 1. ∞ÔÙÂϤÛÌ·Ù· ‰ÂÚÌÔ·ÓÙ›‰Ú·Û˘ Mantoux. ∞ÚÈıÌfi˜ ·È‰ÈÒÓ ·Ó¿ ÂıÓÈÎfiÙËÙ·
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ıÂÙÈ΋ Û ¿ÙÔÌ·: ·) Ì HIV ÓfiÛÔ, ‚) ¤¯ÔÓÙ· ÛÙÂÓ‹ ·ʋ Ì ÂÓ‹ÏÈÎÔ Ì ÂÓÂÚÁfi ÓfiÛÔ, Á) Ì ÂÈÎfiÓ· ÂÔ˘ÏˆÌ¤Ó˘ Ê˘Ì·Ù›ˆÛ˘ ÛÙË Ro ıÒÚ·ÎÔ˜. ñ Mantoux Ì ‰È¿ÌÂÙÚÔ ≥10 mm ıˆÚÂ›Ù·È ıÂÙÈ΋: ·) Û ÌÂÙ·Ó¿ÛÙ˜ ·fi ¯ÒÚ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘, ‚) Û ÌÂÈÔÓfiÙËÙ˜, Á) Û ÙÚfiÊÈÌÔ˘˜ È‰Ú˘Ì¿ÙˆÓ, Ê˘Ï·ÎÈṲ̂ÓÔ˘˜, ‰) Û ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ¿ÙÔÌ·, Â) Û ‚Ú¤ÊË <3 ¯ÚfiÓˆÓ, ÛÙ) Û ȷÙÚÈÎfi Î·È ÓÔÛËÏ¢ÙÈÎfi ÚÔÛˆÈÎfi. ñ Mantoux Ì ‰È¿ÌÂÙÚÔ >15 mm ıˆÚÂ›Ù·È ıÂÙÈ΋ Û fiϘ ÙȘ ˘fiÏÔȘ ηÙËÁÔڛ˜ ÙÔ˘ ÏËı˘ÛÌÔ‡. √È Ô‰ËÁ›Â˜ ·˘Ù¤˜ ‰‡ÛÎÔÏ· ÌÔÚÔ‡Ó Ó· ÂÊ·ÚÌÔÛÙÔ‡Ó ÛÙË ¯ÒÚ· Ì·˜, ·ÊÔ‡ Ô ·ÚÈıÌfi˜ ÙˆÓ HIV ÓÔÛÔ‡ÓÙˆÓ Â›Ó·È Û¯ÂÙÈο ÌÈÎÚfi˜, fiˆ˜ ÂÚÈÔÚÈṲ̂ÓÔ˜ Â›Ó·È Î·È Ô ·ÚÈıÌfi˜ ÙˆÓ ÌÔχÓÛÂˆÓ ·fi ¿Ù˘· Ì˘ÎÔ‚·ÎÙËÚ›‰È· (7). ™ÙË ‰È΋ Ì·˜ ÌÂϤÙË ¯·Ú·ÎÙËÚ›Û·ÌÂ Ê˘ÛÈÔÏÔÁÈÎÒ˜ ıÂÙÈ΋ ÙË Mantoux 9 ·È‰ÈÒÓ (5 ∂ÏÏËÓfiÔ˘Ï· Î·È 4 ·ÏÏÔ‰·Ô›), ÂÂȉ‹ ›¯Â ÚÔËÁËı› ÂÌ‚fiÏÈÔ ÚÔ 1ó ¤ÙÔ˘˜ Î·È ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ‰È‹ıËÛ˘ ‹Ù·Ó ›ÛÔ Ì 10 mm. ∆· 5 ∂ÏÏËÓfiÔ˘Ï· ›¯·Ó ÂÌ‚ÔÏÈ·ÛÙ› ÂÂȉ‹ ·Ó‹Î·Ó Û ÔÌ¿‰· ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ (ÛÙÔ ÂÚÈ‚¿ÏÏÔÓ ÙÔ˘˜ ˘‹Ú¯Â ÂÓ‹ÏÈÎÔ˜, ¿Û¯ˆÓ ·fi ÂÓÂÚÁfi ÓfiÛÔ). ŸÛÔÓ ·ÊÔÚ¿ ÙÔ˘˜ ·ÏÏÔ‰·Ô‡˜, Â›Ó·È ÁÓˆÛÙfi fiÙÈ ÂÌ‚ÔÏÈ¿˙ÔÓÙ·È ÁÈ· Ê˘Ì·Ù›ˆÛË Ì¤Û· ÛÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Ù˘ ˙ˆ‹˜ ÙÔ˘˜. ¶·ıÔÏÔÁÈÎÒ˜ ıÂÙÈ΋ ¯·Ú·ÎÙËÚ›Û·Ì ÙËÓ Mantoux Û 3 ·È‰È¿ (fiÏ· ÚÔÂÚ¯fiÌÂÓ· ·fi ÙËÓ ∞Ï‚·Ó›·). ∆· 2 ÂÍ ·˘ÙÒÓ ·ÚÔ˘Û›·Û·Ó ‰È‹ıËÛË >10 mm ¯ˆÚ›˜ Ó· ¤¯ÂÈ ÚÔËÁËı› ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì BCG, ÂÓÒ ÙÔ 1 ·È‰› ›¯Â ÂÌ‚ÔÏÈ·ÛÙ› ÚÔ 5ÂÙ›·˜, ·ÚÔ˘Û›·˙ fï˜ ‰È‹ıËÛË >17 mm Î·È ·fi ÙÔ ÈÛÙÔ-
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ÚÈÎfi ÙÔ˘ ÚԤ΢Ù ·ʋ ÌÂ Ê˘Ì·ÙÈÎfi ÂÓ‹ÏÈη. ∫·È ÛÙ· 3 ·È‰È¿ ¤ÁÈÓ ·ÈÌ·ÙÔÏÔÁÈÎfi˜ Î·È ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜, ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù· Î·È ¯ÔÚËÁ‹Û·Ì ¯ËÌÂÈÔÚÔʇϷÍË Ì ÈÛÔÓÈ·˙›‰Ë. √ ‰Â›ÎÙ˘ ‰È·ÌfiÏ˘ÓÛ˘ ÛÙËÓ fiÏË Ù˘ ∫ÔÚ›ÓıÔ˘ Â›Ó·È ¯·ÌËÏfi˜ 1,2% Î·È Ê·›ÓÂÙ·È fiÙÈ ÙÔ ÔÛÔÛÙfi ·˘Ùfi ÔÊ›ÏÂÙ·È ·ÔÎÏÂÈÛÙÈο ÛÙÔÓ ·ÏÏÔ‰·fi ÏËı˘ÛÌfi Ù˘ ÂÚÈÔ¯‹˜ Ì·˜. ∆· ÛÙÔȯ›· Ì·˜ Û˘ÌʈÓÔ‡Ó Ì ÂΛӷ Ù˘ ÂȉËÌÈÔÏÔÁÈ΋˜ ÌÂϤÙ˘ ÁÈ· ÙË Ê˘Ì·Ù›ˆÛË ÛÙÔÓ ·È‰ÈÎfi ÏËı˘ÛÌfi ÛÙÔ ¡. ∞ÙÙÈ΋˜ ηٿ ÙËÓ ÂÚ›Ô‰Ô 1987-1998, Û‡Ìʈӷ Ì ÙËÓ ÔÔ›· ·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË Ù˘ ›وÛ˘ Ù˘ ÓfiÛÔ˘ ·Ó¿ÌÂÛ· ÛÙÔ˘˜ ·ÏÏÔ‰·Ô‡˜ Î·È Â·Ó··ÙÚÈÛı¤ÓÙ˜ ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë ÂÚ›Ô‰Ô (11). ™ÙÔ Û‡ÓÔÏÔ Ù˘ ¯ÒÚ·˜ Ì·˜, Ô ‰Â›ÎÙ˘ ‰È·ÌfiÏ˘ÓÛ˘ ÛÙ· ·È‰È¿ Î˘Ì·›ÓÂÙ·È ÛÙÔ 1,8% (˘„ËÏfiÙÂÚÔ˜ ÛÙË µ. ∂ÏÏ¿‰· Î·È ¯·ÌËÏfiÙÂÚÔ˜ ÛÙË ÓËÛȈÙÈ΋) (2). ™‡Ìʈӷ Ì ÛÙÔȯ›· ÙÔ˘ ÀÔ˘ÚÁ›Ԣ ÀÁ›·˜ Î·È ¶ÚfiÓÔÈ·˜, ¤ˆ˜ ÙÔ ¤ÙÔ˜ 1995 ›¯Â ‰È·ÈÛÙˆı› ÙÒÛË ÙÔ˘ ‰Â›ÎÙË ‰È·ÌfiÏ˘ÓÛ˘ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, ÁÂÁÔÓfi˜ Ô˘ ÂÎÊÚ¿˙ÂÈ ÙË ‚ÂÏÙ›ˆÛË ÙˆÓ Û˘ÓıËÎÒÓ ˘ÁÈÂÈÓ‹˜ ηıÒ˜ Î·È ÙˆÓ ·ÓÙ›ÛÙÔȯˆÓ ÎÔÈÓˆÓÈÎÒÓ Î·È ÔÈÎÔÓÔÌÈÎÒÓ. ∆Ô ·˘ÍË̤ÓÔ, fï˜, ÌÂÙ·Ó·ÛÙ¢ÙÈÎfi ·̷ ·fi ¯ÒÚ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘ Ú¤ÂÈ Ó· ı¤ÛÂÈ ÛÂ Û˘Ó·ÁÂÚÌfi ÙȘ ˘ÁÂÈÔÓÔÌÈΤ˜ ˘ËÚÂۛ˜ Ù˘ ¯ÒÚ·˜ Ì·˜. ÃÚÂÈ¿˙ÂÙ·È ·Ó›¯Ó¢ÛË ·ÛıÂÓÒÓ Ì ÂÓÂÚÁfi Ê˘Ì·Ù›ˆÛË, ηٿÏÏËÏË ıÂڷ›·, ¯ËÌÂÈÔÚÔʇϷÍË ÌÔÏ˘Ṳ̂ӈÓ, ÂÌ‚ÔÏÈ·ÛÌfi˜ Ì BCG, ‰ÈÂÓ¤ÚÁÂÈ· Mantoux ÛÙȘ ηٿÏÏËϘ ËÏÈ˘: ·) 12-15 ÌËÓÒÓ, ‚) 6 ÂÙÒÓ, Á) 11 ÂÙÒÓ, ·Ó ‰ÂÓ ¤¯ÂÈ ‹‰Ë Á›ÓÂÈ ÂÌ‚ÔÏÈ·ÛÌfi˜. ªfiÓÔ ¤ÙÛÈ ı· ÌÔÚ¤ÛÔ˘Ì ӷ ÂÈÙ‡¯Ô˘Ì ÙÔ˘˜ ÛÙfi¯Ô˘˜ ÙÔ˘ ¶·ÁÎfiÛÌÈÔ˘ √ÚÁ·ÓÈÛÌÔ‡ ÀÁ›·˜ Î·È Ó· ÂÚÈÔÚ›ÛÔ˘Ì ÙÔ ‰Â›ÎÙË ‰È·ÌfiÏ˘ÓÛ˘ <1% Î·È ÛÙËÓ ∂ÏÏ¿‰·. µÈ‚ÏÈÔÁÚ·Ê›· 1. WHO fact sheet No 104 Revised; April 2000. 2. ∆ÛfiÏ·˜ °. ∏ ÂȉËÌÈÔÏÔÁ›· Ù˘ Ê˘Ì·Ù›ˆÛ˘. ¶·È‰È·ÙÚÈ΋ 1994;57:109-118. 3. °È·ÙÚÔ̷ӈϿ΢ ¡, ª·¯ÏÈÙ˙·Ó¿Î˘ ¡. ∂ȉËÌÈÔÏÔÁ›· Ù˘ Ê˘Ì·Ù›ˆÛ˘. ∞ı‹Ó·: ∂ΉfiÛÂȘ ∂ÏÏËÓÈ΋˜ ¶Ó¢ÌÔÓÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜; 1994. ÛÂÏ. 57-61. 4. Leich AG. Control of Tuberculosis in low prevalence countries. In: Clinical Tuberculosis; PDO Davies, ed. London: Chapman and Hall Medical; 1994. 5. Graf P. Tuberculosis control in high-prevalence countries. πn: Clinical Tuberculosis. ed PDO Davies. London: Chapman and Hall Medical; 1994. 6. °È·ÙÚÔ̷ӈϿ΢ ¡. ∂ȉËÌÈÔÏÔÁ›· Ù˘ Ê˘Ì·Ù›ˆÛ˘. ∞ı‹Ó·: ∂ΉfiÛÂȘ ∂ÏÏËÓÈ΋˜ ¶Ó¢ÌÔÓÔÏÔÁÈ΋˜ ∂Ù·ÈÚ›·˜; 1994. ÛÂÏ. 61-71. 7. ™˘Ú›‰Ë˜ ¶. ÀÂÚ¢·ÈÛıËÛ›· ÂÈ‚Ú·‰˘ÓfiÌÂÓÔ˘ Ù‡Ô˘ ÚÔ˜ ÙÔ Ì˘ÎÔ‚·ÎÙËÚ›‰ÈÔ Î·È Ê˘Ì·ÙÈÓÔ·ÓÙȉڿÛÂȘ. ¶·È‰È·ÙÚÈ΋ 1995;58:571-582.
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8. American Academy of Pediatrics: Report of the committee on infectious diseases. Tuberculosis 1994;480-503. 9. Snider D. Bacille Calmete–Guerin and Tuberculin skin tests. JAMA 1985;253:3483-3489. 10. American Thoracic Society. Diagnostic standards and classification of Tuberculosis. Am Rev Respir Dis 1990;142:450-456. 11. ™˘Ú›‰Ë˜ ¶, ™ÈÓ·ÓÈÒÙ˘ ∫, ∆ÛfiÏÈ· ª, °ÂÏÂ̤ ∞, ™˘Ú›‰Ë˜ °, ª·ıÈÔ˘‰¿Î˘ π Î·È Û˘Ó. ∂ȉËÌÈÔÏÔÁÈ΋ ªÂϤÙË Ù˘
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Ê˘Ì·Ù›ˆÛ˘ Ù˘ ·È‰È΋˜ ËÏÈΛ·˜ ÛÙÔ ¡. ∞ÙÙÈ΋˜; 19871998. ¶·È‰È·ÙÚÈ΋ 1999;62:482-489.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 22-09-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 08-01-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ¡ÈÎfiÏ·Ô˜ ∫·Ì¿˜ ª. ∞ÔÛÙÔÏ›‰Ë 14, ∆.∫. 203 00, §Ô˘ÙÚ¿ÎÈ-∫ÔÚÈÓı›·˜
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ¶·ÏÌÈ΋ Ô͢ÌÂÙÚ›·: ∆È Â›Ó·È Ê˘ÛÈÔÏÔÁÈÎfi ÛÙÔ ∆Ì‹Ì· º˘ÛÈÔÏÔÁÈÎÒÓ ¡ÂÔÁÓÒÓ;1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÙÈÌÒÓ ÎÔÚÂÛÌÔ‡ Ì ·ÏÌÈ΋ Ô͢ÌÂÙÚ›· (∫¶√) Û ˘ÁÈ‹ ÓÂÔÁ¤ÓÓËÙ· ‚Ú¤ÊË. √È ÌÂÙÚ‹ÛÂȘ ¤ÁÈÓ·Ó ÛÙË ‰ÂÍÈ¿ (¢) ¿ÎÚ· ¯Â›Ú· Î·È ¢ ¿ÎÚÔ fi‰· ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹, 24 ÒÚ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË Î·È ÚÈÓ ·fi ÙÔ ÂÍÈÙ‹ÚÈÔ ÙˆÓ ÓÂÔÁÓÒÓ. ¶Ú·ÁÌ·ÙÔÔÈ‹ıËΠηٷÁÚ·Ê‹ ÙˆÓ ÂÍ‹˜ ÏËÚÔÊÔÚÈÒÓ: ËÏÈΛ·˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, ηٿÛÙ·Û˘ ÂÁÚ‹ÁÔÚÛ˘, ʇÏÔ˘, ËÏÈΛ·˜ ·ËÛ˘, ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘, ›‰Ô˘˜ ÙÔÎÂÙÔ‡ Î·È ‚·ıÌÔÏÔÁ›·˜ APGAR. ŒÁÈÓ ·Ó·ÛÎfiËÛË ÙˆÓ Ê·Î¤ÏˆÓ Î·È ÂÏ‹ÊıËÛ·Ó ÂÚ·ÈÙ¤Úˆ ÏËÚÔÊÔڛ˜ ÛÙȘ ÂÚÈÙÒÛÂȘ Ô˘ Ù· ÓÂÔÁÓ¿ ·ÚÔ˘Û›·Û·Ó ∫¶√ ≤92%. ∏ ÔÌ¿‰· ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÌÂÏÂÙ‹ıËÎÂ Û˘ÌÂÚȤϷ‚Â Ê˘ÛÈÔÏÔÁÈο ÓÂÔÁÓ¿, ÂÓÒ ·ÔÎÏ›ÛıËÎ·Ó fiÛ· Ï¿Ì‚·Ó·Ó ıÂڷ›· Ì Ô͢ÁfiÓÔ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó 718 ÓÂÔÁÓ¿: 51% ¿ÚÚÂÓ·, 28% ÁÂÓÓË̤ӷ Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹. ∏ ËÏÈΛ· ·ËÛ˘ ‹Ù·Ó 39,3±1,6 ‚‰ÔÌ¿‰Â˜ (̤ÛË ÙÈÌ‹ ± ™∞), ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 3370±550 g Î·È Ë ‰È¿ÌÂÛË ‚·ıÌÔÏÔÁ›· APGAR 8 ÛÙÔ ÚÒÙÔ Î·È 9 ÛÙÔ ¤ÌÙÔ ÏÂÙfi. ∞ÔÙÂϤÛÌ·Ù·: √ ̤ÛÔ˜ ∫¶√ ¢ڤıË 97,2±1,6% Î·È Ë ‰È¿ÌÂÛË ÙÈÌ‹ ‹Ù·Ó 97%. ªfiÓÔ Ë ËÏÈΛ· ÙÔ˘ ÓÂÔÁÓÔ‡ ÌÂÙ¿ ÙË Á¤ÓÓËÛË ÂËÚ¤·˙ ÛËÌ·ÓÙÈο ÙÔÓ ∫¶√. √ ∫¶√ ·˘Í‹ıËΠηٿ 0,17% ·Ó¿ 24ˆÚÔ (p = 0,0001). √È ÙÈ̤˜ ∫¶√ Ô˘ ÌÂÙÚ‹ıËÎ·Ó fiÙ·Ó Ù· ÓÂÔÁÓ¿ ‹Ù·Ó ·Ó‹Û˘¯· Î·È ¤ÎÏ·ÈÁ·Ó ‹Û·Ó
¯·ÌËÏfiÙÂÚ˜ ÂÎÂ›ÓˆÓ Ô˘ ÌÂÙÚ‹ıËÎ·Ó Î·Ù¿ ÙÔÓ ‡ÓÔ [̤ÛË ÂÏ¿ÙÙˆÛË 0,44% › ·ÓËÛ˘¯›·˜ (p = 0,001), 0,98% Ì ÎÏ¿Ì· (p = 0,0001)]. ™˘ÌÂÚ¿ÛÌ·Ù·: ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ù· ÓÂÔÁ¤ÓÓËÙ· ÛÙÔ ∆Ì‹Ì· º˘ÛÈÔÏÔÁÈÎÒÓ ¡ÂÔÁÓÒÓ ¤¯Ô˘Ó ÁÂÓÈÎfi ̤ÛÔ ∫¶√ 97,2% (±2 ™∞: 94-100%). √ ̤ÛÔ˜ ∫¶√ ·˘Í¿ÓÂÙ·È Ï›ÁÔ Ì ÙËÓ ·‡ÍËÛË Ù˘ ËÏÈΛ·˜ ÙˆÓ ‚ÚÂÊÒÓ ÌÂÙ¿ ÙË Á¤ÓÓËÛË. √È ÙÈ̤˜ ∫¶√ ÛÙ· ÓÂÔÁ¤ÓÓËÙ· Ô˘ Â›Ó·È ·Ó‹Û˘¯· ‹ ÎÏ·›ÓÂ Â›Ó·È ¯·ÌËÏfiÙÂÚ˜ ÂÎÂ›ÓˆÓ Ô˘ ÌÂÙÚÔ‡ÓÙ·È Û ηٿÛÙ·ÛË ËÚÂÌ›·˜ ‹ ηٿ ÙÔÓ ‡ÓÔ. √È ÙÈ̤˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ÌÔÚÔ‡Ó Ó· ¯ÚËÛÈÌÔÔÈËıÔ‡Ó ˆ˜ ÙÈ̤˜ ·Ó·ÊÔÚ¿˜ ÁÈ· ÙËÓ ÂÎÙ›ÌËÛË ÙÔ˘ ∫¶√ Û ÓÂÔÁ¤ÓÓËÙ· ‚Ú¤ÊË Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Û˘ÌÙÒÌ·Ù·. 1Levesque
BM, Pollack P, Griffin BE, Nielsen HC Pulse oximetry: What’s normal in the newborn nursery? Pediatr Pulmonol 2000;30:406-412 ªÈ¯¿Ï˘ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ¶·È‰ÔÓ¢ÌÔÓÔÏfiÁÔ˜ ∂ÈÌÂÏËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ
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ORIGINAL PAPER
§ÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ Î·È ¯·ÌËÏ‹ Û˘ÏÏÔÁÈ΋ ·ÓÔÛ›· ÛÙËÓ ÂӉ¯fiÌÂÓË ·ÈÙÈÔÏÔÁ›· Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ª. ¡Ù·Ï·Ì¿Áη1, ∂. ¶ÂÙÚ›‰Ô˘1,2, ¢. ∆ÚȯfiÔ˘ÏÔ˜1,2, ∞. ªÂÓÙ‹˜3, Õ. ™Î·ÏΛ‰Ô˘1, £. ∫·Ú¿ıÈÔ˜4, º. ∞ı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘5, ª. ∫·ÏÌ·ÓÙ‹6, ¢. ∫ÔÏÈÔ‡Ûη˜7, ∂. ∫ÔÛÌ›‰Ë8, π. ¶·Ó·ÁÈÒÙÔ˘9, º. ∆˙ˆÚÙ˙¿ÙÔ˘-™Ù·ıÔÔ‡ÏÔ˘10
Infectious agents and low herd immunity in the etiology of childhood leukemia M. Dalamaga1, E. Petridou1,2, D. Trichopoulos2, A. Mentis3, A. Skalkidou1, T. Karpathios4, F. Athanasiadou-Piperopoulou5, M. Kalmanti6, D. Koliouskas7, E. Kosmidou8, J. Panagiotou9, F. Tzortzatou-Stathopoulou10
¶ÂÚ›ÏË„Ë: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È Ó· ‰ÈÂÚ¢ÓËı› Ë ˘fiıÂÛË ·Ó ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜ (ALL) ÙˆÓ ·È‰ÈÒÓ ÂÓ‰¤¯ÂÙ·È Ó· ·ÔÙÂÏÔ‡Ó ÙÔ Û¿ÓÈÔ ·ÔÙ¤ÏÂÛÌ· ηı˘ÛÙÂÚË̤Ó˘ ÌË-ÂȉÈ΋˜ Ïԛ̈͢ Û ˘fiÛÙڈ̷ ¯·ÌËÏ‹˜ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜. ∏ ˘fiıÂÛË ÂÚÁ·Û›·˜ ‹Ù·Ó fiÙÈ ÔÈ ·ÛıÂÓ›˜ Ì ALL ı· ›¯·Ó Û˘ÓÔÏÈο ¯·ÌËÏfiÙÂÚ· ›‰· ¤ÎıÂÛ˘ ÛÙÔ Ê¿ÛÌ· ÙˆÓ ÏÔÈÌÔÁfiÓˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÂÍÂÙ¿ÛÙËÎÂ, Ì ÂÍ·›ÚÂÛË ÙË ıÂÙÈ΋ ·ÓÔÛÔÏÔÁÈ΋ ·fiÎÚÈÛË ÛÙÔ ÏÔÈÌÔÁfiÓÔ ÂΛÓÔ ·Ú¿ÁÔÓÙ· Ô˘ ıˆÚÂ›Ù·È fiÙÈ ˘ÚÔ‰fiÙËÛ ÙËÓ ¤Ó·ÚÍË Ù˘ ALL. ™˘ÁÎÚ›ıËηÓ, ˆ˜ ÚÔ˜ ÙÔ ÈÛÙÔÚÈÎfi Î·È ÙËÓ ÔÚÔÏÔÁÈ΋ ·fiÎÚÈÛË Û 10 ÎÔÈÓÔ‡˜ ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜, 94 ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Ô˘ ÓÂԉȷÁÓÒÛÙËÎ·Ó Ì ÔÍ›· Ï¢¯·ÈÌ›·
Abstract: It has been suggested that acute lymphoblastic leukemia (ALL) in children may be a rare outcome of a delayed non specific infection in situations of low herd immunity to a relatively wide range of infectious agents. We assumed that newly diagnosed childhood leukemia cases, in comparison to their controls, would be characterised by a more seronegative spectrum to the infectious agents examined, with the exception of a strongly positive response to that infectious agent, which is assumed to trigger ALL. A case control study was undertaken in Greece of 94 newly diagnosed cases of ALL who were compared to an equal number of hospitalized children (controls) for minor noninfectious conditions, and who were matched for
1 ∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÈÂÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 2 ∆Ì‹Ì· ∂ȉËÌÈÔÏÔÁ›·˜, ™¯ÔÏ‹ ¢ËÌfiÛÈ·˜ ÀÁ›·˜ ¶·ÓÂÈÛÙËÌ›Ô˘ Harvard, ∏¶∞ 3 ¢È·ÁÓˆÛÙÈÎfi ∆Ì‹Ì· ∂ÏÏËÓÈÎfi πÓÛÙÈÙÔ‡ÙÔ Pasteur, ∞ı‹Ó· 4 µ’ ¶·Ó/΋ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ ‘∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡” 5 ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-√ÁÎÔÏÔÁ›·˜, µ’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, ∞ÚÈÛÙÔÙ¤ÏÂÈÔ ¶·ÓÂÈÛÙ‹ÌÈÔ £ÂÛÛ·ÏÔӛ΢, °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ∞Ã∂¶∞ 6 ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-√ÁÎÔÏÔÁ›·˜ ¶·ÓÂÈÛÙËÌÈ·Îfi ¡ÔÛÔÎÔÌÂ›Ô ∏Ú·ÎÏ›Ԣ 7 ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-√ÁÎÔÏÔÁ›·˜ πÔÎÚ¿ÙÂÈÔ °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô £ÂÛÛ·ÏÔӛ΢ 8 ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-√ÁÎÔÏÔÁ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞ÁÏ·˝· ∫˘ÚÈ·ÎÔ‡” 9 ∆Ì‹Ì· ¶·È‰È·ÙÚÈ΋˜ ∞ÈÌ·ÙÔÏÔÁ›·˜-√ÁÎÔÏÔÁ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” 10 ªÔÓ¿‰· ∞ÈÌ·ÙÔÏÔÁ›·˜-√ÁÎÔÏÔÁ›·˜, ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋, π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
1 Department of Hygiene and Epidemiology Athens University Medical School 2 Department of Epidemiology Harvard School of Public Health, USA 3 Diagnostic Services Department Hellenic Pasteur Institute, Athens 4 Second Department of Pediatrics, Athens University Medical School, A. Kyriakou Children’s Hospital 5 Second Department of Paediatrics Aristoteleion University of Thessaloniki AHEPA General Hospital 6 Department of Paediatric Haematology-Oncology University Hospital of Heraklion 7 Department of Paediatric Haematology-Oncology Ippokration General Hospital, Thessaloniki 8 Department of Paediatric Haematology-Oncology A. Kyriakou Children’s Hospital, Athens 9 Department of Paediatric Haematology-Oncology Agia Sophia Children’s Hospital, Athens 10 Unit of Childhood Haematology-Oncology, First Department of Paediatrics, Athens University Medical School, Agia Sophia Children’s Hospital
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ÛÙ· ¤ÍÈ ·È‰È·ÙÚÈο ·ÈÌ·ÙÔÏÔÁÈο-ÔÁÎÔÏÔÁÈο ÙÌ‹Ì·Ù· Ù˘ ¯ÒÚ·˜ Ì ÈÛÔ‰‡Ó·ÌÔ ·ÚÈıÌfi, ÂÍÔÌÔÈˆÌ¤ÓˆÓ ˆ˜ ÚÔ˜ ÙÔ Ê‡ÏÔ Î·È ÙËÓ ËÏÈΛ·, Ì·ÚÙ‡ÚˆÓ, ÔÈ ÔÔ›ÔÈ ÓÔÛËχÙËÎ·Ó ÛÙ· ›‰È· ÓÔÛÔÎÔÌ›· ÁÈ· ÌËÏÔÈÌÒ‰ÂȘ ÓfiÛÔ˘˜. √È ÂӉ›ÍÂȘ Û˘Û¯¤ÙÈÛ˘ Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Ì ÙËÓ ÔÚÔıÂÙÈ΋ ·¿ÓÙËÛË ÛÙÔ Ê¿ÛÌ· ÙˆÓ ÏÔÈÌÔÁfiÓˆÓ ·Ú·ÁfiÓÙˆÓ Ô˘ ÌÂÏÂÙ‹ıËηÓ, Â›Ó·È ÌÈÎÚ¤˜ ÁÈ· Ù· ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ. ∞ÓÙÈı¤Ùˆ˜, ÁÈ· ·È‰È¿ ËÏÈΛ·˜ 5-14 ÂÙÒÓ ‚Ú¤ıËΠıÂÙÈ΋ Î·È ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ÓfiÛÔ˘ Ì ÙÔÓ Èfi Ù˘ ·Ú·Áڛ˘ Î·È Ì›· ÛÂÈÚ¿ ·ÓÙ›ÛÙÚÔÊˆÓ Û˘Û¯ÂÙ›ÛÂˆÓ Ì ÙÔ˘˜ ÈÔ‡˜ Epstein-Barr, ∞ÓıÚÒÈÓÔ ∂ÚËÙÔ˚fi-6, ¶·Ú‚Ô˚fi µ 19, ηıÒ˜ Î·È ÙÔ ª˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜. ™Ù· ·È‰È¿ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 5 ÂÙÒÓ, Ô Èı·Ófi˜ ΛӉ˘ÓÔ˜ Ï¢¯·ÈÌ›·˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ fiÙ·Ó Û ÂÚÈÙÒÛÂȘ ¯·ÌËÏ‹˜ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜ ÁÈ· ·ÚÎÂÙÔ‡˜ ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜, ÙÔ ·ÓÔÛÔÔÈËÙÈÎfi ÙÔ˘˜ Û‡ÛÙËÌ· ‰ÔÎÈÌ¿˙ÂÙ·È ·fi ÌÈ· ηı˘ÛÙÂÚË̤ÓË Ïԛ̈ÍË, Ë ÔÔ›·, Û˘Ó‹ıˆ˜, ÚÔÛ‚¿ÏÏÂÈ ·È‰È¿ ÌÈÎÚfiÙÂÚ˘ ËÏÈΛ·˜.
age and gender. To assess past exposure against a range of infectious agents, a battery of ten serological tests was used. The results showed that in children less than five years of age there was little evidence for an association of childhood leukemia with the serology of any of the ten studied. In contrast, among children over five years of age, there was a statistically significant positive association of leukemia with the Parainfluenza virus and a series of inverse associations with Epstein Barr virus, Human Herpes Virus-6, Mycoplasma pneumonia and Parvovirus B19. In conclusion, among children five years of age or older, the risk of leukemia is higher when in cases of low herd immunity for several agents their immune system is challenged by late infection from an infectious agent which, as a rule, affects children at a younger age.
§¤ÍÂȘ ÎÏÂȉȿ: ·È‰›, ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·, ·ÈÙÈÔÏÔÁ›·, Û˘ÏÏÔÁÈ΋ ·ÓÔÛ›·, ηı˘ÛÙÂÚË̤ÓË Ïԛ̈ÍË, ÏÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜ (Èfi˜ Áڛ˘ ∞, Èfi˜ Áڛ˘ µ, ·Ó·Ó¢ÛÙÈÎfi˜ Û˘Á΢ÙÈ·Îfi˜ Èfi˜, ÈÔ› ·Ú·Áڛ˘, ·‰ÂÓÔ˚fi˜, ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜, ·Ú‚Ô˚fi˜ µ 19, ·ÓıÚÒÈÓÔ˜ ÂÚËÙÔ˚fi˜-6, Èfi˜ EpsteinBarr, Ì˘ÎfiÏ·ÛÌ· Ó¢ÌÔÓ›·˜).
Key words: child, acute childhood leukemia, etiology, herd immunity, delayed infection, infectious agents (Influenza virus A, Influenza virus B, Adenovirus, Respiratory Syncytial Virus, parainfluenza viruses, Cytomegalovirus, EpsteinBarr virus, Human Herpesvirus-6, Parvovirus B19, Mycoplasma pneumoniae).
∂ÈÛ·ÁˆÁ‹ ªÂ ‚¿ÛË ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÔÈ ÈÔ› ¤¯Ô˘Ó ·Ó·ÊÂÚı› ˆ˜ ·›ÙÈ· Ï¢¯·ÈÌ›·˜ ·ÚÎÂÙÒÓ ÔÈÎÈ·ÎÒÓ ˙ÒˆÓ, ηıÒ˜ ›Û˘ Î·È ·fi ÙËÓ ÂÌÏÔ΋ ÙÔ˘ ÈÔ‡ HTLV-1 ÛÙËÓ ·ÈÙÈÔÏÔÁ›· Ì›·˜ Û¿ÓÈ·˜ ÌÔÚÊ‹˜ Ï¢¯·ÈÌ›·˜ ÛÙÔÓ ¿ÓıÚˆÔ, ¤¯ÂÈ ‰È·Ù˘ˆı› Ë ˘fiıÂÛË fiÙÈ Ë ·È‰È΋ Ï¢¯·ÈÌ›· ÂÓ‰¤¯ÂÙ·È Ó· Â›Ó·È ÏÔÈÌÒ‰Ô˘˜ ·Ú¯‹˜. √È ÂȉËÌÈÔÏÔÁÈΤ˜ ÂӉ›ÍÂȘ Ô˘ ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ˘fiıÂÛË Ù˘ ÏÔÈÌÒ‰Ô˘˜ ·ÈÙÈÔÏÔÁ›·˜ ÛÙËÓ Èı·Ó‹ ÚfiÎÏËÛË ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ÚÔ¤Ú¯ÔÓÙ·È ·fi: ·) ÌÂϤÙ˜, fiÔ˘ ‰È·Ê·›ÓÂÙ·È Ë ÙÔÔ¯ÚÔÓÈ΋ Û˘ÚÚÔ‹ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ (1), ‚) ÂÚ¢ÓËÙÈο ‰Â‰Ô̤ӷ, fiÙÈ ÙÔ ÚÒÙÔ ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ¤¯ÂÈ ·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Û ۯ¤ÛË Ì ٷ ˘fiÏÔÈ· ηٿ ÛÂÈÚ¿ Á¤ÓÓËÛ˘ (2,3), Á) ‰ËÌÔÛȇÛÂȘ, Ô˘ Û˘Û¯ÂÙ›˙Ô˘Ó ÙËÓ ·È‰È΋ Ï¢¯·ÈÌ›· Ì ηı˘ÛÙÂÚË̤ÓË ·Ó¿Ù˘ÍË Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜ (herd immunity) (4) Î·È ‰) Â˘Ú‹Ì·Ù· ·fi ηٷÛÙ¿ÛÂȘ fiÔ˘ ·Ú·ÙËÚÂ›Ù·È ÏËı˘ÛÌȷ΋ ·Ó¿ÌÂÈÍË Î·È ¤¯Ô˘Ó ¯ÚËÛÈÌÔÔÈËı› ˆ˜ Ê˘ÛÈο ÂÈÚ¿Ì·Ù· ÁÈ· ÙË
‰ÈÂÚ‡ÓËÛË Ù˘ ÙÔÔ¯ÚÔÓÈ΋˜ Û˘ÚÚÔ‹˜ Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Û ÂÚÈÙÒÛÂȘ ¯·ÌËÏ‹˜ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜. ∞ÚÎÂÙÔ› ·fi ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜, Ô˘ ıÂÒÚËÛ·Ó ˆ˜ Èı·Ó‹ ÙË ÏÔÈÌÒ‰Ë ·ÈÙÈÔÏÔÁ›· Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ (2,4,5,7-10), ÚÔÛ¿ıËÛ·Ó Ó· ·Ó·Ù‡ÍÔ˘Ó ÂÈÛÙËÌÔÓÈΤ˜ ˘Ôı¤ÛÂȘ, ÔÈ Ôԛ˜ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·ÚÎÂÙ¿ ÎÔÈÓ¿ ÛÙÔȯ›·, Ù· ÔÔ›· Ô Greaves ÂÓۈ̿وÛ Û ¤Ó· ÌÔÓÙ¤ÏÔ Û˘ÁÎÏÈÓÔ˘ÛÒÓ ˘Ôı¤ÛÂˆÓ (10). ™‡Ìʈӷ Ì ·˘Ù‹ ÙËÓ ˘fiıÂÛË, Ë ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (ALL) Î·È ÂȉÈÎfiÙÂÚ· Ô Ù‡Ô˜ c-ALL (ÎÔÈÓ‹ ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›·) ·ÔÙÂÏ› ÓfiÛÔ ÙˆÓ ·ÓÂÙ˘ÁÌ¤ÓˆÓ ÎÔÈÓˆÓÈÒÓ Î·È ÌÔÚ› Ó· ıˆÚËı› fiÙÈ ·ÔÙÂÏ› ÙË Û¿ÓÈ· ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË Û ÂÚ›ÙˆÛË Ô˘ ÙÔ ·È‰› ÓÔÛ‹ÛÂÈ Û ÌÂÙ·ÁÂÓ¤ÛÙÂÚË ·fi ÙËÓ ·Ó·ÌÂÓfiÌÂÓË ËÏÈΛ· ·fi Ì›· ‹ ÂÚÈÛÛfiÙÂÚ˜ ÎÔÈÓ¤˜ ÏÔÈÌÒÍÂȘ. ªÂ ‚¿ÛË ÙË ‚ÈÔÏÔÁÈ΋ ÛÙ·ıÂÚ¿, ÁÈ· ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÎÔÈÓ¤˜ ÏÔÈÌÒÍÂȘ, Ë ÚÔÛ‚ÔÏ‹ Û˘Ì‚·›ÓÂÈ ÓˆÚ›˜ ÛÙË ˙ˆ‹ ÂÓfi˜ ·È‰ÈÔ‡ Î·È Ë ÌÂÙ¿‰ÔÛË Á›ÓÂÙ·È Ì¤Ûˆ Ù˘ ÌËÙ¤Ú·˜ ‹ ¿ÏÏˆÓ ·ÙfiÌˆÓ ÙÔ˘ ÛÙÂÓÔ‡ ÂÚÈ‚¿ÏÏÔÓÙÔ˜,
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fiˆ˜ ÁÈ· ·Ú¿‰ÂÈÁÌ· ·fi ·‰¤ÏÊÈ· ÌÂÁ·Ï‡ÙÂÚ˘ ËÏÈΛ·˜. ™ÙȘ Û‡Á¯ÚÔÓ˜ ÎÔÈӈӛ˜, Ë ÚÒÈÌË ¤ÎıÂÛË ‚ÚÂÊÒÓ Î·È ÓË›ˆÓ Û ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜ ηı˘ÛÙÂÚ›, ÂÍ·ÈÙ›·˜ ·ÊÂÓfi˜ Ù˘ ‚ÂÏÙ›ˆÛ˘ ÙˆÓ Û˘ÓıËÎÒÓ ˘ÁÈÂÈÓ‹˜ Î·È ·ÊÂÙ¤ÚÔ˘ ÙˆÓ ÎÔÈÓˆÓÈÎÒÓ ·ÏÏ·ÁÒÓ. ∏ ηı˘ÛÙÂÚË̤ÓË ¤ÎıÂÛË Û ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÂÓ‰¤¯ÂÙ·È Ó· ‚Ú·‰‡ÓÂÈ ÙËÓ ÙÂÏÈ΋ ‰È·ÊÔÚÔÔ›ËÛË ÙÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Ì ·ÔÙ¤ÏÂÛÌ· Ë Ïԛ̈ÍË ÙÔ˘ ·È‰ÈÔ‡ Û ÌÂÁ·Ï‡ÙÂÚË ËÏÈΛ· ·fi ¤Ó· ÎÔÈÓfi ÌÈÎÚÔÔÚÁ·ÓÈÛÌfi Ó· ÚÔηϤÛÂÈ, Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ, ÙËÓ ÈÛ¯˘Ú‹ ·¿ÓÙËÛË ÂÓfi˜ ·ÓÒÚÈÌÔ˘ ·ÓÔÛÔÔÈËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Ì ·ÎfiÏÔ˘ıË ÎψÓÈ΋ ÂÎÙÚÔ‹ ÙˆÓ Î˘ÙÙ¿ÚˆÓ (12). ™‡Ìʈӷ Ì ÙËÓ ˘fiıÂÛË Ù˘ ηı˘ÛÙÂÚË̤Ó˘ Ïԛ̈͢, ·Ó·Ì¤ÓÂÙ·È fiÙÈ Ô Î›Ó‰˘ÓÔ˜ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ı· Â›Ó·È ·˘ÍË̤ÓÔ˜ fiÙ·Ó ÌÂÈÒÓÂÙ·È Ë Û˘¯ÓfiÙËÙ· ÂÌÊ¿ÓÈÛ˘ ÏÔÈÌÒÍÂˆÓ ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· (4,9-11,13). ™ÙË ÌÂϤÙË ·˘Ù‹ Á›ÓÂÙ·È ÚÔÛ¿ıÂÈ· Ó· ·ÍÈÔÏÔÁËı› Ë ˘fiıÂÛË Ù˘ ηı˘ÛÙÂÚË̤Ó˘ Ïԛ̈͢ Ì ÂÚ¢ÓËÙÈÎfi ۯ‰ȷÛÌfi Ù‡Ô˘ ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ (case control study). ∞ӷ̤ÓÂÙ·È fiÙÈ ÔÈ Ó¤Â˜ ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ Ì ÔÍ›· ·È‰È΋ Ï¢¯·ÈÌ›· ı· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ÛÙÔ Û‡ÓÔÏfi ÙÔ˘˜ ¯·ÌËÏfiÙÂÚ· ›‰· ¤ÎıÂÛ˘ Û ¤Ó· ¢ڇ Ê¿ÛÌ· ÏÔÈÌÔÁfiÓˆÓ ·Ú·ÁfiÓÙˆÓ Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ·ÓÙ›ÛÙÔÈ¯Ô˘˜ Ì¿ÚÙ˘Ú˜, Ì ÂÍ·›ÚÂÛË ÙË ıÂÙÈ΋ ·ÓÔÛÔÏÔÁÈ΋ ·fiÎÚÈÛË ÛÙÔ ÏÔÈÌÔÁfiÓÔ ·Ú¿ÁÔÓÙ·, Ô˘ ıˆÚÂ›Ù·È fiÙÈ ˘ÚÔ‰ÔÙ› ÙËÓ ¤Ó·ÚÍË Ù˘ ALL. ™ÙË ÌÂϤÙË ·˘Ù‹ ‰ÂÓ ˘Ô‰ÂÈÎÓ‡ÂÙ·È, ˆ˜ ·ÈÙÈÔÏÔÁÈÎfi˜, οÔÈÔ˜ Û˘ÁÎÂÎÚÈ̤ÓÔ˜ ÏÔÈÌÔÁfiÓÔ˜ ·Ú¿ÁÔÓÙ·˜ ‹ ÔÈ È‰ÈfiÙËÙ¤˜ ÙÔ˘, ·ÏÏ¿ ÙÔ ˙ËÙÔ‡ÌÂÓÔ Â›Ó·È ·Ó Ë Ïԛ̈ÍË Î·ı˘ÛÙÂÚ› Û ۇÁÎÚÈÛË Ì ÙË Û˘Ó‹ıË ËÏÈΛ· ÚÔÛ‚ÔÏ‹˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÓÙ·ÂÙ›·˜ 1993-1997 ¤ÁÈÓ ÛÙË ¯ÒÚ· Ì·˜, ·fi ÙÔ ‰›ÎÙ˘Ô ·È‰È¿ÙÚˆÓ ·ÈÌ·ÙÔÏfiÁˆÓ-ÔÁÎÔÏfiÁˆÓ, ‰È¿ÁÓˆÛË 450 Ó¤ˆÓ ÂÚÈÙÒÛÂˆÓ ·È‰È΋˜ (0-14 ÂÙÒÓ) Ï¢¯·ÈÌ›·˜, Ô˘ ÂȂ‚·ÈÒıËÎ·Ó ÌÂ Ì˘ÂÏfiÁÚ·ÌÌ·. √È 388 ÂÚÈÙÒÛÂȘ ·Ó‹ÎÔ˘Ó ÛÙÔÓ Ù‡Ô Ù˘ ÔÍ›·˜ ÏÂÌÊÔ‚Ï·ÛÙÈ΋˜ Ï¢¯·ÈÌ›·˜. °È· 104 ÂÚÈÙÒÛÂȘ ALL, Ú·ÁÌ·ÙÔÔÈ‹ıËÎÂ Û˘ÏÏÔÁ‹ ·›Ì·ÙÔ˜ ÚÈÓ ÙËÓ Î¿ı ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Î·È Ë ÂÈÏÔÁ‹ ÙˆÓ ·ÛıÂÓÒÓ ÚÔÛ‰ÈÔÚ›ÛÙËΠÌfiÓÔ ·fi ‰ÈÔÈÎËÙÈΤ˜ ‹ Ù¯ÓÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜, Ô˘ ‰ÂÓ Â›¯·Ó fï˜ Û¯¤ÛË Ì ÙȘ ÔÚÔÏÔÁÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ÂÍÂÙ¿˙ÔÓÙ·È. ∂Í¿ÏÏÔ˘, Ë Î·Ù·ÓÔÌ‹ ÙÔ˘ ʇÏÔ˘ Î·È Ù˘ ËÏÈΛ·˜ ÛÙÔ ÂÍÂÙ·˙fiÌÂÓÔ ‰Â›ÁÌ· ‹Ù·Ó ·ÚfiÌÔÈ· Ì ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Î·Ù·ÓÔÌ‹ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ ÛÙÔ Û˘ÓÔÏÈÎfi ÏËı˘ÛÌfi. ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÂÙÒÓ 1995-1997, Û ÔÚÈṲ̂ӷ ·fi Ù· Û˘ÌÌÂÙ¤¯ÔÓÙ· ÓÔÛÔÎÔÌ›· ‰ÂÓ ‰ÈÂÓÂÚÁ‹ıËÎ·Ó Ï‹„ÂȘ ·›Ì·ÙÔ˜ (128 ÂÚÈÙÒÛÂȘ) Î·È ¿ÏÈ ÁÈ· ‰È·‰ÈηÛÙÈÎÔ‡˜ ÏfiÁÔ˘˜, ÂÓÒ ÁÈ· ÙȘ ¿ÏϘ 126 ÂÚÈÙÒÛÂȘ Ë Û˘ÏÏÔÁ‹ ·›Ì·ÙÔ˜ ‰ÂÓ Ú·ÁÌ·ÙÔÔÈ‹ıËΠÁÂÓÈÎÒ˜ ‹ ÚÈÓ ÙËÓ ·Ú¯‹ Ù˘ ıÂڷ¢ÙÈ΋˜ ·Ú¤Ì‚·Û˘. ∆· ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜
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‹Ù·Ó ÙÂÏÈο ·Ó·Ú΋ ‹ ·Î·Ù¿ÏÏËÏ· ÁÈ· 10 ·fi ÙȘ 104 ÂÚÈÙÒÛÂȘ ALL Î·È Û˘ÓÂÒ˜ ‰ÂÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÁÈ· ·Ó¿Ï˘ÛË. ∆ÂÏÈÎÒ˜, ‹Ù·Ó ‰È·ı¤ÛÈÌ· 94 ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ·ÛıÂÓÒÓ Ì ·È‰È΋ Ï¢¯·ÈÌ›·. ™˘ÌÏËڈ̷ÙÈο ÛÙÔȯ›· ·Ú›¯·Ó ÔÈ ÁÔÓ›˜ ‹ ÔÈ Û˘ÓÔ‰Ô› ÙˆÓ ·È‰ÈÒÓ Ì ALL, ÔÈ ÔÔ›ÔÈ, Ì ÙË ‚Ô‹ıÂÈ· ÂÍÂȉÈÎÂ˘Ì¤ÓÔ˘ ÚÔÛˆÈÎÔ‡, ·¿ÓÙËÛ·Ó Û ¤Ó· Έ‰ÈÎÔÔÈË̤ÓÔ ÂÚˆÙËÌ·ÙÔÏfiÁÈÔ. °È· οı ·ÛıÂÓ‹, ¤ÁÈÓ ÚÔÛ¿ıÂÈ· Ó· ‚ÚÂı› ÌÂ Ù˘¯·›· ‰ÂÈÁÌ·ÙÔÏË„›· ¤Ó·˜ Ì¿ÚÙ˘Ú·˜ ÂÍÔÌÔȈ̤ÓÔ˜ (matched control) ˆ˜ ÚÔ˜ ÙÔ Ê‡ÏÔ Î·È ÙËÓ ËÏÈΛ· (± 6 Ì‹Ó˜), Ô˘ ÓÔÛËÏ¢fiÙ·Ó ÛÙÔ ›‰ÈÔ ÓÔÛÔÎÔÌÂ›Ô Ì ‹È·, ÌË ÏÔÈÌÒ‰Ë ÓfiÛÔ Î·È 17 ·fi ÙÔ˘˜ Ì¿ÚÙ˘Ú˜ ·ÓÙÈηٷÛÙ¿ıËÎ·Ó Î·Ù·Ïϋψ˜, ÂÂȉ‹ ‰ÂÓ ÏËÚÔ‡Û·Ó Ù· ÎÚÈÙ‹ÚÈ· Û˘ÌÌÂÙÔ¯‹˜ ÛÙË ÌÂϤÙË. 1. EÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ: ªÂÙ¿ ÙË Ï‹„Ë ÊÏ‚ÈÎÔ‡ ·›Ì·ÙÔ˜, Ù· ‰Â›ÁÌ·Ù· ·›Ì·ÙÔ˜ ¤ËÍ·Ó Û ıÂÚÌÔÎÚ·Û›· ‰ˆÌ·Ù›Ô˘, Ê˘ÁÔÎÂÓÙÚ‹ıËÎ·Ó Î·È ÛÙË Û˘Ó¤¯ÂÈ· Ù· ‰Â›ÁÌ·Ù· ÙˆÓ ÔÚÒÓ ‰È·¯ˆÚ›ÛÙËηÓ, ·ÔıË·ÙËÎ·Ó ÛÙËÓ Î·Ù¿„˘ÍË (-20Æ C) Î·È ÌÂٷʤÚıËÎ·Ó ÛÙÔ ¢È·ÁÓˆÛÙÈÎfi ∆Ì‹Ì· ÙÔ˘ ∂ÏÏËÓÈÎÔ‡ πÓÛÙÈÙÔ‡ÙÔ˘ Pasteur, fiÔ˘ Ú·ÁÌ·ÙÔÔÈ‹ıËÎÂ Ù˘ÊÏfi˜ ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ¤Ó· Û‡ÓÔÏÔ ‰¤Î· ÏÔÈ̈‰ÒÓ ·Ú·ÁfiÓÙˆÓ, ¯ˆÚ›˜ ‰ËÏ·‰‹ Ó· Â›Ó·È ÁÓˆÛÙfi ÛÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ ·Ó Ô ÔÚfi˜ ·Ó‹ÎÂÈ Û ‚·ÛÈΤ˜ ÂÚÈÙÒÛÂȘ ‹ Û ̿ÚÙ˘Ú˜. °È· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ ÈÒÓ Áڛ˘ ∞, µ, ·‰ÂÓÔ˚Ô‡, ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘Á΢ÙÈ·ÎÔ‡ ÈÔ‡ (RSV) Î·È ÈÒÓ ·Ú·Áڛ˘, ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÛÂÈÚ¿ ÙˆÓ ¤ÙÔÈÌˆÓ ·ÓÙȉڷÛÙËÚ›ˆÓ ELISA ÙÔ˘ Ô›ÎÔ˘ Genzyme Virotech Gmbh, Û‡Ìʈӷ Ì ÙȘ ¤ÓıÂÙ˜ Ô‰ËÁ›Â˜ ÙÔ˘ ηٷÛ΢·ÛÙ‹. ∆· ·ÓÙÈÁfiÓ· Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ÛÙȘ ‰ÔÎÈ̷ۛ˜ ›ӷÈ: ÂÓ·ÈÒÚËÌ· ÛÙÂϤ¯Ô˘˜ ∞-Ù‡Ô˘ ÁÈ· ÙÔÓ Èfi Áڛ˘ ∞, ÂÓ·ÈÒÚËÌ· ÛÙÂϤ¯Ô˘˜ µ-Ù‡Ô˘ ÁÈ· ÙÔÓ Èfi Áڛ˘ µ, ˘ÂÚΛÌÂÓÔ ÚÔۂ‚ÏËÌ¤ÓˆÓ Î˘ÙÙ¿ÚˆÓ ·fi ·‰ÂÓÔ˚fi 6 Î·È ÈÒÓ ·Ú·Áڛ˘ 1, 2, 3 ÁÈ· ÙÔÓ ·‰ÂÓÔ˚fi Î·È ÙÔ˘˜ ÈÔ‡˜ ·Ú·Áڛ˘ 1, 2, 3, ηıÒ˜ Î·È ˘ÂÚΛÌÂÓÔ ÚÔۂ‚ÏËÌ¤ÓˆÓ Î˘ÙÙ¿ÚˆÓ ·fi RSV (RSV-ª·ÎÚ‡ Û٤ϯԘ) ÁÈ· ÙÔÓ ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi. ∏ ÌÂıÔ‰ÔÏÔÁ›· ÚÔÛ‰ÈÔÚÈÛÌÔ‡ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È fiÌÔÈ· ÁÈ· οı ¤Ó·Ó ·fi ÙÔ˘˜ ·Ú·¿Óˆ ÈÔ‡˜. ∞ÎÔÏÔ‡ıˆ˜, Ù· ÚԷڷȈ̤ӷ ‰Â›ÁÌ·Ù· ÔÚÒÓ ÚÔÛÙ¤ıËÎ·Ó ÛÙ· ÊÚ¿ÙÈ· Ï·ÎÒÓ, fiÔ˘ ‚Ú›ÛÎÔÓÙ·Ó Î·ıËψ̤ӷ Ù· ·ÓÙ›ÛÙÔȯ· ·ÓÙÈÁfiÓ·. ªÂÙ¿ ·fi ÂÒ·ÛË Î·È ¤ÎÏ˘ÛË ÙˆÓ ÊÚ·ٛˆÓ, ÚÔÛÙ¤ıËΠÙÔ ÂÓ˙˘ÌÈÎfi Û‡ÌÏÂÁÌ·, ÙÔ ÔÔ›Ô ·ÔÙÂÏÂ›Ù·È ·fi ȯÓËıÂÙË̤ӷ Ì ˘ÂÚÔÍÂȉ¿ÛË ·ÓÙÈÛÒÌ·Ù· ›Ô˘ ¤Ó·ÓÙÈ ·ÓıÚÒÈÓ˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ G. ªÂÙ¿ ÙËÓ ÚÔÛı‹ÎË ÙÔ˘ ˘ÔÛÙÚÒÌ·ÙÔ˜ (ÙÂÙÚ·ÌÂı˘ÏÔ‚ÂÓ˙ȉ›ÓË 3,3’,5,5’-∆ªµ) ·ÎÔÏÔ˘ıÔ‡Û ‰È¿Û·Û‹ ÙÔ˘, Ô˘ Û˘Óԉ¢fiÙ·Ó ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÌÏ ¯ÚÒÌ·ÙÔ˜. ∏ ÂÓ˙˘ÌÈ΋ ·ÓÙ›‰Ú·ÛË ÛÙ·Ì·ÙÔ‡Û Ì ÙËÓ ÂÌÊ¿ÓÈÛË Î›ÙÚÈÓÔ˘ ¯ÚÒÌ·ÙÔ˜ ‡ÛÙÂÚ· ·fi ÚÔÛı‹ÎË ÎÈÙÚÈÎÔ‡ ÔͤԘ. √È ÙÈ̤˜ ÔÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÌÂÙÚ‹ıËÎ·Ó Û ̋ÎË Î‡Ì·ÙÔ˜ 450 nm, Ì ̋ÎÔ˜ ·Ó·ÊÔÚ¿˜ Ù· 620 nm, Û ʷÛÌ·ÙÔʈÙfiÌÂÙÚÔ ÌÈÎÚÔÏ·ÎÒÓ ELISA (Hitachi ELISA reader). ∆· ·ÔÙÂϤÛÌ·Ù· ÚԤ΢„·Ó ‰È·ÈÚÒÓÙ·˜ ÙËÓ ÙÈÌ‹ Ù˘ ÔÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ Ì ÙËÓ ÙÈÌ‹ Ù˘ ÔÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ Ô˘ ¤¯ÂÈ ÔÚÈÛı› ˆ˜ Ô˘‰fi˜ (cut-off) Î·È ÔÏÏ·Ï·ÛÈ¿˙ÔÓÙ·˜ ÙÔ ËÏ›ÎÔ Ì ÙÔ 10. ∆· ·ÔÙÂϤÛÌ·Ù· ·ÍÈÔÏÔÁ‹ıËÎ·Ó ˆ˜ ÂÍ‹˜: 0,0-9,0: ·ÚÓËÙÈο, 9-11: ·ÌÊ›‚ÔÏ·, >11: ıÂÙÈο. ∆· ıÂÙÈο ‰Â›ÁÌ·Ù· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·Ó ÂÚ·ÈÙ¤Úˆ ·ÛıÂÓÒ˜ (+), ÌÂÙÚ›ˆ˜ (++) Î·È ÈÛ¯˘ÚÒ˜ (+++) ıÂÙÈο,
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¶·È‰È·ÙÚÈ΋ 2001;64:136-144
¯ÚËÛÈÌÔÔÈÒÓÙ·˜ Ô˘‰Ô‡˜ Ô˘ ·ÓÙÈÛÙÔÈ¯Ô‡Û·Ó Î·Ù¿ ÚÔÛ¤ÁÁÈÛË Û ·ÎÚ·›· ÂηÙÔÛÙÈ·›· ÙÚÈÙËÌfiÚÈ·. To Û‡ÛÙËÌ· IMX CMV IgG Ù˘ Abott, ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· ÙÔÓ ËÌÈÔÛÔÙÈÎfi ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ΢ÙÙ·ÚÔÌÂÁ·ÏÔ˚Ô‡ ÛÙÔÓ ÔÚfi ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ. ™‡Ìʈӷ Ì ÙË ªÈÎÚÔۈ̷Ùȉȷ΋ ∞ÓÔÛÔÂÓ˙˘ÌÈ΋ ª¤ıÔ‰Ô (ª∂π∞), Ô ÔÚfi˜ ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ Âˆ¿˙ÂÙ·È Ì ٷ ÚÔÛÚÔÊË̤ӷ ÌÈÎÚÔۈ̷ٛ‰È· ÛÙÂÚ¿˜ Ê¿Û˘ ÙÔ˘ CMV. ∆Ô Ì›ÁÌ· ÌÂٷʤÚÂÙ·È Û ̛· Á˘¿ÏÈÓË Ì‹ÙÚ·, Ë ÔÔ›· ‰ÂÛ̇ÂÈ Ù· ÌÈÎÚÔۈ̷ٛ‰È·, ÂÈÙÚ¤ÔÓÙ·˜ ÙËÓ ·Ó·ÚÚfiÊËÛË Î·È ¤ÎÏ˘ÛË ÙÔ˘ ÌË-ÚÔÛËψı¤ÓÙÔ˜ ˘ÏÈÎÔ‡ ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ. °È· ÙËÓ ·Ó›¯Ó¢ÛË Ù˘ Û‡˙¢Í˘ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È CMV ·ÓÙÈÁfiÓÔ˘ Û ÛÙÂÚ¿ Ê¿ÛË, ¯ÚËÛÈÌÔÔÈ‹ıËΠۇ˙¢ÁÌ· ÙÔ ÔÔ›Ô ·ÔÙÂÏÂ›Ù·È ·fi ·ÓÙÈÛÒÌ·Ù· ·ÈÁfi˜ ¤Ó·ÓÙÈ ·ÓıÚÒÈÓ˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ G, ÎÂηı·Ṳ́ӷ Ì ¯ÚˆÌ·ÙÔÁÚ·Ê›· ˘„ËÏ‹˜ Û˘ÁÁ¤ÓÂÈ·˜ Î·È È¯ÓËıÂÙË̤ӷ Ì ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË Î·È ÌÂı˘ÏÔ˘Ì‚ÂÏÈÊÂÚÔÓÈÎfi ʈÛÊÔÚÈÎfi Ô͇. √ Ú˘ıÌfi˜ ÊıÔÚÈÛÌÔ‡ Ô˘ ·Ó·Ù‡ÛÛÂÙ·È ·fi ÙÔ ·ÔʈÛÊÔÚ˘ÏȈ̤ÓÔ ÌÂı˘ÏÔ˘Ì‚ÂÏÈÊÂÚÔÓÈÎfi Ô͇ ÌÂÙÚ‹ıËΠÛÙÔ ÊıÔÚÈÛÈfiÌÂÙÚÔ ÂÓÙfi˜ ÙÔ˘ ·Ó·Ï˘Ù‹ IMX. ∆· ·ÔÙÂϤÛÌ·Ù· ÚԤ΢„·Ó ‰È·ÈÚÒÓÙ·˜ ÙËÓ ÙÈÌ‹ ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ Ì ÙËÓ ÙÈÌ‹ ÙÔ˘ ÚÔÙ‡Ô˘ ÔÚÔ‡ ÂϤÁ¯Ô˘ (calibrator) οı ÂÍÂÙ·ÛÙÈ΋˜ ÛÂÈÚ¿˜. ∏ ·ÚÔ˘Û›· Û˘ÁΤÓÙÚˆÛ˘ 15 AU/ml Î·È ¿Óˆ ÛÙÔÓ ÔÚfi ‰Â›ÁÌ·ÙÔ˜ Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ·Ï·È¿˜ ¤ÎıÂÛ˘ ÛÙÔÓ CMV. ∆· ıÂÙÈο ‰Â›ÁÌ·Ù· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·Ó ÂÚ·ÈÙ¤Úˆ ·ÛıÂÓÒ˜ (+), ÌÂÙÚ›ˆ˜ (++) Î·È ÈÛ¯˘ÚÒ˜ (+++) ıÂÙÈο., ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ Ô˘‰Ô‡˜ Ô˘ ·ÓÙÈÛÙÔÈ¯Ô‡Û·Ó Î·Ù¿ ÚÔÛ¤ÁÁÈÛË Û ·ÎÚ·›· ÙÚÈÙËÌfiÚÈ·. °È· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ Ù›ÙÏÔ˘ ÙˆÓ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ Î·„ȉÈÎÒÓ ·ÓÙÈÁfiÓˆÓ (VCA) ÙÔ˘ ÈÔ‡ EpsteinBarr, ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· οı ‰Â›ÁÌ· Ë Ì¤ıÔ‰Ô˜ ÙÔ˘ ¤ÌÌÂÛÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ (IFA VCA IgG) ÙÔ˘ Ô›ÎÔ˘ Gull, Û‡Ìʈӷ Ì ÙȘ ¤ÓıÂÙ˜ Ô‰ËÁ›Â˜ ÙÔ˘ ηٷÛ΢·ÛÙ‹. ø˜ ˘fiÛÙڈ̷ VCA ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë Î˘ÙÙ·ÚÈ΋ ÛÂÈÚ¿ HR1 ·fi ÏÂÌÊÔ·ÙÙ·Ú· ·ÛıÂÓÒÓ Ì ϤÌʈ̷ Burkitt. √È ÔÚÔ› ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ ·Ú·ÈÒıËÎ·Ó 1:20 Î·È ÚÔÛÙ¤ıËÎ·Ó ÛÙ· ÊÚ¿ÙÈ·, fiÔ˘ ÛÙÔÓ ˘ı̤ӷ ÙÔ˘˜ ‚Ú›ÛÎÂÙ·È Î·ıËψ̤ÓÔ ÙÔ VCA ·ÓÙÈÁfiÓÔ. ªÂÙ¿ ÙËÓ ¤ÎÏ˘ÛË ÚÔÛÙ¤ıËΠÛÙ· ÊÚ¿ÙÈ· Ë ÛËÌ·Ṳ̂ÓË Ì ÊıÔÚÈÛ½ÓË ·ÓÙÈ·ÓıÚÒÂÈÔ˜ ·ÓÙÈ-IgG ÛÊ·ÈÚ›ÓË, Ë ÔÔ›· ÂÓÒÓÂÙ·È Ì ÙÔ Û‡ÌÏÂÁÌ· ·ÓÙÈÁfiÓÔ˘-·ÓÙÈÛÒÌ·ÙÔ˜. °È· ÙËÓ ·Ó¿ÁÓˆÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Û ÌÂÁ¤ı˘ÓÛË 200Ã, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ¤Ó· ÌÈÎÚÔÛÎfiÈÔ ÊıÔÚÈÛÌÔ‡ Zeiss Ì FITC ‰ÈÂÁÂÚÙÈÎfi ËıÌfi ÌÏ ʈÙfi˜ Î·È ¤Ó·˜ ËıÌfi˜ÊÚ·ÁÌfi˜ 515 nm. ∂› ıÂÙÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ·ÓÙ›‰Ú·Û˘ ¤Ó·˜ ÎÈÙÚÈÓÔÚ¿ÛÈÓÔ˜ ÊıÔÚÈÛÌfi˜ Û ÎfiÎÎÈÓÔ ˘¤‰·ÊÔ˜. ∏ ıÂÙÈ΋ ·ÓÙ›‰Ú·ÛË Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ·Ï·È¿˜ ¤ÎıÂÛ˘ ÛÙÔÓ Èfi EBV. °È· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ Ù›ÙÏÔ˘ ÙˆÓ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡ HHV-6, ¯ÚËÛÈÌÔÔÈ‹ıËΠÁÈ· οı ‰Â›ÁÌ· Ë Ì¤ıÔ‰Ô˜ ÙÔ˘ ¤ÌÌÂÛÔ˘ ·ÓÔÛÔÊıÔÚÈÛÌÔ‡ ÙÔ˘ °ÂÚÌ·ÓÈÎÔ‡ Ô›ÎÔ˘ BIOS Gmbh, Û‡Ìʈӷ Ì ÙȘ ¤ÓıÂÙ˜ Ô‰ËÁ›Â˜ ÙÔ˘ ηٷÛ΢·ÛÙ‹. √È ÔÚÔ› ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ ·Ú·ÈÒıËÎ·Ó 1:20, ÚÔÛÙ¤ıËÎ·Ó Î·È Âˆ¿ÛÙËÎ·Ó ÛÙ· ÊÚ¿ÙÈ· ÙˆÓ Ï·Îȉ›ˆÓ, fiÔ˘ ÛÙÔÓ ˘ı̤ӷ ÙÔ˘˜ ‚Ú›ÛÎÂÙ·È Î·ıËψ̤ÓÔ Î·ÏÏȤÚÁËÌ· ΢ÙÙ¿ÚˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ ·fi HHV-6. ªÂÙ¿ ÙËÓ ¤ÎÏ˘ÛË ÚÔÛÙ¤ıËΠÛÙ· ÊÚ¿ÙÈ· Ë ÛËÌ·Ṳ̂ÓË Ì ÊıÔÚÈÛ½ÓË ·ÓÙÈ·ÓıÚÒÂÈÔ˜ ·ÓÙÈ-IgG ÛÊ·ÈÚ›ÓË, Ë ÔÔ›· ÂÓÒÓÂÙ·È Ì ÙÔ Û‡ÌÏÂÁÌ· ·ÓÙÈÁfiÓÔ˘-·ÓÙÈÛÒÌ·ÙÔ˜. °È· ÙËÓ ·Ó¿ÁÓˆ-
Paediatriki 2001;64:136-144
ÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ Û ÌÂÁ¤ı˘ÓÛË 200Ã, ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ¤Ó· ÌÈÎÚÔÛÎfiÈÔ ÊıÔÚÈÛÌÔ‡ Zeiss Ì FITC ‰ÈÂÁÂÚÙÈÎfi ËıÌfi ÌÏ ʈÙfi˜ Î·È ¤Ó·˜ ËıÌfi˜-ÊÚ·ÁÌfi˜ 515 nm. ∂› ıÂÙÈÎÒÓ ‰ÂÈÁÌ¿ÙˆÓ ·Ú·ÙËÚÂ›Ù·È ÛÙËÓ ÂÚÈÔ¯‹ Ù˘ ·ÓÙ›‰Ú·Û˘ ¤Ó·˜ ÎÈÙÚÈÓÔÚ¿ÛÈÓÔ˜ ÊıÔÚÈÛÌfi˜. ∏ ıÂÙÈ΋ ·ÓÙ›‰Ú·ÛË Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ·Ï·È¿˜ ¤ÎıÂÛ˘ ÛÙÔÓ Èfi HHV-6. °È· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ÂȉÈÎÒÓ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ·Ú‚Ô˚Ô‡ µ-19 ÛÙÔ˘˜ ÔÚÔ‡˜ ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ, ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ÛÂÈÚ¿ ÙˆÓ ·ÓÙȉڷÛÙËÚ›ˆÓ ELISA ÙÔ˘ Ô›ÎÔ˘ Biotrin Parvovirus B 19 IgG (3˘ ÁÂÓÈ¿˜ ∞ÓÔÛÔÂÓ˙˘ÌÈ΋ ª¤ıÔ‰Ô˜), Û‡Ìʈӷ Ì ÙȘ ¤ÓıÂÙ˜ Ô‰ËÁ›Â˜ ÙÔ˘ ηٷÛ΢·ÛÙ‹. ∆· ÂȉÈο IgG ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔ˘ ·Ú‚Ô˚Ô‡ µ 19 ÛÙÔÓ ÔÚfi ·ÓÙȉÚÔ‡Ó Ì ÙËÓ ÎÂηı·Ṳ́ÓË Î·È ·Ó·Û˘Ó‰˘·Ṳ̂ÓË VP 2 ÚˆÙ½ÓË ÙÔ˘ ·Ú‚Ô˚Ô‡, Ë ÔÔ›· ‚Ú›ÛÎÂÙ·È Î·ıËψ̤ÓË ÛÙÔÓ ˘ı̤ӷ ÙˆÓ ÊÚ·ٛˆÓ. ªÂÙ¿ ·fi ÂÒ·ÛË Î·È ¤ÎÏ˘ÛË ÙˆÓ ÊÚ·ٛˆÓ, ÚÔÛÙ¤ıËΠÙÔ ÂÓ˙˘ÌÈÎfi Û‡˙¢ÁÌ·, ÙÔ ÔÔ›Ô ·ÔÙÂÏÂ›Ù·È ·fi ȯÓËıÂÙË̤ӷ Ì ˘ÂÚÔÍÂȉ¿ÛË ·ÓÙÈÛÒÌ·Ù· ÎÔÓ›ÎÏÔ˘ ¤Ó·ÓÙÈ ·ÓıÚÒÈÓ˘ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘ G. ∆Ô fiÏÔ Û‡ÌÏÂÁÌ· ·ÓȯÓ‡ÂÙ·È Ì ÙËÓ ÚÔÛı‹ÎË ∆ªµ Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÌÏ ¯ÚÒÌ·ÙÔ˜ ·ÚÔ˘Û›· ˘ÂÚÔÍÂȉ¿Û˘. ªÂ ÙËÓ ÚÔÛı‹ÎË 1¡ ıÂ˚ÎÔ‡ ÔͤԘ, ·Ú¿ÁÂÙ·È ÙÔ ÙÂÏÈÎfi ÚÔ˚fiÓ Ù˘ ·ÓÙ›‰Ú·Û˘ ¯ÚÒÌ·ÙÔ˜ ΛÙÚÈÓÔ˘. √È ÙÈ̤˜ ÔÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÌÂÙÚ‹ıËÎ·Ó Û ̋ÎË Î‡Ì·ÙÔ˜ 450 nm, Ì ̋ÎÔ˜ ·Ó·ÊÔÚ¿˜ Ù· 620 nm, Û ʷÛÌ·ÙÔʈÙfiÌÂÙÚÔ ÌÈÎÚÔÏ·ÎÒÓ ELISA (Hitachi ELISA reader). ∏ ÙÈÌ‹ Ù˘ Ô˘‰Ô‡ (cut-off, COV) ÌÂÙÚ‹ıËΠۇÌʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ ηٷÛ΢·ÛÙ‹. √È Ï·Ì‚·ÓfiÌÂÓ˜ ÙÈ̤˜ ·ÍÈÔÏÔÁ‹ıËÎ·Ó ˆ˜ ÂÍ‹˜: ·ÔÚÚfiÊËÛË <0,9 COV: ·ÚÓËÙÈÎfi ‰Â›ÁÌ·, ·ÔÚÚfiÊËÛË >1,1 COV ıÂÙÈÎfi ‰Â›ÁÌ·. ¢Â›ÁÌ·Ù· Ô˘ ‰ÂÓ ‹Ù·Ó ıÂÙÈο ‹ ·ÚÓËÙÈο ¯·Ú·ÎÙËÚ›ÛÙËÎ·Ó ˆ˜ ·ÌÊ›‚ÔÏ·. ∆· ıÂÙÈο ‰Â›ÁÌ·Ù· ¯·Ú·ÎÙËÚ›˙ÔÓÙ·Ó ÂÚ·ÈÙ¤Úˆ ·ÛıÂÓÒ˜ (+), ÌÂÙÚ›ˆ˜ (++) Î·È ÈÛ¯˘ÚÒ˜ (+++) ıÂÙÈο, ¯ÚËÛÈÌÔÔÈÒÓÙ·˜ ÛËÌ›· Ô˘‰ÒÓ (cut-off) ÈÛÔ‰‡Ó·Ì· Ì ÙË ‰È¿ÌÂÛÔ. °È· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ÂȉÈÎÒÓ ÔÏÈÎÒÓ IgG ·ÓÙÈÛˆÌ¿ÙˆÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ‰ÔÎÈÌ·Û›· ·Ó¿ÛÙÚÔÊ˘ ELISA ÙÔ˘ Ô›ÎÔ˘ Mp-Savyon Diagnostics SeroELISA, Û‡Ìʈӷ Ì ÙȘ ¤ÓıÂÙ˜ Ô‰ËÁ›Â˜ ÙÔ˘ ηٷÛ΢·ÛÙ‹. ∂Ó Û˘ÓÙÔÌ›·, ÔÈ ÔÚÔ› ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ Î·È ÔÈ ÔÚÔ› ÂϤÁ¯Ô˘ ˆ¿ÛÙËÎ·Ó Ù·˘Ùfi¯ÚÔÓ· Ì ·ÓÙÈÁfiÓ· ª. Ó¢ÌÔÓ›·˜ Ô˘ Â›Ó·È Û˘˙¢Á̤ӷ Ì ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË Î·È Ì ÂȉÈ΋ ·ÓıÚÒÈÓË ·ÓÔÛÔÛÊ·ÈÚ›ÓË Î·ıËψ̤ÓË ÛÙÔÓ ˘ı̤ӷ ÙˆÓ ÊÚ·ٛˆÓ Ù˘ ÌÈÎÚÔϿη˜. ªÂ ‰È·‰Ô¯ÈΤ˜ ÂÎχÛÂȘ ·Ó·ÚÚÔÊ‹ıËΠÙÔ ÌË-ÚÔÛËψı¤Ó ˘ÏÈÎfi ηıÒ˜ Î·È Ù· ÌË-‰ÂÛÌÂ˘Ì¤Ó· Û˘ÛÙ·ÙÈο ÙÔ˘ ÔÚÔ‡. ™ÙË Û˘Ó¤¯ÂÈ· ÚÔÛÙ¤ıËΠÙÔ ÂÓ˙˘ÌÈÎfi ˘fiÛÙڈ̷ (·Ú·-ÓÈÙÚÔÊ·ÈÓ˘ÏÈÎfi ʈÛÊÔÚÈÎfi Ô͇). √È ÙÈ̤˜ ÔÙÈ΋˜ ˘ÎÓfiÙËÙ·˜ ÌÂÙÚ‹ıËÎ·Ó ÛÙ· 405 nm (Hitachi ELISA reader). √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ÂȤ‰ˆÓ ÙˆÓ ÂȉÈÎÒÓ ÔÏÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔ˘ ª. Ó¢ÌÔÓ›·˜ ÛÙÔÓ ÔÚfi ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ ˘ÔÏÔÁ›ÛÙËΠ̠‚¿ÛË ÁÓˆÛÙÔ‡˜ ÚfiÙ˘Ô˘˜ ÔÚÔ‡˜ (calibrators). ∏ ıÂÙÈ΋ ·ÓÙ›‰Ú·ÛË Â›Ó·È ÂÓ‰ÂÈÎÙÈ΋ ·Ï·È¿˜ ¤ÎıÂÛ˘ ÛÙÔ ª. Ó¢ÌÔÓ›·˜. 2. ™Ù·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË: ∞Ú¯Èο, ¤ÁÈÓ ηٿٷÍË ÙˆÓ ÛÙÔȯ›ˆÓ Î·È ·ÍÈÔÏfiÁËÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ Ì¤Ûˆ ‰È·ÍÔÓÈÎÒÓ ÈÓ¿ÎˆÓ (two by two table). ∞ÎÔÏÔ‡ıˆ˜, Ë ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË Ú·ÁÌ·ÙÔÔÈ‹ıËΠ̠ÙË ¯Ú‹ÛË ÔÏÏ·Ï‹˜ ÏÔÁ·ÚÈıÌÈÛÙÈ΋˜ ÂÍ¿ÚÙËÛ˘ (multiple logistic regression), Ì ·ÌÔÈ‚·›Ô ¤ÏÂÁ¯Ô, ÙfiÛÔ ÁÈ· ÌË-ÔÚÔÏÔÁÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘,
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Paediatriki 2001;64:136-144
fiÛÔ Î·È ÁÈ· ÙȘ ÔÚÔÏÔÁÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ÌÂÏÂÙ‹ıËηÓ. ŸÙ·Ó Ë ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË Û˘ÌÂÚȤϷ‚ fiÏ· Ù· ‰Â‰Ô̤ӷ, ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë ‰ÂÛÌÂ˘Ì¤ÓË ÏÔÁ·ÚÈıÌÈÛÙÈ΋ ÂÍ¿ÚÙËÛË (conditional logistic regression) ˆ˜ ̤ıÔ‰Ô˜ ÂÎÏÔÁ‹˜. ªÂ ‰È·¯ˆÚÈÛÌfi ÙˆÓ ·È‰ÈÒÓ Û ‰‡Ô ÔÌ¿‰Â˜ (οو ÙˆÓ 5 Î·È ¿Óˆ ÙˆÓ 5 ÂÙÒÓ), Ë ‰ÂÛÌÂ˘Ì¤ÓË ÏÔÁ·ÚÈıÌÈÛÙÈ΋ ÂÍ¿ÚÙËÛË ÂÈÙÚ¤ÂÈ ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÛÙÔȯ›ˆÓ ÁÈ· fiÏÔ˘˜ fiÛÔ˘˜ Û˘ÌÌÂÙ›¯·Ó ÛÙË ÌÂϤÙË ¯ˆÚ›˜ ·ÒÏÂÈ· Ù˘ ÂÁ΢ÚfiÙËÙ·˜, Ì ÙËÓ ÚÔ¸fiıÂÛË fiÙÈ ı· ÏËÊıÔ‡Ó ˘fi„Ë ÔÈ ·Ú¿ÁÔÓÙ˜ ÂÍÔÌÔ›ˆÛ˘ (matching factors).
∞ÔÙÂϤÛÌ·Ù· √ ›Ó·Î·˜ 1 ·ÚÔ˘ÛÈ¿˙ÂÈ ÙËÓ Î·Ù·ÓÔÌ‹ ÙˆÓ ÎÔÈÓˆÓÈÎÒÓ Î·È ‰ËÌÔÁÚ·ÊÈÎÒÓ ·Ú·ÁfiÓÙˆÓ, fiˆ˜ ʇÏÔ Î·È ËÏÈΛ·, ÔÈÎÔÁÂÓÂȷ΋ ηٿÛÙ·ÛË Î·È ÌÔÚ-
ʈÙÈÎfi Â›Â‰Ô Ù˘ ÌËÙ¤Ú·˜ ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Î·È ÙˆÓ ÂÍÔÌÔÈˆÌ¤ÓˆÓ Ì·ÚÙ‡ÚˆÓ. ™˘ÌÂÚÈÂÏ‹ÊıËÛ·Ó, ›Û˘, Ù¤ÛÛÂÚȘ ¿ÏϘ ÌÂÙ·‚ÏËÙ¤˜ Ô˘ ·ÚÔ˘Û›·˙·Ó ÛÙȘ ÌÔÓÔ·Ú·ÁÔÓÙÈΤ˜ ·Ó·Ï‡ÛÂȘ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË Ì ÙË ÓfiÛÔ. ∆Ô ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ Î·È Ë ÛÂÈÚ¿ Á¤ÓÓËÛ˘, ÔÈ ÁÓˆÛÙÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·È‰È΋ Ï¢¯·ÈÌ›·, ηıÒ˜ ›Û˘ Î·È ÙÔ È‰ÈfiÎÙËÙÔ Û›ÙÈ ˆ˜ ‰Â›ÎÙ˘ ÂÎÙ›ÌËÛ˘ Ù˘ ÎÔÈÓˆÓÈÎÔ-ÔÈÎÔÓÔÌÈ΋˜ Ù¿Í˘ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ Î·È Ë ·Ó·ÈÌ›· Ù˘ ÌËÙ¤Ú·˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘, ‚Ú¤ıËÎ·Ó ÛËÌ·ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·È‰È΋ Ï¢¯·ÈÌ›·. ª·˙› Ì ÙÔ˘˜ ·Ú¿ÁÔÓÙ˜ ÂÍÔÌÔ›ˆÛ˘, ÔÈ ÌÂÙ·‚ÏËÙ¤˜ ·˘Ù¤˜ ·ÔÙ¤ÏÂÛ·Ó ÙÔ ÎÂÓÙÚÈÎfi ÌÔÓÙ¤ÏÔ
¶›Ó·Î·˜ 1. ∫ÔÈÓˆÓÈΤ˜ Î·È ‰ËÌÔÁÚ·ÊÈΤ˜ ÌÂÙ·‚ÏËÙ¤˜ Î·È Â˘Ú¤ˆ˜ ·Ô‰ÂÎÙÔ› ·Ú·ÁfiÓÙ˜ ÎÈÓ‰‡ÓÔ˘ Û 94 Ӥ˜ ÂÚÈÙÒÛÂȘ ALL Î·È Û 94 ÂÍÔÌÔȈ̤ÓÔ˘˜ ˆ˜ ÚÔ˜ ÙÔ Ê‡ÏÔ Î·È ÙËÓ ËÏÈΛ· Ì¿ÚÙ˘Ú˜ ªÂÙ·‚ÏËÙ‹ º‡ÏÔ ÕÚÚÂÓ £‹Ï˘ ∏ÏÈΛ· (¤ÙË) ≤4 ¤ÙË 5+ √ÈÎÔÁÂÓÂȷ΋ ηٿÛÙ·ÛË ¤ÁÁ·ÌË ‰È¿ÊÔÚ· ªÔÚʈÙÈÎfi Â›Â‰Ô ≤6 ¤ÙË 7-9 10-12 ≥13 π‰ÈÔÎÙËÛ›· ÛÈÙÈÔ‡ ¡·È Ÿ¯È ™ÂÈÚ¿ Á¤ÓÓËÛ˘ ¶ÚÒÙË ÕÏÏË ∞Ó·ÈÌ›· ·ËÛ˘ Ÿ¯È ¡·È µ¿ÚÔ˜ Á¤ÓÓËÛ˘ (g) <2750 2750-2999 3000-3249 3250-3499 3500-3749 ≥3750
140
∞ÛıÂÓ›˜ N (%)
ª¿ÚÙ˘Ú˜ N (%)
56 38
59,6 40,4
56 38
59,6 40,4
52 42
55,3 44,7
48 46
51,1 48,9
88 6
93,6 6,4
88 6
93,6 6,4
27 16 32 19
28,7 17,0 34,1 20,2
23 20 30 21
24,5 21,3 31,9 22,3
74 20
78,7 21,3
59 35
62,7 37,2
55 39
58,5 41,5
41 53
43,6 56,4
73 21
77,7 22,3
83 11
88,3 11,7
6 10 17 19 20 22
6,4 10,6 18,1 20,2 21,3 23,4
18 8 18 17 17 16
19,1 8,5 19,1 18,1 18,1 17,1
∆ÈÌ‹ p ·fi ‰ÔÎÈÌ·Û›· ¯2 ªÔÓÔ·Ú·ÁÔÓÙÈ΋ ·Ó¿Ï˘ÛË ∂ÍÔÌÔȈ̤ÓË ÌÂÙ·‚ÏËÙ‹
∂ÍÔÌÔȈ̤ÓË ÌÂÙ·‚ÏËÙ‹
1,00
0,69
0,02
0,04
0,05
0,03
2001 MAPT- A¶PI§
17-10-01 15:34
™ÂÏ›‰· 141
¶·È‰È·ÙÚÈ΋ 2001;64:136-144
Paediatriki 2001;64:136-144
ÙˆÓ ·Ó·Ï‡ÛˆÓ. ∆Ô ÎÂÓÙÚÈÎfi ÌÔÓÙ¤ÏÔ, ÙÔ ÔÔ›Ô ÚÔ·ÙÂÈ ·fi ÙË ‰ÂÛÌÂ˘Ì¤ÓË Î·È ÙË ÌË ‰ÂÛÌÂ˘Ì¤ÓË ÏÔÁ·ÚÈıÌÈÛÙÈ΋ ÂÍ¿ÚÙËÛË, ·ÚÔ˘ÛÈ¿˙ÂÙ·È ÛÙÔÓ ›Ó·Î· 2. ∆· ·ÔÙÂϤÛÌ·Ù· ·fi ÙȘ ‰‡Ô ÌÂıfi‰Ô˘˜ ·Ó¿Ï˘Û˘ Â›Ó·È Û˘ÁÎÚ›ÛÈÌ· ·ÔÙÂϤÛÌ·Ù·. √ ›Ó·Î·˜ 3 ·ÂÈÎÔÓ›˙ÂÈ Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÔÚÔÏÔÁÈÎÒÓ ÂÍÂÙ¿ÛÂˆÓ Û ·ÛıÂÓ›˜ Î·È Ì¿ÚÙ˘Ú˜. ¶·Ú·ÙËÚÂ›Ù·È ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Ì ÓfiÛËÛË ·fi ÈÔ‡˜ Ù˘ ·Ú·Áڛ˘ Î·È ·ÓÙ›ÛÙÚÔʘ (ÂÓ‰ÂÈÎÙÈΤ˜ ·ÏÏ¿ ÛÙ·ÙÈÛÙÈÎÒ˜ ÌË ÛËÌ·ÓÙÈΤ˜) Û˘Û¯ÂÙ›ÛÂȘ Ì ÙÔÓ Èfi Epstein-Barr Î·È ÙÔ Ì˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜. ™ÙÔÓ ›Ó·Î· 4 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ÂÎÙÈÌÒÌÂÓ· ÌÂÙ¿ ·fi ¤ÏÂÁ¯Ô ÁÈ· ÂӉ¯fiÌÂÓÔ˘˜ Û˘Á¯˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ - Ëϛη ‰È·ÁÒÓÈˆÓ ·Ó·ÏÔÁÈÒÓ (Û¯ÂÙÈÎÔ› ΛӉ˘ÓÔÈ) ÁÈ· ·È‰È΋ Ï¢¯·ÈÌ›· ÛÂ Û˘Ó¿ÚÙËÛË Ì ÙÔ ‚·ıÌfi ÔÚÔıÂÙÈÎfiÙËÙ·˜ ÛÙÔ˘˜ ‰¤Î· ÏÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜ Ô˘ ÂÍÂÙ¿ÛÙËηÓ. ™ÙË Û˘Ó¤¯ÂÈ·, ÂÎÙÈÌ‹ıËÎ·Ó ÔÈ Û¯ÂÙÈÎÔ› ΛӉ˘ÓÔÈ Ï¢¯·ÈÌ›·˜ Û ‰‡Ô ÔÌ¿‰Â˜ ËÏÈÎÈÒÓ, οو ÙˆÓ 5 Î·È ¿Óˆ ÙˆÓ 5 ÂÙÒÓ. ∆· Â˘Ú‹Ì·Ù· ÁÈ· ÙË Û¯¤ÛË Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Ì ÙËÓ ÔÚÔÏÔÁÈ΋ οÙÔ„Ë (profile) ÙˆÓ ·È‰ÈÒÓ Û οı ¤Ó·Ó ·fi ÙÔ˘˜ ÌÂÏÂÙÒÌÂÓÔ˘˜ ÏÔÈÌÒ‰ÂȘ ·Ú¿ÁÔÓÙ˜ Â›Ó·È ÂÓ‰ÂÈÎÙÈο, fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ. ™Â ·ÓÙ›ıÂÛË Ì ٷ ·Ú·¿Óˆ, ÛÙ· ·È‰È¿ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 5 ÂÙÒÓ ·Ó·‰ÂÈÎÓ‡ÂÙ·È Ì›· ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋ ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Ì ÙÔ˘˜ ÈÔ‡˜ Ù˘ ·Ú·Áڛ˘ (p = 0,01), ηıÒ˜ Î·È Ì›· ÛÂÈÚ¿ ÛËÌ·ÓÙÈÎÒÓ ‹ ÂÓ‰ÂÈÎÙÈÎÒÓ ·ÚÓËÙÈÎÒÓ Û˘Û¯ÂÙ›ÛÂˆÓ Ù˘ ÓfiÛÔ˘ Ì ÙÔÓ Èfi Epstein-Barr (p = 0,11), ÙÔÓ Èfi HHV-6 (p = 0,05), ÙÔ ª˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜ (p = 0,02) Î·È ÙÔÓ ¶·Ú‚Ô˚fi µ 19 (p = 0,07). ¶Ú¿ÁÌ·ÙÈ, ÔÈ ÙÚÂȘ ·fi ÙȘ ·ÚÓËÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ, ȉȷ›-
ÙÂÚ· ·˘Ù¤˜ Ì ÙÔ˘˜ ÈÔ‡˜ Epstein-Barr, ∞ÓıÚÒÈÓÔ ∂ÚËÙÔ˚fi-6 Î·È ÙÔ ª˘ÎfiÏ·ÛÌ· Ù˘ Ó¢ÌÔÓ›·˜, Â›Ó·È ·ÚÎÂÙ¿ ÛËÌ·ÓÙÈΤ˜ ÛÙÔ Û‡ÓÔÏÔ ÙˆÓ ‰Â‰Ô̤ӈÓ, Êı¿ÓÔÓÙ·˜ ¤Ó· ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈÎfi ›‰Ô, ÙÔ˘Ï¿¯ÈÛÙÔÓ Û ¤Ó· ·fi Ù· ‰‡Ô ÂÓ·ÏÏ·ÎÙÈο ÌÔÓ٤Ϸ. ∂ÈϤÔÓ, ÛÙË ÌÂϤÙË ·˘Ù‹ ·ÍÈÔÏÔÁ‹ıËΠÂÚ·ÈÙ¤Úˆ Ë ıÂÙÈ΋ Û˘Û¯¤ÙÈÛË Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Ì ÙÔ˘˜ ÈÔ‡˜ ·Ú·Áڛ˘ Î·È Ù·˘Ùfi¯ÚÔÓ· ·ÓÙ›ÛÙÚÔÊ˘ Û˘Û¯¤ÙÈÛ‹˜ Ù˘ Ì ÙÔ˘˜ ÈÔ‡˜ EBV, HHV-6 Î·È ÙÔ ª˘ÎfiÏ·ÛÌ· Û ·ÙÔÌÈÎfi ›‰Ô. ∞fi ÙȘ 94 ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ Ì ·È‰È΋ Ï¢¯·ÈÌ›·, 16 ‚Ú¤ıËÎ·Ó Ù·˘Ùfi¯ÚÔÓ· ÔÚÔıÂÙÈΤ˜ ˆ˜ ÚÔ˜ ÙÔ˘˜ ÈÔ‡˜ ·Ú·Áڛ˘ Î·È ÔÚÔ·ÚÓËÙÈΤ˜ ˆ˜ ÚÔ˜ ÙÔ˘˜ ˘fiÏÔÈÔ˘˜ ·Ú¿ÁÔÓÙ˜, ÂÓÒ Ô ·ÓÙ›ÛÙÔȯԘ ·ÚÈıÌfi˜ Ì·ÚÙ‡ÚˆÓ ‹Ù·Ó 10 (Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜: 1,7, p = 0,20). ¢ÂÓ ·Ú·ÙËÚ‹ıËÎÂ Û˘Û¯¤ÙÈÛË Û 52 ·ÛıÂÓ›˜ Î·È 48 Ì¿ÚÙ˘Ú˜ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ (Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜: 0,9, p = 0,87). øÛÙfiÛÔ, fiÛÔÓ ·ÊÔÚ¿ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 5 ÂÙÒÓ, Ë Û˘Û¯¤ÙÈÛË Â›Ó·È ÛÙ·ÙÈÛÙÈÎÒ˜ ÛËÌ·ÓÙÈ΋ (Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜: 3,9, p = 0,04). ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ô Î›Ó‰˘ÓÔ˜ Ï¢¯·ÈÌ›·˜ ÛÙ· ·È‰È¿ ¿Óˆ ÙˆÓ 5 ÂÙÒÓ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ fiÙ·Ó Ë ¯·ÌËÏ‹ Û˘ÏÏÔÁÈ΋ ÙÔ˘˜ ·ÓÔÛ›· ÁÈ· ÔÏÏÔ‡˜ ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜ ‰ÔÎÈÌ¿˙ÂÙ·È ·fi οÔÈ· ηı˘ÛÙÂÚË̤ÓË Ïԛ̈ÍË, Ù˘ ÔÔ›·˜ Ô ÏÔÈÌ҉˘ ·Ú¿ÁÔÓÙ·˜ ÚÔÛ‚¿ÏÏÂÈ Û˘Ó‹ıˆ˜ (80%) ·È‰È¿ ÌÈÎÚfiÙÂÚ˘ ËÏÈΛ·˜. ™˘˙‹ÙËÛË ∏ ‰ÈÂÍ·ÁˆÁ‹ ÚÔÔÙÈÎÒÓ ÂÚ¢ÓÒÓ ÁÈ· ÙË ÌÂϤÙË Ù˘ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Ì ٷ˘Ùfi¯ÚÔÓË ·ÈÌÔÏË„›· Â›Ó·È ·ÚÎÂÙ¿ ‰‡ÛÎÔÏÔ ¤ÚÁÔ. ∂Í¿ÏÏÔ˘, Ë ‰ÈÂÓ¤ÚÁÂÈ· ÏËı˘ÛÌȷ΋˜ ¤Ú¢ӷ˜ Ù‡Ô˘ ·ÛıÂÓÒÓÌ·ÚÙ‡ÚˆÓ Ô˘ ÂÚÈÏ·Ì‚¿ÓÂÈ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ‹ ÔÚÔÏÔÁÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜, ·ÚÔ˘ÛÈ¿˙ÂÈ ÙfiÛÔ Ù¯ÓÈ-
¶›Ó·Î·˜ 2. ™¯ÂÙÈÎÔ› ΛӉ˘ÓÔÈ (ORs) Î·È 95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (95% CI) ÁÈ· ·Ó¿Ù˘ÍË ·È‰È΋˜ ALL ÛÂ Û˘Ó¿ÚÙËÛË Ì ÁÂÓÈΤ˜ (ÌË ÔÚÔÏÔÁÈΤ˜) ÌÂÙ·‚ÏËÙ¤˜ (ÎÂÓÙÚÈÎfi ÌÔÓÙ¤ÏÔ): ÔÏÏ·Ï‹ (‰ÂÛÌÂ˘Ì¤ÓË ‹ ÌË ‰ÂÛÌÂ˘Ì¤ÓË) ÏÔÁ·ÚÈıÌÈÛÙÈ΋ ÂÍ¿ÚÙËÛË ªÂÙ·‚ÏËÙ‹
∏ÏÈΛ· º‡ÏÔ ™ÂÈÚ¿ Á¤ÓÓËÛ˘ π‰ÈÔÎÙËÛ›· ÛÈÙÈÔ‡ ∞Ó·ÈÌ›· ·ËÛ˘ µ¿ÚÔ˜ Á¤ÓÓËÛ˘
∫·ÙËÁÔÚ›· ‹ ∞‡ÍËÛË
¢ÂÛÌÂ˘Ì¤ÓË OR 95% CI
1 ¤ÙÔ˜ Î·È ¿Óˆ ÕÚÚÂÓ £‹Ï˘ ¶ÚÒÙË ÕÏÏË ¡·È Ÿ¯È Ÿ¯È ¡·È ∞‡ÍËÛË 250 g
∂ÍÔÌÔȈ̤ÓË ÌÂÙ·‚ÏËÙ‹ ∂ÍÔÌÔȈ̤ÓË ÌÂÙ·‚ÏËÙ‹ 1 0,48 1 0,56 1 2,63 1,33
0,25-0,93 0,28-1,11 1,03-6,77 1,05-1,68
ªË ‰ÂÛÌÂ˘Ì¤ÓË OR 95% CI 0,99 1 1,14 1 0,51 1 0,53 1 2,17 1,21
0,92-1,07 0,61-2,14 0,28-0,95 0,27-1,03 0,94-5,00 1,00-1,46
141
2001 MAPT- A¶PI§
17-10-01 15:34
™ÂÏ›‰· 142
¶·È‰È·ÙÚÈ΋ 2001;64:136-144
Paediatriki 2001;64:136-144
¶›Ó·Î·˜ 3. √ÚÔÏÔÁÈο ·ÔÙÂϤÛÌ·Ù· ÁÈ· 10 ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜ Û ·ÛıÂÓ›˜ Î·È Ì¿ÚÙ˘Ú˜ ¶·Ú¿ÁˆÓ
∞‰ÂÓÔ˚fi˜ ·ÛıÂÓ›˜ Ì¿ÚÙ˘Ú˜ ∫˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜ ·ÛıÂÓ›˜ Ì¿ÚÙ˘Ú˜ Epstein Barr ·ÛıÂÓ›˜ Ì¿ÚÙ˘Ú˜ ∞ÓıÚÒÈÓÔ˜ ∂ÚËÙÔ˚fi˜-6 ·ÛıÂÓ›˜ Ì¿ÚÙ˘Ú˜ πfi˜ °Ú›Ë˜ A ·ÛıÂÓ›˜ Ì¿ÚÙ˘Ú˜ πfi˜ °Ú›Ë˜ B ·ÛıÂÓ›˜ Ì¿ÚÙ˘Ú˜ πÔ› ¶·Ú·Áڛ˘ 1,2,3 ·ÛıÂÓ›˜ Ì¿ÚÙ˘Ú˜ ¶·Ú‚Ô˚fi˜ B19 ·ÛıÂÓ›˜ Ì¿ÚÙ˘Ú˜ ∞Ó·Ó¢ÛÙÈÎfi˜ ™˘Á΢ÙÈ·Îfi˜ πfi˜ ·ÛıÂÓ›˜ Ì¿ÚÙ˘Ú˜ ª˘ÎfiÏ·ÛÌ· ¶Ó¢ÌÔÓ›·˜ ·ÛıÂÓ›˜ Ì¿ÚÙ˘Ú˜
·ÚÓËÙÈο
·ÌÊ›‚ÔÏ·
ıÂÙÈο (Ó·È ÂÓ. fi¯È,+)
ıÂÙÈο (++)
ıÂÙÈο (+++)
N
N
N
N
N
20 25
4 2
27 26
28 25
15 16
+0,63
28 42
3 1
28 14
20 21
15 16
+0,27
41 31
2 0
51 63
-
-
-0,09
58 52
8 7
28 35
-
-
-0,31
30 32
11 7
14 22
23 13
16 20
+ 0,92
43 43
7 6
10 20
17 12
17 13
+ 0,57
9 10
1 1
22 34
24 31
38 18
+ 0,03
68 70
3 1
15 8
8 15
-
-0,74
15 13
1 5
26 25
23 29
29 22
+ 0,66
90 81
1 8
3 5
-
-
-0,07
Τ˜ ‰˘Û¯¤ÚÂȘ fiÛÔ Î·È ËıÈο ‰ÈÏ‹ÌÌ·Ù·. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿ fï˜, ÔÈ ¤Ú¢Ó˜ ·ÛıÂÓÒÓ-Ì·ÚÙ‡ÚˆÓ Ô˘ ‰ÈÂÍ¿ÁÔÓÙ·È Û ÓÔÛÔÎÔÌÂÈ·Îfi ÏËı˘ÛÌfi ·ÔÙ¤ÏÂÛ·Ó Î·Ù¿ ÙÔ ·ÚÂÏıfiÓ ı¤Ì· ¤ÓÙÔÓ˘ ÎÚÈÙÈ΋˜ ÏfiÁˆ Ù˘ ·˘ÍË̤Ó˘ Èı·ÓfiÙËÙ·˜ Ô˘ ›¯·Ó ÁÈ· ÛÊ¿ÏÌ·Ù· ÂÈÏÔÁ‹˜ Î·È ÏËÚÔÊfiÚËÛ˘ (15). ™ÙË ÌÂϤÙË ·˘Ù‹ ‰ÂÓ ¤ÁÈÓ ϋ„Ë ·›Ì·ÙÔ˜ Û ¤Ó· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi ·È‰ÈÒÓ (284 ·fi Ù· 388) ÂÍ·ÈÙ›·˜ ÙÔ˘ ·ÔÎÏÂÈÛÌÔ‡ ÙÔ˘˜ ·fi ÙËÓ ¤Ú¢ӷ ÁÈ· ‰ÈÔÈËÎËÙÈÎÔ‡˜ ‹ Ù¯ÓÈÎÔ‡˜ ÏfiÁÔ˘˜. ∂›Ó·È, fï˜,
142
ÎÏ›ÛË (+ or -) Î·È ∆ÈÌ‹ p
·‰‡Ó·ÙÔ ÔÈ ÏfiÁÔÈ ·˘ÙÔ› Ó· Ô‰‹ÁËÛ·Ó Û ÛÊ¿ÏÌ·Ù· ÂÈÏÔÁ‹˜, ·ÊÔ‡ ·ÚÎÂÙ¿ ·È‰È¿ ·ÔÎÏ›ÛÙËÎ·Ó ÁÈ·Ù› Ë ‰È¿ÁÓˆÛË Î·È Ë ¤Ó·ÚÍË Ù˘ ¯ËÌÂÈÔıÂڷ›·˜ ¤ÁÈÓ ηٿ ÙË ‰È¿ÚÎÂÈ· ·ÚÁÈÒÓ, ÚÈÓ ÙË Ï‹„Ë ·›Ì·ÙÔ˜ ·fi ÙÔ˘˜ Ù¯ÓÈÎÔ‡˜ Û˘ÓÂÚÁ¿Ù˜ Ù˘ ¤Ú¢ӷ˜. ∂›Û˘, Ë ÌÂϤÙË ‰ÂÓ ˘fiÎÂÈÙ·È Û ÛÊ¿ÏÌ·Ù· ÏËÚÔÊfiÚËÛ˘, ‰Â‰Ô̤ÓÔ˘ fiÙÈ Ë ÂÈÏÔÁ‹ ÙˆÓ Ì·ÚÙ‡ÚˆÓ ‹Ù·Ó Ù˘¯·›· ·Ó¿ÌÂÛ· Û ·ÛıÂÓ›˜ Ì ÌË-ÏÔÈÌÒ‰Ë ÓÔÛ‹Ì·Ù· ‹ ηٷÛÙ¿ÛÂȘ. ∞ÚÎÂÙ¿ ·È‰È¿ ̠Ϣ¯·ÈÌ›· ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·˘ÍË̤ÓË ÂÈÚÚ¤ÂÈ· ÛÂ
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¶›Ó·Î·˜ 4. ™¯ÂÙÈÎÔ› ΛӉ˘ÓÔÈ1 (ORs) and 95% fiÚÈ· ·ÍÈÔÈÛÙ›·˜ (95% CI) ÁÈ· ·Ó¿Ù˘ÍË ·È‰È΋˜ ALL Û ۯ¤ÛË Ì ËÓ ÔÚÔıÂÙÈÎfiÙËÙ· Û 10 ÏÔÈÌÔÁfiÓÔ˘˜ ·Ú¿ÁÔÓÙ˜: ÔÏÏ·Ï‹ ÏÔÁ·ÚÈıÌÈÛÙÈ΋ ÂÍ¿ÚÙËÛË (‰ÂÛÌÂ˘Ì¤ÓË Î·È ÌË ÌË ‰ÂÛÌÂ˘Ì¤ÓË) Ì ·ÌÔÈ‚·›· ÚÔÙ‡ˆÛË ¶·Ú¿ÁˆÓ ™‡ÓÔÏÔ ·È‰ÈÒÓ 0-4 ÂÙÒÓ 5+ ÂÙÒÓ ¢ÂÛÌÂ˘Ì¤ÓË ªË ‰ÂÛÌÂ˘Ì¤ÓË ¢ÂÛÌÂ˘Ì¤ÓË ªË ‰ÂÛÌÂ˘Ì¤ÓË πÔ› OR 95% CI OR 95% CI OR 95% CI OR 95% CI ∞‰ÂÓÔ˚fi˜ 1,10 0,73-1,66 1,07 0,82-1,39 1,27 0,86-1,88 1,13 0,67-1,89 Epstein-Barr 0,40* 0,21-0,75 0,65* 0,45-0,93 0,66* 0,40-1,08 0,58* 0,30-1,12 ∂ÚËÙÔ˚fi˜-6 0,50* 0,29-0,87 0,71* 0,49-1,03 0,80 0,47-1,37 0,52* 0,27-1,01 πfi˜ °Ú›Ë˜ A 0,85 0,60-1,22 0,97 0,75-1,26 0,99 0,68-1,44 0,84 0,53-1,34 πfi˜ °Ú›Ë˜ B 0,98 0,69-1,41 1,12 0,89-1,42 1,05 0,76-1,44 1,31 0,84-2,02 πÔ› ¶·Ú·Áڛ˘ 1,2,3 1,85* 1,06-3,22 1,39* 1,01-1,91 1,29 0,87-1,93 3,01* 1,30-6,95 ¶·Ú‚Ô˚fi˜ B19 1,14 0,69-1,90 0,97 0,71-1,35 1,24 0,74-2,10 0,61* 0,35-1,05 ∞Ó·Ó¢ÛÙÈÎfi˜ ™˘Á΢ÙÈ·Îfi˜ πfi˜ 0,99 0,66-1,48 1,02 0.76-1,36 1,02 0,72-1,46 0,87 0,44-1,74 ∫˘ÙÙ·ÚÔÌÂÁ·ÏÔ˚fi˜ 1,14 0,87-1,49 1,03 0,83-1,27 0,91 0,67-1,24 1.00 0,69-1,46 ª˘ÎfiÏ·ÛÌ· 0,37* 0,12-1,20 0,44* 0,20-0,97 0,66 0,21-2,15 0,12* 0,02-0,69 1
Ì ÚÔÙ‡ˆÛË Î·È ÁÈ· ÙȘ ÌÂÙ·‚ÏËÙ¤˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ ÌÔÓÙ¤ÏÔ˘ * fiÙ·Ó p <0,10
ÏÔÈÌÒÍÂȘ ÚÈÓ ÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô Ù˘ ‰È¿ÁÓˆÛ˘ Ù˘ ÓfiÛÔ˘. ∏ ηٿÛÙ·ÛË ·˘Ù‹ ı· ‰ËÌÈÔ˘ÚÁÔ‡Û fï˜ ·‡ÍËÛË ÙˆÓ ıÂÙÈÎÒÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÛÙȘ ÔÚÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ ÙˆÓ ·ÛıÂÓÒÓ, ÁÂÁÔÓfi˜, Ô˘ ¤Ú¯ÂÙ·È Û ·ÓÙ›ıÂÛË Ì ٷ ‰Â‰Ô̤ӷ Ù˘ ÌÂϤÙ˘. ∂ÈϤÔÓ, ÙÔ Ì¤ÁÂıÔ˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È ·ÚÎÂÙ¿ ÌÂÁ¿ÏÔ ÁÈ· ÙȘ ·ÈÌ·ÙÔÏÔÁÈΤ˜ ·Ú·Ì¤ÙÚÔ˘˜ Ô˘ ‰ÈÂÚ¢ÓÒÓÙ·È. ∂ÈÛËÌ·›ÓÂÙ·È, Ù¤ÏÔ˜, fiÙÈ ÛÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰ÔÌ¤ÓˆÓ ¤ÁÈÓ ¤ÏÂÁ¯Ô˜ ÁÈ· ÙÔ˘˜ ÂӉ¯fiÌÂÓÔ˘˜ Û˘Á¯˘ÙÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜. ¢ÂÓ ‚Ú¤ıËΠÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ Û˘Û¯¤ÙÈÛË ÌÂٷ͇ ·È‰È΋˜ Ï¢¯·ÈÌ›·˜ Î·È ÏÔÈ̈‰ÒÓ ·Ú·ÁfiÓÙˆÓ ÛÙ· ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 5 ÂÙÒÓ. ∞ÓÙÈı¤Ùˆ˜, Ù· ‰Â‰Ô̤ӷ ÁÈ· Ù· ·È‰È¿ ¿Óˆ ÙˆÓ 5 ÂÙÒÓ Â›Ó·È Û˘Ì‚·Ù¿ Ì ÙËÓ ÂÈÛÙËÌÔÓÈ΋ ˘fiıÂÛË Ô˘ ‰È·Ù˘ÒıËÎÂ. ŒÙÛÈ, Ë Û˘ÏÏÔÁÈ΋ ·ÓÔÛ›·, fiˆ˜ Ê·›ÓÂÙ·È ·fi ÙÔ ÔÚÔÏÔÁÈÎfi Ê¿ÛÌ· Ô˘ ‰È·ÈÛÙÒıËÎÂ, Â›Ó·È ÁÂÓÈÎÒ˜ ¯·ÌËÏfiÙÂÚË ÛÙ· ·È‰È¿ Ì ALL ·Ú¿ ÛÙ· ·È‰È¿ Ù˘ ÔÌ¿‰·˜ ÂϤÁ¯Ô˘. ∂Í¿ÏÏÔ˘, Ù· ·È‰È¿ Ì ALL ·ÚÔ˘Û›·Û·Ó ÈÛ¯˘Ú‹ ·ÓÔÛÔÏÔÁÈ΋ ·fiÎÚÈÛË Û ¤Ó· Û˘ÁÎÂÎÚÈ̤ÓÔ ÏÔÈÌÔÁfiÓÔ ·Ú¿ÁÔÓÙ·, ·˘ÙfiÓ Ô˘ ÂÈο˙ÂÙ·È fiÙÈ ˘ÚÔ‰fiÙËÛ ÙË Ï¢¯·ÈÌ›·. ∞Í›˙ÂÈ Ó· ÛËÌÂȈı› fiÙÈ Ë ÚÔÙÂÈÓfiÌÂÓË ˘fiıÂÛË ÙÂÎÌËÚÈÒÓÂÙ·È ÙfiÛÔ ÛÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ·È‰ÈÒÓ Î·Ù¿ ÔÌ¿‰Â˜ (¶›Ó·Î·˜ 4) fiÛÔ Î·È ÛÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ÛÙÔȯ›ˆÓ Û ·ÙÔÌÈÎfi Â›Â‰Ô (ÙÂÏÂ˘Ù·›· ·Ú¿ÁÚ·ÊÔ˜ ÛÙ· ·ÔÙÂϤÛÌ·Ù·). ™ÙË ÌÂϤÙË ·˘Ù‹ ‰ÂÓ ÂÈÛËÌ¿ÓıËΠ¤Ó·˜ ‹ ÂÚÈÛÛfiÙÂÚÔÈ ÔÚfiÙ˘ÔÈ ÙˆÓ ÈÒÓ ·Ú·Áڛ˘ ˆ˜ ·ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÛÙËÓ ÚfiÎÏËÛË ·È‰È΋˜ Ï¢¯·ÈÌ›·˜. ∞ÓÙÈı¤Ùˆ˜, ıˆÚÂ›Ù·È fiÙÈ ·˘ÙÔ› ÔÈ ÈÔ› ·ÔÙÂÏÔ‡Ó ¤Ó· ˘ÔÛ‡ÓÔÏÔ ÂÓfi˜ ÌÂÁ¿ÏÔ˘ ·ÚÈıÌÔ‡ ÏÔÈÌÔÁfi-
ÓˆÓ ·Ú·ÁfiÓÙˆÓ, ÔÈ ÔÔ›ÔÈ ÛÂ Û˘Ó¿ÚÙËÛË Ì ÙË Ê‡ÛË Ù˘ ÂȉËÌ›·˜, ÙËÓ ·ÓÙ›ÛÙÔÈ¯Ë Û˘ÏÏÔÁÈ΋ ·ÓÔÛ›· Î·È ÙËÓ Î·Ù¿ÛÙ·ÛË ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ÍÂÓÈÛÙ‹ ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÎÂÓÙÚÈÎfi ÚfiÏÔ ÛÙËÓ Èı·Ó‹ ÚfiÎÏËÛË ·È‰È΋˜ ALL. ¢ÂÓ ˘¿Ú¯Ô˘Ó ·ÍÈfiÈÛÙ· ‰Â‰Ô̤ӷ Û¯ÂÙÈο Ì ÙȘ ÂȉËÌÈÔÏÔÁÈΤ˜ ‰È·ÊÔÚÔÔÈ‹ÛÂȘ ηٿ ÙËÓ ÂÚ›Ô‰Ô ‰ÈÂÍ·ÁˆÁ‹˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ηÈ, ηٿ Û˘Ó¤ÂÈ·, ‰ÂÓ Â›Ó·È ÂÊÈÎÙ‹ Ë ÛÙÔȯÂÈÔı¤ÙËÛË Ù˘ ‡·Ú͢ ÂȉËÌ›·˜ ·fi ÈÔ‡˜ ·Ú·Áڛ˘ ÛÙ· ·È‰È¿ ηٿ ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÂÚ›Ô‰Ô. ∆· Â˘Ú‹Ì·Ù· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ Â›Ó·È ÁÂÓÈÎÒ˜ Û˘Ì‚·Ù¿ Ì ÙȘ ȉ¤Â˜ Ô˘ ·Ó¤Ù˘ÍÂ Ô Kinlen (1,5,8,9) Î·È Û˘Ófi„ÈÛÂ Ô Greaves (11). ŸÌˆ˜ ˘¿Ú¯Ô˘Ó ·ÔÎÏ›ÛÂȘ. ŒÙÛÈ, Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ¤Ú¢ӷ˜ Â›Ó·È ÈÔ ÂÌÊ·Ó‹ ÛÙ· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿, ÂÓÒ Ù· ·ÔÙÂϤÛÌ·Ù· ¿ÏÏˆÓ Û˘ÁÁڷʤˆÓ ÂÈÎÂÓÙÚÒıËÎ·Ó Û ÌÈÎÚfiÙÂÚ˘ ËÏÈΛ·˜ ·È‰È¿. ∂ÓÙÔ‡ÙÔȘ, Ù· ·ÔÙ¤ÏÂÛÌ· Ù˘ ¤Ú¢ӷ˜ ·˘Ù‹˜ Û˘Ì‚·‰›˙Ô˘Ó ÂÚÈÛÛfiÙÂÚÔ Ì ٷ ÎÏ·ÛÈο ·Ú·‰Â›ÁÌ·Ù· Ù˘ ·Ú·Ï˘ÙÈ΋˜ ÔÏÈÔÌ˘ÂÏ›Ùȉ·˜ (16) Î·È ›Ûˆ˜ Ù˘ ÛÎÏ‹Ú˘ÓÛ˘ ηٿ Ͽη˜ (17,18). ∂ÈϤÔÓ, Ë ·ÈÙÈÔÏÔÁ›· Ù˘ ·È‰È΋˜ ALL ÛÙ· ÌÈÎÚfiÙÂÚ· ·È‰È¿ ÌÔÚ› Ó· Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÂÓ‰ÔÌ‹ÙÚÈ· Û˘Ì‚¿Ì·Ù· Î·È Î·Ù·ÛÙ¿ÛÂȘ (9,19-25). ™ÙË ÌÂϤÙË ·˘Ù‹ ·ÍÈÔÏÔÁ‹ıËÎÂ Ë ˘fiıÂÛË fiÙÈ Ë ·È‰È΋ Ï¢¯·ÈÌ›· ·ÔÙÂÏ› ›Ûˆ˜ Ì›· Û¿ÓÈ· ÂΉ‹ÏˆÛË ÌÈ·˜ ηı˘ÛÙÂÚË̤Ó˘ ÌË-ÂȉÈ΋˜ Ïԛ̈͢, Ô˘ Á›ÓÂÙ·È Û ¤Ó· ˘fiÛÙڈ̷ ¯·ÌËÏ‹˜ Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜. ÃÚËÛÈÌÔÔÈ‹ıËΠÌÈ· Ó¤· ÚÔÛ¤ÁÁÈÛË Ô˘ ηχÙÂÈ fiϘ ÙȘ Ï¢ڤ˜ Ù˘ ˘fiıÂÛ˘: ÙËÓ Î·ı˘ÛÙÂÚË̤ÓË ·Ó¿Ù˘ÍË Û˘ÏÏÔÁÈ΋˜ ·ÓÔÛ›·˜
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Î·È ÙÔÓ ÂÎÏ˘ÙÈÎfi ÚfiÏÔ Î¿ÔÈ·˜ Ïԛ̈͢. ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Â›Ó·È Û˘Ì‚·Ù¿ Ì ÙËÓ ÚÔÙ·ı›۷ ˘fiıÂÛË. ∂Âȉ‹ ÌÂÏÂÙ‹ıËÎ·Ó ‰¤Î· ÌfiÓÔ ÏÔÈÌÔÁfiÓÔÈ ·Ú¿ÁÔÓÙ˜, Ù· ‰Â‰Ô̤ӷ ÔÚÈÛÌ¤ÓˆÓ ·È‰ÈÒÓ ‰ÂÓ Â›Ó·È Û˘Ì‚·Ù¿ Ì ÙÔ ÚÔÙÂÈÓfiÌÂÓÔ ÚfiÙ˘Ô, ·ÏÏ¿ ηıÔÏÈ΋ Û˘Ì‚·ÙfiÙËÙ· ‰ÂÓ ·Ó·Ì¤ÓÂÙ·È ÛÙË ‰ÈÂÚ‡ÓËÛË ÔÏ˘·ÈÙÈÔÏÔÁÈÎÒÓ ÓÔÛËÌ¿ÙˆÓ. ∫·Ù¿ Û˘Ó¤ÂÈ·, Ù· Â˘Ú‹Ì·Ù· Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜ ÛÙËÚ›˙Ô˘Ó ÙËÓ ˘fiıÂÛË fiÙÈ Èı·ÓÒ˜ Ë ·ÈÙÈÔÏÔÁ›· Ù˘ ALL ÛÙ· ·È‰È¿ ËÏÈΛ·˜ ¿Óˆ ÙˆÓ 5 ÂÙÒÓ ¤¯ÂÈ Û˘¯Ó¿ ÏÔÈÌÒ‰Ë ·ÈÙÈÔÏÔÁ›·. ∂˘¯·ÚÈÛٛ˜ √È Û˘ÁÁÚ·Ê›˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ı· ‹ıÂÏ·Ó Ó· ¢¯·ÚÈÛÙ‹ÛÔ˘Ó ÙÔÓ Î. ¡›ÎÔ ¢ÂÛ‡ÚË ÁÈ· ÙË Û˘Ì‚ÔÏ‹ ÙÔ˘ ÛÙË ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ÙˆÓ ‰Â‰Ô̤ӈÓ.
BÈ‚ÏÈÔÁÚ·Ê›· 1. ªacMahon B. Is Acute Lymphoblastic Leukemia in Children Virus-Related? Am J Epidemiol 1992;136:916-924. 2. MacMahon B, Newill VA. Birth characteristics of children dying of malignant neoplasms. J Natl Cancer Inst 1962;28:231-244. 3. Stark CR, Mantel N. Effects of maternal age and birth order on the risks of mongolism and leukemia. J Natl Cancer Inst 1966;37:687-698. 4. Petridou E, Kassimos D, Kalmanti M, Kosmidis H, Haidas S, Flytzani V et al. Age of exposure to infections and risk of childhood leukaemia. BMJ 1993;307:774. 5. Kinlen LJ. Epidemiological evidence for an infective basis in childhood leukaemia. Br J Cancer 1995;71:1-5. 6. Kinlen LJ, Petridou E. Childhood leukemia and rural population movements in Greece and other countries. Cancer Causes Control 1995;6:445-450. 7. Kinlen L. Evidence for an infective cause of childhood leukaemia: comparison of a Scottish new town with nuclear reprocessing sites in Britain. Lancet 1988;2: 1323-1327. 8. Greaves MF, Alexander FE. An infectious etiology for common acute lymphoblastic leukemia in childhood? Leukemia 1993;7:349-360. 9. Smith MA, Simon R, Strickler HD, McQuillain G, Ries LA, Linet MS. Evidence that childhood acute lymphoblastic leukemia is associated with an infectious agent linked to hygiene conditions. Cancer Causes Control 1998;9: 285-298. 10. Smith M. Considerations on a possible viral etiology for Bprecursor acute lymphoblastic leukemia of childhood. J Immunother 1997;20:89-100. 11. Greaves MF. Aetiology of acute leukemia. Lancet 1997;349:344-349.
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12. Wilson GS, Miles A. Topley and Wilson's: Principles of Bacteriology, Virology and Immunity. Vol 2. 6th ed. London: A. Edward; 1975. 13. Anderson RM, May RM. Immunisation and herd immunity. Lancet 1990;335:641-645. 14. Breslow NE, Day NE. Statistical methods in cancer research. Vol I. The analysis of case control studies. IARC Scientific Publications 32. Lyon, IARC; 1980. 15. Mac Mahon B, Trichopoulos D. Epidemiology: Principles and Methods. 2nd edition. Boston: Little Brown and Co; 1996. 16. Backett EM. Social patterns of antibody to poliovirus. Lancet 1957;i:778-783. 17. Alvord Jr EC, Jahnke U, Fischer EH, Kies MW, Driscoll BF, Compston AS. The multiple causes of multiple sclerosis: the importance of age of infections in childhood. J Child Neurol 1987;2:313-321. 18. Kurtzke JF, Hyllested K. Multiple sclerosis in the Faroe Islands II. Clinical update, transmission, and the nature of MS. Neurology 1986;36:307-328. 19. Petridou E, Trichopoulos D, Kalapothaki V, Kogevinas M, Kalmanti M, Koliouskas D et al. The risk profile of childhood leukaemia in Greece: a nationwide case-control study. British J Cancer 1997;76:1241-1247. 20. Petridou E, Trichopoulos D, Dessypris N, Flytzani V, Haidas S, Kalmanti M et al. Infant leukaemia after in utero exposure to radiation from Chernobyl. Nature 1996;382:352-353. 21. Pui CH, Kane JR, Crist WM. Biology and treatment of infant leukemias. Leukemia 1995;9:762-769. 22. Ford AM, Ridge SA, Cabrera ME, Mahmoud H, Steel CM, Chan LC et al. In utero rearrangements in the trithoraxrelated oncogene in infant leukemias. Nature 1993;363:358-360. 23. MacMahon B, Levy MA. Prenatal origin of childhood leukemia: evidence from twins. New Engl J Med 1964;270:1082-1085. 24. Stewart AM. Leukemia and other neoplasms in childhood following radiation exposure in utero - a general survey of present knowledge. Br J Radiol 1968;41:718-719. 25. Greaves MF. Workshop report. Infant leukaemia biology, aetiology and treatment. Leukemia 1996;10:372-377.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 04-12-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 14-02-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂ϤÓË ¶ÂÙÚ›‰Ô˘ ∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÈÂÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ªÈÎÚ¿˜ ∞Û›·˜ 75, 115 27, °Ô˘‰›, ∞ı‹Ó· e-mail: epetrid@cc.uoa.gr
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ORIGINAL PAPER
™˘ÁÎÚÈÙÈ΋ ÌÂϤÙË ¯ÔÚ‹ÁËÛ˘ Ê˘ÛÈÎÔ‡ Î·È Û˘ÓıÂÙÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙÔ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ ∂. ÷Ù˙ˉ¿ÎË, ∂. ∫ÔڷοÎË, ª. ÃÚÈÛÙÔ‰Ô˘Ï¿ÎË, ∫.ª. ª·ÚÁ¿ÚË, ¢. ª·ÌÔ˘Ï¿Î˘, ∞. ª·ÓÔ˘Ú¿, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
Comparative trial of natural and synthetic surfactants in the treatment of respiratory distress syndrome of prematurity E. Hatzidaki, E. Korakaki, M. Christodoulaki, K.M. Margari, D. Mamoulakis, A. Manoura, C. Giannakopoulou
¶ÂÚ›ÏË„Ë: ∆Ô Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› ·ÈÙÈÔÏÔÁÈο, ÁÂÓÈο Ì ÙËÓ Ó¢ÌÔÓÈ΋ ·ÓˆÚÈÌfiÙËÙ· ·ÏÏ¿ Î·È ÂȉÈÎfiÙÂÚ· Ì ÙËÓ ·Ó¿ÚÎÂÈ· ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ∏ Â͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ıˆÚÂ›Ù·È Û‹ÌÂÚ· ıÂڷ›· ÂÎÏÔÁ‹˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛ‹ ÙÔ˘. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È Ë Û‡ÁÎÚÈÛË Ù˘ ÎÏÈÓÈ΋˜ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ıÂڷ¢ÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ê˘ÛÈ΋˜ (alvofact) Î·È Û˘ÓıÂÙÈ΋˜ (exosurf) ÚÔ¤Ï¢Û˘ ÛÙËÓ ÔÚ›· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Î·È ÛÙËÓ ¤Î‚·ÛË ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ªÂÏÂÙ‹ıËÎ·Ó 92 ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ۇӉÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙË ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘. ∞fi Ù· ÓÂÔÁÓ¿ Ô˘ Û˘ÌÂÚÈÏ¿‚·Ì ÛÙË ÌÂϤÙË Ì·˜ ÌÂ Ù˘¯·›· ÂÈÏÔÁ‹, Û 42 ¯ÔÚËÁ‹ıËÎÂ Û˘ÓıÂÙÈÎfi˜ Î·È Û 50 Ê˘ÛÈÎfi˜ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜. √ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ¯ÔÚËÁ‹ıËΠ۠1 ˆ˜ 3 ‰fiÛÂȘ, ·Ó¿ÏÔÁ· Ì ÙȘ ·Ó¿ÁΘ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢. ∆· ·ÔÙÂϤÛÌ·Ù¿ Ì·˜ ¤‰ÂÈÍ·Ó fiÙÈ Ô ¯ÚfiÓÔ˜ ¯ÔÚ‹ÁËÛ˘ Ù˘ ÚÒÙ˘ ‰fiÛ˘ Â›Ó·È Ï›ÁÔ ÌÂÁ·Ï‡ÙÂÚÔ˜ ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Ê˘ÛÈÎÔ‡, Ë ‰È¿ÚÎÂÈ· Ù˘ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ ·Ó·ÓÔ‹˜, Ù˘ ¯ÔÚ‹ÁËÛ˘ √2 Î·È Ù˘ ÓÔÛËÏ›·˜ Â›Ó·È ÂÏ·ÊÚÒ˜ ÌÂÁ·Ï‡ÙÂÚË ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ÂÓÒ Ë ÂηÙÔÛÙÈ·›· ·‡ÍËÛË ÙÔ˘ ·ÚÙËÚÈÔ΢„ÂÏȉÈÎÔ‡ ËÏ›ÎÔ˘ (a/AP√2) ›ӷÈÂÏ·ÊÚÒ˜ ÌÂÁ·Ï‡ÙÂÚË ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Ê˘ÛÈÎÔ‡. ∏ ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
Abstract: Respiratory distress syndrome is related etiologically to lung immaturity and more particularly to insufficient surfactant. Exogenous administration of surfactant is considered, nowadays, to be the treatment of choice for preterm newborn infants with respiratory distress syndrome. Our aim was to compare the clinical efficacy of therapeutic administration of either a synthetic (exosurf) or a natural (alvofact) surfactant in the clinical course of respiratory distress syndrome as well as on the outcome of the preterm newborns. The study involved 92 preterm newborns with respiratory distress syndrome who were treated in the Department of Neonatology of the University of Crete. Of the newborns selected at random for the study, 42 received synthetic surfactant and 50 natural surfactant. Both types of surfactant were administered in 1 to 3 doses as needed. The results showed that there was a slight delay in the administration of the first dose of the natural surfactant compared to the synthetic. The duration of oxygen administration, ventilatory support and hospitalization was slightly higher in the group treated with synthetic surfactant, whereas the percent increase of the arterial alveolar partial pressure oxygen ratio was slightly higher in the group given natural surfactant. In addition, the mortality rate in the neonatal period was higher in the synthetic surfactant group than in the group receiving natural surfactant (38.1% versus 24%),
Department of Neonatology of the University of Crete
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2001 MAPT- A¶PI§
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¶·È‰È·ÙÚÈ΋ 2001;64:145-153
Paediatriki 2001;64:145-153
ıÓËÛÈÌfiÙËÙ· ÛÙË ÓÂÔÁÓÈ΋ ÂÚ›Ô‰Ô (28Ë Ë̤ڷ) ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚË ÛÙËÓ ÔÌ¿‰· Ô˘ ‹ÚÂ Û˘Óı-ÂÙÈÎfi, Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÔÌ¿‰· Ô˘ ‹ÚÂ Ê˘ÛÈÎfi ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi ·Ú¿ÁÔÓÙ· (38,1% ¤Ó·ÓÙÈ 24%). ∏ ›‰È· Ù¿ÛË ·Ú·ÙËÚ‹ıËÎÂ Î·È ÛÙȘ ÂÈÏÔΤ˜ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ÚÔˆÚfiÙËÙ· Î·È ÙÔ Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, fiˆ˜ ÁÈ· ÙȘ ÂÚÈÙÒÛÂȘ Ó¢ÌÔıÒڷη (11,2% ¤Ó·ÓÙÈ 5,2%, RR 0,90), ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ (34,6% ¤Ó·ÓÙÈ 21,1%, RR 0,90), ÛË„·ÈÌ›·˜ (11,5% ¤Ó·ÓÙÈ 5,2%, RR 0,94) Î·È ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋˜ ‰˘ÛÏ·Û›·˜ (12,5% ¤Ó·ÓÙÈ 2,8%, RR 0,91). ∞ÓÙ›ıÂÙ·, Ë Û˘¯ÓfiÙËÙ· Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ Â›Ó·È ÌÈÎÚfiÙÂÚË ÛÙ· ÓÂÔÁÓ¿ Ô˘ ‹Ú·Ó Û˘ÓıÂÙÈÎfi ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi ·Ú¿ÁÔÓÙ· (3,8% ¤Ó·ÓÙÈ 7,9%, RR 0,90). ™˘ÌÂÚ·›ÓÔ˘ÌÂ, ÏÔÈfiÓ, fiÙÈ Ë ¯Ú‹ÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ê˘ÛÈ΋˜ ÚÔ¤Ï¢Û˘ Ê·›ÓÂÙ·È Ó· ÏÂÔÓÂÎÙ› Û˘ÁÎÚÈÙÈο Ì ÙË ¯Ú‹ÛË ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡.
as were the complications associated with prematurity and RDS such as pneumothorax (11.2% to 5.2%, RR 0.90); intraventricular hemorrhage (34.6% to 21.1%, RR 0.90); septicemia (11.5% to 5.2%, RR 0.94) and bronchopulmonary dysplasia (12.5% to 2.8%, RR 0.91). In contrast the pulmonary hemorrhage rate was lower in the group given synthetic surfactant (3.8% versus 7.9%, RR 0.90). In conclusion, the administration of natural surfactant in preterm newborns with respiratory distress syndrome seems to be more advantageous in comparison with the synthetic one.
§¤ÍÂȘ ÎÏÂȉȿ: ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ (Ê˘ÛÈÎfi˜, Û˘ÓıÂÙÈÎfi˜), Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜.
Key words: surfactant (natural, synthetic), respiratory distress syndrome.
™˘ÓÙÔÌÔÁڷʛ˜ a/APO2 ·ÚÙËÚÈÔ΢„ÂÏȉÈÎfi ËÏ›ÎÔ FiO2 Û˘ÁΤÓÙÚˆÛË Ô͢ÁfiÓÔ˘
∂ÈÛ·ÁˆÁ‹ ∆Ô Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ·ÔÙÂÏ› ‚·ÛÈ΋ ·ÈÙ›· ÓÔÛËÚfiÙËÙ·˜ Î·È ıÓËÛÈÌfiÙËÙ·˜ ÛÙ· ÚfiˆÚ· ÓÂÔÁÓ¿. ∏ Û˘¯ÓfiÙËÙ· Î·È Ë ‚·Ú‡ÙËÙ¿ ÙÔ˘ ·˘Í¿ÓÔÓÙ·È fiÛÔ Ë ËÏÈΛ· ·ËÛ˘ ÂÏ·ÙÙÒÓÂÙ·È, Ì ·ÔÙ¤ÏÂÛÌ· Ù· ÓÂÔÁÓ¿ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È ÚÈÓ ·fi ÙËÓ 32Ë Â‚‰ÔÌ¿‰· Ù˘ ·ËÛ˘ Ó· ¯ÚÂÈ¿˙ÔÓÙ·È, Û˘Ó‹ıˆ˜, Ì˯·ÓÈ΋ ·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË (1,2). ∆Ô Û‡Ó‰ÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› ·ÈÙÈÔÏÔÁÈο, ÁÂÓÈο Ì ÙËÓ Ó¢ÌÔÓÈ΋ ·ÓˆÚÈÌfiÙËÙ· ·ÏÏ¿ Î·È ÂÓ Ì¤ÚÂÈ ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì ÙËÓ ·Ó¿ÚÎÂÈ· ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (3). ªÂ ÙÔÓ fiÚÔ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ ‰ÂÓ ÂÓÓÔԇ̠οÔÈ· ÂÓÈ·›· ÌÔÓÔÌÔÚȷ΋ Ô˘Û›·, ·ÏÏ¿ Û‡ÌÏÔÎÔ Ì›ÁÌ· Ô˘ÛÈÒÓ. ∆· ΢ÚÈfiÙÂÚ· Û˘ÛÙ·ÙÈο ÙÔ˘ Â›Ó·È ÊˆÛÊÔÏÈ›‰È·, Ô˘‰¤ÙÂÚ· Ï›Ë Î·È ÚˆÙ½Ó˜ (4-7). ¢Ú· ÂÏ·ÙÙÒÓÔÓÙ·˜ ÙËÓ ÂÈÊ·ÓÂȷ΋ Ù¿ÛË ÌÂٷ͇ ÙˆÓ ÙÔȯˆÌ¿ÙˆÓ ÙˆÓ Î˘„ÂÏ›‰ˆÓ Î·È ÂÌÔ‰›˙ÔÓÙ·˜ ÙË Û‡ÌÙˆÛ‹ ÙÔ˘˜. ∂›Ó·È ··Ú·›ÙËÙÔ˜ ÁÈ· ÙË Ê˘ÛÈÔÏÔÁÈ΋ Ó¢ÌÔÓÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ÙËÓ ·ÓÙ·ÏÏ·Á‹ ÙˆÓ ·ÂÚ›ˆÓ (2,4). ∆Ô 80% ÙˆÓ ÊˆÛÊÔÏÈȉ›ˆÓ ·ÔÙÂÏ› Ë ÊˆÛÊ·Ùȉ˘ÏÔ¯ÔÏ›ÓË. ∂›Ó·È Ë Ô˘Û›· Ô˘ ηÙÂÍÔ¯‹Ó ÌÂÈÒÓÂÈ ÙËÓ ÂÈÊ·ÓÂȷ΋ Ù¿ÛË (8).
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µÚ›ÛÎÂÙ·È, fï˜, Û ÎÚ˘ÛÙ·ÏÏÈ΋ ÌÔÚÊ‹ Î·È ‰ÂÓ ¤¯ÂÈ ·fi ÌfiÓË Ù˘ ÙËÓ ÈηÓfiÙËÙ· Ù·¯Â›·˜ ›ÛÙÚˆÛ˘ ÛÙÔ ÙÔ›¯ˆÌ· ÙˆÓ Î˘„ÂÏ›‰ˆÓ (6). °È’ ·˘ÙfiÓ ÙÔ ÏfiÁÔ, ÎÚ›ÓÂÙ·È ··Ú·›ÙËÙË Ë ·ÚÔ˘Û›· ÙˆÓ ÏÈfiÊÈÏˆÓ ÚˆÙÂ˚ÓÒÓ B Î·È C, Ô˘ ‚ÔËıÔ‡Ó ÛÙËÓ Î·Ï‡ÙÂÚË ÚÔÛÚfiÊËÛË Î·È Â›ÛÙÚˆÛË ÙˆÓ ÊˆÛÊÔÏÈȉ›ˆÓ ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙËÓ ÂÈÊ¿ÓÂÈ· ÙˆÓ Î˘„ÂÏ›‰ˆÓ (7). ∏ Â͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ıˆÚÂ›Ù·È Û‹ÌÂÚ· ıÂڷ›· ÂÎÏÔÁ‹˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ÙˆÓ ÚÔÒÚˆÓ ÓÂÔÁÓÒÓ (9). ÃÔÚËÁÂ›Ù·È ıÂڷ¢ÙÈο Û ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË Û˘Ó‰ÚfiÌÔ˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, ·ÏÏ¿ Î·È ÚÔÊ˘Ï·ÎÙÈο Û ÚfiˆÚ· ÓÂÔÁÓ¿ ·Ì¤Ûˆ˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, Ì ÙË ¯ÔÚ‹ÁËÛË ÎÔÚÙÈÎÔÛÙÂÚÔÂȉÒÓ ÛÙËÓ ¤ÁÎ˘Ô Ì ÛÎÔfi ÙËÓ ÂÈÙ¿¯˘ÓÛË Ù˘ Ó¢ÌÔÓÈ΋˜ ˆÚ›Ì·ÓÛ˘ ÙÔ˘ ÂÌ‚Ú‡Ô˘ Î·È ÙËÓ Â͈ÁÂÓ‹ ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ΢ڛˆ˜ ‚¤‚·È· ÙËÓ ÚÔÊ˘Ï·ÎÙÈ΋, ¤¯ÂÈ ÌÂȈı› ÛËÌ·ÓÙÈο Ë ÓÔÛËÚfiÙËÙ· ·ÏÏ¿ Î·È Ë ıÓËÛÈÌfiÙËÙ· ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Ì ۇӉÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (10-13). ∏ Â͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Â›Ó·È ·ÛÊ·Ï‹˜ Î·È ·ÔÙÂÏÂÛÌ·ÙÈ΋. ∏ ¯ÔÚ‹ÁËÛË, fï˜, Û΢·ÛÌ¿ÙˆÓ Ô˘ ÂÚȤ¯Ô˘Ó ͤÓ˜ ˙ˆ˚Τ˜ ÚˆÙ½Ó˜ ¤¯ÂÈ ÚÔηϤÛÂÈ ÙÔ ÂӉȷʤÚÔÓ ÙˆÓ ·ÓÔÛÔ‚ÈÔÏfiÁˆÓ, ÂÍ·ÈÙ›·˜ ÙÔ˘
2001 MAPT- A¶PI§
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¶·È‰È·ÙÚÈ΋ 2001;64:145-153
ıˆÚËÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ·Ó¿Ù˘Í˘ ·ÓÙÈۈ̿وÓ. ¶ÚÔ˜ ÙÔ ·ÚfiÓ, fï˜, ‰ÂÓ ˘¿Ú¯Ô˘Ó ÛÙÔȯ›· Ô˘ Ó· ÂÓÔ¯ÔÔÈÔ‡Ó ÙÔÓ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi ·Ú¿ÁÔÓÙ· ÁÈ· ÙËÓ ÚfiÎÏËÛË Î¿ÔÈ·˜ ·ÓÔÛÔÏÔÁÈ΋˜ ‰È·Ù·Ú·¯‹˜ (10-12,14). ŒÓ·˜ ¿ÏÏÔ˜ ÚÔ‚ÏËÌ·ÙÈÛÌfi˜ ‰ËÌÈÔ˘ÚÁ‹ıËΠ·fi ÙËÓ ·Ú·Ù‹ÚËÛË fiÙÈ Ë Ù·¯Â›· ‰Ú¿ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Û˘Óԉ‡ÂÙ·È ·fi ÚÔÛˆÚÈÓ¤˜ ÌÂÙ·‚ÔϤ˜ Ù˘ ÂÁÎÂÊ·ÏÈ΋˜ ÚÔ‹˜ ·›Ì·ÙÔ˜ Î·È ÙÒÛË Ù˘ ›ÂÛ˘ ÛÙË Ì¤ÛË ÂÁÎÂÊ·ÏÈ΋ ·ÚÙËÚ›·. ∏ ÂÁÎÂÊ·ÏÈ΋ ÈÛ¯·ÈÌ›· Ô˘ ÚÔηÏÂ›Ù·È ÌÔÚ› ‰˘ÓËÙÈο Ó· Úԉȷı¤ÛÂÈ Û ÂÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›·. ∞fi ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ ‰ÂÓ ¤¯ÂÈ ‰È·ÈÛÙˆı› ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ ÂÓ‰ÔÎÔÈÏȷ΋˜ ·ÈÌÔÚÚ·Á›·˜ ·fi ÙË ¯Ú‹ÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (9,15,16). ∆· Û΢¿ÛÌ·Ù· Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó ÚÔ¤Ú¯ÔÓÙ·È ·fi ˙Ò· (Ê˘ÛÈÎÔ› ·Ú¿ÁÔÓÙ˜) ‹ ·Ú·Û΢¿˙ÔÓÙ·È ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ (Û˘ÓıÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜). ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ÔÏ˘ÎÂÓÙÚÈΤ˜ ÌÂϤÙ˜ ¤‰ÂÈÍ·Ó fiÙÈ Ë ÎÏÈÓÈ΋ ·ÓÙ·fiÎÚÈÛË ‰È·Ê¤ÚÂÈ ·Ó¿ÏÔÁ· Ù˘ ¯Ú‹Û˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, Ê˘ÛÈ΋˜ ‹ Û˘ÓıÂÙÈ΋˜ ÚÔ¤Ï¢Û˘ (17-19). ∆Ô Û··ÛÌ· alvofact ÂÚȤ¯ÂÈ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi ·Ú¿ÁÔÓÙ· Ê˘ÛÈ΋˜ ÚÔ¤Ï¢Û˘ Ô˘ ·ÔÌÔÓÒÓÂÙ·È ·fi ÙÔ˘˜ Ó‡ÌÔÓ˜ ˘ÁÈÒÓ ‚ÔÔÂȉÒÓ Ì ¤ÎÏ˘ÛË, ÂÓÒ ÙÔ exosurf Â›Ó·È Û··ÛÌ· ÌÂ Û˘ÓıÂÙÈÎfi ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi ·Ú¿ÁÔÓÙ·, ÂχıÂÚÔ ÚˆÙ½Ó˘, Ì ·ÚÈÔ Û˘ÓıÂÙÈÎfi ÙÔ ÊˆÛÊÔÏÈ›‰ÈÔ ‰È·ÏÌÈÙÔʈÛÊ·Ùȉ˘ÏÔ¯ÔÏ›ÓË. ™ÎÔfi˜ ·˘Ù‹˜ Ù˘ ÎÏÈÓÈ΋˜ ÌÂϤÙ˘ ·ÔÙÂÏ› Ë ÂÎÙ›ÌËÛË Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ıÂڷ¢ÙÈ΋˜ ¯ÔÚ‹ÁËÛ˘ Ê˘ÛÈÎÔ‡ (alvofact) Î·È Û˘ÓıÂÙÈÎÔ‡ (exosurf) ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙËÓ ÔÚ›· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Î·È ÛÙËÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ ÙfiÛÔ ¿ÌÂÛˆÓ, fiˆ˜ Ó¢ÌÔıÒڷη, Ó¢ÌÔÓÈ΋˜ ·ÈÌÔÚÚ·Á›·˜, ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜, ÏÔÈÌÒ͈Ó, ÓÂÎÚˆÙÈ΋˜ ÂÓÙÂÚÔÎÔÏ›Ùȉ·˜, ·ÓÔÈÎÙÔ‡ ·ÚÙËÚÈ·ÎÔ‡ fiÚÔ˘, fiÛÔ Î·È ·ÒÙÂÚˆÓ, fiˆ˜ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋˜ ‰˘ÛÏ·Û›·˜, ˘‰ÚÔΤʷÏÔ˘ Î·È ÂÚÈÎÔÈÏȷ΋˜ Ï¢ÎÔ̷ϷΛ·˜. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™ÙË ÌÂϤÙË Ì·˜ Û˘ÌÂÚÈÏ¿‚·Ì 92 ÚfiˆÚ· ÓÂÔÁÓ¿ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙË ¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘ ÛÙË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô ÌÂٷ͇ ÙˆÓ ÂÙÒÓ 1993 Î·È 1999. ∞fi ·˘Ù¿, Û 42 Ù˘¯·›· ÂÈÏÂÁ̤ӷ ÓÂÔÁÓ¿ ¯ÔÚËÁ‹ıËΠÙÔ Û··ÛÌ· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (exosurf) Î·È Û 50 ÙÔ Û··ÛÌ· ÙÔ˘ Ê˘ÛÈÎÔ‡ ·Ú¿ÁÔÓÙ· (alvofact). ∏ ÂÈÏÔÁ‹ ¤ÁÈÓ Ì ‚¿ÛË ÙËÓ Ë̤ڷ Ù˘ ‚‰ÔÌ¿‰·˜ Ô˘ ¤ÁÈÓÂ Ë ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÓÂÔÁÓÔ‡ ÛÙËÓ ÎÏÈÓÈ΋. ™˘ÁÎÂÎÚÈ̤ӷ, ÛÙ· ÓÂÔÁÓ¿ Ô˘ Ë ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜ ¤ÁÈÓÂ
Paediatriki 2001;64:145-153
ÙȘ Ë̤Ú˜ ¢Â˘Ù¤Ú·, ∆ÂÙ¿ÚÙË ‹ ¶·Ú·Û΢‹ ¯ÔÚËÁ‹ıËΠÙÔ Û··ÛÌ· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡, ÂÓÒ Û ÂΛӷ Ô˘ Ë ÂÈÛ·ÁˆÁ‹ ÙÔ˘˜ ¤ÁÈÓ ÙȘ Ë̤Ú˜ ∆Ú›ÙË, ¶¤ÌÙË ‹ ™¿‚‚·ÙÔ ¯ÔÚËÁ‹ıËΠÙÔ Û··ÛÌ· ÙÔ˘ Ê˘ÛÈÎÔ‡. ∞fi ÙË ÌÂϤÙË ÂÍ·ÈÚ¤ıËÎ·Ó ÓÂÔÁÓ¿ Ì ÔÏϷϤ˜ Û˘ÁÁÂÓ›˜ ·ÓˆÌ·Ï›Â˜ Î·È Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ. ∫ÚÈÙ‹ÚÈ· ¯ÔÚ‹ÁËÛ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Î·È ÂÈÛfi‰Ô˘ ÙÔ˘ ÓÂÔÁÓÔ‡ ÛÙË ÌÂϤÙË ‹Ù·Ó: ·) ÎÏÈÓÈ΋ ‰È¿ÁÓˆÛË Û˘Ó‰ÚfiÌÔ˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜, ‚) ËÏÈΛ· ÌÈÎÚfiÙÂÚË ÙˆÓ 72 ˆÚÒÓ, Á) ·Ó¿ÁÎË ‰È·ÛˆÏ‹ÓˆÛ˘ Î·È Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ ·Ó·ÓÔ‹˜ Î·È ‰) ÙÈÌ‹ ÙÔ˘ a/AP√2 ÌÈÎÚfiÙÂÚË ·fi 0,22 Û 2 ‰È·‰Ô¯ÈΤ˜ ÌÂÙÚ‹ÛÂȘ. ∆Ô Û··ÛÌ· ÙÔ˘ Ê˘ÛÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (alvofact) ¯ÔÚËÁ‹ıËΠ۠‰ÔÛÔÏÔÁ›· 1,2 ml ·Ó¿ kg ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜, Ô˘ ·ÓÙÈÛÙÔȯ› Û 50 mg ÔÏÈÎÒÓ ÊˆÛÊÔÏÈȉ›ˆÓ ·Ó¿ kg ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜. ∞Ó¿ÏÔÁ· Ì ÙȘ ·Ó¿ÁΘ ·Ó·Ó¢ÛÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Ë ·Ú¯È΋ ‰fiÛË Â·Ó·Ï·Ì‚·ÓfiÙ·Ó Ì ÌÂÛԉȷÛÙ‹Ì·Ù· 12-24 ˆÚÒÓ, ¯ˆÚ›˜ Ó· ˘ÂÚ‚·›ÓÔÓÙ·È ÔÈ 4 Û˘ÓÔÏÈο ‰fiÛÂȘ Ô˘ ·ÓÙÈÛÙÔÈ¯Ô‡Ó Û 200 mg ÔÏÈÎÒÓ ÊˆÛÊÔÏÈȉ›ˆÓ ·Ó¿ kg ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜. ∆Ô Û··ÛÌ· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (exosurf) ¯ÔÚËÁ‹ıËΠ۠‰ÔÛÔÏÔÁ›· 5 ml ·Ó¿ kg ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜ Ô˘ ·ÓÙÈÛÙÔȯ› Û 67,5 mg ‰È·ÏÌ˘ÙÔ˘ÏʈÛÊ·Ùȉ˘ÏÔ¯ÔÏ›Ó˘ ·Ó¿ kg ‚¿ÚÔ˘˜ ÛÒÌ·ÙÔ˜. ∏ ·Ú¯È΋ ‰fiÛË Â·Ó·Ï·Ì‚·ÓfiÙ·Ó 12 ÒÚ˜ ·ÚÁfiÙÂÚ·, ·Ó¿ÏÔÁ· Ì ÙȘ ·Ó¿ÁΘ ·Ó·Ó¢ÛÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢. °È· ÙË Ì˯·ÓÈ΋ ·Ó·Ó¢ÛÙÈ΋ ˘ÔÛÙ‹ÚÈÍË ÙˆÓ ÓÂÔÁÓÒÓ ¯ÚËÛÈÌÔÔÈ‹ıËÎ·Ó ·Ó·Ó¢ÛÙ‹Ú˜ ȤÛˆ˜ [Dr·ger, babylog 1 HF(8407800)]. ™Ù· ÓÂÔÁÓ¿ Î·È ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ Ô˘ ÌÂÏÂÙ‹Û·Ì ÔÈ ·Ú¿ÌÂÙÚÔÈ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ ÚÔÛ·ÚÌfi˙ÔÓÙ·Ó ¿ÌÂÛ·, ·Ó¿ÏÔÁ· Ì ÙËÓ ÎÏÈÓÈ΋ ·ÓÙ·fiÎÚÈÛË Î·È ÙȘ ÌÂÙ·‚ÔϤ˜ Ù˘ ÔÍÂÔ‚·ÛÈ΋˜ ÈÛÔÚÚÔ›·˜. ∏ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË ¤ÁÈÓ Ì ÙË ÌË ·Ú·ÌÂÙÚÈ΋ ̤ıÔ‰Ô Mann-Whitney U test Î·È ÙÔ x2 test. ™Â ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ ¯ÚËÛÈÌÔÔÈ‹ıËΠÙÔ Fisher exact test Î·È ÚÔÛ‰ÈÔÚ›ÛÙËÎÂ Ô Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ (RR). ¶ÚÔÎÂÈ̤ÓÔ˘ ÁÈ· ÙË Û‡ÁÎÚÈÛË ÙˆÓ ‰È·‰Ô¯ÈÎÒÓ ÌÂÙÚ‹ÛÂˆÓ ÙÔ˘ ·ÚÙËÚÈÔ΢„ÂÏȉÈÎÔ‡ ËÏ›ÎÔ˘ ÚÈÓ, ÛÙÔ 2ˆÚÔ, ÙÔ 6ˆÚÔ Î·È ÌÂÙ¿ ÙÔ 6ˆÚÔ ÙˆÓ ÙÈÌÒÓ ¯ˆÚÈÛÙ¿ ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ Î·È ÙÔ˘ Ê˘ÛÈÎÔ‡, ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Ë one way ANOVA.
∞ÔÙÂϤÛÌ·Ù· ¢ÂÓ ˘‹ÚÍ·Ó ‰È·ÊÔÚ¤˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ Û¯ÂÙÈο Ì ÙÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘, ÙËÓ ËÏÈΛ· ·ËÛ˘, ÙÔÓ ÙÚfiÔ Á¤ÓÓËÛ˘ (ηÈÛ·ÚÈ΋ ÙÔÌ‹ ‹ Ê˘ÛÈÔÏÔÁÈÎfi˜ ÎÔÏÈÎfi˜ ÙÔÎÂÙfi˜) Î·È ÙȘ Û˘Óı‹Î˜ ·Ó¿Ó˄˘ Î·È ·fi Ù· ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Û¯ÂÙÈο Ì ÙË Ì¤ÁÈÛÙË Fi√2 ‹ ÙË Û¯¤ÛË a/APO2, ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (¶›Ó·Î·˜ 1). ŒÍÈ ÚfiˆÚ·, ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËÎÂ Û˘ÓıÂÙÈÎfi˜ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜, ·Â‚›ˆÛ·Ó ÂÓÙfi˜ 36 ˆÚÒÓ ·fi ÙË Á¤ÓÓËÛË. ™ÙËÓ ÔÌ¿‰· Ô˘ ¯ÔÚËÁ‹ıËÎÂ Ê˘ÛÈÎfi˜ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜
147
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Paediatriki 2001;64:145-153
¶›Ó·Î·˜ 1. ∫ÏÈÓÈο ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ Ô˘ ÌÂÏÂÙ‹ıËÎ·Ó ·Ó¿ÏÔÁ· Ì ÙËÓ ÔÌ¿‰· ÛÙËÓ ÔÔ›· ηٷٿ¯ÙËÎ·Ó Û˘ÓıÂÙÈÎfi˜ exosurf (42) mean±SE (95% CI) B° ∏∫ ∞ÚÈıÌfi˜ ‰fiÛÂˆÓ º˘ÛÈÔÏÔÁÈÎfi˜ ÙÔÎÂÙfi˜ ∫·ÈÛ·ÚÈ΋ ÙÔÌ‹
1288,0±55,0 30,5±0,4 1,19±0,07 15 27
(1176,8; 1399,2) (29,7; 31,4) (1,04; 1,33) 53,6 42,2
Ê˘ÛÈÎfi˜ alvofact (50) mean±SE (95% CI) 1365,0±67,3 30,2±0,3 1,82±0,10 13 37
(1229,5; 1500,4) (29,4; 31,0) (1,61; 2,02) 46,4 57,8
SE: standard error of the mean, CI: ‰È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ µ°: ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ ∏∫: ËÏÈΛ· ·ËÛ˘ * U=537,5 z=-4,559 2-tailed p=0,0000
·Ú¿ÁÔÓÙ·˜ ‰ÂÓ ÛËÌÂÈÒıËΠÚÒÈÌÔ˜ ı¿Ó·ÙÔ˜. ™ÙËÓ ÔÌ¿‰· ÙÔ˘ Ê˘ÛÈÎÔ‡, Ô ¯ÚfiÓÔ˜ ¯ÔÚ‹ÁËÛ˘ Ù˘ ÚÒÙ˘ ‰fiÛ˘ Â›Ó·È ÂÏ·ÊÚÒ˜ ÌÂÁ·Ï‡ÙÂÚÔ˜ Û˘ÁÎÚÈÙÈο Ì ÙÔ ¯ÚfiÓÔ ¤Ó·Ú͢ Ù˘ ¯ÔÚ‹ÁËÛ˘ ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡. ∏ ‰È·ÊÔÚ¿ ÛÙÔ ¯ÚfiÓÔ ¤Ó·Ú͢ ¯ÔÚ‹ÁËÛ˘ ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÌÂٷ͇ ÙˆÓ 2 ÔÌ¿‰ˆÓ ‰ÂÓ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈ΋ (U=2016, z=- 0,503, 2 tailed p= 0,615). ¶·Ú·ÙËÚ‹ıËΠ·‡ÍËÛË ÙÔ˘ ·ÚÙËÚÈÔ΢„ÂÏȉÈÎÔ‡ ËÏ›ÎÔ˘ Û ۇÁÎÚÈÛË Ì ÙÔ ·Ú¯ÈÎfi Î·È ÛÙȘ ‰˘Ô ÔÌ¿‰Â˜. ∏ ·‡ÍËÛË ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Ê˘ÛÈÎÔ‡ ·Ú¿ÁÔÓÙ· ‹Ù·Ó 89,4%, 78,9% Î·È 57,8% ÛÙȘ 2, 6 Î·È >6 ÒÚ˜ ·ÓÙ›ÛÙÔȯ·. ™ÙËÓ ÔÌ¿‰· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡, ÔÈ ·ÓÙ›ÛÙÔȯ˜ ·˘Í‹ÛÂȘ ‹Ù·Ó 52,6%, 63,2% Î·È 47,3%. ¶ÚÔÊ·Ó¤˜ Â›Ó·È fiÙÈ Û fiϘ ÙȘ ÌÂÙÚ‹ÛÂȘ Ë ·ÓÙ·fiÎÚÈÛË ‹Ù·Ó ηχÙÂÚË ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Ê˘ÛÈÎÔ‡ ·Ú¿ÁÔÓÙ· (¶›Ó·Î·˜ 2). ∞Ó·ÊÔÚÈο Ì ÙË Û‡ÁÎÚÈÛË ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ·ÚÙËÚÈÔ΢„ÂÏȉÈÎÔ‡ ËÏ›ÎÔ˘ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ Û˘ÓıÂÙÈÎÔ‡ Î·È Ê˘ÛÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙȘ ¯ÚÔÓÈΤ˜ ÂÚÈfi‰Ô˘˜ ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË, ÛÙȘ 2, 6 Î·È >6 ÒÚ˜, ÔÈ ‰È·ÊÔÚ¤˜ ÂÎÙÈÌ‹ıËÎ·Ó Ì ÙË Ì¤ıÔ‰Ô Ù˘ one way ANOVA. ™ËÌ·ÓÙÈΤ˜ ‹Ù·Ó ÔÈ ‰È·ÊÔÚ¤˜ ÙˆÓ ÙÈÌÒÓ ÙÔ˘ ·ÚÙËÚÈÔ΢„ÂÏȉÈÎÔ‡ ËÏ›ÎÔ˘ ÛÙȘ 2, 6 Î·È >6 ÒÚ˜, Û˘ÁÎÚÈÙÈο Ì ÙȘ ÙÈ̤˜ ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ÙfiÛÔ ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ fiÛÔ Î·È ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Ê˘ÛÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (p=0,003 Î·È p=0,015, ·ÓÙ›ÛÙÔȯ·). ∞Ó Î·È ÔÈ ‰È·ÊÔÚ¤˜ ÛÙË Ì¤ÛË ‰È¿ÚÎÂÈ· Ù˘ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢ Ù˘ ·Ó·ÓÔ‹˜, Ù˘ ¯ÔÚ‹ÁËÛ˘ √2 Î·È Ù˘ ÓÔÛËÏ›·˜ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ‰ÂÓ Â›Ó·È ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜ (¶›Ó·Î·˜ 3), ÔÈ ÙÈ̤˜ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚ˜ ÛÙ· ÚfiˆÚ· ÛÙ· ÔÔ›· ¯ÔÚËÁ‹ıËΠÙÔ Û··ÛÌ· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ∏ ›‰Ú·ÛË Ù˘ ¯ÔÚ‹ÁËÛ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈ-
148
ÎÔ‡ ·Ú¿ÁÔÓÙ· ÛÙË ıÓËÛÈÌfiÙËÙ· Ê·›ÓÂÙ·È ÛÙÔÓ ›Ó·Î· 4. ¶·Ú·ÙËÚÂ›Ù·È fiÙÈ Ë ÔÌ¿‰· ÙÔ˘ Ê˘ÛÈÎÔ‡ ·ÚÔ˘ÛÈ¿˙ÂÈ ÌÂȈ̤ÓË ıÓËÛÈÌfiÙËÙ· 24,0% (12/50), Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÔÌ¿‰· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· 38,1% (16/42), Ì ·ÓÙ›ÛÙÔÈ¯Ô Û¯ÂÙÈÎfi ΛӉ˘ÓÔ RR=0,81 (0,61; 1,08). ∂Í·ÈÚÒÓÙ·˜ ÙÔ˘˜ 6 ÚÒÈÌÔ˘˜ ı·Ó¿ÙÔ˘˜ ÙˆÓ 36 ÚÒÙˆÓ ˆÚÒÓ ˙ˆ‹˜, Ë ‰È·ÊÔÚ¿ ÛÙÔ Û¯ÂÙÈÎfi ΛӉ˘ÓÔ ·Ó¿ÌÂÛ· ÛÙȘ 2 ÔÌ¿‰Â˜ ÂÚÈÔÚ›˙ÂÙ·È [RR=0,95 (0,74; 1,23)]. ∏ Û˘¯ÓfiÙËÙ· ÙˆÓ ÂÈÏÔÎÒÓ Ì ÂÍ·›ÚÂÛË ÙËÓ Ó¢ÌÔÓÈ΋ ·ÈÌÔÚÚ·Á›· Â›Ó·È Û·ÊÒ˜ ÌÂÁ·Ï‡ÙÂÚË ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ¯ÔÚËÁ‹ıËÎÂ Û˘ÓıÂÙÈÎfi˜, Û˘ÁÎÚÈÙÈο Ì ÙËÓ ÔÌ¿‰· ÙÔ˘ Ê˘ÛÈÎÔ‡. ŒÙÛÈ, ‰ÈÏ¿ÛȘ ÂÚ›Ô˘ Û ÔÛÔÛÙfi Â›Ó·È ÔÈ ÂÚÈÙÒÛÂȘ Ó¢ÌÔıÒڷη Î·È ÛË„·ÈÌ›·˜ Î·È Û¯Â‰fiÓ ÙÂÙÚ·Ï¿ÛȘ ÔÈ ÂÚÈÙÒÛÂȘ ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋˜ ‰˘ÛÏ·Û›·˜ (¶›Ó·Î·˜ 5) ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡. ∞ÓÙ›ıÂÙ·, ·‡ÍËÛË ÛÙÔ ‰ÈÏ¿ÛÈÔ ÂÚ›Ô˘ Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘ Ó¢ÌÔÓÈ΋˜ ·ÈÌÔÚÚ·Á›·˜ ÛËÌÂÈÒÓÂÙ·È ÛÙ· ÚfiˆÚ· Ô˘ ¤Ï·‚·Ó Ê˘ÛÈÎfi ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi ·Ú¿ÁÔÓÙ·. ™ÙÔ˘˜ ›Ó·Î˜ 6 Î·È 7 Ê·›ÓÔÓÙ·È ·Ó·Ï˘ÙÈο ÔÈ ÂÈÏÔΤ˜ Û οı ÔÌ¿‰· ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ. ∏ ËÏÈΛ· ı·Ó¿ÙÔ˘ ‹Ù·Ó ÂÏ·ÊÚÒ˜ ÌÈÎÚfiÙÂÚË ÛÙ· ÚfiˆÚ· Ù˘ ÔÌ¿‰·˜ ÙÔ˘ Ê˘ÛÈÎÔ‡, Û˘ÁÎÚÈÙÈο ÚÔ˜ ÂΛӷ Ô˘ ¤Ï·‚·Ó ÙÔ Û··ÛÌ· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ (8,9 ± 0,37 ¤Ó·ÓÙÈ 11,7 ± 0,38 Ë̤Ú˜), ¯ˆÚ›˜ ˆÛÙfiÛÔ Ë ‰È·ÊÔÚ¿ Ó· Â›Ó·È ÛËÌ·ÓÙÈ΋ (U= 124,0 , z=- 0,311 , 2-Tailed p=0,76). ™˘˙‹ÙËÛË √È ÚÒÙ˜ ÚÔÛ¿ıÂȘ ¯ÔÚ‹ÁËÛ˘ ıÂڷ›·˜ ˘ÔηٿÛÙ·Û˘ Û ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ۇӉÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ÛÙË ‰ÂηÂÙ›· ÙÔ˘ 1960 ‰ÂÓ ·¤‰ˆÛ·Ó Ù· ·Ó·ÌÂÓfiÌÂÓ· ·ÔÙÂϤÛÌ·Ù·. ∞˘Ùfi ·Ô‰fiıËΠÛÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ Û··ÛÌ· Ô˘ ¯ÔÚËÁ‹ıËΠÂÚÈ›¯Â ÌfiÓÔ ÙÔ ÊˆÛÊÔÏÈ›‰ÈÔ ÊˆÛÊ·Ùȉ˘ÏÔ¯ÔÏ›ÓË (20). ∆Ô 1980
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Paediatriki 2001;64:145-153
¶›Ó·Î·˜ 2. ∞¿ÓÙËÛË ÛÙË ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·
ŒÓ·ÚÍË ¯ÔÚ‹ÁËÛ˘ (min) ªÂÁ›ÛÙË ÙÈÌ‹ Fi√2 a/∞PO2** ÚÈÓ a/APO2 ÛÙÔ 2ˆÚÔ a/APO2 ÛÙÔ 6ˆÚÔ a/APO2 ÌÂÙ¿ ÙÔ 6ˆÚÔ
√Ì¿‰· Û˘ÓıÂÙÈÎÔ‡ (¡Ô 42) mean± SE (95% CI)
√Ì¿‰· Ê˘ÛÈÎÔ‡ (¡Ô 50) mean± SE (95% CI)
168,5±11,3(145,7; 191,5) 0,59± 0,03 (0,50; 0,60) 0,19± 0,02 (0,6; 0,23) 0,29± 0,02 (0,4; 0,34) 0,31± 0,02 (0,26; 0,37) 0,28± 0,02 (0,23; 0,32)
183,6± 17,5(148,5; 218,7) 0,57± 0,04 (0,48; 0,66) 0,19±0,02 (0,16; 0,23) 0,36± 0,03 (0,29;0,43) 0,34± 0,02 (0,28; 0,39) 0,30± 0,02 (0,25; 0,35)
p
>0,05 >0,05 0,970 0,142 0,935 0,4013
SE: standard error of the mean, CI: ¢È¿ÛÙËÌ· ÂÌÈÛÙÔÛ‡Ó˘ ** ∞ÚÙËÚÈÔ΢„ÂÏȉÈÎfi ¶ËÏ›ÎÔ
¶›Ó·Î·˜ 3. ª¤ÛË ‰È¿ÚÎÂÈ· (Ë̤Ú˜) ˘Ô‚Ô‹ıËÛ˘ Ù˘ ·Ó·ÓÔ‹˜, ¯ÔÚ‹ÁËÛ˘ Ô͢ÁfiÓÔ˘ Î·È Û˘ÓÔÏÈ΋˜ ‰È¿ÚÎÂÈ·˜ ÓÔÛËÏ›·˜ ÛÙȘ 2 ÔÌ¿‰Â˜ ÓÂÔÁÓÒÓ
¢È¿ÚÎÂÈ·
√Ì¿‰· Û˘ÓıÂÙÈÎÔ‡ ∂¶ mean±S.E. (95% CI)
∞Ó·Ó¢ÛÙÈ΋˜ ÀÔÛÙ‹ÚÈ͢ ÃÔÚ‹ÁËÛ˘ O2 ¡ÔÛËÏ›·˜
8,9± 1,9 19,2± 7,9 40,4± 8,2
(5,0; 12,8) (3,2; 35,2) (23,9; 56,9)
√Ì¿‰· Ê˘ÛÈÎÔ‡ ∂¶ mean±S.E. (95% CI)
6,0± 1,0 11,7± 1,9 35,1± 5,1
(3,7; 8,1) (7,7; 15,6) (24,7; 45,4)
p
0,366 0,856 0,776
∂¶: ∂ÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ¶·Ú¿ÁÔÓÙ·˜
ÔÈ Fujiwara Î·È Û˘ÓÂÚÁ¿Ù˜, ¯ÔÚ‹ÁËÛ·Ó Âί‡ÏÈÛÌ· ‚Ô›Ԣ Ó‡ÌÔÓ· Û ÓÂÔÁÓ¿ Ì ۇӉÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ·Ó·Ê¤ÚÔÓÙ·˜ ı·̷ÙÈο ·ÔÙÂϤÛÌ·Ù· (21). ∞˘Ù‹ Ë ·Ú·Ù‹ÚËÛË ¤‰ˆÛ ÙÔ ¤Ó·˘ÛÌ· ÁÈ· ηχÙÂÚË Î·È ÏÂÙÔÌÂÚ¤ÛÙÂÚË ÌÂϤÙË Ù˘ Û‡ÓıÂÛ˘ ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·. ∏ ηٷÓfiËÛË Ù˘ Û‡ÓıÂÛ‹˜ ÙÔ˘ ¤ÙÚ„ ÙË Ì·˙È΋ ·Ú·ÁˆÁ‹ Î·È ‰È¿ıÂÛË Û ·ÂÚÈfiÚÈÛÙ˜ ÔÛfiÙËÙ˜ ‰È·ÊfiÚˆÓ ‰Ú·ÛÙÈÎÒÓ Û΢·ÛÌ¿ÙˆÓ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Ô˘ Ù· ÙÂÏÂ˘Ù·›· 10 ¯ÚfiÓÈ· ¤ÊÂÚ·Ó Â·Ó¿ÛÙ·ÛË ÛÙË ıÂڷ›· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ (22). √È ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó ÛÙÔ ÂÌfiÚÈÔ ÚÔ¤Ú¯ÔÓÙ·È ·fi ˙Ò· (Ê˘ÛÈÎÔ› ·Ú¿ÁÔÓÙ˜) ‹ ·Ú·Û΢¿˙ÔÓÙ·È ÛÙÔ ÂÚÁ·ÛÙ‹ÚÈÔ (Û˘ÓıÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜). √È Ê˘ÛÈÎÔ› Ï·Ì‚¿ÓÔÓÙ·È Â›Ù ·fi ·ÌÓÈ·Îfi ˘ÁÚfi ›Ù ·fi ÙÔ˘˜ Ó‡ÌÔÓ˜ ‰È·ÊfiÚˆÓ ˙ÒˆÓ. √È Ê˘ÛÈÎÔ› ·Ú¿ÁÔÓÙ˜, ÂÎÙfi˜ ·fi ʈÛÊÔÏÔ›‰È·, ÂÚȤ¯Ô˘Ó Î·È ÙȘ ÚˆÙ½Ó˜ B Î·È C. ∞ÓÙ›ıÂÙ·, ÔÈ Û˘ÓıÂÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ‰ÂÓ ÂÚȤ¯Ô˘Ó ηıfiÏÔ˘ ÚˆÙ½Ó˜ (23). ∞fi ÚfiÛÊ·Ù˜ ·Ó·ÊÔÚ¤˜ (19,24,25), ·ÏÏ¿ Î·È ·fi Ù· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ Ì·˜, Ê·›ÓÂÙ·È fiÙÈ Ë ‰Ú¿ÛË ÙÔ˘ Ê˘ÛÈÎÔ‡ ·Ú¿ÁÔÓÙ· Â›Ó·È Ù·¯‡ÙÂÚË Î·È ·ÚÔ˘ÛÈ¿˙ÂÈ Î·Ï‡ÙÂÚÔ ·ÔÙ¤ÏÂÛÌ·
ÛÙËÓ Ô͢ÁfiÓˆÛË ÙÔ˘ ¿Û¯ÔÓÙÔ˜ ÓÂÔÁÓÔ‡, fiˆ˜ Î·È ÛÙËÓ ÂÈ‚›ˆÛË. ∞˘Ùfi ¤¯ÂÈ Û˘Û¯ÂÙÈÛÙ› Ì ÙËÓ ·ÚÔ˘Û›· ÙˆÓ ÏÈfiÊÈÏˆÓ ÂȉÈÎÒÓ ÚˆÙÂ˚ÓÒÓ B Î·È C ÛÙ· Û΢¿ÛÌ·Ù· Ê˘ÛÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, Ô˘ ‚ÂÏÙÈÒÓÂÈ ÛËÌ·ÓÙÈο ÙËÓ ÚÔÛÚfiÊËÛË ÙˆÓ ÊˆÛÊÔÏÈȉ›ˆÓ ÛÙËÓ ÂÈÊ¿ÓÂÈ· ·¤Ú· ˘ÁÚÔ‡ (26). ∏ Ù·¯‡ÙÂÚË Î·È Î·Ï‡ÙÂÚË ·ÓÙ·fiÎÚÈÛË ÂÈÙÚ¤ÂÈ ÛÙÔÓ ÎÏÈÓÈÎfi Ó· ‚ÂÏÙÈÒÛÂÈ ¿ÌÂÛ· ÙȘ ·Ú·Ì¤ÙÚÔ˘˜ Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ˘ÔÛÙ‹ÚÈ͢, ÁÂÁÔÓfi˜ ηıÔÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜ ÛÙÔÓ ÂÚÈÔÚÈÛÌfi ÙfiÛÔ Ù˘ Û˘¯ÓfiÙËÙ·˜ fiÛÔ Î·È Ù˘ ÛÔ‚·ÚfiÙËÙ·˜ ÙˆÓ ÂÈÏÔÎÒÓ Ù˘. ∏ ¯ÚfiÓÈ· Ó¢ÌÔÓÈ΋ ÓfiÛÔ˜ Û˘Û¯ÂÙ›˙ÂÙ·È ¿ÌÂÛ· Ì ÙËÓ ÚÔˆÚfiÙËÙ·. ¢È¿ÊÔÚÔÈ ·ÈÙÈÔÏÔÁÈÎÔ› ·Ú¿ÁÔÓÙ˜ ¤¯Ô˘Ó ÂÓÔ¯ÔÔÈËı› ηٿ ηÈÚÔ‡˜ ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛ‹ Ù˘, fiˆ˜ Ë ˘ÂÚ‚ÔÏÈ΋ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ, Ë ·ÚÔ˘Û›· ·ÓÔÈÎÙÔ‡ ‚ÔÙÙ¿ÏÂÈÔ˘ fiÚÔ˘, ÔÈ ÏÔÈÌÒÍÂȘ. ∏ ÌÂÁ·Ï‡ÙÂÚË, fï˜, ¤ÌÊ·ÛË ¤¯ÂÈ ‰Ôı› ÛÙÔ ÚfiÏÔ ÙÔ˘ Ô͢ÁfiÓÔ˘ Î·È ÙÔ˘ ‚·ÚÔÙÚ·‡Ì·ÙÔ˜ ÛÙÔÓ ·ÓÒÚÈÌÔ Ó‡ÌÔÓ· (27). ∂›Ó·È ÁÓˆÛÙfi, ›Û˘, fiÙÈ ÂÈ‚·Ú˘ÓÙÈÎÔ› ·Ú¿ÁÔÓÙ˜ ÁÈ· ÙË ‰ËÌÈÔ˘ÚÁ›· Ó¢ÌÔıÒڷη ÛÙÔÓ ·ÓÒÚÈÌÔ Ó‡ÌÔÓ· ÙÔ˘ ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡ Â›Ó·È Ë ˘„ËÏ‹ ıÂÙÈ΋ ÙÂÏÔÂÎÓ¢ÛÙÈ΋ ›ÂÛË, ÔÈ ÌÂÁ¿ÏÔÈ ¯ÚfiÓÔÈ ÂÈÛÓÔ‹˜, Ë ˘„ËÏ‹ ̤ÛË ›ÂÛË ÙˆÓ ·ÂÚÔÊfiÚˆÓ Ô‰ÒÓ Î·È Ô ÌË Û˘Á¯ÚÔÓÈÛÌfi˜ ÙÔ˘ ÓÂÔÁÓÔ‡ Ì ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· (2).
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Paediatriki 2001;64:145-153
¶›Ó·Î·˜ 4. £·ÓfiÓÙ· Î·È ÂÈ‚ÈÒÛ·ÓÙ· ÓÂÔÁÓ¿ √Ì¿‰· Û˘ÓıÂÙÈÎÔ‡ ∂¶ ∏ÏÈΛ· (Ë̤Ú˜)
√Ì¿‰· Ê˘ÛÈÎÔ‡ ∂¶
0-28Ë ñ 28Ë
£·ÓfiÓÙ· ¡Ô (%) 16 (38,1) 2 (4,8)
˙ÒÓÙ· ¡Ô (%) 26 (61,9) 24 (57,1)
ı·ÓfiÓÙ· ¡Ô (%) 12 (24,0) 2 (4,0)
˙ÒÓÙ· ¡Ô (%) 38 (76,0) 36 (72,0)
™‡ÓÔÏÔ
18 (42,9)
24 (57,1)
14 (28,0)
36 (72,0)
p 0,216* 0,895**
* Mantel-Haenszel, Yates ‰ÈfiÚıˆÛË x2 = 1,53 ** Mantel-Haenszel, Yates ‰ÈfiÚıˆÛË x2 = 0,02 ∂¶: ∂ÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ¶·Ú¿ÁÔÓÙ·˜
¶›Ó·Î·˜ 5. ∂ÈÏÔΤ˜ ÛÙ· ÓÂÔÁÓ¿ Ô˘ ÂÈ‚›ˆÛ·Ó ̤¯ÚÈ ÙËÓ 28Ë Ë̤ڷ ˙ˆ‹˜ √Ì¿‰· Û˘ÓıÂÙÈÎÔ‡ ¶Ó¢ÌÔıÒڷη˜ ¶Ó¢ÌÔÓÈ΋ ·ÈÌÔÚÚ·Á›· ∂ÁÎÂÊ·ÏÈ΋ ·ÈÌÔÚÚ·Á›· ™Ë„·ÈÌ›· µÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ¢˘ÛÏ·Û›· * ** *** **** *****
Mantel-Haenszel, Mantel-Haenszel, Mantel-Haenszel, Mantel-Haenszel, Mantel-Haenszel,
√Ì¿‰· Ê˘ÛÈÎÔ‡
¡Ô 5/26 1/26 9/26 3/26
% 11,2 3,8 34,6 11,5
¡Ô 2/38 3/38 8/38 2/38
% 5,3 7,9 21,1 5,3
3/24
12,5
1/36
2,8
Yates Yates Yates Yates Yates
‰ÈfiÚıˆÛË ‰ÈfiÚıˆÛË ‰ÈfiÚıˆÛË ‰ÈfiÚıˆÛË ‰ÈfiÚıˆÛË
x2 x2 x2 x2 x2
= = = = =
0,90 1,04 0,90 0,94
RR (0,76; (0,93; (0,71; (0,82;
1,08) 1,16) 1,14) 1,09)
0,91 (0,79; 1,05)
1,34 0,01 0,40 0,14 0,39
¶›Ó·Î·˜ 6. ∂ÈÏÔΤ˜ ÛÙ· ı·ÓfiÓÙ· Î·È ˙ÒÓÙ· ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ Û˘ÓıÂÙÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· £·ÓfiÓÙ·
¶Ó¢ÌÔıÒڷη˜ ¶Ó¢ÌÔÓÈ΋ ∞ÈÌ. ∂ÁÎÂÊ·ÏÈ΋ ∞ÈÌ. ™Ë„·ÈÌ›· ¡∂∫ ∞∞¶ À‰ÚÔΤʷÏÔ˜ ™·ÛÌÔ› ÀÔÂÂÓ‰˘Ì·ÙÈ΋ ∞ÈÌ. ªËÓÈÁÁ›Ùȉ· µ¶¢ K‡ÛÙË ∫¡™ ∞ÈÌ.: ¡∂∫: ∞∞¶: µ¶¢: ∫¡™:
150
< 1,5 ËÌ.
1,5-28 ËÌ.
3 1 2 1 -
2 7 2 1 2 1 1 -
∞ÈÌÔÚÚ·Á›· ¡ÂÎÚˆÙÈ΋ ∂ÓÙÂÚÔÎÔÏ›Ùȉ· ∞ÓÔÈÎÙfi˜ ∞ÚÙËÚÈ·Îfi˜ ¶fiÚÔ˜ µÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ¢˘ÛÏ·Û›· ∫ÂÓÙÚÈÎfi ¡Â˘ÚÈÎfi ™‡ÛÙËÌ·
∑ÒÓÙ· >28 ËÌ. 2 1 1 1 -
∑ÒÓÙ· 28Ë ËÌ.
™‡ÓÔÏÔ
3 1 4 4 4 2 3 3 1
8 1 12 8 1 7 1 6 2 3 3 1
p 0,246* 0,925** 0,524*** 0,707**** 0,395*****
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¶›Ó·Î·˜ 7. ∂ÈÏÔΤ˜ ÛÙ· ı·ÓfiÓÙ· Î·È ˙ÒÓÙ· ÓÂÔÁÓ¿ Ù˘ ÔÌ¿‰·˜ ÙÔ˘ Ê˘ÛÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· £·ÓfiÓÙ· < 1,5 ËÌ.
1,5-28 ËÌ.
>28 ËÌ.
∑ÒÓÙ· 28Ë ËÌ.
-
2 3 8 2 -
1 1 1 1 1
6 1 6 1 9 4
9 3 9 9 2 10 5
-
-
-
1 3 1 1
1 3 1 1
-
-
-
2 1
2 1
¶Ó¢ÌÔıÒڷη˜ ¶Ó¢ÌÔÓÈ΋ ∞ÈÌ. ∂ÁÎÂÊ·ÏÈ΋ ∞ÈÌ. ™Ë„·ÈÌ›· ¡∂∫ ∞∞¶ ™·ÛÌÔ› ÀÔÂÂÓ‰˘Ì·ÙÈ΋ ·ÈÌÔÚÚ·Á›· ªËÓÈÁÁ›Ùȉ· µ¶¢ K‡ÛÙË ∫¡™ ¶ÂÚÈÎÔÈÏȷ΋ Ï¢ÎÔ̷ϷΛ· À‰ÚÔΤʷÏÔ˜ ∞ÈÌ.: ¡∂∫: ∞∞¶: B¶¢: ∫¡™:
∑ÒÓÙ· ™‡ÓÔÏÔ
∞ÈÌÔÚÚ·Á›· ¡ÂÎÚˆÙÈ΋ ∂ÓÙÂÚÔÎÔÏ›Ùȉ· ∞ÓÔÈÎÙfi˜ ∞ÚÙËÚÈ·Îfi˜ ¶fiÚÔ˜ µÚÔÁ¯ÔÓ¢ÌÔÓÈ΋ ¢˘ÛÏ·Û›· ∫ÂÓÙÚÈÎfi ¡Â˘ÚÈÎfi ™‡ÛÙËÌ·
∏ ÂÚÈÎÔÈÏȷ΋ Î·È Ë ÂÓ‰ÔÎÔÈÏȷ΋ ·ÈÌÔÚÚ·Á›· ·ÔÙÂÏ› ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ıÓËÛÈÌfiÙËÙ·˜, ·ÏÏ¿ Î·È ÓÔÛËÚfiÙËÙ·˜, ÛÙ· ¯·ÌËÏÔ‡ ‚¿ÚÔ˘˜ Á¤ÓÓËÛ˘ ÚfiˆÚ· ÓÂÔÁÓ¿ Ì ۇӉÚÔÌÔ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜. ∏ ˘ÔÂÂÓ‰˘Ì·ÙÈ΋ ‚Ï·ÛÙÈ΋ ÛÙÈ‚¿‰· Â›Ó·È Ì›· ·ÁÁÂÈÔ‚ÚÈı‹˜ ÂÚÈÔ¯‹. ∫¿ı ÁÂÁÔÓfi˜ Ô˘ ‰È·Ù·Ú¿ÛÛÂÈ ÙËÓ ÂÓ‰Ô·ÁÁÂȷ΋ ›ÂÛË Î·È ÙËÓ ·ÈÌ·ÙÈ΋ ÚÔ‹ ÛÙ· ·ÁÁ›· ÙÔ˘ ÂÁÎÂÊ¿ÏÔ˘, fiˆ˜ ˘ÔÍ›·, ÔͤˆÛË, Ó¢ÌÔıÒڷη˜, ÌË Û˘Á¯ÚÔÓÈÛÌfi˜ ÙÔ˘ ÓÂÔÁÓÔ‡ Ì ÙÔÓ ·Ó·Ó¢ÛÙ‹Ú· ·ÎfiÌ· Î·È ·Ó·ÚÚfiÊËÛË Ù˘ ÙÚ·¯Â›·˜, ÌÔÚ› ‰˘ÓËÙÈο Ó· ÚÔηϤÛÂÈ ÙË Ú‹ÍË ÙˆÓ Â˘¿ÏˆÙˆÓ ·ÁÁ›ˆÓ Ù˘ ‚Ï·ÛÙÈ΋˜ ÛÙÈ‚¿‰·˜ (2,16). √È ÏÔÈÌÒÍÂȘ ·ÔÙÂÏÔ‡Ó Ì›·, ›Û˘, ÛËÌ·ÓÙÈ΋ ·ÈÙ›· ÓÂÔÁÓÈ΋˜ ıÓËÛÈÌfiÙËÙ·˜ Î·È ÓÔÛËÚfiÙËÙ·˜. √È È·ÙÚÈÎÔ› ¯ÂÈÚÈÛÌÔ›, fiˆ˜ Ô Î·ıÂÙËÚÈ·ÛÌfi˜ ÙˆÓ ÔÌÊ·ÏÈÎÒÓ ·ÁÁ›ˆÓ, Ë ‰È·ÛˆÏ‹ÓˆÛË Ù˘ ÙÚ·¯Â›·˜, Ë ¯ÔÚ‹ÁËÛË ·ÚÂÓÙÂÚÈÎÒÓ ‰È·Ï˘Ì¿ÙˆÓ, Ë ·Ú·ÌÔÓ‹ ·ÁÁÂÈ·ÎÒÓ Î·ıÂÙ‹ÚˆÓ, Úԉȷı¤ÙÔ˘Ó ÙËÓ ÂÁηٿÛÙ·ÛË Î·È ÙÔÓ ÔÏÏ·Ï·ÛÈ·ÛÌfi ÙˆÓ ÌÈÎÚÔ‚›ˆÓ. ∏ ÁÚ‹ÁÔÚË ‚ÂÏÙ›ˆÛË ÙÔ˘ ÓÂÔÁÓÔ‡ Î·È Ë ‰˘Ó·ÙfiÙËÙ· Ô˘ ·Ú¤¯ÂÙ·È ÛÙÔÓ ÎÏÈÓÈÎfi Ó· ÂÚÈÔÚ›˙ÂÈ Î·Ù¿ ÙÔ ‰˘Ó·ÙfiÓ ÙÔ˘˜ È·ÙÚÈÎÔ‡˜ ¯ÂÈÚÈÛÌÔ‡˜, ¤¯Ô˘Ó ηıÔÚÈÛÙÈ΋ ÛËÌ·Û›· ÁÈ· ÙËÓ ¤Î‚·ÛË. ™ÙËÓ ÂÚÁ·Û›· Ì·˜ ÌÂÏÂÙ‹Û·Ì ̛· Ù˘¯·ÈÔÔÈË̤ÓË ÛÂÈÚ¿ ÚÔÒÚˆÓ Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙÔ ›‰ÈÔ ÙÌ‹Ì·. °È· ÙÔ ÏfiÁÔ ·˘Ùfi, ÙÔ ‰Â›ÁÌ· Â›Ó·È ÂÚÈÛÛfiÙÂÚÔ ÔÌÔÈÔÁÂÓ¤˜ Î·È ÔÈ Û˘Óı‹Î˜ ÓÔÛËÏ›·˜, fiÛÔÓ ·ÊÔÚ¿ ÛÙËÓ È·ÙÚÈ΋ Î·È ÙË ÓÔÛËÏ¢ÙÈ΋ ÊÚÔÓÙ›‰·, Â›Ó·È ·Ó¿ÏÔÁ˜. ™ÙË ÌÂϤÙË Ì·˜ Û˘ÌÂ-
ÚÈÏ¿‚·Ì ÓÂÔÁÓ¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó ÛÙÔ Ì·ÈÂ˘Ù‹ÚÈÔ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Ì·˜, ·ÏÏ¿ Î·È ÓÂÔÁÓ¿ Ô˘ ÁÂÓÓ‹ıËÎ·Ó Û ȉȈÙÈΤ˜ ÎÏÈÓÈΤ˜ Î·È ¡ÔÛÔÎÔÌ›· Ù˘ ¢ڇÙÂÚ˘ ÂÚÈÔ¯‹˜ ÙÔ˘ ÓËÛÈÔ‡. ∏ ÌÂÙ·ÊÔÚ¿ ÙÔ˘˜ ÛÙÔ ÙÌ‹Ì· Ì·˜, Û ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ, Â›Ó·È Î·ı˘ÛÙÂÚË̤ÓË, ÁÂÁÔÓfi˜ Ô˘ ÔÊ›ÏÂÙ·È ·ÊÂÓfi˜ ÌÂÓ ÛÙË ¯ÈÏÈÔÌÂÙÚÈ΋ ·fiÛÙ·ÛË Î·È ·ÊÂÙ¤ÚÔ˘ ÛÙËÓ ÚÔÛ¿ıÂÈ· ÂÍ·ÛÊ¿ÏÈÛ˘ ηٿÏÏËÏˆÓ Û˘ÓıËÎÒÓ. ∞˘Ùfi Ê·›ÓÂÙ·È Î·È ÛÙÔ ¯ÚfiÓÔ ¯ÔÚ‹ÁËÛ˘ Ù˘ ÚÒÙ˘ ‰fiÛ˘ ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, Ô˘ Û ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ Â›Ó·È Î·ı˘ÛÙÂÚË̤ÓÔ˜. ∏ ÂÈ‚¿Ú˘ÓÛË ÙÔ˘ ÚfiˆÚÔ˘ ÓÂÔÁÓÔ‡ Ô˘ ÌÂٷʤÚÂÙ·È, ÌÔÚ› Ó· Â›Ó·È ÌÂÁ¿ÏË Î·È, fiˆ˜ ¤¯ÂÈ ·Ó·ÊÂÚı›, ÂËÚ¿˙ÂÈ ÛËÌ·ÓÙÈο ÙËÓ ÙÂÏÈ΋ ¤Î‚·ÛË (28). ∏ ‰È·ÊÔÚ¿ ÛÙÔÓ ·ÚÈıÌfi ÙˆÓ ‰fiÛÂˆÓ ÌÂٷ͇ ÙˆÓ 2 ÔÌ¿‰ˆÓ ‰ÈηÈÔÏÔÁÂ›Ù·È ·fi ÙË ÌÈÎÚfiÙÂÚË ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ· ‰Ú¿Û˘ ÙÔ˘ Ê˘ÛÈÎÔ‡ (alvofact) <6 ˆÚÒÓ, fiˆ˜ Ê·›ÓÂÙ·È Î·È ÛÙËÓ ·ÚÔ‡Û· ÂÚÁ·Û›· ·fi ÙȘ ÌÂÙÚ‹ÛÂȘ ÙÔ˘ ·ÚÙËÚÈÔ΢„ÂÏȉÈÎÔ‡ ËÏ›ÎÔ˘ a/AP√2, Û˘ÁÎÚÈÙÈο Ì ÙË ‰Ú¿ÛË ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· (exosurf). ∆· ÓÂÔÁÓ¿ ÙˆÓ ‰‡Ô ˘fi ÌÂϤÙË ÔÌ¿‰ˆÓ, ›¯·Ó ·Ó¿ÏÔÁ˜ ÙÈ̤˜ ̤ÁÈÛÙ˘ Fi√2 Î·È a/APO2 ÛÙȘ ÚÔ Ù˘ ¯ÔÚ‹ÁËÛ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ÌÂÙÚ‹ÛÂȘ. ªÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÙÔ˘ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ÔÈ ÌÂÙÚ‹ÛÂȘ ‰È·ÊÔÚÔÔÈÔ‡ÓÙ·È ˘¤Ú ÙÔ˘ Ê˘ÛÈÎÔ‡, Ì ·˘Í‹ÛÂȘ ÙÔ˘ a/APO2 ηٿ 89,4%, 78,9%, Î·È 57,8% ·ÓÙ›ÛÙÔȯ· ÚÔ˜ ÙÔ˘˜ ¯ÚfiÓÔ˘˜ 2, 6 Î·È >6 ÒÚ˜ ÌÂÙ¿ ÙË ¯Ô-
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Ú‹ÁËÛË. ªÈÎÚfiÙÂÚ˜ ‹Ù·Ó ÔÈ ·˘Í‹ÛÂȘ Ì ÙÔ Û··ÛÌ· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡. ™ËÌ·ÓÙÈΤ˜ ‹Ù·Ó ÔÈ ‰È·ÊÔÚ¤˜ ÙˆÓ ÙÈÌÒÓ ÙÔ˘ a/APO2 ÛÙÔ˘˜ ¯ÚfiÓÔ˘˜ 2, 6 Î·È >6 ÒÚ˜ Û˘ÁÎÚÈÙÈο Ì ÙȘ ÙÈ̤˜ ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ·, ÙfiÛÔ ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡, fiÛÔ Î·È ÛÙËÓ ÔÌ¿‰· ÙÔ˘ Ê˘ÛÈÎÔ‡. ∞Ó·ÊÔÚÈο Ì ÙË ¯ÚÔÓÈ΋ ‰È¿ÚÎÂÈ· Ù˘ Ì˯·ÓÈ΋˜ ˘ÔÛÙ‹ÚÈ͢, ÔÈ ‰È·ÊÔÚ¤˜ Ô˘ ·Ú·ÙËÚ‹ıËÎ·Ó ‰ÂÓ ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈΤ˜. ¶Ú¤ÂÈ, ¿ÓÙˆ˜, Ó· ÛËÌÂȈı› fiÙÈ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·, fiˆ˜ Î·È ÛÙË ÌÂϤÙË Ì·˜, ÙfiÛÔ Ë ‰È¿ÚÎÂÈ· fiÛÔ Î·È Ë ˘ÎÓfiÙËÙ· ÙÔ˘ ¯ÔÚËÁËı¤ÓÙÔ˜ √2 Â›Ó·È ÌÈÎÚfiÙÂÚ˜ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ‹Ú·Ó Û··ÛÌ· Ê˘ÛÈ΋˜ ÚÔ¤Ï¢Û˘ (17-19,24,25,29). ªÈÎÚfiÙÂÚË ÛËÌÂÈÒıËÎÂ Ë Û˘¯ÓfiÙËÙ· Ó¢ÌÔıÒڷη, ÂÁÎÂÊ·ÏÈ΋˜ ·ÈÌÔÚÚ·Á›·˜, ÛË„·ÈÌ›·˜ Î·È ‚ÚÔÁ¯ÔÓ¢ÌÔÓÈ΋˜ ‰˘ÛÏ·Û›·˜ ÛÙËÓ ÔÌ¿‰· ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ‹Ú·Ó ÙÔ Û··ÛÌ· ÙÔ˘ Ê˘ÛÈÎÔ‡. O ·ÓÙ›ÛÙÔȯԘ Û¯ÂÙÈÎfi˜ ΛӉ˘ÓÔ˜ ‹Ù·Ó RR 0,90 (0,76; 1,08), 0,90 (0,71-1,14), 0,94 (0,82; 1,09) Î·È 0,91 (0,79; 1,05). ∂ÓÙÔ‡ÙÔȘ, ‰È·ÊÔÚÂÙÈο ·ÔÙÂϤÛÌ·Ù· ·Ó·ÎÔÈÓÒıËÎ·Ó ·fi ¿ÏÏÔ˘˜ Û˘ÁÁÚ·Ê›˜ Ô˘ ‰ÂÓ ·Ú·Ù‹ÚËÛ·Ó ÛËÌ·ÓÙÈ΋ Ì›ˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ÙˆÓ ı·Ó¿ÙˆÓ ‹ ÙˆÓ ¯ÚfiÓÈˆÓ ÂÈÏÔÎÒÓ ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi, ÛÙÔ Ù¤ÏÔ˜ Ù˘ ÓÂÔÁÓÈ΋˜ ÂÚÈfi‰Ô˘ (18,19,24). ŸÛÔÓ ·ÊÔÚ¿ ÙÔ ÎfiÛÙÔ˜ ÙˆÓ ‰‡Ô Û΢·ÛÌ¿ÙˆÓ Ô˘ ¯ÚËÛÈÌÔÔÈ‹ıËηÓ, Â›Ó·È ·Ó¿ÏÔÁÔ ¯ˆÚ›˜ ÛËÌ·ÓÙÈΤ˜ ‰È·ÊÔÚ¤˜. ™ËÌ·ÓÙÈÎfi ÏÂÔÓ¤ÎÙËÌ· ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ Â›Ó·È Ë ‰˘Ó·ÙfiÙËÙ· ‡ÎÔÏ˘ ÌÂÙ·ÊÔÚ¿˜ ¯ˆÚ›˜ Ó· ··ÈÙÂ›Ù·È „˘Á›Ô, ηıÒ˜ ›Û˘ Î·È Ô ÂÚÈÔÚÈÛÌfi˜ ÙÔ˘ ıˆÚËÙÈÎÔ‡ ÎÈÓ‰‡ÓÔ˘ ÌÂÙ¿‰ÔÛ˘ ÈÔÁÂÓÒÓ ‹ ÌË ÏÔÈÌÒÍÂˆÓ Ô˘ ÂӉ¯Ô̤ӈ˜ ‰ÂÓ ·‰Ú·ÓÔÔÈÔ‡ÓÙ·È Ì ٷ Û˘Ó‹ıË Ì¤Û· Ô˘ ¯ÚËÛÈÌÔÔÈÔ‡ÓÙ·È Î·Ù¿ ÙËÓ ÚÔÂÙÔÈÌ·Û›· ÁÈ· ÎÏÈÓÈ΋ ¯Ú‹ÛË. ∏ ¯ÔÚ‹ÁËÛË ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· Û˘Ó¿ÁÂÙ·È ¤Á¯˘ÛË ÌÂÁ·Ï‡ÙÂÚÔ˘ fiÁÎÔ˘ ˘ÁÚÒÓ ÛÙËÓ ÙÚ·¯Â›·, Ô˘ Û˘Óԉ‡ÂÙ·È ·fi ‚Ú·‰˘Î·Ú‰›·, ˘ÔÍ›·, ÌÂÙ·‚ÔÏ‹ Ù˘ ·ÚÙËÚȷ΋˜ ›ÂÛ˘ Î·È Ù˘ ÚÔ‹˜ ÙÔ˘ ·›Ì·ÙÔ˜ ÛÙ· ÂÁÎÂÊ·ÏÈο ·ÁÁ›·. ∏ Â͈ÁÂÓ‹˜ ¯ÔÚ‹ÁËÛË ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎÔ‡ ·Ú¿ÁÔÓÙ· ıˆÚÂ›Ù·È ıÂڷ›· ÂÎÏÔÁ‹˜ ÛÙËÓ ·ÓÙÈÌÂÙÒÈÛË ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜. √ Ê˘ÛÈÎfi˜ ÂÈÊ·ÓÂÈÔ‰Ú·ÛÙÈÎfi˜ ·Ú¿ÁÔÓÙ·˜ Ê·›ÓÂÙ·È Ó· ÏÂÔÓÂÎÙ› ÙÔ˘ Û˘ÓıÂÙÈÎÔ‡. ∏ ‰Ú¿ÛË ÙÔ˘ Â›Ó·È Ù·¯‡ÙÂÚË Î·È ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙÂÚË. √È ‰È·ÊÔÚ¤˜ Ô˘ ¤¯Ô˘Ó ·Ó·ÊÂÚı› ·fi ÙÔ˘˜ ÂÚ¢ÓËÙ¤˜ ‰ÂÓ ¤¯Ô˘Ó ·ÚÎÒ˜ ÙÂÎÌËÚȈı› ·fi ÈηÓÔÔÈËÙÈÎfi ·ÚÈıÌfi ÌÂÏÂÙÒÓ. ∏ ÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË Û ÌÂÁ·Ï‡ÙÂÚ˜ ÛÂÈÚ¤˜ ÚfiˆÚˆÓ ÓÂÔÁÓÒÓ ÎÚ›ÓÂÙ·È ÂȂ‚ÏË̤ÓË.
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µÈ‚ÏÈÔÁÚ·Ê›· 1. Hack M, Wright LL, Shankaran S, Tyson JE, Horbar JD, Bauer CR et al. Very-low- birth-weight outcomes of the National Institute of Child Health and Human Development Neonatal Network. November 1989 to October 1990. Am J Obstet Gynecol 1995;172:457-464. 2. Martin RJ, Fanaroff AA. The respiratory distress syndrome and its management. In: Fanaroff AA, Martin RJ, editors. Neonatal-Perinatal Medicine, Disease of the fetus and infant. 6th ed. St Louis: Mosby; 1997. p. 1018-1040. 3. Avery ME, Mead J. Surface properties in relation to atelectasis and hyaline membrane disease. Am J Dis Child 1959;97:517-520. 4. Van Golde LM, Batenburg JJ, Robertson B. The pulmonary surfactant system: biochemical aspects and functional significance. Physiol Rev 1988;68:374-455. 5. Gladstone IM, Ray AO, Salafia CM, Perez-Fontan J, Mercurio MR, Jacobs HC. Effect of artificial surfactant on pulmonary function in pre-term and full-term lambs. J Appl Physiol 1990;69:465-472. 6. Notter RH. Surface chemistry of pulmonary surfactant: the role of individual components. In: Robertson B, Van Golde LMG, Batenburg JJ, eds. Pulmonary surfactant. Amsterdam: Elsevier Science; 1984. p. 17-65. 7. Weaver TE, Whitsett JA. Function and regulation of expression of pulmonary surfactant-associated proteins. Biochem J 1991;273:249-264. 8. Mendelson CR, Alcorn JL, Gao E. The pulmonary surfactant protein genes and their regulation in fetal lung. Semin Perinatol 1993;17:223-232. 9. Surfactant replacement therapy for respiratory distress syndrome. American Academy of Pediatrics. Committee on fetus and newborn. Pediatrics 1999;103:684-685. 10. Palta M, Weinstein MR, McGuinness G, Gabbert D, Brady W, Peters ME. A population study. Mortality and morbidity after availability of surfactant therapy. Newborn Lung Project. Arch Pediatr Adolesc Med 1994;148:1295-1301. 11. Soll RF. Surfactant therapy in the USA: trials and current routines. Biol Neonate 1997;71(1 Suppl):1-7. 12. Soll RF, Sinclair JC, Bracken MB. Natural surfactant extract vs synthetic surfactant: meta-analysis of randomized controlled trials [abstract]. Pediatr Res 1995;37:37A. 13. Morley CJ. Systematic review of prophylactic vs rescue surfactant. Arch Dis Child 1997;77:F70-F74. 14. Courtney SE, Long W, McMillan D. Double-blind 1-year follow up of 1540 infants with respiratory distress syndrome randomized to rescue treatment with two doses of synthetic surfactant or air in four clinical trials. J Pediatr 1995;126(Suppl):S43-S52. 15. Skinner J. The effects of surfactant on haemodynamics in hyaline membrane disease. Arch Dis Child 1997;76:F67-F69.
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16. Gunkel JH, Banks PL. Surfactant therapy and intracranial hemorrhage: review of the literature and results of new analyses. Pediatrics 1993;92:775-786. 17. Rollins M, Jenkins J, Tubman R, Corkey C, Wilson D. Comparison of clinical responses to natural and synthetic surfactans. J Perinat Med 1993;21:341-347. 18. A multicenter, randomized trial comparing synthetic surfactant with modified bovine surfactant extract in the treatment of neonatal respiratory distress syndrome. Vermont-Oxford Neonatal Network. Pediatrics 1996;97:1-6. 19. Hudak ML, Farell EE, Rosenberg AA, Jung AL, Auten RL, Durand DJ et al. A multicenter randomized, masked comparison trial of natural versus synthetic surfactant for the treatment of respiratory distress syndrome. J Pediatr 1996;128:396-406. 20. Robillard E, Alarie Y, Dagenais-Perusse P. Microaerosol administration of synthetic b-q-dipalmitoyl-L-a-lecithin in the respiratory distress syndrome: a preliminary report. Can Med Assoc J 1964;90:55-57. 21. Fujiwara T, Maeta H, Chida S, Morita T, Watabe Y, Abe T. Artificial surfactant therapy in hyaline membrane disease. Lancet 1980;1:55-59. 22. Dekowski SA, Holtzman RB. Surfactant replacement therapy. An update on applications. Pediatr Clin North Am 1998;45:549-572. 23. Jobe AH. Pulmonary surfactant therapy. N Engl J Med 1993;328:861-868.
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24. da Costa DE, Pai MG, Al Khusaiby SM. Comparative trial of artificial and natural surfactans in the treatment of respiratory distress syndrome of prematurity: experiences in a developing country. Pediatr Pulmonol 1999;27:312-317. 25. Halliday HL. Natural vs synthetic surfactans in neonatal respiratory distress syndrome. Drugs 1996;51:226-237. 26. Possmayer F. The role of surfactant-associated proteins. Am Rev Respir Dis 1990;142:749-752. 27. McColley SA. Bronchopulmonary dysplasia. Impact of surfactant replacement therapy. Pediatr Clin N Am 1998;45:573-586. 28. Phibbs CS, Bronstein JM, Buxton E, Phibbs RH. The effects of patient volume and level of care at the hospital of birth and neonatal mortality. JAMA 1996;276:1054-1059. 29. Halliday HL. Overview of clinical trials comparing natural and synthetic surfactants. Biol Neonate 1995;67(1 Suppl):32-47.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 27-07-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 15-01-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÃÚÈÛÙ›Ó· °È·ÓÓ·ÎÔÔ‡ÏÔ˘ ∞ÙÏ·ÓÙ›‰Ô˜ 37, 713 05, ∏Ú¿ÎÏÂÈÔ
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ORIGINAL PAPER
√ÏÈ΋ ·ÓÙÈÔÍÂȉˆÙÈ΋ ÈηÓfiÙËÙ· Ï¿ÛÌ·ÙÔ˜ ·ÛıÂÓÒÓ Ì ÎÏ·ÛÈ΋ Ê·ÈÓ˘ÏÎÂÙÔÓÔ˘Ú›· ˘fi ‰›·ÈÙ· ∫.∂. ™Ô‡ÏË1, ™. ∆۷ΛÚ˘2, °.∞. ∫·Ú›Î·˜3, ª. ªÔ‡Î·˜2, ¶. ªÂ¯Ú¿Î˘2
Plasma total antioxidant status in phenylketonuria patients on diet K.H. Schulpis1, S. Tsakiris2, G.A. Karikas3, M. Moukas2, P. Behrakis2
¶ÂÚ›ÏË„Ë: ∏ Ê·ÈÓ˘ÏÎÂÙÔÓÔ˘Ú›· (PKU) Â›Ó·È ¤Ó· ÎÏËÚÔÓÔÌÈÎfi ÓfiÛËÌ· ‰È·Ù·Ú·¯‹˜ ÙÔ˘ ÌÂÙ·‚ÔÏÈÛÌÔ‡ ÙÔ˘ ·ÌÈÓÔͤԘ Ê·ÈÓ˘Ï·Ï·Ó›ÓË (Phe), Ô˘ Ú˘ıÌ›˙ÂÙ·È Ì ÂȉÈ΋ ‰›·ÈÙ· ·ÚfiÌÔÈ· ÙˆÓ Ê˘ÙÔÊ¿ÁˆÓ. ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ë ·ÍÈÔÏfiÁËÛË Ù˘ ÔÏÈ΋˜ ·ÓÙÈÔÍÂȉˆÙÈ΋˜ ÈηÓfiÙËÙ·˜ (√∞π) ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ÙˆÓ PKU ·ÛıÂÓÒÓ, ηı’ fiÛÔÓ Ë “ÂȉÈ΋” ÙÔ˘˜ ‰›·ÈÙ· ÂÊ·ÚÌfi˙ÂÙ·È ÂÊ' fiÚÔ˘ ˙ˆ‹˜. ªÂÏÂÙ‹Û·Ì 22 ·ÛıÂÓ›˜ Ô˘ ·ÎÔÏÔ˘ıÔ‡Ó ÙË ‰›·ÈÙ· (ÔÌ¿‰· ∞) Î·È 24 Ô˘ ÙËÓ ·ÎÔÏÔ˘ıÔ‡Û·Ó “¯·Ï·Ú¿” (ÔÌ¿‰· µ). ™·Ú¿ÓÙ· (¡=40) ˘ÁÈ‹ ·È‰È¿ ‹Ù·Ó Ë ÔÌ¿‰· ÂϤÁ¯Ô˘ (Ì¿ÚÙ˘Ú˜). ÀÔÏÔÁ›ÛÙËÎ·Ó Ù· ‰È·ÈÙËÙÈο ÛÙÔȯ›· Ù˘ ‰È·ÙÚÔÊ‹˜, fiˆ˜ ›Û˘ ÌÂÙÚ‹ıËÎ·Ó ÛÙÔ ·›Ì· Ù· ÏÈ›‰È·, ‚-ηڈ٤ÓÈ·, ·-ÙÔÎÔÊÂÚfiÏË Î·È ‚ÈÙ·Ì›ÓË C Ì HPLC Î·È Û˘Û¯ÂÙ›ÛÙËÎ·Ó Ì ÙËÓ ÔÏÈ΋ ·ÓÙÈÔÍÂȉˆÙÈ΋ ÈηÓfiÙËÙ· (√∞π) ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ÙˆÓ ÔÌ¿‰ˆÓ Ô˘ ˘ÔÏÔÁ›ÛÙËΠ̠ʈÙÔÌÂÙÚÈ΋ ̤ıÔ‰Ô. ∆· ›‰· ÛÙÔ Ï¿ÛÌ· Î·È Ë ÚfiÛÏË„Ë Ù˘ ‚ÈÙ·Ì›Ó˘ C ‰ÂÓ ‰È¤ÊÂÚ·Ó ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ. ∞ÓÙ›ıÂÙ·, ÔÈ ÚÔÛÏ‹„ÂȘ Î·È Ù· ›‰· ÙˆÓ ÏÈȉ›ˆÓ, ‚ηڈÙÂÓ›ˆÓ Î·È ·-ÙÔÎÔÊÂÚfiÏ˘ ÛÙËÓ ÔÌ¿‰· ∞ ‰È¤ÊÂÚ·Ó ÛÙ·ÙÈÛÙÈο (p <0,001) Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÂΛӷ Ù˘ ÔÌ¿‰·˜ µ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ (0,7±0,09, 0,49±0,02, 0,3±0,09 Ìmol/l ÁÈ· Ù· ηڈ٤ÓÈ· Î·È 28,0±0,9, 22,7±0,6, 21,0±0,6 Ìmol/l ÁÈ· ÙËÓ ·-ÙÔÎÔÊÂÚfiÏË). ∏ ÚfiÛÏË„Ë ÙˆÓ ÏÈȉ›ˆÓ Î·È Ù· ›‰¿ ÙÔ˘˜ ÛÙÔ ·›Ì· ‹Ù·Ó Û·ÊÒ˜ ÌÂȈ̤ӷ ÛÙËÓ ÔÌ¿‰· ∞, ÂÓÒ Ë √∞π ‹Ù·Ó ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ·˘ÍË̤ÓË ÛÙËÓ ›‰È· ÔÌ¿‰·. £ÂÙÈΤ˜ Û˘Û¯ÂÙ›ÛÂȘ ‚Ú¤ıËÎ·Ó ÌÂٷ͇ Ù˘ √∞π Î·È ÙˆÓ ÚÔ·Ó·ÊÂÚoÌ¤ÓˆÓ ‚ÈÙ·ÌÈÓÒÓ, ȉȷ›ÙÂÚ· ÛÙËÓ ÔÌ¿‰· ∞. ŒÙÛÈ, ÌÔÚÔ‡ÌÂ
Ó· Û˘ÌÂÚ¿ÓÔ˘ÌÂ
1 πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” 2 ¶ÂÈÚ·Ì·ÙÈ΋ º˘ÛÈÔÏÔÁ›·, ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ 3 ªÔÓ¿‰· º·ÚÌ·ÎÔÎÈÓËÙÈ΋˜ Î·È ¶·ÚÂÓÙÂÚÈ΋˜ ¢È·ÙÚÔÊ‹˜, ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”
1 Institute of Child Health Children’s Hospital “Agia Sophia” 2 Experimental Physiology Lab, University of Athens 3 Pharmacokinetics and Parental Nutrition Unit Children’s Hospital “Agia Sophia”
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fiÙÈ Ë ·˘ÍË̤ÓË √Aπ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ù˘ ÔÌ¿‰·˜ ∞ Èı·ÓfiÓ Ó· ÔÊ›ÏÂÙ·È ÛÙÔ Â›‰Ô˜ Ù˘ ‰›·ÈÙ·˜ Ô˘ ÁÈ· ıÂڷ¢ÙÈÎÔ‡˜ ÏfiÁÔ˘˜ ·ÎÔÏÔ˘ıÔ‡Ó.
especially in group A. In conclusion, PKU patients on a strict diet showed a significantly higher antioxidant status as compared to that of group B (1.6 and 0.99 mmol/l resp p <0.001). This is possibly related to the high amounts of antioxidants present in their special low Phe vegetarian diet.
§¤ÍÂȘ ÎÏÂȉȿ: ÔÏÈ΋ ·ÓÙÈÔÍÂȉˆÙÈ΋ ÈηÓfiÙ˘, Ê·ÈÓ˘ÏÎÂÙÔÓÔ˘Ú›·, ‚-ηڈ٤ÓÈ·, ·-ÙÔÎÔÊÂÚfiÏË, ‚ÈÙ·Ì›ÓË C.
Key words: antioxidant status, phenylketonuria, ‚carotene, ·-tocopherol, vitamin C, vegetarian diet.
∂ÈÛ·ÁˆÁ‹ ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· ÙˆÓ ÙÂÏÂ˘Ù·›ˆÓ ‰ÂηÂÙÈÒÓ, ¤¯ÂÈ ‰È·ÈÛÙˆı› Ë Û˘Û¯¤ÙÈÛË ÙˆÓ ÂÏ¢ı¤ÚˆÓ ÚÈ˙ÒÓ Î·È ÙÔ˘ ÔÍÂȉˆÙÈÎÔ‡ ÛÙÚ˜ ÙˆÓ Î˘ÙÙ¿ÚˆÓ (1,2). π‰È·›ÙÂÚ· ÔÚÈṲ̂Ó˜ Ô˘Û›Â˜, fiˆ˜ ÔÈ ‚Èٷ̛Ә, ‰È·‰Ú·Ì·Ù›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙËÓ ÚfiÏË„Ë ‹ ÙËÓ ·ÓÙÈÛÙÚÔÊ‹ Ì›·˜ ÔÍÂȉˆÙÈ΋˜ ‚Ï¿‚˘. ∏ ˘‰·ÙÔ‰È·Ï˘Ù‹ ‚ÈÙ·Ì›ÓË C ‚Ú›ÛÎÂÙ·È Û ˘„ËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ (2-10 mmol/L) ÛÙÔ Î˘ÙÔÛfiÏÈÔ, ÂÓÒ ÔÈ ÏÈÔ‰È·Ï˘Ù¤˜ · Î·È Á ÙÔÎÔÊÂÚfiϘ (‚ÈÙ·Ì›ÓË ∂) Â›Ó·È Û˘ÛÙ·ÙÈÎfi ÙˆÓ ÏÈȉ›ˆÓ ÙˆÓ ÌÂÌ‚Ú·ÓÒÓ, fiÔ˘ ÚÔÏ·Ì‚¿ÓÔ˘Ó ‹ ÌÂÈÒÓÔ˘Ó ÙË ÏÈȉÈ΋ ˘ÂÚÔÍ›‰ˆÛË (3). ∂Í¿ÏÏÔ˘, ÔÏϤ˜ ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ fiÙÈ Ë ¤ÏÏÂÈ„Ë ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ ÛÙÔ ‰È·ÈÙÔÏfiÁÈÔ Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙËÓ ÂÌÊ¿ÓÈÛË Î·Ú‰È·Î‹˜ ÓfiÛÔ˘ (4), ·ÊÔ‡ Ù· ·ÓÙÈÔÍÂȉˆÙÈο ‚-ηڈ٤ÓÈ·, ·ÙÔÎÔÊÂÚfiÏË Î·È ‚ÈÙ·Ì›ÓË C ¤¯Ô˘Ó ‚ÚÂı› Ó· ¤¯Ô˘Ó ¿ÌÂÛË Û¯¤ÛË ÛÙËÓ ÚfiÏË„Ë Ù˘ ·ıËڈ̿وÛ˘ Ì ÙËÓ ·Ú¤Ì‚·Û‹ ÙÔ˘˜ ÛÙËÓ ÔÍ›‰ˆÛË Ù˘ LDL ¯ÔÏËÛÙÂÚfiÏ˘. ∏ ÌÂÁ·Ï‡ÙÂÚË Û¯¤ÛË Û'·˘Ù‹ ÙË ‰ÈÂÚÁ·Û›· Â›Ó·È ÂΛÓË Ù˘ ‚ÈÙ·Ì›Ó˘ ∂ ˘fi Ù‡ÔÓ Û˘ÌÏËÚÒÌ·ÙÔ˜ ÛÙÔ ‰È·ÈÙÔÏfiÁÈÔ, ÂÓÒ Ù· ‚-ηڈ٤ÓÈ· Î·È Ë ‚ÈÙ·Ì›ÓË C ÛÙË ‰È·ÙÚÔÊ‹ Ê·›ÓÂÙ·È fiÙÈ Û˘ÌÌÂÙ¤¯Ô˘Ó Ôχ ÏÈÁfiÙÂÚÔ ÛÙË Ì›ˆÛË ÙÔ˘ ÎÈÓ‰‡ÓÔ˘ ÂÌÊ¿ÓÈÛ˘ ηډȷ΋˜ ÓfiÛÔ˘ (5,6). ∏ ÎÏ·ÛÈ΋ Ê·ÈÓ˘ÏÎÂÙÔÓÔ˘Ú›· (PKU) Â›Ó·È ¤Ó· ÌÂÙ·‚ÔÏÈÎfi ÓfiÛËÌ·, ÙÔ ÔÔ›Ô Ú˘ıÌ›˙ÂÙ·È Ì ÙË ¯·ÌËÏ‹ ÚfiÛÏË„Ë ÙÔ˘ ·ÌÈÓÔͤԘ Ê·ÈÓ˘Ï·Ï·Ó›ÓË (Phe). ∏ ÂȉÈ΋ ·˘Ù‹ ‰›·ÈÙ· ·Ú¯›˙ÂÈ ·fi ÙȘ ÚÒÙ˜ Ë̤Ú˜ Ù˘ ˙ˆ‹˜, ÒÛÙ ӷ ÚÔÏËÊı› Ë „˘¯ÔÎÈÓËÙÈ΋ ηı˘ÛÙ¤ÚËÛË. £· ÌÔÚÔ‡Û ӷ ¯·Ú·ÎÙËÚÈÛÙ› ˆ˜ ‰›·ÈÙ· ÌË-·ıËڈ̷ÙÔÁfiÓÔ˜, ÛÙÔ ‚·ıÌfi Ô˘ Ë ÚˆÙ½ÓË Ù˘ Â›Ó·È Î˘Ú›ˆ˜ Ê˘ÙÈ΋˜ ÚÔ¤Ï¢Û˘ Î·È ÂÌÂÚȤ¯ÂÈ ÔÏϤ˜ Ê˘ÙÈΤ˜ ›Ó˜ (7). ™˘ÓÂÒ˜, Ù· ›‰· ÙˆÓ ÏÈȉ›ˆÓ ÛÙÔÓ ÔÚfi ÙˆÓ PKU ·ÛıÂÓÒÓ Â›Ó·È ¯·ÌËÏ¿. ∂Âȉ‹ Ë ÂȉÈ΋ ·˘Ù‹ ‰›·ÈÙ· Ú¤ÂÈ Ó· ·ÎÔÏÔ˘ıÂ›Ù·È ·fi ÙÔ˘˜ PKU ·ÛıÂÓ›˜ ηı' fiÏË ÙË ‰È¿ÚÎÂÈ· Ù˘ ˙ˆ‹˜ ÙÔ˘˜, ÂȯÂÈÚ‹Û·Ì ӷ ÌÂÏÂÙ‹ÛÔ˘Ì ÙËÓ Â›‰Ú·Û‹ Ù˘ ÛÙËÓ √ÏÈ΋ ∞ÓÙÈÔÍÂȉˆÙÈ΋ πηÓfiÙËÙ· (√∞π) ÙÔ˘ Ï¿ÛÌ·ÙÔ˜ ÙˆÓ ·ÛıÂÓÒÓ Ì·˜.
ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ ™·Ú¿ÓÙ· ¤ÍÈ (¡=46) ·ÛıÂÓ›˜ Ì PKU ¯ˆÚ›ÛÙËÎ·Ó Û ‰‡Ô ÔÌ¿‰Â˜ ·Ó¿ÏÔÁ· Ì ÙËÓ ÔÈfiÙËÙ· Ù˘ ‰›·ÈÙ·˜ Ô˘ ·ÎÔÏÔ˘ıÔ‡Û·Ó, fiˆ˜ ¯·Ú·ÎÙËÚ›ÛÙËΠ·fi ÙÔÓ Ì¤ÛÔ fiÚÔ ÙˆÓ ÂȤ‰ˆÓ Ù˘ Phe ÛÙÔ ·›Ì· ÙÔ˘˜ ηٿ ÙÔÓ ÚÔËÁÔ‡ÌÂÓÔ ¯ÚfiÓÔ. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ì PKU ›¯·Ó ·ÓȯÓ¢ı› Ì ÙÔÓ ¶ÚÔÏËÙÈÎfi ŒÏÂÁ¯Ô ¡ÂÔÁÓÒÓ (Screening) Î·È ¤ÁÈÓ·Ó Û ·˘ÙÔ‡˜ fiϘ ÔÈ ··Ú·›ÙËÙ˜ ÂÍÂÙ¿ÛÂȘ ÁÈ· Ó· ‰È·ÁÓˆÛı› Ô Ù‡Ô˜ Ù˘ ÓfiÛÔ˘ (.¯. ÊfiÚÙÈÛË Ì ÙÂÙÚ·¸‰ÚÔÙÂÚ›ÓË µ∏4). √È ËÌÂÚ‹ÛȘ ·Ó¿ÁΘ ÙÔ˘˜ Û ڈÙ½ÓË Î·Ï‡ÙÔÓÙ·Ó Î·Ù¿ ÌÂÁ¿ÏÔ Ì¤ÚÔ˜ Ì ÙË ¯ÔÚ‹ÁËÛË ÂȉÈÎÔ‡ ÚˆÙÂ˚ÓÔ‡¯Ô˘ Û΢¿ÛÌ·ÙÔ˜ (PKU2) Ô˘ ‰ÂÓ ÂÚȤ¯ÂÈ Phe Î·È Ï›Ë, ·ÏÏ¿ ÂÚȤ¯ÂÈ ÚfiÛıÂÙ·, ‚Èٷ̛Ә Î·È È¯ÓÔÛÙÔȯ›·. ∏ ÔÌ¿‰· ∞ ÙˆÓ PKU ·ÛıÂÓÒÓ (¡=22) ›¯Â ̤ÛË ËÏÈΛ· 7,7 ± 3,2 ¯ÚfiÓÈ· Î·È Â›Â‰· Phe 192 ± 60 Ìmol/L, Ô˘ ·Ô‰ÂÈÎÓ‡ÂÈ fiÙÈ Ù· ̤ÏË Ù˘ ·ÎÔÏÔ‡ıËÛ·Ó ÛˆÛÙ¿ ÙËÓ “ÂȉÈ΋ ‰›·ÈÙ·”. ∏ ÔÌ¿‰· µ (¡=24) ›¯Â ̤ÛË ËÏÈΛ· 8,0 ± 3,6 Î·È Ì¤ÛË ÙÈÌ‹ Phe 595 ± 104 Ìmol/L, Ô˘ ·Ô‰ÂÈÎÓ‡ÂÈ ÙËÓ Î·Î‹ “ÔÈfiÙËÙ·” Ù˘ ‰›·ÈÙ¿˜ ÙÔ˘˜, ·ÊÔ‡ ·ÎÔÏÔ‡ıËÛ·Ó ¯·Ï·Ú¿ ÙË Û˘ÛÙËÓfiÌÂÓË ÁÈ· ÙË ÓfiÛÔ ÙÔ˘˜ “ÂȉÈ΋” ‰›·ÈÙ·. ™·Ú¿ÓÙ· (¡=40) ˘ÁÈ‹ ·È‰È¿ ·ÚfiÌÔÈ·˜ ËÏÈΛ·˜ (7,68 ± 2,6 ¯ÚfiÓÈ·), ·oÙ¤ÏÂÛ·Ó ÙËÓ ÔÌ¿‰· ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ∆fiÛÔ ÔÈ ÔÌ¿‰Â˜ ÙˆÓ ·ÛıÂÓÒÓ fiÛÔ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ Û˘ÌÏ‹ÚˆÛ·Ó ‰ÂÏÙ›Ô Î·ıËÌÂÚÈÓÔ‡ ‰È·ÈÙÔÏÔÁ›Ô˘ › 30 Ë̤Ú˜. ∆· ÛÙÔȯ›· ‰È·ÙÚÔÊ‹˜ ÚԤ΢„·Ó ηÙfiÈÓ ˘ÔÏÔÁÈÛÌÔ‡, Ô ÔÔ›Ô˜ ¤ÁÈÓ Ì ÙË ‚Ô‹ıÂÈ· ÂȉÈÎÒÓ Î·Ù·ÏfiÁˆÓ ‰È·ÙÚÔÊ‹˜ (8). ªÂÙ¿ ·fi 10-15 ÒÚ˜ ÓËÛÙ›·˜ ¤ÁÈÓ ·ÈÌÔÏË„›· (5,0 ml ·›Ì·) ÁÈ· ÙÔÓ ÚÔÛ‰ÈÔÚÈÛÌfi ÙˆÓ ‚ÈÙ·ÌÈÓÒÓ, ÙÔ˘ √∞π, Ù˘ Phe Î·È ÙˆÓ ÏÈȉ›ˆÓ. ∆· ›‰· ÙˆÓ ‚ÈÙ·ÌÈÓÒÓ, ‚-ηڈÙÂÓ›ˆÓ, ‚ÈÙ·Ì›Ó˘ C Î·È ·-ÙÔÎÔÊÂÚfiÏ˘ ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Ì HPLC ÌÂıfi‰Ô˘˜ (9-11). ∆· ÏÈ›‰È· ÚÔÛ‰ÈÔÚ›ÛÙËÎ·Ó Û‡Ìʈӷ Ì ̛· ̤ıÔ‰Ô ÚÔ˘Ù›Ó·˜ (12), ÂÓÒ Ù· ›‰· Ù˘ Phe Ì ÔÛÔÙÈÎfi ÂÓ˙˘ÌÈÎfi ÚÔÛ‰ÈÔÚÈÛÌfi (13). ∏ √∞π ˘ÔÏÔÁ›ÛÙËΠۇÌʈӷ Ì ÙË Ì¤ıÔ‰Ô Miller Î·È Û˘Ó (14). ∆· ‰Â›ÁÌ·Ù· ‰È·ÙËÚ‹ıËÎ·Ó ˘fi „‡ÍË ÁÈ· 14 Ë̤Ú˜ ÚÈÓ ÙËÓ ·Ó¿Ï˘ÛË. ∆Ô Â‡ÚÔ˜ ·Ó¿Ï˘Û˘ √∞π Î˘Ì¿ÓıËΠ·fi 0-2,5 mmol/l. ∆· ‰Â›ÁÌ·Ù· Ô˘ ›¯·Ó Û˘ÁÎÂÓÙÚÒÛÂȘ ¿Óˆ ÙˆÓ 2,5 mmol ·Ú·ÈÒıËÎ·Ó ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÔÚfi Î·È Â·Ó·Ï‹ÊıËÎÂ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙÔ˘˜. ∆· ·ÔÙÂϤÛÌ·Ù· ÂÎÊÚ¿˙ÔÓÙ·È ˆ˜ ̤ÛË ÙÈÌ‹ ± ÛÙ·ıÂÚ‹ ·fiÎÏÈÛË. ∏ Û‡ÁÎÚÈÛË ÙˆÓ ‚ÈÔ¯ËÌÈÎÒÓ Î·È ÙˆÓ ‰È·ÈÙËÙÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ ¤ÁÈÓ Ì A¡OVA ·ÎÔÏÔ˘ıÔ‡ÌÂÓË ·fi ÙË ‰ÔÎÈÌ·Û›· Dunnet, ÂÓÒ ÔÈ Û˘Û¯ÂÙ›ÛÂȘ ÙÔ˘˜ Ú·ÁÌ·ÙÔÔÈ‹ıËÎ·Ó Ì ÙË ‰ÔÎÈÌ·Û›· Spearman.
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¶·È‰È·ÙÚÈ΋ 2001;64:154-158
AÔÙÂϤÛÌ·Ù· ¢È·ÙÚÔÊÈο ÛÙÔȯ›·: Ÿˆ˜ Ê·›ÓÂÙ·È ÛÙÔÓ ›Ó·Î· 1, Ë ıÂÚÌȉÈ΋ Î·È Ë ÚˆÙÂ˚ÓÈ΋ ÚfiÛÏË„Ë ‰ÂÓ ‰È¤ÊÂÚ ÌÂٷ͇ ÙˆÓ 3 ÔÌ¿‰ˆÓ, ·ÏÏ¿ Ë ÚfiÛÏË„Ë Ê˘ÙÈÎÒÓ ÈÓÒÓ Î·È ÙˆÓ ÔÏ˘·ÎfiÚÂÛÙˆÓ ÏÈÒÓ ‰È¤ÊÂÚ ηٿ Ôχ ÛÙËÓ ÔÌ¿‰· A. ∞ÎfiÌË, Ë ÚfiÛÏË„Ë Ï›Ô˘˜, ÌÔÓÔ·ÎfiÚÂÛÙˆÓ ÏÈÒÓ Î·È Ô ÏfiÁÔ˜ ÔÏ˘·ÎfiÚÂÛÙˆÓ/ÎÔÚÂÛÌ¤ÓˆÓ ÏÈÒÓ, ¯ÔÏËÛÙÂÚfiÏ˘ Î·È ÌÔÓÔ·ÎfiÚÂÛÙˆÓ ‰È¤ÊÂÚ·Ó ÌÂٷ͇ Ù˘ ÔÌ¿‰·˜ ∞ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ, ηıÒ˜ ›Û˘ ÌÂٷ͇ ÙˆÓ ‰‡Ô ÔÌ¿‰ˆÓ ÙˆÓ ·ÛıÂÓÒÓ. ∂›Û˘, ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ‰È¤ÊÂÚ·Ó ÔÈ ÚÔÛÏ‹„ÂȘ ‚-ηڈÙÂÓ›ˆÓ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ fiˆ˜ Î·È Ù˘ ·-ÙÔÎÔÊÂÚfiÏ˘ Ù˘ ÔÌ¿‰·˜ ∞ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ∏ ÚfiÛÏË„Ë Ù˘ ‚ÈÙ·Ì›Ó˘ C ‰ÂÓ ‰È¤ÊÂÚ ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ. µÈÔ¯ËÌÈο Â˘Ú‹Ì·Ù·: ™ÙÔÓ ›Ó·Î· 2 ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È Ù· ›‰· Ù˘ ‚ÈÙ·Ì›Ó˘ C ÛÙÔ Ï¿ÛÌ· Ô˘ ‰ÂÓ ‰È¤ÊÂÚ·Ó ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ. ∞ÓÙ›ıÂÙ·, Ù· ‚ηڈ٤ÓÈ· ›¯·Ó ‰ÈÏ¿ÛÈ· ÛÙ¿ıÌË ÛÙËÓ ÔÌ¿‰· ∞ Î·È Ë ·-ÙÔÎÔÊÂÚfiÏË ‰È¤ÊÂÚ ÛÙ·ÙÈÛÙÈο ÛËÌ·ÓÙÈο ÌfiÓÔ ÛÙËÓ ÔÌ¿‰· ∞ ÙˆÓ PKU ·ÛıÂÓÒÓ. √ ÏfiÁÔ˜ ·-ÙÔÎÔÊÂÚfiÏË/¯ÔÏËÛÙÂÚfiÏË ‰È¤ÊÂÚ ÙfiÛÔ ÌÂٷ͇ ÙˆÓ ‰‡Ô PKU - ÔÌ¿‰ˆÓ, fiÛÔ Î·È ÌÂٷ͇ Ù˘ ÔÌ¿‰·˜ ∞ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ∏ √∞π ÛÙÔ Ï¿ÛÌ· ÙˆÓ ÌÂÏÒÓ Ù˘ ÔÌ¿‰·˜ ∞ ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË, Û˘ÁÎÚÈÓfiÌÂÓË Ì ÂΛÓË Ù˘ µ Î·È ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ∆· ›‰· ÙÔ˘ ·ÌÈÓÔͤԘ Phe, fiˆ˜ ¿ÏψÛÙ ·Ó·ÌÂÓfiÙ·Ó, ‹Ù·Ó Û·ÊÒ˜ ˘„ËÏfiÙÂÚ· ÛÙËÓ ÔÌ¿‰· µ. ™ÙÔÓ ›Ó·Î· 3 Ê·›ÓÔÓÙ·È ÔÈ Û˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ ÙˆÓ ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ ÛÙÔȯ›ˆÓ ‰È·ÙÚÔÊ‹˜, fiˆ˜ ›Û˘ Î·È ÌÂٷ͇ ÙˆÓ ÂȤ‰ˆÓ ÙÔ˘˜ ÛÙÔ Ï¿ÛÌ·
Paediatriki 2001;64:154-158
Û ۯ¤ÛË Ì ÙÔ √∞π ÛÙȘ ÔÌ¿‰Â˜ ÙˆÓ PKU ·ÛıÂÓÒÓ. ∏ ÚÔÛÏ·Ì‚·ÓfiÌÂÓË ‚ÈÙ·Ì›ÓË C Û˘Û¯ÂÙ›˙ÂÙ·È ÛÙÂÓ¿ Ì ÙÔ √∞π Î·È ÛÙȘ ‰‡Ô ÔÌ¿‰Â˜ ÙˆÓ ·ÛıÂÓÒÓ, ÂÓÒ Ù· ‚-ηڈ٤ÓÈ· Î·È Ë ·-ÙÔÎÔÊÂÚfiÏË ÌfiÓÔ ÛÙËÓ ÔÌ¿‰· ∞. Ÿˆ˜ ‹Ù·Ó ·Ó·ÌÂÓfiÌÂÓÔ, Ù· ›‰· Ù˘ ‚ÈÙ·Ì›Ó˘ C ÛÙÔ Ï¿ÛÌ· Û˘Û¯ÂÙ›˙ÔÓÙ·Ó ÛÙÂÓ¿ Ì ÙÔ √∞π Î·È ÛÙȘ ‰‡Ô PKU-ÔÌ¿‰Â˜, ÂÓÒ Ë ·ÙÔÎÔÊÂÚfiÏË Î·È Ô ÏfiÁÔ˜ ·-ÙÔÎÔÊÂÚfiÏË/¯ÔÏËÛÙÂÚ›ÓË Û˘Û¯ÂÙ›˙ÔÓÙ·Ó ÌfiÓÔ ÛÙËÓ ÔÌ¿‰· ∞. ∆· ›‰· ÙÔ˘ ·ÌÈÓÔͤԘ Phe ‰ÂÓ Ê·›ÓÂÙ·È Ó· Û˘Û¯ÂÙ›˙ÔÓÙ·È Ì ÙÔ √∞π Û η̛· ÔÌ¿‰· Ù˘ ÌÂϤÙ˘ ·˘Ù‹˜. ™˘˙‹ÙËÛË ∂ȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ (15-17) ¤¯Ô˘Ó ‹‰Ë ·Ô‰Â›ÍÂÈ fiÙÈ Ô Î›Ó‰˘ÓÔ˜ ÁÈ· ÙËÓ ·Ó¿Ù˘ÍË Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘ Â›Ó·È Û·ÊÒ˜ ÌÈÎÚfiÙÂÚÔ˜ ÛÙÔ˘˜ Ê˘ÙÔÊ¿ÁÔ˘˜ (vegetarian), fiˆ˜ ›Û˘ Â›Ó·È ¯·ÌËÏfiÙÂÚ· Ù· ›‰· ÏÈȉ›ˆÓ ÔÚÔ‡ ÛÙËÓ ÔÌ¿‰· ·˘Ù‹. ∏ ‰È·ÊÔÚ¿ ·˘Ù‹ ÛÙ· ›‰· ÙˆÓ ÏÈȉ›ˆÓ ÂÍËÁÂ›Ù·È ·fi ÙË ÌÂȈ̤ÓË ÂÚÈÂÎÙÈÎfiÙËÙ· ÏÈÒÓ ÛÙË ‰È·ÙÚÔÊ‹ ÙÔ˘˜ Î·È ÙËÓ ‡·ÚÍË Ê˘ÙÈÎÒÓ ÈÓÒÓ (16), ·fi ÙËÓ ¿Ô„Ë fiÙÈ Ë ÂȉÈ΋ ¯·ÌËÏ‹ ÙÈÌ‹ Û Phe ‰›·ÈÙ· Ô˘ ·ÎÔÏÔ˘ıÔ‡Ó ÔÈ ·ÛıÂÓ›˜ Ì·˜ ı· ÌÔÚÔ‡Û ӷ ¯·Ú·ÎÙËÚÈÛı› ˆ˜ ‰›·ÈÙ· Ê˘ÙÔÊ¿ÁˆÓ, ÛÙÔ ‚·ıÌfi Ô˘ ÔÈ PKU ·ÛıÂÓ›˜ ·ÔʇÁÔ˘Ó Û˘ÛÙËÌ·ÙÈο ÙË Ï‹„Ë ÎÚ¤·ÙÔ˜, „·ÚÈÔ‡, ·˘ÁÔ‡ ÎÏ. (18). ¢˘ÛÙ˘¯Ò˜, fï˜, ÔÏÏÔ› ·fi ÙÔ˘˜ PKU ·ÛıÂÓ›˜ ‰ÂÓ ·ÎÔÏÔ˘ıÔ‡Ó Ì ·ÎÚ›‚ÂÈ· ÙËÓ “ÂȉÈ΋” ıÂڷ¢ÙÈ΋ ÙÔ˘˜ ‰›·ÈÙ· ‹ ÙËÓ ·ÎÔÏÔ˘ıÔ‡Ó ¯·Ï·Ú¿, fiˆ˜ Ù· ̤ÏË Ù˘ ÔÌ¿‰·˜ µ. ∞ÓÙ›ıÂÙ·, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ·ÎÔÏÔ˘ıÔ‡Ó ÌÂ
¶›Ó·Î·˜ 1. ∏ÌÂÚ‹ÛÈ· ‰È·ÙÚÔÊÈο ÛÙÔȯ›· (ª¤ÛË ∆ÈÌ‹ ± ™∞) ÙˆÓ ÔÌ¿‰ˆÓ ÙˆÓ º·ÈÓ˘ÏÎÂÙÔÓÔ˘ÚÈÎÒÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ ª·ÚÙ‡ÚˆÓ
™ÙÔȯ›· ¢È·ÙÚÔÊ‹˜ £ÂÚÌ›‰Â˜ (kcal) À‰·Ù¿ÓıڷΘ (g) ¶ÚˆÙ½ÓË (g) º˘Ù. ÿÓ˜ (g) √ÏÈÎfi §›Ô˜ (g) ∫ÔÚÂÛÌ. §›Ô˜ (g) ªÔÓÔ·ÎfiÚÂÛÙÔ §›Ô˜ (g) ¶ÔÏ˘·ÎfiÚÂÛÙÔ §›Ô˜ (g) ¶ÔÏ˘·ÎfiÚ./∫ÔÚÂÛÌ. ÃÔÏËÛÙÂÚfiÏË (g) µÈÙ·Ì›ÓË C (mg) ‚-∫·ÚˆÙ¤ÓÈ· (mg) ·-∆ÔÎÔÊÂÚfiÏË (mg) ™.∞.: ™Ù·ıÂÚ‹ ∞fiÎÏÈÛË
156
¢È·ÙÚÔÊÈ΋ ¶ÚfiÛÏË„Ë (ª¤ÛË ÙÈÌ‹ ± ™∞) √Ì¿‰· A √Ì¿‰· B ª¿ÚÙ˘Ú˜ N=22 N=24 N=40 2020 ± 400 2038 ± 450 2078 ± 1470 268,2 ± 10 232,0 ± 20 230 ± 56 70 ± 12 72,0 ± 2,0 73,0 ± 17 30 ± 8 21 ± 8,0 16,6 ± 4,0 80 ± 25,0 87 ± 4,0 99,0 ± 5,0 29 ± 10 45,0 ± 11 56 ± 11 25 ± 8 32 ± 9 33 ± 8 26 ± 7 11,7 ± 4 11,0 ± 3,5 0,90 ± 0,2 0,3 ± 0,1 0,2 ± 0,1 312 ± 140 330 ± 120 355 ± 110 108 ± 14 102 ± 16 98 ± 11 2011 ± 110 1352 ± 118 1290 ± 120 14,0 ± 1,0 10,0 ± 1,0 9,0 ± 1,0
™Ù·Ù. ™ËÌ·ÓÙÈΤ˜ ¢È·Ê. (P) A vs B vs A vs ª¿ÚÙ˘Ú˜ ª¿ÚÙ˘Ú˜ B 0,05 0,05 0,001 0,012 0,001 0,01 0,001 0,002 0,0001 0,007 0,03 0,001 0,001 0,001 0,0001 0,01 0,001 0,001 0,01 -
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¶›Ó·Î·˜ 2. µÈÔ¯ËÌÈο Â˘Ú‹Ì·Ù· ÛÙȘ √Ì¿‰Â˜ ÙˆÓ º·ÈÓ˘Ï/ÎÒÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ ª·ÚÙ‡ÚˆÓ
‚-∫·ÚˆÙ¤ÓÈ· (Ìmol/l) ·-ToÎÔÊÂÚfiÏË (Ìmol/l) µÈÙ·Ì›ÓË C (Ìmol/l) ÃÔÏËÛÙÂÚfiÏË (mg/dl) ·-∆ÔÎÔÊÂÚfiÏË/ÃÔÏËÛÙÂÚfiÏË HDL (mg/dl) LDL (mg/dl) √ÏÈ΋ ∞ÓÙÈÔÍÂȉˆÙÈ΋ πηÓfiÙËÙ· (√∞π) (mmol/l) º·ÈÓ˘Ï·Ï·Ó›ÓË (Ìmol/l)
√Ì¿‰· A (N=22) 0,7 ± 0,09 28 ± 0,9 36,3 ± 1,1 140 ± 12,0 5,0 ± 0,4 43,0 ± 6,0 80,6 ± 22,0
√Ì¿‰· B (N=24) 0,49 ± 0,02 22,0 ± 0,6 34,5 ± 1,1 190 ± 10,6 3,78 ± 0,1 41,2 ± 6,6 112 ± 20
ª¿ÚÙ˘Ú˜ (N=40) 0,3 ± 0,09 21,0 ± 0,6 37,2 ± 1,01 196 ± 12,0 3,3 ± 0,1 44,0 ± 5,6 116 ± 21
AvsC 0,001 0,03 0,001 0,001 0,001
P ÙÈÌ‹ BvsC 0,01 -
AvsB 0,0001 0,03 0,001 0,001 0,001
1,597 ± 0,208 0,992±0,190 192±60 595±104
1,01 ± 0,180 120±51
0,01 0,01
0,001
0,001 0,001
Û˘Ó¤ÂÈ· ÙË ‰›·ÈÙ¿ ÙÔ˘˜ (ÔÌ¿‰· ∞), ÙfiÛÔ Ù· ›‰· ÙˆÓ ‚-ηڈÙÂÓ›ˆÓ fiÛÔ Î·È Ù˘ ·-ÙÔÎÔÊÂÚfiÏ˘ ÌÂÙÚ‹ıËÎ·Ó ÛËÌ·ÓÙÈο ·˘ÍË̤ӷ ÛÙÔ Ï¿ÛÌ· ÙÔ˘˜. ∆· ›‰· Ù˘ ‚ÈÙ·Ì›Ó˘ C ‰ÂÓ ‰È¤ÊÂÚ·Ó ÌÂٷ͇ ÙˆÓ ÔÌ¿‰ˆÓ Ù˘ ÌÂϤÙ˘, ·ÊÔ‡ Ù· ÂÛÂÚȉÔÂȉ‹ (.¯. ÔÚÙÔοÏÈ·, ÏÂÌfiÓÈ· Î.Ï.) ηٷӷÏÒÓÔÓÙ·È Û˘Ó‹ıˆ˜ ·fi fiÏ· Ù· ∂ÏÏËÓfiÔ˘Ï·. ∞ÎfiÌ·, fiˆ˜ Â›Ó·È ÁÓˆÛÙfi, Ë ÏÔ‡ÛÈ· Û Ϸ¯·ÓÈο Î·È ÊÚÔ‡Ù· ‰›·ÈÙ· Ô˘ ·ÎÔÏÔ˘ı› Ë ÔÌ¿‰· ∞, Â›Ó·È ÏÔ‡ÛÈ· ÛÙȘ ·ÓÙÈÔÍÂȉˆÙÈΤ˜ ‚Èٷ̛Ә, Ê˘ÙÈΤ˜ ›Ó˜ Î·È È¯ÓÔÛÙÔȯ›· (19). ¶ÔÏÏÔ› ÂÚ¢ÓËÙ¤˜ (20,21) Û˘Û¯ÂÙ›˙Ô˘Ó ÙËÓ ·˘ÍË̤ÓË ÚfiÛÏË„Ë Ù˘ ‚ÈÙ·Ì›Ó˘ C Ì Ì›ˆÛË Ù˘ ÂÌÊ¿ÓÈÛ˘ ηډȷÎÒÓ ÂÌÊÚ·ÁÌ¿ÙˆÓ. ™ÙË ÌÂϤÙË ÙÔ˘ Rotterdam, ·Ú·ÙËÚ‹ıËÎ·Ó Ù· ›‰È· ¢ÂÚÁÂÙÈο ·ÔÙÂϤÛÌ·Ù·, fiÙ·Ó Ù· ‚-ηڈ٤ÓÈ· ÚÔÛÏ·Ì‚¿¶›Ó·Î·˜ 3. ™˘Û¯ÂÙ›ÛÂȘ ÌÂٷ͇ Ù˘ √ÏÈ΋˜ ∞ÓÙÈÔÍÂȉˆÙÈ΋˜ πηÓfiÙËÙ·˜ (√∞π) ÛÙÔ Ï¿ÛÌ· Î·È ÙˆÓ ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ ‚ÈÙ·ÌÈÓÒÓ Ù˘ ¢È·ÙÚÔÊ‹˜ Î·È ÙÔ˘ ¶Ï¿ÛÌ·ÙÔ˜ ∞ÛıÂÓÒÓ Ì º·ÈÓ˘ÏÎÂÙÔÓÔ˘Ú›· ¢È·ÙÚÔÊ‹ πηÓ. µÈÙ·Ì›ÓË C ‚-K·ÚˆÙ¤ÓÈ· ·-∆ÔÎÔÊÂÚfiÏË ¶Ï¿ÛÌ· µÈÙ·Ì›ÓË C ‚-∫·ÚˆÙ¤ÓÈ· ·-∆ÔÎÔÊÂÚfiÏË ·-∆ÔÎÔÊ./ÃÔÏËÛÙ. º·ÈÓ˘Ï·Ï·Ó›ÓË * p <0,01 ** p <0,001
√Ì¿‰Â˜
√ÏÈ΋ ∞ÓÙÈÔÍÂȉˆÙÈ΋
A B A B A B
0,72** 0,42* 0,44* 0,15 0,69** 0,26
A B A B A B A B A B
0,63** 0,41* 0,52* 0,20 0,66** 0,22 0,77** 0,10 0,12 0,21
ÓÔÓÙ·Ó Û ·˘ÍË̤Ó˜ ÔÛfiÙËÙ˜. ∆Ô ÙÂÏÂ˘Ù·›Ô ‰ÂÓ Û˘Ó¤‚·ÈÓ Ì ÙËÓ ·˘ÍË̤ÓË ÚfiÛÏË„Ë ‚ÈÙ·Ì›Ó˘ ∂ (4). Ÿˆ˜ Â›Ó·È Â›Û˘ ÁÓˆÛÙfi, Ë ÔÍÂȉˆÌ¤ÓË LDL ¤¯ÂÈ Û¯¤ÛË Ì ÙËÓ ·Ó¿Ù˘ÍË Î·Ú‰È·ÁÁÂȷ΋˜ ÓfiÛÔ˘ Ô˘ ÂËÚ¿˙ÂÙ·È Î·È ·fi ¿ÏÏÔ˘˜ ‰È·ÙÚÔÊÈÎÔ‡˜ ·Ú¿ÁÔÓÙ˜ ÂÎÙfi˜ ÙˆÓ ·ÓÙÈÔÍÂȉˆÙÈÎÒÓ ‚ÈÙ·ÌÈÓÒÓ. ™ÙËÓ ÂÚ›ÙˆÛË ÙˆÓ PKU ·ÛıÂÓÒÓ (ÔÌ¿‰· ∞) ‚Ú¤ıËÎ·Ó ¯·ÌËÏ¿ Ù· ›‰· Ù˘ LDL (17) ·fi ÙË ÌÂȈ̤ÓË ÚfiÛÏË„Ë ÏÈÒÓ, ÂÓÒ Ë ˘„ËÏ‹ ÛÙ¿ıÌË Ù˘ ‚ÈÙ·Ì›Ó˘ ∂ Ô˘ ÂÌÂÚȤ¯ÂÙ·È ÛÙ· ÔÏ˘·ÎfiÚÂÛÙ·, ÚÔÊ˘Ï¿ÛÛÂÈ ÙËÓ ÔÍ›‰ˆÛË Ù˘ LDL (6,22). T· ·ÓˆÙ¤Úˆ ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ Â›Ó·È Û ϋÚË Û˘Ìʈӛ· Ì ٷ ‰Èο Ì·˜ Â˘Ú‹Ì·Ù· Î·È ÙȘ Û˘Û¯ÂÙ›ÛÂȘ, fiˆ˜ Ê·›ÓÔÓÙ·È ÛÙÔÓ ›Ó·Î· 3. ™ÙÔÓ ›‰ÈÔ ›Ó·Î·, οı ·ÓÙÈÔÍÂȉˆÙÈ΋ ‚ÈÙ·Ì›ÓË, ÙfiÛÔ Ù˘ ÚÔÛÏ·Ì‚·ÓfiÌÂÓ˘ Ì ÙȘ ÙÚÔʤ˜, fiÛÔ Î·È Ù˘ ÌÂÙÚËı›۷˜ ÛÙÔ Ï¿ÛÌ· ÛÙȘ ÔÌ¿‰Â˜ ÙˆÓ ·ÛıÂÓÒÓ ÛÙË ÌÂϤÙË, Û˘Û¯ÂÙ›˙ÂÙ·È Ì ÙÔ √∞π. ∆Ô √∞π, Ô˘ ÚÔÛ‰ÈÔÚ›ÛÙËΠ۠PKU ·ÛıÂÓ›˜ ‹Ù·Ó ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚÔ ÛÙËÓ ÔÌ¿‰· ÂÎÂ›ÓˆÓ Ô˘ ·ÎÔÏÔ‡ıËÛ·Ó ¯·Ï·Ú¿ ÙËÓ ÂȉÈ΋ ‰›·ÈÙ· (ÔÌ¿‰· µ), Ô˘ Èı·Ó¿ ÔÊ›ÏÂÙ·È Î·È ÛÙ· ˘„ËÏfiÙÂÚ· ›‰· Ù˘ LDL Î·È Ù· ¯·ÌËÏfiÙÂÚ· ÙˆÓ ‚-ηڈÙÂÓ›ˆÓ Î·È ·-ÙÔÎÔÊÂÚfiÏ˘ ÛÙÔ Ï¿ÛÌ· ÙÔ˘˜. ∏ ·Ú·ÙËÚÔ‡ÌÂÓË ·˘ÍË̤ÓË ÙÈÌ‹ Ù˘ Phe ÛÙÔ ·›Ì· ÙÔ˘˜ ı· ÌÔÚÔ‡Û ÂÈÚfiÛıÂÙ· Ó· ·›˙ÂÈ ÚfiÏÔ “·‰‡Ó·ÌÔ˘ Û·ÚˆÙ‹ √∏ ÔÌ¿‰ˆÓ” ÛÙÔ ‚·ıÌfi Ô˘ ¤¯ÂÈ ‚ÚÂı› Ë ‰ËÌÈÔ˘ÚÁ›· Ô-, Ì-, - Ù˘ÚÔÛÈÓÒÓ (22,23) Ù˘ Phe Ì ÙȘ ÂÚȤ¯Ô˘Û˜ √∏ ÂχıÂÚ˜ Ú›˙˜. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÔÈ ·ÛıÂÓ›˜ Ì PKU Ô˘ ·ÎÔÏÔ˘ıÔ‡Ó ÛˆÛÙ¿ ÙËÓ ÂȉÈ΋ ıÂڷ¢ÙÈ΋ ÙÔ˘˜ ‰›·ÈÙ· ¤¯Ô˘Ó ˘„ËÏ‹ ·ÓÙÈÔÍÂȉˆÙÈ΋ ÈηÓfiÙËÙ· Ï¿ÛÌ·ÙÔ˜ Ô˘ ÔÊ›ÏÂÙ·È ÛÙÔ Â›‰Ô˜ Ù˘ ‰È·ÙÚÔÊ‹˜ ÙÔ˘˜ (Ê˘ÙÔÊ¿ÁÔÈ). ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi ı· ÌÔÚÔ‡Û Èı·Ó¿ Ó· ·›ÍÂÈ ÚÔÛٷ٢ÙÈÎfi ÚfiÏÔ ÁÈ· ÙȘ ·Ûı¤ÓÂȘ Ô˘ Û¯ÂÙ›˙ÔÓÙ·È Ì ÙËÓ ·ÚÔ˘Û›· ÂÏ¢ı¤ÚˆÓ ÚÈ˙ÒÓ.
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∂˘¯·ÚÈÛٛ˜ √È Û˘ÁÁÚ·Ê›˜ ıˆÚÔ‡Ó ˘Ô¯Ú¤ˆÛ‹ ÙÔ˘˜ Ó· ¢¯·ÚÈÛÙ‹ÛÔ˘Ó ÙËÓ Î. ∫. ∆·ÛÛÔÔ‡ÏÔ˘ ÁÈ· ÙËÓ ÂÈÌÂÏË̤ÓË ‰·ÎÙ˘ÏÔÁÚ¿ÊËÛË Ù˘ ÂÚÁ·Û›·˜ ·˘Ù‹˜.
14.
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 31-08-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 11-01-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∫ÏÂÔ¿ÙÚ· ∂. ™Ô‡ÏË πÓÛÙÈÙÔ‡ÙÔ ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, 115 27, ∞ı‹Ó·
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CASE REPORT
∏ ÔÍ›· ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ˆ˜ ÂΉ‹ÏˆÛË Û˘ÁÁÂÓÔ‡˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ Û ‚Ú¤ÊÔ˜ ¡. ª·ÏÙÔÁÈ¿ÓÓ˘, ∂. ¶··Ó‰Ú¤Ô˘, Ã. ÃȈٛÓ˘, µ. ÷ڛÛË, ¢. ∫ÂÚ·Ì›‰·˜
Congenital diaphragmatic hernia presenting with acute respiratory distress in an infant N. Baltogiannis, E. Papandreou, C. Chiotinis, V. Charisi, D. Keramidas
¶ÂÚ›ÏË„Ë: ∏ ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ Ù‡Ô˘ Bochdalek Ì ÂÈÎfiÓ· ÔÍ›·˜ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Î·È Î˘¿ÓˆÛË Â›Ó·È Û¿ÓÈ· ÛÙË ÌË ÓÂÔÁÓÈ΋ ËÏÈΛ·. ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ Â›Ó·È Ó· ÙÔÓÈÛÙ› fiÙÈ Ë Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ·ÙfiÌˆÓ ‚ÚÂÊÈ΋˜ Î·È ·È‰È΋˜ ËÏÈΛ·˜. ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ‚Ú¤ÊÔ˘˜ ËÏÈΛ·˜ 3 ÌËÓÒÓ Ô˘ ·ÚÔ˘Û›·Û ·ÈÊÓ›‰È· ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· ÌÂÙ¿ ÙË Ï‹„Ë Á‡̷ÙÔ˜. ªÂٷʤÚıËΠ۠°ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô fiÔ˘ ·ÓÙÈÌÂÙˆ›ÛıËΠ̠ÙÔÔı¤ÙËÛË ÎÏÂÈÛÙ‹˜ ·ÚÔ¯¤Ù¢Û˘ ÛÙÔ ˘ÁȤ˜ ‰ÂÍÈfi ËÌÈıˆÚ¿ÎÈÔ ÌÂÙ¿ ÙËÓ ÂÎÙ¤ÏÂÛË ·ÎÙÈÓÔÁÚ·Ê›·˜ ıÒÚ·ÎÔ˜, ÌÂ Û˘Ó¤ÂÈ· ÙËÓ ÂÈ‚¿Ú˘ÓÛ‹ ÙÔ˘. ∏ ÌÂÙ·ÊÔÚ¿ ÙÔ˘ ‚Ú¤ÊÔ˘˜ ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ Î·È Ë Â·Ó¿ÏË„Ë Ù˘ ·ÎÙÈÓÔÁÚ·Ê›·˜ ÌÂÙ¿ ÙËÓ ÙÔÔı¤ÙËÛË ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ۈϋӷ, Ô‰‹ÁËÛ·Ó ÛÙË ‰È¿ÁÓˆÛË ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ Bochdalek ·ÚÈÛÙÂÚ¿, ·Ê·›ÚÂÛË Ù˘ ·ÚÔ¯¤Ù¢Û˘ ÙÔ˘ ‰ÂÍÈÔ‡ ËÌÈıˆÚ·Î›Ô˘ Î·È Â›ÁÔ˘Û· ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÈfiÚıˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ ·ÓˆÌ·Ï›·˜ Ì ηϋ ¤Î‚·ÛË. ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ë ·ÓÙÈÌÂÙÒÈÛË Ù¤ÙÔÈˆÓ ÂÚÈÙÒÛÂˆÓ ··ÈÙ› ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ÁÓÒÛÂȘ, ÂÓÒ Ë Î·ı˘ÛÙÂÚË̤ÓË ÌÂÙ·ÊÔÚ¿ Û ÂȉÈο ·È‰Ô¯ÂÈÚÔ˘ÚÁÈο ΤÓÙÚ· ÌÔÚ› Ó· ηٷϋÍÂÈ Û ·ÒÏÂÈ· ÙÔ˘ ·ÛıÂÓ‹.
Abstract: The clinical presentation of congenital diaphragmatic hernia (CDH), Bochdalek type, with acute respiratory distress and cyanosis has rarely been reported to occur in the post-neonatal period. The purpose of this report is to stress the need to include CDH in the differential diagnosis of acute respiratory distress in infants and older children. A 3 month old boy is presented, who developed acute respiratory distress following ingestion of a normal meal. He was admitted to a General Hospital where a closed chest drainage was inserted in the normal right pleural cavity, which led to further deterioration. He was then transferred to our Hospital where, following the insertion of a nasogastric tube, a repeat chest xray led to the diagnosis of CDH. Following removal of the closed chest drainage he underwent emergency surgical correction of the congenital abnormality, which led to an uneventful recovery. We conclude that such cases require expertise knowledge and awareness of this condition and that delayed recognition and transfer to specialized pediatric surgical units may have deleterious results.
§¤ÍÂȘ ÎÏÂȉȿ: ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË ·ÚÈÛÙÂÚ¿.
Key words: respiratory distress, left congenital diaphragmatic hernia.
∂ÈÛ·ÁˆÁ‹ ∏ ÔÍ›· ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· (√∞¢) ÛÙË ‚ÚÂÊÈ΋ ËÏÈΛ· ÌÔÚ›, Û ÔÚÈṲ̂Ó˜ ÂÚÈÙÒÛÂȘ, Ó· Â›Ó·È ÙÔ ·Ú¯ÈÎfi Û‡Ìو̷ ¤ÎÊÚ·Û˘ Ù˘ Û˘ÁÁÂÓÔ‡˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ (™¢). ∏ ηı˘ÛÙÂ-
ÚË̤ÓË ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË Ù˘ ™¢, ÌÂÙ¿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·, ÂÌÊ·Ó›˙ÂÙ·È Û ÔÛÔÛÙfi 5–25% ÙˆÓ ÂÚÈÙÒÛÂˆÓ (1,2). ™ÎÔfi˜ Ù˘ ÂÚÁ·Û›·˜ Â›Ó·È Ó· ÙÔÓÈÛÙ› fiÙÈ Ë Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË Ú¤ÂÈ Ó· ÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘
µ’ ¶·È‰Ô¯ÂÈÚÔ˘ÚÁÈ΋ ∫ÏÈÓÈ΋ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
2nd Surgical Department “Agia Sophia” Children’s Hospital, Athens
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∂ÈÎfiÓ· 1. µÚ¤ÊÔ˜ ËÏÈΛ·˜ 3 ÌËÓÒÓ. ⁄·ÚÍË ÎÔ›ÏÔ˘ ÛÏ¿¯ÓÔ˘ ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈıˆÚ¿ÎÈÔ, ÌÂÙ·ÙfiÈÛË ÌÂÛÔıˆÚ·Î›Ô˘ ‰ÂÍÈ¿, ˘Ô·ÂÚÈÛÌfi˜ Ó‡ÌÔÓ· ‰ÂÍÈ¿ Î·È ÛˆÏ‹Ó·˜ ÎÏÂÈÛÙ‹˜ ·ÚÔ¯¤Ù¢Û˘ ıÒڷη ‰ÂÍÈ¿.
·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ ·ÙfiÌˆÓ ‚ÚÂÊÈ΋˜ Î·È ·È‰È΋˜ ËÏÈΛ·˜. ¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 3 ÌËÓÒÓ Ì ÔÍ›· ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· Î·È Û˘ÁÁÂÓ‹ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË ·ÚÈÛÙÂÚ¿. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ, ËÏÈΛ·˜ 3 ÌËÓÒÓ, ÂÈÛ‹¯ıË ÂÂÈÁfiÓÙˆ˜ Û ·È‰È·ÙÚÈ΋ ÎÏÈÓÈ΋ ÂÚÈÊÂÚÂÈ·ÎÔ‡ ÓÔÛÔÎÔÌ›Ԣ ÌÂ Û˘ÌÙÒÌ·Ù· ÔÍ›·˜ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜ Ô˘ ÂΉËÏÒıËÎ·Ó ÌÂÙ¿ ÙÔ Ù¤ÏÔ˜ Ù˘ Û›ÙÈÛ˘. ∆Ô ‚Ú¤ÊÔ˜ ‹Ù·Ó Ê·ÈÓÔÌÂÓÈο ˘ÁȤ˜ Ì ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi Î·È ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ÂχıÂÚÔ. ŒÁÈÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ Ù˘ ÔÔ›·˜ Ù· Â˘Ú‹Ì·Ù· ‰ÂÓ ·ÍÈÔÏÔÁ‹ıËÎ·Ó ÛˆÛÙ¿. ∂ÓÒ Â›¯Â ÌÂÙ·ÙfiÈÛË ÙÔ˘ ÌÂÛÔıˆÚ·Î›Ô˘ ÚÔ˜ ÙËÓ ˘ÁÈ‹ ÏÂ˘Ú¿, ‡·ÚÍË ÎÔ›ÏÔ˘ ÛÏ¿¯ÓÔ˘ ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈıˆÚ¿ÎÈÔ ¯ˆÚ›˜ ÂÌÊ·Ó‹ ÛËÌ›· Ó¢ÌÔıÒڷη ‹ Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜ ÛÙÔ ‰ÂÍÈfi ËÌÈıˆÚ¿ÎÈÔ (∂ÈÎfiÓ· 1), ÙÔÔıÂÙ‹ıËΠÎÏÂÈÛÙ‹ ·ÚÔ¯¤Ù¢ÛË ÛÙË ‰ÂÍÈ¿ ˘ÁÈ‹ ıˆÚ·ÎÈ΋ ÎÔÈÏfiÙËÙ· Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂȉÂÈÓˆı› Ë √∞¢. √ ·ÛıÂÓ‹˜ ÌÂٷʤÚıËΠÂÛ¢Ṳ̂ӷ ·ÂÚÔÔÚÈÎÒ˜ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Ì·˜. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, ÙÔ ‚Ú¤ÊÔ˜ ·ÚÔ˘Û›·˙ ¤ÓÙÔÓË ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, ΢¿ÓˆÛË, „˘¯Ú¿ ¿ÎÚ·, Ù·¯˘Î·Ú‰›· Î·È ÂÈfiÏ·ÈË ·Ó·ÓÔ‹. ∞fi ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË, ‰È·ÈÛÙÒıËΠ̛ˆÛË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ „Èı˘Ú›ÛÌ·ÙÔ˜ ·ÚÈÛÙÂÚ¿
160
∂ÈÎfiÓ· 2. µÚ¤ÊÔ˜ ËÏÈΛ·˜ 3 ÌËÓÒÓ. ·/· ıÒÚ·ÎÔ˜ – ÎÔÈÏ›·˜ ÌÂÙ¿ ÙËÓ ·Ê·›ÚÂÛË 500ml Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘: Ô ÚÈÓÔÁ·ÛÙÚÈÎfi˜ ۈϋӷ˜ ÂÓÙÔ›˙ÂÙ·È ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈıˆÚ¿ÎÈÔ (‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË Bochdalek). ªÂÛÔıˆÚ¿ÎÈÔ ÛÙË Ê˘ÛÈÔÏÔÁÈ΋ ı¤ÛË Î·È ‚ÂÏÙ›ˆÛË Ù˘ ·ÎÙÈÓÔÏÔÁÈ΋˜ ÂÈÎfiÓ·˜ ÙÔ˘ ‰ÂÍÈÔ‡ ËÌÈıˆÚ·Î›Ô˘ (ÂͤٷÛË ÂÎÏÔÁ‹s ÁÈ· ÙËÓ ·ÎÚÈ‚‹ ‰È¿ÁÓˆÛË).
Î·È ÌÂȈ̤ÓË ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ËÌÈıˆÚ·Î›Ô˘. ∆ÔÔıÂÙ‹ıËΠÚÈÓÔÁ·ÛÙÚÈÎfi˜ ۈϋӷ˜ (·Ê·ÈÚ¤ıËÎ·Ó ÂÚ›Ô˘ 500 ml Á·ÛÙÚÈÎÔ‡ ÂÚȯÔ̤ÓÔ˘) Î·È ¤ÁÈÓ ηډÈÔ·Ó·Ó¢ÛÙÈ΋ ·Ó·˙ˆÔÁfiÓˆÛË. ∞fi ÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜, ÚԤ΢„Â Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË Bochdalek ·ÚÈÛÙÂÚ¿, Ì ·ÚÔ˘Û›· ÙÔ˘ ÛÙÔÌ¿¯Ô˘ Î·È ÂÓÙ¤ÚÔ˘ ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈıˆÚ¿ÎÈÔ (∂ÈÎfiÓ· 2). ªÂÙ¿ ÙË ÛÙ·ıÂÚÔÔ›ËÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Î·È ÙËÓ Â·Ó·ÊÔÚ¿ ÙˆÓ ÙÈÌÒÓ ÙˆÓ ·ÂÚ›ˆÓ ·›Ì·ÙÔ˜ ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰·, ÙÔ ‚Ú¤ÊÔ˜ ¯ÂÈÚÔ˘ÚÁ‹ıËΠÌÂÙ¿ 6ÒÚÔ˘ ·fi ÙËÓ ¤Ó·ÚÍË ÙˆÓ Û˘Ìو̿وÓ. ™ÙÔ ·ÚÈÛÙÂÚfi ËÌÈıˆÚ¿ÎÈÔ ‹Ù·Ó Ô ÛÙfiÌ·¯Ô˜, Ô ÛÏ‹Ó·˜, ÏÂÙfi ¤ÓÙÂÚÔ Î·È ÙÌ‹Ì· ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘. ŒÁÈÓ ·Ó¿Ù·ÍË ÙˆÓ ÛÏ¿¯ÓˆÓ ÛÙËÓ ÂÚÈÙÔÓ·˚΋ ÎÔÈÏfiÙËÙ· Î·È ÙÔ ¯¿ÛÌ· ÙÔ˘ ËÌȉȷÊÚ¿ÁÌ·ÙÔ˜ (∂ÈÎfiÓ· 3) ·ÔηٷÛÙ¿ıËΠ̠ϷÛÙÈ΋ Mayo. ∏ ·ÚÈÛÙÂÚ‹ ˘Â˙ˆÎÔÙÈ΋ ÎÔÈÏfiÙËÙ· ·ÚÔ¯ÂÙ‡ÙËΠ̠ÎÏÂÈÛÙfi Û‡ÛÙËÌ·. ∏ ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ ÔÚ›· ‹Ù·Ó ÔÌ·Ï‹ Î·È Ô ·ÛıÂÓ‹˜ ÂÍ‹Ïı ÙË 14Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ë̤ڷ (∂ÈÎfiÓ· 4).
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∂ÈÎfiÓ· 3. µÚ¤ÊÔ˜ ËÏÈΛ·˜ 3 ÌËÓÒÓ. ¢ÈÂÁ¯ÂÈÚËÙÈ΋ ʈÙÔÁÚ·Ê›·: ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË Bochdalek ·ÚÈÛÙÂÚ¿. ªÂÁ¿ÏÔ ¯¿ÛÌ· ·ÚÈÛÙÂÚÔ‡ ËÌȉȷÊÚ¿ÁÌ·ÙÔ˜ Ì ٷ ÂÓ‰ÔÎÔÈÏȷο ÛÏ¿¯Ó· ÂÓÙfi˜ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ËÌÈıˆÚ·Î›Ô˘ (ÛÙfiÌ·¯Ô˜, ÛÏ‹Ó·˜, ÏÂÙfi Î·È ÙÌ‹Ì· ·¯¤Ô˜ ÂÓÙ¤ÚÔ˘).
™˘˙‹ÙËÛË ∏ Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË Bochdalek (™¢) Û˘Ó‹ıˆ˜ ÂΉËÏÒÓÂÙ·È ÌÂÙ¿ ÙÔÓ ÙÔÎÂÙfi, ÌÂ Û˘¯ÓfiÙËÙ· 1 ÂÚ›ÙˆÛË Û οı 2–4000 ÁÂÓÓ‹ÛÂȘ ˙ÒÓÙˆÓ ÓÂÔÁÓÒÓ. ™Â ‚Ú¤ÊË Ê·ÈÓÔÌÂÓÈο ˘ÁÈ‹ Ì ηϋ ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ ÌÔÚ› Ó· ‰È·ÁÓˆÛı› ™¢ ·ÚÎÂÙÔ‡˜ Ì‹Ó˜ ÌÂÙ¿ ÙË Á¤ÓÓËÛË, Û˘Ó‹ıˆ˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ì›·˜ Ïԛ̈͢ ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ ‹ Û ηٷÛÙ¿ÛÂȘ Ô˘ ‰ËÌÈÔ˘ÚÁÔ‡Ó ·‡ÍËÛË Ù˘ ÂÓ‰ÔÎÔÈÏȷ΋˜ ›ÂÛ˘, fiˆ˜ ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË, ¤ÌÂÙÔÈ Î·È ÌÂÙˆÚÈÛÌfi˜ ÎÔÈÏ›·˜ (.¯. ÂÓÙÂÚ›ÙȘ) (3,4). ∞ÚÎÂÙ¤˜ ÂÚÈÙÒÛÂȘ ηı˘ÛÙÂÚË̤Ó˘ ÂÌÊ¿ÓÈÛ˘ Û˘ÁÁÂÓÔ‡˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ ¤¯Ô˘Ó ÂÚÈÁÚ·Ê› ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·. √ Osebold Î·È Ô Soper ·Ó·Ê¤ÚÔ˘Ó fiÙÈ Ë Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË ÌÂÙ¿ ÙË ÓÂÔÁÓÈ΋ ËÏÈΛ·, ÂÌÊ·Ó›˙ÂÙ·È ÛÙÔ 5% ÙˆÓ ÂÚÈÙÒÛˆÓ, ·ÏÏ¿ Û ¿ÏÏË ÌÂϤÙË Ô Newman Î·È ÔÈ Û˘ÓÂÚÁ¿Ù˜ ·Ó‚¿˙Ô˘Ó ÙÔ ÔÛÔÛÙfi ·˘Ùfi Û 25% (1,2). ∏ ËÏÈΛ· Ô˘ Û˘Ó‹ıˆ˜ ·ÚÔ˘ÛÈ¿˙ÂÙ·È, Î˘Ì·›ÓÂÙ·È ·fi ÙÔ˘˜ 3 Ì‹Ó˜ ¤ˆ˜ Ù· 5 ¤ÙË Î·È ÌÂÚÈΤ˜ ÂÚÈÙÒÛÂȘ Êı¿ÓÔ˘Ó ÛÙËÓ ÂÚ›Ô‰Ô ÙÔ˘ ÂÓ‹ÏÈη (5). ∫ÏÈÓÈο, Ë Î·ı˘ÛÙÂÚË̤ÓË ™¢ ÂÌÊ·Ó›˙ÂÙ·È Ì Â̤ÙÔ˘˜ Î·È Û˘Ìو̷ÙÔÏÔÁ›· ·fi ÙÔ ·Ó·Ó¢ÛÙÈÎfi, Û·ÓÈfiÙÂÚ· Ì ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜, ÌÂÙˆÚÈÛÌfi Î·È ‰È¿ÚÚÔÈ·. ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜, Ë √∞¢ ÂÌÊ·Ó›ÛÙËΠÏfiÁˆ ‰È¿Ù·Û˘ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ ÔÊÂÈÏfiÌÂÓË Û ÌÂÁ¿ÏÔ Á‡̷. ™ËÌÂÈÒÓÂÙ·È fiÙÈ ÙÔ ‚Ú¤ÊÔ˜ ‹Ù·Ó ˘ÁȤ˜ Î·È ‰ÂÓ Â›¯Â ·ÚÔ˘ÛÈ¿ÛÂÈ Ì¤¯ÚÈ ÙfiÙ ÎÏÈÓÈο ÛËÌ›·. ∏ ÂÌÊ¿ÓÈÛË ÙˆÓ Û˘ÌÙˆÌ¿ÙˆÓ ÌÂÙ¿ ÙÔ Á‡̷, Ì ‰È·Ï›ÔÓÙ· ‹ Î·È Ì ˘ÔÙÚÔÈ¿˙ÔÓÙ· ¯·Ú·ÎÙ‹Ú·, Û˘ÓËÁÔÚÔ‡Ó ÛÙË ‰È¿ÁÓˆÛË Ù˘ ηı˘ÛÙÂÚË̤Ó˘ ™¢ (5-8). ∫·Ù¿ ÙË Ê˘ÛÈ΋ ÂͤٷÛË ÙÔ˘ ·È‰ÈÔ‡ ‰È·ÈÛÙÒÓÔÓÙ·È ÂÓÙÂ-
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∂ÈÎfiÓ· 4. µÚ¤ÊÔ˜ ËÏÈΛ·˜ 3 ÌËÓÒÓ. ∞ÎÙÈÓÔÏÔÁÈ΋ ÂÈÎfiÓ· ÌÂÙ¿ ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÔηٿÛÙ·ÛË Ù˘ ‰È·ÊÚ·ÁÌ·ÙÔ΋Ï˘ ·ÚÈÛÙÂÚ¿ (14Ë ÌÂÙÂÁ¯ÂÈÚËÙÈ΋ Ë̤ڷ).
ÚÈÎÔ› ‹¯ÔÈ ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈıˆÚ¿ÎÈÔ Î·È Ì›ˆÛË ÙÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ „Èı˘Ú›ÛÌ·ÙÔ˜, ÌÂÙ·ÙfiÈÛË ÚÔ˜ Ù· ‰ÂÍÈ¿ Ù˘ ·ÎÚfi·Û˘ Ù˘ ÎÔÚ˘Ê‹˜ Ù˘ ηډȿ˜ Î·È ÛηÊÔÂȉ‹˜ ÎÔÈÏ›·. Œ¯ÂÈ ·Ó·ÊÂÚı› ‡·ÚÍË ˘ÚÂÙÔ‡ ÏfiÁˆ Ù˘ ·Ê˘‰¿ÙˆÛ˘ ‹ Ù˘ ÂӉ¯fiÌÂÓ˘ ‰È¿ÙÚËÛ˘ ÎÔ›ÏÔ˘ ÛÏ¿¯ÓÔ˘ (5,7). √ ·ÎÙÈÓÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÌÔÚ› ‡ÎÔÏ· Ó· Ô‰ËÁ‹ÛÂÈ Û ϷÓı·Ṳ̂ÓË ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÏfiÁˆ ÂÛÊ·Ï̤Ó˘ ·ÍÈÔÏfiÁËÛ˘ ÙˆÓ ·ÎÙÈÓÔÁÚ·ÊÈÒÓ. ∆Ô‡ÙÔ Û˘Ì‚·›ÓÂÈ ÁÈ·Ù› ÔÈ ·ÎÙÈÓÔÏÔÁÈΤ˜ ÂÈÎfiÓ˜ ÌÔÚ› Ó· Ô‰ËÁ‹ÛÔ˘Ó ÛÙË ‰È¿ÁÓˆÛË ˘fi Ù¿ÛË Ó¢ÌÔıÒڷη, Û˘ÁÁÂÓÔ‡˜ ·ÛÙ˘ ÙÔ˘ Ó‡ÌÔÓ·, Û˘ÛÙÚÔÊ‹˜ ÙÔ˘ ÛÙÔÌ¿¯Ô˘, Ó¢ÌÔÓ›·˜ ‹ ·ÙÂÏÂÎÙ·Û›·˜ Ì ‹ ¯ˆÚ›˜ ÓÂ˘Ì·ÙÔ·ÛÙÂȘ Î·È Ù¤ÏÔ˜ Ï¢ÚÈÙÈ΋˜ Û˘ÏÏÔÁ‹˜ (7-10) (∂ÈÎfiÓ· 1). ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜, Ë ·ÍÈÔÏfiÁËÛË ÙˆÓ Â˘ÚËÌ¿ÙˆÓ Ù˘ ÚÒÙ˘ ·ÎÙÈÓÔÁÚ·Ê›·˜ ıÒÚ·ÎÔ˜ Ô˘ ¤ÁÈÓ ÛÙÔ Â·Ú¯È·Îfi ÓÔÛÔÎÔÌÂ›Ô ‹Ù·Ó ÂÛÊ·Ï̤ÓË, ‰ÈfiÙÈ ‰ÂÓ ·ÍÈÔÏÔÁ‹ıËÎÂ Ë ‡·ÚÍË ÎÔ›ÏÔ˘ ÛÏ¿¯ÓÔ˘ ÛÙÔ ·ÚÈÛÙÂÚfi ËÌÈıˆÚ¿ÎÈÔ, Ë ÌÂÙ·ÙfiÈÛË Ù˘ ηډȿ˜ ÛÙÔ ‰ÂÍÈfi ËÌÈıˆÚ¿ÎÈÔ Î·ıÒ˜ Î·È Ë ·Ô˘Û›· Ó¢ÌÔıÒڷη ‰ÂÍÈ¿. ∆Ô‡ÙÔ Û˘Ó¤‚Ë ÁÈ·Ù› ÚÈÓ ÙË Ï‹„Ë Ù˘ ·ÎÙÈÓÔÁÚ·Ê›·˜ ‰ÂÓ Â›¯Â ÙÔÔıÂÙËı› ÚÈÓÔÁ·ÛÙÚÈÎfi˜ ۈϋӷ˜ (∂ÈÎfiÓ· 1). ÕÏϘ ·ÂÈÎÔÓÈÛÙÈΤ˜ ̤ıÔ‰ÔÈ Ô˘ ·Ó·Ê¤ÚÔÓÙ·È ·fi ‰È¿ÊÔÚÔ˘˜ Û˘ÁÁÚ·Ê›˜ ÁÈ· ÙËÓ ÂÍ·ÎÚ›‚ˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ ·ÓˆÌ·Ï›·˜, Â›Ó·È Ë Ï‹„Ë ·ÎÙÈÓÔÁÚ·Ê›·˜ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË ÛÎÈ·ÁÚ·ÊÈÎÔ‡ Î·È Ô ˘ÂÚ˯ÔÁÚ·ÊÈÎfi˜ ¤ÏÂÁ¯Ô˜ (6-8,11). ™ÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜, ηٿ ÙËÓ ·Ó¿ÓË„Ë ÙÔ˘ ·ÛıÂÓÔ‡˜ ÙÔÔıÂÙ‹ıËΠÚÈÓÔÁ·ÛÙÚÈÎfi˜ ۈϋӷ˜ Levin ÎÈ ¤ÁÈÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜ Ë ÔÔ›· ·Ó¤‰ÂÈÍ ÙËÓ ‡·ÚÍË
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Ù˘ ™¢ (∂ÈÎfiÓ· 2), ÌÂ Û˘Ó¤ÂÈ· ÙË ¯ÂÈÚÔ˘ÚÁÈ΋ ·ÓÙÈÌÂÙÒÈÛ‹ Ù˘ Ì ηϋ ¤Î‚·ÛË. ∏ Û˘ÁÁÂÓ‹˜ ‰È·ÊÚ·ÁÌ·ÙÔ΋ÏË, ÏÔÈfiÓ, ı· Ú¤ÂÈ Ó· Û˘ÌÂÚÈÏ·Ì‚¿ÓÂÙ·È ÛÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ·Ó·Ó¢ÛÙÈ΋˜ ‰˘Û¯¤ÚÂÈ·˜. ∏ ÚÔÛÂÎÙÈ΋ ÌÂϤÙË ÙˆÓ ·ÎÙÈÓÔÁÚ·ÊÈÒÓ ÙÔ˘ ıÒڷη ÌÂÈÒÓÂÈ ÙËÓ Èı·ÓfiÙËÙ· ÂÛÊ·Ï̤Ó˘ ‰È¿ÁÓˆÛ˘ Î·È Î·ı˘ÛÙ¤ÚËÛ˘ ÛÙË ıÂڷ›· ·˘ÙÒÓ ÙˆÓ ·ÛıÂÓÒÓ. ∏ Û‡Á¯˘ÛË Ì ¿ÏϘ ·ı‹ÛÂȘ ·ÔʇÁÂÙ·È Ì ÙËÓ ÙÔÔı¤ÙËÛË ÚÈÓÔÁ·ÛÙÚÈÎÔ‡ ۈϋӷ Î·È ÙËÓ ·ÔÛ˘Ì›ÂÛË ÙÔ˘ ‰È·ÙÂٷ̤ÓÔ˘ ÛÙÔÌ¿¯Ô˘ Ô˘ ÚÔηÏ› ÙËÓ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· (12). ™˘ÌÂÚ·›ÓÂÙ·È fiÙÈ Ë ·ÓÙÈÌÂÙÒÈÛË Ù¤ÙÔÈˆÓ ÂÚÈÙÒÛÂˆÓ ··ÈÙ› ÂÍÂȉÈÎÂ˘Ì¤Ó˜ ÁÓÒÛÂȘ, ÂÓÒ Ë Î·ı˘ÛÙÂÚË̤ÓË ÌÂÙ·ÊÔÚ¿ Û ÂȉÈο ·È‰Ô¯ÂÈÚÔ˘ÚÁÈο ΤÓÙÚ· ÌÔÚ› Ó· ηٷϋÍÂÈ Û ·ÒÏÂÈ· ÙÔ˘ ·ÛıÂÓ‹.
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µÈ‚ÏÈÔÁÚ·Ê›· 1. Osebold WR, Soper RT. Congenital posterolateral diaphragmatic hernia past infancy. Am J Surg 1976;131:748-754. 2. Newman B, Afshani E, Kapp W. Presentation of congenital diaphragmatic hernia past the neonatal period. Arch Surg 1986;121:813-816. 3. Graivier L, Dorman GW, Votteler TP. Congenital diaphragmatic hernia in children. Surg Gynecol Obstet 1971;132:408. 4. Brill P, Gershwind M, Krasna H. Massive gastric enlargement with delayed presentation of congenital diaphragmatic hernia: report of three cases and review of the literature. J Pediatr Surg 1977;12:66-67. 5. Betremieux P, Dadabie A, Chapuis M, Pladys P, Treguier C, Fremond B. Late presenting Bochdalec hernia
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containing colon: misdiagnosis risk. Eur J Pediatr Surg 1995;5:113-115. Berman L, Stringer D, Ein SH, Shandling B. The late presenting pediatric Bochdalek hernia: a 20-year review. J Pediatr Surg 1988;23:735-739. De Foer, Breysem L, Smet MH, Baert AL. Late-onset Bochdalek hernia with a rare postoperative complication: case report. Pediatr Radiol 1994;24:306-307. Fotter R, Schimpl G, Sorantin E, Fritz K, Landler U. Delayed presentation of congenital diaphragmatic hernia. Pediatr Radiol 1992;22:187-191. Gayer G, Bilik R, Vardi A. CT diagnosis of delayed presentation of congenital diaphragmatic hernia simulating massive pleuropneumonia. Eur Radiol 1999;9:1672-1674. Tsang J, Ryan F. Delayed diaphragmatic herniation masquerading as a complicated parapneumonic effusion. Can Respir J 1999;6:361-366. Schimpl G, Fotter R, Sauer H. Congenital diaphragmatic hernia presenting after the newborn period. Eur J Pediatr 1993;152:765-768. Paut O, Mely L, Viard L, Silicani MA, Guys JM, Camboulives J. Acute presentation of congenital diaphragmatic hernia past the neonatal period: a life threatening emergency. Can Anaesth 1996;43:621-625.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 23-05-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 01-12-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∂. ¶··Ó‰Ú¤Ô˘ ∆ÚÈfiψ˜ 1, 151 27, ªÂÏ›ÛÛÈ·
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∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏
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CASE REPORT
¶·ÚÔ‰È΋ ÊÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË Î·È ˘ÂÚʈÛÊ·Ù·Û·ÈÌ›· ÌÂÙ¿ ·fi Ì·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ Û ÓÂÔÁÓfi π. ∫·Ï¤ÁÈ·˜1, ¡. π·Îˆ‚›‰Ô˘1, ∂. ªÂÁ·ÏÔÁÈ¿ÓÓË1, ™. ƒ¿ÌÌÔ˜2, °. ∫Ô˘Ú¿Î˘, ∏. ¢ÂÏÏ·ÁÚ·ÌÌ¿ÙÈη˜1
Transient cortical hyperostosis and elevation of alkaline phosphatase following long-term administration of prostaglandin J. Kaleyias1, N. Iakovidou1, E. Megaloyianni1, S. Rammos2, G. Kourakis, H. Dellagrammaticas1
¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È ÓÂÔÁÓfi ÌÂ Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· Ô˘ ·ÚÔ˘Û›·Û ·‡ÍËÛË Ù˘ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ Î·È ÊÏÔÈÒ‰Ë ˘ÂÚfiÛÙˆÛË ÌÂÙ¿ ·fi Ì·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ (PGE1). ∆Ô ÓÂÔÁÓfi ¯ÂÈÚÔ˘ÚÁ‹ıËΠ۠ËÏÈΛ· 70 ËÌÂÚÒÓ ÔfiÙÂ Î·È ‰È·ÎfiËÎÂ Ë PGE1. ∏ ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË Â·Ó‹Ïı ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰· ÛÙ·‰È·Î¿ Î·È Ë ÊÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË ˘Ô¯ÒÚËÛ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ PGE1, ÛÙÔȯ›· Ô˘ Û˘ÓËÁÔÚÔ‡Ó ˘¤Ú Ù˘ ·ÚÔ‰È΋˜ ʇÛ˘ Ù˘ ÔÛÙÂÔ¿ıÂÈ·˜ ·fi ÚÔÛÙ·ÁÏ·Ó‰›ÓË.
Abstract: We report an infant with ductusdependent congenital heart disease who was treated with prostaglandin E1 (PGE1) on a longterm basis. On the 25th day of treatment the alkaline phoshatase was found to be elevated while radiography revealed the presence of cortical hyperostosis of the bones. The infant was successfully operated at the age of 70 days and PGE1 was subsequently discontinued. Alkaline phosphatase levels slowly returned to normal values and the cortical hyperostosis receded, which suggests that the prostaglandin-induced osteopathy may be reversible.
§¤ÍÂȘ ÎÏÂȉȿ: ÚÔÛÙ·ÁÏ·Ó‰›ÓË, ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË, ÊÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË, ÔÛÙÂÔ¿ıÂÈ· ·fi ÚÔÛÙ·ÁÏ·Ó‰›ÓË.
Key words: prostaglandin, alkaline phosphatase, cortical hyperostosis, prostaglandin-osteopathy.
∂ÈÛ·ÁˆÁ‹ ∏ ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ ∂1 (PGE1) Â›Ó·È ··Ú·›ÙËÙË Û ÓÂÔÁÓ¿ ÌÂ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ ÂÍ·ÚÙÒÌÂÓ˜ ·fi ÙËÓ ·Ú·ÌÔÓ‹ ·ÓÔÈÎÙÔ‡ ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ fiÚÔ˘, ˆ˜ ¿ÌÂÛË ·Ú¤Ì‚·ÛË Ì¤¯ÚÈ ÙË ‰ÈÔÚıˆÙÈ΋ ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË (1). ª·ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ÂÊ·ÚÌfi˙ÂÙ·È ˆ˜ ·ÚË-
ÁÔÚËÙÈ΋ ıÂڷ›· Û ÌË ¯ÂÈÚÔ˘ÚÁ‹ÛÈ̘ Û˘ÁÁÂÓ›˜ ηډÈÔ¿ıÂȘ ‹ Û ·ÛıÂÓ›˜ Ô˘ ‚Ú›ÛÎÔÓÙ·È Û ·Ó·ÌÔÓ‹ ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜. ™ÙȘ ÂÈÏÔΤ˜ ·fi ÙË ¯ÔÚ‹ÁËÛË Ù˘ PGE1 Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ¿ÓÔȘ, ‚Ú·‰˘Î·Ú‰›·, ‰È¿ÚÚÔȘ, ˘ÚÂÙfi˜, ˘fiÙ·ÛË, Ô›‰ËÌ· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ Î·È ÊÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË (2,3). ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ÓÂÔÁÓÔ‡ Ô˘ ·ÚÔ˘Û›·Û ÊÏÔÈÒ‰Ë ˘ÂÚfiÛÙˆÛË Î·È ˘ÂÚʈÛÊ·Ù·Û·ÈÌ›· ÙËÓ 25Ë Ë̤ڷ ¯ÔÚ‹ÁËÛ˘ PGE1, Ô˘ ˘Ô¯ÒÚËÛ·Ó ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘.
1 ∆Ì‹Ì· ¡ÂÔÁ¤ÓÓËÙˆÓ µ’ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡” 2 ∫·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈÎfi ∫¤ÓÙÚÔ “øÓ¿ÛÂÈÔ”
1 Neonatology Division of B’ Pediatric Clinic of University of Athens Children’s Hospital “P. & A. Kyriakou” 2 Cardiosurgical Center “Onassis”
™˘ÓÙÔÌÔÁڷʛ˜ Aº ∞ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË ÔÚÔ‡ PGE1 ¶ÚÔÛÙ·ÁÏ·Ó‰›ÓË
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¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ¡ÂÔÁÓfi ı‹Ï˘ Ô˘ ÁÂÓÓ‹ıËΠÌÂÙ¿ ·fi ·ËÛË 35 ‚‰ÔÌ¿‰ˆÓ ÌÂ Ê˘ÛÈÔÏÔÁÈÎfi ÙÔÎÂÙfi Î·È ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 2.500 ÁÚ., ·ÚÔ˘Û›·Û ΢¿ÓˆÛË ·fi ÙË Á¤ÓÓËÛË Î·È ÂÈÛ‹¯ıË ÛÙÔ ∆Ì‹Ì· ÙËÓ 5Ë ÒÚ· ˙ˆ‹˜ Û ̤ÙÚÈ· ÁÂÓÈ΋ ηٿÛÙ·ÛË. ∏ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ¤‰ÂÈÍÂ, ÂÎÙfi˜ ·fi ÙËÓ ÎÂÓÙÚÈ΋ ΢¿ÓˆÛË, ¤ÓÙÔÓÔ Û˘ÛÙÔÏÈÎfi ʇÛËÌ· πππ/πV ·ÎÔ˘ÛÙfi Û fiÏÔ ÙÔ ÚÔοډÈÔ. √ ÎÔÚÂÛÌfi˜ Ù˘ Hb ‹Ù·Ó 72%. ªÂ ÙËÓ Èı·Ó‹ ‰È¿ÁÓˆÛË Ù˘ ΢·ÓˆÙÈ΋˜ Û˘ÁÁÂÓÔ‡˜ ηډÈÔ¿ıÂÈ·˜ ÍÂΛÓËÛ ¯ÔÚ‹ÁËÛË ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ (PGE1) Î·È ¤ÁÈÓ ηډÈÔÏÔÁÈ΋ ÂͤٷÛË Ô˘ Û˘ÌÂÚÈÂÏ¿Ì‚·Ó ˘ÂÚ˯ÔÁÚ¿ÊËÌ· Î·È Î·ıÂÙËÚÈ·ÛÌfi ηډȿ˜. ∆¤ıËÎÂ Ë ‰È¿ÁÓˆÛË Ù˘ Û‡ÌÏÔ΢ ΢·ÓˆÙÈ΋˜ ηډÈÔ¿ıÂÈ·˜ Ì ÙȘ ·ÎfiÏÔ˘ı˜ ·ÓˆÌ·Ï›Â˜: 1) ·Ó·ÛÙÚÔÊ‹ ÛÏ¿¯ÓˆÓ (situs inversus) Ì ÌÂÛÔηډ›·, 2) ÎÔÏÔÎÔÈÏȷ΋ Î·È ÎÔÈÏÈÔ·ÚÙËÚȷ΋ ‰˘Û·ÚÌÔÓ›·, 3) ·ÙÚËÛ›· Ó¢ÌÔÓÈ΋˜ ‚·Ï‚›‰·˜, 4) ÌÂÁ¿ÏË ‰Â˘ÙÂÚÔÁÂÓ‹ ÌÂÛÔÎÔÏÈ΋ ÂÈÎÔÈÓˆÓ›·, 5) ˘ÔÏ·ÛÙÈÎfi Û٤ϯԘ Ó¢ÌÔÓÈ΋˜, 6) ·ÔÚÙÈÎfi ÙfiÍÔ ˆ˜ › LÌÂÙ¿ıÂÛ˘. ∏ ÚfiÁÓˆÛË ÁÈ· ¯ÂÈÚÔ˘ÚÁÈ΋ ‰ÈfiÚıˆÛË ‹Ù·Ó ÂÍ·ÈÚÂÙÈο ‰˘ÛÌÂÓ‹˜. √È ÁÔÓ›˜ ·ÚÓ‹ıËÎ·Ó ·Ú¯Èο Ó· Á›ÓÂÈ ·Ó·ÎÔ˘ÊÈÛÙÈ΋ ¤̂·ÛË. ÃÔÚËÁ‹ıËΠÚÔÛÙ·ÁÏ·Ó‰›ÓË ÂÓ‰ÔÊϤ‚È· ÁÈ· 50 Ë̤Ú˜, ÔfiÙÂ Î·È ·ÔÊ·Û›ÛÙËΠӷ Á›ÓÂÈ ·Ó·ÎÔ˘ÊÈÛÙÈ΋ ¤̂·ÛË. ∏ ‰fiÛË Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ ÙÈÙÏÔÔÈ‹ıËΠ̠‚¿ÛË ÙËÓ ÎÏÈÓÈ΋ ·ÓÙ·fiÎÚÈÛË ÙÔ˘ ÓÂÔÁÓÔ‡, ¤ÙÛÈ ÒÛÙ ӷ ‰È·ÙËÚÂ›Ù·È ·ÓÔÈÎÙfi˜ Ô ·ÚÙËÚÈ·Îfi˜ fiÚÔ˜ Ì ÙËÓ ÂÏ¿¯ÈÛÙË ‰˘Ó·Ù‹ ‰fiÛË. ŒÙÛÈ, Ë ·Ú¯È΋ ‰fiÛË ‹Ù·Ó 0,1, ÙË 15Ë Ë̤ڷ 0,075 Î·È ·fi ÙËÓ 25Ë 0,05 Ìg/∫/min Ô˘ ‹Ù·Ó Î·È Ë ÌÈÎÚfiÙÂÚË ¯ÔÚËÁÔ‡ÌÂÓË Ì ÙËÓ ÔÔ›·
˘‹Ú¯Â ÙÔ ÂÈı˘ÌËÙfi ÎÏÈÓÈÎfi ·ÔÙ¤ÏÂÛÌ·, ‰ËÏ·‰‹ ÙË ‰È·Ù‹ÚËÛË ·ÓÔÈÎÙÔ‡ ·ÚÙËÚÈ·ÎÔ‡ fiÚÔ˘. ™Ù· Ï·›ÛÈ· ·Ú·ÎÔÏÔ‡ıËÛ˘ ÙÔ˘ ÓÂÔÁÓÔ‡, ÂÏ‹ÊıËÛ·Ó ‰È·‰Ô¯ÈΤ˜ ÙÈ̤˜ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ (∞º) ÔÚÔ‡. ™ÙËÓ ÂÈÛ·ÁˆÁ‹ Ë ∞º ‹Ù·Ó 160 IU/L, ÙËÓ 5Ë Ë̤ڷ 300 IU/L, ÙË 15Ë 400 IU/L, ÙËÓ 25Ë 1550 IU/L, ÂÓÒ Ï›Á˜ Ë̤Ú˜ ÚÈÓ ÙËÓ Î·Ú‰ÈÔ¯ÂÈÚÔ˘ÚÁÈ΋ ¤̂·ÛË ·ÚÔ˘Û›·Û ÙË Ì¤ÁÈÛÙË ÙÈÌ‹ 2100 IU/L (∂ÈÎfiÓ· 1). √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ÈÛÔÂÓ˙‡ÌˆÓ Ù˘ ∞º ¤‰ÂÈÍ fiÙÈ ‹Ù·Ó ÔÛÙÈ΋˜ ÚÔ¤Ï¢Û˘. √ ˘fiÏÔÈÔ˜ ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ (·Û‚¤ÛÙÈÔ, ÊÒÛÊÔÚÔ˜, ·ÌÈÓÔÙÚ·ÓÛÊÂÚ¿Û˜, Á-ÁÏÔ˘Ù¿ÌÈÏÔ-ÙÚ·ÓÛÊÂÚ¿ÛË) ‹Ù·Ó Û fiϘ ÙȘ ÌÂÙÚ‹ÛÂȘ ÂÓÙfi˜ ÙˆÓ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ. √ ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ ÔÛÙÒÓ ÙËÓ 25Ë Ë̤ڷ ˙ˆ‹˜ ¤‰ÂÈÍÂ Û˘ÌÌÂÙÚÈ΋ ÊÏÔÈÒ‰Ë ˘ÂÚfiÛÙˆÛË. ∂ÓÒ ÙËÓ 1Ë Ë̤ڷ ˙ˆ‹˜ ÛÙËÓ ·ÎÙÈÓÔÁÚ·Ê›· ıÒڷη ‰ÂÓ ‰È·ÎÚ›ÓÔÓÙ·È ÔÛÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ, ÙËÓ 25Ë Ë̤ڷ ‰È·ÈÛÙÒıËΠÊÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË Ô˘ ·ÊÔÚÔ‡Û ٷ ÔÛÙ¿ ÙˆÓ ¿Óˆ ¿ÎÚˆÓ, ÙȘ ÎÏ›‰Â˜, ÙȘ Ï¢ڤ˜ (∂ÈÎfiÓ· 2), ηıÒ˜ Î·È Ù· ÔÛÙ¿ ÙˆÓ Î¿Ùˆ ¿ÎÚˆÓ (∂ÈÎfiÓ· 3). ¢ÂÓ Û˘Ó˘‹Ú¯·Ó ÎÏÈÓÈο ÛËÌ›·, fiˆ˜ Ô›‰ËÌ· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ, ÂÚ˘ıÚfiÙËÙ· ‹ ¢·ÈÛıËÛ›·, ·ÓÙ›ÛÙÔȯ· ÙˆÓ ·ÎÙÈÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ. √ ¤ÏÂÁ¯Ô˜ ÁÈ· Û˘ÁÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ‹Ù·Ó ·ÚÓËÙÈÎfi˜. ¢ÂÓ ÌÂÏÂÙ‹ıËÎ·Ó ÔÈ ‚ÈÔ¯ËÌÈÎÔ› ‰Â›ÎÙ˜ ÙÔ˘ ÔÛÙÈÎÔ‡ ÌÂÙ·‚ÔÏÈÛÌÔ‡ (ÔÛÙÂÔηÏÛ›ÓË, ÌÂÙ·‚Ôϛ٘ ‚ÈÙ·Ì›Ó˘ ¢, ·Ú·ıÔÚÌfiÓË ÎÏ). ™Â ËÏÈΛ· 70 ËÌÂÚÒÓ ¤ÁÈÓ ÙÚÔÔÔÈË̤ÓË Â¤Ì‚·ÛË Blalock Taussig Ì ÙÔÔı¤ÙËÛË ÎÂÓÙÚÈ΋˜ ·Ú¿Î·Ì„˘ (shunt) ·fi ÙËÓ ·ÚÈÛÙÂÚ¿
2500
2000
Aº(πU/L)
2001 MAPT- A¶PI§
PGE1 0,05 Ìg/k/min.
1500
PGE1 0,075 Ìg/k/min.
¢È·ÎÔ‹ PGE1
1000 PGE1 0,1 Ìg/k/min. 500
0 1 ËÌ.
5 ËÌ.
15 ËÌ.
25 ËÌ.
70 ËÌ.
90 ËÌ.
6 ÌËÓÒÓ
14 ÌËÓÒÓ
3 ÂÙÒÓ
∏ÏÈΛ· ¡ÂÔÁÓÔ‡ ∂ÈÎfiÓ· 1. ¶ÔÚ›· Ù˘ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ (∞º) ÔÚÔ‡ ηٿ ÙË ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ Ù˘ PGE1 Î·È ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘.
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∂ÈÎfiÓ· 2. ºÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË Ì·ÎÚÒÓ ÔÛÙÒÓ ¿Óˆ ¿ÎÚÔ˘, ÎÏ›‰·˜ Î·È Ï¢ÚÒÓ ÙËÓ 25Ë Ë̤ڷ ¯ÔÚ‹ÁËÛ˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘.
∂ÈÎfiÓ· 3. ºÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË ÔÛÙÒÓ Î¿Ùˆ ¿ÎÚÔ˘ ÙËÓ 25Ë Ë̤ڷ ¯ÔÚ‹ÁËÛ˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘.
ΛÌÂÓË ·ÓÒÓ˘ÌË ·ÚÙËÚ›· ÛÙËÓ ¤ÎÊ˘ÛË Ù˘ ·ÚÈÛÙÂÚ¿ ΛÌÂÓ˘ Î·È ÌÔÚÊÔÏÔÁÈο ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ Ì ·ÔϛӈÛË ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ fiÚÔ˘. ªÂÙ¿ ÙÔ ¯ÂÈÚÔ˘ÚÁÂ›Ô ¤ÁÈÓ ‰È·ÎÔ‹ Ù˘ ¯ÔÚËÁÔ‡ÌÂÓ˘ PGE1. ™Â ËÏÈΛ· 14 ÌËÓÒÓ ÙÔ ÓÂÔÁÓfi ·ÓÂÁ¯ÂÈÚ‹ıËÎÂ. ŒÁÈÓ ‰È·›ÚÂÛË ÙÔ˘ ÚÔËÁÔ‡ÌÂÓÔ˘ ÎÂÓÙÚÈ΋˜ ·Ú¿Î·Ì„˘, Ï·ÛÙÈ΋ ‰ÂÍÈ¿˜ Ó¢ÌÔÓÈ΋˜ ·ÚÙËÚ›·˜ Ì ·˘ÙfiÏÔÁÔ ÂÚÈηډȷÎfi ÂÌ‚¿ÏˆÌ· Î·È ÙÔÔı¤ÙËÛË ·ÚÈÛÙÂÚÔ‡ ·ÌÊ›‰ÚÔÌÔ˘ Glenn shunt. ∏ ·ÏηÏÈ΋ ʈÛÊ·Ù¿ÛË ‹Ù·Ó 462 IU/L Î·È ÛÙÔÓ ·ÎÙÈÓÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ‰ÂÓ ‰È·ÈÛÙÒıËÎ·Ó Â˘Ú‹Ì·Ù· ÊÏÔÈÒ‰Ô˘˜ ˘ÂÚfiÛÙˆÛ˘ (∂ÈÎfiÓ· 4). ∆ÒÚ·, Û ËÏÈΛ· 3 ÂÙÒÓ, ÙÔ ·È‰› ‰ÂÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÎÙÈÓÔÏÔÁÈο Î·È ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· (∞º 180 IU/L) ÔÛÙÂÔ¿ıÂÈ·˜ ·fi ÚÔÛÙ·ÁÏ·Ó‰›ÓË.
·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÊÏÔÈÒ‰Ô˘˜ ˘ÂÚfiÛÙˆÛ˘, ÂÓÒ Ù· 42 (53%) ˘ÂÚʈÛÊ·Ù·Û·ÈÌ›·. ∆Ô ÔÛÔÛÙfi ÙˆÓ ·ÛıÂÓÒÓ Ì ˘ÂÚfiÛÙˆÛË ·˘Í·ÓfiÙ·Ó ·Ó¿ÏÔÁ· Ì ÙÔ ¯ÚfiÓÔ ¯ÔÚ‹ÁËÛ˘ Ù˘ PGE1. ∞fi ÙÔ Û‡ÓÔÏÔ ÙˆÓ ÓÂÔÁÓÒÓ Ô˘ ÂÌÊ¿ÓÈÛ·Ó ˘ÂÚfiÛÙˆÛË, ÙÔ 42% ÙËÓ ·ÚÔ˘Û›·Û ÙËÓ 30Ë Ë̤ڷ, ÙÔ 87% ÙËÓ 60Ë Î·È ÙÔ 100% ÙËÓ 60Ë. ∏ Û˘¯ÓfiÙËÙ· ·ÏÏ¿ Î·È Ë ‚·Ú‡ÙËÙ· Ù˘ ˘ÂÚfiÛÙˆÛ˘ Û˘Û¯ÂÙÈ˙fiÙ·Ó Ì ÙË ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ Î·È ÙË Û˘ÓÔÏÈ΋ ‰fiÛË Ù˘ PGE1. À„ËÏfiÙÂÚ˜ ÙÈ̤˜ ∞º ›¯·Ó ÔÈ ·ÛıÂÓ›˜ Ì ÛËÌ·ÓÙÈÎÔ‡ ‚·ıÌÔ‡ ÊÏÔÈÒ‰Ë ˘ÂÚfiÛÙˆÛË. ∂›Û˘, ÙÔ ÔÛÔÛÙfi ÓÂÔÁÓÒÓ Ì ˘ÂÚʈÛÊ·Ù·Û·ÈÌ›· ‹Ù·Ó ·Ó¿ÏÔÁÔ ÙÔ˘ ‚·ıÌÔ‡ Ù˘ ˘ÂÚfiÛÙˆÛ˘ (26% Û ·È‰È¿ ¯ˆÚ›˜ ÔÛÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ, 59% Û ·È‰È¿ Ì ‹È˜ Î·È 85% Û ÂΛӷ Ì ‚·ÚȤ˜ ·ÏÏÔÈÒÛÂȘ). ∏ PGE1, fiˆ˜ Â›Ó·È ÁÓˆÛÙfi, ¤¯ÂÈ ÔÛÙÂÔ‚Ï·ÛÙÈ΋ ‰Ú¿ÛË. ŒÓ˙˘Ì· Ô˘ ÙË ‰È·ÛÔ‡Ó, fiˆ˜ Ë 15-˘‰Úfi͢-‰Â¸‰ÚÔÁÂÓ¿ÛË Î·È Ë ¢-13-·Ó·ÁˆÁ¿ÛË, ‚Ú›ÛÎÔÓÙ·È Û ·˘ÍË̤Ó˜ Û˘ÁÎÂÓÙÚÒÛÂȘ ÛÙÔ˘˜ Ó‡ÌÔÓ˜, fiÔ˘ Î·È ÙËÓ ·ÔÈÎÔ‰ÔÌÔ‡Ó Ù·¯‡Ù·Ù·. ¡ÂÔÁÓ¿ Ì ۇÌÏÔÎË Û˘ÁÁÂÓ‹ ηډÈÔ¿ıÂÈ· Ì ‰È·Ê˘Á‹ ̤ۈ ÙÔ˘ ·ÚÙËÚÈ·ÎÔ‡ fiÚÔ˘ ‹/Î·È ÙÔ˘ ˆÔÂȉԇ˜ ÙÚ‹Ì·ÙÔ˜, ¤¯Ô˘Ó ˘„ËÏfiÙÂÚ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ PGE1, ÏfiÁˆ ·Ú¿Î·Ì„˘ ÙˆÓ Ó¢ÌfiÓˆÓ (5,9). ∆· ‰Â‰Ô̤ӷ ·˘Ù¿ Û˘Ì›ÙÔ˘Ó Ì ٷ Â˘Ú‹Ì·Ù· Ù˘ ÂÚ›ÙˆÛ˘ Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È. ∆Ô ÓÂÔÁÓfi ›¯Â ·Ú¿Î·Ì„Ë Ù˘ Ó¢ÌÔÓÈ΋˜ ΢ÎÏÔÊÔÚ›·˜ Î·È ¿Ú·
™˘˙‹ÙËÛË ∆Ô 1981, fiÙ·Ó ÔÈ Lewis Î·È Û˘Ó (2) ÂÚȤÁÚ·„·Ó ÙȘ ·ÚÂÓ¤ÚÁÂȘ Ù˘ PGE1 Û 492 ·ÛıÂÓ›˜, Ë ÊÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË ‰ÂÓ Û˘ÌÂÚÈÏ·Ì‚·ÓfiÙ·Ó. ∞ÎÔÏÔ‡ıˆ˜, ÛÔÚ·‰Èο ÂÚÈÁÚ¿ÊËÎ·Ó ÂÚÈÛÙ·ÙÈο fiÔ˘ ·Ó¤ÊÂÚ·Ó ÙË ÊÏÔÈÒ‰Ë ˘ÂÚfiÛÙˆÛË ˆ˜ ÂÈÏÔ΋ ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ (4-9). √È Karen Î·È Û˘Ó (10) ÌÂϤÙËÛ·Ó ·Ó·‰ÚÔÌÈο 86 ÓÂÔÁÓ¿, ÛÙ· ÔÔ›· ›¯Â ¯ÔÚËÁËı› PGE1 ÂÓ ·Ó·ÌÔÓ‹ ÌÂÙ·ÌfiÛ¯Â˘Û˘ ηډȿ˜. ∆· 53 ÓÂÔÁÓ¿ (62%) ›¯·Ó
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∂ÈÎfiÓ· 4. ∞ÎÙÈÓÔÁÚ·Ê›· ıÒڷη Î·È ¿Óˆ ¿ÎÚˆÓ Û ËÏÈΛ· 14 ÌËÓÒÓ (11 Ì‹Ó˜ Î·È 20 Ë̤Ú˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘). ∏ ·ÓÙ›‰Ú·ÛË ÙÔ˘ ÂÚÈÔÛÙ¤Ô˘ ¤¯ÂÈ ÂÍ·Ê·ÓÈÛı›.
·˘ÍË̤ÓÔ Î›Ó‰˘ÓÔ Î˘ÎÏÔÊÔÚ›·˜ ˘„ËÏÒÓ ÂȤ‰ˆÓ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ ÛÙÔÓ ÔÚfi. ¶·ÚÔ˘Û›·Û ˘ÂÚʈÛÊ·Ù·Û·ÈÌ›· ÛÙÔÓ ·Ó·ÌÂÓfiÌÂÓÔ ·fi Ù· ‚È‚ÏÈÔÁÚ·ÊÈο ‰Â‰Ô̤ӷ ¯ÚfiÓÔ Î·È ÊÏÔÈÒ‰Ë ˘ÂÚfiÛÙˆÛË ÛËÌ·ÓÙÈÎÔ‡ ‚·ıÌÔ‡. §·Ì‚¿ÓÔÓÙ·˜ ˘’fi„ÈÓ fiÙÈ Ù· ›‰· ∞º Â›Ó·È ·Ó¿ÏÔÁ· Ì ÙÔ ‚·ıÌfi Ù˘ ˘ÂÚfiÛÙˆÛ˘, ‰È·ÈÛÙÒÛ·Ì fiÙÈ ÙÔ ÓÂÔÁÓfi ·ÚÔ˘Û›·Û ÛËÌ·ÓÙÈ΋ ˘ÂÚʈÛÊ·Ù·Û·ÈÌ›· Î·È ÛÔ‚·Ú‹ ÊÏÔÈÒ‰Ë ˘ÂÚfiÛÙˆÛË. ∏ ÎÏÈÓÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÊÏÔÈÒ‰Ô˘˜ ˘ÂÚfiÛÙˆÛ˘ ‰ÂÓ Â›Ó·È Û˘Ó‹ı˘. ∂Í·ÈÚÂÙÈο Û¿ÓÈ· ÌÔÚ› Ó· ÚÔ‚¿ÏÏÂÈ ˆ˜ Ô›‰ËÌ· Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ Î·È ÂÚ˘ıÚfiÙËÙ· ˘ÂÚΛÌÂÓÔ˘ ‰¤ÚÌ·ÙÔ˜. ∞ÍÈÔÛËÌ›ˆÙÔ Â›Ó·È fiÙÈ Â¿Ó Û ·˘Ù‹ ÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÂÈÚÔÛÙÂıÔ‡Ó ÁÓˆÛÙ¤˜ ·ÚÂÓ¤ÚÁÂȘ Ù˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ fiˆ˜ ˘ÂÚıÂÚÌ›·, ˘fiÙ·ÛË, ¿ÓÔÈ·, ÙfiÙ ٛıÂÙ·È ÈÛ¯˘Ú¿ Ë ˘Ô„›· ÛË„·ÈÌ›·˜-ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ (12). ™ËÌÂÈÒÓÂÙ·È fiÙÈ Ë ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ‰ÂÓ Â›¯Â ÎÏÈÓÈ΋ ¤ÎÊÚ·ÛË Ù˘ ÊÏÔÈÒ‰Ô˘˜ ˘ÂÚfiÛÙˆÛ˘. ™ÙË ‰È·ÊÔÚÈ΋ ‰È¿ÁÓˆÛË Ù˘ ÊÏÔÈÒ‰Ô˘˜ ˘ÂÚfiÛÙˆÛ˘ Û˘ÌÂÚÈÏ·Ì‚¿ÓÔÓÙ·È Ë ‚ÚÂÊÈ΋ ÊÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË (ÓfiÛÔ˜ Caffey), Ë ˘ÂÚ‚Èٷ̛ӈÛË ∞, ÙÔ ÛÎÔÚ‚Ô‡ÙÔ, Ë Û‡ÊÈÏË, ÙÔ ÙÚ·‡Ì·, Ô fiÁÎÔ˜, Ë Ïԛ̈ÍË Î·È Ë ·ÈÌÔÚÚ·Á›·. ∆· ÂÚÈÛÛfiÙÂÚ· ÓÔÛ‹Ì·Ù·, Ì ÂÍ·›ÚÂÛË ÙË ‚ÚÂÊÈ΋ ÊÏÔÈÒ‰Ë ˘ÂÚfiÛÙˆÛË, Â›Ó·È Â‡ÎÔÏÔ Ó· ‰È·ÊÔÚԉȷÁÓˆÛÙÔ‡Ó Ì ‚¿ÛË ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô, ÙÔ ÈÛÙÔÚÈÎfi Î·È Ù· ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏ ÊÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË Ô˘ ÔÊ›ÏÂÙ·È Û ̷ÎÚÔ¯ÚfiÓÈ· ¯ÔÚ‹ÁËÛË ÚÔÛÙ·ÁÏ·Ó‰›Ó˘, ÔÌÔÈ¿˙ÂÈ Ì ÙË ÓfiÛÔ Caffey ÛÙËÓ ÔÔ›·, fï˜, ¯·Ú·ÎÙËÚÈÛÙÈο ÚÔÛ‚¿ÏÏÂÙ·È Ë Î¿Ùˆ ÁÓ¿ıÔ˜. ∂›Û˘, Ë ˘Ô¯ÒÚËÛË Ù˘ ÊÏÔÈÒ‰Ô˘˜ ˘ÂÚfiÛÙˆÛ˘
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ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ PGE1 ·ÔÎÏ›ÂÈ ÙË ÓfiÛÔ ÙÔ˘ Caffey (10,13) ∏ ÊÏÔÈ҉˘ ˘ÂÚfiÛÙˆÛË ÌÂÙ¿ ·fi ¯ÔÚ‹ÁËÛË PGE1 Â›Ó·È ·Ó·ÛÙÚ¤„ÈÌË, ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË Î·È ˘Ô¯ˆÚ› Û 6-12 Ì‹Ó˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ (13). ªÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ PGE1 ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È, ‰È·ÈÛÙÒıËΠÛÙ·‰È·Î‹ ·ÔηٿÛÙ·ÛË Ù˘ ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ Î·È ˘Ô¯ÒÚËÛË Ù˘ ÊÏÔÈÒ‰Ô˘˜ ˘ÂÚfiÛÙˆÛ˘. ∏ ˘Ô¯ÒÚËÛË Ù˘ ÔÛÙÂÔ¿ıÂÈ·˜ ·fi ÚÔÛÙ·ÁÏ·Ó‰›ÓË ÛÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÂÚÈÁڷʤ˜ Èı·ÓÔÏÔÁÂ›Ù·È Î·È ‰ÂÓ ÙÂÎÌËÚÈÒÓÂÙ·È Ì ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ ·ÛıÂÓÔ‡˜, ·ÊÔ‡ ‰˘ÛÙ˘¯Ò˜ Û˘¯Ó¿ ·˘ÙÔ› ηٷϋÁÔ˘Ó, ÏfiÁˆ Ù˘ ‚·Ú‡ÙËÙ·˜ Ù˘ ηٿÛÙ·Û˘ (7,11). √È Jorgensen Î·È Û˘Ó (11) ˘ÔÛÙËÚ›˙Ô˘Ó ÙËÓ ·ÚÔ‰È΋ ʇÛË Ù˘ ÔÛÙÂÔ¿ıÂÈ·˜ ·fi ÚÔÛÙ·ÁÏ·Ó‰›ÓË ·fi ÈÛÙÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÙÔ˘ ·ÛıÂÓÔ‡˜ ÙÔ˘˜ Ô˘ η٤ÏËÍÂ, Ù· ÔÔ›· ‹Ù·Ó Û˘Ì‚·Ù¿ Ì ˘Ô¯ÒÚËÛË Ù˘ ÊÏÔÈÒ‰Ô˘˜ ˘ÂÚfiÛÙˆÛ˘. √È Host Î·È Û˘Ó (13) ÙÂÎÌËÚÈÒÓÔ˘Ó ÙËÓ ·Ó·ÛÙÚ„ÈÌfiÙËÙ· Ù˘ ‚Ï¿‚˘ Ì ·Ú·ÎÔÏÔ‡ıËÛË Î·È ·ÎÙÈÓÔÏÔÁÈ΋ ÂȂ‚·›ˆÛË, fiˆ˜ Î·È ÛÙÔ ÂÚÈÛÙ·ÙÈÎfi Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È. ∫Ú›ÓÂÙ·È ÛÎfiÈÌË Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ÙÈÌÒÓ Ù˘ ∞º ÔÚÔ‡ ηٿ ÙË ‰È¿ÚÎÂÈ· ¯ÔÚ‹ÁËÛ˘ ÚÔÛÙ·ÁÏ·Ó‰›Ó˘ ˆ˜ ‰Â›ÎÙË Ù˘ ÔÛÙÂÔ‚Ï·ÛÙÈ΋˜ ‰Ú·ÛÙËÚÈfiÙËÙ¿˜ Ù˘. ∂›Û˘, ·Ó Â›Ó·È ÂÊÈÎÙfi, Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÙÈÙÏÔÔ›ËÛË Ù˘ ‰fiÛ˘, ÒÛÙ ӷ ÂÍ·ÛÊ·Ï›˙ÂÙ·È Ë Â›‰Ú·Û‹ Ù˘ ÛÙÔÓ ·ÚÙËÚÈ·Îfi fiÚÔ, ÌÂÈÒÓÔÓÙ·˜ Ù·˘Ùfi¯ÚÔÓ· ÙËÓ Èı·ÓfiÙËÙ· ·ÚÂÓÂÚÁÂÈÒÓ. §fiÁˆ ÙÔ˘ Û˘Ó¯Ҙ ·˘Í·ÓfiÌÂÓÔ˘ ·ÚÈıÌÔ‡ ÓÂÔÁÓÒÓ Ô˘ Ï·Ì‚¿ÓÔ˘Ó ÚÔÛÙ·ÁÏ·Ó‰›ÓË Ì·ÎÚÔ¯ÚfiÓÈ·, Ë ÔÛÙÂÔ¿ıÂÈ· ·fi ÚÔÛÙ·ÁÏ·Ó‰›ÓË ·Ó·Ì¤ÓÂÙ·È fiÙÈ ı· Û˘Ó·ÓÙ¿Ù·È Û˘¯ÓfiÙÂÚ· ·fi ÙÔÓ ·È‰›·ÙÚÔ. ∏ ÔÓÙfiÙËÙ· ·˘Ù‹ ı· Ú¤ÂÈ Ó· Ï·Ì‚¿ÓÂÙ·È ˘’fi„ÈÓ Û οı ‚Ú¤ÊÔ˜ Ô˘ Ï·Ì‚¿ÓÂÈ ÚÔÛÙ·ÁÏ·Ó‰›ÓË Ì·ÎÚÔ¯ÚfiÓÈ·, fiˆ˜ ÂΛӷ Ô˘ Â›Ó·È ˘Ô„‹ÊÈ· ÁÈ· ÌÂÙ·ÌfiÛ¯Â˘ÛË Î·Ú‰È¿˜. ∂›Û˘, ÂÂȉ‹ ÔÈ ÔÛÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ ·Ú·Ì¤ÓÔ˘Ó ·ÚÎÂÙÔ‡˜ Ì‹Ó˜ ÌÂÙ¿ ÙË ‰È·ÎÔ‹ Ù˘ PGE1, Ô ÎÏÈÓÈÎfi˜ È·ÙÚfi˜ Ô˘ ·ÓÙÈÌÂÙˆ›˙ÂÈ ‚Ú¤ÊË Ô˘ ÙÔ˘˜ ¯ÔÚËÁ‹ıËΠÚÔÛÙ·ÁÏ·Ó‰›ÓË, ı· Ú¤ÂÈ Ó· ·Ó·Ì¤ÓÂÈ ÙË ‚Ú·‰Â›· ·ÔηٿÛÙ·ÛË Ù˘ ÔÛÙÂÔ¿ıÂÈ·˜ ·ÔʇÁÔÓÙ·˜ ¿ÛÎÔ˜ ÂÚÁ·ÛÙËÚȷΤ˜ ÂÍÂÙ¿ÛÂȘ ηٿ ÙËÓ ÂÚ›Ô‰Ô Ù˘ ·Ó¿ÚÚˆÛ˘. µÈ‚ÏÈÔÁÚ·Ê›· 1. Freed M, Heymann M, Lewis A, Roehl S, Kensey R. Prostaglandin E1 in infants with ductus arteriosus dependent congenital heart disease. Circulation 1981;64:899-905. 2. Lewis A, Freed M, Heymann M, Roehl S, Kensey R. Side effects of therapy with prostaglandin E1 in infants with critical congenital heart disease. Circulation 1981;64:893-898. 3. Kaufman MB, El-Chaar GM. Bone and tissue changes
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infants awaiting cardiac transplantation. Pediatr Radiol 1994;93:417-420. 11. Jorgensen HRI, Svanholm H, Host A. Bone formation induced in an infant by systemic prostaglandin E2 administration. Acta Orthop Scand 1988;59:464-465. 12. Adevis K, Hush F, de Moor M. Cortical hyperostosis simulating osteomyelitis after short-term PGE1 infusion. Eur J Pediatr 1996;155:173-174. 13. Host A, Halken S, Andersen P. Reversibility of cortical hyperostosis following long-term prostaglandin E1 therapy in infants with ductus-dependet congenital heart disease. Pediatr Radiol 1998;18:149-153.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 31-10-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 20-12-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: πˆÛ‹Ê ∫·Ï¤ÁÈ·˜ ÃÚ˘Û·Óı¤ÌˆÓ 79, 157 72, ∑ˆÁÚ¿ÊÔ˘
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· √È Û˘Ó¤ÂȘ Ù˘ ı¤Û˘ ÛÙÔ Î¿ıÈÛÌ· ·˘ÙÔÎÈÓ‹ÙÔ˘ Î·È Ù˘ ¯Ú‹Û˘ ˙ÒÓ˘ ·ÛÊ·Ï›·˜ ÛÙȘ ηÎÒÛÂȘ ÙˆÓ ·È‰ÈÒÓ Û ·˘ÙÔÎÈÓËÙÈÛÙÈο ·Ù˘¯‹Ì·Ù· ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ Â›Ó·È Ë ÂÎÙ›ÌËÛË ÙˆÓ Û˘ÓÂÂÈÒÓ Ù˘ ¯Ú‹Û˘ ˙ÒÓ˘ ·ÛÊ·Ï›·˜ Î·È Ù˘ ı¤Û˘ ÛÙÔ ·˘ÙÔΛÓËÙÔ Û ۯ¤ÛË Ì ÙËÓ ÚfiÎÏËÛË Î·ÎÒÛÂˆÓ Û ·È‰È¿ Û ÂÚÈÙÒÛÂȘ ·˘ÙÔÎÈÓËÙÈÛÙÈÎÒÓ ·Ù˘¯ËÌ¿ÙˆÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ¶ÂÚÈÂÏ‹ÊıËÎ·Ó ·È‰È¿ οو ÙˆÓ 15 ÂÙÒÓ, Ù· ÔÔ›· ÙÚ·˘Ì·Ù›ÛÙËÎ·Ó Û ÛÔ‚·Ú¿ ·˘ÙÔÎÈÓËÙÈÛÙÈο ·Ù˘¯‹Ì·Ù· ·fi ÙÔ 1992 ¤ˆ˜ ÙÔ 1996. fl˜ ÛÔ‚·Ú¿ ·Ù˘¯‹Ì·Ù· ÔÚ›˙ÔÓÙ·È ÂΛӷ Ô˘ ›¯·Ó ˆ˜ ·ÔÙ¤ÏÂÛÌ· ÙÚ·˘Ì·ÙÈÛÌfi Ì ηٿÁÌ·Ù· ÔÛÙÒÓ ‹ ÛËÌ·ÓÙÈ΋ ·ÈÌÔÚÚ·Á›· ‹ ˘ÏÈ΋ ˙ËÌÈ¿ Ô˘ ÍÂÂÚÓÔ‡Û ٷ 750 ‰ÔÏÏ¿ÚÈ·. ŒÁÈÓ ·Ó¿Ï˘ÛË ÙˆÓ ÛÙÔȯ›ˆÓ Î·È Û˘Û¯ÂÙÈÛÌfi˜ Ì ÙËÓ ËÏÈΛ·, ÙË ¯Ú‹ÛË ˙ÒÓ˘ ·ÛÊ·Ï›·˜, ÙË ı¤ÛË ÙÔ˘ ÂÈ‚¿ÙË-·È‰ÈÔ‡ Î·È ÙÔÓ Ù‡Ô Ù˘ Û‡ÁÎÚÔ˘Û˘. ∞ÔÙÂϤÛÌ·Ù·: ªÂÏÂÙ‹ıËÎ·Ó 5751 ·È‰È¿ Î·È ‚Ú¤ıËΠfiÙÈ ÙÔ 53% ‹Ù·Ó ÂÈ‚¿Ù˜ ηı‹ÌÂÓÔÈ ÛÙÔ ›Ûˆ οıÈÛÌ· ÙÔ˘ ·˘ÙÔÎÈÓ‹ÙÔ˘. ¶ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ ·fi ÙÔ 50% ‹Ù·Ó ¯ˆÚ›˜ ˙ÒÓË ·ÛÊ·Ï›·˜. ∏ ı¤ÛË ÛÙÔ ›Ûˆ οıÈÛÌ· ÚÔÛ¤ÊÂÚ ̛· ÛËÌ·ÓÙÈ΋ ÚÔÛÙ·Û›· Î·È Ë ¯Ú‹ÛË ˙ÒÓ˘ ·ÛÊ·Ï›·˜ ÂÓ›Û¯˘Â ÙÔ ·ÔÙ¤ÏÂÛÌ·. ∆Ô Ì¤ÛÔ ÎfiÛÙÔ˜ ÓÔÛËÏ›·˜ ‹Ù·Ó ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚÔ ÁÈ· ÙÔ˘˜ ÂÈ‚¿Ù˜-·È‰È¿ ÙÔ˘ ÌÚÔÛÙÈÓÔ‡ ηı›ÛÌ·ÙÔ˜ ·˘ÙÔÎÈÓ‹ÙÔ˘.
™˘ÌÂÚ¿ÛÌ·Ù·: ∆· ·È‰È¿ Ô˘ οıÔÓÙ·È ÛÙÔ ›Ûˆ οıÈÛÌ· ·˘ÙÔÎÈÓ‹ÙÔ˘, Û ÂÚ›ÙˆÛË ·˘ÙÔÎÈÓËÙÈÛÙÈÎÔ‡ ·Ù˘¯‹Ì·ÙÔ˜, ¤¯Ô˘Ó ηχÙÂÚË ÚÔÛÙ·Û›·. ∏ ¯Ú‹ÛË ˙ÒÓ˘ ·ÛÊ·Ï›·˜ ÂÓÈÛ¯‡ÂÈ ÙËÓ ÚÔÛÙ·Û›·. ∏ ¯Ú‹ÛË Ù˘ fï˜, Â›Ó·È ÂÚÈÔÚÈṲ̂ÓË. ∏ ÚÔÛÙ·Û›· ·fi ÙË ı¤ÛË ÛÙÔ ›Ûˆ οıÈÛÌ· ·˘ÙÔÎÈÓ‹ÙÔ˘ ·ıÚÔ›˙ÂÙ·È ÛÙËÓ ÚÔÛÙ·Û›· Ô˘ ÂÍ·ÛÊ·Ï›˙ÂÙ·È ·fi ÙË ¯Ú‹ÛË ˙ÒÓ˘ ·ÛÊ·Ï›·˜, ·ÏÏ¿Â›Ó·È ·ÓÂÍ¿ÚÙËÙË ·fi ·˘Ù‹.
Berg M, Cook L, Corneli H, Vernon D, Dean J Effect of Seating position and restrained use on injuries to children in motor vehicle crashes Pediatrics 2000;105(4):831-835 ∫ˆÓÛÙ·ÓÙ›ÓÔ˜ £. ∆ÛÔ˘Ì¿Î·˜ ¶·È‰›·ÙÚÔ˜-¢È¢ı˘ÓÙ‹˜ ∂.™.À. ¡ÔÛÔÎÔÌÂ›Ô ∫.∞.∆. ∞ÙÙÈ΋˜
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™˘ÁÁÂÓ‹˜ Û‡ÊÈÏË: Ì›· Û‡Á¯ÚÔÓË ·ÂÈÏ‹ ∂. ∫ÔڷοÎË, ∂. ÷Ù˙ˉ¿ÎË, ∞. ª·ÓÔ˘Ú¿, ¶. ™Ì˘ÚÓ¿ÎË, π. ¶··Ì·ÛÙÔÚ¿ÎË, Ã. °È·ÓÓ·ÎÔÔ‡ÏÔ˘
Congenital syphilis: a current threat E. Korakaki, E. Hatzidaki, A. Manoura, P. Smirnaki, I. Papamastoraki, C. Giannakopoulou
¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÔÓÙ·È Ù¤ÛÛÂÚȘ ÂÚÈÙÒÛÂȘ ·Û˘Ìو̷ÙÈÎÒÓ ÓÂÔÁÓÒÓ ÌÂ Û˘ÁÁÂÓ‹ Û‡ÊÈÏË, Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÙËÓ ÙÂÏÂ˘Ù·›· ÙÚÈÂÙ›·. ∏ Ù·ÍÈÓfiÌËÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¤ÁÈÓ ۇÌʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ ∫¤ÓÙÚÔ˘ ∂ϤÁ¯Ô˘ ¡ÔÛËÌ¿ÙˆÓ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ ∞ÌÂÚÈ΋˜. ∏ ÚÒÙË ÂÚ›ÙˆÛË ·ÊÔÚÔ‡Û ÓÂÔÁÓfi ·fi ¿Á·ÌÔ˘˜ ÁÔÓ›˜, ·ÏÈÓÓÔÛÙÔ‡ÓÙ˜ ŒÏÏËÓ˜ ·fi ¯ÒÚ˜ Ù˘ ÚÒËÓ ™Ô‚ÈÂÙÈ΋˜ ŒÓˆÛ˘. ™ÙË ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË, Ô ·Ù¤Ú·˜ ‹Ù·Ó Ó·˘ÙÈÎfi˜, ÛÙËÓ ÙÚ›ÙË ÙÔ ÓÂÔÁÓfi ‹Ù·Ó ÂÎÙfi˜ Á¿ÌÔ˘, ÂÓÒ Ë ÙÂÏÂ˘Ù·›· ÂÚ›ÙˆÛË ·ÊÔÚÔ‡Û ·ÏÏÔ‰·Ô‡˜ ÁÔÓ›˜ Ô˘ ›¯·Ó ÌÂÙ·Ó·ÛÙ‡ÛÂÈ ÚfiÛÊ·Ù· ÛÙË ¯ÒÚ· Ì·˜ ·Ó·˙ËÙÒÓÙ·˜ ÂÚÁ·Û›·. ™Â η̛· ·fi ÙȘ ÌËÙ¤Ú˜ ‰ÂÓ Â›¯Â ¯ÔÚËÁËı› ÛˆÛÙ‹ Î·È Â·Ú΋˜ ıÂڷ›· ÚÔÁÂÓÓËÙÈο. ∏ ¢Ú›· ÌÂٷΛÓËÛË ÏËı˘ÛÌÈ·ÎÒÓ ÔÌ¿‰ˆÓ Î·È Ë ÂÏ¢ıÂÚ›· ÛÙ· ‹ıË Ù˘ ÛËÌÂÚÈÓ‹˜ ˙ˆ‹˜ ¤¯Ô˘Ó ʤÚÂÈ ÙË Û˘ÁÁÂÓ‹ Û‡ÊÈÏË Í·Ó¿ ÛÙËÓ ÂÈηÈÚfiÙËÙ·.
Abstract: Four cases of asymptomatic full-term neonates with congenital syphilis are described who were hospitalized in our department during the last three years. The cases were classified according ÙÔ the recommendations of the Centers of Disease Control and Prevention (CDC). The first neonate was born to a mother who was unmarried and had immigrated to Greece, the father of the second neonate was a sailor, the third neonate was born also to an unmarried mother, and the last neonate was born to a mother who had recently immigrated to Greece. All infants were born to seropositive mothers who were inadequately treated. In recent years reemergence of congenital syphilis has occurred, probably as a result of the large population movements as well as the to low ethical standards of the society.
§¤ÍÂȘ ÎÏÂȉȿ: Û˘ÁÁÂÓ‹˜ Û‡ÊÈÏË, ·Û˘Ìو̷ÙÈÎfi ÓÂÔÁÓfi.
Key words: congenital syphilis, asymptomatic neonate.
∂ÈÛ·ÁˆÁ‹ ∏ Û‡ÊÈÏË Û˘Ó¯›˙ÂÈ Ó· ·ÔÙÂÏ› ÛÔ‚·Úfi Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜ Û ÔÏÏ¿ ̤ÚË ÙÔ˘ ÎfiÛÌÔ˘. ¶ÂÚÈÁÚ¿ÊËΠÁÈ· ÚÒÙË ÊÔÚ¿ ÛÙ· ̤۷ ÙÔ˘ ‰¤Î·ÙÔ˘ ¤ÌÙÔ˘ ·ÈÒÓ· Î·È ‹Ú ÙÔ fiÓÔÌ¿ Ù˘ ·fi ¤Ó·Ó ¿Û¯ÔÓÙ· ‚ÔÛÎfi, ÙÔ ™‡ÊÈÏÔ (1). ™Ù· Ù¤ÏË ÙÔ˘ ‰¤Î·ÙÔ˘ ¤Ó·ÙÔ˘ ·ÈÒÓ· Î·È ÛÙȘ ·Ú¯¤˜ ÙÔ˘ ÂÈÎÔÛÙÔ‡ ‹Ù·Ó Û ¤Í·ÚÛË, ÂÓÒ Ì ÙËÓ ·Ó·Î¿Ï˘„Ë Ù˘ ÂÓÈÎÈÏ›Ó˘ ÂÚÈÔÚ›ÛÙËΠÛËÌ·ÓÙÈο. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯ÂÈ ·Ú·ÙËÚËı› ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ¿˜ Ù˘, ΢ڛˆ˜ ÌÂٷ͇ Ó·ÚÒÓ ·ÙfïÓ, ÁÂÁÔÓfi˜ Ô˘ ¤¯ÂÈ Û˘Û¯ÂÙÈÛı› Ì ÙËÓ Â˘Ú›· ÌÂ-
ٷΛÓËÛË ÏËı˘ÛÌÈ·ÎÒÓ ÔÌ¿‰ˆÓ Î·È ÙËÓ ÂÏ¢ıÂÚ›· ËıÒÓ Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙÔ ÛËÌÂÚÈÓfi ÙÚfiÔ ˙ˆ‹˜ (2,3). ∏ ÓfiÛÔ˜ ÌÂÙ·‰›‰ÂÙ·È ·fi ÙËÓ ¤ÁÎ˘Ô ÌËÙ¤Ú· ÛÙÔ ¤Ì‚Ú˘Ô, Û˘Ó‹ıˆ˜ ‰È·Ï·ÎÔ˘ÓÙȷο ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ ‹ ÂÍ Â·Ê‹˜ ηٿ ÙÔÓ ÙÔÎÂÙfi. √ ΛӉ˘ÓÔ˜ ÌÂÙ¿‰ÔÛ‹˜ Ù˘ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ˜ ÌÂÙ¿ ÙË 16Ë Â‚‰ÔÌ¿‰· Ù˘ ·ËÛ˘. ™ÙÔ ÚˆÙÔÁÂÓ¤˜ Î·È ‰Â˘ÙÂÚÔÁÂÓ¤˜ ÛÙ¿‰ÈÔ Ù˘ ÓfiÛÔ˘ ÊÙ¿ÓÂÈ ÙÔ 100%. ∏ ‰È¿ÁÓˆÛ‹ Ù˘ Á›ÓÂÙ·È Ì ÔÚÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô. ∏ ÂÓÈÎÈÏ›ÓË ıˆÚÂ›Ù·È ıÂڷ›· ÂÎÏÔÁ‹˜ ÁÈ· ÙËÓ ¤ÁÎ˘Ô ÌËÙ¤Ú· Î·È ÚÔÛٷهÂÈ ÙÔ ¤Ì‚Ú˘Ô,
¡ÂÔÁÓÔÏÔÁÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∫Ú‹Ù˘
Department of Neonatology of the University of Crete
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ÚÔÏ·Ì‚¿ÓÔÓÙ·˜ ÙËÓ Î¿ıÂÙË ÌÂÙ¿‰ÔÛË. ™Â ·ÏÏÂÚÁ›· Ù˘ ÂÁ·Ԣ ÛÙËÓ ÂÓÈÎÈÏ›ÓË Û˘ÓÈÛÙ¿Ù·È ·Â˘·ÈÛıËÙÔÔ›ËÛË (1,4). ∏ ÛÔ‚·ÚfiÙËÙ· Ù˘ ÚÔÛ‚ÔÏ‹˜ ÂÍ·ÚÙ¿Ù·È ·fi ÙËÓ ËÏÈΛ· ÙÔ˘ ÂÌ‚Ú‡Ô˘ ηٿ ÙË ÌÂÙ¿‰ÔÛË. ∏ Û˘ÁÁÂÓ‹˜ Û‡ÊÈÏË Â›Ó·È ·ÈÙ›· ÚfiˆÚÔ˘ ÙÔÎÂÙÔ‡, ÂÓ‰ÔÌ‹ÙÚÈÔ˘ ı·Ó¿ÙÔ˘, ÂÚÈÁÂÓÓËÙÈ΋˜ ıÓËÛÈÌfiÙËÙ·˜ Î·È ÓÂÔÁÓÈ΋˜ ÓÔÛËÚfiÙËÙ·˜. ∆Ô ÚÔۂ‚ÏË̤ÓÔ ÓÂÔÁÓfi ÌÔÚ› Ó· ·ÚÔ˘ÛÈ¿ÛÂÈ Ë·ÙÔÛÏËÓÔÌÂÁ·Ï›·, ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, ‚ÏÂÓÓÔÁÔÓÔ‰ÂÚÌ·ÙÈΤ˜ ‚Ï¿‚˜, ÔÛÙÂÔ¯ÔÓ‰Ú›Ùȉ·, „¢‰Ô·Ú¿Ï˘ÛË, ÂÍ¿ÓıËÌ·, ·ÈÌÔÏ˘ÙÈ΋ ·Ó·ÈÌ›·, ıÚÔÌ‚ÔÂÓ›· Î·È ÚÔÛ‚ÔÏ‹ ÙÔ˘ ∫ÂÓÙÚÈÎÔ‡ ¡Â˘ÚÈÎÔ‡ ™˘ÛÙ‹Ì·ÙÔ˜. ∏ Û˘ÁÁÂÓ‹˜ Û‡ÊÈÏË ¯·Ú·ÎÙËÚ›˙ÂÙ·È ˆ˜ ÚÒÈÌË fiÙ·Ó ÂÌÊ·ÓÈÛÙÔ‡Ó Ù· Û˘ÌÙÒÌ·Ù· ηٿ Ù· ‰‡Ô ÚÒÙ· ¯ÚfiÓÈ· Ù˘ ˙ˆ‹˜ Î·È ˆ˜ fi„ÈÌË fiÙ·Ó ÂÌÊ·ÓÈÛÙÔ‡Ó ·ÚÁfiÙÂÚ·, ÈÔ Û˘¯Ó¿ ÎÔÓÙ¿ ÛÙËÓ ÂÊ˂›·. ∆· 2/3 ÙˆÓ ÚÔۂ‚ÏËÌ¤ÓˆÓ ÓÂÔÁÓÒÓ Â›Ó·È ·Û˘Ìو̷ÙÈο ÛÙË Á¤ÓÓËÛË Î·È Ô ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÂÁ·Ԣ Â›Ó·È Î·ıÔÚÈÛÙÈÎfi˜, ÙfiÛÔ ÁÈ· ÙËÓ ¤ÁηÈÚË ‰È¿ÁÓˆÛË fiÛÔ Î·È ÁÈ· ÙËÓ ¤Î‚·ÛË ÙˆÓ ÓÂÔÁÓÒÓ ·˘ÙÒÓ (1,4). ¶ÂÚÈÁÚ¿ÊÔÓÙ·È Ù¤ÛÛÂÚȘ ÂÚÈÙÒÛÂȘ ·Û˘Ìو̷ÙÈÎÒÓ ÓÂÔÁÓÒÓ ÌÂ Û˘ÁÁÂÓ‹ Û‡ÊÈÏË, Ô˘ ÓÔÛËχÙËÎ·Ó ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÙËÓ ÙÂÏÂ˘Ù·›· ÙÚÈÂÙ›·. ∏ Ù·ÍÈÓfiÌËÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ ¤ÁÈÓ ۇÌʈӷ Ì ÙȘ Ô‰ËÁ›Â˜ ÙÔ˘ ∫¤ÓÙÚÔ˘ ∂ϤÁ¯Ô˘ ¡ÔÛËÌ¿ÙˆÓ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ ∞ÌÂÚÈ΋˜ (Centers for Disease Control and Prevention). ¶ÂÚÈÁÚ·Ê‹ ÂÚÈÙÒÛÂˆÓ ∫·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÙÂÏÂ˘Ù·›·˜ ÙÚÈÂÙ›·˜ ÓÔÛËχÙËÎ·Ó Ù¤ÛÛÂÚ· ÙÂÏÂÈfiÌËÓ· ÓÂÔÁÓ¿ ÌÂ Û˘ÁÁÂÓ‹ Û‡ÊÈÏË. ∆· ÚÔËÁÔ‡ÌÂÓ· 6 ¯ÚfiÓÈ· ÏÂÈÙÔ˘ÚÁ›·˜ Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ ‰ÂÓ ÓÔÛËχÙËΠηӤӷ ÓÂÔÁÓfi Ì ۇÊÈÏË, Ô‡Ù ·Ó·Ê¤ÚıËΠÂÓ‰ÔÌ‹ÙÚÈÔ˜ ‹ ÂÚÈÁÂÓÓËÙÈÎfi˜ ı¿Ó·ÙÔ˜ ÓÂÔÁÓÔ‡ ÌËÙ¤Ú·˜ Ì ۇÊÈÏË. ∆· Ù¤ÛÛÂÚ· ÓÂÔÁÓ¿ Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ì ‹Ù·Ó ·Û˘Ìو̷ÙÈο ÙÂÏÂÈfiÌËÓ·, Ì ̤ÛÔ ‚¿ÚÔ˜ Á¤ÓÓËÛ˘ 3.755 g (± 465.22 g). ∏ ÚÒÙË ÂÚ›ÙˆÛË ·ÊÔÚÔ‡Û ÓÂÔÁÓfi ·fi ¿Á·ÌÔ˘˜ ÁÔÓ›˜, ·ÏÈÓÓÔÛÙÔ‡ÓÙ˜ ŒÏÏËÓ˜ ·fi ¯ÒÚ˜ Ù˘ ÚÒËÓ ™Ô‚ÈÂÙÈ΋˜ ŒÓˆÛ˘. ™ÙË ‰Â‡ÙÂÚË ÂÚ›ÙˆÛË, Ô ·Ù¤Ú·˜ ‹Ù·Ó Ó·˘ÙÈÎfi˜, ÛÙËÓ ÙÚ›ÙË ÙÔ ÓÂÔÁÓfi ‹Ù·Ó ÂÎÙfi˜ Á¿ÌÔ˘, ÂÓÒ Ë ÙÂÏÂ˘Ù·›· ÂÚ›ÙˆÛË ·ÊÔÚÔ‡Û ·ÏÏÔ‰·Ô‡˜ Ô˘ ›¯·Ó ÌÂÙ·Ó·ÛÙ‡ÛÂÈ ÚfiÛÊ·Ù· ÛÙË ¯ÒÚ· Ì·˜ ·Ó·˙ËÙÒÓÙ·˜ ÂÚÁ·Û›·. ∏ ̤ÛË ËÏÈΛ· Ù˘ ÌËÙ¤Ú·˜ ‹Ù·Ó Ù· 27 ¤ÙË (‡ÚÔ˜ 21-30 ¤ÙË). ¢ÂÓ ·Ó·Ê¤ÚıËΠ¯Ú‹ÛË ÂÍ·ÚÙËÛÈÔÁfiÓˆÓ Ô˘ÛÈÒÓ ·fi η̛· ÌËÙ¤Ú·. ™ÙȘ ÙÚÂȘ ÂÚÈÙÒÛÂȘ (75%), Ë ÓfiÛËÛË Ù˘ ÌËÙ¤Ú·˜ ‰È·ÈÛÙÒıËΠÛÙÔÓ ÚÔÁÂÓÓËÙÈÎfi ¤ÏÂÁ¯Ô Ì ÙÚÂÔÓËÌÈΤ˜ Î·È ÌË ÙÚÂÔÓËÌÈΤ˜ ‰ÔÎÈ̷ۛ˜, ÂÓÒ Û ̛· ÂÚ›ÙˆÛË (25%) Ë ÓfiÛËÛË ‹Ù·Ó ÁÓˆÛÙ‹ ÚÈÓ ·fi ÙËÓ Î‡ËÛË. ∆· ‰‡Ô ÓÂÔÁÓ¿ ÁÂÓÓ‹ıË-
Paediatriki 2001;64:168-171
Î·Ó ·fi ÌËÙ¤Ú˜ Ô˘ ‰ÂÓ ·Ú·ÎÔÏÔ˘ıÔ‡ÓÙ·Ó Ù·ÎÙÈο ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ (<3 Û˘ÓÔÏÈο ÂÈÛΤ„ÂȘ ÚÈÓ ÙÔÓ ÙÔÎÂÙfi). ™Â η̛· ·fi ÙȘ ÌËÙ¤Ú˜ ‰ÂÓ Â›¯Â ¯ÔÚËÁËı› ÛˆÛÙ‹ Î·È Â·Ú΋˜ ıÂڷ›· ÚÔÁÂÓÓËÙÈο. ŸÏ· Ù· ÓÂÔÁÓ¿ ‹Ù·Ó ÔÚÔıÂÙÈο ÛÙȘ ÌË ÂȉÈΤ˜ (VDRL) Î·È ÂȉÈΤ˜ (FTAABS) ÙÚÂÔÓËÌÈΤ˜ ‰ÔÎÈ̷ۛ˜, Ì ٛÙÏÔ˘˜ ¯·ÌËÏfiÙÂÚÔ˘˜ ·fi ÂΛÓÔ˘˜ Ù˘ ÌËÙ¤Ú·˜ ÙÔ˘˜. √ ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· Ë·Ù›Ùȉ· µ Î·È C Î·È ÁÈ· HIV ‹Ù·Ó ·ÚÓËÙÈÎfi˜. √ ·ÈÌ·ÙÔÏÔÁÈÎfi˜ Î·È ‚ÈÔ¯ËÌÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‰ÂÓ ·ÔÎ¿Ï˘„ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏ ÔÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË Î·È Ô ·ÎÙÈÓÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÙˆÓ Ì·ÎÚÒÓ ÔÛÙÒÓ Ô˘ ¤ÁÈÓ Û fiÏ· Ù· ÓÂÔÁÓ¿ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi˜ ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘˜. ∫·È ÛÙ· Ù¤ÛÛÂÚ· ÓÂÔÁÓ¿ ¯ÔÚËÁ‹ıËΠÂÓ‰ÔÊϤ‚È· ÎÚ˘ÛÙ·ÏÏÈ΋ ÂÓÈÎÈÏ›ÓË G ÁÈ· 10 Ë̤Ú˜. µÚ›ÛÎÔÓÙ·È ÛÂ Û˘ÛÙËÌ·ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË ·fi ÙÔ Â͈ÙÂÚÈÎfi È·ÙÚÂ›Ô Ù˘ ÎÏÈÓÈ΋˜ Ì·˜ Î·È ¤¯Ô˘Ó ÔÌ·Ï‹ ÔÚ›·. ™˘˙‹ÙËÛË ∏ Û‡ÊÈÏË ·ÔÙÂÏ› ÛÔ‚·Úfi Úfi‚ÏËÌ· ‰ËÌfiÛÈ·˜ ˘Á›·˜ Î·È Ë Û˘¯ÓfiÙËÙ¿ Ù˘ ¤¯ÂÈ ·˘ÍËı› ÛËÌ·ÓÙÈο Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·. ¶ÚÔÛ‚¿ÏÏÂÈ Û˘Ó‹ıˆ˜ Á˘Ó·›Î˜ Ó·ڋ˜ ËÏÈΛ·˜, ¿Á·Ì˜, ¯·ÌËÏÔ‡ ÎÔÈÓˆÓÈÎÔÔÈÎÔÓÔÌÈÎÔ‡ ÂȤ‰Ô˘, Ô˘ οÓÔ˘Ó ¯Ú‹ÛË ÂÍ·ÚÙËÛÈÔÁfiÓˆÓ Ô˘ÛÈÒÓ, ÌÂ Û˘¯Ó‹ ÂÓ·ÏÏ·Á‹ ÛÂÍÔ˘·ÏÈÎÒÓ Û˘ÓÙÚfiÊˆÓ Î·È ÈÛÙÔÚÈÎfi ÛÂÍÔ˘·ÏÈÎÒ˜ ÌÂÙ·‰È‰fiÌÂÓÔ˘ ÓÔÛ‹Ì·ÙÔ˜. ¶·Ú·ÙËÚÂ›Ù·È Û˘¯ÓfiÙÂÚ· Û ÂΛӘ Ô˘ ηÙÔÈÎÔ‡Ó Û ÊÙˆ¯¤˜ ·ÛÙÈΤ˜ ÂÚÈÔ¯¤˜ Î·È Û ÏËı˘ÛÌÔ‡˜ ÂıÓÈÎÒÓ ÌÂÈÔÓÔًوÓ. √È Á˘Ó·›Î˜ ·˘Ù¤˜ Û˘Ó‹ıˆ˜ ÂÍÂÙ¿˙ÔÓÙ·È ÛÙ· ›ÁÔÓÙ· È·ÙÚ›· ÙˆÓ ¡ÔÛÔÎÔÌ›ˆÓ Î·È ‰ÂÓ ¤¯Ô˘Ó ·Ú΋ ÚÔÁÂÓÓËÙÈ΋ Ì·È¢ÙÈ΋ ·Ú·ÎÔÏÔ‡ıËÛË Î·Ù¿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ËÛ˘ (3,5,6). °È· ÙË ¯ÒÚ· Ì·˜ ‰ÂÓ ˘¿Ú¯Ô˘Ó ¤Á΢ڷ ÛÙ·ÙÈÛÙÈο ÛÙÔȯ›· Û¯ÂÙÈο Ì ÙË Û˘¯ÓfiÙËÙ· Ù˘ Û˘ÁÁÂÓÔ‡˜ Û‡ÊÈÏ˘. ∞fi ÙËÓ ∞’ ¶·ÓÂÈÛÙËÌȷ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ·Ó·Ê¤ÚıËΠfiÙÈ ÛÙËÓ ÂÍ·ÂÙ›· 1985-1991 ‰ÂÓ ÓÔÛËχÙËΠηӤӷ ·È‰› ÌÂ Û˘ÁÁÂÓ‹ Û‡ÊÈÏË, ÂÓÒ Î·Ù¿ ÙËÓ ÙÚÈÂÙ›· 1991-1994 ÓÔÛËχÙËÎ·Ó Ù¤ÛÛÂÚ· ·È‰È¿, ÁÂÁÔÓfi˜ Ô˘ ηٿ ÙÔ˘˜ Û˘ÁÁÚ·Ê›˜ ˘Ô‰ËÏÒÓÂÈ Î¿ÔÈÔ˘ ‚·ıÌÔ‡ ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜. ∞fi ÙÔÓ ∞Ó‰Ú¤Ô˘ Î·È ÙÔ˘˜ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘ ‰ËÌÔÛȇÙËΠfiÙÈ Î·Ù¿ ÙË ‰ˆ‰ÂηÂÙ›· 1976-1988 ÓÔÛËχÙËÎ·Ó Û ‰‡Ô ÂÚÈÊÂÚÂȷο ÓÔÛÔÎÔÌ›· Ù˘ µÔÚ›Ԣ ∂ÏÏ¿‰Ô˜ 14 ‚Ú¤ÊË, ÙˆÓ ÔÔ›ˆÓ ÔÈ ÌËÙ¤Ú˜ ›¯·Ó Û‡ÊÈÏË Î·Ù¿ ÙËÓ Î‡ËÛË. ∆· ‰‡Ô ·˘Ù¿ ¡ÔÛÔÎÔÌ›· ‰¤¯ÔÓÙ·È ·ÛıÂÓ›˜ ·fi ¤Ó· ÌÂÁ¿ÏÔ Ì¤ÚÔ˜ Ù˘ µfiÚÂÈ·˜ ∂ÏÏ¿‰·˜ ηÈ, fiˆ˜ ˘ÔÛÙËÚ›˙Ô˘Ó ÔÈ Û˘ÁÁÚ·Ê›˜, Ù· ÂÚÈÛÙ·ÙÈο ·˘Ù¿ ‰ÂÓ ·ÓÙ·Ó·ÎÏÔ‡Ó Î¿ÔÈ· ÂӉ¯fiÌÂÓË ·‡ÍËÛË Ù˘ Û˘¯ÓfiÙËÙ·˜ Ù˘
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ÓfiÛÔ˘ ÁÈ· ÙË Û˘ÁÎÂÎÚÈ̤ÓË ¯ÚÔÓÈ΋ ÂÚ›Ô‰Ô (2,7). ™ÙÔ ·ÚÂÏıfiÓ, Ë ‰È¿ÁÓˆÛË Ù˘ Û˘ÁÁÂÓÔ‡˜ Û‡ÊÈÏ˘ ÛÙËÚÈ˙fiÙ·Ó ÛÙ· ÎÏÈÓÈο Î·È ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Î·È ÌfiÓÔ Ù· ÓÂÔÁÓ¿ Ì ÎÏÈÓÈο ÂÌÊ·Ó‹ ÓfiÛÔ ‹ Ì ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ÂÓ‰ÂÈÎÙÈο Û˘ÁÁÂÓÔ‡˜ Û‡ÊÈÏ˘ ıˆÚÔ‡ÓÙ·Ó ÚÔۂ‚ÏË̤ӷ. ∆Ô 1988 ÙÔ ∫¤ÓÙÚÔ ∂ϤÁ¯Ô˘ ¡ÔÛËÌ¿ÙˆÓ ÙˆÓ ∏ÓˆÌ¤ÓˆÓ ¶ÔÏÈÙÂÈÒÓ ∞ÌÂÚÈ΋˜ (CDC) fiÚÈÛ ÎÚÈÙ‹ÚÈ· ÁÈ· ÙÔÓ Î·ıÔÚÈÛÌfi Ù˘ Û˘ÁÁÂÓÔ‡˜ Û‡ÊÈÏ˘. ™‡Ìʈӷ Ì ٷ ÎÚÈÙ‹ÚÈ· ·˘Ù¿, ıˆÚÔ‡ÓÙ·È Èı·Ó¿ ÚÔۂ‚ÏË̤ӷ Î·È Ú¤ÂÈ Ó· ıÂڷ‡ÔÓÙ·È Ù· ÓÂÔÁÓ¿ Ô˘ Â›Ó·È Û˘Ìو̷ÙÈο, ηıÒ˜ Î·È ÂΛӷ Ô˘ ÁÂÓÓÈÔ‡ÓÙ·È ·Û˘Ìو̷ÙÈο (·ÓÂÍ¿ÚÙËÙ· ·fi ÙÔÓ Ù›ÙÏÔ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÙÔ˘˜) ·fi ÌËÙ¤Ú˜ ÔÚÔıÂÙÈΤ˜ ÁÈ· Û‡ÊÈÏË, ÌË ıÂÚ·Â˘Ì¤Ó˜ ‹ ·ÙÂÏÒ˜ ıÂÚ·Â˘Ì¤Ó˜. ∞ÙÂÏÒ˜ ıÂÚ·Â˘Ì¤ÓË ıˆÚÂ›Ù·È Ë ÌËÙ¤Ú· fiÙ·Ó ÙÔ Â›‰Ô˜ Ù˘ ıÂڷ›·˜ Â›Ó·È ¿ÁÓˆÛÙÔ, ÙÔ ·ÓÙÈ‚ÈÔÙÈÎfi Ô˘ Ù˘ ¯ÔÚËÁ‹ıËÎÂ Â›Ó·È ‰È·ÊÔÚÂÙÈÎfi ·fi ÙËÓ ÂÓÈÎÈÏ›ÓË, Ë ·ÁˆÁ‹ Ì ÂÓÈÎÈÏ›ÓË ¤ÁÈÓ ̤۷ ÛÙÔÓ ÙÂÏÂ˘Ù·›Ô Ì‹Ó· ÚÈÓ ·fi ÙÔÓ ÙÔÎÂÙfi, ‰ÂÓ ˘‹ÚÍ ÔÚÔÏÔÁÈ΋ ·ÓÙ·fiÎÚÈÛË ÌÂÙ¿ ÙËÓ ÔÏÔÎÏ‹ÚˆÛË Ù˘ ıÂڷ›·˜ ‹ ‰ÂÓ ÂÎÙÈÌ‹ıËÎÂ Ë ·ÓÙ·fiÎÚÈÛË ÛÙË ıÂڷ›·, ·ÊÔ‡ Ô ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ‹Ù·Ó ·Ó·Ú΋˜ (8-10). ∏ ‰È¿ÁÓˆÛË Ù›ıÂÙ·È Ì ÂȉÈΤ˜ ÔÚÔÏÔÁÈΤ˜ ‰ÔÎÈ̷ۛ˜, ÙȘ ÌË ÙÚÂÔÓËÌÈΤ˜ (VDRL, RPR) Î·È ÙȘ ÙÚÂÔÓËÌÈΤ˜ (FTA-ABS, MHA-TP). ∂Ȃ‚·ÈÒÓÂÙ·È Ì ÙËÓ ·Ó›¯Ó¢ÛË ÙˆÓ ÛÂÈÚÔ¯·ÈÙÒÓ Ì ÌÈÎÚÔÛÎfiËÛË Û ÛÎÔÙÂÈÓfi ‰›Ô ÛÙÔ ·ÌÓÈ·Îfi ˘ÁÚfi, ÛÙÔÓ Ï·ÎÔ‡ÓÙ·, ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi, ÛÙȘ Û˘ÊÈÏȉÈΤ˜ ϿΘ, ÛÙȘ ÂÎÎÚ›ÛÂȘ ‚ÏÂÓÓÔÁfiÓˆÓ, ηıÒ˜ Î·È Ì ÙËÓ ·Ó›¯Ó¢ÛË ÙÔ˘ ÁÂÓÂÙÈÎÔ‡ ˘ÏÈÎÔ‡ ÙÔ˘ ÙÚÂÔÓ‹Ì·ÙÔ˜, Ì ÙË ¯Ú‹ÛË Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR). √ ¤ÏÂÁ¯Ô˜ ÚÔÛ‚ÔÏ‹˜ ÙÔ˘ ∫ÂÓÙÚÈÎÔ‡ ¡Â˘ÚÈÎÔ‡ ™˘ÛÙ‹Ì·ÙÔ˜ Á›ÓÂÙ·È Ì ÚÔÛ‰ÈÔÚÈÛÌfi ÙÔ˘ Ï¢ÎÒÌ·ÙÔ˜, ÙˆÓ Ï¢ÎÔ΢ÙÙ¿ÚˆÓ Î·È Ù˘ VDRL ÛÙÔ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô ˘ÁÚfi (4,8). £Âڷ›· ÂÎÏÔÁ‹˜ ÁÈ· Ù· ÓÂÔÁÓ¿ ·˘Ù¿ ·Ú·Ì¤ÓÂÈ Ë ¯ÔÚ‹ÁËÛË ¤Ó˘‰Ú˘ ÎÚ˘ÛÙ·ÏÏÈ΋˜ ÂÓÈÎÈÏ›Ó˘ G Û ‰fiÛË 100.000-150.000 IU/kg/24ˆÚÔ ÂÓ‰ÔÊϤ‚È·, ηٷÓÂÌË̤ÓË Û 2-3 ËÌÂÚ‹ÛȘ ‰fiÛÂȘ › 10 ¤ˆ˜ 14 Ë̤Ú˜. ∏ ¤ÁηÈÚË ¯ÔÚ‹ÁËÛË ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜ Â›Ó·È Î·ıÔÚÈÛÙÈ΋˜ ÛËÌ·Û›·˜ ÁÈ· ÙËÓ ¤Î‚·ÛË (4,8). ªÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Ù˘ ıÂڷ¢ÙÈ΋˜ ·ÁˆÁ‹˜ Â›Ó·È ··Ú·›ÙËÙË Ë Â·Ó¿ÏË„Ë ÙÔ˘ ÔÚÔÏÔÁÈÎÔ‡ ÂϤÁ¯Ô˘, ÁÈ· Ó· ‰È·ÈÛÙˆı› Ë ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ Ù˘. ∏ ∞ÌÂÚÈηÓÈ΋ ∞η‰ËÌ›· ¶·È‰È·ÙÚÈ΋˜ ÚÔÙ›ÓÂÈ ÔÚÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô Ù˘ ÂÁ·Ԣ ÛÙËÓ ·Ú¯‹ Ù˘ ·ËÛ˘ Î·È ÛÙÔÓ ÙÔÎÂÙfi, ÂÓÒ ÛÙȘ ¤ÁÎ˘Â˜ ˘„ËÏÔ‡
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ÎÈÓ‰‡ÓÔ˘ Î·È Î·Ù¿ ÙËÓ 28Ë Â‚‰ÔÌ¿‰·. ∫·Ó¤Ó· ÓÂÔÁÓfi ÌË ÂÏÂÁ̤Ó˘ ÌËÙ¤Ú·˜ ‰ÂÓ Ú¤ÂÈ Ó· ʇÁÂÈ ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô ÚÈÓ ÂÎÙÈÌËı› ÔÚÔÏÔÁÈο Ë ÌËÙ¤Ú· ÙÔ˘ ÁÈ· Û‡ÊÈÏË (4,8,10). ∆· ÓÂÔÁÓ¿ Ô˘ ÂÚÈÁÚ¿ÊÔ˘Ì ÁÂÓÓ‹ıËÎ·Ó ·fi ÌËÙ¤Ú˜ Ô˘ ·Ó‹Î·Ó ÛÙȘ ηÙËÁÔڛ˜ ˘„ËÏÔ‡ ÎÈÓ‰‡ÓÔ˘. ¢‡Ô ·È‰È¿ ·fi ¿Á·Ì˜ ÌËÙ¤Ú˜, ‰‡Ô ·È‰È¿ ·fi ·ÏÏÔ‰·Ô‡˜ ÁÔÓ›˜ Î·È Ù¤ÏÔ˜, ¤Ó· ·È‰› ·fi ·Ù¤Ú· Ó·˘ÙÈÎfi. ∏ ÓfiÛÔ˜ ‰È·ÈÛÙÒıËΠ۠‰‡Ô ÂÚÈÙÒÛÂȘ ÛÙÔÓ ÔÚÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô ÚÔ˘Ù›Ó·˜ ÛÙËÓ ·Ú¯‹ Ù˘ ·ËÛ˘, Û ̛· ÛÙÔ ÙÚ›ÙÔ ÙÚ›ÌËÓÔ, ÂÓÒ ÛÙËÓ ÙÂÏÂ˘Ù·›· ‹Ù·Ó ÁÓˆÛÙ‹ ÚÈÓ ·fi ÙËÓ Î‡ËÛË. ™Â fiϘ ÙȘ ÂÚÈÙÒÛÂȘ Ë ıÂڷ›· ‰ÂÓ ‹Ù·Ó ÛˆÛÙ‹ Î·È Â·Ú΋˜ Î·È Ë ·Ú·ÎÔÏÔ‡ıËÛË ÂÏÏÈ‹˜. ∏ Û˘ÁÁÂÓ‹˜ Û‡ÊÈÏË Ê·›ÓÂÙ·È fiÙÈ ¤Ú¯ÂÙ·È Í·Ó¿ ÛÙËÓ ÂÈηÈÚfiÙËÙ· Î·È ·ÔÙÂÏ› Ì›· Û‡Á¯ÚÔÓË ·ÂÈÏ‹ ÁÈ· ÙË ¯ÒÚ· Ì·˜. ∏ ÌÂٷΛÓËÛË ÏËı˘ÛÌÈ·ÎÒÓ ÔÌ¿‰ˆÓ Î·È Ë ÂÏ¢ıÂÚ›· ÛÙ· ‹ıË Ù˘ ÛËÌÂÚÈÓ‹˜ ˙ˆ‹˜ ¤¯Ô˘Ó ÂӉ¯Ô̤ӈ˜ ‰È·‰Ú·Ì·Ù›ÛÂÈ Î·ıÔÚÈÛÙÈÎfi ÚfiÏÔ. √ ÔÚÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ù˘ ÂÁ·Ԣ ‰ÂÓ Ú¤ÂÈ Ó· ıˆÚÂ›Ù·È ‰Â‰Ô̤ÓÔ˜. ∏ ÂÈÌÔÓ‹ ·fi ÙÔÓ ÎÏÈÓÈÎfi È·ÙÚfi Î·È Ë ·Ó·˙‹ÙËÛË ÙˆÓ ·ÔÙÂÏÂÛÌ¿ÙˆÓ ÙÔ˘ ÔÚÔÏÔÁÈÎÔ‡ ÂϤÁ¯Ô˘ Â›Ó·È ÛËÌ·ÓÙÈ΋ ÁÈ· ÙËÓ ¤ÁηÈÚË ·Ó›¯Ó¢ÛË, ‰È·ÁÓˆÛÙÈ΋ Î·È ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË Î¿ı ÂÚ›ÙˆÛ˘ ÓÂÔÁÓÔ‡ Ô˘ ÁÂÓÓÈ¤Ù·È ·fi ÌËÙ¤Ú· Ì ÂÓÂÚÁ‹, ÌË ıÂÚ·Â˘Ì¤ÓË, ·ÙÂÏÒ˜ ıÂÚ·Â˘Ì¤ÓË, ‹ ·ÎfiÌ· Î·È ·‰È¿ÁÓˆÛÙË Û‡ÊÈÏË. µÈ‚ÏÈÔÁÚ·Ê›· 1. Ingall D, Sanchez PJ, Musher DM. Syphilis. In: Remington JS, Klein JO, eds. Infectious diseases of the fetus and newborn infant. 4th ed. Philadelphia, PA: W.B. Saunders; 1995. p. 529-564. 2. ∞Ó‰ÚÈÒÙË ª, ∆ÛÔ˘Ì¿Î·˜ ∫, °È·ÓÓÔ‡ÏÈ·-∫·Ú·ÓÙ·Ó¿ ∞, ∫·ÙÂÚ¤ÏÔ˜ Ã. ¶ÚÒÈÌË Û˘ÁÁÂÓ‹˜ Û‡ÊÈÏË. ¢ÂÏÙ ∞’ ¶·È‰È·ÙÚ ∫ÏÈÓ ¶·Ó ∞ıËÓÒÓ 1994;41:350-355. 3. Sison CG, Ostrea EM Jr, Reyes MP, Salary V. The resurgence of congenital syphilis: a cocaine-related problem. J Pediatr 1997;130:289-292. 4. American Academy of Pediatrics. Syphilis. In: Pickering LK, ed. 2000 Red Book: Report of the Committee of Infectious Diseases. 25th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2000. p. 547-559. 5. Coles FB, Hipp SS, Silberstein GS, Chen JH. Congenital syphilis surveillance in upstate New York, 1989-1992: implications for prevention and clinical management. J Infect Dis 1995;171:732-735. 6. Kilmarx PH, Zaidi AA, Thomas JC, Nakashima AK, St Louis ME, Flock ML et al. Sociodemographic factors and the variation in syphilis rates among US counties, 1984 through 1993: an ecological analysis. Am J Public Health 1997;87:1937-1943. 7. ∞Ó‰Ú¤Ô˘ ∞, ¶Ú·ÙÛ›‰Ô˘ ¶, ∫Ô˘ÓÙÔ˘Ú¤ÏÏË ∫, ÷ϷÙÛfi-
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ÁÏÔ˘ ª, ∫·¤Ù˘ ∂. ¶ÚÒÈÌË Û˘ÁÁÂÓ‹˜ Û‡ÊÈÏË: ŒÓ· Úfi‚ÏËÌ· Ô˘ ¤¯ÂÈ ·Ú·ÏËÊı›. ¶·È‰È·ÙÚÈ΋ 1990;53:162-168. 8. Darville T. Syphilis. Pediatr Rev 1999;20:160-164. 9. Centers for Disease Control. Guidelines for the prevention and control of congenital syphilis. MMWR 1988;37:S1-S13. 10. Finelly L, Crayne EM, Spitalny KC. Treatment of infants with reactive syphilis serology, New Jersey: 1992 to 1996. Pediatrics 1998;102:e27.
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HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 30-10-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 08-01-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÃÚÈÛÙ›Ó· °È·ÓÓ·ÎÔÔ‡ÏÔ˘ ∞ÙÏ·ÓÙ›‰Ô˜ 37, 713 05 ∏Ú¿ÎÏÂÈÔ, ∫Ú‹ÙË
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ∂›Â‰· IL-8 Î·È Ô˘‰ÂÙÂÚÔÊÈÏÈ΋˜ ÂÏ·ÛÙ¿Û˘ ÛÙËÓ ·Ó·Ó¢ÛÙÈ΋ Ô‰fi ‚ÚÂÊÒÓ Ì ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ·fi RSV1 ™ÎÔfi˜: ™ÎÔfi˜ Ù˘ ÌÂϤÙ˘ ‹Ù·Ó Ó· ‰ÈÂÚ¢ӋÛÂÈ Î·Ù¿ fiÛÔÓ ·ÂÏ¢ıÂÚÒÓÂÙ·È Ë ÈÓÙÂÚÏ¢ΛÓË (IL)-8 ÛÙȘ ·ÓÒÙÂÚ˜ ·Ó·Ó¢ÛÙÈΤ˜ Ô‰Ô‡˜ ÙˆÓ ‚ÚÂÊÒÓ Î·Ù¿ ÙËÓ ÂΉ‹ÏˆÛË ‚ÚÔÁ¯ÈÔÏ›Ùȉ·˜ ·fi ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi (RSV) Î·È Î·Ù¿ fiÛÔÓ Ù· ÔÏ˘ÌÔÚÊÔ‡ÚËÓ·, Ô˘ ·Ó¢ڛÛÎÔÓÙ·È Û ÌÂÁ¿ÏÔ˘˜ ·ÚÈıÌÔ‡˜ ÛÙÔ ‚ÚÔÁ¯ÈÎfi ‰¤Ó‰ÚÔ ÙˆÓ ‚ÚÂÊÒÓ ·˘ÙÒÓ, Û˘Ì‚¿ÏÏÔ˘Ó ÛÙË ÊÏÂÁÌÔÓ‹ ̤ۈ ·Ú·ÁˆÁ‹˜ ÌÂÛÔÏ·‚ËÙÒÓ. ÀÏÈÎfi Î·È Ì¤ıÔ‰ÔÈ: ªÂÏÂÙ‹ıËÎ·Ó 27 ‚Ú¤ÊË Ì ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ· ηٿ ÙË ‰È¿ÚÎÂÈ· ¯ÂÈÌÂÚÈÓ‹˜ ÂȉËÌ›·˜ Î·È 20 ‚Ú¤ÊË ÔÌ¿‰·˜ ÂϤÁ¯Ô˘ Ô˘ ÚÔ¤Ú¯ÔÓÙ·Ó ·fi ÌÂϤÙË ÂÌ‚ÔÏ›Ô˘ ÛÙËÓ ÎÔÈÓfiÙËÙ·. ¢Â›ÁÌ·Ù· ˘ÁÚÔ‡ ·fi ÙÔ˘˜ ·ÂÚ·ÁˆÁÔ‡˜ ÂÏ‹ÊıËÛ·Ó Ì ÚÈÓÈ΋ ¤ÎÏ˘ÛË. ∆· ·ÙÙ·Ú· ·ÔÌ·ÎÚ‡ÓıËÎ·Ó ÌÂ Ê˘ÁÔΤÓÙÚËÛË ·fi ÙÔ ¤ÎÏ˘Ì· Î·È ÙÔ ˘ÂÚΛÌÂÓÔ ˘ÁÚfi Ê˘Ï¿¯ıËΠÛÙÔ˘˜ -70oC. ∞ÎÔÏÔ‡ıËÛ ‰ÈÂÚ‡ÓËÛË ÙˆÓ ‰ÂÈÁÌ¿ÙˆÓ ÁÈ· ÙËÓ ·ÚÔ˘Û›· IL-8 Î·È ÔÏÈ΋˜ ·ÓıÚÒÈÓ˘ Ô˘‰ÂÙÂÚÔÊÈÏÈ΋˜ ÂÏ·ÛÙ¿Û˘ (human neutrophil elastase, HNE), ηıÒ˜ Î·È ÁÈ· ÙË ‰Ú·ÛÙËÚÈfiÙËÙ· Ù˘ Ô˘‰ÂÙÂÚÔÊÈÏÈ΋˜ ÂÏ·ÛÙ¿Û˘. ∞ÔÙÂϤÛÌ·Ù·: ™Ù· ·È‰È¿ Ì ‚ÚÔÁ¯ÈÔÏ›Ùȉ·, Û ۇÁÎÚÈÛË Ì ÙËÓ ÔÌ¿‰· ÂϤÁ¯Ô˘, ·Ó¢ڤıËÛ·Ó ˘„ËÏ¿ ›‰· IL-8 (‰È¿ÌÂÛÔ˜ (‡ÚÔ˜) 1,53 (0-153), ¤Ó·ÓÙÈ 0 (0-5,6) ng.mL–1), HNE (136 (32-694), ¤Ó·ÓÙÈ 14 (0-516) ng.mL–1) Î·È ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÂÏ·ÛÙ¿Û˘ (4 (1-220), ¤Ó·ÓÙÈ 1 (0-339) mU.mL–1).
™˘ÌÂÚ¿ÛÌ·Ù·: ∆· ·ÔÙÂϤÛÌ·Ù· Ù˘ ÌÂϤÙ˘ ‰Â›¯ÓÔ˘Ó fiÙÈ, › ÚÔÛ‚ÔÏ‹˜ Ì ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi, ·ÂÏ¢ıÂÚÒÓÂÙ·È ÈÓÙÂÚÏ¢ΛÓË-8 ÛÙȘ ·ÓÒÙÂÚ˜ ·Ó·Ó¢ÛÙÈΤ˜ Ô‰Ô‡˜ Î·È fiÙÈ Ù· ÚÔ˚fiÓÙ· ÙˆÓ Ô˘‰ÂÙÂÚÔÊ›ÏˆÓ Î˘ÙÙ¿ÚˆÓ ·›˙Ô˘Ó ÛËÌ·ÓÙÈÎfi ÚfiÏÔ ÛÙË ÊÏÂÁÌÔÓÒ‰Ë ·ÓÙ›‰Ú·ÛË Ô˘ ÚÔηÏÂ›Ù·È ·fi ÙÔÓ ·Ó·Ó¢ÛÙÈÎfi Û˘Á΢ÙÈ·Îfi Èfi ÛÙ· ‚Ú¤ÊË Ì ÔÍ›· ‚ÚÔÁ¯ÈÔÏ›Ùȉ·. ∆· Â˘Ú‹Ì·Ù· ·˘Ù¿ ¤Ú¯ÔÓÙ·È Û ·ÓÙ›ıÂÛË Ì ÂΛӷ Ô˘ ¯·Ú·ÎÙËÚ›˙Ô˘Ó ÙËÓ Î·Ù’ ÂÍÔ¯‹Ó ˈÛÈÓÔÊÈÏÈ΋ ·¿ÓÙËÛË Ô˘ ÚÔηÏÂ›Ù·È Û ·ÙÔÈ΋ ÓfiÛÔ ÙÔ˘ ·ÓÒÙÂÚÔ˘ Î·È Î·ÙÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡.
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M, Bell F, Finn A, Rao WH, Nixon L, Shale D, Everard ML IL-8 and neutrophil elastase levels in the respiratory tract of infants with RSV bronchiolitis Eur Respir J 1999;14:139-143 ªÈ¯¿Ï˘ ∞ÓıÚ·ÎfiÔ˘ÏÔ˜ ¶·È‰ÔÓ¢ÌÔÓÔÏfiÁÔ˜ ∂ÈÌÂÏËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ∫ÏÈÓÈ΋˜ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ ¶·ÙÚÒÓ
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CASE REPORT
¡fiÛÔ˜ Kawasaki Ì ·Û˘Ó‹ıË ÚˆÙÔ·ı‹ Ïԛ̈ÍË ·fi ÙÔÓ Èfi Epstein-Barr °. ∆ÚÈ·ÓÙ·Ê˘ÏÏ›‰Ë˜, ¢. ∫·Ú·Î·˚‰fi˜, ¶. ∑ÒÛË, £. µÏ¿¯Ô˘, §. ∫·Ó¿Ú˘, Ã. ∫·Ú‹˜
Kawasaki disease assosiated with primary Epstein-Barr virus infection G. Triantafyllidis, D. Karakaidos, P. Zosi, T. Vlachou, L. Kanaris, C. Karis
¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 11 ¯ÚfiÓˆÓ, ÙÔ ÔÔ›Ô ÂÌÊ¿ÓÈÛ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÓfiÛÔ˘ Kawasaki ÛÂ Û˘Ó‰˘·ÛÌfi Ì ڈÙÔ·ı‹ ÂÓÂÚÁfi Ïԛ̈ÍË ·fi ÙÔÓ Èfi Epstein-Barr. ∏ ‰È¿ÁÓˆÛË Ù˘ ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘ ÛÙËÚ›¯ıËΠÛÙËÓ ·ÚÔ˘Û›· ıÂÙÈÎÒÓ IgM ·ÓÙÈη„ȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·È ÛÙËÓ ÂÌÊ¿ÓÈÛË ‰È·Ù·Ú·¯ÒÓ ÛÙÔ˘˜ µ Î·È T ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ‡˜ ˘ÔÏËı˘ÛÌÔ‡˜. °›ÓÂÙ·È ·Ó·ÛÎfiËÛË Ù˘ Û¯ÂÙÈ΋˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ Î·È ·Ó·˙ËÙÂ›Ù·È Ë Èı·Ó‹ Û¯¤ÛË ÌÂٷ͇ ÙˆÓ ‰‡Ô ÓÔÛËÌ¿ÙˆÓ.
Abstract: A case of an eleven year old boy, who presented with Kawasaki disease in association with an active primary Epstein-Barr viral infection is described. The diagnosis of infectious mononucleosis was based on the presence of positive IgM VCA antibody titers along with subtle lymphocyte subset abnormalities. The relevant literature is reviewed and the possible link between the two diseases is sought.
§¤ÍÂȘ ÎÏÂȉȿ: Èfi˜ ∂pstein-Barr, ÏÔÈÌ҉˘ ÌÔÓÔ˘Ú‹ÓˆÛË, ÓfiÛÔ˜ Kawasaki.
∫eywords: Epstein-Barr virus, infectious mononucleosis, Kawasaki disease.
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∂ÓÙÂο¯ÚÔÓÔ ·ÁfiÚÈ ÚÔÛÎÔÌ›ÛıËΠÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÏfiÁˆ ˘ÚÂÙÔ‡ (ıÂÚÌÔÎÚ·Û›· 39,5oC), Ô ÔÔ›Ô˜ ÂÌÊ·Ó›ÛÙËΠ¤ÓÙ ÂÈÎÔÛÈÙÂÙÚ¿ˆÚ· ÚÈÓ ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ Î·È ‰ÂÓ ˘Ô¯ˆÚÔ‡Û Ì ÙË Ï‹„Ë ·ÓÙÈ˘ÚÂÙÈÎÒÓ. ¢‡Ô ÂÈÎÔÛÈÙÂÙÚ¿ˆÚ· ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘, Ù· ˘ÚÂÙÈο ·̷ٷ ÂÓÙ¿ıËηÓ, ÂÓÒ ÛÙ· Û˘ÌÙÒÌ·Ù· ÚÔÛÙ¤ıËÎ·Ó ¤ÌÂÙÔÈ (4-5 ËÌÂÚËÛ›ˆ˜, ÌË ¯ÔÏÒ‰ÂȘ), ηıÒ˜ Î·È ˘‰·Ú›˜ ‰È·ÚÚÔ˚Τ˜ ÎÂÓÒÛÂȘ (3-4 ËÌÂÚËÛ›ˆ˜) Ì ÚfiÛÌÈÍË ÌÈÎÚ‹˜ ÔÛfiÙËÙ·˜ ‚ϤÓÓ˘. ™ÙÔ ÈÛÙÔÚÈÎfi ÙÔ˘, ·Ó·ÊÂÚfiÙ·Ó ÚÔ 20Ë̤ÚÔ˘ Â̇ÚÂÙË Ïԛ̈ÍË ‰È¿ÚÎÂÈ·˜ 6 ËÌÂÚÒÓ, fiÔ˘ Û Â͈ÙÂÚÈÎfi ¤ÏÂÁ¯Ô ‰È·ÁÓÒÛıËΠÔÍ›· ÏÔÈÌ҉˘ ÌÔÓÔ˘Ú‹ÓˆÛË ·fi ÙÔÓ Èfi Epstein-Barr (ıÂÙÈο IgM ·ÓÙÈη„ȉÈο ·ÓÙÈÛÒÌ·Ù·, ·ÚÓËÙÈο IgG). ∆Ô ·È‰› ·Ú¤ÌÂÈÓ ·‡ÚÂÙÔ ÁÈ· 10 Ë̤Ú˜ Î·È 5 Ë̤Ú˜ ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ·ÓÂÌÊ¿ÓÈÛ ˘ÚÂÙfi ¤ˆ˜ 39oC. ∆Ô ÔÈÎÔÁÂÓÂÈ·Îfi ÙÔ˘
ÈÛÙÔÚÈÎfi ‹Ù·Ó ÂχıÂÚÔ. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÂÌÊ¿ÓÈ˙ ηٷ‚ÔÏ‹, ‰È·ÙËÚÒÓÙ·˜ ·Ú¿ÏÏËÏ· ¿ÚÙÈÔ Â›Â‰Ô Û˘Ó›‰ËÛ˘ Î·È ÂÈÎÔÈÓˆÓ›·˜ Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ. ∏ ıÂÚÌÔÎÚ·Û›· ÂÈÛfi‰Ô˘ ‹Ù·Ó 39,7oC, ÂÓÒ Ù· ˙ˆÙÈο ÙÔ˘ ÛËÌ›· ›¯·Ó ˆ˜ ÂÍ‹˜: ·Ó·ÓÔ¤˜: 25/min, ÛʇÍÂȘ: 123/min Î·È ∞¶: 126/73 mmHg. ∫·Ù¿ ÙËÓ ·ÓÙÈÎÂÈÌÂÓÈ΋ ÂͤٷÛË ‰È·ÈÛÙÒıËΠÂÓÙÔÓfiÙ·ÙË ÂÚ˘ıÚfiÙËÙ· ·ÚÈÛıÌ›ˆÓ, ÁÏÒÛÛ·˜ Î·È Ô˘ÏÔÛÙÔÌ·Ù›Ùȉ·, ÂÓÒ ÛÙËÓ ·ÚÈÛÙÂÚ‹ ÚfiÛıÈ· ÙÚ·¯ËÏÈ΋ ¯ÒÚ· „ËÏ·Ê‹ıËΠ·ÓÒ‰˘ÓË Î·È Â˘Î›ÓËÙË ÏÂÌÊ·‰ÂÓÈ΋ ‰ÈfiÁΈÛË, ‰È·ÛÙ¿ÛÂˆÓ 3x4 ÂÎ. √ ÛÏ‹Ó·˜ „ËÏ·Ê‹ıËΠ2 ÂÎ. οو ·fi ÙÔ ·ÚÈÛÙÂÚfi Ï¢ÚÈÎfi ÙfiÍÔ, ÂÓÒ ÙÔ ‹·Ú ‹Ù·Ó ·„ËÏ¿ÊËÙÔ. ∂ÎÙfi˜ ·fi Ì›· ‹È· Ù·¯˘Î·Ú‰›·, Ë ˘fiÏÔÈË Ê˘ÛÈ΋ ÂͤٷÛË ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ™ÙÔ ÂfiÌÂÓÔ ÂÈÎÔÛÈÙÂÙÚ¿ˆÚÔ ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘, ÙÔ ·È‰› ·ÚÔ˘Û›·Û ¤ÓÙÔÓË Â˘ÂÚÂıÈÛÙfiÙËÙ· Î·È ·ÓËÛ˘¯›·, ›ٷÛË Ù˘ ÚÔ¸¿Ú¯Ô˘Û·˜
¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¡›Î·È·˜ - ¶ÂÈÚ·È¿ “ÕÁÈÔ˜ ¶·ÓÙÂÏ‹̈Ӕ - ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋
¶ÂÚÈÊÂÚÂÈ·Îfi °ÂÓÈÎfi ¡ÔÛÔÎÔÌÂ›Ô ¡›Î·È·˜ - ¶ÂÈÚ·È¿ “ÕÁÈÔ˜ ¶·ÓÙÂÏ‹̈Ӕ - ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋
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Ô˘ÏÔÛÙÔÌ·Ù›Ùȉ·˜ Ì ¤ÓÙÔÓË ÍËÚfiÙËÙ· ÙˆÓ ¯ÂÈϤˆÓ, ÂÓÒ ÛÙËÓ ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÚÔÛÙ¤ıËΠÌÈÎÚÔÎËÏȉ҉˜ ÂÍ¿ÓıËÌ· ÛÙÔÓ ÎÔÚÌfi Î·È Ù· ¿ÎÚ·. ¶ÂÚ› ÙÔ Ù¤ÏÔ˜ ÙÔ˘ ÚÒÙÔ˘ ÂÈÎÔÛÈÙÂÙÚ·ÒÚÔ˘ ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ Î·È ÛÙËÓ ·Ú¯‹ ÙÔ˘ ‰Â‡ÙÂÚÔ˘, ÂΉËÏÒıËΠ·ÌÊÔÙÂÚfiÏ¢ÚË ÂÈÂÊ˘Î›Ùȉ·, Ë ÔÔ›· ‰Â Û˘Óԉ¢fiÙ·Ó ·fi ¤ÎÎÚÈÌ· ‹ ‡Ô, Ô›‰ËÌ· ‚ÏÂÊ¿ÚˆÓ Î·È ·Ï·ÌÒÓ Î·È ‰È¿¯˘ÙÔ ÎÔÈÏÈ·Îfi ¿ÏÁÔ˜. ªÂ ÙËÓ ˘Ô„›· Ù˘ ÓfiÛÔ˘ Kawasaki, ¯ÔÚËÁ‹ıËÎ·Ó ·Ì¤Ûˆ˜ ˘ÂÚ¿ÓÔÛË Á-ÛÊ·ÈÚ›ÓË (2 g/kg) Î·È ·ÛÈÚ›ÓË Û ·ÓÙÈÊÏÂÁÌÔÓÒ‰Ë ‰fiÛË (100 mg/kg). ŒÓ· 48ˆÚÔ ÌÂÙ¿ ÙË ¯ÔÚ‹ÁËÛË Ù˘ Á-ÛÊ·ÈÚ›Ó˘, ‹Ïı ۷ʤÛÙ·ÙË ‚ÂÏÙ›ˆÛË Ù˘ ÁÂÓÈ΋˜ ηٿÛÙ·Û˘ ÙÔ˘ ·È‰ÈÔ‡, Ì ٷ˘Ùfi¯ÚÔÓË ˘Ô¯ÒÚËÛË ÙÔ˘ ˘ÚÂÙÔ‡, ÂÓÒ ·fi ÙËÓ 5Ë Ë̤ڷ ÓÔÛËÏ›·˜ ÙÔ˘ ·Ú·ÙËÚ‹ıËΠ·ÔϤÈÛË, ·Ú¯Èο ÂÚÈÛÙÔÌ·ÙÈο Î·È ÂÚÈÔÓ˘¯Èο ÛÙ· οو ¿ÎÚ· Î·È Î·ÙfiÈÓ ÛÙȘ ·Ï¿Ì˜. ªÂÙ¿ ÙÔ ‰Â‡ÙÂÚÔ 24ˆÚÔ ·fi ÙË ¯ÔÚ‹ÁËÛË Ù˘ Á-ÛÊ·ÈÚ›Ó˘, Ë ÂÈÂÊ˘Î›Ùȉ· Î·È Ë Ô˘ÏÔÛÙÔÌ·Ù›Ùȉ· ¿Ú¯ÈÛ·Ó Ó· ˘Ô¯ˆÚÔ‡Ó, ÂÓÒ ÌÂÙ¿ ÙÔ ¤ÌÙÔ 24ˆÚÔ, ÙÔ ·È‰› ‹Ù·Ó ÙÂÏ›ˆ˜ ηϿ Ì ÙË ‚ÂÏÙ›ˆÛË Î·È ˘Ô¯ÒÚËÛË ÙÔ˘ ÂÍ·Óı‹Ì·ÙÔ˜. ¢Ò‰Âη Ë̤Ú˜ ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘, Ù· ·ÈÌÔÂÙ¿ÏÈ· ¤ÊÙ·Û·Ó ÙȘ 870.000/ÌL (¶›Ó·Î·˜ 1). ∆· ˘ÂÚ˯ÔÁÚ·Ê‹Ì·Ù· ηډȿ˜, Ù· ÔÔ›· ¤ÁÈÓ·Ó ÛÙËÓ ÔÍ›· Ê¿ÛË Ù˘ ·ÁÁÂÈ›ÙȉԘ, ·ÏÏ¿ Î·È Î·Ù¿ ÙËÓ ¤ÍÔ‰Ô, ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο (¶›Ó·Î·˜ 1). √È ÔÚÔÏÔÁÈΤ˜ ‰ÔÎÈ̷ۛ˜ ÂȂ‚·›ˆÛ·Ó ÂÓÂÚÁfi ÏÔÈÌÒ‰Ë ÌÔÓÔ˘Ú‹ÓˆÛË (ıÂÙÈο IgM ·ÓÙÈη„ȉÈο ·ÓÙÈÛÒÌ·Ù· Î·È ·ÚÓËÙÈο ·ÓÙÈ˘ÚËÓÈο: anti-EBNA: <1/20), ÂÓÒ Ù· ıÂÙÈο ·ÓÙÈÛÒÌ·Ù· ÁÈ· ÏÂÙfiÛÂÈÚ· ·Ô‰fiıËÎ·Ó ÛÙËÓ ÔÏ˘ÎψÓÈ΋ ˘ÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›·, ÙËÓ ÔÔ›· ÚÔοÏÂÛÂ Ë ‰È¤ÁÂÚÛË ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ ·fi ÙÔÓ Èfi. ∏ ·Ó¿Ï˘ÛË ÙˆÓ ˘ÔÏËı˘ÛÌÒÓ Î·È ÙˆÓ ÏÂÌ-
ÊÔ΢ÙÙ·ÚÈÎÒÓ ‰ÂÈÎÙÒÓ ·ÔÎ¿Ï˘„ ·‡ÍËÛË ÙˆÓ CD3+ T-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ·ÓÂÛÙÚ·Ì̤ÓÔ ÏfiÁÔ T‚ÔËıËÙÈÎÒÓ / T-ηٷÛÙ·ÏÙÈÎÒÓ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, ηıÒ˜ Î·È ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ CD20+ B-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Â˘Ú‹Ì·Ù· ÂÓ‰ÂÈÎÙÈο ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘. ∞Ó·Ï˘ÙÈο, ÔÈ ÔÚÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ ηıÒ˜ Î·È Ù· ÎÏÈÓÈο Û˘ÌÙÒÌ·Ù· Ù˘ ÓfiÛÔ˘ ·ÂÈÎÔÓ›˙ÔÓÙ·È ÛÙÔ˘˜ ›Ó·Î˜ 3 Î·È 2, ·ÓÙ›ÛÙÔȯ·. ªÂÙ¿ ÙËÓ Â·Ó¿ÏË„Ë ÙÔ˘ ηډȷÎÔ‡ ˘ÂÚ˯ÔÁÚ·Ê‹Ì·ÙÔ˜, ¯ÔÚËÁ‹ıËΠ·ÛÈÚ›ÓË Û ·ÓÙÈ·ÈÌÔÂÙ·ÏÈ΋ ‰fiÛË (5 mg/kg) Î·È Ô ·ÛıÂÓ‹˜ ÂÍ‹Ïı Û Ôχ ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË. ™˘˙‹ÙËÛË ∏ ÓfiÛÔ˜ Kawasaki (KS), Â›Ó·È Ì›· Â̇ÚÂÙË ÔÏ˘Û˘ÛÙËÌ·ÙÈ΋ ·ÁÁÂÈ›Ùȉ·, Ë ÔÔ›· ÂÎχÂÙ·È Ì ·ÓÔÛÔÏÔÁÈÎfi Ì˯·ÓÈÛÌfi ÎÈ ÂÈÏÂÎÙÈο ÚÔÛ‚¿ÏÏÂÈ ÙË ‚ÚÂÊÈ΋ Î·È ÚÒÈÌË ·È‰È΋ ËÏÈΛ·. ¶ÚˆÙÔÂÚÈÁÚ¿ÊËΠÛÙËÓ π·ˆÓ›· ÙÔ 1967, Ë ÔÔ›· ·ÎfiÌË Î·Ù¤¯ÂÈ ÙÔ ÚÔ‚¿‰ÈÛÌ· ÛÙÔÓ ÂÙ‹ÛÈÔ ·ÚÈıÌfi ÂÚÈÛÙ·ÙÈÎÒÓ Ù˘ ÓfiÛÔ˘. ∏ ˘ÔÛÙ‹ÚÈÍË Ù˘ ¿Ô„˘ fiÙÈ Èı·Ófiٷٷ ÚfiÎÂÈÙ·È ÁÈ· ÏÔÈÌ҉˜ ÓfiÛËÌ· ÛÙËÚ›˙ÂÙ·È: ·) ÛÙËÓ ·ÈÊÓ›‰È· ÂÈÛ‚ÔÏ‹ Ù˘ Û˘Ìو̷ÙÔÏÔÁ›·˜ ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘ (˘ÚÂÙfi˜, ÂÍ¿ÓıËÌ·, ÏÂÌÊ·‰ÂÓ›Ùȉ·), ‚) ÛÙËÓ ·˘ÙÔÂÚÈÔÚÈ˙fiÌÂÓË ÎÏÈÓÈ΋ ÙÔ˘ ÔÚ›·, Á) ÛÙËÓ Ù·ÎÙÈ΋ ÂÌÊ¿ÓÈÛË ÂȉËÌÈÒÓ ÛÙËÓ ÎÔÈÓfiÙËÙ· Î·È ‰) ÛÙË Û¯Â‰fiÓ ·ÔÎÏÂÈÛÙÈ΋ ËÏÈÎȷ΋ ÙÔ˘ ηٷÓÔÌ‹, Ì ÎÔÚ˘Ê·›· ›وÛË ÛÙȘ ËÏÈ˘ οو ÙˆÓ ÙÂÛÛ¿ÚˆÓ ÂÙÒÓ (1). ∏ ÙÂÏÂ˘Ù·›· ·Ú·Ù‹ÚËÛË ÌÔÚ› Ó· Û˘Ó‰¤ÛÂÈ ÙËÓ ÂÌÊ¿ÓÈÛË Ù˘ ÓfiÛÔ˘ Ì ڈÙÔ·ı›˜ ÈÔÁÂÓ›˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ Û˘ÁÎÂÎÚÈ̤ÓÔ˘ ËÏÈÎÈ·ÎÔ‡ Ê¿ÛÌ·ÙÔ˜. ∏ Û˘Û¯¤ÙÈÛË Ù˘ ÓfiÛÔ˘ Ì ÏÔÈÌÒ‰Ë ÌÔÓÔ˘Ú‹ÓˆÛË ·fi ÙÔÓ Èfi Epstein-Barr, ¤¯ÂÈ Èı·ÓÔÏÔÁËı› Ì ÙËÓ Î·Ù·ÁÚ·Ê‹ Î·È ÂÚÈÁÚ·Ê‹ ÔÏÏÒÓ
¶›Ó·Î·˜ 1. ∂ÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· Î·È ·Ú·ÎÏÈÓÈΤ˜ ÂÍÂÙ¿ÛÂȘ ·fi ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÛÙÔ ÓÔÛÔÎÔÌÂ›Ô Eπ™√¢√™ Ú·) ñ °ÂÓÈ΋ ·›Ì·ÙÔ˜: Hb: 12 g/dL, Ht: 38% §Â˘Î¿: 5500/mmÑ (¶: 67%, §: 21%, ª: 4%) ∞ª¶: 115.000/ÌL, ∆∫∂: 26 mm/h ñ µÈÔ¯ËÌÈÎfi˜¤ÏÂÁ¯Ô˜: CRP: 11 mg/dL, Na+: 136 mEq/L, K+: 4,6 mEq/L, o˘Ú›·: 24 mg/dL ∫Ú·ÙÈÓ›ÓË: 0,7 mg/dL AST: 52 U/L, ALT: 62 U/L ñ °ÂÓÈ΋ Ô‡ÚˆÓ: ∂µ: 1025, pH: 5, Û¿ÓÈ· ÂÚ˘ıÚ¿ Î·È ˘ÔÛÊ·›ÚÈ· ñ Î/· Ê·Ú˘ÁÁÈÎÔ‡ ÂȯڛÛÌ·ÙÔ˜: Ê˘ÛÈÔÏÔÁÈ΋ ¯ÏˆÚ›‰· ñ Î/˜ ·›Ì·ÙÔ˜: ÛÙ›Ú˜
¢∂À∆∂ƒ∏ ª∂ƒ∞ U/S ηډȿ˜: º˘ÛÈÔÏÔÁÈÎfi
Ro £ÒÚ·ÎÔ˜: Î.Ê.
12Ë ∏ª∂ƒ∞
∏b: 10,4 g/dL, §Â˘Î¿: 8020/mmÑ (¶: 62%, §: 30%, M: 6%) ∞ª¶: 870.000/ÌL ALT: 47 U/L AST: 38 U/L
∂•√¢√™(18Ë Ë̤U/S ηډȿ˜: º˘ÛÈÔÏÔÁÈÎfi Hb: 11,29/dL Ht: 35,6% §: 8.270/mm3 (¶: 48% §: 42% M: 10%) ∞ª¶: 503.000/ÌL ∆∫∂: 20 mm/h
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¶·È‰È·ÙÚÈ΋ 2001;64:172-176
Paediatriki 2001;64:173-176
ÂÚÈÙÒÛˆÓ, ÔÈ Ôԛ˜ ÂȯÂÈÚÔ‡Ó Ó· Û˘Ó‰¤ÛÔ˘Ó ÙÔ ¤Ó· ÓfiÛËÌ· Ì ÙÔ ¿ÏÏÔ (1-6). ∏ ËÏÈÎȷ΋ ηٷÓÔÌ‹ Î·È ÙˆÓ ‰‡Ô Â›Ó·È ·ÚfiÌÔÈ· (3-4 ¤ÙË). ∏ ÎÏÈÓÈ΋ ÂÌÊ¿ÓÈÛË ˘ÚÂÙÔ‡, ÂÍ·Óı‹Ì·ÙÔ˜ Î·È ÏÂÌÊ·‰ÂÓ›Ùȉ·˜ Â›Ó·È ÛÙÔȯ›· Î·È ÙˆÓ ‰‡Ô, Ë ÂÍȉڈ̷ÙÈ΋ ·Ì˘Á‰·Ï›Ùȉ· (›¯ÚÈÛÌ·), fï˜, Û¿ÓÈ· ·Ú·ÙËÚÂ›Ù·È ÛÙË ÓfiÛÔ Kawasaki. ∏ ·ÔϤÈÛË ÙˆÓ ·Ï·ÌÒÓ Î·ıÒ˜ Î·È Ë ·Ó¢ڢÛÌ·ÙÈ΋ ‰È¿Ù·ÛË ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ, ÔÈ Ôԛ˜ Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈΤ˜ Ù˘ ·ÁÁÂÈ›Ùȉ·˜, ‰ÂÓ ·Ú·ÙËÚÔ‡ÓÙ·È ÛÙË ÏÔÈÌÒ‰Ë ÌÔÓÔ˘Ú‹ÓˆÛË. ∏ Û˘Ó‹ı˘ ÛÏËÓÔÌÂÁ·Ï›· Ù˘ ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘ Â›Ó·È Û¿ÓÈ· ÛÙË ÓfiÛÔ Kawasaki, ÂÓÒ Ë ÔÏ˘ÌÔÚÊÔ˘Ú‹ÓˆÛË Ù˘ ÙÂÏÂ˘Ù·›·˜, ¤Ú¯ÂÙ·È Û ·ÓÙ›ıÂÛË Ì ÙËÓ ¿Ù˘Ë ÏÂÌÊÔ΢ÙÙ¿ÚˆÛË Ù˘ Ïԛ̈͢ ·fi Epstein-Barr (1). √ Kikuta Î·È ÔÈ Û˘ÓÂÚÁ¿Ù˜ ÙÔ˘, ÛÙËÓ ÚÔÛ¿ıÂÈ¿ ÙÔ˘˜ Ó· Û˘Û¯ÂÙ›ÛÔ˘Ó Ù· ‰‡Ô ÓÔÛ‹Ì·Ù·, ‚Ú‹Î·Ó fiÙÈ ÙÔ 40% (18 ·fi 45) ÙˆÓ ·ÛıÂÓÒÓ Ì Kawasaki ›¯·Ó ıÂÙÈ΋ ·ÓÙÈۈ̷ÙÈ΋ ·fiÎÚÈÛË ¤Ó·ÓÙÈ ÙÔ˘ ÈÔ‡, Û ۯ¤ÛË Ì ÙÔ 72% (111 ·fi 153) ÙˆÓ Ì·ÚÙ‡ÚˆÓ Î·È ˆ˜ ÙÔ 73% ·˘ÙÒÓ ÙˆÓ ÔÚÔıÂÙÈÎÒÓ ÁÈ· ∂µ ·ÛıÂÓÒÓ Ì Kawasaki ¤ÊÂÚ·Ó ·ÓÙÈη„ȉÈο πgM ·ÓÙÈÛÒÌ·Ù·, Û ·ÓÙ›ıÂÛË Ì ÌfiÏȘ
ÙÔ 6% ÙˆÓ ÔÚÔıÂÙÈÎÒÓ Ì·ÚÙ‡ÚˆÓ. ∂ÈÚfiÛıÂÙ·, fiÏÔÈ ÔÈ 18 (100%) ÔÚÔıÂÙÈÎÔ› ·ÛıÂÓ›˜ ›¯·Ó ·ÚÓËÙÈÎfi Ù›ÙÏÔ ˘ÚËÓÈÎÒÓ (EBNA) ·ÓÙÈۈ̿وÓ, Û ·ÓÙ›ıÂÛË Ì ÌfiÓÔ ÙÔ 25% ÙÔ˘ Û˘ÓfiÏÔ˘ ÙˆÓ ÔÚÔıÂÙÈÎÒÓ Ì·ÚÙ‡ÚˆÓ. ∂ÓÙ˘ˆÛȷ΋ ‹Ù·Ó Ë ·Ú·Ù‹ÚËÛË ˆ˜ fiÏÔÈ ÔÈ ıÂÙÈÎÔ› ·ÓÙÈۈ̷ÙÈÎÔ› Ù›ÙÏÔÈ ÙˆÓ ·ÛıÂÓÒÓ Ì Kawasaki ·ÚÓËÙÈÎÔÔÈ‹ıËÎ·Ó ‰‡Ô ‚‰ÔÌ¿‰Â˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ÙÔ˘˜ ·Ó›¯Ó¢ÛË, οÙÈ Ô˘ ‰ÂÓ Â·ÏËı‡ÙËΠÁÈ· ÙÔ˘˜ Ì¿ÚÙ˘Ú˜. ∆¤ÏÔ˜, ·ÍÈfiÏÔÁË ·Ú·Ù‹ÚËÛË Û˘ÓÈÛÙ¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ ÙÔ 11% ·fi ÙÔ˘˜ ·Ú¯Èο ÔÚÔ·ÚÓËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ ıÂÙÈÎÔÔ›ËÛ·Ó ÙÔ˘˜ ·ÓÙÈۈ̷ÙÈÎÔ‡˜ ÙÔ˘˜ Ù›ÙÏÔ˘˜ ÙÚÂȘ Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁÁÂÈ›Ùȉ·˜ (5). ™˘ÌÂÚ·ÛÌ·ÙÈο ÏÔÈfiÓ, ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ˆ˜ Ì›· ÌË Ê˘ÛÈÔÏÔÁÈ΋ ·ÓÔÛÔÏÔÁÈ΋ ·¿ÓÙËÛË Î·Ù¿ ÙË ‰È·‰ÚÔÌ‹ Ù˘ ÚˆÙÔ·ıÔ‡˜ ÂÓÂÚÁ‹˜ Epstein-Barr Ïԛ̈͢, ÌÔÚ› Ó· ¢ı‡ÓÂÙ·È ÁÈ· ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ‚ÏÂÓÓÔÁÔÓÔ‰ÂÚÌ·ÙÈÎÔ‡ ÏÂÌÊ·‰ÂÓÈÎÔ‡ Û˘Ó‰ÚfiÌÔ˘. ∆·˘Ùfi¯ÚÔÓ·, Ê·›ÓÂÙ·È fiÙÈ ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì Kawasaki ηı˘ÛÙÂÚ› ·Û˘Ó‹ıÈÛÙ· ‹ Î·È ·ÎfiÌË Î·Ù·ÛÙ¤ÏÏÂÙ·È Ë ·ÓÙÈۈ̷ÙÈ΋ ·fiÎÚÈÛË Î·Ù¿ ÙÔ˘ ∂pstein-Barr (3-5). ∆ËÓ ÙÂÏÂ˘Ù·›· ·˘Ù‹ ·Ú·Ù‹ÚËÛË ÚÔÛÂÁÁ›˙ÂÈ Î·È Ë ÌÂϤÙË ÙÔ˘ πwanaga Î·È ÙˆÓ Û˘ÓÂÚÁ·ÙÒÓ
¶›Ó·Î·˜ 2. ∫ÏÈÓÈο Û˘ÌÙÒÌ·Ù· ∫§π¡π∫∏ ™Àª¶∆øª∞∆√§√°π∞ 1
∏ª∂ƒ∂™ ª∂∆∞ ∆∏¡ ∂π™∞°ø°∏ Ã√ƒ∏°∏™∏ Á-™º∞πƒπ¡∏™ 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
¶Àƒ∂∆√™ ∂•∞¡£∏ª∞ ∂¶π¶∂ºÀ∫π∆π¢∞ √À§√™∆√ª∞∆π∆π¢∞ ∞¶√§∂¶π™∏ ¶∞§∞ªø¡ ∆ƒ∞Ã∏§π∫∏ §∂ªº∞¢∂¡π∆π¢∞ ∫√π§π∞∫√ ∞§°√™
¶›Ó·Î·˜ 3. √ÚÔÏÔÁÈΤ˜ ÂÍÂÙ¿ÛÂȘ - ¢Â›ÎÙ˜ ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ √ƒ√§√°π∫√™ ∂§∂°Ã√™ ∞ÓÙÈÛÒÌ·Ù· ÁÈ· ∂BV: IgM VCA (+) IgG VCA: 1/320 Anti-EBNA: <1/20 Leptospira: IgM: (+) IgG: 256 IU/ml Mycoplasma pneumoniae: IgM: >50 IU/ml IgG: 20 IU/ml πgM Î·È IgG ·ÓÙÈÛÒÌ·Ù· ÁÈ· πÏ·Ú¿ Rickettsia conori ·ÚÓËÙÈο Coxsiella burnetti Borrelia burgdorferi Anti-ANA: ·ÚÓËÙÈο Anti-DNA: ·ÚÓËÙÈο
}
174
T-·ÙÙ·Ú· CD3+: 83% CD4+: 33% CD8+: 46% CD4/CD8: 0,7
§∂ªº√∫À∆∆∞ƒπ∫√π ¢∂π∫∆∂™ µ-·ÙÙ·Ú· ∞ÓÔÛÔÛÊ·ÈÚ›Ó˜ CD19+: 2% IgG: 2504 mg/dL CD20+: 2% IgA: 212 mg/dL IgM: 550 mg/dL C3: 79 mg/dL C4: 19 mg/dL
2001 MAPT- A¶PI§
17-10-01 15:35
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¶·È‰È·ÙÚÈ΋ 2001;64:172-176
ÙÔ˘, fiÔ˘ Û ÂȉËÌ›· Kawasaki, ÌfiÓÔ ÙÔ 3% (2 ÛÙÔ˘˜ 69) ÙˆÓ ·ÛıÂÓÒÓ ‹Ù·Ó ÔÚÔıÂÙÈÎÔ› ÁÈ· ÙÔÓ Èfi, Û ·ÓÙ›ıÂÛË Ì ÙÔ 84% (58 ÛÙÔ˘˜ 69) ÙˆÓ Ì·ÚÙ‡ÚˆÓ. ™ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÌÂϤÙË ıˆڋıËΠÂÍ·ÈÚÂÙÈο ·›ı·ÓÔ (p<0,001) Ó· ÔÊ›ÏÂÙ·È ÛÂ Ù˘¯·›Ô ÁÂÁÔÓfi˜ ÙÔ Ê·ÈÓfiÌÂÓÔ Ù˘ ·Ó˘·ÚÍ›·˜ ·ÓÙÈÈÈÎÒÓ ·ÓÙÈۈ̿وÓ, ÙË ÛÙÈÁÌ‹ Ì¿ÏÈÛÙ· Ô˘ fiÏÔÈ ÛÙÔ ÔÈÎÔÁÂÓÂÈ·Îfi ÂÚÈ‚¿ÏÏÔÓ ÙˆÓ ·ÛıÂÓÒÓ ¤ÊÂÚ·Ó ·ÓÙÈÛÒÌ·Ù· ηٿ ÙÔ˘ Epstein-Barr (3). √ ÂÓ ÏfiÁˆ Èfi˜ Ê·›ÓÂÙ·È Ó· ÂÌϤÎÂÙ·È Â›Û˘ Î·È Ì ÙȘ ˘ÔÙÚÔ¤˜ Ù˘ ÓfiÛÔ˘ Kawasaki. ∂›Ó·È ÂӉȷʤÚÔÓ fiÙÈ ·È‰È¿, ÛÙ· ÔÔ›· Ô Ù›ÙÏÔ˜ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Î·Ù¿ ÙÔ˘ ÈÔ‡ ‰ÂÓ ·ÔÎ¿Ï˘Ù ·Ï·È¿ Ïԛ̈ÍË (‰ÂÓ ˘‹Ú¯·Ó ‰ËÏ·‰‹ anti-EBNA ·ÓÙÈÛÒÌ·Ù·), ›¯·Ó ÚԉȿıÂÛË Ó· ·ÓÂÌÊ·Ó›ÛÔ˘Ó ÙËÓ ·ÁÁÂÈ›Ùȉ·, Û ۯ¤ÛË Ì ÂΛӷ Ù· ÔÔ›· ¤ÊÂÚ·Ó ÛÙÔÓ ÔÚfi ÙÔ˘˜ ·ÓÙÈÛÒÌ·Ù· ÂÓ‰ÂÈÎÙÈο ·Ï·È¿˜ Ïԛ̈͢ (7). ™Â ·ÓÙ›ıÂÛË Ì ÙËÓ ·Ú·ÙËÚËı›۷ ηٷÛÙÔÏ‹ Ù˘ ·ÓÙÈۈ̷ÙÈ΋˜ ·fiÎÚÈÛ˘ ηٿ ÙÔ˘ ÈÔ‡ ÛÙÔ˘˜ ¿Û¯ÔÓÙ˜ ·fi Kawasaki, Ë ¯ÚfiÓÈ· ÂÓÂÚÁfi˜ Ïԛ̈ÍË ·fi Epstein-Barr, Ë ÔÔ›· ÎÏÈÓÈο ÂΉËÏÒÓÂÙ·È Ì ˘ÚÂÙfi, ÏÂÌÊ·‰ÂÓÔ¿ıÂÈ·, ÛÏËÓÔÌÂÁ·Ï›·, Ë·Ù›Ùȉ·, ‰È¿ÌÂÛË Ó¢ÌÔÓ›Ùȉ·, Ú·ÁÔÂȉ›Ùȉ· Î·È ÂÚÁ·ÛÙËÚȷο Ì ·Ó·ÈÌ›·, Ï¢ÎÔÂÓ›· Î·È ıÚÔÌ‚Ô΢ÙÙÔÂÓ›·, ÚÔηÏ› ˘ÂÚÁ·ÌÌ·ÛÊ·ÈÚÈÓ·ÈÌ›· Ì ¤ÓÙÔÓË ·ÓÔÛÔÏÔÁÈ΋ Î·È ·ÓÙÈۈ̷ÙÈ΋ ·¿ÓÙËÛË Î·Ù¿ ÙÔ˘ ÈÔ‡. ∏ ÂÌÊ¿ÓÈÛË ·Ó¢ڢÛÌ¿ÙˆÓ ÙˆÓ ÛÙÂÊ·ÓÈ·›ˆÓ ·ÁÁ›ˆÓ, ·ÚfiÌÔÈ· Ì ·˘Ù‹ Ù˘ Kawasaki, Û ¤‰·ÊÔ˜ ¯ÚfiÓÈ·˜ ÂÓÂÚÁÔ‡ ÏÔÈÌÒ‰Ô˘˜ ÌÔÓÔ˘Ú‹ÓˆÛ˘, ÂÓÈÛ¯‡ÂÈ ÙËÓ ¿Ô„Ë fiÙÈ Ô Èfi˜ ‰˘ÓËÙÈο ÌÔÚ› Ó· ÂÓ¤¯ÂÙ·È ÛÙË ‰ËÌÈÔ˘ÚÁ›· ÙÔ˘˜. ∂Ó‰ÂÈÎÙÈ΋ ÙˆÓ ·ÓˆÙ¤Úˆ Â›Ó·È Î·È Ë ·ÚÔ˘Û›· ÁÔÓȉÈÒÌ·Ùfi˜ ÙÔ˘ Û ÙÚ›· ‰Â›ÁÌ·Ù· ‚ÈÔ„›·˜ ηډȷÎÔ‡ ÈÛÙÔ‡, fiÔ˘ ·ÓȯÓ‡ıËΠ̠ÙË Ì¤ıÔ‰Ô Ù˘ ·Ï˘ÛȉˆÙ‹˜ ·ÓÙ›‰Ú·Û˘ Ù˘ ÔÏ˘ÌÂÚ¿Û˘ (PCR) (8). ∆¤ÏÔ˜, ·Ú¿‰ÔÍÔ ·ÔÙÂÏ› ÙÔ ÁÂÁÔÓfi˜ Ù˘ ÂÓÙfiÈÛ˘ ÙÔ˘ ÈÈÎÔ‡ ÁÔÓȉÈÒÌ·ÙÔ˜ Ì ˘‚ÚȉÈ΋ (southern blot) ̤ıÔ‰Ô, ÛÙ· CD4+ ∆-‚ÔËıËÙÈο ÏÂÌÊÔ·ÙÙ·Ú·, ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ì ¯ÚfiÓÈ· ÏÔÈÌÒ‰Ë ÌÔÓÔ˘Ú‹ÓˆÛË, ÙË ÛÙÈÁÌ‹ Ô˘ Â›Ó·È ÁÓˆÛÙfi fiÙÈ Ë gp350/220 ÁÏ˘ÎÔÚˆÙ½ÓË ÙÔ˘ ÈÈÎÔ‡ ÂÚÈ‚Ï‹Ì·ÙÔ˜ Û˘Ó‰¤ÂÙ·È ÂÈÏÂÎÙÈο Ì ÙÔÓ CR2 (CD21) ˘Ô‰Ô¯¤· ÙˆÓ µ-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ (9,10). ∞ÚÎÂÙ¤˜ Ù˘¯¤˜ Ù˘ ÓfiÛÔ˘ Kawasaki, fï˜, ÚÔ‚ÏËÌ·Ù›˙Ô˘Ó ÁÈ· ÙÔ Î·Ù¿ fiÛÔ ÌÔÚ› ÙÂÏÈο Ô Epstein-Barr Ó· Û˘Ó‰¤ÂÙ·È Ì ÙËÓ ·ıÔÁ¤ÓÂÛ‹ ÙÔ˘. ¶ÈÔ Û˘ÁÎÂÎÚÈ̤ӷ, Ë ·ÓÔÛÔÏÔÁÈ΋ ΢ÙÙ·ÚÈ΋ ·fiÎÚÈÛË ÛÙËÓ ·ÁÁÂÈ›Ùȉ·, Û˘Ó›ÛÙ·Ù·È ÛÙËÓ ÂÏ¿ÙÙˆÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÙÔ˘ CD3+ T-ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ‡ ˘ÔÏËı˘ÛÌÔ‡ Î·È ÛÙËÓ Ù·˘Ùfi¯ÚÔÓË ·‡ÍËÛË ÙÔ˘ ·ÓÙ›ÛÙÔÈ¯Ô˘ CD20+ µ-ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ‡. ∂ÈϤÔÓ, ˘¿Ú¯ÂÈ Î·È Ì›· ÂÏ¿ÙÙˆÛË ÙÔ˘ ·ÚÈıÌÔ‡ ηÈ
Paediatriki 2001;64:173-176
Ù˘ ‰Ú·ÛÙËÚÈfiÙËÙ·˜ ÙˆÓ T-ηٷÛÙ·ÏÙÈÎÒÓ (CD8+) ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ, Ë ÔÔ›· ·ÔÙÂÏ› ÙËÓ Î‡ÚÈ· ·ÈÙ›· Ù˘ ÔÏ˘ÎψÓÈ΋˜ µ-ÏÂÌÊÔ΢ÙÙ·ÚÈ΋˜ ‰È¤ÁÂÚÛ˘ Î·È ·˘ÍË̤Ó˘ ·Ú·ÁˆÁ‹˜ ·ÓÔÛÔÛÊ·ÈÚ›Ó˘, Êı¿ÓÔÓÙ·˜ ÛÙËÓ ÎÔڇʈۋ Ù˘ ÙË 2Ë3Ë Â‚‰ÔÌ¿‰· Ù˘ ÓfiÛÔ˘. ∞fi ÙËÓ ¿ÏÏË ÏÂ˘Ú¿, ÛÙËÓ ÔÍ›· ÏÔÈÌÒ‰Ë ÌÔÓÔ˘Ú‹ÓˆÛË ÔÈ ÏÂÌÊÔ΢ÙÙ·ÚÈÎÔ› ÏËı˘ÛÌÔ› ·ÚÔ˘ÛÈ¿˙Ô˘Ó ·‡ÍËÛË ÙÔ˘ ÔÛÔÛÙÔ‡ ÙˆÓ CD3+ TÏÂÌÊÔ΢ÙÙ¿ÚˆÓ Î·È ÂÏ¿ÙÙˆÛË ·˘ÙÔ‡ ÙˆÓ CD20+ B-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∆· ηٷÛÙ·ÏÙÈο (CD8+) TÏÂÌÊÔ·ÙÙ·Ú· Â›Ó·È ·˘ÍË̤ӷ, Ô ÏfiÁÔ˜ ÙˆÓ T‚ÔËıËÙÈÎÒÓ ÚÔ˜ Ù· T-ηٷÛÙ·ÏÙÈο ·ÓÂÛÙÚ·Ì̤ÓÔ˜ Î·È Ë ¤ÎÊÚ·ÛË ÙˆÓ HLA-DR ·ÓÙÈÁfiÓˆÓ ÛÙ· T-·ÙÙ·Ú· ÂÓÈÛ¯˘Ì¤ÓË, Ê·ÈÓfiÌÂÓ· Ô˘ ˘Ô‰ËÏÒÓÔ˘Ó ÂÓÂÚÁÔÔ›ËÛË ÙˆÓ T-ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ™ÙÔ ÂÚÈÛÙ·ÙÈÎfi Ô˘ ÂÚÈÁÚ¿ÊËÎÂ, Ô ·ÛıÂÓ‹˜ Ì·˜ ›¯Â ·Ó·ÌÊÈÛ‚‹ÙËÙË Ïԛ̈ÍË Ì EpsteinBarr, Ë ÔÔ›· Ì·ÚÙ˘ÚÂ›Ù·È ·fi: (·) ÙË ıÂÙÈ΋ ·ÚÔ˘Û›· IgM ·ÓÙÈη„ȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Ì ÙËÓ Ù·˘Ùfi¯ÚÔÓË ·Ô˘Û›· ·ÓÙÈ˘ÚËÓÈÎÒÓ (anti-EBNA: <1/20), (‚) ÙÔ ·˘ÍË̤ÓÔ ÔÛÔÛÙfi CD3+ (83%) Î·È CD8+ (46%) T-ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ˘ÔÏËı˘ÛÌÒÓ ·ÓÙ›ÛÙÔȯ·, (Á) ÙÔÓ ·ÓÂÛÙÚ·Ì̤ÓÔ ÏfiÁÔ CD4+ /CD8+ (0,7) Î·È (‰) ÙËÓ ÂÏ·¯ÈÛÙÔÔ›ËÛË ÙˆÓ CD19+ Î·È CD20+ B-ÏÂÌÊÔ΢ÙÙ·ÚÈÎÒÓ ˘ÔÏËı˘ÛÌÒÓ (ÌfiÏȘ 2%). ∏ ·Ú¿ÏÏËÏË ‰È¿ÁÓˆÛË Ù˘ ÓfiÛÔ˘ Kawasaki, Ù¤ıËΠ‚¿ÛÂÈ ÎÏÈÓÈÎÒÓ Î·È ÂÚÁ·ÛÙËÚÈ·ÎÒÓ ÎÚÈÙËÚ›ˆÓ (·Ú·ÙÂٷ̤ÓÔ˜ ˘ÚÂÙfi˜, ÎËÏȉ҉˜ ÂÍ¿ÓıËÌ·, ÙÚ·¯ËÏÈ΋ ÂÙÂÚfiÏ¢ÚË ÏÂÌÊ·‰ÂÓ›Ùȉ·, ·ÌÊÔÙÂÚfiÏ¢ÚË ÌË ˘Ò‰Ë˜ ÂÈÂÊ˘Î›Ùȉ·, Ô˘ÏÔÛÙÔÌ·Ù›Ùȉ· Î·È ·‡ÍËÛË ÙˆÓ ·ÈÌÔÂÙ·Ï›ˆÓ) (11). ∂ÓÙ˘ˆÛȷ΋ Î·È ›Ûˆ˜ ÂÓ‰ÂÈÎÙÈ΋ Ù˘ Èı·Ó‹˜ Û¯¤Û˘ ÙÔ˘ Epstein-Barr Ì ÙËÓ ·ÁÁÂÈ›Ùȉ· Â›Ó·È Î·È Ë ÂÌÊ¿ÓÈÛË Ù˘ ÙÂÏÂ˘Ù·›·˜ ÛÙÔÓ ·ÛıÂÓ‹ Ì·˜, Ë ËÏÈΛ· ÙÔ˘ ÔÔ›Ô˘ ‰ÂÓ Â›Ó·È ·Ó·ÌÂÓfiÌÂÓË ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Ù˘ ÓfiÛÔ˘. ™˘ÌÂÚ·ÛÌ·ÙÈο, Ë Û¯¤ÛË ÌÂٷ͇ Ù˘ Ïԛ̈͢ ·fi ÙÔÓ Epstein-Barr Î·È Ù˘ ÓfiÛÔ˘ Kawasaki Û˘ÓÔ„›˙ÂÙ·È ÛÙȘ ÂÍ‹˜ ÙÚÂȘ ÂΉԯ¤˜: ·) Ë Û˘Û¯¤ÙÈÛ‹ ÙÔ˘˜ ÌÔÚ› ·ÏÔ‡Ûٷٷ Ó· ÔÊ›ÏÂÙ·È ÛÂ Ù˘¯·›· Û‡ÌÙˆÛË, ηıÒ˜ Ë ‚ÚÂÊÈ΋ Î·È ÚÒÈÌË ·È‰È΋ ËÏÈΛ· ·ÔÙÂÏÔ‡Ó ÂÚÈfi‰Ô˘˜ ηٿ ÙȘ Ôԛ˜ Ë ÔÚÔÌÂÙ·ÙÚÔ‹ Â›Ó·È ÙfiÛÔ Û˘ÓËıÈṲ̂ÓË fiÛÔ Î·È ÁÂÓÈο ·Û˘Ìو̷ÙÈ΋, ‚) Ë ÓfiÛÔ˜ Kawasaki ÌÔÚ› Ó· ·ÓÙÈÚÔۈ‡ÂÈ Ì›· ·Ï˘Û›‰· ·ÓÔÛÔÏÔÁÈÎÒÓ ··ÓÙ‹ÛÂˆÓ ÙÔ˘ ÔÚÁ·ÓÈÛÌÔ‡, ÔÈ Ôԛ˜ ÂӉ¯Ô̤ӈ˜ ÂÎχÔÓÙ·È ·fi ÙË Û˘ÁÎÂÎÚÈ̤ÓË ÈÔÁÂÓ‹ Ïԛ̈ÍË ‹ Î·È ·fi Ïԛ̈ÍË Ì ¿ÏÏÔ˘˜ ·Ú¿ÁÔÓÙ˜ Î·È Á) ÎÔÈÓÔ› ÈÔ›, ÔÈ ÔÔ›ÔÈ ÌÔχÓÔ˘Ó ·ÛıÂÓ›˜ Ì Kawasaki, ÌÔÚ› Ó· ¤¯Ô˘Ó “ÚÔˆıËÙÈÎfi” ÚfiÏÔ ÛÙËÓ ¤ÎÊÚ·ÛË ÙÔ˘ ·ÏËıÈÓÔ‡ ·ÈÙÈÔÏÔÁÈÎÔ‡ ·Ú¿ÁÔÓÙ·.
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¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÛÙÂÚÂfiÙ˘Ë ¤ÎÊÚ·ÛË Ù˘ ÓfiÛÔ˘ Kawasaki ηıÈÛÙ¿ Ì¿ÏÏÔÓ ·›ı·ÓË ÙËÓ ÔÏÏ·Ï‹ ·ÈÙÈÔÏÔÁ›· ÙÔ˘ Û˘Ó‰ÚfiÌÔ˘, ÂÎÙÂٷ̤Ó˜ ̤¯ÚÈ ÙÒÚ· ¤Ú¢Ó˜ ‰ÂÓ ¤¯Ô˘Ó ηٷʤÚÂÈ Ó· ÂÓÔ¯ÔÔÈ‹ÛÔ˘Ó Û˘ÁÎÂÎÚÈ̤ÓÔ ·›ÙÈÔ. √ EpsteinBarr Ê·›ÓÂÙ·È Ó· ‰È·‰Ú·Ì·Ù›˙ÂÈ Ô˘ÛÈ·ÛÙÈÎfi ÚfiÏÔ ÛÙËÓ ·ıÔÁ¤ÓÂÈ¿ Ù˘, ·Ó Î·È ··ÈÙÂ›Ù·È ·ÎfiÌË ·ÚÎÂÙ‹ ¤Ú¢ӷ ¤ˆ˜ fiÙÔ˘ ÙÂÎÌËÚȈı› Ï‹Úˆ˜ οÙÈ Ù¤ÙÔÈÔ. µÈ‚ÏÈÔÁÚ·Ê›· 1. Marchette NJ, Melish ME, Hicks R, Kihara S, Sam E, Ching D. Epstein-Barr virus and other herpesvirus infections in Kawasaki syndrome. J Infect Dis 1990;161:680-684. 2. Melekian B. Kawasaki-like infectious mononucleosis. Acta Paediatr Scand 1982;71:843-844. 3. Iwanaga M, Takada K, Osato T, Saeki Y, Noro S, Sakurada N. Kawasaki disease and Epstein-Barr virus. Lancet 1981;1:938-939. 4. Okano M, Hase N, Sakiyama Y, Matsumoto S. Long term observation in patients with Kawasaki syndrome and their relation to Epstein-Barr virus infection. Pediatr Infect Dis J 1990;9:139-141. 5. Kikuta H, Mizuno F, Osato T, Konno M, Ishikawa N, Noro S et al. Kawasaki disease and an unusual primary infection with Epstein-Barr virus. Pediatrics 1984;73:413-414. 6. Barbour AG, Krueger GG, Feorino PM, Smith CB. Kawasakilike disease in a young adult. Association with primary Epstein-Barr virus infection. JAMA 1979;241:397-398.
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7. Kikuta H, Matsumoto S, Yanase Y, Kawasaki T, Mizuno F, Osato T. Recurrence of Kawasaki disease and EpsteinBarr virus infection. J Infect Dis 1990;162:1215. 8. Kikuta H, Sakiyama Y, Matsumoto S, Hamada I, Yazaki M, Iwaki T et al. Detection of Epstein-Barr virus DNA in cardiac and aortic tissues from chronic active Epstein-Barr virus infection associated with Kawasaki disease like coronary artery aneurysms. J Pediatr 1993;123:90-92. 9. Kikuta H, Taguchi Y, Tomizawa K, Kojima K, Kawamura N, Ishizaka A et al. Epstein-Barr virus genome-positive Tlymphocytes in a boy with chronic active EBV infection associated with Kawasaki-like disease. Nature 1998;333:455-457. 10. Tanner J, Weis J, Fearon D, Whang Y, Kieff E. Epstein-Barr gp350/220 binding to the B-lymphocyte C3d receptor mediates absorption, capping and endocytosis. Cell 1987;50:203-213. 11. Burns JC, Mason WC, Glode MP, Shulman ST, Melish ME, Meissner C et al. Clinical and epidemiologic characteristics of petients referred for evaluation of possible Kawasaki disease. J Pediatr 1991;188:680-686.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 30-10-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 19-12-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ÃÚ›ÛÙÔ˜ ∫·Ú‹˜ ¶·È‰›·ÙÚÔ˜ - ¢È¢ı˘ÓÙ‹˜ ∑·Î‡ÓıÔ˘ 2, ÷ϿӉÚÈ
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∂¡¢π∞º∂ƒ√À™∞ ¶∂ƒπ¶∆ø™∏
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CASE REPORT
¶¿ÚÂÛË ÚÔÛˆÈÎÔ‡ Û ·È‰› Ì ϷÓı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ· ∑. ∏ÏÈÔ‰ÚÔÌ›ÙË1, º. æ‡¯Ô˘1, π. ¡›Î·˜2, •. ∫Ú›ÎÔ˜1, ¶. ¡ÈÎÔÏ·˝‰Ô˘1
Facial palsy caused by latent mastoiditis ∑. ∏ÏÈÔ‰ÚÔÌ›ÙË1, º. æ‡¯Ô˘1, π. ¡›Î·˜2, •. ∫Ú›ÎÔ˜1, ¶. ¡ÈÎÔÏ·˝‰Ô˘1
¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È ·ÁfiÚÈ ËÏÈΛ·˜ 19 ÌËÓÒÓ Ì ϷÓı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ· Ô˘ ‰È·ÁÓÒÛÙËΠÌÂÙ¿ ÙËÓ ÂÁηٿÛÙ·ÛË ¿ÚÂÛ˘ ÚÔÛˆÈÎÔ‡. ¶ÚÔËÁ‹ıËÎ·Ó ÂÂÈÛfi‰È· ˘ÔÙÚÔÈ¿˙Ô˘Û·˜ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜. ∏ ‰È¿ÁÓˆÛË Ù˘ Ï·Óı¿ÓÔ˘Û·˜ Ì·ÛÙÔÂȉ›Ùȉ·˜ ÂÙ¤ıË Ì ˘ÔÏÔÁÈÛÙÈ΋ ÙÔÌÔÁÚ·Ê›· ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜ ÏÈıÔÂȉÒÓ. √ ·ÛıÂÓ‹˜ ·ÓÙÈÌÂÙˆ›ÛÙËÎÂ Û˘ÓÙËÚËÙÈο Ì ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹. ∫·Ù¿ ÙËÓ Â·ÓÂͤٷÛË, ÌÂÙ¿ ·fi ‰‡Ô Ì‹Ó˜, ‰È·ÈÛÙÒıËΠϋÚ˘ ·ÔηٿÛÙ·ÛË Ù˘ ¿ÚÂÛ˘.
Abstract: This is the case of a 19 month old boy with latent mastoiditis, who presented with facial palsy. The patient had recurrent episodes of acute otitis media. The diagnosis of latent mastoiditis was made by high-resolution C/T of the temporal bone. The patient was treated conservatively with antibiotics. On follow-up two months later his facial palsy had completely resolved.
§¤ÍÂȘ ÎÏÂȉȿ: Ï·Óı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ·, ¿ÚÂÛË ÚÔÛˆÈÎÔ‡, ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·.
Key words: latent mastoiditis, facial palsy, C/T scan.
∂ÈÛ·ÁˆÁ‹ ∏ Ì·ÛÙÔÂȉ›Ùȉ· Â›Ó·È ÊÏÂÁÌÔÓ‹ Ù˘ Ô›ÛıÈ·˜ ·fiÊ˘Û˘ ÙÔ˘ ÎÚÔÙ·ÊÈÎÔ‡ ÔÛÙÔ‡. ∞ÎÔÏÔ˘ı› Ïԛ̈ÍË ÙÔ˘ ̤ÛÔ˘ ˆÙfi˜ (1). ∏ Û˘¯ÓfiÙËÙ¿ Ù˘ ·ÚÔ˘ÛÈ¿˙ÂÈ ¿ÓÔ‰Ô ÙËÓ ÙÂÏÂ˘Ù·›· ‰ÂηÂÙ›·, Ë ÔÔ›· ·Ô‰›‰ÂÙ·È ÛÙËÓ ·˘ÍË̤ÓË ¯Ú‹ÛË ÙˆÓ ·È‰ÈÎÒÓ ÛÙ·ıÌÒÓ Î·È ÙËÓ ·˘Í·ÓfiÌÂÓË ·ÓÙÔ¯‹ ÛÙ· ·ÓÙÈ‚ÈÔÙÈο (2). ¢È·ÎÚ›ÓÂÙ·È Û ÔÍ›·, ¯ÚfiÓÈ· Î·È Ï·Óı¿ÓÔ˘Û·. ∏ ÔÍ›· Ì·ÛÙÔÂȉ›Ùȉ· ·Ú·ÙËÚÂ›Ù·È Ì ÌÂÁ·Ï‡ÙÂÚË Û˘¯ÓfiÙËÙ· (55-65%) Û ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ ÙÂÛÛ¿ÚˆÓ ¯ÚfiÓˆÓ. ∞ÎÔÏÔ˘ı› ÔÍ›· ̤ÛË ˆÙ›Ùȉ·, Ë ÔÔ›· ‰ÂÓ ÂϤÁ¯ıËΠ̠ÙË ¯ÔÚËÁÔ‡ÌÂÓË ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹. ∞Ô‰›‰ÂÙ·È Û ·fiÊÚ·ÍË Ù˘ ÂÈÛfi‰Ô˘ ÙÔ˘ Ì·ÛÙÔÂȉÈÎÔ‡ ¿ÓÙÚÔ˘ ·fi ÎÔÎÎȈ̷ÙÒ‰Ë ÈÛÙfi, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ·ÚÂÌÔ‰›˙ÂÙ·È Ô ·ÂÚÈÛÌfi˜ Î·È Ë ·ÚÔ¯¤Ù¢ÛË ÙˆÓ Ì·ÛÙÔÂȉÈÎÒÓ Î˘„ÂÏÒÓ Î·È Ó· ¢ÓÔÂ›Ù·È Ë ·Ó¿Ù˘ÍË
Ïԛ̈͢. ¶ÚÔ‚¿ÏÏÂÈ Û˘Ó‹ıˆ˜ Ì ˘ÚÂÙfi, ˆÙ·ÏÁ›· Î·È ÔÈÛıÔˆÙÈ·›· ‰ÈfiÁΈÛË (1,2). ™ÙË ¯ÚfiÓÈ· Ì·ÛÙÔÂȉ›Ùȉ· ˘¿Ú¯ÂÈ ¿ÓÙ· ÈÛÙÔÚÈÎfi ¯ÚfiÓÈ·˜ ̤Û˘ ˆÙ›Ùȉ·˜. ¶ÚÔ‚¿ÏÏÂÈ Ì ˆÙ·ÏÁ›· Î·È ·ÎÔ˘ÛÙÈΤ˜ ‰È·Ù·Ú·¯¤˜. À¿Ú¯Ô˘Ó ¿ÓÙ· ˆÙÔÛÎÔÈο Â˘Ú‹Ì·Ù·, fiˆ˜ ÚÔ‚ÔÏ‹ ‹ ıÔÏÂÚfiÙËÙ· ÙÔ˘ Ù˘Ì¿ÓÔ˘, ÌÂȈ̤ÓË ÎÈÓËÙÈÎfiÙËÙ· Ù˘ Ù˘Ì·ÓÈ΋˜ ÌÂÌ‚Ú¿Ó˘, ˘ÁÚfi ÛÙÔ Ì¤ÛÔ Ô˘˜, ˆÙfiÚÚÔÈ· Î·È ÌÂÚÈΤ˜ ÊÔÚ¤˜ ¯ÔÏÔÛÙ¿و̷ (2). ™ÙË Ï·Óı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ· ˘¿Ú¯ÂÈ ÈÛÙÔÚÈÎfi ˘ÔÙÚÔÈ¿˙Ô˘Û·˜ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜. ∏ ÎÏÈÓÈ΋ ÚÔ‚ÔÏ‹ ‰ÂÓ Â›Ó·È ıÔÚ˘‚҉˘, ÁÈ·Ù› Ë ÔÛÙ½Ùȉ· ÙÔ˘ Ì·ÛÙÔÂȉԇ˜ ÔÛÙÔ‡ ·Ó·Ù‡ÛÛÂÙ·È ‚Ú·‰¤ˆ˜ Î·È ‰ÂÓ ÚÔηÏÂ›Ù·È fiÓÔ˜ Î·È ‰ÈfiÁΈÛË. ∏ ‰È¿ÁÓˆÛË Á›ÓÂÙ·È Û˘Ó‹ıˆ˜ ÌÂÙ¿ ÙËÓ ÂÌÊ¿ÓÈÛË ÂÈÏÔÎÒÓ, .¯. ÂÓ‰ÔÎÚ¿ÓÈÔ˘ ·ÔÛÙ‹Ì·ÙÔ˜, ÌËÓÈÁÁ›Ùȉ·˜ ‹ ¿ÚÂÛ˘ ÚÔÛˆÈÎÔ‡ (3).
1 ∞’ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” 2 ∆Ì‹Ì· ∞ÍÔÓÈÎÔ‡ Î·È ª·ÁÓËÙÈÎÔ‡ ∆ÔÌÔÁÚ¿ÊÔ˘ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·”, ∞ı‹Ó·
1 ∞’ Pediatric Clinic of University of Athens Children’s Hospital “St. Sophia” 2 Division of Axial and Magnetic Tomography Children’s Hospital “St. Sophia”, Athens
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¶ÂÚÈÁÚ¿ÊÂÙ·È Ë ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 19 ÌËÓÒÓ Ì ¿ÚÂÛË ÚÔÛˆÈÎÔ‡ Ô˘ ÔÊÂÈÏfiÙ·Ó Û ϷÓı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ·. ¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 19 ÌËÓÒÓ ÚÔÛÎÔÌ›ÛÙËΠÛÙËÓ ÎÏÈÓÈ΋ Ì·˜, ÁÈ·Ù› 5 Ë̤Ú˜ ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹ ·ÚÔ˘Û›·Û ·ÈÊÓ›‰È· ÂÚÈÊÂÚÈ΋ ¿ÚÂÛË ÚÔÛˆÈÎÔ‡ ·ÚÈÛÙÂÚ¿. √ ·ÛıÂÓ‹˜ Â›Ó·È ÙÔ ‰Â‡ÙÂÚÔ ·È‰› Ó¤ˆÓ Î·È ˘ÁÈÒÓ ÁÔÓ¤ˆÓ Ì ÂχıÂÚÔ ÎÏËÚÔÓÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi. °ÂÓÓ‹ıËΠÌÂÙ¿ ·fi ÙÂÏÂÈfiÌËÓË Ê˘ÛÈÔÏÔÁÈ΋ ·ËÛË Ì ηÈÛ·ÚÈ΋ ÙÔÌ‹ ÏfiÁˆ ÚÔËÁËı›Û˘ (ηÈÛ·ÚÈ΋˜ ÙÔÌ‹˜) Î·È ‚¿ÚÔ˜, Ì‹ÎÔ˜ ÛÒÌ·ÙÔ˜ Î·È ÂÚ›ÌÂÙÚÔ ÎÂÊ·Ï‹˜ ·Ó¿ÌÂÛ· ÛÙË 10Ë Î·È 25Ë ∂£. ∏ ÂÚÈÁÂÓÓËÙÈ΋ ÂÚ›Ô‰Ô˜ Î·È Ë ·Ó·Ù˘Íȷ΋ ÙÔ˘ ÂͤÏÈÍË ‹Ù·Ó ÛÂ Ê˘ÛÈÔÏÔÁÈο Ï·›ÛÈ·. ∂Ì‚ÔÏÈ¿ÛÙËΠηÓÔÓÈο ÁÈ· ÙËÓ ËÏÈΛ· ÙÔ˘ (DTP: 3¢, Sabin: 3¢, MMR: 1¢, Hib titer: 3¢). ™ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ ·ÚÔ˘Û›·Û ÁÈ· ÚÒÙË ÊÔÚ¿ ÔÍ›· ̤ÛË ˆÙ›Ùȉ·. ∞ÎÔÏÔ‡ıËÛ·Ó ¿ÏÏ· 3 ÂÂÈÛfi‰È· ˆÙ›Ùȉ·˜, ÙÔ ÙÂÏÂ˘Ù·›Ô 4 Ì‹Ó˜ ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹, Ù· ÔÔ›· ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó ¿ÏÏÔÙ Ì ÙÔ Û˘Ó‰˘·ÛÌfi ·ÌÔÍÈÎÈÏÏ›Ó˘ Î·È ÎÏ·‚Ô˘Ï·ÓÈÎÔ‡ ÔͤԘ Î·È ¿ÏÏÔÙ Ì ÛÂÊ·ÎÏfiÚË. ŒÓ· Ì‹Ó· ÚÈÓ ÙËÓ ÂÈÛ·ÁˆÁ‹, ÙÔ ·È‰› ·ÚÔ˘Û›·Û Ïԛ̈ÍË ÙÔ˘ ·ÓÒÙÂÚÔ˘ ·Ó·Ó¢ÛÙÈÎÔ‡ Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËΠÌfiÓÔ Ì ·ÓÙÈ˘ÚÂÙÈο. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹, Ô ·ÛıÂÓ‹˜ ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË, ·‡ÚÂÙÔ˜, ÌÂ Ù˘È΋ ÂÚÈÊÂÚÈ΋ ¿ÚÂÛË ÚÔÛˆÈÎÔ‡ ·ÚÈÛÙÂÚ¿. ¶·ÚÔ˘Û›·˙ ·‰˘Ó·Ì›· Û‡ÁÎÏÂÈÛ˘ ÙÔ˘ ·ÚÈÛÙÂÚÔ‡ ÔÊı·ÏÌÔ‡, ÂÍ·Ê¿ÓÈÛË Ù˘ ÚÈÓÔ¯ÂÈÏÈ΋˜ ·‡Ï·Î·˜ ·ÚÈÛÙÂÚ¿ Î·È ¤ÏÍË Ù˘ ÁˆÓ›·˜ ÙÔ˘ ÛÙfiÌ·ÙÔ˜ ‰ÂÍÈ¿, ÂÚÈÛÛfiÙÂÚÔ ÂÌÊ·Ó‹ fiÙ·Ó ¤ÎÏ·ÈÁ ‹ ÁÂÏÔ‡ÛÂ. ∞fi ÙËÓ ˘fiÏÔÈË Î·Ù¿ Û˘ÛÙ‹Ì·Ù· ÂͤٷÛË ‰ÂÓ ÚԤ΢„·Ó ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏ ·ÚÙËÚȷ΋ ›ÂÛË ‹Ù·Ó 89/49 mmHg (25Ë-50Ë ∂£). ∏ ‚˘ıÔÛÎfiËÛË ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. ∆ËÓ ÂÔ̤ÓË Ù˘ ÂÈÛ·ÁˆÁ‹˜, ÙÔ ·È‰› ·ÚÔ˘Û›·Û Âȉ›ӈÛË Ù˘ ÎÏÈÓÈ΋˜ ÂÈÎfiÓ·˜, ¤Ó· ˘ÚÂÙÈÎfi ·̷ ˆ˜ 38,2oC, ·ÓËÛ˘¯›·, ¢ÂÚÂıÈÛÙfiÙËÙ· Î·È ¤Ó·Ó ¤ÌÂÙÔ. ∂ÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜: Hb 11 gr/dl, Ht 33%, ÏÂ˘Î¿ 13700/mm3, ¶: 22%, §: 68%, ªª: 10%, ·ÈÌÔÂÙ¿ÏÈ· 342000/mm3, TKE 18 mm (1Ë ÒÚ·), CRP 17 mg/dl, Ô˘Ú›· 28 mg/dl, ÎÚ·ÙÈÓ›ÓË 0,7 mg/dl, ÁÏ˘Îfi˙Ë 98 mg/dl, Ca 9 mg/dl, SGOT 41 U/L, SGPT 17 U/L, ∞º 185 U/L, ÁÂÓÈ΋ Ô‡ÚˆÓ Î·Ù¿ ʇÛË, Î/· ·›Ì·ÙÔ˜ ÛÙ›ڷ, ÁÂÓÈ΋ ∂¡À: ·ÙÙ·Ú· 0Îί, § <20mg/dl, ™ 60 mg/dl, Î/· ∂¡À ÛÙ›ڷ, ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ HSV1,2 ÛÙÔ ∂¡À: ·ÚÓËÙÈο, ·ÓÙÈÛÒÌ·Ù· ÔÚÔ‡ ¤Ó·ÓÙÈ HSV1,2, EBV, CMV, borrelia burgdorferi ·ÚÓËÙÈο, πgG 1135 mg/dl, IgA 120 mg/dl, IgM 175 mg/dl. ∏ ˘ÔÏÔÁÈÛÙÈ΋ ÙÔÌÔ-
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ÁÚ·Ê›· ÏÈıÔÂȉÒÓ Û ÂÁοÚÛÈÔ Â›Â‰Ô Ì ÏÂÙ¤˜ ÙÔ̤˜ ¿¯Ô˘˜ 1,5 ¯ÈÏ. Î·È Ù¯ÓÈ΋ ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜, ¤‰ÂÈÍ ·ÌÊÔÙÂÚfiÏ¢ÚË Î·Ù¿ÏË„Ë ÙˆÓ ‰ÔÌÒÓ ÙÔ˘ ̤ÛÔ˘ ˆÙfi˜ Ì ‚·Ú‡ÙÂÚË ÂÈÎfiÓ· ·ÚÈÛÙÂÚ¿. ™ÙÔ ·ÚÈÛÙÂÚfi ÏÈıÔÂȉ¤˜ ·Ú·ÙËÚ‹ıËΠϋÚ˘ ·Ô˘Û›· ·¤ÚˆÛ˘, ÙfiÛÔ Ù˘ Ù˘Ì·ÓÈ΋˜ ÎÔÈÏfiÙËÙ·˜ fiÛÔ Î·È ÙˆÓ Ì·ÛÙÔÂȉÒÓ Î˘„ÂÏÒÓ, ÌÂ Û˘Ó˘¿Ú¯Ô˘Û· ηٷÛÙÚÔÊ‹ ÔÛÙ¤ÈÓˆÓ ‰È·ÊÚ·ÁÌ¿ÙˆÓ, ÂÈÎfiÓ· ÂÓÂÚÁÔ‡ Ì·ÛÙÔÂȉ›Ùȉ·˜. ªÂ ÙË ‰È¿ÁÓˆÛË Ù˘ Ì·ÛÙÔÂȉ›Ùȉ·˜, Ô ·ÛıÂÓ‹˜ ·ÓÙÈÌÂÙˆ›ÛÙËΠ̠ÂÓ‰ÔÊϤ‚È· ¯ÔÚ‹ÁËÛË ÎÂÊÔÙ·Í›Ì˘ Î·È ÎÏÈÓ‰·Ì˘Î›Ó˘. ŒÓ· 24ˆÚÔ ÌÂÙ¿ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜ Ô ˘ÚÂÙfi˜ ˘Ô¯ÒÚËÛÂ, ÂÓÒ ·Ú¤ÌÂÈÓ ‹È· ¢ÂÚÂıÈÛÙfiÙËÙ· Î·È ·ÓËÛ˘¯›·. ∆Ș ÂfiÌÂÓ˜ Ë̤Ú˜ ÙÔ ·È‰› ‹Ù·Ó Û ηϋ ÁÂÓÈ΋ ηٿÛÙ·ÛË Î·È ÌÈÎÚ‹ ‚ÂÏÙ›ˆÛË Ù˘ ¿ÚÂÛ˘ ¿Ú¯ÈÛ ӷ ÛËÌÂÈÒÓÂÙ·È ÙÔ 7Ô 24ˆÚÔ ÓÔÛËÏ›·˜. ªÂÙ¿ ÙË Û˘ÌÏ‹ÚˆÛË 14 ËÌÂÚÒÓ ·ÚÂÓÙÂÚÈ΋˜ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜, ÂÍ‹Ïı ·fi ÙËÓ ÎÏÈÓÈ΋ Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË Ì ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË Ù˘ ¿ÚÂÛ˘ Ô˘ ‹Ù·Ó ÂÌÊ·Ó‹˜ ϤÔÓ ÌfiÓÔ Î·Ù¿ ÙÔ ÎÏ¿Ì·. ∆·˘Ùfi¯ÚÔÓ·, Û˘ÛÙ‹ıËÎÂ Ë Û˘Ó¤¯ÈÛË Ù˘ ıÂڷ›·˜ ÌÂ Û˘Ó‰˘·ÛÌfi ·ÌÔÍÈÎÈÏÏ›Ó˘ Î·È ÎÏ·‚Ô˘Ï·ÓÈÎÔ‡ ÔͤԘ ÁÈ· ¿ÏϘ 14 Ë̤Ú˜. ∫·Ù¿ ÙËÓ Â·ÓÂͤٷÛË, ‰‡Ô Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ¤ÍÔ‰Ô ÙÔ˘ ·ÛıÂÓÔ‡˜ ·fi ÙËÓ ÎÏÈÓÈ΋, ‰È·ÈÛÙÒıËΠϋÚ˘ ·ÔηٿÛÙ·ÛË Ù˘ ¿ÚÂÛ˘. ™˘˙‹ÙËÛË ∏ ȉÈÔ·ı‹˜ ¿ÚÂÛË ÚÔÛˆÈÎÔ‡ Â›Ó·È ÂÍ·ÈÚÂÙÈο Û¿ÓÈ· ÛÙ· ·È‰È¿ ËÏÈΛ·˜ οو ÙˆÓ 2 ÂÙÒÓ. ™˘¯ÓfiÙÂÚË ˘ÔΛÌÂÓË ·ÈÙ›· Â›Ó·È Ô ÙÚ·˘Ì·ÙÈÛÌfi˜ Î·È Ë Ïԛ̈ÍË ÈÔÁÂÓ‹˜ ‹ ÌÈÎÚԂȷ΋ Ì ÙË ÌÔÚÊ‹ ˆÙ›Ùȉ·˜ ‹ Ì·ÛÙÔÂȉ›Ùȉ·˜. ™Â ‰È¿ÊÔÚ˜ ÌÂϤÙ˜, ÙÔ 9-24% ÙˆÓ ·Ú¤ÛÂˆÓ ÚÔÛˆÈÎÔ‡ Û ·È‰È¿ ·Ô‰fiıËΠ۠ÔÍ›· ̤ÛË ˆÙ›Ùȉ· (4). √ ·ÛıÂÓ‹˜ Ì·˜, ËÏÈΛ·˜ 19 ÌËÓÒÓ, ·ÚÔ˘Û›·Û ÂÚÈÊÂÚÈ΋ ¿ÚÂÛË ÚÔÛˆÈÎÔ‡ ÔÊÂÈÏfiÌÂÓË Û ϷÓı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ·. ∏ ‰È¿ÁÓˆÛË Ù˘ Ì·ÛÙÔÂȉ›Ùȉ·˜ ı· ÌÔÚÔ‡Û ӷ ‰È·Ê‡ÁÂÈ ÏfiÁˆ Ù˘ ·‚Ï˯ڋ˜ ÎÏÈÓÈ΋˜ ÚÔ‚ÔÏ‹˜, ·Ó ‰ÂÓ Í¤ÓÈ˙Â Ë ÌÈÎÚ‹ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜. ∏ Ï·Óı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ· ·ÊÔÚ¿ Û˘Ó‹ıˆ˜ ·ÓÔÛÔηٷÛÙ·Ï̤ӷ ¿ÙÔÌ·, ÓÂÔÁÓ¿, ·ÛıÂÓ›˜ Ì ΢ÛÙÈ΋ ›ÓˆÛË Î·È Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË, ÌÔÚ› fï˜ Ó· ·Ú·ÙËÚËı› Î·È Û ¿ÙÔÌ· ¯ˆÚ›˜ ˘ÔΛÌÂÓÔ ÓfiÛËÌ· 15 Ë̤Ú˜ - 3 Ì‹Ó˜ ÌÂÙ¿ ·fi ·Ó·ÚÎÒ˜ ıÂÚ·Â˘Ì¤Ó· ÂÂÈÛfi‰È· ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ (6). √ ·ÛıÂÓ‹˜ Ì·˜ ‰ÂÓ Â›¯Â ·ÓÔÛÔÏÔÁÈ΋ ‰È·Ù·Ú·¯‹ ‹ ¿ÏÏÔ ·Ú¿ÁÔÓÙ· ÎÈÓ‰‡ÓÔ˘ Î·È ·ÚÔ˘Û›·˙ ·fi ÙËÓ ËÏÈΛ· ÙˆÓ 6 ÌËÓÒÓ ˘ÔÙÚÔÈ¿˙ÔÓÙ· ÂÂÈÛfi‰È· ˆÙ›Ùȉ·˜. ™ÙË Ï·Óı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ·, Ù· Â˘Ú‹Ì·Ù· Ù˘ ÔÍ›·˜ ̤Û˘ ˆÙ›Ùȉ·˜ ¤¯Ô˘Ó Û˘Ó‹ıˆ˜ ‚ÂÏÙȈı› ÌÂ
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ÙËÓ ÚÔËÁËı›۷ ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ Î·È Ë ·Ï‹ ˆÙÔÛÎfiËÛË Â›Ó·È Û˘¯Ó¿ ·ÚÓËÙÈ΋. ™ÙË ‰È¿ÁÓˆÛË ÌÔÚ› Ó· ηÙ¢ı‡ÓÔ˘Ó Ë ˆÙÔÛÎfiËÛË Ì ÂÌʇÛËÛË ·¤Ú·, Ô˘ ‰Â›¯ÓÂÈ ÚÔ‚ÔÏ‹ Î·È ÌÂȈ̤ÓË ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ Ù˘Ì¿ÓÔ˘ Î·È ÙÔ ·ÎÔ˘fiÁÚ·ÌÌ·, Ô˘ ‰Â›¯ÓÂÈ ‹È· ‹ ̤ÙÚÈ· ·ÒÏÂÈ· ·ÎÔ‹˜ Ù‡Ô˘ ·ÁˆÁÈÌfiÙËÙ·˜ (‰È·ÊÔÚ¿ ÛÙËÓ ·ÁˆÁ‹ ÙÔ˘ ÂÚÂı›ÛÌ·ÙÔ˜ ̤ۈ ÙÔ˘ ·¤Ú· Î·È ÙÔ˘ ÔÛÙÔ‡). ™ÙÔÓ ·ÛıÂÓ‹ Ì·˜ ‰ÂÓ ¤ÁÈÓ ·ÎÔ˘fiÁÚ·ÌÌ· ÏfiÁˆ Ù˘ ÌÈÎÚ‹˜ ÙÔ˘ ËÏÈΛ·˜. ∆Ô ·ÎÔ˘fiÁÚ·ÌÌ· Á›ÓÂÙ·È ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 4 ‹ 5 ¯ÚfiÓˆÓ (3,5). ∏ ‰È¿ÁÓˆÛË Ù˘ Ï·Óı¿ÓÔ˘Û·˜ Ì·ÛÙÔÂȉ›Ùȉ·˜ Á›ÓÂÙ·È Ì ÙËÓ ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÏÈıÔÂȉÒÓ ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜. ™ËÌ›· Ì·ÛÙÔÂȉ›Ùȉ·˜ Â›Ó·È Ë ıÔÏÂÚfiÙËÙ· ÙˆÓ Ì·ÛÙÔÂȉÒÓ Î˘„ÂÏÒÓ Î·È Ë ÌÂȈ̤ÓË ÓÂ˘Ì¿ÙˆÛ‹ ÙÔ˘˜, Ë ·Û·ÊÔÔ›ËÛË ÙÔ˘ ÂÚÈÁÚ¿ÌÌ·ÙÔ˜ ÙÔ˘ Ì·ÛÙÔÂȉԇ˜ ÔÛÙÔ‡, Ë Î·Ù·ÛÙÚÔÊ‹ ÙˆÓ ÔÛÙÈÎÒÓ ‰ÔΛ‰ˆÓ Î·È Ù˘ ΢„ÂÏȉÈ΋˜ ‰ÔÌ‹˜ Ù˘ Ì·ÛÙÔÂȉԇ˜ ·fiÊ˘Û˘. ∏ ı¤ÛË Ù˘ ·ÍÔÓÈ΋˜ ÙÔÌÔÁÚ·Ê›·˜ Â›Ó·È ÛËÌ·ÓÙÈ΋ Î·È ÛÙË ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ̤ÛÔ˘ ˆÙfi˜ (ÁÈ· ¯ÔÏÔÛÙ¿و̷) Î·È ÙˆÓ ÂÈÏÔÎÒÓ Ù˘ Ì·ÛÙÔÂȉ›Ùȉ·˜ fiˆ˜ Ï·‚˘ÚÈÓı›Ùȉ·˜, ÂÓ‰ÔÎÚ¿ÓÈÔ˘ ·ÔÛÙ‹Ì·ÙÔ˜, ÔÛÙÂÔÌ˘ÂÏ›Ùȉ·˜ ÙÔ˘ ÎÚÔÙ·ÊÈÎÔ‡ ÔÛÙÔ‡ (3,7). ¶·Ï·ÈfiÙÂÚ·, Ë ıÂڷ›· Ù˘ Ì·ÛÙÔÂȉ›Ùȉ·˜ ‹Ù·Ó ۯ‰fiÓ ¿ÓÙ· ¯ÂÈÚÔ˘ÚÁÈ΋. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ·, ÛÙËÓ ÔÍ›· Ì·ÛÙÔÂȉ›Ùȉ· ¯ˆÚ›˜ ÂÈÏÔΤ˜ ¯ÔÚËÁÂ›Ù·È ·ÓÙÈÌÈÎÚԂȷ΋ ·ÁˆÁ‹ Î·È Ì˘ÚÈÁÁÔÙÔÌ‹ Á›ÓÂÙ·È fiÙ·Ó ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ, ‰ËÏ·‰‹ Û˘ÏÏÔÁ‹ ˘ÁÚÔ‡ ÛÙÔ Ì¤ÛÔ Ô˘˜ Î·È ÚÔ‚ÔÏ‹ ‹ ÌÂȈ̤ÓË ÎÈÓËÙÈÎfiÙËÙ· ÙÔ˘ Ù˘Ì¿ÓÔ˘. ∂¿Ó Ë ¯ÔÚ‹ÁËÛË ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜ › 48-72 ÒÚ˜ ‰ÂÓ ÂÈʤÚÂÈ ‚ÂÏÙ›ˆÛË (˘Ô¯ÒÚËÛË ÙÔ˘ ˘ÚÂÙÔ‡, Ù˘ ˆÙ·ÏÁ›·˜ Î·È Ù˘ ÔÈÛıÔˆÙÈ·›·˜ ‰ÈfiÁΈÛ˘), ÂȯÂÈÚÂ›Ù·È Ì·ÛÙÔÂȉÂÎÙÔÌ‹ (8,9). ∏ ¯ÚfiÓÈ· Ì·ÛÙÔÂȉ›Ùȉ· ·ÓÙÈÌÂÙˆ›˙ÂÙ·È ¯ÂÈÚÔ˘ÚÁÈο fiÙ·Ó ˘¿Ú¯ÂÈ ¯ÔÏÔÛÙ¿و̷ ‹ Û ·ÔÙ˘¯›· Ù˘ Û˘ÓÙËÚËÙÈ΋˜ ·ÁˆÁ‹˜ (1). ∂Âȉ‹ Ë Ï·Óı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ· ‰È·ÁÈÁÓÒÛÎÂÙ·È Û˘Ó‹ıˆ˜ ·fi ÙȘ ÂÈÏÔΤ˜ Ù˘, Ë ıÂڷ¢ÙÈ΋ ·ÓÙÈÌÂÙÒÈÛË ÂÚÈÏ·Ì‚¿ÓÂÈ ÙË ıÂڷ›· Ù˘ Ì·ÛÙÔÂȉ›Ùȉ·˜ Î·È Ù˘ ÂÈÏÔ΋˜. ŸÙ·Ó Ë Ï·Óı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ· ÂÈϤÎÂÙ·È Ì ¿ÚÂÛË ÚÔÛˆÈÎÔ‡ ¯ÔÚËÁÂ›Ù·È ·Ú¯Èο ·ÓÙÈ‚ÈÔÙÈ΋ ·ÁˆÁ‹ Î·È ÂÊ’ fiÛÔÓ ‰ÂÓ ·Ú·ÙËÚËı› ‚ÂÏÙ›ˆÛË Ù˘ ¿ÚÂÛ˘, Á›ÓÂÙ·È Ì·ÛÙÔÂȉÂÎÙÔÌ‹ (3,10). ™‡Ìʈӷ Ì ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÌÂϤÙ˜, Ù· ÌÈÎÚfi‚È· Ô˘ ·ÔÌÔÓÒÓÔÓÙ·È Û˘¯ÓfiÙÂÚ· ÛÙËÓ ÔÍ›· Ì·ÛÙÔÂȉ›Ùȉ· Â›Ó·È Ó¢ÌÔÓÈfiÎÔÎÎÔ˜, ÛÙÚÂÙfiÎÔÎÎÔ˜ Ù˘ ÔÌ¿‰·˜ ∞, ¯Ú˘Û›˙ˆÓ ÛÙ·Ê˘ÏfiÎÔÎÎÔ˜ Î·È ÌÔڷͤÏÏ·. ™ÙË Ï·Óı¿ÓÔ˘Û· Ì·ÛÙÔÂȉ›Ùȉ· ·ÔÌÔÓÒÓÔÓÙ·È, ›Û˘, ·Ó·ÂÚfi‚È· ÌÈÎÚfi‚È· (1,2,3). ªÂ ‚¿ÛË ÙËÓ ·Ú·¿Óˆ ÁÓÒÛË Î·È Ì ¿ÁÓˆÛÙÔ ÙÔÓ ·ÈÙÈÔÏÔÁÈÎfi ·Ú¿ÁÔÓÙ·, ¯ÔÚËÁ‹Û·Ì ÛÙÔÓ ·ÛıÂÓ‹ Ì·˜ ÎÏÈÓ‰·Ì˘Î›ÓË Î·È ÎÂÊÔÙ·Í›ÌË Ì ηÏfi
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ıÂڷ¢ÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ∏ ÂÎÙ›ÌËÛË Ù˘ ÔÚ›·˜ Ù˘ ¿ÚÂÛ˘ ÙÔ˘ ÚÔÛˆÈÎÔ‡ ηÏfi Â›Ó·È Ó· Á›ÓÂÙ·È Ì ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈÎfi ¤ÏÂÁ¯Ô, ÁÈ·Ù› Ë ÎÏÈÓÈ΋ ‰ÂÓ ·ÔÙÂÏ› ηÏfi ÎÚÈÙ‹ÚÈÔ Ù˘ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ·˜ Ù˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ıÂڷ›·˜ (11,12). √ ̤ÛÔ˜ ¯ÚfiÓÔ˜ ·ÔηٿÛÙ·Û˘ Â›Ó·È Ì·ÎÚfi˜, ÂÚ›Ô˘ 7 ˆ˜ 8 ‚‰ÔÌ¿‰Â˜ (7). √ ·ÛıÂÓ‹˜ Ì·˜ ·ÚÔ˘Û›·Û ٷ¯‡Ù·ÙË ‚ÂÏÙ›ˆÛË Ù˘ ¿ÚÂÛ˘ (̤۷ Û ̛· ‚‰ÔÌ¿‰· ·fi ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÓÙÈ‚ÈÔÙÈ΋˜ ·ÁˆÁ‹˜) Î·È ‰ÂÓ ¯ÚÂÈ¿ÛÙËΠÂÚ·ÈÙ¤Úˆ ‰ÈÂÚ‡ÓËÛË. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ÛÙ· ·È‰È¿ Ì ¿ÚÂÛË ÚÔÛˆÈÎÔ‡ ηıÔÚ›˙ÂÙ·È ·fi ÙËÓ ËÏÈΛ· ÙÔ˘ ·ÛıÂÓÔ‡˜, ÙÔ ÈÛÙÔÚÈÎfi Î·È Ù· Â˘Ú‹Ì·Ù· Ù˘ ÎÏÈÓÈ΋˜ ÂͤٷÛ˘. ™Ù· ·È‰È¿ ËÏÈΛ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 2 ÂÙÒÓ, Ë È‰ÈÔ·ı‹˜ ¿ÚÂÛË ÚÔÛˆÈÎÔ‡ Â›Ó·È Ôχ Û¿ÓÈ· Î·È Ë ÎÏÈÓÈ΋ ÂͤٷÛË Û˘¯Ó¿ ·Ó·ÍÈfiÈÛÙË. ¶Ú¤ÂÈ, Û˘ÓÂÒ˜, Ó· ·Ó·˙ËÙÂ›Ù·È Û˘ÛÙËÌ·ÙÈο ˘ÔΛÌÂÓË ‚Ï¿‚Ë. ™Ù· ÌÂÁ·Ï‡ÙÂÚ· ·È‰È¿, ÈÛÙÔÚÈÎfi ÙÚ·˘Ì·ÙÈÛÌÔ‡, ·ÓÂÈÏËÌÌ¤ÓˆÓ ˆÙ›ÙȉˆÓ ‹ ÚfiÛÊ·Ù˘ ˆÙ›Ùȉ·˜, Ë Û˘ÁÁÂÓ‹˜ ¿ÚÂÛË, Ë ÚÔÛ‚ÔÏ‹ ÂÓfi˜ ÌfiÓÔ ÎÏ¿‰Ô˘ ÙÔ˘ ÚÔÛˆÈÎÔ‡ ‹ Î·È ¿ÏÏˆÓ ÂÁÎÂÊ·ÏÈÎÒÓ Û˘˙˘ÁÈÒÓ, Ë ÎÂÓÙÚÈ΋ ¿ÚÂÛË Ú¤ÂÈ Ó· ‰ÈÂÚ¢ÓÒÓÙ·È Ì ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÏÈıÔÂȉÒÓ ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜ (13). ™ÙÔ˘˜ ÂÓ‹ÏÈΘ Ì ¿ÚÂÛË ÚÔÛˆÈÎÔ‡, ÛËÌ·ÓÙÈΤ˜ ÏËÚÔÊÔڛ˜ ÁÈ· ÙËÓ ÚfiÁÓˆÛË Î·È ÙËÓ ·Ó¿ÁÎË ¯ÂÈÚÔ˘ÚÁÈ΋˜ ·ÔÛ˘Ì›ÂÛ˘ ‰›ÓÔ˘Ó ÙÔ ËÏÂÎÙÚÔÌ˘ÔÁÚ¿ÊËÌ·, Ë Ù·¯‡ÙËÙ· ·ÁˆÁ‹˜ Ó‡ÚÔ˘ Î·È ÙÔ ËÏÂÎÙÚÔÓ¢ÚÔÁÚ¿ÊËÌ·. √È ‰ÔÎÈ̷ۛ˜ ·˘Ù¤˜ Ú¤ÂÈ Ó· Á›ÓÔ˘Ó ÙȘ ÚÒÙ˜ 48-72 ÒÚ˜ Ù˘ ÓfiÛÔ˘ Î·È Ó· ·ӷϷ̂¿ÓÔÓÙ·È Î¿ı 34 ̤Ú˜ ÁÈ· ‰È¿ÛÙËÌ· 3 ‚‰ÔÌ¿‰ˆÓ. ∆Ô ˘„ËÏfi ÎfiÛÙÔ˜, Ë ·Ó¿ÁÎË Û˘ÓÂÚÁ·Û›·˜ ÙÔ˘ ·ÛıÂÓÔ‡˜, Ë ··ÈÙÔ‡ÌÂÓË ÂÌÂÈÚ›· ÙÔ˘ ÂÍÂÙ¿˙ÔÓÙÔ˜ Î·È Ë Î·Ï‹ Û˘Ó‹ıˆ˜ ÔÚ›· Ù˘ ¿ÚÂÛ˘ ÚÔÛˆÈÎÔ‡ ÛÙ· ·È‰È¿ ÂÚÈÔÚ›˙Ô˘Ó ÛËÌ·ÓÙÈο ÙË ¯ÚËÛÈÌÔÔ›ËÛË ÙˆÓ ‰ÔÎÈÌ·ÛÈÒÓ ·˘ÙÒÓ ÛÙËÓ ·È‰È΋ ËÏÈΛ· (12). ™˘ÌÂÚ·ÛÌ·ÙÈο, Û οı ¿ÚÂÛË ÚÔÛˆÈÎÔ‡ ÂÚÈÊÂÚÈÎÔ‡ Ù‡Ô˘ Û ·È‰› ÌÈÎÚ‹˜ ËÏÈΛ·˜ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ˆÙÔÚÈÓÔÏ·Ú˘ÁÁÔÏÔÁÈ΋ ÂÎÙ›ÌËÛË, ·ÎÔ˘fiÁÚ·ÌÌ· (ÂÊ’ fiÛÔÓ Â›Ó·È ÌÂÁ·Ï‡ÙÂÚÔ ÙˆÓ 4 ¯ÚfiÓˆÓ Î·È Û˘ÓÂÚÁ¿˙ÂÙ·È), ·ÂÈÎÔÓÈÛÙÈÎfi˜ ¤ÏÂÁ¯Ô˜ Ì ·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÏÈıÔÂȉÒÓ ˘„ËÏ‹˜ ¢ÎÚ›ÓÂÈ·˜ Î·È ËÏÂÎÙÚÔÊ˘ÛÈÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ (ËÏÂÎÙÚÔÓ¢ÚÔÁÚ¿ÊËÌ· ÙȘ ÚÒÙ˜ 48-72 ÒÚ˜ Ù˘ ÓfiÛÔ˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙË 18Ë - 21Ë Ì¤Ú·), ÌfiÓÔ Û ÂÚ›ÙˆÛË Ô˘ ‰ÂÓ ˘¿Ú¯ÂÈ ‚ÂÏÙ›ˆÛË Ì ÙË ıÂڷ¢ÙÈ΋ ·Ú¤Ì‚·ÛË. µÈ‚ÏÈÔÁÚ·Ê›· 1. Bitar C, Kluka E, Steele R. Mastoiditis in children. Clin Pediatr 1996;391-395. 2. Hoppe JE, Koster S, Bootz F, Niethammer D. Acute
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mastoidits. Infection 1994;22:178-182. 3. Holt R, Gates G. Masked mastoiditis. Laryngoscope 1983;93:1034-1037. 4. Grundfast K, Guarisco L, Thomsen J, Koch B. Diverse etiologies of facial paralysis in children. Internat J Peadiatr Otorhinolaryg 1990;19:223-239. 5. Nelson W, Vaughan V. Hearing loss. In: Behrman R, eds. Textbook of Pediatrics. 14th ed. Philadelphia: WB Saunders; 1992. p. 1602-1608. 6. Faye-Lund H. Acute and latent mastoiditis. J Latyngol Otol 1989;103:1158-1160. 7. Fritz P, Rieden K, Lenarz T, Haels J, Winkel K. Radiological evaluation of temporal bone disease: High-resolution computed tomografy versus conventional X-ray diagnosis. British J Radiol 1989;62:107-113. 8. Wang E, Burg J. Mastoiditis: A case-based rewiew. Pediatr Emerg Care 1988;14:290-292. 9. Nadal D, Hermann P, Baumann A, Fanconi A. Acute mastoiditis: clinical, microbiological, and therapeutic aspects. Eur J Pediatr 1990;149:560-564. 10. Fukuda T, Sugie H, Ito M, Kikawada T. Bilateral facial palsy
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caused by bilateral mastoiditis. Pediatr Neurol 1998;18: 351-353. 11. Ginsburg CM, Rudoy R, Nelson JD. Acute mastoiditis in infants and children. Clin Pediatr 1980;19:549-553. 12. Fisch U. Maximal nerve excitability testing versus electroneurography. Arch Otolaryngol 1980;106:352-357. 13. Inamura H, Aoyagi M, Tojima H, Kohsyu H, Koike Y. Facial nerve palsy in children: clinical aspects of diagnosis and treatment. Acta Otolorangol 1994;511(Suppl):150-152.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 19-09-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 05-02-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∑ˆ‹ ∏ÏÈÔ‰ÚÔÌ›ÙË ∫Ú·ÙÂÚÔ‡ 25, 157 71, πÏ›ÛÈ·, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ¶·¯˘Û·ÚΛ· ÛÙÔ˘˜ ÂÈ‚ÈÒÛ·ÓÙ˜ ·fi Ï¢¯·ÈÌ›·. ∏ Û˘Ì‚ÔÏ‹ Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜1 Œ¯ÂÈ ÂÚÈÁÚ·Ê› ˘„ËÏfi ÔÛÔÛÙfi ·¯˘Û·ÚΛ·˜ Û ·È‰È¿ Ô˘ ÂÈ‚›ˆÛ·Ó ·fi ÔÍ›· ÏÂÌÊÔ‚Ï·ÛÙÈ΋ Ï¢¯·ÈÌ›· (ALL), ·ÏÏ¿ ‰ÂÓ ¤¯ÂÈ ‰ÈÂÚ¢ÓËı› Ë ÁÂÓÂÙÈ΋ Î·È ÎÔÈÓˆÓÈ΋ ›‰Ú·ÛË ÛÙËÓ ·¯˘Û·ÚΛ· ÛÙËÓ ÔÌ¿‰· ·˘Ù‹ ÙˆÓ ·ÛıÂÓÒÓ. √È Û˘ÁÁÚ·Ê›˜ ÌÂϤÙËÛ·Ó 33 ¿ÙÔÌ· Ì ̷ÎÚ¿ ÂÈ‚›ˆÛË (25 ı‹ÏÂȘ Î·È 8 ¿ÚÚÂÓ˜) Û ÚÒÙË ‡ÊÂÛË, Ô˘ ›¯·Ó Êı¿ÛÂÈ ÙÔ ÙÂÏÈÎfi ÙÔ˘˜ ‡„Ô˜. ŸÏÔÈ ÔÈ ·ÛıÂÓ›˜ ˘Ô‚Ï‹ıËÎ·Ó Û ·ÎÙÈÓÔ‚ÔÏ›· ÎÚ·Ó›Ô˘, ˆ˜ ̤ÚÔ˜ Ù˘ ıÂڷ›·˜ ÙÔ˘ ÎÂÓÙÚÈÎÔ‡ Ó¢ÚÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜ Î·È Û ηӤӷ ‰Â ¯ÔÚËÁ‹ıËΠ·˘ÍËÙÈ΋ ÔÚÌfiÓË. √ ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ (µªπ: ‚¿ÚÔ˜/‡„Ô˜2) ÙˆÓ ·ÛıÂÓÒÓ Î·È ÙˆÓ ‚ÈÔÏÔÁÈÎÒÓ ÙÔ˘˜ ÁÔÓ¤ˆÓ ˘ÔÏÔÁ›ÛıËÎ·Ó Î·È ¤ÁÈÓ ÛÙ·ÙÈÛÙÈ΋ ·Ó¿Ï˘ÛË. ™·Ó ·¯‡Û·ÚÎÔÈ ¯·Ú·ÎÙËÚ›ÛÙËÎ·Ó ÔÈ ·ÛıÂÓ›˜ ÂΛÓÔÈ ÙˆÓ ÔÔ›ˆÓ Ô ‰Â›ÎÙ˘ Ì¿˙·˜ ÛÒÌ·ÙÔ˜ ‹Ù·Ó ÌÂÁ·Ï‡ÙÂÚÔ˜ ·fi ÙËÓ 85Ë ÂηÙÔÛÙÈ·›· ı¤ÛË. ªÂٷ͇ ÙˆÓ ·ÚÚ¤ÓˆÓ ‰ÂÓ ‚Ú¤ıËΠ˘ÂÚ‚ÔÏÈ΋ ·¯˘Û·ÚΛ· ÁÈ· ÙÔ ÙÂÏÈÎfi ‡„Ô˜, ÂÓÒ
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™·ÛÌÔ› ÌÂÙ¿ ·fi ¤ÎıÂÛË Û ÂÓÙÔÌÔ·ˆıËÙÈÎfi ª. ¡·ÚÏ›ÔÁÏÔ˘, °. ªÚÈ·ÛÔ‡Ï˘, ∞. ÷Ù˙‹˜
Seizures after dermal exposure to DEET M. Narlioglou, G. Briassoulis, T. Hatzis
¶ÂÚ›ÏË„Ë: ¶ÂÚÈÁÚ¿ÊÂÙ·È ÂÚ›ÙˆÛË ·ÁÔÚÈÔ‡ ËÏÈΛ·˜ 18 ÌËÓÒÓ, ÙÔ ÔÔ›Ô ÂΉ‹ÏˆÛ ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ· Î·È Û·ÛÌÔ‡˜ ÌÂÙ¿ ·fi ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ ¤ÎıÂÛË Û ¯·ÌËÏ‹˜ ÂÚÈÂÎÙÈÎfiÙËÙ·˜ (17,6%) ‰È·Èı˘ÏÈ΋ ÙÔÏÔ˘·Ì›‰Ë (DEET). ∆Ô ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi ‹Ù·Ó ·ÚÓËÙÈÎfi ÁÈ· Û·ÛÌÔ‡˜ ‹ ¿ÏÏË Ó¢ÚÔÏÔÁÈ΋ ÓfiÛÔ Î·È Ë ·Ó¿Ù˘ÍË ÙÔ˘ ·ÛıÂÓÔ‡˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈ΋. √ ·ÛıÂÓ‹˜ ÂΉ‹ÏˆÛ ÁÂÓÈÎÂ˘Ì¤ÓÔ˘˜ Û·ÛÌÔ‡˜, ¿ÚÚ˘ıÌË ·Ó·ÓÔ‹ Î·È ‹Ù·Ó Û Έ̷ÙÒ‰Ë Î·Ù¿ÛÙ·ÛË, ˘ÂÚÙÔÓÈÎfi˜ Ì ‰È·Ï›ÔÓÙ· ÂÂÈÛfi‰È· ÔÈÛıfiÙÔÓÔ˘. √È ÎfiÚ˜ ‹Ù·Ó ›Û˜ Î·È ·ÓÙȉÚÒÛ˜ ÛÙÔ Êˆ˜ Î·È ‰ÂÓ ˘‹Ú¯·Ó ÂÍ·Óı‹Ì·Ù·. √ ¤ÏÂÁ¯Ô˜ ÙÔ˘ ÂÁÎÂÊ·ÏÔÓˆÙÈ·›Ô˘ ˘ÁÚÔ‡ Î·È Ë ˘ÔÏÔÁÈÛÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈο. ∆Ô ËÏÂÎÙÚÔÂÁÎÂÊ·ÏÔÁÚ¿ÊËÌ·, Ì›· ‚‰ÔÌ¿‰· ÌÂÙ¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ·ÛıÂÓÔ‡˜, ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi. √ ·ÛıÂÓ‹˜ ·Ó¤Î·Ì„Â Î·È ·Ú¤ÌÂÓ ¯ˆÚ›˜ ÚÔ‚Ï‹Ì·Ù· 12 Ì‹Ó˜ ÌÂÙ¿ ÙËÓ ·Ú¯È΋ ÓfiÛÔ. ∞Ó·ÛÎfiËÛË Ù˘ ÙÚ¤¯Ô˘Û·˜ ‚È‚ÏÈÔÁÚ·Ê›·˜ ·ÔÎ¿Ï˘„ 17 ÂÚÈÙÒÛÂȘ ÙÔÍÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ·fi ‰È·Èı˘ÏÈ΋ ÙÔÏÔ˘·Ì›‰Ë Û ·È‰È¿. ∏ ıÓËÛÈÌfiÙËÙ· (16,6%) ‰ÂÓ Û¯ÂÙÈ˙fiÙ·Ó ÛËÌ·ÓÙÈο Ì ÙË Û˘ÁΤÓÙÚˆÛË Ù˘ DEET, ÙË ‰È¿ÚÎÂÈ· ¤ÎıÂÛ˘, ÙÔ Â›‰Ô˜ Ù˘ ¤ÎıÂÛ˘ ÛÙÔÓ ÙÔÍÈÎfi ·Ú¿ÁÔÓÙ·, ÙËÓ ËÏÈΛ· ‹ ÙÔ Ê‡ÏÔ. ¶ÚÔÁÚ·ÌÌ·ÙÈṲ̂Ó˜ ÙÔÍÈÎÔÏÔÁÈΤ˜ Î·È ÂȉËÌÈÔÏÔÁÈΤ˜ ÌÂϤÙ˜ ··ÈÙÔ‡ÓÙ·È ÚÔÎÂÈ̤ÓÔ˘ Ó· ÂÍ·¯ıÔ‡Ó ·ÛʷϤÛÙÂÚ· Û˘ÌÂÚ¿ÛÌ·Ù· Û¯ÂÙÈο Ì ÙËÓ ÙÔÍÈÎfiÙËÙ· Ù˘ ‰È·Èı˘ÏÈ΋˜ ÙÔÏÔ˘·Ì›‰Ë˜, ÂÚÈÏ·Ì‚·ÓÔ̤Ó˘ ·ÚÎÔ‡˜ ÙÂÎÌËÚ›ˆÛ˘ ÙˆÓ ÂȤ‰ˆÓ Ù˘ Û -ÚÔۂ‚ÏË̤ӷ Î·È Ì˷ȉȿ Ô˘ ‹Úı·Ó Û ·ʋ Ì ÂÓÙÔÌÔÎÙfiÓ· ÂÚȤ¯ÔÓÙ· DEET.
Abstract: Respiratory distress and seizures developed in an 18-month-old boy following a brief exposure to low strength (17,6%) N, N-diethyl-mtoluamide (DEET). Family history was negative, with no evidence of a seizure disorder or other neurologic disease. The child’s development had been normal. The patient manifested generalized seizures, respiratory difficulty, and was hypertonic with intermittent episodes of opisthotonus. Pupils were equal and reactive to light. There were no rashes, and the CSF findings as well as CT scan of the brain were normal. An EEG performed a week later was normal. The child recovered and remained well 12 months after the initial illness. A review of the literature revealed 17 reports of DEET-induced encephalopathy in children. Mortality (16,6%) did not correlate significantly with the concentration of the DEET liquid used, the duration of skin exposure, the type of exposure to the toxic substance, the age, or sex. Careful toxicologic and epidemiologic studies must be conducted, including adequate documentation of DEET levels in affected and unaffected children who are exposed to insect repellents containing DEET, in order to draw definitive conclusions regarding the toxicity of diethyl toluamide.
ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ "∞Á›· ™ÔÊ›·", ∞ı‹Ó·
ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ "∞Á›· ™ÔÊ›·", ∞ı‹Ó·
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™ÂÏ›‰· 182
¶·È‰È·ÙÚÈ΋ 2001;64:181-187
§¤ÍÂȘ ÎÏÂȉȿ: ‰È·Èı˘ÏÈ΋ ÙÔÏÔ˘·Ì›‰Ë (DEET), ÂÓÙÔÌÔ·ˆıËÙÈÎfi, ÙÔÍÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·, Û·ÛÌÔ›, ·È‰È¿.
™˘ÓÙÔÌÔÁڷʛ˜ DEET ª∂£ ∫À SaO2
N,N-‰È·Èı˘Ï-Ì-ÙÔÏÔ˘·Ì›‰Ë ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ∫¤ÓÙÚÔ ÀÁ›·˜ ∫ÔÚÂÛÌfi˜ ·ÈÌÔÛÊ·ÈÚ›Ó˘ Û Ô͢ÁfiÓÔ
∂ÈÛ·ÁˆÁ‹ ∏ ‰È·Èı˘ÏÈ΋ ÙÔÏÔ˘·Ì›‰Ë (DEET) Â›Ó·È ¤Ó· ¢ڤˆ˜ ¯ÚËÛÈÌÔÔÈÔ‡ÌÂÓÔ ÂÓÙÔÌÔ·ˆıËÙÈÎfi. ¶·Ú¿ ÙËÓ ·ÔÙÂÏÂÛÌ·ÙÈÎfiÙËÙ¿ Ù˘ Î·È ÙËÓ Â˘Ú›· ¯Ú‹ÛË Ù˘ ·fi ÂηÙÔÌ̇ÚÈ· ·ÓıÚÒÔ˘˜, Ù· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· ÂÚÈÙÒÛÂȘ ÛÔ‚·ÚÒÓ -ÂÓ›ÔÙ ı·Ó·ÙËÊfiÚˆÓ- ·ÓÙȉڿÛˆÓ, Û¯ÂÙÈ˙fiÌÂÓˆÓ Ì ÙË ¯Ú‹ÛË Ù˘ (1,2). √È ÙÔÍÈΤ˜ ·˘Ù¤˜ ·ÓÙȉڿÛÂȘ Â›Ó·È ÙfiÛÔ ÙÔÈΤ˜ fiÛÔ Î·È Û˘ÛÙËÌ·ÙÈΤ˜. ∆ÔÈο ÂΉËÏÒÓÔÓÙ·È Î˘Ú›ˆ˜ Ì ÙË ÌÔÚÊ‹ Ù˘ ÓÂÎÚˆÙÈ΋˜ ‰ÂÚÌ·Ù›Ùȉ·˜, ÎÓ›‰ˆÛ˘ Î·È ·Ó·Ê˘Ï·Í›·˜ ÌÂÙ¿ ·fi ÙÔÈ΋ ÂÊ·ÚÌÔÁ‹ (3). ™ÙȘ Û˘ÛÙËÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÙÔ ÎÒÌ·, ÔÈ Û·ÛÌÔ›, Ë ˘ÂÚÙÔÓ›·, Ë ·Ù·Í›·, Ë ˘fiÙ·ÛË, Ë ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ· Î·È „˘¯ˆÛÈΤ˜ ‹ Ì·ÓȷΤ˜ ÂΉËÏÒÛÂȘ (4). ¶ÂÈÚ·Ì·ÙÈΤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó, ›Û˘, ‰Â›ÍÂÈ ‚Ï·ÙÈΤ˜ ÂȉڿÛÂȘ Ù˘ DEET ÛÙȘ ÁÔÓ¿‰Â˜ Î·È Ù· ¤Ì‚Ú˘· (5). ∂›Û˘, Ù· ·È‰È¿ Â›Ó·È Ôχ ÈÔ Â˘·›ÛıËÙ· Û ۯ¤ÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈÎÔ˘˜ ÛÙËÓ ÙÔÍÈ΋ ‰Ú¿ÛË Ù˘ DEET. ∂›Ó·È ·ÍÈÔÛËÌ›ˆÙÔ fiÙÈ ÔÈ ÌfiÓÔÈ ı¿Ó·ÙÔÈ Ô˘ ¤¯Ô˘Ó ‰ËÌÔÛÈ¢ı› ¤ˆ˜ Û‹ÌÂÚ· ·ÊÔÚÔ‡Ó ·È‰È¿ Ô˘ ›¯·Ó ÂΉËÏÒÛÂÈ ÙÔÍÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· (1,2). ¶·ÚfiÙÈ fï˜ Ù· ·È‰È¿ ·ÚÔ˘ÛÈ¿˙ÔÓÙ·È È‰È·›ÙÂÚ· ¢¿ÏˆÙ· ÛÙË ‰ÂÚÌ·ÙÈ΋ ·ʋ Ì ÙÔÓ ÙÔÍÈÎfi ·Ú¿ÁÔÓÙ·, ÏfiÁˆ ÙÔ˘ Ôχ ÏÂÙÔ‡ ‰¤ÚÌ·ÙÔ˜ Î·È ÙÔ˘ ÌÂÁ·Ï‡ÙÂÚÔ˘ ÏfiÁÔ˘ ÂÈÊ¿ÓÂÈ·˜: Ì¿˙·˜ ÛÒÌ·ÙÔ˜, Ô ÌÂÙ·‚ÔÏÈÛÌfi˜ Î·È Ù· ¯·Ú·ÎÙËÚÈÛÙÈο ·ÔÌ¿ÎÚ˘ÓÛ˘ Ù˘ DEET ·fi ÙÔÓ ÔÚÁ·ÓÈÛÌfi ‰ÂÓ ¤¯Ô˘Ó ̤¯ÚÈ Û‹ÌÂÚ· ÌÂÏÂÙËı›. ¶ÂÚÈÁÚ¿ÊÔ˘Ì ÙËÓ ÂÚ›ÙˆÛË ·È‰ÈÔ‡ Ì ÙÔÍÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÌÂÙ¿ ·fi ‰ÂÚÌ·ÙÈ΋ ¤ÎıÂÛË Û DEET Ô˘ ·ÓÙÈÌÂÙˆ›ÛÙËΠÛÙË ÌÔÓ¿‰· Ì·˜. ∞fi ÙË ‰ÈÂÚ‡ÓËÛË Ù˘ Û¯ÂÙÈ΋˜ ‚È‚ÏÈÔÁÚ·Ê›·˜, ‚ڋηÌ ¿ÏϘ 17 ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ Î¿Ùˆ ÙˆÓ 16 ÂÙÒÓ, Ù· ÔÔ›· ›Û˘ ÂΉ‹ÏˆÛ·Ó Û˘ÌÙÒÌ·Ù· ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÌÂÙ¿ ·fi ¤ÎıÂÛË ÛÙË ‰È·Èı˘ÏÈ΋ ÙÔÏÔ˘·Ì›‰Ë. ™ÎÔfi˜ Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘ ‹Ù·Ó, Ì ÙËÓ Â˘Î·ÈÚ›· Ù˘ ÂÚÈÁÚ·Ê‹˜ ÙÔ˘ ÂӉȷʤÚÔÓÙÔ˜ ·˘ÙÔ‡ ÂÚÈÛÙ·ÙÈÎÔ‡, Ó· ·Ó·Ï‡ÛÔ˘Ì ÙË Û˘¯ÓfiÙËÙ· Î·È ÙË ‚·Ú‡ÙËÙ· Ù˘ ÂΉ‹ÏˆÛ˘ Ù˘ ÙÔÍÈ΋˜ ·˘Ù‹˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÛÙ· ·È‰È¿.
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Key words: N, N-diethyl-m-toluamide, DEET, insect repellents, toxic-encephalopathy, seizures, children.
¶ÂÚÈÁÚ·Ê‹ ÂÚ›ÙˆÛ˘ ∞ÁfiÚÈ ËÏÈΛ·˜ 18 ÌËÓÒÓ ÌÂٷʤÚıËΠ‰È·ÛˆÏËӈ̤ÓÔ ·fi ∫¤ÓÙÚÔ ÀÁ›·˜ (∫À) ÌÈÎÚÔ‡ ÓËÛÈÔ‡ ÛÙË ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ (ª∂£) ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ Ì·˜, ÏfiÁˆ ·ÓÂÈÏËÌÌ¤ÓˆÓ ÁÂÓÈÎÂ˘Ì¤ÓˆÓ ÙÔÓÈÎÔÎÏÔÓÈÎÒÓ Û·ÛÌÒÓ (status) Ô˘ Û˘Óԉ‡ÔÓÙ·Ó ·fi ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó·ÓÔ‹˜. ¶ÚfiÎÂÈÙ·È ÁÈ· ÙÔ 4Ô ·È‰› 6ÌÂÏÔ‡˜ ÔÈÎÔÁ¤ÓÂÈ·˜ ·ı›ÁÁ·ÓˆÓ Ì ÂχıÂÚÔ ÔÈÎÔÁÂÓÂÈ·Îfi Î·È ·ÙÔÌÈÎfi ·Ó·ÌÓËÛÙÈÎfi Î·È Î·Ï‹ „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË. √È ÁÔÓ›˜ ÌÈÎÚÔˆÏËÙ¤˜, ÚÔ ÔÏ›ÁˆÓ ËÌÂÚÒÓ Â›¯·Ó ÂÈÛÎÂÊı› ÙÔ ÓËÛ› ÁÈ· ·ÁÁÂÏÌ·ÙÈÎÔ‡˜ ÏfiÁÔ˘˜. ∂›¯·Ó ‰Â ηٷÛÎËÓÒÛÂÈ Î·È ‰È·Ó˘ÎÙ¤Ú¢·Ó ÛÙËÓ ‡·ÈıÚÔ. ∂ΛÓÔ ÙÔ ÚˆÈÓfi, ÙÔ ÌÈÎÚfiÙÂÚÔ ·È‰› Ù˘ ÔÈÎÔÁ¤ÓÂÈ·˜ ÌÂٷʤÚıËΠÂÂÈÁfiÓÙˆ˜ ÛÙÔ ∫¤ÓÙÚÔ ÀÁ›·˜ ÙÔ˘ ÓËÛÈÔ‡, ÂÂȉ‹ Ï›ÁË ÒÚ· ÌÂÙ¿ ÙËÓ ·Ê‡ÓÈÛ‹ ÙÔ˘ ·ÚÔ˘Û›·Û ÂÂÈÛfi‰ÈÔ ÁÂÓÈÎÂ˘Ì¤ÓˆÓ ÙÔÓÈÎÔÎÏÔÓÈÎÒÓ Û·ÛÌÒÓ. ∆Ô ·È‰› ηٿ ÙËÓ ¿ÊÈÍ‹ ÙÔ˘ ÛÙÔ ∫À Û˘Ó¤¯ÈÛ ӷ οÓÂÈ Û·ÛÌÔ‡˜ Î·È Ó· ÌËÓ ¤¯ÂÈ Â·Ê‹ Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ. ∏ ·Ó·ÓÔ‹ ÙÔ˘ ‹Ù·Ó ¿ÚÚ˘ıÌË Î·È ÙÔ ·È‰› ΢·ÓˆÙÈÎfi, ¤¯ÔÓÙ·˜ SaO2 72%. √È ÎfiÚ˜ ÙÔ˘ ‹Û·Ó ÈÛÔÌÂÁ¤ıÂȘ, ·ÓÙȉÚÒÛ˜ ÛÙÔ Êˆ˜. √È Û·ÛÌÔ› ·ÓÙÈÌÂÙˆ›ÛÙËÎ·Ó Ì ¯ÔÚ‹ÁËÛË ‰È·˙¿Ì˘ ·fi ÙÔ ÔÚıfi Î·È ‰ÈÊ·ÈÓ˘Ï˘‰·ÓÙÔ˝Ó˘ ÂÓ‰ÔÊÏ‚›ˆ˜ (ÊfiÚÙÈÛË). √ ·ÛıÂÓ‹˜, ÂÓÙÔ‡ÙÔȘ, ·Ú¤ÌÂÈÓ Û Έ̷ÙÒ‰Ë Î·Ù¿ÛÙ·ÛË Ì ¿ÚÚ˘ıÌË ·Ó·ÓÔ‹ Î·È ˘ÂÚÙÔÓ›·. ∞ÎÔÏÔ‡ıË۠›ÁÔ˘Û· ÂÓ‰ÔÙÚ·¯Âȷ΋ ‰È·ÛˆÏ‹ÓˆÛË Î·È ·ÂÚÔÌÂÙ·ÊÔÚ¿ ÛÙË ª∂£ ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ Ì·˜ ÁÈ· ÂÚ·ÈÙ¤Úˆ ·ÓÙÈÌÂÙÒÈÛË Î·È ‰ÈÂÚ‡ÓËÛË ÙˆÓ Û·ÛÌÒÓ. ∫·Ù¿ ÙËÓ ÂÈÛ·ÁˆÁ‹ ÙÔ˘ ÛÙË ª∂£, Ô ·ÛıÂÓ‹˜ ›¯Â ıÂÚÌÔÎÚ·Û›· 37ÆC, ÛʇÍÂȘ 160/min, ∞¶ 100/60 mmHg. ∆¤ıËΠ۠Ì˯·ÓÈÎfi ·ÂÚÈÛÌfi ˘fi ηٷÛÙÔÏ‹ Î·È Ì˘Ô¯¿Ï·ÛË. √È ÎfiÚ˜ ‹Ù·Ó ÈÛÔÌÂÁ¤ıÂȘ, ·ÓÙȉÚÒÛ˜ ÛÙÔ Êˆ˜ Î·È ÛÙ· Í˘Ó‹Ì·Ù· Ô ·ÛıÂÓ‹˜ ‹Ù·Ó ˘ÂÚÙÔÓÈÎfi˜ Î·È ·ÚÔ˘Û›·˙ ÙÚfiÌÔ. ¢ÂÓ ˘‹Ú¯Â ÂÍ¿ÓıËÌ·. √ ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ ¤‰ÂÈÍÂ: °ÂÓÈ΋ ·›Ì·ÙÔ˜: Hb 10 gr/dL, Ht 31%, §Â˘Î¿ 10.400/mm3 (¶/56, §/36, ª/8), ∞ÈÌÔÂÙ¿ÏÈ· 345.000/mm3. ∂¡À: ·ÙÙ·Ú· 2/mm3, χÎ. <20mg/dL, ÁÏ. 50mg/dL. CRP ·ÚÓËÙÈ΋. √˘Ú›· 30 mg/dL, ÎÚ·ÙÈÓ›ÓË 0,4 mg/dL, ÁÏ˘Îfi˙Ë 157 mg/dL, Na 132 mEq/L, K 3,7 mEq/L, Cl 98 mEq/L, Ca 9,4 mg/dL. SGOT 245 U/L, SGPT 223 U/L, ÁGT 27 mg/dL, ∞º 332 U/L ÃÔÏÂÚ˘ıÚ›ÓË ÔÏÈ΋ 0,3 mg/dL, NH3 80 mg/dL. √ÏÈο Ï¢ÎÒÌ·Ù· 6,1 g/dL, ·Ï‚Ô˘Ì›ÓË 3,6 g/dL. °·Ï·ÎÙÈÎfi Ô͇ ÔÚÔ‡ 15,4 mg/dL (º∆ 5,7-22). ¶˘ÚÔÛÙ·Ê˘ÏÈÎfi Ô͇ ÔÚÔ‡ 0,47 mg/dL (º∆
2001 MAPT- A¶PI§
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¶·È‰È·ÙÚÈ΋ 2001;64:181-187
0,3-0,7). ∞ÌÈÓfiÁÚ·ÌÌ· ÔÚÔ‡, ·ÌÈÓfiÁÚ·ÌÌ· Ô‡ÚˆÓ Î·È ÔÚÁ·ÓÈο Ôͤ· Ô‡ÚˆÓ Ê˘ÛÈÔÏÔÁÈο. ∞ÎÙÈÓÔÁÚ·Ê›· ıÒÚ·ÎÔ˜, ∏∫° Î·È ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ηډ›·˜ Ê˘ÛÈÔÏÔÁÈο. ∫·ÏÏȤÚÁÂȘ ·›Ì·ÙÔ˜, ∂¡À, ‚ÚÔÁ¯ÈÎÔ‡, Ô‡ÚˆÓ ÛÙ›Ú˜. PCR ÛÙÔ ∂¡À ÁÈ· ÂÚËÙÔ˚Ô‡˜ Î·È ÂÓÙÂÚÔ˚Ô‡˜ ·ÚÓËÙÈ΋. ∆ÔÍÈÎÔÏÔÁÈÎfi˜ ¤ÏÂÁ¯Ô˜ ÁÈ· ¿ÏϘ ÙÔÍÈΤ˜ Ô˘Û›Â˜ (-). ∞ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘ ¯ˆÚ›˜ ·ıÔÏÔÁÈο Â˘Ú‹Ì·Ù·. ∏∂° (ηٿ ÙËÓ ÂÈÛ·ÁˆÁ‹) ‚Ú·‰˘·ÚÚ˘ıÌÈÎfi, ¯ˆÚ›˜ ·È¯ÌËÚ¤˜ ÂÎÊÔÚÙ›ÛÂȘ ‹ ·ÚÔ͢ÓÙÈο ‰˘Ó·ÌÈο. ∏ ·ÓÙÈÌÂÙÒÈÛË ÛÙË ª∂£ ÂÚÈÂÏ¿Ì‚·ÓÂ Û˘Ó¯‹ ηٷÁÚ·Ê‹ ˙ˆÙÈÎÒÓ ÛËÌ›ˆÓ, ·ÚÂÓÙÂÚÈ΋ ¯ÔÚ‹ÁËÛË ˘ÁÚÒÓ, Ì˯·ÓÈ΋ ˘ÔÛÙ‹ÚÈÍË Ù˘ ·Ó·ÓÔ‹˜ Î·È ÛÙ¿Á‰ËÓ Û˘Ó¯‹ ÂÓ‰ÔÊϤ‚È· ¤Á¯˘ÛË Ìȉ·˙ÔÏ¿Ì˘. √ ·ÛıÂÓ‹˜ ·ÔÛˆÏËÓÒıËΠÌÂÙ¿ ·fi 24 ÒÚ˜. ∂ÎÙfi˜ ·fi ‹È· ˘ÂÚÙÔÓ›·, ÙÚfiÌÔ, ‰È¤ÁÂÚÛË Î·È ÔÈÛıfiÙÔÓÔ, ‰ÂÓ ·ÚÔ˘Û›·˙ ¿ÏÏ· ·ıÔÏÔÁÈο Ó¢ÚÔÏÔÁÈο ÛËÌ›· Î·È Â›¯Â ÈηÓÔÔÈËÙÈ΋ ·ʋ Ì ÙÔ ÂÚÈ‚¿ÏÏÔÓ. ™Â ‰‡Ô 24ˆÚ· Ë ÎÏÈÓÈ΋ ÂÈÎfiÓ· ÙÔ˘ ·ÛıÂÓÔ‡˜ ·ÔηٷÛÙ¿ıËΠϋڈ˜ Î·È Ë ‹È· Ó¢ÚÔÏÔÁÈ΋ Û˘Ìو̷ÙÔÏÔÁ›· ˘Ô¯ÒÚËÛÂ. ∆Ô ∏∂° Ô˘ ¤ÁÈÓ ÌÂÙ¿ ·Ô 7 Ë̤Ú˜ ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈÎfi. √ ·ÛıÂÓ‹˜ ÂÍ‹Ïı ·fi ÙÔ ÓÔÛÔÎÔÌÂ›Ô Û ¿ÚÈÛÙË ÁÂÓÈ΋ ηٿÛÙ·ÛË. ŒÓ· ¯ÚfiÓÔ ÌÂÙ¿ ÙÔ Û˘Ì‚¿Ó, ÙÔ ·È‰› ‰ÂÓ ¤¯ÂÈ ·ÚÔ˘ÛÈ¿ÛÂÈ ¿ÏÏÔ ÂÂÈÛfi‰ÈÔ Û·ÛÌÒÓ, ÂÍ·ÎÔÏÔ˘ı› Ó· Â›Ó·È Î·Ï¿ Î·È Ó· ¤¯ÂÈ Î·Ï‹ „˘¯ÔÎÈÓËÙÈ΋ ÂͤÏÈÍË. ∂›ÌÔÓË ‰ÈÂÚ‡ÓËÛË ÙÔ˘ ÈÛÙÔÚÈÎÔ‡ ·ÔÎ¿Ï˘„ fiÙÈ ÙË Ó‡ÎÙ· Ô˘ ÚÔËÁ‹ıËÎÂ ÙˆÓ Û·ÛÌÒÓ (12 ÒÚ˜ ÚÈÓ), Ë ÌËÙ¤Ú· ›¯Â ·Ï›„ÂÈ ÙÔ ÂÎÙÈı¤ÌÂÓÔ ÛÙ· ÎÔ˘Óԇȷ ‰¤ÚÌ· ÙÔ˘ ·È‰ÈÔ‡ Ì ·ÚÎÂÙ‹ ÔÛfiÙËÙ· ÂÓÙÔÌÔ·ˆıËÙÈÎÔ‡ (Autan) Ô˘ ÂÚȤ¯ÂÈ 17,6% DEET. ∞Ó·ÙÚ¤¯ÔÓÙ·˜ ÛÙË ‚È‚ÏÈÔÁÚ·Ê›·, ‚Ú¤ıËÎ·Ó ¿ÏϘ 17 ÂÚÈÙÒÛÂȘ ·È‰ÈÒÓ (<16 ÂÙÒÓ), Ù· ÔÔ›· ÂΉ‹ÏˆÛ·Ó Û˘ÌÙÒÌ·Ù· ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÌÂÙ¿ ·fi ¤ÎıÂÛË ÛÙË DEET. ∆· ȉȷ›ÙÂÚ· ¯·Ú·ÎÙËÚÈÛÙÈο ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ, Ë ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË Î·È ÔÈ ·Ú¿ÌÂÙÚÔÈ ¤ÎıÂÛ˘ ÛÙÔÓ ÙÔÍÈÎfi ·Ú¿ÁÔÓÙ·, Ê·›ÓÔÓÙ·È ÛÙÔÓ ¶›Ó·Î· 1. ∞Ó¿Ï˘ÛË ™˘ÓÔÏÈο ·Ó·Ï‡ıËÎ·Ó 18 ÂÚÈÛÙ·ÙÈο, Û˘ÌÂÚÈÏ·Ì‚·ÓÔ̤ÓÔ˘ ÙÔ˘ ·ÚfiÓÙÔ˜, ÚÔÂÚ¯fiÌÂÓ· ·fi 12 ‰ËÌÔÛȇÛÂȘ ·fi 6 ¯ÒÚ˜ (¶›Ó·Î·˜ 1). ∏ ̤ÛË ËÏÈΛ· ÙˆÓ ·È‰ÈÒÓ ‹Ù·Ó 7,5 ± 4,7 ¤ÙË, 28% ·fi Ù· ÔÔ›· ‹Ù·Ó οو ÙˆÓ 2 ÂÙÒÓ, ÂÓÒ Ë ·Ó·ÏÔÁ›· ·ÁÔÚÈÒÓ – ÎÔÚÈÙÛÈÒÓ ‹Ù·Ó 7:10. ∏ ·Ó¿Ï˘ÛË fiÏˆÓ ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ ¤‰ÂÈÍ fiÙÈ Ë ÚÔηÏÔ‡ÌÂÓË ·fi DEET ÂÁÎÂÊ·ÏÔ¿ıÂÈ· Û ·È‰È¿ ‰ÂÓ ÚÔÂÚ¯fiÙ·Ó ÌfiÓÔ ·fi Ù˘¯·›· ηٿÔÛË ‹ Û˘¯Ó‹ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÓÙÔÌÔ·ˆıËÙÈÎÔ‡. ∂‹ÏıÂ Î·È ÌÂÙ¿ ·fi ‚Ú·¯Â›·˜ ‰È¿ÚÎÂÈ·˜ ˆÚÒÓ ‰ÂÚÌ·ÙÈ΋ ¤ÎıÂÛË ÛÙÔÓ ÙÔÍÈÎfi ·Ú¿ÁÔÓÙ· (17%) ‹ Î·È Â·Ó·ÏËÙÈ΋ ›ıÂÛË ‰È¿Ú-
Paediatriki 2001;64:181-187
ÎÂÈ·˜ ÌÈÎÚfiÙÂÚ˘ ÙˆÓ 3 ËÌÂÚÒÓ (28%). ∂›Û˘, ÛËÌ·ÓÙÈ΋ ‹Ù·Ó Ë ·Ú·Ù‹ÚËÛË fiÙÈ ÙÔ 33% ÙˆÓ ·ÛıÂÓÒÓ ÂΉ‹ÏˆÛ·Ó ÙÔÍÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ÌÂÙ¿ ·fi ‰ÂÚÌ·ÙÈ΋ ¤ÎıÂÛË Û ÂÓÙÔÌÔ·ˆıËÙÈÎfi Ì ÂÚÈÂÎÙÈÎfiÙËÙ· Û DEET <20% ! √È Û·ÛÌÔ› ·ÔÙ¤ÏÂÛ·Ó ÙËÓ Î‡ÚÈ· ÎÏÈÓÈ΋ ÂΉ‹ÏˆÛË (72%) ÌÂÙ¿ ·fi ‰ÂÚÌ·ÙÈ΋ ·ʋ (p<0,01). ∂›Û˘, fiÏÔÈ ÔÈ ·ÛıÂÓ›˜ Ô˘ ¤ı·Ó·Ó ÂΉ‹ÏˆÛ·Ó ÙËÓ ÙÔÍÈ΋ Û˘Ó‰ÚÔÌ‹ ÌÂÙ¿ ·fi ‰ÂÚÌ·ÙÈ΋ ·ʋ. ¶ÔÏÏ·Ï‹ ÏÔÁÈÛÙÈ΋ ·Ó¿Ï˘ÛË ·ÏÈÓ‰ÚfiÌËÛ˘ ¤‰ÂÈÍ fiÙÈ Ë ıÓËÛÈÌfiÙËÙ· (16,6%) ‰ÂÓ Û¯ÂÙÈ˙fiÙ·Ó ÛËÌ·ÓÙÈο Ì ÙË Û˘ÁΤÓÙÚˆÛË Ù˘ DEET ÛÙ· ‰È·Ï‡Ì·Ù·, ÙË ‰È¿ÚÎÂÈ· Ù˘ ¤ÎıÂÛ˘, ÙÔ Â›‰Ô˜ Ù˘ ¤ÎıÂÛ˘, ÙËÓ ËÏÈΛ· ‹ ÙÔ Ê‡ÏÔ. √È ¿ÏϘ ÎÏÈÓÈΤ˜ ÂΉËÏÒÛÂȘ, fiˆ˜ ÎÒÌ· (39%), ‰È·Ù·Ú·¯¤˜ Ù˘ Û˘ÌÂÚÈÊÔÚ¿˜ (28%), ÔÈÛıfiÙÔÓÔ˜ ‹ ˘ÂÚÙÔÓ›· (11%) Î·È Ë·ÙÈ΋ ‰˘ÛÏÂÈÙÔ˘ÚÁ›· (5,5%), ‰ÂÓ ‰È¤ÊÂÚ·Ó ÛËÌ·ÓÙÈο ÌÂٷ͇ ÙˆÓ ·ÛıÂÓÒÓ Ì ¤ÎıÂÛË ÛÙÔÓ ÙÔÍÈÎfi ·Ú¿ÁÔÓÙ· ÌÂÙ¿ ·fi ηٿÔÛË ‹ ̤ۈ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜. ªfiÓÔ Û 3 ÂÚÈÙÒÛÂȘ ÙÔ ∂¡À ¤‰ÂÈÍ ÏÂÌÊÔ΢ÙÙ¿ÚˆÛË ‹ ˘„ËÏ¿ ›‰· ÚˆÙ½Ó˘. ™Â ¤Ó· ÂÚÈÛÙ·ÙÈÎfi ÌÂ Ê˘ÛÈÏÔÁÈÎfi ∂¡À, ÙÔ ∏∂° ‹Ù·Ó ·ıÔÏÔÁÈÎfi, ÂÓÒ ÌfiÓÔ ¤Ó·˜ ·ÛıÂÓ‹˜ ·ÚÔ˘Û›·Û ˘ÂÚ·Ì̈ÓÈ·ÈÌ›·. ∏ ˘ÔÏÔÁÈÛÙÈ΋ Î·È Ë Ì·ÁÓËÙÈ΋ ÙÔÌÔÁÚ·Ê›· ÂÁÎÂÊ¿ÏÔ˘, ÂÊfiÛÔÓ ·Ó·Ê¤ÚÔÓÙ·Ó, ‹Ù·Ó Ê˘ÛÈÔÏÔÁÈΤ˜. ™˘ÓÔÏÈο, Ê˘ÛÈÔÏÔÁÈο ÂÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù· ·Ó·ÎÔÈÓÒıËÎ·Ó Û 8 ÂÚÈÙÒÛÂȘ (44%), ÂÓÒ ÛÙÔ 28% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ÂÓ ‹Ù·Ó ‰È·ı¤ÛÈÌ· (¶›Ó·Î·˜ 1). ∂Ó·ÏÏ·ÎÙÈ΋ ‰È¿ÁÓˆÛË ‰ÂÓ ˘‹Ú¯Â ÛÙÔ 56% ÙˆÓ ÂÚÈÙÒÛˆÓ. √È Èı·Ó¤˜ ÂÓ·ÏÏ·ÎÙÈΤ˜ ‰È·ÁÓÒÛÂȘ Ô˘ ·Ó·Ê¤ÚıËÎ·Ó ·ÊÔÚÔ‡Û·Ó È‰ÈÔ·ı›˜ Û·ÛÌÔ‡˜ (22%) ‹ ÂÁÎÂÊ·Ï›Ùȉ· (22%), ‰ÂÓ ‹Ù·Ó fï˜ ‰˘Ó·ÙfiÓ Ó· ÙÂÎÌËÚȈıÔ‡Ó ÛÙÔ ‰È¿ÛÙËÌ· ̤¯ÚÈ ÙË ‰ËÌÔÛ›Â˘ÛË ÙˆÓ ÂÚÈÛÙ·ÙÈÎÒÓ. ™˘˙‹ÙËÛË ∏ DEET ·Ú·Û΢¿ÛıËΠÙÔ 1946 ·fi ÙÔ ÀÔ˘ÚÁÂ›Ô °ÂˆÚÁ›·˜ ÙˆÓ ∏¶∞ Î·È ÙÔ 1957 ÂÁÎÚ›ıËÎÂ Ë ¯Ú‹ÛË Ù˘ ÁÈ· ÙÔ Â˘Ú‡ ÎÔÈÓfi. ∞ÔÙÂÏ› ÙÔ ÂÓÂÚÁfi Û˘ÛÙ·ÙÈÎfi ÙˆÓ ÂÚÈÛÛfiÙÂÚˆÓ ÂÓÙÔÌÔ·ˆıËÙÈÎÒÓ ÁÈ· ÎÔ˘Óԇȷ, ̇Á˜, ÛÎӛ˜, ÙÛÈÌÔ‡ÚÈ· Î·È „‡ÏÏÔ˘˜. ™ÙÔ ÂÌfiÚÈÔ ‰È·Ù›ıÂÙ·È Â›Ù Û ˘ÁÚ‹ ÌÔÚÊ‹, ›Ù ˘fi ÌÔÚÊ‹ ·ÂÚÔ˙fiÏ, spray, ÏÔÛÈfiÓ, Îڤ̷˜, sticks Î·È ˘ÁÚÒÓ Ì·ÓÙËÏÈÒÓ, Û ÂÚÈÂÎÙÈÎfiÙËÙ· Ô˘ Î˘Ì·›ÓÂÙ·È ·fi 5-100% (1). ™ÙÔ˘˜ ÂÓ‹ÏÈΘ ·ÔÚÚÔÊ¿Ù·È Ì¤Ûˆ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È 9% Ù˘ ÂÊ·ÚÌÔÛı›۷˜ ÔÛfiÙËÙ·˜ ¤¯ÂÈ ·ÔÚÚÔÊËı› ̤۷ Û 12 ÒÚ˜, ÂÓÒ 10-14% Ù˘ ‰fiÛ˘ ·ÂÎÎÚ›ÓÂÙ·È ·Ó·ÏÏÔ›ˆÙË ·fi Ù· Ô‡Ú· ÙËÓ ÚÒÙË ÒÚ·. ∏ DEET ÔÍÂȉÒÓÂÙ·È ÛÙ· Ë·ÙÈο ÌÈÎÚÔÛÒÌ·Ù· Î·È ÔÈ ÌÂÙ·‚Ôϛ٘ Ù˘ ÌÔÚ› Ó· ·Ú·Ì›ÓÔ˘Ó ÛÙÔ ‰¤ÚÌ· ‹ ÙÔÓ ÏÈÒ‰Ë ÈÛÙfi ÁÈ· 1 ‹ 2 Ì‹Ó˜. ∏ ̤ÛË ı·Ó·ÙËÊfiÚÔ˜ ‰fiÛË (LD50) ÌÂÙ¿ ·fi
183
2001 MAPT- A¶PI§
17-10-01 15:35
™ÂÏ›‰· 184
¶·È‰È·ÙÚÈ΋ 2001;64:181-187
Paediatriki 2001;64:181-187
¶›Ó·Î·˜ 1. ¢ËÌÔÛÈ¢ı›Û˜ ÂÚÈÙÒÛÂȘ ÙÔÍÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÌÂÙ¿ ·fi ¤ÎıÂÛË Û DEET Û ·È‰È¿ ∞ÛıÂÓ‹˜ ∏ÏÈΛ· (¤ÙË)
º‡ÏÔ
%DEET
¶ÔÛfiÙËÙ· ÃÚfiÓÔ˜ ÂÊ·ÚÌÔÁ‹˜
∆ÚfiÔ˜ ·ʋ˜
™˘ÌÙÒÌ·Ù·
1
1,5
∞
17,6
™‡ÓÙÔÌË (ÒÚ˜)
¢ÂÚÌ·ÙÈ΋
™·ÛÌÔ›, ÔÈÛıfiÙÔÓÔ˜, ·Ó·Ó¢ÛÙÈ΋ ‰˘Û¯¤ÚÂÈ·, ÎÒÌ· ∫ÂÊ·Ï·ÏÁ›Â˜, ™·ÛÌÔ›, ∞Ù·Í›·, ¢È¤ÁÂÚÛË ¢È¤ÁÂÚÛË, ÔÈÛıfiÙÔÓÔ˜
2
5
∫
10
∫¿ı Ӈ¯Ù· x 3 Ì‹Ó˜
¢ÂÚÌ·ÙÈ΋
3
1,5
∫
10
ªÈÎÚ‹
∫·Ù¿ÔÛË
4 5 6
3,5 14 1
∫ ∫ ∫
15 95 47,5
∏ÌÂÚ‹ÛÈ· x 2 ‚‰ÔÌ¿‰Â˜ 50ml 25ml
¢ÂÚÌ·ÙÈ΋ ∫·Ù¿ÔÛË ∫·Ù¿ÔÛË
7 8
16 8
∫ ∫
95 15 Î·È 100
50ml ™‡ÓÙÔÌË (2 Ë̤Ú˜) + ™‡ÓÙÔÌË (2 Ë̤Ú˜)
∫·Ù¿ÔÛË ¢ÂÚÌ·ÙÈ΋
9
1,5
∫
20
∏ÌÂÚ‹ÛÈ· x 3 Ì‹Ó˜
¢ÂÚÌ·ÙÈ΋
10
6
∫
15
10 ·Ï›„ÂȘ
¢ÂÚÌ·ÙÈ΋
11
1,4
∫
10 ‹ 20
∏ÌÂÚ‹ÛÈ· x 3 ‚‰ÔÌ¿‰Â˜
¢ÂÚÌ·ÙÈ΋
∫ÒÌ·, ·Ù·Í›·, Reye-like syndrome ∫ÒÌ·, ™·ÛÌÔ›
12
5
∞
100 Î·È 15
™‡ÓÙÔÌË (ÒÚ˜)
¢ÂÚÌ·ÙÈ΋
™·ÛÌÔ›
13-16
3-7
17
15
∞ ∞ ∞ ∞ ∞
ÔÈΛÏË ÔÈΛÏË ÔÈΛÏË ÔÈΛÏË ¡∞
™‡ÓÙÔÌË (<3 Ë̤Ú˜) ™‡ÓÙÔÌË (<3 Ë̤Ú˜) ™‡ÓÙÔÌË (<3 Ë̤Ú˜) ™‡ÓÙÔÌË (<3 Ë̤Ú˜) 50-100ml
¢ÂÚÌ·ÙÈ΋ ¢ÂÚÌ·ÙÈ΋ ¢ÂÚÌ·ÙÈ΋ ¢ÂÚÌ·ÙÈ΋ ∫·Ù¿ÔÛË
18
8
NA
30 ‹ >30
™‡ÓÙÔÌË (ÒÚ˜)
¢ÂÚÌ·ÙÈ΋
™·ÛÌÔ› ™·ÛÌÔ› ™·ÛÌÔ› ™·ÛÌÔ›, ∫Ó›‰ˆÛË ∫ÒÌ·, ˘fiÙ·ÛË, ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ·, ·Ó¿ÚÎÂÈ·, ÙÔÍÈ΋ Ë·Ù›Ùȉ· ™·ÛÌÔ›
™·ÛÌÔ› ∫ÒÌ·, ÀfiÙ·ÛË, ÀÂÚÙÔÓ›· ∫ÒÌ·, Û·ÛÌÔ›, ˘ÂÚÙÔÓ›·, ÔÈÛıfiÙÔÓÔ˜ ∫ÒÌ· ∂Í¿ÓıËÌ·, ™·ÛÌÔ›, ªÂÙ·‚ÔÏ‹ Û˘ÌÂÚÈÊÔÚ¿˜, ‰È¤ÁÂÚÛË, ·ÓËÛ˘¯›·, ¿Á¯Ô˜ ∞Ù·Í›·, ÂÚ›ÂÚÁ˜ ÎÈÓ‹ÛÂȘ, ÛÈÂÏfiÚÚÔÈ·,ÔÈÛıfiÙÔÓÔ˜, Ì˘ÔÎÏÔӛ˜, ÙÚfiÌÔ˜
∞=·ÁfiÚÈ, ∫=ÎÔÚ›ÙÛÈ, NA=ÌË ‰È·ı¤ÛÈÌ· ‰Â‰Ô̤ӷ, ∆¶=·ÚfiÓ ÂÚÈÛÙ·ÙÈÎfi, ∫º=ηٿ ʇÛË, AT=·ÍÔÓÈ΋ ÙÔÌÔÁÚ·Ê›·,
Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË Û ÂÈÚ·Ì·Ùfi˙ˆ· Â›Ó·È ÂÚ›Ô˘ 2 g/kg, ÂÓÒ ÌÂÙ¿ ·fi ‰ÂÚÌ·ÙÈ΋ ·ʋ Â›Ó·È 10 ml/kg (1). √È ¤Ú¢Ó˜, ÔÈ Ôԛ˜ ¤¯Ô˘Ó Á›ÓÂÈ Ù· ÙÂÏÂ˘Ù·›· 30 ¯ÚfiÓÈ·, ¤‰ÂÈÍ·Ó ÂΉËÏÒÛÂȘ ÙÔÍÈÎÒÓ ·ÓÙȉڿÛÂˆÓ ÛÙ· ÂÈÚ·Ì·Ùfi˙ˆ· ÌÂÙ¿ ·fi Û˘ÛÙËÌ·ÙÈ΋ ¯ÔÚ‹ÁËÛË, fiˆ˜ ÂÚÁÒ‰Ë ·Ó·ÓÔ‹, ·Ù·Í›·, Û·ÛÌÔ‡˜. ™ÙÔ˘˜ ·ÓıÚÒÔ˘˜, ›Û˘, ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÙfiÛÔ ÙÔÈΤ˜ fiÛÔ Î·È Û˘ÛÙËÌ·ÙÈΤ˜ ÙÔÍÈΤ˜ ÂΉËÏÒÛÂȘ. √È ÙÔÈΤ˜ ÂΉËÏÒÛÂȘ ÂÌÊ·Ó›˙ÔÓÙ·È Ì ‰ÂÚÌ·Ù›Ùȉ· ÌÂÙ¿ ·fi ÙÔÈ΋ ÂÊ·ÚÌÔÁ‹. ™ÙȘ Û˘-
184
ÛÙËÌ·ÙÈΤ˜ ÂΉËÏÒÛÂȘ ÂÚÈÏ·Ì‚¿ÓÔÓÙ·È ÔÈ Û·ÛÌÔ›, ÙÔ ÎÒÌ·, Ë ·Ó·Ó¢ÛÙÈ΋ ·Ó¿ÚÎÂÈ· Î·È Ë ˘fiÙ·ÛË, ÂΉËÏÒÛÂȘ ÔÈ Ôԛ˜ ·Ú·ÙËÚ‹ıËÎ·Ó ÙfiÛÔ ÌÂÙ¿ ·fi Ù˘¯·›· ηٿÔÛË fiÛÔ Î·È ÌÂÙ¿ ·fi ‰ÂÚÌ·ÙÈ΋ ÂÊ·ÚÌÔÁ‹ Ù˘ DEET. ™·ÓÈfiÙÂÚ·, ·Ó·Ê¤ÚÔÓÙ·È ÂÂÈÛfi‰È· Û‡Á¯˘Û˘ ‹ ‰È¤ÁÂÚÛ˘, ÙÚfiÌÔ˘ Î·È ÔÈÛıfiÙÔÓÔ˘ (8), Û˘ÌÙÒÌ·Ù· Ô˘ Ôͤˆ˜ ·ÚÔ˘Û›·Û ÎÈ Ô ·ÛıÂÓ‹˜ Ì·˜. ∏ ¯Ú‹ÛË Ù˘ DEET Â›Ó·È ÂÎÙÂÓ‹˜ Û ÔÏfiÎÏËÚÔ ÙÔÓ ÎfiÛÌÔ Û‹ÌÂÚ·. ¶·Ú¿ ÙËÓ Â˘Ú›· ¯Ú‹ÛË Ù˘, ηٿ ‰È·ÛÙ‹Ì·Ù· ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÂÚÈÙÒÛÂȘ
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∂ÁÎÂÊ·Ï›ÙȘ, ¶·Ú·ÏÔÈÌ҉˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ∂ÁÎÂÊ·Ï›ÙȘ, ¶·Ú·ÏÔÈÌ҉˘ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· π‰ÈÔ·ı›˜ Û·ÛÌÔ› ∫·Ì›· ∫·Ì›·
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ÙÔÈÎÒÓ ‹ Û˘ÛÙËÌ·ÙÈÎÒÓ ÙÔÍÈÎÒÓ ÂΉËÏÒÛˆÓ. Ÿˆ˜ Ê·›ÓÂÙ·È ·fi ÙËÓ ·ÚÔ‡Û· ·Ó¿Ï˘ÛË, Ë ÙÔÍÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ·fi DEET Û˘Óԉ‡ÂÙ·È ·fi ÛËÌ·ÓÙÈ΋ ÓÔÛËÚfiÙËÙ· Î·È ıÓËÛÈÌfiÙËÙ· ÛÙ· ·È‰È¿ (9). √ ·ÛıÂÓ‹˜ Ì·˜ ÂΉ‹ÏˆÛ ·ÓÂÈÏËÌ̤ӷ ÂÂÈÛfi‰È· Û·ÛÌÒÓ Ï›Á˜ ÒÚ˜ ÌÂÙ¿ ·fi ÌÈÎÚ‹˜ ‰È¿ÚÎÂÈ·˜ ¤ÎıÂÛË Û DEET, Ô ‰Â ÂÚÁ·ÛÙËÚÈ·Îfi˜ ¤ÏÂÁ¯Ô˜ Ô˘ ·ÎÔÏÔ‡ıËÛ ÙË ‰ÈÂÚ‡ÓËÛË ÙˆÓ Û·ÛÌÒÓ ·¤‚Ë ·ÚÓËÙÈÎfi˜, fiˆ˜ Î·È ÛÙȘ ÂÚÈÙÒÛÂȘ ·ÛıÂÓÒÓ ÚÔËÁÔ‡ÌÂÓˆÓ ‰ËÌÔÛȇۈÓ. ∏ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÔ˘ÌÂ Â›Ó·È Ë ÚÒÙË ÂÚ›-
ÙˆÛË ÙÔÍÈÎfiÙËÙ·˜ ·fi DEET ÛÙË ¯ÒÚ· Ì·˜. √È ÂÚÈÙÒÛÂȘ ÂΉ‹ÏˆÛ˘ ÙÔÍÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ Î·È ı·Ó¿ÙÔ˘ Â›Ó·È Û¿ÓȘ, ·ÊÔÚÔ‡Ó Î˘Ú›ˆ˜ ·È‰È¿. ∞fi ÙÔ 1961 ̤¯ÚÈ Û‹ÌÂÚ·, ¤¯Ô˘Ó ·Ó·ÊÂÚı› ÛÙË ‰ÈÂıÓ‹ ‚È‚ÏÈÔÁÚ·Ê›· 17 ÂÈϤÔÓ ÂÚÈÙÒÛÂȘ ÙÔÍÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ·fi DEET Û ·È‰È¿. ∞fi ÙËÓ ·Ó¿Ï˘ÛË ÙˆÓ ÂÚÈÙÒÛÂˆÓ ·˘ÙÒÓ ÛÙ· Ï·›ÛÈ· Ù˘ ·ÚÔ‡Û·˜ ÌÂϤÙ˘, ÚԤ΢„ fiÙÈ ÙÔ 28% ·ÊÔÚÔ‡Û ·È‰È¿ ËÏÈΛ·˜ <18 ÌËÓÒÓ, fiˆ˜ ·ÎÚÈ‚Ò˜ Ô ·ÛıÂÓ‹˜ Ì·˜. π‰È·›ÙÂÚ· ÂÓÙ˘ˆÛȷ΋ ‹Ù·Ó Ë ‰È·›ÛÙˆÛË fiÙÈ 12 ·È‰È¿ (70,5%)
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ÂΉ‹ÏˆÛ·Ó Û˘ÌÙÒÌ·Ù· ÙÔÍÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÌÂÙ¿ ·fi ‰ÂÚÌ·ÙÈ΋ ¤ÎıÂÛË Î·È 5 ÌfiÓÔ ·È‰È¿ (29,5%) ÌÂÙ¿ ·fi Ù˘¯·›· ηٿÔÛË DEET. ∞Ó·ÌÊ›‚ÔÏ·, ÂӉȷʤÚÔÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë ÙÔÍÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ·fi DEET Û ·È‰È¿ ÌÔÚ› Ó· ÂΉËψı› fi¯È ÌfiÓÔ ÌÂÙ¿ ·fi Û˘¯Ó‹ ÂÊ·ÚÌÔÁ‹ ÙÔ˘ ÂÓÙÔÌÔ·ˆıËÙÈÎÔ‡, ·ÏÏ¿ Î·È ÌÂÙ¿ ·fi ÂÊ¿·Í ÂÊ·ÚÌÔÁ‹ ·˘ÙÔ‡ (10-12), fiˆ˜ Û˘Ó¤‚Ë Î·È ÛÙËÓ ÂÚ›ÙˆÛË Ô˘ ÂÚÈÁÚ¿ÊÔ˘ÌÂ. ™˘ÓÔÏÈο, ÙÔ 18% ÙˆÓ ÂÚÈÙÒÛÂˆÓ ‰ËÏËÙËÚÈ¿Ûˆ˜ Ì DEET ÛÙ· ·È‰È¿ ›¯Â ı·Ó·ÙËÊfiÚÔ ¤Î‚·ÛË (3 ı¿Ó·ÙÔÈ), ÂÓÒ ÔÈ ÌfiÓÔÈ ı¿Ó·ÙÔÈ Ô˘ ¤¯Ô˘Ó Û˘Ì‚Â› ÌÂÙ¿ ·fi ‰ÂÚÌ·ÙÈ΋ ÂÊ·ÚÌÔÁ‹ ·ÊÔÚÔ‡Û·Ó ·È‰È¿. ∏ ÌÔÓ·‰ÈÎfiÙËÙ· Ù˘ ¢¿ıÂÈ·˜ ·˘Ù‹˜ ÙˆÓ ·È‰ÈÒÓ ·Ú·Ì¤ÓÂÈ ·ÓÂÍ‹ÁËÙË. ∞Ó Î·È Ù· ÛÙÔȯ›· Û¯ÂÙÈο Ì ÙȘ Û˘Óı‹Î˜ ÙÔÍÈÎfiÙËÙ·˜ Ù˘ DEET Â›Ó·È ·ÎfiÌË ÂÏÏÈ‹, ·fi ÙË Û˘ÁΤÓÙÚˆÛË ÙˆÓ ÛÙÔȯ›ˆÓ Ù˘ ÚÔÛÈÙ‹˜ ¤ˆ˜ Û‹ÌÂÚ· ‚È‚ÏÈÔÁÚ·Ê›·˜, Ê·›ÓÂÙ·È fiÙÈ Ù· ·È‰È¿ Â›Ó·È ÈÔ Â˘·›ÛıËÙ· Û ۯ¤ÛË Ì ÙÔ˘˜ ÂÓ‹ÏÈÎÔ˘˜ ÛÙËÓ ÙÔÍÈ΋ ‰Ú¿ÛË Ù˘ DEET (12). ŒÓ· ÛËÌ·ÓÙÈÎfi ÔÛÔÛÙfi (33%) ÙˆÓ ·È‰ÈÒÓ Ù˘ ·ÚÔ‡Û·˜ ·Ó¿Ï˘Û˘ ·Ó¤Ù˘Í·Ó ÛËÌ›· ÙÔÍÈ΋˜ ÂÁÎÂÊ·ÏÔ¿ıÂÈ·˜ ÌÂÙ¿ ·fi ‰ÂÚÌ·ÙÈ΋ ¤ÎıÂÛË Û ·Ú·ÈˆÌ¤ÓÔ DEET 10% (13), 15% (14) ‹ 20% (15). ∆· ÂÓÙÔÌÔÎÙfiÓ· Ì DEET Ô˘ ΢ÎÏÔÊÔÚÔ‡Ó ÛÙË ¯ÒÚ· Ì·˜ ¤¯Ô˘Ó Û˘Ó‹ıˆ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ Ù˘ Ù¿Í˘ ÙˆÓ 9,6-20%. ∂ÓÙÔ‡ÙÔȘ, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·Ú¯È΋ Û˘ÁΤÓÙÚˆÛË ÙÔ˘ ‰È·Ï‡Ì·ÙÔ˜, Ë ÂÍ¿ÙÌÈÛË ÙÔ˘ ·ÏÎÔÔÏÔ‡¯Ô˘ ‰È·Ï‡ÙË ·Ê‹ÓÂÈ Û˘¯Ó¿ ˘„ËÏ‹˜ ˘ÎÓfiÙËÙ·˜ ÙÔÍÈ΋ Ô˘Û›· Û ·ʋ Ì ÙËÓ ÂȉÂÚÌ›‰· (16). ∂›Û˘, Â›Ó·È Èı·ÓfiÓ fiÙÈ Ë ·Èı·ÓfiÏË, Ô ‰È·Ï‡Ù˘ Ù˘ DEET, ÂÓÈÛ¯‡ÂÈ ÙË ‰È·ÂÚ·ÙfiÙËÙ· Ù˘ ÙÔÏÔ˘fiÏ˘ Ôχ ÂÚÈÛÛfiÙÂÚÔ ‰È· ̤ÛÔ˘ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ ÙˆÓ ·È‰ÈÒÓ ·’ fiÙÈ ÙˆÓ ÂÓËϛΈÓ, ÏfiÁˆ Ù˘ ÏÂÙfiÙËÙ¿˜ ÙÔ˘ Î·È Ù˘ ÌÂÁ¿Ï˘ ·Ó·ÏÔÁÈο Ì ÙË Ì¿˙· ÙÔ˘ ÛÒÌ·ÙÔ˜ ÂÈÊ¿ÓÂÈ·˜. °È· ÙÔ ÏfiÁÔ ·˘Ùfi Î·È Ì¤¯ÚȘ fiÙÔ˘ ¤¯Ô˘Ì ·ÚΤÛÙÂÚË ÏËÚÔÊfiÚËÛË, Ë Û‡ÛÙ·ÛË Ù˘ ∞ÌÂÚÈηÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∞η‰ËÌ›·˜ ÁÈ· ··ÁfiÚ¢ÛË Ù˘ ¯Ú‹Û˘ Û ·È‰È¿ Û΢·ÛÌ¿ÙˆÓ Ì ÂÚÈÂÎÙÈÎfiÙËÙ· >10%, Ú¤ÂÈ Ó· ·Ú·Ì›ÓÂÈ Ë Î·Ù¢ı˘ÓÙ‹ÚÈ· ÁÚ·ÌÌ‹ (17). √È Û·ÛÌÔ› ·ÔÙÂÏÔ‡Ó ÙÔ Û˘¯ÓfiÙÂÚÔ Û‡Ìو̷ ÙÔÍÈ΋˜ ÂΉ‹ÏˆÛ˘ ·fi DEET, ȉ›ˆ˜ ÌÂÙ¿ ·fi ‰ÂÚÌ·ÙÈ΋ ·ʋ (18). ∞ÎÔÏÔ˘ıÔ‡Ó ÙÔ ÎÒÌ·, Ë ˘ÂÚÙÔÓ›· Î·È Ô ÔÈÛıfiÙÔÓÔ˜, Ë ·Ù·Í›·, Ë ‰È¤ÁÂÚÛË, Ë ˘fiÙ·ÛË Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ·Ó·ÓÔ‹˜. ™Â ÓÂÎÚÔÙÔÌÈÎfi ˘ÏÈÎfi, ‚Ú¤ıËΠԛ‰ËÌ· ÂÁÎÂÊ¿ÏÔ˘ Î·È Û˘ÌÊfiÚËÛË ÙˆÓ ÌËÓ›ÁÁˆÓ (19). ∏ Ó¢ÚÔÙÔÍÈÎfiÙËÙ·, ˆ˜ ·ÚÈ· ÂΉ‹ÏˆÛË ÙÔÍÈÎfiÙËÙ·˜ ·fi ÙË DEET, ›Ûˆ˜ ÂÚÌËÓ‡ÂÙ·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë DEET Â›Ó·È ÏÈÔ‰È·Ï˘Ù‹ Ô˘Û›· Î·È Û˘ÛÛˆÚ‡ÂÙ·È ÛÙÔÓ ÂÁΤʷÏÔ. ∏ ÌÂÁ¿ÏË ÔÌÔÈfiÙËÙ· Ô˘ ˘¿Ú¯ÂÈ ÛÙË ‰ÔÌ‹ Ù˘ Ì ÙË ÓÈÎÂÙ·Ì›‰Ë, Ì›· Ô˘Û›· Ô˘ ÚÔηÏ› Û·ÛÌÔ‡˜, ÌÔÚ› Ó· ÂÍËÁ‹ÛÂÈ ÙË ÌÂÁ¿ÏË ·˘Ù‹ Û˘¯Ófi-
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ÙËÙ· Û·ÛÌÒÓ Ô˘ ·ÚÔ˘ÛÈ¿˙Ô˘Ó Ù· ·È‰È¿ Ì ÙÔÍÈ΋ ÂÁÎÂÊ·ÏÔ¿ıÂÈ· ·fi DEET. ™˘ÌÂÚ·ÛÌ·ÙÈο, ÂÓÙÔÌÔ·ˆıËÙÈο Ô˘ ÂÚȤ¯Ô˘Ó ÙË ‰Ú·ÛÙÈ΋ Ô˘Û›· DEET Û ‰È¿ÊÔÚ˜ ÌÔÚʤ˜ (lotion, spray, stick) ‰ÂÓ Â›Ó·È ·ÛÊ·Ï‹ fiÙ·Ó ÂÊ·ÚÌfi˙ÔÓÙ·È ÛÙÔ ‰¤ÚÌ· ·È‰ÈÒÓ, Ú¤ÂÈ ‰Â Ó· ·ÔʇÁÂÙ·È Ë Â¿ÏÂÈ„‹ ÙÔ˘˜ Û ‚Ú¤ÊË Î·È ÌÈÎÚ¿ ·È‰È¿. ∫·ıÒ˜ Ë ‰˘ÓËÙÈ΋ ÙÔÍÈÎfiÙËÙ· Ù˘ DEET Â›Ó·È Ôχ ˘„ËÏ‹, ·ÚfiÌÔÈ· ÂÓÙÔÌÔÎÙfiÓ·, ÔÔÈ·Û‰‹ÔÙÂ Û˘ÁΤÓÙÚˆÛ˘ DEET, Ú¤ÂÈ Èı·ÓfiÓ Ó· ·ÓÙÈηٷÛÙ·ıÔ‡Ó ·fi ¿ÏÏ·, ϤÔÓ ·ÛÊ·Ï‹ Û΢¿ÛÌ·Ù·. µÈ‚ÏÈÔÁÚ·Ê›· 1. Are insect repellents safe? [editorial]. Lancet 1988;2:610-611. 2. Tenenbein M. Severe toxic reactions and death following the ingestion of diethyltoluamide-containing insect repellents. JAMA 1987;258:1509-1511. 3. Miller JD. Anaphylaxis associated with insect repellent. N Engl J Med 1982;307:1341-1342. 4. Snyder JW, Poe RO, Stubbins JF, Garrettson LK. Acute manic psychosis following the dermal application of N,NDiethyl-m-toluamide (DEET) in an adult. Clin Toxicol 1986;24:429-439. 5. Vaskov VI, Gleiberman SE, Volkova AP. A study of the long-term effects of the use of repellents. Meditzinskaya Parazit i Parazitarnye Bdezni 1976;720-725. 6. Gilbert IH. Evaluation and use of mosquito repellents. JAMA 1966;196:253-255. 7. Ambrose AN. Pharmacologic and toxicologic studies on N,N-diethyltoluamide. Toxicol Appl Pharmacol 1959;1:97-115. 8. McConnell R, Fidler AT, Chrislip D. Health Hazard Evaluation Report HETA-83-085-1757, Everglades National Park, Everglades, Florida. Govt Reports Announcements & Index (GRA&I) 1987;17:107. 9. Edwards DL, Johnson CE. Insect-repellent-induced toxic encephalopathy in a child. Clin Pharm 1987;6:496-498. 10. Roland EH, Jan JE, Rigg JM. Toxic encephalopathy in a child after brief exposure to insect repellents. Can Med Assoc J 1985;132:155-156. 11. Lipscomb JW, Kramer JE, Leikny JB. Seizure following brief exposure to the insect repellent N,N-diethyl-mtoluamide. Ann Emerg Med 1992;21:315-317. 12. de Garbino JP, Laborde A. Toxicity of an insect repellent: N-N-diethyltoluamide. Vet Hum Toxicol 1983;25:422-423. 13. Gryboski J, Weinstein D, Ordway NK. Toxic encephalopathy apparently related to the use of an insect repellent. N Engl J Med 1961;264:289-291. 14. Osimitz TG, Murphy JV. Neurological effects assosiated with use of the insect repellent N,N-diethyl-m-toluamide. J Toxicol 1997;35:435-441. 15. Gerrettson L. Commentary-DEET. Caution for children still needed. J Toxicol Clin Toxicol 1997;35:443-445. 16. Curtis CF. Making insect repellents safe [letter]. Lancet 1988;2:1020. 17. Shelov SP, ed. Caring for your baby and young child.
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Birth to age 5. New York: Bantam Books; 1994. 18. Oransky S, Roseman B, Fish D, Gentile T, Melius J, Cartter ML et al. Seizures temporally associated with use of DEET insect repellent. New York and Connecticut. MMWR 1989;38:678-680. 19. Zadikoff CM. Toxic encephalopathy associated with use of insect repellent. J Pediatr 1979;95:140-142. 20. Heick HMC, Shipman RT, Norman MG, James W. Reyelike syndrome associated with use of insect repellent in a presumed heterozygote for ornithine carbamoyl transferase deficiency. J Pediatr 1980;97:471-473. 21. Konovalov GA, Romanov AN. Early hemodialysis in the treatment of severe poisonings with the repellents, DETA, benphthalate and dimethylphthalate. Anesteziol Reanimatol 1980;2:54-55.
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22. Oransky S. Letter dated 7/16/91, on file with the Department of Environment, Bureau of Pesticides Management, Albany, NY.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 18-09-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 01-12-2000 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ª·Ú›· ¡·ÚÏ›ÔÁÏÔ˘ ªÔÓ¿‰· ∂ÓÙ·ÙÈ΋˜ £Âڷ›·˜ ¡ÔÛÔÎÔÌÂ›Ô ¶·›‰ˆÓ “∞Á›· ™ÔÊ›·” £Ë‚ÒÓ Î·È §Â‚·‰Â›·˜, °Ô˘‰›, ∞ı‹Ó·
¶ÂÚ›ÏË„Ë ¿ÚıÚÔ˘ ·fi ÙË µÈ‚ÏÈÔÁÚ·Ê›· ¢È·Î‡Ì·ÓÛË ÙÔ˘ fiÓÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ıÂڷ›·˜ ÁÈ· ηÚΛÓÔ Û ·È‰È¿: ¶ÂÚÈÁÚ·ÊÈ΋ ÚÔÛ¤ÁÁÈÛË1 ªÂ ÛÎÔfi Ó· ‰ÈÂÚ¢ÓËı› Ò˜ Ù· ·È‰È¿ ‚ÈÒÓÔ˘Ó ÙȘ ‰È·Î˘Ì¿ÓÛÂȘ ÙÔ˘ fiÓÔ˘ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ·ÓÙÈηÚÎÈÓÈ΋˜ ıÂڷ›·˜, ¤ÁÈÓ·Ó ÚÔÁÚ·ÌÌ·ÙÈṲ̂Ó˜ Û˘ÓÂÓÙ‡ÍÂȘ Û 66 ·È‰È¿ Î·È ÛÙȘ ÔÈÎÔÁ¤ÓÂȤ˜ ÙÔ˘˜. ∫·Ù¿ ÙË ‰È¿ÁÓˆÛË, ÙÔ 49% ÙˆÓ ·È‰ÈÒÓ ‚ÈÒÓÔ˘Ó ÙÔÓ fiÓÔ Ô˘ Û¯ÂÙ›˙ÂÙ·È Ì ÙË ÓfiÛÔ ÙÔ˘˜. ™˘Ó‹ıˆ˜ Ô fiÓÔ˜ ‹Ù·Ó ÂÓÙÔÓfiÙÂÚÔ˜ ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ıÂڷ›·˜, ·Ú’ fiÏÔ Ô˘ ÙÔ ·Ó·ÌÂÓfiÌÂÓÔ ı· ‹Ù·Ó ÂÏ¿ÙÙˆÛË Ù˘ ¤ÓÙ·Û˘ ÙÔ˘ fiÓÔ˘. √ fiÓÔ˜ Ô˘ Û¯ÂÙÈ˙fiÙ·Ó ÙfiÛÔ Ì ÙȘ ‰È·ÁÓˆÛÙÈΤ˜ Ù¯ÓÈΤ˜ fiÛÔ Î·È Ì ÙË ıÂڷ›·, ·ÔÙÂÏÔ‡Û ÙÔ ÛËÌ·ÓÙÈÎfiÙÂÚÔ Úfi‚ÏËÌ· ηٿ ÙËÓ ·Ú¯È΋ Ê¿ÛË Ù˘ ıÂڷ›·˜. ™ÙË Û˘Ó¤¯ÂÈ·, Ô fiÓÔ˜ ·fi ÙȘ ‰È¿ÊÔÚ˜ ‰È·ÁÓˆÛÙÈΤ˜ Ù¯ÓÈΤ˜ (ÔÛÊ˘ÔÓˆÙÈ·›· ·Ú·Î¤ÓÙËÛË, ·Ó·ÚÚfiÊËÛË Ì˘ÂÏÔ‡) ‚·ıÌÈ·›· ÂÏ·ÙÙˆÓfiÙ·Ó, ÂÓÒ Ô fiÓÔ˜ Ô˘ Û¯ÂÙÈ˙fiÙ·Ó Ì ÙË ıÂڷ›· ‹Ù·Ó Û˘Ó¯‹˜ Î·È ¤ÓÙÔÓÔ˜. °È· ÌÂÚÈΤ˜ Ù¯ÓÈΤ˜ Ô fiÓÔ˜ ‹Ù·Ó ¤ÓÙÔÓÔ˜ ηٿ ÙËÓ ·Ú¯È΋ Ê¿ÛË, ËÈfiÙÂÚÔ˜ ÛÙË Û˘Ó¤¯ÂÈ· Î·È Â·ÓÂÚ¯fiÙ·Ó ÛÙ· ÚÒÙ· ›‰· ηٿ ÙËÓ ÙÂÏÈ΋ Ê¿ÛË Ù˘ ıÂڷ›·˜
™¿ÓÈ· Á›ÓÔÓÙ·Ó ÌÂÙÚ‹ÛÂȘ Ù˘ ¤ÓÙ·Û˘ ÙÔ˘ fiÓÔ˘ Î·È ÔÈ ÁÔÓ›˜ ·ÍÈÔÏÔÁÔ‡Û·Ó Î·Ï‡ÙÂÚ· ÙËÓ ¤ÓÙ·ÛË ÙÔ˘ fiÓÔ˘ ÙˆÓ ·È‰ÈÒÓ ÙÔ˘˜ Û ۯ¤ÛË Ì ÙÔ ÚÔÛˆÈÎfi ÙÔ˘ ÓÔÛÔÎÔÌ›Ԣ. ∏ ·‡ÍËÛË Ù˘ ÁÓÒÛ˘ Û¯ÂÙÈο Ì ÙÔÓ fiÓÔ Î·È ÙË ıÂڷ›· ÙÔ˘ Û ·È‰È¿ Ì ηÚΛÓÔ, fiÔ˘ Û˘Ó‹ıˆ˜ Ô fiÓÔ˜ Â›Ó·È È·ÙÚÔÁÂÓ‹˜, ı· Ì·˜ ‚ÔËı‹ÛÂÈ Ó· ηٷÓÔ‹ÛÔ˘Ì ÙȘ ·Ó¿ÁΘ Î·È ÙȘ ··ÈÙ‹ÛÂȘ ÙˆÓ ·È‰ÈÒÓ Î·È ÙˆÓ ÁÔÓ¤ˆÓ, ÒÛÙ ӷ ÂÏ·ÙÙÒÛÔ˘Ì ÙÔÓ fiÓÔ ÛÙÔ ÂÏ¿¯ÈÛÙÔ.
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G, Gordh T, Sörensen S, Kreuger A Pain variations during cancer treatment in children: A descriptive survey Pediatr Hematol Oncol 2000;17: 211-221 º. ∞ı·Ó·ÛÈ¿‰Ô˘-¶ÈÂÚÔÔ‡ÏÔ˘ ∞Ó·Ï. ∫·ıËÁ‹ÙÚÈ·
187
2001 MAPT- A¶PI§
17-10-01 15:35
™ÂÏ›‰· 188
¶·È‰È·ÙÚÈ΋ 2001;64:188-193
™À¡∂Ãπ∑√ª∂¡∏ ¶∞π¢π∞∆ƒπ∫∏ ∂∫¶∞π¢∂À™∏
Paediatriki 2001;64:188-193
CONTINUING MEDICAL EDUCATION
¢È·Ù·Ú·¯¤˜ ı˘ÚÂÔÂȉÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Û ·È‰È¿ Ì ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË ∞. ∫·˚Ì¿Ú·-¶··ı·Ó·Û›Ô˘, Ã. ÷Ù˙Ë·ı·Ó·Û›Ô˘, Ã. £ÂÔ‰ˆÚ›‰Ë˜
Disorders of thyroid function in children with insulin dependent diabetes mellitus (IDDM) A. Kaimara-Papathanasiou, C. Hadjiathanasiou, C. Theodoridis
¶ÂÚ›ÏË„Ë: √È ‰È·Ù·Ú·¯¤˜ Ù˘ ı˘ÚÂÔÂȉÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ Â›Ó·È Û˘¯Ó¤˜ Û ·È‰È¿ Ô˘ ¿Û¯Ô˘Ó ·fi ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË. ∂ÌÊ·Ó›˙ÔÓÙ·È Â›Ù ˆ˜ ·˘ÙÔ¿ÓÔÛË ı˘ÚÂÔÂȉÈ΋ ÓfiÛÔ˜, ‰ËÏ·‰‹ ·ÚÔ˘Û›· ·ÓÙÈı˘ÚÂÔÂȉÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ (∞£∞) ÌfiÓÔÓ, ›Ù ˆ˜ ı˘ÚÂÔÂȉ›ÙȘ Hashimoto (‚ÚÔÁ¯Ô΋ÏË Ì ıÂÙÈο ∞£∞ Î·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ ˘ÂÚ˯ÔÁÚ·ÊÈ΋ ÂÈÎfiÓ·), ›Ù ˆ˜ ˘Ô- ‹ ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi˜. ∏ Û˘¯ÓfiÙËÙ· Ù˘ ·Ó‡ÚÂÛ˘ ∞£∞ {ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ı˘ÚÂÔÂȉÈ΋˜ ˘ÂÚÔÍÂȉ¿Û˘ (·ÓÙÈ- TPO)} Û ‰È·‚ËÙÈο ·È‰È¿ Î˘Ì·›ÓÂÙ·È ·fi 25-40%, fiÛÔ ÂÚ›Ô˘ Î·È Ë Û˘¯ÓfiÙËÙ· Ù˘ ı˘ÚÂÔÂȉ›Ùȉ·˜ Hashimoto. √È ‰È·Ù·Ú·¯¤˜ Ù˘ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ÌÔÚ› Ó· ÂËÚ¿ÛÔ˘Ó ÙË Ú‡ıÌÈÛË ÙÔ˘ ‰È·‚‹ÙË, ÂÓÒ Ë ·ÔÚÚ‡ıÌÈÛË ÙÔ˘ ‰È·‚‹ÙË ÌÔÚ› Ó· ÂËÚ¿ÛÂÈ ÙȘ ‰ÔÎÈ̷ۛ˜ Ù˘ ı˘ÚÂÔÂȉÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜. ∆· Û˘ÌÙÒÌ·Ù· ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ ÌÔÚ› Ó· Â›Ó·È ‹È·, fiˆ˜ ηı˘ÛÙ¤ÚËÛË Ù˘ ηı’ ‡„Ô˜ ·Ó¿Ù˘Í˘, ÂÌÊ¿ÓÈÛË ‚ÚÔÁ¯Ô΋Ï˘ ‹ ÂÌÊ¿ÓÈÛË ˘ÔÁÏ˘Î·ÈÌÈÒÓ, ÂÓÒ Ô ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi˜ ÂÎÙfi˜ ·fi Ù· Û˘Ó‹ıË Û˘ÌÙÒÌ·Ù· (Ù·¯˘Î·Ú‰›Â˜, ·ÒÏÂÈ· ‚¿ÚÔ˘˜, ˘ÂÚÎÈÓËÙÈÎfiÙËÙ·) ÌÔÚ› Ó· ÚÔηϤÛÂÈ ˘ÂÚÁÏ˘Î·ÈÌ›·. ∏ ÎÏÈÓÈ΋ ÂͤٷÛË Ì „ËÏ¿ÊËÛË ÙÔ˘ ı˘ÚÂÔÂȉԇ˜, Ë Î·Ù·ÁÚ·Ê‹ Ù˘ η̇Ï˘ ·Ó¿Ù˘Í˘ ηıÒ˜ Î·È Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ ∞£∞ Â›Ó·È ··Ú·›ÙËÙÔ Ó· Á›ÓÔÓÙ·È ÛÙ· ‰È·‚ËÙÈο ·È‰È¿ ÚÔÎÂÈ̤ÓÔ˘ Ó· ‰È·ÁÓˆÛÙ› Î·È Ó· ıÂڷ¢Ù› ¤ÁηÈÚ· Ù˘¯fiÓ ı˘ÚÂÔÂȉԿıÂÈ·. ™Ù· ‰È·‚ËÙÈο ·È‰È¿ Ì ıÂÙÈο ∞£∞ Ú¤ÂÈ Ó· Á›ÓÂÙ·È ¤ÏÂÁ¯Ô˜ ÙˆÓ Û˘ÁÁÂÓÒÓ Ì ÚÔÛ‰ÈÔÚÈÛÌfi ∞£∞ ÁÈ· ÙË ‰È·›ÛÙˆÛË Ù˘¯fiÓ ·‰È¿ÁÓˆÛÙ˘ ı˘ÚÂÔÂȉԿıÂÈ·˜, ηıÒ˜ Î·È ÚÔÛ‰ÈÔÚÈÛÌfi˜ ¿ÏÏˆÓ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ ÁÈ· ÙËÓ ÚÒÈÌË ‰È¿ÁÓˆÛË ÂÈΛÌÂÓˆÓ ·Ó·ÚÎÂÈÒÓ ¿ÏÏˆÓ ÂÓ‰ÔÎÚÈÓÒÓ ·‰¤ÓˆÓ.
Abstract: Disorders of thyroid function are common in children with IDDM. They present either as an autoimmune thyroid disease (presence of thyroid autoantibodies only), or as Hashimoto thyroiditis (goiter with positive antithyroid antibodies and characteristic u/s appearance), or as hypo- or hyperthyroidism. The frequency of detection of antithyroid antibodies {against thyroid hyperoxidase (anti- TPO)} in diabetic children ranges between 25-40%, a frequency which is similar to the prevalence of Hashimoto thyroiditis. Thyroid function disorders may influence the control of diabetes, and conversely uncontrolled diabetes can influence the results of the thyroid function tests. Signs of hypothyroidism can be mild, as for example growth delay, development of signs of goiter or of hypoglycemia. Hyperthyroidism, besides the usual symptoms (tachycardia, weight loss, hyperkinesis), may also cause hyperglycemia. Diabetic children should be carefully examined for the presence of signs of thyroid dysfunction. Clinical examination should include palpation of the thyroid, careful monitoring of the growth curve and determination of antithyroid antibodies in order to detect promptly the presence of thyroid dysfunction and initiate therapy. In diabetic children with positive antithyroid antibodies, their first degree relatives should be screened for the presence of antithyroid antibodies in order to make an early diagnosis of thyroid dysfunction, as well as the presence of other autoantibodies for the prompt detection of impending failure of other endocrine organs.
∂Ó‰ÔÎÚÈÓÔÏÔÁÈÎfi ∆Ì‹Ì· ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ “¶. & ∞. ∫˘ÚÈ·ÎÔ‡”
Department of Pediatric Endocrinology Children’s Hospital “P. & A. Kyriakou”, Athens
188
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17-10-01 15:35
™ÂÏ›‰· 189
¶·È‰È·ÙÚÈ΋ 2001;64:188-193
Paediatriki 2001;64:188-193
§¤ÍÂȘ ÎÏÂȉȿ: ۷ί·Ú҉˘ ‰È·‚‹Ù˘, ·È‰È¿, ı˘ÚÂÔÂȉ›ÙȘ, ·ÓÙÈı˘ÚÂÔÂȉÈο ·ÓÙÈÛÒÌ·Ù·.
Key words: diabetes mellitus, children, thyroiditis, antithyroid antibodies.
∂ÈÛ·ÁˆÁ‹ H Û˘Û¯¤ÙÈÛË ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ì ¿ÏϘ ÂÓ‰ÔÎÚÈÓÈΤ˜ ‰È·Ù·Ú·¯¤˜ Â›Ó·È ÁÓˆÛÙ‹ ·fi Ù· Ù¤ÏË ÙÔ˘ ÂÚ·Ṳ̂ÓÔ˘ ·ÈÒÓ· (1). √È ·Ú¯ÈΤ˜ ÂӉ›ÍÂȘ fiÙÈ Ô ‰È·‚‹Ù˘ ¤¯ÂÈ Û¯¤ÛË Ì ·ÓÔÛÔÏÔÁÈÎÔ‡˜ Ì˯·ÓÈÛÌÔ‡˜ ÚÔ‹Ïı·Ó ·fi ÈÛÙÔÏÔÁÈΤ˜ ·Ú·ÙËÚ‹ÛÂȘ ·ÁÎÚ¤·ÙÔ˜ ÛÙȘ Ôԛ˜ ˘‹Ú¯Â ‰È‹ıËÛË ÏÂÌÊÔ΢ÙÙ¿ÚˆÓ. ∆Ô 1974 Ì ÙËÓ ·Ó›¯Ó¢ÛË ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙˆÓ Î˘ÙÙ¿ÚˆÓ ÙˆÓ ÓËÛȉ›ˆÓ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ ÂȂ‚·ÈÒıËΠfiÙÈ Ô ‰È·‚‹Ù˘ Â›Ó·È ·˘ÙÔ¿ÓÔÛË ÓfiÛÔ˜ (2,3). ŒÎÙÔÙÂ, ÔÏϤ˜ ÌÂϤÙ˜ ¤¯Ô˘Ó ‰Â›ÍÂÈ ÙËÓ ·ÚÔ˘Û›· ÂȉÈÎÒÓ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ Û ·ÛıÂÓ›˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î·È ÛÂ Û˘ÁÁÂÓ›˜ ÚÒÙÔ˘ ‚·ıÌÔ‡, ÂÓÒ ˘¿Ú¯Ô˘Ó ÂӉ›ÍÂȘ ÁÂÓÂÙÈ΋˜ Û˘Û¯¤ÙÈÛ˘, ÔÈ Ôԛ˜ ÚÔ·ÙÔ˘Ó ·fi ÌÂϤÙ˜ ÙÔ˘ ·ÓÙÈÁfiÓÔ˘ ÈÛÙÔÛ˘Ì‚·ÙfiÙËÙÔ˜ HLA8, Ô˘ ·Ú·ÙËÚÂ›Ù·È ÛÙÔ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË, ÙË ı˘ÚÂÔÙÔ͛ΈÛË Î·È ÙË ÓfiÛÔ ÙÔ˘ Addison (4,5). ¶·Ú¿ ÙËÓ ÙÂÚ¿ÛÙÈ· ÚfiÔ‰Ô Ô˘ ¤¯ÂÈ Á›ÓÂÈ ÛÙÔ˘˜ ÙÔÌ›˜ Ù˘ ·ÓÔÛÔÏÔÁ›·˜ Î·È ÁÂÓÂÙÈ΋˜ ÙȘ ÙÂÏÂ˘Ù·›Â˜ ‰ÂηÂٛ˜, ‰ÂÓ ¤¯ÂÈ ‰È¢ÎÚÈÓÈÛı› Ï‹Úˆ˜ Ô Ì˯·ÓÈÛÌfi˜ Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ‰È·‰Èηۛ·˜ Ô˘ ¢ı‡ÓÂÙ·È ÁÈ· ÙËÓ ÂΉ‹ÏˆÛË Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË Î·È Û˘ÓÔ‰ÒÓ ÂÓ‰ÔÎÚÈÓÔ·ıÂÈÒÓ. √È ‰È·Ù·Ú·¯¤˜ Ù˘ ı˘ÚÂÔÂȉÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÂÌÊ·Ó›˙ÔÓÙ·È Ì ÙȘ ·ÎfiÏÔ˘ı˜ ÌÔÚʤ˜: ·) ·˘ÙÔ¿ÓÔÛË ı˘ÚÂÔÂȉÈ΋ ÓfiÛÔ˜, ‚) ı˘ÚÂÔÂȉ›ÙȘ Hashimoto, Á) ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜, ‰) ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi˜.
ÎÒÓ ·ÓÙÈۈ̿وÓ. ™Â 136 ·ÛıÂÓ›˜ (17,6%) ·Ó¢ڤıËÎ·Ó ıÂÙÈο ·ÓÙÈ- TPO Î·È Ë ·Ó·ÏÔÁ›· ÎÔÚÈÙÛÈÒÓ ÚÔ˜ ·ÁfiÚÈ· ‹Ù·Ó 2/1. ∆· ·ÓÙÈ- ∆g ‹Ù·Ó ıÂÙÈο Û ÔÛÔÛÙfi 1,6%, ÙÔ ÔÔ›Ô ‰ÂÓ ‰È¤ÊÂÚ ·fi ÔÌ¿‰· Ê˘ÛÈÔÏÔÁÈÎÒÓ ·È‰ÈÒÓ (11). ™Â 117 ·fi ÙÔ˘˜ ·ÛıÂÓ›˜ Ì ıÂÙÈο ·ÓÙÈ- ∆ƒ√ ÌÂÏÂÙ‹ıËÎÂ Ë ı˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ù· ÂfiÌÂÓ· 5 ¯ÚfiÓÈ·. √ÎÙÒ ·ÛıÂÓ›˜ (7%) ‹Ù·Ó ˘ÂÚı˘ÚÂÔÂȉÈÎÔ›, 45 (38%) ˘Ôı˘ÚÂÔÂȉÈÎÔ›, ÂÓÒ 64 (55%) ·Ú¤ÌÂÈÓ·Ó Â˘ı˘ÚÂÔÂȉÈÎÔ›, Ì ÙÈÌ‹ fï˜ TSH ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË Î·È ÂχıÂÚË T4 ÛËÌ·ÓÙÈο ¯·ÌËÏfiÙÂÚË Û ۯ¤ÛË Ì ÙȘ ·ÓÙ›ÛÙÔȯ˜ ÙÈ̤˜ ÙˆÓ ·ÛıÂÓÒÓ Ì ·ÚÓËÙÈο ·ÓÙÈ- ∆ƒ√. √ ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi˜ Û 7 ·fi ÙÔ˘˜ 8 ·ÛıÂÓ›˜ ‰È·ÁÓÒÛıËΠÚÈÓ ‹ ηٿ ÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË, ÂÓÒ Û ¤Ó· ·ÛıÂÓ‹ ·ÚÔ˘ÛÈ¿ÛÙËΠÌÂÙ¿ ÙËÓ ÂΉ‹ÏˆÛ‹ ÙÔ˘. ∞fi ÙÔ˘˜ 45 ·ÛıÂÓ›˜ ÛÙÔ˘˜ ÔÔ›Ô˘˜ ‰È·ÈÛÙÒıËΠ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜, Û 4 Ë ‰È¿ÁÓˆÛË ¤ÁÈÓ ÚÈÓ ·fi ÙËÓ ÂÌÊ¿ÓÈÛË ÙÔ˘ ‰È·‚‹ÙË, Û 10 ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ Î·È Û 31 ·fi ·˘ÙÔ‡˜ ÌÂÙ¿ ÙÔÓ ÚÒÙÔ ¯ÚfiÓÔ ·fi ÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ‰È·‚‹ÙË. ¡Â·ÚÔ› ·ÛıÂÓ›˜ Ì ‰È·‚‹ÙË Ù‡Ô˘ π ·ÚÔ˘Û›·˙·Ó ηٿ ÙËÓ ¤Ó·ÚÍË Ù˘ ÓfiÛÔ˘ ıÂÙÈο ∞£∞ ηıÒ˜ Î·È ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙÔȯˆÌ·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ (PCA) Û ÂÓÙ·Ï¿ÛÈ· Û˘¯ÓfiÙËÙ· Û˘ÁÎÚÈÓfiÌÂÓ· Ì ÔÌ¿‰· ÂϤÁ¯Ô˘ ÌË ‰È·‚ËÙÈÎÒÓ ·È‰ÈÒÓ ›‰È·˜ ËÏÈΛ·˜. √È Û˘ÁÁÚ·Ê›˜ Û˘ÌÂÚ·›ÓÔ˘Ó fiÙÈ Èı·ÓfiÓ Ë ·˘ÙÔ¿ÓÔÛË ‰È·‰Èηۛ· Ó· ·Ú¯›˙ÂÈ Û˘Á¯ÚfiÓˆ˜ ÛÙÔ ı˘ÚÂÔÂȉ‹, ÙÔ Á·ÛÙÚÈÎfi ‚ÏÂÓÓÔÁfiÓÔ Î·È Ù· ÓËÛ›‰È· ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜ (9). ™Â ÌÂϤÙ˜ Ô˘ ¤ÁÈÓ·Ó ·ÚÁfiÙÂÚ· Û ÌÈÎÚfiÙÂÚÔ ·ÚÈıÌfi ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ (371 ·ÛıÂÓ›˜ ËÏÈΛ·˜ 3-22 ÂÙÒÓ, Ì ‰È¿ÚÎÂÈ· ‰È·‚‹ÙË 0-17 ¯ÚfiÓÈ·) ‚Ú¤ıËÎ·Ó ıÂÙÈο ·ÓÙÈ- TPO Û ÔÛÔÛÙfi 15,9%, ·ÓÙÈ- Tg Û 7,5% Î·È ·ÚÔ˘Û›· Î·È ÙˆÓ 2 ·ÓÙÈÛˆÌ¿ÙˆÓ Û 4,3% ÙˆÓ ·ÛıÂÓÒÓ. √ Ú˘ıÌfi˜ ıÂÙÈÎÔÔ›ËÛ˘ ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ‹Ù·Ó ÛËÌ·ÓÙÈÎfi˜ ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÊ˂›·˜ (12).
∞˘ÙÔ¿ÓÔÛË ı˘ÚÂÔÂȉÈ΋ ÓfiÛÔ˜ (Autoimmune thyroid disease, AITD) ∞ÔÙÂÏ› ÙËÓ ÈÔ Û˘¯Ó‹ ÂÓ‰ÔÎÚÈÓÔ¿ıÂÈ· ÛÙ· ·È‰È¿ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË. ÷ڷÎÙËÚÈÛÙÈÎfi Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ı˘ÚÂÔÂȉԿıÂÈ·˜ Â›Ó·È Ë ·Ó‡ÚÂÛË ∞£∞ ÛÙÔÓ ÔÚfi ÙˆÓ ·ÛıÂÓÒÓ, ‰ËÏ·‰‹ ·ÓÙÈÌÈÎÚÔÛˆÌÈ·ÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ (·ÓÙÈ- ª), Ù· ÔÔ›· Â›Ó·È Ù·˘ÙfiÛËÌ· Ì ٷ ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ Ù˘ ı˘ÚÂÔÂȉÈ΋˜ ˘ÂÚÔÍÂȉ¿Û˘ (·ÓÙÈ- TPO), ηıÒ˜ Î·È ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ Ù˘ ı˘ÚÂÔÛÊ·ÈÚ›Ó˘ (·ÓÙÈ- Tg). ∏ Û˘¯ÓfiÙËÙ· Ù˘ ·Ó›¯Ó¢Û˘ ∞£∞ Û ‰È·‚ËÙÈο ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ Î˘Ì·›ÓÂÙ·È ·fi 7-40% Î·È Â›Ó·È ÛËÌ·ÓÙÈο ˘„ËÏfiÙÂÚË Ù˘ ·ÓÙ›ÛÙÔȯ˘ ÛÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi (6-10). ∏ ‰È·ÊÔÚ¿ ÛÙË Û˘¯ÓfiÙËÙ· ÔÊ›ÏÂÙ·È ÛÙȘ ‰È·ÊÔÚ¤˜ ÌÂıÔ‰ÔÏÔÁ›·˜, ËÏÈΛ·˜, ʇÏÔ˘ Î·È ÂıÓÈÎfiÙËÙ·˜ ÛÙȘ ÔÌ¿‰Â˜ ·ÛıÂÓÒÓ ÙˆÓ ‰È·ÊfiÚˆÓ ÌÂÏÂÙÒÓ. ∆Ô 1981 Ô Riley ÌÂϤÙËÛ 771 Ó·ÚÔ‡˜ ·ÛıÂÓ›˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Ù‡Ô˘ π ÁÈ· ÙËÓ ·ÚÔ˘Û›· ∞£∞ ηıÒ˜ Î·È ·ÓÙÈÛˆÌ¿ÙˆÓ ¤Ó·ÓÙÈ ÙÔȯˆÌ·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ (PCA) Î·È ·ÓÙÈÂÈÓÂÊÚȉȷ-
£˘ÚÂÔÂȉ›ÙȘ Hashimoto ÷ڷÎÙËÚ›˙ÂÙ·È ·fi ÙËÓ ·ÚÔ˘Û›· ‚ÚÔÁ¯Ô΋Ï˘ Î·È ˘„ËÏÔ‡ Ù›ÙÏÔ˘ ∞£∞. ™¿ÓÈ· ÔÈ ·ÛıÂÓ›˜ ÌÔÚ› Ó· ÌËÓ ¤¯Ô˘Ó ‚ÚÔÁ¯Ô΋ÏË, ÔfiÙÂ Ë ·ÚÔ˘Û›· ∞£∞ Â›Ó·È Ë ÌfiÓË ¤Ó‰ÂÈÍË ı˘ÚÂÔÂȉ›Ùȉ·˜. ∏ ÚÔÁÓˆÛÙÈ΋ ·Í›· ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ÁÈ· ·Ó¿Ù˘ÍË ‰È·Ù·Ú·¯‹˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ‰ÂÓ Â›Ó·È ÛËÌ·ÓÙÈ΋, ȉ›ˆ˜ ÛÙËÓ ·È‰È΋ ËÏÈΛ·. ŒÓ· ÌÈÎÚfi ÔÛÔÛÙfi ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ ·ÚÔ˘ÛÈ¿˙ÂÈ ÎÏÈÓÈο ÛËÌ›· ˘Ô- ‹ ˘ÂÚÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜
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¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ·ÓÙÈÛˆÌ¿ÙˆÓ (13). ∏ Û˘¯ÓfiÙËÙ· Ù˘ ı˘ÚÂÔÂȉ›Ùȉ·˜ Hashimoto Ì ‚¿ÛË ÙËÓ ·ÚÔ˘Û›· ‚ÚÔÁ¯Ô΋Ï˘ Î·È ˘„ËÏÔ‡ Ù›ÙÏÔ˘ ·ÓÙÈÛˆÌ¿ÙˆÓ ·Ó¤Ú¯ÂÙ·È Û ÔÛÔÛÙfi 40% ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ (14). ∂¿Ó ÛÙ· ÎÚÈÙ‹ÚÈ· Ù˘ ‰È¿ÁÓˆÛ˘ ÚÔÛÙÂı› ÙÔ U/S ı˘ÚÂÔÂȉԇ˜ ‹ Ë ‚ÈÔ„›· ‰È¿ ÏÂÙ‹˜ ‚ÂÏfiÓ˘, Ë Û˘¯ÓfiÙËÙ· Â›Ó·È Ôχ ÌÈÎÚfiÙÂÚË (3,9%) (15). ∆Ô ÔÛÔÛÙfi ·˘Ùfi Â›Ó·È Û·ÊÒ˜ ˘„ËÏfiÙÂÚÔ ·fi ÙÔ ·ÓÙ›ÛÙÔÈ¯Ô ÛÙÔ ÁÂÓÈÎfi ·È‰È·ÙÚÈÎfi ÏËı˘ÛÌfi (16). ∫ÏÈÓÈ΋ ÂÈÎfiÓ·: ∏ ‚ÚÔÁ¯Ô΋ÏË ÌÔÚ› Ó· ÂÌÊ·ÓÈÛÙ› ÛÙ·‰È·Î¿, Â›Ó·È ÌÈÎÚÔ‡ ‹ ÌÂÙÚ›Ô˘ ÌÂÁ¤ıÔ˘˜ Î·È ¤¯ÂÈ ·ÓÒÌ·ÏË ÂÈÊ¿ÓÂÈ· Î·È ÂÏ·ÛÙÈ΋ Û‡ÛÙ·ÛË. ∆· ÂÚÈÛÛfiÙÂÚ· ·È‰È¿ Â›Ó·È ÎÏÈÓÈο ¢ı˘ÚÂÔÂȉÈο Î·È ·Û˘Ìو̷ÙÈο, ÂÓÒ ÌÂÚÈο ·Ú·ÔÓÔ‡ÓÙ·È ÁÈ· ·›ÛıËÌ· ›ÂÛ˘ ÛÙÔ Ï·ÈÌfi ‹ ‰˘ÛÎÔϛ˜ ηٿÔÛ˘. ∏ ‚ÚÔÁ¯Ô΋ÏË ÌÔÚ› Ó· ÂÏ·ÙÙˆı› Û ̤ÁÂıÔ˜ Î·È Ó· ÂÍ·Ê·ÓÈÛı› ‹ Ó· ·Ú·Ì›ÓÂÈ ·ÌÂÙ¿‚ÏËÙË ÁÈ· ¯ÚfiÓÈ·. ∞ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ Â›Ó·È Â˘ı˘ÚÂÔÂȉÈÎÔ› ·Ú¯Èο, ÂÌÊ·Ó›˙Ô˘Ó Û˘Ó‹ıˆ˜ ÌÂÙ¿ ÙËÓ ¿ÚÔ‰Ô ÌËÓÒÓ ‹ ÂÙÒÓ ˘Ôı˘ÚÂÔÂȉÈÛÌfi. ∂ÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù·: √È ı˘ÚÂÔÂȉÈΤ˜ ÔÚÌfiÓ˜ Â›Ó·È Û˘Ó‹ıˆ˜ Ê˘ÛÈÔÏÔÁÈΤ˜, ÂÓÒ Ë TSH ÌÔÚ› Ó· Â›Ó·È ÂÏ·ÊÚ¿ ‹ ̤ÙÚÈ· ·˘ÍË̤ÓË Û ÎÏÈÓÈο ¢ı˘ÚÂÔÂȉÈÎÔ‡˜ ·ÛıÂÓ›˜. ªÂ ÙËÓ ¿ÚÔ‰Ô ÙÔ˘ ¯ÚfiÓÔ˘ ·Ó·ÚΛ Ë ÏÂÈÙÔ˘ÚÁ›· ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ Ì ÙÒÛË ·Ú¯Èο Ù˘ ∆4, ÂÓ Û˘Ó¯›· Ù˘ ∆3 Î·È ¿ÓÔ‰Ô Ù˘ TSH. ∆Ô ÁÂÁÔÓfi˜ fiÙÈ ·ÚÎÂÙÔ› ·ÛıÂÓ›˜ Ì ‚ÚÔÁ¯Ô΋ÏË ‰ÂÓ ¤¯Ô˘Ó ·˘ÍË̤ÓË TSH ÔÊ›ÏÂÙ·È Èı·ÓfiÓ ÛÙË ‰Ú¿ÛË ·ÓÔÛÔÛÊ·ÈÚÈÓÒÓ, ÔÈ Ôԛ˜ ÚÔηÏÔ‡Ó ÙËÓ ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ (Thyroid Stimulating Immunoglobulins). ∆Ô ÛÈÓıËÚÔÁÚ¿ÊËÌ· ¤¯ÂÈ ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÂÈÎfiÓ· Ì ·ÓÒÌ·ÏË ÚfiÛÏË„Ë ÙÔ˘ Ú·‰ÈÔÊ·ÚÌ¿ÎÔ˘ ηٿ ÂÚÈÔ¯¤˜. H ÂÈÎfiÓ· ·˘Ù‹, Ë ÔÔ›· Â›Ó·È ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÛÙÔ˘˜ ÂÓ‹ÏÈΘ, ‰ÂÓ ÂÌÊ·Ó›˙ÂÙ·È ¿ÓÙ· ÛÙ· ·È‰È¿. ∞ÓÙ›ıÂÙ·, ÙÔ ˘ÂÚ˯ÔÁÚ¿ÊËÌ· ¤¯ÂÈ ¯·Ú·ÎÙËÚÈÛÙÈ΋ ÂÈÎfiÓ· Ì ·‡ÍËÛË ÙÔ˘ ÌÂÁ¤ıÔ˘˜ ÙÔ˘ ·‰¤Ó· Î·È ·ÓÔÌÔÈÔÁ¤ÓÂÈ· Ù˘ ˘Ê‹˜ ÙÔ˘, Ì ‰È¿Û·ÚÙ˜ ÌÈÎÚ¤˜ ˘Ô˯ÔÁÂÓ›˜ ÂÚÈÔ¯¤˜. ∆· ·ÓÙÈ– TPO Â›Ó·È ıÂÙÈο Û ÔÛÔÛÙfi ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ˘ 90%, ÂÓÒ Ù· ·ÓÙÈ– Tg Û ÔÛÔÛÙfi ÂÚ›Ô˘ 50%. °ÂÓÂÙÈ΋ ÚԉȿıÂÛË: ™Â ÌÂϤÙË 255 ·ÙfiÌˆÓ Ô˘ ›¯·Ó ‰È·‚‹ÙË Ù‡Ô˘ π Û ·È‰È΋ ËÏÈΛ· Î·È 597 Û˘ÁÁÂÓÒÓ ÙÔ˘˜ ÚÒÙÔ˘ ‚·ıÌÔ‡ ‚Ú¤ıËΠ·˘ÍË̤ÓË Â›ÙˆÛË ı˘ÚÂÔÂȉ›Ùȉ·˜ Hashimoto ΢ڛˆ˜ ÛÙȘ Á˘Ó·›Î˜ (54% Û ËÏÈ˘ <40 ÂÙÒÓ, ¤ˆ˜ 75% Û ËÏÈ˘ >50 ÂÙÒÓ) (22). √È ÌÈÛÔ› ÂÚ›Ô˘ ·fi ·˘ÙÔ‡˜ ‹Ù·Ó ¢ı˘ÚÂÔÂȉÈÎÔ› Î·È ·ÚÔ˘Û›·Û·Ó Î·È ¿ÏÏ· ·˘ÙÔ·ÓÙÈÛÒÌ·Ù· ‹ ›¯·Ó ıÂÙÈÎfi ÔÈÎÔÁÂÓÂÈ·Îfi ÈÛÙÔÚÈÎfi Û ۇÁÎÚÈÛË Ì ÙÔ˘˜ ‰È·‚ËÙÈÎÔ‡˜ ·ÛıÂÓ›˜ Ô˘ ‹Ù·Ó ˘Ôı˘ÚÂÔÂȉÈÎÔ› ‹ ‰ÂÓ Â›¯·Ó ı˘ÚÂÔÂȉԿıÂÈ·. ∏ ÁÂÓÂÙÈ΋ ·Ó¿Ï˘ÛË ¤‰ÂÈÍ ‰ÈÏ¿ÛÈ·
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·‡ÍËÛË ÛÙÔÓ ·ÏfiÙ˘Ô DQA1*0501-DQB1*0201 ÛÙÔ˘˜ ·ÛıÂÓ›˜ Ô˘ ›¯·Ó ı˘ÚÂÔÂȉ›Ùȉ· Hashimoto. ∆Ô ÁÂÁÔÓfi˜ ·˘Ùfi Èı·ÓfiÓ Ó· ÔÊ›ÏÂÙ·È ÂÓ Ì¤ÚÂÈ Û ÎÔÈÓ¿ ÁÔÓ›‰È· Ù· ÔÔ›· Úԉȷı¤ÙÔ˘Ó ÛÙȘ ÓfiÛÔ˘˜ (22). £Âڷ›·: ŸÙ·Ó Ë ı˘ÚÂÔÂȉ›Ùȉ· ÚÔηÏ› ˘ÔÎÏÈÓÈÎfi ‹ ¤Î‰ËÏÔ ˘Ôı˘ÚÂÔÂȉÈÛÌfi Ú¤ÂÈ Ó· ¯ÔÚËÁÂ›Ù·È ÔˆÛ‰‹ÔÙ ı˘ÚÔÍ›ÓË Û ‰fiÛË ˘ÔηٿÛÙ·Û˘. ¢ÂÓ ˘¿Ú¯ÂÈ Û˘Ìʈӛ· fiÛÔÓ ·ÊÔÚ¿ ÛÙË ıÂڷ›· ÙˆÓ Â˘ı˘ÚÂÔÂȉÈÎÒÓ ·ÛıÂÓÒÓ. ™Â Ì›· ÌÂϤÙË 32 ·È‰ÈÒÓ Ù· ÔÔ›· ·Ú·ÎÔÏÔ˘ı‹ıËÎ·Ó ÁÈ· 3 ¯ÚfiÓÈ·, ¤Ó· ÔÛÔÛÙfi 8% ‰ÂÓ ¯ÚÂÈ¿ÛÙËΠıÂڷ›·, ÙÔ 33% Ô˘ ¿Ú¯ÈÛ ·Ì¤Ûˆ˜ ÌfiÚÂÛ ӷ ÙË ‰È·Îfi„ÂÈ ÌÂÙ¿ ·fi ¤Ó· ‹ ‰‡Ô ¯ÚfiÓÈ·, ÂÓÒ ÙÔ 59% Ô˘ ‰ÂÓ ¿Ú¯ÈÛ ·Ì¤Ûˆ˜ ıÂڷ›· ·Ó·ÁοÛÙËΠӷ ·Ú¯›ÛÂÈ ÌÂÙ¿ ·fi ¤Ó· ‹ ‰‡Ô ¯ÚfiÓÈ·. ™˘ÓÂÒ˜, Ë ıÂڷ›· Èı·ÓfiÓ Ó· Â›Ó·È ·ÔÙÂÏÂÛÌ·ÙÈ΋ ˆ˜ ÚfiÏË„Ë Û ¢ı˘ÚÂÔÂȉÈÎÔ‡˜ ·ÛıÂÓ›˜ Ì ı˘ÚÂÔÂȉ›Ùȉ· Hashimoto (25). ¢ÂÓ ˘¿Ú¯Ô˘Ó ‚ÈÔ¯ËÌÈÎÔ› ‰Â›ÎÙ˜ Ô˘ Ó· ÚÔ‚Ï¤Ô˘Ó ÙË Ê˘ÛÈ΋ ÂͤÏÈÍË Ù˘ ÓfiÛÔ˘. ∂¿Ó Ë ıÂڷ›· ‰È·ÎÔ› ÏfiÁˆ ›Ù¢Í˘ Ê˘ÛÈÔÏÔÁÈ΋˜ ı˘ÚÂÔÂȉÈ΋˜ ÏÂÈÙÔ˘ÚÁ›·˜, ˘¿Ú¯ÂÈ ÌÂÁ¿ÏË Èı·ÓfiÙËÙ· ˘ÔÙÚÔ‹˜. ∏ ·Ú·ÎÔÏÔ‡ıËÛË ÙˆÓ ·ÛıÂÓÒÓ Â›Ó·È ··Ú·›ÙËÙË. £· Ú¤ÂÈ Ó· ÙÔÓÈÛı› fiÙÈ Ô ÚÔÛ‰ÈÔÚÈÛÌfi˜ ∞£∞ Â›Ó·È ··Ú·›ÙËÙÔ Ó· Á›ÓÂÙ·È Û·Ó ÂͤٷÛË ÚÔ˘Ù›Ó·˜ Û οı ‰È·‚ËÙÈÎfi ·È‰›, Ë ·Ó‡ÚÂÛË ‰Â, ıÂÙÈÎÒÓ ·ÓÙÈÛˆÌ¿ÙˆÓ Â›Ó·È ·Ú¿ÁÔÓÙ·˜ ÎÈÓ‰‡ÓÔ˘ ÁÈ· ·Ó¿Ù˘ÍË ˘Ô- ‹ ˘ÂÚı˘ÚÂÔÂȉÈÛÌÔ‡. ™Â οı ›ÛÎÂ„Ë ·È‰ÈÔ‡ ÛÙÔ ‰È·‚ËÙÔÏÔÁÈÎfi È·ÙÚÂ›Ô ÂÎÙfi˜ ·fi ÙËÓ Î·Ù·ÁÚ·Ê‹ ÙÔ˘ ‡„Ô˘˜ Î·È ÙÔ˘ ‚¿ÚÔ˘˜ ÛÙ· ‰È·ÁÚ¿ÌÌ·Ù·, Ú¤ÂÈ ¿ÓÙ· Ó· „ËÏ·Ê¿Ù·È Ô ı˘ÚÂÔÂȉ‹˜ ÁÈ· Èı·Ó‹ ‰ÈfiÁΈÛË Î·È Ì ÙÔÓ ÂÚÁ·ÛÙËÚÈ·Îfi ¤ÏÂÁ¯Ô Ó· ·Ó·Î·Ï‡ÙÂÙ·È ¤ÁηÈÚ· Î·È Ó· ıÂڷ‡ÂÙ·È Ë ı˘ÚÂÔÂȉ›ÙȘ. ÀÔı˘ÚÂÔÂȉÈÛÌfi˜ ŒÎ‰ËÏÔ˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ (ÂÌÊ¿ÓÈÛË ÎÏÈÓÈÎÒÓ Û˘Ìو̿وÓ, ÂÏ¿ÙÙˆÛË Ù˘ ∆4, ·‡ÍËÛË Ù˘ TSH) ·ÚÔ˘ÛÈ¿˙ÂÙ·È Û ÔÛÔÛÙfi 1-3% ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ, ·ÓÂÍ¿ÚÙËÙ· ·fi ÙËÓ ·ÚÔ˘Û›· ‹ ÌË ∞£∞. √È ·ÛıÂÓ›˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î·È ıÂÙÈο ·ÓÙÈÛÒÌ·Ù· ·Ó·Ù‡ÛÛÔ˘Ó Û˘¯ÓfiÙÂÚ· ˘Ôı˘ÚÂÔÂȉÈÛÌfi. √ ˘ÔÎÏÈÓÈÎfi˜ ‹ ·ÓÙÈÚÚÔÔ‡ÌÂÓÔ˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ¯·Ú·ÎÙËÚ›˙ÂÙ·È ·fi Ê˘ÛÈÔÏÔÁÈ΋ ∆4, ·˘ÍË̤ÓË TSH Î·È ¤ÏÏÂÈ„Ë Û˘ÌÙˆÌ¿ÙˆÓ Î·È ·Ú·ÙËÚÂ›Ù·È Û 1,4-10% ÙˆÓ Ó·ÚÒÓ ‰È·‚ËÙÈÎÒÓ ·ÛıÂÓÒÓ, ·ÎfiÌ· Î·È ¯ˆÚ›˜ ÙËÓ ·ÚÔ˘Û›· ∞£∞ (17). ∫ÏÈÓÈ΋ ÂÈÎfiÓ·: ∆· Û˘ÌÙÒÌ·Ù· ÙÔ˘ ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ ÌÔÚ› Ó· Â›Ó·È ‹È· Î·È Ó· ‰È·Ê‡ÁÔ˘Ó Ù˘ ÚÔÛÔ¯‹˜ ‹ Ó· ·Ô‰ÔıÔ‡Ó Û η΋ Ú‡ıÌÈÛË ÙÔ˘ ‰È·‚‹ÙË (18). ∏ ÂÈ‚Ú¿‰˘ÓÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘
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ÌÔÚ› Ó· ˘ÔÎÚ‡ÙÂÈ ˘Ôı˘ÚÂÔÂȉÈÛÌfi. ∂Ô̤ӈ˜, Â›Ó·È ··Ú·›ÙËÙË Ë ·Ú·ÎÔÏÔ‡ıËÛË ÙÔ˘ Ú˘ıÌÔ‡ ·‡ÍËÛ˘ ÙˆÓ ‰È·‚ËÙÈÎÒÓ ·È‰ÈÒÓ Î·È Ë „ËÏ¿ÊËÛË ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ÁÈ· ÂÎÙ›ÌËÛË Ù˘¯fiÓ ‰ÈfiÁΈÛ˘ ÙÔ˘ ·‰¤Ó·. ™Â ÌÂϤÙË 184 ‰È·‚ËÙÈÎÒÓ ·È‰ÈÒÓ Ôfi ÙËÓ √ÍÊfiÚ‰Ë ·Ó·Ê¤ÚÂÙ·È fiÙÈ ÙÔ ‡„Ô˜ ηٿ ÙË ‰È¿ÁÓˆÛË ‰ÂÓ ‰È¤ÊÂÚ ·fi ÙÔ ‡„Ô˜ ÌË ‰È·‚ËÙÈÎÒÓ ·È‰ÈÒÓ Ù˘ ›‰È·˜ ËÏÈΛ·˜ (19). ∆Ô ÂÊË‚ÈÎfi ¿ÏÌ· ‡„Ô˘˜ ‹Ù·Ó ÌÂȈ̤ÓÔ Î˘Ú›ˆ˜ ÛÙ· ÎÔÚ›ÙÛÈ·. ∆Ô ÙÂÏÈÎfi ·Ó¿ÛÙËÌ· ˘ÔÏÂÈfiÙ·Ó Û ·È‰È¿ ÛÙ· ÔÔ›· Ë ‰È¿ÁÓˆÛË ¤ÁÈÓ Û ËÏÈΛ· 0 - 5 ÂÙÒÓ, ÂÓÒ ‰È·ÙËÚÔ‡ÓÙ·Ó Û ·È‰È¿ ÛÙ· ÔÔ›· Ë ‰È¿ÁÓˆÛË ¤ÁÈÓ ÌÂÙ¿ ÙËÓ ËÏÈΛ· ÙˆÓ 5 ÂÙÒÓ (19). ÕÏÏ· ÎÏÈÓÈο ÛËÌ›· ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡ Â›Ó·È Ë ·‡ÍËÛË ÙÔ˘ ‚¿ÚÔ˘˜, Ë ÙÚ·¯‡ÙËÙ· ÙˆÓ ¯·Ú·ÎÙËÚÈÛÙÈÎÒÓ ÙÔ˘ ÚÔÛÒÔ˘, Ë ÍËÚfiÙËÙ· ÙÔ˘ ‰¤ÚÌ·ÙÔ˜, Ë ·Ú·›ˆÛË Ù˘ ÙÚ›¯ˆÛ˘, Ë ‚Ú·‰‡ÙËÙ· ÙˆÓ ·ÓÙȉڿÛˆÓ, Ë ÙÒÛË Ù˘ Û¯ÔÏÈ΋˜ ·fi‰ÔÛ˘ Î·È ÔÈ ‰È·Ù·Ú·¯¤˜ Ù˘ ÂÌÌ‹ÓÔ˘ Ú‡Ûˆ˜ ÛÙ· ÎÔÚ›ÙÛÈ·. ∂ÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù·: ∞Ó¢ڛÛÎÂÙ·È ·ÓÙÈÚÚÔÔ‡ÌÂÓÔ˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ÌÂ Ê˘ÛÈÔÏÔÁÈΤ˜ ∆3, ∆4 Î·È ·‡ÍËÛË Ù˘ TSH ‹ ¤Î‰ËÏÔ˜ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ Ì ÂÏ¿ÙÙˆÛË Ù˘ ∆3, ∆4 Î·È ·‡ÍËÛË Ù˘ TSH. √È ‰È·Ù·Ú·¯¤˜ Ù˘ Ú‡ıÌÈÛ˘ ÙÔ˘ ‰È·‚‹ÙË ÌÔÚ› Ó· ÂËÚ¿ÛÔ˘Ó Ù· ·ÔÙÂϤÛÌ·Ù· ÙˆÓ ÌÂÙÚ‹ÛÂˆÓ ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ ÛÙÔ ·›Ì·. ™Â ˘ÁÈ›˜ ÔÚÁ·ÓÈÛÌÔ‡˜ Ë ∆4 ÌÂÙ·ÙÚ¤ÂÙ·È ÂÚ›Ô˘ ›Û· Û ∆3 Î·È ·Ó¿ÛÙÚÔÊË ∆3 (rT3) ·ÏÏ¿ ηٿ ÙË ‰È¿ÚÎÂÈ· ÓfiÛÔ˘ ·Ú¿ÁÂÙ·È ÏÈÁfiÙÂÚË ∆3, ÂÓÒ ÂÚÈÛÛfiÙÂÚË ÌÂÙ·ÙÚ¤ÂÙ·È ÛÙËÓ ·ÓÂÓÂÚÁ‹ ÌÔÚÊ‹ rT3. ™Â ÌË ÂÏÂÁ¯fiÌÂÓË ˘ÂÚÁÏ˘Î·ÈÌ›· ‹ ÎÂÙÔͤˆÛË ÂÏ·ÙÙÒÓÂÙ·È Ë ÔÏÈ΋ ı˘ÚÔÍ›ÓË Î·È Ë TBG, Ë fT4 Î·È Ë TSH ·Ú·Ì¤ÓÔ˘Ó Ê˘ÛÈÔÏÔÁÈΤ˜ Î·È ÂÏ·ÙÙÒÓÂÙ·È Â›Û˘ Ë fT3, ÂÓÒ ·˘Í¿ÓÂÙ·È Ë rT3 (18). ™ÙȘ ÂÚÈÙÒÛÂȘ ·˘Ù¤˜ Ë ·ÍÈÔÏfiÁËÛË ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ Â›Ó·È ‰‡ÛÎÔÏË Î·È ÂÍ·ÚÙ¿Ù·È ·fi ÙË Ê¿ÛË Ù˘ ÌÂÙ·‚ÔÏÈ΋˜ ‰È·Ù·Ú·¯‹˜ Ô˘ ÂÈÎÚ·Ù›. √ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ÌÔÚ› Ó· ÚÔηϤÛÂÈ ‰È·Ù·Ú·¯¤˜ ÛÙÔ ÌÂÙ·‚ÔÏÈÛÌfi ÙˆÓ ˘‰·Ù·ÓıÚ¿ÎˆÓ Î·È ÏÈÒÓ (20) Î·È Û˘ÁÎÂÎÚÈ̤ӷ ÂÏ¿ÙÙˆÛË Ù˘ ÓÂÔÁÏ˘ÎÔÁ¤ÓÂÛ˘, Ì ·ÔÙ¤ÏÂÛÌ· ÂÌÊ¿ÓÈÛË ˘ÔÁÏ˘Î·ÈÌÈÒÓ Î·ıÒ˜ Î·È Û˘ÛÛÒÚ¢ÛË Ï›Ô˘˜ Ì ·ÔÙ¤ÏÂÛÌ· ÙËÓ ·‡ÍËÛË Ù˘ ¯ÔÏËÛÙÂÚfiÏ˘ Î·È ÙˆÓ ÙÚÈÁÏ˘ÎÂÚȉ›ˆÓ. £Âڷ›·: ŸÙ·Ó Ë TSH ·Ó¢ڛÛÎÂÙ·È ¿Óˆ ·fi ÙÔ Ê˘ÛÈÔÏÔÁÈÎfi, Ô ·ÛıÂÓ‹˜ Ú¤ÂÈ Ó· ıÂڷ‡ÂÙ·È Ì L-ı˘ÚÔÍ›ÓË Û ‰fiÛË 25-150 Ìg/Ë̤ڷ, ·Ó¿ÏÔÁ· Ì ÙËÓ ËÏÈΛ· (100 Ìg/m2/Ë̤ڷ ‹ 2,5 Ìg/kg/Ë̤ڷ). ∏ ‚ÚÔÁ¯Ô΋ÏË ÌÔÚ› Ó· ÂÏ·ÙÙˆı› Û ̤ÁÂıÔ˜ ‹ Ó· ·Ú·Ì›ÓÂÈ ·ÌÂÙ¿‚ÏËÙË, Ù· ‰Â ·ÓÙÈÛÒÌ·Ù· ¤¯Ô˘Ó ‰È·Î˘Ì¿ÓÛÂȘ, ÙfiÛÔ Û ·ÛıÂÓ›˜ Ô˘ ıÂڷ‡ÙËÎ·Ó fiÛÔ Î·È Û ·˘ÙÔ‡˜ Ô˘ ‰ÂÓ ‹Ú·Ó ıÂÚ·-
Paediatriki 2001;64:188-193
›·. ∂¿Ó, ·Ú¿ ÙËÓ Î·Ù·ÛÙ·ÏÙÈ΋ ıÂڷ›·, ‰ËÌÈÔ˘ÚÁËıÔ‡Ó fi˙ÔÈ ÔÈ ÔÔ›ÔÈ ·˘Í¿ÓÔÓÙ·È Û ̤ÁÂıÔ˜, Ú¤ÂÈ Ó· Á›ÓÂÙ·È ÈÛÙÔÏÔÁÈ΋ ÂͤٷÛË Î·È ·Ê·›ÚÂÛË, ‰ÈfiÙÈ Â›Ó·È ‰˘Ó·ÙfiÓ Û ÌÈÎÚfi ÔÛÔÛÙfi Ó· ·Ó·Ù˘¯ı› ηÚΛÓÔ˜ › ‰¿ÊÔ˘˜ ı˘ÚÂÔÂȉ›Ùȉ·˜. ŸÙ·Ó Ë ı˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›· ·ӤÏıÂÈ ÛÂ Ê˘ÛÈÔÏÔÁÈο ›‰· Ú¤ÂÈ Ó· Á›ÓÂÙ·È ·Ó·ÚÔÛ·ÚÌÔÁ‹ Ù˘ ‰fiÛ˘ Ù˘ ÈÓÛÔ˘Ï›Ó˘. ¶Ú¤ÂÈ ¿ÓÙ· Ó· ˘Ô„È·˙fiÌ·ÛÙ ˘Ôı˘ÚÂÔÂȉÈÛÌfi fiÙ·Ó ÙÔ ‰È·‚ËÙÈÎfi ·È‰› ·ÚÔ˘ÛÈ¿˙ÂÈ ·ÓÂÍ‹ÁËÙ· ˘ÔÁÏ˘Î·È̛˜ ‹ ÙÒÛË ÙÔ˘ Ú˘ıÌÔ‡ ·Ó¿Ù˘Í˘. ∏ ı˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›· Ú¤ÂÈ Ó· ÂÍÂÙ¿˙ÂÙ·È ¿ÓÙ· ηٿ ÙËÓ ÚÒÙË ‰È¿ÁÓˆÛË ÙÔ˘ ‰È·‚‹ÙË ÌÂÙ¿ ÙË ‰ÈfiÚıˆÛË Ù˘ ÎÂÙÔͤˆÛ˘ Î·È ÛÙË Û˘Ó¤¯ÂÈ· ÙÔ˘Ï¿¯ÈÛÙÔÓ Ì›· ÊÔÚ¿ ÙÔ ¯ÚfiÓÔ ·ÎfiÌ· Î·È Û ·ÛıÂÓ›˜ Ì ∞£∞. ∂›Ó·È Ôχ ÛËÌ·ÓÙÈÎfi Ó· ‰È·ÈÛÙÒÛÔ˘Ì ¤ÁηÈÚ· ÙÔÓ ˘ÔÎÏÈÓÈÎfi ˘Ôı˘ÚÂÔÂȉÈÛÌfi Û ¤Ó· ·È‰› Ô˘ ‚Ú›ÛÎÂÙ·È ÛÙËÓ ·Ó¿Ù˘ÍË, ÁÈ·Ù› ·˘Ùfi˜ ÌÔÚ› Ó· ηı˘ÛÙÂÚ‹ÛÂÈ ÙÔ Ú˘ıÌfi ·Ó¿Ù˘Í˘ Î·È ÙËÓ ÂÊË‚È΋ ˆÚ›Ì·ÓÛË. √ ‰È·‚‹Ù˘ Ô˘ ‰ÂÓ Ú˘ıÌ›˙ÂÙ·È Î·Ï¿ ÌÔÚ› Ó· Û˘Óԉ‡ÂÙ·È ·fi ‰È·Ù·Ú·¯¤˜ ÙˆÓ ÏÈȉ›ˆÓ, ÔÈ Ôԛ˜ ÌÔÚ› Ó· ÂȉÂÈÓˆıÔ‡Ó fiÙ·Ó Û˘Ó˘¿Ú¯ÂÈ ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜. ∂Ô̤ӈ˜ ÂÈ‚¿ÏÏÂÙ·È Î·Ï‹ Ú‡ıÌÈÛË ÙÔ˘ ‰È·‚‹ÙË Î·È ·ÓÙÈÌÂÙÒÈÛË Ù˘¯fiÓ Û˘Ó˘¿Ú¯ÔÓÙÔ˜ ˘Ôı˘ÚÂÔÂȉÈÛÌÔ‡. ÀÂÚı˘ÚÂÔÂȉÈÛÌfi˜ √ ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi˜ ÂÌÊ·Ó›˙ÂÙ·È Û˘¯ÓfiÙÂÚ· Û ‰È·‚ËÙÈο ·È‰È¿ Û ۯ¤ÛË Ì ÙÔ ÁÂÓÈÎfi ÏËı˘ÛÌfi Î·È ˘ÔÏÔÁ›˙ÂÙ·È Û ÔÛÔÛÙfi 0,5-7% ÙˆÓ ·È‰ÈÒÓ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË (21,23). °ÂÓÈο ‰ÂÓ Â›Ó·È ÙfiÛÔ Û˘¯Ófi˜ fiÛÔ Ô ˘Ôı˘ÚÂÔÂȉÈÛÌfi˜ ‹ Ë ı˘ÚÂÔÂȉ›ÙȘ Hashimoto. ™˘Ó‹ıˆ˜ ÂÌÊ·Ó›˙ÂÙ·È ÌÂÙ¿ ÙËÓ ÂΉ‹ÏˆÛË ÙÔ˘ ‰È·‚‹ÙË, Û ÌÂÚÈΤ˜ fï˜ ÂÚÈÙÒÛÂȘ ÌÔÚ› Ó· ÚÔËÁÂ›Ù·È ‹ Ó· ÂÌÊ·ÓÈÛı› Û˘Á¯ÚfiÓˆ˜ Ì ÙÔ ‰È·‚‹ÙË. ∫ÏÈÓÈ΋ ÂÈÎfiÓ·: ∆· Û˘ÌÙÒÌ·Ù· Â›Ó·È Ù·¯˘Î·Ú‰›·, ÙÚfiÌÔ˜ Î·È ‰˘Û·ÓÂÍ›· ÛÙË ˙¤ÛÙË. ™˘ÁÎÈÓËÛȷΤ˜ ‰È·Ù·Ú·¯¤˜ Î·È ˘ÂÚÎÈÓËÙÈÎfiÙËÙ· ÌÔÚÔ‡Ó Ó· ÂÌÊ·ÓÈÛıÔ‡Ó ÓˆÚ›˜. ∏ ‚ÚÔÁ¯Ô΋ÏË ÌÔÚ› Ó· Â›Ó·È ÌÈÎÚÔ‡ ‹ ÌÂÙÚ›Ô˘ ÌÂÁ¤ıÔ˘˜, Û˘Ó‹ıˆ˜ ‰Â ˘¿Ú¯ÂÈ Î·È ÂÍfiÊı·ÏÌÔ˜. ∂ÚÁ·ÛÙËÚȷο Â˘Ú‹Ì·Ù·: √È ÙÈ̤˜ Ù˘ ∆3, ∆4, fT3 Î·È f∆4 Â›Ó·È ·˘ÍË̤Ó˜, ÂÓÒ Ë TSH ηÙÂÛÙ·Ï̤ÓË. ™Â ÂÚÈÙÒÛÂȘ ÔÚȷο ·˘ÍËÌ¤ÓˆÓ ÙÈÌÒÓ ÙˆÓ ÂÚÈÊÂÚÈÎÒÓ ÔÚÌÔÓÒÓ ‹ ·Ô˘Û›·˜ ÂÌÊ·ÓÒÓ Û˘Ìو̿وÓ, Ë ‰ÔÎÈÌ·Û›· TRH ÂȂ‚·ÈÒÓÂÈ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ˘ÂÚı˘ÚÂÔÂȉÈÛÌÔ‡. ™ÙÔÓ ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi Ë ÌÂÙ·‚ÔÏÈ΋ ‰È·Ù·Ú·¯‹ Ô˘ ˘ÂÚÈÛ¯‡ÂÈ Â›Ó·È Ë ˘ÂÚÁÏ˘Î·ÈÌ›·. √Ê›ÏÂÙ·È Û ·ÓÙ›ÛÙ·ÛË ÛÙË ‰Ú¿ÛË Ù˘ ÈÓÛÔ˘Ï›Ó˘ ÛÙÔ˘˜ ÂÚÈÊÂÚÈÎÔ‡˜ ÈÛÙÔ‡˜ Î·È ‰È·Ù·Ú·¯‹ Ù˘ ÈηÓfiÙËÙ·˜ ηٷÛÙÔÏ‹˜ Ù˘ ·Ú·ÁˆÁ‹˜ ÁÏ˘Îfi˙˘ ·fi ÙÔ ‹·Ú.
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∫·Ù¿ Û˘Ó¤ÂÈ· Ú¤ÂÈ Ó· ¯ÔÚËÁÔ‡ÓÙ·È Â·ÚΛ˜ ÔÛfiÙËÙ˜ ÈÓÛÔ˘Ï›Ó˘ ÁÈ· Ó· ·ÓÙÈÛÙ·ıÌ›ÛÔ˘Ó ÙËÓ ˘ÂÚÁÏ˘Î·ÈÌ›·. £Âڷ›·: ÃÔÚËÁÔ‡ÓÙ·È ı˘ÚÂÔÛÙ·ÙÈο, fiˆ˜ Ë ÚÔ˘ÏıÂÈԢڷΛÏË, Ë ÌÂıÈÌ·˙fiÏË Î·È Ë Î·Ú‚ÈÌ·˙fiÏË. ∆· Ê¿Ú̷η ·˘Ù¿ ‰ÂÛÌÂ‡Ô˘Ó ÙÔ ¤Ó˙˘ÌÔ ı˘ÚÂÔÂȉÈ΋ ˘ÂÚÔÍÂȉ¿ÛË, ÙÔ ÔÔ›Ô ¯ÚÂÈ¿˙ÂÙ·È ÁÈ· ÙËÓ ÔÚÁ·ÓÔÔ›ËÛË ÙÔ˘ Ȉ‰›Ô˘ ÛÙÔ ı˘ÚÂÔÂȉ‹, Ì ·ÔÙ¤ÏÂÛÌ· Ó· ÂÏ·ÙÙÒÓÂÙ·È Ë ·Ú·ÁˆÁ‹ ÙˆÓ ı˘ÚÂÔÂȉÈÎÒÓ ÔÚÌÔÓÒÓ. ∂ÈÚÔÛı¤Ùˆ˜, Ë ÚÔ˘ÏıÂÈԢڷΛÏË ‰Ú· ÂÚÈÊÂÚÈο, ·Ó·ÛÙ¤ÏÏÔÓÙ·˜ ÙË ÌÂÙ·ÙÚÔ‹ Ù˘ ∆4 Û ∆3. ∏ ‰fiÛË Ù˘ ηڂÈÌ·˙fiÏ˘ Â›Ó·È 0,5–1 mg/kg Ì ̤ÁÈÛÙË ‰fiÛË 30 mg/24ˆÚÔ Î·È Ú¤ÂÈ Ó· ÂÏ·ÙÙÒÓÂÙ·È ÛÙ·‰È·Î¿ ¤ˆ˜ ÙË ¯·ÌËÏfiÙÂÚË ‰˘Ó·Ù‹ ‰fiÛË, Ë ÔÔ›· ÂÍ·ÛÊ·Ï›˙ÂÈ Ê˘ÛÈÔÏÔÁÈ΋ ı˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›·. ∫ÏÈÓÈ΋ ‚ÂÏÙ›ˆÛË ·Ú·ÙËÚÂ›Ù·È ÌÂÙ¿ 2–3 ‚‰ÔÌ¿‰Â˜ Î·È ıÂڷ›· ÙÔ˘ ˘ÂÚı˘ÚÂÔÂȉÈÛÌÔ‡ Û˘Ó‹ıˆ˜ ÌÂÙ¿ ·fi 1-3 Ì‹Ó˜. ÃÚÂÈ¿˙ÂÙ·È Û˘Ó¯‹˜ ·Ú·ÎÔÏÔ‡ıËÛË Ù˘ ıÂڷ›·˜, ‰ÈfiÙÈ ·˘Í·ÓfiÌÂÓ· ›‰· TSH Â›Ó·È ÂÓ‰ÂÈÎÙÈο ˘„ËÏ‹˜ ‰fiÛ˘ Ù˘ ıÂڷ›·˜. ∆· ÙÂÏÂ˘Ù·›· ¯ÚfiÓÈ· ¤¯ÂÈ ·Ó·ÊÂÚı› ·fi ÌÂÚÈÎÔ‡˜ Û˘ÁÁÚ·Ê›˜ Ë ¯ÔÚ‹ÁËÛË Ú·‰ÈÂÓÂÚÁÔ‡ Ȉ‰›Ô˘ Û ·È‰È¿ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î·È ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi Ì ηϿ ·ÔÙÂϤÛÌ·Ù· (23). √È ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ıÂڷ‡ÔÓÙ·È ÈηÓÔÔÈËÙÈο ÁÈ· ÙÔÓ ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi Û˘Ó‹ıˆ˜ ‰ÂÓ ¯ÚÂÈ¿˙ÔÓÙ·È ÌÂÁ¿Ï˜ ·ÏÏ·Á¤˜ ÛÙË ‰fiÛË Ù˘ ÈÓÛÔ˘Ï›Ó˘. ™˘Û¯¤ÙÈÛË Ì ¿ÏϘ ÂÓ‰ÔÎÚÈÓÔ¿ıÂȘ: ∞ÛıÂÓ›˜ Ì ۷ί·ÚÒ‰Ë ‰È·‚‹ÙË Î·È ·˘ÙÔ¿ÓÔÛË ı˘ÚÂÔÂȉԿıÂÈ· Â›Ó·È ‰˘Ó·ÙfiÓ Ó· ·Ó·Ù‡ÍÔ˘Ó ·ÓÙÈÛÒÌ·Ù· ¤Ó·ÓÙÈ ÙˆÓ ÂÈÓÂÊÚȉ›ˆÓ. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ë Û˘¯ÓfiÙËÙ· ÙˆÓ ·ÓÙÈÛˆÌ¿ÙˆÓ ·˘ÙÒÓ ÛÙÔ ‰È·‚‹ÙË Â›Ó·È ¯·ÌËÏ‹ (2-4%), Â›Ó·È ‰˘Ó·ÙfiÓ 20-40% ÙˆÓ ·ÛıÂÓÒÓ ·˘ÙÒÓ Ó· ÂÌÊ·Ó›ÛÔ˘Ó ÂÈÓÂÊÚȉȷ΋ ·Ó¿ÚÎÂÈ·. ∆· Û˘ÌÙÒÌ·Ù· ›ӷÈ: ÌÂÏ¿Á¯ÚˆÛË ÙˆÓ Ù˘¯ÒÓ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È ÙˆÓ ‚ÏÂÓÓÔÁfiÓˆÓ, ·‰˘Ó·Ì›·, ˘fiÙ·ÛË, ÂÏ¿ÙÙˆÛË ÙˆÓ ·Ó·ÁÎÒÓ Û ÈÓÛÔ˘Ï›ÓË Î·È ÂÌÊ¿ÓÈÛË ˘ÔÁÏ˘Î·ÈÌÈÒÓ, ηıÒ˜ Î·È ËÏÂÎÙÚÔÏ˘ÙÈΤ˜ ‰È·Ù·Ú·¯¤˜ (˘ÔÓ·ÙÚÈ·ÈÌ›·, ˘ÂÚηÏÈ·ÈÌ›·). ªÂÚÈÎÔ› ·ÛıÂÓ›˜ ÂÌÊ·Ó›˙Ô˘Ó ÚÔÛ‚ÔÏ‹ ÙÔ˘ ·ÁÎÚ¤·ÙÔ˜, ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ Î·È ÙÔ˘ ‚ÏÂÓÓÔÁfiÓÔ˘ ÙÔ˘ ÛÙÔÌ¿¯Ô˘ ÛÙ· Ï·›ÛÈ· Û˘Ó‰ÚfiÌÔ˘ ·˘ÙÔ¿ÓÔÛ˘ ÔÏ˘ÂÓ‰ÔÎÚÈÓÔ¿ıÂÈ·˜ (11). ¢È·ÎÚ›ÓÔÓÙ·È 2 Ù‡ÔÈ Û˘Ó‰ÚfiÌÔ˘ ·˘ÙÔ¿ÓÔÛ˘ ÔÏ˘ÂÓ‰ÔÎÚÈÓÔ¿ıÂÈ·˜: Ô Ù‡Ô˜ π (˘Ô·Ú·ı˘ÚÂÔÂȉÈÛÌfi˜, ÓfiÛÔ˜ ÙÔ˘ Addison, ÌÔÓÈÏ›·ÛË), fiÔ˘ Ë ÂÌÊ¿ÓÈÛË ‰È·‚‹ÙË Â›Ó·È Û¿ÓÈ· (26) Î·È Ô Ù‡Ô˜ ππ (ı˘ÚÂÔÂȉ›ÙȘ, ۷ί·Ú҉˘ ‰È·‚‹Ù˘, ÓfiÛÔ˜ ÙÔ˘ Addison), ÛÙÔÓ ÔÔ›Ô Ô ‰È·‚‹Ù˘ Â›Ó·È Û˘¯Ófi˜. ¶·Ú¿ ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ô ˘ÂÚı˘ÚÂÔÂȉÈÛÌfi˜ Â›Ó·È Û¿ÓÈÔ˜ Î·È ÚÔ‚¿ÏÏÂÈ ÙȘ ÂÚÈÛÛfiÙÂÚ˜ ÊÔÚ¤˜ ÌÂ Ù˘È΋ Û˘Ìو̷ÙÔÏÔÁ›·, ı· Ú¤ÂÈ ÂÓÙÔ‡ÙÔȘ Ó·
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¤¯Ô˘Ì ˘’ fi„ÈÓ Ì·˜ fiÙÈ ÌÔÚ› Ó· ÂΉËψı› Î·È Ì ¿Ù˘· Û˘ÌÙÒÌ·Ù·, fiˆ˜ .¯. ‰È·Ù·Ú·¯¤˜ Ù˘ Ú‡ıÌÈÛ˘ (˘ÂÚÁÏ˘Î·È̛˜), Â˘Û˘ÁÎÈÓËÛ›·, Ó¢ÚÈÎfiÙËÙ·, ‰È·Ù·Ú·¯¤˜ ÙÔ˘ ·ÎÏÔ˘ ,Ù· ÔÔ›· Û˘Ó‹ıˆ˜ ·Ô‰›‰ÔÓÙ·È ÛÙËÓ ÂÊ˂›·. ¢È·‚ËÙÈÎÔ› ·ÛıÂÓ›˜ ÔÈ ÔÔ›ÔÈ ·ÚÔ˘ÛÈ¿˙Ô˘Ó ıÂÙÈο ∞£∞ ÌÔÚ› Ó· ÂΉËÏÒÛÔ˘Ó ÌÂÏÏÔÓÙÈο fiÏÔ ÙÔ Ê¿ÛÌ· Ù˘ ·˘ÙÔ¿ÓÔÛ˘ ÔÏ˘ÂÓ‰ÔÎÚÈÓÔ¿ıÂÈ·˜. √È ·ÛıÂÓ›˜ ·˘ÙÔ› ı· Ú¤ÂÈ Ó· ÂϤÁ¯ÔÓÙ·È ÁÈ· ÙËÓ ·ÚÔ˘Û›· ¿ÏÏˆÓ ·˘ÙÔ·ÓÙÈÛˆÌ¿ÙˆÓ (·ÓÙÈÙÔȯˆÌ·ÙÈÎÒÓ Î˘ÙÙ¿ÚˆÓ ÛÙÔÌ¿¯Ô˘, ·ÓÙÈÂÈÓÂÊÚȉȷÎÒÓ, Î.Ï.). π‰È·›ÙÂÚ· Û˘¯Ó¤˜ Â›Ó·È ÔÈ Î·Ù·ÛÙ¿ÛÂȘ ·˘Ù¤˜ fiÙ·Ó ˘¿Ú¯Ô˘Ó ¯ÚˆÌÔÛˆÌȷΤ˜ ·ÓˆÌ·Ï›Â˜ (Û. Turner, Û. Down) (27). µÈ‚ÏÈÔÁÚ·Ê›· 1. Ogle JW. St Georges Hospital Rep; 1886. 2. Bottazzo GF, Florin-Christensen A, Doniach D. Islet cell antibodies in diabetes mellitus with autoimmune polyendocrine deficiencies. Lancet 1974;2:1279-1283. 3. MacCuish AC, Barnes EW, Irvine WJ, Duncan LJP. Antibodies to pancreatic islet cells in insulin dependent diabetics with co-existent autoimmune disease. Lancet 1974;2 :1529-1531. 4. Irvine WJ, Clarke BF, Scarth L, Cullen DR, Duncan LJP. Thyroid and gastric autoimmunity in patients with diabetes mellitus. Lancet 1970;2:163-168. 5. Grumet C, Konishi J, Payne R, Kriss JP. Association of Grave’s disease with HL-A8. Clin Res 1973;21:493. 6. Bright GM, Blizzard RM, Kaiser DL, Clarke WL. Organ specific autoantibodies in children with common endocrine diseases. J Pediatr 1982;100: 8-14. 7. Landin-Olsson M, Karlsson A, Dahlquist G, Blom L, Lernmark A, Sundkvist G. Islet cell and other organ-specific autoantibodies in all children developing type I insulindependent diabetes mellitus in Sweden during one year and in matched controls. Diabetologia 1989;32:387-393. 8. Neufeld M, Maclaren NK, Riley WJ, Lezotte D, McLaughlin JV, Silverstein J et al. Islet cell and other organ - specific antibodies in U.S caucasians and blacks with insulindependent diabetes mellitus. Diabetes 1980;29:589-592. 9. Riley WJ, Winer A, Goldstein D. Coincident presence of thyro-gastric autoimmunity at onset of type I (insulindependent) diabetes. Diabetologia 1983;24:418-421. 10. d’ Annunzio G, Cortona L, Vitali L, Pessino P, Lorini R. Prevalence of Hashimoto’s thyroiditis in children and adolescents with insulin-dependent diabetes mellitus. In: Fois A, Laron Z, Morgese G, eds. An Update on Childhood Diabetes and Short Stature. Bologna: Monduzzi Publisher; 1993. p. 49-52. 11. Riley WJ, MacLaren NK, Lezotte DC. Thyroid autoimmunity in insulin dependent diabetes. The case for routine screening. J Pediatr 1981;98:350-354. 12. McKenna M, Herskowitz R, Wolfsdorf Jl. Screening for thyroid disease in children with IDDM. Diabetes Care 1990;13:801-803. 13. Mazzella M, Mulas R, Caratozzolo A, Cotellessa M, Romano C. A perspective evaluation of thyroid function and anti-
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Metab 1998;11:59-62. 26. ∫·˚Ì¿Ú·-¶··ı·Ó·Û›Ô˘ ∞, ÷Ù˙Ë·ı·Ó·Û›Ô˘ Ã, ¶··ıÂÔ‰ÒÚÔ˘ ∞, ∫·Ú‹˜ Ã, ¢¤ÏÏÈÔ˜ ¢, £ÂÔ‰ˆÚ›‰Ë˜ Ã. ™‡Ó‰ÚÔÌÔ ·˘ÙÔ¿ÓÔÛ˘ ÔÏ˘ÂÓ‰ÔÎÚÈÓÔ¿ıÂÈ·˜ Ù‡Ô˘ π. π·ÙÚÈ΋ 1996;70:263-266. 27. Dacou Voutetakis C, Sertedaki A, Maniati-Christidis M, Sarri C, Karadima G, Petersen MB et al. Insulin dependent diabetes mellitus (IDDM) and autoimmune thyroiditis in a boy with a ring chromosome 18: additional evidence of autoimmunity or IDDM gene(s) on chromosome 18. J Med Genet 1999;36:156-158. 28. ƒÔ‡ÛË ª, ¡¤Ô˘ ¶, ∫·ÛÛÈÔ‡ ∫, °ÏËÓ¤ÏÏË ∂, ºÔ˘ÛÙÔ‡ÎÔ˘ ª, ∫·Ú·ÁÈ¿ÓÓË Ã Î·È Û˘Ó. ¢È·Ù·Ú·¯¤˜ ÙÔ˘ ı˘ÚÂÔÂȉԇ˜ ·‰¤Ó· Û ·È‰È¿ Ì ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË [¶ÂÚ›ÏË„Ë]. 28o ¶·ÓÂÏ ¶·È‰ ™˘Ó; 1990 2-3 πÔ˘Ó›Ô˘; £ÂÛÛ·ÏÔÓ›ÎË;1990. 29. ∫·Ú·ÁÈ¿ÓÓË Ã, ∫·Ú‹˜ Ã, ∫ÔÓÙ·Í¿ÎË Ã, ºˆÙÂÈÓÔ‡ ∞, ºÔ˘ÛÙÔ‡ÎÔ˘ ª, £ÂÔ‰ˆÚ›‰Ë˜ Ã Î·È Û˘Ó. £˘ÚÂÔÂȉ›ÙȘ Hashimoto Î·È ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ˜ ۷ί·Ú҉˘ ‰È·‚‹Ù˘ [¶ÂÚ›ÏË„Ë]. 32o ¶·ÓÂÏ. ¶·È‰. ™˘Ó. 1994 16-18 πÔ˘Ó›Ô˘; ∫¤Ú΢ڷ; 1994. ÛÂÏ. 59. 30. ∑ÒÛË ¶, °ÂˆÚÁÈ¿‰Ë˜ ∏, ¶ÂÙÚÔÔ‡ÏÔ˘ Ã, ÷Ù˙Ë‚·ÛÈÏ›Ԣ ∞, µÏ¿¯Ô˘ £, ∫·Ú‹˜ Ã. £˘ÚÂÔÂȉÈ΋ ÏÂÈÙÔ˘ÚÁ›· Î·È ˘ÂÚ˯ÔÁÚ·ÊÈο Â˘Ú‹Ì·Ù· ·È‰ÈÒÓ Ì ÈÓÛÔ˘ÏÈÓÔÂÍ·ÚÙÒÌÂÓÔ Û·Î¯·ÚÒ‰Ë ‰È·‚‹ÙË [¶ÂÚ›ÏË„Ë]. 37o ¶·ÓÂÏ. ¶·È‰. ™˘Ó. 1999 28-30 ª·˝Ô˘; £ÂÛÛ·ÏÔÓ›ÎË; 1999. ÛÂÏ. 35. 31. §·‰‹˜ µ, £ÂÔ‰ˆÚ›‰Ë˜ Ã, ªÂÚ‰Ô‡ÛË ∂, ∞ı·Ó·Û¿ÎË ∫, ∫ˆÛÙ·Ú›‰Ô˘ ™, ∫·ÙÙ¿Ì˘ Ã. ∂Ó‰ÔÎÚÈÓÔÏÔÁÈΤ˜ ‰È·Ù·Ú·¯¤˜ Û ¿Û¯ÔÓÙ˜ Ì ÌÂÛÔÁÂȷ΋ ·Ó·ÈÌ›· [¶ÂÚ›ÏË„Ë]. 33o ¶·ÓÂÏ. ¶·È‰. ™˘Ó. 1995 9-11 πÔ˘Ó›Ô˘. §‹ÌÓÔ˜; 1995. ÛÂÏ. 38. 32. Kassiou K, Neou P, Foustoukou M, Skoutari M, Terzopoulou K, Bartsokas CH. Thyroid function and autoantibodies in Greek children with IDDM. XVI th ISGD Annual Meeting; 1990 September 6-9; Oslo, Norway; 1990. p. 24.
HÌÂÚÔÌËÓ›· ˘Ô‚ÔÏ‹˜: 15-06-2000 HÌÂÚÔÌËÓ›· ¤ÁÎÚÈÛ˘: 08-01-2001 ¢È‡ı˘ÓÛË ·ÏÏËÏÔÁÚ·Ê›·˜: ∞. ∫·˚Ì¿Ú·–¶··ı·Ó·Û›Ô˘ ª¿ÚÎÔ˘ ªfiÙÛ·ÚË 8, 152 36 ∞ı‹Ó·
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Paediatriki 2001;64:194-195
LETTERS
∞ÍÈfiÙÈÌÔÈ ∫‡ÚÈÔÈ, ™¯ÂÙÈο Ì ÙËÓ ÂÚ›ÙˆÛË ‚ÈÙ·ÌÈÓÔÂÍ·ÚÙÒÌÂÓÔ˘ Ú·¯ÈÙÈÛÌÔ‡ Ù‡Ô˘ π (VDDR-I) Ô˘ ÂÚÈÁÚ¿ÊÂÙ·È ÛÙÔ ¿ÚıÚÔ ÙˆÓ ∫·Ú·Î·˚‰Ô‡ Î·È Û˘Ó [¶∞π¢π∞∆ƒπ∫∏ 2000;63(5):426-429] Û¯ÔÏÈ¿˙Ô˘Ì ÌÂÚÈο Â˘Ú‹Ì·Ù·. ™‡Ìʈӷ Ì ٷ ÛÙÔȯ›· Ô˘ ·Ú·Ù›ıÂÓÙ·È ‰È·ÙËÚԇ̠ÂÈÊ˘Ï¿ÍÂȘ ˆ˜ ÚÔ˜ ÙË ‰È¿ÁÓˆÛË ÙÔ˘ ‚ÈÙ·ÌÈÓÔÂÍ·ÚÙÒÌÂÓÔ˘ Ú·¯ÈÙÈÛÌÔ‡ Ù‡Ô˘ π (VDDR-I) ‹ ÙÚÔÊÈÎÔ‡ Ú·¯ÈÙÈÛÌÔ‡, fiˆ˜ ›¯Â ·Ú¯Èο ÙÂı› Ë ‰È¿ÁÓˆÛË. ∆· ÛËÌ›· Ô˘ Ù›ıÂÓÙ·È ˘fi ·ÌÊÈÛ‚‹ÙËÛË Â›Ó·È Ù· ·Ú·Î¿Ùˆ: ·) ∏ ÁÚ‹ÁÔÚË Î·È ÛËÌ·ÓÙÈ΋ ‚ÂÏÙ›ˆÛË ÙˆÓ ·Ú·Ì¤ÙÚˆÓ ·Û‚ÂÛÙ›Ô˘ (Ca), ʈÛÊfiÚÔ˘ (Pi) Î·È ·ÏηÏÈ΋˜ ʈÛÊ·Ù¿Û˘ ηٿ ÙË ‰È¿ÚÎÂÈ· ÔÏ›ÁˆÓ ËÌÂÚÒÓ ÓÔÛËÏ›·˜ ÏfiÁˆ ηχÙÂÚˆÓ ‰È·ÙÚÔÊÈÎÒÓ Û˘ÓıËÎÒÓ Î·È ÚÈÓ ÙËÓ ·ÁˆÁ‹ Ì 1,25 (√∏)2 ‚ÈÙ·Ì›ÓË D, Ô˘ ‰ÂÓ ·Ú·ÙËÚÂ›Ù·È ÛÙÔÓ VDDR-I. ¢ÂÓ ·Ó·Ê¤ÚÂÙ·È Ë ‰È¿ÚÎÂÈ· ÓÔÛËÏ›·˜ ÚÈÓ ÙË ¯ÔÚ‹ÁËÛË ‚ÈÙ·Ì›Ó˘ D. ‚) ∆· ÌË ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù·, Ù· ÔÔ›· ı· ¤Ú ӷ ›¯·Ó ÂÌÊ·ÓÈÛÙ›. ™Â ·Ó¿ÏÔÁË ÂÚ›ÙˆÛË VDDR-I ÛÙËÓ ¶·È‰È·ÙÚÈ΋ ∫ÏÈÓÈ΋ ÙÔ˘ ¶·ÓÂÈÛÙËÌ›Ô˘ πˆ·ÓÓ›ÓˆÓ (·‰ÂÚÊ¿ÎÈ ‹‰Ë ‰È·ÁÓˆṲ̂ÓÔ˘ VDDR-I), ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù· ÂÌÊ·Ó›ÛÙËÎ·Ó ·fi ÙÔÓ 3Ô Ì‹Ó· ˙ˆ‹˜. Á) ∏ ˘„ËÏ‹ ÙÈÌ‹ ·Ú·ıÔÚÌfiÓ˘ ÛÙÔÓ ÔÚfi ··ÓÙ¿Ù·È Î·È ÛÙÔÓ ÙÚÔÊÈÎfi Ú·¯ÈÙÈÛÌfi. ‰) √ ÚÔÛ‰ÈÔÚÈÛÌfi˜ ÙˆÓ Û˘ÁÎÂÓÙÚÒÛÂˆÓ Pi Û ԇڷ 24ÒÚÔ˘ ‰ÂÓ Â›Ó·È ·Ô‰ÂÎÙfi˜ ‰Â›ÎÙ˘ ·¤ÎÎÚÈÛ˘. ∏ ÛˆÏËÓ·Úȷ΋ ·ӷÚÚfiÊËÛË ÙÔ˘ Pi (TRP) ‹ Ë Ì¤ÁÈÛÙË ÛˆÏËÓ·Úȷ΋ ·ӷÚÚfiÊËÛ‹ ÙÔ˘ (TmP/GFR) Û ‰Â›ÁÌ· Ô‡ÚˆÓ ÚÈÓ ÙË Ï‹„Ë ÙÚÔÊ‹˜, ÁÈ’ ·˘Ù‹ ÙËÓ ËÏÈΛ·, Â›Ó·È ÈÔ ·ÍÈfiÈÛÙÔÈ ‰Â›ÎÙ˜. Â) √È ÙÈ̤˜ ÙÔ˘ ÔÏÈÎÔ‡ Ca ÔÚÔ‡ ‹Ù·Ó ̤۷ ÛÙ· Ê˘ÛÈÔÏÔÁÈο fiÚÈ· Î·È ÔÙ˘ ÈÔÓÈṲ̂ÓÔ˘ ÛÙ· ηÙÒÙÂÚ· Ê˘ÛÈÔÏÔÁÈο. ™˘Ó‹ıˆ˜, ÛÙÔÓ VDDR-I ÔÈ ÙÈ̤˜ ÙÔ˘ Ca ÔÚÔ‡ Â›Ó·È ÛËÌ·ÓÙÈο ¯·ÌËϤ˜ ÚÈÓ ÙË ıÂڷ›·, ·ÎfiÌË Î·È Û ·˘Ù‹ ÙËÓ ËÏÈΛ·. ÛÙ) ∆· ›‰· Ù˘ 1,25(√∏)2D ‚Ú¤ıËÎ·Ó ¯·ÌËÏ¿ Û¯ÂÙÈο Ì ÙȘ Ê˘ÛÈÔÏÔÁÈΤ˜ ÙÈ̤˜ Ô˘ ·Ú·Ù›ıÂÓÙ·È, ·ÏÏ¿ fi¯È ÙfiÛÔ ¯·ÌËÏ¿ ÒÛÙ ӷ ÂȂ‚·ÈÒÛÔ˘Ó Î·ÙËÁÔÚËÌ·ÙÈο ÙË ‰È¿ÁÓˆÛË. ¶·Ú’ fiÙÈ fiˆ˜ ÂÈÛËÌ·›ÓÔ˘Ó ÔÈ Û˘ÁÁÚ·Ê›˜ ÙÔ ·È‰› ¤Ê˘Á ·fi ÙËÓ ∂ÏÏ¿‰· Î·È ‰ÂÓ ‹Ù·Ó ‰˘Ó·Ùfi Ó· Á›ÓÂÈ ÂÈÛٷ̤ӈ˜ Ë ‰ÈÂÚ‡ÓËÛË Î·È Â·Ï‹ı¢ÛË ÁÈ· VDDR-I, Ë ‰È΋ Ì·˜ ÁÓÒÌË Ù›ÓÂÈ Ó· Û˘ÌʈӋÛÂÈ Ì ÙËÓ ·Ú¯È΋ ¿Ô„Ë ÙˆÓ Û˘ÁÁڷʤˆÓ fiÙÈ ÚfiÎÂÈÙ·È ÁÈ· ÂÚ›ÙˆÛË ÙÚÔÊÈÎÔ‡ ‚ÈÔ¯ËÌÈÎÔ‡ Ú·¯ÈÙÈÛÌÔ‡ ¯ˆÚ›˜ ·ÎÙÈÓÔÏÔÁÈο Â˘Ú‹Ì·Ù·. Œ¯ÂÈ ·Ó·ÊÂÚı› Î·È Û ¿ÏϘ ¯ÒÚ˜ ÙÔ˘ ·Ó·Ù˘ÛÛfiÌÂÓÔ˘ ÎfiÛÌÔ˘ (1,2) fiÙÈ Ì›· ¿ÏÏË ·ÈÙ›· ÙÚÔÊÈÎÔ‡ Ú·¯ÈÙÈÛÌÔ‡ Â›Ó·È Ë ·Ó·Ú΋˜ ÚfiÛÏË„Ë ÌÂÙ¿ÏÏˆÓ Î·È Î˘Ú›ˆ˜ ·Û‚ÂÛÙ›Ô˘ ‹/Î·È ÊˆÛÊÔÚÈÎÒÓ Â›Ù ̤ۈ ıËÏ·ÛÌÔ‡ ‹/Î·È Ì¤Ûˆ ¿ÏÏˆÓ ‰È·ÙÚÔÊÈÎÒÓ Û˘ÓËıÂÈÒÓ (fiˆ˜ ¯ÔÚÙÔÊ¿Á˜ ‰›·ÈÙ˜). ∞˘Ù‹ Ë ·Ó¿ÚÎÂÈ· Ô‰ËÁ› Û ڷ¯ÈÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ Û ‚Ú¤ÊË ¿Óˆ ÙˆÓ 6 ÌËÓÒÓ ÔÏϤ˜ ÊÔÚ¤˜ ÌÂ Ê˘ÛÈÔÏÔÁÈο ›‰· 25OHD ÛÙÔÓ ÔÚfi (ÛÙ· 25 ng/ml) Î·È ÙÈ̤˜ ·Û‚ÂÛÙ›Ô˘ ÛÙÔÓ ÔÚfi ˘„ËÏfiÙÂÚ˜ ·fi 9 mg/dl Î·È ÂÓ›ÔÙ ¯·ÌËϤ˜ Û˘ÁÎÂÓÙÚÒÛÂȘ 1,25(OH)2D (3,4). ™ÙËÓ ∂ÏÏ¿‰· ÔÈ Lapatsanis Î·È Û˘Ó (1976) ·Ó·Ê¤ÚÔ˘Ó Â›Û˘ ÂÚÈÙÒÛÂȘ ÙÚÔÊÈÎÔ‡ Ú·¯ÈÙÈÛÌÔ‡ Ì ڷ¯ÈÙÈΤ˜ ·ÏÏÔÈÒÛÂȘ Û ‚Ú¤ÊË ËÏÈΛ·˜ 2-12 ÌËÓÒÓ Ì ˘ÔʈÛÊ·Ù·Û·ÈÌ›· ÌfiÓÔ Î·È Ê˘ÛÈÔÏÔÁÈÎfi ·Û‚¤ÛÙÈÔ(5). ªÂ ÙÈÌ‹ ¶¤ÙÚÔ˜ ¢. §··ÙÛ¿Ó˘ √Ì. ∫·ıËÁËÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ¶·Ó/Ì›Ô˘ πˆ·ÓÓ›ÓˆÓ
ÕÓÓ· ÿÏÏ· ∂›ÎÔ˘ÚË ∫·ıËÁ‹ÙÚÈ· ∆Ô̤· ÀÁ›·˜ ÙÔ˘ ¶·È‰ÈÔ‡
µÈ‚ÏÈÔÁÚ·Ê›· 1. Pfitzner MA, Thacker TD, Pettifor JM, Zoakah AI, Lawson JO, Isichei CO, Fischet PR. Absence of vitamin D deficiency in young Nigerian children. J Pediatr 1998;133:740-744. 2. Oggini LM, Worsfold M, Oyelami OA, Sharp CA, Powell DE, Davie MWJ. Etiology of rickets in Nigerian children. J Pediatr 1996;128:692-694. 3. Hellebostad M, Markestad T, Halvorsen KS. Vitamin D deficiency rickets and vitamin B12 deficiency in vegetarian children. Acta Paediatr Scand 1985;74:191-195. 4. Kruse K. Pathophysiology of calcium metabolism in children with vitamin D deficiency rickets. J Pediatr 1995;126:736-741. 5. Lapatsanis P, Makaronis G, Vretos C, Doxiadis S. Two types of nutritional rickets in infants. Am J Clin Nutr 1976;29:1222-1226.
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™¯ÂÙÈο Ì ÙËÓ ·fi 19-12-2000 ÂÈÛÙoÏ‹ ÙÔ˘ Û‚·ÛÙÔ‡ ηıËÁËÙ‹ Î. §··ÙÛ¿ÓË Î·È Ù˘ Î. ÿÏÏ· Ô˘ ·Ó·Ê¤ÚÂÙ·È ÛÙËÓ ÂÚÁ·Û›· Ì·˜ Ì ı¤Ì· «ƒ·¯›Ùȉ· ÂÍ·ÚÙÒÌÂÓË ·fi ÙË ‚ÈÙ·Ì›ÓË D Ù‡Ô˘ 1» Ô˘ ‰ËÌÔÛȇÙËΠÛÙËÓ ¶∞π¢π∞∆ƒπ∫∏ 2000;63:426-429, ı· ı¤Ï·Ì ӷ ‰È¢ÎÚÈÓ›ÛÔ˘Ì ٷ ·ÎfiÏÔ˘ı·: - ∏ ¤ÏÏÂÈ„Ë ·ÎÙÈÓÔÏÔÁÈÎÒÓ Â˘ÚËÌ¿ÙˆÓ ÛÙËÓ ÂÚ›ÙˆÛ‹ Ì·˜ (ÏËÓ Ù˘ ÌÂÁ¿Ï˘ ÚfiÛıÈ·˜ ËÁ‹˜), ÈÛÙ‡ԢÌ fiÙÈ ÔÊ›ÏÂÙ·È ·Ê’ ÂÓfi˜ ÛÙË ÌÈÎÚ‹ ËÏÈΛ· Ù˘ ·ÛıÂÓÔ‡˜ Î·È ·Ê’ ÂÙ¤ÚÔ˘ ÛÙÔ fiÙÈ Ë ¤ÏÏÂÈ„Ë Ù˘ 1,25(OH)2D ‰ÂÓ ‹Ù·Ó Ï‹Ú˘. - ŸÛÔÓ ·ÊÔÚ¿ ÙËÓ ·¤ÎÎÚÈÛË ƒ ÛÙ· Ô‡Ú·, ¯ÚËÛÈÌÔÔÈ‹ıËÎÂ Û·Ó ‰Â›ÎÙ˘ Ë ÛˆÏËÓ·Úȷ΋ ·ӷÚÚfiÊËÛË ƒ Ô˘ ‹Ù·Ó ÂÓÙfi˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ (94%) Î·È ÁÈ· ÏfiÁÔ˘˜ ÌfiÓÔ Û˘ÓÙÔÌ›·˜ ·Ó·Ê¤ÚÂÙ·È ÛÙÔ Î›ÌÂÓÔ Û·Ó Û˘ÏÏÔÁ‹ Ô‡ÚˆÓ 24h ÁÈ· Ca ƒ, Î.Ï. ÂÓÙfi˜ Ê˘ÛÈÔÏÔÁÈÎÒÓ ÔÚ›ˆÓ. - ∆Ô ·È‰› ·Ú·ÎÔÏÔ˘ı‹ıËΠÛÙËÓ ÎÏÈÓÈ΋ Ì·˜ ÁÈ· ¯ÚÔÓÈÎfi ‰È¿ÛÙËÌ· ÌÂÁ·Ï‡ÙÂÚÔ ÙÔ˘ ÌËÓfi˜ ¤ˆ˜ ÙËÓ ¤Ó·ÚÍË Ù˘ ·ÁˆÁ‹˜. ™ÙÔ ‰È¿ÛÙËÌ· ·˘Ùfi ¤ÁÈÓ ·ӿÏË„Ë Ù˘ ̤ÙÚËÛ˘ ÙˆÓ ÙÈÌÒÓ 25(√∏)D Î·È 1,25(OH)2D Ô˘ ‹Ù·Ó ·Ó¿ÏÔÁ˜ ÙˆÓ ·Ú¯ÈÎÒÓ [25(√∏)=28 pg/ml, 1,25(OH)2D=16 pg/ml] Î·È ÁÈ’ ·˘Ùfi ‰ÂÓ ·Ó·Ê¤ÚÔÓÙ·È ÛÙËÓ ÂÚÁ·Û›· Ì·˜. - Ÿˆ˜ ÛËÌÂÈÒÓÂÙ·È ÛÙË Û˘˙‹ÙËÛË (¶›Ó·Î·˜ 1) Î·È Ô ÙÚÔÊÈÎfi˜ Ú·¯ÈÙÈÛÌfi˜ ¤¯ÂÈ Â˘Ú‹Ì·Ù· ‰Â˘ÙÂÚÔ·ıÔ‡˜ ˘ÂÚ·Ú·ı˘ÚÂÔÂȉÈÛÌÔ‡, ·ÏÏ¿ ÙÔ ¯·Ú·ÎÙËÚÈÛÙÈÎfi Û ·˘ÙfiÓ Â›Ó·È Ù· ¯·ÌËÏ¿ ›‰· Ù˘ 25(√∏)D, ÂÓÒ ÛÙȘ Û¿ÓȘ ÂÚÈÙÒÛÂȘ (fiˆ˜ ·˘Ù¤˜ Ô˘ ·Ó·Ê¤ÚÔ˘Ó ÔÈ Û˘ÁÁÚ·Ê›˜ Ù˘ ›ÛÙÔÏ‹˜ ÛÙȘ ‚È‚ÏÈÔÁÚ·ÊÈΤ˜ ÙÔ˘˜ ·Ú·Ô̤˜) Ô˘ ÔÊ›ÏÔÓÙ·È Û ¤ÏÏÂÈ„Ë Ca, P Î·È È¯ÓÔÛÙÔȯ›ˆÓ, Ù· ›‰· Ù˘ 25(√∏)D Â›Ó·È Ê˘ÛÈÔÏÔÁÈο, Ë 1,25(√∏)2D Â›Ó·È ·˘ÍË̤ÓË Â›Ù Û ·fiÏ˘Ù˜ ÙÈ̤˜, ›Ù Û ۯ¤ÛË Ì ٷ ›‰· Ù˘ 25(√∏)D. √È ·˘ÍË̤Ó˜ ÙÈ̤˜ Ù˘ 1,25(√∏)2D Û ·˘Ù¤˜ ÙȘ ÂÚÈÙÒÛÂȘ ÂÍËÁÔ‡ÓÙ·È ·fi ÙÔ ÁÂÁÔÓfi˜ fiÙÈ Ô ¯·ÌËÏfi˜ ƒ, ÙÔ ¯·ÌËÏfi Ca Î·È Ë ·˘ÍË̤ÓË ƒ∆∏ ·˘Í¿ÓÔ˘Ó ÙË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ 1·˘‰ÚÔÍ˘Ï¿Û˘ (1), (2), (3). ∞ÓÙ›ıÂÙ· ÛÙËÓ ·ÛıÂÓ‹ Ì·˜, Ë 25(√∏)D Â›Ó·È Ê˘ÛÈÔÏÔÁÈ΋ Î·È Ë 1,25(√∏)2D (·Ú¿ ÙÔ ¯·ÌËÏfi ƒ, ÙÔ ¯·ÌËÏfi Ca Î·È ÙËÓ ·˘ÍË̤ÓË ƒ∆∏) Â›Ó·È ÌÂȈ̤ÓË, ÁÂÁÔÓfi˜ Ô˘ ‰Â›¯ÓÂÈ fiÙÈ ˘¿Ú¯ÂÈ ÌÂȈ̤ÓË ‰Ú·ÛÙÈÎfiÙËÙ· Ù˘ 1·-˘‰ÚÔÍ˘Ï¿Û˘. ∆ËÓ ·¿ÓÙËÛË ÛÙÔ ÂÚÒÙËÌ· ·Ó ˘¿Ú¯ÂÈ ‰ÔÌÈ΋ ‚Ï¿‚Ë Ù˘ 1·-˘‰ÚÔÍ˘Ï¿Û˘ ‹ ›‰Ú·ÛË Î¿ÔÈÔ˘ ¿ÁÓˆÛÙÔ˘ ·Ú¿ÁÔÓÙ· Ô˘ ÌÂÈÒÓÂÈ ÙË ‰Ú·ÛÙÈÎfiÙËÙ¿ Ù˘, ı· ¤‰ÈÓÂ Ë ·Ó¿Ï˘ÛË ÙÔ˘ DNA ÙÔ˘ ÁfiÓÔ˘ Ù˘ 1·-˘‰ÚÔÍ˘Ï¿Û˘, ̤ıÔ‰Ô˜ Ô˘ ÚÔ˜ ÙÔ ·ÚfiÓ ‰ÂÓ Â›Ó·È ÂÊ·ÚÌfiÛÈÌË, ·Ú¿ ÌfiÓÔ Û ÂÚ¢ÓËÙÈÎfi ›‰Ô. µÈ‚ÏÈÔÁÚ·Ê›· 1. Herny HL. Vitamin D hydroxylases. J Cell Biochem 1992;49:4-9. 2. Breslaw NA. Normal and abnormal regulation of 1,25(OH)2D synthesis. Am J Med Sci 1998;296:417-425. 3. Takeyama K, Kitanaka S, Sato T, Kobori M, Yanagisawa J, Koto S. 25-Hydroxyvitamin D3.1 alpha hydroxylase and vitamin D synthesis. Science 1997;277:1827-1830.
ªÂ ÂÎÙ›ÌËÛË ∫·Ú‹˜ ÃÚ›ÛÙÔ˜ ¢È¢ı˘ÓÙ‹˜ ¶·È‰È·ÙÚÈ΋˜ ¶.°.¡. ¡›Î·È·˜
∫·Ú·Î·˚‰fi˜ ¢ÈÔÓ‡ÛÈÔ˜ ¶·È‰›·ÙÚÔ˜
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Paediatriki 2001;64:196
PEADIATRIC NEWS
∞. ¶ÚÔ¸Ôı¤ÛÂȘ ∞fiÎÙËÛ˘ ¶ÈÛÙÔÔÈËÙÈÎÔ‡ ™˘Ó¯È˙fiÌÂÓ˘ ¶·È‰È·ÙÚÈ΋˜ ∂η›‰Â˘Û˘ Î·È ŒÁÎÚÈÛË ¡¤ˆÓ ¶ÚÔÁÚ·ÌÌ¿ÙˆÓ ◊‰Ë ¤¯ÂÈ Û˘ÌÏËÚˆı› ¤Ó·˜ ¯ÚfiÓÔ˜ ·fi ÙËÓ Â›ÛËÌË ¤Ó·ÚÍË Ù˘ ™˘Ó¯È˙fiÌÂÓ˘ ¶·È‰È·ÙÚÈ΋˜ ∂η›‰Â˘Û˘ (™¶∂) ˘fi ÙËÓ Î·ıÔ‰‹ÁËÛË Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜. √È ¶·È‰›·ÙÚÔÈ Ô˘ ¤¯Ô˘Ó Û˘ÁÎÂÓÙÚÒÛÂÈ 50 ÌfiÚÈ· ™¶∂ ÌÔÚÔ‡Ó Ó· ˘Ô‚¿ÏÔ˘Ó Ù· ÚˆÙfiÙ˘· ÙˆÓ ÈÛÙÔÔÈËÙÈÎÒÓ ·Ú·ÎÔÏÔ‡ıËÛ˘ ÂÁÎÂÎÚÈ̤ӷ ·fi ÙËÓ ∂ÈÙÚÔ‹ ™¶∂ ∂ÈÛÙËÌÔÓÈÎÒÓ ∂ΉËÏÒÛˆÓ, ÒÛÙ ӷ ÂΉÔı› ÙÔ ÈÛÙÔÔÈËÙÈÎfi ™¶∂, ÙÔ ÔÔ›Ô Î·È ı· ÙÔ˘˜ ·ÔÛÙ·Ï›. ∂›Û˘, ·È‰›·ÙÚÔÈ Ô˘ ı· Û˘ÁÎÂÓÙÚÒÛÔ˘Ó 50 ÌfiÚÈ· ™¶∂ ̤¯ÚÈ 31 ¢ÂÎÂÌ‚Ú›Ô˘ 2000, ı· Ú¤ÂÈ Ó· ˘Ô‚¿ÏÔ˘Ó Ù· ÈÛÙÔÔÈËÙÈο ·Ú·ÎÔÏÔ‡ıËÛ˘, ÁÈ· Ó· ÙÔ˘˜ ¯ÔÚËÁËıÔ‡Ó Ù· ÈÛÙÔÔÈËÙÈο ™¶∂. ∂Âȉ‹ Ë ¤Ó·ÚÍË Ù˘ ™¶∂ ÍÂΛÓËÛ ÙÔ˘˜ ÙÂÏÂ˘Ù·›Ô˘˜ Ì‹Ó˜ ÙÔ˘ 1999 Î·È ˆ˜ ÂÎ ÙÔ‡ÙÔ˘ ‰ÂÓ ˘‹Ú¯Â ·Ú΋˜ ¯ÚfiÓÔ˜ ÁÈ· Û˘ÌÏ‹ÚˆÛË ÙˆÓ ··ÈÙÔ‡ÌÂÓˆÓ ÌÔÚ›ˆÓ ̤۷ ÛÙÔ ›‰ÈÔ ¤ÙÔ˜, ηْ ÂÍ·›ÚÂÛË, Ù· ÌfiÚÈ· ÙÔ˘ 1999 ÌÔÚÔ‡Ó Ó· ÌÂÙ·ÊÂÚıÔ‡Ó ÁÈ· ÙÔ ¤ÙÔ˜ 2000. ∆· ÚˆÙfiÙ˘· ‰ÈηÈÔÏÔÁËÙÈο Û˘ÌÌÂÙÔ¯‹˜ ÛÙË Û˘Ó¯È˙fiÌÂÓË Âη›‰Â˘ÛË, ÁÈ· ÙËÓ ¤Î‰ÔÛË ÙÔ˘ ÈÛÙÔÔÈËÙÈÎÔ‡ ™¶∂, ÌÔÚÔ‡Ó Ó· ÚÔÛÎÔÌÈÛıÔ‡Ó ‹ ·ÔÛÙ·ÏÔ‡Ó, ÌÂ Û˘ÛÙË̤ÓÔ ÁÚ¿ÌÌ· ‹ Ì ÌÂÙ·ÊÔÚÈ΋ ÂÙ·ÈÚ›·, ÛÙ· ÁÚ·Ê›· Ù˘ ∂ÏÏËÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ ∂Ù·ÈÚ›·˜. √È ·È‰›·ÙÚÔÈ, ÚÈÓ ·ÔÛÙ›ÏÔ˘Ó Ù· ‰ÈηÈÔÏÔÁËÙÈο, ı· Ú¤ÂÈ Ó· ÎÚ·Ù‹ÛÔ˘Ó Ì›· Ï‹ÚË ÛÂÈÚ¿ ʈÙÔÙ˘ÈÒÓ, ÁÈ· ÙË ‰È¢ı¤ÙËÛË ÂӉ¯fiÌÂÓ˘ ÌÂÏÏÔÓÙÈ΋˜ ‰È·ÊÔÚ¿˜. ŸÛÔÈ ·È‰›·ÙÚÔÈ ‰ÂÓ ı· ηÙÔÚıÒÛÔ˘Ó Ó· Û˘ÁÎÂÓÙÚÒÛÔ˘Ó 50 ÌfiÚÈ· ™¶∂ ̤¯ÚÈ ÙÔ Ù¤ÏÔ˜ ÙÔ˘2000, ÌÔÚÔ‡Ó Ó· ÛÙԯ‡ÛÔ˘Ó ÛÙË Û˘ÁΤÓÙÚˆÛË 150 ÌÔÚ›ˆÓ ™¶∂ ̤¯ÚÈ ÙÔ Ù¤ÏÔ˜ ÙÔ˘ 2002, ÁÈ· ·fiÎÙËÛË ÈÛÙÔÔÈËÙÈÎÔ‡ ÙÚÈÂÙÔ‡˜ ‰È¿ÚÎÂÈ·˜. ™ÙË Û˘Ó‰ڛ·ÛË Ù˘ ∂ÈÙÚÔ‹˜ ™¶∂, ÛÙȘ 01-11-2000, ÂÁÎÚ›ıËÎ·Ó ÔÈ ·ÎfiÏÔ˘ı˜ ÂÈÛÙËÌÔÓÈΤ˜ ÂΉËÏÒÛÂȘ: 1. ∏ÌÂÚ›‰· «∂ÍÂÏ›ÍÂȘ ÛÙËÓ ¶·È‰È·ÙÚÈ΋ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·, ∏·ÙÔÏÔÁ›· Î·È ¢È·ÙÚÔÊ‹» Ô˘ ÔÚÁ·ÓÒÓÂÙ·È ·fi ÙËÓ ∂ÏÏËÓÈ΋ ∂Ù·ÈÚ›· ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜, ∏·ÙÔÏÔÁ›·˜ Î·È ¢È·ÙÚÔÊ‹˜: 6 ÌfiÚÈ· ÁÈ· ¶·È‰ÔÁ·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˘˜ Î·È 3 ÌfiÚÈ· ÁÈ· °ÂÓÈÎÔ‡˜ ¶·È‰È¿ÙÚÔ˘˜ ¿ÏÏˆÓ ˘ÔÂȉÈÎÔًوÓ. 2. ™˘ÌfiÛÈÔ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ¶·È‰È·ÙÚÈ΋˜ °·ÛÙÚÂÓÙÂÚÔÏÔÁ›·˜, ∏·ÙÔÏÔÁ›·˜ Î·È ¢È·ÙÚÔÊ‹˜: 3 ÌfiÚÈ· ÁÈ· ¶·È‰ÔÁ·ÛÙÚÂÓÙÂÚÔÏfiÁÔ˘˜, 2 ÌfiÚÈ· ÁÈ· °ÂÓÈÎÔ‡˜ ¶·È‰È¿ÙÚÔ˘˜ Î·È ¶·È‰È¿ÙÚÔ˘˜ ¿ÏÏˆÓ ˘ÔÂȉÈÎÔًوÓ. 3. ™ÂÌÈÓ¿ÚÈÔ «¶·È‰È·ÙÚÈÎÒÓ §ÔÈÌÒ͈ӻ £ÂÛÛ·ÏÔӛ΢, ˘fi ÙËÓ ·ÈÁ›‰· Ù˘ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ §ÔÈÌÒ͈Ó: 4 ÌfiÚÈ·. ∫·ıËÁËÙ‹˜ ¡ÈÎfiÏ·Ô˜ °. ªÂÚ¿Ù˘ ¶Úfi‰ÚÔ˜ ™¶∂
∫·ıËÁ‹ÙÚÈ· ∞. ª·Ï·Î¿-∑·ÊÂÈÚ›Ô˘ ¶Úfi‰ÚÔ˜ ∂¶∂
µ. µÚ¿‚¢ÛË ÙÔ˘ ∫¤ÓÙÚÔ˘ ¢ËÏËÙËÚÈ¿ÛÂˆÓ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ «¶. & ∞. ∫˘ÚÈ·ÎÔ‡» ™ÙȘ 28 ¢ÂÎÂÌ‚Ú›Ô˘ 2000, Ë ∞η‰ËÌ›· ∞ıËÓÒÓ ·¤ÓÂÈÌ µÚ·‚Â›Ô ÛÙÔ ∫¤ÓÙÚÔ ¢ËÏËÙËÚÈ¿ÛÂˆÓ ÙÔ˘ ¡ÔÛÔÎÔÌ›Ԣ ¶·›‰ˆÓ «¶. & ∞. ∫˘ÚÈ·ÎÔ‡» Ì ÙËÓ Â˘Î·ÈÚ›· Û˘ÌÏ‹ÚˆÛ˘ 25 ¯ÚfiÓˆÓ Û˘Ó¯ԇ˜ ÏÂÈÙÔ˘ÚÁ›·˜ ÙÔ˘. ∆Ô ‚Ú·‚¢fiÌÂÓÔ ∫¤ÓÙÚÔ, ÙÔ ÌÔÓ·‰ÈÎfi ÛÙËÓ ∂ÏÏ¿‰· ÁÈ· ÙËÓ ÚfiÏË„Ë Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ‰ËÏËÙËÚÈ¿ÛˆÓ, ÏÂÈÙÔ˘ÚÁ› ·fi ÙÔ 1975, ηχÙÂÈ fiÏË ÙË ¯ÒÚ· ηÈ, ·fi 7ÂÙ›·˜ Î·È ÙËÓ ∫‡ÚÔ. ™ÙÔ ∫¤ÓÙÚÔ ÏÂÈÙÔ˘ÚÁ› ·Ú·Ïϋψ˜ Î·È ˘ËÚÂÛ›· «¶·ÚÔ¯‹˜ ¶ÏËÚÔÊÔÚÈÒÓ ∆ÂÚ·ÙÔÁ¤ÓÂÛ˘» Ô˘ ÏËÚÔÊÔÚ› ÙÔ˘˜ È·ÙÚÔ‡˜-ª·ÈÂ˘Ù‹Ú˜ Î·È ÙȘ ÌËÙ¤Ú˜ ÁÈ· ÙËÓ Èı·Ó‹ ÙÂÚ·ÙÔÁfiÓÔ ‰Ú¿ÛË Ê·ÚÌ¿ÎˆÓ Ô˘ ¤¯Ô˘Ó ÏËÊı› ηٿ ÙË ‰È¿ÚÎÂÈ· Ù˘ ÂÁ΢ÌÔÛ‡Ó˘ ‹ ηٿ ÙË ‰È¿ÚÎÂÈ· ÙÔ˘ ıËÏ·ÛÌÔ‡. ™ËÌ·ÓÙÈ΋ Â›Ó·È Ë Û˘Ì‚ÔÏ‹ ÙÔ˘ ∫¤ÓÙÚÔ˘ ÛÙËÓ Âη›‰Â˘ÛË ÊÔÈÙËÙÒÓ π·ÙÚÈ΋˜ Î·È ÌÂÙÂη›‰Â˘ÛË ÓÔÛËÏ¢ÙÒÓ, Ê·ÚÌ·ÎÔÔÈÒÓ Î·È ÁÈ·ÙÚÒÓ, ηıÒ˜ Î·È ÛÙÔÓ ÙÔ̤· ÂÓË̤ڈÛ˘ ÙÔ˘ ÎÔÈÓÔ‡ Î·È Î˘Ú›ˆ˜ ÙˆÓ ÁÔÓ¤ˆÓ, ÁÈ· ÙËÓ ÚfiÏË„Ë ÙˆÓ ‰ËÏËÙËÚÈ¿ÛÂˆÓ ÛÙ· ·È‰È¿. ∏ ∂ÈÛÙËÌÔÓÈ΋ ™˘ÓÙ·ÎÙÈ΋ ∂ÈÙÚÔ‹ ÙÔ˘ ¶ÂÚÈÔ‰ÈÎÔ‡ «¶∞π¢π∞∆ƒπ∫∏» ·Â˘ı‡ÓÂÈ ıÂÚÌ¿ Û˘Á¯·ÚËÙ‹ÚÈ· ÚÔ˜ ÙÔÓ ¿ÌÈÛıÔ ∂›ÎÔ˘ÚÔ ∫·ıËÁËÙ‹ Î. ¶·‡ÏÔ ∫. µÏ¿¯Ô, √ÚÁ·ÓˆÙ‹ Î·È ¢È¢ı˘ÓÙ‹ ÙÔ˘ ∫¤ÓÙÚÔ˘ › 25ÂÙ›·˜. °. ÿ‰Ú˘ÛË Ù˘ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ¶·È‰È·ÙÚÈ΋˜ ¢ÂÚÌ·ÙÔÏÔÁ›·˜ ∏ ∂ÈÛÙËÌÔÓÈ΋ ∂ÈÙÚÔ‹ ÙÔ˘ ÂÚÈÔ‰ÈÎÔ‡ Ì·˜, Ì ȉȷ›ÙÂÚË ¯·Ú¿, Û·˜ ÂÓËÌÂÚÒÓÂÈ ÁÈ· ÙËÓ ›‰Ú˘ÛË Ù˘ «∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ¶·È‰È·ÙÚÈ΋˜ ¢ÂÚÌ·ÙÔÏÔÁ›·˜». ∆· È‰Ú˘ÙÈο ̤ÏË ·ÔÙÂÏÔ‡Ó ‰ÂÚÌ·ÙÔÏfiÁÔÈ Î·È ·È‰›·ÙÚÔÈ Ì ÂȉÈÎfi ÂӉȷʤÚÔÓ ÛÙË ‰ÈÂÚ‡ÓËÛË Î·È ·ÓÙÈÌÂÙÒÈÛË ÙˆÓ ‰ÂÚÌ·ÙÔÏÔÁÈÎÒÓ ÚÔ‚ÏËÌ¿ÙˆÓ ÙˆÓ ·È‰ÈÒÓ. ∂˘¯fiÌÂı· ηϋ ÂÈÙ˘¯›· ÛÙÔ ¤ÚÁÔ ÙÔ˘˜
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22nd Course of Pediatric Dermatology ¶ÏËÚÔÊÔڛ˜: e-mail: alain.taieb@dermatol.u-bordeaux2.fr
Arcachon, °·ÏÏ›·
28 ∞ÚÈÏ›Ô˘ – 1 ª·˝Ô˘
Pediatric Academic Societies Annual Meeting Baltimore Convention Center Baltimore, Maryland ¶ÏËÚÔÊÔڛ˜: Program Office ∆ËÏ.: ++281 419 0052 Fax: ++281 419 0082 e-mail: info@aps-spr.org
µ·ÏÙÈÌfiÚË, ∏¶∞
5-6 ª·˝Ô˘
10Ë ¢ÈËÌÂÚ›‰· ¶·È‰È·ÙÚÈÎÒÓ ∞Ó·Ó¢ÛÙÈÎÒÓ ¶·ı‹ÛÂˆÓ ∂Î·È‰Â˘ÙÈÎfi ∫¤ÓÙÚÔ ∞ÁÚÔÙÈ΋˜ ∆Ú¿Â˙·˜, ¡. ∂Ú˘ıÚ·›·, ∞ı‹Ó· √ÚÁ¿ÓˆÛË: ∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì· °¡¶¶ ™˘ÓÂÚÁ·Û›·: ∂ÏÏËÓÈ΋ ¶·È‰ÔÓ¢ÌÔÏÔÁÈ΋ ∂Ù·ÈÚ›· ¶ÏËÚÔÊÔڛ˜: ∞ÏÏÂÚÁÈÔÏÔÁÈÎfi ∆Ì‹Ì· °¡¶¶ 152 36, ¶. ¶ÂÓÙ¤ÏË ∆ËÏ.: 01 80 36 472 Fax: 01 61 31 173 e-mail: kpriftis@otenet.gr
∞ı‹Ó·
18-20 ª·˝Ô˘
13Ô ¶·ÓÂÏÏ‹ÓÈÔ ™˘Ó¤‰ÚÈÔ ∂ÏÏËÓÈ΋˜ ∂Ù·ÈÚ›·˜ ∫ÔÈÓˆÓÈ΋˜ ¶·È‰È·ÙÚÈ΋˜ Î·È ¶ÚÔ·ÁˆÁ‹˜ Ù˘ ÀÁ›·˜ £¤Ì·: π·ÙÚÔÎÔÈÓˆÓÈΤ˜ ÂÈÙÒÛÂȘ ÙˆÓ ÏÔÈ̈‰ÒÓ ÓÔÛËÌ¿ÙˆÓ Û ·È‰È¿ Î·È ÂÊ‹‚Ô˘˜ ¶ÏËÚÔÊÔڛ˜: ∂ϤÓË ¶ÂÙÚ›‰Ô˘ ∂ÚÁ·ÛÙ‹ÚÈÔ ÀÁÂÈÈÓ‹˜ Î·È ∂ȉËÌÈÔÏÔÁ›·˜ π·ÙÚÈ΋ ™¯ÔÏ‹ ¶·ÓÂÈÛÙËÌ›Ô˘ ∞ıËÓÒÓ ª. ∞Û›·˜ 75, 115 27, ∞ı‹Ó· ∆ËÏ.: 775 9962 – 0944 974249 Fax: 777 3840 – 748 5872 ∏ÏÂÎÙÚÔÓÈ΋ ‰È‡ı˘ÓÛË Ù˘ ∂Ù·ÈÚ›·˜ ÁÈ· ˘Ô‚ÔÏ‹ ÂÚÈÏ‹„ˆÓ: http://www.socped.gr ‹ e-mail: epetrid@cc.uoa.gr
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39Ô ¶·ÓÂÏÏ‹ÓÈÔ ¶·È‰È·ÙÚÈÎfi ™˘Ó¤‰ÚÈÔ ¶ÏËÚÔÊÔڛ˜: C & C International Convention & Congresses ¶·Ú·‰Â›ÛÔ˘ 16, 151 25, ∞ı‹Ó· ∆ËÏ.: 01 68 89 100 Fax: 01 68 44 777
∫Ú‹ÙË
European Society for Paediatric Hematology and Oncology (ESPHI)
Lucerne, ∂Ï‚ÂÙ›·
¶ ƒ ø ∆ ∏
2001 MAPT- A¶PI§
1-3 π√À¡π√À 2 0 0 1 C R E TA M A R I S H OT E L Kƒ∏∆∏
EììèîéëÜ ¦áéäéáôòéëÜ EôáéòåÝá Îôï÷ éäòàóåö÷ 1931
17-20 πÔ˘Ó›Ô˘
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™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
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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 )
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Combining prefixes T G M k h da d c m Ì n p f a
2001 MAPT- A¶PI§
17-10-01 15:35
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CECLOR: ¶∂ƒπ§∏æ∏ Ã∞ƒ∞∫∆∏ƒπ™∆π∫ø¡ ¶ƒO´O¡∆O™ ∂N¢EI•EI™: ∆Ô CECLOR® ÂӉ›ÎÓ˘Ù·È ÛÙË ıÂڷ›· ÙˆÓ ·ÎfiÏÔ˘ıˆÓ ÏÔÈÌÒ͈Ó, fiÙ·Ó ·˘Ù¤˜ ÚÔηÏÔ‡ÓÙ·È ·fi Ù· ·Ó·ÊÂÚfiÌÂÓ· ηو٤ڈ ÛÙÂϤ¯Ë ÌÈÎÚÔÔÚÁ·ÓÈÛÌÒÓ ÂÊfiÛÔÓ ·˘Ù¿ Â›Ó·È Â˘·›ÛıËÙ· Û ·˘Ùfi: §ÔÈÌÒÍÂȘ ÙˆÓ ·ÓˆÙ¤ÚˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ. ª¤ÛË ˘Ò‰Ë˜ ˆÙ›Ùȉ·: ÚÔηÏÔ‡ÌÂÓË ·fi S. pneumoniae, H. influenzae, Staphylococci (ÂÍ·ÈÚÔ˘Ì¤ÓˆÓ ÙˆÓ ÛÙÂϯÒÓ Ô˘ Â›Ó·È ·ÓıÂÎÙÈο ÛÙË ÌÂıÈÎÈÏÏ›ÓË), ‚-·ÈÌÔÏ˘ÙÈÎfi ™ÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞ Î·È ª. catarrhalis. º·Ú˘ÁÁ›Ùȉ· Î·È ·Ì˘Á‰·Ï›Ùȉ·, ·fi ‚-·ÈÌÔÏ˘ÙÈÎfi ™ÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞.¶·Ú·ÚÚÈÓÔÎÔÏ›Ùȉ· ·fi ¢·›ÛıËÙ· ÛÙÂϤ¯Ë H. influenzae ( ‚-Ï·ÎÙ·Ì¿ÛË ±), ‚-·ÈÌÔÏ˘ÙÈÎfi ÛÙÚÂÙfiÎÔÎÎÔ ÔÌ¿‰·˜ ∞, S. pneumoniae, M. catarrhalis Î·È S. aureus ( ‚-Ï·ÎÙ·Ì¿Û˘ ±). ™ÙË ¯ÚfiÓÈ· ÌÔÚÊ‹ ··ÈÙÂ›Ù·È Û˘Ó‹ıˆ˜ ÚÔÛı‹ÎË Î·È ÂÓfi˜ ¿ÏÏÔ˘ ·ÓÙÈÌÈÎÚÔ‚È·ÎÔ‡ ·Ú¿ÁÔÓÙ·, ‰Ú·ÛÙÈÎÔ‡ ÛÙÔ˘˜ ·Ó·ÂÚfi‚ÈÔ˘˜ ÔÚÁ·ÓÈÛÌÔ‡˜. §ÔÈÌÒÍÂȘ ÙˆÓ Î·ÙˆÙ¤ÚˆÓ ·Ó·Ó¢ÛÙÈÎÒÓ Ô‰ÒÓ: √Í›· ‚ÚÔÁ¯›Ùȉ·, Î·È ÔÍ›˜ ÂÍ¿ÚÛÂȘ ¯ÚfiÓÈ·˜ ‚ÚÔÁ¯›Ùȉ·˜ Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi S. pneumoniae, H. influenzae (‚-Ï·ÎÙ·Ì¿ÛË ±), H. parainfluenzae, M. catarrhalis (‚-Ï·ÎÙ·Ì¿ÛË ±), S. aureus. ¶Ó¢ÌÔÓ›· Û ·ÛıÂÓ›˜ Ù˘ ÎÔÈÓfiÙËÙ·˜ Ô˘ ÚÔηÏÂ›Ù·È ·Ô S. pneumoniae, H. influenzae (‚-Ï·ÎÙ·Ì¿Û˱) Î·È M. catarrhalis(‚-Ï·ÎÙ·Ì¿Û˱). ªË ÂÈÂÏÂÁ̤Ó˜ ÏÔÈÌÒÍÂȘ ÙÔ˘ Ô˘ÚÔÔÈÔÁÂÓÓËÙÈÎÔ‡ Û˘ÛÙ‹Ì·ÙÔ˜, Û˘ÌÂÚÈÏ·Ì‚·ÓÔÌ¤ÓˆÓ Ù˘ ˘ÂÏÔÓÂÊÚ›Ùȉ·˜ Î·È Î˘ÛÙ›Ùȉ·˜, (Ì ٷ˘Ùfi¯ÚÔÓË Î¿Ï˘„Ë ÁÈ· Ù· ·Ó·ÂÚfi‚È· ) Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi ∂. coli, P. mirabilis, Klebsiella spp. §ÔÈÌÒÍÂȘ ÙÔ˘ ‰¤ÚÌ·ÙÔ˜ Î·È Ì·Ï·ÎÒÓ ÌÔÚ›ˆÓ, Ô˘ ÚÔηÏÔ‡ÓÙ·È ·fi Staphylococcus aureus (‚-Ï·ÎÙ·Ì¿Û˱) Î·È ‚-·ÈÌÔÏ˘ÙÈÎÒÓ ÛÙÚÂÙÔÎfiÎÎˆÓ ÔÌ¿‰·˜ ∞. ANTEN¢EI•EI™: °ÓˆÛÙ‹ ˘ÂÚ¢·ÈÛıËÛ›· ÛÙË ÎÂÊ·ÎÏfiÚË Î·È ¿ÏϘ ÎÂÊ·ÏÔÛÔÚ›Ó˜ ηıÒ˜ Î·È ÈÛÙÔÚÈÎfi ·Ó·Ê˘Ï·ÎÙÈ΋˜ ·ÓÙ›‰Ú·Û˘ ÛÙȘ ÂÓÈÎÈÏϛӘ. ∞¡∂¶π£Àª∏∆∂™ ∂¡∂ƒ°∂π∂™: ∞ÏÏÂÚÁÈΤ˜ ·ÓÙȉڿÛÂȘ (‰È·ÛÙ·˘ÚÔ‡ÌÂÓË ·ÏÏÂÚÁ›· Ì ÙȘ ÂÓÈÎÈÏϛӘ10%). ¡·˘Ù›·,¤ÌÂÙÔÈ, ‰È¿ÚÚÔȘ, ÂÈÁ·ÛÙÚÈÎfi˜ ÊfiÚÙÔ˜. ∞§§∏§∂¶π¢ƒ∞™∂π™: ∏ Û‡Á¯ÚÔÓË ¯ÔÚ‹ÁËÛË ÚÔ‚ÂÓÂÛ›‰Ë˜ ·Ó·ÛÙ¤ÏÏÂÈ ÙËÓ ·¤ÎÎÚÈÛË ÙÔ˘ CECLOR® ·fi ÙÔ˘˜ ÓÂÊÚÔ‡˜ fiˆ˜ Û˘Ì‚·›ÓÂÈ Î·È Ì ¿ÏÏ· ·ÓÙÈ‚ÈÔÙÈο. ™‡Á¯ÚÔÓË ¯ÔÚ‹ÁËÛË Ì ÙÂÙڷ΢ÎϛӘ ‹ ¯ÏˆÚ·ÌÊÂÓÈÎfiÏË, ¤¯ÂÈ ·ÓÙ·ÁˆÓÈÛÙÈÎfi ·ÔÙ¤ÏÂÛÌ·. ŸÙ·Ó ¯ÔÚËÁÂ›Ù·È Û ÌÂÁ¿Ï˜ ‰fiÛÂȘ Ì·˙› Ì ¿ÏÏ· ÓÂÊÚÔÙÔÍÈο Ê¿Ú̷η, fiˆ˜ ·ÌÈÓÔÁÏ˘ÎÔÛ›‰Â˜, ·˘Í¿ÓÂÙ·È Ô Î›Ó‰˘ÓÔ˜ ÓÂÊÚÔÙÔÍÈÎfiÙËÙ·˜ ¢√™√§√°π∞: XÔÚËÁÂ›Ù·È ·fi ÙÔ˘ ÛÙfiÌ·ÙÔ˜, Ì ‹ ¯ˆÚ›˜ Ê·ÁËÙfi. ∂Ó‹ÏÈΘ: 250 mg οı 8 ÒÚ˜, ‰ÈÏ·ÛÈ·˙fiÌÂÓË Û ÛÔ‚·Ú¤˜ ÏÔÈÌÒÍÂȘ. M¤ÁÈÛÙË ‰fiÛË ÁÈ· ÙÔ˘˜ ÂÓ‹ÏÈΘ 4 gr ËÌÂÚËÛ›ˆ˜ ¶·È‰È¿: 20-40 mg/kg ËÌÂÚËÛ›ˆ˜ ‰È·ÈÚÂ̤ÓË Û ÙÚÂȘ ›Û˜ ‰fiÛÂȘ. ™ÙË ıÂڷ›· Ù˘ ̤Û˘ ˆÙ›Ùȉ·˜ Î·È Ê·Ú˘ÁÁ›Ùȉ·˜, Ë Û˘ÓÔÏÈ΋ ËÌÂÚ‹ÛÈ· ‰fiÛË ÌÔÚ› Ó· ‰È·ÈÚÂı› Î·È Ó· ¯ÔÚËÁËı› ·Ó¿ 12ˆÚÔ. ª¤ÁÈÛÙË Û˘ÓÈÛÙÒÌÂÓË ‰fiÛË ÛÙ· ·È‰È¿ Â›Ó·È 1 gr ËÌÂÚËÛ›ˆ˜. ªOƒº∂™: Susp 125mg/5ml, 60ml, Susp 250mg/5ml, 60ml, Susp 375mg/5ml, 60ml, Caps 500mg Û ÎÔ˘Ù› ÙˆÓ 12. ¶ÔÛÔÛÙfi ÂȯÔÚ‹ÁËÛ˘ ·fi Ù· Ù·Ì›·: 75 %
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